2009.fee.schedule
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Fee Schedule 2009 Procedure Code Pricing Action Code Description
Maximum Allowable
0001F
9
HEART FAILURE COMPOSITE
$0.00
0001T
O
ENDOVAS REPR ABDO AO ANEURYS
$0.00
0002F
O
TOBACCO USE, SMOKING, ASSESS
$0.00
0002T
9
ENDOVAS REPR ABDO AO ANEURYS
$0.00
0003F
O
TOBACCO USE, NON-SMOKING
$0.00
0003T
O
CERVICOGRAPHY
$0.00
0004F
O
TOBACCO USE TXMNT COUNSELING
$0.00
0005F
9
OSTEOARTHRITIS COMPOSITE
$0.00
0005T
O
PERC CATH STENT/BRAIN CV ART
$0.00
0006F
O
STATIN THERAPY, PRESCRIBED
$0.00
0006T
O
PERC CATH STENT/BRAIN CV ART
$0.00
0007F
O
BETA-BLOCKER THX PRESCRIBED
$0.00
0007T
O
PERC CATH STENT/BRAIN CV ART
$0.00
0008F
O
ACE INHIBITOR THX PRESCRIBED
$0.00
0008T
O
UPPER GI ENDOSCOPY W/SUTURE
$0.00
0009F
O
ASSESS ANGINAL SYMPTOM/LEVEL
$0.00
0009T
O
ENDOMETRIAL CRYOABLATION
$0.00
00100
A
ANESTH, SALIVARY GLAND
$0.00
00102
A
ANESTH, REPAIR OF CLEFT LIP
$0.00
00103
A
ANESTH, BLEPHAROPLASTY
$0.00
00104
A
ANESTH, ELECTROSHOCK
$0.00
0010F
O
ASSESS ANGINAL SYMPTOM/LEVEL
$0.00
0010T
O
TB TEST, GAMMA INTERFERON
$0.00
0011F
O
ORAL ANTIPLAT THX PRESCRIBED
$0.00
00120
A
ANESTH, EAR SURGERY
$0.00
00124
A
ANESTH, EAR EXAM
$0.00
00126
A
ANESTH, TYMPANOTOMY
$0.00
0012F
9
CAP BACTERIAL ASSESS
$0.00
0012T
O
OSTEOCHONDRAL KNEE AUTOGRAFT
$0.00
0013T
O
OSTEOCHONDRAL KNEE ALLOGRAFT
$0.00
00140
A
ANESTH, PROCEDURES ON EYE
$0.00
00142
A
ANESTH, LENS SURGERY
$0.00
00144
A
ANESTH, CORNEAL TRANSPLANT
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
00145
A
ANESTH, VITREORETINAL SURG
$0.00
00147
A
ANESTH, IRIDECTOMY
$0.00
00148
A
ANESTH, EYE EXAM
$0.00
0014F
9
COMP PREOP ASSESS CAT SURG
$0.00
0014T
O
MENISCAL TRANSPLANTATION, MEDIAL OR
$0.00
0015F
9
MELAN FOLLOW-UP COMPLETE
$0.00
00160
A
ANESTH, NOSE/SINUS SURGERY
$0.00
00162
A
ANESTH, NOSE/SINUS SURGERY
$0.00
00164
A
ANESTH, BIOPSY OF NOSE
$0.00
0016T
9
THERMOTX CHOROID VASC LESION
$0.00
00170
A
ANESTH, PROCEDURE ON MOUTH
$0.00
00172
A
ANESTH, CLEFT PALATE REPAIR
$0.00
00174
A
ANESTH, PHARYNGEAL SURGERY
$0.00
00176
A
ANESTH, PHARYNGEAL SURGERY
$0.00
0017T
9
PHOTOCOAGULAT MACULAR DRUSEN
$0.00
0018T
O
TRANSCRANIAL MAGNETIC STIMUL
$0.00
00190
A
ANESTH, FACE/SKULL BONE SURG
$0.00
00192
A
ANESTH, FACIAL BONE SURGERY
$0.00
0019T
9
EXTRACORP SHOCK WAVE, MS, NOS
$0.00
0020T
O
EXTRACORP SHOCK WAVE TX, FT
$0.00
00210
A
ANESTH, CRANIAL SURG NOS
$0.00
00211
A
ANESTH, CRAN SURG, HEMOTOMA
$0.00
00212
A
ANESTH, SKULL DRAINAGE
$0.00
00214
A
ANESTH, SKULL DRAINAGE
$0.00
00215
A
ANESTH, SKULL REPAIR/FRACT
$0.00
00216
A
ANESTH, HEAD VESSEL SURGERY
$0.00
00218
A
ANESTH, SPECIAL HEAD SURGERY
$0.00
0021T
O
FETAL OXIMETRY, TRNSVAG/CERV
$0.00
00220
A
ANESTH, INTRCRN NERVE
$0.00
00222
A
ANESTH, HEAD NERVE SURGERY
$0.00
0023T
O
PHENOTYPE DRUG TEST, HIV 1
$0.00
0024T
O
TRANSCATH CARDIAC REDUCTION
$0.00
0025T
O
ULTRASONIC PACHYMETRY
$0.00
0026T
O
MEASURE REMNANT LIPOPROTEINS
$0.00
0027T
O
ENDOSCOPIC EPIDURAL LYSIS
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
0028T
O
DEXA BODY COMPOSITION STUDY
$0.00
0029T
O
MAGNETIC TX FOR INCONTINENCE
$0.00
00300
A
ANESTH, HEAD/NECK/PTRUNK
$0.00
0030T
9
ANTIPROTHROMBIN ANTIBODY
$0.00
0031T
O
SPECULOSCOPY
$0.00
00320
A
ANESTH, NECK ORGAN, 1 & OVER
$0.00
00322
A
ANESTH, BIOPSY OF THYROID
$0.00
00326
A
ANESTH, LARYNX/TRACH, < 1 YR
$0.00
0032T
O
SPECULOSCOPY W/DIRECT SAMPLE
$0.00
0033T
O
ENDOVASC TAA REPR INCL SUBCL
$0.00
0034T
O
ENDOVASC TAA REPR W/O SUBCL
$0.00
00350
A
ANESTH, NECK VESSEL SURGERY
$0.00
00352
A
ANESTH, NECK VESSEL SURGERY
$0.00
0035T
O
INSERT ENDOVASC PROSTH, TAA
$0.00
0036T
O
ENDOVASC PROSTH, TAA, ADD-ON
$0.00
0037T
O
ARTERY TRANSPOSE/ENDOVAS TAA
$0.00
0038T
O
RAD ENDOVASC TAA RPR W/COVER
$0.00
0039T
O
RAD S/I, ENDOVASC TAA REPAIR
$0.00
00400
A
ANESTH, SKIN, EXT/PER/ATRUNK
$0.00
00402
A
ANESTH, SURGERY OF BREAST
$0.00
00404
A
ANESTH, SURGERY OF BREAST
$0.00
00406
A
ANESTH, SURGERY OF BREAST
$0.00
0040T
O
RAD S/I, ENDOVASC TAA PROSTH
$0.00
00410
A
ANESTH, CORRECT HEART RHYTHM
$0.00
0041T
O
DETECT UR INFECT AGNT W/CPAS
$0.00
00420
9
ANESTH, SKIN SURGERY, BACK
$0.00
0042T
9
CT PERFUSION W/CONTRAST, CBF
$0.00
0043T
O
CO EXPIRED GAS ANALYSIS
$0.00
0044T
O
WHOLE BODY PHOTOGRAPHY
$0.00
00450
A
ANESTH, SURGERY OF SHOULDER
$0.00
00452
A
ANESTH, SURGERY OF SHOULDER
$0.00
00454
A
ANESTH, COLLAR BONE BIOPSY
$0.00
0045T
O
WHOLE BODY PHOTOGRAPHY
$0.00
0046T
O
CATH LAVAGE, MAMMARY DUCT(S)
$0.00
00470
A
ANESTH, REMOVAL OF RIB
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
00472
A
ANESTH, CHEST WALL REPAIR
$0.00
00474
A
ANESTH, SURGERY OF RIB(S)
$0.00
0047T
O
CATH LAVAGE, MAMMARY DUCT(S)
$0.00
0048T
9
IMPLANT VENTRICULAR DEVICE
$0.00
0049T
O
EXTERNAL CIRCULATION ASSIST
$0.00
00500
A
ANESTH, ESOPHAGEAL SURGERY
$0.00
0050T
9
REMOVAL CIRCULATION ASSIST
$0.00
0051T
9
IMPLANT TOTAL HEART SYSTEM
$0.00
00520
A
ANESTH, CHEST PROCEDURE
$0.00
00522
A
ANESTH, CHEST LINING BIOPSY
$0.00
00524
A
ANESTH, CHEST DRAINAGE
$0.00
00528
A
ANESTH, CHEST PARTITION VIEW
$0.00
00529
9
ANESTH, CHEST PARTITION VIEW
$0.00
0052T
9
REPLACE COMPONENT HEART SYST
$0.00
00530
A
ANESTH, PACEMAKER INSERTION
$0.00
00532
A
ANESTH, VASCULAR ACCESS
$0.00
00534
A
ANESTH, CARDIOVERTER/DEFIB
$0.00
00537
A
ANESTH, CARDIAC ELECTROPHYS
$0.00
00539
A
ANESTH,TRACHEOBRONCHIAL RECONSTRUC
$0.00
0053T
9
REPLACE COMPONENT HEART SYST
$0.00
00540
A
ANESTH, CHEST SURGERY
$0.00
00541
A
ANESTH, ONE LUNG VENTILATION
$0.00
00542
A
ANESTH, RELEASE OF LUNG
$0.00
00544
O
ANESTH, CHEST LINING REMOVAL
$0.00
00546
A
ANESTH, LUNG,CHEST WALL SURG
$0.00
00548
A
ANESTH, TRACHEA,BRONCHI SURG
$0.00
0054T
O
BONE SURGERY USING COMPUTER
$0.00
00550
A
ANESTH, STERNAL DEBRIDEMENT
$0.00
0055T
O
BONE SURGERY USING COMPUTER
$0.00
00560
A
ANESTH, HEART SURG W/O PUMP
$0.00
00561
A
ANESTH, HEART SURG < AGE 1
$0.00
00562
A
ANESTH HRT SURG W/PMP AGE 1+
$0.00
00563
A
ANESTH, HEART SURG W/ARREST
$0.00
00566
A
ANESTH, CABG W/O PUMP
$0.00
00567
A
ANESTH, CABG W/PUMP
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
0056T
O
BONE SURGERY USING COMPUTER
$0.00
0057T
O
UPPR GI SCOPE W/ THRML TXMNT
$0.00
00580
A
ANESTH, HEART/LUNG TRANSPLNT
$0.00
0058T
O
CRYOPRESERVATION, OVARY TISS
$0.00
0059T
O
CRYOPRESERVATION, OOCYTE
$0.00
00600
A
ANESTH, SPINE, CORD SURGERY
$0.00
00604
A
ANESTH, SITTING PROCEDURE
$0.00
0060T
O
ELECTRICAL IMPEDANCE SCAN
$0.00
0061T
O
DESTRUCTION OF TUMOR, BREAST
$0.00
00620
A
ANESTH, SPINE, CORD SURGERY
$0.00
00622
A
ANESTH, REMOVAL OF NERVES
$0.00
00625
A
ANES SPINE TRANTHOR W/O VENT
$0.00
00626
A
ANES, SPINE TRANSTHOR W/VENT
$0.00
0062T
9
REP INTRADISC ANNULUS;1 LEV
$0.00
00630
A
ANESTH, SPINE, CORD SURGERY
$0.00
00632
A
ANESTH, REMOVAL OF NERVES
$0.00
00634
5
ANESTH FOR CHEMONUCLEOLYSIS
$0.00
00635
A
ANESTH, LUMBAR PUNCTURE
$0.00
0063T
9
REP INTRADISC ANNULUS;>1LEV
$0.00
00640
A
ANESTH, SPINE MANIPULATION
$0.00
0064T
9
SPECTROSCOP EVAL EXPIRED GAS
$0.00
0065T
O
OCULAR PHOTOSCREEN BILAT
$0.00
0066T
9
CT COLONOGRAPHY;SCREEN
$0.00
00670
A
ANESTH, SPINE, CORD SURGERY
$0.00
0067T
9
CT COLONOGRAPHY;DX
$0.00
0068T
9
INTERP/REPT HEART SOUND
$0.00
0069T
9
ANALYSIS ONLY HEART SOUND
$0.00
00700
A
ANESTH, ABDOMINAL WALL SURG
$0.00
00702
A
ANESTH, FOR LIVER BIOPSY
$0.00
0070T
9
INTERP ONLY HEART SOUND
$0.00
0071T
9
U/S LEIOMYOMATA ABLATE <200
$0.00
0072T
9
U/S LEIOMYOMATA ABLATE >200
$0.00
00730
A
ANESTH, ABDOMINAL WALL SURG
$0.00
0073T
9
DELIVERY, COMP IMRT
$0.00
00740
A
ANESTH, UPPER GI VISUALIZE
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
0074T
O
ONLINE PHYSICIAN E/M
$0.00
00750
A
ANESTH, REPAIR OF HERNIA
$0.00
00752
A
ANESTH, REPAIR OF HERNIA
$0.00
00754
A
ANESTH, REPAIR OF HERNIA
$0.00
00756
A
ANESTH, REPAIR OF HERNIA
$0.00
0075T
9
PERQ STENT/CHEST VERT ART
$0.00
0076T
9
S&I STENT/CHEST VERT ART
$0.00
00770
A
ANESTH, BLOOD VESSEL REPAIR
$0.00
0077T
9
CEREB THERM PERFUSION PROBE
$0.00
0078T
9
ENDOVASC AORT REPR W/DEVICE
$0.00
00790
A
ANESTH, SURG UPPER ABDOMEN
$0.00
00792
A
ANESTH, HEMORR/EXCISE LIVER
$0.00
00794
A
ANESTH, PANCREAS REMOVAL
$0.00
00796
A
ANESTH, FOR LIVER TRANSPLANT
$0.00
00797
A
ANESTH, SURGERY FOR OBESITY
$0.00
0079T
9
ENDOVASC VISC EXTNSN REPR
$0.00
00800
A
ANESTH, ABDOMINAL WALL SURG
$0.00
00802
A
ANESTH, FAT LAYER REMOVAL
$0.00
00806
O
ANESTHESIA FOR LAPAROSCOPIC PROCEDU
$0.00
0080T
9
ENDOVASC AORT REPR RAD S&I
$0.00
00810
A
ANESTH, LOW INTESTINE SCOPE
$0.00
0081T
9
ENDOVASC VISC EXTNSN S&I
$0.00
00820
A
ANESTH, ABDOMINAL WALL SURG
$0.00
0082T
O
STEREOTACTIC RAD DELIVERY
$0.00
00830
A
ANESTH, REPAIR OF HERNIA
$0.00
00832
A
ANESTH, REPAIR OF HERNIA
$0.00
00834
A
ANESTH, HERNIA REPAIR< 1 YR
$0.00
00836
A
ANESTH HERNIA REPAIR PREEMIE
$0.00
0083T
O
STEREOTACTIC RAD TX MNGMT
$0.00
00840
A
ANESTH, SURG LOWER ABDOMEN
$0.00
00842
A
ANESTH, AMNIOCENTESIS
$0.00
00844
A
ANESTH, PELVIS SURGERY
$0.00
00846
A
ANESTH, HYSTERECTOMY
$0.00
00848
A
ANESTH, PELVIC ORGAN SURG
$0.00
0084T
9
TEMP PROSTATE URETHRAL STENT
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
00850
9
ANESTH, CESAREAN SECTION
$0.00
00851
A
ANESTH, TUBAL LIGATION
$0.00
00855
9
ANESTH, HYSTERECTOMY
$0.00
00857
9
ANALGESIA, LABOR & C-SECTION
$0.00
0085T
9
BREATH TEST HEART REJECT
$0.00
00860
A
ANESTH, SURGERY OF ABDOMEN
$0.00
00862
A
ANESTH, KIDNEY/URETER SURG
$0.00
00864
A
ANESTH, REMOVAL OF BLADDER
$0.00
00865
A
ANESTH, REMOVAL OF PROSTATE
$0.00
00866
A
ANESTH, REMOVAL OF ADRENAL
$0.00
00868
A
ANESTH, KIDNEY TRANSPLANT
$0.00
00869
O
ANESTH, VASECTOMY
$0.00
0086T
9
L VENTRICLE FILL PRESSURE
$0.00
00870
A
ANESTH, BLADDER STONE SURG
$0.00
00872
A
ANESTH KIDNEY STONE DESTRUCT
$0.00
00873
A
ANESTH KIDNEY STONE DESTRUCT
$0.00
0087T
9
SPERM EVAL HYALURONAN
$0.00
00880
A
ANESTH, ABDOMEN VESSEL SURG
$0.00
00882
A
ANESTH, MAJOR VEIN LIGATION
$0.00
00884
9
ANESTH, MAJOR VEIN REVISION
$0.00
0088T
O
RF TONGUE BASE VOL REDUXN
$0.00
0089T
O
ACTIGRAPHY TESTING, 3-DAY
$0.00
00900
9
ANESTH, PERINEAL PROCEDURE
$0.00
00902
A
ANESTH, ANORECTAL SURGERY
$0.00
00904
A
ANESTH, PERINEAL SURGERY
$0.00
00906
A
ANESTH, REMOVAL OF VULVA
$0.00
00908
A
ANESTH, REMOVAL OF PROSTATE
$0.00
0090T
O
CERVICAL ARTIFIC DISC
$0.00
00910
A
ANESTH, BLADDER SURGERY
$0.00
00912
A
ANESTH, BLADDER TUMOR SURG
$0.00
00914
A
ANESTH, REMOVAL OF PROSTATE
$0.00
00916
A
ANESTH, BLEEDING CONTROL
$0.00
00918
A
ANESTH, STONE REMOVAL
$0.00
0091T
O
LUMBAR ARTIFIC DISC
$0.00
00920
A
ANESTH, GENITALIA SURGERY
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
00921
A
ANESTH, VASECTOMY
$0.00
00922
A
ANESTH, SPERM DUCT SURGERY
$0.00
00924
A
ANESTH, TESTIS EXPLORATION
$0.00
00926
A
ANESTH, REMOVAL OF TESTIS
$0.00
00928
A
ANESTH, REMOVAL OF TESTIS
$0.00
0092T
9
ARTIFIC DISC ADDL
$0.00
00930
A
ANESTH, TESTIS SUSPENSION
$0.00
00932
A
ANESTH, AMPUTATION OF PENIS
$0.00
00934
A
ANESTH, PENIS, NODES REMOVAL
$0.00
00936
A
ANESTH, PENIS, NODES REMOVAL
$0.00
00938
9
ANESTH, INSERT PENIS DEVICE
$0.00
0093T
O
CERVICAL ARTIFIC DISKECTOMY
$0.00
00940
A
ANESTH, VAGINAL PROCEDURES
$0.00
00942
A
ANESTH, SURG ON VAG/URETHRAL
$0.00
00944
A
ANESTH, VAGINAL HYSTERECTOMY
$0.00
00946
9
ANESTH, VAGINAL DELIVERY
$0.00
00948
A
ANESTH, REPAIR OF CERVIX
$0.00
0094T
O
LUMBAR ARTIFIC DISKECTOMY
$0.00
00950
A
ANESTH, VAGINAL ENDOSCOPY
$0.00
00952
A
ANESTH, HYSTEROSCOPE/GRAPH
$0.00
00955
9
ANALGESIA, VAGINAL DELIVERY
$0.00
0095T
9
ARTIFIC DISKECTOMY ADDL
$0.00
0096T
O
REV CERVICAL ARTIFIC DISC
$0.00
0097T
O
REV LUMBAR ARTIFIC DISC
$0.00
0098T
9
REV ARTIFIC DISC ADDL
$0.00
0099T
9
IMPLANT CORNEAL RING
$0.00
01000
9
ANESTH, SKIN SURGERY, PELVIS
$0.00
0100T
9
PROSTH RETINA RECEIVE&GEN
$0.00
0101T
9
EXTRACORP SHOCKWV TX,HI ENRG
$0.00
0102T
9
EXTRACORP SHOCKWV TX,ANESTH
$0.00
0103T
9
HOLOTRANSCOBALAMIN
$0.00
0104T
9
AT REST CARDIO GAS REBREATHE
$0.00
0105T
9
EXERC CARDIO GAS REBREATHE
$0.00
0106T
9
TOUCH QUANT SENSORY TEST
$0.00
0107T
9
VIBRATE QUANT SENSORY TEST
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
0108T
9
COOL QUANT SENSORY TEST
$0.00
0109T
9
HEAT QUANT SENSORY TEST
$0.00
0110T
9
NOS QUANT SENSORY TEST
$0.00
01110
9
ANESTH, SKIN SURGERY, PELVIS
$0.00
01112
A
ANESTH, BONE ASPIRATE/BX
$0.00
0111T
9
RBC MEMBRANES FATTY ACIDS
$0.00
01120
A
ANESTH, PELVIS SURGERY
$0.00
01130
A
ANESTH, BODY CAST PROCEDURE
$0.00
01140
A
ANESTH, AMPUTATION AT PELVIS
$0.00
01150
A
ANESTH, PELVIC TUMOR SURGERY
$0.00
0115T
O
MED TX MNGMT 15 MIN
$0.00
01160
A
ANESTH, PELVIS PROCEDURE
$0.00
0116T
O
MED TX MNGMT SUBSQT
$0.00
01170
A
ANESTH, PELVIS SURGERY
$0.00
01173
A
ANESTH, FX REPAIR, PELVIS
$0.00
0117T
O
MED TX MNGMT ADDL 15 MIN
$0.00
01180
A
ANESTH, PELVIS NERVE REMOVAL
$0.00
01190
A
ANESTH, PELVIS NERVE REMOVAL
$0.00
01200
A
ANESTH, HIP JOINT PROCEDURE
$0.00
01202
A
ANESTH, ARTHROSCOPY OF HIP
$0.00
0120T
O
FIBROADENOMA CRYOABLATE, EA
$0.00
01210
A
ANESTH, HIP JOINT SURGERY
$0.00
01212
A
ANESTH, HIP DISARTICULATION
$0.00
01214
A
ANESTH, HIP ARTHROPLASTY
$0.00
01215
A
ANESTH, REVISE HIP REPAIR
$0.00
01220
A
ANESTH, PROCEDURE ON FEMUR
$0.00
01230
A
ANESTH, SURGERY OF FEMUR
$0.00
01232
A
ANESTH, AMPUTATION OF FEMUR
$0.00
01234
A
ANESTH, RADICAL FEMUR SURG
$0.00
0123T
9
SCLERAL FISTULIZATION
$0.00
01240
9
ANESTH, UPPER LEG SKIN SURG
$0.00
0124T
9
CONJUNCTIVAL DRUG PLACEMENT
$0.00
01250
A
ANESTH, UPPER LEG SURGERY
$0.00
01260
A
ANESTH, UPPER LEG VEINS SURG
$0.00
0126T
9
CHD RISK IMT STUDY
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
01270
A
ANESTH, THIGH ARTERIES SURG
$0.00
01272
A
ANESTH, FEMORAL ARTERY SURG
$0.00
01274
A
ANESTH, FEMORAL EMBOLECTOMY
$0.00
01300
9
ANESTH, SKIN SURGERY, KNEE
$0.00
0130T
9
CHRON CARE DRUG INVESTIGATN
$0.00
01320
A
ANESTH, KNEE AREA SURGERY
$0.00
0133T
O
ESOPHAGEAL IMPLANT INJEXN
$0.00
01340
A
ANESTH, KNEE AREA PROCEDURE
$0.00
0135T
O
PERQ CRYOABLATE RENAL TUMOR
$0.00
01360
A
ANESTH, KNEE AREA SURGERY
$0.00
0137T
O
PROSTATE SATURATION SAMPLING
$0.00
01380
A
ANESTH, KNEE JOINT PROCEDURE
$0.00
01382
A
ANESTH, DX KNEE ARTHROSCOPY
$0.00
01390
A
ANESTH, KNEE AREA PROCEDURE
$0.00
01392
A
ANESTH, KNEE AREA SURGERY
$0.00
01400
A
ANESTH, KNEE JOINT SURGERY
$0.00
01402
A
ANESTH, KNEE ARTHROPLASTY
$0.00
01404
A
ANESTH, AMPUTATION AT KNEE
$0.00
0140T
9
EXHALED BREATH CONDENSATE PH
$0.00
0141T
9
PERQ ISLET TRANSPLANT
$0.00
01420
A
ANESTH, KNEE JOINT CASTING
$0.00
0142T
9
OPEN ISLET TRANSPLANT
$0.00
01430
A
ANESTH, KNEE VEINS SURGERY
$0.00
01432
A
ANESTH, KNEE VESSEL SURG
$0.00
0143T
9
LAPAROSCOPIC ISLET TRANSPLNT
$0.00
01440
A
ANESTH, KNEE ARTERIES SURG
$0.00
01442
A
ANESTH, KNEE ARTERY SURG
$0.00
01444
A
ANESTH, KNEE ARTERY REPAIR
$0.00
0144T
9
CT HEART WO DYE; QUAL CALC
$0.00
0145T
9
CT HEART W/WO DYE FUNCT
$0.00
01460
9
ANESTH, LOWER LEG SKIN SURG
$0.00
01462
A
ANESTH, LOWER LEG PROCEDURE
$0.00
01464
A
ANESTH, ANKLE/FT ARTHROSCOPY
$0.00
0146T
9
CCTA W/WO DYE
$0.00
01470
A
ANESTH, LOWER LEG SURGERY
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
01472
A
ANESTH, ACHILLES TENDON SURG
$0.00
01474
A
ANESTH, LOWER LEG SURGERY
$0.00
0147T
9
CCTA W/WO, QUAN CALCIUM
$0.00
01480
A
ANESTH, LOWER LEG BONE SURG
$0.00
01482
A
ANESTH, RADICAL LEG SURGERY
$0.00
01484
A
ANESTH, LOWER LEG REVISION
$0.00
01486
A
ANESTH, ANKLE REPLACEMENT
$0.00
0148T
9
CCTA W/WO, STRXR
$0.00
01490
A
ANESTH, LOWER LEG CASTING
$0.00
0149T
9
CCTA W/WO, STRXR QUAN CALC
$0.00
01500
A
ANESTH, LEG ARTERIES SURG
$0.00
01502
A
ANESTH, LWR LEG EMBOLECTOMY
$0.00
0150T
9
CCTA W/WO, DISEASE STRXR
$0.00
0151T
9
CT HEART FUNCT ADD-ON
$0.00
01520
A
ANESTH, LOWER LEG VEIN SURG
$0.00
01522
A
ANESTH, LOWER LEG VEIN SURG
$0.00
0152T
9
COMPUTER CHEST ADD-ON
$0.00
0153T
O
TCATH SENSOR ANEURYSM SAC
$0.00
0154T
O
STUDY SENSOR ANEURYSM SAC
$0.00
0155T
9
LAP IMPL GAST CURVE ELECTRD
$0.00
0156T
9
LAP REMV GAST CURVE ELECTRD
$0.00
0157T
9
OPEN IMPL GAST CURVE ELECTRD
$0.00
0158T
9
OPEN REMV GAST CURVE ELECTRD
$0.00
0159T
9
CAD BREAST MRI
$0.00
01600
9
ANESTH, SHOULDER SKIN SURG
$0.00
0160T
9
TCRANIAL MAGN STIM TX PLAN
$0.00
01610
A
ANESTH, SURGERY OF SHOULDER
$0.00
0161T
9
TCRANIAL MAGN STIM TX DELIV
$0.00
01620
A
ANESTH, SHOULDER PROCEDURE
$0.00
01622
A
ANES DX SHOULDER ARTHROSCOPY
$0.00
0162T
O
ANAL PROGRAM GAST NEUROSTIM
$0.00
01630
A
ANESTH, SURGERY OF SHOULDER
$0.00
01632
A
ANESTH, SURGERY OF SHOULDER
$0.00
01634
A
ANESTH, SHOULDER JOINT AMPUT
$0.00
01636
A
ANESTH, FOREQUARTER AMPUT
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
01638
A
ANESTH, SHOULDER REPLACEMENT
$0.00
0163T
9
LUMB ARTIF DISKECTOMY ADDL
$0.00
0164T
9
REMOVE LUMB ARTIF DISC ADDL
$0.00
01650
A
ANESTH, SHOULDER ARTERY SURG
$0.00
01652
A
ANESTH, SHOULDER VESSEL SURG
$0.00
01654
A
ANESTH, SHOULDER VESSEL SURG
$0.00
01656
A
ANESTH, ARM-LEG VESSEL SURG
$0.00
0165T
9
REVISE LUMB ARTIF DISC ADDL
$0.00
0166T
9
TCATH VSD CLOSE W/O BYPASS
$0.00
01670
A
ANESTH, SHOULDER VEIN SURG
$0.00
0167T
9
TCATH VSD CLOSE W BYPASS
$0.00
01680
A
ANESTH, SHOULDER CASTING
$0.00
01682
A
ANESTH, AIRPLANE CAST
$0.00
0168T
9
RHINOPHOTOTX LIGHT APP BILAT
$0.00
0169T
9
PLACE STEREO CATH BRAIN
$0.00
01700
9
ANESTH, ELBOW AREA SKIN SURG
$0.00
0170T
9
ANORECTAL FISTULA PLUG RPR
$0.00
01710
A
ANESTH, ELBOW AREA SURGERY
$0.00
01712
A
ANESTH, UPPR ARM TENDON SURG
$0.00
01714
A
ANESTH, UPPR ARM TENDON SURG
$0.00
01716
A
ANESTH, BICEPS TENDON REPAIR
$0.00
0171T
9
LUMBAR SPINE PROCES DISTRACT
$0.00
0172T
9
LUMBAR SPINE PROCES ADDL
$0.00
01730
A
ANESTH, UPPR ARM PROCEDURE
$0.00
01732
A
ANESTH, DX ELBOW ARTHROSCOPY
$0.00
0173T
9
IOP MONIT IO PRESSURE
$0.00
01740
A
ANESTH, UPPER ARM SURGERY
$0.00
01742
A
ANESTH, HUMERUS SURGERY
$0.00
01744
A
ANESTH, HUMERUS REPAIR
$0.00
0174T
9
CAD CXR WITH INTERP
$0.00
01756
A
ANESTH, RADICAL HUMERUS SURG
$0.00
01758
A
ANESTH, HUMERAL LESION SURG
$0.00
0175T
9
CAD CXR REMOTE
$0.00
01760
A
ANESTH, ELBOW REPLACEMENT
$0.00
0176T
9
AQU CANAL DILAT W/O RETENT
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
01770
A
ANESTH, UPPR ARM ARTERY SURG
$0.00
01772
A
ANESTH, UPPR ARM EMBOLECTOMY
$0.00
0177T
9
AQU CANAL DILAT W RETENT
$0.00
01780
A
ANESTH, UPPER ARM VEIN SURG
$0.00
01782
A
ANESTH, UPPR ARM VEIN REPAIR
$0.00
0178T
9
64 LEAD ECG W I&R
$0.00
0179T
9
64 LEAD ECG W TRACING
$0.00
01800
9
ANESTH, LOWER ARM SKIN SURG
$0.00
0180T
9
64 LEAD ECG W I&R ONLY
$0.00
01810
A
ANESTH, LOWER ARM SURGERY
$0.00
0181T
9
CORNEAL HYSTERESIS
$0.00
01820
A
ANESTH, LOWER ARM PROCEDURE
$0.00
01829
A
ANESTH, DX WRIST ARTHROSCOPY
$0.00
0182T
9
HDR ELECT BRACHYTHERAPY
$0.00
01830
A
ANESTH, LOWER ARM SURGERY
$0.00
01832
A
ANESTH, WRIST REPLACEMENT
$0.00
0183T
9
WOUND ULTRASOUND
$0.00
01840
A
ANESTH, LWR ARM ARTERY SURG
$0.00
01842
A
ANESTH, LWR ARM EMBOLECTOMY
$0.00
01844
A
ANESTH, VASCULAR SHUNT SURG
$0.00
0184T
9
EXC RECTAL TUMOR ENDOSCOPIC
$0.00
01850
A
ANESTH, LOWER ARM VEIN SURG
$0.00
01852
A
ANESTH, LWR ARM VEIN REPAIR
$0.00
0185T
9
COMPTR PROBABILITY ANALYSIS
$0.00
01860
A
ANESTH, LOWER ARM CASTING
$0.00
0186T
9
SUPRACHOROIDAL DRUG DELIVERY
$0.00
0187T
9
OPHTHALMIC DX IMAGE ANTERIOR
$0.00
0188T
9
VIDEOCONF CRIT CARE 74 MIN
$0.00
0189T
9
VIDEOCONF CRIT CARE ADDL 30
$0.00
01900
9
ANESTH, UTERUS/TUBE INJECT
$0.00
01902
9
ANESTH, BURR HOLES, SKULL
$0.00
01904
9
ANESTH, SKULL X-RAY INJECT
$0.00
01905
O
ANES, SPINE INJECT, X-RAY/RE
$0.00
01906
9
ANESTH, LUMBAR MYELOGRAPHY
$0.00
01908
9
ANESTH, CERVICAL MYELOGRAPHY
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
0190T
9
PLACE INTRAOC RADIATION SRC
$0.00
01910
9
ANESTH, SKULL MYELOGRAPHY
$0.00
01912
9
ANESTH, LUMBAR DISKOGRAPHY
$0.00
01914
9
ANESTH, CERVICAL DISKOGRAPHY
$0.00
01916
A
ANESTH, DX ARTERIOGRAPHY
$0.00
01918
9
ANESTH, LIMB ARTERIOGRAM
$0.00
0191T
9
INSERT ANT SEGMENT DRAIN INT
$0.00
01920
A
ANESTH, CATHETERIZE HEART
$0.00
01921
9
ANESTH, VESSEL SURGERY
$0.00
01922
A
ANESTH, CAT OR MRI SCAN
$0.00
01924
A
ANES, THER INTERVEN RAD, ART
$0.00
01925
A
ANES, THER INTERVEN RAD, CAR
$0.00
01926
A
ANES, TX INTERV RAD HRT/CRAN
$0.00
0192T
9
INSERT ANT SEGMENT DRAIN EXT
$0.00
01930
A
ANES, THER INTERVEN RAD, VEI
$0.00
01931
A
ANES, THER INTERVEN RAD, TIP
$0.00
01932
A
ANES, TX INTERV RAD, TH VEIN
$0.00
01933
A
ANES, TX INTERV RAD, CRAN V
$0.00
01935
A
ANESTH, PERC IMG DX SP PROC
$0.00
01936
A
ANESTH, PERC IMG TX SP PROC
$0.00
0193T
9
RF BLADDER NECK MICROREMODEL
$0.00
0194T
9
PROCALCITONIN (PCT)
$0.00
01951
A
ANESTH, BURN, LESS 4 PERCENT
$0.00
01952
A
ANESTH, BURN, 4-9 PERCENT
$0.00
01953
5
ANESTH, BURN, EACH 9 PERCENT
$0.00
01958
A
ANESTH, ANTEPARTUM MANIPUL
$0.00
0195T
9
ARTHROD PRESAC INTERBODY
$0.00
01960
A
ANESTH, VAGINAL DELIVERY
$0.00
01961
A
ANESTH, CS DELIVERY
$0.00
01962
A
ANESTH, EMER HYSTERECTOMY
$0.00
01963
A
ANESTH, CS HYSTERECTOMY
$0.00
01964
O
ANESTH, ABORTION PROCEDURES
$0.00
01965
A
ANESTH, INC/MISSED AB PROC
$0.00
01966
A
ANESTH, INDUCED AB PROCEDURE
$0.00
01967
A
ANESTH/ANALG, VAG DELIVERY
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
01968
A
ANES/ANALG CS DELIVER ADD-ON
$0.00
01969
A
ANESTH/ANALG CS HYST ADD-ON
$0.00
0196T
9
ARTHROD PRESAC INTERBODY EAC
$0.00
0197T
9
INTRAFRACTION TRACK MOTION
$0.00
0198T
9
OCULAR BLOOD FLOW MEASURE
$0.00
01990
A
SUPPORT FOR ORGAN DONOR
$0.00
01991
A
ANESTH, NERVE BLOCK/INJ
$0.00
01992
A
ANESTH, N BLOCK/INJ, PRONE
$0.00
01995
O
REGIONAL ANESTHESIA LIMB
$0.00
01996
3
HOSP MANAGE CONT DRUG ADMIN
01999
5
UNLISTED ANESTH PROCEDURE
$0.00
0500F
9
INITIAL PRENATAL CARE VISIT
$0.00
0501F
9
PRENATAL FLOW SHEET
$0.00
0502F
9
SUBSEQUENT PRENATAL CARE
$0.00
0503F
9
POSTPARTUM CARE VISIT
$0.00
0505F
9
HEMODIALYSIS PLAN DOCÏD
$0.00
0507F
9
PERITON DIALYSIS PLAN DOCÏD
$0.00
0509F
9
URINE INCON PLAN DOCÏD
$0.00
0513F
9
ELEV BP PLAN OF CARE DOCÏD
$0.00
0514F
9
CARE PLAN HGB DOCÏD ESA PT
$0.00
0516F
9
ANEMIA PLAN OF CARE DOCÏD
$0.00
0517F
9
GLAUCOMA PLAN OF CARE DOCÏD
$0.00
0518F
9
FALL PLAN OF CARE DOCÏD
$0.00
0519F
9
PLANÏD CHEMO DOCÏD B/4 TXMNT
$0.00
0520F
9
RAD DOS LIMTS B/4 3D RAD
$0.00
0521F
9
PLAN OF CARE 4 PAIN DOCÏD
$0.00
0525F
9
INITIAL VISIT FOR EPISODE
$0.00
0526F
9
SUBS VISIT FOR EPISODE
$0.00
0528F
9
RCMND FLW-UP 10 YRS DOCD
$0.00
0529F
9
INTRVL 3+YRS PTS CLNSCP DOCD
$0.00
0535F
9
DYSPNEA MNGMNT PLAN DOCD
$0.00
0540F
9
GLUCO MNGMNT PLAN DOCD
$0.00
0575F
9
HIV RNA PLAN CARE DOCD
$0.00
10000
O
INCISION AND DRAINAGE OF INFECTED O
$0.00
10001
O
INCISION AND DRAINAGE OF INFECTED O
$0.00
$48.15
Procedure Code Pricing Action Code Description
Maximum Allowable
10002
O
INCISION AND DRAINAGE OF INFECTED O
$0.00
10003
O
INCISION AND DRAINAGE OF INFECTED O
$0.00
1000F
9
TOBACCO USE ASSESSED
$0.00
1000H
O
PART H-ONLY DME, SUPPLIES AND HEARI
$0.00
1001F
O
TOBACCO USE, NON-SMOKING
$0.00
10020
O
INCISION AND DRAINAGE OF FURUNCLE
$0.00
10021
3
FNA W/O IMAGE
$127.26
10022
3
FNA W/IMAGE
$130.85
1002F
9
ASSESS ANGINAL SYMPTOM/LEVEL
$0.00
1003F
9
LEVEL OF ACTIVITY ASSESS
$0.00
10040
3
ACNE SURGERY
1004F
9
CLIN SYMP VOL OVRLD ASSESS
$0.00
1005F
9
ASTHMA SYMPTOMS EVALUATE
$0.00
10060
3
DRAINAGE OF SKIN ABSCESS
$97.53
10061
3
DRAINAGE OF SKIN ABSCESS
$166.28
1006F
9
OSTEOARTHRITIS ASSESS
$0.00
1007F
9
ANTI-INFLM/ANLGSC OTC ASSESS
$0.00
10080
3
DRAINAGE OF PILONIDAL CYST
$146.46
10081
3
DRAINAGE OF PILONIDAL CYST
$228.59
1008F
9
GI/RENAL RISK ASSESS
$0.00
10100
O
INCISION AND DRAINAGE OF ONYCHIA OR
$0.00
10101
O
INCISION AND DRAINAGE OF ONYCHIA OR
$0.00
1010H
O
TRANSPORTATION IN VEHICLE OTHER THA
$0.00
1011H
O
TRANSPORTATION IN VEHICLE OTHER THA
$0.00
10120
3
REMOVE FOREIGN BODY
$120.03
10121
3
REMOVE FOREIGN BODY
$232.67
1012H
O
TRANSPORTATION IN VEHICLE OTHER THA
$0.00
1013H
O
TRANSPORTATION IN VEHICLE OTHER THA
$0.00
10140
3
DRAINAGE OF HEMATOMA/FLUID
10141
O
INCISION AND DRAINAGE OF HEMATOMA C
$0.00
1015F
9
COPD SYMPTOMS ASSESS
$0.00
1015H
O
SOCIAL WORK
$0.00
10160
3
PUNCTURE DRAINAGE OF LESION
1016H
O
PARENT TRAINING
10180
3
COMPLEX DRAINAGE, WOUND
$90.31
$137.58
$86.51 $0.00 $206.70
Procedure Code Pricing Action Code Description
Maximum Allowable
1018F
9
ASSESS DYSPNEA NOT PRESENT
$0.00
1019F
9
ASSESS DYSPNEA PRESENT
$0.00
1020H
O
INDIVIDUAL DEVELOPMENTAL SERVICES
$0.00
1021H
O
GROUP DEVELOPMENTAL SERVICES
$0.00
1022F
9
PNEUMO IMM STATUS ASSESS
$0.00
1022H
O
CO-TREAT/SIMULTANEOUS DEVELOPMENTAL
$0.00
1023H
O
DEVELOPMENTAL EVALUATION
$0.00
1026F
9
CO-MORBID CONDITION ASSESS
$0.00
1030F
9
INFLUENZA IMM STATUS ASSESS
$0.00
1034F
9
CURRENT TOBACCO SMOKER
$0.00
1035F
9
SMOKELESS TOBACCO USER
$0.00
1036F
9
TOBACCO NON-USER
$0.00
1038F
9
PERSISTENT ASTHMA
$0.00
1039F
9
INTERMITTENT ASTHMA
$0.00
1040F
9
SM-IV INFO MDD DOCD
$0.00
1050F
9
HISTORY OF MOLE CHANGES
$0.00
1055F
9
VISUAL FUNCT STATUS ASSESS
$0.00
1060F
9
DOC PERM/CONT/PAROX ATR. FIB
$0.00
1061F
9
DOC LACK PERM+CONT+PAROX FIB
$0.00
1065F
9
ISCHM STROKE SYMP LT3 HRSB/4
$0.00
1066F
9
ISCHM STROKE SYMP GE3 HRSB/4
$0.00
1070F
9
ALARM SYMP ASSESSED-ABSENT
$0.00
1071F
9
ALARM SYMP ASSESSED-1+ PRSNT
$0.00
1090F
9
PRES/ABSN URINE INCON ASSESS
$0.00
1091F
9
URINE INCON CHARACTERIZED
$0.00
11000
3
DEBRIDE INFECTED SKIN
$48.26
11001
3
DEBRIDE INFECTED SKIN ADD-ON
$20.18
11004
3
DEBRIDE GENITALIA & PERINEUM
$533.60
11005
3
DEBRIDE ABDOM WALL
$695.64
11006
3
DEBRIDE GENIT/PER/ABDOM WALL
$659.25
11008
3
REMOVE MESH FROM ABD WALL
$250.97
1100F
9
PTFALLS ASSESS-DOCÏD GE2+/YR
11010
3
DEBRIDE SKIN, FX
$418.79
11011
3
DEBRIDE SKIN/MUSCLE, FX
$466.00
11012
3
DEBRIDE SKIN/MUSCLE/BONE, FX
$635.98
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
1101F
9
PT FALLS ASSESS-DOCÏD LE1/YR
$0.00
11040
3
DEBRIDE SKIN, PARTIAL
$42.23
11041
3
DEBRIDE SKIN, FULL
$49.34
11042
3
DEBRIDE SKIN/TISSUE
$66.83
11043
3
DEBRIDE TISSUE/MUSCLE
$243.48
11044
3
DEBRIDE TISSUE/MUSCLE/BONE
$332.79
11050
O
PARING OR CURETTEMENT OF BENIGN HYP
$0.00
11051
O
PARING OR CURETTEMENT OF BENIGN HYP
$0.00
11052
O
PARING OR CURETTEMENT OF BENIGN HYP
$0.00
11055
3
TRIM SKIN LESION
$43.55
11056
3
TRIM SKIN LESIONS, 2 TO 4
$53.05
11057
3
TRIM SKIN LESIONS, OVER 4
$63.90
11060
O
SHAVING OF EPIDERMAL OR SUPERFICIAL
$0.00
11061
O
SHAVING OF EPIDERMAL OR SUPERFICIAL
$0.00
11062
O
SHAVING OF EPIDERMAL OR SPUERFICIAL
$0.00
11100
3
BIOPSY, SKIN LESION
$92.88
11101
3
BIOPSY, SKIN ADD-ON
$29.92
1110F
9
PT LFT INPT FAC W/IN 60 DAYS
$0.00
1111F
9
DSCHRG MED/CURRENT MED MERGE
$0.00
1116F
9
AURIC/PERI PAIN ASSESSED
$0.00
1118F
9
GERD SYMPS ASSESSED 12 MONTH
$0.00
1119F
9
INIT. EVAL FOR CONDITION
$0.00
11200
3
REMOVAL OF SKIN TAGS
$72.81
11201
3
REMOVE SKIN TAGS ADD-ON
$16.76
1121F
9
SUBS. EVAL FOR CONDITION
$0.00
1123F
9
ACP DISCUSS/DSCN MKR DOCÏD
$0.00
1124F
9
ACP DISCUSS-NO DSCNMKR DOCÏD
$0.00
1125F
9
AMNT PAIN NOTED; PAIN PRSNT
$0.00
1126F
9
AMNT PAIN NOTED; NONE PRSNT
$0.00
1127F
9
NEW EPISODE FOR CONDITION
$0.00
1128F
9
SUBS. EPISODE FOR CONDITION
$0.00
11300
3
SHAVE SKIN LESION
$60.72
11301
3
SHAVE SKIN LESION
$83.09
11302
3
SHAVE SKIN LESION
$99.35
11303
3
SHAVE SKIN LESION
$116.60
Procedure Code Pricing Action Code Description
Maximum Allowable
11305
3
SHAVE SKIN LESION
$62.22
11306
3
SHAVE SKIN LESION
$85.86
11307
3
SHAVE SKIN LESION
$101.57
11308
3
SHAVE SKIN LESION
$113.77
1130F
9
BK PAIN + FXN ASSESSED
11310
3
SHAVE SKIN LESION
$75.48
11311
3
SHAVE SKIN LESION
$95.66
11312
3
SHAVE SKIN LESION
$110.50
11313
3
SHAVE SKIN LESION
$137.93
1134F
9
EPSD BK PAIN FOR =< 6 WKS
$0.00
1135F
9
EPSD BK PAIN FOR > 6 WKS
$0.00
1136F
9
EPSD BK PAIN FOR <= 12 WKS
$0.00
1137F
9
EPSD BK PAIN FOR > 12 WKS
$0.00
11400
3
EXC TR-EXT B9+MARG 0.5 < CM
$103.15
11401
3
EXC TR-EXT B9+MARG 0.6-1 CM
$126.55
11402
3
EXC TR-EXT B9+MARG 1.1-2 CM
$141.11
11403
3
EXC TR-EXT B9+MARG 2.1-3 CM
$161.92
11404
3
EXC TR-EXT B9+MARG 3.1-4 CM
$184.36
11406
3
EXC TR-EXT B9+MARG > 4.0 CM
$258.85
11420
3
EXC H-F-NK-SP B9+MARG 0.5 <
$104.07
11421
3
EXC H-F-NK-SP B9+MARG 0.6-1
$134.80
11422
3
EXC H-F-NK-SP B9+MARG 1.1-2
$150.42
11423
3
EXC H-F-NK-SP B9+MARG 2.1-3
$174.94
11424
3
EXC H-F-NK-SP B9+MARG 3.1-4
$201.50
11426
3
EXC H-F-NK-SP B9+MARG > 4 CM
$287.64
11440
3
EXC FACE-MM B9+MARG 0.5 < CM
$114.16
11441
3
EXC FACE-MM B9+MARG 0.6-1 CM
$144.33
11442
3
EXC FACE-MM B9+MARG 1.1-2 CM
$162.50
11443
3
EXC FACE-MM B9+MARG 2.1-3 CM
$194.67
11444
3
EXC FACE-MM B9+MARG 3.1-4 CM
$245.07
11446
3
EXC FACE-MM B9+MARG > 4 CM
$332.73
11450
3
REMOVAL, SWEAT GLAND LESION
$308.53
11451
3
REMOVAL, SWEAT GLAND LESION
$402.91
11462
3
REMOVAL, SWEAT GLAND LESION
$305.01
11463
3
REMOVAL, SWEAT GLAND LESION
$414.61
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
11470
3
REMOVAL, SWEAT GLAND LESION
$338.17
11471
3
REMOVAL, SWEAT GLAND LESION
$424.61
1150F
9
DOC PT RSK DEATH W/IN 1YR
$0.00
1151F
9
DOC NO PT RSK DEATH W/IN 1YR
$0.00
1152F
9
DOC ADVNCD DIS COMFORT 1ST
$0.00
1153F
9
DOC ADVNCD DIS CMFRT NOT 1ST
$0.00
1157F
9
ADVNC CARE PLAN IN RCRD
$0.00
1158F
9
ADVNC CARE PLAN TLK DOCD
$0.00
1159F
9
MED LIST DOCD IN RCRD
$0.00
11600
3
EXC TR-EXT MLG+MARG 0.5 < CM
$158.31
11601
3
EXC TR-EXT MLG+MARG 0.6-1 CM
$195.59
11602
3
EXC TR-EXT MLG+MARG 1.1-2 CM
$214.93
11603
3
EXC TR-EXT MLG+MARG 2.1-3 CM
$243.68
11604
3
EXC TR-EXT MLG+MARG 3.1-4 CM
$268.97
11606
3
EXC TR-EXT MLG+MARG > 4 CM
$377.37
1160F
9
RVW MEDS BY RX/DR IN RCRD
11620
3
EXC H-F-NK-SP MLG+MARG 0.5 <
$161.75
11621
3
EXC H-F-NK-SP MLG+MARG 0.6-1
$197.42
11622
3
EXC H-F-NK-SP MLG+MARG 1.1-2
$223.37
11623
3
EXC H-F-NK-SP MLG+MARG 2.1-3
$260.17
11624
3
EXC H-F-NK-SP MLG+MARG 3.1-4
$292.28
11626
3
EXC H-F-NK-SP MLG+MAR > 4 CM
$355.26
11640
3
EXC FACE-MM MALIG+MARG 0.5 <
$169.22
11641
3
EXC FACE-MM MALIG+MARG 0.6-1
$207.88
11642
3
EXC FACE-MM MALIG+MARG 1.1-2
$239.47
11643
3
EXC FACE-MM MALIG+MARG 2.1-3
$280.83
11644
3
EXC FACE-MM MALIG+MARG 3.1-4
$346.28
11646
3
EXC FACE-MM MLG+MARG > 4 CM
$455.02
11700
O
DEBRIDEMENT OF NAILS, MANUAL; FIVE
$0.00
11701
O
DEBRIDEMENT OF NAILS, MANUAL; EACH
$0.00
1170F
9
FXNL STATUS ASSESSED
$0.00
11710
O
DEBRIDEMENT OF NAILS, ELECTRIC GRIN
$0.00
11711
O
DEBRIDEMENT OF NAILS, ELECTRIC GRIN
$0.00
11719
3
TRIM NAIL(S)
$19.12
11720
3
DEBRIDE NAIL, 1-5
$27.92
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
11721
3
DEBRIDE NAIL, 6 OR MORE
$39.83
11730
3
REMOVAL OF NAIL PLATE
$88.14
11731
O
REMOVAL OF SECOND NAIL PLATE
11732
3
REMOVE NAIL PLATE, ADD-ON
$40.91
11740
3
DRAIN BLOOD FROM UNDER NAIL
$40.43
11750
3
REMOVAL OF NAIL BED
$190.86
11752
3
REMOVE NAIL BED/FINGER TIP
$271.38
11755
3
BIOPSY, NAIL UNIT
$119.31
11760
3
REPAIR OF NAIL BED
$179.77
11762
3
RECONSTRUCTION OF NAIL BED
$239.80
11765
3
EXCISION OF NAIL FOLD, TOE
$115.28
11770
3
REMOVAL OF PILONIDAL LESION
$229.44
11771
3
REMOVAL OF PILONIDAL LESION
$469.52
11772
3
REMOVAL OF PILONIDAL LESION
$569.91
1180F
9
THROMBOEMB RISK ASSESSED
$0.00
11900
3
INJECTION INTO SKIN LESIONS
$50.49
11901
3
ADDED SKIN LESIONS INJECTION
$63.69
11920
3
CORRECT SKIN COLOR DEFECTS
$162.74
11921
3
CORRECT SKIN COLOR DEFECTS
$185.35
11922
3
CORRECT SKIN COLOR DEFECTS
$54.68
11950
3
THERAPY FOR CONTOUR DEFECTS
$67.69
11951
3
THERAPY FOR CONTOUR DEFECTS
$90.27
11952
3
THERAPY FOR CONTOUR DEFECTS
$127.08
11954
3
THERAPY FOR CONTOUR DEFECTS
$145.30
11960
3
INSERT TISSUE EXPANDER(S)
$818.94
11970
3
REPLACE TISSUE EXPANDER
$535.99
11971
3
REMOVE TISSUE EXPANDER(S)
$406.68
11975
5
INSERT CONTRACEPTIVE CAP
11976
3
REMOVAL OF CONTRACEPTIVE CAP
11977
5
REMOVAL/REINSERT CONTRA CAP
$0.00
11980
5
IMPLANT HORMONE PELLET(S)
$0.00
11981
5
INSERT DRUG IMPLANT DEVICE
$0.00
11982
3
REMOVE DRUG IMPLANT DEVICE
$142.73
11983
5
REMOVE/INSERT DRUG IMPLANT
$0.00
12001
3
REPAIR SUPERFICIAL WOUND(S)
$130.50
$0.00
$0.00 $134.82
Procedure Code Pricing Action Code Description
Maximum Allowable
12002
3
REPAIR SUPERFICIAL WOUND(S)
$138.92
12004
3
REPAIR SUPERFICIAL WOUND(S)
$163.80
12005
3
REPAIR SUPERFICIAL WOUND(S)
$204.03
12006
3
REPAIR SUPERFICIAL WOUND(S)
$253.02
12007
3
REPAIR SUPERFICIAL WOUND(S)
$286.66
12011
3
REPAIR SUPERFICIAL WOUND(S)
$138.80
12013
3
REPAIR SUPERFICIAL WOUND(S)
$153.04
12014
3
REPAIR SUPERFICIAL WOUND(S)
$180.27
12015
3
REPAIR SUPERFICIAL WOUND(S)
$226.28
12016
3
REPAIR SUPERFICIAL WOUND(S)
$270.19
12017
3
REPAIR SUPERFICIAL WOUND(S)
$238.35
12018
3
REPAIR SUPERFICIAL WOUND(S)
$295.75
12020
3
CLOSURE OF SPLIT WOUND
$237.58
12021
3
CLOSURE OF SPLIT WOUND
$140.25
12031
3
INTMD WND REPAIR S/TR/EXT
$210.65
12032
3
INTMD WND REPAIR S/TR/EXT
$272.13
12034
3
INTMD WND REPAIR S/TR/EXT
$267.07
12035
3
INTMD WND REPAIR S/TR/EXT
$326.00
12036
3
INTMD WND REPAIR S/TR/EXT
$356.80
12037
3
INTMD WND REPAIR S/TR/EXT
$402.29
12041
3
INTMD WND REPAIR N-HF/GENIT
$220.47
12042
3
INTMD WND REPAIR N-HG/GENIT
$257.24
12044
3
INTMD WND REPAIR N-HG/GENIT
$296.85
12045
3
INTMD WND REPAIR N-HG/GENIT
$328.44
12046
3
INTMD WND REPAIR N-HG/GENIT
$389.22
12047
3
INTMD WND REPAIR N-HG/GENIT
$417.40
12051
3
INTMD WND REPAIR FACE/MM
$237.22
12052
3
INTMD WND REPAIR FACE/MM
$269.01
12053
3
INTMD WND REPAIR FACE/MM
$295.55
12054
3
INTMD WND REPAIR, FACE/MM
$312.35
12055
3
INTMD WND REPAIR FACE/MM
$375.74
12056
3
INTMD WND REPAIR FACE/MM
$443.54
12057
3
INTMD WND REPAIR FACE/MM
$495.54
1220F
9
PT SCREENED FOR DEPRESSION
13100
3
REPAIR OF WOUND OR LESION
$0.00 $281.11
Procedure Code Pricing Action Code Description
Maximum Allowable
13101
3
REPAIR OF WOUND OR LESION
$355.18
13102
3
REPAIR WOUND/LESION ADD-ON
13120
3
REPAIR OF WOUND OR LESION
$291.98
13121
3
REPAIR OF WOUND OR LESION
$393.23
13122
3
REPAIR WOUND/LESION ADD-ON
$107.18
13131
3
REPAIR OF WOUND OR LESION
$322.07
13132
3
REPAIR OF WOUND OR LESION
$515.03
13133
3
REPAIR WOUND/LESION ADD-ON
$151.34
13150
3
REPAIR OF WOUND OR LESION
$320.64
13151
3
REPAIR OF WOUND OR LESION
$365.33
13152
3
REPAIR OF WOUND OR LESION
$503.07
13153
3
REPAIR WOUND/LESION ADD-ON
$166.22
13160
3
LATE CLOSURE OF WOUND
$725.82
13300
O
REPAIR OF WOUND OR LESION
14000
3
SKIN TISSUE REARRANGEMENT
$547.00
14001
3
SKIN TISSUE REARRANGEMENT
$710.01
14020
3
SKIN TISSUE REARRANGEMENT
$615.94
14021
3
SKIN TISSUE REARRANGEMENT
$779.22
14040
3
SKIN TISSUE REARRANGEMENT
$683.21
14041
3
SKIN TISSUE REARRANGEMENT
$849.88
14060
3
SKIN TISSUE REARRANGEMENT
$693.85
14061
3
SKIN TISSUE REARRANGEMENT
$910.83
14300
3
SKIN TISSUE REARRANGEMENT
$983.00
14350
3
SKIN TISSUE REARRANGEMENT
$674.97
15000
O
WOUND PREP, 1ST 100 SQ CM
$0.00
15001
O
WOUND PREP, ADDL 100 SQ CM
$0.00
15002
3
WOUND PREP, TRK/ARM/LEG
$296.71
15003
3
WOUND PREP, ADDL 100 CM
$64.49
15004
3
WOUND PREP, F/N/HF/G
$359.68
15005
3
WND PREP, F/N/HF/G, ADDL CM
$107.92
15040
3
HARVEST CULTURED SKIN GRAFT
$226.95
15050
3
SKIN PINCH GRAFT
$479.14
15100
3
SKIN SPLT GRFT, TRNK/ARM/LEG
$767.29
15101
3
SKIN SPLT GRFT T/A/L, ADD-ON
$169.63
15110
3
EPIDRM AUTOGRFT TRNK/ARM/LEG
$755.14
$95.85
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
15111
3
EPIDRM AUTOGRFT T/A/L ADD-ON
$109.68
15115
3
EPIDRM A-GRFT FACE/NCK/HF/G
$764.23
15116
3
EPIDRM A-GRFT F/N/HF/G ADDL
$149.00
15120
3
SKN SPLT A-GRFT FAC/NCK/HF/G
$833.15
15121
3
SKN SPLT A-GRFT F/N/HF/G ADD
$238.98
15130
3
DERM AUTOGRAFT, TRNK/ARM/LEG
$597.11
15131
3
DERM AUTOGRAFT T/A/L ADD-ON
15135
3
DERM AUTOGRAFT FACE/NCK/HF/G
15136
3
DERM AUTOGRAFT, F/N/HF/G ADD
$82.06
15150
3
CULT EPIDERM GRFT T/ARM/LEG
$621.77
15151
3
CULT EPIDERM GRFT T/A/L ADDL
$115.52
15152
3
CULT EPIDERM GRAFT T/A/L +%
$150.59
15155
3
CULT EPIDERM GRAFT, F/N/HF/G
$654.18
15156
3
CULT EPIDRM GRFT F/N/HFG ADD
$160.50
15157
3
CULT EPIDERM GRFT F/N/HFG +%
$177.18
15170
3
ACELL GRAFT TRUNK/ARMS/LEGS
$379.18
15171
3
ACELL GRAFT T/ARM/LEG ADD-ON
$84.71
15175
3
ACELLULAR GRAFT, F/N/HF/G
$481.52
15176
3
ACELL GRAFT, F/N/HF/G ADD-ON
$135.53
15200
3
SKIN FULL GRAFT, TRUNK
$712.99
15201
3
SKIN FULL GRAFT TRUNK ADD-ON
$132.32
15220
3
SKIN FULL GRAFT SCLP/ARM/LEG
$679.85
15221
3
SKIN FULL GRAFT ADD-ON
$123.25
15240
3
SKIN FULL GRFT FACE/GENIT/HF
$815.10
15241
3
SKIN FULL GRAFT ADD-ON
$164.40
15260
3
SKIN FULL GRAFT EEN & LIPS
$883.47
15261
3
SKIN FULL GRAFT ADD-ON
$191.57
15300
3
APPLY SKINALLOGRFT, T/ARM/LG
$304.72
15301
3
APPLY SKNALLOGRFT T/A/L ADDL
$57.20
15320
3
APPLY SKIN ALLOGRFT F/N/HF/G
$343.33
15321
3
APLY SKNALLOGRFT F/N/HFG ADD
$85.25
15330
3
APLY ACELL ALOGRFT T/ARM/LEG
$282.24
15331
3
APLY ACELL GRFT T/A/L ADD-ON
15335
3
APPLY ACELL GRAFT, F/N/HF/G
15336
3
APLY ACELL GRFT F/N/HF/G ADD
$89.32 $767.23
$57.20 $296.72 $79.56
Procedure Code Pricing Action Code Description
Maximum Allowable
15340
3
APPLY CULT SKIN SUBSTITUTE
$282.83
15341
3
APPLY CULT SKIN SUB ADD-ON
$42.23
15342
O
CULTURED SKIN GRAFT, 25 CM
$0.00
15343
O
CULTURE SKN GRAFT ADDL 25 CM
$0.00
15350
O
SKIN HOMOGRAFT
$0.00
15351
O
SKIN HOMOGRAFT ADD-ON
$0.00
15360
3
APPLY CULT DERM SUB, T/A/L
15361
3
APLY CULT DERM SUB T/A/L ADD
$64.04
15365
3
APPLY CULT DERM SUB F/N/HF/G
$315.27
15366
3
APPLY CULT DERM F/HF/G ADD
$78.81
15400
3
APPLY SKIN XENOGRAFT, T/A/L
$351.15
15401
3
APPLY SKN XENOGRFT T/A/L ADD
15410
O
FREE TRANSPLANTATION OF SKIN FLAP B
$0.00
15412
O
FREE TRANSPLANTATION OF SKIN FLAP B
$0.00
15414
O
FREE TRANSPLANTATION OF SKIN FLAP B
$0.00
15416
O
FREE TRANSPLANTATION OF SKIN FLAP B
$0.00
15420
3
APPLY SKIN XGRAFT, F/N/HF/G
$396.09
15421
3
APPLY SKN XGRFT F/N/HF/G ADD
$103.00
15430
3
APPLY ACELLULAR XENOGRAFT
$466.19
15431
6
APPLY ACELLULAR XGRAFT ADD
$0.00
15500
O
FORMATION OF TUBE PEDICLE WITHOUT T
$0.00
15505
O
FORMATION OF TUBE PEDICLE WITHOUT T
$0.00
15510
O
FORMATION OF TUBE PEDICLE WITHOUT T
$0.00
15515
O
FORMATION OF TUBE PEDICLE WITHOUT T
$0.00
15540
O
PRIMARY ATTACHMENT OF OPEN OR TUBED
$0.00
15545
O
PRIMARY ATTACHMENT OF OPEN OR TUBED
$0.00
15550
O
PRIMARY ATTACHMENT OF OPEN OR TUBED
$0.00
15555
O
PRIMARY ATTACHMENT OF OPEN OR TUBED
$0.00
15570
3
FORM SKIN PEDICLE FLAP
$783.20
15572
3
FORM SKIN PEDICLE FLAP
$759.58
15574
3
FORM SKIN PEDICLE FLAP
$801.38
15576
3
FORM SKIN PEDICLE FLAP
$712.61
15580
O
ATTACH SKIN PEDICLE GRAFT
15600
3
SKIN GRAFT
$291.70
15610
3
SKIN GRAFT
$292.24
$321.18
$84.19
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
15620
3
SKIN GRAFT
$387.30
15625
O
SKIN GRAFT
$0.00
15630
3
SKIN GRAFT
$409.21
15650
3
TRANSFER SKIN PEDICLE FLAP
$456.11
15700
O
EXCISION OF LESION AND/OR EXCISIONA
$0.00
15710
O
EXCISION OF LESION AND/OR EXCISIONA
$0.00
15720
O
EXCISION OF LESION AND/OR EXCISIONA
$0.00
15730
O
EXCISION OF LESION AND/OR EXCISIONA
$0.00
15731
3
FOREHEAD FLAP W/VASC PEDICLE
$1,008.10
15732
3
MUSCLE-SKIN GRAFT, HEAD/NECK
$1,332.34
15734
3
MUSCLE-SKIN GRAFT, TRUNK
$1,213.83
15736
3
MUSCLE-SKIN GRAFT, ARM
$1,214.45
15738
3
MUSCLE-SKIN GRAFT, LEG
$1,294.40
15740
3
ISLAND PEDICLE FLAP GRAFT
$903.99
15750
3
NEUROVASCULAR PEDICLE GRAFT
$819.07
15755
O
FREE FLAP (MICROVASCULAR TRANSFER)
15756
3
FREE MYO/SKIN FLAP MICROVASC
$2,150.81
15757
3
FREE SKIN FLAP, MICROVASC
$2,128.85
15758
3
FREE FASCIAL FLAP, MICROVASC
$2,130.66
15760
3
COMPOSITE SKIN GRAFT
$750.03
15770
3
DERMA-FAT-FASCIA GRAFT
$587.41
15775
3
HAIR TRANSPLANT PUNCH GRAFTS
$289.67
15776
3
HAIR TRANSPLANT PUNCH GRAFTS
$401.20
15780
3
ABRASION TREATMENT OF SKIN
$740.53
15781
3
ABRASION TREATMENT OF SKIN
$476.04
15782
3
ABRASION TREATMENT OF SKIN
$505.19
15783
3
ABRASION TREATMENT OF SKIN
$433.54
15786
3
ABRASION, LESION, SINGLE
$212.68
15787
3
ABRASION, LESIONS, ADD-ON
15788
9
CHEMICAL PEEL, FACE, EPIDERM
$0.00
15789
9
CHEMICAL PEEL, FACE, DERMAL
$0.00
15790
O
CHEMICAL PEEL (CHEMEXFOLIATION) TOT
$0.00
15791
O
CHEMICAL PEEL (CHEMEXFOLIATION) REG
$0.00
15792
9
CHEMICAL PEEL, NONFACIAL
$0.00
15793
9
CHEMICAL PEEL, NONFACIAL
$0.00
$0.00
$43.81
Procedure Code Pricing Action Code Description
Maximum Allowable
15810
O
SALABRASION
$0.00
15811
O
SALABRASION
$0.00
15819
3
PLASTIC SURGERY, NECK
$659.53
15820
3
REVISION OF LOWER EYELID
$473.80
15821
3
REVISION OF LOWER EYELID
$503.50
15822
3
REVISION OF UPPER EYELID
$371.52
15823
3
REVISION OF UPPER EYELID
$585.34
15824
9
REMOVAL OF FOREHEAD WRINKLES
$0.00
15825
5
REMOVAL OF NECK WRINKLES
$0.00
15826
5
REMOVAL OF BROW WRINKLES
$0.00
15828
5
REMOVAL OF FACE WRINKLES
$0.00
15829
5
REMOVAL OF SKIN WRINKLES
$0.00
15830
3
EXC SKIN ABD
15831
O
EXCISE EXCESSIVE SKIN TISSUE
$0.00
15832
3
EXCISE EXCESSIVE SKIN TISSUE
$797.56
15833
3
EXCISE EXCESSIVE SKIN TISSUE
$752.89
15834
3
EXCISE EXCESSIVE SKIN TISSUE
$748.78
15835
3
EXCISE EXCESSIVE SKIN TISSUE
$791.52
15836
3
EXCISE EXCESSIVE SKIN TISSUE
$660.31
15837
3
EXCISE EXCESSIVE SKIN TISSUE
$686.24
15838
3
EXCISE EXCESSIVE SKIN TISSUE
$515.60
15839
3
EXCISE EXCESSIVE SKIN TISSUE
$759.22
15840
3
GRAFT FOR FACE NERVE PALSY
$907.71
15841
3
GRAFT FOR FACE NERVE PALSY
$1,516.31
15842
3
FLAP FOR FACE NERVE PALSY
$2,393.91
15845
3
SKIN AND MUSCLE REPAIR, FACE
15847
6
EXC SKIN ABD ADD-ON
$0.00
15850
9
REMOVAL OF SUTURES
$0.00
15851
3
REMOVAL OF SUTURES
$83.55
15852
3
DRESSING CHANGE NOT FOR BURN
$43.61
15860
3
TEST FOR BLOOD FLOW IN GRAFT
15876
5
SUCTION ASSISTED LIPECTOMY
$0.00
15877
9
SUCTION ASSISTED LIPECTOMY
$0.00
15878
9
SUCTION ASSISTED LIPECTOMY
$0.00
15879
9
SUCTION ASSISTED LIPECTOMY
$0.00
$1,048.64
$851.27
$102.77
Procedure Code Pricing Action Code Description
Maximum Allowable
15920
3
REMOVAL OF TAIL BONE ULCER
$523.57
15922
3
REMOVAL OF TAIL BONE ULCER
$665.41
15931
3
REMOVE SACRUM PRESSURE SORE
$594.75
15933
3
REMOVE SACRUM PRESSURE SORE
$733.77
15934
3
REMOVE SACRUM PRESSURE SORE
$816.59
15935
3
REMOVE SACRUM PRESSURE SORE
$973.07
15936
3
REMOVE SACRUM PRESSURE SORE
$791.96
15937
3
REMOVE SACRUM PRESSURE SORE
$926.49
15940
3
REMOVE HIP PRESSURE SORE
$611.90
15941
3
REMOVE HIP PRESSURE SORE
$796.97
15944
3
REMOVE HIP PRESSURE SORE
$784.49
15945
3
REMOVE HIP PRESSURE SORE
$871.60
15946
3
REMOVE HIP PRESSURE SORE
$1,455.12
15950
3
REMOVE THIGH PRESSURE SORE
$507.96
15951
3
REMOVE THIGH PRESSURE SORE
$724.04
15952
3
REMOVE THIGH PRESSURE SORE
$760.90
15953
3
REMOVE THIGH PRESSURE SORE
$847.70
15954
O
EXCISION, TROCHANTERIC PRESSURE ULC
$0.00
15955
O
EXCISION, TROCHANTERIC PRESSURE ULC
$0.00
15956
3
REMOVE THIGH PRESSURE SORE
$1,019.44
15958
3
REMOVE THIGH PRESSURE SORE
$1,041.15
15960
O
EXCISION, HEEL PRESSURE ULCER, WITH
$0.00
15961
O
EXCISION, HEEL PRESSURE ULCER, WITH
$0.00
15964
O
EXCISION, HEEL PRESSURE ULCER, WITH
$0.00
15965
O
EXCISION, HEEL PRESSURE ULCER, WITH
$0.00
15966
O
EXCISION, HEEL PRESSURE ULCER, WITH
$0.00
15967
O
EXCISION, HEEL PRESSURE ULCER, WITH
$0.00
15970
O
EXCISION, LEG PRESSURE ULCER, WITH
$0.00
15971
O
EXCISION, LEG PRESSURE ULCER, WITH
$0.00
15972
O
EXCISION, LEG PRESSURE ULCER, WITH
$0.00
15973
O
EXCISION, LEG PRESSURE ULCER, WITH
$0.00
15974
O
EXCISION, LEG PRESSURE ULCER, WITH
$0.00
15975
O
EXCISION, LEG PRESSURE ULCER, WITH
$0.00
15980
O
EXCISION, KNEE PRESSURE ULCER, WITH
$0.00
15981
O
EXCISION, KNEE PRESSURE ULCER, WITH
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
15982
O
EXCISION, KNEE PRESSURE ULCER, WITH
$0.00
15983
O
EXCISION, KNEE PRESSURE ULCER, WITH
$0.00
15999
5
REMOVAL OF PRESSURE SORE
$0.00
16000
3
INITIAL TREATMENT OF BURN(S)
$61.45
16010
O
TREATMENT OF BURN(S)
$0.00
16015
O
TREATMENT OF BURN(S)
$0.00
16020
3
DRESS/DEBRID P-THICK BURN, S
$72.65
16025
3
DRESS/DEBRID P-THICK BURN, M
$130.93
16030
3
DRESS/DEBRID P-THICK BURN, L
$156.98
16035
3
INCISION OF BURN SCAB, INITI
$194.95
16036
3
ESCHAROTOMY; ADDÏL INCISION
16040
O
BURN WOUND EXCISION
$0.00
16041
O
BURN WOUND EXCISION
$0.00
16042
O
BURN WOUND EXCISION
$0.00
17000
3
DESTRUCT PREMALG LESION
17001
O
DESTRUCTION BY ANY METHOD, INCLUDIN
$0.00
17002
O
DESTRUCTION BY ANY METHOD, INCLUDIN
$0.00
17003
3
DESTRUCT PREMALG LES, 2-14
$6.81
17004
3
DESTROY PREMLG LESIONS 15+
17010
O
DESTRUCTION BY ANY METHOD, INCLUDIN
$0.00
17100
O
DESTRUCTION BY ANY METHOD, INCLUDIN
$0.00
17101
O
DESTRUCTION BY ANY METHOD, INCLUDIN
$0.00
17102
O
DESTRUCTION BY ANY METHOD, INCLUDIN
$0.00
17104
O
DESTRUCTION BY ANY METHOD, INCLUDIN
$0.00
17105
O
DESTRUCTION BY ANY METHOD, INCLUDIN
$0.00
17106
3
DESTRUCTION OF SKIN LESIONS
$308.56
17107
3
DESTRUCTION OF SKIN LESIONS
$408.96
17108
3
DESTRUCTION OF SKIN LESIONS
$521.92
17110
3
DESTRUCT B9 LESION, 1-14
17111
3
DESTRUCT LESION, 15 OR MORE
17200
O
ELECTROSURGICAL DESTRUCTION OF MULT
$0.00
17201
O
ELECTROSURGICAL DESTRUCTION OF MULT
$0.00
17250
3
CHEMICAL CAUTERY, TISSUE
$66.63
17260
3
DESTRUCTION OF SKIN LESIONS
$84.84
17261
3
DESTRUCTION OF SKIN LESIONS
$126.91
$77.62
$70.57
$157.14
$98.34 $116.49
Procedure Code Pricing Action Code Description
Maximum Allowable
17262
3
DESTRUCTION OF SKIN LESIONS
$154.37
17263
3
DESTRUCTION OF SKIN LESIONS
$170.25
17264
3
DESTRUCTION OF SKIN LESIONS
$182.13
17266
3
DESTRUCTION OF SKIN LESIONS
$206.64
17270
3
DESTRUCTION OF SKIN LESIONS
$131.53
17271
3
DESTRUCTION OF SKIN LESIONS
$145.24
17272
3
DESTRUCTION OF SKIN LESIONS
$166.20
17273
3
DESTRUCTION OF SKIN LESIONS
$185.32
17274
3
DESTRUCTION OF SKIN LESIONS
$219.15
17276
3
DESTRUCTION OF SKIN LESIONS
$253.48
17280
3
DESTRUCTION OF SKIN LESIONS
$123.58
17281
3
DESTRUCTION OF SKIN LESIONS
$157.39
17282
3
DESTRUCTION OF SKIN LESIONS
$182.38
17283
3
DESTRUCTION OF SKIN LESIONS
$220.06
17284
3
DESTRUCTION OF SKIN LESIONS
$255.70
17286
3
DESTRUCTION OF SKIN LESIONS
$322.76
17303
O
CHEMOSURGERY (MOHS' TECHNIQUE), FIR
$0.00
17304
O
1 STAGE MOHS, UP TO 5 SPEC
$0.00
17305
O
2 STAGE MOHS, UP TO 5 SPEC
$0.00
17306
O
3 STAGE MOHS, UP TO 5 SPEC
$0.00
17307
O
MOHS ADDL STAGE UP TO 5 SPEC
$0.00
17310
O
MOHS ANY STAGE > 5 SPEC EACH
$0.00
17311
3
MOHS, 1 STAGE, H/N/HF/G
$621.05
17312
3
MOHS ADDL STAGE
$372.81
17313
3
MOHS, 1 STAGE, T/A/L
$567.01
17314
3
MOHS, ADDL STAGE, T/A/L
$345.51
17315
3
MOHS SURG, ADDL BLOCK
$73.95
17340
3
CRYOTHERAPY OF SKIN
$43.51
17360
3
SKIN PEEL THERAPY
17380
9
HAIR REMOVAL BY ELECTROLYSIS
$0.00
17999
5
SKIN TISSUE PROCEDURE
$0.00
19000
3
DRAINAGE OF BREAST LESION
$103.29
19001
3
DRAIN BREAST LESION ADD-ON
$25.58
19020
3
INCISION OF BREAST LESION
$385.11
19030
3
INJECTION FOR BREAST X-RAY
$158.13
$117.96
Procedure Code Pricing Action Code Description
Maximum Allowable
19100
3
BX BREAST PERCUT W/O IMAGE
$125.74
19101
3
BIOPSY OF BREAST, OPEN
$286.00
19102
3
BX BREAST PERCUT W/IMAGE
$207.18
19103
3
BX BREAST PERCUT W/DEVICE
$186.74
19105
3
CRYOSURG ABLATE FA, EACH
19110
3
NIPPLE EXPLORATION
$398.32
19112
3
EXCISE BREAST DUCT FISTULA
$373.28
19120
3
REMOVAL OF BREAST LESION
$409.92
19125
3
EXCISION, BREAST LESION
$388.13
19126
3
EXCISION, ADDL BREAST LESION
$145.24
19140
O
REMOVAL OF BREAST TISSUE
$0.00
19160
O
PARTIAL MASTECTOMY
$0.00
19162
O
P-MASTECTOMY W/LN REMOVAL
$0.00
19180
O
REMOVAL OF BREAST
$0.00
19182
O
REMOVAL OF BREAST
$0.00
19200
O
REMOVAL OF BREAST
$0.00
19220
O
REMOVAL OF BREAST
$0.00
19240
O
REMOVAL OF BREAST
$0.00
19260
3
REMOVAL OF CHEST WALL LESION
$1,071.36
19271
3
REVISION OF CHEST WALL
$1,459.38
19272
3
EXTENSIVE CHEST WALL SURGERY
$1,615.78
19290
3
PLACE NEEDLE WIRE, BREAST
$64.44
19291
3
PLACE NEEDLE WIRE, BREAST
$66.36
19295
3
PLACE BREAST CLIP, PERCUT
$87.12
19296
3
PLACE PO BREAST CATH FOR RAD
19297
3
PLACE BREAST CATH FOR RAD
19298
3
PLACE BREAST RAD TUBE/CATHS
19300
9
REMOVAL OF BREAST TISSUE
19301
3
PARTICAL MASTECTOMY
$540.06
19302
3
P-MASTECTOMY W/LN REMOVAL
$773.89
19303
3
MAST, SIMPLE, COMPLETE
$834.83
19304
3
MAST, SUBQ
$486.28
19305
3
MAST, RADICAL
$965.49
19306
3
MAST, RAD, URBAN TYPE
$1,012.30
19307
3
MAST, MOD RAD
$1,018.19
$2,032.71
$3,631.74 $84.39 $1,226.63 $0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
19316
3
SUSPENSION OF BREAST
$695.26
19318
3
REDUCTION OF LARGE BREAST
19324
9
ENLARGE BREAST
$0.00
19325
9
ENLARGE BREAST WITH IMPLANT
$0.00
19328
3
REMOVAL OF BREAST IMPLANT
$435.80
19330
3
REMOVAL OF IMPLANT MATERIAL
$559.96
19340
3
IMMEDIATE BREAST PROSTHESIS
$361.79
19342
3
DELAYED BREAST PROSTHESIS
$823.27
19350
3
BREAST RECONSTRUCTION
$756.55
19355
9
CORRECT INVERTED NIPPLE(S)
19357
3
BREAST RECONSTRUCTION
19360
O
BREAST RECONSTRUCTION WITH MUSCLE O
19361
3
BREAST RECONSTR W/LAT FLAP
19362
O
BREAST RECONSTRUCTION WITH TRANSVER
19364
3
BREAST RECONSTRUCTION
$2,528.30
19366
3
BREAST RECONSTRUCTION
$1,245.94
19367
3
BREAST RECONSTRUCTION
$1,637.04
19368
3
BREAST RECONSTRUCTION
$2,027.37
19369
3
BREAST RECONSTRUCTION
$1,847.64
19370
3
SURGERY OF BREAST CAPSULE
$607.27
19371
3
REMOVAL OF BREAST CAPSULE
$700.29
19380
3
REVISE BREAST RECONSTRUCTION
$685.14
19396
3
DESIGN CUSTOM BREAST IMPLANT
$196.38
19499
5
BREAST SURGERY PROCEDURE
20000
3
INCISION OF ABSCESS
$183.40
20005
3
INCISION OF DEEP ABSCESS
$271.71
2000F
9
BLOOD PRESSURE MEASURE
$0.00
2001F
9
WEIGHT RECORD
$0.00
2002F
9
CLIN SIGN VOL OVRLD ASSESS
$0.00
2003F
O
AUSCULTATION HEART PERFORM
$0.00
2004F
9
INITIAL EXAM INVOLVED JOINTS
$0.00
20100
3
EXPLORE WOUND, NECK
$534.18
20101
3
EXPLORE WOUND, CHEST
$352.98
20102
3
EXPLORE WOUND, ABDOMEN
$412.80
20103
3
EXPLORE WOUND, EXTREMITY
$502.01
$1,023.98
$0.00 $1,383.73 $0.00 $1,484.53 $0.00
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
2010F
9
VITAL SIGNS RECORDED
$0.00
2014F
9
MENTAL STATUS ASSESS
$0.00
20150
3
EXCISE EPIPHYSEAL BAR
$870.81
2018F
9
HYDRATION STATUS ASSESS
$0.00
2019F
9
DILATED MACUL EXAM DONE
$0.00
20200
3
MUSCLE BIOPSY
$171.56
20205
3
DEEP MUSCLE BIOPSY
$233.49
20206
3
NEEDLE BIOPSY, MUSCLE
$241.14
2020F
9
DILATED FUNDUS EVAL DONE
$0.00
2021F
9
DILAT MACUL+ EXAM DONE
$0.00
20220
3
BONE BIOPSY, TROCAR/NEEDLE
$164.87
20225
3
BONE BIOPSY, TROCAR/NEEDLE
$112.76
2022F
9
DIL RETINA EXAM INTERP REV
20240
3
BONE BIOPSY, EXCISIONAL
$207.64
20245
3
BONE BIOPSY, EXCISIONAL
$566.98
2024F
9
7 FIELD PHOTO INTERP DOC REV
20250
3
OPEN BONE BIOPSY
$341.19
20251
3
OPEN BONE BIOPSY
$378.40
2026F
9
EYE IMAGE VALID TO DX REV
$0.00
2027F
9
OPTIC NERVE HEAD EVAL DONE
$0.00
2028F
9
FOOT EXAM PERFORMED
$0.00
2029F
9
COMPLETE PHYS SKIN EXAM DONE
$0.00
2030F
9
H2O STAT DOCÏD, NORMAL
$0.00
2031F
9
H2O STAT DOCÏD, DEHYDRATED
$0.00
2035F
9
TYMP MEMB MOTION EXAMÏD
$0.00
2040F
9
BK PN XM ON INIT VISIT DATE
$0.00
2044F
9
DOC MNTL TST B/4 BK TRXMNT
$0.00
20500
3
INJECTION OF SINUS TRACT
20501
3
INJECT SINUS TRACT FOR X-RAY
2050F
9
WOUND CHAR SIZE ETC DOCD
20520
3
REMOVAL OF FOREIGN BODY
$170.20
20525
3
REMOVAL OF FOREIGN BODY
$417.52
20526
3
THER INJECTION, CARP TUNNEL
$68.50
20550
3
INJ TENDON SHEATH/LIGAMENT
$52.99
20551
3
INJ TENDON ORIGIN/INSERTION
$52.38
$0.00
$0.00
$105.96 $38.84 $0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
20552
3
INJ TRIGGER POINT, 1/2 MUSCL
$47.71
20553
3
INJECT TRIGGER POINTS, =/> 3
$53.27
20555
3
PLACE NDL MUSC/TIS FOR RT
$310.86
20600
3
DRAIN/INJECT, JOINT/BURSA
$49.90
20605
3
DRAIN/INJECT, JOINT/BURSA
$53.58
20610
3
DRAIN/INJECT, JOINT/BURSA
$69.32
20612
3
ASPIRATE/INJ GANGLION CYST
$53.29
20615
3
TREATMENT OF BONE CYST
$195.30
20650
3
INSERT AND REMOVE BONE PIN
$177.30
20660
3
APPLY, REM FIXATION DEVICE
$229.54
20661
3
APPLICATION OF HEAD BRACE
$419.88
20662
3
APPLICATION OF PELVIS BRACE
$433.43
20663
3
APPLICATION OF THIGH BRACE
$401.18
20664
3
HALO BRACE APPLICATION
$685.24
20665
3
REMOVAL OF FIXATION DEVICE
$110.12
20670
3
REMOVAL OF SUPPORT IMPLANT
$135.41
20680
3
REMOVAL OF SUPPORT IMPLANT
$373.62
20690
3
APPLY BONE FIXATION DEVICE
$489.61
20692
3
APPLY BONE FIXATION DEVICE
$916.34
20693
3
ADJUST BONE FIXATION DEVICE
$415.39
20694
3
REMOVE BONE FIXATION DEVICE
$380.79
20696
3
COMP MULTIPLANE EXT FIXATION
$981.74
20697
3
COMP EXT FIXATE STRUT CHANGE
$1,223.25
20802
3
REPLANTATION, ARM, COMPLETE
$2,238.62
20804
O
REPLANTATION, ARM (INCLUDES SURGICA
20805
3
REPLANT FOREARM, COMPLETE
20806
O
REPLANTATION, FOREARM (INCLUDES RAD
20808
3
REPLANTATION HAND, COMPLETE
20812
O
REPLANTATION, HAND (INCLUDES HAND T
20816
3
REPLANTATION DIGIT, COMPLETE
20820
O
REPLANTATION, DIGIT, EXCLUDING THUM
20822
3
REPLANTATION DIGIT, COMPLETE
20823
O
REPLANTATION, DIGIT, EXCLUDING THUM
20824
3
REPLANTATION THUMB, COMPLETE
20826
O
REPLANTATION, THUMB (INCLUDES CARPO
$0.00 $2,744.46 $0.00 $3,732.20 $0.00 $2,070.54 $0.00 $1,756.93 $0.00 $2,061.98 $0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
20827
3
REPLANTATION THUMB, COMPLETE
$1,827.39
20828
O
REPLANTATION, THUMB (INCLUDES DISTA
$0.00
20832
O
REPLANTATION, LEG; COMPLETE AMPUTAT
$0.00
20834
O
REPLANTATION, LEG; INCOMPLETE AMPUT
$0.00
20838
3
REPLANTATION FOOT, COMPLETE
20840
O
REPLANTATION, FOOT; INCOMPLETE AMPU
20900
3
REMOVAL OF BONE FOR GRAFT
$381.50
20902
3
REMOVAL OF BONE FOR GRAFT
$333.45
20910
3
REMOVE CARTILAGE FOR GRAFT
$391.13
20912
3
REMOVE CARTILAGE FOR GRAFT
$438.20
20920
3
REMOVAL OF FASCIA FOR GRAFT
$369.22
20922
3
REMOVAL OF FASCIA FOR GRAFT
$548.83
20924
3
REMOVAL OF TENDON FOR GRAFT
$457.10
20926
3
REMOVAL OF TISSUE FOR GRAFT
$394.60
20930
9
SP BONE ALGRFT MORSEL ADD-ON
$0.00
20931
3
SP BONE ALGRFT STRUCT ADD-ON
$103.82
20936
9
SP BONE AGRFT LOCAL ADD-ON
20937
3
SP BONE AGRFT MORSEL ADD-ON
$158.11
20938
3
SP BONE AGRFT STRUCT ADD-ON
$171.69
20950
3
FLUID PRESSURE, MUSCLE
$222.84
20955
3
FIBULA BONE GRAFT, MICROVASC
$2,333.14
20956
3
ILIAC BONE GRAFT, MICROVASC
$2,435.55
20957
3
MT BONE GRAFT, MICROVASC
$2,316.85
20960
O
BONE GRAFT WITH MICROVASCULAR ANAST
20962
3
OTHER BONE GRAFT, MICROVASC
$2,388.58
20969
3
BONE/SKIN GRAFT, MICROVASC
$2,582.88
20970
3
BONE/SKIN GRAFT, ILIAC CREST
$2,596.85
20971
O
FREE OSTEOCUTANEOUS FLAP WITH MICRO
20972
3
BONE/SKIN GRAFT, METATARSAL
$2,362.07
20973
3
BONE/SKIN GRAFT, GREAT TOE
$2,477.55
20974
3
ELECTRICAL BONE STIMULATION
$59.17
20975
3
ELECTRICAL BONE STIMULATION
$163.18
20976
O
ELECTRICAL STIMULATION TO AID BONE
20979
3
US BONE STIMULATION
20982
3
ABLATE, BONE TUMOR(S) PERQ
$2,264.18 $0.00
$0.00
$0.00
$0.00
$0.00 $48.34 $3,475.81
Procedure Code Pricing Action Code Description
Maximum Allowable
20985
3
CPTR-ASST DIR MS PX
$140.03
20986
O
CPTR-ASST DIR MS PX IO IMG
$0.00
20987
O
CPTR-ASST DIR MS PX PRE IMG
$0.00
20999
5
MUSCULOSKELETAL SURGERY
$0.00
21010
3
INCISION OF JAW JOINT
$657.52
21015
3
RESECTION OF FACIAL TUMOR
$385.12
21025
3
EXCISION OF BONE, LOWER JAW
$795.07
21026
3
EXCISION OF FACIAL BONE(S)
$528.08
21029
3
CONTOUR OF FACE BONE LESION
$670.40
21030
3
EXCISE MAX/ZYGOMA B9 TUMOR
$441.41
21031
3
REMOVE EXOSTOSIS, MANDIBLE
$340.58
21032
3
REMOVE EXOSTOSIS, MAXILLA
$345.13
21034
3
EXCISE MAX/ZYGOMA MLG TUMOR
21040
3
EXCISE MANDIBLE LESION
21041
O
REMOVAL OF JAW BONE LESION
$0.00
21044
3
REMOVAL OF JAW BONE LESION
$794.66
21045
3
EXTENSIVE JAW SURGERY
21046
3
REMOVE MANDIBLE CYST COMPLEX
21047
3
EXCISE LWR JAW CYST W/REPAIR
$1,181.86
21048
3
REMOVE MAXILLA CYST COMPLEX
$995.38
21049
3
EXCIS UPPR JAW CYST W/REPAIR
21050
3
REMOVAL OF JAW JOINT
$781.81
21060
3
REMOVE JAW JOINT CARTILAGE
$713.16
21070
3
REMOVE CORONOID PROCESS
$580.41
21073
3
MNPJ OF TMJ W/ANESTH
$328.95
21076
3
PREPARE FACE/ORAL PROSTHESIS
$873.18
21077
3
PREPARE FACE/ORAL PROSTHESIS
$2,150.91
21079
3
PREPARE FACE/ORAL PROSTHESIS
$1,472.63
21080
3
PREPARE FACE/ORAL PROSTHESIS
$1,673.03
21081
3
PREPARE FACE/ORAL PROSTHESIS
$1,527.13
21082
3
PREPARE FACE/ORAL PROSTHESIS
$1,422.47
21083
3
PREPARE FACE/ORAL PROSTHESIS
$1,351.98
21084
3
PREPARE FACE/ORAL PROSTHESIS
$1,539.38
21085
3
PREPARE FACE/ORAL PROSTHESIS
$623.05
21086
3
PREPARE FACE/ORAL PROSTHESIS
$1,569.01
$1,194.92 $445.11
$1,106.86 $983.00
$1,143.60
Procedure Code Pricing Action Code Description
Maximum Allowable
21087
3
PREPARE FACE/ORAL PROSTHESIS
$1,563.28
21088
5
PREPARE FACE/ORAL PROSTHESIS
$0.00
21089
5
PREPARE FACE/ORAL PROSTHESIS
$0.00
21100
3
MAXILLOFACIAL FIXATION
$639.52
21110
3
INTERDENTAL FIXATION
$670.75
21116
3
INJECTION, JAW JOINT X-RAY
$136.12
21120
3
RECONSTRUCTION OF CHIN
$556.86
21121
3
RECONSTRUCTION OF CHIN
$691.58
21122
3
RECONSTRUCTION OF CHIN
$649.07
21123
3
RECONSTRUCTION OF CHIN
$774.62
21125
3
AUGMENTATION, LOWER JAW BONE
$2,753.42
21127
3
AUGMENTATION, LOWER JAW BONE
$3,278.07
21137
3
REDUCTION OF FOREHEAD
$650.58
21138
3
REDUCTION OF FOREHEAD
$812.19
21139
3
REDUCTION OF FOREHEAD
$910.46
21141
3
RECONSTRUCT MIDFACE, LEFORT
$1,222.45
21142
3
RECONSTRUCT MIDFACE, LEFORT
$1,205.28
21143
3
RECONSTRUCT MIDFACE, LEFORT
$1,251.54
21144
O
RECONSTRUCTION MIDFACE, LEFORT I; I
21145
3
RECONSTRUCT MIDFACE, LEFORT
$1,400.33
21146
3
RECONSTRUCT MIDFACE, LEFORT
$1,497.26
21147
3
RECONSTRUCT MIDFACE, LEFORT
$1,540.01
21150
3
RECONSTRUCT MIDFACE, LEFORT
$1,528.63
21151
3
RECONSTRUCT MIDFACE, LEFORT
$1,856.40
21154
3
RECONSTRUCT MIDFACE, LEFORT
$1,869.08
21155
3
RECONSTRUCT MIDFACE, LEFORT
$2,116.84
21159
3
RECONSTRUCT MIDFACE, LEFORT
$2,558.39
21160
3
RECONSTRUCT MIDFACE, LEFORT
$2,628.74
21172
3
RECONSTRUCT ORBIT/FOREHEAD
$1,617.79
21175
3
RECONSTRUCT ORBIT/FOREHEAD
$1,954.61
21179
3
RECONSTRUCT ENTIRE FOREHEAD
$1,340.86
21180
3
RECONSTRUCT ENTIRE FOREHEAD
$1,529.13
21181
3
CONTOUR CRANIAL BONE LESION
21182
3
RECONSTRUCT CRANIAL BONE
$1,856.89
21183
3
RECONSTRUCT CRANIAL BONE
$2,077.91
$0.00
$640.53
Procedure Code Pricing Action Code Description
Maximum Allowable
21184
3
RECONSTRUCT CRANIAL BONE
$2,219.37
21188
3
RECONSTRUCTION OF MIDFACE
$1,480.45
21193
3
RECONST LWR JAW W/O GRAFT
$1,126.43
21194
3
RECONST LWR JAW W/GRAFT
$1,286.04
21195
3
RECONST LWR JAW W/O FIXATION
$1,212.70
21196
3
RECONST LWR JAW W/FIXATION
$1,321.37
21198
3
RECONSTR LWR JAW SEGMENT
$1,041.31
21199
3
RECONSTR LWR JAW W/ADVANCE
21200
O
OSTEOTOMY (EG, FOR PROGNATHISM, MIC
$0.00
21202
O
OSTEOTOMY (EG, FOR PROGNATHISM, MIC
$0.00
21203
O
OSTEOTOMY (EG, FOR PROGNATHISM, MIC
$0.00
21204
O
OSTEOTOMY (EG, FOR PROGNATHISM, MIC
$0.00
21206
3
RECONSTRUCT UPPER JAW BONE
$1,025.51
21208
3
AUGMENTATION OF FACIAL BONES
$1,553.28
21209
3
REDUCTION OF FACIAL BONES
21210
3
FACE BONE GRAFT
21215
3
LOWER JAW BONE GRAFT
$776.10
21230
3
RIB CARTILAGE GRAFT
$693.44
21235
3
EAR CARTILAGE GRAFT
$648.51
21240
3
RECONSTRUCTION OF JAW JOINT
$1,003.06
21242
3
RECONSTRUCTION OF JAW JOINT
$919.51
21243
3
RECONSTRUCTION OF JAW JOINT
$1,508.01
21244
3
RECONSTRUCTION OF LOWER JAW
21245
3
RECONSTRUCTION OF JAW
$1,021.52
21246
3
RECONSTRUCTION OF JAW
$771.86
21247
3
RECONSTRUCT LOWER JAW BONE
21248
3
RECONSTRUCTION OF JAW
$959.96
21249
3
RECONSTRUCTION OF JAW
$1,328.84
21250
O
OSTEOPLASTY OF MAXILLA AND/OR OTHER
$0.00
21254
O
OSTEOPLASTY OF MAXILLA AND/OR OTHER
$0.00
21255
3
RECONSTRUCT LOWER JAW BONE
$1,305.54
21256
3
RECONSTRUCTION OF ORBIT
$1,058.83
21260
3
REVISE EYE SOCKETS
$1,199.53
21261
3
REVISE EYE SOCKETS
$2,040.55
21263
3
REVISE EYE SOCKETS
$1,835.87
$935.18
$731.65 $1,863.02
$944.00
$1,465.39
Procedure Code Pricing Action Code Description
Maximum Allowable
21267
3
REVISE EYE SOCKETS
$1,400.25
21268
3
REVISE EYE SOCKETS
$1,734.18
21270
3
AUGMENTATION, CHEEK BONE
$815.75
21275
3
REVISION, ORBITOFACIAL BONES
$728.93
21280
3
REVISION OF EYELID
$472.14
21282
3
REVISION OF EYELID
$313.18
21295
3
REVISION OF JAW MUSCLE/BONE
$157.23
21296
3
REVISION OF JAW MUSCLE/BONE
$381.69
21299
5
CRANIO/MAXILLOFACIAL SURGERY
$0.00
21300
O
TREATMENT OF SKULL FRACTURE
$0.00
21310
3
TREATMENT OF NOSE FRACTURE
$95.86
21315
3
TREATMENT OF NOSE FRACTURE
$233.70
21320
3
TREATMENT OF NOSE FRACTURE
$224.58
21325
3
TREATMENT OF NOSE FRACTURE
$422.39
21330
3
TREATMENT OF NOSE FRACTURE
$516.60
21335
3
TREATMENT OF NOSE FRACTURE
$664.06
21336
3
TREAT NASAL SEPTAL FRACTURE
$576.27
21337
3
TREAT NASAL SEPTAL FRACTURE
$348.72
21338
3
TREAT NASOETHMOID FRACTURE
$661.61
21339
3
TREAT NASOETHMOID FRACTURE
$735.41
21340
3
TREATMENT OF NOSE FRACTURE
$727.08
21343
3
TREATMENT OF SINUS FRACTURE
$1,037.07
21344
3
TREATMENT OF SINUS FRACTURE
$1,355.99
21345
3
TREAT NOSE/JAW FRACTURE
$718.70
21346
3
TREAT NOSE/JAW FRACTURE
$859.82
21347
3
TREAT NOSE/JAW FRACTURE
$996.21
21348
3
TREAT NOSE/JAW FRACTURE
$1,048.98
21355
3
TREAT CHEEK BONE FRACTURE
$390.63
21356
3
TREAT CHEEK BONE FRACTURE
$437.78
21360
3
TREAT CHEEK BONE FRACTURE
$476.35
21365
3
TREAT CHEEK BONE FRACTURE
$994.49
21366
3
TREAT CHEEK BONE FRACTURE
$1,104.46
21385
3
TREAT EYE SOCKET FRACTURE
$643.01
21386
3
TREAT EYE SOCKET FRACTURE
$598.64
21387
3
TREAT EYE SOCKET FRACTURE
$670.49
Procedure Code Pricing Action Code Description
Maximum Allowable
21390
3
TREAT EYE SOCKET FRACTURE
$692.58
21395
3
TREAT EYE SOCKET FRACTURE
$871.94
21400
3
TREAT EYE SOCKET FRACTURE
$157.83
21401
3
TREAT EYE SOCKET FRACTURE
$421.35
21406
3
TREAT EYE SOCKET FRACTURE
$485.75
21407
3
TREAT EYE SOCKET FRACTURE
$574.57
21408
3
TREAT EYE SOCKET FRACTURE
$789.31
21421
3
TREAT MOUTH ROOF FRACTURE
$650.29
21422
3
TREAT MOUTH ROOF FRACTURE
$603.12
21423
3
TREAT MOUTH ROOF FRACTURE
$715.57
21431
3
TREAT CRANIOFACIAL FRACTURE
$662.70
21432
3
TREAT CRANIOFACIAL FRACTURE
$601.22
21433
3
TREAT CRANIOFACIAL FRACTURE
$1,536.31
21435
3
TREAT CRANIOFACIAL FRACTURE
$1,213.02
21436
3
TREAT CRANIOFACIAL FRACTURE
$1,783.68
21440
3
TREAT DENTAL RIDGE FRACTURE
$474.58
21445
3
TREAT DENTAL RIDGE FRACTURE
$671.15
21450
3
TREAT LOWER JAW FRACTURE
$494.13
21451
3
TREAT LOWER JAW FRACTURE
$650.91
21452
3
TREAT LOWER JAW FRACTURE
$539.35
21453
3
TREAT LOWER JAW FRACTURE
$753.31
21454
3
TREAT LOWER JAW FRACTURE
$496.59
21455
O
CLOSED MANIPULATIVE TREATMENT BY IN
21461
3
TREAT LOWER JAW FRACTURE
$823.04
21462
3
TREAT LOWER JAW FRACTURE
$1,853.84
21465
3
TREAT LOWER JAW FRACTURE
$821.18
21470
3
TREAT LOWER JAW FRACTURE
$1,070.69
21480
3
RESET DISLOCATED JAW
$81.28
21485
3
RESET DISLOCATED JAW
$582.57
21490
3
REPAIR DISLOCATED JAW
$832.65
21493
O
TREAT HYOID BONE FRACTURE
$0.00
21494
O
TREAT HYOID BONE FRACTURE
$0.00
21495
3
TREAT HYOID BONE FRACTURE
$612.21
21497
3
INTERDENTAL WIRING
$588.77
21499
5
HEAD SURGERY PROCEDURE
$0.00
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
21501
3
DRAIN NECK/CHEST LESION
$388.90
21502
3
DRAIN CHEST LESION
$469.91
21510
3
DRAINAGE OF BONE LESION
$416.51
21550
3
BIOPSY OF NECK/CHEST
$229.01
21555
3
REMOVE LESION, NECK/CHEST
$382.49
21556
3
REMOVE LESION, NECK/CHEST
$371.30
21557
3
REMOVE TUMOR, NECK/CHEST
$523.58
21600
3
PARTIAL REMOVAL OF RIB
$497.73
21610
3
PARTIAL REMOVAL OF RIB
$963.44
21615
3
REMOVAL OF RIB
$608.35
21616
3
REMOVAL OF RIB AND NERVES
$777.96
21620
3
PARTIAL REMOVAL OF STERNUM
$472.33
21627
3
STERNAL DEBRIDEMENT
$496.93
21630
3
EXTENSIVE STERNUM SURGERY
$1,152.12
21632
3
EXTENSIVE STERNUM SURGERY
$1,138.03
21633
O
RADICAL RESECTION OF STERNUM; FOR O
21685
3
HYOID MYOTOMY & SUSPENSION
$899.84
21700
3
REVISION OF NECK MUSCLE
$382.61
21705
3
REVISION OF NECK MUSCLE/RIB
$586.66
21720
3
REVISION OF NECK MUSCLE
$369.28
21725
3
REVISION OF NECK MUSCLE
$480.13
21740
3
RECONSTRUCTION OF STERNUM
$989.78
21742
5
REPAIR STERN/NUSS W/O SCOPE
$0.00
21743
5
REPAIR STERNUM/NUSS W/SCOPE
$0.00
21750
3
REPAIR OF STERNUM SEPARATION
21800
3
TREATMENT OF RIB FRACTURE
$86.72
21805
3
TREATMENT OF RIB FRACTURE
$231.91
21810
3
TREATMENT OF RIB FRACTURE(S)
$450.97
21820
3
TREAT STERNUM FRACTURE
$115.72
21825
3
TREAT STERNUM FRACTURE
$512.55
21899
5
NECK/CHEST SURGERY PROCEDURE
21920
3
BIOPSY SOFT TISSUE OF BACK
$228.53
21925
3
BIOPSY SOFT TISSUE OF BACK
$373.66
21930
3
REMOVE LESION, BACK OR FLANK
$416.98
21935
3
REMOVE TUMOR, BACK
$0.00
$656.85
$0.00
$1,049.71
Procedure Code Pricing Action Code Description
Maximum Allowable
22010
3
I&D, P-SPINE, C/T/CERV-THOR
$812.16
22015
3
I&D, P-SPINE, L/S/LS
$807.75
22100
3
REMOVE PART OF NECK VERTEBRA
$734.09
22101
3
REMOVE PART, THORAX VERTEBRA
$732.18
22102
3
REMOVE PART, LUMBAR VERTEBRA
$729.24
22103
3
REMOVE EXTRA SPINE SEGMENT
$132.24
22105
O
PARTIAL RESECTION OF VERTEBRAL COMP
$0.00
22106
O
PARTIAL RESECTION OF VERTEBRAL COMP
$0.00
22107
O
PARTIAL RESECTION OF VERTEBRAL COMP
$0.00
22110
3
REMOVE PART OF NECK VERTEBRA
$911.11
22112
3
REMOVE PART, THORAX VERTEBRA
$881.24
22114
3
REMOVE PART, LUMBAR VERTEBRA
$904.94
22116
3
REMOVE EXTRA SPINE SEGMENT
$131.49
22140
O
RECONSTRUCTION OF SPINE WITH BONE G
$0.00
22141
O
RECONSTRUCTION OF SPINE WITH BONE G
$0.00
22142
O
RECONSTRUCTION OF SPINE WITH BONE G
$0.00
22145
O
RECONSTRUCTION OF SPINE FOLLOWING V
$0.00
22148
O
HARVESTING OF BONE AUTOGRAFT FOR VE
$0.00
22150
O
RECONSTRUCTION OF SPINE WITH PREFAB
$0.00
22151
O
RECONSTRUCTION OF SPINE WITH PREFAB
$0.00
22152
O
RECONSTRUCTION OF SPINE WITH PREFAB
$0.00
22206
3
CUT SPINE 3 COL, THOR
$2,160.60
22207
3
CUT SPINE 3 COL, LUMB
$2,132.62
22208
3
CUT SPINE 3 COL, ADDL SEG
22210
3
REVISION OF NECK SPINE
$1,590.80
22212
3
REVISION OF THORAX SPINE
$1,316.56
22214
3
REVISION OF LUMBAR SPINE
$1,324.89
22216
3
REVISE, EXTRA SPINE SEGMENT
22220
3
REVISION OF NECK SPINE
$1,432.03
22222
3
REVISION OF THORAX SPINE
$1,302.22
22224
3
REVISION OF LUMBAR SPINE
$1,417.53
22226
3
REVISE, EXTRA SPINE SEGMENT
22230
O
OSTEOTOMY OF SPINE, ANY APPROACH, E
22305
3
TREAT SPINE PROCESS FRACTURE
$165.01
22310
3
TREAT SPINE FRACTURE
$254.39
$542.31
$344.73
$343.25 $0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
22315
3
TREAT SPINE FRACTURE
$760.65
22318
3
TREAT ODONTOID FX W/O GRAFT
$1,430.46
22319
3
TREAT ODONTOID FX W/GRAFT
$1,570.90
22325
3
TREAT SPINE FRACTURE
$1,254.01
22326
3
TREAT NECK SPINE FRACTURE
$1,306.22
22327
3
TREAT THORAX SPINE FRACTURE
$1,296.57
22328
3
TREAT EACH ADD SPINE FX
$259.74
22505
3
MANIPULATION OF SPINE
$110.95
22520
3
PERCUT VERTEBROPLASTY THOR
$2,110.61
22521
3
PERCUT VERTEBROPLASTY LUMB
$2,056.31
22522
3
PERCUT VERTEBROPLASTY ADDÏL
$235.05
22523
3
PERCUT KYPHOPLASTY, THOR
$560.36
22524
3
PERCUT KYPHOPLASTY, LUMBAR
$536.90
22525
3
PERCUT KYPHOPLASTY, ADD-ON
$250.37
22526
9
IDET, SINGLE LEVEL
$0.00
22527
9
IDET, 1 OR MORE LEVELS
$0.00
22532
3
LAT THORAX SPINE FUSION
$1,559.30
22533
3
LAT LUMBAR SPINE FUSION
$1,469.78
22534
3
LAT THOR/LUMB, ADDÏL SEG
$340.13
22548
3
NECK SPINE FUSION
$1,660.29
22554
3
NECK SPINE FUSION
$1,149.95
22556
3
THORAX SPINE FUSION
$1,487.35
22558
3
LUMBAR SPINE FUSION
$1,366.37
22585
3
ADDITIONAL SPINAL FUSION
22590
3
SPINE & SKULL SPINAL FUSION
$1,380.62
22595
3
NECK SPINAL FUSION
$1,311.16
22600
3
NECK SPINE FUSION
$1,124.75
22610
3
THORAX SPINE FUSION
$1,110.11
22612
3
LUMBAR SPINE FUSION
$1,435.03
22614
3
SPINE FUSION, EXTRA SEGMENT
22625
O
ARTHRODESIS, LATERAL TRANSVERSE PRO
22630
3
LUMBAR SPINE FUSION
22632
3
SPINE FUSION, EXTRA SEGMENT
22650
O
ARTHRODESIS, POSTERIOR, POSTEROLATE
22800
3
FUSION OF SPINE
$314.09
$366.73 $0.00 $1,380.63 $297.88 $0.00 $1,220.47
Procedure Code Pricing Action Code Description
Maximum Allowable
22802
3
FUSION OF SPINE
$1,938.09
22804
3
FUSION OF SPINE
$2,238.20
22808
3
FUSION OF SPINE
$1,648.98
22810
3
FUSION OF SPINE
$1,837.86
22812
3
FUSION OF SPINE
$2,012.25
22818
3
KYPHECTOMY, 1-2 SEGMENTS
$2,027.13
22819
3
KYPHECTOMY, 3 OR MORE
$2,335.49
22820
O
HARVESTING OF BONE AUTOGRAFT THROUG
22830
3
EXPLORATION OF SPINAL FUSION
$728.28
22840
3
INSERT SPINE FIXATION DEVICE
$715.74
22841
9
INSERT SPINE FIXATION DEVICE
$0.00
22842
3
INSERT SPINE FIXATION DEVICE
$717.32
22843
3
INSERT SPINE FIXATION DEVICE
$763.61
22844
3
INSERT SPINE FIXATION DEVICE
$936.05
22845
3
INSERT SPINE FIXATION DEVICE
$684.49
22846
3
INSERT SPINE FIXATION DEVICE
$710.73
22847
3
INSERT SPINE FIXATION DEVICE
$784.28
22848
3
INSERT PELV FIXATION DEVICE
$341.06
22849
3
REINSERT SPINAL FIXATION
22850
3
REMOVE SPINE FIXATION DEVICE
$644.52
22851
3
APPLY SPINE PROSTH DEVICE
$381.60
22852
3
REMOVE SPINE FIXATION DEVICE
$616.33
22855
3
REMOVE SPINE FIXATION DEVICE
$998.74
22856
3
CERV ARTIFIC DISKECTOMY
$1,492.64
22857
3
LUMBAR ARTIF DISKECTOMY
$1,556.36
22861
3
REVISE CERV ARTIFIC DISC
$1,818.88
22862
3
REVISE LUMBAR ARTIF DISC
$1,794.55
22864
3
REMOVE CERV ARTIF DISC
$1,665.72
22865
3
REMOVE LUMB ARTIF DISC
$1,925.16
22899
5
SPINE SURGERY PROCEDURE
22900
3
REMOVE ABDOMINAL WALL LESION
22999
5
ABDOMEN SURGERY PROCEDURE
$0.00
23000
3
REMOVAL OF CALCIUM DEPOSITS
$472.62
23020
3
RELEASE SHOULDER JOINT
$622.19
23030
3
DRAIN SHOULDER LESION
$377.27
$0.00
$1,178.99
$0.00 $367.75
Procedure Code Pricing Action Code Description
Maximum Allowable
23031
3
DRAIN SHOULDER BURSA
$345.16
23035
3
DRAIN SHOULDER BONE LESION
$617.43
23040
3
EXPLORATORY SHOULDER SURGERY
$647.92
23044
3
EXPLORATORY SHOULDER SURGERY
$514.03
23065
3
BIOPSY SHOULDER TISSUES
$190.52
23066
3
BIOPSY SHOULDER TISSUES
$449.48
23075
3
REMOVAL OF SHOULDER LESION
$229.95
23076
3
REMOVAL OF SHOULDER LESION
$505.48
23077
3
REMOVE TUMOR OF SHOULDER
23100
3
BIOPSY OF SHOULDER JOINT
$437.75
23101
3
SHOULDER JOINT SURGERY
$402.39
23105
3
REMOVE SHOULDER JOINT LINING
$573.07
23106
3
INCISION OF COLLARBONE JOINT
$427.03
23107
3
EXPLORE TREAT SHOULDER JOINT
$595.35
23120
3
PARTIAL REMOVAL, COLLAR BONE
$515.58
23125
3
REMOVAL OF COLLAR BONE
$633.00
23130
3
REMOVE SHOULDER BONE, PART
$542.26
23140
3
REMOVAL OF BONE LESION
$460.86
23145
3
REMOVAL OF BONE LESION
$621.68
23146
3
REMOVAL OF BONE LESION
$540.10
23150
3
REMOVAL OF HUMERUS LESION
$588.26
23155
3
REMOVAL OF HUMERUS LESION
$712.60
23156
3
REMOVAL OF HUMERUS LESION
$605.64
23170
3
REMOVE COLLAR BONE LESION
$475.76
23172
3
REMOVE SHOULDER BLADE LESION
$488.16
23174
3
REMOVE HUMERUS LESION
$677.62
23180
3
REMOVE COLLAR BONE LESION
$616.93
23182
3
REMOVE SHOULDER BLADE LESION
$595.41
23184
3
REMOVE HUMERUS LESION
$671.76
23190
3
PARTIAL REMOVAL OF SCAPULA
$499.93
23195
3
REMOVAL OF HEAD OF HUMERUS
$677.90
23200
3
REMOVAL OF COLLAR BONE
$799.05
23210
3
REMOVAL OF SHOULDER BLADE
$836.12
23220
3
PARTIAL REMOVAL OF HUMERUS
$968.28
23221
3
PARTIAL REMOVAL OF HUMERUS
$1,129.37
$1,070.75
Procedure Code Pricing Action Code Description
Maximum Allowable
23222
3
PARTIAL REMOVAL OF HUMERUS
$1,537.23
23330
3
REMOVE SHOULDER FOREIGN BODY
$199.02
23331
3
REMOVE SHOULDER FOREIGN BODY
$528.01
23332
3
REMOVE SHOULDER FOREIGN BODY
$800.67
23350
3
INJECTION FOR SHOULDER X-RAY
$144.76
23395
3
MUSCLE TRANSFER,SHOULDER/ARM
$1,165.84
23397
3
MUSCLE TRANSFERS
$1,043.69
23400
3
FIXATION OF SHOULDER BLADE
$885.15
23405
3
INCISION OF TENDON & MUSCLE
$569.64
23406
3
INCISE TENDON(S) & MUSCLE(S)
$711.47
23410
3
REPAIR ROTATOR CUFF, ACUTE
$755.35
23412
3
REPAIR ROTATOR CUFF, CHRONIC
$789.33
23415
3
RELEASE OF SHOULDER LIGAMENT
$629.41
23420
3
REPAIR OF SHOULDER
$884.62
23430
3
REPAIR BICEPS TENDON
$669.60
23440
3
REMOVE/TRANSPLANT TENDON
$690.39
23450
3
REPAIR SHOULDER CAPSULE
$865.71
23455
3
REPAIR SHOULDER CAPSULE
$923.31
23460
3
REPAIR SHOULDER CAPSULE
$999.55
23462
3
REPAIR SHOULDER CAPSULE
$980.23
23465
3
REPAIR SHOULDER CAPSULE
$1,022.80
23466
3
REPAIR SHOULDER CAPSULE
$1,008.97
23470
3
RECONSTRUCT SHOULDER JOINT
$1,112.61
23472
3
RECONSTRUCT SHOULDER JOINT
$1,377.07
23480
3
REVISION OF COLLAR BONE
$744.30
23485
3
REVISION OF COLLAR BONE
$879.00
23490
3
REINFORCE CLAVICLE
$759.38
23491
3
REINFORCE SHOULDER BONES
$925.73
23500
3
TREAT CLAVICLE FRACTURE
$182.75
23505
3
TREAT CLAVICLE FRACTURE
$300.96
23510
O
TREATMENT OF OPEN CLAVICULAR FRACTU
23515
3
TREAT CLAVICLE FRACTURE
$632.24
23520
3
TREAT CLAVICLE DISLOCATION
$189.53
23525
3
TREAT CLAVICLE DISLOCATION
$294.49
23530
3
TREAT CLAVICLE DISLOCATION
$483.99
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
23532
3
TREAT CLAVICLE DISLOCATION
$557.68
23540
3
TREAT CLAVICLE DISLOCATION
$187.14
23545
3
TREAT CLAVICLE DISLOCATION
$270.47
23550
3
TREAT CLAVICLE DISLOCATION
$514.26
23552
3
TREAT CLAVICLE DISLOCATION
$592.11
23570
3
TREAT SHOULDER BLADE FX
$195.47
23575
3
TREAT SHOULDER BLADE FX
$333.65
23580
O
TREATMENT OF OPEN SCAPULAR FRACTURE
23585
3
TREAT SCAPULA FRACTURE
$856.16
23600
3
TREAT HUMERUS FRACTURE
$273.62
23605
3
TREAT HUMERUS FRACTURE
$403.69
23610
O
TREATMENT OF OPEN HUMERAL (SURGICAL
23615
3
TREAT HUMERUS FRACTURE
$785.07
23616
3
TREAT HUMERUS FRACTURE
$1,171.97
23620
3
TREAT HUMERUS FRACTURE
$225.41
23625
3
TREAT HUMERUS FRACTURE
$327.22
23630
3
TREAT HUMERUS FRACTURE
$674.19
23650
3
TREAT SHOULDER DISLOCATION
$253.97
23655
3
TREAT SHOULDER DISLOCATION
$337.62
23658
O
TREATMENT OF OPEN SHOULDER DISLOCAT
23660
3
TREAT SHOULDER DISLOCATION
$521.42
23665
3
TREAT DISLOCATION/FRACTURE
$364.10
23670
3
TREAT DISLOCATION/FRACTURE
$756.65
23675
3
TREAT DISLOCATION/FRACTURE
$475.44
23680
3
TREAT DISLOCATION/FRACTURE
$819.51
23700
3
FIXATION OF SHOULDER
$175.25
23800
3
FUSION OF SHOULDER JOINT
$931.36
23802
3
FUSION OF SHOULDER JOINT
$1,130.53
23900
3
AMPUTATION OF ARM & GIRDLE
$1,204.87
23920
3
AMPUTATION AT SHOULDER JOINT
$976.95
23921
3
AMPUTATION FOLLOW-UP SURGERY
$354.10
23929
5
SHOULDER SURGERY PROCEDURE
23930
3
DRAINAGE OF ARM LESION
$313.13
23931
3
DRAINAGE OF ARM BURSA
$245.16
23935
3
DRAIN ARM/ELBOW BONE LESION
$444.79
$0.00
$0.00
$0.00
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
24000
3
EXPLORATORY ELBOW SURGERY
$422.89
24006
3
RELEASE ELBOW JOINT
$639.62
24065
3
BIOPSY ARM/ELBOW SOFT TISSUE
$223.68
24066
3
BIOPSY ARM/ELBOW SOFT TISSUE
$518.43
24075
3
REMOVE ARM/ELBOW LESION
$420.75
24076
3
REMOVE ARM/ELBOW LESION
$424.54
24077
3
REMOVE TUMOR OF ARM/ELBOW
$733.56
24100
3
BIOPSY ELBOW JOINT LINING
$361.00
24101
3
EXPLORE/TREAT ELBOW JOINT
$444.78
24102
3
REMOVE ELBOW JOINT LINING
$551.58
24105
3
REMOVAL OF ELBOW BURSA
$299.19
24110
3
REMOVE HUMERUS LESION
$522.04
24115
3
REMOVE/GRAFT BONE LESION
$658.62
24116
3
REMOVE/GRAFT BONE LESION
$781.94
24120
3
REMOVE ELBOW LESION
$467.26
24125
3
REMOVE/GRAFT BONE LESION
$539.74
24126
3
REMOVE/GRAFT BONE LESION
$572.96
24130
3
REMOVAL OF HEAD OF RADIUS
$451.53
24134
3
REMOVAL OF ARM BONE LESION
$678.24
24136
3
REMOVE RADIUS BONE LESION
$535.61
24138
3
REMOVE ELBOW BONE LESION
$593.38
24140
3
PARTIAL REMOVAL OF ARM BONE
$646.38
24145
3
PARTIAL REMOVAL OF RADIUS
$542.10
24147
3
PARTIAL REMOVAL OF ELBOW
$563.64
24149
3
RADICAL RESECTION OF ELBOW
$1,041.12
24150
3
EXTENSIVE HUMERUS SURGERY
$881.83
24151
3
EXTENSIVE HUMERUS SURGERY
$1,013.28
24152
3
EXTENSIVE RADIUS SURGERY
$663.14
24153
3
EXTENSIVE RADIUS SURGERY
$709.37
24155
3
REMOVAL OF ELBOW JOINT
$767.54
24160
3
REMOVE ELBOW JOINT IMPLANT
$543.06
24164
3
REMOVE RADIUS HEAD IMPLANT
$443.85
24200
3
REMOVAL OF ARM FOREIGN BODY
$174.14
24201
3
REMOVAL OF ARM FOREIGN BODY
$487.00
24220
3
INJECTION FOR ELBOW X-RAY
$158.53
Procedure Code Pricing Action Code Description
Maximum Allowable
24300
3
MANIPULATE ELBOW W/ANESTH
$348.71
24301
3
MUSCLE/TENDON TRANSFER
$679.26
24305
3
ARM TENDON LENGTHENING
$518.86
24310
3
REVISION OF ARM TENDON
$424.82
24320
3
REPAIR OF ARM TENDON
$699.44
24330
3
REVISION OF ARM MUSCLES
$645.64
24331
3
REVISION OF ARM MUSCLES
$713.96
24332
3
TENOLYSIS, TRICEPS
$541.53
24340
3
REPAIR OF BICEPS TENDON
$550.69
24341
3
REPAIR ARM TENDON/MUSCLE
$648.56
24342
3
REPAIR OF RUPTURED TENDON
$709.71
24343
3
REPR ELBOW LAT LIGMNT W/TISS
$630.22
24344
3
RECONSTRUCT ELBOW LAT LIGMNT
$982.15
24345
3
REPR ELBW MED LIGMNT W/TISSU
$626.01
24346
3
RECONSTRUCT ELBOW MED LIGMNT
$984.39
24350
O
REPAIR OF TENNIS ELBOW
$0.00
24351
O
REPAIR OF TENNIS ELBOW
$0.00
24352
O
REPAIR OF TENNIS ELBOW
$0.00
24354
O
REPAIR OF TENNIS ELBOW
$0.00
24356
O
REVISION OF TENNIS ELBOW
$0.00
24357
3
REPAIR ELBOW, PERC
$395.07
24358
3
REPAIR ELBOW W/DEB, OPEN
$466.01
24359
3
REPAIR ELBOW DEB/ATTCH OPEN
$585.90
24360
3
RECONSTRUCT ELBOW JOINT
$815.80
24361
3
RECONSTRUCT ELBOW JOINT
$914.74
24362
3
RECONSTRUCT ELBOW JOINT
$967.31
24363
3
REPLACE ELBOW JOINT
24365
3
RECONSTRUCT HEAD OF RADIUS
$575.99
24366
3
RECONSTRUCT HEAD OF RADIUS
$616.89
24400
3
REVISION OF HUMERUS
$744.84
24410
3
REVISION OF HUMERUS
$950.96
24420
3
REVISION OF HUMERUS
$893.92
24430
3
REPAIR OF HUMERUS
$948.48
24435
3
REPAIR HUMERUS WITH GRAFT
$963.27
24470
3
REVISION OF ELBOW JOINT
$566.94
$1,355.58
Procedure Code Pricing Action Code Description
Maximum Allowable
24495
3
DECOMPRESSION OF FOREARM
$591.80
24498
3
REINFORCE HUMERUS
$791.00
24500
3
TREAT HUMERUS FRACTURE
$297.76
24505
3
TREAT HUMERUS FRACTURE
$432.24
24506
O
TREATMENT OF CLOSED HUMERAL SHAFT F
$0.00
24510
O
TREATMENT OF OPEN HUMERAL SHAFT FRA
$0.00
24515
3
TREAT HUMERUS FRACTURE
$793.22
24516
3
TREAT HUMERUS FRACTURE
$784.23
24530
3
TREAT HUMERUS FRACTURE
$320.54
24531
O
TREATMENT OF CLOSED HUMERAL SUPRACO
24535
3
TREAT HUMERUS FRACTURE
24536
O
TREATMENT OF CLOSED HUMERAL SUPRACO
24538
3
TREAT HUMERUS FRACTURE
24540
O
TREATMENT OF OPEN HUMERAL SUPRACOND
$0.00
24542
O
TREATMENT OF OPEN HUMERAL SUPRACOND
$0.00
24545
3
TREAT HUMERUS FRACTURE
$824.51
24546
3
TREAT HUMERUS FRACTURE
$958.78
24560
3
TREAT HUMERUS FRACTURE
$267.64
24565
3
TREAT HUMERUS FRACTURE
$444.55
24566
3
TREAT HUMERUS FRACTURE
$627.26
24570
O
TREATMENT OF OPEN HUMERAL EPICONDYL
24575
3
TREAT HUMERUS FRACTURE
$664.49
24576
3
TREAT HUMERUS FRACTURE
$281.71
24577
3
TREAT HUMERUS FRACTURE
$462.48
24578
O
TREATMENT OF OPEN HUMERAL CONDYLAR
24579
3
TREAT HUMERUS FRACTURE
24580
O
TREATMENT OF CLOSED COMMINUTED ELBO
$0.00
24581
O
TREATMENT OF CLOSED COMMINUTED ELBO
$0.00
24582
3
TREAT HUMERUS FRACTURE
24583
O
TREATMENT OF OPEN COMMINUTED ELBOW
$0.00
24585
O
OPEN TREATMENT OF CLOSED OR OPEN CO
$0.00
24586
3
TREAT ELBOW FRACTURE
$996.53
24587
3
TREAT ELBOW FRACTURE
$992.17
24588
O
OPEN TREATMENT OF CLOSED OR OPEN CO
24600
3
TREAT ELBOW DISLOCATION
$0.00 $540.59 $0.00 $669.58
$0.00
$0.00 $754.54
$699.81
$0.00 $313.18
Procedure Code Pricing Action Code Description
Maximum Allowable
24605
3
TREAT ELBOW DISLOCATION
$406.05
24610
O
TREATMENT OF OPEN ELBOW DISLOCATION
24615
3
TREAT ELBOW DISLOCATION
$645.96
24620
3
TREAT ELBOW FRACTURE
$490.13
24625
O
TREATMENT OF OPEN MONTEGGIA TYPE OF
24635
3
TREAT ELBOW FRACTURE
$680.84
24640
3
TREAT ELBOW DISLOCATION
$103.77
24650
3
TREAT RADIUS FRACTURE
$217.48
24655
3
TREAT RADIUS FRACTURE
$375.03
24660
O
TREATMENT OF OPEN RADIAL HEAD OR NE
24665
3
TREAT RADIUS FRACTURE
$581.88
24666
3
TREAT RADIUS FRACTURE
$660.46
24670
3
TREAT ULNAR FRACTURE
$244.33
24675
3
TREAT ULNAR FRACTURE
$396.14
24680
O
TREATMENT OF OPEN ULNAR FRACTURE, P
24685
3
TREAT ULNAR FRACTURE
$584.53
24800
3
FUSION OF ELBOW JOINT
$716.11
24802
3
FUSION/GRAFT OF ELBOW JOINT
$907.58
24900
3
AMPUTATION OF UPPER ARM
$647.21
24920
3
AMPUTATION OF UPPER ARM
$642.87
24925
3
AMPUTATION FOLLOW-UP SURGERY
$499.79
24930
3
AMPUTATION FOLLOW-UP SURGERY
$681.76
24931
3
AMPUTATE UPPER ARM & IMPLANT
$759.97
24935
3
REVISION OF AMPUTATION
$922.12
24940
5
REVISION OF UPPER ARM
$0.00
24999
5
UPPER ARM/ELBOW SURGERY
$0.00
25000
3
INCISION OF TENDON SHEATH
$311.35
25001
3
INCISE FLEXOR CARPI RADIALIS
$294.05
25005
O
TENDON SHEATH INCISION; AT WRIST FO
25020
3
DECOMPRESS FOREARM 1 SPACE
$515.49
25023
3
DECOMPRESS FOREARM 1 SPACE
$988.76
25024
3
DECOMPRESS FOREARM 2 SPACES
$689.74
25025
3
DECOMPRESS FOREARM 2 SPACES
$1,061.87
25028
3
DRAINAGE OF FOREARM LESION
$459.10
25031
3
DRAINAGE OF FOREARM BURSA
$337.12
$0.00
$0.00
$0.00
$0.00
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
25035
3
TREAT FOREARM BONE LESION
$582.72
25040
3
EXPLORE/TREAT WRIST JOINT
$514.18
25065
3
BIOPSY FOREARM SOFT TISSUES
$222.20
25066
3
BIOPSY FOREARM SOFT TISSUES
$337.73
25075
3
REMOVAL FOREARM LESION SUBCU
$295.40
25076
3
REMOVAL FOREARM LESION DEEP
$399.41
25077
3
REMOVE TUMOR, FOREARM/WRIST
$674.69
25085
3
INCISION OF WRIST CAPSULE
$415.01
25100
3
BIOPSY OF WRIST JOINT
$308.36
25101
3
EXPLORE/TREAT WRIST JOINT
$363.34
25105
3
REMOVE WRIST JOINT LINING
$441.38
25107
3
REMOVE WRIST JOINT CARTILAGE
$548.68
25109
3
EXCISE TENDON FOREARM/WRIST
$467.85
25110
3
REMOVE WRIST TENDON LESION
$323.48
25111
3
REMOVE WRIST TENDON LESION
$280.55
25112
3
REREMOVE WRIST TENDON LESION
$342.37
25115
3
REMOVE WRIST/FOREARM LESION
$723.46
25116
3
REMOVE WRIST/FOREARM LESION
$586.09
25118
3
EXCISE WRIST TENDON SHEATH
$343.57
25119
3
PARTIAL REMOVAL OF ULNA
$454.68
25120
3
REMOVAL OF FOREARM LESION
$500.30
25125
3
REMOVE/GRAFT FOREARM LESION
$581.72
25126
3
REMOVE/GRAFT FOREARM LESION
$587.40
25130
3
REMOVAL OF WRIST LESION
$403.01
25135
3
REMOVE & GRAFT WRIST LESION
$502.74
25136
3
REMOVE & GRAFT WRIST LESION
$444.61
25145
3
REMOVE FOREARM BONE LESION
$513.51
25150
3
PARTIAL REMOVAL OF ULNA
$521.13
25151
3
PARTIAL REMOVAL OF RADIUS
$577.54
25170
3
EXTENSIVE FOREARM SURGERY
$802.43
25210
3
REMOVAL OF WRIST BONE
$441.41
25215
3
REMOVAL OF WRIST BONES
$568.36
25230
3
PARTIAL REMOVAL OF RADIUS
$390.98
25240
3
PARTIAL REMOVAL OF ULNA
$396.71
25246
3
INJECTION FOR WRIST X-RAY
$160.82
Procedure Code Pricing Action Code Description
Maximum Allowable
25248
3
REMOVE FOREARM FOREIGN BODY
$394.95
25250
3
REMOVAL OF WRIST PROSTHESIS
$468.86
25251
3
REMOVAL OF WRIST PROSTHESIS
$639.68
25259
3
MANIPULATE WRIST W/ANESTHES
$349.85
25260
3
REPAIR FOREARM TENDON/MUSCLE
$612.88
25263
3
REPAIR FOREARM TENDON/MUSCLE
$611.89
25265
3
REPAIR FOREARM TENDON/MUSCLE
$725.36
25270
3
REPAIR FOREARM TENDON/MUSCLE
$492.57
25272
3
REPAIR FOREARM TENDON/MUSCLE
$553.90
25274
3
REPAIR FOREARM TENDON/MUSCLE
$655.74
25275
3
REPAIR FOREARM TENDON SHEATH
$602.78
25280
3
REVISE WRIST/FOREARM TENDON
$561.09
25290
3
INCISE WRIST/FOREARM TENDON
$477.03
25295
3
RELEASE WRIST/FOREARM TENDON
$522.66
25300
3
FUSION OF TENDONS AT WRIST
$614.44
25301
3
FUSION OF TENDONS AT WRIST
$584.98
25310
3
TRANSPLANT FOREARM TENDON
$607.38
25312
3
TRANSPLANT FOREARM TENDON
$702.42
25315
3
REVISE PALSY HAND TENDON(S)
$752.76
25316
3
REVISE PALSY HAND TENDON(S)
$869.84
25317
O
FLEXOR ORIGIN SLIDE FOR VOLKMANN CO
$0.00
25318
O
FLEXOR ORIGIN SLIDE FOR VOLKMANN CO
$0.00
25320
3
REPAIR/REVISE WRIST JOINT
25330
O
ARTHROPLASTY, WRIST;
$0.00
25331
O
ARTHROPLASTY, WRIST; WITH IMPLANT
$0.00
25332
3
REVISE WRIST JOINT
$762.88
25335
3
REALIGNMENT OF HAND
$866.14
25337
3
RECONSTRUCT ULNA/RADIOULNAR
$796.39
25350
3
REVISION OF RADIUS
$668.30
25355
3
REVISION OF RADIUS
$750.87
25360
3
REVISION OF ULNA
$648.68
25365
3
REVISE RADIUS & ULNA
$881.13
25370
3
REVISE RADIUS OR ULNA
$960.45
25375
3
REVISE RADIUS & ULNA
$926.96
25390
3
SHORTEN RADIUS OR ULNA
$755.16
$865.47
Procedure Code Pricing Action Code Description
Maximum Allowable
25391
3
LENGTHEN RADIUS OR ULNA
$958.51
25392
3
SHORTEN RADIUS & ULNA
$972.88
25393
3
LENGTHEN RADIUS & ULNA
25394
3
REPAIR CARPAL BONE, SHORTEN
$700.69
25400
3
REPAIR RADIUS OR ULNA
$792.03
25405
3
REPAIR/GRAFT RADIUS OR ULNA
25415
3
REPAIR RADIUS & ULNA
25420
3
REPAIR/GRAFT RADIUS & ULNA
25425
3
REPAIR/GRAFT RADIUS OR ULNA
25426
3
REPAIR/GRAFT RADIUS & ULNA
25430
3
VASC GRAFT INTO CARPAL BONE
$639.34
25431
3
REPAIR NONUNION CARPAL BONE
$707.57
25440
3
REPAIR/GRAFT WRIST BONE
$703.68
25441
3
RECONSTRUCT WRIST JOINT
$852.12
25442
3
RECONSTRUCT WRIST JOINT
$726.64
25443
3
RECONSTRUCT WRIST JOINT
$697.13
25444
3
RECONSTRUCT WRIST JOINT
$743.40
25445
3
RECONSTRUCT WRIST JOINT
$650.99
25446
3
WRIST REPLACEMENT
25447
3
REPAIR WRIST JOINT(S)
$734.88
25449
3
REMOVE WRIST JOINT IMPLANT
$938.10
25450
3
REVISION OF WRIST JOINT
$545.91
25455
3
REVISION OF WRIST JOINT
$621.57
25490
3
REINFORCE RADIUS
$687.12
25491
3
REINFORCE ULNA
$725.43
25492
3
REINFORCE RADIUS AND ULNA
$873.43
25500
3
TREAT FRACTURE OF RADIUS
$222.68
25505
3
TREAT FRACTURE OF RADIUS
$434.27
25510
O
TREATMENT OF OPEN RADIAL SHAFT FRAC
25515
3
TREAT FRACTURE OF RADIUS
$600.84
25520
3
TREAT FRACTURE OF RADIUS
$478.32
25525
3
TREAT FRACTURE OF RADIUS
$726.25
25526
3
TREAT FRACTURE OF RADIUS
$891.46
25530
3
TREAT FRACTURE OF ULNA
$216.23
25535
3
TREAT FRACTURE OF ULNA
$420.81
$1,092.72
$1,005.72 $945.57 $1,124.40 $974.20 $1,015.86
$1,070.43
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
25540
O
TREATMENT OF OPEN ULNAR SHAFT FRACT
$0.00
25545
3
TREAT FRACTURE OF ULNA
$562.76
25560
3
TREAT FRACTURE RADIUS & ULNA
$225.65
25565
3
TREAT FRACTURE RADIUS & ULNA
$454.44
25570
O
TREATMENT OF OPEN RADIAL AND ULNAR
25574
3
TREAT FRACTURE RADIUS & ULNA
$590.99
25575
3
TREAT FRACTURE RADIUS/ULNA
$803.56
25600
3
TREAT FRACTURE RADIUS/ULNA
$245.94
25605
3
TREAT FRACTURE RADIUS/ULNA
$533.62
25606
3
TREAT FX DISTAL RADIAL
$592.49
25607
3
TREAT FX RAD EXTRA-ARTICUL
$639.19
25608
3
TREAT FX RAD INTRA-ARTICUL
$728.68
25609
3
TREAT FX RADIAL 3+ FRAG
$929.83
25610
O
TREATMENT OF CLOSED, COMPLEX, DISTA
$0.00
25611
O
TREAT FRACTURE RADIUS/ULNA
$0.00
25615
O
TREATMENT OF OPEN DISTAL RADIAL FRA
$0.00
25620
O
TREAT FRACTURE RADIUS/ULNA
$0.00
25622
3
TREAT WRIST BONE FRACTURE
$252.37
25624
3
TREAT WRIST BONE FRACTURE
$398.85
25626
O
TREATMENT OF OPEN CARPAL SCAPHOID (
25628
3
TREAT WRIST BONE FRACTURE
$641.81
25630
3
TREAT WRIST BONE FRACTURE
$258.18
25635
3
TREAT WRIST BONE FRACTURE
$377.11
25640
O
TREATMENT OF OPEN CARPAL BONE FRACT
25645
3
TREAT WRIST BONE FRACTURE
$506.62
25650
3
TREAT WRIST BONE FRACTURE
$269.05
25651
3
PIN ULNAR STYLOID FRACTURE
$419.89
25652
3
TREAT FRACTURE ULNAR STYLOID
$552.32
25660
3
TREAT WRIST DISLOCATION
$350.63
25665
O
TREATMENT OF OPEN RADIOCARPAL OR IN
25670
3
TREAT WRIST DISLOCATION
$546.54
25671
3
PIN RADIOULNAR DISLOCATION
$462.02
25675
3
TREAT WRIST DISLOCATION
$370.93
25676
3
TREAT WRIST DISLOCATION
$566.22
25680
3
TREAT WRIST FRACTURE
$404.17
$0.00
$0.00
$0.00
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
25685
3
TREAT WRIST FRACTURE
$657.84
25690
3
TREAT WRIST DISLOCATION
$409.40
25695
3
TREAT WRIST DISLOCATION
$567.67
25800
3
FUSION OF WRIST JOINT
$671.57
25805
3
FUSION/GRAFT OF WRIST JOINT
$774.00
25810
3
FUSION/GRAFT OF WRIST JOINT
$781.41
25820
3
FUSION OF HAND BONES
$550.10
25825
3
FUSE HAND BONES WITH GRAFT
$677.48
25830
3
FUSION, RADIOULNAR JNT/ULNA
$849.11
25900
3
AMPUTATION OF FOREARM
$675.32
25905
3
AMPUTATION OF FOREARM
$667.34
25907
3
AMPUTATION FOLLOW-UP SURGERY
$583.26
25909
3
AMPUTATION FOLLOW-UP SURGERY
$656.44
25915
3
AMPUTATION OF FOREARM
$1,146.26
25920
3
AMPUTATE HAND AT WRIST
$616.55
25922
3
AMPUTATE HAND AT WRIST
$521.06
25924
3
AMPUTATION FOLLOW-UP SURGERY
$602.05
25927
3
AMPUTATION OF HAND
$702.18
25929
3
AMPUTATION FOLLOW-UP SURGERY
$503.21
25931
3
AMPUTATION FOLLOW-UP SURGERY
$640.34
25999
5
FOREARM OR WRIST SURGERY
26010
3
DRAINAGE OF FINGER ABSCESS
$222.73
26011
3
DRAINAGE OF FINGER ABSCESS
$340.13
26020
3
DRAIN HAND TENDON SHEATH
$378.10
26025
3
DRAINAGE OF PALM BURSA
$369.19
26030
3
DRAINAGE OF PALM BURSA(S)
$435.89
26034
3
TREAT HAND BONE LESION
$472.77
26035
3
DECOMPRESS FINGERS/HAND
$734.99
26037
3
DECOMPRESS FINGERS/HAND
$508.43
26040
3
RELEASE PALM CONTRACTURE
$271.38
26045
3
RELEASE PALM CONTRACTURE
$413.15
26055
3
INCISE FINGER TENDON SHEATH
$497.57
26060
3
INCISION OF FINGER TENDON
$232.42
26070
3
EXPLORE/TREAT HAND JOINT
$263.84
26075
3
EXPLORE/TREAT FINGER JOINT
$279.70
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
26080
3
EXPLORE/TREAT FINGER JOINT
$337.98
26100
3
BIOPSY HAND JOINT LINING
$283.79
26105
3
BIOPSY FINGER JOINT LINING
$290.48
26110
3
BIOPSY FINGER JOINT LINING
$278.92
26115
3
REMOVAL HAND LESION SUBCUT
$545.00
26116
3
REMOVAL HAND LESION, DEEP
$425.42
26117
3
REMOVE TUMOR, HAND/FINGER
$579.28
26121
3
RELEASE PALM CONTRACTURE
$532.89
26123
3
RELEASE PALM CONTRACTURE
$729.12
26125
3
RELEASE PALM CONTRACTURE
$259.53
26130
3
REMOVE WRIST JOINT LINING
$403.95
26135
3
REVISE FINGER JOINT, EACH
$491.29
26140
3
REVISE FINGER JOINT, EACH
$446.90
26145
3
TENDON EXCISION, PALM/FINGER
$454.20
26160
3
REMOVE TENDON SHEATH LESION
$497.33
26170
3
REMOVAL OF PALM TENDON, EACH
$357.36
26180
3
REMOVAL OF FINGER TENDON
$390.79
26185
3
REMOVE FINGER BONE
$467.08
26200
3
REMOVE HAND BONE LESION
$400.93
26205
3
REMOVE/GRAFT BONE LESION
$538.16
26210
3
REMOVAL OF FINGER LESION
$388.85
26215
3
REMOVE/GRAFT FINGER LESION
$493.40
26230
3
PARTIAL REMOVAL OF HAND BONE
$448.51
26235
3
PARTIAL REMOVAL, FINGER BONE
$440.59
26236
3
PARTIAL REMOVAL, FINGER BONE
$390.61
26250
3
EXTENSIVE HAND SURGERY
$520.14
26255
3
EXTENSIVE HAND SURGERY
$789.60
26260
3
EXTENSIVE FINGER SURGERY
$487.19
26261
3
EXTENSIVE FINGER SURGERY
$602.95
26262
3
PARTIAL REMOVAL OF FINGER
$407.01
26320
3
REMOVAL OF IMPLANT FROM HAND
$304.19
26340
3
MANIPULATE FINGER W/ANESTH
$274.88
26350
3
REPAIR FINGER/HAND TENDON
$637.00
26352
3
REPAIR/GRAFT HAND TENDON
$722.90
26356
3
REPAIR FINGER/HAND TENDON
$944.70
Procedure Code Pricing Action Code Description
Maximum Allowable
26357
3
REPAIR FINGER/HAND TENDON
$775.75
26358
3
REPAIR/GRAFT HAND TENDON
$820.24
26370
3
REPAIR FINGER/HAND TENDON
$688.63
26372
3
REPAIR/GRAFT HAND TENDON
$797.47
26373
3
REPAIR FINGER/HAND TENDON
$758.28
26390
3
REVISE HAND/FINGER TENDON
$742.23
26392
3
REPAIR/GRAFT HAND TENDON
$868.84
26410
3
REPAIR HAND TENDON
$506.75
26412
3
REPAIR/GRAFT HAND TENDON
$614.29
26415
3
EXCISION, HAND/FINGER TENDON
$643.45
26416
3
GRAFT HAND OR FINGER TENDON
$688.64
26418
3
REPAIR FINGER TENDON
$509.44
26420
3
REPAIR/GRAFT FINGER TENDON
$637.94
26426
3
REPAIR FINGER/HAND TENDON
$512.34
26428
3
REPAIR/GRAFT FINGER TENDON
$670.40
26432
3
REPAIR FINGER TENDON
$443.23
26433
3
REPAIR FINGER TENDON
$475.17
26434
3
REPAIR/GRAFT FINGER TENDON
$569.24
26437
3
REALIGNMENT OF TENDONS
$554.94
26440
3
RELEASE PALM/FINGER TENDON
$558.87
26442
3
RELEASE PALM & FINGER TENDON
$843.68
26445
3
RELEASE HAND/FINGER TENDON
$519.27
26449
3
RELEASE FOREARM/HAND TENDON
$676.13
26450
3
INCISION OF PALM TENDON
$358.19
26455
3
INCISION OF FINGER TENDON
$355.77
26460
3
INCISE HAND/FINGER TENDON
$346.03
26471
3
FUSION OF FINGER TENDONS
$546.68
26474
3
FUSION OF FINGER TENDONS
$524.72
26476
3
TENDON LENGTHENING
$510.83
26477
3
TENDON SHORTENING
$515.40
26478
3
LENGTHENING OF HAND TENDON
$559.28
26479
3
SHORTENING OF HAND TENDON
$553.17
26480
3
TRANSPLANT HAND TENDON
$673.43
26483
3
TRANSPLANT/GRAFT HAND TENDON
$759.27
26485
3
TRANSPLANT PALM TENDON
$727.80
Procedure Code Pricing Action Code Description
Maximum Allowable
26489
3
TRANSPLANT/GRAFT PALM TENDON
$784.93
26490
3
REVISE THUMB TENDON
$701.73
26492
3
TENDON TRANSFER WITH GRAFT
$781.68
26494
3
HAND TENDON/MUSCLE TRANSFER
$710.36
26496
3
REVISE THUMB TENDON
$769.99
26497
3
FINGER TENDON TRANSFER
$770.53
26498
3
FINGER TENDON TRANSFER
$1,027.69
26499
3
REVISION OF FINGER
$736.55
26500
3
HAND TENDON RECONSTRUCTION
$557.96
26502
3
HAND TENDON RECONSTRUCTION
$629.31
26504
O
HAND TENDON RECONSTRUCTION
$0.00
26508
3
RELEASE THUMB CONTRACTURE
$560.93
26510
3
THUMB TENDON TRANSFER
$532.33
26516
3
FUSION OF KNUCKLE JOINT
$627.46
26517
3
FUSION OF KNUCKLE JOINTS
$738.10
26518
3
FUSION OF KNUCKLE JOINTS
$744.93
26520
3
RELEASE KNUCKLE CONTRACTURE
$584.12
26525
3
RELEASE FINGER CONTRACTURE
$586.54
26527
O
ARTHROPLASTY, CARPOMETACARPAL JOINT
26530
3
REVISE KNUCKLE JOINT
$476.49
26531
3
REVISE KNUCKLE WITH IMPLANT
$554.60
26535
3
REVISE FINGER JOINT
$356.88
26536
3
REVISE/IMPLANT FINGER JOINT
$598.81
26540
3
REPAIR HAND JOINT
$589.49
26541
3
REPAIR HAND JOINT WITH GRAFT
$719.42
26542
3
REPAIR HAND JOINT WITH GRAFT
$609.36
26545
3
RECONSTRUCT FINGER JOINT
$620.25
26546
3
REPAIR NONUNION HAND
$869.97
26548
3
RECONSTRUCT FINGER JOINT
$682.36
26550
3
CONSTRUCT THUMB REPLACEMENT
$1,335.53
26551
3
GREAT TOE-HAND TRANSFER
$2,905.51
26552
O
RECONSTRUCTION THUMB WITH TOE
26553
3
SINGLE TRANSFER, TOE-HAND
$2,535.67
26554
3
DOUBLE TRANSFER, TOE-HAND
$3,321.88
26555
3
POSITIONAL CHANGE OF FINGER
$1,231.40
$0.00
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
26556
3
TOE JOINT TRANSFER
$2,619.72
26557
O
TOE TO FINGER TRANSFER; FIRST STAGE
$0.00
26558
O
TOE TO FINGER TRANSFER; EACH DELAY
$0.00
26559
O
TOE TO FINGER TRANSFER; SECOND STAG
$0.00
26560
3
REPAIR OF WEB FINGER
$507.95
26561
3
REPAIR OF WEB FINGER
$811.23
26562
3
REPAIR OF WEB FINGER
$1,180.23
26565
3
CORRECT METACARPAL FLAW
$603.76
26567
3
CORRECT FINGER DEFORMITY
$609.80
26568
3
LENGTHEN METACARPAL/FINGER
$802.63
26580
3
REPAIR HAND DEFORMITY
26585
O
REPAIR FINGER DEFORMITY
26587
3
RECONSTRUCT EXTRA FINGER
26590
3
REPAIR FINGER DEFORMITY
26591
3
REPAIR MUSCLES OF HAND
$390.07
26593
3
RELEASE MUSCLES OF HAND
$531.11
26596
3
EXCISION CONSTRICTING TISSUE
$654.94
26597
O
RELEASE OF SCAR CONTRACTURE
26600
3
TREAT METACARPAL FRACTURE
$235.19
26605
3
TREAT METACARPAL FRACTURE
$271.36
26607
3
TREAT METACARPAL FRACTURE
$387.58
26608
3
TREAT METACARPAL FRACTURE
$420.31
26610
O
TREATMENT OF OPEN METACARPAL FRACTU
26615
3
TREAT METACARPAL FRACTURE
$486.77
26641
3
TREAT THUMB DISLOCATION
$310.88
26645
3
TREAT THUMB FRACTURE
$355.09
26650
3
TREAT THUMB FRACTURE
$420.94
26655
O
TREATMENT OF OPEN CARPOMETACARPAL F
$0.00
26660
O
TREATMENT OF OPEN CARPOMETACARPAL F
$0.00
26665
3
TREAT THUMB FRACTURE
$540.26
26670
3
TREAT HAND DISLOCATION
$280.53
26675
3
TREAT HAND DISLOCATION
$379.01
26676
3
PIN HAND DISLOCATION
$440.78
26680
O
TREATMENT OF OPEN CARPOMETACARPAL D
26685
3
TREAT HAND DISLOCATION
$1,250.80 $0.00 $854.81 $1,136.96
$0.00
$0.00
$0.00 $499.67
Procedure Code Pricing Action Code Description
Maximum Allowable
26686
3
TREAT HAND DISLOCATION
$553.24
26700
3
TREAT KNUCKLE DISLOCATION
$267.36
26705
3
TREAT KNUCKLE DISLOCATION
$347.72
26706
3
PIN KNUCKLE DISLOCATION
$381.59
26710
O
TREATMENT OF OPEN METACARPOPHALANGE
26715
3
TREAT KNUCKLE DISLOCATION
$487.65
26720
3
TREAT FINGER FRACTURE, EACH
$162.99
26725
3
TREAT FINGER FRACTURE, EACH
$290.96
26727
3
TREAT FINGER FRACTURE, EACH
$413.23
26730
O
TREATMENT OF OPEN PHALANGEAL SHAFT
26735
3
TREAT FINGER FRACTURE, EACH
$507.72
26740
3
TREAT FINGER FRACTURE, EACH
$189.83
26742
3
TREAT FINGER FRACTURE, EACH
$318.52
26744
O
TREATMENT OF OPEN ARTICULAR FRACTUR
26746
3
TREAT FINGER FRACTURE, EACH
$620.70
26750
3
TREAT FINGER FRACTURE, EACH
$152.12
26755
3
TREAT FINGER FRACTURE, EACH
$267.19
26756
3
PIN FINGER FRACTURE, EACH
$364.57
26760
O
TREATMENT OF OPEN DISTAL PHALANGEAL
26765
3
TREAT FINGER FRACTURE, EACH
$413.23
26770
3
TREAT FINGER DISLOCATION
$227.09
26775
3
TREAT FINGER DISLOCATION
$324.73
26776
3
PIN FINGER DISLOCATION
$387.69
26780
O
TREATMENT OF OPEN INTERPHALANGEAL J
26785
3
TREAT FINGER DISLOCATION
$450.51
26820
3
THUMB FUSION WITH GRAFT
$703.34
26841
3
FUSION OF THUMB
$651.94
26842
3
THUMB FUSION WITH GRAFT
$707.46
26843
3
FUSION OF HAND JOINT
$655.08
26844
3
FUSION/GRAFT OF HAND JOINT
$730.38
26850
3
FUSION OF KNUCKLE
$621.18
26852
3
FUSION OF KNUCKLE WITH GRAFT
$711.45
26860
3
FUSION OF FINGER JOINT
$499.62
26861
3
FUSION OF FINGER JNT, ADD-ON
$97.85
26862
3
FUSION/GRAFT OF FINGER JOINT
$647.52
$0.00
$0.00
$0.00
$0.00
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
26863
3
FUSE/GRAFT ADDED JOINT
$218.24
26910
3
AMPUTATE METACARPAL BONE
$636.83
26951
3
AMPUTATION OF FINGER/THUMB
$551.78
26952
3
AMPUTATION OF FINGER/THUMB
$577.96
26989
5
HAND/FINGER SURGERY
26990
3
DRAINAGE OF PELVIS LESION
$552.66
26991
3
DRAINAGE OF PELVIS BURSA
$620.60
26992
3
DRAINAGE OF BONE LESION
$869.53
27000
3
INCISION OF HIP TENDON
$401.35
27001
3
INCISION OF HIP TENDON
$486.46
27003
3
INCISION OF HIP TENDON
$522.34
27005
3
INCISION OF HIP TENDON
$659.13
27006
3
INCISION OF HIP TENDONS
$666.14
27010
O
GLUTEAL-ILIOTIBIAL FASCIOTOMY (OBER
$0.00
27015
O
ILIAC CREST FASCIOTOMY (SOUTTER OR
$0.00
27025
3
INCISION OF HIP/THIGH FASCIA
$806.18
27027
3
BUTTOCK FASCIOTOMY
$786.14
27030
3
DRAINAGE OF HIP JOINT
$859.89
27033
3
EXPLORATION OF HIP JOINT
$890.35
27035
3
DENERVATION OF HIP JOINT
$994.29
27036
3
EXCISION OF HIP JOINT/MUSCLE
$910.49
27040
3
BIOPSY OF SOFT TISSUES
$303.84
27041
3
BIOPSY OF SOFT TISSUES
$621.78
27047
3
REMOVE HIP/PELVIS LESION
$553.69
27048
3
REMOVE HIP/PELVIS LESION
$427.04
27049
3
REMOVE TUMOR, HIP/PELVIS
$903.32
27050
3
BIOPSY OF SACROILIAC JOINT
$312.53
27052
3
BIOPSY OF HIP JOINT
$498.99
27054
3
REMOVAL OF HIP JOINT LINING
$612.56
27057
3
BUTTOCK FASCIOTOMY W/DBRDMT
$871.82
27060
3
REMOVAL OF ISCHIAL BURSA
$385.43
27062
3
REMOVE FEMUR LESION/BURSA
$403.11
27065
3
REMOVAL OF HIP BONE LESION
$449.54
27066
3
REMOVAL OF HIP BONE LESION
$730.06
27067
3
REMOVE/GRAFT HIP BONE LESION
$925.82
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
27070
3
PARTIAL REMOVAL OF HIP BONE
$764.99
27071
3
PARTIAL REMOVAL OF HIP BONE
$821.17
27075
3
EXTENSIVE HIP SURGERY
$2,108.04
27076
3
EXTENSIVE HIP SURGERY
$1,456.04
27077
3
EXTENSIVE HIP SURGERY
$2,436.63
27078
3
EXTENSIVE HIP SURGERY
$921.28
27079
3
EXTENSIVE HIP SURGERY
$880.47
27080
3
REMOVAL OF TAIL BONE
$442.74
27086
3
REMOVE HIP FOREIGN BODY
$218.09
27087
3
REMOVE HIP FOREIGN BODY
$569.85
27090
3
REMOVAL OF HIP PROSTHESIS
$754.46
27091
3
REMOVAL OF HIP PROSTHESIS
$1,459.52
27093
3
INJECTION FOR HIP X-RAY
$177.86
27095
3
INJECTION FOR HIP X-RAY
$214.83
27096
3
INJECT SACROILIAC JOINT
$162.86
27097
3
REVISION OF HIP TENDON
$601.56
27098
3
TRANSFER TENDON TO PELVIS
$560.78
27100
3
TRANSFER OF ABDOMINAL MUSCLE
$742.03
27105
3
TRANSFER OF SPINAL MUSCLE
$776.89
27110
3
TRANSFER OF ILIOPSOAS MUSCLE
$867.10
27111
3
TRANSFER OF ILIOPSOAS MUSCLE
$772.96
27120
3
RECONSTRUCTION OF HIP SOCKET
$1,175.08
27122
3
RECONSTRUCTION OF HIP SOCKET
$1,006.89
27125
3
PARTIAL HIP REPLACEMENT
$1,024.91
27126
O
PARTIAL HIP REPLACEMENT (HEMIARTHRO
$0.00
27127
O
PARTIAL HIP REPLACEMENT (HEMIARTHRO
$0.00
27130
3
TOTAL HIP ARTHROPLASTY
$1,321.42
27132
3
TOTAL HIP ARTHROPLASTY
$1,544.00
27134
3
REVISE HIP JOINT REPLACEMENT
$1,790.53
27137
3
REVISE HIP JOINT REPLACEMENT
$1,365.00
27138
3
REVISE HIP JOINT REPLACEMENT
$1,420.71
27140
3
TRANSPLANT FEMUR RIDGE
27146
3
INCISION OF HIP BONE
$1,151.97
27147
3
REVISION OF HIP BONE
$1,342.37
27151
3
INCISION OF HIP BONES
$1,396.78
$817.45
Procedure Code Pricing Action Code Description
Maximum Allowable
27156
3
REVISION OF HIP BONES
$1,565.52
27157
O
ACETABULAR AUGMENTATION (WILSON PRO
27158
3
REVISION OF PELVIS
$1,258.34
27161
3
INCISION OF NECK OF FEMUR
$1,114.62
27165
3
INCISION/FIXATION OF FEMUR
$1,244.99
27170
3
REPAIR/GRAFT FEMUR HEAD/NECK
$1,078.22
27175
3
TREAT SLIPPED EPIPHYSIS
$599.88
27176
3
TREAT SLIPPED EPIPHYSIS
$829.18
27177
3
TREAT SLIPPED EPIPHYSIS
$1,011.34
27178
3
TREAT SLIPPED EPIPHYSIS
$820.28
27179
3
REVISE HEAD/NECK OF FEMUR
$883.69
27181
3
TREAT SLIPPED EPIPHYSIS
$983.91
27185
3
REVISION OF FEMUR EPIPHYSIS
$624.15
27187
3
REINFORCE HIP BONES
$906.21
27190
O
TREATMENT OF CLOSED SACRAL FRACTURE
$0.00
27192
O
OPEN TREATMENT OF CLOSED OR OPEN SA
$0.00
27193
3
TREAT PELVIC RING FRACTURE
$415.27
27194
3
TREAT PELVIC RING FRACTURE
$646.34
27195
O
TREATMENT OF SACROILIAC AND/OR SYMP
$0.00
27196
O
TREATMENT OF SACROILIAC AND/OR SYMP
$0.00
27200
3
TREAT TAIL BONE FRACTURE
27201
O
TREATMENT OF OPEN COCCYGEAL FRACTUR
27202
3
TREAT TAIL BONE FRACTURE
27210
O
TREATMENT OF CLOSED ILIAC, PUBIC OR
$0.00
27212
O
TREATMENT OF OPEN ILIAC, PUBIC OR I
$0.00
27214
O
OPEN TREATMENT OF CLOSED OR OPEN IL
$0.00
27215
3
TREAT PELVIC FRACTURE(S)
$668.95
27216
3
TREAT PELVIC RING FRACTURE
$977.70
27217
3
TREAT PELVIC RING FRACTURE
$925.70
27218
3
TREAT PELVIC RING FRACTURE
$1,263.37
27220
3
TREAT HIP SOCKET FRACTURE
$468.01
27222
3
TREAT HIP SOCKET FRACTURE
$888.00
27224
O
OPEN TREATMENT OF CLOSED OR OPEN AC
$0.00
27225
O
OPEN TREATMENT OF CLOSED OR OPEN AC
$0.00
27226
3
TREAT HIP WALL FRACTURE
$0.00
$151.17 $0.00 $577.65
$944.13
Procedure Code Pricing Action Code Description
Maximum Allowable
27227
3
TREAT HIP FRACTURE(S)
$1,529.43
27228
3
TREAT HIP FRACTURE(S)
$1,751.41
27230
3
TREAT THIGH FRACTURE
$416.86
27232
3
TREAT THIGH FRACTURE
$704.50
27234
O
TREATMENT OF OPEN FEMORAL FRACTURE,
27235
3
TREAT THIGH FRACTURE
$828.64
27236
3
TREAT THIGH FRACTURE
$1,083.62
27238
3
TREAT THIGH FRACTURE
$402.92
27240
3
TREAT THIGH FRACTURE
$866.58
27242
O
TREATMENT OF OPEN INTERTROCHANTERIC
27244
3
TREAT THIGH FRACTURE
$1,114.67
27245
3
TREAT THIGH FRACTURE
$1,155.93
27246
3
TREAT THIGH FRACTURE
$341.10
27248
3
TREAT THIGH FRACTURE
$684.47
27250
3
TREAT HIP DISLOCATION
$214.95
27252
3
TREAT HIP DISLOCATION
$684.35
27253
3
TREAT HIP DISLOCATION
$860.99
27254
3
TREAT HIP DISLOCATION
$1,163.19
27255
O
OPEN TREATMENT OF CLOSED OR OPEN HI
27256
3
TREAT HIP DISLOCATION
$262.72
27257
3
TREAT HIP DISLOCATION
$304.57
27258
3
TREAT HIP DISLOCATION
$1,009.35
27259
3
TREAT HIP DISLOCATION
$1,415.26
27265
3
TREAT HIP DISLOCATION
$348.90
27266
3
TREAT HIP DISLOCATION
$520.91
27267
3
CLTX THIGH FX
$371.81
27268
3
CLTX THIGH FX W/MNPJ
$460.21
27269
3
OPTX THIGH FX
27275
3
MANIPULATION OF HIP JOINT
$161.79
27280
3
FUSION OF SACROILIAC JOINT
$934.32
27282
3
FUSION OF PUBIC BONES
$731.67
27284
3
FUSION OF HIP JOINT
$1,417.98
27286
3
FUSION OF HIP JOINT
$1,500.78
27290
3
AMPUTATION OF LEG AT HIP
$1,432.03
27295
3
AMPUTATION OF LEG AT HIP
$1,156.64
$0.00
$0.00
$0.00
$1,105.87
Procedure Code Pricing Action Code Description
Maximum Allowable
27299
5
PELVIS/HIP JOINT SURGERY
$0.00
27301
3
DRAIN THIGH/KNEE LESION
$585.66
27303
3
DRAINAGE OF BONE LESION
$574.97
27305
3
INCISE THIGH TENDON & FASCIA
$419.28
27306
3
INCISION OF THIGH TENDON
$339.58
27307
3
INCISION OF THIGH TENDONS
$417.93
27310
3
EXPLORATION OF KNEE JOINT
$655.61
27315
O
PARTIAL REMOVAL, THIGH NERVE
$0.00
27320
O
PARTIAL REMOVAL, THIGH NERVE
$0.00
27323
3
BIOPSY, THIGH SOFT TISSUES
$236.19
27324
3
BIOPSY, THIGH SOFT TISSUES
$341.63
27325
3
NEURECTOMY, HAMSTRING
$473.20
27326
3
NEURECTOMY, POPLITEAL
$436.79
27327
3
REMOVAL OF THIGH LESION
$399.42
27328
3
REMOVAL OF THIGH LESION
$376.60
27329
3
REMOVE TUMOR, THIGH/KNEE
$938.65
27330
3
BIOPSY, KNEE JOINT LINING
$358.23
27331
3
EXPLORE/TREAT KNEE JOINT
$423.42
27332
3
REMOVAL OF KNEE CARTILAGE
$574.46
27333
3
REMOVAL OF KNEE CARTILAGE
$520.49
27334
3
REMOVE KNEE JOINT LINING
$611.32
27335
3
REMOVE KNEE JOINT LINING
$691.56
27340
3
REMOVAL OF KNEECAP BURSA
$324.43
27345
3
REMOVAL OF KNEE CYST
$428.80
27347
3
REMOVE KNEE CYST
$459.74
27350
3
REMOVAL OF KNEECAP
$584.44
27355
3
REMOVE FEMUR LESION
$541.69
27356
3
REMOVE FEMUR LESION/GRAFT
$664.22
27357
3
REMOVE FEMUR LESION/GRAFT
$736.53
27358
3
REMOVE FEMUR LESION/FIXATION
$267.79
27360
3
PARTIAL REMOVAL, LEG BONE(S)
$766.90
27365
3
EXTENSIVE LEG SURGERY
27370
3
INJECTION FOR KNEE X-RAY
$152.31
27372
3
REMOVAL OF FOREIGN BODY
$527.33
27380
3
REPAIR OF KNEECAP TENDON
$530.84
$1,116.34
Procedure Code Pricing Action Code Description
Maximum Allowable
27381
3
REPAIR/GRAFT KNEECAP TENDON
$723.55
27385
3
REPAIR OF THIGH MUSCLE
$568.39
27386
3
REPAIR/GRAFT OF THIGH MUSCLE
$750.44
27390
3
INCISION OF THIGH TENDON
$393.53
27391
3
INCISION OF THIGH TENDONS
$512.80
27392
3
INCISION OF THIGH TENDONS
$631.82
27393
3
LENGTHENING OF THIGH TENDON
$454.58
27394
3
LENGTHENING OF THIGH TENDONS
$587.56
27395
3
LENGTHENING OF THIGH TENDONS
$795.76
27396
3
TRANSPLANT OF THIGH TENDON
$552.33
27397
3
TRANSPLANTS OF THIGH TENDONS
$813.34
27400
3
REVISE THIGH MUSCLES/TENDONS
$615.23
27403
3
REPAIR OF KNEE CARTILAGE
$578.18
27405
3
REPAIR OF KNEE LIGAMENT
$609.25
27407
3
REPAIR OF KNEE LIGAMENT
$695.50
27409
3
REPAIR OF KNEE LIGAMENTS
$874.90
27412
3
AUTOCHONDROCYTE IMPLANT KNEE
$1,514.53
27415
3
OSTEOCHONDRAL KNEE ALLOGRAFT
$1,268.26
27416
3
OSTEOCHONDRAL KNEE AUTOGRAFT
$876.41
27418
3
REPAIR DEGENERATED KNEECAP
$755.01
27420
3
REVISION OF UNSTABLE KNEECAP
$676.04
27422
3
REVISION OF UNSTABLE KNEECAP
$673.27
27424
3
REVISION/REMOVAL OF KNEECAP
$675.08
27425
3
LAT RETINACULAR RELEASE OPEN
$393.99
27427
3
RECONSTRUCTION, KNEE
$648.21
27428
3
RECONSTRUCTION, KNEE
$998.30
27429
3
RECONSTRUCTION, KNEE
$1,117.99
27430
3
REVISION OF THIGH MUSCLES
$669.03
27435
3
INCISION OF KNEE JOINT
$717.78
27437
3
REVISE KNEECAP
$594.89
27438
3
REVISE KNEECAP WITH IMPLANT
$762.22
27440
3
REVISION OF KNEE JOINT
$695.90
27441
3
REVISION OF KNEE JOINT
$718.46
27442
3
REVISION OF KNEE JOINT
$789.38
27443
3
REVISION OF KNEE JOINT
$739.43
Procedure Code Pricing Action Code Description
Maximum Allowable
27445
3
REVISION OF KNEE JOINT
$1,151.76
27446
3
REVISION OF KNEE JOINT
$1,021.41
27447
3
TOTAL KNEE ARTHROPLASTY
$1,414.96
27448
3
INCISION OF THIGH
$744.59
27450
3
INCISION OF THIGH
$928.01
27454
3
REALIGNMENT OF THIGH BONE
27455
3
REALIGNMENT OF KNEE
$857.56
27457
3
REALIGNMENT OF KNEE
$883.15
27465
3
SHORTENING OF THIGH BONE
$1,111.74
27466
3
LENGTHENING OF THIGH BONE
$1,079.15
27468
3
SHORTEN/LENGTHEN THIGHS
$1,221.98
27470
3
REPAIR OF THIGH
$1,076.12
27472
3
REPAIR/GRAFT OF THIGH
$1,163.30
27475
3
SURGERY TO STOP LEG GROWTH
$591.77
27477
3
SURGERY TO STOP LEG GROWTH
$663.34
27479
3
SURGERY TO STOP LEG GROWTH
$854.11
27485
3
SURGERY TO STOP LEG GROWTH
$605.58
27486
3
REVISE/REPLACE KNEE JOINT
$1,290.83
27487
3
REVISE/REPLACE KNEE JOINT
$1,628.27
27488
3
REMOVAL OF KNEE PROSTHESIS
$1,092.14
27495
3
REINFORCE THIGH
$1,034.62
27496
3
DECOMPRESSION OF THIGH/KNEE
$451.38
27497
3
DECOMPRESSION OF THIGH/KNEE
$489.78
27498
3
DECOMPRESSION OF THIGH/KNEE
$533.79
27499
3
DECOMPRESSION OF THIGH/KNEE
$592.32
27500
3
TREATMENT OF THIGH FRACTURE
$455.24
27501
3
TREATMENT OF THIGH FRACTURE
$447.18
27502
3
TREATMENT OF THIGH FRACTURE
$712.96
27503
3
TREATMENT OF THIGH FRACTURE
$725.99
27504
O
TREATMENT OF OPEN FEMORAL SHAFT FRA
27506
3
TREATMENT OF THIGH FRACTURE
$1,213.79
27507
3
TREATMENT OF THIGH FRACTURE
$899.27
27508
3
TREATMENT OF THIGH FRACTURE
$459.38
27509
3
TREATMENT OF THIGH FRACTURE
$578.24
27510
3
TREATMENT OF THIGH FRACTURE
$630.28
$1,170.29
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
27511
3
TREATMENT OF THIGH FRACTURE
$931.37
27512
O
TREATMENT OF OPEN FEMORAL FRACTURE,
27513
3
TREATMENT OF THIGH FRACTURE
$1,171.23
27514
3
TREATMENT OF THIGH FRACTURE
$941.92
27516
3
TREAT THIGH FX GROWTH PLATE
$430.07
27517
3
TREAT THIGH FX GROWTH PLATE
$605.23
27518
O
TREATMENT OF OPEN DISTAL FEMORAL EP
27519
3
TREAT THIGH FX GROWTH PLATE
$851.84
27520
3
TREAT KNEECAP FRACTURE
$271.62
27522
O
TREATMENT OF OPEN PATELLAR FRACTURE
27524
3
TREAT KNEECAP FRACTURE
$682.90
27530
3
TREAT KNEE FRACTURE
$340.81
27532
3
TREAT KNEE FRACTURE
$544.52
27534
O
TREATMENT OF OPEN TIBIAL FRACTURE,
27535
3
TREAT KNEE FRACTURE
$831.44
27536
3
TREAT KNEE FRACTURE
$1,081.80
27537
O
OPEN TREATMENT OF CLOSED OR OPEN TI
27538
3
TREAT KNEE FRACTURE(S)
$407.75
27540
3
TREAT KNEE FRACTURE
$755.12
27550
3
TREAT KNEE DISLOCATION
$430.61
27552
3
TREAT KNEE DISLOCATION
$557.25
27554
O
TREATMENT OF OPEN KNEE DISLOCATION,
27556
3
TREAT KNEE DISLOCATION
$837.65
27557
3
TREAT KNEE DISLOCATION
$1,002.08
27558
3
TREAT KNEE DISLOCATION
$1,124.00
27560
3
TREAT KNEECAP DISLOCATION
$315.72
27562
3
TREAT KNEECAP DISLOCATION
$411.24
27564
O
TREATMENT OF OPEN PATELLAR DISLOCAT
27566
3
TREAT KNEECAP DISLOCATION
$812.97
27570
3
FIXATION OF KNEE JOINT
$132.19
27580
3
FUSION OF KNEE
27590
3
AMPUTATE LEG AT THIGH
$752.64
27591
3
AMPUTATE LEG AT THIGH
$834.93
27592
3
AMPUTATE LEG AT THIGH
$639.10
27594
3
AMPUTATION FOLLOW-UP SURGERY
$462.92
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$1,317.71
Procedure Code Pricing Action Code Description
Maximum Allowable
27596
3
AMPUTATION FOLLOW-UP SURGERY
$669.71
27598
3
AMPUTATE LOWER LEG AT KNEE
$680.96
27599
5
LEG SURGERY PROCEDURE
27600
3
DECOMPRESSION OF LOWER LEG
$384.45
27601
3
DECOMPRESSION OF LOWER LEG
$398.91
27602
3
DECOMPRESSION OF LOWER LEG
$470.83
27603
3
DRAIN LOWER LEG LESION
$464.29
27604
3
DRAIN LOWER LEG BURSA
$407.29
27605
3
INCISION OF ACHILLES TENDON
$325.68
27606
3
INCISION OF ACHILLES TENDON
$270.20
27607
3
TREAT LOWER LEG BONE LESION
$556.58
27610
3
EXPLORE/TREAT ANKLE JOINT
$594.35
27612
3
EXPLORATION OF ANKLE JOINT
$518.50
27613
3
BIOPSY LOWER LEG SOFT TISSUE
$221.70
27614
3
BIOPSY LOWER LEG SOFT TISSUE
$498.54
27615
3
REMOVE TUMOR, LOWER LEG
$799.32
27618
3
REMOVE LOWER LEG LESION
$434.95
27619
3
REMOVE LOWER LEG LESION
$693.46
27620
3
EXPLORE/TREAT ANKLE JOINT
$418.39
27625
3
REMOVE ANKLE JOINT LINING
$540.87
27626
3
REMOVE ANKLE JOINT LINING
$584.10
27630
3
REMOVAL OF TENDON LESION
$477.20
27635
3
REMOVE LOWER LEG BONE LESION
$538.10
27637
3
REMOVE/GRAFT LEG BONE LESION
$682.33
27638
3
REMOVE/GRAFT LEG BONE LESION
$710.78
27640
3
PARTIAL REMOVAL OF TIBIA
$787.49
27641
3
PARTIAL REMOVAL OF FIBULA
$631.13
27645
3
EXTENSIVE LOWER LEG SURGERY
$955.12
27646
3
EXTENSIVE LOWER LEG SURGERY
$844.54
27647
3
EXTENSIVE ANKLE/HEEL SURGERY
$745.74
27648
3
INJECTION FOR ANKLE X-RAY
$146.76
27650
3
REPAIR ACHILLES TENDON
$614.81
27652
3
REPAIR/GRAFT ACHILLES TENDON
$676.16
27654
3
REPAIR OF ACHILLES TENDON
$660.27
27656
3
REPAIR LEG FASCIA DEFECT
$480.36
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
27658
3
REPAIR OF LEG TENDON, EACH
$348.77
27659
3
REPAIR OF LEG TENDON, EACH
$457.80
27664
3
REPAIR OF LEG TENDON, EACH
$332.64
27665
3
REPAIR OF LEG TENDON, EACH
$380.96
27675
3
REPAIR LOWER LEG TENDONS
$466.47
27676
3
REPAIR LOWER LEG TENDONS
$566.39
27680
3
RELEASE OF LOWER LEG TENDON
$395.19
27681
3
RELEASE OF LOWER LEG TENDONS
$470.76
27685
3
REVISION OF LOWER LEG TENDON
$565.24
27686
3
REVISE LOWER LEG TENDONS
$513.83
27687
3
REVISION OF CALF TENDON
$422.85
27690
3
REVISE LOWER LEG TENDON
$582.01
27691
3
REVISE LOWER LEG TENDON
$683.19
27692
3
REVISE ADDITIONAL LEG TENDON
$103.69
27695
3
REPAIR OF ANKLE LIGAMENT
$450.32
27696
3
REPAIR OF ANKLE LIGAMENTS
$537.07
27698
3
REPAIR OF ANKLE LIGAMENT
$603.20
27700
3
REVISION OF ANKLE JOINT
$569.85
27702
3
RECONSTRUCT ANKLE JOINT
$911.52
27703
3
RECONSTRUCTION, ANKLE JOINT
27704
3
REMOVAL OF ANKLE IMPLANT
$516.71
27705
3
INCISION OF TIBIA
$699.63
27707
3
INCISION OF FIBULA
$356.27
27709
3
INCISION OF TIBIA & FIBULA
27712
3
REALIGNMENT OF LOWER LEG
$997.23
27715
3
REVISION OF LOWER LEG
$973.69
27720
3
REPAIR OF TIBIA
$800.79
27722
3
REPAIR/GRAFT OF TIBIA
$798.70
27724
3
REPAIR/GRAFT OF TIBIA
$1,175.05
27725
3
REPAIR OF LOWER LEG
$1,093.94
27726
3
REPAIR FIBULA NONUNION
$832.66
27727
3
REPAIR OF LOWER LEG
$886.94
27730
3
REPAIR OF TIBIA EPIPHYSIS
$533.39
27732
3
REPAIR OF FIBULA EPIPHYSIS
$362.30
27734
3
REPAIR LOWER LEG EPIPHYSES
$542.49
$1,054.55
$1,019.97
Procedure Code Pricing Action Code Description
Maximum Allowable
27740
3
REPAIR OF LEG EPIPHYSES
$602.36
27742
3
REPAIR OF LEG EPIPHYSES
$633.53
27745
3
REINFORCE TIBIA
$687.07
27750
3
TREATMENT OF TIBIA FRACTURE
$293.45
27752
3
TREATMENT OF TIBIA FRACTURE
$472.08
27754
O
TREATMENT OF OPEN TIBIAL SHAFT FRAC
27756
3
TREATMENT OF TIBIA FRACTURE
$511.42
27758
3
TREATMENT OF TIBIA FRACTURE
$806.98
27759
3
TREATMENT OF TIBIA FRACTURE
$914.31
27760
3
CLTX MEDIAL ANKLE FX
$282.75
27762
3
CLTX MED ANKLE FX W/MNPJ
$422.67
27764
O
TREATMENT OF OPEN DISTAL TIBIAL FRA
27766
3
OPTX MEDIAL ANKLE FX
$550.67
27767
3
CLTX POST ANKLE FX
$224.45
27768
3
CLTX POST ANKLE FX W/MNPJ
$360.64
27769
3
OPTX POST ANKLE FX
$626.48
27780
3
TREATMENT OF FIBULA FRACTURE
$253.06
27781
3
TREATMENT OF FIBULA FRACTURE
$366.15
27782
O
TREATMENT OF OPEN PROXIMAL FIBULA O
27784
3
TREATMENT OF FIBULA FRACTURE
$624.03
27786
3
TREATMENT OF ANKLE FRACTURE
$268.07
27788
3
TREATMENT OF ANKLE FRACTURE
$369.28
27790
O
TREATMENT OF OPEN DISTAL FIBULAR FR
27792
3
TREATMENT OF ANKLE FRACTURE
27800
O
TREATMENT OF CLOSED TIBIA AND FIBUL
$0.00
27802
O
TREATMENT OF CLOSED TIBIA AND FIBUL
$0.00
27804
O
TREATMENT OF OPEN TIBIA AND FIBULA
$0.00
27806
O
OPEN TREATMENT OF CLOSED OR OPEN TI
$0.00
27808
3
TREATMENT OF ANKLE FRACTURE
$280.64
27810
3
TREATMENT OF ANKLE FRACTURE
$413.62
27812
O
TREATMENT OF OPEN BIMALLEOLAR ANKLE
27814
3
TREATMENT OF ANKLE FRACTURE
$704.51
27816
3
TREATMENT OF ANKLE FRACTURE
$265.44
27818
3
TREATMENT OF ANKLE FRACTURE
$426.09
27820
O
TREATMENT OF OPEN TRIMALLEOLAR ANKL
$0.00
$0.00
$0.00
$0.00 $630.95
$0.00
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
27822
3
TREATMENT OF ANKLE FRACTURE
$772.16
27823
3
TREATMENT OF ANKLE FRACTURE
$879.20
27824
3
TREAT LOWER LEG FRACTURE
$266.36
27825
3
TREAT LOWER LEG FRACTURE
$485.07
27826
3
TREAT LOWER LEG FRACTURE
$740.44
27827
3
TREAT LOWER LEG FRACTURE
$987.29
27828
3
TREAT LOWER LEG FRACTURE
$1,179.70
27829
3
TREAT LOWER LEG JOINT
$591.78
27830
3
TREAT LOWER LEG DISLOCATION
$309.49
27831
3
TREAT LOWER LEG DISLOCATION
$337.49
27832
3
TREAT LOWER LEG DISLOCATION
$636.00
27840
3
TREAT ANKLE DISLOCATION
$310.65
27842
3
TREAT ANKLE DISLOCATION
$435.00
27844
O
TREATMENT OF OPEN ANKLE DISLOCATION
27846
3
TREAT ANKLE DISLOCATION
$672.07
27848
3
TREAT ANKLE DISLOCATION
$760.76
27860
3
FIXATION OF ANKLE JOINT
$162.44
27870
3
FUSION OF ANKLE JOINT, OPEN
$958.56
27871
3
FUSION OF TIBIOFIBULAR JOINT
$630.19
27880
3
AMPUTATION OF LOWER LEG
$844.82
27881
3
AMPUTATION OF LOWER LEG
$816.48
27882
3
AMPUTATION OF LOWER LEG
$575.00
27884
3
AMPUTATION FOLLOW-UP SURGERY
$535.03
27886
3
AMPUTATION FOLLOW-UP SURGERY
$610.28
27888
3
AMPUTATION OF FOOT AT ANKLE
$645.75
27889
3
AMPUTATION OF FOOT AT ANKLE
$629.53
27892
3
DECOMPRESSION OF LEG
$495.46
27893
3
DECOMPRESSION OF LEG
$501.80
27894
3
DECOMPRESSION OF LEG
$769.89
27899
5
LEG/ANKLE SURGERY PROCEDURE
28001
3
DRAINAGE OF BURSA OF FOOT
$241.49
28002
3
TREATMENT OF FOOT INFECTION
$449.27
28003
3
TREATMENT OF FOOT INFECTION
$617.65
28005
3
TREAT FOOT BONE LESION
$569.75
28008
3
INCISION OF FOOT FASCIA
$381.13
$0.00
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
28010
3
INCISION OF TOE TENDON
$211.35
28011
3
INCISION OF TOE TENDONS
$299.17
28020
3
EXPLORATION OF FOOT JOINT
$452.80
28022
3
EXPLORATION OF FOOT JOINT
$417.92
28024
3
EXPLORATION OF TOE JOINT
$397.35
28030
O
REMOVAL OF FOOT NERVE
28035
3
DECOMPRESSION OF TIBIA NERVE
$455.55
28043
3
EXCISION OF FOOT LESION
$303.48
28045
3
EXCISION OF FOOT LESION
$425.86
28046
3
RESECTION OF TUMOR, FOOT
$772.64
28050
3
BIOPSY OF FOOT JOINT LINING
$400.58
28052
3
BIOPSY OF FOOT JOINT LINING
$369.35
28054
3
BIOPSY OF TOE JOINT LINING
$347.21
28055
3
NEURECTOMY, FOOT
$369.79
28060
3
PARTIAL REMOVAL, FOOT FASCIA
$448.71
28062
3
REMOVAL OF FOOT FASCIA
$527.49
28070
3
REMOVAL OF FOOT JOINT LINING
$445.17
28072
3
REMOVAL OF FOOT JOINT LINING
$439.43
28080
3
REMOVAL OF FOOT LESION
$431.05
28086
3
EXCISE FOOT TENDON SHEATH
$471.79
28088
3
EXCISE FOOT TENDON SHEATH
$400.58
28090
3
REMOVAL OF FOOT LESION
$403.84
28092
3
REMOVAL OF TOE LESIONS
$365.06
28100
3
REMOVAL OF ANKLE/HEEL LESION
$520.93
28102
3
REMOVE/GRAFT FOOT LESION
$518.63
28103
3
REMOVE/GRAFT FOOT LESION
$418.53
28104
3
REMOVAL OF FOOT LESION
$446.64
28106
3
REMOVE/GRAFT FOOT LESION
$441.69
28107
3
REMOVE/GRAFT FOOT LESION
$495.84
28108
3
REMOVAL OF TOE LESIONS
$376.09
28110
3
PART REMOVAL OF METATARSAL
$395.29
28111
3
PART REMOVAL OF METATARSAL
$449.38
28112
3
PART REMOVAL OF METATARSAL
$425.66
28113
3
PART REMOVAL OF METATARSAL
$508.41
28114
3
REMOVAL OF METATARSAL HEADS
$922.88
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
28116
3
REVISION OF FOOT
$658.77
28118
3
REMOVAL OF HEEL BONE
$511.80
28119
3
REMOVAL OF HEEL SPUR
$455.91
28120
3
PART REMOVAL OF ANKLE/HEEL
$506.52
28122
3
PARTIAL REMOVAL OF FOOT BONE
$587.56
28124
3
PARTIAL REMOVAL OF TOE
$417.61
28126
3
PARTIAL REMOVAL OF TOE
$338.01
28130
3
REMOVAL OF ANKLE BONE
$589.89
28140
3
REMOVAL OF METATARSAL
$553.13
28150
3
REMOVAL OF TOE
$376.56
28153
3
PARTIAL REMOVAL OF TOE
$351.24
28160
3
PARTIAL REMOVAL OF TOE
$360.50
28171
3
EXTENSIVE FOOT SURGERY
$576.84
28173
3
EXTENSIVE FOOT SURGERY
$658.21
28175
3
EXTENSIVE FOOT SURGERY
$483.46
28190
3
REMOVAL OF FOOT FOREIGN BODY
$215.78
28192
3
REMOVAL OF FOOT FOREIGN BODY
$413.28
28193
3
REMOVAL OF FOOT FOREIGN BODY
$473.58
28200
3
REPAIR OF FOOT TENDON
$413.33
28202
3
REPAIR/GRAFT OF FOOT TENDON
$548.54
28208
3
REPAIR OF FOOT TENDON
$398.11
28210
3
REPAIR/GRAFT OF FOOT TENDON
$511.33
28220
3
RELEASE OF FOOT TENDON
$392.86
28222
3
RELEASE OF FOOT TENDONS
$453.54
28225
3
RELEASE OF FOOT TENDON
$341.78
28226
3
RELEASE OF FOOT TENDONS
$410.48
28230
3
INCISION OF FOOT TENDON(S)
$377.59
28232
3
INCISION OF TOE TENDON
$335.35
28234
3
INCISION OF FOOT TENDON
$347.91
28236
O
TRANSFER OF TENDON, ANTERIOR TIBIAL
28238
3
REVISION OF FOOT TENDON
$601.32
28240
3
RELEASE OF BIG TOE
$388.52
28250
3
REVISION OF FOOT FASCIA
$493.63
28260
3
RELEASE OF MIDFOOT JOINT
$602.21
28261
3
REVISION OF FOOT TENDON
$871.62
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
28262
3
REVISION OF FOOT AND ANKLE
$1,219.90
28264
3
RELEASE OF MIDFOOT JOINT
$781.05
28270
3
RELEASE OF FOOT CONTRACTURE
$420.02
28272
3
RELEASE OF TOE JOINT, EACH
$343.45
28280
3
FUSION OF TOES
$460.95
28285
3
REPAIR OF HAMMERTOE
$406.94
28286
3
REPAIR OF HAMMERTOE
$397.64
28288
3
PARTIAL REMOVAL OF FOOT BONE
$509.72
28289
3
REPAIR HALLUX RIGIDUS
$643.29
28290
3
CORRECTION OF BUNION
$502.45
28292
3
CORRECTION OF BUNION
$683.52
28293
3
CORRECTION OF BUNION
$912.86
28294
3
CORRECTION OF BUNION
$660.23
28296
3
CORRECTION OF BUNION
$648.04
28297
3
CORRECTION OF BUNION
$731.81
28298
3
CORRECTION OF BUNION
$631.93
28299
3
CORRECTION OF BUNION
$810.29
28300
3
INCISION OF HEEL BONE
$616.18
28302
3
INCISION OF ANKLE BONE
$610.34
28304
3
INCISION OF MIDFOOT BONES
$701.43
28305
3
INCISE/GRAFT MIDFOOT BONES
$644.31
28306
3
INCISION OF METATARSAL
$527.08
28307
3
INCISION OF METATARSAL
$622.21
28308
3
INCISION OF METATARSAL
$477.46
28309
3
INCISION OF METATARSALS
$830.06
28310
3
REVISION OF BIG TOE
$469.92
28312
3
REVISION OF TOE
$430.88
28313
3
REPAIR DEFORMITY OF TOE
$452.30
28315
3
REMOVAL OF SESAMOID BONE
$414.97
28320
3
REPAIR OF FOOT BONES
$582.57
28322
3
REPAIR OF METATARSALS
$682.55
28340
3
RESECT ENLARGED TOE TISSUE
$543.44
28341
3
RESECT ENLARGED TOE
$625.44
28344
3
REPAIR EXTRA TOE(S)
$418.74
28345
3
REPAIR WEBBED TOE(S)
$504.23
Procedure Code Pricing Action Code Description
Maximum Allowable
28360
3
RECONSTRUCT CLEFT FOOT
$895.94
28400
3
TREATMENT OF HEEL FRACTURE
$213.05
28405
3
TREATMENT OF HEEL FRACTURE
$346.72
28406
3
TREATMENT OF HEEL FRACTURE
$475.97
28410
O
TREATMENT OF OPEN CALCANEAL FRACTUR
28415
3
TREAT HEEL FRACTURE
$1,044.31
28420
3
TREAT/GRAFT HEEL FRACTURE
$1,098.88
28430
3
TREATMENT OF ANKLE FRACTURE
$199.25
28435
3
TREATMENT OF ANKLE FRACTURE
$281.02
28436
3
TREATMENT OF ANKLE FRACTURE
$382.10
28440
O
TREATMENT OF OPEN TALUS FRACTURE, W
28445
3
TREAT ANKLE FRACTURE
28446
3
OSTEOCHONDRAL TALUS AUTOGRFT
28450
3
TREAT MIDFOOT FRACTURE, EACH
$184.35
28455
3
TREAT MIDFOOT FRACTURE, EACH
$255.47
28456
3
TREAT MIDFOOT FRACTURE
$245.61
28460
O
TREATMENT OF OPEN TARSAL BONE FRACT
28465
3
TREAT MIDFOOT FRACTURE, EACH
$560.26
28470
3
TREAT METATARSAL FRACTURE
$184.03
28475
3
TREAT METATARSAL FRACTURE
$233.13
28476
3
TREAT METATARSAL FRACTURE
$304.06
28480
O
TREATMENT OF OPEN METATARSAL FRACTU
28485
3
TREAT METATARSAL FRACTURE
$483.75
28490
3
TREAT BIG TOE FRACTURE
$118.80
28495
3
TREAT BIG TOE FRACTURE
$149.93
28496
3
TREAT BIG TOE FRACTURE
$366.14
28500
O
TREATMENT OF OPEN FRACTURE GREAT TO
28505
3
TREAT BIG TOE FRACTURE
$579.69
28510
3
TREATMENT OF TOE FRACTURE
$102.90
28515
3
TREATMENT OF TOE FRACTURE
$135.55
28520
O
TREATMENT OF OPEN FRACTURE, PHALANX
28525
3
TREAT TOE FRACTURE
28530
3
TREAT SESAMOID BONE FRACTURE
$99.25
28531
3
TREAT SESAMOID BONE FRACTURE
$323.00
28540
3
TREAT FOOT DISLOCATION
$175.92
$0.00
$0.00 $984.15 $1,077.80
$0.00
$0.00
$0.00
$0.00 $488.94
Procedure Code Pricing Action Code Description
Maximum Allowable
28545
3
TREAT FOOT DISLOCATION
$216.50
28546
3
TREAT FOOT DISLOCATION
$410.28
28550
O
TREATMENT OF OPEN TARSAL BONE DISLO
28555
3
REPAIR FOOT DISLOCATION
$758.15
28570
3
TREAT FOOT DISLOCATION
$152.04
28575
3
TREAT FOOT DISLOCATION
$290.96
28576
3
TREAT FOOT DISLOCATION
$318.59
28580
O
TREATMENT OF OPEN TALOTARSAL JOINT
28585
3
REPAIR FOOT DISLOCATION
$807.63
28600
3
TREAT FOOT DISLOCATION
$183.75
28605
3
TREAT FOOT DISLOCATION
$237.22
28606
3
TREAT FOOT DISLOCATION
$352.53
28610
O
TREATMENT OF OPEN TARSOMETATARSAL J
28615
3
REPAIR FOOT DISLOCATION
$705.87
28630
3
TREAT TOE DISLOCATION
$130.59
28635
3
TREAT TOE DISLOCATION
$156.16
28636
3
TREAT TOE DISLOCATION
$257.92
28640
O
TREATMENT OF OPEN METATARSOPHALANGE
28645
3
REPAIR TOE DISLOCATION
$548.13
28660
3
TREAT TOE DISLOCATION
$95.11
28665
3
TREAT TOE DISLOCATION
$138.78
28666
3
TREAT TOE DISLOCATION
$179.30
28670
O
TREATMENT OF OPEN INTERPHALANGEAL J
28675
3
REPAIR OF TOE DISLOCATION
28705
3
FUSION OF FOOT BONES
$1,212.27
28715
3
FUSION OF FOOT BONES
$898.20
28725
3
FUSION OF FOOT BONES
$739.12
28730
3
FUSION OF FOOT BONES
$773.80
28735
3
FUSION OF FOOT BONES
$739.53
28737
3
REVISION OF FOOT BONES
$655.51
28740
3
FUSION OF FOOT BONES
$580.33
28750
3
FUSION OF BIG TOE JOINT
$732.12
28755
3
FUSION OF BIG TOE JOINT
$441.11
28760
3
FUSION OF BIG TOE JOINT
$543.90
28800
3
AMPUTATION OF MIDFOOT
$529.65
$0.00
$0.00
$0.00
$0.00
$0.00 $500.55
Procedure Code Pricing Action Code Description
Maximum Allowable
28805
3
AMPUTATION THRU METATARSAL
$695.61
28810
3
AMPUTATION TOE & METATARSAL
$408.13
28820
3
AMPUTATION OF TOE
$467.01
28825
3
PARTIAL AMPUTATION OF TOE
$505.34
28890
3
HIGH ENERGY ESWT, PLANTAR F
$306.99
28899
5
FOOT/TOES SURGERY PROCEDURE
29000
3
APPLICATION OF BODY CAST
$237.38
29010
3
APPLICATION OF BODY CAST
$216.38
29015
3
APPLICATION OF BODY CAST
$209.66
29020
3
APPLICATION OF BODY CAST
$200.78
29025
3
APPLICATION OF BODY CAST
$227.92
29035
3
APPLICATION OF BODY CAST
$211.56
29040
3
APPLICATION OF BODY CAST
$203.67
29044
3
APPLICATION OF BODY CAST
$229.08
29046
3
APPLICATION OF BODY CAST
$249.99
29049
3
APPLICATION OF FIGURE EIGHT
29055
3
APPLICATION OF SHOULDER CAST
$181.34
29058
3
APPLICATION OF SHOULDER CAST
$97.47
29065
3
APPLICATION OF LONG ARM CAST
$82.38
29075
3
APPLICATION OF FOREARM CAST
$76.48
29085
3
APPLY HAND/WRIST CAST
$81.40
29086
3
APPLY FINGER CAST
$62.28
29105
3
APPLY LONG ARM SPLINT
$75.37
29125
3
APPLY FOREARM SPLINT
$58.62
29126
3
APPLY FOREARM SPLINT
$67.28
29130
3
APPLICATION OF FINGER SPLINT
$35.57
29131
3
APPLICATION OF FINGER SPLINT
$44.03
29200
3
STRAPPING OF CHEST
$47.11
29220
3
STRAPPING OF LOW BACK
$48.60
29240
3
STRAPPING OF SHOULDER
$52.68
29260
3
STRAPPING OF ELBOW OR WRIST
$45.62
29280
3
STRAPPING OF HAND OR FINGER
$44.08
29305
3
APPLICATION OF HIP CAST
$204.78
29325
3
APPLICATION OF HIP CASTS
$227.80
29345
3
APPLICATION OF LONG LEG CAST
$118.26
$0.00
$75.59
Procedure Code Pricing Action Code Description
Maximum Allowable
29355
3
APPLICATION OF LONG LEG CAST
$122.27
29358
3
APPLY LONG LEG CAST BRACE
$133.25
29365
3
APPLICATION OF LONG LEG CAST
$106.11
29405
3
APPLY SHORT LEG CAST
$78.09
29425
3
APPLY SHORT LEG CAST
$84.42
29435
3
APPLY SHORT LEG CAST
$103.53
29440
3
ADDITION OF WALKER TO CAST
29445
3
APPLY RIGID LEG CAST
$129.61
29450
3
APPLICATION OF LEG CAST
$136.62
29505
3
APPLICATION, LONG LEG SPLINT
$66.50
29515
3
APPLICATION LOWER LEG SPLINT
$62.26
29520
3
STRAPPING OF HIP
$44.41
29530
3
STRAPPING OF KNEE
$46.33
29540
3
STRAPPING OF ANKLE AND/OR FT
$38.15
29550
3
STRAPPING OF TOES
$37.09
29580
3
APPLICATION OF PASTE BOOT
$46.84
29590
3
APPLICATION OF FOOT SPLINT
$50.02
29700
3
REMOVAL/REVISION OF CAST
$56.67
29705
3
REMOVAL/REVISION OF CAST
$59.48
29710
3
REMOVAL/REVISION OF CAST
$104.07
29715
3
REMOVAL/REVISION OF CAST
$79.37
29720
3
REPAIR OF BODY CAST
$70.06
29730
3
WINDOWING OF CAST
$57.77
29740
3
WEDGING OF CAST
$82.79
29750
3
WEDGING OF CLUBFOOT CAST
$90.36
29799
5
CASTING/STRAPPING PROCEDURE
29800
3
JAW ARTHROSCOPY/SURGERY
$467.19
29804
3
JAW ARTHROSCOPY/SURGERY
$579.45
29805
3
SHOULDER ARTHROSCOPY, DX
$423.04
29806
3
SHOULDER ARTHROSCOPY/SURGERY
$967.17
29807
3
SHOULDER ARTHROSCOPY/SURGERY
$942.17
29815
O
SHOULDER ARTHROSCOPY
29819
3
SHOULDER ARTHROSCOPY/SURGERY
$530.11
29820
3
SHOULDER ARTHROSCOPY/SURGERY
$489.23
29821
3
SHOULDER ARTHROSCOPY/SURGERY
$534.30
$46.31
$0.00
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
29822
3
SHOULDER ARTHROSCOPY/SURGERY
$519.04
29823
3
SHOULDER ARTHROSCOPY/SURGERY
$567.81
29824
3
SHOULDER ARTHROSCOPY/SURGERY
$605.04
29825
3
SHOULDER ARTHROSCOPY/SURGERY
$529.38
29826
3
SHOULDER ARTHROSCOPY/SURGERY
$607.14
29827
3
ARTHROSCOP ROTATOR CUFF REPR
$991.35
29828
3
ARTHROSCOPY BICEPS TENODESIS
$829.33
29830
3
ELBOW ARTHROSCOPY
$408.07
29834
3
ELBOW ARTHROSCOPY/SURGERY
$444.69
29835
3
ELBOW ARTHROSCOPY/SURGERY
$456.37
29836
3
ELBOW ARTHROSCOPY/SURGERY
$524.48
29837
3
ELBOW ARTHROSCOPY/SURGERY
$478.40
29838
3
ELBOW ARTHROSCOPY/SURGERY
$534.70
29840
3
WRIST ARTHROSCOPY
$400.30
29843
3
WRIST ARTHROSCOPY/SURGERY
$430.10
29844
3
WRIST ARTHROSCOPY/SURGERY
$446.59
29845
3
WRIST ARTHROSCOPY/SURGERY
$509.76
29846
3
WRIST ARTHROSCOPY/SURGERY
$469.75
29847
3
WRIST ARTHROSCOPY/SURGERY
$487.71
29848
3
WRIST ENDOSCOPY/SURGERY
$444.71
29850
3
KNEE ARTHROSCOPY/SURGERY
$515.99
29851
3
KNEE ARTHROSCOPY/SURGERY
$850.91
29855
3
TIBIAL ARTHROSCOPY/SURGERY
$712.97
29856
3
TIBIAL ARTHROSCOPY/SURGERY
$911.82
29860
3
HIP ARTHROSCOPY, DX
$586.93
29861
3
HIP ARTHROSCOPY/SURGERY
$650.97
29862
3
HIP ARTHROSCOPY/SURGERY
$727.34
29863
3
HIP ARTHROSCOPY/SURGERY
$719.58
29866
3
AUTGRFT IMPLNT, KNEE W/SCOPE
$948.36
29867
3
ALLGRFT IMPLNT, KNEE W/SCOPE
$1,148.70
29868
3
MENISCAL TRNSPL, KNEE W/SCPE
$1,535.53
29870
3
KNEE ARTHROSCOPY, DX
$367.12
29871
3
KNEE ARTHROSCOPY/DRAINAGE
$461.33
29873
3
KNEE ARTHROSCOPY/SURGERY
$461.41
29874
3
KNEE ARTHROSCOPY/SURGERY
$483.65
Procedure Code Pricing Action Code Description
Maximum Allowable
29875
3
KNEE ARTHROSCOPY/SURGERY
$446.38
29876
3
KNEE ARTHROSCOPY/SURGERY
$586.23
29877
3
KNEE ARTHROSCOPY/SURGERY
$554.83
29879
3
KNEE ARTHROSCOPY/SURGERY
$593.58
29880
3
KNEE ARTHROSCOPY/SURGERY
$619.69
29881
3
KNEE ARTHROSCOPY/SURGERY
$577.57
29882
3
KNEE ARTHROSCOPY/SURGERY
$625.41
29883
3
KNEE ARTHROSCOPY/SURGERY
$763.55
29884
3
KNEE ARTHROSCOPY/SURGERY
$553.13
29885
3
KNEE ARTHROSCOPY/SURGERY
$670.97
29886
3
KNEE ARTHROSCOPY/SURGERY
$565.79
29887
3
KNEE ARTHROSCOPY/SURGERY
$667.10
29888
3
KNEE ARTHROSCOPY/SURGERY
$904.52
29889
3
KNEE ARTHROSCOPY/SURGERY
$1,105.23
29891
3
ANKLE ARTHROSCOPY/SURGERY
$629.03
29892
3
ANKLE ARTHROSCOPY/SURGERY
$642.45
29893
3
SCOPE, PLANTAR FASCIOTOMY
$527.39
29894
3
ANKLE ARTHROSCOPY/SURGERY
$471.84
29895
3
ANKLE ARTHROSCOPY/SURGERY
$456.37
29897
3
ANKLE ARTHROSCOPY/SURGERY
$478.28
29898
3
ANKLE ARTHROSCOPY/SURGERY
$534.21
29899
3
ANKLE ARTHROSCOPY/SURGERY
$960.63
29900
3
MCP JOINT ARTHROSCOPY, DX
$411.38
29901
3
MCP JOINT ARTHROSCOPY, SURG
$450.72
29902
3
MCP JOINT ARTHROSCOPY, SURG
$481.78
29904
3
SUBTALAR ARTHRO W/FB RMVL
$558.48
29905
3
SUBTALAR ARTHRO W/EXC
$601.32
29906
3
SUBTALAR ARTHRO W/DEB
$633.47
29907
3
SUBTALAR ARTHRO W/FUSION
$775.66
29909
O
ARTHROSCOPY OF JOINT
$0.00
29999
5
ARTHROSCOPY OF JOINT
$0.00
30000
3
DRAINAGE OF NOSE LESION
3000F
O
BLOOD PRESS
30020
3
DRAINAGE OF NOSE LESION
3002F
O
BLOOD PRESSURE > 140/90 MMHG
$204.06 $0.00 $197.40 $0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
3006F
9
CXR DOC REV
$0.00
30100
3
INTRANASAL BIOPSY
$124.00
30110
3
REMOVAL OF NOSE POLYP(S)
$199.48
30115
3
REMOVAL OF NOSE POLYP(S)
$385.58
30117
3
REMOVAL OF INTRANASAL LESION
$736.52
30118
3
REMOVAL OF INTRANASAL LESION
$693.85
3011F
9
LIPID PANEL DOC REV
30120
3
REVISION OF NOSE
$463.60
30124
3
REMOVAL OF NOSE LESION
$243.53
30125
3
REMOVAL OF NOSE LESION
$554.09
30130
3
EXCISE INFERIOR TURBINATE
$337.06
30140
3
RESECT INFERIOR TURBINATE
$385.62
3014F
9
SCREEN MAMMO DOC REV
30150
3
PARTIAL REMOVAL OF NOSE
$711.22
30160
3
REMOVAL OF NOSE
$714.27
3016F
9
PT SCRND UNHLTHY OH USE
$0.00
3017F
9
COLORECTAL CA SCREEN DOC REV
$0.00
3018F
9
PRE-PRXD RSK ET AL DOCD
$0.00
30200
3
INJECTION TREATMENT OF NOSE
3020F
9
LVF ASSESS
30210
3
NASAL SINUS THERAPY
3021F
9
LVEF MOD/SEVER DEPRS SYST
$0.00
30220
9
INSERT NASAL SEPTAL BUTTON
$0.00
3022F
9
LVEF =40% SYSTOLIC
$0.00
3023F
9
SPIROM DOC REV
$0.00
3025F
9
SPIROM FEV/FVC<70% W COPD
$0.00
3027F
9
SPIROM FEV/FVC=70%/ W/O COPD
$0.00
3028F
9
O2 SATURATION DOC REV
$0.00
30300
3
REMOVE NASAL FOREIGN BODY
$199.88
30310
3
REMOVE NASAL FOREIGN BODY
$183.65
30320
3
REMOVE NASAL FOREIGN BODY
$404.84
3035F
9
O2 SATURATION =88% /PA0 =55
$0.00
3037F
9
O2 SATURATION> 88% /PAO>55
$0.00
30400
3
RECONSTRUCTION OF NOSE
$932.41
3040F
9
FEV<40% PREDICTED VALUE
$0.00
$0.00
$0.00
$99.19 $0.00 $130.19
Procedure Code Pricing Action Code Description
Maximum Allowable
30410
3
RECONSTRUCTION OF NOSE
$1,103.64
30420
3
RECONSTRUCTION OF NOSE
$1,238.92
3042F
9
FEV= 40% PREDICTED VALUE
$0.00
30430
3
REVISION OF NOSE
$817.16
30435
9
REVISION OF NOSE
$0.00
3044F
9
HG A1C LEVEL LT 7.0%
$0.00
30450
3
REVISION OF NOSE
3045F
9
HG A1C LEVEL 7.09.0%
30460
3
REVISION OF NOSE
$688.59
30462
3
REVISION OF NOSE
$1,385.43
30465
3
REPAIR NASAL STENOSIS
3046F
9
HEMOGLOBIN A1C LEVEL > 9.0%
$0.00
3047F
O
HEMOGLOBIN A1C LEVEL = 9.0%
$0.00
3048F
9
LDL-C <100 MG/DL
$0.00
3049F
9
LDL-C 100-129 MG/DL
$0.00
3050F
9
LDL-C = 130 MG/DL
$0.00
30520
3
REPAIR OF NASAL SEPTUM
$541.21
30540
3
REPAIR NASAL DEFECT
$603.85
30545
3
REPAIR NASAL DEFECT
$872.65
30560
3
RELEASE OF NASAL ADHESIONS
$236.69
30580
3
REPAIR UPPER JAW FISTULA
$563.83
30600
3
REPAIR MOUTH/NOSE FISTULA
$519.10
3060F
9
POS MICROALBUMINURIA REV
$0.00
3061F
9
NEG MICROALBUMINURIA REV
$0.00
30620
3
INTRANASAL RECONSTRUCTION
3062F
9
POS MACROALBUMINURIA REV
30630
3
REPAIR NASAL SEPTUM DEFECT
3066F
9
NEPHROPATHY DOC TX
$0.00
3072F
9
LOW RISK FOR RETINOPATHY
$0.00
3073F
9
PRE-SURG EYE MEASURES DOCD
$0.00
3074F
9
SYST BP LT 130 MM HG
$0.00
3075F
9
SYST BP GE 130 - 139MM HG
$0.00
3076F
O
SYST BP < 140 MM HG
$0.00
3077F
9
SYST BP = 140 MM HG6 IT
$0.00
3078F
9
DIAST BP < 80 MM HG
$0.00
$1,425.18 $0.00
$883.20
$553.36 $0.00 $560.68
Procedure Code Pricing Action Code Description
Maximum Allowable
3079F
9
DIAST BP 80-89 MM HG
$0.00
30800
O
CAUTERIZATION TURBINATES, UNILATERA
$0.00
30801
3
ABLATE INF TURBINATE, SUPERF
$198.95
30802
3
CAUTERIZATION, INNER NOSE
$256.40
30805
O
CAUTERIZATION TURBINATES, UNILATERA
$0.00
3080F
9
DIAST BP = 90 MM HG
$0.00
30820
O
CRYOSURGERY OF TURBINATES, UNILATER
$0.00
3082F
9
KT/V LT1.2
$0.00
3083F
9
KT/V GE 1.2 AND <1.7
$0.00
3084F
9
KT/V GE 1.7
$0.00
3085F
9
SUICIDE RISK ASSESSED
$0.00
3088F
9
MDD, MILD
$0.00
3089F
9
MDD, MODERATE
$0.00
30901
3
CONTROL OF NOSEBLEED
$93.57
30903
3
CONTROL OF NOSEBLEED
$172.38
30905
3
CONTROL OF NOSEBLEED
$214.59
30906
3
REPEAT CONTROL OF NOSEBLEED
$246.51
3090F
9
MDD, SEVERE; W/O PSYCH
30915
3
LIGATION, NASAL SINUS ARTERY
3091F
9
MDD, SEVERE; W/ PSYCH
30920
3
LIGATION, UPPER JAW ARTERY
3092F
9
MDD, IN REMISSION
30930
3
THER FX, NASAL INF TURBINATE
3093F
9
DOC NEW DIAG 1ST/ADDL. MDD
$0.00
3095F
9
CENTRAL DEXA RESULTS DOCÏD
$0.00
3096F
9
CENTRAL DEXA ORDERED
$0.00
30999
5
NASAL SURGERY PROCEDURE
$0.00
31000
3
IRRIGATION, MAXILLARY SINUS
$158.21
31002
3
IRRIGATION, SPHENOID SINUS
$180.52
3100F
9
IMAGE TEST REF CAROT DIAM
$0.00
31020
3
EXPLORATION, MAXILLARY SINUS
$428.79
31030
3
EXPLORATION, MAXILLARY SINUS
$622.58
31032
3
EXPLORE SINUS, REMOVE POLYPS
$513.21
31040
3
EXPLORATION BEHIND UPPER JAW
$674.75
31050
3
EXPLORATION, SPHENOID SINUS
$443.66
$0.00 $519.80 $0.00 $747.91 $0.00 $109.25
Procedure Code Pricing Action Code Description
Maximum Allowable
31051
3
SPHENOID SINUS SURGERY
$579.43
31070
3
EXPLORATION OF FRONTAL SINUS
$390.11
31071
O
SINUSOTOMY FRONTAL; INTRANASAL
31075
3
EXPLORATION OF FRONTAL SINUS
$706.58
31080
3
REMOVAL OF FRONTAL SINUS
$911.99
31081
3
REMOVAL OF FRONTAL SINUS
$1,115.52
31084
3
REMOVAL OF FRONTAL SINUS
$1,065.05
31085
3
REMOVAL OF FRONTAL SINUS
$1,126.31
31086
3
REMOVAL OF FRONTAL SINUS
$1,007.82
31087
3
REMOVAL OF FRONTAL SINUS
$997.92
31090
3
EXPLORATION OF SINUSES
$899.70
3110F
9
PRES/ABSN HMRHG/LESION DOCÏD
$0.00
3111F
9
CT/MRI BRAIN DONE W/IN 24HRS
$0.00
3112F
9
CT/MRI BRAIN DONE GT24 HRS
$0.00
31200
3
REMOVAL OF ETHMOID SINUS
$480.24
31201
3
REMOVAL OF ETHMOID SINUS
$658.73
31205
3
REMOVAL OF ETHMOID SINUS
$772.10
3120F
9
12-LEAD ECG PERFORMED
31225
3
REMOVAL OF UPPER JAW
$1,658.38
31230
3
REMOVAL OF UPPER JAW
$1,857.84
31231
3
NASAL ENDOSCOPY, DX
$170.86
31233
3
NASAL/SINUS ENDOSCOPY, DX
$239.82
31235
3
NASAL/SINUS ENDOSCOPY, DX
$275.44
31237
3
NASAL/SINUS ENDOSCOPY, SURG
$296.58
31238
3
NASAL/SINUS ENDOSCOPY, SURG
$305.23
31239
3
NASAL/SINUS ENDOSCOPY, SURG
$603.48
31240
3
NASAL/SINUS ENDOSCOPY, SURG
$151.89
31245
O
NASAL/SINUS ENDOSCOPY, SURGICAL, WI
$0.00
31246
O
NASAL/SINUS ENDOSCOPY, SURGICAL, WI
$0.00
31247
O
NASAL/SINUS ENDOSCOPY, SURGICAL, WI
$0.00
31248
O
NASAL/SINUS ENDOSCOPY, SURGICAL, WI
$0.00
31249
O
NASAL/SINUS ENDOSCOPY, SURGICAL, WI
$0.00
31250
O
NASAL ENDOSCOPY, DIAGNOSTIC (INCLUD
$0.00
31251
O
NASAL/SINUS ENDOSCOPY, SURGICAL, WI
$0.00
31252
O
NASAL ENDOSCOPY, SURGICAL WITH NASA
$0.00
$0.00
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
31254
3
REVISION OF ETHMOID SINUS
$259.78
31255
3
REMOVAL OF ETHMOID SINUS
$383.42
31256
3
EXPLORATION MAXILLARY SINUS
$188.33
31258
O
NASAL ENDOSCOPY, SURGICAL WITH REMO
$0.00
31260
O
MAXILLARY SINUS ENDOSCOPY, DIAGNOST
$0.00
31261
O
NASAL/SINUS ENDOSCOPY, SURGICAL, WI
$0.00
31262
O
NASAL/SINUS ENDOSCOPY, SURGICAL, WI
$0.00
31263
O
MAXILLARY SINUS ENDOSCOPY, SURGICAL
$0.00
31264
O
NASAL/SINUS ENDOSCOPY, SURGICAL, WI
$0.00
31265
O
MAXILLARY SINUS ENDOSCOPY, SURGICAL
$0.00
31266
O
NASAL/SINUS ENDOSCOPY, SURGICAL, WI
$0.00
31267
3
ENDOSCOPY, MAXILLARY SINUS
31268
O
MAXILLARY SINUS ENDOSCOPY, SURGICAL
$0.00
31269
O
NASAL/SINUS ENDOSCOPY, SURGICAL, WI
$0.00
31270
O
SPHENOID ENDOSCOPY, DIAGNOSTIC
$0.00
31271
O
NASAL/SINUS ENDOSCOPY, SURGICAL, WI
$0.00
31275
O
SPHENOID ENDOSCOPY, SURGICAL;
$0.00
31276
3
SINUS ENDOSCOPY, SURGICAL
31277
O
SPHENOID ENDOSCOPY, SURGICAL WITH R
$0.00
31280
O
NASAL/SINUS ENDOSCOPY, SURGICAL, WI
$0.00
31281
O
NASAL/SINUS ENDOSCOPY, SURGICAL, WI
$0.00
31282
O
NASAL/SINUS ENDOSCOPY, SURGICAL, WI
$0.00
31283
O
NASAL/SINUS ENDOSCOPY, SURGICAL, WI
$0.00
31284
O
NASAL/SINUS ENDOSCOPY, SURGICAL, WI
$0.00
31285
O
SINUS ENDOSCOPY, TWO OR MORE SINUSE
$0.00
31286
O
NASAL/SINUS ENDOSCOPY, SURGICAL, WI
$0.00
31287
3
NASAL/SINUS ENDOSCOPY, SURG
$221.16
31288
3
NASAL/SINUS ENDOSCOPY, SURG
$256.41
31290
3
NASAL/SINUS ENDOSCOPY, SURG
$1,068.78
31291
3
NASAL/SINUS ENDOSCOPY, SURG
$1,126.31
31292
3
NASAL/SINUS ENDOSCOPY, SURG
$925.24
31293
3
NASAL/SINUS ENDOSCOPY, SURG
$1,007.79
31294
3
NASAL/SINUS ENDOSCOPY, SURG
$1,156.67
31299
5
SINUS SURGERY PROCEDURE
$0.00
31300
3
REMOVAL OF LARYNX LESION
$1,139.92
$302.95
$483.23
Procedure Code Pricing Action Code Description
Maximum Allowable
3130F
9
UPPER GI ENDOSCOPY PERFORMED
$0.00
31320
3
DIAGNOSTIC INCISION, LARYNX
3132F
9
DOC REF. UPPER GI ENDOSCOPY
31360
3
REMOVAL OF LARYNX
$1,814.36
31365
3
REMOVAL OF LARYNX
$2,268.78
31367
3
PARTIAL REMOVAL OF LARYNX
$1,963.12
31368
3
PARTIAL REMOVAL OF LARYNX
$2,193.12
31370
3
PARTIAL REMOVAL OF LARYNX
$1,848.31
31375
3
PARTIAL REMOVAL OF LARYNX
$1,748.20
31380
3
PARTIAL REMOVAL OF LARYNX
$1,723.01
31382
3
PARTIAL REMOVAL OF LARYNX
$1,886.43
31390
3
REMOVAL OF LARYNX & PHARYNX
$2,528.86
31395
3
RECONSTRUCT LARYNX & PHARYNX
$2,684.84
31400
3
REVISION OF LARYNX
3140F
9
UPPER GI ENDO SHOWS BARRTTÏS
$0.00
3141F
9
UPPER GI ENDO NOT BARRTTÏS
$0.00
31420
3
REMOVAL OF EPIGLOTTIS
3142F
9
BARIUM SWALLOW TEST ORDERED
31500
3
INSERT EMERGENCY AIRWAY
31502
3
CHANGE OF WINDPIPE AIRWAY
$33.30
31505
3
DIAGNOSTIC LARYNGOSCOPY
$75.50
3150F
9
FORCEPS ESOPH BIOPSY DONE
31510
3
LARYNGOSCOPY WITH BIOPSY
$192.23
31511
3
REMOVE FOREIGN BODY, LARYNX
$192.29
31512
3
REMOVAL OF LARYNX LESION
$189.93
31513
9
INJECTION INTO VOCAL CORD
$0.00
31515
3
LARYNGOSCOPY FOR ASPIRATION
$190.05
31520
3
DX LARYNGOSCOPY, NEWBORN
$144.33
31525
3
DX LARYNGOSCOPY EXCL NB
$228.05
31526
3
DX LARYNGOSCOPY W/OPER SCOPE
$149.00
31527
9
LARYNGOSCOPY FOR TREATMENT
31528
3
LARYNGOSCOPY AND DILATION
$135.83
31529
9
LARYNGOSCOPY AND DILATION
$0.00
31530
3
LARYNGOSCOPY W/FB REMOVAL
$187.26
31531
3
LARYNGOSCOPY W/FB & OP SCOPE
$201.79
$583.78 $0.00
$907.78
$758.99 $0.00 $104.34
$0.00
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
31535
3
LARYNGOSCOPY W/BIOPSY
$179.41
31536
3
LARYNGOSCOPY W/BX & OP SCOPE
$200.35
31540
3
LARYNGOSCOPY W/EXC OF TUMOR
$230.18
31541
3
LARYNSCOP W/TUMR EXC + SCOPE
$251.72
31545
3
REMOVE VC LESION W/SCOPE
$340.47
31546
3
REMOVE VC LESION SCOPE/GRAFT
$518.33
3155F
9
CYTOGEN TEST MARROW B/4 TX
31560
3
LARYNGOSCOP W/ARYTENOIDECTOM
$297.85
31561
3
LARYNSCOP, REMVE CART + SCOP
$326.35
31570
3
LARYNGOSCOPE W/VC INJ
$317.28
31571
3
LARYNGOSCOP W/VC INJ + SCOPE
$237.51
31575
3
DIAGNOSTIC LARYNGOSCOPY
$105.79
31576
3
LARYNGOSCOPY WITH BIOPSY
$205.74
31577
9
REMOVE FOREIGN BODY, LARYNX
31578
3
REMOVAL OF LARYNX LESION
$257.47
31579
3
DIAGNOSTIC LARYNGOSCOPY
$199.68
31580
3
REVISION OF LARYNX
$1,088.96
31582
3
REVISION OF LARYNX
$1,731.56
31584
3
TREAT LARYNX FRACTURE
$1,382.50
31585
O
TREAT LARYNX FRACTURE
$0.00
31586
O
TREAT LARYNX FRACTURE
$0.00
31587
3
REVISION OF LARYNX
$900.72
31588
3
REVISION OF LARYNX
$1,025.87
31590
9
REINNERVATE LARYNX
$0.00
31595
9
LARYNX NERVE SURGERY
$0.00
31599
5
LARYNX SURGERY PROCEDURE
$0.00
31600
3
INCISION OF WINDPIPE
$372.25
31601
3
INCISION OF WINDPIPE
$246.63
31603
3
INCISION OF WINDPIPE
$209.88
31605
3
INCISION OF WINDPIPE
$172.65
3160F
9
DOC FE+ STORES B/4 EPO THX
31610
3
INCISION OF WINDPIPE
$644.45
31611
3
SURGERY/SPEECH PROSTHESIS
$484.70
31612
3
PUNCTURE/CLEAR WINDPIPE
$73.99
31613
3
REPAIR WINDPIPE OPENING
$401.41
$0.00
$0.00
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
31614
9
REPAIR WINDPIPE OPENING
$0.00
31615
3
VISUALIZATION OF WINDPIPE
$168.35
31620
3
ENDOBRONCHIAL US ADD-ON
$266.73
31622
3
DX BRONCHOSCOPE/WASH
$139.15
31623
3
DX BRONCHOSCOPE/BRUSH
$326.38
31624
3
DX BRONCHOSCOPE/LAVAGE
$141.15
31625
3
BRONCHOSCOPY W/BIOPSY(S)
$326.24
31628
3
BRONCHOSCOPY/LUNG BX, EACH
$183.36
31629
3
BRONCHOSCOPY/NEEDLE BX, EACH
$196.20
31630
3
BRONCHOSCOPY DILATE/FX REPR
$196.31
31631
3
BRONCHOSCOPY, DILATE W/STENT
$221.25
31632
3
BRONCHOSCOPY/LUNG BX, ADDÏL
$71.80
31633
3
BRONCHOSCOPY/NEEDLE BX ADDÏL
$86.49
31635
3
BRONCHOSCOPY W/FB REMOVAL
$334.69
31636
3
BRONCHOSCOPY, BRONCH STENTS
$216.17
31637
3
BRONCHOSCOPY, STENT ADD-ON
$76.58
31638
3
BRONCHOSCOPY, REVISE STENT
$242.50
31640
3
BRONCHOSCOPY W/TUMOR EXCISE
$251.15
31641
3
BRONCHOSCOPY, TREAT BLOCKAGE
$248.04
31643
3
DIAG BRONCHOSCOPE/CATHETER
$170.18
31645
3
BRONCHOSCOPY, CLEAR AIRWAYS
$154.47
31646
3
BRONCHOSCOPY, RECLEAR AIRWAY
$133.83
31656
3
BRONCHOSCOPY, INJ FOR X-RAY
$304.81
31659
O
BRONCHOSCOPY; WITH OTHER BRONCHOSCO
$0.00
31700
O
INSERTION OF AIRWAY CATHETER
$0.00
31708
O
INSTILL AIRWAY CONTRAST DYE
$0.00
3170F
9
FLOW CYTO DONE B/4 TX
$0.00
31710
O
INSERTION OF AIRWAY CATHETER
$0.00
31715
3
INJECTION FOR BRONCHUS X-RAY
$53.55
31717
3
BRONCHIAL BRUSH BIOPSY
31719
O
TRANSTRACHEAL (PERCUTANEOUS) INTROD
31720
3
CLEARANCE OF AIRWAYS
$50.27
31725
3
CLEARANCE OF AIRWAYS
$90.41
31730
3
INTRO, WINDPIPE WIRE/TUBE
31750
3
REPAIR OF WINDPIPE
$286.15 $0.00
$818.94 $1,217.18
Procedure Code Pricing Action Code Description
Maximum Allowable
31755
3
REPAIR OF WINDPIPE
$1,545.80
31760
3
REPAIR OF WINDPIPE
$1,303.25
31766
3
RECONSTRUCTION OF WINDPIPE
$1,699.18
31770
3
REPAIR/GRAFT OF BRONCHUS
$1,259.06
31775
3
RECONSTRUCT BRONCHUS
$1,301.28
31780
3
RECONSTRUCT WINDPIPE
$1,102.49
31781
3
RECONSTRUCT WINDPIPE
$1,335.01
31785
3
REMOVE WINDPIPE LESION
$1,008.89
31786
3
REMOVE WINDPIPE LESION
$1,403.10
31800
3
REPAIR OF WINDPIPE INJURY
$637.05
31805
3
REPAIR OF WINDPIPE INJURY
$774.17
31820
3
CLOSURE OF WINDPIPE LESION
$387.94
31825
3
REPAIR OF WINDPIPE DEFECT
$542.00
31830
3
REVISE WINDPIPE SCAR
$390.90
31899
5
AIRWAYS SURGICAL PROCEDURE
$0.00
32000
O
DRAINAGE OF CHEST
$0.00
32001
O
TOTAL LUNG LAVAGE
$0.00
32002
O
TREATMENT OF COLLAPSED LUNG
$0.00
32005
O
TREAT LUNG LINING CHEMICALLY
$0.00
3200F
9
BARIUM SWALLOW TEST NOT REQ
$0.00
32019
O
INSERT PLEURAL CATHETER
$0.00
32020
O
INSERTION OF CHEST TUBE
$0.00
32035
3
EXPLORATION OF CHEST
$659.64
32036
3
EXPLORATION OF CHEST
$715.33
32095
3
BIOPSY THROUGH CHEST WALL
$586.88
32100
3
EXPLORATION/BIOPSY OF CHEST
$905.94
3210F
9
GRP A STREP TEST PERFORMED
$0.00
32110
3
EXPLORE/REPAIR CHEST
32120
3
RE-EXPLORATION OF CHEST
$812.59
32124
3
EXPLORE CHEST FREE ADHESIONS
$863.60
32140
3
REMOVAL OF LUNG LESION(S)
$923.67
32141
3
REMOVE/TREAT LUNG LESIONS
32150
3
REMOVAL OF LUNG LESION(S)
$930.72
32151
3
REMOVE LUNG FOREIGN BODY
$952.35
3215F
9
PT IMMUNITY TO HEP A DOCÏD
$1,363.70
$1,392.19
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
32160
3
OPEN CHEST HEART MASSAGE
$714.41
3216F
9
PT IMMUNITY TO HEP B DOCÏD
$0.00
3218F
9
RNA TSTNG HEP C DOCÏD-DONE
$0.00
32200
3
DRAIN, OPEN, LUNG LESION
32201
3
DRAIN, PERCUT, LUNG LESION
3220F
9
HEP C QUANT RNA TSTNG DOCÏD
32215
3
TREAT CHEST LINING
32220
3
RELEASE OF LUNG
32225
3
PARTIAL RELEASE OF LUNG
3230F
9
NOTE HRING TST W/IN 6 MON
32310
3
REMOVAL OF CHEST LINING
32315
O
PLEURECTOMY; PARTIAL
32320
3
FREE/REMOVE CHEST LINING
32400
3
NEEDLE BIOPSY CHEST LINING
$145.52
32402
3
OPEN BIOPSY CHEST LINING
$528.92
32405
3
BIOPSY, LUNG OR MEDIASTINUM
32420
3
PUNCTURE/CLEAR LUNG
$108.88
32421
3
THORACENTESIS FOR ASPIRATION
$151.96
32422
3
THORACENTESIS W/TUBE INSERT
$191.31
32440
3
REMOVAL OF LUNG
$1,500.02
32442
3
SLEEVE PNEUMONECTOMY
$2,779.09
32445
3
REMOVAL OF LUNG
$3,159.30
32450
O
PNEUMONECTOMY, EXTRAPLEURAL WITH EM
32480
3
PARTIAL REMOVAL OF LUNG
$1,415.56
32482
3
BILOBECTOMY
$1,510.12
32484
3
SEGMENTECTOMY
$1,364.75
32485
O
REMOVAL OF LUNG, OTHER THAN TOTAL P
32486
3
SLEEVE LOBECTOMY
$2,173.89
32488
3
COMPLETION PNEUMONECTOMY
$2,203.35
32490
O
LOBECTOMY, TOTAL OR SEGMENTAL WITH
32491
3
LUNG VOLUME REDUCTION
$1,406.70
32500
3
PARTIAL REMOVAL OF LUNG
$1,369.19
32501
3
REPAIR BRONCHUS ADD-ON
$238.27
32503
3
RESECT APICAL LUNG TUMOR
$1,727.34
32504
3
RESECT APICAL LUNG TUM/CHEST
$1,983.90
$1,045.13 $889.23 $0.00 $750.25 $1,498.45 $931.87 $0.00 $859.92 $0.00 $1,500.54
$98.96
$0.00
$0.00
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
3250F
9
NONPRIM LOC ANAT BX SITE TUM
$0.00
32520
O
REMOVE LUNG & REVISE CHEST
$0.00
32522
O
REMOVE LUNG & REVISE CHEST
$0.00
32525
O
REMOVE LUNG & REVISE CHEST
$0.00
32540
3
REMOVAL OF LUNG LESION
32545
O
EXTRAPLEURAL ENUCLEATION OF EMPYEMA
32550
3
INSERT PLEURAL CATH
$755.79
32551
3
INSERTION OF CHEST TUBE
$169.65
32560
3
TREAT LUNG LINING CHEMICALLY
$281.94
32601
3
THORACOSCOPY, DIAGNOSTIC
$297.11
32602
3
THORACOSCOPY, DIAGNOSTIC
$322.19
32603
3
THORACOSCOPY, DIAGNOSTIC
$417.32
32604
3
THORACOSCOPY, DIAGNOSTIC
$468.68
32605
3
THORACOSCOPY, DIAGNOSTIC
$369.96
32606
3
THORACOSCOPY, DIAGNOSTIC
$447.72
3260F
9
PT CAT/PN CAT/HIST GRD DOCÏD
32650
3
THORACOSCOPY, SURGICAL
$637.52
32651
3
THORACOSCOPY, SURGICAL
$1,004.00
32652
3
THORACOSCOPY, SURGICAL
$1,523.55
32653
3
THORACOSCOPY, SURGICAL
$973.07
32654
3
THORACOSCOPY, SURGICAL
$1,074.84
32655
3
THORACOSCOPY, SURGICAL
$888.90
32656
3
THORACOSCOPY, SURGICAL
$762.73
32657
3
THORACOSCOPY, SURGICAL
$752.60
32658
3
THORACOSCOPY, SURGICAL
$688.11
32659
3
THORACOSCOPY, SURGICAL
$699.24
3265F
9
RNA TSTNG HEPC VIR ORD/DOCÏD
32660
3
THORACOSCOPY, SURGICAL
$985.38
32661
3
THORACOSCOPY, SURGICAL
$768.14
32662
3
THORACOSCOPY, SURGICAL
$859.73
32663
3
THORACOSCOPY, SURGICAL
$1,321.27
32664
3
THORACOSCOPY, SURGICAL
$816.49
32665
3
THORACOSCOPY, SURGICAL
$1,143.60
3266F
9
HEPC GN TSTNG DOCÏD B/4TXMNT
$0.00
3268F
9
PSA/T/G1SC DOCÏD B/4 TXMNT
$0.00
$1,568.58 $0.00
$0.00
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
3269F
9
BONE SCN B/4 TXMNT/AFTR DX
$0.00
32700
O
THORACOSCOPY, EXPLORATORY (SEPARATE
$0.00
32705
O
THORACOSCOPY, EXPLORATORY (SEPARATE
$0.00
3270F
9
NO BONE SCN B/4 TXMNT/AFTRDX
$0.00
3271F
9
LOW RISK, PROSTATE CANCER
$0.00
3272F
9
MED. RISK, PROSTATE CANCER
$0.00
3273F
9
HIGH RISK, PROSTATE CANCER
$0.00
3274F
9
PROST CNCR RSK NOT LW/MD/HGH
$0.00
3278F
9
SERUM LVLS CA/IPTH/LPD ORD
$0.00
3279F
9
HGB LVL >/=13 G/DL
$0.00
32800
3
REPAIR LUNG HERNIA
3280F
9
HGB LVL 11-12.9 G/DL
32810
3
CLOSE CHEST AFTER DRAINAGE
32815
3
CLOSE BRONCHIAL FISTULA
3281F
9
HGB LVL <11 G/DL
32820
3
RECONSTRUCT INJURED CHEST
3284F
9
IOP DOWN >15% OF PRE-SVC LVL
$0.00
32850
9
DONOR PNEUMONECTOMY
$0.00
32851
3
LUNG TRANSPLANT, SINGLE
$2,451.44
32852
3
LUNG TRANSPLANT WITH BYPASS
$2,715.09
32853
3
LUNG TRANSPLANT, DOUBLE
$2,926.86
32854
3
LUNG TRANSPLANT WITH BYPASS
$3,189.02
32855
9
PREPARE DONOR LUNG, SINGLE
$0.00
32856
9
PREPARE DONOR LUNG, DOUBLE
$0.00
3285F
9
IOP DOWN <15% OF PRE-SVC LVL
$0.00
3288F
9
FALL RISK ASSESSMENT DOCÏD
$0.00
32900
3
REMOVAL OF RIB(S)
$1,289.30
32905
3
REVISE & REPAIR CHEST WALL
$1,271.91
32906
3
REVISE & REPAIR CHEST WALL
$1,578.79
3290F
9
PT=D(RH)- AND UNSENSITIZED
$0.00
3291F
9
PT=D(RH)+OR SENSITIZED
$0.00
3292F
9
HIV TSTNG ASKED/DOCÏD/REVWÏD
$0.00
32940
3
REVISION OF LUNG
32960
3
THERAPEUTIC PNEUMOTHORAX
$132.44
32997
3
TOTAL LUNG LAVAGE
$343.17
$877.63 $0.00 $849.64 $2,505.54 $0.00 $1,265.62
$1,165.45
Procedure Code Pricing Action Code Description
Maximum Allowable
32998
3
PERQ RF ABLATE TX, PUL TUMOR
$2,733.40
32999
5
CHEST SURGERY PROCEDURE
$0.00
3300F
9
AJCC STAGE DOCD B/4 THXPY
$0.00
33010
3
DRAINAGE OF HEART SAC
$120.37
33011
3
REPEAT DRAINAGE OF HEART SAC
$117.65
33015
3
INCISION OF HEART SAC
$512.75
3301F
9
CANCER STAGE DOCD METAST
33020
3
INCISION OF HEART SAC
$825.53
33025
3
INCISION OF HEART SAC
$762.21
3302F
O
AJCC STAGE 0 DOCÏD
33030
3
PARTIAL REMOVAL OF HEART SAC
$1,219.15
33031
3
PARTIAL REMOVAL OF HEART SAC
$1,360.49
3303F
O
AJCC STAGE IA DOCÏD
$0.00
3304F
O
AJCC STAGE IB DOCÏD
$0.00
33050
3
REMOVAL OF HEART SAC LESION
3305F
O
AJCC STAGE IC DOCÏD
$0.00
3306F
O
AJCC STAGE IIA DOCÏD
$0.00
3307F
O
AJCC STAGE IIB DOCÏD
$0.00
3308F
O
AJCC STAGE IIC DOCÏD
$0.00
3309F
O
AJCC STAGE IIIA DOCÏD
$0.00
33100
O
PERICARDIECTOMY (SEPARATE PROCEDURE
$0.00
3310F
O
AJCC STAGE IIIB DOCÏD
$0.00
3311F
O
AJCC STAGE IIIC DOCÏD
$0.00
33120
3
REMOVAL OF HEART LESION
3312F
O
AJCC STAGE IVA DOCÏD
33130
3
REMOVAL OF HEART LESION
3313F
O
AJCC STAGE IVB DOCÏD
33140
3
HEART REVASCULARIZE (TMR)
33141
3
HEART TMR W/OTHER PROCEDURE
3314F
O
AJCC STAGE IVC DOCÏD
$0.00
3315F
9
ER +OR PR +BREAST CANCER
$0.00
3316F
9
ER- OR PR- BREAST CANCER
$0.00
3317F
9
PATH RPT MALIG CANCER DOCÏD
$0.00
3318F
9
PATH RPT MALIG CANCER DOCÏD
$0.00
3319F
9
X-RAY/CT/ULTRSND ET AL ORDÏD
$0.00
$0.00
$0.00
$943.12
$1,488.23 $0.00 $1,310.86 $0.00 $1,494.68 $145.38
Procedure Code Pricing Action Code Description
Maximum Allowable
33200
O
INSERTION OF HEART PACEMAKER
$0.00
33201
O
INSERTION OF HEART PACEMAKER
$0.00
33202
3
INSERT EPICARD ELTRD, OPEN
$744.17
33203
3
INSERT EPICARD ELTRD, ENDO
$784.72
33206
3
INSERTION OF HEART PACEMAKER
$457.42
33207
3
INSERTION OF HEART PACEMAKER
$489.30
33208
3
INSERTION OF HEART PACEMAKER
$527.25
3320F
9
NO XRAY/CT/ ET AL ORDÏD
33210
3
INSERTION OF HEART ELECTRODE
$180.65
33211
3
INSERTION OF HEART ELECTRODE
$181.26
33212
3
INSERTION OF PULSE GENERATOR
$341.78
33213
3
INSERTION OF PULSE GENERATOR
$390.00
33214
3
UPGRADE OF PACEMAKER SYSTEM
$483.79
33215
3
REPOSITION PACING-DEFIB LEAD
$309.31
33216
3
INSERT LEAD PACE-DEFIB, ONE
$381.50
33217
3
INSERT LEAD PACE-DEFIB, DUAL
$378.19
33218
3
REPAIR LEAD PACE-DEFIB, ONE
$394.49
33219
O
REPAIR OF PACEMAKER WITH REPLACEMEN
$0.00
3321F
9
AJCC CNCR 0/IA MELAN DOCD
$0.00
33220
3
REPAIR LEAD PACE-DEFIB, DUAL
$398.09
33222
3
REVISE POCKET, PACEMAKER
$347.69
33223
3
REVISE POCKET, PACING-DEFIB
$420.16
33224
3
INSERT PACING LEAD & CONNECT
$510.85
33225
3
L VENTRIC PACING LEAD ADD-ON
$460.40
33226
3
REPOSITION L VENTRIC LEAD
$493.64
3322F
9
MELAN >AJCC STAGE 0 OR IA
$0.00
33232
O
REMOVAL OF PERMANENT PACEMAKER
$0.00
33233
3
REMOVAL OF PACEMAKER SYSTEM
$243.69
33234
3
REMOVAL OF PACEMAKER SYSTEM
$491.36
33235
3
REMOVAL PACEMAKER ELECTRODE
$635.57
33236
3
REMOVE ELECTRODE/THORACOTOMY
$747.65
33237
3
REMOVE ELECTRODE/THORACOTOMY
$826.70
33238
3
REMOVE ELECTRODE/THORACOTOMY
$890.80
33240
3
INSERT PULSE GENERATOR
$469.58
33241
3
REMOVE PULSE GENERATOR
$230.24
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
33242
O
REPAIR PULSE GENERATOR/LEADS
$0.00
33243
3
REMOVE ELTRD/THORACOTOMY
33244
3
REMOVE ELTRD, TRANSVEN
33245
O
INSERT EPIC ELTRD PACE-DEFIB
$0.00
33246
O
INSERT EPIC ELTRD/GENERATOR
$0.00
33247
O
INSERT/REPLACE LEADS
$0.00
33248
O
REVISION OR REMOVAL OF AUTOMATIC IM
$0.00
33249
3
ELTRD/INSERT PACE-DEFIB
33250
3
ABLATE HEART DYSRHYTHM FOCUS
$1,400.28
33251
3
ABLATE HEART DYSRHYTHM FOCUS
$1,551.30
33253
O
RECONSTRUCT ATRIA
33254
3
ABLATE ATRIA, LMTD
$1,306.65
33255
3
ABLATE ATRIA W/O BYPASS, EXT
$1,598.51
33256
3
ABLATE ATRIA W/BYPASS, EXTEN
$1,905.68
33257
3
ABLATE ATRIA, LMTD, ADD-ON
$552.15
33258
3
ABLATE ATRIA, X10SV, ADD-ON
$623.28
33259
3
ABLATE ATRIA W/BYPASS ADD-ON
$813.39
3325F
9
PREOP ASSES 4 CATARACT SURG
$0.00
33260
O
OPERATIVE ABLATION OF ARRHYTHMOGENI
$0.00
33261
3
ABLATE HEART DYSRHYTHM FOCUS
$1,543.51
33265
3
ABLATE ATRIA, LMTD, ENDO
$1,303.69
33266
3
ABLATE ATRIA, X10SV, ENDO
$1,787.93
33282
3
IMPLANT PAT-ACTIVE HT RECORD
$326.89
33284
3
REMOVE PAT-ACTIVE HT RECORD
$236.21
33300
3
REPAIR OF HEART WOUND
$2,207.25
33305
3
REPAIR OF HEART WOUND
$3,680.75
3330F
9
IMAGING STUDY ORDERED (BKP)
$0.00
33310
3
EXPLORATORY HEART SURGERY
$1,117.35
33315
3
EXPLORATORY HEART SURGERY
$1,420.23
3331F
9
BK IMAGING TST NOT ORDERED
33320
3
REPAIR MAJOR BLOOD VESSEL(S)
$1,013.03
33321
3
REPAIR MAJOR VESSEL
$1,142.16
33322
3
REPAIR MAJOR BLOOD VESSEL(S)
$1,326.19
33330
3
INSERT MAJOR VESSEL GRAFT
$1,337.46
33332
3
INSERT MAJOR VESSEL GRAFT
$1,337.08
$1,309.43 $863.22
$913.06
$0.00
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
33335
3
INSERT MAJOR VESSEL GRAFT
$1,804.33
33350
O
GREAT VESSEL REPAIR WITH OTHER MAJO
33400
3
REPAIR OF AORTIC VALVE
$2,173.52
33401
3
VALVULOPLASTY, OPEN
$1,441.40
33403
3
VALVULOPLASTY, W/CP BYPASS
$1,447.11
33404
3
PREPARE HEART-AORTA CONDUIT
$1,712.54
33405
3
REPLACEMENT OF AORTIC VALVE
$2,218.88
33406
3
REPLACEMENT OF AORTIC VALVE
$2,736.02
33407
O
VALVOTOMY, AORTIC VALVE (COMMISSURO
$0.00
33408
O
VALVOTOMY, AORTIC VALVE (COMMISSURO
$0.00
3340F
9
MAMMO ASSESS INC XRAY DOCD
$0.00
33410
3
REPLACEMENT OF AORTIC VALVE
$2,414.64
33411
3
REPLACEMENT OF AORTIC VALVE
$3,151.03
33412
3
REPLACEMENT OF AORTIC VALVE
$2,395.63
33413
3
REPLACEMENT OF AORTIC VALVE
$3,107.56
33414
3
REPAIR OF AORTIC VALVE
$2,078.06
33415
3
REVISION, SUBVALVULAR TISSUE
$1,924.68
33416
3
REVISE VENTRICLE MUSCLE
$1,934.82
33417
3
REPAIR OF AORTIC VALVE
$1,615.32
3341F
9
MAMMO ASSESS NEGATIVE DOCD
33420
3
REVISION OF MITRAL VALVE
$1,308.44
33422
3
REVISION OF MITRAL VALVE
$1,621.30
33425
3
REPAIR OF MITRAL VALVE
$2,522.20
33426
3
REPAIR OF MITRAL VALVE
$2,291.35
33427
3
REPAIR OF MITRAL VALVE
$2,390.98
3342F
9
MAMMO ASSESS BENGN DOCD
33430
3
REPLACEMENT OF MITRAL VALVE
$2,649.64
3343F
9
MAMMO PROBABLY BENGN DOCD
$0.00
3344F
9
MAMMO ASSESS SUSP, DOCD
$0.00
33452
O
VALVOTOMY, TRICUSPID VALVE, WITH CA
$0.00
3345F
9
MAMMO ASSESS HGHLYMALIG DOC
$0.00
33460
3
REVISION OF TRICUSPID VALVE
$2,243.90
33463
3
VALVULOPLASTY, TRICUSPID
$2,834.69
33464
3
VALVULOPLASTY, TRICUSPID
$2,285.23
33465
3
REPLACE TRICUSPID VALVE
$2,556.65
$0.00
$0.00
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
33468
3
REVISION OF TRICUSPID VALVE
$1,807.15
33470
3
REVISION OF PULMONARY VALVE
$1,141.46
33471
3
VALVOTOMY, PULMONARY VALVE
$1,273.04
33472
3
REVISION OF PULMONARY VALVE
$1,285.66
33474
3
REVISION OF PULMONARY VALVE
$1,967.72
33475
3
REPLACEMENT, PULMONARY VALVE
$2,218.68
33476
3
REVISION OF HEART CHAMBER
$1,405.46
33478
3
REVISION OF HEART CHAMBER
$1,512.32
33480
O
REPLACEMENT AND/OR REPAIR, DOUBLE V
$0.00
33481
O
SINGLE VALVE REPLACEMENT WITH COMMI
$0.00
33482
O
SINGLE VALVE REPLACEMENT WITH COMMI
$0.00
33483
O
DOUBLE VALVE REPLACEMENT
$0.00
33485
O
DOUBLE VALVE REPLACEMENT WITH COMMI
$0.00
33490
O
REPLACEMENT AND/OR REPAIR, TRIPLE V
$0.00
33492
O
TRIPLE VALVE REPLACEMENT
$0.00
33496
3
REPAIR, PROSTH VALVE CLOT
$1,616.85
33500
3
REPAIR HEART VESSEL FISTULA
$1,517.21
33501
3
REPAIR HEART VESSEL FISTULA
$1,053.23
33502
3
CORONARY ARTERY CORRECTION
$1,217.79
33503
3
CORONARY ARTERY GRAFT
$1,307.97
33504
3
CORONARY ARTERY GRAFT
$1,389.42
33505
3
REPAIR ARTERY W/TUNNEL
$1,906.10
33506
3
REPAIR ARTERY, TRANSLOCATION
$1,977.80
33507
3
REPAIR ART, INTRAMURAL
$1,674.15
33508
3
ENDOSCOPIC VEIN HARVEST
3350F
9
MAMMO BX PROVEN MALIG DOCD
33510
3
CABG, VEIN, SINGLE
$1,887.44
33511
3
CABG, VEIN, TWO
$2,059.76
33512
3
CABG, VEIN, THREE
$2,318.80
33513
3
CABG, VEIN, FOUR
$2,367.58
33514
3
CABG, VEIN, FIVE
$2,509.48
33516
3
CABG, VEIN, SIX OR MORE
$2,609.56
33517
3
CABG, ARTERY-VEIN, SINGLE
$179.02
33518
3
CABG, ARTERY-VEIN, TWO
$387.37
33519
3
CABG, ARTERY-VEIN, THREE
$516.97
$15.73 $0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
3351F
9
NEG SCRN DEP SYMP BY DEPTOOL
$0.00
33520
O
CORONARY ARTERY BYPASS, NONAUTOGENO
$0.00
33521
3
CABG, ARTERY-VEIN, FOUR
$625.80
33522
3
CABG, ARTERY-VEIN, FIVE
$712.09
33523
3
CABG, ART-VEIN, SIX OR MORE
$812.72
33525
O
CORONARY ARTERY BYPASS, NONAUTOGENO
$0.00
33528
O
CORONARY ARTERY BYPASS, NONAUTOGENO
$0.00
3352F
9
NO SIG DEP SYMP BY DEP TOOL
$0.00
33530
3
CORONARY ARTERY, BYPASS/REOP
33533
3
CABG, ARTERIAL, SINGLE
$1,838.58
33534
3
CABG, ARTERIAL, TWO
$2,136.77
33535
3
CABG, ARTERIAL, THREE
$2,371.58
33536
3
CABG, ARTERIAL, FOUR OR MORE
$2,539.90
3353F
9
MILD-MOD DEP SYMP BY DEPTOOL
33542
3
REMOVAL OF HEART LESION
$2,444.91
33545
3
REPAIR OF HEART DAMAGE
$2,884.20
33548
3
RESTORE/REMODEL, VENTRICLE
$2,833.80
3354F
9
CLIN SIG DEP SYM BY DEP TOOL
$0.00
33570
O
CORONARY ANGIOPLASTY (ENDARTERECTOM
$0.00
33572
3
OPEN CORONARY ENDARTERECTOMY
33575
O
CORONARY ANGIOPLASTY (ENDARTERECTOM
33600
3
CLOSURE OF VALVE
$1,645.44
33602
3
CLOSURE OF VALVE
$1,566.82
33606
3
ANASTOMOSIS/ARTERY-AORTA
$1,707.65
33608
3
REPAIR ANOMALY W/CONDUIT
$1,754.32
33610
3
REPAIR BY ENLARGEMENT
$1,711.04
33611
3
REPAIR DOUBLE VENTRICLE
$1,878.69
33612
3
REPAIR DOUBLE VENTRICLE
$1,939.67
33615
3
REPAIR, MODIFIED FONTAN
$1,935.57
33617
3
REPAIR SINGLE VENTRICLE
$2,074.27
33619
3
REPAIR SINGLE VENTRICLE
$2,539.95
33641
3
REPAIR HEART SEPTUM DEFECT
$1,543.78
33645
3
REVISION OF HEART VEINS
$1,522.49
33647
3
REPAIR HEART SEPTUM DEFECTS
$1,621.16
33649
O
REPAIR OF TRICUSPID ATRESIA (EG, FO
$492.51
$0.00
$227.48 $0.00
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
33660
3
REPAIR OF HEART DEFECTS
$1,695.05
33665
3
REPAIR OF HEART DEFECTS
$1,834.11
33670
3
REPAIR OF HEART CHAMBERS
$1,905.86
33675
3
CLOSE MULT VSD
$1,903.21
33676
3
CLOSE MULT VSD W/RESECTION
$1,981.75
33677
3
CL MULT VSD W/REM PUL BAND
$2,059.58
33681
3
REPAIR HEART SEPTUM DEFECT
$1,762.73
33684
3
REPAIR HEART SEPTUM DEFECT
$1,796.80
33688
3
REPAIR HEART SEPTUM DEFECT
$1,802.56
33690
3
REINFORCE PULMONARY ARTERY
$1,111.39
33692
3
REPAIR OF HEART DEFECTS
$1,699.89
33694
3
REPAIR OF HEART DEFECTS
$1,914.18
33696
O
COMPLETE REPAIR TETRALOGY OF FALLOT
33697
3
REPAIR OF HEART DEFECTS
33698
O
COMPLETE REPAIR TETRALOGY OF FALLOT
33702
3
REPAIR OF HEART DEFECTS
3370F
9
AJCC BRST CNCR STAGE 0 DOCD
33710
3
REPAIR OF HEART DEFECTS
$1,791.93
33720
3
REPAIR OF HEART DEFECT
$1,495.53
33722
3
REPAIR OF HEART DEFECT
$1,485.90
33724
3
REPAIR VENOUS ANOMALY
$1,517.70
33726
3
REPAIR PUL VENOUS STENOSIS
$1,980.21
3372F
9
AJCC BRST CNCR STAGE 1 +DOCD
33730
3
REPAIR HEART-VEIN DEFECT(S)
$1,884.99
33732
3
REPAIR HEART-VEIN DEFECT
$1,577.25
33735
3
REVISION OF HEART CHAMBER
$1,201.82
33736
3
REVISION OF HEART CHAMBER
$1,340.37
33737
3
REVISION OF HEART CHAMBER
$1,250.33
33738
O
ATRIAL SEPTECTOMY OR SEPTOSTOMY TRA
$0.00
33739
O
ATRIAL SEPTECTOMY OR SEPTOSTOMY BLA
$0.00
3374F
9
AJCC BRST CNCR STAGE 1 +DOCD
$0.00
33750
3
MAJOR VESSEL SHUNT
$1,262.34
33755
3
MAJOR VESSEL SHUNT
$1,242.32
33762
3
MAJOR VESSEL SHUNT
$1,240.18
33764
3
MAJOR VESSEL SHUNT & GRAFT
$1,221.17
$0.00 $2,065.09 $0.00 $1,475.09 $0.00
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
33766
3
MAJOR VESSEL SHUNT
$1,347.78
33767
3
MAJOR VESSEL SHUNT
$1,359.24
33768
3
CAVOPULMONARY SHUNTING
3376F
9
AJCC BRSTCNCR STAGE 2 DOCD
33770
3
REPAIR GREAT VESSELS DEFECT
$2,064.65
33771
3
REPAIR GREAT VESSELS DEFECT
$2,114.89
33774
3
REPAIR GREAT VESSELS DEFECT
$1,744.39
33775
3
REPAIR GREAT VESSELS DEFECT
$1,814.76
33776
3
REPAIR GREAT VESSELS DEFECT
$1,909.71
33777
3
REPAIR GREAT VESSELS DEFECT
$1,869.72
33778
3
REPAIR GREAT VESSELS DEFECT
$2,295.27
33779
3
REPAIR GREAT VESSELS DEFECT
$2,199.00
33780
3
REPAIR GREAT VESSELS DEFECT
$2,288.07
33781
3
REPAIR GREAT VESSELS DEFECT
$2,246.94
33786
3
REPAIR ARTERIAL TRUNK
$2,211.41
33788
3
REVISION OF PULMONARY ARTERY
$1,495.12
3378F
9
AJCC BRSTCNCR STAGE 3 DOCD
33800
3
AORTIC SUSPENSION
33802
3
REPAIR VESSEL DEFECT
$1,009.35
33803
3
REPAIR VESSEL DEFECT
$1,096.52
3380F
9
AJCC BRSTCNCR STAGE 4 DOCD
33813
3
REPAIR SEPTAL DEFECT
$1,248.46
33814
3
REPAIR SEPTAL DEFECT
$1,467.45
33820
3
REVISE MAJOR VESSEL
$940.45
33822
3
REVISE MAJOR VESSEL
$998.49
33824
3
REVISE MAJOR VESSEL
$1,128.75
3382F
9
AJCC CLN CNCR STAGE 0 DOCD
$0.00
33830
O
PATENT DUCTUS ARTERIOSUS LIGATION O
$0.00
33840
3
REMOVE AORTA CONSTRICTION
$1,139.47
33845
3
REMOVE AORTA CONSTRICTION
$1,318.59
3384F
9
AJCC CLN CNCR STAGE 1 DOCD
$0.00
33851
3
REMOVE AORTA CONSTRICTION
$1,209.70
33852
3
REPAIR SEPTAL DEFECT
$1,313.87
33853
3
REPAIR SEPTAL DEFECT
$1,813.85
33855
O
EXCISION OF COARCTATION OF AORTA, W
$413.47 $0.00
$0.00 $937.52
$0.00
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
33860
3
ASCENDING AORTIC GRAFT
$3,017.52
33861
3
ASCENDING AORTIC GRAFT
$2,354.27
33863
3
ASCENDING AORTIC GRAFT
$3,015.63
33864
3
ASCENDING AORTIC GRAFT
$3,100.20
33865
O
ASCENDING AORTA GRAFT, WITH CARDIOP
$0.00
3386F
9
AJCC CLN CNCR STAGE 2 DOCD
$0.00
33870
3
TRANSVERSE AORTIC ARCH GRAFT
$2,457.25
33875
3
THORACIC AORTIC GRAFT
$1,907.19
33877
3
THORACOABDOMINAL GRAFT
$3,381.99
33880
3
ENDOVASC TAA REPR INCL SUBCL
$1,753.49
33881
3
ENDOVASC TAA REPR W/O SUBCL
$1,505.60
33883
3
INSERT ENDOVASC PROSTH, TAA
$1,100.46
33884
3
ENDOVASC PROSTH, TAA, ADD-ON
$401.25
33886
3
ENDOVASC PROSTH, DELAYED
$945.53
33889
3
ARTERY TRANSPOSE/ENDOVAS TAA
$787.87
3388F
9
AJCC CLN CNCR STAGE 3 DOCD
33891
3
CAR-CAR BP GRFT/ENDOVAS TAA
3390F
9
AJCC CLN CNCR STAGE 4 DOCD
$0.00
33910
3
REMOVE LUNG ARTERY EMBOLI
$1,597.09
33915
3
REMOVE LUNG ARTERY EMBOLI
$1,275.60
33916
3
SURGERY OF GREAT VESSEL
$1,602.40
33917
3
REPAIR PULMONARY ARTERY
$1,451.01
33918
O
REPAIR PULMONARY ATRESIA
$0.00
33919
O
REPAIR PULMONARY ATRESIA
$0.00
33920
3
REPAIR PULMONARY ATRESIA
$1,747.21
33922
3
TRANSECT PULMONARY ARTERY
$1,322.95
33924
3
REMOVE PULMONARY SHUNT
33925
3
RPR PUL ART UNIFOCAL W/O CPB
$1,701.13
33926
3
REPR PUL ART, UNIFOCAL W/CPB
$2,256.60
33930
9
REMOVAL OF DONOR HEART/LUNG
$0.00
33933
9
PREPARE DONOR HEART/LUNG
$0.00
33935
3
TRANSPLANTATION, HEART/LUNG
33940
9
REMOVAL OF DONOR HEART
$0.00
33944
9
PREPARE DONOR HEART
$0.00
33945
3
TRANSPLANTATION OF HEART
$0.00 $985.29
$278.68
$3,346.95
$4,441.23
Procedure Code Pricing Action Code Description
Maximum Allowable
33960
3
EXTERNAL CIRCULATION ASSIST
$968.04
33961
3
EXTERNAL CIRCULATION ASSIST
$539.61
33967
3
INSERT IA PERCUT DEVICE
$266.75
33968
3
REMOVE AORTIC ASSIST DEVICE
33970
3
AORTIC CIRCULATION ASSIST
$357.37
33971
3
AORTIC CIRCULATION ASSIST
$688.83
33972
O
INTRA-AORTIC BALLOON COUNTERPULSATI
33973
3
INSERT BALLOON DEVICE
$520.94
33974
3
REMOVE INTRA-AORTIC BALLOON
$878.00
33975
3
IMPLANT VENTRICULAR DEVICE
$1,075.80
33976
3
IMPLANT VENTRICULAR DEVICE
$1,196.18
33977
3
REMOVE VENTRICULAR DEVICE
$1,162.00
33978
3
REMOVE VENTRICULAR DEVICE
$1,278.55
33979
3
INSERT INTRACORPOREAL DEVICE
$2,359.16
33980
3
REMOVE INTRACORPOREAL DEVICE
$3,473.72
33999
5
CARDIAC SURGERY PROCEDURE
34001
3
REMOVAL OF ARTERY CLOT
$932.57
34051
3
REMOVAL OF ARTERY CLOT
$936.72
34101
3
REMOVAL OF ARTERY CLOT
$594.53
34111
3
REMOVAL OF ARM ARTERY CLOT
$594.29
34151
3
REMOVAL OF ARTERY CLOT
$1,373.62
34201
3
REMOVAL OF ARTERY CLOT
$967.22
34203
3
REMOVAL OF LEG ARTERY CLOT
$950.03
34401
3
REMOVAL OF VEIN CLOT
$1,418.42
34421
3
REMOVAL OF VEIN CLOT
$720.20
34451
3
REMOVAL OF VEIN CLOT
$1,483.59
34471
3
REMOVAL OF VEIN CLOT
$1,037.86
34490
3
REMOVAL OF VEIN CLOT
$597.88
34501
3
REPAIR VALVE, FEMORAL VEIN
$926.98
34502
3
RECONSTRUCT VENA CAVA
3450F
9
DYSPNEA SCRND, NO-MILD DYSP
34510
3
TRANSPOSITION OF VEIN VALVE
3451F
9
DYSPNEA SCRND MOD-HIGH DYSP
34520
3
CROSS-OVER VEIN GRAFT
$1,009.57
3452F
9
DYSPNEA NOT SCREENED
$0.00
$34.16
$0.00
$0.00
$1,499.20 $0.00 $1,051.37 $0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
34530
3
LEG VEIN FUSION
$949.54
3455F
9
TB SCRNG DONE-INTERPD 6MON
$0.00
3470F
9
RA DISEASE ACTIVITY, LOW
$0.00
3471F
9
RA DISEASE ACTIVITY, MOD
$0.00
3472F
9
RA DISEASE ACTIVITY, HIGH
$0.00
3475F
9
DISEASE PROGN RA POOR DOCD
$0.00
3476F
9
DISEASE PROGN RA GOOD DOCD
$0.00
34800
3
ENDOVAS AAA REPR W/SM TUBE
$1,129.34
34802
3
ENDOVAS AAA REPR W/2-P PART
$1,232.87
34803
3
ENDOVAS AAA REPR W/3-P PART
$1,260.90
34804
3
ENDOVAS AAA REPR W/1-P PART
$1,232.15
34805
3
ENDOVAS AAA REPR W/LONG TUBE
$1,156.71
34806
3
ANEURYSM PRESS SENSOR ADD-ON
$104.46
34808
3
ENDOVAS ILIAC A DEVICE ADDON
$205.36
34812
3
XPOSE FOR ENDOPROSTH, FEMORL
$339.74
34813
3
FEMORAL ENDOVAS GRAFT ADD-ON
$236.02
34820
3
XPOSE FOR ENDOPROSTH, ILIAC
$487.88
34825
3
ENDOVASC EXTEND PROSTH, INIT
$691.51
34826
3
ENDOVASC EXTEN PROSTH, ADDÏL
$203.99
34830
3
OPEN AORTIC TUBE PROSTH REPR
$1,802.15
34831
3
OPEN AORTOILIAC PROSTH REPR
$1,908.20
34832
3
OPEN AORTOFEMOR PROSTH REPR
$1,936.08
34833
3
XPOSE FOR ENDOPROSTH, ILIAC
$607.47
34834
3
XPOSE, ENDOPROSTH, BRACHIAL
$275.58
34900
3
ENDOVASC ILIAC REPR W/GRAFT
$897.11
3490F
9
HISTORY - AIDS-DEFINING COND
$0.00
3491F
9
HIV UNSURE BABY OF HIV+MOMS
$0.00
3492F
9
HISTORY CD4+CELL COUNT <350
$0.00
3493F
9
NO HIST CD4+CELL CNT <350
$0.00
3494F
9
CD4+CELL COUNT <200CELLS/MM3
$0.00
3495F
9
CD4+CELL CNT 200-499 CELLS
$0.00
3496F
9
CD4+ CELL COUNT >=500 CELLS
$0.00
3497F
9
CD4+ CELL PERCENTAGE <15%
$0.00
3498F
9
CD4+ CELL PERCENTAGE >=15%
$0.00
35001
3
REPAIR DEFECT OF ARTERY
$1,119.07
Procedure Code Pricing Action Code Description
Maximum Allowable
35002
3
REPAIR ARTERY RUPTURE, NECK
$1,181.02
35005
3
REPAIR DEFECT OF ARTERY
$1,028.37
3500F
9
CD4 +CELL CNT/% DOCD AS DONE
35011
3
REPAIR DEFECT OF ARTERY
35013
3
REPAIR ARTERY RUPTURE, ARM
$1,217.33
35021
3
REPAIR DEFECT OF ARTERY
$1,195.32
35022
3
REPAIR ARTERY RUPTURE, CHEST
$1,350.10
3502F
9
HIV RNA VRL LD
$0.00
3503F
9
HIV RNA VRL LDNOT
$0.00
35045
3
REPAIR DEFECT OF ARM ARTERY
35081
3
REPAIR DEFECT OF ARTERY
$1,708.53
35082
3
REPAIR ARTERY RUPTURE, AORTA
$2,145.55
35091
3
REPAIR DEFECT OF ARTERY
$1,806.74
35092
3
REPAIR ARTERY RUPTURE, AORTA
$2,561.30
35102
3
REPAIR DEFECT OF ARTERY
$1,853.25
35103
3
REPAIR ARTERY RUPTURE, GROIN
$2,216.73
3510F
9
DOC TB SCRNG-RSLTS INTERPD
35111
3
REPAIR DEFECT OF ARTERY
$1,366.95
35112
3
REPAIR ARTERY RUPTURE,SPLEEN
$1,674.39
3511F
9
CHLMYD/GONRH TSTS DOCD DONE
$0.00
35121
3
REPAIR DEFECT OF ARTERY
$1,622.15
35122
3
REPAIR ARTERY RUPTURE, BELLY
$1,941.93
3512F
9
SYPH SCRNG DOCD AS DONE
35131
3
REPAIR DEFECT OF ARTERY
$1,384.33
35132
3
REPAIR ARTERY RUPTURE, GROIN
$1,671.90
3513F
9
HEP B SCRNG DOCD AS DONE
35141
3
REPAIR DEFECT OF ARTERY
$1,098.15
35142
3
REPAIR ARTERY RUPTURE, THIGH
$1,313.60
3514F
9
HEP C SCRNG DOCD AS DONE
35151
3
REPAIR DEFECT OF ARTERY
$1,238.17
35152
3
REPAIR ARTERY RUPTURE, KNEE
$1,437.76
3515F
9
PT HAS DOCD IMMUN TO HEP C
$0.00
35161
O
REPAIR DEFECT OF ARTERY
$0.00
35162
O
REPAIR ARTERY RUPTURE
$0.00
35180
3
REPAIR BLOOD VESSEL LESION
$0.00 $981.35
$954.51
$0.00
$0.00
$0.00
$0.00
$825.41
Procedure Code Pricing Action Code Description
Maximum Allowable
35182
3
REPAIR BLOOD VESSEL LESION
$1,691.77
35184
3
REPAIR BLOOD VESSEL LESION
$996.50
35188
3
REPAIR BLOOD VESSEL LESION
$836.90
35189
3
REPAIR BLOOD VESSEL LESION
$1,559.45
35190
3
REPAIR BLOOD VESSEL LESION
$730.58
35201
3
REPAIR BLOOD VESSEL LESION
$916.27
35206
3
REPAIR BLOOD VESSEL LESION
$748.73
35207
3
REPAIR BLOOD VESSEL LESION
$680.50
35211
3
REPAIR BLOOD VESSEL LESION
$1,330.39
35216
3
REPAIR BLOOD VESSEL LESION
$1,848.46
35221
3
REPAIR BLOOD VESSEL LESION
$1,367.42
35226
3
REPAIR BLOOD VESSEL LESION
$826.68
35231
3
REPAIR BLOOD VESSEL LESION
$1,148.98
35236
3
REPAIR BLOOD VESSEL LESION
$957.36
35241
3
REPAIR BLOOD VESSEL LESION
$1,389.55
35246
3
REPAIR BLOOD VESSEL LESION
$1,509.91
35251
3
REPAIR BLOOD VESSEL LESION
$1,625.32
35256
3
REPAIR BLOOD VESSEL LESION
$1,006.34
35261
3
REPAIR BLOOD VESSEL LESION
$1,017.82
35266
3
REPAIR BLOOD VESSEL LESION
$843.47
35271
3
REPAIR BLOOD VESSEL LESION
$1,328.32
35276
3
REPAIR BLOOD VESSEL LESION
$1,394.24
35281
3
REPAIR BLOOD VESSEL LESION
$1,553.97
35286
3
REPAIR BLOOD VESSEL LESION
$923.99
35301
3
RECHANNELING OF ARTERY
$1,035.69
35302
3
RECHANNELING OF ARTERY
$1,100.63
35303
3
RECHANNELING OF ARTERY
$1,211.03
35304
3
RECHANNELING OF ARTERY
$1,259.23
35305
3
RECHANNELING OF ARTERY
$1,209.56
35306
3
RECHANNELING OF ARTERY
$451.75
35311
3
RECHANNELING OF ARTERY
$1,484.11
35321
3
RECHANNELING OF ARTERY
$880.87
35331
3
RECHANNELING OF ARTERY
$1,453.65
35341
3
RECHANNELING OF ARTERY
$1,367.82
35351
3
RECHANNELING OF ARTERY
$1,271.09
Procedure Code Pricing Action Code Description
Maximum Allowable
35355
3
RECHANNELING OF ARTERY
$1,032.56
35361
3
RECHANNELING OF ARTERY
$1,564.71
35363
3
RECHANNELING OF ARTERY
$1,705.05
35371
3
RECHANNELING OF ARTERY
$814.38
35372
3
RECHANNELING OF ARTERY
$976.99
35381
O
RECHANNELING OF ARTERY
$0.00
35390
3
REOPERATION, CAROTID ADD-ON
$159.40
35400
3
ANGIOSCOPY
$150.78
35450
3
REPAIR ARTERIAL BLOCKAGE
$510.72
35452
3
REPAIR ARTERIAL BLOCKAGE
$354.50
35454
3
REPAIR ARTERIAL BLOCKAGE
$311.00
35456
3
REPAIR ARTERIAL BLOCKAGE
$376.31
35458
3
REPAIR ARTERIAL BLOCKAGE
$482.83
35459
3
REPAIR ARTERIAL BLOCKAGE
$443.50
35460
3
REPAIR VENOUS BLOCKAGE
$308.20
35470
3
REPAIR ARTERIAL BLOCKAGE
$455.07
35471
3
REPAIR ARTERIAL BLOCKAGE
$544.51
35472
3
REPAIR ARTERIAL BLOCKAGE
$372.61
35473
3
REPAIR ARTERIAL BLOCKAGE
$321.98
35474
3
REPAIR ARTERIAL BLOCKAGE
$389.07
35475
3
REPAIR ARTERIAL BLOCKAGE
$486.72
35476
3
REPAIR VENOUS BLOCKAGE
$310.88
35480
3
ATHERECTOMY, OPEN
$553.82
35481
3
ATHERECTOMY, OPEN
$399.59
35482
3
ATHERECTOMY, OPEN
$349.55
35483
3
ATHERECTOMY, OPEN
$421.65
35484
3
ATHERECTOMY, OPEN
$524.79
35485
3
ATHERECTOMY, OPEN
$488.68
35490
3
ATHERECTOMY, PERCUTANEOUS
$607.81
35491
3
ATHERECTOMY, PERCUTANEOUS
$407.25
35492
3
ATHERECTOMY, PERCUTANEOUS
$369.95
35493
3
ATHERECTOMY, PERCUTANEOUS
$450.76
35494
3
ATHERECTOMY, PERCUTANEOUS
$571.34
35495
3
ATHERECTOMY, PERCUTANEOUS
$522.04
35500
3
HARVEST VEIN FOR BYPASS
$318.96
Procedure Code Pricing Action Code Description
Maximum Allowable
35501
3
ARTERY BYPASS GRAFT
$1,543.09
35506
3
ARTERY BYPASS GRAFT
$1,312.33
35507
O
ARTERY BYPASS GRAFT
$0.00
35508
3
ARTERY BYPASS GRAFT
$1,356.18
35509
3
ARTERY BYPASS GRAFT
$1,483.07
3550F
9
LOW RSK THROMBOEMBOLISM
35510
3
ARTERY BYPASS GRAFT
$1,243.76
35511
3
ARTERY BYPASS GRAFT
$1,170.73
35512
3
ARTERY BYPASS GRAFT
$1,212.21
35515
3
ARTERY BYPASS GRAFT
$1,307.39
35516
3
ARTERY BYPASS GRAFT
$1,196.76
35518
3
ARTERY BYPASS GRAFT
$1,191.53
3551F
9
INTRMED RSK THROMBOEMBOLISM
35521
3
ARTERY BYPASS GRAFT
$1,253.17
35522
3
ARTERY BYPASS GRAFT
$1,184.66
35523
3
ARTERY BYPASS GRAFT
$1,255.32
35525
3
ARTERY BYPASS GRAFT
$1,111.79
35526
3
ARTERY BYPASS GRAFT
$1,641.15
3552F
9
HGH RISK FOR THROMBOEMBOLISM
35531
3
ARTERY BYPASS GRAFT
$1,999.52
35533
3
ARTERY BYPASS GRAFT
$1,549.05
35535
3
ARTERY BYPASS GRAFT
$1,985.29
35536
3
ARTERY BYPASS GRAFT
$1,723.98
35537
3
ARTERY BYPASS GRAFT
$2,138.07
35538
3
ARTERY BYPASS GRAFT
$2,399.99
35539
3
ARTERY BYPASS GRAFT
$2,224.20
35540
3
ARTERY BYPASS GRAFT
$2,491.69
35541
O
ARTERY BYPASS GRAFT
$0.00
35546
O
ARTERY BYPASS GRAFT
$0.00
35548
3
ARTERY BYPASS GRAFT
$1,188.86
35549
3
ARTERY BYPASS GRAFT
$1,292.31
35551
3
ARTERY BYPASS GRAFT
$1,472.68
35556
3
ARTERY BYPASS GRAFT
$1,366.78
35558
3
ARTERY BYPASS GRAFT
$1,211.36
3555F
9
PT INR MEASUREMENT PERFORMED
$0.00
$0.00
$0.00
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
35560
3
ARTERY BYPASS GRAFT
$1,761.11
35563
3
ARTERY BYPASS GRAFT
$1,349.89
35565
3
ARTERY BYPASS GRAFT
$1,308.13
35566
3
ARTERY BYPASS GRAFT
$1,639.46
35570
3
ARTERY BYPASS GRAFT
$1,534.82
35571
3
ARTERY BYPASS GRAFT
$1,327.03
35572
3
HARVEST FEMOROPOPLITEAL VEIN
35582
O
VEIN BYPASS GRAFT
$0.00
35583
3
VEIN BYPASS GRAFT
$1,411.21
35585
3
VEIN BYPASS GRAFT
$1,652.53
35587
3
VEIN BYPASS GRAFT
$1,368.63
35600
3
HARVEST ART FOR CABG ADD-ON
35601
3
ARTERY BYPASS GRAFT
$1,425.91
35606
3
ARTERY BYPASS GRAFT
$1,160.22
35612
3
ARTERY BYPASS GRAFT
$909.69
35616
3
ARTERY BYPASS GRAFT
$1,110.19
35621
3
ARTERY BYPASS GRAFT
$1,096.26
35623
3
BYPASS GRAFT, NOT VEIN
$1,345.37
35626
3
ARTERY BYPASS GRAFT
$1,545.84
35631
3
ARTERY BYPASS GRAFT
$1,839.45
35632
3
ARTERY BYPASS GRAFT
$1,885.04
35633
3
ARTERY BYPASS GRAFT
$2,035.24
35634
3
ARTERY BYPASS GRAFT
$1,844.95
35636
3
ARTERY BYPASS GRAFT
$1,633.74
35637
3
BYPASS GRAFT, WITH OTHER THAN VEIN
$1,689.45
35638
3
BYPASS GRAFT, WITH OTHER THAN VEIN
$1,726.54
35641
O
ARTERY BYPASS GRAFT
$0.00
35642
3
ARTERY BYPASS GRAFT
$1,025.47
35645
3
ARTERY BYPASS GRAFT
$970.74
35646
3
ARTERY BYPASS GRAFT
$1,705.45
35647
3
ARTERY BYPASS GRAFT
$1,544.11
35650
3
ARTERY BYPASS GRAFT
$1,056.31
35651
3
ARTERY BYPASS GRAFT
$1,367.89
35654
3
ARTERY BYPASS GRAFT
$1,362.85
35656
3
ARTERY BYPASS GRAFT
$1,074.48
$345.82
$254.65
Procedure Code Pricing Action Code Description
Maximum Allowable
35661
3
ARTERY BYPASS GRAFT
$1,076.10
35663
3
ARTERY BYPASS GRAFT
$1,247.02
35665
3
ARTERY BYPASS GRAFT
$1,168.20
35666
3
ARTERY BYPASS GRAFT
$1,260.75
35671
3
ARTERY BYPASS GRAFT
$1,111.04
35681
3
COMPOSITE BYPASS GRAFT
$79.69
35682
3
COMPOSITE BYPASS GRAFT
$355.55
35683
3
COMPOSITE BYPASS GRAFT
$419.39
35685
3
BYPASS GRAFT PATENCY/PATCH
$199.68
35686
3
BYPASS GRAFT/AV FIST PATENCY
$167.22
35691
3
ARTERIAL TRANSPOSITION
$978.84
35693
3
ARTERIAL TRANSPOSITION
$869.40
35694
3
ARTERIAL TRANSPOSITION
$1,011.46
35695
3
ARTERIAL TRANSPOSITION
$1,053.60
35697
3
REIMPLANT ARTERY EACH
$148.82
35700
3
REOPERATION, BYPASS GRAFT
$153.14
35701
3
EXPLORATION, CAROTID ARTERY
$526.14
3570F
9
RPRT BONE SCINT X-REFW/X-RAY
$0.00
35721
3
EXPLORATION, FEMORAL ARTERY
$447.03
3572F
9
PT CONSID POSS RISK FX
$0.00
3573F
9
PT NOT CONSID POSS RISK FX
$0.00
35741
3
EXPLORATION POPLITEAL ARTERY
$489.05
35761
3
EXPLORATION OF ARTERY/VEIN
$362.35
35800
3
EXPLORE NECK VESSELS
$465.04
35820
3
EXPLORE CHEST VESSELS
35840
3
EXPLORE ABDOMINAL VESSELS
$606.87
35860
3
EXPLORE LIMB VESSELS
$393.03
35870
3
REPAIR VESSEL GRAFT DEFECT
35875
3
REMOVAL OF CLOT IN GRAFT
$584.81
35876
3
REMOVAL OF CLOT IN GRAFT
$935.08
35879
3
REVISE GRAFT W/VEIN
$915.39
35881
3
REVISE GRAFT W/VEIN
$1,017.68
35883
3
REVISE GRAFT W/NONAUTO GRAFT
$1,185.13
35884
3
REVISE GRAFT W/VEIN
$1,249.56
35900
O
EXCISION OF INFECTED GRAFT
$1,813.15
$1,266.44
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
35901
3
EXCISION, GRAFT, NECK
$492.05
35903
3
EXCISION, GRAFT, EXTREMITY
$556.30
35905
3
EXCISION, GRAFT, THORAX
$1,722.14
35907
3
EXCISION, GRAFT, ABDOMEN
$1,896.49
35910
O
EXCISION OF INFECTED GRAFT WITH REV
36000
3
PLACE NEEDLE IN VEIN
36002
3
PSEUDOANEURYSM INJECTION TRT
36005
3
INJECTION EXT VENOGRAPHY
36010
3
PLACE CATHETER IN VEIN
$122.69
36011
3
PLACE CATHETER IN VEIN
$158.60
36012
3
PLACE CATHETER IN VEIN
$854.83
36013
3
PLACE CATHETER IN ARTERY
$790.73
36014
3
PLACE CATHETER IN ARTERY
$824.53
36015
3
PLACE CATHETER IN ARTERY
$903.89
36100
3
ESTABLISH ACCESS TO ARTERY
$522.68
36120
3
ESTABLISH ACCESS TO ARTERY
$433.06
36140
3
ESTABLISH ACCESS TO ARTERY
$102.28
36145
3
ARTERY TO VEIN SHUNT
36160
3
ESTABLISH ACCESS TO AORTA
$526.25
36200
3
PLACE CATHETER IN AORTA
$155.51
36215
3
PLACE CATHETER IN ARTERY
$242.85
36216
3
PLACE CATHETER IN ARTERY
$273.75
36217
3
PLACE CATHETER IN ARTERY
$327.74
36218
3
PLACE CATHETER IN ARTERY
$52.19
36230
O
SELECTIVE CATHETER PLACEMENT, CORON
36245
3
PLACE CATHETER IN ARTERY
$250.47
36246
3
PLACE CATHETER IN ARTERY
$272.84
36247
3
PLACE CATHETER IN ARTERY
$324.76
36248
3
PLACE CATHETER IN ARTERY
$161.99
36260
3
INSERTION OF INFUSION PUMP
$558.54
36261
3
REVISION OF INFUSION PUMP
$341.17
36262
3
REMOVAL OF INFUSION PUMP
$260.07
36299
5
VESSEL INJECTION PROCEDURE
$0.00
36400
3
BL DRAW < 3 YRS FEM/JUGULAR
$24.65
36405
3
BL DRAW < 3 YRS SCALP VEIN
$22.52
$0.00 $24.42 $163.95 $48.82
$99.97
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
36406
3
BL DRAW < 3 YRS OTHER VEIN
$16.29
36410
3
NON-ROUTINE BL DRAW > 3 YRS
$18.13
36415
3
ROUTINE VENIPUNCTURE
$15.00
36416
9
CAPILLARY BLOOD DRAW
$0.00
36420
3
VEIN ACCESS CUTDOWN < 1 YR
$47.01
36425
3
VEIN ACCESS CUTDOWN > 1 YR
$37.10
36430
3
BLOOD TRANSFUSION SERVICE
$36.19
36440
3
BL PUSH TRANSFUSE, 2 YR OR <
$49.56
36450
3
BL EXCHANGE/TRANSFUSE, NB
$114.30
36455
3
BL EXCHANGE/TRANSFUSE NON-NB
$124.81
36460
3
TRANSFUSION SERVICE, FETAL
$325.05
36468
5
INJECTION(S), SPIDER VEINS
$0.00
36469
9
INJECTION(S), SPIDER VEINS
$0.00
36470
3
INJECTION THERAPY OF VEIN
$131.66
36471
3
INJECTION THERAPY OF VEINS
$161.92
36475
3
ENDOVENOUS RF, 1ST VEIN
$330.34
36476
3
ENDOVENOUS RF, VEIN ADD-ON
$161.33
36478
3
ENDOVENOUS LASER, 1ST VEIN
$333.66
36479
3
ENDOVENOUS LASER VEIN ADDON
$162.44
36481
3
INSERTION OF CATHETER, VEIN
$404.20
36488
O
INSERTION OF CATHETER, VEIN
$0.00
36489
O
INSERTION OF CATHETER, VEIN
$0.00
36490
O
INSERTION OF CATHETER, VEIN
$0.00
36491
O
INSERTION OF CATHETER, VEIN
$0.00
36493
O
REPOSITIONING OF CVC
$0.00
36495
O
INSERTION OF IMPLANTABLE INTRAVENOU
$0.00
36496
O
REVISION OF IMPLANTABLE INTRAVENOUS
$0.00
36497
O
REMOVAL OF IMPLANTABLE INTRAVENOUS
$0.00
36500
3
INSERTION OF CATHETER, VEIN
$179.02
36510
3
INSERTION OF CATHETER, VEIN
$105.31
36511
3
APHERESIS WBC
$87.01
36512
3
APHERESIS RBC
$88.49
36513
3
APHERESIS PLATELETS
$91.39
36514
3
APHERESIS PLASMA
36515
3
APHERESIS, ADSORP/REINFUSE
$504.43 $1,888.62
Procedure Code Pricing Action Code Description
Maximum Allowable
36516
3
APHERESIS, SELECTIVE
$2,139.19
36520
O
PLASMA AND/OR CELL EXCHANGE
$0.00
36521
O
APHERESIS W/ ADSORP/REINFUSE
$0.00
36522
3
PHOTOPHERESIS
36530
O
INSERTION OF INFUSION PUMP
$0.00
36531
O
REVISION OF INFUSION PUMP
$0.00
36532
O
REMOVAL OF INFUSION PUMP
$0.00
36533
O
INSERTION OF ACCESS DEVICE
$0.00
36534
O
REVISION OF ACCESS DEVICE
$0.00
36535
O
REMOVAL OF ACCESS DEVICE
$0.00
36536
O
REMOVE CVA DEVICE OBSTRUCT
$0.00
36537
O
REMOVE CVA LUMEN OBSTRUCT
$0.00
36540
O
COLLECT BLOOD VENOUS DEVICE
$0.00
36550
O
DECLOT VASCULAR DEVICE
$0.00
36555
3
INSERT NON-TUNNEL CV CATH
$264.40
36556
3
INSERT NON-TUNNEL CV CATH
$116.81
36557
3
INSERT TUNNELED CV CATH
$290.90
36558
3
INSERT TUNNELED CV CATH
$276.92
36560
3
INSERT TUNNELED CV CATH
$343.83
36561
3
INSERT TUNNELED CV CATH
$332.68
36563
3
INSERT TUNNELED CV CATH
$345.19
36565
3
INSERT TUNNELED CV CATH
$937.90
36566
3
INSERT TUNNELED CV CATH
$3,524.15
36568
3
INSERT PICC CATH
$94.90
36569
3
INSERT PICC CATH
$95.10
36570
3
INSERT PICVAD CATH
$1,142.45
36571
3
INSERT PICVAD CATH
$298.79
36575
3
REPAIR TUNNELED CV CATH
$156.65
36576
3
REPAIR TUNNELED CV CATH
$346.64
36578
3
REPLACE TUNNELED CV CATH
$486.38
36580
3
REPLACE CVAD CATH
36581
3
REPLACE TUNNELED CV CATH
$196.60
36582
3
REPLACE TUNNELED CV CATH
$1,027.76
36583
3
REPLACE TUNNELED CV CATH
$1,028.06
36584
3
REPLACE PICC CATH
$98.66
$68.37
$222.30
Procedure Code Pricing Action Code Description
Maximum Allowable
36585
3
REPLACE PICVAD CATH
$1,056.35
36589
3
REMOVAL TUNNELED CV CATH
$160.44
36590
3
REMOVAL TUNNELED CV CATH
$261.54
36591
3
DRAW BLOOD OFF VENOUS DEVICE
$22.42
36592
3
COLLECT BLOOD FROM PICC
$24.64
36593
3
DECLOT VASCULAR DEVICE
$35.11
36595
3
MECH REMOV TUNNELED CV CATH
$593.61
36596
3
MECH REMOV TUNNELED CV CATH
$133.37
36597
3
REPOSITION VENOUS CATHETER
$124.40
36598
3
INJ W/FLUOR, EVAL CV DEVICE
$112.31
36600
3
WITHDRAWAL OF ARTERIAL BLOOD
$29.66
36620
3
INSERTION CATHETER, ARTERY
$49.06
36625
3
INSERTION CATHETER, ARTERY
$102.33
36640
3
INSERTION CATHETER, ARTERY
$115.56
36660
3
INSERTION CATHETER, ARTERY
$64.85
36680
3
INSERT NEEDLE, BONE CAVITY
$57.35
36800
3
INSERTION OF CANNULA
$152.71
36810
3
INSERTION OF CANNULA
$202.94
36815
3
INSERTION OF CANNULA
$143.79
36818
3
AV FUSE, UPPR ARM, CEPHALIC
$653.89
36819
3
AV FUSE, UPPR ARM, BASILIC
$769.33
36820
3
AV FUSION/FOREARM VEIN
$772.04
36821
3
AV FUSION DIRECT ANY SITE
$641.66
36822
3
INSERTION OF CANNULA(S)
$363.34
36823
3
INSERTION OF CANNULA(S)
$1,228.91
36825
3
ARTERY-VEIN AUTOGRAFT
$558.28
36830
3
ARTERY-VEIN NONAUTOGRAFT
$637.18
36831
3
OPEN THROMBECT AV FISTULA
$440.64
36832
3
AV FISTULA REVISION, OPEN
$562.04
36833
3
AV FISTULA REVISION
$634.79
36834
3
REPAIR A-V ANEURYSM
$596.20
36835
3
ARTERY TO VEIN SHUNT
$442.42
36838
3
DIST REVAS LIGATION, HEMO
36840
O
INSERTION MANDRIL
$0.00
36845
O
ANASTOMOSIS MANDRIL
$0.00
$1,133.72
Procedure Code Pricing Action Code Description
Maximum Allowable
36860
3
EXTERNAL CANNULA DECLOTTING
$184.27
36861
3
CANNULA DECLOTTING
$145.70
36870
3
PERCUT THROMBECT AV FISTULA
$300.39
37140
3
REVISION OF CIRCULATION
$1,296.53
37145
3
REVISION OF CIRCULATION
$1,400.42
37160
3
REVISION OF CIRCULATION
$1,216.87
37180
3
REVISION OF CIRCULATION
$1,362.65
37181
3
SPLICE SPLEEN/KIDNEY VEINS
$1,473.11
37182
3
INSERT HEPATIC SHUNT (TIPS)
$882.15
37183
3
REMOVE HEPATIC SHUNT (TIPS)
$419.52
37184
3
PRIM ART MECH THROMBECTOMY
$2,370.47
37185
3
PRIM ART M-THROMBECT ADD-ON
$782.91
37186
3
SEC ART M-THROMBECT ADD-ON
$1,599.48
37187
3
VENOUS MECH THROMBECTOMY
$419.32
37188
3
VENOUS M-THROMBECTOMY ADD-ON
37190
O
PLASTIC REPAIR OF ARTERIOVENOUS ANE
37195
3
THROMBOLYTIC THERAPY, STROKE
$326.02
37200
3
TRANSCATHETER BIOPSY
$234.13
37201
3
TRANSCATHETER THERAPY INFUSE
$277.91
37202
3
TRANSCATHETER THERAPY INFUSE
$334.92
37203
3
TRANSCATHETER RETRIEVAL
$266.56
37204
3
TRANSCATHETER OCCLUSION
$929.58
37205
3
TRANSCATH IV STENT, PERCUT
$437.82
37206
3
TRANSCATH IV STENT/PERC ADDL
$213.07
37207
3
TRANSCATH IV STENT, OPEN
$423.38
37208
3
TRANSCATH IV STENT/OPEN ADDL
$204.62
37209
3
CHANGE IV CATH AT THROMB TX
$114.66
37210
3
EMBOLIZATION UTERINE FIBROID
$554.72
37215
3
TRANSCATH STENT, CCA W/EPS
37216
3
TRANSCATH STENT, CCA W/O EPS
$998.72
37250
3
IV US FIRST VESSEL ADD-ON
$108.91
37251
3
IV US EACH ADD VESSEL ADD-ON
$80.95
37500
3
ENDOSCOPY LIGATE PERF VEINS
$665.93
37501
5
VASCULAR ENDOSCOPY PROCEDURE
37565
3
LIGATION OF NECK VEIN
$1,932.81 $0.00
$1,090.70
$0.00 $660.74
Procedure Code Pricing Action Code Description
Maximum Allowable
37600
3
LIGATION OF NECK ARTERY
$675.50
37605
3
LIGATION OF NECK ARTERY
$772.50
37606
3
LIGATION OF NECK ARTERY
$504.86
37607
3
LIGATION OF A-V FISTULA
$360.61
37609
3
TEMPORAL ARTERY PROCEDURE
$274.41
37615
3
LIGATION OF NECK ARTERY
$447.08
37616
3
LIGATION OF CHEST ARTERY
$1,037.34
37617
3
LIGATION OF ABDOMEN ARTERY
$1,232.18
37618
3
LIGATION OF EXTREMITY ARTERY
$357.70
37620
3
REVISION OF MAJOR VEIN
$646.08
37650
3
REVISION OF MAJOR VEIN
$487.77
37660
3
REVISION OF MAJOR VEIN
$1,153.91
37700
3
REVISE LEG VEIN
$240.23
37718
3
LIGATE/STRIP SHORT LEG VEIN
$394.29
37720
O
REMOVAL OF LEG VEIN
37722
3
LIGATE/STRIP LONG LEG VEIN
37730
O
REMOVAL OF LEG VEINS
37735
3
REMOVAL OF LEG VEINS/LESION
$605.87
37760
3
LIGATION, LEG VEINS, OPEN
$596.56
37765
3
PHLEB VEINS - EXTREM - TO 20
$429.45
37766
3
PHLEB VEINS - EXTREM 20+
$521.68
37780
3
REVISION OF LEG VEIN
$247.85
37785
3
LIGATE/DIVIDE/EXCISE VEIN
$334.61
37788
3
REVASCULARIZATION, PENIS
$1,323.87
37790
3
PENILE VENOUS OCCLUSION
$480.35
37799
5
VASCULAR SURGERY PROCEDURE
38100
3
REMOVAL OF SPLEEN, TOTAL
38101
3
REMOVAL OF SPLEEN, PARTIAL
38102
3
REMOVAL OF SPLEEN, TOTAL
38115
3
REPAIR OF RUPTURED SPLEEN
$1,109.70
38120
3
LAPAROSCOPY, SPLENECTOMY
$926.88
38129
5
LAPAROSCOPE PROC, SPLEEN
$0.00
38200
3
INJECTION FOR SPLEEN X-RAY
$133.93
38204
9
BL DONOR SEARCH MANAGEMENT
$0.00
38205
9
HARVEST ALLOGENIC STEM CELLS
$0.00
$0.00 $455.75 $0.00
$0.00 $997.96 $1,003.29 $238.39
Procedure Code Pricing Action Code Description
Maximum Allowable
38206
3
HARVEST AUTO STEM CELLS
$77.46
38207
9
CRYOPRESERVE STEM CELLS
$0.00
38208
9
THAW PRESERVED STEM CELLS
$0.00
38209
9
WASH HARVEST STEM CELLS
$0.00
38210
9
T-CELL DEPLETION OF HARVEST
$0.00
38211
9
TUMOR CELL DEPLETE OF HARVST
$0.00
38212
9
RBC DEPLETION OF HARVEST
$0.00
38213
9
PLATELET DEPLETE OF HARVEST
$0.00
38214
9
VOLUME DEPLETE OF HARVEST
$0.00
38215
9
HARVEST STEM CELL CONCENTRTE
$0.00
38220
3
BONE MARROW ASPIRATION
$148.85
38221
3
BONE MARROW BIOPSY
$164.88
38230
3
BONE MARROW COLLECTION
$299.49
38231
O
STEM CELL COLLECTION
38240
3
BONE MARROW/STEM TRANSPLANT
$120.02
38241
3
BONE MARROW/STEM TRANSPLANT
$120.77
38242
3
LYMPHOCYTE INFUSE TRANSPLANT
$91.49
38300
3
DRAINAGE, LYMPH NODE LESION
$244.59
38305
3
DRAINAGE, LYMPH NODE LESION
$413.38
38308
3
INCISION OF LYMPH CHANNELS
$395.80
38380
3
THORACIC DUCT PROCEDURE
$510.96
38381
3
THORACIC DUCT PROCEDURE
$759.15
38382
3
THORACIC DUCT PROCEDURE
$613.96
38500
3
BIOPSY/REMOVAL, LYMPH NODES
$284.38
38505
3
NEEDLE BIOPSY, LYMPH NODES
$120.53
38510
3
BIOPSY/REMOVAL, LYMPH NODES
$458.91
38520
3
BIOPSY/REMOVAL, LYMPH NODES
$413.78
38525
3
BIOPSY/REMOVAL, LYMPH NODES
$374.74
38530
3
BIOPSY/REMOVAL, LYMPH NODES
$481.72
38542
9
EXPLORE DEEP NODE(S), NECK
38550
3
REMOVAL, NECK/ARMPIT LESION
$427.26
38555
3
REMOVAL, NECK/ARMPIT LESION
$887.12
38562
3
REMOVAL, PELVIC LYMPH NODES
$637.84
38564
3
REMOVAL, ABDOMEN LYMPH NODES
$631.76
38570
3
LAPAROSCOPY, LYMPH NODE BIOP
$515.08
$0.00
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
38571
3
LAPAROSCOPY, LYMPHADENECTOMY
$810.54
38572
3
LAPAROSCOPY, LYMPHADENECTOMY
$888.19
38589
5
LAPAROSCOPE PROC, LYMPHATIC
38700
3
REMOVAL OF LYMPH NODES, NECK
$715.48
38720
3
REMOVAL OF LYMPH NODES, NECK
$1,186.81
38724
3
REMOVAL OF LYMPH NODES, NECK
$1,286.82
38740
3
REMOVE ARMPIT LYMPH NODES
$598.63
38745
3
REMOVE ARMPIT LYMPH NODES
$761.21
38746
3
REMOVE THORACIC LYMPH NODES
$249.68
38747
3
REMOVE ABDOMINAL LYMPH NODES
$242.96
38760
3
REMOVE GROIN LYMPH NODES
$751.01
38765
3
REMOVE GROIN LYMPH NODES
$1,166.02
38770
3
REMOVE PELVIS LYMPH NODES
$783.77
38780
3
REMOVE ABDOMEN LYMPH NODES
$987.04
38790
3
INJECT FOR LYMPHATIC X-RAY
$77.31
38792
3
IDENTIFY SENTINEL NODE
$37.77
38794
3
ACCESS THORACIC LYMPH DUCT
38999
5
BLOOD/LYMPH SYSTEM PROCEDURE
39000
3
EXPLORATION OF CHEST
$457.20
39010
3
EXPLORATION OF CHEST
$756.14
39020
O
MEDIASTINOTOMY WITH EXPLORATION, DR
39200
3
REMOVAL CHEST LESION
$836.75
39220
3
REMOVAL CHEST LESION
$1,077.45
39400
3
VISUALIZATION OF CHEST
39499
5
CHEST PROCEDURE
39501
3
REPAIR DIAPHRAGM LACERATION
$766.74
39502
3
REPAIR PARAESOPHAGEAL HERNIA
$918.91
39503
3
REPAIR OF DIAPHRAGM HERNIA
$5,337.56
39520
3
REPAIR OF DIAPHRAGM HERNIA
$918.94
39530
3
REPAIR OF DIAPHRAGM HERNIA
$878.99
39531
3
REPAIR OF DIAPHRAGM HERNIA
$917.71
39540
3
REPAIR OF DIAPHRAGM HERNIA
$782.73
39541
3
REPAIR OF DIAPHRAGM HERNIA
$844.30
39545
3
REVISION OF DIAPHRAGM
$833.87
39547
O
IMBRICATION OF DIAPHRAGM FOR EVENTR
$0.00
$294.53 $0.00
$0.00
$470.41 $0.00
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
39560
3
RESECT DIAPHRAGM, SIMPLE
$719.33
39561
3
RESECT DIAPHRAGM, COMPLEX
39599
5
DIAPHRAGM SURGERY PROCEDURE
$0.00
4000F
9
TOBACCO USE TXMNT COUNSELING
$0.00
4001F
9
TOBACCO USE TXMNT, PHARMACOL
$0.00
4002F
9
STATIN THERAPY, RX
$0.00
4003F
9
PT ED WRITE/ORAL, PTS W/ HF
$0.00
4005F
9
PHARM THX FOR OP RXÏD
$0.00
4006F
9
BETA-BLOCKER THERAPY RX
$0.00
4007F
O
ANTIOX VIT/MIN SUPP RXÏD
$0.00
4009F
9
ACE/ARB INHIBITOR THERAPY RX
$0.00
4011F
9
ORAL ANTIPLATELET THERAPY RX
$0.00
4012F
9
WARFARIN THERAPY RX
$0.00
4014F
9
WRITTEN DISCHARGE INSTR PRVD
$0.00
4015F
9
PERSIST ASTHMA MEDICINE CTRL
$0.00
4016F
9
ANTI-INFLM/ANLGSC AGENT RX
$0.00
4017F
9
GI PROPHYLAXIS FOR NSAID RX
$0.00
4018F
9
THERAPY EXERCISE JOINT RX
$0.00
4019F
9
DOC RECPT COUNSL VIT D/CALC+
$0.00
4025F
9
INHALED BRONCHODILATOR RX
$0.00
4030F
9
OXYGEN THERAPY RX
$0.00
4033F
9
PULMONARY REHAB REC
$0.00
4035F
9
INFLUENZA IMM REC
$0.00
4037F
9
INFLUENZA IMM ORDER/ADMIN
$0.00
4040F
9
PNEUMOC VAC/ADMIN/RCVD
$0.00
4041F
9
DOC ORDER CEFAZOLIN/CEFUROX
$0.00
4042F
9
DOC ANTIBIO NOT GIVEN
$0.00
4043F
9
DOC ORDER GIVEN STOP ANTIBIO
$0.00
4044F
9
DOC ORDER GIVEN VTE PROPHYLX
$0.00
4045F
9
EMPIRIC ANTIBIOTIC RX
$0.00
4046F
9
DOC ANTIBIO GIVEN B/4 SURG
$0.00
4047F
9
DOC ANTIBIO GIVEN B/4 SURG
$0.00
4048F
9
DOC ANTIBIO GIVEN B/4 SURG
$0.00
40490
3
BIOPSY OF LIP
4049F
9
DOC ORDER GIVEN STOP ANTIBIO
$1,119.75
$117.63 $0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
40500
3
PARTIAL EXCISION OF LIP
$444.79
4050F
9
HT CARE PLAN DOC
40510
3
PARTIAL EXCISION OF LIP
4051F
9
REFERRED FOR AN AV FISTULA
40520
3
PARTIAL EXCISION OF LIP
$442.16
40525
3
RECONSTRUCT LIP WITH FLAP
$504.89
40527
3
RECONSTRUCT LIP WITH FLAP
$596.01
4052F
9
HEMODIALYSIS VIA AV FISTULA
40530
3
PARTIAL REMOVAL OF LIP
4053F
9
HEMODIALYSIS VIA AV GRAFT
$0.00
4054F
9
HEMODIALYSIS VIA CATHETER
$0.00
4055F
9
PT. RCVNG PERITON DIALYSIS
$0.00
4056F
9
APPROP. ORAL REHYD. RECOMMD
$0.00
4058F
9
PED GASTRO ED GIVEN, CAREGVR
$0.00
4060F
9
PSYCH SVCS PROVIDED
$0.00
4062F
9
PT REFERRAL PSYCH DOCÏD
$0.00
4064F
9
ANTIDEPRESSANT RX
$0.00
40650
3
REPAIR LIP
$367.60
40652
3
REPAIR LIP
$432.65
40654
3
REPAIR LIP
$509.81
4065F
9
ANTIPSYCHOTIC RX
$0.00
4066F
9
ECT PROVIDED
$0.00
4067F
9
PT REFERRAL FOR ECT DOCÏD
$0.00
40700
3
REPAIR CLEFT LIP/NASAL
$843.25
40701
3
REPAIR CLEFT LIP/NASAL
$1,047.01
40702
3
REPAIR CLEFT LIP/NASAL
$810.63
4070F
9
DVT PROPHYLX RECVÏD DAY 2
40720
3
REPAIR CLEFT LIP/NASAL
4073F
9
ORAL ANTIPLAT THX RX DISCHRG
$0.00
4075F
9
ANTICOAG THX RX AT DISCHRG
$0.00
40761
3
REPAIR CLEFT LIP/NASAL
4077F
9
DOC T-PA ADMIN CONSIDERED
$0.00
40799
5
LIP SURGERY PROCEDURE
$0.00
4079F
9
DOC REHAB SVCS CONSIDERED
$0.00
40800
3
DRAINAGE OF MOUTH LESION
$0.00 $429.94 $0.00
$0.00 $487.43
$0.00 $895.82
$970.21
$178.73
Procedure Code Pricing Action Code Description
Maximum Allowable
40801
3
DRAINAGE OF MOUTH LESION
$273.03
40804
3
REMOVAL, FOREIGN BODY, MOUTH
$182.24
40805
3
REMOVAL, FOREIGN BODY, MOUTH
$286.01
40806
3
INCISION OF LIP FOLD
40808
3
BIOPSY OF MOUTH LESION
$160.90
40810
3
EXCISION OF MOUTH LESION
$178.57
40812
3
EXCISE/REPAIR MOUTH LESION
$250.43
40814
3
EXCISE/REPAIR MOUTH LESION
$336.45
40816
3
EXCISION OF MOUTH LESION
$354.39
40818
3
EXCISE ORAL MUCOSA FOR GRAFT
$312.59
40819
3
EXCISE LIP OR CHEEK FOLD
$268.27
40820
3
TREATMENT OF MOUTH LESION
$233.57
40830
3
REPAIR MOUTH LACERATION
$214.20
40831
3
REPAIR MOUTH LACERATION
$283.96
40840
3
RECONSTRUCTION OF MOUTH
$723.07
40842
3
RECONSTRUCTION OF MOUTH
$711.62
40843
3
RECONSTRUCTION OF MOUTH
$927.19
40844
3
RECONSTRUCTION OF MOUTH
$1,230.11
40845
3
RECONSTRUCTION OF MOUTH
$1,336.61
4084F
9
ASPIRIN RECVÏD W/IN 24 HRS
$0.00
40899
5
MOUTH SURGERY PROCEDURE
$0.00
4090F
9
PT RCVNG EPO THXPY
$0.00
4095F
9
PT NOT RCVNG EPO THXPY
$0.00
41000
3
DRAINAGE OF MOUTH LESION
$141.74
41005
3
DRAINAGE OF MOUTH LESION
$199.83
41006
3
DRAINAGE OF MOUTH LESION
$318.95
41007
3
DRAINAGE OF MOUTH LESION
$320.02
41008
3
DRAINAGE OF MOUTH LESION
$328.99
41009
3
DRAINAGE OF MOUTH LESION
$349.50
4100F
9
BIPHOS THXPY VEIN ORD/RECÏVD
41010
3
INCISION OF TONGUE FOLD
$179.65
41015
3
DRAINAGE OF MOUTH LESION
$375.79
41016
3
DRAINAGE OF MOUTH LESION
$385.84
41017
3
DRAINAGE OF MOUTH LESION
$388.79
41018
3
DRAINAGE OF MOUTH LESION
$444.71
$95.22
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
41019
3
PLACE NEEDLES H&N FOR RT
$460.53
41100
3
BIOPSY OF TONGUE
$149.76
41105
3
BIOPSY OF TONGUE
$149.96
41108
3
BIOPSY OF FLOOR OF MOUTH
$129.00
4110F
9
INT. MAM ART USED FOR CABG
41110
3
EXCISION OF TONGUE LESION
$185.71
41112
3
EXCISION OF TONGUE LESION
$292.39
41113
3
EXCISION OF TONGUE LESION
$320.25
41114
3
EXCISION OF TONGUE LESION
$578.10
41115
3
EXCISION OF TONGUE FOLD
$216.20
41116
3
EXCISION OF MOUTH LESION
$286.77
41120
3
PARTIAL REMOVAL OF TONGUE
$950.79
41130
3
PARTIAL REMOVAL OF TONGUE
$1,170.28
41135
3
TONGUE AND NECK SURGERY
$1,944.94
41140
3
REMOVAL OF TONGUE
$2,003.00
41145
3
TONGUE REMOVAL, NECK SURGERY
$2,506.10
41150
3
TONGUE, MOUTH, JAW SURGERY
$1,982.26
41153
3
TONGUE, MOUTH, NECK SURGERY
$2,147.63
41155
3
TONGUE, JAW, & NECK SURGERY
$2,666.21
4115F
9
BETA BLCKR ADMIN W/IN 24 HRS
$0.00
4120F
9
ANTIBIOT RXÏD/GIVEN
$0.00
4124F
9
ANTIBIOT NOT RXÏD/GIVEN
$0.00
41250
3
REPAIR TONGUE LACERATION
$201.57
41251
3
REPAIR TONGUE LACERATION
$208.00
41252
3
REPAIR TONGUE LACERATION
$272.77
4130F
9
TOPICAL PREP RX, AOE
$0.00
4131F
9
SYST ANTIMICROBIAL THX RX
$0.00
4132F
9
NO SYST ANTIMICROBIAL THX RX
$0.00
4133F
9
ANTIHIST/DECONG RX/RECOM
$0.00
4134F
9
NO ANTIHIST/DECONG RX/RECOM
$0.00
4135F
9
SYSTEMIC CORTICOSTEROIDS RX
$0.00
4136F
9
SYST CORTICOSTEROIDS NOT RX
$0.00
4148F
9
HEP A VAC INJXN ADMIN/RECVD
$0.00
4149F
9
HEP B VAC INJXN ADMIN/RECVD
$0.00
41500
3
FIXATION OF TONGUE
$0.00
$404.07
Procedure Code Pricing Action Code Description
Maximum Allowable
4150F
9
PT RECVNG ANTIVIR TXMNT HEPC
$0.00
41510
3
TONGUE TO LIP SURGERY
$370.98
41512
3
TONGUE SUSPENSION
$564.76
4151F
9
PT NOT RECVNG ANTIV HEP C
41520
3
RECONSTRUCTION, TONGUE FOLD
4152F
O
DOCÏD PEGINTF/RIB THXY CONSD
41530
3
TONGUE BASE VOL REDUCTION
4153F
9
COMBO PEGINTF/RIB RX
$0.00
4154F
O
HEP A VAC SERIES RECOMMENDED
$0.00
4155F
9
HEP A VAC SERIES PREV RECVD
$0.00
4156F
O
HEP B VAC SERIES RECOMMENDED
$0.00
4157F
9
HEP B VAC SERIES PREV RECVD
$0.00
4158F
9
PT EDU RE: ALCOH DRNKNG DONE
$0.00
41599
5
TONGUE AND MOUTH SURGERY
$0.00
4159F
9
CONTRCP TALK B/4 ANTIV TXMNT
$0.00
4163F
9
PT COUNS 4 TXMNT OPT PROST
$0.00
4164F
9
ADJV HRMNL THXPY RXÏD
$0.00
4165F
9
3D-CRT/IMRT RECEIVED
$0.00
4167F
9
HD BED TILTED, 1ST DAY VENT
$0.00
4168F
9
PT CARE, ICU&VENT W/IN 24HRS
$0.00
4169F
9
NO PT CARE ICU/VENT IN 24HRS
$0.00
4171F
9
PT. RCVNG ESA THXPY
$0.00
4172F
9
PT. NOT RCVNG ESA THXPY
$0.00
4174F
9
COUNS., POTENT. GLAUC IMPCT
$0.00
4175F
9
VIS OF >=20/40 W/IN 90 DAYS
$0.00
4176F
9
TALK RE UV LIGHT, PT/CRGVR
$0.00
4177F
9
TALK PT/CRGVR RE: AREDS,PREV
$0.00
4178F
9
ANTID GLBLN RCVÏD W/IN 26WKS
$0.00
4179F
9
TAMOXIFEN/AI PRESCRIBED
$0.00
41800
3
DRAINAGE OF GUM LESION
$201.39
41805
3
REMOVAL FOREIGN BODY, GUM
$207.83
41806
3
REMOVAL FOREIGN BODY,JAWBONE
$302.37
4180F
9
ADJV THXPYRXÏD/RCVÏD STG3A-C
$0.00
4181F
9
CONFORMAL RADN THXPY RCVD 00
$0.00
41820
5
EXCISION, GUM, EACH QUADRANT
$0.00
$0.00 $306.21 $0.00 $2,867.27
Procedure Code Pricing Action Code Description
Maximum Allowable
41821
5
EXCISION OF GUM FLAP
$0.00
41822
3
EXCISION OF GUM LESION
$253.70
41823
3
EXCISION OF GUM LESION
$377.59
41825
3
EXCISION OF GUM LESION
$181.98
41826
3
EXCISION OF GUM LESION
$254.95
41827
3
EXCISION OF GUM LESION
$377.94
41828
3
EXCISION OF GUM LESION
$269.56
4182F
9
NO CONFORMAL RADN THXPY
41830
3
REMOVAL OF GUM TISSUE
41850
5
TREATMENT OF GUM LESION
$0.00
4185F
9
CONTINUOUS PPI OR H2RA RCVÏD
$0.00
4186F
9
NO CONT. PPI OR H2RA RCVÏD
$0.00
41870
5
GUM GRAFT
$0.00
41872
3
REPAIR GUM
$320.81
41874
3
REPAIR TOOTH SOCKET
$325.23
4187F
9
ANTI RHEUM DRUGTHXPYRXÏD/GVN
$0.00
4188F
9
APPROP ACE/ARB TSTNG DONE
$0.00
41899
5
DENTAL SURGERY PROCEDURE
$0.00
4189F
9
APPROP DIGOXIN TSTNG DONE
$0.00
4190F
9
APPROP DIURETIC TSTNG DONE
$0.00
4191F
9
APPROP ANTICONVULS TSTNG
$0.00
4192F
9
PT NOT RCVNG GLUCOCO THXPY
$0.00
4193F
9
PT RCVNG<10MG DAILY PREDNISO
$0.00
4194F
9
PT RCVNG>10MG DAILY PREDNISO
$0.00
4195F
9
PT RCVNG ANTI-RHEUM THXPY RA
$0.00
4196F
9
PTNOT RCVNG ANTI-RHM THXPYRA
$0.00
42000
3
DRAINAGE MOUTH ROOF LESION
4200F
9
EXTERNAL BEAM TO PROST ONLY
$0.00
4201F
9
EXTRNL BEAM OTHER THAN PROST
$0.00
42100
3
BIOPSY ROOF OF MOUTH
$132.72
42104
3
EXCISION LESION, MOUTH ROOF
$185.16
42106
3
EXCISION LESION, MOUTH ROOF
$234.81
42107
3
EXCISION LESION, MOUTH ROOF
$406.50
4210F
9
ACE/ARB THXPY FOR >= 6 MONS
$0.00
42120
3
REMOVE PALATE/LESION
$0.00 $341.32
$139.97
$881.60
Procedure Code Pricing Action Code Description
Maximum Allowable
42140
3
EXCISION OF UVULA
$221.79
42145
3
REPAIR PALATE, PHARYNX/UVULA
$638.83
42160
3
TREATMENT MOUTH ROOF LESION
$214.03
42180
3
REPAIR PALATE
$216.34
42182
3
REPAIR PALATE
$295.43
42200
3
RECONSTRUCT CLEFT PALATE
$809.23
42205
3
RECONSTRUCT CLEFT PALATE
$861.80
4220F
9
DIGOXIN THXPY FOR >= 6 MONS
42210
3
RECONSTRUCT CLEFT PALATE
$972.99
42215
3
RECONSTRUCT CLEFT PALATE
$640.05
4221F
9
DIURETIC THXPY FOR >= 6 MONS
42220
3
RECONSTRUCT CLEFT PALATE
$497.13
42225
3
RECONSTRUCT CLEFT PALATE
$859.36
42226
3
LENGTHENING OF PALATE
$852.26
42227
3
LENGTHENING OF PALATE
$828.79
42235
3
REPAIR PALATE
$677.00
42260
3
REPAIR NOSE TO LIP FISTULA
$752.32
42280
9
PREPARATION, PALATE MOLD
$0.00
42281
3
INSERTION, PALATE PROSTHESIS
42299
5
PALATE/UVULA SURGERY
42300
3
DRAINAGE OF SALIVARY GLAND
$185.53
42305
3
DRAINAGE OF SALIVARY GLAND
$394.20
4230F
9
ANTICONV THXPY FOR >= 6 MONS
42310
3
DRAINAGE OF SALIVARY GLAND
$144.24
42320
3
DRAINAGE OF SALIVARY GLAND
$223.19
42325
O
CREATE SALIVARY CYST DRAIN
$0.00
42326
O
CREATE SALIVARY CYST DRAIN
$0.00
42330
3
REMOVAL OF SALIVARY STONE
$207.72
42335
3
REMOVAL OF SALIVARY STONE
$331.48
42340
3
REMOVAL OF SALIVARY STONE
$415.81
42400
3
BIOPSY OF SALIVARY GLAND
$98.81
42405
3
BIOPSY OF SALIVARY GLAND
$272.87
42408
3
EXCISION OF SALIVARY CYST
$406.99
42409
3
DRAINAGE OF SALIVARY CYST
$295.38
4240F
9
INSTR XRCZ 4BK PN >12 WEEKS
$0.00
$0.00
$181.34 $0.00
$0.00
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
42410
3
EXCISE PAROTID GLAND/LESION
$570.59
42415
3
EXCISE PAROTID GLAND/LESION
$1,028.35
42420
3
EXCISE PAROTID GLAND/LESION
$1,178.31
42425
3
EXCISE PAROTID GLAND/LESION
$776.59
42426
3
EXCISE PAROTID GLAND/LESION
$1,260.31
4242F
9
SPRVSD XRCZ BK PN >12 WEEKS
$0.00
42440
3
EXCISE SUBMAXILLARY GLAND
$429.48
42450
3
EXCISE SUBLINGUAL GLAND
$406.54
4245F
9
PT INSTR NRML LIFEST
$0.00
4248F
9
PT INSTR-NO BD REST>= 4 DAYS
$0.00
42500
3
REPAIR SALIVARY DUCT
$387.84
42505
3
REPAIR SALIVARY DUCT
$502.37
42507
3
PAROTID DUCT DIVERSION
$470.69
42508
3
PAROTID DUCT DIVERSION
$668.64
42509
3
PAROTID DUCT DIVERSION
$763.94
4250F
9
WRMNG 4 SURG - NORMOTHERMIA
42510
3
PAROTID DUCT DIVERSION
$578.65
42550
3
INJECTION FOR SALIVARY X-RAY
$139.51
42600
3
CLOSURE OF SALIVARY FISTULA
$436.12
4260F
9
WOUND SRFC CULTURETECH USED
$0.00
4261F
9
TECH OTHER THAN SURFC CULTR
$0.00
42650
3
DILATION OF SALIVARY DUCT
4265F
9
WET-DRY DRESSINGS RX-RECMD
42660
3
DILATION OF SALIVARY DUCT
$95.78
42665
3
LIGATION OF SALIVARY DUCT
$276.65
4266F
9
NO WET-DRY DRSSINGS RX-RECMD
$0.00
4267F
9
COMPRSSION THXPY PRESCRIBED
$0.00
4268F
9
PT ED RE COMP THXPY RCVD
$0.00
42699
5
SALIVARY SURGERY PROCEDURE
$0.00
4269F
9
APPROPOS MTHD OFFLOADING RXD
$0.00
42700
3
DRAINAGE OF TONSIL ABSCESS
$168.20
4270F
9
PT RCVNG ANTI R-VIRAL THXPY
$0.00
4271F
9
PT RCVNG ANTI R-VIRAL THXPY
$0.00
42720
3
DRAINAGE OF THROAT ABSCESS
$415.33
42725
3
DRAINAGE OF THROAT ABSCESS
$744.19
$0.00
$74.67 $0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
4274F
9
FLU IMMUNO ADMIND RCVD
$0.00
4275F
9
POTENT ANTIVIR THXPY RXD
$0.00
4279F
9
PCP PROPHYLAXIS RXD
$0.00
42800
3
BIOPSY OF THROAT
$141.01
42802
3
BIOPSY OF THROAT
$216.12
42804
3
BIOPSY OF UPPER NOSE/THROAT
$180.52
42806
3
BIOPSY OF UPPER NOSE/THROAT
$203.37
42808
3
EXCISE PHARYNX LESION
$205.40
42809
3
REMOVE PHARYNX FOREIGN BODY
$152.78
4280F
9
PCP PROPHYLAX RXD 3MON LOW %
42810
3
EXCISION OF NECK CYST
$346.69
42815
3
EXCISION OF NECK CYST
$508.11
42820
3
REMOVE TONSILS AND ADENOIDS
$267.73
42821
3
REMOVE TONSILS AND ADENOIDS
$279.60
42825
3
REMOVAL OF TONSILS
$240.19
42826
3
REMOVAL OF TONSILS
$231.86
42830
3
REMOVAL OF ADENOIDS
$189.39
42831
3
REMOVAL OF ADENOIDS
$204.47
42835
3
REMOVAL OF ADENOIDS
$170.74
42836
3
REMOVAL OF ADENOIDS
$222.61
42842
3
EXTENSIVE SURGERY OF THROAT
$885.02
42844
3
EXTENSIVE SURGERY OF THROAT
$1,242.75
42845
3
EXTENSIVE SURGERY OF THROAT
$2,026.30
42860
3
EXCISION OF TONSIL TAGS
$171.60
42870
3
EXCISION OF LINGUAL TONSIL
$525.48
42880
O
EXCISION NASOPHARYNGEAL LESION (EG,
42890
3
PARTIAL REMOVAL OF PHARYNX
$1,262.48
42892
3
REVISION OF PHARYNGEAL WALLS
$1,654.36
42894
3
REVISION OF PHARYNGEAL WALLS
$2,118.36
42900
3
REPAIR THROAT WOUND
4290F
9
PT SCRNED FOR INJ DRUG USE
$0.00
4293F
9
PT SCRND - HGH-RSK SEX BEHAV
$0.00
42950
3
RECONSTRUCTION OF THROAT
$725.88
42953
3
REPAIR THROAT, ESOPHAGUS
$894.27
42955
3
SURGICAL OPENING OF THROAT
$682.99
$0.00
$0.00
$318.26
Procedure Code Pricing Action Code Description
Maximum Allowable
42960
3
CONTROL THROAT BLEEDING
$155.45
42961
3
CONTROL THROAT BLEEDING
$386.02
42962
3
CONTROL THROAT BLEEDING
$477.72
42970
3
CONTROL NOSE/THROAT BLEEDING
$356.77
42971
3
CONTROL NOSE/THROAT BLEEDING
$420.79
42972
3
CONTROL NOSE/THROAT BLEEDING
$472.49
42999
5
THROAT SURGERY PROCEDURE
$0.00
43000
O
ESOPHAGOTOMY, CERVICAL APPROACH; WI
$0.00
4300F
9
PT RCVNG WARF THXPY
$0.00
4301F
9
PT NOT RCVNG WARF THXPY
$0.00
43020
3
INCISION OF ESOPHAGUS
$484.75
43030
3
THROAT MUSCLE SURGERY
$480.59
43040
O
ESOPHAGOTOMY, THORACIC APPROACH; WI
43045
3
INCISION OF ESOPHAGUS
4305F
9
PT ED RE FT CARE INSPCT RCVD
$0.00
4306F
9
PT TLK PSYCH & RX OPD ADDIC
$0.00
43100
3
EXCISION OF ESOPHAGUS LESION
$574.28
43101
3
EXCISION OF ESOPHAGUS LESION
$949.61
43105
O
WIDE EXCISION OF MALIGNANT LESION O
$0.00
43106
O
WIDE EXCISION OF MALIGNANT LESION O
$0.00
43107
3
REMOVAL OF ESOPHAGUS
$2,345.28
43108
3
REMOVAL OF ESOPHAGUS
$3,937.01
43110
O
ESOPHAGECTOMY (AT UPPER TWO-THIRDS
$0.00
43111
O
ESOPHAGECTOMY (AT UPPER TWO-THIRDS
$0.00
43112
3
REMOVAL OF ESOPHAGUS
$2,506.07
43113
3
REMOVAL OF ESOPHAGUS
$3,938.89
43115
O
ESOPHAGECTOMY (AT UPPER TWO-THIRDS
43116
3
PARTIAL REMOVAL OF ESOPHAGUS
$4,478.28
43117
3
PARTIAL REMOVAL OF ESOPHAGUS
$2,291.76
43118
3
PARTIAL REMOVAL OF ESOPHAGUS
$3,242.62
43119
O
TOTAL ESOPHAGECTOMY WITH GASTROPHAR
$0.00
43120
O
ESOPHAGOGASTRECTOMY (LOWER THIRD) A
$0.00
43121
3
PARTIAL REMOVAL OF ESOPHAGUS
$2,579.12
43122
3
PARTIAL REMOVAL OF ESOPHAGUS
$2,317.43
43123
3
PARTIAL REMOVAL OF ESOPHAGUS
$3,958.21
$0.00 $1,216.08
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
43124
3
REMOVAL OF ESOPHAGUS
$3,386.97
43130
3
REMOVAL OF ESOPHAGUS POUCH
$726.73
43135
3
REMOVAL OF ESOPHAGUS POUCH
$1,353.28
43136
O
DIVERTICULOPEXY OF HYPOPHARYNX, WIT
43200
3
ESOPHAGUS ENDOSCOPY
$199.31
43201
3
ESOPH SCOPE W/SUBMUCOUS INJ
$274.22
43202
3
ESOPHAGUS ENDOSCOPY, BIOPSY
$262.28
43204
3
ESOPH SCOPE W/SCLEROSIS INJ
$212.91
43205
3
ESOPHAGUS ENDOSCOPY/LIGATION
$213.51
4320F
9
PT TALK PSYCHSOC+RX OH DPND
43215
3
ESOPHAGUS ENDOSCOPY
$145.87
43216
3
ESOPHAGUS ENDOSCOPY/LESION
$184.09
43217
3
ESOPHAGUS ENDOSCOPY
$350.55
43219
3
ESOPHAGUS ENDOSCOPY
$162.38
43220
3
ESOPH ENDOSCOPY, DILATION
$120.16
43226
3
ESOPH ENDOSCOPY, DILATION
$134.02
43227
3
ESOPH ENDOSCOPY, REPAIR
$199.32
43228
3
ESOPH ENDOSCOPY, ABLATION
$212.75
43231
3
ESOPH ENDOSCOPY W/US EXAM
$181.24
43232
3
ESOPH ENDOSCOPY W/US FN BX
$249.59
43234
3
UPPER GI ENDOSCOPY, EXAM
$260.01
43235
3
UPPR GI ENDOSCOPY, DIAGNOSIS
$280.73
43236
3
UPPR GI SCOPE W/SUBMUC INJ
$349.68
43237
3
ENDOSCOPIC US EXAM, ESOPH
$228.32
43238
3
UPPR GI ENDOSCOPY W/US FN BX
$282.86
43239
3
UPPER GI ENDOSCOPY, BIOPSY
$324.85
43240
3
ESOPH ENDOSCOPE W/DRAIN CYST
$379.47
43241
3
UPPER GI ENDOSCOPY WITH TUBE
$148.23
43242
3
UPPR GI ENDOSCOPY W/US FN BX
$404.81
43243
3
UPPER GI ENDOSCOPY & INJECT
$255.15
43244
3
UPPER GI ENDOSCOPY/LIGATION
$282.88
43245
3
UPPR GI SCOPE DILATE STRICTR
$178.28
43246
3
PLACE GASTROSTOMY TUBE
$238.68
43247
3
OPERATIVE UPPER GI ENDOSCOPY
$190.85
43248
3
UPPR GI ENDOSCOPY/GUIDE WIRE
$180.56
$0.00
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
43249
3
ESOPH ENDOSCOPY, DILATION
$166.21
43250
3
UPPER GI ENDOSCOPY/TUMOR
$178.25
43251
3
OPERATIVE UPPER GI ENDOSCOPY
$207.57
43255
3
OPERATIVE UPPER GI ENDOSCOPY
$270.11
43256
3
UPPR GI ENDOSCOPY W/STENT
$242.61
43257
3
UPPR GI SCOPE W/THRML TXMNT
$297.60
43258
3
OPERATIVE UPPER GI ENDOSCOPY
$254.44
43259
3
ENDOSCOPIC ULTRASOUND EXAM
$289.97
43260
3
ENDO CHOLANGIOPANCREATOGRAPH
$331.98
43261
3
ENDO CHOLANGIOPANCREATOGRAPH
$348.96
43262
3
ENDO CHOLANGIOPANCREATOGRAPH
$409.76
43263
3
ENDO CHOLANGIOPANCREATOGRAPH
$405.45
43264
3
ENDO CHOLANGIOPANCREATOGRAPH
$491.86
43265
3
ENDO CHOLANGIOPANCREATOGRAPH
$551.93
43267
3
ENDO CHOLANGIOPANCREATOGRAPH
$407.91
43268
3
ENDO CHOLANGIOPANCREATOGRAPH
$414.93
43269
3
ENDO CHOLANGIOPANCREATOGRAPH
$454.17
43271
3
ENDO CHOLANGIOPANCREATOGRAPH
$409.39
43272
3
ENDO CHOLANGIOPANCREATOGRAPH
$408.64
43273
3
ENDOSCOPIC PANCREATOSCOPY
$123.80
43279
3
LAP MYOTOMY, HELLER
43280
3
LAPAROSCOPY, FUNDOPLASTY
43289
5
LAPAROSCOPE PROC, ESOPH
43300
3
REPAIR OF ESOPHAGUS
43305
3
REPAIR ESOPHAGUS AND FISTULA
$1,019.53
43310
3
REPAIR OF ESOPHAGUS
$1,418.73
43312
3
REPAIR ESOPHAGUS AND FISTULA
$1,565.78
43313
3
ESOPHAGOPLASTY CONGENITAL
$2,489.03
43314
3
TRACHEO-ESOPHAGOPLASTY CONG
$2,857.94
43320
3
FUSE ESOPHAGUS & STOMACH
$1,246.32
43321
O
ESOPHAGOGASTROSTOMY (CARDIOPLASTY),
43324
3
REVISE ESOPHAGUS & STOMACH
$1,207.62
43325
3
REVISE ESOPHAGUS & STOMACH
$1,188.75
43326
3
REVISE ESOPHAGUS & STOMACH
$1,213.25
43330
3
REPAIR OF ESOPHAGUS
$1,165.95
$1,147.30 $958.13 $0.00 $570.75
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
43331
3
REPAIR OF ESOPHAGUS
$1,266.20
43340
3
FUSE ESOPHAGUS & INTESTINE
$1,210.79
43341
3
FUSE ESOPHAGUS & INTESTINE
$1,335.63
43350
3
SURGICAL OPENING, ESOPHAGUS
$1,034.24
43351
3
SURGICAL OPENING, ESOPHAGUS
$1,215.58
43352
3
SURGICAL OPENING, ESOPHAGUS
$994.66
43360
3
GASTROINTESTINAL REPAIR
$2,124.60
43361
3
GASTROINTESTINAL REPAIR
$2,371.86
43400
3
LIGATE ESOPHAGUS VEINS
$1,467.69
43401
3
ESOPHAGUS SURGERY FOR VEINS
$1,381.79
43405
3
LIGATE/STAPLE ESOPHAGUS
$1,341.29
43410
3
REPAIR ESOPHAGUS WOUND
$919.48
43415
3
REPAIR ESOPHAGUS WOUND
$1,563.06
43420
3
REPAIR ESOPHAGUS OPENING
$919.47
43425
3
REPAIR ESOPHAGUS OPENING
$1,374.23
43450
3
DILATE ESOPHAGUS
43451
O
DILATION OF ESOPHAGUS, BY UNGUIDED
43453
3
DILATE ESOPHAGUS
43455
O
DILATION OF ESOPHAGUS, BY BALLOON O
43456
3
DILATE ESOPHAGUS
$147.65
43458
3
DILATE ESOPHAGUS
$363.91
43460
3
PRESSURE TREATMENT ESOPHAGUS
$209.04
43496
5
FREE JEJUNUM FLAP, MICROVASC
$0.00
43499
5
ESOPHAGUS SURGERY PROCEDURE
$0.00
43500
3
SURGICAL OPENING OF STOMACH
43501
3
SURGICAL REPAIR OF STOMACH
$1,177.74
43502
3
SURGICAL REPAIR OF STOMACH
$1,333.33
43510
3
SURGICAL OPENING OF STOMACH
$849.49
43520
3
INCISION OF PYLORIC MUSCLE
$620.99
43600
3
BIOPSY OF STOMACH
$101.19
43605
3
BIOPSY OF STOMACH
$727.51
43610
3
EXCISION OF STOMACH LESION
$858.97
43611
3
EXCISION OF STOMACH LESION
$1,068.92
43620
3
REMOVAL OF STOMACH
$1,739.94
43621
3
REMOVAL OF STOMACH
$1,979.44
$148.81 $0.00 $281.38 $0.00
$685.62
Procedure Code Pricing Action Code Description
Maximum Allowable
43622
3
REMOVAL OF STOMACH
$2,008.72
43625
O
GASTRECTOMY, TOTAL WITH REPAIR BY I
$0.00
43630
O
HEMIGASTRECTOMY OR DISTAL SUBTOTAL
$0.00
43631
3
REMOVAL OF STOMACH, PARTIAL
$1,277.07
43632
3
REMOVAL OF STOMACH, PARTIAL
$1,736.41
43633
3
REMOVAL OF STOMACH, PARTIAL
$1,652.94
43634
3
REMOVAL OF STOMACH, PARTIAL
$1,825.51
43635
3
REMOVAL OF STOMACH, PARTIAL
$101.89
43638
O
REMOVAL OF STOMACH, PARTIAL
$0.00
43639
O
REMOVAL OF STOMACH, PARTIAL
$0.00
43640
3
VAGOTOMY & PYLORUS REPAIR
$1,027.24
43641
3
VAGOTOMY & PYLORUS REPAIR
$1,035.93
43644
3
LAP GASTRIC BYPASS/ROUX-EN-Y
$1,519.51
43645
3
LAP GASTR BYPASS INCL SMLL I
$1,625.44
43647
6
LAP IMPL ELECTRODE, ANTRUM
$0.00
43648
6
LAP REVISE/REMV ELTRD ANTRUM
$0.00
43651
3
LAPAROSCOPY, VAGUS NERVE
$572.06
43652
3
LAPAROSCOPY, VAGUS NERVE
$669.13
43653
3
LAPAROSCOPY, GASTROSTOMY
$488.91
43659
5
LAPAROSCOPE PROC, STOM
$0.00
43750
O
PLACE GASTROSTOMY TUBE
$0.00
43752
3
NASAL/OROGASTRIC W/STENT
$39.78
43760
3
CHANGE GASTROSTOMY TUBE
$48.00
43761
3
REPOSITION GASTROSTOMY TUBE
$116.72
43770
3
LAP PLACE GASTR ADJ DEVICE
$975.76
43771
3
LAP REVISE GASTR ADJ DEVICE
43772
3
LAP RMVL GASTR ADJ DEVICE
43773
3
LAP REPLACE GASTR ADJ DEVICE
$1,113.15
43774
3
LAP RMVL GASTR ADJ ALL PARTS
$842.03
43800
3
RECONSTRUCTION OF PYLORUS
$815.44
43810
3
FUSION OF STOMACH AND BOWEL
$883.44
43820
3
FUSION OF STOMACH AND BOWEL
$1,143.25
43825
3
FUSION OF STOMACH AND BOWEL
$1,136.59
43830
3
PLACE GASTROSTOMY TUBE
$606.72
43831
3
PLACE GASTROSTOMY TUBE
$508.62
$1,112.17 $841.04
Procedure Code Pricing Action Code Description
Maximum Allowable
43832
3
PLACE GASTROSTOMY TUBE
$932.26
43840
3
REPAIR OF STOMACH LESION
$1,159.62
43842
3
V-BAND GASTROPLASTY
$1,131.27
43843
3
GASTROPLASTY W/O V-BAND
$1,108.00
43844
O
GASTRIC BYPASS, OTHER THAN WITH ROU
43845
3
GASTRIC RESTRICTIVE PROCEDURE
$1,714.11
43846
3
GASTRIC BYPASS FOR OBESITY
$1,428.81
43847
3
GASTRIC BYPASS INCL SMALL I
$1,560.20
43848
3
REVISION GASTROPLASTY
$1,693.47
43850
3
REVISE STOMACH-BOWEL FUSION
$1,417.76
43855
3
REVISE STOMACH-BOWEL FUSION
$1,481.94
43860
3
REVISE STOMACH-BOWEL FUSION
$1,439.90
43865
3
REVISE STOMACH-BOWEL FUSION
$1,497.61
43870
3
REPAIR STOMACH OPENING
43880
3
REPAIR STOMACH-BOWEL FISTULA
43881
6
IMPL/REDO ELECTRD, ANTRUM
$0.00
43882
6
REVISE/REMOVE ELECTRD ANTRUM
$0.00
43885
O
ANTERIOR GASTROPEXY FOR HIATAL HERN
$0.00
43886
3
REVISE GASTRIC PORT, OPEN
$293.92
43887
3
REMOVE GASTRIC PORT, OPEN
$275.75
43888
3
CHANGE GASTRIC PORT, OPEN
$388.63
43999
5
STOMACH SURGERY PROCEDURE
44005
3
FREEING OF BOWEL ADHESION
$961.57
44010
3
INCISION OF SMALL BOWEL
$756.75
44015
3
INSERT NEEDLE CATH BOWEL
$130.85
44020
3
EXPLORE SMALL INTESTINE
$850.17
44021
3
DECOMPRESS SMALL BOWEL
$860.28
44025
3
INCISION OF LARGE BOWEL
$865.57
44040
O
EXTERIORIZATION OF INTESTINE (MIKUL
44050
3
REDUCE BOWEL OBSTRUCTION
44055
3
CORRECT MALROTATION OF BOWEL
44100
3
BIOPSY OF BOWEL
$109.17
44110
3
EXCISE INTESTINE LESION(S)
$741.92
44111
3
EXCISION OF BOWEL LESION(S)
$863.35
44120
3
REMOVAL OF SMALL INTESTINE
$1,068.63
$0.00
$618.27 $1,406.92
$0.00
$0.00 $819.61 $1,311.07
Procedure Code Pricing Action Code Description
Maximum Allowable
44121
3
REMOVAL OF SMALL INTESTINE
$219.88
44125
3
REMOVAL OF SMALL INTESTINE
$1,037.95
44126
3
ENTERECTOMY W/O TAPER, CONG
$2,141.52
44127
3
ENTERECTOMY W/TAPER, CONG
$2,492.87
44128
3
ENTERECTOMY CONG, ADD-ON
44130
3
BOWEL TO BOWEL FUSION
44131
O
ENTEROENTEROSTOMY, ANASTOMOSIS OF I
$0.00
44132
9
ENTERECTOMY, CADAVER DONOR
$0.00
44133
5
ENTERECTOMY, LIVE DONOR
$0.00
44135
5
INTESTINE TRANSPLNT, CADAVER
$0.00
44136
5
INTESTINE TRANSPLANT, LIVE
$0.00
44137
6
REMOVE INTESTINAL ALLOGRAFT
$0.00
44139
3
MOBILIZATION OF COLON
44140
3
PARTIAL REMOVAL OF COLON
$1,181.78
44141
3
PARTIAL REMOVAL OF COLON
$1,557.02
44143
3
PARTIAL REMOVAL OF COLON
$1,456.75
44144
3
PARTIAL REMOVAL OF COLON
$1,528.69
44145
3
PARTIAL REMOVAL OF COLON
$1,471.84
44146
3
PARTIAL REMOVAL OF COLON
$1,842.07
44147
3
PARTIAL REMOVAL OF COLON
$1,656.54
44150
3
REMOVAL OF COLON
$1,617.01
44151
3
REMOVAL OF COLON/ILEOSTOMY
$1,847.82
44152
O
REMOVAL OF COLON/ILEOSTOMY
$0.00
44153
O
REMOVAL OF COLON/ILEOSTOMY
$0.00
44155
3
REMOVAL OF COLON/ILEOSTOMY
$1,810.13
44156
3
REMOVAL OF COLON/ILEOSTOMY
$1,989.96
44157
3
COLECTOMY W/ILEOANAL ANAST
$1,889.59
44158
3
COLECTOMY W/NEO-RECTUM POUCH
$1,936.57
44160
3
REMOVAL OF COLON
$1,088.83
44180
3
LAP, ENTEROLYSIS
$812.53
44186
3
LAP, JEJUNOSTOMY
$574.10
44187
3
LAP, ILEO/JEJUNO-STOMY
$968.00
44188
3
LAP, COLOSTOMY
44200
O
LAPAROSCOPY, ENTEROLYSIS
$0.00
44201
O
LAPAROSCOPY, JEJUNOSTOMY
$0.00
$220.97 $1,118.87
$110.05
$1,070.67
Procedure Code Pricing Action Code Description
Maximum Allowable
44202
3
LAP, ENTERECTOMY
$1,222.97
44203
3
LAP RESECT S/INTESTINE, ADDL
44204
3
LAPARO PARTIAL COLECTOMY
$1,364.84
44205
3
LAP COLECTOMY PART W/ILEUM
$1,191.86
44206
3
LAP PART COLECTOMY W/STOMA
$1,549.14
44207
3
L COLECTOMY/COLOPROCTOSTOMY
$1,625.81
44208
3
L COLECTOMY/COLOPROCTOSTOMY
$1,769.51
44209
O
LAPAROSCOPE PROC, INTESTINE
44210
3
LAPARO TOTAL PROCTOCOLECTOMY
$1,582.62
44211
3
LAP COLECTOMY W/PROCTECTOMY
$1,942.44
44212
3
LAPARO TOTAL PROCTOCOLECTOMY
$1,822.68
44213
3
LAP, MOBIL SPLENIC FL ADD-ON
44227
3
LAP, CLOSE ENTEROSTOMY
44238
5
LAPAROSCOPE PROC, INTESTINE
$0.00
44239
O
LAPAROSCOPE PROC, RECTUM
$0.00
44300
3
OPEN BOWEL TO SKIN
44305
O
ENTEROSTOMY OR CECOSTOMY, TUBE (EG,
44310
3
ILEOSTOMY/JEJUNOSTOMY
$920.39
44312
3
REVISION OF ILEOSTOMY
$525.14
44314
3
REVISION OF ILEOSTOMY
$892.06
44316
3
DEVISE BOWEL POUCH
$1,219.59
44320
3
COLOSTOMY
$1,050.13
44322
3
COLOSTOMY WITH BIOPSIES
$840.65
44340
3
REVISION OF COLOSTOMY
$528.93
44345
3
REVISION OF COLOSTOMY
$919.70
44346
3
REVISION OF COLOSTOMY
$1,031.83
44360
3
SMALL BOWEL ENDOSCOPY
$150.34
44361
3
SMALL BOWEL ENDOSCOPY/BIOPSY
$165.63
44363
3
SMALL BOWEL ENDOSCOPY
$195.88
44364
3
SMALL BOWEL ENDOSCOPY
$211.11
44365
3
SMALL BOWEL ENDOSCOPY
$187.99
44366
3
SMALL BOWEL ENDOSCOPY
$248.82
44369
3
SMALL BOWEL ENDOSCOPY
$254.10
44370
3
SMALL BOWEL ENDOSCOPY/STENT
$273.94
44372
3
SMALL BOWEL ENDOSCOPY
$241.78
$218.90
$0.00
$172.59 $1,477.64
$736.85 $0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
44373
3
SMALL BOWEL ENDOSCOPY
$195.88
44376
3
SMALL BOWEL ENDOSCOPY
$289.35
44377
3
SMALL BOWEL ENDOSCOPY/BIOPSY
$307.03
44378
3
SMALL BOWEL ENDOSCOPY
$393.70
44379
3
S BOWEL ENDOSCOPE W/STENT
$417.49
44380
3
SMALL BOWEL ENDOSCOPY
$65.69
44382
3
SMALL BOWEL ENDOSCOPY
$78.95
44383
3
ILEOSCOPY W/STENT
$168.87
44385
3
ENDOSCOPY OF BOWEL POUCH
$231.30
44386
3
ENDOSCOPY, BOWEL POUCH/BIOP
$322.34
44388
3
COLONOSCOPY
$319.95
44389
3
COLONOSCOPY WITH BIOPSY
$371.94
44390
3
COLONOSCOPY FOR FOREIGN BODY
$429.22
44391
3
COLONOSCOPY FOR BLEEDING
$480.86
44392
3
COLONOSCOPY & POLYPECTOMY
$402.35
44393
3
COLONOSCOPY, LESION REMOVAL
$466.97
44394
3
COLONOSCOPY W/SNARE
$470.96
44397
3
COLONOSCOPY W/STENT
$262.70
44500
9
INTRO, GASTROINTESTINAL TUBE
$0.00
44600
O
SUTURE OF INTESTINE (ENTERORRHAPHY)
$0.00
44602
3
SUTURE, SMALL INTESTINE
$1,210.79
44603
3
SUTURE, SMALL INTESTINE
$1,388.29
44604
3
SUTURE, LARGE INTESTINE
$932.41
44605
3
REPAIR OF BOWEL LESION
44610
O
SUTURE OF INTESTINE (ENTERORRHAPHY)
44615
3
INTESTINAL STRICTUROPLASTY
$947.82
44620
3
REPAIR BOWEL OPENING
$757.12
44625
3
REPAIR BOWEL OPENING
$896.18
44626
3
REPAIR BOWEL OPENING
$1,423.71
44640
3
REPAIR BOWEL-SKIN FISTULA
$1,242.41
44650
3
REPAIR BOWEL FISTULA
$1,292.19
44660
3
REPAIR BOWEL-BLADDER FISTULA
$1,254.79
44661
3
REPAIR BOWEL-BLADDER FISTULA
$1,404.86
44680
3
SURGICAL REVISION, INTESTINE
$936.04
44700
3
SUSPEND BOWEL W/PROSTHESIS
$906.18
$1,150.44 $0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
44701
3
INTRAOP COLON LAVAGE ADD-ON
$152.17
44715
9
PREPARE DONOR INTESTINE
$0.00
44720
9
PREP DONOR INTESTINE/VENOUS
$0.00
44721
9
PREP DONOR INTESTINE/ARTERY
$0.00
44799
5
UNLISTED PROCEDURE INTESTINE
$0.00
44800
3
EXCISION OF BOWEL POUCH
$668.19
44820
3
EXCISION OF MESENTERY LESION
$737.00
44850
3
REPAIR OF MESENTERY
$650.27
44899
5
BOWEL SURGERY PROCEDURE
44900
3
DRAIN APP ABSCESS, OPEN
$666.07
44901
3
DRAIN APP ABSCESS, PERCUT
$933.52
44950
3
APPENDECTOMY
$564.07
44955
3
APPENDECTOMY ADD-ON
44960
3
APPENDECTOMY
$759.21
44970
3
LAPAROSCOPY, APPENDECTOMY
$519.30
44979
5
LAPAROSCOPE PROC, APP
45000
3
DRAINAGE OF PELVIC ABSCESS
$363.79
45005
3
DRAINAGE OF RECTAL ABSCESS
$223.13
45020
3
DRAINAGE OF RECTAL ABSCESS
$474.13
45100
3
BIOPSY OF RECTUM
$253.35
45108
3
REMOVAL OF ANORECTAL LESION
$307.74
45110
3
REMOVAL OF RECTUM
45111
3
PARTIAL REMOVAL OF RECTUM
45112
3
REMOVAL OF RECTUM
$1,676.17
45113
3
PARTIAL PROCTECTOMY
$1,720.45
45114
3
PARTIAL REMOVAL OF RECTUM
$1,570.27
45116
3
PARTIAL REMOVAL OF RECTUM
$1,410.98
45119
3
REMOVE RECTUM W/RESERVOIR
$1,722.56
45120
3
REMOVAL OF RECTUM
$1,377.22
45121
3
REMOVAL OF RECTUM AND COLON
$1,506.52
45123
3
PARTIAL PROCTECTOMY
45126
3
PELVIC EXENTERATION
45130
3
EXCISION OF RECTAL PROLAPSE
$955.04
45135
3
EXCISION OF RECTAL PROLAPSE
$1,170.08
45136
3
EXCISE ILEOANAL RESERVIOR
$1,620.56
$0.00
$76.47
$0.00
$1,629.13 $956.93
$976.78 $2,546.97
Procedure Code Pricing Action Code Description
Maximum Allowable
45150
3
EXCISION OF RECTAL STRICTURE
$350.20
45160
3
EXCISION OF RECTAL LESION
$870.22
45170
3
EXCISION OF RECTAL LESION
$680.54
45180
O
EXCISION AND/OR ELECTRODESICCATION
45190
3
DESTRUCTION, RECTAL TUMOR
45300
3
PROCTOSIGMOIDOSCOPY DX
45302
O
PROCTOSIGMOIDOSCOPY; WITH COLLECTIO
45303
3
PROCTOSIGMOIDOSCOPY DILATE
$765.38
45305
3
PROCTOSIGMOIDOSCOPY W/BX
$158.96
45307
3
PROCTOSIGMOIDOSCOPY FB
$176.52
45308
3
PROCTOSIGMOIDOSCOPY REMOVAL
$161.98
45309
3
PROCTOSIGMOIDOSCOPY REMOVAL
$182.36
45310
O
PROCTOSIGMOIDOSCOPY; WITH REMOVAL O
45315
3
PROCTOSIGMOIDOSCOPY REMOVAL
$196.21
45317
3
PROCTOSIGMOIDOSCOPY BLEED
$189.31
45320
3
PROCTOSIGMOIDOSCOPY ABLATE
$190.92
45321
3
PROCTOSIGMOIDOSCOPY VOLVUL
$94.85
45327
3
PROCTOSIGMOIDOSCOPY W/STENT
$110.80
45330
3
DIAGNOSTIC SIGMOIDOSCOPY
$126.06
45331
3
SIGMOIDOSCOPY AND BIOPSY
$160.45
45332
3
SIGMOIDOSCOPY W/FB REMOVAL
$263.75
45333
3
SIGMOIDOSCOPY & POLYPECTOMY
$265.35
45334
3
SIGMOIDOSCOPY FOR BLEEDING
$156.32
45335
3
SIGMOIDOSCOPY W/SUBMUC INJ
$227.10
45336
O
SIGMOIDOSCOPY, FLEXIBLE FIBEROPTIC;
45337
3
SIGMOIDOSCOPY & DECOMPRESS
$133.73
45338
3
SIGMOIDOSCOPY W/TUMR REMOVE
$295.58
45339
3
SIGMOIDOSCOPY W/ABLATE TUMR
$305.51
45340
3
SIG W/BALLOON DILATION
$406.09
45341
3
SIGMOIDOSCOPY W/ULTRASOUND
$149.22
45342
3
SIGMOIDOSCOPY W/US GUIDE BX
$228.08
45345
3
SIGMOIDOSCOPY W/STENT
$165.68
45355
3
SURGICAL COLONOSCOPY
$190.25
45378
3
DIAGNOSTIC COLONOSCOPY
$369.74
45379
3
COLONOSCOPY W/FB REMOVAL
$469.39
$0.00 $593.32 $97.57 $0.00
$0.00
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
45380
3
COLONOSCOPY AND BIOPSY
$443.97
45381
3
COLONOSCOPY, SUBMUCOUS INJ
$432.35
45382
3
COLONOSCOPY/CONTROL BLEEDING
$585.46
45383
3
LESION REMOVAL COLONOSCOPY
$527.40
45384
3
LESION REMOVE COLONOSCOPY
$435.49
45385
3
LESION REMOVAL COLONOSCOPY
$500.04
45386
3
COLONOSCOPY DILATE STRICTURE
$620.37
45387
3
COLONOSCOPY W/STENT
$328.44
45391
3
COLONOSCOPY W/ENDOSCOPE US
$283.64
45392
3
COLONOSCOPY W/ENDOSCOPIC FNB
$358.75
45395
3
LAP, REMOVAL OF RECTUM
$1,761.52
45397
3
LAP, REMOVE RECTUM W/POUCH
$1,906.77
45400
3
LAPAROSCOPIC PROC
$1,015.96
45402
3
LAP PROCTOPEXY W/SIG RESECT
$1,357.77
45499
6
LAPAROSCOPE PROC, RECTUM
45500
3
REPAIR OF RECTUM
$448.85
45505
3
REPAIR OF RECTUM
$492.57
45520
3
TREATMENT OF RECTAL PROLAPSE
$114.02
45540
3
CORRECT RECTAL PROLAPSE
$937.08
45541
3
CORRECT RECTAL PROLAPSE
$806.79
45550
3
REPAIR RECTUM/REMOVE SIGMOID
45560
3
REPAIR OF RECTOCELE
$639.24
45562
3
EXPLORATION/REPAIR OF RECTUM
$979.24
45563
3
EXPLORATION/REPAIR OF RECTUM
$1,417.05
45800
3
REPAIR RECT/BLADDER FISTULA
$1,099.54
45805
3
REPAIR FISTULA W/COLOSTOMY
$1,241.48
45820
3
REPAIR RECTOURETHRAL FISTULA
$1,091.64
45825
3
REPAIR FISTULA W/COLOSTOMY
$1,314.34
45900
3
REDUCTION OF RECTAL PROLAPSE
$173.60
45905
3
DILATION OF ANAL SPHINCTER
$147.78
45910
3
DILATION OF RECTAL NARROWING
$174.88
45915
3
REMOVE RECTAL OBSTRUCTION
$275.39
45990
3
SURG DX EXAM, ANORECTAL
45999
5
RECTUM SURGERY PROCEDURE
$0.00
46000
O
FISTULOTOMY, SUBCUTANEOUS
$0.00
$0.00
$1,288.92
$96.86
Procedure Code Pricing Action Code Description
Maximum Allowable
46020
3
PLACEMENT OF SETON
$221.92
46030
3
REMOVAL OF RECTAL MARKER
$111.99
46040
3
INCISION OF RECTAL ABSCESS
$433.89
46045
3
INCISION OF RECTAL ABSCESS
$357.00
46050
3
INCISION OF ANAL ABSCESS
$156.77
46060
3
INCISION OF RECTAL ABSCESS
$393.21
46070
3
INCISION OF ANAL SEPTUM
$201.56
46080
3
INCISION OF ANAL SPHINCTER
$203.00
46083
3
INCISE EXTERNAL HEMORRHOID
$154.53
46200
3
REMOVAL OF ANAL FISSURE
$341.84
46210
3
REMOVAL OF ANAL CRYPT
$314.61
46211
3
REMOVAL OF ANAL CRYPTS
$424.68
46220
3
REMOVAL OF ANAL TAG
$164.80
46221
3
LIGATION OF HEMORRHOID(S)
$215.24
46230
3
REMOVAL OF ANAL TAGS
$225.08
46250
3
HEMORRHOIDECTOMY
$374.95
46255
3
HEMORRHOIDECTOMY
$417.87
46257
3
REMOVE HEMORRHOIDS & FISSURE
$352.14
46258
3
REMOVE HEMORRHOIDS & FISTULA
$384.90
46260
3
HEMORRHOIDECTOMY
$399.66
46261
3
REMOVE HEMORRHOIDS & FISSURE
$446.49
46262
3
REMOVE HEMORRHOIDS & FISTULA
$466.46
46270
3
REMOVAL OF ANAL FISTULA
$404.73
46275
3
REMOVAL OF ANAL FISTULA
$428.10
46280
3
REMOVAL OF ANAL FISTULA
$389.96
46281
O
CLOSURE OF ANAL FISTULA WITH RECTAL
46285
3
REMOVAL OF ANAL FISTULA
$415.83
46288
3
REPAIR ANAL FISTULA
$460.48
46320
3
REMOVAL OF HEMORRHOID CLOT
$148.34
46500
3
INJECTION INTO HEMORRHOID(S)
$181.11
46505
3
CHEMODENERVATION ANAL MUSC
$234.62
46600
3
DIAGNOSTIC ANOSCOPY
46602
O
ANOSCOPY FOR COLLECTION OF SPECIMEN
46604
3
ANOSCOPY AND DILATION
$458.56
46606
3
ANOSCOPY AND BIOPSY
$187.00
$0.00
$72.98 $0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
46608
3
ANOSCOPY, REMOVE FOR BODY
$193.00
46610
3
ANOSCOPY, REMOVE LESION
$190.93
46611
3
ANOSCOPY
$150.09
46612
3
ANOSCOPY, REMOVE LESIONS
$228.90
46614
3
ANOSCOPY, CONTROL BLEEDING
$115.21
46615
3
ANOSCOPY
$132.12
46700
3
REPAIR OF ANAL STRICTURE
$553.66
46705
3
REPAIR OF ANAL STRICTURE
$457.89
46706
3
REPR OF ANAL FISTULA W/GLUE
$146.80
46710
3
REPR PER/VAG POUCH SNGL PROC
$941.85
46712
3
REPR PER/VAG POUCH DBL PROC
46715
3
REP PERF ANOPER FISTU
46716
3
REP PERF ANOPER/VESTIB FISTU
$1,108.79
46730
3
CONSTRUCTION OF ABSENT ANUS
$1,670.41
46735
3
CONSTRUCTION OF ABSENT ANUS
$1,949.77
46740
3
CONSTRUCTION OF ABSENT ANUS
$1,790.53
46742
3
REPAIR OF IMPERFORATED ANUS
$2,115.75
46744
3
REPAIR OF CLOACAL ANOMALY
$3,013.24
46746
3
REPAIR OF CLOACAL ANOMALY
$3,486.32
46748
3
REPAIR OF CLOACAL ANOMALY
$3,638.02
46750
3
REPAIR OF ANAL SPHINCTER
$668.84
46751
3
REPAIR OF ANAL SPHINCTER
$557.22
46753
3
RECONSTRUCTION OF ANUS
$505.56
46754
3
REMOVAL OF SUTURE FROM ANUS
$243.89
46760
3
REPAIR OF ANAL SPHINCTER
$945.90
46761
3
REPAIR OF ANAL SPHINCTER
$817.42
46762
3
IMPLANT ARTIFICIAL SPHINCTER
$806.46
46900
3
DESTRUCTION, ANAL LESION(S)
$198.03
46910
3
DESTRUCTION, ANAL LESION(S)
$206.68
46916
3
CRYOSURGERY, ANAL LESION(S)
$204.76
46917
3
LASER SURGERY, ANAL LESIONS
$397.18
46922
3
EXCISION OF ANAL LESION(S)
$215.53
46924
3
DESTRUCTION, ANAL LESION(S)
$161.77
46930
3
DESTROY INTERNAL HEMORRHOIDS
$190.45
46934
O
DESTRUCTION OF HEMORRHOIDS
$1,918.19 $451.94
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
46935
O
DESTRUCTION OF HEMORRHOIDS
$0.00
46936
O
DESTRUCTION OF HEMORRHOIDS
$0.00
46937
3
CRYOTHERAPY OF RECTAL LESION
$220.74
46938
3
CRYOTHERAPY OF RECTAL LESION
$385.19
46940
3
TREATMENT OF ANAL FISSURE
$185.64
46942
3
TREATMENT OF ANAL FISSURE
$172.09
46945
3
LIGATION OF HEMORRHOIDS
$241.12
46946
3
LIGATION OF HEMORRHOIDS
$260.57
46947
3
HEMORRHOIDOPEXY BY STAPLING
$327.28
46999
5
ANUS SURGERY PROCEDURE
47000
3
NEEDLE BIOPSY OF LIVER
47001
3
NEEDLE BIOPSY, LIVER ADD-ON
$94.22
47010
3
OPEN DRAINAGE, LIVER LESION
$1,047.71
47011
3
PERCUT DRAIN, LIVER LESION
$189.26
47015
3
INJECT/ASPIRATE LIVER CYST
$993.71
47100
3
WEDGE BIOPSY OF LIVER
$729.22
47120
3
PARTIAL REMOVAL OF LIVER
$2,046.78
47122
3
EXTENSIVE REMOVAL OF LIVER
$3,042.64
47125
3
PARTIAL REMOVAL OF LIVER
$2,725.63
47130
3
PARTIAL REMOVAL OF LIVER
$2,930.41
47133
9
REMOVAL OF DONOR LIVER
$0.00
47134
O
PARTIAL REMOVAL, DONOR LIVER
$0.00
47135
3
TRANSPLANTATION OF LIVER
$4,314.50
47136
3
TRANSPLANTATION OF LIVER
$3,681.05
47140
9
PARTIAL REMOVAL, DONOR LIVER
$0.00
47141
9
PARTIAL REMOVAL, DONOR LIVER
$0.00
47142
9
PARTIAL REMOVAL, DONOR LIVER
$0.00
47143
9
PREP DONOR LIVER, WHOLE
$0.00
47144
9
PREP DONOR LIVER, 3-SEGMENT
$0.00
47145
9
PREP DONOR LIVER, LOBE SPLIT
$0.00
47146
9
PREP DONOR LIVER/VENOUS
$0.00
47147
9
PREP DONOR LIVER/ARTERIAL
$0.00
47300
3
SURGERY FOR LIVER LESION
47350
3
REPAIR LIVER WOUND
47355
O
HEPATORRHAPHY, SUTURE OF LIVER WOUN
$0.00 $310.35
$977.79 $1,199.36 $0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
47360
3
REPAIR LIVER WOUND
$1,630.71
47361
3
REPAIR LIVER WOUND
$2,678.15
47362
3
REPAIR LIVER WOUND
$1,244.22
47370
3
LAPARO ABLATE LIVER TUMOR RF
$1,096.11
47371
3
LAPARO ABLATE LIVER CRYOSURG
$1,117.27
47379
5
LAPAROSCOPE PROCEDURE, LIVER
$0.00
47380
3
OPEN ABLATE LIVER TUMOR RF
$1,281.15
47381
3
OPEN ABLATE LIVER TUMOR CRYO
$1,306.57
47382
3
PERCUT ABLATE LIVER RF
47399
5
LIVER SURGERY PROCEDURE
47400
3
INCISION OF LIVER DUCT
$1,859.80
47420
3
INCISION OF BILE DUCT
$1,174.25
47425
3
INCISION OF BILE DUCT
$1,185.87
47440
O
DUODENOCHOLEDOCHOTOMY, TRANSDUODENA
47460
3
INCISE BILE DUCT SPHINCTER
47480
3
INCISION OF GALLBLADDER
$747.24
47490
3
INCISION OF GALLBLADDER
$504.63
47500
3
INJECTION FOR LIVER X-RAYS
$100.65
47505
3
INJECTION FOR LIVER X-RAYS
$38.84
47510
3
INSERT CATHETER, BILE DUCT
$477.39
47511
3
INSERT BILE DUCT DRAIN
$598.29
47525
3
CHANGE BILE DUCT CATHETER
$505.86
47530
3
REVISE/REINSERT BILE TUBE
47550
3
BILE DUCT ENDOSCOPY ADD-ON
$150.77
47552
3
BILIARY ENDOSCOPY THRU SKIN
$324.25
47553
3
BILIARY ENDOSCOPY THRU SKIN
$323.78
47554
3
BILIARY ENDOSCOPY THRU SKIN
$474.32
47555
3
BILIARY ENDOSCOPY THRU SKIN
$388.53
47556
3
BILIARY ENDOSCOPY THRU SKIN
$439.51
47560
3
LAPAROSCOPY W/CHOLANGIO
$243.57
47561
3
LAPARO W/CHOLANGIO/BIOPSY
$264.52
47562
3
LAPAROSCOPIC CHOLECYSTECTOMY
$647.26
47563
3
LAPARO CHOLECYSTECTOMY/GRAPH
$662.22
47564
3
LAPARO CHOLECYSTECTOMY/EXPLR
$764.55
47570
3
LAPARO CHOLECYSTOENTEROSTOMY
$682.82
$811.29 $0.00
$0.00 $1,120.95
$1,384.58
Procedure Code Pricing Action Code Description
Maximum Allowable
47579
5
LAPAROSCOPE PROC, BILIARY
$0.00
47600
3
REMOVAL OF GALLBLADDER
$927.10
47605
3
REMOVAL OF GALLBLADDER
$858.18
47610
3
REMOVAL OF GALLBLADDER
$1,099.40
47612
3
REMOVAL OF GALLBLADDER
$1,110.63
47620
3
REMOVAL OF GALLBLADDER
$1,205.51
47630
3
REMOVE BILE DUCT STONE
$543.15
47700
3
EXPLORATION OF BILE DUCTS
$917.01
47701
3
BILE DUCT REVISION
47710
O
EXCISION OF BILE DUCT TUMOR, WITH R
47711
3
EXCISION OF BILE DUCT TUMOR
$1,365.15
47712
3
EXCISION OF BILE DUCT TUMOR
$1,747.02
47715
3
EXCISION OF BILE DUCT CYST
$1,147.85
47716
O
FUSION OF BILE DUCT CYST
$0.00
47719
O
FUSION OF BILE DUCT CYST
$0.00
47720
3
FUSE GALLBLADDER & BOWEL
$992.24
47721
3
FUSE UPPER GI STRUCTURES
$1,170.08
47740
3
FUSE GALLBLADDER & BOWEL
$1,130.68
47741
3
FUSE GALLBLADDER & BOWEL
$1,280.63
47760
3
FUSE BILE DUCTS AND BOWEL
$1,925.11
47765
3
FUSE LIVER DUCTS & BOWEL
$2,538.40
47780
3
FUSE BILE DUCTS AND BOWEL
$2,104.34
47785
3
FUSE BILE DUCTS AND BOWEL
$2,741.54
47800
3
RECONSTRUCTION OF BILE DUCTS
$1,378.47
47801
3
PLACEMENT, BILE DUCT SUPPORT
$977.42
47802
3
FUSE LIVER DUCT & INTESTINE
$1,323.72
47900
3
SUTURE BILE DUCT INJURY
$1,193.10
47999
5
BILE TRACT SURGERY PROCEDURE
48000
3
DRAINAGE OF ABDOMEN
$1,652.28
48001
3
PLACEMENT OF DRAIN, PANCREAS
$2,029.95
48005
O
RESECT/DEBRIDE PANCREAS
48020
3
REMOVAL OF PANCREATIC STONE
48100
3
BIOPSY OF PANCREAS, OPEN
$774.50
48102
3
NEEDLE BIOPSY, PANCREAS
$517.04
48105
3
RESECT/DEBRIDE PANCREAS
$1,576.73 $0.00
$0.00
$0.00 $1,020.27
$2,501.57
Procedure Code Pricing Action Code Description
Maximum Allowable
48120
3
REMOVAL OF PANCREAS LESION
$966.71
48140
3
PARTIAL REMOVAL OF PANCREAS
$1,368.22
48145
3
PARTIAL REMOVAL OF PANCREAS
$1,420.76
48146
3
PANCREATECTOMY
$1,622.69
48148
3
REMOVAL OF PANCREATIC DUCT
$1,077.45
48150
3
PARTIAL REMOVAL OF PANCREAS
$2,736.81
48151
O
PANCREATECTOMY, NEAR-TOTAL, WITH PR
48152
3
PANCREATECTOMY
$2,530.96
48153
3
PANCREATECTOMY
$2,732.90
48154
3
PANCREATECTOMY
$2,537.18
48155
3
REMOVAL OF PANCREAS
$1,574.61
48160
5
PANCREAS REMOVAL/TRANSPLANT
$0.00
48180
O
FUSE PANCREAS AND BOWEL
$0.00
48400
9
INJECTION, INTRAOP ADD-ON
$0.00
48500
3
SURGERY OF PANCREATIC CYST
$987.22
48510
3
DRAIN PANCREATIC PSEUDOCYST
$937.78
48511
3
DRAIN PANCREATIC PSEUDOCYST
$903.65
48520
3
FUSE PANCREAS CYST AND BOWEL
$955.73
48540
3
FUSE PANCREAS CYST AND BOWEL
$1,141.68
48545
3
PANCREATORRHAPHY
$1,156.20
48547
3
DUODENAL EXCLUSION
$1,558.50
48548
3
FUSE PANCREAS AND BOWEL
$1,460.38
48550
9
DONOR PANCREATECTOMY
$0.00
48551
9
PREP DONOR PANCREAS
$0.00
48552
9
PREP DONOR PANCREAS/VENOUS
$0.00
48554
3
TRANSPL ALLOGRAFT PANCREAS
$2,177.48
48556
3
REMOVAL, ALLOGRAFT PANCREAS
$1,083.79
48999
5
PANCREAS SURGERY PROCEDURE
$0.00
49000
3
EXPLORATION OF ABDOMEN
$680.97
49002
3
REOPENING OF ABDOMEN
$891.40
49010
3
EXPLORATION BEHIND ABDOMEN
$843.09
49020
3
DRAIN ABDOMINAL ABSCESS
$1,394.63
49021
3
DRAIN ABDOMINAL ABSCESS
$864.27
49040
3
DRAIN, OPEN, ABDOM ABSCESS
$874.47
49041
3
DRAIN, PERCUT, ABDOM ABSCESS
$881.47
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
49060
3
DRAIN, OPEN, RETROP ABSCESS
$978.92
49061
3
DRAIN, PERCUT, RETROPER ABSC
$189.26
49062
3
DRAIN TO PERITONEAL CAVITY
$666.05
49080
3
PUNCTURE, PERITONEAL CAVITY
$69.01
49081
3
REMOVAL OF ABDOMINAL FLUID
$152.18
49085
O
REMOVE ABDOMEN FOREIGN BODY
49180
3
BIOPSY, ABDOMINAL MASS
49200
O
REMOVAL OF ABDOMINAL LESION
$0.00
49201
O
REMOVE ABDOM LESION, COMPLEX
$0.00
49203
3
EXC ABD TUM 5 CM OR LESS
$1,065.96
49204
3
EXC ABD TUM OVER 5 CM
$1,360.38
49205
3
EXC ABD TUM OVER 10 CM
$1,557.22
49215
3
EXCISE SACRAL SPINE TUMOR
$1,952.41
49220
3
MULTIPLE SURGERY, ABDOMEN
$850.70
49250
3
EXCISION OF UMBILICUS
$509.14
49255
3
REMOVAL OF OMENTUM
$690.68
49300
O
PERITONEOSCOPY WITHOUT BIOPSY
$0.00
49301
O
PERITONEOSCOPY WITH BIOPSY
$0.00
49302
O
PERITONEOSCOPY WITH GUIDED TRANSHEP
$0.00
49303
O
PERITONEOSCOPY WITH GUIDED TRANSHEP
$0.00
49310
O
LAPAROSCOPY, SURGICAL; CHOLECYSTECT
$0.00
49311
O
LAPAROSCOPY, SURGICAL; CHOLECYSTECT
$0.00
49315
O
LAPAROSCOPY, SURGICAL;APPENDECTOMY
$0.00
49320
3
DIAG LAPARO SEPARATE PROC
$291.74
49321
3
LAPAROSCOPY, BIOPSY
$306.99
49322
3
LAPAROSCOPY, ASPIRATION
$333.51
49323
3
LAPARO DRAIN LYMPHOCELE
$566.35
49324
3
LAP INSERTION PERM IP CATH
$346.91
49325
3
LAP REVISION PERM IP CATH
$372.33
49326
3
LAP W/OMENTOPEXY ADD-ON
$170.74
49329
5
LAPARO PROC, ABDM/PER/OMENT
49400
3
AIR INJECTION INTO ABDOMEN
49401
O
PNEUMOPERITONEUM (SEPARATE PROCEDUR
49402
3
REMOVE FOREIGN BODY, ADBOMEN
$750.93
49419
3
INSRT ABDOM CATH FOR CHEMOTX
$402.98
$0.00 $162.93
$0.00 $169.49 $0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
49420
3
INSERT ABDOM DRAIN, TEMP
$127.99
49421
3
INSERT ABDOM DRAIN, PERM
$345.80
49422
3
REMOVE PERM CANNULA/CATHETER
$346.00
49423
3
EXCHANGE DRAINAGE CATHETER
$76.51
49424
3
ASSESS CYST, CONTRAST INJECT
$39.94
49425
3
INSERT ABDOMEN-VENOUS DRAIN
$675.92
49426
3
REVISE ABDOMEN-VENOUS SHUNT
$575.79
49427
3
INJECTION, ABDOMINAL SHUNT
49428
3
LIGATION OF SHUNT
$387.87
49429
3
REMOVAL OF SHUNT
$409.02
49435
3
INSERT SUBQ EXTEN TO IP CATH
$109.29
49436
3
EMBEDDED IP CATH EXIT-SITE
$162.36
49440
3
PLACE GASTROSTOMY TUBE PERC
$1,063.95
49441
3
PLACE DUOD/JEJ TUBE PERC
$1,154.92
49442
3
PLACE CECOSTOMY TUBE PERC
$1,035.62
49446
3
CHANGE G-TUBE TO G-J PERC
49450
3
REPLACE G/C TUBE PERC
$67.89
49451
3
REPLACE DUOD/JEJ TUBE PERC
$94.64
49452
3
REPLACE G-J TUBE PERC
$147.55
49460
3
FIX G/COLON TUBE W/DEVICE
$796.74
49465
3
FLUORO EXAM OF G/COLON TUBE
$165.95
49491
3
RPR HERN PREEMIE REDUC
$679.23
49492
3
RPR ING HERN PREMIE, BLOCKED
$829.29
49495
3
RPR ING HERNIA BABY, REDUC
$345.82
49496
3
RPR ING HERNIA BABY, BLOCKED
$524.68
49500
3
RPR ING HERNIA, INIT, REDUCE
$344.85
49501
3
RPR ING HERNIA, INIT BLOCKED
$520.75
49505
3
PRP I/HERN INIT REDUC >5 YR
$451.56
49507
3
PRP I/HERN INIT BLOCK >5 YR
$555.29
49510
O
REPAIR INGUINAL HERNIA, AGE 5 OR OV
$0.00
49515
O
REPAIR INGUINAL HERNIA, AGE 5 OR OV
$0.00
49520
3
REREPAIR ING HERNIA, REDUCE
$551.17
49521
3
REREPAIR ING HERNIA, BLOCKED
$671.65
49525
3
REPAIR ING HERNIA, SLIDING
$498.60
49530
O
REPAIR INGUINAL HERNIA, ANY AGE INC
$46.05
$968.12
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
49535
O
REPAIR INGUINAL HERNIA, ANY AGE STR
$0.00
49540
3
REPAIR LUMBAR HERNIA
$589.37
49550
3
RPR REM HERNIA, INIT, REDUCE
$500.99
49552
O
REPAIR FEMORAL HERNIA, HENRY APPROA
49553
3
RPR FEM HERNIA, INIT BLOCKED
$548.07
49555
3
REREPAIR FEM HERNIA, REDUCE
$521.53
49557
3
REREPAIR FEM HERNIA, BLOCKED
$632.83
49560
3
RPR VENTRAL HERN INIT, REDUC
$646.96
49561
3
RPR VENTRAL HERN INIT, BLOCK
$815.33
49565
3
REREPAIR VENTRL HERN, REDUCE
$670.80
49566
3
REREPAIR VENTRL HERN, BLOCK
$823.76
49568
3
HERNIA REPAIR W/MESH
$242.22
49570
3
RPR EPIGASTRIC HERN, REDUCE
$355.90
49572
3
RPR EPIGASTRIC HERN, BLOCKED
$440.31
49575
O
REPAIR EPIGASTRIC HERNIA, PROPERITO
49580
3
RPR UMBIL HERN, REDUC < 5 YR
49581
O
REPAIR UMBILICAL HERNIA AGE 5 OR OV
49582
3
RPR UMBIL HERN, BLOCK < 5 YR
$411.29
49585
3
RPR UMBIL HERN, REDUC > 5 YR
$382.42
49587
3
RPR UMBIL HERN, BLOCK > 5 YR
$452.72
49590
3
REPAIR SPIGELIAN HERNIA
$496.79
49600
3
REPAIR UMBILICAL LESION
$641.15
49605
3
REPAIR UMBILICAL LESION
$4,412.89
49606
3
REPAIR UMBILICAL LESION
$1,000.49
49610
3
REPAIR UMBILICAL LESION
$596.02
49611
3
REPAIR UMBILICAL LESION
$538.14
49650
3
LAP ING HERNIA REPAIR INIT
$372.01
49651
3
LAP ING HERNIA REPAIR RECUR
$480.68
49652
3
LAP VENT/ABD HERNIA REPAIR
$697.45
49653
3
LAP VENT/ABD HERN PROC COMP
$871.08
49654
3
LAP INC HERNIA REPAIR
$800.64
49655
3
LAP INC HERN REPAIR COMP
$963.71
49656
3
LAP INC HERNIA REPAIR RECUR
$803.52
49657
3
LAP INC HERN RECUR COMP
49659
5
LAPARO PROC, HERNIA REPAIR
$0.00
$0.00 $277.77 $0.00
$1,159.17 $0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
49900
3
REPAIR OF ABDOMINAL WALL
$713.91
49904
3
OMENTAL FLAP, EXTRA-ABDOM
49905
3
OMENTAL FLAP, INTRA-ABDOM
49906
5
FREE OMENTAL FLAP, MICROVASC
$0.00
49999
5
ABDOMEN SURGERY PROCEDURE
$0.00
50010
3
EXPLORATION OF KIDNEY
$699.38
50020
3
RENAL ABSCESS, OPEN DRAIN
$996.39
50021
3
RENAL ABSCESS, PERCUT DRAIN
$172.54
50040
3
DRAINAGE OF KIDNEY
$940.04
50045
3
EXPLORATION OF KIDNEY
$948.90
5005F
9
PT COUNSLD ON EXAM FOR MOLES
50060
3
REMOVAL OF KIDNEY STONE
$1,168.12
50065
3
INCISION OF KIDNEY
$1,227.03
50070
3
INCISION OF KIDNEY
$1,220.69
50075
3
REMOVAL OF KIDNEY STONE
$1,500.03
50080
3
REMOVAL OF KIDNEY STONE
$892.92
50081
3
REMOVAL OF KIDNEY STONE
$1,310.55
50100
3
REVISE KIDNEY BLOOD VESSELS
$953.23
5010F
9
MACUL+FNDNGS TO DR MNG DM
$0.00
50120
3
EXPLORATION OF KIDNEY
$967.29
50125
3
EXPLORE AND DRAIN KIDNEY
$999.91
50130
3
REMOVAL OF KIDNEY STONE
$1,058.70
50135
3
EXPLORATION OF KIDNEY
$1,146.04
5015F
9
DOC FX & TEST/TXMNT FOR OP
50200
3
BIOPSY OF KIDNEY
$144.77
50205
3
BIOPSY OF KIDNEY
$671.57
5020F
9
TXMNTS 2 MAIN DR BY 1 MON
50220
3
REMOVE KIDNEY, OPEN
$1,041.66
50225
3
REMOVAL KIDNEY OPEN, COMPLEX
$1,206.19
50230
3
REMOVAL KIDNEY OPEN, RADICAL
$1,307.75
50234
3
REMOVAL OF KIDNEY & URETER
$1,328.04
50236
3
REMOVAL OF KIDNEY & URETER
$1,503.71
50240
3
PARTIAL REMOVAL OF KIDNEY
$1,350.61
50250
3
CRYOABLATE RENAL MASS OPEN
$1,253.79
50280
3
REMOVAL OF KIDNEY LESION
$1,332.39 $323.40
$0.00
$0.00
$0.00
$963.26
Procedure Code Pricing Action Code Description
Maximum Allowable
50290
3
REMOVAL OF KIDNEY LESION
$887.63
50300
9
REMOVE CADAVER DONOR KIDNEY
50320
3
REMOVE KIDNEY, LIVING DONOR
50323
9
PREP CADAVER RENAL ALLOGRAFT
$0.00
50325
9
PREP DONOR RENAL GRAFT
$0.00
50327
9
PREP RENAL GRAFT/VENOUS
$0.00
50328
9
PREP RENAL GRAFT/ARTERIAL
$0.00
50329
9
PREP RENAL GRAFT/URETERAL
$0.00
50340
3
REMOVAL OF KIDNEY
50360
3
TRANSPLANTATION OF KIDNEY
$2,215.04
50365
3
TRANSPLANTATION OF KIDNEY
$2,494.92
50370
3
REMOVE TRANSPLANTED KIDNEY
$1,036.08
50380
3
REIMPLANTATION OF KIDNEY
$1,756.67
50382
3
CHANGE URETER STENT, PERCUT
$1,279.44
50384
3
REMOVE URETER STENT, PERCUT
$1,100.03
50385
3
CHANGE STENT VIA TRANSURETH
$1,253.56
50386
3
REMOVE STENT VIA TRANSURETH
$811.86
50387
3
CHANGE EXT/INT URETER STENT
$593.05
50389
3
REMOVE RENAL TUBE W/FLUORO
$344.15
50390
3
DRAINAGE OF KIDNEY LESION
$100.65
50391
3
INSTLL RX AGNT INTO RNAL TUB
$130.33
50392
3
INSERT KIDNEY DRAIN
$185.11
50393
3
INSERT URETERAL TUBE
$225.65
50394
3
INJECTION FOR KIDNEY X-RAY
$105.62
50395
3
CREATE PASSAGE TO KIDNEY
$186.45
50396
3
MEASURE KIDNEY PRESSURE
$120.69
50398
3
CHANGE KIDNEY TUBE
50400
3
REVISION OF KIDNEY/URETER
$1,179.30
50405
3
REVISION OF KIDNEY/URETER
$1,430.45
50500
3
REPAIR OF KIDNEY WOUND
$1,139.98
5050F
9
PLAN 2 MAIN DR. BY 1 MONTH
$0.00
50520
3
CLOSE KIDNEY-SKIN FISTULA
$1,057.71
50525
3
REPAIR RENAL-ABDOMEN FISTULA
$1,320.33
50526
3
REPAIR RENAL-ABDOMEN FISTULA
$1,380.59
50540
3
REVISION OF HORSESHOE KIDNEY
$1,154.63
$0.00 $1,313.00
$809.14
$75.51
Procedure Code Pricing Action Code Description
Maximum Allowable
50541
3
LAPARO ABLATE RENAL CYST
$941.71
50542
3
LAPARO ABLATE RENAL MASS
$1,194.99
50543
3
LAPARO PARTIAL NEPHRECTOMY
$1,524.46
50544
3
LAPAROSCOPY, PYELOPLASTY
$1,284.21
50545
3
LAPARO RADICAL NEPHRECTOMY
$1,378.44
50546
3
LAPAROSCOPIC NEPHRECTOMY
$1,223.08
50547
3
LAPARO REMOVAL DONOR KIDNEY
$1,467.30
50548
3
LAPARO REMOVE W/URETER
$1,389.60
50549
5
LAPAROSCOPE PROC, RENAL
50551
3
KIDNEY ENDOSCOPY
$379.03
50553
3
KIDNEY ENDOSCOPY
$395.32
50555
3
KIDNEY ENDOSCOPY & BIOPSY
$431.21
50557
3
KIDNEY ENDOSCOPY & TREATMENT
$440.09
50559
O
RENAL ENDOSCOPY/RADIOTRACER
$0.00
50561
3
KIDNEY ENDOSCOPY & TREATMENT
$498.98
50562
3
RENAL SCOPE W/TUMOR RESECT
$605.16
50570
3
KIDNEY ENDOSCOPY
$512.49
50572
3
KIDNEY ENDOSCOPY
$557.72
50574
3
KIDNEY ENDOSCOPY & BIOPSY
$588.99
50575
3
KIDNEY ENDOSCOPY
$744.77
50576
3
KIDNEY ENDOSCOPY & TREATMENT
$588.16
50578
O
RENAL ENDOSCOPY/RADIOTRACER
$0.00
50580
3
KIDNEY ENDOSCOPY & TREATMENT
$629.69
50590
3
FRAGMENTING OF KIDNEY STONE
$950.85
50592
3
PERC RF ABLATE RENAL TUMOR
$3,646.91
50593
3
PERC CRYO ABLATE RENAL TUM
$4,706.51
50600
3
EXPLORATION OF URETER
$955.78
50605
3
INSERT URETERAL SUPPORT
$919.94
5060F
9
FNDNGS MAMMO 2PT W/IN 3 DAYS
50610
3
REMOVAL OF URETER STONE
$975.82
50620
3
REMOVAL OF URETER STONE
$925.69
5062F
9
DOC F2FMAMMO FNDNG IN 5 DAYS
50630
3
REMOVAL OF URETER STONE
50650
3
REMOVAL OF URETER
$1,055.25
50660
3
REMOVAL OF URETER
$1,166.30
$0.00
$0.00
$0.00 $902.04
Procedure Code Pricing Action Code Description
Maximum Allowable
50684
3
INJECTION FOR URETER X-RAY
$50.91
50686
3
MEASURE URETER PRESSURE
$92.83
50688
3
CHANGE OF URETER TUBE/STENT
$81.18
50690
3
INJECTION FOR URETER X-RAY
$101.55
50700
3
REVISION OF URETER
$945.35
50715
3
RELEASE OF URETER
$1,114.00
50722
3
RELEASE OF URETER
$969.10
50725
3
RELEASE/REVISE URETER
50727
3
REVISE URETER
$511.76
50728
3
REVISE URETER
$703.07
50740
3
FUSION OF URETER & KIDNEY
$1,091.41
50750
3
FUSION OF URETER & KIDNEY
$1,187.12
50760
3
FUSION OF URETERS
$1,106.48
50770
3
SPLICING OF URETERS
$1,147.77
50780
3
REIMPLANT URETER IN BLADDER
$1,110.10
50782
3
REIMPLANT URETER IN BLADDER
$1,089.56
50783
3
REIMPLANT URETER IN BLADDER
$1,129.22
50785
3
REIMPLANT URETER IN BLADDER
$1,231.92
50800
3
IMPLANT URETER IN BOWEL
50810
3
FUSION OF URETER & BOWEL
$1,229.11
50815
3
URINE SHUNT TO INTESTINE
$1,248.52
50820
3
CONSTRUCT BOWEL BLADDER
$1,328.45
50825
3
CONSTRUCT BOWEL BLADDER
$1,685.83
50830
3
REVISE URINE FLOW
$1,828.94
50840
3
REPLACE URETER BY BOWEL
$1,256.66
50845
3
APPENDICO-VESICOSTOMY
$1,275.30
50860
3
TRANSPLANT URETER TO SKIN
$965.67
50900
3
REPAIR OF URETER
$849.62
50920
3
CLOSURE URETER/SKIN FISTULA
$898.80
50930
3
CLOSURE URETER/BOWEL FISTULA
50940
3
RELEASE OF URETER
50945
3
LAPAROSCOPY URETEROLITHOTOMY
$1,002.42
50947
3
LAPARO NEW URETER/BLADDER
$1,420.39
50948
3
LAPARO NEW URETER/BLADDER
$1,318.97
50949
5
LAPAROSCOPE PROC, URETER
$1,110.04
$936.78
$1,085.44 $903.89
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
50951
3
ENDOSCOPY OF URETER
$395.99
50953
3
ENDOSCOPY OF URETER
$417.78
50955
3
URETER ENDOSCOPY & BIOPSY
$462.34
50957
3
URETER ENDOSCOPY & TREATMENT
$449.36
50959
O
URETER ENDOSCOPY & TRACER
50961
3
URETER ENDOSCOPY & TREATMENT
$405.71
50970
3
URETER ENDOSCOPY
$386.66
50972
3
URETER ENDOSCOPY & CATHETER
$372.20
50974
3
URETER ENDOSCOPY & BIOPSY
$492.76
50976
3
URETER ENDOSCOPY & TREATMENT
$485.27
50978
O
URETER ENDOSCOPY & TRACER
50980
3
URETER ENDOSCOPY & TREATMENT
51000
O
DRAINAGE OF BLADDER
$0.00
51005
O
DRAINAGE OF BLADDER
$0.00
5100F
9
RSK FX REF W/N 24 HRS X-RAY
$0.00
51010
O
DRAINAGE OF BLADDER
$0.00
51020
3
INCISE & TREAT BLADDER
$474.40
51030
3
INCISE & TREAT BLADDER
$469.50
51040
3
INCISE & DRAIN BLADDER
$296.98
51045
3
INCISE BLADDER/DRAIN URETER
$472.50
51050
3
REMOVAL OF BLADDER STONE
$481.15
51060
3
REMOVAL OF URETER STONE
$592.40
51065
3
REMOVE URETER CALCULUS
$588.21
51080
3
DRAINAGE OF BLADDER ABSCESS
$412.51
51100
3
DRAIN BLADDER BY NEEDLE
51101
3
DRAIN BLADDER BY TROCAR/CATH
$127.95
51102
3
DRAIN BL W/CATH INSERTION
$240.73
51500
3
REMOVAL OF BLADDER CYST
$632.29
51520
3
REMOVAL OF BLADDER LESION
$596.34
51525
3
REMOVAL OF BLADDER LESION
$876.22
51530
3
REMOVAL OF BLADDER LESION
$780.69
51535
3
REPAIR OF URETER LESION
$792.90
51550
3
PARTIAL REMOVAL OF BLADDER
$962.61
51555
3
PARTIAL REMOVAL OF BLADDER
$1,279.62
51565
3
REVISE BLADDER & URETER(S)
$1,308.42
$0.00
$0.00 $371.27
$61.98
Procedure Code Pricing Action Code Description
Maximum Allowable
51570
3
REMOVAL OF BLADDER
$1,493.30
51575
3
REMOVAL OF BLADDER & NODES
$1,867.37
51580
3
REMOVE BLADDER/REVISE TRACT
$1,946.62
51585
3
REMOVAL OF BLADDER & NODES
$2,167.82
51590
3
REMOVE BLADDER/REVISE TRACT
$1,974.19
51595
3
REMOVE BLADDER/REVISE TRACT
$2,243.76
51596
3
REMOVE BLADDER/CREATE POUCH
$2,412.34
51597
3
REMOVAL OF PELVIC STRUCTURES
$2,325.93
51600
3
INJECTION FOR BLADDER X-RAY
$45.45
51605
3
PREPARATION FOR BLADDER XRAY
$39.36
51610
3
INJECTION FOR BLADDER X-RAY
51700
3
IRRIGATION OF BLADDER
$89.08
51701
3
INSERT BLADDER CATHETER
$62.08
51702
3
INSERT TEMP BLADDER CATH
$80.19
51703
3
INSERT BLADDER CATH, COMPLEX
$143.66
51705
3
CHANGE OF BLADDER TUBE
$115.76
51710
3
CHANGE OF BLADDER TUBE
$163.08
51715
3
ENDOSCOPIC INJECTION/IMPLANT
$300.32
51720
3
TREATMENT OF BLADDER LESION
$119.07
51725
3
SIMPLE CYSTOMETROGRAM
$225.65
51726
3
COMPLEX CYSTOMETROGRAM
$329.03
51736
3
URINE FLOW MEASUREMENT
51739
O
SOUND RECORDING OF EXTERNAL STREAM
51741
3
ELECTRO-UROFLOWMETRY, FIRST
51772
3
URETHRA PRESSURE PROFILE
$252.72
51784
3
ANAL/URINARY MUSCLE STUDY
$206.76
51785
3
ANAL/URINARY MUSCLE STUDY
$224.64
51792
3
URINARY REFLEX STUDY
$236.35
51795
3
URINE VOIDING PRESSURE STUDY
$310.24
51797
3
INTRAABDOMINAL PRESSURE TEST
$153.18
51798
3
US URINE CAPACITY MEASURE
51800
3
REVISION OF BLADDER/URETHRA
$1,064.35
51820
3
REVISION OF URINARY TRACT
$1,083.43
51840
3
ATTACH BLADDER/URETHRA
$647.72
51841
3
ATTACH BLADDER/URETHRA
$768.21
$113.51
$54.66 $0.00 $86.26
$21.14
Procedure Code Pricing Action Code Description
Maximum Allowable
51845
3
REPAIR BLADDER NECK
$590.99
51860
3
REPAIR OF BLADDER WOUND
$721.82
51865
3
REPAIR OF BLADDER WOUND
$894.04
51880
3
REPAIR OF BLADDER OPENING
$468.99
51900
3
REPAIR BLADDER/VAGINA LESION
$829.26
51920
3
CLOSE BLADDER-UTERUS FISTULA
$766.82
51925
3
HYSTERECTOMY/BLADDER REPAIR
$999.02
51940
3
CORRECTION OF BLADDER DEFECT
$1,635.00
51960
3
REVISION OF BLADDER & BOWEL
$1,414.27
51980
3
CONSTRUCT BLADDER OPENING
$725.42
51990
3
LAPARO URETHRAL SUSPENSION
$744.13
51992
3
LAPARO SLING OPERATION
$811.14
51999
6
LAPAROSCOPE PROC, BLA
52000
3
CYSTOSCOPY
$128.52
52001
3
CYSTOSCOPY, REMOVAL OF CLOTS
$394.88
52005
3
CYSTOSCOPY & URETER CATHETER
$298.76
52007
3
CYSTOSCOPY AND BIOPSY
$561.28
52010
3
CYSTOSCOPY & DUCT CATHETER
$416.85
52204
3
CYSTOSCOPY W/BIOPSY(S)
$145.42
52214
3
CYSTOSCOPY AND TREATMENT
$603.54
52224
3
CYSTOSCOPY AND TREATMENT
$865.04
52234
3
CYSTOSCOPY AND TREATMENT
$255.82
52235
3
CYSTOSCOPY AND TREATMENT
$299.86
52240
3
CYSTOSCOPY AND TREATMENT
$523.97
52250
3
CYSTOSCOPY AND RADIOTRACER
$251.30
52260
3
CYSTOSCOPY AND TREATMENT
$216.68
52265
3
CYSTOSCOPY AND TREATMENT
$439.00
52270
3
CYSTOSCOPY & REVISE URETHRA
$422.69
52275
3
CYSTOSCOPY & REVISE URETHRA
$578.12
52276
3
CYSTOSCOPY AND TREATMENT
$275.80
52277
3
CYSTOSCOPY AND TREATMENT
$336.78
52281
3
CYSTOSCOPY AND TREATMENT
$317.43
52282
3
CYSTOSCOPY, IMPLANT STENT
$347.45
52283
3
CYSTOSCOPY AND TREATMENT
$291.10
52285
3
CYSTOSCOPY AND TREATMENT
$293.48
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
52290
3
CYSTOSCOPY AND TREATMENT
$253.78
52300
3
CYSTOSCOPY AND TREATMENT
$291.30
52301
3
CYSTOSCOPY AND TREATMENT
$306.27
52305
3
CYSTOSCOPY AND TREATMENT
$289.44
52310
3
CYSTOSCOPY AND TREATMENT
$260.86
52315
3
CYSTOSCOPY AND TREATMENT
$461.25
52317
3
REMOVE BLADDER STONE
$345.49
52318
3
REMOVE BLADDER STONE
$492.98
52320
3
CYSTOSCOPY AND TREATMENT
$256.09
52325
3
CYSTOSCOPY, STONE REMOVAL
$333.09
52327
3
CYSTOSCOPY, INJECT MATERIAL
$550.37
52330
3
CYSTOSCOPY AND TREATMENT
$274.15
52332
3
CYSTOSCOPY AND TREATMENT
$149.06
52334
3
CREATE PASSAGE TO KIDNEY
$266.40
52335
O
ENDOSCOPY OF URINARY TRACT
$0.00
52336
O
CYSTOSCOPY, STONE REMOVAL
$0.00
52337
O
CYSTOSCOPY, STONE REMOVAL
$0.00
52338
O
CYSTOSCOPY AND TREATMENT
$0.00
52339
O
CYSTOSCOPY AND TREATMENT
$0.00
52340
O
CYSTOSCOPY AND TREATMENT
$0.00
52341
3
CYSTO W/URETER STRICTURE TX
$303.15
52342
3
CYSTO W/UP STRICTURE TX
$329.51
52343
3
CYSTO W/RENAL STRICTURE TX
$366.43
52344
3
CYSTO/URETERO, STRICTURE TX
$397.46
52345
3
CYSTO/URETERO W/UP STRICTURE
$423.81
52346
3
CYSTOURETERO W/RENAL STRICT
$478.19
52347
O
CYSTOSCOPY, RESECT DUCTS
52351
3
CYSTOURETERO & OR PYELOSCOPE
$326.09
52352
3
CYSTOURETERO W/STONE REMOVE
$382.94
52353
3
CYSTOURETERO W/LITHOTRIPSY
$440.44
52354
3
CYSTOURETERO W/BIOPSY
$407.12
52355
3
CYSTOURETERO W/EXCISE TUMOR
$485.20
52400
3
CYSTOURETERO W/CONGEN REPR
$499.14
52402
3
CYSTOURETHRO CUT EJACUL DUCT
$278.87
52450
3
INCISION OF PROSTATE
$477.48
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
52500
3
REVISION OF BLADDER NECK
$498.80
52510
O
DILATION PROSTATIC URETHRA
52601
3
PROSTATECTOMY (TURP)
52606
O
CONTROL POSTOP BLEEDING
$0.00
52612
O
PROSTATECTOMY, FIRST STAGE
$0.00
52614
O
PROSTATECTOMY, SECOND STAGE
$0.00
52620
O
REMOVE RESIDUAL PROSTATE
$0.00
52630
3
REMOVE PROSTATE REGROWTH
$452.70
52640
3
RELIEVE BLADDER CONTRACTURE
$310.05
52647
3
LASER SURGERY OF PROSTATE
$658.82
52648
3
LASER SURGERY OF PROSTATE
$2,301.11
52649
3
PROSTATE LASER ENUCLEATION
$1,004.71
52650
O
TRANSURETHRAL CRYOSURGICAL REMOVAL
52700
3
DRAINAGE OF PROSTATE ABSCESS
$442.31
53000
3
INCISION OF URETHRA
$151.83
53010
3
INCISION OF URETHRA
$297.99
53020
3
INCISION OF URETHRA
$100.38
53025
3
INCISION OF URETHRA
$65.95
53040
3
DRAINAGE OF URETHRA ABSCESS
$400.19
53060
3
DRAINAGE OF URETHRA ABSCESS
$176.46
53080
3
DRAINAGE OF URINARY LEAKAGE
$444.35
53085
3
DRAINAGE OF URINARY LEAKAGE
$626.53
53200
3
BIOPSY OF URETHRA
$158.72
53210
3
REMOVAL OF URETHRA
$785.34
53215
3
REMOVAL OF URETHRA
$953.62
53220
3
TREATMENT OF URETHRA LESION
$459.39
53230
3
REMOVAL OF URETHRA LESION
$611.80
53235
3
REMOVAL OF URETHRA LESION
$651.18
53240
3
SURGERY FOR URETHRA POUCH
$437.86
53250
3
REMOVAL OF URETHRA GLAND
$406.42
53260
3
TREATMENT OF URETHRA LESION
$202.66
53265
3
TREATMENT OF URETHRA LESION
$225.55
53270
3
REMOVAL OF URETHRA GLAND
$206.31
53275
3
REPAIR OF URETHRA DEFECT
$271.21
53400
3
REVISE URETHRA, STAGE 1
$816.97
$0.00 $843.59
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
53405
3
REVISE URETHRA, STAGE 2
$899.66
53410
3
RECONSTRUCTION OF URETHRA
$1,003.60
53415
3
RECONSTRUCTION OF URETHRA
$1,156.84
53420
3
RECONSTRUCT URETHRA, STAGE 1
$821.09
53425
3
RECONSTRUCT URETHRA, STAGE 2
$966.63
53430
3
RECONSTRUCTION OF URETHRA
$963.34
53431
3
RECONSTRUCT URETHRA/BLADDER
53440
3
MALE SLING PROCEDURE
$896.14
53442
3
REMOVE/REVISE MALE SLING
$789.59
53443
O
RECONSTRUCTION OF URETHRA
53444
3
INSERT TANDEM CUFF
$814.80
53445
3
INSERT URO/VES NCK SPHINCTER
$900.35
53446
3
REMOVE URO SPHINCTER
$658.54
53447
3
REMOVE/REPLACE UR SPHINCTER
$832.30
53448
3
REMOV/REPLC UR SPHINCTR COMP
53449
3
REPAIR URO SPHINCTER
$625.98
53450
3
REVISION OF URETHRA
$416.87
53460
3
REVISION OF URETHRA
$467.99
53500
3
URETHRLYS, TRANSVAG W/ SCOPE
$751.36
53502
3
REPAIR OF URETHRA INJURY
$494.64
53505
3
REPAIR OF URETHRA INJURY
$497.15
53510
3
REPAIR OF URETHRA INJURY
$646.53
53515
3
REPAIR OF URETHRA INJURY
$814.44
53520
3
REPAIR OF URETHRA DEFECT
$567.60
53600
3
DILATE URETHRA STRICTURE
$88.65
53601
3
DILATE URETHRA STRICTURE
$86.61
53605
3
DILATE URETHRA STRICTURE
$66.75
53620
3
DILATE URETHRA STRICTURE
$127.08
53621
3
DILATE URETHRA STRICTURE
$120.51
53640
O
PASSAGE OF FILIFORM AND FOLLOWER FO
53660
3
DILATION OF URETHRA
$75.37
53661
3
DILATION OF URETHRA
$74.99
53665
3
DILATION OF URETHRA
$38.95
53670
O
INSERT URINARY CATHETER
$0.00
53675
O
INSERT URINARY CATHETER
$0.00
$1,182.35
$0.00
$1,313.73
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
53800
O
TWO OR THREE GLASS TEST INCLUDING E
$0.00
53850
3
PROSTATIC MICROWAVE THERMOTX
$2,593.54
53852
3
PROSTATIC RF THERMOTX
$2,493.94
53853
O
PROSTATIC WATER THERMOTHER
$0.00
53899
5
UROLOGY SURGERY PROCEDURE
$0.00
54000
3
SLITTING OF PREPUCE
$161.16
54001
3
SLITTING OF PREPUCE
$197.55
54015
3
DRAIN PENIS LESION
$316.77
54050
3
DESTRUCTION, PENIS LESION(S)
$121.26
54055
3
DESTRUCTION, PENIS LESION(S)
$115.75
54056
3
CRYOSURGERY, PENIS LESION(S)
$126.69
54057
3
LASER SURG, PENIS LESION(S)
$139.61
54060
3
EXCISION OF PENIS LESION(S)
$188.15
54065
3
DESTRUCTION, PENIS LESION(S)
$205.65
54100
3
BIOPSY OF PENIS
$189.34
54105
3
BIOPSY OF PENIS
$283.74
54110
3
TREATMENT OF PENIS LESION
$636.85
54111
3
TREAT PENIS LESION, GRAFT
$822.39
54112
3
TREAT PENIS LESION, GRAFT
$965.18
54115
3
TREATMENT OF PENIS LESION
$460.31
54120
3
PARTIAL REMOVAL OF PENIS
$644.28
54125
3
REMOVAL OF PENIS
$829.74
54130
3
REMOVE PENIS & NODES
$1,227.46
54135
3
REMOVE PENIS & NODES
$1,557.30
54150
3
CIRCUMCISION W/REGIONL BLOCK
54152
O
CIRCUMCISION
54160
3
CIRCUMCISION, NEONATE
$148.23
54161
3
CIRCUM 28 DAYS OR OLDER
$201.46
54162
3
LYSIS PENIL CIRCUMIC LESION
$277.16
54163
3
REPAIR OF CIRCUMCISION
$222.44
54164
9
FRENULOTOMY OF PENIS
54200
3
TREATMENT OF PENIS LESION
$113.35
54205
3
TREATMENT OF PENIS LESION
$548.18
54220
3
TREATMENT OF PENIS LESION
$218.84
54230
3
PREPARE PENIS STUDY
$100.32
$99.46 $0.00
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
54231
O
DYNAMIC CAVERNOSOMETRY
$0.00
54235
O
PENILE INJECTION
$0.00
54240
O
PENIS STUDY
$0.00
54250
O
PENIS STUDY
$0.00
54300
3
REVISION OF PENIS
$664.09
54304
3
REVISION OF PENIS
$777.52
54308
3
RECONSTRUCTION OF URETHRA
$740.40
54312
3
RECONSTRUCTION OF URETHRA
$855.63
54316
3
RECONSTRUCTION OF URETHRA
$1,034.28
54318
3
RECONSTRUCTION OF URETHRA
$746.45
54322
3
RECONSTRUCTION OF URETHRA
$809.40
54324
3
RECONSTRUCTION OF URETHRA
$1,005.49
54326
3
RECONSTRUCTION OF URETHRA
$943.69
54328
3
REVISE PENIS/URETHRA
$958.11
54332
3
REVISE PENIS/URETHRA
$1,047.56
54336
3
REVISE PENIS/URETHRA
$1,186.22
54340
3
SECONDARY URETHRAL SURGERY
$576.67
54344
3
SECONDARY URETHRAL SURGERY
$992.76
54348
3
SECONDARY URETHRAL SURGERY
$1,053.65
54352
3
RECONSTRUCT URETHRA/PENIS
$1,484.40
54360
3
PENIS PLASTIC SURGERY
$746.12
54380
3
REPAIR PENIS
$826.80
54385
3
REPAIR PENIS
$1,000.79
54390
3
REPAIR PENIS AND BLADDER
$1,209.05
54400
O
INSERT SEMI-RIGID PROSTHESIS
$0.00
54401
O
INSERT SELF-CONTD PROSTHESIS
$0.00
54402
O
REMOVE PENIS PROSTHESIS
$0.00
54405
O
INSERT MULTI-COMP PENIS PROS
$0.00
54406
9
REMOVE MUTI-COMP PENIS PROS
$0.00
54407
O
REMOVE MULTI-COMP PROSTHESIS
$0.00
54408
9
REPAIR MULTI-COMP PENIS PROS
$0.00
54409
O
REVISE PENIS PROSTHESIS
$0.00
54410
9
REMOVE/REPLACE PENIS PROSTH
$0.00
54411
9
REMOV/REPLC PENIS PROS, COMP
$0.00
54415
9
REMOVE SELF-CONTD PENIS PROS
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
54416
9
REMV/REPL PENIS CONTAIN PROS
$0.00
54417
9
REMV/REPLC PENIS PROS, COMPL
$0.00
54420
3
REVISION OF PENIS
$725.93
54430
3
REVISION OF PENIS
$658.12
54435
3
REVISION OF PENIS
$426.80
54440
5
REPAIR OF PENIS
54450
3
PREPUTIAL STRETCHING
$75.22
54500
3
BIOPSY OF TESTIS
$77.67
54505
3
BIOPSY OF TESTIS
$218.46
54510
O
REMOVAL OF TESTIS LESION
54512
3
EXCISE LESION TESTIS
$547.38
54520
3
REMOVAL OF TESTIS
$332.31
54522
3
ORCHIECTOMY, PARTIAL
$593.65
54530
3
REMOVAL OF TESTIS
$518.27
54535
3
EXTENSIVE TESTIS SURGERY
$750.46
54550
3
EXPLORATION FOR TESTIS
$499.27
54560
3
EXPLORATION FOR TESTIS
$679.27
54600
3
REDUCE TESTIS TORSION
$462.08
54620
3
SUSPENSION OF TESTIS
$310.08
54640
3
SUSPENSION OF TESTIS
$475.03
54645
O
ORCHIOPEXY, ANY TYPE, WITH OR WITHO
54650
3
ORCHIOPEXY (FOWLER-STEPHENS)
54660
9
REVISION OF TESTIS
54670
3
REPAIR TESTIS INJURY
$413.15
54680
3
RELOCATION OF TESTIS(ES)
$800.66
54690
3
LAPAROSCOPY, ORCHIECTOMY
$645.62
54692
3
LAPAROSCOPY, ORCHIOPEXY
$791.05
54699
5
LAPAROSCOPE PROC, TESTIS
$0.00
54700
3
DRAINAGE OF SCROTUM
$215.40
54800
3
BIOPSY OF EPIDIDYMIS
$135.73
54820
O
EXPLORATION OF EPIDIDYMIS
54830
3
REMOVE EPIDIDYMIS LESION
$376.29
54840
3
REMOVE EPIDIDYMIS LESION
$330.34
54860
3
REMOVAL OF EPIDIDYMIS
$426.37
54861
3
REMOVAL OF EPIDIDYMIS
$575.95
$0.00
$0.00
$0.00 $725.83 $0.00
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
54865
3
EXPLORE EPIDIDYMIS
$363.41
54900
3
FUSION OF SPERMATIC DUCTS
$769.84
54901
3
FUSION OF SPERMATIC DUCTS
$1,098.53
55000
3
DRAINAGE OF HYDROCELE
$124.72
55040
3
REMOVAL OF HYDROCELE
$343.40
55041
3
REMOVAL OF HYDROCELES
$516.03
55060
3
REPAIR OF HYDROCELE
$383.97
55100
3
DRAINAGE OF SCROTUM ABSCESS
$220.72
55110
3
EXPLORE SCROTUM
$390.42
55120
3
REMOVAL OF SCROTUM LESION
$358.43
55150
3
REMOVAL OF SCROTUM
$494.49
55175
3
REVISION OF SCROTUM
$367.75
55180
3
REVISION OF SCROTUM
$697.80
55200
9
INCISION OF SPERM DUCT
55250
3
REMOVAL OF SPERM DUCT(S)
55300
9
PREPARE, SPERM DUCT X-RAY
$0.00
55400
9
REPAIR OF SPERM DUCT
$0.00
55450
3
LIGATION OF SPERM DUCT
$391.95
55500
3
REMOVAL OF HYDROCELE
$380.49
55520
3
REMOVAL OF SPERM CORD LESION
$390.66
55530
3
REVISE SPERMATIC CORD VEINS
$360.15
55535
3
REVISE SPERMATIC CORD VEINS
$435.05
55540
3
REVISE HERNIA & SPERM VEINS
$473.05
55550
3
LAPARO LIGATE SPERMATIC VEIN
$430.42
55559
5
LAPARO PROC, SPERMATIC CORD
$0.00
55600
3
INCISE SPERM DUCT POUCH
$434.43
55605
3
INCISE SPERM DUCT POUCH
$512.28
55650
3
REMOVE SPERM DUCT POUCH
$728.60
55680
3
REMOVE SPERM POUCH LESION
$345.59
55700
3
BIOPSY OF PROSTATE
$237.54
55705
3
BIOPSY OF PROSTATE
$275.96
55706
3
PROSTATE SATURATION SAMPLING
$391.41
55720
3
DRAINAGE OF PROSTATE ABSCESS
$472.46
55725
3
DRAINAGE OF PROSTATE ABSCESS
$599.76
55740
O
PROSTATOLITHOTOMY, REMOVAL OF PROST
$0.00 $231.48
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
55801
3
REMOVAL OF PROSTATE
$1,112.17
55810
3
EXTENSIVE PROSTATE SURGERY
$1,344.62
55812
3
EXTENSIVE PROSTATE SURGERY
$1,652.44
55815
3
EXTENSIVE PROSTATE SURGERY
$1,812.35
55821
3
REMOVAL OF PROSTATE
$895.13
55831
3
REMOVAL OF PROSTATE
$969.84
55840
3
EXTENSIVE PROSTATE SURGERY
$1,372.57
55842
3
EXTENSIVE PROSTATE SURGERY
$1,470.74
55845
3
EXTENSIVE PROSTATE SURGERY
$1,681.62
55859
O
PERCUT/NEEDLE INSERT, PROS
55860
3
SURGICAL EXPOSURE, PROSTATE
55862
3
EXTENSIVE PROSTATE SURGERY
$1,134.28
55865
3
EXTENSIVE PROSTATE SURGERY
$1,373.86
55866
3
LAPARO RADICAL PROSTATECTOMY
$1,787.09
55870
O
VAG HYST W/ENTEROCELE REPAIR
55873
3
CRYOABLATE PROSTATE
55875
3
TRANSPERI NEEDLE PLACE, PROS
$779.78
55876
3
PLACE RT DEVICE/MARKER, PROS
$145.80
55899
5
GENITAL SURGERY PROCEDURE
$0.00
55920
3
PLACE NEEDLES PELVIC FOR RT
$437.29
55970
9
SEX TRANSFORMATION, M TO F
$0.00
55980
9
SEX TRANSFORMATION, F TO M
$0.00
56000
O
INCISION AND DRAINAGE OF PERINEAL A
$0.00
56100
O
BIOPSY OF PERINEUM (SEPARATE PROCED
$0.00
56200
O
PERINEOPLASTY, REPAIR OF PERINEUM,
$0.00
56300
O
LAPAROSCOPY; DIAGNOSTIC
$0.00
56301
O
LAPAROSCOPY; TUBAL CAUTERY
$0.00
56302
O
LAPAROSCOPY; TUBAL BLOCK
$0.00
56303
O
LAPAROSCOPY; EXCISE LESIONS
$0.00
56304
O
LAPAROSCOPY; LYSIS
$0.00
56305
O
LAPAROSCOPY; BIOPSY
$0.00
56306
O
LAPAROSCOPY; ASPIRATION
$0.00
56307
O
LAPAROSCOPY; REMOVE ADNEXA
$0.00
56308
O
LAPAROSCOPY; HYSTERECTOMY
$0.00
56309
O
LAPAROSCOPY; REMOVE MYOMA
$0.00
$0.00 $897.87
$0.00 $1,170.77
Procedure Code Pricing Action Code Description
Maximum Allowable
56310
O
LAPAROSCOPIC ENTEROLYSIS
$0.00
56311
O
LAPAROSCOPIC LYMPH NODE BIOP
$0.00
56312
O
LAPAROSCOPIC LYMPHADENECTOMY
$0.00
56313
O
LAPAROSCOPIC LYMPHADENECTOMY
$0.00
56314
O
LAPAR; DRAIN LYMPHOCELE
$0.00
56315
O
LAPAROSCOPIC APPENDECTOMY
$0.00
56316
O
LAPAROSCOPIC HERNIA REPAIR
$0.00
56317
O
LAPAROSCOPIC HERNIA REPAIR
$0.00
56318
O
LAPAROSCOPIC ORCHIECTOMY
$0.00
56320
O
LAPAROSCOPY, SPERMATIC VEINS
$0.00
56321
O
LAPAROSCOPY; ADRENALECTOMY
$0.00
56322
O
LAPAROSCOPY, VAGUS NERVES
$0.00
56323
O
LAPAROSCOPY, VAGUS NERVES
$0.00
56324
O
LAPAROSCOPY, CHOLECYSTOENTER
$0.00
56340
O
LAPAROSCOPIC CHOLECYSTECTOMY
$0.00
56341
O
LAPAROSCOPIC CHOLECYSTECTOMY
$0.00
56342
O
LAPAROSCOPIC CHOLECYSTECTOMY
$0.00
56343
O
LAPAROSCOPIC SALPINGOSTOMY
$0.00
56344
O
LAPAROSCOPIC FIMBRIOPLASTY
$0.00
56345
O
LAPAROSCOPIC SPLENECTOMY
$0.00
56346
O
LAPAROSCOPIC GASTROSTOMY
$0.00
56347
O
LAPAROSCOPIC JEJUNOSTOMY
$0.00
56348
O
LAPARO; RESECT INTESTINE
$0.00
56349
O
LAPAROSCOPY; FUNDOPLASTY
$0.00
56350
O
HYSTEROSCOPY; DIAGNOSTIC
$0.00
56351
O
HYSTEROSCOPY; BIOPSY
$0.00
56352
O
HYSTEROSCOPY; LYSIS
$0.00
56353
O
HYSTEROSCOPY; RESECT SEPTUM
$0.00
56354
O
HYSTEROSCOPY; REMOVE MYOMA
$0.00
56355
O
HYSTEROSCOPY; REMOVE IMPACT
$0.00
56356
O
HYSTEROSCOPY; ABLATION
$0.00
56360
O
PERITONEOSCOPY; WITHOUT BIOPSY
$0.00
56361
O
PERITONEOSCOPY; WITH BIOPSY
$0.00
56362
O
LAPAROSCOPY W/CHOLANGIO
$0.00
56363
O
LAPAROSCOPY W/BIOPSY
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
56399
O
LAPAROSCOPY PROCEDURE
$0.00
56400
O
INCISION AND DRAINAGE, ABSCESS OF V
$0.00
56405
3
I & D OF VULVA/PERINEUM
$101.35
56420
3
DRAINAGE OF GLAND ABSCESS
$117.44
56440
3
SURGERY FOR VULVA LESION
$170.61
56441
3
LYSIS OF LABIAL LESION(S)
$140.60
56442
3
HYMENOTOMY
56501
3
DESTROY, VULVA LESIONS, SIM
$121.81
56515
3
DESTROY VULVA LESION/S COMPL
$207.13
56600
O
BIOPSY OF VULVA (SEPARATE PROCEDURE
56605
3
BIOPSY OF VULVA/PERINEUM
$78.28
56606
3
BIOPSY OF VULVA/PERINEUM
$36.12
56620
3
PARTIAL REMOVAL OF VULVA
$459.45
56625
3
COMPLETE REMOVAL OF VULVA
$551.67
56630
3
EXTENSIVE VULVA SURGERY
$805.41
56631
3
EXTENSIVE VULVA SURGERY
$1,024.51
56632
3
EXTENSIVE VULVA SURGERY
$1,186.63
56633
3
EXTENSIVE VULVA SURGERY
$1,050.05
56634
3
EXTENSIVE VULVA SURGERY
$1,109.56
56635
O
VULVECTOMY, RADICAL WITH INGUINOFEM
56637
3
EXTENSIVE VULVA SURGERY
$1,310.61
56640
3
EXTENSIVE VULVA SURGERY
$1,306.51
56680
O
CLITORIDECTOMY SIMPLE
$0.00
56685
O
CLITORIDECTOMY EXTENSIVE
$0.00
56700
3
PARTIAL REMOVAL OF HYMEN
$173.07
56710
O
PLASTIC REVISION OF HYMEN
$0.00
56720
O
INCISION OF HYMEN
$0.00
56740
3
REMOVE VAGINA GLAND LESION
$275.86
56800
3
REPAIR OF VAGINA
$227.17
56805
3
REPAIR CLITORIS
56810
3
REPAIR OF PERINEUM
$243.82
56820
3
EXAM OF VULVA W/SCOPE
$103.76
56821
3
EXAM/BIOPSY OF VULVA W/SCOPE
$138.77
57000
3
EXPLORATION OF VAGINA
$177.86
57010
3
DRAINAGE OF PELVIC ABSCESS
$399.83
$45.82
$0.00
$0.00
$1,067.46
Procedure Code Pricing Action Code Description
Maximum Allowable
57020
3
DRAINAGE OF PELVIC FLUID
$88.23
57022
3
I & D VAGINAL HEMATOMA, PP
$154.84
57023
3
I & D VAG HEMATOMA, NON-OB
$290.01
57061
3
DESTROY VAG LESIONS, SIMPLE
$106.28
57065
3
DESTROY VAG LESIONS, COMPLEX
$179.42
57100
3
BIOPSY OF VAGINA
$82.84
57105
3
BIOPSY OF VAGINA
$126.90
57106
3
REMOVE VAGINA WALL, PARTIAL
$440.96
57107
3
REMOVE VAGINA TISSUE, PART
57108
O
PARTIAL REMOVAL OF VAGINA
57109
3
VAGINECTOMY PARTIAL W/NODES
57110
3
REMOVE VAGINA WALL, COMPLETE
57111
3
REMOVE VAGINA TISSUE, COMPL
$1,502.36
57112
3
VAGINECTOMY W/NODES, COMPL
$1,594.58
57120
3
CLOSURE OF VAGINA
57126
9
COMPLEX CYSTOMETROGRAM (EG, CALIBRA
57130
3
REMOVE VAGINA LESION
$169.20
57135
3
REMOVE VAGINA LESION
$181.20
57150
3
TREAT VAGINA INFECTION
57155
3
INSERT UTERI TANDEMS/OVOIDS
$394.91
57160
3
INSERT PESSARY/OTHER DEVICE
$72.65
57170
3
FITTING OF DIAPHRAGM/CAP
$65.10
57180
3
TREAT VAGINAL BLEEDING
$133.46
57200
3
REPAIR OF VAGINA
$276.28
57210
3
REPAIR VAGINA/PERINEUM
$342.11
57220
3
REVISION OF URETHRA
$297.66
57230
3
REPAIR OF URETHRAL LESION
$372.00
57240
3
REPAIR BLADDER & VAGINA
$617.04
57250
3
REPAIR RECTUM & VAGINA
$602.97
57260
3
REPAIR OF VAGINA
$751.19
57265
3
EXTENSIVE REPAIR OF VAGINA
$839.43
57267
3
INSERT MESH/PELVIC FLR ADDON
$252.94
57268
3
REPAIR OF BOWEL BULGE
$448.16
57270
3
REPAIR OF BOWEL POUCH
$742.24
57280
3
SUSPENSION OF VAGINA
$902.57
$1,300.48 $0.00 $1,485.94 $837.88
$476.31 $0.00
$47.95
Procedure Code Pricing Action Code Description
Maximum Allowable
57282
3
COLPOPEXY, EXTRAPERITONEAL
$475.41
57283
3
COLPOPEXY, INTRAPERITONEAL
$640.48
57284
3
REPAIR PARAVAG DEFECT, OPEN
$782.57
57285
3
REPAIR PARAVAG DEFECT, VAG
$624.92
57287
3
REVISE/REMOVE SLING REPAIR
$659.79
57288
3
REPAIR BLADDER DEFECT
$692.63
57289
3
REPAIR BLADDER & VAGINA
$727.58
57291
3
CONSTRUCTION OF VAGINA
$505.66
57292
3
CONSTRUCT VAGINA WITH GRAFT
$772.65
57295
3
REVISE VAG GRAFT VIA VAGINA
$460.33
57296
3
REVISE VAG GRAFT, OPEN ABD
$882.80
57300
3
REPAIR RECTUM-VAGINA FISTULA
$494.18
57305
3
REPAIR RECTUM-VAGINA FISTULA
$823.77
57307
3
FISTULA REPAIR & COLOSTOMY
$921.68
57308
3
FISTULA REPAIR, TRANSPERINE
$589.25
57310
3
REPAIR URETHROVAGINAL LESION
$462.41
57311
3
REPAIR URETHROVAGINAL LESION
$527.45
57320
3
REPAIR BLADDER-VAGINA LESION
$525.49
57330
3
REPAIR BLADDER-VAGINA LESION
$744.91
57335
3
REPAIR VAGINA
57400
3
DILATION OF VAGINA
$126.91
57410
3
PELVIC EXAMINATION
$99.75
57415
3
REMOVE VAGINAL FOREIGN BODY
$149.14
57420
3
EXAM OF VAGINA W/SCOPE
$109.05
57421
3
EXAM/BIOPSY OF VAG W/SCOPE
$146.82
57423
3
REPAIR PARAVAG DEFECT, LAP
$863.06
57425
3
LAPAROSCOPY, SURG, COLPOPEXY
$910.02
57450
O
CULDOSCOPY, DIAGNOSTIC
$0.00
57451
O
CULDOSCOPY, DIAGNOSTIC WITH BIOPSY
$0.00
57452
3
EXAM OF CERVIX W/SCOPE
$102.65
57454
3
BX/CURETT OF CERVIX W/SCOPE
$144.69
57455
3
BIOPSY OF CERVIX W/SCOPE
$134.91
57456
3
ENDOCERV CURETTAGE W/SCOPE
$127.58
57460
3
BX OF CERVIX W/SCOPE, LEEP
$281.93
57461
3
CONZ OF CERVIX W/SCOPE, LEEP
$315.77
$1,084.35
Procedure Code Pricing Action Code Description
Maximum Allowable
57500
3
BIOPSY OF CERVIX
$124.87
57505
3
ENDOCERVICAL CURETTAGE
57510
3
CAUTERIZATION OF CERVIX
$124.43
57511
3
CRYOCAUTERY OF CERVIX
$135.87
57513
3
LASER SURGERY OF CERVIX
$134.02
57520
3
CONIZATION OF CERVIX
$287.70
57522
3
CONIZATION OF CERVIX
$246.03
57530
3
REMOVAL OF CERVIX
$319.88
57531
3
REMOVAL OF CERVIX, RADICAL
57540
3
REMOVAL OF RESIDUAL CERVIX
$723.69
57545
3
REMOVE CERVIX/REPAIR PELVIS
$763.33
57550
3
REMOVAL OF RESIDUAL CERVIX
$378.04
57555
3
REMOVE CERVIX/REPAIR VAGINA
$557.05
57556
3
REMOVE CERVIX, REPAIR BOWEL
$532.26
57558
3
D&C OF CERVICAL STUMP
$116.94
57700
3
REVISION OF CERVIX
$285.22
57720
3
REVISION OF CERVIX
$284.91
57800
3
DILATION OF CERVICAL CANAL
57820
O
D & C OF RESIDUAL CERVIX
$0.00
58100
3
BIOPSY OF UTERUS LINING
$103.35
58101
O
ENDOMETRIAL WASHINGS (EG, FOR CYTOL
$0.00
58102
O
OFFICE ENDOMETRIAL CURETTAGE
$0.00
58110
3
BX DONE W/COLPOSCOPY ADD-ON
$45.94
58120
3
DILATION AND CURETTAGE
$233.08
58140
3
MYOMECTOMY ABDOM METHOD
$847.93
58145
3
MYOMECTOMY VAG METHOD
$503.69
58146
3
MYOMECTOMY ABDOM COMPLEX
58150
3
TOTAL HYSTERECTOMY
$918.49
58152
3
TOTAL HYSTERECTOMY
$1,159.43
58180
3
PARTIAL HYSTERECTOMY
58200
3
EXTENSIVE HYSTERECTOMY
$1,213.89
58210
3
EXTENSIVE HYSTERECTOMY
$1,616.80
58240
3
REMOVAL OF PELVIS CONTENTS
$2,541.08
58260
3
VAGINAL HYSTERECTOMY
$767.84
58262
3
VAG HYST INCLUDING T/O
$857.65
$95.09
$1,578.50
$56.66
$1,079.67
$882.17
Procedure Code Pricing Action Code Description
Maximum Allowable
58263
3
VAG HYST W/T/O & VAG REPAIR
$923.97
58265
O
VAGINAL HYSTERECTOMY WITH PLASTIC R
58267
3
VAG HYST W/URINARY REPAIR
$981.65
58270
3
VAG HYST W/ENTEROCELE REPAIR
$822.21
58275
3
HYSTERECTOMY/REVISE VAGINA
$915.00
58280
3
HYSTERECTOMY/REVISE VAGINA
$978.73
58285
3
EXTENSIVE HYSTERECTOMY
$1,226.96
58290
3
VAG HYST COMPLEX
$1,074.60
58291
3
VAG HYST INCL T/O, COMPLEX
$1,167.74
58292
3
VAG HYST T/O & REPAIR, COMPL
$1,230.37
58293
3
VAG HYST W/URO REPAIR, COMPL
$1,277.26
58294
3
VAG HYST W/ENTEROCELE, COMPL
$1,134.94
58300
5
INSERT INTRAUTERINE DEVICE
58301
3
REMOVE INTRAUTERINE DEVICE
58310
9
ARTIFICIAL INSEMINATION
$0.00
58311
9
ARTIFICIAL INSEMINATION WITH SPERM
$0.00
58320
O
INSUFFLATION OF UTERUS AND TUBES WI
$0.00
58321
9
ARTIFICIAL INSEMINATION
$0.00
58322
9
ARTIFICIAL INSEMINATION
$0.00
58323
9
SPERM WASHING
$0.00
58340
3
CATHETER FOR HYSTEROGRAPHY
58345
9
REOPEN FALLOPIAN TUBE
58346
3
INSERT HEYMAN UTERI CAPSULE
58350
9
REOPEN FALLOPIAN TUBE
58353
3
ENDOMETR ABLATE, THERMAL
$205.90
58356
3
ENDOMETRIAL CRYOABLATION
$1,997.50
58400
3
SUSPENSION OF UTERUS
$417.03
58410
3
SUSPENSION OF UTERUS
$744.65
58520
3
REPAIR OF RUPTURED UTERUS
$727.04
58540
3
REVISION OF UTERUS
$843.98
58541
3
LSH, UTERUS 250 G OR LESS
$796.41
58542
3
LSH W/T/O UT 250 G OR LESS
$884.19
58543
3
LSH UTERUS ABOVE 250 G
$898.82
58544
3
LSH W/T/O UTERUS ABOVE 250 G
$971.03
58545
3
LAPAROSCOPIC MYOMECTOMY
$830.99
$0.00
$0.00 $90.39
$121.96 $0.00 $424.16 $0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
58546
3
LAPARO-MYOMECTOMY, COMPLEX
$1,052.70
58548
3
LAP RADICAL HYST
$1,640.76
58550
3
LAPARO-ASST VAG HYSTERECTOMY
58551
O
LAPAROSCOPY, REMOVE MYOMA
58552
3
LAPARO-VAG HYST INCL T/O
58553
3
LAPARO-VAG HYST, COMPLEX
$1,058.10
58554
3
LAPARO-VAG HYST W/T/O, COMPL
$1,212.61
58555
3
HYSTEROSCOPY, DX, SEP PROC
$225.81
58558
3
HYSTEROSCOPY, BIOPSY
$304.67
58559
3
HYSTEROSCOPY, LYSIS
$323.26
58560
3
HYSTEROSCOPY, RESECT SEPTUM
$365.30
58561
3
HYSTEROSCOPY, REMOVE MYOMA
$516.86
58562
3
HYSTEROSCOPY, REMOVE FB
$321.81
58563
3
HYSTEROSCOPY, ABLATION
$323.26
58565
3
HYSTEROSCOPY, STERILIZATION
$413.53
58570
3
TLH, UTERUS 250 G OR LESS
$854.87
58571
3
TLH W/T/O 250 G OR LESS
$938.91
58572
3
TLH, UTERUS OVER 250 G
$1,062.16
58573
3
TLH W/T/O UTERUS OVER 250 G
$1,201.89
58578
5
LAPARO PROC, UTERUS
$0.00
58579
5
HYSTEROSCOPE PROCEDURE
$0.00
58600
3
DIVISION OF FALLOPIAN TUBE
$337.61
58605
3
DIVISION OF FALLOPIAN TUBE
$307.11
58611
3
LIGATE OVIDUCT(S) ADD-ON
58615
3
OCCLUDE FALLOPIAN TUBE(S)
$232.32
58660
3
LAPAROSCOPY, LYSIS
$624.86
58661
3
LAPAROSCOPY, REMOVE ADNEXA
$600.05
58662
3
LAPAROSCOPY, EXCISE LESIONS
$657.08
58670
3
LAPAROSCOPY, TUBAL CAUTERY
$340.07
58671
3
LAPAROSCOPY, TUBAL BLOCK
$339.94
58672
3
LAPAROSCOPY, FIMBRIOPLASTY
$691.21
58673
3
LAPAROSCOPY, SALPINGOSTOMY
$751.77
58679
5
LAPARO PROC, OVIDUCT-OVARY
58700
3
REMOVAL OF FALLOPIAN TUBE
$707.96
58720
3
REMOVAL OF OVARY/TUBE(S)
$665.36
$821.14 $0.00 $905.78
$73.14
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
58740
3
ADHESIOLYSIS TUBE, OVARY
$811.15
58750
9
REPAIR OVIDUCT
$0.00
58752
9
REVISE OVARIAN TUBE(S)
$0.00
58760
9
FIMBRIOPLASTY
$0.00
58770
3
CREATE NEW TUBAL OPENING
$782.91
58800
3
DRAINAGE OF OVARIAN CYST(S)
$298.24
58805
3
DRAINAGE OF OVARIAN CYST(S)
$376.18
58820
3
DRAIN OVARY ABSCESS, OPEN
$291.05
58822
3
DRAIN OVARY ABSCESS, PERCUT
$654.76
58823
3
DRAIN PELVIC ABSCESS, PERCUT
$874.47
58825
3
TRANSPOSITION, OVARY(S)
$646.78
58900
3
BIOPSY OF OVARY(S)
$383.74
58920
3
PARTIAL REMOVAL OF OVARY(S)
$651.05
58925
3
REMOVAL OF OVARIAN CYST(S)
$678.84
58940
3
REMOVAL OF OVARY(S)
$465.40
58943
3
REMOVAL OF OVARY(S)
$1,036.51
58950
3
RESECT OVARIAN MALIGNANCY
$988.92
58951
3
RESECT OVARIAN MALIGNANCY
$1,274.51
58952
3
RESECT OVARIAN MALIGNANCY
$1,437.64
58953
3
TAH, RAD DISSECT FOR DEBULK
$1,782.84
58954
3
TAH RAD DEBULK/LYMPH REMOVE
$1,935.16
58956
3
BSO, OMENTECTOMY W/TAH
$1,250.78
58957
3
RESECT RECURRENT GYN MAL
$1,372.37
58958
3
RESECT RECUR GYN MAL W/LYM
$1,525.07
58960
3
EXPLORATION OF ABDOMEN
58970
9
RETRIEVAL OF OOCYTE
$0.00
58972
O
CULTURE AND FERTILIZATION OF OOCYTE
$0.00
58974
9
TRANSFER OF EMBRYO
$0.00
58976
9
TRANSFER OF EMBRYO
$0.00
58980
O
LAPAROSCOPY, SURGICAL
$0.00
58982
O
LAPAROSCOPY, SURGICAL WITH FULGURAT
$0.00
58983
O
LAPAROSCOPY, SURGICAL WITH OCCLUSIO
$0.00
58984
O
LAPAROSCOPY, SURGICAL WITH FULGURAT
$0.00
58985
O
LAPAROSCOPY, SURGICAL WITH LYSIS OF
$0.00
58986
O
LAPAROSCOPY, SURGICAL WITH BIOPSY (
$0.00
$854.85
Procedure Code Pricing Action Code Description
Maximum Allowable
58987
O
LAPAROSCOPY, SURGICAL WITH ASPIRATI
$0.00
58988
O
LAPAROSCOPY, SURGICAL WITH REMOVAL
$0.00
58990
O
HYSTEROSCOPY DIAGNOSTIC
$0.00
58992
O
HYSTEROSCOPY WITH LYSIS OF INTRAUTE
$0.00
58994
O
HYSTEROSCOPY WITH REMOVAL OF SUBMUC
$0.00
58996
O
HYSTEROSCOPY; WITH ENDOMETRIAL ABLA
$0.00
58999
5
GENITAL SURGERY PROCEDURE
$0.00
59000
3
AMNIOCENTESIS, DIAGNOSTIC
$121.54
59001
3
AMNIOCENTESIS, THERAPEUTIC
$173.02
59012
3
FETAL CORD PUNCTURE,PRENATAL
$190.27
59015
3
CHORION BIOPSY
$145.79
59020
3
FETAL CONTRACT STRESS TEST
$66.41
59025
3
FETAL NON-STRESS TEST
$43.97
59030
3
FETAL SCALP BLOOD SAMPLE
59050
3
FETAL MONITOR W/REPORT
$47.19
59051
3
FETAL MONITOR/INTERPRET ONLY
$39.02
59070
3
TRANSABDOM AMNIOINFUS W/US
$371.42
59072
3
UMBILICAL CORD OCCLUD W/US
$447.46
59074
3
FETAL FLUID DRAINAGE W/US
$351.46
59076
3
FETAL SHUNT PLACEMENT, W/US
$437.11
59100
3
REMOVE UTERUS LESION
$761.92
59120
3
TREAT ECTOPIC PREGNANCY
$728.31
59121
3
TREAT ECTOPIC PREGNANCY
$731.49
59130
3
TREAT ECTOPIC PREGNANCY
$853.15
59135
3
TREAT ECTOPIC PREGNANCY
$864.74
59136
3
TREAT ECTOPIC PREGNANCY
$807.15
59140
3
TREAT ECTOPIC PREGNANCY
$363.06
59150
3
TREAT ECTOPIC PREGNANCY
$708.02
59151
3
TREAT ECTOPIC PREGNANCY
$691.52
59160
3
D & C AFTER DELIVERY
$199.40
59200
3
INSERT CERVICAL DILATOR
59300
3
EPISIOTOMY OR VAGINAL REPAIR
$179.63
59320
3
REVISION OF CERVIX
$143.06
59325
3
REVISION OF CERVIX
$225.32
59350
3
REPAIR OF UTERUS
$258.54
$105.66
$69.76
Procedure Code Pricing Action Code Description
Maximum Allowable
59400
7
OBSTETRICAL CARE
$0.00
59409
3
OBSTETRICAL CARE
$717.47
59410
3
OBSTETRICAL CARE
$833.70
59412
9
ANTEPARTUM MANIPULATION
59414
3
DELIVER PLACENTA
59420
O
ANTEPARTUM CARE ONLY (SEPARATE PROC
$0.00
59425
9
ANTEPARTUM CARE ONLY
$0.00
59426
9
ANTEPARTUM CARE ONLY
$0.00
59430
3
CARE AFTER DELIVERY
59510
7
CESAREAN DELIVERY
59514
3
CESAREAN DELIVERY ONLY
$717.47
59515
3
CESAREAN DELIVERY
$833.70
59525
3
REMOVE UTERUS AFTER CESAREAN
$452.10
59610
9
VBAC DELIVERY
59612
3
VBAC DELIVERY ONLY
$717.47
59614
3
VBAC CARE AFTER DELIVERY
$833.70
59618
9
ATTEMPTED VBAC DELIVERY
$0.00
59620
3
ATTEMPTED VBAC DELIVERY ONLY
$717.47
59622
3
ATTEMPTED VBAC AFTER CARE
$833.70
59812
3
TREATMENT OF MISCARRIAGE
$290.55
59820
3
CARE OF MISCARRIAGE
$344.91
59821
3
TREATMENT OF MISCARRIAGE
$350.52
59830
3
TREAT UTERUS INFECTION
$402.08
59840
3
ABORTION
$201.48
59841
3
ABORTION
$349.65
59850
3
ABORTION
$359.82
59851
3
ABORTION
$369.77
59852
3
ABORTION
$519.36
59855
3
ABORTION
$383.63
59856
3
ABORTION
$452.57
59857
3
ABORTION
$541.56
59866
9
ABORTION (MPR)
59870
3
EVACUATE MOLE OF UTERUS
$433.90
59871
3
REMOVE CERCLAGE SUTURE
$125.07
59897
6
FETAL INVAS PX W/US
$0.00 $85.50
$130.24 $0.00
$0.00
$0.00
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
59898
5
LAPARO PROC, OB CARE/DELIVER
$0.00
59899
5
MATERNITY CARE PROCEDURE
$0.00
60000
3
DRAIN THYROID/TONGUE CYST
$145.95
60001
O
ASPIRATE/INJECT THYRIOD CYST
$0.00
6005F
9
CARE LEVEL RATIONALE DOC
$0.00
60100
3
BIOPSY OF THYROID
6010F
9
DYSPHAG TEST DONE B/4 EATING
$0.00
6015F
9
DYSPHAG TEST DONE B/4 EATING
$0.00
60200
3
REMOVE THYROID LESION
6020F
9
NPO (NOTHING-MOUTH) ORDERED
60210
3
PARTIAL THYROID EXCISION
$630.88
60212
3
PARTIAL THYROID EXCISION
$905.34
60220
3
PARTIAL REMOVAL OF THYROID
$691.52
60225
3
PARTIAL REMOVAL OF THYROID
$831.19
60240
3
REMOVAL OF THYROID
$878.96
60245
O
THYROIDECTOMY, SUBTOTAL OR PARTIAL;
$0.00
60246
O
THYROIDECTOMY, SUBTOTAL OR PARTIAL;
$0.00
60252
3
REMOVAL OF THYROID
$1,187.09
60254
3
EXTENSIVE THYROID SURGERY
$1,530.05
60260
3
REPEAT THYROID SURGERY
60270
3
REMOVAL OF THYROID
$1,249.20
60271
3
REMOVAL OF THYROID
$958.20
60280
3
REMOVE THYROID DUCT LESION
$398.83
60281
3
REMOVE THYROID DUCT LESION
$531.34
60300
3
ASPIR/INJ THYROID CYST
$102.89
6030F
9
MAX STERILE BARRIERS FOLLWD
$0.00
6040F
9
APPRO RAD DS DVCS TECHS DOCD
$0.00
6045F
9
RADXPS IN END RPRT4FLURO PXD
$0.00
60500
3
EXPLORE PARATHYROID GLANDS
60502
3
RE-EXPLORE PARATHYROIDS
$1,144.01
60505
3
EXPLORE PARATHYROID GLANDS
$1,257.06
60512
3
AUTOTRANSPLANT PARATHYROID
$222.38
60520
3
REMOVAL OF THYMUS GLAND
$939.24
60521
3
REMOVAL OF THYMUS GLAND
$1,079.13
60522
3
REMOVAL OF THYMUS GLAND
$1,300.92
$108.79
$590.91 $0.00
$991.53
$911.50
Procedure Code Pricing Action Code Description
Maximum Allowable
60540
3
EXPLORE ADRENAL GLAND
$991.39
60545
3
EXPLORE ADRENAL GLAND
$1,126.94
60600
3
REMOVE CAROTID BODY LESION
$1,308.04
60605
3
REMOVE CAROTID BODY LESION
$1,644.64
60650
3
LAPAROSCOPY ADRENALECTOMY
$1,102.63
60659
5
LAPARO PROC, ENDOCRINE
$0.00
60699
5
ENDOCRINE SURGERY PROCEDURE
$0.00
61000
3
REMOVE CRANIAL CAVITY FLUID
$101.35
61001
3
REMOVE CRANIAL CAVITY FLUID
$99.23
61020
3
REMOVE BRAIN CAVITY FLUID
$118.67
61026
3
INJECTION INTO BRAIN CANAL
$118.21
61050
3
REMOVE BRAIN CANAL FLUID
$100.96
61055
3
INJECTION INTO BRAIN CANAL
$129.76
61070
3
BRAIN CANAL SHUNT PROCEDURE
61105
3
TWIST DRILL HOLE
61106
O
DRILL SKULL FOR EXAM/SURGERY
61107
3
DRILL SKULL FOR IMPLANTATION
$286.49
61108
3
DRILL SKULL FOR DRAINAGE
$771.45
61120
3
BURR HOLE FOR PUNCTURE
$632.31
61130
O
PIERCE SKULL, EXAM/SURGERY
61140
3
PIERCE SKULL FOR BIOPSY
$1,095.40
61150
3
PIERCE SKULL FOR DRAINAGE
$1,171.29
61151
3
PIERCE SKULL FOR DRAINAGE
$848.57
61154
3
PIERCE SKULL & REMOVE CLOT
$1,097.78
61156
3
PIERCE SKULL FOR DRAINAGE
$1,093.26
61210
3
PIERCE SKULL, IMPLANT DEVICE
$334.48
61215
3
INSERT BRAIN-FLUID DEVICE
$423.46
61250
3
PIERCE SKULL & EXPLORE
$739.18
61253
3
PIERCE SKULL & EXPLORE
$812.98
61304
3
OPEN SKULL FOR EXPLORATION
$1,442.22
61305
3
OPEN SKULL FOR EXPLORATION
$1,738.88
61312
3
OPEN SKULL FOR DRAINAGE
$1,802.95
61313
3
OPEN SKULL FOR DRAINAGE
$1,724.56
61314
3
OPEN SKULL FOR DRAINAGE
$1,595.98
61315
3
OPEN SKULL FOR DRAINAGE
$1,816.51
$75.80 $389.12 $0.00
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
61316
3
IMPLT CRAN BONE FLAP TO ABDO
$78.76
61320
3
OPEN SKULL FOR DRAINAGE
$1,679.85
61321
3
OPEN SKULL FOR DRAINAGE
$1,840.45
61322
3
DECOMPRESSIVE CRANIOTOMY
$2,042.85
61323
3
DECOMPRESSIVE LOBECTOMY
$2,077.64
61330
3
DECOMPRESS EYE SOCKET
$1,425.29
61332
3
EXPLORE/BIOPSY EYE SOCKET
$1,650.65
61333
3
EXPLORE ORBIT/REMOVE LESION
$1,667.95
61334
3
EXPLORE ORBIT/REMOVE OBJECT
$1,082.21
61340
3
SUBTEMPORAL DECOMPRESSION
$1,251.75
61343
3
INCISE SKULL (PRESS RELIEF)
$1,932.50
61345
3
RELIEVE CRANIAL PRESSURE
$1,789.02
61440
3
INCISE SKULL FOR SURGERY
$1,751.24
61450
3
INCISE SKULL FOR SURGERY
$1,658.52
61458
3
INCISE SKULL FOR BRAIN WOUND
$1,768.92
61460
3
INCISE SKULL FOR SURGERY
$1,792.27
61470
3
INCISE SKULL FOR SURGERY
$1,663.82
61480
3
INCISE SKULL FOR SURGERY
$1,613.68
61490
3
INCISE SKULL FOR SURGERY
$1,673.98
61500
3
REMOVAL OF SKULL LESION
$1,184.43
61501
3
REMOVE INFECTED SKULL BONE
$1,015.76
61510
3
REMOVAL OF BRAIN LESION
$1,908.80
61512
3
REMOVE BRAIN LINING LESION
$2,251.46
61514
3
REMOVAL OF BRAIN ABSCESS
$1,671.92
61516
3
REMOVAL OF BRAIN LESION
$1,631.20
61517
3
IMPLT BRAIN CHEMOTX ADD-ON
61518
3
REMOVAL OF BRAIN LESION
$2,422.97
61519
3
REMOVE BRAIN LINING LESION
$2,608.02
61520
3
REMOVAL OF BRAIN LESION
$3,333.41
61521
3
REMOVAL OF BRAIN LESION
$2,801.88
61522
3
REMOVAL OF BRAIN ABSCESS
$1,923.54
61524
3
REMOVAL OF BRAIN LESION
$1,815.84
61526
3
REMOVAL OF BRAIN LESION
$3,025.69
61530
3
REMOVAL OF BRAIN LESION
$2,570.46
61531
3
IMPLANT BRAIN ELECTRODES
$1,054.49
$78.77
Procedure Code Pricing Action Code Description
Maximum Allowable
61533
3
IMPLANT BRAIN ELECTRODES
$1,329.62
61534
3
REMOVAL OF BRAIN LESION
$1,432.65
61535
3
REMOVE BRAIN ELECTRODES
61536
3
REMOVAL OF BRAIN LESION
$2,281.57
61537
3
REMOVAL OF BRAIN TISSUE
$2,099.67
61538
3
REMOVAL OF BRAIN TISSUE
$2,250.86
61539
3
REMOVAL OF BRAIN TISSUE
$2,065.21
61540
3
REMOVAL OF BRAIN TISSUE
$1,938.23
61541
3
INCISION OF BRAIN TISSUE
$1,860.65
61542
3
REMOVAL OF BRAIN TISSUE
$2,018.61
61543
3
REMOVAL OF BRAIN TISSUE
$1,885.05
61544
3
REMOVE & TREAT BRAIN LESION
$1,553.06
61545
3
EXCISION OF BRAIN TUMOR
$2,777.03
61546
3
REMOVAL OF PITUITARY GLAND
$2,012.97
61548
3
REMOVAL OF PITUITARY GLAND
$1,366.26
61550
3
RELEASE OF SKULL SEAMS
$896.49
61552
3
RELEASE OF SKULL SEAMS
$1,177.86
61553
O
CRANIECTOMY FOR CRANIOSTENOSIS EACH
$0.00
61555
O
RECONSTRUCTION OF SKULL BY MULTIPLE
$0.00
61556
3
INCISE SKULL/SUTURES
$1,435.99
61557
3
INCISE SKULL/SUTURES
$1,479.38
61558
3
EXCISION OF SKULL/SUTURES
$1,523.58
61559
3
EXCISION OF SKULL/SUTURES
$2,115.28
61561
O
RECONSTRUCTION OF SKULL BY ORBITAL
61563
3
EXCISION OF SKULL TUMOR
$1,700.03
61564
3
EXCISION OF SKULL TUMOR
$2,128.20
61566
3
REMOVAL OF BRAIN TISSUE
$1,964.54
61567
3
INCISION OF BRAIN TISSUE
$2,210.37
61570
3
REMOVE FOREIGN BODY, BRAIN
$1,607.08
61571
3
INCISE SKULL FOR BRAIN WOUND
$1,745.95
61575
3
SKULL BASE/BRAINSTEM SURGERY
$2,078.24
61576
3
SKULL BASE/BRAINSTEM SURGERY
$3,330.83
61580
3
CRANIOFACIAL APPROACH, SKULL
$2,192.58
61581
3
CRANIOFACIAL APPROACH, SKULL
$2,460.80
61582
3
CRANIOFACIAL APPROACH, SKULL
$2,529.00
$858.87
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
61583
3
CRANIOFACIAL APPROACH, SKULL
$2,551.18
61584
3
ORBITOCRANIAL APPROACH/SKULL
$2,484.97
61585
3
ORBITOCRANIAL APPROACH/SKULL
$2,631.08
61586
3
RESECT NASOPHARYNX, SKULL
$1,901.42
61590
3
INFRATEMPORAL APPROACH/SKULL
$2,785.17
61591
3
INFRATEMPORAL APPROACH/SKULL
$2,805.01
61592
3
ORBITOCRANIAL APPROACH/SKULL
$2,795.35
61595
3
TRANSTEMPORAL APPROACH/SKULL
$2,110.19
61596
3
TRANSCOCHLEAR APPROACH/SKULL
$2,316.93
61597
3
TRANSCONDYLAR APPROACH/SKULL
$2,532.05
61598
3
TRANSPETROSAL APPROACH/SKULL
$2,247.71
61600
3
RESECT/EXCISE CRANIAL LESION
$1,900.62
61601
3
RESECT/EXCISE CRANIAL LESION
$2,075.89
61605
3
RESECT/EXCISE CRANIAL LESION
$1,989.41
61606
3
RESECT/EXCISE CRANIAL LESION
$2,658.99
61607
3
RESECT/EXCISE CRANIAL LESION
$2,464.37
61608
3
RESECT/EXCISE CRANIAL LESION
$2,866.64
61609
3
TRANSECT ARTERY, SINUS
$551.19
61610
3
TRANSECT ARTERY, SINUS
$1,690.57
61611
3
TRANSECT ARTERY, SINUS
$426.91
61612
3
TRANSECT ARTERY, SINUS
$1,502.59
61613
3
REMOVE ANEURYSM, SINUS
$2,787.38
61615
3
RESECT/EXCISE LESION, SKULL
$2,206.58
61616
3
RESECT/EXCISE LESION, SKULL
$2,895.02
61618
3
REPAIR DURA
$1,143.13
61619
3
REPAIR DURA
$1,317.42
61623
3
ENDOVASC TEMPORY VESSEL OCCL
61624
3
TRANSCATH OCCLUSION, CNS
61626
3
TRANSCATH OCCLUSION, NON-CNS
61630
3
INTRACRANIAL ANGIOPLASTY
$1,199.75
61635
3
INTRACRAN ANGIOPLSTY W/STENT
$1,313.58
61640
3
DILATE IC VASOSPASM, INIT
$609.95
61641
3
DILATE IC VASOSPASM ADD-ON
$214.33
61642
3
DILATE IC VASOSPASM ADD-ON
$428.65
61680
3
INTRACRANIAL VESSEL SURGERY
$528.60 $1,051.73 $856.93
$1,992.70
Procedure Code Pricing Action Code Description
Maximum Allowable
61682
3
INTRACRANIAL VESSEL SURGERY
$3,739.92
61684
3
INTRACRANIAL VESSEL SURGERY
$2,490.92
61686
3
INTRACRANIAL VESSEL SURGERY
$4,005.03
61690
3
INTRACRANIAL VESSEL SURGERY
$1,896.06
61692
3
INTRACRANIAL VESSEL SURGERY
$3,234.74
61697
3
BRAIN ANEURYSM REPR, COMPLX
$3,657.69
61698
3
BRAIN ANEURYSM REPR, COMPLX
$3,935.37
61700
3
BRAIN ANEURYSM REPR, SIMPLE
$3,059.05
61702
3
INNER SKULL VESSEL SURGERY
$3,425.79
61703
3
CLAMP NECK ARTERY
$1,176.27
61705
3
REVISE CIRCULATION TO HEAD
$2,251.87
61708
3
REVISE CIRCULATION TO HEAD
$1,947.14
61710
3
REVISE CIRCULATION TO HEAD
$1,772.25
61711
3
FUSION OF SKULL ARTERIES
$2,295.21
61712
O
SKULL OR SPINE MICROSURGERY
61720
3
INCISE SKULL/BRAIN SURGERY
$1,025.30
61735
3
INCISE SKULL/BRAIN SURGERY
$1,258.72
61750
3
INCISE SKULL/BRAIN BIOPSY
$1,229.26
61751
3
BRAIN BIOPSY W/CT/MR GUIDE
$1,199.05
61760
3
IMPLANT BRAIN ELECTRODES
$1,351.63
61770
3
INCISE SKULL FOR TREATMENT
$1,334.23
61780
O
STEREOTACTIC LOCALIZATION, ANY METH
61790
3
TREAT TRIGEMINAL NERVE
$745.08
61791
3
TREAT TRIGEMINAL TRACT
$964.26
61793
O
FOCUS RADIATION BEAM
61795
3
BRAIN SURGERY USING COMPUTER
$223.94
61796
3
SRS, CRANIAL LESION SIMPLE
$702.09
61797
3
SRS, CRAN LES SIMPLE, ADDL
$191.15
61798
3
SRS, CRANIAL LESION COMPLEX
$702.09
61799
3
SRS, CRAN LES COMPLEX, ADDL
$264.24
61800
3
APPLY SRS HEADFRAME ADD-ON
$135.10
61850
3
IMPLANT NEUROELECTRODES
$856.38
61855
O
IMPLANT NEUROELECTRODES
$0.00
61860
3
IMPLANT NEUROELECTRODES
$1,363.01
61862
O
IMPLANT NEUROSTIMUL, SUBCORT
$0.00
$0.00
$0.00
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
61863
3
IMPLANT NEUROELECTRODE
$1,323.63
61864
3
IMPLANT NEUROELECTRDE, ADDL
61865
O
IMPLANT NEUROELECTRODES
61867
3
IMPLANT NEUROELECTRODE
61868
3
IMPLANT NEUROELECTRDE, ADDÏL
61870
3
IMPLANT NEUROELECTRODES
$1,037.23
61875
3
IMPLANT NEUROELECTRODES
$1,010.22
61880
3
REVISE/REMOVE NEUROELECTRODE
$479.00
61885
3
INSRT/REDO NEUROSTIM 1 ARRAY
$555.45
61886
3
IMPLANT NEUROSTIM ARRAYS
$699.92
61888
3
REVISE/REMOVE NEURORECEIVER
$349.67
62000
3
TREAT SKULL FRACTURE
$769.53
62005
3
TREAT SKULL FRACTURE
$1,085.55
62010
3
TREATMENT OF HEAD INJURY
$1,325.74
62100
3
REPAIR BRAIN FLUID LEAKAGE
$1,410.97
62115
3
REDUCTION OF SKULL DEFECT
$1,250.42
62116
3
REDUCTION OF SKULL DEFECT
$1,554.91
62117
3
REDUCTION OF SKULL DEFECT
$1,678.14
62120
3
REPAIR SKULL CAVITY LESION
$1,601.90
62121
3
INCISE SKULL REPAIR
$1,459.83
62140
3
REPAIR OF SKULL DEFECT
$918.20
62141
3
REPAIR OF SKULL DEFECT
$1,008.30
62142
3
REMOVE SKULL PLATE/FLAP
$769.26
62143
3
REPLACE SKULL PLATE/FLAP
$900.40
62145
3
REPAIR OF SKULL & BRAIN
$1,232.91
62146
3
REPAIR OF SKULL WITH GRAFT
$1,058.17
62147
3
REPAIR OF SKULL WITH GRAFT
$1,256.35
62148
3
RETR BONE FLAP TO FIX SKULL
$112.54
62160
3
NEUROENDOSCOPY ADD-ON
$172.61
62161
3
DISSECT BRAIN W/SCOPE
$1,326.45
62162
3
REMOVE COLLOID CYST W/SCOPE
$1,649.22
62163
3
NEUROENDOSCOPY W/FB REMOVAL
$1,069.22
62164
3
REMOVE BRAIN TUMOR W/SCOPE
$1,757.89
62165
3
REMOVE PITUIT TUMOR W/SCOPE
$1,364.53
62180
3
ESTABLISH BRAIN CAVITY SHUNT
$1,389.63
$360.82 $0.00 $1,949.47 $536.27
Procedure Code Pricing Action Code Description
Maximum Allowable
62190
3
ESTABLISH BRAIN CAVITY SHUNT
$791.96
62192
3
ESTABLISH BRAIN CAVITY SHUNT
$843.47
62194
3
REPLACE/IRRIGATE CATHETER
$344.07
62200
3
ESTABLISH BRAIN CAVITY SHUNT
$1,202.00
62201
3
BRAIN CAVITY SHUNT W/SCOPE
$1,033.11
62220
3
ESTABLISH BRAIN CAVITY SHUNT
$885.94
62223
3
ESTABLISH BRAIN CAVITY SHUNT
$910.61
62225
3
REPLACE/IRRIGATE CATHETER
$435.39
62230
3
REPLACE/REVISE BRAIN SHUNT
$732.65
62252
3
CSF SHUNT REPROGRAM
62256
3
REMOVE BRAIN CAVITY SHUNT
$509.85
62258
3
REPLACE BRAIN CAVITY SHUNT
$984.69
62263
3
EPIDURAL LYSIS MULT SESSIONS
$598.98
62264
3
EPIDURAL LYSIS ON SINGLE DAY
$365.91
62267
3
INTERDISCAL PERQ ASPIR, DX
$237.68
62268
3
DRAIN SPINAL CORD CYST
$434.42
62269
3
NEEDLE BIOPSY, SPINAL CORD
$471.46
62270
3
SPINAL FLUID TAP, DIAGNOSTIC
$144.41
62272
3
DRAIN CEREBRO SPINAL FLUID
$170.49
62273
3
INJECT EPIDURAL PATCH
$152.41
62274
O
INJECT SPINAL ANESTHETIC
$0.00
62275
O
INJECT SPINAL ANESTHETIC
$0.00
62276
O
INJECT SPINAL ANESTHETIC
$0.00
62277
O
INJECT SPINAL ANESTHETIC
$0.00
62278
O
INJECT SPINAL ANESTHETIC
$0.00
62279
O
INJECT SPINAL ANESTHETIC
$0.00
62280
3
TREAT SPINAL CORD LESION
$283.81
62281
3
TREAT SPINAL CORD LESION
$262.65
62282
3
TREAT SPINAL CANAL LESION
$272.93
62284
3
INJECTION FOR MYELOGRAM
$208.62
62287
3
PERCUTANEOUS DISKECTOMY
$504.98
62288
O
INJECTION INTO SPINAL CANAL
$0.00
62289
O
INJECTION INTO SPINAL CANAL
$0.00
62290
3
INJECT FOR SPINE DISK X-RAY
$303.11
62291
3
INJECT FOR SPINE DISK X-RAY
$283.61
$92.48
Procedure Code Pricing Action Code Description
Maximum Allowable
62292
3
INJECTION INTO DISK LESION
$452.37
62294
3
INJECTION INTO SPINAL ARTERY
$729.68
62298
O
INJECTION INTO SPINAL CANAL
62310
3
INJECT SPINE C/T
$200.16
62311
3
INJECT SPINE L/S (CD)
$176.98
62318
3
INJECT SPINE W/CATH, C/T
$214.04
62319
3
INJECT SPINE W/CATH L/S (CD)
$193.68
62350
3
IMPLANT SPINAL CANAL CATH
$353.08
62351
3
IMPLANT SPINAL CANAL CATH
$745.79
62355
3
REMOVE SPINAL CANAL CATHETER
$265.32
62360
3
INSERT SPINE INFUSION DEVICE
$255.37
62361
3
IMPLANT SPINE INFUSION PUMP
$352.38
62362
3
IMPLANT SPINE INFUSION PUMP
$371.28
62365
3
REMOVE SPINE INFUSION DEVICE
$293.68
62367
3
ANALYZE SPINE INFUSION PUMP
$35.61
62368
3
ANALYZE SPINE INFUSION PUMP
$50.79
63001
3
REMOVAL OF SPINAL LAMINA
$1,082.80
63003
3
REMOVAL OF SPINAL LAMINA
$1,089.45
63005
3
REMOVAL OF SPINAL LAMINA
$1,035.44
63010
O
LAMINECTOMY FOR EXPLORATION/DECOMPR
63011
3
REMOVAL OF SPINAL LAMINA
$977.62
63012
3
REMOVAL OF SPINAL LAMINA
$1,053.04
63015
3
REMOVAL OF SPINAL LAMINA
$1,301.12
63016
3
REMOVAL OF SPINAL LAMINA
$1,337.34
63017
3
REMOVAL OF SPINAL LAMINA
$1,091.93
63020
3
NECK SPINE DISK SURGERY
$1,033.13
63030
3
LOW BACK DISK SURGERY
$859.03
63035
3
SPINAL DISK SURGERY ADD-ON
$181.77
63040
3
LAMINOTOMY, SINGLE CERVICAL
$1,253.63
63042
3
LAMINOTOMY, SINGLE LUMBAR
$1,174.52
63043
5
LAMINOTOMY, ADDÏL CERVICAL
$0.00
63044
5
LAMINOTOMY, ADDÏL LUMBAR
$0.00
63045
3
REMOVAL OF SPINAL LAMINA
$1,121.71
63046
3
REMOVAL OF SPINAL LAMINA
$1,072.34
63047
3
REMOVAL OF SPINAL LAMINA
$979.39
$0.00
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
63048
3
REMOVE SPINAL LAMINA ADD-ON
$195.60
63050
3
CERVICAL LAMINOPLASTY
$1,347.41
63051
3
C-LAMINOPLASTY W/GRAFT/PLATE
$1,521.28
63055
3
DECOMPRESS SPINAL CORD
$1,442.44
63056
3
DECOMPRESS SPINAL CORD
$1,332.01
63057
3
DECOMPRESS SPINE CORD ADD-ON
63064
3
DECOMPRESS SPINAL CORD
63066
3
DECOMPRESS SPINE CORD ADD-ON
63075
3
NECK SPINE DISK SURGERY
$1,232.23
63076
3
NECK SPINE DISK SURGERY
$231.33
63077
3
SPINE DISK SURGERY, THORAX
$1,350.00
63078
3
SPINE DISK SURGERY, THORAX
$184.04
63081
3
REMOVAL OF VERTEBRAL BODY
63082
3
REMOVE VERTEBRAL BODY ADD-ON
63085
3
REMOVAL OF VERTEBRAL BODY
63086
3
REMOVE VERTEBRAL BODY ADD-ON
63087
3
REMOVAL OF VERTEBRAL BODY
63088
3
REMOVE VERTEBRAL BODY ADD-ON
63090
3
REMOVAL OF VERTEBRAL BODY
63091
3
REMOVE VERTEBRAL BODY ADD-ON
63101
3
REMOVAL OF VERTEBRAL BODY
$2,023.66
63102
3
REMOVAL OF VERTEBRAL BODY
$2,014.78
63103
3
REMOVE VERTEBRAL BODY ADD-ON
63170
3
INCISE SPINAL CORD TRACT(S)
$1,355.65
63172
3
DRAINAGE OF SPINAL CYST
$1,220.88
63173
3
DRAINAGE OF SPINAL CYST
$1,504.93
63180
3
REVISE SPINAL CORD LIGAMENTS
$1,226.12
63182
3
REVISE SPINAL CORD LIGAMENTS
$1,310.59
63185
3
INCISE SPINAL COLUMN/NERVES
$998.87
63190
3
INCISE SPINAL COLUMN/NERVES
$1,148.29
63191
3
INCISE SPINAL COLUMN/NERVES
$1,090.04
63194
3
INCISE SPINAL COLUMN & CORD
$1,304.51
63195
3
INCISE SPINAL COLUMN & CORD
$1,319.96
63196
3
INCISE SPINAL COLUMN & CORD
$1,553.35
63197
3
INCISE SPINAL COLUMN & CORD
$1,480.91
$299.65 $1,576.75 $184.79
$1,581.44 $249.75 $1,689.53 $177.30 $2,156.93 $242.79 $1,765.94 $166.73
$266.41
Procedure Code Pricing Action Code Description
Maximum Allowable
63198
3
INCISE SPINAL COLUMN & CORD
$1,635.80
63199
3
INCISE SPINAL COLUMN & CORD
$1,740.22
63200
3
RELEASE OF SPINAL CORD
$1,324.62
63250
3
REVISE SPINAL CORD VESSELS
$2,565.66
63251
3
REVISE SPINAL CORD VESSELS
$2,663.35
63252
3
REVISE SPINAL CORD VESSELS
$2,665.17
63265
3
EXCISE INTRASPINAL LESION
$1,466.64
63266
3
EXCISE INTRASPINAL LESION
$1,507.41
63267
3
EXCISE INTRASPINAL LESION
$1,215.34
63268
3
EXCISE INTRASPINAL LESION
$1,219.78
63270
3
EXCISE INTRASPINAL LESION
$1,803.86
63271
3
EXCISE INTRASPINAL LESION
$1,814.86
63272
3
EXCISE INTRASPINAL LESION
$1,672.31
63273
3
EXCISE INTRASPINAL LESION
$1,578.38
63275
3
BIOPSY/EXCISE SPINAL TUMOR
$1,574.65
63276
3
BIOPSY/EXCISE SPINAL TUMOR
$1,568.93
63277
3
BIOPSY/EXCISE SPINAL TUMOR
$1,377.75
63278
3
BIOPSY/EXCISE SPINAL TUMOR
$1,348.71
63280
3
BIOPSY/EXCISE SPINAL TUMOR
$1,862.12
63281
3
BIOPSY/EXCISE SPINAL TUMOR
$1,840.87
63282
3
BIOPSY/EXCISE SPINAL TUMOR
$1,737.56
63283
3
BIOPSY/EXCISE SPINAL TUMOR
$1,646.33
63285
3
BIOPSY/EXCISE SPINAL TUMOR
$2,283.40
63286
3
BIOPSY/EXCISE SPINAL TUMOR
$2,276.15
63287
3
BIOPSY/EXCISE SPINAL TUMOR
$2,400.90
63290
3
BIOPSY/EXCISE SPINAL TUMOR
$2,429.19
63295
3
REPAIR OF LAMINECTOMY DEFECT
63300
3
REMOVAL OF VERTEBRAL BODY
$1,623.41
63301
3
REMOVAL OF VERTEBRAL BODY
$1,818.81
63302
3
REMOVAL OF VERTEBRAL BODY
$1,807.89
63303
3
REMOVAL OF VERTEBRAL BODY
$1,888.92
63304
3
REMOVAL OF VERTEBRAL BODY
$2,007.54
63305
3
REMOVAL OF VERTEBRAL BODY
$2,046.22
63306
3
REMOVAL OF VERTEBRAL BODY
$2,150.90
63307
3
REMOVAL OF VERTEBRAL BODY
$1,992.47
$288.44
Procedure Code Pricing Action Code Description
Maximum Allowable
63308
3
REMOVE VERTEBRAL BODY ADD-ON
$300.23
63600
3
REMOVE SPINAL CORD LESION
$749.50
63610
3
STIMULATION OF SPINAL CORD
$1,244.66
63615
3
REMOVE LESION OF SPINAL CORD
$1,013.06
63620
3
SRS, SPINAL LESION
$702.09
63621
3
SRS, SPINAL LESION, ADDL
$219.77
63650
3
IMPLANT NEUROELECTRODES
$372.83
63652
O
PERCUTANEOUS IMPLANTATION OF NEUROS
63655
3
IMPLANT NEUROELECTRODES
63656
O
LAMINECTOMY FOR IMPLANTATION OF NEU
$0.00
63657
O
LAMINECTOMY FOR IMPLANTATION OF NEU
$0.00
63658
O
LAMINECTOMY FOR IMPLANTATION OF NEU
$0.00
63660
3
REVISE/REMOVE NEUROELECTRODE
$394.32
63685
3
INSRT/REDO SPINE N GENERATOR
$358.61
63688
3
REVISE/REMOVE NEURORECEIVER
$321.69
63690
O
ANALYSIS OF NEURORECEIVER
$0.00
63691
O
ANALYSIS OF NEURORECEIVER
$0.00
63700
3
REPAIR OF SPINAL HERNIATION
$1,083.94
63702
3
REPAIR OF SPINAL HERNIATION
$1,219.40
63704
3
REPAIR OF SPINAL HERNIATION
$1,357.02
63706
3
REPAIR OF SPINAL HERNIATION
$1,581.61
63707
3
REPAIR SPINAL FLUID LEAKAGE
$801.33
63709
3
REPAIR SPINAL FLUID LEAKAGE
$973.08
63710
3
GRAFT REPAIR OF SPINE DEFECT
$972.32
63740
3
INSTALL SPINAL SHUNT
$825.84
63741
3
INSTALL SPINAL SHUNT
$535.13
63744
3
REVISION OF SPINAL SHUNT
$562.89
63746
3
REMOVAL OF SPINAL SHUNT
$492.42
63750
O
INSERTION, SUBARACHNOID CATHETER WI
$0.00
63780
O
INSERTION OR REPLACEMENT, SUBARACHN
$0.00
64400
3
N BLOCK INJ, TRIGEMINAL
64402
3
N BLOCK INJ, FACIAL
64405
3
N BLOCK INJ, OCCIPITAL
64408
3
N BLOCK INJ, VAGUS
$109.35
64410
3
N BLOCK INJ, PHRENIC
$127.57
$0.00 $747.15
$98.27 $100.43 $94.56
Procedure Code Pricing Action Code Description
Maximum Allowable
64412
3
N BLOCK INJ, SPINAL ACCESSOR
$127.27
64413
3
N BLOCK INJ, CERVICAL PLEXUS
$105.18
64415
3
N BLOCK INJ, BRACHIAL PLEXUS
$119.75
64416
3
N BLOCK CONT INFUSE, B PLEX
$85.42
64417
3
N BLOCK INJ, AXILLARY
$121.01
64418
3
N BLOCK INJ, SUPRASCAPULAR
$123.53
64420
3
N BLOCK INJ, INTERCOST, SNG
$147.60
64421
3
N BLOCK INJ, INTERCOST, MLT
$217.95
64425
3
N BLOCK INJ, ILIO-ING/HYPOGI
$117.41
64430
3
N BLOCK INJ, PUDENDAL
$144.41
64435
3
N BLOCK INJ, PARACERVICAL
$133.66
64440
O
INJECTION FOR NERVE BLOCK
$0.00
64441
O
INJECTION FOR NERVE BLOCK
$0.00
64442
O
INJECTION FOR NERVE BLOCK
$0.00
64443
O
INJECT, NERVE BLOCK ADD-ON
$0.00
64445
3
N BLOCK INJ, SCIATIC, SNG
64446
3
N BLK INJ, SCIATIC, CONT INF
$85.37
64447
3
N BLOCK INJ FEM, SINGLE
$64.63
64448
3
N BLOCK INJ FEM, CONT INF
$75.50
64449
3
N BLOCK INJ, LUMBAR PLEXUS
$84.54
64450
3
N BLOCK, OTHER PERIPHERAL
$94.71
64455
3
N BLOCK INJ, PLANTAR DIGIT
$48.19
64470
3
INJ PARAVERTEBRAL C/T
$241.77
64472
3
INJ PARAVERTEBRAL C/T ADD-ON
$103.84
64475
3
INJ PARAVERTEBRAL L/S
$216.93
64476
3
INJ PARAVERTEBRAL L/S ADD-ON
64479
3
INJ FORAMEN EPIDURAL C/T
$255.62
64480
3
INJ FORAMEN EPIDURAL ADD-ON
$127.67
64483
3
INJ FORAMEN EPIDURAL L/S
$249.11
64484
3
INJ FORAMEN EPIDURAL ADD-ON
$125.61
64505
3
N BLOCK, SPENOPALATINE GANGL
64508
3
N BLOCK, CAROTID SINUS S/P
$131.17
64510
3
N BLOCK, STELLATE GANGLION
$130.31
64517
3
N BLOCK INJ, HYPOGAS PLXS
$155.57
64520
3
N BLOCK, LUMBAR/THORACIC
$171.05
$124.42
$87.35
$93.14
Procedure Code Pricing Action Code Description
Maximum Allowable
64530
3
N BLOCK INJ, CELIAC PELUS
$176.42
64550
3
APPLY NEUROSTIMULATOR
$14.44
64553
3
IMPLANT NEUROELECTRODES
$185.92
64555
3
IMPLANT NEUROELECTRODES
$197.67
64560
3
IMPLANT NEUROELECTRODES
$195.69
64561
3
IMPLANT NEUROELECTRODES
$399.44
64565
3
IMPLANT NEUROELECTRODES
$156.19
64573
3
IMPLANT NEUROELECTRODES
$525.89
64575
3
IMPLANT NEUROELECTRODES
$258.77
64577
3
IMPLANT NEUROELECTRODES
$321.61
64580
3
IMPLANT NEUROELECTRODES
$268.59
64581
3
IMPLANT NEUROELECTRODES
$774.44
64585
3
REVISE/REMOVE NEUROELECTRODE
$312.04
64590
3
INSRT/REDO PN/GASTR STIMUL
$292.15
64595
3
REVISE/RMV PN/GASTR STIMUL
$302.97
64600
3
INJECTION TREATMENT OF NERVE
$369.88
64605
3
INJECTION TREATMENT OF NERVE
$519.22
64610
3
INJECTION TREATMENT OF NERVE
$630.51
64612
3
DESTROY NERVE, FACE MUSCLE
$141.05
64613
3
DESTROY NERVE, NECK MUSCLE
$138.83
64614
3
DESTROY NERVE, EXTREM MUSC
$155.69
64620
3
INJECTION TREATMENT OF NERVE
$248.22
64622
3
DESTR PARAVERTEBRL NERVE L/S
$297.82
64623
3
DESTR PARAVERTEBRAL N ADD-ON
$110.76
64626
3
DESTR PARAVERTEBRL NERVE C/T
$346.12
64627
3
DESTR PARAVERTEBRAL N ADD-ON
$151.46
64630
3
INJECTION TREATMENT OF NERVE
$214.12
64632
3
N BLOCK INJ, COMMON DIGIT
64640
3
INJECTION TREATMENT OF NERVE
$210.92
64650
3
CHEMODENERV ECCRINE GLANDS
$61.57
64653
3
CHEMODENERV ECCRINE GLANDS
$71.44
64680
3
INJECTION TREATMENT OF NERVE
$282.02
64681
3
INJECTION TREATMENT OF NERVE
$363.61
64702
3
REVISE FINGER/TOE NERVE
$414.13
64704
3
REVISE HAND/FOOT NERVE
$304.32
$79.20
Procedure Code Pricing Action Code Description
Maximum Allowable
64708
3
REVISE ARM/LEG NERVE
$430.13
64712
3
REVISION OF SCIATIC NERVE
$493.15
64713
3
REVISION OF ARM NERVE(S)
$689.09
64714
3
REVISE LOW BACK NERVE(S)
$587.55
64716
3
REVISION OF CRANIAL NERVE
$470.60
64718
3
REVISE ULNAR NERVE AT ELBOW
$507.78
64719
3
REVISE ULNAR NERVE AT WRIST
$352.16
64721
3
CARPAL TUNNEL SURGERY
$372.34
64722
3
RELIEVE PRESSURE ON NERVE(S)
$300.66
64726
3
RELEASE FOOT/TOE NERVE
$264.68
64727
3
INTERNAL NERVE REVISION
$171.82
64732
3
INCISION OF BROW NERVE
$344.36
64734
3
INCISION OF CHEEK NERVE
$371.72
64736
3
INCISION OF CHIN NERVE
$351.43
64738
3
INCISION OF JAW NERVE
$414.47
64740
3
INCISION OF TONGUE NERVE
$414.17
64742
3
INCISION OF FACIAL NERVE
$422.85
64744
3
INCISE NERVE, BACK OF HEAD
$371.31
64746
3
INCISE DIAPHRAGM NERVE
$400.22
64752
3
INCISION OF VAGUS NERVE
$452.49
64755
9
INCISION OF STOMACH NERVES
64760
3
INCISION OF VAGUS NERVE
$426.81
64761
3
INCISION OF PELVIS NERVE
$404.51
64763
3
INCISE HIP/THIGH NERVE
$491.33
64766
3
INCISE HIP/THIGH NERVE
$564.72
64771
3
SEVER CRANIAL NERVE
$531.24
64772
3
INCISION OF SPINAL NERVE
$510.51
64774
3
REMOVE SKIN NERVE LESION
$368.56
64776
3
REMOVE DIGIT NERVE LESION
$354.10
64778
3
DIGIT NERVE SURGERY ADD-ON
$170.59
64782
3
REMOVE LIMB NERVE LESION
$416.72
64783
3
LIMB NERVE SURGERY ADD-ON
$203.95
64784
3
REMOVE NERVE LESION
$648.60
64786
3
REMOVE SCIATIC NERVE LESION
$972.42
64787
3
IMPLANT NERVE END
$234.11
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
64788
3
REMOVE SKIN NERVE LESION
$346.46
64790
3
REMOVAL OF NERVE LESION
$741.54
64792
3
REMOVAL OF NERVE LESION
$961.56
64795
3
BIOPSY OF NERVE
$175.48
64802
3
REMOVE SYMPATHETIC NERVES
$543.23
64804
3
REMOVE SYMPATHETIC NERVES
$827.25
64809
3
REMOVE SYMPATHETIC NERVES
$777.63
64818
3
REMOVE SYMPATHETIC NERVES
$603.59
64820
3
REMOVE SYMPATHETIC NERVES
$679.89
64821
3
REMOVE SYMPATHETIC NERVES
$614.32
64822
3
REMOVE SYMPATHETIC NERVES
$606.51
64823
3
REMOVE SYMPATHETIC NERVES
$688.26
64830
O
MICROREPAIR OF NERVE
64831
3
REPAIR OF DIGIT NERVE
$609.02
64832
3
REPAIR NERVE ADD-ON
$317.28
64834
3
REPAIR OF HAND OR FOOT NERVE
$672.13
64835
3
REPAIR OF HAND OR FOOT NERVE
$728.69
64836
3
REPAIR OF HAND OR FOOT NERVE
$728.37
64837
3
REPAIR NERVE ADD-ON
$352.32
64840
3
REPAIR OF LEG NERVE
$827.93
64856
3
REPAIR/TRANSPOSE NERVE
$915.80
64857
3
REPAIR ARM/LEG NERVE
$957.33
64858
3
REPAIR SCIATIC NERVE
64859
3
NERVE SURGERY
64861
3
REPAIR OF ARM NERVES
$1,243.60
64862
3
REPAIR OF LOW BACK NERVES
$1,216.70
64864
3
REPAIR OF FACIAL NERVE
$793.45
64865
3
REPAIR OF FACIAL NERVE
$1,052.87
64866
3
FUSION OF FACIAL/OTHER NERVE
$1,093.97
64868
3
FUSION OF FACIAL/OTHER NERVE
$956.87
64870
3
FUSION OF FACIAL/OTHER NERVE
$929.66
64872
3
SUBSEQUENT REPAIR OF NERVE
$112.07
64874
3
REPAIR & REVISE NERVE ADD-ON
$164.61
64876
3
REPAIR NERVE/SHORTEN BONE
$179.38
64885
3
NERVE GRAFT, HEAD OR NECK
$0.00
$1,104.07 $238.91
$1,033.01
Procedure Code Pricing Action Code Description
Maximum Allowable
64886
3
NERVE GRAFT, HEAD OR NECK
$1,225.65
64890
3
NERVE GRAFT, HAND OR FOOT
$986.46
64891
3
NERVE GRAFT, HAND OR FOOT
$1,017.46
64892
3
NERVE GRAFT, ARM OR LEG
$959.60
64893
3
NERVE GRAFT, ARM OR LEG
$1,009.62
64895
3
NERVE GRAFT, HAND OR FOOT
$1,183.24
64896
3
NERVE GRAFT, HAND OR FOOT
$1,306.37
64897
3
NERVE GRAFT, ARM OR LEG
$1,146.06
64898
3
NERVE GRAFT, ARM OR LEG
$1,250.19
64901
3
NERVE GRAFT ADD-ON
$559.99
64902
3
NERVE GRAFT ADD-ON
$643.28
64905
3
NERVE PEDICLE TRANSFER
$917.68
64907
3
NERVE PEDICLE TRANSFER
$1,205.21
64910
3
NERVE REPAIR W/ALLOGRAFT
$739.53
64911
3
NEURORRAPHY W/VEIN AUTOGRAFT
$891.09
64999
5
NERVOUS SYSTEM SURGERY
65091
3
REVISE EYE
$530.87
65093
3
REVISE EYE WITH IMPLANT
$530.11
65101
3
REMOVAL OF EYE
$612.09
65103
3
REMOVE EYE/INSERT IMPLANT
$638.89
65105
3
REMOVE EYE/ATTACH IMPLANT
$704.58
65110
3
REMOVAL OF EYE
$1,024.81
65112
3
REMOVE EYE/REVISE SOCKET
$1,206.53
65114
3
REMOVE EYE/REVISE SOCKET
$1,253.86
65125
3
REVISE OCULAR IMPLANT
$384.38
65130
3
INSERT OCULAR IMPLANT
$605.29
65135
3
INSERT OCULAR IMPLANT
$616.39
65140
3
ATTACH OCULAR IMPLANT
$671.41
65150
3
REVISE OCULAR IMPLANT
$487.26
65155
3
REINSERT OCULAR IMPLANT
$708.14
65175
3
REMOVAL OF OCULAR IMPLANT
$545.67
65205
3
REMOVE FOREIGN BODY FROM EYE
$47.90
65210
3
REMOVE FOREIGN BODY FROM EYE
$58.70
65220
3
REMOVE FOREIGN BODY FROM EYE
$49.12
65222
3
REMOVE FOREIGN BODY FROM EYE
$64.50
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
65230
O
REMOVAL OF FOREIGN BODY, INTRAOCULA
$0.00
65235
3
REMOVE FOREIGN BODY FROM EYE
65240
O
REMOVAL OF FOREIGN BODY, INTRAOCULA
$0.00
65245
O
REMOVAL OF FOREIGN BODY, INTRAOCULA
$0.00
65260
3
REMOVE FOREIGN BODY FROM EYE
$794.82
65265
3
REMOVE FOREIGN BODY FROM EYE
$894.39
65270
3
REPAIR OF EYE WOUND
$225.30
65272
3
REPAIR OF EYE WOUND
$287.38
65273
3
REPAIR OF EYE WOUND
$315.52
65275
3
REPAIR OF EYE WOUND
$462.62
65280
3
REPAIR OF EYE WOUND
$553.44
65285
3
REPAIR OF EYE WOUND
$862.24
65286
3
REPAIR OF EYE WOUND
$585.96
65290
3
REPAIR OF EYE SOCKET WOUND
$406.62
65300
O
DELIMITING KERATOTOMY
$0.00
65400
3
REMOVAL OF EYE LESION
$555.72
65410
3
BIOPSY OF CORNEA
$121.13
65420
3
REMOVAL OF EYE LESION
$430.87
65426
3
REMOVAL OF EYE LESION
$542.50
65430
3
CORNEAL SMEAR
$97.46
65435
3
CURETTE/TREAT CORNEA
$67.47
65436
3
CURETTE/TREAT CORNEA
$319.73
65450
3
TREATMENT OF CORNEAL LESION
$265.51
65600
3
REVISION OF CORNEA
$321.79
65710
3
CORNEAL TRANSPLANT
$915.18
65730
3
CORNEAL TRANSPLANT
$1,017.40
65750
3
CORNEAL TRANSPLANT
$1,030.91
65755
3
CORNEAL TRANSPLANT
$1,024.89
65756
3
CORNEAL TRNSPL, ENDOTHELIAL
65757
6
PREP CORNEAL ENDO ALLOGRAFT
$0.00
65760
5
REVISION OF CORNEA
$0.00
65765
5
REVISION OF CORNEA
$0.00
65767
5
CORNEAL TISSUE TRANSPLANT
$0.00
65770
3
REVISE CORNEA WITH IMPLANT
$1,177.70
65771
5
RADIAL KERATOTOMY
$579.93
$985.80
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
65772
3
CORRECTION OF ASTIGMATISM
$371.57
65775
3
CORRECTION OF ASTIGMATISM
$455.35
65780
3
OCULAR RECONST, TRANSPLANT
$734.11
65781
3
OCULAR RECONST, TRANSPLANT
$1,111.66
65782
3
OCULAR RECONST, TRANSPLANT
$959.32
65800
3
DRAINAGE OF EYE
$127.34
65805
3
DRAINAGE OF EYE
$139.18
65810
3
DRAINAGE OF EYE
$386.20
65815
3
DRAINAGE OF EYE
$530.77
65820
3
RELIEVE INNER EYE PRESSURE
$622.51
65825
O
GONIOTOMY WITH GONIOPUNCTURE
$0.00
65830
O
GONIOPUNCTURE, WITHOUT GONIOTOMY
$0.00
65850
3
INCISION OF EYE
$705.44
65855
3
LASER SURGERY OF EYE
$283.67
65860
3
INCISE INNER EYE ADHESIONS
$262.03
65865
3
INCISE INNER EYE ADHESIONS
$395.67
65870
3
INCISE INNER EYE ADHESIONS
$488.37
65875
3
INCISE INNER EYE ADHESIONS
$518.81
65880
3
INCISE INNER EYE ADHESIONS
$546.58
65900
3
REMOVE EYE LESION
$801.52
65920
3
REMOVE IMPLANT OF EYE
$648.84
65930
3
REMOVE BLOOD CLOT FROM EYE
$533.65
66020
3
INJECTION TREATMENT OF EYE
$156.31
66030
3
INJECTION TREATMENT OF EYE
$138.51
66130
3
REMOVE EYE LESION
$589.23
66150
3
GLAUCOMA SURGERY
$714.56
66155
3
GLAUCOMA SURGERY
$712.26
66160
3
GLAUCOMA SURGERY
$809.72
66165
3
GLAUCOMA SURGERY
$697.96
66170
3
GLAUCOMA SURGERY
$980.53
66172
3
INCISION OF EYE
66180
3
IMPLANT EYE SHUNT
$972.49
66185
3
REVISE EYE SHUNT
$615.44
66220
3
REPAIR EYE LESION
$601.48
66225
3
REPAIR/GRAFT EYE LESION
$772.41
$1,232.20
Procedure Code Pricing Action Code Description
Maximum Allowable
66250
3
FOLLOW-UP SURGERY OF EYE
$623.44
66500
3
INCISION OF IRIS
$293.23
66505
3
INCISION OF IRIS
$320.96
66600
3
REMOVE IRIS AND LESION
$677.60
66605
3
REMOVAL OF IRIS
$878.47
66625
3
REMOVAL OF IRIS
$356.21
66630
3
REMOVAL OF IRIS
$468.18
66635
3
REMOVAL OF IRIS
$472.87
66680
3
REPAIR IRIS & CILIARY BODY
$423.55
66682
9
REPAIR IRIS & CILIARY BODY
$0.00
66700
3
DESTRUCTION, CILIARY BODY
66701
O
CYCLODIATHERMY SUBSEQUENT
$0.00
66702
O
CILIARY BODY DESTRUCTION, ANY METHO
$0.00
66710
3
CILIARY TRANSSLERAL THERAPY
$365.64
66711
3
CILIARY ENDOSCOPIC ABLATION
$523.39
66720
3
DESTRUCTION, CILIARY BODY
$384.35
66721
O
CYCLOCRYOTHERAPY SUBSEQUENT
66740
3
DESTRUCTION, CILIARY BODY
66741
O
CYCLODIALYSIS SUBSEQUENT
66761
3
REVISION OF IRIS
$373.28
66762
3
REVISION OF IRIS
$390.91
66770
3
REMOVAL OF INNER EYE LESION
$433.98
66800
O
DISCISSION OF LENS CAPSULE INCISION
$0.00
66801
O
DISCISSION OF LENS CAPSULE INCISION
$0.00
66802
O
DISCISSION OF LENS CAPSULE LASER SU
$0.00
66820
3
INCISION, SECONDARY CATARACT
$329.85
66821
3
AFTER CATARACT LASER SURGERY
$267.68
66825
3
REPOSITION INTRAOCULAR LENS
$631.25
66830
3
REMOVAL OF LENS LESION
$589.07
66840
3
REMOVAL OF LENS MATERIAL
$574.25
66850
3
REMOVAL OF LENS MATERIAL
$655.37
66852
3
REMOVAL OF LENS MATERIAL
$701.10
66915
O
EXPRESSION OF LENS, LINEAR, ONE OR
66920
3
EXTRACTION OF LENS
$625.66
66930
3
EXTRACTION OF LENS
$710.83
$372.16
$0.00 $363.05 $0.00
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
66940
3
EXTRACTION OF LENS
$645.87
66982
3
CATARACT SURGERY, COMPLEX
$887.39
66983
3
CATARACT SURG W/IOL, 1 STAGE
$612.23
66984
3
CATARACT SURG W/IOL, 1 STAGE
$636.87
66985
3
INSERT LENS PROSTHESIS
$631.01
66986
3
EXCHANGE LENS PROSTHESIS
$771.53
66990
3
OPHTHALMIC ENDOSCOPE ADD-ON
66999
5
EYE SURGERY PROCEDURE
67005
3
PARTIAL REMOVAL OF EYE FLUID
$389.62
67010
3
PARTIAL REMOVAL OF EYE FLUID
$450.61
67015
3
RELEASE OF EYE FLUID
$481.59
67025
3
REPLACE EYE FLUID
$600.25
67027
3
IMPLANT EYE DRUG SYSTEM
$709.76
67028
3
INJECTION EYE DRUG
$179.81
67030
3
INCISE INNER EYE STRANDS
$431.00
67031
3
LASER SURGERY, EYE STRANDS
$318.75
67036
3
REMOVAL OF INNER EYE FLUID
$801.45
67038
O
STRIP RETINAL MEMBRANE
67039
3
LASER TREATMENT OF RETINA
$1,027.13
67040
3
LASER TREATMENT OF RETINA
$1,184.47
67041
3
VIT FOR MACULAR PUCKER
$1,105.87
67042
3
VIT FOR MACULAR HOLE
$1,266.18
67043
3
VIT FOR MEMBRANE DISSECT
$1,328.99
67101
3
REPAIR DETACHED RETINA
$642.64
67105
3
REPAIR DETACHED RETINA
$594.14
67107
3
REPAIR DETACHED RETINA
$1,008.06
67108
3
REPAIR DETACHED RETINA
$1,340.89
67109
O
REPAIR OF RETINAL DETACHMENT, ONE O
67110
3
REPAIR DETACHED RETINA
67112
3
REREPAIR DETACHED RETINA
$1,106.57
67113
3
REPAIR RETINAL DETACH, CPLX
$1,455.41
67115
3
RELEASE ENCIRCLING MATERIAL
$406.82
67120
3
REMOVE EYE IMPLANT MATERIAL
$542.61
67121
3
REMOVE EYE IMPLANT MATERIAL
$751.70
67141
3
TREATMENT OF RETINA
$429.52
$78.56 $0.00
$0.00
$0.00 $719.08
Procedure Code Pricing Action Code Description
Maximum Allowable
67145
3
TREATMENT OF RETINA
$432.88
67208
3
TREATMENT OF RETINAL LESION
$495.52
67210
3
TREATMENT OF RETINAL LESION
$577.95
67218
3
TREATMENT OF RETINAL LESION
$1,170.50
67220
3
TREATMENT OF CHOROID LESION
$887.55
67221
3
OCULAR PHOTODYNAMIC THER
$251.93
67225
3
EYE PHOTODYNAMIC THER ADD-ON
67227
3
TREATMENT OF RETINAL LESION
$504.92
67228
3
TREATMENT OF RETINAL LESION
$997.15
67229
3
TR RETINAL LES PRETERM INF
$958.47
67250
3
REINFORCE EYE WALL
$654.69
67255
3
REINFORCE/GRAFT EYE WALL
$700.29
67299
5
EYE SURGERY PROCEDURE
67311
3
REVISE EYE MUSCLE
$495.26
67312
3
REVISE TWO EYE MUSCLES
$591.60
67313
O
STRABISMUS SURGERY ON PATIENT NOT P
67314
3
REVISE EYE MUSCLE
$555.13
67316
3
REVISE TWO EYE MUSCLES
$663.95
67318
3
REVISE EYE MUSCLE(S)
$581.09
67320
3
REVISE EYE MUSCLE(S) ADD-ON
$275.14
67331
3
EYE SURGERY FOLLOW-UP ADD-ON
$260.44
67332
3
REREVISE EYE MUSCLES ADD-ON
$283.31
67334
3
REVISE EYE MUSCLE W/SUTURE
$256.98
67335
3
EYE SUTURE DURING SURGERY
$129.44
67340
3
REVISE EYE MUSCLE ADD-ON
$306.17
67343
3
RELEASE EYE TISSUE
$539.50
67345
3
DESTROY NERVE OF EYE MUSCLE
$196.71
67346
3
BIOPSY, EYE MUSCLE
$171.22
67350
O
BIOPSY EYE MUSCLE
$0.00
67399
5
EYE MUSCLE SURGERY PROCEDURE
$0.00
67400
3
EXPLORE/BIOPSY EYE SOCKET
$779.20
67405
3
EXPLORE/DRAIN EYE SOCKET
$663.78
67412
3
EXPLORE/TREAT EYE SOCKET
$721.34
67413
3
EXPLORE/TREAT EYE SOCKET
$721.92
67414
3
EXPLR/DECOMPRESS EYE SOCKET
$25.77
$0.00
$0.00
$1,101.61
Procedure Code Pricing Action Code Description
Maximum Allowable
67415
3
ASPIRATION, ORBITAL CONTENTS
$90.56
67420
3
EXPLORE/TREAT EYE SOCKET
$1,373.92
67430
3
EXPLORE/TREAT EYE SOCKET
$1,046.87
67440
3
EXPLORE/DRAIN EYE SOCKET
$1,009.18
67445
3
EXPLR/DECOMPRESS EYE SOCKET
$1,182.30
67450
3
EXPLORE/BIOPSY EYE SOCKET
$1,047.22
67500
3
INJECT/TREAT EYE SOCKET
$75.95
67505
3
INJECT/TREAT EYE SOCKET
$74.31
67515
3
INJECT/TREAT EYE SOCKET
$78.84
67550
3
INSERT EYE SOCKET IMPLANT
$811.93
67560
3
REVISE EYE SOCKET IMPLANT
$826.30
67570
3
DECOMPRESS OPTIC NERVE
$970.69
67599
5
ORBIT SURGERY PROCEDURE
67700
3
DRAINAGE OF EYELID ABSCESS
$225.88
67710
3
INCISION OF EYELID
$190.68
67715
3
INCISION OF EYELID FOLD
$200.66
67800
3
REMOVE EYELID LESION
$106.07
67801
3
REMOVE EYELID LESIONS
$135.88
67805
3
REMOVE EYELID LESIONS
$168.45
67808
3
REMOVE EYELID LESION(S)
$302.18
67810
3
BIOPSY OF EYELID
$193.71
67820
3
REVISE EYELASHES
$44.44
67825
3
REVISE EYELASHES
$107.54
67830
3
REVISE EYELASHES
$225.68
67835
3
REVISE EYELASHES
$367.26
67840
3
REMOVE EYELID LESION
$235.72
67850
3
TREAT EYELID LESION
$189.59
67875
3
CLOSURE OF EYELID BY SUTURE
$147.16
67880
3
REVISION OF EYELID
$379.08
67882
3
REVISION OF EYELID
$467.16
67900
3
REPAIR BROW DEFECT
$540.23
67901
3
REPAIR EYELID DEFECT
$583.04
67902
3
REPAIR EYELID DEFECT
$596.16
67903
3
REPAIR EYELID DEFECT
$516.48
67904
3
REPAIR EYELID DEFECT
$610.53
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
67906
3
REPAIR EYELID DEFECT
$431.43
67907
O
REPAIR OF BLEPHAROPTOSIS SUPERIOR R
67908
3
REPAIR EYELID DEFECT
$411.40
67909
3
REVISE EYELID DEFECT
$452.09
67911
3
REVISE EYELID DEFECT
$461.55
67912
3
CORRECTION EYELID W/IMPLANT
$769.11
67914
3
REPAIR EYELID DEFECT
$329.39
67915
3
REPAIR EYELID DEFECT
$295.26
67916
3
REPAIR EYELID DEFECT
$452.97
67917
3
REPAIR EYELID DEFECT
$494.67
67921
3
REPAIR EYELID DEFECT
$313.73
67922
3
REPAIR EYELID DEFECT
$285.92
67923
3
REPAIR EYELID DEFECT
$477.14
67924
3
REPAIR EYELID DEFECT
$494.27
67930
3
REPAIR EYELID WOUND
$310.63
67935
3
REPAIR EYELID WOUND
$503.66
67938
3
REMOVE EYELID FOREIGN BODY
$206.06
67950
3
REVISION OF EYELID
$486.79
67961
3
REVISION OF EYELID
$486.23
67966
3
REVISION OF EYELID
$638.66
67971
3
RECONSTRUCTION OF EYELID
$612.74
67973
3
RECONSTRUCTION OF EYELID
$793.50
67974
3
RECONSTRUCTION OF EYELID
$790.20
67975
3
RECONSTRUCTION OF EYELID
$578.82
67999
5
REVISION OF EYELID
68020
3
INCISE/DRAIN EYELID LINING
$99.54
68040
3
TREATMENT OF EYELID LESIONS
$55.36
68100
3
BIOPSY OF EYELID LINING
$146.04
68110
3
REMOVE EYELID LINING LESION
$189.97
68115
3
REMOVE EYELID LINING LESION
$263.90
68130
3
REMOVE EYELID LINING LESION
$452.48
68135
3
REMOVE EYELID LINING LESION
$130.73
68200
3
TREAT EYELID BY INJECTION
$35.73
68320
3
REVISE/GRAFT EYELID LINING
$599.28
68325
3
REVISE/GRAFT EYELID LINING
$546.92
$0.00
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
68326
3
REVISE/GRAFT EYELID LINING
$532.45
68328
3
REVISE/GRAFT EYELID LINING
$594.52
68330
3
REVISE EYELID LINING
$503.07
68335
3
REVISE/GRAFT EYELID LINING
$534.12
68340
3
SEPARATE EYELID ADHESIONS
$453.42
68360
3
REVISE EYELID LINING
$441.58
68362
3
REVISE EYELID LINING
$541.33
68371
3
HARVEST EYE TISSUE, ALOGRAFT
$348.60
68399
5
EYELID LINING SURGERY
68400
3
INCISE/DRAIN TEAR GLAND
$238.27
68420
3
INCISE/DRAIN TEAR SAC
$271.14
68440
3
INCISE TEAR DUCT OPENING
68500
3
REMOVAL OF TEAR GLAND
$806.66
68505
3
PARTIAL REMOVAL, TEAR GLAND
$811.93
68510
3
BIOPSY OF TEAR GLAND
$385.06
68520
3
REMOVAL OF TEAR SAC
$571.67
68525
3
BIOPSY OF TEAR SAC
$229.40
68530
3
CLEARANCE OF TEAR DUCT
$368.37
68540
3
REMOVE TEAR GLAND LESION
$771.51
68550
3
REMOVE TEAR GLAND LESION
$947.99
68700
3
REPAIR TEAR DUCTS
$498.03
68705
3
REVISE TEAR DUCT OPENING
$200.58
68720
3
CREATE TEAR SAC DRAIN
$632.13
68745
3
CREATE TEAR DUCT DRAIN
$634.88
68750
3
CREATE TEAR DUCT DRAIN
$652.86
68760
3
CLOSE TEAR DUCT OPENING
$170.06
68761
3
CLOSE TEAR DUCT OPENING
$123.59
68770
3
CLOSE TEAR SYSTEM FISTULA
$491.58
68800
O
DILATION OF LACRIMAL PUNCTUM, WITH
68801
3
DILATE TEAR DUCT OPENING
$102.79
68810
3
PROBE NASOLACRIMAL DUCT
$198.71
68811
3
PROBE NASOLACRIMAL DUCT
$171.71
68815
3
PROBE NASOLACRIMAL DUCT
$375.32
68816
3
PROBE NL DUCT W/BALLOON
$579.09
68820
O
PROBING OF NASOLACRIMAL DUCT, WITH
$0.00
$89.85
$0.00
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
68825
O
PROBING OF NASOLACRIMAL DUCT, WITH
$0.00
68830
O
PROBING OF NASOLACRIMAL DUCT, WITH
$0.00
68840
3
EXPLORE/IRRIGATE TEAR DUCTS
$104.13
68850
3
INJECTION FOR TEAR SAC X-RAY
$58.38
68899
5
TEAR DUCT SYSTEM SURGERY
69000
3
DRAIN EXTERNAL EAR LESION
$161.51
69005
3
DRAIN EXTERNAL EAR LESION
$190.73
69020
3
DRAIN OUTER EAR CANAL LESION
$206.58
69090
9
PIERCE EARLOBES
69100
3
BIOPSY OF EXTERNAL EAR
69105
3
BIOPSY OF EXTERNAL EAR CANAL
$126.33
69110
3
REMOVE EXTERNAL EAR, PARTIAL
$410.32
69120
3
REMOVAL OF EXTERNAL EAR
$361.57
69140
3
REMOVE EAR CANAL LESION(S)
$791.65
69145
3
REMOVE EAR CANAL LESION(S)
$345.59
69150
3
EXTENSIVE EAR CANAL SURGERY
$960.49
69155
3
EXTENSIVE EAR/NECK SURGERY
69200
3
CLEAR OUTER EAR CANAL
$109.92
69205
3
CLEAR OUTER EAR CANAL
$92.23
69210
O
REMOVE IMPACTED EAR WAX
$0.00
69220
3
CLEAN OUT MASTOID CAVITY
$123.39
69222
3
CLEAN OUT MASTOID CAVITY
$197.80
69300
3
REVISE EXTERNAL EAR
$586.47
69310
3
REBUILD OUTER EAR CANAL
$987.06
69320
3
REBUILD OUTER EAR CANAL
$1,404.47
69399
5
OUTER EAR SURGERY PROCEDURE
69400
3
INFLATE MIDDLE EAR CANAL
$128.20
69401
3
INFLATE MIDDLE EAR CANAL
$74.73
69405
3
CATHETERIZE MIDDLE EAR CANAL
69410
O
INSET MIDDLE EAR (BAFFLE)
69420
3
INCISION OF EARDRUM
$171.03
69421
3
INCISION OF EARDRUM
$137.86
69424
3
REMOVE VENTILATING TUBE
$116.35
69433
3
CREATE EARDRUM OPENING
$177.93
69436
3
CREATE EARDRUM OPENING
$149.62
$0.00
$0.00 $96.22
$1,539.45
$0.00
$233.56 $0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
69440
3
EXPLORATION OF MIDDLE EAR
$621.13
69450
9
EARDRUM REVISION
69501
3
MASTOIDECTOMY
$665.41
69502
3
MASTOIDECTOMY
$884.79
69505
3
REMOVE MASTOID STRUCTURES
$1,097.45
69511
3
EXTENSIVE MASTOID SURGERY
$1,128.07
69530
3
EXTENSIVE MASTOID SURGERY
$1,516.23
69535
3
REMOVE PART OF TEMPORAL BONE
$2,457.55
69540
3
REMOVE EAR LESION
$186.86
69550
3
REMOVE EAR LESION
$948.95
69552
3
REMOVE EAR LESION
$1,443.05
69554
3
REMOVE EAR LESION
$2,282.15
69601
3
MASTOID SURGERY REVISION
$954.16
69602
3
MASTOID SURGERY REVISION
$992.92
69603
3
MASTOID SURGERY REVISION
$1,160.08
69604
3
MASTOID SURGERY REVISION
$1,024.39
69605
3
MASTOID SURGERY REVISION
$1,431.95
69610
3
REPAIR OF EARDRUM
$355.84
69620
3
REPAIR OF EARDRUM
$627.12
69631
3
REPAIR EARDRUM STRUCTURES
$798.81
69632
3
REBUILD EARDRUM STRUCTURES
$980.06
69633
3
REBUILD EARDRUM STRUCTURES
$944.54
69635
3
REPAIR EARDRUM STRUCTURES
$1,112.91
69636
3
REBUILD EARDRUM STRUCTURES
$1,260.93
69637
3
REBUILD EARDRUM STRUCTURES
$1,255.27
69641
3
REVISE MIDDLE EAR & MASTOID
$948.69
69642
3
REVISE MIDDLE EAR & MASTOID
$1,222.84
69643
3
REVISE MIDDLE EAR & MASTOID
$1,116.78
69644
3
REVISE MIDDLE EAR & MASTOID
$1,355.96
69645
3
REVISE MIDDLE EAR & MASTOID
$1,328.65
69646
3
REVISE MIDDLE EAR & MASTOID
$1,411.43
69650
3
RELEASE MIDDLE EAR BONE
$722.45
69660
3
REVISE MIDDLE EAR BONE
$848.95
69661
9
REVISE MIDDLE EAR BONE
$0.00
69662
3
REVISE MIDDLE EAR BONE
$1,063.36
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
69666
3
REPAIR MIDDLE EAR STRUCTURES
$733.29
69667
3
REPAIR MIDDLE EAR STRUCTURES
$735.86
69670
3
REMOVE MASTOID AIR CELLS
$857.88
69676
3
REMOVE MIDDLE EAR NERVE
$757.33
69700
3
CLOSE MASTOID FISTULA
$630.99
69710
5
IMPLANT/REPLACE HEARING AID
69711
3
REMOVE/REPAIR HEARING AID
$789.21
69714
3
IMPLANT TEMPLE BONE W/STIMUL
$985.42
69715
3
TEMPLE BNE IMPLNT W/STIMULAT
$1,224.49
69717
3
TEMPLE BONE IMPLANT REVISION
$1,041.54
69718
3
REVISE TEMPLE BONE IMPLANT
$1,280.30
69720
3
RELEASE FACIAL NERVE
$1,070.85
69725
3
RELEASE FACIAL NERVE
$1,739.12
69740
3
REPAIR FACIAL NERVE
$1,075.92
69745
3
REPAIR FACIAL NERVE
$1,143.26
69799
5
MIDDLE EAR SURGERY PROCEDURE
69801
3
INCISE INNER EAR
$679.87
69802
3
INCISE INNER EAR
$951.60
69805
3
EXPLORE INNER EAR
$963.44
69806
3
EXPLORE INNER EAR
$866.20
69820
3
ESTABLISH INNER EAR WINDOW
$787.31
69840
3
REVISE INNER EAR WINDOW
$828.40
69905
3
REMOVE INNER EAR
$838.89
69910
3
REMOVE INNER EAR & MASTOID
$936.17
69915
3
INCISE INNER EAR NERVE
$1,415.40
69930
3
IMPLANT COCHLEAR DEVICE
$1,138.44
69949
5
INNER EAR SURGERY PROCEDURE
69950
3
INCISE INNER EAR NERVE
$1,675.03
69955
3
RELEASE FACIAL NERVE
$1,833.26
69960
3
RELEASE INNER EAR CANAL
$1,775.92
69970
3
REMOVE INNER EAR LESION
$1,983.90
69979
5
TEMPORAL BONE SURGERY
$0.00
69990
3
MICROSURGERY ADD-ON
$198.95
70010
3
CONTRAST X-RAY OF BRAIN
$170.26
70011
O
MYELOGRAPHY, POSTERIOR FOSSA COMPLE
$0.00
$0.00
$0.00
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
70015
3
CONTRAST X-RAY OF BRAIN
$142.11
70016
O
CISTERNOGRAPHY, POSITIVE CONTRAST C
70030
3
X-RAY EYE FOR FOREIGN BODY
$27.87
70100
3
X-RAY EXAM OF JAW
$30.08
7010F
9
PT INFO INTO RECALL SYSTEM
70110
3
X-RAY EXAM OF JAW
$38.96
70120
3
X-RAY EXAM OF MASTOIDS
$32.77
70130
3
X-RAY EXAM OF MASTOIDS
$54.13
70134
3
X-RAY EXAM OF MIDDLE EAR
$46.36
70140
3
X-RAY EXAM OF FACIAL BONES
$29.43
70150
3
X-RAY EXAM OF FACIAL BONES
$42.15
70160
3
X-RAY EXAM OF NASAL BONES
$31.57
70170
3
X-RAY EXAM OF TEAR DUCT
$0.00
70171
O
DACRYOCYSTOGRAPHY, NASOLACRIMAL DUC
$0.00
70190
3
X-RAY EXAM OF EYE SOCKETS
$34.96
70200
3
X-RAY EXAM OF EYE SOCKETS
$43.61
7020F
9
MAMMO ASSESS CAT IN DBASE
$0.00
70210
3
X-RAY EXAM OF SINUSES
$29.46
70220
3
X-RAY EXAM OF SINUSES
$38.47
70240
3
X-RAY EXAM, PITUITARY SADDLE
$28.95
70250
3
X-RAY EXAM OF SKULL
$35.65
7025F
9
PT INFOSYS ALARM 4 NXT MAMMO
70260
3
X-RAY EXAM OF SKULL
$47.34
70300
3
X-RAY EXAM OF TEETH
$13.91
70310
3
X-RAY EXAM OF TEETH
$33.43
70320
3
FULL MOUTH X-RAY OF TEETH
$43.07
70328
3
X-RAY EXAM OF JAW JOINT
$29.33
70330
3
X-RAY EXAM OF JAW JOINTS
$46.62
70332
3
X-RAY EXAM OF JAW JOINT
$83.65
70333
O
TEMPOROMANDIBULAR JOINT ARTHROGRAPH
70336
3
MAGNETIC IMAGE, JAW JOINT
70350
3
X-RAY HEAD FOR ORTHODONTIA
$20.10
70355
3
PANORAMIC X-RAY OF JAWS
$22.39
70360
3
X-RAY EXAM OF NECK
$26.75
70370
3
THROAT X-RAY & FLUOROSCOPY
$73.62
$0.00
$0.00
$0.00
$0.00 $425.18
Procedure Code Pricing Action Code Description
Maximum Allowable
70371
3
SPEECH EVALUATION, COMPLEX
$96.33
70373
3
CONTRAST X-RAY OF LARYNX
$79.47
70374
O
LARYNGOGRAPHY, CONTRAST COMPLETE PR
70380
3
X-RAY EXAM OF SALIVARY GLAND
$36.48
70390
3
X-RAY EXAM OF SALIVARY DUCT
$98.77
70391
O
SIALOGRAPHY COMPLETE PROCEDURE
70450
3
CT HEAD/BRAIN W/O DYE
$219.23
70460
3
CT HEAD/BRAIN W/DYE
$283.53
70470
3
CT HEAD/BRAIN W/O & W/DYE
$343.32
70480
3
CT ORBIT/EAR/FOSSA W/O DYE
$261.48
70481
3
CT ORBIT/EAR/FOSSA W/DYE
$381.20
70482
3
CT ORBIT/EAR/FOSSA W/O&W/DYE
$417.80
70486
3
CT MAXILLOFACIAL W/O DYE
$253.88
70487
3
CT MAXILLOFACIAL W/DYE
$341.61
70488
3
CT MAXILLOFACIAL W/O & W/DYE
$415.97
70490
3
CT SOFT TISSUE NECK W/O DYE
$261.21
70491
3
CT SOFT TISSUE NECK W/DYE
$335.59
70492
3
CT SFT TSUE NCK W/O & W/DYE
$407.80
70496
3
CT ANGIOGRAPHY, HEAD
$444.88
70498
3
CT ANGIOGRAPHY, NECK
$445.24
70540
3
MRI ORBIT/FACE/NECK W/O DYE
$420.92
70541
O
MAGNETIC IMAGE, HEAD (MRA)
70542
3
MRI ORBIT/FACE/NECK W/DYE
$514.55
70543
3
MRI ORBT/FAC/NCK W/O & W/DYE
$652.35
70544
3
MR ANGIOGRAPHY HEAD W/O DYE
$412.18
70545
3
MR ANGIOGRAPHY HEAD W/DYE
$492.34
70546
3
MR ANGIOGRAPH HEAD W/O&W/DYE
$637.80
70547
3
MR ANGIOGRAPHY NECK W/O DYE
$412.04
70548
3
MR ANGIOGRAPHY NECK W/DYE
$492.60
70549
3
MR ANGIOGRAPH NECK W/O&W/DYE
$637.80
70551
3
MRI BRAIN W/O DYE
$426.20
70552
3
MRI BRAIN W/DYE
$520.88
70553
3
MRI BRAIN W/O & W/DYE
$658.38
70554
3
FMRI BRAIN BY TECH
$620.22
70555
3
FMRI BRAIN BY PHYS/PSYCH
$0.00
$0.00
$0.00
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
70557
3
MRI BRAIN W/O DYE
$0.00
70558
3
MRI BRAIN W/DYE
$0.00
70559
3
MRI BRAIN W/O & W/DYE
$0.00
71010
3
CHEST X-RAY
$23.78
71015
3
CHEST X-RAY
$29.29
71020
3
CHEST X-RAY
$31.61
71021
3
CHEST X-RAY
$38.07
71022
3
CHEST X-RAY
$45.79
71023
3
CHEST X-RAY AND FLUOROSCOPY
$66.40
71030
3
CHEST X-RAY
$46.16
71034
3
CHEST X-RAY AND FLUOROSCOPY
$91.30
71035
3
CHEST X-RAY
$34.14
71036
O
X-RAY GUIDANCE FOR BIOPSY
$0.00
71037
O
NEEDLE BIOPSY OF INTRATHORACIC LESI
$0.00
71038
O
X-RAY GUIDANCE FOR BIOPSY
$0.00
71040
3
CONTRAST X-RAY OF BRONCHI
$95.09
71041
O
BRONCHOGRAPHY, UNILATERAL COMPLETE
71060
3
CONTRAST X-RAY OF BRONCHI
71061
O
BRONCHOGRAPHY, BILATERAL COMPLETE P
$0.00
71090
3
X-RAY & PACEMAKER INSERTION
$0.00
71100
3
X-RAY EXAM OF RIBS
$32.35
71101
3
X-RAY EXAM OF RIBS/CHEST
$38.95
71110
3
X-RAY EXAM OF RIBS
$40.30
71111
3
X-RAY EXAM OF RIBS/CHEST
$51.56
71120
3
X-RAY EXAM OF BREASTBONE
$32.38
71130
3
X-RAY EXAM OF BREASTBONE
$37.16
71250
3
CT THORAX W/O DYE
$254.31
71260
3
CT THORAX W/DYE
$343.49
71270
3
CT THORAX W/O & W/DYE
$413.50
71275
3
CT ANGIOGRAPHY, CHEST
$453.94
71550
3
MRI CHEST W/O DYE
$426.20
71551
3
MRI CHEST W/DYE
$519.96
71552
3
MRI CHEST W/O & W/DYE
$660.83
71555
3
MRI ANGIO CHEST W OR W/O DYE
$523.84
72010
3
X-RAY EXAM OF SPINE
$0.00 $138.60
$68.28
Procedure Code Pricing Action Code Description
Maximum Allowable
72020
3
X-RAY EXAM OF SPINE
$23.45
72040
3
X-RAY EXAM OF NECK SPINE
$36.42
72050
3
X-RAY EXAM OF NECK SPINE
$51.58
72052
3
X-RAY EXAM OF NECK SPINE
$64.69
72069
3
X-RAY EXAM OF TRUNK SPINE
$34.46
72070
3
X-RAY EXAM OF THORACIC SPINE
$33.46
72072
3
X-RAY EXAM OF THORACIC SPINE
$38.14
72074
3
X-RAY EXAM OF THORACIC SPINE
$44.66
72080
3
X-RAY EXAM OF TRUNK SPINE
$34.94
72090
3
X-RAY EXAM OF TRUNK SPINE
$45.95
72100
3
X-RAY EXAM OF LOWER SPINE
$38.27
72110
3
X-RAY EXAM OF LOWER SPINE
$53.42
72114
3
X-RAY EXAM OF LOWER SPINE
$69.86
72120
3
X-RAY EXAM OF LOWER SPINE
$47.99
72125
3
CT NECK SPINE W/O DYE
$254.31
72126
3
CT NECK SPINE W/DYE
$342.77
72127
3
CT NECK SPINE W/O & W/DYE
$407.72
72128
3
CT CHEST SPINE W/O DYE
$254.31
72129
3
CT CHEST SPINE W/DYE
$343.15
72130
3
CT CHEST SPINE W/O & W/DYE
$408.09
72131
3
CT LUMBAR SPINE W/O DYE
$254.31
72132
3
CT LUMBAR SPINE W/DYE
$342.77
72133
3
CT LUMBAR SPINE W/O & W/DYE
$408.09
72141
3
MRI NECK SPINE W/O DYE
$430.96
72142
3
MRI NECK SPINE W/DYE
$527.60
72146
3
MRI CHEST SPINE W/O DYE
$431.06
72147
3
MRI CHEST SPINE W/DYE
$527.19
72148
3
MRI LUMBAR SPINE W/O DYE
$424.93
72149
3
MRI LUMBAR SPINE W/DYE
$520.88
72156
3
MRI NECK SPINE W/O & W/DYE
$668.83
72157
3
MRI CHEST SPINE W/O & W/DYE
$668.42
72158
3
MRI LUMBAR SPINE W/O & W/DYE
$658.13
72159
3
MR ANGIO SPINE W/O&W/DYE
$653.63
72170
3
X-RAY EXAM OF PELVIS
$25.65
72190
3
X-RAY EXAM OF PELVIS
$39.02
Procedure Code Pricing Action Code Description
Maximum Allowable
72191
3
CT ANGIOGRAPH PELV W/O&W/DYE
$448.15
72192
3
CT PELVIS W/O DYE
$250.94
72193
3
CT PELVIS W/DYE
$325.97
72194
3
CT PELVIS W/O & W/DYE
$405.71
72195
3
MRI PELVIS W/O DYE
$425.81
72196
3
MRI PELVIS W/DYE
$520.17
72197
3
MRI PELVIS W/O & W/DYE
$657.47
72198
3
MR ANGIO PELVIS W/O & W/DYE
$522.74
72200
3
X-RAY EXAM SACROILIAC JOINTS
$28.61
72202
3
X-RAY EXAM SACROILIAC JOINTS
$34.60
72220
3
X-RAY EXAM OF TAILBONE
$29.09
72240
3
CONTRAST X-RAY OF NECK SPINE
72241
O
MYELOGRAPHY, CERVICAL COMPLETE PROC
72255
3
CONTRAST X-RAY, THORAX SPINE
72256
O
MYELOGRAPHY, THORACIC COMPLETE PROC
72265
3
CONTRAST X-RAY, LOWER SPINE
72266
O
MYELOGRAPHY, LUMBOSACRAL COMPLETE P
72270
3
CONTRAST X-RAY, SPINE
72271
O
MYELOGRAPHY, ENTIRE SPINAL CANAL CO
72275
3
EPIDUROGRAPHY
$102.89
72285
3
X-RAY C/T SPINE DISK
$175.44
72286
O
DISKOGRAPHY, CERVICAL COMPLETE PROC
$0.00
72291
3
PERQ VERTEBROPLASTY, FLUOR
$0.00
72292
3
PERQ VERTEBROPLASTY, CT
$0.00
72295
3
X-RAY OF LOWER SPINE DISK
$156.40
72296
O
DISKOGRAPHY, LUMBAR COMPLETE PROCED
73000
3
X-RAY EXAM OF COLLAR BONE
$27.14
73010
3
X-RAY EXAM OF SHOULDER BLADE
$27.87
73020
3
X-RAY EXAM OF SHOULDER
$23.09
73030
3
X-RAY EXAM OF SHOULDER
$29.44
73040
3
CONTRAST X-RAY OF SHOULDER
73041
O
RADIOLOGIC EXAMINATION, SHOULDER, A
73050
3
X-RAY EXAM OF SHOULDERS
$35.34
73060
3
X-RAY EXAM OF HUMERUS
$28.71
73070
3
X-RAY EXAM OF ELBOW
$26.41
$157.41 $0.00 $143.75 $0.00 $146.43 $0.00 $228.42 $0.00
$0.00
$105.84 $0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
73080
3
X-RAY EXAM OF ELBOW
$33.89
73085
3
CONTRAST X-RAY OF ELBOW
$95.48
73086
O
RADIOLOGIC EXAMINATION, ELBOW, ARTH
73090
3
X-RAY EXAM OF FOREARM
$26.77
73092
3
X-RAY EXAM OF ARM, INFANT
$27.51
73100
3
X-RAY EXAM OF WRIST
$27.88
73110
3
X-RAY EXAM OF WRIST
$33.41
73115
3
CONTRAST X-RAY OF WRIST
73116
O
RADIOLOGIC EXAMINATION, WRIST, ARTH
73120
3
X-RAY EXAM OF HAND
$26.40
73130
3
X-RAY EXAM OF HAND
$30.46
73140
3
X-RAY EXAM OF FINGER(S)
$28.28
73200
3
CT UPPER EXTREMITY W/O DYE
$251.22
73201
3
CT UPPER EXTREMITY W/DYE
$325.88
73202
3
CT UPPR EXTREMITY W/O&W/DYE
$406.24
73206
3
CT ANGIO UPR EXTRM W/O&W/DYE
$448.63
73218
3
MRI UPPER EXTREMITY W/O DYE
$420.68
73219
3
MRI UPPER EXTREMITY W/DYE
$514.91
73220
3
MRI UPPR EXTREMITY W/O&W/DYE
$652.85
73221
3
MRI JOINT UPR EXTREM W/O DYE
$420.79
73222
3
MRI JOINT UPR EXTREM W/DYE
$514.28
73223
3
MRI JOINT UPR EXTR W/O&W/DYE
$652.08
73225
3
MR ANGIO UPR EXTR W/O&W/DYE
$637.36
73500
3
X-RAY EXAM OF HIP
$24.91
73510
3
X-RAY EXAM OF HIP
$36.06
73520
3
X-RAY EXAM OF HIPS
$38.96
73525
3
CONTRAST X-RAY OF HIP
$95.35
73526
O
RADIOLOGIC EXAMINATION, HIP, ARTHRO
$0.00
73530
3
X-RAY EXAM OF HIP
$0.00
73540
3
X-RAY EXAM OF PELVIS & HIPS
$36.07
73542
3
X-RAY EXAM, SACROILIAC JOINT
$77.92
73550
3
X-RAY EXAM OF THIGH
$27.98
73560
3
X-RAY EXAM OF KNEE, 1 OR 2
$27.87
73562
3
X-RAY EXAM OF KNEE, 3
$33.51
73564
3
X-RAY EXAM, KNEE, 4 OR MORE
$39.00
$0.00
$101.29 $0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
73565
3
X-RAY EXAM OF KNEES
$29.71
73580
3
CONTRAST X-RAY OF KNEE JOINT
73581
O
RADIOLOGIC EXAMINATION, KNEE, ARTHR
73590
3
X-RAY EXAM OF LOWER LEG
$26.75
73592
3
X-RAY EXAM OF LEG, INFANT
$27.51
73600
3
X-RAY EXAM OF ANKLE
$26.40
73610
3
X-RAY EXAM OF ANKLE
$30.46
73615
3
CONTRAST X-RAY OF ANKLE
$97.94
73616
O
RADIOLOGIC EXAMINATION, ANKLE, ARTH
73620
3
X-RAY EXAM OF FOOT
$25.67
73630
3
X-RAY EXAM OF FOOT
$30.09
73650
3
X-RAY EXAM OF HEEL
$26.03
73660
3
X-RAY EXAM OF TOE(S)
$26.80
73700
3
CT LOWER EXTREMITY W/O DYE
$251.22
73701
3
CT LOWER EXTREMITY W/DYE
$328.10
73702
3
CT LWR EXTREMITY W/O&W/DYE
$406.60
73706
3
CT ANGIO LWR EXTR W/O&W/DYE
$453.48
73718
3
MRI LOWER EXTREMITY W/O DYE
$420.92
73719
3
MRI LOWER EXTREMITY W/DYE
$514.55
73720
3
MRI LWR EXTREMITY W/O&W/DYE
$652.85
73721
3
MRI JNT OF LWR EXTRE W/O DYE
$420.79
73722
3
MRI JOINT OF LWR EXTR W/DYE
$514.78
73723
3
MRI JOINT LWR EXTR W/O&W/DYE
$652.08
73725
3
MR ANG LWR EXT W OR W/O DYE
$524.06
74000
3
X-RAY EXAM OF ABDOMEN
$25.26
74010
3
X-RAY EXAM OF ABDOMEN
$37.14
74020
3
X-RAY EXAM OF ABDOMEN
$39.68
74022
3
X-RAY EXAM SERIES, ABDOMEN
$47.99
74150
3
CT ABDOMEN W/O DYE
$255.75
74160
3
CT ABDOMEN W/DYE
$365.64
74170
3
CT ABDOMEN W/O & W/DYE
$415.38
74175
3
CT ANGIO ABDOM W/O & W/DYE
$453.10
74181
3
MRI ABDOMEN W/O DYE
$425.66
74182
3
MRI ABDOMEN W/DYE
$520.57
74183
3
MRI ABDOMEN W/O & W/DYE
$657.47
$119.13 $0.00
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
74185
3
MRI ANGIO, ABDOM W ORW/O DYE
$522.61
74190
3
X-RAY EXAM OF PERITONEUM
74210
3
CONTRST X-RAY EXAM OF THROAT
$76.16
74220
3
CONTRAST X-RAY, ESOPHAGUS
$86.38
74230
3
CINE/VID X-RAY, THROAT/ESOPH
$88.75
74235
3
REMOVE ESOPHAGUS OBSTRUCTION
74240
3
X-RAY EXAM, UPPER GI TRACT
$106.78
74241
3
X-RAY EXAM, UPPER GI TRACT
$113.81
74245
3
X-RAY EXAM, UPPER GI TRACT
$170.79
74246
3
CONTRST X-RAY UPPR GI TRACT
$122.42
74247
3
CONTRST X-RAY UPPR GI TRACT
$123.90
74249
3
CONTRST X-RAY UPPR GI TRACT
$183.24
74250
3
X-RAY EXAM OF SMALL BOWEL
$100.66
74251
3
X-RAY EXAM OF SMALL BOWEL
$180.87
74260
3
X-RAY EXAM OF SMALL BOWEL
$114.82
74270
3
CONTRAST X-RAY EXAM OF COLON
$124.03
74280
3
CONTRAST X-RAY EXAM OF COLON
$194.73
74283
3
CONTRAST X-RAY EXAM OF COLON
$190.35
74290
3
CONTRAST X-RAY, GALLBLADDER
$64.26
74291
3
CONTRAST X-RAYS, GALLBLADDER
$55.56
74300
O
X-RAY BILE DUCTS/PANCREAS
$0.00
74301
3
X-RAYS AT SURGERY ADD-ON
$0.00
74305
3
X-RAY BILE DUCTS/PANCREAS
$0.00
74320
3
CONTRAST X-RAY OF BILE DUCTS
74321
O
CHOLANGIOGRAPHY, PERCUTANEOUS, TRAN
74327
3
X-RAY BILE STONE REMOVAL
74328
3
X-RAY BILE DUCT ENDOSCOPY
$0.00
74329
3
X-RAY FOR PANCREAS ENDOSCOPY
$0.00
74330
3
X-RAY BILE/PANC ENDOSCOPY
$0.00
74340
3
X-RAY GUIDE FOR GI TUBE
$0.00
74350
O
X-RAY GUIDE, STOMACH TUBE
$0.00
74351
O
PERCUTANEOUS PLACEMENT OF GASTROSTO
$0.00
74355
3
X-RAY GUIDE, INTESTINAL TUBE
$0.00
74356
O
PERCUTANEOUS PLACEMENT OF ENTEROCLY
$0.00
74360
3
X-RAY GUIDE, GI DILATION
$0.00
$0.00
$0.00
$114.06 $0.00 $129.67
Procedure Code Pricing Action Code Description
Maximum Allowable
74361
O
INTRALUMINAL DILATION OF STRICTURES
$0.00
74363
3
X-RAY, BILE DUCT DILATION
$0.00
74400
3
CONTRST X-RAY, URINARY TRACT
74405
O
CONTRAST X-RAY URINARY TRACT
74410
3
CONTRST X-RAY, URINARY TRACT
$114.91
74415
3
CONTRST X-RAY, URINARY TRACT
$131.78
74420
3
CONTRST X-RAY, URINARY TRACT
$0.00
74425
3
CONTRST X-RAY, URINARY TRACT
$0.00
74426
O
UROGRAPHY, ANTEGRADE, (PYELOSTOGRAM
$0.00
74430
3
CONTRAST X-RAY, BLADDER
74431
O
CYSTOGRAPHY, MINIMUM OF THREE VIEWS
74440
3
X-RAY, MALE GENITAL TRACT
74441
O
VASOGRAPHY, VESICULOGRAPHY, OR EPID
$0.00
74445
3
X-RAY EXAM OF PENIS
$0.00
74446
O
CORPORA CAVERNOSOGRAPHY COMPLETE PR
$0.00
74450
3
X-RAY, URETHRA/BLADDER
$0.00
74451
O
URETHROCYSTOGRAPHY, RETROGRADE COMP
$0.00
74455
3
X-RAY, URETHRA/BLADDER
74456
O
URETHROCYSTOGRAPHY, VOIDING COMPLET
$0.00
74470
3
X-RAY EXAM OF KIDNEY LESION
$0.00
74471
O
RADIOLOGIC EXAMINATION, RENAL CYST
$0.00
74475
3
X-RAY CONTROL, CATH INSERT
74476
O
INTRODUCTION OF INTRACATHETER OR CA
74480
3
X-RAY CONTROL, CATH INSERT
74481
O
INTRODUCTION OF URETERAL CATHETER O
74485
3
X-RAY GUIDE, GU DILATION
74486
O
DILATION OF NEPHROSTOMY OR URETERS
74710
3
X-RAY MEASUREMENT OF PELVIS
$43.28
74740
3
X-RAY, FEMALE GENITAL TRACT
$77.48
74741
O
HYSTEROSALPINGOGRAPHY COMPLETE PROC
$0.00
74742
9
X-RAY, FALLOPIAN TUBE
$0.00
74775
3
X-RAY EXAM OF PERINEUM
$0.00
75120
O
RADIOLOGIC EXAMINATION, HAND; TWO V
$0.00
75500
O
ANGIOCARDIOGRAPHY BY CINERADIOGRAPH
$0.00
75501
O
ANGIOCARDIOGRAPHY BY CINERADIOGRAPH
$0.00
$108.99 $0.00
$78.05 $0.00 $83.89
$90.45
$123.39 $0.00 $123.76 $0.00 $117.99 $0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
75505
O
ANGIOCARDIOGRAPHY BY SERIALOGRAPHY,
$0.00
75506
O
ANGIOCARDIOGRAPHY BY SERIALOGRAPHY,
$0.00
75507
O
ANGIOCARDIOGRAPHY BY SERIALOGRAPHY,
$0.00
75509
O
ANGIOCARDIOGRAPHY BY SERIALOGRAPHY,
$0.00
75519
O
CARDIAC RADIOGRAPHY, SELECTIVE CARD
$0.00
75520
O
CARDIAC RADIOGRAPHY, SELECTIVE CARD
$0.00
75523
O
CARDIAC RADIOGRAPHY, SELECTIVE CARD
$0.00
75524
O
CARDIAC RADIOGRAPHY, SELECTIVE CARD
$0.00
75527
O
CARDIAC RADIOGRAPHY, SELECTIVE CARD
$0.00
75528
O
CARDIAC RADIOGRAPHY, SELECTIVE CARD
$0.00
75552
O
HEART MRI FOR MORPH W/O DYE
$0.00
75553
O
HEART MRI FOR MORPH W/DYE
$0.00
75554
O
CARDIAC MRI/FUNCTION
$0.00
75555
O
CARDIAC MRI/LIMITED STUDY
$0.00
75556
O
CARDIAC MRI/FLOW MAPPING
$0.00
75557
3
CARDIAC MRI FOR MORPH
$470.10
75558
3
CARDIAC MRI FLOW/VELOCITY
$628.75
75559
3
CARDIAC MRI W/STRESS IMG
$507.87
75560
3
CARDIAC MRI FLOW/VEL/STRESS
$822.90
75561
3
CARDIAC MRI FOR MORPH W/DYE
$676.46
75562
3
CARD MRI FLOW/VEL W/DYE
$815.28
75563
3
CARD MRI W/STRESS IMG & DYE
$705.54
75564
3
HT MRI W/FLO/VEL/STRS & DYE
$958.74
75600
3
CONTRAST X-RAY EXAM OF AORTA
$321.57
75601
O
AORTOGRAPHY, THORACIC, WITHOUT SERI
75605
3
CONTRAST X-RAY EXAM OF AORTA
75606
O
AORTOGRAPHY, THORACIC, BY SERIALOGR
75625
3
CONTRAST X-RAY EXAM OF AORTA
75626
O
AORTOGRAPHY, ABDOMINAL, TRANSLUMBAR
$0.00
75627
O
AORTOGRAPHY, ABDOMINAL, CATHETER, B
$0.00
75628
O
AORTOGRAPHY, ABDOMINAL, CATHETER, B
$0.00
75630
3
X-RAY AORTA, LEG ARTERIES
75631
O
AORTOGRAPHY, ABDOMINAL PLUS BILATER
75635
3
CT ANGIO ABDOMINAL ARTERIES
$480.58
75650
3
ARTERY X-RAYS, HEAD & NECK
$289.00
$0.00 $273.42 $0.00 $269.60
$312.36 $0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
75651
O
ANGIOGRAPHY, CERVICOCEREBRAL, CATHE
$0.00
75652
O
ANGIOGRAPHY, CERVICOCEREBRAL, SELEC
$0.00
75653
O
ANGIOGRAPHY, CERVICOCEREBRAL, SELEC
$0.00
75654
O
ANGIOGRAPHY, CERVICOCEREBRAL, SELEC
$0.00
75655
O
ANGIOGRAPHY, CERVICOCEREBRAL, SELEC
$0.00
75656
O
ANGIOGRAPHY, CERVICOCEREBRAL, SELEC
$0.00
75657
O
ANGIOGRAPHY, CERVICOCEREBRAL, SELEC
$0.00
75658
3
ARTERY X-RAYS, ARM
75659
O
ANGIOGRAPHY, BRACHIAL, RETROGRADE C
75660
3
ARTERY X-RAYS, HEAD & NECK
75661
O
ANGIOGRAPHY, EXTERNAL CAROTID, CERE
75662
3
ARTERY X-RAYS, HEAD & NECK
75663
O
ANGIOGRAPHY, EXTERNAL CAROTID, CERE
75665
3
ARTERY X-RAYS, HEAD & NECK
75667
O
ANGIOGRAPHY, CAROTID, CEREBRAL, UNI
$0.00
75669
O
ANGIOGRAPHY, CAROTID, CEREBRAL, UNI
$0.00
75671
3
ARTERY X-RAYS, HEAD & NECK
75672
O
ANGIOGRAPHY, CAROTID, CEREBRAL, BIL
$0.00
75673
O
ANGIOGRAPHY, CAROTID, CEREBRAL, BIL
$0.00
75676
3
ARTERY X-RAYS, NECK
75677
O
ANGIOGRAPHY, CAROTID, CERVICAL, UNI
$0.00
75678
O
ANGIOGRAPHY, CAROTID, CERVICAL, UNI
$0.00
75680
3
ARTERY X-RAYS, NECK
75681
O
ANGIOGRAPHY, CAROTID, CERVICAL, BIL
$0.00
75682
O
ANGIOGRAPHY, CAROTID, CERVICAL, BIL
$0.00
75685
3
ARTERY X-RAYS, SPINE
75686
O
ANGIOGRAPHY, VERTEBRAL DIRECT PUNCT
$0.00
75687
O
ANGIOGRAPHY, VERTEBRAL CATHETER, CO
$0.00
75690
O
ANGIOGRAPHY, VERTEBRAL, CERVICAL, U
$0.00
75692
O
ANGIOGRAPHY, VERTEBRAL, CERVICAL, U
$0.00
75695
O
ANGIOGRAPHY, VERTEBRAL, CERVICAL, B
$0.00
75697
O
ANGIOGRAPHY, VERTEBRAL, CERVICAL, B
$0.00
75705
3
ARTERY X-RAYS, SPINE
75706
O
ANGIOGRAPHY, SPINAL, SELECTIVE COMP
75710
3
ARTERY X-RAYS, ARM/LEG
$285.90 $0.00 $291.20 $0.00 $334.40 $0.00 $298.94
$338.70
$291.44
$325.02
$291.94
$335.42 $0.00 $285.37
Procedure Code Pricing Action Code Description
Maximum Allowable
75711
O
ANGIOGRAPHY, EXTREMITY, UNILATERAL
$0.00
75712
O
ANGIOGRAPHY, EXTREMITY, UNILATERAL
$0.00
75716
3
ARTERY X-RAYS, ARMS/LEGS
75717
O
ANGIOGRAPHY, EXTREMITY, BILATERAL W
$0.00
75718
O
ANGIOGRAPHY, EXTREMITY, BILATERAL B
$0.00
75722
3
ARTERY X-RAYS, KIDNEY
75723
O
ANGIOGRAPHY, RENAL, UNILATERAL, SEL
75724
3
ARTERY X-RAYS, KIDNEYS
75725
O
ANGIOGRAPHY, RENAL, BILATERAL, SELE
75726
3
ARTERY X-RAYS, ABDOMEN
75727
O
ANGIOGRAPHY, VISCERAL SELECTIVE (WI
$0.00
75728
O
ANGIOGRAPHY, VISCERAL SUPRASELECTIV
$0.00
75731
3
ARTERY X-RAYS, ADRENAL GLAND
75732
O
ANGIOGRAPHY, ADRENAL, UNILATERAL, S
75733
3
ARTERY X-RAYS, ADRENALS
75734
O
ANGIOGRAPHY, ADRENAL, BILATERAL, SE
75736
3
ARTERY X-RAYS, PELVIS
75737
O
ANGIOGRAPHY, PELVIC SELECTIVE, COMP
$0.00
75738
O
ANGIOGRAPHY, PELVIC SUPRASELECTIVE,
$0.00
75741
3
ARTERY X-RAYS, LUNG
75742
O
ANGIOGRAPHY, PULMONARY, UNILATERAL,
75743
3
ARTERY X-RAYS, LUNGS
75744
O
ANGIOGRAPHY, PULMONARY, BILATERAL,
75746
3
ARTERY X-RAYS, LUNG
75747
O
ANGIOGRAPHY, PULMONARY CATHETER, NO
$0.00
75748
O
ANGIOGRAPHY, PULMONARY VENOUS INJEC
$0.00
75750
O
ANGIOGRAPHY, CORONARY, ROOT INJECTI
$0.00
75751
O
ANGIOGRAPHY, CORONARY, ROOT INJECTI
$0.00
75752
O
ANGIOGRAPHY, CORONARY, UNILATERAL S
$0.00
75753
O
ANGIOGRAPHY, CORONARY, UNILATERAL S
$0.00
75754
O
ANGIOGRAPHY, CORONARY, BILATERAL SE
$0.00
75755
O
ANGIOGRAPHY, CORONARY, BILATERAL SE
$0.00
75756
3
ARTERY X-RAYS, CHEST
75757
O
ANGIOGRAPHY, INTERNAL MAMMARY COMPL
$0.00
75762
O
ANGIOGRAPHY, CORONARY BYPASS, UNILA
$0.00
$318.43
$281.93 $0.00 $328.45 $0.00 $282.30
$292.15 $0.00 $331.13 $0.00 $284.76
$273.09 $0.00 $298.77 $0.00 $276.01
$293.15
Procedure Code Pricing Action Code Description
Maximum Allowable
75764
O
ANGIOGRAPHY, CORONARY BYPASS, UNILA
$0.00
75766
O
ANGIOGRAPHY, CORONARY BYPASS, MULTI
$0.00
75767
O
ANGIOGRAPHY, CORONARY BYPASS, MULTI
$0.00
75774
3
ARTERY X-RAY, EACH VESSEL
75775
O
ANGIOGRAPHY, SELECTIVE, EACH ADDITI
75790
3
VISUALIZE A-V SHUNT
75801
3
LYMPH VESSEL X-RAY, ARM/LEG
$0.00
75802
O
LYMPHANGIOGRAPHY, EXTREMITY ONLY, U
$0.00
75803
3
LYMPH VESSEL X-RAY,ARMS/LEGS
$0.00
75804
O
LYMPHANGIOGRAPHY, EXTREMITY ONLY, B
$0.00
75805
3
LYMPH VESSEL X-RAY, TRUNK
$0.00
75806
O
LYMPHANGIOGRAPHY, PELVIC/ABDOMINAL,
$0.00
75807
3
LYMPH VESSEL X-RAY, TRUNK
$0.00
75808
O
LYMPHANGIOGRAPHY, PELVIC/ABDOMINAL,
$0.00
75809
3
NONVASCULAR SHUNT, X-RAY
75810
3
VEIN X-RAY, SPLEEN/LIVER
$0.00
75811
O
SPLENOPORTOGRAPHY COMPLETE PROCEDUR
$0.00
75820
3
VEIN X-RAY, ARM/LEG
75821
O
VENOGRAPHY, EXTREMITY, UNILATERAL C
75822
3
VEIN X-RAY, ARMS/LEGS
75823
O
VENOGRAPHY, EXTREMITY, BILATERAL CO
75825
3
VEIN X-RAY, TRUNK
75826
O
VENOGRAPHY, CAVAL, INFERIOR, WITH S
75827
3
VEIN X-RAY, CHEST
75828
O
VENOGRAPHY, CAVAL, SUPERIOR, WITH S
75831
3
VEIN X-RAY, KIDNEY
75832
O
VENOGRAPHY, RENAL, UNILATERAL, SELE
75833
3
VEIN X-RAY, KIDNEYS
75834
O
VENOGRAPHY, RENAL, BILATERAL, SELEC
75840
3
VEIN X-RAY, ADRENAL GLAND
75841
O
VENOGRAPHY, ADRENAL, UNILATERAL, SE
75842
3
VEIN X-RAY, ADRENAL GLANDS
75843
O
VENOGRAPHY, ADRENAL, BILATERAL, SEL
75860
3
VEIN X-RAY, NECK
75861
O
VENOGRAPHY, SINUS OR JUGULAR, CATHE
$214.88 $0.00 $174.45
$86.87
$119.23 $0.00 $145.62 $0.00 $259.86 $0.00 $259.38 $0.00 $262.94 $0.00 $293.18 $0.00 $260.59 $0.00 $294.91 $0.00 $268.37 $0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
75870
3
VEIN X-RAY, SKULL
$266.03
75871
O
VENOGRAPHY, SUPERIOR SAGITTAL SINUS
75872
3
VEIN X-RAY, SKULL
75873
O
VENOGRAPHY, EPIDURAL COMPLETE PROCE
75880
3
VEIN X-RAY, EYE SOCKET
75881
O
VENOGRAPHY, ORBITAL COMPLETE PROCED
75885
3
VEIN X-RAY, LIVER
75886
O
PERCUTANEOUS TRANSHEPATIC PORTOGRAP
75887
3
VEIN X-RAY, LIVER
75888
O
PERCUTANEOUS TRANSHEPATIC PORTOGRAP
75889
3
VEIN X-RAY, LIVER
75890
O
HEPATIC VENOGRAPHY WEDGED OR FREE,
75891
3
VEIN X-RAY, LIVER
75892
O
HEPATIC VENOGRAPHY, WEDGED OR FREE,
75893
3
VENOUS SAMPLING BY CATHETER
75894
3
X-RAYS, TRANSCATH THERAPY
$0.00
75895
O
TRANSCATHETER THERAPY, EMBOLIZATION
$0.00
75896
3
X-RAYS, TRANSCATH THERAPY
$0.00
75897
O
TRANSCATHETER THERAPY, INFUSION (EG
$0.00
75898
3
FOLLOW-UP ANGIOGRAPHY
$0.00
75900
3
INTRAVASCULAR CATH EXCHANGE
$0.00
75901
3
REMOVE CVA DEVICE OBSTRUCT
$166.54
75902
3
REMOVE CVA LUMEN OBSTRUCT
$92.72
75940
3
X-RAY PLACEMENT, VEIN FILTER
$0.00
75941
O
PERCUTANEOUS PLACEMENT OF IVC FILTE
$0.00
75945
3
INTRAVASCULAR US
$0.00
75946
3
INTRAVASCULAR US ADD-ON
$0.00
75950
O
TRANSCATHETER INTRAVASCULAR OCCLUSI
$0.00
75951
O
TRANSCATHETER INTRAVASCULAR OCCLUSI
$0.00
75952
3
ENDOVASC REPAIR ABDOM AORTA
$0.00
75953
3
ABDOM ANEURYSM ENDOVAS RPR
$0.00
75954
3
ILIAC ANEURYSM ENDOVAS RPR
$0.00
75955
O
TRANSCATHETER INTRAVASCULAR OCCLUSI
$0.00
75956
3
ENDOVASCULAR REPAIR OF DESCENDING
$0.00
75957
3
XRAY, ENDOVASC THOR AO REPR
$0.00
$0.00 $290.36 $0.00 $120.33 $0.00 $279.57 $0.00 $281.80 $0.00 $263.81 $0.00 $263.81 $0.00 $232.41
Procedure Code Pricing Action Code Description
Maximum Allowable
75958
3
XRAY, PLACE PROX EXT THOR AO
$0.00
75959
3
XRAY, PLACE DIST EXT THOR AO
$0.00
75960
3
TRANSCATH IV STENT RS&I
$263.01
75961
3
RETRIEVAL, BROKEN CATHETER
$411.90
75962
3
REPAIR ARTERIAL BLOCKAGE
$281.70
75963
O
PERCUTANEOUS TRANSLUMINAL ANGIOPLAS
75964
3
REPAIR ARTERY BLOCKAGE, EACH
75965
O
PERCUTANEOUS TRANSLUMINAL ANGIOPLAS
75966
3
REPAIR ARTERIAL BLOCKAGE
75967
O
PERCUTANEOUS TRANSLUMINAL ANGIOPLAS
75968
3
REPAIR ARTERY BLOCKAGE, EACH
75969
O
PERCUTANEOUS TRANSLUMINAL ANGIOPLAS
$0.00
75970
3
VASCULAR BIOPSY
$0.00
75971
O
TRANSCATHETER BIOPSY COMPLETE PROCE
$0.00
75978
3
REPAIR VENOUS BLOCKAGE
75979
O
PERCUTANEOUS TRANSLUMINAL ANGIOPLAS
$0.00
75980
3
CONTRAST XRAY EXAM BILE DUCT
$0.00
75981
O
PERCUTANEOUS TRANSHEPATIC BILIARY D
$0.00
75982
9
CONTRAST XRAY EXAM BILE DUCT
$0.00
75983
O
PERCUTANEOUS PLACEMENT OF DRAINAGE
$0.00
75984
3
XRAY CONTROL CATHETER CHANGE
75985
O
CHANGE OF PERCUTANEOUS DRAINAGE CAT
75989
3
ABSCESS DRAINAGE UNDER X-RAY
75990
O
RADIOLOGICAL GUIDANCE FOR PERCUTANE
$0.00
75992
3
ATHERECTOMY, X-RAY EXAM
$0.00
75993
3
ATHERECTOMY, X-RAY EXAM
$0.00
75994
3
ATHERECTOMY, X-RAY EXAM
$0.00
75995
3
ATHERECTOMY, X-RAY EXAM
$0.00
75996
3
ATHERECTOMY, X-RAY EXAM
$0.00
75998
O
FLUOROGUIDE FOR VEIN DEVICE
$0.00
76000
3
FLUOROSCOPE EXAMINATION
76001
3
FLUOROSCOPE EXAM, EXTENSIVE
$0.00
76003
O
NEEDLE LOCALIZATION BY X-RAY
$0.00
76005
O
FLUOROGUIDE FOR SPINE INJECT
$0.00
76006
O
X-RAY STRESS VIEW
$0.00
$0.00 $166.23 $0.00 $329.90 $0.00 $166.73
$277.02
$114.12 $0.00 $143.55
$93.02
Procedure Code Pricing Action Code Description
Maximum Allowable
76010
3
X-RAY, NOSE TO RECTUM
$27.85
76012
O
PERCUT VERTEBROPLASTY FLUOR
$0.00
76013
O
PERCUT VERTEBROPLASTY, CT
$0.00
76020
O
X-RAYS FOR BONE AGE
$0.00
76040
O
X-RAYS, BONE EVALUATION
$0.00
76061
O
X-RAYS, BONE SURVEY
$0.00
76062
O
X-RAYS, BONE SURVEY
$0.00
76065
O
X-RAYS, BONE EVALUATION
$0.00
76066
O
JOINT SURVEY, SINGLE VIEW
$0.00
76070
O
CT BONE DENSITY, AXIAL
$0.00
76071
O
CT BONE DENSITY, PERIPHERAL
$0.00
76075
O
DXA BONE DENSITY, AXIAL
$0.00
76076
O
DXA BONE DENSITY/PERIPHERAL
$0.00
76077
O
DXA BONE DENSITY/V-FRACTURE
$0.00
76078
O
RADIOGRAPHIC ABSORPTIOMETRY
$0.00
76080
3
X-RAY EXAM OF FISTULA
76081
O
RADIOLOGIC EXAMINATION, FISTULA OR
$0.00
76082
O
COMPUTER MAMMOGRAM ADD-ON
$0.00
76083
O
COMPUTER MAMMOGRAM ADD-ON
$0.00
76085
O
COMPUTER MAMMOGRAM ADD-ON
$0.00
76086
O
X-RAY OF MAMMARY DUCT
$0.00
76087
O
MAMMARY DUCTOGRAM OR GALACTOGRAM, S
$0.00
76088
O
X-RAY OF MAMMARY DUCTS
$0.00
76089
O
MAMMARY DUCTOGRAM OR GALACTOGRAM, M
$0.00
76090
O
MAMMOGRAM, ONE BREAST
$0.00
76091
O
MAMMOGRAM, BOTH BREASTS
$0.00
76092
O
MAMM0GRAM, SCREENING
$0.00
76093
O
MAGNETIC IMAGE, BREAST
$0.00
76094
O
MAGNETIC IMAGE, BOTH BREASTS
$0.00
76095
O
STEREOTACTIC BREAST BIOPSY
$0.00
76096
O
X-RAY OF NEEDLE WIRE, BREAST
$0.00
76097
O
LOCALIZATION OF BREAST NODULE OR CA
$0.00
76098
3
X-RAY EXAM, BREAST SPECIMEN
$19.75
76100
3
X-RAY EXAM OF BODY SECTION
$104.72
76101
3
COMPLEX BODY SECTION X-RAY
$186.41
$63.36
Procedure Code Pricing Action Code Description
Maximum Allowable
76102
3
COMPLEX BODY SECTION X-RAYS
$231.62
76120
3
CINE/VIDEO X-RAYS
76125
3
CINE/VIDEO X-RAYS ADD-ON
76140
3
X-RAY CONSULTATION
$38.59
76150
3
X-RAY EXAM, DRY PROCESS
$18.59
76350
5
SPECIAL X-RAY CONTRAST STUDY
$0.00
76355
O
CT SCAN FOR LOCALIZATION
$0.00
76360
O
CT SCAN FOR NEEDLE BIOPSY
$0.00
76361
O
COMPUTERIZED TOMOGRAPHY GUIDANCE FO
$0.00
76362
O
CT GUIDE FOR TISSUE ABLATION
$0.00
76365
O
CAT SCAN FOR CYST ASPIRATION
$0.00
76366
O
COMPUTERIZED TOMOGRAPHY GUIDANCE FO
$0.00
76370
O
CT SCAN FOR THERAPY GUIDE
$0.00
76375
O
3D/HOLOGRAPH RECONSTR ADD-ON
$0.00
76376
3
3D RENDER W/O POSTPROCESS
76377
3
3D RENDERING W/POSTPROCESS
$110.78
76380
3
CAT SCAN FOLLOW-UP STUDY
$155.31
76390
3
MR SPECTROSCOPY
$462.91
76393
O
MR GUIDANCE FOR NEEDLE PLACE
$0.00
76394
O
MRI FOR TISSUE ABLATION
$0.00
76400
O
MAGNETIC IMAGE, BONE MARROW
$0.00
76490
O
US FOR TISSUE ABLATION
$0.00
76496
5
FLUOROSCOPIC PROCEDURE
$0.00
76497
5
CT PROCEDURE
$0.00
76498
5
MRI PROCEDURE
$0.00
76499
5
RADIOGRAPHIC PROCEDURE
$0.00
76506
3
ECHO EXAM OF HEAD
76510
3
OPHTH US, B & QUANT A
76511
3
OPHTH US, QUANT A ONLY
$96.25
76512
3
OPHTH US, B W/NON-QUANT A
$90.07
76513
3
ECHO EXAM OF EYE, WATER BATH
$83.40
76514
3
ECHO EXAM OF EYE, THICKNESS
$12.47
76516
3
ECHO EXAM OF EYE
$66.69
76519
3
ECHO EXAM OF EYE
$71.49
76529
3
ECHO EXAM OF EYE
$67.50
$75.39 $0.00
$80.53
$95.64 $147.63
Procedure Code Pricing Action Code Description
Maximum Allowable
76536
3
US EXAM OF HEAD AND NECK
$110.40
76604
3
US EXAM, CHEST
$86.14
76645
3
US EXAM, BREAST(S)
$90.35
76700
3
US EXAM, ABDOM, COMPLETE
$136.43
76705
3
ECHO EXAM OF ABDOMEN
$103.58
76770
3
US EXAM ABDO BACK WALL, COMP
$130.73
76775
3
US EXAM ABDO BACK WALL, LIM
$111.72
76776
3
US EXAM K TRANSPL W/DOPPLER
$145.49
76778
O
US EXAM KIDNEY TRANSPLANT
76800
3
US EXAM, SPINAL CANAL
$122.25
76801
3
OB US < 14 WKS, SINGLE FETUS
$130.53
76802
3
OB US < 14 WKS, ADDÏL FETUS
76805
3
OB US >/= 14 WKS, SNGL FETUS
$145.69
76810
3
OB US >/= 14 WKS, ADDL FETUS
$99.67
76811
3
OB US, DETAILED, SNGL FETUS
$203.47
76812
3
OB US, DETAILED, ADDL FETUS
$147.70
76813
3
OB US NUCHAL MEAS, 1 GEST
$126.95
76814
3
OB US NUCHAL MEAS, ADD-ON
$82.08
76815
3
OB US, LIMITED, FETUS(S)
$90.56
76816
3
OB US, FOLLOW-UP, PER FETUS
$105.00
76817
3
TRANSVAGINAL US, OBSTETRIC
$99.94
76818
3
FETAL BIOPHYS PROFILE W/NST
$120.24
76819
3
FETAL BIOPHYS PROFIL W/O NST
$93.11
76820
3
UMBILICAL ARTERY ECHO
$53.63
76821
3
MIDDLE CEREBRAL ARTERY ECHO
$97.00
76825
3
ECHO EXAM OF FETAL HEART
$207.81
76826
3
ECHO EXAM OF FETAL HEART
$114.76
76827
3
ECHO EXAM OF FETAL HEART
$71.40
76828
3
ECHO EXAM OF FETAL HEART
$52.60
76830
3
TRANSVAGINAL US, NON-OB
$119.83
76831
3
ECHO EXAM, UTERUS
$119.80
76855
O
ECHOGRAPHY, PELVIC AREA (DOPPLER)
76856
3
US EXAM, PELVIC, COMPLETE
76857
3
US EXAM, PELVIC, LIMITED
76870
3
US EXAM, SCROTUM
$0.00
$73.05
$0.00 $120.57 $83.28 $119.52
Procedure Code Pricing Action Code Description
Maximum Allowable
76872
3
US, TRANSRECTAL
$134.99
76873
3
ECHOGRAP TRANS R, PROS STUDY
$176.36
76880
3
US EXAM, EXTREMITY
$125.39
76885
3
US EXAM INFANT HIPS, DYNAMIC
$100.32
76886
3
US EXAM INFANT HIPS, STATIC
76925
O
ECHOGRAPHY, PERIPHERAL VASCULAR SYS
$0.00
76926
O
ECHOGRAPHY, HEAD AND TRUNK, VASCULA
$0.00
76930
3
ECHO GUIDE, CARDIOCENTESIS
76931
O
ULTRASONIC GUIDANCE FOR PERICARDIOC
$0.00
76932
3
ECHO GUIDE FOR HEART BIOPSY
$0.00
76933
O
ULTRASONIC GUIDANCE FOR ENDOMYOCARD
$0.00
76934
O
ECHO GUIDE FOR CHEST TAP
$0.00
76935
O
ULTRASONIC GUIDANCE FOR THORACENTES
$0.00
76936
3
ECHO GUIDE FOR ARTERY REPAIR
76937
3
US GUIDE, VASCULAR ACCESS
76938
O
ECHO EXAM FOR DRAINAGE
$0.00
76939
O
ULTRASONIC GUIDANCE FOR CYST (ANY L
$0.00
76940
3
US GUIDE, TISSUE ABLATION
$0.00
76941
3
ECHO GUIDE FOR TRANSFUSION
$0.00
76942
3
ECHO GUIDE FOR BIOPSY
76943
O
ULTRASONIC GUIDANCE FOR NEEDLE BIOP
$0.00
76945
3
ECHO GUIDE, VILLUS SAMPLING
$0.00
76946
3
ECHO GUIDE FOR AMNIOCENTESIS
76947
O
ULTRASONIC GUIDANCE FOR AMNIOCENTES
$0.00
76948
9
ECHO GUIDE, OVA ASPIRATION
$0.00
76949
O
ULTRASONIC GUIDANCE FOR ASPIRATION
$0.00
76950
3
ECHO GUIDANCE RADIOTHERAPY
$70.44
76960
O
ECHO GUIDANCE RADIOTHERAPY
$0.00
76965
3
ECHO GUIDANCE RADIOTHERAPY
$146.22
76970
3
ULTRASOUND EXAM FOLLOW-UP
$82.39
76975
3
GI ENDOSCOPIC ULTRASOUND
76977
3
US BONE DENSITY MEASURE
76986
O
ULTRASOUND GUIDE INTRAOPER
$0.00
76998
3
US GUIDE, INTRAOP
$0.00
76999
5
ECHO EXAMINATION PROCEDURE
$0.00
$93.69
$98.18
$196.13 $35.65
$186.03
$44.18
$0.00 $13.95
Procedure Code Pricing Action Code Description
Maximum Allowable
77001
3
FLUOROGUIDE FOR VEIN DEVICE
$104.58
77002
3
NEEDLE LOCALIZATION BY XRAY
$70.63
77003
3
FLUOROGUIDE FOR SPINE INJECT
$58.59
77011
3
CT SCAN FOR LOCALIZATION
$684.12
77012
3
CT SCAN FOR NEEDLE BIOPSY
$198.01
77013
3
CT GUIDE FOR TISSUE ABLATION
77014
3
CT SCAN FOR THERAPY GUIDE
$186.01
77021
3
MR GUIDANCE FOR NEEDLE PLACE
$449.00
77022
3
MRI FOR TISSUE ABLATION
77031
3
STEREOTACT GUIDE FOR BRST BX
77032
3
GUIDANCE FOR NEEDLE, BREAST
$59.51
77051
3
COMPUTER DX MAMMOGRAM ADD-ON
$12.24
77052
3
COMP SCREEN MAMMOGRAM ADD-ON
$12.24
77053
3
X-RAY OF MAMMARY DUCT
$76.22
77054
3
X-RAY OF MAMMARY DUCTS
$102.82
77055
3
MAMMOGRAM, ONE BREAST
$84.85
77056
3
MAMMOGRAM, BOTH BREASTS
77057
3
MAMMOGRAM, SCREENING
77058
3
MRI, ONE BREAST
$846.16
77059
3
MRI, BOTH BREASTS
$908.55
77071
3
X-RAY STRESS VIEW
$39.01
77072
3
X-RAYS FOR BONE AGE
$23.40
77073
3
X-RAYS, BONE LENGTH STUDIES
$37.34
77074
3
X-RAYS, BONE SURVEY, LIMITED
$68.65
77075
3
X-RAYS, BONE SURVEY COMPLETE
$99.71
77076
3
X-RAYS, BONE SURVEY, INFANT
$92.74
77077
3
JOINT SURVEY, SINGLE VIEW
$42.20
77078
3
CT BONE DENSITY, AXIAL
$85.16
77079
3
CT BONE DENSITY, PERIPHERAL
$57.73
77080
3
DXA BONE DENSITY, AXIAL
$70.98
77081
3
DXA BONE DENSITY/PERIPHERAL
$30.01
77082
3
DXA BONE DENSITY, VERT FX
$28.96
77083
3
RADIOGRAPHIC ABSORPTIOMETRY
$26.33
77084
3
MAGNETIC IMAGE, BONE MARROW
$432.47
77261
3
RADIATION THERAPY PLANNING
$0.00
$0.00 $191.70
$107.66 $81.39
$70.21
Procedure Code Pricing Action Code Description
Maximum Allowable
77262
3
RADIATION THERAPY PLANNING
$105.39
77263
3
RADIATION THERAPY PLANNING
$156.34
77280
3
SET RADIATION THERAPY FIELD
$185.19
77285
3
SET RADIATION THERAPY FIELD
$319.50
77290
3
SET RADIATION THERAPY FIELD
$496.39
77295
3
SET RADIATION THERAPY FIELD
$680.86
77299
5
RADIATION THERAPY PLANNING
$0.00
77300
3
RADIATION THERAPY DOSE PLAN
77301
3
RADIOTHERAPY DOSE PLAN, IMRT
77305
3
TELETX ISODOSE PLAN SIMPLE
77310
3
TELETX ISODOSE PLAN INTERMED
$101.36
77315
3
TELETX ISODOSE PLAN COMPLEX
$147.90
77321
3
SPECIAL TELETX PORT PLAN
$121.88
77326
3
BRACHYTX ISODOSE CALC SIMP
$142.91
77327
3
BRACHYTX ISODOSE CALC INTERM
$203.55
77328
3
BRACHYTX ISODOSE PLAN COMPL
$278.52
77331
3
SPECIAL RADIATION DOSIMETRY
$62.10
77332
3
RADIATION TREATMENT AID(S)
$77.89
77333
3
RADIATION TREATMENT AID(S)
$68.36
77334
3
RADIATION TREATMENT AID(S)
$158.14
77336
3
RADIATION PHYSICS CONSULT
$62.25
77370
3
RADIATION PHYSICS CONSULT
$118.55
77371
3
SRS, MULTISOURCE
$1,188.49
77372
3
SRS, LINEAR BASED
$827.57
77373
3
SBRT DELIVERY
77380
O
PROTON BEAM DELIVERY
$0.00
77381
O
PROTON BEAM TREATMENT
$0.00
77399
5
EXTERNAL RADIATION DOSIMETRY
$0.00
77400
O
DAILY MEGAVOLTAGE TREATMENT MANAGEM
$0.00
77401
3
RADIATION TREATMENT DELIVERY
$31.84
77402
3
RADIATION TREATMENT DELIVERY
$137.58
77403
3
RADIATION TREATMENT DELIVERY
$120.94
77404
3
RADIATION TREATMENT DELIVERY
$133.14
77405
O
DAILY MEGAVOLTAGE TREATMENT MANAGEM
77406
3
RADIATION TREATMENT DELIVERY
$71.14 $2,176.54 $72.97
$1,532.98
$0.00 $134.25
Procedure Code Pricing Action Code Description
Maximum Allowable
77407
3
RADIATION TREATMENT DELIVERY
$215.83
77408
3
RADIATION TREATMENT DELIVERY
$162.22
77409
3
RADIATION TREATMENT DELIVERY
$178.86
77410
O
DAILY MEGAVOLTAGE TREATMENT MANAGEM
77411
3
RADIATION TREATMENT DELIVERY
$177.75
77412
3
RADIATION TREATMENT DELIVERY
$209.04
77413
3
RADIATION TREATMENT DELIVERY
$210.52
77414
3
RADIATION TREATMENT DELIVERY
$233.82
77415
O
THERAPEUTIC RADIOLOGY TREATMENT POR
77416
3
RADIATION TREATMENT DELIVERY
77417
3
RADIOLOGY PORT FILM(S)
77418
3
RADIATION TX DELIVERY, IMRT
77419
O
WEEKLY RADIATION THERAPY
$0.00
77420
O
WEEKLY RADIATION THERAPY
$0.00
77421
3
STEREOSCOPIC X-RAY GUIDANCE
$114.04
77422
3
NEUTRON BEAM TX, SIMPLE
$196.84
77423
3
NEUTRON BEAM TX, COMPLEX
$226.05
77425
O
WEEKLY RADIATION THERAPY
$0.00
77427
3
RADIATION TX MANAGEMENT, X5
77430
O
WEEKLY RADIATION THERAPY
77431
3
RADIATION THERAPY MANAGEMENT
77432
3
STEREOTACTIC RADIATION TRMT
$395.62
77435
3
SBRT MANAGEMENT
$656.58
77465
O
DAILY KILOVOLTAGE TREATMENT MANAGEM
77470
3
SPECIAL RADIATION TREATMENT
77499
5
RADIATION THERAPY MANAGEMENT
$0.00
77520
5
PROTON TRMT, SIMPLE W/O COMP
$0.00
77522
5
PROTON TRMT, SIMPLE W/COMP
$0.00
77523
5
PROTON TRMT, INTERMEDIATE
$0.00
77525
5
PROTON TREATMENT, COMPLEX
$0.00
77600
9
HYPERTHERMIA TREATMENT
$0.00
77605
9
HYPERTHERMIA TREATMENT
$0.00
77610
9
HYPERTHERMIA TREATMENT
$0.00
77615
9
HYPERTHERMIA TREATMENT
$0.00
77620
3
HYPERTHERMIA TREATMENT
$390.46
$0.00
$0.00 $234.93 $16.12 $528.10
$186.20 $0.00 $95.31
$0.00 $254.51
Procedure Code Pricing Action Code Description
Maximum Allowable
77750
3
INFUSE RADIOACTIVE MATERIALS
$337.26
77761
3
APPLY INTRCAV RADIAT SIMPLE
$351.09
77762
3
APPLY INTRCAV RADIAT INTERM
$478.01
77763
3
APPLY INTRCAV RADIAT COMPL
$675.84
77776
3
APPLY INTERSTIT RADIAT SIMPL
$411.61
77777
3
APPLY INTERSTIT RADIAT INTER
$571.38
77778
3
APPLY INTERSTIT RADIAT COMPL
$817.02
77781
O
REMOTE AFTERLOADING HIGH INTENSITY
$0.00
77782
O
REMOTE AFTERLOADING HIGH INTENSITY
$0.00
77783
O
REMOTE AFTERLOADING HIGH INTENSITY
$0.00
77784
O
REMOTE AFTERLOADING HIGH INTENSITY
$0.00
77785
3
HDR BRACHYTX, 1 CHANNEL
$186.42
77786
3
HDR BRACHYTX, 2-12 CHANNEL
$561.94
77787
3
HDR BRACHYTX OVER 12 CHAN
$834.94
77789
3
APPLY SURFACE RADIATION
$104.40
77790
3
RADIATION HANDLING
77799
5
RADIUM/RADIOISOTOPE THERAPY
78000
3
THYROID, SINGLE UPTAKE
$69.10
78001
3
THYROID, MULTIPLE UPTAKES
$87.74
78003
3
THYROID SUPPRESS/STIMUL
$76.32
78006
3
THYROID IMAGING WITH UPTAKE
$216.32
78007
3
THYROID IMAGE, MULT UPTAKES
$131.51
78010
3
THYROID IMAGING
$150.52
78011
3
THYROID IMAGING WITH FLOW
$161.03
78015
3
THYROID MET IMAGING
$203.26
78016
3
THYROID MET IMAGING/STUDIES
$309.03
78017
O
THYROID MET IMAGING, MULT
$0.00
78018
3
THYROID MET IMAGING, BODY
$311.48
78020
3
THYROID MET UPTAKE
78070
3
PARATHYROID NUCLEAR IMAGING
$171.91
78075
3
ADRENAL NUCLEAR IMAGING
$405.67
78099
5
ENDOCRINE NUCLEAR PROCEDURE
78102
3
BONE MARROW IMAGING, LTD
$159.80
78103
3
BONE MARROW IMAGING, MULT
$214.60
78104
3
BONE MARROW IMAGING, BODY
$246.05
$87.26 $0.00
$90.35
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
78110
3
PLASMA VOLUME, SINGLE
$76.49
78111
3
PLASMA VOLUME, MULTIPLE
$97.60
78120
3
RED CELL MASS, SINGLE
$86.89
78121
3
RED CELL MASS, MULTIPLE
78122
9
BLOOD VOLUME
78130
3
RED CELL SURVIVAL STUDY
$152.31
78135
3
RED CELL SURVIVAL KINETICS
$318.70
78140
3
RED CELL SEQUESTRATION
$147.33
78160
O
PLASMA IRON TURNOVER
$0.00
78162
O
RADIOIRON ABSORPTION EXAM
$0.00
78170
O
RED CELL IRON UTILIZATION
$0.00
78172
O
TOTAL BODY IRON ESTIMATION
$0.00
78185
3
SPLEEN IMAGING
78186
O
SPLEEN IMAGING ONLY WITH VASCULAR F
78190
3
KINETICS, STUDY OF PLATELET SURVIV
$221.42
78191
3
PLATELET SURVIVAL
$197.75
78192
O
WHITE BLOOD CELL LOCALIZATION LIMIT
$0.00
78193
O
WHITE BLOOD CELL LOCALIZATION WHOLE
$0.00
78195
3
LYMPH SYSTEM IMAGING
78199
5
BLOOD/LYMPH NUCLEAR EXAM
78201
3
LIVER IMAGING
$171.26
78202
3
LIVER IMAGING WITH FLOW
$197.68
78205
3
LIVER IMAGING (3D)
$236.12
78206
3
LIVER IMAGE (3D) WITH FLOW
$329.23
78215
3
LIVER AND SPLEEN IMAGING
$182.91
78216
3
LIVER & SPLEEN IMAGE/FLOW
$137.93
78220
3
LIVER FUNCTION STUDY
$143.81
78223
3
HEPATOBILIARY IMAGING
$306.16
78225
O
LIVER-LUNG IMAGING (EG, SUBPHRENIC
78230
3
SALIVARY GLAND IMAGING
$155.73
78231
3
SERIAL SALIVARY IMAGING
$132.56
78232
3
SALIVARY GLAND FUNCTION EXAM
$135.09
78258
3
ESOPHAGEAL MOTILITY STUDY
$216.85
78261
3
GASTRIC MUCOSA IMAGING
$239.53
78262
3
GASTROESOPHAGEAL REFLUX EXAM
$236.22
$105.24 $0.00
$185.74 $0.00
$327.24 $0.00
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
78264
3
GASTRIC EMPTYING STUDY
$271.96
78267
5
BREATH TST ATTAIN/ANAL C-14
$0.00
78268
5
BREATH TEST ANALYSIS, C-14
$0.00
78270
3
VIT B-12 ABSORPTION EXAM
$78.92
78271
3
VIT B-12 ABSRP EXAM, INT FAC
$79.65
78272
3
VIT B-12 ABSORP, COMBINED
$90.28
78276
O
GASTROINTESTINAL ASPIRATE BLOOD LOS
78278
3
ACUTE GI BLOOD LOSS IMAGING
78280
O
GASTROINTESTINAL BLOOD LOSS STUDY (
$0.00
78282
3
GI PROTEIN LOSS EXAM
$0.00
78290
3
MECKELÏS DIVERT EXAM
$281.87
78291
3
LEVEEN/SHUNT PATENCY EXAM
$238.47
78299
5
GI NUCLEAR PROCEDURE
78300
3
BONE IMAGING, LIMITED AREA
$167.46
78305
3
BONE IMAGING, MULTIPLE AREAS
$222.62
78306
3
BONE IMAGING, WHOLE BODY
$246.59
78310
O
BONE IMAGING VASCULAR FLOW ONLY
78315
3
BONE IMAGING, 3 PHASE
$300.61
78320
3
BONE IMAGING (3D)
$252.59
78350
3
BONE MINERAL, SINGLE PHOTON
$33.33
78351
3
BONE MINERAL, DUAL PHOTON
$15.02
78380
O
JOINT IMAGING LIMITED AREA
$0.00
78381
O
JOINT IMAGING MULTIPLE AREAS
$0.00
78399
5
MUSCULOSKELETAL NUCLEAR EXAM
$0.00
78414
3
NON-IMAGING HEART FUNCTION
$0.00
78415
O
CARDIAC BLOOD POOL IMAGING, FUNCTIO
$0.00
78425
O
CARDIAC REGURGITANT INDEX
$0.00
78428
3
CARDIAC SHUNT IMAGING
78435
O
CARDIAC FLOW IMAGING (IE, ANGIOCARD
78445
3
VASCULAR FLOW IMAGING
78455
O
VENOUS THROMBOSIS STUDY
78456
3
ACUTE VENOUS THROMBUS IMAGE
$242.74
78457
3
VENOUS THROMBOSIS IMAGING
$187.24
78458
3
VEN THROMBOSIS IMAGES, BILAT
$206.37
78459
3
HEART MUSCLE IMAGING (PET)
$274.66
$0.00 $296.34
$0.00
$0.00
$194.38 $0.00 $163.34 $0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
78460
3
HEART MUSCLE BLOOD, SINGLE
$187.49
78461
3
HEART MUSCLE BLOOD, MULTIPLE
$210.48
78464
3
HEART IMAGE (3D), SINGLE
$274.66
78465
3
HEART IMAGE (3D), MULTIPLE
$486.74
78466
3
HEART INFARCT IMAGE
$178.83
78467
O
MYOCARDIAL IMAGING, INFARCT AVID, A
78468
3
HEART INFARCT IMAGE (EF)
$225.74
78469
3
HEART INFARCT IMAGE (3D)
$256.58
78470
O
CARDIAC OUTPUT
$0.00
78471
O
CARDIAC BLOOD POOL IMAGING, GATED E
$0.00
78472
3
GATED HEART, PLANAR, SINGLE
$260.93
78473
3
GATED HEART, MULTIPLE
$356.48
78474
O
CARDIAC BLOOD POOL IMAGING, GATED E
$0.00
78475
O
CARDIAC BLOOD POOL IMAGING, GATED E
$0.00
78476
O
CARDIAC BLOOD POOL IMAGING, GATED E
$0.00
78477
O
CARDIAC BLOOD POOL IMAGING, GATED E
$0.00
78478
3
HEART WALL MOTION ADD-ON
78479
O
CARDIAC BLOOD POOL IMAGING, GATED E
78480
3
HEART FUNCTION ADD-ON
78481
3
HEART FIRST PASS, SINGLE
$228.78
78483
3
HEART FIRST PASS, MULTIPLE
$323.09
78484
O
CARDIAC BLOOD POOL IMAGING, FIRST P
$0.00
78485
O
CARDIAC BLOOD POOL IMAGING, FIRST P
$0.00
78486
O
CARDIAC BLOOD POOL IMAGING, FIRST P
$0.00
78487
O
CARDIAC BLOOD POOL IMAGING, FIRST P
$0.00
78489
O
CARDIAC BLOOD POOL IMAGING, FIRST P
$0.00
78491
3
HEART IMAGE (PET), SINGLE
$323.62
78492
3
HEART IMAGE (PET), MULTIPLE
$323.62
78494
3
HEART IMAGE, SPECT
$284.57
78496
3
HEART FIRST PASS ADD-ON
$116.86
78499
5
CARDIOVASCULAR NUCLEAR EXAM
78580
3
LUNG PERFUSION IMAGING
78581
O
PULMONARY PERFUSION IMAGING GASEOUS
$0.00
78582
O
PULMONARY PERFUSION IMAGING GASEOUS
$0.00
78584
3
LUNG V/Q IMAGE SINGLE BREATH
$0.00
$58.82 $0.00 $49.09
$0.00 $206.72
$156.50
Procedure Code Pricing Action Code Description
Maximum Allowable
78585
3
LUNG V/Q IMAGING
$341.26
78586
3
AEROSOL LUNG IMAGE, SINGLE
$157.88
78587
3
AEROSOL LUNG IMAGE, MULTIPLE
$198.80
78588
3
PERFUSION LUNG IMAGE
$316.57
78591
3
VENT IMAGE, 1 BREATH, 1 PROJ
$160.09
78593
3
VENT IMAGE, 1 PROJ, GAS
$188.67
78594
3
VENT IMAGE, MULT PROJ, GAS
$220.62
78596
3
LUNG DIFFERENTIAL FUNCTION
$366.37
78599
5
RESPIRATORY NUCLEAR EXAM
$0.00
78600
3
BRAIN IMAGE < 4 VIEWS
$171.88
78601
3
BRAIN IMAGE W/FLOW < 4 VIEWS
$204.55
78605
3
BRAIN IMAGE 4+ VIEWS
$191.21
78606
3
BRAIN IMAGE W/FLOW 4 + VIEWS
$299.99
78607
3
BRAIN IMAGING (3D)
$358.93
78608
3
BRAIN IMAGING (PET)
$323.62
78609
3
BRAIN IMAGING (PET)
$323.62
78610
3
BRAIN FLOW IMAGING ONLY
$173.81
78615
O
CEREBRAL VASCULAR FLOW IMAGE
78630
3
CEREBROSPINAL FLUID SCAN
$318.38
78635
3
CSF VENTRICULOGRAPHY
$289.97
78645
3
CSF SHUNT EVALUATION
$218.43
78647
3
CEREBROSPINAL FLUID SCAN
$335.58
78650
3
CSF LEAKAGE IMAGING
$310.73
78652
O
CSF LEAKAGE DETECTION AND LOCALIZAT
$0.00
78655
O
RADIOPHARMACEUTICAL IDENTIFICATION
$0.00
78660
3
NUCLEAR EXAM OF TEAR FLOW
78699
5
NERVOUS SYSTEM NUCLEAR EXAM
78700
3
KIDNEY IMAGING, MORPHOL
$170.50
78701
3
KIDNEY IMAGING WITH FLOW
$204.20
78704
O
IMAGING RENOGRAM
78707
3
K FLOW/FUNCT IMAGE W/O DRUG
$237.09
78708
3
K FLOW/FUNCT IMAGE W/DRUG
$192.29
78709
3
K FLOW/FUNCT IMAGE, MULTIPLE
$349.41
78710
3
KIDNEY IMAGING (3D)
$234.34
78715
O
RENAL VASCULAR FLOW EXAM
$0.00
$161.67 $0.00
$0.00
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
78725
3
KIDNEY FUNCTION STUDY
$98.77
78726
O
KIDNEY FUNCTION STUDY INCLUDING PHA
$0.00
78727
O
KIDNEY TRANSPLANT EVALUATION
$0.00
78730
3
URINARY BLADDER RETENTION
78740
3
URETERAL REFLUX STUDY
78760
O
TESTICULAR IMAGING
78761
3
TESTICULAR IMAGING W/FLOW
78799
5
GENITOURINARY NUCLEAR EXAM
78800
3
TUMOR IMAGING, LIMITED AREA
$181.55
78801
3
TUMOR IMAGING, MULT AREAS
$243.22
78802
3
TUMOR IMAGING, WHOLE BODY
$318.75
78803
3
TUMOR IMAGING (3D)
$350.96
78804
3
TUMOR IMAGING, WHOLE BODY
$562.87
78805
3
ABSCESS IMAGING, LTD AREA
$181.96
78806
3
ABSCESS IMAGING, WHOLE BODY
$333.63
78807
3
NUCLEAR LOCALIZATION/ABSCESS
$351.46
78808
3
IV INJ RA DRUG DX STUDY
78810
O
TUMOR IMAGING (PET)
$0.00
78811
3
PET IMAGE, LTD AREA
$0.00
78812
3
PET IMAGE, SKULL-THIGH
$0.00
78813
3
PET IMAGE, FULL BODY
$0.00
78814
3
PET IMAGE W/CT, LMTD
$0.00
78815
3
PET IMAGE W/CT, SKULL-THIGH
$0.00
78816
3
PET IMAGE W/CT, FULL BODY
$0.00
78890
O
NUCLEAR MEDICINE DATA PROC
$0.00
78891
O
NUCLEAR MED DATA PROC
$0.00
78990
O
PROVIDE DIAG RADIONUCLIDE(S)
$0.00
78999
5
NUCLEAR DIAGNOSTIC EXAM
$0.00
79000
O
INIT HYPERTHYROID THERAPY
$0.00
79001
O
REPEAT HYPERTHYROID THERAPY
$0.00
79005
3
NUCLEAR RX, ORAL ADMIN
79020
O
THYROID ABLATION
$0.00
79030
O
THYROID ABLATION, CARCINOMA
$0.00
79035
O
THYROID METASTATIC THERAPY
$0.00
79100
O
HEMATOPOETIC NUCLEAR THERAPY
$0.00
$76.16 $202.90 $0.00 $203.19 $0.00
$44.73
$152.41
Procedure Code Pricing Action Code Description
Maximum Allowable
79101
3
NUCLEAR RX, IV ADMIN
$171.80
79200
3
NUCLEAR RX, INTRACAV ADMIN
$174.22
79300
3
NUCLR RX, INTERSTIT COLLOID
$0.00
79400
O
NONHEMATO NUCLEAR THERAPY
$0.00
79403
3
HEMATOPOIETIC NUCLEAR TX
79420
O
INTRAVASCULAR NUCLEAR THER
79440
3
NUCLEAR RX, INTRA-ARTICULAR
79445
3
NUCLEAR RX, INTRA-ARTERIAL
$0.00
79900
O
PROVIDE THER RADIOPHARM(S)
$0.00
79999
5
NUCLEAR MEDICINE THERAPY
$0.00
80002
O
AUTOMATED MULTICHANNEL TEST 1 OR 2
$0.00
80003
O
AUTOMATED MULTICHANNEL TEST 3 CLINI
$0.00
80004
O
AUTOMATED MULTICHANNEL TEST 4 CLINI
$0.00
80005
O
AUTOMATED MULTICHANNEL TEST 5 CLINI
$0.00
80006
O
AUTOMATED MULTICHANNEL TEST 6 CLINI
$0.00
80007
O
AUTOMATED MULTICHANNEL TEST 7 CLINI
$0.00
80008
O
AUTOMATED MULTICHANNEL TEST 8 CLINI
$0.00
80009
O
AUTOMATED MULTICHANNEL TEST 9 CLINI
$0.00
80010
O
AUTOMATED MULTICHANNEL TEST 10 CLIN
$0.00
80011
O
AUTOMATED MULTICHANNEL TEST 11 CLIN
$0.00
80012
O
AUTOMATED MULTICHANNEL TEST 12 CLIN
$0.00
80016
O
AUTOMATED MULTICHANNEL TEST 13-16 C
$0.00
80018
O
AUTOMATED MULTICHANNEL TEST 17-18 C
$0.00
80019
O
AUTOMATED MULTICHANNEL TEST; 19 CLI
$0.00
80031
O
THERAPEUTIC QUANTITATIVE DRUG MONIT
$0.00
80032
O
THERAPEUTIC QUANTITATIVE DRUG MONIT
$0.00
80033
O
THERAPEUTIC QUANTITATIVE DRUG MONIT
$0.00
80034
O
THERAPEUTIC QUANTITATIVE DRUG MONIT
$0.00
80040
O
SERUM RADIOIMMUNOASSAY FOR CIRCULAT
$0.00
80042
O
SERUM ANTIMICROBIAL LEVEL, BIOASSAY
$0.00
80047
3
METABOLIC PANEL IONIZED CA
$12.11
80048
3
METABOLIC PANEL TOTAL CA
$12.11
80049
9
METABOLIC PANEL, BASIC
$0.00
80050
3
GENERAL HEALTH PANEL
$16.32
80051
3
ELECTROLYTE PANEL
$10.04
$218.51 $0.00 $160.68
Procedure Code Pricing Action Code Description
Maximum Allowable
80052
9
PRE-MARITAL PROFILE
$0.00
80053
3
COMPREHEN METABOLIC PANEL
$15.13
80054
9
COMPREHEN METABOLIC PANEL
$0.00
80055
3
OBSTETRIC PANEL
80056
9
AMENORRHEA PROFILE
$0.00
80057
9
MALE INFERTILITY AND/OR GYNECOMASTI
$0.00
80058
O
HEPATIC FUNCTION PANEL
$0.00
80059
O
HEPATITIS PANEL
$0.00
80060
O
HYPERTENSION PANEL
$0.00
80061
3
LIPID PANEL
80062
O
CARDIAC EVALUATION (INCLUDING CORON
$0.00
80063
O
CARDIAC INJURY PANEL
$0.00
80064
O
CARDIAC INJURY PANEL WITH CREATINE
$0.00
80065
O
METABOLIC PANEL
$0.00
80066
O
MALABSORPTION PANEL
$0.00
80067
O
PULMONARY (LUNG FUNCTION) PANEL
$0.00
80068
O
LUNG MATURITY PROFILE
$0.00
80069
3
RENAL FUNCTION PANEL
$12.43
80070
O
THYROID PANEL
$0.00
80071
O
THYROID PANEL WITH THYROTROPIN RELE
$0.00
80072
O
ARTHRITIS PANEL
$0.00
80073
O
RENAL PANEL
$0.00
80074
3
ACUTE HEPATITIS PANEL
80075
O
PARATHYROID PANEL
80076
3
HEPATIC FUNCTION PANEL
80080
O
PROSTATIC PANEL
$0.00
80082
O
PANCREATIC PANEL
$0.00
80084
O
PITUITARY PANEL
$0.00
80085
O
MICROCYTIC ANEMIA PANEL
$0.00
80086
O
MACROCYTIC ANEMIA PANEL
$0.00
80088
O
TRANSITION PANEL (FOR MANAGEMENT OF
$0.00
80089
O
MUSCLE PANEL
$0.00
80090
O
TORCH ANTIBODY PANEL
$0.00
80091
O
THYROID PANEL
$0.00
80092
O
THYROID PANEL W/TSH
$0.00
$23.08
$19.18
$67.88 $0.00 $11.69
Procedure Code Pricing Action Code Description
Maximum Allowable
80099
O
UNLISTED PANEL
$0.00
80100
3
DRUG SCREEN, QUALITATE/MULTI
$20.81
80101
3
DRUG SCREEN, SINGLE
$19.71
80102
3
DRUG CONFIRMATION
$18.95
80103
5
DRUG ANALYSIS, TISSUE PREP
80150
3
ASSAY OF AMIKACIN
$21.57
80152
3
ASSAY OF AMITRIPTYLINE
$25.62
80154
3
ASSAY OF BENZODIAZEPINES
$22.97
80156
3
ASSAY, CARBAMAZEPINE, TOTAL
$20.83
80157
3
ASSAY, CARBAMAZEPINE, FREE
$18.97
80158
3
ASSAY OF CYCLOSPORINE
$25.83
80160
3
ASSAY OF DESIPRAMINE
$24.63
80162
3
ASSAY OF DIGOXIN
$19.00
80164
3
ASSAY, DIPROPYLACETIC ACID
$19.38
80166
3
ASSAY OF DOXEPIN
$22.19
80168
3
ASSAY OF ETHOSUXIMIDE
$21.56
80170
3
ASSAY OF GENTAMICIN
$23.45
80172
3
ASSAY OF GOLD
$23.30
80173
3
ASSAY OF HALOPERIDOL
$20.83
80174
3
ASSAY OF IMIPRAMINE
$24.63
80176
3
ASSAY OF LIDOCAINE
$21.02
80178
3
ASSAY OF LITHIUM
80182
3
ASSAY OF NORTRIPTYLINE
$19.38
80184
3
ASSAY OF PHENOBARBITAL
$16.39
80185
3
ASSAY OF PHENYTOIN, TOTAL
$18.97
80186
3
ASSAY OF PHENYTOIN, FREE
$19.70
80188
3
ASSAY OF PRIMIDONE
$23.75
80190
3
ASSAY OF PROCAINAMIDE
$23.97
80192
3
ASSAY OF PROCAINAMIDE
$23.97
80194
3
ASSAY OF QUINIDINE
$20.88
80195
3
ASSAY OF SIROLIMUS
$19.64
80196
3
ASSAY OF SALICYLATE
$10.15
80197
3
ASSAY OF TACROLIMUS
$19.64
80198
3
ASSAY OF THEOPHYLLINE
$20.25
80200
3
ASSAY OF TOBRAMYCIN
$23.06
$0.00
$9.46
Procedure Code Pricing Action Code Description
Maximum Allowable
80201
3
ASSAY OF TOPIRAMATE
$17.05
80202
3
ASSAY OF VANCOMYCIN
$19.38
80299
3
QUANTITATIVE ASSAY, DRUG
$19.59
80400
3
ACTH STIMULATION PANEL
$46.67
80402
3
ACTH STIMULATION PANEL
$124.40
80406
3
ACTH STIMULATION PANEL
$111.97
80408
3
ALDOSTERONE SUPPRESSION EVAL
$179.58
80410
3
CALCITONIN STIMUL PANEL
80412
3
CRH STIMULATION PANEL
80414
3
TESTOSTERONE RESPONSE
$73.89
80415
3
ESTRADIOL RESPONSE PANEL
$79.97
80416
3
RENIN STIMULATION PANEL
$188.87
80417
3
RENIN STIMULATION PANEL
$62.96
80418
3
PITUITARY EVALUATION PANEL
$829.32
80420
3
DEXAMETHASONE PANEL
$102.74
80422
3
GLUCAGON TOLERANCE PANEL
$65.91
80424
3
GLUCAGON TOLERANCE PANEL
$72.27
80426
3
GONADOTROPIN HORMONE PANEL
80428
3
GROWTH HORMONE PANEL
$95.41
80430
3
GROWTH HORMONE PANEL
$112.26
80432
3
INSULIN SUPPRESSION PANEL
$193.30
80434
3
INSULIN TOLERANCE PANEL
$144.75
80435
3
INSULIN TOLERANCE PANEL
$147.34
80436
3
METYRAPONE PANEL
$130.44
80438
3
TRH STIMULATION PANEL
$72.12
80439
3
TRH STIMULATION PANEL
$96.16
80440
3
TRH STIMULATION PANEL
$83.20
80500
3
LAB PATHOLOGY CONSULTATION
$22.88
80502
3
LAB PATHOLOGY CONSULTATION
$76.36
81000
3
URINALYSIS, NONAUTO W/SCOPE
$4.52
81001
3
URINALYSIS, AUTO W/SCOPE
$4.52
81002
3
URINALYSIS NONAUTO W/O SCOPE
$3.67
81003
3
URINALYSIS, AUTO, W/O SCOPE
$3.21
81004
O
URINALYSIS COMPONENTS, SINGLE, NOT
$0.00
81005
3
URINALYSIS
$3.10
$64.30 $471.63
$212.39
Procedure Code Pricing Action Code Description
Maximum Allowable
81007
3
URINE SCREEN FOR BACTERIA
$3.68
81010
O
URINALYSIS CONCENTRATION AND DILUTI
$0.00
81011
O
URINALYSIS WATER DEPRIVATION TEST
$0.00
81012
O
URINALYSIS WATER DEPRIVATION TEST W
$0.00
81015
3
MICROSCOPIC EXAM OF URINE
$4.34
81020
3
URINALYSIS, GLASS TEST
$4.40
81025
3
URINE PREGNANCY TEST
$9.06
81030
O
QUANTITATIVE SEDIMENT ANALYSIS AND
$0.00
81050
3
URINALYSIS, VOLUME MEASURE
$4.12
81099
5
URINALYSIS TEST PROCEDURE
$0.00
82000
3
ASSAY OF BLOOD ACETALDEHYDE
$17.73
82003
3
ASSAY OF ACETAMINOPHEN
$28.96
82005
O
ACETOACETIC ACID
$0.00
82009
3
TEST FOR ACETONE/KETONES
$6.46
82010
3
ACETONE ASSAY
82011
O
ACETYLSALICYLIC ACID QUANTITATIVE
$0.00
82012
O
ACETYLSALICYLIC ACID QUALITATIVE
$0.00
82013
3
ACETYLCHOLINESTERASE ASSAY
82015
O
ACIDITY, TITRATABLE, URINE
82016
3
ACYLCARNITINES, QUAL
$19.84
82017
3
ACYLCARNITINES, QUANT
$24.14
82024
3
ASSAY OF ACTH
$55.27
82030
3
ASSAY OF ADP & AMP
$36.92
82035
O
ADENOSINE 5'-TRIPHOSPHATE, BLOOD
$0.00
82040
3
ASSAY OF SERUM ALBUMIN
$7.09
82042
3
ASSAY OF URINE ALBUMIN
$2.52
82043
3
MICROALBUMIN, QUANTITATIVE
$8.28
82044
3
MICROALBUMIN, SEMIQUANT
$3.64
82045
3
ALBUMIN, ISCHEMIA MODIFIED
$48.57
82055
3
ASSAY OF ETHANOL
$15.46
82060
O
ALCOHOL (ETHANOL), BLOOD BY GAS-LIQ
$0.00
82065
O
ALCOHOL (ETHANOL), URINE CHEMICAL
$0.00
82070
O
ALCOHOL (ETHANOL), URINE BY GAS-LIQ
$0.00
82072
O
ALCOHOL (ETHANOL) GELATION
$0.00
82075
3
ASSAY OF BREATH ETHANOL
$11.69
$12.37 $0.00
$17.25
Procedure Code Pricing Action Code Description
Maximum Allowable
82076
O
ALCOHOL ISOPROPYL
$0.00
82078
O
ALCOHOL METHYL
$0.00
82085
3
ASSAY OF ALDOLASE
82086
O
ALDOLASE, BLOOD COLORIMETRIC
$0.00
82087
O
ALDOSTERONE DOUBLE ISOTOPE TECHNIQU
$0.00
82088
3
ASSAY OF ALDOSTERONE
$58.31
82089
O
ALDOSTERONE RIA, URINE
$0.00
82091
O
ALDOSTERONE SALINE INFUSION TEST
$0.00
82095
O
ALKALOIDS, TISSUE SCREENING
$0.00
82096
O
ALKALOIDS, TISSUE QUANTITATIVE
$0.00
82100
O
ALKALOIDS, URINE SCREENING
$0.00
82101
3
ASSAY OF URINE ALKALOIDS
$42.95
82103
3
ALPHA-1-ANTITRYPSIN, TOTAL
$19.22
82104
3
ALPHA-1-ANTITRYPSIN, PHENO
$20.69
82105
3
ALPHA-FETOPROTEIN, SERUM
$24.00
82106
3
ALPHA-FETOPROTEIN, AMNIOTIC
$24.00
82107
3
ALPHA-FETOPROTEIN L3
$90.65
82108
3
ASSAY OF ALUMINUM
$36.46
82112
O
AMIKACIN
$0.00
82120
3
AMINES, VAGINAL FLUID QUAL
$5.38
82126
O
AMINO ACID NITROGEN, ALPHA
$0.00
82127
3
AMINO ACID, SINGLE QUAL
$19.84
82128
3
AMINO ACIDS, MULT QUAL
$19.84
82130
O
AMINO ACIDS ANALYSIS
82131
3
AMINO ACIDS, SINGLE QUANT
82134
O
AMINOHIPPURATE, PARA (PAH)
$0.00
82135
3
ASSAY, AMINOLEVULINIC ACID
$23.56
82136
3
AMINO ACIDS, QUANT, 2-5
$24.14
82137
O
AMINOPHYLLINE
$0.00
82138
O
AMITRIPTYLINE
$0.00
82139
3
AMINO ACIDS, QUAN, 6 OR MORE
$24.14
82140
3
ASSAY OF AMMONIA
$20.85
82141
O
AMMONIA URINE
$0.00
82142
O
AMMONIUM CHLORIDE LOADING TEST
$0.00
82143
3
AMNIOTIC FLUID SCAN
$9.83
$13.89
$0.00 $24.14
Procedure Code Pricing Action Code Description
Maximum Allowable
82145
3
ASSAY OF AMPHETAMINES
$22.25
82150
3
ASSAY OF AMYLASE
82154
3
ANDROSTANEDIOL GLUCURONIDE
82156
O
AMYLASE, URINE (DIASTASE)
82157
3
ASSAY OF ANDROSTENEDIONE
82159
O
ANDROSTERONE
82160
3
ASSAY OF ANDROSTERONE
$35.78
82163
3
ASSAY OF ANGIOTENSIN II
$29.37
82164
3
ANGIOTENSIN I ENZYME TEST
$20.88
82165
O
ANILINE
$0.00
82168
O
ANTIHISTAMINES
$0.00
82170
O
ANTIMONY, URINE
$0.00
82172
3
ASSAY OF APOLIPOPROTEIN
$22.17
82173
O
ARGININE TOLERANCE TEST
$0.00
82175
3
ASSAY OF ARSENIC
$27.15
82180
3
ASSAY OF ASCORBIC ACID
$14.14
82190
3
ATOMIC ABSORPTION
$21.33
82205
3
ASSAY OF BARBITURATES
$16.39
82210
O
BARBITURATES QUANTITATIVE AND IDENT
$0.00
82225
O
BARIUM
$0.00
82230
O
BERYLLIUM, URINE
$0.00
82231
O
BETA-2 MICROGLOBULIN, RIA URINE
$0.00
82232
3
ASSAY OF BETA-2 PROTEIN
82235
O
BICARBONATE EXCRETION, URINE
$0.00
82236
O
BICARBONATE LOADING TEST
$0.00
82239
3
BILE ACIDS, TOTAL
$24.51
82240
3
BILE ACIDS, CHOLYLGLYCINE
$38.03
82245
O
BILE PIGMENTS, URINE
$0.00
82247
3
BILIRUBIN, TOTAL
$7.18
82248
3
BILIRUBIN, DIRECT
$7.18
82250
O
ASSAY BILIRUBIN
$0.00
82251
O
ASSAY OF BILIRUBIN
$0.00
82252
3
FECAL BILIRUBIN TEST
$6.51
82260
O
BILIRUBIN URINE, QUANTITATIVE
$0.00
82261
3
ASSAY OF BIOTINIDASE
$9.27 $41.26 $0.00 $41.89 $0.00
$23.15
$24.14
Procedure Code Pricing Action Code Description
Maximum Allowable
82265
O
BILIRUBIN AMNIOTIC FLUID, QUANTITAT
$0.00
82268
O
BISMUTH
$0.00
82270
3
OCCULT BLOOD, FECES
$4.66
82271
3
OCCULT BLOOD, OTHER SOURCES
$4.66
82272
3
OCCULT BLD FECES, 1-3 TESTS
$4.66
82273
O
TEST FOR BLOOD, OTHER SOURCE
$0.00
82274
3
ASSAY TEST FOR BLOOD, FECAL
82280
O
BORIC ACID BLOOD
$0.00
82285
O
BORIC ACID URINE
$0.00
82286
3
ASSAY OF BRADYKININ
$9.86
82290
O
BROMIDES BLOOD
$0.00
82291
O
BROMIDES URINE
$0.00
82300
3
ASSAY OF CADMIUM
82305
O
CAFFEINE
82306
3
ASSAY OF VITAMIN D
$42.36
82307
3
ASSAY OF VITAMIN D
$46.11
82308
3
ASSAY OF CALCITONIN
$21.43
82310
3
ASSAY OF CALCIUM
$7.38
82315
O
CALCIUM, BLOOD FLUOROMETRIC
$0.00
82320
O
CALCIUM, BLOOD EMISSION FLAME PHOTO
$0.00
82325
O
CALCIUM, BLOOD ATOMIC ABSORPTION FL
$0.00
82330
3
ASSAY OF CALCIUM
$9.07
82331
3
CALCIUM INFUSION TEST
$7.41
82335
O
CALCIUM, URINE QUALITATIVE (SULKOWI
$0.00
82340
3
ASSAY OF CALCIUM IN URINE
$8.63
82355
3
CALCULUS ANALYSIS, QUAL
$16.55
82360
3
CALCULUS ASSAY, QUANT
$18.42
82365
3
CALCULUS SPECTROSCOPY
$18.45
82370
3
X-RAY ASSAY, CALCULUS
$17.92
82372
O
CARBAMAZEPINE, SERUM
$0.00
82373
3
ASSAY, C-D TRANSFER MEASURE
$25.84
82374
3
ASSAY, BLOOD CARBON DIOXIDE
$7.00
82375
3
CARBOXYHEMOGLOBIN; QUANTITATIVE
82376
3
ASSAY, CARBOXYHB, QUAL
82378
3
CARCINOEMBRYONIC ANTIGEN
$22.76
$33.11 $0.00
$17.64 $7.86 $27.15
Procedure Code Pricing Action Code Description
Maximum Allowable
82379
3
ASSAY OF CARNITINE
$24.14
82380
3
ASSAY OF CAROTENE
$13.20
82382
3
ASSAY, URINE CATECHOLAMINES
$24.60
82383
3
ASSAY, BLOOD CATECHOLAMINES
$35.86
82384
3
ASSAY, THREE CATECHOLAMINES
$36.13
82387
3
ASSAY OF CATHEPSIN-D
$29.77
82390
3
ASSAY OF CERULOPLASMIN
$15.37
82397
3
CHEMILUMINESCENT ASSAY
$20.22
82400
O
CHLORAL HYDRATE BLOOD
$0.00
82405
O
CHLORAL HYDRATE URINE
$0.00
82415
3
ASSAY OF CHLORAMPHENICOL
$18.13
82418
O
CHLORAZEPATE DIPOTASSIUM
$0.00
82420
O
CHLORDIAZEPOXIDE BLOOD
$0.00
82425
O
CHLORDIAZEPOXIDE URINE
$0.00
82435
3
ASSAY OF BLOOD CHLORIDE
$6.57
82436
3
ASSAY OF URINE CHLORIDE
$7.19
82437
O
CHLORIDES SWEAT (WITHOUT IONTOPHORE
$0.00
82438
3
ASSAY, OTHER FLUID CHLORIDES
$7.00
82441
3
TEST FOR CHLOROHYDROCARBONS
$8.58
82443
O
CHLOROTHIAZIDE-HYDROCHLOROTHIAZIDE
$0.00
82465
3
ASSAY, BLD/SERUM CHOLESTEROL
$6.23
82470
O
CHOLESTEROL, SERUM TOTAL AND ESTERS
$0.00
82480
3
ASSAY, SERUM CHOLINESTERASE
$11.28
82482
3
ASSAY, RBC CHOLINESTERASE
$11.00
82484
O
CHOLINESTERASE SERUM AND RBC
82485
3
ASSAY, CHONDROITIN SULFATE
$29.55
82486
3
GAS/LIQUID CHROMATOGRAPHY
$25.84
82487
3
PAPER CHROMATOGRAPHY
$22.84
82488
3
PAPER CHROMATOGRAPHY
$30.58
82489
3
THIN LAYER CHROMATOGRAPHY
$26.46
82491
3
CHROMOTOGRAPHY, QUANT, SING
$25.84
82492
3
CHROMOTOGRAPHY, QUANT, MULT
$25.84
82495
3
ASSAY OF CHROMIUM
$29.02
82507
3
ASSAY OF CITRATE
$39.79
82512
O
CLONAZEPAM
$0.00
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
82520
3
ASSAY OF COCAINE
$19.96
82523
3
COLLAGEN CROSSLINKS
$15.53
82525
3
ASSAY OF COPPER
$17.76
82526
O
COPPER URINE
82528
3
ASSAY OF CORTICOSTERONE
82529
O
CORTISOL FLUOROMETRIC, PLASMA
82530
3
CORTISOL, FREE
82531
O
CORTISOL CPB, PLASMA
$0.00
82532
O
CORTISOL CPB, URINE
$0.00
82533
3
TOTAL CORTISOL
82534
O
CORTISOL RIA, URINE
$0.00
82536
O
CORTISOL AFTER ADRENOCORTICOTROPIC
$0.00
82537
O
CORTISOL 48 HOURS AFTER CONTINUOUS
$0.00
82538
O
CORTISOL AFTER METYRAPONE TARTRATE
$0.00
82539
O
CORTISOL DEXAMETHASONE SUPPRESSION
$0.00
82540
3
ASSAY OF CREATINE
$6.62
82541
3
COLUMN CHROMOTOGRAPHY, QUAL
$25.84
82542
3
COLUMN CHROMOTOGRAPHY, QUANT
$25.84
82543
3
COLUMN CHROMOTOGRAPH/ISOTOPE
$25.84
82544
3
COLUMN CHROMOTOGRAPH/ISOTOPE
$25.84
82545
O
CREATINE URINE
$0.00
82546
O
CREATINE AND CREATININE
$0.00
82550
3
ASSAY OF CK (CPK)
$9.32
82552
3
ASSAY OF CPK IN BLOOD
$19.17
82553
3
CREATINE, MB FRACTION
$10.86
82554
3
CREATINE, ISOFORMS
$16.98
82555
O
CREATINE PHOSPHOKINASE (CPK), BLOOD
$0.00
82565
3
ASSAY OF CREATININE
$6.57
82570
3
ASSAY OF URINE CREATININE
$7.41
82575
3
CREATININE CLEARANCE TEST
$13.51
82585
3
ASSAY OF CRYOFIBRINOGEN
$12.27
82595
3
ASSAY OF CRYOGLOBULIN
82600
3
ASSAY OF CYANIDE
82601
O
CYANIDE TISSUE
$0.00
82606
O
CYANOCOBALAMIN (VITAMIN B-12) BIOAS
$0.00
$0.00 $32.20 $0.00 $23.92
$23.33
$9.26 $27.76
Procedure Code Pricing Action Code Description
Maximum Allowable
82607
3
VITAMIN B-12
$21.57
82608
3
B-12 BINDING CAPACITY
$20.49
82610
3
CYSTATIN C
$19.45
82614
O
CYSTINE, BLOOD, QUALITATIVE
82615
3
TEST FOR URINE CYSTINES
82620
O
CYSTINE AND HOMOCYSTINE, URINE QUAN
$0.00
82624
O
CYSTINE AMINOPEPTIDASE
$0.00
82626
3
DEHYDROEPIANDROSTERONE
$36.16
82627
3
DEHYDROEPIANDROSTERONE
$31.81
82628
O
DESIPRAMINE
82633
3
DESOXYCORTICOSTERONE
$44.33
82634
3
DEOXYCORTISOL
$41.89
82635
O
DIACETIC ACID
$0.00
82636
O
DIAZEPAM
$0.00
82638
3
ASSAY OF DIBUCAINE NUMBER
82639
O
DICUMAROL
$0.00
82640
O
DIGITOXIN (DIGITALIS) BLOOD, RIA
$0.00
82641
O
DIGITOXIN (DIGITALIS) URINE
$0.00
82643
O
DIGOXIN, RIA
$0.00
82646
3
ASSAY OF DIHYDROCODEINONE
$29.55
82649
3
ASSAY OF DIHYDROMORPHINONE
$36.78
82651
3
ASSAY OF DIHYDROTESTOSTERONE
$36.94
82652
3
ASSAY OF DIHYDROXYVITAMIN D
$55.08
82654
3
ASSAY OF DIMETHADIONE
$19.82
82656
3
ELASTASE, PANCREATIC (EL-1), FECAL
$15.76
82657
3
ENZYME CELL ACTIVITY
$25.84
82658
3
ENZYME CELL ACTIVITY, RA
$25.84
82660
O
DRUG SCREEN (AMPHETAMINES, BARBITUR
82664
3
ELECTROPHORETIC TEST
$49.16
82666
3
ASSAY OF EPIANDROSTERONE
$30.74
82668
3
ASSAY OF ERYTHROPOIETIN
$24.89
82670
3
ASSAY OF ESTRADIOL
$39.98
82671
3
ASSAY OF ESTROGENS
$46.21
82672
3
ASSAY OF ESTROGEN
$14.26
82673
O
ESTRIOL FLUOROMETRIC
$0.00 $11.68
$0.00
$16.65
$0.00
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
82674
O
ESTRIOL GLC
$0.00
82676
O
ESTRIOL CHEMICAL
$0.00
82677
3
ASSAY OF ESTRIOL
$34.60
82678
O
ESTRONE CHEMICAL
$0.00
82679
3
ASSAY OF ESTRONE
$33.58
82690
3
ASSAY OF ETHCHLORVYNOL
$24.74
82691
O
ETHCHLORVYNOL URINE
$0.00
82692
O
ETHOSUXIMIDE
$0.00
82693
3
ASSAY OF ETHYLENE GLYCOL
82694
O
ETIOCHOLANOLONE
82696
3
ASSAY OF ETIOCHOLANOLONE
82705
3
FATS/LIPIDS, FECES, QUAL
$7.28
82710
3
FATS/LIPIDS, FECES, QUANT
$4.12
82715
3
ASSAY OF FECAL FAT
82720
O
FATTY ACIDS, BLOOD ESTERIFIED
82725
3
ASSAY OF BLOOD FATTY ACIDS
$19.05
82726
3
LONG CHAIN FATTY ACIDS
$25.84
82727
O
FERRIC CHLORIDE, URINE
$0.00
82728
3
ASSAY OF FERRITIN
82730
O
FIBRINOGEN, QUANTITATIVE
82731
3
ASSAY OF FETAL FIBRONECTIN
$90.65
82735
3
ASSAY OF FLUORIDE
$26.54
82740
O
FLUORIDE URINE
$0.00
82741
O
FLUCYTOSINE (5-FLUOROCYTOSINE)
$0.00
82742
3
ASSAY OF FLURAZEPAM
82745
O
FOLIC ACID (FOLATE), BLOOD BIOASSAY
82746
3
BLOOD FOLIC ACID SERUM
$21.04
82747
3
ASSAY OF FOLIC ACID, RBC
$24.65
82750
O
FORMIMINOGLUTAMIC ACID (FIGLU), URI
$0.00
82755
O
FREE RADICAL ASSAY TECHNIQUE FOR DR
$0.00
82756
O
FREE THYROXINE INDEX (T-7)
$0.00
82757
3
ASSAY OF SEMEN FRUCTOSE
$24.81
82759
3
ASSAY OF RBC GALACTOKINASE
$30.74
82760
3
ASSAY OF GALACTOSE
$16.02
82763
O
GALACTOSE TOLERANCE TEST
$18.44 $0.00 $33.74
$12.51 $0.00
$19.49 $0.00
$22.50 $0.00
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
82765
O
GALACTOSE URINE
$0.00
82775
3
ASSAY GALACTOSE TRANSFERASE
$30.14
82776
3
GALACTOSE TRANSFERASE TEST
$12.00
82780
O
GALLIUM
82784
3
ASSAY OF GAMMAGLOBULIN IGM
$13.31
82785
3
ASSAY OF GAMMAGLOBULIN IGE
$23.57
82786
O
GAMMAGLOBULIN, SALT PRECIPITATION M
82787
3
IGG 1, 2, 3 OR 4, EACH
82790
O
GASES, BLOOD, OXYGEN SATURATION BY
$0.00
82791
O
GASES, BLOOD, OXYGEN SATURATION BY
$0.00
82792
O
GASES, BLOOD, OXYGEN SATURATION QUA
$0.00
82793
O
GASES, BLOOD, OXYGEN SATURATION BY
$0.00
82795
O
GASES, BLOOD, OXYGEN SATURATION BY
$0.00
82800
3
BLOOD PH
82801
O
GASES, BLOOD PCO2
$0.00
82802
O
GASES, BLOOD PH, PCO2 BY ELECTRODE
$0.00
82803
3
BLOOD GASES: PH, PO2 & PCO2
82804
O
GASES, BLOOD PO2 BY ELECTRODE
82805
3
BLOOD GASES W/02 SATURATION
$40.60
82810
3
BLOOD GASES, O2 SAT ONLY
$12.49
82812
O
GASES, BLOOD PO2 BY MANOMETRY
$0.00
82817
O
GASES, BLOOD PH, PCO2 BY TONOMETRY
$0.00
82820
3
HEMOGLOBIN-OXYGEN AFFINITY
82926
3
ASSAY OF GASTRIC ACID
$7.80
82927
O
GASTRIC ACID, FREE AND TOTAL EACH A
$0.00
82928
3
ASSAY OF GASTRIC ACID
$9.37
82929
O
GASTRIC ACID, FREE OR TOTAL EACH AD
$0.00
82931
O
GASTRIC ACID, PH TITRATION SINGLE S
$0.00
82932
O
GASTRIC ACID, PH TITRATION EACH ADD
$0.00
82938
3
GASTRIN TEST
$25.31
82941
3
ASSAY OF GASTRIN
$25.24
82942
O
GLOBULIN, SERUM
$0.00
82943
3
ASSAY OF GLUCAGON
82944
O
GLUCOSAMINE
$0.00
82945
3
GLUCOSE OTHER FLUID
$5.62
$0.00
$0.00 $11.48
$12.12
$27.69 $0.00
$14.30
$20.44
Procedure Code Pricing Action Code Description
Maximum Allowable
82946
3
GLUCAGON TOLERANCE TEST
$21.57
82947
3
ASSAY, GLUCOSE, BLOOD QUANT
$5.62
82948
3
REAGENT STRIP/BLOOD GLUCOSE
$4.54
82949
O
GLUCOSE FERMENTATION
$0.00
82950
3
GLUCOSE TEST
$6.79
82951
3
GLUCOSE TOLERANCE TEST (GTT)
82952
3
GTT-ADDED SAMPLES
82953
3
GLUCOSE-TOLBUTAMIDE TEST
82954
O
GLUCOSE, URINE
82955
3
ASSAY OF G6PD ENZYME
$13.88
82960
3
TEST FOR G6PD ENZYME
$8.66
82961
O
GLUCOSE TOLERANCE TEST, INTRAVENOUS
$0.00
82962
3
GLUCOSE BLOOD TEST
$3.35
82963
3
ASSAY OF GLUCOSIDASE
$30.74
82965
3
ASSAY OF GDH ENZYME
$11.06
82975
3
ASSAY OF GLUTAMINE
$22.67
82977
3
ASSAY OF GGT
$9.58
82978
3
ASSAY OF GLUTATHIONE
$8.53
82979
3
ASSAY, RBC GLUTATHIONE
$9.86
82980
3
ASSAY OF GLUTETHIMIDE
$26.22
82985
3
GLYCATED PROTEIN
$21.57
82995
O
GOLD, BLOOD
$0.00
83000
O
GONADOTROPIN, PITUITARY, FOLLICLE S
$0.00
83001
3
GONADOTROPIN (FSH)
$26.60
83002
3
GONADOTROPIN (LH)
$26.50
83003
3
ASSAY, GROWTH HORMONE (HGH)
$23.85
83004
O
GROWTH HORMONE, HUMAN (HGH) (SOMATO
83008
3
ASSAY OF GUANOSINE
$24.02
83009
3
H PYLORI (C-13), BLOOD
$96.38
83010
3
ASSAY OF HAPTOGLOBIN, QUANT
$18.00
83011
O
HAPTOGLOBIN QUANTITATIVE, ELECTROPH
83012
3
ASSAY OF HAPTOGLOBINS
$24.60
83013
3
H PYLORI (C-13), BREATH
$96.38
83014
3
H PYLORI DRUG ADMIN
$11.25
83015
3
HEAVY METAL SCREEN
$26.95
$18.42 $4.12 $21.68 $0.00
$0.00
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
83018
3
QUANTITATIVE SCREEN, METALS
$31.42
83019
O
BREATH ISOTOPE TEST
83020
3
HEMOGLOBIN ELECTROPHORESIS
$18.42
83021
3
HEMOGLOBIN CHROMOTOGRAPHY
$25.84
83026
3
HEMOGLOBIN, COPPER SULFATE
$3.38
83030
3
FETAL HEMOGLOBIN, CHEMICAL
$11.84
83033
3
FETAL HEMOGLOBIN ASSAY, QUAL
83036
3
GLYCOSYLATED HEMOGLOBIN TEST
$13.89
83037
3
GLYCOSYLATED HB, HOME DEVICE
$13.89
83040
O
HEMOGLOBIN METHEMOGLOBIN, ELECTROPH
$0.00
83045
3
BLOOD METHEMOGLOBIN TEST
$7.10
83050
3
BLOOD METHEMOGLOBIN ASSAY
$10.48
83051
3
ASSAY OF PLASMA HEMOGLOBIN
$4.12
83052
O
HEMOGLOBIN SICKLE, TURBIDIMETRIC
$0.00
83053
O
HEMOGLOBIN SOLUBILITY, S-D, ETC
$0.00
83055
3
BLOOD SULFHEMOGLOBIN TEST
$4.12
83060
3
BLOOD SULFHEMOGLOBIN ASSAY
83065
3
ASSAY OF HEMOGLOBIN HEAT
$9.86
83068
3
HEMOGLOBIN STABILITY SCREEN
$3.36
83069
3
ASSAY OF URINE HEMOGLOBIN
$5.64
83070
3
ASSAY OF HEMOSIDERIN, QUAL
$6.79
83071
3
ASSAY OF HEMOSIDERIN, QUANT
$9.18
83080
3
ASSAY OF B HEXOSAMINIDASE
$24.14
83086
O
HISTIDINE BLOOD, QUALITATIVE
$0.00
83087
O
HISTIDINE URINE, QUALITATIVE
$0.00
83088
3
ASSAY OF HISTAMINE
$42.26
83090
3
ASSAY OF HOMOCYSTINE
$24.14
83093
O
HOMOGENTISIC ACID BLOOD, QUALITATIV
$0.00
83094
O
HOMOGENTISIC ACID URINE, QUALITATIV
$0.00
83095
O
HOMOGENTISIC ACID URINE, QUANTITATI
$0.00
83150
3
ASSAY OF FOR HVA
83485
O
HYDROXYBUTYRIC DEHYDROGENASE, ALPHA
$0.00
83486
O
HYDROXYBUTYRIC DEHYDROGENASE, ALPHA
$0.00
83491
3
ASSAY OF CORTICOSTEROIDS
83492
O
HYDROXYCORTICOSTEROIDS, 17- (17-OHC
$0.00
$8.25
$11.84
$27.69
$25.06 $0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
83493
O
HYDROXYCORTICOSTEROIDS, 17- (17-OHC
$0.00
83494
O
HYDROXYCORTICOSTEROIDS, 17- (17-OHC
$0.00
83495
O
HYDROXYCORTICOSTEROIDS, 17- (17-OHC
$0.00
83496
O
HYDROXYCORTICOSTEROIDS, 17- (17-OHC
$0.00
83497
3
ASSAY OF 5-HIAA
$18.45
83498
3
ASSAY OF PROGESTERONE
$38.87
83499
3
ASSAY OF PROGESTERONE
$20.77
83500
3
ASSAY, FREE HYDROXYPROLINE
$32.41
83505
3
ASSAY, TOTAL HYDROXYPROLINE
$34.78
83510
O
HYDROXYPROLINE, URINE FREE AND TOTA
83516
3
IMMUNOASSAY, NONANTIBODY
$15.76
83518
3
IMMUNOASSAY, DIPSTICK
$12.13
83519
3
IMMUNOASSAY, NONANTIBODY
$19.34
83520
3
IMMUNOASSAY, RIA
$18.53
83523
O
IMIPRAMINE
$0.00
83524
O
INDICAN, URINE
$0.00
83525
3
ASSAY OF INSULIN
83526
O
INSULIN TOLERANCE TEST
83527
3
ASSAY OF INSULIN
$18.53
83528
3
ASSAY OF INTRINSIC FACTOR
$22.76
83530
O
INULIN CLEARANCE
$0.00
83540
3
ASSAY OF IRON
$9.27
83545
O
IRON, SERUM AUTOMATED
$0.00
83546
O
IRON, SERUM RADIOACTIVE UPTAKE METH
$0.00
83550
3
IRON BINDING TEST
83555
O
IRON BINDING CAPACITY, SERUM AUTOMA
$0.00
83565
O
IRON BINDING CAPACITY, SERUM RADIOA
$0.00
83570
3
ASSAY OF IDH ENZYME
83571
O
ISOCITRIC DEHYDROGENASE (IDH), BLOO
$0.00
83576
O
ISONICOTINIC ACID HYDRAZIDE (INH)
$0.00
83578
O
KANAMYCIN
$0.00
83582
3
ASSAY OF KETOGENIC STEROIDS
83583
O
KETOGENIC STEROIDS, URINE 11-DESOXY
$0.00
83584
O
KETOGLUTARATE, ALPHA
$0.00
83586
3
ASSAY 17- KETOSTEROIDS
$0.00
$16.36 $0.00
$12.51
$10.76
$20.28
$18.32
Procedure Code Pricing Action Code Description
Maximum Allowable
83587
O
KETOSTEROIDS, 17- (17-KS), BLOOD FR
$0.00
83588
O
KETOSTEROIDS, 17- (17-KS), BLOOD RI
$0.00
83589
O
KETOSTEROIDS, 17- (17-KS), URINE TO
$0.00
83590
O
KETOSTEROIDS, 17- (17-KS), URINE FR
$0.00
83593
3
FRACTIONATION, KETOSTEROIDS
83597
O
KETOSTEROIDS, 17- (17-KS), URINE 11
$0.00
83599
O
KETOSTEROIDS, 17-OH, RIA
$0.00
83600
O
KYNURENIC ACID
$0.00
83605
3
ASSAY OF LACTIC ACID
83610
O
LACTIC DEHYDROGENASE (LDH), RIA
$0.00
83615
3
LACTATE (LD) (LDH) ENZYME
$8.02
83620
O
LACTIC DEHYDROGENASE (LDH), BLOOD C
$0.00
83624
O
LACTIC DEHYDROGENASE (LDH), BLOOD H
$0.00
83625
3
ASSAY OF LDH ENZYMES
83626
O
LACTIC DEHYDROGENASE (LDH), BLOOD I
$0.00
83628
O
LACTIC DEHYDROGENASE, LIVER (LLDH)
$0.00
83629
O
LACTIC DEHYDROGENASE (LDH), URINE
$0.00
83630
3
LACTOFERRIN, FECAL (QUAL)
$28.09
83631
3
LACTOFERRIN, FECAL; QUANTITATIVE
$28.09
83632
3
PLACENTAL LACTOGEN
$28.92
83633
3
TEST URINE FOR LACTOSE
83634
3
ASSAY OF URINE FOR LACTOSE
83645
O
LEAD, SCREENING BLOOD
$0.00
83650
O
LEAD, SCREENING URINE
$0.00
83655
3
ASSAY OF LEAD
83660
O
LEAD, QUANTITATIVE URINE
83661
3
L/S RATIO, FETAL LUNG
$31.45
83662
3
FOAM STABILITY, FETAL LUNG
$27.07
83663
3
FLUORO POLARIZE, FETAL LUNG
$27.07
83664
3
LAMELLAR BDY, FETAL LUNG
$27.07
83670
3
ASSAY OF LAP ENZYME
$13.11
83675
O
LEUCINE AMINOPEPTIDASE (LAP), BLOOD
$0.00
83680
O
LEUCINE AMINOPEPTIDASE (LAP), URINE
$0.00
83681
O
LEUCINE TOLERANCE TEST
$0.00
83685
O
LIDOCAINE
$0.00
$37.63
$15.28
$18.32
$7.88 $16.49
$17.32 $0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
83690
3
ASSAY OF LIPASE
$9.86
83695
3
ASSAY OF LIPOPROTEIN(A)
$18.53
83698
3
ASSAY LIPOPROTEIN PLA2
$48.57
83700
3
LIPOPROTEIN, BLOOD; ELECTROPHORETI
$16.11
83701
3
LIPOPROTEIN BLD, HR FRACTION
$35.52
83704
3
LIPOPROTEIN, BLD, BY NMR
$45.15
83705
O
LIPIDS, BLOOD FRACTIONATED (CHOLEST
$0.00
83715
O
ASSAY OF BLOOD LIPOPROTEINS
$0.00
83716
O
ASSAY OF BLOOD LIPOPROTEINS
$0.00
83717
O
ASSAY BLOOD LIPOPROTEINS
$0.00
83718
3
ASSAY OF LIPOPROTEIN
$11.72
83719
3
ASSAY OF BLOOD LIPOPROTEIN
$16.65
83720
O
LIPOPROTEIN CHOLESTEROL FRACTIONATI
83721
3
ASSAY OF BLOOD LIPOPROTEIN
$13.65
83725
O
LITHIUM, BLOOD, QUANTITATIVE
$0.00
83727
3
ASSAY OF LRH HORMONE
83728
O
LYSERGIC ACID DIETHYLAMIDE (LSD), R
$0.00
83730
O
MACROGLOBULINS (SIA TEST)
$0.00
83735
3
ASSAY OF MAGNESIUM
$9.58
83740
O
MAGNESIUM, BLOOD FLUOROMETRIC
$0.00
83750
O
MAGNESIUM, BLOOD ATOMIC ABSORPTION
$0.00
83755
O
MAGNESIUM, URINE CHEMICAL
$0.00
83760
O
MAGNESIUM, URINE FLUOROMETRIC
$0.00
83765
O
MAGNESIUM, URINE ATOMIC ABSORPTION
$0.00
83775
3
ASSAY OF MD ENZYME
$10.55
83785
3
ASSAY OF MANGANESE
$15.57
83788
3
MASS SPECTROMETRY QUAL
$25.84
83789
3
MASS SPECTROMETRY QUANT
$25.84
83790
O
MANNITOL CLEARANCE
$0.00
83795
O
MELANIN, URINE, QUALITATIVE
$0.00
83799
O
MEPERIDINE, QUANTITATIVE
$0.00
83805
3
ASSAY OF MEPROBAMATE
$25.23
83825
3
ASSAY OF MERCURY
$23.27
83830
O
MERCURY, QUANTITATIVE URINE
83835
3
ASSAY OF METANEPHRINES
$0.00
$24.60
$0.00 $24.25
Procedure Code Pricing Action Code Description
Maximum Allowable
83840
3
ASSAY OF METHADONE
$23.30
83842
O
METHAPYRILENE
$0.00
83845
O
METHAQUALONE
$0.00
83857
3
ASSAY OF METHEMALBUMIN
$15.37
83858
3
ASSAY OF METHSUXIMIDE
$21.21
83859
O
METHYPRYLON
$0.00
83860
O
MORPHINE SCREENING
$0.00
83861
O
MORPHINE QUANTITATIVE
$0.00
83862
O
MORPHINE RIA
$0.00
83864
3
MUCOPOLYSACCHARIDES
83865
O
MUCOPOLYSACCHARIDES, ACID, URINE QU
83866
3
MUCOPOLYSACCHARIDES SCREEN
83872
3
ASSAY SYNOVIAL FLUID MUCIN
83873
3
ASSAY OF CSF PROTEIN
$24.62
83874
3
ASSAY OF MYOGLOBIN
$18.48
83875
O
MYOGLOBIN, URINE
83876
3
ASSAY, MYELOPEROXIDASE
$18.53
83880
3
NATRIURETIC PEPTIDE
$48.57
83883
3
ASSAY, NEPHELOMETRY NOT SPEC
$19.45
83885
3
ASSAY OF NICKEL
$35.05
83887
3
ASSAY OF NICOTINE
$33.89
83890
3
MOLECULE ISOLATE
$5.73
83891
3
MOLECULE ISOLATE NUCLEIC
$5.73
83892
3
MOLECULAR DIAGNOSTICS
$5.73
83893
3
MOLECULE DOT/SLOT/BLOT
$5.73
83894
3
MOLECULE GEL ELECTROPHOR
$5.73
83895
O
NITROGEN, TOTAL URINE, 24-HOUR SPEC
$0.00
83896
3
MOLECULAR DIAGNOSTICS
$5.73
83897
3
MOLECULE NUCLEIC TRANSFER
$5.73
83898
3
MOLECULE NUCLEIC AMPLI, EACH
$23.98
83900
3
MOLECULE NUCLEIC AMPLI 2 SEQ
$47.97
83901
3
MOLECULE NUCLEIC AMPLI ADDON
$23.98
83902
3
MOLECULAR DIAGNOSTICS
$20.31
83903
3
MOLECULE MUTATION SCAN
$23.98
83904
3
MOLECULE MUTATION IDENTIFY
$23.98
$28.49 $0.00 $14.10 $8.39
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
83905
3
MOLECULE MUTATION IDENTIFY
$23.98
83906
3
MOLECULE MUTATION IDENTIFY
$23.98
83907
3
LYSE CELLS FOR NUCLEIC EXT
$19.11
83908
3
NUCLEIC ACID, SIGNAL AMPLI
$23.98
83909
3
NUCLEIC ACID, HIGH RESOLUTE
$23.98
83910
O
NONPROTEIN NITROGEN (NPN), BLOOD
$0.00
83912
3
GENETIC EXAMINATION
$5.73
83913
3
NUCLEIC ACID PROBE, WITH ELECTROPHO
$19.11
83914
3
MUTATION IDENT OLA/SBCE/ASPE
$23.98
83915
3
ASSAY OF NUCLEOTIDASE
$15.96
83916
3
OLIGOCLONAL BANDS
$28.77
83917
O
ORGANIC ACIDS SCREEN, QUALITATIVE
83918
3
ORGANIC ACIDS, TOTAL, QUANT
$23.56
83919
3
ORGANIC ACIDS, QUAL, EACH
$23.56
83920
O
ORNITHINE CARBAMYL TRANSFERASE (OCT
83921
3
ORGANIC ACID, SINGLE, QUANT
$23.56
83925
3
ASSAY OF OPIATES
$27.84
83930
3
ASSAY OF BLOOD OSMOLALITY
$9.46
83935
3
ASSAY OF URINE OSMOLALITY
$9.75
83937
3
ASSAY OF OSTEOCALCIN
83938
O
OUABAIN
83945
3
ASSAY OF OXALATE
83946
O
OXAZEPAM
$0.00
83947
O
OXYBUTYRIC ACID, BETA
$0.00
83948
O
OXYCODINONE
$0.00
83949
O
OXYTOCINASE, RIA
$0.00
83950
3
ONCOPROTEIN, HER-2/NEU
$90.65
83951
3
ONCOPROTEIN, DCP
$90.65
83965
O
PARALDEHYDE, BLOOD, QUANTITATIVE
83970
3
ASSAY OF PARATHORMONE
83971
O
PENICILLIN, URINE
$0.00
83972
O
PENTAZOCINE
$0.00
83973
O
PENTOSE, URINE, QUALITATIVE
$0.00
83975
O
PEPSINOGEN, BLOOD
$0.00
83985
O
PESTICIDE OTHER THAN CHLORINATED HY
$0.00
$0.00
$0.00
$42.72 $0.00 $18.42
$0.00 $59.06
Procedure Code Pricing Action Code Description
Maximum Allowable
83986
3
ASSAY OF BODY FLUID ACIDITY
$3.36
83992
3
ASSAY FOR PHENCYCLIDINE
$21.03
83993
3
ASSAY FOR CALPROTECTIN FECAL
$28.09
83995
O
PHENOL, BLOOD OR URINE
$0.00
84005
O
PHENOLSULFONPHTHALEIN (PSP) TEST, U
$0.00
84021
O
PHENOTHIAZINE, URINE QUALITATIVE, C
$0.00
84022
3
ASSAY OF PHENOTHIAZINE
84030
3
ASSAY OF BLOOD PKU
$7.88
84031
O
PHENYLALANINE (PKU), BLOOD FLUOROME
$0.00
84033
O
PHENYLBUTAZONE
$0.00
84035
3
ASSAY OF PHENYLKETONES
$5.23
84037
O
PHENYLKETONES URINE, QUALITATIVE
$0.00
84038
O
PHENYLPROPANOLAMINE
$0.00
84039
O
PHENYLPYRUVIC ACID BLOOD
$0.00
84040
O
PHENYLPYRUVIC ACID URINE
$0.00
84045
O
PHENYTOIN
$0.00
84060
3
ASSAY ACID PHOSPHATASE
$8.25
84061
3
PHOSPHATASE, FORENSIC EXAM
$8.25
84065
O
PHOSPHATASE, ACID PROSTATIC FRACTIO
$0.00
84066
3
ASSAY PROSTATE PHOSPHATASE
84075
3
ASSAY ALKALINE PHOSPHATASE
$6.53
84078
3
ASSAY ALKALINE PHOSPHATASE
$10.45
84080
3
ASSAY ALKALINE PHOSPHATASES
$21.16
84081
3
AMNIOTIC FLUID ENZYME TEST
$23.64
84082
O
PHOSPHATES, TUBULAR REABSORPTION OF
$0.00
84083
O
PHOSPHOGLUCOMUTASE, ISOENZYMES
$0.00
84085
3
ASSAY OF RBC PG6D ENZYME
$9.64
84087
3
ASSAY PHOSPHOHEXOSE ENZYMES
84090
O
PHOSPHOLIPIDS, BLOOD
$0.00
84100
3
ASSAY OF PHOSPHORUS
$6.79
84105
3
ASSAY OF URINE PHOSPHORUS
$7.41
84106
3
TEST FOR PORPHOBILINOGEN
$6.13
84110
3
ASSAY OF PORPHOBILINOGEN
$11.05
84118
O
PORPHYRINS, COPRO-, URINE QUANTITAT
84119
3
TEST URINE FOR PORPHYRINS
$22.29
$13.42
$14.77
$0.00 $12.32
Procedure Code Pricing Action Code Description
Maximum Allowable
84120
3
ASSAY OF URINE PORPHYRINS
$20.89
84121
O
PORPHYRINS URO-, COPRO- AND PORPHOB
84126
3
ASSAY OF FECES PORPHYRINS
$36.45
84127
3
ASSAY OF FECES PORPHYRINS
$16.67
84128
O
PORPHYRINS, PLASMA
$0.00
84132
3
ASSAY OF SERUM POTASSIUM
$6.57
84133
3
ASSAY OF URINE POTASSIUM
$6.15
84134
3
ASSAY OF PREALBUMIN
$20.87
84135
3
ASSAY OF PREGNANEDIOL
$27.38
84136
O
PREGNANEDIOL OTHER METHOD (SPECIFY)
84138
3
ASSAY OF PREGNANETRIOL
84139
O
PREGNANETRIOL OTHER METHOD (SPECIFY
84140
3
ASSAY OF PREGNENOLONE
84141
O
PRIMIDONE
$0.00
84142
O
PROCAINAMIDE
$0.00
84143
3
ASSAY OF 17-HYDROXYPREGNENO
$32.65
84144
3
ASSAY OF PROGESTERONE
$29.85
84146
3
ASSAY OF PROLACTIN
$27.73
84147
O
PROPOXYPHENE
$0.00
84149
O
PROPRANOLOL
$0.00
84150
3
ASSAY OF PROSTAGLANDIN
$35.72
84152
3
ASSAY OF PSA, COMPLEXED
$26.31
84153
3
ASSAY OF PSA, TOTAL
$26.31
84154
3
ASSAY OF PSA, FREE
$26.31
84155
3
ASSAY OF PROTEIN, SERUM
$4.78
84156
3
ASSAY OF PROTEIN, URINE
$4.78
84157
3
ASSAY OF PROTEIN, OTHER
$4.78
84160
3
ASSAY OF PROTEIN, ANY SOURCE
$7.41
84163
3
PAPPA, SERUM
$20.76
84165
3
PROTEIN E-PHORESIS, SERUM
$15.37
84166
3
PROTEIN E-PHORESIS/URINE/CSF
$25.52
84170
O
PROTEIN, TOTAL, AND ALBUMIN/GLOBULI
$0.00
84175
O
PROTEIN;ELECTROPHORESIS,OTHER SOURC
$0.00
84176
O
PROTEIN, SPECIAL STUDIES (EG, MONOC
$0.00
84180
O
PROTEIN, URINE QUANTITATIVE, 24-HOU
$0.00
$0.00
$0.00 $27.10 $0.00 $29.59
Procedure Code Pricing Action Code Description
Maximum Allowable
84181
3
WESTERN BLOT TEST
$24.37
84182
3
PROTEIN, WESTERN BLOT TEST
$25.75
84185
O
PROTEIN, URINE BENCE-JONES
$0.00
84190
O
PROTEIN, URINE ELECTROPHORETIC FRAC
$0.00
84195
O
PROTEIN, SPINAL FLUID SEMI-QUANTITA
$0.00
84200
O
PROTEIN, SPINAL FLUID ELECTROPHORET
$0.00
84201
O
PROTIRELIN, THYROTROPIN RELEASING H
$0.00
84202
3
ASSAY RBC PROTOPORPHYRIN
$20.53
84203
3
TEST RBC PROTOPORPHYRIN
$12.32
84205
O
PROTRIPTYLENE
84206
3
ASSAY OF PROINSULIN
$11.17
84207
3
ASSAY OF VITAMIN B-6
$40.20
84208
O
PYROPHOSPHATE VS URATE, CRYSTALS (P
84210
3
ASSAY OF PYRUVATE
$15.53
84220
3
ASSAY OF PYRUVATE KINASE
$13.49
84228
3
ASSAY OF QUININE
$16.65
84230
O
QUINIDINE, BLOOD
$0.00
84231
O
RADIOIMMUNOASSAY (RIA) NOT ELSEWHER
$0.00
84232
O
RELEASING FACTOR
$0.00
84233
3
ASSAY OF ESTROGEN
$90.65
84234
3
ASSAY OF PROGESTERONE
$92.83
84235
3
ASSAY OF ENDOCRINE HORMONE
$74.88
84236
O
RECEPTOR ASSAY PROGESTERONE AND EST
84238
3
ASSAY, NONENDOCRINE RECEPTOR
$52.32
84244
3
ASSAY OF RENIN
$31.48
84246
O
RENIN (ANGIOTENSIN I) FUROSEMIDE TE
84252
3
ASSAY OF VITAMIN B-2
$28.22
84255
3
ASSAY OF SELENIUM
$36.52
84260
3
ASSAY OF SEROTONIN
$44.33
84270
3
ASSAY OF SEX HORMONE GLOBUL
$28.22
84275
3
ASSAY OF SIALIC ACID
$19.22
84285
3
ASSAY OF SILICA
$33.69
84295
3
ASSAY OF SERUM SODIUM
$6.65
84300
3
ASSAY OF URINE SODIUM
$6.96
84302
3
ASSAY OF SWEAT SODIUM
$6.96
$0.00
$0.00
$0.00
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
84305
3
ASSAY OF SOMATOMEDIN
$28.10
84307
3
ASSAY OF SOMATOSTATIN
$26.17
84310
O
SORBITOL DEHYDROGENASE, SERUM
84311
3
SPECTROPHOTOMETRY
84315
3
BODY FLUID SPECIFIC GRAVITY
$3.59
84318
O
STERCOBILIN, QUALITATIVE, FECES
$0.00
84324
O
STRYCHNINE
$0.00
84375
3
CHROMATOGRAM ASSAY, SUGARS
84376
3
SUGARS, SINGLE, QUAL
$7.88
84377
3
SUGARS, MULTIPLE, QUAL
$7.88
84378
3
SUGARS, SINGLE, QUANT
$16.49
84379
3
SUGARS MULTIPLE QUANT
$16.49
84392
3
ASSAY OF URINE SULFATE
$6.79
84395
O
SULFONAMIDE, BLOOD, CHEMICAL
$0.00
84402
3
ASSAY OF TESTOSTERONE
$36.44
84403
3
ASSAY OF TOTAL TESTOSTERONE
$36.95
84405
O
TESTOSTERONE, URINE, RIA
$0.00
84406
O
TESTOSTERONE, BINDING PROTEIN
$0.00
84407
O
TETRACAINE
$0.00
84408
O
TETRAHYDROCANNABINOL THC (MARIJUANA
$0.00
84409
O
TETRAHYDROCORTISONE OR TETRAHYDROCO
$0.00
84410
O
THALLIUM, BLOOD OR URINE
$0.00
84420
O
THEOPHYLLINE, BLOOD OR SALIVA
$0.00
84425
3
ASSAY OF VITAMIN B-1
84430
3
ASSAY OF THIOCYANATE
84432
3
ASSAY OF THYROGLOBULIN
84434
O
THIORIDAZINE
$0.00
84435
O
THYROXINE, (T-4), CPB OR RESIN UPTA
$0.00
84436
3
ASSAY OF TOTAL THYROXINE
$9.83
84437
3
ASSAY OF NEONATAL THYROXINE
$9.26
84439
3
ASSAY OF FREE THYROXINE
$12.91
84442
3
ASSAY OF THYROID ACTIVITY
$21.16
84443
3
ASSAY THYROID STIM HORMONE
$24.04
84444
O
THYROTROPIN RELEASING FACTOR (TRF)
84445
3
ASSAY OF TSI
$0.00 $10.00
$28.05
$30.39 $6.53 $22.98
$0.00 $72.76
Procedure Code Pricing Action Code Description
Maximum Allowable
84446
3
ASSAY OF VITAMIN E
$20.29
84447
O
TOXICOLOGY, SCREEN GENERAL
$0.00
84448
O
TOXICOLOGY, SCREEN SEDATIVE (ACID A
$0.00
84449
3
ASSAY OF TRANSCORTIN
84450
3
TRANSFERASE (AST) (SGOT)
$7.40
84455
O
TRANSAMINASE, GLUTAMIC OXALOACETIC
$0.00
84460
3
ALANINE AMINO (ALT) (SGPT)
$7.58
84465
O
TRANSAMINASE, GLUTAMIC PYRUVIC (SGP
$0.00
84466
3
ASSAY OF TRANSFERRIN
84472
O
TRICHLOROETHANOL
$0.00
84474
O
TRICHLOROACETIC ACID
$0.00
84476
O
TRIFLUOPERAZINE
$0.00
84478
3
ASSAY OF TRIGLYCERIDES
$8.23
84479
3
ASSAY OF THYROID (T3 OR T4)
$9.26
84480
3
ASSAY, TRIIODOTHYRONINE (T3)
$20.29
84481
3
FREE ASSAY (FT-3)
$24.25
84482
3
T3 REVERSE
$22.55
84483
O
TRIMETHADIONE
84484
3
ASSAY OF TROPONIN, QUANT
$12.47
84485
3
ASSAY DUODENAL FLUID TRYPSIN
$10.74
84488
3
TEST FECES FOR TRYPSIN
$10.45
84490
3
ASSAY OF FECES FOR TRYPSIN
$10.89
84510
3
ASSAY OF TYROSINE
$14.88
84512
3
ASSAY OF TROPONIN, QUAL
$10.55
84520
3
ASSAY OF UREA NITROGEN
$5.64
84525
3
UREA NITROGEN SEMI-QUANT
$5.38
84540
3
ASSAY OF URINE/UREA-N
$6.79
84545
3
UREA-N CLEARANCE TEST
$9.45
84550
3
ASSAY OF BLOOD/URIC ACID
$6.46
84555
O
URIC ACID URICASE, ULTRAVIOLET METH
$0.00
84560
3
ASSAY OF URINE/URIC ACID
$4.95
84565
O
UROBILIN, URINE QUALITATIVE
$0.00
84570
O
UROBILIN, URINE QUANTITATIVE, TIMED
$0.00
84575
O
UROBILIN, FECES, QUANTITATIVE
$0.00
84577
3
ASSAY OF FECES/UROBILINOGEN
$17.86
$25.75
$18.27
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
84578
3
TEST URINE UROBILINOGEN
$4.12
84580
3
ASSAY OF URINE UROBILINOGEN
$10.15
84583
3
ASSAY OF URINE UROBILINOGEN
$7.19
84584
O
UROPEPSIN, URINE
$0.00
84585
3
ASSAY OF URINE VMA
$22.19
84586
3
ASSAY OF VIP
$50.56
84588
3
ASSAY OF VASOPRESSIN
$48.57
84589
O
VISCOSITY
84590
3
ASSAY OF VITAMIN A
$16.59
84591
3
ASSAY OF NOS VITAMIN
$16.59
84595
O
VITAMIN A, BLOOD INCLUDING CAROTENE
84597
3
ASSAY OF VITAMIN K
$19.61
84600
3
ASSAY OF VOLATILES
$23.00
84605
O
VOLUME, BLOOD, DYE METHOD (EVANS BL
$0.00
84610
O
VOLUME, BLOOD, DYE METHOD (EVANS BL
$0.00
84613
O
WARFARIN
$0.00
84615
O
XANTHURENIC ACID
$0.00
84620
3
XYLOSE TOLERANCE TEST
$6.65
84630
3
ASSAY OF ZINC
84635
O
ZINC, QUANTITATIVE URINE
84681
3
ASSAY OF C-PEPTIDE
84695
O
GENTAMICIN
84702
3
CHORIONIC GONADOTROPIN TEST
$20.76
84703
3
CHORIONIC GONADOTROPIN ASSAY
$10.75
84704
3
HCG, FREE BETACHAIN TEST
$20.76
84800
O
THYROID STIMULATING HORMONE (TSH),
$0.00
84810
O
TOBRAMYCIN
$0.00
84830
9
OVULATION TESTS
$0.00
84999
5
CLINICAL CHEMISTRY TEST
$0.00
85000
O
BLEEDING TIME DUKE
$0.00
85002
3
BLEEDING TIME TEST
$6.44
85004
3
AUTOMATED DIFF WBC COUNT
$9.26
85005
O
BLOOD COUNT BASOPHIL COUNT, DIRECT
$0.00
85007
3
BL SMEAR W/DIFF WBC COUNT
$4.92
85008
3
BL SMEAR W/O DIFF WBC COUNT
$4.92
$0.00
$0.00
$16.30 $0.00 $29.77 $0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
85009
3
MANUAL DIFF WBC COUNT B-COAT
$5.32
85012
O
BLOOD COUNT EOSINOPHIL COUNT, DIREC
$0.00
85013
3
SPUN MICROHEMATOCRIT
$3.39
85014
3
HEMATOCRIT
$3.39
85018
3
HEMOGLOBIN
$3.39
85021
O
AUTOMATED HEMOGRAM
$0.00
85022
O
AUTOMATED HEMOGRAM
$0.00
85023
O
AUTOMATED HEMOGRAM
$0.00
85024
O
AUTOMATED HEMOGRAM
$0.00
85025
3
COMPLETE CBC W/AUTO DIFF WBC
85027
3
COMPLETE CBC, AUTOMATED
$9.26
85029
O
AUTOMATED HEMOGRAM
$0.00
85030
O
AUTOMATED HEMOGRAM
$0.00
85031
O
MANUAL HEMOGRAM, CBC
$0.00
85032
3
MANUAL CELL COUNT, EACH
$6.15
85041
3
AUTOMATED RBC COUNT
$4.12
85044
3
MANUAL RETICULOCYTE COUNT
$6.15
85045
3
AUTOMATED RETICULOCYTE COUNT
$5.73
85046
3
RETICYTE/HGB CONCENTRATE
$7.99
85048
3
AUTOMATED LEUKOCYTE COUNT
$3.64
85049
3
AUTOMATED PLATELET COUNT
$6.40
85055
3
RETICULATED PLATELET ASSAY
$38.31
85060
3
BLOOD SMEAR INTERPRETATION
$25.45
85095
O
BONE MARROW ASPIRATION
85097
3
BONE MARROW INTERPRETATION
85100
O
BONE MARROW SMEAR AND/OR CELL BLOCK
$0.00
85101
O
BONE MARROW SMEAR AND/OR CELL BLOCK
$0.00
85102
O
BONE MARROW BIOPSY
$0.00
85103
O
BONE MARROW BIOPSY, NEEDLE OR TROCA
$0.00
85105
O
BONE MARROW BIOPSY, NEEDLE OR TROCA
$0.00
85109
O
BONE MARROW BIOPSY, NEEDLE OR TROCA
$0.00
85130
3
CHROMOGENIC SUBSTRATE ASSAY
85170
3
BLOOD CLOT RETRACTION
$5.17
85171
O
CLOT RETRACTION QUANTITATIVE
$0.00
85172
O
CLOT RETRACTION INHIBITION BY DRUGS
$0.00
$11.12
$0.00 $104.59
$17.02
Procedure Code Pricing Action Code Description
Maximum Allowable
85175
3
BLOOD CLOT LYSIS TIME
$6.51
85210
3
BLOOD CLOT FACTOR II TEST
$8.25
85220
3
BLOOD CLOT FACTOR V TEST
$25.25
85230
3
BLOOD CLOT FACTOR VII TEST
$25.62
85240
3
BLOOD CLOT FACTOR VIII TEST
$25.62
85242
O
CLOTTING FACTOR VIII (AHG), TWO STA
85244
3
BLOOD CLOT FACTOR VIII TEST
$29.21
85245
3
BLOOD CLOT FACTOR VIII TEST
$32.84
85246
3
BLOOD CLOT FACTOR VIII TEST
$32.84
85247
3
BLOOD CLOT FACTOR VIII TEST
$32.84
85250
3
BLOOD CLOT FACTOR IX TEST
$27.23
85260
3
BLOOD CLOT FACTOR X TEST
$25.62
85270
3
BLOOD CLOT FACTOR XI TEST
$25.62
85280
3
BLOOD CLOT FACTOR XII TEST
$27.69
85290
3
BLOOD CLOT FACTOR XIII TEST
$11.58
85291
3
BLOOD CLOT FACTOR XIII TEST
$11.58
85292
3
BLOOD CLOT FACTOR ASSAY
$27.10
85293
3
BLOOD CLOT FACTOR ASSAY
$27.10
85300
3
ANTITHROMBIN III TEST
$13.85
85301
3
ANTITHROMBIN III TEST
$15.47
85302
3
BLOOD CLOT INHIBITOR ANTIGEN
$17.20
85303
3
BLOOD CLOT INHIBITOR TEST
$19.79
85305
3
BLOOD CLOT INHIBITOR ASSAY
$16.59
85306
3
BLOOD CLOT INHIBITOR TEST
$21.92
85307
3
ASSAY ACTIVATED PROTEIN C
$21.92
85310
O
CLOTTING INHIBITORS OR ANTICOAGULAN
$0.00
85311
O
CLOTTING INHIBITORS OR ANTICOAGULAN
$0.00
85320
O
CLOTTING INHIBITORS OR ANTICOAGULAN
$0.00
85330
O
CLOTTING INHIBITORS OR ANTICOAGULAN
$0.00
85335
3
FACTOR INHIBITOR TEST
$18.42
85337
3
THROMBOMODULIN
$14.92
85340
O
CLOTTING INHIBITORS OR ANTICOAGULAN
$0.00
85341
O
CLOTTING INHIBITORS OR ANTICOAGULAN
$0.00
85345
3
COAGULATION TIME
$4.78
85347
3
COAGULATION TIME
$6.10
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
85348
3
COAGULATION TIME
$5.33
85360
3
EUGLOBULIN LYSIS
$12.00
85362
3
FIBRIN DEGRADATION PRODUCTS
$9.86
85363
O
FIBRIN DEGRADATION (SPLIT) PRODUCTS
$0.00
85364
O
FIBRIN DEGRADATION (SPLIT) PRODUCTS
$0.00
85365
O
FIBRIN DEGRADATION (SPLIT) PRODUCTS
$0.00
85366
3
FIBRINOGEN TEST
85367
O
FIBRIN DEGRADATION (SPLIT) PRODUCTS
$0.00
85368
O
FIBRIN DEGRADATION (SPLIT) PRODUCTS
$0.00
85369
O
FIBRIN DEGRADATION (SPLIT) PRODUCTS
$0.00
85370
3
FIBRINOGEN TEST
85371
O
FIBRINOGEN, SEMIQUANTITATIVE LATEX
$0.00
85372
O
FIBRINOGEN, SEMIQUANTITATIVE TURBID
$0.00
85376
O
FIBRINOGEN THROMBIN WITH PLASMA DIL
$0.00
85377
O
FIBRINOGEN THROMBIN TIME DILUTION
$0.00
85378
3
FIBRIN DEGRADE, SEMIQUANT
$10.20
85379
3
FIBRIN DEGRADATION, QUANT
$11.58
85380
3
FIBRIN DEGRADATION, VTE
$11.58
85384
3
FIBRINOGEN
$12.15
85385
3
FIBRINOGEN
$12.15
85390
3
FIBRINOLYSINS SCREEN
$7.39
85392
O
FIBRINOLYSINS WITH EACA CONTROL
$0.00
85395
O
FIBRINOLYSINS SEMIQUANTITATIVE
$0.00
85396
3
CLOTTING ASSAY, WHOLE BLOOD
$21.84
85397
3
CLOTTING FUNCT ACTIVITY
$32.84
85398
O
FIBRINOLYSIS, QUANTITATIVE
85400
3
FIBRINOLYTIC PLASMIN
$12.65
85410
3
FIBRINOLYTIC ANTIPLASMIN
$11.03
85415
3
FIBRINOLYTIC PLASMINOGEN
$20.79
85420
3
FIBRINOLYTIC PLASMINOGEN
$9.36
85421
3
FIBRINOLYTIC PLASMINOGEN
$14.57
85426
O
FIBRINOLYTIC MECHANISMS VON WILLEBR
$0.00
85441
3
HEINZ BODIES, DIRECT
$6.02
85445
3
HEINZ BODIES, INDUCED
$8.25
85460
3
HEMOGLOBIN, FETAL
$12.32
$11.58
$0.00
$11.07
Procedure Code Pricing Action Code Description
Maximum Allowable
85461
3
HEMOGLOBIN, FETAL
$9.50
85475
3
HEMOLYSIN
$11.17
85520
3
HEPARIN ASSAY
$18.73
85525
3
HEPARIN NEUTRALIZATION
$16.95
85530
3
HEPARIN-PROTAMINE TOLERANCE
$20.29
85535
O
IRON STAIN, BLOOD CELLS
$0.00
85536
3
IRON STAIN PERIPHERAL BLOOD
$9.26
85538
O
LEDER STAIN (ESTERASE) BLOOD OR BON
$0.00
85540
3
WBC ALKALINE PHOSPHATASE
85544
O
LUPUS ERYTHEMATOSUS (LE) CELL PREP
85547
3
RBC MECHANICAL FRAGILITY
85548
O
MORPHOLOGY OF RED BLOOD CELLS, ONLY
85549
3
MURAMIDASE
85555
3
RBC OSMOTIC FRAGILITY
$9.56
85556
O
OSMOTIC FRAGILITY, RBC INCUBATED, Q
$0.00
85557
3
RBC OSMOTIC FRAGILITY
$19.11
85560
O
PEROXIDASE STAIN, WBC
$0.00
85575
O
PLATELET; IN VITRO AGGREGATION,EACH
$0.00
85576
3
BLOOD PLATELET AGGREGATION
85577
O
PLATELET RETENTION (IN VITRO), GLAS
$0.00
85580
O
PLATELET COUNT (REES-ECKER)
$0.00
85585
O
BLOOD PLATELET ESTIMATION
$0.00
85590
O
PLATELET COUNT, MANUAL
$0.00
85595
O
PLATELET COUNT, AUTOMATED
$0.00
85597
3
PLATELET NEUTRALIZATION
85610
3
PROTHROMBIN TIME
$5.63
85611
3
PROTHROMBIN TEST
$5.64
85612
3
VIPER VENOM PROTHROMBIN TIME
$13.69
85613
3
RUSSELL VIPER VENOM, DILUTED
$13.69
85615
O
PROTHROMBIN UTILIZATION (CONSUMPTIO
$0.00
85618
O
PROTHROMBIN-PROCONVERTIN, P&P (OWRE
$0.00
85630
O
RED BLOOD CELL SIZE (PRICE-JONES)
$0.00
85632
O
RED BLOOD CELL PEROXIDE HEMOLYSIS
$0.00
85635
3
REPTILASE TEST
85650
O
SEDIMENTATION RATE (ESR) WINTROBE T
$12.31 $0.00 $12.31 $0.00 $20.77
$30.74
$25.72
$10.01 $0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
85651
3
RBC SED RATE, NONAUTOMATED
$5.08
85652
3
RBC SED RATE, AUTOMATED
$3.86
85660
3
RBC SICKLE CELL TEST
$6.46
85665
O
STREPTOKINASE TITER (PLASMINOGEN AC
$0.00
85667
O
T-CELL DEPLETION (ANY METHOD) OF BO
$0.00
85670
3
THROMBIN TIME, PLASMA
$8.27
85675
3
THROMBIN TIME, TITER
$9.80
85700
O
THROMBOPLASTIN GENERATION TEST SCRE
$0.00
85705
3
THROMBOPLASTIN INHIBITION
85710
O
THROMBOPLASTIN GENERATION TEST DEFI
$0.00
85711
O
THROMBOPLASTIN GENERATION TEST WITH
$0.00
85720
O
THROMBOPLASTIN GENERATION TEST ALL
$0.00
85730
3
THROMBOPLASTIN TIME, PARTIAL
$8.58
85732
3
THROMBOPLASTIN TIME, PARTIAL
$9.26
85810
3
BLOOD VISCOSITY EXAMINATION
$16.71
85820
O
VISCOSITY SERUM OR PLASMA
$0.00
85999
5
HEMATOLOGY PROCEDURE
$0.00
86000
3
AGGLUTININS, FEBRILE
$9.99
86001
3
ALLERGEN SPECIFIC IGG
$7.47
86002
O
AGGLUTININS FEBRILE PANEL (TYPHOID
$0.00
86003
3
ALLERGEN SPECIFIC IGE
$7.47
86004
O
AGGLUTININS WARM
$0.00
86005
3
ALLERGEN SPECIFIC IGE
$4.15
86006
O
ANTIBODY, NON-RBC QUALITATIVE FIRST
$0.00
86007
O
ANTIBODY, NON-RBC QUALITATIVE EACH
$0.00
86008
O
ANTIBODY, NON-RBC, QUANTITATIVE FIR
$0.00
86009
O
ANTIBODY, NON-RBC, QUANTITATIVE EAC
$0.00
86011
O
ANTIBODY, DETECTION, LEUKOCYTE ANTI
$0.00
86012
O
ANTIBODY ABSORPTION, COLD AUTO ABSO
$0.00
86013
O
ANTIBODY ABSORPTION, COLD AUTO ABSO
$0.00
86014
O
ANTIBODY, PLATELET ANTIBODIES (AGGL
$0.00
86016
O
ANTIBODY SCREEN, RBC, EACH SERUM
$0.00
86019
O
ANTIBODY (RBC) ELUTION, ANY METHOD,
$0.00
86021
3
WBC ANTIBODY IDENTIFICATION
$19.03
86022
3
PLATELET ANTIBODIES
$19.03
$12.18
Procedure Code Pricing Action Code Description
Maximum Allowable
86023
3
IMMUNOGLOBULIN ASSAY
$17.83
86024
O
ANTIBODY IDENTIFICATION RBC ANTIBOD
$0.00
86031
O
ANTIHUMAN GLOBULIN TEST DIRECT (COO
$0.00
86032
O
ANTIHUMAN GLOBULIN TEST INDIRECT, Q
$0.00
86033
O
ANTIHUMAN GLOBULIN TEST INDIRECT, T
$0.00
86034
O
ANTIHUMAN GLOBULIN TEST ENZYME TECH
$0.00
86038
3
ANTINUCLEAR ANTIBODIES
$17.30
86039
3
ANTINUCLEAR ANTIBODIES (ANA)
$15.97
86060
3
ANTISTREPTOLYSIN O, TITER
$10.45
86063
3
ANTISTREPTOLYSIN O, SCREEN
$8.27
86064
O
B CELLS, TOTAL COUNT
$0.00
86066
O
ANTITRYPSIN, ALPHA-1 PI (PROTEASE I
$0.00
86067
O
ANTITRYPSIN, ALPHA-1 OTHER METHOD (
$0.00
86068
O
BLOOD COMPATIBILITY TEST CROSSMATCH
$0.00
86070
O
BLOOD COMPATIBILITY TEST CROSSMATCH
$0.00
86077
9
PHYSICIAN BLOOD BANK SERVICE
$0.00
86078
9
PHYSICIAN BLOOD BANK SERVICE
$0.00
86079
9
PHYSICIAN BLOOD BANK SERVICE
$0.00
86080
O
BLOOD TYPING ABO ONLY
$0.00
86082
O
BLOOD TYPING ABO AND RHO(D)
$0.00
86083
O
BLOOD TYPING ABO, RH(D) AND RBC ANT
$0.00
86084
O
BLOOD TYPING ANTIGEN SCREENING FOR
$0.00
86085
O
BLOOD TYPING ANTIGEN SCREENING FOR
$0.00
86095
O
BLOOD TYPING RBC ANTIGENS, OTHER TH
$0.00
86100
O
BLOOD TYPING RHO(D) ONLY
$0.00
86105
O
BLOOD TYPING RH GENOTYPING, COMPLET
$0.00
86115
O
BLOOD TYPING ANTI-RH IMMUNOGLOBULIN
$0.00
86128
O
COLLECTION, PROCESSING AND STORAGE
$0.00
86130
O
COLLECTION AND PROCESSING FOR TRANS
$0.00
86140
3
C-REACTIVE PROTEIN
$7.41
86141
3
C-REACTIVE PROTEIN, HS
$18.53
86146
3
GLYCOPROTEIN ANTIBODY
$36.40
86147
3
CARDIOLIPIN ANTIBODY
$36.40
86148
3
PHOSPHOLIPID ANTIBODY
$14.20
86149
O
CARCINOEMBRYONIC ANTIGEN (CEA) GEL
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
86151
O
CARCINOEMBRYONIC ANTIGEN (CEA) RIA
$0.00
86155
3
CHEMOTAXIS ASSAY
86156
3
COLD AGGLUTININ, SCREEN
86157
3
COLD AGGLUTININ, TITER
86158
O
COMPLEMENT C'1 ESTERASE
$0.00
86159
O
COMPLEMENT C'2 ESTERASE
$0.00
86160
3
COMPLEMENT, ANTIGEN
$17.18
86161
3
COMPLEMENT/FUNCTION ACTIVITY
$17.18
86162
3
COMPLEMENT, TOTAL (CH50)
$29.08
86163
O
COMPLEMENT C'3 ESTERASE
$0.00
86164
O
COMPLEMENT C'4 ESTERASE
$0.00
86171
3
COMPLEMENT FIXATION, EACH
$10.11
86185
3
COUNTERIMMUNOELECTROPHORESIS
$12.80
86200
3
CCP ANTIBODY
$18.53
86215
3
DEOXYRIBONUCLEASE, ANTIBODY
$18.96
86225
3
DNA ANTIBODY
$19.66
86226
3
DNA ANTIBODY, SINGLE STRAND
$17.33
86235
3
NUCLEAR ANTIGEN ANTIBODY
$25.66
86243
3
FC RECEPTOR
$29.36
86244
O
FETO-PROTEIN, ALPHA-1, RIA OR EIA
$0.00
86255
3
FLUORESCENT ANTIBODY, SCREEN
$17.25
86256
3
FLUORESCENT ANTIBODY, TITER
$12.51
86265
O
FROZEN BLOOD, PREPARATION FOR FREEZ
$0.00
86266
O
FROZEN BLOOD, PREPARATION FOR FREEZ
$0.00
86267
O
FROZEN BLOOD, PREPARATION FOR FREEZ
$0.00
86277
3
GROWTH HORMONE ANTIBODY
$22.52
86280
3
HEMAGGLUTINATION INHIBITION
$11.72
86281
O
HEMOLYSINS, ACID (FOR PAROXYSMAL HE
$0.00
86282
O
HEMOLYSINS AND AGGLUTININS, AUTO, S
$0.00
86283
O
HEMOLYSINS AND AGGLUTININS, AUTO, S
$0.00
86287
O
HEPATITIS B SURFACE ANTIGEN (HBSAG)
$0.00
86288
O
HEPATITIS B CORE ANTIGEN (HBCAG), R
$0.00
86289
O
HEPATITIS B CORE ANTIBODY (HBCAB);
$0.00
86290
O
HEPATITIS B CORE ANTIBODY (HBCAB);
$0.00
86291
O
HEPATITIS B SURFACE ANTIBODY (HBSAB
$0.00
$22.86 $9.13 $11.53
Procedure Code Pricing Action Code Description
Maximum Allowable
86293
O
HEPATITIS BE ANTIGEN (HBEAG)
$0.00
86294
3
IMMUNOASSAY, TUMOR, QUAL
86295
O
HEPATITIS BE ANTIBODY (HBEAB)
$0.00
86296
O
HEPATITIS A ANTIBODY (HAAB); IGG AN
$0.00
86298
O
HEPATITIS A ANTIBODY (HAAB) (EG, RI
$0.00
86299
O
HEPATITIS A ANTIBODY (HAAB); IGM AN
$0.00
86300
3
IMMUNOASSAY, TUMOR, CA 15-3
$29.77
86301
3
IMMUNOASSAY, TUMOR, CA 19-9
$29.77
86302
O
HEPATITIS C ANTIBODY;
$0.00
86303
O
HEPATITIS C ANTIBODY; CONFIRMATORY
$0.00
86304
3
IMMUNOASSAY, TUMOR, CA 125
86305
O
HETEROPHILE ANTIBODIES QUANTITATIVE
$0.00
86306
O
HEPATITIS, DELTA AGENT
$0.00
86308
3
HETEROPHILE ANTIBODIES
$7.41
86309
3
HETEROPHILE ANTIBODIES
$8.79
86310
3
HETEROPHILE ANTIBODIES
$10.55
86311
O
HIV, ANTIGEN
$0.00
86312
O
HIV (HTLV-III) ANTIBODY DETECTION I
$0.00
86313
O
IMMUNOASSAY FOR INFECTIOUS AGENT AN
$0.00
86314
O
HIV (HTLV-III) ANTIBODY DETECTION C
$0.00
86315
O
IMMUNOASSAY FOR INFECTIOUS AGENT AN
$0.00
86316
3
IMMUNOASSAY, TUMOR OTHER
$29.77
86317
3
IMMUNOASSAY,INFECTIOUS AGENT
$21.45
86318
3
IMMUNOASSAY,INFECTIOUS AGENT
$18.53
86319
O
IMMUNOASSAY TECHNIQUE FOR DRUGS
86320
3
SERUM IMMUNOELECTROPHORESIS
$32.07
86325
3
OTHER IMMUNOELECTROPHORESIS
$30.50
86327
3
IMMUNOELECTROPHORESIS ASSAY
$32.47
86329
3
IMMUNODIFFUSION
$20.10
86331
3
IMMUNODIFFUSION OUCHTERLONY
$17.15
86332
3
IMMUNE COMPLEX ASSAY
$34.88
86333
O
IMMUNE COMPLEX ASSAY RAJI CELL
86334
3
IMMUNOFIX E-PHORESIS, SERUM
$31.97
86335
3
IMMUNOFIXATION ELECTROPHORESIS; OT
$41.99
86336
3
INHIBIN A
$22.29
$25.04
$29.77
$0.00
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
86337
3
INSULIN ANTIBODIES
$20.91
86338
O
INSULIN FACTOR ANTIBODIES, RIA
86340
3
INTRINSIC FACTOR ANTIBODY
$21.57
86341
3
ISLET CELL ANTIBODY
$28.31
86342
O
IRRADIATION OF BLOOD PRODUCTS, EACH
86343
3
LEUKOCYTE HISTAMINE RELEASE
$17.84
86344
3
LEUKOCYTE PHAGOCYTOSIS
$11.43
86349
O
LEUKOCYTE TRANSFUSION (LEUKAPHERESI
86353
3
LYMPHOCYTE TRANSFORMATION
$70.15
86355
3
B CELLS, TOTAL COUNT
$53.98
86356
3
MONONUCLEAR CELL ANTIGEN
$38.31
86357
3
NATURAL KILLER (NK) CELLS, TOTAL C
$53.98
86358
O
LYMPHOCYTES B-CELL EVALUATION
86359
3
T CELLS, TOTAL COUNT
$53.98
86360
3
T CELL, ABSOLUTE COUNT/RATIO
$67.23
86361
3
T CELL, ABSOLUTE COUNT
$38.31
86367
3
STEM CELLS, TOTAL COUNT
$53.98
86376
3
MICROSOMAL ANTIBODY
$20.83
86377
O
MICROSOMAL ANTIBODY (THYROID) OTHER
86378
3
MIGRATION INHIBITORY FACTOR
86379
O
NK CELLS, TOTAL COUNT
86382
3
NEUTRALIZATION TEST, VIRAL
$24.20
86384
3
NITROBLUE TETRAZOLIUM DYE
$16.30
86385
O
PATERNITY TESTING, ABO+RH FACTORS+M
$0.00
86386
O
PATERNITY TESTING, ABO+RH FACTORS+M
$0.00
86403
3
PARTICLE AGGLUTINATION TEST
86404
O
POOLING OF PLATELETS OR OTHER BLOOD
$0.00
86405
O
PRECIPITIN TEST FOR BLOOD (SPECIES
$0.00
86406
3
PARTICLE AGGLUTINATION TEST
86410
O
PRETREATMENT OF RBC'S FOR USE IN RB
$0.00
86411
O
PRETREATMENT OF RBC'S FOR USE IN RB
$0.00
86412
O
PRETREATMENT OF RBC'S FOR USE IN RB
$0.00
86417
O
PRETREATMENT OF SERUM FOR USE IN RB
$0.00
86418
O
PRETREATMENT OF SERUM FOR USE IN RB
$0.00
86419
O
PRETREATMENT OF SERUM FOR USE IN RB
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00 $28.18 $0.00
$14.58
$15.22
Procedure Code Pricing Action Code Description
Maximum Allowable
86420
O
PRETREATMENT OF SERUM FOR USE IN RB
$0.00
86421
O
RADIOALLERGOSORBENT TEST, IN VITRO
$0.00
86422
9
RADIOALLERGOSORBENT TEST, IN VITRO
$0.00
86423
O
RADIOIMMUNOSORBENT TEST (RIST) IGE,
$0.00
86430
3
RHEUMATOID FACTOR TEST
$8.12
86431
3
RHEUMATOID FACTOR, QUANT
$8.12
86455
O
SKIN TEST ANERGY TESTING, ONE OR MO
$0.00
86480
3
TB TEST, CELL IMMUN MEASURE
86485
5
SKIN TEST, CANDIDA
$0.00
86486
6
SKIN TEST, NOS ANTIGEN
$0.00
86490
3
COCCIDIOIDOMYCOSIS SKIN TEST
$11.81
86510
3
HISTOPLASMOSIS SKIN TEST
$12.97
86540
O
SKIN TEST MUMPS
$0.00
86580
3
TB INTRADERMAL TEST
$5.00
86585
O
TB TINE TEST
$0.00
86586
O
SKIN TEST, UNLISTED
$0.00
86587
O
STEM CELLS (IE, CD34), TOTAL COUNT
$0.00
86588
O
STREPTOCOLLUS, DIRECT SCREEN
$0.00
86590
3
STREPTOKINASE, ANTIBODY
86592
3
BLOOD SEROLOGY, QUALITATIVE
$5.87
86593
3
BLOOD SEROLOGY, QUANTITATIVE
$6.25
86594
O
THYROID AUTOANTIBODIES
$0.00
86595
O
TISSUE CULTURE
$0.00
86600
O
TOXOPLASMOSIS, DYE TEST
$0.00
86602
3
ANTINOMYCES ANTIBODY
$14.55
86603
3
ADENOVIRUS ANTIBODY
$18.41
86606
3
ASPERGILLUS ANTIBODY
$21.54
86609
3
BACTERIUM ANTIBODY
$18.43
86611
3
BARTONELLA ANTIBODY
$14.55
86612
3
BLASTOMYCES ANTIBODY
$18.46
86615
3
BORDETELLA ANTIBODY
$18.87
86617
3
LYME DISEASE ANTIBODY
$22.16
86618
3
LYME DISEASE ANTIBODY
$24.37
86619
3
BORRELIA ANTIBODY
$19.15
86622
3
BRUCELLA ANTIBODY
$11.70
$88.68
$15.79
Procedure Code Pricing Action Code Description
Maximum Allowable
86625
3
CAMPYLOBACTER ANTIBODY
$18.78
86628
3
CANDIDA ANTIBODY
$17.18
86630
O
TRANSFER FACTOR TEST (TFT)
86631
3
CHLAMYDIA ANTIBODY
$10.11
86632
3
CHLAMYDIA IGM ANTIBODY
$18.16
86635
3
COCCIDIOIDES ANTIBODY
$16.42
86638
3
Q FEVER ANTIBODY
$17.35
86641
3
CRYPTOCOCCUS ANTIBODY
$20.63
86644
3
CMV ANTIBODY
$20.60
86645
3
CMV ANTIBODY, IGM
$24.11
86648
3
DIPHTHERIA ANTIBODY
$21.77
86650
O
TREPONEMA ANTIBODIES, FLUORESCENT,
86651
3
ENCEPHALITIS ANTIBODY
$18.87
86652
3
ENCEPHALITIS ANTIBODY
$18.87
86653
3
ENCEPHALITIS ANTIBODY
$18.87
86654
3
ENCEPHALITIS ANTIBODY
$18.87
86658
3
ENTEROVIRUS ANTIBODY
$18.65
86662
O
TREPONEMA PALLIDUM TEST, OTHER, SPE
86663
3
EPSTEIN-BARR ANTIBODY
$18.78
86664
3
EPSTEIN-BARR ANTIBODY
$21.89
86665
3
EPSTEIN-BARR ANTIBODY
$25.95
86666
3
EHRLICHIA ANTIBODY
$14.55
86668
3
FRANCISELLA TULARENSIS
$14.88
86671
3
FUNGUS ANTIBODY
$17.54
86674
3
GIARDIA LAMBLIA ANTIBODY
$21.07
86677
3
HELICOBACTER PYLORI
$20.77
86681
O
ADRENAL CORTEX ANTIBODIES, RIA
86682
3
HELMINTH ANTIBODY
86683
O
HEMOGLOBIN, FECAL ANTIBODY
86684
3
HEMOPHILUS INFLUENZA
86685
O
ANTI-ACHR (ACETYLCHOLINE RECEPTOR)
86687
3
HTLV-I ANTIBODY
$12.00
86688
3
HTLV-II ANTIBODY
$15.11
86689
3
HTLV/HIV CONFIRMATORY TEST
$27.69
86692
3
HEPATITIS, DELTA AGENT
$24.56
$0.00
$0.00
$0.00
$0.00 $18.61 $0.00 $22.67 $0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
86694
3
HERPES SIMPLEX TEST
$20.60
86695
3
HERPES SIMPLEX TEST
$18.87
86696
3
HERPES SIMPLEX TYPE 2
$27.69
86698
3
HISTOPLASMA
$17.88
86701
3
HIV-1
$12.70
86702
3
HIV-2
$15.11
86703
3
HIV-1/HIV-2, SINGLE ASSAY
$19.62
86704
3
HEP B CORE ANTIBODY, TOTAL
$17.25
86705
3
HEP B CORE ANTIBODY, IGM
$16.84
86706
3
HEP B SURFACE ANTIBODY
$15.37
86707
3
HEP BE ANTIBODY
$16.55
86708
3
HEP A ANTIBODY, TOTAL
$17.73
86709
3
HEP A ANTIBODY, IGM
$16.11
86710
3
INFLUENZA VIRUS ANTIBODY
$19.40
86713
3
LEGIONELLA ANTIBODY
$21.90
86717
3
LEISHMANIA ANTIBODY
$17.53
86720
3
LEPTOSPIRA ANTIBODY
$18.87
86723
3
LISTERIA MONOCYTOGENES AB
$18.87
86727
3
LYMPH CHORIOMENINGITIS AB
$18.41
86729
3
LYMPHO VENEREUM ANTIBODY
$10.11
86732
3
MUCORMYCOSIS ANTIBODY
$18.87
86735
3
MUMPS ANTIBODY
$18.68
86738
3
MYCOPLASMA ANTIBODY
$18.95
86741
3
NEISSERIA MENINGITIDIS
$18.87
86744
3
NOCARDIA ANTIBODY
$18.87
86747
3
PARVOVIRUS ANTIBODY
$21.51
86750
3
MALARIA ANTIBODY
$18.87
86753
3
PROTOZOA ANTIBODY NOS
$17.73
86756
3
RESPIRATORY VIRUS ANTIBODY
$18.44
86757
3
RICKETTSIA ANTIBODY
$27.69
86759
3
ROTAVIRUS ANTIBODY
$18.87
86762
3
RUBELLA ANTIBODY
$20.60
86765
3
RUBEOLA ANTIBODY
$14.01
86768
3
SALMONELLA ANTIBODY
$18.87
86771
3
SHIGELLA ANTIBODY
$18.87
Procedure Code Pricing Action Code Description
Maximum Allowable
86774
3
TETANUS ANTIBODY
$21.18
86777
3
TOXOPLASMA ANTIBODY
$20.60
86778
3
TOXOPLASMA ANTIBODY, IGM
$20.61
86781
3
TREPONEMA PALLIDUM, CONFIRM
$18.95
86784
3
TRICHINELLA ANTIBODY
$17.97
86787
3
VARICELLA-ZOSTER ANTIBODY
$18.43
86788
3
WEST NILE VIRUS AB, IGM
$24.11
86789
3
WEST NILE VIRUS ANTIBODY
$20.60
86790
3
VIRUS ANTIBODY NOS
$18.43
86793
3
YERSINIA ANTIBODY
$12.42
86800
3
THYROGLOBULIN ANTIBODY
$22.76
86803
3
HEPATITIS C AB TEST
$20.42
86804
3
HEP C AB TEST, CONFIRM
$22.16
86805
3
LYMPHOCYTOTOXICITY ASSAY
$48.17
86806
3
LYMPHOCYTOTOXICITY ASSAY
$48.17
86807
3
CYTOTOXIC ANTIBODY SCREENING
$56.61
86808
3
CYTOTOXIC ANTIBODY SCREENING
$42.46
86812
3
HLA TYPING, A, B, OR C
$36.93
86813
3
HLA TYPING, A, B, OR C
$82.97
86816
3
HLA TYPING, DR/DQ
$39.86
86817
3
HLA TYPING, DR/DQ
$92.12
86821
3
LYMPHOCYTE CULTURE, MIXED
$80.79
86822
3
LYMPHOCYTE CULTURE, PRIMED
$52.31
86849
5
IMMUNOLOGY PROCEDURE
86850
3
RBC ANTIBODY SCREEN
$15.00
86860
5
RBC ANTIBODY ELUTION
$0.00
86870
3
RBC ANTIBODY IDENTIFICATION
86880
3
COOMBS TEST, DIRECT
$7.68
86885
3
COOMBS TEST, INDIRECT, QUAL
$8.18
86886
3
COOMBS TEST, INDIRECT, TITER
$7.41
86890
5
AUTOLOGOUS BLOOD PROCESS
$0.00
86891
5
AUTOLOGOUS BLOOD, OP SALVAGE
$0.00
86900
3
BLOOD TYPING, ABO
$4.26
86901
3
BLOOD TYPING, RH (D)
$4.26
86903
3
BLOOD TYPING, ANTIGEN SCREEN
$0.00
$15.00
$13.50
Procedure Code Pricing Action Code Description
Maximum Allowable
86904
3
BLOOD TYPING, PATIENT SERUM
$13.60
86905
3
BLOOD TYPING, RBC ANTIGENS
$5.47
86906
3
BLOOD TYPING, RH PHENOTYPE
$11.08
86910
9
BLOOD TYPING, PATERNITY TEST
$0.00
86911
9
BLOOD TYPING, ANTIGEN SYSTEM
$0.00
86915
O
BONE MARROW/STEM CELL PREP
$0.00
86920
3
COMPATIBILITY TEST, SPIN
$36.00
86921
3
COMPATIBILITY TEST, INCUBATE
$36.00
86922
3
COMPATIBILITY TEST, ANTIGLOB
$36.00
86923
6
COMPATIBILITY TEST, ELECTRIC
$0.00
86927
5
PLASMA, FRESH FROZEN
$0.00
86930
5
FROZEN BLOOD PREP
$0.00
86931
5
FROZEN BLOOD THAW
$0.00
86932
5
FROZEN BLOOD FREEZE/THAW
$0.00
86940
3
HEMOLYSINS/AGGLUTININS, AUTO
$8.73
86941
3
HEMOLYSINS/AGGLUTININS
$17.02
86945
3
BLOOD PRODUCT/IRRADIATION
$42.00
86950
5
LEUKACYTE TRANSFUSION
$0.00
86960
6
VOL REDUCTION OF BLOOD/PROD
$0.00
86965
5
POOLING BLOOD PLATELETS
$0.00
86970
5
RBC PRETREATMENT
$0.00
86971
5
RBC PRETREATMENT
$0.00
86972
5
RBC PRETREATMENT
$0.00
86975
5
RBC PRETREATMENT, SERUM
$0.00
86976
5
RBC PRETREATMENT, SERUM
$0.00
86977
5
RBC PRETREATMENT, SERUM
$0.00
86978
5
RBC PRETREATMENT, SERUM
$0.00
86985
5
SPLIT BLOOD OR PRODUCTS
$0.00
86999
5
TRANSFUSION PROCEDURE
$0.00
87001
3
SMALL ANIMAL INOCULATION
$18.91
87003
3
SMALL ANIMAL INOCULATION
$24.09
87015
3
SPECIMEN CONCENTRATION
$9.56
87040
3
BLOOD CULTURE FOR BACTERIA
$14.77
87045
3
FECES CULTURE, BACTERIA
$13.49
87046
3
STOOL CULTR, BACTERIA, EACH
$13.49
Procedure Code Pricing Action Code Description
Maximum Allowable
87060
O
NOSE/THROAT CULTURE, BACT
$0.00
87070
3
CULTURE, BACTERIA, OTHER
$12.32
87071
3
CULTURE BACTERI AEROBIC OTHR
$13.49
87072
O
CULTURE OF SPECIMEN BY KIT
87073
3
CULTURE BACTERIA ANAEROBIC
$13.49
87075
3
CULTR BACTERIA, EXCEPT BLOOD
$13.53
87076
3
CULTURE ANAEROBE IDENT, EACH
$11.56
87077
3
CULTURE AEROBIC IDENTIFY
$11.56
87081
3
CULTURE SCREEN ONLY
$9.50
87082
O
CULTURE OF SPECIMEN BY KIT
$0.00
87083
O
CULTURE OF SPECIMEN BY KIT
$0.00
87084
3
CULTURE OF SPECIMEN BY KIT
$12.32
87085
O
CULTURE OF SPECIMEN BY KIT
$0.00
87086
3
URINE CULTURE/COLONY COUNT
87087
O
URINE BACTERIA CULTURE
$0.00
87088
3
URINE BACTERIA CULTURE
$11.58
87101
3
SKIN FUNGI CULTURE
$11.03
87102
3
FUNGUS ISOLATION CULTURE
$12.01
87103
3
BLOOD FUNGUS CULTURE
$12.91
87106
3
FUNGI IDENTIFICATION, YEAST
$14.77
87107
3
FUNGI IDENTIFICATION, MOLD
$14.77
87109
3
MYCOPLASMA
$22.02
87110
3
CHLAMYDIA CULTURE
$28.03
87116
3
MYCOBACTERIA CULTURE
$15.46
87117
O
MYCOBACTERIA CULTURE
$0.00
87118
3
MYCOBACTERIC IDENTIFICATION
87140
3
CULTURE TYPE IMMUNOFLUORESC
87143
3
CULTURE TYPING, GLC/HPLC
87145
O
CULTURE TYPING, PHAGE METHOD
$0.00
87147
3
CULTURE TYPE, IMMUNOLOGIC
$7.41
87149
3
CULTURE TYPE, NUCLEIC ACID
$28.68
87151
O
CULTURE TYPING, SEROLOGIC
$0.00
87152
3
CULTURE TYPE PULSE FIELD GEL
$7.49
87155
O
CULTURE TYPING, PRECIPITIN
$0.00
87158
3
CULTURE TYPING, ADDED METHOD
$7.49
$0.00
$11.55
$15.66 $6.92 $17.92
Procedure Code Pricing Action Code Description
Maximum Allowable
87163
O
SPECIAL MICROBIOLOGY CULTURE
$0.00
87164
3
DARK FIELD EXAMINATION
$15.37
87166
3
DARK FIELD EXAMINATION
$16.16
87168
3
MACROSCOPIC EXAM ARTHROPOD
$6.11
87169
3
MACROSCOPIC EXAM PARASITE
$6.11
87172
3
PINWORM EXAM
$6.11
87174
O
ENDOTOXIN, BACTERIAL
$0.00
87175
O
ASSAY, ENDOTOXIN, BACTERIAL
$0.00
87176
3
TISSUE HOMOGENIZATION, CULTR
$8.42
87177
3
OVA AND PARASITES SMEARS
87178
O
MICROBIAL IDENTIFICATION, NUCLEIC A
$0.00
87179
O
MICROBIAL IDENTIFICATION, NUCLEIC A
$0.00
87181
3
MICROBE SUSCEPTIBLE, DIFFUSE
$6.79
87184
3
MICROBE SUSCEPTIBLE, DISK
$9.87
87185
3
MICROBE SUSCEPTIBLE, ENZYME
$6.79
87186
3
MICROBE SUSCEPTIBLE, MIC
$12.37
87187
3
MICROBE SUSCEPTIBLE, MLC
$14.83
87188
3
MICROBE SUSCEPT, MACROBROTH
$9.18
87190
3
MICROBE SUSCEPT, MYCOBACTERI
$8.08
87192
O
ANTIBIOTIC SENSITIVITY, EACH
$0.00
87197
3
BACTERICIDAL LEVEL, SERUM
$16.63
87198
O
CYTOMEGALOVIRUS ANTIBODY DFA
$0.00
87199
O
ENTEROVIRUS ANTIBODY, DFA
$0.00
87205
3
SMEAR, GRAM STAIN
$6.11
87206
3
SMEAR, FLUORESCENT/ACID STAI
$6.92
87207
3
SMEAR, SPECIAL STAIN
$8.25
87208
O
SMEAR, STAIN & INTERPRET
$0.00
87209
3
SMEAR, COMPLEX STAIN
87210
3
SMEAR, WET MOUNT, SALINE/INK
$6.11
87211
O
SMEAR, STAIN & INTERPRET
$0.00
87220
3
TISSUE EXAM FOR FUNGI
$4.95
87230
3
ASSAY, TOXIN OR ANTITOXIN
$24.96
87250
3
VIRUS INOCULATE, EGGS/ANIMAL
$27.98
87252
3
VIRUS INOCULATION, TISSUE
$37.30
87253
3
VIRUS INOCULATE TISSUE, ADDL
$28.90
$12.73
$24.76
Procedure Code Pricing Action Code Description
Maximum Allowable
87254
3
VIRUS INOCULATION, SHELL VIA
$27.98
87255
3
GENET VIRUS ISOLATE, HSV
$48.45
87260
3
ADENOVIRUS AG, IF
$15.76
87265
3
PERTUSSIS AG, IF
$15.76
87267
3
ENTEROVIRUS ANTIBODY, DFA
$15.76
87269
3
GIARDIA AG, IF
$15.76
87270
3
CHLAMYDIA TRACHOMATIS AG, IF
$15.76
87271
3
CYTOMEGALOVIRUS DFA
$15.76
87272
3
CRYPTOSPORIDIUM AG, IF
$15.76
87273
3
HERPES SIMPLEX 2, AG, IF
$15.76
87274
3
HERPES SIMPLEX 1, AG, IF
$15.76
87275
3
INFLUENZA B, AG, IF
$15.76
87276
3
INFLUENZA A, AG, IF
$15.76
87277
3
LEGIONELLA MICDADEI, AG, IF
$15.76
87278
3
LEGION PNEUMOPHILIA AG, IF
$15.76
87279
3
PARAINFLUENZA, AG, IF
$15.76
87280
3
RESPIRATORY SYNCYTIAL AG, IF
$15.76
87281
3
PNEUMOCYSTIS CARINII, AG, IF
$15.76
87283
3
RUBEOLA, AG, IF
$15.76
87285
3
TREPONEMA PALLIDUM, AG, IF
$15.76
87290
3
VARICELLA ZOSTER, AG, IF
$15.76
87299
3
ANTIBODY DETECTION, NOS, IF
$15.76
87300
3
AG DETECTION, POLYVAL, IF
$15.76
87301
3
ADENOVIRUS AG, EIA
$15.76
87305
3
ASPERGILLUS AG, EIA
$15.76
87320
3
CHYLMD TRACH AG, EIA
$15.76
87324
3
CLOSTRIDIUM AG, EIA
$15.76
87327
3
CRYPTOCOCCUS NEOFORM AG, EIA
$15.76
87328
3
CRYPTOSPORIDIUM AG, EIA
$15.76
87329
3
GIARDIA AG, EIA
$15.76
87332
3
CYTOMEGALOVIRUS AG, EIA
$15.76
87335
3
E COLI 0157 AG, EIA
$15.76
87336
3
ENTAMOEB HIST DISPR, AG, EIA
$15.76
87337
3
ENTAMOEB HIST GROUP, AG, EIA
$15.76
87338
3
HPYLORI, STOOL, EIA
$15.76
Procedure Code Pricing Action Code Description
Maximum Allowable
87339
3
H PYLORI AG, EIA
$15.76
87340
3
HEPATITIS B SURFACE AG, EIA
$14.51
87341
3
HEPATITIS B SURFACE, AG, EIA
$14.51
87350
3
HEPATITIS BE AG, EIA
$16.49
87380
3
HEPATITIS DELTA AG, EIA
$23.50
87385
3
HISTOPLASMA CAPSUL AG, EIA
$15.76
87390
3
HIV-1 AG, EIA
$25.24
87391
3
HIV-2 AG, EIA
$25.24
87400
3
INFLUENZA A/B, AG, EIA
$15.76
87420
3
RESP SYNCYTIAL AG, EIA
$15.76
87425
3
ROTAVIRUS AG, EIA
$15.76
87427
3
SHIGA-LIKE TOXIN AG, EIA
$15.76
87430
3
STREP A AG, EIA
$15.76
87449
3
AG DETECT NOS, EIA, MULT
$15.76
87450
3
AG DETECT NOS, EIA, SINGLE
$13.71
87451
3
AG DETECT POLYVAL, EIA, MULT
$13.71
87470
3
BARTONELLA, DNA, DIR PROBE
$28.68
87471
3
BARTONELLA, DNA, AMP PROBE
$50.23
87472
3
BARTONELLA, DNA, QUANT
$40.60
87475
3
LYME DIS, DNA, DIR PROBE
$28.68
87476
3
LYME DIS, DNA, AMP PROBE
$50.23
87477
3
LYME DIS, DNA, QUANT
$40.60
87480
3
CANDIDA, DNA, DIR PROBE
$28.68
87481
3
CANDIDA, DNA, AMP PROBE
$50.23
87482
3
CANDIDA, DNA, QUANT
$40.60
87485
3
CHYLMD PNEUM, DNA, DIR PROBE
$28.68
87486
3
CHYLMD PNEUM, DNA, AMP PROBE
$50.23
87487
3
CHYLMD PNEUM, DNA, QUANT
$40.60
87490
3
CHYLMD TRACH, DNA, DIR PROBE
$28.68
87491
3
CHYLMD TRACH, DNA, AMP PROBE
$50.23
87492
3
CHYLMD TRACH, DNA, QUANT
$40.60
87495
3
CYTOMEG, DNA, DIR PROBE
$28.68
87496
3
CYTOMEG, DNA, AMP PROBE
$50.23
87497
3
CYTOMEG, DNA, QUANT
$40.60
87498
3
ENTEROVIRUS, DNA, AMP PROBE
$50.23
Procedure Code Pricing Action Code Description
Maximum Allowable
87500
3
VANOMYCIN, DNA, AMP PROBE
$50.23
87510
3
GARDNER VAG, DNA, DIR PROBE
$28.68
87511
3
GARDNER VAG, DNA, AMP PROBE
$50.23
87512
3
GARDNER VAG, DNA, QUANT
$40.60
87515
3
HEPATITIS B, DNA, DIR PROBE
$28.68
87516
3
HEPATITIS B, DNA, AMP PROBE
$50.23
87517
3
HEPATITIS B, DNA, QUANT
$40.60
87520
3
HEPATITIS C, RNA, DIR PROBE
$28.68
87521
3
HEPATITIS C, RNA, AMP PROBE
$50.23
87522
3
HEPATITIS C, RNA, QUANT
$40.60
87525
3
HEPATITIS G, DNA, DIR PROBE
$28.68
87526
3
HEPATITIS G, DNA, AMP PROBE
$50.23
87527
3
HEPATITIS G, DNA, QUANT
$40.60
87528
3
HSV, DNA, DIR PROBE
$28.68
87529
3
HSV, DNA, AMP PROBE
$50.23
87530
3
HSV, DNA, QUANT
$40.60
87531
3
HHV-6, DNA, DIR PROBE
$28.68
87532
3
HHV-6, DNA, AMP PROBE
$50.23
87533
3
HHV-6, DNA, QUANT
$40.60
87534
3
HIV-1, DNA, DIR PROBE
$28.68
87535
3
HIV-1, DNA, AMP PROBE
$50.23
87536
3
HIV-1, DNA, QUANT
87537
3
HIV-2, DNA, DIR PROBE
$28.68
87538
3
HIV-2, DNA, AMP PROBE
$50.23
87539
3
HIV-2, DNA, QUANT
$40.60
87540
3
LEGION PNEUMO, DNA, DIR PROB
$28.68
87541
3
LEGION PNEUMO, DNA, AMP PROB
$50.23
87542
3
LEGION PNEUMO, DNA, QUANT
$40.60
87550
3
MYCOBACTERIA, DNA, DIR PROBE
$28.68
87551
3
MYCOBACTERIA, DNA, AMP PROBE
$50.23
87552
3
MYCOBACTERIA, DNA, QUANT
$40.60
87555
3
M.TUBERCULO, DNA, DIR PROBE
$28.68
87556
3
M.TUBERCULO, DNA, AMP PROBE
$50.23
87557
3
M.TUBERCULO, DNA, QUANT
$40.60
87560
3
M.AVIUM-INTRA, DNA, DIR PROB
$28.68
$121.76
Procedure Code Pricing Action Code Description
Maximum Allowable
87561
3
M.AVIUM-INTRA, DNA, AMP PROB
$50.23
87562
3
M.AVIUM-INTRA, DNA, QUANT
$40.60
87580
3
M.PNEUMON, DNA, DIR PROBE
$28.68
87581
3
M.PNEUMON, DNA, AMP PROBE
$50.23
87582
3
M.PNEUMON, DNA, QUANT
$40.60
87590
3
N.GONORRHOEAE, DNA, DIR PROB
$28.68
87591
3
N.GONORRHOEAE, DNA, AMP PROB
$50.23
87592
3
N.GONORRHOEAE, DNA, QUANT
$40.60
87620
3
HPV, DNA, DIR PROBE
$28.68
87621
3
HPV, DNA, AMP PROBE
$50.23
87622
3
HPV, DNA, QUANT
$40.60
87640
3
STAPH A, DNA, AMP PROBE
$50.23
87641
3
MR-STAPH, DNA, AMP PROBE
$50.23
87650
3
STREP A, DNA, DIR PROBE
$28.68
87651
3
STREP A, DNA, AMP PROBE
$50.23
87652
3
STREP A, DNA, QUANT
$40.60
87653
3
STREP B, DNA, AMP PROBE
$50.23
87660
3
TRICHOMONAS VAGIN, DIR PROBE
$28.68
87797
3
DETECT AGENT NOS, DNA, DIR
$28.68
87798
3
DETECT AGENT NOS, DNA, AMP
$50.23
87799
3
DETECT AGENT NOS, DNA, QUANT
$61.29
87800
3
DETECT AGNT MULT, DNA, DIREC
$57.39
87801
3
DETECT AGNT MULT, DNA, AMPLI
$100.44
87802
3
STREP B ASSAY W/OPTIC
$15.76
87803
3
CLOSTRIDIUM TOXIN A W/OPTIC
$15.76
87804
3
INFLUENZA ASSAY W/OPTIC
$15.76
87807
3
INFECTIOUS AGENT ANTIGEN DETECTION
$15.76
87808
3
TRICHOMONAS ASSAY W/OPTIC
$15.76
87809
3
ADENOVIRUS ASSAY W/OPTIC
$15.76
87810
3
CHYLMD TRACH ASSAY W/OPTIC
$15.76
87850
3
N. GONORRHOEAE ASSAY W/OPTIC
$15.76
87880
3
STREP A ASSAY W/OPTIC
$15.76
87899
3
AGENT NOS ASSAY W/OPTIC
$15.76
87900
3
PHENOTYPE, INFECT AGENT DRUG
$186.50
87901
3
GENOTYPE, DNA, HIV REVERSE T
$368.36
Procedure Code Pricing Action Code Description
Maximum Allowable
87902
3
GENOTYPE, DNA, HEPATITIS C
$368.36
87903
3
PHENOTYPE, DNA HIV W/CULTURE
$699.16
87904
3
PHENOTYPE, DNA HIV W/CLT ADD
$37.30
87905
3
SIALIDASE ENZYME ASSAY
$8.99
87999
5
MICROBIOLOGY PROCEDURE
$0.00
88000
9
AUTOPSY (NECROPSY), GROSS
$0.00
88005
9
AUTOPSY (NECROPSY), GROSS
$0.00
88007
9
AUTOPSY (NECROPSY), GROSS
$0.00
88012
9
AUTOPSY (NECROPSY), GROSS
$0.00
88014
9
AUTOPSY (NECROPSY), GROSS
$0.00
88016
9
AUTOPSY (NECROPSY), GROSS
$0.00
88020
9
AUTOPSY (NECROPSY), COMPLETE
$0.00
88025
9
AUTOPSY (NECROPSY), COMPLETE
$0.00
88027
9
AUTOPSY (NECROPSY), COMPLETE
$0.00
88028
9
AUTOPSY (NECROPSY), COMPLETE
$0.00
88029
9
AUTOPSY (NECROPSY), COMPLETE
$0.00
88036
9
LIMITED AUTOPSY
$0.00
88037
9
LIMITED AUTOPSY
$0.00
88040
9
FORENSIC AUTOPSY (NECROPSY)
$0.00
88045
9
CORONERÏS AUTOPSY (NECROPSY)
$0.00
88099
9
NECROPSY (AUTOPSY) PROCEDURE
$0.00
88104
3
CYTOPATH FL NONGYN, SMEARS
$51.49
88106
3
CYTOPATH FL NONGYN, FILTER
$46.46
88107
3
CYTOPATH FL NONGYN, SM/FLTR
$68.58
88108
3
CYTOPATH, CONCENTRATE TECH
$53.81
88112
3
CYTOPATH, CELL ENHANCE TECH
$123.81
88125
3
FORENSIC CYTOPATHOLOGY
$20.54
88130
3
SEX CHROMATIN IDENTIFICATION
$21.53
88140
3
SEX CHROMATIN IDENTIFICATION
$11.44
88141
3
CYTOPATH, C/V, INTERPRET
$23.24
88142
3
CYTOPATH, C/V, THIN LAYER
$28.99
88143
3
CYTOPATH C/V THIN LAYER REDO
$28.99
88144
O
CYTOPATH, C/V, THIN LYR REDO
$0.00
88145
O
CYTOPATH, C/V, THIN LYR SEL
$0.00
88147
3
CYTOPATH, C/V, AUTOMATED
$16.29
Procedure Code Pricing Action Code Description
Maximum Allowable
88148
3
CYTOPATH, C/V, AUTO RESCREEN
$21.75
88150
3
CYTOPATH, C/V, MANUAL
$15.11
88151
O
CYTOPATHOLOGY, SMEARS, CERVICAL OR
88152
3
CYTOPATH, C/V, AUTO REDO
$15.11
88153
3
CYTOPATH, C/V, REDO
$15.11
88154
3
CYTOPATH, C/V, SELECT
$15.11
88155
3
CYTOPATH, C/V, INDEX ADD-ON
$8.58
88156
O
CYTOPATH CERV/VAG TBS
$0.00
88157
O
CYTOPATHOLOGY, SMEARS, CERVICAL OR
$0.00
88158
O
CYTOPATH CERV/VAG TBS AUTO
$0.00
88160
3
CYTOPATH SMEAR, OTHER SOURCE
$55.77
88161
3
CYTOPATH SMEAR, OTHER SOURCE
$54.23
88162
3
CYTOPATH SMEAR, OTHER SOURCE
$56.99
88164
3
CYTOPATH TBS, C/V, MANUAL
$15.11
88165
3
CYTOPATH TBS, C/V, REDO
$15.11
88166
3
CYTOPATH TBS, C/V, AUTO REDO
$15.11
88167
3
CYTOPATH TBS, C/V, SELECT
$15.11
88170
O
FINE NEEDLE ASPIRATION
$0.00
88171
O
FINE NEEDLE ASPIRATION
$0.00
88172
3
CYTOPATHOLOGY EVAL OF FNA
$49.53
88173
3
CYTOPATH EVAL, FNA, REPORT
$122.91
88174
3
CYTOPATH, C/V AUTO, IN FLUID
$30.57
88175
3
CYTOPATH C/V AUTO FLUID REDO
$37.91
88180
O
CELL MARKER STUDY
$0.00
88182
3
CELL MARKER STUDY
$93.14
88184
3
FLOWCYTOMETRY/ TC, 1 MARKER
$49.26
88185
3
FLOWCYTOMETRY/TC, ADD-ON
$24.22
88187
3
FLOWCYTOMETRY/READ, 2-8
$63.03
88188
3
FLOWCYTOMETRY/READ, 9-15
$83.19
88189
3
FLOWCYTOMETRY/READ, 16 & >
$109.59
88199
5
CYTOPATHOLOGY PROCEDURE
$0.00
88230
3
TISSUE CULTURE, LYMPHOCYTE
$166.70
88233
3
TISSUE CULTURE, SKIN/BIOPSY
$201.37
88235
3
TISSUE CULTURE, PLACENTA
$210.70
88237
3
TISSUE CULTURE, BONE MARROW
$180.72
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
88239
3
TISSUE CULTURE, TUMOR
$211.08
88240
3
CELL CRYOPRESERVE/STORAGE
$14.46
88241
3
FROZEN CELL PREPARATION
$14.46
88245
3
CHROMOSOME ANALYSIS, 20-25
$213.00
88248
3
CHROMOSOME ANALYSIS, 50-100
$247.78
88249
3
CHROMOSOME ANALYSIS, 100
$247.78
88250
O
CHROMOSOME ANALYSIS
$0.00
88260
O
CHROMOSOME ANALYSIS: 5 CELLS
$0.00
88261
3
CHROMOSOME ANALYSIS, 5
$252.89
88262
3
CHROMOSOME ANALYSIS, 15-20
$178.34
88263
3
CHROMOSOME ANALYSIS, 45
$215.03
88264
3
CHROMOSOME ANALYSIS, 20-25
$178.34
88267
3
CHROMOSOME ANALYS, PLACENTA
$257.22
88269
3
CHROMOSOME ANALYS, AMNIOTIC
$237.98
88271
3
CYTOGENETICS, DNA PROBE
$30.64
88272
3
CYTOGENETICS, 3-5
$38.31
88273
3
CYTOGENETICS, 10-30
$45.97
88274
3
CYTOGENETICS, 25-99
$49.80
88275
3
CYTOGENETICS, 100-300
$57.47
88280
3
CHROMOSOME KARYOTYPE STUDY
$35.91
88283
3
CHROMOSOME BANDING STUDY
$98.15
88285
3
CHROMOSOME COUNT, ADDITIONAL
$27.19
88289
3
CHROMOSOME STUDY, ADDITIONAL
$49.27
88291
3
CYTO/MOLECULAR REPORT
$31.20
88299
5
CYTOGENETIC STUDY
88300
3
SURGICAL PATH, GROSS
$14.46
88302
3
TISSUE EXAM BY PATHOLOGIST
$32.51
88304
3
TISSUE EXAM BY PATHOLOGIST
$42.89
88305
3
TISSUE EXAM BY PATHOLOGIST
$97.57
88307
3
TISSUE EXAM BY PATHOLOGIST
$166.79
88309
3
TISSUE EXAM BY PATHOLOGIST
$217.13
88311
3
DECALCIFY TISSUE
$17.46
88312
3
SPECIAL STAINS
$73.61
88313
3
SPECIAL STAINS
$51.85
88314
3
HISTOCHEMICAL STAIN
$52.71
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
88317
O
INTERPRETATION AND REPORT BY TREATI
$0.00
88318
3
CHEMICAL HISTOCHEMISTRY
$47.79
88319
3
ENZYME HISTOCHEMISTRY
$94.40
88321
3
MICROSLIDE CONSULTATION
$82.65
88323
9
MICROSLIDE CONSULTATION
$0.00
88325
3
COMPREHENSIVE REVIEW OF DATA
88329
3
PATH CONSULT INTROP
$50.44
88331
3
PATH CONSULT INTRAOP, 1 BLOC
$85.84
88332
3
PATH CONSULT INTRAOP, ADDÏL
$42.97
88333
3
INTRAOP CYTO PATH CONSULT, 1
$90.40
88334
3
INTRAOP CYTO PATH CONSULT, 2
$52.97
88342
3
IMMUNOHISTOCHEMISTRY
$86.31
88346
3
IMMUNOFLUORESCENT STUDY
$90.16
88347
3
IMMUNOFLUORESCENT STUDY
$102.53
88348
3
ELECTRON MICROSCOPY
$388.66
88349
3
SCANNING ELECTRON MICROSCOPY
$417.97
88355
3
ANALYSIS, SKELETAL MUSCLE
$175.05
88356
3
ANALYSIS, NERVE
$231.50
88358
3
ANALYSIS, TUMOR
$63.47
88360
3
TUMOR IMMUNOHISTOCHEM/MANUAL
$106.57
88361
3
TUMOR IMMUNOHISTOCHEM/COMPUT
$141.54
88362
3
NERVE TEASING PREPARATIONS
$256.79
88365
3
INSITU HYBRIDIZATION (FISH)
$122.58
88367
3
INSITU HYBRIDIZATION, AUTO
$200.25
88368
3
INSITU HYBRIDIZATION, MANUAL
$143.52
88371
3
PROTEIN, WESTERN BLOT TISSUE
$31.79
88372
3
PROTEIN ANALYSIS W/PROBE
$32.56
88380
5
MICRODISSECTION, LASER
$0.00
88381
6
MICRODISSECTION, MANUAL
$0.00
88384
3
EVAL MOLECULAR PROBES, 11-50
$326.65
88385
3
EVAL MOLECUL PROBES, 51-250
$335.50
88386
3
EVAL MOLECUL PROBES, 251-500
$349.50
88399
5
SURGICAL PATHOLOGY PROCEDURE
$0.00
88400
O
BILIRUBIN TOTAL TRANSCUT
$0.00
88720
3
BILIRUBIN TOTAL TRANSCUT
$7.18
$199.53
Procedure Code Pricing Action Code Description
Maximum Allowable
88740
3
TRANSCUTANEOUS CARBOXYHB
$7.18
88741
3
TRANSCUTANEOUS METHB
$7.18
89049
6
CHCT FOR MAL HYPERTHERMIA
$0.00
89050
3
BODY FLUID CELL COUNT
$6.76
89051
3
BODY FLUID CELL COUNT
$7.88
89055
3
LEUKOCYTE ASSESSMENT, FECAL
$6.11
89060
3
EXAM,SYNOVIAL FLUID CRYSTALS
$10.23
89100
3
SAMPLE INTESTINAL CONTENTS
$85.26
89105
3
SAMPLE INTESTINAL CONTENTS
$106.19
89125
3
SPECIMEN FAT STAIN
89130
3
SAMPLE STOMACH CONTENTS
$84.96
89132
3
SAMPLE STOMACH CONTENTS
$64.72
89135
3
SAMPLE STOMACH CONTENTS
$92.70
89136
3
SAMPLE STOMACH CONTENTS
$70.12
89140
3
SAMPLE STOMACH CONTENTS
$116.57
89141
3
SAMPLE STOMACH CONTENTS
$138.65
89160
3
EXAM FECES FOR MEAT FIBERS
$5.27
89190
3
NASAL SMEAR FOR EOSINOPHILS
$6.79
89205
O
OCCULT BLOOD, ANY SOURCE EXCEPT FEC
$0.00
89220
3
SPUTUM SPECIMEN COLLECTION
89225
3
STARCH GRANULES, FECES
$4.78
89230
3
COLLECT SWEAT FOR TEST
$17.60
89235
3
WATER LOAD TEST
$7.88
89240
6
PATHOLOGY LAB PROCEDURE
$0.00
89250
9
CULTR OOCYTE/EMBRYO <4 DAYS
$0.00
89251
9
CULTR OOCYTE/EMBRYO <4 DAYS
$0.00
89252
O
ASSIST OOCYTE FERTILIZATION
$0.00
89253
9
EMBRYO HATCHING
$0.00
89254
9
OOCYTE IDENTIFICATION
$0.00
89255
9
PREPARE EMBRYO FOR TRANSFER
$0.00
89256
O
PREPARE CRYOPRESERVED EMBRYO
$0.00
89257
9
SPERM IDENTIFICATION
$0.00
89258
9
CRYOPRESERVATION; EMBRYO(S)
$0.00
89259
9
CRYOPRESERVATION, SPERM
$0.00
89260
9
SPERM ISOLATION, SIMPLE
$0.00
$6.17
$16.06
Procedure Code Pricing Action Code Description
Maximum Allowable
89261
9
SPERM ISOLATION, COMPLEX
$0.00
89264
9
IDENTIFY SPERM TISSUE
$0.00
89268
9
INSEMINATION OF OOCYTES
$0.00
89272
9
EXTENDED CULTURE OF OOCYTES
$0.00
89280
9
ASSIST OOCYTE FERTILIZATION
$0.00
89281
9
ASSIST OOCYTE FERTILIZATION
$0.00
89290
9
BIOPSY, OOCYTE POLAR BODY
$0.00
89291
9
BIOPSY, OOCYTE POLAR BODY
$0.00
89300
9
SEMEN ANALYSIS W/HUHNER
$0.00
89310
3
SEMEN ANALYSIS W/COUNT
$12.32
89320
3
SEMEN ANAL VOL/COUNT/MOT
$17.25
89321
3
SEMEN ANAL, SPERM DETECTION
$17.25
89322
3
SEMEN ANAL, STRICT CRITERIA
$22.18
89325
3
SPERM ANTIBODY TEST
$15.27
89329
9
SPERM EVALUATION TEST
$0.00
89330
9
EVALUATION, CERVICAL MUCUS
$0.00
89331
3
RETROGRADE EJACULATION ANAL
$28.03
89335
9
CRYOPRESERVE TESTICULAR TISS
$0.00
89342
9
STORAGE/YEAR; EMBRYO(S)
$0.00
89343
9
STORAGE/YEAR; SPERM/SEMEN
$0.00
89344
9
STORAGE/YEAR; REPROD TISSUE
$0.00
89346
9
STORAGE/YEAR; OOCYTE(S)
$0.00
89350
O
SPUTUM SPECIMEN COLLECTION
$0.00
89352
9
THAWING CRYOPRESRVED; EMBRYO
$0.00
89353
9
THAWING CRYOPRESRVED; SPERM
$0.00
89354
9
THAW CRYOPRSVRD; REPROD TISS
$0.00
89355
O
EXAM FECES FOR STARCH
$0.00
89356
9
THAWING CRYOPRESRVED; OOCYTE
$0.00
89360
O
COLLECT SWEAT FOR TEST
$0.00
89365
O
WATER LOAD TEST
$0.00
89399
O
PATHOLOGY LAB PROCEDURE
$0.00
90000
O
OFFICE AND OTHER OUTPATIENT MEDICAL
$0.00
90010
O
OFFICE AND OTHER OUTPATIENT MEDICAL
$0.00
90015
O
OFFICE AND OTHER OUTPATIENT MEDICAL
$0.00
90017
O
OFFICE AND OTHER OUTPATIENT MEDICAL
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
90020
O
OFFICE AND OTHER OUTPATIENT MEDICAL
$0.00
90030
O
OFFICE AND OTHER OUTPATIENT MEDICAL
$0.00
90040
O
OFFICE AND OTHER OUTPATIENT MEDICAL
$0.00
90050
O
OFFICE AND OTHER OUTPATIENT MEDICAL
$0.00
90060
O
OFFICE AND OTHER OUTPATIENT MEDICAL
$0.00
90070
O
OFFICE AND OTHER OUTPATIENT MEDICAL
$0.00
90080
O
OFFICE AND OTHER OUTPATIENT MEDICAL
$0.00
90100
O
HOME MEDICAL SERVICE, NEW PATIENT B
$0.00
90110
O
HOME MEDICAL SERVICE, NEW PATIENT L
$0.00
90115
O
HOME MEDICAL SERVICE, NEW PATIENT I
$0.00
90117
O
HOME MEDICAL SERVICE, NEW PATIENT E
$0.00
90130
O
HOME MEDICAL SERVICE, ESTABLISHED P
$0.00
90140
O
HOME MEDICAL SERVICE, ESTABLISHED P
$0.00
90150
O
HOME MEDICAL SERVICE, ESTABLISHED P
$0.00
90160
O
HOME MEDICAL SERVICE, ESTABLISHED P
$0.00
90170
O
HOME MEDICAL SERVICE, ESTABLISHED P
$0.00
90200
O
INITIAL HOSPITAL CARE BRIEF HISTORY
$0.00
90215
O
INITIAL HOSPITAL CARE INTERMEDIATE
$0.00
90220
O
INITIAL HOSPITAL CARE COMPREHENSIVE
$0.00
90225
O
HISTORY AND EXAMINATION OF THE NORM
$0.00
90240
O
SUBSEQUENT HOSPITAL CARE, EACH DAY
$0.00
90250
O
SUBSEQUENT HOSPITAL CARE, EACH DAY
$0.00
90260
O
SUBSEQUENT HOSPITAL CARE, EACH DAY
$0.00
90270
O
SUBSEQUENT HOSPITAL CARE, EACH DAY
$0.00
90280
O
SUBSEQUENT HOSPITAL CARE, EACH DAY
$0.00
90281
5
HUMAN IG, IM
$0.00
90282
O
SUBSEQUENT HOSPITAL CARE, EACH DAY
$0.00
90283
5
HUMAN IG, IV
$0.00
90284
6
HUMAN IG, SC
$0.00
90287
5
BOTULINUM ANTITOXIN
$0.00
90288
5
BOTULISM IG, IV
$0.00
90291
5
CMV IG, IV
$0.00
90292
O
HOSPITAL DISCHARGE DAY MANAGEMENT
$0.00
90296
5
DIPHTHERIA ANTITOXIN
$0.00
90300
O
INITIAL CARE, SKILLED NURSING FACIL
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
90315
O
INITIAL CARE, SKILLED NURSING FACIL
$0.00
90320
O
INITIAL CARE, SKILLED NURSING FACIL
$0.00
90340
O
SUBSEQUENT CARE, SKILLED NURSING FA
$0.00
90350
O
SUBSEQUENT CARE, SKILLED NURSING FA
$0.00
90360
O
SUBSEQUENT CARE, SKILLED NURSING FA
$0.00
90370
O
SUBSEQUENT CARE, SKILLED NURSING FA
$0.00
90371
5
HEP B IG, IM
$0.00
90375
5
RABIES IG, IM/SC
$0.00
90376
5
RABIES IG, HEAT TREATED
$0.00
90378
5
RSV IG, IM, 50MG
$0.00
90379
5
RSV IG, IV
$0.00
90384
5
RH IG, FULL-DOSE, IM
$0.00
90385
5
RH IG, MINIDOSE, IM
$0.00
90386
5
RH IG, IV
$0.00
90389
5
TETANUS IG, IM
$0.00
90393
5
VACCINA IG, IM
$0.00
90396
5
VARICELLA-ZOSTER IG, IM
$0.00
90399
5
IMMUNE GLOBULIN
$0.00
90400
O
REST HOME (EG, BOARDING HOME), DOMI
$0.00
90410
O
REST HOME (EG, BOARDING HOME), DOMI
$0.00
90415
O
REST HOME (EG, BOARDING HOME), DOMI
$0.00
90420
O
REST HOME (EG, BOARDING HOME), DOMI
$0.00
90430
O
REST HOME (EG, BOARDING HOME), DOMI
$0.00
90440
O
REST HOME (EG, BOARDING HOME), DOMI
$0.00
90450
O
REST HOME (EG, BOARDING HOME), DOMI
$0.00
90460
O
REST HOME (EG, BOARDING HOME), DOMI
$0.00
90465
9
IMMUNE ADMIN 1 INJ, < 8 YRS
$0.00
90466
9
IMMUNE ADMIN ADDL INJ, < 8 Y
$0.00
90467
9
IMMUNE ADMIN O OR N, < 8 YRS
$0.00
90468
9
IMMUNE ADMIN O/N, ADDL < 8 Y
$0.00
90470
O
REST HOME (EG, BOARDING HOME), DOMI
$0.00
90471
9
IMMUNIZATION ADMIN
$0.00
90472
9
IMMUNIZATION ADMIN, EACH ADD
$0.00
90473
9
IMMUNE ADMIN ORAL/NASAL
$0.00
90474
9
IMMUNE ADMIN ORAL/NASAL ADDL
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
90476
5
ADENOVIRUS VACCINE, TYPE 4
$0.00
90477
5
ADENOVIRUS VACCINE, TYPE 7
$0.00
90500
O
EMERGENCY DEPARTMENT SERVICE, NEW P
$0.00
90505
O
EMERGENCY DEPARTMENT SERVICE, NEW P
$0.00
90510
O
EMERGENCY DEPARTMENT SERVICE, NEW P
$0.00
90515
O
EMERGENCY DEPARTMENT SERVICE, NEW P
$0.00
90517
O
EMERGENCY DEPARTMENT SERVICE, NEW P
$0.00
90520
O
EMERGENCY DEPARTMENT SERVICE, NEW P
$0.00
90530
O
EMERGENCY DEPARTMENT SERVICE, ESTAB
$0.00
90540
O
EMERGENCY DEPARTMENT SERVICE, ESTAB
$0.00
90550
O
EMERGENCY DEPARTMENT SERVICE, ESTAB
$0.00
90560
O
EMERGENCY DEPARTMENT SERVICE, ESTAB
$0.00
90570
O
EMERGENCY DEPARTMENT SERVICE, ESTAB
$0.00
90580
O
EMERGENCY DEPARTMENT SERVICE, ESTAB
$0.00
90581
5
ANTHRAX VACCINE, SC
$0.00
90585
5
BCG VACCINE, PERCUT
$0.00
90586
5
BCG VACCINE, INTRAVESICAL
$0.00
90590
9
PHYSICIAN DIRECTION OF EMERGENCY ME
$0.00
90592
9
CHOLERA VACCINE, ORAL
$0.00
90600
O
INITIAL CONSULTATION LIMITED
$0.00
90605
O
INITIAL CONSULTATION INTERMEDIATE
$0.00
90610
O
INITIAL CONSULTATION EXTENDED
$0.00
90620
O
INITIAL CONSULTATION COMPREHENSIVE
$0.00
90630
O
INITIAL CONSULTATION COMPLEX
$0.00
90632
3
HEP A VACCINE, ADULT IM
90633
5
HEP A VACC, PED/ADOL, 2 DOSE
$0.00
90634
5
HEP A VACC, PED/ADOL, 3 DOSE
$0.00
90636
6
HEP A/HEP B VACC, ADULT IM
$0.00
90640
9
FOLLOW-UP CONSULTATION BRIEF
$0.00
90641
9
FOLLOW-UP CONSULTATION LIMITED
$0.00
90642
9
FOLLOW-UP CONSULTATION INTERMEDIATE
$0.00
90643
9
FOLLOW-UP CONSULTATION COMPLEX
$0.00
90645
5
HIB VACCINE, HBOC, IM
$0.00
90646
5
HIB VACCINE, PRP-D, IM
$0.00
90647
5
HIB VACCINE, PRP-OMP, IM
$0.00
$48.22
Procedure Code Pricing Action Code Description
Maximum Allowable
90648
5
HIB VACCINE, PRP-T, IM
$0.00
90650
9
HPV VACCINE TYPES 16, 18, BIVALENT
$0.00
90651
9
CONFIRMATORY CONSULTATION INTERMEDI
$0.00
90652
9
CONFIRMATORY CONSULTATION EXTENDED
$0.00
90653
9
CONFIRMATORY CONSULTATION COMPREHEN
$0.00
90654
9
CONFIRMATORY CONSULTATION COMPLEX
$0.00
90655
5
FLU VACCINE NO PRESERV 6-35M
$0.00
90656
5
FLU VACCINE NO PRESERV 3 & >
$0.00
90657
5
FLU VACCINE, 3 YRS, IM
$0.00
90658
3
FLU VACCINE, 3 YRS & >, IM
90659
O
FLU VACCINE, WHOLE, IM
$0.00
90660
5
FLU VACCINE, NASAL
$0.00
90661
9
FLU VACC CELL CULT PRSV FREE
$0.00
90662
9
FLU VACC PRSV FREE INC ANTIG
$0.00
90663
9
FLU VACC PANDEMIC
$0.00
90665
3
LYME DISEASE VACCINE, IM
90669
5
PNEUMOCOCCAL VACC, PED <5
$0.00
90675
5
RABIES VACCINE, IM
$0.00
90676
5
RABIES VACCINE, ID
$0.00
90680
5
ROTOVIRUS VACC 3 DOSE, ORAL
$0.00
90681
6
ROTAVIRUS VACCINE, HUMAN, ATTENUAT
$0.00
90690
9
TYPHOID VACCINE, ORAL
$0.00
90691
9
TYPHOID VACCINE, IM
$0.00
90692
9
TYPHOID VACCINE, H-P, SC/ID
$0.00
90693
9
TYPHOID VACCINE, AKD, SC
$0.00
90696
6
DIPTHERIA,TETANUS TOXOIDS,ACELLULA
$0.00
90698
6
DTAP-HIB-IP VACCINE, IM
$0.00
90699
O
UNLISTED MEDICAL SERVICE, GENERAL
$0.00
90700
5
DTAP VACCINE, < 7 YRS, IM
$0.00
90701
5
DTP VACCINE, IM
$0.00
90702
5
DT VACCINE < 7, IM
$0.00
90703
3
TETANUS VACCINE, IM
90704
5
MUMPS VACCINE, SC
$0.00
90705
5
MEASLES VACCINE, SC
$0.00
90706
5
RUBELLA VACCINE, SC
$0.00
$13.22
$53.35
$22.47
Procedure Code Pricing Action Code Description
Maximum Allowable
90707
3
MMR VACCINE, SC
$44.73
90708
5
MEASLES-RUBELLA VACCINE, SC
$0.00
90709
O
RUBELLA & MUMPS VACCINE, SC
$0.00
90710
5
MMRV VACCINE, SC
$0.00
90711
O
COMBINED VACCINE
$0.00
90712
5
ORAL POLIOVIRUS VACCINE
$0.00
90713
6
POLIOVIRUS, IPV, SC/IM
$0.00
90714
3
TD VACCINE NO PRSRV >/= 7 IM
$19.98
90715
3
TDAP VACCINE >7 IM
$35.05
90716
6
CHICKEN POX VACCINE, SC
$0.00
90717
9
YELLOW FEVER VACCINE, SC
$0.00
90718
3
TD VACCINE > 7, IM
90719
5
DIPHTHERIA VACCINE, IM
$0.00
90720
5
DTP/HIB VACCINE, IM
$0.00
90721
6
DTAP/HIB VACCINE, IM
$0.00
90723
5
DTAP-HEP B-IPV VACCINE, IM
$0.00
90724
O
INFLUENZA IMMUNIZATION
$0.00
90725
9
CHOLERA VACCINE, INJECTABLE
$0.00
90726
O
RABIES IMMUNIZATION
$0.00
90727
9
PLAGUE VACCINE, IM
$0.00
90728
O
BCG IMMUNIZATION
$0.00
90730
O
HEPATITIS A VACCINE
$0.00
90731
O
IMMUNIZATION, ACTIVE; HEPATITIS B V
$0.00
90732
3
PNEUMOCOCCAL VACCINE
$12.85
90733
3
MENINGOCOCCAL VACCINE, SC
$12.85
90734
3
MENINGOCOCCAL VACCINE, IM
$41.00
90735
9
ENCEPHALITIS VACCINE, SC
$0.00
90736
6
ZOSTER VACC, SC
$0.00
90737
O
INFLUENZA B IMMUNIZATION
$0.00
90738
9
JAPANESE ENCEPHALITIS VIRUS VACCIN
$0.00
90740
5
HEPB VACC, ILL PAT 3 DOSE IM
$0.00
90741
O
PASSIVE IMMUNIZATION, ISG
$0.00
90742
O
SPECIAL PASSIVE IMMUNIZATION
$0.00
90743
5
HEP B VACC, ADOL, 2 DOSE, IM
$0.00
90744
5
HEPB VACC PED/ADOL 3 DOSE IM
$0.00
$13.85
Procedure Code Pricing Action Code Description
Maximum Allowable
90745
O
HEPB VACCINE, ADOL/RISK, IM
$0.00
90746
3
HEP B VACCINE, ADULT, IM
90747
5
HEPB VACC, ILL PAT 4 DOSE IM
$0.00
90748
6
HEP B/HIB VACCINE, IM
$0.00
90749
5
VACCINE TOXOID
$0.00
90750
9
INITIAL HISTORY AND EXAMINATION REL
$0.00
90751
9
INITIAL HISTORY AND EXAMINATION REL
$0.00
90752
O
INITIAL HISTORY AND EXAMINATION REL
$0.00
90753
O
INITIAL HISTORY AND EXAMINATION REL
$0.00
90754
O
INITIAL HISTORY AND EXAMINATION REL
$0.00
90755
9
INFANT CARE TO ONE YEAR OF AGE, WIT
$0.00
90757
O
NEWBORN CARE, IN OTHER THAN HOSPITA
$0.00
90760
O
HYDRATION IV INFUSION, INIT
$0.00
90761
O
HYDRATE IV INFUSION, ADD-ON
$0.00
90762
O
INTERVAL HISTORY AND EXAMINATION RE
$0.00
90763
O
INTERVAL HISTORY AND EXAMINATION RE
$0.00
90764
O
INTERVAL HISTORY AND EXAMINATION RE
$0.00
90765
O
THER/PROPH/DIAG IV INF, INIT
$0.00
90766
O
THER/PROPH/DG IV INF, ADD-ON
$0.00
90767
O
TX/PROPH/DG ADDL SEQ IV INF
$0.00
90768
O
THER/DIAG CONCURRENT INF
$0.00
90769
O
SC THER INFUSION, UP TO 1 HR
$0.00
90770
O
SC THER INFUSION, ADDL HR
$0.00
90771
O
SC THER INFUSION, RESET PUMP
$0.00
90772
O
THER/PROPH/DIAG INJ, SC/IM
$0.00
90773
O
THER/PROPH/DIAG INJ, IA
$0.00
90774
O
THERAPEUTIC, PROPHYLACTIC OR DIAG
$0.00
90775
O
TX/PRO/DX INJ NEW DRUG ADDON
$0.00
90776
O
TX/PRO/DX INJ SAME DRUG ADON
$0.00
90778
O
CIRCADIAN RESPIRATORY PATTERN RECOR
$0.00
90779
O
THER/PROP/DIAG INJ/INF PROC
$0.00
90780
O
IV INFUSION THERAPY, 1 HOUR
$0.00
90781
O
IV INFUSION, ADDITIONAL HOUR
$0.00
90782
O
INJECTION, SC/IM
$0.00
90783
O
INJECTION, IA
$0.00
$59.71
Procedure Code Pricing Action Code Description
Maximum Allowable
90784
O
INJECTION, IV
$0.00
90788
O
INJECTION OF ANTIBIOTIC
$0.00
90798
O
INTRAVENOUS THERAPY FOR SEVERE OR I
$0.00
90799
O
THER/PROPHYLACTIC/DX INJECT
$0.00
90801
3
PSY DX INTERVIEW
$152.51
90802
3
INTAC PSY DX INTERVIEW
$162.48
90804
3
PSYTX, OFFICE, 20-30 MIN
$66.73
90805
3
PSYTX, OFF, 20-30 MIN W/E&M
$74.29
90806
3
PSYTX, OFF, 45-50 MIN
$92.92
90807
3
PSYTX, OFF, 45-50 MIN W/E&M
$104.22
90808
3
PSYTX, OFFICE, 75-80 MIN
$136.47
90809
3
PSYTX, OFF, 75-80, W/E&M
$147.38
90810
3
INTAC PSYTX, OFF, 20-30 MIN
$70.72
90811
3
INTAC PSYTX, 20-30, W/E&M
$82.55
90812
3
INTAC PSYTX, OFF, 45-50 MIN
$101.32
90813
3
INTAC PSYTX, 45-50 MIN W/E&M
$112.62
90814
3
INTAC PSYTX, OFF, 75-80 MIN
$146.81
90815
3
INTAC PSYTX, 75-80 W/E&M
$155.78
90816
3
PSYTX, HOSP, 20-30 MIN
$61.63
90817
3
PSYTX, HOSP, 20-30 MIN W/E&M
$68.41
90818
3
PSYTX, HOSP, 45-50 MIN
$91.72
90819
3
PSYTX, HOSP, 45-50 MIN W/E&M
$98.36
90820
9
INTERACTIVE MEDICAL PSYCHIATRIC DIA
90821
3
PSYTX, HOSP, 75-80 MIN
$135.26
90822
3
PSYTX, HOSP, 75-80 MIN W/E&M
$142.15
90823
3
INTAC PSYTX, HOSP, 20-30 MIN
$66.53
90824
3
INTAC PSYTX, HSP 20-30 W/E&M
$73.95
90825
9
PSYCHIATRIC EVALUATION OF HOSPITAL
90826
3
INTAC PSYTX, HOSP, 45-50 MIN
$97.25
90827
3
INTAC PSYTX, HSP 45-50 W/E&M
$103.26
90828
3
INTAC PSYTX, HOSP, 75-80 MIN
$140.55
90829
3
INTAC PSYTX, HSP 75-80 W/E&M
$146.80
90830
O
PSYCHOLOGICAL TESTING (INCLUDES PSY
$0.00
90835
9
NARCOSYNTHESIS FOR PSYCHIATRIC DIAG
$0.00
90841
9
INDIVIDUAL MEDICAL PSYCHOTHERAPY BY
$0.00
$0.00
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
90842
9
INDIVIDUAL MEDICAL PSYCHOTHERAPY BY
$0.00
90843
9
INDIVIDUAL MEDICAL PSYCHOTHERAPY BY
$0.00
90844
9
INDIVIDUAL MEDICAL PSYCHOTHERAPY BY
$0.00
90845
3
PSYCHOANALYSIS
$81.19
90846
3
FAMILY PSYTX W/O PATIENT
$86.69
90847
3
FAMILY PSYTX W/PATIENT
90849
3
MULTIPLE FAMILY GROUP PSYTX
$32.65
90853
3
GROUP PSYCHOTHERAPY
$30.94
90855
9
INTERACTIVE INDIVIDUAL MEDICAL PSYC
90857
3
INTAC GROUP PSYTX
$34.95
90862
3
MEDICATION MANAGEMENT
$55.13
90865
9
NARCOSYNTHESIS
90870
3
ELECTROCONVULSIVE THERAPY
$137.28
90871
O
ELECTROCONVULSIVE THERAPY
$0.00
90875
9
PSYCHOPHYSIOLOGICAL THERAPY
$0.00
90876
9
PSYCHOPHYSIOLOGICAL THERAPY
$0.00
90880
9
HYPNOTHERAPY
$0.00
90882
9
ENVIRONMENTAL MANIPULATION
$0.00
90885
3
PSY EVALUATION OF RECORDS
90887
9
CONSULTATION WITH FAMILY
$0.00
90889
9
PREPARATION OF REPORT
$0.00
90899
O
PSYCHIATRIC SERVICE/THERAPY
$0.00
90900
O
BIOFEEDBACK TRAINING; BY ELECTROMYO
$0.00
90901
9
BIOFEEDBACK TRAIN, ANY METH
$0.00
90902
O
BIOFEEDBACK TRAINING; IN CONDUCTION
$0.00
90904
O
BIOFEEDBACK TRAINING; REGULATION OF
$0.00
90906
9
BIOFEEDBACK TRAINING REGULATION OF
$0.00
90908
O
BIOFEEDBACK TRAINING; BY ELECTROENC
$0.00
90910
O
BIOFEEDBACK TRAINING; BY ELECTRO-OC
$0.00
90911
3
BIOFEEDBACK PERI/URO/RECTAL
$86.11
90915
O
BIOFEEDBACK TRAINING; OTHER
$0.00
90918
O
ESRD RELATED SERVICES, MONTH
$0.00
90919
O
ESRD RELATED SERVICES, MONTH
$0.00
90920
O
ESRD RELATED SERVICES, MONTH
$0.00
90921
O
ESRD RELATED SERVICES, MONTH
$0.00
$107.90
$0.00
$0.00
$47.71
Procedure Code Pricing Action Code Description
Maximum Allowable
90922
O
ESRD RELATED SERVICES, DAY
$0.00
90923
O
ESRD RELATED SERVICES, DAY
$0.00
90924
O
ESRD RELATED SERVICES, DAY
$0.00
90925
O
ESRD RELATED SERVICES, DAY
$0.00
90935
3
HEMODIALYSIS, ONE EVALUATION
$65.99
90937
3
HEMODIALYSIS, REPEATED EVAL
$108.13
90939
O
HEMODIALYSIS STUDY, TRANSCUT
$0.00
90940
5
HEMODIALYSIS ACCESS STUDY
$0.00
90945
3
DIALYSIS, ONE EVALUATION
$68.51
90947
3
DIALYSIS, REPEATED EVAL
$110.66
90951
3
ESRD SERV, 4 VISITS P MO, <2
$955.25
90952
6
ESRD SERV, 2-3 VSTS P MO, <2
$0.00
90953
6
ESRD SERV, 1 VISIT P MO, <2
$0.00
90954
3
ESRD SERV, 4 VSTS P MO, 2-11
$780.77
90955
3
ESRD SRV 2-3 VSTS P MO, 2-11
$443.17
90956
3
ESRD SRV, 1 VISIT P MO, 2-11
$300.22
90957
3
ESRD SRV, 4 VSTS P MO, 12-19
$628.02
90958
3
ESRD SRV 2-3 VSTS P MO 12-19
$424.14
90959
3
ESRD SERV, 1 VST P MO, 12-19
$278.25
90960
3
ESRD SRV, 4 VISITS P MO, 20+
$280.12
90961
3
ESRD SRV, 2-3 VSTS P MO, 20+
$225.83
90962
3
ESRD SERV, 1 VISIT P MO, 20+
$163.02
90963
3
ESRD HOME PT, SERV P MO, <2
$539.04
90964
3
ESRD HOME PT SERV P MO, 2-11
$448.39
90965
3
ESRD HOME PT SERV P MO 12-19
$426.55
90966
3
ESRD HOME PT, SERV P MO, 20+
$223.24
90967
3
ESRD HOME PT SERV P DAY, <2
$19.40
90968
3
ESRD HOME PT SRV P DAY, 2-11
$15.02
90969
3
ESRD HOME PT SRV P DAY 12-19
$14.67
90970
3
ESRD HOME PT SERV P DAY, 20+
$7.83
90988
O
SUPERVISION OF HEMODIALYSIS IN HOSP
$0.00
90989
9
DIALYSIS TRAINING, COMPLETE
$0.00
90990
O
HEMODIALYSIS TRAINING AND/OR COUNSE
$0.00
90991
O
HOME HEMODIALYSIS CARE, OUTPATIENT,
$0.00
90992
9
PERITONEAL DIALYSIS TRAINING AND/OR
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
90993
9
DIALYSIS TRAINING, INCOMPL
$0.00
90994
O
SUPERVISION OF CHRONIC AMBULATORY P
$0.00
90995
O
END STAGE RENAL DISEASE (ESRD) RELA
$0.00
90997
3
HEMOPERFUSION
90998
O
END STAGE RENAL DISEASE (ESRD) RELA
$0.00
90999
5
DIALYSIS PROCEDURE
$0.00
91000
3
ESOPHAGEAL INTUBATION
91010
3
ESOPHAGUS MOTILITY STUDY
$186.55
91011
3
ESOPHAGUS MOTILITY STUDY
$250.08
91012
3
ESOPHAGUS MOTILITY STUDY
$254.19
91020
3
GASTRIC MOTILITY STUDIES
$226.86
91022
3
DUODENAL MOTILITY STUDY
$186.19
91030
3
ACID PERFUSION OF ESOPHAGUS
$135.99
91032
O
ESOPHAGUS, ACID REFLUX TEST
$0.00
91033
O
PROLONGED ACID REFLUX TEST
$0.00
91034
3
GASTROESOPHAGEAL REFLUX TEST
$196.15
91035
3
G-ESOPH REFLX TST W/ELECTROD
$463.42
91037
3
ESOPH IMPED FUNCTION TEST
$156.96
91038
3
ESOPH IMPED FUNCT TEST > 1H
$137.94
91040
3
ESOPH BALLOON DISTENSION TST
$375.46
91052
3
GASTRIC ANALYSIS TEST
$121.12
91055
3
GASTRIC INTUBATION FOR SMEAR
$130.65
91060
O
GASTRIC SALINE LOAD TEST
91065
3
BREATH HYDROGEN TEST
91100
O
PASS INTESTINE BLEEDING TUBE
91105
3
GASTRIC INTUBATION TREATMENT
91110
3
GI TRACT CAPSULE ENDOSCOPY
$891.82
91111
3
ESOPHAGEAL CAPSULE ENDOSCOPY
$699.46
91120
3
RECTAL SENSATION TEST
$384.83
91122
3
ANAL PRESSURE RECORD
$227.62
91123
3
IRRIGATE FECAL IMPACTION
91132
3
ELECTROGASTROGRAPHY
$0.00
91133
3
ELECTROGASTROGRAPHY W/TEST
$0.00
91299
5
GASTROENTEROLOGY PROCEDURE
$0.00
92002
3
EYE EXAM, NEW PATIENT
$87.90
$88.04
$0.00 $64.80 $0.00 $78.27
$92.29
$67.41
Procedure Code Pricing Action Code Description
Maximum Allowable
92004
3
EYE EXAM, NEW PATIENT
$126.63
92012
3
EYE EXAM ESTABLISHED PAT
92014
3
EYE EXAM & TREATMENT
92015
3
REFRACTION
92018
3
NEW EYE EXAM & TREATMENT
92019
3
EYE EXAM & TREATMENT
$63.06
92020
3
SPECIAL EYE EVALUATION
$23.81
92025
3
CORNEAL TOPOGRAPHY
$31.11
92060
3
SPECIAL EYE EVALUATION
$53.84
92065
3
ORTHOPTIC/PLEOPTIC TRAINING
$42.54
92070
9
FITTING OF CONTACT LENS
92081
3
VISUAL FIELD EXAMINATION(S)
$48.47
92082
3
VISUAL FIELD EXAMINATION(S)
$64.27
92083
3
VISUAL FIELD EXAMINATION(S)
$73.43
92100
3
SERIAL TONOMETRY EXAM(S)
$81.05
92120
3
TONOGRAPHY & EYE EVALUATION
$66.77
92130
3
WATER PROVOCATION TONOGRAPHY
$73.79
92135
3
OPHTH DX IMAGING POST SEG
$42.56
92136
3
OPHTHALMIC BIOMETRY
$75.93
92140
3
GLAUCOMA PROVOCATIVE TESTS
$52.49
92225
3
SPECIAL EYE EXAM, INITIAL
$22.69
92226
3
SPECIAL EYE EXAM, SUBSEQUENT
$20.53
92230
3
EYE EXAM WITH PHOTOS
$55.19
92235
3
EYE EXAM WITH PHOTOS
$117.75
92240
3
ICG ANGIOGRAPHY
$201.68
92250
3
EYE EXAM WITH PHOTOS
$66.11
92260
3
OPHTHALMOSCOPY/DYNAMOMETRY
$16.26
92265
3
EYE MUSCLE EVALUATION
$71.05
92270
3
ELECTRO-OCULOGRAPHY
$81.90
92275
3
ELECTRORETINOGRAPHY
$122.70
92280
O
VISUALLY EVOKED POTENTIAL (RESPONSE
92283
3
COLOR VISION EXAMINATION
$42.04
92284
3
DARK ADAPTATION EYE EXAM
$56.38
92285
3
EYE PHOTOGRAPHY
$38.68
92286
3
INTERNAL EYE PHOTOGRAPHY
$71.07 $103.59 $31.57 $126.87
$0.00
$0.00
$110.32
Procedure Code Pricing Action Code Description
Maximum Allowable
92287
3
INTERNAL EYE PHOTOGRAPHY
$104.48
92310
9
CONTACT LENS FITTING
$0.00
92311
O
CONTACT LENS FITTING
$0.00
92312
O
CONTACT LENS FITTING
$0.00
92313
9
CONTACT LENS FITTING
$0.00
92314
9
PRESCRIPTION OF CONTACT LENS
$0.00
92315
O
PRESCRIPTION OF CONTACT LENS
$0.00
92316
O
PRESCRIPTION OF CONTACT LENS
$0.00
92317
9
PRESCRIPTION OF CONTACT LENS
$0.00
92325
9
MODIFICATION OF CONTACT LENS
$0.00
92326
9
REPLACEMENT OF CONTACT LENS
$0.00
92330
O
FITTING OF ARTIFICIAL EYE
$0.00
92335
O
FITTING OF ARTIFICIAL EYE
$0.00
92340
9
FITTING OF SPECTACLES
$0.00
92341
9
FITTING OF SPECTACLES
$0.00
92342
9
FITTING OF SPECTACLES
$0.00
92352
9
SPECIAL SPECTACLES FITTING
$0.00
92353
9
SPECIAL SPECTACLES FITTING
$0.00
92354
9
SPECIAL SPECTACLES FITTING
$0.00
92355
9
SPECIAL SPECTACLES FITTING
$0.00
92358
9
EYE PROSTHESIS SERVICE
$0.00
92370
9
REPAIR & ADJUST SPECTACLES
$0.00
92371
9
REPAIR & ADJUST SPECTACLES
$0.00
92390
O
SUPPLY OF SPECTACLES
$0.00
92391
O
SUPPLY OF CONTACT LENSES
$0.00
92392
O
SUPPLY OF LOW VISION AIDS
$0.00
92393
O
SUPPLY OF ARTIFICIAL EYE
$0.00
92395
O
SUPPLY OF SPECTACLES
$0.00
92396
O
SUPPLY OF CONTACT LENSES
$0.00
92499
5
EYE SERVICE OR PROCEDURE
$0.00
92502
3
EAR AND THROAT EXAMINATION
$91.02
92504
3
EAR MICROSCOPY EXAMINATION
$27.74
92506
3
SPEECH/HEARING EVALUATION
92507
3
SPEECH/HEARING THERAPY
$61.95
92508
3
SPEECH/HEARING THERAPY
$29.50
$149.39
Procedure Code Pricing Action Code Description
Maximum Allowable
92510
O
REHAB FOR EAR IMPLANT
$0.00
92511
3
NASOPHARYNGOSCOPY
92512
3
NASAL FUNCTION STUDIES
$57.84
92516
3
FACIAL NERVE FUNCTION TEST
$59.97
92520
3
LARYNGEAL FUNCTION STUDIES
$58.57
92525
O
ORAL FUNCTION EVALUATION
92526
3
ORAL FUNCTION THERAPY
92531
5
SPONTANEOUS NYSTAGMUS STUDY
$0.00
92532
5
POSITIONAL NYSTAGMUS TEST
$0.00
92533
5
CALORIC VESTIBULAR TEST
$0.00
92534
5
OPTOKINETIC NYSTAGMUS TEST
$0.00
92541
3
SPONTANEOUS NYSTAGMUS TEST
$57.40
92542
3
POSITIONAL NYSTAGMUS TEST
$59.84
92543
3
CALORIC VESTIBULAR TEST
$27.71
92544
3
OPTOKINETIC NYSTAGMUS TEST
$48.09
92545
3
OSCILLATING TRACKING TEST
$45.17
92546
3
SINUSOIDAL ROTATIONAL TEST
$81.33
92547
3
SUPPLEMENTAL ELECTRICAL TEST
92548
3
POSTUROGRAPHY
$91.71
92551
3
PURE TONE HEARING TEST, AIR
$10.59
92552
3
PURE TONE AUDIOMETRY, AIR
$21.30
92553
3
AUDIOMETRY, AIR & BONE
$28.43
92555
3
SPEECH THRESHOLD AUDIOMETRY
$15.75
92556
3
SPEECH AUDIOMETRY, COMPLETE
$24.36
92557
3
COMPREHENSIVE HEARING TEST
$43.91
92559
9
GROUP AUDIOMETRIC TESTING
$0.00
92560
5
BEKESY AUDIOMETRY, SCREEN
$0.00
92561
3
BEKESY AUDIOMETRY, DIAGNOSIS
$27.69
92562
3
LOUDNESS BALANCE TEST
$22.40
92563
3
TONE DECAY HEARING TEST
$20.19
92564
3
SISI HEARING TEST
$19.32
92565
3
STENGER TEST, PURE TONE
$12.42
92566
O
IMPEDANCE TESTING
92567
3
TYMPANOMETRY
$17.09
92568
3
ACOUSTIC REFL THRESHOLD TST
$17.61
$146.82
$0.00 $79.28
$5.14
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
92569
3
ACOUSTIC REFLEX DECAY TEST
$14.02
92571
3
FILTERED SPEECH HEARING TEST
$16.12
92572
3
STAGGERED SPONDAIC WORD TEST
$17.25
92573
O
LOMBARD TEST
$0.00
92574
O
SWINGING STORY TEST
$0.00
92575
3
SENSORINEURAL ACUITY TEST
$34.86
92576
3
SYNTHETIC SENTENCE TEST
$20.80
92577
3
STENGER TEST, SPEECH
$16.84
92578
O
DELAYED AUDITORY FEEDBACK TEST
92579
3
VISUAL AUDIOMETRY (VRA)
92580
O
ELECTRODERMAL AUDIOMETRY
$0.00
92581
O
EVOKED RESPONSE (EEG) AUDIOMETRY
$0.00
92582
3
CONDITIONING PLAY AUDIOMETRY
$40.63
92583
3
SELECT PICTURE AUDIOMETRY
$32.60
92584
3
ELECTROCOCHLEOGRAPHY
$66.03
92585
3
AUDITOR EVOKE POTENT, COMPRE
$99.22
92586
3
AUDITOR EVOKE POTENT, LIMIT
$61.40
92587
3
EVOKED AUDITORY TEST
$37.84
92588
3
EVOKED AUDITORY TEST
$62.06
92589
O
AUDITORY FUNCTION TEST(S)
$0.00
92590
9
HEARING AID EXAM, ONE EAR
$0.00
92591
9
HEARING AID EXAM, BOTH EARS
$0.00
92592
9
HEARING AID CHECK, ONE EAR
$0.00
92593
9
HEARING AID CHECK, BOTH EARS
$0.00
92594
9
ELECTRO HEARNG AID TEST, ONE
$0.00
92595
9
ELECTRO HEARNG AID TST, BOTH
$0.00
92596
9
EAR PROTECTOR EVALUATION
$0.00
92597
9
ORAL SPEECH DEVICE EVAL
$0.00
92598
9
MODIFY ORAL SPEECH DEVICE
$0.00
92599
O
ENT PROCEDURE/SERVICE
$0.00
92601
3
COCHLEAR IMPLT F/UP EXAM < 7
92602
3
REPROGRAM COCHLEAR IMPLT < 7
92603
3
COCHLEAR IMPLT F/UP EXAM 7 >
92604
3
REPROGRAM COCHLEAR IMPLT 7 >
$81.10
92605
5
EVAL FOR NONSPEECH DEVICE RX
$0.00
$0.00 $43.09
$151.89 $95.09 $136.43
Procedure Code Pricing Action Code Description
Maximum Allowable
92606
5
NON-SPEECH DEVICE SERVICE
$0.00
92607
3
EX FOR SPEECH DEVICE RX, 1HR
$153.52
92608
3
EX FOR SPEECH DEVICE RX ADDL
$29.29
92609
3
USE OF SPEECH DEVICE SERVICE
$81.56
92610
3
EVALUATE SWALLOWING FUNCTION
$78.82
92611
3
MOTION FLUOROSCOPY/SWALLOW
$85.84
92612
3
ENDOSCOPY SWALLOW TST (FEES)
$153.18
92613
3
ENDOSCOPY SWALLOW TST (FEES)
$37.29
92614
3
LARYNGOSCOPIC SENSORY TEST
$136.18
92615
3
EVAL LARYNGOSCOPY SENSE TST
$33.32
92616
3
FEES W/LARYNGEAL SENSE TEST
$186.93
92617
3
INTERPRT FEES/LARYNGEAL TEST
$40.89
92620
9
AUDITORY FUNCTION, 60 MIN
$0.00
92621
9
AUDITORY FUNCTION, + 15 MIN
$0.00
92625
9
TINNITUS ASSESSMENT
$0.00
92626
9
EVAL AUD REHAB STATUS
$0.00
92627
9
EVAL AUD STATUS REHAB ADD-ON
$0.00
92630
9
AUD REHAB PRE-LING HEAR LOSS
$0.00
92633
9
AUD REHAB POSTLING HEAR LOSS
$0.00
92640
3
AUD BRAINSTEM IMPLT PROGRAMG
$73.71
92700
5
ENT PROCEDURE/SERVICE
92950
3
HEART/LUNG RESUSCITATION CPR
92953
9
TEMPORARY EXTERNAL PACING
$0.00
92960
3
CARDIOVERSION ELECTRIC, EXT
$257.69
92961
9
CARDIOVERSION, ELECTRIC, INT
$0.00
92970
3
CARDIOASSIST, INTERNAL
$179.91
92971
3
CARDIOASSIST, EXTERNAL
$103.14
92973
3
PERCUT CORONARY THROMBECTOMY
$183.72
92974
3
CATH PLACE, CARDIO BRACHYTX
$168.43
92975
3
DISSOLVE CLOT, HEART VESSEL
$403.43
92977
3
DISSOLVE CLOT, HEART VESSEL
$131.55
92978
3
INTRAVASC US, HEART ADD-ON
$0.00
92979
3
INTRAVASC US, HEART ADD-ON
$0.00
92980
3
INSERT INTRACORONARY STENT
$837.46
92981
3
INSERT INTRACORONARY STENT
$232.88
$0.00 $268.58
Procedure Code Pricing Action Code Description
Maximum Allowable
92982
3
CORONARY ARTERY DILATION
$620.97
92984
3
CORONARY ARTERY DILATION
$166.25
92986
3
REVISION OF AORTIC VALVE
$1,378.25
92987
3
REVISION OF MITRAL VALVE
$1,426.53
92990
3
REVISION OF PULMONARY VALVE
$1,097.73
92992
5
REVISION OF HEART CHAMBER
$0.00
92993
5
REVISION OF HEART CHAMBER
$0.00
92995
3
CORONARY ATHERECTOMY
$684.35
92996
3
CORONARY ATHERECTOMY ADD-ON
$179.53
92997
3
PUL ART BALLOON REPR, PERCUT
$631.78
92998
3
PUL ART BALLOON REPR, PERCUT
$323.91
93000
3
ELECTROCARDIOGRAM, COMPLETE
$20.84
93005
3
ELECTROCARDIOGRAM, TRACING
$11.94
93010
3
ELECTROCARDIOGRAM REPORT
$8.90
93012
9
TRANSMISSION OF ECG
$0.00
93014
9
REPORT ON TRANSMITTED ECG
$0.00
93015
3
CARDIOVASCULAR STRESS TEST
$100.03
93016
9
CARDIOVASCULAR STRESS TEST
$0.00
93017
3
CARDIOVASCULAR STRESS TEST
$59.57
93018
3
CARDIOVASCULAR STRESS TEST
$16.14
93024
3
CARDIAC DRUG STRESS TEST
$121.95
93025
3
MICROVOLT T-WAVE ASSESS
$215.75
93040
3
RHYTHM ECG WITH REPORT
$13.22
93041
3
RHYTHM ECG, TRACING
$5.42
93042
3
RHYTHM ECG, REPORT
$7.80
93201
O
PHONOCARDIOGRAM WITH OR WITHOUT ECG
$0.00
93202
O
PHONOCARDIOGRAM WITH OR WITHOUT ECG
$0.00
93204
O
PHONOCARDIOGRAM WITH OR WITHOUT ECG
$0.00
93205
O
PHONOCARDIOGRAM WITH ECG LEAD, WITH
$0.00
93208
O
PHONOCARDIOGRAM WITH ECG LEAD, WITH
$0.00
93209
O
PHONOCARDIOGRAM WITH ECG LEAD, WITH
$0.00
93210
O
PHONOCARDIOGRAM, INTRACARDIAC
$0.00
93220
O
VECTORCARDIOGRAM (VCG), WITH OR WIT
$0.00
93221
O
VECTORCARDIOGRAM (VCG), WITH OR WIT
$0.00
93222
O
VECTORCARDIOGRAM (VCG), WITH OR WIT
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
93224
3
ECG MONITOR/REPORT, 24 HRS
$118.61
93225
3
ECG MONITOR/RECORD, 24 HRS
$35.56
93226
3
ECG MONITOR/REPORT, 24 HRS
$54.74
93227
3
ECG MONITOR/REVIEW, 24 HRS
$28.30
93228
3
REMOTE 30 DAY ECG REV/REPORT
$25.34
93229
6
REMOTE 30 DAY ECG TECH SUPP
93230
3
ECG MONITOR/REPORT, 24 HRS
$121.30
93231
3
ECG MONITOR/RECORD, 24 HRS
$35.54
93232
3
ECG MONITOR/REPORT, 24 HRS
$58.57
93233
3
ECG MONITOR/REVIEW, 24 HRS
$27.20
93235
3
ECG MONITOR/REPORT, 24 HRS
$124.39
93236
3
ECG MONITOR/REPORT, 24 HRS
$101.38
93237
3
ECG MONITOR/REVIEW, 24 HRS
$24.32
93255
O
APEXCARDIOGRAPHY
$0.00
93268
3
ECG RECORD/REVIEW
$267.82
93270
3
ECG RECORDING
93271
3
ECG/MONITORING AND ANALYSIS
93272
3
ECG/REVIEW, INTERPRET ONLY
$27.20
93278
3
ECG/SIGNAL-AVERAGED
$39.91
93279
3
PM DEVICE PROGR EVAL, SNGL
$55.72
93280
O
CARDIAC FLUOROSCOPY
93281
3
PM DEVICE PROGR EVAL, MULTI
$77.22
93282
3
ICD DEVICE PROG EVAL, 1 SNGL
$71.24
93283
3
ICD DEVICE PROGR EVAL, DUAL
$86.76
93284
3
ICD DEVICE PROGR EVAL, MULT
$101.68
93285
3
ILR DEVICE EVAL PROGR
$48.12
93286
3
PRE-OP PM DEVICE EVAL
$27.20
93287
3
PRE-OP ICD DEVICE EVAL
$35.76
93288
3
PM DEVICE EVAL IN PERSON
$43.18
93289
3
ICD DEVICE INTERROGATE
$66.41
93290
3
ICM DEVICE EVAL
$31.60
93291
3
ILR DEVICE INTERROGATE
$41.34
93292
3
WCD DEVICE INTERROGATE
$37.27
93293
3
PM PHONE R-STRIP DEVICE EVAL
$59.29
93294
3
PM DEVICE INTERROGATE REMOTE
$36.51
$0.00
$21.14 $219.48
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
93295
3
ICD DEVICE INTERROGAT REMOTE
$66.06
93296
3
PM/ICD REMOTE TECH SERV
$37.21
93297
3
ICM DEVICE INTERROGAT REMOTE
$25.34
93298
3
ILR DEVICE INTERROGAT REMOTE
$29.41
93299
6
ICM/ILR REMOTE TECH SERV
93303
3
ECHO TRANSTHORACIC
$218.56
93304
3
ECHO TRANSTHORACIC
$135.40
93306
3
TTE W/DOPPLER, COMPLETE
$267.90
93307
3
TTE W/O DOPPLER, COMPLETE
$177.01
93308
3
TTE, F-UP OR LMTD
$112.00
93312
3
ECHO TRANSESOPHAGEAL
$326.31
93313
3
ECHO TRANSESOPHAGEAL
$40.56
93314
3
ECHO TRANSESOPHAGEAL
$281.43
93315
3
ECHO TRANSESOPHAGEAL
$0.00
93316
3
ECHO TRANSESOPHAGEAL
$44.76
93317
3
ECHO TRANSESOPHAGEAL
$0.00
93318
3
ECHO TRANSESOPHAGEAL INTRAOP
$0.00
93320
3
DOPPLER ECHO EXAM, HEART
$78.07
93321
3
DOPPLER ECHO EXAM, HEART
$34.51
93325
3
DOPPLER COLOR FLOW ADD-ON
$52.51
93350
3
STRESS TTE ONLY
$212.88
93351
3
STRESS TTE COMPLETE
$255.25
93352
3
ADMIN ECG CONTRAST AGENT
93501
3
RIGHT HEART CATHETERIZATION
$803.84
93503
3
INSERT/PLACE HEART CATHETER
$108.78
93505
3
BIOPSY OF HEART LINING
$753.91
93508
3
CATH PLACEMENT, ANGIOGRAPHY
$1,070.17
93510
3
LEFT HEART CATHETERIZATION
$1,327.90
93511
3
LEFT HEART CATHETERIZATION
$0.00
93514
3
LEFT HEART CATHETERIZATION
$0.00
93524
3
LEFT HEART CATHETERIZATION
$0.00
93526
3
RT & LT HEART CATHETERS
$1,702.25
93527
3
RT & LT HEART CATHETERS
$0.00
93528
3
RT & LT HEART CATHETERS
$0.00
93529
3
RT, LT HEART CATHETERIZATION
$0.00
$0.00
$38.81
Procedure Code Pricing Action Code Description
Maximum Allowable
93530
3
RT HEART CATH, CONGENITAL
$0.00
93531
3
R & L HEART CATH, CONGENITAL
$0.00
93532
3
R & L HEART CATH, CONGENITAL
$0.00
93533
3
R & L HEART CATH, CONGENITAL
$0.00
93536
O
INSERT CIRCULATION ASSI
$0.00
93539
3
INJECTION, CARDIAC CATH
$81.45
93540
3
INJECTION, CARDIAC CATH
$244.09
93541
3
INJECTION FOR LUNG ANGIOGRAM
93542
3
INJECTION FOR HEART X-RAYS
$148.14
93543
3
INJECTION FOR HEART X-RAYS
$80.85
93544
3
INJECTION FOR AORTOGRAPHY
$58.71
93545
3
INJECT FOR CORONARY X-RAYS
$21.92
93546
O
COMBINED LEFT HEART CATHETERIZATION
$0.00
93547
O
COMBINED LEFT HEART CATHETERIZATION
$0.00
93548
O
COMBINED LEFT HEART CATHETERIZATION
$0.00
93549
O
COMBINED RIGHT AND LEFT HEART CATHE
$0.00
93550
O
COMBINED RIGHT AND LEFT HEART CATHE
$0.00
93551
O
SELECTIVE OPACIFICATION OF AORTOCOR
$0.00
93552
O
COMBINED LEFT HEART CATHETERIZATION
$0.00
93553
O
COMBINED LEFT HEART CATHETERIZATION
$0.00
93555
3
IMAGING, CARDIAC CATH
$115.08
93556
3
IMAGING, CARDIAC CATH
$160.91
93561
3
CARDIAC OUTPUT MEASUREMENT
$0.00
93562
3
CARDIAC OUTPUT MEASUREMENT
$0.00
93571
3
HEART FLOW RESERVE MEASURE
$0.00
93572
3
HEART FLOW RESERVE MEASURE
$0.00
93580
3
TRANSCATH CLOSURE OF ASD
$1,005.95
93581
3
TRANSCATH CLOSURE OF VSD
$1,315.39
93600
3
BUNDLE OF HIS RECORDING
$0.00
93602
3
INTRA-ATRIAL RECORDING
$0.00
93603
3
RIGHT VENTRICULAR RECORDING
$0.00
93607
O
LEFT VENTRICULAR RECORDING
$0.00
93609
3
MAP TACHYCARDIA, ADD-ON
$0.00
93610
3
INTRA-ATRIAL PACING
$0.00
93612
3
INTRAVENTRICULAR PACING
$0.00
$15.78
Procedure Code Pricing Action Code Description
Maximum Allowable
93613
3
ELECTROPHYS MAP 3D, ADD-ON
$390.19
93615
3
ESOPHAGEAL RECORDING
$0.00
93616
3
ESOPHAGEAL RECORDING
$0.00
93618
3
HEART RHYTHM PACING
$0.00
93619
3
ELECTROPHYSIOLOGY EVALUATION
$0.00
93620
3
ELECTROPHYSIOLOGY EVALUATION
$0.00
93621
3
ELECTROPHYSIOLOGY EVALUATION
$0.00
93622
3
ELECTROPHYSIOLOGY EVALUATION
$0.00
93623
3
STIMULATION, PACING HEART
$0.00
93624
3
ELECTROPHYSIOLOGIC STUDY
$0.00
93631
3
HEART PACING, MAPPING
$0.00
93640
3
EVALUATION HEART DEVICE
$0.00
93641
3
ELECTROPHYSIOLOGY EVALUATION
$0.00
93642
3
ELECTROPHYSIOLOGY EVALUATION
$471.24
93650
3
ABLATE HEART DYSRHYTHM FOCUS
$594.58
93651
3
ABLATE HEART DYSRHYTHM FOCUS
$903.92
93652
3
ABLATE HEART DYSRHYTHM FOCUS
$983.68
93660
3
TILT TABLE EVALUATION
$172.24
93662
3
INTRACARDIAC ECG (ICE)
$0.00
93668
9
PERIPHERAL VASCULAR REHAB
$0.00
93701
3
BIOIMPEDANCE, THORACIC
$34.28
93720
3
TOTAL BODY PLETHYSMOGRAPHY
$46.21
93721
3
PLETHYSMOGRAPHY TRACING
$38.04
93722
3
PLETHYSMOGRAPHY REPORT
$8.16
93724
3
ANALYZE PACEMAKER SYSTEM
93727
O
ANALYZE ILR SYSTEM
$0.00
93731
O
ANALYZE PACEMAKER SYSTEM
$0.00
93732
O
ANALYZE PACEMAKER SYSTEM
$0.00
93733
O
TELEPHONE ANALY, PACEMAKER
$0.00
93734
O
ANALYZE PACEMAKER SYSTEM
$0.00
93735
O
ANALYZE PACEMAKER SYSTEM
$0.00
93736
O
TELEPHONIC ANALY, PACEMAKER
$0.00
93737
O
ANALYZE CARDIO/DEFIBRILLATOR
$0.00
93738
O
ANALYZE CARDIO/DEFIBRILLATOR
$0.00
93740
O
TEMPERATURE GRADIENT STUDIES
$0.00
$331.98
Procedure Code Pricing Action Code Description
Maximum Allowable
93741
O
ANALYZE HT PACE DEVICE SNGL
$0.00
93742
O
ANALYZE HT PACE DEVICE SNGL
$0.00
93743
O
ANALYZE HT PACE DEVICE DUAL
$0.00
93744
O
ANALYZE HT PACE DEVICE DUAL
$0.00
93745
3
SET-UP CARDIOVERT-DEFIBRILL
$215.95
93760
O
CEPHALIC THERMOGRAM
$0.00
93762
O
PERIPHERAL THERMOGRAM
$0.00
93770
3
MEASURE VENOUS PRESSURE
$8.42
93784
3
AMBULATORY BP MONITORING
$66.06
93786
3
AMBULATORY BP RECORDING
$30.18
93788
3
AMBULATORY BP ANALYSIS
$16.88
93790
3
REVIEW/REPORT BP RECORDING
$18.99
93797
3
CARDIAC REHAB
$18.13
93798
3
CARDIAC REHAB/MONITOR
$26.15
93799
5
CARDIOVASCULAR PROCEDURE
$0.00
93850
O
NON-INVASIVE STUDIES OF CEREBRAL AR
$0.00
93860
O
NON-INVASIVE STUDIES OF CAROTID ART
$0.00
93870
O
NON-INVASIVE STUDIES OF CAROTID ART
$0.00
93875
3
EXTRACRANIAL STUDY
$102.06
93880
3
EXTRACRANIAL STUDY
$184.41
93882
3
EXTRACRANIAL STUDY
$163.97
93886
3
INTRACRANIAL STUDY
$200.50
93888
3
INTRACRANIAL STUDY
$94.15
93890
3
TRANSCRANIAL DOPPLER STUDY OF THE
$147.23
93892
3
TCD, EMBOLI DETECT W/O INJ
$154.19
93893
3
TCD, EMBOLI DETECT W/INJ
$154.57
93910
O
NON-INVASIVE STUDIES OF LOWER EXTRE
$0.00
93920
O
NON-INVASIVE PHYSIOLOGIC STUDIES OF
$0.00
93921
O
NON-INVASIVE PHYSIOLOGIC STUDIES OF
$0.00
93922
3
EXTREMITY STUDY
$121.23
93923
3
EXTREMITY STUDY
$186.84
93924
3
EXTREMITY STUDY
$230.25
93925
3
LOWER EXTREMITY STUDY
$183.37
93926
3
LOWER EXTREMITY STUDY
$118.20
93930
3
UPPER EXTREMITY STUDY
$177.06
Procedure Code Pricing Action Code Description
Maximum Allowable
93931
3
UPPER EXTREMITY STUDY
$113.60
93950
O
NON-INVASIVE STUDIES OF EXTREMITY V
$0.00
93960
O
QUANTITATIVE VENOUS FLOW STUDIES (E
$0.00
93965
3
EXTREMITY STUDY
$123.81
93970
3
EXTREMITY STUDY
$187.73
93971
3
EXTREMITY STUDY
$120.57
93975
3
VASCULAR STUDY
$245.61
93976
3
VASCULAR STUDY
$213.69
93978
3
VASCULAR STUDY
$186.29
93979
3
VASCULAR STUDY
$120.10
93980
3
PENILE VASCULAR STUDY
$182.65
93981
3
PENILE VASCULAR STUDY
$128.63
93982
3
ANEURYSM PRESSURE SENS STUDY
93990
3
DOPPLER FLOW TESTING
94002
9
VENT MGMT INPAT, INIT DAY
$0.00
94003
9
VENT MGMT INPAT, SUBQ DAY
$0.00
94004
9
VENT MGMT NF PER DAY
$0.00
94005
9
HOME VENT MGMT SUPERVISION
$0.00
94010
3
BREATHING CAPACITY TEST
$33.05
94014
3
PATIENT RECORDED SPIROMETRY
$48.51
94015
3
PATIENT RECORDED SPIROMETRY
$23.90
94016
3
REVIEW PATIENT SPIROMETRY
$24.61
94060
3
EVALUATION OF WHEEZING
$57.86
94070
3
EVALUATION OF WHEEZING
$59.31
94150
3
VITAL CAPACITY TEST
$22.58
94160
O
VITAL CAPACITY SCREENING TESTS: TOT
94200
3
LUNG FUNCTION TEST (MBC/MVV)
$22.39
94240
3
RESIDUAL LUNG CAPACITY
$38.83
94250
3
EXPIRED GAS COLLECTION
$24.37
94260
3
THORACIC GAS VOLUME
$31.35
94350
3
LUNG NITROGEN WASHOUT CURVE
$34.52
94360
3
MEASURE AIRFLOW RESISTANCE
$43.13
94370
3
BREATH AIRWAY CLOSING VOLUME
$33.30
94375
3
RESPIRATORY FLOW VOLUME LOOP
$36.94
94400
3
CO2 BREATHING RESPONSE CURVE
$52.31
$40.17 $110.87
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
94450
3
HYPOXIA RESPONSE CURVE
$50.37
94452
3
HAST W/REPORT
$55.66
94453
3
HAST W/OXYGEN TITRATE
$74.40
94610
3
SURFACTANT ADMIN THRU TUBE
$61.36
94620
3
PULMONARY STRESS TEST/SIMPLE
$71.09
94621
3
PULM STRESS TEST/COMPLEX
94640
3
AIRWAY INHALATION TREATMENT
$13.42
94642
3
AEROSOL INHALATION TREATMENT
$34.88
94644
3
CBT, 1ST HOUR
$34.50
94645
3
CBT, EACH ADDL HOUR
$13.42
94650
O
PRESSURE BREATHING (IPPB)
$0.00
94651
O
PRESSURE BREATHING (IPPB)
$0.00
94652
O
PRESSURE BREATHING (IPPB)
$0.00
94656
O
INITIAL VENTILATOR MGMT
$0.00
94657
O
CONTINUED VENTILATOR MGMT
$0.00
94660
9
POS AIRWAY PRESSURE, CPAP
$0.00
94662
9
NEG PRESS VENTILATION, CNP
$0.00
94664
3
EVALUATE PT USE OF INHALER
$14.64
94665
O
AEROSOL OR VAPOR INHALATIONS
$0.00
94667
9
CHEST WALL MANIPULATION
$0.00
94668
9
CHEST WALL MANIPULATION
$0.00
94680
3
EXHALED AIR ANALYSIS, O2
$57.56
94681
3
EXHALED AIR ANALYSIS, O2/CO2
$62.39
94690
3
EXHALED AIR ANALYSIS
$50.66
94700
O
ANALYSIS OF ARTERIAL BLOOD GAS (OXY
$0.00
94705
O
ANALYSIS OF ARTERIAL BLOOD GAS (OXY
$0.00
94710
O
ANALYSIS OF ARTERIAL BLOOD GAS (OXY
$0.00
94715
O
HEMOGLOBIN-OXYGEN AFFINITY (PO2 FOR
$0.00
94720
3
MONOXIDE DIFFUSING CAPACITY
$51.26
94725
3
MEMBRANE DIFFUSION CAPACITY
$66.39
94750
3
PULMONARY COMPLIANCE STUDY
$71.16
94760
3
MEASURE BLOOD OXYGEN LEVEL
$2.70
94761
3
MEASURE BLOOD OXYGEN LEVEL
$5.14
94762
3
MEASURE BLOOD OXYGEN LEVEL
$29.02
94770
3
EXHALED CARBON DIOXIDE TEST
$36.11
$161.05
Procedure Code Pricing Action Code Description
Maximum Allowable
94772
3
BREATH RECORDING, INFANT
$167.00
94774
9
PED HOME APNEA REC, COMPL
$0.00
94775
9
PED HOME APNEA REC, HK-UP
$0.00
94776
9
PED HOME APNEA REC, DOWNLD
$0.00
94777
9
PED HOME APNEA REC, REPORT
$0.00
94799
O
PULMONARY SERVICE/PROCEDURE
$0.00
95000
O
PERCUTANEOUS TESTS (SCRATCH, PUNCTU
$0.00
95001
O
PERCUTANEOUS TESTS (SCRATCH, PUNCTU
$0.00
95002
O
PERCUTANEOUS TESTS (SCRATCH, PUNCTU
$0.00
95003
O
PERCUTANEOUS TESTS (SCRATCH, PUNCTU
$0.00
95004
3
PERCUT ALLERGY SKIN TESTS
$5.77
95005
O
PERCUTANEOUS TESTS (SCRATCH, PUNCTU
$0.00
95006
O
PERCUTANEOUS TESTS (SCRATCH, PUNCTU
$0.00
95007
O
PERCUTANEOUS TESTS (SCRATCH, PUNCTU
$0.00
95010
3
PERCUT ALLERGY TITRATE TEST
95011
O
PERCUTANEOUS TESTS (SCRATCH, PUNCTU
95012
3
EXHALED NITRIC OXIDE MEAS
95014
O
INTRACUTANEOUS (INTRADERMAL) TESTS,
95015
3
ID ALLERGY TITRATE-DRUG/BUG
95016
O
INTRACUTANEOUS (INTRADERMAL) TESTS,
$0.00
95017
O
INTRACUTANEOUS (INTRADERMAL) TESTS,
$0.00
95018
O
INTRACUTANEOUS (INTRADERMAL) TESTS,
$0.00
95020
O
INTRACUTANEOUS (INTRADERMAL) TESTS
$0.00
95021
O
INTRACUTANEOUS (INTRADERMAL) TESTS
$0.00
95022
O
INTRACUTANEOUS (INTRADERMAL) TESTS
$0.00
95023
O
INTRACUTANEOUS (INTRADERMAL) TESTS
$0.00
95024
3
ID ALLERGY TEST, DRUG/BUG
$6.88
95027
3
ID ALLERGY TITRATE-AIRBORNE
$4.66
95028
3
ID ALLERGY TEST-DELAYED TYPE
95030
O
INTRACUTANEOUS (INTRADERMAL) TESTS
$0.00
95031
O
INTRACUTANEOUS (INTRADERMAL) TESTS
$0.00
95032
O
INTRACUTANEOUS (INTRADERMAL) TESTS
$0.00
95033
O
INTRACUTANEOUS (INTRADERMAL) TESTS
$0.00
95034
O
INTRACUTANEOUS (INTRADERMAL) TESTS
$0.00
95040
O
PATCH OR APPLICATION TESTS UP TO 10
$0.00
$17.06 $0.00 $19.84 $0.00 $12.62
$10.96
Procedure Code Pricing Action Code Description
Maximum Allowable
95041
O
PATCH OR APPLICATION TESTS 11-20 TE
$0.00
95042
O
PATCH OR APPLICATION TESTS 21-30 TE
$0.00
95043
O
PATCH OR APPLICATION TESTS MORE THA
$0.00
95044
3
ALLERGY PATCH TESTS
$6.15
95050
9
PHOTO PATCH TESTS UP TO 10 TESTS
$0.00
95051
9
PHOTO PATCH TESTS MORE THAN 10 TEST
$0.00
95052
3
PHOTO PATCH TEST
$6.90
95056
3
PHOTOSENSITIVITY TESTS
$35.00
95060
3
EYE ALLERGY TESTS
$23.40
95065
3
NOSE ALLERGY TEST
$21.32
95070
3
BRONCHIAL ALLERGY TESTS
$43.37
95071
3
BRONCHIAL ALLERGY TESTS
$53.71
95075
3
INGESTION CHALLENGE TEST
$62.02
95078
O
PROVOCATIVE TESTING
$0.00
95080
9
PASSIVE TRANSFER TESTS UP TO 10 TES
$0.00
95081
9
PASSIVE TRANSFER TESTS 11-20 TESTS
$0.00
95082
9
PASSIVE TRANSFER TESTS MORE THAN 20
$0.00
95105
O
MEDICAL CONFERENCE SERVICES (EG, US
$0.00
95115
3
IMMUNOTHERAPY, ONE INJECTION
$10.46
95117
3
IMMUNOTHERAPY INJECTIONS
$12.68
95120
9
IMMUNOTHERAPY, ONE INJECTION
$0.00
95125
9
IMMUNOTHERAPY, MANY ANTIGENS
$0.00
95130
9
IMMUNOTHERAPY, INSECT VENOM
$0.00
95131
9
IMMUNOTHERAPY, INSECT VENOMS
$0.00
95132
9
IMMUNOTHERAPY, INSECT VENOMS
$0.00
95133
9
IMMUNOTHERAPY, INSECT VENOMS
$0.00
95134
9
IMMUNOTHERAPY, INSECT VENOMS
$0.00
95135
9
PROFESSIONAL SERVICES FOR THE SUPER
$0.00
95140
9
PROFESSIONAL SERVICES FOR THE SUPER
$0.00
95144
3
ANTIGEN THERAPY SERVICES
$11.62
95145
3
ANTIGEN THERAPY SERVICES
$15.33
95146
3
ANTIGEN THERAPY SERVICES
$25.30
95147
3
ANTIGEN THERAPY SERVICES
$24.57
95148
3
ANTIGEN THERAPY SERVICES
$34.55
95149
3
ANTIGEN THERAPY SERVICES
$45.27
Procedure Code Pricing Action Code Description
Maximum Allowable
95150
9
PROFESSIONAL SERVICE FOR THE SUPERV
$0.00
95155
O
PROFESSIONAL SERVICE FOR THE SUPERV
$0.00
95165
3
ANTIGEN THERAPY SERVICES
$11.62
95170
3
ANTIGEN THERAPY SERVICES
$9.04
95180
3
RAPID DESENSITIZATION
95199
5
ALLERGY IMMUNOLOGY SERVICES
95250
3
GLUCOSE MONITORING, CONT
95251
3
GLUC MONITOR, CONT, PHYS I&R
95803
9
ACTIGRAPHY TESTING
95805
3
MULTIPLE SLEEP LATENCY TEST
95806
9
SLEEP STUDY, UNATTENDED
95807
3
SLEEP STUDY, ATTENDED
$497.21
95808
3
POLYSOMNOGRAPHY, 1-3
$650.98
95810
3
POLYSOMNOGRAPHY, 4 OR MORE
$774.72
95811
3
POLYSOMNOGRAPHY W/CPAP
$853.98
95812
3
EEG, 41-60 MINUTES
$237.50
95813
3
EEG, OVER 1 HOUR
$290.66
95816
3
EEG, AWAKE AND DROWSY
$217.67
95817
O
ELECTROENCEPHALOGRAM (EEG) INCLUDIN
95819
3
EEG, AWAKE AND ASLEEP
95821
O
ELECTROENCEPHALOGRAM (EEG) INCLUDIN
95822
3
EEG, COMA OR SLEEP ONLY
95823
O
ELECTROENCEPHALOGRAM (EEG); PHYSICA
$0.00
95824
3
EEG, CEREBRAL DEATH ONLY
$0.00
95826
O
ELECTROENCEPHALOGRAM (EEG); INTRACE
$0.00
95827
3
EEG, ALL NIGHT RECORDING
95828
O
POLYSOMNOGRAPHY (RECORDING, ANALYSI
95829
3
SURGERY ELECTROCORTICOGRAM
95830
9
INSERT ELECTRODES FOR EEG
95831
3
LIMB MUSCLE TESTING, MANUAL
$25.40
95832
3
HAND MUSCLE TESTING, MANUAL
$23.78
95833
3
BODY MUSCLE TESTING, MANUAL
$35.03
95834
3
BODY MUSCLE TESTING, MANUAL
$41.39
95842
O
MUSCLE TESTING, ELECTRICAL: REACTIO
$0.00
95851
9
RANGE OF MOTION MEASUREMENTS
$0.00
$139.34 $0.00 $131.49 $39.36 $0.00 $424.27 $0.00
$0.00 $233.94 $0.00 $232.81
$378.10 $0.00 $1,213.27 $0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
95852
3
RANGE OF MOTION MEASUREMENTS
$12.67
95857
3
TENSILON TEST
$40.87
95858
O
TENSILON TEST & MYOGRAM
95860
3
MUSCLE TEST, ONE LIMB
95861
3
MUSCLE TEST, 2 LIMBS
$116.19
95863
3
MUSCLE TEST, 3 LIMBS
$138.44
95864
3
MUSCLE TEST, 4 LIMBS
$158.96
95865
3
MUSCLE TEST, LARYNX
$111.24
95866
3
MUSCLE TEST, HEMIDIAPHRAGM
$91.06
95867
3
MUSCLE TEST CRAN NERV UNILAT
$69.83
95868
3
MUSCLE TEST CRAN NERVE BILAT
$95.58
95869
3
MUSCLE TEST, THOR PARASPINAL
$44.86
95870
3
MUSCLE TEST, NONPARASPINAL
$43.76
95872
9
MUSCLE TEST, ONE FIBER
95873
3
GUIDE NERV DESTR, ELEC STIM
$45.61
95874
3
GUIDE NERV DESTR, NEEDLE EMG
$43.02
95875
3
LIMB EXERCISE TEST
$91.48
95880
O
ASSESSMENT OF APHASIA (INCLUDES ASS
$0.00
95881
O
DEVELOPMENTAL TESTING (INCLUDES ASS
$0.00
95882
O
NEUROBEHAVIORAL STATUS EXAM (CLINIC
$0.00
95883
O
NEUROPSYCHOLOGICAL TESTING BATTERY
$0.00
95900
3
MOTOR NERVE CONDUCTION TEST
$52.57
95903
3
MOTOR NERVE CONDUCTION TEST
$61.46
95904
3
SENSE NERVE CONDUCTION TEST
$46.38
95920
3
INTRAOP NERVE TEST ADD-ON
95921
3
AUTONOMIC NERV FUNCTION TEST
$72.42
95922
3
AUTONOMIC NERV FUNCTION TEST
$87.00
95923
3
AUTONOMIC NERV FUNCTION TEST
$114.81
95925
3
SOMATOSENSORY TESTING
$117.08
95926
3
SOMATOSENSORY TESTING
$114.99
95927
3
SOMATOSENSORY TESTING
$117.82
95928
3
C MOTOR EVOKED, UPPR LIMBS
$186.63
95929
3
C MOTOR EVOKED, LWR LIMBS
$196.99
95930
3
VISUAL EVOKED POTENTIAL TEST
$104.17
95933
3
BLINK REFLEX TEST
$0.00 $80.35
$0.00
$148.20
$63.04
Procedure Code Pricing Action Code Description
Maximum Allowable
95934
3
H-REFLEX TEST
$47.29
95935
O
''H'' OR ''F'' REFLEX STUDY, BY ELE
95936
3
H-REFLEX TEST
$41.55
95937
3
NEUROMUSCULAR JUNCTION TEST
$55.94
95950
3
AMBULATORY EEG MONITORING
95951
3
EEG MONITORING/VIDEORECORD
$0.00
95952
9
MONITORING FOR LOCALIZATION OF CERE
$0.00
95953
3
EEG MONITORING/COMPUTER
95954
9
EEG MONITORING/GIVING DRUGS
$0.00
95955
9
EEG DURING SURGERY
$0.00
95956
3
EEG MONITORING, CABLE/RADIO
$706.49
95957
3
EEG DIGITAL ANALYSIS
$257.43
95958
9
EEG MONITORING/FUNCTION TEST
95961
3
ELECTRODE STIMULATION, BRAIN
$226.53
95962
3
ELECTRODE STIM, BRAIN ADD-ON
$208.72
95965
3
MEG, SPONTANEOUS
$0.00
95966
3
MEG, EVOKED, SINGLE
$0.00
95967
3
MEG, EVOKED, EACH ADDÏL
$0.00
95970
3
ANALYZE NEUROSTIM, NO PROG
$49.33
95971
3
ANALYZE NEUROSTIM, SIMPLE
$56.17
95972
3
ANALYZE NEUROSTIM, COMPLEX
$99.84
95973
3
ANALYZE NEUROSTIM, COMPLEX
$54.52
95974
3
CRANIAL NEUROSTIM, COMPLEX
$167.24
95975
3
CRANIAL NEUROSTIM, COMPLEX
$92.46
95978
3
ANALYZE NEUROSTIM BRAIN/1H
$198.89
95979
3
ANALYZ NEUROSTIM BRAIN ADDON
$88.98
95980
3
IO ANAL GAST N-STIM INIT
$39.50
95981
3
IO ANAL GAST N-STIM SUBSQ
$27.47
95982
3
IO GA N-STIM SUBSQ W/REPROG
$42.54
95990
3
SPIN/BRAIN PUMP REFIL & MAIN
$59.11
95991
3
SPIN/BRAIN PUMP REFIL & MAIN
$86.99
95992
3
CANALITH REPOSITIONING PROC
$40.59
95999
5
NEUROLOGICAL PROCEDURE
$0.00
96000
9
MOTION ANALYSIS, VIDEO/3D
$0.00
96001
9
MOTION TEST W/FT PRESS MEAS
$0.00
$0.00
$234.77
$397.02
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
96002
9
DYNAMIC SURFACE EMG
$0.00
96003
9
DYNAMIC FINE WIRE EMG
$0.00
96004
9
PHYS REVIEW OF MOTION TESTS
$0.00
96020
3
FUNCTIONAL BRAIN MAPPING
$0.00
96040
9
GENETIC COUNSELING, 30 MIN
$0.00
96100
O
PSYCHOLOGICAL TESTING
$0.00
96101
3
PSYCHO TESTING BY PSYCH/PHYS
$83.56
96102
9
PSYCHO TESTING BY TECHNICIAN
$0.00
96103
9
PSYCHO TESTING ADMIN BY COMP
$0.00
96105
9
ASSESSMENT OF APHASIA
$0.00
96110
3
DEVELOPMENTAL TEST, LIM
96111
7
DEVELOPMENTAL TEST, EXTEND
$0.00
96115
O
NEUROBEHAVIOR STATUS EXAM
$0.00
96116
9
NEUROBEHAVIORAL STATUS EXAM
$0.00
96117
O
NEUROPSYCH TEST BATTERY
$0.00
96118
3
NEUROPSYCH TST BY PSYCH/PHYS
96119
9
NEUROPSYCH TESTING BY TEC
$0.00
96120
9
NEUROPSYCH TST ADMIN W/COMP
$0.00
96125
9
COGNITIVE TEST BY HC PRO
$0.00
96150
9
ASSESS HLTH/BEHAVE, INIT
$0.00
96151
9
ASSESS HLTH/BEHAVE, SUBSEQ
$0.00
96152
9
INTERVENE HLTH/BEHAVE, INDIV
$0.00
96153
9
INTERVENE HLTH/BEHAVE, GROUP
$0.00
96154
7
INTERV HLTH/BEHAV, FAM W/PT
$0.00
96155
7
INTERV HLTH/BEHAV FAM NO PT
$0.00
96360
3
HYDRATION IV INFUSION, INIT
$56.93
96361
3
HYDRATE IV INFUSION, ADD-ON
$16.38
96365
3
THER/PROPH/DIAG IV INF, INIT
$69.44
96366
3
THER/PROPH/DIAG IV INF ADDON
$21.81
96367
3
TX/PROPH/DG ADDL SEQ IV INF
$34.74
96368
3
THER/DIAG CONCURRENT INF
$20.34
96369
3
SC THER INFUSION, UP TO 1 HR
96370
3
SC THER INFUSION, ADDL HR
$15.52
96371
3
SC THER INFUSION, RESET PUMP
$74.19
96372
9
THER/PROPH/DIAG INJ, SC/IM
$10.97
$106.27
$152.39
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
96373
9
THER/PROPH/DIAG INJ, IA
$0.00
96374
9
THER/PROPH/DIAG INJ, IV PUSH
$0.00
96375
9
TX/PRO/DX INJ NEW DRUG ADDON
$0.00
96376
6
TX/PRO/DX INJ NEW DRUG ADON
$0.00
96379
9
THER/PROP/DIAG INJ/INF PROC
$0.00
96400
O
CHEMOTHERAPY, SC/IM
$0.00
96401
3
CHEMO, ANTI-NEOPL, SQ/IM
$68.75
96402
3
CHEMO HORMON ANTINEOPL SQ/IM
$37.35
96405
3
CHEMO INTRALESIONAL, UP TO 7
$85.48
96406
3
CHEMO INTRALESIONAL OVER 7
$118.04
96408
O
CHEMOTHERAPY, PUSH TECHNIQUE
96409
3
CHEMO, IV PUSH, SNGL DRUG
96410
O
CHEMOTHERAPY,INFUSION METHOD
96411
3
CHEMO, IV PUSH, ADDL DRUG
96412
O
CHEMO, INFUSE METHOD ADD-ON
96413
3
CHEMO, IV INFUSION, 1 HR
96414
O
CHEMO, INFUSE METHOD ADD-ON
96415
3
CHEMO, IV INFUSION, ADDL HR
96416
3
CHEMO PROLONG INFUSE W/PUMP
96417
3
CHEMO IV INFUS EACH ADDL SEQ
96420
3
CHEMO, IA, PUSH TECNIQUE
$109.29
96422
3
CHEMO IA INFUSION UP TO 1 HR
$176.95
96423
3
CHEMO IA INFUSE EACH ADDL HR
96425
3
CHEMOTHERAPY,INFUSION METHOD
$174.36
96440
3
CHEMOTHERAPY, INTRACAVITARY
$607.84
96445
3
CHEMOTHERAPY, INTRACAVITARY
$287.89
96450
3
CHEMOTHERAPY, INTO CNS
$210.26
96520
O
PORT PUMP REFILL & MAIN
96521
3
REFILL/MAINT, PORTABLE PUMP
$129.10
96522
3
REFILL/MAINT PUMP/RESVR SYST
$109.51
96523
3
IRRIG DRUG DELIVERY DEVICE
96530
O
SYST PUMP REFILL & MAIN
96542
3
CHEMOTHERAPY INJECTION
96545
O
PROVIDE CHEMOTHERAPY AGENT
$0.00
96549
5
CHEMOTHERAPY, UNSPECIFIED
$0.00
$0.00 $113.53 $0.00 $64.42 $0.00 $149.82 $0.00 $33.24 $163.59 $74.25
$79.02
$0.00
$25.70 $0.00 $135.69
Procedure Code Pricing Action Code Description
Maximum Allowable
96567
3
PHOTODYNAMIC TX, SKIN
$119.27
96570
3
PHOTODYNAMIC TX, 30 MIN
$56.73
96571
3
PHOTODYNAMIC TX, ADDL 15 MIN
$27.40
96900
3
ULTRAVIOLET LIGHT THERAPY
$19.71
96902
3
TRICHOGRAM
$20.81
96904
9
WHOLE BODY PHOTOGRAPHY
96910
3
PHOTOCHEMOTHERAPY WITH UV-B
$63.81
96912
3
PHOTOCHEMOTHERAPY WITH UV-A
$81.79
96913
3
PHOTOCHEMOTHERAPY, UV-A OR B
$113.31
96920
3
LASER TX, SKIN < 250 SQ CM
$162.46
96921
3
LASER TX, SKIN 250-500 SQ CM
$158.99
96922
3
LASER TX, SKIN > 500 SQ CM
$234.97
96999
5
DERMATOLOGICAL PROCEDURE
97001
3
PT EVALUATION
$69.59
97002
3
PT RE-EVALUATION
$37.45
97003
3
OT EVALUATION
$73.89
97004
3
OT RE-EVALUATION
$42.99
97005
9
ATHLETIC TRAIN EVAL
$0.00
97006
9
ATHLETIC TRAIN REEVAL
$0.00
97010
3
HOT OR COLD PACKS THERAPY
$4.61
97012
3
MECHANICAL TRACTION THERAPY
$14.35
97014
3
ELECTRIC STIMULATION THERAPY
$13.33
97016
3
VASOPNEUMATIC DEVICE THERAPY
$15.17
97018
3
PARAFFIN BATH THERAPY
$7.93
97020
O
MICROWAVE THERAPY
$0.00
97022
3
WHIRLPOOL THERAPY
$17.40
97024
3
DIATHERMY EG, MICROWAVE
$5.34
97026
3
INFRARED THERAPY
$4.97
97028
3
ULTRAVIOLET THERAPY
$6.06
97032
3
ELECTRICAL STIMULATION
$16.20
97033
3
ELECTRIC CURRENT THERAPY
$24.32
97034
3
CONTRAST BATH THERAPY
$14.77
97035
3
ULTRASOUND THERAPY
$11.44
97036
3
HYDROTHERAPY
$25.40
97039
3
PHYSICAL THERAPY TREATMENT
$11.27
$0.00
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
97110
3
THERAPEUTIC EXERCISES
$28.02
97112
3
NEUROMUSCULAR REEDUCATION
$28.89
97113
3
AQUATIC THERAPY/EXERCISES
$34.45
97114
O
PHYSICAL MEDICINE TREATMENT TO ONE
97116
3
GAIT TRAINING THERAPY
97118
O
PHYSICAL MEDICINE TREATMENT TO ONE
$0.00
97120
O
PHYSICAL MEDICINE TREATMENT TO ONE
$0.00
97122
O
MANUAL TRACTION THERAPY
$0.00
97124
3
MASSAGE THERAPY
97126
O
PHYSICAL MEDICINE TREATMENT TO ONE
$0.00
97128
O
PHYSICAL MEDICINE TREATMENT TO ONE
$0.00
97139
3
PHYSICAL MEDICINE PROCEDURE
$15.30
97140
3
MANUAL THERAPY
$25.96
97145
O
PHYSICAL MEDICINE TREATMENT TO ONE
97150
3
GROUP THERAPEUTIC PROCEDURES
97220
O
HUBBARD TANK; INITIAL 30 MINUTES, E
$0.00
97221
O
HUBBARD TANK; EACH ADDITIONAL 15 MI
$0.00
97240
O
POOL THERAPY OR HUBBARD TANK WITH T
$0.00
97241
O
POOL THERAPY OR HUBBARD TANK WITH T
$0.00
97250
O
MYOFASCIAL RELEASE
$0.00
97260
O
REGIONAL MANIPULATION
$0.00
97261
O
SUPPLEMENTAL MANIPULATIONS
$0.00
97265
O
JOINT MOBILIZATION
$0.00
97500
O
ORTHOTICS TRAINING (DYNAMIC BRACING
$0.00
97501
O
ORTHOTICS TRAINING (DYNAMIC BRACING
$0.00
97504
O
ORTHOTIC TRAINING
$0.00
97520
O
PROSTHETIC TRAINING
$0.00
97521
O
PROSTHETIC TRAINING; EACH ADDITIONA
$0.00
97530
3
THERAPEUTIC ACTIVITIES
97531
O
KINETIC ACTIVITIES TO INCREASE COOR
97532
3
COGNITIVE SKILLS DEVELOPMENT
$24.10
97533
3
SENSORY INTEGRATION
$25.94
97535
3
SELF CARE MNGMENT TRAINING
$29.63
97537
3
COMMUNITY/WORK REINTEGRATION
$26.68
97540
O
TRAINING IN ACTIVITIES OF DAILY LIV
$0.00
$0.00 $24.52
$22.36
$0.00 $17.65
$29.65 $0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
97541
O
TRAINING IN ACTIVITIES OF DAILY LIV
$0.00
97542
3
WHEELCHAIR MNGMENT TRAINING
97545
O
WORK HARDENING
$0.00
97546
O
WORK HARDENING ADD-ON
$0.00
97597
3
ACTIVE WOUND CARE/20 CM OR <
$58.53
97598
3
ACTIVE WOUND CARE > 20 CM
$72.30
97601
O
WOUND(S) CARE, SELECTIVE
$0.00
97602
9
WOUND(S) CARE NON-SELECTIVE
$0.00
97605
3
NEG PRESS WOUND TX, < 50 CM
$34.55
97606
3
NEG PRESS WOUND TX, > 50 CM
$36.95
97700
O
OFFICE VISIT, INCLUDING ONE OF THE
$0.00
97701
O
OFFICE VISIT, INCLUDING ONE OF THE
$0.00
97703
O
PROSTHETIC CHECKOUT
$0.00
97720
O
EXTREMITY TESTING FOR STRENGTH, DEX
$0.00
97721
O
EXTREMITY TESTING FOR STRENGTH, DEX
$0.00
97750
3
PHYSICAL PERFORMANCE TEST
97752
O
MUSCLE TESTING WITH TORQUE CURVES D
97755
3
ASSISTIVE TECHNOLOGY ASSESS
$32.99
97760
3
ORTHOTIC MGMT AND TRAINING
$31.96
97761
3
PROSTHETIC TRAINING
$28.39
97762
3
C/O FOR ORTHOTIC/PROSTH USE
$33.45
97770
O
COGNITIVE SKILLS DEVELOPMENT
$0.00
97780
O
ACUPUNCTURE W/O STIMUL
$0.00
97781
O
ACUPUNCTURE W/STIMUL
$0.00
97799
5
PHYSICAL MEDICINE PROCEDURE
$0.00
97802
7
MEDICAL NUTRITION, INDIV, IN
$0.00
97803
7
MED NUTRITION, INDIV, SUBSEQ
$0.00
97804
9
MEDICAL NUTRITION, GROUP
$0.00
97810
9
ACUPUNCT W/O STIMUL 15 MIN
$0.00
97811
9
ACUPUNCT W/O STIMUL ADDL 15M
$0.00
97813
9
ACUPUNCT W/STIMUL 15 MIN
$0.00
97814
9
ACUPUNCT W/STIMUL ADDL 15M
$0.00
98900
O
MEDICAL CONFERENCE BY PHYSICIAN REG
$0.00
98902
O
MEDICAL CONFERENCE BY PHYSICIAN REG
$0.00
98910
O
MEDICAL CONFERENCE BY PHYSICIAN WIT
$0.00
$27.04
$28.76 $0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
98912
O
MEDICAL CONFERENCE BY PHYSICIAN WIT
$0.00
98920
9
TELEPHONE CALL BY A PHYSICIAN TO PA
$0.00
98921
9
TELEPHONE CALL BY A PHYSICIAN TO PA
$0.00
98922
9
TELEPHONE CALL BY A PHYSICIAN TO PA
$0.00
98925
3
OSTEOPATHIC MANIPULATION
$27.66
98926
3
OSTEOPATHIC MANIPULATION
$37.99
98927
3
OSTEOPATHIC MANIPULATION
$49.19
98928
3
OSTEOPATHIC MANIPULATION
$57.73
98929
3
OSTEOPATHIC MANIPULATION
$66.28
98940
9
CHIROPRACTIC MANIPULATION
$0.00
98941
9
CHIROPRACTIC MANIPULATION
$0.00
98942
9
CHIROPRACTIC MANIPULATION
$0.00
98943
9
CHIROPRACTIC MANIPULATION
$0.00
98960
9
SELF-MGMT EDUC & TRAIN, 1 PT
$0.00
98961
9
SELF-MGMT EDUC/TRAIN, 2-4 PT
$0.00
98962
9
SELF-MGMT EDUC/TRAIN, 5-8 PT
$0.00
98966
9
HC PRO PHONE CALL 5-10 MIN
$0.00
98967
9
HC PRO PHONE CALL 11-20 MIN
$0.00
98968
9
HC PRO PHONE CALL 21-30 MIN
$0.00
98969
9
ONLINE SERVICE BY HC PRO
$0.00
99000
9
SPECIMEN HANDLING
$0.00
99001
3
SPECIMEN HANDLING
$3.10
99002
9
DEVICE HANDLING
$0.00
99024
9
POSTOP FOLLOW-UP VISIT
$0.00
99025
O
INITIAL SURGICAL EVALUATION
$0.00
99026
9
IN-HOSPITAL ON CALL SERVICE
$0.00
99027
9
OUT-OF-HOSP ON CALL SERVICE
$0.00
99050
3
MEDICAL SERVICES AFTER HRS
$20.00
99051
9
MED SERV, EVE/WKEND/HOLIDAY
$0.00
99052
O
MEDICAL SERVICES AT NIGHT
$0.00
99053
9
MED SERV 10PM-8AM, 24 HR FAC
$0.00
99054
O
MEDICAL SERVCS, UNUSUAL HRS
$0.00
99056
O
MED SERVICE OUT OF OFFICE
$0.00
99058
9
OFFICE EMERGENCY CARE
$0.00
99060
9
OUT OF OFFICE EMERG MED SERV
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
99062
O
EMERGENCY CARE FACILITY SERVICES: W
$0.00
99064
O
EMERGENCY CARE FACILITY SERVICES: W
$0.00
99065
O
EMERGENCY CARE FACILITY SERVICES: W
$0.00
99070
O
SPECIAL SUPPLIES
$0.00
99071
9
PATIENT EDUCATION MATERIALS
$0.00
99075
9
MEDICAL TESTIMONY
$0.00
99078
9
GROUP HEALTH EDUCATION
$0.00
99080
9
SPECIAL REPORTS OR FORMS
$0.00
99082
9
UNUSUAL PHYSICIAN TRAVEL
$0.00
99090
9
COMPUTER DATA ANALYSIS
$0.00
99091
9
COLLECT/REVIEW DATA FROM PT
$0.00
99100
9
SPECIAL ANESTHESIA SERVICE
$0.00
99116
9
ANESTHESIA WITH HYPOTHERMIA
$0.00
99135
9
SPECIAL ANESTHESIA PROCEDURE
$0.00
99140
9
EMERGENCY ANESTHESIA
$0.00
99141
O
SEDATION, IV/IM OR INHALANT
$0.00
99142
O
SEDATION, ORAL/RECTAL/NASAL
$0.00
99143
9
MOD CS BY SAME PHYS, < 5 YRS
$0.00
99144
9
MOD CS BY SAME PHYS, 5 YRS +
$0.00
99145
9
MOD CS BY SAME PHYS ADD-ON
$0.00
99148
3
MOD CS DIFF PHYS < 5 YRS
$112.36
99149
3
MOD CS DIFF PHYS 5 YRS +
$112.36
99150
3
MODERATE SEDATION SERVICES (OTHER
99151
O
PROLONGED PHYSICIAN ATTENDANCE REQU
$0.00
99152
O
NEWBORN RESUSCITATION: CARE OF THE
$0.00
99160
O
CRITICAL CARE, INITIAL, INCLUDING T
$0.00
99162
O
CRITICAL CARE, INITIAL, INCLUDING T
$0.00
99170
3
ANOGENITAL EXAM, CHILD
99171
O
CRITICAL CARE, SUBSEQUENT FOLLOW-UP
$0.00
99172
O
OCULAR FUNCTION SCREEN
$0.00
99173
3
VISUAL ACUITY SCREEN
$2.46
99174
3
OCULAR PHOTOSCREENING WITH INTERPR
$25.75
99175
3
INDUCTION OF VOMITING
$25.32
99178
O
ADMINISTRATION AND MEDICAL INTERPRE
$0.00
99180
O
HYPERBARIC OXYGEN PRESSURIZATION IN
$0.00
$56.18
$142.46
Procedure Code Pricing Action Code Description
Maximum Allowable
99182
O
HYPERBARIC OXYGEN PRESSURIZATION SU
$0.00
99183
3
HYPERBARIC OXYGEN THERAPY
99185
3
REGIONAL HYPOTHERMIA
$57.15
99186
3
TOTAL BODY HYPOTHERMIA
$72.53
99190
9
SPECIAL PUMP SERVICES
$0.00
99191
9
SPECIAL PUMP SERVICES
$0.00
99192
9
SPECIAL PUMP SERVICES
$0.00
99195
3
PHLEBOTOMY
99199
5
SPECIAL SERVICE/PROC/REPORT
$0.00
99201
3
OFFICE/OUTPATIENT VISIT, NEW
$36.76
99202
3
OFFICE/OUTPATIENT VISIT, NEW
$63.33
99203
3
OFFICE/OUTPATIENT VISIT, NEW
$91.44
99204
3
OFFICE/OUTPATIENT VISIT, NEW
$140.89
99205
3
OFFICE/OUTPATIENT VISIT, NEW
$177.71
99211
3
OFFICE/OUTPATIENT VISIT, EST
$18.88
99212
3
OFFICE/OUTPATIENT VISIT, EST
$37.13
99213
3
OFFICE/OUTPATIENT VISIT, EST
$61.32
99214
3
OFFICE/OUTPATIENT VISIT, EST
$92.24
99215
3
OFFICE/OUTPATIENT VISIT, EST
$124.40
99217
3
OBSERVATION CARE DISCHARGE
$66.03
99218
3
OBSERVATION CARE
$61.97
99219
3
OBSERVATION CARE
$102.53
99220
3
OBSERVATION CARE
$143.84
99221
3
INITIAL HOSPITAL CARE
$88.82
99222
3
INITIAL HOSPITAL CARE
$121.24
99223
3
INITIAL HOSPITAL CARE
$178.49
99231
3
SUBSEQUENT HOSPITAL CARE
$36.75
99232
3
SUBSEQUENT HOSPITAL CARE
$66.16
99233
3
SUBSEQUENT HOSPITAL CARE
$94.72
99234
3
OBSERV/HOSP SAME DATE
$125.65
99235
3
OBSERV/HOSP SAME DATE
$164.88
99236
3
OBSERV/HOSP SAME DATE
$204.84
99238
3
HOSPITAL DISCHARGE DAY
$65.80
99239
3
HOSPITAL DISCHARGE DAY
$95.45
99241
3
OFFICE CONSULTATION
$48.47
$189.12
$71.83
Procedure Code Pricing Action Code Description
Maximum Allowable
99242
3
OFFICE CONSULTATION
$90.21
99243
3
OFFICE CONSULTATION
$123.90
99244
3
OFFICE CONSULTATION
$183.10
99245
3
OFFICE CONSULTATION
$224.78
99251
3
INPATIENT CONSULTATION
$48.02
99252
3
INPATIENT CONSULTATION
$74.62
99253
3
INPATIENT CONSULTATION
$113.33
99254
3
INPATIENT CONSULTATION
$163.93
99255
3
INPATIENT CONSULTATION
$199.75
99261
O
FOLLOW-UP INPATIENT CONSULT
$0.00
99262
O
FOLLOW-UP INPATIENT CONSULT
$0.00
99263
O
FOLLOW-UP INPATIENT CONSULT
$0.00
99271
O
CONFIRMATORY CONSULTATION
$0.00
99272
O
CONFIRMATORY CONSULTATION
$0.00
99273
O
CONFIRMATORY CONSULTATION
$0.00
99274
O
CONFIRMATORY CONSULTATION
$0.00
99275
O
CONFIRMATORY CONSULTATION
$0.00
99281
3
EMERGENCY DEPT VISIT
$19.88
99282
3
EMERGENCY DEPT VISIT
$38.69
99283
3
EMERGENCY DEPT VISIT
$60.03
99284
3
EMERGENCY DEPT VISIT
$112.21
99285
3
EMERGENCY DEPT VISIT
$166.82
99288
9
DIRECT ADVANCED LIFE SUPPORT
$0.00
99289
O
PED CRIT CARE TRANSPORT
$0.00
99290
O
PED CRIT CARE TRANSPORT ADDL
$0.00
99291
3
CRITICAL CARE, FIRST HOUR
$251.98
99292
3
CRITICAL CARE, ADDÏL 30 MIN
$113.36
99293
O
PED CRITICAL CARE, INITIAL
$0.00
99294
O
PED CRITICAL CARE, SUBSEQ
$0.00
99295
O
NEONATE CRIT CARE, INITIAL
$0.00
99296
O
NEONATE CRITICAL CARE SUBSEQ
$0.00
99297
O
NEONATAL CRITICAL CARE
$0.00
99298
O
IC FOR LBW INFANT < 1500 GM
$0.00
99299
O
IC, LBW INFANT 1500-2500 GM
$0.00
99300
O
IC, INFANT PBW 2501-5000 GM
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
99301
O
NURSING FACILITY CARE
$0.00
99302
O
NURSING FACILITY CARE
$0.00
99303
O
NURSING FACILITY CARE
$0.00
99304
3
NURSING FACILITY CARE, INIT
$79.43
99305
3
NURSING FACILITY CARE, INIT
$110.86
99306
3
NURSING FACILITY CARE, INIT
$142.27
99307
3
NURSING FAC CARE, SUBSEQ
$39.34
99308
3
NURSING FAC CARE, SUBSEQ
$60.15
99309
3
NURSING FAC CARE, SUBSEQ
$79.75
99310
3
NURSING FAC CARE, SUBSEQ
$117.69
99311
O
NURSING FAC CARE, SUBSEQ
$0.00
99312
O
NURSING FAC CARE, SUBSEQ
$0.00
99313
O
NURSING FAC CARE, SUBSEQ
$0.00
99315
9
NURSING FAC DISCHARGE DAY
$0.00
99316
9
NURSING FAC DISCHARGE DAY
$0.00
99318
3
ANNUAL NURSING FAC ASSESSMNT
99321
O
REST HOME VISIT, NEW PATIENT
$0.00
99322
O
REST HOME VISIT, NEW PATIENT
$0.00
99323
O
REST HOME VISIT, NEW PATIENT
$0.00
99324
9
DOMICIL/R-HOME VISIT NEW PAT
$0.00
99325
9
DOMICIL/R-HOME VISIT NEW PAT
$0.00
99326
9
DOMICIL/R-HOME VISIT NEW PAT
$0.00
99327
9
DOMICIL/R-HOME VISIT NEW PAT
$0.00
99328
9
DOMICIL/R-HOME VISIT NEW PAT
$0.00
99331
O
REST HOME VISIT, EST PAT
$0.00
99332
O
REST HOME VISIT, EST PAT
$0.00
99333
O
REST HOME VISIT, EST PAT
$0.00
99334
9
DOMICIL/R-HOME VISIT EST PAT
$0.00
99335
9
DOMICIL/R-HOME VISIT EST PAT
$0.00
99336
9
DOMICIL/R-HOME VISIT EST PAT
$0.00
99337
9
DOMICIL/R-HOME VISIT EST PAT
$0.00
99339
9
DOMICIL/R-HOME CARE SUPERVIS
$0.00
99340
9
DOMICIL/R-HOME CARE SUPERVIS
$0.00
99341
3
HOME VISIT, NEW PATIENT
$53.56
99342
3
HOME VISIT, NEW PATIENT
$77.80
$83.01
Procedure Code Pricing Action Code Description
Maximum Allowable
99343
3
HOME VISIT, NEW PATIENT
$124.97
99344
3
HOME VISIT, NEW PATIENT
$163.83
99345
3
HOME VISIT, NEW PATIENT
$196.94
99347
3
HOME VISIT, EST PATIENT
$52.22
99348
3
HOME VISIT, EST PATIENT
$78.63
99349
3
HOME VISIT, EST PATIENT
$114.26
99350
3
HOME VISIT, EST PATIENT
$159.14
99351
O
HOME VISIT FOR THE EVALUATION AND M
$0.00
99352
O
HOME VISIT FOR THE EVALUATION AND M
$0.00
99353
O
HOME VISIT FOR THE EVALUATION AND M
$0.00
99354
3
PROLONGED SERVICE, OFFICE
$91.04
99355
3
PROLONGED SERVICE, OFFICE
$90.07
99356
3
PROLONGED SERVICE, INPATIENT
$82.75
99357
3
PROLONGED SERVICE, INPATIENT
$83.36
99358
9
PROLONGED SERV, W/O CONTACT
$0.00
99359
9
PROLONGED SERV, W/O CONTACT
$0.00
99360
3
PHYSICIAN STANDBY SERVICES
$58.87
99361
O
PHYSICIAN/TEAM CONFERENCE
$0.00
99362
O
PHYSICIAN/TEAM CONFERENCE
$0.00
99363
9
ANTICOAG MGMT, INIT
$0.00
99364
9
ANTICOAG MGMT, SUBSEQ
$0.00
99366
9
TEAM CONF W/PAT BY HC PRO
$0.00
99367
9
TEAM CONF W/O PAT BY PHYS
$0.00
99368
9
TEAM CONF W/O PAT BY HC PRO
$0.00
99371
O
PHYSICIAN PHONE CONSULTATION
$0.00
99372
O
PHYSICIAN PHONE CONSULTATION
$0.00
99373
O
PHYSICIAN PHONE CONSULTATION
$0.00
99374
9
HOME HEALTH CARE SUPERVISION
$0.00
99375
9
HOME HEALTH CARE SUPERVISION
$0.00
99376
9
PHYSICIAN SUPERVISION OF PATIENTS U
$0.00
99377
9
HOSPICE CARE SUPERVISION
$0.00
99378
9
HOSPICE CARE SUPERVISION
$0.00
99379
9
NURSING FAC CARE SUPERVISION
$0.00
99380
9
NURSING FAC CARE SUPERVISION
$0.00
99381
3
INIT PM E/M, NEW PAT, INF
$90.68
Procedure Code Pricing Action Code Description
Maximum Allowable
99382
3
INIT PM E/M, NEW PAT 1-4 YRS
$98.60
99383
3
PREV VISIT, NEW, AGE 5-11
$97.86
99384
3
PREV VISIT, NEW, AGE 12-17
$106.39
99385
3
PREV VISIT, NEW, AGE 18-39
$106.39
99386
3
PREV VISIT, NEW, AGE 40-64
$124.31
99387
3
INIT PM E/M, NEW PAT 65+ YRS
$136.29
99391
3
PER PM REEVAL, EST PAT, INF
$75.49
99392
3
PREV VISIT, EST, AGE 1-4
$84.02
99393
3
PREV VISIT, EST, AGE 5-11
$83.65
99394
3
PREV VISIT, EST, AGE 12-17
$91.94
99395
3
PREV VISIT, EST, AGE 18-39
$92.32
99396
3
PREV VISIT, EST, AGE 40-64
$100.84
99397
3
PER PM REEVAL EST PAT 65+ YR
$113.19
99401
7
PREVENTIVE COUNSELING, INDIV
$0.00
99402
7
PREVENTIVE COUNSELING, INDIV
$0.00
99403
7
PREVENTIVE COUNSELING, INDIV
$0.00
99404
7
PREVENTIVE COUNSELING, INDIV
$0.00
99406
9
BEHAV CHNG SMOKING 3-10 MIN
$0.00
99407
9
BEHAV CHNG SMOKING > 10 MIN
$0.00
99408
9
AUDIT/DAST, 15-30 MIN
$0.00
99409
9
AUDIT/DAST, OVER 30 MIN
$0.00
99411
9
PREVENTIVE COUNSELING, GROUP
$0.00
99412
9
PREVENTIVE COUNSELING, GROUP
$0.00
99420
9
HEALTH RISK ASSESSMENT TEST
$0.00
99429
9
UNLISTED PREVENTIVE SERVICE
$0.00
99431
O
INITIAL CARE, NORMAL NEWBORN
$0.00
99432
O
NEWBORN CARE, NOT IN HOSP
$0.00
99433
O
NORMAL NEWBORN CARE/HOSPITAL
$0.00
99435
O
NEWBORN DISCHARGE DAY HOSP
$0.00
99436
O
ATTENDANCE, BIRTH
$0.00
99438
9
INFANT CARE TO ONE YEAR OF AGE, WIT
$0.00
99440
O
NEWBORN RESUSCITATION
$0.00
99441
9
PHONE E/M BY PHYS 5-10 MIN
$0.00
99442
9
PHONE E/M BY PHYS 11-20 MIN
$0.00
99443
9
PHONE E/M BY PHYS 21-30 MIN
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
99444
9
ONLINE E/M BY PHYS
$0.00
99450
9
BASIC LIFE DISABILITY EXAM
$0.00
99455
9
WORK RELATED DISABILITY EXAM
$0.00
99456
9
DISABILITY EXAMINATION
$0.00
99460
3
INIT NB EM PER DAY, HOSP
$55.58
99461
3
INIT NB EM PER DAY, NON-FAC
$84.04
99462
3
SBSQ NB EM PER DAY, HOSP
$29.65
99463
3
SAME DAY NB DISCHARGE
$74.64
99464
3
ATTENDANCE AT DELIVERY
$69.83
99465
3
NB RESUSCITATION
$143.44
99466
3
PED CRIT CARE TRANSPORT
$228.67
99467
3
PED CRIT CARE TRANSPORT ADDL
$114.15
99468
3
NEONATE CRIT CARE, INITIAL
$854.56
99469
3
NEONATE CRIT CARE, SUBSQ
$374.89
99471
3
PED CRITICAL CARE, INITIAL
$763.14
99472
3
PED CRITICAL CARE, SUBSQ
$378.01
99475
3
PED CRIT CARE AGE 2-5, INIT
$525.56
99476
3
PED CRIT CARE AGE 2-5, SUBSQ
$313.16
99477
3
INIT DAY HOSP NEONATE CARE
$333.60
99478
3
IC, LBW INF < 1500 GM SUBSQ
$135.98
99479
3
IC LBW INF 1500-2500 G SUBSQ
$119.42
99480
3
IC INF PBW 2501-5000 G SUBSQ
$114.87
99499
5
UNLISTED E&M SERVICE
$0.00
99500
9
HOME VISIT, PRENATAL
$0.00
99501
9
HOME VISIT, POSTNATAL
$0.00
99502
9
HOME VISIT, NB CARE
$0.00
99503
9
HOME VISIT, RESP THERAPY
$0.00
99504
9
HOME VISIT MECH VENTILATOR
$0.00
99505
9
HOME VISIT, STOMA CARE
$0.00
99506
9
HOME VISIT, IM INJECTION
$0.00
99507
9
HOME VISIT, CATH MAINTAIN
$0.00
99508
9
HOME VISIT, SLEEP STUDIES
$0.00
99509
9
HOME VISIT DAY LIFE ACTIVITY
$0.00
99510
7
HOME VISIT, SING/M/FAM COUNS
$0.00
99511
9
HOME VISIT, FECAL/ENEMA MGMT
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
99512
9
HOME VISIT FOR HEMODIALYSIS
$0.00
99539
9
HOME VISIT, NOS
$0.00
99551
O
HOME INFUS, PAIN MGMT, IV/SC
$0.00
99552
O
HM INFUS PAIN MGMT, EPID/ITH
$0.00
99553
O
HOME INFUSE, TOCOLYTIC TX
$0.00
99554
O
HOME INFUS, HORMONE/PLATELET
$0.00
99555
O
HOME INFUSE, CHEMOTHERAPHY
$0.00
99556
O
HOME INFUS, ANTIBIO/FUNG/VIR
$0.00
99557
O
HOME INFUSE, ANTICOAGULANT
$0.00
99558
O
HOME INFUSE, IMMUNOTHERAPY
$0.00
99559
O
HOME INFUS, PERITON DIALYSIS
$0.00
99560
O
HOME INFUS, ENTERO NUTRITION
$0.00
99561
O
HOME INFUSE, HYDRATION TX
$0.00
99562
O
HOME INFUS, PARENT NUTRITION
$0.00
99563
O
HOME ADMIN, PENTAMIDINE
$0.00
99564
O
HME INFUS, ANTIHEMOPHIL AGNT
$0.00
99565
O
HOME INFUS, PROTEINASE INHIB
$0.00
99566
O
HOME INFUSE, IV THERAPY
$0.00
99567
O
HOME INFUSE, SYMPATH AGENT
$0.00
99568
O
HOME INFUS, MISC DRUG, DAILY
$0.00
99569
O
HOME INFUSE, EACH ADDL TX
$0.00
99600
9
HOME VISIT NOS
$0.00
99601
9
HOME INFUSION/VISIT, 2 HRS
$0.00
99602
9
HOME INFUSION, EACH ADDTL HR
$0.00
99605
9
MTMS BY PHARM, NP, 15 MIN
$0.00
99606
9
MTMS BY PHARM, EST, 15 MIN
$0.00
99607
9
MTMS BY PHARM, ADDL 15 MIN
$0.00
A0010
9
AMBULANCE SERVICE, BASIC LIFE SUPPO
$0.00
A0020
9
AMBULANCE SERVICE, (BLS) PER MILE,
$0.00
A0021
9
OUTSIDE STATE AMBULANCE SERV
$0.00
A0030
9
AIR AMBULANCE SERVICE
$0.00
A0040
O
HELICOPTER AMBULANCE SERVICE
$0.00
A0050
9
WATER AMB SERVICE EMERGENCY
$0.00
A0060
9
AMBULANCE SERVICE, WAITING TIME, ON
$0.00
A0070
O
AMBULANCE SERVICE, OXYGEN, ADMINIST
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
A0080
9
NONINTEREST ESCORT IN NON ER
$0.00
A0090
3
INTEREST ESCORT IN NON ER
$0.20
A0100
7
NONEMERGENCY TRANSPORT TAXI
$0.00
A0110
7
NONEMERGENCY TRANSPORT BUS
$0.00
A0120
7
NONER TRANSPORT MINI-BUS
$0.00
A0130
3
NONER TRANSPORT WHEELCH VAN
A0140
5
NONEMERGENCY TRANSPORT AIR
$0.00
A0150
O
NON-EMERGENCY TRANSPORTATION, AMBUL
$0.00
A0160
9
NONER TRANSPORT CASE WORKER
$0.00
A0170
5
TRANSPORT PARKING FEES/TOLLS
$0.00
A0180
5
NONER TRANSPORT LODGNG RECIP
$0.00
A0190
5
NONER TRANSPORT MEALS RECIP
$0.00
A0200
5
NONER TRANSPORT LODGNG ESCRT
$0.00
A0210
5
NONER TRANSPORT MEALS ESCORT
$0.00
A0215
9
AMBULANCE SERVICE, MISCELLANEOUS DI
$0.00
A0220
9
AMBULANCE SERVICE, ADVANCED LIFE SU
$0.00
A0221
9
AMBULANCE SERVICE, (ALS) PER MILE,
$0.00
A0222
9
AMBULANCE SERVICE, RETURN TRIP, TRA
$0.00
A0223
9
AMBULANCE SERVICE, ADVANCED LIFE SU
$0.00
A0225
3
NEONATAL EMERGENCY TRANSPORT
A0300
9
AMBULANCE BASIC NON-EMER ALL
$0.00
A0302
9
AMBULANCE BASIC EMERGENY ALL
$0.00
A0304
9
AMB ADV NON-ER NO SERV ALL
$0.00
A0306
9
AMB ADV NON-ER SPEC SERV ALL
$0.00
A0308
9
AMB ADV ER NO SPEC SERV ALL
$0.00
A0310
9
AMB ADV ER SPEC SERV ALL
$0.00
A0320
9
AMB BASIC NON-ER + SUPPLIES
$0.00
A0322
9
AMB BASIC EMERG + SUPPLIES
$0.00
A0324
9
ADV NON-ER SERV SEP MILEAGE
$0.00
A0326
9
ADV NON-ER NO SERV SEP MILE
$0.00
A0328
9
ADV ER NO SERV SEP MILEAGE
$0.00
A0330
9
ADV ER SPEC SERV SEP MILE
$0.00
A0340
9
AMB BASIC NON-ER + MILEAGE
$0.00
A0342
9
AMBUL BASIC EMER + MILEAGE
$0.00
A0344
9
AMB ADV NON-ER NO SERV +MILE
$0.00
$11.01
$95.00
Procedure Code Pricing Action Code Description
Maximum Allowable
A0346
9
AMB ADV NON-ER SERV + MILE
$0.00
A0348
9
ADV EMER NO SPEC SERV + MILE
$0.00
A0350
9
ADV EMER SPEC SERV + MILEAGE
$0.00
A0360
9
BASIC NON-ER SEP MILE & SUPP
$0.00
A0362
9
BASIC EMER SEP MILE & SUPPLY
$0.00
A0364
9
ADV NON-ER NO SERV SEP MI&SU
$0.00
A0366
9
ADV NON-ER SERV SEP MIL&SUPP
$0.00
A0368
9
ADV ER NO SERV SEP MILE&SUPP
$0.00
A0370
9
ADV ER SPEC SERV SEP MI&SUPP
$0.00
A0380
3
BASIC LIFE SUPPORT MILEAGE
$1.50
A0382
9
BASIC SUPPORT ROUTINE SUPPLS
$0.00
A0384
9
BLS DEFIBRILLATION SUPPLIES
$0.00
A0390
3
ADVANCED LIFE SUPPORT MILEAG
$1.50
A0392
9
ALS DEFIBRILLATION SUPPLIES
$0.00
A0394
9
ALS IV DRUG THERAPY SUPPLIES
$0.00
A0396
9
ALS ESOPHAGEAL INTUB SUPPLS
$0.00
A0398
9
ALS ROUTINE DISPOSBLE SUPPLS
$0.00
A0420
9
AMBULANCE WAITING 1/2 HR
$0.00
A0422
3
AMBULANCE 02 LIFE SUSTAINING
$12.00
A0424
5
EXTRA AMBULANCE ATTENDANT
$0.00
A0425
9
GROUND MILEAGE
$0.00
A0426
3
ALS 1
$35.00
A0427
3
ALS1-EMERGENCY
$55.00
A0428
3
BLS
$35.00
A0429
3
BLS-EMERGENCY
$55.00
A0430
9
FIXED WING AIR TRANSPORT
A0431
3
ROTARY WING AIR TRANSPORT
$2,124.00
A0432
9
PI VOLUNTEER AMBULANCE CO
$0.00
A0433
9
ALS 2
$0.00
A0434
9
SPECIALTY CARE TRANSPORT
$0.00
A0435
9
FIXED WING AIR MILEAGE
$0.00
A0436
3
ROTARY WING AIR MILEAGE
A0800
O
AMB TRANS 7PM-7AM
$0.00
A0888
9
NONCOVERED AMBULANCE MILEAGE
$0.00
A0998
9
AMBULANCE RESPONSE/TREATMENT
$0.00
$0.00
$12.80
Procedure Code Pricing Action Code Description
Maximum Allowable
A0999
9
UNLISTED AMBULANCE SERVICE
$0.00
A2000
9
MANIPULATION OF SPINE BY CHIROPRACT
$0.00
A4190
O
TRANSPARENT FILM, EACH
$0.00
A4200
O
GAUZE PADS, MEDICATED OR NON-MEDICA
$0.00
A4202
O
GAUZE, ELASTIC, ALL TYPES, PER ROLL
$0.00
A4203
O
GAUZE, NON-ELASTIC, PER ROLL
$0.00
A4204
O
ABSORPTIVE DRESSING (E.G. HYDROCOLL
$0.00
A4205
O
NON-ABSORPTIVE DRESSING (E.G. HYDRO
$0.00
A4206
3
1 CC STERILE SYRINGE&NEEDLE
$0.22
A4207
3
2 CC STERILE SYRINGE&NEEDLE
$0.20
A4208
3
3 CC STERILE SYRINGE&NEEDLE
$0.18
A4209
3
5+ CC STERILE SYRINGE&NEEDLE
$0.36
A4210
3
NONNEEDLE INJECTION DEVICE
$1.50
A4211
O
SUPP FOR SELF-ADM INJECTIONS
$0.00
A4212
5
NON CORING NEEDLE OR STYLET
$0.00
A4213
3
20+ CC SYRINGE ONLY
$0.68
A4214
O
30 CC STERILE WATER/SALINE
$0.00
A4215
5
STERILE NEEDLE
$0.00
A4216
3
STERILE WATER/SALINE, 10 ML
$0.54
A4217
3
STERILE WATER/SALINE, 500 ML
$3.13
A4218
6
STERILE SALINE OR WATER
$0.00
A4220
9
INFUSION PUMP REFILL KIT
$0.00
A4221
3
MAINT DRUG INFUS CATH PER WK
$22.52
A4222
3
INFUSION SUPPLIES WITH PUMP
$46.50
A4223
6
INFUSION SUPPLIES W/O PUMP
$0.00
A4230
3
INFUS INSULIN PUMP NON NEEDL
$10.07
A4231
5
INFUSION INSULIN PUMP NEEDLE
$0.00
A4232
3
SYRINGE W/NEEDLE INSULIN 3CC
$2.54
A4233
6
ALKALIN BATT FOR GLUCOSE MON
$0.00
A4234
6
J-CELL BATT FOR GLUCOSE MON
$0.00
A4235
3
LITHIUM BATT FOR GLUCOSE MON
$2.34
A4236
6
SILVR OXIDE BATT GLUCOSE MON
$0.00
A4244
3
ALCOHOL OR PEROXIDE PER PINT
$1.00
A4245
3
ALCOHOL WIPES PER BOX
$10.00
A4246
3
BETADINE/PHISOHEX SOLUTION
$10.00
Procedure Code Pricing Action Code Description
Maximum Allowable
A4247
3
BETADINE/IODINE SWABS/WIPES
$8.00
A4248
6
CHLORHEXIDINE ANTISEPT
$0.00
A4250
3
URINE REAGENT STRIPS/TABLETS
A4252
6
BLOOD KETONE TEST OR STRIP
$0.00
A4253
9
BLOOD GLUCOSE/REAGENT STRIPS
$0.00
A4254
O
BATTERY FOR GLUCOSE MONITOR
$0.00
A4255
9
GLUCOSE MONITOR PLATFORMS
$0.00
A4256
9
CALIBRATOR SOLUTION/CHIPS
$0.00
A4257
9
REPLACE LENSSHIELD CARTRIDGE
$0.00
A4258
9
LANCET DEVICE EACH
$0.00
A4259
9
LANCETS PER BOX
$0.00
A4260
O
LEVONORGESTREL (CONTRACEPTIVE) IMP
$0.00
A4261
9
CERVICAL CAP CONTRACEPTIVE
$0.00
A4262
9
TEMPORARY TEAR DUCT PLUG
$0.00
A4263
9
PERMANENT TEAR DUCT PLUG
$0.00
A4265
9
PARAFFIN
$0.00
A4266
9
DIAPHRAGM
$0.00
A4267
9
MALE CONDOM
$0.00
A4268
9
FEMALE CONDOM
$0.00
A4269
9
SPERMICIDE
$0.00
A4270
9
DISPOSABLE ENDOSCOPE SHEATH
$0.00
A4280
3
BRST PRSTHS ADHSV ATTCHMNT
$4.62
A4281
5
REPLACEMENT BREASTPUMP TUBE
$0.00
A4282
5
REPLACEMENT BREASTPUMP ADPT
$0.00
A4283
5
REPLACEMENT BREASTPUMP CAP
$0.00
A4284
5
REPLCMNT BREAST PUMP SHIELD
$0.00
A4285
5
REPLCMNT BREAST PUMP BOTTLE
$0.00
A4286
5
REPLCMNT BREASTPUMP LOK RING
$0.00
A4290
5
SACRAL NERVE STIM TEST LEAD
$0.00
A4300
9
CATH IMPL VASC ACCESS PORTAL
$0.00
A4301
9
IMPLANTABLE ACCESS SYST PERC
$0.00
A4305
3
DRUG DELIVERY SYSTEM >=50 ML
$17.04
A4306
3
DRUG DELIVERY SYSTEM <=50 ML
$29.64
A4310
3
INSERT TRAY W/O BAG/CATH
A4311
3
CATHETER W/O BAG 2-WAY LATEX
$17.25
$6.81 $12.04
Procedure Code Pricing Action Code Description
Maximum Allowable
A4312
3
CATH W/O BAG 2-WAY SILICONE
$14.62
A4313
3
CATHETER W/BAG 3-WAY
$17.31
A4314
3
CATH W/DRAINAGE 2-WAY LATEX
$22.90
A4315
3
CATH W/DRAINAGE 2-WAY SILCNE
$24.61
A4316
3
CATH W/DRAINAGE 3-WAY
$25.71
A4319
O
STERILE H2O IRRIGATION SOLUT
$0.00
A4320
3
IRRIGATION TRAY
$4.81
A4321
9
CATH THERAPEUTIC IRRIG AGENT
$0.00
A4322
3
IRRIGATION SYRINGE
$2.81
A4323
O
SALINE IRRIGATION SOLUTION
$0.00
A4324
O
MALE EXT CATH W/ADH COATING
$0.00
A4325
O
MALE EXT CATH W/ADH STRIP
$0.00
A4326
3
MALE EXTERNAL CATHETER
$10.29
A4327
3
FEM URINARY COLLECT DEV CUP
$40.32
A4328
3
FEM URINARY COLLECT POUCH
$9.97
A4329
O
EXTERNAL CATHETER START SET
$0.00
A4330
3
STOOL COLLECTION POUCH
$6.82
A4331
3
EXTENSION DRAINAGE TUBING
$3.04
A4332
3
LUBE STERILE PACKET
$0.12
A4333
3
URINARY CATH ANCHOR DEVICE
$2.10
A4334
3
URINARY CATH LEG STRAP
$4.71
A4335
5
INCONTINENCE SUPPLY
$0.00
A4338
3
INDWELLING CATHETER LATEX
$10.08
A4340
3
INDWELLING CATHETER SPECIAL
$30.28
A4344
3
CATH INDW FOLEY 2 WAY SILICN
$12.99
A4346
3
CATH INDW FOLEY 3 WAY
$16.26
A4347
O
MALE EXTERNAL CATHETER
$0.00
A4348
O
MALE EXT CATH EXTENDED WEAR
$0.00
A4349
3
DISPOSABLE MALE EXTERNAL CAT
$2.02
A4350
9
CATHETER CARE KIT
$0.00
A4351
3
STRAIGHT TIP URINE CATHETER
$1.66
A4352
3
COUDE TIP URINARY CATHETER
$6.12
A4353
3
INTERMITTENT URINARY CATH
$6.66
A4354
3
CATH INSERTION TRAY W/BAG
$11.16
A4355
3
BLADDER IRRIGATION TUBING
$8.50
Procedure Code Pricing Action Code Description
Maximum Allowable
A4356
3
EXT URETH CLMP OR COMPR DVC
$43.52
A4357
3
BEDSIDE DRAINAGE BAG
$8.77
A4358
3
URINARY LEG OR ABDOMEN BAG
$6.33
A4359
O
URINARY SUSPENSORY W/O LEG B
$0.00
A4360
9
ADULT INCONTINENCE GARMENT
$0.00
A4361
3
OSTOMY FACE PLATE
$17.42
A4362
3
SOLID SKIN BARRIER
$3.30
A4363
6
OSTOMY CLAMP
$0.00
A4364
3
ADHESIVE, LIQUID OR EQUAL
$2.80
A4365
3
ADHESIVE REMOVER WIPES
$10.80
A4366
6
OSTOMY VENT
$0.00
A4367
3
OSTOMY BELT
$7.01
A4368
9
OSTOMY FILTER
$0.00
A4369
3
SKIN BARRIER LIQUID PER OZ
$2.30
A4370
O
SKIN BARRIER PASTE PER OZ
$0.00
A4371
3
SKIN BARRIER POWDER PER OZ
$3.48
A4372
3
SKIN BARRIER SOLID 4X4 EQUIV
$3.98
A4373
3
SKIN BARRIER WITH FLANGE
$5.99
A4374
O
SKIN BARRIER EXTENDED WEAR
$0.00
A4375
3
DRAINABLE PLASTIC PCH W FCPL
$16.38
A4376
3
DRAINABLE RUBBER PCH W FCPLT
$45.38
A4377
3
DRAINABLE PLSTIC PCH W/O FP
A4378
3
DRAINABLE RUBBER PCH W/O FP
$29.33
A4379
3
URINARY PLASTIC POUCH W FCPL
$14.33
A4380
3
URINARY RUBBER POUCH W FCPLT
$35.60
A4381
3
URINARY PLASTIC POUCH W/O FP
$4.40
A4382
3
URINARY HVY PLSTC PCH W/O FP
$23.48
A4383
3
URINARY RUBBER POUCH W/O FP
$26.89
A4384
3
OSTOMY FACEPLT/SILICONE RING
$9.18
A4385
3
OST SKN BARRIER SLD EXT WEAR
$4.86
A4386
O
OST SKN BARRIER W FLNG EX WR
$0.00
A4387
3
OST CLSD POUCH W ATT ST BARR
$3.83
A4388
3
DRAINABLE PCH W EX WEAR BARR
$4.16
A4389
3
DRAINABLE PCH W ST WEAR BARR
$5.93
A4390
3
DRAINABLE PCH EX WEAR CONVEX
$9.17
$4.09
Procedure Code Pricing Action Code Description
Maximum Allowable
A4391
3
URINARY POUCH W EX WEAR BARR
$6.74
A4392
3
URINARY POUCH W ST WEAR BARR
$6.34
A4393
3
URINE PCH W EX WEAR BAR CONV
$8.75
A4394
3
OSTOMY POUCH LIQ DEODORANT
$2.46
A4395
3
OSTOMY POUCH SOLID DEODORANT
$0.05
A4396
3
PERISTOMAL HERNIA SUPPRT BLT
A4397
3
IRRIGATION SUPPLY SLEEVE
A4398
3
OSTOMY IRRIGATION BAG
$13.17
A4399
3
OSTOMY IRRIG CONE/CATH W BRS
$11.70
A4400
3
OSTOMY IRRIGATION SET
$46.62
A4402
3
LUBRICANT PER OUNCE
$1.32
A4404
3
OSTOMY RING EACH
$1.52
A4405
3
NONPECTIN BASED OSTOMY PASTE
$3.40
A4406
3
PECTIN BASED OSTOMY PASTE
$5.74
A4407
3
EXT WEAR OST SKN BARR <=4SQÊ
$8.76
A4408
3
EXT WEAR OST SKN BARR >4SQÊ
$9.87
A4409
3
OST SKN BARR CONVEX <=4 SQ I
$6.22
A4410
3
OST SKN BARR EXTND >4 SQ
$9.04
A4411
6
OST SKN BARR EXTND =4SQ
$0.00
A4412
6
OST POUCH DRAIN HIGH OUTPUT
$0.00
A4413
3
2 PC DRAINABLE OST POUCH
$5.50
A4414
3
OST SKNBAR W/O CONV<=4 SQ IN
$4.93
A4415
3
OST SKN BARR W/O CONV >4 SQI
$6.00
A4416
3
OST PCH CLSD W BARRIER/FILTR
$2.75
A4417
6
OST PCH W BAR/BLTINCONV/FLTR
$0.00
A4418
6
OST PCH CLSD W/O BAR W FILTR
$0.00
A4419
3
OST PCH FOR BAR W FLANGE/FLT
$1.74
A4420
6
OST PCH CLSD FOR BAR W LK FL
$0.00
A4421
3
OSTOMY SUPPLY MISC
A4422
3
OST POUCH ABSORBENT MATERIAL
$0.12
A4423
3
OST PCH FOR BAR W LK FL/FLTR
$1.86
A4424
3
OST PCH DRAIN W BAR & FILTER
$4.75
A4425
3
OST PCH DRAIN FOR BARRIER FL
$3.58
A4426
3
OST PCH DRAIN 2 PIECE SYSTEM
$2.73
A4427
3
OST PCH DRAIN/BARR LK FLNG/F
$2.78
$38.61 $4.57
$200.00
Procedure Code Pricing Action Code Description
Maximum Allowable
A4428
3
URINE OST POUCH W FAUCET/TAP
$6.51
A4429
3
URINE OST POUCH W BLTINCONV
$8.25
A4430
3
OST URINE PCH W B/BLTIN CONV
$8.52
A4431
3
OST PCH URINE W BARRIER/TAPV
$6.22
A4432
3
OS PCH URINE W BAR/FANGE/TAP
$3.59
A4433
3
URINE OST PCH BAR W LOCK FLN
$3.34
A4434
3
OST PCH URINE W LOCK FLNG/FT
$3.76
A4450
3
NON-WATERPROOF TAPE
$0.09
A4452
3
WATERPROOF TAPE
$0.36
A4454
O
TAPE ALL TYPES ALL SIZES
$0.00
A4455
3
ADHESIVE REMOVER PER OUNCE
$1.33
A4458
5
REUSABLE ENEMA BAG
$0.00
A4460
O
ELASTIC COMPRESSION BANDAGE
$0.00
A4461
6
SURGICL DRESS HOLD NON-REUSE
$0.00
A4462
O
ABDMNL DRSSNG HOLDER/BINDER
$0.00
A4463
6
SURGICAL DRESS HOLDER REUSE
$0.00
A4464
O
JOINT SUPPORT DEVICE/GARMENT
$0.00
A4465
9
NON-ELASTIC EXTREMITY BINDER
$0.00
A4470
5
GRAVLEE JET WASHER
$0.00
A4480
3
VABRA ASPIRATOR
A4481
9
TRACHEOSTOMA FILTER
$0.00
A4483
3
MOISTURE EXCHANGER
$2.86
A4490
3
ABOVE KNEE SURGICAL STOCKING
$60.00
A4495
3
THIGH LENGTH SURG STOCKING
$60.00
A4500
3
BELOW KNEE SURGICAL STOCKING
$30.00
A4510
3
FULL LENGTH SURG STOCKING
$60.00
A4520
9
INCONTINENCE GARMENT ANYTYPE
$0.00
A4521
O
ADULT SIZE DIAPER SM EACH
$0.00
A4522
O
ADULT SIZE DIAPER MED EACH
$0.00
A4523
O
ADULT SIZE DIAPER LG EACH
$0.00
A4524
O
ADULT SIZE DIAPER XL EACH
$0.00
A4525
O
ADULT SIZE BRIEF SM EACH
$0.00
A4526
O
ADULT SIZE BRIEF MED EACH
$0.00
A4527
O
ADULT SIZE BRIEF LG EACH
$0.00
A4528
O
ADULT SIZE BRIEF XL EACH
$0.00
$20.00
Procedure Code Pricing Action Code Description
Maximum Allowable
A4529
O
CHILD SIZE DIAPER SM/MED EA
$0.00
A4530
O
CHILD SIZE DIAPER LG EACH
$0.00
A4531
O
CHILD SIZE BRIEF SM/MED EACH
$0.00
A4532
O
CHILD SIZE BRIEF LG EACH
$0.00
A4533
O
YOUTH SIZE DIAPER EACH
$0.00
A4534
9
YOUTH SIZE BRIEF EACH
$0.00
A4535
O
DISP INCONT LINER/SHIELD EA
$0.00
A4536
O
PROT UNDERWR WSHBL ANY SZ EA
$0.00
A4537
O
UNDER PAD REUSABLE ANY SZ EA
$0.00
A4538
O
REUSABLE DIAPER FROM DPR SVC
$0.00
A4550
9
SURGICAL TRAYS
$0.00
A4554
3
DISPOSABLE UNDERPADS
$0.20
A4555
9
PRIMARY SURGICAL DRESSING KIT, (E.G
$0.00
A4556
5
ELECTRODES, PAIR
$0.00
A4557
3
LEAD WIRES, PAIR
A4558
3
CONDUCTIVE GEL OR PASTE
$4.44
A4559
9
COUPLING GEL OR PASTE
$0.00
A4560
O
PESSARY
$0.00
A4561
3
PESSARY RUBBER, ANY TYPE
$17.78
A4562
3
PESSARY, NON RUBBER,ANY TYPE
$44.25
A4565
3
SLINGS
$60.00
A4570
3
SPLINT
$50.00
A4572
O
RIB BELT
$0.00
A4575
9
HYPERBARIC O2 CHAMBER DISPS
$0.00
A4580
O
CAST SUPPLIES (PLASTER)
$0.00
A4581
9
SUPPLIES RISSER JACKET
$0.00
A4590
O
SPECIAL CASTING MATERIAL
$0.00
A4595
3
TENS SUPPL 2 LEAD PER MONTH
$27.56
A4600
6
SLEEVE, INTER LIMB COMP DEV
$0.00
A4601
6
LITH ION BATT, NON-PROS USE
$0.00
A4604
3
TUBING WITH HEATING ELEMENT
A4605
6
TRACH SUCTION CATH CLOSE SYS
$0.00
A4606
5
OXYGEN PROBE USED W OXIMETER
$0.00
A4608
3
TRANSTRACHEAL OXYGEN CATH
A4609
O
TRACH SUCTION CATH CLSED SYS
$17.16
$66.81
$58.32 $0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
A4610
O
TRACH SUCTION CATH CLSED SYS
$0.00
A4611
3
HEAVY DUTY BATTERY
A4612
3
BATTERY CABLES
A4613
3
BATTERY CHARGER
A4614
3
HAND-HELD PEFR METER
$22.75
A4615
3
CANNULA NASAL
$20.00
A4616
3
TUBING (OXYGEN) PER FOOT
$1.00
A4617
3
MOUTH PIECE
$5.00
A4618
3
BREATHING CIRCUITS
$8.51
A4619
3
FACE TENT
$1.21
A4620
3
VARIABLE CONCENTRATION MASK
$20.00
A4621
O
TRACHEOTOMY MASK OR COLLAR
$0.00
A4622
O
TRACHEOSTOMY OR LARNGECTOMY
$0.00
A4623
3
TRACHEOSTOMY INNER CANNULA
$6.25
A4624
3
TRACHEAL SUCTION TUBE
$2.25
A4625
3
TRACH CARE KIT FOR NEW TRACH
$6.61
A4626
3
TRACHEOSTOMY CLEANING BRUSH
$3.05
A4627
9
SPACER BAG/RESERVOIR
$0.00
A4628
3
OROPHARYNGEAL SUCTION CATH
$3.51
A4629
3
TRACHEOSTOMY CARE KIT
$4.42
A4630
3
REPL BAT T.E.N.S. OWN BY PT
$5.45
A4631
O
WHEELCHAIR BATTERY
$0.00
A4632
O
INFUS PUMP RPLCEMNT BATTERY
$0.00
A4633
3
UVL REPLACEMENT BULB
A4634
5
REPLACEMENT BULB TH LIGHTBOX
$0.00
A4635
3
UNDERARM CRUTCH PAD
$4.16
A4636
3
HANDGRIP FOR CANE ETC
$3.42
A4637
3
REPL TIP CANE/CRUTCH/WALKER
$1.90
A4638
6
REPL BATT PULSE GEN SYS
$0.00
A4639
3
INFRARED HT SYS REPLCMNT PAD
A4640
3
ALTERNATING PRESSURE PAD
$51.49
A4641
9
RADIOPHARM DX AGENT NOC
$0.00
A4642
9
IN111 SATUMOMAB
$0.00
A4643
O
HIGH DOSE CONTRAST MRI
$0.00
A4644
O
CONTRAST 100-199 MGS IODINE
$0.00
$187.94 $65.00 $137.96
$41.04
$287.21
Procedure Code Pricing Action Code Description
Maximum Allowable
A4645
O
CONTRAST 200-299 MGS IODINE
$0.00
A4646
O
CONTRAST 300-399 MGS IODINE
$0.00
A4647
O
SUPP- PARAMAGNETIC CONTR MAT
$0.00
A4648
9
TISSUE MARKER, IMPLANTABLE, ANY TY
$0.00
A4649
9
SURGICAL SUPPLIES
$0.00
A4650
9
IMPLANTABLE RADIATION DOSIMETER, E
$0.00
A4651
9
CALIBRATED MICROCAP TUBE
$0.00
A4652
9
MICROCAPILLARY TUBE SEALANT
$0.00
A4653
5
PD CATHETER ANCHOR BELT
$0.00
A4655
9
ESRD SYRINGE/NEEDLE
$0.00
A4656
O
NEEDLE ANY SIZE
$0.00
A4657
9
SYRINGE W/WO NEEDLE
$0.00
A4660
3
SPHYG/BP APP W CUFF AND STET
$20.00
A4663
3
DIALYSIS BLOOD PRESSURE CUFF
$6.27
A4670
5
AUTOMATIC BP MONITOR, DIAL
$0.00
A4671
6
DISPOSABLE CYCLER SET
$0.00
A4672
6
DRAINAGE EXT LINE, DIALYSIS
$0.00
A4673
6
EXT LINE W EASY LOCK CONNECT
$0.00
A4674
6
CHEM/ANTISEPT SOLUTION, 8OZ
$0.00
A4680
9
ACTIFICIAL CARBON FILTER, EA
$0.00
A4690
9
DIALYZER, EACH
$0.00
A4700
9
STANDARD DIALYSATE SOLUTION
$0.00
A4705
9
BICARB DIALYSATE SOLUTION
$0.00
A4706
9
BICARBONATE CONC SOL PER GAL
$0.00
A4707
9
BICARBONATE CONC POW PER PAC
$0.00
A4708
9
ACETATE CONC SOL PER GALLON
$0.00
A4709
9
ACID CONC SOL PER GALLON
$0.00
A4712
O
STERILE WATER INJ PER 10 ML
$0.00
A4714
9
TREATED WATER PER GALLON
$0.00
A4719
9
¾Y SET¾ TUBING
$0.00
A4720
9
DIALYSAT SOL FLD VOL > 249CC
$0.00
A4721
9
DIALYSAT SOL FLD VOL > 999CC
$0.00
A4722
9
DIALYS SOL FLD VOL > 1999CC
$0.00
A4723
9
DIALYS SOL FLD VOL > 2999CC
$0.00
A4724
9
DIALYS SOL FLD VOL > 3999CC
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
A4725
9
DIALYS SOL FLD VOL > 4999CC
$0.00
A4726
9
DIALYS SOL FLD VOL > 5999CC
$0.00
A4728
6
DIALYSATE SOLUTION, NON-DEX
$0.00
A4730
9
FISTULA CANNULATION SET, EA
$0.00
A4735
9
LOCAL/TOPICAL ANESTHETICS
$0.00
A4736
9
TOPICAL ANESTHETIC, PER GRAM
$0.00
A4737
9
INJ ANESTHETIC PER 10 ML
$0.00
A4740
9
SHUNT ACCESSORY
$0.00
A4750
9
ART OR VENOUS BLOOD TUBING
$0.00
A4755
9
COMB ART/VENOUS BLOOD TUBING
$0.00
A4760
9
DIALYSATE SOL TEST KIT, EACH
$0.00
A4765
9
DIALYSATE CONC POW PER PACK
$0.00
A4766
9
DIALYSATE CONC SOL ADD 10 ML
$0.00
A4770
9
BLOOD COLLECTION TUBE/VACUUM
$0.00
A4771
9
SERUM CLOTTING TIME TUBE
$0.00
A4772
9
BLOOD GLUCOSE TEST STRIPS
$0.00
A4773
9
OCCULT BLOOD TEST STRIPS
$0.00
A4774
9
AMMONIA TEST STRIPS
$0.00
A4780
9
ESRD STERILIZING AGENT
$0.00
A4790
9
ESRD CLEANSING AGENTS
$0.00
A4800
9
HEPARIN/ANTIDOTE DIALYSIS
$0.00
A4801
9
HEPARIN PER 1000 UNITS
$0.00
A4802
9
PROTAMINE SULFATE PER 50 MG
$0.00
A4820
9
SUPPLIES HEMODIALYSIS KIT
$0.00
A4850
9
RUBBER TIPPED HEMOSTATS
$0.00
A4860
9
DISPOSABLE CATHETER TIPS
$0.00
A4870
9
PLUMB/ELEC WK HM HEMO EQUIP
$0.00
A4880
9
WATER STORAGE TANKS
$0.00
A4890
9
REPAIR/MAINT CONT HEMO EQUIP
$0.00
A4900
9
CAPD SUPPLY KIT
$0.00
A4901
9
CCPD SUPPLY KIT
$0.00
A4905
9
IPD SUPPLY KIT
$0.00
A4910
9
ESRD NONMEDICAL SUPPLIES
$0.00
A4911
9
DRAIN BAG/BOTTLE
$0.00
A4912
9
GOMCO DRAIN BOTTLE
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
A4913
9
MISC DIALYSIS SUPPLIES NOC
$0.00
A4914
9
PREPARATION KIT
$0.00
A4918
9
VENOUS PRESSURE CLAMP
$0.00
A4919
9
SUPP DIALYSIS DIALYZER HOLDE
$0.00
A4920
9
HARVARD PRESSURE CLAMP
$0.00
A4921
9
MEASURING CYLINDER
$0.00
A4927
3
NON-STERILE GLOVES
$6.19
A4928
9
SURGICAL MASK
$0.00
A4929
9
TOURNIQUET FOR DIALYSIS, EA
$0.00
A4930
3
STERILE, GLOVES PER PAIR
$0.44
A4931
9
REUSABLE ORAL THERMOMETER
$0.00
A4932
9
REUSABLE RECTAL THERMOMETER
$0.00
A5051
3
POUCH CLSD W BARR ATTACHED
$2.21
A5052
3
CLSD OSTOMY POUCH W/O BARR
$1.59
A5053
3
CLSD OSTOMY POUCH FACEPLATE
$1.66
A5054
3
CLSD OSTOMY POUCH W/FLANGE
$1.37
A5055
3
STOMA CAP
$1.35
A5061
3
POUCH DRAINABLE W BARRIER AT
$2.58
A5062
3
DRNBLE OSTOMY POUCH W/O BARR
$2.12
A5063
3
DRAIN OSTOMY POUCH W/FLANGE
$2.09
A5064
O
DRAIN OSTOMY POUCH W/FCEPLTE
$0.00
A5065
O
DRAIN OSTOMY POUCH ON FCPLTE
$0.00
A5071
3
URINARY POUCH W/BARRIER
$4.15
A5072
3
URINARY POUCH W/O BARRIER
$3.36
A5073
3
URINARY POUCH ON BARR W/FLNG
$3.04
A5074
O
URINARY POUCH W/FACEPLATE
$0.00
A5075
O
URINARY POUCH ON FACEPLATE
$0.00
A5081
3
CONTINENT STOMA PLUG
$3.14
A5082
3
CONTINENT STOMA CATHETER
A5083
6
STOMA ABSORPTIVE COVER
$0.00
A5093
3
OSTOMY ACCESSORY CONVEX INSE
$1.85
A5102
3
BEDSIDE DRAIN BTL W/WO TUBE
$21.39
A5105
3
URINARY SUSPENSORY
$38.88
A5112
3
URINARY LEG BAG
$28.07
A5113
3
LATEX LEG STRAP
$4.48
$11.34
Procedure Code Pricing Action Code Description
Maximum Allowable
A5114
3
FOAM/FABRIC LEG STRAP
$8.52
A5119
O
SKIN BARRIER WIPES BOX PR 50
$0.00
A5120
3
SKIN BARRIER, WIPE OR SWAB
$0.23
A5121
3
SOLID SKIN BARRIER 6X6
$6.24
A5122
3
SOLID SKIN BARRIER 8X8
$10.42
A5123
O
SKIN BARRIER WITH FLANGE
$0.00
A5126
3
DISK/FOAM PAD +OR- ADHESIVE
$1.26
A5131
3
APPLIANCE CLEANER
A5149
O
INCONTINENCE/OSTOMY SUPPLY
A5200
3
PERCUTANEOUS CATHETER ANCHOR
A5500
5
DIAB SHOE FOR DENSITY INSERT
$0.00
A5501
5
DIABETIC CUSTOM MOLDED SHOE
$0.00
A5502
9
DIABETIC SHOE DENSITY INSERT
$0.00
A5503
5
DIABETIC SHOE W/ROLLER/ROCKR
$0.00
A5504
5
DIABETIC SHOE WITH WEDGE
$0.00
A5505
5
DIAB SHOE W/METATARSAL BAR
$0.00
A5506
5
DIABETIC SHOE W/OFF SET HEEL
$0.00
A5507
5
MODIFICATION DIABETIC SHOE
$0.00
A5508
5
DIABETIC DELUXE SHOE
$0.00
A5509
O
DIRECT HEAT FORM SHOE INSERT
$0.00
A5510
5
COMPRESSION FORM SHOE INSERT
$0.00
A5511
O
CUSTOM FAB MOLDED SHOE INSER
$0.00
A5512
6
MULTI DEN INSERT DIRECT FORM
$0.00
A5513
6
MULTI DEN INSERT CUSTOM MOLD
$0.00
A6000
5
WOUND WARMING WOUND COVER
$0.00
A6010
3
COLLAGEN BASED WOUND FILLER
$30.62
A6011
3
COLLAGEN GEL/PASTE WOUND FIL
$2.28
A6020
O
COLLAGEN WOUND DRESSING
$0.00
A6021
3
COLLAGEN DRESSING <=16 SQ IN
$20.05
A6022
3
COLLAGEN DRSG>6<=48 SQ IN
$20.05
A6023
3
COLLAGEN DRESSING >48 SQ IN
$181.51
A6024
3
COLLAGEN DSG WOUND FILLER
$5.90
A6025
9
SILICONE GEL SHEET, EACH
$0.00
A6154
9
WOUND POUCH EACH
$0.00
A6196
3
ALGINATE DRESSING <=16 SQ IN
$7.01
$15.13 $0.00 $10.78
Procedure Code Pricing Action Code Description
Maximum Allowable
A6197
3
ALGINATE DRSG >16 <=48 SQ IN
$15.68
A6198
3
ALGINATE DRESSING > 48 SQ IN
$15.68
A6199
3
ALGINATE DRSG WOUND FILLER
$5.04
A6200
3
COMPOS DRSG <=16 NO BORDER
$9.06
A6201
3
COMPOS DRSG >16<=48 NO BDR
$19.84
A6202
3
COMPOS DRSG >48 NO BORDER
$33.27
A6203
3
COMPOSITE DRSG <= 16 SQ IN
$3.19
A6204
3
COMPOSITE DRSG >16<=48 SQ IN
$5.94
A6205
3
COMPOSITE DRSG > 48 SQ IN
$5.94
A6206
3
CONTACT LAYER <= 16 SQ IN
$2.07
A6207
3
CONTACT LAYER >16<= 48 SQ IN
$7.00
A6208
3
CONTACT LAYER > 48 SQ IN
$7.00
A6209
3
FOAM DRSG <=16 SQ IN W/O BDR
$7.14
A6210
3
FOAM DRG >16<=48 SQ IN W/O B
$19.00
A6211
3
FOAM DRG > 48 SQ IN W/O BRDR
$28.01
A6212
3
FOAM DRG <=16 SQ IN W/BORDER
$9.25
A6213
3
FOAM DRG >16<=48 SQ IN W/BDR
$9.82
A6214
3
FOAM DRG > 48 SQ IN W/BORDER
$9.82
A6215
5
FOAM DRESSING WOUND FILLER
$0.00
A6216
3
NON-STERILE GAUZE<=16 SQ IN
$0.05
A6217
3
NON-STERILE GAUZE>16<=48 SQ
$0.41
A6218
3
NON-STERILE GAUZE > 48 SQ IN
$0.41
A6219
3
GAUZE <= 16 SQ IN W/BORDER
$0.91
A6220
3
GAUZE >16 <=48 SQ IN W/BORDR
$2.46
A6221
3
GAUZE > 48 SQ IN W/BORDER
$2.46
A6222
3
GAUZE <=16 IN NO W/SAL W/O B
$2.03
A6223
3
GAUZE >16<=48 NO W/SAL W/O B
$2.30
A6224
3
GAUZE > 48 IN NO W/SAL W/O B
$3.44
A6228
3
GAUZE <= 16 SQ IN WATER/SAL
$2.30
A6229
3
GAUZE >16<=48 SQ IN WATR/SAL
$3.44
A6230
3
GAUZE > 48 SQ IN WATER/SALNE
$3.44
A6231
3
HYDROGEL DSG<=16 SQ IN
$4.45
A6232
3
HYDROGEL DSG>16<=48 SQ IN
$6.57
A6233
3
HYDROGEL DRESSING >48 SQ IN
$18.30
A6234
3
HYDROCOLLD DRG <=16 W/O BDR
$6.24
Procedure Code Pricing Action Code Description
Maximum Allowable
A6235
3
HYDROCOLLD DRG >16<=48 W/O B
$16.05
A6236
3
HYDROCOLLD DRG > 48 IN W/O B
$25.99
A6237
3
HYDROCOLLD DRG <=16 IN W/BDR
$7.54
A6238
3
HYDROCOLLD DRG >16<=48 W/BDR
$21.74
A6239
3
HYDROCOLLD DRG > 48 IN W/BDR
$21.74
A6240
3
HYDROCOLLD DRG FILLER PASTE
$11.68
A6241
3
HYDROCOLLOID DRG FILLER DRY
$2.45
A6242
3
HYDROGEL DRG <=16 IN W/O BDR
$5.79
A6243
3
HYDROGEL DRG >16<=48 W/O BDR
$11.75
A6244
3
HYDROGEL DRG >48 IN W/O BDR
$37.46
A6245
3
HYDROGEL DRG <= 16 IN W/BDR
$6.93
A6246
3
HYDROGEL DRG >16<=48 IN W/B
$9.46
A6247
3
HYDROGEL DRG > 48 SQ IN W/B
$22.68
A6248
3
HYDROGEL DRSG GEL FILLER
$15.49
A6250
9
SKIN SEAL PROTECT MOISTURIZR
$0.00
A6251
3
ABSORPT DRG <=16 SQ IN W/O B
$1.90
A6252
3
ABSORPT DRG >16 <=48 W/O BDR
$3.10
A6253
3
ABSORPT DRG > 48 SQ IN W/O B
$6.05
A6254
3
ABSORPT DRG <=16 SQ IN W/BDR
$1.16
A6255
3
ABSORPT DRG >16<=48 IN W/BDR
$2.89
A6256
3
ABSORPT DRG > 48 SQ IN W/BDR
$2.89
A6257
3
TRANSPARENT FILM <= 16 SQ IN
$1.46
A6258
3
TRANSPARENT FILM >16<=48 IN
$4.10
A6259
3
TRANSPARENT FILM > 48 SQ IN
$10.43
A6260
9
WOUND CLEANSER ANY TYPE/SIZE
$0.00
A6261
5
WOUND FILLER GEL/PASTE /OZ
$0.00
A6262
5
WOUND FILLER DRY FORM / GRAM
$0.00
A6263
O
NON-STERILE ELASTIC GAUZE/YD
$0.00
A6264
O
NON-STERILE NO ELASTIC GAUZE
$0.00
A6265
O
TAPE PER 18 SQ INCHES
$0.00
A6266
3
IMPREG GAUZE NO H20/SAL/YARD
$1.83
A6402
3
STERILE GAUZE <= 16 SQ IN
$0.12
A6403
3
STERILE GAUZE>16 <= 48 SQ IN
$0.41
A6404
3
STERILE GAUZE > 48 SQ IN
$0.41
A6405
O
STERILE ELASTIC GAUZE /YD
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
A6406
O
STERILE NON-ELASTIC GAUZE/YD
$0.00
A6407
3
PACKING STRIPS, NON-IMPREG
$1.88
A6410
5
STERILE EYE PAD
$0.00
A6411
5
NON-STERILE EYE PAD
$0.00
A6412
5
OCCLUSIVE EYE PATCH
$0.00
A6413
9
ADHESIVE BANDAGE, FIRST-AID
$0.00
A6421
O
PAD BANDAGE >=3 <5IN W /ROLL
$0.00
A6422
O
CONF BANDAGE NS >=3<5ÊW/ROLL
$0.00
A6424
O
CONF BANDAGE NS >=5ÊW /ROLL
$0.00
A6426
O
CONF BANDAGE S >=3<5Ê W/ROLL
$0.00
A6428
O
CONF BANDAGE S >=5Ê W /ROLL
$0.00
A6430
O
LT COMPRES BDG >=3<5ÊW /ROLL
$0.00
A6432
O
LT COMPRES BDG >=5ÊW /ROLL
$0.00
A6434
O
MO COMPRES BDG >=3<5ÊW /ROLL
$0.00
A6436
O
HI COMPRES BDG >=3<5ÊW /ROLL
$0.00
A6438
O
SELF-ADHER BDG >=3<5ÊW /ROLL
$0.00
A6440
O
ZINC PASTE BDG >=3<5ÊW /ROLL
$0.00
A6441
3
PAD BAND W>=3" <5"/YD
$0.67
A6442
3
CONFORM BAND N/S W<3"/YD
$0.17
A6443
3
CONFORM BAND N/S W>=3"<5"/YD
$0.29
A6444
6
CONFORM BAND N/S W>=5"/YD
$0.00
A6445
3
CONFORM BAND S W <3"/YD
$0.32
A6446
3
CONFORM BAND S W>=3" <5"/YD
$0.41
A6447
3
CONFORM BAND S W >=5"/YD
$0.67
A6448
3
LT COMPRES BAND <3"/YD
$1.16
A6449
3
LT COMPRES BAND >=3" <5"/YD
$1.75
A6450
6
LT COMPRES BAND >=5"/YD
$0.00
A6451
6
MOD COMPRES BAND W>=3"<5"/YD
$0.00
A6452
3
HIGH COMPRES BAND W>=3"<5"YD
$5.91
A6453
3
SELF-ADHER BAND W <3"/YD
$0.61
A6454
3
SELF-ADHER BAND W>=3" <5"/YD
$0.77
A6455
3
SELF-ADHER BAND >=5"/YD
$1.39
A6456
3
ZINC PASTE BAND W >=3"<5"/YD
$1.28
A6457
3
TUBULAR DRESSING
$1.14
A6501
5
COMPRES BURNGARMENT BODYSUIT
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
A6502
5
COMPRES BURNGARMENT CHINSTRP
$0.00
A6503
5
COMPRES BURNGARMENT FACEHOOD
$0.00
A6504
5
CMPRSBURNGARMENT GLOVE-WRIST
$0.00
A6505
5
CMPRSBURNGARMENT GLOVE-ELBOW
$0.00
A6506
5
CMPRSBURNGRMNT GLOVE-AXILLA
$0.00
A6507
5
CMPRS BURNGARMENT FOOT-KNEE
$0.00
A6508
5
CMPRS BURNGARMENT FOOT-THIGH
$0.00
A6509
5
COMPRES BURN GARMENT JACKET
$0.00
A6510
5
COMPRES BURN GARMENT LEOTARD
$0.00
A6511
5
COMPRES BURN GARMENT PANTY
$0.00
A6512
5
COMPRES BURN GARMENT, NOC
$0.00
A6513
6
COMPRESS BURN MASK FACE/NECK
$0.00
A6530
6
COMPRESSION STOCKING BK18-30
$0.00
A6531
6
COMPRESSION STOCKING BK30-40
$0.00
A6532
6
COMPRESSION STOCKING BK40-50
$0.00
A6533
6
GC STOCKING THIGHLNGTH 18-30
$0.00
A6534
6
GC STOCKING THIGHLNGTH 30-40
$0.00
A6535
6
GC STOCKING THIGHLNGTH 40-50
$0.00
A6536
6
GC STOCKING FULL LNGTH 18-30
$0.00
A6537
6
GC STOCKING FULL LNGTH 30-40
$0.00
A6538
6
GC STOCKING FULL LNGTH 40-50
$0.00
A6539
6
GC STOCKING WAISTLNGTH 18-30
$0.00
A6540
6
GC STOCKING WAISTLNGTH 30-40
$0.00
A6541
6
GC STOCKING WAISTLNGTH 40-50
$0.00
A6542
6
GC STOCKING CUSTOM MADE
$0.00
A6543
6
GC STOCKING LYMPHEDEMA
$0.00
A6544
6
GC STOCKING GARTER BELT
$0.00
A6545
6
GRAD COMP NON-ELASTIC BK
$0.00
A6549
6
G COMPRESSION STOCKING
$0.00
A6550
6
NEG PRES WOUND THER DRSG SET
$0.00
A6551
O
NEG PRESS WOUND THER CANISTR
$0.00
A7000
3
DISPOSABLE CANISTER FOR PUMP
$7.97
A7001
3
NONDISPOSABLE PUMP CANISTER
$28.55
A7002
3
TUBING USED W SUCTION PUMP
$3.31
A7003
3
NEBULIZER ADMINISTRATION SET
$2.61
Procedure Code Pricing Action Code Description
Maximum Allowable
A7004
3
DISPOSABLE NEBULIZER SML VOL
$1.47
A7005
3
NONDISPOSABLE NEBULIZER SET
$26.59
A7006
3
FILTERED NEBULIZER ADMIN SET
$7.78
A7007
3
LG VOL NEBULIZER DISPOSABLE
$3.80
A7008
3
DISPOSABLE NEBULIZER PREFILL
$10.52
A7009
3
NEBULIZER RESERVOIR BOTTLE
$36.26
A7010
3
DISPOSABLE CORRUGATED TUBING
$22.31
A7011
5
NONDISPOS CORRUGATED TUBING
$0.00
A7012
3
NEBULIZER WATER COLLEC DEVIC
$3.42
A7013
3
DISPOSABLE COMPRESSOR FILTER
$0.71
A7014
3
COMPRESSOR NONDISPOS FILTER
$3.87
A7015
3
AEROSOL MASK USED W NEBULIZE
$1.57
A7016
3
NEBULIZER DOME & MOUTHPIECE
$6.24
A7017
3
NEBULIZER NOT USED W OXYGEN
$128.23
A7018
3
WATER DISTILLED W/NEBULIZER
$0.37
A7019
O
SALINE SOLUTION DISPENSER
$0.00
A7020
O
STERILE H2O OR NSS W LGV NEB
$0.00
A7025
3
REPLACE CHEST COMPRESS VEST
$434.94
A7026
3
REPLACE CHST CMPRSS SYS HOSE
$28.75
A7027
6
COMBINATION ORAL/NASAL MASK
$0.00
A7028
6
REPL ORAL CUSHION COMBO MASK
$0.00
A7029
6
REPL NASAL PILLOW COMB MASK
$0.00
A7030
3
CPAP FULL FACE MASK
A7031
3
REPLACEMENT FACEMASK INTERFA
$69.77
A7032
3
REPLACEMENT NASAL CUSHION
$40.53
A7033
3
REPLACEMENT NASAL PILLOWS
$28.41
A7034
3
NASAL APPLICATION DEVICE
A7035
3
POS AIRWAY PRESS HEADGEAR
$35.42
A7036
3
POS AIRWAY PRESS CHINSTRAP
$18.20
A7037
3
POS AIRWAY PRESSURE TUBING
$39.21
A7038
3
POS AIRWAY PRESSURE FILTER
$4.58
A7039
3
FILTER, NON DISPOSABLE W PAP
$15.33
A7040
6
ONE WAY CHEST DRAIN VALVE
$0.00
A7041
6
WATER SEAL DRAIN CONTAINER
$0.00
A7042
9
IMPLANTED PLEURAL CATHETER
$0.00
$188.64
$117.64
Procedure Code Pricing Action Code Description
Maximum Allowable
A7043
5
VACUUM DRAINAGEBOTTLE/TUBING
$0.00
A7044
3
PAP ORAL INTERFACE
A7045
3
REPL EXHALATION PORT FOR PAP
$19.47
A7046
6
REPL WATER CHAMBER, PAP DEV
$0.00
A7501
3
TRACHEOSTOMA VALVE W DIAPHRA
$100.18
A7502
3
REPLACEMENT DIAPHRAGM/FPLATE
$47.61
A7503
3
HMES FILTER HOLDER OR CAP
$10.81
A7504
3
TRACHEOSTOMA HMES FILTER
$0.64
A7505
3
HMES OR TRACH VALVE HOUSING
$4.46
A7506
3
HMES/TRACHVALVE ADHESIVEDISK
$0.32
A7507
3
INTEGRATED FILTER & HOLDER
$2.37
A7508
3
HOUSING & INTEGRATED ADHESIV
$2.74
A7509
3
HEAT & MOISTURE EXCHANGE SYS
$1.34
A7520
6
TRACH/LARYN TUBE NON-CUFFED
$0.00
A7521
6
TRACH/LARYN TUBE CUFFED
$0.00
A7522
6
TRACH/LARYN TUBE STAINLESS
$0.00
A7523
6
TRACHEOSTOMY SHOWER PROTECT
$0.00
A7524
6
TRACHEOSTOMA STENT/STUD/BTTN
$0.00
A7525
3
TRACHEOSTOMY MASK
$2.07
A7526
3
TRACHEOSTOMY TUBE COLLAR
$3.37
A7527
6
TRACH/LARYN TUBE PLUG/STOP
$0.00
A8000
6
SOFT PROTECT HELMET PREFAB
$0.00
A8001
6
HARD PROTECT HELMET PREFAB
$0.00
A8002
6
SOFT PROTECT HELMET CUSTOM
$0.00
A8003
6
HARD PROTECT HELMET CUSTOM
$0.00
A8004
6
REPL SOFT INTERFACE, HELMET
$0.00
A9150
9
MISC/EXPER NON-PRESCRIPT DRU
$0.00
A9152
9
SINGLE VITAMIN NOS
$0.00
A9153
9
MULTI-VITAMIN NOS
$0.00
A9155
6
ARTIFICIAL SALIVA
$0.00
A9160
9
PODIATRIST NON-COVERED SERVI
$0.00
A9170
9
CHIROPRACTOR NON-COVERED SER
$0.00
A9180
9
PEDICULOSIS (LICE INFESTATION) TRE
$0.00
A9190
9
MISC/EXPE PERSONAL COMFORT I
$0.00
A9250
9
NURSING HOME RENTALS
$0.00
$120.91
Procedure Code Pricing Action Code Description
Maximum Allowable
A9260
9
NON-CERTIFIED PHYSICAL THERAPISTS
$0.00
A9270
9
NON-COVERED ITEM OR SERVICE
$0.00
A9274
6
EXT AMB INSULIN DELIVERY SYS
$0.00
A9275
9
DISP HOME GLUCOSE MONITOR
$0.00
A9276
9
DISPOSABLE SENSOR, CGM SYS
$0.00
A9277
9
EXTERNAL TRANSMITTER, CGM
$0.00
A9278
9
EXTERNAL RECEIVER, CGM SYS
$0.00
A9279
9
MONITORING FEATURE/DEVICENOC
$0.00
A9280
6
ALERT OR ALARM DEVICE, NOC
$0.00
A9281
9
REACHING/GRABBING DEVICE
$0.00
A9282
9
WIG ANY TYPE
$0.00
A9283
6
FOOT PRESS OFF LOAD SUPP DEV
$0.00
A9284
9
NON-ELECTRONIC SPIROMETER
$0.00
A9290
9
DESCRIPTION OF SERVICE DOES NOT IND
$0.00
A9300
O
EXERCISE EQUIPMENT
$0.00
A9500
9
TC99M SESTAMIBI
$0.00
A9501
9
TECHNETIUM TC-99M TEBOROXIME
$0.00
A9502
9
TC99M TETROFOSMIN
$0.00
A9503
9
TC99M MEDRONATE
$0.00
A9504
9
TC99M APCITIDE
$0.00
A9505
9
TL201 THALLIUM
$0.00
A9507
9
IN111 CAPROMAB
$0.00
A9508
9
I131 IODOBENGUATE, DX
$0.00
A9509
9
IODINE I-123 SOD IODIDE MIL
$0.00
A9510
9
TC99M DISOFENIN
$0.00
A9511
O
TECHNETIUM TC 99M DEPREOTIDE
$0.00
A9512
9
TC99M PERTECHNETATE
$0.00
A9513
O
TECHNETIUM TC-99M MEBROFENIN
$0.00
A9514
O
TECHNETIUMTC99MPYROPHOSPHATE
$0.00
A9515
O
TECHNETIUM TC-99M PENTETATE
$0.00
A9516
9
IODINE I-123 SOD IODIDE MIC
$0.00
A9517
9
I131 IODIDE CAP, RX
$0.00
A9518
O
I-131 SODIUM IODIDE SOLUTION
$0.00
A9519
O
TECHNETIUMTC-99MMACROAG ALBU
$0.00
A9520
O
TECHNETIUMTC-99M SULFUR CLLD
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
A9521
9
TC99M EXAMETAZIME
$0.00
A9522
O
INDIUM111IBRITUMOMABTIUXETAN
$0.00
A9523
O
YTTRIUM90IBRITUMOMABTIUXETAN
$0.00
A9524
9
I131 SERUM ALBUMIN, DX
$0.00
A9525
O
LOW/ISO-OSMOLAR CONTRAST MAT
$0.00
A9526
9
NITROGEN N-13 AMMONIA
$0.00
A9527
9
IODINE I-125 SODIUM IODIDE
$0.00
A9528
9
IODINE I-131 IODIDE CAP, DX
$0.00
A9529
9
I131 IODIDE SOL, DX
$0.00
A9530
9
I131 IODIDE SOL, RX
$0.00
A9531
9
I131 MAX 100UCI
$0.00
A9532
9
I125 SERUM ALBUMIN, DX
$0.00
A9533
O
I-131 TOSITUMOMAB DIAGNOSTIC
$0.00
A9534
O
I-131 TOSITUMOMAB THERAPEUT
$0.00
A9535
9
INJECTION, METHYLENE BLUE
$0.00
A9536
9
TC99M DEPREOTIDE
$0.00
A9537
9
TC99M MEBROFENIN
$0.00
A9538
9
TC99M PYROPHOSPHATE
$0.00
A9539
9
TC99M PENTETATE
$0.00
A9540
9
TC99M MAA
$0.00
A9541
9
TC99M SULFUR COLLOID
$0.00
A9542
9
IN111 IBRITUMOMAB, DX
$0.00
A9543
9
Y90 IBRITUMOMAB, RX
$0.00
A9544
9
I131 TOSITUMOMAB, DX
$0.00
A9545
9
I131 TOSITUMOMAB, RX
$0.00
A9546
9
CO57/58
$0.00
A9547
9
IN111 OXYQUINOLINE
$0.00
A9548
9
IN111 PENTETATE
$0.00
A9549
O
TC99M ARCITUMOMAB
$0.00
A9550
9
TC99M GLUCEPTATE
$0.00
A9551
9
TC99M SUCCIMER
$0.00
A9552
9
F18 FDG
$0.00
A9553
9
CR51 CHROMATE
$0.00
A9554
9
I125 IOTHALAMATE, DX
$0.00
A9555
9
RB82 RUBIDIUM
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
A9556
9
GA67 GALLIUM
$0.00
A9557
9
TC99M BICISATE
$0.00
A9558
9
XE133 XENON 10MCI
$0.00
A9559
9
CO57 CYANO
$0.00
A9560
9
TC99M LABELED RBC
$0.00
A9561
9
TC99M OXIDRONATE
$0.00
A9562
9
TC99M MERTIATIDE
$0.00
A9563
9
P32 NA PHOSPHATE
$0.00
A9564
9
P32 CHROMIC PHOSPHATE
$0.00
A9565
O
IN111 PENTETREOTIDE
$0.00
A9566
9
TC99M FANOLESOMAB
$0.00
A9567
9
TECHNETIUM TC-99M AEROSOL
$0.00
A9568
9
TECHNETIUM TC99M ARCITUMOMAB
$0.00
A9569
9
TECHNETIUM TC-99M AUTO WBC
$0.00
A9570
9
INDIUM IN-111 AUTO WBC
$0.00
A9571
9
INDIUM IN-111 AUTO PLATELET
$0.00
A9572
9
INDIUM IN-111 PENTETREOTIDE
$0.00
A9576
9
INJ PROHANCE MULTIPACK
$0.00
A9577
9
INJ MULTIHANCE
$0.00
A9578
9
INJ MULTIHANCE MULTIPACK
$0.00
A9579
9
GAD-BASE MR CONTRAST NOS,1ML
$0.00
A9580
9
SODIUM FLUORIDE F-18
$0.00
A9600
9
SR89 STRONTIUM
$0.00
A9603
9
I-131SODIUMIODIDECAP PER MCI
$0.00
A9605
9
SM 153 LEXIDRONM
$0.00
A9698
9
NON-RAD CONTRAST MATERIALNOC
$0.00
A9699
9
RADIOPHARM RX AGENT NOC
$0.00
A9700
9
ECHOCARDIOGRAPHY CONTRAST
$0.00
A9900
5
SUPPLY/ACCESSORY/SERVICE
$0.00
A9901
9
DELIVERY/SET UP/DISPENSING
$0.00
A9999
5
MISC DME SUPPLY OR ACCESS, NOS
$0.00
ASC0001
7
AMBULATORY SURGICAL CENTER
$0.00
ASC0002
7
AMBULATORY SURGICAL CENTER
$0.00
ASC0003
7
AMBULATORY SURGICAL CENTER
$0.00
ASC0004
7
AMBULATORY SURGICAL CENTER
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
ASC0005
7
AMBULATORY SURGICAL CENTER
$0.00
ASC0006
7
AMBULATORY SURGICAL CENTER
$0.00
ASC0007
7
AMBULATORY SURGICAL CENTER
$0.00
ASC0008
7
AMBULATORY SURGICAL CENTER
$0.00
ASC0009
7
AMBULATORY SURGICAL CENTER
$0.00
B4034
3
ENTER FEED SUPKIT SYR BY DAY
$5.60
B4035
3
ENTERAL FEED SUPP PUMP PER D
$10.67
B4036
3
ENTERAL FEED SUP KIT GRAV BY
$7.31
B4081
3
ENTERAL NG TUBING W/ STYLET
$19.78
B4082
3
ENTERAL NG TUBING W/O STYLET
$14.73
B4083
3
ENTERAL STOMACH TUBE LEVINE
$2.25
B4084
O
GASTROSTOMY/JEJUNOSTOMY TUBI
$0.00
B4085
9
GASTROSTOMY TUBE W/RING EACH
$0.00
B4086
O
GASTROSTOMY/JEJUNOSTOMY TUBE
$0.00
B4087
6
GASTRO/JEJUNO TUBE, STD
$0.00
B4088
6
GASTRO/JEJUNO TUBE, LOW-PRO
$0.00
B4100
5
FOOD THICKENER ORAL
$0.00
B4102
6
EF ADULT FLUIDS AND ELECTRO
$0.00
B4103
6
EF PED FLUID AND ELECTROLYTE
$0.00
B4104
6
ADDITIVE FOR ENTERAL FORMULA
$0.00
B4149
6
EF BLENDERIZED FOODS
$0.00
B4150
3
EF COMPLET W/INTACT NUTRIENT
$0.61
B4151
O
ENTERAL FORMULAE CAT1NATURAL
$0.00
B4152
3
EF CALORIE DENSE>/=1.5KCAL
$0.51
B4153
3
EF HYDROLYZED/AMINO ACIDS
$1.74
B4154
3
EF SPEC METABOLIC NONINHERIT
$1.12
B4155
3
EF INCOMPLETE/MODULAR
$0.89
B4156
O
ENTERAL FORMULAE CATEGORY VI
$0.00
B4157
6
EF SPECIAL METABOLIC INHERIT
$0.00
B4158
3
EF PED COMPLETE INTACT NUT
$0.65
B4159
6
EF PED COMPLETE SOY BASED
$0.00
B4160
6
EF PED CALORIC DENSE>/=0.7KC
$0.00
B4161
3
EF PED HYDROLYZED/AMINO ACID
$1.80
B4162
6
EF PED SPECMETABOLIC INHERIT
$0.00
B4164
9
PARENTERAL 50% DEXTROSE SOLU
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
B4168
9
PARENTERAL SOL AMINO ACID 3.
$0.00
B4172
9
PARENTERAL SOL AMINO ACID 5.
$0.00
B4176
9
PARENTERAL SOL AMINO ACID 7-
$0.00
B4178
9
PARENTERAL SOL AMINO ACID >
$0.00
B4180
9
PARENTERAL SOL CARB > 50%
$0.00
B4184
O
PARENTERAL SOL LIPIDS 10%
$0.00
B4185
6
PARENTERAL SOL 10 GM LIPIDS
$0.00
B4186
O
PARENTERAL SOL LIPIDS 20%
$0.00
B4189
9
PARENTERAL SOL AMINO ACID &
$0.00
B4193
9
PARENTERAL SOL 52-73 GM PROT
$0.00
B4197
9
PARENTERAL SOL 74-100 GM PRO
$0.00
B4199
9
PARENTERAL SOL > 100GM PROTE
$0.00
B4216
9
PARENTERAL NUTRITION ADDITIV
$0.00
B4220
3
PARENTERAL SUPPLY KIT PREMIX
$8.09
B4222
O
PARENTERAL SUPPLY KIT HOMEMI
$0.00
B4224
3
PARENTERAL ADMINISTRATION KI
$25.29
B5000
9
PARENTERAL SOL RENAL-AMIROSY
$0.00
B5100
9
PARENTERAL SOL HEPATIC-FREAM
$0.00
B5200
9
PARENTERAL SOL STRES-BRNCH C
$0.00
B9000
3
ENTER INFUSION PUMP W/O ALRM
$988.00
B9002
3
ENTERAL INFUSION PUMP W/ ALA
$988.00
B9004
3
PARENTERAL INFUS PUMP PORTAB
$2,551.22
B9006
3
PARENTERAL INFUS PUMP STATIO
$1,970.80
B9998
5
ENTERAL SUPP NOT OTHERWISE C
$0.00
B9999
5
PARENTERAL SUPP NOT OTHRWS C
$0.00
BONUS
O
MCO SPECIFIC CODE: SMART START OUT
$0.00
C1000
9
PERCLOSCLOSR PROSTARARTVAS
$0.00
C1001
9
ACUNAV-DIAGNSTIC ULTRSND CA
$0.00
C1003
9
CATH, ABLATION, LIVEWIRE TC
$0.00
C1004
9
FAST-CATH,SWARTZ,SAFL,CSTA
$0.00
C1006
9
ARRAY POST CHAMB IOL
$0.00
C1007
9
AMS 700/AMBICOR PROSTHESIS
$0.00
C1008
9
UROLUME-IMPLT URETHRAL STNT
$0.00
C1009
9
PLASMA,CRYOPRECIPITATE-REDUC
$0.00
C1010
O
BLOOD, L/R, CMV-NEG
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
C1011
O
PLATELETS, HLA-M, L/R, UNIT
$0.00
C1012
9
PLATELET CONC, L/R, IRRAD
$0.00
C1013
9
PLATELET CONC, L/R, UNIT
$0.00
C1014
9
PLATELET,APH/PHER, L/R, UNIT
$0.00
C1015
O
PLT, PHER,L/R,CMV, IRRAD
$0.00
C1016
O
BLOOD,L/R,FROZ/DEGLY/WASHED
$0.00
C1017
O
PLT, APH/PHER,L/R,CMV-NEG
$0.00
C1018
O
BLOOD, L/R, IRRADIATED
$0.00
C1019
9
PLT, APH/PHER, L/R, IRRAD
$0.00
C1020
O
RBC, FRZ/DEG/WSH, L/R, IRRAD
$0.00
C1021
O
RBC, L/R, CMV NEG, IRRAD
$0.00
C1022
O
PLASMA, FRZ WITHIN 24 HOUR
$0.00
C1024
9
QUINOPRISTIN 10ML/DALFOPRIS
$0.00
C1025
9
MARINR CS CATH
$0.00
C1026
9
RF PERFRMR CATH 5F RF MARINR
$0.00
C1027
9
MAGIC X/SHORT RADIUS 14MM
$0.00
C1028
9
PRCIS TWST TRSNSVG ANCH SYS
$0.00
C1029
9
CRE GUIDED BALLOON DIL CATH
$0.00
C1030
9
CTHTR:MRSHAL,BLU MAX UTR DMD
$0.00
C1031
9
MR COMP/MOD LEVEEN NED ELECT
$0.00
C1033
9
SONICATH MDL 37-410
$0.00
C1034
9
SURPASS, LONG30 SURPASS-CATH
$0.00
C1035
9
CATH, ULTRA ICE
$0.00
C1036
9
R PORT/RESERVOIR IMPL DEV
$0.00
C1037
9
VAXCELCHRONIC DIALYSIS CATH
$0.00
C1038
9
ULTRACROSS IMAGING CATH
$0.00
C1039
9
WALLSTENT, RP/TRACH
$0.00
C1040
9
WALLSTENT, TIPS
$0.00
C1042
9
WALLSTENT, BILIARY
$0.00
C1043
9
ATHERECTOMY SYS, CORONARY
$0.00
C1045
9
I-131 MIBG(IOBEN-SULFATE)0.5
$0.00
C1047
9
NOGA/NAVI-STAR CATH
$0.00
C1048
9
NEUROCYBERNETICPROS:GEN
$0.00
C1050
9
PROSORBA COLUMN
$0.00
C1051
9
OASIS THROMBECTOMY CATH
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
C1053
9
ENSITE 3000 CATHETER
$0.00
C1054
9
HYDROLYSER THROMB CATH 6/7F
$0.00
C1055
9
TRANSESOPH 210, 210-S CATH
$0.00
C1056
9
THERMACHOICE II CATH
$0.00
C1057
9
MICROMARK TISSUE MARKER
$0.00
C1058
9
TC 99M OXIDRONATE, PER VIAL
$0.00
C1059
9
CARTICEL,AUTO CULT-CHNDR CYT
$0.00
C1060
9
ACS MULTI-LINK TRISTAR STENT
$0.00
C1061
9
ACS VIKING GUIDING CATH
$0.00
C1063
9
ENDOTAK ENDURANCE EZ,RX LEAD
$0.00
C1064
9
I-131 CAP, EACH ADD MCI
$0.00
C1065
9
I-131 SOL, EACH ADD MCI
$0.00
C1066
9
IN 111 SATUMOMAB PENDETIDE
$0.00
C1067
9
MEGALINK BILIARY STENT
$0.00
C1068
9
PULSAR DDD PMKR
$0.00
C1069
9
DISCOVERY DR, PMKR
$0.00
C1071
9
PULSAR MAX, PULSAR SR PMKR
$0.00
C1072
9
GUIDANT:BLLN DIL CATH
$0.00
C1073
9
MORCELLATOR
$0.00
C1074
9
RX/OTW VIATRAC-PERI DIL CATH
$0.00
C1075
9
GUIDANT:LEAD,PMKR
$0.00
C1076
9
VENTAK MINI SC DEFIB
$0.00
C1077
9
VENTAK VR,PRIZM VR, SC DEFIB
$0.00
C1078
9
VENTAK:PRIZM,AV III DR DEFIB
$0.00
C1079
O
CO 57/58 PER 0.5 UCI
$0.00
C1080
O
I-131 TOSITUMOMAB, DX
$0.00
C1081
O
I-131 TOSITUMOMAB, TX
$0.00
C1082
O
IN-111 IBRITUMOMAB TIUXETAN
$0.00
C1083
O
YTTRIUM 90 IBRITUMOMAB TIUXE
$0.00
C1084
9
DENILEUKIN DIFTITOX, 300 MCG
$0.00
C1086
9
TEMOZOLOMIDE, 5 MG
$0.00
C1087
9
I-123 PER 100 UCI
$0.00
C1088
9
LASER OPTIC TR SYS
$0.00
C1089
9
CO 57, 0.5 MCI
$0.00
C1090
9
IN 111 CHLORIDE, PER MCI
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
C1091
O
IN111 OXYQUINOLINE,PER0.5MCI
$0.00
C1092
O
IN 111 PENTETATE PER 0.5 MCI
$0.00
C1093
O
TC99M FANOLESOMAB
$0.00
C1094
9
TC99MALBUMIN AGGR,PER 1.0MCI
$0.00
C1095
9
TC 99M DEPREOTIDE, PER VIAL
$0.00
C1096
9
TC 99M EXAMETAZIME, PER DOSE
$0.00
C1097
9
TC 99M MEBROFENIN, PER VIAL
$0.00
C1098
9
TC 99M PENTETATE, PER VIAL
$0.00
C1099
9
TC 99M PYROPHOSPHATE,PER VIA
$0.00
C1100
9
MEDTRONIC AVE GT1 GUIDEWIRE
$0.00
C1101
9
MEDTRONIC AVE ZUMA GUIDECATH
$0.00
C1102
9
SYNERGY NEUROSTIM GENRTR
$0.00
C1103
9
MICRO JEWEL DEFIBRILLATOR
$0.00
C1104
9
RF CONDUCTR ABLATION CATH
$0.00
C1105
9
SIGMA 300VDD PMKR
$0.00
C1106
9
SYNERGYEX PT PROGRMR
$0.00
C1107
9
TORQR,SOLOIST CATH
$0.00
C1109
9
IMPLANTABLE ANCHOR:ETHICON
$0.00
C1110
9
STABLE MAPPER,CATH ELECTR
$0.00
C1111
9
ANEURXAORT-UNI-ILIAC STNT
$0.00
C1112
9
ANEURX STENT GRAFT/DEL CATH
$0.00
C1113
9
TLNT ENDO SPRNG STNT GRFT SY
$0.00
C1114
9
TALNTSPRGSTNT+GRAF ENDO PROS
$0.00
C1115
9
5038S, 5038 5038L PACE LEAD
$0.00
C1116
9
CAPSURESP PACING LEAD
$0.00
C1117
9
ANCURE ENDOGRAFT DEL SYS
$0.00
C1118
9
SIGMA300DR LEGIIDR, PMKR
$0.00
C1119
9
SPRINT6932,6943 DEFIB LEAD
$0.00
C1120
9
SPRINT6942,6945 DEFIB LEAD
$0.00
C1121
9
GEM DEFIBRILLATOR
$0.00
C1122
O
TC 99M ARCITUMOMAB PER VIAL
$0.00
C1123
9
GEM II VR DEFIBRILLATOR
$0.00
C1124
9
INTERSTIM TEST STIM KIT
$0.00
C1125
9
KAPPA 400SR,TOPAZ II SR PMKR
$0.00
C1126
9
KAPPA 700 DR, PMKR
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
C1127
9
KAPPA 700SR, SC PMKR
$0.00
C1128
9
KAPPA 700D, RUBY IID PMKR
$0.00
C1129
9
KAPPA 700VDD, PMKR
$0.00
C1130
9
SIGMA200D, LGCY IID DC PMKR
$0.00
C1131
9
SIGMA 200DR, PMKR
$0.00
C1132
9
SIGMA 200 SR LEG II:SC PA
$0.00
C1133
9
SIGMA SR, VITA SR, PMKR
$0.00
C1134
9
SIGMA 300D PMKR
$0.00
C1135
9
ENTITY DR 5326L/R, DC, PMKR
$0.00
C1136
9
AFFINITY DR 5330L/R, DC, PMK
$0.00
C1137
9
CARDIOSEAL IMPLANT SYS
$0.00
C1143
9
ADDVENT MOD 2060BL, VDD
$0.00
C1144
9
AFNTY SP 5130,INTEGRITY SR
$0.00
C1145
9
ANGIO-SEAL 6FR,8FR
$0.00
C1146
9
VETT TUBE
$0.00
C1147
9
AV PLUS DX 1368:LEAD
$0.00
C1148
9
CONTOUR MD SC DEFIB
$0.00
C1149
9
ENTITY DC 5226R,PMKR
$0.00
C1151
9
PASSIVEPLUS DX LEAD, 10MDLS
$0.00
C1152
9
LIFESITE ACCESS SYSTEM
$0.00
C1153
9
REGENCY SC+2402L PMKR
$0.00
C1154
9
SPL:SPO1,02,04-DEFIB LEAD
$0.00
C1155
9
REPLIFORM 8 SQ CM
$0.00
C1156
9
TR1102TRSR+2260L,2264L,5131
$0.00
C1157
9
TRILOGY DCT 23/8L PMKR
$0.00
C1158
9
TVL LEAD SV01,SV02,SV04
$0.00
C1159
9
TVL RV02, RV06,RV07:LEAD
$0.00
C1160
9
TVL-ADX 1559:LEAD
$0.00
C1161
9
TENDRIL DX, 1388 PACING LEAD
$0.00
C1162
9
TEMPODR TRILOGYDR+DC PMKR
$0.00
C1163
9
TENDRIL SDX, 1488T LEAD
$0.00
C1164
9
IODINE-125 BRACHYTX SEED
$0.00
C1166
O
CYTARABINE LIPOSOMAL, 10 MG
$0.00
C1167
O
EPIRUBICIN HCL, 2 MG
$0.00
C1170
9
ABBI DISP BIOPSY DEVICE
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
C1171
9
AUTOSUTURE SITE MARKER STPLE
$0.00
C1172
9
SPACEMAKER DISSECT BALLOON
$0.00
C1173
9
COR STNTS540,S670,O-WIRE STN
$0.00
C1174
9
BARD BRACHYTX NEEDLE
$0.00
C1175
9
MIBB DISP BIOPSY DEVICE
$0.00
C1176
9
MAMMOTOME HH PROBE W/VAC SYS
$0.00
C1177
9
11-G MAMMOTOME PROBE
$0.00
C1178
O
BUSULFAN IV, 6 MG
$0.00
C1179
9
14-G MAMMOTOME PROBE
$0.00
C1180
9
VIGOR SR, SC, PMKR
$0.00
C1181
9
MERIDIAN SSI, SC, PMKR
$0.00
C1182
9
PULSAR SSI, SC, PMKR
$0.00
C1183
9
JADE IIS, SIGMA 300S, SC, PM
$0.00
C1184
9
SIGMA 200S, SC, PMKR
$0.00
C1188
9
I-131 CAP, PER 1-5 MCI
$0.00
C1200
O
TC 99M SODIUM GLUCOHEPTONAT
$0.00
C1201
O
TC 99M SUCCIMER, PER VIAL
$0.00
C1202
9
TC 99M SULFUR COLLOID, VIAL
$0.00
C1203
9
VERTEPORFIN FOR INJ
$0.00
C1205
9
TC 99M DISOFENIN, PER VIAL
$0.00
C1207
O
OCTREOTIDE ACETATE DEPOT 1MG
$0.00
C1300
9
HYPERBARIC OXYGEN
$0.00
C1302
9
SQ01: LEAD
$0.00
C1303
9
CAPSURE FIX 6940/4068-110
$0.00
C1304
9
SONCATH MDL 37-416,-418
$0.00
C1305
O
APLIGRAF
$0.00
C1306
9
NEUROCYBERNETICPROS:LEAD
$0.00
C1311
9
TRILOGY DR+/DAO PMKR
$0.00
C1312
9
MAGIC WALLSTENT--MINI
$0.00
C1313
9
MAGIC MEDIUM,RADIUS 31MM
$0.00
C1314
9
MAGIC WALLSTENT--LONG
$0.00
C1315
9
VIGOR DR, MERIDIAN DR PMKR
$0.00
C1316
9
MERIDIAN DDD PMKR
$0.00
C1317
9
DISCOVERY SR, PMKR
$0.00
C1318
9
MERIDIAN SR PMKR
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
C1319
9
WALLSTENT: ENTERAL--60MM
$0.00
C1320
9
WALLSTENT: ILIAC
$0.00
C1321
9
PALATE/BASE OF TONGUE ELECTR
$0.00
C1322
9
TURBINATE SOMNOPLASTY ELECTR
$0.00
C1323
9
VAPR/T DISP ELECTRODE
$0.00
C1324
9
LIGASURE DISPOSABLE ELECTROD
$0.00
C1325
9
PALLADIUM-103 SEED
$0.00
C1326
9
ANGIO-JET RHEOLYTIC THROMB
$0.00
C1328
9
ANS RENEW NS TRNSMTR
$0.00
C1329
9
VERSAPOINT DISP ELECTRODE
$0.00
C1333
9
PALMAZ CORINTHIAN BIL STENT
$0.00
C1334
9
CROWN,MINI-CROWN,CROSSLC
$0.00
C1335
9
MESH, PROLENE
$0.00
C1336
9
CONSTANT FLOW IMP PUMP
$0.00
C1337
9
ISOMED 8472-20/35/60
$0.00
C1348
9
I-131 SOL, PER 1-6 MCI
$0.00
C1350
9
PROSTASEED I-125, PER SOURCE
$0.00
C1351
9
CAPSURE FIX LEAD
$0.00
C1352
9
GEM II DR
$0.00
C1353
9
ITREL INTERSTM NEUROSTIM+EXT
$0.00
C1354
9
KAPPA 400DR,DIAMOND II 820DR
$0.00
C1355
9
KAPPA 600DR, VITA DR
$0.00
C1356
9
PROFILE MD V-186HV3 SC DEFIB
$0.00
C1357
9
ANGSTROM MD V-190HV3 SC DEF
$0.00
C1358
9
AFFINITY DC 5230R, PMKR
$0.00
C1359
9
PULSAR,PULSAR MAX DR, PMKR
$0.00
C1360
9
OCULAR PHOTODYNAMIC TX
$0.00
C1361
9
REVEAL CARDIAC RECORDER
$0.00
C1362
9
HERCULINK,OTW,SDS BIL STNT
$0.00
C1363
9
GEM DR, DC, DEFIB
$0.00
C1364
9
PHOTON DR V-230HV3 DC DEFIB
$0.00
C1365
9
GUIDEWIRE, HI-TORQUE14/18/35
$0.00
C1366
9
GUIDEWIRE,PTCA,HI-TORQUE
$0.00
C1367
9
GUIDE WIRE, HI-TORQUECROSSIT
$0.00
C1368
9
ON-Q PAIN MGT SYS
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
C1369
9
ANS RENEW STIM SYS RECVR
$0.00
C1370
9
TENSION-FREE VAGINAL TAPE
$0.00
C1371
9
SYMP NITINOL TRANSHEP BIL SY
$0.00
C1372
9
CORDIS NITINOL BIL STENT
$0.00
C1375
9
STENT, CORONARY, NIR
$0.00
C1376
9
ANS RENEW STIM SYS LEAD
$0.00
C1377
9
SPECIFY 3988 NEURO LEAD
$0.00
C1378
9
INTERSTIM TX 3080/3886 LEAD
$0.00
C1379
9
PISCES-QUAD 3887 LEAD
$0.00
C1420
9
STAPLETAC2 BONEW/DERMIS
$0.00
C1421
9
STAPLETAC2 BONE WO DERMIS
$0.00
C1450
9
ORTHOSPHERE ARTHROPLASTY
$0.00
C1451
9
ORTHOSPHERE ARTHROPLASTY KIT
$0.00
C1500
9
ATHERECTOMY SYS, PERIPHERAL
$0.00
C1700
9
AUTHEN MICK TP BRACHY NEEDLE
$0.00
C1701
9
MEDTEC MT-BT-5201-25 NEEDLE
$0.00
C1702
9
WWMT BRACHY NEEDLE
$0.00
C1703
9
MENTOR PROSTATE BRACHY
$0.00
C1704
9
MT-BT-5001-25/5051-25
$0.00
C1705
9
BEST FLEXI BRACHY NEEDLE
$0.00
C1706
9
INDIGO PROSTATE SEEDING NDL
$0.00
C1707
9
VARISOURCE IMPLT NDL
$0.00
C1708
9
UROMED PROSTATE SEED NDL
$0.00
C1709
9
REMINGTON BRACHYTX NEEDLE
$0.00
C1710
9
US BIOPSY PROSTATE NEEDLE
$0.00
C1711
9
MD TECH BRACHYTX NEEDLE
$0.00
C1712
9
IMAGYN BRACHYTX NEEDLE
$0.00
C1713
9
ANCHOR/SCREW BN/BN,TIS/BN
$0.00
C1714
9
CATH, TRANS ATHERECTOMY, DIR
$0.00
C1715
9
BRACHYTHERAPY NEEDLE
$0.00
C1716
9
BRACHYTX, NON-STR, GOLD-198
$0.00
C1717
O
BRACHYTX, NON-STR,HDR IR-192
$0.00
C1718
O
BRACHYTX SOURCE, IODINE 125
$0.00
C1719
9
BRACHYTX, NS, NON-HDRIR-192
$0.00
C1720
O
BRACHYTX SOUR, PALLADIUM 103
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
C1721
9
AICD, DUAL CHAMBER
$0.00
C1722
9
AICD, SINGLE CHAMBER
$0.00
C1724
9
CATH, TRANS ATHEREC,ROTATION
$0.00
C1725
9
CATH, TRANSLUMIN NON-LASER
$0.00
C1726
9
CATH, BAL DIL, NON-VASCULAR
$0.00
C1727
9
CATH, BAL TIS DIS, NON-VAS
$0.00
C1728
9
CATH, BRACHYTX SEED ADM
$0.00
C1729
9
CATH, DRAINAGE
$0.00
C1730
9
CATH, EP, 19 OR FEW ELECT
$0.00
C1731
9
CATH, EP, 20 OR MORE ELEC
$0.00
C1732
9
CATH, EP, DIAG/ABL, 3D/VECT
$0.00
C1733
9
CATH, EP, OTHR THAN COOL-TIP
$0.00
C1750
9
CATH, HEMODIALYSIS,LONG-TERM
$0.00
C1751
9
CATH, INF, PER/CENT/MIDLINE
$0.00
C1752
9
CATH,HEMODIALYSIS,SHORT-TERM
$0.00
C1753
9
CATH, INTRAVAS ULTRASOUND
$0.00
C1754
9
CATHETER, INTRADISCAL
$0.00
C1755
9
CATHETER, INTRASPINAL
$0.00
C1756
9
CATH, PACING, TRANSESOPH
$0.00
C1757
9
CATH, THROMBECTOMY/EMBOLECT
$0.00
C1758
9
CATHETER, URETERAL
$0.00
C1759
9
CATH, INTRA ECHOCARDIOGRAPHY
$0.00
C1760
9
CLOSURE DEV, VASC
$0.00
C1762
9
CONN TISS, HUMAN(INC FASCIA)
$0.00
C1763
9
CONN TISS, NON-HUMAN
$0.00
C1764
9
EVENT RECORDER, CARDIAC
$0.00
C1765
9
ADHESION BARRIER
$0.00
C1766
9
INTRO/SHEATH,STRBLE,NON-PEEL
$0.00
C1767
9
GENERATOR, NEURO NON-RECHARG
$0.00
C1768
9
GRAFT, VASCULAR
$0.00
C1769
9
GUIDE WIRE
$0.00
C1770
9
IMAGING COIL, MR, INSERTABLE
$0.00
C1771
9
REP DEV, URINARY, W/SLING
$0.00
C1772
9
INFUSION PUMP, PROGRAMMABLE
$0.00
C1773
9
RET DEV, INSERTABLE
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
C1775
O
FDG, PER DOSE (4-40 MCI/ML)
$0.00
C1776
9
JOINT DEVICE (IMPLANTABLE)
$0.00
C1777
9
LEAD, AICD, ENDO SINGLE COIL
$0.00
C1778
9
LEAD, NEUROSTIMULATOR
$0.00
C1779
9
LEAD, PMKR, TRANSVENOUS VDD
$0.00
C1780
9
LENS, INTRAOCULAR (NEW TECH)
$0.00
C1781
9
MESH (IMPLANTABLE)
$0.00
C1782
9
MORCELLATOR
$0.00
C1783
9
OCULAR IMP, AQUEOUS DRAIN DE
$0.00
C1784
9
OCULAR DEV, INTRAOP, DET RET
$0.00
C1785
9
PMKR, DUAL, RATE-RESP
$0.00
C1786
9
PMKR, SINGLE, RATE-RESP
$0.00
C1787
9
PATIENT PROGR, NEUROSTIM
$0.00
C1788
9
PORT, INDWELLING, IMP
$0.00
C1789
9
PROSTHESIS, BREAST, IMP
$0.00
C1790
9
IRIDIUM 192 HDR
$0.00
C1791
9
ONCOSEED, RAPID STRAND I-125
$0.00
C1792
9
UROMED I-125 BRACHY SEED
$0.00
C1793
9
BARD INTERSOURCE P-103 SEED
$0.00
C1794
9
BARD ISOSEED P-103 SEED
$0.00
C1795
9
BARD BRACHYSOURCE I-125
$0.00
C1796
9
SOURCETECH MED I-125
$0.00
C1797
9
DRAXIMAGE I-125 SEED
$0.00
C1798
9
SYNCOR I-125 PHARMASEED
$0.00
C1799
9
I-PLANT I-125 BRACHYTX SEED
$0.00
C1800
9
PD-103 BRACHYTX SEED
$0.00
C1801
9
IOGOLD I-125 BRACHYTX SEED
$0.00
C1802
9
IRIDIUM 192 BRACHYTX SEEDS
$0.00
C1803
9
BEST IODINE 125 BRACHYTX SDS
$0.00
C1804
9
BEST PALLADIUM 103 SEEDS
$0.00
C1805
9
ISOSTAR IODINE-125 SEEDS
$0.00
C1806
9
BEST GOLD 198 BRACHYTX SEED
$0.00
C1810
9
D114S DILATATION CATH
$0.00
C1811
9
SUGICAL DYNAMICS ANCHORS
$0.00
C1812
9
OBL ANCHORS
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
C1813
9
PROSTHESIS, PENILE, INFLATAB
$0.00
C1814
9
RETINAL TAMP, SILICONE OIL
$0.00
C1815
9
PROS, URINARY SPH, IMP
$0.00
C1816
9
RECEIVER/TRANSMITTER, NEURO
$0.00
C1817
9
SEPTAL DEFECT IMP SYS
$0.00
C1818
9
INTEGRATED KERATOPROSTHESIS
$0.00
C1819
9
TISSUE LOCALIZATION-EXCISION
$0.00
C1820
9
GENERATOR NEURO RECHG BAT SY
$0.00
C1821
9
INTERSPINOUS IMPLANT
$0.00
C1850
9
REPLIFORM 14/21 SQ CM
$0.00
C1851
9
REPLIFORM 24/28 SQ CM
$0.00
C1852
9
TRANSCYTE, PER 247 SQ CM
$0.00
C1853
9
SUSPEND, PER 8/14 SQ CM
$0.00
C1854
9
SUSPEND, PER 24/28 SQ CM
$0.00
C1855
9
SUSPEND, PER 36 SQ CM
$0.00
C1856
9
SUSPEND, PER 48 SQ CM
$0.00
C1857
9
SUSPEND, PER 84 SQ CM
$0.00
C1858
9
DURADERM, PER 8/14 SQ CM
$0.00
C1859
9
DURADERM, PER 21/24/28 SQ CM
$0.00
C1860
9
DURADERM, PER 48 SQ CM
$0.00
C1861
9
DURADERM, PER 36 SQ CM
$0.00
C1862
9
DURADERM, PER 72 SQ CM
$0.00
C1863
9
DURADERM, PER 84 SQ CM
$0.00
C1864
9
SPERMATEX, PER 13.44 SQ CM
$0.00
C1865
9
FASLATA, PER 8/14 SQ CM
$0.00
C1866
9
FASLATA, PER 24/28 SQ CM
$0.00
C1867
9
FASLATA, PER 36/48 SQ CM
$0.00
C1868
9
FASLATA, PER 96 SQ CM
$0.00
C1869
9
GORE THYROPLASTY DEVICE
$0.00
C1870
9
DERMMATRIX, PER 16 SQ CM
$0.00
C1871
9
DERMMATRIX, 32 OR 64 SQ CM
$0.00
C1872
9
DERMAGRAFT, PER 37.5 SQ CM
$0.00
C1873
9
BARD 3DMAX MESH
$0.00
C1874
9
STENT, COATED/COV W/DEL SYS
$0.00
C1875
9
STENT, COATED/COV W/O DEL SY
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
C1876
9
STENT, NON-COA/NON-COV W/DEL
$0.00
C1877
9
STENT, NON-COAT/COV W/O DEL
$0.00
C1878
9
MATRL FOR VOCAL CORD
$0.00
C1879
O
TISSUE MARKER, IMPLANTABLE
$0.00
C1880
9
VENA CAVA FILTER
$0.00
C1881
9
DIALYSIS ACCESS SYSTEM
$0.00
C1882
9
AICD, OTHER THAN SING/DUAL
$0.00
C1883
9
ADAPT/EXT, PACING/NEURO LEAD
$0.00
C1884
9
EMBOLIZATION PROTECT SYST
$0.00
C1885
9
CATH, TRANSLUMIN ANGIO LASER
$0.00
C1887
9
CATHETER, GUIDING
$0.00
C1888
9
ENDOVAS NON-CARDIAC ABL CATH
$0.00
C1891
9
INFUSION PUMP,NON-PROG, PERM
$0.00
C1892
9
INTRO/SHEATH,FIXED,PEEL-AWAY
$0.00
C1893
9
INTRO/SHEATH, FIXED,NON-PEEL
$0.00
C1894
9
INTRO/SHEATH, NON-LASER
$0.00
C1895
9
LEAD, AICD, ENDO DUAL COIL
$0.00
C1896
9
LEAD, AICD, NON SING/DUAL
$0.00
C1897
9
LEAD, NEUROSTIM TEST KIT
$0.00
C1898
9
LEAD, PMKR, OTHER THAN TRANS
$0.00
C1899
9
LEAD, PMKR/AICD COMBINATION
$0.00
C1900
9
LEAD, CORONARY VENOUS
$0.00
C1925
9
INJECTION, RISPERIDONE
$0.00
C1929
9
MAVERICK PTCA CATH
$0.00
C1930
9
COYOTE DIL CATH, 20/30/40MM
$0.00
C1931
9
TALON DIL CATH
$0.00
C1932
9
SCIMED REMEDY DIL CATH
$0.00
C1933
9
OPTI-PLAST XL/CENTURION CATH
$0.00
C1934
9
ULTRAVERSE 3.5F BAL DIL CATH
$0.00
C1935
9
WORKHORSE PTA BAL CATH
$0.00
C1936
9
UROMAX ULTRA BAL DIL CATH
$0.00
C1937
9
SYNERGY/EXPLORER CATH
$0.00
C1938
9
UROFORCE BAL DIL CATH
$0.00
C1939
9
RAPTUR, NINJA PTCA DIL CATH
$0.00
C1940
9
POWERFLEX,OPTA 5/LP BAL CATH
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
C1941
9
JUPITER PTA DIL CATH
$0.00
C1942
9
CORDIS MAXI LD PTA BAL CATH
$0.00
C1943
9
RXCROSSSAIL OTW OPENSAIL
$0.00
C1944
9
RAPID EXCHANGE BIL DIL CATH
$0.00
C1945
9
SAVVY PTA DIL CATH
$0.00
C1946
9
R1S RAPID DIL CATH
$0.00
C1947
9
GAZELLE BAL DIL CATH
$0.00
C1948
9
ORACLE MEGASONICS CATH
$0.00
C1949
9
ORACLE MEGASONICS CATH
$0.00
C1979
9
VISIONS PV/AVANAR US CATH
$0.00
C1980
9
ATLANTIS SR CORONARY CATH
$0.00
C1981
9
PTCA CATHETERS
$0.00
C2000
9
ORBITER ST STEERABLE CATH
$0.00
C2001
9
CONSTELLATION DIAG CATH
$0.00
C2002
9
IRVINE 5F INQUIRY EP CATH
$0.00
C2003
9
IRVINE 6F INQUIRY EP CATH
$0.00
C2004
9
EP CATH--OCTAPOLAR
$0.00
C2005
9
EP TIP CATH--HEXAPOLAR
$0.00
C2006
9
EP CATH--DECAPOLAR
$0.00
C2007
9
IRVINE 6F LUMA-CATH EP CATH
$0.00
C2008
9
LUMA-CATH EP CATH 81910-15
$0.00
C2009
9
IRVINE 7F LUMA-CATH EP CATH
$0.00
C2010
9
FIXED CURVE EP CATH
$0.00
C2011
9
DEFLECTABLE TIP CATH--QUAD
$0.00
C2012
9
CELSIUS ABLN CATH
$0.00
C2013
9
CELSIUS LARGE ABLN CATH
$0.00
C2014
9
CELSIUS II ASYM ABLN CATH
$0.00
C2015
9
CELSIUS II SYM ABLN CATH
$0.00
C2016
9
NAVI-STAR DS, NAVI-STAR THER
$0.00
C2017
9
NAVI-STAR ABLN CATH
$0.00
C2018
9
POLARIS T ABLATION CATH
$0.00
C2019
9
EP DEFLECTABLE CATH
$0.00
C2020
9
BLAZER II XP ABLN CATH
$0.00
C2021
9
SILVERFLEX EP CATH
$0.00
C2022
9
CP CHILLI COOLED ABLN CATH
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
C2023
9
CHILLI CLD ABLNCATH-STD,LG
$0.00
C2100
9
CP CS REFERENCE CATH
$0.00
C2101
9
CP RV REFERENCE CATH
$0.00
C2102
9
CP RADII 7F EP CATH
$0.00
C2103
9
CP RADII 7F EP CATH W/TRACK
$0.00
C2104
9
LASSO DEFLECTABLE CATH
$0.00
C2151
9
VERIPATH GUIDING CATH
$0.00
C2152
9
CORDIS VISTA BRITE TIP CATH
$0.00
C2153
9
BARD VIKING CATH
$0.00
C2200
9
ARROW-TREROTOLA PTD CATH
$0.00
C2300
9
VARISOURCE STND CATH
$0.00
C2597
9
CLINICATH 16/18 SGL/DBL
$0.00
C2598
9
CLINICATH 18/20/24G--SINGLE
$0.00
C2599
9
CLINICATH 16/18 DOUBLE
$0.00
C2600
9
GOLD PROBE CATHETER
$0.00
C2601
9
BARD DL URETERAL CATH
$0.00
C2602
9
VITESSE LASER CATH 1.4/1.7MM
$0.00
C2603
9
VITESSE LASER CATH 2.0MM
$0.00
C2604
9
VITESSE E LASER CATH 2.0MM
$0.00
C2605
9
EXTREME LASER CATH
$0.00
C2606
9
SPINECATH XL CATHETER
$0.00
C2607
9
SPINECATH INTRADISCAL CATH
$0.00
C2608
9
SCIMED 6F WISEGUIDE CATHETER
$0.00
C2609
9
FLEXIMA BIL DRAINAGE CATH
$0.00
C2610
9
FLEXTIPPLUS INTRASPINAL CATH
$0.00
C2611
9
ALGOLINE INTRASPINAL CATH
$0.00
C2612
9
INDURA CATHETER
$0.00
C2614
9
PROBE, PERC LUMB DISC
$0.00
C2615
9
SEALANT, PULMONARY, LIQUID
$0.00
C2616
9
BRACHYTX, NON-STR,YTTRIUM-90
$0.00
C2617
9
STENT, NON-COR, TEM W/O DEL
$0.00
C2618
9
PROBE, CRYOABLATION
$0.00
C2619
9
PMKR, DUAL, NON RATE-RESP
$0.00
C2620
9
PMKR, SINGLE, NON RATE-RESP
$0.00
C2621
9
PMKR, OTHER THAN SING/DUAL
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
C2622
9
PROSTHESIS, PENILE, NON-INF
$0.00
C2625
9
STENT, NON-COR, TEM W/DEL SY
$0.00
C2626
9
INFUSION PUMP, NON-PROG,TEMP
$0.00
C2627
9
CATH, SUPRAPUBIC/CYSTOSCOPIC
$0.00
C2628
9
CATHETER, OCCLUSION
$0.00
C2629
9
INTRO/SHEATH, LASER
$0.00
C2630
9
CATH, EP, COOL-TIP
$0.00
C2631
9
REP DEV, URINARY, W/O SLING
$0.00
C2632
O
BRACHYTX SOL, I-125, PER MCI
$0.00
C2633
O
BRACHYTX SOURCE, CESIUM-131
$0.00
C2634
9
BRACHYTX, NON-STR, HA, I-125
$0.00
C2635
9
BRACHYTX, NON-STR, HA, P-103
$0.00
C2636
9
BRACHY LINEAR, NON-STR,P-103
$0.00
C2637
9
BRACHY,NON-STR,YTTERBIUM-169
$0.00
C2638
9
BRACHYTX, STRANDED, I-125
$0.00
C2639
9
BRACHYTX, NON-STRANDED,I-125
$0.00
C2640
9
BRACHYTX, STRANDED, P-103
$0.00
C2641
9
BRACHYTX, NON-STRANDED,P-103
$0.00
C2642
9
BRACHYTX, STRANDED, C-131
$0.00
C2643
9
BRACHYTX, NON-STRANDED,C-131
$0.00
C2676
9
RSPONSE CV CATHETER
$0.00
C2698
9
BRACHYTX, STRANDED, NOS
$0.00
C2699
9
BRACHYTX, NON-STRANDED, NOS
$0.00
C2700
9
MYCROPHYLAX PLUS SC DEFIB
$0.00
C2701
9
PHYLAX XM SC DEFIB
$0.00
C2702
9
VENTAK PRIZM 2 VR DEFIB
$0.00
C2703
9
VENTAK PRIZM VR HE DEFIB
$0.00
C2704
9
VENTAK MINI IV+ DEFIB
$0.00
C2801
9
DEFENDER IV DR 612 DC DEFIB
$0.00
C2802
9
PHYLAX AV
$0.00
C2803
9
VENTAK PRIZM DR HE DEFIB
$0.00
C2804
9
VENTAK PRIZM 2 DR DEFIB
$0.00
C2805
9
JEWEL AF 7250 DEFIB
$0.00
C2806
9
GEM VR 7227 DEFIB
$0.00
C2807
9
CONTAK CD 1823
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
C2808
9
CONTAK TR 1241
$0.00
C3001
9
KAINOX SL/RV DEFIB LEAD
$0.00
C3002
9
EASYTRAK DEFIB LEAD
$0.00
C3003
9
ENDOTAK SQ ARAY XP LEAD
$0.00
C3004
9
INTERVENE DEFIB LEAD
$0.00
C3400
9
SILTEX SPECTRUM,CONTOUR PROF
$0.00
C3401
9
SALINE-FILLED SPECTRUM
$0.00
C3500
9
ALPHA I INF PRO
$0.00
C3510
9
AMS 800 URINARY PROS
$0.00
C3551
9
CHOICE/PT GRAPHIX/LUGE/TROOP
$0.00
C3552
9
HI-TORQUE WHISPER
$0.00
C3553
9
CORDIS GUIDEWIRES
$0.00
C3554
9
JINDO GUIDEWIRE
$0.00
C3555
9
WHOLEY HI-TORQUE PLUS GW
$0.00
C3556
9
WAVE/FLOWWIRE GUIDEWIRE
$0.00
C3557
9
HYTEK GUIDEWIRE
$0.00
C3800
9
SYNCHROMED EL INFUSION PUMP
$0.00
C3801
9
ARROW/MICROJECT PCA SYS
$0.00
C3851
9
ELASTIC UV IOLAA-4203T/TF/TL
$0.00
C4000
9
OPUS G 4621, 4624 SC PMKR
$0.00
C4001
9
OPUS S 4121/4124 SC PMKR
$0.00
C4002
9
TALENT 113 SC PMKR
$0.00
C4003
9
KAIROS SR SC PMKR
$0.00
C4004
9
ACTROS SR, ACTROSSR-B SC PMK
$0.00
C4005
9
PHILOS SR/SR-B SC PMKR
$0.00
C4006
9
PULSAR MAX II SR PMKR
$0.00
C4007
9
MARATHON SR PMKR
$0.00
C4008
9
DISCOVERY II SSI PMKR
$0.00
C4009
9
DISCOVERY II SR PMKR
$0.00
C4300
9
INTEGRITY AFX DR 5342 PMKR
$0.00
C4301
9
INTEGRITY AFX DR 5346 PMKR
$0.00
C4302
9
AFFINITY VDR 5430 PMKR
$0.00
C4303
9
BRIO 112 DC PMKR
$0.00
C4304
9
BRIO212,TALENT213/223DCPMKR
$0.00
C4305
9
BRIO 222 DC PMKR
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
C4306
9
BRIO 220 DC PMKR
$0.00
C4307
9
KAIROS DR DC PMKR
$0.00
C4308
9
INOS2, INOS2+ DC PMKR
$0.00
C4309
9
ACTROS DR,D,DR-A,SLR DC PMKR
$0.00
C4310
9
ACTROS DR-B DC PMKR
$0.00
C4311
9
PHILOS DR/DR-B/SLR DC PMKR
$0.00
C4312
9
PULSAR MAX II DR PMKR
$0.00
C4313
9
MARATHON DR PMKR
$0.00
C4314
9
MOMENTUM DR PMKR
$0.00
C4315
9
SELECTION AFM PMKR
$0.00
C4316
9
DISCOVERY II DR
$0.00
C4317
9
DISCOVERY II DDD
$0.00
C4600
9
SYNOX,POLYROX,ELOX,RETROX
$0.00
C4601
9
AESCULA LV PMKR LEAD
$0.00
C4602
9
TENDRIL SDX, 1488K PMKR LEAD
$0.00
C4603
9
OSCOR PR/FLEXION PMKR LEAD
$0.00
C4604
9
CRYSTALLINEACTFIX,CAPSUREFIX
$0.00
C4605
9
CAPSURE EPI PMKR LEAD
$0.00
C4606
9
FLEXTEND PMKR LEAD
$0.00
C4607
9
FINELINEII/EZ, THINLINEII/EZ
$0.00
C5000
9
BX VELOCITY W/HEPACOAT
$0.00
C5001
9
MEMOTHERM BIL STENT, SM, MED
$0.00
C5002
9
MEMOTHERM BIL STENT, LARGE
$0.00
C5003
9
MEMOTHERM BIL STENT, X-LARGE
$0.00
C5004
9
PALMAZCORINTHIAN IQ BIL STNT
$0.00
C5005
9
PALMAZCORINTHIAN IQ TRANS/BI
$0.00
C5006
9
PALMAZTRANS BIL STENTSYS-MED
$0.00
C5007
9
PALMAZTRANS XL BIL ST-40MM
$0.00
C5008
9
PALMAZTRANS XL BIL ST-50MM
$0.00
C5009
9
VISTAFLEX BILIARY STENT
$0.00
C5010
9
RAPID EXCHANGE BIL STENT SYS
$0.00
C5011
9
INTRASTENT, INTRASTENT LP
$0.00
C5012
9
INTRASTENT DOUBLESTRUT LD
$0.00
C5013
9
INTRASTENT DOUBLESTRUT, XS
$0.00
C5014
9
AVE BRIDGE STENTSYS10/17/28
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
C5015
9
AVE/X3 BRIDGE SYS, 40-100
$0.00
C5016
9
BILIARY STENT SINGLE USE COV
$0.00
C5017
9
WALLSTENTRP-BIL-20/40/60/68
$0.00
C5018
9
WALLSTENTRP BIL--80/94MM
$0.00
C5019
9
FLEXIMA BIL STENT SYS
$0.00
C5020
9
SMART NITINOL STENT--20MM
$0.00
C5021
9
SMART NITINOL STENT--40/60MM
$0.00
C5022
9
SMART NITINOL STENT--80MM
$0.00
C5023
9
BX VELOCITY STENT--8/13MM
$0.00
C5024
9
BX VELOCITY STENT
$0.00
C5025
9
BX VELOCITY STENT--23MM
$0.00
C5026
9
BX VELOCITY STENT--28/33MM
$0.00
C5027
9
BX VELOCITY W/HEP--8/13MM
$0.00
C5028
9
BX VELOCITY W/HEP--18MM
$0.00
C5029
9
BX VELOCITY W/HEP--23MM
$0.00
C5030
9
STENT, CORONARY, S660 9/12MM
$0.00
C5031
9
STENT, CORONARY, S660 15/18
$0.00
C5032
9
STENT,CORONARY, S660 24/30
$0.00
C5033
9
NIROYAL STNT SYS, 9MM
$0.00
C5034
9
NIROYAL STENT SYS, 12/15MM
$0.00
C5035
9
NIROYAL STENT SYS, 18MM
$0.00
C5036
9
NIROYAL STENT SYS, 25MM
$0.00
C5037
9
NIROYAL STENT SYS, 31MM
$0.00
C5038
9
BX VELOCITY STNT W/RAPTOR
$0.00
C5039
9
INTRACOIL PERIP STENT--40MM
$0.00
C5040
9
INTRACOIL PERIPH STENT--60MM
$0.00
C5041
9
BESTENT OVER-THE-WIRE24/30MM
$0.00
C5042
9
BESTENT OVER-THE-WIRE 18MM
$0.00
C5043
9
BESTENT OVER-THE-WIRE 15MM
$0.00
C5044
9
BESTENT OVER-THE-WIRE 9/12MM
$0.00
C5045
9
MULTILINK TETRA COR STENT SY
$0.00
C5046
9
RADIUS 20MM COR STENT
$0.00
C5047
9
NIROYAL ELITE COR STENT SYS
$0.00
C5048
9
GR II CORONARY STENT
$0.00
C5130
9
WILSON-COOK Z-STENT
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
C5131
9
BARD COLORECTAL STENT--60MM
$0.00
C5132
9
BARD COLORECTAL STENT--80MM
$0.00
C5133
9
BARD COLORECTAL STENT-100MM
$0.00
C5134
9
ENTERAL WALLSTENT--90MM
$0.00
C5279
9
CONTOUR/PERCUFLEX STENT
$0.00
C5280
9
INLAY DBL URETERAL STENT
$0.00
C5281
9
WALLGRAFT TRACH SYS 70MM
$0.00
C5282
9
WALLGRAFT TRACH SYS 20/30/50
$0.00
C5283
9
WALLSTENT/RP TIPS--80MM
$0.00
C5284
9
WALLSTENT TRACHULTRAFLEX
$0.00
C5600
9
CLOSURE DEV, VASOSEAL ES
$0.00
C5601
9
VASOSEAL 1000
$0.00
C6001
9
COMPOSIX MESH 8/18 IN
$0.00
C6002
9
COMPOSIX MESH 32 IN
$0.00
C6003
9
COMPOSIX MESH 48 IN
$0.00
C6004
9
COMPOSIX MESH 80 IN
$0.00
C6005
9
COMPOSIX MESH 140 IN
$0.00
C6006
9
COMPOSIX MESH 144 IN
$0.00
C6012
9
PELVICOL COLLAGEN 8/14 SQ CM
$0.00
C6013
9
PELVICOL COLLAGEN 21/24/28
$0.00
C6014
9
PELVICOL COLLAGEN 40 SQ CM
$0.00
C6015
9
PELVICOL COLLAGEN 48 SQ CM
$0.00
C6016
9
PELVICOL COLLAGEN 96 SQ CM
$0.00
C6017
9
GORE-TEX DUALMESH 75/96 SQCM
$0.00
C6018
9
GORE-TEX DUALMESH 150SQCM
$0.00
C6019
9
GORE-TEX DUALMESH 285 SQCM
$0.00
C6020
9
GORE-TEX DUALMESH 432SQCM
$0.00
C6021
9
GORE-TEX DUALMESH 600 SQCM
$0.00
C6022
9
GORE-TEX DUALMESH 884 SQCM
$0.00
C6023
9
GORE-TEXPLUS 1MM,75/96 SQCM
$0.00
C6024
9
GORE-TEXPLUS 1MM, 150 SQ CM
$0.00
C6025
9
GORE-TEXPLUS 1MM, 285 SQ CM
$0.00
C6026
9
GORE-TEXPLUS 1MM, 432 SQCM
$0.00
C6027
9
GORE-TEXPLUS 1MM, 600 SQCM
$0.00
C6028
9
GORE-TEXPLUS 1MM,884 SQ CM
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
C6029
9
GORE-TEXPLUS 2MM, 150 SQ CM
$0.00
C6030
9
GORE-TEXPLUS 2MM, 285 SQ CM
$0.00
C6031
9
GORE-TEXPLUS 2MM, 432 SQ CM
$0.00
C6032
9
GORE-TEXPLUS 2MM, 600 SQ CM
$0.00
C6033
9
GORE-TEXPLUS 2MM,884 SQ CM
$0.00
C6034
9
BARD EPTFE: 150 SQ CM-2MM
$0.00
C6035
9
BARD EPTFE150SQCM-1MM,75-2MM
$0.00
C6036
9
BARD EPTFE: 50/75SQCM-1,2MM
$0.00
C6037
9
BARD EPFTE: 300SQ CM-1MM
$0.00
C6038
9
BARD EPTFE: 600SQ CM-1MM
$0.00
C6039
9
BARD EPTFE: 884 CM--1MM
$0.00
C6040
9
BARD EPTFE: 600SQ CM-2MM
$0.00
C6041
9
BARD EPTFE: 884SQ CM-2MM
$0.00
C6050
9
FEMALE SLING SYS W/WO MATRL
$0.00
C6051
9
STRATASIS SLING, 20/40CM
$0.00
C6052
9
STRATASIS SLING, 60CM
$0.00
C6053
9
SURGISIS SOFT GRAFT
$0.00
C6054
9
SURGISIS ENCHANCED GRAFT
$0.00
C6055
9
SURGISIS ENHANCED TISSUE
$0.00
C6056
9
SURGISIS SOFT TISSUE GRAFT
$0.00
C6057
9
SURGISIS HERNIA GRAFT
$0.00
C6058
9
SURGIPRO HERNIA PLUG,MED/LG
$0.00
C6080
9
MALE SLING SYS W/WO MATRL
$0.00
C6200
9
EXXCEL SFT EPTFE VAS GRAFT
$0.00
C6201
9
IMPRA VENAFLO-10/20CM
$0.00
C6202
9
IMPRA VENAFLO-30/40CM
$0.00
C6203
9
IMPRA VENAFLO-50CM/VT45
$0.00
C6204
9
IMPRA VENAFLO-STEPPED
$0.00
C6205
9
IMPRA CARBOFLO-10CM
$0.00
C6206
9
IMPRA CARBOFLO-20CM
$0.00
C6207
9
IMPRA CARBOFLO-30/34/40CM
$0.00
C6208
9
IMPRA CARBOFLO-40/50CM
$0.00
C6209
9
IMPRA CARBOFLO-CTRFLEX
$0.00
C6210
9
EXXCEL EPTFE VAS GRAFT
$0.00
C6300
9
VANGUARD III ENDOVAS GRAFT
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
C6500
9
PREFACE GUIDING SHEATH
$0.00
C6501
9
SOFT TIP SHEATHS
$0.00
C6525
9
SPECTRANETICS LASER SHEATH
$0.00
C6600
9
MICRO LITHO FLEX PROBES
$0.00
C6650
9
FAST-CATH GUIDING INTRODUCER
$0.00
C6651
9
SEAL-AWAYGUIDING INTRODUCER
$0.00
C6652
9
BARD EXCALIBUR INTRODUCER
$0.00
C6700
9
FOCAL SEAL-L
$0.00
C8099
9
SPECTRANETICS LEAD LOCK DEV
$0.00
C8100
9
ADHESION BARRIER, ADCON-L
$0.00
C8102
9
SURGIVISION ESOPH COIL
$0.00
C8103
9
CAPIO CAPTURING DEV
$0.00
C8500
9
ATHEROCATH-GTO
$0.00
C8501
9
VIGOR SSI, SC, PMKR
$0.00
C8502
9
LIVEWIRE STEERABLE EP CATH
$0.00
C8503
9
SYNCHROMED VAS CATH
$0.00
C8504
9
VASOSEAL HEMOSTASIS DEV
$0.00
C8505
9
SYNCHROMED INFUSION PUMP
$0.00
C8506
9
PMKR LEADS 4057M,4058M
$0.00
C8507
9
6721L/M/S,6939 LEAD
$0.00
C8508
9
CAPSURE 4965 DEFIB LEAD
$0.00
C8509
9
TRANSVENE 6933/6937 LEAD
$0.00
C8510
9
DP-3238 DEFIB LEAD
$0.00
C8511
9
ENDOTAK DSP DEFIB LEAD
$0.00
C8512
9
ON-POINT,PISCES-QUAD LEAD
$0.00
C8513
9
PISCES,RESUME II LEAD
$0.00
C8514
9
DURA II PENILE PROSTHESIS
$0.00
C8516
9
MENTOR ACU-FORM/MAL PROS
$0.00
C8518
9
VIGOR DDD DC PMKR
$0.00
C8519
9
VISTA DDD C PMKR
$0.00
C8520
9
LEGACY II S, SC, PMKR
$0.00
C8521
9
MEDTRONIC MATTRIX RCVR/TRMR
$0.00
C8522
9
PALMAZ BAL STENT
$0.00
C8523
9
WALLSTENT TRANS BIL
$0.00
C8524
9
WALLSTENT ESOP
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
C8525
9
WALLSTENT ESOPH--DOUBLE
$0.00
C8526
9
OPTIPLAST XT PTA CATH
$0.00
C8528
9
MS CLASSIQUE BL DIL CATH
$0.00
C8529
9
CRISTA CATH II DEF 20-POLE
$0.00
C8530
9
GEL-FILLED/SMOOTH MAMMARY PR
$0.00
C8531
9
WILSON-COOK ESOPH Z-STENT
$0.00
C8532
9
ULTRAFLEX ESOPHAGEAL PROS
$0.00
C8533
9
SYNCHROMED VAS CATH 8700A/V
$0.00
C8534
9
AMS 650 PENILE PROSTHESIS
$0.00
C8535
9
ZA/SPIRAL Z BIL STENT
$0.00
C8536
9
ESOPH Z METAL STENT
$0.00
C8539
9
QUANTUM DIL BALLOON
$0.00
C8540
9
FLEX-EZ BAL DILATOR
$0.00
C8541
9
CARSON/PASSPRT DIL CATH
$0.00
C8542
9
URETHRAMAX DIL CATH
$0.00
C8543
9
AMPLATZ RENAL DIL
$0.00
C8550
9
LIVEWIRE 5F, 7F EP CATH
$0.00
C8551
9
LIVEWIRE 7F DUO-DECAPOLAR
$0.00
C8552
9
SANTURO FIXED CURVE CATH
$0.00
C8597
9
WISDOM ST GUIDEWIRE
$0.00
C8598
9
SV GUIDEWIRE-5/8/14CM
$0.00
C8599
9
STABILIZER XS GUIDEWIRE
$0.00
C8600
9
SHINOBI PLUS GUIDEWIRE
$0.00
C8650
9
XL CHECK-FLO INTRODUCER
$0.00
C8724
9
OCTAD NEURO LEAD
$0.00
C8725
9
SYMMIX NEURO LEAD
$0.00
C8748
9
ENDOTAK SQ PATCH DEFIB LEAD
$0.00
C8749
9
ENDOTAK SQ ARRAY DEFIB LEAD
$0.00
C8750
9
UNITY VDDR DC PMKR
$0.00
C8775
9
2188 COR PMKR LEAD
$0.00
C8776
9
INNOMEDICA PMKR LEAD
$0.00
C8777
9
UNIPASS PMKR LEAD
$0.00
C8800
9
LG PALMAZ BIL STENT
$0.00
C8801
9
GIANTURCO BIL Z STENT
$0.00
C8802
9
OASIS STENT INTRO SYS
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
C8830
9
GIANTURCO-ROUBIN COR SNT
$0.00
C8890
9
PERFLUORON, 2ML
$0.00
C8891
9
PERFLUORON, 5/7ML
$0.00
C8900
9
MRA W/CONT, ABD
$0.00
C8901
9
MRA W/O CONT, ABD
$0.00
C8902
9
MRA W/O FOL W/CONT, ABD
$0.00
C8903
9
MRI W/CONT, BREAST, UNI
$0.00
C8904
9
MRI W/O CONT, BREAST, UNI
$0.00
C8905
9
MRI W/O FOL W/CONT, BRST, UN
$0.00
C8906
9
MRI W/CONT, BREAST, BI
$0.00
C8907
9
MRI W/O CONT, BREAST, BI
$0.00
C8908
9
MRI W/O FOL W/CONT, BREAST,
$0.00
C8909
9
MRA W/CONT, CHEST
$0.00
C8910
9
MRA W/O CONT, CHEST
$0.00
C8911
9
MRA W/O FOL W/CONT, CHEST
$0.00
C8912
9
MRA W/CONT, LWR EXT
$0.00
C8913
9
MRA W/O CONT, LWR EXT
$0.00
C8914
9
MRA W/O FOL W/CONT, LWR EXT
$0.00
C8918
9
MRA W/CONT, PELVIS
$0.00
C8919
9
MRA W/O CONT, PELVIS
$0.00
C8920
9
MRA W/O FOL W/CONT, PELVIS
$0.00
C8921
9
TTE W OR W/O FOL W/CONT, COM
$0.00
C8922
9
TTE W OR W/O FOL W/CONT, F/U
$0.00
C8923
9
2D TTE W OR W/O FOL W/CON,CO
$0.00
C8924
9
2D TTE W OR W/O FOL W/CON,FU
$0.00
C8925
9
2D TEE W OR W/O FOL W/CON,IN
$0.00
C8926
9
TEE W OR W/O FOL W/CONT,CONG
$0.00
C8927
9
TEE W OR W/O FOL W/CONT, MON
$0.00
C8928
9
TTE W OR W/O FOL W/CON,STRES
$0.00
C8929
9
TTE W OR WO FOL WCON,DOPPLER
$0.00
C8930
9
TTE W OR W/O CONTR, CONT ECG
$0.00
C8950
O
INTRAVENOUS INFUSION FOR THERAPY/
$0.00
C8951
O
INTRAVENOUS INFUSION FOR THERAPY/
$0.00
C8952
O
THERAPEUTIC, PROPHYLACTIC OR DIAGN
$0.00
C8953
O
CHEMOTHERAPY ADMINISTRATION, INTRA
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
C8954
O
CHEMOTHERAPY ADMINISTRATION, INTRA
$0.00
C8955
O
CHEMOTHERAPY ADMINISTRATION, INTRA
$0.00
C8956
9
REFILLING AND MAINTENANCE OF PORTA
$0.00
C8957
9
INTRAVENOUS INFUSION FOR THERAPY/
$0.00
C9000
O
NA CHROMATECR51, PER 0.25MCI
$0.00
C9001
9
LINEZOLID INJ, 200MG
$0.00
C9002
9
TENECTEPLASE, 50MG/VIAL
$0.00
C9003
O
PALIVIZUMAB, PER 50 MG
$0.00
C9004
9
GEMTUZUMAB OZOGAMICIN INJ,5M
$0.00
C9005
9
RETEPLASE INJ, HALF-KIT,18.8
$0.00
C9006
9
TACROLIMUS INJ, PER 5 MG
$0.00
C9007
O
BACLOFEN INTRATHECAL KIT-1AM
$0.00
C9008
O
BACLOFEN REFILL KIT-500MCG
$0.00
C9009
O
BACLOFEN REFILL KIT-2000MCG
$0.00
C9010
O
BACLOFEN REFILL KIT--4000MCG
$0.00
C9011
9
CAFFEINE CITRATE, INJ, 1ML
$0.00
C9013
O
CO 57 COBALTOUS CHLORIDE
$0.00
C9019
9
CASPOFUNGIN ACETATE, 5 MG
$0.00
C9020
9
SIROLIMUS TABLET, 1 MG
$0.00
C9100
9
IODINATED I-131 ALBUMIN
$0.00
C9102
O
51 NA CHROMATE, 50MCI
$0.00
C9103
O
NA IOTHALAMATE I-125, 10 UCI
$0.00
C9104
9
ANTI-THYMOCYTE GLOBULIN,25MG
$0.00
C9105
O
HEP B IMM GLOB, PER 1 ML
$0.00
C9106
9
SIROLIMUS 1MG/ML
$0.00
C9107
9
TINZAPARIN SODIUM, 2ML VIAL
$0.00
C9108
9
THYROTROPIN ALFA, 1.1 MG
$0.00
C9109
O
TIROFIBAN HCL, 6.25 MG
$0.00
C9110
9
ALEMTUZUMAB, PER 10MG/ML
$0.00
C9111
O
INJ, BIVALIRUDIN, 250MG VIAL
$0.00
C9112
O
PERFLUTREN LIPID MICRO, 2ML
$0.00
C9113
9
INJ PANTOPRAZOLE SODIUM, VIA
$0.00
C9114
9
NESIRITIDE, PER 1.5 MG VIAL
$0.00
C9115
9
INJ, ZOLEDRONIC ACID, 2 MG
$0.00
C9116
O
ERTAPENEM SODIUM, PER 1 GM
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
C9119
O
INJECTION, PEGFILGRASTIM
$0.00
C9120
O
INJECTION, FULVESTRANT
$0.00
C9121
9
INJECTION, ARGATROBAN
$0.00
C9123
O
TRANSCYTE, PER 247 SQ CM
$0.00
C9124
O
INJECTION, DAPTOMYCIN
$0.00
C9125
O
INJECTION, RISPERIDONE
$0.00
C9126
O
INJECTION, NATALIZUMAB
$0.00
C9200
O
ORCEL, PER 36 CM2
$0.00
C9201
O
DERMAGRAFT, PER 37.5 SQ CM
$0.00
C9202
O
OCTAFLUOROPROPANE
$0.00
C9203
O
PERFLEXANE LIPID MICRO
$0.00
C9205
O
OXALIPLATIN
$0.00
C9206
O
INTEGRA, PER CM2
$0.00
C9207
O
INJECTION, BORTEZOMIB
$0.00
C9208
O
INJECTION, AGALSIDASE BETA
$0.00
C9209
O
INJECTION, LARONIDASE
$0.00
C9210
O
INJECTION, PALONOSETRON HCL
$0.00
C9211
O
INJ, ALEFACEPT, IV
$0.00
C9212
O
INJ, ALEFACEPT, IM
$0.00
C9213
O
INJECTION, PEMETREXED
$0.00
C9214
O
INJECTION, BEVACIZUMAB
$0.00
C9215
O
INJECTION, CETUXIMAB
$0.00
C9216
O
ABARELIX, INJECT SUSPENSION
$0.00
C9217
O
INJECTION, OMALIZUMAB
$0.00
C9218
O
INJECTION, AZACITIDINE
$0.00
C9220
O
SODIUM HYALURONATE
$0.00
C9221
O
GRAFTJACKET REG MATRIX
$0.00
C9222
O
GRAFTJACKET SFTTIS
$0.00
C9224
O
INJECTION, GALSULFASE
$0.00
C9225
O
FLUOCINOLONE ACETONIDE
$0.00
C9227
O
INJECTION, MICAFUNGIN SODIUM, PER
$0.00
C9228
O
INJECTION, TIGECYCLINE, PER 1 MG
$0.00
C9229
O
INJECTION, IBANDRONATE SODIUM, PER
$0.00
C9230
O
INJECTION, ABATACEPT, PER 10 MG
$0.00
C9231
O
INJECTION, DECITABINE, PER 1 MG
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
C9232
O
INJECTION, IDURSULFASE
$0.00
C9233
O
INJECTION, RANIBIZUMAB
$0.00
C9234
O
INJ, ALGLUCOSIDASE ALFA
$0.00
C9235
O
INJECTION, PANITUMUMAB
$0.00
C9238
O
INJ, LEVETIRACETAM
$0.00
C9239
O
INJ, TEMSIROLIMUS
$0.00
C9241
O
INJ DORIPENEM 10 MG
$0.00
C9245
9
INJECTION, ROMIPLOSTIM
$0.00
C9246
9
INJ, GADOXETATE DISODIUM
$0.00
C9247
9
INJ, IOBENGUANE, I-123, DX
$0.00
C9248
9
INJ, CLEVIDIPINE BUTYRATE
$0.00
C9350
O
POROUS COLLAGEN TUBE PER CM
$0.00
C9351
O
ACELLULAR DERM TISSUE PERCM2
$0.00
C9352
9
NEURAGEN NERVE GUIDE, PER CM
$0.00
C9353
9
NEURAWRAP NERVE PROTECTOR,CM
$0.00
C9356
9
TENOGLIDE TENDON PROT, CM2
$0.00
C9358
9
SURGIMEND, 0.5CM2
$0.00
C9359
9
IMPLANT, BONE VOID FILLER
$0.00
C9399
9
UNCLASSIFIED DRUGS OR BIOLOGICALS
$0.00
C9400
O
THALLOUS CHLORIDE, BRAND
$0.00
C9401
O
STRONTIUM-89 CHLORIDE,BRAND
$0.00
C9402
O
TH I131 SO IODIDE CAP, BRAND
$0.00
C9403
O
DX I131 SO IODIDE CAP, BRAND
$0.00
C9404
O
DX I131 SO IODIDE SOL, BRAND
$0.00
C9405
O
TH I131 SO IODIDE SOL, BRAND
$0.00
C9408
9
FDG, BRAND, PER DOSE
$0.00
C9410
O
DEXRAZOXANE HCL INJ, BRAND
$0.00
C9411
O
PAMIDRONATE DISODIUM, BRAND
$0.00
C9412
O
GANCICLOVIR IMPLANT, BRAND
$0.00
C9413
O
SODIUM HYALURONATE INJ, BRAND
$0.00
C9414
O
ETOPOSIDE ORAL, BRAND
$0.00
C9415
O
DOXORUBIC HCL CHEMO, BRAND
$0.00
C9416
9
BCG LIVE INTRAVESICAL, BRAND
$0.00
C9417
O
BLEOMYCIN SULFATE INJ, BRAND
$0.00
C9418
O
CISPLATIN INJ, BRAND
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
C9419
O
INJ CLADRIBINE, BRAND
$0.00
C9420
O
CYCLOPHOSPHAMIDE INJ, BRAND
$0.00
C9421
O
CYCLOPHOSPHAMIDE LYO, BRAND
$0.00
C9422
O
CYTARABINE HCL INJ, BRAND
$0.00
C9423
O
DACARBAZINE INJ, BRAND
$0.00
C9424
O
DAUNORUBICIN, BRAND
$0.00
C9425
O
ETOPOSIDE INJ, BRAND
$0.00
C9426
O
FLOXURIDINE INJ, BRAND
$0.00
C9427
O
IFOSFOMIDE INJ, BRAND
$0.00
C9428
O
MESNA INJECTION, BRAND
$0.00
C9429
O
IDARUBICIN HCL INJ, BRAND
$0.00
C9430
O
LEUPROLIDE ACETATE INJ, BRAN
$0.00
C9431
O
PACLITAXEL INJ, BRAND
$0.00
C9432
O
MITOMYCIN INJ, BRAND
$0.00
C9433
O
THIOTEPA INJ, BRAND
$0.00
C9434
9
GALLIUM GA 67, BRAND
$0.00
C9435
O
GONADORELIN HYDROCH, BRAND
$0.00
C9436
O
AZATHIOPRINE PARENTERAL,BRND
$0.00
C9437
O
CARMUS BISCHL NITRO INJ
$0.00
C9438
O
CYCLOSPORINE ORAL, BRAND
$0.00
C9439
O
DIETHYLSTILBESTROL INJECTION
$0.00
C9500
9
PLATELETS, IRRAD, EA UNIT
$0.00
C9501
9
PLATELETS, PHERESIS, EA UNIT
$0.00
C9502
9
PLATELETS, PHER/IRRAD, EA UN
$0.00
C9503
O
FRESH FROZEN PLASMA, EA UNIT
$0.00
C9504
9
RBC, DEGLYCEROLIZED, EA UNIT
$0.00
C9505
9
RBC, IRRADIATED, EACH UNIT
$0.00
C9700
9
WATER INDUCED THERMO
$0.00
C9701
O
STRETTA SYSTEM
$0.00
C9702
9
CHKMATE/NOVOST/GALILEO BRACH
$0.00
C9703
O
BARD ENDOSCOPIC SUTURING SYS
$0.00
C9704
O
INJ INERT SUBS UPPER GI
$0.00
C9708
9
PREVIEW TX PLANNING SOFTWARE
$0.00
C9711
O
H.E.L.P. APHERESIS SYSTEM
$0.00
C9712
O
INSERT PH CAPSULE, GERD
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
C9713
O
NON-CONTACT LASER VAP PROSTA
$0.00
C9714
O
BREAST INTERS RAD TX, IMMED
$0.00
C9715
O
BREAST INTERS RAD TX, DELAY
$0.00
C9716
9
RADIOFREQUENCY ENERGY TO ANUS
$0.00
C9718
O
KYPHOPLASTY, FIRST VERTEBRA
$0.00
C9719
O
KYPHOPLASTY, EACH ADDL
$0.00
C9720
O
HE ESW TX, TENNIS ELBOW
$0.00
C9721
O
HE ESW TX, PLANTAR FASCIITIS
$0.00
C9722
O
KV IMAGING W/IR TRACKING
$0.00
C9723
O
DYN IR PERF IMG
$0.00
C9724
9
EPS GAST CARDIA PLIC
$0.00
C9725
9
PLACE ENDORECTAL APP
$0.00
C9726
9
RXT BREAST APPL PLACE/REMOV
$0.00
C9727
9
INSERT PALATE IMPLANTS
$0.00
C9728
9
PLACE DEVICE/MARKER, NON PRO
$0.00
C9898
9
INPNT STAY RADIOLABELED ITEM
$0.00
C9899
9
INPT IMPLANT PROS DEV,NO COV
$0.00
CEDCL
O
MCO SPECIFIC CODE: SMART START COM
$0.00
CEDRV
O
MCO SPECIFIC CODE: SMART START CHI
$0.00
D0110
O
INITIAL ORAL EXAMINATION
$0.00
D0120
1
PERIODIC ORAL EVALUATION
$0.00
D0130
O
EMERGENCY ORAL EXAMINATION
$0.00
D0140
1
LIMIT ORAL EVAL PROBLM FOCUS
$0.00
D0145
1
ORAL EVALUATION, PT < 3YRS
$0.00
D0150
1
COMPREHENSVE ORAL EVALUATION
$0.00
D0160
1
EXTENSV ORAL EVAL PROB FOCUS
$0.00
D0170
1
RE-EVAL,EST PT,PROBLEM FOCUS
$0.00
D0180
9
COMP PERIODONTAL EVALUATION
$0.00
D0210
1
INTRAOR COMPLETE FILM SERIES
$0.00
D0220
1
INTRAORAL PERIAPICAL FIRST F
$0.00
D0230
1
INTRAORAL PERIAPICAL EA ADD
$0.00
D0240
1
INTRAORAL OCCLUSAL FILM
$0.00
D0250
1
EXTRAORAL FIRST FILM
$0.00
D0260
1
EXTRAORAL EA ADDITIONAL FILM
$0.00
D0270
1
DENTAL BITEWING SINGLE FILM
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
D0272
1
DENTAL BITEWINGS TWO FILMS
$0.00
D0273
1
BITEWINGS - THREE FILMS
$0.00
D0274
1
DENTAL BITEWINGS FOUR FILMS
$0.00
D0275
9
BITEWINGS-EACH ADDITIONAL FILM
$0.00
D0277
1
VERT BITEWINGS-SEV TO EIGHT
$0.00
D0290
1
DENTAL FILM SKULL/FACIAL BON
$0.00
D0310
1
DENTAL SALIOGRAPHY
$0.00
D0320
1
DENTAL TMJ ARTHROGRAM INCL I
$0.00
D0321
1
DENTAL OTHER TMJ FILMS
$0.00
D0322
1
DENTAL TOMOGRAPHIC SURVEY
$0.00
D0330
1
DENTAL PANORAMIC FILM
$0.00
D0340
1
DENTAL CEPHALOMETRIC FILM
$0.00
D0350
9
ORAL/FACIAL PHOTO IMAGES
$0.00
D0360
1
CONE BEAM CT
$0.00
D0362
1
CONE BEAM, TWO DIMENSIONAL
$0.00
D0363
1
CONE BEAM, THREE DIMENSIONAL
$0.00
D0410
9
BACTERIOLOGIC STUDIES FOR DETERMINA
$0.00
D0415
9
COLLECTION OF MICROORGANISMS
$0.00
D0416
9
VIRAL CULTURE
$0.00
D0417
9
COLLECT & PREP SALIVA SAMPLE
$0.00
D0418
9
ANALYSIS OF SALIVA SAMPLE
$0.00
D0420
9
CARIES SUSCEPTIBILITY TESTS
$0.00
D0421
9
GEN TST SUSCEPT ORAL DISEASE
$0.00
D0425
9
CARRIES SUSCEPTIBILITY TESTS
$0.00
D0431
9
DIAG TST DETECT MUCOS ABNORM
$0.00
D0460
1
PULP VITALITY TEST
$0.00
D0470
1
DIAGNOSTIC CASTS
$0.00
D0471
9
DIAGNOSTIC PHOTOGRAPHS
$0.00
D0472
1
GROSS EXAM, PREP & REPORT
$0.00
D0473
1
MICRO EXAM, PREP & REPORT
$0.00
D0474
1
MICRO W EXAM OF SURG MARGINS
$0.00
D0475
9
DECALCIFICATION PROCEDURE
$0.00
D0476
9
SPEC STAINS FOR MICROORGANIS
$0.00
D0477
9
SPEC STAINS NOT FOR MICROORG
$0.00
D0478
9
IMMUNOHISTOCHEMICAL STAINS
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
D0479
9
TISSUE IN-SITU HYBRIDIZATION
$0.00
D0480
1
CYTOPATH SMEAR PREP & REPORT
$0.00
D0481
9
ELECTRON MICROSCOPY DIAGNOST
$0.00
D0482
9
DIRECT IMMUNOFLUORESCENCE
$0.00
D0483
9
INDIRECT IMMUNOFLUORESCENCE
$0.00
D0484
9
CONSULT SLIDES PREP ELSEWHER
$0.00
D0485
9
CONSULT INC PREP OF SLIDES
$0.00
D0486
9
ACCESSION OF BRUSH BIOPSY
$0.00
D0501
O
HISTOPATHOLOGIC EXAMINATIONS
$0.00
D0502
1
OTHER ORAL PATHOLOGY PROCEDU
$0.00
D0999
1
UNSPECIFIED DIAGNOSTIC PROCE
$0.00
D1110
1
DENTAL PROPHYLAXIS ADULT
$0.00
D1120
1
DENTAL PROPHYLAXIS CHILD
$0.00
D1201
O
TOPICAL FLUOR W PROPHY CHILD
$0.00
D1202
9
TOPICAL APPLICATION OF FLUORIDE (IN
$0.00
D1203
1
TOPICAL APP FLUORIDE CHILD
$0.00
D1204
1
TOPICAL APP FLUORIDE ADULT
$0.00
D1205
O
TOPICAL FLUORIDE W/ PROPHY A
$0.00
D1206
1
TOPICAL FLUORIDE VARNISH
$0.00
D1310
9
NUTRI COUNSEL-CONTROL CARIES
$0.00
D1320
1
TOBACCO COUNSELING
$0.00
D1330
9
ORAL HYGIENE INSTRUCTION
$0.00
D1351
1
DENTAL SEALANT PER TOOTH
$0.00
D1510
1
SPACE MAINTAINER FXD UNILAT
$0.00
D1515
1
FIXED BILAT SPACE MAINTAINER
$0.00
D1520
1
REMOVE UNILAT SPACE MAINTAIN
$0.00
D1525
1
REMOVE BILAT SPACE MAINTAIN
$0.00
D1550
1
RECEMENT SPACE MAINTAINER
$0.00
D1555
1
REMOVE FIX SPACE MAINTAINER
$0.00
D2110
O
AMALGAM ONE SURFACE PRIMARY
$0.00
D2120
O
AMALGAM TWO SURFACES PRIMARY
$0.00
D2130
O
AMALGAM THREE SURFACES PRIMA
$0.00
D2131
O
AMALGAM FOUR/MORE SURF PRIMA
$0.00
D2140
1
AMALGAM ONE SURFACE PERMANEN
$0.00
D2150
1
AMALGAM TWO SURFACES PERMANE
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
D2160
1
AMALGAM THREE SURFACES PERMA
$0.00
D2161
1
AMALGAM 4 OR > SURFACES PERM
$0.00
D2210
9
SILCATE CEMENT PER RESTORAT
$0.00
D2330
1
RESIN ONE SURFACE-ANTERIOR
$0.00
D2331
1
RESIN TWO SURFACES-ANTERIOR
$0.00
D2332
1
RESIN THREE SURFACES-ANTERIO
$0.00
D2335
1
RESIN 4/> SURF OR W INCIS AN
$0.00
D2336
O
COMPOSITE RESIN CROWN
$0.00
D2337
O
COMPO RESIN CROWN ANT-PERM
$0.00
D2380
O
RESIN ONE SURF POSTER PRIMAR
$0.00
D2381
O
RESIN TWO SURF POSTER PRIMAR
$0.00
D2382
O
RESIN THREE/MORE SURF POST P
$0.00
D2385
O
RESIN ONE SURF POSTER PERMAN
$0.00
D2386
O
RESIN TWO SURF POSTER PERMAN
$0.00
D2387
O
RESIN THREE/MORE SURF POST P
$0.00
D2388
O
RESIN FOUR/MORE, POST PERM
$0.00
D2390
1
ANT RESIN-BASED CMPST CROWN
$0.00
D2391
1
POST 1 SRFC RESINBASED CMPST
$0.00
D2392
1
POST 2 SRFC RESINBASED CMPST
$0.00
D2393
1
POST 3 SRFC RESINBASED CMPST
$0.00
D2394
1
POST >=4SRFC RESINBASE CMPST
$0.00
D2410
9
DENTAL GOLD FOIL ONE SURFACE
$0.00
D2420
9
DENTAL GOLD FOIL TWO SURFACE
$0.00
D2430
9
DENTAL GOLD FOIL THREE SURFA
$0.00
D2510
9
DENTAL INLAY METALIC 1 SURF
$0.00
D2520
9
DENTAL INLAY METALLIC 2 SURF
$0.00
D2530
9
DENTAL INLAY METL 3/MORE SUR
$0.00
D2540
O
ONLAY-METALLIC-PER TOOTH (IN ADDITI
$0.00
D2542
9
DENTAL ONLAY METALLIC 2 SURF
$0.00
D2543
9
DENTAL ONLAY METALLIC 3 SURF
$0.00
D2544
9
DENTAL ONLAY METL 4/MORE SUR
$0.00
D2610
9
INLAY PORCELAIN/CERAMIC 1 SU
$0.00
D2620
9
INLAY PORCELAIN/CERAMIC 2 SU
$0.00
D2630
9
DENTAL ONLAY PORC 3/MORE SUR
$0.00
D2642
9
DENTAL ONLAY PORCELIN 2 SURF
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
D2643
9
DENTAL ONLAY PORCELIN 3 SURF
$0.00
D2644
9
DENTAL ONLAY PORC 4/MORE SUR
$0.00
D2650
9
DENTAL INLAY RESIN ONE SURFACE
$0.00
D2651
9
DENTAL INLAY RESIN 2 SURFACES
$0.00
D2652
9
DENTAL INLAY RESIN 3 OR MORE SURFA
$0.00
D2662
9
DENTAL ONLAY RESIN 2 SURFACE
$0.00
D2663
9
DENTAL ONLAY RESIN 3 SURFACE
$0.00
D2664
9
DENTAL ONLAY RESIN 4/MRE SUR
$0.00
D2710
1
CROWN RESIN-BASED INDIRECT
$0.00
D2712
1
CROWN 3/4 RESIN-BASED COMPOS
$0.00
D2720
9
CROWN RESIN W/ HIGH NOBLE ME
$0.00
D2721
1
CROWN RESIN W/ BASE METAL
$0.00
D2722
1
CROWN RESIN W/ NOBLE METAL
$0.00
D2740
9
CROWN PORCELAIN/CERAMIC SUBS
$0.00
D2750
9
CROWN PORCELAIN W/ H NOBLE M
$0.00
D2751
1
CROWN PORCELAIN FUSED BASE M
$0.00
D2752
1
CROWN PORCELAIN W/ NOBLE MET
$0.00
D2780
9
CROWN 3/4 CAST HI NOBLE MET
$0.00
D2781
1
CROWN 3/4 CAST BASE METAL
$0.00
D2782
1
CROWN 3/4 CAST NOBLE METAL
$0.00
D2783
9
CROWN 3/4 PORCELAIN/CERAMIC
$0.00
D2790
9
CROWN FULL CAST HIGH NOBLE M
$0.00
D2791
1
CROWN FULL CAST BASE METAL
$0.00
D2792
1
CROWN FULL CAST NOBLE METAL
$0.00
D2794
9
CROWN-TITANIUM
$0.00
D2799
1
PROVISIONAL CROWN
$0.00
D2810
9
CROWN 3/4 CAST METALLIC
$0.00
D2910
1
RECEMENT INLAY ONLAY OR PART
$0.00
D2915
1
RECEMENT CAST OR PREFAB POST
$0.00
D2920
1
DENTAL RECEMENT CROWN
$0.00
D2930
1
PREFAB STNLSS STEEL CRWN PRI
$0.00
D2931
1
PREFAB STNLSS STEEL CROWN PE
$0.00
D2932
1
PREFABRICATED RESIN CROWN
$0.00
D2933
1
PREFAB STAINLESS STEEL CROWN
$0.00
D2934
1
PREFAB STEEL CROWN PRIMARY
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
D2940
1
DENTAL SEDATIVE FILLING
$0.00
D2950
1
CORE BUILD-UP INCL ANY PINS
$0.00
D2951
1
TOOTH PIN RETENTION
$0.00
D2952
1
POST AND CORE CAST + CROWN
$0.00
D2953
1
EACH ADDTNL CAST POST
$0.00
D2954
1
PREFAB POST/CORE + CROWN
$0.00
D2955
1
POST REMOVAL
$0.00
D2957
1
EACH ADDTNL PREFAB POST
$0.00
D2960
9
LAMINATE LABIAL VENEER
$0.00
D2961
9
LAMINATE LABIAL VENEER
$0.00
D2962
9
LAMINATE LABIAL VENEER
$0.00
D2970
1
TEMPORARY- FRACTURED TOOTH
$0.00
D2971
9
ADD PROC CONSTRUCT NEW CROWN
$0.00
D2975
9
COPING
$0.00
D2980
1
CROWN REPAIR
$0.00
D2999
1
DENTAL UNSPEC RESTORATIVE PR
$0.00
D3110
1
PULP CAP DIRECT
$0.00
D3120
1
PULP CAP INDIRECT
$0.00
D3220
1
THERAPEUTIC PULPOTOMY
$0.00
D3221
1
GROSS PULPAL DEBRIDEMENT
$0.00
D3222
1
PART PULP FOR APEXOGENESIS
$0.00
D3230
1
PULPAL THERAPY ANTERIOR PRIM
$0.00
D3240
1
PULPAL THERAPY POSTERIOR PRI
$0.00
D3310
1
END THXPY, ANTERIOR TOOTH
$0.00
D3320
1
END THXPY, BICUSPID TOOTH
$0.00
D3330
1
END THXPY, MOLAR
$0.00
D3331
9
NON-SURG TX ROOT CANAL OBS
$0.00
D3332
1
INCOMPLETE ENDODONTIC TX
$0.00
D3333
1
INTERNAL ROOT REPAIR
$0.00
D3340
9
FOUR OR MORE CANALS (EXCLUDING FINA
$0.00
D3346
1
RETREAT ROOT CANAL ANTERIOR
$0.00
D3347
1
RETREAT ROOT CANAL BICUSPID
$0.00
D3348
1
RETREAT ROOT CANAL MOLAR
$0.00
D3350
9
APEXIFICATION (PER TREATMENT VISIT)
$0.00
D3351
1
APEXIFICATION/RECALC INITIAL
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
D3352
1
APEXIFICATION/RECALC INTERIM
$0.00
D3353
1
APEXIFICATION/RECALC FINAL
$0.00
D3410
1
APICOECT/PERIRAD SURG ANTER
$0.00
D3411
9
APICOECTOMY (PER TOOTH) - EACH ADDI
$0.00
D3421
1
ROOT SURGERY BICUSPID
$0.00
D3425
1
ROOT SURGERY MOLAR
$0.00
D3426
1
ROOT SURGERY EA ADD ROOT
$0.00
D3430
1
RETROGRADE FILLING
$0.00
D3440
9
APICAL CURETTAGE
$0.00
D3450
1
ROOT AMPUTATION
$0.00
D3460
9
ENDODONTIC ENDOSSEOUS IMPLAN
$0.00
D3470
1
INTENTIONAL REPLANTATION
$0.00
D3910
1
ISOLATION- TOOTH W RUBB DAM
$0.00
D3920
9
TOOTH SPLITTING
$0.00
D3940
9
RECALCIFICATION OR REPAIR (PERFORAT
$0.00
D3950
9
CANAL PREP/FITTING OF DOWEL
$0.00
D3960
9
BLEACHING OF DISCOLORED TOOT
$0.00
D3999
1
ENDODONTIC PROCEDURE
$0.00
D4210
1
GINGIVECTOMY/PLASTY PER QUAD
$0.00
D4211
1
GINGIVECTOMY/PLASTY PER TOOT
$0.00
D4220
O
GINGIVAL CURETTAGE PER QUADR
$0.00
D4230
1
ANA CROWN EXP 4 OR> PER QUAD
$0.00
D4231
1
ANA CROWN EXP 1-3 PER QUAD
$0.00
D4240
1
GINGIVAL FLAP PROC W/ PLANIN
$0.00
D4241
1
GNGVL FLAP W ROOTPLAN 1-3 TH
$0.00
D4245
1
APICALLY POSITIONED FLAP
$0.00
D4249
1
CROWN LENGTHEN HARD TISSUE
$0.00
D4260
1
OSSEOUS SURGERY PER QUADRANT
$0.00
D4261
1
OSSEOUS SURGL-3TEETHPERQUAD
$0.00
D4262
O
BONE REPLACEMENT GRAFT-MULTIPLE SIT
$0.00
D4263
1
BONE REPLCE GRAFT FIRST SITE
$0.00
D4264
1
BONE REPLCE GRAFT EACH ADD
$0.00
D4265
1
BIO MTRLS TO AID SOFT/OS REG
$0.00
D4266
1
GUIDED TISS REGEN RESORBLE
$0.00
D4267
1
GUIDED TISS REGEN NONRESORB
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
D4268
1
SURGICAL REVISION PROCEDURE
$0.00
D4270
1
PEDICLE SOFT TISSUE GRAFT PR
$0.00
D4271
1
FREE SOFT TISSUE GRAFT PROC
$0.00
D4272
9
APICALLY REPOSITIONING FLAP PROCEDU
$0.00
D4273
1
SUBEPITHELIAL TISSUE GRAFT
$0.00
D4274
1
DISTAL/PROXIMAL WEDGE PROC
$0.00
D4275
1
SOFT TISSUE ALLOGRAFT
$0.00
D4276
1
CON TISSUE W DBLE PED GRAFT
$0.00
D4320
1
PROVISION SPLNT INTRACORONAL
$0.00
D4321
1
PROVISIONAL SPLINT EXTRACORO
$0.00
D4340
9
PERIODONTAL SCALING AND ROOT PLANIN
$0.00
D4341
1
PERIODONTAL SCALING & ROOT
$0.00
D4342
1
PERIODONTAL SCALING 1-3TEETH
$0.00
D4355
1
FULL MOUTH DEBRIDEMENT
$0.00
D4381
1
LOCALIZED DELIVERY ANTIMICRO
$0.00
D4910
1
PERIODONTAL MAINT PROCEDURES
$0.00
D4920
1
UNSCHEDULED DRESSING CHANGE
$0.00
D4999
1
UNSPECIFIED PERIODONTAL PROC
$0.00
D5110
1
DENTURES COMPLETE MAXILLARY
$0.00
D5120
1
DENTURES COMPLETE MANDIBLE
$0.00
D5130
1
DENTURES IMMEDIAT MAXILLARY
$0.00
D5140
1
DENTURES IMMEDIAT MANDIBLE
$0.00
D5211
1
DENTURES MAXILL PART RESIN
$0.00
D5212
1
DENTURES MAND PART RESIN
$0.00
D5213
1
DENTURES MAXILL PART METAL
$0.00
D5214
1
DENTURES MANDIBL PART METAL
$0.00
D5215
9
UPPER PARTIAL - HIGH NOBLE CAST BAS
$0.00
D5216
9
LOWER PARTIAL - HIGH NOBLE CAST BAS
$0.00
D5225
1
MAXILLARY PART DENTURE FLEX
$0.00
D5226
1
MANDIBULAR PART DENTURE FLEX
$0.00
D5280
9
REMOVABLE UNILATERAL PARTIAL DENTUR
$0.00
D5281
9
REMOVABLE PARTIAL DENTURE
$0.00
D5410
1
DENTURES ADJUST CMPLT MAXIL
$0.00
D5411
1
DENTURES ADJUST CMPLT MAND
$0.00
D5421
1
DENTURES ADJUST PART MAXILL
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
D5422
1
DENTURES ADJUST PART MANDBL
$0.00
D5510
1
DENTUR REPR BROKEN COMPL BAS
$0.00
D5520
1
REPLACE DENTURE TEETH COMPLT
$0.00
D5610
1
DENTURES REPAIR RESIN BASE
$0.00
D5620
1
REP PART DENTURE CAST FRAME
$0.00
D5630
1
REP PARTIAL DENTURE CLASP
$0.00
D5640
1
REPLACE PART DENTURE TEETH
$0.00
D5650
1
ADD TOOTH TO PARTIAL DENTURE
$0.00
D5660
1
ADD CLASP TO PARTIAL DENTURE
$0.00
D5670
1
REPLC TTH&ACRLC ON MTL FRMWK
$0.00
D5671
1
REPLC TTH&ACRLC MANDIBULAR
$0.00
D5710
9
DENTURES REBASE CMPLT MAXIL
$0.00
D5711
9
DENTURES REBASE CMPLT MAND
$0.00
D5720
9
DENTURES REBASE PART MAXILL
$0.00
D5721
9
DENTURES REBASE PART MANDBL
$0.00
D5730
1
DENTURE RELN CMPLT MAXIL CH
$0.00
D5731
1
DENTURE RELN CMPLT MAND CHR
$0.00
D5740
1
DENTURE RELN PART MAXIL CHR
$0.00
D5741
1
DENTURE RELN PART MAND CHR
$0.00
D5750
1
DENTURE RELN CMPLT MAX LAB
$0.00
D5751
1
DENTURE RELN CMPLT MAND LAB
$0.00
D5760
1
DENTURE RELN PART MAXIL LAB
$0.00
D5761
1
DENTURE RELN PART MAND LAB
$0.00
D5810
1
DENTURE INTERM CMPLT MAXILL
$0.00
D5811
1
DENTURE INTERM CMPLT MANDBL
$0.00
D5820
1
DENTURE INTERM PART MAXILL
$0.00
D5821
1
DENTURE INTERM PART MANDBL
$0.00
D5850
1
DENTURE TISS CONDITN MAXILL
$0.00
D5851
1
DENTURE TISS CONDTIN MANDBL
$0.00
D5860
9
OVERDENTURE COMPLETE
$0.00
D5861
9
OVERDENTURE PARTIAL
$0.00
D5862
9
PRECISION ATTACHMENT
$0.00
D5867
9
REPLACEMENT OF PRECISION ATT
$0.00
D5875
9
PROSTHESIS MODIFICATION
$0.00
D5899
1
REMOVABLE PROSTHODONTIC PROC
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
D5911
1
FACIAL MOULAGE SECTIONAL
$0.00
D5912
1
FACIAL MOULAGE COMPLETE
$0.00
D5913
1
NASAL PROSTHESIS
$0.00
D5914
1
AURICULAR PROSTHESIS
$0.00
D5915
1
ORBITAL PROSTHESIS
$0.00
D5916
1
OCULAR PROSTHESIS
$0.00
D5917
9
COMPOSITE FACIAL PROSTHESIS
$0.00
D5918
9
REPLACEMENT PROSTHESIS
$0.00
D5919
1
FACIAL PROSTHESIS
$0.00
D5920
9
OCULAR IMPLANT
$0.00
D5921
9
ORBITAL IMPLANT
$0.00
D5922
1
NASAL SEPTAL PROSTHESIS
$0.00
D5923
1
OCULAR PROSTHESIS INTERIM
$0.00
D5924
1
CRANIAL PROSTHESIS
$0.00
D5925
1
FACIAL AUGMENTATION IMPLANT
$0.00
D5926
1
REPLACEMENT NASAL PROSTHESIS
$0.00
D5927
1
AURICULAR REPLACEMENT
$0.00
D5928
1
ORBITAL REPLACEMENT
$0.00
D5929
1
FACIAL REPLACEMENT
$0.00
D5931
1
SURGICAL OBTURATOR
$0.00
D5932
1
POSTSURGICAL OBTURATOR
$0.00
D5933
1
REFITTING OF OBTURATOR
$0.00
D5934
1
MANDIBULAR FLANGE PROSTHESIS
$0.00
D5935
1
MANDIBULAR DENTURE PROSTH
$0.00
D5936
1
TEMP OBTURATOR PROSTHESIS
$0.00
D5937
1
TRISMUS APPLIANCE
$0.00
D5951
1
FEEDING AID
$0.00
D5952
1
PEDIATRIC SPEECH AID
$0.00
D5953
1
ADULT SPEECH AID
$0.00
D5954
1
SUPERIMPOSED PROSTHESIS
$0.00
D5955
1
PALATAL LIFT PROSTHESIS
$0.00
D5956
9
OBTURATOR
$0.00
D5957
9
SPEECH BULB
$0.00
D5958
1
INTRAORAL CON DEF INTER PLT
$0.00
D5959
1
INTRAORAL CON DEF MOD PALAT
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
D5960
1
MODIFY SPEECH AID PROSTHESIS
$0.00
D5971
9
SIMPLE IMPLANT
$0.00
D5972
9
COMPLEX IMPLANT
$0.00
D5973
9
SUBPERIOSTEAL IMPLANT
$0.00
D5974
9
ENDOSSEOUS IMPLANT (IN THE BONE)
$0.00
D5976
9
MANDIBULAR STAPLE IMPLANT
$0.00
D5982
9
SURGICAL STENT
$0.00
D5983
9
RADIATION APPLICATOR
$0.00
D5984
9
RADIATION SHIELD
$0.00
D5985
9
RADIATION CONE LOCATOR
$0.00
D5986
1
FLUORIDE APPLICATOR
$0.00
D5987
1
COMMISSURE SPLINT
$0.00
D5988
1
SURGICAL SPLINT
$0.00
D5991
1
TOPICAL MEDICAMENT CARRIER
$0.00
D5999
1
MAXILLOFACIAL PROSTHESIS
$0.00
D6010
9
ODONTICS ENDOSTEAL IMPLANT
$0.00
D6012
9
ENDOSTEAL IMPLANT
$0.00
D6020
O
ODONTICS ABUTMENT PLACEMENT
$0.00
D6040
9
SURGICAL PLACEMENT:EPOSTEAL IMPLAN
$0.00
D6050
9
SURGICAL PLACEMENT TRANSOSTEAL
$0.00
D6053
9
IMPLNT/ABTMNT SPPRT REMV DNT
$0.00
D6054
9
IMPLNT/ABTMNT SPPRT REMVPRTL
$0.00
D6055
9
DENTAL IMPLANT SUPPORTED BAR
$0.00
D6056
9
PREFABRICATED ABUTMENT
$0.00
D6057
9
CUSTOM ABUTMENT
$0.00
D6058
9
ABUTMENT SUPPORTED CROWN
$0.00
D6059
9
ABUTMENT SUPPORTED MTL CROWN
$0.00
D6060
9
ABUTMENT SUPPORTED MTL CROWN
$0.00
D6061
9
ABUTMENT SUPPORTED MTL CROWN
$0.00
D6062
9
ABUTMENT SUPPORTED MTL CROWN
$0.00
D6063
9
ABUTMENT SUPPORTED MTL CROWN
$0.00
D6064
9
ABUTMENT SUPPORTED MTL CROWN
$0.00
D6065
9
IMPLANT SUPPORTED CROWN
$0.00
D6066
9
IMPLANT SUPPORTED MTL CROWN
$0.00
D6067
9
IMPLANT SUPPORTED MTL CROWN
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
D6068
9
ABUTMENT SUPPORTED RETAINER
$0.00
D6069
9
ABUTMENT SUPPORTED RETAINER
$0.00
D6070
9
ABUTMENT SUPPORTED RETAINER
$0.00
D6071
9
ABUTMENT SUPPORTED RETAINER
$0.00
D6072
9
ABUTMENT SUPPORTED RETAINER
$0.00
D6073
9
ABUTMENT SUPPORTED RETAINER
$0.00
D6074
9
ABUTMENT SUPPORTED RETAINER
$0.00
D6075
9
IMPLANT SUPPORTED RETAINER
$0.00
D6076
9
IMPLANT SUPPORTED RETAINER
$0.00
D6077
9
IMPLANT SUPPORTED RETAINER
$0.00
D6078
9
IMPLNT/ABUT SUPRTD FIXD DENT
$0.00
D6079
9
IMPLNT/ABUT SUPRTD FIXD DENT
$0.00
D6080
9
IMPLANT MAINTENANCE PROCEDURES INC
$0.00
D6090
9
REPAIR IMPLANT SUPPORTED PROSTHESI
$0.00
D6091
9
REPL SEMI/PRECISION ATTACH
$0.00
D6092
9
RECEMENT SUPP CROWN
$0.00
D6093
9
RECEMENT SUPP PART DENTURE
$0.00
D6094
9
ABUT SUPPORT CROWN TITANIUM
$0.00
D6095
9
ODONTICS REPR ABUTMENT
$0.00
D6100
9
IMPLANT REMOVAL, BY REPORT.
$0.00
D6190
9
RADIO/SURGICAL IMPLANT INDEX
$0.00
D6194
9
ABUT SUPPORT RETAINER TITANI
$0.00
D6199
9
UNSPECIFIED IMPLANT PROCEDURE, BY
$0.00
D6205
9
PONTIC-INDIRECT RESIN BASED
$0.00
D6210
9
PROSTHODONT HIGH NOBLE METAL
$0.00
D6211
1
BRIDGE BASE METAL CAST
$0.00
D6212
1
BRIDGE NOBLE METAL CAST
$0.00
D6214
9
PONTIC TITANIUM
$0.00
D6240
9
BRIDGE PORCELAIN HIGH NOBLE
$0.00
D6241
1
BRIDGE PORCELAIN BASE METAL
$0.00
D6242
1
BRIDGE PORCELAIN NOBEL METAL
$0.00
D6245
9
BRIDGE PORCELAIN/CERAMIC
$0.00
D6250
9
BRIDGE RESIN W/HIGH NOBLE
$0.00
D6251
1
BRIDGE RESIN BASE METAL
$0.00
D6252
1
BRIDGE RESIN W/NOBLE METAL
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
D6253
9
PROVISIONAL PONTIC
$0.00
D6519
9
INLAY/ONLAY PORCE/CERAMIC
$0.00
D6520
9
DENTAL RETAINER TWO SURFACES
$0.00
D6530
9
RETAINER METALLIC 3+ SURFACE
$0.00
D6540
O
ONLAY-METALLIC-PER TOOTH (IN ADDITI
$0.00
D6543
9
DENTAL RETAINR ONLAY 3 SURF
$0.00
D6544
9
DENTAL RETAINR ONLAY 4/MORE
$0.00
D6545
1
DENTAL RETAINR CAST METL
$0.00
D6548
9
PORCELAIN/CERAMIC RETAINER
$0.00
D6600
9
PORCELAIN/CERAMIC INLAY 2SRF
$0.00
D6601
9
PORC/CERAM INLAY >= 3 SURFAC
$0.00
D6602
9
CST HGH NBLE MTL INLAY 2 SRF
$0.00
D6603
9
CST HGH NBLE MTL INLAY >=3SR
$0.00
D6604
9
CST BSE MTL INLAY 2 SURFACES
$0.00
D6605
9
CST BSE MTL INLAY >= 3 SURFA
$0.00
D6606
9
CAST NOBLE METAL INLAY 2 SUR
$0.00
D6607
9
CST NOBLE MTL INLAY >=3 SURF
$0.00
D6608
9
ONLAY PORC/CRMC 2 SURFACES
$0.00
D6609
9
ONLAY PORC/CRMC >=3 SURFACES
$0.00
D6610
9
ONLAY CST HGH NBL MTL 2 SRFC
$0.00
D6611
9
ONLAY CST HGH NBL MTL >=3SRF
$0.00
D6612
9
ONLAY CST BASE MTL 2 SURFACE
$0.00
D6613
9
ONLAY CST BASE MTL >=3 SURFA
$0.00
D6614
9
ONLAY CST NBL MTL 2 SURFACES
$0.00
D6615
9
ONLAY CST NBL MTL >=3 SURFAC
$0.00
D6624
9
INLAY TITANIUM
$0.00
D6634
9
ONLAY TITANIUM
$0.00
D6710
9
CROWN-INDIRECT RESIN BASED
$0.00
D6720
9
RETAIN CROWN RESIN W HI NBLE
$0.00
D6721
1
CROWN RESIN W/BASE METAL
$0.00
D6722
1
CROWN RESIN W/NOBLE METAL
$0.00
D6740
9
CROWN PORCELAIN/CERAMIC
$0.00
D6750
9
CROWN PORCELAIN HIGH NOBLE
$0.00
D6751
1
CROWN PORCELAIN BASE METAL
$0.00
D6752
1
CROWN PORCELAIN NOBLE METAL
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
D6780
9
CROWN 3/4 HIGH NOBLE METAL
$0.00
D6781
9
CROWN 3/4 CAST BASED METAL
$0.00
D6782
9
CROWN 3/4 CAST NOBLE METAL
$0.00
D6783
9
CROWN 3/4 PORCELAIN/CERAMIC
$0.00
D6790
9
CROWN FULL HIGH NOBLE METAL
$0.00
D6791
1
CROWN FULL BASE METAL CAST
$0.00
D6792
1
CROWN FULL NOBLE METAL CAST
$0.00
D6793
9
PROVISIONAL RETAINER CROWN
$0.00
D6794
9
CROWN TITANIUM
$0.00
D6920
9
DENTAL CONNECTOR BAR
$0.00
D6930
1
DENTAL RECEMENT BRIDGE
$0.00
D6940
9
STRESS BREAKER
$0.00
D6950
9
PRECISION ATTACHMENT
$0.00
D6970
9
POST & CORE PLUS RETAINER
$0.00
D6971
O
CAST POST BRIDGE RETAINER
$0.00
D6972
1
PREFAB POST & CORE PLUS RETA
$0.00
D6973
9
CORE BUILD UP FOR RETAINER, INCLUD
$0.00
D6975
9
COPING METAL
$0.00
D6976
9
EACH ADDTNL CAST POST
$0.00
D6977
9
EACH ADDTL PREFAB POST
$0.00
D6980
1
BRIDGE REPAIR
$0.00
D6985
1
PEDIATRIC PARTIAL DENTURE FX
$0.00
D6999
1
FIXED PROSTHODONTIC PROC
$0.00
D7110
O
ORAL SURGERY SINGLE TOOTH
$0.00
D7111
1
EXTRACTION CORONAL REMNANTS
$0.00
D7120
O
EACH ADD TOOTH EXTRACTION
$0.00
D7130
O
TOOTH ROOT REMOVAL
$0.00
D7140
1
EXTRACTION ERUPTED TOOTH/EXR
$0.00
D7210
1
REM IMP TOOTH W MUCOPER FLP
$0.00
D7220
1
IMPACT TOOTH REMOV SOFT TISS
$0.00
D7230
1
IMPACT TOOTH REMOV PART BONY
$0.00
D7240
1
IMPACT TOOTH REMOV COMP BONY
$0.00
D7241
1
IMPACT TOOTH REM BONY W/COMP
$0.00
D7250
1
TOOTH ROOT REMOVAL
$0.00
D7260
1
ORAL ANTRAL FISTULA CLOSURE
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
D7261
1
PRIMARY CLOSURE SINUS PERF
$0.00
D7270
1
TOOTH REIMPLANTATION
$0.00
D7271
O
TOOTH IMPLANTATION
$0.00
D7272
1
TOOTH TRANSPLANTATION
$0.00
D7280
1
EXPOSURE IMPACT TOOTH ORTHOD
$0.00
D7281
O
EXPOSURE TOOTH AID ERUPTION
$0.00
D7282
1
MOBILIZE ERUPTED/MALPOS TOOT
$0.00
D7283
1
PLACE DEVICE IMPACTED TOOTH
$0.00
D7285
9
BIOPSY OF ORAL TISSUE HARD
$0.00
D7286
9
BIOPSY OF ORAL TISSUE SOFT
$0.00
D7287
9
EXFOLIATIVE CYTOLOG COLLECT
$0.00
D7288
9
BRUSH BIOPSY
$0.00
D7290
1
REPOSITIONING OF TEETH
$0.00
D7291
1
TRANSSEPTAL FIBEROTOMY
$0.00
D7292
9
SCREW RETAINED PLATE
$0.00
D7293
9
TEMP ANCHORAGE DEV W FLAP
$0.00
D7294
9
TEMP ANCHORAGE DEV W/O FLAP
$0.00
D7310
1
ALVEOPLASTY W/ EXTRACTION
$0.00
D7311
1
ALVEOLOPLASTY W/EXTRACT 1-3
$0.00
D7320
1
ALVEOPLASTY W/O EXTRACTION
$0.00
D7321
1
ALVEOLOPLASTY NOT W/EXTRACTS
$0.00
D7340
1
VESTIBULOPLASTY RIDGE EXTENS
$0.00
D7350
1
VESTIBULOPLASTY EXTEN GRAFT
$0.00
D7410
9
RAD EXC LESION UP TO 1.25 CM
$0.00
D7411
9
EXCISION BENIGN LESION>1.25C
$0.00
D7412
9
EXCISION BENIGN LESION COMPL
$0.00
D7413
9
EXCISION MALIG LESION<=1.25C
$0.00
D7414
9
EXCISION MALIG LESION>1.25CM
$0.00
D7415
9
EXCISION MALIG LES COMPLICAT
$0.00
D7420
9
LESION > 1.25 CM
$0.00
D7430
9
EXC BENIGN TUMOR TO 1.25 CM
$0.00
D7431
9
BENIGN TUMOR EXC > 1.25 CM
$0.00
D7440
9
MALIG TUMOR EXC TO 1.25 CM
$0.00
D7441
9
MALIG TUMOR > 1.25 CM
$0.00
D7450
9
REM ODONTOGEN CYST TO 1.25CM
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
D7451
9
REM ODONTOGEN CYST > 1.25 CM
$0.00
D7460
9
REM NONODONTO CYST TO 1.25CM
$0.00
D7461
9
REM NONODONTO CYST > 1.25 CM
$0.00
D7465
9
LESION DESTRUCTION
$0.00
D7470
9
REM EXOSTOSIS MAXILLA/MANDIB
$0.00
D7471
9
REM EXOSTOSIS ANY SITE
$0.00
D7472
9
REMOVAL OF TORUS PALATINUS
$0.00
D7473
9
REMOVE TORUS MANDIBULARIS
$0.00
D7480
9
PARTIAL OSTECTOMY
$0.00
D7485
9
SURG REDUCT OSSEOUSTUBEROSIT
$0.00
D7490
9
MAXILLA OR MANDIBLE RESECTIO
$0.00
D7510
1
I&D ABSC INTRAORAL SOFT TISS
$0.00
D7511
1
INCISION/DRAIN ABSCESS INTRA
$0.00
D7520
1
I&D ABSCESS EXTRAORAL
$0.00
D7521
1
INCISION/DRAIN ABSCESS EXTRA
$0.00
D7530
1
REMOVAL FB SKIN/AREOLAR TISS
$0.00
D7540
1
REMOVAL OF FB REACTION
$0.00
D7550
1
REMOVAL OF SLOUGHED OFF BONE
$0.00
D7560
1
MAXILLARY SINUSOTOMY
$0.00
D7610
9
MAXILLA OPEN REDUCT SIMPLE
$0.00
D7620
9
CLSD REDUCT SIMPL MAXILLA FX
$0.00
D7630
9
OPEN RED SIMPL MANDIBLE FX
$0.00
D7640
9
CLSD RED SIMPL MANDIBLE FX
$0.00
D7650
9
OPEN RED SIMP MALAR/ZYGOM FX
$0.00
D7660
9
CLSD RED SIMP MALAR/ZYGOM FX
$0.00
D7670
9
CLOSD RDUCTN SPLINT ALVEOLUS
$0.00
D7671
9
ALVEOLUS OPEN REDUCTION
$0.00
D7680
9
REDUCT SIMPLE FACIAL BONE FX
$0.00
D7710
9
MAXILLA OPEN REDUCT COMPOUND
$0.00
D7720
9
CLSD REDUCT COMPD MAXILLA FX
$0.00
D7730
9
OPEN REDUCT COMPD MANDBLE FX
$0.00
D7740
9
CLSD REDUCT COMPD MANDBLE FX
$0.00
D7750
9
OPEN RED COMP MALAR/ZYGMA FX
$0.00
D7760
9
CLSD RED COMP MALAR/ZYGMA FX
$0.00
D7770
9
OPEN REDUC COMPD ALVEOLUS FX
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
D7771
9
ALVEOLUS CLSD REDUC STBLZ TE
$0.00
D7780
9
REDUCT COMPND FACIAL BONE FX
$0.00
D7810
9
TMJ OPEN REDUCT-DISLOCATION
$0.00
D7820
9
CLOSED TMP MANIPULATION
$0.00
D7830
9
TMJ MANIPULATION UNDER ANEST
$0.00
D7840
9
REMOVAL OF TMJ CONDYLE
$0.00
D7850
9
TMJ MENISCECTOMY
$0.00
D7852
9
DISC REPAIR
$0.00
D7854
9
SYNOVECTOMY
$0.00
D7856
9
MYOTOMY
$0.00
D7858
9
JOINT RECONSTRUCTION
$0.00
D7860
9
TMJ CUTTING INTO JOINT
$0.00
D7865
9
ARTHROPLASTY
$0.00
D7870
9
TMJ ASPIRATION JOINT FLUID
$0.00
D7871
9
LYSIS + LAVAGE W CATHETERS
$0.00
D7872
9
ARTHROSCOPY- DIAGNOSIS WITH
$0.00
D7873
9
ARTHOSCOPY- SURGICAL: LAVAGE AND
$0.00
D7874
9
ARTHROSCOPY- SURGICAL: DISC REPOSI
$0.00
D7875
9
ARTHROSCOPY- SURGICAL: SYNOVECTOMY
$0.00
D7876
9
ARTHROSCOPY- SURGICAL: DISCECTOMY
$0.00
D7877
9
ARTHROSCOPY- SURGICAL DEBRIDEMENT
$0.00
D7880
1
OCCLUSAL ORTHOTIC APPLIANCE
$0.00
D7899
1
TMJ UNSPECIFIED THERAPY
$0.00
D7910
1
DENT SUTUR RECENT WND TO 5CM
$0.00
D7911
1
DENTAL SUTURE WOUND TO 5 CM
$0.00
D7912
1
SUTURE COMPLICATE WND > 5 CM
$0.00
D7920
9
DENTAL SKIN GRAFT
$0.00
D7940
9
RESHAPING BONE ORTHOGNATHIC
$0.00
D7941
9
BONE CUTTING RAMUS CLOSED
$0.00
D7942
9
BONE CUTTING RAMUS OPEN
$0.00
D7943
9
CUTTING RAMUS OPEN W/GRAFT
$0.00
D7944
9
BONE CUTTING SEGMENTED
$0.00
D7945
9
BONE CUTTING BODY MANDIBLE
$0.00
D7946
9
RECONSTRUCTION MAXILLA TOTAL
$0.00
D7947
9
RECONSTRUCT MAXILLA SEGMENT
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
D7948
9
RECONSTRUCT MIDFACE NO GRAFT
$0.00
D7949
9
RECONSTRUCT MIDFACE W/GRAFT
$0.00
D7950
9
MANDIBLE GRAFT
$0.00
D7951
9
SINUS AUG W BONE/BONE SUP
$0.00
D7953
9
BONE REPLACEMENT GRAFT
$0.00
D7955
9
REPAIR MAXILLOFACIAL DEFECTS
$0.00
D7960
1
FRENULECTOMY/FRENULOTOMY
$0.00
D7963
1
FRENULOPLASTY
$0.00
D7970
1
EXCISION HYPERPLASTIC TISSUE
$0.00
D7971
1
EXCISION PERICORONAL GINGIVA
$0.00
D7972
9
SURG REDCT FIBROUS TUBEROSIT
$0.00
D7980
9
SIALOLITHOTOMY
$0.00
D7981
9
EXCISION OF SALIVARY GLAND
$0.00
D7982
9
SIALODOCHOPLASTY
$0.00
D7983
9
CLOSURE OF SALIVARY FISTULA
$0.00
D7990
9
EMERGENCY TRACHEOTOMY
$0.00
D7991
9
DENTAL CORONOIDECTOMY
$0.00
D7992
9
EMINENECTOMY
$0.00
D7993
O
IMPLANT-FACIAL BONES (HOMOLOGOUS, H
$0.00
D7994
O
IMPLANT-OTHER THAN FACIAL BONES
$0.00
D7995
9
SYNTHETIC GRAFT FACIAL BONES
$0.00
D7996
9
IMPLANT MANDIBLE FOR AUGMENT
$0.00
D7997
1
APPLIANCE REMOVAL
$0.00
D7998
9
INTRAORAL PLACE OF FIX DEV
$0.00
D7999
1
ORAL SURGERY PROCEDURE
$0.00
D8010
1
LIMITED DENTAL TX PRIMARY
$0.00
D8020
1
LIMITED DENTAL TX TRANSITION
$0.00
D8030
1
LIMITED DENTAL TX ADOLESCENT
$0.00
D8040
1
LIMITED DENTAL TX ADULT
$0.00
D8050
1
INTERCEP DENTAL TX PRIMARY
$0.00
D8060
1
INTERCEP DENTAL TX TRANSITN
$0.00
D8070
1
COMPRE DENTAL TX TRANSITION
$0.00
D8080
3
COMPRE DENTAL TX ADOLESCENT
D8090
1
COMPRE DENTAL TX ADULT
$0.00
D8110
O
REMOVABLE APPLIANCE THERAPY
$0.00
$1,585.00
Procedure Code Pricing Action Code Description
Maximum Allowable
D8120
O
FIXED APPLIANCE THERAPY
$0.00
D8210
1
ORTHODONTIC REM APPLIANCE TX
$0.00
D8220
1
FIXED APPLIANCE THERAPY HABT
$0.00
D8360
O
REMOVABLE APPLIANCE THERAPY
$0.00
D8370
O
FIXED APPLIANCE THERAPY
$0.00
D8460
O
CLASS I MALOCCLUSION
$0.00
D8470
O
CLASS II MALOCCLUSION
$0.00
D8480
O
CLASS III MALOCCLUSION
$0.00
D8560
O
CLASS I MALOCCLUSION
$0.00
D8570
O
CLASS II MALOCCLUSION
$0.00
D8580
O
CLASS III MALOCCLUSION
$0.00
D8650
O
TREATMENT OF THE ATYPICAL OR EXTEND
$0.00
D8660
3
PREORTHODONTIC TX VISIT
$225.00
D8670
3
PERIODIC ORTHODONTC TX VISIT
$465.00
D8680
1
ORTHODONTIC RETENTION
$0.00
D8690
1
ORTHODONTIC TREATMENT
$0.00
D8691
1
REPAIR ORTHO APPLIANCE
$0.00
D8692
1
REPLACEMENT RETAINER
$0.00
D8693
9
REBOND/CEMENT/REPAIR RETAIN
$0.00
D8750
O
POST-TREATMENT STABILIZATION
$0.00
D8999
1
ORTHODONTIC PROCEDURE
$0.00
D9110
1
TX DENTAL PAIN MINOR PROC
$0.00
D9120
1
FIX PARTIAL DENTURE SECTION
$0.00
D9210
1
DENT ANESTHESIA W/O SURGERY
$0.00
D9211
9
REGIONAL BLOCK ANESTHESIA
$0.00
D9212
9
TRIGEMINAL BLOCK ANESTHESIA
$0.00
D9215
9
LOCAL ANESTHESIA
$0.00
D9220
1
GENERAL ANESTHESIA
$0.00
D9221
1
GENERAL ANESTHESIA EA AD 15M
$0.00
D9230
1
ANALGESIA
$0.00
D9240
9
INTRAVENOUS SEDATION
$0.00
D9241
1
INTRAVENOUS SEDATION
$0.00
D9242
1
IV SEDATION EA AD 30 M
$0.00
D9248
1
SEDATION (NON-IV)
$0.00
D9310
1
DENTAL CONSULTATION
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
D9410
9
DENTAL HOUSE CALL
$0.00
D9420
9
HOSPITAL CALL
$0.00
D9430
9
OFFICE VISIT DURING HOURS
$0.00
D9440
1
OFFICE VISIT AFTER HOURS
$0.00
D9450
9
CASE PRESENTATION TX PLAN
$0.00
D9610
1
DENT THERAPEUTIC DRUG INJECT
$0.00
D9612
1
THERA PAR DRUGS 2 OR > ADMIN
$0.00
D9630
9
OTHER DRUGS/MEDICAMENTS
$0.00
D9910
1
DENT APPL DESENSITIZING MED
$0.00
D9911
1
APPL DESENSITIZING RESIN
$0.00
D9920
1
BEHAVIOR MANAGEMENT
$0.00
D9930
1
TREATMENT OF COMPLICATIONS
$0.00
D9940
1
DENTAL OCCLUSAL GUARD
$0.00
D9941
9
FABRICATION ATHLETIC GUARD
$0.00
D9942
9
REPAIR/RELINE OCCLUSAL GUARD
$0.00
D9950
9
OCCLUSION ANALYSIS
$0.00
D9951
9
LIMITED OCCLUSAL ADJUSTMENT
$0.00
D9952
9
COMPLETE OCCLUSAL ADJUSTMENT
$0.00
D9960
9
COMPLETION OF CLAIM FORM
$0.00
D9970
9
ENAMEL MICROABRASION
$0.00
D9971
9
ODONTOPLASTY 1-2 TEETH
$0.00
D9972
9
EXTRNL BLEACHING PER ARCH
$0.00
D9973
9
EXTRNL BLEACHING PER TOOTH
$0.00
D9974
9
INTRNL BLEACHING PER TOOTH
$0.00
D9999
1
ADJUNCTIVE PROCEDURE
$0.00
DCD03
O
MCO SPECIFIC CODE: DEVELOPMENTAL CE
$0.00
DCP01
O
MCO SPECIFIC CODE: PARENT INFANT PR
$0.00
DCT02
O
MCO SPECIFIC CODE: TODDLER PROGRAM
$0.00
E0100
3
CANE ADJUST/FIXED WITH TIP
$20.16
E0105
3
CANE ADJUST/FIXED QUAD/3 PRO
$46.99
E0110
3
CRUTCH FOREARM PAIR
$69.54
E0111
3
CRUTCH FOREARM EACH
$50.95
E0112
3
CRUTCH UNDERARM PAIR WOOD
$35.40
E0113
3
CRUTCH UNDERARM EACH WOOD
$20.21
E0114
3
CRUTCH UNDERARM PAIR NO WOOD
$45.15
Procedure Code Pricing Action Code Description
Maximum Allowable
E0116
3
CRUTCH UNDERARM EACH NO WOOD
$22.76
E0117
5
UNDERARM SPRINGASSIST CRUTCH
$0.00
E0118
6
CRUTCH SUBSTITUTE
$0.00
E0130
3
WALKER RIGID ADJUST/FIXED HT
$57.13
E0135
3
WALKER FOLDING ADJUST/FIXED
$77.57
E0140
6
WALKER W TRUNK SUPPORT
E0141
3
RIGID WHEELED WALKER ADJ/FIX
E0142
O
WALKER RIGID WHEELED WITH SE
E0143
3
WALKER FOLDING WHEELED W/O S
$115.02
E0144
3
ENCLOSED WALKER W REAR SEAT
$304.66
E0145
O
WALKER WHLED SEAT/CRUTCH ATT
$0.00
E0146
O
FOLDING WALKER WHEELS W SEAT
$0.00
E0147
3
WALKER VARIABLE WHEEL RESIST
$549.91
E0148
3
HEAVYDUTY WALKER NO WHEELS
$121.55
E0149
3
HEAVY DUTY WHEELED WALKER
$213.53
E0150
9
UNDERARM PAD, CRUTCH, REPLACEMENT,
$0.00
E0151
9
HANDGRIP, CANE, CRUTCH, OR WALKER R
$0.00
E0152
9
TIP, CANE OR CRUTCH WALKER REPLACEM
$0.00
E0153
3
FOREARM CRUTCH PLATFORM ATTA
$66.38
E0154
3
WALKER PLATFORM ATTACHMENT
$66.38
E0155
3
WALKER WHEEL ATTACHMENT,PAIR
$30.20
E0156
3
WALKER SEAT ATTACHMENT
$25.29
E0157
3
WALKER CRUTCH ATTACHMENT
$66.61
E0158
3
WALKER LEG EXTENDERS SET OF4
$30.78
E0159
9
BRAKE FOR WHEELED WALKER
$0.00
E0160
3
SITZ TYPE BATH OR EQUIPMENT
$31.62
E0161
3
SITZ BATH/EQUIPMENT W/FAUCET
$25.09
E0162
3
SITZ BATH CHAIR
E0163
3
COMMODE CHAIR WITH FIXED ARM
$98.08
E0164
O
COMMODE CHAIR MOBILE FIXED A
$0.00
E0165
3
COMMODE CHAIR WITH DETACHARM
E0166
O
COMMODE CHAIR MOBILE DETACH
E0167
3
COMMODE CHAIR PAIL OR PAN
E0168
3
HEAVYDUTY/WIDE COMMODE CHAIR
E0169
O
SEATLIFT INCORP COMMODECHAIR
$0.00 $110.30 $0.00
$139.39
$144.20 $0.00 $10.11 $144.38 $0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
E0170
6
COMMODE CHAIR ELECTRIC
$0.00
E0171
6
COMMODE CHAIR NON-ELECTRIC
$0.00
E0172
6
SEAT LIFT MECHANISM TOILET
$0.00
E0175
3
COMMODE CHAIR FOOT REST
$53.86
E0176
O
AIR PRESSRE PAD/CUSHION NONP
$0.00
E0177
O
WATER PRESS PAD/CUSHION NONP
$0.00
E0178
O
GEL PRESSRE PAD/CUSHION NONP
$0.00
E0179
O
DRY PRESSRE PAD/CUSHION NONP
$0.00
E0180
O
PRESS PAD ALTERNATING W PUMP
$0.00
E0181
3
PRESS PAD ALTERNATING W/ PUM
$304.20
E0182
3
REPLACE PUMP, ALT PRESS PAD
$235.90
E0183
9
FLOTATION PAD FOR WHEELCHAIR
E0184
3
DRY PRESSURE MATTRESS
$186.27
E0185
3
GEL PRESSURE MATTRESS PAD
$306.01
E0186
3
AIR PRESSURE MATTRESS
$182.80
E0187
3
WATER PRESSURE MATTRESS
$209.20
E0188
3
SYNTHETIC SHEEPSKIN PAD
$23.85
E0189
3
LAMBSWOOL SHEEPSKIN PAD
$36.30
E0190
6
POSITIONING CUSHION
$0.00
E0191
3
PROTECTOR HEEL OR ELBOW
$9.56
E0192
O
PAD WHEELCHR LOW PRESS/POSIT
$0.00
E0193
3
POWERED AIR FLOTATION BED
E0194
3
AIR FLUIDIZED BED
$0.00
E0195
9
REPLACEMENT PAD FOR USE WITH MEDICA
$0.00
E0196
3
GEL PRESSURE MATTRESS
$287.60
E0197
3
AIR PRESSURE PAD FOR MATTRES
$211.98
E0198
3
WATER PRESSURE PAD FOR MATTR
$211.98
E0199
3
DRY PRESSURE PAD FOR MATTRES
$30.66
E0200
3
HEAT LAMP WITHOUT STAND
$75.85
E0202
3
PHOTOTHERAPY LIGHT W/ PHOTOM
E0203
5
THERAPEUTIC LIGHTBOX TABLETP
E0205
3
HEAT LAMP WITH STAND
E0210
3
ELECTRIC HEAT PAD STANDARD
$31.22
E0215
3
ELECTRIC HEAT PAD MOIST
$67.77
E0217
3
WATER CIRC HEAT PAD W PUMP
$0.00
$6,956.30
$564.10 $0.00 $157.81
$403.72
Procedure Code Pricing Action Code Description
Maximum Allowable
E0218
9
WATER CIRC COLD PAD W PUMP
$0.00
E0220
3
HOT WATER BOTTLE
$6.89
E0221
5
INFRARED HEATING PAD SYSTEM
$0.00
E0225
3
HYDROCOLLATOR UNIT
E0230
3
ICE CAP OR COLLAR
$6.89
E0231
5
WOUND WARMING DEVICE
$0.00
E0232
5
WARMING CARD FOR NWT
$0.00
E0235
3
PARAFFIN BATH UNIT PORTABLE
$155.40
E0236
3
PUMP FOR WATER CIRCULATING P
$358.90
E0237
O
WATER CIRCULATING HEAT/COLD PAD WIT
E0238
3
HEAT PAD NON-ELECTRIC MOIST
E0239
3
HYDROCOLLATOR UNIT PORTABLE
E0240
6
BATH/SHOWER CHAIR
$0.00
E0241
5
BATH TUB WALL RAIL
$0.00
E0242
5
BATH TUB RAIL FLOOR
$0.00
E0243
5
TOILET RAIL
$0.00
E0244
5
TOILET SEAT RAISED
$0.00
E0245
5
TUB STOOL OR BENCH
$0.00
E0246
5
TRANSFER TUB RAIL ATTACHMENT
$0.00
E0247
6
TRANS BENCH W/WO COMM OPEN
$0.00
E0248
6
HDTRANS BENCH W/WO COMM OPEN
$0.00
E0249
3
PAD WATER CIRCULATING HEAT U
$95.29
E0250
3
HOSP BED FIXED HT W/ MATTRES
$880.70
E0251
3
HOSP BED FIXD HT W/O MATTRES
$667.40
E0252
9
HOSPITAL BED, FIXED HEIGHT, WITH MA
E0255
3
HOSPITAL BED VAR HT W/ MATTR
$1,058.30
E0256
3
HOSPITAL BED VAR HT W/O MATT
$706.90
E0260
3
HOSP BED SEMI-ELECTR W/ MATT
$1,512.70
E0261
3
HOSP BED SEMI-ELECTR W/O MAT
$1,233.60
E0265
3
HOSP BED TOTAL ELECTR W/ MAT
$1,800.70
E0266
3
HOSP BED TOTAL ELEC W/O MATT
$1,359.80
E0270
9
HOSPITAL BED INSTITUTIONAL T
E0271
3
MATTRESS INNERSPRING
$212.42
E0272
3
MATTRESS FOAM RUBBER
$186.47
E0273
5
BED BOARD
$316.04
$0.00 $25.87 $430.35
$0.00
$0.00
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
E0274
5
OVER-BED TABLE
$0.00
E0275
3
BED PAN STANDARD
$14.64
E0276
3
BED PAN FRACTURE
$12.73
E0277
3
POWERED PRES-REDU AIR MATTRS
E0280
3
BED CRADLE
E0290
3
HOSP BED FX HT W/O RAILS W/M
$673.30
E0291
3
HOSP BED FX HT W/O RAIL W/O
$489.00
E0292
3
HOSP BED VAR HT W/O RAIL W/O
$701.60
E0293
3
HOSP BED VAR HT W/O RAIL W/
$644.30
E0294
3
HOSP BED SEMI-ELECT W/ MATTR
$1,177.20
E0295
3
HOSP BED SEMI-ELECT W/O MATT
$1,147.10
E0296
3
HOSP BED TOTAL ELECT W/ MATT
$1,479.10
E0297
3
HOSP BED TOTAL ELECT W/O MAT
$1,077.10
E0298
O
HEAVYDUTY/XTRA WIDE HOSP BED
$0.00
E0300
6
ENCLOSED PED CRIB HOSP GRADE
$0.00
E0301
6
HD HOSP BED, 350-600 LBS
$0.00
E0302
6
EX HD HOSP BED > 600 LBS
$0.00
E0303
6
HOSP BED HVY DTY XTRA WIDE
$0.00
E0304
6
HOSP BED XTRA HVY DTY X WIDE
$0.00
E0305
3
RAILS BED SIDE HALF LENGTH
$160.00
E0310
3
RAILS BED SIDE FULL LENGTH
$185.74
E0315
9
BED ACCESSORY BRD/TBL/SUPPRT
$0.00
E0316
5
BED SAFETY ENCLOSURE
$0.00
E0325
3
URINAL MALE JUG-TYPE
$9.67
E0326
3
URINAL FEMALE JUG-TYPE
$9.48
E0328
6
PED HOSPITAL BED, MANUAL
$0.00
E0329
6
PED HOSPITAL BED SEMI/ELECT
$0.00
E0350
9
CONTROL UNIT BOWEL SYSTEM
$0.00
E0352
9
DISPOSABLE PACK W/BOWEL SYST
$0.00
E0370
9
AIR ELEVATOR FOR HEEL
$0.00
E0371
5
NONPOWER MATTRESS OVERLAY
$0.00
E0372
3
POWERED AIR MATTRESS OVERLAY
$0.00
E0373
5
NONPOWERED PRESSURE MATTRESS
$0.00
E0400
O
OXYGEN CONTENTS, GASEOUS, PER CUBIC
$0.00
E0405
O
OXYGEN CONTENTS, GASEOUS, PER 100 C
$0.00
$1.00 $35.40
Procedure Code Pricing Action Code Description
Maximum Allowable
E0410
O
OXYGEN CONTENTS, LIQUID, PER POUND
$0.00
E0415
O
OXYGEN CONTENTS, LIQUID, PER 100 PO
$0.00
E0416
O
OXYGEN REFILL FOR PORTABLE GASEOUS
$0.00
E0424
3
STATIONARY COMPRESSED GAS 02
$1.00
E0425
5
GAS SYSTEM STATIONARY COMPRE
$0.00
E0430
5
OXYGEN SYSTEM GAS PORTABLE
$0.00
E0431
3
PORTABLE GASEOUS 02
$0.00
E0434
3
PORTABLE LIQUID 02
$1.00
E0435
5
OXYGEN SYSTEM LIQUID PORTABL
$0.00
E0439
3
STATIONARY LIQUID 02
$1.00
E0440
5
OXYGEN SYSTEM LIQUID STATION
$0.00
E0441
3
OXYGEN CONTENTS, GASEOUS
$148.00
E0442
3
OXYGEN CONTENTS, LIQUID
$148.00
E0443
3
PORTABLE 02 CONTENTS, GAS
$18.31
E0444
3
PORTABLE 02 CONTENTS, LIQUID
$18.31
E0445
3
OXIMETER NON-INVASIVE
$1.00
E0450
3
VOL CONTROL VENT INVASIV INT
$1.00
E0451
O
VOLUME VENTILATOR; PORTABLE (INCLUD
$0.00
E0452
O
INTERMIT ASSIS DEVICE W CPAP
$0.00
E0453
9
VENTILATOR 12 HRS/LESS PER D
$0.00
E0454
O
PRESSURE VENTILATOR
$0.00
E0455
O
OXYGEN TENT EXCL CROUP/PED T
$0.00
E0457
3
CHEST SHELL
$0.00
E0458
9
NEGATIVE PRESSURE PUMP
$0.00
E0459
3
CHEST WRAP
E0460
O
NEG PRESS VENT PORTABL/STATN
$0.00
E0461
5
VOL CONTROL VENT NONINV INT
$0.00
E0462
3
ROCKING BED W/ OR W/O SIDE R
$2,625.00
E0463
6
PRESS SUPP VENT INVASIVE INT
$0.00
E0464
6
PRESS SUPP VENT NONINV INT
$0.00
E0470
3
RAD W/O BACKUP NON-INV INTFC
$0.00
E0471
3
RAD W/BACKUP NON INV INTRFC
$0.00
E0472
6
RAD W BACKUP INVASIVE INTRFC
$0.00
E0480
3
PERCUSSOR ELECT/PNEUM HOME M
E0481
5
INTRPULMNRY PERCUSS VENT SYS
$458.40
$395.80 $0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
E0482
5
COUGH STIMULATING DEVICE
$0.00
E0483
5
CHEST COMPRESSION GEN SYSTEM
$0.00
E0484
3
NON-ELEC OSCILLATORY PEP DVC
$36.92
E0485
6
ORAL DEVICE/APPLIANCE PREFAB
$0.00
E0486
6
ORAL DEVICE/APPLIANCE CUSFAB
$0.00
E0487
6
ELECTRONIC SPIROMETER
$0.00
E0500
3
IPPB ALL TYPES
$0.00
E0505
9
IPPB MACHINES WITH MANUAL VALVES EL
$0.00
E0510
9
IPPB MACHINES WITH AUTOMATIC VALVES
$0.00
E0515
9
IPPB MACHINES WITH AUTOMATIC VALVES
$0.00
E0550
3
HUMIDIF EXTENS SUPPLE W IPPB
$451.60
E0555
9
HUMIDIFIER FOR USE W/ REGULA
$0.00
E0560
3
HUMIDIFIER SUPPLEMENTAL W/ I
$164.09
E0561
3
HUMIDIFIER NONHEATED W PAP
$107.00
E0562
3
HUMIDIFIER HEATED USED W PAP
$301.22
E0565
3
COMPRESSOR AIR POWER SOURCE
$467.20
E0570
3
NEBULIZER WITH COMPRESSION
$177.80
E0571
5
AEROSOL COMPRESSOR FOR SVNEB
$0.00
E0572
5
AEROSOL COMPRESSOR ADJUST PR
$0.00
E0574
5
ULTRASONIC GENERATOR W SVNEB
$0.00
E0575
3
NEBULIZER ULTRASONIC
E0580
9
NEBULIZER FOR USE W/ REGULAT
E0585
3
NEBULIZER W/ COMPRESSOR & HE
E0590
O
DISPENSING FEE DME NEB DRUG
$0.00
E0600
3
SUCTION PUMP PORTAB HOM MODL
$1.00
E0601
3
CONT AIRWAY PRESSURE DEVICE
$0.00
E0602
9
MANUAL BREAST PUMP
$0.00
E0603
3
ELECTRIC BREAST PUMP
E0604
5
HOSP GRADE ELEC BREAST PUMP
E0605
3
VAPORIZER ROOM TYPE
E0606
3
DRAINAGE BOARD POSTURAL
E0607
9
BLOOD GLUCOSE MONITOR HOME
$0.00
E0608
O
APNEA MONITOR
$0.00
E0609
O
BLOOD GLUC MON W/SPECIAL FEA
$0.00
E0610
3
PACEMAKER MONITR AUDIBLE/VIS
$227.56
$530.00 $0.00 $315.90
$742.80 $0.00 $25.29 $175.60
Procedure Code Pricing Action Code Description
Maximum Allowable
E0615
3
PACEMAKER MONITR DIGITAL/VIS
$403.28
E0616
9
CARDIAC EVENT RECORDER
$0.00
E0617
5
AUTOMATIC EXT DEFIBRILLATOR
$0.00
E0618
3
APNEA MONITOR
E0619
3
APNEA MONITOR W RECORDER
$1.00
E0620
9
CAP BLD SKIN PIERCING LASER
$0.00
E0621
3
PATIENT LIFT SLING OR SEAT
E0625
5
PATIENT LIFT BATHROOM OR TOI
E0627
3
SEAT LIFT INCORP LIFT-CHAIR
$316.39
E0628
3
SEAT LIFT FOR PT FURN-ELECTR
$316.39
E0629
3
SEAT LIFT FOR PT FURN-NON-EL
$316.39
E0630
3
PATIENT LIFT HYDRAULIC
$917.70
E0635
3
PATIENT LIFT ELECTRIC
$936.90
E0636
5
PT SUPPORT & POSITIONING SYS
$0.00
E0637
6
COMBINATION SIT TO STAND SYS
$0.00
E0638
6
STANDING FRAME SYS
$0.00
E0639
6
MOVEABLE PATIENT LIFT SYSTEM
$0.00
E0640
6
FIXED PATIENT LIFT SYSTEM
$0.00
E0641
6
MULTI-POSITION STND FRAM SYS
$0.00
E0642
6
DYNAMIC STANDING FRAME
$0.00
E0650
3
PNEUMA COMPRESOR NON-SEGMENT
$689.02
E0651
3
PNEUM COMPRESSOR SEGMENTAL
$878.65
E0652
3
PNEUM COMPRES W/CAL PRESSURE
E0655
3
PNEUMATIC APPLIANCE HALF ARM
E0656
6
SEGMENTAL PNEUMATIC TRUNK
$0.00
E0657
6
SEGMENTAL PNEUMATIC CHEST
$0.00
E0660
3
PNEUMATIC APPLIANCE FULL LEG
$139.07
E0665
3
PNEUMATIC APPLIANCE FULL ARM
$111.40
E0666
3
PNEUMATIC APPLIANCE HALF LEG
$112.29
E0667
3
SEG PNEUMATIC APPL FULL LEG
$309.75
E0668
3
SEG PNEUMATIC APPL FULL ARM
$359.33
E0669
3
SEG PNEUMATIC APPLI HALF LEG
$166.53
E0670
O
SEGMENTAL PNEUMATIC APPLIANCE FOR U
$0.00
E0671
9
PRESSURE PNEUM APPL FULL LEG
$0.00
E0672
9
PRESSURE PNEUM APPL FULL ARM
$0.00
$3,000.00
$91.83 $0.00
$5,012.71 $87.76
Procedure Code Pricing Action Code Description
Maximum Allowable
E0673
9
PRESSURE PNEUM APPL HALF LEG
$0.00
E0675
6
PNEUMATIC COMPRESSION DEVICE
$0.00
E0676
6
INTER LIMB COMPRESS DEV NOS
$0.00
E0690
O
ULTRAVIOLET CABINET
$0.00
E0691
5
UVL PNL 2 SQ FT OR LESS
$0.00
E0692
5
UVL SYS PANEL 4 FT
$0.00
E0693
5
UVL SYS PANEL 6 FT
$0.00
E0694
5
UVL MD CABINET SYS 6 FT
$0.00
E0700
5
SAFETY EQUIPMENT
$0.00
E0701
O
HELMET W FACE GUARD PREFAB
$0.00
E0705
6
TRANSFER DEVICE
$0.00
E0710
5
RESTRAINTS ANY TYPE
$0.00
E0720
3
TENS TWO LEAD
$314.34
E0730
3
TENS FOUR LEAD
$354.51
E0731
3
CONDUCTIVE GARMENT FOR TENS/
$341.24
E0740
9
INCONTINENCE TREATMENT SYSTM
$0.00
E0744
3
NEUROMUSCULAR STIM FOR SCOLI
$824.90
E0745
3
NEUROMUSCULAR STIM FOR SHOCK
$806.30
E0746
O
ELECTROMYOGRAPH BIOFEEDBACK
$0.00
E0747
3
ELEC OSTEOGEN STIM NOT SPINE
$3,774.74
E0748
3
ELEC OSTEOGEN STIM SPINAL
$3,890.70
E0749
O
ELEC OSTEOGEN STIM IMPLANTED
$0.00
E0750
O
IMPLANTABLE ELECTRICAL NERVE STIMUL
$0.00
E0751
9
PULSE GENERATOR OR RECEIVER
$0.00
E0752
O
NEUROSTIMULATOR ELECTRODE
$0.00
E0753
9
NEUROSTIMULATOR ELECTRODES
$0.00
E0754
O
PULSEGENERATOR PT PROGRAMMER
$0.00
E0755
5
ELECTRONIC SALIVARY REFLEX S
$0.00
E0756
O
IMPLANTABLE PULSE GENERATOR
$0.00
E0757
O
IMPLANTABLE RF RECEIVER
$0.00
E0758
O
EXTERNAL RF TRANSMITTER
$0.00
E0759
O
REPLACE RDFRQUNCY TRANSMITTR
$0.00
E0760
9
OSTEOGEN ULTRASOUND STIMLTOR
$0.00
E0761
5
NONTHERM ELECTROMGNTC DEVICE
$0.00
E0762
6
TRANS ELEC JT STIM DEV SYS
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
E0764
6
FUNCTIONAL NEUROMUSCULARSTIM
$0.00
E0765
5
NERVE STIMULATOR FOR TX N&V
$0.00
E0769
6
ELECTRIC WOUND TREATMENT DEV
$0.00
E0770
6
FUNCTIONAL ELECTRIC STIM NOS
$0.00
E0776
3
IV POLE
E0779
3
AMB INFUSION PUMP MECHANICAL
$15.67
E0780
3
MECH AMB INFUSION PUMP <8HRS
$9.92
E0781
3
EXTERNAL AMBULATORY INFUS PU
$2,484.00
E0782
O
NON-PROGRAMBLE INFUSION PUMP
$0.00
E0783
9
PROGRAMMABLE INFUSION PUMP
$0.00
E0784
5
EXT AMB INFUSN PUMP INSULIN
$0.00
E0785
9
REPLACEMENT IMPL PUMP CATHET
$0.00
E0786
9
IMPLANTABLE PUMP REPLACEMENT
$0.00
E0791
3
PARENTERAL INFUSION PUMP STA
E0830
5
AMBULATORY TRACTION DEVICE
E0840
3
TRACT FRAME ATTACH HEADBOARD
E0849
6
CERVICAL PNEUM TRAC EQUIP
E0850
3
TRACTION STAND FREE STANDING
$85.43
E0855
3
CERVICAL TRACTION EQUIPMENT
$480.86
E0856
6
CERVIC COLLAR W AIR BLADDER
E0860
3
TRACT EQUIP CERVICAL TRACT
E0870
3
TRACT FRAME ATTACH FOOTBOARD
$100.51
E0880
3
TRAC STAND FREE STAND EXTREM
$102.09
E0890
3
TRACTION FRAME ATTACH PELVIC
$97.91
E0900
3
TRAC STAND FREE STAND PELVIC
$104.19
E0910
3
TRAPEZE BAR ATTACHED TO BED
$180.20
E0911
6
HD TRAPEZE BAR ATTACH TO BED
$0.00
E0912
6
HD TRAPEZE BAR FREE STANDING
$0.00
E0920
3
FRACTURE FRAME ATTACHED TO B
$415.70
E0930
3
FRACTURE FRAME FREE STANDING
$372.00
E0935
5
CONT PAS MOTION EXERCISE DEV
$0.00
E0936
6
CPM DEVICE, OTHER THAN KNEE
$0.00
E0940
3
TRAPEZE BAR FREE STANDING
$313.20
E0941
3
GRAVITY ASSISTED TRACTION DE
$363.00
E0942
3
CERVICAL HEAD HARNESS/HALTER
$136.96
$2,421.20 $0.00 $59.59 $0.00
$0.00 $36.86
$18.99
Procedure Code Pricing Action Code Description
Maximum Allowable
E0943
O
CERVICAL PILLOW
$0.00
E0944
3
PELVIC BELT/HARNESS/BOOT
$43.89
E0945
3
BELT/HARNESS EXTREMITY
$42.41
E0946
3
FRACTURE FRAME DUAL W CROSS
$532.90
E0947
3
FRACTURE FRAME ATTACHMNTS PE
$580.20
E0948
3
FRACTURE FRAME ATTACHMNTS CE
$561.19
E0950
3
TRAY
$99.45
E0951
3
LOOP HEEL
$18.02
E0952
3
TOE LOOP/HOLDER, EACH
$18.02
E0953
O
PNEUMATIC TIRE
$0.00
E0954
O
WHEELCHAIR SEMI-PNEUMATIC CA
$0.00
E0955
6
CUSHIONED HEADREST
$0.00
E0956
6
W/C LATERAL TRUNK/HIP SUPPOR
$0.00
E0957
6
W/C MEDIAL THIGH SUPPORT
$0.00
E0958
3
WHLCHR ATT- CONV 1 ARM DRIVE
E0959
3
AMPUTEE ADAPTER
E0960
6
W/C SHOULDER HARNESS/STRAPS
E0961
3
WHEELCHAIR BRAKE EXTENSION
E0962
O
WHEELCHAIR 1 INCH CUSHION
$0.00
E0963
O
WHEELCHAIR 2 INCH CUSHION
$0.00
E0964
O
WHEELCHAIR 3 INCH CUSHION
$0.00
E0965
O
WHEELCHAIR 4 INCH CUSHION
$0.00
E0966
3
WHEELCHAIR HEAD REST EXTENSI
$61.94
E0967
3
MANUAL WC HAND RIM W PROJECT
$126.41
E0968
3
WHEELCHAIR COMMODE SEAT
$161.60
E0969
3
WHEELCHAIR NARROWING DEVICE
$139.86
E0970
3
WHEELCHAIR NO. 2 FOOTPLATES
$46.08
E0971
3
WHEELCHAIR ANTI-TIPPING DEVI
$62.90
E0972
O
TRANSFER BOARD OR DEVICE
E0973
3
W/CH ACCESS DET ADJ ARMREST
E0974
3
W/CH ACCESS ANTI-ROLLBACK
E0975
O
WHEELCHAIR REINFORCED SEAT U
$0.00
E0976
O
WHEELCHAIR REINFORCED BACK U
$0.00
E0977
O
WHEELCHAIR WEDGE CUSHION
$0.00
E0978
3
W/C ACC,SAF BELT PELV STRAP
$42.81
$393.10 $84.59 $0.00 $27.82
$0.00 $109.99 $75.59
Procedure Code Pricing Action Code Description
Maximum Allowable
E0979
O
WHEELCHAIR BELT WITH VELCRO
$0.00
E0980
3
WHEELCHAIR SAFETY VEST
E0981
6
SEAT UPHOLSTERY, REPLACEMENT
$0.00
E0982
6
BACK UPHOLSTERY, REPLACEMENT
$0.00
E0983
6
ADD PWR JOYSTICK
$0.00
E0984
6
ADD PWR TILLER
$0.00
E0985
6
W/C SEAT LIFT MECHANISM
$0.00
E0986
6
MAN W/C PUSH-RIM POW ASSIST
$0.00
E0990
3
WHELLCHAIR ELEVATING LEG RES
E0991
O
WHEELCHAIR UPHOLSTRY SEAT
E0992
3
WHEELCHAIR SOLID SEAT INSERT
$88.48
E0993
O
WHEELCHAIR BACK UPHOLSTERY
$0.00
E0994
3
WHEELCHAIR ARM REST
$15.18
E0995
3
WHEELCHAIR CALF REST
$25.29
E0996
O
WHEELCHAIR TIRE SOLID
$0.00
E0997
O
WHEELCHAIR CASTER W/ A FORK
$0.00
E0998
O
WHEELCHAIR CASTER W/O A FORK
$0.00
E0999
O
WHEELCHR PNEUMATIC TIRE W/WH
$0.00
E1000
O
WHEELCHAIR TIRE PNEUMATIC CA
$0.00
E1001
O
WHEELCHAIR WHEEL
$0.00
E1002
6
PWR SEAT TILT
$0.00
E1003
6
PWR SEAT RECLINE
$0.00
E1004
6
PWR SEAT RECLINE MECH
$0.00
E1005
6
WHEELCHAIR ACCESSORY, POWER SEAT
$0.00
E1006
6
PWR SEAT COMBO W/O SHEAR
$0.00
E1007
3
PWR SEAT COMBO W/SHEAR
$8,741.27
E1008
3
PWR SEAT COMBO PWR SHEAR
$8,742.05
E1009
6
ADD MECH LEG ELEVATION
$0.00
E1010
6
ADD PWR LEG ELEVATION
$0.00
E1011
5
PED WC MODIFY WIDTH ADJUSTM
$0.00
E1012
O
INT SEAT SYS PLANAR PED W/C
$0.00
E1013
O
INT SEAT SYS CONTOUR PED W/C
$0.00
E1014
5
RECLINING BACK ADD PED W/C
$0.00
E1015
5
SHOCK ABSORBER FOR MAN W/C
$0.00
E1016
5
SHOCK ABSORBER FOR POWER W/C
$0.00
$31.62
$112.35 $0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
E1017
5
HD SHCK ABSRBR FOR HD MAN WC
$0.00
E1018
5
HD SHCK ABSRBER FOR HD POWWC
$0.00
E1020
5
RESIDUAL LIMB SUPPORT SYSTEM
$0.00
E1025
O
PEDWC LAT/THOR SUP NOCONTOUR
$0.00
E1026
O
PEDWC CONTOURED LAT/THOR SUP
$0.00
E1027
O
PED WC LAT/ANT SUPPORT
$0.00
E1028
3
W/C MANUAL SWINGAWAY
E1029
6
W/C VENT TRAY FIXED
$0.00
E1030
6
W/C VENT TRAY GIMBALED
$0.00
E1031
3
ROLLABOUT CHAIR WITH CASTERS
E1035
5
PATIENT TRANSFER SYSTEM
$0.00
E1037
5
TRANSPORT CHAIR, PED SIZE
$0.00
E1038
5
TRANSPORT CHAIR PT WT<=300LB
$0.00
E1039
6
TRANSPORT CHAIR PT WT >300LB
$0.00
E1050
3
WHELCHR FXD FULL LENGTH ARMS
E1060
3
WHEELCHAIR DETACHABLE ARMS
E1065
O
WHEELCHAIR POWER ATTACHMENT
$0.00
E1066
O
WHEELCHAIR BATTERY CHARGER
$0.00
E1069
O
WHEELCHAIR DEEP CYCLE BATTER
$0.00
E1070
3
WHEELCHAIR DETACHABLE FOOT R
$838.60
E1083
3
HEMI-WHEELCHAIR FIXED ARMS
$709.40
E1084
3
HEMI-WHEELCHAIR DETACHABLE A
$883.70
E1085
3
HEMI-WHEELCHAIR FIXED ARMS
$623.40
E1086
3
HEMI-WHEELCHAIR DETACHABLE A
$757.10
E1087
3
WHEELCHAIR LIGHTWT FIXED ARM
$1,139.60
E1088
3
WHEELCHAIR LIGHTWEIGHT DET A
$1,358.29
E1089
3
WHEELCHAIR LIGHTWT FIXED ARM
$1,082.80
E1090
3
WHEELCHAIR LIGHTWEIGHT DET A
$1,042.60
E1091
3
WHEELCHAIR YOUTH
E1092
3
WHEELCHAIR WIDE W/ LEG RESTS
$1,157.70
E1093
3
WHEELCHAIR WIDE W/ FOOT REST
$995.60
E1100
3
WHCHR S-RECL FXD ARM LEG RES
$935.10
E1110
3
WHEELCHAIR SEMI-RECL DETACH
$778.30
E1130
3
WHLCHR STAND FXD ARM FT REST
$420.70
E1140
3
WHEELCHAIR STANDARD DETACH A
$647.00
$206.54
$455.00
$917.40 $1,135.60
$751.00
Procedure Code Pricing Action Code Description
Maximum Allowable
E1150
3
WHEELCHAIR STANDARD W/ LEG R
$735.00
E1160
3
WHEELCHAIR FIXED ARMS
$563.00
E1161
5
MANUAL ADULT WC W TILTINSPAC
E1170
3
WHLCHR AMPU FXD ARM LEG REST
$804.60
E1171
3
WHEELCHAIR AMPUTEE W/O LEG R
$643.40
E1172
3
WHEELCHAIR AMPUTEE DETACH AR
$827.40
E1180
3
WHEELCHAIR AMPUTEE W/ FOOT R
$776.00
E1190
3
WHEELCHAIR AMPUTEE W/ LEG RE
$1,054.70
E1195
3
WHEELCHAIR AMPUTEE HEAVY DUT
$961.90
E1200
3
WHEELCHAIR AMPUTEE FIXED ARM
$689.20
E1210
O
WHLCHR MOTO FUL ARM LEG REST
$0.00
E1211
O
WHEELCHAIR MOTORIZED W/ DET
$0.00
E1212
O
WHEELCHAIR MOTORIZED W FULL
$0.00
E1213
O
WHEELCHAIR MOTORIZED W/ DET
$0.00
E1220
5
WHLCHR SPECIAL SIZE/CONSTRC
$0.00
E1221
3
WHEELCHAIR SPEC SIZE W FOOT
$428.10
E1222
3
WHEELCHAIR SPEC SIZE W/ LEG
$610.70
E1223
3
WHEELCHAIR SPEC SIZE W FOOT
$666.80
E1224
3
WHEELCHAIR SPEC SIZE W/ LEG
$731.10
E1225
3
MANUAL SEMI-RECLINING BACK
$407.20
E1226
3
MANUAL FULLY RECLINING BACK
$522.01
E1227
3
WHEELCHAIR SPEC SZ SPEC HT A
$265.23
E1228
3
WHEELCHAIR SPEC SZ SPEC HT B
$214.50
E1229
6
PEDIATRIC WHEELCHAIR NOS
E1230
3
POWER OPERATED VEHICLE
E1231
5
RIGID PED W/C TILT-IN-SPACE
$0.00
E1232
5
FOLDING PED WC TILT-IN-SPACE
$0.00
E1233
5
RIG PED WC TLTNSPC W/O SEAT
$0.00
E1234
5
FLD PED WC TLTNSPC W/O SEAT
$0.00
E1235
5
RIGID PED WC ADJUSTABLE
$0.00
E1236
5
FOLDING PED WC ADJUSTABLE
$0.00
E1237
5
RGD PED WC ADJSTABL W/O SEAT
$0.00
E1238
5
FLD PED WC ADJSTABL W/O SEAT
$0.00
E1239
6
PED POWER WHEELCHAIR NOS
$0.00
E1240
3
WHCHR LITWT DET ARM LEG REST
$0.00
$0.00 $1,946.92
$928.10
Procedure Code Pricing Action Code Description
Maximum Allowable
E1250
3
WHEELCHAIR LIGHTWT FIXED ARM
$684.70
E1260
3
WHEELCHAIR LIGHTWT FOOT REST
$713.70
E1270
3
WHEELCHAIR LIGHTWEIGHT LEG R
$604.40
E1280
3
WHCHR H-DUTY DET ARM LEG RES
$1,005.00
E1285
3
WHEELCHAIR HEAVY DUTY FIXED
$923.50
E1290
3
WHEELCHAIR HVY DUTY DETACH A
$958.20
E1295
3
WHEELCHAIR HEAVY DUTY FIXED
$1,046.20
E1296
3
WHEELCHAIR SPECIAL SEAT HEIG
$399.82
E1297
3
WHEELCHAIR SPECIAL SEAT DEPT
$85.07
E1298
3
WHEELCHAIR SPEC SEAT DEPTH/W
$365.36
E1300
5
WHIRLPOOL PORTABLE
E1310
3
WHIRLPOOL NON-PORTABLE
E1340
3
REPAIR FOR DME, PER 15 MIN
E1350
O
REPAIR OR NON-ROUTINE SERVICE (E.G.
$0.00
E1353
5
OXYGEN SUPPLIES REGULATOR
$0.00
E1354
6
WHEELED CART, PORT CYL/CONC
$0.00
E1355
3
OXYGEN SUPPLIES STAND/RACK
$46.67
E1356
O
BREATHING CIRCUITS
$0.00
E1357
6
BATTERY CHARGER, PORT CONC
$0.00
E1358
6
DC POWER ADAPTER, PORT CONC
$0.00
E1372
3
OXY SUPPL HEATER FOR NEBULIZ
$155.98
E1375
O
OXYGEN SUPPL NEBULIZER PORTA
$0.00
E1377
O
OXYGEN CONCENTRATOR TO 244 C
$0.00
E1378
O
OXYGEN CONCENTRATOR TO 488 C
$0.00
E1379
O
OXYGEN CONCENTRATOR TO 732 C
$0.00
E1380
O
OXYGEN CONCENTRATOR TO 976 C
$0.00
E1381
O
OXYGEN CONCENTRAT TO 1220 CU
$0.00
E1382
O
OXYGEN CONCENTRAT TO 1464 CU
$0.00
E1383
O
OXYGEN CONCENTRAT TO 1708 CU
$0.00
E1384
O
OXYGEN CONCENTRAT TO 1952 CU
$0.00
E1385
O
OXYGEN CONCENTRATOR > 1952 C
$0.00
E1388
O
OXYGEN CONCENTRATOR, EQUIVALENT TO
$0.00
E1389
O
OXYGEN CONCENTRATOR, EQUIVALENT TO
$0.00
E1390
3
OXYGEN CONCENTRATOR
$0.00
E1391
6
OXYGEN CONCENTRATOR
$0.00
$0.00 $2,054.39 $25.00
Procedure Code Pricing Action Code Description
Maximum Allowable
E1392
6
PORTABLE OXYGEN CONCENTRATOR
$0.00
E1393
O
OXYGEN CONCENTRATOR, EQUIVALENT TO
$0.00
E1394
O
OXYGEN CONCENTRATOR, EQUIVALENT TO
$0.00
E1395
O
OXYGEN CONCENTRATOR, EQUIVALENT TO
$0.00
E1396
O
OXYGEN CONCENTRATOR, EQUIVALENT TO
$0.00
E1399
3
DURABLE MEDICAL EQUIPMENT MI
$325.00
E1400
9
OXYGEN CONCENTRATOR < 2 LITE
$0.00
E1401
O
OXYGEN CONCENTRATOR 2-3 LITE
$0.00
E1402
O
OXYGEN CONCENTRATOR 3-4 LITE
$0.00
E1403
O
OXYGEN CONCENTRATOR 4-5 LITE
$0.00
E1404
9
OXYGEN CONCENTRATOR > 5 LITE
$0.00
E1405
5
O2/WATER VAPOR ENRICH W/HEAT
$0.00
E1406
5
O2/WATER VAPOR ENRICH W/O HE
$0.00
E1500
9
CENTRIFUGE
$0.00
E1510
5
KIDNEY DIALYSATE DELIVRY SYS
$0.00
E1520
5
HEPARIN INFUSION PUMP
$0.00
E1530
5
REPLACEMENT AIR BUBBLE DETEC
$0.00
E1540
5
REPLACEMENT PRESSURE ALARM
$0.00
E1550
5
BATH CONDUCTIVITY METER
$0.00
E1560
5
REPLACE BLOOD LEAK DETECTOR
$0.00
E1570
5
ADJUSTABLE CHAIR FOR ESRD PT
$0.00
E1575
5
TRANSDUCER PROTECT/FLD BAR
$0.00
E1580
5
UNIPUNCTURE CONTROL SYSTEM
$0.00
E1590
5
HEMODIALYSIS MACHINE
$0.00
E1592
5
AUTO INTERM PERITONEAL DIALY
$0.00
E1594
5
CYCLER DIALYSIS MACHINE
$0.00
E1600
5
DELI/INSTALL CHRG HEMO EQUIP
$0.00
E1610
5
REVERSE OSMOSIS H2O PURI SYS
$0.00
E1615
5
DEIONIZER H2O PURI SYSTEM
$0.00
E1620
5
REPLACEMENT BLOOD PUMP
$0.00
E1625
5
WATER SOFTENING SYSTEM
$0.00
E1630
5
RECIPROCATING PERITONEAL DIA
$0.00
E1632
5
WEARABLE ARTIFICIAL KIDNEY
$0.00
E1634
6
PERITONEAL DIALYSIS CLAMP
$0.00
E1635
5
COMPACT TRAVEL HEMODIALYZER
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
E1636
5
SORBENT CARTRIDGES PER 10
$0.00
E1637
9
HEMOSTATS FOR DIALYSIS, EACH
$0.00
E1638
9
PERI DIALYSIS HEATING PAD
$0.00
E1639
9
DIALYSIS SCALE
$0.00
E1640
O
REPLACEMENT COMPONENTS FOR D
$0.00
E1699
5
DIALYSIS EQUIPMENT NOC
$0.00
E1700
O
JAW MOTION REHAB SYSTEM
$0.00
E1701
O
REPL CUSHIONS FOR JAW MOTION
$0.00
E1702
O
REPL MEASR SCALES JAW MOTION
$0.00
E1800
9
ADJUST ELBOW EXT/FLEX DEVICE
$0.00
E1801
9
SPS ELBOW DEVICE
$0.00
E1802
5
ADJST FOREARM PRO/SUP DEVICE
$0.00
E1805
9
ADJUST WRIST EXT/FLEX DEVICE
$0.00
E1806
9
SPS WRIST DEVICE
$0.00
E1810
9
ADJUST KNEE EXT/FLEX DEVICE
$0.00
E1811
9
SPS KNEE DEVICE
$0.00
E1812
6
KNEE EXT/FLEX W ACT RES CTRL
$0.00
E1815
9
ADJUST ANKLE EXT/FLEX DEVICE
$0.00
E1816
9
SPS ANKLE DEVICE
$0.00
E1818
9
SPS FOREARM DEVICE
$0.00
E1820
9
SOFT INTERFACE MATERIAL
$0.00
E1821
9
REPLACEMENT INTERFACE SPSD
$0.00
E1825
9
ADJUST FINGER EXT/FLEX DEVC
$0.00
E1830
9
ADJUST TOE EXT/FLEX DEVICE
$0.00
E1840
9
ADJ SHOULDER EXT/FLEX DEVICE
$0.00
E1841
6
STATIC STR SHLDR DEV ROM ADJ
$0.00
E1900
O
SPEECH COMMUNICATION DEVICE
$0.00
E1902
5
AAC NON-ELECTRONIC BOARD
$0.00
E2000
3
GASTRIC SUCTION PUMP HME MDL
$1.00
E2100
5
BLD GLUCOSE MONITOR W VOICE
$0.00
E2101
5
BLD GLUCOSE MONITOR W LANCE
$0.00
E2120
6
PULSE GEN SYS TX ENDOLYMP FL
$0.00
E2201
6
MAN W/CH ACC SEAT W>=20"<24"
$0.00
E2202
6
SEAT WIDTH 24-27 IN
$0.00
E2203
6
FRAME DEPTH LESS THAN 22 IN
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
E2204
6
FRAME DEPTH 22 TO 25 IN
$0.00
E2205
6
MANUAL WC ACCESSORY, HANDRIM
$0.00
E2206
3
COMPLETE WHEEL LOCK ASSEMBLY
$40.68
E2207
6
CRUTCH AND CANE HOLDER
$0.00
E2208
6
CYLINDER TANK CARRIER
$0.00
E2209
6
ARM TROUGH EACH
$0.00
E2210
6
WHEELCHAIR BEARINGS
$0.00
E2211
6
PNEUMATIC PROPULSION TIRE
$0.00
E2212
6
PNEUMATIC PROP TIRE TUBE
$0.00
E2213
6
PNEUMATIC PROP TIRE INSERT
$0.00
E2214
6
PNEUMATIC CASTER TIRE EACH
$0.00
E2215
6
PNEUMATIC CASTER TIRE TUBE
$0.00
E2216
6
FOAM FILLED PROPULSION TIRE
$0.00
E2217
6
FOAM FILLED CASTER TIRE EACH
$0.00
E2218
6
FOAM PROPULSION TIRE EACH
$0.00
E2219
6
FOAM CASTER TIRE ANY SIZE EA
$0.00
E2220
6
SOLID PROPULSION TIRE EACH
$0.00
E2221
6
SOLID CASTER TIRE EACH
$0.00
E2222
6
SOLID CASTER INTEGRATED WHL
$0.00
E2223
6
VALVE REPLACEMENT ONLY EACH
$0.00
E2224
6
PROPULSION WHL EXCLUDES TIRE
$0.00
E2225
6
CASTER WHEEL EXCLUDES TIRE
$0.00
E2226
6
CASTER FORK REPLACEMENT ONLY
$0.00
E2227
6
GEAR REDUCTION DRIVE WHEEL
$0.00
E2228
6
MWC ACC, WHEELCHAIR BRAKE
$0.00
E2230
6
MANUAL STANDING SYSTEM
$0.00
E2231
6
SOLID SEAT SUPPORT BASE
$0.00
E2291
6
PLANAR BACK FOR PED SIZE WC
$0.00
E2292
6
PLANAR SEAT FOR PED SIZE WC
$0.00
E2293
6
CONTOUR BACK FOR PED SIZE WC
$0.00
E2294
6
CONTOUR SEAT FOR PED SIZE WC
$0.00
E2295
6
PED DYNAMIC SEATING FRAME
$0.00
E2300
6
PWR SEAT ELEVATION SYS
$0.00
E2301
6
PWR STANDING
$0.00
E2310
6
ELECTRO CONNECT BTW CONTROL
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
E2311
3
ELECTRO CONNECT BTW 2 SYS
$2,369.20
E2312
6
MINI-PROP REMOTE JOYSTICK
$0.00
E2313
6
PWC HARNESS, EXPAND CONTROL
$0.00
E2320
O
HAND CHIN CONTROL
$0.00
E2321
6
HAND INTERFACE JOYSTICK
$0.00
E2322
6
MULT MECH SWITCHES
$0.00
E2323
6
SPECIAL JOYSTICK HANDLE
$0.00
E2324
6
CHIN CUP INTERFACE
$0.00
E2325
6
SIP AND PUFF INTERFACE
$0.00
E2326
6
BREATH TUBE KIT
$0.00
E2327
6
HEAD CONTROL INTERFACE MECH
$0.00
E2328
6
HEAD/EXTREMITY CONTROL INTER
$0.00
E2329
6
HEAD CONTROL NONPROPORTIONAL
$0.00
E2330
6
HEAD CONTROL PROXIMITY SWITC
$0.00
E2331
6
ATTENDANT CONTROL
$0.00
E2340
6
W/C WDTH 20-23 IN SEAT FRAME
$0.00
E2341
6
W/C WDTH 24-27 IN SEAT FRAME
$0.00
E2342
6
W/C DPTH 20-21 IN SEAT FRAME
$0.00
E2343
6
W/C DPTH 22-25 IN SEAT FRAME
$0.00
E2351
6
ELECTRONIC SGD INTERFACE
$0.00
E2360
3
22NF NONSEALED LEADACID
$112.34
E2361
3
22NF SEALED LEADACID BATTERY
$139.47
E2362
3
GR24 NONSEALED LEADACID
E2363
3
GR24 SEALED LEADACID BATTERY
$186.00
E2364
3
U1NONSEALED LEADACID BATTERY
$112.34
E2365
3
U1 SEALED LEADACID BATTERY
$112.17
E2366
3
BATTERY CHARGER, SINGLE MODE
$263.62
E2367
3
BATTERY CHARGER, DUAL MODE
$419.07
E2368
6
POWER WC MOTOR REPLACEMENT
$0.00
E2369
6
PWR WC GEAR BOX REPLACEMENT
$0.00
E2370
6
PWR WC MOTOR/GEAR BOX COMBO
$0.00
E2371
6
GR27 SEALED LEADACID BATTERY
$0.00
E2372
6
GR27 NON-SEALED LEADACID
$0.00
E2373
6
HAND/CHIN CTRL SPEC JOYSTICK
$0.00
E2374
6
HAND/CHIN CTRL STD JOYSTICK
$0.00
$91.98
Procedure Code Pricing Action Code Description
Maximum Allowable
E2375
6
NON-EXPANDABLE CONTROLLER
$0.00
E2376
6
EXPANDABLE CONTROLLER, REPL
$0.00
E2377
6
EXPANDABLE CONTROLLER, INITL
$0.00
E2381
6
PNEUM DRIVE WHEEL TIRE
$0.00
E2382
6
TUBE, PNEUM WHEEL DRIVE TIRE
$0.00
E2383
6
INSERT, PNEUM WHEEL DRIVE
$0.00
E2384
6
PNEUMATIC CASTER TIRE
$0.00
E2385
6
TUBE, PNEUMATIC CASTER TIRE
$0.00
E2386
6
FOAM FILLED DRIVE WHEEL TIRE
$0.00
E2387
6
FOAM FILLED CASTER TIRE
$0.00
E2388
6
FOAM DRIVE WHEEL TIRE
$0.00
E2389
6
FOAM CASTER TIRE
$0.00
E2390
6
SOLID DRIVE WHEEL TIRE
$0.00
E2391
6
SOLID CASTER TIRE
$0.00
E2392
6
SOLID CASTER TIRE, INTEGRATE
$0.00
E2393
6
VALVE, PNEUMATIC TIRE TUBE
$0.00
E2394
6
DRIVE WHEEL EXCLUDES TIRE
$0.00
E2395
6
CASTER WHEEL EXCLUDES TIRE
$0.00
E2396
6
CASTER FORK
$0.00
E2397
6
PWC ACC, LITH-BASED BATTERY
$0.00
E2399
6
NOC INTERFACE
$0.00
E2402
6
NEG PRESS WOUND THERAPY PUMP
$0.00
E2500
6
SGD DIGITIZED PRE-REC <=8MIN
$0.00
E2502
6
SGD PREREC MSG >8MIN <=20MIN
$0.00
E2504
6
SGD PREREC MSG>20MIN <=40MIN
$0.00
E2506
6
SGD PREREC MSG > 40 MIN
$0.00
E2508
6
SGD SPELLING PHYS CONTACT
$0.00
E2510
6
SGD W MULTI METHODS MSG/ACCS
$0.00
E2511
6
SGD SFTWRE PRGRM FOR PC/PDA
$0.00
E2512
6
SGD ACCESSORY, MOUNTING SYS
$0.00
E2599
6
SGD ACCESSORY NOC
$0.00
E2601
6
GEN W/C CUSHION WDTH < 22 IN
$0.00
E2602
6
GEN W/C CUSHION WDTH >=22 IN
$0.00
E2603
6
SKIN PROTECT WC CUS WD <22IN
$0.00
E2604
6
SKIN PROTECT WC CUS WD>=22IN
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
E2605
6
POSITION WC CUSH WDTH <22 IN
$0.00
E2606
6
POSITION WC CUSH WDTH>=22 IN
$0.00
E2607
6
SKIN PRO/POS WC CUS WD <22IN
$0.00
E2608
6
SKIN PRO/POS WC CUS WD>=22IN
$0.00
E2609
6
CUSTOM FABRICATE W/C CUSHION
$0.00
E2610
6
POWERED W/C CUSHION
$0.00
E2611
6
GEN USE BACK CUSH WDTH <22IN
$0.00
E2612
6
GEN USE BACK CUSH WDTH>=22IN
$0.00
E2613
6
POSITION BACK CUSH WD <22IN
$0.00
E2614
6
POSITION BACK CUSH WD>=22IN
$0.00
E2615
6
POS BACK POST/LAT WDTH <22IN
$0.00
E2616
6
POS BACK POST/LAT WDTH>=22IN
$0.00
E2617
6
CUSTOM FAB W/C BACK CUSHION
$0.00
E2618
O
WC ACC SOLID SEAT SUPP BASE
$0.00
E2619
6
REPLACE COVER W/C SEAT CUSH
$0.00
E2620
6
WC PLANAR BACK CUSH WD <22IN
$0.00
E2621
6
WC PLANAR BACK CUSH WD>=22IN
$0.00
E4610
9
LANCET DEVICE
$0.00
E8000
6
POSTERIOR GAIT TRAINER
$0.00
E8001
6
UPRIGHT GAIT TRAINER
$0.00
E8002
6
ANTERIOR GAIT TRAINER
$0.00
EDUCW
O
MCO SPECIFIC CODE: SMART START INDI
$0.00
EDURN
O
MCO SPECIFIC CODE: SMART START INDI
$0.00
EDUSW
O
MCO SPECIFIC CODE: SMART START INDI
$0.00
EXRCL
O
MCO SPECIFIC CODE: SMART START PRE
$0.00
FS001
O
MCO SPECIFIC CODE: FULL BABY FIRST
$0.00
FS002
O
MCO SPECIFIC CODE: LATE REFERRAL BA
$0.00
FS003
O
MCO SPECIFIC CODE: PARTIAL BABY FIR
$0.00
FS100
O
MCO SPECIFIC CODE: PREGNANT MOTHER
$0.00
FS104
O
MCO SPECIFIC CODE: SMART START, PRE
$0.00
FS105
O
MCO SPECIFIC CODE: SMART START, PRE
$0.00
FS106
O
MCO SPECIFIC CODE: SMART START, PRE
$0.00
FS107
O
MCO SPECIFIC CODE: SMART START, PRE
$0.00
FS108
O
MCO SPECIFIC CODE: SMART START, PRE
$0.00
FS109
O
MCO SPECIFIC CODE: SMART START, PRE
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
FS110
O
MCO SPECIFIC CODE: RESOURCE MOTHER'
$0.00
FS111
O
MCO SPECIFIC CODE: RESOURCE MOTHER'
$0.00
FS112
O
MCO SPECIFIC CODE: RSEOURCE MOTHER'
$0.00
FS912
O
MCO SPECIFIC CODE: NEOCATE 1+, 100
$0.00
FS913
O
MCO SPECIFIC CODE: NEOCATE 1+, 8 OU
$0.00
G0001
O
DRAWING BLOOD FOR SPECIMEN
$0.00
G0002
9
TEMPORARY URINARY CATHETER
$0.00
G0004
9
ECG TRANSM PHYS REVIEW & INT
$0.00
G0005
9
ECG 24 HOUR RECORDING
$0.00
G0006
9
ECG TRANSMISSION & ANALYSIS
$0.00
G0007
9
ECG PHY REVIEW & INTERPRET
$0.00
G0008
9
ADMIN INFLUENZA VIRUS VAC
$0.00
G0009
9
ADMIN PNEUMOCOCCAL VACCINE
$0.00
G0010
9
ADMIN HEPATITIS B VACCINE
$0.00
G0015
9
POST SYMPTOM ECG TRACING
$0.00
G0016
9
POST SYMPTOM ECG MD REVIEW
$0.00
G0020
O
IMPRESSION AND CUSTOM PREPARATION;
$0.00
G0021
O
IMPRESSION AND CUSTOM PREPARATION;
$0.00
G0025
O
COLLAGEN SKIN TEST KIT
$0.00
G0026
O
FECAL LEUKOCYTE EXAMINATION
$0.00
G0027
9
SEMEN ANALYSIS
$0.00
G0030
O
PET IMAGING PREV PET SINGLE
$0.00
G0031
O
PET IMAGING PREV PET MULTPLE
$0.00
G0032
O
PET FOLLOW SPECT 78464 SINGL
$0.00
G0033
O
PET FOLLOW SPECT 78464 MULT
$0.00
G0034
O
PET FOLLOW SPECT 76865 SINGL
$0.00
G0035
O
PET FOLLOW SPECT 78465 MULT
$0.00
G0036
O
PET FOLLOW CORNRY ANGIO SING
$0.00
G0037
O
PET FOLLOW CORNRY ANGIO MULT
$0.00
G0038
O
PET FOLLOW MYOCARD PERF SING
$0.00
G0039
O
PET FOLLOW MYOCARD PERF MULT
$0.00
G0040
O
PET FOLLOW STRESS ECHO SINGL
$0.00
G0041
O
PET FOLLOW STRESS ECHO MULT
$0.00
G0042
O
PET FOLLOW VENTRICULOGM SING
$0.00
G0043
O
PET FOLLOW VENTRICULOGM MULT
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
G0044
O
PET FOLLOWING REST ECG SINGL
$0.00
G0045
O
PET FOLLOWING REST ECG MULT
$0.00
G0046
O
PET FOLLOW STRESS ECG SINGL
$0.00
G0047
O
PET FOLLOW STRESS ECG MULT
$0.00
G0050
9
RESIDUAL URINE BY ULTRASOUND
$0.00
G0051
9
DESTRUCTION BY ANY METHOD, INCLUDIN
$0.00
G0052
9
DESTRUCTION BY ANY METHOD, INCLUDIN
$0.00
G0053
9
DESTRUCTION BY ANY METHOD, INCLUDIN
$0.00
G0054
O
BLOOD CHOLESTEROL TEST, BY CHOLESTE
$0.00
G0055
O
GLUCOSE POST DOSE (INCLUDES GLUCOSE
$0.00
G0056
O
GLUCOSE TOLERANCE TEST (GTT), BY DI
$0.00
G0057
O
GLUCOSE TOLERANCE TEST (GTT), BY DI
$0.00
G0058
O
AUTOMATED MULTICHANNEL TEST; 20 CLI
$0.00
G0059
O
AUTOMATED MULTICHANNEL TEST; 21 CLI
$0.00
G0060
O
AUTOMATED MULTICHANNEL TEST, 22 CLI
$0.00
G0061
O
LUNG VOLUME REDUCTION SURGERY (REDU
$0.00
G0062
9
PERIPHERAL SKELETAL BONE MINERAL DE
$0.00
G0063
9
CENTRAL SKELETAL BONE MINERAL DENSI
$0.00
G0064
9
PHYSICIAN SUPERVISION OF A PATIENT
$0.00
G0065
9
PHYSICIAN SUPERVISION OF A HOSPICE
$0.00
G0066
9
PHYSICIAN SUPERVISION OF A NURSING
$0.00
G0071
9
INDIVIDUAL PSYCHOTHERAPY, INSIGHT O
$0.00
G0072
9
INDIVIDUAL PSYCHOTHERAPY, INSIGHT O
$0.00
G0073
9
INDIVIDUAL PSYCHOTHERAPY, INSIGHT O
$0.00
G0074
9
INDIVIDUAL PSYCHOTHERAPY, INSIGHT O
$0.00
G0075
9
INDIVIDUAL PSYCHOTHERAPY, INSIGHT O
$0.00
G0076
9
INDIVIDUAL PSYCHOTHERAPY, INSIGHT O
$0.00
G0077
9
INDIVIDUAL PSYCHOTHERAPY, INTERACTI
$0.00
G0078
9
INDIVIDUAL PSYCHOTHERAPY, INTERACTI
$0.00
G0079
9
INDIVIDUAL PSYCHOTHERAPY, INTERACTI
$0.00
G0080
9
INDIVIDUAL PSYCHOTHERAPY, INTERACTI
$0.00
G0081
9
INDIVIDUAL PSYCHOTHERAPY, INTERACTI
$0.00
G0082
9
INDIVIDUAL PSYCHOTHERAPY, INTERACTI
$0.00
G0083
9
INDIVIDUAL PSYCHOTHERAPY, INSIGHT O
$0.00
G0084
9
INDIVIDUAL PSYCHOTHERAPY, INSIGHT O
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
G0085
9
INDIVIDUAL PSYCHOTHERAPY, INSIGHT O
$0.00
G0086
9
INDIVIDUAL PSYCHOTHERAPY, INSIGHT O
$0.00
G0087
9
INDIVIDUAL PSYCHOTHERAPY, INSIGHT O
$0.00
G0088
9
INDIVIDUAL PSYCHOTHERAPY, INSIGHT O
$0.00
G0089
9
INDIVIDUAL PSYCHOTHERAPY, INTERACTI
$0.00
G0090
9
INDIVIDUAL PSYCHOTHERAPY, INTERACTI
$0.00
G0091
9
INDIVIDUAL PSYCHOTHERAPY, INTERACTI
$0.00
G0092
9
INDIVIDUAL PSYCHOTHERAPY, INTERACTI
$0.00
G0093
9
INDIVIDUAL PSYCHOTHERAPY, INTERACTI
$0.00
G0094
9
INDIVIDUAL PSYCHOTHERAPY, INTERACTI
$0.00
G0101
9
CA SCREEN;PELVIC/BREAST EXAM
$0.00
G0102
9
PROSTATE CA SCREENING; DRE
$0.00
G0103
9
PSA, TOTAL SCREENING
$0.00
G0104
9
CA SCREEN;FLEXI SIGMOIDSCOPE
$0.00
G0105
9
COLORECTAL SCRN; HI RISK IND
$0.00
G0106
9
COLON CA SCREEN;BARIUM ENEMA
$0.00
G0107
O
CA SCREEN; FECAL BLOOD TEST
$0.00
G0108
9
DIAB MANAGE TRN PER INDIV
$0.00
G0109
9
DIAB MANAGE TRN IND/GROUP
$0.00
G0110
O
NETT PULM-REHAB EDUC; IND
$0.00
G0111
O
NETT PULM-REHAB EDUC; GROUP
$0.00
G0112
O
NETT;NUTRITION GUID, INITIAL
$0.00
G0113
O
NETT;NUTRITION GUID,SUBSEQNT
$0.00
G0114
O
NETT; PSYCHOSOCIAL CONSULT
$0.00
G0115
O
NETT; PSYCHOLOGICAL TESTING
$0.00
G0116
O
NETT; PSYCHOSOCIAL COUNSEL
$0.00
G0117
9
GLAUCOMA SCRN HGH RISK DIREC
$0.00
G0118
9
GLAUCOMA SCRN HGH RISK DIREC
$0.00
G0120
9
COLON CA SCRN; BARIUM ENEMA
$0.00
G0121
9
COLON CA SCRN NOT HI RSK IND
$0.00
G0122
9
COLON CA SCRN; BARIUM ENEMA
$0.00
G0123
3
SCREEN CERV/VAG THIN LAYER
$28.00
G0124
9
SCREEN C/V THIN LAYER BY MD
$0.00
G0125
O
PET IMAGE PULMONARY NODULE
$0.00
G0126
9
LUNG IMAGE (PET) STAGING
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
G0127
9
TRIM NAIL(S)
$0.00
G0128
9
CORF SKILLED NURSING SERVICE
$0.00
G0129
9
PARTIAL HOSP PROG SERVICE
$0.00
G0130
9
SINGLE ENERGY X-RAY STUDY
$0.00
G0131
9
CT SCAN, BONE DENSITY STUDY
$0.00
G0132
9
CT SCAN, BONE DENSITY STUDY
$0.00
G0141
9
SCR C/V CYTO,AUTOSYS AND MD
$0.00
G0143
9
SCR C/V CYTO,THINLAYER,RESCR
$0.00
G0144
9
SCR C/V CYTO,THINLAYER,RESCR
$0.00
G0145
9
SCR C/V CYTO,THINLAYER,RESCR
$0.00
G0147
9
SCR C/V CYTO, AUTOMATED SYS
$0.00
G0148
9
SCR C/V CYTO, AUTOSYS, RESCR
$0.00
G0151
7
HHCP-SERV OF PT,EA 15 MIN
$0.00
G0152
7
HHCP-SERV OF OT,EA 15 MIN
$0.00
G0153
7
HHCP-SVS OF S/L PATH,EA 15MN
$0.00
G0154
7
HHCP-SVS OF RN,EA 15 MIN
$0.00
G0155
9
HHCP-SVS OF CSW,EA 15 MIN
$0.00
G0156
7
HHCP-SVS OF AIDE,EA 15 MIN
$0.00
G0159
9
PERC DECLOT DIALYSIS GRAFT
$0.00
G0160
9
CRYO. ABLATION, PROSTATE
$0.00
G0161
9
ECHO GUIDE FOR CRYO PROBES
$0.00
G0163
9
PET FOR REC OF COLORECTAL CA
$0.00
G0164
9
PET FOR LYMPHOMA STAGING
$0.00
G0165
9
PET,REC OF MELANOMA/MET CA
$0.00
G0166
9
EXTRNL COUNTERPULSE, PER TX
$0.00
G0167
O
HYPERBARIC OZ TX;NO MD REQRD
$0.00
G0168
9
WOUND CLOSURE BY ADHESIVE
$0.00
G0169
9
REMOVAL TISSUE; NO ANESTHSIA
$0.00
G0170
9
SKIN BIOGRAFT
$0.00
G0171
9
SKIN BIOGRAFT ADD-ON
$0.00
G0172
9
PHP;TRAIN & ED, PER DAY
$0.00
G0173
9
LINEAR ACC STEREO RADSUR COM
$0.00
G0174
9
INTENSITYMODULATEDRADIATION
$0.00
G0175
7
OPPS SERVICE,SCHED TEAM CONF
$0.00
G0176
3
OPPS/PHP;ACTIVITY THERAPY
$10,128.26
Procedure Code Pricing Action Code Description
Maximum Allowable
G0177
O
OPPS/PHP; TRAIN & EDUC SERV
$0.00
G0178
9
INTENSITYMODULATEDRADIATION
$0.00
G0179
9
MD RECERTIFICATION HHA PT
$0.00
G0180
9
MD CERTIFICATION HHA PATIENT
$0.00
G0181
9
HOME HEALTH CARE SUPERVISION
$0.00
G0182
9
HOSPICE CARE SUPERVISION
$0.00
G0183
9
DESTRUCTION OF LOCALIZED LESION OF
$0.00
G0184
9
OCULAR PHOTDYNAMICTX 2ND EYE
$0.00
G0185
9
TRANSPUPPILLARY THERMOTX
$0.00
G0186
9
DSTRY EYE LESN,FDR VSSL TECH
$0.00
G0187
9
DSTRY MCLR DRUSEN,PHOTOCOAG
$0.00
G0188
9
XRAY LWR EXTRMTY-FULL LNGTH
$0.00
G0190
9
IMMUNIZATION ADMINISTRATION
$0.00
G0191
9
IMMUNIZATION ADMIN,EACH ADD
$0.00
G0192
9
IMMUNIZATION ORAL/INTRANASAL
$0.00
G0193
9
ENDOSCOPICSTUDYSWALLOWFUNCTN
$0.00
G0194
9
SENSORYTESTINGENDOSCOPICSTUD
$0.00
G0195
9
CLINICALEVALSWALLOWINGFUNCT
$0.00
G0196
9
EVALOFSWALLOWINGWITHRADIOOPA
$0.00
G0197
9
EVALOFPTFORPRESCIPSPEECHDEVI
$0.00
G0198
9
PATIENTADAPATION&TRAINFORSPE
$0.00
G0199
9
REEVALUATIONOFPATIENTUSESPEC
$0.00
G0200
9
EVALOFPATIENTPRESCIPOFVOICEP
$0.00
G0201
9
MODIFORTRAININGINUSEVOICEPRO
$0.00
G0202
3
SCREENINGMAMMOGRAPHYDIGITAL
$136.60
G0204
3
DIAGNOSTICMAMMOGRAPHYDIGITAL
$154.48
G0206
3
DIAGNOSTICMAMMOGRAPHYDIGITAL
$123.32
G0210
O
PET IMG WHOLEBODY DXLUNG
$0.00
G0211
O
PET IMG WHOLBODY INIT LUNG
$0.00
G0212
O
PET IMG WHOLEBOD RESTAG LUNG
$0.00
G0213
O
PET IMG WHOLBODY DX
$0.00
G0214
O
PET IMG WHOLEBOD INIT
$0.00
G0215
O
PETIMG WHOLEBOD RESTAG
$0.00
G0216
O
PET IMG WHOLEBOD DX MELANOMA
$0.00
G0217
O
PET IMG WHOLEBOD INIT MELAN
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
G0218
O
PET IMG WHOLEBOD RESTAG MELA
$0.00
G0219
9
PET IMG WHOLBOD MELANO NONCO
$0.00
G0220
O
PET IMG WHOLEBOD DX LYMPHOMA
$0.00
G0221
O
PET IMAG WHOLBOD INIT LYMPHO
$0.00
G0222
O
PET IMAG WHOLBOD RESTA LYMPH
$0.00
G0223
O
PET IMAG WHOLBOD REG DX HEAD
$0.00
G0224
O
PET IMAG WHOLBOD REG INI HEA
$0.00
G0225
O
PET WHOL RESTAG HEADNECKONLY
$0.00
G0226
O
PET IMG WHOLBODY DX ESOPHAGL
$0.00
G0227
O
PET IMG WHOLBOD INI ESOPHAGE
$0.00
G0228
O
PET IMG WHOLBOD RESTG ESOPHA
$0.00
G0229
O
PET IMG METABOLOC BRAIN PRES
$0.00
G0230
O
PET MYOCARD VIABILITY POST
$0.00
G0231
O
PET WHBD COLOREC; GAMMA CAM
$0.00
G0232
O
PET WHBD LYMPHOMA; GAMMA CAM
$0.00
G0233
O
PET WHBD MELANOMA; GAMMA CAM
$0.00
G0234
O
PET WHBD PULM NOD; GAMMA CAM
$0.00
G0235
6
PET NOT OTHERWISE SPECIFIED
$0.00
G0236
O
DIGITAL FILM CONVERT DIAG MA
$0.00
G0237
9
THERAPEUTIC PROCD STRG ENDUR
$0.00
G0238
9
OTH RESP PROC, INDIV
$0.00
G0239
9
OTH RESP PROC, GROUP
$0.00
G0240
9
CRITIC CARE BY MD TRANSPORT
$0.00
G0241
9
EACH ADDITIONAL 30 MINUTES
$0.00
G0242
O
MULTISOURCE PHOTON STER PLAN
$0.00
G0243
O
MULTISOUR PHOTON STERO TREAT
$0.00
G0244
O
OBSERV CARE BY FACILITY TOPT
$0.00
G0245
9
INITIAL FOOT EXAM PT LOPS
$0.00
G0246
9
FOLLOWUP EVAL OF FOOT PT LOP
$0.00
G0247
9
ROUTINE FOOTCARE PT W LOPS
$0.00
G0248
9
DEMONSTRATE USE HOME INR MON
$0.00
G0249
9
PROVIDE INR TEST MATER/EQUIP
$0.00
G0250
9
MD INR TEST REVIE INTER MGMT
$0.00
G0251
9
LINEAR ACC BASED STERO RADIO
$0.00
G0252
3
PET IMAGING INITIAL DX
$521.95
Procedure Code Pricing Action Code Description
Maximum Allowable
G0253
O
PET IMAGE BRST DECTION RECUR
$0.00
G0254
O
PET IMAGE BRST EVAL TO TX
$0.00
G0255
5
CURRENT PERCEP THRESHOLD TST
$0.00
G0256
O
PROSTATE BRACHY W PALLADIUM
$0.00
G0257
5
UNSCHED DIALYSIS ESRD PT HOS
$0.00
G0258
O
IV INFUSION DURING OBS STAY
$0.00
G0259
5
INJECT FOR SACROILIAC JOINT
$0.00
G0260
5
INJ FOR SACROILIAC JT ANESTH
$0.00
G0261
O
PROSTATE BRACHY W IODINE SEE
$0.00
G0262
O
SM INTESTINAL IMAGE CAPSULE
$0.00
G0263
O
ADM WITH CHF, CP, ASTHMA
$0.00
G0264
O
ASSMT OTR CHF, CP, ASTHMA
$0.00
G0265
O
CRYOPRESEVATION FREEZE+STORA
$0.00
G0266
O
THAWING + EXPANSION FROZ CEL
$0.00
G0267
O
BONE MARROW OR PSC HARVEST
$0.00
G0268
9
REMOVAL OF IMPACTED WAX MD
$0.00
G0269
5
OCCLUSIVE DEVICE IN VEIN ART
$0.00
G0270
5
MNT SUBS TX FOR CHANGE DX
$0.00
G0271
5
GROUP MNT 2 OR MORE 30 MINS
$0.00
G0272
O
NASO/ORO GASTRIC TUBE PL MD
$0.00
G0273
O
PRETX PLANNING, NON-HODGKINS
$0.00
G0274
O
RADIOPHARM TX, NON-HODGKINS
$0.00
G0275
3
RENAL ANGIO, CARDIAC CATH
$13.49
G0278
3
ILIAC ART ANGIO,CARDIAC CATH
$13.85
G0279
O
EXCORP SHOCK TX, ELBOW EPI
$0.00
G0280
O
EXCORP SHOCK TX OTHER THAN
$0.00
G0281
5
ELEC STIM UNATTEND FOR PRESS
$0.00
G0282
5
ELECT STIM WOUND CARE NOT PD
$0.00
G0283
9
ELEC STIM OTHER THAN WOUND
$0.00
G0288
3
RECON, CTA FOR SURG PLAN
G0289
3
ARTHRO, LOOSE BODY + CHONDRO
G0290
5
DRUG-ELUTING STENTS, SINGLE
$0.00
G0291
5
DRUG-ELUTING STENTS,EACH ADD
$0.00
G0292
O
ADM EXP DRUGS,CLINICAL TRIAL
$0.00
G0293
9
NON-COV SURG PROC,CLIN TRIAL
$0.00
$234.70 $84.90
Procedure Code Pricing Action Code Description
Maximum Allowable
G0294
9
NON-COV PROC, CLINICAL TRIAL
$0.00
G0295
9
ELECTROMAGNETIC THERAPY ONC
$0.00
G0296
O
PET IMGE RESTAG THYROD CANCE
$0.00
G0297
O
INSERT SINGLE CHAMBER/CD
$0.00
G0298
O
INSERT DUAL CHAMBER/CD
$0.00
G0299
O
INSER/REPOS SINGLE ICD+LEADS
$0.00
G0300
O
INSERT REPOSIT LEAD DUAL+GEN
$0.00
G0302
9
PRE-OP SERVICE LVRS COMPLETE
$0.00
G0303
9
PRE-OP SERVICE LVRS 10-15DOS
$0.00
G0304
9
PRE-OP SERVICE LVRS 1-9 DOS
$0.00
G0305
9
POST OP SERVICE LVRS MIN 6
$0.00
G0306
9
CBC/DIFFWBC W/O PLATELET
$0.00
G0307
9
CBC WITHOUT PLATELET
$0.00
G0308
O
ESRD RELATED SVC 4+MO < 2YRS
$0.00
G0309
O
ESRD RELATED SVC 2-3MO <2YRS
$0.00
G0310
O
ESRD RELATED SVC 1 VST <2YRS
$0.00
G0311
O
ESRD RELATED SVS 4+MO 2-11YR
$0.00
G0312
O
ESRD RELATE SVS 2-3 MO 2-11Y
$0.00
G0313
O
ESRD RELATED SVS 1 MON 2-11Y
$0.00
G0314
O
ESRD RELATED SVS 4+ MO 12-19
$0.00
G0315
O
ESRD RELATED SVS 2-3MO/12-19
$0.00
G0316
O
ESRD RELATED SVS 1VIS/12-19Y
$0.00
G0317
O
ESRD RELATED SVS 4+MO 20+YRS
$0.00
G0318
O
ESRD RELATED SVS 2-3 MO 20+Y
$0.00
G0319
O
ESRD RELATED SVS 1VISIT 20+Y
$0.00
G0320
O
ESD RELATED SVS HOME UNDR 2
$0.00
G0321
O
ESRDRELATEDSVS HOME MO 2-11Y
$0.00
G0322
O
ESRD RELATED SVS HOM MO12-19
$0.00
G0323
O
ESRD RELATED SVS HOME MO 20+
$0.00
G0324
O
ESRD RELATE SVS HOME/DY<2Y
$0.00
G0325
O
ESRD RELATE HOME/DAY/ 2-11YR
$0.00
G0326
O
ESRD RELATE HOME/DY 12-19YR
$0.00
G0327
O
ESRD RELATE HOME/DY 20+YRS
$0.00
G0328
5
FECAL BLOOD SCRN IMMUNOASSAY
$0.00
G0329
9
ELECTROMAGNTIC TX FOR ULCERS
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
G0332
O
PREADMIN IV IMMUNOGLOBULIN
$0.00
G0333
9
DISPENSE FEE INITIAL 30 DAY
$0.00
G0336
O
PET IMAGING BRAIN ALZHEIMERS
$0.00
G0337
9
HOSPICE EVALUATION PREELECTI
$0.00
G0338
O
LINEAR ACCELERATOR STERO PLN
$0.00
G0339
9
ROBOT LIN-RADSURG COM, FIRST
$0.00
G0340
9
ROBOT LINEAR STERORADIO MAX5
$0.00
G0341
9
PERCUTANEOUS ISLET CELLTRANS
$0.00
G0342
9
LAPAROSCOPY ISLET CELL TRANS
$0.00
G0343
9
LAPAROTOMY ISLET CELL TRANSP
$0.00
G0344
O
INITIAL PREVENTIVE EXAM
$0.00
G0345
O
IV INFUSE HYDRATION, INITIAL
$0.00
G0346
O
EACH ADDITIONAL INFUSE HOUR
$0.00
G0347
O
IV INFUSION THERAPY/DIAGNOST
$0.00
G0348
O
EACH ADDITIONAL HR UP TO 8HR
$0.00
G0349
O
ADDITIONAL SEQUENTIAL INFUSE
$0.00
G0350
O
CONCURRENT INFUSION
$0.00
G0351
O
THERAPEUTIC/DIAGNOSTIC INJEC
$0.00
G0353
O
IV PUSH,SINGLE ORINITIAL DRU
$0.00
G0354
O
EACH ADDITION SEQUENTIAL IV
$0.00
G0355
O
CHEMO ADMINISRATE SUBCUT/IM
$0.00
G0356
O
HORMONAL ANTI-NEOPLASTIC
$0.00
G0357
O
IV PUSH SINGLE/INITIAL SUBST
$0.00
G0358
O
IV PUSH EACH ADDITIONAL DRUG
$0.00
G0359
O
CHEMOTHERAPY IV ONE HR INITI
$0.00
G0360
O
EACH ADDITIONAL HR 1-8 HRS
$0.00
G0361
O
PROLONG CHEMO INFUSE>8HRS PU
$0.00
G0362
O
EACH ADD SEQUENTIAL INFUSION
$0.00
G0363
O
IRRIGATE IMPLANTED VENOUS DE
$0.00
G0364
3
BONE MARROW ASPIRATE &BIOPSY
G0365
9
VESSEL MAPPING HEMO ACCESS
$0.00
G0366
O
EKG FOR INITIAL PREVENT EXAM
$0.00
G0367
O
EKG TRACING FOR INITIAL PREV
$0.00
G0368
O
EKG INTERPRET & REPORT PREVE
$0.00
G0369
O
SUPPLYING FEE FOR THE INITIAL SUPP
$0.00
$12.24
Procedure Code Pricing Action Code Description
Maximum Allowable
G0370
O
SUPPLYING FEE FOR EACH SUPPLIED PR
$0.00
G0371
O
DISPENSING FEE FOR A 30 DAY PERIOD
$0.00
G0372
9
MD SERVICE REQUIRED FOR PMD
$0.00
G0374
O
DISPENSING FEE FOR EACH DISPENSED
$0.00
G0375
O
SMOKE/TOBACCO COUNSELNG 3-10
$0.00
G0376
O
SMOKE/TOBACCO COUNSELING >10
$0.00
G0378
9
HOSPITAL OBSERVATION PER HR
$0.00
G0379
9
DIRECT ADMIT HOSPITAL OBSERV
$0.00
G0380
9
LEV 1 HOSP TYPE B ED VISIT
$0.00
G0381
9
LEV 2 HOSP TYPE B ED VISIT
$0.00
G0382
9
LEV 3 HOSP TYPE B ED VISIT
$0.00
G0383
9
LEV 4 HOSP TYPE B ED VISIT
$0.00
G0384
9
LEV 5 HOSP TYPE B ED VISIT
$0.00
G0389
6
ULTRASOUND EXAM AAA SCREEN
$0.00
G0390
9
TRAUMA RESPONS W/HOSP CRITI
$0.00
G0392
3
AV FISTULA OR GRAFT ARTERIAL
$476.40
G0393
3
AV FISTULA OR GRAFT VENOUS
$304.63
G0394
O
BLOOD OCCULT TEST,COLORECTAL
$0.00
G0396
9
ALCOHOL/SUBS INTERV 15-30MN
$0.00
G0397
9
ALCOHOL/SUBS INTERV >30 MIN
$0.00
G0398
9
HOME SLEEP TEST/TYPE 2 PORTA
$0.00
G0399
9
HOME SLEEP TEST/TYPE 3 PORTA
$0.00
G0400
9
HOME SLEEP TEST/TYPE 4 PORTA
$0.00
G0402
9
INITIAL PREVENTIVE EXAM
$0.00
G0403
9
EKG FOR INITIAL PREVENT EXAM
$0.00
G0404
9
EKG TRACING FOR INITIAL PREV
$0.00
G0405
9
EKG INTERPRET & REPORT PREVE
$0.00
G0406
9
TELHEALTH INPT CONSULT 15MIN
$0.00
G0407
9
TELHEATH INPT CONSULT 25MIN
$0.00
G0408
9
TELHEALTH INPT CONSULT 35MIN
$0.00
G0409
9
CORF RELATED SERV 15 MINS EA
$0.00
G0410
9
GRP PSYCH PARTIAL HOSP 45-50
$0.00
G0411
9
INTER ACTIVE GRP PSYCH PARTI
$0.00
G0412
9
OPEN TX ILIAC SPINE UNI/BIL
$0.00
G0413
9
PELVIC RING FRACTURE UNI/BIL
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
G0414
9
PELVIC RING FX TREAT INT FIX
$0.00
G0415
9
OPEN TX POST PELVIC FXCTURE
$0.00
G0416
6
SAT BIOPSY PROSTATE 1-20 SPC
$0.00
G0417
6
SAT BIOPSY PROSTATE 21-40
$0.00
G0418
6
SAT BIOPSY PROSTATE 41-60
$0.00
G0419
6
SAT BIOPSY PROSTATE: >60
$0.00
G3001
6
ADMIN + SUPPLY, TOSITUMOMAB
$0.00
G8006
9
AMI PT RECD ASPIRIN AT ARRIV
$0.00
G8007
9
AMI PT DID NOT RECEIV ASPIRI
$0.00
G8008
9
AMI PT INELIGIBLE FOR ASPIRI
$0.00
G8009
9
AMI PT RECD BBLOCK AT ARR
$0.00
G8010
9
AMI PT DID NOT REC BBLOCK
$0.00
G8011
9
AMI PT INELIG BBLOC AT ARRIV
$0.00
G8012
9
PNEUM PT RECV ANTIBIOTIC 4 H
$0.00
G8013
9
PNEUM PT W/O ANTIBIOTIC 4 HR
$0.00
G8014
9
PNEUM PT NOT ELIG ANTIBIOTIC
$0.00
G8015
9
DIABETIC PT W/ HBA1C>9%
$0.00
G8016
9
DIABETIC PT W/ HBA1C
$0.00
G8017
9
DM PT INELIG FOR HBA1C MEASU
$0.00
G8018
9
CARE NOT PROVIDED FOR HBA1C
$0.00
G8019
9
DIABETIC PT W/LDL>= 100MG/DL
$0.00
G8020
9
DIAB PT W/LDL< 100MG/DL
$0.00
G8021
9
DIAB PT INELIG FOR LDL MEAS
$0.00
G8022
9
CARE NOT PROVIDED FOR LDL
$0.00
G8023
9
DM PT W BP>=140/80
$0.00
G8024
9
DIABETIC PT WBP<140/80
$0.00
G8025
9
DIABETIC PT INELIG FOR BP ME
$0.00
G8026
9
DIABET PT W NO CARE RE BP ME
$0.00
G8027
9
HF P W/LVSD ON ACE-I/ARB
$0.00
G8028
9
HF PT W/LVSD NOT ON ACE-I/AR
$0.00
G8029
9
HF PT NOT ELIG FOR ACE-I/ARB
$0.00
G8030
9
HF PT W/LVSD ON BBLOCKER
$0.00
G8031
9
HF PT W/LVSD NOT ON BBLOCKER
$0.00
G8032
9
HF PT NOT ELIG FOR BBLOCKER
$0.00
G8033
9
PMI-CAD PT ON BBLOCKER
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
G8034
9
PMI-CAD PT NOT ON BBLOCKER
$0.00
G8035
9
PMI-CAD PT INELIG BBLOCKER
$0.00
G8036
9
AMI-CAD PT DOC ON ANTIPLATEL
$0.00
G8037
9
AMI-CAD PT NOT DOCU ON ANTIP
$0.00
G8038
9
AMI-CAD INELIG ANTIPLATE MEA
$0.00
G8039
9
CAD PT W/LDL>100MG/DL
$0.00
G8040
9
CAD PT W/LDL
$0.00
G8041
9
CAD PT NOT ELIGIBLE FOR LDL
$0.00
G8051
9
OSTEOPOROSIS ASSESS
$0.00
G8052
9
OSTEOPOR PT NOT ASSESS
$0.00
G8053
9
PT INELIG FOR OSTEOPOR MEAS
$0.00
G8054
9
FALLS ASSESS NOT DOCUM 12 MO
$0.00
G8055
9
FALLS ASSESS W/ 12 MON
$0.00
G8056
9
NOT ELIG FOR FALLS ASSESSMEN
$0.00
G8057
9
HEARING ASSESS RECEIVE
$0.00
G8058
9
PT W/O HEARING ASSESS
$0.00
G8059
9
PT INELIG FOR HEARING ASSESS
$0.00
G8060
9
URINARY INCONT PT ASSESS
$0.00
G8061
9
PT NOT ASSESS FOR URINARY IN
$0.00
G8062
9
PT NOT ELIG FOR URINARY INCO
$0.00
G8075
9
ESRD PT W/ DIALY OF URR>=65%
$0.00
G8076
9
ESRD PT W/ DIALY OF URR<65%
$0.00
G8077
9
ESRD PT NOT ELIG FOR URR/KTV
$0.00
G8078
9
ESRD PT W/HCT>OR=33
$0.00
G8079
9
ESRD PT W/HCT<33
$0.00
G8080
9
ESRD PT INELIG FOR HCT/HGB
$0.00
G8081
9
ESRD PT W/ AUTO AV FISTULA
$0.00
G8082
9
ESRD PT W OTHER FISTULA
$0.00
G8085
9
ESRD PT INELIG AUTO AV FISTU
$0.00
G8093
9
COPD PT REC SMOKING CESSAT
$0.00
G8094
9
COPD PT W/O SMOKE CESSAT INT
$0.00
G8099
9
OSTEOPO PT GIVEN CA+VITD SUP
$0.00
G8100
9
OSTEOP PT INELIG FOR CA+VITD
$0.00
G8103
9
NEW DX OSTEO PT W/ANTIRESORP
$0.00
G8104
9
OSTEO PT INELIG FOR ANTIRESO
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
G8106
9
BONE DENS MEAS TEST PERF
$0.00
G8107
9
BONE DENS MEAS TEST INELIG
$0.00
G8108
9
PT RECEIV INFLUENZA VACC
$0.00
G8109
9
PT W/O INFLUENZA VACC
$0.00
G8110
9
PT INELIG FOR INFLUENZA VACC
$0.00
G8111
9
PT RECEIV MAMMOGRAM
$0.00
G8112
9
PT NOT DOC MAMMOGRAM
$0.00
G8113
9
PT INELIGIBLE MAMMOGRAPHY
$0.00
G8114
9
CARE NOT PROVIDED FOR MAMOGR
$0.00
G8115
9
PT RECEIV PNEUMO VACC
$0.00
G8116
9
PT DID NOT REC PNEUMO VACC
$0.00
G8117
9
PT WAS INELIG FOR PNEUMO VAC
$0.00
G8126
9
PT TREAT W/ANTIDEPRESS12WKS
$0.00
G8127
9
PT NOT TREAT W/ANTIDEPRES12W
$0.00
G8128
9
PT INELIG FOR ANTIDEPRES MED
$0.00
G8129
9
PT TREAT W/ANTIDEPRES FOR 6M
$0.00
G8130
9
PT NOT TREAT W/ANTIDEPRES 6M
$0.00
G8131
9
PT INELIG FOR ANTIDEPRES MED
$0.00
G8152
9
PT W/AB 1 HR PRIOR TO INCISI
$0.00
G8153
9
PT NOT DOC FOR AB 1 HR PRIOR
$0.00
G8154
9
PT INELIGI FOR AB THERAPY
$0.00
G8155
9
PT RECD THROMBOEMB PROPHYLAX
$0.00
G8156
9
PT DID NOT REC THROMBOEMBO
$0.00
G8157
9
PT INELIGI FOR THROMBOLISM
$0.00
G8158
O
PT RECD CABG W/ IMA
$0.00
G8159
9
PT W/CABG W/O IMA
$0.00
G8160
O
PT INELIG FOR CABG W/IMA
$0.00
G8161
O
ISO CABG PT REC PREOP BBLOCK
$0.00
G8162
9
ISO CABG PT W/O PREOP BBLOCK
$0.00
G8163
O
ISO CABG PT INELIG FOR PREO
$0.00
G8164
9
ISO CABG PT W/PROLNG INTUB
$0.00
G8165
9
ISO CABG PT W/O PROLNG INTUB
$0.00
G8166
9
ISO CABG REQ SURG REXPO
$0.00
G8167
9
ISO CABG W/O SURG EXPLO
$0.00
G8170
9
CEA/EXT BYPASS PT ON ASPIRIN
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
G8171
9
PT W/CAROT ENDARCT/EXT BYPAS
$0.00
G8172
9
CEA/EXT BYPASS PT NOT ON ASP
$0.00
G8182
9
CAD PT CARE NOT PROV LDL
$0.00
G8183
9
HF/ATRIAL FIB PT ON WARFARIN
$0.00
G8184
9
HF/ATRIAL FIB PT INELIG WARF
$0.00
G8185
9
OSTEOARTH PT W/ ASSESS PAIN
$0.00
G8186
9
OSTEOARTH PT INELIG ASSESS
$0.00
G8191
O
ANTIBIOTIC GIVEN PRIOR SURG
$0.00
G8192
O
ANTIB GIVEN PRIOR SURG INCIS
$0.00
G8193
9
ANTIBIO NOT DOC PRIOR SURG
$0.00
G8194
O
PT NOT ELIG FOR ANTIBIOTIC
$0.00
G8195
O
ANTIBIOTIC GIVEN PRIOR SURG
$0.00
G8196
9
ANTIBIO NOT DOCUM PRIOR SURG
$0.00
G8197
O
ANTIB ORDER PRIOR TO SURG
$0.00
G8198
O
CEFAZOLIN DOCUMENTED ORDERED
$0.00
G8199
O
CEFAZOLIN GIVEN PROPHYLAXIS
$0.00
G8200
9
CEFAZOLIN NOT DOCUM PROPHY
$0.00
G8201
O
PT NOT ELIGI FOR CEFAZOLIN
$0.00
G8202
O
ORDER GIVEN TO D/C ANTIBIO
$0.00
G8203
O
ANTIB WAS D/C 24HRS SURG TIM
$0.00
G8204
9
MD NOT DOC ORDER TO D/C ANTI
$0.00
G8205
O
PT NOT ELIGI FOR PROPH ANTIB
$0.00
G8206
O
MD DOC PROPHYLACTIC AB GIVEN
$0.00
G8207
O
CLINI DOC ORDER TO D/C ANTIB
$0.00
G8208
O
CLINI DOC AB WAS D/C 48 H
$0.00
G8209
9
CLINICIAN DID NOT DOC
$0.00
G8210
O
CLINI DOC PT INELIGIB ANTI
$0.00
G8211
O
CLINI DOC PROPH AB GIV
$0.00
G8212
O
CLINI ORDER GIVEN FOR VTE
$0.00
G8213
O
CLINI GIVEN VTE PROP
$0.00
G8214
9
CLINI NOT DOC ORDER VTE
$0.00
G8215
O
CLINI DOC PT INELIG VTE
$0.00
G8216
O
PT RECEIVED DVT PROPHYLAXIS
$0.00
G8217
9
PT NOT RECEIVED DVT PROPH
$0.00
G8218
O
PT INELIG DVT PROPHYLAXIS
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
G8219
9
RECEIVED DVT PROPH DAY 2
$0.00
G8220
9
PT NOT REC DVT PROPH DAY 2
$0.00
G8221
9
PT INELIG FOR DVT PROPH
$0.00
G8222
O
PT PRESCRIBE PLATELET AT D/C
$0.00
G8223
9
PT NOT DOC FOR PRESC ANTIPLA
$0.00
G8224
O
PT INELIG FOR ANTIPLAT PROPH
$0.00
G8225
O
PT PRESCRIB ANTICOAG AT D/C
$0.00
G8226
9
PT NO PRESCR ANTICOA AT D/C
$0.00
G8227
O
PT NOT DOC TO HAVE PERM/AF
$0.00
G8228
O
CLIN PT INELIG ANTICOAG D/C
$0.00
G8229
O
PT DOC TO HAVE ADMIN T-PA
$0.00
G8230
O
PT INELIG T-PA ISCH STROK>3H
$0.00
G8231
9
PT NOT DOC FOR ADMIN T-PA
$0.00
G8232
O
PT RECEIVED DYSPHAGIA SCREEN
$0.00
G8234
9
PT NOT DOC DYSPHAGIA SCREEN
$0.00
G8235
O
PT RECEIVED NPO
$0.00
G8236
O
PT INELIG DYSPHAGIA SCREEN
$0.00
G8237
O
PT DOC REC REHAB SERV
$0.00
G8238
9
PT NOT DOC TO REC REHAB SERV
$0.00
G8239
O
INTER CAROTID STENOSIS <30%
$0.00
G8240
9
INTER CAROTID STENOSIS30-99%
$0.00
G8241
O
PT INELIG CANDIDATE ITO MEAS
$0.00
G8242
O
PT DOC TO HAVE CT/MRI W/LES
$0.00
G8243
9
PT NOT DOC MRI/CT W/O LESION
$0.00
G8245
O
CLINI DOC PRESE/ABS ALARM
$0.00
G8246
9
PT INELIG HX W NEW/CHG MOLE
$0.00
G8247
O
PT W/ALARM SYMP UPPER ENDO
$0.00
G8248
9
PT W/ONE ALARM SYMP NOT DOC
$0.00
G8249
O
PT INELIG FOR UPPER ENDO
$0.00
G8250
O
PT W/BARRETTS ESOPH ENDO RE
$0.00
G8251
9
PT NOT DOC W/BARRETTS, ENDO
$0.00
G8252
O
PT INELIG FOR ESOPHAG BIOP
$0.00
G8253
O
PT REC ORDER FOR BARIUM
$0.00
G8254
9
PT W/NO DOC ORDER FOR BARIUM
$0.00
G8255
O
CLINI DOC PT INELIG BAR SWAL
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
G8256
O
CLINI DOC REV D/C MEDS W/MED
$0.00
G8257
9
PT NOT DOC REV MEDS D/C
$0.00
G8258
O
PT INELIG FOR D/C MEDS REV
$0.00
G8259
O
PT DOC TO HAV DECISION MAKER
$0.00
G8260
9
PT NOT DOC TO HAVE DEC MAKER
$0.00
G8261
O
CLIN DOC PT INELIG DEC MAKER
$0.00
G8262
O
PT DOC ASSESS URINY INCON
$0.00
G8263
9
PT NOT DOC ASSESS URINARY IN
$0.00
G8264
O
PT INELIG ASSESS URINARY INC
$0.00
G8265
O
PT DOC REC CHARC URIN INCON
$0.00
G8266
9
PT NOT DOC CHARC URIN INCON
$0.00
G8267
O
PT DOC REC PLAN URINARY INCO
$0.00
G8268
9
PT NOT DOC REC CARE URIN INC
$0.00
G8269
O
CLIN NOT PROV CARE URIN INCO
$0.00
G8270
O
PT RECEIV SCREEN FOR FALL
$0.00
G8271
9
PT NO DOC SCREEN FALL
$0.00
G8272
O
CLIN DOC PT INELIG FALL RISK
$0.00
G8273
O
CLIN NOT PROV CARE SCRE FALL
$0.00
G8274
9
CLINI NOT DOC PRES/ABS ALARM
$0.00
G8275
O
PT HX W/ NEW MOLES
$0.00
G8276
9
PT NOT DOC MOLE CHANGE
$0.00
G8277
O
PT INELIG FOR ASSESS MOLE
$0.00
G8278
O
PT DOC REC PE SKIN
$0.00
G8279
9
PT NOT DOC REC PE
$0.00
G8280
O
PT INELIG PE SKIN
$0.00
G8281
O
PT REC COUNSEL FOR SELF-EXAM
$0.00
G8282
9
PT NOT DOC TO REC COUNS
$0.00
G8283
O
PT INELIG FOR COUNSEL
$0.00
G8284
O
PT DOC TO REC PRES OSTEO
$0.00
G8285
9
PT DID NOT REC PRES OSTEO
$0.00
G8286
O
PT INELIG TO REC PRES OSTEO
$0.00
G8287
O
CLIN NOT PROV CARE FOR PHARM
$0.00
G8288
O
PT DOC REC CA/VIT D
$0.00
G8289
9
PT NOT DOC REC CA/VIT D
$0.00
G8290
O
CLIN DOC PT INELIG CA/VIT D
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
G8291
O
CLIN NO PRO CARE PT CA/VIT D
$0.00
G8292
O
COPD PT W/SPIR RESULTS
$0.00
G8293
9
COPD PT W/O SPIR RESULTS
$0.00
G8294
O
COPD PT INELIG SPIR RESULTS
$0.00
G8295
O
COPD PT DOC BRONCH THER
$0.00
G8296
9
COPD PT NOT DOC BRONCH THER
$0.00
G8297
O
COPD PT INELIG BRONCH THERAP
$0.00
G8298
9
PT DOC OPTIC NERVE EVAL
$0.00
G8299
9
PT NOT DOC OPTIC NERV EVAL
$0.00
G8300
O
PT INELIG FOR OPTIC NERV EVA
$0.00
G8301
O
CLIN NOT PROV CARE POAG
$0.00
G8302
9
PT DOC W/ TARGET IOP
$0.00
G8303
9
PT NOT DOC W/ IOP
$0.00
G8304
9
CLIN DOC PT INELIG IOP
$0.00
G8305
9
CLIN NOT PROV CARE POAG
$0.00
G8306
9
POAG W/ IOP REC CARE PLAN
$0.00
G8307
9
POAG W/ IOP NO CARE PLAN
$0.00
G8308
9
POAG W/ IOP NOT DOC PLAN
$0.00
G8309
O
PT DOC REC ANTIOXIDANT
$0.00
G8310
9
PT NOT DOC REC ANTIOX
$0.00
G8311
O
PT INELIG FOR ANTIOXIDANT
$0.00
G8312
O
CLIN NO PROV CARE FOR ANTIOX
$0.00
G8313
O
PT DOC REC MACULAR EXAM
$0.00
G8314
9
PT NOT DOC TO REC MAC EXAM
$0.00
G8315
O
CLIN DOC PT INELIG MAC EXAM
$0.00
G8316
O
CLIN NO PRO CARE FOR MAC DEG
$0.00
G8317
O
PT DOC TO HAVE VISUAL FUNC
$0.00
G8318
9
PT DOC NOT HAVE VISUAL FUNC
$0.00
G8319
O
PT INELIG FOR VIS FUNC STAT
$0.00
G8320
O
CLIN NOT PROV CARE CATARAC
$0.00
G8321
O
PT DOC TO PRE AXIAL LENG
$0.00
G8322
9
PT NOT DOC PRE AXIAL LENG
$0.00
G8323
O
PT INELIG FOR PRE SURG AXIAL
$0.00
G8324
O
CLIN NOT PROV CARE FOR IOL
$0.00
G8325
O
PT REC FUND EXAM PRIOR SURG
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
G8326
9
PT NOT DOC REC FUNDUS EXAM
$0.00
G8327
O
PT INELIG FOR PRE SURG FUNDU
$0.00
G8328
O
CLIN NOT PROV CARE FUND EVAL
$0.00
G8329
O
PT DOC REC DILATED MACULAR
$0.00
G8330
9
PT NOT DOC REC DILATED MAC
$0.00
G8331
O
PT INELIG DILATE FUNDUS
$0.00
G8332
O
CLIN PROV NO CARE DIABETIC R
$0.00
G8333
O
PT DOC TO HAVE MACULAR EXAM
$0.00
G8334
9
DOC OF MACULAR NOT GIV MD
$0.00
G8335
O
CLIN DOC PT INELIG MACULAR
$0.00
G8336
O
CLIN DID NOT PRO CARE DIABET
$0.00
G8337
O
CLIN DOC PT WAS TEST OSTEO
$0.00
G8338
9
CLIN NOT DOC PT TEST OSTEO
$0.00
G8339
O
PT INELIG FOR TEST OSTEO
$0.00
G8340
O
PT DOC HAVE DEXA
$0.00
G8341
9
PT NOT DOC FOR DEXA
$0.00
G8342
O
CLIN DOC PT INELIG DEXA
$0.00
G8343
O
CLIN NOT PROV CARE DEXA
$0.00
G8344
O
PT DOC HAVE DEXA PERFORM
$0.00
G8345
9
PT NOT DOC HAVE DEXA
$0.00
G8346
O
CLIN DOC PT INELIG DEXA
$0.00
G8347
O
CLIN NOT PROV CARE DEXA
$0.00
G8351
9
PT NOT DOC ECG
$0.00
G8354
9
PT NOT REC ASPIRIN PRIOR ER
$0.00
G8357
9
PT NOT DOC TO HAVE ECG
$0.00
G8360
9
PT NOT DOC VITAL SIGNS RECOR
$0.00
G8362
9
PT NOT DOC 02 SAT ASSESS
$0.00
G8365
9
PT NOT DOC MENTAL STATUS
$0.00
G8367
9
PT NOT DOC HAVE EMPIRIC AB
$0.00
G8370
9
ASTHMA PT W SURVEY NOT DOCUM
$0.00
G8371
9
CHEMOTHER NOT REC STG3 COLON
$0.00
G8372
9
CHEMOTHER REC STG3 COLON CA
$0.00
G8373
9
CHEMO PLAN DOCUMEN PRIOR CHE
$0.00
G8374
9
CHEMO PLAN NOT DOC PRIOR CHE
$0.00
G8375
9
CLL PT W/O DOC FLOW CYTOMETR
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
G8376
9
BRST CA PT INELIG TAMOXIFEN
$0.00
G8377
9
MD DOC COLON CA PT INELIG CH
$0.00
G8378
9
MD DOC PT INELIG RADIATION
$0.00
G8379
9
DOC RADIAT TX RECOM 12MO OV
$0.00
G8380
9
PT W STGIC-3BRST CA NOT REC
$0.00
G8381
9
PT W STGIC-3BRST CA REC TAM
$0.00
G8382
9
MM PT W/O DOC IV BISPHOPHON
$0.00
G8383
9
NO DOC RADIATION REC 12MO OV
$0.00
G8384
9
BASE CYTOGEN TEST MDS NOTPER
$0.00
G8385
9
DIABET PT NO DO HGB A1C 12M
$0.00
G8386
9
DIABET PT NODOC LDLIPROTEI
$0.00
G8387
9
ESRD PT W HCT/HGB NOT DOCUME
$0.00
G8388
9
ESRD PT W URR/KTV NOTDOC ELI
$0.00
G8389
9
MDS PT NO DOC FE ST PRIO EPO
$0.00
G8390
9
DIABETIC W/O DOCUMENT BP 12M
$0.00
G8391
9
PT W ASTHMA NO DOC MED OR TX
$0.00
G8395
9
LVEF>=40% DOC NORMAL OR MILD
$0.00
G8396
9
LVEF NOT PERFORMED
$0.00
G8397
9
DIL MACULA/FUNDUS EXAM/W DOC
$0.00
G8398
9
DIL MACULAR/FUNDUS NOT PERFO
$0.00
G8399
9
PT W/DXA DOCUMENT OR ORDER
$0.00
G8400
9
PT W/DXA NO DOCUMENT OR ORDE
$0.00
G8401
9
PT INELIG OSTEO SCREEN MEASU
$0.00
G8402
9
SMOKE PREVEN INTERVEN COUNSE
$0.00
G8403
9
SMOKE PREVEN NOCOUNSEL
$0.00
G8404
9
LOW EXTEMITY NEUR EXAM DOCUM
$0.00
G8405
9
LOW EXTEMITY NEUR NOT PERFOR
$0.00
G8406
9
PT INELIG LOWER EXTREM NEURO
$0.00
G8407
9
ABI DOCUMENTED
$0.00
G8408
9
ABI NOT DOCUMENTED
$0.00
G8409
9
PT INELIG FOR ABI MEASURE
$0.00
G8410
9
EVAL ON FOOT DOCUMENTED
$0.00
G8415
9
EVAL ON FOOT NOT PERFORMED
$0.00
G8416
9
PT INELIG FOOTWEAR EVALUATIO
$0.00
G8417
9
CALC BMI ABV UP PARAM F/U
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
G8418
9
CALC BMI BLW LOW PARAM F/U
$0.00
G8419
9
CALC BMI OUT NRM PARAM NOF/U
$0.00
G8420
9
CALC BMI NORM PARAMETERS
$0.00
G8421
9
BMI NOT CALCULATED
$0.00
G8422
9
PT INELIG BMI CALCULATION
$0.00
G8423
9
PT SCREEN FLU VAC & COUNSEL
$0.00
G8424
9
FLU VACCINE NOT SCREEN
$0.00
G8425
9
FLU VACCINE SCREEN NOT CURRE
$0.00
G8426
9
PT NOT APPROP SCREEN & COUNC
$0.00
G8427
9
DOC MEDS VERIFIED W/PT OR RE
$0.00
G8428
9
MEDS DOCUMENT W/O VERIFICA
$0.00
G8429
9
INCOMPLETE DOC PT ON MEDS
$0.00
G8430
9
PT INELIG MED CHECK
$0.00
G8431
9
POS CLIN DEPRES SCRN F/U DOC
$0.00
G8432
9
CLIN DEPRESSION SCREEN NOT D
$0.00
G8433
9
PT INELIG; SCRN CLIN DEP
$0.00
G8434
9
COGNITIVE IMPAIRMENT SCREEN
$0.00
G8435
9
COGNITIVE SCREEN NOT DOCUMEN
$0.00
G8436
9
PT INELIG FOR COGNITIVE IMPA
$0.00
G8437
9
CARE PLAN DEVELOP & DOCUMENT
$0.00
G8438
9
PT INELIG FOR DEVLP CARE PLN
$0.00
G8439
9
CARE PLAN DEVELP & NOT DOCUM
$0.00
G8440
9
PAIN ASSESS F/U PLN DOCUMENT
$0.00
G8441
9
NO DOCUMENT OF PAIN ASSESS
$0.00
G8442
9
PT INELIG PAIN ASSESSMENT
$0.00
G8443
9
PRESCRIPTION BY E-PRESCRIB S
$0.00
G8445
9
PRESCRIP NOT GEN AT ENCOUNTE
$0.00
G8446
9
SOME PRESCRIB PRINT OR CALL
$0.00
G8447
9
PT VIS DOC USE CCHIT CER EHR
$0.00
G8448
9
PT VIS DOC W/NON-CCHIT EHR
$0.00
G8449
9
PT NOT DOC W/EMR DUE TO SYST
$0.00
G8450
9
BETA-BLOC RX PT W/ABN LVEF
$0.00
G8451
9
PT W/ABN LVEF INELIG B-BLOC
$0.00
G8452
9
PT W/ABN LVEF B-BLOC NO RX
$0.00
G8453
9
TOB USE CESS INT COUNSEL
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
G8454
9
TOB USE CESS INT NO COUNSEL
$0.00
G8455
9
CURRENT TOBACCO SMOKER
$0.00
G8456
9
SMOKELESS TOBACCO USER
$0.00
G8457
9
CUR TOBACCO NON-USER
$0.00
G8458
9
PT INELIG GENO NO ANTVIR TX
$0.00
G8459
9
DOC PT REC ANTIVIR TREAT
$0.00
G8460
9
PT INELIG RNA NO ANTVIR TX
$0.00
G8461
9
PT REC ANTIVIR TREAT HEP C
$0.00
G8462
9
PT INELIG COUNS NO ANTVIR TX
$0.00
G8463
9
PT REC ANTIVIRAL TREAT DOC
$0.00
G8464
9
PT INELIG; LO TO NO DTER RSK
$0.00
G8465
9
HIGH RISK RECURRENCE PRO CA
$0.00
G8466
9
PT INELIG SUIC; MDD REMIS
$0.00
G8467
9
NEW DX INIT/REC EPISODE MDD
$0.00
G8468
9
ACE/ARB RX PT W/ABN LVEF
$0.00
G8469
9
PT W/ABN LVEF INELIG ACE/ARB
$0.00
G8470
9
PT W/ NORMAL LVEF
$0.00
G8471
9
LVEF NOT PERFORMED/DOC
$0.00
G8472
9
ACE/ARB NO RX PT W/ABN LVEF
$0.00
G8473
9
ACE/ARB THXPY RX'D
$0.00
G8474
9
ACE/ARB NOT RX'D; DOC REAS
$0.00
G8475
9
ACE/ARB THXPY NOT RX'D
$0.00
G8476
9
BP SYS <130 AND DIAS <80
$0.00
G8477
9
BP SYS>=130 AND/OR DIAS >=80
$0.00
G8478
9
BP NOT PERFORMED/DOC
$0.00
G8479
9
MD RX'D ACE/ARB THXPY
$0.00
G8480
9
PT INELIG ACE/ARB THXPY
$0.00
G8481
9
MD NOT RX'D ACE/ARB THXPY
$0.00
G8482
9
FLU IMMUNIZE ORDER/ADMIN
$0.00
G8483
9
FLU IMM NO ORD/ADMIN DOC REA
$0.00
G8484
9
FLU IMMUNIZE NO ORDER/ADMIN
$0.00
G8485
9
REPORT, DIABETES MEASURES
$0.00
G8486
9
REPORT, PREV CARE MEASURES
$0.00
G8487
9
REPORT CKD MEASURES
$0.00
G8488
9
REPORT ESRD MEASURES
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
G8489
9
CAD MEASURES GRP
$0.00
G8490
9
RA MEASURES GRP
$0.00
G8491
9
HIV/AIDS MEASURES GRP
$0.00
G8492
9
PREV CARE MEASURES GRP
$0.00
G8493
9
BACK PAIN MEASURES GRP
$0.00
G8494
9
DM MEAS QUAL ACT PERFORM
$0.00
G8495
9
CKD MEAS QUAL ACT PERFORM
$0.00
G8496
9
PC MEAS QUAL ACT PERFORM
$0.00
G8497
9
CABG MEAS QUAL ACT PERFORM
$0.00
G8498
9
CAD MEAS QUAL ACT PERFORM
$0.00
G8499
9
RA MEAS QUAL ACT PERFORM
$0.00
G8500
9
HIV MEAS QUAL ACT PERFORM
$0.00
G8501
9
PERIO MEAS QUAL ACT PERFORM
$0.00
G8502
9
BP MEAS QUAL ACT PERFORM
$0.00
G8503
9
DOC PROPH ANTIBX W/IN 1 HR
$0.00
G8504
9
DOC ORD PRO ANTBX W/IN 1 HR
$0.00
G8505
9
NO DOC PROPH ANTIBX W/IN 1HR
$0.00
G8506
9
PT REC ACE/ARB
$0.00
G8507
9
PT INELIG PT VERIF MEDS
$0.00
G8508
9
PT INELIG; PAIN ASSES NO F/U
$0.00
G8509
9
PAIN ASSESS NO F/U PLN DOC
$0.00
G8510
9
PT INELIG NEG SCRN DEPRES
$0.00
G8511
9
CLIN DEPRES SCRN NO F/U DOC
$0.00
G8512
9
PAIN SEV QUANT PRESENT
$0.00
G8513
9
ABI MEAS & DOC
$0.00
G8514
9
PT INELIG; ABI MEASURE
$0.00
G8515
9
NO ABI MEASUREMENT
$0.00
G8516
9
SCRN FAL RSK >2 FAL OR W/INJ
$0.00
G8517
9
SCRN FALL RSK; <2 FALLS
$0.00
G8518
9
CLIN STG B/F LUN/ESO CA SURG
$0.00
G8519
9
PT IN; CLIN CA STG B/F SURG
$0.00
G8520
9
CLIN STG B/F SURG NOT DOC
$0.00
G8521
9
ANTPLT RECD 48 HRS & DISCH
$0.00
G8522
9
PT INELIG; ANTIPLT THERAPY
$0.00
G8523
9
ANTPLT NOT RECD REAS NO SPEC
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
G8524
9
PATCH CLOSURE CONV CEA
$0.00
G8525
9
NO PATCH CLOSURE CEA
$0.00
G8526
9
NO PATCH CLOSURE CONV CEA
$0.00
G8527
9
DOC ORD ANTIMIC PROPHY
$0.00
G8528
9
PT INELIG; PROPH ANTIBIOT
$0.00
G8529
9
NO DOC ORD ANTIMIC PROPHY
$0.00
G8530
9
AUTO AV FISTULA RECD
$0.00
G8531
9
PT INELIG; AUTO AV FISTULA
$0.00
G8532
9
NO AUTO AV FISTULA; NO REAS
$0.00
G8533
9
PARTIC IN CLIN DATA BASE REG
$0.00
G8534
9
DOC ELDER MAL SCRN F/U PLAN
$0.00
G8535
9
PT INELIG NO ELD MAL SCRN
$0.00
G8536
9
NO DOC ELDER MAL SCRN
$0.00
G8537
9
PT INELIG ELDMAL SCRN NO F/U
$0.00
G8538
9
ELD MAL SCRN NO F/U PLN
$0.00
G8539
9
CUR FUNCT ASSESS & CARE PLN
$0.00
G8540
9
PT INELIG FUNCT ASSESS
$0.00
G8541
9
NO DOC CUR FUNCT ASSESS
$0.00
G8542
9
PT INELIG FUNC ASSES NO PLN
$0.00
G8543
9
CUR FUNCT ASSES; NO CARE PLN
$0.00
G8544
9
CABG MEASURES GRP
$0.00
G9001
7
MCCD, INITIAL RATE
$0.00
G9002
7
MCCD,MAINTENANCE RATE
$0.00
G9003
9
MCCD, RISK ADJ HI, INITIAL
$0.00
G9004
9
MCCD, RISK ADJ LO, INITIAL
$0.00
G9005
7
MCCD, RISK ADJ, MAINTENANCE
$0.00
G9006
7
MCCD, HOME MONITORING
$0.00
G9007
7
MCCD, SCH TEAM CONF
$0.00
G9008
7
MCCD,PHYS COOR-CARE OVRSGHT
$0.00
G9009
7
MCCD, RISK ADJ, LEVEL 3
$0.00
G9010
9
MCCD, RISK ADJ, LEVEL 4
$0.00
G9011
7
MCCD, RISK ADJ, LEVEL 5
$0.00
G9012
7
OTHER SPECIFIED CASE MGMT
$0.00
G9013
9
ESRD DEMO BUNDLE LEVEL I
$0.00
G9014
9
ESRD DEMO BUNDLE-LEVEL II
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
G9016
9
DEMO-SMOKING CESSATION COUN
$0.00
G9017
9
AMANTADINE HCL 100MG ORAL
$0.00
G9018
9
ZANAMIVIR,INHALATION PWD 10M
$0.00
G9019
9
OSELTAMIVIR PHOSPHATE 75MG
$0.00
G9020
9
RIMANTADINE HCL 100MG ORAL
$0.00
G9021
O
CHEMOTHERAPY ASSESSMENT FOR NAUSEA
$0.00
G9022
O
CHEMOTHERAPY ASSESSMENT FOR NAUSEA
$0.00
G9023
O
CHEMOTHERAPY ASSESSMENT FOR NAUSEA
$0.00
G9024
O
CHEMOTHERAPY ASSESSMENT FOR NAUSEA
$0.00
G9025
O
CHEMOTHERAPY ASSESSMENT FOR PAIN
$0.00
G9026
O
CHEMOTHERAPY ASSESSMENT FOR PAIN
$0.00
G9027
O
CHEMOTHERAPY ASSESSMENT FOR PAIN
$0.00
G9028
O
CHEMOTHERAPY ASSESSMENT FOR PAIN
$0.00
G9029
O
CHEMOTHERAPY ASSESSMENT FOR LACK O
$0.00
G9030
O
CHEMOTHERAPY ASSESSMENT FOR LACK O
$0.00
G9031
O
CHEMOTHERAPY ASSESSMENT FOR LACK O
$0.00
G9032
O
CHEMOTHERAPY ASSESSMENT FOR LACK O
$0.00
G9033
9
AMANTADINE HCL ORAL BRAND
$0.00
G9034
9
SERVICES PROVIDED BY OCCUPATIONAL
$0.00
G9035
9
SERVICES PROVIDED BY ORIENTATION
$0.00
G9036
9
SERVICES PROVIDED BY LOW VISION TH
$0.00
G9037
9
SERVICES PROVIDED BY REHABILITATIO
$0.00
G9041
9
LOW VISION REHAB OCCUPATIONA
$0.00
G9042
9
LOW VISION REHAB ORIENT/MOBI
$0.00
G9043
9
LOW VISION LOWVISION THERAPI
$0.00
G9044
9
LOW VISION REHABILATE TEACHE
$0.00
G9050
9
ONCOLOGY WORK-UP EVALUATION
$0.00
G9051
9
ONCOLOGY TX DECISION-MGMT
$0.00
G9052
9
ONC SURVEILLANCE FOR DISEASE
$0.00
G9053
9
ONC EXPECTANT MANAGEMENT PT
$0.00
G9054
9
ONC SUPERVISION PALLIATIVE
$0.00
G9055
9
ONC VISIT UNSPECIFIED NOS
$0.00
G9056
9
ONC PRAC MGMT ADHERES GUIDE
$0.00
G9057
9
ONC PRACT MGMT DIFFERS TRIAL
$0.00
G9058
9
ONC PRAC MGMT DISAGREE W/GUI
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
G9059
9
ONC PRAC MGMT PT OPT ALTERNA
$0.00
G9060
9
ONC PRAC MGMT DIF PT COMORB
$0.00
G9061
9
ONC PRAC COND NOADD BY GUIDE
$0.00
G9062
9
ONC PRAC GUIDE DIFFERS NOS
$0.00
G9063
9
ONC DX NSCLC STGI NO DX PROG
$0.00
G9064
9
ONC DX NSCLC STG2 NO DX PROG
$0.00
G9065
9
ONC DX NSCLC STG3A NODX PROG
$0.00
G9066
9
ONC DX NSCLC STG3B-4 METASTA
$0.00
G9067
9
ONC DX NSCLC DX UNKNOWN NOS
$0.00
G9068
9
ONC DX NSCLC/SCLC LIMITED
$0.00
G9069
9
ONC DX SCLC/NSCLC EXT AT DX
$0.00
G9070
9
ONC DX SCLC/NSCLC EXT UNKNWN
$0.00
G9071
9
ONC DX BRST STG1 2B NO DX PR
$0.00
G9072
9
ONC DX BRST STG1-2 NOPROGRES
$0.00
G9073
9
ONC DX BRST STG3-W/PROGRES
$0.00
G9074
9
ONC DX BRST STG3-NOPROGRESS
$0.00
G9075
9
ONC DX BRST METASTIC/ RECUR
$0.00
G9076
O
ONC DX BRST UNKNOWN NOS
$0.00
G9077
9
ONC DX PROSTATE T1NO PROGRES
$0.00
G9078
9
ONC DX PROSTATE T2NO PROGRES
$0.00
G9079
9
ONC DX PROSTATE T3B-T4NOPROG
$0.00
G9080
9
ONC DX PROSTATE W/RISE PSA
$0.00
G9081
O
ONC DX PROSTATE METS NO CAST
$0.00
G9082
O
ONC DX PROSTATE CASTRATE MET
$0.00
G9083
9
ONC DX PROSTATE UNKNWN NOS
$0.00
G9084
9
ONC DX COLON T1-3,N1-2,NO PR
$0.00
G9085
9
ONC DX COLON T4, N0 W/O PROG
$0.00
G9086
9
ONC DX COLON T1-4 NO DX PROG
$0.00
G9087
9
ONC DX COLON RADIOLG EVID DX
$0.00
G9088
9
ONC DX COLON M1/METS W/O RAD
$0.00
G9089
9
ONC DX COLON EXTENT UNKNOWN
$0.00
G9090
9
ONC DX RECTAL T1-2 NO PROGR
$0.00
G9091
9
ONC DX RECTAL T3 N0 NO PROG
$0.00
G9092
9
ONC DX RECTAL T1-3,N1-2NOPRG
$0.00
G9093
9
ONC DX RECTAL T4,N,M0 NO PRG
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
G9094
9
ONC DX RECTAL M1 W/METS PROG
$0.00
G9095
9
ONC DX RECTAL EXTENT UNKNWN
$0.00
G9096
9
ONC DX ESOPHAG T1-T3 NOPROG
$0.00
G9097
9
ONC DX ESOPHAGEAL T4 NO PROG
$0.00
G9098
9
ONC DX ESOPHAGEAL METS RECUR
$0.00
G9099
9
ONC DX ESOPHAGEAL UNKNOWN
$0.00
G9100
9
ONC DX GASTRIC NO RECURRENCE
$0.00
G9101
9
ONC DX GASTRIC P R1-R2NOPROG
$0.00
G9102
9
ONC DX GASTRIC UNRESECTABLE
$0.00
G9103
9
ONC DX GASTRIC RECURRENT
$0.00
G9104
9
ONC DX GASTRIC UNKNOWN NOS
$0.00
G9105
9
ONC DX PANCREATC P R0 RES NO
$0.00
G9106
9
ONC DX PANCREATC P R1/R2 NO
$0.00
G9107
9
ONC DX PANCREATIC UNRESECTAB
$0.00
G9108
9
ONC DX PANCREATIC UNKNWN NOS
$0.00
G9109
9
ONC DX HEAD/NECK T1-T2NO PRG
$0.00
G9110
9
ONC DX HEAD/NECK T3-4 NOPROG
$0.00
G9111
9
ONC DX HEAD/NECK M1 METS REC
$0.00
G9112
9
ONC DX HEAD/NECK EXT UNKNOWN
$0.00
G9113
9
ONC DX OVARIAN STG1A-B NO PR
$0.00
G9114
9
ONC DX OVARIAN STG1A-B OR 2
$0.00
G9115
9
ONC DX OVARIAN STG3/4 NOPROG
$0.00
G9116
9
ONC DX OVARIAN RECURRENCE
$0.00
G9117
9
ONC DX OVARIAN UNKNOWN NOS
$0.00
G9118
O
ONC DX NHL STG 1-2 NOT RELAP
$0.00
G9119
O
ONC DX NHL STG 3-4 NOT RELAP
$0.00
G9120
O
ONC DX NHL TRANS TO LG BCELL
$0.00
G9121
O
ONC NHLSTG 1-2 NO RELAP NO
$0.00
G9122
O
ONC DX NHL STG 3/4NO RELAP
$0.00
G9123
9
ONC DX NHL LGE BCELL RELAP
$0.00
G9124
9
ONC DX NHL RELAPSE/REFRACTOR
$0.00
G9125
9
ONC DX NHL STG UNKNOWN
$0.00
G9126
9
ONC DX OVARIAN STG IA/B
$0.00
G9127
O
ONC DX MULTI MYELOMA STAGE I
$0.00
G9128
9
ONC DX MULT MYELOMA STG2 HIG
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
G9129
9
ONC DX MULT MYELOMA UNKWN OP
$0.00
G9130
9
ONC DX MULTI MYELOMA UNKNOWN
$0.00
G9131
9
ONC DX BRST UNKNOWN NOS
$0.00
G9132
9
ONC DX PROSTATE METS NO CAST
$0.00
G9133
9
ONC DX PROSTATE CLINICAL MET
$0.00
G9134
9
ONC NHLSTG 1-2 NO RELAP NO
$0.00
G9135
9
ONC DX NHL STG 3-4 NOT RELAP
$0.00
G9136
9
ONC DX NHL TRANS TO LG BCELL
$0.00
G9137
9
ONC DX NHL RELAPSE/REFRACTOR
$0.00
G9138
9
ONC DX NHL STG UNKNOWN
$0.00
G9139
9
ONC DX CML DX STATUS UNKNOWN
$0.00
G9140
9
FRONTIER EXTENDED STAY DEMO
$0.00
H0001
7
ALCOHOL AND/OR DRUG ASSESS
$0.00
H0002
7
ALCOHOL AND/OR DRUG SCREENIN
$0.00
H0003
9
ALCOHOL AND/OR DRUG SCREENIN
$0.00
H0004
9
ALCOHOL AND/OR DRUG SERVICES
$0.00
H0005
7
ALCOHOL AND/OR DRUG SERVICES
$0.00
H0006
9
ALCOHOL AND/OR DRUG SERVICES
$0.00
H0007
7
ALCOHOL AND/OR DRUG SERVICES
$0.00
H0008
9
ALCOHOL AND/OR DRUG SERVICES
$0.00
H0009
9
ALCOHOL AND/OR DRUG SERVICES
$0.00
H0010
9
ALCOHOL AND/OR DRUG SERVICES
$0.00
H0011
9
ALCOHOL AND/OR DRUG SERVICES
$0.00
H0012
9
ALCOHOL AND/OR DRUG SERVICES
$0.00
H0013
9
ALCOHOL AND/OR DRUG SERVICES
$0.00
H0014
9
ALCOHOL AND/OR DRUG SERVICES
$0.00
H0015
7
ALCOHOL AND/OR DRUG SERVICES
$0.00
H0016
9
ALCOHOL AND/OR DRUG SERVICES
$0.00
H0017
7
ALCOHOL AND/OR DRUG SERVICES
$0.00
H0018
7
ALCOHOL AND/OR DRUG SERVICES
$0.00
H0019
7
ALCOHOL AND/OR DRUG SERVICES
$0.00
H0020
3
ALCOHOL AND/OR DRUG SERVICES
$4.00
H0021
9
ALCOHOL AND/OR DRUG TRAINING
$0.00
H0022
9
ALCOHOL AND/OR DRUG INTERVEN
$0.00
H0023
9
ALCOHOL AND/OR DRUG OUTREACH
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
H0024
9
ALCOHOL AND/OR DRUG PREVENTI
$0.00
H0025
9
ALCOHOL AND/OR DRUG PREVENTI
$0.00
H0026
9
ALCOHOL AND/OR DRUG PREVENTI
$0.00
H0027
9
ALCOHOL AND/OR DRUG PREVENTI
$0.00
H0028
9
ALCOHOL AND/OR DRUG PREVENTI
$0.00
H0029
9
ALCOHOL AND/OR DRUG PREVENTI
$0.00
H0030
9
ALCOHOL AND/OR DRUG HOTLINE
$0.00
H0031
7
MH HEALTH ASSESS BY NON-MD
$0.00
H0032
7
MH SVC PLAN DEV BY NON-MD
$0.00
H0033
9
ORAL MED ADM DIRECT OBSERVE
$0.00
H0034
9
MED TRNG & SUPPORT PER 15MIN
$0.00
H0035
9
MH PARTIAL HOSP TX UNDER 24H
$0.00
H0036
9
COMM PSY FACE-FACE PER 15MIN
$0.00
H0037
7
COMM PSY SUP TX PGM PER DIEM
$0.00
H0038
9
SELF-HELP/PEER SVC PER 15MIN
$0.00
H0039
7
ASSER COM TX FACE-FACE/15MIN
$0.00
H0040
9
ASSERT COMM TX PGM PER DIEM
$0.00
H0041
9
FOS C CHLD NON-THER PER DIEM
$0.00
H0042
9
FOS C CHLD NON-THER PER MON
$0.00
H0043
7
SUPPORTED HOUSING, PER DIEM
$0.00
H0044
9
SUPPORTED HOUSING, PER MONTH
$0.00
H0045
9
RESPITE NOT-IN-HOME PER DIEM
$0.00
H0046
7
MENTAL HEALTH SERVICE, NOS
$0.00
H0047
9
ALCOHOL/DRUG ABUSE SVC NOS
$0.00
H0048
9
SPEC COLL NON-BLOOD:A/D TEST
$0.00
H0049
9
ALCOHOL/DRUG SCREENING
$0.00
H0050
9
ALCOHOL/DRUG SERVICE 15 MIN
$0.00
H1000
9
PRENATAL CARE ATRISK ASSESSM
$0.00
H1001
9
ANTEPARTUM MANAGEMENT
$0.00
H1002
9
CARECOORDINATION PRENATAL
$0.00
H1003
9
PRENATAL AT RISK EDUCATION
$0.00
H1004
9
FOLLOW UP HOME VISIT/PRENTAL
$0.00
H1005
9
PRENATALCARE ENHANCED SRV PK
$0.00
H1010
9
NONMED FAMILY PLANNING ED
$0.00
H1011
9
FAMILY ASSESSMENT
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
H2000
9
COMP MULTIDISIPLN EVALUATION
$0.00
H2001
9
REHABILITATION PROGRAM 1/2 D
$0.00
H2010
9
COMPREHENSIVE MED SVC 15 MIN
$0.00
H2011
7
CRISIS INTERVEN SVC, 15 MIN
$0.00
H2012
7
BEHAV HLTH DAY TREAT, PER HR
$0.00
H2013
9
PSYCH HLTH FAC SVC, PER DIEM
$0.00
H2014
9
SKILLS TRAIN AND DEV, 15 MIN
$0.00
H2015
9
COMP COMM SUPP SVC, 15 MIN
$0.00
H2016
7
COMP COMM SUPP SVC, PER DIEM
$0.00
H2017
9
PSYSOC REHAB SVC, PER 15 MIN
$0.00
H2018
7
PSYSOC REHAB SVC, PER DIEM
$0.00
H2019
9
THER BEHAV SVC, PER 15 MIN
$0.00
H2020
7
THER BEHAV SVC, PER DIEM
$0.00
H2021
9
COM WRAP-AROUND SV, 15 MIN
$0.00
H2022
9
COM WRAP-AROUND SV, PER DIEM
$0.00
H2023
9
SUPPPORTED EMPLOY, PER 15 MIN
$0.00
H2024
7
SUPPORTED EMPLOY, PER DIEM
$0.00
H2025
9
SUPP MAINT EMPLOY, 15 MIN
$0.00
H2026
9
SUPP MAINT EMPLOY, PER DIEM
$0.00
H2027
7
PSYCHOED SVC, PER 15 MIN
$0.00
H2028
9
SEX OFFEND TX SVC, 15 MIN
$0.00
H2029
9
SEX OFFEND TX SVC, PER DIEM
$0.00
H2030
9
MH CLUBHOUSE SVC, PER 15 MIN
$0.00
H2031
9
MH CLUBHOUSE SVC, PER DIEM
$0.00
H2032
9
ACTIVITY THERAPY, PER 15 MIN
$0.00
H2033
9
MULTISYS THER/JUVENILE 15MIN
$0.00
H2034
9
A/D HALFWAY HOUSE, PER DIEM
$0.00
H2035
7
A/D TX PROGRAM, PER HOUR
$0.00
H2036
7
A/D TX PROGRAM, PER DIEM
$0.00
H2037
9
DEV DELAY PREV DP CH, 15 MIN
$0.00
H5010
9
THERAPY, INDIVIDUAL, BY SOCIAL WORK
$0.00
H5020
9
PSYCHOTHERAPY, GROUP (MAXIMUM 8 PER
$0.00
H5025
9
PSYCHOTHERAPY, GROUP (MAXIMUM 8 PER
$0.00
H5030
9
OTHER SERVICES BY SOCIAL WORKER, PS
$0.00
H5040
9
RESIDENTIAL CARE IN PUBLIC INSTITUT
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
H5050
9
RESIDENTIAL CARE IN PRIVATE INSTITU
$0.00
H5060
9
PUBLIC SPECIAL SCHOOLS OR DAY CARE
$0.00
H5090
9
SPECIAL CLASS PRIVATE
$0.00
H5100
9
SPECIAL CLASS PRIVATE PROPRIETARY
$0.00
H5110
9
SUMMER TREATMENT CAMP
$0.00
H5120
9
SPECIALIZED CARE NURSING HOME, CONV
$0.00
H5130
9
VISITING TEACHER SERVICES
$0.00
H5160
9
READING THERAPY
$0.00
H5170
9
OTHER SPECIAL EDUCATION OR VOCATION
$0.00
H5180
9
TRANSPORTATION FOR HANDICAPPED
$0.00
H5190
9
NURSING CARE, HOME
$0.00
H5200
9
NURSING CARE, OTHER
$0.00
H5220
9
REHABILITATIVE EVALUATION, 0-20 MIN
$0.00
H5230
9
REHABILITATIVE EVALUATION, 21-40 MI
$0.00
H5240
9
REHABILITATIVE EVALUATION, 41-60 MI
$0.00
H5299
9
REHABILITATIVE EVALUATION, NOT OTHE
$0.00
H5300
9
OCCUPATIONAL THERAPY, EXCLUDING INI
$0.00
HI010
O
MCO SPECIFIC CODE: HOME INFUSION PA
$0.00
HI011
O
MCO SPECIFIC CODE: HOME INFUSION PA
$0.00
HI012
O
MCO SPECIFIC CODE: HOME INFUSION PA
$0.00
HI013
O
MCO SPECIFIC CODE: HOME INFUSION PA
$0.00
HI014
O
MCO SPECIFIC CODE: HOME INFUSION PA
$0.00
HI020
O
MCO SPECIFIC CODE: HOME INFUSION PA
$0.00
HI021
O
MCO SPECIFIC: HOME INFUSION PACKAGE
$0.00
HI022
O
MCO SPECIFIC CODE: HOME INFUSION PA
$0.00
HI023
O
MCO SPECIFIC CODE: HOME INFUSION PA
$0.00
HI024
O
MCO SPECIFIC CODE: HOME INFUSION PA
$0.00
HI030
O
MCO SPECIFIC CODE: HOME INFUSION PA
$0.00
HI031
O
MCO SCPECIFIC CODE: HOME INFUSION P
$0.00
HI032
O
MCO SPECIFIC CODE: HOME INFUSION PA
$0.00
HI033
O
MCO SPECIFIC CODE: HOME INFUSION PA
$0.00
HI034
O
MCO SPECIFIC CODE: HOME INFUSION PA
$0.00
HI040
O
MCO SPECIFIC CODE: HOME INFUSION PA
$0.00
HI041
O
MCO SPECIFIC CODE: HOME INFUSION PA
$0.00
HI042
O
MCO SPECIFIC CODE: HOME INFUSION PA
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
HI043
O
MCO SPECIFIC CODE: HOME INFUSION PA
$0.00
HI044
O
MCO SPECIFIC CODE: HOME INFUSION PA
$0.00
HI050
O
MCO SPECIFIC CODE: HOME INFUSION PA
$0.00
HI060
O
MCO SPECIFIC CODE: HOME INFUSION PA
$0.00
HI070
O
MCO SPECIFIC CODE: HOME INFUSION PA
$0.00
HI080
O
MCO SPECIFIC CODE: HOME INFUSION, S
$0.00
HI081
O
MCO SPECIFIC CODE: HOME INFUSION, S
$0.00
HI082
O
MCO SPECIFIC CODE: HOME INFUSION, S
$0.00
HI090
O
MCO SPECIFIC CODE: HOME INFUSION PA
$0.00
HI091
O
MCO SPECIFIC CODE: HOME INFUSION PA
$0.00
HI092
O
MCO SPECIFIC CODE: HOME INFUSION PA
$0.00
HI093
O
MCO SPECIFIC CODE: HOME INFUSION PA
$0.00
HI094
O
MCO SPECIFIC CODE: HOME INFUSION PA
$0.00
HI100
O
MCO SPECIFIC CODE: HOME INFUSION PA
$0.00
HI110
O
MCO SPECIFIC CODE: HOME INFUSION PA
$0.00
HI120
O
MCO SPECIFIC CODE: HOME INFUSION, E
$0.00
HI130
O
MCO SPECIFIC CODE: HOME INFUSION PA
$0.00
HI140
O
MCO SPECIFIC CODE: HOME INFUSION PA
$0.00
HI160
O
MCO SPECIFIC CODE: HOME INFUSION PA
$0.00
HI170
O
MCO SPECIFIC CODE: HOME INFUSION PA
$0.00
HI171
O
MCO SPECIFIC CODE: HOME INFUSION PA
$0.00
HI172
O
MCO SPECIFIC CODE: HOME INFUSION PA
$0.00
HI180
O
MCO SPECIFIC CODE: HOME INFUSION PA
$0.00
HI190
O
MCO SPECIFIC CODE: HOME INFUSION PA
$0.00
HM1CW
O
MCO SPECIFIC CODE: SMART START INIT
$0.00
HM1RN
O
MCO SPECIFIC CODE: SMART START INIT
$0.00
HM1SW
O
MCO SPECIFIC CODE: SMART START INIT
$0.00
HM2CW
O
MCO SPECIFIC CODE: SMART START POST
$0.00
HM2RN
O
MCO SPECIFIC CODE: SMART START POST
$0.00
HM2SW
O
MCO SPECIFIC CODE: SMART START POST
$0.00
J0110
O
ADMINISTRATION OF INJECTION, INCLUD
$0.00
J0120
5
TETRACYCLIN INJECTION
$0.00
J0128
6
ABARELIX INJECTION
$0.00
J0129
3
ABATACEPT INJECTION
$19.04
J0130
3
ABCIXIMAB INJECTION
$444.32
Procedure Code Pricing Action Code Description
Maximum Allowable
J0132
5
ACETYLCYSTEINE INJECTION
$0.00
J0133
5
ACYCLOVIR INJECTION
$0.00
J0135
6
ADALIMUMAB INJECTION
$0.00
J0150
3
INJECTION ADENOSINE 6 MG
$9.62
J0151
5
ADENOSINE INJECTION
$0.00
J0152
3
ADENOSINE INJECTION
$37.63
J0170
3
ADRENALIN EPINEPHRIN INJECT
$0.67
J0180
6
AGALSIDASE BETA INJECTION
$0.00
J0190
5
INJ BIPERIDEN LACTATE/5 MG
$0.00
J0200
9
ALATROFLOXACIN MESYLATE
$0.00
J0205
5
ALGLUCERASE INJECTION
$0.00
J0207
3
AMIFOSTINE
J0210
5
METHYLDOPATE HCL INJECTION
$0.00
J0215
6
ALEFACEPT
$0.00
J0220
3
INJECTION, ALGLUCOSIDASE ALFA,
J0230
O
INJECTION, ALLERGY DESENSITIZATION,
$0.00
J0240
O
INJECTION, ALLERGY DESENSITIZATION,
$0.00
J0256
5
ALPHA 1 PROTEINASE INHIBITOR
$0.00
J0270
9
ALPROSTADIL FOR INJECTION
$0.00
J0275
9
ALPROSTADIL URETHRAL SUPPOS
$0.00
J0278
5
AMIKACIN SULFATE INJECTION
$0.00
J0280
3
AMINOPHYLLIN 250 MG INJ
$0.42
J0282
5
AMIODARONE HCL
$0.00
J0285
5
AMPHOTERICIN B
$0.00
J0286
O
AMPHOTERICIN B LIPID COMPLEX
$0.00
J0287
3
AMPHOTERICIN B LIPID COMPLEX
$10.58
J0288
5
AMPHO B CHOLESTERYL SULFATE
$0.00
J0289
3
AMPHOTERICIN B LIPOSOME INJ
J0290
3
AMPICILLIN 500 MG INJ
$1.34
J0295
3
AMPICILLIN SODIUM PER 1.5 GM
$3.12
J0300
5
AMOBARBITAL 125 MG INJ
$0.00
J0330
3
SUCCINYCHOLINE CHLORIDE INJ
$0.14
J0340
O
NANDROLON PHENPROPIONATE INJ
$0.00
J0348
3
ANIDULAFUNGIN INJECTION
$1.28
J0350
5
INJECTION ANISTREPLASE 30 U
$0.00
$188.30
$123.84
$15.59
Procedure Code Pricing Action Code Description
Maximum Allowable
J0360
5
HYDRALAZINE HCL INJECTION
$0.00
J0364
3
APOMORPHINE HYDROCHLORIDE
$3.71
J0365
5
APROTONIN, 10,000 KIU
$0.00
J0380
5
INJ METARAMINOL BITARTRATE
$0.00
J0390
5
CHLOROQUINE INJECTION
$0.00
J0395
5
ARBUTAMINE HCL INJECTION
$0.00
J0400
3
INJECTION, ARIPIPRAZOLE, INTRAMUSC
$0.29
J0456
3
AZITHROMYCIN
$9.17
J0460
3
ATROPINE SULFATE INJECTION
$0.28
J0470
5
DIMECAPROL INJECTION
$0.00
J0475
6
BACLOFEN 10 MG INJECTION
$0.00
J0476
3
BACLOFEN INTRATHECAL TRIAL
J0480
5
BASILIXIMAB
$0.00
J0500
5
DICYCLOMINE INJECTION
$0.00
J0510
O
BENZQUINAMIDE INJECTION
$0.00
J0515
5
INJ BENZTROPINE MESYLATE
$0.00
J0520
5
BETHANECHOL CHLORIDE INJECT
$0.00
J0530
5
PENICILLIN G BENZATHINE INJ
$0.00
J0540
5
PENICILLIN G BENZATHINE INJ
$0.00
J0550
5
PENICILLIN G BENZATHINE INJ
$0.00
J0560
5
PENICILLIN G BENZATHINE INJ
$0.00
J0570
3
PENICILLIN G BENZATHINE INJ
$13.60
J0580
5
PENICILLIN G BENZATHINE INJ
$0.00
J0583
6
BIVALIRUDIN
$0.00
J0585
3
BOTULINUM TOXIN A PER UNIT
$5.41
J0587
3
BOTULINUM TOXIN TYPE B
$8.87
J0590
O
ETHYLNOREPINEPHRINE HCL INJ
$0.00
J0592
5
BUPRENORPHINE HYDROCHLORIDE
$0.00
J0594
3
BUSULFAN INJECTION
$9.53
J0595
6
BUTORPHANOL TARTRATE 1 MG
$0.00
J0600
5
EDETATE CALCIUM DISODIUM INJ
$0.00
J0610
3
CALCIUM GLUCONATE INJECTION
$0.29
J0620
5
CALCIUM GLYCER & LACT/10 ML
$0.00
J0630
5
CALCITONIN SALMON INJECTION
$0.00
J0635
O
CALCITRIOL INJECTION
$0.00
$69.97
Procedure Code Pricing Action Code Description
Maximum Allowable
J0636
5
INJ CALCITRIOL PER 0.1 MCG
$0.00
J0637
5
CASPOFUNGIN ACETATE
$0.00
J0640
3
LEUCOVORIN CALCIUM INJECTION
$1.95
J0641
3
LEVOLEUCOVORIN INJECTION
$1.05
J0670
3
INJ MEPIVACAINE HCL/10 ML
$1.82
J0680
O
INJECTION, DESLANOSIDE, UP TO 0.4 M
$0.00
J0690
3
CEFAZOLIN SODIUM INJECTION
$0.59
J0692
3
CEFEPIME HCL FOR INJECTION
$5.25
J0694
3
CEFOXITIN SODIUM INJECTION
$6.45
J0695
O
CEFONOCID SODIUM INJECTION
$0.00
J0696
3
CEFTRIAXONE SODIUM INJECTION
$13.78
J0697
5
STERILE CEFUROXIME INJECTION
$0.00
J0698
5
CEFOTAXIME SODIUM INJECTION
$0.00
J0700
O
INJECTION, BETAMETHASONE, UP TO 6 M
$0.00
J0702
3
BETAMETHASONE ACET&SOD PHOSP
$6.08
J0704
5
BETAMETHASONE SOD PHOSP/4 MG
$0.00
J0706
5
CAFFEINE CITRATE INJECTION
$0.00
J0710
5
CEPHAPIRIN SODIUM INJECTION
$0.00
J0713
5
INJ CEFTAZIDIME PER 500 MG
$0.00
J0715
5
CEFTIZOXIME SODIUM / 500 MG
$0.00
J0720
5
CHLORAMPHENICOL SODIUM INJEC
$0.00
J0725
5
CHORIONIC GONADOTROPIN/1000U
$0.00
J0730
O
CHLORPHENIRAMIN MALEATE INJ
$0.00
J0735
5
CLONIDINE HYDROCHLORIDE
$0.00
J0740
3
CIDOFOVIR INJECTION
J0743
3
CILASTATIN SODIUM INJECTION
J0744
3
CIPROFLOXACIN IV
$1.66
J0745
5
INJ CODEINE PHOSPHATE /30 MG
$0.00
J0760
6
COLCHICINE INJECTION
$0.00
J0770
5
COLISTIMETHATE SODIUM INJ
$0.00
J0780
5
PROCHLORPERAZINE INJECTION
$0.00
J0790
O
INJECTION, NIKETHAMIDE, UP TO 1.5 M
$0.00
J0795
5
CORTICORELIN OVINE TRIFLUTAL
$0.00
J0800
3
CORTICOTROPIN INJECTION
J0810
O
CORTISONE INJECTION
$761.41 $13.68
$2,425.07 $0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
J0820
O
INJECTION, CORTIGEL 40, UP TO 40 UN
$0.00
J0830
O
INJECTION, CORTROPHIN ZINC HYDROXID
$0.00
J0835
3
INJ COSYNTROPIN PER 0.25 MG
J0840
O
INJECTION, WARFARIN SODIUM, UP TO 5
J0850
3
CYTOMEGALOVIRUS IMM IV /VIAL
J0878
3
DAPTOMYCIN INJECTION
$0.38
J0880
O
DARBEPOETIN ALFA INJECTION
$0.00
J0881
3
DARBEPOETIN ALFA, NON-ESRD
$3.06
J0882
5
DARBEPOETIN ALFA, ESRD USE
$0.00
J0885
3
EPOETIN ALFA, NON-ESRD
$9.20
J0886
5
EPOETIN ALFA 1000 UNITS ESRD
$0.00
J0894
3
DECITABINE INJECTION
J0895
5
DEFEROXAMINE MESYLATE INJ
$0.00
J0900
5
TESTOSTERONE ENANTHATE INJ
$0.00
J0945
5
BROMPHENIRAMINE MALEATE INJ
$0.00
J0970
5
ESTRADIOL VALERATE INJECTION
$0.00
J1000
5
DEPO-ESTRADIOL CYPIONATE INJ
$0.00
J1020
3
METHYLPREDNISOLONE 20 MG INJ
$1.88
J1030
3
METHYLPREDNISOLONE 40 MG INJ
$4.14
J1040
3
METHYLPREDNISOLONE 80 MG INJ
$10.57
J1050
5
MEDROXYPROGESTERONE INJ
$0.00
J1051
3
MEDROXYPROGESTERONE INJ
$7.28
J1055
3
MEDRXYPROGESTER ACETATE INJ
$28.91
J1056
3
MA/EC CONTRACEPTIVEINJECTION
$22.50
J1060
5
TESTOSTERONE CYPIONATE 1 ML
$0.00
J1070
5
TESTOSTERONE CYPIONAT 100 MG
$0.00
J1080
5
TESTOSTERONE CYPIONAT 200 MG
$0.00
J1090
O
TESTOSTERONE CYPIONATE 50 MG
$0.00
J1094
6
INJ DEXAMETHASONE ACETATE
$0.00
J1095
5
INJ DEXAMETHASONE ACETATE
$0.00
J1100
3
DEXAMETHASONE SODIUM PHOS
$0.09
J1110
3
INJ DIHYDROERGOTAMINE MESYLT
$22.69
J1120
5
ACETAZOLAMID SODIUM INJECTIO
$0.00
J1155
O
INJECTION, DIGITOXIN
$0.00
J1160
5
DIGOXIN INJECTION
$0.00
$98.20 $0.00 $878.83
$27.68
Procedure Code Pricing Action Code Description
Maximum Allowable
J1162
5
DIGOXIN IMMUNE FAB (OVINE)
$0.00
J1165
5
PHENYTOIN SODIUM INJECTION
$0.00
J1170
6
HYDROMORPHONE INJECTION
$0.00
J1180
5
DYPHYLLINE INJECTION
$0.00
J1190
5
DEXRAZOXANE HCL INJECTION
$0.00
J1200
3
DIPHENHYDRAMINE HCL INJECTIO
$0.73
J1205
5
CHLOROTHIAZIDE SODIUM INJ
$0.00
J1212
5
DIMETHYL SULFOXIDE 50% 50 ML
$0.00
J1230
5
METHADONE INJECTION
$0.00
J1240
5
DIMENHYDRINATE INJECTION
$0.00
J1245
3
DIPYRIDAMOLE INJECTION
$7.52
J1250
3
INJ DOBUTAMINE HCL/250 MG
$3.25
J1260
3
DOLASETRON MESYLATE
$4.63
J1265
5
DOPAMINE INJECTION
$0.00
J1267
3
DORIPENEM INJECTION
$0.65
J1270
5
INJECTION, DOXERCALCIFEROL
$0.00
J1300
3
ECULIZUMAB INJECTION
J1320
5
AMITRIPTYLINE INJECTION
J1324
3
ENFUVIRTIDE INJECTION
$26.04
J1325
3
EPOPROSTENOL INJECTION
$11.93
J1327
5
EPTIFIBATIDE INJECTION
$0.00
J1330
5
ERGONOVINE MALEATE INJECTION
$0.00
J1335
3
ERTAPENEM INJECTION
J1340
O
INJECTION, AQUEOUS OR SALINE PLACEB
$0.00
J1350
O
INJECTION, ERYTHROMYCIN-IM, UP TO 1
$0.00
J1360
O
INJECTION, ERTHROMYCIN-IV, UP TO 50
$0.00
J1362
O
ERYTHROMYCIN GLUCEP / 250 MG
$0.00
J1364
5
ERYTHRO LACTOBIONATE /500 MG
$0.00
J1380
5
ESTRADIOL VALERATE 10 MG INJ
$0.00
J1390
5
ESTRADIOL VALERATE 20 MG INJ
$0.00
J1410
3
INJ ESTROGEN CONJUGATE 25 MG
$78.49
J1430
3
ETHANOLAMINE OLEATE 100 MG
$79.46
J1435
5
INJECTION ESTRONE PER 1 MG
$0.00
J1436
5
ETIDRONATE DISODIUM INJ
$0.00
J1438
5
ETANERCEPT INJECTION
$0.00
$176.19 $0.00
$26.07
Procedure Code Pricing Action Code Description
Maximum Allowable
J1440
3
FILGRASTIM 300 MCG INJECITON
$202.11
J1441
3
FILGRASTIM 480 MCG INJECTION
$274.45
J1450
5
FLUCONAZOLE
$0.00
J1451
5
FOMEPIZOLE, 15 MG
$0.00
J1452
5
INTRAOCULAR FOMIVIRSEN NA
$0.00
J1453
3
FOSAPREPITANT INJECTION
$1.57
J1455
3
FOSCARNET SODIUM INJECTION
J1457
6
GALLIUM NITRATE INJECTION
J1458
3
GALSULFASE INJECTION
$326.65
J1459
3
INJ IVIG PRIVIGEN 500 MG
$34.15
J1460
5
GAMMA GLOBULIN 1 CC INJ
$0.00
J1470
5
GAMMA GLOBULIN 2 CC INJ
$0.00
J1480
5
GAMMA GLOBULIN 3 CC INJ
$0.00
J1490
5
GAMMA GLOBULIN 4 CC INJ
$0.00
J1500
5
GAMMA GLOBULIN 5 CC INJ
$0.00
J1510
5
GAMMA GLOBULIN 6 CC INJ
$0.00
J1520
5
GAMMA GLOBULIN 7 CC INJ
$0.00
J1530
5
GAMMA GLOBULIN 8 CC INJ
$0.00
J1540
5
GAMMA GLOBULIN 9 CC INJ
$0.00
J1550
5
GAMMA GLOBULIN 10 CC INJ
$0.00
J1560
5
GAMMA GLOBULIN > 10 CC INJ
$0.00
J1561
3
IMMUNE GLOBULIN 500 MG
J1562
3
VIVAGLOBIN, INJ
$7.02
J1563
O
IV IMMUNE GLOBULIN
$0.00
J1564
O
IMMUNE GLOBULIN 10 MG
$0.00
J1565
5
RSV-IVIG
$0.00
J1566
5
IMMUNE GLOBULIN, POWDER
$0.00
J1567
O
IMMUNE GLOBULIN, LIQUID
$0.00
J1568
3
OCTAGAM INJECTION
$36.87
J1569
3
GAMMAGARD LIQUID INJECTION
$35.38
J1570
6
GANCICLOVIR SODIUM INJECTION
J1571
3
HEPAGAM B IM INJECTION
$44.09
J1572
3
FLEBOGAMMA INJECTION
$35.60
J1573
3
HEPAGAM B INTRAVENOUS, INJ
$44.09
J1580
3
GARAMYCIN GENTAMICIN INJ
$10.61 $0.00
$35.53
$0.00
$0.69
Procedure Code Pricing Action Code Description
Maximum Allowable
J1590
5
GATIFLOXACIN INJECTION
$0.00
J1595
3
INJECTION GLATIRAMER ACETATE
J1600
5
GOLD SODIUM THIOMALEATE INJ
$0.00
J1610
5
GLUCAGON HYDROCHLORIDE/1 MG
$0.00
J1620
5
GONADORELIN HYDROCH/ 100 MCG
$0.00
J1625
O
INJECTION, GRANISETRON HYDROCHLORID
$0.00
J1626
3
GRANISETRON HCL INJECTION
$3.45
J1630
5
HALOPERIDOL INJECTION
$0.00
J1631
5
HALOPERIDOL DECANOATE INJ
$0.00
J1640
5
INJECTION, HEMIN, 1 MG
$0.00
J1642
3
INJ HEPARIN SODIUM PER 10 U
$0.02
J1644
3
INJ HEPARIN SODIUM PER 1000U
$0.11
J1645
5
DALTEPARIN SODIUM
$0.00
J1650
3
INJ ENOXAPARIN SODIUM
$6.20
J1652
5
FONDAPARINUX SODIUM
$0.00
J1655
3
TINZAPARIN SODIUM INJECTION
$2.12
J1660
O
INJECTION, HISTAMINE, UP TO 2.75 MG
$0.00
J1670
5
TETANUS IMMUNE GLOBULIN INJ
$0.00
J1675
5
HISTRELIN ACETATE
$0.00
J1690
O
PREDNISOLONE TEBUTATE INJ
$0.00
J1700
5
HYDROCORTISONE ACETATE INJ
$0.00
J1710
5
HYDROCORTISONE SODIUM PH INJ
$0.00
J1720
3
HYDROCORTISONE SODIUM SUCC I
$2.10
J1730
5
DIAZOXIDE INJECTION
$0.00
J1739
O
HYDROXYPROGESTERONE CAP 125
$0.00
J1740
3
IBANDRONATE SODIUM INJECTION
J1741
O
HYDROXYPROGESTERONE CAP 250
$0.00
J1742
5
IBUTILIDE FUMARATE INJECTION
$0.00
J1743
3
IDURSULFASE INJECTION
J1745
3
INFLIXIMAB INJECTION
J1750
6
IRON DEXTRAN
$0.00
J1751
O
IRON DEXTRAN 165 INJECTION
$0.00
J1752
O
IRON DEXTRAN 267 INJECTION
$0.00
J1755
O
IRON SUCROSE INJECTION
$0.00
J1756
3
IRON SUCROSE INJECTION
$0.37
$67.64
$138.96
$452.09 $57.08
Procedure Code Pricing Action Code Description
Maximum Allowable
J1760
O
IRON DEXTRAN 2 CC INJ
$0.00
J1770
O
IRON DEXTRAN 5 CC INJ
$0.00
J1780
O
IRON DEXTRAN 10 CC INJ
$0.00
J1785
5
INJECTION IMIGLUCERASE /UNIT
$0.00
J1790
5
DROPERIDOL INJECTION
$0.00
J1800
5
PROPRANOLOL INJECTION
$0.00
J1810
5
DROPERIDOL/FENTANYL INJ
$0.00
J1815
3
INSULIN INJECTION
$0.19
J1817
5
INSULIN FOR INSULIN PUMP USE
$0.00
J1820
O
INSULIN INJECTION
$0.00
J1825
3
INTERFERON BETA-1A
J1830
5
INTERFERON BETA-1B / .25 MG
$0.00
J1835
5
INTRACONAZOLE INJECTION
$0.00
J1840
5
KANAMYCIN SULFATE 500 MG INJ
$0.00
J1850
5
KANAMYCIN SULFATE 75 MG INJ
$0.00
J1885
3
KETOROLAC TROMETHAMINE INJ
$0.30
J1890
5
CEPHALOTHIN SODIUM INJECTION
$0.00
J1910
O
KUTAPRESSIN INJECTION
$0.00
J1930
6
INJECTION, LANREOTIDE, 1 MG
$0.00
J1931
3
LARONIDASE INJECTION
$24.96
J1940
3
FUROSEMIDE INJECTION
$0.21
J1945
5
LEPIRUDIN
$0.00
J1950
5
LEUPROLIDE ACETATE /3.75 MG
$0.00
J1953
3
LEVETIRACETAM INJECTION
$0.43
J1955
5
INJ LEVOCARNITINE PER 1 GM
$0.00
J1956
3
LEVOFLOXACIN INJECTION
$5.97
J1960
5
LEVORPHANOL TARTRATE INJ
$0.00
J1970
O
METHOTRIMEPRAZINE INJECTION
$0.00
J1980
5
HYOSCYAMINE SULFATE INJ
$0.00
J1990
5
CHLORDIAZEPOXIDE INJECTION
$0.00
J2000
O
LIDOCAINE INJECTION
$0.00
J2001
3
LIDOCAINE INJECTION
$0.02
J2010
5
LINCOMYCIN INJECTION
$0.00
J2020
5
LINEZOLID INJECTION
$0.00
J2050
O
INJECTION, LIVER, UP TO 20 MCG
$0.00
$542.32
Procedure Code Pricing Action Code Description
Maximum Allowable
J2060
3
LORAZEPAM INJECTION
$0.75
J2100
O
INJECTION, LUMINAL SODIUM, UP TO 12
$0.00
J2150
3
MANNITOL INJECTION
$0.91
J2160
O
INJECTION, CYCLIZINE LACTATE, UP TO
$0.00
J2170
3
MECASERMIN INJECTION
J2175
3
MEPERIDINE HYDROCHL /100 MG
$0.54
J2180
5
MEPERIDINE/PROMETHAZINE INJ
$0.00
J2185
6
MEROPENEM
$0.00
J2190
O
INJECTION, MERSALYL WITH THEOPHYLLI
$0.00
J2210
5
METHYLERGONOVIN MALEATE INJ
$0.00
J2220
5
INJECTION, METHYLANDROSTENEDIOL, AL
$0.00
J2240
O
METOCURINE IODIDE INJECTION
$0.00
J2248
3
MICAFUNGIN SODIUM INJECTION
$1.96
J2250
3
INJ MIDAZOLAM HYDROCHLORIDE
$0.16
J2260
5
INJECTION, MILRINONE LACTATE 5MG
$0.00
J2270
3
MORPHINE SULFATE INJECTION
$0.26
J2271
5
MORPHINE SO4 INJECTION 100MG
$0.00
J2275
5
MORPHINE SULFATE INJECTION
$0.00
J2278
5
ZICONOTIDE INJECTION
$0.00
J2280
6
INJ, MOXIFLOXACIN 100 MG
$0.00
J2300
3
INJ NALBUPHINE HYDROCHLORIDE
$1.55
J2310
3
INJ NALOXONE HYDROCHLORIDE
$3.72
J2315
3
NALTREXONE, DEPOT FORM
$1.88
J2320
5
NANDROLONE DECANOATE 50 MG
$0.00
J2321
5
NANDROLONE DECANOATE 100 MG
$0.00
J2322
5
NANDROLONE DECANOATE 200 MG
$0.00
J2323
3
NATALIZUMAB INJECTION
$7.91
J2324
O
NESIRITIDE
$0.00
J2325
5
NESIRITIDE INJECTION
$0.00
J2330
O
THIOTHIXENE INJECTION
$0.00
J2350
O
NIACINAMIDE/NIACIN INJECTION
$0.00
J2352
O
OCTREOTIDE ACETATE INJECTION
$0.00
J2353
6
OCTREOTIDE INJECTION, DEPOT
$0.00
J2354
6
OCTREOTIDE INJ, NON-DEPOT
$0.00
J2355
5
OPRELVEKIN INJECTION
$0.00
$17.65
Procedure Code Pricing Action Code Description
Maximum Allowable
J2357
3
OMALIZUMAB INJECTION
$18.23
J2360
5
ORPHENADRINE INJECTION
$0.00
J2370
5
PHENYLEPHRINE HCL INJECTION
$0.00
J2400
5
CHLOROPROCAINE HCL INJECTION
$0.00
J2405
3
ONDANSETRON HCL INJECTION
$0.21
J2410
5
OXYMORPHONE HCL INJECTION
$0.00
J2425
5
PALIFERMIN INJECTION
$0.00
J2430
5
PAMIDRONATE DISODIUM /30 MG
$0.00
J2440
5
PAPAVERIN HCL INJECTION
$0.00
J2460
5
OXYTETRACYCLINE INJECTION
$0.00
J2469
3
PALONOSETRON HCL
J2480
O
HYDROCHLORIDES OF OPIUM INJ
$0.00
J2490
O
INJECTION, PARALDEHYDE, UP TO 5 ML
$0.00
J2495
O
INJECTION, TRIDIHEXETHYL CHLORIDE P
$0.00
J2500
O
PARICALCITOL
$0.00
J2501
5
PARICALCITOL
$0.00
J2503
5
PEGAPTANIB SODIUM INJECTION
$0.00
J2504
5
PEGADEMASE BOVINE, 25 IU
$0.00
J2505
3
INJECTION, PEGFILGRASTIM 6MG
J2510
5
PENICILLIN G PROCAINE INJ
$0.00
J2512
O
INJ PENTAGASTRIN PER 2 ML
$0.00
J2513
5
PENTASTARCH 10% SOLUTION
$0.00
J2515
3
PENTOBARBITAL SODIUM INJ
$9.17
J2520
5
INJECTION, THIOPENTAL SODIUM
$0.00
J2540
3
PENICILLIN G POTASSIUM INJ
$0.79
J2543
5
PIPERACILLIN/TAZOBACTAM
$0.00
J2545
9
PENTAMIDINE NON-COMP UNIT
$0.00
J2550
3
PROMETHAZINE HCL INJECTION
$1.36
J2560
5
PHENOBARBITAL SODIUM INJ
$0.00
J2590
5
OXYTOCIN INJECTION
$0.00
J2595
O
INJECTION, VASOPRESSIN TANNATE
$0.00
J2597
5
INJ DESMOPRESSIN ACETATE
$0.00
J2600
O
INJECTION, POSTERIOR PITUITARY, UP
$0.00
J2640
O
PREDNISOLONE SODIUM PH INJ
$0.00
J2650
5
PREDNISOLONE ACETATE INJ
$0.00
$16.64
$2,176.15
Procedure Code Pricing Action Code Description
Maximum Allowable
J2670
5
TOTAZOLINE HCL INJECTION
$0.00
J2672
O
INJECTION, PROPANTHELINE BROMIDE
$0.00
J2675
O
INJ PROGESTERONE PER 50 MG
$0.00
J2680
5
FLUPHENAZINE DECANOATE 25 MG
$0.00
J2690
5
PROCAINAMIDE HCL INJECTION
$0.00
J2700
3
OXACILLIN SODIUM INJECITON
$1.82
J2710
5
NEOSTIGMINE METHYLSLFTE INJ
$0.00
J2720
5
INJ PROTAMINE SULFATE/10 MG
$0.00
J2724
6
PROTEIN C CONCENTRATE
$0.00
J2725
5
INJ PROTIRELIN PER 250 MCG
$0.00
J2730
5
PRALIDOXIME CHLORIDE INJ
$0.00
J2760
9
PHENTOLAINE MESYLATE INJ
$0.00
J2765
3
METOCLOPRAMIDE HCL INJECTION
$1.30
J2770
5
QUINUPRISTIN/DALFOPRISTIN
$0.00
J2778
3
RANIBIZUMAB INJECTION
J2780
3
RANITIDINE HYDROCHLORIDE INJ
$0.99
J2783
6
RASBURICASE
$0.00
J2785
3
REGADENOSON INJECTION
$47.40
J2788
3
RHO D IMMUNE GLOBULIN 50 MCG
$23.50
J2790
3
RHO D IMMUNE GLOBULIN INJ
$86.26
J2791
6
RHOPHYLAC INJECTION
J2792
3
RHO(D) IMMUNE GLOBULIN H, SD
J2794
6
RISPERIDONE, LONG ACTING
$0.00
J2795
5
ROPIVACAINE HCL INJECTION
$0.00
J2800
5
METHOCARBAMOL INJECTION
$0.00
J2805
5
SINCALIDE INJECTION
$0.00
J2810
5
INJ THEOPHYLLINE PER 40 MG
$0.00
J2820
3
SARGRAMOSTIM INJECTION
J2825
O
INJECTION, SARRACENIA PURPUREA PLAN
$0.00
J2850
5
INJ SECRETIN SYNTHETIC HUMAN
$0.00
J2860
O
SECOBARBITAL SODIUM INJ
$0.00
J2910
5
AUROTHIOGLUCOSE INJECITON
$0.00
J2914
O
INJECTION, SODIUM SALICYLATE
$0.00
J2915
O
NA FERRIC GLUCONATE COMPLEX
$0.00
J2916
5
NA FERRIC GLUCONATE COMPLEX
$0.00
$406.60
$0.00 $16.39
$24.07
Procedure Code Pricing Action Code Description
Maximum Allowable
J2920
3
METHYLPREDNISOLONE INJECTION
$1.70
J2930
3
METHYLPREDNISOLONE INJECTION
$2.95
J2940
5
SOMATREM INJECTION
$0.00
J2941
5
SOMATROPIN INJECTION
$0.00
J2950
5
PROMAZINE HCL INJECITON
$0.00
J2970
O
METHICILLIN SODIUM INJECTION
$0.00
J2993
5
RETEPLASE INJECTION
$0.00
J2994
9
RETEPLASE DOUBLE BOLUS
$0.00
J2995
5
INJ STREPTOKINASE /250000 IU
$0.00
J2996
O
ALTEPLASE RECOMBINANT INJ
$0.00
J2997
3
ALTEPLASE RECOMBINANT
$34.10
J3000
3
STREPTOMYCIN INJECTION
$4.61
J3005
O
INJECTION, STRONTIUM-89 CHLORIDE, P
$0.00
J3010
3
FENTANYL CITRATE INJECITON
$0.18
J3030
5
SUMATRIPTAN SUCCINATE / 6 MG
$0.00
J3050
O
INJECTION, DECAMETHONIUM BROMIDE, U
$0.00
J3070
5
PENTAZOCINE INJECTION
$0.00
J3080
O
CHLORPROTHIXENE INJECTION
$0.00
J3100
O
TENECTEPLASE INJECTION
$0.00
J3101
9
TENECTEPLASE INJECTION
$0.00
J3105
5
TERBUTALINE SULFATE INJ
$0.00
J3110
6
TERIPARATIDE INJECTION
$0.00
J3120
5
TESTOSTERONE ENANTHATE INJ
$0.00
J3130
5
TESTOSTERONE ENANTHATE INJ
$0.00
J3140
5
TESTOSTERONE SUSPENSION INJ
$0.00
J3150
5
TESTOSTERON PROPIONATE INJ
$0.00
J3180
O
INJECTION, TETANUS TOXOID, UP TO 1
$0.00
J3230
5
CHLORPROMAZINE HCL INJECTION
$0.00
J3240
5
THYROTROPIN INJECTION
$0.00
J3243
6
TIGECYCLINE INJECTION
$0.00
J3245
O
TIROFIBAN HYDROCHLORIDE
$0.00
J3246
6
TIROFIBAN HCL
$0.00
J3250
5
TRIMETHOBENZAMIDE HCL INJ
$0.00
J3260
5
TOBRAMYCIN SULFATE INJECTION
$0.00
J3265
5
INJECTION TORSEMIDE 10 MG/ML
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
J3270
O
IMIPRAMINE HCL INJECTION
$0.00
J3280
5
THIETHYLPERAZINE MALEATE INJ
$0.00
J3285
5
TREPROSTINIL INJECTION
$0.00
J3300
6
INJECTION, TRIAMCINOLONE ACETONIDE,
$0.00
J3301
3
TRIAMCINOLONE ACET INJ NOS
$1.40
J3302
5
TRIAMCINOLONE DIACETATE INJ
$0.00
J3303
3
TRIAMCINOLONE HEXACETONL INJ
$1.33
J3305
5
INJ TRIMETREXATE GLUCORONATE
$0.00
J3310
5
PERPHENAZINE INJECITON
$0.00
J3315
5
TRIPTORELIN PAMOATE
$0.00
J3320
5
SPECTINOMYCN DI-HCL INJ
$0.00
J3340
O
INJECTION, CRYPTENAMINE ACETATE, UP
$0.00
J3350
5
UREA INJECTION
$0.00
J3355
9
UROFOLLITROPIN, 75 IU
$0.00
J3360
5
DIAZEPAM INJECTION
$0.00
J3364
5
UROKINASE 5000 IU INJECTION
$0.00
J3365
5
UROKINASE 250,000 IU INJ
$0.00
J3370
3
VANCOMYCIN HCL INJECITON
$3.08
J3380
O
INJECTION, ISOXSUPRINE HCL, UP TO 1
$0.00
J3390
O
METHOXAMINE INJECTION
$0.00
J3395
O
VERTEPORFIN INJECTION
$0.00
J3396
6
VERTEPORFIN INJECTION
$0.00
J3400
5
TRIFLUPROMAZINE HCL INJ
$0.00
J3410
3
HYDROXYZINE HCL INJECITON
$0.25
J3411
3
THIAMINE HCL 100 MG
$2.63
J3415
6
PYRIDOXINE HCL 100 MG
$0.00
J3420
3
VITAMIN B12 INJECTION
$0.13
J3430
5
VITAMIN K PHYTONADIONE INJ
$0.00
J3450
O
MEPHENTERMINE SULFATE INJ
$0.00
J3465
6
INJECTION, VORICONAZOLE
$0.00
J3470
5
HYALURONIDASE INJECTION
$0.00
J3471
5
OVINE, UP TO 999 USP UNITS
$0.00
J3472
5
OVINE, 1000 USP UNITS
$0.00
J3473
3
HYALURONIDASE RECOMBINANT
$0.48
J3475
3
INJ MAGNESIUM SULFATE
$0.05
Procedure Code Pricing Action Code Description
Maximum Allowable
J3480
3
INJ POTASSIUM CHLORIDE
$0.02
J3485
5
ZIDOVUDINE
$0.00
J3486
3
ZIPRASIDONE MESYLATE
$5.38
J3487
3
ZOLEDRONIC ACID
$5.36
J3488
3
RECLAST INJECTION
J3490
5
DRUGS UNCLASSIFIED INJECTION
$0.00
J3500
O
VITAMIN THERAPY
$0.00
J3520
5
EDETATE DISODIUM PER 150 MG
$0.00
J3530
9
NASAL VACCINE INHALATION
$0.00
J3535
9
METERED DOSE INHALER DRUG
$0.00
J3540
O
AUTOGENOUS BLOOD EXTRACT, INTRAVENO
$0.00
J3550
O
INTRA-ARTERIAL OXYGEN INJECTION
$0.00
J3560
O
ADRENAL CORTEX EXTRACT
$0.00
J3570
9
LAETRILE AMYGDALIN VIT B17
$0.00
J3590
5
UNCLASSIFIED BIOLOGICS
$0.00
J6015
O
TYPHUS
$0.00
J7010
O
VIAL OF ALLERGY VACCINE, SINGLE DOS
$0.00
J7020
O
VIAL OF ALLERGY VACCINE, MULTIPLE D
$0.00
J7030
3
NORMAL SALINE SOLUTION INFUS
$218.51
J7040
3
NORMAL SALINE SOLUTION INFUS
$1.08
J7042
3
5% DEXTROSE/NORMAL SALINE
$0.54
J7050
3
NORMAL SALINE SOLUTION INFUS
$0.27
J7051
O
STERILE SALINE/WATER
$0.00
J7060
3
5% DEXTROSE/WATER
$1.09
J7070
5
D5W INFUSION
$0.00
J7080
O
INFUSION, ALBUMISOL 5%, 500 ML VIAL
$0.00
J7090
O
INFUSION, ALBUMISOL 25%, 50 ML VIAL
$0.00
J7100
5
DEXTRAN 40 INFUSION
$0.00
J7110
5
DEXTRAN 75 INFUSION
$0.00
J7120
5
RINGERS LACTATE INFUSION
$0.00
J7130
5
HYPERTONIC SALINE SOLUTION
$0.00
J7140
9
PRESCRIPTION DRUG, ORAL, DISPENSED
$0.00
J7150
9
PRESCRIPTION DRUG, ORAL CHEMOTHERAP
$0.00
J7186
6
ANTIHEMOPHILIC VIII/VWF COMP
$0.00
J7187
3
HUMATE-P, INJ
$0.86
$215.21
Procedure Code Pricing Action Code Description
Maximum Allowable
J7188
O
INJ VONWILLEBRAND FACTOR IU
$0.00
J7189
5
FACTOR VIIA
$0.00
J7190
5
FACTOR VIII
$0.00
J7191
5
FACTOR VIII (PORCINE)
$0.00
J7192
5
FACTOR VIII RECOMBINANT
$0.00
J7193
5
FACTOR IX NON-RECOMBINANT
$0.00
J7194
5
FACTOR IX COMPLEX
$0.00
J7195
5
FACTOR IX RECOMBINANT
$0.00
J7196
O
OTHR HEMOPHILIA CLOT FACTORS
$0.00
J7198
5
ANTI-INHIBITOR
$0.00
J7199
5
HEMOPHILIA CLOT FACTOR NOC
$0.00
J7300
9
INTRAUT COPPER CONTRACEPTIVE
$0.00
J7302
3
LEVONORGESTREL IU CONTRACEPT
J7303
6
CONTRACEPTIVE VAGINAL RING
$0.00
J7304
9
CONTRACEPTIVE HORMONE PATCH
$0.00
J7306
9
LEVONORGESTREL IMPLANT SYS
$0.00
J7307
3
ETONOGESTREL IMPLANT SYSTEM
J7308
9
AMINOLEVULINIC ACID HCL TOP
$0.00
J7310
9
GANCICLOVIR LONG ACT IMPLANT
$0.00
J7311
9
FLUOCINOLONE ACETONIDE IMPLT
$0.00
J7315
O
SODIUM HYALURONATE INJECTION
$0.00
J7316
O
SODIUM HYALURONATE INJECTION
$0.00
J7317
O
SODIUM HYALURONATE INJECTION
$0.00
J7319
O
SODIUM HYALURONATE INJECTION
$0.00
J7321
3
HYALGAN/SUPARTZ INJ PER DOSE
$97.39
J7322
3
SYNVISC INJ PER DOSE
$182.84
J7323
3
EUFLEXXA INJ PER DOSE
$111.01
J7324
3
ORTHOVISC INJ PER DOSE
$178.09
J7330
9
CULTURED CHONDROCYTES IMPLNT
$0.00
J7340
O
METABOLIC ACTIVE D/E TISSUE
$0.00
J7341
O
NON-HUMAN, METABOLIC TISSUE
$0.00
J7342
O
METABOLICALLY ACTIVE TISSUE
$0.00
J7343
O
NONMETABOLIC ACT D/E TISSUE
$0.00
J7344
O
NONMETABOLIC ACTIVE TISSUE
$0.00
J7345
O
NON-HUMAN, NON-METAB TISSUE
$0.00
$468.71
$483.70
Procedure Code Pricing Action Code Description
Maximum Allowable
J7346
O
INJECTABLE HUMAN TISSUE
$0.00
J7347
O
INTEGRA MATRIX TISSUE
$0.00
J7348
O
TISSUEMEND TISSUE
$0.00
J7349
O
PRIMATRIX TISSUE
$0.00
J7350
O
INJECTABLE HUMAN TISSUE
$0.00
J7500
9
AZATHIOPRINE ORAL 50MG
$0.00
J7501
5
AZATHIOPRINE PARENTERAL
$0.00
J7502
9
CYCLOSPORINE ORAL 100 MG
$0.00
J7503
O
CYCLOSPORINE PARENTERAL
$0.00
J7504
5
LYMPHOCYTE IMMUNE GLOBULIN
$0.00
J7505
5
MONOCLONAL ANTIBODIES
$0.00
J7506
9
PREDNISONE ORAL
$0.00
J7507
9
TACROLIMUS ORAL PER 1 MG
$0.00
J7508
O
TACROLIMUS ORAL PER 5 MG
$0.00
J7509
9
METHYLPREDNISOLONE ORAL
$0.00
J7510
9
PREDNISOLONE ORAL PER 5 MG
$0.00
J7511
5
ANTITHYMOCYTE GLOBULN RABBIT
$0.00
J7513
5
DACLIZUMAB, PARENTERAL
$0.00
J7515
9
CYCLOSPORINE ORAL 25 MG
$0.00
J7516
5
CYCLOSPORIN PARENTERAL 250MG
$0.00
J7517
9
MYCOPHENOLATE MOFETIL ORAL
$0.00
J7518
9
MYCOPHENOLIC ACID
$0.00
J7520
9
SIROLIMUS, ORAL
$0.00
J7525
5
TACROLIMUS INJECTION
$0.00
J7599
5
IMMUNOSUPPRESSIVE DRUG NOC
$0.00
J7602
O
ALBUTEROL INH NON-COMP CON
$0.00
J7603
O
ALBUTEROL INH NON-COMP U D
$0.00
J7604
9
ACETYLCYSTEINE COMP UNIT
$0.00
J7605
9
ARFORMOTEROL NON-COMP UNIT
$0.00
J7606
9
FORMOTEROL FUMARATE, INH
$0.00
J7607
9
LEVALBUTEROL COMP CON
$0.00
J7608
9
ACETYLCYSTEINE NON-COMP UNIT
$0.00
J7609
9
ALBUTEROL COMP UNIT
$0.00
J7610
9
ALBUTEROL COMP CON
$0.00
J7611
9
ALBUTEROL NON-COMP CON
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
J7612
9
LEVALBUTEROL NON-COMP CON
$0.00
J7613
9
ALBUTEROL NON-COMP UNIT
$0.00
J7614
9
LEVALBUTEROL NON-COMP UNIT
$0.00
J7615
9
LEVALBUTEROL COMP UNIT
$0.00
J7616
O
ALBUTEROL COMPOUND SOLUTION
$0.00
J7617
O
LEVALBUTEROL COMPOUNDED SOL
$0.00
J7618
O
ALBUTEROL INH SOL CON
$0.00
J7619
O
ALBUTEROL INH SOL U D
$0.00
J7620
9
ALBUTEROL IPRATROP NON-COMP
$0.00
J7621
O
(LEVO)ALBUTEROL/IPRA-BROMIDE
$0.00
J7622
9
BECLOMETHASONE COMP UNIT
$0.00
J7624
9
BETAMETHASONE COMP UNIT
$0.00
J7625
O
ALBUTEROL SULFATE .5% INJ
$0.00
J7626
9
BUDESONIDE NON-COMP UNIT
$0.00
J7627
9
BUDESONIDE COMP UNIT
$0.00
J7628
9
BITOLTEROL MESYLATE COMP CON
$0.00
J7629
9
BITOLTEROL MESYLATE COMP UNT
$0.00
J7630
O
CROMOLYN SODIUM INJECITON
$0.00
J7631
9
CROMOLYN SODIUM NONCOMP UNIT
$0.00
J7632
9
CROMOLYN SODIUM COMP UNIT
$0.00
J7633
9
BUDESONIDE NON-COMP CON
$0.00
J7634
9
BUDESONIDE COMP CON
$0.00
J7635
9
ATROPINE COMP CON
$0.00
J7636
9
ATROPINE COMP UNIT
$0.00
J7637
9
DEXAMETHASONE COMP CON
$0.00
J7638
9
DEXAMETHASONE COMP UNIT
$0.00
J7639
9
DORNASE ALFA NON-COMP UNIT
$0.00
J7640
9
FORMOTEROL COMP UNIT
$0.00
J7641
9
FLUNISOLIDE COMP UNIT
$0.00
J7642
9
GLYCOPYRROLATE COMP CON
$0.00
J7643
9
GLYCOPYRROLATE COMP UNIT
$0.00
J7644
9
IPRATROPIUM BROMIDE NON-COMP
$0.00
J7645
9
IPRATROPIUM BROMIDE
$0.00
J7647
9
ISOETHARINE COMP CON
$0.00
J7648
9
ISOETHARINE NON-COMP CON
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
J7649
9
ISOETHARINE NON-COMP UNIT
$0.00
J7650
9
ISOETHARINE COMP UNIT
$0.00
J7651
O
ISOETHARINE HCL .125% INJ
$0.00
J7652
O
ISOETHARINE HCL .167% INJ
$0.00
J7653
O
ISOETHARINE HCL .2%/ INJ
$0.00
J7654
O
ISOETHARINE HCL .25% INJ
$0.00
J7655
O
ISOETHARINE HCL 1% INJ
$0.00
J7657
9
ISOPROTERENOL COMP CON
$0.00
J7658
9
ISOPROTERENOL NON-COMP CON
$0.00
J7659
9
ISOPROTERENOL NON-COMP UNIT
$0.00
J7660
9
ISOPROTERENOL COMP UNIT
$0.00
J7665
O
ISOPROTERENOL HCL 1% INJ
$0.00
J7667
9
METAPROTERENOL COMP CON
$0.00
J7668
9
METAPROTERENOL NON-COMP CON
$0.00
J7669
9
METAPROTERENOL NON-COMP UNIT
$0.00
J7670
9
METAPROTERENOL COMP UNIT
$0.00
J7672
O
METAPROTERENOL SULFATE .6%
$0.00
J7674
9
METHACHOLINE CHLORIDE, NEB
$0.00
J7675
O
METAPROTERENOL SULFATE 5%
$0.00
J7676
9
PENTAMIDINE COMP UNIT DOSE
$0.00
J7680
9
TERBUTALINE SULF COMP CON
$0.00
J7681
9
TERBUTALINE SULF COMP UNIT
$0.00
J7682
9
TOBRAMYCIN NON-COMP UNIT
$0.00
J7683
9
TRIAMCINOLONE COMP CON
$0.00
J7684
9
TRIAMCINOLONE COMP UNIT
$0.00
J7685
9
TOBRAMYCIN COMP UNIT
$0.00
J7699
O
INHALATION SOLUTION FOR DME
$0.00
J7799
O
NON-INHALATION DRUG FOR DME
$0.00
J8498
9
ANTIEMETIC RECTAL/SUPP NOS
$0.00
J8499
9
ORAL PRESCRIP DRUG NON CHEMO
$0.00
J8501
9
ORAL APREPITANT
$0.00
J8510
9
ORAL BUSULFAN
$0.00
J8515
9
CABERGOLINE, ORAL 0.25MG
$0.00
J8520
9
CAPECITABINE, ORAL, 150 MG
$0.00
J8521
9
CAPECITABINE, ORAL, 500 MG
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
J8530
9
CYCLOPHOSPHAMIDE ORAL 25 MG
$0.00
J8540
9
ORAL DEXAMETHASONE
$0.00
J8560
9
ETOPOSIDE ORAL 50 MG
$0.00
J8565
9
GEFITINIB ORAL
$0.00
J8597
9
ANTIEMETIC DRUG ORAL NOS
$0.00
J8600
9
MELPHALAN ORAL 2 MG
$0.00
J8610
9
METHOTREXATE ORAL 2.5 MG
$0.00
J8650
9
NABILONE ORAL
$0.00
J8700
9
TEMOZOLMIDE
$0.00
J8705
9
TOPOTECAN ORAL
$0.00
J8999
9
ORAL PRESCRIPTION DRUG CHEMO
$0.00
J9000
3
DOXORUBICIN HCL INJECTION
$3.79
J9001
3
DOXORUBICIN HCL LIPOSOME INJ
J9010
O
ALEMTUZUMAB INJECTION
$0.00
J9015
5
ALDESLEUKIN INJECTION
$0.00
J9017
5
ARSENIC TRIOXIDE INJECTION
$0.00
J9020
3
ASPARAGINASE INJECTION
J9025
3
AZACITIDINE INJECTION
$4.64
J9027
5
CLOFARABINE INJECTION
$0.00
J9031
3
BCG LIVE INTRAVESICAL VAC
J9033
3
BENDAMUSTINE INJECTION
$18.58
J9035
3
BEVACIZUMAB INJECTION
$57.39
J9040
3
BLEOMYCIN SULFATE INJECTION
$24.24
J9041
3
BORTEZOMIB INJECTION
$36.11
J9045
3
CARBOPLATIN INJECTION
$5.75
J9050
5
CARMUSTINE INJECTION
$0.00
J9055
3
CETUXIMAB INJECTION
J9060
3
CISPLATIN 10 MG INJECITON
$2.23
J9062
3
CISPLATIN 50 MG INJECITON
$11.14
J9065
5
INJ CLADRIBINE PER 1 MG
$0.00
J9070
5
CYCLOPHOSPHAMIDE 100 MG INJ
$0.00
J9080
5
CYCLOPHOSPHAMIDE 200 MG INJ
$0.00
J9090
3
CYCLOPHOSPHAMIDE 500 MG INJ
$14.50
J9091
3
CYCLOPHOSPHAMIDE 1.0 GRM INJ
$29.00
J9092
5
CYCLOPHOSPHAMIDE 2.0 GRM INJ
$0.00
$441.25
$57.68
$125.35
$49.54
Procedure Code Pricing Action Code Description
Maximum Allowable
J9093
3
CYCLOPHOSPHAMIDE LYOPHILIZED
$5.16
J9094
5
CYCLOPHOSPHAMIDE LYOPHILIZED
$0.00
J9095
5
CYCLOPHOSPHAMIDE LYOPHILIZED
$0.00
J9096
5
CYCLOPHOSPHAMIDE LYOPHILIZED
$0.00
J9097
5
CYCLOPHOSPHAMIDE LYOPHILIZED
$0.00
J9098
6
CYTARABINE LIPOSOME INJ
$0.00
J9100
3
CYTARABINE HCL 100 MG INJ
$0.88
J9110
3
CYTARABINE HCL 500 MG INJ
$6.83
J9120
5
DACTINOMYCIN INJECTION
$0.00
J9130
3
DACARBAZINE 100 MG INJ
$4.39
J9140
3
DACARBAZINE 200 MG INJ
$8.54
J9150
3
DAUNORUBICIN INJECTION
$16.26
J9151
5
DAUNORUBICIN CITRATE INJ
$0.00
J9160
5
DENILEUKIN DIFTITOX INJ
$0.00
J9165
5
DIETHYLSTILBESTROL INJECTION
$0.00
J9170
3
DOCETAXEL INJECTION
J9175
5
ELLIOTTS B SOLUTION PER ML
$0.00
J9178
6
INJ, EPIRUBICIN HCL, 2 MG
$0.00
J9180
O
EPIRUBICIN HCL INJECTION
$0.00
J9181
3
ETOPOSIDE INJECTION
$0.48
J9182
O
ETOPOSIDE 100 MG INJ
$0.00
J9185
5
FLUDARABINE PHOSPHATE INJ
$0.00
J9190
3
FLUOROURACIL INJECTION
$1.55
J9200
5
FLOXURIDINE INJECTION
$0.00
J9201
3
GEMCITABINE HCL INJECTION
$138.19
J9202
3
GOSERELIN ACETATE IMPLANT
$182.99
J9206
3
IRINOTECAN INJECTION
$21.72
J9207
3
IXABEPILONE INJECTION
$63.46
J9208
5
IFOSFOMIDE INJECTION
$0.00
J9209
5
MESNA INJECTION
$0.00
J9211
5
IDARUBICIN HCL INJECTION
$0.00
J9212
5
INTERFERON ALFACON-1 INJ
$0.00
J9213
5
INTERFERON ALFA-2A INJ
$0.00
J9214
3
INTERFERON ALFA-2B INJ
$14.71
J9215
5
INTERFERON ALFA-N3 INJ
$0.00
$336.94
Procedure Code Pricing Action Code Description
Maximum Allowable
J9216
5
INTERFERON GAMMA 1-B INJ
$0.00
J9217
3
LEUPROLIDE ACETATE SUSPNSION
J9218
5
LEUPROLIDE ACETATE INJECITON
$0.00
J9219
5
LEUPROLIDE ACETATE IMPLANT
$0.00
J9225
5
VANTAS IMPLANT
$0.00
J9226
6
SUPPRELIN LA IMPLANT
$0.00
J9230
5
MECHLORETHAMINE HCL INJ
$0.00
J9240
O
MEDROXYPROGESTERONE ACETATE, 100 MG
$0.00
J9245
5
INJ MELPHALAN HYDROCHL 50 MG
$0.00
J9250
5
METHOTREXATE SODIUM INJ
$0.00
J9260
3
METHOTREXATE SODIUM INJ
$1.69
J9261
3
NELARABINE INJECTION
J9263
3
OXALIPLATIN
$9.57
J9264
3
PACLITAXEL PROTEIN BOUND
$9.07
J9265
3
PACLITAXEL INJECTION
$5.28
J9266
5
PEGASPARGASE INJECTION
$0.00
J9268
5
PENTOSTATIN INJECTION
$0.00
J9270
5
PLICAMYCIN (MITHRAMYCIN) INJ
$0.00
J9280
3
MITOMYCIN 5 MG INJ
$15.64
J9290
5
MITOMYCIN 20 MG INJ
$0.00
J9291
5
MITOMYCIN 40 MG INJ
$0.00
J9293
5
MITOXANTRONE HYDROCHL / 5 MG
$0.00
J9295
O
POLYESTRADIOL PHOSPHATE 40 MG
$0.00
J9300
5
GEMTUZUMAB OZOGAMICIN INJ
$0.00
J9303
3
PANITUMUMAB INJECTION
$83.56
J9305
6
PEMETREXED INJECTION
$0.00
J9310
3
RITUXIMAB INJECTION
J9320
5
STREPTOZOCIN INJECTION
$0.00
J9330
3
TEMSIROLIMUS INJECTION
$48.53
J9340
5
THIOTEPA INJECTION
J9350
3
TOPOTECAN INJECTION
J9355
3
TRASTUZUMAB INJECTION
J9357
5
VALRUBICIN INJECTION
$0.00
J9360
3
VINBLASTINE SULFATE INJ
$0.79
J9370
3
VINCRISTINE SULFATE 1 MG INJ
$5.68
$515.00
$96.96
$535.32
$0.00 $939.34 $61.64
Procedure Code Pricing Action Code Description
Maximum Allowable
J9375
3
VINCRISTINE SULFATE 2 MG INJ
$11.36
J9380
5
VINCRISTINE SULFATE 5 MG INJ
$0.00
J9390
3
VINORELBINE TARTRATE INJ
$19.64
J9395
3
INJECTION, FULVESTRANT
$81.38
J9600
5
PORFIMER SODIUM INJECTION
$0.00
J9999
5
CHEMOTHERAPY DRUG
$0.00
K0001
3
STANDARD WHEELCHAIR
K0002
5
STND HEMI (LOW SEAT) WHLCHR
$0.00
K0003
3
LIGHTWEIGHT WHEELCHAIR
$0.00
K0004
3
HIGH STRENGTH LTWT WHLCHR
$1.00
K0005
3
ULTRALIGHTWEIGHT WHEELCHAIR
K0006
5
HEAVY DUTY WHEELCHAIR
$0.00
K0007
5
EXTRA HEAVY DUTY WHEELCHAIR
$0.00
K0008
9
CSTM MANUAL WHEELCHAIR/BASE
$0.00
K0009
5
OTHER MANUAL WHEELCHAIR/BASE
$0.00
K0010
5
STND WT FRAME POWER WHLCHR
$0.00
K0011
5
STND WT PWR WHLCHR W CONTROL
$0.00
K0012
5
LTWT PORTBL POWER WHLCHR
$0.00
K0013
9
CUSTOM POWER WHLCHR BASE
$0.00
K0014
5
OTHER POWER WHLCHR BASE
$0.00
K0015
3
DETACH NON-ADJUS HGHT ARMRST
$180.80
K0016
O
DETACH ADJUST ARMRST CMPLETE
$0.00
K0017
3
DETACH ADJUST ARMREST BASE
$50.85
K0018
3
DETACH ADJUST ARMRST UPPER
$28.41
K0019
3
ARM PAD EACH
$14.58
K0020
3
FIXED ADJUST ARMREST PAIR
$46.23
K0021
O
ANTI-TIPPING DEVICE EACH
$0.00
K0022
O
REINFORCED BACK UPHOLSTERY
$0.00
K0023
O
PLANR BACK INSRT FOAM W/STRP
$0.00
K0024
O
PLNR BACK INSRT FOAM W/HRDWR
$0.00
K0025
O
HOOK-ON HEADREST EXTENSION
$0.00
K0026
O
BACK UPHOLST LGTWT WHLCHR
$0.00
K0027
O
BACK UPHOLST OTHER WHLCHR
$0.00
K0028
O
MANUAL FULLY RECLINING BACK
$0.00
K0029
O
REINFORCED SEAT UPHOLSTERY
$0.00
$532.70
$1,839.61
Procedure Code Pricing Action Code Description
Maximum Allowable
K0030
O
SOLID PLNR SEAT SNGL DNSFOAM
$0.00
K0031
O
SAFETY BELT/PELVIC STRAP
$0.00
K0032
O
SEAT UPHOLS LGTWT WHLCHR
$0.00
K0033
O
SEAT UPHOLSTERY OTHER WHLCHR
$0.00
K0034
O
HEEL LOOP EACH
$0.00
K0035
O
HEEL LOOP WITH ANKLE STRAP
$0.00
K0036
O
TOE LOOP EACH
$0.00
K0037
3
HIGH MOUNT FLIP-UP FOOTREST
$47.93
K0038
3
LEG STRAP EACH
$24.14
K0039
3
LEG STRAP H STYLE EACH
$53.61
K0040
3
ADJUSTABLE ANGLE FOOTPLATE
$74.30
K0041
3
LARGE SIZE FOOTPLATE EACH
$52.65
K0042
3
STANDARD SIZE FOOTPLATE EACH
$36.25
K0043
3
FTRST LOWER EXTENSION TUBE
$19.44
K0044
3
FTRST UPPER HANGER BRACKET
$16.56
K0045
3
FOOTREST COMPLETE ASSEMBLY
$56.34
K0046
3
ELEVAT LEGRST LOW EXTENSION
$19.44
K0047
3
ELEVAT LEGRST UP HANGR BRACK
$76.10
K0048
O
ELEVATE LEGREST COMPLETE
$0.00
K0049
O
CALF PAD EACH
$0.00
K0050
3
RATCHET ASSEMBLY
$32.34
K0051
3
CAM RELESE ASSEM FTRST/LGRST
$52.35
K0052
3
SWINGAWAY DETACH FOOTREST
$91.98
K0053
3
ELEVATE FOOTREST ARTICULATE
$101.51
K0054
O
SEAT WDTH 10-12/15/17/20 WC
$0.00
K0055
O
SEAT DPTH 15/17/18 LTWT WC
$0.00
K0056
3
SEAT HT <17 OR >=21 LTWT WC
$94.63
K0057
O
SEAT WDTH 19/20 HVY DTY WC
$0.00
K0058
O
SEAT DPTH 17/18 POWER WC
$0.00
K0059
O
PLASTIC COATED HANDRIM EACH
$0.00
K0060
O
STEEL HANDRIM EACH
$0.00
K0061
O
ALUMINUM HANDRIM EACH
$0.00
K0062
O
HANDRIM 8-10 VERT/OBLIQ PROJ
$0.00
K0063
O
HNDRM 12-16 VERT/OBLIQ PROJ
$0.00
K0064
O
ZERO PRESSURE TUBE FLAT FREE
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
K0065
3
SPOKE PROTECTORS
$44.24
K0066
O
SOLID TIRE ANY SIZE EACH
$0.00
K0067
O
PNEUMATIC TIRE ANY SIZE EACH
$0.00
K0068
O
PNEUMATIC TIRE TUBE EACH
$0.00
K0069
3
REAR WHL COMPLETE SOLID TIRE
K0070
3
REAR WHL COMPL PNEUM TIRE
$182.26
K0071
3
FRONT CASTR COMPL PNEUM TIRE
$108.71
K0072
3
FRNT CSTR CMPL SEM-PNEUM TIR
$65.43
K0073
3
CASTER PIN LOCK EACH
$34.63
K0074
O
PNEUMATIC CASTER TIRE EACH
$0.00
K0075
O
SEMI-PNEUMATIC CASTER TIRE
$0.00
K0076
O
SOLID CASTER TIRE EACH
$0.00
K0077
3
FRONT CASTER ASSEM COMPLETE
K0078
O
PNEUMATIC CASTER TIRE TUBE
$0.00
K0079
O
WHEEL LOCK EXTENSION PAIR
$0.00
K0080
O
ANTI-ROLLBACK DEVICE PAIR
$0.00
K0081
O
WHEEL LOCK ASSEMBLY COMPLETE
$0.00
K0082
O
22 NF NONSEALED LEADACID
$0.00
K0083
O
22NF SEALED LEADACID BATTERY
$0.00
K0084
O
GR24 NONSEALED LEADACID
$0.00
K0085
O
GR 24 SEALED LEAD ACID BATTERY
$0.00
K0086
O
U1NONSEALED LEADACID BATTERY
$0.00
K0087
O
U1 SEALED LEADACID BATTERY
$0.00
K0088
O
BATTERY CHARGER, SINGLE MODE
$0.00
K0089
O
BATTERY CHARGER, DUAL MODE
$0.00
K0090
O
REAR TIRE POWER WHEELCHAIR
$0.00
K0091
O
REAR TIRE TUBE POWER WHLCHR
$0.00
K0092
O
REAR ASSEM CMPLT POWR WHLCHR
$0.00
K0093
O
REAR ZERO PRESSURE TIRE TUBE
$0.00
K0094
O
WHEEL TIRE FOR POWER BASE
$0.00
K0095
O
WHEEL TIRE TUBE EACH BASE
$0.00
K0096
O
WHEEL ASSEM POWR BASE COMPLT
$0.00
K0097
O
WHEEL ZERO PRESURE TIRE TUBE
$0.00
K0098
3
DRIVE BELT POWER WHEELCHAIR
$27.07
K0099
O
PWR WHEELCHAIR FRONT CASTER
$99.42
$58.56
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
K0100
O
AMPUTEE ADAPTER PAIR
$0.00
K0101
O
ONE-ARM DRIVE ATTACHMENT
$0.00
K0102
O
CRUTCH AND CANE HOLDER
$0.00
K0103
O
TRANSFER BOARD < 25"
$0.00
K0104
O
CYLINDER TANK CARRIER
$0.00
K0105
3
IV HANGER
K0106
O
ARM TROUGH EACH
$0.00
K0107
O
WHEELCHAIR TRAY
$0.00
K0108
5
W/C COMPONENT-ACCESSORY NOS
$0.00
K0109
9
CUSTOMIZE WHLCHR BASE FRAME
$0.00
K0110
9
SUPPLIES FOR MAINTENANCE OF DRUG IN
$0.00
K0111
9
SUPPLIES FOR EXTERNAL DRUG INFUSION
$0.00
K0112
O
TRUNK VEST SUPPRT INNR FRAME
$0.00
K0113
O
TRUNK VEST SUPRT W/O INR FRM
$0.00
K0114
O
WHLCHR BACK SUPRT INR FRAME
$0.00
K0115
O
BACK MODULE ORTHOTIC SYSTEM
$0.00
K0116
O
BACK & SEAT MODUL ORTHOT SYS
$0.00
K0117
O
UNLISTED ITEM, ORTHOTIC SEATING, BA
$0.00
K0118
O
TENS SUPPLIES - ONE MONTH SUPPLY FO
$0.00
K0119
9
AZATHIOPRINE ORAL TAB 50 MG
$0.00
K0120
9
AZATHIOPRINE PRENTRL 100 MG
$0.00
K0121
9
CYCLOSPORINE ORAL 25 MG
$0.00
K0122
9
CYCLOSPORINE PRENTRL 250 MG
$0.00
K0123
9
IMUN/ANTITYMOCYT GLOB 250 MG
$0.00
K0124
9
MONOCLONAL ANTIBODIES - PARENTERAL,
$0.00
K0125
9
PREDNISONE - ORAL, 5 MG
$0.00
K0126
9
REPLACE SOFT INTERFACE MATERIAL, MU
$0.00
K0127
9
REPLACE SOFT INTERFACE MATERIAL, AN
$0.00
K0128
9
REPLACE SOFT INTERFACE MATERIAL, FO
$0.00
K0129
9
ANKLE CONTRACTURE SPLINT
$0.00
K0130
9
FOOT DROP SPLINT, RECUMBENT POSITIO
$0.00
K0131
O
SPRING-POWERED DEVICE FOR LANCET
$0.00
K0132
O
MALE EXTERNAL CATHETER WITH OR WITH
$0.00
K0133
O
INTERMITTENT URINARY CATHETER, DISP
$0.00
K0134
O
INTERMITTENT URINARY CATHETER, DISP
$0.00
$98.94
Procedure Code Pricing Action Code Description
Maximum Allowable
K0135
O
INTERMITTENT URINARY CATHETER, REUS
$0.00
K0136
O
INTERMITTENT URINARY CATHETER, REUS
$0.00
K0137
9
SKIN BARRIER LIQUID PER OZ
$0.00
K0138
9
SKIN BARRIER PASTE PER OZ
$0.00
K0139
9
SKIN BARRIER POWDER PER OZ
$0.00
K0140
9
ACETYLCYSTEINE, COMPOUNDED, PER MG,
$0.00
K0141
9
ALBUTEROL SULFATE, COMPOUNDED, PER
$0.00
K0142
9
CROMOLYN SODIUM, COMPOUNDED, PER MG
$0.00
K0143
9
ISOETHARINE HYDROCHLORIDE, COMPOUND
$0.00
K0144
9
ISOPROTHERENOL HYDROCHLORIDE, COMPO
$0.00
K0145
9
METAPROTERENOL, COMPOUNDED, PER MG,
$0.00
K0146
9
TERBUTALINE, COMPOUNDED, PER MG, IN
$0.00
K0147
O
GASTROSTOMY TUBE, SILICONE WITH SLI
$0.00
K0148
O
HYDROGEL DRESSING, EACH
$0.00
K0149
O
HYDROCOLLOID DRESSING, EACH
$0.00
K0150
O
ALGINATE DRESSING, EACH
$0.00
K0151
O
FOAM DRESSING, EACH
$0.00
K0152
9
PASTES, POWDERS, GRANULES, BEADS, C
$0.00
K0153
O
COMPOSITE DRESSING, EACH
$0.00
K0154
9
WOUND POUCH, EACH
$0.00
K0162
O
PROGRESSIVE LENS, EACH LENS
$0.00
K0163
9
VACUUM ERECTION SYSTEM
$0.00
K0164
O
OROPHARYNGEAL SUCTION CATHETER, EAC
$0.00
K0165
O
TRACHEOSTOMY CARE KIT FOR ESTABLISH
$0.00
K0166
O
METHYLPREDNISOLONE - ORAL, 4 MG
$0.00
K0167
O
PREDNISOLONE - ORAL, 5 MG
$0.00
K0168
9
DISPOSABLE NEBULIZER SET
$0.00
K0169
9
DISPOSABLE NEBULIZER SMALL
$0.00
K0170
9
NON DISPOSABLE NEBULIZER SET
$0.00
K0171
9
FILTERED NEBULIZER SET
$0.00
K0172
9
DISPOSABLE NEBULIZER UNFILL
$0.00
K0173
9
DISPOSABLE NEBULIZER PREFILL
$0.00
K0174
9
RESERVOIR BOTTLE W NEBULIZER
$0.00
K0175
9
DISPOSABLE CORRUGATED TUBING
$0.00
K0176
9
NON DISPOS CORRUGATED TUBING
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
K0177
9
WATER COLLEC DEV W NEBULIZER
$0.00
K0178
9
DISPOSBL FILTER W COMPRESSOR
$0.00
K0179
9
NON-DISPOS FILTER W/COMPRESS
$0.00
K0180
9
AEROSOL MASK WITH NEBULIZER
$0.00
K0181
9
DOME & MOUTHPIECE W/ NEBULIZ
$0.00
K0182
9
WATER DISTILLED W/ NEBULIZER
$0.00
K0183
O
NASAL APPLICATION DEVICE
$0.00
K0184
O
NASAL PILLOW OR FACE SEAL
$0.00
K0185
O
POS AIRWAY PRESSURE HEADGEAR
$0.00
K0186
O
POS AIRWAY PRSSURE CHINSTRAP
$0.00
K0187
O
POS AIRWAY PRESSURE TUBING
$0.00
K0188
O
POS AIRWAY PRESSURE FILTER
$0.00
K0189
O
FILTER NONDISPOSABLE W PAP
$0.00
K0190
9
DISPOSABLE CANISTER W/PUMP
$0.00
K0191
9
NON-DISPOSBL CANISTER W/PUMP
$0.00
K0192
9
TUBING USED W/ SUCTION PUMP
$0.00
K0193
9
AIRWAY PRESSURE DEV/W HMDFER
$0.00
K0194
9
ASSIST DEVICE W/HUMIDIFIER
$0.00
K0195
3
ELEVATING WHLCHAIR LEG RESTS
$0.00
K0196
9
ALGINATE DRESSING, WOUND COVER, PAD
$0.00
K0197
9
ALGINATE DRESSING, WOUND COVER, PAD
$0.00
K0198
9
ALGINATE DRESSING, WOUND COVER, PAD
$0.00
K0199
9
ALGINATE DRESSING, WOUND FILLER, PE
$0.00
K0203
9
COMPOSITE DRESSING, PAD SIZE 16 SQ.
$0.00
K0204
9
COMPOSITE DRESSING, PAD SIZE MORE T
$0.00
K0205
9
COMPOSITE DRESSING, PAD SIZE MORE T
$0.00
K0206
9
CONTACT LAYER, 16 SQ. IN. OR LESS,
$0.00
K0207
9
CONTACT LAYER, MORE THAN 16 BUT LES
$0.00
K0208
9
CONTACT LAYER, MORE THAN 48 SQ. IN.
$0.00
K0209
9
FOAM DRESSING, WOUND COVER, PAD SIZ
$0.00
K0210
9
FOAM DRESSING, WOUND COVER, PAD SIZ
$0.00
K0211
9
FOAM DRESSING, WOUND COVER, PAD SIZ
$0.00
K0212
9
FOAM DRESSING, WOUND COVER, PAD SIZ
$0.00
K0213
9
FOAM DRESSING, WOUND COVER, PAD SIZ
$0.00
K0214
9
FOAM DRESSING, WOUND COVER, PAD SIZ
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
K0215
9
FOAM DRESSING, WOUND FILLER, PER GR
$0.00
K0216
9
GAUZE, NON-IMPREGNATED, NON-STERILE
$0.00
K0217
9
GAUZE, NON-IMPREGNATED, NON-STERILE
$0.00
K0218
9
GAUZE, NON-IMPREGNATED, NON-STERILE
$0.00
K0219
9
GAUZE, NON-IMPREGNATED, PAD SIZE 16
$0.00
K0220
9
GAUZE, NON-IMPREGNATED, PAD SIZE MO
$0.00
K0221
9
GAUZE, NON-IMPREGNATED, PAD SIZE MO
$0.00
K0222
9
GAUZE, IMPREGNATED, OTHER THAN WATE
$0.00
K0223
9
GAUZE, IMPREGNATED, OTHER THAN WATE
$0.00
K0224
9
GAUZE, IMPREGNATED, OTHER THAN WATE
$0.00
K0228
9
GAUZE, IMPREGNATED, WATER OR NORMAL
$0.00
K0229
9
GAUZE, IMPREGNATED, WATER OR NORMAL
$0.00
K0230
9
GAUZE, IMPREGNATED, WATER OR NORMAL
$0.00
K0234
9
HYDROCOLLOID DRESSING, WOUND COVER,
$0.00
K0235
9
HYDROCOLLOID DRESSING, WOUND COVER,
$0.00
K0236
9
HYDROCOLLOID DRESSING, WOUND COVER,
$0.00
K0237
9
HYDROCOLLOID DRESSING, WOUND COVER,
$0.00
K0238
9
HYDROCOLLOID DRESSING, WOUND COVER,
$0.00
K0239
9
HYDROCOLLOID DRESSING, WOUND COVER,
$0.00
K0240
9
HYDROCOLLOID DRESSING, WOUND FILLER
$0.00
K0241
9
HYDROCOLLOID DRESSING, WOUND FILLER
$0.00
K0242
9
HYDROGEL DRESSING, WOUND COVER, PAD
$0.00
K0243
9
HYDROGEL DRESSING, WOUND COVER, PAD
$0.00
K0244
9
HYDROGEL DRESSING, WOUND COVER, PAD
$0.00
K0245
9
HYDROGEL DRESSING, WOUND COVER, PAD
$0.00
K0246
9
HYDROGEL DRESSING, WOUND COVER, PAD
$0.00
K0247
9
HYDROGEL DRESSING, WOUND COVER, PAD
$0.00
K0248
9
HYDROGEL DRESSING, WOUND FILLER, GE
$0.00
K0249
9
HYDROGEL DRESSING, WOUND FILLER, DR
$0.00
K0250
9
SKIN SEALANTS, PROTECTANTS, MOISTUR
$0.00
K0251
9
SPECIALTY ABSORPTIVE DRESSING, WOUN
$0.00
K0252
9
SPECIALTY ABSORPTIVE DRESSING, WOUN
$0.00
K0253
9
SPECIALTY ABSORPTIVE DRESSING, WOUN
$0.00
K0254
9
SPECIALTY ABSORPTIVE DRESSING, WOUN
$0.00
K0255
9
SPECIALTY ABSORPTIVE DRESSING, WOUN
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
K0256
9
SPECIALTY ABSORPTIVE DRESSING, WOUN
$0.00
K0257
9
TRANSPARENT FILM, 16 SQ. IN. OR LES
$0.00
K0258
9
TRANSPARENT FILM, MORE THAN 16 BUT
$0.00
K0259
9
TRANSPARENT FILM, MORE THAN 48 SQ.
$0.00
K0260
9
WOUND CLEANSERS, ANY TYPE, ANY SIZE
$0.00
K0261
9
WOUND FILLER, NOT ELSEWHERE CLASSIF
$0.00
K0262
9
WOUND FILLER, NOT ELSEWHERE CLASSIF
$0.00
K0263
9
GAUZE, ELASTIC, NON-STERILE, ALL T
$0.00
K0264
9
GAUZE, NON-ELASTIC, NON-STERILE, PE
$0.00
K0265
9
TAPE, ALL TYPES, PER 18 SQUARE INCH
$0.00
K0266
9
GAUZE, IMPREGNATED, OTHER THAN WATE
$0.00
K0267
O
REPLACEMENT BATTERY, ANY TYPE, FOR
$0.00
K0268
O
HUMIDIFIER NONHEATED W PAP
$0.00
K0269
9
AEROSOL COMPRESSOR CPAP DEV
$0.00
K0270
9
ULTRASONIC GENERATOR W NEBUL
$0.00
K0271
9
POUCH, DRAINABLE; WITH FACEPLATE AT
$0.00
K0272
9
POUCH, DRAINABLE; WITHOUT FACEPLATE
$0.00
K0273
9
POUCH, URINARY; WITH FACEPLATE ATTA
$0.00
K0274
9
POUCH, URINARY; WITHOUT FACEPLATE A
$0.00
K0275
9
OSTOMY FACEPLATE; CONVEX; REUSABLE;
$0.00
K0276
9
OSTOMY FACEPLATE; CONVEX; CUSTOM FI
$0.00
K0277
9
SKIN BARRIER SOLID 4X4 EQUIV
$0.00
K0278
9
SKIN BARRIER WITH FLANGE
$0.00
K0279
9
SKIN BARRIER EXTENDED WEAR
$0.00
K0280
9
EXTENSION DRAINAGE TUBING
$0.00
K0281
9
LUBRICANT CATHETER INSERTION
$0.00
K0283
9
SALINE SOLUTION DISPENSER
$0.00
K0284
9
EXTERNAL INFUSION PUMP REUSE
$0.00
K0285
9
REPAIR OF PROSTHETIC DEVICE, LABOR
$0.00
K0400
9
SKIN SUPPORT ATTACHMENT EACH
$0.00
K0401
9
DIABETIC DELUXE SHOE
$0.00
K0402
9
GAUZE, NON-IMPREGNATED, STERILE, PA
$0.00
K0403
9
GAUZE, NON-IMPREGNATED, STERILE, PA
$0.00
K0404
9
GAUZE, NON-IMPREGNATED, STERILE, PA
$0.00
K0405
9
GAUZE, ELASTIC, STERILE, ALL TYPES,
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
K0406
9
GAUZE, NON-ELASTIC, STERILE, PER LI
$0.00
K0407
9
URINARY CATH SKIN ATTACHMENT
$0.00
K0408
9
URINARY CATH LEG STRAP
$0.00
K0409
9
STERILE H2O IRRIGATION SOLUT
$0.00
K0410
9
MALE EXT CATH W/ADH COATING
$0.00
K0411
9
MALE EXT CATH W/ADH STRIP
$0.00
K0412
9
MYCOPHENOLATE MOFETIL 25O MG
$0.00
K0413
O
NON-POWERED, ADVANCED PRESSURE-REDU
$0.00
K0414
O
POWERED AIR OVERLAY FOR MATTRESS, S
$0.00
K0415
O
RX ANTIEMETIC DRG, ORAL NOS
$0.00
K0416
O
RX ANTIEMETIC DRG,RECTAL NOS
$0.00
K0417
9
MECH INFUS PUMP SHT TRM DRUG
$0.00
K0418
9
ORAL CYCLOSPORIN
$0.00
K0419
9
DRAINABLE PLSTIC PCH W FCPLT
$0.00
K0420
9
DRAINABLE RUBBER PCH W FCPLT
$0.00
K0421
9
DRAINABLE PLSTIC PCH W/O FP
$0.00
K0422
9
DRAINABLE RUBBER PCH W/O FP
$0.00
K0423
9
URINARY PLSTIC POUCH W FCPLT
$0.00
K0424
9
URINARY RUBBER POUCH W FCPLT
$0.00
K0425
9
URINARY PLSTIC POUCH W/O FP
$0.00
K0426
9
URINARY HVY PLSTC PCH W/O FP
$0.00
K0427
9
URINARY RUBBER POUCH W/O FP
$0.00
K0428
9
OSTOMY FACEPLT/SILICONE RING
$0.00
K0429
9
SKIN BARRIER SOLID EXT WEAR
$0.00
K0430
9
SKIN BARRIER W FLANG EX WEAR
$0.00
K0431
9
CLOSED POUCH W ST WEAR BAR
$0.00
K0432
9
DRAINABLE PCH W EX WEAR BAR
$0.00
K0433
9
DRAINABLE PCH W ST WEAR BAR
$0.00
K0434
9
DRAINABLE PCH EX WEAR CONVEX
$0.00
K0435
9
URINARY POUCH W EX WEAR BAR
$0.00
K0436
9
URINARY POUCH W ST WEAR BAR
$0.00
K0437
9
URINE PCH W EX WEAR BAR CONV
$0.00
K0438
9
OSTOMY POUCH LIQ DEODORANT
$0.00
K0439
9
OSTOMY POUCH SOLID DEODORANT
$0.00
K0440
9
NASAL PROSTHESIS
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
K0441
9
MIDFACIAL PROSTHESIS
$0.00
K0442
9
ORBITAL PROSTHESIS
$0.00
K0443
9
UPPER FACIAL PROSTHESIS
$0.00
K0444
9
HEMI-FACIAL PROSTHESIS
$0.00
K0445
9
AURICULAR PROSTHESIS
$0.00
K0446
9
PARTIAL FACIAL PROSTHESIS
$0.00
K0447
9
NASAL SEPTAL PROSTHESIS
$0.00
K0448
9
UNSPEC MAXILLOFACIAL PROSTH
$0.00
K0449
9
REPAIR MAXILLOFACIAL PROSTH
$0.00
K0450
9
LIQ ADHES FOR FACIAL PROSTH
$0.00
K0451
9
ADHESIVE REMOVER WIPES
$0.00
K0452
O
WHEELCHAIR BEARINGS
$0.00
K0453
9
AMPHOTERICIN B
$0.00
K0455
9
PUMP UNINTERRUPTED INFUSION
$0.00
K0456
O
HEAVYDUTY/XTRA WIDE HOSP BED
$0.00
K0457
O
HEAVYDUTY/WIDE COMMODE CHAIR
$0.00
K0458
O
HEAVYDUTY WALKER NO WHEELS
$0.00
K0459
O
HEAVY DUTY WHEELED WALKER
$0.00
K0460
O
WC POWER ADD-ON JOYSTICK
$0.00
K0461
O
WC POWER ADD-ON TILLER CNTRL
$0.00
K0462
9
TEMPORARY REPLACEMENT EQPMNT
$0.00
K0501
9
AEROSOL COMPRESSOR FOR SVNEB
$0.00
K0503
9
ACETYLCYSTEINE INH SOL U D
$0.00
K0504
9
ALBUTEROL INH SOL CON
$0.00
K0505
9
ALBUTEROL INH SOL U D
$0.00
K0506
9
ATROPINE INH SOL CON
$0.00
K0507
9
ATROPINE INH SOL U D
$0.00
K0508
9
BITOLTEROL MES INH SOL CON
$0.00
K0509
9
BITOLTEROL MES INH SOL U D
$0.00
K0511
9
CROMOLYN SODIUM INH SOL U D
$0.00
K0512
9
DEXAMETHASONE INH SOL CON
$0.00
K0513
9
DEXAMETHASONE INH SOL U D
$0.00
K0514
9
DORNASE ALPHA INH SOL U D
$0.00
K0515
9
GLYCOPYRROLATE INH SOL CON
$0.00
K0516
9
GLYCOPYRROLATE INH SOL U D
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
K0518
9
IPRATROPIUM BROM INH SOL U D
$0.00
K0519
9
ISOETHARINE HCL INH SOL CON
$0.00
K0520
9
ISOETHARINE HCL INH SOL U D
$0.00
K0521
9
ISOPROTERENOLHCL INH SOL CON
$0.00
K0522
9
ISOPROTERENOLHCL INH SOL U D
$0.00
K0523
9
METAPROTERENOL INH SOL CON
$0.00
K0524
9
METAPROTERENOL INH SOL U D
$0.00
K0525
9
TERBUTALINE SO4 INH SOL CON
$0.00
K0526
9
TERBUTALINE SO4 INH SOL U D
$0.00
K0527
9
TRIAMCINOLONE INH SOL CON
$0.00
K0528
9
TRIAMCINOLONE INH SOL U D
$0.00
K0529
9
STERILE H20 OR NSS W LV NEB
$0.00
K0530
9
NEBULIZER NOT USED W OXYGEN
$0.00
K0531
O
HEATED HUMIDIFIER USED W PAP
$0.00
K0532
O
NONINVASIVE ASSIST WO BACKUP
$0.00
K0533
O
NONINVASIVE ASSIST W BACKUP
$0.00
K0534
O
INVASIVE ASSIST W BACKUP
$0.00
K0538
O
NEG PRESSURE WND THRPY PUMP
$0.00
K0539
O
NEG PRES WND THRPY DSG SET
$0.00
K0540
O
NEG PRES WND THRP CANISTER
$0.00
K0541
O
SGD PRERECORDED MSG <= 8 MIN
$0.00
K0542
O
SGD PRERECORDED MSG > 8 MIN
$0.00
K0543
O
SGD MSG FORMED BY SPELLING
$0.00
K0544
O
SGD W MULTI METHODS MSG/ACCS
$0.00
K0545
O
SGD SFTWRE PRGRM FOR PC/PDA
$0.00
K0546
O
SGD ACCESSORY,MOUNTING SYSTM
$0.00
K0547
O
SGD ACCESSORY NOC
$0.00
K0549
O
HOSPITAL BED, HEAVY DUTY, EXTRA WI
$0.00
K0550
O
HOSPITAL BED, EXTRA HEAVY DUTY, EX
$0.00
K0551
9
RESIDUAL LIMB SUPPORT SYSTEM
$0.00
K0552
6
SUPPLY/EXT INF PUMP SYR TYPE
$0.00
K0556
O
SOCKET INSERT W LOCK MECH
$0.00
K0557
O
SOCKET INSERT W/O LOCK MECH
$0.00
K0558
O
INTL CUSTM CONG/ATYP INSERT
$0.00
K0559
O
INITIAL CUSTOM SOCKET INSERT
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
K0561
9
NONPECTIN BASED OSTOMY PASTE
$0.00
K0562
9
PECTIN BASED OSTOMY PASTE
$0.00
K0563
O
OSTOMY SKIN BARRIER WITH FLANGE (S
$0.00
K0565
O
OSTOMY SKIN BARRIER WITH FLANGE (S
$0.00
K0570
O
BUILT IN CONVEXITY, 4X INCHES OR S
$0.00
K0572
O
TAPE, NON WATERPROOF, PER 18 SQUAR
$0.00
K0573
O
TAPE, WATERPROOF, PER 18 SQUARE IN
$0.00
K0581
O
OST PCH CLSD W BARRIER/FILTR
$0.00
K0582
O
OST PCH W BAR/BLTINCONV/FLTR
$0.00
K0583
O
OST PCH CLSD W/O BAR W FILTR
$0.00
K0584
O
OST PCH FOR BAR W FLANGE/FLT
$0.00
K0585
O
OST PCH CLSD FOR BAR W LK FL
$0.00
K0586
O
OST PCH FOR BAR W LK FL/FLTR
$0.00
K0587
O
OST PCH DRAIN W BAR & FILTER
$0.00
K0588
O
OST PCH DRAIN FOR BARRIER FL
$0.00
K0589
O
OST PCH DRAIN 2 PIECE SYSTEM
$0.00
K0590
O
OST PCH DRAIN/BARR LK FLNG/F
$0.00
K0591
O
URINE OST POUCH W FAUCET/TAP
$0.00
K0592
O
URINE OST POUCH W BLTINCONV
$0.00
K0593
O
OST URINE PCH W B/BLTIN CONV
$0.00
K0594
O
OST PCH URINE W BARRIER/TAPV
$0.00
K0595
O
OS PCH URINE W BAR/FANGE/TAP
$0.00
K0596
O
URINE OST PCH BAR W LOCK FLN
$0.00
K0597
O
OST PCH URINE W LOCK FLNG/FT
$0.00
K0600
O
FUNCTIONAL NEUROMUSCULARSTIM
$0.00
K0601
6
REPL BATT SILVER OXIDE 1.5 V
$0.00
K0602
6
REPL BATT SILVER OXIDE 3 V
$0.00
K0603
6
REPL BATT ALKALINE 1.5 V
$0.00
K0604
6
REPL BATT LITHIUM 3.6 V
$0.00
K0605
6
REPL BATT LITHIUM 4.5 V
$0.00
K0606
6
AED GARMENT W ELEC ANALYSIS
$0.00
K0607
6
REPL BATT FOR AED
$0.00
K0608
6
REPL GARMENT FOR AED
$0.00
K0609
6
REPL ELECTRODE FOR AED
$0.00
K0618
O
TLSO 2 PIECE RIGID SHELL
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
K0619
O
TLSO 3 PIECE RIGID SHELL
$0.00
K0620
O
TUBULAR ELASTIC DRESSING
$0.00
K0627
O
CERVICAL PNEUM TRAC EQUIP
$0.00
K0628
O
MULT DENS INSERT DIRECT FORM
$0.00
K0629
O
MULT DENS INSERT CUSTOM MOLD
$0.00
K0630
O
SIO FLEX PELVISACRAL PREFAB
$0.00
K0631
O
SIO FLEX PELVISACRAL CUSTOM
$0.00
K0632
O
SIO PANEL PREFAB
$0.00
K0633
O
SIO PANEL CUSTOM
$0.00
K0634
O
LO FLEXIBLE L1 BELOW L5 PRE
$0.00
K0635
O
LO SAG STAYS/PANELS PRE-FAB
$0.00
K0636
O
LO SAGITT RIGID PANEL PREFAB
$0.00
K0637
O
LO FLEX W/O RIGID STAYS PRE
$0.00
K0638
O
LSO FLEX W/RIGID STAYS CUST
$0.00
K0639
O
LSO POST RIGID PANEL PRE
$0.00
K0640
O
LSO SAG-CORO RIGID FRAME PRE
$0.00
K0641
O
LSO SAG-COR RIGID FRAME CUST
$0.00
K0642
O
LSO FLEXION CONTROL PREFAB
$0.00
K0643
O
LSO FLEXION CONTROL CUSTOM
$0.00
K0644
O
LSO SAGIT RIGID PANEL PREFAB
$0.00
K0645
O
LSO SAGITTAL RIGID PANEL CUS
$0.00
K0646
O
LSO SAG-CORONAL PANEL PREFAB
$0.00
K0647
O
LSO SAG-CORONAL PANEL CUSTOM
$0.00
K0648
O
LSO S/C SHELL/PANEL PREFAB
$0.00
K0649
O
LSO S/C SHELL/PANEL CUSTOM
$0.00
K0650
O
GEN W/C CUSHION WIDTH LESS THAN 22
$0.00
K0651
O
GEN W/C CUSHION WIDTH GREATER THAN
$0.00
K0652
O
SKIN PROTECT W/C CUS WD LESS THAN2
$0.00
K0653
O
SKIN PROTECT W/C CUS WD GREATER TH
$0.00
K0654
O
POSITION W/C CUSH WIDTH LESS THAN2
$0.00
K0655
O
POSITION W/C CUSH WIDTH GREATER TH
$0.00
K0656
O
SKIN PRO/POS W/C CUS WD LESS THAN2
$0.00
K0657
O
SKIN PRO/POS W/C CUS WD GREATER TH
$0.00
K0658
O
CUSTOM FABRICATE W/C CUSHION
$0.00
K0659
O
POWERED W/C CUSHION
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
K0660
O
GEN USE BACK CUSH WIDTH LESS THAN2
$0.00
K0661
O
GEN USE BACK CUSH WIDTH GREATER TH
$0.00
K0662
O
POSITION BACK CUSH WDTH LESS THAN2
$0.00
K0663
O
POSITION BACK CUSH WDTH GREATER TH
$0.00
K0664
O
POS BACK POST/LAT WIDTH LESS THAN2
$0.00
K0665
O
POS BACK POST/LAT WIDTH GREATER TH
$0.00
K0666
O
CUSTOM FAB W/C BACK CUSHION
$0.00
K0667
O
MT HARDWRE MAN/LIGHT PWR W/C
$0.00
K0668
O
REP ACE COVER W/C SEAT CUSH
$0.00
K0669
6
SEAT/BACK CUS NO SADMERC VER
$0.00
K0670
O
STANCE PHASE ONLY
$0.00
K0672
6
REMOVABLE SOFT INTERFACE LE
$0.00
K0730
6
CTRL DOSE INH DRUG DELIV SYS
$0.00
K0733
6
12-24HR SEALED LEAD ACID
$0.00
K0734
6
ADJ SKIN PRO W/C CUS WD<22IN
$0.00
K0735
6
ADJ SKIN PRO WC CUS WD>=22IN
$0.00
K0736
6
ADJ SKIN PRO/POS WC CUS<22IN
$0.00
K0737
6
ADJ SKIN PRO/POS WC CUS>=22Ê
$0.00
K0738
6
PORTABLE GAS OXYGEN SYSTEM
$0.00
K0800
6
POV GROUP 1 STD UP TO 300LBS
$0.00
K0801
6
POV GROUP 1 HD 301-450 LBS
$0.00
K0802
6
POV GROUP 1 VHD 451-600 LBS
$0.00
K0806
6
POV GROUP 2 STD UP TO 300LBS
$0.00
K0807
6
POV GROUP 2 HD 301-450 LBS
$0.00
K0808
6
POV GROUP 2 VHD 451-600 LBS
$0.00
K0812
6
POWER OPERATED VEHICLE NOC
$0.00
K0813
6
PWC GP 1 STD PORT SEAT/BACK
$0.00
K0814
6
PWC GP 1 STD PORT CAP CHAIR
$0.00
K0815
6
PWC GP 1 STD SEAT/BACK
$0.00
K0816
6
PWC GP 1 STD CAP CHAIR
$0.00
K0820
6
PWC GP 2 STD PORT SEAT/BACK
$0.00
K0821
6
PWC GP 2 STD PORT CAP CHAIR
$0.00
K0822
6
PWC GP 2 STD SEAT/BACK
$0.00
K0823
6
PWC GP 2 STD CAP CHAIR
$0.00
K0824
6
PWC GP 2 HD SEAT/BACK
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
K0825
6
PWC GP 2 HD CAP CHAIR
$0.00
K0826
6
PWC GP 2 VHD SEAT/BACK
$0.00
K0827
6
PWC GP VHD CAP CHAIR
$0.00
K0828
6
PWC GP 2 XTRA HD SEAT/BACK
$0.00
K0829
6
PWC GP 2 XTRA HD CAP CHAIR
$0.00
K0830
6
PWC GP2 STD SEAT ELEVATE S/B
$0.00
K0831
6
PWC GP2 STD SEAT ELEVATE CAP
$0.00
K0835
6
PWC GP2 STD SING POW OPT S/B
$0.00
K0836
6
PWC GP2 STD SING POW OPT CAP
$0.00
K0837
6
PWC GP 2 HD SING POW OPT S/B
$0.00
K0838
6
PWC GP 2 HD SING POW OPT CAP
$0.00
K0839
6
PWC GP2 VHD SING POW OPT S/B
$0.00
K0840
6
PWC GP2 XHD SING POW OPT S/B
$0.00
K0841
6
PWC GP2 STD MULT POW OPT S/B
$0.00
K0842
6
PWC GP2 STD MULT POW OPT CAP
$0.00
K0843
6
PWC GP2 HD MULT POW OPT S/B
$0.00
K0848
6
PWC GP 3 STD SEAT/BACK
$0.00
K0849
6
PWC GP 3 STD CAP CHAIR
$0.00
K0850
6
PWC GP 3 HD SEAT/BACK
$0.00
K0851
6
PWC GP 3 HD CAP CHAIR
$0.00
K0852
6
PWC GP 3 VHD SEAT/BACK
$0.00
K0853
6
PWC GP 3 VHD CAP CHAIR
$0.00
K0854
6
PWC GP 3 XHD SEAT/BACK
$0.00
K0855
6
PWC GP 3 XHD CAP CHAIR
$0.00
K0856
6
PWC GP3 STD SING POW OPT S/B
$0.00
K0857
6
PWC GP3 STD SING POW OPT CAP
$0.00
K0858
6
PWC GP3 HD SING POW OPT S/B
$0.00
K0859
6
PWC GP3 HD SING POW OPT CAP
$0.00
K0860
6
PWC GP3 VHD SING POW OPT S/B
$0.00
K0861
6
PWC GP3 STD MULT POW OPT S/B
$0.00
K0862
6
PWC GP3 HD MULT POW OPT S/B
$0.00
K0863
6
PWC GP3 VHD MULT POW OPT S/B
$0.00
K0864
6
PWC GP3 XHD MULT POW OPT S/B
$0.00
K0868
6
PWC GP 4 STD SEAT/BACK
$0.00
K0869
6
PWC GP 4 STD CAP CHAIR
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
K0870
6
PWC GP 4 HD SEAT/BACK
$0.00
K0871
6
PWC GP 4 VHD SEAT/BACK
$0.00
K0877
6
PWC GP4 STD SING POW OPT S/B
$0.00
K0878
6
PWC GP4 STD SING POW OPT CAP
$0.00
K0879
6
PWC GP4 HD SING POW OPT S/B
$0.00
K0880
6
PWC GP4 VHD SING POW OPT S/B
$0.00
K0884
6
PWC GP4 STD MULT POW OPT S/B
$0.00
K0885
6
PWC GP4 STD MULT POW OPT CAP
$0.00
K0886
6
PWC GP4 HD MULT POW S/B
$0.00
K0890
6
PWC GP5 PED SING POW OPT S/B
$0.00
K0891
6
PWC GP5 PED MULT POW OPT S/B
$0.00
K0898
6
POWER WHEELCHAIR NOC
$0.00
K0899
9
POW MOBIL DEV NO SADMERC
$0.00
KKEVL
O
MCO SPECIFIC CODE: DPH KIDS KARE IN
$0.00
KKTX1
O
MCO SPECIFIC CODE: DPH KIDS KARE TE
$0.00
KKTX2
O
MCO SPECIFIC CODE: DPH KIDS KARE TE
$0.00
L0100
O
CRANIAL ORTHOSIS/HELMET MOLD
$0.00
L0101
O
ONE-ARM DRIVE ATTACHMENT, EACH
$0.00
L0110
O
CRANIAL ORTHOSIS/HELMET NONM
$0.00
L0112
6
CRANIAL CERVICAL ORTHOSIS
$0.00
L0113
6
CRANIAL CERVICAL TORTICOLLIS
$0.00
L0120
3
CERV FLEXIBLE NON-ADJUSTABLE
$20.07
L0130
3
FLEX THERMOPLASTIC COLLAR MO
$141.92
L0140
3
CERVICAL SEMI-RIGID ADJUSTAB
$46.91
L0150
3
CERV SEMI-RIG ADJ MOLDED CHN
$86.11
L0160
3
CERV SEMI-RIG WIRE OCC/MAND
$112.45
L0170
3
CERVICAL COLLAR MOLDED TO PT
$463.04
L0172
3
CERV COL THERMPLAS FOAM 2 PI
$100.39
L0174
3
CERV COL FOAM 2 PIECE W THOR
$197.24
L0180
3
CER POST COL OCC/MAN SUP ADJ
$273.50
L0190
3
CERV COLLAR SUPP ADJ CERV BA
$355.67
L0200
3
CERV COL SUPP ADJ BAR & THOR
$370.78
L0210
3
THORACIC RIB BELT
L0220
3
THOR RIB BELT CUSTOM FABRICA
L0300
O
TLSO FLEX SURGICAL SUPPORT
$34.05 $101.25 $0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
L0310
O
TLSO FLEXIBLE CUSTOM FABRICA
$0.00
L0315
O
TLSO FLEX ELAS RIGID POST PA
$0.00
L0317
O
TLSO FLEX HYPEXT ELAS POST P
$0.00
L0320
O
TLSO A-P CONTRL W APRON FRNT
$0.00
L0321
O
TLSO ANTI-POST-CNTRL PREFAB
$0.00
L0330
O
TLSO ANT-POS-LATERAL CONTROL
$0.00
L0331
O
TLSO ANT-POST-LAT CNTRL PRFB
$0.00
L0340
O
TLSO A-P-L-ROTARY WITH APRON
$0.00
L0350
O
TLSO FLEX COMPRESS JACKET CU
$0.00
L0360
O
TLSO FLEX COMPRESS JACKET MO
$0.00
L0370
O
TLSO A-P-L-ROTARY HYPEREXTEN
$0.00
L0380
O
TLSO A-P-L-ROT W/ POS EXTENS
$0.00
L0390
O
TLSO A-P-L CONTROL MOLDED
$0.00
L0391
O
TLSO ANT-POST-LAT-ROT CNTRL
$0.00
L0400
O
TLSO A-P-L W INTERFACE MATER
$0.00
L0410
O
TLSO A-P-L TWO PIECE CONSTR
$0.00
L0420
O
TLSO A-P-L 2 PIECE W INTERFA
$0.00
L0430
6
TLSO A-P-L W INTERFACE CUSTM
$0.00
L0440
O
TLSO A-P-L OVERLAP FRNT CUST
$0.00
L0450
5
TLSO FLEX PREFAB THORACIC
$0.00
L0452
5
TLSO FLEX CUSTOM FAB THORACI
$0.00
L0454
5
TLSO FLEX PREFAB SACROCOC-T9
$0.00
L0456
5
TLSO FLEX PREFAB
$0.00
L0458
5
TLSO 2MOD SYMPHIS-XIPHO PRE
$0.00
L0460
5
TLSO2MOD SYMPHYSIS-STERN PRE
$0.00
L0462
3
TLSO 3MOD SACRO-SCAP PRE
$1,050.90
L0464
5
TLSO 4MOD SACRO-SCAP PRE
$0.00
L0466
5
TLSO RIGID FRAME PRE SOFT AP
$0.00
L0468
5
TLSO RIGID FRAME PREFAB PELV
$0.00
L0470
5
TLSO RIGID FRAME PRE SUBCLAV
$0.00
L0472
5
TLSO RIGID FRAME HYPEREX PRE
$0.00
L0474
5
TLSO RIGID FRAME PRE PELVIC
$0.00
L0476
O
TLSO FLEXION COMPRES JAC PRE
$0.00
L0478
O
TLSO FLEXION COMPRES JAC CUS
$0.00
L0480
5
TLSO RIGID PLASTIC CUSTOM FA
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
L0482
5
TLSO RIGID LINED CUSTOM FAB
$0.00
L0484
5
TLSO RIGID PLASTIC CUST FAB
$0.00
L0486
5
TLSO RIGIDLINED CUST FAB TWO
$0.00
L0488
5
TLSO RIGID LINED PRE ONE PIE
$0.00
L0490
5
TLSO RIGID PLASTIC PRE ONE
$0.00
L0491
6
TLSO 2 PIECE RIGID SHELL
$0.00
L0492
6
TLSO 3 PIECE RIGID SHELL
$0.00
L0500
O
LSO FLEX SURGICAL SUPPORT
$0.00
L0510
O
LSO FLEXIBLE CUSTOM FABRICAT
$0.00
L0515
O
LSO FLEX ELAS W/ RIG POST PA
$0.00
L0520
O
LSO A-P-L CONTROL WITH APRON
$0.00
L0530
O
LSO ANT-POS CONTROL W APRON
$0.00
L0540
O
LSO LUMBAR FLEXION A-P-L
$0.00
L0550
O
LSO A-P-L CONTROL MOLDED
$0.00
L0560
O
LSO A-P-L W INTERFACE
$0.00
L0561
O
PREFAB LSO
$0.00
L0565
O
LSO A-P-L CONTROL CUSTOM
$0.00
L0600
O
SACROILIAC FLEX SURG SUPPORT
$0.00
L0610
O
SACROILIAC FLEXIBLE CUSTM FA
$0.00
L0620
O
SACROILIAC SEMI-RIG W APRON
$0.00
L0621
6
SIO FLEX PELVISACRAL PREFAB
$0.00
L0622
6
SIO FLEX PELVISACRAL CUSTOM
$0.00
L0623
6
SIO PANEL PREFAB
$0.00
L0624
6
SIO PANEL CUSTOM
$0.00
L0625
6
LO FLEXIBL L1-BELOW L5 PRE
$0.00
L0626
6
LO SAG STAYS/PANELS PRE-FAB
$0.00
L0627
6
LO SAGITT RIGID PANEL PREFAB
$0.00
L0628
6
LO FLEX W/O RIGID STAYS PRE
$0.00
L0629
6
LSO FLEX W/RIGID STAYS CUST
$0.00
L0630
3
LSO POST RIGID PANEL PRE
L0631
6
LSO SAG-CORO RIGID FRAME PRE
$0.00
L0632
6
LSO SAG RIGID FRAME CUST
$0.00
L0633
6
LSO FLEXION CONTROL PREFAB
$0.00
L0634
6
LSO FLEXION CONTROL CUSTOM
$0.00
L0635
6
LSO SAGIT RIGID PANEL PREFAB
$0.00
$127.26
Procedure Code Pricing Action Code Description
Maximum Allowable
L0636
6
LSO SAGITTAL RIGID PANEL CUS
$0.00
L0637
6
LSO SAG-CORONAL PANEL PREFAB
$0.00
L0638
6
LSO SAG-CORONAL PANEL CUSTOM
$0.00
L0639
6
LSO S/C SHELL/PANEL PREFAB
$0.00
L0640
6
LSO S/C SHELL/PANEL CUSTOM
$0.00
L0700
3
CTLSO A-P-L CONTROL MOLDED
$1,467.79
L0710
3
CTLSO A-P-L CONTROL W/ INTER
$1,499.54
L0810
3
HALO CERVICAL INTO JCKT VEST
$1,875.37
L0820
3
HALO CERVICAL INTO BODY JACK
$1,683.27
L0830
3
HALO CERV INTO MILWAUKEE TYP
$2,372.22
L0859
6
MRI COMPATIBLE SYSTEM
$0.00
L0860
O
MAGNETIC RESONANC IMAGE COMP
$0.00
L0861
6
HALO REPL LINER/INTERFACE
$0.00
L0900
O
TORSO/PTOSIS SUPPORT
$0.00
L0910
O
TORSO & PTOSIS SUPP CUSTM FA
$0.00
L0920
O
TORSO/PENDULOUS ABD SUPPORT
$0.00
L0930
O
PENDULOUS ABDOMEN SUPP CUSTM
$0.00
L0940
O
TORSO/POSTSURGICAL SUPPORT
$0.00
L0950
O
POST SURG SUPPORT CUSTOM FAB
$0.00
L0960
O
POST SURGICAL SUPPORT PADS
$0.00
L0970
3
TLSO CORSET FRONT
$96.55
L0972
3
LSO CORSET FRONT
$86.71
L0974
3
TLSO FULL CORSET
$128.76
L0976
3
LSO FULL CORSET
$114.81
L0978
3
AXILLARY CRUTCH EXTENSION
$151.56
L0980
3
PERONEAL STRAPS PAIR
$16.53
L0982
3
STOCKING SUPP GRIPS SET OF F
$11.69
L0984
3
PROTECTIVE BODY SOCK EACH
$48.54
L0986
O
SPINAL ORTH ABDM PNL PREFAB
$0.00
L0999
5
ADD TO SPINAL ORTHOSIS NOS
$0.00
L1000
3
CTLSO MILWAUKE INITIAL MODEL
L1001
6
CTLSO INFANT IMMOBILIZER
$0.00
L1005
5
TENSION BASED SCOLIOSIS ORTH
$0.00
L1010
3
CTLSO AXILLA SLING
$48.19
L1020
3
KYPHOSIS PAD
$62.06
$1,472.64
Procedure Code Pricing Action Code Description
Maximum Allowable
L1025
3
KYPHOSIS PAD FLOATING
$118.46
L1030
3
LUMBAR BOLSTER PAD
$45.67
L1040
3
LUMBAR OR LUMBAR RIB PAD
$59.77
L1050
3
STERNAL PAD
$72.03
L1060
3
THORACIC PAD
$86.42
L1070
3
TRAPEZIUS SLING
$84.40
L1080
3
OUTRIGGER
$47.48
L1085
3
OUTRIGGER BIL W/ VERT EXTENS
L1090
3
LUMBAR SLING
L1100
3
RING FLANGE PLASTIC/LEATHER
$135.65
L1110
3
RING FLANGE PLAS/LEATHER MOL
$183.38
L1120
3
COVERS FOR UPRIGHT EACH
L1200
3
FURNSH INITIAL ORTHOSIS ONLY
L1210
3
LATERAL THORACIC EXTENSION
$187.88
L1220
3
ANTERIOR THORACIC EXTENSION
$179.47
L1230
3
MILWAUKEE TYPE SUPERSTRUCTUR
$460.04
L1240
3
LUMBAR DEROTATION PAD
$62.18
L1250
3
ANTERIOR ASIS PAD
$62.18
L1260
3
ANTERIOR THORACIC DEROTATION
$63.50
L1270
3
ABDOMINAL PAD
$64.52
L1280
3
RIB GUSSET (ELASTIC) EACH
$74.19
L1290
3
LATERAL TROCHANTERIC PAD
$58.74
L1300
3
BODY JACKET MOLD TO PATIENT
$1,322.50
L1310
3
POST-OPERATIVE BODY JACKET
$1,358.90
L1499
5
SPINAL ORTHOSIS NOS
L1500
3
THKAO MOBILITY FRAME
L1510
3
THKAO STANDING FRAME
L1520
3
THKAO SWIVEL WALKER
L1600
3
ABDUCT HIP FLEX FREJKA W CVR
$92.52
L1610
3
ABDUCT HIP FLEX FREJKA COVR
$40.82
L1620
3
ABDUCT HIP FLEX PAVLIK HARNE
$115.65
L1630
3
ABDUCT CONTROL HIP SEMI-FLEX
$121.67
L1640
3
PELV BAND/SPREAD BAR THIGH C
$370.37
L1650
3
HO ABDUCTION HIP ADJUSTABLE
$187.41
L1652
5
HO BI THIGHCUFFS W SPRDR BAR
$128.42 $84.96
$31.00 $1,124.98
$0.00 $1,363.82 $862.81 $1,638.02
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
L1660
3
HO ABDUCTION STATIC PLASTIC
$122.87
L1680
3
PELVIC & HIP CONTROL THIGH C
$874.83
L1685
3
POST-OP HIP ABDUCT CUSTOM FA
$892.79
L1686
3
HO POST-OP HIP ABDUCTION
$824.39
L1690
3
COMBINATION BILATERAL HO
$1,449.30
L1700
3
LEG PERTHES ORTH TORONTO TYP
$1,096.46
L1710
3
LEGG PERTHES ORTH NEWINGTON
$1,283.53
L1720
3
LEGG PERTHES ORTHOSIS TRILAT
$946.12
L1730
3
LEGG PERTHES ORTH SCOTTISH R
$812.63
L1750
O
LEGG PERTHES SLING
L1755
3
LEGG PERTHES PATTEN BOTTOM T
L1800
3
KNEE ORTHOSES ELAS W STAYS
$52.19
L1810
3
KO ELASTIC WITH JOINTS
$70.71
L1815
3
ELASTIC WITH CONDYLAR PADS
$74.89
L1820
3
KO ELAS W/ CONDYLE PADS & JO
$109.56
L1825
3
KO ELASTIC KNEE CAP
$48.39
L1830
3
KO IMMOBILIZER CANVAS LONGIT
$66.62
L1831
6
KNEE ORTH POS LOCKING JOINT
$0.00
L1832
3
KO ADJ JNT POS RIGID SUPPORT
$507.82
L1834
3
KO W/0 JOINT RIGID MOLDED TO
$557.35
L1836
5
RIGID KO WO JOINTS
L1840
3
KO DEROT ANT CRUCIATE CUSTOM
$742.41
L1843
3
KO SINGLE UPRIGHT CUSTOM FIT
$672.48
L1844
3
KO W/ADJ JT ROT CNTRL MOLDED
$1,165.61
L1845
3
KO W/ ADJ FLEX/EXT ROTAT CUS
$697.85
L1846
3
KO W ADJ FLEX/EXT ROTAT MOLD
$791.83
L1847
3
KO ADJUSTABLE W AIR CHAMBERS
$431.07
L1850
3
KO SWEDISH TYPE
$218.25
L1855
O
KO PLAS DOUB UPRIGHT JNT MOL
$0.00
L1858
O
KO POLYCENTRIC PNEUMATIC PAD
$0.00
L1860
3
KO SUPRACONDYLAR SOCKET MOLD
L1870
O
KO DOUB UPRIGHT LACERS MOLDE
$0.00
L1880
O
KO DOUB UPRIGHT CUFFS/LACERS
$0.00
L1885
O
KNEE UPRIGHT W/RESISTANCE
$0.00
L1900
3
AFO SPRNG WIR DRSFLX CALF BD
$0.00 $1,289.59
$0.00
$770.45
$193.70
Procedure Code Pricing Action Code Description
Maximum Allowable
L1901
5
PREFAB ANKLE ORTHOSIS
$0.00
L1902
3
AFO ANKLE GAUNTLET
L1904
3
AFO MOLDED ANKLE GAUNTLET
L1906
3
AFO MULTILIGAMENTUS ANKLE SU
L1907
6
AFO SUPRAMALLEOLAR CUSTOM
$0.00
L1910
3
AFO SING BAR CLASP ATTACH SH
$196.12
L1920
3
AFO SING UPRIGHT W/ ADJUST S
$251.01
L1930
3
AFO PLASTIC
$169.85
L1932
6
AFO RIG ANT TIB PREFAB TCF/=
L1940
3
AFO MOLDED TO PATIENT PLASTI
$355.08
L1945
3
AFO MOLDED PLAS RIG ANT TIB
$848.95
L1950
3
AFO SPIRAL MOLDED TO PT PLAS
$562.89
L1951
6
AFO SPIRAL PREFABRICATED
L1960
3
AFO POS SOLID ANK PLASTIC MO
$424.55
L1970
3
AFO PLASTIC MOLDED W/ANKLE J
$510.90
L1971
6
AFO W/ANKLE JOINT, PREFAB
L1980
3
AFO SING SOLID STIRRUP CALF
$263.51
L1990
3
AFO DOUB SOLID STIRRUP CALF
$320.05
L2000
3
KAFO SING FRE STIRR THI/CALF
$758.23
L2005
6
KAFO SNG/DBL MECHANICAL ACT
L2010
3
KAFO SNG SOLID STIRRUP W/O J
$707.32
L2020
3
KAFO DBL SOLID STIRRUP BAND/
$890.63
L2030
3
KAFO DBL SOLID STIRRUP W/O J
$808.48
L2034
6
KAFO PLA SIN UP W/WO K/A CUS
$0.00
L2035
3
KAFO PLASTIC PEDIATRIC SIZE
L2036
3
KAFO PLAS DOUB FREE KNEE MOL
$1,380.47
L2037
3
KAFO PLAS SING FREE KNEE MOL
$1,287.91
L2038
3
KAFO W/O JOINT MULTI-AXIS AN
$1,308.30
L2039
O
KAFO,PLSTIC,MEDLAT ROTAT CON
$0.00
L2040
3
HKAFO TORSION BIL ROT STRAPS
$158.68
L2050
3
HKAFO TORSION CABLE HIP PELV
$342.03
L2060
3
HKAFO TORSION BALL BEARING J
$416.86
L2070
3
HKAFO TORSION UNILAT ROT STR
$107.04
L2080
3
HKAFO UNILAT TORSION CABLE
$258.25
L2090
3
HKAFO UNILAT TORSION BALL BR
$314.84
$66.93 $402.52 $86.35
$0.00
$0.00
$0.00
$0.00
$131.14
Procedure Code Pricing Action Code Description
Maximum Allowable
L2102
O
AFO TIBIAL FX CAST PLSTR MOL
$0.00
L2104
O
AFO TIB FX CAST SYNTHETIC MO
$0.00
L2106
3
AFO TIB FX CAST PLASTER MOLD
$488.18
L2108
3
AFO TIB FX CAST MOLDED TO PT
$850.00
L2112
3
AFO TIBIAL FRACTURE SOFT
$390.97
L2114
3
AFO TIB FX SEMI-RIGID
$490.39
L2116
3
AFO TIBIAL FRACTURE RIGID
$564.23
L2122
O
KAFO FEM FX CAST PLASTER MOL
$0.00
L2124
O
KAFO FEM FX CAST SYNTHET MOL
$0.00
L2126
3
KAFO FEM FX CAST THERMOPLAS
$943.82
L2128
3
KAFO FEM FX CAST MOLDED TO P
$1,336.53
L2132
3
KAFO FEMORAL FX CAST SOFT
$724.60
L2134
3
KAFO FEM FX CAST SEMI-RIGID
$773.23
L2136
3
KAFO FEMORAL FX CAST RIGID
$922.89
L2180
3
PLAS SHOE INSERT W ANK JOINT
$86.13
L2182
3
DROP LOCK KNEE
$71.37
L2184
3
LIMITED MOTION KNEE JOINT
$97.56
L2186
3
ADJ MOTION KNEE JNT LERMAN T
$135.31
L2188
3
QUADRILATERAL BRIM
$259.14
L2190
3
WAIST BELT
L2192
3
PELVIC BAND & BELT THIGH FLA
$294.02
L2200
3
LIMITED ANKLE MOTION EA JNT
$34.14
L2210
3
DORSIFLEXION ASSIST EACH JOI
$49.41
L2220
3
DORSI & PLANTAR FLEX ASS/RES
$58.80
L2230
3
SPLIT FLAT CALIPER STIRR & P
$55.09
L2232
6
ROCKER BOTTOM, CONTACT AFO
$0.00
L2240
3
ROUND CALIPER AND PLATE ATTA
$68.19
L2250
3
FOOT PLATE MOLDED STIRRUP AT
$276.47
L2260
3
REINFORCED SOLID STIRRUP
$143.93
L2265
3
LONG TONGUE STIRRUP
$84.55
L2270
3
VARUS/VALGUS STRAP PADDED/LI
$39.65
L2275
3
PLASTIC MOD LOW EXT PAD/LINE
$93.48
L2280
3
MOLDED INNER BOOT
$326.87
L2300
3
ABDUCTION BAR JOINTED ADJUST
$204.94
L2310
3
ABDUCTION BAR-STRAIGHT
$102.64
$66.96
Procedure Code Pricing Action Code Description
Maximum Allowable
L2320
3
NON-MOLDED LACER
$147.73
L2330
3
LACER MOLDED TO PATIENT MODE
$309.23
L2335
3
ANTERIOR SWING BAND
$190.92
L2340
3
PRE-TIBIAL SHELL MOLDED TO P
$413.33
L2350
3
PROSTHETIC TYPE SOCKET MOLDE
$713.86
L2360
3
EXTENDED STEEL SHANK
L2370
3
PATTEN BOTTOM
$240.71
L2375
3
TORSION ANK & HALF SOLID STI
$101.69
L2380
3
TORSION STRAIGHT KNEE JOINT
$88.39
L2385
3
STRAIGHT KNEE JOINT HEAVY DU
$96.17
L2387
6
ADD LE POLY KNEE CUSTOM KAFO
$0.00
L2390
3
OFFSET KNEE JOINT EACH
L2395
3
OFFSET KNEE JOINT HEAVY DUTY
$112.34
L2397
3
SUSPENSION SLEEVE LOWER EXT
$87.53
L2405
3
KNEE JOINT DROP LOCK EA JNT
$65.34
L2415
3
KNEE JOINT CAM LOCK EACH JOI
$91.03
L2425
3
KNEE DISC/DIAL LOCK/ADJ FLEX
$107.43
L2430
3
KNEE JNT RATCHET LOCK EA JNT
$107.43
L2435
O
KNEE JOINT POLYCENTRIC JOINT
$0.00
L2492
3
KNEE LIFT LOOP DROP LOCK RIN
$97.54
L2500
3
THI/GLUT/ISCHIA WGT BEARING
$233.34
L2510
3
TH/WGHT BEAR QUAD-LAT BRIM M
$523.55
L2520
3
TH/WGHT BEAR QUAD-LAT BRIM C
$345.37
L2525
3
TH/WGHT BEAR NAR M-L BRIM MO
$931.80
L2526
3
TH/WGHT BEAR NAR M-L BRIM CU
$531.72
L2530
3
THIGH/WGHT BEAR LACER NON-MO
$168.70
L2540
3
THIGH/WGHT BEAR LACER MOLDED
$303.55
L2550
3
THIGH/WGHT BEAR HIGH ROLL CU
$206.21
L2570
3
HIP CLEVIS TYPE 2 POSIT JNT
$341.99
L2580
3
PELVIC CONTROL PELVIC SLING
$333.23
L2600
3
HIP CLEVIS/THRUST BEARING FR
$182.48
L2610
3
HIP CLEVIS/THRUST BEARING LO
$193.28
L2620
3
PELVIC CONTROL HIP HEAVY DUT
$217.32
L2622
3
HIP JOINT ADJUSTABLE FLEXION
$246.37
L2624
3
HIP ADJ FLEX EXT ABDUCT CONT
$237.76
$37.15
$80.51
Procedure Code Pricing Action Code Description
Maximum Allowable
L2627
3
PLASTIC MOLD RECIPRO HIP & C
$1,297.39
L2628
3
METAL FRAME RECIPRO HIP & CA
$1,276.17
L2630
3
PELVIC CONTROL BAND & BELT U
$177.79
L2640
3
PELVIC CONTROL BAND & BELT B
$241.29
L2650
3
PELV & THOR CONTROL GLUTEAL
$102.75
L2660
3
THORACIC CONTROL THORACIC BA
$133.82
L2670
3
THORAC CONT PARASPINAL UPRIG
$129.79
L2680
3
THORAC CONT LAT SUPPORT UPRI
$120.23
L2750
3
PLATING CHROME/NICKEL PR BAR
$60.02
L2755
3
CARBON GRAPHITE LAMINATION
$97.91
L2760
3
EXTENSION PER EXTENSION PER
$43.62
L2768
5
ORTHO SIDEBAR DISCONNECT
L2770
3
LOW EXT ORTHOSIS PER BAR/JNT
$44.33
L2780
3
NON-CORROSIVE FINISH
$48.59
L2785
3
DROP LOCK RETAINER EACH
$22.86
L2795
3
KNEE CONTROL FULL KNEECAP
$61.97
L2800
3
KNEE CAP MEDIAL OR LATERAL P
$95.24
L2810
3
KNEE CONTROL CONDYLAR PAD
$74.77
L2820
3
SOFT INTERFACE BELOW KNEE SE
$62.35
L2830
3
SOFT INTERFACE ABOVE KNEE SE
$67.46
L2840
3
TIBIAL LENGTH SOCK FX OR EQU
$39.88
L2850
3
FEMORAL LGTH SOCK FX OR EQUA
$44.46
L2860
O
TORSION MECHANISM KNEE/ANKLE
$0.00
L2999
5
LOWER EXTREMITY ORTHOSIS NOS
$0.00
L3000
3
FT INSERT UCB BERKELEY SHELL
L3001
5
FOOT INSERT REMOV MOLDED SPE
$0.00
L3002
5
FOOT INSERT PLASTAZOTE OR EQ
$0.00
L3003
5
FOOT INSERT SILICONE GEL EAC
$0.00
L3010
5
FOOT LONGITUDINAL ARCH SUPPO
$0.00
L3020
3
FOOT LONGITUD/METATARSAL SUP
$155.91
L3030
5
FOOT ARCH SUPPORT REMOV PREM
$0.00
L3031
6
FOOT LAMIN/PREPREG COMPOSITE
$0.00
L3040
5
FT ARCH SUPRT PREMOLD LONGIT
$0.00
L3050
5
FOOT ARCH SUPP PREMOLD METAT
$0.00
L3060
5
FOOT ARCH SUPP LONGITUD/META
$0.00
$0.00
$80.00
Procedure Code Pricing Action Code Description
Maximum Allowable
L3070
5
ARCH SUPRT ATT TO SHO LONGIT
$0.00
L3080
5
ARCH SUPP ATT TO SHOE METATA
$0.00
L3090
5
ARCH SUPP ATT TO SHOE LONG/M
$0.00
L3100
5
HALLUS-VALGUS NGHT DYNAMIC S
$0.00
L3140
5
ABDUCTION ROTATION BAR SHOE
$0.00
L3150
5
ABDUCT ROTATION BAR W/O SHOE
$0.00
L3160
5
SHOE STYLED POSITIONING DEV
$0.00
L3170
5
FOOT PLASTIC HEEL STABILIZER
$0.00
L3201
5
OXFORD W SUPINAT/PRONAT INF
$0.00
L3202
5
OXFORD W/ SUPINAT/PRONATOR C
$0.00
L3203
5
OXFORD W/ SUPINATOR/PRONATOR
$0.00
L3204
5
HIGHTOP W/ SUPP/PRONATOR INF
$0.00
L3206
5
HIGHTOP W/ SUPP/PRONATOR CHI
$0.00
L3207
5
HIGHTOP W/ SUPP/PRONATOR JUN
$0.00
L3208
5
SURGICAL BOOT EACH INFANT
$0.00
L3209
5
SURGICAL BOOT EACH CHILD
$0.00
L3211
5
SURGICAL BOOT EACH JUNIOR
$0.00
L3212
5
BENESCH BOOT PAIR INFANT
$0.00
L3213
5
BENESCH BOOT PAIR CHILD
$0.00
L3214
5
BENESCH BOOT PAIR JUNIOR
$0.00
L3215
3
ORTHOPEDIC FTWEAR LADIES OXF
$86.72
L3216
5
ORTHOPED LADIES SHOES DPTH I
$0.00
L3217
5
LADIES SHOES HIGHTOP DEPTH I
$0.00
L3218
O
LADIES SURGICAL BOOT EACH
$0.00
L3219
3
ORTHOPEDIC MENS SHOES OXFORD
L3221
5
ORTHOPEDIC MENS SHOES DPTH I
$0.00
L3222
5
MENS SHOES HIGHTOP DEPTH INL
$0.00
L3223
O
MENS SURGICAL BOOT EACH
$0.00
L3224
3
WOMAN'S SHOE OXFORD BRACE
$47.77
L3225
3
MAN'S SHOE OXFORD BRACE
$49.05
L3230
5
CUSTOM SHOES DEPTH INLAY
$0.00
L3250
5
CUSTOM MOLD SHOE REMOV PROST
$0.00
L3251
5
SHOE MOLDED TO PT SILICONE S
$0.00
L3252
5
SHOE MOLDED PLASTAZOTE CUST
$0.00
L3253
5
SHOE MOLDED PLASTAZOTE CUST
$0.00
$89.02
Procedure Code Pricing Action Code Description
Maximum Allowable
L3254
5
ORTH FOOT NON-STNDARD SIZE/W
$0.00
L3255
5
ORTH FOOT NON-STANDARD SIZE/
$0.00
L3257
5
ORTH FOOT ADD CHARGE SPLIT S
$0.00
L3260
5
AMBULATORY SURGICAL BOOT EAC
$0.00
L3265
5
PLASTAZOTE SANDAL EACH
$0.00
L3300
5
SHO LIFT TAPER TO METATARSAL
$0.00
L3310
5
SHOE LIFT ELEV HEEL/SOLE NEO
$0.00
L3320
5
SHOE LIFT ELEV HEEL/SOLE COR
$0.00
L3330
5
LIFTS ELEVATION METAL EXTENS
$0.00
L3332
5
SHOE LIFTS TAPERED TO ONE-HA
$0.00
L3334
5
SHOE LIFTS ELEVATION HEEL /I
$0.00
L3340
5
SHOE WEDGE SACH
$0.00
L3350
5
SHOE HEEL WEDGE
$0.00
L3360
5
SHOE SOLE WEDGE OUTSIDE SOLE
$0.00
L3370
5
SHOE SOLE WEDGE BETWEEN SOLE
$0.00
L3380
5
SHOE CLUBFOOT WEDGE
$0.00
L3390
5
SHOE OUTFLARE WEDGE
$0.00
L3400
5
SHOE METATARSAL BAR WEDGE RO
$0.00
L3410
5
SHOE METATARSAL BAR BETWEEN
$0.00
L3420
5
FULL SOLE/HEEL WEDGE BTWEEN
$0.00
L3430
5
SHO HEEL COUNT PLAST REINFOR
$0.00
L3440
5
HEEL LEATHER REINFORCED
$0.00
L3450
5
SHOE HEEL SACH CUSHION TYPE
$0.00
L3455
5
SHOE HEEL NEW LEATHER STANDA
$0.00
L3460
5
SHOE HEEL NEW RUBBER STANDAR
$0.00
L3465
5
SHOE HEEL THOMAS WITH WEDGE
$0.00
L3470
5
SHOE HEEL THOMAS EXTEND TO B
$0.00
L3480
5
SHOE HEEL PAD & DEPRESS FOR
$0.00
L3485
5
SHOE HEEL PAD REMOVABLE FOR
$0.00
L3500
5
ORTHO SHOE ADD LEATHER INSOL
$0.00
L3510
5
ORTHOPEDIC SHOE ADD RUB INSL
$0.00
L3520
5
O SHOE ADD FELT W LEATH INSL
$0.00
L3530
5
ORTHO SHOE ADD HALF SOLE
$0.00
L3540
5
ORTHO SHOE ADD FULL SOLE
$0.00
L3550
5
O SHOE ADD STANDARD TOE TAP
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
L3560
5
O SHOE ADD HORSESHOE TOE TAP
$0.00
L3570
5
O SHOE ADD INSTEP EXTENSION
$0.00
L3580
5
O SHOE ADD INSTEP VELCRO CLO
$0.00
L3590
5
O SHOE CONVERT TO SOF COUNTE
$0.00
L3595
5
ORTHO SHOE ADD MARCH BAR
$0.00
L3600
5
TRANS SHOE CALIP PLATE EXIST
$0.00
L3610
3
TRANS SHOE CALIPER PLATE NEW
L3620
5
TRANS SHOE SOLID STIRRUP EXI
$0.00
L3630
5
TRANS SHOE SOLID STIRRUP NEW
$0.00
L3640
5
SHOE DENNIS BROWNE SPLINT BO
$0.00
L3649
5
ORTHOPEDIC SHOE MODIFICA NOS
$0.00
L3650
3
SHLDER FIG 8 ABDUCT RESTRAIN
L3651
5
PREFAB SHOULDER ORTHOSIS
$0.00
L3652
5
PREFAB DBL SHOULDER ORTHOSIS
$0.00
L3660
3
ABDUCT RESTRAINER CANVAS&WEB
$72.21
L3670
3
ACROMIO/CLAVICULAR CANVAS&WE
$95.42
L3671
6
SO CAP DESIGN W/O JNTS CF
$0.00
L3672
6
SO AIRPLANE W/O JNTS CF
$0.00
L3673
6
SO AIRPLANE W/JOINT CF
$0.00
L3675
3
CANVAS VEST SO
L3677
5
SO HARD PLASTIC STABILIZER
L3700
3
ELBOW ORTHOSES ELAS W STAYS
$49.04
L3701
3
PREFAB ELBOW ORTHOSIS
$14.56
L3702
6
EO W/O JOINTS CF
L3710
3
ELBOW ELASTIC WITH METAL JOI
$109.80
L3720
3
FOREARM/ARM CUFFS FREE MOTIO
$489.89
L3730
3
FOREARM/ARM CUFFS EXT/FLEX A
$633.36
L3740
3
CUFFS ADJ LOCK W/ ACTIVE CON
$750.90
L3760
3
EO WITHJOINT, PREFABRICATED
$341.11
L3762
5
RIGID EO WO JOINTS
$0.00
L3763
6
EWHO RIGID W/O JNTS CF
$0.00
L3764
6
EWHO W/JOINT(S) CF
$0.00
L3765
6
EWHFO RIGID W/O JNTS CF
$0.00
L3766
6
EWHFO W/JOINT(S) CF
$0.00
L3800
O
WHFO SHORT OPPONEN NO ATTACH
$0.00
$30.00
$47.75
$119.70 $0.00
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
L3805
O
WHFO LONG OPPONENS NO ATTACH
$0.00
L3806
6
WHFO W/JOINT(S) CUSTOM FAB
$0.00
L3807
3
WHFO,NO JOINT, PREFABRICATED
L3808
6
WHFO, RIGID W/O JOINTS
$0.00
L3810
O
WHFO THUMB ABDUCTION BAR
$0.00
L3815
O
WHFO SECOND M.P. ABDUCTION A
$0.00
L3820
O
WHFO IP EXT ASST W/ MP EXT S
$0.00
L3825
O
WHFO M.P. EXTENSION STOP
$0.00
L3830
O
WHFO M.P. EXTENSION ASSIST
$0.00
L3835
O
WHFO M.P. SPRING EXTENSION A
$0.00
L3840
O
WHFO SPRING SWIVEL THUMB
$0.00
L3845
O
WHFO THUMB IP EXT ASS W/ MP
$0.00
L3850
O
ACTION WRIST W/ DORSIFLEX AS
$0.00
L3855
O
WHFO ADJ M.P. FLEXION CONTRO
$0.00
L3860
O
WHFO ADJ M.P. FLEX CTRL & I.
$0.00
L3890
O
TORSION MECHANISM WRIST/ELBO
$0.00
L3900
3
HINGE EXTENSION/FLEX WRIST/F
L3901
3
HINGE EXT/FLEX WRIST FINGER
L3902
O
WHFO EXT POWER COMPRESS GAS
L3904
3
WHFO ELECTRIC CUSTOM FITTED
L3905
6
WHO W/NONTORSION JNT(S) CF
L3906
3
WHO W/O JOINTS CF
L3907
O
WHFO WRST GAUNTLT THMB SPICA
L3908
3
WRIST COCK-UP NON-MOLDED
L3909
5
PREFAB WRIST ORTHOSIS
$0.00
L3910
O
WHFO SWANSON DESIGN
$0.00
L3911
5
PREFAB HAND FINGER ORTHOSIS
$0.00
L3912
3
FLEX GLOVE W/ELASTIC FINGER
L3913
6
HFO W/O JOINTS CF
$0.00
L3914
O
WHO WRIST EXTENSION COCK-UP
$0.00
L3915
6
WHO W NONTOR JNT(S) PREFAB
$0.00
L3916
O
WHFO WRIST EXTENS W/ OUTRIGG
$0.00
L3917
6
PREFAB METACARPL FX ORTHOSIS
$0.00
L3918
O
HFO KNUCKLE BENDER
$0.00
L3919
6
HO W/O JOINTS CF
$0.00
$170.55
$994.57 $1,129.43 $0.00 $2,057.53 $0.00 $300.34 $0.00 $47.27
$81.88
Procedure Code Pricing Action Code Description
Maximum Allowable
L3920
O
KNUCKLE BENDER WITH OUTRIGGE
$0.00
L3921
6
HFO W/JOINT(S) CF
$0.00
L3922
O
KNUCKLE BEND 2 SEG TO FLEX J
$0.00
L3923
3
HFO W/O JOINTS PF
L3924
O
OPPENHEIMER
$0.00
L3925
6
FO PIP/DIP WITH JOINT/SPRING
$0.00
L3926
O
THOMAS SUSPENSION
$0.00
L3927
6
FO PIP/DIP W/O JOINT/SPRING
$0.00
L3928
O
FINGER EXTENSION W/ CLOCK SP
$0.00
L3929
6
HFO NONTORSION JOINT, PREFAB
$0.00
L3930
O
FINGER EXTENSION WITH WRIST
$0.00
L3931
6
WHFO NONTORSION JOINT PREFAB
$0.00
L3932
O
SAFETY PIN SPRING WIRE
$0.00
L3933
6
FO W/O JOINTS CF
$0.00
L3934
O
SAFETY PIN MODIFIED
$0.00
L3935
6
FO NONTORSION JOINT CF
$0.00
L3936
O
PALMER
$0.00
L3938
O
DORSAL WRIST
$0.00
L3940
O
DORSAL WRIST W/ OUTRIGGER AT
$0.00
L3942
O
REVERSE KNUCKLE BENDER
$0.00
L3944
O
REVERSE KNUCKLE BEND W/ OUTR
$0.00
L3946
O
HFO COMPOSITE ELASTIC
$0.00
L3948
O
FINGER KNUCKLE BENDER
$0.00
L3950
O
OPPENHEIMER W/ KNUCKLE BEND
$0.00
L3952
O
OPPENHEIMER W/ REV KNUCKLE 2
$0.00
L3954
O
SPREADING HAND
$0.00
L3956
5
ADD JOINT UPPER EXT ORTHOSIS
$0.00
L3960
3
SEWHO AIRPLAN DESIG ABDU POS
$516.83
L3961
6
SEWHO CAP DESIGN W/O JNTS CF
$0.00
L3962
3
SEWHO ERBS PALSEY DESIGN ABD
$504.11
L3963
O
MOLDED W/ ARTICULATING ELBOW
$0.00
L3964
3
SEO MOBILE ARM SUP ATT TO WC
$594.21
L3965
3
ARM SUPP ATT TO WC RANCHO TY
$948.19
L3966
3
MOBILE ARM SUPPORTS RECLININ
$714.31
L3967
6
SEWHO AIRPLANE W/O JNTS CF
$25.99
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
L3968
3
FRICTION DAMPENING ARM SUPP
$903.93
L3969
3
MONOSUSPENSION ARM/HAND SUPP
$615.05
L3970
3
ELEVAT PROXIMAL ARM SUPPORT
$252.86
L3971
6
SEWHO CAP DESIGN W/JNT(S) CF
$0.00
L3972
3
OFFSET/LAT ROCKER ARM W/ ELA
$160.79
L3973
6
SEWHO AIRPLANE W/JNT(S) CF
L3974
3
MOBILE ARM SUPPORT SUPINATOR
L3975
6
SEWHFO CAP DESIGN W/O JNT CF
$0.00
L3976
6
SEWHFO AIRPLANE W/O JNTS CF
$0.00
L3977
6
SEWHFO CAP DESGN W/JNT(S) CF
$0.00
L3978
6
SEWHFO AIRPLANE W/JNT(S) CF
$0.00
L3980
3
UPP EXT FX ORTHOSIS HUMERAL
$224.99
L3982
3
UPPER EXT FX ORTHOSIS RAD/UL
$262.29
L3984
3
UPPER EXT FX ORTHOSIS WRIST
$241.83
L3985
O
FOREARM HAND FX ORTH W/ WR H
$0.00
L3986
O
HUMERAL RAD/ULNA WRIST FX OR
$0.00
L3995
3
SOCK FRACTURE OR EQUAL EACH
$25.05
L3999
5
UPPER LIMB ORTHOSIS NOS
L4000
3
REPL GIRDLE MILWAUKEE ORTH
L4002
6
REPLACE STRAP, ANY ORTHOSIS
L4010
3
REPLACE TRILATERAL SOCKET BR
$481.87
L4020
3
REPLACE QUADLAT SOCKET BRIM
$673.89
L4030
3
REPLACE SOCKET BRIM CUST FIT
$362.50
L4040
3
REPLACE MOLDED THIGH LACER
$295.81
L4045
3
REPLACE NON-MOLDED THIGH LAC
$235.52
L4050
3
REPLACE MOLDED CALF LACER
$296.42
L4055
3
REPLACE NON-MOLDED CALF LACE
$191.94
L4060
3
REPLACE HIGH ROLL CUFF
$228.18
L4070
3
REPLACE PROX & DIST UPRIGHT
$202.07
L4080
3
REPL MET BAND KAFO-AFO PROX
$82.87
L4090
3
REPL MET BAND KAFO-AFO CALF/
$65.40
L4100
3
REPL LEATH CUFF KAFO PROX TH
$85.87
L4110
3
REPL LEATH CUFF KAFO-AFO CAL
$64.70
L4130
3
REPLACE PRETIBIAL SHELL
L4200
O
REPAIR OF ORTHOTIC DEVICE, HOURLY R
$0.00 $136.38
$0.00 $988.41 $0.00
$362.78 $0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
L4205
3
ORTHO DVC REPAIR PER 15 MIN
$6.25
L4210
5
ORTH DEV REPAIR/REPL MINOR P
$0.00
L4310
O
MULT-PODUS/EQ ORTH PREP MGMT
$0.00
L4320
O
LOW EXT MGMT SYS FT POS AFO
$0.00
L4350
3
ANKLE CONTROL ORTHOSI PREFAB
$71.87
L4360
3
PNEUMATI WALKING BOOT PREFAB
$220.93
L4370
3
PNEUMATIC FULL LEG SPLINT
$146.11
L4380
3
PNEUMATIC KNEE SPLINT
L4386
3
NON-PNEUM WALK BOOT PREFAB
L4390
O
REPLACE MULTI-PODUS SPLINT
$0.00
L4392
3
REPLACE AFO SOFT INTERFACE
$17.63
L4394
3
REPLACE FOOT DROP SPINT
$12.87
L4396
3
STATIC AFO
L4398
3
FOOT DROP SPLINT RECUMBENT
$57.91
L5000
3
SHO INSERT W ARCH TOE FILLER
$426.36
L5010
3
MOLD SOCKET ANK HGT W/ TOE F
$931.27
L5020
3
TIBIAL TUBERCLE HGT W/ TOE F
$1,515.92
L5050
3
ANK SYMES MOLD SCKT SACH FT
$1,755.51
L5060
3
SYMES MET FR LEATH SOCKET AR
$2,112.77
L5100
3
MOLDED SOCKET SHIN SACH FOOT
$1,828.78
L5105
3
PLAST SOCKET JTS/THGH LACER
$2,902.64
L5150
3
MOLD SCKT EXT KNEE SHIN SACH
$2,686.23
L5160
3
MOLD SOCKET BENT KNEE SHIN S
$2,921.76
L5200
3
KNE SING AXIS FRIC SHIN SACH
$2,545.10
L5210
3
NO KNEE/ANKLE JOINTS W/ FT B
$1,856.19
L5220
3
NO KNEE JOINT WITH ARTIC ALI
$2,109.89
L5230
3
FEM FOCAL DEFIC CONSTANT FRI
$2,909.97
L5250
3
HIP CANAD SING AXI CONS FRIC
$3,968.93
L5270
3
TILT TABLE LOCKING HIP SING
$3,934.16
L5280
3
HEMIPELVECT CANAD SING AXIS
$3,894.82
L5300
O
BK SACH SOFT COVER & FINISH
$0.00
L5301
5
BK MOLD SOCKET SACH FT ENDO
$0.00
L5310
O
KNEE DISART SACH SOFT CV/FIN
$0.00
L5311
5
KNEE DISART, SACH FT, ENDO
$0.00
L5320
O
AK OPEN END SACH SOFT CV/FIN
$0.00
$82.45 $124.58
$125.77
Procedure Code Pricing Action Code Description
Maximum Allowable
L5321
5
AK OPEN END SACH
$0.00
L5330
O
HIP CANADIAN SACH SFT CV/FIN
$0.00
L5331
5
HIP DISART CANADIAN SACH FT
$0.00
L5340
O
HEMIPELVECTOMY CANAD CV/FIN
$0.00
L5341
5
HEMIPELVECTOMY CANADIAN SACH
$0.00
L5400
3
POSTOP DRESS & 1 CAST CHG BK
$920.64
L5410
3
POSTOP DSG BK EA ADD CAST CH
$403.36
L5420
3
POSTOP DSG & 1 CAST CHG AK/D
L5430
3
POSTOP DSG AK EA ADD CAST CH
$513.24
L5450
3
POSTOP APP NON-WGT BEAR DSG
$328.33
L5460
3
POSTOP APP NON-WGT BEAR DSG
$483.92
L5500
3
INIT BK PTB PLASTER DIRECT
$982.44
L5505
3
INIT AK ISCHAL PLSTR DIRECT
$1,330.47
L5510
3
PREP BK PTB PLASTER MOLDED
$1,113.65
L5520
3
PERP BK PTB THERMOPLS DIRECT
$1,100.03
L5530
3
PREP BK PTB THERMOPLS MOLDED
$1,392.40
L5535
3
PREP BK PTB OPEN END SOCKET
$1,372.22
L5540
3
PREP BK PTB LAMINATED SOCKET
$1,448.99
L5560
3
PREP AK ISCHIAL PLAST MOLDED
$1,486.72
L5570
3
PREP AK ISCHIAL DIRECT FORM
$1,545.67
L5580
3
PREP AK ISCHIAL THERMO MOLD
$1,804.46
L5585
3
PREP AK ISCHIAL OPEN END
$1,957.15
L5590
3
PREP AK ISCHIAL LAMINATED
$1,838.87
L5595
3
HIP DISARTIC SACH THERMOPLS
$3,232.24
L5600
3
HIP DISART SACH LAMINAT MOLD
$3,525.47
L5610
3
ABOVE KNEE HYDRACADENCE
$1,583.72
L5611
3
AK 4 BAR LINK W/FRIC SWING
$1,232.45
L5613
3
AK 4 BAR LING W/HYDRAUL SWIG
$1,874.64
L5614
3
4-BAR LINK ABOVE KNEE W/SWNG
$1,267.18
L5616
3
AK UNIV MULTIPLEX SYS FRICT
$1,038.91
L5617
3
AK/BK SELF-ALIGNING UNIT EA
$420.17
L5618
3
TEST SOCKET SYMES
$242.04
L5620
3
TEST SOCKET BELOW KNEE
$212.67
L5622
3
TEST SOCKET KNEE DISARTICULA
$324.80
L5624
3
TEST SOCKET ABOVE KNEE
$309.88
$1,162.72
Procedure Code Pricing Action Code Description
Maximum Allowable
L5626
3
TEST SOCKET HIP DISARTICULAT
$435.56
L5628
3
TEST SOCKET HEMIPELVECTOMY
$412.54
L5629
3
BELOW KNEE ACRYLIC SOCKET
$315.05
L5630
3
SYME TYP EXPANDABL WALL SCKT
$343.30
L5631
3
AK/KNEE DISARTIC ACRYLIC SOC
$410.52
L5632
3
SYMES TYPE PTB BRIM DESIGN S
$169.85
L5634
3
SYMES TYPE POSTER OPENING SO
$232.68
L5636
3
SYMES TYPE MEDIAL OPENING SO
$194.91
L5637
3
BELOW KNEE TOTAL CONTACT
$260.35
L5638
3
BELOW KNEE LEATHER SOCKET
$372.27
L5639
3
BELOW KNEE WOOD SOCKET
$873.31
L5640
3
KNEE DISARTICULAT LEATHER SO
$531.69
L5642
3
ABOVE KNEE LEATHER SOCKET
$476.00
L5643
3
HIP FLEX INNER SOCKET EXT FR
L5644
3
ABOVE KNEE WOOD SOCKET
$451.81
L5645
3
BK FLEX INNER SOCKET EXT FRA
$610.34
L5646
3
BELOW KNEE CUSHION SOCKET
$419.12
L5647
3
BELOW KNEE SUCTION SOCKET
$608.48
L5648
3
ABOVE KNEE CUSHION SOCKET
$503.62
L5649
3
ISCH CONTAINMT/NARROW M-L SO
L5650
3
TOT CONTACT AK/KNEE DISART S
$373.43
L5651
3
AK FLEX INNER SOCKET EXT FRA
$918.63
L5652
3
SUCTION SUSP AK/KNEE DISART
$333.50
L5653
3
KNEE DISART EXPAND WALL SOCK
$445.19
L5654
3
SOCKET INSERT SYMES
$253.68
L5655
3
SOCKET INSERT BELOW KNEE
$214.80
L5656
3
SOCKET INSERT KNEE ARTICULAT
$302.59
L5658
3
SOCKET INSERT ABOVE KNEE
$294.67
L5660
O
SOCK INSRT SYME SILICONE GEL
L5661
3
MULTI-DUROMETER SYMES
L5662
O
SOCKET INSERT BK SILICONE GE
$0.00
L5663
O
SOCK KNEE DISARTIC SILICONE
$0.00
L5664
O
SOCKET INSERT AK SILICONE GE
$0.00
L5665
3
MULTI-DUROMETER BELOW KNEE
$391.67
L5666
3
BELOW KNEE CUFF SUSPENSION
$58.20
$1,190.58
$1,528.91
$0.00 $512.05
Procedure Code Pricing Action Code Description
Maximum Allowable
L5667
O
SOCKET INSERT W LOCK LOWER
$0.00
L5668
3
SOCKET INSERT W/O LOCK LOWER
L5669
O
BELOW KNEE SOCKET W/O LOCK
L5670
3
BK MOLDED SUPRACONDYLAR SUSP
L5671
5
BK/AK LOCKING MECHANISM
L5672
3
BK REMOVABLE MEDIAL BRIM SUS
L5673
6
SOCKET INSERT W LOCK MECH
$0.00
L5674
O
BK SUSPENSION SLEEVE
$0.00
L5675
O
BK HEAVY DUTY SUSP SLEEVE
$0.00
L5676
3
BK KNEE JOINTS SINGLE AXIS P
$277.19
L5677
3
BK KNEE JOINTS POLYCENTRIC P
$377.16
L5678
3
BK JOINT COVERS PAIR
L5679
6
SOCKET INSERT W/O LOCK MECH
L5680
3
BK THIGH LACER NON-MOLDED
L5681
6
INTL CUSTM CONG/LATYP INSERT
L5682
3
BK THIGH LACER GLUT/ISCHIA M
L5683
6
INITIAL CUSTOM SOCKET INSERT
L5684
3
BK FORK STRAP
L5685
6
BELOW KNEE SUS/SEAL SLEEVE
L5686
3
BK BACK CHECK
$49.66
L5688
3
BK WAIST BELT WEBBING
$46.72
L5690
3
BK WAIST BELT PADDED AND LIN
$90.49
L5692
3
AK PELVIC CONTROL BELT LIGHT
$105.02
L5694
3
AK PELVIC CONTROL BELT PAD/L
$138.77
L5695
3
AK SLEEVE SUSP NEOPRENE/EQUA
$145.59
L5696
3
AK/KNEE DISARTIC PELVIC JOIN
$159.10
L5697
3
AK/KNEE DISARTIC PELVIC BAND
$64.62
L5698
3
AK/KNEE DISARTIC SILESIAN BA
$80.36
L5699
3
SHOULDER HARNESS
L5700
3
REPLACE SOCKET BELOW KNEE
$2,203.73
L5701
3
REPLACE SOCKET ABOVE KNEE
$2,733.93
L5702
3
REPLACE SOCKET HIP
$3,445.70
L5703
6
SYMES ANKLE W/O (SACH) FOOT
L5704
3
CUSTOM SHAPE COVER BK
$449.33
L5705
3
CUSTOM SHAPE COVER AK
$823.79
$77.71 $0.00 $236.56 $0.00 $289.06
$30.37 $0.00 $264.93 $0.00 $478.39 $0.00 $36.81 $0.00
$142.63
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
L5706
3
CUSTOM SHAPE CVR KNEE DISART
$803.52
L5707
3
CUSTOM SHAPE CVR HIP DISART
$1,079.50
L5710
3
KNE-SHIN EXO SNG AXI MNL LOC
$275.12
L5711
3
KNEE-SHIN EXO MNL LOCK ULTRA
$417.34
L5712
3
KNEE-SHIN EXO FRICT SWG & ST
$329.61
L5714
3
KNEE-SHIN EXO VARIABLE FRICT
$339.91
L5716
3
KNEE-SHIN EXO MECH STANCE PH
$557.52
L5718
3
KNEE-SHIN EXO FRCT SWG & STA
$696.84
L5722
3
KNEE-SHIN PNEUM SWG FRCT EXO
$727.18
L5724
3
KNEE-SHIN EXO FLUID SWING PH
$1,154.61
L5726
3
KNEE-SHIN EXT JNTS FLD SWG E
$1,516.14
L5728
3
KNEE-SHIN FLUID SWG & STANCE
$1,888.89
L5780
3
KNEE-SHIN PNEUM/HYDRA PNEUM
$910.73
L5781
5
LOWER LIMB PROS VACUUM PUMP
$0.00
L5782
5
HD LOW LIMB PROS VACUUM PUMP
$0.00
L5785
3
EXOSKELETAL BK ULTRALT MATER
$397.43
L5790
3
EXOSKELETAL AK ULTRA-LIGHT M
$550.01
L5795
3
EXOSKEL HIP ULTRA-LIGHT MATE
$821.31
L5810
3
ENDOSKEL KNEE-SHIN MNL LOCK
$382.08
L5811
3
ENDO KNEE-SHIN MNL LCK ULTRA
$557.88
L5812
3
ENDO KNEE-SHIN FRCT SWG & ST
$432.41
L5814
3
ENDO KNEE-SHIN HYDRAL SWG PH
$2,788.88
L5816
3
ENDO KNEE-SHIN POLYC MCH STA
$650.54
L5818
3
ENDO KNEE-SHIN FRCT SWG & ST
$734.59
L5822
3
ENDO KNEE-SHIN PNEUM SWG FRC
$1,425.17
L5824
3
ENDO KNEE-SHIN FLUID SWING P
$1,173.08
L5826
3
MINIATURE KNEE JOINT
$2,368.56
L5828
3
ENDO KNEE-SHIN FLUID SWG/STA
$2,236.15
L5830
3
ENDO KNEE-SHIN PNEUM/SWG PHA
$1,588.87
L5840
3
MULTI-AXIAL KNEE/SHIN SYSTEM
$2,801.79
L5845
3
KNEE-SHIN SYS STANCE FLEXION
$1,345.96
L5846
O
KNEE-SHIN SYS MICROPROCESSOR
$0.00
L5847
O
MICROPROCESSOR CNTRL FEATURE
$0.00
L5848
5
KNEE-SHIN SYS HYDRAUL STANCE
$0.00
L5850
3
ENDO AK/HIP KNEE EXTENS ASSI
$101.61
Procedure Code Pricing Action Code Description
Maximum Allowable
L5855
3
MECH HIP EXTENSION ASSIST
$236.23
L5856
6
ELEC KNEE-SHIN SWING/STANCE
$0.00
L5857
6
ELEC KNEE-SHIN SWING ONLY
$0.00
L5858
6
STANCE PHASE ONLY
$0.00
L5910
3
ENDO BELOW KNEE ALIGNABLE SY
$279.01
L5920
3
ENDO AK/HIP ALIGNABLE SYSTEM
$405.87
L5925
3
ABOVE KNEE MANUAL LOCK
$257.02
L5930
3
HIGH ACTIVITY KNEE FRAME
$2,527.60
L5940
3
ENDO BK ULTRA-LIGHT MATERIAL
$383.70
L5950
3
ENDO AK ULTRA-LIGHT MATERIAL
$648.20
L5960
3
ENDO HIP ULTRA-LIGHT MATERIA
$776.46
L5962
3
BELOW KNEE FLEX COVER SYSTEM
$449.63
L5964
3
ABOVE KNEE FLEX COVER SYSTEM
$805.38
L5966
3
HIP FLEXIBLE COVER SYSTEM
$1,037.45
L5968
3
MULTIAXIAL ANKLE W DORSIFLEX
$2,728.85
L5970
3
FOOT EXTERNAL KEEL SACH FOOT
L5971
6
SACH FOOT, REPLACEMENT
L5972
3
FLEXIBLE KEEL FOOT
$269.59
L5974
3
FOOT SINGLE AXIS ANKLE/FOOT
$227.45
L5975
3
COMBO ANKLE/FOOT PROSTHESIS
$348.14
L5976
3
ENERGY STORING FOOT
$428.39
L5978
3
FT PROSTH MULTIAXIAL ANKL/FT
$223.23
L5979
3
MULTI-AXIAL ANKLE/FT PROSTH
$1,791.29
L5980
3
FLEX FOOT SYSTEM
$2,836.17
L5981
3
FLEX-WALK SYS LOW EXT PROSTH
$2,451.49
L5982
3
EXOSKELETAL AXIAL ROTATION U
$442.22
L5984
3
ENDOSKELETAL AXIAL ROTATION
$438.30
L5985
3
LWR EXT DYNAMIC PROSTH PYLON
$212.05
L5986
3
MULTI-AXIAL ROTATION UNIT
$487.29
L5987
3
SHANK FT W VERT LOAD PYLON
$5,402.07
L5988
3
VERTICAL SHOCK REDUCING PYLO
$1,500.16
L5989
O
PYLON W ELCTRNC FORCE SENSOR
$0.00
L5990
5
USER ADJUSTABLE HEEL HEIGHT
$0.00
L5993
O
HEAVY DUTY FEATURE, FOOT
$0.00
L5994
O
HEAVY DUTY FEATURE, KNEE
$0.00
$167.93 $0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
L5995
O
LOWER EXT PROS HEAVYDUTY FEA
$0.00
L5999
5
LOWR EXTREMITY PROSTHES NOS
$0.00
L6000
3
PAR HAND ROBIN-AIDS THUM REM
$1,016.37
L6010
3
HAND ROBIN-AIDS LITTLE/RING
$1,131.05
L6020
3
PART HAND ROBIN-AIDS NO FING
$1,054.53
L6025
5
PART HAND DISART MYOELECTRIC
L6050
3
WRST MLD SCK FLX HNG TRI PAD
$1,453.10
L6055
3
WRST MOLD SOCK W/EXP INTERFA
$2,309.76
L6100
3
ELB MOLD SOCK FLEX HINGE PAD
$1,472.21
L6110
3
ELBOW MOLD SOCK SUSPENSION T
$1,561.53
L6120
3
ELBOW MOLD DOUB SPLT SOC STE
$1,819.73
L6130
3
ELBOW STUMP ACTIVATED LOCK H
$1,980.21
L6200
3
ELBOW MOLD OUTSID LOCK HINGE
$2,086.82
L6205
3
ELBOW MOLDED W/ EXPAND INTER
$3,477.47
L6250
3
ELBOW INTER LOC ELBOW FORARM
$2,054.13
L6300
3
SHLDER DISART INT LOCK ELBOW
$2,849.88
L6310
3
SHOULDER PASSIVE RESTOR COMP
$2,343.65
L6320
3
SHOULDER PASSIVE RESTOR CAP
$1,307.24
L6350
3
THORACIC INTERN LOCK ELBOW
$2,996.21
L6360
3
THORACIC PASSIVE RESTOR COMP
$2,459.71
L6370
3
THORACIC PASSIVE RESTOR CAP
$1,851.78
L6380
3
POSTOP DSG CAST CHG WRST/ELB
$1,000.12
L6382
3
POSTOP DSG CAST CHG ELB DIS/
$1,196.80
L6384
3
POSTOP DSG CAST CHG SHLDER/T
$1,460.42
L6386
3
POSTOP EA CAST CHG & REALIGN
$350.22
L6388
3
POSTOP APPLICAT RIGID DSG ON
$336.28
L6400
3
BELOW ELBOW PROSTH TISS SHAP
$1,778.70
L6450
3
ELB DISART PROSTH TISS SHAP
$2,358.38
L6500
3
ABOVE ELBOW PROSTH TISS SHAP
$2,360.31
L6550
3
SHLDR DISAR PROSTH TISS SHAP
$2,916.91
L6570
3
SCAP THORAC PROSTH TISS SHAP
$3,539.21
L6580
3
WRIST/ELBOW BOWDEN CABLE MOL
$1,235.42
L6582
3
WRIST/ELBOW BOWDEN CBL DIR F
$1,052.79
L6584
3
ELBOW FAIR LEAD CABLE MOLDED
$1,705.33
L6586
3
ELBOW FAIR LEAD CABLE DIR FO
$1,491.81
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
L6588
3
SHDR FAIR LEAD CABLE MOLDED
$2,462.65
L6590
3
SHDR FAIR LEAD CABLE DIRECT
$2,252.61
L6600
3
POLYCENTRIC HINGE PAIR
$151.99
L6605
3
SINGLE PIVOT HINGE PAIR
$141.87
L6610
3
FLEXIBLE METAL HINGE PAIR
$127.35
L6611
6
ADDITIONAL SWITCH, EXT POWER
$0.00
L6615
3
DISCONNECT LOCKING WRIST UNI
$157.03
L6616
3
DISCONNECT INSERT LOCKING WR
$66.15
L6620
3
FLEXION/EXTENSION WRIST UNIT
$246.46
L6621
6
FLEX/EXT WRIST W/WO FRICTION
$0.00
L6623
3
SPRING-ASS ROT WRST W/ LATCH
L6624
6
FLEX/EXT/ROTATION WRIST UNIT
$0.00
L6625
3
ROTATION WRST W/ CABLE LOCK
$410.51
L6628
3
QUICK DISCONN HOOK ADAPTER O
$419.48
L6629
3
LAMINATION COLLAR W/ COUPLIN
$111.91
L6630
3
STAINLESS STEEL ANY WRIST
$164.86
L6632
3
LATEX SUSPENSION SLEEVE EACH
L6635
3
LIFT ASSIST FOR ELBOW
$152.70
L6637
3
NUDGE CONTROL ELBOW LOCK
$316.97
L6638
5
ELEC LOCK ON MANUAL PW ELBOW
$0.00
L6639
6
HEAVY DUTY ELBOW FEATURE
$0.00
L6640
3
SHOULDER ABDUCTION JOINT PAI
$216.31
L6641
3
EXCURSION AMPLIFIER PULLEY T
$143.76
L6642
3
EXCURSION AMPLIFIER LEVER TY
$204.69
L6645
3
SHOULDER FLEXION-ABDUCTION J
$248.55
L6646
5
MULTIPO LOCKING SHOULDER JNT
$0.00
L6647
5
SHOULDER LOCK ACTUATOR
$0.00
L6648
5
EXT PWRD SHLDER LOCK/UNLOCK
$0.00
L6650
3
SHOULDER UNIVERSAL JOINT
L6655
3
STANDARD CONTROL CABLE EXTRA
$57.46
L6660
3
HEAVY DUTY CONTROL CABLE
$70.21
L6665
3
TEFLON OR EQUAL CABLE LINING
$40.14
L6670
3
HOOK TO HAND CABLE ADAPTER
$38.06
L6672
3
HARNESS CHEST/SHLDER SADDLE
$128.98
L6675
3
HARNESS FIGURE OF 8 SING CON
$91.86
$564.15
$54.98
$258.92
Procedure Code Pricing Action Code Description
Maximum Allowable
L6676
3
HARNESS FIGURE OF 8 DUAL CON
$92.77
L6677
6
UE TRIPLE CONTROL HARNESS
L6680
3
TEST SOCK WRIST DISART/BEL E
$177.47
L6682
3
TEST SOCK ELBW DISART/ABOVE
$198.90
L6684
3
TEST SOCKET SHLDR DISART/THO
$266.63
L6686
3
SUCTION SOCKET
$495.85
L6687
3
FRAME TYP SOCKET BEL ELBOW/W
$441.23
L6688
3
FRAME TYP SOCK ABOVE ELB/DIS
$426.80
L6689
3
FRAME TYP SOCKET SHOULDER DI
$515.42
L6690
3
FRAME TYP SOCK INTERSCAP-THO
$558.16
L6691
3
REMOVABLE INSERT EACH
$333.79
L6692
3
SILICONE GEL INSERT OR EQUAL
$427.78
L6693
3
LOCKINGELBOW FOREARM CNTRBAL
L6694
6
ELBOW SOCKET INS USE W/LOCK
$0.00
L6695
6
ELBOW SOCKET INS USE W/O LCK
$0.00
L6696
6
CUS ELBO SKT IN FOR CON/ATYP
$0.00
L6697
6
CUS ELBO SKT IN NOT CON/ATYP
$0.00
L6698
6
BELOW/ABOVE ELBOW LOCK MECH
$0.00
L6700
O
TERMINAL DEVICE MODEL #3
$0.00
L6703
6
TERM DEV, PASSIVE HAND MITT
$0.00
L6704
6
TERM DEV, SPORT/REC/WORK ATT
$0.00
L6705
O
TERMINAL DEVICE MODEL #5
$0.00
L6706
6
TERM DEV MECH HOOK VOL OPEN
$0.00
L6707
6
TERM DEV MECH HOOK VOL CLOSE
$0.00
L6708
6
TERM DEV MECH HAND VOL OPEN
$0.00
L6709
6
TERM DEV MECH HAND VOL CLOSE
$0.00
L6710
O
TERMINAL DEVICE MODEL #5X
$0.00
L6711
6
PED TERM DEV, HOOK, VOL OPEN
$0.00
L6712
6
PED TERM DEV, HOOK, VOL CLOS
$0.00
L6713
6
PED TERM DEV, HAND, VOL OPEN
$0.00
L6714
6
PED TERM DEV, HAND, VOL CLOS
$0.00
L6715
O
TERMINAL DEVICE MODEL #5XA
$0.00
L6720
O
TERMINAL DEVICE MODEL #6
$0.00
L6721
6
HOOK/HAND, HVY DTY, VOL OPEN
$0.00
L6722
6
HOOK/HAND, HVY DTY, VOL CLOS
$0.00
$0.00
$2,131.93
Procedure Code Pricing Action Code Description
Maximum Allowable
L6725
O
TERMINAL DEVICE MODEL #7
$0.00
L6730
O
TERMINAL DEVICE MODEL #7LO
$0.00
L6735
O
TERMINAL DEVICE MODEL #8
$0.00
L6740
O
TERMINAL DEVICE MODEL #8X
$0.00
L6745
O
TERMINAL DEVICE MODEL #88X
$0.00
L6750
O
TERMINAL DEVICE MODEL #10P
$0.00
L6755
O
TERMINAL DEVICE MODEL #10X
$0.00
L6765
O
TERMINAL DEVICE MODEL #12P
$0.00
L6770
O
TERMINAL DEVICE MODEL #99X
$0.00
L6775
O
TERMINAL DEVICE MODEL#555
$0.00
L6780
O
TERMINAL DEVICE MODEL #SS555
$0.00
L6790
O
HOOKS-ACCU HOOK OR EQUAL
$0.00
L6795
O
HOOKS-2 LOAD OR EQUAL
$0.00
L6800
O
HOOKS-APRL VC OR EQUAL
$0.00
L6805
3
TERM DEV MODIFIER WRIST UNIT
L6806
O
TRS GRIP VC OR EQUAL
$0.00
L6807
O
TERM DEVICE GRIP1/2 OR EQUAL
$0.00
L6808
O
TERM DEVICE INFANT OR CHILD
$0.00
L6809
O
TRS SUPER SPORT PASSIVE
$0.00
L6810
3
TERM DEV PRECISION PINCH DEV
L6825
O
HANDS DORRANCE VO
$0.00
L6830
O
HAND APRL VC
$0.00
L6835
O
HAND SIERRA VO
$0.00
L6840
O
HAND BECKER IMPERIAL
$0.00
L6845
O
HAND BECKER LOCK GRIP
$0.00
L6850
O
TERM DVC-HAND BECKER PLYLITE
$0.00
L6855
O
HAND ROBIN-AIDS VO
$0.00
L6860
O
HAND ROBIN-AIDS VO SOFT
$0.00
L6865
O
HAND PASSIVE HAND
$0.00
L6867
O
HAND DETROIT INFANT HAND
$0.00
L6868
O
PASSIVE INF HAND STEEPER/HOS
$0.00
L6870
O
HAND CHILD MITT
$0.00
L6872
O
HAND NYU CHILD HAND
$0.00
L6873
O
HAND MECH INF STEEPER OR EQU
$0.00
L6875
O
HAND BOCK VC
$0.00
$275.35
$150.10
Procedure Code Pricing Action Code Description
Maximum Allowable
L6880
O
HAND BOCK VO
$0.00
L6881
5
TERM DEV AUTO GRASP FEATURE
$0.00
L6882
9
MICROPROCESSOR CONTROL UPLMB
$0.00
L6883
6
REPLC SOCKT BELOW E/W DISA
$0.00
L6884
6
REPLC SOCKT ABOVE ELBOW DISA
$0.00
L6885
6
REPLC SOCKT SHLDR DIS/INTERC
$0.00
L6890
3
PREFAB GLOVE FOR TERM DEVICE
$130.10
L6895
3
CUSTOM GLOVE FOR TERM DEVICE
$473.54
L6900
3
HAND RESTORAT THUMB/1 FINGER
$1,228.99
L6905
3
HAND RESTORATION MULTIPLE FI
$1,206.52
L6910
3
HAND RESTORATION NO FINGERS
$1,238.56
L6915
3
HAND RESTORATION REPLACMNT G
L6920
3
WRIST DISARTICUL SWITCH CTRL
$5,896.34
L6925
3
WRIST DISART MYOELECTRONIC C
$6,464.09
L6930
3
BELOW ELBOW SWITCH CONTROL
$5,578.08
L6935
3
BELOW ELBOW MYOELECTRONIC CT
$6,600.69
L6940
3
ELBOW DISARTICULATION SWITCH
$7,272.04
L6945
3
ELBOW DISART MYOELECTRONIC C
$8,133.63
L6950
3
ABOVE ELBOW SWITCH CONTROL
$7,706.82
L6955
3
ABOVE ELBOW MYOELECTRONIC CT
$9,372.94
L6960
3
SHLDR DISARTIC SWITCH CONTRO
$9,950.82
L6965
3
SHLDR DISARTIC MYOELECTRONIC
$11,398.65
L6970
3
INTERSCAPULAR-THOR SWITCH CT
$12,251.26
L6975
3
INTERSCAP-THOR MYOELECTRONIC
$13,525.58
L7007
6
ADULT ELECTRIC HAND
$0.00
L7008
6
PEDIATRIC ELECTRIC HAND
$0.00
L7009
6
ADULT ELECTRIC HOOK
$0.00
L7010
O
HAND OTTO BACK STEEPER/EQ SW
$0.00
L7015
O
HAND SYS TEKNIK VILLAGE SWIT
$0.00
L7020
O
ELECTRONIC GREIFER SWITCH CT
$0.00
L7025
O
ELECTRON HAND MYOELECTRONIC
$0.00
L7030
O
HAND SYS TEKNIK VILL MYOELEC
$0.00
L7035
O
ELECTRON GREIFER MYOELECTRO
$0.00
L7040
3
PREHENSILE ACTUATOR
$2,225.23
L7045
3
PEDIATRIC ELECTRIC HOOK
$1,236.40
$478.87
Procedure Code Pricing Action Code Description
Maximum Allowable
L7160
O
ELECTRONIC ELBOW, BOSTON OR EQUAL,
$0.00
L7165
O
ELECTRONIC ELBOW, BOSTON OR EQUAL,
$0.00
L7170
3
ELECTRONIC ELBOW HOSMER SWIT
L7180
3
ELECTRONIC ELBOW SEQUENTIAL
L7181
6
ELECTRONIC ELBO SIMULTANEOUS
L7185
3
ELECTRON ELBOW ADOLESCENT SW
$4,592.13
L7186
3
ELECTRON ELBOW CHILD SWITCH
$7,012.55
L7190
3
ELBOW ADOLESCENT MYOELECTRON
$5,978.78
L7191
3
ELBOW CHILD MYOELECTRONIC CT
$7,553.10
L7260
3
ELECTRON WRIST ROTATOR OTTO
$1,945.02
L7261
3
ELECTRON WRIST ROTATOR UTAH
$3,581.46
L7266
3
SERVO CONTROL STEEPER OR EQU
$757.35
L7272
3
ANALOGUE CONTROL UNB OR EQUA
$1,688.10
L7274
3
PROPORTIONAL CTL 12 VOLT UTA
$5,406.56
L7360
3
SIX VOLT BAT OTTO BOCK/EQ EA
$228.56
L7362
3
BATTERY CHRGR SIX VOLT OTTO
$205.92
L7364
3
TWELVE VOLT BATTERY UTAH/EQU
$380.62
L7366
3
BATTERY CHRGR 12 VOLT UTAH/E
$512.77
L7367
5
REPLACEMNT LITHIUM IONBATTER
$0.00
L7368
5
LITHIUM ION BATTERY CHARGER
$0.00
L7400
6
ADD UE PROST BE/WD, ULTLITE
$0.00
L7401
6
ADD UE PROST A/E ULTLITE MAT
$0.00
L7402
6
ADD UE PROST S/D ULTLITE MAT
$0.00
L7403
6
ADD UE PROST B/E ACRYLIC
$0.00
L7404
6
ADD UE PROST A/E ACRYLIC
$0.00
L7405
6
ADD UE PROST S/D ACRYLIC
$0.00
L7499
5
UPPER EXTREMITY PROSTHES NOS
$0.00
L7500
5
PROSTHETIC DVC REPAIR HOURLY
$0.00
L7510
5
PROSTHETIC DEVICE REPAIR REP
$0.00
L7520
3
REPAIR PROSTHESIS PER 15 MIN
$6.25
L7600
6
PROSTHETIC DONNING SLEEVE
$0.00
L7611
O
PED TERM DEV, HOOK, VOL OPEN
$0.00
L7612
O
PED TERM DEV, HOOK, VOL CLOS
$0.00
L7613
O
PED TERM DEV, HAND, VOL OPEN
$0.00
L7614
O
PED TERM DEV, HAND, VOL CLOS
$0.00
$4,485.23 $26,708.37 $0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
L7621
O
HOOK/HAND, HVY DTY, VOL OPEN
$0.00
L7622
O
HOOK/HAND, HVY DTY, VOL CLOS
$0.00
L7900
9
VACUUM ERECTION SYSTEM
$0.00
L8000
3
MASTECTOMY BRA
L8001
5
BREAST PROSTHESIS BRA & FORM
$0.00
L8002
5
BRST PRSTH BRA & BILAT FORM
$0.00
L8010
3
MASTECTOMY SLEEVE
$46.39
L8015
3
EXT BREASTPROSTHESIS GARMENT
$45.02
L8020
3
MASTECTOMY FORM
$191.37
L8030
3
BREAST PROSTHESIS SILICONE/E
$247.69
L8035
3
CUSTOM BREAST PROSTHESIS
L8039
5
BREAST PROSTHESIS NOS
L8040
3
NASAL PROSTHESIS
$1,294.46
L8041
3
MIDFACIAL PROSTHESIS
$1,560.25
L8042
3
ORBITAL PROSTHESIS
$1,753.08
L8043
3
UPPER FACIAL PROSTHESIS
$1,963.45
L8044
3
HEMI-FACIAL PROSTHESIS
$2,173.82
L8045
3
AURICULAR PROSTHESIS
$1,517.49
L8046
3
PARTIAL FACIAL PROSTHESIS
$1,402.47
L8047
3
NASAL SEPTAL PROSTHESIS
L8048
5
UNSPEC MAXILLOFACIAL PROSTH
$0.00
L8049
3
REPAIR MAXILLOFACIAL PROSTH
$15.69
L8100
O
COMPRESSION STOCKING BK18-30
$0.00
L8110
O
COMPRESSION STOCKING BK30-40
$0.00
L8120
O
COMPRESSION STOCKING BK40-50
$0.00
L8130
O
GC STOCKING THIGHLNGTH 18-30
$0.00
L8140
O
GC STOCKING THIGHLNGTH 30-40
$0.00
L8150
O
GC STOCKING THIGHLNGTH 40-50
$0.00
L8160
O
GC STOCKING FULL LNGTH 18-30
$0.00
L8170
O
GC STOCKING FULL LNGTH 30-40
$0.00
L8180
O
GC STOCKING FULL LNGTH 40-50
$0.00
L8190
O
GC STOCKING WAISTLNGTH 18-30
$0.00
L8195
O
GC STOCKING WAISTLNGTH 30-40
$0.00
L8200
O
GC STOCKING WAISTLNGTH 40-50
$0.00
L8210
O
GC STOCKING CUSTOM MADE
$0.00
$27.93
$2,751.16 $0.00
$718.77
Procedure Code Pricing Action Code Description
Maximum Allowable
L8220
O
GC STOCKING LYMPHEDEMA
$0.00
L8230
O
GC STOCKING GARTER BELT
$0.00
L8239
O
G COMPRESSION STOCKING NOS
$0.00
L8300
3
TRUSS SINGLE W/ STANDARD PAD
$64.52
L8310
3
TRUSS DOUBLE W/ STANDARD PAD
$101.87
L8320
3
TRUSS ADDITION TO STD PAD WA
$45.67
L8330
3
TRUSS ADD TO STD PAD SCROTAL
$37.77
L8400
3
SHEATH BELOW KNEE
$13.28
L8410
3
SHEATH ABOVE KNEE
$17.75
L8415
3
SHEATH UPPER LIMB
$17.44
L8417
3
PROS SHEATH/SOCK W GEL CUSHN
$56.42
L8420
3
PROSTHETIC SOCK MULTI PLY BK
$15.68
L8430
3
PROSTHETIC SOCK MULTI PLY AK
$16.93
L8435
3
PROS SOCK MULTI PLY UPPER LM
$16.09
L8440
3
SHRINKER BELOW KNEE
$31.99
L8460
3
SHRINKER ABOVE KNEE
$50.98
L8465
3
SHRINKER UPPER LIMB
$45.15
L8470
3
PROS SOCK SINGLE PLY BK
$5.11
L8480
3
PROS SOCK SINGLE PLY AK
$7.04
L8485
3
PROS SOCK SINGLE PLY UPPER L
$8.84
L8490
O
AIR SEAL SUCTION RETEN SYSTM
$0.00
L8499
5
UNLISTED MISC PROSTHETIC SER
$0.00
L8500
3
ARTIFICIAL LARYNX
L8501
3
TRACHEOSTOMY SPEAKING VALVE
L8505
5
ARTIFICIAL LARYNX, ACCESSORY
$0.00
L8507
5
TRACH-ESOPH VOICE PROS PT IN
$0.00
L8509
5
TRACH-ESOPH VOICE PROS MD IN
$0.00
L8510
5
VOICE AMPLIFIER
$0.00
L8511
6
INDWELLING TRACH INSERT
$0.00
L8512
6
GEL CAP FOR TRACH VOICE PROS
$0.00
L8513
6
TRACH PROS CLEANING DEVICE
$0.00
L8514
6
REPL TRACH PUNCTURE DILATOR
$0.00
L8515
6
GEL CAP APP DEVICE FOR TRACH
$0.00
L8603
9
COLLAGEN IMP URINARY 2.5 ML
$0.00
L8604
9
DEXTRANOMER/HYALURONIC ACID
$0.00
$673.10 $92.40
Procedure Code Pricing Action Code Description
Maximum Allowable
L8606
3
SYNTHETIC IMPLNT URINARY 1ML
$166.75
L8609
6
ARTIFICIAL CORNEA
$0.00
L8614
9
COCHLEAR DEVICE,
$0.00
L8615
6
COCH IMPLANT HEADSET REPLACE
$0.00
L8616
6
COCH IMPLANT MICROPHONE REPL
$0.00
L8617
6
COCH IMPLANT TRANS COIL REPL
$0.00
L8618
6
COCH IMPLANT TRAN CABLE REPL
$0.00
L8619
3
REPLACE COCHLEAR PROCESSOR
$6,403.44
L8620
O
REPL LITHIUM ION BATTERY
$0.00
L8621
6
REPL ZINC AIR BATTERY
$0.00
L8622
6
REPL ALKALINE BATTERY
$0.00
L8623
6
LITH ION BATT CID,NON-EARLVL
$0.00
L8624
6
LITH ION BATT CID, EAR LEVEL
$0.00
L8630
9
METACARPOPHALANGEAL JOINT IMPLANT
$0.00
L8631
9
MCP JOINT REPL 2 PC OR MORE
$0.00
L8641
9
METATARSAL JOINT IMPLANT
$0.00
L8642
9
HALLUX IMPLANT
$0.00
L8658
9
INTERPHALANGEAL JOINT SPACER, SILI
$0.00
L8659
9
INTERPHALANGEAL JOINT REPL
$0.00
L8670
9
VASCULAR GRAFT MATERIAL, SYNTHETIC
$0.00
L8680
9
IMPLANTABLE NEUROSTIMULATOR ELECTR
$0.00
L8681
6
PT PRGRM FOR IMPLT NEUROSTIM
$0.00
L8682
6
IMPLT NEUROSTIM RADIOFQ REC
$0.00
L8683
6
RADIOFQ TRSMTR FOR IMPLT NEU
$0.00
L8684
6
RADIOF TRSMTR IMPLT SCRL NEU
$0.00
L8685
9
IMPLT NROSTM PLS GEN SNG REC
$0.00
L8686
9
IMPLT NROSTM PLS GEN SNG NON
$0.00
L8687
9
IMPLT NROSTM PLS GEN DUA REC
$0.00
L8688
9
IMPLT NROSTM PLS GEN DUA NON
$0.00
L8689
6
EXTERNAL RECHARG SYS INTERN
$0.00
L8690
9
AUD OSSEO DEV, INT/EXT COMP
$0.00
L8691
6
AUD OSSEO DEV EXT SND PROCES
$0.00
L8695
6
EXTERNAL RECHARG SYS EXTERN
$0.00
L8699
9
PROSTHETIC IMPLANT NOS
$0.00
L9900
5
O&P SUPPLY/ACCESSORY/SERVICE
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
L9999
O
SALES TAX, ORTHOTIC/PROSTHETIC/OTHE
$0.00
M0005
9
OFFICE VISITS WITH TWO OR MORE MODA
$0.00
M0006
9
OFFICE VISITS WITH ONE OF THE ABOVE
$0.00
M0007
9
OFFICE VISITS INCLUDING COMBINATION
$0.00
M0008
9
OFFICE VISIT INCLUDING COMBINATION
$0.00
M0009
9
NOT OTHERWISE CLASSIFIED, OFFICE VI
$0.00
M0019
9
NOT OTHERWISE CLASSIFIED, HOME VISI
$0.00
M0021
9
PER DIEM INPATIENT HOSPITAL CARE WH
$0.00
M0022
9
I.C.U. CARE FOLLOW-UP WHEN ONE OR
$0.00
M0023
9
ROUTINE NEWBORN CARE, INHOSPITAL, I
$0.00
M0024
9
CHEMOTHERAPY(FOR MALIGNANCIES, FOLL
$0.00
M0029
9
NOT OTHERWISE CLASSIFIED, HOSPITAL
$0.00
M0039
9
NOT OTHERWISE CLASSIFIED, SNF, ECF,
$0.00
M0049
9
NOT OTHERWISE CLASSIFIED, NH, BOARD
$0.00
M0059
9
NOT OTHERWISE CLASSIFIED, EMERGENCY
$0.00
M0064
9
BRIEF OFFICE VISIT FOR THE SOLE PU
$0.00
M0070
9
INSULIN SHOCK THERAPY, HYPOGLYCEMIA
$0.00
M0071
9
ORTHOMOLECULAR THERAPY
$0.00
M0072
9
IMMUNOTHERAPY FOR MALIGNANT DISEASE
$0.00
M0075
9
CELLULAR THERAPY
$0.00
M0076
9
PROLOTHERAPY
$0.00
M0080
9
HYPERTHERMIA THERAPY (TO INCLUDE SY
$0.00
M0100
9
INTRAGASTRIC HYPOTHERMIA
$0.00
M0101
9
FOOT CARE HYGIENIC/PM
$0.00
M0260
9
TONSILLECTOMY, WITH OR WITHOUT ADEN
$0.00
M0261
9
TONSILLECTOMY, WITH OR WITHOUT ADEN
$0.00
M0300
9
IV CHELATIONTHERAPY
$0.00
M0301
9
FABRIC WRAPPING OF ANEURYSM
$0.00
M0520
9
ELECTRONIC PACEMAKER ANALYSIS, PULS
$0.00
M0525
9
SINGLE LEAD EKG WITH ANALYSIS OF PA
$0.00
M0526
9
COMPUTER TRACING AND INTERPRETATION
$0.00
M0530
9
CARDIAC EVENTS RECORDER, ELECTROCAR
$0.00
M0535
9
CARDIAC EVENTS RECORDER, ELECTROCAR
$0.00
M0540
9
SIGNAL-AVERAGING EKG
$0.00
M0560
9
PNEUMOPLETHYSMOGRAPHY VENOUS OCCLUS
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
M0575
9
ELECTROENCEPHALOGRAM (EEG), INTERPR
$0.00
M0580
9
TRANSTELEPHONIC ELECTROENCEPHALOGRA
$0.00
M0585
9
ACHILLES REFLEX RESPONSE, ELECTRICA
$0.00
M0590
9
MONITORING ECG, EEG OR PRESSURE IN
$0.00
M0601
9
PSYCHOLOGICAL TESTING, WITH WRITTEN
$0.00
M0702
9
BRIEF, OSTEOPATHIC MANIPULATIVE THE
$0.00
M0704
9
LIMITED, OSTEOPATHIC MANIPULATIVE T
$0.00
M0706
9
INTERMEDIATE OSTEOPATHIC MANIPULATI
$0.00
M0708
9
EXTENDED OSTEOPATHIC MANIPULATIVE T
$0.00
M0710
9
COMPREHENSIVE OSTEOPATHIC MANIPULAT
$0.00
M0722
9
BRIEF INPATIENT HOSPITAL OMT (UP TO
$0.00
M0724
9
LIMITED INPATIENT HOSPITAL OMT (UP
$0.00
M0726
9
INTERMEDIATE INPATIENT HOSPITAL OMT
$0.00
M0728
9
EXTENDED INPATIENT HOSPITAL OMT (UP
$0.00
M0730
9
COMPREHENSIVE INPATIENT HOSPITAL OM
$0.00
M0799
9
PHYSICAL MEDICINE, NOT OTHERWISE CL
$0.00
M0900
9
EXCISION, REVISION OR REMOVAL OF A-
$0.00
M0910
9
INSERTION CATHETERS FEMORAL VEIN, U
$0.00
M0945
9
OUTPATIENT DIALYSIS RELATED PHYSICI
$0.00
M0974
9
SELF DIALYSIS TRAINING, ANY MODE, C
$0.00
M0978
9
SELF DIALYSIS TRAINING, ANY MODE, C
$0.00
ORVCW
O
MCO SPECIFIC CODE: SMART START OUR
$0.00
ORVRN
O
MCO SPECIFIC CODE: SMART START OUTR
$0.00
ORVSW
O
MCO SPECIFIC CODE: SMART START OUTR
$0.00
P2028
9
CEPHALIN FLOCULATION TEST
$0.00
P2029
9
CONGO RED BLOOD TEST
$0.00
P2031
9
HAIR ANALYSIS
$0.00
P2032
9
ICTERUS INDEX, BLOOD
$0.00
P2033
9
BLOOD THYMOL TURBIDITY
$0.00
P2038
9
BLOOD MUCOPROTEIN
$0.00
P3000
9
SCREEN PAP BY TECH W MD SUPV
$0.00
P3001
9
SCREENING PAP SMEAR BY PHYS
$0.00
P7001
9
CULTURE BACTERIAL URINE
$0.00
P7020
9
VACCINE, AUTOGENOUS (MEDICAL NECESS
$0.00
P9005
9
ADMINISTRATION FEE CHARGE BY A PROV
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
P9006
9
MULTIPLE PATHOLOGY SERVICES
$0.00
P9007
9
HANDLING CHARGE FOR PURCHASED LAB S
$0.00
P9010
9
WHOLE BLOOD FOR TRANSFUSION
$0.00
P9011
9
BLOOD SPLIT UNIT
$0.00
P9012
9
CRYOPRECIPITATE EACH UNIT
$0.00
P9013
9
UNIT/S BLOOD FIBRINOGEN
$0.00
P9014
9
GAMMA GLOBULIN 1 ML
$0.00
P9015
9
RH IMMUNE GLOBULIN 1 ML
$0.00
P9016
9
RBC LEUKOCYTES REDUCED
$0.00
P9017
9
PLASMA 1 DONOR FRZ W/IN 8 HR
$0.00
P9018
9
PLASMA PROTEIN FRACT, UNIT
$0.00
P9019
9
PLATELETS, EACH UNIT
$0.00
P9020
9
PLAELET RICH PLASMA UNIT
$0.00
P9021
9
RED BLOOD CELLS UNIT
$0.00
P9022
9
WASHED RED BLOOD CELLS UNIT
$0.00
P9023
9
FROZEN PLASMA, POOLED, SD
$0.00
P9024
9
FACTOR VIII DILUTION, EACH BOTTLE.
$0.00
P9031
9
PLATELETS LEUKOCYTES REDUCED
$0.00
P9032
9
PLATELETS, IRRADIATED
$0.00
P9033
9
PLATELETS LEUKOREDUCED IRRAD
$0.00
P9034
9
PLATELETS, PHERESIS
$0.00
P9035
9
PLATELET PHERES LEUKOREDUCED
$0.00
P9036
9
PLATELET PHERESIS IRRADIATED
$0.00
P9037
9
PLATE PHERES LEUKOREDU IRRAD
$0.00
P9038
9
RBC IRRADIATED
$0.00
P9039
9
RBC DEGLYCEROLIZED
$0.00
P9040
9
RBC LEUKOREDUCED IRRADIATED
$0.00
P9041
9
ALBUMIN (HUMAN),5%, 50ML
$0.00
P9042
9
ALBUMIN (HUMAN), 25%
$0.00
P9043
9
PLASMA PROTEIN FRACT,5%,50ML
$0.00
P9044
9
CRYOPRECIPITATEREDUCEDPLASMA
$0.00
P9045
9
ALBUMIN (HUMAN), 5%, 250 ML
$0.00
P9046
9
ALBUMIN (HUMAN), 25%, 20 ML
$0.00
P9047
9
ALBUMIN (HUMAN), 25%, 50ML
$0.00
P9048
9
PLASMAPROTEIN FRACT,5%,250ML
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
P9050
9
GRANULOCYTES, PHERESIS UNIT
$0.00
P9051
9
BLOOD, L/R, CMV-NEG
$0.00
P9052
9
PLATELETS, HLA-M, L/R, UNIT
$0.00
P9053
9
PLT, PHER, L/R CMV-NEG, IRR
$0.00
P9054
9
BLOOD, L/R, FROZ/DEGLY/WASH
$0.00
P9055
9
PLT, APH/PHER, L/R, CMV-NEG
$0.00
P9056
9
BLOOD, L/R, IRRADIATED
$0.00
P9057
9
RBC, FRZ/DEG/WSH, L/R, IRRAD
$0.00
P9058
9
RBC, L/R, CMV-NEG, IRRAD
$0.00
P9059
9
PLASMA, FRZ BETWEEN 8-24HOUR
$0.00
P9060
9
FR FRZ PLASMA DONOR RETESTED
$0.00
P9603
9
ONE-WAY ALLOW PRORATED MILES
$0.00
P9604
9
ONE-WAY ALLOW PRORATED TRIP
$0.00
P9605
O
ROUTINE VENIPUNCTURE FOR COLLECTION
$0.00
P9610
9
URINE SPECIMEN COLLECT SINGL
$0.00
P9612
9
CATHETERIZE FOR URINE SPEC
$0.00
P9615
9
URINE SPECIMEN COLLECT MULT
$0.00
PEDCL
O
MCO SPECIFIC CODE: SMART START PREN
$0.00
Q0033
9
LINOZ V. BOWEN AMBULANCE REIMBURSE
$0.00
Q0034
9
ADMIN OF INFLUENZA VACCINE
$0.00
Q0035
9
CARDIOKYMOGRAPHY
$0.00
Q0036
O
OXYGEN CONCENTRATOR, HIGH HUMIDITY
$0.00
Q0037
5
OXYGEN AND WATER VAPOR ENRICHING SY
$0.00
Q0038
O
OXYGEN CONTENTS, GASEOUS, PER UNIT
$0.00
Q0039
9
OXYGEN CONTENTS, LIQUID, PER UNIT,
$0.00
Q0040
O
PORTABLE OXYGEN CONTENTS, GASEOUS P
$0.00
Q0041
O
PORTABLE OXYGEN CONTENTS, LIQUID, P
$0.00
Q0042
O
STATIONARY COMPRESSED GAS SYSTEM RE
$0.00
Q0043
O
STATIONARY LIQUID OXYGEN SYSTEM REN
$0.00
Q0045
9
ANESTHESIA FOR IRIDECTOMY
$0.00
Q0046
9
PORTABLE LIQUID OXYGEN SYSTEM RENTA
$0.00
Q0047
9
ANESTHESIA FOR BLEPHAROPLASTY
$0.00
Q0066
9
ASSESSMENT OF CARDIAC OUTPUT BY ELE
$0.00
Q0068
9
EXTRACORPEAL PLASMAPHERESIS
$0.00
Q0081
9
INFUSION THER OTHER THAN CHE
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
Q0082
9
ACTIVITY THERAPY W/PARTIAL H
$0.00
Q0083
9
CHEMO BY OTHER THAN INFUSION
$0.00
Q0084
9
CHEMOTHERAPY BY INFUSION
$0.00
Q0085
9
CHEMO BY BOTH INFUSION AND O
$0.00
Q0086
O
PHYSICAL THERAPY EVALUATION/
$0.00
Q0091
9
OBTAINING SCREEN PAP SMEAR
$0.00
Q0092
O
SET UP PORT XRAY EQUIPMENT
$0.00
Q0093
O
FILGRASTIM (G-CSF), PER 100 MCG
$0.00
Q0094
O
SARGRAMOSTIM (GM-CSF), PER 250 MCG
$0.00
Q0095
O
URINE PREGNANCY TESTS, VISUAL COLOR
$0.00
Q0096
O
OVULATION TEST KITS, VISUAL COLOR C
$0.00
Q0097
O
HEMOGLOBIN; BY COPPER SULFATE METHO
$0.00
Q0098
O
GLUCOSE, BLOOD; BY GLUCOSE MONITORI
$0.00
Q0100
O
URINALYSIS BY DIP STICK OR TABLET F
$0.00
Q0101
O
MICROHEMATOCRIT, SPUN
$0.00
Q0102
O
SEDIMENTATION RATE, ERYTHROCYTE; NO
$0.00
Q0103
9
PHYSICAL THERAPY EVALUATION, INITIA
$0.00
Q0104
9
PHYSICAL THERAPY RE-EVALUATION, PER
$0.00
Q0109
9
OCCUPATIONAL THERAPY EVALUATION, IN
$0.00
Q0110
9
OCCUPATIONAL THERAPY RE-EVALUATION,
$0.00
Q0111
O
WET MOUNTS/ W PREPARATIONS
$0.00
Q0112
O
POTASSIUM HYDROXIDE PREPS
$0.00
Q0113
O
PINWORM EXAMINATIONS
$0.00
Q0114
9
FERN TEST
$0.00
Q0115
9
POST-COITAL MUCOUS EXAM
$0.00
Q0116
O
HEMOGLOBIN BY SINGLE ANALYTE INSTRU
$0.00
Q0117
9
FOR DIABETICS ONLY, FITTING (INCLUD
$0.00
Q0118
9
FOR DIABETICS ONLY, FITTING (INCLUD
$0.00
Q0119
9
FOR DIABETICS ONLY, MULTIPLE DENSIT
$0.00
Q0120
9
FOR DIABETICS ONLY, MODIFICATION (I
$0.00
Q0121
9
FOR DIABETICS ONLY, MODIFICATION (I
$0.00
Q0122
9
FOR DIABETICS ONLY, MODIFICATION (I
$0.00
Q0123
9
FOR DIABETICS ONLY, MODIFICATION (I
$0.00
Q0132
9
DISPENSING FEE DME NEB DRUG
$0.00
Q0136
O
NON ESRD EPOETIN ALPHA INJ
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
Q0137
O
INJECTION, DARBEPOETIN ALFA
$0.00
Q0138
O
INJECTION, DEXAMETHASONE ACETATE, 1
$0.00
Q0144
9
AZITHROMYCIN DIHYDRATE, ORAL
$0.00
Q0156
9
HUMAN ALBUMIN 5%
$0.00
Q0157
O
HUMAN ALBUMIN 25%
$0.00
Q0160
9
FACTOR IX NON-RECOMBINANT
$0.00
Q0161
9
FACTOR IX RECOMBINANT
$0.00
Q0163
9
DIPHENHYDRAMINE HCL 50MG
$0.00
Q0164
9
PROCHLORPERAZINE MALEATE 5MG
$0.00
Q0165
9
PROCHLORPERAZINE MALEATE10MG
$0.00
Q0166
9
GRANISETRON HCL 1 MG ORAL
$0.00
Q0167
9
DRONABINOL 2.5MG ORAL
$0.00
Q0168
9
DRONABINOL 5MG ORAL
$0.00
Q0169
9
PROMETHAZINE HCL 12.5MG ORAL
$0.00
Q0170
9
PROMETHAZINE HCL 25 MG ORAL
$0.00
Q0171
9
CHLORPROMAZINE HCL 10MG ORAL
$0.00
Q0172
9
CHLORPROMAZINE HCL 25MG ORAL
$0.00
Q0173
9
TRIMETHOBENZAMIDE HCL 250MG
$0.00
Q0174
9
THIETHYLPERAZINE MALEATE10MG
$0.00
Q0175
9
PERPHENAZINE 4MG ORAL
$0.00
Q0176
9
PERPHENAZINE 8MG ORAL
$0.00
Q0177
9
HYDROXYZINE PAMOATE 25MG
$0.00
Q0178
9
HYDROXYZINE PAMOATE 50MG
$0.00
Q0179
9
ONDANSETRON HCL 8 MG ORAL
$0.00
Q0180
9
DOLASETRON MESYLATE ORAL
$0.00
Q0181
9
UNSPECIFIED ORAL ANTI-EMETIC
$0.00
Q0182
O
NONMETABOLIC ACT D/E TISSUE
$0.00
Q0183
O
NONMETABOLIC ACTIVE TISSUE
$0.00
Q0184
9
METABOLICALLY ACTIVE TISSUE
$0.00
Q0185
9
METABOLIC ACTIVE D/E TISSUE
$0.00
Q0186
9
PARAMEDIC INTERCEPT, RURAL
$0.00
Q0187
O
FACTOR VIIA RECOMBINANT
$0.00
Q0480
9
DRIVER PNEUMATIC VAD, REP
$0.00
Q0481
9
MICROPRCSR CU ELEC VAD, REP
$0.00
Q0482
9
MICROPRCSR CU COMBO VAD, REP
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
Q0483
9
MONITOR ELEC VAD, REP
$0.00
Q0484
9
MONITOR ELEC OR COMB VAD REP
$0.00
Q0485
9
MONITOR CABLE ELEC VAD, REP
$0.00
Q0486
9
MON CABLE ELEC/PNEUM VAD REP
$0.00
Q0487
9
LEADS ANY TYPE VAD, REP ONLY
$0.00
Q0488
9
PWR PACK BASE ELEC VAD, REP
$0.00
Q0489
9
PWR PCK BASE COMBO VAD, REP
$0.00
Q0490
9
EMR PWR SOURCE ELEC VAD, REP
$0.00
Q0491
9
EMR PWR SOURCE COMBO VAD REP
$0.00
Q0492
9
EMR PWR CBL ELEC VAD, REP
$0.00
Q0493
9
EMR PWR CBL COMBO VAD, REP
$0.00
Q0494
9
EMR HD PMP ELEC/COMBO, REP
$0.00
Q0495
9
CHARGER ELEC/COMBO VAD, REP
$0.00
Q0496
9
BATTERY ELEC/COMBO VAD, REP
$0.00
Q0497
9
BAT CLPS ELEC/COMB VAD, REP
$0.00
Q0498
9
HOLSTER ELEC/COMBO VAD, REP
$0.00
Q0499
9
BELT/VEST ELEC/COMBO VAD REP
$0.00
Q0500
9
FILTERS ELEC/COMBO VAD, REP
$0.00
Q0501
9
SHWR COV ELEC/COMBO VAD, REP
$0.00
Q0502
9
MOBILITY CART PNEUM VAD, REP
$0.00
Q0503
9
BATTERY PNEUM VAD REPLACEMNT
$0.00
Q0504
9
PWR ADPT PNEUM VAD, REP VEH
$0.00
Q0505
9
MISCL SUPPLY/ACCESSORY VAD
$0.00
Q0510
9
DISPENS FEE IMMUNOSUPRESSIVE
$0.00
Q0511
9
SUP FEE ANTIEM,ANTICA,IMMUNO
$0.00
Q0512
9
PX SUP FEE ANTI-CAN SUB PRES
$0.00
Q0513
9
DISP FEE INHAL DRUGS/30 DAYS
$0.00
Q0514
9
DISP FEE INHAL DRUGS/90 DAYS
$0.00
Q0515
5
SERMORELIN ACETATE INJECTION
$0.00
Q1001
O
NTIOL CATEGORY 1
$0.00
Q1002
O
NTIOL CATEGORY 2
$0.00
Q1003
9
NTIOL CATEGORY 3
$0.00
Q1004
9
NTIOL CATEGORY 4
$0.00
Q1005
9
NTIOL CATEGORY 5
$0.00
Q2001
O
ORAL CABERGOLINE 0.5 MG
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
Q2002
O
ELLIOTTS B SOLUTION PER ML
$0.00
Q2003
O
APROTININ, 10,000 KIU
$0.00
Q2004
5
BLADDER CALCULI IRRIG SOL
$0.00
Q2005
O
CORTICORELIN OVINE TRIFLUTAT
$0.00
Q2006
O
DIGOXIN IMMUNE FAB (OVINE)
$0.00
Q2007
O
ETHANOLAMINE OLEATE 100 MG
$0.00
Q2008
O
FOMEPIZOLE, 15 MG
$0.00
Q2009
5
FOSPHENYTOIN, 50 MG
$0.00
Q2010
O
GLATIRAMER ACETATE, PER DOSE
$0.00
Q2011
O
HEMIN, PER 1 MG
$0.00
Q2012
O
PEGADEMASE BOVINE, 25 IU
$0.00
Q2013
O
PENTASTARCH 10% SOLUTION
$0.00
Q2014
O
SERMORELIN ACETATE, 0.5 MG
$0.00
Q2015
O
SOMATREM, 5 MG
$0.00
Q2016
O
SOMATROPIN, 1 MG
$0.00
Q2017
5
TENIPOSIDE, 50 MG
$0.00
Q2018
O
UROFOLLITROPIN, 75 IU
$0.00
Q2019
O
BASILIXIMAB
$0.00
Q2020
O
HISTRELIN ACETATE
$0.00
Q2021
O
LEPIRUDIN
$0.00
Q2022
O
VONWILLEBRANDFACTRCMPLXPERIU
$0.00
Q3000
O
RUBIDIUM RB 82
$0.00
Q3001
5
BRACHYTHERAPY RADIOELEMENTS
$0.00
Q3002
O
GALLIUM GA 67
$0.00
Q3003
O
TECHNETIUM TC99M BICISATE
$0.00
Q3004
O
XENON XE 133
$0.00
Q3005
O
TECHNETIUM TC99M MERTIATIDE
$0.00
Q3006
O
TECHNETIUM TC99M GLUCEPATATE
$0.00
Q3007
O
SODIUM PHOSPHATE P32
$0.00
Q3008
O
INDIUM 111-IN PENTETREOTIDE
$0.00
Q3009
O
TECHNETIUM TC99M OXIDRONATE
$0.00
Q3010
O
TECHNETIUM TC99MLABELEDRBCS
$0.00
Q3011
O
CHROMIC PHOSPHATE P32
$0.00
Q3012
O
CYANOCOBALAMIN COBALT CO57
$0.00
Q3014
9
TELEHEALTH FACILITY FEE
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
Q3017
9
ALS ASSESSMENT
$0.00
Q3019
O
ALS EMER TRANS NO ALS SERV
$0.00
Q3020
O
ALS NONEMER TRANS NO ALS SER
$0.00
Q3021
5
PED HEPATITIS B VACCINE INJ
$0.00
Q3022
5
HEPATITIS B VACCINE ADULT DS
$0.00
Q3023
5
INJECTION HEPATITIS BVACCINE
$0.00
Q3025
5
IM INJ INTERFERON BETA 1-A
$0.00
Q3026
5
SUBC INJ INTERFERON BETA-1A
$0.00
Q3031
9
COLLAGEN SKIN TEST
$0.00
Q4001
9
CAST SUP BODY CAST PLASTER
$0.00
Q4002
9
CAST SUP BODY CAST FIBERGLAS
$0.00
Q4003
9
CAST SUP SHOULDER CAST PLSTR
$0.00
Q4004
9
CAST SUP SHOULDER CAST FBRGL
$0.00
Q4005
9
CAST SUP LONG ARM ADULT PLST
$0.00
Q4006
9
CAST SUP LONG ARM ADULT FBRG
$0.00
Q4007
9
CAST SUP LONG ARM PED PLSTER
$0.00
Q4008
9
CAST SUP LONG ARM PED FBRGLS
$0.00
Q4009
9
CAST SUP SHT ARM ADULT PLSTR
$0.00
Q4010
9
CAST SUP SHT ARM ADULT FBRGL
$0.00
Q4011
9
CAST SUP SHT ARM PED PLASTER
$0.00
Q4012
9
CAST SUP SHT ARM PED FBRGLAS
$0.00
Q4013
9
CAST SUP GAUNTLET PLASTER
$0.00
Q4014
9
CAST SUP GAUNTLET FIBERGLASS
$0.00
Q4015
9
CAST SUP GAUNTLET PED PLSTER
$0.00
Q4016
9
CAST SUP GAUNTLET PED FBRGLS
$0.00
Q4017
9
CAST SUP LNG ARM SPLINT PLST
$0.00
Q4018
9
CAST SUP LNG ARM SPLINT FBRG
$0.00
Q4019
9
CAST SUP LNG ARM SPLNT PED P
$0.00
Q4020
9
CAST SUP LNG ARM SPLNT PED F
$0.00
Q4021
9
CAST SUP SHT ARM SPLINT PLST
$0.00
Q4022
9
CAST SUP SHT ARM SPLINT FBRG
$0.00
Q4023
9
CAST SUP SHT ARM SPLNT PED P
$0.00
Q4024
9
CAST SUP SHT ARM SPLNT PED F
$0.00
Q4025
9
CAST SUP HIP SPICA PLASTER
$0.00
Q4026
9
CAST SUP HIP SPICA FIBERGLAS
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
Q4027
9
CAST SUP HIP SPICA PED PLSTR
$0.00
Q4028
9
CAST SUP HIP SPICA PED FBRGL
$0.00
Q4029
9
CAST SUP LONG LEG PLASTER
$0.00
Q4030
9
CAST SUP LONG LEG FIBERGLASS
$0.00
Q4031
9
CAST SUP LNG LEG PED PLASTER
$0.00
Q4032
9
CAST SUP LNG LEG PED FBRGLS
$0.00
Q4033
9
CAST SUP LNG LEG CYLINDER PL
$0.00
Q4034
9
CAST SUP LNG LEG CYLINDER FB
$0.00
Q4035
9
CAST SUP LNGLEG CYLNDR PED P
$0.00
Q4036
9
CAST SUP LNGLEG CYLNDR PED F
$0.00
Q4037
9
CAST SUP SHRT LEG PLASTER
$0.00
Q4038
9
CAST SUP SHRT LEG FIBERGLASS
$0.00
Q4039
9
CAST SUP SHRT LEG PED PLSTER
$0.00
Q4040
9
CAST SUP SHRT LEG PED FBRGLS
$0.00
Q4041
9
CAST SUP LNG LEG SPLNT PLSTR
$0.00
Q4042
9
CAST SUP LNG LEG SPLNT FBRGL
$0.00
Q4043
9
CAST SUP LNG LEG SPLNT PED P
$0.00
Q4044
9
CAST SUP LNG LEG SPLNT PED F
$0.00
Q4045
9
CAST SUP SHT LEG SPLNT PLSTR
$0.00
Q4046
9
CAST SUP SHT LEG SPLNT FBRGL
$0.00
Q4047
9
CAST SUP SHT LEG SPLNT PED P
$0.00
Q4048
9
CAST SUP SHT LEG SPLNT PED F
$0.00
Q4049
9
FINGER SPLINT, STATIC
$0.00
Q4050
9
CAST SUPPLIES UNLISTED
$0.00
Q4051
9
SPLINT SUPPLIES MISC
$0.00
Q4054
O
DARBEPOETIN ALFA, ESRD USE
$0.00
Q4055
O
EPOETIN ALFA, ESRD USE
$0.00
Q4075
O
ACYCLOVIR, 5 MG
$0.00
Q4076
O
DOPAMINE HCL, 40 MG
$0.00
Q4077
O
TREPROSTINIL, 1 MG
$0.00
Q4079
O
NATALIZUMAB INJECTION
$0.00
Q4080
9
ILOPROST NON-COMP UNIT DOSE
$0.00
Q4081
6
EPOETIN ALFA, 100 UNITS ESRD
$0.00
Q4082
9
DRUG/BIO NOC PART B DRUG CAP
$0.00
Q4083
O
HYALURONAN OR DERIVATIVE, HYALGAN
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
Q4084
O
HYALURONAN OR DERIVATIVE, SYNVISC,
$0.00
Q4085
O
HYALURONAN OR DERIVATIVE, EUFLEXXA
$0.00
Q4086
O
HYALURONAN OR DERIVATIVE, ORTHVISC
$0.00
Q4096
O
INJECTION, VON WILLEBRAND FACTOR C
$0.00
Q4097
O
INJECTION, IMMUNE GLOBULIN (PRIVIG
$0.00
Q4098
O
INJECTION, IRON DEXTRAN, 50 MG
$0.00
Q4099
O
FORMOTEROL FUMARATE INHALATION UD
$0.00
Q4100
9
SKIN SUBSTITUTE, NOS
$0.00
Q4101
9
APLIGRAF SKIN SUB
$0.00
Q4102
9
OASIS WOUND MATRIX SKIN SUB
$0.00
Q4103
9
OASIS BURN MATRIX SKIN SUB
$0.00
Q4104
9
INTEGRA BMWD SKIN SUB
$0.00
Q4105
9
INTEGRA DRT SKIN SUB
$0.00
Q4106
9
DERMAGRAFT SKIN SUB
$0.00
Q4107
9
GRAFTJACKET SKIN SUB
$0.00
Q4108
9
INTEGRA MATRIX SKIN SUB
$0.00
Q4109
9
TISSUEMEND SKIN SUB
$0.00
Q4110
9
PRIMATRIX SKIN SUB
$0.00
Q4111
9
GAMMAGRAFT SKIN SUB
$0.00
Q4112
9
CYMETRA ALLOGRAFT
$0.00
Q4113
9
GRAFTJACKET EXPRESS ALLOGRAF
$0.00
Q4114
9
INTEGRA FLOWABLE WOUND MATRI
$0.00
Q5001
9
HOSPICE IN PATIENT HOME
$0.00
Q5002
9
HOSPICE IN ASSISTED LIVING
$0.00
Q5003
9
HOSPICE IN LT/NON-SKILLED NF
$0.00
Q5004
9
HOSPICE IN SNF
$0.00
Q5005
9
HOSPICE, INPATIENT HOSPITAL
$0.00
Q5006
9
HOSPICE IN HOSPICE FACILITY
$0.00
Q5007
9
HOSPICE IN LTCH
$0.00
Q5008
9
HOSPICE IN INPATIENT PSYCH
$0.00
Q5009
9
HOSPICE CARE, NOS
$0.00
Q9920
O
EPOETIN WITH HCT <= 20
$0.00
Q9921
O
EPOETIN WITH HCT = 21
$0.00
Q9922
O
EPOETIN WITH HCT = 22
$0.00
Q9923
O
EPOETIN WITH HCT = 23
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
Q9924
O
EPOETIN WITH HCT = 24
$0.00
Q9925
O
EPOETIN WITH HCT = 25
$0.00
Q9926
O
EPOETIN WITH HCT = 26
$0.00
Q9927
O
EPOETIN WITH HCT = 27
$0.00
Q9928
O
EPOETIN WITH HCT = 28
$0.00
Q9929
O
EPOETIN WITH HCT = 29
$0.00
Q9930
O
EPOETIN WITH HCT = 30
$0.00
Q9931
O
EPOETIN WITH HCT = 31
$0.00
Q9932
O
EPOETIN WITH HCT = 32
$0.00
Q9933
O
EPOETIN WITH HCT = 33
$0.00
Q9934
O
EPOETIN WITH HCT = 34
$0.00
Q9935
O
EPOETIN WITH HCT = 35
$0.00
Q9936
O
EPOETIN WITH HCT = 36
$0.00
Q9937
O
EPOETIN WITH HCT = 37
$0.00
Q9938
O
EPOETIN WITH HCT = 38
$0.00
Q9939
O
EPOETIN WITH HCT = 39
$0.00
Q9940
O
EPOETIN WITH HCT >= 40
$0.00
Q9945
O
LOCM <=149 MG/ML IODINE, 1ML
$0.00
Q9946
O
LOCM 150-199MG/ML IODINE,1ML
$0.00
Q9947
O
LOCM 200-249MG/ML IODINE,1ML
$0.00
Q9948
O
LOCM 250-299MG/ML IODINE,1ML
$0.00
Q9949
O
LOCM 300-349MG/ML IODINE,1ML
$0.00
Q9950
O
LOCM 350-399MG/ML IODINE,1ML
$0.00
Q9951
9
LOCM >= 400 MG/ML IODINE,1ML
$0.00
Q9952
O
INJ GAD-BASE MR CONTRAST,1ML
$0.00
Q9953
9
INJ FE-BASED MR CONTRAST,1ML
$0.00
Q9954
9
ORAL MR CONTRAST, 100 ML
$0.00
Q9955
5
INJ PERFLEXANE LIP MICROS,ML
$0.00
Q9956
5
INJ OCTAFLUOROPROPANE MIC,ML
$0.00
Q9957
5
INJ PERFLUTREN LIP MICROS,ML
$0.00
Q9958
9
HOCM <=149 MG/ML IODINE, 1ML
$0.00
Q9959
9
HOCM 150-199MG/ML IODINE,1ML
$0.00
Q9960
9
HOCM 200-249MG/ML IODINE,1ML
$0.00
Q9961
9
HOCM 250-299MG/ML IODINE,1ML
$0.00
Q9962
9
HOCM 300-349MG/ML IODINE,1ML
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
Q9963
9
HOCM 350-399MG/ML IODINE,1ML
$0.00
Q9964
9
HOCM>= 400MG/ML IODINE, 1ML
$0.00
Q9965
9
LOCM 100-199MG/ML IODINE,1ML
$0.00
Q9966
9
LOCM 200-299MG/ML IODINE,1ML
$0.00
Q9967
9
LOCM 300-399MG/ML IODINE,1ML
$0.00
R0059
9
NOT OTHERWISE CLASSIFIED, CHEST
$0.00
R0065
9
CIRCULATION TIME, RADIONUCLIDE STUD
$0.00
R0070
9
TRANSPORT PORTABLE X-RAY
$0.00
R0075
9
TRANSPORT PORT X-RAY MULTIPL
$0.00
R0076
9
TRANSPORT PORTABLE EKG
$0.00
R0085
9
MULTIPLE RADIOLOGY SERVICES
$0.00
S0009
O
INJECTION, BUTORPHANOL TARTR
$0.00
S0010
O
INJECTION, SOMATREM, 5 MG
$0.00
S0011
O
INJECTION, SOMATROPIN, 5 MG
$0.00
S0012
9
BUTORPHANOL TARTRATE, NASAL
$0.00
S0014
9
TACRINE HYDROCHLORIDE, 10 MG
$0.00
S0016
O
INJECTION, AMIKACIN SULFATE
$0.00
S0017
5
INJECTION, AMINOCAPROIC ACID
$0.00
S0020
3
INJECTION, BUPIVICAINE HYDRO
$1.69
S0021
5
INJECTION, CEFOPERAZONE SOD
$0.00
S0023
5
INJECTION, CIMETIDINE HYDROC
$0.00
S0024
O
INJECTION, CIPROFLOXACIN
$0.00
S0028
5
INJECTION, FAMOTIDINE, 20 MG
$0.00
S0029
O
INJECTION, FLUCONAZOLE
$0.00
S0030
5
INJECTION, METRONIDAZOLE
$0.00
S0032
5
INJECTION, NAFCILLIN SODIUM
$0.00
S0034
5
INJECTION, OFLOXACIN, 400 MG
$0.00
S0039
5
INJECTION, SULFAMETHOXAZOLE
$0.00
S0040
5
INJECTION, TICARCILLIN DISOD
$0.00
S0071
O
INJECTION, ACYCLOVIR SODIUM
$0.00
S0072
O
INJECTION, AMIKACIN SULFATE
$0.00
S0073
5
INJECTION, AZTREONAM, 500 MG
$0.00
S0074
5
INJECTION, CEFOTETAN DISODIU
$0.00
S0077
5
INJECTION, CLINDAMYCIN PHOSP
$0.00
S0078
5
INJECTION, FOSPHENYTOIN SODI
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
S0079
O
OCTREOTIDE 100 MCG
$0.00
S0080
5
INJECTION, PENTAMIDINE ISETH
$0.00
S0081
5
INJECTION, PIPERACILLIN SODI
$0.00
S0085
O
INJECTION, GATIFLOXACIN
$0.00
S0086
O
INJECTION, VERTEPORFIN, 15MG
$0.00
S0087
O
ALEMTUZUMAB 30 MG
$0.00
S0088
9
IMATINIB 100 MG
$0.00
S0090
9
SILDENAFIL CITRATE, 25 MG
$0.00
S0091
5
GRANISETRON 1MG
$0.00
S0092
9
HYDROMORPHONE 250 MG
$0.00
S0093
9
MORPHINE 500 MG
$0.00
S0096
O
INJECTION, ITRACONAZOLE, 200
$0.00
S0097
O
INJECTION, IBUTILIDE FUMARAT
$0.00
S0098
O
INJECTION, SODIUM FERRIC GLU
$0.00
S0104
9
ZIDOVUDINE ORAL 100 MG
$0.00
S0106
9
BUPROPION HCL SR 60 TABLETS
$0.00
S0107
O
INJ, OMALIZUMAB 25 MG
$0.00
S0108
9
MERCAPTOPURINE 50 MG
$0.00
S0109
9
METHADONE ORAL 5 MG
$0.00
S0114
O
TREPROSTINIL SODIUM INJECT
$0.00
S0115
O
BORTEZOMIB 3.5 MG
$0.00
S0116
O
BEVACIZUMAB, 100MG
$0.00
S0117
9
TRETINOIN TOPICAL 5G
$0.00
S0118
O
ZICONOTIDE INJ
$0.00
S0122
9
INJ MENOTROPINS 75 IU
$0.00
S0124
O
INJ UROFOLLITROPIN 75 IU
$0.00
S0126
9
INJ FOLLITROPIN ALFA 75 IU
$0.00
S0128
9
INJ FOLLITROPIN BETA 75 IU
$0.00
S0130
O
INJ C GONADOTROPIN 5000 IU
$0.00
S0132
9
INJ GANIRELIX ACETAT 250 MCG
$0.00
S0133
O
HISTRELIN IMPLANT
$0.00
S0135
5
PEGFILGRASTIM INJECTION 6MG
$0.00
S0136
9
CLOZAPINE, 25 MG
$0.00
S0137
9
DIDANOSINE, 25 MG
$0.00
S0138
9
FINASTERIDE, 5 MG
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
S0139
9
MINOXIDIL, 10 MG
$0.00
S0140
9
SAQUINAVIR, 200 MG
$0.00
S0141
O
ZALCITABINE, 0.375 MG
$0.00
S0142
9
COLISTIMETHATE INH SOL MG
$0.00
S0143
O
AZTREONAM, INH SOL GRAM
$0.00
S0145
5
PEG INTERFERON ALFA-2A/180
$0.00
S0146
5
PEG INTERFERON ALFA-2B/10
$0.00
S0147
O
ALGLUCOSIDASE ALFA 20 MG
$0.00
S0155
5
EPOPROSTENOL DILUTANT
$0.00
S0156
5
EXEMESTANE, 25 MG
$0.00
S0157
9
BECAPLERMIN GEL 1%, 0.5 GM
$0.00
S0158
O
INJECTION LARONIDASE
$0.00
S0159
O
INJECTION AGALSIDASE
$0.00
S0160
9
DEXTROAMPHETAMINE
$0.00
S0161
5
CALCITROL
$0.00
S0162
5
INJECTION EFALIZUMAB
$0.00
S0163
O
INJECTION RISPERIDONELA
$0.00
S0164
5
INJECTION PANTOPRAZOLE
$0.00
S0165
O
INJECTION ABARELIX
$0.00
S0166
9
INJ OLANZAPINE 2.5MG
$0.00
S0167
O
INJ APOMORPHINE HCL 1MG
$0.00
S0168
O
INJ AZACITIDINE 100 MG
$0.00
S0170
9
ANASTROZOLE 1 MG
$0.00
S0171
5
BUMETANIDE 0.5 MG
$0.00
S0172
9
CHLORAMBUCIL 2 MG
$0.00
S0173
O
DEXAMETHASONE 4 MG
$0.00
S0174
9
DOLASETRON 50 MG
$0.00
S0175
9
FLUTAMIDE 125 MG
$0.00
S0176
9
HYDROXYUREA 500 MG
$0.00
S0177
9
LEVAMISOLE 50 MG
$0.00
S0178
9
LOMUSTINE 10 MG
$0.00
S0179
9
MEGESTROL 20 MG
$0.00
S0180
O
ETONOGESTREL IMPLANT SYSTEM
$0.00
S0181
9
ONDANSETRON 4 MG
$0.00
S0182
9
PROCARBAZINE 5 MG
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
S0183
9
PROCHLORPERAZINE 5 MG
$0.00
S0187
9
TAMOXIFEN 10 MG
$0.00
S0189
9
TESTOSTERONE PELLET 75 MG
$0.00
S0190
5
MIFEPRISTONE, ORAL, 200 MG
$0.00
S0191
5
MISOPROSTOL, ORAL, 200 MCG
$0.00
S0194
9
VITAMIN SUPPL 100 CAPS
$0.00
S0195
5
PNEUMOCOCCAL CONJUGATE VAC
$0.00
S0196
9
POLY-L-LACTIC ACID 1ML FACE
$0.00
S0197
9
PRENATAL VITAMINS 30 DAY
$0.00
S0198
O
INJ PEGAPTANIB 0.3 MG
$0.00
S0199
9
MEDICALLY INDUCED ABORTION BY ORAL
$0.00
S0201
9
PARTIAL HOSPITALIZATION SERV
$0.00
S0206
9
SURGERY IN OFFICE
$0.00
S0207
9
PARAMEDICINTERCEP NONHOSPALS
$0.00
S0208
9
PARAMED INTRCEPT NONVOL
$0.00
S0209
3
WC VAN MILEAGE PER MI
$0.42
S0215
3
NONEMERG TRANSP MILEAGE
$0.42
S0220
6
MEDICAL CONFERENCE BY PHYSIC
$0.00
S0221
6
MEDICAL CONFERENCE, 60 MIN
$0.00
S0250
9
COMP GERIATR ASSMT TEAM
$0.00
S0255
9
HOSPICE REFER VISIT NONMD
$0.00
S0257
9
END OF LIFE COUNSELING
$0.00
S0260
9
H&P FOR SURGERY
$0.00
S0265
9
GENETIC COUNSEL 15 MINS
$0.00
S0270
9
HOME STD CASE RATE 30 DAYS
$0.00
S0271
9
HOME HOSPICE CASE 30 DAYS
$0.00
S0272
9
HOME EPISODIC CASE 30 DAYS
$0.00
S0273
9
MD HOME VISIT OUTSIDE CAP
$0.00
S0274
9
NURSE PRACTR VISIT OUTS CAP
$0.00
S0302
9
COMPLETED EPSDT
$0.00
S0310
9
HOSPITALIST VISIT
$0.00
S0315
9
DISEASE MANAGEMENT PROGRAM
$0.00
S0316
9
FOLLOW-UP/REASSESSMENT
$0.00
S0317
9
DISEASE MGMT PER DIEM
$0.00
S0320
9
RN TELEPHONE CALLS TO DMP
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
S0340
9
LIFESTYLE MOD 1ST STAGE
$0.00
S0341
9
LIFESTYLE MOD 2 OR 3 STAGE
$0.00
S0342
9
LIFESTYLE MOD 4TH STAGE
$0.00
S0345
9
HOME ECG MONITRNG GLOBAL 24H
$0.00
S0346
9
HOME ECG MONITRNG TECH 24HR
$0.00
S0347
9
HOME ECG MONITRNG PROF 24HR
$0.00
S0390
5
ROUT FOOT CARE PER VISIT
$0.00
S0395
9
IMPRESSION CASTING FT
$0.00
S0400
9
GLOBAL ESWL KIDNEY
$0.00
S0500
6
DISPOS CONT LENS
$0.00
S0504
9
SINGL PRSCRP LENS
$0.00
S0506
9
BIFOC PRSCP LENS
$0.00
S0508
9
TRIFOC PRSCRP LENS
$0.00
S0510
9
NON-PRSCRP LENS
$0.00
S0512
6
DAILY CONT LENS
$0.00
S0514
9
COLOR CONT LENS
$0.00
S0515
9
SCLERAL LENS LIQUID BANDAGE
$0.00
S0516
6
SAFETY FRAMES
$0.00
S0518
9
SUNGLASS FRAMES
$0.00
S0580
3
POLYCARB LENS
$18.96
S0581
6
NONSTND LENS
$0.00
S0590
9
MISC INTEGRAL LENS SERV
$0.00
S0592
6
COMP CONT LENS EVAL
$0.00
S0595
9
NEW LENSES IN PTS OLD FRAME
$0.00
S0601
9
SCREENING PROCTOSCOPY
$0.00
S0605
9
DIGITAL RECTAL EXAMINATION,
$0.00
S0610
3
ANNUAL GYNECOLOGICAL EXAMINA
$63.33
S0612
3
ANNUAL GYNECOLOGICAL EXAMINA
$61.32
S0613
9
ANN BREAST EXAM
$0.00
S0618
9
AUDIOMETRY FOR HEARING AID
$0.00
S0620
6
ROUTINE OPHTHALMOLOGICAL EXA
$0.00
S0621
6
ROUTINE OPHTHALMOLOGICAL EXA
$0.00
S0622
9
PHYS EXAM FOR COLLEGE
$0.00
S0625
9
DIGITAL SCREENING RETINA
$0.00
S0630
9
REMOVAL OF SUTURES
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
S0800
9
LASER IN SITU KERATOMILEUSIS
$0.00
S0810
9
PHOTOREFRACTIVE KERATECTOMY
$0.00
S0812
9
PHOTOTHERAP KERATECT
$0.00
S0820
O
COMPUTERIZED CORNEAL TOPOGRA
$0.00
S0830
O
ULTRASOUND PACHYMETRY
$0.00
S1001
9
DELUXE ITEM
$0.00
S1002
9
CUSTOM ITEM
$0.00
S1015
9
IV TUBING EXTENSION SET
$0.00
S1016
9
NON-PVC INTRAVENOUS ADMINIST
$0.00
S1025
O
INHAL NITRIC OXIDE NEONATE
$0.00
S1030
9
GLUC MONITOR PURCHASE
$0.00
S1031
9
GLUC MONITOR RENTAL
$0.00
S1040
6
CRANIAL REMOLDING ORTHOSIS
$0.00
S2050
9
DONOR ENTERECTOMY, WITH PREP
$0.00
S2052
9
TRANSPLANTATION OF SMALL INT
$0.00
S2053
9
TRANSPLANTATION OF SMALL INT
$0.00
S2054
9
TRANSPLANTATION OF MULTIVISC
$0.00
S2055
9
HARVESTING OF DONOR MULTIVIS
$0.00
S2060
9
LOBAR LUNG TRANSPLANTATION
$0.00
S2061
9
DONOR LOBECTOMY (LUNG)
$0.00
S2065
9
SIMULT PANC KIDN TRANS
$0.00
S2066
9
BREAST GAP FLAP RECONST
$0.00
S2067
9
BREAST "STACKED" DIEP/GAP
$0.00
S2068
9
BREAST DIEP OR SIEA FLAP
$0.00
S2070
9
CYSTO LASER TX URETERAL CALC
$0.00
S2075
O
LAP INC/VENT HERNIA REPAIR
$0.00
S2076
O
LAP UMBILICAL HERNIA REPAIR
$0.00
S2077
O
LAP MESH IMPLANT HERN REP
$0.00
S2078
O
LAP SUPRACERV HYSTERECTOMY
$0.00
S2079
9
LAP ESOPHAGOMYOTOMY
$0.00
S2080
9
LAUP
$0.00
S2082
O
LAP ADJUSTABLE GASTRIC BAND
$0.00
S2083
9
ADJUSTMENT GASTRIC BAND
$0.00
S2085
O
LAPAROSCOP GASTRIC BYPASS
$0.00
S2090
O
OPEN CRYOSURG RENAL
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
S2091
O
PERC CRYOSURG RENAL
$0.00
S2095
9
TRANSCATH EMBOLIZ MICROSPHER
$0.00
S2102
9
ISLET CELL TISSUE TRANSPLANT
$0.00
S2103
9
ADRENAL TISSUE TRANSPLANT
$0.00
S2107
5
ADOPTIVE IMMUNOTHERAPY
$0.00
S2109
9
AUTOLOGOUS CHONDROCYTE TRANS
$0.00
S2112
9
KNEE ARTHROSCP HARV
$0.00
S2113
O
ARTHRO CHONDROCYTE IMPLANT
$0.00
S2114
O
ARTHROSC SH TENODESIS BICEPS
$0.00
S2115
9
PERIACETABULAR OSTEOTOMY
$0.00
S2117
9
ARTHROEREISIS, SUBTALAR
$0.00
S2118
9
TOTAL HIP RESURFACING
$0.00
S2120
9
LOW DENSITY LIPOPROTEIN(LDL)
$0.00
S2130
O
ERA OF REFLUX SAPHENOUS VEIN
$0.00
S2131
O
LASER ABLAT SAPHENOUS VEIN
$0.00
S2135
O
NEUROLYSIS INTERSPACE FOOT
$0.00
S2140
9
CORD BLOOD HARVESTING
$0.00
S2142
9
CORD BLOOD-DERIVED STEM-CELL
$0.00
S2150
9
BMT HARV/TRANSPL 28D PKG
$0.00
S2152
9
SOLID ORGAN TRANSPL PKG
$0.00
S2180
9
DONOR LEUKOCYTE INFUSION
$0.00
S2190
9
SUBCUTANEOUS IMPLANTATION OF
$0.00
S2202
9
ECHOSCLEROTHERAPY
$0.00
S2204
9
TRANSMYOCARDIAL LASER REVASC
$0.00
S2205
9
MINIMALLY INVASIVE DIRECT CO
$0.00
S2206
9
MINIMALLY INVASIVE DIRECT CO
$0.00
S2207
9
MINIMALLY INVASIVE DIRECT CO
$0.00
S2208
9
MINIMALLY INVASIVE DIRECT CO
$0.00
S2209
9
MINIMALLY INVASIVE DIRECT CO
$0.00
S2210
9
CRYOSURGICAL ABLATION (IN SI
$0.00
S2211
O
TRANSV CAROTID STENT PLACEMT
$0.00
S2213
O
IMPLANT GASTRIC STIM
$0.00
S2215
O
UGI ENDOSCOPY INJ IMPLANT
$0.00
S2220
9
THROMBECTOMY, CORONARY
$0.00
S2225
9
MYRINGOTOMY LASER-ASSIST
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
S2230
9
IMPLANT SEMI-IMP HEAR
$0.00
S2235
9
IMPLANT AUDITORY BRAIN IMP
$0.00
S2250
O
UTERINE ARTERY EMBOLIZ
$0.00
S2260
9
INDUCED ABORTION 17-24 WEEKS
$0.00
S2262
O
ABORTION MATERNAL INDIC 25W
$0.00
S2265
9
INDUCED ABORTION 25-28 WKS
$0.00
S2266
9
INDUCED ABORTION 29-31 WKS
$0.00
S2267
9
INDUCED ABORTION 32 OR MORE
$0.00
S2270
9
INSERTION VAGINAL CYLINDER
$0.00
S2300
9
ARTHROSCOPY, SHOULDER, SURGI
$0.00
S2325
6
HIP CORE DECOMPRESSION
$0.00
S2340
9
CHEMODENERVATION OF ABDUCTOR
$0.00
S2341
9
CHEMODENERV ADDUCT VOCAL
$0.00
S2342
9
NASAL ENDOSCOP PO DEBRID
$0.00
S2344
9
ENDOSC BALLOON SINUPLASTY
$0.00
S2348
9
DECOMPRESS DISC RF LUMBAR
$0.00
S2350
9
DISKECTOMY, ANTERIOR, WITH D
$0.00
S2351
9
DISKECTOMY, ANTERIOR, WITH D
$0.00
S2360
9
VERTEBROPLAST CERV 1ST
$0.00
S2361
9
VERTEBROPLAST CERV ADDL
$0.00
S2362
O
KYPHOPLASTY, FIRST VERTEBRA
$0.00
S2363
O
KYPHOPLASTY, EACH ADDL
$0.00
S2370
O
INTRADISCAL ELECTROTHERMAL
$0.00
S2371
O
EACH ADDITIONAL INTERSPACE
$0.00
S2400
5
FETAL SURG CONGEN HERNIA
$0.00
S2401
9
FETAL SURG URIN TRAC OBSTR
$0.00
S2402
9
FETAL SURG CONG CYST MALF
$0.00
S2403
9
FETAL SURG PULMON SEQUEST
$0.00
S2404
9
FETAL SURG MYELOMENINGO
$0.00
S2405
5
FETAL SURG SACROCOC TERATOMA
$0.00
S2409
9
FETAL SURG NOC
$0.00
S2411
9
FETOSCOP LASER THER TTTS
$0.00
S2900
9
ROBOTIC SURGICAL SYSTEM
$0.00
S3000
9
BILAT DIL RETINAL EXAM
$0.00
S3005
9
EVAL SELF-ASSESS DEPRESSION
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
S3600
9
STAT LAB
$0.00
S3601
9
STAT LAB HOME/NF
$0.00
S3620
9
NEWBORN METABOLIC SCREENING
$0.00
S3625
9
MATERNAL TRIPLE SCREEN TEST
$0.00
S3626
9
MATERNAL SERUM QUAD SCREEN
$0.00
S3628
6
PLACENTAL ALPHA MICROGLOBULIN-1RAP
$0.00
S3630
9
EOSINOPHIL BLOOD COUNT
$0.00
S3645
9
HIV-1 ANTIBODY TESTING OF OR
$0.00
S3650
9
SALIVA TEST, HORMONE LEVEL;
$0.00
S3652
9
SALIVA TEST, HORMONE LEVEL;
$0.00
S3655
9
ANTISPERM ANTIBODIES TEST
$0.00
S3700
9
BLADDER TUMOR-ASSOCIATED
$0.00
S3701
O
NMP-22 ASSAY
$0.00
S3708
9
GASTROINTESTINAL FAT ABSORPT
$0.00
S3711
9
CIRCULATING TUMOR CELL TEST
$0.00
S3800
9
GENETIC TESTING ALS
$0.00
S3818
9
BRCA1 GENE ANAL
$0.00
S3819
9
BRCA2 GENE ANAL
$0.00
S3820
9
COMP BRCA1/BRCA2
$0.00
S3822
9
SING MUTATION BRST/OVAR
$0.00
S3823
9
3 MUTATION BRST/OVAR
$0.00
S3828
9
COMP MLH1 GENE
$0.00
S3829
9
COMP MLH2 GENE
$0.00
S3830
9
GENE TEST HNPCC COMP
$0.00
S3831
9
GENE TEST HNPCC SINGLE
$0.00
S3833
9
COMP APC SEQUENCE
$0.00
S3834
9
SING MUTATION APC
$0.00
S3835
9
GENE TEST CYSTIC FIBROSIS
$0.00
S3837
9
GENE TEST HEMOCHROMATO
$0.00
S3840
9
DNA ANALYSIS RET-ONCOGENE
$0.00
S3841
9
GENE TEST RETINOBLASTOMA
$0.00
S3842
9
GENE TEST HIPPEL-LINDAU
$0.00
S3843
9
DNA ANALYSIS FACTOR V
$0.00
S3844
9
DNA ANALYSIS DEAFNESS
$0.00
S3845
9
GENE TEST ALPHA-THALASSEMIA
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
S3846
9
GENE TEST BETA-THALASSEMIA
$0.00
S3847
9
GENE TEST TAY-SACHS
$0.00
S3848
9
GENE TEST GAUCHER
$0.00
S3849
9
GENE TEST NIEMANN-PICK
$0.00
S3850
9
GENE TEST SICKLE CELL
$0.00
S3851
9
GENE TEST CANAVAN
$0.00
S3852
9
DNA ANALYSIS APOE ALZHEIMER
$0.00
S3853
9
GENE TEST MYO MUSCLR DYST
$0.00
S3854
9
GENE PROFILE PANEL BREAST
$0.00
S3855
9
GENE TEST PRESENILIN-1 GENE
$0.00
S3860
9
GENET TEST CARDIAC ION-COMP
$0.00
S3861
9
GENETIC TEST BRUGADA
$0.00
S3862
9
GENET TEST CARDIAC ION-SPEC
$0.00
S3890
9
FECAL DNA ANALYSIS
$0.00
S3900
9
SURFACE EMG
$0.00
S3902
9
BALLISTOCARDIOGRAM
$0.00
S3904
9
MASTERS TWO STEP
$0.00
S3905
9
AUTO HANDHELD DIAG NERV TEST
$0.00
S3906
9
TRANSFUSION, DIRECT, BLOOD
$0.00
S4005
9
INTERIM LABOR FACILITY GLOBA
$0.00
S4011
9
IVF PACKAGE
$0.00
S4013
9
COMPL GIFT CASE RATE
$0.00
S4014
9
COMPL ZIFT CASE RATE
$0.00
S4015
9
COMPLETE IVF NOS CASE RATE
$0.00
S4016
9
FROZEN IVF CASE RATE
$0.00
S4017
9
IVF CANC A STIM CASE RATE
$0.00
S4018
9
F EMB TRNS CANC CASE RATE
$0.00
S4020
9
IVF CANC A ASPIR CASE RATE
$0.00
S4021
9
IVF CANC P ASPIR CASE RATE
$0.00
S4022
9
ASST OOCYTE FERT CASE RATE
$0.00
S4023
9
INCOMPL DONOR EGG CASE RATE
$0.00
S4025
9
DONOR SERV IVF CASE RATE
$0.00
S4026
9
PROCURE DONOR SPERM
$0.00
S4027
9
STORE PREV FROZ EMBRYOS
$0.00
S4028
9
MICROSURG EPI SPERM ASP
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
S4030
9
SPERM PROCURE INIT VISIT
$0.00
S4031
9
SPERM PROCURE SUBS VISIT
$0.00
S4035
9
STIMULATED IUI CASE RATE
$0.00
S4036
O
INTRAVAG CULT CASE RATE
$0.00
S4037
9
CRYO EMBRYO TRANSF CASE RATE
$0.00
S4040
9
MONIT STORE CRYO EMBRYO 30 D
$0.00
S4042
9
OVULATION MGMT PER CYCLE
$0.00
S4386
O
EARLY INTERVENTION
$0.00
S4516
O
MULTI-DISCIPLINARY ASSESSMENT/EVALU
$0.00
S4518
5
ENVIROMENTAL LEAD TESTING
$0.00
S4981
9
INSERT LEVONORGESTREL IUS
$0.00
S4989
9
CONTRACEPT IUD
$0.00
S4990
9
NICOTINE PATCH LEGEND
$0.00
S4991
9
NICOTINE PATCH NONLEGEND
$0.00
S4993
9
CONTRACEPTIVE PILLS FOR BC
$0.00
S4995
9
SMOKING CESSATION GUM
$0.00
S5000
9
PRESCRIPTION DRUG, GENERIC
$0.00
S5001
9
PRESCRIPTION DRUG,BRAND NAME
$0.00
S5002
9
FAT EMULSION 10% IN 250 ML
$0.00
S5003
9
FAT EMULSION 20% IN 250 ML
$0.00
S5010
9
5% DEXTROSE AND 0.45% SALINE
$0.00
S5011
9
5% DEXTROSE IN LACTATED RING
$0.00
S5012
9
5% DEXTROSE WITH POTASSIUM
$0.00
S5013
9
5%DEXTROSE/0.45%SALINE1000ML
$0.00
S5014
9
D5W/0.45NS W KCL AND MGS04
$0.00
S5016
9
ANTIBIOTIC ADMIN SUPPLIES W/
$0.00
S5017
9
ANTIBIOTIC ADMINSUPPLIES W/O
$0.00
S5018
9
PAIN THERAPY ADMIN SUPPLIES
$0.00
S5019
9
CHEMOTHERAPY ADMIN SUPPLIES
$0.00
S5020
9
CHEMOTHERAPY ADMIN SUPPLIES
$0.00
S5021
9
HYDRATION THERAPY ADMIN SUPP
$0.00
S5022
9
GROWTH HORMONE THERAPY
$0.00
S5025
9
INFUSION PUMP RENTAL,PERDIEM
$0.00
S5035
9
HIT ROUTINE DEVICE MAINT
$0.00
S5036
9
HIT DEVICE REPAIR
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
S5100
9
ADULT DAYCARE SERVICES 15 MIN
$0.00
S5101
7
ADULT DAY CARE PER HALF DAY
$0.00
S5102
7
ADULY DAY CARE PER DIEM
$0.00
S5105
7
CENTERBASED DAYCARE PERDIEM
$0.00
S5108
9
HOMECARE TRAIN PT 15 MIN
$0.00
S5109
9
HOMECARE TRAIN PT SESSION
$0.00
S5110
9
FAMILY HOMECARE TRAINING 15M
$0.00
S5111
9
FAMILY HOMECARE TRAIN SESSION
$0.00
S5115
9
NONFAMILY HOMECARE TRAIN 15M
$0.00
S5116
9
NON FAMILY HC TRAIN SESSION
$0.00
S5120
9
CHORE SERVICES PER 15 MIN
$0.00
S5121
9
CHORE SERVICES PER DIEM
$0.00
S5125
9
ATTENDANT CARE SERVICES 15 M
$0.00
S5126
9
ATTENDANT CARE SERVICE 15M
$0.00
S5130
7
HOMAKER SERVICE NOS PER 15M
$0.00
S5131
9
HOMEMAKER SERVICE NOS PER 15 M
$0.00
S5135
9
ADULT COMPANION CARE PER 15M
$0.00
S5136
9
ADULT COMPANION CARE PER DIEM
$0.00
S5140
7
ADULT FOSTER CARE PER DIEM
$0.00
S5141
9
ADULT FOSTER CARE PER MONTH
$0.00
S5145
7
CHILD FOSTERCARE TH PER DIEM
$0.00
S5146
9
THER FOSTERCARE CHILD MONTH
$0.00
S5150
9
UNSKILLED RESPITE CARE 15M
$0.00
S5151
9
UNSKILLED RESPIT CARE DIEM
$0.00
S5160
7
EMERGENCY RESPONSE SYSTEM ERS INST
$0.00
S5161
7
EMERGENCY RESPONSE SYSTEM ERS PER
$0.00
S5162
7
EMERGENCY RESPONSE SYSTEM PURCHASE
$0.00
S5165
5
HOME MODIFICATIONS PER SERV
$0.00
S5170
9
HOMEDELIVERED PREPARED MEAL
$0.00
S5175
9
LAUNDRY SERV EXT PROF ORDER
$0.00
S5180
9
HH RESPIRATORY THRPY IN EVAL
$0.00
S5181
9
HH RESIRATORY THRPY NOS DAY
$0.00
S5185
9
MED REMINDER SER PER MONTH
$0.00
S5190
6
WELLNESS ASSESSMENT BY NONPH
$0.00
S5199
9
PERSONAL CARE ITEM NOS EACH
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
S5497
9
HIT CATH CARE NOC
$0.00
S5498
9
HIT SIMPLE CATH CARE
$0.00
S5501
9
HIT COMPLEX CATH CARE
$0.00
S5502
9
HIT INTERIM CATH CARE
$0.00
S5503
9
MAINTENANCE OF IMPLANTED VAS
$0.00
S5517
9
HIT DECLOTTING KIT
$0.00
S5518
9
HIT CATH REPAIR KIT
$0.00
S5520
9
HIT PICC INSERT KIT
$0.00
S5521
9
HIT MIDLINE CATH INSERT KIT
$0.00
S5522
9
HIT PICC INSERT NO SUPP
$0.00
S5523
9
HIP MIDLINE CATH INSERT KIT
$0.00
S5550
6
INSULIN RAPID 5 U
$0.00
S5551
6
INSULIN MOST RAPID 5 U
$0.00
S5552
6
INSULIN INTERMED 5 U
$0.00
S5553
6
INSULIN LONG ACTING 5 U
$0.00
S5560
6
INSULIN REUSE PEN 1.5 ML
$0.00
S5561
6
INSULIN REUSE PEN 3 ML
$0.00
S5565
9
INSULIN CARTRIDGE 150 U
$0.00
S5566
9
INSULIN CARTRIDGE 300 U
$0.00
S5570
9
INSULIN DISPOS PEN 1.5 ML
$0.00
S5571
9
INSULIN DISPOS PEN 3 ML
$0.00
S8001
9
RADIOFREQUENCY STIMULATION
$0.00
S8004
O
WHOLEBODY RADIOPHARM TRGCELL
$0.00
S8030
9
TANTALUM RING APPLICATION
$0.00
S8035
9
MAGNETIC SOURCE IMAGING
$0.00
S8037
9
MRCP
$0.00
S8040
9
TOPOGRAPHIC BRAIN MAPPING
$0.00
S8042
5
MRI LOW FIELD
$0.00
S8048
9
ISOLATED LIMB PERFUSION
$0.00
S8049
9
INTRAOPERATIVE RADIATION THE
$0.00
S8055
9
US GUIDANCE FETAL REDUCT
$0.00
S8060
9
SUPPLY OF CONTRAST MATERIAL
$0.00
S8075
O
CAD OF DIGITAL MAMMOGR
$0.00
S8080
9
SCINTIMAMMOGRAPHY
$0.00
S8085
9
FLUORINE-18 FLUORODEOXYGLUCO
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
S8092
9
ELECTRON BEAM COMPUTED TOMOG
$0.00
S8093
O
CT ANGIOGRAPHY CORONARY
$0.00
S8095
O
WIG (FOR MEDICALLY-INDUCED H
$0.00
S8096
9
PORTABLE PEAK FLOW METER
$0.00
S8097
9
ASTHMA KIT
$0.00
S8100
9
SPACER WITHOUT MASK
$0.00
S8101
9
SPACER WITH MASK
$0.00
S8105
O
OXIMETER FOR MEASURING BLOOD
$0.00
S8110
9
PEAK EXPIRATORY FLOW RATE (P
$0.00
S8120
9
O2 CONTENTS GAS CUBIC FT
$0.00
S8121
9
O2 CONTENTS LIQUID LB
$0.00
S8180
O
TRACH SHOWER PROTECTOR
$0.00
S8181
O
TRACH TUBE HOLDER
$0.00
S8182
O
HUMIDIFIER NON-SERVO
$0.00
S8183
O
HUMIDIFIER DUAL SERVO
$0.00
S8185
9
FLUTTER DEVICE
$0.00
S8186
9
SWIVEL ADAPTOR
$0.00
S8189
9
TRACH SUPPLY NOC
$0.00
S8190
9
ELECTRONIC SPIROMETER
$0.00
S8200
9
CHEST COMPRESSION VEST
$0.00
S8205
9
CHEST COMPRESSION SYSTEM GEN
$0.00
S8210
9
MUCUS TRAP
$0.00
S8260
O
ORAL ORTHOTIC FOR TREATMENT
$0.00
S8262
5
MANDIB ORTHO REPOS DEVICE
$0.00
S8265
5
HABERMAN FEEDER
$0.00
S8270
9
ENURESIS ALARM
$0.00
S8300
9
SACRAL NERVE STIMULATION TES
$0.00
S8301
9
INFECT CONTROL SUPPLIES NOS
$0.00
S8400
9
INCONTINENCE PANTS, EACH
$0.00
S8401
O
CHILD-SIZE DIAPER
$0.00
S8402
9
DIAPERS, EACH
$0.00
S8403
O
ADULT-SIZE PULL-UP BRIEF
$0.00
S8404
9
CHILD-SIZE PULL-UP BRIEF
$0.00
S8405
O
INCONTINENCE LINERS, EACH
$0.00
S8415
9
SUPPLIES FOR HOME DELIVERY
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
S8420
9
CUSTOM GRADIENT SLEEV/GLOV
$0.00
S8421
9
READY GRADIENT SLEEV/GLOV
$0.00
S8422
9
CUSTOM GRAD SLEEVE MED
$0.00
S8423
9
CUSTOM GRAD SLEEVE HEAVY
$0.00
S8424
9
READY GRADIENT SLEEVE
$0.00
S8425
9
CUSTOM GRAD GLOVE MED
$0.00
S8426
9
CUSTOM GRAD GLOVE HEAVY
$0.00
S8427
9
READY GRADIENT GLOVE
$0.00
S8428
9
READY GRADIENT GAUNTLET
$0.00
S8429
9
GRADIENT PRESSURE WRAP
$0.00
S8430
9
PADDING FOR COMPRSSN BDG
$0.00
S8431
9
COMPRESSION BANDAGE
$0.00
S8433
O
SKIN SUPPORT/BREAST PROSTH
$0.00
S8450
9
SPLINT DIGIT
$0.00
S8451
9
SPLINT WRIST OR ANKLE
$0.00
S8452
9
SPLINT ELBOW
$0.00
S8460
9
CAMISOLE POST-MAST
$0.00
S8490
9
100 INSULIN SYRINGES
$0.00
S8940
9
HIPPOTHERAPY PER SESSION
$0.00
S8945
O
PT PHONOPHORESIS 30 MINS
$0.00
S8948
6
LOW-LEVEL LASER TRMT 15 MIN
$0.00
S8950
9
COMPLEX LYMPHEDEMA THERAPY,
$0.00
S8990
9
PT OR MANIP FOR MAINT
$0.00
S8999
9
RESUSCITATION BAG
$0.00
S9001
9
HOME UTERINE MONITOR WITH OR
$0.00
S9007
9
ULTRAFILTRATION MONITOR
$0.00
S9015
9
AUTOMATED EEG MONITORING
$0.00
S9022
O
DIGITAL SUBTRACTION ANGIOGRA
$0.00
S9023
9
XENON REGIONAL CEREBRAL BLOO
$0.00
S9024
9
PARANASAL SINUS ULTRASOUND
$0.00
S9025
9
OMNICARDIOGRAM/CARDIOINTEGRA
$0.00
S9033
9
GAIT ANALYSIS
$0.00
S9034
5
ESWL FOR GALLSTONES
$0.00
S9035
9
MEDICAL EQUIPMENT OR SUPPLIE
$0.00
S9055
9
PROCUREN OR OTHER GROWTH FAC
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
S9056
9
COMA STIMULATION PER DIEM
$0.00
S9061
9
MEDICAL SUPPLIES AND EQUIPME
$0.00
S9075
9
SMOKING CESSATION TREATMENT
$0.00
S9083
7
URGENT CARE CENTER GLOBAL
$0.00
S9085
9
MENISCAL ALLOGRAFT TRANSPLAN
$0.00
S9088
9
SERVICES PROVIDED IN URGENT
$0.00
S9090
9
VERTEBRAL AXIAL DECOMPRESSIO
$0.00
S9092
O
CANOLITH REPOSITIONING
$0.00
S9097
9
HOME VISIT WOUND CARE
$0.00
S9098
9
HOME PHOTOTHERAPY VISIT
$0.00
S9105
5
EVALUATION BY OCULARIST
$0.00
S9109
9
CHF TELEMONITORING MONTH
$0.00
S9117
9
BACK SCHOOL VISIT
$0.00
S9122
7
HOME HEALTH AIDE OR CERTIFIE
$0.00
S9123
3
NURSING CARE IN HOME RN
$51.50
S9124
3
NURSING CARE, IN THE HOME; B
$46.14
S9125
7
RESPITE CARE, IN THE HOME, P
$0.00
S9126
9
HOSPICE CARE, IN THE HOME, P
$0.00
S9127
7
SOCIAL WORK VISIT, IN THE HO
$0.00
S9128
3
SPEECH THERAPY, IN THE HOME,
$43.50
S9129
3
OCCUPATIONAL THERAPY, IN THE
$43.50
S9131
3
PT IN THE HOME PER DIEM
$43.50
S9140
9
DIABETIC MANAGEMENT PROGRAM,
$0.00
S9141
9
DIABETIC MANAGEMENT PROGRAM,
$0.00
S9145
5
INSULIN PUMP INITIATION
$0.00
S9152
9
SPEECH THERAPY, RE-EVAL
$0.00
S9200
9
NURSING SERVICES AND ALL NEC
$0.00
S9208
9
HOME MGMT PRETERM LABOR
$0.00
S9209
9
HOME MGMT PPROM
$0.00
S9210
9
NURSING SERVICES AND ALL NEC
$0.00
S9211
5
HOME MGMT GEST HYPERTENSION
$0.00
S9212
9
HM POSTPAR HYPER PER DIEM
$0.00
S9213
9
HM PREECLAMP PER DIEM
$0.00
S9214
9
HM GEST DM PER DIEM
$0.00
S9216
9
GEST HYPER W NURS DIEM
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
S9217
9
POSTPAR HYPER W NURS DIEM
$0.00
S9218
9
PREECLAMP W NURS DIEM
$0.00
S9220
9
NURSING SERVICES AND ALL NEC
$0.00
S9225
9
NURSING SERVICES AND ALL NEC
$0.00
S9230
9
NURSING SERVICES AND ALL NEC
$0.00
S9300
9
NURSING SERVICES AND ALL NEC
$0.00
S9308
9
NURSING SERVICES AND ALL NEC
$0.00
S9310
9
NURSING SERVICES AND ALL NEC
$0.00
S9325
9
HIT PAIN MGMT PER DIEM
$0.00
S9326
9
HIT CONT PAIN PER DIEM
$0.00
S9327
9
HIT INT PAIN PER DIEM
$0.00
S9328
9
HIT PAIN IMP PUMP DIEM
$0.00
S9329
9
HIT CHEMO PER DIEM
$0.00
S9330
9
HIT CONT CHEM DIEM
$0.00
S9331
9
HIT INTERMIT CHEMO DIEM
$0.00
S9335
9
HT HEMODIALYSIS DIEM
$0.00
S9336
9
HIT CONT ANTICOAG DIEM
$0.00
S9338
9
HIT IMMUNOTHERAPY DIEM
$0.00
S9339
9
HIT PERITON DIALYSIS DIEM
$0.00
S9340
9
HIT ENTERAL PER DIEM
$0.00
S9341
9
HIT ENTERAL GRAV DIEM
$0.00
S9342
9
HIT ENTERAL PUMP DIEM
$0.00
S9343
9
HIT ENTERAL BOLUS NURS
$0.00
S9345
9
HIT ANTI-HEMOPHIL DIEM
$0.00
S9346
9
HIT ALPHA-1-PROTEINAS DIEM
$0.00
S9347
9
HIT LONGTERM INFUSION DIEM
$0.00
S9348
9
HIT SYMPATHOMIM DIEM
$0.00
S9349
9
HIT TOCOLYSIS DIEM
$0.00
S9351
9
HIT CONT ANTIEMETIC DIEM
$0.00
S9353
9
HIT CONT INSULIN DIEM
$0.00
S9355
9
HIT CHELATION DIEM
$0.00
S9357
9
HIT ENZYME REPLACE DIEM
$0.00
S9359
9
HIT ANTI-TNF PER DIEM
$0.00
S9361
9
HIT DIURETIC INFUS DIEM
$0.00
S9363
9
HIT ANTI-SPASMOTIC DIEM
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
S9364
9
HIT TPN TOTAL DIEM
$0.00
S9365
9
HIT TPN 1 LITER DIEM
$0.00
S9366
9
HIT TPN 2 LITER DIEM
$0.00
S9367
9
HIT TPN 3 LITER DIEM
$0.00
S9368
9
HIT TPN OVER 3L DIEM
$0.00
S9370
9
HT INJ ANTIEMETIC DIEM
$0.00
S9372
9
HT INJ ANTICOAG DIEM
$0.00
S9373
9
HIT HYDRA TOTAL DIEM
$0.00
S9374
9
HIT HYDRA 1 LITER DIEM
$0.00
S9375
9
HIT HYDRA 2 LITER DIEM
$0.00
S9376
9
HIT HYDRA 3 LITER DIEM
$0.00
S9377
9
HIT HYDRA OVER 3L DIEM
$0.00
S9379
9
HIT NOC PER DIEM
$0.00
S9381
9
HIT HIGH RISK/ESCORT
$0.00
S9395
9
NURSING SERVICES AND ALL NEC
$0.00
S9401
9
ANTICOAG CLINIC PER SESSION
$0.00
S9420
9
NURSING SERVICES AND ALL NEC
$0.00
S9423
9
NURSING SERVICES, PATIENT AS
$0.00
S9425
9
NURSING SERVICES AND ALL NEC
$0.00
S9430
9
PHARMACY COMP/DISP SERV
$0.00
S9433
9
MEDICAL FOOD ORAL 100% NUTR
$0.00
S9434
6
MOD SOLID FOOD SUPPL
$0.00
S9435
9
MEDICAL FOODS FOR INBORN ERR
$0.00
S9436
9
LAMAZE CLASS
$0.00
S9437
9
CHILDBIRTH REFRESHER CLASS
$0.00
S9438
9
CESAREAN BIRTH CLASS
$0.00
S9439
9
VBAC CLASS
$0.00
S9441
9
ASTHMA EDUCATION
$0.00
S9442
9
BIRTHING CLASS
$0.00
S9443
9
LACTATION CLASS
$0.00
S9444
9
PARENTING CLASS
$0.00
S9445
7
PT EDUCATION NOC INDIVID
$0.00
S9446
9
PT EDUCATION NOC GROUP
$0.00
S9447
9
INFANT SAFETY CLASS
$0.00
S9449
9
WEIGHT MGMT CLASS
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
S9451
9
EXERCISE CLASS
$0.00
S9452
9
NUTRITION CLASS
$0.00
S9453
9
SMOKING CESSATION CLASS
$0.00
S9454
9
STRESS MGMT CLASS
$0.00
S9455
9
DIABETIC MANAGEMENT PROGRAM,
$0.00
S9460
9
DIABETIC MANAGEMENT PROGRAM,
$0.00
S9465
9
DIABETIC MANAGEMENT PROGRAM,
$0.00
S9470
3
NUTRITIONAL COUNSELING, DIET
$44.00
S9472
9
CARDIAC REHABILITATION PROGR
$0.00
S9473
9
PULMONARY REHABILITATION PRO
$0.00
S9474
9
ENTEROSTOMAL THERAPY BY A RE
$0.00
S9475
9
AMBULATORY SETTING SUBSTANCE
$0.00
S9476
9
VESTIBULAR REHAB PER DIEM
$0.00
S9480
9
INTENSIVE OUTPATIENT PSYCHIA
$0.00
S9482
9
FAMILY STABILIZATION 15 MIN
$0.00
S9484
7
CRISIS INTERVENTION PER HOUR
$0.00
S9485
9
CRISIS INTERVENTION MENTAL H
$0.00
S9490
9
HIT CORTICOSEROID DIEM
$0.00
S9494
9
HIT ANTIBIOTIC TOTAL DIEM
$0.00
S9497
9
HIT ANTIBIOTIC Q3H DIEM
$0.00
S9500
9
HIT ANTIBIOTIC Q24H DIEM
$0.00
S9501
9
HIT ANTIBIOTIC Q12H DIEM
$0.00
S9502
9
HIT ANTIBIOTIC Q8H DIEM
$0.00
S9503
9
HIT ANTIBIOTIC Q6H DIEM
$0.00
S9504
9
HIT ANTIBIOTIC Q4H DIEM
$0.00
S9524
O
NURSING SERVICES RELATED TO
$0.00
S9526
9
SKILLED NURSING VISITS FOR
$0.00
S9527
9
INSERTION OF A PERIPHERALLY
$0.00
S9528
9
INSERTION OF MIDLINE CENTRAL
$0.00
S9529
9
VENIPUNCTURE HOME/SNF
$0.00
S9533
9
PAIN MANAGEMENT, INTRAVENOUS
$0.00
S9535
9
ADMINISTRATION OF HEMATOPOIE
$0.00
S9537
9
HT HEM HORM INJ DIEM
$0.00
S9538
9
HIT BLOOD PRODUCTS DIEM
$0.00
S9539
9
ADMINISTRATION OF ANTIBIOTIC
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
S9542
9
HT INJ NOC PER DIEM
$0.00
S9543
O
ADMINISTRATION OF MEDICATION
$0.00
S9545
9
ADMINISTRATION OF IMMUNE GLO
$0.00
S9546
O
HOME INF BLOOD PROD NURS SER
$0.00
S9550
9
HOME IV THERAPY, HYDRATION
$0.00
S9555
9
ADDITIONAL HOME INFUSION
$0.00
S9558
9
HT INJ GROWTH HORM DIEM
$0.00
S9559
9
HIT INJ INTERFERON DIEM
$0.00
S9560
9
HT INJ HORMONE DIEM
$0.00
S9562
9
PALIVIZUMAB HOME INJ PERDIEM
$0.00
S9590
9
IN HOME IRRIGATION THERAPY
$0.00
S9800
9
HT RN PER HOUR
$0.00
S9802
O
SPECIALTY DRUG ADMIN/NSG SRV
$0.00
S9803
O
EACH ADDITIONAL HOUR
$0.00
S9806
O
RN INFUSION SUITE VISIT
$0.00
S9810
9
HT PHARM PER HOUR
$0.00
S9900
9
CHRISTIAN SCI PRACT VISIT
$0.00
S9970
9
HEALTH CLUB MEMBERSHIP YR
$0.00
S9975
9
TRANSPLANT RELATED PER DIEM
$0.00
S9976
9
LODGING PER DIEM
$0.00
S9977
9
MEALS PER DIEM
$0.00
S9981
9
MED RECORD COPY ADMIN
$0.00
S9982
9
MED RECORD COPY PER PAGE
$0.00
S9986
9
NOT MEDICALLY NECESSARY SVC
$0.00
S9988
9
SERV PART OF PHASE I TRIAL
$0.00
S9989
9
SERVICES OUTSIDE US
$0.00
S9990
9
SERVICES PROVIDED AS PART OF
$0.00
S9991
9
SERVICES PROVIDED AS PART OF
$0.00
S9992
9
TRANSPORTATION COSTS TO AND
$0.00
S9994
9
LODGING COSTS (E.G. HOTEL CH
$0.00
S9996
9
MEALS FOR CLINICAL TRIAL PAR
$0.00
S9999
9
SALES TAX
$0.00
SARCW
O
MCO SPECIFIC CODE: SMART START SUBS
$0.00
SARRN
O
MCO SPECIFIC CODE: SMART START SUBS
$0.00
SARSW
O
MCO SPECIFIC CODE: SMART START SUBS
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
T1000
7
PRIVATE DUTY/INDEPENDENT NSG
$0.00
T1001
7
NURSING ASSESSMENT/EVALUATN
$0.00
T1002
3
RN SERVICES UP TO 15 MINUTES
$19.00
T1003
9
LPN/LVN SERVICES UP TO 15MIN
$0.00
T1004
9
NSG AIDE SERVICE UP TO 15MIN
$0.00
T1005
7
RESPITE CARE SERVICE 15 MIN
$0.00
T1006
9
FAMILY/COUPLE COUNSELING
$0.00
T1007
9
TREATMENT PLAN DEVELOPMENT
$0.00
T1008
O
DAY TREATMENT FOR INDIVIDUAL
$0.00
T1009
9
CHILD SITTING SERVICES
$0.00
T1010
9
MEALS WHEN RECEIVE SERVICES
$0.00
T1011
O
ALCOHOL/SUBSTANCE ABUSE NOC
$0.00
T1012
9
ALCOHOL/SUBSTANCE ABUSE SKIL
$0.00
T1013
9
SIGN LANG/ORAL INTERPRETER
$0.00
T1014
9
TELEHEALTH TRANSMIT, PER MIN
$0.00
T1015
9
CLINIC SERVICE
$0.00
T1016
9
CASE MANAGEMENT
$0.00
T1017
9
TARGETED CASE MANAGEMENT
$0.00
T1018
9
SCHOOL-BASED IEP SER BUNDLED
$0.00
T1019
9
PERSONAL CARE SER PER 15 MIN
$0.00
T1020
9
PERSONAL CARE SER PER DIEM
$0.00
T1021
9
HH AIDE OR CN AIDE PER VISIT
$0.00
T1022
9
CONTRACTED SERVICES PER DAY
$0.00
T1023
7
PROGRAM INTAKE ASSESSMENT
$0.00
T1024
3
TEAM EVALUATION & MANAGEMENT
T1025
9
PED COMPR CARE PKG, PER DIEM
$0.00
T1026
9
PED COMPR CARE PKG, PER HOUR
$0.00
T1027
9
FAMILY TRAINING & COUNSELING
$0.00
T1028
9
HOME ENVIRONMENT ASSESSMENT
$0.00
T1029
5
DWELLING LEAD INVESTIGATION
$0.00
T1030
9
RN HOME CARE PER DIEM
$0.00
T1031
9
LPN HOME CARE PER DIEM
$0.00
T1500
O
REUSABLE DIAPER/PANT
$0.00
T1502
9
MEDICATION ADMIN VISIT
$0.00
T1503
9
MED ADMIN, NOT ORAL/INJECT
$0.00
$1,429.81
Procedure Code Pricing Action Code Description
Maximum Allowable
T1999
9
NOC RETAIL ITEMS ANDSUPPLIES
$0.00
T2001
3
NONEMERGENCY TRANSPORTATION ATTEND
T2002
7
N-ET; PER DIEM
T2003
3
NON-EMERGENCY TRANSPORTATION; ENCOU
T2004
9
N-ET; COMMERC CARRIER PASS
$0.00
T2005
9
N-ET; STRETCHER VAN
$0.00
T2006
O
AMB RESPONSE & TRT, NO TRANS
$0.00
T2007
9
NON-EMER TRANSPORT WAIT TIME
$0.00
T2010
9
PASRR LEVEL I
$0.00
T2011
9
PASRR LEVEL II
$0.00
T2012
9
HABIL. ED. WAIVER; PER DIEM
$0.00
T2013
9
HABIL. ED. WAIVER, PER HOUR
$0.00
T2014
7
HABIL. PREVOC WAIVER, PER D
$0.00
T2015
7
HABIL. PREVOC WAIVER PER HR
$0.00
T2016
7
HABIL., RES. WAIVER PER DIEM
$0.00
T2017
9
HABIL., RES. WAIVER 15 MIN
$0.00
T2018
7
HABIL. SUP EMPL WAIVER/DAY
$0.00
T2019
9
HABIL. SUP EMPL WAIVER 15 MIN
$0.00
T2020
7
DAY HABIL WAIVER PER DIEM
$0.00
T2021
7
DAY HABIL WAIVER PER 15 MIN
$0.00
T2022
7
CASE MANAGEMENT, PER MONTH
$0.00
T2023
9
TARGETED CASE MGMT PER MONTH
$0.00
T2024
9
SERV ASMNT/CARE PLAN WAIVER
$0.00
T2025
7
WAIVER SERVICE, NOS
$0.00
T2026
9
SPECIAL CHILDCARE WAIVER/D
$0.00
T2027
9
SPEC CHILDCARE WAIVER 15 MIN
$0.00
T2028
9
SPECIAL SUPPLY, NOS WAIVER
$0.00
T2029
9
SPECIAL MED EQUIP, NOS WAIVER
$0.00
T2030
9
ASSIST LIVING WAIVER/MONTH
$0.00
T2031
9
ASSIST LIVING WAIVER/D
$0.00
T2032
9
RES CARE, NOS WAIVER/MONTH
$0.00
T2033
7
RES, NOS WAIVER PER DIEM
$0.00
T2034
9
CRISIS INTERVEN WAIVER/D
$0.00
T2035
9
UTILITY SERVICES WAIVER
$0.00
T2036
9
CAMP OVERNITE WAIVER/SESSION
$0.00
$10.10 $0.00 $10.10
Procedure Code Pricing Action Code Description
Maximum Allowable
T2037
9
CAMP DAY WAIVER/SESSION
$0.00
T2038
9
COMM TRANS WAIVER/SERVICE
$0.00
T2039
9
VEHICLE MOD WAIVER/SERVICE
$0.00
T2040
9
FINANCIAL MGT WAIVER/15 MIN
$0.00
T2041
9
SUPPORT BROKER WAIVER/15 MIN
$0.00
T2042
9
HOSPICE ROUTINE HOME CARE
$0.00
T2043
9
HOSPICE CONTINUOUS HOME CARE
$0.00
T2044
9
HOSPICE RESPITE CARE
$0.00
T2045
9
HOSPICE GENERAL CARE
$0.00
T2046
9
HOSPICE LONG TERM CARE, R&B
$0.00
T2048
9
BH LTC RES R&B, PER DIEM
$0.00
T2049
9
N-ET; STRETCHER VAN, MILEAGE
$0.00
T2101
9
BREAST MILK PROC/STORE/DIST
$0.00
T4521
3
ADULT SIZE BRIEF/DIAPER SM
$0.50
T4522
3
ADULT SIZE BRIEF/DIAPER MED
$0.50
T4523
3
ADULT SIZE BRIEF/DIAPER LG
$0.74
T4524
3
ADULT SIZE BRIEF/DIAPER XL
$0.88
T4525
3
ADULT SIZE PULL-ON SM
$0.50
T4526
3
ADULT SIZE PULL-ON MED
$0.50
T4527
3
ADULT SIZE PULL-ON LG
$0.74
T4528
3
ADULT SIZE PULL-ON XL
$0.88
T4529
3
PED SIZE BRIEF/DIAPER SM/MED
$0.25
T4530
3
PED SIZE BRIEF/DIAPER LG
$0.37
T4531
3
PED SIZE PULL-ON SM/MED
$0.25
T4532
3
PED SIZE PULL-ON LG
$0.37
T4533
3
YOUTH SIZE BRIEF/DIAPER
$0.47
T4534
3
YOUTH SIZE PULL-ON
$0.47
T4535
3
DISPOSABLE LINER/SHIELD/PAD
$0.33
T4536
9
REUSABLE PULL-ON ANY SIZE
$0.00
T4537
9
REUSABLE UNDERPAD BED SIZE
$0.00
T4538
9
DIAPER SERV REUSABLE DIAPER
$0.00
T4539
9
REUSE DIAPER/BRIEF ANY SIZE
$0.00
T4540
9
REUSABLE UNDERPAD CHAIR SIZE
$0.00
T4541
3
LARGE DISPOSABLE UNDERPAD
$0.54
T4542
3
SMALL DISPOSABLE UNDERPAD
$0.20
Procedure Code Pricing Action Code Description
Maximum Allowable
T4543
6
DISP BARIATRIC BRIEF/DIAPER
$0.00
T5001
6
POSITION SEAT SPEC ORTH NEED
$0.00
T5999
9
SUPPLY, NOS
$0.00
TBEVL
O
MCO SPECIFIC CODE: DPH INITIAL EVAL
$0.00
TBTXA
O
MCO SPECIFIC CODE: DPH TB TREATMENT
$0.00
TBTXS
O
MCO SPECIFIC CODE: DPH TB TREATMENT
$0.00
TI10H
O
PART C SPECIFIC CODE: INTERPERIODIC
$0.00
TI11H
O
PART C SPECIFIC CODE: INTERPERIODIC
$0.00
TI12H
O
PART C SPECIFIC CODE: INTERPERIODIC
$0.00
TI13H
7
PART C SPECIFIC CODE: INTERPERIODIC
$0.00
TI420
O
MCO SPECIFIC CODE: INTERPERIODIC CO
$0.00
TI42H
O
INTERPERIODIC CONSULTATION BY A PHY
$0.00
TI430
O
MCO SPECIFIC CODE: INTERPERIODIC CO
$0.00
TI43H
O
INTERPERIODIC CONSULTATION BY A OCC
$0.00
TI440
O
MCO SPECIFIC CODE: INTERPERIODIC CO
$0.00
TI44H
O
INTERPERIODIC CONSULTATION BY A SPE
$0.00
TV10H
O
PART C SPECIFIC CODE: TREATMENT VIS
$0.00
TV11H
O
PART C SPECIFIC CODE: TREATMENT VIS
$0.00
TV12H
O
PART C SPECIFIC CODE: TREATMENT VIS
$0.00
TV420
O
MCO SPECIFIC CODE: TRANSDISCIPLINAR
$0.00
TV42H
O
TRANSDISCIPLINARY VISIT BY A PHYSIC
$0.00
TV430
O
MCO SPECIFIC CODE: TRANSDISCIPLINAR
$0.00
TV43H
O
TRANSDISCIPLINARY VISIT BY A OCCUPA
$0.00
TV440
O
MCO SPECIFIC CODE: TRANSDISCIPLINAR
$0.00
TV44H
O
TRANSDISCIPLINARY VISIT BY A SPEECH
$0.00
V2020
3
VISION SVCS FRAMES PURCHASES
V2025
6
EYEGLASSES DELUX FRAMES
V2100
3
LENS SPHER SINGLE PLANO 4.00
$38.15
V2101
3
SINGLE VISN SPHERE 4.12-7.00
$40.00
V2102
3
SINGL VISN SPHERE 7.12-20.00
$58.93
V2103
3
SPHEROCYLINDR 4.00D/12-2.00D
$35.97
V2104
3
SPHEROCYLINDR 4.00D/2.12-4D
$38.98
V2105
3
SPHEROCYLINDER 4.00D/4.25-6D
$43.37
V2106
3
SPHEROCYLINDER 4.00D/>6.00D
$48.13
V2107
3
SPHEROCYLINDER 4.25D/12-2D
$44.62
$49.74 $0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
V2108
3
SPHEROCYLINDER 4.25D/2.12-4D
$47.40
V2109
3
SPHEROCYLINDER 4.25D/4.25-6D
$52.44
V2110
3
SPHEROCYLINDER 4.25D/OVER 6D
$51.74
V2111
3
SPHEROCYLINDR 7.25D/.25-2.25
$53.06
V2112
3
SPHEROCYLINDR 7.25D/2.25-4D
$58.86
V2113
3
SPHEROCYLINDR 7.25D/4.25-6D
$1.79
V2114
3
SPHEROCYLINDER OVER 12.00D
$71.89
V2115
3
LENS LENTICULAR BIFOCAL
$63.63
V2116
O
NONASPHERIC LENS BIFOCAL
$0.00
V2117
O
ASPHERIC LENS BIFOCAL
$0.00
V2118
3
LENS ANISEIKONIC SINGLE
$77.56
V2121
6
LENTICULAR LENS, SINGLE
$0.00
V2199
6
LENS SINGLE VISION NOT OTH C
$0.00
V2200
3
LENS SPHER BIFOC PLANO 4.00D
$52.57
V2201
3
LENS SPHERE BIFOCAL 4.12-7.0
$57.57
V2202
3
LENS SPHERE BIFOCAL 7.12-20.
$69.55
V2203
3
LENS SPHCYL BIFOCAL 4.00D/.1
$54.25
V2204
3
LENS SPHCY BIFOCAL 4.00D/2.1
$57.19
V2205
3
LENS SPHCY BIFOCAL 4.00D/4.2
$61.83
V2206
3
LENS SPHCY BIFOCAL 4.00D/OVE
$66.43
V2207
3
LENS SPHCY BIFOCAL 4.25-7D/.
$58.71
V2208
3
LENS SPHCY BIFOCAL 4.25-7/2.
$62.97
V2209
3
LENS SPHCY BIFOCAL 4.25-7/4.
$67.36
V2210
3
LENS SPHCY BIFOCAL 4.25-7/OV
$75.32
V2211
3
LENS SPHCY BIFO 7.25-12/.25-
$72.60
V2212
3
LENS SPHCYL BIFO 7.25-12/2.2
$72.60
V2213
3
LENS SPHCYL BIFO 7.25-12/4.2
$68.64
V2214
3
LENS SPHCYL BIFOCAL OVER 12.
$88.57
V2215
3
LENS LENTICULAR BIFOCAL
$75.38
V2216
O
LENS LENTICULAR NONASPHERIC
$0.00
V2217
O
LENS LENTICULAR ASPHERIC BIF
$0.00
V2218
3
LENS ANISEIKONIC BIFOCAL
V2219
3
LENS BIFOCAL SEG WIDTH OVER
$47.09
V2220
3
LENS BIFOCAL ADD OVER 3.25D
$38.19
V2221
6
LENTICULAR LENS, BIFOCAL
$106.98
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
V2299
6
LENS BIFOCAL SPECIALITY
$0.00
V2300
3
LENS SPHERE TRIFOCAL 4.00D
$62.84
V2301
3
LENS SPHERE TRIFOCAL 4.12-7.
$73.64
V2302
3
LENS SPHERE TRIFOCAL 7.12-20
$86.73
V2303
3
LENS SPHCY TRIFOCAL 4.0/.12-
$57.57
V2304
3
LENS SPHCY TRIFOCAL 4.0/2.25
$67.29
V2305
3
LENS SPHCY TRIFOCAL 4.0/4.25
$77.94
V2306
3
LENS SPHCYL TRIFOCAL 4.00/>6
$82.73
V2307
3
LENS SPHCY TRIFOCAL 4.25-7/.
$76.36
V2308
3
LENS SPHC TRIFOCAL 4.25-7/2.
$79.36
V2309
3
LENS SPHC TRIFOCAL 4.25-7/4.
$82.96
V2310
3
LENS SPHC TRIFOCAL 4.25-7/>6
$88.00
V2311
3
LENS SPHC TRIFO 7.25-12/.25-
$79.49
V2312
3
LENS SPHC TRIFO 7.25-12/2.25
$79.95
V2313
3
LENS SPHC TRIFO 7.25-12/4.25
$82.94
V2314
3
LENS SPHCYL TRIFOCAL OVER 12
V2315
3
LENS LENTICULAR TRIFOCAL
V2316
O
LENS LENTICULAR NONASPHERIC
$0.00
V2317
O
LENS LENTICULAR ASPHERIC TRI
$0.00
V2318
3
LENS ANISEIKONIC TRIFOCAL
V2319
3
LENS TRIFOCAL SEG WIDTH > 28
$52.52
V2320
3
LENS TRIFOCAL ADD OVER 3.25D
$55.41
V2321
6
LENTICULAR LENS, TRIFOCAL
$0.00
V2399
6
LENS TRIFOCAL SPECIALITY
$0.00
V2410
3
LENS VARIAB ASPHERICITY SING
$82.58
V2430
3
LENS VARIABLE ASPHERICITY BI
$92.26
V2499
6
VARIABLE ASPHERICITY LENS
V2500
3
CONTACT LENS PMMA SPHERICAL
$85.97
V2501
3
CNTCT LENS PMMA-TORIC/PRISM
$116.84
V2502
3
CONTACT LENS PMMA BIFOCAL
$153.78
V2503
3
CNTCT LENS PMMA COLOR VISION
$148.27
V2510
3
CNTCT GAS PERMEABLE SPHERICL
$116.23
V2511
3
CNTCT TORIC PRISM BALLAST
$150.69
V2512
3
CNTCT LENS GAS PERMBL BIFOCL
$185.42
V2513
3
CONTACT LENS EXTENDED WEAR
$151.11
$106.56 $94.65
$148.07
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
V2520
3
CONTACT LENS HYDROPHILIC
$107.68
V2521
3
CNTCT LENS HYDROPHILIC TORIC
$169.90
V2522
3
CNTCT LENS HYDROPHIL BIFOCL
$151.60
V2523
3
CNTCT LENS HYDROPHIL EXTEND
$149.83
V2530
3
CONTACT LENS GAS IMPERMEABLE
$202.40
V2531
3
CONTACT LENS GAS PERMEABLE
$421.66
V2599
6
CONTACT LENS/ES OTHER TYPE
$0.00
V2600
6
HAND HELD LOW VISION AIDS
$0.00
V2610
6
SINGLE LENS SPECTACLE MOUNT
$0.00
V2615
6
TELESCOP/OTHR COMPOUND LENS
$0.00
V2620
9
PROSTHETIC, EYE, GLASS, STOCK
$0.00
V2621
9
PROSTHETIC, EYE PLASTIC, STOCK
$0.00
V2622
9
PROSTHETIC, EYE, GLASS, CUSTOM
$0.00
V2623
3
PLASTIC EYE PROSTH CUSTOM
V2624
3
POLISHING ARTIFICAL EYE
V2625
3
ENLARGEMNT OF EYE PROSTHESIS
$293.59
V2626
3
REDUCTION OF EYE PROSTHESIS
$158.26
V2627
3
SCLERAL COVER SHELL
$1,022.12
V2628
3
FABRICATION & FITTING
$241.34
V2629
6
PROSTHETIC EYE OTHER TYPE
$0.00
V2630
6
ANTER CHAMBER INTRAOCUL LENS
$0.00
V2631
6
IRIS SUPPORT INTRAOCLR LENS
$0.00
V2632
6
POST CHMBR INTRAOCULAR LENS
$0.00
V2700
3
BALANCE LENS
V2702
9
DELUXE LENS FEATURE
V2710
3
GLASS/PLASTIC SLAB OFF PRISM
V2715
3
PRISM LENS/ES
V2718
3
FRESNELL PRISM PRESS-ON LENS
$23.48
V2730
3
SPECIAL BASE CURVE
$16.73
V2740
O
ROSE TINT PLASTIC
$0.00
V2741
O
NON-ROSE TINT PLASTIC
$0.00
V2742
O
ROSE TINT GLASS
$0.00
V2743
O
NON-ROSE TINT GLASS
$0.00
V2744
5
TINT PHOTOCHROMATIC LENS/ES
$0.00
V2745
9
TINT, ANY COLOR/SOLID/GRAD
$0.00
$712.05 $64.39
$42.70 $0.00 $59.65 $9.76
Procedure Code Pricing Action Code Description
Maximum Allowable
V2750
5
ANTI-REFLECTIVE COATING
$0.00
V2755
9
UV LENS/ES
$0.00
V2756
9
EYE GLASS CASE
$0.00
V2760
3
SCRATCH RESISTANT COATING
V2761
9
MIRROR COATING
$0.00
V2762
9
POLARIZATION, ANY LENS
$0.00
V2770
9
OCCLUDER LENS/ES
$0.00
V2780
9
OVERSIZE LENS/ES
$0.00
V2781
9
PROGRESSIVE LENS PER LENS
$0.00
V2782
6
LENS, 1.54-1.65 P/1.60-1.79G
$0.00
V2783
6
LENS, >= 1.66 P/>=1.80 G
$0.00
V2784
3
LENS POLYCARB OR EQUAL
V2785
6
CORNEAL TISSUE PROCESSING
$0.00
V2786
9
OCCUPATIONAL MULTIFOCAL LENS
$0.00
V2787
9
ASTIGMATISM-CORRECT FUNCTION
$0.00
V2788
9
PRESBYOPIA-CORRECT FUNCTION
$0.00
V2790
6
AMNIOTIC MEMBRANE
$0.00
V2797
9
VIS ITEM/SVC IN OTHER CODE
$0.00
V2799
6
MISCELLANEOUS VISION SERVICE
$0.00
V5000
9
BASIC AUDIOLOGIC ASSESSMENT - HEARI
$0.00
V5001
9
COMPREHENSIVE AUDIOLOGIC ASSESSMENT
$0.00
V5002
9
ASSESSMENT OF VESTIBULAR AND/OR AUD
$0.00
V5003
9
ASSESSMENT OF VESTIBULAR AND/OR AUD
$0.00
V5008
3
HEARING SCREENING
V5010
9
ASSESSMENT FOR HEARING AID
$0.00
V5011
9
HEARING AID FITTING/CHECKING
$0.00
V5012
9
COMPLETE COCHLEAR IMPLANT REHABILIT
$0.00
V5014
5
HEARING AID REPAIR/MODIFYING
$0.00
V5016
9
UNLISTED AUDIOLOGIC PROCEDURE (SPEC
$0.00
V5020
9
CONFORMITY EVALUATION
$0.00
V5030
5
BODY-WORN HEARING AID AIR
$0.00
V5040
5
BODY-WORN HEARING AID BONE
$0.00
V5050
5
HEARING AID MONAURAL IN EAR
$0.00
V5060
5
BEHIND EAR HEARING AID
$0.00
V5070
5
GLASSES AIR CONDUCTION
$0.00
$16.31
$37.16
$16.00
Procedure Code Pricing Action Code Description
Maximum Allowable
V5080
5
GLASSES BONE CONDUCTION
$0.00
V5090
3
HEARING AID DISPENSING FEE
V5095
5
IMPLANT MID EAR HEARING PROS
$0.00
V5100
5
BODY-WORN BILAT HEARING AID
$0.00
V5110
9
HEARING AID DISPENSING FEE
$0.00
V5120
5
BODY-WORN BINAUR HEARING AID
$0.00
V5130
5
IN EAR BINAURAL HEARING AID
$0.00
V5140
5
BEHIND EAR BINAUR HEARING AI
$0.00
V5150
5
GLASSES BINAURAL HEARING AID
$0.00
V5160
9
DISPENSING FEE BINAURAL
$0.00
V5170
5
WITHIN EAR CROS HEARING AID
$0.00
V5180
5
BEHIND EAR CROS HEARING AID
$0.00
V5190
5
GLASSES CROS HEARING AID
$0.00
V5200
9
CROS HEARING AID DISPENS FEE
$0.00
V5210
5
IN EAR BICROS HEARING AID
$0.00
V5220
5
BEHIND EAR BICROS HEARING AI
$0.00
V5230
5
GLASSES BICROS HEARING AID
$0.00
V5240
9
DISPENSING FEE BICROS
$0.00
V5241
9
DISPENSING FEE, MONAURAL
$0.00
V5242
5
HEARING AID, MONAURAL, CIC
$0.00
V5243
5
HEARING AID, MONAURAL, ITC
$0.00
V5244
5
HEARING AID, PROG, MON, CIC
$0.00
V5245
5
HEARING AID, PROG, MON, ITC
$0.00
V5246
5
HEARING AID, PROG, MON, ITE
$0.00
V5247
5
HEARING AID, PROG, MON, BTE
$0.00
V5248
5
HEARING AID, BINAURAL, CIC
$0.00
V5249
5
HEARING AID, BINAURAL, ITC
$0.00
V5250
5
HEARING AID, PROG, BIN, CIC
$0.00
V5251
5
HEARING AID, PROG, BIN, ITC
$0.00
V5252
5
HEARING AID, PROG, BIN, ITE
$0.00
V5253
5
HEARING AID, PROG, BIN, BTE
$0.00
V5254
5
HEARING ID, DIGIT, MON, CIC
$0.00
V5255
5
HEARING AID, DIGIT, MON, ITC
$0.00
V5256
5
HEARING AID, DIGIT, MON, ITE
$0.00
V5257
5
HEARING AID, DIGIT, MON, BTE
$0.00
$400.00
Procedure Code Pricing Action Code Description
Maximum Allowable
V5258
5
HEARING AID, DIGIT, BIN, CIC
$0.00
V5259
5
HEARING AID, DIGIT, BIN, ITC
$0.00
V5260
5
HEARING AID, DIGIT, BIN, ITE
$0.00
V5261
5
HEARING AID, DIGIT, BIN, BTE
$0.00
V5262
5
HEARING AID, DISP, MONAURAL
$0.00
V5263
5
HEARING AID, DISP, BINAURAL
$0.00
V5264
9
EAR MOLD/INSERT
$0.00
V5265
9
EAR MOLD/INSERT, DISP
$0.00
V5266
5
BATTERY FOR HEARING DEVICE
$0.00
V5267
5
HEARING AID SUPPLY/ACCESSORY
$0.00
V5268
9
ALD TELEPHONE AMPLIFIER
$0.00
V5269
9
ALERTING DEVICE, ANY TYPE
$0.00
V5270
9
ALD, TV AMPLIFIER, ANY TYPE
$0.00
V5271
9
ALD, TV CAPTION DECODER
$0.00
V5272
9
TDD
$0.00
V5273
9
ALD FOR COCHLEAR IMPLANT
$0.00
V5274
9
ALD UNSPECIFIED
$0.00
V5275
9
EAR IMPRESSION
$0.00
V5298
5
HEARING AID NOC
$0.00
V5299
9
HEARING SERVICE
$0.00
V5301
9
BASIC ASSESSMENT OF SPECIFIC SINGLE
$0.00
V5310
9
COMPREHENSIVE ASSESSMENT OF SPEECH,
$0.00
V5321
9
ASSESSMENT FOR ORAL OR LARYNGEAL PR
$0.00
V5322
9
ASSESSMENT FOR AUGMENTATIVE COMMUNI
$0.00
V5330
9
TREATMENT FOR SPEECH, LANGUAGE, ORA
$0.00
V5335
9
REPAIR/MODIFICATION OF ORAL OR LARY
$0.00
V5336
5
REPAIR COMMUNICATION DEVICE
$0.00
V5360
9
UNLISTED SPEECH-LANGUAGE SERVICE (S
$0.00
V5362
3
SPEECH SCREENING
$16.00
V5363
3
LANGUAGE SCREENING
$16.00
V5364
3
DYSPHAGIA SCREENING
$16.00
W5950
O
MCO SPECIFIC CODE: INTAKE/RISK ASSE
$0.00
W9026
O
HOSPITAL VISIT,INITIAL,OUTPATIENT;E
$0.00
W9045
O
ER SUPPORT SERVICES,SPECIAL NON-EME
$0.00
W9047
O
ER SUPPORT SERVICES, SPECIAL EMERGE
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
W9049
O
HOSPITAL OUTPATIENT CLINIC VISIT
$0.00
W9057
O
RURAL HEALTH CLINIC VISIT
$0.00
WW101
O
OFFICE VISIT COPAY
$0.00
WW102
O
EMERGENCY ROOM COPAY
$0.00
WW103
O
VISION CARE COPAY
$0.00
WW104
O
TRANSPORTATION COPAY
$0.00
WW105
O
INPATIENT HOSPITAL VISIT OR PROCEDU
$0.00
WW106
O
OUTPATIENT HOSPITAL CO-PAY, EXCLUDI
$0.00
WW201
O
INJECTION, AMPICILLIN SODIUM AND SU
$0.00
WW202
O
INJECTION, AMPICILLIN SODIUM AND SU
$0.00
WW203
O
INJECTION, LEUCOVORIN CALCIUM, UP T
$0.00
WW204
O
INJECTION, CYTOVENE, UP TO 500 MG
$0.00
WW205
O
INJECTION, HEPARIN SODIUM, UP TO 50
$0.00
WW206
O
INJECTION, HEPARIN SODIUM, UP TO 10
$0.00
WW207
O
INJECTION, HEPARIN SODIUM, UP TO 20
$0.00
WW208
O
INJECTION, PROMETHAZINE HCL, UP TO
$0.00
WW209
O
INJECTION, NALBUPHINE, UP TO 20 MG.
$0.00
WW210
O
INJECTION, LORAZEPAN, UP TO 2 MG.
$0.00
WW211
O
INJECTION, CEFTAZADIME, UP TO 500 M
$0.00
WW212
O
INJECTION, CEFTAZADIME, UP TO 1,000
$0.00
WW213
O
INFECTION, STINGING INSECT VENOM, S
$0.00
WW214
O
INJECTION, STINGING INSECT VENOM, M
$0.00
WW215
O
INJECTION, POISON IVY/ OAK, PROPHYL
$0.00
WW216
O
INJECTION, LONG ACTING ADRENALIN, U
$0.00
WW217
O
INJECTION, LEUPROLIDE ACETATE DEPOT
$0.00
WW218
O
INJECTION, LEUPROLIDE ACETATE DEPOT
$0.00
WW219
O
INJECTION, HEPARIN SODIUM FLUSH, UP
$0.00
WW220
O
INJECTION, KETOROLAC TROMETHAMINE,
$0.00
WW221
O
INJECTION, KETOROLAC TROMETHAMINE,
$0.00
WW222
O
INJECTION, MARCAINE HCL, UP TO 10CC
$0.00
WW223
O
INJECTION, ONDANSETRON HCL, UP TO 1
$0.00
WW224
O
IMMUNIZATION, ACTIVE; DIPHTHEIA AND
$0.00
WW225
O
INJECTION, DEPO-PROVERA, 150 MG/ML
$0.00
WW226
O
IMMUNIZATION, ACTIVE; DPT AND HIB
$0.00
WW227
O
INJECTION, MIDAZOLAM, UP TO 10 MG.
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
WW228
O
INJECTION, FLUMAZENIL, UP TO 0.5 MG
$0.00
WW229
O
INJECTION, NALOXONE HCL, UP TO O.4
$0.00
WW230
O
INJECTION, KYTRIL, 1MG/ML
$0.00
WW231
O
INJECTION, HEPARIN SODIUM, PER 100
$0.00
WW232
O
INJECTION, DEXAMETHASONE ACETATE, 1
$0.00
WW301
O
ROUTINE GYNECOLOGICAL EVALUATION IN
$0.00
WW302
O
ROUTINE GYNECOLOGICAL EVALUATION IN
$0.00
WW303
O
INITIAL ANTEPARTUM CARE
$0.00
WW304
O
USE OF A BIRTHING CENTER FACILITY F
$0.00
WW305
O
USE OF A BIRTHING CENTER FACILITY W
$0.00
WW310
O
INSERTION OF HORMONAL CONTRACEPTIVE
$0.00
WW311
O
REMOVAL OF HORMONAL CONTRACEPTIVE I
$0.00
WW312
O
PROVISION AND INSERTION OF VAGINAL
$0.00
WW313
O
INSERTION OF VAGINAL RING CONTAININ
$0.00
WW351
O
HOSPITAL BASED EMERGENCY ROOM PHYSI
$0.00
WW401
O
METHADONE CLINIC SERVICES
$0.00
WW402
O
OPIOID MEDICATION DISPENSING FOR IN
$0.00
WW403
O
OPIOID THERAPY PHYSICAL EVALUATION
$0.00
WW404
O
OPIOID DOSAGE MONITORING FOR INDIVI
$0.00
WW430
O
CHRONIC RENAL DISEASE PROGRAM-NEPRO
$0.00
WW451
O
INSERTION OF AN EPIDURAL OR SUBARAC
$0.00
WW452
O
RE-INJECTION OF A NARCOTIC INTO AN
$0.00
WW453
O
MAINTENANCE OF INTRAVENOUS ACCESS C
$0.00
WW501
O
VISION PROGRAM UNDER EPSDT - ROUTIN
$0.00
WW502
O
VISION PROGRAM UNDER EPSDT - PROVIS
$0.00
WW503
O
VISION PROGRAM UNDER EPSDT - PROVIS
$0.00
WW504
O
EPSDT/VISION-CONTACT LENS TO CORREC
$0.00
WW505
O
VISION PROGRAM UNDER EPSDT-PROVISIO
$0.00
WW506
O
VISION PROGRAM UNDER EPSDT-STOCK SI
$0.00
WW507
O
VISION PROGRAM UNDER EPSDT-PROVISIO
$0.00
WW508
O
VISION PROGRAM UNDER EPSDT-STOCK SI
$0.00
WW509
O
VISION PROGRAM UNDER EPSDT-PROVISIO
$0.00
WW510
O
VISION PROGRAM UNDER EPSDT-NON-STOC
$0.00
WW511
O
VISION PROGRAM UNDER EPSDT-PROVISIO
$0.00
WW512
O
VISION PROGRAM UNDER EPSDT-NON-STOC
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
WW513
O
VISION PROGRAM UNDER EPSDT-PROVISIO
$0.00
WW514
O
VISION PROGRAM UNDER EPSDT-BIFOCAL
$0.00
WW515
O
VISION PROGARM UNDER EPSDT-PROVISIO
$0.00
WW516
O
VISION PROGRAM UNDER EPSDT-BIFOCAL
$0.00
WW517
O
VISION PROGRAM UNDER EPSDT-PROVISIO
$0.00
WW518
O
VISION PROGRAM UNDER EPSDT-BIFOCAL
$0.00
WW519
O
VISION PROGRAM UNDER EPSDT-REPLACEM
$0.00
WW520
O
VISION PROGRAM UNDER EPSDT-POLYCARB
$0.00
WW521
O
VISION PROGRAM UNDER EPSDT-PHOTO GR
$0.00
WW522
O
VISION PROGRAM UNDER EPSDT-REPLACEM
$0.00
WW523
O
VISION PROGRAM UNDER EPSDT-REPLACEM
$0.00
WW524
O
VISION PROGRAM UNDER EPSDT-UNLISTED
$0.00
WW531
O
EPSDT SCREENING WITHOUT TREATMENT R
$0.00
WW532
O
EPSDT SCREENING WITHOUT TREATMENT R
$0.00
WW533
O
EPSDT SCREENING WITHOUT TREATMENT R
$0.00
WW534
O
EPSDT SCREENING WITHOUT TREATMENT R
$0.00
WW535
O
EPSDT SCREENING WITHOUT TREATMENT R
$0.00
WW536
O
EPSDT SCREENING WITH TREATMENT REFE
$0.00
WW537
O
EPSDT SCREENING WITH TREATMENT REFE
$0.00
WW538
O
EPSDT SCREENING WITH TREATMENT REFE
$0.00
WW539
O
EPSDT SCREENING WITH TREATMENT REFE
$0.00
WW540
O
EPSDT SCREENING WITH TREATMENT REFE
$0.00
WW571
O
DPH SPECIAL DENTAL CLINIC REFERRALS
$0.00
WW572
O
EPSDT - TOTAL YEARLY DENTAL CARE FO
$0.00
WW573
O
DENTAL CARE FOR INDIVIDUALS, EPSDT,
$0.00
WW574
O
DENTAL SERVICES FOR SPECIAL NEEDS P
$0.00
WW575
O
ENVIRONMENTAL INSPECTION FOR SOURCE
$0.00
WW601
O
POTENTIAL ACUITY METER (PAM)
$0.00
WW651
O
COMMUNITY SUPPORT SERVICES - MENTAL
$0.00
WW652
O
PSYCHOSOCIAL REHABILITATION CENTER
$0.00
WW653
O
RESIDENTIAL REHABILITATION MENTAL H
$0.00
WW654
O
PERSONAL CARE-DADAMH APPROVED C.S.S
$0.00
WW655
O
COMMUNITY SUPPORT SERVICES-ALCOHOL
$0.00
WW660
O
PHYS SERVICE DADAMH COMM MENTAL HEA
$0.00
WW661
O
PHYS SUPERVISED DADAMH COMM MENTAL
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
WW663
O
PHYS SUPERVISED DADAMH CMHC SERVICE
$0.00
WW664
O
PHYSICIAN SERVICE - DADAMH COMMUNIT
$0.00
WW665
O
PHYS. SUPERVISED DADAMH COMMUNITY M
$0.00
WW668
O
EPSDT BEHAVIORAL HEALTH SERVICES, A
$0.00
WW701
O
PRIVATE DUTY NURSE, EMPLOYED BY AGE
$0.00
WW702
O
EPSDT EXTENDED PRIVATE DUTY NURSE,E
$0.00
WW703
O
PRIVATE DUTY NURSE,SELF-EMPLOYED,PE
$0.00
WW704
O
PRIVATE DUTY NURSE,SELF-EMPLOYED, P
$0.00
WW705
O
PRIVATE DUTY NURSE, SELF-EMPLOYED,
$0.00
WW706
O
PRIVATE DUTY NURSE, SELF-EMPLOYED,
$0.00
WW707
O
PRIVATE DUTY NURSE,SELF-EMPLOYED,PE
$0.00
WW708
O
PRIVATE DUTY NURSE,SELF-EMPLOYED,PE
$0.00
WW709
O
PRIVATE DUTY NURSE,SELF-EMPLOYED, P
$0.00
WW710
O
PRIVATE DUTY NURSE,SELF-EMPLOYED,PE
$0.00
WW711
O
PRIVATE DUTY NURSE,SELF-EMPLOYED,PE
$0.00
WW712
O
PRIVATE DUTY NURSE,SELF-EMPLOYED, P
$0.00
WW713
O
EPSDT EXTENDED PRIVATE DUTY NURSE,S
$0.00
WW714
O
EPSDT EXTENDED PRIVATE DUTY NURSE,S
$0.00
WW715
O
EPSDT EXTENDED PRIVATE DUTY NURSE,S
$0.00
WW716
O
EPSDT EXTENDED PRIVATE DUTY NURSE,S
$0.00
WW717
O
EPSDT EXTENDED PRIVATE DUTY NURSE,S
$0.00
WW718
O
EPSDT EXTENDED PRIVATE DUTY NURSE,S
$0.00
WW719
O
EPSDT EXTENDED PRIVATE DUTY NURSE,S
$0.00
WW720
O
EPSDT EXTENDED PRIVATE DUTY NURSE,S
$0.00
WW721
O
EPSDT EXTENDED PRIVATE DUTY NURSE,S
$0.00
WW722
O
EPSDT EXTENDED PRIVATE DUTY NURSE,S
$0.00
WW751
O
'PULMONARY EVALUATION AND DIAGNOSTI
$0.00
WW752
O
MULTICHANNEL RECORDING OF 3 TO 5 PH
$0.00
WW753
O
MULTICHANNEL RECORDING OF 6 TO 12 P
$0.00
WW754
O
4 HR OVERNIGHT GROWTH HORMONE TEST;
$0.00
WW755
O
12 HR OVERNIGHT GROWTH HORMONE TEST
$0.00
WW797
O
ENTERAL FORMULAE NOC
$0.00
WW798
O
DISPOSABLE INCONTINENCE PRODUCTS ME
$0.00
WW799
O
DIAPERS THAT ARE MEDICALLY NECESSAR
$0.00
WW800
O
EPSDT NON-STATE PLAN SUPPLIES FOR U
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
WW801
O
MISCELLANEOUS SUPPLIES
$0.00
WW802
O
EPSDT
$0.00
WW803
O
NEEDLE WASTE UNIT (ALL SIZES) - IV
$0.00
WW804
O
INJECTION CAPS
$0.00
WW805
O
HUBER NEEDLE (ALL SIZES)
$0.00
WW806
O
SYRINGES (ALL TYPES)
$0.00
WW808
O
ADMINISTRATION SET-INCLUDES TUBING
$0.00
WW809
O
IV TUBING - ALL SIZES & TYPES
$0.00
WW810
O
CLAMP SCISSORS
$0.00
WW811
O
INTRAVENOUS CATHETER -ANGIO CATH, B
$0.00
WW812
O
IV START KIT
$0.00
WW813
O
IV CATHETER DRESSING KIT
$0.00
WW814
O
PEAK EXPIRATORY FLOW METER, EPSDT,
$0.00
WW815
O
MOUTHPIECE FOR PEAK FLOW METER, BOX
$0.00
WW816
O
LANCET DEVICE
$0.00
WW821
O
FEDERALLY QUALIFIED HEALTH CENTER E
$0.00
WW822
O
LINE MAINTENANCE-WEEKLY-SINGLE LUME
$0.00
WW823
O
LINE MAINTENANCE-WEEKLY-DOUBLE LUME
$0.00
WW824
O
LINE MAINTENANCE-WEEKLY-TRIPLE LUME
$0.00
WW825
O
PROTECTED NEEDLE HOUSING
$0.00
WW826
O
THERMOMETER-MERCURY
$0.00
WW827
O
HIBICLENS- 4 OZ
$0.00
WW828
O
TUBEX HOLDER
$0.00
WW829
O
CHEMO SPILL KIT-INCLUDES SAFETY GLA
$0.00
WW830
O
VIAL ADAPTER
$0.00
WW831
O
PICC INSERTION TRAY
$0.00
WW838
O
ENURESIS ALARM FOR AGES 4-20
$0.00
WW839
O
PHOTOTHERAPY BLANKET
$0.00
WW840
9
CARBON ELECTRODES FOR APNEA MONITOR
$0.00
WW841
O
STICKY ELECTRODES FOR APNEA MONITOR
$0.00
WW842
O
FOAM/VELCRO BELT FOR USE WITH CARBO
$0.00
WW843
9
LEAD WIRES FOR APNEA MONITOR-1 SET
$0.00
WW844
O
PULSE OXIMETER
$0.00
WW845
O
OXIBANDS - FOR USE WITH PULSE OXIME
$0.00
WW846
O
OXISENSOR / PROBE - FOR USE WITH PU
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
WW847
O
MEMORY MONITOR - RENTAL - INCLUDES
$0.00
WW848
O
SKIN LEVEL GASTROSTOMY KIT
$0.00
WW849
O
ADAPTER FOR SKIN LEVEL GASTROSTOMY
$0.00
WW850
O
OXYGEN CONTENT, LIQUID, PER POUND
$0.00
WW851
O
OXYGEN CONTENT, GASEOUS, PER EACH D
$0.00
WW852
O
OXYGEN CONTENT, GASEOUS, PER EACH E
$0.00
WW853
O
OXYGEN CONTENT, GASEOUS, PER EACH H
$0.00
WW854
O
OXYGEN CONTENT, GASEOUS, PER EACH M
$0.00
WW855
O
OXYGEN CONTENT, GASEOUS, PER EACH C
$0.00
WW856
O
STATIONARY COMPRESSED GAS SYSTEM; I
$0.00
WW858
O
STATIONARY LIQUID OXYGEN SYSTEM, IN
$0.00
WW860
O
OXYGEN CONCENTRATOR
$0.00
WW870
O
REPAIR OF PATIENT OWNED DURABLE MED
$0.00
WW871
O
EPSDT NON-STATE PLAN ORTHOTIC/PROST
$0.00
WW880
O
ARGININGE POWDER
$0.00
WW881
O
SPECIAL NEEDS EQUIPMENT - MISCELLAN
$0.00
WW900
O
HEARING ASSESSMENT-EPSDT SCHOOL BAS
$0.00
WW901
O
VISION ASSESSMENT-EPSDT SCHOOL BASE
$0.00
WW902
O
IMMUNIZATION ASSESSMENT-EPSDT SCHOO
$0.00
WW903
O
DEVELOPMENTAL/ORTHOPEDIC ASSESSMENT
$0.00
WW904
O
DENTAL ASSESSMENT-EPSDT SCHOOL BASE
$0.00
WW905
O
HEALTH EDUCATION ASSESSMENT-EPSDT S
$0.00
WW906
O
DENTAL HEALTH EDUCATION-EPSDT SCHOO
$0.00
WW910
O
INDIVIDUAL NURSING TREATMENT-EPSDT
$0.00
WW920
O
OCCUPATIONAL THERAPY EVALUATION-EPS
$0.00
WW921
O
INDIVIDUAL OCCUPATIONAL THERAPY TRE
$0.00
WW922
O
GROUP OCCUPATIONAL THERAPY TREATMEN
$0.00
WW930
O
PHYSICAL THERAPY ASSESSMENT-EPSDT S
$0.00
WW931
O
INDIVIDUAL PHYSICAL THERAPY TREATME
$0.00
WW932
O
GROUP PHYSICAL THERAPY TREATMENT-EP
$0.00
WW936
O
ICT PLACEMENT FOR 0-0-S RTC-BASED B
$0.00
WW937
O
ICT PLACEMENT FOR 0-0-S RTC-BASED B
$0.00
WW938
O
ICT PLACEMENT FOR O-O-S RTC-BASED B
$0.00
WW939
O
ICT PLACEMENT FOR 0-0-S RTC-BASED B
$0.00
WW940
O
MENTAL HEALTH TREATMENT ASSESSMENT-
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
WW941
O
INDIVIDUAL MENTAL HEALTH TREATMENT
$0.00
WW942
O
GROUP MENTAL HEALTH TREATMENT THERA
$0.00
WW943
O
FAMILY MENTAL HEALTH TREATMENT THER
$0.00
WW944
O
INDIVIDUAL MENTAL HEALTH CO-TREATME
$0.00
WW945
O
GROUP MENTAL HEALTH CO-TREATMENT TH
$0.00
WW946
O
FAMILY MENTAL HEALTH CO-TREATMENT T
$0.00
WW947
O
MENTAL HEALTH CASE CONSULTATION-EPS
$0.00
WW948
O
AU CLAIR BEHAVIORAL THERAPY, EPSDT
$0.00
WW950
O
SPEECH, LANGUAGE AND HEARING ASSESS
$0.00
WW951
O
INDIVIDUAL SPEECH/LANGUAGE THERAPY-
$0.00
WW952
O
INDIVIDUAL HEARING THERAPY-EPSDT SC
$0.00
WW953
O
GROUP SPEECH/LANGUAGE THERAPY-EPSDT
$0.00
WW954
O
INDIVUDUAL SPEECH/LANGUAGE CO-TREAT
$0.00
WW955
O
INDIVIDUAL HEARING CO-TREATMENT THE
$0.00
WW956
O
GROUP SPEECH/LANGAUAGE CO-TREATMENT
$0.00
WW960
O
TRANSPORTATION,ROUND TRIP-EPSDT SCH
$0.00
WW967
O
ASSESSMENT OF HIGHER CEREBRAL FUNCT
$0.00
WW968
O
PDDN EARLY INTERVENTION THERAPIES,
$0.00
WW969
O
EARLY INTERVENTION MULTI-DISCIPLINA
$0.00
WW970
O
CHILD DEVELOPMENT ORIENTED FAMILY T
$0.00
WW975
O
MENTAL HEALTH TREATMENT EVALUATION,
$0.00
WW976
O
INDIVIDUAL MENTAL HEALTH TREATMENT
$0.00
WW980
O
SPEECH/LANGUAGE/HEARING SCREEN, EPS
$0.00
WW981
O
SPEECH/LANGUAGE/HEARING COMPREHENSI
$0.00
WW982
O
SPEECH/LANGUAGE/HEARING INDIVIDUAL
$0.00
WW983
O
GROUP SPEECH/LANGUAGE/HEARING THERA
$0.00
WW985
O
OCCUPATIONAL THERAPY SCREEN, EPSDT,
$0.00
WW986
O
OCCUPATIONAL THERAPY EVALUATION, CO
$0.00
WW987
O
OCCUPATIONAL THERAPY TREATMENT, IND
$0.00
WW990
O
PHYSICAL THERAPY SCREEN, EPSDT, AGE
$0.00
WW991
O
PHYSICAL THERAPY EVALUATION, COMPRE
$0.00
WW992
O
INDIVIDUAL PHYSICAL THERAPY TREATME
$0.00
WW995
O
INITIAL NUTRITION CONSULTATION
$0.00
WW996
O
NUTRITION COUNSELING
$0.00
WW997
O
ASTHMA REHABILITATION CASE MANAGEME
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
WW998
O
NURSING SERVICES, INTERMITTENT, EPS
$0.00
WW999
O
EPSDT CASE MANAGEMENT SERVICE FOR C
$0.00
X0019
O
MCO SPECIFIC CODE: PRIVATE DUTY NUR
$0.00
YY001
O
NURSING HOME ANCILLARIES - OXYGEN H
$0.00
YY002
O
NURSING HOME ANCILLARIES - OXYGEN P
$0.00
YY003
O
NURSING HOME ANCILLARIES - OXYGEN C
$0.00
YY004
O
NURSING HOME ANCILLARIES - PHYSICAL
$0.00
YY005
O
NURSING HOME ANCILLARIES - PHYSICAL
$0.00
YY006
O
NURSING HOME ANCILLARIES - SPEECH T
$0.00
YY007
O
NURSING HOME ANCILLARIES - SPEECH T
$0.00
YY008
O
NURSING HOME ANCILLARIES - OCCUPATI
$0.00
YY009
O
NURSING HOME ANCILLARIES - OCCUPATI
$0.00
YY101
O
EXTENDED PREGNANCY-PER FIFTEEN MINU
$0.00
YY102
O
EXTENDED PREGNANCY-NUTRITION PER FI
$0.00
YY103
O
EXTENDED PREGNANCY-SOCIAL WORK PER
$0.00
YY201
O
HOSPICE - ROUTINE HOME CARE PER DAY
$0.00
YY202
O
HOSPICE - CONTINUOUS HOME CARE PER
$0.00
YY203
O
HOSPICE - INPATIENT RESPIT CARE PER
$0.00
YY204
O
HOSPICE - GENERAL INPATIENT CARE PE
$0.00
YY205
O
HOSPICE - NURSING HOME ROOM AND BOA
$0.00
YY301
O
FAMILY AND CHILDREN'S SERVICES CLIN
$0.00
YY302
O
FAMILY AND CHILDREN'S SERVICES NURS
$0.00
YY303
O
FAMILY AND CHILDREN'S SERVICES NURS
$0.00
YY304
O
FAMILY AND CHILDREN'S SERVICES EPSD
$0.00
YY401
O
DPH SPECIALTY AUDIOLOGY CLINIC VISI
$0.00
YY402
O
DPH SPECIALTY CARDIAC CLINIC VISIT
$0.00
YY403
O
DPH SPECIALTY ORTHOPEDIC CLINIC VIS
$0.00
YY404
O
DPH SPECIALTY NEUROLOGY CLINIC VISI
$0.00
YY405
O
DPH SPECIALTY SPEECH CLINIC VISIT
$0.00
YY406
O
DPH GENERAL MEDICAL CLINIC VISIT
$0.00
YY407
O
DPH URINALYSIS
$0.00
YY408
O
DPH PRENATAL CLINIC VISIT
$0.00
YY409
O
DPH TUBERCULOSIS CLINIC VISIT
$0.00
YY410
O
DPH STD CLINIC VISIT
$0.00
YY411
O
DPH ENHANCED CARE FOR AT-RISK CHILD
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
YY431
O
DPH - SPECIALTY FAMILY PLANNING CLI
$0.00
YY432
O
DPH - SPECIALTY FAMILY PLANNING CLI
$0.00
YY433
O
DPH - SPECIALTY FAMILY PLANNING CLI
$0.00
YY434
O
DPH FAMILY PLANNING CLINIC VISIT -
$0.00
YY441
O
DPH - SUPPLIED DIAPHRAGM
$0.00
YY442
O
DPH - SUPPLIED FOAM
$0.00
YY443
O
DPH - SUPPLIED BIRTH CONTROL PILLS
$0.00
YY444
O
DPH - SUPPLIED IUD
$0.00
YY445
O
DPH - SUPPLIED PREGNANCY TEST
$0.00
YY471
O
DPH - HEALTH SCREENING - AGE 35 TO
$0.00
YY472
O
DPH - HEALTH SCREENING - AGE 50 TO
$0.00
YY473
O
DPH - HEALTH SCREENING - AGE 60 AND
$0.00
YY501
O
TRANSPORTATION IN VEHICLE OTHER THA
$0.00
YY502
O
TRANSPORTATION IN VEHICLE OTHER THA
$0.00
YY503
O
TRANSPORTATION IN VEHICLE OTHER THA
$0.00
YY504
O
TRANSPORTATION IN VEHICLE OTHER THA
$0.00
YY505
O
TRANSPORTATION IN VEHICLE OTHER THA
$0.00
YY506
O
AMBULANCE - EMERGENCY TRANSPORT (ON
$0.00
YY507
O
AMBULANCE - EMERGENCY TRANSPORT (ON
$0.00
YY508
O
AMBULANCE - NON-EMERGENCY TRANSPORT
$0.00
YY509
O
AMBULANCE, NON-EMERGENCY TRANSPORT,
$0.00
YY510
O
AMBULANCE, NON-EMERGENCY TRANSPORT,
$0.00
YY511
O
ADDITIONAL AMBULANCE CREW(S) NECESS
$0.00
YY512
O
CHRONIC RENAL DISEASE PROGRAM MILEA
$0.00
YY513
O
AMBULANCE, NEONATAL EMERGENCY TRANS
$0.00
YY514
O
AMBULANCE, NEONATAL EMERGENCY TRANS
$0.00
YY515
O
TRANSPORTATION IN VEHICLE OTHER THA
$0.00
YY516
O
TRANSPORTATION IN VEHICLE OTHER THA
$0.00
YY517
O
TRANSPORTATION IN VEHICLE OTHER THA
$0.00
YY518
O
TRANSPORTATION-TAXI SERVICE-METERED
$0.00
YY519
O
TRANSPORTATION IN VEHICLE OTHER THA
$0.00
YY520
O
TRANSPORTATION IN VEHICLE OTHER THA
$0.00
YY521
O
TRANSPORTATION IN VEHICLE OTHER THA
$0.00
YY522
O
TRANSPORTATION IN VEHICLE OTHER THA
$0.00
YY523
O
TRANSPORTATION IN VEHICLE OTHER THA
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
YY524
O
TRANSPORTATION IN VEHICLE OTHER THA
$0.00
YY525
O
TRANSPORTATION IN VEHICLE OTHER THA
$0.00
YY526
O
TRANSPORTATION IN VEHICLE OTHER THA
$0.00
YY560
O
HCBS WAIVER FOR THE MENTALLY RETARD
$0.00
YY561
O
HCBS WAIVER FOR THE MENTALLY RETARD
$0.00
YY562
O
HCBS WAIVER FOR THE MENTALLY RETARD
$0.00
YY563
O
HCBS WAIVER FOR THE MENTALLY RETARD
$0.00
YY564
O
HCBS WAIVER FOR THE MENTALLY RETARD
$0.00
YY565
O
HCBS WAIVER FOR THE MENTALLY RETARD
$0.00
YY566
O
HCBS WAIVER FOR THE MENTALLY RETARD
$0.00
YY577
O
HCBS WAIVER FOR THE MENTALLY RETARD
$0.00
YY578
O
HCBS WAIVER FOR THE MENTALLY RETARD
$0.00
YY579
O
HCBS WAIVER FOR THE MENTALLY RETARD
$0.00
YY580
O
HCBS WAIVER FOR THE MENTALLY RETARD
$0.00
YY581
O
HCBS WAIVER FOR THE MENTALLY RETARD
$0.00
YY582
O
HCBS WAIVER FOR THE MENTALLY RETARD
$0.00
YY583
O
HCBS WAIVER FOR THE MENTALLY RETARD
$0.00
YY584
O
HCBS WAIVER FOR THE MENTALLY RETARD
$0.00
YY585
O
HCBS WAIVER FOR THE MENTALLY RETARD
$0.00
YY586
O
HCBS WAIVER FOR THE MENTALLY RETARD
$0.00
YY587
O
HCBS WAIVER FOR THE MENTALLY RETARD
$0.00
YY599
O
HOME AND COMMUNITY-BASED SERVICES W
$0.00
YY600
O
HOME AND COMMUNITY-BASED SERVICES W
$0.00
YY601
O
HCBS WAIVER FOR THE MENTALLY RETARD
$0.00
YY602
O
HCBS WAIVER FOR THE MENTALLY RETARD
$0.00
YY603
O
HCBS WAIVER FOR THE MENTALLY RETARD
$0.00
YY604
O
HCBS WAIVER FOR THE MENTALLY RETARD
$0.00
YY605
O
HCBS WAIVER FOR THE MENTALLY RETARD
$0.00
YY606
O
HOME AND COMMUNITY - BASED SERVICES
$0.00
YY607
O
HCBS WAIVER FOR MENTALLY RETARDED R
$0.00
YY608
O
HCBS WAIVER FOR THE MENTALLY-RETARD
$0.00
YY609
O
HCBS WAIVER FOR THE MENTALLY RETARD
$0.00
YY610
O
HCBS WAIVER FOR THE MENTALLY RETARD
$0.00
YY611
O
HCBS WAIVER FOR THE MENTALLY RETARD
$0.00
YY612
O
HCBS WAIVER FOR THE MENTALLY RETARD
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
YY613
O
HCBS WAIVER FOR THE MENTALLY RETARD
$0.00
YY614
O
HOME AND COMMUNITY-BASED SERVICES F
$0.00
YY615
O
HCBS WAIVER FOR THE MENTALLY RETARD
$0.00
YY616
O
HCBS WAIVER FOR THE MENTALLY RETARD
$0.00
YY617
O
HOME AND COMMUNITY-BASED WAIVER FOR
$0.00
YY618
O
HCBS WAIVER FOR THE MENTALLY RETARD
$0.00
YY619
O
HCBS WAIVER FOR THE MENTALLY RETARD
$0.00
YY620
O
HCBS WAIVER FOR THE MENTALLY RETARD
$0.00
YY621
O
HCBS WAIVER FOR THE MENTALLY RETARD
$0.00
YY629
O
HOME AND COMMUNITY-BASED SERVICES W
$0.00
YY630
O
HOME AND COMMUNITY-BASED SERVICES W
$0.00
YY631
O
HOME AND COMMUNITY-BASED SERVICES W
$0.00
YY632
O
HOME AND COMMUNITY-BASED SERVICES W
$0.00
YY633
O
HOME AND COMMUNITY-BASED SERVICES W
$0.00
YY634
O
HOME AND COMMUNITY-BASED SERVICES W
$0.00
YY635
O
HOME AND COMMUNITY-BASED SERVICES W
$0.00
YY636
O
HOME AND COMMUNITY-BASED SERVICES W
$0.00
YY637
O
HOME AND COMMUNITY-BASED SERVICES W
$0.00
YY638
O
HOME AND COMMUNITY-BASED SERVICES W
$0.00
YY639
O
HOME AND COMMUNITY-BASED SERVICES W
$0.00
YY640
O
HOME AND COMMUNITY-BASED SERVICES W
$0.00
YY641
O
HOME AND COMMUNITY-BASED SERVICES W
$0.00
YY642
O
HOME AND COMMUNITY-BASED SERVICES W
$0.00
YY643
O
HOME AND COMMUNITY-BASED SERVICES W
$0.00
YY644
O
HOME & COMMUNITY-BASED SERVICES WAI
$0.00
YY645
O
HOME & COMMUNITY-BASED WAIVER FOR A
$0.00
YY646
O
HOME & COMMUNITY BASED WAIVER FOR A
$0.00
YY647
O
HOME & COMMUNITY-BASED WAIVER FOR A
$0.00
YY648
O
HOME&COMMUNITY-BASED WAIVER FOR AID
$0.00
YY649
O
HOME & COMMUNITY-BASED WAIVER FOR A
$0.00
YY650
O
HOME AND COMMUNITY-BASED SERVICES W
$0.00
YY651
O
HOME AND COMMUNITY - BASED SERVICES
$0.00
YY652
O
AGED AND DISABLED WAIVER - EMERGENC
$0.00
YY653
O
HOME AND COMMUNITY - BASED SERVICES
$0.00
YY654
O
HOME AND COMMUNITY - BASED SERVICES
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
YY655
O
HOME AND COMMUNITY - BASED SERVICES
$0.00
YY656
O
HOME AND COMMUNITY-BASED SERVICES W
$0.00
YY657
O
HOME AND COMMUNITY - BASED SERVICES
$0.00
YY658
O
HOME AND COMMUNITY - BASED SERVICES
$0.00
YY659
O
HOME AND COMMUNITY - BASED SERVICES
$0.00
YY660
O
HOME AND COMMUNITY-BASED SERVICES W
$0.00
YY661
O
HCBS-A/D-WAIVER-DURABLE MEDICAL EQU
$0.00
YY662
O
HOME AND COMMUNITY-BASED WAIVER FOR
$0.00
YY663
O
HOME AND COMMUNITY-BASED WAIVER FOR
$0.00
YY664
O
HOME & COMMUNITY BASED SERVICES FOR
$0.00
YY701
O
HOME HEALTH-SKILLED NURSE VISIT-PLA
$0.00
YY702
O
HOME HEALTH - NURSE AIDE - PER 15 M
$0.00
YY703
O
HOME HEALTH - PHYSICAL THERAPY EVAL
$0.00
YY704
O
HOME HEALTH - PHYSICAL THERAPY TREA
$0.00
YY705
O
HOME HEALTH - OCCUPATIONAL THERAPY
$0.00
YY706
O
HOME HEALTH - OCCUPATIONAL THERAPY
$0.00
YY707
O
HOME HEALTH - SPEECH THERAPY EVALUA
$0.00
YY708
O
HOME HEALTH - SPEECH THERAPY TREATM
$0.00
YY709
O
HOME HEALTH- MEDICALLY NECESSARY SU
$0.00
YY710
O
HOME HEALTH-SKILLED NURSE VISIT-ADU
$0.00
YY711
O
HOME HEALTH-NURSE AIDE-ADULT FOSTER
$0.00
YY712
O
HOME HEALTH-PHYSICAL THERAPY EVALUA
$0.00
YY713
O
HOME HEALTH-PHYSICAL THERAPY TREATM
$0.00
YY714
O
HOME HEALTH-OCCUPATIONAL THERAPY EV
$0.00
YY715
O
HOME HEALTH-OCCUPATIONAL THERAPY TR
$0.00
YY716
O
HOME HEALTH-SPEECH THERAPY EVALUATI
$0.00
YY717
O
HOME HEALTH-SPEECH THERAPY TREATMEN
$0.00
YY718
O
HOME HEALTH-NURSE AIDE-HCBS/WAIVER
$0.00
YY719
O
HOME HEALTH-SKILLED NURSE VISIT-HCB
$0.00
YY720
O
HOME HEALTH-PHYSICAL THERAPY EVALUA
$0.00
YY721
O
HOME HEALTH-PHYSICAL THERAPY TREATM
$0.00
YY722
O
HOME HEALTH-OCCUPATIONAL THERAPY EV
$0.00
YY723
O
HOME HEALTH-OCCUPATIONAL THERAPY TR
$0.00
YY724
O
HOME HEALTH-SPEECH THERAPY EVALUATI
$0.00
YY725
O
HOME HEALTH-SPEECH THERAPY TREATMEN
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
YY726
O
HOME HEALTH-SKILLED NURSE VISIT-IN
$0.00
YY727
O
HOME HEALTH-SKILLED NURSE VISIT-ASS
$0.00
YY728
O
HOME HEALTH-NURSE AIDE-ASSISTED LIV
$0.00
YY740
O
MH/SA ASSESSMENT, EPSDT-DSCYF, AGE
$0.00
YY741
O
CLINICAL COORDINATION, EPSDT-DSCYF,
$0.00
YY742
O
CLINICAL BEHAVIORAL GUIDANCE,PERIOD
$0.00
YY750
O
MENTAL HEALTH CRISIS SERVICES, EPSD
$0.00
YY751
O
CENTER-BASED INDIVIDUAL OUTPATIENT
$0.00
YY752
O
MEDICATION MONITORING OR PSYCHIATRI
$0.00
YY753
O
CENTER-BASED OUTPATIENT GROUP MENTA
$0.00
YY754
O
RTC-BASED INDIVIDUAL OUT-PT MENTAL
$0.00
YY755
O
MENTAL HEALTH DAY TREATMENT, EPSDT-
$0.00
YY756
O
RTC-BASED INDIVIDUAL MENTAL HEALTH
$0.00
YY757
O
RTC-BASED INDIVIDUAL MENTAL HEALTH
$0.00
YY758
O
RTC-BASED INDIVIDUAL MENTAL HEALTH
$0.00
YY760
O
DRUG/ALCOHOL INTENSIVE INDIVIDUAL D
$0.00
YY761
O
DRUG/ALCOHOL INDIVIDUAL OUTPATIENT
$0.00
YY762
O
DRUG/ALCOHOL GROUP OUTPATIENT SERVI
$0.00
YY763
O
DRUG/ALCOHOL TREATMENT PROGRAM IN A
$0.00
YY764
7
DRUG\ALCOHOL PARTIAL DAY TREATMENT
$0.00
YY765
O
MENTAL HEALTH/SUBSTANCE ABUSE SERVI
$0.00
YY801
O
PRESCRIBED PEDIATRIC EXTENDED CARE
$0.00
YY802
O
PRESCRIBED PEDIATRIC EXTENDED CARE
$0.00
YY803
O
PRESCRIBED PEDIATRIC EXTENDED CARE(
$0.00
YY804
O
PRESCRIBED PEDIATRIC EXTENDED CARE
$0.00
YY805
O
PRESCRIBED PEDIATRIC EXTENDED CARE
$0.00
YY806
O
PRESCRIBED PEDIATRIC EXTENDED CARE
$0.00
YY807
O
PRESCRIBED PEDIATRIC EXTENDED CARE
$0.00
YY808
O
PRESCRIBED PEDIATRIC EXTENDED CARE
$0.00
YY822
O
VFC IMMUNIZATION CODE CREATED FOR L
$0.00
YY850
O
DAY HEALTH & REHAB FOR MR & DD CLIE
$0.00
YY851
O
DAY HEALTH & REHAB FOR MR & DD CLIE
$0.00
YY852
O
DAY HEALTH AND REHABILITATION FOR N
$0.00
YY853
O
DAY HEALTH AND REHABILITATION FOR N
$0.00
YY921
O
MONTHLY CAPITATED RATE, PEDIATRIC M
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
Z0402
O
PORTABLE OXYGEN REFILL (13 TO 28 CU
$0.00
Z0406
O
H TANK REFILL (151-282 CU. FT.)
$0.00
Z0445
O
OXYGEN CONCENTRATOR
$0.00
Z0526
O
WARM-N-FORM ORTHOSIS
$0.00
Z3255
O
ORTHOPEDIC SHOES ATTACHED TO BRACE
$0.00
Z4442
O
TRACHEOSTOMY SUCTION KIT
$0.00
Z4443
O
TRACHEOSTOMY SUCTION CATHETER
$0.00
ZE001
O
MCO SPECIFIC CODE: HOME INFUSION SE
$0.00
ZE002
O
MCO SPECIFIC CODE: HOME INFUSION SE
$0.00
ZH003
O
MCO SPECIFIC CODE: HOME INFUSION SE
$0.00
ZH004
O
MCO SPECIFIC CODE: HOME INFUSION SE
$0.00
ZH005
O
MCO SPECIFIC CODE: HOME INFUSION SE
$0.00
ZH010
O
MCO SPECIFIC CODE: HOME INFUSION SE
$0.00
ZH011
O
MCO SPECIFIC CODE: HOME INFUSION SE
$0.00
ZH020
O
MCO SPECIFIC CODE: HOME INFUSION SE
$0.00
ZH021
O
MCO SPECIFIC CODE: HOME INFUSION SE
$0.00
ZM001
O
MCO SPECIFIC CODE: HOME INFUSION SE
$0.00
ZR001
O
MCO SPECIFIC CODE: HOME INFUSION SE
$0.00
ZR002
O
MCO SPECIFIC CODE: HOME INFUSION SE
$0.00
Pricing Action Codes Pricing Action Code Pricing Action Description 1
PAY PERCENTAGE OF BILLED AMOUNT.
3
LOWER OF BILLED OR ALLOWED AMOUNT.
5
MANUAL PRICE - INDIVIDUAL CONSIDERATION. SET EDIT TO SUSPEND.
6
MANUAL PRICE - NO REASONABLE CHARGE ESTABLISHED. SET EDIT TO SUSPEND.
7
ONLY LEVEL I PRICING SHOULD BE USED. SET EDIT TO SUSPEND.
9
NON-COVERED. SET EDIT TO AUTODENY.
A
LOWER OF BILLED AMOUNT OR ((RVU + BILLED UNITS) X CONVERSION FACTOR DOLLAR AMOUNT)
O
OBSOLETE. SET EDIT TO AUTODENY.
SUSPEND.
FACTOR DOLLAR AMOUNT) .
Procedure Modifier Pricing Procedure Code Procedure Code Modifier Pricing Action Code Modifier Price 11975
26
5
$120.18
11977
26
5
$215.89
11980
26
5
$95.19
11981
26
5
$124.16
11983
26
5
$219.93
51725
26
3
$77.91
51725
TC
3
$147.74
51726
26
3
$88.62
51726
TC
3
$240.40
51736
26
3
$31.87
51736
TC
3
$22.79
51741
26
3
$59.54
51741
TC
3
$26.72
51772
26
3
$82.57
51772
TC
3
$170.16
51784
26
3
$78.63
51784
TC
3
$128.14
51785
26
3
$78.75
51785
TC
3
$145.88
51792
26
3
$56.52
51792
TC
3
$179.84
51795
26
3
$78.99
51795
TC
3
$231.25
51797
26
3
$45.14
51797
TC
3
$108.05
58300
26
5
$73.72
59020
26
3
$35.18
59020
TC
3
$31.23
59025
26
3
$28.34
59025
TC
3
$15.64
62252
26
3
$42.45
62252
TC
3
$50.02
70010
26
3
$59.62
Procedure Code Procedure Code Modifier Pricing Action Code Modifier Price 70010
TC
3
$110.64
70015
26
3
$61.07
70015
TC
3
$81.04
70030
26
3
$8.54
70030
TC
3
$19.34
70100
26
3
$8.89
70100
TC
3
$21.19
70110
26
3
$12.50
70110
TC
3
$26.47
70120
26
3
$8.89
70120
TC
3
$23.88
70130
26
3
$17.06
70130
TC
3
$37.06
70134
26
3
$17.06
70134
TC
3
$29.29
70140
26
3
$9.25
70140
TC
3
$20.19
70150
26
3
$12.86
70150
TC
3
$29.29
70160
26
3
$8.54
70160
TC
3
$23.03
70170
26
3
$15.02
70190
26
3
$10.33
70190
TC
3
$24.62
70200
26
3
$13.95
70200
TC
3
$29.66
70210
26
3
$8.54
70210
TC
3
$20.92
70220
26
3
$12.13
70220
TC
3
$26.34
70240
26
3
$9.61
70240
TC
3
$19.34
70250
26
3
$11.77
70250
TC
3
$23.88
70260
26
3
$16.70
Procedure Code Procedure Code Modifier Pricing Action Code Modifier Price 70260
TC
3
$30.64
70300
26
3
$5.29
70300
TC
3
$8.61
70310
26
3
$8.17
70310
TC
3
$25.25
70320
26
3
$11.05
70320
TC
3
$32.02
70328
26
3
$8.89
70328
TC
3
$20.44
70330
26
3
$12.14
70330
TC
3
$34.48
70332
26
3
$26.43
70332
TC
3
$57.22
70336
26
3
$74.53
70336
TC
3
$350.65
70350
26
3
$8.54
70350
TC
3
$11.57
70355
26
3
$9.98
70355
TC
3
$12.42
70360
26
3
$8.54
70360
TC
3
$18.23
70370
26
3
$15.74
70370
TC
3
$57.87
70371
26
3
$40.95
70371
TC
3
$55.37
70373
26
3
$20.64
70373
TC
3
$58.83
70380
26
3
$8.54
70380
TC
3
$27.95
70390
26
3
$19.24
70390
TC
3
$79.54
70450
26
3
$43.16
70450
TC
3
$176.06
70460
26
3
$57.10
70460
TC
3
$226.43
Procedure Code Procedure Code Modifier Pricing Action Code Modifier Price 70470
26
3
$64.20
70470
TC
3
$279.12
70480
26
3
$64.55
70480
TC
3
$196.93
70481
26
3
$69.61
70481
TC
3
$311.59
70482
26
3
$72.84
70482
TC
3
$344.95
70486
26
3
$57.47
70486
TC
3
$196.41
70487
26
3
$66.01
70487
TC
3
$275.60
70488
26
3
$71.40
70488
TC
3
$344.57
70490
26
3
$64.93
70490
TC
3
$196.28
70491
26
3
$69.61
70491
TC
3
$265.99
70492
26
3
$72.84
70492
TC
3
$334.95
70496
26
3
$88.86
70496
TC
3
$356.02
70498
26
3
$89.22
70498
TC
3
$356.02
70540
26
3
$67.80
70540
TC
3
$353.13
70542
26
3
$81.38
70542
TC
3
$433.17
70543
26
3
$108.06
70543
TC
3
$544.28
70544
26
3
$60.35
70544
TC
3
$351.83
70545
26
3
$60.35
70545
TC
3
$431.99
70546
26
3
$90.64
Procedure Code Procedure Code Modifier Pricing Action Code Modifier Price 70546
TC
3
$547.16
70547
26
3
$60.35
70547
TC
3
$351.70
70548
26
3
$60.35
70548
TC
3
$432.26
70549
26
3
$90.64
70549
TC
3
$547.16
70551
26
3
$74.53
70551
TC
3
$351.68
70552
26
3
$89.92
70552
TC
3
$430.96
70553
26
3
$118.89
70553
TC
3
$539.49
70554
26
3
$107.37
70554
TC
3
$512.84
70555
26
3
$129.63
70557
26
3
$147.32
70558
26
3
$160.74
70559
26
3
$163.43
71010
26
3
$8.89
71010
TC
3
$14.90
71015
26
3
$10.33
71015
TC
3
$18.96
71020
26
3
$11.05
71020
TC
3
$20.55
71021
26
3
$13.21
71021
TC
3
$24.86
71022
26
3
$15.39
71022
TC
3
$30.41
71023
26
3
$19.36
71023
TC
3
$47.04
71030
26
3
$15.39
71030
TC
3
$30.77
71034
26
3
$24.68
71034
TC
3
$66.62
Procedure Code Procedure Code Modifier Pricing Action Code Modifier Price 71035
26
3
$9.26
71035
TC
3
$24.88
71040
26
3
$29.20
71040
TC
3
$65.88
71060
26
3
$37.14
71060
TC
3
$101.46
71090
26
3
$29.39
71100
26
3
$11.05
71100
TC
3
$21.30
71101
26
3
$13.21
71101
TC
3
$25.73
71110
26
3
$13.21
71110
TC
3
$27.08
71111
26
3
$15.74
71111
TC
3
$35.82
71120
26
3
$9.98
71120
TC
3
$22.40
71130
26
3
$11.05
71130
TC
3
$26.10
71250
26
3
$58.55
71250
TC
3
$195.76
71260
26
3
$62.51
71260
TC
3
$280.98
71270
26
3
$69.61
71270
TC
3
$343.89
71275
26
3
$97.38
71275
TC
3
$356.54
71550
26
3
$73.21
71550
TC
3
$353.00
71551
26
3
$86.66
71551
TC
3
$433.30
71552
26
3
$114.58
71552
TC
3
$546.25
71555
26
3
$92.11
71555
TC
3
$431.74
Procedure Code Procedure Code Modifier Pricing Action Code Modifier Price 72010
26
3
$21.74
72010
TC
3
$46.54
72020
26
3
$7.82
72020
TC
3
$15.64
72040
26
3
$11.05
72040
TC
3
$25.36
72050
26
3
$15.39
72050
TC
3
$36.19
72052
26
3
$18.15
72052
TC
3
$46.54
72069
26
3
$11.05
72069
TC
3
$23.40
72070
26
3
$11.05
72070
TC
3
$22.40
72072
26
3
$11.05
72072
TC
3
$27.08
72074
26
3
$11.05
72074
TC
3
$33.60
72080
26
3
$11.05
72080
TC
3
$23.88
72090
26
3
$14.31
72090
TC
3
$31.64
72100
26
3
$11.05
72100
TC
3
$27.20
72110
26
3
$15.39
72110
TC
3
$38.04
72114
26
3
$18.15
72114
TC
3
$51.71
72120
26
3
$11.05
72120
TC
3
$36.93
72125
26
3
$58.55
72125
TC
3
$195.76
72126
26
3
$61.43
72126
TC
3
$281.35
72127
26
3
$63.83
Procedure Code Procedure Code Modifier Pricing Action Code Modifier Price 72127
TC
3
$343.89
72128
26
3
$58.55
72128
TC
3
$195.76
72129
26
3
$61.80
72129
TC
3
$281.35
72130
26
3
$64.20
72130
TC
3
$343.89
72131
26
3
$58.55
72131
TC
3
$195.76
72132
26
3
$61.80
72132
TC
3
$280.98
72133
26
3
$64.20
72133
TC
3
$343.89
72141
26
3
$80.29
72141
TC
3
$350.65
72142
26
3
$96.65
72142
TC
3
$430.96
72146
26
3
$80.66
72146
TC
3
$350.40
72147
26
3
$97.02
72147
TC
3
$430.17
72148
26
3
$74.53
72148
TC
3
$350.40
72149
26
3
$89.92
72149
TC
3
$430.96
72156
26
3
$129.22
72156
TC
3
$539.60
72157
26
3
$129.60
72157
TC
3
$538.82
72158
26
3
$118.52
72158
TC
3
$539.60
72159
26
3
$90.01
72159
TC
3
$563.62
72170
26
3
$8.54
72170
TC
3
$17.12
Procedure Code Procedure Code Modifier Pricing Action Code Modifier Price 72190
26
3
$10.70
72190
TC
3
$28.32
72191
26
3
$91.74
72191
TC
3
$356.42
72192
26
3
$55.31
72192
TC
3
$195.64
72193
26
3
$58.55
72193
TC
3
$267.42
72194
26
3
$61.43
72194
TC
3
$344.28
72195
26
3
$73.21
72195
TC
3
$352.61
72196
26
3
$87.40
72196
TC
3
$432.78
72197
26
3
$113.84
72197
TC
3
$543.64
72198
26
3
$91.01
72198
TC
3
$431.74
72200
26
3
$8.54
72200
TC
3
$20.07
72202
26
3
$9.61
72202
TC
3
$24.99
72220
26
3
$8.54
72220
TC
3
$20.55
72240
26
3
$45.68
72240
TC
3
$111.73
72255
26
3
$44.57
72255
TC
3
$99.18
72265
26
3
$41.71
72265
TC
3
$104.72
72270
26
3
$67.08
72270
TC
3
$161.34
72275
26
3
$35.88
72275
TC
3
$67.01
72285
26
3
$55.70
Procedure Code Procedure Code Modifier Pricing Action Code Modifier Price 72285
TC
3
$119.74
72291
26
3
$68.06
72292
26
3
$70.95
72295
26
3
$40.71
72295
TC
3
$115.69
73000
26
3
$8.17
73000
TC
3
$18.96
73010
26
3
$8.54
73010
TC
3
$19.34
73020
26
3
$7.45
73020
TC
3
$15.64
73030
26
3
$9.26
73030
TC
3
$20.19
73040
26
3
$27.17
73040
TC
3
$78.66
73050
26
3
$10.35
73050
TC
3
$24.99
73060
26
3
$8.54
73060
TC
3
$20.19
73070
26
3
$7.45
73070
TC
3
$18.96
73080
26
3
$8.54
73080
TC
3
$25.36
73085
26
3
$26.80
73085
TC
3
$68.69
73090
26
3
$7.80
73090
TC
3
$18.96
73092
26
3
$7.80
73092
TC
3
$19.71
73100
26
3
$8.17
73100
TC
3
$19.71
73110
26
3
$8.54
73110
TC
3
$24.88
73115
26
3
$27.17
73115
TC
3
$74.12
Procedure Code Procedure Code Modifier Pricing Action Code Modifier Price 73120
26
3
$7.80
73120
TC
3
$18.59
73130
26
3
$8.54
73130
TC
3
$21.92
73140
26
3
$6.73
73140
TC
3
$21.55
73200
26
3
$54.94
73200
TC
3
$196.28
73201
26
3
$58.55
73201
TC
3
$267.33
73202
26
3
$61.43
73202
TC
3
$344.80
73206
26
3
$92.47
73206
TC
3
$356.15
73218
26
3
$67.42
73218
TC
3
$353.26
73219
26
3
$81.38
73219
TC
3
$433.53
73220
26
3
$108.43
73220
TC
3
$544.42
73221
26
3
$67.80
73221
TC
3
$353.00
73222
26
3
$81.38
73222
TC
3
$432.91
73223
26
3
$108.06
73223
TC
3
$544.03
73225
26
3
$86.40
73225
TC
3
$550.96
73500
26
3
$8.54
73500
TC
3
$16.38
73510
26
3
$10.70
73510
TC
3
$25.36
73520
26
3
$12.86
73520
TC
3
$26.10
73525
26
3
$27.41
Procedure Code Procedure Code Modifier Pricing Action Code Modifier Price 73525
TC
3
$67.94
73530
26
3
$14.67
73540
26
3
$9.98
73540
TC
3
$26.10
73542
26
3
$27.71
73542
TC
3
$50.20
73550
26
3
$8.54
73550
TC
3
$19.44
73560
26
3
$8.54
73560
TC
3
$19.34
73562
26
3
$9.26
73562
TC
3
$24.26
73564
26
3
$11.05
73564
TC
3
$27.95
73565
26
3
$8.90
73565
TC
3
$20.82
73580
26
3
$27.41
73580
TC
3
$91.72
73590
26
3
$8.54
73590
TC
3
$18.23
73592
26
3
$7.80
73592
TC
3
$19.71
73600
26
3
$7.80
73600
TC
3
$18.59
73610
26
3
$8.54
73610
TC
3
$21.92
73615
26
3
$27.04
73615
TC
3
$70.90
73620
26
3
$7.80
73620
TC
3
$17.86
73630
26
3
$8.54
73630
TC
3
$21.55
73650
26
3
$7.80
73650
TC
3
$18.23
73660
26
3
$6.36
Procedure Code Procedure Code Modifier Pricing Action Code Modifier Price 73660
TC
3
$20.44
73700
26
3
$54.94
73700
TC
3
$196.28
73701
26
3
$58.92
73701
TC
3
$269.19
73702
26
3
$61.80
73702
TC
3
$344.80
73706
26
3
$97.17
73706
TC
3
$356.31
73718
26
3
$67.80
73718
TC
3
$353.13
73719
26
3
$81.38
73719
TC
3
$433.17
73720
26
3
$108.43
73720
TC
3
$544.42
73721
26
3
$67.80
73721
TC
3
$353.00
73722
26
3
$81.75
73722
TC
3
$433.03
73723
26
3
$108.43
73723
TC
3
$543.66
73725
26
3
$92.09
73725
TC
3
$431.97
74000
26
3
$8.89
74000
TC
3
$16.38
74010
26
3
$11.42
74010
TC
3
$25.73
74020
26
3
$13.58
74020
TC
3
$26.10
74022
26
3
$16.11
74022
TC
3
$31.88
74150
26
3
$59.99
74150
TC
3
$195.76
74160
26
3
$64.56
74160
TC
3
$301.07
Procedure Code Procedure Code Modifier Pricing Action Code Modifier Price 74170
26
3
$70.69
74170
TC
3
$344.70
74175
26
3
$96.43
74175
TC
3
$356.68
74181
26
3
$73.58
74181
TC
3
$352.08
74182
26
3
$87.40
74182
TC
3
$433.17
74183
26
3
$113.84
74183
TC
3
$543.64
74185
26
3
$91.01
74185
TC
3
$431.60
74190
26
3
$24.28
74210
26
3
$18.52
74210
TC
3
$57.63
74220
26
3
$23.21
74220
TC
3
$63.18
74230
26
3
$26.81
74230
TC
3
$61.94
74235
26
3
$61.47
74240
26
3
$34.99
74240
TC
3
$71.79
74241
26
3
$34.61
74241
TC
3
$79.18
74245
26
3
$46.05
74245
TC
3
$124.75
74246
26
3
$34.99
74246
TC
3
$87.43
74247
26
3
$34.99
74247
TC
3
$88.91
74249
26
3
$46.05
74249
TC
3
$137.19
74250
26
3
$23.56
74250
TC
3
$77.10
74251
26
3
$34.99
Procedure Code Procedure Code Modifier Pricing Action Code Modifier Price 74251
TC
3
$145.88
74260
26
3
$25.00
74260
TC
3
$89.82
74270
26
3
$34.99
74270
TC
3
$89.04
74280
26
3
$50.02
74280
TC
3
$144.72
74283
26
3
$101.69
74283
TC
3
$88.65
74290
26
3
$16.11
74290
TC
3
$48.15
74291
26
3
$9.98
74291
TC
3
$45.58
74300
26
O
$18.66
74301
26
3
$10.70
74305
26
3
$21.40
74320
26
3
$27.54
74320
TC
3
$86.52
74327
26
3
$35.71
74327
TC
3
$93.95
74328
26
3
$35.71
74329
26
3
$35.71
74330
26
3
$45.69
74340
26
3
$27.17
74355
26
3
$38.60
74360
26
3
$28.28
74363
26
3
$44.97
74400
26
3
$24.65
74400
TC
3
$84.34
74410
26
3
$25.01
74410
TC
3
$89.89
74415
26
3
$24.65
74415
TC
3
$107.13
74420
26
3
$18.52
74425
26
3
$18.52
Procedure Code Procedure Code Modifier Pricing Action Code Modifier Price 74430
26
3
$16.35
74430
TC
3
$61.70
74440
26
3
$19.24
74440
TC
3
$64.66
74445
26
3
$59.05
74450
26
3
$17.08
74455
26
3
$17.08
74455
TC
3
$73.38
74470
26
3
$27.54
74475
26
3
$27.54
74475
TC
3
$95.85
74480
26
3
$27.54
74480
TC
3
$96.22
74485
26
3
$27.78
74485
TC
3
$90.22
74710
26
3
$17.43
74710
TC
3
$25.84
74740
26
3
$19.24
74740
TC
3
$58.24
74775
26
3
$31.38
75600
26
3
$26.49
75600
TC
3
$295.08
75605
26
3
$59.68
75605
TC
3
$213.74
75625
26
3
$58.07
75625
TC
3
$211.52
75630
26
3
$92.85
75630
TC
3
$219.51
75635
26
3
$123.52
75635
TC
3
$357.06
75650
26
3
$76.36
75650
TC
3
$212.63
75658
26
3
$65.49
75658
TC
3
$220.39
75660
26
3
$67.10
Procedure Code Procedure Code Modifier Pricing Action Code Modifier Price 75660
TC
3
$224.10
75662
26
3
$86.27
75662
TC
3
$248.13
75665
26
3
$67.45
75665
TC
3
$231.49
75671
26
3
$85.02
75671
TC
3
$253.67
75676
26
3
$66.97
75676
TC
3
$224.46
75680
26
3
$85.40
75680
TC
3
$239.62
75685
26
3
$67.10
75685
TC
3
$224.83
75705
26
3
$112.07
75705
TC
3
$223.35
75710
26
3
$58.31
75710
TC
3
$227.06
75716
26
3
$66.97
75716
TC
3
$251.45
75722
26
3
$59.31
75722
TC
3
$222.62
75724
26
3
$80.69
75724
TC
3
$247.75
75726
26
3
$58.20
75726
TC
3
$224.10
75731
26
3
$61.40
75731
TC
3
$230.75
75733
26
3
$71.54
75733
TC
3
$259.58
75736
26
3
$58.81
75736
TC
3
$225.94
75741
26
3
$67.10
75741
TC
3
$205.98
75743
26
3
$85.40
75743
TC
3
$213.38
Procedure Code Procedure Code Modifier Pricing Action Code Modifier Price 75746
26
3
$57.83
75746
TC
3
$218.18
75756
26
3
$62.03
75756
TC
3
$231.12
75774
26
3
$18.52
75774
TC
3
$196.36
75790
26
3
$91.20
75790
TC
3
$83.25
75801
26
3
$40.10
75803
26
3
$59.64
75805
26
3
$41.60
75807
26
3
$59.64
75809
26
3
$23.56
75809
TC
3
$63.31
75810
26
3
$58.57
75820
26
3
$36.08
75820
TC
3
$83.14
75822
26
3
$53.50
75822
TC
3
$92.13
75825
26
3
$57.58
75825
TC
3
$202.28
75827
26
3
$56.35
75827
TC
3
$203.02
75831
26
3
$57.70
75831
TC
3
$205.24
75833
26
3
$74.63
75833
TC
3
$218.55
75840
26
3
$56.83
75840
TC
3
$203.76
75842
26
3
$75.63
75842
TC
3
$219.28
75860
26
3
$59.07
75860
TC
3
$209.31
75870
26
3
$57.47
75870
TC
3
$208.56
Procedure Code Procedure Code Modifier Pricing Action Code Modifier Price 75872
26
3
$60.73
75872
TC
3
$229.64
75880
26
3
$34.60
75880
TC
3
$85.73
75885
26
3
$73.60
75885
TC
3
$205.98
75887
26
3
$73.60
75887
TC
3
$208.20
75889
26
3
$58.20
75889
TC
3
$205.60
75891
26
3
$58.20
75891
TC
3
$205.60
75893
26
3
$27.17
75893
TC
3
$205.24
75894
26
3
$66.85
75896
26
3
$67.24
75898
26
3
$84.67
75900
26
3
$24.88
75901
26
3
$24.65
75901
TC
3
$141.89
75902
26
3
$19.59
75902
TC
3
$73.13
75940
26
3
$27.28
75945
26
3
$20.80
75946
26
3
$20.30
75952
26
3
$223.25
75953
26
3
$67.61
75954
26
3
$110.25
75956
26
3
$349.86
75957
26
3
$299.53
75958
26
3
$197.75
75959
26
3
$173.88
75960
26
3
$42.33
75960
TC
3
$220.69
75961
26
3
$214.61
Procedure Code Procedure Code Modifier Pricing Action Code Modifier Price 75961
TC
3
$197.29
75962
26
3
$27.41
75962
TC
3
$254.29
75964
26
3
$18.38
75964
TC
3
$147.83
75966
26
3
$68.58
75966
TC
3
$261.31
75968
26
3
$18.88
75968
TC
3
$147.83
75970
26
3
$42.44
75978
26
3
$26.80
75978
TC
3
$250.22
75980
26
3
$73.23
75984
26
3
$36.80
75984
TC
3
$77.32
75989
26
3
$60.36
75989
TC
3
$83.19
75992
26
3
$28.15
75993
26
3
$18.52
75994
26
3
$61.80
75995
26
3
$65.76
75996
26
3
$18.15
76000
26
3
$8.54
76000
TC
3
$84.50
76001
26
3
$34.38
76010
26
3
$9.26
76010
TC
3
$18.59
76080
26
3
$27.54
76080
TC
3
$35.82
76098
26
3
$8.17
76098
TC
3
$11.57
76100
26
3
$29.20
76100
TC
3
$75.51
76101
26
3
$28.84
76101
TC
3
$157.56
Procedure Code Procedure Code Modifier Pricing Action Code Modifier Price 76102
26
3
$28.47
76102
TC
3
$203.15
76120
26
3
$18.87
76120
TC
3
$56.53
76125
26
3
$14.33
76376
26
3
$10.58
76376
TC
3
$69.94
76377
26
3
$40.87
76377
TC
3
$69.91
76380
26
3
$49.28
76380
TC
3
$106.03
76390
26
3
$69.08
76390
TC
3
$393.83
76506
26
3
$32.46
76506
TC
3
$63.18
76510
26
3
$79.40
76510
TC
3
$68.23
76511
26
3
$47.99
76511
TC
3
$48.27
76512
26
3
$48.12
76512
TC
3
$41.95
76513
26
3
$32.94
76513
TC
3
$50.46
76514
26
3
$8.90
76514
TC
3
$3.57
76516
26
3
$27.30
76516
TC
3
$39.39
76519
26
3
$27.67
76519
TC
3
$43.83
76529
26
3
$28.98
76529
TC
3
$38.51
76536
26
3
$27.52
76536
TC
3
$82.89
76604
26
3
$27.53
76604
TC
3
$58.61
Procedure Code Procedure Code Modifier Pricing Action Code Modifier Price 76645
26
3
$27.17
76645
TC
3
$63.18
76700
26
3
$40.62
76700
TC
3
$95.80
76705
26
3
$29.94
76705
TC
3
$73.64
76770
26
3
$37.14
76770
TC
3
$93.58
76775
26
3
$29.95
76775
TC
3
$81.77
76776
26
3
$38.23
76776
TC
3
$107.26
76800
26
3
$53.41
76800
TC
3
$68.84
76801
26
3
$49.27
76801
TC
3
$81.25
76802
26
3
$40.97
76802
TC
3
$32.09
76805
26
3
$48.90
76805
TC
3
$96.78
76810
26
3
$48.18
76810
TC
3
$51.49
76811
26
3
$92.60
76811
TC
3
$110.87
76812
26
3
$86.59
76812
TC
3
$61.10
76813
26
3
$56.67
76813
TC
3
$70.28
76814
26
3
$47.67
76814
TC
3
$34.41
76815
26
3
$32.08
76815
TC
3
$58.49
76816
26
3
$41.69
76816
TC
3
$63.31
76817
26
3
$36.76
Procedure Code Procedure Code Modifier Pricing Action Code Modifier Price 76817
TC
3
$63.18
76818
26
3
$51.29
76818
TC
3
$68.94
76819
26
3
$37.85
76819
TC
3
$55.26
76820
26
3
$24.50
76820
TC
3
$29.13
76821
26
3
$34.23
76821
TC
3
$62.77
76825
26
3
$81.68
76825
TC
3
$126.12
76826
26
3
$39.99
76826
TC
3
$74.77
76827
26
3
$28.23
76827
TC
3
$43.18
76828
26
3
$27.38
76828
TC
3
$25.21
76830
26
3
$34.25
76830
TC
3
$85.58
76831
26
3
$34.95
76831
TC
3
$84.84
76856
26
3
$34.61
76856
TC
3
$85.96
76857
26
3
$19.60
76857
TC
3
$63.68
76870
26
3
$32.46
76870
TC
3
$87.06
76872
26
3
$35.97
76872
TC
3
$99.02
76873
26
3
$78.25
76873
TC
3
$98.11
76880
26
3
$28.82
76880
TC
3
$96.56
76885
26
3
$37.14
76885
TC
3
$63.18
Procedure Code Procedure Code Modifier Pricing Action Code Modifier Price 76886
26
3
$30.63
76886
TC
3
$63.05
76930
26
3
$36.25
76930
TC
3
$61.92
76932
26
3
$36.25
76936
26
3
$101.21
76936
TC
3
$94.91
76937
26
3
$15.50
76937
TC
3
$20.14
76940
26
3
$104.41
76941
26
3
$65.83
76942
26
3
$33.91
76942
TC
3
$152.13
76945
26
3
$32.79
76946
26
3
$18.49
76946
TC
3
$25.69
76950
26
3
$28.84
76950
TC
3
$41.61
76965
26
3
$68.66
76965
TC
3
$77.57
76970
26
3
$19.21
76970
TC
3
$63.18
76975
26
3
$41.37
76977
26
3
$2.76
76977
TC
3
$11.18
76998
26
3
$60.42
77001
26
3
$18.99
77001
TC
3
$85.58
77002
26
3
$26.43
77002
TC
3
$44.20
77003
26
3
$27.70
77003
TC
3
$30.88
77011
26
3
$60.34
77011
TC
3
$623.79
77012
26
3
$58.92
Procedure Code Procedure Code Modifier Pricing Action Code Modifier Price 77012
TC
3
$139.09
77013
26
3
$203.09
77014
26
3
$42.05
77014
TC
3
$143.95
77021
26
3
$76.46
77021
TC
3
$372.54
77022
26
3
$212.35
77031
26
3
$80.05
77031
TC
3
$111.65
77032
26
3
$28.25
77032
TC
3
$31.25
77051
26
3
$3.13
77051
TC
3
$9.11
77052
26
3
$3.13
77052
TC
3
$9.11
77280
26
3
$34.85
77280
TC
3
$150.35
77285
26
3
$52.03
77285
TC
3
$267.46
77290
26
3
$77.25
77290
TC
3
$419.14
77295
26
3
$225.76
77295
TC
3
$455.09
77300
26
3
$30.63
77300
TC
3
$40.49
77301
26
3
$395.67
77301
TC
3
$1,780.88
77305
26
3
$34.85
77305
TC
3
$38.13
77310
26
3
$52.03
77310
TC
3
$49.33
77315
26
3
$77.25
77315
TC
3
$70.64
77321
26
3
$46.98
77321
TC
3
$74.91
Procedure Code Procedure Code Modifier Pricing Action Code Modifier Price 77326
26
3
$45.89
77326
TC
3
$97.02
77327
26
3
$68.73
77327
TC
3
$134.82
77328
26
3
$103.57
77328
TC
3
$174.95
77331
26
3
$43.14
77331
TC
3
$18.96
77332
26
3
$26.67
77332
TC
3
$51.21
77333
26
3
$41.70
77333
TC
3
$26.67
77334
26
3
$61.28
77334
TC
3
$96.87
77421
26
3
$19.22
77421
TC
3
$94.82
77470
26
3
$103.57
77470
TC
3
$150.93
77620
26
3
$77.55
77620
TC
3
$312.91
77750
26
3
$244.63
77750
TC
3
$92.63
77761
26
3
$187.64
77761
TC
3
$163.44
77762
26
3
$283.80
77762
TC
3
$194.22
77763
26
3
$425.95
77763
TC
3
$249.89
77776
26
3
$235.10
77776
TC
3
$176.51
77777
26
3
$375.70
77777
TC
3
$195.68
77778
26
3
$556.92
77778
TC
3
$260.09
77789
26
3
$56.60
Procedure Code Procedure Code Modifier Pricing Action Code Modifier Price 77789
TC
3
$47.80
77790
26
3
$52.03
77790
TC
3
$35.23
78000
26
3
$9.61
78000
TC
3
$59.49
78001
26
3
$13.23
78001
TC
3
$74.51
78003
26
3
$16.46
78003
TC
3
$59.85
78006
26
3
$24.65
78006
TC
3
$191.67
78007
26
3
$25.37
78007
TC
3
$106.13
78010
26
3
$19.59
78010
TC
3
$130.93
78011
26
3
$22.84
78011
TC
3
$138.19
78015
26
3
$33.91
78015
TC
3
$169.35
78016
26
3
$41.48
78016
TC
3
$267.55
78018
26
3
$43.52
78018
TC
3
$267.96
78020
26
3
$30.42
78020
TC
3
$59.92
78070
26
3
$41.72
78070
TC
3
$130.18
78075
26
3
$37.51
78075
TC
3
$368.16
78102
26
3
$27.90
78102
TC
3
$131.91
78103
26
3
$37.87
78103
TC
3
$176.73
78104
26
3
$40.77
78104
TC
3
$205.29
Procedure Code Procedure Code Modifier Pricing Action Code Modifier Price 78110
26
3
$9.61
78110
TC
3
$66.88
78111
26
3
$11.43
78111
TC
3
$86.17
78120
26
3
$11.79
78120
TC
3
$75.10
78121
26
3
$16.11
78121
TC
3
$89.13
78122
26
9
$23.48
78130
26
3
$31.02
78130
TC
3
$121.29
78135
26
3
$32.46
78135
TC
3
$286.23
78140
26
3
$31.02
78140
TC
3
$116.32
78185
26
3
$20.32
78185
TC
3
$165.41
78190
26
3
$54.55
78190
TC
3
$166.87
78191
26
3
$30.65
78191
TC
3
$167.10
78195
26
3
$60.96
78195
TC
3
$266.29
78201
26
3
$21.75
78201
TC
3
$149.52
78202
26
3
$25.36
78202
TC
3
$172.31
78205
26
3
$36.07
78205
TC
3
$200.05
78206
26
3
$48.57
78206
TC
3
$280.66
78215
26
3
$24.65
78215
TC
3
$158.26
78216
26
3
$28.62
78216
TC
3
$109.31
Procedure Code Procedure Code Modifier Pricing Action Code Modifier Price 78220
26
3
$24.65
78220
TC
3
$119.17
78223
26
3
$42.43
78223
TC
3
$263.72
78230
26
3
$22.47
78230
TC
3
$133.25
78231
26
3
$26.09
78231
TC
3
$106.49
78232
26
3
$23.93
78232
TC
3
$111.16
78258
26
3
$37.89
78258
TC
3
$178.97
78261
26
3
$34.99
78261
TC
3
$204.55
78262
26
3
$33.89
78262
TC
3
$202.33
78264
26
3
$39.32
78264
TC
3
$232.64
78270
26
3
$9.98
78270
TC
3
$68.94
78271
26
3
$9.60
78271
TC
3
$70.05
78272
26
3
$12.85
78272
TC
3
$77.43
78278
26
3
$50.02
78278
TC
3
$246.32
78282
26
3
$19.24
78290
26
3
$34.63
78290
TC
3
$247.23
78291
26
3
$44.61
78291
TC
3
$193.86
78300
26
3
$31.38
78300
TC
3
$136.08
78305
26
3
$41.71
78305
TC
3
$180.91
Procedure Code Procedure Code Modifier Pricing Action Code Modifier Price 78306
26
3
$43.52
78306
TC
3
$203.07
78315
26
3
$51.46
78315
TC
3
$249.16
78320
26
3
$52.54
78320
TC
3
$200.05
78350
26
3
$10.69
78350
TC
3
$22.64
78414
26
3
$21.36
78428
26
3
$41.16
78428
TC
3
$153.22
78445
26
3
$24.65
78445
TC
3
$138.69
78456
26
3
$53.70
78456
TC
3
$189.04
78457
26
3
$38.58
78457
TC
3
$148.66
78458
26
3
$45.69
78458
TC
3
$160.68
78459
26
3
$58.03
78459
TC
3
$216.65
78460
26
3
$43.89
78460
TC
3
$143.61
78461
26
3
$62.90
78461
TC
3
$147.59
78464
26
3
$58.03
78464
TC
3
$216.65
78465
26
3
$78.51
78465
TC
3
$408.23
78466
26
3
$36.09
78466
TC
3
$142.74
78468
26
3
$42.98
78468
TC
3
$182.75
78469
26
3
$48.38
78469
TC
3
$208.20
Procedure Code Procedure Code Modifier Pricing Action Code Modifier Price 78472
26
3
$51.14
78472
TC
3
$209.79
78473
26
3
$78.00
78473
TC
3
$278.48
78478
26
3
$27.21
78478
TC
3
$31.61
78480
26
3
$17.48
78480
TC
3
$31.61
78481
26
3
$53.12
78481
TC
3
$175.67
78483
26
3
$80.71
78483
TC
3
$242.37
78491
26
3
$55.17
78491
TC
3
$268.45
78492
26
3
$55.17
78492
TC
3
$268.45
78494
26
3
$62.57
78494
TC
3
$221.99
78496
26
3
$26.85
78496
TC
3
$90.00
78580
26
3
$37.51
78580
TC
3
$169.21
78584
26
3
$50.02
78584
TC
3
$106.49
78585
26
3
$55.31
78585
TC
3
$285.95
78586
26
3
$20.32
78586
TC
3
$137.56
78587
26
3
$25.01
78587
TC
3
$173.79
78588
26
3
$55.31
78588
TC
3
$261.26
78591
26
3
$20.32
78591
TC
3
$139.78
78593
26
3
$24.65
Procedure Code Procedure Code Modifier Pricing Action Code Modifier Price 78593
TC
3
$164.03
78594
26
3
$26.81
78594
TC
3
$193.80
78596
26
3
$62.85
78596
TC
3
$303.53
78600
26
3
$22.49
78600
TC
3
$149.39
78601
26
3
$25.73
78601
TC
3
$178.82
78605
26
3
$27.19
78605
TC
3
$164.03
78606
26
3
$32.46
78606
TC
3
$267.53
78607
26
3
$62.16
78607
TC
3
$296.76
78608
26
3
$55.17
78608
TC
3
$268.45
78609
26
3
$55.17
78609
TC
3
$268.45
78610
26
3
$15.77
78610
TC
3
$158.04
78630
26
3
$34.63
78630
TC
3
$283.75
78635
26
3
$31.15
78635
TC
3
$258.83
78645
26
3
$28.98
78645
TC
3
$189.45
78647
26
3
$45.32
78647
TC
3
$290.26
78650
26
3
$31.02
78650
TC
3
$279.71
78660
26
3
$26.81
78660
TC
3
$134.86
78700
26
3
$22.84
78700
TC
3
$147.66
Procedure Code Procedure Code Modifier Pricing Action Code Modifier Price 78701
26
3
$24.65
78701
TC
3
$179.56
78707
26
3
$48.57
78707
TC
3
$188.52
78708
26
3
$61.45
78708
TC
3
$130.84
78709
26
3
$71.42
78709
TC
3
$277.99
78710
26
3
$33.55
78710
TC
3
$200.79
78725
26
3
$18.87
78725
TC
3
$79.91
78730
26
3
$8.80
78730
TC
3
$67.36
78740
26
3
$29.22
78740
TC
3
$173.69
78761
26
3
$36.07
78761
TC
3
$167.12
78800
26
3
$33.05
78800
TC
3
$148.50
78801
26
3
$40.15
78801
TC
3
$203.07
78802
26
3
$43.52
78802
TC
3
$275.23
78803
26
3
$55.31
78803
TC
3
$295.66
78804
26
3
$54.35
78804
TC
3
$508.52
78805
26
3
$36.79
78805
TC
3
$145.18
78806
26
3
$43.52
78806
TC
3
$290.11
78807
26
3
$55.44
78807
TC
3
$296.02
78811
26
3
$79.11
Procedure Code Procedure Code Modifier Pricing Action Code Modifier Price 78812
26
3
$98.59
78813
26
3
$102.20
78814
26
3
$111.94
78815
26
3
$123.84
78816
26
3
$127.10
79005
26
3
$89.90
79005
TC
3
$62.50
79101
26
3
$103.75
79101
TC
3
$68.05
79200
26
3
$101.00
79200
TC
3
$73.23
79300
26
3
$81.73
79403
26
3
$114.96
79403
TC
3
$103.55
79440
26
3
$100.75
79440
TC
3
$59.92
79445
26
3
$122.28
83020
26
3
$20.56
83912
26
3
$5.60
84165
26
3
$20.56
84166
26
3
$19.93
84181
26
3
$19.79
84182
26
3
$20.95
85390
26
3
$20.17
85576
26
3
$20.56
86255
26
3
$20.56
86256
26
3
$20.56
86320
26
3
$20.56
86325
26
3
$20.56
86327
26
3
$23.62
86334
26
3
$20.56
86335
26
3
$19.02
87164
26
3
$19.01
87207
26
3
$20.95
88104
26
3
$31.57
Procedure Code Procedure Code Modifier Pricing Action Code Modifier Price 88104
TC
3
$19.92
88106
26
3
$31.57
88106
TC
3
$14.90
88107
26
3
$43.25
88107
TC
3
$25.33
88108
26
3
$31.57
88108
TC
3
$22.24
88112
26
3
$66.40
88112
TC
3
$57.41
88125
26
3
$14.83
88125
TC
3
$5.71
88160
26
3
$28.12
88160
TC
3
$27.65
88161
26
3
$28.12
88161
TC
3
$26.10
88162
26
3
$43.25
88162
TC
3
$13.74
88172
26
3
$33.86
88172
TC
3
$15.67
88173
26
3
$77.87
88173
TC
3
$45.04
88182
26
3
$43.63
88182
TC
3
$49.50
88300
26
3
$4.89
88300
TC
3
$9.57
88302
26
3
$7.56
88302
TC
3
$24.94
88304
26
3
$12.53
88304
TC
3
$30.35
88305
26
3
$42.27
88305
TC
3
$55.30
88307
26
3
$89.26
88307
TC
3
$77.54
88309
26
3
$128.39
88309
TC
3
$88.75
Procedure Code Procedure Code Modifier Pricing Action Code Modifier Price 88311
26
3
$13.68
88311
TC
3
$3.78
88312
26
3
$30.42
88312
TC
3
$43.19
88313
26
3
$13.68
88313
TC
3
$38.17
88314
26
3
$25.45
88314
TC
3
$27.26
88318
26
3
$23.62
88318
TC
3
$23.87
88319
26
3
$29.65
88319
TC
3
$64.75
88331
26
3
$66.87
88331
TC
3
$18.97
88332
26
3
$33.09
88332
TC
3
$9.87
88333
26
3
$59.71
88333
TC
3
$30.69
88334
26
3
$34.67
88334
TC
3
$18.30
88342
26
3
$47.84
88342
TC
3
$38.47
88346
26
3
$48.22
88346
TC
3
$41.95
88347
26
3
$47.83
88347
TC
3
$54.70
88348
26
3
$84.37
88348
TC
3
$304.29
88349
26
3
$43.25
88349
TC
3
$374.71
88355
26
3
$103.70
88355
TC
3
$71.36
88356
26
3
$167.57
88356
TC
3
$63.93
88358
26
3
$55.97
Procedure Code Procedure Code Modifier Pricing Action Code Modifier Price 88358
TC
3
$7.51
88360
26
3
$59.52
88360
TC
3
$47.05
88361
26
3
$55.20
88361
TC
3
$86.34
88362
26
3
$120.90
88362
TC
3
$135.89
88365
26
3
$52.43
88365
TC
3
$70.16
88367
26
3
$69.42
88367
TC
3
$130.83
88368
26
3
$75.29
88368
TC
3
$68.23
88371
26
3
$19.40
88372
26
3
$20.95
88384
26
3
$67.70
88384
TC
3
$258.95
88385
26
3
$84.63
88385
TC
3
$250.87
88386
26
3
$106.44
88386
TC
3
$243.06
89060
26
3
$20.95
91000
26
3
$35.68
91000
TC
3
$52.37
91010
26
3
$66.07
91010
TC
3
$120.48
91011
26
3
$81.15
91011
TC
3
$168.91
91012
26
3
$78.01
91012
TC
3
$176.18
91020
26
3
$75.69
91020
TC
3
$151.17
91022
26
3
$77.91
91022
TC
3
$108.28
91030
26
3
$49.00
Procedure Code Procedure Code Modifier Pricing Action Code Modifier Price 91030
TC
3
$86.99
91034
26
3
$51.25
91034
TC
3
$144.88
91035
26
3
$83.76
91035
TC
3
$379.65
91037
26
3
$52.00
91037
TC
3
$104.96
91038
26
3
$58.86
91038
TC
3
$79.08
91040
26
3
$53.48
91040
TC
3
$321.98
91052
26
3
$40.04
91052
TC
3
$81.08
91055
26
3
$45.51
91055
TC
3
$85.14
91065
26
3
$10.35
91065
TC
3
$54.46
91110
26
3
$192.49
91110
TC
3
$699.32
91120
26
3
$48.17
91120
TC
3
$336.66
91122
26
3
$89.29
91122
TC
3
$138.34
91132
26
3
$27.93
91133
26
3
$35.76
92060
26
3
$34.75
92060
TC
3
$19.09
92065
26
3
$17.53
92065
TC
3
$25.01
92081
26
3
$17.91
92081
TC
3
$30.56
92082
26
3
$21.87
92082
TC
3
$42.39
92083
26
3
$25.13
92083
TC
3
$48.30
Procedure Code Procedure Code Modifier Pricing Action Code Modifier Price 92135
26
3
$17.92
92135
TC
3
$24.64
92136
26
3
$27.67
92136
TC
3
$48.27
92235
26
3
$41.62
92235
TC
3
$76.12
92240
26
3
$56.66
92240
TC
3
$145.02
92250
26
3
$21.87
92250
TC
3
$44.24
92265
26
3
$39.14
92265
TC
3
$31.91
92270
26
3
$39.64
92270
TC
3
$42.26
92275
26
3
$51.60
92275
TC
3
$71.10
92283
26
3
$8.54
92283
TC
3
$33.52
92284
26
3
$11.41
92284
TC
3
$44.97
92285
26
3
$10.35
92285
TC
3
$28.34
92286
26
3
$33.31
92286
TC
3
$77.01
92541
26
3
$19.95
92541
TC
3
$37.45
92542
26
3
$16.46
92542
TC
3
$43.37
92543
26
3
$5.29
92543
TC
3
$22.42
92544
26
3
$12.86
92544
TC
3
$35.23
92545
26
3
$11.42
92545
TC
3
$33.75
92546
26
3
$14.30
Procedure Code Procedure Code Modifier Pricing Action Code Modifier Price 92546
TC
3
$67.03
92548
26
3
$25.00
92548
TC
3
$66.71
92585
26
3
$25.24
92585
TC
3
$73.97
92587
26
3
$6.73
92587
TC
3
$31.11
92588
26
3
$17.91
92588
TC
3
$44.15
92978
26
3
$99.03
92979
26
3
$79.88
93024
26
3
$62.73
93024
TC
3
$59.22
93025
26
3
$40.83
93025
TC
3
$174.92
93278
26
3
$12.87
93278
TC
3
$27.04
93303
26
3
$68.48
93303
TC
3
$150.07
93304
26
3
$38.74
93304
TC
3
$96.65
93307
26
3
$49.49
93307
TC
3
$127.52
93308
26
3
$29.03
93308
TC
3
$82.98
93312
26
3
$115.29
93312
TC
3
$211.03
93314
26
3
$65.22
93314
TC
3
$216.21
93315
26
3
$147.72
93317
26
3
$91.35
93318
26
3
$111.18
93320
26
3
$20.47
93320
TC
3
$57.59
93321
26
3
$8.18
Procedure Code Procedure Code Modifier Pricing Action Code Modifier Price 93321
TC
3
$26.32
93325
26
3
$3.85
93325
TC
3
$48.66
93350
26
3
$79.99
93350
TC
3
$132.89
93501
26
3
$167.67
93501
TC
3
$636.17
93505
26
3
$242.46
93505
TC
3
$511.45
93508
26
3
$233.09
93508
TC
3
$837.08
93510
26
3
$245.85
93510
TC
3
$1,082.05
93511
26
3
$285.00
93514
26
3
$391.97
93524
26
3
$392.96
93526
26
3
$338.74
93526
TC
3
$1,363.51
93527
26
3
$410.28
93528
26
3
$486.58
93529
26
3
$271.87
93530
26
3
$231.32
93531
26
3
$452.78
93532
26
3
$536.56
93533
26
3
$361.24
93555
26
3
$44.45
93555
TC
3
$70.63
93556
26
3
$45.54
93556
TC
3
$115.38
93561
26
3
$23.52
93562
26
3
$7.44
93571
26
3
$98.67
93572
26
3
$77.56
93600
26
3
$117.67
93602
26
3
$117.17
Procedure Code Procedure Code Modifier Pricing Action Code Modifier Price 93603
26
3
$117.41
93609
26
3
$277.65
93610
26
3
$166.54
93612
26
3
$165.67
93615
26
3
$53.47
93616
26
3
$68.35
93618
26
3
$238.55
93619
26
3
$412.08
93620
26
3
$647.42
93621
26
3
$117.09
93622
26
3
$171.14
93623
26
3
$158.76
93624
26
3
$270.75
93631
26
3
$396.51
93640
26
3
$194.77
93641
26
3
$329.69
93642
26
3
$270.77
93642
TC
3
$200.47
93660
26
3
$103.36
93660
TC
3
$68.87
93662
26
3
$153.23
93701
26
3
$8.90
93701
TC
3
$25.38
93724
26
3
$265.97
93724
TC
3
$66.01
93770
26
3
$7.80
93770
TC
3
$0.61
93875
26
3
$11.05
93875
TC
3
$90.99
93880
26
3
$30.54
93880
TC
3
$153.88
93882
26
3
$20.06
93882
TC
3
$143.91
93886
26
3
$46.49
93886
TC
3
$154.01
Procedure Code Procedure Code Modifier Pricing Action Code Modifier Price 93888
26
3
$31.49
93888
TC
3
$62.66
93890
26
3
$49.37
93890
TC
3
$97.85
93892
26
3
$56.21
93892
TC
3
$97.98
93893
26
3
$56.59
93893
TC
3
$97.98
93922
26
3
$12.37
93922
TC
3
$108.85
93923
26
3
$22.59
93923
TC
3
$164.25
93924
26
3
$25.72
93924
TC
3
$204.53
93925
26
3
$29.08
93925
TC
3
$154.29
93926
26
3
$19.70
93926
TC
3
$98.50
93930
26
3
$23.31
93930
TC
3
$153.74
93931
26
3
$15.49
93931
TC
3
$98.11
93965
26
3
$17.42
93965
TC
3
$106.40
93970
26
3
$34.24
93970
TC
3
$153.49
93971
26
3
$22.72
93971
TC
3
$97.85
93975
26
3
$91.46
93975
TC
3
$154.13
93976
26
3
$60.70
93976
TC
3
$152.99
93978
26
3
$32.80
93978
TC
3
$153.49
93979
26
3
$21.99
Procedure Code Procedure Code Modifier Pricing Action Code Modifier Price 93979
TC
3
$98.11
93980
26
3
$64.70
93980
TC
3
$117.95
93981
26
3
$22.12
93981
TC
3
$106.52
93990
26
3
$12.24
93990
TC
3
$98.63
94010
26
3
$8.16
94010
TC
3
$24.88
94060
26
3
$14.28
94060
TC
3
$43.58
94070
26
3
$28.08
94070
TC
3
$31.23
94150
26
3
$3.85
94150
TC
3
$18.73
94200
26
3
$5.28
94200
TC
3
$17.12
94240
26
3
$12.12
94240
TC
3
$26.71
94250
26
3
$5.28
94250
TC
3
$19.09
94260
26
3
$6.00
94260
TC
3
$25.36
94350
26
3
$12.12
94350
TC
3
$22.40
94360
26
3
$12.12
94360
TC
3
$31.02
94370
26
3
$12.12
94370
TC
3
$21.19
94375
26
3
$14.28
94375
TC
3
$22.66
94400
26
3
$19.08
94400
TC
3
$33.23
94450
26
3
$18.47
94450
TC
3
$31.91
Procedure Code Procedure Code Modifier Pricing Action Code Modifier Price 94452
26
3
$14.51
94452
TC
3
$41.15
94453
26
3
$18.84
94453
TC
3
$55.57
94620
26
3
$30.24
94620
TC
3
$40.85
94621
26
3
$69.56
94621
TC
3
$91.49
94680
26
3
$12.12
94680
TC
3
$45.43
94681
26
3
$9.23
94681
TC
3
$53.16
94690
26
3
$3.48
94690
TC
3
$47.18
94720
26
3
$12.12
94720
TC
3
$39.15
94725
26
3
$12.12
94725
TC
3
$54.26
94750
26
3
$10.67
94750
TC
3
$60.49
94770
26
3
$7.08
94770
TC
3
$29.04
95805
26
3
$90.04
95805
TC
3
$334.23
95807
26
3
$78.98
95807
TC
3
$418.22
95808
26
3
$126.65
95808
TC
3
$524.33
95810
26
3
$166.83
95810
TC
3
$607.88
95811
26
3
$179.30
95811
TC
3
$674.68
95812
26
3
$52.97
95812
TC
3
$184.53
95813
26
3
$84.31
Procedure Code Procedure Code Modifier Pricing Action Code Modifier Price 95813
TC
3
$206.35
95816
26
3
$52.97
95816
TC
3
$164.70
95819
26
3
$52.97
95819
TC
3
$180.97
95822
26
3
$52.97
95822
TC
3
$179.84
95824
26
3
$36.28
95827
26
3
$52.36
95827
TC
3
$325.74
95829
26
3
$307.37
95829
TC
3
$905.90
95860
26
3
$48.44
95860
TC
3
$31.91
95861
26
3
$77.41
95861
TC
3
$38.78
95863
26
3
$92.64
95863
TC
3
$45.81
95864
26
3
$99.15
95864
TC
3
$59.81
95865
26
3
$79.83
95865
TC
3
$31.41
95866
26
3
$63.35
95866
TC
3
$27.70
95867
26
3
$39.30
95867
TC
3
$30.54
95868
26
3
$58.53
95868
TC
3
$37.06
95869
26
3
$18.50
95869
TC
3
$26.36
95870
26
3
$18.50
95870
TC
3
$25.25
95873
26
3
$19.62
95873
TC
3
$25.99
95874
26
3
$18.87
Procedure Code Procedure Code Modifier Pricing Action Code Modifier Price 95874
TC
3
$24.14
95875
26
3
$54.18
95875
TC
3
$37.30
95900
26
3
$21.03
95900
TC
3
$31.54
95903
26
3
$29.56
95903
TC
3
$31.91
95904
26
3
$17.06
95904
TC
3
$29.32
95920
26
3
$105.49
95920
TC
3
$42.72
95921
26
3
$43.85
95921
TC
3
$28.58
95922
26
3
$46.96
95922
TC
3
$40.04
95923
26
3
$44.45
95923
TC
3
$70.35
95925
26
3
$26.91
95925
TC
3
$90.17
95926
26
3
$26.67
95926
TC
3
$88.32
95927
26
3
$27.28
95927
TC
3
$90.54
95928
26
3
$73.16
95928
TC
3
$113.48
95929
26
3
$73.53
95929
TC
3
$123.46
95930
26
3
$17.42
95930
TC
3
$86.75
95933
26
3
$29.44
95933
TC
3
$33.60
95934
26
3
$25.36
95934
TC
3
$21.92
95936
26
3
$27.40
95936
TC
3
$14.16
Procedure Code Procedure Code Modifier Pricing Action Code Modifier Price 95937
26
3
$33.28
95937
TC
3
$22.66
95950
26
3
$73.99
95950
TC
3
$160.78
95951
26
3
$294.18
95953
26
3
$160.82
95953
TC
3
$236.20
95956
26
3
$151.23
95956
TC
3
$555.26
95957
26
3
$97.42
95957
TC
3
$160.00
95961
26
3
$155.34
95961
TC
3
$71.19
95962
26
3
$161.19
95962
TC
3
$47.52
95965
26
3
$402.28
95966
26
3
$200.37
95967
26
3
$171.43
A7017
RR
3
$12.82
A7017
UE
3
$96.17
B9000
RR
3
$125.00
B9000
UE
3
$741.00
B9002
RR
3
$125.00
B9002
UE
3
$741.00
B9004
RR
3
$403.88
B9004
UE
3
$1,913.41
B9006
RR
3
$400.00
B9006
UE
3
$1,478.10
E0100
RR
3
$4.84
E0100
UE
3
$16.08
E0105
RR
3
$7.46
E0105
UE
3
$32.84
E0110
RR
3
$15.31
E0110
UE
3
$52.16
E0111
RR
3
$8.06
Procedure Code Procedure Code Modifier Pricing Action Code Modifier Price E0111
UE
3
$39.32
E0112
RR
3
$9.50
E0112
UE
3
$27.00
E0113
RR
3
$4.92
E0113
UE
3
$15.18
E0114
RR
3
$8.20
E0114
UE
3
$34.12
E0116
RR
3
$5.17
E0116
UE
3
$17.07
E0130
RR
3
$16.10
E0130
UE
3
$51.20
E0135
RR
3
$16.51
E0135
UE
3
$56.91
E0141
RR
3
$21.39
E0141
UE
3
$82.73
E0143
RR
3
$20.66
E0143
UE
3
$86.08
E0144
RR
3
$25.91
E0144
UE
3
$194.21
E0147
RR
3
$54.98
E0147
UE
3
$412.45
E0148
RR
3
$12.17
E0148
UE
3
$91.15
E0149
RR
3
$21.35
E0149
UE
3
$160.14
E0153
RR
3
$7.49
E0153
UE
3
$49.77
E0154
RR
3
$8.19
E0154
UE
3
$49.77
E0155
RR
3
$3.68
E0155
UE
3
$23.01
E0156
RR
3
$3.23
E0156
UE
3
$18.99
E0157
RR
3
$8.60
E0157
UE
3
$49.97
Procedure Code Procedure Code Modifier Pricing Action Code Modifier Price E0158
RR
3
$3.39
E0158
UE
3
$23.24
E0160
RR
3
$4.14
E0160
UE
3
$23.70
E0161
RR
3
$3.41
E0161
UE
3
$18.80
E0162
RR
3
$14.62
E0162
UE
3
$108.10
E0163
RR
3
$23.37
E0163
UE
3
$81.36
E0165
RR
3
$15.32
E0165
UE
3
$96.45
E0167
RR
3
$1.21
E0167
UE
3
$7.58
E0168
RR
3
$14.50
E0168
UE
3
$108.28
E0175
RR
3
$5.39
E0175
UE
3
$39.64
E0181
RR
3
$22.47
E0181
UE
3
$201.60
E0182
RR
3
$25.05
E0182
UE
3
$216.38
E0183
UE
9
$233.34
E0184
RR
3
$23.50
E0184
UE
3
$142.86
E0185
RR
3
$42.99
E0185
UE
3
$234.85
E0186
RR
3
$19.42
E0187
RR
3
$22.21
E0188
UE
3
$14.04
E0189
RR
3
$3.63
E0189
UE
3
$23.31
E0191
RR
3
$0.97
E0191
UE
3
$7.14
E0193
RR
3
$806.39
Procedure Code Procedure Code Modifier Pricing Action Code Modifier Price E0193
UE
3
$5,217.23
E0194
RR
3
$3,113.39
E0196
RR
3
$30.54
E0197
RR
3
$29.25
E0197
UE
3
$186.21
E0198
RR
3
$21.96
E0198
UE
3
$160.86
E0199
RR
3
$3.06
E0199
UE
3
$23.00
E0200
RR
3
$10.29
E0200
UE
3
$56.90
E0202
RR
3
$59.90
E0202
UE
3
$673.58
E0205
RR
3
$20.42
E0205
UE
3
$118.35
E0210
RR
3
$2.94
E0210
UE
3
$23.42
E0215
RR
3
$7.09
E0215
UE
3
$50.83
E0217
RR
3
$44.96
E0217
UE
3
$302.77
E0225
RR
3
$31.15
E0225
UE
3
$237.02
E0235
RR
3
$16.51
E0235
UE
3
$148.28
E0236
RR
3
$38.12
E0238
RR
3
$2.60
E0238
UE
3
$19.02
E0239
RR
3
$43.04
E0239
UE
3
$322.78
E0249
RR
3
$10.47
E0249
UE
3
$71.46
E0250
RR
3
$93.53
E0250
UE
3
$712.05
E0251
RR
3
$70.87
Procedure Code Procedure Code Modifier Pricing Action Code Modifier Price E0251
UE
3
$601.88
E0255
RR
3
$112.39
E0255
UE
3
$688.88
E0256
RR
3
$75.06
E0260
RR
3
$160.65
E0260
UE
3
$1,083.60
E0261
RR
3
$131.01
E0265
RR
3
$191.23
E0265
UE
3
$1,412.85
E0266
RR
3
$144.42
E0266
UE
3
$938.40
E0271
RR
3
$22.07
E0271
UE
3
$165.95
E0272
RR
3
$20.21
E0272
UE
3
$139.85
E0275
RR
3
$1.52
E0275
UE
3
$10.98
E0276
RR
3
$1.49
E0276
UE
3
$10.07
E0277
RR
3
$642.27
E0280
RR
3
$3.93
E0280
UE
3
$26.55
E0290
RR
3
$71.50
E0291
RR
3
$51.95
E0292
RR
3
$74.50
E0293
RR
3
$68.41
E0294
RR
3
$124.99
E0295
RR
3
$121.83
E0296
RR
3
$157.09
E0297
RR
3
$114.39
E0305
RR
3
$17.02
E0305
UE
3
$104.02
E0310
RR
3
$21.78
E0310
UE
3
$140.55
E0325
UE
3
$6.40
Procedure Code Procedure Code Modifier Pricing Action Code Modifier Price E0326
RR
3
$1.14
E0326
UE
3
$7.07
E0371
RR
5
$415.05
E0372
RR
3
$503.67
E0373
RR
5
$576.95
E0424
RR
3
$230.17
E0431
RR
3
$36.19
E0434
RR
3
$36.19
E0439
RR
3
$230.17
E0445
RR
3
$195.00
E0450
RR
3
$850.00
E0451
UE
O
$4,296.56
E0453
RR
9
$520.64
E0457
RR
3
$58.79
E0459
RR
3
$48.69
E0462
RR
3
$278.78
E0462
UE
3
$1,831.27
E0480
RR
3
$42.04
E0480
UE
3
$289.20
E0484
RR
3
$3.69
E0484
UE
3
$27.70
E0500
RR
3
$98.86
E0550
RR
3
$47.95
E0550
UE
3
$373.50
E0560
RR
3
$19.23
E0560
UE
3
$123.07
E0565
RR
3
$49.61
E0565
UE
3
$318.83
E0570
RR
3
$18.88
E0571
RR
5
$28.12
E0572
RR
5
$35.76
E0574
RR
5
$37.81
E0575
RR
3
$94.83
E0585
RR
3
$33.55
E0600
RR
3
$43.80
Procedure Code Procedure Code Modifier Pricing Action Code Modifier Price E0601
RR
3
$99.59
E0603
RR
3
$74.28
E0605
RR
3
$2.94
E0605
UE
3
$20.82
E0606
RR
3
$18.66
E0610
RR
3
$24.00
E0610
UE
3
$170.69
E0615
RR
3
$55.97
E0615
UE
3
$302.46
E0618
RR
3
$300.00
E0619
RR
3
$330.00
E0621
RR
3
$8.85
E0621
UE
3
$69.23
E0627
RR
3
$31.64
E0627
UE
3
$237.27
E0628
RR
3
$31.64
E0628
UE
3
$237.27
E0629
RR
3
$31.64
E0629
UE
3
$237.27
E0630
RR
3
$97.47
E0630
UE
3
$662.78
E0635
RR
3
$99.50
E0635
UE
3
$637.65
E0650
RR
3
$85.01
E0650
UE
3
$516.77
E0651
RR
3
$87.87
E0651
UE
3
$658.99
E0652
RR
3
$501.26
E0652
UE
3
$3,759.53
E0655
RR
3
$12.13
E0655
UE
3
$65.91
E0660
RR
3
$15.91
E0660
UE
3
$104.30
E0665
RR
3
$13.46
E0665
UE
3
$83.66
Procedure Code Procedure Code Modifier Pricing Action Code Modifier Price E0666
RR
3
$13.62
E0666
UE
3
$84.24
E0667
RR
3
$30.98
E0667
UE
3
$232.30
E0668
RR
3
$35.46
E0668
UE
3
$269.50
E0669
RR
3
$16.66
E0669
UE
3
$124.90
E0720
RR
3
$29.59
E0730
RR
3
$33.38
E0730
UE
3
$265.88
E0744
RR
3
$87.60
E0744
UE
3
$632.40
E0745
RR
3
$85.64
E0745
UE
3
$603.75
E0746
UE
O
$521.09
E0776
RR
3
$17.84
E0776
UE
3
$100.76
E0781
RR
3
$215.39
E0781
UE
3
$1,335.90
E0782
UE
O
$2,774.69
E0791
RR
3
$257.13
E0791
UE
3
$1,391.93
E0840
RR
3
$15.61
E0840
UE
3
$44.67
E0850
RR
3
$12.65
E0850
UE
3
$64.08
E0855
RR
3
$48.08
E0855
UE
3
$360.64
E0860
RR
3
$6.23
E0860
UE
3
$28.23
E0870
RR
3
$12.65
E0870
UE
3
$75.39
E0880
RR
3
$18.86
E0880
UE
3
$77.27
Procedure Code Procedure Code Modifier Pricing Action Code Modifier Price E0890
RR
3
$30.34
E0890
UE
3
$78.87
E0900
RR
3
$26.43
E0900
UE
3
$78.17
E0910
RR
3
$19.13
E0910
UE
3
$131.93
E0920
RR
3
$44.14
E0920
UE
3
$292.05
E0930
RR
3
$39.52
E0930
UE
3
$254.40
E0935
RR
5
$21.75
E0940
RR
3
$33.26
E0940
UE
3
$217.20
E0941
RR
3
$38.56
E0941
UE
3
$278.40
E0942
RR
3
$2.24
E0942
UE
3
$14.22
E0944
RR
3
$4.40
E0944
UE
3
$32.92
E0945
RR
3
$4.24
E0945
UE
3
$32.83
E0946
RR
3
$56.60
E0946
UE
3
$408.08
E0947
RR
3
$60.17
E0947
UE
3
$435.14
E0948
RR
3
$56.10
E0948
UE
3
$395.78
E0950
RR
3
$9.96
E0950
UE
3
$74.59
E0951
RR
3
$1.81
E0951
UE
3
$13.52
E0952
RR
3
$1.81
E0952
UE
3
$13.52
E0958
RR
3
$41.74
E0958
UE
3
$278.25
Procedure Code Procedure Code Modifier Pricing Action Code Modifier Price E0959
RR
3
$8.50
E0959
UE
3
$64.02
E0961
RR
3
$2.78
E0961
UE
3
$20.86
E0966
RR
3
$6.19
E0966
UE
3
$46.45
E0967
RR
3
$12.65
E0967
UE
3
$94.83
E0968
RR
3
$17.15
E0968
UE
3
$111.15
E0969
RR
3
$13.99
E0969
UE
3
$104.89
E0970
RR
3
$4.11
E0970
UE
3
$34.56
E0971
RR
3
$7.14
E0971
UE
3
$47.17
E0973
RR
3
$10.47
E0973
UE
3
$82.50
E0974
RR
3
$7.95
E0974
UE
3
$56.69
E0978
RR
3
$4.26
E0978
UE
3
$32.12
E0980
RR
3
$3.15
E0980
UE
3
$23.59
E0990
RR
3
$12.65
E0990
UE
3
$87.77
E0992
RR
3
$8.85
E0992
UE
3
$66.38
E0994
RR
3
$1.52
E0994
UE
3
$11.37
E0995
RR
3
$2.54
E0995
UE
3
$18.99
E1031
RR
3
$48.32
E1031
UE
3
$352.50
E1050
RR
3
$97.43
Procedure Code Procedure Code Modifier Pricing Action Code Modifier Price E1050
UE
3
$651.53
E1060
RR
3
$120.61
E1060
UE
3
$769.57
E1070
RR
3
$89.06
E1070
UE
3
$544.05
E1083
RR
3
$75.33
E1083
UE
3
$462.83
E1084
RR
3
$93.85
E1084
UE
3
$590.70
E1085
RR
3
$66.21
E1085
UE
3
$443.55
E1086
RR
3
$80.40
E1086
UE
3
$540.83
E1087
RR
3
$121.03
E1087
UE
3
$855.90
E1088
RR
3
$144.24
E1088
UE
3
$890.63
E1089
RR
3
$114.99
E1089
UE
3
$798.38
E1090
RR
3
$110.73
E1090
UE
3
$633.38
E1091
RR
3
$79.76
E1091
UE
3
$640.80
E1092
RR
3
$122.94
E1092
UE
3
$896.93
E1093
RR
3
$105.74
E1093
UE
3
$763.13
E1100
RR
3
$99.32
E1100
UE
3
$627.53
E1110
RR
3
$82.66
E1110
UE
3
$541.05
E1130
RR
3
$44.67
E1130
UE
3
$316.05
E1140
RR
3
$68.73
E1140
UE
3
$498.08
Procedure Code Procedure Code Modifier Pricing Action Code Modifier Price E1150
RR
3
$78.04
E1150
UE
3
$581.48
E1160
RR
3
$59.79
E1160
UE
3
$420.00
E1170
RR
3
$85.45
E1170
UE
3
$522.98
E1171
RR
3
$68.33
E1171
UE
3
$480.08
E1172
RR
3
$87.87
E1172
UE
3
$537.75
E1180
RR
3
$82.41
E1180
UE
3
$497.33
E1190
RR
3
$112.01
E1190
UE
3
$693.08
E1195
RR
3
$102.16
E1195
UE
3
$562.95
E1200
RR
3
$73.20
E1200
UE
3
$447.97
E1221
RR
3
$45.45
E1222
RR
3
$64.85
E1223
RR
3
$70.81
E1223
UE
3
$477.15
E1224
RR
3
$77.64
E1225
RR
3
$43.24
E1228
RR
3
$22.79
E1230
RR
3
$194.69
E1230
UE
3
$1,454.64
E1240
RR
3
$98.55
E1240
UE
3
$641.18
E1250
RR
3
$72.71
E1250
UE
3
$441.68
E1260
RR
3
$75.79
E1260
UE
3
$467.33
E1270
RR
3
$64.19
E1270
UE
3
$407.63
Procedure Code Procedure Code Modifier Pricing Action Code Modifier Price E1280
RR
3
$106.74
E1280
UE
3
$681.23
E1285
RR
3
$98.07
E1285
UE
3
$592.05
E1290
RR
3
$101.77
E1290
UE
3
$566.33
E1295
RR
3
$111.11
E1295
UE
3
$679.95
E1296
RR
3
$40.61
E1296
UE
3
$299.87
E1297
RR
3
$9.44
E1297
UE
3
$63.79
E1298
RR
3
$36.55
E1298
UE
3
$274.02
E1310
RR
3
$175.72
E1310
UE
3
$1,540.80
E1353
RR
5
$308.71
E1355
RR
3
$4.67
E1355
UE
3
$35.00
E1372
RR
3
$22.66
E1372
UE
3
$115.46
E1390
RR
3
$230.17
E1405
RR
5
$263.04
E1406
RR
5
$248.37
E2000
RR
3
$50.57
G0202
26
3
$33.81
G0202
TC
3
$102.79
G0204
26
3
$42.24
G0204
TC
3
$112.23
G0206
26
3
$33.81
G0206
TC
3
$89.51
G0252
26
3
$74.46
G0252
TC
3
$447.50
K0001
RR
3
$53.27
K0001
UE
3
$399.52
Procedure Code Procedure Code Modifier Pricing Action Code Modifier Price K0002
RR
5
$81.43
K0003
RR
3
$76.15
K0004
RR
3
$113.03
K0005
RR
3
$183.95
K0005
UE
3
$1,379.69
K0006
RR
5
$106.07
K0015
RR
3
$18.09
K0015
UE
3
$135.60
K0017
RR
3
$5.08
K0017
UE
3
$38.14
K0018
RR
3
$2.83
K0018
UE
3
$21.33
K0019
RR
3
$1.63
K0019
UE
3
$12.19
K0020
RR
3
$4.63
K0020
UE
3
$34.66
K0037
RR
3
$4.28
K0037
UE
3
$35.95
K0038
RR
3
$2.41
K0038
UE
3
$18.11
K0039
RR
3
$5.37
K0039
UE
3
$40.21
K0040
RR
3
$7.41
K0040
UE
3
$55.71
K0041
RR
3
$5.28
K0042
RR
3
$3.61
K0042
UE
3
$27.18
K0043
RR
3
$1.94
K0043
UE
3
$14.59
K0044
RR
3
$1.66
K0044
UE
3
$12.41
K0045
RR
3
$5.64
K0045
UE
3
$42.26
K0046
RR
3
$1.94
K0046
UE
3
$14.59
Procedure Code Procedure Code Modifier Pricing Action Code Modifier Price K0047
RR
3
$7.64
K0047
UE
3
$57.06
K0050
RR
3
$3.22
K0050
UE
3
$24.26
K0051
RR
3
$5.26
K0051
UE
3
$39.24
K0052
RR
3
$9.19
K0052
UE
3
$68.98
K0053
RR
3
$10.14
K0053
UE
3
$76.13
K0056
RR
3
$9.47
K0056
UE
3
$70.98
K0065
RR
3
$4.43
K0065
UE
3
$33.18
K0069
RR
3
$9.94
K0069
UE
3
$74.56
K0070
RR
3
$15.50
K0070
UE
3
$136.70
K0071
RR
3
$10.87
K0071
UE
3
$81.52
K0072
RR
3
$6.54
K0072
UE
3
$49.07
K0073
RR
3
$3.46
K0073
UE
3
$25.97
K0077
RR
3
$5.85
K0077
UE
3
$43.91
K0098
RR
3
$2.71
K0098
UE
3
$20.29
K0105
RR
3
$9.88
K0105
UE
3
$74.20
K0193
RR
9
$107.84
K0195
RR
3
$21.07
Q0037
RR
5
$275.35
Procedure Percentage Pricing Procedure Code
Description
Pricing Percent
D0120
PERIODIC ORAL EVALUATION
80%
D0140
LIMIT ORAL EVAL PROBLM FOCUS
80%
D0145
ORAL EVALUATION, PT < 3YRS
80%
D0150
COMPREHENSVE ORAL EVALUATION
80%
D0160
EXTENSV ORAL EVAL PROB FOCUS
80%
D0170
RE-EVAL,EST PT,PROBLEM FOCUS
80%
D0210
INTRAOR COMPLETE FILM SERIES
80%
D0220
INTRAORAL PERIAPICAL FIRST F
80%
D0230
INTRAORAL PERIAPICAL EA ADD
80%
D0240
INTRAORAL OCCLUSAL FILM
80%
D0250
EXTRAORAL FIRST FILM
80%
D0260
EXTRAORAL EA ADDITIONAL FILM
80%
D0270
DENTAL BITEWING SINGLE FILM
80%
D0272
DENTAL BITEWINGS TWO FILMS
80%
D0273
BITEWINGS - THREE FILMS
80%
D0274
DENTAL BITEWINGS FOUR FILMS
80%
D0277
VERT BITEWINGS-SEV TO EIGHT
80%
D0290
DENTAL FILM SKULL/FACIAL BON
80%
D0310
DENTAL SALIOGRAPHY
80%
D0320
DENTAL TMJ ARTHROGRAM INCL I
80%
D0321
DENTAL OTHER TMJ FILMS
80%
D0322
DENTAL TOMOGRAPHIC SURVEY
80%
D0330
DENTAL PANORAMIC FILM
80%
D0340
DENTAL CEPHALOMETRIC FILM
80%
D0360
CONE BEAM CT
80%
D0362
CONE BEAM, TWO DIMENSIONAL
80%
D0363
CONE BEAM, THREE DIMENSIONAL
80%
D0460
PULP VITALITY TEST
80%
D0470
DIAGNOSTIC CASTS
80%
D0472
GROSS EXAM, PREP & REPORT
80%
D0473
MICRO EXAM, PREP & REPORT
80%
D0474
MICRO W EXAM OF SURG MARGINS
80%
D0480
CYTOPATH SMEAR PREP & REPORT
80%
Procedure Code
Description
Pricing Percent
D0502
OTHER ORAL PATHOLOGY PROCEDU
80%
D0999
UNSPECIFIED DIAGNOSTIC PROCE
80%
D1110
DENTAL PROPHYLAXIS ADULT
80%
D1120
DENTAL PROPHYLAXIS CHILD
80%
D1203
TOPICAL APP FLUORIDE CHILD
80%
D1204
TOPICAL APP FLUORIDE ADULT
80%
D1206
TOPICAL FLUORIDE VARNISH
80%
D1320
TOBACCO COUNSELING
80%
D1351
DENTAL SEALANT PER TOOTH
80%
D1510
SPACE MAINTAINER FXD UNILAT
80%
D1515
FIXED BILAT SPACE MAINTAINER
80%
D1520
REMOVE UNILAT SPACE MAINTAIN
80%
D1525
REMOVE BILAT SPACE MAINTAIN
80%
D1550
RECEMENT SPACE MAINTAINER
80%
D1555
REMOVE FIX SPACE MAINTAINER
80%
D2140
AMALGAM ONE SURFACE PERMANEN
80%
D2150
AMALGAM TWO SURFACES PERMANE
80%
D2160
AMALGAM THREE SURFACES PERMA
80%
D2161
AMALGAM 4 OR > SURFACES PERM
80%
D2330
RESIN ONE SURFACE-ANTERIOR
80%
D2331
RESIN TWO SURFACES-ANTERIOR
80%
D2332
RESIN THREE SURFACES-ANTERIO
80%
D2335
RESIN 4/> SURF OR W INCIS AN
80%
D2390
ANT RESIN-BASED CMPST CROWN
80%
D2391
POST 1 SRFC RESINBASED CMPST
80%
D2392
POST 2 SRFC RESINBASED CMPST
80%
D2393
POST 3 SRFC RESINBASED CMPST
80%
D2394
POST >=4SRFC RESINBASE CMPST
80%
D2710
CROWN RESIN-BASED INDIRECT
80%
D2712
CROWN 3/4 RESIN-BASED COMPOS
80%
D2721
CROWN RESIN W/ BASE METAL
80%
D2722
CROWN RESIN W/ NOBLE METAL
80%
D2751
CROWN PORCELAIN FUSED BASE M
80%
D2752
CROWN PORCELAIN W/ NOBLE MET
80%
D2781
CROWN 3/4 CAST BASE METAL
80%
Procedure Code
Description
Pricing Percent
D2782
CROWN 3/4 CAST NOBLE METAL
80%
D2791
CROWN FULL CAST BASE METAL
80%
D2792
CROWN FULL CAST NOBLE METAL
80%
D2799
PROVISIONAL CROWN
80%
D2910
RECEMENT INLAY ONLAY OR PART
80%
D2915
RECEMENT CAST OR PREFAB POST
80%
D2920
DENTAL RECEMENT CROWN
80%
D2930
PREFAB STNLSS STEEL CRWN PRI
80%
D2931
PREFAB STNLSS STEEL CROWN PE
80%
D2932
PREFABRICATED RESIN CROWN
80%
D2933
PREFAB STAINLESS STEEL CROWN
80%
D2934
PREFAB STEEL CROWN PRIMARY
80%
D2940
DENTAL SEDATIVE FILLING
80%
D2950
CORE BUILD-UP INCL ANY PINS
80%
D2951
TOOTH PIN RETENTION
80%
D2952
POST AND CORE CAST + CROWN
80%
D2953
EACH ADDTNL CAST POST
80%
D2954
PREFAB POST/CORE + CROWN
80%
D2955
POST REMOVAL
80%
D2957
EACH ADDTNL PREFAB POST
80%
D2970
TEMPORARY- FRACTURED TOOTH
80%
D2980
CROWN REPAIR
80%
D2999
DENTAL UNSPEC RESTORATIVE PR
80%
D3110
PULP CAP DIRECT
80%
D3120
PULP CAP INDIRECT
80%
D3220
THERAPEUTIC PULPOTOMY
80%
D3221
GROSS PULPAL DEBRIDEMENT
80%
D3222
PART PULP FOR APEXOGENESIS
80%
D3230
PULPAL THERAPY ANTERIOR PRIM
80%
D3240
PULPAL THERAPY POSTERIOR PRI
80%
D3310
END THXPY, ANTERIOR TOOTH
80%
D3320
END THXPY, BICUSPID TOOTH
80%
D3330
END THXPY, MOLAR
80%
D3332
INCOMPLETE ENDODONTIC TX
80%
D3333
INTERNAL ROOT REPAIR
80%
Procedure Code
Description
Pricing Percent
D3346
RETREAT ROOT CANAL ANTERIOR
80%
D3347
RETREAT ROOT CANAL BICUSPID
80%
D3348
RETREAT ROOT CANAL MOLAR
80%
D3351
APEXIFICATION/RECALC INITIAL
80%
D3352
APEXIFICATION/RECALC INTERIM
80%
D3353
APEXIFICATION/RECALC FINAL
80%
D3410
APICOECT/PERIRAD SURG ANTER
80%
D3421
ROOT SURGERY BICUSPID
80%
D3425
ROOT SURGERY MOLAR
80%
D3426
ROOT SURGERY EA ADD ROOT
80%
D3430
RETROGRADE FILLING
80%
D3450
ROOT AMPUTATION
80%
D3470
INTENTIONAL REPLANTATION
80%
D3910
ISOLATION- TOOTH W RUBB DAM
80%
D3999
ENDODONTIC PROCEDURE
80%
D4210
GINGIVECTOMY/PLASTY PER QUAD
80%
D4211
GINGIVECTOMY/PLASTY PER TOOT
80%
D4230
ANA CROWN EXP 4 OR> PER QUAD
80%
D4231
ANA CROWN EXP 1-3 PER QUAD
80%
D4240
GINGIVAL FLAP PROC W/ PLANIN
80%
D4241
GNGVL FLAP W ROOTPLAN 1-3 TH
80%
D4245
APICALLY POSITIONED FLAP
80%
D4249
CROWN LENGTHEN HARD TISSUE
80%
D4260
OSSEOUS SURGERY PER QUADRANT
80%
D4261
OSSEOUS SURGL-3TEETHPERQUAD
80%
D4263
BONE REPLCE GRAFT FIRST SITE
80%
D4264
BONE REPLCE GRAFT EACH ADD
80%
D4265
BIO MTRLS TO AID SOFT/OS REG
80%
D4266
GUIDED TISS REGEN RESORBLE
80%
D4267
GUIDED TISS REGEN NONRESORB
80%
D4268
SURGICAL REVISION PROCEDURE
80%
D4270
PEDICLE SOFT TISSUE GRAFT PR
80%
D4271
FREE SOFT TISSUE GRAFT PROC
80%
D4273
SUBEPITHELIAL TISSUE GRAFT
80%
D4274
DISTAL/PROXIMAL WEDGE PROC
80%
Procedure Code
Description
Pricing Percent
D4275
SOFT TISSUE ALLOGRAFT
80%
D4276
CON TISSUE W DBLE PED GRAFT
80%
D4320
PROVISION SPLNT INTRACORONAL
80%
D4321
PROVISIONAL SPLINT EXTRACORO
80%
D4341
PERIODONTAL SCALING & ROOT
80%
D4342
PERIODONTAL SCALING 1-3TEETH
80%
D4355
FULL MOUTH DEBRIDEMENT
80%
D4381
LOCALIZED DELIVERY ANTIMICRO
80%
D4910
PERIODONTAL MAINT PROCEDURES
80%
D4920
UNSCHEDULED DRESSING CHANGE
80%
D4999
UNSPECIFIED PERIODONTAL PROC
80%
D5110
DENTURES COMPLETE MAXILLARY
80%
D5120
DENTURES COMPLETE MANDIBLE
80%
D5130
DENTURES IMMEDIAT MAXILLARY
80%
D5140
DENTURES IMMEDIAT MANDIBLE
80%
D5211
DENTURES MAXILL PART RESIN
80%
D5212
DENTURES MAND PART RESIN
80%
D5213
DENTURES MAXILL PART METAL
80%
D5214
DENTURES MANDIBL PART METAL
80%
D5225
MAXILLARY PART DENTURE FLEX
80%
D5226
MANDIBULAR PART DENTURE FLEX
80%
D5410
DENTURES ADJUST CMPLT MAXIL
80%
D5411
DENTURES ADJUST CMPLT MAND
80%
D5421
DENTURES ADJUST PART MAXILL
80%
D5422
DENTURES ADJUST PART MANDBL
80%
D5510
DENTUR REPR BROKEN COMPL BAS
80%
D5520
REPLACE DENTURE TEETH COMPLT
80%
D5610
DENTURES REPAIR RESIN BASE
80%
D5620
REP PART DENTURE CAST FRAME
80%
D5630
REP PARTIAL DENTURE CLASP
80%
D5640
REPLACE PART DENTURE TEETH
80%
D5650
ADD TOOTH TO PARTIAL DENTURE
80%
D5660
ADD CLASP TO PARTIAL DENTURE
80%
D5670
REPLC TTH&ACRLC ON MTL FRMWK
80%
D5671
REPLC TTH&ACRLC MANDIBULAR
80%
Procedure Code
Description
Pricing Percent
D5730
DENTURE RELN CMPLT MAXIL CH
80%
D5731
DENTURE RELN CMPLT MAND CHR
80%
D5740
DENTURE RELN PART MAXIL CHR
80%
D5741
DENTURE RELN PART MAND CHR
80%
D5750
DENTURE RELN CMPLT MAX LAB
80%
D5751
DENTURE RELN CMPLT MAND LAB
80%
D5760
DENTURE RELN PART MAXIL LAB
80%
D5761
DENTURE RELN PART MAND LAB
80%
D5810
DENTURE INTERM CMPLT MAXILL
80%
D5811
DENTURE INTERM CMPLT MANDBL
80%
D5820
DENTURE INTERM PART MAXILL
80%
D5821
DENTURE INTERM PART MANDBL
80%
D5850
DENTURE TISS CONDITN MAXILL
80%
D5851
DENTURE TISS CONDTIN MANDBL
80%
D5899
REMOVABLE PROSTHODONTIC PROC
80%
D5911
FACIAL MOULAGE SECTIONAL
80%
D5912
FACIAL MOULAGE COMPLETE
80%
D5913
NASAL PROSTHESIS
80%
D5914
AURICULAR PROSTHESIS
80%
D5915
ORBITAL PROSTHESIS
80%
D5916
OCULAR PROSTHESIS
80%
D5919
FACIAL PROSTHESIS
80%
D5922
NASAL SEPTAL PROSTHESIS
80%
D5923
OCULAR PROSTHESIS INTERIM
80%
D5924
CRANIAL PROSTHESIS
80%
D5925
FACIAL AUGMENTATION IMPLANT
80%
D5926
REPLACEMENT NASAL PROSTHESIS
80%
D5927
AURICULAR REPLACEMENT
80%
D5928
ORBITAL REPLACEMENT
80%
D5929
FACIAL REPLACEMENT
80%
D5931
SURGICAL OBTURATOR
80%
D5932
POSTSURGICAL OBTURATOR
80%
D5933
REFITTING OF OBTURATOR
80%
D5934
MANDIBULAR FLANGE PROSTHESIS
80%
D5935
MANDIBULAR DENTURE PROSTH
80%
Procedure Code
Description
Pricing Percent
D5936
TEMP OBTURATOR PROSTHESIS
80%
D5937
TRISMUS APPLIANCE
80%
D5951
FEEDING AID
80%
D5952
PEDIATRIC SPEECH AID
80%
D5953
ADULT SPEECH AID
80%
D5954
SUPERIMPOSED PROSTHESIS
80%
D5955
PALATAL LIFT PROSTHESIS
80%
D5958
INTRAORAL CON DEF INTER PLT
80%
D5959
INTRAORAL CON DEF MOD PALAT
80%
D5960
MODIFY SPEECH AID PROSTHESIS
80%
D5986
FLUORIDE APPLICATOR
80%
D5987
COMMISSURE SPLINT
80%
D5988
SURGICAL SPLINT
80%
D5991
TOPICAL MEDICAMENT CARRIER
80%
D5999
MAXILLOFACIAL PROSTHESIS
80%
D6211
BRIDGE BASE METAL CAST
80%
D6212
BRIDGE NOBLE METAL CAST
80%
D6241
BRIDGE PORCELAIN BASE METAL
80%
D6242
BRIDGE PORCELAIN NOBEL METAL
80%
D6251
BRIDGE RESIN BASE METAL
80%
D6252
BRIDGE RESIN W/NOBLE METAL
80%
D6545
DENTAL RETAINR CAST METL
80%
D6721
CROWN RESIN W/BASE METAL
80%
D6722
CROWN RESIN W/NOBLE METAL
80%
D6751
CROWN PORCELAIN BASE METAL
80%
D6752
CROWN PORCELAIN NOBLE METAL
80%
D6791
CROWN FULL BASE METAL CAST
80%
D6792
CROWN FULL NOBLE METAL CAST
80%
D6930
DENTAL RECEMENT BRIDGE
80%
D6972
PREFAB POST & CORE PLUS RETA
80%
D6980
BRIDGE REPAIR
80%
D6985
PEDIATRIC PARTIAL DENTURE FX
80%
D6999
FIXED PROSTHODONTIC PROC
80%
D7111
EXTRACTION CORONAL REMNANTS
80%
D7140
EXTRACTION ERUPTED TOOTH/EXR
80%
Procedure Code
Description
Pricing Percent
D7210
REM IMP TOOTH W MUCOPER FLP
80%
D7220
IMPACT TOOTH REMOV SOFT TISS
80%
D7230
IMPACT TOOTH REMOV PART BONY
80%
D7240
IMPACT TOOTH REMOV COMP BONY
80%
D7241
IMPACT TOOTH REM BONY W/COMP
80%
D7250
TOOTH ROOT REMOVAL
80%
D7260
ORAL ANTRAL FISTULA CLOSURE
80%
D7261
PRIMARY CLOSURE SINUS PERF
80%
D7270
TOOTH REIMPLANTATION
80%
D7272
TOOTH TRANSPLANTATION
80%
D7280
EXPOSURE IMPACT TOOTH ORTHOD
80%
D7282
MOBILIZE ERUPTED/MALPOS TOOT
80%
D7283
PLACE DEVICE IMPACTED TOOTH
80%
D7290
REPOSITIONING OF TEETH
80%
D7291
TRANSSEPTAL FIBEROTOMY
80%
D7310
ALVEOPLASTY W/ EXTRACTION
80%
D7311
ALVEOLOPLASTY W/EXTRACT 1-3
80%
D7320
ALVEOPLASTY W/O EXTRACTION
80%
D7321
ALVEOLOPLASTY NOT W/EXTRACTS
80%
D7340
VESTIBULOPLASTY RIDGE EXTENS
80%
D7350
VESTIBULOPLASTY EXTEN GRAFT
80%
D7510
I&D ABSC INTRAORAL SOFT TISS
80%
D7511
INCISION/DRAIN ABSCESS INTRA
80%
D7520
I&D ABSCESS EXTRAORAL
80%
D7521
INCISION/DRAIN ABSCESS EXTRA
80%
D7530
REMOVAL FB SKIN/AREOLAR TISS
80%
D7540
REMOVAL OF FB REACTION
80%
D7550
REMOVAL OF SLOUGHED OFF BONE
80%
D7560
MAXILLARY SINUSOTOMY
80%
D7880
OCCLUSAL ORTHOTIC APPLIANCE
80%
D7899
TMJ UNSPECIFIED THERAPY
80%
D7910
DENT SUTUR RECENT WND TO 5CM
80%
D7911
DENTAL SUTURE WOUND TO 5 CM
80%
D7912
SUTURE COMPLICATE WND > 5 CM
80%
D7960
FRENULECTOMY/FRENULOTOMY
80%
Procedure Code
Description
Pricing Percent
D7963
FRENULOPLASTY
80%
D7970
EXCISION HYPERPLASTIC TISSUE
80%
D7971
EXCISION PERICORONAL GINGIVA
80%
D7997
APPLIANCE REMOVAL
80%
D7999
ORAL SURGERY PROCEDURE
80%
D8010
LIMITED DENTAL TX PRIMARY
80%
D8020
LIMITED DENTAL TX TRANSITION
80%
D8030
LIMITED DENTAL TX ADOLESCENT
80%
D8040
LIMITED DENTAL TX ADULT
80%
D8050
INTERCEP DENTAL TX PRIMARY
80%
D8060
INTERCEP DENTAL TX TRANSITN
80%
D8070
COMPRE DENTAL TX TRANSITION
80%
D8090
COMPRE DENTAL TX ADULT
80%
D8210
ORTHODONTIC REM APPLIANCE TX
80%
D8220
FIXED APPLIANCE THERAPY HABT
80%
D8680
ORTHODONTIC RETENTION
80%
D8690
ORTHODONTIC TREATMENT
80%
D8691
REPAIR ORTHO APPLIANCE
80%
D8692
REPLACEMENT RETAINER
80%
D8999
ORTHODONTIC PROCEDURE
80%
D9110
TX DENTAL PAIN MINOR PROC
80%
D9120
FIX PARTIAL DENTURE SECTION
80%
D9210
DENT ANESTHESIA W/O SURGERY
80%
D9220
GENERAL ANESTHESIA
80%
D9221
GENERAL ANESTHESIA EA AD 15M
80%
D9230
ANALGESIA
80%
D9241
INTRAVENOUS SEDATION
80%
D9242
IV SEDATION EA AD 30 M
80%
D9248
SEDATION (NON-IV)
80%
D9310
DENTAL CONSULTATION
80%
D9440
OFFICE VISIT AFTER HOURS
80%
D9610
DENT THERAPEUTIC DRUG INJECT
80%
D9612
THERA PAR DRUGS 2 OR > ADMIN
80%
D9910
DENT APPL DESENSITIZING MED
80%
D9911
APPL DESENSITIZING RESIN
80%
Procedure Code
Description
Pricing Percent
D9920
BEHAVIOR MANAGEMENT
80%
D9930
TREATMENT OF COMPLICATIONS
80%
D9940
DENTAL OCCLUSAL GUARD
80%
D9999
ADJUNCTIVE PROCEDURE
80%
Procedure RVU Pricing Procedure Code Description
RVU
RVU Coeff Value
00100
ANESTH, SALIVARY GLAND
5.00
16.05
00102
ANESTH, REPAIR OF CLEFT LIP
6.00
16.05
00103
ANESTH, BLEPHAROPLASTY
5.00
16.05
00104
ANESTH, ELECTROSHOCK
4.00
16.05
00120
ANESTH, EAR SURGERY
4.00
16.05
00124
ANESTH, EAR EXAM
4.00
16.05
00126
ANESTH, TYMPANOTOMY
4.00
16.05
00140
ANESTH, PROCEDURES ON EYE
5.00
16.05
00142
ANESTH, LENS SURGERY
6.00
16.05
00144
ANESTH, CORNEAL TRANSPLANT
6.00
16.05
00145
ANESTH, VITREORETINAL SURG
6.00
16.05
00147
ANESTH, IRIDECTOMY
4.00
16.05
00148
ANESTH, EYE EXAM
4.00
16.05
00160
ANESTH, NOSE/SINUS SURGERY
5.00
16.05
00162
ANESTH, NOSE/SINUS SURGERY
7.00
16.05
00164
ANESTH, BIOPSY OF NOSE
4.00
16.05
00170
ANESTH, PROCEDURE ON MOUTH
5.00
16.05
00172
ANESTH, CLEFT PALATE REPAIR
6.00
16.05
00174
ANESTH, PHARYNGEAL SURGERY
6.00
16.05
00176
ANESTH, PHARYNGEAL SURGERY
7.00
16.05
00190
ANESTH, FACE/SKULL BONE SURG
5.00
16.05
00192
ANESTH, FACIAL BONE SURGERY
7.00
16.05
00210
ANESTH, CRANIAL SURG NOS
11.00
16.05
00211
ANESTH, CRAN SURG, HEMOTOMA
10.00
16.05
00212
ANESTH, SKULL DRAINAGE
5.00
16.05
00214
ANESTH, SKULL DRAINAGE
9.00
16.05
00215
ANESTH, SKULL REPAIR/FRACT
9.00
16.05
00216
ANESTH, HEAD VESSEL SURGERY
15.00
16.05
00218
ANESTH, SPECIAL HEAD SURGERY
13.00
16.05
00220
ANESTH, INTRCRN NERVE
10.00
16.05
00222
ANESTH, HEAD NERVE SURGERY
6.00
16.05
00300
ANESTH, HEAD/NECK/PTRUNK
5.00
16.05
00320
ANESTH, NECK ORGAN, 1 & OVER
6.00
16.05
Procedure Code Description
RVU
RVU Coeff Value
00322
ANESTH, BIOPSY OF THYROID
3.00
16.05
00326
ANESTH, LARYNX/TRACH, < 1 YR
7.00
16.05
00350
ANESTH, NECK VESSEL SURGERY
10.00
16.05
00352
ANESTH, NECK VESSEL SURGERY
5.00
16.05
00400
ANESTH, SKIN, EXT/PER/ATRUNK
3.00
16.05
00402
ANESTH, SURGERY OF BREAST
5.00
16.05
00404
ANESTH, SURGERY OF BREAST
5.00
16.05
00406
ANESTH, SURGERY OF BREAST
13.00
16.05
00410
ANESTH, CORRECT HEART RHYTHM
4.00
16.05
00450
ANESTH, SURGERY OF SHOULDER
5.00
16.05
00452
ANESTH, SURGERY OF SHOULDER
6.00
16.05
00454
ANESTH, COLLAR BONE BIOPSY
3.00
16.05
00470
ANESTH, REMOVAL OF RIB
6.00
16.05
00472
ANESTH, CHEST WALL REPAIR
10.00
16.05
00474
ANESTH, SURGERY OF RIB(S)
13.00
16.05
00500
ANESTH, ESOPHAGEAL SURGERY
15.00
16.05
00520
ANESTH, CHEST PROCEDURE
6.00
16.05
00522
ANESTH, CHEST LINING BIOPSY
4.00
16.05
00524
ANESTH, CHEST DRAINAGE
4.00
16.05
00528
ANESTH, CHEST PARTITION VIEW
8.00
16.05
00530
ANESTH, PACEMAKER INSERTION
4.00
16.05
00532
ANESTH, VASCULAR ACCESS
4.00
16.05
00534
ANESTH, CARDIOVERTER/DEFIB
7.00
16.05
00537
ANESTH, CARDIAC ELECTROPHYS
10.00
16.05
00539
ANESTH,TRACHEOBRONCHIAL RECONSTRUC
18.00
16.05
00540
ANESTH, CHEST SURGERY
13.00
16.05
00541
ANESTH, ONE LUNG VENTILATION
15.00
16.05
00542
ANESTH, RELEASE OF LUNG
15.00
16.05
00544
ANESTH, CHEST LINING REMOVAL
15.00
16.05
00546
ANESTH, LUNG,CHEST WALL SURG
15.00
16.05
00548
ANESTH, TRACHEA,BRONCHI SURG
17.00
16.05
00550
ANESTH, STERNAL DEBRIDEMENT
10.00
16.05
00560
ANESTH, HEART SURG W/O PUMP
15.00
16.05
00561
ANESTH, HEART SURG < AGE 1
25.00
16.05
00562
ANESTH HRT SURG W/PMP AGE 1+
20.00
16.05
Procedure Code Description
RVU
RVU Coeff Value
00563
ANESTH, HEART SURG W/ARREST
25.00
16.05
00566
ANESTH, CABG W/O PUMP
25.00
16.05
00567
ANESTH, CABG W/PUMP
18.00
16.05
00580
ANESTH, HEART/LUNG TRANSPLNT
20.00
16.05
00600
ANESTH, SPINE, CORD SURGERY
10.00
16.05
00604
ANESTH, SITTING PROCEDURE
13.00
16.05
00620
ANESTH, SPINE, CORD SURGERY
10.00
16.05
00622
ANESTH, REMOVAL OF NERVES
13.00
16.05
00625
ANES SPINE TRANTHOR W/O VENT
13.00
16.05
00626
ANES, SPINE TRANSTHOR W/VENT
15.00
16.05
00630
ANESTH, SPINE, CORD SURGERY
8.00
16.05
00632
ANESTH, REMOVAL OF NERVES
7.00
16.05
00635
ANESTH, LUMBAR PUNCTURE
4.00
16.05
00640
ANESTH, SPINE MANIPULATION
3.00
16.05
00670
ANESTH, SPINE, CORD SURGERY
13.00
16.05
00700
ANESTH, ABDOMINAL WALL SURG
4.00
16.05
00702
ANESTH, FOR LIVER BIOPSY
4.00
16.05
00730
ANESTH, ABDOMINAL WALL SURG
5.00
16.05
00740
ANESTH, UPPER GI VISUALIZE
5.00
16.05
00750
ANESTH, REPAIR OF HERNIA
4.00
16.05
00752
ANESTH, REPAIR OF HERNIA
6.00
16.05
00754
ANESTH, REPAIR OF HERNIA
7.00
16.05
00756
ANESTH, REPAIR OF HERNIA
7.00
16.05
00770
ANESTH, BLOOD VESSEL REPAIR
15.00
16.05
00790
ANESTH, SURG UPPER ABDOMEN
7.00
16.05
00792
ANESTH, HEMORR/EXCISE LIVER
7.00
16.05
00794
ANESTH, PANCREAS REMOVAL
13.00
16.05
00796
ANESTH, FOR LIVER TRANSPLANT
30.00
16.05
00797
ANESTH, SURGERY FOR OBESITY
10.00
16.05
00800
ANESTH, ABDOMINAL WALL SURG
4.00
16.05
00802
ANESTH, FAT LAYER REMOVAL
5.00
16.05
00810
ANESTH, LOW INTESTINE SCOPE
5.00
16.05
00820
ANESTH, ABDOMINAL WALL SURG
5.00
16.05
00830
ANESTH, REPAIR OF HERNIA
4.00
16.05
00832
ANESTH, REPAIR OF HERNIA
6.00
16.05
Procedure Code Description
RVU
RVU Coeff Value
00834
ANESTH, HERNIA REPAIR< 1 YR
5.00
16.05
00836
ANESTH HERNIA REPAIR PREEMIE
6.00
16.05
00840
ANESTH, SURG LOWER ABDOMEN
6.00
16.05
00842
ANESTH, AMNIOCENTESIS
4.00
16.05
00844
ANESTH, PELVIS SURGERY
7.00
16.05
00846
ANESTH, HYSTERECTOMY
8.00
16.05
00848
ANESTH, PELVIC ORGAN SURG
8.00
16.05
00851
ANESTH, TUBAL LIGATION
6.00
16.05
00860
ANESTH, SURGERY OF ABDOMEN
6.00
16.05
00862
ANESTH, KIDNEY/URETER SURG
7.00
16.05
00864
ANESTH, REMOVAL OF BLADDER
8.00
16.05
00865
ANESTH, REMOVAL OF PROSTATE
7.00
16.05
00866
ANESTH, REMOVAL OF ADRENAL
10.00
16.05
00868
ANESTH, KIDNEY TRANSPLANT
10.00
16.05
00869
ANESTH, VASECTOMY
3.00
16.05
00870
ANESTH, BLADDER STONE SURG
5.00
16.05
00872
ANESTH KIDNEY STONE DESTRUCT
7.00
16.05
00873
ANESTH KIDNEY STONE DESTRUCT
5.00
16.05
00880
ANESTH, ABDOMEN VESSEL SURG
15.00
16.05
00882
ANESTH, MAJOR VEIN LIGATION
10.00
16.05
00902
ANESTH, ANORECTAL SURGERY
5.00
16.05
00904
ANESTH, PERINEAL SURGERY
7.00
16.05
00906
ANESTH, REMOVAL OF VULVA
4.00
16.05
00908
ANESTH, REMOVAL OF PROSTATE
6.00
16.05
00910
ANESTH, BLADDER SURGERY
3.00
16.05
00910
ANESTH, BLADDER SURGERY
4.00
16.05
00912
ANESTH, BLADDER TUMOR SURG
5.00
16.05
00914
ANESTH, REMOVAL OF PROSTATE
5.00
16.05
00916
ANESTH, BLEEDING CONTROL
5.00
16.05
00918
ANESTH, STONE REMOVAL
5.00
16.05
00920
ANESTH, GENITALIA SURGERY
3.00
16.05
00921
ANESTH, VASECTOMY
3.00
16.05
00922
ANESTH, SPERM DUCT SURGERY
6.00
16.05
00924
ANESTH, TESTIS EXPLORATION
4.00
16.05
00926
ANESTH, REMOVAL OF TESTIS
4.00
16.05
Procedure Code Description
RVU
RVU Coeff Value
00928
ANESTH, REMOVAL OF TESTIS
6.00
16.05
00930
ANESTH, TESTIS SUSPENSION
4.00
16.05
00932
ANESTH, AMPUTATION OF PENIS
4.00
16.05
00934
ANESTH, PENIS, NODES REMOVAL
6.00
16.05
00936
ANESTH, PENIS, NODES REMOVAL
8.00
16.05
00940
ANESTH, VAGINAL PROCEDURES
3.00
16.05
00942
ANESTH, SURG ON VAG/URETHRAL
4.00
16.05
00944
ANESTH, VAGINAL HYSTERECTOMY
6.00
16.05
00948
ANESTH, REPAIR OF CERVIX
4.00
16.05
00950
ANESTH, VAGINAL ENDOSCOPY
5.00
16.05
00952
ANESTH, HYSTEROSCOPE/GRAPH
4.00
16.05
01112
ANESTH, BONE ASPIRATE/BX
5.00
16.05
01120
ANESTH, PELVIS SURGERY
6.00
16.05
01130
ANESTH, BODY CAST PROCEDURE
3.00
16.05
01140
ANESTH, AMPUTATION AT PELVIS
15.00
16.05
01150
ANESTH, PELVIC TUMOR SURGERY
10.00
16.05
01160
ANESTH, PELVIS PROCEDURE
4.00
16.05
01170
ANESTH, PELVIS SURGERY
8.00
16.05
01173
ANESTH, FX REPAIR, PELVIS
12.00
16.05
01180
ANESTH, PELVIS NERVE REMOVAL
3.00
16.05
01190
ANESTH, PELVIS NERVE REMOVAL
4.00
16.05
01200
ANESTH, HIP JOINT PROCEDURE
4.00
16.05
01202
ANESTH, ARTHROSCOPY OF HIP
4.00
16.05
01210
ANESTH, HIP JOINT SURGERY
6.00
16.05
01212
ANESTH, HIP DISARTICULATION
10.00
16.05
01214
ANESTH, HIP ARTHROPLASTY
8.00
16.05
01215
ANESTH, REVISE HIP REPAIR
10.00
16.05
01220
ANESTH, PROCEDURE ON FEMUR
4.00
16.05
01230
ANESTH, SURGERY OF FEMUR
6.00
16.05
01232
ANESTH, AMPUTATION OF FEMUR
5.00
16.05
01234
ANESTH, RADICAL FEMUR SURG
8.00
16.05
01250
ANESTH, UPPER LEG SURGERY
4.00
16.05
01250
ANESTH, UPPER LEG SURGERY
8.00
16.05
01260
ANESTH, UPPER LEG VEINS SURG
3.00
16.05
01270
ANESTH, THIGH ARTERIES SURG
8.00
16.05
Procedure Code Description
RVU
RVU Coeff Value
01272
ANESTH, FEMORAL ARTERY SURG
4.00
16.05
01274
ANESTH, FEMORAL EMBOLECTOMY
6.00
16.05
01320
ANESTH, KNEE AREA SURGERY
4.00
16.05
01340
ANESTH, KNEE AREA PROCEDURE
4.00
16.05
01360
ANESTH, KNEE AREA SURGERY
5.00
16.05
01380
ANESTH, KNEE JOINT PROCEDURE
3.00
16.05
01382
ANESTH, DX KNEE ARTHROSCOPY
3.00
16.05
01390
ANESTH, KNEE AREA PROCEDURE
3.00
16.05
01392
ANESTH, KNEE AREA SURGERY
4.00
16.05
01400
ANESTH, KNEE JOINT SURGERY
4.00
16.05
01402
ANESTH, KNEE ARTHROPLASTY
7.00
16.05
01404
ANESTH, AMPUTATION AT KNEE
5.00
16.05
01420
ANESTH, KNEE JOINT CASTING
3.00
16.05
01430
ANESTH, KNEE VEINS SURGERY
3.00
16.05
01432
ANESTH, KNEE VESSEL SURG
6.00
16.05
01440
ANESTH, KNEE ARTERIES SURG
8.00
16.05
01442
ANESTH, KNEE ARTERY SURG
8.00
16.05
01444
ANESTH, KNEE ARTERY REPAIR
8.00
16.05
01462
ANESTH, LOWER LEG PROCEDURE
3.00
16.05
01464
ANESTH, ANKLE/FT ARTHROSCOPY
3.00
16.05
01470
ANESTH, LOWER LEG SURGERY
3.00
16.05
01472
ANESTH, ACHILLES TENDON SURG
5.00
16.05
01474
ANESTH, LOWER LEG SURGERY
5.00
16.05
01480
ANESTH, LOWER LEG BONE SURG
3.00
16.05
01482
ANESTH, RADICAL LEG SURGERY
4.00
16.05
01484
ANESTH, LOWER LEG REVISION
4.00
16.05
01486
ANESTH, ANKLE REPLACEMENT
7.00
16.05
01490
ANESTH, LOWER LEG CASTING
3.00
16.05
01500
ANESTH, LEG ARTERIES SURG
8.00
16.05
01502
ANESTH, LWR LEG EMBOLECTOMY
6.00
16.05
01520
ANESTH, LOWER LEG VEIN SURG
3.00
16.05
01522
ANESTH, LOWER LEG VEIN SURG
5.00
16.05
01610
ANESTH, SURGERY OF SHOULDER
5.00
16.05
01620
ANESTH, SHOULDER PROCEDURE
4.00
16.05
01622
ANES DX SHOULDER ARTHROSCOPY
4.00
16.05
Procedure Code Description
RVU
RVU Coeff Value
01630
ANESTH, SURGERY OF SHOULDER
5.00
16.05
01632
ANESTH, SURGERY OF SHOULDER
6.00
16.05
01634
ANESTH, SHOULDER JOINT AMPUT
9.00
16.05
01636
ANESTH, FOREQUARTER AMPUT
15.00
16.05
01638
ANESTH, SHOULDER REPLACEMENT
10.00
16.05
01650
ANESTH, SHOULDER ARTERY SURG
6.00
16.05
01652
ANESTH, SHOULDER VESSEL SURG
10.00
16.05
01654
ANESTH, SHOULDER VESSEL SURG
8.00
16.05
01656
ANESTH, ARM-LEG VESSEL SURG
10.00
16.05
01670
ANESTH, SHOULDER VEIN SURG
4.00
16.05
01680
ANESTH, SHOULDER CASTING
3.00
16.05
01682
ANESTH, AIRPLANE CAST
4.00
16.05
01710
ANESTH, ELBOW AREA SURGERY
3.00
16.05
01712
ANESTH, UPPR ARM TENDON SURG
5.00
16.05
01714
ANESTH, UPPR ARM TENDON SURG
5.00
16.05
01716
ANESTH, BICEPS TENDON REPAIR
5.00
16.05
01730
ANESTH, UPPR ARM PROCEDURE
3.00
16.05
01732
ANESTH, DX ELBOW ARTHROSCOPY
3.00
16.05
01740
ANESTH, UPPER ARM SURGERY
4.00
16.05
01742
ANESTH, HUMERUS SURGERY
5.00
16.05
01744
ANESTH, HUMERUS REPAIR
5.00
16.05
01756
ANESTH, RADICAL HUMERUS SURG
6.00
16.05
01758
ANESTH, HUMERAL LESION SURG
5.00
16.05
01760
ANESTH, ELBOW REPLACEMENT
7.00
16.05
01770
ANESTH, UPPR ARM ARTERY SURG
6.00
16.05
01772
ANESTH, UPPR ARM EMBOLECTOMY
6.00
16.05
01780
ANESTH, UPPER ARM VEIN SURG
3.00
16.05
01782
ANESTH, UPPR ARM VEIN REPAIR
4.00
16.05
01810
ANESTH, LOWER ARM SURGERY
3.00
16.05
01820
ANESTH, LOWER ARM PROCEDURE
3.00
16.05
01829
ANESTH, DX WRIST ARTHROSCOPY
3.00
16.05
01830
ANESTH, LOWER ARM SURGERY
3.00
16.05
01832
ANESTH, WRIST REPLACEMENT
6.00
16.05
01840
ANESTH, LWR ARM ARTERY SURG
6.00
16.05
01842
ANESTH, LWR ARM EMBOLECTOMY
6.00
16.05
Procedure Code Description
RVU
RVU Coeff Value
01844
ANESTH, VASCULAR SHUNT SURG
6.00
16.05
01850
ANESTH, LOWER ARM VEIN SURG
3.00
16.05
01852
ANESTH, LWR ARM VEIN REPAIR
4.00
16.05
01860
ANESTH, LOWER ARM CASTING
3.00
16.05
01905
ANES, SPINE INJECT, X-RAY/RE
5.00
16.05
01916
ANESTH, DX ARTERIOGRAPHY
6.00
16.05
01920
ANESTH, CATHETERIZE HEART
7.00
16.05
01922
ANESTH, CAT OR MRI SCAN
7.00
16.05
01924
ANES, THER INTERVEN RAD, ART
6.00
16.05
01925
ANES, THER INTERVEN RAD, CAR
8.00
16.05
01926
ANES, TX INTERV RAD HRT/CRAN
10.00
16.05
01930
ANES, THER INTERVEN RAD, VEI
5.00
16.05
01931
ANES, THER INTERVEN RAD, TIP
6.00
16.05
01932
ANES, TX INTERV RAD, TH VEIN
8.00
16.05
01933
ANES, TX INTERV RAD, CRAN V
10.00
16.05
01935
ANESTH, PERC IMG DX SP PROC
5.00
16.05
01936
ANESTH, PERC IMG TX SP PROC
5.00
16.05
01951
ANESTH, BURN, LESS 4 PERCENT
3.00
16.05
01952
ANESTH, BURN, 4-9 PERCENT
5.00
16.05
01958
ANESTH, ANTEPARTUM MANIPUL
5.00
16.05
01960
ANESTH, VAGINAL DELIVERY
5.00
16.05
01961
ANESTH, CS DELIVERY
3.00
16.05
01961
ANESTH, CS DELIVERY
7.00
16.05
01962
ANESTH, EMER HYSTERECTOMY
5.00
16.05
01963
ANESTH, CS HYSTERECTOMY
8.00
16.05
01964
ANESTH, ABORTION PROCEDURES
4.00
16.05
01965
ANESTH, INC/MISSED AB PROC
4.00
16.05
01966
ANESTH, INDUCED AB PROCEDURE
4.00
16.05
01967
ANESTH/ANALG, VAG DELIVERY
5.00
16.05
01968
ANES/ANALG CS DELIVER ADD-ON
3.00
16.05
01969
ANESTH/ANALG CS HYST ADD-ON
5.00
16.05
01990
SUPPORT FOR ORGAN DONOR
7.00
16.05
01991
ANESTH, NERVE BLOCK/INJ
3.00
16.05
01992
ANESTH, N BLOCK/INJ, PRONE
5.00
16.05
01995
REGIONAL ANESTHESIA LIMB
5.00
16.05
Procedure Code Description
RVU
RVU Coeff Value
10040
ACNE SURGERY
1.92
1.00
10040
ACNE SURGERY
1.94
1.00
10040
ACNE SURGERY
2.19
1.00
10040
ACNE SURGERY
4.00
1.00
10060
DRAINAGE OF SKIN ABSCESS
1.92
1.00
10060
DRAINAGE OF SKIN ABSCESS
2.21
1.00
10060
DRAINAGE OF SKIN ABSCESS
2.35
1.00
10060
DRAINAGE OF SKIN ABSCESS
3.00
1.00
10061
DRAINAGE OF SKIN ABSCESS
3.98
1.00
10061
DRAINAGE OF SKIN ABSCESS
4.00
1.00
10061
DRAINAGE OF SKIN ABSCESS
4.12
1.00
10061
DRAINAGE OF SKIN ABSCESS
4.18
1.00
10080
DRAINAGE OF PILONIDAL CYST
1.99
1.00
10080
DRAINAGE OF PILONIDAL CYST
2.40
1.00
10080
DRAINAGE OF PILONIDAL CYST
2.42
1.00
10080
DRAINAGE OF PILONIDAL CYST
4.00
1.00
10081
DRAINAGE OF PILONIDAL CYST
4.00
1.00
10081
DRAINAGE OF PILONIDAL CYST
4.19
1.00
10120
REMOVE FOREIGN BODY
1.68
1.00
10120
REMOVE FOREIGN BODY
1.75
1.00
10120
REMOVE FOREIGN BODY
2.30
1.00
10120
REMOVE FOREIGN BODY
3.00
1.00
10121
REMOVE FOREIGN BODY
3.00
1.00
10121
REMOVE FOREIGN BODY
4.72
1.00
10121
REMOVE FOREIGN BODY
4.73
1.00
10121
REMOVE FOREIGN BODY
4.87
1.00
10140
DRAINAGE OF HEMATOMA/FLUID
2.55
1.00
10140
DRAINAGE OF HEMATOMA/FLUID
2.62
1.00
10140
DRAINAGE OF HEMATOMA/FLUID
3.00
1.00
10140
DRAINAGE OF HEMATOMA/FLUID
3.02
1.00
10160
PUNCTURE DRAINAGE OF LESION
1.73
1.00
10160
PUNCTURE DRAINAGE OF LESION
1.79
1.00
10160
PUNCTURE DRAINAGE OF LESION
2.43
1.00
10160
PUNCTURE DRAINAGE OF LESION
2.44
1.00
10160
PUNCTURE DRAINAGE OF LESION
3.00
1.00
Procedure Code Description
RVU
RVU Coeff Value
10180
COMPLEX DRAINAGE, WOUND
3.00
1.00
10180
COMPLEX DRAINAGE, WOUND
3.77
1.00
10180
COMPLEX DRAINAGE, WOUND
4.48
1.00
10180
COMPLEX DRAINAGE, WOUND
4.63
1.00
11000
DEBRIDE INFECTED SKIN
0.85
1.00
11000
DEBRIDE INFECTED SKIN
0.88
1.00
11000
DEBRIDE INFECTED SKIN
0.89
1.00
11000
DEBRIDE INFECTED SKIN
3.00
1.00
11001
DEBRIDE INFECTED SKIN ADD-ON
0.43
1.00
11004
DEBRIDE GENITALIA & PERINEUM
15.03
1.00
11005
DEBRIDE ABDOM WALL
19.63
1.00
11006
DEBRIDE GENIT/PER/ABDOM WALL
18.72
1.00
11008
REMOVE MESH FROM ABD WALL
7.17
1.00
11010
DEBRIDE SKIN, FX
3.00
1.00
11010
DEBRIDE SKIN, FX
6.61
1.00
11010
DEBRIDE SKIN, FX
7.06
1.00
11010
DEBRIDE SKIN, FX
7.34
1.00
11011
DEBRIDE SKIN/MUSCLE, FX
3.00
1.00
11011
DEBRIDE SKIN/MUSCLE, FX
7.89
1.00
11011
DEBRIDE SKIN/MUSCLE, FX
7.95
1.00
11011
DEBRIDE SKIN/MUSCLE, FX
8.08
1.00
11012
DEBRIDE SKIN/MUSCLE/BONE, FX
5.00
1.00
11012
DEBRIDE SKIN/MUSCLE/BONE, FX
11.47
1.00
11012
DEBRIDE SKIN/MUSCLE/BONE, FX
11.80
1.00
11012
DEBRIDE SKIN/MUSCLE/BONE, FX
12.00
1.00
11040
DEBRIDE SKIN, PARTIAL
0.73
1.00
11040
DEBRIDE SKIN, PARTIAL
0.76
1.00
11040
DEBRIDE SKIN, PARTIAL
0.77
1.00
11040
DEBRIDE SKIN, PARTIAL
3.00
1.00
11041
DEBRIDE SKIN, FULL
0.92
1.00
11041
DEBRIDE SKIN, FULL
1.21
1.00
11041
DEBRIDE SKIN, FULL
1.22
1.00
11041
DEBRIDE SKIN, FULL
3.00
1.00
11042
DEBRIDE SKIN/TISSUE
1.23
1.00
11042
DEBRIDE SKIN/TISSUE
1.68
1.00
Procedure Code Description
RVU
RVU Coeff Value
11042
DEBRIDE SKIN/TISSUE
3.00
1.00
11043
DEBRIDE TISSUE/MUSCLE
3.00
1.00
11043
DEBRIDE TISSUE/MUSCLE
5.26
1.00
11043
DEBRIDE TISSUE/MUSCLE
5.28
1.00
11043
DEBRIDE TISSUE/MUSCLE
5.95
1.00
11044
DEBRIDE TISSUE/MUSCLE/BONE
3.00
1.00
11044
DEBRIDE TISSUE/MUSCLE/BONE
7.24
1.00
11044
DEBRIDE TISSUE/MUSCLE/BONE
7.31
1.00
11044
DEBRIDE TISSUE/MUSCLE/BONE
8.19
1.00
11055
TRIM SKIN LESION
0.61
1.00
11055
TRIM SKIN LESION
0.62
1.00
11055
TRIM SKIN LESION
0.63
1.00
11056
TRIM SKIN LESIONS, 2 TO 4
0.86
1.00
11056
TRIM SKIN LESIONS, 2 TO 4
0.89
1.00
11056
TRIM SKIN LESIONS, 2 TO 4
0.90
1.00
11057
TRIM SKIN LESIONS, OVER 4
1.12
1.00
11057
TRIM SKIN LESIONS, OVER 4
1.15
1.00
11057
TRIM SKIN LESIONS, OVER 4
1.16
1.00
11100
BIOPSY, SKIN LESION
1.23
1.00
11100
BIOPSY, SKIN LESION
1.24
1.00
11100
BIOPSY, SKIN LESION
3.00
1.00
11101
BIOPSY, SKIN ADD-ON
0.62
1.00
11101
BIOPSY, SKIN ADD-ON
0.63
1.00
11101
BIOPSY, SKIN ADD-ON
0.64
1.00
11200
REMOVAL OF SKIN TAGS
1.12
1.00
11200
REMOVAL OF SKIN TAGS
1.59
1.00
11200
REMOVAL OF SKIN TAGS
1.70
1.00
11200
REMOVAL OF SKIN TAGS
3.00
1.00
11201
REMOVE SKIN TAGS ADD-ON
0.43
1.00
11300
SHAVE SKIN LESION
0.76
1.00
11300
SHAVE SKIN LESION
0.77
1.00
11301
SHAVE SKIN LESION
1.27
1.00
11301
SHAVE SKIN LESION
1.28
1.00
11301
SHAVE SKIN LESION
1.29
1.00
11302
SHAVE SKIN LESION
1.57
1.00
Procedure Code Description
RVU
RVU Coeff Value
11302
SHAVE SKIN LESION
1.58
1.00
11302
SHAVE SKIN LESION
1.60
1.00
11303
SHAVE SKIN LESION
1.83
1.00
11303
SHAVE SKIN LESION
1.84
1.00
11303
SHAVE SKIN LESION
1.88
1.00
11305
SHAVE SKIN LESION
0.97
1.00
11305
SHAVE SKIN LESION
0.98
1.00
11305
SHAVE SKIN LESION
0.99
1.00
11305
SHAVE SKIN LESION
3.00
1.00
11306
SHAVE SKIN LESION
1.46
1.00
11306
SHAVE SKIN LESION
1.47
1.00
11306
SHAVE SKIN LESION
3.00
1.00
11307
SHAVE SKIN LESION
1.69
1.00
11307
SHAVE SKIN LESION
1.72
1.00
11307
SHAVE SKIN LESION
3.00
1.00
11308
SHAVE SKIN LESION
2.08
1.00
11308
SHAVE SKIN LESION
2.09
1.00
11308
SHAVE SKIN LESION
3.00
1.00
11310
SHAVE SKIN LESION
1.10
1.00
11310
SHAVE SKIN LESION
1.11
1.00
11311
SHAVE SKIN LESION
1.59
1.00
11311
SHAVE SKIN LESION
1.60
1.00
11311
SHAVE SKIN LESION
1.61
1.00
11312
SHAVE SKIN LESION
1.82
1.00
11312
SHAVE SKIN LESION
1.83
1.00
11312
SHAVE SKIN LESION
1.85
1.00
11313
SHAVE SKIN LESION
2.45
1.00
11313
SHAVE SKIN LESION
2.48
1.00
11400
EXC TR-EXT B9+MARG 0.5 < CM
1.81
1.00
11400
EXC TR-EXT B9+MARG 0.5 < CM
1.86
1.00
11400
EXC TR-EXT B9+MARG 0.5 < CM
1.87
1.00
11400
EXC TR-EXT B9+MARG 0.5 < CM
3.00
1.00
11401
EXC TR-EXT B9+MARG 0.6-1 CM
2.37
1.00
11401
EXC TR-EXT B9+MARG 0.6-1 CM
2.40
1.00
11401
EXC TR-EXT B9+MARG 0.6-1 CM
2.48
1.00
Procedure Code Description
RVU
RVU Coeff Value
11401
EXC TR-EXT B9+MARG 0.6-1 CM
3.00
1.00
11402
EXC TR-EXT B9+MARG 1.1-2 CM
2.75
1.00
11402
EXC TR-EXT B9+MARG 1.1-2 CM
2.77
1.00
11402
EXC TR-EXT B9+MARG 1.1-2 CM
3.00
1.00
11403
EXC TR-EXT B9+MARG 2.1-3 CM
3.00
1.00
11403
EXC TR-EXT B9+MARG 2.1-3 CM
3.30
1.00
11403
EXC TR-EXT B9+MARG 2.1-3 CM
3.31
1.00
11403
EXC TR-EXT B9+MARG 2.1-3 CM
3.50
1.00
11404
EXC TR-EXT B9+MARG 3.1-4 CM
3.00
1.00
11404
EXC TR-EXT B9+MARG 3.1-4 CM
3.66
1.00
11404
EXC TR-EXT B9+MARG 3.1-4 CM
3.69
1.00
11404
EXC TR-EXT B9+MARG 3.1-4 CM
3.90
1.00
11406
EXC TR-EXT B9+MARG > 4.0 CM
3.00
1.00
11406
EXC TR-EXT B9+MARG > 4.0 CM
4.69
1.00
11406
EXC TR-EXT B9+MARG > 4.0 CM
4.73
1.00
11406
EXC TR-EXT B9+MARG > 4.0 CM
5.82
1.00
11420
EXC H-F-NK-SP B9+MARG 0.5 <
2.02
1.00
11420
EXC H-F-NK-SP B9+MARG 0.5 <
2.06
1.00
11420
EXC H-F-NK-SP B9+MARG 0.5 <
3.00
1.00
11421
EXC H-F-NK-SP B9+MARG 0.6-1
2.67
1.00
11421
EXC H-F-NK-SP B9+MARG 0.6-1
2.71
1.00
11421
EXC H-F-NK-SP B9+MARG 0.6-1
2.73
1.00
11421
EXC H-F-NK-SP B9+MARG 0.6-1
3.00
1.00
11422
EXC H-F-NK-SP B9+MARG 1.1-2
3.00
1.00
11422
EXC H-F-NK-SP B9+MARG 1.1-2
3.14
1.00
11422
EXC H-F-NK-SP B9+MARG 1.1-2
3.15
1.00
11422
EXC H-F-NK-SP B9+MARG 1.1-2
3.30
1.00
11423
EXC H-F-NK-SP B9+MARG 2.1-3
3.00
1.00
11423
EXC H-F-NK-SP B9+MARG 2.1-3
3.67
1.00
11423
EXC H-F-NK-SP B9+MARG 2.1-3
3.68
1.00
11423
EXC H-F-NK-SP B9+MARG 2.1-3
3.85
1.00
11424
EXC H-F-NK-SP B9+MARG 3.1-4
3.00
1.00
11424
EXC H-F-NK-SP B9+MARG 3.1-4
4.28
1.00
11424
EXC H-F-NK-SP B9+MARG 3.1-4
4.29
1.00
11424
EXC H-F-NK-SP B9+MARG 3.1-4
4.44
1.00
Procedure Code Description
RVU
RVU Coeff Value
11426
EXC H-F-NK-SP B9+MARG > 4 CM
3.00
1.00
11426
EXC H-F-NK-SP B9+MARG > 4 CM
6.27
1.00
11426
EXC H-F-NK-SP B9+MARG > 4 CM
6.29
1.00
11426
EXC H-F-NK-SP B9+MARG > 4 CM
6.79
1.00
11440
EXC FACE-MM B9+MARG 0.5 < CM
2.42
1.00
11440
EXC FACE-MM B9+MARG 0.5 < CM
2.49
1.00
11440
EXC FACE-MM B9+MARG 0.5 < CM
2.55
1.00
11440
EXC FACE-MM B9+MARG 0.5 < CM
4.00
1.00
11441
EXC FACE-MM B9+MARG 0.6-1 CM
3.00
1.00
11441
EXC FACE-MM B9+MARG 0.6-1 CM
3.12
1.00
11441
EXC FACE-MM B9+MARG 0.6-1 CM
3.18
1.00
11442
EXC FACE-MM B9+MARG 1.1-2 CM
3.47
1.00
11442
EXC FACE-MM B9+MARG 1.1-2 CM
3.52
1.00
11442
EXC FACE-MM B9+MARG 1.1-2 CM
3.55
1.00
11442
EXC FACE-MM B9+MARG 1.1-2 CM
4.00
1.00
11443
EXC FACE-MM B9+MARG 2.1-3 CM
4.00
1.00
11443
EXC FACE-MM B9+MARG 2.1-3 CM
4.34
1.00
11443
EXC FACE-MM B9+MARG 2.1-3 CM
4.37
1.00
11443
EXC FACE-MM B9+MARG 2.1-3 CM
4.39
1.00
11444
EXC FACE-MM B9+MARG 3.1-4 CM
3.00
1.00
11444
EXC FACE-MM B9+MARG 3.1-4 CM
5.63
1.00
11444
EXC FACE-MM B9+MARG 3.1-4 CM
5.67
1.00
11446
EXC FACE-MM B9+MARG > 4 CM
3.00
1.00
11446
EXC FACE-MM B9+MARG > 4 CM
7.62
1.00
11446
EXC FACE-MM B9+MARG > 4 CM
7.67
1.00
11446
EXC FACE-MM B9+MARG > 4 CM
7.96
1.00
11450
REMOVAL, SWEAT GLAND LESION
3.97
1.00
11450
REMOVAL, SWEAT GLAND LESION
4.00
1.00
11450
REMOVAL, SWEAT GLAND LESION
5.07
1.00
11450
REMOVAL, SWEAT GLAND LESION
5.82
1.00
11451
REMOVAL, SWEAT GLAND LESION
4.00
1.00
11451
REMOVAL, SWEAT GLAND LESION
5.77
1.00
11451
REMOVAL, SWEAT GLAND LESION
6.97
1.00
11451
REMOVAL, SWEAT GLAND LESION
7.71
1.00
11462
REMOVAL, SWEAT GLAND LESION
3.69
1.00
Procedure Code Description
RVU
RVU Coeff Value
11462
REMOVAL, SWEAT GLAND LESION
4.00
1.00
11462
REMOVAL, SWEAT GLAND LESION
4.81
1.00
11462
REMOVAL, SWEAT GLAND LESION
5.60
1.00
11463
REMOVAL, SWEAT GLAND LESION
4.00
1.00
11463
REMOVAL, SWEAT GLAND LESION
5.92
1.00
11463
REMOVAL, SWEAT GLAND LESION
7.11
1.00
11463
REMOVAL, SWEAT GLAND LESION
7.87
1.00
11470
REMOVAL, SWEAT GLAND LESION
4.00
1.00
11470
REMOVAL, SWEAT GLAND LESION
4.78
1.00
11470
REMOVAL, SWEAT GLAND LESION
5.88
1.00
11470
REMOVAL, SWEAT GLAND LESION
6.63
1.00
11471
REMOVAL, SWEAT GLAND LESION
4.00
1.00
11471
REMOVAL, SWEAT GLAND LESION
6.53
1.00
11471
REMOVAL, SWEAT GLAND LESION
7.66
1.00
11471
REMOVAL, SWEAT GLAND LESION
8.36
1.00
11600
EXC TR-EXT MLG+MARG 0.5 < CM
2.39
1.00
11600
EXC TR-EXT MLG+MARG 0.5 < CM
2.40
1.00
11600
EXC TR-EXT MLG+MARG 0.5 < CM
2.79
1.00
11600
EXC TR-EXT MLG+MARG 0.5 < CM
3.00
1.00
11601
EXC TR-EXT MLG+MARG 0.6-1 CM
3.00
1.00
11601
EXC TR-EXT MLG+MARG 0.6-1 CM
3.16
1.00
11601
EXC TR-EXT MLG+MARG 0.6-1 CM
3.17
1.00
11601
EXC TR-EXT MLG+MARG 0.6-1 CM
3.61
1.00
11602
EXC TR-EXT MLG+MARG 1.1-2 CM
3.00
1.00
11602
EXC TR-EXT MLG+MARG 1.1-2 CM
3.37
1.00
11602
EXC TR-EXT MLG+MARG 1.1-2 CM
3.38
1.00
11602
EXC TR-EXT MLG+MARG 1.1-2 CM
3.97
1.00
11603
EXC TR-EXT MLG+MARG 2.1-3 CM
3.00
1.00
11603
EXC TR-EXT MLG+MARG 2.1-3 CM
3.70
1.00
11603
EXC TR-EXT MLG+MARG 2.1-3 CM
3.71
1.00
11603
EXC TR-EXT MLG+MARG 2.1-3 CM
4.72
1.00
11604
EXC TR-EXT MLG+MARG 3.1-4 CM
3.00
1.00
11604
EXC TR-EXT MLG+MARG 3.1-4 CM
3.99
1.00
11604
EXC TR-EXT MLG+MARG 3.1-4 CM
4.02
1.00
11604
EXC TR-EXT MLG+MARG 3.1-4 CM
5.19
1.00
Procedure Code Description
RVU
RVU Coeff Value
11606
EXC TR-EXT MLG+MARG > 4 CM
3.00
1.00
11606
EXC TR-EXT MLG+MARG > 4 CM
5.47
1.00
11606
EXC TR-EXT MLG+MARG > 4 CM
5.51
1.00
11606
EXC TR-EXT MLG+MARG > 4 CM
7.70
1.00
11620
EXC H-F-NK-SP MLG+MARG 0.5 <
2.25
1.00
11620
EXC H-F-NK-SP MLG+MARG 0.5 <
2.26
1.00
11620
EXC H-F-NK-SP MLG+MARG 0.5 <
2.83
1.00
11620
EXC H-F-NK-SP MLG+MARG 0.5 <
3.00
1.00
11621
EXC H-F-NK-SP MLG+MARG 0.6-1
3.00
1.00
11621
EXC H-F-NK-SP MLG+MARG 0.6-1
3.15
1.00
11621
EXC H-F-NK-SP MLG+MARG 0.6-1
3.65
1.00
11622
EXC H-F-NK-SP MLG+MARG 1.1-2
3.00
1.00
11622
EXC H-F-NK-SP MLG+MARG 1.1-2
3.66
1.00
11622
EXC H-F-NK-SP MLG+MARG 1.1-2
4.21
1.00
11623
EXC H-F-NK-SP MLG+MARG 2.1-3
3.00
1.00
11623
EXC H-F-NK-SP MLG+MARG 2.1-3
4.43
1.00
11623
EXC H-F-NK-SP MLG+MARG 2.1-3
4.44
1.00
11623
EXC H-F-NK-SP MLG+MARG 2.1-3
5.19
1.00
11624
EXC H-F-NK-SP MLG+MARG 3.1-4
3.00
1.00
11624
EXC H-F-NK-SP MLG+MARG 3.1-4
5.12
1.00
11624
EXC H-F-NK-SP MLG+MARG 3.1-4
5.14
1.00
11624
EXC H-F-NK-SP MLG+MARG 3.1-4
5.91
1.00
11626
EXC H-F-NK-SP MLG+MAR > 4 CM
3.00
1.00
11626
EXC H-F-NK-SP MLG+MAR > 4 CM
7.09
1.00
11626
EXC H-F-NK-SP MLG+MAR > 4 CM
7.11
1.00
11626
EXC H-F-NK-SP MLG+MAR > 4 CM
7.43
1.00
11640
EXC FACE-MM MALIG+MARG 0.5 <
2.59
1.00
11640
EXC FACE-MM MALIG+MARG 0.5 <
2.99
1.00
11640
EXC FACE-MM MALIG+MARG 0.5 <
4.00
1.00
11641
EXC FACE-MM MALIG+MARG 0.6-1
3.88
1.00
11641
EXC FACE-MM MALIG+MARG 0.6-1
3.91
1.00
11641
EXC FACE-MM MALIG+MARG 0.6-1
4.00
1.00
11642
EXC FACE-MM MALIG+MARG 1.1-2
4.00
1.00
11642
EXC FACE-MM MALIG+MARG 1.1-2
4.54
1.00
11642
EXC FACE-MM MALIG+MARG 1.1-2
4.61
1.00
Procedure Code Description
RVU
RVU Coeff Value
11643
EXC FACE-MM MALIG+MARG 2.1-3
3.00
1.00
11643
EXC FACE-MM MALIG+MARG 2.1-3
5.35
1.00
11643
EXC FACE-MM MALIG+MARG 2.1-3
5.76
1.00
11644
EXC FACE-MM MALIG+MARG 3.1-4
3.00
1.00
11644
EXC FACE-MM MALIG+MARG 3.1-4
6.89
1.00
11644
EXC FACE-MM MALIG+MARG 3.1-4
6.92
1.00
11644
EXC FACE-MM MALIG+MARG 3.1-4
7.19
1.00
11646
EXC FACE-MM MLG+MARG > 4 CM
3.00
1.00
11646
EXC FACE-MM MLG+MARG > 4 CM
9.98
1.00
11646
EXC FACE-MM MLG+MARG > 4 CM
10.01
1.00
11646
EXC FACE-MM MLG+MARG > 4 CM
10.14
1.00
11719
TRIM NAIL(S)
0.24
1.00
11719
TRIM NAIL(S)
0.25
1.00
11720
DEBRIDE NAIL, 1-5
0.45
1.00
11720
DEBRIDE NAIL, 1-5
0.47
1.00
11720
DEBRIDE NAIL, 1-5
3.00
1.00
11721
DEBRIDE NAIL, 6 OR MORE
0.78
1.00
11721
DEBRIDE NAIL, 6 OR MORE
0.79
1.00
11721
DEBRIDE NAIL, 6 OR MORE
0.80
1.00
11721
DEBRIDE NAIL, 6 OR MORE
3.00
1.00
11730
REMOVAL OF NAIL PLATE
1.56
1.00
11730
REMOVAL OF NAIL PLATE
1.66
1.00
11730
REMOVAL OF NAIL PLATE
1.67
1.00
11730
REMOVAL OF NAIL PLATE
3.00
1.00
11732
REMOVE NAIL PLATE, ADD-ON
0.81
1.00
11732
REMOVE NAIL PLATE, ADD-ON
0.85
1.00
11740
DRAIN BLOOD FROM UNDER NAIL
0.54
1.00
11740
DRAIN BLOOD FROM UNDER NAIL
0.55
1.00
11740
DRAIN BLOOD FROM UNDER NAIL
0.81
1.00
11740
DRAIN BLOOD FROM UNDER NAIL
3.00
1.00
11750
REMOVAL OF NAIL BED
2.79
1.00
11750
REMOVAL OF NAIL BED
3.00
1.00
11750
REMOVAL OF NAIL BED
3.77
1.00
11750
REMOVAL OF NAIL BED
4.44
1.00
11752
REMOVE NAIL BED/FINGER TIP
3.00
1.00
Procedure Code Description
RVU
RVU Coeff Value
11752
REMOVE NAIL BED/FINGER TIP
4.76
1.00
11752
REMOVE NAIL BED/FINGER TIP
6.02
1.00
11752
REMOVE NAIL BED/FINGER TIP
6.65
1.00
11755
BIOPSY, NAIL UNIT
1.92
1.00
11755
BIOPSY, NAIL UNIT
1.93
1.00
11755
BIOPSY, NAIL UNIT
2.21
1.00
11755
BIOPSY, NAIL UNIT
3.00
1.00
11760
REPAIR OF NAIL BED
3.00
1.00
11760
REPAIR OF NAIL BED
3.33
1.00
11762
RECONSTRUCTION OF NAIL BED
3.00
1.00
11762
RECONSTRUCTION OF NAIL BED
5.09
1.00
11762
RECONSTRUCTION OF NAIL BED
5.11
1.00
11762
RECONSTRUCTION OF NAIL BED
5.12
1.00
11765
EXCISION OF NAIL FOLD, TOE
1.23
1.00
11765
EXCISION OF NAIL FOLD, TOE
1.27
1.00
11765
EXCISION OF NAIL FOLD, TOE
1.71
1.00
11765
EXCISION OF NAIL FOLD, TOE
3.00
1.00
11770
REMOVAL OF PILONIDAL LESION
4.00
1.00
11770
REMOVAL OF PILONIDAL LESION
4.08
1.00
11770
REMOVAL OF PILONIDAL LESION
4.41
1.00
11770
REMOVAL OF PILONIDAL LESION
4.49
1.00
11771
REMOVAL OF PILONIDAL LESION
4.00
1.00
11771
REMOVAL OF PILONIDAL LESION
9.74
1.00
11771
REMOVAL OF PILONIDAL LESION
10.21
1.00
11771
REMOVAL OF PILONIDAL LESION
10.40
1.00
11772
REMOVAL OF PILONIDAL LESION
4.00
1.00
11772
REMOVAL OF PILONIDAL LESION
11.66
1.00
11772
REMOVAL OF PILONIDAL LESION
12.02
1.00
11772
REMOVAL OF PILONIDAL LESION
13.57
1.00
11900
INJECTION INTO SKIN LESIONS
0.76
1.00
11900
INJECTION INTO SKIN LESIONS
0.79
1.00
11900
INJECTION INTO SKIN LESIONS
4.00
1.00
11901
ADDED SKIN LESIONS INJECTION
1.19
1.00
11901
ADDED SKIN LESIONS INJECTION
1.20
1.00
11901
ADDED SKIN LESIONS INJECTION
1.23
1.00
Procedure Code Description
RVU
RVU Coeff Value
11901
ADDED SKIN LESIONS INJECTION
4.00
1.00
11920
CORRECT SKIN COLOR DEFECTS
2.58
1.00
11920
CORRECT SKIN COLOR DEFECTS
2.60
1.00
11920
CORRECT SKIN COLOR DEFECTS
2.97
1.00
11921
CORRECT SKIN COLOR DEFECTS
3.14
1.00
11921
CORRECT SKIN COLOR DEFECTS
3.16
1.00
11921
CORRECT SKIN COLOR DEFECTS
3.50
1.00
11922
CORRECT SKIN COLOR DEFECTS
0.79
1.00
11922
CORRECT SKIN COLOR DEFECTS
0.80
1.00
11950
THERAPY FOR CONTOUR DEFECTS
1.30
1.00
11950
THERAPY FOR CONTOUR DEFECTS
1.31
1.00
11950
THERAPY FOR CONTOUR DEFECTS
1.32
1.00
11951
THERAPY FOR CONTOUR DEFECTS
1.81
1.00
11951
THERAPY FOR CONTOUR DEFECTS
1.82
1.00
11952
THERAPY FOR CONTOUR DEFECTS
2.56
1.00
11952
THERAPY FOR CONTOUR DEFECTS
2.58
1.00
11952
THERAPY FOR CONTOUR DEFECTS
2.63
1.00
11954
THERAPY FOR CONTOUR DEFECTS
2.97
1.00
11954
THERAPY FOR CONTOUR DEFECTS
2.98
1.00
11954
THERAPY FOR CONTOUR DEFECTS
2.99
1.00
11954
THERAPY FOR CONTOUR DEFECTS
3.00
1.00
11960
INSERT TISSUE EXPANDER(S)
5.00
1.00
11960
INSERT TISSUE EXPANDER(S)
20.65
1.00
11960
INSERT TISSUE EXPANDER(S)
20.90
1.00
11960
INSERT TISSUE EXPANDER(S)
22.98
1.00
11970
REPLACE TISSUE EXPANDER
12.81
1.00
11970
REPLACE TISSUE EXPANDER
14.08
1.00
11970
REPLACE TISSUE EXPANDER
15.13
1.00
11971
REMOVE TISSUE EXPANDER(S)
3.00
1.00
11971
REMOVE TISSUE EXPANDER(S)
6.20
1.00
11971
REMOVE TISSUE EXPANDER(S)
6.22
1.00
11971
REMOVE TISSUE EXPANDER(S)
6.25
1.00
11971
REMOVE TISSUE EXPANDER(S)
7.14
1.00
11971
REMOVE TISSUE EXPANDER(S)
7.45
1.00
11975
INSERT CONTRACEPTIVE CAP
2.17
1.00
Procedure Code Description
RVU
RVU Coeff Value
11975
INSERT CONTRACEPTIVE CAP
2.20
1.00
11975
INSERT CONTRACEPTIVE CAP
2.22
1.00
11976
REMOVAL OF CONTRACEPTIVE CAP
2.54
1.00
11976
REMOVAL OF CONTRACEPTIVE CAP
2.65
1.00
11976
REMOVAL OF CONTRACEPTIVE CAP
2.67
1.00
11976
REMOVAL OF CONTRACEPTIVE CAP
3.00
1.00
11977
REMOVAL/REINSERT CONTRA CAP
4.82
1.00
11977
REMOVAL/REINSERT CONTRA CAP
4.89
1.00
11977
REMOVAL/REINSERT CONTRA CAP
4.93
1.00
11980
IMPLANT HORMONE PELLET(S)
2.12
1.00
11980
IMPLANT HORMONE PELLET(S)
2.14
1.00
11981
INSERT DRUG IMPLANT DEVICE
2.20
1.00
11981
INSERT DRUG IMPLANT DEVICE
2.23
1.00
11981
INSERT DRUG IMPLANT DEVICE
2.33
1.00
11982
REMOVE DRUG IMPLANT DEVICE
2.65
1.00
11982
REMOVE DRUG IMPLANT DEVICE
2.73
1.00
11982
REMOVE DRUG IMPLANT DEVICE
2.83
1.00
11983
REMOVE/INSERT DRUG IMPLANT
4.89
1.00
11983
REMOVE/INSERT DRUG IMPLANT
4.97
1.00
11983
REMOVE/INSERT DRUG IMPLANT
5.14
1.00
12001
REPAIR SUPERFICIAL WOUND(S)
2.27
1.00
12001
REPAIR SUPERFICIAL WOUND(S)
2.35
1.00
12001
REPAIR SUPERFICIAL WOUND(S)
2.61
1.00
12001
REPAIR SUPERFICIAL WOUND(S)
3.00
1.00
12002
REPAIR SUPERFICIAL WOUND(S)
2.90
1.00
12002
REPAIR SUPERFICIAL WOUND(S)
2.93
1.00
12002
REPAIR SUPERFICIAL WOUND(S)
2.97
1.00
12002
REPAIR SUPERFICIAL WOUND(S)
3.00
1.00
12004
REPAIR SUPERFICIAL WOUND(S)
3.00
1.00
12004
REPAIR SUPERFICIAL WOUND(S)
3.41
1.00
12004
REPAIR SUPERFICIAL WOUND(S)
3.44
1.00
12004
REPAIR SUPERFICIAL WOUND(S)
3.50
1.00
12005
REPAIR SUPERFICIAL WOUND(S)
4.00
1.00
12005
REPAIR SUPERFICIAL WOUND(S)
4.25
1.00
12005
REPAIR SUPERFICIAL WOUND(S)
4.31
1.00
Procedure Code Description
RVU
RVU Coeff Value
12005
REPAIR SUPERFICIAL WOUND(S)
4.37
1.00
12006
REPAIR SUPERFICIAL WOUND(S)
3.00
1.00
12006
REPAIR SUPERFICIAL WOUND(S)
5.37
1.00
12006
REPAIR SUPERFICIAL WOUND(S)
5.51
1.00
12006
REPAIR SUPERFICIAL WOUND(S)
5.57
1.00
12007
REPAIR SUPERFICIAL WOUND(S)
3.00
1.00
12007
REPAIR SUPERFICIAL WOUND(S)
6.16
1.00
12007
REPAIR SUPERFICIAL WOUND(S)
6.32
1.00
12007
REPAIR SUPERFICIAL WOUND(S)
6.40
1.00
12011
REPAIR SUPERFICIAL WOUND(S)
2.34
1.00
12011
REPAIR SUPERFICIAL WOUND(S)
2.43
1.00
12011
REPAIR SUPERFICIAL WOUND(S)
2.70
1.00
12011
REPAIR SUPERFICIAL WOUND(S)
3.00
1.00
12013
REPAIR SUPERFICIAL WOUND(S)
3.08
1.00
12013
REPAIR SUPERFICIAL WOUND(S)
3.11
1.00
12013
REPAIR SUPERFICIAL WOUND(S)
3.15
1.00
12013
REPAIR SUPERFICIAL WOUND(S)
4.00
1.00
12014
REPAIR SUPERFICIAL WOUND(S)
3.71
1.00
12014
REPAIR SUPERFICIAL WOUND(S)
3.72
1.00
12014
REPAIR SUPERFICIAL WOUND(S)
3.77
1.00
12014
REPAIR SUPERFICIAL WOUND(S)
4.00
1.00
12015
REPAIR SUPERFICIAL WOUND(S)
4.00
1.00
12015
REPAIR SUPERFICIAL WOUND(S)
4.65
1.00
12015
REPAIR SUPERFICIAL WOUND(S)
4.70
1.00
12015
REPAIR SUPERFICIAL WOUND(S)
4.76
1.00
12016
REPAIR SUPERFICIAL WOUND(S)
4.00
1.00
12016
REPAIR SUPERFICIAL WOUND(S)
5.68
1.00
12016
REPAIR SUPERFICIAL WOUND(S)
5.80
1.00
12016
REPAIR SUPERFICIAL WOUND(S)
5.87
1.00
12017
REPAIR SUPERFICIAL WOUND(S)
4.00
1.00
12017
REPAIR SUPERFICIAL WOUND(S)
6.77
1.00
12017
REPAIR SUPERFICIAL WOUND(S)
7.00
1.00
12017
REPAIR SUPERFICIAL WOUND(S)
7.08
1.00
12018
REPAIR SUPERFICIAL WOUND(S)
4.00
1.00
12018
REPAIR SUPERFICIAL WOUND(S)
8.26
1.00
Procedure Code Description
RVU
RVU Coeff Value
12018
REPAIR SUPERFICIAL WOUND(S)
8.34
1.00
12018
REPAIR SUPERFICIAL WOUND(S)
8.41
1.00
12020
CLOSURE OF SPLIT WOUND
4.28
1.00
12020
CLOSURE OF SPLIT WOUND
4.66
1.00
12020
CLOSURE OF SPLIT WOUND
4.74
1.00
12021
CLOSURE OF SPLIT WOUND
3.05
1.00
12021
CLOSURE OF SPLIT WOUND
3.45
1.00
12021
CLOSURE OF SPLIT WOUND
3.48
1.00
12031
INTMD WND REPAIR S/TR/EXT
3.07
1.00
12031
INTMD WND REPAIR S/TR/EXT
3.14
1.00
12031
INTMD WND REPAIR S/TR/EXT
3.95
1.00
12031
INTMD WND REPAIR S/TR/EXT
4.00
1.00
12032
INTMD WND REPAIR S/TR/EXT
3.90
1.00
12032
INTMD WND REPAIR S/TR/EXT
4.00
1.00
12032
INTMD WND REPAIR S/TR/EXT
4.49
1.00
12032
INTMD WND REPAIR S/TR/EXT
4.85
1.00
12034
INTMD WND REPAIR S/TR/EXT
4.00
1.00
12034
INTMD WND REPAIR S/TR/EXT
4.57
1.00
12034
INTMD WND REPAIR S/TR/EXT
4.58
1.00
12034
INTMD WND REPAIR S/TR/EXT
5.08
1.00
12035
INTMD WND REPAIR S/TR/EXT
4.00
1.00
12035
INTMD WND REPAIR S/TR/EXT
5.40
1.00
12035
INTMD WND REPAIR S/TR/EXT
5.96
1.00
12035
INTMD WND REPAIR S/TR/EXT
5.99
1.00
12036
INTMD WND REPAIR S/TR/EXT
4.00
1.00
12036
INTMD WND REPAIR S/TR/EXT
6.91
1.00
12036
INTMD WND REPAIR S/TR/EXT
6.92
1.00
12036
INTMD WND REPAIR S/TR/EXT
6.94
1.00
12037
INTMD WND REPAIR S/TR/EXT
4.00
1.00
12037
INTMD WND REPAIR S/TR/EXT
7.96
1.00
12037
INTMD WND REPAIR S/TR/EXT
8.03
1.00
12037
INTMD WND REPAIR S/TR/EXT
8.09
1.00
12041
INTMD WND REPAIR N-HF/GENIT
3.37
1.00
12041
INTMD WND REPAIR N-HF/GENIT
3.45
1.00
12041
INTMD WND REPAIR N-HF/GENIT
4.00
1.00
Procedure Code Description
RVU
RVU Coeff Value
12041
INTMD WND REPAIR N-HF/GENIT
4.23
1.00
12042
INTMD WND REPAIR N-HG/GENIT
4.00
1.00
12042
INTMD WND REPAIR N-HG/GENIT
4.32
1.00
12042
INTMD WND REPAIR N-HG/GENIT
4.93
1.00
12044
INTMD WND REPAIR N-HG/GENIT
4.00
1.00
12044
INTMD WND REPAIR N-HG/GENIT
4.98
1.00
12044
INTMD WND REPAIR N-HG/GENIT
4.99
1.00
12044
INTMD WND REPAIR N-HG/GENIT
5.33
1.00
12045
INTMD WND REPAIR N-HG/GENIT
4.00
1.00
12045
INTMD WND REPAIR N-HG/GENIT
5.85
1.00
12045
INTMD WND REPAIR N-HG/GENIT
6.21
1.00
12045
INTMD WND REPAIR N-HG/GENIT
6.22
1.00
12046
INTMD WND REPAIR N-HG/GENIT
4.00
1.00
12046
INTMD WND REPAIR N-HG/GENIT
7.20
1.00
12046
INTMD WND REPAIR N-HG/GENIT
7.35
1.00
12046
INTMD WND REPAIR N-HG/GENIT
7.48
1.00
12047
INTMD WND REPAIR N-HG/GENIT
4.00
1.00
12047
INTMD WND REPAIR N-HG/GENIT
7.95
1.00
12047
INTMD WND REPAIR N-HG/GENIT
8.04
1.00
12047
INTMD WND REPAIR N-HG/GENIT
8.23
1.00
12051
INTMD WND REPAIR FACE/MM
4.00
1.00
12051
INTMD WND REPAIR FACE/MM
4.02
1.00
12051
INTMD WND REPAIR FACE/MM
4.04
1.00
12051
INTMD WND REPAIR FACE/MM
4.53
1.00
12052
INTMD WND REPAIR FACE/MM
4.00
1.00
12052
INTMD WND REPAIR FACE/MM
4.32
1.00
12052
INTMD WND REPAIR FACE/MM
5.30
1.00
12053
INTMD WND REPAIR FACE/MM
4.00
1.00
12053
INTMD WND REPAIR FACE/MM
4.86
1.00
12053
INTMD WND REPAIR FACE/MM
5.39
1.00
12054
INTMD WND REPAIR, FACE/MM
4.00
1.00
12054
INTMD WND REPAIR, FACE/MM
5.35
1.00
12054
INTMD WND REPAIR, FACE/MM
5.74
1.00
12055
INTMD WND REPAIR FACE/MM
4.00
1.00
12055
INTMD WND REPAIR FACE/MM
6.97
1.00
Procedure Code Description
RVU
RVU Coeff Value
12055
INTMD WND REPAIR FACE/MM
6.98
1.00
12055
INTMD WND REPAIR FACE/MM
7.02
1.00
12056
INTMD WND REPAIR FACE/MM
4.00
1.00
12056
INTMD WND REPAIR FACE/MM
8.59
1.00
12056
INTMD WND REPAIR FACE/MM
8.72
1.00
12056
INTMD WND REPAIR FACE/MM
8.82
1.00
12057
INTMD WND REPAIR FACE/MM
4.00
1.00
12057
INTMD WND REPAIR FACE/MM
9.80
1.00
12057
INTMD WND REPAIR FACE/MM
10.19
1.00
12057
INTMD WND REPAIR FACE/MM
10.31
1.00
13100
REPAIR OF WOUND OR LESION
4.00
1.00
13100
REPAIR OF WOUND OR LESION
5.15
1.00
13100
REPAIR OF WOUND OR LESION
5.17
1.00
13100
REPAIR OF WOUND OR LESION
5.92
1.00
13101
REPAIR OF WOUND OR LESION
3.00
1.00
13101
REPAIR OF WOUND OR LESION
6.40
1.00
13101
REPAIR OF WOUND OR LESION
6.43
1.00
13101
REPAIR OF WOUND OR LESION
6.86
1.00
13101
REPAIR OF WOUND OR LESION
6.87
1.00
13101
REPAIR OF WOUND OR LESION
7.17
1.00
13102
REPAIR WOUND/LESION ADD-ON
1.92
1.00
13102
REPAIR WOUND/LESION ADD-ON
1.93
1.00
13120
REPAIR OF WOUND OR LESION
3.00
1.00
13120
REPAIR OF WOUND OR LESION
5.40
1.00
13120
REPAIR OF WOUND OR LESION
5.41
1.00
13120
REPAIR OF WOUND OR LESION
6.18
1.00
13121
REPAIR OF WOUND OR LESION
3.00
1.00
13121
REPAIR OF WOUND OR LESION
6.94
1.00
13121
REPAIR OF WOUND OR LESION
6.97
1.00
13121
REPAIR OF WOUND OR LESION
8.12
1.00
13122
REPAIR WOUND/LESION ADD-ON
2.21
1.00
13131
REPAIR OF WOUND OR LESION
3.00
1.00
13131
REPAIR OF WOUND OR LESION
6.22
1.00
13131
REPAIR OF WOUND OR LESION
6.25
1.00
13131
REPAIR OF WOUND OR LESION
6.96
1.00
Procedure Code Description
RVU
RVU Coeff Value
13132
REPAIR OF WOUND OR LESION
3.00
1.00
13132
REPAIR OF WOUND OR LESION
9.50
1.00
13132
REPAIR OF WOUND OR LESION
9.52
1.00
13132
REPAIR OF WOUND OR LESION
10.43
1.00
13132
REPAIR OF WOUND OR LESION
10.45
1.00
13132
REPAIR OF WOUND OR LESION
11.69
1.00
13133
REPAIR WOUND/LESION ADD-ON
3.41
1.00
13133
REPAIR WOUND/LESION ADD-ON
3.42
1.00
13133
REPAIR WOUND/LESION ADD-ON
3.43
1.00
13150
REPAIR OF WOUND OR LESION
3.00
1.00
13150
REPAIR OF WOUND OR LESION
6.74
1.00
13150
REPAIR OF WOUND OR LESION
6.76
1.00
13150
REPAIR OF WOUND OR LESION
6.95
1.00
13151
REPAIR OF WOUND OR LESION
3.00
1.00
13151
REPAIR OF WOUND OR LESION
7.81
1.00
13151
REPAIR OF WOUND OR LESION
8.06
1.00
13152
REPAIR OF WOUND OR LESION
3.00
1.00
13152
REPAIR OF WOUND OR LESION
10.69
1.00
13152
REPAIR OF WOUND OR LESION
10.71
1.00
13152
REPAIR OF WOUND OR LESION
10.83
1.00
13153
REPAIR WOUND/LESION ADD-ON
3.72
1.00
13153
REPAIR WOUND/LESION ADD-ON
3.74
1.00
13160
LATE CLOSURE OF WOUND
3.00
1.00
13160
LATE CLOSURE OF WOUND
18.00
1.00
13160
LATE CLOSURE OF WOUND
19.04
1.00
13160
LATE CLOSURE OF WOUND
20.57
1.00
14000
SKIN TISSUE REARRANGEMENT
4.00
1.00
14000
SKIN TISSUE REARRANGEMENT
11.00
1.00
14000
SKIN TISSUE REARRANGEMENT
11.55
1.00
14000
SKIN TISSUE REARRANGEMENT
12.52
1.00
14001
SKIN TISSUE REARRANGEMENT
4.00
1.00
14001
SKIN TISSUE REARRANGEMENT
15.08
1.00
14001
SKIN TISSUE REARRANGEMENT
15.83
1.00
14001
SKIN TISSUE REARRANGEMENT
16.62
1.00
14020
SKIN TISSUE REARRANGEMENT
4.00
1.00
Procedure Code Description
RVU
RVU Coeff Value
14020
SKIN TISSUE REARRANGEMENT
12.44
1.00
14020
SKIN TISSUE REARRANGEMENT
13.17
1.00
14020
SKIN TISSUE REARRANGEMENT
14.32
1.00
14021
SKIN TISSUE REARRANGEMENT
4.00
1.00
14021
SKIN TISSUE REARRANGEMENT
17.87
1.00
14021
SKIN TISSUE REARRANGEMENT
18.49
1.00
14021
SKIN TISSUE REARRANGEMENT
18.61
1.00
14040
SKIN TISSUE REARRANGEMENT
4.00
1.00
14040
SKIN TISSUE REARRANGEMENT
15.38
1.00
14040
SKIN TISSUE REARRANGEMENT
15.47
1.00
14040
SKIN TISSUE REARRANGEMENT
16.24
1.00
14041
SKIN TISSUE REARRANGEMENT
4.00
1.00
14041
SKIN TISSUE REARRANGEMENT
20.04
1.00
14041
SKIN TISSUE REARRANGEMENT
21.01
1.00
14041
SKIN TISSUE REARRANGEMENT
21.11
1.00
14060
SKIN TISSUE REARRANGEMENT
4.00
1.00
14060
SKIN TISSUE REARRANGEMENT
16.89
1.00
14060
SKIN TISSUE REARRANGEMENT
16.93
1.00
14060
SKIN TISSUE REARRANGEMENT
17.15
1.00
14061
SKIN TISSUE REARRANGEMENT
4.00
1.00
14061
SKIN TISSUE REARRANGEMENT
21.37
1.00
14061
SKIN TISSUE REARRANGEMENT
22.68
1.00
14061
SKIN TISSUE REARRANGEMENT
22.81
1.00
14300
SKIN TISSUE REARRANGEMENT
4.00
1.00
14300
SKIN TISSUE REARRANGEMENT
21.97
1.00
14300
SKIN TISSUE REARRANGEMENT
22.00
1.00
14300
SKIN TISSUE REARRANGEMENT
24.00
1.00
14350
SKIN TISSUE REARRANGEMENT
3.00
1.00
14350
SKIN TISSUE REARRANGEMENT
17.06
1.00
14350
SKIN TISSUE REARRANGEMENT
18.03
1.00
14350
SKIN TISSUE REARRANGEMENT
19.09
1.00
15000
WOUND PREP, 1ST 100 SQ CM
3.00
1.00
15000
WOUND PREP, 1ST 100 SQ CM
6.59
1.00
15000
WOUND PREP, 1ST 100 SQ CM
6.64
1.00
15000
WOUND PREP, 1ST 100 SQ CM
6.72
1.00
Procedure Code Description
RVU
RVU Coeff Value
15001
WOUND PREP, ADDL 100 SQ CM
1.53
1.00
15001
WOUND PREP, ADDL 100 SQ CM
1.54
1.00
15001
WOUND PREP, ADDL 100 SQ CM
1.55
1.00
15002
WOUND PREP, TRK/ARM/LEG
5.87
1.00
15003
WOUND PREP, ADDL 100 CM
1.19
1.00
15004
WOUND PREP, F/N/HF/G
7.34
1.00
15005
WND PREP, F/N/HF/G, ADDL CM
2.36
1.00
15040
HARVEST CULTURED SKIN GRAFT
3.29
1.00
15050
SKIN PINCH GRAFT
3.00
1.00
15050
SKIN PINCH GRAFT
8.75
1.00
15050
SKIN PINCH GRAFT
9.58
1.00
15050
SKIN PINCH GRAFT
10.99
1.00
15100
SKIN SPLT GRFT, TRNK/ARM/LEG
4.00
1.00
15100
SKIN SPLT GRFT, TRNK/ARM/LEG
17.97
1.00
15100
SKIN SPLT GRFT, TRNK/ARM/LEG
18.08
1.00
15100
SKIN SPLT GRFT, TRNK/ARM/LEG
18.09
1.00
15101
SKIN SPLT GRFT T/A/L, ADD-ON
2.91
1.00
15101
SKIN SPLT GRFT T/A/L, ADD-ON
3.38
1.00
15101
SKIN SPLT GRFT T/A/L, ADD-ON
3.60
1.00
15110
EPIDRM AUTOGRFT TRNK/ARM/LEG
18.60
1.00
15111
EPIDRM AUTOGRFT T/A/L ADD-ON
2.81
1.00
15115
EPIDRM A-GRFT FACE/NCK/HF/G
19.20
1.00
15116
EPIDRM A-GRFT F/N/HF/G ADDL
3.87
1.00
15120
SKN SPLT A-GRFT FAC/NCK/HF/G
4.00
1.00
15120
SKN SPLT A-GRFT FAC/NCK/HF/G
18.68
1.00
15120
SKN SPLT A-GRFT FAC/NCK/HF/G
18.76
1.00
15120
SKN SPLT A-GRFT FAC/NCK/HF/G
19.75
1.00
15121
SKN SPLT A-GRFT F/N/HF/G ADD
4.45
1.00
15121
SKN SPLT A-GRFT F/N/HF/G ADD
4.79
1.00
15121
SKN SPLT A-GRFT F/N/HF/G ADD
4.87
1.00
15130
DERM AUTOGRAFT, TRNK/ARM/LEG
14.14
1.00
15131
DERM AUTOGRAFT T/A/L ADD-ON
2.30
1.00
15135
DERM AUTOGRAFT FACE/NCK/HF/G
19.38
1.00
15136
DERM AUTOGRAFT, F/N/HF/G ADD
2.18
1.00
15150
CULT EPIDERM GRFT T/ARM/LEG
16.15
1.00
Procedure Code Description
RVU
RVU Coeff Value
15151
CULT EPIDERM GRFT T/A/L ADDL
3.04
1.00
15152
CULT EPIDERM GRAFT T/A/L +%
4.00
1.00
15155
CULT EPIDERM GRAFT, F/N/HF/G
17.25
1.00
15156
CULT EPIDRM GRFT F/N/HFG ADD
4.33
1.00
15157
CULT EPIDERM GRFT F/N/HFG +%
4.70
1.00
15170
ACELL GRAFT TRUNK/ARMS/LEGS
9.25
1.00
15171
ACELL GRAFT T/ARM/LEG ADD-ON
2.30
1.00
15175
ACELLULAR GRAFT, F/N/HF/G
12.26
1.00
15176
ACELL GRAFT, F/N/HF/G ADD-ON
3.64
1.00
15200
SKIN FULL GRAFT, TRUNK
3.00
1.00
15200
SKIN FULL GRAFT, TRUNK
14.30
1.00
15200
SKIN FULL GRAFT, TRUNK
14.90
1.00
15200
SKIN FULL GRAFT, TRUNK
16.50
1.00
15201
SKIN FULL GRAFT TRUNK ADD-ON
2.08
1.00
15201
SKIN FULL GRAFT TRUNK ADD-ON
2.10
1.00
15201
SKIN FULL GRAFT TRUNK ADD-ON
2.11
1.00
15201
SKIN FULL GRAFT TRUNK ADD-ON
2.12
1.00
15201
SKIN FULL GRAFT TRUNK ADD-ON
2.13
1.00
15220
SKIN FULL GRAFT SCLP/ARM/LEG
3.00
1.00
15220
SKIN FULL GRAFT SCLP/ARM/LEG
14.73
1.00
15220
SKIN FULL GRAFT SCLP/ARM/LEG
15.11
1.00
15220
SKIN FULL GRAFT SCLP/ARM/LEG
15.59
1.00
15221
SKIN FULL GRAFT ADD-ON
1.89
1.00
15221
SKIN FULL GRAFT ADD-ON
1.90
1.00
15240
SKIN FULL GRFT FACE/GENIT/HF
3.00
1.00
15240
SKIN FULL GRFT FACE/GENIT/HF
16.85
1.00
15240
SKIN FULL GRFT FACE/GENIT/HF
17.64
1.00
15240
SKIN FULL GRFT FACE/GENIT/HF
19.87
1.00
15241
SKIN FULL GRAFT ADD-ON
2.96
1.00
15241
SKIN FULL GRAFT ADD-ON
2.97
1.00
15241
SKIN FULL GRAFT ADD-ON
2.99
1.00
15260
SKIN FULL GRAFT EEN & LIPS
4.00
1.00
15260
SKIN FULL GRAFT EEN & LIPS
19.40
1.00
15260
SKIN FULL GRAFT EEN & LIPS
19.59
1.00
15260
SKIN FULL GRAFT EEN & LIPS
21.43
1.00
Procedure Code Description
RVU
RVU Coeff Value
15261
SKIN FULL GRAFT ADD-ON
3.70
1.00
15261
SKIN FULL GRAFT ADD-ON
3.86
1.00
15261
SKIN FULL GRAFT ADD-ON
4.00
1.00
15300
APPLY SKINALLOGRFT, T/ARM/LG
7.38
1.00
15301
APPLY SKNALLOGRFT T/A/L ADDL
1.51
1.00
15320
APPLY SKIN ALLOGRFT F/N/HF/G
8.36
1.00
15321
APLY SKNALLOGRFT F/N/HFG ADD
2.27
1.00
15330
APLY ACELL ALOGRFT T/ARM/LEG
6.72
1.00
15331
APLY ACELL GRFT T/A/L ADD-ON
1.52
1.00
15335
APPLY ACELL GRAFT, F/N/HF/G
7.18
1.00
15336
APLY ACELL GRFT F/N/HF/G ADD
2.09
1.00
15340
APPLY CULT SKIN SUBSTITUTE
6.84
1.00
15341
APPLY CULT SKIN SUB ADD-ON
0.72
1.00
15342
CULTURED SKIN GRAFT, 25 CM
1.66
1.00
15342
CULTURED SKIN GRAFT, 25 CM
1.84
1.00
15342
CULTURED SKIN GRAFT, 25 CM
3.00
1.00
15343
CULTURE SKN GRAFT ADDL 25 CM
0.37
1.00
15350
SKIN HOMOGRAFT
3.00
1.00
15350
SKIN HOMOGRAFT
8.32
1.00
15350
SKIN HOMOGRAFT
8.76
1.00
15350
SKIN HOMOGRAFT
9.33
1.00
15351
SKIN HOMOGRAFT ADD-ON
1.50
1.00
15351
SKIN HOMOGRAFT ADD-ON
1.52
1.00
15360
APPLY CULT DERM SUB, T/A/L
7.70
1.00
15361
APLY CULT DERM SUB T/A/L ADD
1.66
1.00
15365
APPLY CULT DERM SUB F/N/HF/G
7.69
1.00
15366
APPLY CULT DERM F/HF/G ADD
2.07
1.00
15400
APPLY SKIN XENOGRAFT, T/A/L
3.00
1.00
15400
APPLY SKIN XENOGRAFT, T/A/L
8.57
1.00
15400
APPLY SKIN XENOGRAFT, T/A/L
8.87
1.00
15400
APPLY SKIN XENOGRAFT, T/A/L
9.24
1.00
15401
APPLY SKN XENOGRFT T/A/L ADD
1.50
1.00
15401
APPLY SKN XENOGRFT T/A/L ADD
1.57
1.00
15420
APPLY SKIN XGRAFT, F/N/HF/G
9.84
1.00
15421
APPLY SKN XGRFT F/N/HF/G ADD
2.24
1.00
Procedure Code Description 15430
APPLY ACELLULAR XENOGRAFT
15570
RVU
RVU Coeff Value
12.58
1.00
FORM SKIN PEDICLE FLAP
4.00
1.00
15570
FORM SKIN PEDICLE FLAP
16.24
1.00
15570
FORM SKIN PEDICLE FLAP
17.04
1.00
15570
FORM SKIN PEDICLE FLAP
18.10
1.00
15572
FORM SKIN PEDICLE FLAP
4.00
1.00
15572
FORM SKIN PEDICLE FLAP
16.00
1.00
15572
FORM SKIN PEDICLE FLAP
16.63
1.00
15572
FORM SKIN PEDICLE FLAP
18.28
1.00
15574
FORM SKIN PEDICLE FLAP
4.00
1.00
15574
FORM SKIN PEDICLE FLAP
17.64
1.00
15574
FORM SKIN PEDICLE FLAP
17.93
1.00
15574
FORM SKIN PEDICLE FLAP
19.29
1.00
15576
FORM SKIN PEDICLE FLAP
4.00
1.00
15576
FORM SKIN PEDICLE FLAP
15.70
1.00
15576
FORM SKIN PEDICLE FLAP
15.97
1.00
15576
FORM SKIN PEDICLE FLAP
16.88
1.00
15600
SKIN GRAFT
4.00
1.00
15600
SKIN GRAFT
4.44
1.00
15600
SKIN GRAFT
4.84
1.00
15600
SKIN GRAFT
5.04
1.00
15610
SKIN GRAFT
4.00
1.00
15610
SKIN GRAFT
5.29
1.00
15610
SKIN GRAFT
5.75
1.00
15610
SKIN GRAFT
5.97
1.00
15620
SKIN GRAFT
4.00
1.00
15620
SKIN GRAFT
6.61
1.00
15620
SKIN GRAFT
6.95
1.00
15620
SKIN GRAFT
7.87
1.00
15630
SKIN GRAFT
4.00
1.00
15630
SKIN GRAFT
7.21
1.00
15630
SKIN GRAFT
7.54
1.00
15630
SKIN GRAFT
8.59
1.00
15650
TRANSFER SKIN PEDICLE FLAP
4.00
1.00
15650
TRANSFER SKIN PEDICLE FLAP
8.06
1.00
Procedure Code Description
RVU
RVU Coeff Value
15650
TRANSFER SKIN PEDICLE FLAP
8.41
1.00
15650
TRANSFER SKIN PEDICLE FLAP
9.69
1.00
15731
FOREHEAD FLAP W/VASC PEDICLE
25.57
1.00
15732
MUSCLE-SKIN GRAFT, HEAD/NECK
4.00
1.00
15732
MUSCLE-SKIN GRAFT, HEAD/NECK
31.84
1.00
15732
MUSCLE-SKIN GRAFT, HEAD/NECK
32.04
1.00
15732
MUSCLE-SKIN GRAFT, HEAD/NECK
33.36
1.00
15734
MUSCLE-SKIN GRAFT, TRUNK
4.00
1.00
15734
MUSCLE-SKIN GRAFT, TRUNK
32.40
1.00
15734
MUSCLE-SKIN GRAFT, TRUNK
32.43
1.00
15734
MUSCLE-SKIN GRAFT, TRUNK
34.36
1.00
15734
MUSCLE-SKIN GRAFT, TRUNK
34.41
1.00
15734
MUSCLE-SKIN GRAFT, TRUNK
34.56
1.00
15736
MUSCLE-SKIN GRAFT, ARM
3.00
1.00
15736
MUSCLE-SKIN GRAFT, ARM
29.62
1.00
15736
MUSCLE-SKIN GRAFT, ARM
29.78
1.00
15736
MUSCLE-SKIN GRAFT, ARM
29.86
1.00
15738
MUSCLE-SKIN GRAFT, LEG
3.00
1.00
15738
MUSCLE-SKIN GRAFT, LEG
31.98
1.00
15738
MUSCLE-SKIN GRAFT, LEG
32.12
1.00
15738
MUSCLE-SKIN GRAFT, LEG
32.43
1.00
15740
ISLAND PEDICLE FLAP GRAFT
4.00
1.00
15740
ISLAND PEDICLE FLAP GRAFT
17.92
1.00
15740
ISLAND PEDICLE FLAP GRAFT
18.86
1.00
15740
ISLAND PEDICLE FLAP GRAFT
21.56
1.00
15750
NEUROVASCULAR PEDICLE GRAFT
4.00
1.00
15750
NEUROVASCULAR PEDICLE GRAFT
20.77
1.00
15750
NEUROVASCULAR PEDICLE GRAFT
21.83
1.00
15750
NEUROVASCULAR PEDICLE GRAFT
23.08
1.00
15756
FREE MYO/SKIN FLAP MICROVASC
4.00
1.00
15756
FREE MYO/SKIN FLAP MICROVASC
59.19
1.00
15756
FREE MYO/SKIN FLAP MICROVASC
59.62
1.00
15756
FREE MYO/SKIN FLAP MICROVASC
61.03
1.00
15757
FREE SKIN FLAP, MICROVASC
4.00
1.00
15757
FREE SKIN FLAP, MICROVASC
60.19
1.00
Procedure Code Description
RVU
RVU Coeff Value
15757
FREE SKIN FLAP, MICROVASC
60.56
1.00
15757
FREE SKIN FLAP, MICROVASC
60.97
1.00
15758
FREE FASCIAL FLAP, MICROVASC
4.00
1.00
15758
FREE FASCIAL FLAP, MICROVASC
60.35
1.00
15758
FREE FASCIAL FLAP, MICROVASC
60.62
1.00
15758
FREE FASCIAL FLAP, MICROVASC
61.02
1.00
15760
COMPOSITE SKIN GRAFT
4.00
1.00
15760
COMPOSITE SKIN GRAFT
16.08
1.00
15760
COMPOSITE SKIN GRAFT
16.62
1.00
15760
COMPOSITE SKIN GRAFT
17.77
1.00
15770
DERMA-FAT-FASCIA GRAFT
4.00
1.00
15770
DERMA-FAT-FASCIA GRAFT
14.38
1.00
15770
DERMA-FAT-FASCIA GRAFT
15.14
1.00
15770
DERMA-FAT-FASCIA GRAFT
16.55
1.00
15775
HAIR TRANSPLANT PUNCH GRAFTS
4.00
1.00
15775
HAIR TRANSPLANT PUNCH GRAFTS
5.74
1.00
15775
HAIR TRANSPLANT PUNCH GRAFTS
5.79
1.00
15775
HAIR TRANSPLANT PUNCH GRAFTS
6.06
1.00
15776
HAIR TRANSPLANT PUNCH GRAFTS
4.00
1.00
15776
HAIR TRANSPLANT PUNCH GRAFTS
8.65
1.00
15776
HAIR TRANSPLANT PUNCH GRAFTS
9.03
1.00
15776
HAIR TRANSPLANT PUNCH GRAFTS
9.06
1.00
15780
ABRASION TREATMENT OF SKIN
4.00
1.00
15780
ABRASION TREATMENT OF SKIN
14.28
1.00
15780
ABRASION TREATMENT OF SKIN
14.84
1.00
15780
ABRASION TREATMENT OF SKIN
16.22
1.00
15781
ABRASION TREATMENT OF SKIN
9.92
1.00
15781
ABRASION TREATMENT OF SKIN
10.52
1.00
15781
ABRASION TREATMENT OF SKIN
10.66
1.00
15782
ABRASION TREATMENT OF SKIN
8.68
1.00
15782
ABRASION TREATMENT OF SKIN
8.86
1.00
15782
ABRASION TREATMENT OF SKIN
10.25
1.00
15783
ABRASION TREATMENT OF SKIN
8.12
1.00
15783
ABRASION TREATMENT OF SKIN
8.76
1.00
15783
ABRASION TREATMENT OF SKIN
9.23
1.00
Procedure Code Description
RVU
RVU Coeff Value
15786
ABRASION, LESION, SINGLE
3.43
1.00
15786
ABRASION, LESION, SINGLE
3.46
1.00
15786
ABRASION, LESION, SINGLE
4.00
1.00
15787
ABRASION, LESIONS, ADD-ON
0.49
1.00
15787
ABRASION, LESIONS, ADD-ON
0.51
1.00
15810
SALABRASION
4.00
1.00
15810
SALABRASION
8.89
1.00
15810
SALABRASION
9.11
1.00
15810
SALABRASION
9.12
1.00
15811
SALABRASION
4.00
1.00
15811
SALABRASION
10.64
1.00
15811
SALABRASION
10.95
1.00
15811
SALABRASION
11.53
1.00
15819
PLASTIC SURGERY, NECK
16.82
1.00
15819
PLASTIC SURGERY, NECK
17.50
1.00
15819
PLASTIC SURGERY, NECK
18.53
1.00
15820
REVISION OF LOWER EYELID
4.00
1.00
15820
REVISION OF LOWER EYELID
10.70
1.00
15820
REVISION OF LOWER EYELID
10.84
1.00
15820
REVISION OF LOWER EYELID
11.92
1.00
15821
REVISION OF LOWER EYELID
4.00
1.00
15821
REVISION OF LOWER EYELID
11.44
1.00
15821
REVISION OF LOWER EYELID
11.60
1.00
15821
REVISION OF LOWER EYELID
12.64
1.00
15822
REVISION OF UPPER EYELID
4.00
1.00
15822
REVISION OF UPPER EYELID
8.90
1.00
15822
REVISION OF UPPER EYELID
9.07
1.00
15822
REVISION OF UPPER EYELID
9.15
1.00
15823
REVISION OF UPPER EYELID
4.00
1.00
15823
REVISION OF UPPER EYELID
13.50
1.00
15823
REVISION OF UPPER EYELID
13.67
1.00
15823
REVISION OF UPPER EYELID
14.99
1.00
15830
EXC SKIN ABD
29.96
1.00
15831
EXCISE EXCESSIVE SKIN TISSUE
4.00
1.00
15831
EXCISE EXCESSIVE SKIN TISSUE
21.39
1.00
Procedure Code Description
RVU
RVU Coeff Value
15831
EXCISE EXCESSIVE SKIN TISSUE
22.17
1.00
15831
EXCISE EXCESSIVE SKIN TISSUE
22.31
1.00
15832
EXCISE EXCESSIVE SKIN TISSUE
4.00
1.00
15832
EXCISE EXCESSIVE SKIN TISSUE
20.48
1.00
15832
EXCISE EXCESSIVE SKIN TISSUE
21.41
1.00
15832
EXCISE EXCESSIVE SKIN TISSUE
22.58
1.00
15833
EXCISE EXCESSIVE SKIN TISSUE
4.00
1.00
15833
EXCISE EXCESSIVE SKIN TISSUE
18.87
1.00
15833
EXCISE EXCESSIVE SKIN TISSUE
20.27
1.00
15833
EXCISE EXCESSIVE SKIN TISSUE
21.28
1.00
15834
EXCISE EXCESSIVE SKIN TISSUE
4.00
1.00
15834
EXCISE EXCESSIVE SKIN TISSUE
18.98
1.00
15834
EXCISE EXCESSIVE SKIN TISSUE
19.96
1.00
15834
EXCISE EXCESSIVE SKIN TISSUE
21.22
1.00
15835
EXCISE EXCESSIVE SKIN TISSUE
4.00
1.00
15835
EXCISE EXCESSIVE SKIN TISSUE
19.73
1.00
15835
EXCISE EXCESSIVE SKIN TISSUE
20.64
1.00
15835
EXCISE EXCESSIVE SKIN TISSUE
22.40
1.00
15836
EXCISE EXCESSIVE SKIN TISSUE
4.00
1.00
15836
EXCISE EXCESSIVE SKIN TISSUE
16.47
1.00
15836
EXCISE EXCESSIVE SKIN TISSUE
17.29
1.00
15836
EXCISE EXCESSIVE SKIN TISSUE
18.68
1.00
15837
EXCISE EXCESSIVE SKIN TISSUE
4.00
1.00
15837
EXCISE EXCESSIVE SKIN TISSUE
15.63
1.00
15837
EXCISE EXCESSIVE SKIN TISSUE
16.36
1.00
15837
EXCISE EXCESSIVE SKIN TISSUE
16.90
1.00
15838
EXCISE EXCESSIVE SKIN TISSUE
4.00
1.00
15838
EXCISE EXCESSIVE SKIN TISSUE
13.39
1.00
15838
EXCISE EXCESSIVE SKIN TISSUE
13.91
1.00
15838
EXCISE EXCESSIVE SKIN TISSUE
14.42
1.00
15839
EXCISE EXCESSIVE SKIN TISSUE
16.01
1.00
15839
EXCISE EXCESSIVE SKIN TISSUE
16.64
1.00
15839
EXCISE EXCESSIVE SKIN TISSUE
18.28
1.00
15840
GRAFT FOR FACE NERVE PALSY
4.00
1.00
15840
GRAFT FOR FACE NERVE PALSY
24.16
1.00
Procedure Code Description
RVU
RVU Coeff Value
15840
GRAFT FOR FACE NERVE PALSY
24.68
1.00
15840
GRAFT FOR FACE NERVE PALSY
25.51
1.00
15841
GRAFT FOR FACE NERVE PALSY
4.00
1.00
15841
GRAFT FOR FACE NERVE PALSY
40.42
1.00
15841
GRAFT FOR FACE NERVE PALSY
41.51
1.00
15841
GRAFT FOR FACE NERVE PALSY
42.77
1.00
15842
FLAP FOR FACE NERVE PALSY
4.00
1.00
15842
FLAP FOR FACE NERVE PALSY
64.73
1.00
15842
FLAP FOR FACE NERVE PALSY
65.72
1.00
15842
FLAP FOR FACE NERVE PALSY
67.85
1.00
15845
SKIN AND MUSCLE REPAIR, FACE
4.00
1.00
15845
SKIN AND MUSCLE REPAIR, FACE
21.84
1.00
15845
SKIN AND MUSCLE REPAIR, FACE
22.87
1.00
15845
SKIN AND MUSCLE REPAIR, FACE
23.78
1.00
15850
REMOVAL OF SUTURES
5.00
1.00
15851
REMOVAL OF SUTURES
1.18
1.00
15851
REMOVAL OF SUTURES
1.25
1.00
15851
REMOVAL OF SUTURES
1.26
1.00
15851
REMOVAL OF SUTURES
3.00
1.00
15852
DRESSING CHANGE NOT FOR BURN
1.24
1.00
15852
DRESSING CHANGE NOT FOR BURN
1.29
1.00
15852
DRESSING CHANGE NOT FOR BURN
1.30
1.00
15852
DRESSING CHANGE NOT FOR BURN
3.00
1.00
15860
TEST FOR BLOOD FLOW IN GRAFT
2.89
1.00
15860
TEST FOR BLOOD FLOW IN GRAFT
2.90
1.00
15860
TEST FOR BLOOD FLOW IN GRAFT
2.94
1.00
15920
REMOVAL OF TAIL BONE ULCER
4.00
1.00
15920
REMOVAL OF TAIL BONE ULCER
14.27
1.00
15920
REMOVAL OF TAIL BONE ULCER
14.55
1.00
15920
REMOVAL OF TAIL BONE ULCER
14.80
1.00
15922
REMOVAL OF TAIL BONE ULCER
4.00
1.00
15922
REMOVAL OF TAIL BONE ULCER
18.27
1.00
15922
REMOVAL OF TAIL BONE ULCER
18.48
1.00
15922
REMOVAL OF TAIL BONE ULCER
18.84
1.00
15931
REMOVE SACRUM PRESSURE SORE
4.00
1.00
Procedure Code Description
RVU
RVU Coeff Value
15931
REMOVE SACRUM PRESSURE SORE
15.75
1.00
15931
REMOVE SACRUM PRESSURE SORE
16.13
1.00
15931
REMOVE SACRUM PRESSURE SORE
16.86
1.00
15933
REMOVE SACRUM PRESSURE SORE
4.00
1.00
15933
REMOVE SACRUM PRESSURE SORE
19.97
1.00
15933
REMOVE SACRUM PRESSURE SORE
20.14
1.00
15933
REMOVE SACRUM PRESSURE SORE
20.77
1.00
15934
REMOVE SACRUM PRESSURE SORE
4.00
1.00
15934
REMOVE SACRUM PRESSURE SORE
22.33
1.00
15934
REMOVE SACRUM PRESSURE SORE
22.45
1.00
15934
REMOVE SACRUM PRESSURE SORE
23.17
1.00
15935
REMOVE SACRUM PRESSURE SORE
5.00
1.00
15935
REMOVE SACRUM PRESSURE SORE
26.09
1.00
15935
REMOVE SACRUM PRESSURE SORE
26.83
1.00
15935
REMOVE SACRUM PRESSURE SORE
27.58
1.00
15936
REMOVE SACRUM PRESSURE SORE
5.00
1.00
15936
REMOVE SACRUM PRESSURE SORE
22.31
1.00
15936
REMOVE SACRUM PRESSURE SORE
22.48
1.00
15936
REMOVE SACRUM PRESSURE SORE
22.49
1.00
15937
REMOVE SACRUM PRESSURE SORE
5.00
1.00
15937
REMOVE SACRUM PRESSURE SORE
25.97
1.00
15937
REMOVE SACRUM PRESSURE SORE
26.29
1.00
15940
REMOVE HIP PRESSURE SORE
4.00
1.00
15940
REMOVE HIP PRESSURE SORE
16.24
1.00
15940
REMOVE HIP PRESSURE SORE
16.74
1.00
15940
REMOVE HIP PRESSURE SORE
17.35
1.00
15941
REMOVE HIP PRESSURE SORE
6.00
1.00
15941
REMOVE HIP PRESSURE SORE
22.46
1.00
15941
REMOVE HIP PRESSURE SORE
22.47
1.00
15941
REMOVE HIP PRESSURE SORE
22.55
1.00
15944
REMOVE HIP PRESSURE SORE
4.00
1.00
15944
REMOVE HIP PRESSURE SORE
21.26
1.00
15944
REMOVE HIP PRESSURE SORE
21.60
1.00
15944
REMOVE HIP PRESSURE SORE
22.21
1.00
15945
REMOVE HIP PRESSURE SORE
4.00
1.00
Procedure Code Description
RVU
RVU Coeff Value
15945
REMOVE HIP PRESSURE SORE
23.58
1.00
15945
REMOVE HIP PRESSURE SORE
24.07
1.00
15945
REMOVE HIP PRESSURE SORE
24.68
1.00
15946
REMOVE HIP PRESSURE SORE
37.84
1.00
15946
REMOVE HIP PRESSURE SORE
38.75
1.00
15946
REMOVE HIP PRESSURE SORE
41.27
1.00
15946
REMOVE HIP PRESSURE SORE
999.99
1.00
15950
REMOVE THIGH PRESSURE SORE
4.00
1.00
15950
REMOVE THIGH PRESSURE SORE
13.49
1.00
15950
REMOVE THIGH PRESSURE SORE
13.96
1.00
15950
REMOVE THIGH PRESSURE SORE
14.37
1.00
15951
REMOVE THIGH PRESSURE SORE
6.00
1.00
15951
REMOVE THIGH PRESSURE SORE
19.85
1.00
15951
REMOVE THIGH PRESSURE SORE
20.02
1.00
15951
REMOVE THIGH PRESSURE SORE
20.49
1.00
15952
REMOVE THIGH PRESSURE SORE
3.00
1.00
15952
REMOVE THIGH PRESSURE SORE
19.97
1.00
15952
REMOVE THIGH PRESSURE SORE
20.64
1.00
15952
REMOVE THIGH PRESSURE SORE
21.55
1.00
15953
REMOVE THIGH PRESSURE SORE
6.00
1.00
15953
REMOVE THIGH PRESSURE SORE
22.80
1.00
15953
REMOVE THIGH PRESSURE SORE
23.34
1.00
15953
REMOVE THIGH PRESSURE SORE
24.01
1.00
15956
REMOVE THIGH PRESSURE SORE
4.00
1.00
15956
REMOVE THIGH PRESSURE SORE
27.56
1.00
15956
REMOVE THIGH PRESSURE SORE
28.33
1.00
15956
REMOVE THIGH PRESSURE SORE
28.91
1.00
15958
REMOVE THIGH PRESSURE SORE
4.00
1.00
15958
REMOVE THIGH PRESSURE SORE
27.86
1.00
15958
REMOVE THIGH PRESSURE SORE
28.59
1.00
15958
REMOVE THIGH PRESSURE SORE
29.51
1.00
16000
INITIAL TREATMENT OF BURN(S)
1.21
1.00
16000
INITIAL TREATMENT OF BURN(S)
1.22
1.00
16000
INITIAL TREATMENT OF BURN(S)
1.23
1.00
16000
INITIAL TREATMENT OF BURN(S)
3.00
1.00
Procedure Code Description
RVU
RVU Coeff Value
16010
TREATMENT OF BURN(S)
1.30
1.00
16010
TREATMENT OF BURN(S)
1.58
1.00
16010
TREATMENT OF BURN(S)
1.59
1.00
16010
TREATMENT OF BURN(S)
3.00
1.00
16015
TREATMENT OF BURN(S)
3.00
1.00
16015
TREATMENT OF BURN(S)
3.51
1.00
16015
TREATMENT OF BURN(S)
3.77
1.00
16015
TREATMENT OF BURN(S)
3.81
1.00
16020
DRESS/DEBRID P-THICK BURN, S
1.12
1.00
16020
DRESS/DEBRID P-THICK BURN, S
1.44
1.00
16020
DRESS/DEBRID P-THICK BURN, S
1.48
1.00
16025
DRESS/DEBRID P-THICK BURN, M
2.68
1.00
16025
DRESS/DEBRID P-THICK BURN, M
2.95
1.00
16025
DRESS/DEBRID P-THICK BURN, M
3.01
1.00
16030
DRESS/DEBRID P-THICK BURN, L
3.17
1.00
16030
DRESS/DEBRID P-THICK BURN, L
3.36
1.00
16030
DRESS/DEBRID P-THICK BURN, L
3.42
1.00
16035
INCISION OF BURN SCAB, INITI
5.00
1.00
16035
INCISION OF BURN SCAB, INITI
5.56
1.00
16035
INCISION OF BURN SCAB, INITI
5.61
1.00
16035
INCISION OF BURN SCAB, INITI
5.64
1.00
16036
ESCHAROTOMY; ADDÏL INCISION
2.22
1.00
16036
ESCHAROTOMY; ADDÏL INCISION
2.23
1.00
17000
DESTRUCT PREMALG LESION
0.90
1.00
17000
DESTRUCT PREMALG LESION
0.96
1.00
17000
DESTRUCT PREMALG LESION
1.35
1.00
17000
DESTRUCT PREMALG LESION
3.00
1.00
17003
DESTRUCT PREMALG LES, 2-14
0.12
1.00
17003
DESTRUCT PREMALG LES, 2-14
0.23
1.00
17004
DESTROY PREMLG LESIONS 15+
3.40
1.00
17004
DESTROY PREMLG LESIONS 15+
4.18
1.00
17004
DESTROY PREMLG LESIONS 15+
4.22
1.00
17106
DESTRUCTION OF SKIN LESIONS
7.07
1.00
17106
DESTRUCTION OF SKIN LESIONS
8.08
1.00
17106
DESTRUCTION OF SKIN LESIONS
8.26
1.00
Procedure Code Description
RVU
RVU Coeff Value
17107
DESTRUCTION OF SKIN LESIONS
9.41
1.00
17107
DESTRUCTION OF SKIN LESIONS
15.06
1.00
17107
DESTRUCTION OF SKIN LESIONS
15.24
1.00
17108
DESTRUCTION OF SKIN LESIONS
12.17
1.00
17108
DESTRUCTION OF SKIN LESIONS
21.75
1.00
17108
DESTRUCTION OF SKIN LESIONS
21.93
1.00
17110
DESTRUCT B9 LESION, 1-14
1.14
1.00
17110
DESTRUCT B9 LESION, 1-14
1.19
1.00
17110
DESTRUCT B9 LESION, 1-14
1.69
1.00
17110
DESTRUCT B9 LESION, 1-14
3.00
1.00
17111
DESTRUCT LESION, 15 OR MORE
1.52
1.00
17111
DESTRUCT LESION, 15 OR MORE
1.56
1.00
17111
DESTRUCT LESION, 15 OR MORE
2.10
1.00
17111
DESTRUCT LESION, 15 OR MORE
3.00
1.00
17250
CHEMICAL CAUTERY, TISSUE
0.88
1.00
17250
CHEMICAL CAUTERY, TISSUE
0.90
1.00
17250
CHEMICAL CAUTERY, TISSUE
0.93
1.00
17260
DESTRUCTION OF SKIN LESIONS
1.36
1.00
17260
DESTRUCTION OF SKIN LESIONS
1.40
1.00
17260
DESTRUCTION OF SKIN LESIONS
1.68
1.00
17260
DESTRUCTION OF SKIN LESIONS
3.00
1.00
17261
DESTRUCTION OF SKIN LESIONS
1.77
1.00
17261
DESTRUCTION OF SKIN LESIONS
1.82
1.00
17261
DESTRUCTION OF SKIN LESIONS
2.27
1.00
17261
DESTRUCTION OF SKIN LESIONS
3.00
1.00
17262
DESTRUCTION OF SKIN LESIONS
2.40
1.00
17262
DESTRUCTION OF SKIN LESIONS
2.44
1.00
17262
DESTRUCTION OF SKIN LESIONS
2.90
1.00
17262
DESTRUCTION OF SKIN LESIONS
3.00
1.00
17263
DESTRUCTION OF SKIN LESIONS
2.69
1.00
17263
DESTRUCTION OF SKIN LESIONS
2.75
1.00
17263
DESTRUCTION OF SKIN LESIONS
3.00
1.00
17263
DESTRUCTION OF SKIN LESIONS
3.21
1.00
17264
DESTRUCTION OF SKIN LESIONS
2.88
1.00
17264
DESTRUCTION OF SKIN LESIONS
2.93
1.00
Procedure Code Description
RVU
RVU Coeff Value
17264
DESTRUCTION OF SKIN LESIONS
3.00
1.00
17264
DESTRUCTION OF SKIN LESIONS
3.43
1.00
17266
DESTRUCTION OF SKIN LESIONS
3.00
1.00
17266
DESTRUCTION OF SKIN LESIONS
3.41
1.00
17266
DESTRUCTION OF SKIN LESIONS
3.46
1.00
17266
DESTRUCTION OF SKIN LESIONS
3.99
1.00
17270
DESTRUCTION OF SKIN LESIONS
1.98
1.00
17270
DESTRUCTION OF SKIN LESIONS
2.03
1.00
17270
DESTRUCTION OF SKIN LESIONS
2.45
1.00
17270
DESTRUCTION OF SKIN LESIONS
3.00
1.00
17271
DESTRUCTION OF SKIN LESIONS
2.26
1.00
17271
DESTRUCTION OF SKIN LESIONS
2.30
1.00
17271
DESTRUCTION OF SKIN LESIONS
2.76
1.00
17271
DESTRUCTION OF SKIN LESIONS
3.00
1.00
17272
DESTRUCTION OF SKIN LESIONS
2.69
1.00
17272
DESTRUCTION OF SKIN LESIONS
2.73
1.00
17272
DESTRUCTION OF SKIN LESIONS
3.00
1.00
17272
DESTRUCTION OF SKIN LESIONS
3.20
1.00
17273
DESTRUCTION OF SKIN LESIONS
3.00
1.00
17273
DESTRUCTION OF SKIN LESIONS
3.10
1.00
17273
DESTRUCTION OF SKIN LESIONS
3.15
1.00
17273
DESTRUCTION OF SKIN LESIONS
3.61
1.00
17274
DESTRUCTION OF SKIN LESIONS
3.00
1.00
17274
DESTRUCTION OF SKIN LESIONS
3.88
1.00
17274
DESTRUCTION OF SKIN LESIONS
3.92
1.00
17274
DESTRUCTION OF SKIN LESIONS
4.43
1.00
17276
DESTRUCTION OF SKIN LESIONS
3.00
1.00
17276
DESTRUCTION OF SKIN LESIONS
4.77
1.00
17276
DESTRUCTION OF SKIN LESIONS
4.82
1.00
17276
DESTRUCTION OF SKIN LESIONS
5.34
1.00
17280
DESTRUCTION OF SKIN LESIONS
1.75
1.00
17280
DESTRUCTION OF SKIN LESIONS
1.80
1.00
17280
DESTRUCTION OF SKIN LESIONS
2.23
1.00
17280
DESTRUCTION OF SKIN LESIONS
3.00
1.00
17281
DESTRUCTION OF SKIN LESIONS
2.61
1.00
Procedure Code Description
RVU
RVU Coeff Value
17281
DESTRUCTION OF SKIN LESIONS
2.66
1.00
17281
DESTRUCTION OF SKIN LESIONS
3.11
1.00
17282
DESTRUCTION OF SKIN LESIONS
3.11
1.00
17282
DESTRUCTION OF SKIN LESIONS
3.16
1.00
17282
DESTRUCTION OF SKIN LESIONS
3.61
1.00
17283
DESTRUCTION OF SKIN LESIONS
3.98
1.00
17283
DESTRUCTION OF SKIN LESIONS
4.02
1.00
17283
DESTRUCTION OF SKIN LESIONS
4.52
1.00
17284
DESTRUCTION OF SKIN LESIONS
4.84
1.00
17284
DESTRUCTION OF SKIN LESIONS
4.90
1.00
17284
DESTRUCTION OF SKIN LESIONS
5.39
1.00
17286
DESTRUCTION OF SKIN LESIONS
6.84
1.00
17286
DESTRUCTION OF SKIN LESIONS
6.89
1.00
17286
DESTRUCTION OF SKIN LESIONS
7.26
1.00
17304
1 STAGE MOHS, UP TO 5 SPEC
3.00
1.00
17304
1 STAGE MOHS, UP TO 5 SPEC
11.46
1.00
17304
1 STAGE MOHS, UP TO 5 SPEC
11.53
1.00
17304
1 STAGE MOHS, UP TO 5 SPEC
11.57
1.00
17305
2 STAGE MOHS, UP TO 5 SPEC
4.30
1.00
17305
2 STAGE MOHS, UP TO 5 SPEC
4.33
1.00
17305
2 STAGE MOHS, UP TO 5 SPEC
4.34
1.00
17306
3 STAGE MOHS, UP TO 5 SPEC
4.31
1.00
17306
3 STAGE MOHS, UP TO 5 SPEC
4.34
1.00
17306
3 STAGE MOHS, UP TO 5 SPEC
4.35
1.00
17307
MOHS ADDL STAGE UP TO 5 SPEC
3.00
1.00
17307
MOHS ADDL STAGE UP TO 5 SPEC
4.32
1.00
17307
MOHS ADDL STAGE UP TO 5 SPEC
4.36
1.00
17307
MOHS ADDL STAGE UP TO 5 SPEC
4.37
1.00
17310
MOHS ANY STAGE > 5 SPEC EACH
0.98
1.00
17310
MOHS ANY STAGE > 5 SPEC EACH
1.44
1.00
17310
MOHS ANY STAGE > 5 SPEC EACH
1.47
1.00
17310
MOHS ANY STAGE > 5 SPEC EACH
3.00
1.00
17311
MOHS, 1 STAGE, H/N/HF/G
9.70
1.00
17312
MOHS ADDL STAGE
5.16
1.00
17313
MOHS, 1 STAGE, T/A/L
8.71
1.00
Procedure Code Description
RVU
RVU Coeff Value
17314
MOHS, ADDL STAGE, T/A/L
4.79
1.00
17315
MOHS SURG, ADDL BLOCK
1.36
1.00
17340
CRYOTHERAPY OF SKIN
1.06
1.00
17340
CRYOTHERAPY OF SKIN
1.12
1.00
17340
CRYOTHERAPY OF SKIN
1.18
1.00
17340
CRYOTHERAPY OF SKIN
3.00
1.00
17360
SKIN PEEL THERAPY
2.21
1.00
17360
SKIN PEEL THERAPY
2.25
1.00
17360
SKIN PEEL THERAPY
2.51
1.00
17360
SKIN PEEL THERAPY
3.00
1.00
19000
DRAINAGE OF BREAST LESION
1.20
1.00
19000
DRAINAGE OF BREAST LESION
1.22
1.00
19000
DRAINAGE OF BREAST LESION
1.28
1.00
19000
DRAINAGE OF BREAST LESION
3.00
1.00
19001
DRAIN BREAST LESION ADD-ON
0.59
1.00
19001
DRAIN BREAST LESION ADD-ON
0.60
1.00
19001
DRAIN BREAST LESION ADD-ON
0.61
1.00
19020
INCISION OF BREAST LESION
3.00
1.00
19020
INCISION OF BREAST LESION
6.75
1.00
19020
INCISION OF BREAST LESION
7.15
1.00
19020
INCISION OF BREAST LESION
7.31
1.00
19030
INJECTION FOR BREAST X-RAY
2.11
1.00
19030
INJECTION FOR BREAST X-RAY
2.12
1.00
19030
INJECTION FOR BREAST X-RAY
2.19
1.00
19030
INJECTION FOR BREAST X-RAY
3.00
1.00
19100
BX BREAST PERCUT W/O IMAGE
1.80
1.00
19100
BX BREAST PERCUT W/O IMAGE
1.81
1.00
19100
BX BREAST PERCUT W/O IMAGE
3.00
1.00
19101
BIOPSY OF BREAST, OPEN
3.00
1.00
19101
BIOPSY OF BREAST, OPEN
5.10
1.00
19101
BIOPSY OF BREAST, OPEN
5.27
1.00
19101
BIOPSY OF BREAST, OPEN
5.43
1.00
19102
BX BREAST PERCUT W/IMAGE
2.81
1.00
19102
BX BREAST PERCUT W/IMAGE
2.82
1.00
19102
BX BREAST PERCUT W/IMAGE
2.87
1.00
Procedure Code Description
RVU
RVU Coeff Value
19102
BX BREAST PERCUT W/IMAGE
3.00
1.00
19103
BX BREAST PERCUT W/DEVICE
3.00
1.00
19103
BX BREAST PERCUT W/DEVICE
5.11
1.00
19103
BX BREAST PERCUT W/DEVICE
5.13
1.00
19103
BX BREAST PERCUT W/DEVICE
5.17
1.00
19103
BX BREAST PERCUT W/DEVICE
5.20
1.00
19103
BX BREAST PERCUT W/DEVICE
5.22
1.00
19103
BX BREAST PERCUT W/DEVICE
5.28
1.00
19105
CRYOSURG ABLATE FA, EACH
5.29
1.00
19110
NIPPLE EXPLORATION
3.00
1.00
19110
NIPPLE EXPLORATION
7.88
1.00
19110
NIPPLE EXPLORATION
8.09
1.00
19110
NIPPLE EXPLORATION
9.17
1.00
19112
EXCISE BREAST DUCT FISTULA
3.00
1.00
19112
EXCISE BREAST DUCT FISTULA
6.80
1.00
19112
EXCISE BREAST DUCT FISTULA
7.13
1.00
19112
EXCISE BREAST DUCT FISTULA
7.26
1.00
19120
REMOVAL OF BREAST LESION
3.00
1.00
19120
REMOVAL OF BREAST LESION
9.21
1.00
19120
REMOVAL OF BREAST LESION
9.31
1.00
19120
REMOVAL OF BREAST LESION
9.92
1.00
19125
EXCISION, BREAST LESION
3.00
1.00
19125
EXCISION, BREAST LESION
9.93
1.00
19125
EXCISION, BREAST LESION
10.09
1.00
19125
EXCISION, BREAST LESION
10.14
1.00
19125
EXCISION, BREAST LESION
10.76
1.00
19125
EXCISION, BREAST LESION
10.86
1.00
19125
EXCISION, BREAST LESION
11.00
1.00
19126
EXCISION, ADDL BREAST LESION
4.16
1.00
19126
EXCISION, ADDL BREAST LESION
4.25
1.00
19126
EXCISION, ADDL BREAST LESION
4.30
1.00
19140
REMOVAL OF BREAST TISSUE
3.00
1.00
19140
REMOVAL OF BREAST TISSUE
9.18
1.00
19140
REMOVAL OF BREAST TISSUE
9.22
1.00
19140
REMOVAL OF BREAST TISSUE
9.31
1.00
Procedure Code Description
RVU
RVU Coeff Value
19160
PARTIAL MASTECTOMY
3.00
1.00
19160
PARTIAL MASTECTOMY
10.17
1.00
19160
PARTIAL MASTECTOMY
10.20
1.00
19160
PARTIAL MASTECTOMY
11.12
1.00
19162
P-MASTECTOMY W/LN REMOVAL
3.00
1.00
19162
P-MASTECTOMY W/LN REMOVAL
21.55
1.00
19162
P-MASTECTOMY W/LN REMOVAL
21.65
1.00
19162
P-MASTECTOMY W/LN REMOVAL
22.79
1.00
19180
REMOVAL OF BREAST
3.00
1.00
19180
REMOVAL OF BREAST
14.91
1.00
19180
REMOVAL OF BREAST
15.00
1.00
19180
REMOVAL OF BREAST
15.61
1.00
19182
REMOVAL OF BREAST
3.00
1.00
19182
REMOVAL OF BREAST
13.48
1.00
19182
REMOVAL OF BREAST
13.50
1.00
19182
REMOVAL OF BREAST
13.52
1.00
19200
REMOVAL OF BREAST
5.00
1.00
19200
REMOVAL OF BREAST
25.33
1.00
19200
REMOVAL OF BREAST
25.37
1.00
19200
REMOVAL OF BREAST
26.07
1.00
19220
REMOVAL OF BREAST
5.00
1.00
19220
REMOVAL OF BREAST
25.88
1.00
19220
REMOVAL OF BREAST
26.02
1.00
19220
REMOVAL OF BREAST
26.40
1.00
19240
REMOVAL OF BREAST
5.00
1.00
19240
REMOVAL OF BREAST
26.21
1.00
19240
REMOVAL OF BREAST
26.32
1.00
19240
REMOVAL OF BREAST
26.36
1.00
19260
REMOVAL OF CHEST WALL LESION
13.00
1.00
19260
REMOVAL OF CHEST WALL LESION
26.21
1.00
19260
REMOVAL OF CHEST WALL LESION
28.70
1.00
19260
REMOVAL OF CHEST WALL LESION
30.32
1.00
19271
REVISION OF CHEST WALL
13.00
1.00
19271
REVISION OF CHEST WALL
32.48
1.00
19271
REVISION OF CHEST WALL
39.84
1.00
Procedure Code Description
RVU
RVU Coeff Value
19271
REVISION OF CHEST WALL
41.13
1.00
19272
EXTENSIVE CHEST WALL SURGERY
13.00
1.00
19272
EXTENSIVE CHEST WALL SURGERY
36.33
1.00
19272
EXTENSIVE CHEST WALL SURGERY
43.76
1.00
19272
EXTENSIVE CHEST WALL SURGERY
45.59
1.00
19290
PLACE NEEDLE WIRE, BREAST
1.75
1.00
19290
PLACE NEEDLE WIRE, BREAST
1.76
1.00
19290
PLACE NEEDLE WIRE, BREAST
1.77
1.00
19290
PLACE NEEDLE WIRE, BREAST
1.81
1.00
19291
PLACE NEEDLE WIRE, BREAST
0.87
1.00
19291
PLACE NEEDLE WIRE, BREAST
0.88
1.00
19291
PLACE NEEDLE WIRE, BREAST
0.90
1.00
19295
PLACE BREAST CLIP, PERCUT
2.36
1.00
19295
PLACE BREAST CLIP, PERCUT
2.66
1.00
19295
PLACE BREAST CLIP, PERCUT
2.78
1.00
19296
PLACE PO BREAST CATH FOR RAD
5.31
1.00
19297
PLACE BREAST CATH FOR RAD
2.40
1.00
19298
PLACE BREAST RAD TUBE/CATHS
8.70
1.00
19301
PARTICAL MASTECTOMY
15.22
1.00
19302
P-MASTECTOMY W/LN REMOVAL
22.03
1.00
19303
MAST, SIMPLE, COMPLETE
23.52
1.00
19304
MAST, SUBQ
13.78
1.00
19305
MAST, RADICAL
27.37
1.00
19306
MAST, RAD, URBAN TYPE
28.71
1.00
19307
MAST, MOD RAD
28.89
1.00
19316
SUSPENSION OF BREAST
5.00
1.00
19316
SUSPENSION OF BREAST
19.41
1.00
19316
SUSPENSION OF BREAST
19.65
1.00
19316
SUSPENSION OF BREAST
19.75
1.00
19318
REDUCTION OF LARGE BREAST
6.00
1.00
19318
REDUCTION OF LARGE BREAST
28.84
1.00
19318
REDUCTION OF LARGE BREAST
29.03
1.00
19318
REDUCTION OF LARGE BREAST
29.26
1.00
19328
REMOVAL OF BREAST IMPLANT
6.00
1.00
19328
REMOVAL OF BREAST IMPLANT
10.83
1.00
Procedure Code Description
RVU
RVU Coeff Value
19328
REMOVAL OF BREAST IMPLANT
11.48
1.00
19328
REMOVAL OF BREAST IMPLANT
12.32
1.00
19330
REMOVAL OF IMPLANT MATERIAL
6.00
1.00
19330
REMOVAL OF IMPLANT MATERIAL
13.60
1.00
19330
REMOVAL OF IMPLANT MATERIAL
14.63
1.00
19330
REMOVAL OF IMPLANT MATERIAL
15.87
1.00
19340
IMMEDIATE BREAST PROSTHESIS
10.20
1.00
19340
IMMEDIATE BREAST PROSTHESIS
10.26
1.00
19340
IMMEDIATE BREAST PROSTHESIS
10.37
1.00
19340
IMMEDIATE BREAST PROSTHESIS
999.99
1.00
19342
DELAYED BREAST PROSTHESIS
5.00
1.00
19342
DELAYED BREAST PROSTHESIS
20.24
1.00
19342
DELAYED BREAST PROSTHESIS
21.61
1.00
19342
DELAYED BREAST PROSTHESIS
23.33
1.00
19350
BREAST RECONSTRUCTION
6.00
1.00
19350
BREAST RECONSTRUCTION
16.67
1.00
19350
BREAST RECONSTRUCTION
17.17
1.00
19350
BREAST RECONSTRUCTION
17.21
1.00
19357
BREAST RECONSTRUCTION
6.00
1.00
19357
BREAST RECONSTRUCTION
29.94
1.00
19357
BREAST RECONSTRUCTION
34.34
1.00
19357
BREAST RECONSTRUCTION
39.15
1.00
19361
BREAST RECONSTR W/LAT FLAP
6.00
1.00
19361
BREAST RECONSTR W/LAT FLAP
31.61
1.00
19361
BREAST RECONSTR W/LAT FLAP
33.52
1.00
19361
BREAST RECONSTR W/LAT FLAP
41.96
1.00
19364
BREAST RECONSTRUCTION
5.00
1.00
19364
BREAST RECONSTRUCTION
69.30
1.00
19364
BREAST RECONSTRUCTION
70.13
1.00
19364
BREAST RECONSTRUCTION
72.00
1.00
19366
BREAST RECONSTRUCTION
5.00
1.00
19366
BREAST RECONSTRUCTION
33.82
1.00
19366
BREAST RECONSTRUCTION
35.22
1.00
19366
BREAST RECONSTRUCTION
35.57
1.00
19367
BREAST RECONSTRUCTION
5.00
1.00
Procedure Code Description
RVU
RVU Coeff Value
19367
BREAST RECONSTRUCTION
45.61
1.00
19367
BREAST RECONSTRUCTION
45.98
1.00
19367
BREAST RECONSTRUCTION
46.59
1.00
19368
BREAST RECONSTRUCTION
5.00
1.00
19368
BREAST RECONSTRUCTION
56.86
1.00
19368
BREAST RECONSTRUCTION
57.01
1.00
19368
BREAST RECONSTRUCTION
57.91
1.00
19369
BREAST RECONSTRUCTION
5.00
1.00
19369
BREAST RECONSTRUCTION
52.60
1.00
19369
BREAST RECONSTRUCTION
53.48
1.00
19369
BREAST RECONSTRUCTION
53.71
1.00
19370
SURGERY OF BREAST CAPSULE
6.00
1.00
19370
SURGERY OF BREAST CAPSULE
14.99
1.00
19370
SURGERY OF BREAST CAPSULE
16.03
1.00
19370
SURGERY OF BREAST CAPSULE
17.18
1.00
19371
REMOVAL OF BREAST CAPSULE
5.00
1.00
19371
REMOVAL OF BREAST CAPSULE
17.51
1.00
19371
REMOVAL OF BREAST CAPSULE
18.43
1.00
19371
REMOVAL OF BREAST CAPSULE
19.86
1.00
19380
REVISE BREAST RECONSTRUCTION
5.00
1.00
19380
REVISE BREAST RECONSTRUCTION
17.17
1.00
19380
REVISE BREAST RECONSTRUCTION
18.07
1.00
19380
REVISE BREAST RECONSTRUCTION
19.38
1.00
19396
DESIGN CUSTOM BREAST IMPLANT
3.42
1.00
19396
DESIGN CUSTOM BREAST IMPLANT
3.44
1.00
19396
DESIGN CUSTOM BREAST IMPLANT
3.45
1.00
22900
REMOVE ABDOMINAL WALL LESION
6.00
1.00
22900
REMOVE ABDOMINAL WALL LESION
9.77
1.00
22900
REMOVE ABDOMINAL WALL LESION
10.42
1.00
22900
REMOVE ABDOMINAL WALL LESION
10.67
1.00
23000
REMOVAL OF CALCIUM DEPOSITS
4.00
1.00
23000
REMOVAL OF CALCIUM DEPOSITS
9.07
1.00
23000
REMOVAL OF CALCIUM DEPOSITS
9.11
1.00
23000
REMOVAL OF CALCIUM DEPOSITS
12.24
1.00
23020
RELEASE SHOULDER JOINT
5.00
1.00
Procedure Code Description
RVU
RVU Coeff Value
23020
RELEASE SHOULDER JOINT
17.68
1.00
23020
RELEASE SHOULDER JOINT
17.98
1.00
23020
RELEASE SHOULDER JOINT
21.11
1.00
23030
DRAIN SHOULDER LESION
5.00
1.00
23030
DRAIN SHOULDER LESION
6.57
1.00
23030
DRAIN SHOULDER LESION
6.86
1.00
23030
DRAIN SHOULDER LESION
8.39
1.00
23031
DRAIN SHOULDER BURSA
3.00
1.00
23031
DRAIN SHOULDER BURSA
5.44
1.00
23031
DRAIN SHOULDER BURSA
5.83
1.00
23031
DRAIN SHOULDER BURSA
7.41
1.00
23035
DRAIN SHOULDER BONE LESION
5.00
1.00
23035
DRAIN SHOULDER BONE LESION
17.52
1.00
23035
DRAIN SHOULDER BONE LESION
18.55
1.00
23035
DRAIN SHOULDER BONE LESION
25.61
1.00
23040
EXPLORATORY SHOULDER SURGERY
5.00
1.00
23040
EXPLORATORY SHOULDER SURGERY
18.41
1.00
23040
EXPLORATORY SHOULDER SURGERY
18.58
1.00
23040
EXPLORATORY SHOULDER SURGERY
22.63
1.00
23044
EXPLORATORY SHOULDER SURGERY
5.00
1.00
23044
EXPLORATORY SHOULDER SURGERY
14.59
1.00
23044
EXPLORATORY SHOULDER SURGERY
14.78
1.00
23044
EXPLORATORY SHOULDER SURGERY
19.10
1.00
23065
BIOPSY SHOULDER TISSUES
3.00
1.00
23065
BIOPSY SHOULDER TISSUES
3.74
1.00
23065
BIOPSY SHOULDER TISSUES
3.98
1.00
23065
BIOPSY SHOULDER TISSUES
4.20
1.00
23066
BIOPSY SHOULDER TISSUES
5.00
1.00
23066
BIOPSY SHOULDER TISSUES
8.57
1.00
23066
BIOPSY SHOULDER TISSUES
8.82
1.00
23066
BIOPSY SHOULDER TISSUES
11.15
1.00
23075
REMOVAL OF SHOULDER LESION
3.00
1.00
23075
REMOVAL OF SHOULDER LESION
4.51
1.00
23075
REMOVAL OF SHOULDER LESION
5.85
1.00
23076
REMOVAL OF SHOULDER LESION
5.00
1.00
Procedure Code Description
RVU
RVU Coeff Value
23076
REMOVAL OF SHOULDER LESION
14.33
1.00
23076
REMOVAL OF SHOULDER LESION
14.45
1.00
23076
REMOVAL OF SHOULDER LESION
16.92
1.00
23077
REMOVE TUMOR OF SHOULDER
3.00
1.00
23077
REMOVE TUMOR OF SHOULDER
29.01
1.00
23077
REMOVE TUMOR OF SHOULDER
30.39
1.00
23077
REMOVE TUMOR OF SHOULDER
32.16
1.00
23100
BIOPSY OF SHOULDER JOINT
5.00
1.00
23100
BIOPSY OF SHOULDER JOINT
12.41
1.00
23100
BIOPSY OF SHOULDER JOINT
12.69
1.00
23100
BIOPSY OF SHOULDER JOINT
15.97
1.00
23101
SHOULDER JOINT SURGERY
4.00
1.00
23101
SHOULDER JOINT SURGERY
11.41
1.00
23101
SHOULDER JOINT SURGERY
11.89
1.00
23101
SHOULDER JOINT SURGERY
15.49
1.00
23105
REMOVE SHOULDER JOINT LINING
5.00
1.00
23105
REMOVE SHOULDER JOINT LINING
16.28
1.00
23105
REMOVE SHOULDER JOINT LINING
16.75
1.00
23105
REMOVE SHOULDER JOINT LINING
19.91
1.00
23106
INCISION OF COLLARBONE JOINT
4.00
1.00
23106
INCISION OF COLLARBONE JOINT
12.10
1.00
23106
INCISION OF COLLARBONE JOINT
12.71
1.00
23106
INCISION OF COLLARBONE JOINT
16.03
1.00
23107
EXPLORE TREAT SHOULDER JOINT
5.00
1.00
23107
EXPLORE TREAT SHOULDER JOINT
16.92
1.00
23107
EXPLORE TREAT SHOULDER JOINT
17.44
1.00
23107
EXPLORE TREAT SHOULDER JOINT
20.55
1.00
23120
PARTIAL REMOVAL, COLLAR BONE
5.00
1.00
23120
PARTIAL REMOVAL, COLLAR BONE
14.62
1.00
23120
PARTIAL REMOVAL, COLLAR BONE
14.77
1.00
23120
PARTIAL REMOVAL, COLLAR BONE
18.07
1.00
23125
REMOVAL OF COLLAR BONE
5.00
1.00
23125
REMOVAL OF COLLAR BONE
18.01
1.00
23125
REMOVAL OF COLLAR BONE
18.54
1.00
23125
REMOVAL OF COLLAR BONE
21.74
1.00
Procedure Code Description
RVU
RVU Coeff Value
23130
REMOVE SHOULDER BONE, PART
5.00
1.00
23130
REMOVE SHOULDER BONE, PART
15.38
1.00
23130
REMOVE SHOULDER BONE, PART
15.92
1.00
23130
REMOVE SHOULDER BONE, PART
18.81
1.00
23140
REMOVAL OF BONE LESION
4.00
1.00
23140
REMOVAL OF BONE LESION
13.08
1.00
23140
REMOVAL OF BONE LESION
13.28
1.00
23140
REMOVAL OF BONE LESION
16.35
1.00
23145
REMOVAL OF BONE LESION
5.00
1.00
23145
REMOVAL OF BONE LESION
17.65
1.00
23145
REMOVAL OF BONE LESION
18.16
1.00
23145
REMOVAL OF BONE LESION
22.38
1.00
23146
REMOVAL OF BONE LESION
4.00
1.00
23146
REMOVAL OF BONE LESION
15.35
1.00
23146
REMOVAL OF BONE LESION
16.29
1.00
23146
REMOVAL OF BONE LESION
20.31
1.00
23150
REMOVAL OF HUMERUS LESION
4.00
1.00
23150
REMOVAL OF HUMERUS LESION
16.67
1.00
23150
REMOVAL OF HUMERUS LESION
16.81
1.00
23150
REMOVAL OF HUMERUS LESION
19.99
1.00
23155
REMOVAL OF HUMERUS LESION
4.00
1.00
23155
REMOVAL OF HUMERUS LESION
20.24
1.00
23155
REMOVAL OF HUMERUS LESION
20.27
1.00
23155
REMOVAL OF HUMERUS LESION
24.17
1.00
23156
REMOVAL OF HUMERUS LESION
4.00
1.00
23156
REMOVAL OF HUMERUS LESION
17.21
1.00
23156
REMOVAL OF HUMERUS LESION
17.47
1.00
23156
REMOVAL OF HUMERUS LESION
20.60
1.00
23170
REMOVE COLLAR BONE LESION
5.00
1.00
23170
REMOVE COLLAR BONE LESION
13.50
1.00
23170
REMOVE COLLAR BONE LESION
14.22
1.00
23170
REMOVE COLLAR BONE LESION
18.87
1.00
23172
REMOVE SHOULDER BLADE LESION
5.00
1.00
23172
REMOVE SHOULDER BLADE LESION
13.80
1.00
23172
REMOVE SHOULDER BLADE LESION
14.45
1.00
Procedure Code Description 23172
REMOVE SHOULDER BLADE LESION
23174
RVU
RVU Coeff Value
18.55
1.00
REMOVE HUMERUS LESION
5.00
1.00
23174
REMOVE HUMERUS LESION
19.24
1.00
23174
REMOVE HUMERUS LESION
19.44
1.00
23174
REMOVE HUMERUS LESION
23.00
1.00
23180
REMOVE COLLAR BONE LESION
5.00
1.00
23180
REMOVE COLLAR BONE LESION
17.50
1.00
23180
REMOVE COLLAR BONE LESION
19.15
1.00
23180
REMOVE COLLAR BONE LESION
26.53
1.00
23182
REMOVE SHOULDER BLADE LESION
4.00
1.00
23182
REMOVE SHOULDER BLADE LESION
16.87
1.00
23182
REMOVE SHOULDER BLADE LESION
18.33
1.00
23182
REMOVE SHOULDER BLADE LESION
26.13
1.00
23184
REMOVE HUMERUS LESION
4.00
1.00
23184
REMOVE HUMERUS LESION
19.07
1.00
23184
REMOVE HUMERUS LESION
20.41
1.00
23184
REMOVE HUMERUS LESION
27.70
1.00
23190
PARTIAL REMOVAL OF SCAPULA
5.00
1.00
23190
PARTIAL REMOVAL OF SCAPULA
14.18
1.00
23190
PARTIAL REMOVAL OF SCAPULA
14.63
1.00
23190
PARTIAL REMOVAL OF SCAPULA
16.93
1.00
23195
REMOVAL OF HEAD OF HUMERUS
4.00
1.00
23195
REMOVAL OF HEAD OF HUMERUS
19.22
1.00
23195
REMOVAL OF HEAD OF HUMERUS
19.28
1.00
23195
REMOVAL OF HEAD OF HUMERUS
22.30
1.00
23200
REMOVAL OF COLLAR BONE
6.00
1.00
23200
REMOVAL OF COLLAR BONE
22.72
1.00
23200
REMOVAL OF COLLAR BONE
22.82
1.00
23200
REMOVAL OF COLLAR BONE
28.08
1.00
23210
REMOVAL OF SHOULDER BLADE
6.00
1.00
23210
REMOVAL OF SHOULDER BLADE
23.71
1.00
23210
REMOVAL OF SHOULDER BLADE
23.77
1.00
23210
REMOVAL OF SHOULDER BLADE
28.57
1.00
23220
PARTIAL REMOVAL OF HUMERUS
5.00
1.00
23220
PARTIAL REMOVAL OF HUMERUS
27.58
1.00
Procedure Code Description
RVU
RVU Coeff Value
23220
PARTIAL REMOVAL OF HUMERUS
27.86
1.00
23220
PARTIAL REMOVAL OF HUMERUS
32.32
1.00
23221
PARTIAL REMOVAL OF HUMERUS
5.00
1.00
23221
PARTIAL REMOVAL OF HUMERUS
32.24
1.00
23221
PARTIAL REMOVAL OF HUMERUS
32.58
1.00
23221
PARTIAL REMOVAL OF HUMERUS
37.38
1.00
23222
PARTIAL REMOVAL OF HUMERUS
5.00
1.00
23222
PARTIAL REMOVAL OF HUMERUS
43.79
1.00
23222
PARTIAL REMOVAL OF HUMERUS
43.82
1.00
23222
PARTIAL REMOVAL OF HUMERUS
48.31
1.00
23330
REMOVE SHOULDER FOREIGN BODY
3.00
1.00
23330
REMOVE SHOULDER FOREIGN BODY
3.75
1.00
23330
REMOVE SHOULDER FOREIGN BODY
3.98
1.00
23330
REMOVE SHOULDER FOREIGN BODY
5.80
1.00
23331
REMOVE SHOULDER FOREIGN BODY
5.00
1.00
23331
REMOVE SHOULDER FOREIGN BODY
14.98
1.00
23331
REMOVE SHOULDER FOREIGN BODY
15.39
1.00
23331
REMOVE SHOULDER FOREIGN BODY
18.46
1.00
23332
REMOVE SHOULDER FOREIGN BODY
5.00
1.00
23332
REMOVE SHOULDER FOREIGN BODY
22.78
1.00
23332
REMOVE SHOULDER FOREIGN BODY
22.86
1.00
23332
REMOVE SHOULDER FOREIGN BODY
25.64
1.00
23350
INJECTION FOR SHOULDER X-RAY
1.39
1.00
23350
INJECTION FOR SHOULDER X-RAY
1.43
1.00
23350
INJECTION FOR SHOULDER X-RAY
3.00
1.00
23395
MUSCLE TRANSFER,SHOULDER/ARM
5.00
1.00
23395
MUSCLE TRANSFER,SHOULDER/ARM
32.32
1.00
23395
MUSCLE TRANSFER,SHOULDER/ARM
33.18
1.00
23395
MUSCLE TRANSFER,SHOULDER/ARM
33.41
1.00
23397
MUSCLE TRANSFERS
29.75
1.00
23397
MUSCLE TRANSFERS
30.21
1.00
23397
MUSCLE TRANSFERS
32.98
1.00
23400
FIXATION OF SHOULDER BLADE
6.00
1.00
23400
FIXATION OF SHOULDER BLADE
25.21
1.00
23400
FIXATION OF SHOULDER BLADE
25.98
1.00
Procedure Code Description
RVU
RVU Coeff Value
23400
FIXATION OF SHOULDER BLADE
30.03
1.00
23405
INCISION OF TENDON & MUSCLE
5.00
1.00
23405
INCISION OF TENDON & MUSCLE
16.20
1.00
23405
INCISION OF TENDON & MUSCLE
16.72
1.00
23405
INCISION OF TENDON & MUSCLE
19.18
1.00
23406
INCISE TENDON(S) & MUSCLE(S)
5.00
1.00
23406
INCISE TENDON(S) & MUSCLE(S)
20.27
1.00
23406
INCISE TENDON(S) & MUSCLE(S)
20.97
1.00
23406
INCISE TENDON(S) & MUSCLE(S)
24.16
1.00
23410
REPAIR ROTATOR CUFF, ACUTE
4.00
1.00
23410
REPAIR ROTATOR CUFF, ACUTE
21.57
1.00
23410
REPAIR ROTATOR CUFF, ACUTE
23.90
1.00
23410
REPAIR ROTATOR CUFF, ACUTE
26.98
1.00
23412
REPAIR ROTATOR CUFF, CHRONIC
5.00
1.00
23412
REPAIR ROTATOR CUFF, CHRONIC
22.56
1.00
23412
REPAIR ROTATOR CUFF, CHRONIC
25.43
1.00
23412
REPAIR ROTATOR CUFF, CHRONIC
28.49
1.00
23415
RELEASE OF SHOULDER LIGAMENT
4.00
1.00
23415
RELEASE OF SHOULDER LIGAMENT
17.94
1.00
23415
RELEASE OF SHOULDER LIGAMENT
19.61
1.00
23415
RELEASE OF SHOULDER LIGAMENT
21.81
1.00
23420
REPAIR OF SHOULDER
4.00
1.00
23420
REPAIR OF SHOULDER
25.19
1.00
23420
REPAIR OF SHOULDER
26.30
1.00
23420
REPAIR OF SHOULDER
29.47
1.00
23430
REPAIR BICEPS TENDON
3.00
1.00
23430
REPAIR BICEPS TENDON
19.06
1.00
23430
REPAIR BICEPS TENDON
19.77
1.00
23430
REPAIR BICEPS TENDON
22.88
1.00
23440
REMOVE/TRANSPLANT TENDON
5.00
1.00
23440
REMOVE/TRANSPLANT TENDON
19.67
1.00
23440
REMOVE/TRANSPLANT TENDON
20.52
1.00
23440
REMOVE/TRANSPLANT TENDON
23.77
1.00
23450
REPAIR SHOULDER CAPSULE
5.00
1.00
23450
REPAIR SHOULDER CAPSULE
24.69
1.00
Procedure Code Description
RVU
RVU Coeff Value
23450
REPAIR SHOULDER CAPSULE
25.49
1.00
23450
REPAIR SHOULDER CAPSULE
28.56
1.00
23455
REPAIR SHOULDER CAPSULE
5.00
1.00
23455
REPAIR SHOULDER CAPSULE
26.34
1.00
23455
REPAIR SHOULDER CAPSULE
27.22
1.00
23455
REPAIR SHOULDER CAPSULE
30.26
1.00
23460
REPAIR SHOULDER CAPSULE
4.00
1.00
23460
REPAIR SHOULDER CAPSULE
28.50
1.00
23460
REPAIR SHOULDER CAPSULE
29.34
1.00
23460
REPAIR SHOULDER CAPSULE
32.00
1.00
23462
REPAIR SHOULDER CAPSULE
5.00
1.00
23462
REPAIR SHOULDER CAPSULE
27.95
1.00
23462
REPAIR SHOULDER CAPSULE
28.67
1.00
23462
REPAIR SHOULDER CAPSULE
31.59
1.00
23465
REPAIR SHOULDER CAPSULE
4.00
1.00
23465
REPAIR SHOULDER CAPSULE
29.07
1.00
23465
REPAIR SHOULDER CAPSULE
29.18
1.00
23465
REPAIR SHOULDER CAPSULE
31.77
1.00
23466
REPAIR SHOULDER CAPSULE
5.00
1.00
23466
REPAIR SHOULDER CAPSULE
27.88
1.00
23466
REPAIR SHOULDER CAPSULE
28.68
1.00
23466
REPAIR SHOULDER CAPSULE
30.06
1.00
23470
RECONSTRUCT SHOULDER JOINT
4.00
1.00
23470
RECONSTRUCT SHOULDER JOINT
31.74
1.00
23470
RECONSTRUCT SHOULDER JOINT
31.97
1.00
23470
RECONSTRUCT SHOULDER JOINT
32.14
1.00
23472
RECONSTRUCT SHOULDER JOINT
5.00
1.00
23472
RECONSTRUCT SHOULDER JOINT
38.11
1.00
23472
RECONSTRUCT SHOULDER JOINT
38.20
1.00
23472
RECONSTRUCT SHOULDER JOINT
39.29
1.00
23480
REVISION OF COLLAR BONE
5.00
1.00
23480
REVISION OF COLLAR BONE
21.20
1.00
23480
REVISION OF COLLAR BONE
21.81
1.00
23480
REVISION OF COLLAR BONE
24.90
1.00
23485
REVISION OF COLLAR BONE
5.00
1.00
Procedure Code Description
RVU
RVU Coeff Value
23485
REVISION OF COLLAR BONE
25.06
1.00
23485
REVISION OF COLLAR BONE
25.54
1.00
23485
REVISION OF COLLAR BONE
28.62
1.00
23490
REINFORCE CLAVICLE
5.00
1.00
23490
REINFORCE CLAVICLE
21.46
1.00
23490
REINFORCE CLAVICLE
21.99
1.00
23490
REINFORCE CLAVICLE
25.21
1.00
23491
REINFORCE SHOULDER BONES
5.00
1.00
23491
REINFORCE SHOULDER BONES
26.39
1.00
23491
REINFORCE SHOULDER BONES
27.30
1.00
23491
REINFORCE SHOULDER BONES
29.97
1.00
23500
TREAT CLAVICLE FRACTURE
3.00
1.00
23500
TREAT CLAVICLE FRACTURE
4.94
1.00
23500
TREAT CLAVICLE FRACTURE
4.96
1.00
23500
TREAT CLAVICLE FRACTURE
5.09
1.00
23505
TREAT CLAVICLE FRACTURE
4.00
1.00
23505
TREAT CLAVICLE FRACTURE
8.04
1.00
23505
TREAT CLAVICLE FRACTURE
8.05
1.00
23505
TREAT CLAVICLE FRACTURE
8.31
1.00
23515
TREAT CLAVICLE FRACTURE
5.00
1.00
23515
TREAT CLAVICLE FRACTURE
15.16
1.00
23515
TREAT CLAVICLE FRACTURE
16.87
1.00
23515
TREAT CLAVICLE FRACTURE
17.87
1.00
23520
TREAT CLAVICLE DISLOCATION
3.00
1.00
23520
TREAT CLAVICLE DISLOCATION
5.10
1.00
23520
TREAT CLAVICLE DISLOCATION
5.18
1.00
23520
TREAT CLAVICLE DISLOCATION
5.35
1.00
23525
TREAT CLAVICLE DISLOCATION
3.00
1.00
23525
TREAT CLAVICLE DISLOCATION
7.73
1.00
23525
TREAT CLAVICLE DISLOCATION
8.00
1.00
23525
TREAT CLAVICLE DISLOCATION
8.02
1.00
23530
TREAT CLAVICLE DISLOCATION
4.00
1.00
23530
TREAT CLAVICLE DISLOCATION
13.76
1.00
23530
TREAT CLAVICLE DISLOCATION
14.36
1.00
23530
TREAT CLAVICLE DISLOCATION
16.36
1.00
Procedure Code Description
RVU
RVU Coeff Value
23532
TREAT CLAVICLE DISLOCATION
5.00
1.00
23532
TREAT CLAVICLE DISLOCATION
15.84
1.00
23532
TREAT CLAVICLE DISLOCATION
16.28
1.00
23532
TREAT CLAVICLE DISLOCATION
17.74
1.00
23540
TREAT CLAVICLE DISLOCATION
4.00
1.00
23540
TREAT CLAVICLE DISLOCATION
4.98
1.00
23540
TREAT CLAVICLE DISLOCATION
5.04
1.00
23540
TREAT CLAVICLE DISLOCATION
5.17
1.00
23545
TREAT CLAVICLE DISLOCATION
4.00
1.00
23545
TREAT CLAVICLE DISLOCATION
6.97
1.00
23545
TREAT CLAVICLE DISLOCATION
7.10
1.00
23545
TREAT CLAVICLE DISLOCATION
7.33
1.00
23550
TREAT CLAVICLE DISLOCATION
4.00
1.00
23550
TREAT CLAVICLE DISLOCATION
14.60
1.00
23550
TREAT CLAVICLE DISLOCATION
14.74
1.00
23550
TREAT CLAVICLE DISLOCATION
16.55
1.00
23552
TREAT CLAVICLE DISLOCATION
5.00
1.00
23552
TREAT CLAVICLE DISLOCATION
16.82
1.00
23552
TREAT CLAVICLE DISLOCATION
17.12
1.00
23552
TREAT CLAVICLE DISLOCATION
18.66
1.00
23570
TREAT SHOULDER BLADE FX
4.00
1.00
23570
TREAT SHOULDER BLADE FX
5.29
1.00
23570
TREAT SHOULDER BLADE FX
5.45
1.00
23570
TREAT SHOULDER BLADE FX
5.56
1.00
23575
TREAT SHOULDER BLADE FX
4.00
1.00
23575
TREAT SHOULDER BLADE FX
8.85
1.00
23575
TREAT SHOULDER BLADE FX
8.93
1.00
23575
TREAT SHOULDER BLADE FX
8.96
1.00
23585
TREAT SCAPULA FRACTURE
5.00
1.00
23585
TREAT SCAPULA FRACTURE
18.06
1.00
23585
TREAT SCAPULA FRACTURE
19.79
1.00
23585
TREAT SCAPULA FRACTURE
24.17
1.00
23600
TREAT HUMERUS FRACTURE
4.00
1.00
23600
TREAT HUMERUS FRACTURE
7.06
1.00
23600
TREAT HUMERUS FRACTURE
7.11
1.00
Procedure Code Description
RVU
RVU Coeff Value
23600
TREAT HUMERUS FRACTURE
7.22
1.00
23605
TREAT HUMERUS FRACTURE
3.00
1.00
23605
TREAT HUMERUS FRACTURE
10.54
1.00
23605
TREAT HUMERUS FRACTURE
10.63
1.00
23605
TREAT HUMERUS FRACTURE
12.37
1.00
23615
TREAT HUMERUS FRACTURE
5.00
1.00
23615
TREAT HUMERUS FRACTURE
19.61
1.00
23615
TREAT HUMERUS FRACTURE
21.13
1.00
23615
TREAT HUMERUS FRACTURE
22.21
1.00
23616
TREAT HUMERUS FRACTURE
5.00
1.00
23616
TREAT HUMERUS FRACTURE
33.61
1.00
23616
TREAT HUMERUS FRACTURE
38.96
1.00
23616
TREAT HUMERUS FRACTURE
40.49
1.00
23620
TREAT HUMERUS FRACTURE
4.00
1.00
23620
TREAT HUMERUS FRACTURE
5.97
1.00
23620
TREAT HUMERUS FRACTURE
6.02
1.00
23620
TREAT HUMERUS FRACTURE
6.19
1.00
23625
TREAT HUMERUS FRACTURE
3.00
1.00
23625
TREAT HUMERUS FRACTURE
8.68
1.00
23625
TREAT HUMERUS FRACTURE
9.12
1.00
23625
TREAT HUMERUS FRACTURE
10.21
1.00
23630
TREAT HUMERUS FRACTURE
4.00
1.00
23630
TREAT HUMERUS FRACTURE
15.17
1.00
23630
TREAT HUMERUS FRACTURE
16.82
1.00
23630
TREAT HUMERUS FRACTURE
19.03
1.00
23650
TREAT SHOULDER DISLOCATION
6.50
1.00
23650
TREAT SHOULDER DISLOCATION
6.63
1.00
23650
TREAT SHOULDER DISLOCATION
7.28
1.00
23655
TREAT SHOULDER DISLOCATION
4.00
1.00
23655
TREAT SHOULDER DISLOCATION
9.35
1.00
23655
TREAT SHOULDER DISLOCATION
9.47
1.00
23655
TREAT SHOULDER DISLOCATION
9.53
1.00
23660
TREAT SHOULDER DISLOCATION
4.00
1.00
23660
TREAT SHOULDER DISLOCATION
14.81
1.00
23660
TREAT SHOULDER DISLOCATION
15.06
1.00
Procedure Code Description
RVU
RVU Coeff Value
23660
TREAT SHOULDER DISLOCATION
16.74
1.00
23665
TREAT DISLOCATION/FRACTURE
4.00
1.00
23665
TREAT DISLOCATION/FRACTURE
9.67
1.00
23665
TREAT DISLOCATION/FRACTURE
10.11
1.00
23665
TREAT DISLOCATION/FRACTURE
11.06
1.00
23670
TREAT DISLOCATION/FRACTURE
4.00
1.00
23670
TREAT DISLOCATION/FRACTURE
16.04
1.00
23670
TREAT DISLOCATION/FRACTURE
17.93
1.00
23670
TREAT DISLOCATION/FRACTURE
21.35
1.00
23675
TREAT DISLOCATION/FRACTURE
5.00
1.00
23675
TREAT DISLOCATION/FRACTURE
12.46
1.00
23675
TREAT DISLOCATION/FRACTURE
13.10
1.00
23675
TREAT DISLOCATION/FRACTURE
13.75
1.00
23680
TREAT DISLOCATION/FRACTURE
5.00
1.00
23680
TREAT DISLOCATION/FRACTURE
19.81
1.00
23680
TREAT DISLOCATION/FRACTURE
21.51
1.00
23680
TREAT DISLOCATION/FRACTURE
23.22
1.00
23700
FIXATION OF SHOULDER
4.00
1.00
23700
FIXATION OF SHOULDER
4.98
1.00
23700
FIXATION OF SHOULDER
5.24
1.00
23700
FIXATION OF SHOULDER
6.52
1.00
23800
FUSION OF SHOULDER JOINT
4.00
1.00
23800
FUSION OF SHOULDER JOINT
26.51
1.00
23800
FUSION OF SHOULDER JOINT
26.98
1.00
23800
FUSION OF SHOULDER JOINT
30.79
1.00
23802
FUSION OF SHOULDER JOINT
4.00
1.00
23802
FUSION OF SHOULDER JOINT
29.63
1.00
23802
FUSION OF SHOULDER JOINT
32.14
1.00
23802
FUSION OF SHOULDER JOINT
32.85
1.00
23900
AMPUTATION OF ARM & GIRDLE
15.00
1.00
23900
AMPUTATION OF ARM & GIRDLE
34.40
1.00
23900
AMPUTATION OF ARM & GIRDLE
34.58
1.00
23900
AMPUTATION OF ARM & GIRDLE
37.88
1.00
23920
AMPUTATION AT SHOULDER JOINT
9.00
1.00
23920
AMPUTATION AT SHOULDER JOINT
27.00
1.00
Procedure Code Description
RVU
RVU Coeff Value
23920
AMPUTATION AT SHOULDER JOINT
27.83
1.00
23920
AMPUTATION AT SHOULDER JOINT
30.55
1.00
23921
AMPUTATION FOLLOW-UP SURGERY
3.00
1.00
23921
AMPUTATION FOLLOW-UP SURGERY
10.04
1.00
23921
AMPUTATION FOLLOW-UP SURGERY
11.58
1.00
23921
AMPUTATION FOLLOW-UP SURGERY
13.17
1.00
23930
DRAINAGE OF ARM LESION
3.00
1.00
23930
DRAINAGE OF ARM LESION
5.50
1.00
23930
DRAINAGE OF ARM LESION
5.68
1.00
23930
DRAINAGE OF ARM LESION
7.31
1.00
23931
DRAINAGE OF ARM BURSA
3.00
1.00
23931
DRAINAGE OF ARM BURSA
3.96
1.00
23931
DRAINAGE OF ARM BURSA
4.23
1.00
23931
DRAINAGE OF ARM BURSA
5.88
1.00
23935
DRAIN ARM/ELBOW BONE LESION
3.00
1.00
23935
DRAIN ARM/ELBOW BONE LESION
12.61
1.00
23935
DRAIN ARM/ELBOW BONE LESION
13.22
1.00
23935
DRAIN ARM/ELBOW BONE LESION
20.54
1.00
24000
EXPLORATORY ELBOW SURGERY
3.00
1.00
24000
EXPLORATORY ELBOW SURGERY
11.98
1.00
24000
EXPLORATORY ELBOW SURGERY
12.10
1.00
24000
EXPLORATORY ELBOW SURGERY
12.76
1.00
24006
RELEASE ELBOW JOINT
5.00
1.00
24006
RELEASE ELBOW JOINT
18.15
1.00
24006
RELEASE ELBOW JOINT
18.52
1.00
24006
RELEASE ELBOW JOINT
19.28
1.00
24065
BIOPSY ARM/ELBOW SOFT TISSUE
3.00
1.00
24065
BIOPSY ARM/ELBOW SOFT TISSUE
4.03
1.00
24065
BIOPSY ARM/ELBOW SOFT TISSUE
4.17
1.00
24065
BIOPSY ARM/ELBOW SOFT TISSUE
5.57
1.00
24066
BIOPSY ARM/ELBOW SOFT TISSUE
3.00
1.00
24066
BIOPSY ARM/ELBOW SOFT TISSUE
10.08
1.00
24066
BIOPSY ARM/ELBOW SOFT TISSUE
10.21
1.00
24066
BIOPSY ARM/ELBOW SOFT TISSUE
12.64
1.00
24075
REMOVE ARM/ELBOW LESION
3.00
1.00
Procedure Code Description
RVU
RVU Coeff Value
24075
REMOVE ARM/ELBOW LESION
7.86
1.00
24075
REMOVE ARM/ELBOW LESION
8.10
1.00
24075
REMOVE ARM/ELBOW LESION
10.49
1.00
24076
REMOVE ARM/ELBOW LESION
3.00
1.00
24076
REMOVE ARM/ELBOW LESION
12.03
1.00
24076
REMOVE ARM/ELBOW LESION
12.22
1.00
24076
REMOVE ARM/ELBOW LESION
14.34
1.00
24077
REMOVE TUMOR OF ARM/ELBOW
6.00
1.00
24077
REMOVE TUMOR OF ARM/ELBOW
20.85
1.00
24077
REMOVE TUMOR OF ARM/ELBOW
21.98
1.00
24077
REMOVE TUMOR OF ARM/ELBOW
26.86
1.00
24100
BIOPSY ELBOW JOINT LINING
3.00
1.00
24100
BIOPSY ELBOW JOINT LINING
10.16
1.00
24100
BIOPSY ELBOW JOINT LINING
10.23
1.00
24100
BIOPSY ELBOW JOINT LINING
11.34
1.00
24101
EXPLORE/TREAT ELBOW JOINT
3.00
1.00
24101
EXPLORE/TREAT ELBOW JOINT
12.60
1.00
24101
EXPLORE/TREAT ELBOW JOINT
12.99
1.00
24101
EXPLORE/TREAT ELBOW JOINT
13.93
1.00
24102
REMOVE ELBOW JOINT LINING
3.00
1.00
24102
REMOVE ELBOW JOINT LINING
15.66
1.00
24102
REMOVE ELBOW JOINT LINING
16.16
1.00
24102
REMOVE ELBOW JOINT LINING
17.07
1.00
24105
REMOVAL OF ELBOW BURSA
3.00
1.00
24105
REMOVAL OF ELBOW BURSA
8.43
1.00
24105
REMOVAL OF ELBOW BURSA
8.54
1.00
24105
REMOVAL OF ELBOW BURSA
9.48
1.00
24110
REMOVE HUMERUS LESION
5.00
1.00
24110
REMOVE HUMERUS LESION
14.82
1.00
24110
REMOVE HUMERUS LESION
15.28
1.00
24110
REMOVE HUMERUS LESION
18.51
1.00
24115
REMOVE/GRAFT BONE LESION
5.00
1.00
24115
REMOVE/GRAFT BONE LESION
18.36
1.00
24115
REMOVE/GRAFT BONE LESION
18.74
1.00
24115
REMOVE/GRAFT BONE LESION
21.30
1.00
Procedure Code Description
RVU
RVU Coeff Value
24116
REMOVE/GRAFT BONE LESION
3.00
1.00
24116
REMOVE/GRAFT BONE LESION
22.28
1.00
24116
REMOVE/GRAFT BONE LESION
22.90
1.00
24116
REMOVE/GRAFT BONE LESION
26.04
1.00
24120
REMOVE ELBOW LESION
3.00
1.00
24120
REMOVE ELBOW LESION
13.25
1.00
24120
REMOVE ELBOW LESION
13.57
1.00
24120
REMOVE ELBOW LESION
14.47
1.00
24125
REMOVE/GRAFT BONE LESION
3.00
1.00
24125
REMOVE/GRAFT BONE LESION
15.12
1.00
24125
REMOVE/GRAFT BONE LESION
15.24
1.00
24125
REMOVE/GRAFT BONE LESION
16.05
1.00
24126
REMOVE/GRAFT BONE LESION
4.00
1.00
24126
REMOVE/GRAFT BONE LESION
16.19
1.00
24126
REMOVE/GRAFT BONE LESION
16.36
1.00
24126
REMOVE/GRAFT BONE LESION
17.24
1.00
24130
REMOVAL OF HEAD OF RADIUS
3.00
1.00
24130
REMOVAL OF HEAD OF RADIUS
12.79
1.00
24130
REMOVAL OF HEAD OF RADIUS
13.24
1.00
24130
REMOVAL OF HEAD OF RADIUS
14.17
1.00
24134
REMOVAL OF ARM BONE LESION
4.00
1.00
24134
REMOVAL OF ARM BONE LESION
19.26
1.00
24134
REMOVAL OF ARM BONE LESION
20.48
1.00
24134
REMOVAL OF ARM BONE LESION
27.50
1.00
24136
REMOVE RADIUS BONE LESION
3.00
1.00
24136
REMOVE RADIUS BONE LESION
15.25
1.00
24136
REMOVE RADIUS BONE LESION
15.39
1.00
24136
REMOVE RADIUS BONE LESION
16.42
1.00
24138
REMOVE ELBOW BONE LESION
3.00
1.00
24138
REMOVE ELBOW BONE LESION
16.80
1.00
24138
REMOVE ELBOW BONE LESION
17.06
1.00
24138
REMOVE ELBOW BONE LESION
17.20
1.00
24140
PARTIAL REMOVAL OF ARM BONE
4.00
1.00
24140
PARTIAL REMOVAL OF ARM BONE
18.33
1.00
24140
PARTIAL REMOVAL OF ARM BONE
20.14
1.00
Procedure Code Description 24140
PARTIAL REMOVAL OF ARM BONE
24145
RVU
RVU Coeff Value
27.97
1.00
PARTIAL REMOVAL OF RADIUS
3.00
1.00
24145
PARTIAL REMOVAL OF RADIUS
15.36
1.00
24145
PARTIAL REMOVAL OF RADIUS
16.94
1.00
24145
PARTIAL REMOVAL OF RADIUS
20.23
1.00
24147
PARTIAL REMOVAL OF ELBOW
4.00
1.00
24147
PARTIAL REMOVAL OF ELBOW
15.96
1.00
24147
PARTIAL REMOVAL OF ELBOW
17.42
1.00
24147
PARTIAL REMOVAL OF ELBOW
20.22
1.00
24149
RADICAL RESECTION OF ELBOW
4.00
1.00
24149
RADICAL RESECTION OF ELBOW
27.29
1.00
24149
RADICAL RESECTION OF ELBOW
27.88
1.00
24149
RADICAL RESECTION OF ELBOW
29.52
1.00
24150
EXTENSIVE HUMERUS SURGERY
6.00
1.00
24150
EXTENSIVE HUMERUS SURGERY
25.13
1.00
24150
EXTENSIVE HUMERUS SURGERY
25.53
1.00
24150
EXTENSIVE HUMERUS SURGERY
30.31
1.00
24151
EXTENSIVE HUMERUS SURGERY
6.00
1.00
24151
EXTENSIVE HUMERUS SURGERY
28.86
1.00
24151
EXTENSIVE HUMERUS SURGERY
29.87
1.00
24151
EXTENSIVE HUMERUS SURGERY
34.73
1.00
24152
EXTENSIVE RADIUS SURGERY
6.00
1.00
24152
EXTENSIVE RADIUS SURGERY
18.80
1.00
24152
EXTENSIVE RADIUS SURGERY
19.33
1.00
24152
EXTENSIVE RADIUS SURGERY
21.08
1.00
24153
EXTENSIVE RADIUS SURGERY
6.00
1.00
24153
EXTENSIVE RADIUS SURGERY
18.12
1.00
24153
EXTENSIVE RADIUS SURGERY
19.24
1.00
24153
EXTENSIVE RADIUS SURGERY
19.84
1.00
24155
REMOVAL OF ELBOW JOINT
4.00
1.00
24155
REMOVAL OF ELBOW JOINT
21.83
1.00
24155
REMOVAL OF ELBOW JOINT
21.84
1.00
24155
REMOVAL OF ELBOW JOINT
22.57
1.00
24160
REMOVE ELBOW JOINT IMPLANT
3.00
1.00
24160
REMOVE ELBOW JOINT IMPLANT
15.41
1.00
Procedure Code Description
RVU
RVU Coeff Value
24160
REMOVE ELBOW JOINT IMPLANT
15.85
1.00
24160
REMOVE ELBOW JOINT IMPLANT
15.88
1.00
24164
REMOVE RADIUS HEAD IMPLANT
4.00
1.00
24164
REMOVE RADIUS HEAD IMPLANT
12.58
1.00
24164
REMOVE RADIUS HEAD IMPLANT
12.89
1.00
24164
REMOVE RADIUS HEAD IMPLANT
13.02
1.00
24200
REMOVAL OF ARM FOREIGN BODY
3.00
1.00
24200
REMOVAL OF ARM FOREIGN BODY
3.40
1.00
24200
REMOVAL OF ARM FOREIGN BODY
3.61
1.00
24200
REMOVAL OF ARM FOREIGN BODY
5.26
1.00
24201
REMOVAL OF ARM FOREIGN BODY
3.00
1.00
24201
REMOVAL OF ARM FOREIGN BODY
9.19
1.00
24201
REMOVAL OF ARM FOREIGN BODY
9.57
1.00
24201
REMOVAL OF ARM FOREIGN BODY
12.18
1.00
24220
INJECTION FOR ELBOW X-RAY
1.83
1.00
24220
INJECTION FOR ELBOW X-RAY
1.84
1.00
24220
INJECTION FOR ELBOW X-RAY
1.89
1.00
24220
INJECTION FOR ELBOW X-RAY
3.00
1.00
24300
MANIPULATE ELBOW W/ANESTH
3.00
1.00
24300
MANIPULATE ELBOW W/ANESTH
9.77
1.00
24300
MANIPULATE ELBOW W/ANESTH
9.79
1.00
24300
MANIPULATE ELBOW W/ANESTH
9.81
1.00
24301
MUSCLE/TENDON TRANSFER
3.00
1.00
24301
MUSCLE/TENDON TRANSFER
19.30
1.00
24301
MUSCLE/TENDON TRANSFER
19.93
1.00
24301
MUSCLE/TENDON TRANSFER
20.72
1.00
24305
ARM TENDON LENGTHENING
3.00
1.00
24305
ARM TENDON LENGTHENING
14.69
1.00
24305
ARM TENDON LENGTHENING
15.30
1.00
24305
ARM TENDON LENGTHENING
16.22
1.00
24310
REVISION OF ARM TENDON
3.00
1.00
24310
REVISION OF ARM TENDON
12.03
1.00
24310
REVISION OF ARM TENDON
12.58
1.00
24310
REVISION OF ARM TENDON
15.25
1.00
24320
REPAIR OF ARM TENDON
3.00
1.00
Procedure Code Description
RVU
RVU Coeff Value
24320
REPAIR OF ARM TENDON
19.49
1.00
24320
REPAIR OF ARM TENDON
19.89
1.00
24320
REPAIR OF ARM TENDON
22.61
1.00
24330
REVISION OF ARM MUSCLES
3.00
1.00
24330
REVISION OF ARM MUSCLES
18.35
1.00
24330
REVISION OF ARM MUSCLES
18.91
1.00
24330
REVISION OF ARM MUSCLES
19.68
1.00
24331
REVISION OF ARM MUSCLES
3.00
1.00
24331
REVISION OF ARM MUSCLES
20.30
1.00
24331
REVISION OF ARM MUSCLES
20.93
1.00
24331
REVISION OF ARM MUSCLES
21.54
1.00
24332
TENOLYSIS, TRICEPS
3.00
1.00
24332
TENOLYSIS, TRICEPS
13.43
1.00
24332
TENOLYSIS, TRICEPS
14.95
1.00
24332
TENOLYSIS, TRICEPS
15.34
1.00
24340
REPAIR OF BICEPS TENDON
3.00
1.00
24340
REPAIR OF BICEPS TENDON
15.64
1.00
24340
REPAIR OF BICEPS TENDON
16.09
1.00
24340
REPAIR OF BICEPS TENDON
16.83
1.00
24341
REPAIR ARM TENDON/MUSCLE
3.00
1.00
24341
REPAIR ARM TENDON/MUSCLE
16.84
1.00
24341
REPAIR ARM TENDON/MUSCLE
16.94
1.00
24341
REPAIR ARM TENDON/MUSCLE
18.33
1.00
24342
REPAIR OF RUPTURED TENDON
4.00
1.00
24342
REPAIR OF RUPTURED TENDON
20.21
1.00
24342
REPAIR OF RUPTURED TENDON
20.85
1.00
24342
REPAIR OF RUPTURED TENDON
21.54
1.00
24343
REPR ELBOW LAT LIGMNT W/TISS
3.00
1.00
24343
REPR ELBOW LAT LIGMNT W/TISS
17.67
1.00
24343
REPR ELBOW LAT LIGMNT W/TISS
17.85
1.00
24343
REPR ELBOW LAT LIGMNT W/TISS
17.93
1.00
24344
RECONSTRUCT ELBOW LAT LIGMNT
3.00
1.00
24344
RECONSTRUCT ELBOW LAT LIGMNT
27.01
1.00
24344
RECONSTRUCT ELBOW LAT LIGMNT
27.50
1.00
24344
RECONSTRUCT ELBOW LAT LIGMNT
27.90
1.00
Procedure Code Description
RVU
RVU Coeff Value
24345
REPR ELBW MED LIGMNT W/TISSU
3.00
1.00
24345
REPR ELBW MED LIGMNT W/TISSU
17.67
1.00
24345
REPR ELBW MED LIGMNT W/TISSU
17.74
1.00
24345
REPR ELBW MED LIGMNT W/TISSU
17.83
1.00
24346
RECONSTRUCT ELBOW MED LIGMNT
3.00
1.00
24346
RECONSTRUCT ELBOW MED LIGMNT
27.01
1.00
24346
RECONSTRUCT ELBOW MED LIGMNT
27.36
1.00
24346
RECONSTRUCT ELBOW MED LIGMNT
27.95
1.00
24350
REPAIR OF TENNIS ELBOW
3.00
1.00
24350
REPAIR OF TENNIS ELBOW
11.60
1.00
24350
REPAIR OF TENNIS ELBOW
11.63
1.00
24350
REPAIR OF TENNIS ELBOW
12.41
1.00
24351
REPAIR OF TENNIS ELBOW
3.00
1.00
24351
REPAIR OF TENNIS ELBOW
12.69
1.00
24351
REPAIR OF TENNIS ELBOW
12.75
1.00
24351
REPAIR OF TENNIS ELBOW
13.66
1.00
24352
REPAIR OF TENNIS ELBOW
3.00
1.00
24352
REPAIR OF TENNIS ELBOW
13.54
1.00
24352
REPAIR OF TENNIS ELBOW
13.63
1.00
24352
REPAIR OF TENNIS ELBOW
14.52
1.00
24354
REPAIR OF TENNIS ELBOW
3.00
1.00
24354
REPAIR OF TENNIS ELBOW
13.54
1.00
24354
REPAIR OF TENNIS ELBOW
13.61
1.00
24354
REPAIR OF TENNIS ELBOW
14.51
1.00
24356
REVISION OF TENNIS ELBOW
3.00
1.00
24356
REVISION OF TENNIS ELBOW
13.92
1.00
24356
REVISION OF TENNIS ELBOW
14.02
1.00
24356
REVISION OF TENNIS ELBOW
14.91
1.00
24357
REPAIR ELBOW, PERC
11.17
1.00
24358
REPAIR ELBOW W/DEB, OPEN
13.20
1.00
24359
REPAIR ELBOW DEB/ATTCH OPEN
16.64
1.00
24360
RECONSTRUCT ELBOW JOINT
3.00
1.00
24360
RECONSTRUCT ELBOW JOINT
23.21
1.00
24360
RECONSTRUCT ELBOW JOINT
23.68
1.00
24360
RECONSTRUCT ELBOW JOINT
23.71
1.00
Procedure Code Description
RVU
RVU Coeff Value
24361
RECONSTRUCT ELBOW JOINT
3.00
1.00
24361
RECONSTRUCT ELBOW JOINT
25.99
1.00
24361
RECONSTRUCT ELBOW JOINT
26.67
1.00
24361
RECONSTRUCT ELBOW JOINT
26.85
1.00
24362
RECONSTRUCT ELBOW JOINT
3.00
1.00
24362
RECONSTRUCT ELBOW JOINT
27.26
1.00
24362
RECONSTRUCT ELBOW JOINT
27.59
1.00
24362
RECONSTRUCT ELBOW JOINT
29.32
1.00
24363
REPLACE ELBOW JOINT
7.00
1.00
24363
REPLACE ELBOW JOINT
32.54
1.00
24363
REPLACE ELBOW JOINT
35.03
1.00
24363
REPLACE ELBOW JOINT
38.48
1.00
24365
RECONSTRUCT HEAD OF RADIUS
3.00
1.00
24365
RECONSTRUCT HEAD OF RADIUS
16.36
1.00
24365
RECONSTRUCT HEAD OF RADIUS
16.81
1.00
24366
RECONSTRUCT HEAD OF RADIUS
3.00
1.00
24366
RECONSTRUCT HEAD OF RADIUS
17.53
1.00
24366
RECONSTRUCT HEAD OF RADIUS
18.09
1.00
24366
RECONSTRUCT HEAD OF RADIUS
18.10
1.00
24400
REVISION OF HUMERUS
5.00
1.00
24400
REVISION OF HUMERUS
21.20
1.00
24400
REVISION OF HUMERUS
21.80
1.00
24400
REVISION OF HUMERUS
25.58
1.00
24410
REVISION OF HUMERUS
5.00
1.00
24410
REVISION OF HUMERUS
27.13
1.00
24410
REVISION OF HUMERUS
27.51
1.00
24410
REVISION OF HUMERUS
30.82
1.00
24420
REVISION OF HUMERUS
5.00
1.00
24420
REVISION OF HUMERUS
25.40
1.00
24420
REVISION OF HUMERUS
26.28
1.00
24420
REVISION OF HUMERUS
32.53
1.00
24430
REPAIR OF HUMERUS
5.00
1.00
24430
REPAIR OF HUMERUS
24.71
1.00
24430
REPAIR OF HUMERUS
26.94
1.00
24430
REPAIR OF HUMERUS
27.79
1.00
Procedure Code Description
RVU
RVU Coeff Value
24435
REPAIR HUMERUS WITH GRAFT
5.00
1.00
24435
REPAIR HUMERUS WITH GRAFT
26.20
1.00
24435
REPAIR HUMERUS WITH GRAFT
27.35
1.00
24435
REPAIR HUMERUS WITH GRAFT
29.38
1.00
24470
REVISION OF ELBOW JOINT
4.00
1.00
24470
REVISION OF ELBOW JOINT
16.15
1.00
24470
REVISION OF ELBOW JOINT
17.83
1.00
24470
REVISION OF ELBOW JOINT
18.47
1.00
24495
DECOMPRESSION OF FOREARM
4.00
1.00
24495
DECOMPRESSION OF FOREARM
16.70
1.00
24495
DECOMPRESSION OF FOREARM
18.27
1.00
24495
DECOMPRESSION OF FOREARM
19.32
1.00
24498
REINFORCE HUMERUS
5.00
1.00
24498
REINFORCE HUMERUS
22.53
1.00
24498
REINFORCE HUMERUS
23.19
1.00
24498
REINFORCE HUMERUS
26.27
1.00
24500
TREAT HUMERUS FRACTURE
3.00
1.00
24500
TREAT HUMERUS FRACTURE
7.00
1.00
24500
TREAT HUMERUS FRACTURE
7.31
1.00
24500
TREAT HUMERUS FRACTURE
7.58
1.00
24505
TREAT HUMERUS FRACTURE
3.00
1.00
24505
TREAT HUMERUS FRACTURE
11.18
1.00
24505
TREAT HUMERUS FRACTURE
11.31
1.00
24505
TREAT HUMERUS FRACTURE
12.99
1.00
24515
TREAT HUMERUS FRACTURE
5.00
1.00
24515
TREAT HUMERUS FRACTURE
22.57
1.00
24515
TREAT HUMERUS FRACTURE
22.94
1.00
24515
TREAT HUMERUS FRACTURE
24.86
1.00
24516
TREAT HUMERUS FRACTURE
5.00
1.00
24516
TREAT HUMERUS FRACTURE
22.33
1.00
24516
TREAT HUMERUS FRACTURE
22.71
1.00
24516
TREAT HUMERUS FRACTURE
25.42
1.00
24530
TREAT HUMERUS FRACTURE
5.00
1.00
24530
TREAT HUMERUS FRACTURE
8.00
1.00
24530
TREAT HUMERUS FRACTURE
8.17
1.00
Procedure Code Description
RVU
RVU Coeff Value
24530
TREAT HUMERUS FRACTURE
8.94
1.00
24535
TREAT HUMERUS FRACTURE
3.00
1.00
24535
TREAT HUMERUS FRACTURE
14.26
1.00
24535
TREAT HUMERUS FRACTURE
14.42
1.00
24535
TREAT HUMERUS FRACTURE
14.72
1.00
24538
TREAT HUMERUS FRACTURE
3.00
1.00
24538
TREAT HUMERUS FRACTURE
19.01
1.00
24538
TREAT HUMERUS FRACTURE
19.62
1.00
24538
TREAT HUMERUS FRACTURE
21.53
1.00
24545
TREAT HUMERUS FRACTURE
3.00
1.00
24545
TREAT HUMERUS FRACTURE
20.63
1.00
24545
TREAT HUMERUS FRACTURE
22.30
1.00
24545
TREAT HUMERUS FRACTURE
23.38
1.00
24546
TREAT HUMERUS FRACTURE
5.00
1.00
24546
TREAT HUMERUS FRACTURE
27.39
1.00
24546
TREAT HUMERUS FRACTURE
29.61
1.00
24546
TREAT HUMERUS FRACTURE
31.70
1.00
24560
TREAT HUMERUS FRACTURE
3.00
1.00
24560
TREAT HUMERUS FRACTURE
6.31
1.00
24560
TREAT HUMERUS FRACTURE
6.43
1.00
24560
TREAT HUMERUS FRACTURE
6.67
1.00
24565
TREAT HUMERUS FRACTURE
3.00
1.00
24565
TREAT HUMERUS FRACTURE
11.64
1.00
24565
TREAT HUMERUS FRACTURE
11.84
1.00
24565
TREAT HUMERUS FRACTURE
12.35
1.00
24566
TREAT HUMERUS FRACTURE
3.00
1.00
24566
TREAT HUMERUS FRACTURE
17.22
1.00
24566
TREAT HUMERUS FRACTURE
17.72
1.00
24566
TREAT HUMERUS FRACTURE
19.23
1.00
24575
TREAT HUMERUS FRACTURE
4.00
1.00
24575
TREAT HUMERUS FRACTURE
18.95
1.00
24575
TREAT HUMERUS FRACTURE
20.53
1.00
24575
TREAT HUMERUS FRACTURE
20.68
1.00
24576
TREAT HUMERUS FRACTURE
3.00
1.00
24576
TREAT HUMERUS FRACTURE
6.55
1.00
Procedure Code Description
RVU
RVU Coeff Value
24576
TREAT HUMERUS FRACTURE
6.91
1.00
24576
TREAT HUMERUS FRACTURE
7.10
1.00
24577
TREAT HUMERUS FRACTURE
3.00
1.00
24577
TREAT HUMERUS FRACTURE
12.07
1.00
24577
TREAT HUMERUS FRACTURE
12.45
1.00
24577
TREAT HUMERUS FRACTURE
12.92
1.00
24579
TREAT HUMERUS FRACTURE
3.00
1.00
24579
TREAT HUMERUS FRACTURE
21.50
1.00
24579
TREAT HUMERUS FRACTURE
22.36
1.00
24579
TREAT HUMERUS FRACTURE
24.53
1.00
24582
TREAT HUMERUS FRACTURE
3.00
1.00
24582
TREAT HUMERUS FRACTURE
19.00
1.00
24582
TREAT HUMERUS FRACTURE
19.78
1.00
24582
TREAT HUMERUS FRACTURE
20.52
1.00
24586
TREAT ELBOW FRACTURE
4.00
1.00
24586
TREAT ELBOW FRACTURE
28.38
1.00
24586
TREAT ELBOW FRACTURE
28.41
1.00
24586
TREAT ELBOW FRACTURE
28.86
1.00
24587
TREAT ELBOW FRACTURE
4.00
1.00
24587
TREAT ELBOW FRACTURE
28.18
1.00
24587
TREAT ELBOW FRACTURE
28.25
1.00
24587
TREAT ELBOW FRACTURE
28.63
1.00
24600
TREAT ELBOW DISLOCATION
3.00
1.00
24600
TREAT ELBOW DISLOCATION
8.03
1.00
24600
TREAT ELBOW DISLOCATION
8.33
1.00
24600
TREAT ELBOW DISLOCATION
9.83
1.00
24605
TREAT ELBOW DISLOCATION
3.00
1.00
24605
TREAT ELBOW DISLOCATION
11.23
1.00
24605
TREAT ELBOW DISLOCATION
11.48
1.00
24605
TREAT ELBOW DISLOCATION
11.53
1.00
24615
TREAT ELBOW DISLOCATION
3.00
1.00
24615
TREAT ELBOW DISLOCATION
18.36
1.00
24615
TREAT ELBOW DISLOCATION
18.70
1.00
24615
TREAT ELBOW DISLOCATION
18.72
1.00
24620
TREAT ELBOW FRACTURE
3.00
1.00
Procedure Code Description
RVU
RVU Coeff Value
24620
TREAT ELBOW FRACTURE
13.87
1.00
24620
TREAT ELBOW FRACTURE
14.17
1.00
24620
TREAT ELBOW FRACTURE
14.59
1.00
24635
TREAT ELBOW FRACTURE
3.00
1.00
24635
TREAT ELBOW FRACTURE
19.51
1.00
24635
TREAT ELBOW FRACTURE
29.60
1.00
24635
TREAT ELBOW FRACTURE
31.67
1.00
24640
TREAT ELBOW DISLOCATION
2.13
1.00
24640
TREAT ELBOW DISLOCATION
2.20
1.00
24640
TREAT ELBOW DISLOCATION
3.00
1.00
24640
TREAT ELBOW DISLOCATION
3.15
1.00
24650
TREAT RADIUS FRACTURE
3.00
1.00
24650
TREAT RADIUS FRACTURE
5.23
1.00
24650
TREAT RADIUS FRACTURE
5.36
1.00
24650
TREAT RADIUS FRACTURE
5.51
1.00
24655
TREAT RADIUS FRACTURE
3.00
1.00
24655
TREAT RADIUS FRACTURE
9.69
1.00
24655
TREAT RADIUS FRACTURE
9.78
1.00
24655
TREAT RADIUS FRACTURE
10.39
1.00
24665
TREAT RADIUS FRACTURE
3.00
1.00
24665
TREAT RADIUS FRACTURE
16.51
1.00
24665
TREAT RADIUS FRACTURE
16.97
1.00
24665
TREAT RADIUS FRACTURE
18.99
1.00
24666
TREAT RADIUS FRACTURE
4.00
1.00
24666
TREAT RADIUS FRACTURE
18.76
1.00
24666
TREAT RADIUS FRACTURE
19.12
1.00
24666
TREAT RADIUS FRACTURE
21.29
1.00
24670
TREAT ULNAR FRACTURE
3.00
1.00
24670
TREAT ULNAR FRACTURE
5.95
1.00
24670
TREAT ULNAR FRACTURE
6.00
1.00
24670
TREAT ULNAR FRACTURE
6.16
1.00
24675
TREAT ULNAR FRACTURE
3.00
1.00
24675
TREAT ULNAR FRACTURE
10.31
1.00
24675
TREAT ULNAR FRACTURE
11.05
1.00
24685
TREAT ULNAR FRACTURE
3.00
1.00
Procedure Code Description
RVU
RVU Coeff Value
24685
TREAT ULNAR FRACTURE
16.62
1.00
24685
TREAT ULNAR FRACTURE
17.79
1.00
24685
TREAT ULNAR FRACTURE
20.11
1.00
24800
FUSION OF ELBOW JOINT
3.00
1.00
24800
FUSION OF ELBOW JOINT
20.32
1.00
24800
FUSION OF ELBOW JOINT
21.59
1.00
24800
FUSION OF ELBOW JOINT
22.55
1.00
24802
FUSION/GRAFT OF ELBOW JOINT
3.00
1.00
24802
FUSION/GRAFT OF ELBOW JOINT
25.86
1.00
24802
FUSION/GRAFT OF ELBOW JOINT
26.27
1.00
24802
FUSION/GRAFT OF ELBOW JOINT
27.14
1.00
24900
AMPUTATION OF UPPER ARM
4.00
1.00
24900
AMPUTATION OF UPPER ARM
18.36
1.00
24900
AMPUTATION OF UPPER ARM
18.38
1.00
24900
AMPUTATION OF UPPER ARM
21.99
1.00
24920
AMPUTATION OF UPPER ARM
4.00
1.00
24920
AMPUTATION OF UPPER ARM
18.29
1.00
24920
AMPUTATION OF UPPER ARM
18.52
1.00
24920
AMPUTATION OF UPPER ARM
23.58
1.00
24925
AMPUTATION FOLLOW-UP SURGERY
4.00
1.00
24925
AMPUTATION FOLLOW-UP SURGERY
14.16
1.00
24925
AMPUTATION FOLLOW-UP SURGERY
14.48
1.00
24925
AMPUTATION FOLLOW-UP SURGERY
17.70
1.00
24930
AMPUTATION FOLLOW-UP SURGERY
4.00
1.00
24930
AMPUTATION FOLLOW-UP SURGERY
19.23
1.00
24930
AMPUTATION FOLLOW-UP SURGERY
19.39
1.00
24930
AMPUTATION FOLLOW-UP SURGERY
23.26
1.00
24931
AMPUTATE UPPER ARM & IMPLANT
4.00
1.00
24931
AMPUTATE UPPER ARM & IMPLANT
20.69
1.00
24931
AMPUTATE UPPER ARM & IMPLANT
21.67
1.00
24931
AMPUTATE UPPER ARM & IMPLANT
23.51
1.00
24935
REVISION OF AMPUTATION
25.87
1.00
24935
REVISION OF AMPUTATION
26.24
1.00
24935
REVISION OF AMPUTATION
29.77
1.00
25000
INCISION OF TENDON SHEATH
3.00
1.00
Procedure Code Description
RVU
RVU Coeff Value
25000
INCISION OF TENDON SHEATH
8.73
1.00
25000
INCISION OF TENDON SHEATH
10.86
1.00
25000
INCISION OF TENDON SHEATH
11.42
1.00
25001
INCISE FLEXOR CARPI RADIALIS
3.00
1.00
25001
INCISE FLEXOR CARPI RADIALIS
8.00
1.00
25001
INCISE FLEXOR CARPI RADIALIS
8.20
1.00
25001
INCISE FLEXOR CARPI RADIALIS
8.27
1.00
25020
DECOMPRESS FOREARM 1 SPACE
3.00
1.00
25020
DECOMPRESS FOREARM 1 SPACE
14.47
1.00
25020
DECOMPRESS FOREARM 1 SPACE
16.77
1.00
25020
DECOMPRESS FOREARM 1 SPACE
18.06
1.00
25023
DECOMPRESS FOREARM 1 SPACE
4.00
1.00
25023
DECOMPRESS FOREARM 1 SPACE
27.92
1.00
25023
DECOMPRESS FOREARM 1 SPACE
30.22
1.00
25023
DECOMPRESS FOREARM 1 SPACE
31.84
1.00
25024
DECOMPRESS FOREARM 2 SPACES
3.00
1.00
25024
DECOMPRESS FOREARM 2 SPACES
18.51
1.00
25024
DECOMPRESS FOREARM 2 SPACES
18.82
1.00
25024
DECOMPRESS FOREARM 2 SPACES
19.49
1.00
25025
DECOMPRESS FOREARM 2 SPACES
3.00
1.00
25025
DECOMPRESS FOREARM 2 SPACES
29.15
1.00
25025
DECOMPRESS FOREARM 2 SPACES
29.96
1.00
25025
DECOMPRESS FOREARM 2 SPACES
30.47
1.00
25028
DRAINAGE OF FOREARM LESION
4.00
1.00
25028
DRAINAGE OF FOREARM LESION
12.88
1.00
25028
DRAINAGE OF FOREARM LESION
14.46
1.00
25028
DRAINAGE OF FOREARM LESION
16.03
1.00
25031
DRAINAGE OF FOREARM BURSA
3.00
1.00
25031
DRAINAGE OF FOREARM BURSA
9.48
1.00
25031
DRAINAGE OF FOREARM BURSA
12.98
1.00
25031
DRAINAGE OF FOREARM BURSA
14.78
1.00
25035
TREAT FOREARM BONE LESION
3.00
1.00
25035
TREAT FOREARM BONE LESION
16.45
1.00
25035
TREAT FOREARM BONE LESION
22.56
1.00
25035
TREAT FOREARM BONE LESION
25.21
1.00
Procedure Code Description
RVU
RVU Coeff Value
25040
EXPLORE/TREAT WRIST JOINT
3.00
1.00
25040
EXPLORE/TREAT WRIST JOINT
14.56
1.00
25040
EXPLORE/TREAT WRIST JOINT
15.67
1.00
25040
EXPLORE/TREAT WRIST JOINT
17.62
1.00
25065
BIOPSY FOREARM SOFT TISSUES
3.00
1.00
25065
BIOPSY FOREARM SOFT TISSUES
4.11
1.00
25065
BIOPSY FOREARM SOFT TISSUES
4.69
1.00
25065
BIOPSY FOREARM SOFT TISSUES
4.92
1.00
25066
BIOPSY FOREARM SOFT TISSUES
3.00
1.00
25066
BIOPSY FOREARM SOFT TISSUES
9.50
1.00
25066
BIOPSY FOREARM SOFT TISSUES
11.95
1.00
25066
BIOPSY FOREARM SOFT TISSUES
13.04
1.00
25075
REMOVAL FOREARM LESION SUBCU
3.00
1.00
25075
REMOVAL FOREARM LESION SUBCU
8.31
1.00
25075
REMOVAL FOREARM LESION SUBCU
10.34
1.00
25075
REMOVAL FOREARM LESION SUBCU
11.53
1.00
25076
REMOVAL FOREARM LESION DEEP
3.00
1.00
25076
REMOVAL FOREARM LESION DEEP
11.23
1.00
25076
REMOVAL FOREARM LESION DEEP
15.60
1.00
25076
REMOVAL FOREARM LESION DEEP
18.39
1.00
25077
REMOVE TUMOR, FOREARM/WRIST
3.00
1.00
25077
REMOVE TUMOR, FOREARM/WRIST
19.08
1.00
25077
REMOVE TUMOR, FOREARM/WRIST
23.76
1.00
25077
REMOVE TUMOR, FOREARM/WRIST
26.37
1.00
25085
INCISION OF WRIST CAPSULE
5.00
1.00
25085
INCISION OF WRIST CAPSULE
11.71
1.00
25085
INCISION OF WRIST CAPSULE
13.65
1.00
25085
INCISION OF WRIST CAPSULE
17.50
1.00
25100
BIOPSY OF WRIST JOINT
3.00
1.00
25100
BIOPSY OF WRIST JOINT
8.68
1.00
25100
BIOPSY OF WRIST JOINT
9.90
1.00
25100
BIOPSY OF WRIST JOINT
12.06
1.00
25101
EXPLORE/TREAT WRIST JOINT
3.00
1.00
25101
EXPLORE/TREAT WRIST JOINT
10.25
1.00
25101
EXPLORE/TREAT WRIST JOINT
11.36
1.00
Procedure Code Description
RVU
RVU Coeff Value
25101
EXPLORE/TREAT WRIST JOINT
13.31
1.00
25105
REMOVE WRIST JOINT LINING
3.00
1.00
25105
REMOVE WRIST JOINT LINING
12.46
1.00
25105
REMOVE WRIST JOINT LINING
14.25
1.00
25105
REMOVE WRIST JOINT LINING
17.87
1.00
25107
REMOVE WRIST JOINT CARTILAGE
3.00
1.00
25107
REMOVE WRIST JOINT CARTILAGE
15.44
1.00
25107
REMOVE WRIST JOINT CARTILAGE
15.82
1.00
25107
REMOVE WRIST JOINT CARTILAGE
18.87
1.00
25109
EXCISE TENDON FOREARM/WRIST
13.22
1.00
25110
REMOVE WRIST TENDON LESION
3.00
1.00
25110
REMOVE WRIST TENDON LESION
9.10
1.00
25110
REMOVE WRIST TENDON LESION
11.75
1.00
25110
REMOVE WRIST TENDON LESION
13.02
1.00
25111
REMOVE WRIST TENDON LESION
3.00
1.00
25111
REMOVE WRIST TENDON LESION
7.89
1.00
25111
REMOVE WRIST TENDON LESION
8.72
1.00
25111
REMOVE WRIST TENDON LESION
10.48
1.00
25112
REREMOVE WRIST TENDON LESION
3.00
1.00
25112
REREMOVE WRIST TENDON LESION
9.66
1.00
25112
REREMOVE WRIST TENDON LESION
10.60
1.00
25112
REREMOVE WRIST TENDON LESION
12.56
1.00
25115
REMOVE WRIST/FOREARM LESION
3.00
1.00
25115
REMOVE WRIST/FOREARM LESION
20.36
1.00
25115
REMOVE WRIST/FOREARM LESION
24.59
1.00
25115
REMOVE WRIST/FOREARM LESION
27.29
1.00
25116
REMOVE WRIST/FOREARM LESION
3.00
1.00
25116
REMOVE WRIST/FOREARM LESION
16.49
1.00
25116
REMOVE WRIST/FOREARM LESION
21.72
1.00
25116
REMOVE WRIST/FOREARM LESION
24.37
1.00
25118
EXCISE WRIST TENDON SHEATH
3.00
1.00
25118
EXCISE WRIST TENDON SHEATH
9.68
1.00
25118
EXCISE WRIST TENDON SHEATH
10.90
1.00
25118
EXCISE WRIST TENDON SHEATH
13.01
1.00
25119
PARTIAL REMOVAL OF ULNA
3.00
1.00
Procedure Code Description
RVU
RVU Coeff Value
25119
PARTIAL REMOVAL OF ULNA
12.84
1.00
25119
PARTIAL REMOVAL OF ULNA
14.76
1.00
25119
PARTIAL REMOVAL OF ULNA
18.38
1.00
25120
REMOVAL OF FOREARM LESION
3.00
1.00
25120
REMOVAL OF FOREARM LESION
14.09
1.00
25120
REMOVAL OF FOREARM LESION
19.51
1.00
25120
REMOVAL OF FOREARM LESION
22.22
1.00
25125
REMOVE/GRAFT FOREARM LESION
3.00
1.00
25125
REMOVE/GRAFT FOREARM LESION
16.36
1.00
25125
REMOVE/GRAFT FOREARM LESION
21.91
1.00
25125
REMOVE/GRAFT FOREARM LESION
24.89
1.00
25126
REMOVE/GRAFT FOREARM LESION
3.00
1.00
25126
REMOVE/GRAFT FOREARM LESION
16.59
1.00
25126
REMOVE/GRAFT FOREARM LESION
22.06
1.00
25126
REMOVE/GRAFT FOREARM LESION
24.48
1.00
25130
REMOVAL OF WRIST LESION
3.00
1.00
25130
REMOVAL OF WRIST LESION
11.36
1.00
25130
REMOVAL OF WRIST LESION
12.56
1.00
25130
REMOVAL OF WRIST LESION
14.36
1.00
25135
REMOVE & GRAFT WRIST LESION
3.00
1.00
25135
REMOVE & GRAFT WRIST LESION
14.19
1.00
25135
REMOVE & GRAFT WRIST LESION
15.48
1.00
25135
REMOVE & GRAFT WRIST LESION
17.05
1.00
25136
REMOVE & GRAFT WRIST LESION
3.00
1.00
25136
REMOVE & GRAFT WRIST LESION
12.59
1.00
25136
REMOVE & GRAFT WRIST LESION
13.34
1.00
25136
REMOVE & GRAFT WRIST LESION
15.05
1.00
25145
REMOVE FOREARM BONE LESION
3.00
1.00
25145
REMOVE FOREARM BONE LESION
14.46
1.00
25145
REMOVE FOREARM BONE LESION
19.82
1.00
25145
REMOVE FOREARM BONE LESION
22.92
1.00
25150
PARTIAL REMOVAL OF ULNA
3.00
1.00
25150
PARTIAL REMOVAL OF ULNA
14.74
1.00
25150
PARTIAL REMOVAL OF ULNA
16.65
1.00
25150
PARTIAL REMOVAL OF ULNA
20.33
1.00
Procedure Code Description
RVU
RVU Coeff Value
25151
PARTIAL REMOVAL OF RADIUS
3.00
1.00
25151
PARTIAL REMOVAL OF RADIUS
16.29
1.00
25151
PARTIAL REMOVAL OF RADIUS
21.58
1.00
25151
PARTIAL REMOVAL OF RADIUS
24.60
1.00
25170
EXTENSIVE FOREARM SURGERY
4.00
1.00
25170
EXTENSIVE FOREARM SURGERY
22.71
1.00
25170
EXTENSIVE FOREARM SURGERY
28.36
1.00
25170
EXTENSIVE FOREARM SURGERY
30.37
1.00
25210
REMOVAL OF WRIST BONE
3.00
1.00
25210
REMOVAL OF WRIST BONE
12.45
1.00
25210
REMOVAL OF WRIST BONE
13.72
1.00
25210
REMOVAL OF WRIST BONE
15.52
1.00
25215
REMOVAL OF WRIST BONES
3.00
1.00
25215
REMOVAL OF WRIST BONES
16.06
1.00
25215
REMOVAL OF WRIST BONES
18.00
1.00
25215
REMOVAL OF WRIST BONES
21.43
1.00
25230
PARTIAL REMOVAL OF RADIUS
3.00
1.00
25230
PARTIAL REMOVAL OF RADIUS
11.03
1.00
25230
PARTIAL REMOVAL OF RADIUS
12.24
1.00
25230
PARTIAL REMOVAL OF RADIUS
14.24
1.00
25240
PARTIAL REMOVAL OF ULNA
3.00
1.00
25240
PARTIAL REMOVAL OF ULNA
11.19
1.00
25240
PARTIAL REMOVAL OF ULNA
13.08
1.00
25240
PARTIAL REMOVAL OF ULNA
16.93
1.00
25246
INJECTION FOR WRIST X-RAY
2.01
1.00
25246
INJECTION FOR WRIST X-RAY
2.02
1.00
25246
INJECTION FOR WRIST X-RAY
2.08
1.00
25246
INJECTION FOR WRIST X-RAY
3.00
1.00
25248
REMOVE FOREARM FOREIGN BODY
3.00
1.00
25248
REMOVE FOREARM FOREIGN BODY
11.11
1.00
25248
REMOVE FOREARM FOREIGN BODY
14.53
1.00
25248
REMOVE FOREARM FOREIGN BODY
15.91
1.00
25250
REMOVAL OF WRIST PROSTHESIS
5.00
1.00
25250
REMOVAL OF WRIST PROSTHESIS
13.26
1.00
25250
REMOVAL OF WRIST PROSTHESIS
13.60
1.00
Procedure Code Description
RVU
RVU Coeff Value
25250
REMOVAL OF WRIST PROSTHESIS
13.63
1.00
25251
REMOVAL OF WRIST PROSTHESIS
5.00
1.00
25251
REMOVAL OF WRIST PROSTHESIS
18.07
1.00
25251
REMOVAL OF WRIST PROSTHESIS
18.77
1.00
25251
REMOVAL OF WRIST PROSTHESIS
18.80
1.00
25259
MANIPULATE WRIST W/ANESTHES
3.00
1.00
25259
MANIPULATE WRIST W/ANESTHES
9.71
1.00
25259
MANIPULATE WRIST W/ANESTHES
9.81
1.00
25259
MANIPULATE WRIST W/ANESTHES
9.82
1.00
25260
REPAIR FOREARM TENDON/MUSCLE
3.00
1.00
25260
REPAIR FOREARM TENDON/MUSCLE
17.26
1.00
25260
REPAIR FOREARM TENDON/MUSCLE
22.86
1.00
25260
REPAIR FOREARM TENDON/MUSCLE
25.89
1.00
25263
REPAIR FOREARM TENDON/MUSCLE
3.00
1.00
25263
REPAIR FOREARM TENDON/MUSCLE
17.23
1.00
25263
REPAIR FOREARM TENDON/MUSCLE
22.75
1.00
25263
REPAIR FOREARM TENDON/MUSCLE
25.75
1.00
25265
REPAIR FOREARM TENDON/MUSCLE
3.00
1.00
25265
REPAIR FOREARM TENDON/MUSCLE
20.47
1.00
25265
REPAIR FOREARM TENDON/MUSCLE
26.01
1.00
25265
REPAIR FOREARM TENDON/MUSCLE
28.78
1.00
25270
REPAIR FOREARM TENDON/MUSCLE
3.00
1.00
25270
REPAIR FOREARM TENDON/MUSCLE
13.86
1.00
25270
REPAIR FOREARM TENDON/MUSCLE
19.51
1.00
25270
REPAIR FOREARM TENDON/MUSCLE
22.93
1.00
25272
REPAIR FOREARM TENDON/MUSCLE
3.00
1.00
25272
REPAIR FOREARM TENDON/MUSCLE
15.61
1.00
25272
REPAIR FOREARM TENDON/MUSCLE
21.40
1.00
25272
REPAIR FOREARM TENDON/MUSCLE
24.67
1.00
25274
REPAIR FOREARM TENDON/MUSCLE
3.00
1.00
25274
REPAIR FOREARM TENDON/MUSCLE
18.51
1.00
25274
REPAIR FOREARM TENDON/MUSCLE
24.13
1.00
25274
REPAIR FOREARM TENDON/MUSCLE
27.06
1.00
25275
REPAIR FOREARM TENDON SHEATH
3.00
1.00
25275
REPAIR FOREARM TENDON SHEATH
17.06
1.00
Procedure Code Description
RVU
RVU Coeff Value
25275
REPAIR FOREARM TENDON SHEATH
17.07
1.00
25275
REPAIR FOREARM TENDON SHEATH
17.32
1.00
25280
REVISE WRIST/FOREARM TENDON
3.00
1.00
25280
REVISE WRIST/FOREARM TENDON
15.80
1.00
25280
REVISE WRIST/FOREARM TENDON
21.34
1.00
25280
REVISE WRIST/FOREARM TENDON
24.42
1.00
25290
INCISE WRIST/FOREARM TENDON
3.00
1.00
25290
INCISE WRIST/FOREARM TENDON
13.37
1.00
25290
INCISE WRIST/FOREARM TENDON
21.61
1.00
25290
INCISE WRIST/FOREARM TENDON
24.57
1.00
25295
RELEASE WRIST/FOREARM TENDON
3.00
1.00
25295
RELEASE WRIST/FOREARM TENDON
14.71
1.00
25295
RELEASE WRIST/FOREARM TENDON
20.17
1.00
25295
RELEASE WRIST/FOREARM TENDON
23.34
1.00
25300
FUSION OF TENDONS AT WRIST
3.00
1.00
25300
FUSION OF TENDONS AT WRIST
17.36
1.00
25300
FUSION OF TENDONS AT WRIST
18.60
1.00
25300
FUSION OF TENDONS AT WRIST
19.93
1.00
25301
FUSION OF TENDONS AT WRIST
3.00
1.00
25301
FUSION OF TENDONS AT WRIST
16.56
1.00
25301
FUSION OF TENDONS AT WRIST
17.85
1.00
25301
FUSION OF TENDONS AT WRIST
19.46
1.00
25310
TRANSPLANT FOREARM TENDON
3.00
1.00
25310
TRANSPLANT FOREARM TENDON
17.12
1.00
25310
TRANSPLANT FOREARM TENDON
22.79
1.00
25310
TRANSPLANT FOREARM TENDON
25.89
1.00
25312
TRANSPLANT FOREARM TENDON
3.00
1.00
25312
TRANSPLANT FOREARM TENDON
19.82
1.00
25312
TRANSPLANT FOREARM TENDON
25.35
1.00
25312
TRANSPLANT FOREARM TENDON
28.28
1.00
25315
REVISE PALSY HAND TENDON(S)
3.00
1.00
25315
REVISE PALSY HAND TENDON(S)
21.27
1.00
25315
REVISE PALSY HAND TENDON(S)
26.59
1.00
25315
REVISE PALSY HAND TENDON(S)
29.77
1.00
25316
REVISE PALSY HAND TENDON(S)
3.00
1.00
Procedure Code Description
RVU
RVU Coeff Value
25316
REVISE PALSY HAND TENDON(S)
24.57
1.00
25316
REVISE PALSY HAND TENDON(S)
31.07
1.00
25316
REVISE PALSY HAND TENDON(S)
33.78
1.00
25320
REPAIR/REVISE WRIST JOINT
3.00
1.00
25320
REPAIR/REVISE WRIST JOINT
23.55
1.00
25320
REPAIR/REVISE WRIST JOINT
23.59
1.00
25320
REPAIR/REVISE WRIST JOINT
24.39
1.00
25332
REVISE WRIST JOINT
3.00
1.00
25332
REVISE WRIST JOINT
21.67
1.00
25332
REVISE WRIST JOINT
22.21
1.00
25335
REALIGNMENT OF HAND
3.00
1.00
25335
REALIGNMENT OF HAND
24.55
1.00
25335
REALIGNMENT OF HAND
26.58
1.00
25335
REALIGNMENT OF HAND
29.49
1.00
25337
RECONSTRUCT ULNA/RADIOULNAR
3.00
1.00
25337
RECONSTRUCT ULNA/RADIOULNAR
22.49
1.00
25337
RECONSTRUCT ULNA/RADIOULNAR
22.80
1.00
25337
RECONSTRUCT ULNA/RADIOULNAR
25.33
1.00
25350
REVISION OF RADIUS
3.00
1.00
25350
REVISION OF RADIUS
18.89
1.00
25350
REVISION OF RADIUS
24.46
1.00
25350
REVISION OF RADIUS
26.93
1.00
25355
REVISION OF RADIUS
3.00
1.00
25355
REVISION OF RADIUS
21.27
1.00
25355
REVISION OF RADIUS
26.79
1.00
25355
REVISION OF RADIUS
29.21
1.00
25360
REVISION OF ULNA
3.00
1.00
25360
REVISION OF ULNA
18.33
1.00
25360
REVISION OF ULNA
24.00
1.00
25360
REVISION OF ULNA
26.49
1.00
25365
REVISE RADIUS & ULNA
3.00
1.00
25365
REVISE RADIUS & ULNA
25.02
1.00
25365
REVISE RADIUS & ULNA
30.32
1.00
25365
REVISE RADIUS & ULNA
32.58
1.00
25370
REVISE RADIUS OR ULNA
3.00
1.00
Procedure Code Description
RVU
RVU Coeff Value
25370
REVISE RADIUS OR ULNA
27.25
1.00
25370
REVISE RADIUS OR ULNA
31.91
1.00
25370
REVISE RADIUS OR ULNA
33.66
1.00
25375
REVISE RADIUS & ULNA
3.00
1.00
25375
REVISE RADIUS & ULNA
26.32
1.00
25375
REVISE RADIUS & ULNA
31.96
1.00
25375
REVISE RADIUS & ULNA
34.30
1.00
25390
SHORTEN RADIUS OR ULNA
3.00
1.00
25390
SHORTEN RADIUS OR ULNA
21.36
1.00
25390
SHORTEN RADIUS OR ULNA
26.95
1.00
25390
SHORTEN RADIUS OR ULNA
29.47
1.00
25391
LENGTHEN RADIUS OR ULNA
3.00
1.00
25391
LENGTHEN RADIUS OR ULNA
27.18
1.00
25391
LENGTHEN RADIUS OR ULNA
32.59
1.00
25391
LENGTHEN RADIUS OR ULNA
34.75
1.00
25392
SHORTEN RADIUS & ULNA
3.00
1.00
25392
SHORTEN RADIUS & ULNA
27.54
1.00
25392
SHORTEN RADIUS & ULNA
32.26
1.00
25392
SHORTEN RADIUS & ULNA
34.05
1.00
25393
LENGTHEN RADIUS & ULNA
3.00
1.00
25393
LENGTHEN RADIUS & ULNA
31.08
1.00
25393
LENGTHEN RADIUS & ULNA
35.99
1.00
25393
LENGTHEN RADIUS & ULNA
38.37
1.00
25394
REPAIR CARPAL BONE, SHORTEN
3.00
1.00
25394
REPAIR CARPAL BONE, SHORTEN
19.87
1.00
25394
REPAIR CARPAL BONE, SHORTEN
20.09
1.00
25394
REPAIR CARPAL BONE, SHORTEN
20.30
1.00
25400
REPAIR RADIUS OR ULNA
4.00
1.00
25400
REPAIR RADIUS OR ULNA
22.44
1.00
25400
REPAIR RADIUS OR ULNA
28.20
1.00
25400
REPAIR RADIUS OR ULNA
30.64
1.00
25405
REPAIR/GRAFT RADIUS OR ULNA
4.00
1.00
25405
REPAIR/GRAFT RADIUS OR ULNA
28.52
1.00
25405
REPAIR/GRAFT RADIUS OR ULNA
34.29
1.00
25405
REPAIR/GRAFT RADIUS OR ULNA
36.81
1.00
Procedure Code Description
RVU
RVU Coeff Value
25415
REPAIR RADIUS & ULNA
4.00
1.00
25415
REPAIR RADIUS & ULNA
26.80
1.00
25415
REPAIR RADIUS & ULNA
32.40
1.00
25415
REPAIR RADIUS & ULNA
34.61
1.00
25420
REPAIR/GRAFT RADIUS & ULNA
4.00
1.00
25420
REPAIR/GRAFT RADIUS & ULNA
31.90
1.00
25420
REPAIR/GRAFT RADIUS & ULNA
37.52
1.00
25420
REPAIR/GRAFT RADIUS & ULNA
39.87
1.00
25425
REPAIR/GRAFT RADIUS OR ULNA
3.00
1.00
25425
REPAIR/GRAFT RADIUS OR ULNA
27.54
1.00
25425
REPAIR/GRAFT RADIUS OR ULNA
37.21
1.00
25425
REPAIR/GRAFT RADIUS OR ULNA
41.62
1.00
25426
REPAIR/GRAFT RADIUS & ULNA
3.00
1.00
25426
REPAIR/GRAFT RADIUS & ULNA
28.92
1.00
25426
REPAIR/GRAFT RADIUS & ULNA
35.78
1.00
25426
REPAIR/GRAFT RADIUS & ULNA
38.17
1.00
25430
VASC GRAFT INTO CARPAL BONE
3.00
1.00
25430
VASC GRAFT INTO CARPAL BONE
17.81
1.00
25430
VASC GRAFT INTO CARPAL BONE
17.94
1.00
25430
VASC GRAFT INTO CARPAL BONE
18.06
1.00
25431
REPAIR NONUNION CARPAL BONE
3.00
1.00
25431
REPAIR NONUNION CARPAL BONE
17.38
1.00
25431
REPAIR NONUNION CARPAL BONE
19.33
1.00
25431
REPAIR NONUNION CARPAL BONE
20.17
1.00
25440
REPAIR/GRAFT WRIST BONE
3.00
1.00
25440
REPAIR/GRAFT WRIST BONE
19.96
1.00
25440
REPAIR/GRAFT WRIST BONE
21.53
1.00
25440
REPAIR/GRAFT WRIST BONE
23.10
1.00
25441
RECONSTRUCT WRIST JOINT
3.00
1.00
25441
RECONSTRUCT WRIST JOINT
24.22
1.00
25441
RECONSTRUCT WRIST JOINT
24.87
1.00
25441
RECONSTRUCT WRIST JOINT
24.97
1.00
25442
RECONSTRUCT WRIST JOINT
3.00
1.00
25442
RECONSTRUCT WRIST JOINT
20.56
1.00
25442
RECONSTRUCT WRIST JOINT
21.09
1.00
Procedure Code Description
RVU
RVU Coeff Value
25442
RECONSTRUCT WRIST JOINT
21.10
1.00
25443
RECONSTRUCT WRIST JOINT
3.00
1.00
25443
RECONSTRUCT WRIST JOINT
19.69
1.00
25443
RECONSTRUCT WRIST JOINT
20.58
1.00
25443
RECONSTRUCT WRIST JOINT
20.59
1.00
25444
RECONSTRUCT WRIST JOINT
3.00
1.00
25444
RECONSTRUCT WRIST JOINT
21.09
1.00
25444
RECONSTRUCT WRIST JOINT
21.75
1.00
25444
RECONSTRUCT WRIST JOINT
21.92
1.00
25445
RECONSTRUCT WRIST JOINT
3.00
1.00
25445
RECONSTRUCT WRIST JOINT
18.48
1.00
25445
RECONSTRUCT WRIST JOINT
19.07
1.00
25445
RECONSTRUCT WRIST JOINT
19.13
1.00
25446
WRIST REPLACEMENT
3.00
1.00
25446
WRIST REPLACEMENT
30.40
1.00
25446
WRIST REPLACEMENT
30.92
1.00
25446
WRIST REPLACEMENT
30.99
1.00
25447
REPAIR WRIST JOINT(S)
3.00
1.00
25447
REPAIR WRIST JOINT(S)
20.47
1.00
25447
REPAIR WRIST JOINT(S)
20.51
1.00
25447
REPAIR WRIST JOINT(S)
20.81
1.00
25449
REMOVE WRIST JOINT IMPLANT
3.00
1.00
25449
REMOVE WRIST JOINT IMPLANT
26.65
1.00
25449
REMOVE WRIST JOINT IMPLANT
27.15
1.00
25449
REMOVE WRIST JOINT IMPLANT
27.17
1.00
25450
REVISION OF WRIST JOINT
3.00
1.00
25450
REVISION OF WRIST JOINT
15.51
1.00
25450
REVISION OF WRIST JOINT
19.33
1.00
25450
REVISION OF WRIST JOINT
21.84
1.00
25455
REVISION OF WRIST JOINT
3.00
1.00
25455
REVISION OF WRIST JOINT
17.47
1.00
25455
REVISION OF WRIST JOINT
22.10
1.00
25455
REVISION OF WRIST JOINT
24.84
1.00
25490
REINFORCE RADIUS
3.00
1.00
25490
REINFORCE RADIUS
19.41
1.00
Procedure Code Description
RVU
RVU Coeff Value
25490
REINFORCE RADIUS
25.00
1.00
25490
REINFORCE RADIUS
27.44
1.00
25491
REINFORCE ULNA
3.00
1.00
25491
REINFORCE ULNA
20.52
1.00
25491
REINFORCE ULNA
26.44
1.00
25491
REINFORCE ULNA
28.95
1.00
25492
REINFORCE RADIUS AND ULNA
3.00
1.00
25492
REINFORCE RADIUS AND ULNA
24.80
1.00
25492
REINFORCE RADIUS AND ULNA
29.84
1.00
25492
REINFORCE RADIUS AND ULNA
32.01
1.00
25500
TREAT FRACTURE OF RADIUS
3.00
1.00
25500
TREAT FRACTURE OF RADIUS
5.50
1.00
25500
TREAT FRACTURE OF RADIUS
5.66
1.00
25500
TREAT FRACTURE OF RADIUS
5.69
1.00
25505
TREAT FRACTURE OF RADIUS
3.00
1.00
25505
TREAT FRACTURE OF RADIUS
11.28
1.00
25505
TREAT FRACTURE OF RADIUS
11.34
1.00
25505
TREAT FRACTURE OF RADIUS
11.71
1.00
25515
TREAT FRACTURE OF RADIUS
3.00
1.00
25515
TREAT FRACTURE OF RADIUS
17.10
1.00
25515
TREAT FRACTURE OF RADIUS
18.11
1.00
25515
TREAT FRACTURE OF RADIUS
20.40
1.00
25520
TREAT FRACTURE OF RADIUS
5.00
1.00
25520
TREAT FRACTURE OF RADIUS
12.92
1.00
25520
TREAT FRACTURE OF RADIUS
13.15
1.00
25520
TREAT FRACTURE OF RADIUS
13.54
1.00
25525
TREAT FRACTURE OF RADIUS
5.00
1.00
25525
TREAT FRACTURE OF RADIUS
20.74
1.00
25525
TREAT FRACTURE OF RADIUS
24.19
1.00
25525
TREAT FRACTURE OF RADIUS
25.84
1.00
25526
TREAT FRACTURE OF RADIUS
5.00
1.00
25526
TREAT FRACTURE OF RADIUS
25.32
1.00
25526
TREAT FRACTURE OF RADIUS
28.72
1.00
25526
TREAT FRACTURE OF RADIUS
30.18
1.00
25530
TREAT FRACTURE OF ULNA
3.00
1.00
Procedure Code Description
RVU
RVU Coeff Value
25530
TREAT FRACTURE OF ULNA
5.22
1.00
25530
TREAT FRACTURE OF ULNA
5.28
1.00
25530
TREAT FRACTURE OF ULNA
5.44
1.00
25535
TREAT FRACTURE OF ULNA
3.00
1.00
25535
TREAT FRACTURE OF ULNA
11.12
1.00
25535
TREAT FRACTURE OF ULNA
11.15
1.00
25535
TREAT FRACTURE OF ULNA
11.68
1.00
25545
TREAT FRACTURE OF ULNA
3.00
1.00
25545
TREAT FRACTURE OF ULNA
16.02
1.00
25545
TREAT FRACTURE OF ULNA
18.02
1.00
25545
TREAT FRACTURE OF ULNA
20.27
1.00
25560
TREAT FRACTURE RADIUS & ULNA
3.00
1.00
25560
TREAT FRACTURE RADIUS & ULNA
5.41
1.00
25560
TREAT FRACTURE RADIUS & ULNA
5.61
1.00
25560
TREAT FRACTURE RADIUS & ULNA
5.66
1.00
25565
TREAT FRACTURE RADIUS & ULNA
3.00
1.00
25565
TREAT FRACTURE RADIUS & ULNA
11.77
1.00
25565
TREAT FRACTURE RADIUS & ULNA
11.86
1.00
25565
TREAT FRACTURE RADIUS & ULNA
12.41
1.00
25574
TREAT FRACTURE RADIUS & ULNA
5.00
1.00
25574
TREAT FRACTURE RADIUS & ULNA
15.29
1.00
25574
TREAT FRACTURE RADIUS & ULNA
16.70
1.00
25574
TREAT FRACTURE RADIUS & ULNA
17.02
1.00
25575
TREAT FRACTURE RADIUS/ULNA
3.00
1.00
25575
TREAT FRACTURE RADIUS/ULNA
21.58
1.00
25575
TREAT FRACTURE RADIUS/ULNA
22.78
1.00
25575
TREAT FRACTURE RADIUS/ULNA
22.89
1.00
25600
TREAT FRACTURE RADIUS/ULNA
3.00
1.00
25600
TREAT FRACTURE RADIUS/ULNA
5.98
1.00
25600
TREAT FRACTURE RADIUS/ULNA
6.08
1.00
25600
TREAT FRACTURE RADIUS/ULNA
6.24
1.00
25605
TREAT FRACTURE RADIUS/ULNA
3.00
1.00
25605
TREAT FRACTURE RADIUS/ULNA
12.79
1.00
25605
TREAT FRACTURE RADIUS/ULNA
12.89
1.00
25605
TREAT FRACTURE RADIUS/ULNA
14.24
1.00
Procedure Code Description
RVU
RVU Coeff Value
25606
TREAT FX DISTAL RADIAL
16.74
1.00
25607
TREAT FX RAD EXTRA-ARTICUL
18.08
1.00
25608
TREAT FX RAD INTRA-ARTICUL
20.72
1.00
25609
TREAT FX RADIAL 3+ FRAG
26.46
1.00
25611
TREAT FRACTURE RADIUS/ULNA
3.00
1.00
25611
TREAT FRACTURE RADIUS/ULNA
17.90
1.00
25611
TREAT FRACTURE RADIUS/ULNA
18.09
1.00
25611
TREAT FRACTURE RADIUS/ULNA
19.22
1.00
25620
TREAT FRACTURE RADIUS/ULNA
4.00
1.00
25620
TREAT FRACTURE RADIUS/ULNA
17.23
1.00
25620
TREAT FRACTURE RADIUS/ULNA
17.24
1.00
25620
TREAT FRACTURE RADIUS/ULNA
19.63
1.00
25622
TREAT WRIST BONE FRACTURE
3.00
1.00
25622
TREAT WRIST BONE FRACTURE
6.02
1.00
25622
TREAT WRIST BONE FRACTURE
6.13
1.00
25622
TREAT WRIST BONE FRACTURE
6.37
1.00
25624
TREAT WRIST BONE FRACTURE
3.00
1.00
25624
TREAT WRIST BONE FRACTURE
10.16
1.00
25624
TREAT WRIST BONE FRACTURE
10.27
1.00
25624
TREAT WRIST BONE FRACTURE
10.63
1.00
25628
TREAT WRIST BONE FRACTURE
3.00
1.00
25628
TREAT WRIST BONE FRACTURE
17.60
1.00
25628
TREAT WRIST BONE FRACTURE
18.16
1.00
25628
TREAT WRIST BONE FRACTURE
19.52
1.00
25630
TREAT WRIST BONE FRACTURE
3.00
1.00
25630
TREAT WRIST BONE FRACTURE
6.27
1.00
25630
TREAT WRIST BONE FRACTURE
6.39
1.00
25630
TREAT WRIST BONE FRACTURE
6.56
1.00
25635
TREAT WRIST BONE FRACTURE
3.00
1.00
25635
TREAT WRIST BONE FRACTURE
8.74
1.00
25635
TREAT WRIST BONE FRACTURE
9.51
1.00
25635
TREAT WRIST BONE FRACTURE
9.53
1.00
25645
TREAT WRIST BONE FRACTURE
3.00
1.00
25645
TREAT WRIST BONE FRACTURE
14.37
1.00
25645
TREAT WRIST BONE FRACTURE
15.15
1.00
Procedure Code Description
RVU
RVU Coeff Value
25645
TREAT WRIST BONE FRACTURE
17.65
1.00
25650
TREAT WRIST BONE FRACTURE
3.00
1.00
25650
TREAT WRIST BONE FRACTURE
6.63
1.00
25650
TREAT WRIST BONE FRACTURE
6.72
1.00
25650
TREAT WRIST BONE FRACTURE
6.96
1.00
25651
PIN ULNAR STYLOID FRACTURE
3.00
1.00
25651
PIN ULNAR STYLOID FRACTURE
11.61
1.00
25651
PIN ULNAR STYLOID FRACTURE
11.77
1.00
25651
PIN ULNAR STYLOID FRACTURE
11.85
1.00
25652
TREAT FRACTURE ULNAR STYLOID
3.00
1.00
25652
TREAT FRACTURE ULNAR STYLOID
15.47
1.00
25652
TREAT FRACTURE ULNAR STYLOID
15.63
1.00
25652
TREAT FRACTURE ULNAR STYLOID
15.67
1.00
25660
TREAT WRIST DISLOCATION
3.00
1.00
25660
TREAT WRIST DISLOCATION
9.85
1.00
25660
TREAT WRIST DISLOCATION
10.12
1.00
25660
TREAT WRIST DISLOCATION
10.84
1.00
25670
TREAT WRIST DISLOCATION
3.00
1.00
25670
TREAT WRIST DISLOCATION
15.50
1.00
25670
TREAT WRIST DISLOCATION
16.28
1.00
25670
TREAT WRIST DISLOCATION
18.72
1.00
25671
PIN RADIOULNAR DISLOCATION
3.00
1.00
25671
PIN RADIOULNAR DISLOCATION
12.83
1.00
25671
PIN RADIOULNAR DISLOCATION
12.95
1.00
25671
PIN RADIOULNAR DISLOCATION
13.06
1.00
25675
TREAT WRIST DISLOCATION
3.00
1.00
25675
TREAT WRIST DISLOCATION
9.62
1.00
25675
TREAT WRIST DISLOCATION
9.96
1.00
25675
TREAT WRIST DISLOCATION
10.67
1.00
25676
TREAT WRIST DISLOCATION
3.00
1.00
25676
TREAT WRIST DISLOCATION
16.06
1.00
25676
TREAT WRIST DISLOCATION
16.68
1.00
25676
TREAT WRIST DISLOCATION
18.92
1.00
25680
TREAT WRIST FRACTURE
3.00
1.00
25680
TREAT WRIST FRACTURE
11.41
1.00
Procedure Code Description
RVU
RVU Coeff Value
25680
TREAT WRIST FRACTURE
11.47
1.00
25680
TREAT WRIST FRACTURE
13.08
1.00
25685
TREAT WRIST FRACTURE
3.00
1.00
25685
TREAT WRIST FRACTURE
18.69
1.00
25685
TREAT WRIST FRACTURE
19.15
1.00
25685
TREAT WRIST FRACTURE
21.47
1.00
25690
TREAT WRIST DISLOCATION
3.00
1.00
25690
TREAT WRIST DISLOCATION
11.57
1.00
25690
TREAT WRIST DISLOCATION
11.82
1.00
25690
TREAT WRIST DISLOCATION
13.49
1.00
25695
TREAT WRIST DISLOCATION
3.00
1.00
25695
TREAT WRIST DISLOCATION
16.10
1.00
25695
TREAT WRIST DISLOCATION
16.81
1.00
25695
TREAT WRIST DISLOCATION
19.27
1.00
25800
FUSION OF WRIST JOINT
3.00
1.00
25800
FUSION OF WRIST JOINT
19.05
1.00
25800
FUSION OF WRIST JOINT
20.42
1.00
25800
FUSION OF WRIST JOINT
21.98
1.00
25805
FUSION/GRAFT OF WRIST JOINT
3.00
1.00
25805
FUSION/GRAFT OF WRIST JOINT
21.96
1.00
25805
FUSION/GRAFT OF WRIST JOINT
23.32
1.00
25805
FUSION/GRAFT OF WRIST JOINT
24.60
1.00
25810
FUSION/GRAFT OF WRIST JOINT
3.00
1.00
25810
FUSION/GRAFT OF WRIST JOINT
22.08
1.00
25810
FUSION/GRAFT OF WRIST JOINT
22.12
1.00
25810
FUSION/GRAFT OF WRIST JOINT
23.28
1.00
25820
FUSION OF HAND BONES
3.00
1.00
25820
FUSION OF HAND BONES
15.56
1.00
25820
FUSION OF HAND BONES
16.48
1.00
25820
FUSION OF HAND BONES
18.09
1.00
25825
FUSE HAND BONES WITH GRAFT
3.00
1.00
25825
FUSE HAND BONES WITH GRAFT
19.14
1.00
25825
FUSE HAND BONES WITH GRAFT
19.93
1.00
25825
FUSE HAND BONES WITH GRAFT
21.13
1.00
25830
FUSION, RADIOULNAR JNT/ULNA
3.00
1.00
Procedure Code Description
RVU
RVU Coeff Value
25830
FUSION, RADIOULNAR JNT/ULNA
23.87
1.00
25830
FUSION, RADIOULNAR JNT/ULNA
26.26
1.00
25830
FUSION, RADIOULNAR JNT/ULNA
28.45
1.00
25900
AMPUTATION OF FOREARM
4.00
1.00
25900
AMPUTATION OF FOREARM
19.04
1.00
25900
AMPUTATION OF FOREARM
23.19
1.00
25900
AMPUTATION OF FOREARM
24.57
1.00
25905
AMPUTATION OF FOREARM
3.00
1.00
25905
AMPUTATION OF FOREARM
18.86
1.00
25905
AMPUTATION OF FOREARM
23.21
1.00
25905
AMPUTATION OF FOREARM
25.93
1.00
25907
AMPUTATION FOLLOW-UP SURGERY
3.00
1.00
25907
AMPUTATION FOLLOW-UP SURGERY
16.43
1.00
25907
AMPUTATION FOLLOW-UP SURGERY
21.22
1.00
25907
AMPUTATION FOLLOW-UP SURGERY
24.00
1.00
25909
AMPUTATION FOLLOW-UP SURGERY
3.00
1.00
25909
AMPUTATION FOLLOW-UP SURGERY
18.57
1.00
25909
AMPUTATION FOLLOW-UP SURGERY
23.00
1.00
25909
AMPUTATION FOLLOW-UP SURGERY
25.65
1.00
25915
AMPUTATION OF FOREARM
5.00
1.00
25915
AMPUTATION OF FOREARM
32.62
1.00
25915
AMPUTATION OF FOREARM
39.47
1.00
25915
AMPUTATION OF FOREARM
42.63
1.00
25920
AMPUTATE HAND AT WRIST
3.00
1.00
25920
AMPUTATE HAND AT WRIST
17.45
1.00
25920
AMPUTATE HAND AT WRIST
17.95
1.00
25920
AMPUTATE HAND AT WRIST
19.65
1.00
25922
AMPUTATE HAND AT WRIST
3.00
1.00
25922
AMPUTATE HAND AT WRIST
14.74
1.00
25922
AMPUTATE HAND AT WRIST
15.78
1.00
25922
AMPUTATE HAND AT WRIST
17.41
1.00
25924
AMPUTATION FOLLOW-UP SURGERY
3.00
1.00
25924
AMPUTATION FOLLOW-UP SURGERY
17.04
1.00
25924
AMPUTATION FOLLOW-UP SURGERY
17.96
1.00
25924
AMPUTATION FOLLOW-UP SURGERY
19.78
1.00
Procedure Code Description
RVU
RVU Coeff Value
25927
AMPUTATION OF HAND
5.00
1.00
25927
AMPUTATION OF HAND
19.74
1.00
25927
AMPUTATION OF HAND
22.17
1.00
25927
AMPUTATION OF HAND
24.00
1.00
25929
AMPUTATION FOLLOW-UP SURGERY
3.00
1.00
25929
AMPUTATION FOLLOW-UP SURGERY
14.27
1.00
25929
AMPUTATION FOLLOW-UP SURGERY
14.71
1.00
25929
AMPUTATION FOLLOW-UP SURGERY
16.31
1.00
25931
AMPUTATION FOLLOW-UP SURGERY
3.00
1.00
25931
AMPUTATION FOLLOW-UP SURGERY
17.99
1.00
25931
AMPUTATION FOLLOW-UP SURGERY
20.92
1.00
25931
AMPUTATION FOLLOW-UP SURGERY
23.78
1.00
26010
DRAINAGE OF FINGER ABSCESS
3.00
1.00
26010
DRAINAGE OF FINGER ABSCESS
3.29
1.00
26010
DRAINAGE OF FINGER ABSCESS
3.37
1.00
26010
DRAINAGE OF FINGER ABSCESS
3.46
1.00
26011
DRAINAGE OF FINGER ABSCESS
3.00
1.00
26011
DRAINAGE OF FINGER ABSCESS
4.62
1.00
26011
DRAINAGE OF FINGER ABSCESS
4.80
1.00
26011
DRAINAGE OF FINGER ABSCESS
4.92
1.00
26020
DRAIN HAND TENDON SHEATH
3.00
1.00
26020
DRAIN HAND TENDON SHEATH
10.57
1.00
26020
DRAIN HAND TENDON SHEATH
10.65
1.00
26020
DRAIN HAND TENDON SHEATH
10.94
1.00
26025
DRAINAGE OF PALM BURSA
3.00
1.00
26025
DRAINAGE OF PALM BURSA
10.42
1.00
26025
DRAINAGE OF PALM BURSA
10.60
1.00
26025
DRAINAGE OF PALM BURSA
10.89
1.00
26030
DRAINAGE OF PALM BURSA(S)
4.00
1.00
26030
DRAINAGE OF PALM BURSA(S)
12.32
1.00
26030
DRAINAGE OF PALM BURSA(S)
12.50
1.00
26030
DRAINAGE OF PALM BURSA(S)
12.79
1.00
26034
TREAT HAND BONE LESION
3.00
1.00
26034
TREAT HAND BONE LESION
13.06
1.00
26034
TREAT HAND BONE LESION
13.36
1.00
Procedure Code Description 26034
TREAT HAND BONE LESION
26035
RVU
RVU Coeff Value
13.44
1.00
DECOMPRESS FINGERS/HAND
3.00
1.00
26035
DECOMPRESS FINGERS/HAND
18.62
1.00
26035
DECOMPRESS FINGERS/HAND
18.95
1.00
26035
DECOMPRESS FINGERS/HAND
20.77
1.00
26037
DECOMPRESS FINGERS/HAND
3.00
1.00
26037
DECOMPRESS FINGERS/HAND
14.40
1.00
26037
DECOMPRESS FINGERS/HAND
14.60
1.00
26037
DECOMPRESS FINGERS/HAND
14.89
1.00
26040
RELEASE PALM CONTRACTURE
3.00
1.00
26040
RELEASE PALM CONTRACTURE
7.53
1.00
26040
RELEASE PALM CONTRACTURE
7.64
1.00
26040
RELEASE PALM CONTRACTURE
7.86
1.00
26045
RELEASE PALM CONTRACTURE
3.00
1.00
26045
RELEASE PALM CONTRACTURE
11.60
1.00
26045
RELEASE PALM CONTRACTURE
11.69
1.00
26045
RELEASE PALM CONTRACTURE
12.00
1.00
26055
INCISE FINGER TENDON SHEATH
3.00
1.00
26055
INCISE FINGER TENDON SHEATH
6.64
1.00
26055
INCISE FINGER TENDON SHEATH
6.97
1.00
26055
INCISE FINGER TENDON SHEATH
7.30
1.00
26060
INCISION OF FINGER TENDON
3.00
1.00
26060
INCISION OF FINGER TENDON
6.44
1.00
26060
INCISION OF FINGER TENDON
6.54
1.00
26060
INCISION OF FINGER TENDON
6.68
1.00
26070
EXPLORE/TREAT HAND JOINT
3.00
1.00
26070
EXPLORE/TREAT HAND JOINT
7.36
1.00
26070
EXPLORE/TREAT HAND JOINT
7.43
1.00
26070
EXPLORE/TREAT HAND JOINT
7.46
1.00
26075
EXPLORE/TREAT FINGER JOINT
3.00
1.00
26075
EXPLORE/TREAT FINGER JOINT
7.86
1.00
26075
EXPLORE/TREAT FINGER JOINT
7.88
1.00
26075
EXPLORE/TREAT FINGER JOINT
8.02
1.00
26080
EXPLORE/TREAT FINGER JOINT
3.00
1.00
26080
EXPLORE/TREAT FINGER JOINT
9.34
1.00
Procedure Code Description
RVU
RVU Coeff Value
26080
EXPLORE/TREAT FINGER JOINT
9.52
1.00
26080
EXPLORE/TREAT FINGER JOINT
9.64
1.00
26100
BIOPSY HAND JOINT LINING
3.00
1.00
26100
BIOPSY HAND JOINT LINING
7.99
1.00
26100
BIOPSY HAND JOINT LINING
8.02
1.00
26100
BIOPSY HAND JOINT LINING
8.30
1.00
26105
BIOPSY FINGER JOINT LINING
3.00
1.00
26105
BIOPSY FINGER JOINT LINING
8.09
1.00
26105
BIOPSY FINGER JOINT LINING
8.19
1.00
26105
BIOPSY FINGER JOINT LINING
8.41
1.00
26110
BIOPSY FINGER JOINT LINING
3.00
1.00
26110
BIOPSY FINGER JOINT LINING
7.77
1.00
26110
BIOPSY FINGER JOINT LINING
7.85
1.00
26110
BIOPSY FINGER JOINT LINING
8.03
1.00
26115
REMOVAL HAND LESION SUBCUT
3.00
1.00
26115
REMOVAL HAND LESION SUBCUT
8.77
1.00
26115
REMOVAL HAND LESION SUBCUT
8.90
1.00
26115
REMOVAL HAND LESION SUBCUT
9.10
1.00
26116
REMOVAL HAND LESION, DEEP
3.00
1.00
26116
REMOVAL HAND LESION, DEEP
11.88
1.00
26116
REMOVAL HAND LESION, DEEP
11.99
1.00
26116
REMOVAL HAND LESION, DEEP
12.27
1.00
26117
REMOVE TUMOR, HAND/FINGER
3.00
1.00
26117
REMOVE TUMOR, HAND/FINGER
16.40
1.00
26117
REMOVE TUMOR, HAND/FINGER
16.50
1.00
26117
REMOVE TUMOR, HAND/FINGER
16.79
1.00
26121
RELEASE PALM CONTRACTURE
3.00
1.00
26121
RELEASE PALM CONTRACTURE
15.08
1.00
26121
RELEASE PALM CONTRACTURE
15.20
1.00
26121
RELEASE PALM CONTRACTURE
15.56
1.00
26123
RELEASE PALM CONTRACTURE
3.00
1.00
26123
RELEASE PALM CONTRACTURE
19.11
1.00
26123
RELEASE PALM CONTRACTURE
19.43
1.00
26123
RELEASE PALM CONTRACTURE
20.58
1.00
26125
RELEASE PALM CONTRACTURE
7.42
1.00
Procedure Code Description
RVU
RVU Coeff Value
26125
RELEASE PALM CONTRACTURE
7.69
1.00
26125
RELEASE PALM CONTRACTURE
7.75
1.00
26130
REMOVE WRIST JOINT LINING
3.00
1.00
26130
REMOVE WRIST JOINT LINING
11.19
1.00
26130
REMOVE WRIST JOINT LINING
11.44
1.00
26130
REMOVE WRIST JOINT LINING
11.49
1.00
26135
REVISE FINGER JOINT, EACH
3.00
1.00
26135
REVISE FINGER JOINT, EACH
13.90
1.00
26135
REVISE FINGER JOINT, EACH
14.03
1.00
26135
REVISE FINGER JOINT, EACH
14.39
1.00
26140
REVISE FINGER JOINT, EACH
3.00
1.00
26140
REVISE FINGER JOINT, EACH
12.62
1.00
26140
REVISE FINGER JOINT, EACH
12.68
1.00
26140
REVISE FINGER JOINT, EACH
13.05
1.00
26145
TENDON EXCISION, PALM/FINGER
3.00
1.00
26145
TENDON EXCISION, PALM/FINGER
12.84
1.00
26145
TENDON EXCISION, PALM/FINGER
12.87
1.00
26145
TENDON EXCISION, PALM/FINGER
13.22
1.00
26160
REMOVE TENDON SHEATH LESION
3.00
1.00
26160
REMOVE TENDON SHEATH LESION
7.40
1.00
26160
REMOVE TENDON SHEATH LESION
7.66
1.00
26160
REMOVE TENDON SHEATH LESION
7.96
1.00
26170
REMOVAL OF PALM TENDON, EACH
3.00
1.00
26170
REMOVAL OF PALM TENDON, EACH
10.07
1.00
26170
REMOVAL OF PALM TENDON, EACH
10.09
1.00
26170
REMOVAL OF PALM TENDON, EACH
10.36
1.00
26180
REMOVAL OF FINGER TENDON
3.00
1.00
26180
REMOVAL OF FINGER TENDON
10.92
1.00
26180
REMOVAL OF FINGER TENDON
11.02
1.00
26180
REMOVAL OF FINGER TENDON
11.29
1.00
26185
REMOVE FINGER BONE
3.00
1.00
26185
REMOVE FINGER BONE
11.54
1.00
26185
REMOVE FINGER BONE
11.96
1.00
26185
REMOVE FINGER BONE
13.13
1.00
26200
REMOVE HAND BONE LESION
3.00
1.00
Procedure Code Description
RVU
RVU Coeff Value
26200
REMOVE HAND BONE LESION
11.34
1.00
26200
REMOVE HAND BONE LESION
11.36
1.00
26200
REMOVE HAND BONE LESION
11.65
1.00
26205
REMOVE/GRAFT BONE LESION
3.00
1.00
26205
REMOVE/GRAFT BONE LESION
15.24
1.00
26205
REMOVE/GRAFT BONE LESION
15.34
1.00
26205
REMOVE/GRAFT BONE LESION
15.68
1.00
26210
REMOVAL OF FINGER LESION
3.00
1.00
26210
REMOVAL OF FINGER LESION
10.91
1.00
26210
REMOVAL OF FINGER LESION
10.97
1.00
26210
REMOVAL OF FINGER LESION
11.27
1.00
26215
REMOVE/GRAFT FINGER LESION
3.00
1.00
26215
REMOVE/GRAFT FINGER LESION
13.93
1.00
26215
REMOVE/GRAFT FINGER LESION
13.94
1.00
26215
REMOVE/GRAFT FINGER LESION
14.28
1.00
26230
PARTIAL REMOVAL OF HAND BONE
3.00
1.00
26230
PARTIAL REMOVAL OF HAND BONE
12.70
1.00
26230
PARTIAL REMOVAL OF HAND BONE
12.85
1.00
26230
PARTIAL REMOVAL OF HAND BONE
13.18
1.00
26235
PARTIAL REMOVAL, FINGER BONE
3.00
1.00
26235
PARTIAL REMOVAL, FINGER BONE
12.46
1.00
26235
PARTIAL REMOVAL, FINGER BONE
12.59
1.00
26235
PARTIAL REMOVAL, FINGER BONE
12.87
1.00
26236
PARTIAL REMOVAL, FINGER BONE
3.00
1.00
26236
PARTIAL REMOVAL, FINGER BONE
11.03
1.00
26236
PARTIAL REMOVAL, FINGER BONE
11.15
1.00
26236
PARTIAL REMOVAL, FINGER BONE
11.39
1.00
26250
EXTENSIVE HAND SURGERY
3.00
1.00
26250
EXTENSIVE HAND SURGERY
14.70
1.00
26250
EXTENSIVE HAND SURGERY
15.03
1.00
26255
EXTENSIVE HAND SURGERY
3.00
1.00
26255
EXTENSIVE HAND SURGERY
22.38
1.00
26255
EXTENSIVE HAND SURGERY
22.74
1.00
26255
EXTENSIVE HAND SURGERY
23.03
1.00
26260
EXTENSIVE FINGER SURGERY
3.00
1.00
Procedure Code Description
RVU
RVU Coeff Value
26260
EXTENSIVE FINGER SURGERY
13.77
1.00
26260
EXTENSIVE FINGER SURGERY
13.84
1.00
26260
EXTENSIVE FINGER SURGERY
14.16
1.00
26261
EXTENSIVE FINGER SURGERY
3.00
1.00
26261
EXTENSIVE FINGER SURGERY
16.15
1.00
26261
EXTENSIVE FINGER SURGERY
16.32
1.00
26261
EXTENSIVE FINGER SURGERY
17.02
1.00
26262
PARTIAL REMOVAL OF FINGER
3.00
1.00
26262
PARTIAL REMOVAL OF FINGER
11.51
1.00
26262
PARTIAL REMOVAL OF FINGER
11.55
1.00
26262
PARTIAL REMOVAL OF FINGER
11.79
1.00
26320
REMOVAL OF IMPLANT FROM HAND
3.00
1.00
26320
REMOVAL OF IMPLANT FROM HAND
8.57
1.00
26320
REMOVAL OF IMPLANT FROM HAND
8.81
1.00
26320
REMOVAL OF IMPLANT FROM HAND
8.97
1.00
26340
MANIPULATE FINGER W/ANESTH
3.00
1.00
26340
MANIPULATE FINGER W/ANESTH
7.44
1.00
26340
MANIPULATE FINGER W/ANESTH
7.60
1.00
26340
MANIPULATE FINGER W/ANESTH
7.66
1.00
26350
REPAIR FINGER/HAND TENDON
3.00
1.00
26350
REPAIR FINGER/HAND TENDON
17.76
1.00
26350
REPAIR FINGER/HAND TENDON
22.35
1.00
26350
REPAIR FINGER/HAND TENDON
26.75
1.00
26352
REPAIR/GRAFT HAND TENDON
3.00
1.00
26352
REPAIR/GRAFT HAND TENDON
20.21
1.00
26352
REPAIR/GRAFT HAND TENDON
24.87
1.00
26352
REPAIR/GRAFT HAND TENDON
29.11
1.00
26356
REPAIR FINGER/HAND TENDON
3.00
1.00
26356
REPAIR FINGER/HAND TENDON
26.32
1.00
26356
REPAIR FINGER/HAND TENDON
28.16
1.00
26356
REPAIR FINGER/HAND TENDON
30.55
1.00
26357
REPAIR FINGER/HAND TENDON
3.00
1.00
26357
REPAIR FINGER/HAND TENDON
21.74
1.00
26357
REPAIR FINGER/HAND TENDON
26.33
1.00
26357
REPAIR FINGER/HAND TENDON
30.79
1.00
Procedure Code Description
RVU
RVU Coeff Value
26358
REPAIR/GRAFT HAND TENDON
3.00
1.00
26358
REPAIR/GRAFT HAND TENDON
22.98
1.00
26358
REPAIR/GRAFT HAND TENDON
27.85
1.00
26358
REPAIR/GRAFT HAND TENDON
31.95
1.00
26370
REPAIR FINGER/HAND TENDON
3.00
1.00
26370
REPAIR FINGER/HAND TENDON
19.26
1.00
26370
REPAIR FINGER/HAND TENDON
24.14
1.00
26370
REPAIR FINGER/HAND TENDON
28.68
1.00
26372
REPAIR/GRAFT HAND TENDON
3.00
1.00
26372
REPAIR/GRAFT HAND TENDON
22.36
1.00
26372
REPAIR/GRAFT HAND TENDON
27.35
1.00
26372
REPAIR/GRAFT HAND TENDON
31.82
1.00
26373
REPAIR FINGER/HAND TENDON
3.00
1.00
26373
REPAIR FINGER/HAND TENDON
21.22
1.00
26373
REPAIR FINGER/HAND TENDON
26.20
1.00
26373
REPAIR FINGER/HAND TENDON
30.70
1.00
26390
REVISE HAND/FINGER TENDON
3.00
1.00
26390
REVISE HAND/FINGER TENDON
20.88
1.00
26390
REVISE HAND/FINGER TENDON
24.41
1.00
26390
REVISE HAND/FINGER TENDON
27.03
1.00
26392
REPAIR/GRAFT HAND TENDON
3.00
1.00
26392
REPAIR/GRAFT HAND TENDON
24.40
1.00
26392
REPAIR/GRAFT HAND TENDON
29.42
1.00
26392
REPAIR/GRAFT HAND TENDON
34.07
1.00
26410
REPAIR HAND TENDON
3.00
1.00
26410
REPAIR HAND TENDON
14.12
1.00
26410
REPAIR HAND TENDON
17.90
1.00
26410
REPAIR HAND TENDON
21.50
1.00
26412
REPAIR/GRAFT HAND TENDON
3.00
1.00
26412
REPAIR/GRAFT HAND TENDON
17.17
1.00
26412
REPAIR/GRAFT HAND TENDON
21.18
1.00
26412
REPAIR/GRAFT HAND TENDON
24.50
1.00
26415
EXCISION, HAND/FINGER TENDON
3.00
1.00
26415
EXCISION, HAND/FINGER TENDON
18.03
1.00
26415
EXCISION, HAND/FINGER TENDON
21.54
1.00
Procedure Code Description
RVU
RVU Coeff Value
26415
EXCISION, HAND/FINGER TENDON
25.01
1.00
26416
GRAFT HAND OR FINGER TENDON
3.00
1.00
26416
GRAFT HAND OR FINGER TENDON
19.22
1.00
26416
GRAFT HAND OR FINGER TENDON
26.02
1.00
26416
GRAFT HAND OR FINGER TENDON
29.13
1.00
26418
REPAIR FINGER TENDON
3.00
1.00
26418
REPAIR FINGER TENDON
14.16
1.00
26418
REPAIR FINGER TENDON
17.79
1.00
26418
REPAIR FINGER TENDON
20.88
1.00
26420
REPAIR/GRAFT FINGER TENDON
3.00
1.00
26420
REPAIR/GRAFT FINGER TENDON
17.86
1.00
26420
REPAIR/GRAFT FINGER TENDON
22.02
1.00
26420
REPAIR/GRAFT FINGER TENDON
25.29
1.00
26426
REPAIR FINGER/HAND TENDON
3.00
1.00
26426
REPAIR FINGER/HAND TENDON
14.40
1.00
26426
REPAIR FINGER/HAND TENDON
20.85
1.00
26426
REPAIR FINGER/HAND TENDON
24.08
1.00
26428
REPAIR/GRAFT FINGER TENDON
3.00
1.00
26428
REPAIR/GRAFT FINGER TENDON
18.76
1.00
26428
REPAIR/GRAFT FINGER TENDON
22.79
1.00
26428
REPAIR/GRAFT FINGER TENDON
26.29
1.00
26432
REPAIR FINGER TENDON
3.00
1.00
26432
REPAIR FINGER TENDON
12.35
1.00
26432
REPAIR FINGER TENDON
15.28
1.00
26432
REPAIR FINGER TENDON
17.86
1.00
26433
REPAIR FINGER TENDON
3.00
1.00
26433
REPAIR FINGER TENDON
13.26
1.00
26433
REPAIR FINGER TENDON
16.60
1.00
26433
REPAIR FINGER TENDON
19.39
1.00
26434
REPAIR/GRAFT FINGER TENDON
3.00
1.00
26434
REPAIR/GRAFT FINGER TENDON
15.93
1.00
26434
REPAIR/GRAFT FINGER TENDON
19.00
1.00
26434
REPAIR/GRAFT FINGER TENDON
21.47
1.00
26437
REALIGNMENT OF TENDONS
3.00
1.00
26437
REALIGNMENT OF TENDONS
15.52
1.00
Procedure Code Description
RVU
RVU Coeff Value
26437
REALIGNMENT OF TENDONS
18.68
1.00
26437
REALIGNMENT OF TENDONS
20.96
1.00
26440
RELEASE PALM/FINGER TENDON
3.00
1.00
26440
RELEASE PALM/FINGER TENDON
15.55
1.00
26440
RELEASE PALM/FINGER TENDON
19.94
1.00
26440
RELEASE PALM/FINGER TENDON
24.51
1.00
26442
RELEASE PALM & FINGER TENDON
3.00
1.00
26442
RELEASE PALM & FINGER TENDON
23.56
1.00
26442
RELEASE PALM & FINGER TENDON
25.89
1.00
26442
RELEASE PALM & FINGER TENDON
29.41
1.00
26445
RELEASE HAND/FINGER TENDON
3.00
1.00
26445
RELEASE HAND/FINGER TENDON
14.42
1.00
26445
RELEASE HAND/FINGER TENDON
18.88
1.00
26445
RELEASE HAND/FINGER TENDON
23.56
1.00
26449
RELEASE FOREARM/HAND TENDON
3.00
1.00
26449
RELEASE FOREARM/HAND TENDON
18.94
1.00
26449
RELEASE FOREARM/HAND TENDON
24.39
1.00
26449
RELEASE FOREARM/HAND TENDON
27.86
1.00
26450
INCISION OF PALM TENDON
3.00
1.00
26450
INCISION OF PALM TENDON
10.02
1.00
26450
INCISION OF PALM TENDON
11.79
1.00
26450
INCISION OF PALM TENDON
12.70
1.00
26455
INCISION OF FINGER TENDON
3.00
1.00
26455
INCISION OF FINGER TENDON
9.95
1.00
26455
INCISION OF FINGER TENDON
11.70
1.00
26455
INCISION OF FINGER TENDON
12.56
1.00
26460
INCISE HAND/FINGER TENDON
3.00
1.00
26460
INCISE HAND/FINGER TENDON
9.67
1.00
26460
INCISE HAND/FINGER TENDON
11.30
1.00
26460
INCISE HAND/FINGER TENDON
12.10
1.00
26471
FUSION OF FINGER TENDONS
3.00
1.00
26471
FUSION OF FINGER TENDONS
15.29
1.00
26471
FUSION OF FINGER TENDONS
18.25
1.00
26471
FUSION OF FINGER TENDONS
20.52
1.00
26474
FUSION OF FINGER TENDONS
3.00
1.00
Procedure Code Description
RVU
RVU Coeff Value
26474
FUSION OF FINGER TENDONS
14.64
1.00
26474
FUSION OF FINGER TENDONS
17.98
1.00
26474
FUSION OF FINGER TENDONS
20.32
1.00
26476
TENDON LENGTHENING
3.00
1.00
26476
TENDON LENGTHENING
14.27
1.00
26476
TENDON LENGTHENING
17.29
1.00
26476
TENDON LENGTHENING
19.60
1.00
26477
TENDON SHORTENING
3.00
1.00
26477
TENDON SHORTENING
14.40
1.00
26477
TENDON SHORTENING
17.40
1.00
26477
TENDON SHORTENING
19.76
1.00
26478
LENGTHENING OF HAND TENDON
3.00
1.00
26478
LENGTHENING OF HAND TENDON
15.64
1.00
26478
LENGTHENING OF HAND TENDON
18.96
1.00
26478
LENGTHENING OF HAND TENDON
21.22
1.00
26479
SHORTENING OF HAND TENDON
3.00
1.00
26479
SHORTENING OF HAND TENDON
15.48
1.00
26479
SHORTENING OF HAND TENDON
18.73
1.00
26479
SHORTENING OF HAND TENDON
21.15
1.00
26480
TRANSPLANT HAND TENDON
3.00
1.00
26480
TRANSPLANT HAND TENDON
18.80
1.00
26480
TRANSPLANT HAND TENDON
23.37
1.00
26480
TRANSPLANT HAND TENDON
27.47
1.00
26483
TRANSPLANT/GRAFT HAND TENDON
3.00
1.00
26483
TRANSPLANT/GRAFT HAND TENDON
21.26
1.00
26483
TRANSPLANT/GRAFT HAND TENDON
25.64
1.00
26483
TRANSPLANT/GRAFT HAND TENDON
29.75
1.00
26485
TRANSPLANT PALM TENDON
3.00
1.00
26485
TRANSPLANT PALM TENDON
20.35
1.00
26485
TRANSPLANT PALM TENDON
24.83
1.00
26485
TRANSPLANT PALM TENDON
28.98
1.00
26489
TRANSPLANT/GRAFT PALM TENDON
3.00
1.00
26489
TRANSPLANT/GRAFT PALM TENDON
22.00
1.00
26489
TRANSPLANT/GRAFT PALM TENDON
23.26
1.00
26489
TRANSPLANT/GRAFT PALM TENDON
27.57
1.00
Procedure Code Description
RVU
RVU Coeff Value
26490
REVISE THUMB TENDON
3.00
1.00
26490
REVISE THUMB TENDON
19.69
1.00
26490
REVISE THUMB TENDON
22.83
1.00
26490
REVISE THUMB TENDON
25.00
1.00
26492
TENDON TRANSFER WITH GRAFT
3.00
1.00
26492
TENDON TRANSFER WITH GRAFT
21.96
1.00
26492
TENDON TRANSFER WITH GRAFT
25.02
1.00
26492
TENDON TRANSFER WITH GRAFT
26.96
1.00
26494
HAND TENDON/MUSCLE TRANSFER
3.00
1.00
26494
HAND TENDON/MUSCLE TRANSFER
19.95
1.00
26494
HAND TENDON/MUSCLE TRANSFER
23.43
1.00
26494
HAND TENDON/MUSCLE TRANSFER
25.74
1.00
26496
REVISE THUMB TENDON
3.00
1.00
26496
REVISE THUMB TENDON
21.66
1.00
26496
REVISE THUMB TENDON
24.60
1.00
26496
REVISE THUMB TENDON
26.63
1.00
26497
FINGER TENDON TRANSFER
3.00
1.00
26497
FINGER TENDON TRANSFER
21.66
1.00
26497
FINGER TENDON TRANSFER
24.93
1.00
26497
FINGER TENDON TRANSFER
27.06
1.00
26498
FINGER TENDON TRANSFER
3.00
1.00
26498
FINGER TENDON TRANSFER
29.01
1.00
26498
FINGER TENDON TRANSFER
32.63
1.00
26498
FINGER TENDON TRANSFER
34.45
1.00
26499
REVISION OF FINGER
3.00
1.00
26499
REVISION OF FINGER
20.70
1.00
26499
REVISION OF FINGER
23.60
1.00
26499
REVISION OF FINGER
26.94
1.00
26500
HAND TENDON RECONSTRUCTION
5.00
1.00
26500
HAND TENDON RECONSTRUCTION
15.61
1.00
26500
HAND TENDON RECONSTRUCTION
18.87
1.00
26500
HAND TENDON RECONSTRUCTION
21.60
1.00
26502
HAND TENDON RECONSTRUCTION
3.00
1.00
26502
HAND TENDON RECONSTRUCTION
17.66
1.00
26502
HAND TENDON RECONSTRUCTION
20.76
1.00
Procedure Code Description
RVU
RVU Coeff Value
26502
HAND TENDON RECONSTRUCTION
23.28
1.00
26504
HAND TENDON RECONSTRUCTION
3.00
1.00
26504
HAND TENDON RECONSTRUCTION
21.32
1.00
26504
HAND TENDON RECONSTRUCTION
21.48
1.00
26504
HAND TENDON RECONSTRUCTION
23.39
1.00
26508
RELEASE THUMB CONTRACTURE
3.00
1.00
26508
RELEASE THUMB CONTRACTURE
15.72
1.00
26508
RELEASE THUMB CONTRACTURE
19.03
1.00
26508
RELEASE THUMB CONTRACTURE
21.36
1.00
26510
THUMB TENDON TRANSFER
3.00
1.00
26510
THUMB TENDON TRANSFER
14.86
1.00
26510
THUMB TENDON TRANSFER
18.07
1.00
26510
THUMB TENDON TRANSFER
20.44
1.00
26516
FUSION OF KNUCKLE JOINT
3.00
1.00
26516
FUSION OF KNUCKLE JOINT
17.60
1.00
26516
FUSION OF KNUCKLE JOINT
20.88
1.00
26516
FUSION OF KNUCKLE JOINT
23.12
1.00
26517
FUSION OF KNUCKLE JOINTS
3.00
1.00
26517
FUSION OF KNUCKLE JOINTS
20.76
1.00
26517
FUSION OF KNUCKLE JOINTS
23.94
1.00
26517
FUSION OF KNUCKLE JOINTS
26.20
1.00
26518
FUSION OF KNUCKLE JOINTS
3.00
1.00
26518
FUSION OF KNUCKLE JOINTS
20.93
1.00
26518
FUSION OF KNUCKLE JOINTS
24.14
1.00
26518
FUSION OF KNUCKLE JOINTS
26.27
1.00
26520
RELEASE KNUCKLE CONTRACTURE
3.00
1.00
26520
RELEASE KNUCKLE CONTRACTURE
16.26
1.00
26520
RELEASE KNUCKLE CONTRACTURE
20.70
1.00
26520
RELEASE KNUCKLE CONTRACTURE
24.80
1.00
26525
RELEASE FINGER CONTRACTURE
3.00
1.00
26525
RELEASE FINGER CONTRACTURE
16.33
1.00
26525
RELEASE FINGER CONTRACTURE
20.86
1.00
26525
RELEASE FINGER CONTRACTURE
25.01
1.00
26530
REVISE KNUCKLE JOINT
3.00
1.00
26530
REVISE KNUCKLE JOINT
13.48
1.00
Procedure Code Description
RVU
RVU Coeff Value
26530
REVISE KNUCKLE JOINT
13.59
1.00
26530
REVISE KNUCKLE JOINT
13.74
1.00
26531
REVISE KNUCKLE WITH IMPLANT
3.00
1.00
26531
REVISE KNUCKLE WITH IMPLANT
15.68
1.00
26531
REVISE KNUCKLE WITH IMPLANT
15.87
1.00
26531
REVISE KNUCKLE WITH IMPLANT
16.11
1.00
26535
REVISE FINGER JOINT
3.00
1.00
26535
REVISE FINGER JOINT
9.59
1.00
26535
REVISE FINGER JOINT
9.72
1.00
26535
REVISE FINGER JOINT
10.08
1.00
26536
REVISE/IMPLANT FINGER JOINT
3.00
1.00
26536
REVISE/IMPLANT FINGER JOINT
16.75
1.00
26536
REVISE/IMPLANT FINGER JOINT
17.06
1.00
26536
REVISE/IMPLANT FINGER JOINT
17.49
1.00
26540
REPAIR HAND JOINT
3.00
1.00
26540
REPAIR HAND JOINT
16.51
1.00
26540
REPAIR HAND JOINT
19.75
1.00
26540
REPAIR HAND JOINT
22.13
1.00
26541
REPAIR HAND JOINT WITH GRAFT
3.00
1.00
26541
REPAIR HAND JOINT WITH GRAFT
20.20
1.00
26541
REPAIR HAND JOINT WITH GRAFT
23.79
1.00
26541
REPAIR HAND JOINT WITH GRAFT
25.99
1.00
26542
REPAIR HAND JOINT WITH GRAFT
3.00
1.00
26542
REPAIR HAND JOINT WITH GRAFT
17.07
1.00
26542
REPAIR HAND JOINT WITH GRAFT
20.21
1.00
26542
REPAIR HAND JOINT WITH GRAFT
22.43
1.00
26545
RECONSTRUCT FINGER JOINT
3.00
1.00
26545
RECONSTRUCT FINGER JOINT
17.38
1.00
26545
RECONSTRUCT FINGER JOINT
20.65
1.00
26545
RECONSTRUCT FINGER JOINT
23.23
1.00
26546
REPAIR NONUNION HAND
3.00
1.00
26546
REPAIR NONUNION HAND
24.39
1.00
26546
REPAIR NONUNION HAND
25.48
1.00
26546
REPAIR NONUNION HAND
26.21
1.00
26548
RECONSTRUCT FINGER JOINT
3.00
1.00
Procedure Code Description
RVU
RVU Coeff Value
26548
RECONSTRUCT FINGER JOINT
19.15
1.00
26548
RECONSTRUCT FINGER JOINT
22.59
1.00
26548
RECONSTRUCT FINGER JOINT
25.03
1.00
26550
CONSTRUCT THUMB REPLACEMENT
3.00
1.00
26550
CONSTRUCT THUMB REPLACEMENT
37.71
1.00
26550
CONSTRUCT THUMB REPLACEMENT
41.54
1.00
26550
CONSTRUCT THUMB REPLACEMENT
46.51
1.00
26551
GREAT TOE-HAND TRANSFER
3.00
1.00
26551
GREAT TOE-HAND TRANSFER
83.01
1.00
26551
GREAT TOE-HAND TRANSFER
88.14
1.00
26551
GREAT TOE-HAND TRANSFER
90.05
1.00
26553
SINGLE TRANSFER, TOE-HAND
3.00
1.00
26553
SINGLE TRANSFER, TOE-HAND
71.04
1.00
26553
SINGLE TRANSFER, TOE-HAND
71.82
1.00
26553
SINGLE TRANSFER, TOE-HAND
76.42
1.00
26554
DOUBLE TRANSFER, TOE-HAND
3.00
1.00
26554
DOUBLE TRANSFER, TOE-HAND
95.07
1.00
26554
DOUBLE TRANSFER, TOE-HAND
101.50
1.00
26554
DOUBLE TRANSFER, TOE-HAND
102.25
1.00
26555
POSITIONAL CHANGE OF FINGER
3.00
1.00
26555
POSITIONAL CHANGE OF FINGER
34.75
1.00
26555
POSITIONAL CHANGE OF FINGER
37.85
1.00
26555
POSITIONAL CHANGE OF FINGER
41.27
1.00
26556
TOE JOINT TRANSFER
3.00
1.00
26556
TOE JOINT TRANSFER
73.42
1.00
26556
TOE JOINT TRANSFER
88.20
1.00
26556
TOE JOINT TRANSFER
89.73
1.00
26560
REPAIR OF WEB FINGER
3.00
1.00
26560
REPAIR OF WEB FINGER
14.22
1.00
26560
REPAIR OF WEB FINGER
16.37
1.00
26560
REPAIR OF WEB FINGER
18.97
1.00
26561
REPAIR OF WEB FINGER
3.00
1.00
26561
REPAIR OF WEB FINGER
22.82
1.00
26561
REPAIR OF WEB FINGER
24.66
1.00
26561
REPAIR OF WEB FINGER
27.73
1.00
Procedure Code Description
RVU
RVU Coeff Value
26562
REPAIR OF WEB FINGER
3.00
1.00
26562
REPAIR OF WEB FINGER
33.26
1.00
26562
REPAIR OF WEB FINGER
33.75
1.00
26562
REPAIR OF WEB FINGER
35.35
1.00
26565
CORRECT METACARPAL FLAW
3.00
1.00
26565
CORRECT METACARPAL FLAW
16.91
1.00
26565
CORRECT METACARPAL FLAW
20.20
1.00
26565
CORRECT METACARPAL FLAW
22.53
1.00
26567
CORRECT FINGER DEFORMITY
3.00
1.00
26567
CORRECT FINGER DEFORMITY
17.09
1.00
26567
CORRECT FINGER DEFORMITY
20.21
1.00
26567
CORRECT FINGER DEFORMITY
22.54
1.00
26568
LENGTHEN METACARPAL/FINGER
3.00
1.00
26568
LENGTHEN METACARPAL/FINGER
22.54
1.00
26568
LENGTHEN METACARPAL/FINGER
26.49
1.00
26568
LENGTHEN METACARPAL/FINGER
30.59
1.00
26580
REPAIR HAND DEFORMITY
3.00
1.00
26580
REPAIR HAND DEFORMITY
33.89
1.00
26580
REPAIR HAND DEFORMITY
35.29
1.00
26580
REPAIR HAND DEFORMITY
35.51
1.00
26587
RECONSTRUCT EXTRA FINGER
3.00
1.00
26587
RECONSTRUCT EXTRA FINGER
19.93
1.00
26587
RECONSTRUCT EXTRA FINGER
24.14
1.00
26587
RECONSTRUCT EXTRA FINGER
24.43
1.00
26590
REPAIR FINGER DEFORMITY
3.00
1.00
26590
REPAIR FINGER DEFORMITY
32.35
1.00
26590
REPAIR FINGER DEFORMITY
33.92
1.00
26590
REPAIR FINGER DEFORMITY
36.74
1.00
26591
REPAIR MUSCLES OF HAND
3.00
1.00
26591
REPAIR MUSCLES OF HAND
10.83
1.00
26591
REPAIR MUSCLES OF HAND
14.14
1.00
26591
REPAIR MUSCLES OF HAND
17.42
1.00
26593
RELEASE MUSCLES OF HAND
3.00
1.00
26593
RELEASE MUSCLES OF HAND
14.82
1.00
26593
RELEASE MUSCLES OF HAND
17.58
1.00
Procedure Code Description 26593
RELEASE MUSCLES OF HAND
26596
RVU
RVU Coeff Value
19.73
1.00
EXCISION CONSTRICTING TISSUE
3.00
1.00
26596
EXCISION CONSTRICTING TISSUE
18.52
1.00
26596
EXCISION CONSTRICTING TISSUE
19.00
1.00
26596
EXCISION CONSTRICTING TISSUE
19.68
1.00
26600
TREAT METACARPAL FRACTURE
3.00
1.00
26600
TREAT METACARPAL FRACTURE
4.90
1.00
26600
TREAT METACARPAL FRACTURE
5.04
1.00
26600
TREAT METACARPAL FRACTURE
6.06
1.00
26605
TREAT METACARPAL FRACTURE
3.00
1.00
26605
TREAT METACARPAL FRACTURE
6.89
1.00
26605
TREAT METACARPAL FRACTURE
6.96
1.00
26605
TREAT METACARPAL FRACTURE
7.68
1.00
26607
TREAT METACARPAL FRACTURE
3.00
1.00
26607
TREAT METACARPAL FRACTURE
10.97
1.00
26607
TREAT METACARPAL FRACTURE
12.54
1.00
26607
TREAT METACARPAL FRACTURE
14.52
1.00
26608
TREAT METACARPAL FRACTURE
3.00
1.00
26608
TREAT METACARPAL FRACTURE
11.86
1.00
26608
TREAT METACARPAL FRACTURE
12.58
1.00
26608
TREAT METACARPAL FRACTURE
15.16
1.00
26615
TREAT METACARPAL FRACTURE
3.00
1.00
26615
TREAT METACARPAL FRACTURE
11.69
1.00
26615
TREAT METACARPAL FRACTURE
13.70
1.00
26615
TREAT METACARPAL FRACTURE
14.52
1.00
26641
TREAT THUMB DISLOCATION
3.00
1.00
26641
TREAT THUMB DISLOCATION
7.95
1.00
26641
TREAT THUMB DISLOCATION
8.02
1.00
26641
TREAT THUMB DISLOCATION
9.22
1.00
26645
TREAT THUMB FRACTURE
3.00
1.00
26645
TREAT THUMB FRACTURE
9.22
1.00
26645
TREAT THUMB FRACTURE
9.24
1.00
26645
TREAT THUMB FRACTURE
10.30
1.00
26650
TREAT THUMB FRACTURE
3.00
1.00
26650
TREAT THUMB FRACTURE
11.89
1.00
Procedure Code Description
RVU
RVU Coeff Value
26650
TREAT THUMB FRACTURE
13.40
1.00
26650
TREAT THUMB FRACTURE
15.73
1.00
26665
TREAT THUMB FRACTURE
3.00
1.00
26665
TREAT THUMB FRACTURE
15.19
1.00
26665
TREAT THUMB FRACTURE
15.56
1.00
26665
TREAT THUMB FRACTURE
18.09
1.00
26670
TREAT HAND DISLOCATION
7.10
1.00
26670
TREAT HAND DISLOCATION
7.14
1.00
26670
TREAT HAND DISLOCATION
8.80
1.00
26675
TREAT HAND DISLOCATION
3.00
1.00
26675
TREAT HAND DISLOCATION
9.72
1.00
26675
TREAT HAND DISLOCATION
9.77
1.00
26675
TREAT HAND DISLOCATION
9.90
1.00
26676
PIN HAND DISLOCATION
3.00
1.00
26676
PIN HAND DISLOCATION
12.43
1.00
26676
PIN HAND DISLOCATION
13.22
1.00
26676
PIN HAND DISLOCATION
15.58
1.00
26685
TREAT HAND DISLOCATION
3.00
1.00
26685
TREAT HAND DISLOCATION
14.13
1.00
26685
TREAT HAND DISLOCATION
14.38
1.00
26685
TREAT HAND DISLOCATION
17.07
1.00
26686
TREAT HAND DISLOCATION
3.00
1.00
26686
TREAT HAND DISLOCATION
15.67
1.00
26686
TREAT HAND DISLOCATION
16.23
1.00
26686
TREAT HAND DISLOCATION
18.72
1.00
26700
TREAT KNUCKLE DISLOCATION
3.00
1.00
26700
TREAT KNUCKLE DISLOCATION
6.98
1.00
26700
TREAT KNUCKLE DISLOCATION
7.00
1.00
26700
TREAT KNUCKLE DISLOCATION
7.06
1.00
26705
TREAT KNUCKLE DISLOCATION
3.00
1.00
26705
TREAT KNUCKLE DISLOCATION
9.01
1.00
26705
TREAT KNUCKLE DISLOCATION
9.02
1.00
26705
TREAT KNUCKLE DISLOCATION
9.10
1.00
26706
PIN KNUCKLE DISLOCATION
3.00
1.00
26706
PIN KNUCKLE DISLOCATION
10.78
1.00
Procedure Code Description
RVU
RVU Coeff Value
26706
PIN KNUCKLE DISLOCATION
10.97
1.00
26706
PIN KNUCKLE DISLOCATION
11.74
1.00
26715
TREAT KNUCKLE DISLOCATION
3.00
1.00
26715
TREAT KNUCKLE DISLOCATION
12.34
1.00
26715
TREAT KNUCKLE DISLOCATION
13.74
1.00
26715
TREAT KNUCKLE DISLOCATION
15.14
1.00
26720
TREAT FINGER FRACTURE, EACH
3.00
1.00
26720
TREAT FINGER FRACTURE, EACH
3.55
1.00
26720
TREAT FINGER FRACTURE, EACH
4.17
1.00
26720
TREAT FINGER FRACTURE, EACH
4.50
1.00
26725
TREAT FINGER FRACTURE, EACH
3.00
1.00
26725
TREAT FINGER FRACTURE, EACH
7.04
1.00
26725
TREAT FINGER FRACTURE, EACH
7.36
1.00
26725
TREAT FINGER FRACTURE, EACH
7.89
1.00
26727
TREAT FINGER FRACTURE, EACH
3.00
1.00
26727
TREAT FINGER FRACTURE, EACH
11.65
1.00
26727
TREAT FINGER FRACTURE, EACH
12.45
1.00
26727
TREAT FINGER FRACTURE, EACH
15.10
1.00
26735
TREAT FINGER FRACTURE, EACH
3.00
1.00
26735
TREAT FINGER FRACTURE, EACH
12.76
1.00
26735
TREAT FINGER FRACTURE, EACH
14.31
1.00
26735
TREAT FINGER FRACTURE, EACH
15.66
1.00
26740
TREAT FINGER FRACTURE, EACH
3.00
1.00
26740
TREAT FINGER FRACTURE, EACH
4.85
1.00
26740
TREAT FINGER FRACTURE, EACH
4.92
1.00
26740
TREAT FINGER FRACTURE, EACH
4.99
1.00
26742
TREAT FINGER FRACTURE, EACH
3.00
1.00
26742
TREAT FINGER FRACTURE, EACH
8.16
1.00
26742
TREAT FINGER FRACTURE, EACH
8.28
1.00
26742
TREAT FINGER FRACTURE, EACH
9.62
1.00
26746
TREAT FINGER FRACTURE, EACH
3.00
1.00
26746
TREAT FINGER FRACTURE, EACH
12.60
1.00
26746
TREAT FINGER FRACTURE, EACH
15.53
1.00
26746
TREAT FINGER FRACTURE, EACH
17.43
1.00
26750
TREAT FINGER FRACTURE, EACH
3.00
1.00
Procedure Code Description
RVU
RVU Coeff Value
26750
TREAT FINGER FRACTURE, EACH
4.01
1.00
26750
TREAT FINGER FRACTURE, EACH
4.14
1.00
26750
TREAT FINGER FRACTURE, EACH
4.30
1.00
26755
TREAT FINGER FRACTURE, EACH
3.00
1.00
26755
TREAT FINGER FRACTURE, EACH
6.54
1.00
26755
TREAT FINGER FRACTURE, EACH
6.57
1.00
26755
TREAT FINGER FRACTURE, EACH
6.60
1.00
26756
PIN FINGER FRACTURE, EACH
3.00
1.00
26756
PIN FINGER FRACTURE, EACH
10.26
1.00
26756
PIN FINGER FRACTURE, EACH
11.10
1.00
26756
PIN FINGER FRACTURE, EACH
13.84
1.00
26765
TREAT FINGER FRACTURE, EACH
3.00
1.00
26765
TREAT FINGER FRACTURE, EACH
9.56
1.00
26765
TREAT FINGER FRACTURE, EACH
11.60
1.00
26765
TREAT FINGER FRACTURE, EACH
12.65
1.00
26770
TREAT FINGER DISLOCATION
5.81
1.00
26770
TREAT FINGER DISLOCATION
5.90
1.00
26770
TREAT FINGER DISLOCATION
6.00
1.00
26775
TREAT FINGER DISLOCATION
3.00
1.00
26775
TREAT FINGER DISLOCATION
8.04
1.00
26775
TREAT FINGER DISLOCATION
8.20
1.00
26776
PIN FINGER DISLOCATION
3.00
1.00
26776
PIN FINGER DISLOCATION
10.92
1.00
26776
PIN FINGER DISLOCATION
11.76
1.00
26776
PIN FINGER DISLOCATION
14.44
1.00
26785
TREAT FINGER DISLOCATION
3.00
1.00
26785
TREAT FINGER DISLOCATION
9.66
1.00
26785
TREAT FINGER DISLOCATION
12.64
1.00
26785
TREAT FINGER DISLOCATION
12.69
1.00
26820
THUMB FUSION WITH GRAFT
3.00
1.00
26820
THUMB FUSION WITH GRAFT
19.76
1.00
26820
THUMB FUSION WITH GRAFT
23.22
1.00
26820
THUMB FUSION WITH GRAFT
25.59
1.00
26841
FUSION OF THUMB
3.00
1.00
26841
FUSION OF THUMB
18.29
1.00
Procedure Code Description
RVU
RVU Coeff Value
26841
FUSION OF THUMB
21.82
1.00
26841
FUSION OF THUMB
23.56
1.00
26842
THUMB FUSION WITH GRAFT
3.00
1.00
26842
THUMB FUSION WITH GRAFT
19.88
1.00
26842
THUMB FUSION WITH GRAFT
23.27
1.00
26842
THUMB FUSION WITH GRAFT
25.58
1.00
26843
FUSION OF HAND JOINT
3.00
1.00
26843
FUSION OF HAND JOINT
18.38
1.00
26843
FUSION OF HAND JOINT
21.47
1.00
26843
FUSION OF HAND JOINT
23.53
1.00
26844
FUSION/GRAFT OF HAND JOINT
3.00
1.00
26844
FUSION/GRAFT OF HAND JOINT
20.52
1.00
26844
FUSION/GRAFT OF HAND JOINT
23.75
1.00
26844
FUSION/GRAFT OF HAND JOINT
26.05
1.00
26850
FUSION OF KNUCKLE
3.00
1.00
26850
FUSION OF KNUCKLE
17.41
1.00
26850
FUSION OF KNUCKLE
20.59
1.00
26850
FUSION OF KNUCKLE
22.75
1.00
26852
FUSION OF KNUCKLE WITH GRAFT
3.00
1.00
26852
FUSION OF KNUCKLE WITH GRAFT
19.96
1.00
26852
FUSION OF KNUCKLE WITH GRAFT
22.97
1.00
26852
FUSION OF KNUCKLE WITH GRAFT
25.35
1.00
26860
FUSION OF FINGER JOINT
3.00
1.00
26860
FUSION OF FINGER JOINT
13.93
1.00
26860
FUSION OF FINGER JOINT
16.95
1.00
26860
FUSION OF FINGER JOINT
19.04
1.00
26861
FUSION OF FINGER JNT, ADD-ON
2.80
1.00
26861
FUSION OF FINGER JNT, ADD-ON
2.92
1.00
26861
FUSION OF FINGER JNT, ADD-ON
2.94
1.00
26862
FUSION/GRAFT OF FINGER JOINT
3.00
1.00
26862
FUSION/GRAFT OF FINGER JOINT
18.15
1.00
26862
FUSION/GRAFT OF FINGER JOINT
21.22
1.00
26862
FUSION/GRAFT OF FINGER JOINT
23.67
1.00
26863
FUSE/GRAFT ADDED JOINT
6.23
1.00
26863
FUSE/GRAFT ADDED JOINT
6.58
1.00
Procedure Code Description
RVU
RVU Coeff Value
26863
FUSE/GRAFT ADDED JOINT
6.63
1.00
26910
AMPUTATE METACARPAL BONE
3.00
1.00
26910
AMPUTATE METACARPAL BONE
17.89
1.00
26910
AMPUTATE METACARPAL BONE
20.38
1.00
26910
AMPUTATE METACARPAL BONE
22.57
1.00
26951
AMPUTATION OF FINGER/THUMB
3.00
1.00
26951
AMPUTATION OF FINGER/THUMB
15.37
1.00
26951
AMPUTATION OF FINGER/THUMB
15.88
1.00
26951
AMPUTATION OF FINGER/THUMB
18.21
1.00
26952
AMPUTATION OF FINGER/THUMB
3.00
1.00
26952
AMPUTATION OF FINGER/THUMB
16.18
1.00
26952
AMPUTATION OF FINGER/THUMB
19.42
1.00
26952
AMPUTATION OF FINGER/THUMB
21.30
1.00
33010
DRAINAGE OF HEART SAC
3.35
1.00
33010
DRAINAGE OF HEART SAC
3.36
1.00
33010
DRAINAGE OF HEART SAC
3.38
1.00
33010
DRAINAGE OF HEART SAC
4.00
1.00
33011
REPEAT DRAINAGE OF HEART SAC
3.31
1.00
33011
REPEAT DRAINAGE OF HEART SAC
3.39
1.00
33011
REPEAT DRAINAGE OF HEART SAC
3.40
1.00
33011
REPEAT DRAINAGE OF HEART SAC
4.00
1.00
33015
INCISION OF HEART SAC
10.00
1.00
33015
INCISION OF HEART SAC
11.96
1.00
33015
INCISION OF HEART SAC
12.54
1.00
33015
INCISION OF HEART SAC
14.38
1.00
33020
INCISION OF HEART SAC
20.00
1.00
33020
INCISION OF HEART SAC
21.24
1.00
33020
INCISION OF HEART SAC
22.12
1.00
33020
INCISION OF HEART SAC
23.46
1.00
33025
INCISION OF HEART SAC
20.00
1.00
33025
INCISION OF HEART SAC
20.27
1.00
33025
INCISION OF HEART SAC
21.47
1.00
33025
INCISION OF HEART SAC
21.71
1.00
33030
PARTIAL REMOVAL OF HEART SAC
15.00
1.00
33030
PARTIAL REMOVAL OF HEART SAC
31.16
1.00
Procedure Code Description
RVU
RVU Coeff Value
33030
PARTIAL REMOVAL OF HEART SAC
33.41
1.00
33030
PARTIAL REMOVAL OF HEART SAC
34.72
1.00
33031
PARTIAL REMOVAL OF HEART SAC
15.00
1.00
33031
PARTIAL REMOVAL OF HEART SAC
35.21
1.00
33031
PARTIAL REMOVAL OF HEART SAC
38.14
1.00
33031
PARTIAL REMOVAL OF HEART SAC
38.75
1.00
33050
REMOVAL OF HEART SAC LESION
20.00
1.00
33050
REMOVAL OF HEART SAC LESION
24.33
1.00
33050
REMOVAL OF HEART SAC LESION
26.40
1.00
33050
REMOVAL OF HEART SAC LESION
26.83
1.00
33120
REMOVAL OF HEART LESION
24.00
1.00
33120
REMOVAL OF HEART LESION
39.89
1.00
33120
REMOVAL OF HEART LESION
42.47
1.00
33120
REMOVAL OF HEART LESION
43.67
1.00
33130
REMOVAL OF HEART LESION
15.00
1.00
33130
REMOVAL OF HEART LESION
34.57
1.00
33130
REMOVAL OF HEART LESION
36.64
1.00
33130
REMOVAL OF HEART LESION
37.32
1.00
33140
HEART REVASCULARIZE (TMR)
20.00
1.00
33140
HEART REVASCULARIZE (TMR)
32.94
1.00
33140
HEART REVASCULARIZE (TMR)
33.65
1.00
33140
HEART REVASCULARIZE (TMR)
42.38
1.00
33141
HEART TMR W/OTHER PROCEDURE
4.26
1.00
33141
HEART TMR W/OTHER PROCEDURE
6.96
1.00
33141
HEART TMR W/OTHER PROCEDURE
7.08
1.00
33200
INSERTION OF HEART PACEMAKER
15.00
1.00
33200
INSERTION OF HEART PACEMAKER
20.85
1.00
33200
INSERTION OF HEART PACEMAKER
21.02
1.00
33200
INSERTION OF HEART PACEMAKER
23.37
1.00
33201
INSERTION OF HEART PACEMAKER
18.12
1.00
33201
INSERTION OF HEART PACEMAKER
18.35
1.00
33201
INSERTION OF HEART PACEMAKER
21.10
1.00
33202
INSERT EPICARD ELTRD, OPEN
21.17
1.00
33203
INSERT EPICARD ELTRD, ENDO
22.18
1.00
33206
INSERTION OF HEART PACEMAKER
6.00
1.00
Procedure Code Description
RVU
RVU Coeff Value
33206
INSERTION OF HEART PACEMAKER
11.83
1.00
33206
INSERTION OF HEART PACEMAKER
12.80
1.00
33206
INSERTION OF HEART PACEMAKER
12.86
1.00
33207
INSERTION OF HEART PACEMAKER
6.00
1.00
33207
INSERTION OF HEART PACEMAKER
13.48
1.00
33207
INSERTION OF HEART PACEMAKER
13.71
1.00
33207
INSERTION OF HEART PACEMAKER
14.84
1.00
33208
INSERTION OF HEART PACEMAKER
6.00
1.00
33208
INSERTION OF HEART PACEMAKER
13.63
1.00
33208
INSERTION OF HEART PACEMAKER
14.75
1.00
33208
INSERTION OF HEART PACEMAKER
15.10
1.00
33210
INSERTION OF HEART ELECTRODE
4.75
1.00
33210
INSERTION OF HEART ELECTRODE
4.76
1.00
33210
INSERTION OF HEART ELECTRODE
5.06
1.00
33210
INSERTION OF HEART ELECTRODE
6.00
1.00
33211
INSERTION OF HEART ELECTRODE
4.91
1.00
33211
INSERTION OF HEART ELECTRODE
4.92
1.00
33211
INSERTION OF HEART ELECTRODE
5.09
1.00
33211
INSERTION OF HEART ELECTRODE
6.00
1.00
33212
INSERTION OF PULSE GENERATOR
6.00
1.00
33212
INSERTION OF PULSE GENERATOR
9.46
1.00
33212
INSERTION OF PULSE GENERATOR
9.58
1.00
33212
INSERTION OF PULSE GENERATOR
10.58
1.00
33213
INSERTION OF PULSE GENERATOR
6.00
1.00
33213
INSERTION OF PULSE GENERATOR
10.69
1.00
33213
INSERTION OF PULSE GENERATOR
10.92
1.00
33213
INSERTION OF PULSE GENERATOR
11.89
1.00
33214
UPGRADE OF PACEMAKER SYSTEM
6.00
1.00
33214
UPGRADE OF PACEMAKER SYSTEM
13.36
1.00
33214
UPGRADE OF PACEMAKER SYSTEM
13.55
1.00
33214
UPGRADE OF PACEMAKER SYSTEM
14.46
1.00
33215
REPOSITION PACING-DEFIB LEAD
8.27
1.00
33215
REPOSITION PACING-DEFIB LEAD
8.36
1.00
33215
REPOSITION PACING-DEFIB LEAD
8.66
1.00
33216
INSERT LEAD PACE-DEFIB, ONE
6.00
1.00
Procedure Code Description
RVU
RVU Coeff Value
33216
INSERT LEAD PACE-DEFIB, ONE
10.50
1.00
33216
INSERT LEAD PACE-DEFIB, ONE
10.64
1.00
33216
INSERT LEAD PACE-DEFIB, ONE
11.46
1.00
33217
INSERT LEAD PACE-DEFIB, DUAL
6.00
1.00
33217
INSERT LEAD PACE-DEFIB, DUAL
10.50
1.00
33217
INSERT LEAD PACE-DEFIB, DUAL
10.56
1.00
33217
INSERT LEAD PACE-DEFIB, DUAL
11.69
1.00
33218
REPAIR LEAD PACE-DEFIB, ONE
6.00
1.00
33218
REPAIR LEAD PACE-DEFIB, ONE
10.28
1.00
33218
REPAIR LEAD PACE-DEFIB, ONE
10.52
1.00
33218
REPAIR LEAD PACE-DEFIB, ONE
11.00
1.00
33220
REPAIR LEAD PACE-DEFIB, DUAL
6.00
1.00
33220
REPAIR LEAD PACE-DEFIB, DUAL
10.32
1.00
33220
REPAIR LEAD PACE-DEFIB, DUAL
10.60
1.00
33220
REPAIR LEAD PACE-DEFIB, DUAL
11.10
1.00
33222
REVISE POCKET, PACEMAKER
3.00
1.00
33222
REVISE POCKET, PACEMAKER
9.43
1.00
33222
REVISE POCKET, PACEMAKER
9.72
1.00
33222
REVISE POCKET, PACEMAKER
9.78
1.00
33223
REVISE POCKET, PACING-DEFIB
6.00
1.00
33223
REVISE POCKET, PACING-DEFIB
11.62
1.00
33223
REVISE POCKET, PACING-DEFIB
11.74
1.00
33223
REVISE POCKET, PACING-DEFIB
12.31
1.00
33224
INSERT PACING LEAD & CONNECT
13.33
1.00
33224
INSERT PACING LEAD & CONNECT
13.49
1.00
33224
INSERT PACING LEAD & CONNECT
14.31
1.00
33225
L VENTRIC PACING LEAD ADD-ON
11.81
1.00
33225
L VENTRIC PACING LEAD ADD-ON
11.99
1.00
33225
L VENTRIC PACING LEAD ADD-ON
12.89
1.00
33226
REPOSITION L VENTRIC LEAD
12.84
1.00
33226
REPOSITION L VENTRIC LEAD
12.99
1.00
33226
REPOSITION L VENTRIC LEAD
13.85
1.00
33233
REMOVAL OF PACEMAKER SYSTEM
6.00
1.00
33233
REMOVAL OF PACEMAKER SYSTEM
6.78
1.00
33233
REMOVAL OF PACEMAKER SYSTEM
6.87
1.00
Procedure Code Description
RVU
RVU Coeff Value
33233
REMOVAL OF PACEMAKER SYSTEM
7.63
1.00
33234
REMOVAL OF PACEMAKER SYSTEM
6.00
1.00
33234
REMOVAL OF PACEMAKER SYSTEM
13.44
1.00
33234
REMOVAL OF PACEMAKER SYSTEM
13.75
1.00
33234
REMOVAL OF PACEMAKER SYSTEM
14.04
1.00
33235
REMOVAL PACEMAKER ELECTRODE
6.00
1.00
33235
REMOVAL PACEMAKER ELECTRODE
16.58
1.00
33235
REMOVAL PACEMAKER ELECTRODE
17.07
1.00
33235
REMOVAL PACEMAKER ELECTRODE
17.78
1.00
33236
REMOVE ELECTRODE/THORACOTOMY
6.00
1.00
33236
REMOVE ELECTRODE/THORACOTOMY
21.24
1.00
33236
REMOVE ELECTRODE/THORACOTOMY
21.86
1.00
33236
REMOVE ELECTRODE/THORACOTOMY
23.47
1.00
33237
REMOVE ELECTRODE/THORACOTOMY
6.00
1.00
33237
REMOVE ELECTRODE/THORACOTOMY
23.38
1.00
33237
REMOVE ELECTRODE/THORACOTOMY
23.42
1.00
33237
REMOVE ELECTRODE/THORACOTOMY
25.06
1.00
33238
REMOVE ELECTRODE/THORACOTOMY
6.00
1.00
33238
REMOVE ELECTRODE/THORACOTOMY
25.32
1.00
33238
REMOVE ELECTRODE/THORACOTOMY
25.34
1.00
33238
REMOVE ELECTRODE/THORACOTOMY
26.05
1.00
33240
INSERT PULSE GENERATOR
6.00
1.00
33240
INSERT PULSE GENERATOR
12.89
1.00
33240
INSERT PULSE GENERATOR
13.10
1.00
33240
INSERT PULSE GENERATOR
13.90
1.00
33241
REMOVE PULSE GENERATOR
6.00
1.00
33241
REMOVE PULSE GENERATOR
6.40
1.00
33241
REMOVE PULSE GENERATOR
6.48
1.00
33241
REMOVE PULSE GENERATOR
7.16
1.00
33243
REMOVE ELTRD/THORACOTOMY
6.00
1.00
33243
REMOVE ELTRD/THORACOTOMY
36.07
1.00
33243
REMOVE ELTRD/THORACOTOMY
36.94
1.00
33243
REMOVE ELTRD/THORACOTOMY
37.16
1.00
33244
REMOVE ELTRD, TRANSVEN
6.00
1.00
33244
REMOVE ELTRD, TRANSVEN
23.24
1.00
Procedure Code Description
RVU
RVU Coeff Value
33244
REMOVE ELTRD, TRANSVEN
23.97
1.00
33244
REMOVE ELTRD, TRANSVEN
24.16
1.00
33245
INSERT EPIC ELTRD PACE-DEFIB
13.00
1.00
33245
INSERT EPIC ELTRD PACE-DEFIB
23.85
1.00
33245
INSERT EPIC ELTRD PACE-DEFIB
24.21
1.00
33245
INSERT EPIC ELTRD PACE-DEFIB
26.60
1.00
33246
INSERT EPIC ELTRD/GENERATOR
13.00
1.00
33246
INSERT EPIC ELTRD/GENERATOR
33.62
1.00
33246
INSERT EPIC ELTRD/GENERATOR
33.77
1.00
33246
INSERT EPIC ELTRD/GENERATOR
37.29
1.00
33249
ELTRD/INSERT PACE-DEFIB
6.00
1.00
33249
ELTRD/INSERT PACE-DEFIB
23.66
1.00
33249
ELTRD/INSERT PACE-DEFIB
24.30
1.00
33249
ELTRD/INSERT PACE-DEFIB
25.47
1.00
33250
ABLATE HEART DYSRHYTHM FOCUS
34.17
1.00
33250
ABLATE HEART DYSRHYTHM FOCUS
37.28
1.00
33250
ABLATE HEART DYSRHYTHM FOCUS
39.86
1.00
33251
ABLATE HEART DYSRHYTHM FOCUS
39.49
1.00
33251
ABLATE HEART DYSRHYTHM FOCUS
41.82
1.00
33251
ABLATE HEART DYSRHYTHM FOCUS
44.19
1.00
33253
RECONSTRUCT ATRIA
15.00
1.00
33253
RECONSTRUCT ATRIA
49.36
1.00
33253
RECONSTRUCT ATRIA
49.39
1.00
33253
RECONSTRUCT ATRIA
51.53
1.00
33254
ABLATE ATRIA, LMTD
37.31
1.00
33255
ABLATE ATRIA W/O BYPASS, EXT
45.59
1.00
33256
ABLATE ATRIA W/BYPASS, EXTEN
54.45
1.00
33257
ABLATE ATRIA, LMTD, ADD-ON
15.57
1.00
33258
ABLATE ATRIA, X10SV, ADD-ON
17.61
1.00
33259
ABLATE ATRIA W/BYPASS ADD-ON
23.10
1.00
33261
ABLATE HEART DYSRHYTHM FOCUS
40.09
1.00
33261
ABLATE HEART DYSRHYTHM FOCUS
42.49
1.00
33261
ABLATE HEART DYSRHYTHM FOCUS
43.93
1.00
33265
ABLATE ATRIA, LMTD, ENDO
37.23
1.00
33266
ABLATE ATRIA, X10SV, ENDO
51.15
1.00
Procedure Code Description
RVU
RVU Coeff Value
33282
IMPLANT PAT-ACTIVE HT RECORD
6.00
1.00
33282
IMPLANT PAT-ACTIVE HT RECORD
8.74
1.00
33282
IMPLANT PAT-ACTIVE HT RECORD
9.08
1.00
33282
IMPLANT PAT-ACTIVE HT RECORD
9.47
1.00
33284
REMOVE PAT-ACTIVE HT RECORD
6.00
1.00
33284
REMOVE PAT-ACTIVE HT RECORD
6.36
1.00
33284
REMOVE PAT-ACTIVE HT RECORD
6.54
1.00
33284
REMOVE PAT-ACTIVE HT RECORD
7.12
1.00
33300
REPAIR OF HEART WOUND
15.00
1.00
33300
REPAIR OF HEART WOUND
29.50
1.00
33300
REPAIR OF HEART WOUND
31.91
1.00
33300
REPAIR OF HEART WOUND
62.14
1.00
33305
REPAIR OF HEART WOUND
15.00
1.00
33305
REPAIR OF HEART WOUND
35.34
1.00
33305
REPAIR OF HEART WOUND
37.65
1.00
33305
REPAIR OF HEART WOUND
103.23
1.00
33310
EXPLORATORY HEART SURGERY
15.00
1.00
33310
EXPLORATORY HEART SURGERY
30.86
1.00
33310
EXPLORATORY HEART SURGERY
31.81
1.00
33310
EXPLORATORY HEART SURGERY
33.20
1.00
33315
EXPLORATORY HEART SURGERY
20.00
1.00
33315
EXPLORATORY HEART SURGERY
36.79
1.00
33315
EXPLORATORY HEART SURGERY
39.01
1.00
33315
EXPLORATORY HEART SURGERY
40.44
1.00
33320
REPAIR MAJOR BLOOD VESSEL(S)
15.00
1.00
33320
REPAIR MAJOR BLOOD VESSEL(S)
27.06
1.00
33320
REPAIR MAJOR BLOOD VESSEL(S)
28.75
1.00
33320
REPAIR MAJOR BLOOD VESSEL(S)
29.89
1.00
33321
REPAIR MAJOR VESSEL
15.00
1.00
33321
REPAIR MAJOR VESSEL
32.61
1.00
33321
REPAIR MAJOR VESSEL
33.29
1.00
33321
REPAIR MAJOR VESSEL
35.62
1.00
33322
REPAIR MAJOR BLOOD VESSEL(S)
15.00
1.00
33322
REPAIR MAJOR BLOOD VESSEL(S)
34.06
1.00
33322
REPAIR MAJOR BLOOD VESSEL(S)
36.45
1.00
Procedure Code Description
RVU
RVU Coeff Value
33322
REPAIR MAJOR BLOOD VESSEL(S)
37.69
1.00
33330
INSERT MAJOR VESSEL GRAFT
15.00
1.00
33330
INSERT MAJOR VESSEL GRAFT
34.75
1.00
33330
INSERT MAJOR VESSEL GRAFT
36.85
1.00
33330
INSERT MAJOR VESSEL GRAFT
38.01
1.00
33332
INSERT MAJOR VESSEL GRAFT
15.00
1.00
33332
INSERT MAJOR VESSEL GRAFT
37.46
1.00
33332
INSERT MAJOR VESSEL GRAFT
38.05
1.00
33332
INSERT MAJOR VESSEL GRAFT
39.59
1.00
33335
INSERT MAJOR VESSEL GRAFT
15.00
1.00
33335
INSERT MAJOR VESSEL GRAFT
47.95
1.00
33335
INSERT MAJOR VESSEL GRAFT
50.03
1.00
33335
INSERT MAJOR VESSEL GRAFT
51.44
1.00
33400
REPAIR OF AORTIC VALVE
15.00
1.00
33400
REPAIR OF AORTIC VALVE
46.59
1.00
33400
REPAIR OF AORTIC VALVE
47.92
1.00
33400
REPAIR OF AORTIC VALVE
61.62
1.00
33401
VALVULOPLASTY, OPEN
15.00
1.00
33401
VALVULOPLASTY, OPEN
39.95
1.00
33401
VALVULOPLASTY, OPEN
40.71
1.00
33401
VALVULOPLASTY, OPEN
41.06
1.00
33403
VALVULOPLASTY, W/CP BYPASS
15.00
1.00
33403
VALVULOPLASTY, W/CP BYPASS
41.08
1.00
33403
VALVULOPLASTY, W/CP BYPASS
41.24
1.00
33403
VALVULOPLASTY, W/CP BYPASS
42.21
1.00
33404
PREPARE HEART-AORTA CONDUIT
20.00
1.00
33404
PREPARE HEART-AORTA CONDUIT
45.79
1.00
33404
PREPARE HEART-AORTA CONDUIT
47.07
1.00
33404
PREPARE HEART-AORTA CONDUIT
48.89
1.00
33405
REPLACEMENT OF AORTIC VALVE
15.00
1.00
33405
REPLACEMENT OF AORTIC VALVE
56.38
1.00
33405
REPLACEMENT OF AORTIC VALVE
57.97
1.00
33405
REPLACEMENT OF AORTIC VALVE
63.27
1.00
33406
REPLACEMENT OF AORTIC VALVE
15.00
1.00
33406
REPLACEMENT OF AORTIC VALVE
59.88
1.00
Procedure Code Description
RVU
RVU Coeff Value
33406
REPLACEMENT OF AORTIC VALVE
61.55
1.00
33406
REPLACEMENT OF AORTIC VALVE
77.68
1.00
33410
REPLACEMENT OF AORTIC VALVE
20.00
1.00
33410
REPLACEMENT OF AORTIC VALVE
52.57
1.00
33410
REPLACEMENT OF AORTIC VALVE
54.03
1.00
33410
REPLACEMENT OF AORTIC VALVE
68.51
1.00
33411
REPLACEMENT OF AORTIC VALVE
20.00
1.00
33411
REPLACEMENT OF AORTIC VALVE
58.38
1.00
33411
REPLACEMENT OF AORTIC VALVE
60.05
1.00
33411
REPLACEMENT OF AORTIC VALVE
89.23
1.00
33412
REPLACEMENT OF AORTIC VALVE
20.00
1.00
33412
REPLACEMENT OF AORTIC VALVE
66.43
1.00
33412
REPLACEMENT OF AORTIC VALVE
68.06
1.00
33412
REPLACEMENT OF AORTIC VALVE
68.51
1.00
33413
REPLACEMENT OF AORTIC VALVE
15.00
1.00
33413
REPLACEMENT OF AORTIC VALVE
67.86
1.00
33413
REPLACEMENT OF AORTIC VALVE
69.48
1.00
33413
REPLACEMENT OF AORTIC VALVE
88.35
1.00
33414
REPAIR OF AORTIC VALVE
15.00
1.00
33414
REPAIR OF AORTIC VALVE
49.10
1.00
33414
REPAIR OF AORTIC VALVE
52.12
1.00
33414
REPAIR OF AORTIC VALVE
59.13
1.00
33415
REVISION, SUBVALVULAR TISSUE
20.00
1.00
33415
REVISION, SUBVALVULAR TISSUE
43.14
1.00
33415
REVISION, SUBVALVULAR TISSUE
46.45
1.00
33415
REVISION, SUBVALVULAR TISSUE
54.76
1.00
33416
REVISE VENTRICLE MUSCLE
48.53
1.00
33416
REVISE VENTRICLE MUSCLE
50.61
1.00
33416
REVISE VENTRICLE MUSCLE
55.16
1.00
33417
REPAIR OF AORTIC VALVE
20.00
1.00
33417
REPAIR OF AORTIC VALVE
46.11
1.00
33417
REPAIR OF AORTIC VALVE
46.52
1.00
33417
REPAIR OF AORTIC VALVE
49.62
1.00
33420
REVISION OF MITRAL VALVE
15.00
1.00
33420
REVISION OF MITRAL VALVE
34.12
1.00
Procedure Code Description
RVU
RVU Coeff Value
33420
REVISION OF MITRAL VALVE
34.30
1.00
33420
REVISION OF MITRAL VALVE
36.89
1.00
33422
REVISION OF MITRAL VALVE
15.00
1.00
33422
REVISION OF MITRAL VALVE
42.27
1.00
33422
REVISION OF MITRAL VALVE
43.59
1.00
33422
REVISION OF MITRAL VALVE
46.23
1.00
33425
REPAIR OF MITRAL VALVE
15.00
1.00
33425
REPAIR OF MITRAL VALVE
42.58
1.00
33425
REPAIR OF MITRAL VALVE
43.68
1.00
33425
REPAIR OF MITRAL VALVE
71.32
1.00
33426
REPAIR OF MITRAL VALVE
53.29
1.00
33426
REPAIR OF MITRAL VALVE
54.83
1.00
33426
REPAIR OF MITRAL VALVE
65.19
1.00
33427
REPAIR OF MITRAL VALVE
62.89
1.00
33427
REPAIR OF MITRAL VALVE
64.57
1.00
33427
REPAIR OF MITRAL VALVE
68.31
1.00
33430
REPLACEMENT OF MITRAL VALVE
20.00
1.00
33430
REPLACEMENT OF MITRAL VALVE
53.99
1.00
33430
REPLACEMENT OF MITRAL VALVE
55.58
1.00
33430
REPLACEMENT OF MITRAL VALVE
75.16
1.00
33460
REVISION OF TRICUSPID VALVE
15.00
1.00
33460
REVISION OF TRICUSPID VALVE
38.58
1.00
33460
REVISION OF TRICUSPID VALVE
40.75
1.00
33460
REVISION OF TRICUSPID VALVE
63.40
1.00
33463
VALVULOPLASTY, TRICUSPID
15.00
1.00
33463
VALVULOPLASTY, TRICUSPID
42.39
1.00
33463
VALVULOPLASTY, TRICUSPID
43.66
1.00
33463
VALVULOPLASTY, TRICUSPID
79.94
1.00
33464
VALVULOPLASTY, TRICUSPID
15.00
1.00
33464
VALVULOPLASTY, TRICUSPID
45.08
1.00
33464
VALVULOPLASTY, TRICUSPID
46.27
1.00
33464
VALVULOPLASTY, TRICUSPID
64.76
1.00
33465
REPLACE TRICUSPID VALVE
15.00
1.00
33465
REPLACE TRICUSPID VALVE
46.15
1.00
33465
REPLACE TRICUSPID VALVE
48.20
1.00
Procedure Code Description
RVU
RVU Coeff Value
33465
REPLACE TRICUSPID VALVE
72.39
1.00
33468
REVISION OF TRICUSPID VALVE
15.00
1.00
33468
REVISION OF TRICUSPID VALVE
48.65
1.00
33468
REVISION OF TRICUSPID VALVE
51.41
1.00
33468
REVISION OF TRICUSPID VALVE
54.22
1.00
33470
REVISION OF PULMONARY VALVE
15.00
1.00
33470
REVISION OF PULMONARY VALVE
31.95
1.00
33470
REVISION OF PULMONARY VALVE
34.95
1.00
33470
REVISION OF PULMONARY VALVE
37.29
1.00
33471
VALVOTOMY, PULMONARY VALVE
15.00
1.00
33471
VALVOTOMY, PULMONARY VALVE
35.66
1.00
33471
VALVOTOMY, PULMONARY VALVE
36.39
1.00
33471
VALVOTOMY, PULMONARY VALVE
37.97
1.00
33472
REVISION OF PULMONARY VALVE
20.00
1.00
33472
REVISION OF PULMONARY VALVE
36.79
1.00
33472
REVISION OF PULMONARY VALVE
37.71
1.00
33472
REVISION OF PULMONARY VALVE
40.42
1.00
33474
REVISION OF PULMONARY VALVE
15.00
1.00
33474
REVISION OF PULMONARY VALVE
37.39
1.00
33474
REVISION OF PULMONARY VALVE
39.30
1.00
33474
REVISION OF PULMONARY VALVE
55.67
1.00
33475
REPLACEMENT, PULMONARY VALVE
15.00
1.00
33475
REPLACEMENT, PULMONARY VALVE
51.61
1.00
33475
REPLACEMENT, PULMONARY VALVE
54.51
1.00
33475
REPLACEMENT, PULMONARY VALVE
63.16
1.00
33476
REVISION OF HEART CHAMBER
15.00
1.00
33476
REVISION OF HEART CHAMBER
39.75
1.00
33476
REVISION OF HEART CHAMBER
40.65
1.00
33476
REVISION OF HEART CHAMBER
42.24
1.00
33478
REVISION OF HEART CHAMBER
15.00
1.00
33478
REVISION OF HEART CHAMBER
43.19
1.00
33478
REVISION OF HEART CHAMBER
44.12
1.00
33478
REVISION OF HEART CHAMBER
45.45
1.00
33496
REPAIR, PROSTH VALVE CLOT
15.00
1.00
33496
REPAIR, PROSTH VALVE CLOT
44.19
1.00
Procedure Code Description
RVU
RVU Coeff Value
33496
REPAIR, PROSTH VALVE CLOT
46.18
1.00
33496
REPAIR, PROSTH VALVE CLOT
47.87
1.00
33500
REPAIR HEART VESSEL FISTULA
40.43
1.00
33500
REPAIR HEART VESSEL FISTULA
42.21
1.00
33500
REPAIR HEART VESSEL FISTULA
43.33
1.00
33501
REPAIR HEART VESSEL FISTULA
15.00
1.00
33501
REPAIR HEART VESSEL FISTULA
28.56
1.00
33501
REPAIR HEART VESSEL FISTULA
29.81
1.00
33501
REPAIR HEART VESSEL FISTULA
30.38
1.00
33502
CORONARY ARTERY CORRECTION
15.00
1.00
33502
CORONARY ARTERY CORRECTION
34.72
1.00
33502
CORONARY ARTERY CORRECTION
35.19
1.00
33502
CORONARY ARTERY CORRECTION
40.59
1.00
33503
CORONARY ARTERY GRAFT
10.00
1.00
33503
CORONARY ARTERY GRAFT
33.29
1.00
33503
CORONARY ARTERY GRAFT
36.75
1.00
33503
CORONARY ARTERY GRAFT
37.25
1.00
33504
CORONARY ARTERY GRAFT
20.00
1.00
33504
CORONARY ARTERY GRAFT
39.61
1.00
33504
CORONARY ARTERY GRAFT
40.20
1.00
33504
CORONARY ARTERY GRAFT
44.62
1.00
33505
REPAIR ARTERY W/TUNNEL
15.00
1.00
33505
REPAIR ARTERY W/TUNNEL
41.65
1.00
33505
REPAIR ARTERY W/TUNNEL
46.72
1.00
33505
REPAIR ARTERY W/TUNNEL
53.61
1.00
33506
REPAIR ARTERY, TRANSLOCATION
15.00
1.00
33506
REPAIR ARTERY, TRANSLOCATION
53.96
1.00
33506
REPAIR ARTERY, TRANSLOCATION
56.40
1.00
33506
REPAIR ARTERY, TRANSLOCATION
58.38
1.00
33507
REPAIR ART, INTRAMURAL
47.76
1.00
33508
ENDOSCOPIC VEIN HARVEST
0.45
1.00
33510
CABG, VEIN, SINGLE
20.00
1.00
33510
CABG, VEIN, SINGLE
47.65
1.00
33510
CABG, VEIN, SINGLE
49.15
1.00
33510
CABG, VEIN, SINGLE
53.77
1.00
Procedure Code Description
RVU
RVU Coeff Value
33511
CABG, VEIN, TWO
20.00
1.00
33511
CABG, VEIN, TWO
49.55
1.00
33511
CABG, VEIN, TWO
51.14
1.00
33511
CABG, VEIN, TWO
58.60
1.00
33512
CABG, VEIN, THREE
20.00
1.00
33512
CABG, VEIN, THREE
52.25
1.00
33512
CABG, VEIN, THREE
53.89
1.00
33512
CABG, VEIN, THREE
65.83
1.00
33513
CABG, VEIN, FOUR
20.00
1.00
33513
CABG, VEIN, FOUR
52.90
1.00
33513
CABG, VEIN, FOUR
54.62
1.00
33513
CABG, VEIN, FOUR
67.27
1.00
33514
CABG, VEIN, FIVE
20.00
1.00
33514
CABG, VEIN, FIVE
54.28
1.00
33514
CABG, VEIN, FIVE
56.11
1.00
33514
CABG, VEIN, FIVE
71.16
1.00
33516
CABG, VEIN, SIX OR MORE
20.00
1.00
33516
CABG, VEIN, SIX OR MORE
57.53
1.00
33516
CABG, VEIN, SIX OR MORE
59.40
1.00
33516
CABG, VEIN, SIX OR MORE
74.05
1.00
33517
CABG, ARTERY-VEIN, SINGLE
3.73
1.00
33517
CABG, ARTERY-VEIN, SINGLE
3.80
1.00
33517
CABG, ARTERY-VEIN, SINGLE
5.10
1.00
33517
CABG, ARTERY-VEIN, SINGLE
20.00
1.00
33518
CABG, ARTERY-VEIN, TWO
7.04
1.00
33518
CABG, ARTERY-VEIN, TWO
7.17
1.00
33518
CABG, ARTERY-VEIN, TWO
11.00
1.00
33518
CABG, ARTERY-VEIN, TWO
20.00
1.00
33519
CABG, ARTERY-VEIN, THREE
10.32
1.00
33519
CABG, ARTERY-VEIN, THREE
10.51
1.00
33519
CABG, ARTERY-VEIN, THREE
14.70
1.00
33519
CABG, ARTERY-VEIN, THREE
20.00
1.00
33521
CABG, ARTERY-VEIN, FOUR
13.63
1.00
33521
CABG, ARTERY-VEIN, FOUR
13.89
1.00
33521
CABG, ARTERY-VEIN, FOUR
17.83
1.00
Procedure Code Description
RVU
RVU Coeff Value
33521
CABG, ARTERY-VEIN, FOUR
20.00
1.00
33522
CABG, ARTERY-VEIN, FIVE
16.94
1.00
33522
CABG, ARTERY-VEIN, FIVE
17.26
1.00
33522
CABG, ARTERY-VEIN, FIVE
20.00
1.00
33522
CABG, ARTERY-VEIN, FIVE
20.36
1.00
33523
CABG, ART-VEIN, SIX OR MORE
20.00
1.00
33523
CABG, ART-VEIN, SIX OR MORE
20.23
1.00
33523
CABG, ART-VEIN, SIX OR MORE
20.63
1.00
33523
CABG, ART-VEIN, SIX OR MORE
23.27
1.00
33530
CORONARY ARTERY, BYPASS/REOP
8.49
1.00
33530
CORONARY ARTERY, BYPASS/REOP
8.64
1.00
33530
CORONARY ARTERY, BYPASS/REOP
13.97
1.00
33530
CORONARY ARTERY, BYPASS/REOP
999.99
1.00
33533
CABG, ARTERIAL, SINGLE
20.00
1.00
33533
CABG, ARTERIAL, SINGLE
48.91
1.00
33533
CABG, ARTERIAL, SINGLE
50.41
1.00
33533
CABG, ARTERIAL, SINGLE
52.46
1.00
33534
CABG, ARTERIAL, TWO
20.00
1.00
33534
CABG, ARTERIAL, TWO
52.64
1.00
33534
CABG, ARTERIAL, TWO
54.32
1.00
33534
CABG, ARTERIAL, TWO
60.78
1.00
33535
CABG, ARTERIAL, THREE
20.00
1.00
33535
CABG, ARTERIAL, THREE
55.77
1.00
33535
CABG, ARTERIAL, THREE
57.46
1.00
33535
CABG, ARTERIAL, THREE
67.41
1.00
33536
CABG, ARTERIAL, FOUR OR MORE
20.00
1.00
33536
CABG, ARTERIAL, FOUR OR MORE
58.42
1.00
33536
CABG, ARTERIAL, FOUR OR MORE
59.79
1.00
33536
CABG, ARTERIAL, FOUR OR MORE
72.23
1.00
33542
REMOVAL OF HEART LESION
20.00
1.00
33542
REMOVAL OF HEART LESION
46.24
1.00
33542
REMOVAL OF HEART LESION
49.89
1.00
33542
REMOVAL OF HEART LESION
69.28
1.00
33545
REPAIR OF HEART DAMAGE
15.00
1.00
33545
REPAIR OF HEART DAMAGE
57.76
1.00
Procedure Code Description
RVU
RVU Coeff Value
33545
REPAIR OF HEART DAMAGE
61.19
1.00
33545
REPAIR OF HEART DAMAGE
81.75
1.00
33548
RESTORE/REMODEL, VENTRICLE
80.40
1.00
33572
OPEN CORONARY ENDARTERECTOMY
6.44
1.00
33572
OPEN CORONARY ENDARTERECTOMY
6.53
1.00
33572
OPEN CORONARY ENDARTERECTOMY
6.56
1.00
33600
CLOSURE OF VALVE
15.00
1.00
33600
CLOSURE OF VALVE
44.86
1.00
33600
CLOSURE OF VALVE
47.07
1.00
33600
CLOSURE OF VALVE
48.70
1.00
33602
CLOSURE OF VALVE
15.00
1.00
33602
CLOSURE OF VALVE
44.54
1.00
33602
CLOSURE OF VALVE
44.70
1.00
33602
CLOSURE OF VALVE
47.87
1.00
33606
ANASTOMOSIS/ARTERY-AORTA
15.00
1.00
33606
ANASTOMOSIS/ARTERY-AORTA
48.77
1.00
33606
ANASTOMOSIS/ARTERY-AORTA
48.79
1.00
33606
ANASTOMOSIS/ARTERY-AORTA
52.56
1.00
33608
REPAIR ANOMALY W/CONDUIT
15.00
1.00
33608
REPAIR ANOMALY W/CONDUIT
50.18
1.00
33608
REPAIR ANOMALY W/CONDUIT
50.26
1.00
33608
REPAIR ANOMALY W/CONDUIT
52.88
1.00
33610
REPAIR BY ENLARGEMENT
15.00
1.00
33610
REPAIR BY ENLARGEMENT
48.93
1.00
33610
REPAIR BY ENLARGEMENT
49.61
1.00
33610
REPAIR BY ENLARGEMENT
53.29
1.00
33611
REPAIR DOUBLE VENTRICLE
15.00
1.00
33611
REPAIR DOUBLE VENTRICLE
52.14
1.00
33611
REPAIR DOUBLE VENTRICLE
53.54
1.00
33611
REPAIR DOUBLE VENTRICLE
56.49
1.00
33612
REPAIR DOUBLE VENTRICLE
15.00
1.00
33612
REPAIR DOUBLE VENTRICLE
55.55
1.00
33612
REPAIR DOUBLE VENTRICLE
55.56
1.00
33612
REPAIR DOUBLE VENTRICLE
59.41
1.00
33615
REPAIR, MODIFIED FONTAN
15.00
1.00
Procedure Code Description
RVU
RVU Coeff Value
33615
REPAIR, MODIFIED FONTAN
52.89
1.00
33615
REPAIR, MODIFIED FONTAN
55.07
1.00
33615
REPAIR, MODIFIED FONTAN
55.95
1.00
33617
REPAIR SINGLE VENTRICLE
15.00
1.00
33617
REPAIR SINGLE VENTRICLE
57.98
1.00
33617
REPAIR SINGLE VENTRICLE
59.40
1.00
33617
REPAIR SINGLE VENTRICLE
63.00
1.00
33619
REPAIR SINGLE VENTRICLE
15.00
1.00
33619
REPAIR SINGLE VENTRICLE
71.55
1.00
33619
REPAIR SINGLE VENTRICLE
72.60
1.00
33619
REPAIR SINGLE VENTRICLE
76.95
1.00
33641
REPAIR HEART SEPTUM DEFECT
20.00
1.00
33641
REPAIR HEART SEPTUM DEFECT
34.22
1.00
33641
REPAIR HEART SEPTUM DEFECT
36.01
1.00
33641
REPAIR HEART SEPTUM DEFECT
43.88
1.00
33645
REVISION OF HEART VEINS
20.00
1.00
33645
REVISION OF HEART VEINS
40.56
1.00
33645
REVISION OF HEART VEINS
42.36
1.00
33645
REVISION OF HEART VEINS
43.45
1.00
33647
REPAIR HEART SEPTUM DEFECTS
20.00
1.00
33647
REPAIR HEART SEPTUM DEFECTS
46.00
1.00
33647
REPAIR HEART SEPTUM DEFECTS
46.61
1.00
33647
REPAIR HEART SEPTUM DEFECTS
49.75
1.00
33660
REPAIR OF HEART DEFECTS
15.00
1.00
33660
REPAIR OF HEART DEFECTS
46.94
1.00
33660
REPAIR OF HEART DEFECTS
48.49
1.00
33660
REPAIR OF HEART DEFECTS
50.19
1.00
33665
REPAIR OF HEART DEFECTS
15.00
1.00
33665
REPAIR OF HEART DEFECTS
47.07
1.00
33665
REPAIR OF HEART DEFECTS
50.08
1.00
33665
REPAIR OF HEART DEFECTS
52.18
1.00
33670
REPAIR OF HEART CHAMBERS
15.00
1.00
33670
REPAIR OF HEART CHAMBERS
50.97
1.00
33670
REPAIR OF HEART CHAMBERS
53.37
1.00
33670
REPAIR OF HEART CHAMBERS
54.41
1.00
Procedure Code Description
RVU
RVU Coeff Value
33675
CLOSE MULT VSD
54.42
1.00
33676
CLOSE MULT VSD W/RESECTION
56.75
1.00
33677
CL MULT VSD W/REM PUL BAND
58.99
1.00
33681
REPAIR HEART SEPTUM DEFECT
20.00
1.00
33681
REPAIR HEART SEPTUM DEFECT
49.59
1.00
33681
REPAIR HEART SEPTUM DEFECT
50.32
1.00
33681
REPAIR HEART SEPTUM DEFECT
52.21
1.00
33684
REPAIR HEART SEPTUM DEFECT
20.00
1.00
33684
REPAIR HEART SEPTUM DEFECT
47.87
1.00
33684
REPAIR HEART SEPTUM DEFECT
50.35
1.00
33684
REPAIR HEART SEPTUM DEFECT
50.94
1.00
33688
REPAIR HEART SEPTUM DEFECT
20.00
1.00
33688
REPAIR HEART SEPTUM DEFECT
45.84
1.00
33688
REPAIR HEART SEPTUM DEFECT
48.91
1.00
33688
REPAIR HEART SEPTUM DEFECT
51.58
1.00
33690
REINFORCE PULMONARY ARTERY
15.00
1.00
33690
REINFORCE PULMONARY ARTERY
31.43
1.00
33690
REINFORCE PULMONARY ARTERY
32.93
1.00
33690
REINFORCE PULMONARY ARTERY
35.76
1.00
33692
REPAIR OF HEART DEFECTS
15.00
1.00
33692
REPAIR OF HEART DEFECTS
48.64
1.00
33692
REPAIR OF HEART DEFECTS
49.27
1.00
33692
REPAIR OF HEART DEFECTS
51.99
1.00
33694
REPAIR OF HEART DEFECTS
15.00
1.00
33694
REPAIR OF HEART DEFECTS
53.42
1.00
33694
REPAIR OF HEART DEFECTS
54.82
1.00
33694
REPAIR OF HEART DEFECTS
56.68
1.00
33697
REPAIR OF HEART DEFECTS
15.00
1.00
33697
REPAIR OF HEART DEFECTS
56.38
1.00
33697
REPAIR OF HEART DEFECTS
58.55
1.00
33697
REPAIR OF HEART DEFECTS
60.15
1.00
33702
REPAIR OF HEART DEFECTS
15.00
1.00
33702
REPAIR OF HEART DEFECTS
42.10
1.00
33702
REPAIR OF HEART DEFECTS
43.31
1.00
33702
REPAIR OF HEART DEFECTS
46.84
1.00
Procedure Code Description
RVU
RVU Coeff Value
33710
REPAIR OF HEART DEFECTS
15.00
1.00
33710
REPAIR OF HEART DEFECTS
48.39
1.00
33710
REPAIR OF HEART DEFECTS
51.04
1.00
33710
REPAIR OF HEART DEFECTS
51.79
1.00
33720
REPAIR OF HEART DEFECT
15.00
1.00
33720
REPAIR OF HEART DEFECT
42.71
1.00
33720
REPAIR OF HEART DEFECT
42.75
1.00
33720
REPAIR OF HEART DEFECT
46.11
1.00
33722
REPAIR OF HEART DEFECT
15.00
1.00
33722
REPAIR OF HEART DEFECT
41.62
1.00
33722
REPAIR OF HEART DEFECT
46.89
1.00
33722
REPAIR OF HEART DEFECT
50.12
1.00
33724
REPAIR VENOUS ANOMALY
43.38
1.00
33726
REPAIR PUL VENOUS STENOSIS
56.57
1.00
33730
REPAIR HEART-VEIN DEFECT(S)
20.00
1.00
33730
REPAIR HEART-VEIN DEFECT(S)
51.87
1.00
33730
REPAIR HEART-VEIN DEFECT(S)
53.96
1.00
33730
REPAIR HEART-VEIN DEFECT(S)
55.12
1.00
33732
REPAIR HEART-VEIN DEFECT
15.00
1.00
33732
REPAIR HEART-VEIN DEFECT
44.92
1.00
33732
REPAIR HEART-VEIN DEFECT
44.97
1.00
33732
REPAIR HEART-VEIN DEFECT
48.14
1.00
33735
REVISION OF HEART CHAMBER
15.00
1.00
33735
REVISION OF HEART CHAMBER
32.79
1.00
33735
REVISION OF HEART CHAMBER
33.92
1.00
33735
REVISION OF HEART CHAMBER
34.76
1.00
33736
REVISION OF HEART CHAMBER
20.00
1.00
33736
REVISION OF HEART CHAMBER
38.15
1.00
33736
REVISION OF HEART CHAMBER
38.69
1.00
33736
REVISION OF HEART CHAMBER
41.78
1.00
33737
REVISION OF HEART CHAMBER
15.00
1.00
33737
REVISION OF HEART CHAMBER
35.71
1.00
33737
REVISION OF HEART CHAMBER
36.28
1.00
33737
REVISION OF HEART CHAMBER
39.55
1.00
33750
MAJOR VESSEL SHUNT
15.00
1.00
Procedure Code Description
RVU
RVU Coeff Value
33750
MAJOR VESSEL SHUNT
33.79
1.00
33750
MAJOR VESSEL SHUNT
35.29
1.00
33750
MAJOR VESSEL SHUNT
36.53
1.00
33755
MAJOR VESSEL SHUNT
15.00
1.00
33755
MAJOR VESSEL SHUNT
34.15
1.00
33755
MAJOR VESSEL SHUNT
35.50
1.00
33755
MAJOR VESSEL SHUNT
36.97
1.00
33762
MAJOR VESSEL SHUNT
15.00
1.00
33762
MAJOR VESSEL SHUNT
33.92
1.00
33762
MAJOR VESSEL SHUNT
35.40
1.00
33762
MAJOR VESSEL SHUNT
36.78
1.00
33764
MAJOR VESSEL SHUNT & GRAFT
15.00
1.00
33764
MAJOR VESSEL SHUNT & GRAFT
34.40
1.00
33764
MAJOR VESSEL SHUNT & GRAFT
34.84
1.00
33764
MAJOR VESSEL SHUNT & GRAFT
36.87
1.00
33766
MAJOR VESSEL SHUNT
15.00
1.00
33766
MAJOR VESSEL SHUNT
38.13
1.00
33766
MAJOR VESSEL SHUNT
38.54
1.00
33766
MAJOR VESSEL SHUNT
41.13
1.00
33767
MAJOR VESSEL SHUNT
20.00
1.00
33767
MAJOR VESSEL SHUNT
38.95
1.00
33767
MAJOR VESSEL SHUNT
40.06
1.00
33767
MAJOR VESSEL SHUNT
42.83
1.00
33768
CAVOPULMONARY SHUNTING
11.87
1.00
33770
REPAIR GREAT VESSELS DEFECT
20.00
1.00
33770
REPAIR GREAT VESSELS DEFECT
57.13
1.00
33770
REPAIR GREAT VESSELS DEFECT
59.17
1.00
33770
REPAIR GREAT VESSELS DEFECT
59.46
1.00
33771
REPAIR GREAT VESSELS DEFECT
20.00
1.00
33771
REPAIR GREAT VESSELS DEFECT
52.71
1.00
33771
REPAIR GREAT VESSELS DEFECT
54.27
1.00
33771
REPAIR GREAT VESSELS DEFECT
60.56
1.00
33774
REPAIR GREAT VESSELS DEFECT
20.00
1.00
33774
REPAIR GREAT VESSELS DEFECT
49.93
1.00
33774
REPAIR GREAT VESSELS DEFECT
50.20
1.00
Procedure Code Description
RVU
RVU Coeff Value
33774
REPAIR GREAT VESSELS DEFECT
51.74
1.00
33775
REPAIR GREAT VESSELS DEFECT
51.66
1.00
33775
REPAIR GREAT VESSELS DEFECT
51.94
1.00
33775
REPAIR GREAT VESSELS DEFECT
53.46
1.00
33776
REPAIR GREAT VESSELS DEFECT
54.60
1.00
33776
REPAIR GREAT VESSELS DEFECT
55.39
1.00
33776
REPAIR GREAT VESSELS DEFECT
57.03
1.00
33777
REPAIR GREAT VESSELS DEFECT
53.64
1.00
33777
REPAIR GREAT VESSELS DEFECT
53.80
1.00
33777
REPAIR GREAT VESSELS DEFECT
55.38
1.00
33778
REPAIR GREAT VESSELS DEFECT
62.75
1.00
33778
REPAIR GREAT VESSELS DEFECT
65.55
1.00
33778
REPAIR GREAT VESSELS DEFECT
65.69
1.00
33778
REPAIR GREAT VESSELS DEFECT
999.99
1.00
33779
REPAIR GREAT VESSELS DEFECT
54.54
1.00
33779
REPAIR GREAT VESSELS DEFECT
56.77
1.00
33779
REPAIR GREAT VESSELS DEFECT
61.95
1.00
33780
REPAIR GREAT VESSELS DEFECT
64.65
1.00
33780
REPAIR GREAT VESSELS DEFECT
67.10
1.00
33780
REPAIR GREAT VESSELS DEFECT
69.36
1.00
33781
REPAIR GREAT VESSELS DEFECT
55.88
1.00
33781
REPAIR GREAT VESSELS DEFECT
56.77
1.00
33781
REPAIR GREAT VESSELS DEFECT
64.32
1.00
33786
REPAIR ARTERIAL TRUNK
15.00
1.00
33786
REPAIR ARTERIAL TRUNK
61.39
1.00
33786
REPAIR ARTERIAL TRUNK
63.22
1.00
33786
REPAIR ARTERIAL TRUNK
63.86
1.00
33788
REVISION OF PULMONARY ARTERY
15.00
1.00
33788
REVISION OF PULMONARY ARTERY
42.61
1.00
33788
REVISION OF PULMONARY ARTERY
42.77
1.00
33788
REVISION OF PULMONARY ARTERY
45.32
1.00
33800
AORTIC SUSPENSION
10.00
1.00
33800
AORTIC SUSPENSION
25.77
1.00
33800
AORTIC SUSPENSION
26.80
1.00
33800
AORTIC SUSPENSION
29.80
1.00
Procedure Code Description
RVU
RVU Coeff Value
33802
REPAIR VESSEL DEFECT
15.00
1.00
33802
REPAIR VESSEL DEFECT
28.71
1.00
33802
REPAIR VESSEL DEFECT
28.81
1.00
33802
REPAIR VESSEL DEFECT
32.24
1.00
33803
REPAIR VESSEL DEFECT
15.00
1.00
33803
REPAIR VESSEL DEFECT
31.46
1.00
33803
REPAIR VESSEL DEFECT
32.58
1.00
33803
REPAIR VESSEL DEFECT
35.74
1.00
33813
REPAIR SEPTAL DEFECT
34.96
1.00
33813
REPAIR SEPTAL DEFECT
35.58
1.00
33813
REPAIR SEPTAL DEFECT
38.37
1.00
33814
REPAIR SEPTAL DEFECT
41.50
1.00
33814
REPAIR SEPTAL DEFECT
41.93
1.00
33814
REPAIR SEPTAL DEFECT
44.76
1.00
33820
REVISE MAJOR VESSEL
15.00
1.00
33820
REVISE MAJOR VESSEL
26.82
1.00
33820
REVISE MAJOR VESSEL
27.19
1.00
33820
REVISE MAJOR VESSEL
29.84
1.00
33822
REVISE MAJOR VESSEL
15.00
1.00
33822
REVISE MAJOR VESSEL
28.54
1.00
33822
REVISE MAJOR VESSEL
29.13
1.00
33822
REVISE MAJOR VESSEL
33.49
1.00
33824
REVISE MAJOR VESSEL
15.00
1.00
33824
REVISE MAJOR VESSEL
32.22
1.00
33824
REVISE MAJOR VESSEL
32.70
1.00
33824
REVISE MAJOR VESSEL
34.76
1.00
33840
REMOVE AORTA CONSTRICTION
15.00
1.00
33840
REMOVE AORTA CONSTRICTION
32.29
1.00
33840
REMOVE AORTA CONSTRICTION
33.81
1.00
33840
REMOVE AORTA CONSTRICTION
36.94
1.00
33845
REMOVE AORTA CONSTRICTION
15.00
1.00
33845
REMOVE AORTA CONSTRICTION
37.01
1.00
33845
REMOVE AORTA CONSTRICTION
37.56
1.00
33845
REMOVE AORTA CONSTRICTION
40.15
1.00
33851
REMOVE AORTA CONSTRICTION
15.00
1.00
Procedure Code Description
RVU
RVU Coeff Value
33851
REMOVE AORTA CONSTRICTION
34.57
1.00
33851
REMOVE AORTA CONSTRICTION
35.47
1.00
33851
REMOVE AORTA CONSTRICTION
38.93
1.00
33852
REPAIR SEPTAL DEFECT
37.11
1.00
33852
REPAIR SEPTAL DEFECT
38.97
1.00
33852
REPAIR SEPTAL DEFECT
42.24
1.00
33853
REPAIR SEPTAL DEFECT
20.00
1.00
33853
REPAIR SEPTAL DEFECT
51.69
1.00
33853
REPAIR SEPTAL DEFECT
51.72
1.00
33853
REPAIR SEPTAL DEFECT
54.85
1.00
33860
ASCENDING AORTIC GRAFT
20.00
1.00
33860
ASCENDING AORTIC GRAFT
59.68
1.00
33860
ASCENDING AORTIC GRAFT
61.20
1.00
33860
ASCENDING AORTIC GRAFT
85.63
1.00
33861
ASCENDING AORTIC GRAFT
20.00
1.00
33861
ASCENDING AORTIC GRAFT
64.86
1.00
33861
ASCENDING AORTIC GRAFT
66.42
1.00
33861
ASCENDING AORTIC GRAFT
67.39
1.00
33863
ASCENDING AORTIC GRAFT
20.00
1.00
33863
ASCENDING AORTIC GRAFT
69.28
1.00
33863
ASCENDING AORTIC GRAFT
70.74
1.00
33863
ASCENDING AORTIC GRAFT
85.85
1.00
33864
ASCENDING AORTIC GRAFT
88.23
1.00
33870
TRANSVERSE AORTIC ARCH GRAFT
20.00
1.00
33870
TRANSVERSE AORTIC ARCH GRAFT
68.56
1.00
33870
TRANSVERSE AORTIC ARCH GRAFT
69.92
1.00
33870
TRANSVERSE AORTIC ARCH GRAFT
70.33
1.00
33875
THORACIC AORTIC GRAFT
20.00
1.00
33875
THORACIC AORTIC GRAFT
52.11
1.00
33875
THORACIC AORTIC GRAFT
54.24
1.00
33875
THORACIC AORTIC GRAFT
54.50
1.00
33877
THORACOABDOMINAL GRAFT
15.00
1.00
33877
THORACOABDOMINAL GRAFT
65.08
1.00
33877
THORACOABDOMINAL GRAFT
69.42
1.00
33877
THORACOABDOMINAL GRAFT
95.87
1.00
Procedure Code Description
RVU
RVU Coeff Value
33880
ENDOVASC TAA REPR INCL SUBCL
49.55
1.00
33881
ENDOVASC TAA REPR W/O SUBCL
42.53
1.00
33883
INSERT ENDOVASC PROSTH, TAA
31.21
1.00
33884
ENDOVASC PROSTH, TAA, ADD-ON
11.43
1.00
33886
ENDOVASC PROSTH, DELAYED
26.81
1.00
33889
ARTERY TRANSPOSE/ENDOVAS TAA
22.61
1.00
33891
CAR-CAR BP GRFT/ENDOVAS TAA
28.28
1.00
33910
REMOVE LUNG ARTERY EMBOLI
20.00
1.00
33910
REMOVE LUNG ARTERY EMBOLI
39.76
1.00
33910
REMOVE LUNG ARTERY EMBOLI
41.93
1.00
33910
REMOVE LUNG ARTERY EMBOLI
45.49
1.00
33915
REMOVE LUNG ARTERY EMBOLI
15.00
1.00
33915
REMOVE LUNG ARTERY EMBOLI
32.12
1.00
33915
REMOVE LUNG ARTERY EMBOLI
34.59
1.00
33915
REMOVE LUNG ARTERY EMBOLI
35.84
1.00
33916
SURGERY OF GREAT VESSEL
40.89
1.00
33916
SURGERY OF GREAT VESSEL
43.81
1.00
33916
SURGERY OF GREAT VESSEL
45.58
1.00
33917
REPAIR PULMONARY ARTERY
15.00
1.00
33917
REPAIR PULMONARY ARTERY
40.55
1.00
33917
REPAIR PULMONARY ARTERY
41.39
1.00
33917
REPAIR PULMONARY ARTERY
43.61
1.00
33918
REPAIR PULMONARY ATRESIA
15.00
1.00
33918
REPAIR PULMONARY ATRESIA
42.60
1.00
33918
REPAIR PULMONARY ATRESIA
42.72
1.00
33918
REPAIR PULMONARY ATRESIA
45.46
1.00
33919
REPAIR PULMONARY ATRESIA
20.00
1.00
33919
REPAIR PULMONARY ATRESIA
61.76
1.00
33919
REPAIR PULMONARY ATRESIA
63.35
1.00
33919
REPAIR PULMONARY ATRESIA
65.16
1.00
33920
REPAIR PULMONARY ATRESIA
20.00
1.00
33920
REPAIR PULMONARY ATRESIA
49.89
1.00
33920
REPAIR PULMONARY ATRESIA
50.17
1.00
33920
REPAIR PULMONARY ATRESIA
52.46
1.00
33922
TRANSECT PULMONARY ARTERY
20.00
1.00
Procedure Code Description
RVU
RVU Coeff Value
33922
TRANSECT PULMONARY ARTERY
37.23
1.00
33922
TRANSECT PULMONARY ARTERY
37.68
1.00
33922
TRANSECT PULMONARY ARTERY
40.20
1.00
33924
REMOVE PULMONARY SHUNT
8.01
1.00
33924
REMOVE PULMONARY SHUNT
8.06
1.00
33924
REMOVE PULMONARY SHUNT
8.23
1.00
33925
RPR PUL ART UNIFOCAL W/O CPB
48.68
1.00
33926
REPR PUL ART, UNIFOCAL W/CPB
64.72
1.00
33935
TRANSPLANTATION, HEART/LUNG
20.00
1.00
33935
TRANSPLANTATION, HEART/LUNG
95.78
1.00
33935
TRANSPLANTATION, HEART/LUNG
97.00
1.00
33935
TRANSPLANTATION, HEART/LUNG
99.77
1.00
33945
TRANSPLANTATION OF HEART
20.00
1.00
33945
TRANSPLANTATION OF HEART
69.31
1.00
33945
TRANSPLANTATION OF HEART
70.24
1.00
33945
TRANSPLANTATION OF HEART
125.31
1.00
33960
EXTERNAL CIRCULATION ASSIST
26.46
1.00
33960
EXTERNAL CIRCULATION ASSIST
26.84
1.00
33960
EXTERNAL CIRCULATION ASSIST
27.77
1.00
33961
EXTERNAL CIRCULATION ASSIST
15.27
1.00
33961
EXTERNAL CIRCULATION ASSIST
16.05
1.00
33961
EXTERNAL CIRCULATION ASSIST
16.31
1.00
33967
INSERT IA PERCUT DEVICE
4.00
1.00
33967
INSERT IA PERCUT DEVICE
7.00
1.00
33967
INSERT IA PERCUT DEVICE
7.03
1.00
33967
INSERT IA PERCUT DEVICE
7.50
1.00
33968
REMOVE AORTIC ASSIST DEVICE
0.94
1.00
33968
REMOVE AORTIC ASSIST DEVICE
0.95
1.00
33968
REMOVE AORTIC ASSIST DEVICE
0.97
1.00
33970
AORTIC CIRCULATION ASSIST
9.74
1.00
33970
AORTIC CIRCULATION ASSIST
9.87
1.00
33970
AORTIC CIRCULATION ASSIST
10.18
1.00
33971
AORTIC CIRCULATION ASSIST
15.00
1.00
33971
AORTIC CIRCULATION ASSIST
16.92
1.00
33971
AORTIC CIRCULATION ASSIST
18.84
1.00
Procedure Code Description
RVU
RVU Coeff Value
33971
AORTIC CIRCULATION ASSIST
19.47
1.00
33973
INSERT BALLOON DEVICE
14.08
1.00
33973
INSERT BALLOON DEVICE
14.29
1.00
33973
INSERT BALLOON DEVICE
14.86
1.00
33973
INSERT BALLOON DEVICE
15.00
1.00
33974
REMOVE INTRA-AORTIC BALLOON
15.00
1.00
33974
REMOVE INTRA-AORTIC BALLOON
24.13
1.00
33974
REMOVE INTRA-AORTIC BALLOON
24.86
1.00
33974
REMOVE INTRA-AORTIC BALLOON
26.87
1.00
33975
IMPLANT VENTRICULAR DEVICE
15.00
1.00
33975
IMPLANT VENTRICULAR DEVICE
29.00
1.00
33975
IMPLANT VENTRICULAR DEVICE
29.35
1.00
33975
IMPLANT VENTRICULAR DEVICE
30.88
1.00
33976
IMPLANT VENTRICULAR DEVICE
15.00
1.00
33976
IMPLANT VENTRICULAR DEVICE
33.34
1.00
33976
IMPLANT VENTRICULAR DEVICE
33.95
1.00
33976
IMPLANT VENTRICULAR DEVICE
34.27
1.00
33977
REMOVE VENTRICULAR DEVICE
15.00
1.00
33977
REMOVE VENTRICULAR DEVICE
32.23
1.00
33977
REMOVE VENTRICULAR DEVICE
33.09
1.00
33977
REMOVE VENTRICULAR DEVICE
33.33
1.00
33978
REMOVE VENTRICULAR DEVICE
15.00
1.00
33978
REMOVE VENTRICULAR DEVICE
35.76
1.00
33978
REMOVE VENTRICULAR DEVICE
36.50
1.00
33978
REMOVE VENTRICULAR DEVICE
36.71
1.00
33979
INSERT INTRACORPOREAL DEVICE
15.00
1.00
33979
INSERT INTRACORPOREAL DEVICE
65.70
1.00
33979
INSERT INTRACORPOREAL DEVICE
67.80
1.00
33979
INSERT INTRACORPOREAL DEVICE
67.86
1.00
33980
REMOVE INTRACORPOREAL DEVICE
15.00
1.00
33980
REMOVE INTRACORPOREAL DEVICE
87.24
1.00
33980
REMOVE INTRACORPOREAL DEVICE
87.32
1.00
33980
REMOVE INTRACORPOREAL DEVICE
99.15
1.00
34001
REMOVAL OF ARTERY CLOT
10.00
1.00
34001
REMOVAL OF ARTERY CLOT
20.22
1.00
Procedure Code Description
RVU
RVU Coeff Value
34001
REMOVAL OF ARTERY CLOT
21.40
1.00
34001
REMOVAL OF ARTERY CLOT
26.47
1.00
34051
REMOVAL OF ARTERY CLOT
10.00
1.00
34051
REMOVAL OF ARTERY CLOT
24.02
1.00
34051
REMOVAL OF ARTERY CLOT
25.30
1.00
34051
REMOVAL OF ARTERY CLOT
26.68
1.00
34101
REMOVAL OF ARTERY CLOT
5.00
1.00
34101
REMOVAL OF ARTERY CLOT
15.82
1.00
34101
REMOVAL OF ARTERY CLOT
16.71
1.00
34101
REMOVAL OF ARTERY CLOT
16.94
1.00
34111
REMOVAL OF ARM ARTERY CLOT
10.00
1.00
34111
REMOVAL OF ARM ARTERY CLOT
15.62
1.00
34111
REMOVAL OF ARM ARTERY CLOT
16.40
1.00
34111
REMOVAL OF ARM ARTERY CLOT
16.93
1.00
34151
REMOVAL OF ARTERY CLOT
10.00
1.00
34151
REMOVAL OF ARTERY CLOT
37.08
1.00
34151
REMOVAL OF ARTERY CLOT
37.63
1.00
34151
REMOVAL OF ARTERY CLOT
39.29
1.00
34201
REMOVAL OF ARTERY CLOT
4.00
1.00
34201
REMOVAL OF ARTERY CLOT
16.08
1.00
34201
REMOVAL OF ARTERY CLOT
16.69
1.00
34201
REMOVAL OF ARTERY CLOT
27.32
1.00
34203
REMOVAL OF LEG ARTERY CLOT
8.00
1.00
34203
REMOVAL OF LEG ARTERY CLOT
25.33
1.00
34203
REMOVAL OF LEG ARTERY CLOT
26.22
1.00
34203
REMOVAL OF LEG ARTERY CLOT
27.12
1.00
34401
REMOVAL OF VEIN CLOT
10.00
1.00
34401
REMOVAL OF VEIN CLOT
36.25
1.00
34401
REMOVAL OF VEIN CLOT
37.13
1.00
34401
REMOVAL OF VEIN CLOT
40.34
1.00
34421
REMOVAL OF VEIN CLOT
6.00
1.00
34421
REMOVAL OF VEIN CLOT
18.83
1.00
34421
REMOVAL OF VEIN CLOT
19.46
1.00
34421
REMOVAL OF VEIN CLOT
20.47
1.00
34451
REMOVAL OF VEIN CLOT
10.00
1.00
Procedure Code Description
RVU
RVU Coeff Value
34451
REMOVAL OF VEIN CLOT
39.35
1.00
34451
REMOVAL OF VEIN CLOT
40.37
1.00
34451
REMOVAL OF VEIN CLOT
42.43
1.00
34471
REMOVAL OF VEIN CLOT
10.00
1.00
34471
REMOVAL OF VEIN CLOT
16.01
1.00
34471
REMOVAL OF VEIN CLOT
16.60
1.00
34471
REMOVAL OF VEIN CLOT
29.19
1.00
34490
REMOVAL OF VEIN CLOT
10.00
1.00
34490
REMOVAL OF VEIN CLOT
16.19
1.00
34490
REMOVAL OF VEIN CLOT
16.71
1.00
34490
REMOVAL OF VEIN CLOT
17.03
1.00
34501
REPAIR VALVE, FEMORAL VEIN
8.00
1.00
34501
REPAIR VALVE, FEMORAL VEIN
26.18
1.00
34501
REPAIR VALVE, FEMORAL VEIN
26.46
1.00
34501
REPAIR VALVE, FEMORAL VEIN
26.62
1.00
34502
RECONSTRUCT VENA CAVA
20.00
1.00
34502
RECONSTRUCT VENA CAVA
40.92
1.00
34502
RECONSTRUCT VENA CAVA
42.76
1.00
34502
RECONSTRUCT VENA CAVA
42.86
1.00
34510
TRANSPOSITION OF VEIN VALVE
3.00
1.00
34510
TRANSPOSITION OF VEIN VALVE
29.92
1.00
34510
TRANSPOSITION OF VEIN VALVE
30.33
1.00
34510
TRANSPOSITION OF VEIN VALVE
30.82
1.00
34520
CROSS-OVER VEIN GRAFT
3.00
1.00
34520
CROSS-OVER VEIN GRAFT
28.34
1.00
34520
CROSS-OVER VEIN GRAFT
28.66
1.00
34520
CROSS-OVER VEIN GRAFT
28.75
1.00
34530
LEG VEIN FUSION
3.00
1.00
34530
LEG VEIN FUSION
26.89
1.00
34530
LEG VEIN FUSION
27.44
1.00
34530
LEG VEIN FUSION
27.75
1.00
34800
ENDOVAS AAA REPR W/SM TUBE
7.00
1.00
34800
ENDOVAS AAA REPR W/SM TUBE
31.18
1.00
34800
ENDOVAS AAA REPR W/SM TUBE
31.73
1.00
34800
ENDOVAS AAA REPR W/SM TUBE
32.13
1.00
Procedure Code Description
RVU
RVU Coeff Value
34802
ENDOVAS AAA REPR W/2-P PART
7.00
1.00
34802
ENDOVAS AAA REPR W/2-P PART
34.34
1.00
34802
ENDOVAS AAA REPR W/2-P PART
34.79
1.00
34802
ENDOVAS AAA REPR W/2-P PART
34.96
1.00
34803
ENDOVAS AAA REPR W/3-P PART
35.64
1.00
34804
ENDOVAS AAA REPR W/1-P PART
7.00
1.00
34804
ENDOVAS AAA REPR W/1-P PART
34.34
1.00
34804
ENDOVAS AAA REPR W/1-P PART
34.80
1.00
34804
ENDOVAS AAA REPR W/1-P PART
34.93
1.00
34805
ENDOVAS AAA REPR W/LONG TUBE
32.75
1.00
34805
ENDOVAS AAA REPR W/LONG TUBE
33.30
1.00
34806
ANEURYSM PRESS SENSOR ADD-ON
3.00
1.00
34808
ENDOVAS ILIAC A DEVICE ADDON
5.82
1.00
34808
ENDOVAS ILIAC A DEVICE ADDON
5.85
1.00
34808
ENDOVAS ILIAC A DEVICE ADDON
5.90
1.00
34812
XPOSE FOR ENDOPROSTH, FEMORL
9.53
1.00
34812
XPOSE FOR ENDOPROSTH, FEMORL
9.57
1.00
34812
XPOSE FOR ENDOPROSTH, FEMORL
9.83
1.00
34812
XPOSE FOR ENDOPROSTH, FEMORL
15.00
1.00
34813
FEMORAL ENDOVAS GRAFT ADD-ON
6.74
1.00
34813
FEMORAL ENDOVAS GRAFT ADD-ON
6.78
1.00
34820
XPOSE FOR ENDOPROSTH, ILIAC
13.75
1.00
34820
XPOSE FOR ENDOPROSTH, ILIAC
13.83
1.00
34820
XPOSE FOR ENDOPROSTH, ILIAC
14.05
1.00
34820
XPOSE FOR ENDOPROSTH, ILIAC
15.00
1.00
34825
ENDOVASC EXTEND PROSTH, INIT
7.00
1.00
34825
ENDOVASC EXTEND PROSTH, INIT
18.81
1.00
34825
ENDOVASC EXTEND PROSTH, INIT
19.19
1.00
34825
ENDOVASC EXTEND PROSTH, INIT
19.58
1.00
34826
ENDOVASC EXTEN PROSTH, ADDÏL
5.81
1.00
34826
ENDOVASC EXTEN PROSTH, ADDÏL
5.83
1.00
34826
ENDOVASC EXTEN PROSTH, ADDÏL
5.85
1.00
34830
OPEN AORTIC TUBE PROSTH REPR
15.00
1.00
34830
OPEN AORTIC TUBE PROSTH REPR
48.24
1.00
34830
OPEN AORTIC TUBE PROSTH REPR
49.12
1.00
Procedure Code Description
RVU
RVU Coeff Value
34830
OPEN AORTIC TUBE PROSTH REPR
51.52
1.00
34831
OPEN AORTOILIAC PROSTH REPR
15.00
1.00
34831
OPEN AORTOILIAC PROSTH REPR
49.55
1.00
34831
OPEN AORTOILIAC PROSTH REPR
50.14
1.00
34831
OPEN AORTOILIAC PROSTH REPR
54.60
1.00
34832
OPEN AORTOFEMOR PROSTH REPR
15.00
1.00
34832
OPEN AORTOFEMOR PROSTH REPR
52.25
1.00
34832
OPEN AORTOFEMOR PROSTH REPR
53.02
1.00
34832
OPEN AORTOFEMOR PROSTH REPR
55.34
1.00
34833
XPOSE FOR ENDOPROSTH, ILIAC
17.33
1.00
34833
XPOSE FOR ENDOPROSTH, ILIAC
17.43
1.00
34833
XPOSE FOR ENDOPROSTH, ILIAC
17.68
1.00
34834
XPOSE, ENDOPROSTH, BRACHIAL
7.90
1.00
34834
XPOSE, ENDOPROSTH, BRACHIAL
8.16
1.00
34834
XPOSE, ENDOPROSTH, BRACHIAL
8.32
1.00
34900
ENDOVASC ILIAC REPR W/GRAFT
25.53
1.00
34900
ENDOVASC ILIAC REPR W/GRAFT
25.98
1.00
34900
ENDOVASC ILIAC REPR W/GRAFT
26.11
1.00
35001
REPAIR DEFECT OF ARTERY
6.00
1.00
35001
REPAIR DEFECT OF ARTERY
30.47
1.00
35001
REPAIR DEFECT OF ARTERY
31.95
1.00
35001
REPAIR DEFECT OF ARTERY
32.14
1.00
35002
REPAIR ARTERY RUPTURE, NECK
6.00
1.00
35002
REPAIR ARTERY RUPTURE, NECK
31.89
1.00
35002
REPAIR ARTERY RUPTURE, NECK
32.91
1.00
35002
REPAIR ARTERY RUPTURE, NECK
33.74
1.00
35005
REPAIR DEFECT OF ARTERY
10.00
1.00
35005
REPAIR DEFECT OF ARTERY
27.26
1.00
35005
REPAIR DEFECT OF ARTERY
28.61
1.00
35005
REPAIR DEFECT OF ARTERY
29.08
1.00
35011
REPAIR DEFECT OF ARTERY
10.00
1.00
35011
REPAIR DEFECT OF ARTERY
26.70
1.00
35011
REPAIR DEFECT OF ARTERY
27.56
1.00
35011
REPAIR DEFECT OF ARTERY
28.06
1.00
35013
REPAIR ARTERY RUPTURE, ARM
6.00
1.00
Procedure Code Description
RVU
RVU Coeff Value
35013
REPAIR ARTERY RUPTURE, ARM
32.65
1.00
35013
REPAIR ARTERY RUPTURE, ARM
34.00
1.00
35013
REPAIR ARTERY RUPTURE, ARM
34.79
1.00
35021
REPAIR DEFECT OF ARTERY
20.00
1.00
35021
REPAIR DEFECT OF ARTERY
30.19
1.00
35021
REPAIR DEFECT OF ARTERY
31.45
1.00
35021
REPAIR DEFECT OF ARTERY
34.08
1.00
35022
REPAIR ARTERY RUPTURE, CHEST
6.00
1.00
35022
REPAIR ARTERY RUPTURE, CHEST
34.60
1.00
35022
REPAIR ARTERY RUPTURE, CHEST
35.65
1.00
35022
REPAIR ARTERY RUPTURE, CHEST
38.49
1.00
35045
REPAIR DEFECT OF ARM ARTERY
6.00
1.00
35045
REPAIR DEFECT OF ARM ARTERY
26.63
1.00
35045
REPAIR DEFECT OF ARM ARTERY
27.28
1.00
35045
REPAIR DEFECT OF ARM ARTERY
27.43
1.00
35081
REPAIR DEFECT OF ARTERY
12.00
1.00
35081
REPAIR DEFECT OF ARTERY
42.86
1.00
35081
REPAIR DEFECT OF ARTERY
43.34
1.00
35081
REPAIR DEFECT OF ARTERY
48.74
1.00
35082
REPAIR ARTERY RUPTURE, AORTA
6.00
1.00
35082
REPAIR ARTERY RUPTURE, AORTA
57.17
1.00
35082
REPAIR ARTERY RUPTURE, AORTA
58.70
1.00
35082
REPAIR ARTERY RUPTURE, AORTA
61.35
1.00
35091
REPAIR DEFECT OF ARTERY
15.00
1.00
35091
REPAIR DEFECT OF ARTERY
51.86
1.00
35091
REPAIR DEFECT OF ARTERY
53.40
1.00
35091
REPAIR DEFECT OF ARTERY
53.91
1.00
35092
REPAIR ARTERY RUPTURE, AORTA
6.00
1.00
35092
REPAIR ARTERY RUPTURE, AORTA
66.24
1.00
35092
REPAIR ARTERY RUPTURE, AORTA
67.83
1.00
35092
REPAIR ARTERY RUPTURE, AORTA
73.23
1.00
35102
REPAIR DEFECT OF ARTERY
12.00
1.00
35102
REPAIR DEFECT OF ARTERY
46.53
1.00
35102
REPAIR DEFECT OF ARTERY
47.27
1.00
35102
REPAIR DEFECT OF ARTERY
52.92
1.00
Procedure Code Description
RVU
RVU Coeff Value
35103
REPAIR ARTERY RUPTURE, GROIN
6.00
1.00
35103
REPAIR ARTERY RUPTURE, GROIN
59.68
1.00
35103
REPAIR ARTERY RUPTURE, GROIN
60.93
1.00
35103
REPAIR ARTERY RUPTURE, GROIN
63.44
1.00
35111
REPAIR DEFECT OF ARTERY
15.00
1.00
35111
REPAIR DEFECT OF ARTERY
36.99
1.00
35111
REPAIR DEFECT OF ARTERY
37.65
1.00
35111
REPAIR DEFECT OF ARTERY
39.07
1.00
35112
REPAIR ARTERY RUPTURE,SPLEEN
6.00
1.00
35112
REPAIR ARTERY RUPTURE,SPLEEN
43.60
1.00
35112
REPAIR ARTERY RUPTURE,SPLEEN
44.32
1.00
35112
REPAIR ARTERY RUPTURE,SPLEEN
47.81
1.00
35121
REPAIR DEFECT OF ARTERY
7.00
1.00
35121
REPAIR DEFECT OF ARTERY
45.00
1.00
35121
REPAIR DEFECT OF ARTERY
45.91
1.00
35121
REPAIR DEFECT OF ARTERY
46.44
1.00
35122
REPAIR ARTERY RUPTURE, BELLY
6.00
1.00
35122
REPAIR ARTERY RUPTURE, BELLY
52.00
1.00
35122
REPAIR ARTERY RUPTURE, BELLY
53.08
1.00
35122
REPAIR ARTERY RUPTURE, BELLY
55.46
1.00
35131
REPAIR DEFECT OF ARTERY
12.00
1.00
35131
REPAIR DEFECT OF ARTERY
37.49
1.00
35131
REPAIR DEFECT OF ARTERY
38.30
1.00
35131
REPAIR DEFECT OF ARTERY
39.66
1.00
35132
REPAIR ARTERY RUPTURE, GROIN
6.00
1.00
35132
REPAIR ARTERY RUPTURE, GROIN
44.30
1.00
35132
REPAIR ARTERY RUPTURE, GROIN
45.37
1.00
35132
REPAIR ARTERY RUPTURE, GROIN
47.82
1.00
35141
REPAIR DEFECT OF ARTERY
5.00
1.00
35141
REPAIR DEFECT OF ARTERY
30.15
1.00
35141
REPAIR DEFECT OF ARTERY
30.91
1.00
35141
REPAIR DEFECT OF ARTERY
31.42
1.00
35142
REPAIR ARTERY RUPTURE, THIGH
6.00
1.00
35142
REPAIR ARTERY RUPTURE, THIGH
34.61
1.00
35142
REPAIR ARTERY RUPTURE, THIGH
35.78
1.00
Procedure Code Description 35142
REPAIR ARTERY RUPTURE, THIGH
35151
RVU
RVU Coeff Value
37.55
1.00
REPAIR DEFECT OF ARTERY
8.00
1.00
35151
REPAIR DEFECT OF ARTERY
34.11
1.00
35151
REPAIR DEFECT OF ARTERY
34.98
1.00
35151
REPAIR DEFECT OF ARTERY
35.42
1.00
35152
REPAIR ARTERY RUPTURE, KNEE
6.00
1.00
35152
REPAIR ARTERY RUPTURE, KNEE
37.97
1.00
35152
REPAIR ARTERY RUPTURE, KNEE
39.34
1.00
35152
REPAIR ARTERY RUPTURE, KNEE
41.08
1.00
35161
REPAIR DEFECT OF ARTERY
8.00
1.00
35161
REPAIR DEFECT OF ARTERY
29.67
1.00
35161
REPAIR DEFECT OF ARTERY
30.59
1.00
35162
REPAIR ARTERY RUPTURE
6.00
1.00
35162
REPAIR ARTERY RUPTURE
30.85
1.00
35162
REPAIR ARTERY RUPTURE
32.03
1.00
35180
REPAIR BLOOD VESSEL LESION
10.00
1.00
35180
REPAIR BLOOD VESSEL LESION
21.41
1.00
35180
REPAIR BLOOD VESSEL LESION
22.32
1.00
35180
REPAIR BLOOD VESSEL LESION
23.18
1.00
35182
REPAIR BLOOD VESSEL LESION
44.18
1.00
35182
REPAIR BLOOD VESSEL LESION
45.08
1.00
35182
REPAIR BLOOD VESSEL LESION
48.35
1.00
35184
REPAIR BLOOD VESSEL LESION
27.13
1.00
35184
REPAIR BLOOD VESSEL LESION
27.93
1.00
35184
REPAIR BLOOD VESSEL LESION
28.47
1.00
35188
REPAIR BLOOD VESSEL LESION
22.39
1.00
35188
REPAIR BLOOD VESSEL LESION
23.78
1.00
35188
REPAIR BLOOD VESSEL LESION
23.90
1.00
35189
REPAIR BLOOD VESSEL LESION
41.58
1.00
35189
REPAIR BLOOD VESSEL LESION
42.52
1.00
35189
REPAIR BLOOD VESSEL LESION
44.59
1.00
35190
REPAIR BLOOD VESSEL LESION
3.00
1.00
35190
REPAIR BLOOD VESSEL LESION
19.96
1.00
35190
REPAIR BLOOD VESSEL LESION
20.83
1.00
35190
REPAIR BLOOD VESSEL LESION
20.84
1.00
Procedure Code Description
RVU
RVU Coeff Value
35201
REPAIR BLOOD VESSEL LESION
10.00
1.00
35201
REPAIR BLOOD VESSEL LESION
24.33
1.00
35201
REPAIR BLOOD VESSEL LESION
25.55
1.00
35201
REPAIR BLOOD VESSEL LESION
26.17
1.00
35206
REPAIR BLOOD VESSEL LESION
5.00
1.00
35206
REPAIR BLOOD VESSEL LESION
21.09
1.00
35206
REPAIR BLOOD VESSEL LESION
21.37
1.00
35206
REPAIR BLOOD VESSEL LESION
21.80
1.00
35207
REPAIR BLOOD VESSEL LESION
5.00
1.00
35207
REPAIR BLOOD VESSEL LESION
19.03
1.00
35207
REPAIR BLOOD VESSEL LESION
19.29
1.00
35207
REPAIR BLOOD VESSEL LESION
21.06
1.00
35211
REPAIR BLOOD VESSEL LESION
15.00
1.00
35211
REPAIR BLOOD VESSEL LESION
36.20
1.00
35211
REPAIR BLOOD VESSEL LESION
37.93
1.00
35211
REPAIR BLOOD VESSEL LESION
38.72
1.00
35216
REPAIR BLOOD VESSEL LESION
15.00
1.00
35216
REPAIR BLOOD VESSEL LESION
30.38
1.00
35216
REPAIR BLOOD VESSEL LESION
32.59
1.00
35216
REPAIR BLOOD VESSEL LESION
52.15
1.00
35221
REPAIR BLOOD VESSEL LESION
6.00
1.00
35221
REPAIR BLOOD VESSEL LESION
36.27
1.00
35221
REPAIR BLOOD VESSEL LESION
36.49
1.00
35221
REPAIR BLOOD VESSEL LESION
39.06
1.00
35226
REPAIR BLOOD VESSEL LESION
5.00
1.00
35226
REPAIR BLOOD VESSEL LESION
23.01
1.00
35226
REPAIR BLOOD VESSEL LESION
23.58
1.00
35226
REPAIR BLOOD VESSEL LESION
24.29
1.00
35231
REPAIR BLOOD VESSEL LESION
10.00
1.00
35231
REPAIR BLOOD VESSEL LESION
30.56
1.00
35231
REPAIR BLOOD VESSEL LESION
31.37
1.00
35231
REPAIR BLOOD VESSEL LESION
32.80
1.00
35236
REPAIR BLOOD VESSEL LESION
8.00
1.00
35236
REPAIR BLOOD VESSEL LESION
26.47
1.00
35236
REPAIR BLOOD VESSEL LESION
27.19
1.00
Procedure Code Description
RVU
RVU Coeff Value
35236
REPAIR BLOOD VESSEL LESION
27.35
1.00
35241
REPAIR BLOOD VESSEL LESION
15.00
1.00
35241
REPAIR BLOOD VESSEL LESION
37.79
1.00
35241
REPAIR BLOOD VESSEL LESION
39.68
1.00
35241
REPAIR BLOOD VESSEL LESION
40.44
1.00
35246
REPAIR BLOOD VESSEL LESION
15.00
1.00
35246
REPAIR BLOOD VESSEL LESION
40.60
1.00
35246
REPAIR BLOOD VESSEL LESION
42.90
1.00
35246
REPAIR BLOOD VESSEL LESION
43.14
1.00
35251
REPAIR BLOOD VESSEL LESION
10.00
1.00
35251
REPAIR BLOOD VESSEL LESION
44.10
1.00
35251
REPAIR BLOOD VESSEL LESION
44.25
1.00
35251
REPAIR BLOOD VESSEL LESION
46.48
1.00
35256
REPAIR BLOOD VESSEL LESION
8.00
1.00
35256
REPAIR BLOOD VESSEL LESION
28.35
1.00
35256
REPAIR BLOOD VESSEL LESION
28.78
1.00
35256
REPAIR BLOOD VESSEL LESION
29.11
1.00
35261
REPAIR BLOOD VESSEL LESION
10.00
1.00
35261
REPAIR BLOOD VESSEL LESION
26.57
1.00
35261
REPAIR BLOOD VESSEL LESION
27.44
1.00
35261
REPAIR BLOOD VESSEL LESION
29.08
1.00
35266
REPAIR BLOOD VESSEL LESION
8.00
1.00
35266
REPAIR BLOOD VESSEL LESION
23.35
1.00
35266
REPAIR BLOOD VESSEL LESION
24.05
1.00
35266
REPAIR BLOOD VESSEL LESION
24.08
1.00
35271
REPAIR BLOOD VESSEL LESION
20.00
1.00
35271
REPAIR BLOOD VESSEL LESION
36.02
1.00
35271
REPAIR BLOOD VESSEL LESION
37.86
1.00
35271
REPAIR BLOOD VESSEL LESION
38.46
1.00
35276
REPAIR BLOOD VESSEL LESION
15.00
1.00
35276
REPAIR BLOOD VESSEL LESION
38.35
1.00
35276
REPAIR BLOOD VESSEL LESION
39.80
1.00
35276
REPAIR BLOOD VESSEL LESION
40.46
1.00
35281
REPAIR BLOOD VESSEL LESION
15.00
1.00
35281
REPAIR BLOOD VESSEL LESION
41.23
1.00
Procedure Code Description
RVU
RVU Coeff Value
35281
REPAIR BLOOD VESSEL LESION
41.91
1.00
35281
REPAIR BLOOD VESSEL LESION
44.43
1.00
35286
REPAIR BLOOD VESSEL LESION
7.00
1.00
35286
REPAIR BLOOD VESSEL LESION
25.90
1.00
35286
REPAIR BLOOD VESSEL LESION
26.25
1.00
35286
REPAIR BLOOD VESSEL LESION
26.39
1.00
35301
RECHANNELING OF ARTERY
6.00
1.00
35301
RECHANNELING OF ARTERY
29.19
1.00
35301
RECHANNELING OF ARTERY
29.61
1.00
35301
RECHANNELING OF ARTERY
29.86
1.00
35302
RECHANNELING OF ARTERY
31.53
1.00
35303
RECHANNELING OF ARTERY
34.69
1.00
35304
RECHANNELING OF ARTERY
36.08
1.00
35305
RECHANNELING OF ARTERY
34.65
1.00
35306
RECHANNELING OF ARTERY
13.00
1.00
35311
RECHANNELING OF ARTERY
15.00
1.00
35311
RECHANNELING OF ARTERY
40.67
1.00
35311
RECHANNELING OF ARTERY
42.07
1.00
35311
RECHANNELING OF ARTERY
42.30
1.00
35321
RECHANNELING OF ARTERY
6.00
1.00
35321
RECHANNELING OF ARTERY
24.08
1.00
35321
RECHANNELING OF ARTERY
25.03
1.00
35321
RECHANNELING OF ARTERY
25.17
1.00
35331
RECHANNELING OF ARTERY
12.00
1.00
35331
RECHANNELING OF ARTERY
39.73
1.00
35331
RECHANNELING OF ARTERY
40.71
1.00
35331
RECHANNELING OF ARTERY
41.59
1.00
35341
RECHANNELING OF ARTERY
12.00
1.00
35341
RECHANNELING OF ARTERY
38.39
1.00
35341
RECHANNELING OF ARTERY
39.20
1.00
35341
RECHANNELING OF ARTERY
39.44
1.00
35351
RECHANNELING OF ARTERY
12.00
1.00
35351
RECHANNELING OF ARTERY
34.92
1.00
35351
RECHANNELING OF ARTERY
35.37
1.00
35351
RECHANNELING OF ARTERY
36.38
1.00
Procedure Code Description
RVU
RVU Coeff Value
35355
RECHANNELING OF ARTERY
15.00
1.00
35355
RECHANNELING OF ARTERY
28.42
1.00
35355
RECHANNELING OF ARTERY
28.76
1.00
35355
RECHANNELING OF ARTERY
29.53
1.00
35361
RECHANNELING OF ARTERY
12.00
1.00
35361
RECHANNELING OF ARTERY
42.23
1.00
35361
RECHANNELING OF ARTERY
43.12
1.00
35361
RECHANNELING OF ARTERY
44.79
1.00
35363
RECHANNELING OF ARTERY
15.00
1.00
35363
RECHANNELING OF ARTERY
45.09
1.00
35363
RECHANNELING OF ARTERY
46.12
1.00
35363
RECHANNELING OF ARTERY
48.72
1.00
35371
RECHANNELING OF ARTERY
12.00
1.00
35371
RECHANNELING OF ARTERY
22.62
1.00
35371
RECHANNELING OF ARTERY
23.28
1.00
35371
RECHANNELING OF ARTERY
23.29
1.00
35372
RECHANNELING OF ARTERY
27.26
1.00
35372
RECHANNELING OF ARTERY
27.90
1.00
35372
RECHANNELING OF ARTERY
27.97
1.00
35381
RECHANNELING OF ARTERY
6.00
1.00
35381
RECHANNELING OF ARTERY
24.82
1.00
35381
RECHANNELING OF ARTERY
25.81
1.00
35381
RECHANNELING OF ARTERY
25.87
1.00
35390
REOPERATION, CAROTID ADD-ON
4.58
1.00
35390
REOPERATION, CAROTID ADD-ON
4.64
1.00
35390
REOPERATION, CAROTID ADD-ON
4.72
1.00
35400
ANGIOSCOPY
4.33
1.00
35400
ANGIOSCOPY
4.39
1.00
35400
ANGIOSCOPY
4.53
1.00
35450
REPAIR ARTERIAL BLOCKAGE
14.59
1.00
35450
REPAIR ARTERIAL BLOCKAGE
14.93
1.00
35450
REPAIR ARTERIAL BLOCKAGE
15.10
1.00
35452
REPAIR ARTERIAL BLOCKAGE
10.15
1.00
35452
REPAIR ARTERIAL BLOCKAGE
10.76
1.00
35452
REPAIR ARTERIAL BLOCKAGE
10.99
1.00
Procedure Code Description
RVU
RVU Coeff Value
35454
REPAIR ARTERIAL BLOCKAGE
8.92
1.00
35454
REPAIR ARTERIAL BLOCKAGE
9.48
1.00
35454
REPAIR ARTERIAL BLOCKAGE
9.68
1.00
35456
REPAIR ARTERIAL BLOCKAGE
10.79
1.00
35456
REPAIR ARTERIAL BLOCKAGE
11.38
1.00
35456
REPAIR ARTERIAL BLOCKAGE
11.62
1.00
35458
REPAIR ARTERIAL BLOCKAGE
13.82
1.00
35458
REPAIR ARTERIAL BLOCKAGE
14.50
1.00
35458
REPAIR ARTERIAL BLOCKAGE
14.80
1.00
35459
REPAIR ARTERIAL BLOCKAGE
12.71
1.00
35459
REPAIR ARTERIAL BLOCKAGE
13.18
1.00
35459
REPAIR ARTERIAL BLOCKAGE
13.42
1.00
35459
REPAIR ARTERIAL BLOCKAGE
999.99
1.00
35460
REPAIR VENOUS BLOCKAGE
8.83
1.00
35460
REPAIR VENOUS BLOCKAGE
9.33
1.00
35460
REPAIR VENOUS BLOCKAGE
9.51
1.00
35460
REPAIR VENOUS BLOCKAGE
999.99
1.00
35470
REPAIR ARTERIAL BLOCKAGE
12.71
1.00
35470
REPAIR ARTERIAL BLOCKAGE
12.84
1.00
35470
REPAIR ARTERIAL BLOCKAGE
13.02
1.00
35470
REPAIR ARTERIAL BLOCKAGE
13.07
1.00
35470
REPAIR ARTERIAL BLOCKAGE
999.99
1.00
35471
REPAIR ARTERIAL BLOCKAGE
14.85
1.00
35471
REPAIR ARTERIAL BLOCKAGE
15.04
1.00
35471
REPAIR ARTERIAL BLOCKAGE
15.10
1.00
35471
REPAIR ARTERIAL BLOCKAGE
15.30
1.00
35471
REPAIR ARTERIAL BLOCKAGE
999.99
1.00
35472
REPAIR ARTERIAL BLOCKAGE
10.24
1.00
35472
REPAIR ARTERIAL BLOCKAGE
10.56
1.00
35472
REPAIR ARTERIAL BLOCKAGE
10.61
1.00
35472
REPAIR ARTERIAL BLOCKAGE
999.99
1.00
35473
REPAIR ARTERIAL BLOCKAGE
8.97
1.00
35473
REPAIR ARTERIAL BLOCKAGE
9.00
1.00
35473
REPAIR ARTERIAL BLOCKAGE
9.09
1.00
35473
REPAIR ARTERIAL BLOCKAGE
9.33
1.00
Procedure Code Description
RVU
RVU Coeff Value
35473
REPAIR ARTERIAL BLOCKAGE
9.36
1.00
35473
REPAIR ARTERIAL BLOCKAGE
999.99
1.00
35474
REPAIR ARTERIAL BLOCKAGE
10.70
1.00
35474
REPAIR ARTERIAL BLOCKAGE
10.71
1.00
35474
REPAIR ARTERIAL BLOCKAGE
10.82
1.00
35474
REPAIR ARTERIAL BLOCKAGE
10.83
1.00
35474
REPAIR ARTERIAL BLOCKAGE
10.86
1.00
35474
REPAIR ARTERIAL BLOCKAGE
10.97
1.00
35474
REPAIR ARTERIAL BLOCKAGE
999.99
1.00
35475
REPAIR ARTERIAL BLOCKAGE
13.57
1.00
35475
REPAIR ARTERIAL BLOCKAGE
13.58
1.00
35475
REPAIR ARTERIAL BLOCKAGE
13.67
1.00
35475
REPAIR ARTERIAL BLOCKAGE
13.69
1.00
35475
REPAIR ARTERIAL BLOCKAGE
13.70
1.00
35475
REPAIR ARTERIAL BLOCKAGE
14.08
1.00
35475
REPAIR ARTERIAL BLOCKAGE
14.11
1.00
35475
REPAIR ARTERIAL BLOCKAGE
999.99
1.00
35476
REPAIR VENOUS BLOCKAGE
8.63
1.00
35476
REPAIR VENOUS BLOCKAGE
8.66
1.00
35476
REPAIR VENOUS BLOCKAGE
8.73
1.00
35476
REPAIR VENOUS BLOCKAGE
8.77
1.00
35476
REPAIR VENOUS BLOCKAGE
9.19
1.00
35476
REPAIR VENOUS BLOCKAGE
9.21
1.00
35476
REPAIR VENOUS BLOCKAGE
999.99
1.00
35480
ATHERECTOMY, OPEN
15.00
1.00
35480
ATHERECTOMY, OPEN
15.80
1.00
35480
ATHERECTOMY, OPEN
16.71
1.00
35480
ATHERECTOMY, OPEN
16.93
1.00
35481
ATHERECTOMY, OPEN
11.46
1.00
35481
ATHERECTOMY, OPEN
11.83
1.00
35481
ATHERECTOMY, OPEN
12.09
1.00
35481
ATHERECTOMY, OPEN
15.00
1.00
35482
ATHERECTOMY, OPEN
9.99
1.00
35482
ATHERECTOMY, OPEN
10.44
1.00
35482
ATHERECTOMY, OPEN
10.63
1.00
Procedure Code Description
RVU
RVU Coeff Value
35482
ATHERECTOMY, OPEN
15.00
1.00
35483
ATHERECTOMY, OPEN
8.00
1.00
35483
ATHERECTOMY, OPEN
12.08
1.00
35483
ATHERECTOMY, OPEN
12.38
1.00
35483
ATHERECTOMY, OPEN
12.61
1.00
35484
ATHERECTOMY, OPEN
8.00
1.00
35484
ATHERECTOMY, OPEN
14.99
1.00
35484
ATHERECTOMY, OPEN
15.76
1.00
35484
ATHERECTOMY, OPEN
16.01
1.00
35485
ATHERECTOMY, OPEN
8.00
1.00
35485
ATHERECTOMY, OPEN
14.01
1.00
35485
ATHERECTOMY, OPEN
14.57
1.00
35485
ATHERECTOMY, OPEN
14.82
1.00
35490
ATHERECTOMY, PERCUTANEOUS
6.00
1.00
35490
ATHERECTOMY, PERCUTANEOUS
16.43
1.00
35490
ATHERECTOMY, PERCUTANEOUS
17.06
1.00
35491
ATHERECTOMY, PERCUTANEOUS
10.00
1.00
35491
ATHERECTOMY, PERCUTANEOUS
11.42
1.00
35491
ATHERECTOMY, PERCUTANEOUS
11.49
1.00
35491
ATHERECTOMY, PERCUTANEOUS
11.53
1.00
35492
ATHERECTOMY, PERCUTANEOUS
10.00
1.00
35492
ATHERECTOMY, PERCUTANEOUS
10.28
1.00
35492
ATHERECTOMY, PERCUTANEOUS
10.35
1.00
35492
ATHERECTOMY, PERCUTANEOUS
10.38
1.00
35493
ATHERECTOMY, PERCUTANEOUS
5.00
1.00
35493
ATHERECTOMY, PERCUTANEOUS
12.43
1.00
35493
ATHERECTOMY, PERCUTANEOUS
12.47
1.00
35493
ATHERECTOMY, PERCUTANEOUS
12.66
1.00
35494
ATHERECTOMY, PERCUTANEOUS
8.00
1.00
35494
ATHERECTOMY, PERCUTANEOUS
15.38
1.00
35494
ATHERECTOMY, PERCUTANEOUS
15.40
1.00
35494
ATHERECTOMY, PERCUTANEOUS
16.01
1.00
35495
ATHERECTOMY, PERCUTANEOUS
8.00
1.00
35495
ATHERECTOMY, PERCUTANEOUS
14.46
1.00
35495
ATHERECTOMY, PERCUTANEOUS
14.49
1.00
Procedure Code Description 35495
ATHERECTOMY, PERCUTANEOUS
35500
RVU
RVU Coeff Value
14.68
1.00
HARVEST VEIN FOR BYPASS
9.15
1.00
35500
HARVEST VEIN FOR BYPASS
9.17
1.00
35500
HARVEST VEIN FOR BYPASS
9.23
1.00
35501
ARTERY BYPASS GRAFT
6.00
1.00
35501
ARTERY BYPASS GRAFT
28.95
1.00
35501
ARTERY BYPASS GRAFT
30.48
1.00
35501
ARTERY BYPASS GRAFT
44.15
1.00
35506
ARTERY BYPASS GRAFT
6.00
1.00
35506
ARTERY BYPASS GRAFT
30.13
1.00
35506
ARTERY BYPASS GRAFT
31.96
1.00
35506
ARTERY BYPASS GRAFT
37.35
1.00
35507
ARTERY BYPASS GRAFT
6.00
1.00
35507
ARTERY BYPASS GRAFT
30.03
1.00
35507
ARTERY BYPASS GRAFT
31.84
1.00
35507
ARTERY BYPASS GRAFT
31.93
1.00
35508
ARTERY BYPASS GRAFT
10.00
1.00
35508
ARTERY BYPASS GRAFT
28.84
1.00
35508
ARTERY BYPASS GRAFT
30.92
1.00
35508
ARTERY BYPASS GRAFT
38.53
1.00
35509
ARTERY BYPASS GRAFT
6.00
1.00
35509
ARTERY BYPASS GRAFT
27.73
1.00
35509
ARTERY BYPASS GRAFT
29.40
1.00
35509
ARTERY BYPASS GRAFT
42.43
1.00
35510
ARTERY BYPASS GRAFT
35.20
1.00
35510
ARTERY BYPASS GRAFT
35.24
1.00
35511
ARTERY BYPASS GRAFT
6.00
1.00
35511
ARTERY BYPASS GRAFT
31.63
1.00
35511
ARTERY BYPASS GRAFT
32.66
1.00
35511
ARTERY BYPASS GRAFT
33.43
1.00
35512
ARTERY BYPASS GRAFT
34.33
1.00
35512
ARTERY BYPASS GRAFT
34.57
1.00
35515
ARTERY BYPASS GRAFT
10.00
1.00
35515
ARTERY BYPASS GRAFT
28.84
1.00
35515
ARTERY BYPASS GRAFT
30.68
1.00
Procedure Code Description
RVU
RVU Coeff Value
35515
ARTERY BYPASS GRAFT
37.21
1.00
35516
ARTERY BYPASS GRAFT
6.00
1.00
35516
ARTERY BYPASS GRAFT
24.00
1.00
35516
ARTERY BYPASS GRAFT
25.41
1.00
35516
ARTERY BYPASS GRAFT
34.00
1.00
35518
ARTERY BYPASS GRAFT
4.00
1.00
35518
ARTERY BYPASS GRAFT
31.47
1.00
35518
ARTERY BYPASS GRAFT
32.34
1.00
35518
ARTERY BYPASS GRAFT
34.05
1.00
35521
ARTERY BYPASS GRAFT
6.00
1.00
35521
ARTERY BYPASS GRAFT
33.35
1.00
35521
ARTERY BYPASS GRAFT
34.24
1.00
35521
ARTERY BYPASS GRAFT
35.80
1.00
35522
ARTERY BYPASS GRAFT
33.56
1.00
35522
ARTERY BYPASS GRAFT
33.57
1.00
35523
ARTERY BYPASS GRAFT
35.51
1.00
35525
ARTERY BYPASS GRAFT
31.54
1.00
35525
ARTERY BYPASS GRAFT
32.05
1.00
35526
ARTERY BYPASS GRAFT
15.00
1.00
35526
ARTERY BYPASS GRAFT
44.13
1.00
35526
ARTERY BYPASS GRAFT
45.10
1.00
35526
ARTERY BYPASS GRAFT
46.72
1.00
35531
ARTERY BYPASS GRAFT
15.00
1.00
35531
ARTERY BYPASS GRAFT
53.24
1.00
35531
ARTERY BYPASS GRAFT
54.20
1.00
35531
ARTERY BYPASS GRAFT
57.21
1.00
35533
ARTERY BYPASS GRAFT
4.00
1.00
35533
ARTERY BYPASS GRAFT
41.71
1.00
35533
ARTERY BYPASS GRAFT
42.56
1.00
35533
ARTERY BYPASS GRAFT
44.25
1.00
35535
ARTERY BYPASS GRAFT
56.81
1.00
35536
ARTERY BYPASS GRAFT
10.00
1.00
35536
ARTERY BYPASS GRAFT
46.90
1.00
35536
ARTERY BYPASS GRAFT
47.81
1.00
35536
ARTERY BYPASS GRAFT
49.38
1.00
Procedure Code Description
RVU
RVU Coeff Value
35537
ARTERY BYPASS GRAFT
61.24
1.00
35538
ARTERY BYPASS GRAFT
68.73
1.00
35539
ARTERY BYPASS GRAFT
63.75
1.00
35540
ARTERY BYPASS GRAFT
71.42
1.00
35541
ARTERY BYPASS GRAFT
12.00
1.00
35541
ARTERY BYPASS GRAFT
39.26
1.00
35541
ARTERY BYPASS GRAFT
40.31
1.00
35541
ARTERY BYPASS GRAFT
40.69
1.00
35546
ARTERY BYPASS GRAFT
12.00
1.00
35546
ARTERY BYPASS GRAFT
38.86
1.00
35546
ARTERY BYPASS GRAFT
39.84
1.00
35546
ARTERY BYPASS GRAFT
40.08
1.00
35548
ARTERY BYPASS GRAFT
12.00
1.00
35548
ARTERY BYPASS GRAFT
33.08
1.00
35548
ARTERY BYPASS GRAFT
33.95
1.00
35548
ARTERY BYPASS GRAFT
33.96
1.00
35549
ARTERY BYPASS GRAFT
12.00
1.00
35549
ARTERY BYPASS GRAFT
35.93
1.00
35549
ARTERY BYPASS GRAFT
36.93
1.00
35549
ARTERY BYPASS GRAFT
37.07
1.00
35551
ARTERY BYPASS GRAFT
15.00
1.00
35551
ARTERY BYPASS GRAFT
40.75
1.00
35551
ARTERY BYPASS GRAFT
42.04
1.00
35551
ARTERY BYPASS GRAFT
42.08
1.00
35556
ARTERY BYPASS GRAFT
15.00
1.00
35556
ARTERY BYPASS GRAFT
33.48
1.00
35556
ARTERY BYPASS GRAFT
34.49
1.00
35556
ARTERY BYPASS GRAFT
38.95
1.00
35558
ARTERY BYPASS GRAFT
5.00
1.00
35558
ARTERY BYPASS GRAFT
31.77
1.00
35558
ARTERY BYPASS GRAFT
32.67
1.00
35558
ARTERY BYPASS GRAFT
34.59
1.00
35560
ARTERY BYPASS GRAFT
15.00
1.00
35560
ARTERY BYPASS GRAFT
47.51
1.00
35560
ARTERY BYPASS GRAFT
48.61
1.00
Procedure Code Description
RVU
RVU Coeff Value
35560
ARTERY BYPASS GRAFT
50.44
1.00
35563
ARTERY BYPASS GRAFT
12.00
1.00
35563
ARTERY BYPASS GRAFT
35.97
1.00
35563
ARTERY BYPASS GRAFT
36.76
1.00
35563
ARTERY BYPASS GRAFT
38.62
1.00
35565
ARTERY BYPASS GRAFT
5.00
1.00
35565
ARTERY BYPASS GRAFT
34.62
1.00
35565
ARTERY BYPASS GRAFT
35.40
1.00
35565
ARTERY BYPASS GRAFT
37.38
1.00
35566
ARTERY BYPASS GRAFT
5.00
1.00
35566
ARTERY BYPASS GRAFT
41.61
1.00
35566
ARTERY BYPASS GRAFT
41.97
1.00
35566
ARTERY BYPASS GRAFT
46.77
1.00
35570
ARTERY BYPASS GRAFT
43.86
1.00
35571
ARTERY BYPASS GRAFT
5.00
1.00
35571
ARTERY BYPASS GRAFT
37.51
1.00
35571
ARTERY BYPASS GRAFT
37.95
1.00
35571
ARTERY BYPASS GRAFT
38.10
1.00
35572
HARVEST FEMOROPOPLITEAL VEIN
9.91
1.00
35572
HARVEST FEMOROPOPLITEAL VEIN
9.93
1.00
35572
HARVEST FEMOROPOPLITEAL VEIN
10.02
1.00
35582
VEIN BYPASS GRAFT
3.00
1.00
35582
VEIN BYPASS GRAFT
41.33
1.00
35582
VEIN BYPASS GRAFT
42.46
1.00
35583
VEIN BYPASS GRAFT
3.00
1.00
35583
VEIN BYPASS GRAFT
35.29
1.00
35583
VEIN BYPASS GRAFT
35.60
1.00
35583
VEIN BYPASS GRAFT
40.21
1.00
35585
VEIN BYPASS GRAFT
3.00
1.00
35585
VEIN BYPASS GRAFT
44.54
1.00
35585
VEIN BYPASS GRAFT
45.89
1.00
35585
VEIN BYPASS GRAFT
47.19
1.00
35587
VEIN BYPASS GRAFT
3.00
1.00
35587
VEIN BYPASS GRAFT
38.87
1.00
35587
VEIN BYPASS GRAFT
39.13
1.00
Procedure Code Description 35587
VEIN BYPASS GRAFT
35600
RVU
RVU Coeff Value
39.50
1.00
HARVEST ART FOR CABG ADD-ON
7.17
1.00
35600
HARVEST ART FOR CABG ADD-ON
7.29
1.00
35600
HARVEST ART FOR CABG ADD-ON
7.31
1.00
35601
ARTERY BYPASS GRAFT
10.00
1.00
35601
ARTERY BYPASS GRAFT
26.91
1.00
35601
ARTERY BYPASS GRAFT
28.64
1.00
35601
ARTERY BYPASS GRAFT
40.78
1.00
35606
ARTERY BYPASS GRAFT
6.00
1.00
35606
ARTERY BYPASS GRAFT
28.63
1.00
35606
ARTERY BYPASS GRAFT
30.36
1.00
35606
ARTERY BYPASS GRAFT
33.08
1.00
35612
ARTERY BYPASS GRAFT
10.00
1.00
35612
ARTERY BYPASS GRAFT
24.20
1.00
35612
ARTERY BYPASS GRAFT
25.73
1.00
35612
ARTERY BYPASS GRAFT
25.90
1.00
35616
ARTERY BYPASS GRAFT
10.00
1.00
35616
ARTERY BYPASS GRAFT
24.32
1.00
35616
ARTERY BYPASS GRAFT
26.04
1.00
35616
ARTERY BYPASS GRAFT
31.53
1.00
35621
ARTERY BYPASS GRAFT
5.00
1.00
35621
ARTERY BYPASS GRAFT
30.35
1.00
35621
ARTERY BYPASS GRAFT
30.71
1.00
35621
ARTERY BYPASS GRAFT
31.38
1.00
35623
BYPASS GRAFT, NOT VEIN
5.00
1.00
35623
BYPASS GRAFT, NOT VEIN
35.89
1.00
35623
BYPASS GRAFT, NOT VEIN
36.80
1.00
35623
BYPASS GRAFT, NOT VEIN
38.47
1.00
35626
ARTERY BYPASS GRAFT
15.00
1.00
35626
ARTERY BYPASS GRAFT
41.57
1.00
35626
ARTERY BYPASS GRAFT
43.23
1.00
35626
ARTERY BYPASS GRAFT
44.22
1.00
35631
ARTERY BYPASS GRAFT
15.00
1.00
35631
ARTERY BYPASS GRAFT
50.24
1.00
35631
ARTERY BYPASS GRAFT
51.24
1.00
Procedure Code Description
RVU
RVU Coeff Value
35631
ARTERY BYPASS GRAFT
52.70
1.00
35632
ARTERY BYPASS GRAFT
53.94
1.00
35633
ARTERY BYPASS GRAFT
58.25
1.00
35634
ARTERY BYPASS GRAFT
52.79
1.00
35636
ARTERY BYPASS GRAFT
15.00
1.00
35636
ARTERY BYPASS GRAFT
43.98
1.00
35636
ARTERY BYPASS GRAFT
44.67
1.00
35636
ARTERY BYPASS GRAFT
46.69
1.00
35637
BYPASS GRAFT, WITH OTHER THAN VEIN
48.36
1.00
35638
BYPASS GRAFT, WITH OTHER THAN VEIN
49.41
1.00
35641
ARTERY BYPASS GRAFT
10.00
1.00
35641
ARTERY BYPASS GRAFT
37.67
1.00
35641
ARTERY BYPASS GRAFT
39.05
1.00
35641
ARTERY BYPASS GRAFT
39.15
1.00
35642
ARTERY BYPASS GRAFT
10.00
1.00
35642
ARTERY BYPASS GRAFT
27.68
1.00
35642
ARTERY BYPASS GRAFT
28.89
1.00
35642
ARTERY BYPASS GRAFT
29.17
1.00
35645
ARTERY BYPASS GRAFT
10.00
1.00
35645
ARTERY BYPASS GRAFT
27.07
1.00
35645
ARTERY BYPASS GRAFT
27.75
1.00
35645
ARTERY BYPASS GRAFT
28.05
1.00
35646
ARTERY BYPASS GRAFT
12.00
1.00
35646
ARTERY BYPASS GRAFT
47.63
1.00
35646
ARTERY BYPASS GRAFT
48.48
1.00
35646
ARTERY BYPASS GRAFT
48.79
1.00
35647
ARTERY BYPASS GRAFT
12.00
1.00
35647
ARTERY BYPASS GRAFT
43.04
1.00
35647
ARTERY BYPASS GRAFT
43.74
1.00
35647
ARTERY BYPASS GRAFT
44.16
1.00
35650
ARTERY BYPASS GRAFT
4.00
1.00
35650
ARTERY BYPASS GRAFT
28.41
1.00
35650
ARTERY BYPASS GRAFT
29.35
1.00
35650
ARTERY BYPASS GRAFT
30.20
1.00
35651
ARTERY BYPASS GRAFT
12.00
1.00
Procedure Code Description
RVU
RVU Coeff Value
35651
ARTERY BYPASS GRAFT
38.07
1.00
35651
ARTERY BYPASS GRAFT
38.94
1.00
35651
ARTERY BYPASS GRAFT
39.05
1.00
35654
ARTERY BYPASS GRAFT
4.00
1.00
35654
ARTERY BYPASS GRAFT
37.44
1.00
35654
ARTERY BYPASS GRAFT
38.19
1.00
35654
ARTERY BYPASS GRAFT
38.98
1.00
35656
ARTERY BYPASS GRAFT
5.00
1.00
35656
ARTERY BYPASS GRAFT
29.96
1.00
35656
ARTERY BYPASS GRAFT
30.73
1.00
35656
ARTERY BYPASS GRAFT
30.81
1.00
35661
ARTERY BYPASS GRAFT
8.00
1.00
35661
ARTERY BYPASS GRAFT
28.59
1.00
35661
ARTERY BYPASS GRAFT
29.74
1.00
35661
ARTERY BYPASS GRAFT
30.74
1.00
35663
ARTERY BYPASS GRAFT
15.00
1.00
35663
ARTERY BYPASS GRAFT
32.99
1.00
35663
ARTERY BYPASS GRAFT
33.86
1.00
35663
ARTERY BYPASS GRAFT
35.62
1.00
35665
ARTERY BYPASS GRAFT
15.00
1.00
35665
ARTERY BYPASS GRAFT
31.74
1.00
35665
ARTERY BYPASS GRAFT
32.57
1.00
35665
ARTERY BYPASS GRAFT
33.40
1.00
35666
ARTERY BYPASS GRAFT
4.00
1.00
35666
ARTERY BYPASS GRAFT
35.52
1.00
35666
ARTERY BYPASS GRAFT
36.00
1.00
35666
ARTERY BYPASS GRAFT
36.10
1.00
35671
ARTERY BYPASS GRAFT
8.00
1.00
35671
ARTERY BYPASS GRAFT
30.76
1.00
35671
ARTERY BYPASS GRAFT
31.40
1.00
35671
ARTERY BYPASS GRAFT
31.72
1.00
35681
COMPOSITE BYPASS GRAFT
2.29
1.00
35681
COMPOSITE BYPASS GRAFT
2.33
1.00
35681
COMPOSITE BYPASS GRAFT
2.35
1.00
35682
COMPOSITE BYPASS GRAFT
10.22
1.00
Procedure Code Description
RVU
RVU Coeff Value
35682
COMPOSITE BYPASS GRAFT
10.47
1.00
35682
COMPOSITE BYPASS GRAFT
10.59
1.00
35683
COMPOSITE BYPASS GRAFT
12.05
1.00
35683
COMPOSITE BYPASS GRAFT
12.36
1.00
35683
COMPOSITE BYPASS GRAFT
12.50
1.00
35685
BYPASS GRAFT PATENCY/PATCH
5.69
1.00
35685
BYPASS GRAFT PATENCY/PATCH
5.74
1.00
35685
BYPASS GRAFT PATENCY/PATCH
5.82
1.00
35686
BYPASS GRAFT/AV FIST PATENCY
4.72
1.00
35686
BYPASS GRAFT/AV FIST PATENCY
4.80
1.00
35686
BYPASS GRAFT/AV FIST PATENCY
4.82
1.00
35691
ARTERIAL TRANSPOSITION
10.00
1.00
35691
ARTERIAL TRANSPOSITION
27.65
1.00
35691
ARTERIAL TRANSPOSITION
28.00
1.00
35691
ARTERIAL TRANSPOSITION
28.95
1.00
35693
ARTERIAL TRANSPOSITION
10.00
1.00
35693
ARTERIAL TRANSPOSITION
23.75
1.00
35693
ARTERIAL TRANSPOSITION
24.82
1.00
35693
ARTERIAL TRANSPOSITION
25.27
1.00
35694
ARTERIAL TRANSPOSITION
10.00
1.00
35694
ARTERIAL TRANSPOSITION
28.95
1.00
35694
ARTERIAL TRANSPOSITION
29.12
1.00
35694
ARTERIAL TRANSPOSITION
30.34
1.00
35695
ARTERIAL TRANSPOSITION
10.00
1.00
35695
ARTERIAL TRANSPOSITION
29.13
1.00
35695
ARTERIAL TRANSPOSITION
30.13
1.00
35695
ARTERIAL TRANSPOSITION
30.37
1.00
35697
REIMPLANT ARTERY EACH
4.27
1.00
35697
REIMPLANT ARTERY EACH
4.44
1.00
35700
REOPERATION, BYPASS GRAFT
4.40
1.00
35700
REOPERATION, BYPASS GRAFT
4.47
1.00
35700
REOPERATION, BYPASS GRAFT
4.54
1.00
35700
REOPERATION, BYPASS GRAFT
8.00
1.00
35701
EXPLORATION, CAROTID ARTERY
6.00
1.00
35701
EXPLORATION, CAROTID ARTERY
13.73
1.00
Procedure Code Description
RVU
RVU Coeff Value
35701
EXPLORATION, CAROTID ARTERY
14.44
1.00
35701
EXPLORATION, CAROTID ARTERY
14.93
1.00
35721
EXPLORATION, FEMORAL ARTERY
5.00
1.00
35721
EXPLORATION, FEMORAL ARTERY
12.36
1.00
35721
EXPLORATION, FEMORAL ARTERY
12.71
1.00
35721
EXPLORATION, FEMORAL ARTERY
12.90
1.00
35741
EXPLORATION POPLITEAL ARTERY
4.00
1.00
35741
EXPLORATION POPLITEAL ARTERY
13.42
1.00
35741
EXPLORATION POPLITEAL ARTERY
13.91
1.00
35741
EXPLORATION POPLITEAL ARTERY
13.94
1.00
35761
EXPLORATION OF ARTERY/VEIN
10.15
1.00
35761
EXPLORATION OF ARTERY/VEIN
10.26
1.00
35761
EXPLORATION OF ARTERY/VEIN
10.39
1.00
35800
EXPLORE NECK VESSELS
4.00
1.00
35800
EXPLORE NECK VESSELS
11.71
1.00
35800
EXPLORE NECK VESSELS
12.64
1.00
35800
EXPLORE NECK VESSELS
13.18
1.00
35820
EXPLORE CHEST VESSELS
18.68
1.00
35820
EXPLORE CHEST VESSELS
20.00
1.00
35820
EXPLORE CHEST VESSELS
22.00
1.00
35820
EXPLORE CHEST VESSELS
50.96
1.00
35840
EXPLORE ABDOMINAL VESSELS
6.00
1.00
35840
EXPLORE ABDOMINAL VESSELS
15.93
1.00
35840
EXPLORE ABDOMINAL VESSELS
16.35
1.00
35840
EXPLORE ABDOMINAL VESSELS
17.25
1.00
35860
EXPLORE LIMB VESSELS
4.00
1.00
35860
EXPLORE LIMB VESSELS
9.72
1.00
35860
EXPLORE LIMB VESSELS
10.36
1.00
35860
EXPLORE LIMB VESSELS
11.13
1.00
35870
REPAIR VESSEL GRAFT DEFECT
6.00
1.00
35870
REPAIR VESSEL GRAFT DEFECT
34.59
1.00
35870
REPAIR VESSEL GRAFT DEFECT
34.93
1.00
35870
REPAIR VESSEL GRAFT DEFECT
36.13
1.00
35875
REMOVAL OF CLOT IN GRAFT
6.00
1.00
35875
REMOVAL OF CLOT IN GRAFT
16.52
1.00
Procedure Code Description
RVU
RVU Coeff Value
35875
REMOVAL OF CLOT IN GRAFT
16.67
1.00
35875
REMOVAL OF CLOT IN GRAFT
17.40
1.00
35876
REMOVAL OF CLOT IN GRAFT
8.00
1.00
35876
REMOVAL OF CLOT IN GRAFT
26.73
1.00
35876
REMOVAL OF CLOT IN GRAFT
26.83
1.00
35876
REMOVAL OF CLOT IN GRAFT
27.68
1.00
35879
REVISE GRAFT W/VEIN
8.00
1.00
35879
REVISE GRAFT W/VEIN
24.96
1.00
35879
REVISE GRAFT W/VEIN
25.36
1.00
35879
REVISE GRAFT W/VEIN
26.14
1.00
35881
REVISE GRAFT W/VEIN
8.00
1.00
35881
REVISE GRAFT W/VEIN
27.90
1.00
35881
REVISE GRAFT W/VEIN
28.46
1.00
35881
REVISE GRAFT W/VEIN
29.07
1.00
35883
REVISE GRAFT W/NONAUTO GRAFT
33.95
1.00
35884
REVISE GRAFT W/VEIN
35.82
1.00
35901
EXCISION, GRAFT, NECK
10.00
1.00
35901
EXCISION, GRAFT, NECK
13.99
1.00
35901
EXCISION, GRAFT, NECK
14.63
1.00
35901
EXCISION, GRAFT, NECK
14.91
1.00
35903
EXCISION, GRAFT, EXTREMITY
8.00
1.00
35903
EXCISION, GRAFT, EXTREMITY
15.82
1.00
35903
EXCISION, GRAFT, EXTREMITY
16.63
1.00
35903
EXCISION, GRAFT, EXTREMITY
18.50
1.00
35905
EXCISION, GRAFT, THORAX
15.00
1.00
35905
EXCISION, GRAFT, THORAX
47.05
1.00
35905
EXCISION, GRAFT, THORAX
48.52
1.00
35905
EXCISION, GRAFT, THORAX
49.26
1.00
35907
EXCISION, GRAFT, ABDOMEN
15.00
1.00
35907
EXCISION, GRAFT, ABDOMEN
51.68
1.00
35907
EXCISION, GRAFT, ABDOMEN
51.74
1.00
35907
EXCISION, GRAFT, ABDOMEN
54.27
1.00
36000
PLACE NEEDLE IN VEIN
0.24
1.00
36000
PLACE NEEDLE IN VEIN
0.26
1.00
36002
PSEUDOANEURYSM INJECTION TRT
3.06
1.00
Procedure Code Description
RVU
RVU Coeff Value
36002
PSEUDOANEURYSM INJECTION TRT
3.07
1.00
36005
INJECTION EXT VENOGRAPHY
1.31
1.00
36005
INJECTION EXT VENOGRAPHY
1.32
1.00
36005
INJECTION EXT VENOGRAPHY
1.35
1.00
36005
INJECTION EXT VENOGRAPHY
1.37
1.00
36010
PLACE CATHETER IN VEIN
3.40
1.00
36010
PLACE CATHETER IN VEIN
3.41
1.00
36010
PLACE CATHETER IN VEIN
3.42
1.00
36010
PLACE CATHETER IN VEIN
3.47
1.00
36010
PLACE CATHETER IN VEIN
5.00
1.00
36011
PLACE CATHETER IN VEIN
4.36
1.00
36011
PLACE CATHETER IN VEIN
4.38
1.00
36011
PLACE CATHETER IN VEIN
4.44
1.00
36011
PLACE CATHETER IN VEIN
4.47
1.00
36011
PLACE CATHETER IN VEIN
4.49
1.00
36011
PLACE CATHETER IN VEIN
999.99
1.00
36012
PLACE CATHETER IN VEIN
4.87
1.00
36012
PLACE CATHETER IN VEIN
5.04
1.00
36012
PLACE CATHETER IN VEIN
999.99
1.00
36013
PLACE CATHETER IN ARTERY
3.36
1.00
36013
PLACE CATHETER IN ARTERY
3.39
1.00
36013
PLACE CATHETER IN ARTERY
3.65
1.00
36013
PLACE CATHETER IN ARTERY
999.99
1.00
36014
PLACE CATHETER IN ARTERY
4.18
1.00
36014
PLACE CATHETER IN ARTERY
4.38
1.00
36014
PLACE CATHETER IN ARTERY
999.99
1.00
36015
PLACE CATHETER IN ARTERY
4.85
1.00
36015
PLACE CATHETER IN ARTERY
4.86
1.00
36015
PLACE CATHETER IN ARTERY
5.06
1.00
36015
PLACE CATHETER IN ARTERY
999.99
1.00
36100
ESTABLISH ACCESS TO ARTERY
4.00
1.00
36100
ESTABLISH ACCESS TO ARTERY
4.32
1.00
36100
ESTABLISH ACCESS TO ARTERY
4.34
1.00
36100
ESTABLISH ACCESS TO ARTERY
4.46
1.00
36120
ESTABLISH ACCESS TO ARTERY
2.79
1.00
Procedure Code Description
RVU
RVU Coeff Value
36120
ESTABLISH ACCESS TO ARTERY
2.80
1.00
36120
ESTABLISH ACCESS TO ARTERY
4.00
1.00
36140
ESTABLISH ACCESS TO ARTERY
2.79
1.00
36140
ESTABLISH ACCESS TO ARTERY
2.82
1.00
36140
ESTABLISH ACCESS TO ARTERY
2.84
1.00
36140
ESTABLISH ACCESS TO ARTERY
2.89
1.00
36145
ARTERY TO VEIN SHUNT
2.76
1.00
36145
ARTERY TO VEIN SHUNT
2.78
1.00
36145
ARTERY TO VEIN SHUNT
2.79
1.00
36145
ARTERY TO VEIN SHUNT
2.80
1.00
36145
ARTERY TO VEIN SHUNT
2.81
1.00
36145
ARTERY TO VEIN SHUNT
5.00
1.00
36160
ESTABLISH ACCESS TO AORTA
3.58
1.00
36160
ESTABLISH ACCESS TO AORTA
3.61
1.00
36160
ESTABLISH ACCESS TO AORTA
3.78
1.00
36160
ESTABLISH ACCESS TO AORTA
4.00
1.00
36200
PLACE CATHETER IN AORTA
4.21
1.00
36200
PLACE CATHETER IN AORTA
4.22
1.00
36200
PLACE CATHETER IN AORTA
4.28
1.00
36200
PLACE CATHETER IN AORTA
5.00
1.00
36215
PLACE CATHETER IN ARTERY
3.00
1.00
36215
PLACE CATHETER IN ARTERY
6.52
1.00
36215
PLACE CATHETER IN ARTERY
6.55
1.00
36215
PLACE CATHETER IN ARTERY
6.59
1.00
36215
PLACE CATHETER IN ARTERY
6.60
1.00
36215
PLACE CATHETER IN ARTERY
6.69
1.00
36215
PLACE CATHETER IN ARTERY
6.82
1.00
36216
PLACE CATHETER IN ARTERY
7.32
1.00
36216
PLACE CATHETER IN ARTERY
7.33
1.00
36216
PLACE CATHETER IN ARTERY
7.38
1.00
36216
PLACE CATHETER IN ARTERY
7.40
1.00
36216
PLACE CATHETER IN ARTERY
7.43
1.00
36216
PLACE CATHETER IN ARTERY
7.52
1.00
36216
PLACE CATHETER IN ARTERY
7.69
1.00
36216
PLACE CATHETER IN ARTERY
999.99
1.00
Procedure Code Description
RVU
RVU Coeff Value
36217
PLACE CATHETER IN ARTERY
8.82
1.00
36217
PLACE CATHETER IN ARTERY
8.83
1.00
36217
PLACE CATHETER IN ARTERY
8.90
1.00
36217
PLACE CATHETER IN ARTERY
8.91
1.00
36217
PLACE CATHETER IN ARTERY
8.92
1.00
36217
PLACE CATHETER IN ARTERY
9.03
1.00
36217
PLACE CATHETER IN ARTERY
9.23
1.00
36217
PLACE CATHETER IN ARTERY
999.99
1.00
36218
PLACE CATHETER IN ARTERY
1.41
1.00
36218
PLACE CATHETER IN ARTERY
1.42
1.00
36218
PLACE CATHETER IN ARTERY
1.43
1.00
36218
PLACE CATHETER IN ARTERY
1.44
1.00
36218
PLACE CATHETER IN ARTERY
1.47
1.00
36245
PLACE CATHETER IN ARTERY
3.00
1.00
36245
PLACE CATHETER IN ARTERY
6.60
1.00
36245
PLACE CATHETER IN ARTERY
6.66
1.00
36245
PLACE CATHETER IN ARTERY
6.68
1.00
36245
PLACE CATHETER IN ARTERY
6.76
1.00
36245
PLACE CATHETER IN ARTERY
6.88
1.00
36245
PLACE CATHETER IN ARTERY
7.04
1.00
36246
PLACE CATHETER IN ARTERY
7.37
1.00
36246
PLACE CATHETER IN ARTERY
7.48
1.00
36246
PLACE CATHETER IN ARTERY
7.49
1.00
36246
PLACE CATHETER IN ARTERY
7.56
1.00
36246
PLACE CATHETER IN ARTERY
7.69
1.00
36246
PLACE CATHETER IN ARTERY
999.99
1.00
36247
PLACE CATHETER IN ARTERY
8.78
1.00
36247
PLACE CATHETER IN ARTERY
8.79
1.00
36247
PLACE CATHETER IN ARTERY
8.91
1.00
36247
PLACE CATHETER IN ARTERY
8.93
1.00
36247
PLACE CATHETER IN ARTERY
9.01
1.00
36247
PLACE CATHETER IN ARTERY
9.16
1.00
36247
PLACE CATHETER IN ARTERY
999.99
1.00
36248
PLACE CATHETER IN ARTERY
1.42
1.00
36248
PLACE CATHETER IN ARTERY
1.43
1.00
Procedure Code Description
RVU
RVU Coeff Value
36248
PLACE CATHETER IN ARTERY
1.47
1.00
36260
INSERTION OF INFUSION PUMP
3.00
1.00
36260
INSERTION OF INFUSION PUMP
15.81
1.00
36260
INSERTION OF INFUSION PUMP
15.89
1.00
36260
INSERTION OF INFUSION PUMP
16.21
1.00
36261
REVISION OF INFUSION PUMP
9.28
1.00
36261
REVISION OF INFUSION PUMP
9.66
1.00
36261
REVISION OF INFUSION PUMP
9.70
1.00
36262
REMOVAL OF INFUSION PUMP
6.93
1.00
36262
REMOVAL OF INFUSION PUMP
7.30
1.00
36262
REMOVAL OF INFUSION PUMP
7.36
1.00
36400
BL DRAW < 3 YRS FEM/JUGULAR
0.48
1.00
36400
BL DRAW < 3 YRS FEM/JUGULAR
0.49
1.00
36405
BL DRAW < 3 YRS SCALP VEIN
0.40
1.00
36405
BL DRAW < 3 YRS SCALP VEIN
0.43
1.00
36406
BL DRAW < 3 YRS OTHER VEIN
0.24
1.00
36406
BL DRAW < 3 YRS OTHER VEIN
0.25
1.00
36410
NON-ROUTINE BL DRAW > 3 YRS
0.24
1.00
36420
VEIN ACCESS CUTDOWN < 1 YR
1.33
1.00
36420
VEIN ACCESS CUTDOWN < 1 YR
1.40
1.00
36420
VEIN ACCESS CUTDOWN < 1 YR
1.41
1.00
36425
VEIN ACCESS CUTDOWN > 1 YR
1.03
1.00
36425
VEIN ACCESS CUTDOWN > 1 YR
1.04
1.00
36425
VEIN ACCESS CUTDOWN > 1 YR
1.05
1.00
36430
BLOOD TRANSFUSION SERVICE
1.00
1.00
36430
BLOOD TRANSFUSION SERVICE
1.06
1.00
36430
BLOOD TRANSFUSION SERVICE
1.07
1.00
36440
BL PUSH TRANSFUSE, 2 YR OR <
1.40
1.00
36440
BL PUSH TRANSFUSE, 2 YR OR <
1.41
1.00
36440
BL PUSH TRANSFUSE, 2 YR OR <
1.43
1.00
36450
BL EXCHANGE/TRANSFUSE, NB
3.11
1.00
36450
BL EXCHANGE/TRANSFUSE, NB
3.13
1.00
36450
BL EXCHANGE/TRANSFUSE, NB
3.24
1.00
36455
BL EXCHANGE/TRANSFUSE NON-NB
3.38
1.00
36455
BL EXCHANGE/TRANSFUSE NON-NB
3.51
1.00
Procedure Code Description
RVU
RVU Coeff Value
36455
BL EXCHANGE/TRANSFUSE NON-NB
3.57
1.00
36460
TRANSFUSION SERVICE, FETAL
3.00
1.00
36460
TRANSFUSION SERVICE, FETAL
9.29
1.00
36460
TRANSFUSION SERVICE, FETAL
9.42
1.00
36460
TRANSFUSION SERVICE, FETAL
9.51
1.00
36470
INJECTION THERAPY OF VEIN
1.58
1.00
36470
INJECTION THERAPY OF VEIN
1.65
1.00
36470
INJECTION THERAPY OF VEIN
1.88
1.00
36471
INJECTION THERAPY OF VEINS
2.27
1.00
36471
INJECTION THERAPY OF VEINS
2.35
1.00
36471
INJECTION THERAPY OF VEINS
2.65
1.00
36475
ENDOVENOUS RF, 1ST VEIN
9.29
1.00
36475
ENDOVENOUS RF, 1ST VEIN
9.30
1.00
36475
ENDOVENOUS RF, 1ST VEIN
9.48
1.00
36475
ENDOVENOUS RF, 1ST VEIN
9.62
1.00
36475
ENDOVENOUS RF, 1ST VEIN
9.63
1.00
36476
ENDOVENOUS RF, VEIN ADD-ON
4.54
1.00
36476
ENDOVENOUS RF, VEIN ADD-ON
4.64
1.00
36476
ENDOVENOUS RF, VEIN ADD-ON
4.70
1.00
36478
ENDOVENOUS LASER, 1ST VEIN
9.38
1.00
36478
ENDOVENOUS LASER, 1ST VEIN
9.50
1.00
36478
ENDOVENOUS LASER, 1ST VEIN
9.62
1.00
36478
ENDOVENOUS LASER, 1ST VEIN
9.63
1.00
36479
ENDOVENOUS LASER VEIN ADDON
4.57
1.00
36479
ENDOVENOUS LASER VEIN ADDON
4.60
1.00
36479
ENDOVENOUS LASER VEIN ADDON
4.66
1.00
36479
ENDOVENOUS LASER VEIN ADDON
4.70
1.00
36481
INSERTION OF CATHETER, VEIN
10.19
1.00
36481
INSERTION OF CATHETER, VEIN
11.36
1.00
36481
INSERTION OF CATHETER, VEIN
999.99
1.00
36488
INSERTION OF CATHETER, VEIN
2.18
1.00
36488
INSERTION OF CATHETER, VEIN
999.99
1.00
36489
INSERTION OF CATHETER, VEIN
3.62
1.00
36489
INSERTION OF CATHETER, VEIN
4.00
1.00
36490
INSERTION OF CATHETER, VEIN
2.67
1.00
Procedure Code Description
RVU
RVU Coeff Value
36490
INSERTION OF CATHETER, VEIN
3.00
1.00
36491
INSERTION OF CATHETER, VEIN
2.32
1.00
36491
INSERTION OF CATHETER, VEIN
3.00
1.00
36493
REPOSITIONING OF CVC
2.13
1.00
36493
REPOSITIONING OF CVC
999.99
1.00
36500
INSERTION OF CATHETER, VEIN
4.92
1.00
36500
INSERTION OF CATHETER, VEIN
5.03
1.00
36500
INSERTION OF CATHETER, VEIN
5.05
1.00
36510
INSERTION OF CATHETER, VEIN
1.57
1.00
36510
INSERTION OF CATHETER, VEIN
1.77
1.00
36510
INSERTION OF CATHETER, VEIN
1.87
1.00
36511
APHERESIS WBC
2.44
1.00
36511
APHERESIS WBC
2.50
1.00
36511
APHERESIS WBC
2.52
1.00
36512
APHERESIS RBC
2.48
1.00
36512
APHERESIS RBC
2.50
1.00
36512
APHERESIS RBC
2.52
1.00
36513
APHERESIS PLATELETS
2.50
1.00
36513
APHERESIS PLATELETS
2.52
1.00
36513
APHERESIS PLATELETS
2.59
1.00
36514
APHERESIS PLASMA
2.42
1.00
36514
APHERESIS PLASMA
2.50
1.00
36514
APHERESIS PLASMA
2.52
1.00
36515
APHERESIS, ADSORP/REINFUSE
2.37
1.00
36515
APHERESIS, ADSORP/REINFUSE
2.50
1.00
36515
APHERESIS, ADSORP/REINFUSE
2.54
1.00
36516
APHERESIS, SELECTIVE
1.71
1.00
36516
APHERESIS, SELECTIVE
1.80
1.00
36516
APHERESIS, SELECTIVE
2.50
1.00
36522
PHOTOPHERESIS
2.77
1.00
36530
INSERTION OF INFUSION PUMP
3.00
1.00
36530
INSERTION OF INFUSION PUMP
10.46
1.00
36531
REVISION OF INFUSION PUMP
3.00
1.00
36531
REVISION OF INFUSION PUMP
8.56
1.00
36532
REMOVAL OF INFUSION PUMP
3.00
1.00
Procedure Code Description
RVU
RVU Coeff Value
36532
REMOVAL OF INFUSION PUMP
5.16
1.00
36533
INSERTION OF ACCESS DEVICE
3.00
1.00
36533
INSERTION OF ACCESS DEVICE
9.19
1.00
36534
REVISION OF ACCESS DEVICE
3.00
1.00
36534
REVISION OF ACCESS DEVICE
4.45
1.00
36535
REMOVAL OF ACCESS DEVICE
3.00
1.00
36535
REMOVAL OF ACCESS DEVICE
4.30
1.00
36536
REMOVE CVA DEVICE OBSTRUCT
5.30
1.00
36537
REMOVE CVA LUMEN OBSTRUCT
1.28
1.00
36540
COLLECT BLOOD VENOUS DEVICE
0.24
1.00
36550
DECLOT VASCULAR DEVICE
0.68
1.00
36550
DECLOT VASCULAR DEVICE
0.69
1.00
36550
DECLOT VASCULAR DEVICE
0.76
1.00
36555
INSERT NON-TUNNEL CV CATH
3.46
1.00
36555
INSERT NON-TUNNEL CV CATH
3.71
1.00
36556
INSERT NON-TUNNEL CV CATH
3.31
1.00
36556
INSERT NON-TUNNEL CV CATH
3.34
1.00
36556
INSERT NON-TUNNEL CV CATH
3.39
1.00
36556
INSERT NON-TUNNEL CV CATH
3.43
1.00
36557
INSERT TUNNELED CV CATH
8.15
1.00
36557
INSERT TUNNELED CV CATH
8.23
1.00
36557
INSERT TUNNELED CV CATH
8.24
1.00
36557
INSERT TUNNELED CV CATH
8.26
1.00
36557
INSERT TUNNELED CV CATH
8.32
1.00
36558
INSERT TUNNELED CV CATH
7.85
1.00
36558
INSERT TUNNELED CV CATH
7.91
1.00
36560
INSERT TUNNELED CV CATH
9.71
1.00
36560
INSERT TUNNELED CV CATH
9.73
1.00
36560
INSERT TUNNELED CV CATH
9.79
1.00
36560
INSERT TUNNELED CV CATH
9.85
1.00
36561
INSERT TUNNELED CV CATH
9.38
1.00
36561
INSERT TUNNELED CV CATH
9.40
1.00
36561
INSERT TUNNELED CV CATH
9.43
1.00
36561
INSERT TUNNELED CV CATH
9.45
1.00
36561
INSERT TUNNELED CV CATH
9.52
1.00
Procedure Code Description
RVU
RVU Coeff Value
36563
INSERT TUNNELED CV CATH
9.84
1.00
36563
INSERT TUNNELED CV CATH
9.85
1.00
36563
INSERT TUNNELED CV CATH
9.94
1.00
36563
INSERT TUNNELED CV CATH
10.02
1.00
36565
INSERT TUNNELED CV CATH
9.26
1.00
36565
INSERT TUNNELED CV CATH
9.45
1.00
36565
INSERT TUNNELED CV CATH
9.51
1.00
36565
INSERT TUNNELED CV CATH
9.52
1.00
36566
INSERT TUNNELED CV CATH
9.90
1.00
36566
INSERT TUNNELED CV CATH
10.12
1.00
36568
INSERT PICC CATH
2.60
1.00
36568
INSERT PICC CATH
2.62
1.00
36568
INSERT PICC CATH
2.67
1.00
36568
INSERT PICC CATH
2.72
1.00
36569
INSERT PICC CATH
2.55
1.00
36569
INSERT PICC CATH
2.58
1.00
36569
INSERT PICC CATH
2.63
1.00
36569
INSERT PICC CATH
2.70
1.00
36570
INSERT PICVAD CATH
8.54
1.00
36570
INSERT PICVAD CATH
8.70
1.00
36571
INSERT PICVAD CATH
8.46
1.00
36571
INSERT PICVAD CATH
8.50
1.00
36571
INSERT PICVAD CATH
8.51
1.00
36571
INSERT PICVAD CATH
8.58
1.00
36575
REPAIR TUNNELED CV CATH
1.12
1.00
36575
REPAIR TUNNELED CV CATH
1.52
1.00
36576
REPAIR TUNNELED CV CATH
5.08
1.00
36576
REPAIR TUNNELED CV CATH
5.54
1.00
36578
REPLACE TUNNELED CV CATH
5.81
1.00
36578
REPLACE TUNNELED CV CATH
6.28
1.00
36580
REPLACE CVAD CATH
1.88
1.00
36580
REPLACE CVAD CATH
1.91
1.00
36580
REPLACE CVAD CATH
1.92
1.00
36580
REPLACE CVAD CATH
1.96
1.00
36581
REPLACE TUNNELED CV CATH
5.47
1.00
Procedure Code Description
RVU
RVU Coeff Value
36581
REPLACE TUNNELED CV CATH
5.50
1.00
36581
REPLACE TUNNELED CV CATH
5.55
1.00
36581
REPLACE TUNNELED CV CATH
5.86
1.00
36582
REPLACE TUNNELED CV CATH
8.04
1.00
36582
REPLACE TUNNELED CV CATH
8.54
1.00
36583
REPLACE TUNNELED CV CATH
8.05
1.00
36583
REPLACE TUNNELED CV CATH
8.60
1.00
36584
REPLACE PICC CATH
1.90
1.00
36584
REPLACE PICC CATH
2.02
1.00
36585
REPLACE PICVAD CATH
7.56
1.00
36585
REPLACE PICVAD CATH
8.00
1.00
36589
REMOVAL TUNNELED CV CATH
3.82
1.00
36589
REMOVAL TUNNELED CV CATH
3.93
1.00
36590
REMOVAL TUNNELED CV CATH
5.35
1.00
36590
REMOVAL TUNNELED CV CATH
5.44
1.00
36591
DRAW BLOOD OFF VENOUS DEVICE
0.61
1.00
36592
COLLECT BLOOD FROM PICC
0.67
1.00
36593
DECLOT VASCULAR DEVICE
1.08
1.00
36595
MECH REMOV TUNNELED CV CATH
5.31
1.00
36595
MECH REMOV TUNNELED CV CATH
5.33
1.00
36596
MECH REMOV TUNNELED CV CATH
1.26
1.00
36596
MECH REMOV TUNNELED CV CATH
1.29
1.00
36597
REPOSITION VENOUS CATHETER
1.71
1.00
36597
REPOSITION VENOUS CATHETER
1.77
1.00
36598
INJ W/FLUOR, EVAL CV DEVICE
1.67
1.00
36600
WITHDRAWAL OF ARTERIAL BLOOD
0.42
1.00
36600
WITHDRAWAL OF ARTERIAL BLOOD
0.43
1.00
36600
WITHDRAWAL OF ARTERIAL BLOOD
999.99
1.00
36620
INSERTION CATHETER, ARTERY
1.39
1.00
36620
INSERTION CATHETER, ARTERY
1.45
1.00
36620
INSERTION CATHETER, ARTERY
1.46
1.00
36620
INSERTION CATHETER, ARTERY
999.99
1.00
36625
INSERTION CATHETER, ARTERY
2.80
1.00
36625
INSERTION CATHETER, ARTERY
2.82
1.00
36625
INSERTION CATHETER, ARTERY
2.93
1.00
Procedure Code Description
RVU
RVU Coeff Value
36640
INSERTION CATHETER, ARTERY
3.00
1.00
36640
INSERTION CATHETER, ARTERY
3.27
1.00
36640
INSERTION CATHETER, ARTERY
3.37
1.00
36660
INSERTION CATHETER, ARTERY
1.85
1.00
36660
INSERTION CATHETER, ARTERY
1.93
1.00
36660
INSERTION CATHETER, ARTERY
1.94
1.00
36680
INSERT NEEDLE, BONE CAVITY
1.63
1.00
36680
INSERT NEEDLE, BONE CAVITY
1.79
1.00
36680
INSERT NEEDLE, BONE CAVITY
1.90
1.00
36800
INSERTION OF CANNULA
4.00
1.00
36800
INSERTION OF CANNULA
4.30
1.00
36800
INSERTION OF CANNULA
4.36
1.00
36800
INSERTION OF CANNULA
4.45
1.00
36810
INSERTION OF CANNULA
5.00
1.00
36810
INSERTION OF CANNULA
5.78
1.00
36810
INSERTION OF CANNULA
6.13
1.00
36810
INSERTION OF CANNULA
6.61
1.00
36815
INSERTION OF CANNULA
4.00
1.00
36815
INSERTION OF CANNULA
4.10
1.00
36815
INSERTION OF CANNULA
4.14
1.00
36818
AV FUSE, UPPR ARM, CEPHALIC
18.75
1.00
36819
AV FUSE, UPPR ARM, BASILIC
5.00
1.00
36819
AV FUSE, UPPR ARM, BASILIC
21.97
1.00
36819
AV FUSE, UPPR ARM, BASILIC
21.98
1.00
36819
AV FUSE, UPPR ARM, BASILIC
22.26
1.00
36820
AV FUSION/FOREARM VEIN
6.00
1.00
36820
AV FUSION/FOREARM VEIN
21.99
1.00
36820
AV FUSION/FOREARM VEIN
22.05
1.00
36820
AV FUSION/FOREARM VEIN
22.26
1.00
36821
AV FUSION DIRECT ANY SITE
5.00
1.00
36821
AV FUSION DIRECT ANY SITE
14.80
1.00
36821
AV FUSION DIRECT ANY SITE
14.84
1.00
36821
AV FUSION DIRECT ANY SITE
18.19
1.00
36822
INSERTION OF CANNULA(S)
10.29
1.00
36822
INSERTION OF CANNULA(S)
10.66
1.00
Procedure Code Description
RVU
RVU Coeff Value
36822
INSERTION OF CANNULA(S)
13.19
1.00
36823
INSERTION OF CANNULA(S)
4.00
1.00
36823
INSERTION OF CANNULA(S)
33.08
1.00
36823
INSERTION OF CANNULA(S)
33.56
1.00
36823
INSERTION OF CANNULA(S)
35.02
1.00
36825
ARTERY-VEIN AUTOGRAFT
12.00
1.00
36825
ARTERY-VEIN AUTOGRAFT
15.91
1.00
36825
ARTERY-VEIN AUTOGRAFT
16.28
1.00
36825
ARTERY-VEIN AUTOGRAFT
16.41
1.00
36830
ARTERY-VEIN NONAUTOGRAFT
6.00
1.00
36830
ARTERY-VEIN NONAUTOGRAFT
18.22
1.00
36830
ARTERY-VEIN NONAUTOGRAFT
18.87
1.00
36830
ARTERY-VEIN NONAUTOGRAFT
19.36
1.00
36831
OPEN THROMBECT AV FISTULA
5.00
1.00
36831
OPEN THROMBECT AV FISTULA
12.57
1.00
36831
OPEN THROMBECT AV FISTULA
12.72
1.00
36831
OPEN THROMBECT AV FISTULA
12.91
1.00
36832
AV FISTULA REVISION, OPEN
5.00
1.00
36832
AV FISTULA REVISION, OPEN
16.06
1.00
36832
AV FISTULA REVISION, OPEN
16.63
1.00
36832
AV FISTULA REVISION, OPEN
17.16
1.00
36833
AV FISTULA REVISION
5.00
1.00
36833
AV FISTULA REVISION
18.15
1.00
36833
AV FISTULA REVISION
18.74
1.00
36833
AV FISTULA REVISION
19.24
1.00
36834
REPAIR A-V ANEURYSM
14.78
1.00
36834
REPAIR A-V ANEURYSM
15.00
1.00
36834
REPAIR A-V ANEURYSM
16.01
1.00
36834
REPAIR A-V ANEURYSM
16.98
1.00
36835
ARTERY TO VEIN SHUNT
12.47
1.00
36835
ARTERY TO VEIN SHUNT
12.49
1.00
36835
ARTERY TO VEIN SHUNT
12.56
1.00
36838
DIST REVAS LIGATION, HEMO
32.45
1.00
36838
DIST REVAS LIGATION, HEMO
32.95
1.00
36860
EXTERNAL CANNULA DECLOTTING
2.80
1.00
Procedure Code Description
RVU
RVU Coeff Value
36860
EXTERNAL CANNULA DECLOTTING
3.00
1.00
36860
EXTERNAL CANNULA DECLOTTING
3.45
1.00
36860
EXTERNAL CANNULA DECLOTTING
3.48
1.00
36861
CANNULA DECLOTTING
4.12
1.00
36861
CANNULA DECLOTTING
4.17
1.00
36861
CANNULA DECLOTTING
8.00
1.00
36870
PERCUT THROMBECT AV FISTULA
3.00
1.00
36870
PERCUT THROMBECT AV FISTULA
7.78
1.00
36870
PERCUT THROMBECT AV FISTULA
8.40
1.00
36870
PERCUT THROMBECT AV FISTULA
8.42
1.00
36870
PERCUT THROMBECT AV FISTULA
8.45
1.00
36870
PERCUT THROMBECT AV FISTULA
8.57
1.00
36870
PERCUT THROMBECT AV FISTULA
8.60
1.00
37140
REVISION OF CIRCULATION
11.00
1.00
37140
REVISION OF CIRCULATION
35.12
1.00
37140
REVISION OF CIRCULATION
35.52
1.00
37140
REVISION OF CIRCULATION
36.62
1.00
37145
REVISION OF CIRCULATION
15.00
1.00
37145
REVISION OF CIRCULATION
38.02
1.00
37145
REVISION OF CIRCULATION
38.49
1.00
37145
REVISION OF CIRCULATION
39.90
1.00
37160
REVISION OF CIRCULATION
15.00
1.00
37160
REVISION OF CIRCULATION
32.90
1.00
37160
REVISION OF CIRCULATION
33.48
1.00
37160
REVISION OF CIRCULATION
34.68
1.00
37180
REVISION OF CIRCULATION
15.00
1.00
37180
REVISION OF CIRCULATION
37.51
1.00
37180
REVISION OF CIRCULATION
38.09
1.00
37180
REVISION OF CIRCULATION
38.91
1.00
37181
SPLICE SPLEEN/KIDNEY VEINS
11.00
1.00
37181
SPLICE SPLEEN/KIDNEY VEINS
40.21
1.00
37181
SPLICE SPLEEN/KIDNEY VEINS
40.92
1.00
37181
SPLICE SPLEEN/KIDNEY VEINS
41.99
1.00
37182
INSERT HEPATIC SHUNT (TIPS)
24.78
1.00
37182
INSERT HEPATIC SHUNT (TIPS)
24.86
1.00
Procedure Code Description
RVU
RVU Coeff Value
37182
INSERT HEPATIC SHUNT (TIPS)
25.04
1.00
37183
REMOVE HEPATIC SHUNT (TIPS)
11.55
1.00
37183
REMOVE HEPATIC SHUNT (TIPS)
11.59
1.00
37183
REMOVE HEPATIC SHUNT (TIPS)
11.78
1.00
37184
PRIM ART MECH THROMBECTOMY
12.69
1.00
37185
PRIM ART M-THROMBECT ADD-ON
4.67
1.00
37186
SEC ART M-THROMBECT ADD-ON
7.18
1.00
37187
VENOUS MECH THROMBECTOMY
11.54
1.00
37187
VENOUS MECH THROMBECTOMY
11.61
1.00
37187
VENOUS MECH THROMBECTOMY
11.69
1.00
37187
VENOUS MECH THROMBECTOMY
11.79
1.00
37188
VENOUS M-THROMBECTOMY ADD-ON
8.54
1.00
37195
THROMBOLYTIC THERAPY, STROKE
8.40
1.00
37195
THROMBOLYTIC THERAPY, STROKE
8.54
1.00
37195
THROMBOLYTIC THERAPY, STROKE
15.00
1.00
37200
TRANSCATHETER BIOPSY
6.28
1.00
37200
TRANSCATHETER BIOPSY
6.30
1.00
37200
TRANSCATHETER BIOPSY
6.58
1.00
37200
TRANSCATHETER BIOPSY
999.99
1.00
37201
TRANSCATHETER THERAPY INFUSE
7.77
1.00
37201
TRANSCATHETER THERAPY INFUSE
7.80
1.00
37201
TRANSCATHETER THERAPY INFUSE
999.99
1.00
37202
TRANSCATHETER THERAPY INFUSE
9.16
1.00
37202
TRANSCATHETER THERAPY INFUSE
9.40
1.00
37202
TRANSCATHETER THERAPY INFUSE
999.99
1.00
37203
TRANSCATHETER RETRIEVAL
7.29
1.00
37203
TRANSCATHETER RETRIEVAL
7.35
1.00
37203
TRANSCATHETER RETRIEVAL
7.37
1.00
37203
TRANSCATHETER RETRIEVAL
7.48
1.00
37203
TRANSCATHETER RETRIEVAL
7.81
1.00
37203
TRANSCATHETER RETRIEVAL
7.83
1.00
37203
TRANSCATHETER RETRIEVAL
999.99
1.00
37204
TRANSCATHETER OCCLUSION
25.14
1.00
37204
TRANSCATHETER OCCLUSION
25.16
1.00
37204
TRANSCATHETER OCCLUSION
26.27
1.00
Procedure Code Description
RVU
RVU Coeff Value
37204
TRANSCATHETER OCCLUSION
999.99
1.00
37205
TRANSCATH IV STENT, PERCUT
12.33
1.00
37205
TRANSCATH IV STENT, PERCUT
12.37
1.00
37205
TRANSCATH IV STENT, PERCUT
12.50
1.00
37205
TRANSCATH IV STENT, PERCUT
12.53
1.00
37206
TRANSCATH IV STENT/PERC ADDL
5.83
1.00
37206
TRANSCATH IV STENT/PERC ADDL
5.93
1.00
37206
TRANSCATH IV STENT/PERC ADDL
6.01
1.00
37207
TRANSCATH IV STENT, OPEN
12.14
1.00
37207
TRANSCATH IV STENT, OPEN
12.51
1.00
37207
TRANSCATH IV STENT, OPEN
12.70
1.00
37208
TRANSCATH IV STENT/OPEN ADDL
5.88
1.00
37208
TRANSCATH IV STENT/OPEN ADDL
5.98
1.00
37208
TRANSCATH IV STENT/OPEN ADDL
6.04
1.00
37209
CHANGE IV CATH AT THROMB TX
3.15
1.00
37209
CHANGE IV CATH AT THROMB TX
3.23
1.00
37210
EMBOLIZATION UTERINE FIBROID
14.33
1.00
37210
EMBOLIZATION UTERINE FIBROID
14.88
1.00
37210
EMBOLIZATION UTERINE FIBROID
15.57
1.00
37215
TRANSCATH STENT, CCA W/EPS
30.54
1.00
37216
TRANSCATH STENT, CCA W/O EPS
28.01
1.00
37250
IV US FIRST VESSEL ADD-ON
3.04
1.00
37250
IV US FIRST VESSEL ADD-ON
3.06
1.00
37250
IV US FIRST VESSEL ADD-ON
3.09
1.00
37250
IV US FIRST VESSEL ADD-ON
999.99
1.00
37251
IV US EACH ADD VESSEL ADD-ON
2.31
1.00
37251
IV US EACH ADD VESSEL ADD-ON
2.32
1.00
37500
ENDOSCOPY LIGATE PERF VEINS
18.58
1.00
37500
ENDOSCOPY LIGATE PERF VEINS
18.94
1.00
37500
ENDOSCOPY LIGATE PERF VEINS
20.10
1.00
37565
LIGATION OF NECK VEIN
6.00
1.00
37565
LIGATION OF NECK VEIN
16.41
1.00
37565
LIGATION OF NECK VEIN
17.05
1.00
37565
LIGATION OF NECK VEIN
18.74
1.00
37600
LIGATION OF NECK ARTERY
5.00
1.00
Procedure Code Description
RVU
RVU Coeff Value
37600
LIGATION OF NECK ARTERY
17.95
1.00
37600
LIGATION OF NECK ARTERY
18.38
1.00
37600
LIGATION OF NECK ARTERY
19.18
1.00
37605
LIGATION OF NECK ARTERY
6.00
1.00
37605
LIGATION OF NECK ARTERY
20.36
1.00
37605
LIGATION OF NECK ARTERY
20.96
1.00
37605
LIGATION OF NECK ARTERY
22.07
1.00
37606
LIGATION OF NECK ARTERY
6.00
1.00
37606
LIGATION OF NECK ARTERY
11.81
1.00
37606
LIGATION OF NECK ARTERY
14.38
1.00
37607
LIGATION OF A-V FISTULA
10.00
1.00
37607
LIGATION OF A-V FISTULA
10.26
1.00
37607
LIGATION OF A-V FISTULA
10.48
1.00
37607
LIGATION OF A-V FISTULA
10.55
1.00
37609
TEMPORAL ARTERY PROCEDURE
5.00
1.00
37609
TEMPORAL ARTERY PROCEDURE
5.23
1.00
37609
TEMPORAL ARTERY PROCEDURE
5.27
1.00
37609
TEMPORAL ARTERY PROCEDURE
5.73
1.00
37615
LIGATION OF NECK ARTERY
6.00
1.00
37615
LIGATION OF NECK ARTERY
9.94
1.00
37615
LIGATION OF NECK ARTERY
10.53
1.00
37615
LIGATION OF NECK ARTERY
12.59
1.00
37616
LIGATION OF CHEST ARTERY
6.00
1.00
37616
LIGATION OF CHEST ARTERY
26.95
1.00
37616
LIGATION OF CHEST ARTERY
29.00
1.00
37616
LIGATION OF CHEST ARTERY
29.51
1.00
37617
LIGATION OF ABDOMEN ARTERY
6.00
1.00
37617
LIGATION OF ABDOMEN ARTERY
33.17
1.00
37617
LIGATION OF ABDOMEN ARTERY
33.29
1.00
37617
LIGATION OF ABDOMEN ARTERY
35.17
1.00
37618
LIGATION OF EXTREMITY ARTERY
4.00
1.00
37618
LIGATION OF EXTREMITY ARTERY
8.87
1.00
37618
LIGATION OF EXTREMITY ARTERY
9.07
1.00
37618
LIGATION OF EXTREMITY ARTERY
10.11
1.00
37620
REVISION OF MAJOR VEIN
7.00
1.00
Procedure Code Description
RVU
RVU Coeff Value
37620
REVISION OF MAJOR VEIN
16.71
1.00
37620
REVISION OF MAJOR VEIN
17.16
1.00
37620
REVISION OF MAJOR VEIN
18.18
1.00
37650
REVISION OF MAJOR VEIN
4.00
1.00
37650
REVISION OF MAJOR VEIN
13.01
1.00
37650
REVISION OF MAJOR VEIN
13.19
1.00
37650
REVISION OF MAJOR VEIN
13.83
1.00
37660
REVISION OF MAJOR VEIN
5.00
1.00
37660
REVISION OF MAJOR VEIN
31.48
1.00
37660
REVISION OF MAJOR VEIN
31.49
1.00
37660
REVISION OF MAJOR VEIN
32.83
1.00
37700
REVISE LEG VEIN
3.00
1.00
37700
REVISE LEG VEIN
6.81
1.00
37700
REVISE LEG VEIN
7.01
1.00
37700
REVISE LEG VEIN
7.27
1.00
37718
LIGATE/STRIP SHORT LEG VEIN
10.95
1.00
37720
REMOVAL OF LEG VEIN
3.00
1.00
37720
REMOVAL OF LEG VEIN
9.90
1.00
37720
REMOVAL OF LEG VEIN
10.12
1.00
37720
REMOVAL OF LEG VEIN
10.13
1.00
37722
LIGATE/STRIP LONG LEG VEIN
12.90
1.00
37730
REMOVAL OF LEG VEINS
3.00
1.00
37730
REMOVAL OF LEG VEINS
12.53
1.00
37730
REMOVAL OF LEG VEINS
12.59
1.00
37730
REMOVAL OF LEG VEINS
12.61
1.00
37735
REMOVAL OF LEG VEINS/LESION
4.00
1.00
37735
REMOVAL OF LEG VEINS/LESION
17.27
1.00
37735
REMOVAL OF LEG VEINS/LESION
17.46
1.00
37735
REMOVAL OF LEG VEINS/LESION
17.47
1.00
37760
LIGATION, LEG VEINS, OPEN
4.00
1.00
37760
LIGATION, LEG VEINS, OPEN
17.00
1.00
37760
LIGATION, LEG VEINS, OPEN
17.17
1.00
37760
LIGATION, LEG VEINS, OPEN
17.21
1.00
37765
PHLEB VEINS - EXTREM - TO 20
12.04
1.00
37765
PHLEB VEINS - EXTREM - TO 20
12.37
1.00
Procedure Code Description
RVU
RVU Coeff Value
37766
PHLEB VEINS - EXTREM 20+
14.60
1.00
37766
PHLEB VEINS - EXTREM 20+
15.03
1.00
37780
REVISION OF LEG VEIN
3.00
1.00
37780
REVISION OF LEG VEIN
7.02
1.00
37780
REVISION OF LEG VEIN
7.20
1.00
37780
REVISION OF LEG VEIN
7.21
1.00
37785
LIGATE/DIVIDE/EXCISE VEIN
3.00
1.00
37785
LIGATE/DIVIDE/EXCISE VEIN
6.96
1.00
37785
LIGATE/DIVIDE/EXCISE VEIN
7.04
1.00
37785
LIGATE/DIVIDE/EXCISE VEIN
7.10
1.00
37788
REVASCULARIZATION, PENIS
32.90
1.00
37788
REVASCULARIZATION, PENIS
34.86
1.00
37788
REVASCULARIZATION, PENIS
37.38
1.00
37788
REVASCULARIZATION, PENIS
999.99
1.00
37790
PENILE VENOUS OCCLUSION
3.00
1.00
37790
PENILE VENOUS OCCLUSION
13.48
1.00
37790
PENILE VENOUS OCCLUSION
13.62
1.00
37790
PENILE VENOUS OCCLUSION
15.08
1.00
40490
BIOPSY OF LIP
1.89
1.00
40490
BIOPSY OF LIP
1.90
1.00
40490
BIOPSY OF LIP
4.00
1.00
40500
PARTIAL EXCISION OF LIP
4.00
1.00
40500
PARTIAL EXCISION OF LIP
9.09
1.00
40500
PARTIAL EXCISION OF LIP
9.54
1.00
40500
PARTIAL EXCISION OF LIP
10.28
1.00
40510
PARTIAL EXCISION OF LIP
4.00
1.00
40510
PARTIAL EXCISION OF LIP
9.03
1.00
40510
PARTIAL EXCISION OF LIP
9.94
1.00
40510
PARTIAL EXCISION OF LIP
11.59
1.00
40520
PARTIAL EXCISION OF LIP
4.00
1.00
40520
PARTIAL EXCISION OF LIP
9.14
1.00
40520
PARTIAL EXCISION OF LIP
10.20
1.00
40520
PARTIAL EXCISION OF LIP
11.96
1.00
40525
RECONSTRUCT LIP WITH FLAP
4.00
1.00
40525
RECONSTRUCT LIP WITH FLAP
14.21
1.00
Procedure Code Description
RVU
RVU Coeff Value
40525
RECONSTRUCT LIP WITH FLAP
15.26
1.00
40525
RECONSTRUCT LIP WITH FLAP
16.59
1.00
40527
RECONSTRUCT LIP WITH FLAP
4.00
1.00
40527
RECONSTRUCT LIP WITH FLAP
16.77
1.00
40527
RECONSTRUCT LIP WITH FLAP
17.96
1.00
40527
RECONSTRUCT LIP WITH FLAP
19.19
1.00
40530
PARTIAL REMOVAL OF LIP
4.00
1.00
40530
PARTIAL REMOVAL OF LIP
10.35
1.00
40530
PARTIAL REMOVAL OF LIP
11.15
1.00
40530
PARTIAL REMOVAL OF LIP
12.11
1.00
40650
REPAIR LIP
4.00
1.00
40650
REPAIR LIP
7.27
1.00
40650
REPAIR LIP
7.80
1.00
40650
REPAIR LIP
8.76
1.00
40652
REPAIR LIP
4.00
1.00
40652
REPAIR LIP
8.89
1.00
40652
REPAIR LIP
9.95
1.00
40652
REPAIR LIP
11.45
1.00
40654
REPAIR LIP
5.00
1.00
40654
REPAIR LIP
10.78
1.00
40654
REPAIR LIP
11.84
1.00
40654
REPAIR LIP
13.29
1.00
40700
REPAIR CLEFT LIP/NASAL
6.00
1.00
40700
REPAIR CLEFT LIP/NASAL
23.40
1.00
40700
REPAIR CLEFT LIP/NASAL
23.61
1.00
40700
REPAIR CLEFT LIP/NASAL
24.04
1.00
40701
REPAIR CLEFT LIP/NASAL
8.00
1.00
40701
REPAIR CLEFT LIP/NASAL
29.26
1.00
40701
REPAIR CLEFT LIP/NASAL
29.47
1.00
40701
REPAIR CLEFT LIP/NASAL
29.91
1.00
40702
REPAIR CLEFT LIP/NASAL
8.00
1.00
40702
REPAIR CLEFT LIP/NASAL
22.71
1.00
40702
REPAIR CLEFT LIP/NASAL
22.83
1.00
40702
REPAIR CLEFT LIP/NASAL
23.59
1.00
40720
REPAIR CLEFT LIP/NASAL
8.00
1.00
Procedure Code Description
RVU
RVU Coeff Value
40720
REPAIR CLEFT LIP/NASAL
25.35
1.00
40720
REPAIR CLEFT LIP/NASAL
25.61
1.00
40720
REPAIR CLEFT LIP/NASAL
26.79
1.00
40761
REPAIR CLEFT LIP/NASAL
6.00
1.00
40761
REPAIR CLEFT LIP/NASAL
27.22
1.00
40761
REPAIR CLEFT LIP/NASAL
27.45
1.00
40761
REPAIR CLEFT LIP/NASAL
28.52
1.00
40799
LIP SURGERY PROCEDURE
999.99
1.00
40800
DRAINAGE OF MOUTH LESION
2.13
1.00
40800
DRAINAGE OF MOUTH LESION
2.42
1.00
40800
DRAINAGE OF MOUTH LESION
3.18
1.00
40800
DRAINAGE OF MOUTH LESION
4.00
1.00
40801
DRAINAGE OF MOUTH LESION
4.26
1.00
40801
DRAINAGE OF MOUTH LESION
4.78
1.00
40801
DRAINAGE OF MOUTH LESION
5.00
1.00
40801
DRAINAGE OF MOUTH LESION
5.55
1.00
40804
REMOVAL, FOREIGN BODY, MOUTH
2.36
1.00
40804
REMOVAL, FOREIGN BODY, MOUTH
2.47
1.00
40804
REMOVAL, FOREIGN BODY, MOUTH
3.21
1.00
40804
REMOVAL, FOREIGN BODY, MOUTH
5.00
1.00
40805
REMOVAL, FOREIGN BODY, MOUTH
4.61
1.00
40805
REMOVAL, FOREIGN BODY, MOUTH
4.88
1.00
40805
REMOVAL, FOREIGN BODY, MOUTH
5.00
1.00
40805
REMOVAL, FOREIGN BODY, MOUTH
5.75
1.00
40806
INCISION OF LIP FOLD
0.86
1.00
40806
INCISION OF LIP FOLD
1.19
1.00
40806
INCISION OF LIP FOLD
1.28
1.00
40806
INCISION OF LIP FOLD
3.00
1.00
40808
BIOPSY OF MOUTH LESION
2.05
1.00
40808
BIOPSY OF MOUTH LESION
2.12
1.00
40808
BIOPSY OF MOUTH LESION
2.67
1.00
40808
BIOPSY OF MOUTH LESION
4.00
1.00
40810
EXCISION OF MOUTH LESION
2.56
1.00
40810
EXCISION OF MOUTH LESION
2.63
1.00
40810
EXCISION OF MOUTH LESION
3.17
1.00
Procedure Code Description
RVU
RVU Coeff Value
40810
EXCISION OF MOUTH LESION
4.00
1.00
40812
EXCISE/REPAIR MOUTH LESION
4.00
1.00
40812
EXCISE/REPAIR MOUTH LESION
4.20
1.00
40812
EXCISE/REPAIR MOUTH LESION
4.30
1.00
40812
EXCISE/REPAIR MOUTH LESION
4.95
1.00
40814
EXCISE/REPAIR MOUTH LESION
5.00
1.00
40814
EXCISE/REPAIR MOUTH LESION
6.66
1.00
40814
EXCISE/REPAIR MOUTH LESION
7.01
1.00
40814
EXCISE/REPAIR MOUTH LESION
7.64
1.00
40816
EXCISION OF MOUTH LESION
4.00
1.00
40816
EXCISION OF MOUTH LESION
7.11
1.00
40816
EXCISION OF MOUTH LESION
7.38
1.00
40816
EXCISION OF MOUTH LESION
7.98
1.00
40818
EXCISE ORAL MUCOSA FOR GRAFT
4.00
1.00
40818
EXCISE ORAL MUCOSA FOR GRAFT
6.11
1.00
40818
EXCISE ORAL MUCOSA FOR GRAFT
6.66
1.00
40818
EXCISE ORAL MUCOSA FOR GRAFT
6.79
1.00
40819
EXCISE LIP OR CHEEK FOLD
4.00
1.00
40819
EXCISE LIP OR CHEEK FOLD
5.54
1.00
40819
EXCISE LIP OR CHEEK FOLD
5.86
1.00
40819
EXCISE LIP OR CHEEK FOLD
6.13
1.00
40820
TREATMENT OF MOUTH LESION
3.66
1.00
40820
TREATMENT OF MOUTH LESION
3.73
1.00
40820
TREATMENT OF MOUTH LESION
4.00
1.00
40820
TREATMENT OF MOUTH LESION
4.26
1.00
40830
REPAIR MOUTH LACERATION
3.99
1.00
40830
REPAIR MOUTH LACERATION
4.00
1.00
40830
REPAIR MOUTH LACERATION
4.40
1.00
40830
REPAIR MOUTH LACERATION
4.44
1.00
40831
REPAIR MOUTH LACERATION
4.00
1.00
40831
REPAIR MOUTH LACERATION
5.45
1.00
40831
REPAIR MOUTH LACERATION
5.62
1.00
40831
REPAIR MOUTH LACERATION
5.79
1.00
40840
RECONSTRUCTION OF MOUTH
3.00
1.00
40840
RECONSTRUCTION OF MOUTH
15.66
1.00
Procedure Code Description
RVU
RVU Coeff Value
40840
RECONSTRUCTION OF MOUTH
16.24
1.00
40840
RECONSTRUCTION OF MOUTH
17.03
1.00
40842
RECONSTRUCTION OF MOUTH
4.00
1.00
40842
RECONSTRUCTION OF MOUTH
15.38
1.00
40842
RECONSTRUCTION OF MOUTH
15.90
1.00
40842
RECONSTRUCTION OF MOUTH
16.60
1.00
40843
RECONSTRUCTION OF MOUTH
4.00
1.00
40843
RECONSTRUCTION OF MOUTH
20.25
1.00
40843
RECONSTRUCTION OF MOUTH
20.64
1.00
40843
RECONSTRUCTION OF MOUTH
21.70
1.00
40844
RECONSTRUCTION OF MOUTH
4.00
1.00
40844
RECONSTRUCTION OF MOUTH
26.59
1.00
40844
RECONSTRUCTION OF MOUTH
28.90
1.00
40844
RECONSTRUCTION OF MOUTH
29.71
1.00
40845
RECONSTRUCTION OF MOUTH
4.00
1.00
40845
RECONSTRUCTION OF MOUTH
30.99
1.00
40845
RECONSTRUCTION OF MOUTH
32.29
1.00
40845
RECONSTRUCTION OF MOUTH
33.87
1.00
41000
DRAINAGE OF MOUTH LESION
2.80
1.00
41000
DRAINAGE OF MOUTH LESION
2.81
1.00
41000
DRAINAGE OF MOUTH LESION
2.89
1.00
41000
DRAINAGE OF MOUTH LESION
4.00
1.00
41005
DRAINAGE OF MOUTH LESION
2.82
1.00
41005
DRAINAGE OF MOUTH LESION
2.99
1.00
41005
DRAINAGE OF MOUTH LESION
3.19
1.00
41005
DRAINAGE OF MOUTH LESION
5.00
1.00
41006
DRAINAGE OF MOUTH LESION
5.00
1.00
41006
DRAINAGE OF MOUTH LESION
6.56
1.00
41006
DRAINAGE OF MOUTH LESION
6.89
1.00
41006
DRAINAGE OF MOUTH LESION
6.98
1.00
41007
DRAINAGE OF MOUTH LESION
5.00
1.00
41007
DRAINAGE OF MOUTH LESION
6.36
1.00
41007
DRAINAGE OF MOUTH LESION
6.51
1.00
41007
DRAINAGE OF MOUTH LESION
6.68
1.00
41008
DRAINAGE OF MOUTH LESION
6.82
1.00
Procedure Code Description
RVU
RVU Coeff Value
41008
DRAINAGE OF MOUTH LESION
6.89
1.00
41008
DRAINAGE OF MOUTH LESION
7.00
1.00
41008
DRAINAGE OF MOUTH LESION
7.14
1.00
41009
DRAINAGE OF MOUTH LESION
5.00
1.00
41009
DRAINAGE OF MOUTH LESION
7.11
1.00
41009
DRAINAGE OF MOUTH LESION
7.41
1.00
41009
DRAINAGE OF MOUTH LESION
7.73
1.00
41010
INCISION OF TONGUE FOLD
2.73
1.00
41010
INCISION OF TONGUE FOLD
4.00
1.00
41010
INCISION OF TONGUE FOLD
4.38
1.00
41010
INCISION OF TONGUE FOLD
4.59
1.00
41015
DRAINAGE OF MOUTH LESION
5.00
1.00
41015
DRAINAGE OF MOUTH LESION
7.48
1.00
41015
DRAINAGE OF MOUTH LESION
8.36
1.00
41015
DRAINAGE OF MOUTH LESION
8.48
1.00
41016
DRAINAGE OF MOUTH LESION
5.00
1.00
41016
DRAINAGE OF MOUTH LESION
7.73
1.00
41016
DRAINAGE OF MOUTH LESION
8.47
1.00
41016
DRAINAGE OF MOUTH LESION
8.82
1.00
41017
DRAINAGE OF MOUTH LESION
4.00
1.00
41017
DRAINAGE OF MOUTH LESION
7.71
1.00
41017
DRAINAGE OF MOUTH LESION
8.59
1.00
41017
DRAINAGE OF MOUTH LESION
8.86
1.00
41018
DRAINAGE OF MOUTH LESION
5.00
1.00
41018
DRAINAGE OF MOUTH LESION
9.24
1.00
41018
DRAINAGE OF MOUTH LESION
9.76
1.00
41018
DRAINAGE OF MOUTH LESION
10.38
1.00
41019
PLACE NEEDLES H&N FOR RT
12.96
1.00
41100
BIOPSY OF TONGUE
2.79
1.00
41100
BIOPSY OF TONGUE
3.15
1.00
41100
BIOPSY OF TONGUE
3.19
1.00
41100
BIOPSY OF TONGUE
4.00
1.00
41105
BIOPSY OF TONGUE
2.82
1.00
41105
BIOPSY OF TONGUE
2.84
1.00
41105
BIOPSY OF TONGUE
2.85
1.00
Procedure Code Description
RVU
RVU Coeff Value
41105
BIOPSY OF TONGUE
4.00
1.00
41108
BIOPSY OF FLOOR OF MOUTH
2.23
1.00
41108
BIOPSY OF FLOOR OF MOUTH
2.27
1.00
41108
BIOPSY OF FLOOR OF MOUTH
4.00
1.00
41110
EXCISION OF TONGUE LESION
2.93
1.00
41110
EXCISION OF TONGUE LESION
2.97
1.00
41110
EXCISION OF TONGUE LESION
3.31
1.00
41110
EXCISION OF TONGUE LESION
4.00
1.00
41112
EXCISION OF TONGUE LESION
4.00
1.00
41112
EXCISION OF TONGUE LESION
5.64
1.00
41112
EXCISION OF TONGUE LESION
5.68
1.00
41112
EXCISION OF TONGUE LESION
6.30
1.00
41113
EXCISION OF TONGUE LESION
4.00
1.00
41113
EXCISION OF TONGUE LESION
6.36
1.00
41113
EXCISION OF TONGUE LESION
6.45
1.00
41113
EXCISION OF TONGUE LESION
7.01
1.00
41114
EXCISION OF TONGUE LESION
4.00
1.00
41114
EXCISION OF TONGUE LESION
14.55
1.00
41114
EXCISION OF TONGUE LESION
15.54
1.00
41114
EXCISION OF TONGUE LESION
16.22
1.00
41115
EXCISION OF TONGUE FOLD
3.75
1.00
41115
EXCISION OF TONGUE FOLD
4.41
1.00
41115
EXCISION OF TONGUE FOLD
4.47
1.00
41115
EXCISION OF TONGUE FOLD
6.00
1.00
41116
EXCISION OF MOUTH LESION
4.00
1.00
41116
EXCISION OF MOUTH LESION
5.42
1.00
41116
EXCISION OF MOUTH LESION
5.51
1.00
41116
EXCISION OF MOUTH LESION
6.01
1.00
41120
PARTIAL REMOVAL OF TONGUE
6.00
1.00
41120
PARTIAL REMOVAL OF TONGUE
18.18
1.00
41120
PARTIAL REMOVAL OF TONGUE
19.35
1.00
41120
PARTIAL REMOVAL OF TONGUE
26.36
1.00
41130
PARTIAL REMOVAL OF TONGUE
6.00
1.00
41130
PARTIAL REMOVAL OF TONGUE
20.47
1.00
41130
PARTIAL REMOVAL OF TONGUE
21.62
1.00
Procedure Code Description 41130
PARTIAL REMOVAL OF TONGUE
41135
RVU
RVU Coeff Value
32.50
1.00
TONGUE AND NECK SURGERY
6.00
1.00
41135
TONGUE AND NECK SURGERY
39.89
1.00
41135
TONGUE AND NECK SURGERY
40.74
1.00
41135
TONGUE AND NECK SURGERY
54.27
1.00
41140
REMOVAL OF TONGUE
6.00
1.00
41140
REMOVAL OF TONGUE
43.75
1.00
41140
REMOVAL OF TONGUE
44.67
1.00
41140
REMOVAL OF TONGUE
55.94
1.00
41145
TONGUE REMOVAL, NECK SURGERY
6.00
1.00
41145
TONGUE REMOVAL, NECK SURGERY
51.73
1.00
41145
TONGUE REMOVAL, NECK SURGERY
53.47
1.00
41145
TONGUE REMOVAL, NECK SURGERY
69.94
1.00
41150
TONGUE, MOUTH, JAW SURGERY
6.00
1.00
41150
TONGUE, MOUTH, JAW SURGERY
40.51
1.00
41150
TONGUE, MOUTH, JAW SURGERY
41.87
1.00
41150
TONGUE, MOUTH, JAW SURGERY
55.29
1.00
41153
TONGUE, MOUTH, NECK SURGERY
41.75
1.00
41153
TONGUE, MOUTH, NECK SURGERY
43.25
1.00
41153
TONGUE, MOUTH, NECK SURGERY
59.91
1.00
41155
TONGUE, JAW, & NECK SURGERY
8.00
1.00
41155
TONGUE, JAW, & NECK SURGERY
48.11
1.00
41155
TONGUE, JAW, & NECK SURGERY
49.71
1.00
41155
TONGUE, JAW, & NECK SURGERY
74.41
1.00
41250
REPAIR TONGUE LACERATION
3.58
1.00
41250
REPAIR TONGUE LACERATION
3.71
1.00
41250
REPAIR TONGUE LACERATION
3.77
1.00
41250
REPAIR TONGUE LACERATION
4.00
1.00
41251
REPAIR TONGUE LACERATION
4.17
1.00
41251
REPAIR TONGUE LACERATION
4.42
1.00
41251
REPAIR TONGUE LACERATION
4.45
1.00
41251
REPAIR TONGUE LACERATION
5.00
1.00
41252
REPAIR TONGUE LACERATION
4.00
1.00
41252
REPAIR TONGUE LACERATION
5.40
1.00
41252
REPAIR TONGUE LACERATION
5.53
1.00
Procedure Code Description
RVU
RVU Coeff Value
41252
REPAIR TONGUE LACERATION
5.54
1.00
41500
FIXATION OF TONGUE
5.00
1.00
41500
FIXATION OF TONGUE
7.64
1.00
41500
FIXATION OF TONGUE
8.30
1.00
41500
FIXATION OF TONGUE
11.16
1.00
41510
TONGUE TO LIP SURGERY
6.00
1.00
41510
TONGUE TO LIP SURGERY
6.80
1.00
41510
TONGUE TO LIP SURGERY
8.46
1.00
41510
TONGUE TO LIP SURGERY
10.22
1.00
41512
TONGUE SUSPENSION
15.66
1.00
41520
RECONSTRUCTION, TONGUE FOLD
4.00
1.00
41520
RECONSTRUCTION, TONGUE FOLD
5.95
1.00
41520
RECONSTRUCTION, TONGUE FOLD
6.18
1.00
41520
RECONSTRUCTION, TONGUE FOLD
6.38
1.00
41530
TONGUE BASE VOL REDUCTION
10.26
1.00
41800
DRAINAGE OF GUM LESION
2.63
1.00
41800
DRAINAGE OF GUM LESION
2.72
1.00
41800
DRAINAGE OF GUM LESION
3.22
1.00
41800
DRAINAGE OF GUM LESION
4.00
1.00
41805
REMOVAL FOREIGN BODY, GUM
3.28
1.00
41805
REMOVAL FOREIGN BODY, GUM
3.68
1.00
41805
REMOVAL FOREIGN BODY, GUM
4.09
1.00
41805
REMOVAL FOREIGN BODY, GUM
5.00
1.00
41806
REMOVAL FOREIGN BODY,JAWBONE
4.00
1.00
41806
REMOVAL FOREIGN BODY,JAWBONE
5.36
1.00
41806
REMOVAL FOREIGN BODY,JAWBONE
6.10
1.00
41806
REMOVAL FOREIGN BODY,JAWBONE
6.42
1.00
41820
EXCISION, GUM, EACH QUADRANT
4.00
1.00
41822
EXCISION OF GUM LESION
3.51
1.00
41822
EXCISION OF GUM LESION
3.93
1.00
41822
EXCISION OF GUM LESION
4.47
1.00
41822
EXCISION OF GUM LESION
5.00
1.00
41823
EXCISION OF GUM LESION
5.00
1.00
41823
EXCISION OF GUM LESION
6.59
1.00
41823
EXCISION OF GUM LESION
7.75
1.00
Procedure Code Description
RVU
RVU Coeff Value
41823
EXCISION OF GUM LESION
8.05
1.00
41825
EXCISION OF GUM LESION
3.18
1.00
41825
EXCISION OF GUM LESION
3.77
1.00
41825
EXCISION OF GUM LESION
3.78
1.00
41825
EXCISION OF GUM LESION
4.00
1.00
41826
EXCISION OF GUM LESION
5.00
1.00
41826
EXCISION OF GUM LESION
5.12
1.00
41826
EXCISION OF GUM LESION
5.14
1.00
41826
EXCISION OF GUM LESION
5.41
1.00
41827
EXCISION OF GUM LESION
5.00
1.00
41827
EXCISION OF GUM LESION
7.25
1.00
41827
EXCISION OF GUM LESION
7.55
1.00
41827
EXCISION OF GUM LESION
7.59
1.00
41828
EXCISION OF GUM LESION
4.00
1.00
41828
EXCISION OF GUM LESION
5.56
1.00
41828
EXCISION OF GUM LESION
5.71
1.00
41828
EXCISION OF GUM LESION
6.71
1.00
41830
REMOVAL OF GUM TISSUE
4.00
1.00
41830
REMOVAL OF GUM TISSUE
6.52
1.00
41830
REMOVAL OF GUM TISSUE
7.07
1.00
41830
REMOVAL OF GUM TISSUE
7.19
1.00
41872
REPAIR GUM
4.00
1.00
41872
REPAIR GUM
5.65
1.00
41872
REPAIR GUM
6.34
1.00
41872
REPAIR GUM
6.54
1.00
41874
REPAIR TOOTH SOCKET
4.00
1.00
41874
REPAIR TOOTH SOCKET
5.72
1.00
41874
REPAIR TOOTH SOCKET
6.47
1.00
41874
REPAIR TOOTH SOCKET
6.66
1.00
42000
DRAINAGE MOUTH ROOF LESION
2.60
1.00
42000
DRAINAGE MOUTH ROOF LESION
2.86
1.00
42000
DRAINAGE MOUTH ROOF LESION
5.00
1.00
42100
BIOPSY ROOF OF MOUTH
2.76
1.00
42100
BIOPSY ROOF OF MOUTH
2.79
1.00
42100
BIOPSY ROOF OF MOUTH
3.91
1.00
Procedure Code Description
RVU
RVU Coeff Value
42100
BIOPSY ROOF OF MOUTH
4.00
1.00
42104
EXCISION LESION, MOUTH ROOF
3.33
1.00
42104
EXCISION LESION, MOUTH ROOF
3.47
1.00
42104
EXCISION LESION, MOUTH ROOF
4.00
1.00
42104
EXCISION LESION, MOUTH ROOF
4.33
1.00
42106
EXCISION LESION, MOUTH ROOF
4.56
1.00
42106
EXCISION LESION, MOUTH ROOF
4.90
1.00
42106
EXCISION LESION, MOUTH ROOF
5.10
1.00
42106
EXCISION LESION, MOUTH ROOF
6.00
1.00
42107
EXCISION LESION, MOUTH ROOF
4.00
1.00
42107
EXCISION LESION, MOUTH ROOF
8.76
1.00
42107
EXCISION LESION, MOUTH ROOF
8.87
1.00
42107
EXCISION LESION, MOUTH ROOF
9.00
1.00
42120
REMOVE PALATE/LESION
4.00
1.00
42120
REMOVE PALATE/LESION
12.25
1.00
42120
REMOVE PALATE/LESION
12.72
1.00
42120
REMOVE PALATE/LESION
24.42
1.00
42140
EXCISION OF UVULA
3.00
1.00
42140
EXCISION OF UVULA
3.89
1.00
42140
EXCISION OF UVULA
4.13
1.00
42140
EXCISION OF UVULA
5.11
1.00
42145
REPAIR PALATE, PHARYNX/UVULA
5.00
1.00
42145
REPAIR PALATE, PHARYNX/UVULA
15.33
1.00
42145
REPAIR PALATE, PHARYNX/UVULA
16.11
1.00
42145
REPAIR PALATE, PHARYNX/UVULA
17.83
1.00
42160
TREATMENT MOUTH ROOF LESION
3.87
1.00
42160
TREATMENT MOUTH ROOF LESION
4.61
1.00
42160
TREATMENT MOUTH ROOF LESION
4.63
1.00
42160
TREATMENT MOUTH ROOF LESION
6.00
1.00
42180
REPAIR PALATE
4.69
1.00
42180
REPAIR PALATE
4.80
1.00
42180
REPAIR PALATE
4.85
1.00
42180
REPAIR PALATE
6.00
1.00
42182
REPAIR PALATE
6.00
1.00
42182
REPAIR PALATE
6.87
1.00
Procedure Code Description
RVU
RVU Coeff Value
42182
REPAIR PALATE
7.16
1.00
42182
REPAIR PALATE
7.21
1.00
42200
RECONSTRUCT CLEFT PALATE
6.00
1.00
42200
RECONSTRUCT CLEFT PALATE
22.16
1.00
42200
RECONSTRUCT CLEFT PALATE
22.75
1.00
42200
RECONSTRUCT CLEFT PALATE
23.11
1.00
42205
RECONSTRUCT CLEFT PALATE
6.00
1.00
42205
RECONSTRUCT CLEFT PALATE
23.34
1.00
42205
RECONSTRUCT CLEFT PALATE
23.61
1.00
42205
RECONSTRUCT CLEFT PALATE
24.32
1.00
42210
RECONSTRUCT CLEFT PALATE
6.00
1.00
42210
RECONSTRUCT CLEFT PALATE
25.25
1.00
42210
RECONSTRUCT CLEFT PALATE
26.50
1.00
42210
RECONSTRUCT CLEFT PALATE
27.58
1.00
42215
RECONSTRUCT CLEFT PALATE
6.00
1.00
42215
RECONSTRUCT CLEFT PALATE
17.52
1.00
42215
RECONSTRUCT CLEFT PALATE
18.07
1.00
42215
RECONSTRUCT CLEFT PALATE
18.47
1.00
42220
RECONSTRUCT CLEFT PALATE
6.00
1.00
42220
RECONSTRUCT CLEFT PALATE
13.14
1.00
42220
RECONSTRUCT CLEFT PALATE
13.94
1.00
42220
RECONSTRUCT CLEFT PALATE
14.16
1.00
42225
RECONSTRUCT CLEFT PALATE
6.00
1.00
42225
RECONSTRUCT CLEFT PALATE
18.09
1.00
42225
RECONSTRUCT CLEFT PALATE
19.44
1.00
42225
RECONSTRUCT CLEFT PALATE
23.87
1.00
42226
LENGTHENING OF PALATE
6.00
1.00
42226
LENGTHENING OF PALATE
18.75
1.00
42226
LENGTHENING OF PALATE
20.26
1.00
42226
LENGTHENING OF PALATE
23.75
1.00
42227
LENGTHENING OF PALATE
6.00
1.00
42227
LENGTHENING OF PALATE
17.69
1.00
42227
LENGTHENING OF PALATE
18.31
1.00
42227
LENGTHENING OF PALATE
23.09
1.00
42235
REPAIR PALATE
6.00
1.00
Procedure Code Description
RVU
RVU Coeff Value
42235
REPAIR PALATE
13.80
1.00
42235
REPAIR PALATE
14.54
1.00
42235
REPAIR PALATE
18.83
1.00
42260
REPAIR NOSE TO LIP FISTULA
6.00
1.00
42260
REPAIR NOSE TO LIP FISTULA
17.64
1.00
42260
REPAIR NOSE TO LIP FISTULA
17.65
1.00
42260
REPAIR NOSE TO LIP FISTULA
18.26
1.00
42281
INSERTION, PALATE PROSTHESIS
3.87
1.00
42300
DRAINAGE OF SALIVARY GLAND
3.87
1.00
42300
DRAINAGE OF SALIVARY GLAND
3.94
1.00
42300
DRAINAGE OF SALIVARY GLAND
3.97
1.00
42300
DRAINAGE OF SALIVARY GLAND
4.00
1.00
42305
DRAINAGE OF SALIVARY GLAND
5.00
1.00
42305
DRAINAGE OF SALIVARY GLAND
11.05
1.00
42305
DRAINAGE OF SALIVARY GLAND
11.56
1.00
42305
DRAINAGE OF SALIVARY GLAND
11.82
1.00
42310
DRAINAGE OF SALIVARY GLAND
3.16
1.00
42310
DRAINAGE OF SALIVARY GLAND
3.23
1.00
42310
DRAINAGE OF SALIVARY GLAND
3.32
1.00
42310
DRAINAGE OF SALIVARY GLAND
4.00
1.00
42320
DRAINAGE OF SALIVARY GLAND
4.00
1.00
42320
DRAINAGE OF SALIVARY GLAND
4.54
1.00
42320
DRAINAGE OF SALIVARY GLAND
4.65
1.00
42320
DRAINAGE OF SALIVARY GLAND
4.67
1.00
42325
CREATE SALIVARY CYST DRAIN
4.00
1.00
42325
CREATE SALIVARY CYST DRAIN
4.07
1.00
42325
CREATE SALIVARY CYST DRAIN
5.19
1.00
42325
CREATE SALIVARY CYST DRAIN
5.31
1.00
42326
CREATE SALIVARY CYST DRAIN
5.00
1.00
42326
CREATE SALIVARY CYST DRAIN
5.88
1.00
42326
CREATE SALIVARY CYST DRAIN
7.21
1.00
42326
CREATE SALIVARY CYST DRAIN
7.28
1.00
42330
REMOVAL OF SALIVARY STONE
3.42
1.00
42330
REMOVAL OF SALIVARY STONE
4.00
1.00
42330
REMOVAL OF SALIVARY STONE
4.21
1.00
Procedure Code Description
RVU
RVU Coeff Value
42330
REMOVAL OF SALIVARY STONE
4.26
1.00
42335
REMOVAL OF SALIVARY STONE
4.00
1.00
42335
REMOVAL OF SALIVARY STONE
6.60
1.00
42335
REMOVAL OF SALIVARY STONE
6.95
1.00
42335
REMOVAL OF SALIVARY STONE
7.20
1.00
42340
REMOVAL OF SALIVARY STONE
4.00
1.00
42340
REMOVAL OF SALIVARY STONE
8.69
1.00
42340
REMOVAL OF SALIVARY STONE
9.27
1.00
42340
REMOVAL OF SALIVARY STONE
9.74
1.00
42400
BIOPSY OF SALIVARY GLAND
1.23
1.00
42400
BIOPSY OF SALIVARY GLAND
1.51
1.00
42400
BIOPSY OF SALIVARY GLAND
1.57
1.00
42400
BIOPSY OF SALIVARY GLAND
4.00
1.00
42405
BIOPSY OF SALIVARY GLAND
4.00
1.00
42405
BIOPSY OF SALIVARY GLAND
5.87
1.00
42405
BIOPSY OF SALIVARY GLAND
6.06
1.00
42405
BIOPSY OF SALIVARY GLAND
6.87
1.00
42408
EXCISION OF SALIVARY CYST
4.00
1.00
42408
EXCISION OF SALIVARY CYST
8.44
1.00
42408
EXCISION OF SALIVARY CYST
9.00
1.00
42408
EXCISION OF SALIVARY CYST
9.42
1.00
42409
DRAINAGE OF SALIVARY CYST
4.00
1.00
42409
DRAINAGE OF SALIVARY CYST
5.72
1.00
42409
DRAINAGE OF SALIVARY CYST
6.14
1.00
42409
DRAINAGE OF SALIVARY CYST
6.40
1.00
42410
EXCISE PAROTID GLAND/LESION
4.00
1.00
42410
EXCISE PAROTID GLAND/LESION
16.07
1.00
42410
EXCISE PAROTID GLAND/LESION
16.90
1.00
42410
EXCISE PAROTID GLAND/LESION
17.98
1.00
42415
EXCISE PAROTID GLAND/LESION
5.00
1.00
42415
EXCISE PAROTID GLAND/LESION
28.92
1.00
42415
EXCISE PAROTID GLAND/LESION
29.64
1.00
42415
EXCISE PAROTID GLAND/LESION
30.62
1.00
42420
EXCISE PAROTID GLAND/LESION
6.00
1.00
42420
EXCISE PAROTID GLAND/LESION
33.15
1.00
Procedure Code Description
RVU
RVU Coeff Value
42420
EXCISE PAROTID GLAND/LESION
34.08
1.00
42420
EXCISE PAROTID GLAND/LESION
35.07
1.00
42425
EXCISE PAROTID GLAND/LESION
6.00
1.00
42425
EXCISE PAROTID GLAND/LESION
21.82
1.00
42425
EXCISE PAROTID GLAND/LESION
23.25
1.00
42425
EXCISE PAROTID GLAND/LESION
24.46
1.00
42426
EXCISE PAROTID GLAND/LESION
6.00
1.00
42426
EXCISE PAROTID GLAND/LESION
35.48
1.00
42426
EXCISE PAROTID GLAND/LESION
36.55
1.00
42426
EXCISE PAROTID GLAND/LESION
37.66
1.00
42440
EXCISE SUBMAXILLARY GLAND
3.00
1.00
42440
EXCISE SUBMAXILLARY GLAND
12.06
1.00
42440
EXCISE SUBMAXILLARY GLAND
12.64
1.00
42440
EXCISE SUBMAXILLARY GLAND
13.46
1.00
42450
EXCISE SUBLINGUAL GLAND
3.00
1.00
42450
EXCISE SUBLINGUAL GLAND
9.18
1.00
42450
EXCISE SUBLINGUAL GLAND
9.26
1.00
42450
EXCISE SUBLINGUAL GLAND
9.74
1.00
42500
REPAIR SALIVARY DUCT
4.00
1.00
42500
REPAIR SALIVARY DUCT
8.74
1.00
42500
REPAIR SALIVARY DUCT
8.83
1.00
42500
REPAIR SALIVARY DUCT
9.44
1.00
42505
REPAIR SALIVARY DUCT
5.00
1.00
42505
REPAIR SALIVARY DUCT
11.69
1.00
42505
REPAIR SALIVARY DUCT
12.06
1.00
42505
REPAIR SALIVARY DUCT
12.08
1.00
42507
PAROTID DUCT DIVERSION
5.00
1.00
42507
PAROTID DUCT DIVERSION
12.10
1.00
42507
PAROTID DUCT DIVERSION
12.75
1.00
42507
PAROTID DUCT DIVERSION
13.11
1.00
42508
PAROTID DUCT DIVERSION
5.00
1.00
42508
PAROTID DUCT DIVERSION
16.88
1.00
42508
PAROTID DUCT DIVERSION
17.86
1.00
42508
PAROTID DUCT DIVERSION
18.76
1.00
42509
PAROTID DUCT DIVERSION
5.00
1.00
Procedure Code Description
RVU
RVU Coeff Value
42509
PAROTID DUCT DIVERSION
21.38
1.00
42509
PAROTID DUCT DIVERSION
21.44
1.00
42509
PAROTID DUCT DIVERSION
22.43
1.00
42510
PAROTID DUCT DIVERSION
5.00
1.00
42510
PAROTID DUCT DIVERSION
14.94
1.00
42510
PAROTID DUCT DIVERSION
15.81
1.00
42510
PAROTID DUCT DIVERSION
16.16
1.00
42550
INJECTION FOR SALIVARY X-RAY
1.73
1.00
42550
INJECTION FOR SALIVARY X-RAY
1.74
1.00
42550
INJECTION FOR SALIVARY X-RAY
1.79
1.00
42600
CLOSURE OF SALIVARY FISTULA
4.00
1.00
42600
CLOSURE OF SALIVARY FISTULA
9.10
1.00
42600
CLOSURE OF SALIVARY FISTULA
9.74
1.00
42600
CLOSURE OF SALIVARY FISTULA
10.83
1.00
42650
DILATION OF SALIVARY DUCT
1.23
1.00
42650
DILATION OF SALIVARY DUCT
1.52
1.00
42650
DILATION OF SALIVARY DUCT
1.55
1.00
42650
DILATION OF SALIVARY DUCT
4.00
1.00
42660
DILATION OF SALIVARY DUCT
2.02
1.00
42660
DILATION OF SALIVARY DUCT
2.05
1.00
42660
DILATION OF SALIVARY DUCT
2.38
1.00
42660
DILATION OF SALIVARY DUCT
4.00
1.00
42665
LIGATION OF SALIVARY DUCT
5.00
1.00
42665
LIGATION OF SALIVARY DUCT
5.29
1.00
42665
LIGATION OF SALIVARY DUCT
5.70
1.00
42665
LIGATION OF SALIVARY DUCT
6.21
1.00
42700
DRAINAGE OF TONSIL ABSCESS
3.45
1.00
42700
DRAINAGE OF TONSIL ABSCESS
3.49
1.00
42700
DRAINAGE OF TONSIL ABSCESS
3.62
1.00
42700
DRAINAGE OF TONSIL ABSCESS
4.00
1.00
42720
DRAINAGE OF THROAT ABSCESS
4.00
1.00
42720
DRAINAGE OF THROAT ABSCESS
9.70
1.00
42720
DRAINAGE OF THROAT ABSCESS
10.22
1.00
42720
DRAINAGE OF THROAT ABSCESS
10.57
1.00
42725
DRAINAGE OF THROAT ABSCESS
4.00
1.00
Procedure Code Description
RVU
RVU Coeff Value
42725
DRAINAGE OF THROAT ABSCESS
19.66
1.00
42725
DRAINAGE OF THROAT ABSCESS
20.04
1.00
42725
DRAINAGE OF THROAT ABSCESS
20.86
1.00
42800
BIOPSY OF THROAT
2.85
1.00
42800
BIOPSY OF THROAT
2.91
1.00
42800
BIOPSY OF THROAT
4.00
1.00
42800
BIOPSY OF THROAT
4.11
1.00
42802
BIOPSY OF THROAT
3.46
1.00
42802
BIOPSY OF THROAT
3.61
1.00
42802
BIOPSY OF THROAT
4.00
1.00
42802
BIOPSY OF THROAT
4.35
1.00
42804
BIOPSY OF UPPER NOSE/THROAT
2.93
1.00
42804
BIOPSY OF UPPER NOSE/THROAT
3.14
1.00
42804
BIOPSY OF UPPER NOSE/THROAT
3.90
1.00
42806
BIOPSY OF UPPER NOSE/THROAT
3.44
1.00
42806
BIOPSY OF UPPER NOSE/THROAT
3.64
1.00
42806
BIOPSY OF UPPER NOSE/THROAT
4.00
1.00
42806
BIOPSY OF UPPER NOSE/THROAT
4.46
1.00
42808
EXCISE PHARYNX LESION
4.23
1.00
42808
EXCISE PHARYNX LESION
4.44
1.00
42808
EXCISE PHARYNX LESION
5.00
1.00
42808
EXCISE PHARYNX LESION
5.62
1.00
42809
REMOVE PHARYNX FOREIGN BODY
3.32
1.00
42809
REMOVE PHARYNX FOREIGN BODY
3.33
1.00
42809
REMOVE PHARYNX FOREIGN BODY
3.68
1.00
42809
REMOVE PHARYNX FOREIGN BODY
5.00
1.00
42810
EXCISION OF NECK CYST
4.00
1.00
42810
EXCISION OF NECK CYST
6.92
1.00
42810
EXCISION OF NECK CYST
7.25
1.00
42810
EXCISION OF NECK CYST
8.00
1.00
42815
EXCISION OF NECK CYST
4.00
1.00
42815
EXCISION OF NECK CYST
13.12
1.00
42815
EXCISION OF NECK CYST
14.18
1.00
42815
EXCISION OF NECK CYST
14.20
1.00
42820
REMOVE TONSILS AND ADENOIDS
5.00
1.00
Procedure Code Description
RVU
RVU Coeff Value
42820
REMOVE TONSILS AND ADENOIDS
7.49
1.00
42820
REMOVE TONSILS AND ADENOIDS
7.71
1.00
42820
REMOVE TONSILS AND ADENOIDS
8.44
1.00
42821
REMOVE TONSILS AND ADENOIDS
5.00
1.00
42821
REMOVE TONSILS AND ADENOIDS
7.83
1.00
42821
REMOVE TONSILS AND ADENOIDS
8.32
1.00
42821
REMOVE TONSILS AND ADENOIDS
8.82
1.00
42825
REMOVAL OF TONSILS
5.00
1.00
42825
REMOVAL OF TONSILS
6.70
1.00
42825
REMOVAL OF TONSILS
7.02
1.00
42825
REMOVAL OF TONSILS
7.35
1.00
42826
REMOVAL OF TONSILS
5.00
1.00
42826
REMOVAL OF TONSILS
6.48
1.00
42826
REMOVAL OF TONSILS
6.86
1.00
42826
REMOVAL OF TONSILS
7.36
1.00
42830
REMOVAL OF ADENOIDS
5.00
1.00
42830
REMOVAL OF ADENOIDS
5.17
1.00
42830
REMOVAL OF ADENOIDS
5.28
1.00
42830
REMOVAL OF ADENOIDS
5.41
1.00
42831
REMOVAL OF ADENOIDS
4.00
1.00
42831
REMOVAL OF ADENOIDS
5.45
1.00
42831
REMOVAL OF ADENOIDS
5.70
1.00
42831
REMOVAL OF ADENOIDS
5.80
1.00
42835
REMOVAL OF ADENOIDS
4.00
1.00
42835
REMOVAL OF ADENOIDS
4.77
1.00
42835
REMOVAL OF ADENOIDS
5.13
1.00
42835
REMOVAL OF ADENOIDS
5.62
1.00
42836
REMOVAL OF ADENOIDS
4.00
1.00
42836
REMOVAL OF ADENOIDS
6.22
1.00
42836
REMOVAL OF ADENOIDS
6.59
1.00
42836
REMOVAL OF ADENOIDS
7.08
1.00
42842
EXTENSIVE SURGERY OF THROAT
7.00
1.00
42842
EXTENSIVE SURGERY OF THROAT
16.23
1.00
42842
EXTENSIVE SURGERY OF THROAT
17.19
1.00
42842
EXTENSIVE SURGERY OF THROAT
24.59
1.00
Procedure Code Description
RVU
RVU Coeff Value
42844
EXTENSIVE SURGERY OF THROAT
7.00
1.00
42844
EXTENSIVE SURGERY OF THROAT
25.57
1.00
42844
EXTENSIVE SURGERY OF THROAT
26.71
1.00
42844
EXTENSIVE SURGERY OF THROAT
34.61
1.00
42845
EXTENSIVE SURGERY OF THROAT
7.00
1.00
42845
EXTENSIVE SURGERY OF THROAT
42.48
1.00
42845
EXTENSIVE SURGERY OF THROAT
43.49
1.00
42845
EXTENSIVE SURGERY OF THROAT
56.59
1.00
42860
EXCISION OF TONSIL TAGS
4.78
1.00
42860
EXCISION OF TONSIL TAGS
4.99
1.00
42860
EXCISION OF TONSIL TAGS
5.00
1.00
42860
EXCISION OF TONSIL TAGS
5.46
1.00
42870
EXCISION OF LINGUAL TONSIL
4.00
1.00
42870
EXCISION OF LINGUAL TONSIL
10.64
1.00
42870
EXCISION OF LINGUAL TONSIL
11.88
1.00
42870
EXCISION OF LINGUAL TONSIL
14.55
1.00
42890
PARTIAL REMOVAL OF PHARYNX
7.00
1.00
42890
PARTIAL REMOVAL OF PHARYNX
23.36
1.00
42890
PARTIAL REMOVAL OF PHARYNX
24.67
1.00
42890
PARTIAL REMOVAL OF PHARYNX
35.15
1.00
42892
REVISION OF PHARYNGEAL WALLS
7.00
1.00
42892
REVISION OF PHARYNGEAL WALLS
28.07
1.00
42892
REVISION OF PHARYNGEAL WALLS
29.31
1.00
42892
REVISION OF PHARYNGEAL WALLS
46.06
1.00
42894
REVISION OF PHARYNGEAL WALLS
7.00
1.00
42894
REVISION OF PHARYNGEAL WALLS
39.90
1.00
42894
REVISION OF PHARYNGEAL WALLS
41.49
1.00
42894
REVISION OF PHARYNGEAL WALLS
59.08
1.00
42900
REPAIR THROAT WOUND
5.00
1.00
42900
REPAIR THROAT WOUND
8.96
1.00
42900
REPAIR THROAT WOUND
9.40
1.00
42900
REPAIR THROAT WOUND
9.41
1.00
42950
RECONSTRUCTION OF THROAT
8.00
1.00
42950
RECONSTRUCTION OF THROAT
15.39
1.00
42950
RECONSTRUCTION OF THROAT
16.20
1.00
Procedure Code Description
RVU
RVU Coeff Value
42950
RECONSTRUCTION OF THROAT
20.16
1.00
42953
REPAIR THROAT, ESOPHAGUS
5.00
1.00
42953
REPAIR THROAT, ESOPHAGUS
17.36
1.00
42953
REPAIR THROAT, ESOPHAGUS
18.68
1.00
42953
REPAIR THROAT, ESOPHAGUS
24.81
1.00
42955
SURGICAL OPENING OF THROAT
5.00
1.00
42955
SURGICAL OPENING OF THROAT
13.72
1.00
42955
SURGICAL OPENING OF THROAT
14.55
1.00
42955
SURGICAL OPENING OF THROAT
19.02
1.00
42960
CONTROL THROAT BLEEDING
4.00
1.00
42960
CONTROL THROAT BLEEDING
4.35
1.00
42960
CONTROL THROAT BLEEDING
4.54
1.00
42960
CONTROL THROAT BLEEDING
4.61
1.00
42961
CONTROL THROAT BLEEDING
10.79
1.00
42961
CONTROL THROAT BLEEDING
10.91
1.00
42961
CONTROL THROAT BLEEDING
11.26
1.00
42962
CONTROL THROAT BLEEDING
5.00
1.00
42962
CONTROL THROAT BLEEDING
13.37
1.00
42962
CONTROL THROAT BLEEDING
13.48
1.00
42962
CONTROL THROAT BLEEDING
13.83
1.00
42970
CONTROL NOSE/THROAT BLEEDING
4.00
1.00
42970
CONTROL NOSE/THROAT BLEEDING
9.48
1.00
42970
CONTROL NOSE/THROAT BLEEDING
9.57
1.00
42970
CONTROL NOSE/THROAT BLEEDING
9.98
1.00
42971
CONTROL NOSE/THROAT BLEEDING
11.71
1.00
42971
CONTROL NOSE/THROAT BLEEDING
11.78
1.00
42971
CONTROL NOSE/THROAT BLEEDING
12.47
1.00
42972
CONTROL NOSE/THROAT BLEEDING
5.00
1.00
42972
CONTROL NOSE/THROAT BLEEDING
13.25
1.00
42972
CONTROL NOSE/THROAT BLEEDING
13.28
1.00
42972
CONTROL NOSE/THROAT BLEEDING
13.31
1.00
43020
INCISION OF ESOPHAGUS
6.00
1.00
43020
INCISION OF ESOPHAGUS
13.69
1.00
43020
INCISION OF ESOPHAGUS
14.62
1.00
43020
INCISION OF ESOPHAGUS
15.25
1.00
Procedure Code Description
RVU
RVU Coeff Value
43030
THROAT MUSCLE SURGERY
6.00
1.00
43030
THROAT MUSCLE SURGERY
13.51
1.00
43030
THROAT MUSCLE SURGERY
14.22
1.00
43030
THROAT MUSCLE SURGERY
15.22
1.00
43045
INCISION OF ESOPHAGUS
15.00
1.00
43045
INCISION OF ESOPHAGUS
33.35
1.00
43045
INCISION OF ESOPHAGUS
33.44
1.00
43045
INCISION OF ESOPHAGUS
34.53
1.00
43100
EXCISION OF ESOPHAGUS LESION
6.00
1.00
43100
EXCISION OF ESOPHAGUS LESION
16.18
1.00
43100
EXCISION OF ESOPHAGUS LESION
16.40
1.00
43100
EXCISION OF ESOPHAGUS LESION
17.18
1.00
43101
EXCISION OF ESOPHAGUS LESION
6.00
1.00
43101
EXCISION OF ESOPHAGUS LESION
26.34
1.00
43101
EXCISION OF ESOPHAGUS LESION
26.67
1.00
43101
EXCISION OF ESOPHAGUS LESION
27.07
1.00
43107
REMOVAL OF ESOPHAGUS
15.00
1.00
43107
REMOVAL OF ESOPHAGUS
61.05
1.00
43107
REMOVAL OF ESOPHAGUS
61.31
1.00
43107
REMOVAL OF ESOPHAGUS
66.75
1.00
43108
REMOVAL OF ESOPHAGUS
15.00
1.00
43108
REMOVAL OF ESOPHAGUS
53.00
1.00
43108
REMOVAL OF ESOPHAGUS
53.82
1.00
43108
REMOVAL OF ESOPHAGUS
110.69
1.00
43112
REMOVAL OF ESOPHAGUS
15.00
1.00
43112
REMOVAL OF ESOPHAGUS
66.10
1.00
43112
REMOVAL OF ESOPHAGUS
66.66
1.00
43112
REMOVAL OF ESOPHAGUS
71.41
1.00
43113
REMOVAL OF ESOPHAGUS
15.00
1.00
43113
REMOVAL OF ESOPHAGUS
55.64
1.00
43113
REMOVAL OF ESOPHAGUS
56.08
1.00
43113
REMOVAL OF ESOPHAGUS
110.77
1.00
43116
PARTIAL REMOVAL OF ESOPHAGUS
15.00
1.00
43116
PARTIAL REMOVAL OF ESOPHAGUS
51.14
1.00
43116
PARTIAL REMOVAL OF ESOPHAGUS
52.66
1.00
Procedure Code Description
RVU
RVU Coeff Value
43116
PARTIAL REMOVAL OF ESOPHAGUS
125.31
1.00
43117
PARTIAL REMOVAL OF ESOPHAGUS
15.00
1.00
43117
PARTIAL REMOVAL OF ESOPHAGUS
60.55
1.00
43117
PARTIAL REMOVAL OF ESOPHAGUS
60.60
1.00
43117
PARTIAL REMOVAL OF ESOPHAGUS
65.27
1.00
43118
PARTIAL REMOVAL OF ESOPHAGUS
15.00
1.00
43118
PARTIAL REMOVAL OF ESOPHAGUS
51.31
1.00
43118
PARTIAL REMOVAL OF ESOPHAGUS
52.16
1.00
43118
PARTIAL REMOVAL OF ESOPHAGUS
91.39
1.00
43121
PARTIAL REMOVAL OF ESOPHAGUS
15.00
1.00
43121
PARTIAL REMOVAL OF ESOPHAGUS
45.99
1.00
43121
PARTIAL REMOVAL OF ESOPHAGUS
46.05
1.00
43121
PARTIAL REMOVAL OF ESOPHAGUS
72.85
1.00
43122
PARTIAL REMOVAL OF ESOPHAGUS
15.00
1.00
43122
PARTIAL REMOVAL OF ESOPHAGUS
60.37
1.00
43122
PARTIAL REMOVAL OF ESOPHAGUS
60.56
1.00
43122
PARTIAL REMOVAL OF ESOPHAGUS
66.06
1.00
43123
PARTIAL REMOVAL OF ESOPHAGUS
15.00
1.00
43123
PARTIAL REMOVAL OF ESOPHAGUS
52.11
1.00
43123
PARTIAL REMOVAL OF ESOPHAGUS
52.98
1.00
43123
PARTIAL REMOVAL OF ESOPHAGUS
111.30
1.00
43124
REMOVAL OF ESOPHAGUS
15.00
1.00
43124
REMOVAL OF ESOPHAGUS
44.00
1.00
43124
REMOVAL OF ESOPHAGUS
45.21
1.00
43124
REMOVAL OF ESOPHAGUS
95.23
1.00
43130
REMOVAL OF ESOPHAGUS POUCH
13.00
1.00
43130
REMOVAL OF ESOPHAGUS POUCH
20.48
1.00
43130
REMOVAL OF ESOPHAGUS POUCH
20.63
1.00
43130
REMOVAL OF ESOPHAGUS POUCH
21.67
1.00
43135
REMOVAL OF ESOPHAGUS POUCH
13.00
1.00
43135
REMOVAL OF ESOPHAGUS POUCH
26.47
1.00
43135
REMOVAL OF ESOPHAGUS POUCH
27.86
1.00
43135
REMOVAL OF ESOPHAGUS POUCH
38.30
1.00
43200
ESOPHAGUS ENDOSCOPY
2.74
1.00
43200
ESOPHAGUS ENDOSCOPY
2.82
1.00
Procedure Code Description
RVU
RVU Coeff Value
43200
ESOPHAGUS ENDOSCOPY
2.88
1.00
43200
ESOPHAGUS ENDOSCOPY
4.00
1.00
43201
ESOPH SCOPE W/SUBMUCOUS INJ
3.44
1.00
43201
ESOPH SCOPE W/SUBMUCOUS INJ
3.48
1.00
43201
ESOPH SCOPE W/SUBMUCOUS INJ
3.50
1.00
43202
ESOPHAGUS ENDOSCOPY, BIOPSY
2.99
1.00
43202
ESOPHAGUS ENDOSCOPY, BIOPSY
3.00
1.00
43202
ESOPHAGUS ENDOSCOPY, BIOPSY
3.04
1.00
43202
ESOPHAGUS ENDOSCOPY, BIOPSY
3.14
1.00
43204
ESOPH SCOPE W/SCLEROSIS INJ
4.00
1.00
43204
ESOPH SCOPE W/SCLEROSIS INJ
5.52
1.00
43204
ESOPH SCOPE W/SCLEROSIS INJ
5.62
1.00
43204
ESOPH SCOPE W/SCLEROSIS INJ
5.99
1.00
43205
ESOPHAGUS ENDOSCOPY/LIGATION
5.00
1.00
43205
ESOPHAGUS ENDOSCOPY/LIGATION
5.54
1.00
43205
ESOPHAGUS ENDOSCOPY/LIGATION
5.64
1.00
43205
ESOPHAGUS ENDOSCOPY/LIGATION
6.00
1.00
43215
ESOPHAGUS ENDOSCOPY
4.00
1.00
43215
ESOPHAGUS ENDOSCOPY
4.03
1.00
43215
ESOPHAGUS ENDOSCOPY
4.11
1.00
43216
ESOPHAGUS ENDOSCOPY/LESION
3.73
1.00
43216
ESOPHAGUS ENDOSCOPY/LESION
3.76
1.00
43216
ESOPHAGUS ENDOSCOPY/LESION
3.83
1.00
43216
ESOPHAGUS ENDOSCOPY/LESION
5.00
1.00
43217
ESOPHAGUS ENDOSCOPY
4.32
1.00
43217
ESOPHAGUS ENDOSCOPY
4.40
1.00
43217
ESOPHAGUS ENDOSCOPY
4.52
1.00
43217
ESOPHAGUS ENDOSCOPY
6.00
1.00
43219
ESOPHAGUS ENDOSCOPY
4.36
1.00
43219
ESOPHAGUS ENDOSCOPY
4.57
1.00
43219
ESOPHAGUS ENDOSCOPY
6.00
1.00
43220
ESOPH ENDOSCOPY, DILATION
3.23
1.00
43220
ESOPH ENDOSCOPY, DILATION
3.32
1.00
43220
ESOPH ENDOSCOPY, DILATION
3.38
1.00
43220
ESOPH ENDOSCOPY, DILATION
4.00
1.00
Procedure Code Description
RVU
RVU Coeff Value
43226
ESOPH ENDOSCOPY, DILATION
3.54
1.00
43226
ESOPH ENDOSCOPY, DILATION
3.63
1.00
43226
ESOPH ENDOSCOPY, DILATION
3.77
1.00
43226
ESOPH ENDOSCOPY, DILATION
6.00
1.00
43227
ESOPH ENDOSCOPY, REPAIR
5.28
1.00
43227
ESOPH ENDOSCOPY, REPAIR
5.38
1.00
43227
ESOPH ENDOSCOPY, REPAIR
5.61
1.00
43227
ESOPH ENDOSCOPY, REPAIR
6.00
1.00
43228
ESOPH ENDOSCOPY, ABLATION
5.64
1.00
43228
ESOPH ENDOSCOPY, ABLATION
5.74
1.00
43228
ESOPH ENDOSCOPY, ABLATION
6.00
1.00
43231
ESOPH ENDOSCOPY W/US EXAM
4.76
1.00
43231
ESOPH ENDOSCOPY W/US EXAM
4.96
1.00
43231
ESOPH ENDOSCOPY W/US EXAM
5.00
1.00
43231
ESOPH ENDOSCOPY W/US EXAM
5.09
1.00
43232
ESOPH ENDOSCOPY W/US FN BX
5.00
1.00
43232
ESOPH ENDOSCOPY W/US FN BX
6.62
1.00
43232
ESOPH ENDOSCOPY W/US FN BX
6.84
1.00
43232
ESOPH ENDOSCOPY W/US FN BX
7.02
1.00
43234
UPPER GI ENDOSCOPY, EXAM
3.07
1.00
43234
UPPER GI ENDOSCOPY, EXAM
3.18
1.00
43234
UPPER GI ENDOSCOPY, EXAM
5.00
1.00
43235
UPPR GI ENDOSCOPY, DIAGNOSIS
3.58
1.00
43235
UPPR GI ENDOSCOPY, DIAGNOSIS
3.62
1.00
43235
UPPR GI ENDOSCOPY, DIAGNOSIS
3.88
1.00
43235
UPPR GI ENDOSCOPY, DIAGNOSIS
5.00
1.00
43236
UPPR GI SCOPE W/SUBMUC INJ
4.32
1.00
43236
UPPR GI SCOPE W/SUBMUC INJ
4.35
1.00
43236
UPPR GI SCOPE W/SUBMUC INJ
4.71
1.00
43237
ENDOSCOPIC US EXAM, ESOPH
5.86
1.00
43237
ENDOSCOPIC US EXAM, ESOPH
6.46
1.00
43238
UPPR GI ENDOSCOPY W/US FN BX
7.26
1.00
43238
UPPR GI ENDOSCOPY W/US FN BX
7.97
1.00
43239
UPPER GI ENDOSCOPY, BIOPSY
4.00
1.00
43239
UPPER GI ENDOSCOPY, BIOPSY
4.24
1.00
Procedure Code Description
RVU
RVU Coeff Value
43239
UPPER GI ENDOSCOPY, BIOPSY
4.27
1.00
43239
UPPER GI ENDOSCOPY, BIOPSY
4.59
1.00
43240
ESOPH ENDOSCOPE W/DRAIN CYST
5.00
1.00
43240
ESOPH ENDOSCOPE W/DRAIN CYST
9.92
1.00
43240
ESOPH ENDOSCOPE W/DRAIN CYST
9.93
1.00
43240
ESOPH ENDOSCOPE W/DRAIN CYST
10.69
1.00
43241
UPPER GI ENDOSCOPY WITH TUBE
3.87
1.00
43241
UPPER GI ENDOSCOPY WITH TUBE
3.90
1.00
43241
UPPER GI ENDOSCOPY WITH TUBE
4.17
1.00
43241
UPPER GI ENDOSCOPY WITH TUBE
5.00
1.00
43242
UPPR GI ENDOSCOPY W/US FN BX
5.00
1.00
43242
UPPR GI ENDOSCOPY W/US FN BX
10.43
1.00
43242
UPPR GI ENDOSCOPY W/US FN BX
11.38
1.00
43243
UPPER GI ENDOSCOPY & INJECT
5.00
1.00
43243
UPPER GI ENDOSCOPY & INJECT
6.64
1.00
43243
UPPER GI ENDOSCOPY & INJECT
6.65
1.00
43243
UPPER GI ENDOSCOPY & INJECT
7.17
1.00
43244
UPPER GI ENDOSCOPY/LIGATION
5.00
1.00
43244
UPPER GI ENDOSCOPY/LIGATION
7.29
1.00
43244
UPPER GI ENDOSCOPY/LIGATION
7.30
1.00
43244
UPPER GI ENDOSCOPY/LIGATION
7.95
1.00
43245
UPPR GI SCOPE DILATE STRICTR
4.70
1.00
43245
UPPR GI SCOPE DILATE STRICTR
4.74
1.00
43245
UPPR GI SCOPE DILATE STRICTR
5.00
1.00
43245
UPPR GI SCOPE DILATE STRICTR
5.02
1.00
43246
PLACE GASTROSTOMY TUBE
5.00
1.00
43246
PLACE GASTROSTOMY TUBE
6.32
1.00
43246
PLACE GASTROSTOMY TUBE
6.35
1.00
43246
PLACE GASTROSTOMY TUBE
6.72
1.00
43247
OPERATIVE UPPER GI ENDOSCOPY
4.98
1.00
43247
OPERATIVE UPPER GI ENDOSCOPY
5.00
1.00
43247
OPERATIVE UPPER GI ENDOSCOPY
5.01
1.00
43247
OPERATIVE UPPER GI ENDOSCOPY
5.37
1.00
43248
UPPR GI ENDOSCOPY/GUIDE WIRE
4.65
1.00
43248
UPPR GI ENDOSCOPY/GUIDE WIRE
4.68
1.00
Procedure Code Description
RVU
RVU Coeff Value
43248
UPPR GI ENDOSCOPY/GUIDE WIRE
5.00
1.00
43248
UPPR GI ENDOSCOPY/GUIDE WIRE
5.07
1.00
43249
ESOPH ENDOSCOPY, DILATION
4.31
1.00
43249
ESOPH ENDOSCOPY, DILATION
4.33
1.00
43249
ESOPH ENDOSCOPY, DILATION
4.67
1.00
43249
ESOPH ENDOSCOPY, DILATION
6.00
1.00
43250
UPPER GI ENDOSCOPY/TUMOR
4.72
1.00
43250
UPPER GI ENDOSCOPY/TUMOR
4.76
1.00
43250
UPPER GI ENDOSCOPY/TUMOR
5.00
1.00
43250
UPPER GI ENDOSCOPY/TUMOR
5.02
1.00
43251
OPERATIVE UPPER GI ENDOSCOPY
5.00
1.00
43251
OPERATIVE UPPER GI ENDOSCOPY
5.42
1.00
43251
OPERATIVE UPPER GI ENDOSCOPY
5.45
1.00
43251
OPERATIVE UPPER GI ENDOSCOPY
5.84
1.00
43255
OPERATIVE UPPER GI ENDOSCOPY
5.00
1.00
43255
OPERATIVE UPPER GI ENDOSCOPY
6.97
1.00
43255
OPERATIVE UPPER GI ENDOSCOPY
7.59
1.00
43256
UPPR GI ENDOSCOPY W/STENT
5.00
1.00
43256
UPPR GI ENDOSCOPY W/STENT
6.35
1.00
43256
UPPR GI ENDOSCOPY W/STENT
6.39
1.00
43256
UPPR GI ENDOSCOPY W/STENT
6.82
1.00
43257
UPPR GI SCOPE W/THRML TXMNT
8.36
1.00
43258
OPERATIVE UPPER GI ENDOSCOPY
5.00
1.00
43258
OPERATIVE UPPER GI ENDOSCOPY
6.62
1.00
43258
OPERATIVE UPPER GI ENDOSCOPY
6.65
1.00
43258
OPERATIVE UPPER GI ENDOSCOPY
7.15
1.00
43259
ENDOSCOPIC ULTRASOUND EXAM
5.00
1.00
43259
ENDOSCOPIC ULTRASOUND EXAM
7.06
1.00
43259
ENDOSCOPIC ULTRASOUND EXAM
7.50
1.00
43259
ENDOSCOPIC ULTRASOUND EXAM
8.14
1.00
43260
ENDO CHOLANGIOPANCREATOGRAPH
4.00
1.00
43260
ENDO CHOLANGIOPANCREATOGRAPH
8.59
1.00
43260
ENDO CHOLANGIOPANCREATOGRAPH
8.67
1.00
43260
ENDO CHOLANGIOPANCREATOGRAPH
9.33
1.00
43261
ENDO CHOLANGIOPANCREATOGRAPH
5.00
1.00
Procedure Code Description
RVU
RVU Coeff Value
43261
ENDO CHOLANGIOPANCREATOGRAPH
9.03
1.00
43261
ENDO CHOLANGIOPANCREATOGRAPH
9.11
1.00
43261
ENDO CHOLANGIOPANCREATOGRAPH
9.81
1.00
43262
ENDO CHOLANGIOPANCREATOGRAPH
5.00
1.00
43262
ENDO CHOLANGIOPANCREATOGRAPH
10.60
1.00
43262
ENDO CHOLANGIOPANCREATOGRAPH
10.69
1.00
43262
ENDO CHOLANGIOPANCREATOGRAPH
11.52
1.00
43263
ENDO CHOLANGIOPANCREATOGRAPH
5.00
1.00
43263
ENDO CHOLANGIOPANCREATOGRAPH
10.40
1.00
43263
ENDO CHOLANGIOPANCREATOGRAPH
10.50
1.00
43263
ENDO CHOLANGIOPANCREATOGRAPH
11.40
1.00
43264
ENDO CHOLANGIOPANCREATOGRAPH
5.00
1.00
43264
ENDO CHOLANGIOPANCREATOGRAPH
12.73
1.00
43264
ENDO CHOLANGIOPANCREATOGRAPH
12.80
1.00
43264
ENDO CHOLANGIOPANCREATOGRAPH
13.83
1.00
43265
ENDO CHOLANGIOPANCREATOGRAPH
14.24
1.00
43265
ENDO CHOLANGIOPANCREATOGRAPH
14.33
1.00
43265
ENDO CHOLANGIOPANCREATOGRAPH
15.52
1.00
43267
ENDO CHOLANGIOPANCREATOGRAPH
5.00
1.00
43267
ENDO CHOLANGIOPANCREATOGRAPH
10.59
1.00
43267
ENDO CHOLANGIOPANCREATOGRAPH
10.69
1.00
43267
ENDO CHOLANGIOPANCREATOGRAPH
11.47
1.00
43268
ENDO CHOLANGIOPANCREATOGRAPH
5.00
1.00
43268
ENDO CHOLANGIOPANCREATOGRAPH
10.69
1.00
43268
ENDO CHOLANGIOPANCREATOGRAPH
11.66
1.00
43269
ENDO CHOLANGIOPANCREATOGRAPH
5.00
1.00
43269
ENDO CHOLANGIOPANCREATOGRAPH
11.64
1.00
43269
ENDO CHOLANGIOPANCREATOGRAPH
11.73
1.00
43269
ENDO CHOLANGIOPANCREATOGRAPH
12.77
1.00
43271
ENDO CHOLANGIOPANCREATOGRAPH
5.00
1.00
43271
ENDO CHOLANGIOPANCREATOGRAPH
10.59
1.00
43271
ENDO CHOLANGIOPANCREATOGRAPH
10.68
1.00
43271
ENDO CHOLANGIOPANCREATOGRAPH
11.51
1.00
43272
ENDO CHOLANGIOPANCREATOGRAPH
5.00
1.00
43272
ENDO CHOLANGIOPANCREATOGRAPH
10.60
1.00
Procedure Code Description
RVU
RVU Coeff Value
43272
ENDO CHOLANGIOPANCREATOGRAPH
10.69
1.00
43272
ENDO CHOLANGIOPANCREATOGRAPH
11.49
1.00
43273
ENDOSCOPIC PANCREATOSCOPY
3.48
1.00
43279
LAP MYOTOMY, HELLER
32.69
1.00
43280
LAPAROSCOPY, FUNDOPLASTY
6.00
1.00
43280
LAPAROSCOPY, FUNDOPLASTY
26.67
1.00
43280
LAPAROSCOPY, FUNDOPLASTY
27.21
1.00
43280
LAPAROSCOPY, FUNDOPLASTY
27.32
1.00
43300
REPAIR OF ESOPHAGUS
13.00
1.00
43300
REPAIR OF ESOPHAGUS
16.14
1.00
43300
REPAIR OF ESOPHAGUS
16.67
1.00
43300
REPAIR OF ESOPHAGUS
17.24
1.00
43305
REPAIR ESOPHAGUS AND FISTULA
19.00
1.00
43305
REPAIR ESOPHAGUS AND FISTULA
28.72
1.00
43305
REPAIR ESOPHAGUS AND FISTULA
29.78
1.00
43305
REPAIR ESOPHAGUS AND FISTULA
31.45
1.00
43310
REPAIR OF ESOPHAGUS
12.00
1.00
43310
REPAIR OF ESOPHAGUS
40.34
1.00
43310
REPAIR OF ESOPHAGUS
40.52
1.00
43310
REPAIR OF ESOPHAGUS
43.23
1.00
43312
REPAIR ESOPHAGUS AND FISTULA
15.00
1.00
43312
REPAIR ESOPHAGUS AND FISTULA
44.46
1.00
43312
REPAIR ESOPHAGUS AND FISTULA
44.74
1.00
43312
REPAIR ESOPHAGUS AND FISTULA
50.00
1.00
43313
ESOPHAGOPLASTY CONGENITAL
15.00
1.00
43313
ESOPHAGOPLASTY CONGENITAL
70.86
1.00
43313
ESOPHAGOPLASTY CONGENITAL
71.91
1.00
43313
ESOPHAGOPLASTY CONGENITAL
72.37
1.00
43314
TRACHEO-ESOPHAGOPLASTY CONG
15.00
1.00
43314
TRACHEO-ESOPHAGOPLASTY CONG
78.91
1.00
43314
TRACHEO-ESOPHAGOPLASTY CONG
79.48
1.00
43314
TRACHEO-ESOPHAGOPLASTY CONG
81.42
1.00
43320
FUSE ESOPHAGUS & STOMACH
13.00
1.00
43320
FUSE ESOPHAGUS & STOMACH
31.09
1.00
43320
FUSE ESOPHAGUS & STOMACH
31.97
1.00
Procedure Code Description 43320
FUSE ESOPHAGUS & STOMACH
43324
RVU
RVU Coeff Value
35.45
1.00
REVISE ESOPHAGUS & STOMACH
7.00
1.00
43324
REVISE ESOPHAGUS & STOMACH
31.43
1.00
43324
REVISE ESOPHAGUS & STOMACH
31.77
1.00
43324
REVISE ESOPHAGUS & STOMACH
34.40
1.00
43325
REVISE ESOPHAGUS & STOMACH
7.00
1.00
43325
REVISE ESOPHAGUS & STOMACH
30.86
1.00
43325
REVISE ESOPHAGUS & STOMACH
31.56
1.00
43325
REVISE ESOPHAGUS & STOMACH
33.82
1.00
43326
REVISE ESOPHAGUS & STOMACH
31.27
1.00
43326
REVISE ESOPHAGUS & STOMACH
32.07
1.00
43326
REVISE ESOPHAGUS & STOMACH
34.56
1.00
43326
REVISE ESOPHAGUS & STOMACH
999.99
1.00
43330
REPAIR OF ESOPHAGUS
13.00
1.00
43330
REPAIR OF ESOPHAGUS
30.16
1.00
43330
REPAIR OF ESOPHAGUS
30.85
1.00
43330
REPAIR OF ESOPHAGUS
33.20
1.00
43331
REPAIR OF ESOPHAGUS
15.00
1.00
43331
REPAIR OF ESOPHAGUS
32.26
1.00
43331
REPAIR OF ESOPHAGUS
33.19
1.00
43331
REPAIR OF ESOPHAGUS
36.05
1.00
43340
FUSE ESOPHAGUS & INTESTINE
13.00
1.00
43340
FUSE ESOPHAGUS & INTESTINE
30.46
1.00
43340
FUSE ESOPHAGUS & INTESTINE
31.75
1.00
43340
FUSE ESOPHAGUS & INTESTINE
34.38
1.00
43341
FUSE ESOPHAGUS & INTESTINE
15.00
1.00
43341
FUSE ESOPHAGUS & INTESTINE
33.46
1.00
43341
FUSE ESOPHAGUS & INTESTINE
35.07
1.00
43341
FUSE ESOPHAGUS & INTESTINE
37.96
1.00
43350
SURGICAL OPENING, ESOPHAGUS
13.00
1.00
43350
SURGICAL OPENING, ESOPHAGUS
25.65
1.00
43350
SURGICAL OPENING, ESOPHAGUS
27.10
1.00
43350
SURGICAL OPENING, ESOPHAGUS
29.12
1.00
43351
SURGICAL OPENING, ESOPHAGUS
15.00
1.00
43351
SURGICAL OPENING, ESOPHAGUS
29.99
1.00
Procedure Code Description
RVU
RVU Coeff Value
43351
SURGICAL OPENING, ESOPHAGUS
30.47
1.00
43351
SURGICAL OPENING, ESOPHAGUS
34.48
1.00
43352
SURGICAL OPENING, ESOPHAGUS
6.00
1.00
43352
SURGICAL OPENING, ESOPHAGUS
25.23
1.00
43352
SURGICAL OPENING, ESOPHAGUS
26.26
1.00
43352
SURGICAL OPENING, ESOPHAGUS
28.22
1.00
43360
GASTROINTESTINAL REPAIR
15.00
1.00
43360
GASTROINTESTINAL REPAIR
54.42
1.00
43360
GASTROINTESTINAL REPAIR
55.24
1.00
43360
GASTROINTESTINAL REPAIR
60.55
1.00
43361
GASTROINTESTINAL REPAIR
15.00
1.00
43361
GASTROINTESTINAL REPAIR
61.67
1.00
43361
GASTROINTESTINAL REPAIR
62.40
1.00
43361
GASTROINTESTINAL REPAIR
67.26
1.00
43400
LIGATE ESOPHAGUS VEINS
12.00
1.00
43400
LIGATE ESOPHAGUS VEINS
31.79
1.00
43400
LIGATE ESOPHAGUS VEINS
32.53
1.00
43400
LIGATE ESOPHAGUS VEINS
41.24
1.00
43401
ESOPHAGUS SURGERY FOR VEINS
15.00
1.00
43401
ESOPHAGUS SURGERY FOR VEINS
33.71
1.00
43401
ESOPHAGUS SURGERY FOR VEINS
34.17
1.00
43401
ESOPHAGUS SURGERY FOR VEINS
39.33
1.00
43405
LIGATE/STAPLE ESOPHAGUS
15.00
1.00
43405
LIGATE/STAPLE ESOPHAGUS
31.15
1.00
43405
LIGATE/STAPLE ESOPHAGUS
31.57
1.00
43405
LIGATE/STAPLE ESOPHAGUS
38.10
1.00
43410
REPAIR ESOPHAGUS WOUND
7.00
1.00
43410
REPAIR ESOPHAGUS WOUND
22.53
1.00
43410
REPAIR ESOPHAGUS WOUND
23.55
1.00
43410
REPAIR ESOPHAGUS WOUND
26.02
1.00
43415
REPAIR ESOPHAGUS WOUND
12.00
1.00
43415
REPAIR ESOPHAGUS WOUND
39.08
1.00
43415
REPAIR ESOPHAGUS WOUND
39.18
1.00
43415
REPAIR ESOPHAGUS WOUND
44.48
1.00
43420
REPAIR ESOPHAGUS OPENING
7.00
1.00
Procedure Code Description
RVU
RVU Coeff Value
43420
REPAIR ESOPHAGUS OPENING
22.85
1.00
43420
REPAIR ESOPHAGUS OPENING
24.13
1.00
43420
REPAIR ESOPHAGUS OPENING
25.93
1.00
43425
REPAIR ESOPHAGUS OPENING
13.00
1.00
43425
REPAIR ESOPHAGUS OPENING
33.48
1.00
43425
REPAIR ESOPHAGUS OPENING
34.28
1.00
43425
REPAIR ESOPHAGUS OPENING
39.07
1.00
43450
DILATE ESOPHAGUS
2.07
1.00
43450
DILATE ESOPHAGUS
2.19
1.00
43450
DILATE ESOPHAGUS
2.37
1.00
43450
DILATE ESOPHAGUS
5.00
1.00
43453
DILATE ESOPHAGUS
2.26
1.00
43453
DILATE ESOPHAGUS
2.39
1.00
43453
DILATE ESOPHAGUS
2.57
1.00
43453
DILATE ESOPHAGUS
6.00
1.00
43456
DILATE ESOPHAGUS
3.00
1.00
43456
DILATE ESOPHAGUS
3.75
1.00
43456
DILATE ESOPHAGUS
3.89
1.00
43456
DILATE ESOPHAGUS
3.97
1.00
43456
DILATE ESOPHAGUS
4.04
1.00
43456
DILATE ESOPHAGUS
4.15
1.00
43458
DILATE ESOPHAGUS
4.46
1.00
43458
DILATE ESOPHAGUS
4.60
1.00
43458
DILATE ESOPHAGUS
4.85
1.00
43458
DILATE ESOPHAGUS
5.00
1.00
43460
PRESSURE TREATMENT ESOPHAGUS
4.00
1.00
43460
PRESSURE TREATMENT ESOPHAGUS
5.51
1.00
43460
PRESSURE TREATMENT ESOPHAGUS
5.53
1.00
43460
PRESSURE TREATMENT ESOPHAGUS
5.89
1.00
43496
FREE JEJUNUM FLAP, MICROVASC
5.00
1.00
43500
SURGICAL OPENING OF STOMACH
7.00
1.00
43500
SURGICAL OPENING OF STOMACH
16.97
1.00
43500
SURGICAL OPENING OF STOMACH
17.04
1.00
43500
SURGICAL OPENING OF STOMACH
19.48
1.00
43501
SURGICAL REPAIR OF STOMACH
7.00
1.00
Procedure Code Description
RVU
RVU Coeff Value
43501
SURGICAL REPAIR OF STOMACH
30.19
1.00
43501
SURGICAL REPAIR OF STOMACH
30.24
1.00
43501
SURGICAL REPAIR OF STOMACH
33.54
1.00
43502
SURGICAL REPAIR OF STOMACH
15.00
1.00
43502
SURGICAL REPAIR OF STOMACH
34.73
1.00
43502
SURGICAL REPAIR OF STOMACH
34.82
1.00
43502
SURGICAL REPAIR OF STOMACH
38.01
1.00
43510
SURGICAL OPENING OF STOMACH
7.00
1.00
43510
SURGICAL OPENING OF STOMACH
20.74
1.00
43510
SURGICAL OPENING OF STOMACH
21.51
1.00
43510
SURGICAL OPENING OF STOMACH
24.00
1.00
43520
INCISION OF PYLORIC MUSCLE
7.00
1.00
43520
INCISION OF PYLORIC MUSCLE
16.29
1.00
43520
INCISION OF PYLORIC MUSCLE
16.64
1.00
43520
INCISION OF PYLORIC MUSCLE
17.65
1.00
43600
BIOPSY OF STOMACH
2.85
1.00
43600
BIOPSY OF STOMACH
3.04
1.00
43600
BIOPSY OF STOMACH
3.07
1.00
43600
BIOPSY OF STOMACH
5.00
1.00
43605
BIOPSY OF STOMACH
6.00
1.00
43605
BIOPSY OF STOMACH
18.30
1.00
43605
BIOPSY OF STOMACH
18.40
1.00
43605
BIOPSY OF STOMACH
20.69
1.00
43610
EXCISION OF STOMACH LESION
6.00
1.00
43610
EXCISION OF STOMACH LESION
22.15
1.00
43610
EXCISION OF STOMACH LESION
22.43
1.00
43610
EXCISION OF STOMACH LESION
24.46
1.00
43611
EXCISION OF STOMACH LESION
7.00
1.00
43611
EXCISION OF STOMACH LESION
27.08
1.00
43611
EXCISION OF STOMACH LESION
27.15
1.00
43611
EXCISION OF STOMACH LESION
30.42
1.00
43620
REMOVAL OF STOMACH
7.00
1.00
43620
REMOVAL OF STOMACH
44.62
1.00
43620
REMOVAL OF STOMACH
45.02
1.00
43620
REMOVAL OF STOMACH
49.59
1.00
Procedure Code Description
RVU
RVU Coeff Value
43621
REMOVAL OF STOMACH
7.00
1.00
43621
REMOVAL OF STOMACH
45.59
1.00
43621
REMOVAL OF STOMACH
45.97
1.00
43621
REMOVAL OF STOMACH
56.28
1.00
43622
REMOVAL OF STOMACH
7.00
1.00
43622
REMOVAL OF STOMACH
48.13
1.00
43622
REMOVAL OF STOMACH
48.49
1.00
43622
REMOVAL OF STOMACH
57.18
1.00
43631
REMOVAL OF STOMACH, PARTIAL
7.00
1.00
43631
REMOVAL OF STOMACH, PARTIAL
34.03
1.00
43631
REMOVAL OF STOMACH, PARTIAL
34.17
1.00
43631
REMOVAL OF STOMACH, PARTIAL
36.41
1.00
43632
REMOVAL OF STOMACH, PARTIAL
7.00
1.00
43632
REMOVAL OF STOMACH, PARTIAL
34.05
1.00
43632
REMOVAL OF STOMACH, PARTIAL
34.18
1.00
43632
REMOVAL OF STOMACH, PARTIAL
49.19
1.00
43633
REMOVAL OF STOMACH, PARTIAL
7.00
1.00
43633
REMOVAL OF STOMACH, PARTIAL
34.79
1.00
43633
REMOVAL OF STOMACH, PARTIAL
34.91
1.00
43633
REMOVAL OF STOMACH, PARTIAL
46.89
1.00
43634
REMOVAL OF STOMACH, PARTIAL
7.00
1.00
43634
REMOVAL OF STOMACH, PARTIAL
37.71
1.00
43634
REMOVAL OF STOMACH, PARTIAL
37.85
1.00
43634
REMOVAL OF STOMACH, PARTIAL
51.77
1.00
43635
REMOVAL OF STOMACH, PARTIAL
2.92
1.00
43635
REMOVAL OF STOMACH, PARTIAL
2.99
1.00
43635
REMOVAL OF STOMACH, PARTIAL
3.01
1.00
43635
REMOVAL OF STOMACH, PARTIAL
999.99
1.00
43638
REMOVAL OF STOMACH, PARTIAL
7.00
1.00
43638
REMOVAL OF STOMACH, PARTIAL
43.01
1.00
43638
REMOVAL OF STOMACH, PARTIAL
43.60
1.00
43638
REMOVAL OF STOMACH, PARTIAL
44.59
1.00
43639
REMOVAL OF STOMACH, PARTIAL
7.00
1.00
43639
REMOVAL OF STOMACH, PARTIAL
43.97
1.00
43639
REMOVAL OF STOMACH, PARTIAL
44.14
1.00
Procedure Code Description 43639
REMOVAL OF STOMACH, PARTIAL
43640
RVU
RVU Coeff Value
45.14
1.00
VAGOTOMY & PYLORUS REPAIR
7.00
1.00
43640
VAGOTOMY & PYLORUS REPAIR
26.05
1.00
43640
VAGOTOMY & PYLORUS REPAIR
26.11
1.00
43640
VAGOTOMY & PYLORUS REPAIR
29.23
1.00
43641
VAGOTOMY & PYLORUS REPAIR
7.00
1.00
43641
VAGOTOMY & PYLORUS REPAIR
26.43
1.00
43641
VAGOTOMY & PYLORUS REPAIR
26.50
1.00
43641
VAGOTOMY & PYLORUS REPAIR
29.47
1.00
43644
LAP GASTRIC BYPASS/ROUX-EN-Y
43.19
1.00
43645
LAP GASTR BYPASS INCL SMLL I
46.26
1.00
43651
LAPAROSCOPY, VAGUS NERVE
6.00
1.00
43651
LAPAROSCOPY, VAGUS NERVE
15.77
1.00
43651
LAPAROSCOPY, VAGUS NERVE
16.17
1.00
43651
LAPAROSCOPY, VAGUS NERVE
16.28
1.00
43652
LAPAROSCOPY, VAGUS NERVE
6.00
1.00
43652
LAPAROSCOPY, VAGUS NERVE
18.77
1.00
43652
LAPAROSCOPY, VAGUS NERVE
19.04
1.00
43652
LAPAROSCOPY, VAGUS NERVE
19.05
1.00
43653
LAPAROSCOPY, GASTROSTOMY
6.00
1.00
43653
LAPAROSCOPY, GASTROSTOMY
12.74
1.00
43653
LAPAROSCOPY, GASTROSTOMY
12.88
1.00
43653
LAPAROSCOPY, GASTROSTOMY
13.86
1.00
43750
PLACE GASTROSTOMY TUBE
3.00
1.00
43750
PLACE GASTROSTOMY TUBE
7.17
1.00
43750
PLACE GASTROSTOMY TUBE
7.44
1.00
43750
PLACE GASTROSTOMY TUBE
7.60
1.00
43752
NASAL/OROGASTRIC W/STENT
0.96
1.00
43752
NASAL/OROGASTRIC W/STENT
1.11
1.00
43752
NASAL/OROGASTRIC W/STENT
3.00
1.00
43760
CHANGE GASTROSTOMY TUBE
1.36
1.00
43760
CHANGE GASTROSTOMY TUBE
1.38
1.00
43760
CHANGE GASTROSTOMY TUBE
1.63
1.00
43760
CHANGE GASTROSTOMY TUBE
3.00
1.00
43761
REPOSITION GASTROSTOMY TUBE
2.89
1.00
Procedure Code Description
RVU
RVU Coeff Value
43761
REPOSITION GASTROSTOMY TUBE
2.91
1.00
43761
REPOSITION GASTROSTOMY TUBE
2.92
1.00
43770
LAP PLACE GASTR ADJ DEVICE
27.76
1.00
43771
LAP REVISE GASTR ADJ DEVICE
31.67
1.00
43772
LAP RMVL GASTR ADJ DEVICE
23.95
1.00
43773
LAP REPLACE GASTR ADJ DEVICE
31.70
1.00
43774
LAP RMVL GASTR ADJ ALL PARTS
23.95
1.00
43800
RECONSTRUCTION OF PYLORUS
7.00
1.00
43800
RECONSTRUCTION OF PYLORUS
20.90
1.00
43800
RECONSTRUCTION OF PYLORUS
21.20
1.00
43800
RECONSTRUCTION OF PYLORUS
23.21
1.00
43810
FUSION OF STOMACH AND BOWEL
7.00
1.00
43810
FUSION OF STOMACH AND BOWEL
22.19
1.00
43810
FUSION OF STOMACH AND BOWEL
22.49
1.00
43810
FUSION OF STOMACH AND BOWEL
25.14
1.00
43820
FUSION OF STOMACH AND BOWEL
7.00
1.00
43820
FUSION OF STOMACH AND BOWEL
23.22
1.00
43820
FUSION OF STOMACH AND BOWEL
23.51
1.00
43820
FUSION OF STOMACH AND BOWEL
32.39
1.00
43825
FUSION OF STOMACH AND BOWEL
6.00
1.00
43825
FUSION OF STOMACH AND BOWEL
29.02
1.00
43825
FUSION OF STOMACH AND BOWEL
29.06
1.00
43825
FUSION OF STOMACH AND BOWEL
32.36
1.00
43830
PLACE GASTROSTOMY TUBE
6.00
1.00
43830
PLACE GASTROSTOMY TUBE
15.13
1.00
43830
PLACE GASTROSTOMY TUBE
15.23
1.00
43830
PLACE GASTROSTOMY TUBE
17.21
1.00
43831
PLACE GASTROSTOMY TUBE
7.00
1.00
43831
PLACE GASTROSTOMY TUBE
12.93
1.00
43831
PLACE GASTROSTOMY TUBE
13.35
1.00
43831
PLACE GASTROSTOMY TUBE
14.40
1.00
43832
PLACE GASTROSTOMY TUBE
6.00
1.00
43832
PLACE GASTROSTOMY TUBE
23.84
1.00
43832
PLACE GASTROSTOMY TUBE
24.19
1.00
43832
PLACE GASTROSTOMY TUBE
26.49
1.00
Procedure Code Description
RVU
RVU Coeff Value
43840
REPAIR OF STOMACH LESION
7.00
1.00
43840
REPAIR OF STOMACH LESION
23.78
1.00
43840
REPAIR OF STOMACH LESION
23.80
1.00
43840
REPAIR OF STOMACH LESION
32.85
1.00
43842
V-BAND GASTROPLASTY
7.00
1.00
43842
V-BAND GASTROPLASTY
28.41
1.00
43842
V-BAND GASTROPLASTY
31.19
1.00
43842
V-BAND GASTROPLASTY
32.16
1.00
43843
GASTROPLASTY W/O V-BAND
7.00
1.00
43843
GASTROPLASTY W/O V-BAND
28.59
1.00
43843
GASTROPLASTY W/O V-BAND
30.99
1.00
43843
GASTROPLASTY W/O V-BAND
31.54
1.00
43845
GASTRIC RESTRICTIVE PROCEDURE
48.90
1.00
43846
GASTRIC BYPASS FOR OBESITY
7.00
1.00
43846
GASTRIC BYPASS FOR OBESITY
36.74
1.00
43846
GASTRIC BYPASS FOR OBESITY
39.24
1.00
43846
GASTRIC BYPASS FOR OBESITY
40.68
1.00
43847
GASTRIC BYPASS INCL SMALL I
7.00
1.00
43847
GASTRIC BYPASS INCL SMALL I
40.78
1.00
43847
GASTRIC BYPASS INCL SMALL I
43.92
1.00
43847
GASTRIC BYPASS INCL SMALL I
44.46
1.00
43848
REVISION GASTROPLASTY
7.00
1.00
43848
REVISION GASTROPLASTY
44.48
1.00
43848
REVISION GASTROPLASTY
47.69
1.00
43848
REVISION GASTROPLASTY
48.26
1.00
43850
REVISE STOMACH-BOWEL FUSION
6.00
1.00
43850
REVISE STOMACH-BOWEL FUSION
36.83
1.00
43850
REVISE STOMACH-BOWEL FUSION
36.93
1.00
43850
REVISE STOMACH-BOWEL FUSION
40.42
1.00
43855
REVISE STOMACH-BOWEL FUSION
6.00
1.00
43855
REVISE STOMACH-BOWEL FUSION
38.90
1.00
43855
REVISE STOMACH-BOWEL FUSION
38.92
1.00
43855
REVISE STOMACH-BOWEL FUSION
42.26
1.00
43860
REVISE STOMACH-BOWEL FUSION
6.00
1.00
43860
REVISE STOMACH-BOWEL FUSION
37.33
1.00
Procedure Code Description
RVU
RVU Coeff Value
43860
REVISE STOMACH-BOWEL FUSION
37.44
1.00
43860
REVISE STOMACH-BOWEL FUSION
41.04
1.00
43865
REVISE STOMACH-BOWEL FUSION
6.00
1.00
43865
REVISE STOMACH-BOWEL FUSION
39.52
1.00
43865
REVISE STOMACH-BOWEL FUSION
39.63
1.00
43865
REVISE STOMACH-BOWEL FUSION
42.71
1.00
43870
REPAIR STOMACH OPENING
6.00
1.00
43870
REPAIR STOMACH OPENING
15.09
1.00
43870
REPAIR STOMACH OPENING
15.45
1.00
43870
REPAIR STOMACH OPENING
17.55
1.00
43880
REPAIR STOMACH-BOWEL FISTULA
7.00
1.00
43880
REPAIR STOMACH-BOWEL FISTULA
36.92
1.00
43880
REPAIR STOMACH-BOWEL FISTULA
37.26
1.00
43880
REPAIR STOMACH-BOWEL FISTULA
40.11
1.00
43886
REVISE GASTRIC PORT, OPEN
8.19
1.00
43887
REMOVE GASTRIC PORT, OPEN
7.78
1.00
43888
CHANGE GASTRIC PORT, OPEN
10.93
1.00
44005
FREEING OF BOWEL ADHESION
6.00
1.00
44005
FREEING OF BOWEL ADHESION
24.66
1.00
44005
FREEING OF BOWEL ADHESION
24.82
1.00
44005
FREEING OF BOWEL ADHESION
27.38
1.00
44010
INCISION OF SMALL BOWEL
7.00
1.00
44010
INCISION OF SMALL BOWEL
19.27
1.00
44010
INCISION OF SMALL BOWEL
19.89
1.00
44010
INCISION OF SMALL BOWEL
21.52
1.00
44015
INSERT NEEDLE CATH BOWEL
3.00
1.00
44015
INSERT NEEDLE CATH BOWEL
3.75
1.00
44015
INSERT NEEDLE CATH BOWEL
3.78
1.00
44015
INSERT NEEDLE CATH BOWEL
3.81
1.00
44020
EXPLORE SMALL INTESTINE
6.00
1.00
44020
EXPLORE SMALL INTESTINE
21.40
1.00
44020
EXPLORE SMALL INTESTINE
21.59
1.00
44020
EXPLORE SMALL INTESTINE
24.19
1.00
44021
DECOMPRESS SMALL BOWEL
6.00
1.00
44021
DECOMPRESS SMALL BOWEL
21.50
1.00
Procedure Code Description
RVU
RVU Coeff Value
44021
DECOMPRESS SMALL BOWEL
22.10
1.00
44021
DECOMPRESS SMALL BOWEL
24.47
1.00
44025
INCISION OF LARGE BOWEL
5.00
1.00
44025
INCISION OF LARGE BOWEL
21.79
1.00
44025
INCISION OF LARGE BOWEL
21.98
1.00
44025
INCISION OF LARGE BOWEL
24.63
1.00
44050
REDUCE BOWEL OBSTRUCTION
5.00
1.00
44050
REDUCE BOWEL OBSTRUCTION
21.40
1.00
44050
REDUCE BOWEL OBSTRUCTION
21.60
1.00
44050
REDUCE BOWEL OBSTRUCTION
23.34
1.00
44055
CORRECT MALROTATION OF BOWEL
6.00
1.00
44055
CORRECT MALROTATION OF BOWEL
32.34
1.00
44055
CORRECT MALROTATION OF BOWEL
32.52
1.00
44055
CORRECT MALROTATION OF BOWEL
37.34
1.00
44100
BIOPSY OF BOWEL
3.08
1.00
44100
BIOPSY OF BOWEL
3.19
1.00
44100
BIOPSY OF BOWEL
3.25
1.00
44100
BIOPSY OF BOWEL
4.00
1.00
44110
EXCISE INTESTINE LESION(S)
6.00
1.00
44110
EXCISE INTESTINE LESION(S)
18.27
1.00
44110
EXCISE INTESTINE LESION(S)
18.50
1.00
44110
EXCISE INTESTINE LESION(S)
21.08
1.00
44111
EXCISION OF BOWEL LESION(S)
6.00
1.00
44111
EXCISION OF BOWEL LESION(S)
21.91
1.00
44111
EXCISION OF BOWEL LESION(S)
22.56
1.00
44111
EXCISION OF BOWEL LESION(S)
24.56
1.00
44120
REMOVAL OF SMALL INTESTINE
6.00
1.00
44120
REMOVAL OF SMALL INTESTINE
25.85
1.00
44120
REMOVAL OF SMALL INTESTINE
25.91
1.00
44120
REMOVAL OF SMALL INTESTINE
30.39
1.00
44121
REMOVAL OF SMALL INTESTINE
6.30
1.00
44121
REMOVAL OF SMALL INTESTINE
6.47
1.00
44121
REMOVAL OF SMALL INTESTINE
6.52
1.00
44125
REMOVAL OF SMALL INTESTINE
6.00
1.00
44125
REMOVAL OF SMALL INTESTINE
26.62
1.00
Procedure Code Description
RVU
RVU Coeff Value
44125
REMOVAL OF SMALL INTESTINE
26.67
1.00
44125
REMOVAL OF SMALL INTESTINE
29.54
1.00
44126
ENTERECTOMY W/O TAPER, CONG
6.00
1.00
44126
ENTERECTOMY W/O TAPER, CONG
50.04
1.00
44126
ENTERECTOMY W/O TAPER, CONG
53.65
1.00
44126
ENTERECTOMY W/O TAPER, CONG
60.98
1.00
44127
ENTERECTOMY W/TAPER, CONG
6.00
1.00
44127
ENTERECTOMY W/TAPER, CONG
57.22
1.00
44127
ENTERECTOMY W/TAPER, CONG
61.69
1.00
44127
ENTERECTOMY W/TAPER, CONG
71.10
1.00
44128
ENTERECTOMY CONG, ADD-ON
6.34
1.00
44128
ENTERECTOMY CONG, ADD-ON
6.52
1.00
44128
ENTERECTOMY CONG, ADD-ON
6.63
1.00
44130
BOWEL TO BOWEL FUSION
6.00
1.00
44130
BOWEL TO BOWEL FUSION
22.21
1.00
44130
BOWEL TO BOWEL FUSION
22.29
1.00
44130
BOWEL TO BOWEL FUSION
31.66
1.00
44133
ENTERECTOMY, LIVE DONOR
6.00
1.00
44136
INTESTINE TRANSPLANT, LIVE
6.00
1.00
44139
MOBILIZATION OF COLON
3.15
1.00
44139
MOBILIZATION OF COLON
3.22
1.00
44139
MOBILIZATION OF COLON
3.24
1.00
44140
PARTIAL REMOVAL OF COLON
6.00
1.00
44140
PARTIAL REMOVAL OF COLON
32.00
1.00
44140
PARTIAL REMOVAL OF COLON
32.24
1.00
44140
PARTIAL REMOVAL OF COLON
33.67
1.00
44141
PARTIAL REMOVAL OF COLON
6.00
1.00
44141
PARTIAL REMOVAL OF COLON
31.66
1.00
44141
PARTIAL REMOVAL OF COLON
31.98
1.00
44141
PARTIAL REMOVAL OF COLON
44.00
1.00
44143
PARTIAL REMOVAL OF COLON
6.00
1.00
44143
PARTIAL REMOVAL OF COLON
35.90
1.00
44143
PARTIAL REMOVAL OF COLON
36.20
1.00
44143
PARTIAL REMOVAL OF COLON
41.40
1.00
44144
PARTIAL REMOVAL OF COLON
6.00
1.00
Procedure Code Description
RVU
RVU Coeff Value
44144
PARTIAL REMOVAL OF COLON
33.12
1.00
44144
PARTIAL REMOVAL OF COLON
33.47
1.00
44144
PARTIAL REMOVAL OF COLON
43.35
1.00
44145
PARTIAL REMOVAL OF COLON
6.00
1.00
44145
PARTIAL REMOVAL OF COLON
39.68
1.00
44145
PARTIAL REMOVAL OF COLON
39.93
1.00
44145
PARTIAL REMOVAL OF COLON
41.92
1.00
44146
PARTIAL REMOVAL OF COLON
6.00
1.00
44146
PARTIAL REMOVAL OF COLON
42.86
1.00
44146
PARTIAL REMOVAL OF COLON
43.13
1.00
44146
PARTIAL REMOVAL OF COLON
52.20
1.00
44147
PARTIAL REMOVAL OF COLON
6.00
1.00
44147
PARTIAL REMOVAL OF COLON
31.30
1.00
44147
PARTIAL REMOVAL OF COLON
31.52
1.00
44147
PARTIAL REMOVAL OF COLON
46.83
1.00
44150
REMOVAL OF COLON
6.00
1.00
44150
REMOVAL OF COLON
38.20
1.00
44150
REMOVAL OF COLON
38.54
1.00
44150
REMOVAL OF COLON
45.81
1.00
44151
REMOVAL OF COLON/ILEOSTOMY
7.00
1.00
44151
REMOVAL OF COLON/ILEOSTOMY
42.40
1.00
44151
REMOVAL OF COLON/ILEOSTOMY
42.76
1.00
44151
REMOVAL OF COLON/ILEOSTOMY
52.37
1.00
44152
REMOVAL OF COLON/ILEOSTOMY
7.00
1.00
44152
REMOVAL OF COLON/ILEOSTOMY
42.13
1.00
44152
REMOVAL OF COLON/ILEOSTOMY
42.32
1.00
44152
REMOVAL OF COLON/ILEOSTOMY
42.92
1.00
44153
REMOVAL OF COLON/ILEOSTOMY
7.00
1.00
44153
REMOVAL OF COLON/ILEOSTOMY
47.66
1.00
44153
REMOVAL OF COLON/ILEOSTOMY
47.91
1.00
44153
REMOVAL OF COLON/ILEOSTOMY
48.49
1.00
44155
REMOVAL OF COLON/ILEOSTOMY
6.00
1.00
44155
REMOVAL OF COLON/ILEOSTOMY
43.68
1.00
44155
REMOVAL OF COLON/ILEOSTOMY
43.99
1.00
44155
REMOVAL OF COLON/ILEOSTOMY
51.26
1.00
Procedure Code Description
RVU
RVU Coeff Value
44156
REMOVAL OF COLON/ILEOSTOMY
7.00
1.00
44156
REMOVAL OF COLON/ILEOSTOMY
48.17
1.00
44156
REMOVAL OF COLON/ILEOSTOMY
48.58
1.00
44156
REMOVAL OF COLON/ILEOSTOMY
56.46
1.00
44157
COLECTOMY W/ILEOANAL ANAST
53.68
1.00
44158
COLECTOMY W/NEO-RECTUM POUCH
55.03
1.00
44160
REMOVAL OF COLON
6.00
1.00
44160
REMOVAL OF COLON
28.41
1.00
44160
REMOVAL OF COLON
28.63
1.00
44160
REMOVAL OF COLON
30.98
1.00
44180
LAP, ENTEROLYSIS
23.14
1.00
44186
LAP, JEJUNOSTOMY
16.32
1.00
44187
LAP, ILEO/JEJUNO-STOMY
27.45
1.00
44188
LAP, COLOSTOMY
30.39
1.00
44200
LAPAROSCOPY, ENTEROLYSIS
6.00
1.00
44200
LAPAROSCOPY, ENTEROLYSIS
22.28
1.00
44200
LAPAROSCOPY, ENTEROLYSIS
22.41
1.00
44200
LAPAROSCOPY, ENTEROLYSIS
22.46
1.00
44201
LAPAROSCOPY, JEJUNOSTOMY
6.00
1.00
44201
LAPAROSCOPY, JEJUNOSTOMY
15.38
1.00
44201
LAPAROSCOPY, JEJUNOSTOMY
15.64
1.00
44201
LAPAROSCOPY, JEJUNOSTOMY
15.70
1.00
44202
LAP, ENTERECTOMY
6.00
1.00
44202
LAP, ENTERECTOMY
33.34
1.00
44202
LAP, ENTERECTOMY
33.60
1.00
44202
LAP, ENTERECTOMY
34.86
1.00
44203
LAP RESECT S/INTESTINE, ADDL
6.27
1.00
44203
LAP RESECT S/INTESTINE, ADDL
6.47
1.00
44203
LAP RESECT S/INTESTINE, ADDL
6.49
1.00
44204
LAPARO PARTIAL COLECTOMY
6.00
1.00
44204
LAPARO PARTIAL COLECTOMY
37.84
1.00
44204
LAPARO PARTIAL COLECTOMY
38.12
1.00
44204
LAPARO PARTIAL COLECTOMY
38.89
1.00
44205
LAP COLECTOMY PART W/ILEUM
6.00
1.00
44205
LAP COLECTOMY PART W/ILEUM
33.53
1.00
Procedure Code Description
RVU
RVU Coeff Value
44205
LAP COLECTOMY PART W/ILEUM
33.77
1.00
44205
LAP COLECTOMY PART W/ILEUM
33.97
1.00
44206
LAP PART COLECTOMY W/STOMA
40.24
1.00
44206
LAP PART COLECTOMY W/STOMA
40.77
1.00
44206
LAP PART COLECTOMY W/STOMA
44.11
1.00
44207
L COLECTOMY/COLOPROCTOSTOMY
44.04
1.00
44207
L COLECTOMY/COLOPROCTOSTOMY
44.23
1.00
44207
L COLECTOMY/COLOPROCTOSTOMY
46.33
1.00
44208
L COLECTOMY/COLOPROCTOSTOMY
47.62
1.00
44208
L COLECTOMY/COLOPROCTOSTOMY
47.87
1.00
44208
L COLECTOMY/COLOPROCTOSTOMY
50.36
1.00
44210
LAPARO TOTAL PROCTOCOLECTOMY
42.16
1.00
44210
LAPARO TOTAL PROCTOCOLECTOMY
42.46
1.00
44210
LAPARO TOTAL PROCTOCOLECTOMY
45.01
1.00
44211
LAP COLECTOMY W/PROCTECTOMY
52.35
1.00
44211
LAP COLECTOMY W/PROCTECTOMY
52.50
1.00
44211
LAP COLECTOMY W/PROCTECTOMY
55.24
1.00
44212
LAPARO TOTAL PROCTOCOLECTOMY
48.92
1.00
44212
LAPARO TOTAL PROCTOCOLECTOMY
49.06
1.00
44212
LAPARO TOTAL PROCTOCOLECTOMY
51.78
1.00
44213
LAP, MOBIL SPLENIC FL ADD-ON
4.94
1.00
44227
LAP, CLOSE ENTEROSTOMY
42.11
1.00
44300
OPEN BOWEL TO SKIN
6.00
1.00
44300
OPEN BOWEL TO SKIN
18.62
1.00
44300
OPEN BOWEL TO SKIN
18.68
1.00
44300
OPEN BOWEL TO SKIN
20.95
1.00
44310
ILEOSTOMY/JEJUNOSTOMY
6.00
1.00
44310
ILEOSTOMY/JEJUNOSTOMY
23.96
1.00
44310
ILEOSTOMY/JEJUNOSTOMY
24.02
1.00
44310
ILEOSTOMY/JEJUNOSTOMY
26.18
1.00
44312
REVISION OF ILEOSTOMY
5.00
1.00
44312
REVISION OF ILEOSTOMY
12.65
1.00
44312
REVISION OF ILEOSTOMY
12.69
1.00
44312
REVISION OF ILEOSTOMY
14.84
1.00
44314
REVISION OF ILEOSTOMY
6.00
1.00
Procedure Code Description
RVU
RVU Coeff Value
44314
REVISION OF ILEOSTOMY
22.75
1.00
44314
REVISION OF ILEOSTOMY
22.82
1.00
44314
REVISION OF ILEOSTOMY
25.30
1.00
44316
DEVISE BOWEL POUCH
6.00
1.00
44316
DEVISE BOWEL POUCH
31.21
1.00
44316
DEVISE BOWEL POUCH
31.36
1.00
44316
DEVISE BOWEL POUCH
34.61
1.00
44320
COLOSTOMY
5.00
1.00
44320
COLOSTOMY
26.75
1.00
44320
COLOSTOMY
26.86
1.00
44320
COLOSTOMY
29.86
1.00
44322
COLOSTOMY WITH BIOPSIES
6.00
1.00
44322
COLOSTOMY WITH BIOPSIES
21.91
1.00
44322
COLOSTOMY WITH BIOPSIES
22.08
1.00
44322
COLOSTOMY WITH BIOPSIES
23.72
1.00
44340
REVISION OF COLOSTOMY
5.00
1.00
44340
REVISION OF COLOSTOMY
12.63
1.00
44340
REVISION OF COLOSTOMY
12.70
1.00
44340
REVISION OF COLOSTOMY
14.96
1.00
44345
REVISION OF COLOSTOMY
6.00
1.00
44345
REVISION OF COLOSTOMY
23.57
1.00
44345
REVISION OF COLOSTOMY
23.68
1.00
44345
REVISION OF COLOSTOMY
26.14
1.00
44346
REVISION OF COLOSTOMY
6.00
1.00
44346
REVISION OF COLOSTOMY
25.73
1.00
44346
REVISION OF COLOSTOMY
25.84
1.00
44346
REVISION OF COLOSTOMY
29.31
1.00
44360
SMALL BOWEL ENDOSCOPY
3.88
1.00
44360
SMALL BOWEL ENDOSCOPY
4.09
1.00
44360
SMALL BOWEL ENDOSCOPY
4.22
1.00
44360
SMALL BOWEL ENDOSCOPY
6.00
1.00
44361
SMALL BOWEL ENDOSCOPY/BIOPSY
4.26
1.00
44361
SMALL BOWEL ENDOSCOPY/BIOPSY
4.47
1.00
44361
SMALL BOWEL ENDOSCOPY/BIOPSY
4.65
1.00
44361
SMALL BOWEL ENDOSCOPY/BIOPSY
6.00
1.00
Procedure Code Description
RVU
RVU Coeff Value
44363
SMALL BOWEL ENDOSCOPY
5.12
1.00
44363
SMALL BOWEL ENDOSCOPY
5.33
1.00
44363
SMALL BOWEL ENDOSCOPY
5.51
1.00
44363
SMALL BOWEL ENDOSCOPY
6.00
1.00
44364
SMALL BOWEL ENDOSCOPY
5.50
1.00
44364
SMALL BOWEL ENDOSCOPY
5.71
1.00
44364
SMALL BOWEL ENDOSCOPY
5.93
1.00
44364
SMALL BOWEL ENDOSCOPY
6.00
1.00
44365
SMALL BOWEL ENDOSCOPY
4.91
1.00
44365
SMALL BOWEL ENDOSCOPY
5.12
1.00
44365
SMALL BOWEL ENDOSCOPY
5.28
1.00
44365
SMALL BOWEL ENDOSCOPY
6.00
1.00
44366
SMALL BOWEL ENDOSCOPY
6.00
1.00
44366
SMALL BOWEL ENDOSCOPY
6.43
1.00
44366
SMALL BOWEL ENDOSCOPY
6.64
1.00
44366
SMALL BOWEL ENDOSCOPY
6.99
1.00
44369
SMALL BOWEL ENDOSCOPY
6.00
1.00
44369
SMALL BOWEL ENDOSCOPY
6.55
1.00
44369
SMALL BOWEL ENDOSCOPY
6.76
1.00
44369
SMALL BOWEL ENDOSCOPY
7.14
1.00
44370
SMALL BOWEL ENDOSCOPY/STENT
5.00
1.00
44370
SMALL BOWEL ENDOSCOPY/STENT
7.03
1.00
44370
SMALL BOWEL ENDOSCOPY/STENT
7.16
1.00
44370
SMALL BOWEL ENDOSCOPY/STENT
7.70
1.00
44372
SMALL BOWEL ENDOSCOPY
6.48
1.00
44372
SMALL BOWEL ENDOSCOPY
6.68
1.00
44372
SMALL BOWEL ENDOSCOPY
6.81
1.00
44373
SMALL BOWEL ENDOSCOPY
5.17
1.00
44373
SMALL BOWEL ENDOSCOPY
5.41
1.00
44373
SMALL BOWEL ENDOSCOPY
5.51
1.00
44376
SMALL BOWEL ENDOSCOPY
6.00
1.00
44376
SMALL BOWEL ENDOSCOPY
7.64
1.00
44376
SMALL BOWEL ENDOSCOPY
7.85
1.00
44376
SMALL BOWEL ENDOSCOPY
8.15
1.00
44377
SMALL BOWEL ENDOSCOPY/BIOPSY
6.00
1.00
Procedure Code Description
RVU
RVU Coeff Value
44377
SMALL BOWEL ENDOSCOPY/BIOPSY
8.01
1.00
44377
SMALL BOWEL ENDOSCOPY/BIOPSY
8.24
1.00
44377
SMALL BOWEL ENDOSCOPY/BIOPSY
8.63
1.00
44378
SMALL BOWEL ENDOSCOPY
6.00
1.00
44378
SMALL BOWEL ENDOSCOPY
10.28
1.00
44378
SMALL BOWEL ENDOSCOPY
10.49
1.00
44378
SMALL BOWEL ENDOSCOPY
11.07
1.00
44379
S BOWEL ENDOSCOPE W/STENT
5.00
1.00
44379
S BOWEL ENDOSCOPE W/STENT
10.85
1.00
44379
S BOWEL ENDOSCOPE W/STENT
10.96
1.00
44379
S BOWEL ENDOSCOPE W/STENT
11.76
1.00
44380
SMALL BOWEL ENDOSCOPY
1.71
1.00
44380
SMALL BOWEL ENDOSCOPY
1.84
1.00
44380
SMALL BOWEL ENDOSCOPY
1.91
1.00
44380
SMALL BOWEL ENDOSCOPY
6.00
1.00
44382
SMALL BOWEL ENDOSCOPY
2.03
1.00
44382
SMALL BOWEL ENDOSCOPY
2.22
1.00
44382
SMALL BOWEL ENDOSCOPY
2.23
1.00
44382
SMALL BOWEL ENDOSCOPY
6.00
1.00
44383
ILEOSCOPY W/STENT
4.38
1.00
44383
ILEOSCOPY W/STENT
4.49
1.00
44383
ILEOSCOPY W/STENT
4.74
1.00
44383
ILEOSCOPY W/STENT
6.00
1.00
44385
ENDOSCOPY OF BOWEL POUCH
2.83
1.00
44385
ENDOSCOPY OF BOWEL POUCH
2.90
1.00
44385
ENDOSCOPY OF BOWEL POUCH
2.92
1.00
44385
ENDOSCOPY OF BOWEL POUCH
6.00
1.00
44386
ENDOSCOPY, BOWEL POUCH/BIOP
3.33
1.00
44386
ENDOSCOPY, BOWEL POUCH/BIOP
3.36
1.00
44386
ENDOSCOPY, BOWEL POUCH/BIOP
3.42
1.00
44386
ENDOSCOPY, BOWEL POUCH/BIOP
6.00
1.00
44388
COLONOSCOPY
4.20
1.00
44388
COLONOSCOPY
4.38
1.00
44388
COLONOSCOPY
4.42
1.00
44388
COLONOSCOPY
6.00
1.00
Procedure Code Description
RVU
RVU Coeff Value
44389
COLONOSCOPY WITH BIOPSY
4.63
1.00
44389
COLONOSCOPY WITH BIOPSY
4.82
1.00
44389
COLONOSCOPY WITH BIOPSY
4.93
1.00
44389
COLONOSCOPY WITH BIOPSY
6.00
1.00
44390
COLONOSCOPY FOR FOREIGN BODY
5.60
1.00
44390
COLONOSCOPY FOR FOREIGN BODY
5.78
1.00
44390
COLONOSCOPY FOR FOREIGN BODY
5.91
1.00
44390
COLONOSCOPY FOR FOREIGN BODY
6.00
1.00
44391
COLONOSCOPY FOR BLEEDING
6.00
1.00
44391
COLONOSCOPY FOR BLEEDING
6.28
1.00
44391
COLONOSCOPY FOR BLEEDING
6.31
1.00
44391
COLONOSCOPY FOR BLEEDING
6.73
1.00
44392
COLONOSCOPY & POLYPECTOMY
5.61
1.00
44392
COLONOSCOPY & POLYPECTOMY
5.79
1.00
44392
COLONOSCOPY & POLYPECTOMY
5.82
1.00
44392
COLONOSCOPY & POLYPECTOMY
6.00
1.00
44393
COLONOSCOPY, LESION REMOVAL
6.00
1.00
44393
COLONOSCOPY, LESION REMOVAL
7.04
1.00
44393
COLONOSCOPY, LESION REMOVAL
7.23
1.00
44393
COLONOSCOPY, LESION REMOVAL
7.41
1.00
44394
COLONOSCOPY W/SNARE
5.00
1.00
44394
COLONOSCOPY W/SNARE
6.48
1.00
44394
COLONOSCOPY W/SNARE
6.67
1.00
44394
COLONOSCOPY W/SNARE
6.86
1.00
44397
COLONOSCOPY W/STENT
6.00
1.00
44397
COLONOSCOPY W/STENT
7.05
1.00
44397
COLONOSCOPY W/STENT
7.10
1.00
44397
COLONOSCOPY W/STENT
7.40
1.00
44602
SUTURE, SMALL INTESTINE
6.00
1.00
44602
SUTURE, SMALL INTESTINE
23.72
1.00
44602
SUTURE, SMALL INTESTINE
23.73
1.00
44602
SUTURE, SMALL INTESTINE
34.32
1.00
44603
SUTURE, SMALL INTESTINE
6.00
1.00
44603
SUTURE, SMALL INTESTINE
27.57
1.00
44603
SUTURE, SMALL INTESTINE
27.62
1.00
Procedure Code Description
RVU
RVU Coeff Value
44603
SUTURE, SMALL INTESTINE
39.34
1.00
44604
SUTURE, LARGE INTESTINE
6.00
1.00
44604
SUTURE, LARGE INTESTINE
24.14
1.00
44604
SUTURE, LARGE INTESTINE
24.21
1.00
44604
SUTURE, LARGE INTESTINE
26.57
1.00
44605
REPAIR OF BOWEL LESION
6.00
1.00
44605
REPAIR OF BOWEL LESION
29.73
1.00
44605
REPAIR OF BOWEL LESION
29.82
1.00
44605
REPAIR OF BOWEL LESION
32.74
1.00
44615
INTESTINAL STRICTUROPLASTY
6.00
1.00
44615
INTESTINAL STRICTUROPLASTY
24.21
1.00
44615
INTESTINAL STRICTUROPLASTY
24.31
1.00
44615
INTESTINAL STRICTUROPLASTY
26.97
1.00
44620
REPAIR BOWEL OPENING
5.00
1.00
44620
REPAIR BOWEL OPENING
18.73
1.00
44620
REPAIR BOWEL OPENING
18.81
1.00
44620
REPAIR BOWEL OPENING
21.49
1.00
44625
REPAIR BOWEL OPENING
5.00
1.00
44625
REPAIR BOWEL OPENING
22.84
1.00
44625
REPAIR BOWEL OPENING
22.95
1.00
44625
REPAIR BOWEL OPENING
25.47
1.00
44626
REPAIR BOWEL OPENING
6.00
1.00
44626
REPAIR BOWEL OPENING
37.98
1.00
44626
REPAIR BOWEL OPENING
38.24
1.00
44626
REPAIR BOWEL OPENING
40.59
1.00
44640
REPAIR BOWEL-SKIN FISTULA
5.00
1.00
44640
REPAIR BOWEL-SKIN FISTULA
31.93
1.00
44640
REPAIR BOWEL-SKIN FISTULA
32.00
1.00
44640
REPAIR BOWEL-SKIN FISTULA
35.39
1.00
44650
REPAIR BOWEL FISTULA
6.00
1.00
44650
REPAIR BOWEL FISTULA
33.19
1.00
44650
REPAIR BOWEL FISTULA
33.27
1.00
44650
REPAIR BOWEL FISTULA
36.82
1.00
44660
REPAIR BOWEL-BLADDER FISTULA
6.00
1.00
44660
REPAIR BOWEL-BLADDER FISTULA
31.06
1.00
Procedure Code Description
RVU
RVU Coeff Value
44660
REPAIR BOWEL-BLADDER FISTULA
31.10
1.00
44660
REPAIR BOWEL-BLADDER FISTULA
35.49
1.00
44661
REPAIR BOWEL-BLADDER FISTULA
6.00
1.00
44661
REPAIR BOWEL-BLADDER FISTULA
36.14
1.00
44661
REPAIR BOWEL-BLADDER FISTULA
36.22
1.00
44661
REPAIR BOWEL-BLADDER FISTULA
39.90
1.00
44680
SURGICAL REVISION, INTESTINE
5.00
1.00
44680
SURGICAL REVISION, INTESTINE
23.41
1.00
44680
SURGICAL REVISION, INTESTINE
23.51
1.00
44680
SURGICAL REVISION, INTESTINE
26.62
1.00
44700
SUSPEND BOWEL W/PROSTHESIS
6.00
1.00
44700
SUSPEND BOWEL W/PROSTHESIS
24.20
1.00
44700
SUSPEND BOWEL W/PROSTHESIS
24.24
1.00
44700
SUSPEND BOWEL W/PROSTHESIS
25.74
1.00
44701
INTRAOP COLON LAVAGE ADD-ON
4.35
1.00
44701
INTRAOP COLON LAVAGE ADD-ON
4.38
1.00
44701
INTRAOP COLON LAVAGE ADD-ON
4.41
1.00
44800
EXCISION OF BOWEL POUCH
5.00
1.00
44800
EXCISION OF BOWEL POUCH
17.84
1.00
44800
EXCISION OF BOWEL POUCH
17.98
1.00
44800
EXCISION OF BOWEL POUCH
18.99
1.00
44820
EXCISION OF MESENTERY LESION
6.00
1.00
44820
EXCISION OF MESENTERY LESION
18.75
1.00
44820
EXCISION OF MESENTERY LESION
18.84
1.00
44820
EXCISION OF MESENTERY LESION
20.95
1.00
44850
REPAIR OF MESENTERY
6.00
1.00
44850
REPAIR OF MESENTERY
16.86
1.00
44850
REPAIR OF MESENTERY
16.95
1.00
44850
REPAIR OF MESENTERY
18.48
1.00
44900
DRAIN APP ABSCESS, OPEN
5.00
1.00
44900
DRAIN APP ABSCESS, OPEN
15.85
1.00
44900
DRAIN APP ABSCESS, OPEN
15.87
1.00
44900
DRAIN APP ABSCESS, OPEN
18.90
1.00
44901
DRAIN APP ABSCESS, PERCUT
4.00
1.00
44901
DRAIN APP ABSCESS, PERCUT
4.70
1.00
Procedure Code Description
RVU
RVU Coeff Value
44901
DRAIN APP ABSCESS, PERCUT
4.83
1.00
44901
DRAIN APP ABSCESS, PERCUT
8.06
1.00
44950
APPENDECTOMY
6.00
1.00
44950
APPENDECTOMY
15.38
1.00
44950
APPENDECTOMY
15.40
1.00
44950
APPENDECTOMY
16.07
1.00
44955
APPENDECTOMY ADD-ON
2.19
1.00
44955
APPENDECTOMY ADD-ON
2.24
1.00
44955
APPENDECTOMY ADD-ON
2.25
1.00
44960
APPENDECTOMY
6.00
1.00
44960
APPENDECTOMY
18.95
1.00
44960
APPENDECTOMY
19.01
1.00
44960
APPENDECTOMY
21.59
1.00
44970
LAPAROSCOPY, APPENDECTOMY
6.00
1.00
44970
LAPAROSCOPY, APPENDECTOMY
13.80
1.00
44970
LAPAROSCOPY, APPENDECTOMY
13.98
1.00
44970
LAPAROSCOPY, APPENDECTOMY
14.76
1.00
45000
DRAINAGE OF PELVIC ABSCESS
4.00
1.00
45000
DRAINAGE OF PELVIC ABSCESS
7.94
1.00
45000
DRAINAGE OF PELVIC ABSCESS
7.97
1.00
45000
DRAINAGE OF PELVIC ABSCESS
10.23
1.00
45005
DRAINAGE OF RECTAL ABSCESS
3.74
1.00
45005
DRAINAGE OF RECTAL ABSCESS
3.83
1.00
45005
DRAINAGE OF RECTAL ABSCESS
3.90
1.00
45005
DRAINAGE OF RECTAL ABSCESS
5.00
1.00
45020
DRAINAGE OF RECTAL ABSCESS
5.00
1.00
45020
DRAINAGE OF RECTAL ABSCESS
8.51
1.00
45020
DRAINAGE OF RECTAL ABSCESS
13.30
1.00
45100
BIOPSY OF RECTUM
4.00
1.00
45100
BIOPSY OF RECTUM
6.46
1.00
45100
BIOPSY OF RECTUM
6.50
1.00
45100
BIOPSY OF RECTUM
7.14
1.00
45108
REMOVAL OF ANORECTAL LESION
4.00
1.00
45108
REMOVAL OF ANORECTAL LESION
8.21
1.00
45108
REMOVAL OF ANORECTAL LESION
8.24
1.00
Procedure Code Description
RVU
RVU Coeff Value
45108
REMOVAL OF ANORECTAL LESION
8.70
1.00
45110
REMOVAL OF RECTUM
6.00
1.00
45110
REMOVAL OF RECTUM
42.77
1.00
45110
REMOVAL OF RECTUM
43.19
1.00
45110
REMOVAL OF RECTUM
46.27
1.00
45111
PARTIAL REMOVAL OF RECTUM
6.00
1.00
45111
PARTIAL REMOVAL OF RECTUM
25.43
1.00
45111
PARTIAL REMOVAL OF RECTUM
25.60
1.00
45111
PARTIAL REMOVAL OF RECTUM
27.21
1.00
45112
REMOVAL OF RECTUM
7.00
1.00
45112
REMOVAL OF RECTUM
44.96
1.00
45112
REMOVAL OF RECTUM
45.14
1.00
45112
REMOVAL OF RECTUM
47.65
1.00
45113
PARTIAL PROCTECTOMY
7.00
1.00
45113
PARTIAL PROCTECTOMY
45.69
1.00
45113
PARTIAL PROCTECTOMY
45.79
1.00
45113
PARTIAL PROCTECTOMY
48.87
1.00
45114
PARTIAL REMOVAL OF RECTUM
7.00
1.00
45114
PARTIAL REMOVAL OF RECTUM
40.79
1.00
45114
PARTIAL REMOVAL OF RECTUM
41.04
1.00
45114
PARTIAL REMOVAL OF RECTUM
44.68
1.00
45116
PARTIAL REMOVAL OF RECTUM
7.00
1.00
45116
PARTIAL REMOVAL OF RECTUM
36.80
1.00
45116
PARTIAL REMOVAL OF RECTUM
37.03
1.00
45116
PARTIAL REMOVAL OF RECTUM
40.10
1.00
45119
REMOVE RECTUM W/RESERVOIR
7.00
1.00
45119
REMOVE RECTUM W/RESERVOIR
45.82
1.00
45119
REMOVE RECTUM W/RESERVOIR
45.90
1.00
45119
REMOVE RECTUM W/RESERVOIR
48.89
1.00
45120
REMOVAL OF RECTUM
7.00
1.00
45120
REMOVAL OF RECTUM
37.19
1.00
45120
REMOVAL OF RECTUM
37.50
1.00
45120
REMOVAL OF RECTUM
39.15
1.00
45121
REMOVAL OF RECTUM AND COLON
7.00
1.00
45121
REMOVAL OF RECTUM AND COLON
41.04
1.00
Procedure Code Description
RVU
RVU Coeff Value
45121
REMOVAL OF RECTUM AND COLON
41.39
1.00
45121
REMOVAL OF RECTUM AND COLON
42.86
1.00
45123
PARTIAL PROCTECTOMY
6.00
1.00
45123
PARTIAL PROCTECTOMY
24.77
1.00
45123
PARTIAL PROCTECTOMY
24.83
1.00
45123
PARTIAL PROCTECTOMY
27.70
1.00
45126
PELVIC EXENTERATION
8.00
1.00
45126
PELVIC EXENTERATION
67.80
1.00
45126
PELVIC EXENTERATION
68.37
1.00
45126
PELVIC EXENTERATION
72.05
1.00
45130
EXCISION OF RECTAL PROLAPSE
4.00
1.00
45130
EXCISION OF RECTAL PROLAPSE
24.49
1.00
45130
EXCISION OF RECTAL PROLAPSE
24.57
1.00
45130
EXCISION OF RECTAL PROLAPSE
27.08
1.00
45135
EXCISION OF RECTAL PROLAPSE
6.00
1.00
45135
EXCISION OF RECTAL PROLAPSE
29.34
1.00
45135
EXCISION OF RECTAL PROLAPSE
29.56
1.00
45135
EXCISION OF RECTAL PROLAPSE
33.22
1.00
45136
EXCISE ILEOANAL RESERVIOR
4.00
1.00
45136
EXCISE ILEOANAL RESERVIOR
42.33
1.00
45136
EXCISE ILEOANAL RESERVIOR
43.06
1.00
45136
EXCISE ILEOANAL RESERVIOR
45.85
1.00
45150
EXCISION OF RECTAL STRICTURE
4.00
1.00
45150
EXCISION OF RECTAL STRICTURE
9.19
1.00
45150
EXCISION OF RECTAL STRICTURE
9.21
1.00
45150
EXCISION OF RECTAL STRICTURE
9.88
1.00
45160
EXCISION OF RECTAL LESION
6.00
1.00
45160
EXCISION OF RECTAL LESION
23.17
1.00
45160
EXCISION OF RECTAL LESION
23.27
1.00
45160
EXCISION OF RECTAL LESION
24.67
1.00
45170
EXCISION OF RECTAL LESION
4.00
1.00
45170
EXCISION OF RECTAL LESION
17.77
1.00
45170
EXCISION OF RECTAL LESION
17.81
1.00
45170
EXCISION OF RECTAL LESION
19.30
1.00
45190
DESTRUCTION, RECTAL TUMOR
4.00
1.00
Procedure Code Description
RVU
RVU Coeff Value
45190
DESTRUCTION, RECTAL TUMOR
15.33
1.00
45190
DESTRUCTION, RECTAL TUMOR
15.62
1.00
45190
DESTRUCTION, RECTAL TUMOR
16.79
1.00
45300
PROCTOSIGMOIDOSCOPY DX
0.66
1.00
45300
PROCTOSIGMOIDOSCOPY DX
0.75
1.00
45300
PROCTOSIGMOIDOSCOPY DX
1.26
1.00
45300
PROCTOSIGMOIDOSCOPY DX
4.00
1.00
45303
PROCTOSIGMOIDOSCOPY DILATE
0.76
1.00
45303
PROCTOSIGMOIDOSCOPY DILATE
0.86
1.00
45303
PROCTOSIGMOIDOSCOPY DILATE
2.14
1.00
45303
PROCTOSIGMOIDOSCOPY DILATE
4.00
1.00
45305
PROCTOSIGMOIDOSCOPY W/BX
1.55
1.00
45305
PROCTOSIGMOIDOSCOPY W/BX
1.64
1.00
45305
PROCTOSIGMOIDOSCOPY W/BX
1.95
1.00
45305
PROCTOSIGMOIDOSCOPY W/BX
4.00
1.00
45307
PROCTOSIGMOIDOSCOPY FB
1.51
1.00
45307
PROCTOSIGMOIDOSCOPY FB
1.62
1.00
45307
PROCTOSIGMOIDOSCOPY FB
2.45
1.00
45307
PROCTOSIGMOIDOSCOPY FB
4.00
1.00
45308
PROCTOSIGMOIDOSCOPY REMOVAL
1.35
1.00
45308
PROCTOSIGMOIDOSCOPY REMOVAL
1.45
1.00
45308
PROCTOSIGMOIDOSCOPY REMOVAL
2.08
1.00
45308
PROCTOSIGMOIDOSCOPY REMOVAL
4.00
1.00
45309
PROCTOSIGMOIDOSCOPY REMOVAL
2.46
1.00
45309
PROCTOSIGMOIDOSCOPY REMOVAL
2.97
1.00
45309
PROCTOSIGMOIDOSCOPY REMOVAL
3.08
1.00
45309
PROCTOSIGMOIDOSCOPY REMOVAL
4.00
1.00
45315
PROCTOSIGMOIDOSCOPY REMOVAL
2.19
1.00
45315
PROCTOSIGMOIDOSCOPY REMOVAL
2.29
1.00
45315
PROCTOSIGMOIDOSCOPY REMOVAL
2.76
1.00
45315
PROCTOSIGMOIDOSCOPY REMOVAL
4.00
1.00
45317
PROCTOSIGMOIDOSCOPY BLEED
2.32
1.00
45317
PROCTOSIGMOIDOSCOPY BLEED
2.42
1.00
45317
PROCTOSIGMOIDOSCOPY BLEED
2.90
1.00
45317
PROCTOSIGMOIDOSCOPY BLEED
4.00
1.00
Procedure Code Description
RVU
RVU Coeff Value
45320
PROCTOSIGMOIDOSCOPY ABLATE
2.44
1.00
45320
PROCTOSIGMOIDOSCOPY ABLATE
2.55
1.00
45320
PROCTOSIGMOIDOSCOPY ABLATE
2.77
1.00
45320
PROCTOSIGMOIDOSCOPY ABLATE
4.00
1.00
45321
PROCTOSIGMOIDOSCOPY VOLVUL
1.85
1.00
45321
PROCTOSIGMOIDOSCOPY VOLVUL
1.96
1.00
45321
PROCTOSIGMOIDOSCOPY VOLVUL
2.67
1.00
45321
PROCTOSIGMOIDOSCOPY VOLVUL
4.00
1.00
45327
PROCTOSIGMOIDOSCOPY W/STENT
2.47
1.00
45327
PROCTOSIGMOIDOSCOPY W/STENT
2.61
1.00
45327
PROCTOSIGMOIDOSCOPY W/STENT
3.12
1.00
45327
PROCTOSIGMOIDOSCOPY W/STENT
5.00
1.00
45330
DIAGNOSTIC SIGMOIDOSCOPY
1.53
1.00
45330
DIAGNOSTIC SIGMOIDOSCOPY
1.54
1.00
45330
DIAGNOSTIC SIGMOIDOSCOPY
1.64
1.00
45330
DIAGNOSTIC SIGMOIDOSCOPY
4.00
1.00
45331
SIGMOIDOSCOPY AND BIOPSY
1.75
1.00
45331
SIGMOIDOSCOPY AND BIOPSY
1.86
1.00
45331
SIGMOIDOSCOPY AND BIOPSY
1.99
1.00
45331
SIGMOIDOSCOPY AND BIOPSY
4.00
1.00
45332
SIGMOIDOSCOPY W/FB REMOVAL
2.65
1.00
45332
SIGMOIDOSCOPY W/FB REMOVAL
2.77
1.00
45332
SIGMOIDOSCOPY W/FB REMOVAL
2.92
1.00
45332
SIGMOIDOSCOPY W/FB REMOVAL
4.00
1.00
45333
SIGMOIDOSCOPY & POLYPECTOMY
2.66
1.00
45333
SIGMOIDOSCOPY & POLYPECTOMY
2.78
1.00
45333
SIGMOIDOSCOPY & POLYPECTOMY
2.90
1.00
45333
SIGMOIDOSCOPY & POLYPECTOMY
4.00
1.00
45334
SIGMOIDOSCOPY FOR BLEEDING
3.97
1.00
45334
SIGMOIDOSCOPY FOR BLEEDING
4.00
1.00
45334
SIGMOIDOSCOPY FOR BLEEDING
4.10
1.00
45334
SIGMOIDOSCOPY FOR BLEEDING
4.39
1.00
45335
SIGMOIDOSCOPY W/SUBMUC INJ
2.08
1.00
45335
SIGMOIDOSCOPY W/SUBMUC INJ
2.22
1.00
45335
SIGMOIDOSCOPY W/SUBMUC INJ
2.42
1.00
Procedure Code Description
RVU
RVU Coeff Value
45337
SIGMOIDOSCOPY & DECOMPRESS
3.46
1.00
45337
SIGMOIDOSCOPY & DECOMPRESS
3.59
1.00
45337
SIGMOIDOSCOPY & DECOMPRESS
3.77
1.00
45337
SIGMOIDOSCOPY & DECOMPRESS
4.00
1.00
45338
SIGMOIDOSCOPY W/TUMR REMOVE
3.44
1.00
45338
SIGMOIDOSCOPY W/TUMR REMOVE
3.57
1.00
45338
SIGMOIDOSCOPY W/TUMR REMOVE
3.77
1.00
45338
SIGMOIDOSCOPY W/TUMR REMOVE
4.00
1.00
45339
SIGMOIDOSCOPY W/ABLATE TUMR
4.00
1.00
45339
SIGMOIDOSCOPY W/ABLATE TUMR
4.54
1.00
45339
SIGMOIDOSCOPY W/ABLATE TUMR
4.67
1.00
45339
SIGMOIDOSCOPY W/ABLATE TUMR
4.99
1.00
45340
SIG W/BALLOON DILATION
2.49
1.00
45340
SIG W/BALLOON DILATION
2.80
1.00
45340
SIG W/BALLOON DILATION
3.05
1.00
45341
SIGMOIDOSCOPY W/ULTRASOUND
3.96
1.00
45341
SIGMOIDOSCOPY W/ULTRASOUND
4.17
1.00
45341
SIGMOIDOSCOPY W/ULTRASOUND
4.19
1.00
45341
SIGMOIDOSCOPY W/ULTRASOUND
5.00
1.00
45342
SIGMOIDOSCOPY W/US GUIDE BX
5.00
1.00
45342
SIGMOIDOSCOPY W/US GUIDE BX
5.93
1.00
45342
SIGMOIDOSCOPY W/US GUIDE BX
6.10
1.00
45342
SIGMOIDOSCOPY W/US GUIDE BX
6.41
1.00
45345
SIGMOIDOSCOPY W/STENT
4.30
1.00
45345
SIGMOIDOSCOPY W/STENT
4.47
1.00
45345
SIGMOIDOSCOPY W/STENT
4.66
1.00
45345
SIGMOIDOSCOPY W/STENT
5.00
1.00
45355
SURGICAL COLONOSCOPY
4.00
1.00
45355
SURGICAL COLONOSCOPY
5.02
1.00
45355
SURGICAL COLONOSCOPY
5.22
1.00
45355
SURGICAL COLONOSCOPY
5.39
1.00
45378
DIAGNOSTIC COLONOSCOPY
4.00
1.00
45378
DIAGNOSTIC COLONOSCOPY
5.51
1.00
45378
DIAGNOSTIC COLONOSCOPY
5.62
1.00
45378
DIAGNOSTIC COLONOSCOPY
5.77
1.00
Procedure Code Description
RVU
RVU Coeff Value
45379
COLONOSCOPY W/FB REMOVAL
4.00
1.00
45379
COLONOSCOPY W/FB REMOVAL
6.84
1.00
45379
COLONOSCOPY W/FB REMOVAL
7.02
1.00
45379
COLONOSCOPY W/FB REMOVAL
7.23
1.00
45380
COLONOSCOPY AND BIOPSY
4.00
1.00
45380
COLONOSCOPY AND BIOPSY
6.46
1.00
45380
COLONOSCOPY AND BIOPSY
6.65
1.00
45380
COLONOSCOPY AND BIOPSY
6.95
1.00
45381
COLONOSCOPY, SUBMUCOUS INJ
6.11
1.00
45381
COLONOSCOPY, SUBMUCOUS INJ
6.13
1.00
45381
COLONOSCOPY, SUBMUCOUS INJ
6.57
1.00
45382
COLONOSCOPY/CONTROL BLEEDING
4.00
1.00
45382
COLONOSCOPY/CONTROL BLEEDING
8.19
1.00
45382
COLONOSCOPY/CONTROL BLEEDING
8.24
1.00
45382
COLONOSCOPY/CONTROL BLEEDING
8.87
1.00
45383
LESION REMOVAL COLONOSCOPY
4.00
1.00
45383
LESION REMOVAL COLONOSCOPY
8.52
1.00
45383
LESION REMOVAL COLONOSCOPY
8.69
1.00
45383
LESION REMOVAL COLONOSCOPY
8.94
1.00
45384
LESION REMOVE COLONOSCOPY
4.00
1.00
45384
LESION REMOVE COLONOSCOPY
6.85
1.00
45384
LESION REMOVE COLONOSCOPY
7.03
1.00
45384
LESION REMOVE COLONOSCOPY
7.22
1.00
45385
LESION REMOVAL COLONOSCOPY
4.00
1.00
45385
LESION REMOVAL COLONOSCOPY
7.72
1.00
45385
LESION REMOVAL COLONOSCOPY
7.90
1.00
45385
LESION REMOVAL COLONOSCOPY
8.25
1.00
45386
COLONOSCOPY DILATE STRICTURE
6.63
1.00
45386
COLONOSCOPY DILATE STRICTURE
6.65
1.00
45386
COLONOSCOPY DILATE STRICTURE
7.10
1.00
45387
COLONOSCOPY W/STENT
5.00
1.00
45387
COLONOSCOPY W/STENT
8.65
1.00
45387
COLONOSCOPY W/STENT
8.76
1.00
45387
COLONOSCOPY W/STENT
9.25
1.00
45391
COLONOSCOPY W/ENDOSCOPE US
7.99
1.00
Procedure Code Description
RVU
RVU Coeff Value
45392
COLONOSCOPY W/ENDOSCOPIC FNB
10.07
1.00
45395
LAP, REMOVAL OF RECTUM
50.02
1.00
45397
LAP, REMOVE RECTUM W/POUCH
54.08
1.00
45400
LAPAROSCOPIC PROC
28.84
1.00
45402
LAP PROCTOPEXY W/SIG RESECT
38.60
1.00
45500
REPAIR OF RECTUM
4.00
1.00
45500
REPAIR OF RECTUM
11.55
1.00
45500
REPAIR OF RECTUM
11.99
1.00
45500
REPAIR OF RECTUM
12.66
1.00
45505
REPAIR OF RECTUM
4.00
1.00
45505
REPAIR OF RECTUM
11.78
1.00
45505
REPAIR OF RECTUM
12.04
1.00
45505
REPAIR OF RECTUM
13.90
1.00
45520
TREATMENT OF RECTAL PROLAPSE
0.78
1.00
45520
TREATMENT OF RECTAL PROLAPSE
0.79
1.00
45520
TREATMENT OF RECTAL PROLAPSE
0.98
1.00
45520
TREATMENT OF RECTAL PROLAPSE
3.00
1.00
45540
CORRECT RECTAL PROLAPSE
5.00
1.00
45540
CORRECT RECTAL PROLAPSE
24.52
1.00
45540
CORRECT RECTAL PROLAPSE
25.34
1.00
45540
CORRECT RECTAL PROLAPSE
26.60
1.00
45541
CORRECT RECTAL PROLAPSE
4.00
1.00
45541
CORRECT RECTAL PROLAPSE
20.44
1.00
45541
CORRECT RECTAL PROLAPSE
21.06
1.00
45541
CORRECT RECTAL PROLAPSE
22.86
1.00
45550
REPAIR RECTUM/REMOVE SIGMOID
5.00
1.00
45550
REPAIR RECTUM/REMOVE SIGMOID
34.17
1.00
45550
REPAIR RECTUM/REMOVE SIGMOID
34.73
1.00
45550
REPAIR RECTUM/REMOVE SIGMOID
36.61
1.00
45560
REPAIR OF RECTOCELE
4.00
1.00
45560
REPAIR OF RECTOCELE
16.56
1.00
45560
REPAIR OF RECTOCELE
17.20
1.00
45560
REPAIR OF RECTOCELE
18.07
1.00
45562
EXPLORATION/REPAIR OF RECTUM
4.00
1.00
45562
EXPLORATION/REPAIR OF RECTUM
23.80
1.00
Procedure Code Description
RVU
RVU Coeff Value
45562
EXPLORATION/REPAIR OF RECTUM
23.83
1.00
45562
EXPLORATION/REPAIR OF RECTUM
27.73
1.00
45563
EXPLORATION/REPAIR OF RECTUM
7.00
1.00
45563
EXPLORATION/REPAIR OF RECTUM
36.21
1.00
45563
EXPLORATION/REPAIR OF RECTUM
36.26
1.00
45563
EXPLORATION/REPAIR OF RECTUM
40.30
1.00
45800
REPAIR RECT/BLADDER FISTULA
4.00
1.00
45800
REPAIR RECT/BLADDER FISTULA
26.61
1.00
45800
REPAIR RECT/BLADDER FISTULA
26.82
1.00
45800
REPAIR RECT/BLADDER FISTULA
31.07
1.00
45805
REPAIR FISTULA W/COLOSTOMY
6.00
1.00
45805
REPAIR FISTULA W/COLOSTOMY
32.12
1.00
45805
REPAIR FISTULA W/COLOSTOMY
32.16
1.00
45805
REPAIR FISTULA W/COLOSTOMY
35.07
1.00
45820
REPAIR RECTOURETHRAL FISTULA
4.00
1.00
45820
REPAIR RECTOURETHRAL FISTULA
27.56
1.00
45820
REPAIR RECTOURETHRAL FISTULA
27.80
1.00
45820
REPAIR RECTOURETHRAL FISTULA
30.76
1.00
45825
REPAIR FISTULA W/COLOSTOMY
6.00
1.00
45825
REPAIR FISTULA W/COLOSTOMY
32.30
1.00
45825
REPAIR FISTULA W/COLOSTOMY
32.35
1.00
45825
REPAIR FISTULA W/COLOSTOMY
37.17
1.00
45900
REDUCTION OF RECTAL PROLAPSE
3.00
1.00
45900
REDUCTION OF RECTAL PROLAPSE
3.80
1.00
45900
REDUCTION OF RECTAL PROLAPSE
4.34
1.00
45900
REDUCTION OF RECTAL PROLAPSE
4.90
1.00
45905
DILATION OF ANAL SPHINCTER
3.00
1.00
45905
DILATION OF ANAL SPHINCTER
3.38
1.00
45905
DILATION OF ANAL SPHINCTER
3.90
1.00
45905
DILATION OF ANAL SPHINCTER
4.17
1.00
45910
DILATION OF RECTAL NARROWING
3.00
1.00
45910
DILATION OF RECTAL NARROWING
4.06
1.00
45910
DILATION OF RECTAL NARROWING
4.63
1.00
45910
DILATION OF RECTAL NARROWING
4.93
1.00
45915
REMOVE RECTAL OBSTRUCTION
4.00
1.00
Procedure Code Description
RVU
RVU Coeff Value
45915
REMOVE RECTAL OBSTRUCTION
4.41
1.00
45915
REMOVE RECTAL OBSTRUCTION
4.52
1.00
45915
REMOVE RECTAL OBSTRUCTION
5.51
1.00
45990
SURG DX EXAM, ANORECTAL
2.74
1.00
46020
PLACEMENT OF SETON
3.00
1.00
46020
PLACEMENT OF SETON
5.03
1.00
46020
PLACEMENT OF SETON
5.45
1.00
46020
PLACEMENT OF SETON
5.50
1.00
46030
REMOVAL OF RECTAL MARKER
2.07
1.00
46030
REMOVAL OF RECTAL MARKER
2.17
1.00
46030
REMOVAL OF RECTAL MARKER
2.53
1.00
46030
REMOVAL OF RECTAL MARKER
4.00
1.00
46040
INCISION OF RECTAL ABSCESS
3.00
1.00
46040
INCISION OF RECTAL ABSCESS
8.49
1.00
46040
INCISION OF RECTAL ABSCESS
8.70
1.00
46040
INCISION OF RECTAL ABSCESS
9.79
1.00
46045
INCISION OF RECTAL ABSCESS
4.00
1.00
46045
INCISION OF RECTAL ABSCESS
7.49
1.00
46045
INCISION OF RECTAL ABSCESS
7.71
1.00
46045
INCISION OF RECTAL ABSCESS
10.04
1.00
46050
INCISION OF ANAL ABSCESS
2.18
1.00
46050
INCISION OF ANAL ABSCESS
2.29
1.00
46050
INCISION OF ANAL ABSCESS
2.62
1.00
46050
INCISION OF ANAL ABSCESS
3.00
1.00
46060
INCISION OF RECTAL ABSCESS
3.00
1.00
46060
INCISION OF RECTAL ABSCESS
9.61
1.00
46060
INCISION OF RECTAL ABSCESS
9.92
1.00
46060
INCISION OF RECTAL ABSCESS
11.08
1.00
46070
INCISION OF ANAL SEPTUM
4.00
1.00
46070
INCISION OF ANAL SEPTUM
4.92
1.00
46070
INCISION OF ANAL SEPTUM
5.38
1.00
46070
INCISION OF ANAL SEPTUM
5.67
1.00
46080
INCISION OF ANAL SPHINCTER
3.00
1.00
46080
INCISION OF ANAL SPHINCTER
3.90
1.00
46080
INCISION OF ANAL SPHINCTER
3.95
1.00
Procedure Code Description
RVU
RVU Coeff Value
46080
INCISION OF ANAL SPHINCTER
4.32
1.00
46083
INCISE EXTERNAL HEMORRHOID
2.49
1.00
46083
INCISE EXTERNAL HEMORRHOID
2.64
1.00
46083
INCISE EXTERNAL HEMORRHOID
3.05
1.00
46200
REMOVAL OF ANAL FISSURE
3.00
1.00
46200
REMOVAL OF ANAL FISSURE
6.07
1.00
46200
REMOVAL OF ANAL FISSURE
6.20
1.00
46200
REMOVAL OF ANAL FISSURE
7.38
1.00
46210
REMOVAL OF ANAL CRYPT
3.00
1.00
46210
REMOVAL OF ANAL CRYPT
5.10
1.00
46210
REMOVAL OF ANAL CRYPT
5.12
1.00
46210
REMOVAL OF ANAL CRYPT
6.21
1.00
46211
REMOVAL OF ANAL CRYPTS
3.00
1.00
46211
REMOVAL OF ANAL CRYPTS
7.50
1.00
46211
REMOVAL OF ANAL CRYPTS
7.64
1.00
46211
REMOVAL OF ANAL CRYPTS
9.05
1.00
46220
REMOVAL OF ANAL TAG
2.25
1.00
46220
REMOVAL OF ANAL TAG
2.67
1.00
46220
REMOVAL OF ANAL TAG
2.83
1.00
46220
REMOVAL OF ANAL TAG
3.00
1.00
46221
LIGATION OF HEMORRHOID(S)
3.23
1.00
46221
LIGATION OF HEMORRHOID(S)
3.30
1.00
46221
LIGATION OF HEMORRHOID(S)
4.48
1.00
46230
REMOVAL OF ANAL TAGS
3.00
1.00
46230
REMOVAL OF ANAL TAGS
4.12
1.00
46230
REMOVAL OF ANAL TAGS
4.24
1.00
46230
REMOVAL OF ANAL TAGS
4.44
1.00
46250
HEMORRHOIDECTOMY
3.00
1.00
46250
HEMORRHOIDECTOMY
6.86
1.00
46250
HEMORRHOIDECTOMY
6.97
1.00
46250
HEMORRHOIDECTOMY
7.47
1.00
46255
HEMORRHOIDECTOMY
4.00
1.00
46255
HEMORRHOIDECTOMY
7.88
1.00
46255
HEMORRHOIDECTOMY
7.98
1.00
46255
HEMORRHOIDECTOMY
8.51
1.00
Procedure Code Description
RVU
RVU Coeff Value
46257
REMOVE HEMORRHOIDS & FISSURE
4.00
1.00
46257
REMOVE HEMORRHOIDS & FISSURE
9.01
1.00
46257
REMOVE HEMORRHOIDS & FISSURE
9.04
1.00
46257
REMOVE HEMORRHOIDS & FISSURE
9.94
1.00
46258
REMOVE HEMORRHOIDS & FISTULA
4.00
1.00
46258
REMOVE HEMORRHOIDS & FISTULA
9.56
1.00
46258
REMOVE HEMORRHOIDS & FISTULA
9.80
1.00
46258
REMOVE HEMORRHOIDS & FISTULA
10.86
1.00
46260
HEMORRHOIDECTOMY
3.00
1.00
46260
HEMORRHOIDECTOMY
10.44
1.00
46260
HEMORRHOIDECTOMY
10.97
1.00
46260
HEMORRHOIDECTOMY
11.30
1.00
46261
REMOVE HEMORRHOIDS & FISSURE
4.00
1.00
46261
REMOVE HEMORRHOIDS & FISSURE
11.57
1.00
46261
REMOVE HEMORRHOIDS & FISSURE
11.82
1.00
46261
REMOVE HEMORRHOIDS & FISSURE
12.61
1.00
46262
REMOVE HEMORRHOIDS & FISTULA
4.00
1.00
46262
REMOVE HEMORRHOIDS & FISTULA
12.20
1.00
46262
REMOVE HEMORRHOIDS & FISTULA
12.52
1.00
46262
REMOVE HEMORRHOIDS & FISTULA
13.17
1.00
46270
REMOVAL OF ANAL FISTULA
3.00
1.00
46270
REMOVAL OF ANAL FISTULA
6.52
1.00
46270
REMOVAL OF ANAL FISTULA
6.64
1.00
46270
REMOVAL OF ANAL FISTULA
8.93
1.00
46275
REMOVAL OF ANAL FISTULA
3.00
1.00
46275
REMOVAL OF ANAL FISTULA
7.60
1.00
46275
REMOVAL OF ANAL FISTULA
7.72
1.00
46275
REMOVAL OF ANAL FISTULA
9.58
1.00
46280
REMOVAL OF ANAL FISTULA
3.00
1.00
46280
REMOVAL OF ANAL FISTULA
9.88
1.00
46280
REMOVAL OF ANAL FISTULA
10.17
1.00
46280
REMOVAL OF ANAL FISTULA
10.99
1.00
46285
REMOVAL OF ANAL FISTULA
4.00
1.00
46285
REMOVAL OF ANAL FISTULA
6.84
1.00
46285
REMOVAL OF ANAL FISTULA
7.03
1.00
Procedure Code Description
RVU
RVU Coeff Value
46285
REMOVAL OF ANAL FISTULA
9.43
1.00
46288
REPAIR ANAL FISTULA
4.00
1.00
46288
REPAIR ANAL FISTULA
11.56
1.00
46288
REPAIR ANAL FISTULA
11.92
1.00
46288
REPAIR ANAL FISTULA
12.99
1.00
46320
REMOVAL OF HEMORRHOID CLOT
2.63
1.00
46320
REMOVAL OF HEMORRHOID CLOT
2.69
1.00
46320
REMOVAL OF HEMORRHOID CLOT
3.00
1.00
46320
REMOVAL OF HEMORRHOID CLOT
3.29
1.00
46500
INJECTION INTO HEMORRHOID(S)
2.30
1.00
46500
INJECTION INTO HEMORRHOID(S)
2.37
1.00
46500
INJECTION INTO HEMORRHOID(S)
3.00
1.00
46500
INJECTION INTO HEMORRHOID(S)
3.04
1.00
46505
CHEMODENERVATION ANAL MUSC
5.50
1.00
46600
DIAGNOSTIC ANOSCOPY
0.69
1.00
46600
DIAGNOSTIC ANOSCOPY
0.93
1.00
46600
DIAGNOSTIC ANOSCOPY
0.97
1.00
46600
DIAGNOSTIC ANOSCOPY
3.00
1.00
46604
ANOSCOPY AND DILATION
1.69
1.00
46604
ANOSCOPY AND DILATION
1.86
1.00
46604
ANOSCOPY AND DILATION
2.06
1.00
46604
ANOSCOPY AND DILATION
4.00
1.00
46606
ANOSCOPY AND BIOPSY
1.16
1.00
46606
ANOSCOPY AND BIOPSY
1.33
1.00
46606
ANOSCOPY AND BIOPSY
1.85
1.00
46606
ANOSCOPY AND BIOPSY
4.00
1.00
46608
ANOSCOPY, REMOVE FOR BODY
2.06
1.00
46608
ANOSCOPY, REMOVE FOR BODY
2.11
1.00
46608
ANOSCOPY, REMOVE FOR BODY
2.35
1.00
46608
ANOSCOPY, REMOVE FOR BODY
4.00
1.00
46610
ANOSCOPY, REMOVE LESION
1.91
1.00
46610
ANOSCOPY, REMOVE LESION
2.04
1.00
46610
ANOSCOPY, REMOVE LESION
2.09
1.00
46610
ANOSCOPY, REMOVE LESION
4.00
1.00
46611
ANOSCOPY
2.12
1.00
Procedure Code Description
RVU
RVU Coeff Value
46611
ANOSCOPY
2.60
1.00
46611
ANOSCOPY
2.79
1.00
46611
ANOSCOPY
3.00
1.00
46612
ANOSCOPY, REMOVE LESIONS
2.53
1.00
46612
ANOSCOPY, REMOVE LESIONS
3.36
1.00
46612
ANOSCOPY, REMOVE LESIONS
3.56
1.00
46612
ANOSCOPY, REMOVE LESIONS
4.00
1.00
46614
ANOSCOPY, CONTROL BLEEDING
1.81
1.00
46614
ANOSCOPY, CONTROL BLEEDING
2.84
1.00
46614
ANOSCOPY, CONTROL BLEEDING
3.05
1.00
46614
ANOSCOPY, CONTROL BLEEDING
4.00
1.00
46615
ANOSCOPY
2.59
1.00
46615
ANOSCOPY
3.00
1.00
46615
ANOSCOPY
3.85
1.00
46615
ANOSCOPY
4.06
1.00
46700
REPAIR OF ANAL STRICTURE
5.00
1.00
46700
REPAIR OF ANAL STRICTURE
14.04
1.00
46700
REPAIR OF ANAL STRICTURE
14.33
1.00
46700
REPAIR OF ANAL STRICTURE
15.63
1.00
46705
REPAIR OF ANAL STRICTURE
5.00
1.00
46705
REPAIR OF ANAL STRICTURE
11.52
1.00
46705
REPAIR OF ANAL STRICTURE
11.69
1.00
46705
REPAIR OF ANAL STRICTURE
12.95
1.00
46706
REPR OF ANAL FISTULA W/GLUE
3.80
1.00
46706
REPR OF ANAL FISTULA W/GLUE
3.84
1.00
46706
REPR OF ANAL FISTULA W/GLUE
4.15
1.00
46710
REPR PER/VAG POUCH SNGL PROC
26.53
1.00
46712
REPR PER/VAG POUCH DBL PROC
54.39
1.00
46715
REP PERF ANOPER FISTU
4.00
1.00
46715
REP PERF ANOPER FISTU
11.75
1.00
46715
REP PERF ANOPER FISTU
12.19
1.00
46715
REP PERF ANOPER FISTU
12.80
1.00
46716
REP PERF ANOPER/VESTIB FISTU
4.00
1.00
46716
REP PERF ANOPER/VESTIB FISTU
23.75
1.00
46716
REP PERF ANOPER/VESTIB FISTU
24.60
1.00
Procedure Code Description
RVU
RVU Coeff Value
46716
REP PERF ANOPER/VESTIB FISTU
31.12
1.00
46730
CONSTRUCTION OF ABSENT ANUS
5.00
1.00
46730
CONSTRUCTION OF ABSENT ANUS
41.01
1.00
46730
CONSTRUCTION OF ABSENT ANUS
41.20
1.00
46730
CONSTRUCTION OF ABSENT ANUS
47.06
1.00
46735
CONSTRUCTION OF ABSENT ANUS
6.00
1.00
46735
CONSTRUCTION OF ABSENT ANUS
48.88
1.00
46735
CONSTRUCTION OF ABSENT ANUS
48.89
1.00
46735
CONSTRUCTION OF ABSENT ANUS
55.06
1.00
46740
CONSTRUCTION OF ABSENT ANUS
6.00
1.00
46740
CONSTRUCTION OF ABSENT ANUS
44.53
1.00
46740
CONSTRUCTION OF ABSENT ANUS
45.57
1.00
46740
CONSTRUCTION OF ABSENT ANUS
50.40
1.00
46742
REPAIR OF IMPERFORATED ANUS
4.00
1.00
46742
REPAIR OF IMPERFORATED ANUS
56.43
1.00
46742
REPAIR OF IMPERFORATED ANUS
56.46
1.00
46742
REPAIR OF IMPERFORATED ANUS
59.68
1.00
46744
REPAIR OF CLOACAL ANOMALY
4.00
1.00
46744
REPAIR OF CLOACAL ANOMALY
76.33
1.00
46744
REPAIR OF CLOACAL ANOMALY
76.46
1.00
46744
REPAIR OF CLOACAL ANOMALY
85.71
1.00
46746
REPAIR OF CLOACAL ANOMALY
4.00
1.00
46746
REPAIR OF CLOACAL ANOMALY
86.36
1.00
46746
REPAIR OF CLOACAL ANOMALY
86.63
1.00
46746
REPAIR OF CLOACAL ANOMALY
99.18
1.00
46748
REPAIR OF CLOACAL ANOMALY
4.00
1.00
46748
REPAIR OF CLOACAL ANOMALY
91.26
1.00
46748
REPAIR OF CLOACAL ANOMALY
92.73
1.00
46748
REPAIR OF CLOACAL ANOMALY
101.96
1.00
46750
REPAIR OF ANAL SPHINCTER
4.00
1.00
46750
REPAIR OF ANAL SPHINCTER
16.16
1.00
46750
REPAIR OF ANAL SPHINCTER
16.57
1.00
46750
REPAIR OF ANAL SPHINCTER
18.88
1.00
46751
REPAIR OF ANAL SPHINCTER
4.00
1.00
46751
REPAIR OF ANAL SPHINCTER
15.21
1.00
Procedure Code Description
RVU
RVU Coeff Value
46751
REPAIR OF ANAL SPHINCTER
15.71
1.00
46751
REPAIR OF ANAL SPHINCTER
15.93
1.00
46753
RECONSTRUCTION OF ANUS
3.00
1.00
46753
RECONSTRUCTION OF ANUS
12.86
1.00
46753
RECONSTRUCTION OF ANUS
12.88
1.00
46753
RECONSTRUCTION OF ANUS
14.30
1.00
46754
REMOVAL OF SUTURE FROM ANUS
3.68
1.00
46754
REMOVAL OF SUTURE FROM ANUS
4.00
1.00
46754
REMOVAL OF SUTURE FROM ANUS
4.04
1.00
46754
REMOVAL OF SUTURE FROM ANUS
5.21
1.00
46760
REPAIR OF ANAL SPHINCTER
4.00
1.00
46760
REPAIR OF ANAL SPHINCTER
22.36
1.00
46760
REPAIR OF ANAL SPHINCTER
22.56
1.00
46760
REPAIR OF ANAL SPHINCTER
26.72
1.00
46761
REPAIR OF ANAL SPHINCTER
4.00
1.00
46761
REPAIR OF ANAL SPHINCTER
20.89
1.00
46761
REPAIR OF ANAL SPHINCTER
21.25
1.00
46761
REPAIR OF ANAL SPHINCTER
23.12
1.00
46762
IMPLANT ARTIFICIAL SPHINCTER
4.00
1.00
46762
IMPLANT ARTIFICIAL SPHINCTER
19.11
1.00
46762
IMPLANT ARTIFICIAL SPHINCTER
19.14
1.00
46762
IMPLANT ARTIFICIAL SPHINCTER
22.74
1.00
46900
DESTRUCTION, ANAL LESION(S)
2.79
1.00
46900
DESTRUCTION, ANAL LESION(S)
2.86
1.00
46900
DESTRUCTION, ANAL LESION(S)
3.00
1.00
46900
DESTRUCTION, ANAL LESION(S)
3.41
1.00
46910
DESTRUCTION, ANAL LESION(S)
3.00
1.00
46910
DESTRUCTION, ANAL LESION(S)
3.13
1.00
46910
DESTRUCTION, ANAL LESION(S)
3.27
1.00
46910
DESTRUCTION, ANAL LESION(S)
3.46
1.00
46916
CRYOSURGERY, ANAL LESION(S)
3.37
1.00
46916
CRYOSURGERY, ANAL LESION(S)
3.57
1.00
46916
CRYOSURGERY, ANAL LESION(S)
3.62
1.00
46917
LASER SURGERY, ANAL LESIONS
3.17
1.00
46917
LASER SURGERY, ANAL LESIONS
3.30
1.00
Procedure Code Description
RVU
RVU Coeff Value
46917
LASER SURGERY, ANAL LESIONS
3.54
1.00
46922
EXCISION OF ANAL LESION(S)
3.00
1.00
46922
EXCISION OF ANAL LESION(S)
3.16
1.00
46922
EXCISION OF ANAL LESION(S)
3.28
1.00
46922
EXCISION OF ANAL LESION(S)
3.46
1.00
46924
DESTRUCTION, ANAL LESION(S)
4.00
1.00
46924
DESTRUCTION, ANAL LESION(S)
4.36
1.00
46924
DESTRUCTION, ANAL LESION(S)
4.44
1.00
46924
DESTRUCTION, ANAL LESION(S)
4.47
1.00
46924
DESTRUCTION, ANAL LESION(S)
4.56
1.00
46924
DESTRUCTION, ANAL LESION(S)
4.65
1.00
46930
DESTROY INTERNAL HEMORRHOIDS
3.81
1.00
46934
DESTRUCTION OF HEMORRHOIDS
4.00
1.00
46934
DESTRUCTION OF HEMORRHOIDS
6.51
1.00
46934
DESTRUCTION OF HEMORRHOIDS
7.02
1.00
46934
DESTRUCTION OF HEMORRHOIDS
7.35
1.00
46935
DESTRUCTION OF HEMORRHOIDS
3.00
1.00
46935
DESTRUCTION OF HEMORRHOIDS
3.46
1.00
46935
DESTRUCTION OF HEMORRHOIDS
3.83
1.00
46935
DESTRUCTION OF HEMORRHOIDS
3.85
1.00
46936
DESTRUCTION OF HEMORRHOIDS
3.00
1.00
46936
DESTRUCTION OF HEMORRHOIDS
6.30
1.00
46936
DESTRUCTION OF HEMORRHOIDS
6.61
1.00
46936
DESTRUCTION OF HEMORRHOIDS
7.42
1.00
46937
CRYOTHERAPY OF RECTAL LESION
4.00
1.00
46937
CRYOTHERAPY OF RECTAL LESION
4.05
1.00
46937
CRYOTHERAPY OF RECTAL LESION
4.32
1.00
46937
CRYOTHERAPY OF RECTAL LESION
4.58
1.00
46938
CRYOTHERAPY OF RECTAL LESION
4.00
1.00
46938
CRYOTHERAPY OF RECTAL LESION
7.83
1.00
46938
CRYOTHERAPY OF RECTAL LESION
8.31
1.00
46938
CRYOTHERAPY OF RECTAL LESION
8.93
1.00
46940
TREATMENT OF ANAL FISSURE
3.00
1.00
46940
TREATMENT OF ANAL FISSURE
3.30
1.00
46940
TREATMENT OF ANAL FISSURE
3.62
1.00
Procedure Code Description
RVU
RVU Coeff Value
46940
TREATMENT OF ANAL FISSURE
3.64
1.00
46942
TREATMENT OF ANAL FISSURE
2.87
1.00
46942
TREATMENT OF ANAL FISSURE
3.00
1.00
46942
TREATMENT OF ANAL FISSURE
3.23
1.00
46945
LIGATION OF HEMORRHOIDS
3.93
1.00
46945
LIGATION OF HEMORRHOIDS
4.00
1.00
46945
LIGATION OF HEMORRHOIDS
4.16
1.00
46945
LIGATION OF HEMORRHOIDS
5.14
1.00
46946
LIGATION OF HEMORRHOIDS
4.00
1.00
46946
LIGATION OF HEMORRHOIDS
4.70
1.00
46946
LIGATION OF HEMORRHOIDS
5.25
1.00
46946
LIGATION OF HEMORRHOIDS
5.45
1.00
46947
HEMORRHOIDOPEXY BY STAPLING
9.30
1.00
47000
NEEDLE BIOPSY OF LIVER
2.64
1.00
47000
NEEDLE BIOPSY OF LIVER
2.75
1.00
47000
NEEDLE BIOPSY OF LIVER
3.00
1.00
47001
NEEDLE BIOPSY, LIVER ADD-ON
2.70
1.00
47001
NEEDLE BIOPSY, LIVER ADD-ON
2.75
1.00
47001
NEEDLE BIOPSY, LIVER ADD-ON
2.77
1.00
47010
OPEN DRAINAGE, LIVER LESION
12.00
1.00
47010
OPEN DRAINAGE, LIVER LESION
25.32
1.00
47010
OPEN DRAINAGE, LIVER LESION
26.32
1.00
47010
OPEN DRAINAGE, LIVER LESION
29.62
1.00
47011
PERCUT DRAIN, LIVER LESION
5.11
1.00
47011
PERCUT DRAIN, LIVER LESION
5.32
1.00
47011
PERCUT DRAIN, LIVER LESION
8.25
1.00
47011
PERCUT DRAIN, LIVER LESION
10.00
1.00
47015
INJECT/ASPIRATE LIVER CYST
7.00
1.00
47015
INJECT/ASPIRATE LIVER CYST
23.69
1.00
47015
INJECT/ASPIRATE LIVER CYST
23.81
1.00
47015
INJECT/ASPIRATE LIVER CYST
28.14
1.00
47100
WEDGE BIOPSY OF LIVER
6.00
1.00
47100
WEDGE BIOPSY OF LIVER
18.65
1.00
47100
WEDGE BIOPSY OF LIVER
18.72
1.00
47100
WEDGE BIOPSY OF LIVER
20.69
1.00
Procedure Code Description
RVU
RVU Coeff Value
47120
PARTIAL REMOVAL OF LIVER
12.00
1.00
47120
PARTIAL REMOVAL OF LIVER
53.49
1.00
47120
PARTIAL REMOVAL OF LIVER
54.34
1.00
47120
PARTIAL REMOVAL OF LIVER
58.30
1.00
47122
EXTENSIVE REMOVAL OF LIVER
13.00
1.00
47122
EXTENSIVE REMOVAL OF LIVER
81.01
1.00
47122
EXTENSIVE REMOVAL OF LIVER
82.16
1.00
47122
EXTENSIVE REMOVAL OF LIVER
86.82
1.00
47125
PARTIAL REMOVAL OF LIVER
13.00
1.00
47125
PARTIAL REMOVAL OF LIVER
72.63
1.00
47125
PARTIAL REMOVAL OF LIVER
73.79
1.00
47125
PARTIAL REMOVAL OF LIVER
77.77
1.00
47130
PARTIAL REMOVAL OF LIVER
13.00
1.00
47130
PARTIAL REMOVAL OF LIVER
78.60
1.00
47130
PARTIAL REMOVAL OF LIVER
79.70
1.00
47130
PARTIAL REMOVAL OF LIVER
83.62
1.00
47134
PARTIAL REMOVAL, DONOR LIVER
13.00
1.00
47134
PARTIAL REMOVAL, DONOR LIVER
56.69
1.00
47135
TRANSPLANTATION OF LIVER
13.00
1.00
47135
TRANSPLANTATION OF LIVER
122.99
1.00
47135
TRANSPLANTATION OF LIVER
123.28
1.00
47135
TRANSPLANTATION OF LIVER
132.17
1.00
47136
TRANSPLANTATION OF LIVER
13.00
1.00
47136
TRANSPLANTATION OF LIVER
104.36
1.00
47136
TRANSPLANTATION OF LIVER
104.89
1.00
47136
TRANSPLANTATION OF LIVER
117.36
1.00
47300
SURGERY FOR LIVER LESION
7.00
1.00
47300
SURGERY FOR LIVER LESION
23.52
1.00
47300
SURGERY FOR LIVER LESION
23.58
1.00
47300
SURGERY FOR LIVER LESION
27.75
1.00
47350
REPAIR LIVER WOUND
13.00
1.00
47350
REPAIR LIVER WOUND
29.97
1.00
47350
REPAIR LIVER WOUND
30.02
1.00
47350
REPAIR LIVER WOUND
34.10
1.00
47360
REPAIR LIVER WOUND
13.00
1.00
Procedure Code Description
RVU
RVU Coeff Value
47360
REPAIR LIVER WOUND
40.61
1.00
47360
REPAIR LIVER WOUND
41.14
1.00
47360
REPAIR LIVER WOUND
46.34
1.00
47361
REPAIR LIVER WOUND
13.00
1.00
47361
REPAIR LIVER WOUND
69.44
1.00
47361
REPAIR LIVER WOUND
69.80
1.00
47361
REPAIR LIVER WOUND
76.26
1.00
47362
REPAIR LIVER WOUND
13.00
1.00
47362
REPAIR LIVER WOUND
28.75
1.00
47362
REPAIR LIVER WOUND
29.27
1.00
47362
REPAIR LIVER WOUND
35.32
1.00
47370
LAPARO ABLATE LIVER TUMOR RF
7.00
1.00
47370
LAPARO ABLATE LIVER TUMOR RF
28.87
1.00
47370
LAPARO ABLATE LIVER TUMOR RF
30.26
1.00
47370
LAPARO ABLATE LIVER TUMOR RF
31.24
1.00
47371
LAPARO ABLATE LIVER CRYOSURG
7.00
1.00
47371
LAPARO ABLATE LIVER CRYOSURG
28.88
1.00
47371
LAPARO ABLATE LIVER CRYOSURG
30.26
1.00
47371
LAPARO ABLATE LIVER CRYOSURG
31.83
1.00
47380
OPEN ABLATE LIVER TUMOR RF
7.00
1.00
47380
OPEN ABLATE LIVER TUMOR RF
33.39
1.00
47380
OPEN ABLATE LIVER TUMOR RF
34.86
1.00
47380
OPEN ABLATE LIVER TUMOR RF
36.48
1.00
47381
OPEN ABLATE LIVER TUMOR CRYO
7.00
1.00
47381
OPEN ABLATE LIVER TUMOR CRYO
33.92
1.00
47381
OPEN ABLATE LIVER TUMOR CRYO
35.24
1.00
47381
OPEN ABLATE LIVER TUMOR CRYO
37.17
1.00
47382
PERCUT ABLATE LIVER RF
4.00
1.00
47382
PERCUT ABLATE LIVER RF
22.58
1.00
47382
PERCUT ABLATE LIVER RF
22.64
1.00
47382
PERCUT ABLATE LIVER RF
22.79
1.00
47400
INCISION OF LIVER DUCT
7.00
1.00
47400
INCISION OF LIVER DUCT
48.19
1.00
47400
INCISION OF LIVER DUCT
48.75
1.00
47400
INCISION OF LIVER DUCT
52.60
1.00
Procedure Code Description
RVU
RVU Coeff Value
47420
INCISION OF BILE DUCT
7.00
1.00
47420
INCISION OF BILE DUCT
30.72
1.00
47420
INCISION OF BILE DUCT
30.73
1.00
47420
INCISION OF BILE DUCT
33.42
1.00
47425
INCISION OF BILE DUCT
6.00
1.00
47425
INCISION OF BILE DUCT
30.60
1.00
47425
INCISION OF BILE DUCT
30.65
1.00
47425
INCISION OF BILE DUCT
33.74
1.00
47460
INCISE BILE DUCT SPHINCTER
4.00
1.00
47460
INCISE BILE DUCT SPHINCTER
27.93
1.00
47460
INCISE BILE DUCT SPHINCTER
28.24
1.00
47460
INCISE BILE DUCT SPHINCTER
31.78
1.00
47480
INCISION OF GALLBLADDER
7.00
1.00
47480
INCISION OF GALLBLADDER
17.80
1.00
47480
INCISION OF GALLBLADDER
18.25
1.00
47480
INCISION OF GALLBLADDER
21.15
1.00
47490
INCISION OF GALLBLADDER
3.00
1.00
47490
INCISION OF GALLBLADDER
13.45
1.00
47490
INCISION OF GALLBLADDER
14.07
1.00
47490
INCISION OF GALLBLADDER
15.05
1.00
47500
INJECTION FOR LIVER X-RAYS
2.71
1.00
47500
INJECTION FOR LIVER X-RAYS
2.83
1.00
47500
INJECTION FOR LIVER X-RAYS
4.00
1.00
47505
INJECTION FOR LIVER X-RAYS
1.05
1.00
47505
INJECTION FOR LIVER X-RAYS
1.09
1.00
47510
INSERT CATHETER, BILE DUCT
4.00
1.00
47510
INSERT CATHETER, BILE DUCT
12.88
1.00
47510
INSERT CATHETER, BILE DUCT
13.26
1.00
47510
INSERT CATHETER, BILE DUCT
13.34
1.00
47511
INSERT BILE DUCT DRAIN
16.14
1.00
47511
INSERT BILE DUCT DRAIN
16.76
1.00
47511
INSERT BILE DUCT DRAIN
21.34
1.00
47511
INSERT BILE DUCT DRAIN
999.99
1.00
47525
CHANGE BILE DUCT CATHETER
3.22
1.00
47525
CHANGE BILE DUCT CATHETER
9.04
1.00
Procedure Code Description
RVU
RVU Coeff Value
47525
CHANGE BILE DUCT CATHETER
9.09
1.00
47530
REVISE/REINSERT BILE TUBE
3.00
1.00
47530
REVISE/REINSERT BILE TUBE
10.03
1.00
47530
REVISE/REINSERT BILE TUBE
10.51
1.00
47530
REVISE/REINSERT BILE TUBE
11.07
1.00
47550
BILE DUCT ENDOSCOPY ADD-ON
4.32
1.00
47550
BILE DUCT ENDOSCOPY ADD-ON
4.36
1.00
47550
BILE DUCT ENDOSCOPY ADD-ON
4.41
1.00
47552
BILIARY ENDOSCOPY THRU SKIN
5.00
1.00
47552
BILIARY ENDOSCOPY THRU SKIN
8.90
1.00
47552
BILIARY ENDOSCOPY THRU SKIN
8.94
1.00
47552
BILIARY ENDOSCOPY THRU SKIN
9.12
1.00
47553
BILIARY ENDOSCOPY THRU SKIN
5.00
1.00
47553
BILIARY ENDOSCOPY THRU SKIN
9.10
1.00
47553
BILIARY ENDOSCOPY THRU SKIN
9.29
1.00
47553
BILIARY ENDOSCOPY THRU SKIN
9.30
1.00
47554
BILIARY ENDOSCOPY THRU SKIN
5.00
1.00
47554
BILIARY ENDOSCOPY THRU SKIN
13.24
1.00
47554
BILIARY ENDOSCOPY THRU SKIN
13.32
1.00
47554
BILIARY ENDOSCOPY THRU SKIN
13.47
1.00
47555
BILIARY ENDOSCOPY THRU SKIN
5.00
1.00
47555
BILIARY ENDOSCOPY THRU SKIN
10.92
1.00
47555
BILIARY ENDOSCOPY THRU SKIN
10.96
1.00
47555
BILIARY ENDOSCOPY THRU SKIN
10.98
1.00
47556
BILIARY ENDOSCOPY THRU SKIN
12.33
1.00
47556
BILIARY ENDOSCOPY THRU SKIN
12.34
1.00
47556
BILIARY ENDOSCOPY THRU SKIN
12.35
1.00
47556
BILIARY ENDOSCOPY THRU SKIN
999.99
1.00
47560
LAPAROSCOPY W/CHOLANGIO
6.00
1.00
47560
LAPAROSCOPY W/CHOLANGIO
6.98
1.00
47560
LAPAROSCOPY W/CHOLANGIO
7.22
1.00
47560
LAPAROSCOPY W/CHOLANGIO
7.30
1.00
47561
LAPARO W/CHOLANGIO/BIOPSY
6.00
1.00
47561
LAPARO W/CHOLANGIO/BIOPSY
7.56
1.00
47561
LAPARO W/CHOLANGIO/BIOPSY
7.80
1.00
Procedure Code Description
RVU
RVU Coeff Value
47561
LAPARO W/CHOLANGIO/BIOPSY
7.89
1.00
47562
LAPAROSCOPIC CHOLECYSTECTOMY
6.00
1.00
47562
LAPAROSCOPIC CHOLECYSTECTOMY
17.23
1.00
47562
LAPAROSCOPIC CHOLECYSTECTOMY
17.43
1.00
47562
LAPAROSCOPIC CHOLECYSTECTOMY
18.41
1.00
47563
LAPARO CHOLECYSTECTOMY/GRAPH
6.00
1.00
47563
LAPARO CHOLECYSTECTOMY/GRAPH
18.42
1.00
47563
LAPARO CHOLECYSTECTOMY/GRAPH
18.70
1.00
47563
LAPARO CHOLECYSTECTOMY/GRAPH
18.87
1.00
47564
LAPARO CHOLECYSTECTOMY/EXPLR
6.00
1.00
47564
LAPARO CHOLECYSTECTOMY/EXPLR
21.75
1.00
47564
LAPARO CHOLECYSTECTOMY/EXPLR
21.82
1.00
47564
LAPARO CHOLECYSTECTOMY/EXPLR
21.92
1.00
47570
LAPARO CHOLECYSTOENTEROSTOMY
6.00
1.00
47570
LAPARO CHOLECYSTOENTEROSTOMY
19.36
1.00
47570
LAPARO CHOLECYSTOENTEROSTOMY
19.47
1.00
47570
LAPARO CHOLECYSTOENTEROSTOMY
19.49
1.00
47600
REMOVAL OF GALLBLADDER
7.00
1.00
47600
REMOVAL OF GALLBLADDER
21.16
1.00
47600
REMOVAL OF GALLBLADDER
21.41
1.00
47600
REMOVAL OF GALLBLADDER
26.29
1.00
47605
REMOVAL OF GALLBLADDER
7.00
1.00
47605
REMOVAL OF GALLBLADDER
22.73
1.00
47605
REMOVAL OF GALLBLADDER
22.97
1.00
47605
REMOVAL OF GALLBLADDER
24.43
1.00
47610
REMOVAL OF GALLBLADDER
7.00
1.00
47610
REMOVAL OF GALLBLADDER
28.72
1.00
47610
REMOVAL OF GALLBLADDER
29.02
1.00
47610
REMOVAL OF GALLBLADDER
31.31
1.00
47612
REMOVAL OF GALLBLADDER
7.00
1.00
47612
REMOVAL OF GALLBLADDER
28.62
1.00
47612
REMOVAL OF GALLBLADDER
28.83
1.00
47612
REMOVAL OF GALLBLADDER
31.62
1.00
47620
REMOVAL OF GALLBLADDER
7.00
1.00
47620
REMOVAL OF GALLBLADDER
31.33
1.00
Procedure Code Description
RVU
RVU Coeff Value
47620
REMOVAL OF GALLBLADDER
31.53
1.00
47620
REMOVAL OF GALLBLADDER
34.34
1.00
47630
REMOVE BILE DUCT STONE
7.00
1.00
47630
REMOVE BILE DUCT STONE
12.65
1.00
47630
REMOVE BILE DUCT STONE
14.45
1.00
47630
REMOVE BILE DUCT STONE
15.24
1.00
47700
EXPLORATION OF BILE DUCTS
7.00
1.00
47700
EXPLORATION OF BILE DUCTS
24.77
1.00
47700
EXPLORATION OF BILE DUCTS
25.53
1.00
47700
EXPLORATION OF BILE DUCTS
26.08
1.00
47701
BILE DUCT REVISION
7.00
1.00
47701
BILE DUCT REVISION
42.97
1.00
47701
BILE DUCT REVISION
43.87
1.00
47701
BILE DUCT REVISION
44.90
1.00
47711
EXCISION OF BILE DUCT TUMOR
7.00
1.00
47711
EXCISION OF BILE DUCT TUMOR
35.40
1.00
47711
EXCISION OF BILE DUCT TUMOR
36.03
1.00
47711
EXCISION OF BILE DUCT TUMOR
38.86
1.00
47712
EXCISION OF BILE DUCT TUMOR
7.00
1.00
47712
EXCISION OF BILE DUCT TUMOR
45.91
1.00
47712
EXCISION OF BILE DUCT TUMOR
46.54
1.00
47712
EXCISION OF BILE DUCT TUMOR
49.76
1.00
47715
EXCISION OF BILE DUCT CYST
7.00
1.00
47715
EXCISION OF BILE DUCT CYST
29.14
1.00
47715
EXCISION OF BILE DUCT CYST
29.18
1.00
47715
EXCISION OF BILE DUCT CYST
32.64
1.00
47716
FUSION OF BILE DUCT CYST
7.00
1.00
47716
FUSION OF BILE DUCT CYST
26.00
1.00
47716
FUSION OF BILE DUCT CYST
26.05
1.00
47716
FUSION OF BILE DUCT CYST
26.39
1.00
47719
FUSION OF BILE DUCT CYST
29.07
1.00
47720
FUSE GALLBLADDER & BOWEL
7.00
1.00
47720
FUSE GALLBLADDER & BOWEL
25.08
1.00
47720
FUSE GALLBLADDER & BOWEL
25.76
1.00
47720
FUSE GALLBLADDER & BOWEL
28.19
1.00
Procedure Code Description
RVU
RVU Coeff Value
47721
FUSE UPPER GI STRUCTURES
7.00
1.00
47721
FUSE UPPER GI STRUCTURES
29.69
1.00
47721
FUSE UPPER GI STRUCTURES
30.35
1.00
47721
FUSE UPPER GI STRUCTURES
33.27
1.00
47740
FUSE GALLBLADDER & BOWEL
7.00
1.00
47740
FUSE GALLBLADDER & BOWEL
28.82
1.00
47740
FUSE GALLBLADDER & BOWEL
29.47
1.00
47740
FUSE GALLBLADDER & BOWEL
32.14
1.00
47741
FUSE GALLBLADDER & BOWEL
7.00
1.00
47741
FUSE GALLBLADDER & BOWEL
32.86
1.00
47741
FUSE GALLBLADDER & BOWEL
33.49
1.00
47741
FUSE GALLBLADDER & BOWEL
36.44
1.00
47760
FUSE BILE DUCTS AND BOWEL
7.00
1.00
47760
FUSE BILE DUCTS AND BOWEL
39.40
1.00
47760
FUSE BILE DUCTS AND BOWEL
39.99
1.00
47760
FUSE BILE DUCTS AND BOWEL
54.55
1.00
47765
FUSE LIVER DUCTS & BOWEL
7.00
1.00
47765
FUSE LIVER DUCTS & BOWEL
38.36
1.00
47765
FUSE LIVER DUCTS & BOWEL
39.43
1.00
47765
FUSE LIVER DUCTS & BOWEL
71.56
1.00
47780
FUSE BILE DUCTS AND BOWEL
7.00
1.00
47780
FUSE BILE DUCTS AND BOWEL
40.48
1.00
47780
FUSE BILE DUCTS AND BOWEL
40.94
1.00
47780
FUSE BILE DUCTS AND BOWEL
59.56
1.00
47785
FUSE BILE DUCTS AND BOWEL
7.00
1.00
47785
FUSE BILE DUCTS AND BOWEL
47.38
1.00
47785
FUSE BILE DUCTS AND BOWEL
48.36
1.00
47785
FUSE BILE DUCTS AND BOWEL
77.47
1.00
47800
RECONSTRUCTION OF BILE DUCTS
7.00
1.00
47800
RECONSTRUCTION OF BILE DUCTS
35.75
1.00
47800
RECONSTRUCTION OF BILE DUCTS
36.40
1.00
47800
RECONSTRUCTION OF BILE DUCTS
39.24
1.00
47801
PLACEMENT, BILE DUCT SUPPORT
7.00
1.00
47801
PLACEMENT, BILE DUCT SUPPORT
24.31
1.00
47801
PLACEMENT, BILE DUCT SUPPORT
25.89
1.00
Procedure Code Description 47801
PLACEMENT, BILE DUCT SUPPORT
47802
RVU
RVU Coeff Value
27.43
1.00
FUSE LIVER DUCT & INTESTINE
7.00
1.00
47802
FUSE LIVER DUCT & INTESTINE
33.50
1.00
47802
FUSE LIVER DUCT & INTESTINE
34.52
1.00
47802
FUSE LIVER DUCT & INTESTINE
37.64
1.00
47900
SUTURE BILE DUCT INJURY
7.00
1.00
47900
SUTURE BILE DUCT INJURY
30.79
1.00
47900
SUTURE BILE DUCT INJURY
31.46
1.00
47900
SUTURE BILE DUCT INJURY
33.95
1.00
48000
DRAINAGE OF ABDOMEN
7.00
1.00
48000
DRAINAGE OF ABDOMEN
41.20
1.00
48000
DRAINAGE OF ABDOMEN
41.79
1.00
48000
DRAINAGE OF ABDOMEN
46.98
1.00
48001
PLACEMENT OF DRAIN, PANCREAS
4.00
1.00
48001
PLACEMENT OF DRAIN, PANCREAS
51.64
1.00
48001
PLACEMENT OF DRAIN, PANCREAS
52.05
1.00
48001
PLACEMENT OF DRAIN, PANCREAS
57.88
1.00
48005
RESECT/DEBRIDE PANCREAS
7.00
1.00
48005
RESECT/DEBRIDE PANCREAS
61.42
1.00
48005
RESECT/DEBRIDE PANCREAS
61.47
1.00
48005
RESECT/DEBRIDE PANCREAS
64.24
1.00
48020
REMOVAL OF PANCREATIC STONE
7.00
1.00
48020
REMOVAL OF PANCREATIC STONE
24.44
1.00
48020
REMOVAL OF PANCREATIC STONE
24.67
1.00
48020
REMOVAL OF PANCREATIC STONE
28.98
1.00
48100
BIOPSY OF PANCREAS, OPEN
7.00
1.00
48100
BIOPSY OF PANCREAS, OPEN
19.16
1.00
48100
BIOPSY OF PANCREAS, OPEN
20.14
1.00
48100
BIOPSY OF PANCREAS, OPEN
22.00
1.00
48102
NEEDLE BIOPSY, PANCREAS
7.00
1.00
48102
NEEDLE BIOPSY, PANCREAS
7.02
1.00
48102
NEEDLE BIOPSY, PANCREAS
7.26
1.00
48102
NEEDLE BIOPSY, PANCREAS
7.36
1.00
48105
RESECT/DEBRIDE PANCREAS
71.26
1.00
48120
REMOVAL OF PANCREAS LESION
7.00
1.00
Procedure Code Description
RVU
RVU Coeff Value
48120
REMOVAL OF PANCREAS LESION
24.36
1.00
48120
REMOVAL OF PANCREAS LESION
24.56
1.00
48120
REMOVAL OF PANCREAS LESION
27.50
1.00
48140
PARTIAL REMOVAL OF PANCREAS
7.00
1.00
48140
PARTIAL REMOVAL OF PANCREAS
35.07
1.00
48140
PARTIAL REMOVAL OF PANCREAS
35.57
1.00
48140
PARTIAL REMOVAL OF PANCREAS
38.95
1.00
48145
PARTIAL REMOVAL OF PANCREAS
7.00
1.00
48145
PARTIAL REMOVAL OF PANCREAS
36.60
1.00
48145
PARTIAL REMOVAL OF PANCREAS
37.45
1.00
48145
PARTIAL REMOVAL OF PANCREAS
40.46
1.00
48146
PANCREATECTOMY
8.00
1.00
48146
PANCREATECTOMY
41.38
1.00
48146
PANCREATECTOMY
42.12
1.00
48146
PANCREATECTOMY
46.14
1.00
48148
REMOVAL OF PANCREATIC DUCT
7.00
1.00
48148
REMOVAL OF PANCREATIC DUCT
26.93
1.00
48148
REMOVAL OF PANCREATIC DUCT
27.93
1.00
48148
REMOVAL OF PANCREATIC DUCT
30.63
1.00
48150
PARTIAL REMOVAL OF PANCREAS
7.00
1.00
48150
PARTIAL REMOVAL OF PANCREAS
72.92
1.00
48150
PARTIAL REMOVAL OF PANCREAS
73.81
1.00
48150
PARTIAL REMOVAL OF PANCREAS
78.01
1.00
48152
PANCREATECTOMY
8.00
1.00
48152
PANCREATECTOMY
66.94
1.00
48152
PANCREATECTOMY
68.07
1.00
48152
PANCREATECTOMY
72.12
1.00
48153
PANCREATECTOMY
8.00
1.00
48153
PANCREATECTOMY
72.87
1.00
48153
PANCREATECTOMY
73.87
1.00
48153
PANCREATECTOMY
77.90
1.00
48154
PANCREATECTOMY
8.00
1.00
48154
PANCREATECTOMY
67.36
1.00
48154
PANCREATECTOMY
68.33
1.00
48154
PANCREATECTOMY
72.31
1.00
Procedure Code Description
RVU
RVU Coeff Value
48155
REMOVAL OF PANCREAS
7.00
1.00
48155
REMOVAL OF PANCREAS
39.19
1.00
48155
REMOVAL OF PANCREAS
40.42
1.00
48155
REMOVAL OF PANCREAS
44.72
1.00
48180
FUSE PANCREAS AND BOWEL
7.00
1.00
48180
FUSE PANCREAS AND BOWEL
37.60
1.00
48180
FUSE PANCREAS AND BOWEL
37.81
1.00
48180
FUSE PANCREAS AND BOWEL
38.12
1.00
48500
SURGERY OF PANCREATIC CYST
7.00
1.00
48500
SURGERY OF PANCREATIC CYST
23.87
1.00
48500
SURGERY OF PANCREATIC CYST
24.29
1.00
48500
SURGERY OF PANCREATIC CYST
28.02
1.00
48510
DRAIN PANCREATIC PSEUDOCYST
7.00
1.00
48510
DRAIN PANCREATIC PSEUDOCYST
22.87
1.00
48510
DRAIN PANCREATIC PSEUDOCYST
23.12
1.00
48510
DRAIN PANCREATIC PSEUDOCYST
26.58
1.00
48511
DRAIN PANCREATIC PSEUDOCYST
4.00
1.00
48511
DRAIN PANCREATIC PSEUDOCYST
5.51
1.00
48511
DRAIN PANCREATIC PSEUDOCYST
5.76
1.00
48511
DRAIN PANCREATIC PSEUDOCYST
7.89
1.00
48520
FUSE PANCREAS CYST AND BOWEL
7.00
1.00
48520
FUSE PANCREAS CYST AND BOWEL
24.02
1.00
48520
FUSE PANCREAS CYST AND BOWEL
24.21
1.00
48520
FUSE PANCREAS CYST AND BOWEL
27.18
1.00
48540
FUSE PANCREAS CYST AND BOWEL
7.00
1.00
48540
FUSE PANCREAS CYST AND BOWEL
30.05
1.00
48540
FUSE PANCREAS CYST AND BOWEL
30.16
1.00
48540
FUSE PANCREAS CYST AND BOWEL
32.53
1.00
48545
PANCREATORRHAPHY
7.00
1.00
48545
PANCREATORRHAPHY
28.14
1.00
48545
PANCREATORRHAPHY
28.47
1.00
48545
PANCREATORRHAPHY
32.85
1.00
48547
DUODENAL EXCLUSION
7.00
1.00
48547
DUODENAL EXCLUSION
38.92
1.00
48547
DUODENAL EXCLUSION
39.11
1.00
Procedure Code Description
RVU
RVU Coeff Value
48547
DUODENAL EXCLUSION
44.37
1.00
48548
FUSE PANCREAS AND BOWEL
41.59
1.00
48554
TRANSPL ALLOGRAFT PANCREAS
7.00
1.00
48554
TRANSPL ALLOGRAFT PANCREAS
49.41
1.00
48554
TRANSPL ALLOGRAFT PANCREAS
55.42
1.00
48554
TRANSPL ALLOGRAFT PANCREAS
61.61
1.00
48556
REMOVAL, ALLOGRAFT PANCREAS
7.00
1.00
48556
REMOVAL, ALLOGRAFT PANCREAS
25.69
1.00
48556
REMOVAL, ALLOGRAFT PANCREAS
25.81
1.00
48556
REMOVAL, ALLOGRAFT PANCREAS
30.69
1.00
49000
EXPLORATION OF ABDOMEN
5.00
1.00
49000
EXPLORATION OF ABDOMEN
18.49
1.00
49000
EXPLORATION OF ABDOMEN
18.91
1.00
49000
EXPLORATION OF ABDOMEN
19.37
1.00
49002
REOPENING OF ABDOMEN
5.00
1.00
49002
REOPENING OF ABDOMEN
16.82
1.00
49002
REOPENING OF ABDOMEN
17.51
1.00
49002
REOPENING OF ABDOMEN
25.18
1.00
49010
EXPLORATION BEHIND ABDOMEN
6.00
1.00
49010
EXPLORATION BEHIND ABDOMEN
19.68
1.00
49010
EXPLORATION BEHIND ABDOMEN
20.43
1.00
49010
EXPLORATION BEHIND ABDOMEN
23.87
1.00
49020
DRAIN ABDOMINAL ABSCESS
6.00
1.00
49020
DRAIN ABDOMINAL ABSCESS
34.63
1.00
49020
DRAIN ABDOMINAL ABSCESS
35.56
1.00
49020
DRAIN ABDOMINAL ABSCESS
39.61
1.00
49021
DRAIN ABDOMINAL ABSCESS
4.00
1.00
49021
DRAIN ABDOMINAL ABSCESS
4.68
1.00
49021
DRAIN ABDOMINAL ABSCESS
4.86
1.00
49021
DRAIN ABDOMINAL ABSCESS
8.82
1.00
49040
DRAIN, OPEN, ABDOM ABSCESS
7.00
1.00
49040
DRAIN, OPEN, ABDOM ABSCESS
20.98
1.00
49040
DRAIN, OPEN, ABDOM ABSCESS
22.55
1.00
49040
DRAIN, OPEN, ABDOM ABSCESS
24.80
1.00
49041
DRAIN, PERCUT, ABDOM ABSCESS
4.00
1.00
Procedure Code Description
RVU
RVU Coeff Value
49041
DRAIN, PERCUT, ABDOM ABSCESS
5.52
1.00
49041
DRAIN, PERCUT, ABDOM ABSCESS
5.75
1.00
49041
DRAIN, PERCUT, ABDOM ABSCESS
9.79
1.00
49060
DRAIN, OPEN, RETROP ABSCESS
7.00
1.00
49060
DRAIN, OPEN, RETROP ABSCESS
24.25
1.00
49060
DRAIN, OPEN, RETROP ABSCESS
26.21
1.00
49060
DRAIN, OPEN, RETROP ABSCESS
27.71
1.00
49061
DRAIN, PERCUT, RETROPER ABSC
4.00
1.00
49061
DRAIN, PERCUT, RETROPER ABSC
5.08
1.00
49061
DRAIN, PERCUT, RETROPER ABSC
5.11
1.00
49061
DRAIN, PERCUT, RETROPER ABSC
5.12
1.00
49061
DRAIN, PERCUT, RETROPER ABSC
5.18
1.00
49061
DRAIN, PERCUT, RETROPER ABSC
5.32
1.00
49061
DRAIN, PERCUT, RETROPER ABSC
9.49
1.00
49062
DRAIN TO PERITONEAL CAVITY
4.00
1.00
49062
DRAIN TO PERITONEAL CAVITY
18.14
1.00
49062
DRAIN TO PERITONEAL CAVITY
18.91
1.00
49062
DRAIN TO PERITONEAL CAVITY
19.51
1.00
49080
PUNCTURE, PERITONEAL CAVITY
1.88
1.00
49080
PUNCTURE, PERITONEAL CAVITY
1.89
1.00
49080
PUNCTURE, PERITONEAL CAVITY
1.90
1.00
49080
PUNCTURE, PERITONEAL CAVITY
1.94
1.00
49080
PUNCTURE, PERITONEAL CAVITY
7.00
1.00
49081
REMOVAL OF ABDOMINAL FLUID
1.83
1.00
49081
REMOVAL OF ABDOMINAL FLUID
1.90
1.00
49081
REMOVAL OF ABDOMINAL FLUID
4.00
1.00
49085
REMOVE ABDOMEN FOREIGN BODY
7.00
1.00
49085
REMOVE ABDOMEN FOREIGN BODY
18.74
1.00
49085
REMOVE ABDOMEN FOREIGN BODY
19.25
1.00
49085
REMOVE ABDOMEN FOREIGN BODY
19.58
1.00
49180
BIOPSY, ABDOMINAL MASS
2.39
1.00
49180
BIOPSY, ABDOMINAL MASS
2.40
1.00
49180
BIOPSY, ABDOMINAL MASS
2.49
1.00
49180
BIOPSY, ABDOMINAL MASS
5.00
1.00
49200
REMOVAL OF ABDOMINAL LESION
5.00
1.00
Procedure Code Description
RVU
RVU Coeff Value
49200
REMOVAL OF ABDOMINAL LESION
16.42
1.00
49200
REMOVAL OF ABDOMINAL LESION
17.16
1.00
49200
REMOVAL OF ABDOMINAL LESION
17.44
1.00
49201
REMOVE ABDOM LESION, COMPLEX
6.00
1.00
49201
REMOVE ABDOM LESION, COMPLEX
23.69
1.00
49201
REMOVE ABDOM LESION, COMPLEX
24.43
1.00
49201
REMOVE ABDOM LESION, COMPLEX
24.87
1.00
49203
EXC ABD TUM 5 CM OR LESS
30.30
1.00
49204
EXC ABD TUM OVER 5 CM
38.70
1.00
49205
EXC ABD TUM OVER 10 CM
44.32
1.00
49215
EXCISE SACRAL SPINE TUMOR
6.00
1.00
49215
EXCISE SACRAL SPINE TUMOR
50.53
1.00
49215
EXCISE SACRAL SPINE TUMOR
50.72
1.00
49215
EXCISE SACRAL SPINE TUMOR
55.61
1.00
49220
MULTIPLE SURGERY, ABDOMEN
6.00
1.00
49220
MULTIPLE SURGERY, ABDOMEN
23.37
1.00
49220
MULTIPLE SURGERY, ABDOMEN
24.02
1.00
49220
MULTIPLE SURGERY, ABDOMEN
24.20
1.00
49250
EXCISION OF UMBILICUS
6.00
1.00
49250
EXCISION OF UMBILICUS
13.68
1.00
49250
EXCISION OF UMBILICUS
14.27
1.00
49250
EXCISION OF UMBILICUS
14.45
1.00
49255
REMOVAL OF OMENTUM
5.00
1.00
49255
REMOVAL OF OMENTUM
18.13
1.00
49255
REMOVAL OF OMENTUM
18.75
1.00
49255
REMOVAL OF OMENTUM
19.60
1.00
49320
DIAG LAPARO SEPARATE PROC
6.00
1.00
49320
DIAG LAPARO SEPARATE PROC
8.29
1.00
49320
DIAG LAPARO SEPARATE PROC
8.33
1.00
49320
DIAG LAPARO SEPARATE PROC
8.61
1.00
49321
LAPAROSCOPY, BIOPSY
6.00
1.00
49321
LAPAROSCOPY, BIOPSY
8.68
1.00
49321
LAPAROSCOPY, BIOPSY
8.73
1.00
49321
LAPAROSCOPY, BIOPSY
8.92
1.00
49322
LAPAROSCOPY, ASPIRATION
6.00
1.00
Procedure Code Description
RVU
RVU Coeff Value
49322
LAPAROSCOPY, ASPIRATION
9.37
1.00
49322
LAPAROSCOPY, ASPIRATION
9.47
1.00
49322
LAPAROSCOPY, ASPIRATION
9.69
1.00
49323
LAPARO DRAIN LYMPHOCELE
6.00
1.00
49323
LAPARO DRAIN LYMPHOCELE
14.39
1.00
49323
LAPARO DRAIN LYMPHOCELE
15.05
1.00
49323
LAPARO DRAIN LYMPHOCELE
16.08
1.00
49324
LAP INSERTION PERM IP CATH
9.85
1.00
49325
LAP REVISION PERM IP CATH
10.60
1.00
49326
LAP W/OMENTOPEXY ADD-ON
4.89
1.00
49400
AIR INJECTION INTO ABDOMEN
2.71
1.00
49400
AIR INJECTION INTO ABDOMEN
2.79
1.00
49400
AIR INJECTION INTO ABDOMEN
2.80
1.00
49400
AIR INJECTION INTO ABDOMEN
6.00
1.00
49402
REMOVE FOREIGN BODY, ADBOMEN
21.35
1.00
49419
INSRT ABDOM CATH FOR CHEMOTX
10.86
1.00
49419
INSRT ABDOM CATH FOR CHEMOTX
11.01
1.00
49419
INSRT ABDOM CATH FOR CHEMOTX
11.42
1.00
49420
INSERT ABDOM DRAIN, TEMP
3.32
1.00
49420
INSERT ABDOM DRAIN, TEMP
3.50
1.00
49420
INSERT ABDOM DRAIN, TEMP
3.61
1.00
49420
INSERT ABDOM DRAIN, TEMP
4.00
1.00
49421
INSERT ABDOM DRAIN, PERM
4.00
1.00
49421
INSERT ABDOM DRAIN, PERM
9.39
1.00
49421
INSERT ABDOM DRAIN, PERM
9.81
1.00
49421
INSERT ABDOM DRAIN, PERM
10.15
1.00
49422
REMOVE PERM CANNULA/CATHETER
4.00
1.00
49422
REMOVE PERM CANNULA/CATHETER
9.81
1.00
49422
REMOVE PERM CANNULA/CATHETER
9.86
1.00
49422
REMOVE PERM CANNULA/CATHETER
9.91
1.00
49423
EXCHANGE DRAINAGE CATHETER
2.06
1.00
49423
EXCHANGE DRAINAGE CATHETER
2.09
1.00
49423
EXCHANGE DRAINAGE CATHETER
2.15
1.00
49423
EXCHANGE DRAINAGE CATHETER
2.21
1.00
49423
EXCHANGE DRAINAGE CATHETER
4.00
1.00
Procedure Code Description
RVU
RVU Coeff Value
49424
ASSESS CYST, CONTRAST INJECT
1.08
1.00
49424
ASSESS CYST, CONTRAST INJECT
1.10
1.00
49424
ASSESS CYST, CONTRAST INJECT
1.12
1.00
49424
ASSESS CYST, CONTRAST INJECT
1.23
1.00
49424
ASSESS CYST, CONTRAST INJECT
1.24
1.00
49425
INSERT ABDOMEN-VENOUS DRAIN
4.00
1.00
49425
INSERT ABDOMEN-VENOUS DRAIN
18.46
1.00
49425
INSERT ABDOMEN-VENOUS DRAIN
19.23
1.00
49425
INSERT ABDOMEN-VENOUS DRAIN
19.27
1.00
49426
REVISE ABDOMEN-VENOUS SHUNT
7.00
1.00
49426
REVISE ABDOMEN-VENOUS SHUNT
15.56
1.00
49426
REVISE ABDOMEN-VENOUS SHUNT
16.37
1.00
49426
REVISE ABDOMEN-VENOUS SHUNT
16.63
1.00
49427
INJECTION, ABDOMINAL SHUNT
1.30
1.00
49427
INJECTION, ABDOMINAL SHUNT
1.42
1.00
49427
INJECTION, ABDOMINAL SHUNT
1.43
1.00
49428
LIGATION OF SHUNT
4.00
1.00
49428
LIGATION OF SHUNT
9.53
1.00
49428
LIGATION OF SHUNT
9.71
1.00
49428
LIGATION OF SHUNT
11.00
1.00
49429
REMOVAL OF SHUNT
4.00
1.00
49429
REMOVAL OF SHUNT
11.65
1.00
49429
REMOVAL OF SHUNT
11.67
1.00
49429
REMOVAL OF SHUNT
11.81
1.00
49435
INSERT SUBQ EXTEN TO IP CATH
3.13
1.00
49436
EMBEDDED IP CATH EXIT-SITE
4.58
1.00
49440
PLACE GASTROSTOMY TUBE PERC
6.58
1.00
49441
PLACE DUOD/JEJ TUBE PERC
7.18
1.00
49442
PLACE CECOSTOMY TUBE PERC
5.93
1.00
49446
CHANGE G-TUBE TO G-J PERC
4.77
1.00
49450
REPLACE G/C TUBE PERC
1.88
1.00
49450
REPLACE G/C TUBE PERC
1.91
1.00
49451
REPLACE DUOD/JEJ TUBE PERC
2.59
1.00
49451
REPLACE DUOD/JEJ TUBE PERC
2.66
1.00
49452
REPLACE G-J TUBE PERC
4.04
1.00
Procedure Code Description
RVU
RVU Coeff Value
49452
REPLACE G-J TUBE PERC
4.15
1.00
49460
FIX G/COLON TUBE W/DEVICE
1.36
1.00
49465
FLUORO EXAM OF G/COLON TUBE
0.89
1.00
49491
RPR HERN PREEMIE REDUC
4.00
1.00
49491
RPR HERN PREEMIE REDUC
17.51
1.00
49491
RPR HERN PREEMIE REDUC
17.74
1.00
49491
RPR HERN PREEMIE REDUC
19.28
1.00
49492
RPR ING HERN PREMIE, BLOCKED
4.00
1.00
49492
RPR ING HERN PREMIE, BLOCKED
21.78
1.00
49492
RPR ING HERN PREMIE, BLOCKED
21.92
1.00
49492
RPR ING HERN PREMIE, BLOCKED
23.58
1.00
49495
RPR ING HERNIA BABY, REDUC
4.00
1.00
49495
RPR ING HERNIA BABY, REDUC
9.58
1.00
49495
RPR ING HERNIA BABY, REDUC
9.82
1.00
49495
RPR ING HERNIA BABY, REDUC
9.95
1.00
49496
RPR ING HERNIA BABY, BLOCKED
4.00
1.00
49496
RPR ING HERNIA BABY, BLOCKED
14.26
1.00
49496
RPR ING HERNIA BABY, BLOCKED
14.88
1.00
49496
RPR ING HERNIA BABY, BLOCKED
15.82
1.00
49500
RPR ING HERNIA, INIT, REDUCE
4.00
1.00
49500
RPR ING HERNIA, INIT, REDUCE
9.17
1.00
49500
RPR ING HERNIA, INIT, REDUCE
9.28
1.00
49500
RPR ING HERNIA, INIT, REDUCE
9.77
1.00
49501
RPR ING HERNIA, INIT BLOCKED
4.00
1.00
49501
RPR ING HERNIA, INIT BLOCKED
14.03
1.00
49501
RPR ING HERNIA, INIT BLOCKED
14.07
1.00
49501
RPR ING HERNIA, INIT BLOCKED
14.79
1.00
49505
PRP I/HERN INIT REDUC >5 YR
4.00
1.00
49505
PRP I/HERN INIT REDUC >5 YR
12.24
1.00
49505
PRP I/HERN INIT REDUC >5 YR
12.26
1.00
49505
PRP I/HERN INIT REDUC >5 YR
12.84
1.00
49507
PRP I/HERN INIT BLOCK >5 YR
4.00
1.00
49507
PRP I/HERN INIT BLOCK >5 YR
15.10
1.00
49507
PRP I/HERN INIT BLOCK >5 YR
15.80
1.00
49507
PRP I/HERN INIT BLOCK >5 YR
16.41
1.00
Procedure Code Description
RVU
RVU Coeff Value
49520
REREPAIR ING HERNIA, REDUCE
4.00
1.00
49520
REREPAIR ING HERNIA, REDUCE
15.12
1.00
49520
REREPAIR ING HERNIA, REDUCE
15.69
1.00
49520
REREPAIR ING HERNIA, REDUCE
15.81
1.00
49521
REREPAIR ING HERNIA, BLOCKED
4.00
1.00
49521
REREPAIR ING HERNIA, BLOCKED
18.48
1.00
49521
REREPAIR ING HERNIA, BLOCKED
18.69
1.00
49521
REREPAIR ING HERNIA, BLOCKED
19.14
1.00
49525
REPAIR ING HERNIA, SLIDING
4.00
1.00
49525
REPAIR ING HERNIA, SLIDING
13.58
1.00
49525
REPAIR ING HERNIA, SLIDING
14.14
1.00
49525
REPAIR ING HERNIA, SLIDING
14.18
1.00
49540
REPAIR LUMBAR HERNIA
4.00
1.00
49540
REPAIR LUMBAR HERNIA
16.27
1.00
49540
REPAIR LUMBAR HERNIA
16.78
1.00
49540
REPAIR LUMBAR HERNIA
16.80
1.00
49550
RPR REM HERNIA, INIT, REDUCE
4.00
1.00
49550
RPR REM HERNIA, INIT, REDUCE
13.68
1.00
49550
RPR REM HERNIA, INIT, REDUCE
13.80
1.00
49550
RPR REM HERNIA, INIT, REDUCE
14.25
1.00
49553
RPR FEM HERNIA, INIT BLOCKED
4.00
1.00
49553
RPR FEM HERNIA, INIT BLOCKED
14.89
1.00
49553
RPR FEM HERNIA, INIT BLOCKED
15.11
1.00
49553
RPR FEM HERNIA, INIT BLOCKED
15.59
1.00
49555
REREPAIR FEM HERNIA, REDUCE
4.00
1.00
49555
REREPAIR FEM HERNIA, REDUCE
14.29
1.00
49555
REREPAIR FEM HERNIA, REDUCE
14.84
1.00
49555
REREPAIR FEM HERNIA, REDUCE
14.99
1.00
49557
REREPAIR FEM HERNIA, BLOCKED
4.00
1.00
49557
REREPAIR FEM HERNIA, BLOCKED
17.33
1.00
49557
REREPAIR FEM HERNIA, BLOCKED
17.54
1.00
49557
REREPAIR FEM HERNIA, BLOCKED
18.02
1.00
49560
RPR VENTRAL HERN INIT, REDUC
4.00
1.00
49560
RPR VENTRAL HERN INIT, REDUC
17.97
1.00
49560
RPR VENTRAL HERN INIT, REDUC
18.43
1.00
Procedure Code Description
RVU
RVU Coeff Value
49560
RPR VENTRAL HERN INIT, REDUC
18.52
1.00
49561
RPR VENTRAL HERN INIT, BLOCK
6.00
1.00
49561
RPR VENTRAL HERN INIT, BLOCK
21.82
1.00
49561
RPR VENTRAL HERN INIT, BLOCK
22.01
1.00
49561
RPR VENTRAL HERN INIT, BLOCK
23.23
1.00
49565
REREPAIR VENTRL HERN, REDUCE
4.00
1.00
49565
REREPAIR VENTRL HERN, REDUCE
18.04
1.00
49565
REREPAIR VENTRL HERN, REDUCE
18.68
1.00
49565
REREPAIR VENTRL HERN, REDUCE
19.09
1.00
49566
REREPAIR VENTRL HERN, BLOCK
6.00
1.00
49566
REREPAIR VENTRL HERN, BLOCK
22.06
1.00
49566
REREPAIR VENTRL HERN, BLOCK
22.24
1.00
49566
REREPAIR VENTRL HERN, BLOCK
23.47
1.00
49568
HERNIA REPAIR W/MESH
6.00
1.00
49568
HERNIA REPAIR W/MESH
6.94
1.00
49568
HERNIA REPAIR W/MESH
7.10
1.00
49568
HERNIA REPAIR W/MESH
7.16
1.00
49570
RPR EPIGASTRIC HERN, REDUCE
4.00
1.00
49570
RPR EPIGASTRIC HERN, REDUCE
9.48
1.00
49570
RPR EPIGASTRIC HERN, REDUCE
9.62
1.00
49570
RPR EPIGASTRIC HERN, REDUCE
10.09
1.00
49572
RPR EPIGASTRIC HERN, BLOCKED
6.00
1.00
49572
RPR EPIGASTRIC HERN, BLOCKED
10.92
1.00
49572
RPR EPIGASTRIC HERN, BLOCKED
11.22
1.00
49572
RPR EPIGASTRIC HERN, BLOCKED
12.48
1.00
49580
RPR UMBIL HERN, REDUC < 5 YR
5.00
1.00
49580
RPR UMBIL HERN, REDUC < 5 YR
7.15
1.00
49580
RPR UMBIL HERN, REDUC < 5 YR
7.37
1.00
49580
RPR UMBIL HERN, REDUC < 5 YR
7.85
1.00
49582
RPR UMBIL HERN, BLOCK < 5 YR
4.00
1.00
49582
RPR UMBIL HERN, BLOCK < 5 YR
10.86
1.00
49582
RPR UMBIL HERN, BLOCK < 5 YR
11.67
1.00
49582
RPR UMBIL HERN, BLOCK < 5 YR
12.08
1.00
49585
RPR UMBIL HERN, REDUC > 5 YR
4.00
1.00
49585
RPR UMBIL HERN, REDUC > 5 YR
10.21
1.00
Procedure Code Description
RVU
RVU Coeff Value
49585
RPR UMBIL HERN, REDUC > 5 YR
10.80
1.00
49585
RPR UMBIL HERN, REDUC > 5 YR
10.85
1.00
49587
RPR UMBIL HERN, BLOCK > 5 YR
4.00
1.00
49587
RPR UMBIL HERN, BLOCK > 5 YR
12.11
1.00
49587
RPR UMBIL HERN, BLOCK > 5 YR
12.36
1.00
49587
RPR UMBIL HERN, BLOCK > 5 YR
12.86
1.00
49590
REPAIR SPIGELIAN HERNIA
4.00
1.00
49590
REPAIR SPIGELIAN HERNIA
13.55
1.00
49590
REPAIR SPIGELIAN HERNIA
14.13
1.00
49600
REPAIR UMBILICAL LESION
5.00
1.00
49600
REPAIR UMBILICAL LESION
17.69
1.00
49600
REPAIR UMBILICAL LESION
18.16
1.00
49600
REPAIR UMBILICAL LESION
18.19
1.00
49605
REPAIR UMBILICAL LESION
6.00
1.00
49605
REPAIR UMBILICAL LESION
107.64
1.00
49605
REPAIR UMBILICAL LESION
108.46
1.00
49605
REPAIR UMBILICAL LESION
125.57
1.00
49606
REPAIR UMBILICAL LESION
7.00
1.00
49606
REPAIR UMBILICAL LESION
28.56
1.00
49606
REPAIR UMBILICAL LESION
29.02
1.00
49606
REPAIR UMBILICAL LESION
29.88
1.00
49610
REPAIR UMBILICAL LESION
7.00
1.00
49610
REPAIR UMBILICAL LESION
16.67
1.00
49610
REPAIR UMBILICAL LESION
16.86
1.00
49610
REPAIR UMBILICAL LESION
18.04
1.00
49611
REPAIR UMBILICAL LESION
7.00
1.00
49611
REPAIR UMBILICAL LESION
15.14
1.00
49611
REPAIR UMBILICAL LESION
16.94
1.00
49611
REPAIR UMBILICAL LESION
19.21
1.00
49650
LAP ING HERNIA REPAIR INIT
6.00
1.00
49650
LAP ING HERNIA REPAIR INIT
10.14
1.00
49650
LAP ING HERNIA REPAIR INIT
10.26
1.00
49650
LAP ING HERNIA REPAIR INIT
10.60
1.00
49651
LAP ING HERNIA REPAIR RECUR
6.00
1.00
49651
LAP ING HERNIA REPAIR RECUR
13.33
1.00
Procedure Code Description
RVU
RVU Coeff Value
49651
LAP ING HERNIA REPAIR RECUR
13.36
1.00
49651
LAP ING HERNIA REPAIR RECUR
13.68
1.00
49652
LAP VENT/ABD HERNIA REPAIR
19.87
1.00
49653
LAP VENT/ABD HERN PROC COMP
24.80
1.00
49654
LAP INC HERNIA REPAIR
22.80
1.00
49655
LAP INC HERN REPAIR COMP
27.45
1.00
49656
LAP INC HERNIA REPAIR RECUR
22.89
1.00
49657
LAP INC HERN RECUR COMP
33.05
1.00
49900
REPAIR OF ABDOMINAL WALL
5.00
1.00
49900
REPAIR OF ABDOMINAL WALL
20.02
1.00
49900
REPAIR OF ABDOMINAL WALL
20.16
1.00
49900
REPAIR OF ABDOMINAL WALL
20.29
1.00
49904
OMENTAL FLAP, EXTRA-ABDOM
37.73
1.00
49904
OMENTAL FLAP, EXTRA-ABDOM
37.79
1.00
49904
OMENTAL FLAP, EXTRA-ABDOM
37.89
1.00
49905
OMENTAL FLAP, INTRA-ABDOM
9.23
1.00
49905
OMENTAL FLAP, INTRA-ABDOM
9.50
1.00
49905
OMENTAL FLAP, INTRA-ABDOM
9.58
1.00
49906
FREE OMENTAL FLAP, MICROVASC
4.00
1.00
50010
EXPLORATION OF KIDNEY
6.00
1.00
50010
EXPLORATION OF KIDNEY
17.33
1.00
50010
EXPLORATION OF KIDNEY
18.25
1.00
50010
EXPLORATION OF KIDNEY
19.65
1.00
50020
RENAL ABSCESS, OPEN DRAIN
6.00
1.00
50020
RENAL ABSCESS, OPEN DRAIN
24.41
1.00
50020
RENAL ABSCESS, OPEN DRAIN
28.02
1.00
50020
RENAL ABSCESS, OPEN DRAIN
29.20
1.00
50021
RENAL ABSCESS, PERCUT DRAIN
4.64
1.00
50021
RENAL ABSCESS, PERCUT DRAIN
4.66
1.00
50021
RENAL ABSCESS, PERCUT DRAIN
4.73
1.00
50021
RENAL ABSCESS, PERCUT DRAIN
4.85
1.00
50021
RENAL ABSCESS, PERCUT DRAIN
6.00
1.00
50021
RENAL ABSCESS, PERCUT DRAIN
13.51
1.00
50040
DRAINAGE OF KIDNEY
6.00
1.00
50040
DRAINAGE OF KIDNEY
24.33
1.00
Procedure Code Description
RVU
RVU Coeff Value
50040
DRAINAGE OF KIDNEY
26.34
1.00
50040
DRAINAGE OF KIDNEY
26.59
1.00
50045
EXPLORATION OF KIDNEY
6.00
1.00
50045
EXPLORATION OF KIDNEY
23.52
1.00
50045
EXPLORATION OF KIDNEY
24.40
1.00
50045
EXPLORATION OF KIDNEY
26.66
1.00
50060
REMOVAL OF KIDNEY STONE
6.00
1.00
50060
REMOVAL OF KIDNEY STONE
28.67
1.00
50060
REMOVAL OF KIDNEY STONE
29.57
1.00
50060
REMOVAL OF KIDNEY STONE
32.77
1.00
50065
INCISION OF KIDNEY
6.00
1.00
50065
INCISION OF KIDNEY
28.36
1.00
50065
INCISION OF KIDNEY
29.93
1.00
50065
INCISION OF KIDNEY
34.49
1.00
50070
INCISION OF KIDNEY
6.00
1.00
50070
INCISION OF KIDNEY
30.16
1.00
50070
INCISION OF KIDNEY
31.05
1.00
50070
INCISION OF KIDNEY
34.25
1.00
50075
REMOVAL OF KIDNEY STONE
6.00
1.00
50075
REMOVAL OF KIDNEY STONE
37.31
1.00
50075
REMOVAL OF KIDNEY STONE
38.46
1.00
50075
REMOVAL OF KIDNEY STONE
42.11
1.00
50080
REMOVAL OF KIDNEY STONE
7.00
1.00
50080
REMOVAL OF KIDNEY STONE
23.58
1.00
50080
REMOVAL OF KIDNEY STONE
25.04
1.00
50080
REMOVAL OF KIDNEY STONE
25.73
1.00
50081
REMOVAL OF KIDNEY STONE
7.00
1.00
50081
REMOVAL OF KIDNEY STONE
33.69
1.00
50081
REMOVAL OF KIDNEY STONE
35.33
1.00
50081
REMOVAL OF KIDNEY STONE
36.77
1.00
50100
REVISE KIDNEY BLOOD VESSELS
6.00
1.00
50100
REVISE KIDNEY BLOOD VESSELS
26.04
1.00
50100
REVISE KIDNEY BLOOD VESSELS
27.09
1.00
50100
REVISE KIDNEY BLOOD VESSELS
27.39
1.00
50120
EXPLORATION OF KIDNEY
6.00
1.00
Procedure Code Description
RVU
RVU Coeff Value
50120
EXPLORATION OF KIDNEY
24.11
1.00
50120
EXPLORATION OF KIDNEY
25.03
1.00
50120
EXPLORATION OF KIDNEY
27.16
1.00
50125
EXPLORE AND DRAIN KIDNEY
6.00
1.00
50125
EXPLORE AND DRAIN KIDNEY
24.91
1.00
50125
EXPLORE AND DRAIN KIDNEY
25.95
1.00
50125
EXPLORE AND DRAIN KIDNEY
28.14
1.00
50130
REMOVAL OF KIDNEY STONE
6.00
1.00
50130
REMOVAL OF KIDNEY STONE
25.89
1.00
50130
REMOVAL OF KIDNEY STONE
26.74
1.00
50130
REMOVAL OF KIDNEY STONE
29.69
1.00
50135
EXPLORATION OF KIDNEY
6.00
1.00
50135
EXPLORATION OF KIDNEY
28.55
1.00
50135
EXPLORATION OF KIDNEY
29.41
1.00
50135
EXPLORATION OF KIDNEY
32.15
1.00
50200
BIOPSY OF KIDNEY
3.00
1.00
50200
BIOPSY OF KIDNEY
3.67
1.00
50200
BIOPSY OF KIDNEY
3.68
1.00
50200
BIOPSY OF KIDNEY
4.06
1.00
50205
BIOPSY OF KIDNEY
6.00
1.00
50205
BIOPSY OF KIDNEY
17.66
1.00
50205
BIOPSY OF KIDNEY
18.45
1.00
50205
BIOPSY OF KIDNEY
19.03
1.00
50220
REMOVE KIDNEY, OPEN
6.00
1.00
50220
REMOVE KIDNEY, OPEN
25.96
1.00
50220
REMOVE KIDNEY, OPEN
26.88
1.00
50220
REMOVE KIDNEY, OPEN
29.27
1.00
50225
REMOVAL KIDNEY OPEN, COMPLEX
6.00
1.00
50225
REMOVAL KIDNEY OPEN, COMPLEX
30.08
1.00
50225
REMOVAL KIDNEY OPEN, COMPLEX
30.95
1.00
50225
REMOVAL KIDNEY OPEN, COMPLEX
33.88
1.00
50230
REMOVAL KIDNEY OPEN, RADICAL
6.00
1.00
50230
REMOVAL KIDNEY OPEN, RADICAL
32.50
1.00
50230
REMOVAL KIDNEY OPEN, RADICAL
33.46
1.00
50230
REMOVAL KIDNEY OPEN, RADICAL
36.71
1.00
Procedure Code Description
RVU
RVU Coeff Value
50234
REMOVAL OF KIDNEY & URETER
7.00
1.00
50234
REMOVAL OF KIDNEY & URETER
33.06
1.00
50234
REMOVAL OF KIDNEY & URETER
33.91
1.00
50234
REMOVAL OF KIDNEY & URETER
37.28
1.00
50236
REMOVAL OF KIDNEY & URETER
6.00
1.00
50236
REMOVAL OF KIDNEY & URETER
38.04
1.00
50236
REMOVAL OF KIDNEY & URETER
39.57
1.00
50236
REMOVAL OF KIDNEY & URETER
42.19
1.00
50240
PARTIAL REMOVAL OF KIDNEY
7.00
1.00
50240
PARTIAL REMOVAL OF KIDNEY
34.11
1.00
50240
PARTIAL REMOVAL OF KIDNEY
35.69
1.00
50240
PARTIAL REMOVAL OF KIDNEY
37.88
1.00
50250
CRYOABLATE RENAL MASS OPEN
35.14
1.00
50280
REMOVAL OF KIDNEY LESION
6.00
1.00
50280
REMOVAL OF KIDNEY LESION
23.73
1.00
50280
REMOVAL OF KIDNEY LESION
24.61
1.00
50280
REMOVAL OF KIDNEY LESION
27.04
1.00
50290
REMOVAL OF KIDNEY LESION
6.00
1.00
50290
REMOVAL OF KIDNEY LESION
22.70
1.00
50290
REMOVAL OF KIDNEY LESION
23.64
1.00
50290
REMOVAL OF KIDNEY LESION
25.04
1.00
50320
REMOVE KIDNEY, LIVING DONOR
6.00
1.00
50320
REMOVE KIDNEY, LIVING DONOR
34.23
1.00
50320
REMOVE KIDNEY, LIVING DONOR
34.29
1.00
50320
REMOVE KIDNEY, LIVING DONOR
37.09
1.00
50340
REMOVAL OF KIDNEY
6.00
1.00
50340
REMOVAL OF KIDNEY
20.45
1.00
50340
REMOVAL OF KIDNEY
22.37
1.00
50340
REMOVAL OF KIDNEY
22.93
1.00
50360
TRANSPLANTATION OF KIDNEY
6.00
1.00
50360
TRANSPLANTATION OF KIDNEY
50.82
1.00
50360
TRANSPLANTATION OF KIDNEY
51.93
1.00
50360
TRANSPLANTATION OF KIDNEY
62.61
1.00
50365
TRANSPLANTATION OF KIDNEY
6.00
1.00
50365
TRANSPLANTATION OF KIDNEY
59.53
1.00
Procedure Code Description
RVU
RVU Coeff Value
50365
TRANSPLANTATION OF KIDNEY
61.39
1.00
50365
TRANSPLANTATION OF KIDNEY
70.57
1.00
50370
REMOVE TRANSPLANTED KIDNEY
6.00
1.00
50370
REMOVE TRANSPLANTED KIDNEY
22.74
1.00
50370
REMOVE TRANSPLANTED KIDNEY
24.45
1.00
50370
REMOVE TRANSPLANTED KIDNEY
29.24
1.00
50380
REIMPLANTATION OF KIDNEY
6.00
1.00
50380
REIMPLANTATION OF KIDNEY
36.05
1.00
50380
REIMPLANTATION OF KIDNEY
36.16
1.00
50380
REIMPLANTATION OF KIDNEY
49.39
1.00
50382
CHANGE URETER STENT, PERCUT
8.03
1.00
50384
REMOVE URETER STENT, PERCUT
7.31
1.00
50385
CHANGE STENT VIA TRANSURETH
6.86
1.00
50386
REMOVE STENT VIA TRANSURETH
5.18
1.00
50387
CHANGE EXT/INT URETER STENT
2.91
1.00
50389
REMOVE RENAL TUBE W/FLUORO
1.60
1.00
50390
DRAINAGE OF KIDNEY LESION
2.71
1.00
50390
DRAINAGE OF KIDNEY LESION
2.83
1.00
50390
DRAINAGE OF KIDNEY LESION
5.00
1.00
50391
INSTLL RX AGNT INTO RNAL TUB
2.89
1.00
50392
INSERT KIDNEY DRAIN
4.66
1.00
50392
INSERT KIDNEY DRAIN
5.00
1.00
50392
INSERT KIDNEY DRAIN
5.19
1.00
50393
INSERT URETERAL TUBE
5.00
1.00
50393
INSERT URETERAL TUBE
5.72
1.00
50393
INSERT URETERAL TUBE
5.73
1.00
50393
INSERT URETERAL TUBE
6.33
1.00
50394
INJECTION FOR KIDNEY X-RAY
1.06
1.00
50394
INJECTION FOR KIDNEY X-RAY
1.43
1.00
50394
INJECTION FOR KIDNEY X-RAY
5.00
1.00
50395
CREATE PASSAGE TO KIDNEY
4.66
1.00
50395
CREATE PASSAGE TO KIDNEY
4.67
1.00
50395
CREATE PASSAGE TO KIDNEY
5.00
1.00
50395
CREATE PASSAGE TO KIDNEY
5.23
1.00
50396
MEASURE KIDNEY PRESSURE
3.06
1.00
Procedure Code Description
RVU
RVU Coeff Value
50396
MEASURE KIDNEY PRESSURE
3.07
1.00
50396
MEASURE KIDNEY PRESSURE
3.38
1.00
50396
MEASURE KIDNEY PRESSURE
5.00
1.00
50398
CHANGE KIDNEY TUBE
2.01
1.00
50398
CHANGE KIDNEY TUBE
2.02
1.00
50398
CHANGE KIDNEY TUBE
2.07
1.00
50398
CHANGE KIDNEY TUBE
999.99
1.00
50400
REVISION OF KIDNEY/URETER
7.00
1.00
50400
REVISION OF KIDNEY/URETER
28.65
1.00
50400
REVISION OF KIDNEY/URETER
29.90
1.00
50400
REVISION OF KIDNEY/URETER
33.09
1.00
50405
REVISION OF KIDNEY/URETER
7.00
1.00
50405
REVISION OF KIDNEY/URETER
36.05
1.00
50405
REVISION OF KIDNEY/URETER
36.82
1.00
50405
REVISION OF KIDNEY/URETER
40.18
1.00
50500
REPAIR OF KIDNEY WOUND
10.00
1.00
50500
REPAIR OF KIDNEY WOUND
30.06
1.00
50500
REPAIR OF KIDNEY WOUND
31.61
1.00
50500
REPAIR OF KIDNEY WOUND
32.25
1.00
50520
CLOSE KIDNEY-SKIN FISTULA
6.00
1.00
50520
CLOSE KIDNEY-SKIN FISTULA
27.47
1.00
50520
CLOSE KIDNEY-SKIN FISTULA
28.53
1.00
50520
CLOSE KIDNEY-SKIN FISTULA
29.76
1.00
50525
REPAIR RENAL-ABDOMEN FISTULA
6.00
1.00
50525
REPAIR RENAL-ABDOMEN FISTULA
34.22
1.00
50525
REPAIR RENAL-ABDOMEN FISTULA
35.77
1.00
50525
REPAIR RENAL-ABDOMEN FISTULA
37.17
1.00
50526
REPAIR RENAL-ABDOMEN FISTULA
13.00
1.00
50526
REPAIR RENAL-ABDOMEN FISTULA
36.81
1.00
50526
REPAIR RENAL-ABDOMEN FISTULA
38.91
1.00
50526
REPAIR RENAL-ABDOMEN FISTULA
39.07
1.00
50540
REVISION OF HORSESHOE KIDNEY
6.00
1.00
50540
REVISION OF HORSESHOE KIDNEY
29.99
1.00
50540
REVISION OF HORSESHOE KIDNEY
31.18
1.00
50540
REVISION OF HORSESHOE KIDNEY
32.41
1.00
Procedure Code Description
RVU
RVU Coeff Value
50541
LAPARO ABLATE RENAL CYST
6.00
1.00
50541
LAPARO ABLATE RENAL CYST
23.36
1.00
50541
LAPARO ABLATE RENAL CYST
23.58
1.00
50541
LAPARO ABLATE RENAL CYST
26.43
1.00
50542
LAPARO ABLATE RENAL MASS
29.70
1.00
50542
LAPARO ABLATE RENAL MASS
29.74
1.00
50542
LAPARO ABLATE RENAL MASS
33.52
1.00
50543
LAPARO PARTIAL NEPHRECTOMY
37.34
1.00
50543
LAPARO PARTIAL NEPHRECTOMY
37.37
1.00
50543
LAPARO PARTIAL NEPHRECTOMY
42.78
1.00
50544
LAPAROSCOPY, PYELOPLASTY
6.00
1.00
50544
LAPAROSCOPY, PYELOPLASTY
32.37
1.00
50544
LAPAROSCOPY, PYELOPLASTY
32.54
1.00
50544
LAPAROSCOPY, PYELOPLASTY
36.07
1.00
50545
LAPARO RADICAL NEPHRECTOMY
7.00
1.00
50545
LAPARO RADICAL NEPHRECTOMY
34.67
1.00
50545
LAPARO RADICAL NEPHRECTOMY
34.93
1.00
50545
LAPARO RADICAL NEPHRECTOMY
38.72
1.00
50546
LAPAROSCOPIC NEPHRECTOMY
6.00
1.00
50546
LAPAROSCOPIC NEPHRECTOMY
29.80
1.00
50546
LAPAROSCOPIC NEPHRECTOMY
30.40
1.00
50546
LAPAROSCOPIC NEPHRECTOMY
34.36
1.00
50547
LAPARO REMOVAL DONOR KIDNEY
6.00
1.00
50547
LAPARO REMOVAL DONOR KIDNEY
38.33
1.00
50547
LAPARO REMOVAL DONOR KIDNEY
38.36
1.00
50547
LAPARO REMOVAL DONOR KIDNEY
41.54
1.00
50548
LAPARO REMOVE W/URETER
6.00
1.00
50548
LAPARO REMOVE W/URETER
35.07
1.00
50548
LAPARO REMOVE W/URETER
35.27
1.00
50548
LAPARO REMOVE W/URETER
39.04
1.00
50551
KIDNEY ENDOSCOPY
6.00
1.00
50551
KIDNEY ENDOSCOPY
7.77
1.00
50551
KIDNEY ENDOSCOPY
7.79
1.00
50551
KIDNEY ENDOSCOPY
8.61
1.00
50553
KIDNEY ENDOSCOPY
8.34
1.00
Procedure Code Description
RVU
RVU Coeff Value
50553
KIDNEY ENDOSCOPY
8.35
1.00
50553
KIDNEY ENDOSCOPY
9.08
1.00
50555
KIDNEY ENDOSCOPY & BIOPSY
6.00
1.00
50555
KIDNEY ENDOSCOPY & BIOPSY
9.08
1.00
50555
KIDNEY ENDOSCOPY & BIOPSY
9.09
1.00
50555
KIDNEY ENDOSCOPY & BIOPSY
9.95
1.00
50557
KIDNEY ENDOSCOPY & TREATMENT
6.00
1.00
50557
KIDNEY ENDOSCOPY & TREATMENT
9.19
1.00
50557
KIDNEY ENDOSCOPY & TREATMENT
9.20
1.00
50557
KIDNEY ENDOSCOPY & TREATMENT
10.11
1.00
50559
RENAL ENDOSCOPY/RADIOTRACER
9.29
1.00
50559
RENAL ENDOSCOPY/RADIOTRACER
9.36
1.00
50561
KIDNEY ENDOSCOPY & TREATMENT
6.00
1.00
50561
KIDNEY ENDOSCOPY & TREATMENT
10.54
1.00
50561
KIDNEY ENDOSCOPY & TREATMENT
10.55
1.00
50561
KIDNEY ENDOSCOPY & TREATMENT
11.55
1.00
50562
RENAL SCOPE W/TUMOR RESECT
15.75
1.00
50562
RENAL SCOPE W/TUMOR RESECT
15.78
1.00
50562
RENAL SCOPE W/TUMOR RESECT
16.99
1.00
50570
KIDNEY ENDOSCOPY
6.00
1.00
50570
KIDNEY ENDOSCOPY
13.23
1.00
50570
KIDNEY ENDOSCOPY
13.27
1.00
50570
KIDNEY ENDOSCOPY
14.42
1.00
50572
KIDNEY ENDOSCOPY
6.00
1.00
50572
KIDNEY ENDOSCOPY
14.40
1.00
50572
KIDNEY ENDOSCOPY
14.43
1.00
50572
KIDNEY ENDOSCOPY
15.73
1.00
50574
KIDNEY ENDOSCOPY & BIOPSY
6.00
1.00
50574
KIDNEY ENDOSCOPY & BIOPSY
15.31
1.00
50574
KIDNEY ENDOSCOPY & BIOPSY
15.35
1.00
50574
KIDNEY ENDOSCOPY & BIOPSY
16.57
1.00
50575
KIDNEY ENDOSCOPY
6.00
1.00
50575
KIDNEY ENDOSCOPY
19.42
1.00
50575
KIDNEY ENDOSCOPY
19.45
1.00
50575
KIDNEY ENDOSCOPY
20.96
1.00
Procedure Code Description
RVU
RVU Coeff Value
50576
KIDNEY ENDOSCOPY & TREATMENT
6.00
1.00
50576
KIDNEY ENDOSCOPY & TREATMENT
15.25
1.00
50576
KIDNEY ENDOSCOPY & TREATMENT
15.28
1.00
50576
KIDNEY ENDOSCOPY & TREATMENT
16.55
1.00
50578
RENAL ENDOSCOPY/RADIOTRACER
6.00
1.00
50578
RENAL ENDOSCOPY/RADIOTRACER
15.75
1.00
50578
RENAL ENDOSCOPY/RADIOTRACER
15.78
1.00
50580
KIDNEY ENDOSCOPY & TREATMENT
6.00
1.00
50580
KIDNEY ENDOSCOPY & TREATMENT
16.46
1.00
50580
KIDNEY ENDOSCOPY & TREATMENT
16.48
1.00
50580
KIDNEY ENDOSCOPY & TREATMENT
17.72
1.00
50590
FRAGMENTING OF KIDNEY STONE
7.00
1.00
50590
FRAGMENTING OF KIDNEY STONE
14.57
1.00
50590
FRAGMENTING OF KIDNEY STONE
14.76
1.00
50590
FRAGMENTING OF KIDNEY STONE
16.14
1.00
50592
PERC RF ABLATE RENAL TUMOR
10.44
1.00
50593
PERC CRYO ABLATE RENAL TUM
13.25
1.00
50600
EXPLORATION OF URETER
5.00
1.00
50600
EXPLORATION OF URETER
24.00
1.00
50600
EXPLORATION OF URETER
24.94
1.00
50600
EXPLORATION OF URETER
26.82
1.00
50605
INSERT URETERAL SUPPORT
7.00
1.00
50605
INSERT URETERAL SUPPORT
23.80
1.00
50605
INSERT URETERAL SUPPORT
24.85
1.00
50605
INSERT URETERAL SUPPORT
25.95
1.00
50610
REMOVAL OF URETER STONE
5.00
1.00
50610
REMOVAL OF URETER STONE
24.44
1.00
50610
REMOVAL OF URETER STONE
25.44
1.00
50610
REMOVAL OF URETER STONE
27.47
1.00
50620
REMOVAL OF URETER STONE
5.00
1.00
50620
REMOVAL OF URETER STONE
22.86
1.00
50620
REMOVAL OF URETER STONE
23.71
1.00
50620
REMOVAL OF URETER STONE
25.96
1.00
50630
REMOVAL OF URETER STONE
5.00
1.00
50630
REMOVAL OF URETER STONE
22.57
1.00
Procedure Code Description
RVU
RVU Coeff Value
50630
REMOVAL OF URETER STONE
23.44
1.00
50630
REMOVAL OF URETER STONE
25.32
1.00
50650
REMOVAL OF URETER
5.00
1.00
50650
REMOVAL OF URETER
26.17
1.00
50650
REMOVAL OF URETER
27.31
1.00
50650
REMOVAL OF URETER
29.60
1.00
50660
REMOVAL OF URETER
6.00
1.00
50660
REMOVAL OF URETER
29.20
1.00
50660
REMOVAL OF URETER
30.31
1.00
50660
REMOVAL OF URETER
32.73
1.00
50684
INJECTION FOR URETER X-RAY
1.05
1.00
50684
INJECTION FOR URETER X-RAY
1.06
1.00
50684
INJECTION FOR URETER X-RAY
1.32
1.00
50684
INJECTION FOR URETER X-RAY
1.36
1.00
50684
INJECTION FOR URETER X-RAY
1.42
1.00
50686
MEASURE URETER PRESSURE
2.27
1.00
50686
MEASURE URETER PRESSURE
2.60
1.00
50686
MEASURE URETER PRESSURE
7.00
1.00
50688
CHANGE OF URETER TUBE/STENT
2.26
1.00
50688
CHANGE OF URETER TUBE/STENT
2.92
1.00
50688
CHANGE OF URETER TUBE/STENT
2.99
1.00
50690
INJECTION FOR URETER X-RAY
1.60
1.00
50690
INJECTION FOR URETER X-RAY
1.61
1.00
50690
INJECTION FOR URETER X-RAY
2.00
1.00
50700
REVISION OF URETER
5.00
1.00
50700
REVISION OF URETER
23.53
1.00
50700
REVISION OF URETER
24.82
1.00
50700
REVISION OF URETER
26.57
1.00
50715
RELEASE OF URETER
5.00
1.00
50715
RELEASE OF URETER
29.93
1.00
50715
RELEASE OF URETER
31.57
1.00
50715
RELEASE OF URETER
32.29
1.00
50722
RELEASE OF URETER
5.00
1.00
50722
RELEASE OF URETER
26.06
1.00
50722
RELEASE OF URETER
27.32
1.00
Procedure Code Description 50722
RELEASE OF URETER
50725
RVU
RVU Coeff Value
27.48
1.00
RELEASE/REVISE URETER
5.00
1.00
50725
RELEASE/REVISE URETER
28.51
1.00
50725
RELEASE/REVISE URETER
29.79
1.00
50725
RELEASE/REVISE URETER
31.23
1.00
50727
REVISE URETER
6.00
1.00
50727
REVISE URETER
13.99
1.00
50727
REVISE URETER
14.33
1.00
50727
REVISE URETER
14.48
1.00
50728
REVISE URETER
6.00
1.00
50728
REVISE URETER
19.77
1.00
50728
REVISE URETER
19.78
1.00
50728
REVISE URETER
20.45
1.00
50740
FUSION OF URETER & KIDNEY
5.00
1.00
50740
FUSION OF URETER & KIDNEY
28.15
1.00
50740
FUSION OF URETER & KIDNEY
29.00
1.00
50740
FUSION OF URETER & KIDNEY
30.88
1.00
50750
FUSION OF URETER & KIDNEY
5.00
1.00
50750
FUSION OF URETER & KIDNEY
29.25
1.00
50750
FUSION OF URETER & KIDNEY
30.38
1.00
50750
FUSION OF URETER & KIDNEY
33.30
1.00
50760
FUSION OF URETERS
5.00
1.00
50760
FUSION OF URETERS
27.85
1.00
50760
FUSION OF URETERS
29.04
1.00
50760
FUSION OF URETERS
31.14
1.00
50770
SPLICING OF URETERS
5.00
1.00
50770
SPLICING OF URETERS
29.24
1.00
50770
SPLICING OF URETERS
30.31
1.00
50770
SPLICING OF URETERS
32.26
1.00
50780
REIMPLANT URETER IN BLADDER
5.00
1.00
50780
REIMPLANT URETER IN BLADDER
27.64
1.00
50780
REIMPLANT URETER IN BLADDER
28.78
1.00
50780
REIMPLANT URETER IN BLADDER
31.22
1.00
50782
REIMPLANT URETER IN BLADDER
7.00
1.00
50782
REIMPLANT URETER IN BLADDER
30.69
1.00
Procedure Code Description
RVU
RVU Coeff Value
50782
REIMPLANT URETER IN BLADDER
30.70
1.00
50782
REIMPLANT URETER IN BLADDER
31.73
1.00
50783
REIMPLANT URETER IN BLADDER
7.00
1.00
50783
REIMPLANT URETER IN BLADDER
31.50
1.00
50783
REIMPLANT URETER IN BLADDER
31.93
1.00
50783
REIMPLANT URETER IN BLADDER
32.08
1.00
50785
REIMPLANT URETER IN BLADDER
5.00
1.00
50785
REIMPLANT URETER IN BLADDER
30.64
1.00
50785
REIMPLANT URETER IN BLADDER
31.78
1.00
50785
REIMPLANT URETER IN BLADDER
34.57
1.00
50800
IMPLANT URETER IN BOWEL
6.00
1.00
50800
IMPLANT URETER IN BOWEL
22.60
1.00
50800
IMPLANT URETER IN BOWEL
24.43
1.00
50800
IMPLANT URETER IN BOWEL
26.30
1.00
50810
FUSION OF URETER & BOWEL
7.00
1.00
50810
FUSION OF URETER & BOWEL
31.74
1.00
50810
FUSION OF URETER & BOWEL
34.11
1.00
50810
FUSION OF URETER & BOWEL
34.81
1.00
50815
URINE SHUNT TO INTESTINE
7.00
1.00
50815
URINE SHUNT TO INTESTINE
30.41
1.00
50815
URINE SHUNT TO INTESTINE
32.22
1.00
50815
URINE SHUNT TO INTESTINE
35.05
1.00
50820
CONSTRUCT BOWEL BLADDER
7.00
1.00
50820
CONSTRUCT BOWEL BLADDER
32.66
1.00
50820
CONSTRUCT BOWEL BLADDER
34.60
1.00
50820
CONSTRUCT BOWEL BLADDER
37.40
1.00
50825
CONSTRUCT BOWEL BLADDER
7.00
1.00
50825
CONSTRUCT BOWEL BLADDER
41.97
1.00
50825
CONSTRUCT BOWEL BLADDER
44.11
1.00
50825
CONSTRUCT BOWEL BLADDER
47.35
1.00
50830
REVISE URINE FLOW
7.00
1.00
50830
REVISE URINE FLOW
46.54
1.00
50830
REVISE URINE FLOW
48.28
1.00
50830
REVISE URINE FLOW
51.43
1.00
50840
REPLACE URETER BY BOWEL
7.00
1.00
Procedure Code Description
RVU
RVU Coeff Value
50840
REPLACE URETER BY BOWEL
30.42
1.00
50840
REPLACE URETER BY BOWEL
32.18
1.00
50840
REPLACE URETER BY BOWEL
35.25
1.00
50845
APPENDICO-VESICOSTOMY
6.00
1.00
50845
APPENDICO-VESICOSTOMY
31.25
1.00
50845
APPENDICO-VESICOSTOMY
31.77
1.00
50845
APPENDICO-VESICOSTOMY
35.79
1.00
50860
TRANSPLANT URETER TO SKIN
5.00
1.00
50860
TRANSPLANT URETER TO SKIN
23.45
1.00
50860
TRANSPLANT URETER TO SKIN
24.60
1.00
50860
TRANSPLANT URETER TO SKIN
27.14
1.00
50900
REPAIR OF URETER
6.00
1.00
50900
REPAIR OF URETER
21.14
1.00
50900
REPAIR OF URETER
22.00
1.00
50900
REPAIR OF URETER
23.88
1.00
50920
CLOSURE URETER/SKIN FISTULA
6.00
1.00
50920
CLOSURE URETER/SKIN FISTULA
22.11
1.00
50920
CLOSURE URETER/SKIN FISTULA
23.12
1.00
50920
CLOSURE URETER/SKIN FISTULA
25.19
1.00
50930
CLOSURE URETER/BOWEL FISTULA
6.00
1.00
50930
CLOSURE URETER/BOWEL FISTULA
28.77
1.00
50930
CLOSURE URETER/BOWEL FISTULA
29.77
1.00
50930
CLOSURE URETER/BOWEL FISTULA
30.48
1.00
50940
RELEASE OF URETER
7.00
1.00
50940
RELEASE OF URETER
22.37
1.00
50940
RELEASE OF URETER
23.20
1.00
50940
RELEASE OF URETER
25.42
1.00
50945
LAPAROSCOPY URETEROLITHOTOMY
6.00
1.00
50945
LAPAROSCOPY URETEROLITHOTOMY
25.14
1.00
50945
LAPAROSCOPY URETEROLITHOTOMY
25.32
1.00
50945
LAPAROSCOPY URETEROLITHOTOMY
28.19
1.00
50947
LAPARO NEW URETER/BLADDER
6.00
1.00
50947
LAPARO NEW URETER/BLADDER
36.39
1.00
50947
LAPARO NEW URETER/BLADDER
36.52
1.00
50947
LAPARO NEW URETER/BLADDER
40.04
1.00
Procedure Code Description
RVU
RVU Coeff Value
50948
LAPARO NEW URETER/BLADDER
6.00
1.00
50948
LAPARO NEW URETER/BLADDER
33.18
1.00
50948
LAPARO NEW URETER/BLADDER
33.30
1.00
50948
LAPARO NEW URETER/BLADDER
37.07
1.00
50951
ENDOSCOPY OF URETER
6.00
1.00
50951
ENDOSCOPY OF URETER
8.11
1.00
50951
ENDOSCOPY OF URETER
8.12
1.00
50951
ENDOSCOPY OF URETER
8.98
1.00
50953
ENDOSCOPY OF URETER
6.00
1.00
50953
ENDOSCOPY OF URETER
8.67
1.00
50953
ENDOSCOPY OF URETER
8.68
1.00
50953
ENDOSCOPY OF URETER
9.88
1.00
50955
URETER ENDOSCOPY & BIOPSY
6.00
1.00
50955
URETER ENDOSCOPY & BIOPSY
9.39
1.00
50955
URETER ENDOSCOPY & BIOPSY
9.42
1.00
50955
URETER ENDOSCOPY & BIOPSY
10.68
1.00
50957
URETER ENDOSCOPY & TREATMENT
6.00
1.00
50957
URETER ENDOSCOPY & TREATMENT
9.43
1.00
50957
URETER ENDOSCOPY & TREATMENT
9.44
1.00
50957
URETER ENDOSCOPY & TREATMENT
10.36
1.00
50959
URETER ENDOSCOPY & TRACER
5.98
1.00
50959
URETER ENDOSCOPY & TRACER
6.03
1.00
50961
URETER ENDOSCOPY & TREATMENT
6.00
1.00
50961
URETER ENDOSCOPY & TREATMENT
8.39
1.00
50961
URETER ENDOSCOPY & TREATMENT
8.40
1.00
50961
URETER ENDOSCOPY & TREATMENT
9.27
1.00
50970
URETER ENDOSCOPY
3.00
1.00
50970
URETER ENDOSCOPY
9.93
1.00
50970
URETER ENDOSCOPY
9.95
1.00
50970
URETER ENDOSCOPY
10.88
1.00
50972
URETER ENDOSCOPY & CATHETER
3.00
1.00
50972
URETER ENDOSCOPY & CATHETER
9.60
1.00
50972
URETER ENDOSCOPY & CATHETER
9.62
1.00
50972
URETER ENDOSCOPY & CATHETER
10.47
1.00
50974
URETER ENDOSCOPY & BIOPSY
6.00
1.00
Procedure Code Description
RVU
RVU Coeff Value
50974
URETER ENDOSCOPY & BIOPSY
12.71
1.00
50974
URETER ENDOSCOPY & BIOPSY
12.73
1.00
50974
URETER ENDOSCOPY & BIOPSY
13.86
1.00
50976
URETER ENDOSCOPY & TREATMENT
6.00
1.00
50976
URETER ENDOSCOPY & TREATMENT
12.56
1.00
50976
URETER ENDOSCOPY & TREATMENT
12.58
1.00
50976
URETER ENDOSCOPY & TREATMENT
13.66
1.00
50978
URETER ENDOSCOPY & TRACER
6.00
1.00
50978
URETER ENDOSCOPY & TRACER
7.12
1.00
50978
URETER ENDOSCOPY & TRACER
7.14
1.00
50980
URETER ENDOSCOPY & TREATMENT
6.00
1.00
50980
URETER ENDOSCOPY & TREATMENT
9.52
1.00
50980
URETER ENDOSCOPY & TREATMENT
9.53
1.00
50980
URETER ENDOSCOPY & TREATMENT
10.44
1.00
51000
DRAINAGE OF BLADDER
1.08
1.00
51000
DRAINAGE OF BLADDER
3.00
1.00
51005
DRAINAGE OF BLADDER
1.45
1.00
51005
DRAINAGE OF BLADDER
1.46
1.00
51005
DRAINAGE OF BLADDER
3.00
1.00
51010
DRAINAGE OF BLADDER
3.00
1.00
51010
DRAINAGE OF BLADDER
5.69
1.00
51010
DRAINAGE OF BLADDER
5.84
1.00
51010
DRAINAGE OF BLADDER
6.55
1.00
51020
INCISE & TREAT BLADDER
5.00
1.00
51020
INCISE & TREAT BLADDER
11.19
1.00
51020
INCISE & TREAT BLADDER
12.21
1.00
51020
INCISE & TREAT BLADDER
13.25
1.00
51030
INCISE & TREAT BLADDER
5.00
1.00
51030
INCISE & TREAT BLADDER
11.36
1.00
51030
INCISE & TREAT BLADDER
12.55
1.00
51030
INCISE & TREAT BLADDER
13.16
1.00
51040
INCISE & DRAIN BLADDER
5.00
1.00
51040
INCISE & DRAIN BLADDER
7.59
1.00
51040
INCISE & DRAIN BLADDER
8.29
1.00
51040
INCISE & DRAIN BLADDER
8.47
1.00
Procedure Code Description
RVU
RVU Coeff Value
51045
INCISE BLADDER/DRAIN URETER
5.00
1.00
51045
INCISE BLADDER/DRAIN URETER
11.39
1.00
51045
INCISE BLADDER/DRAIN URETER
12.70
1.00
51045
INCISE BLADDER/DRAIN URETER
13.22
1.00
51050
REMOVAL OF BLADDER STONE
5.00
1.00
51050
REMOVAL OF BLADDER STONE
11.17
1.00
51050
REMOVAL OF BLADDER STONE
11.87
1.00
51050
REMOVAL OF BLADDER STONE
13.45
1.00
51060
REMOVAL OF URETER STONE
5.00
1.00
51060
REMOVAL OF URETER STONE
14.11
1.00
51060
REMOVAL OF URETER STONE
15.04
1.00
51060
REMOVAL OF URETER STONE
16.57
1.00
51065
REMOVE URETER CALCULUS
5.00
1.00
51065
REMOVE URETER CALCULUS
13.95
1.00
51065
REMOVE URETER CALCULUS
14.88
1.00
51065
REMOVE URETER CALCULUS
16.46
1.00
51080
DRAINAGE OF BLADDER ABSCESS
5.00
1.00
51080
DRAINAGE OF BLADDER ABSCESS
10.03
1.00
51080
DRAINAGE OF BLADDER ABSCESS
11.45
1.00
51080
DRAINAGE OF BLADDER ABSCESS
11.53
1.00
51100
DRAIN BLADDER BY NEEDLE
1.11
1.00
51101
DRAIN BLADDER BY TROCAR/CATH
1.50
1.00
51102
DRAIN BL W/CATH INSERTION
4.36
1.00
51500
REMOVAL OF BLADDER CYST
6.00
1.00
51500
REMOVAL OF BLADDER CYST
16.26
1.00
51500
REMOVAL OF BLADDER CYST
16.87
1.00
51500
REMOVAL OF BLADDER CYST
17.83
1.00
51520
REMOVAL OF BLADDER LESION
5.00
1.00
51520
REMOVAL OF BLADDER LESION
14.77
1.00
51520
REMOVAL OF BLADDER LESION
15.74
1.00
51520
REMOVAL OF BLADDER LESION
16.71
1.00
51525
REMOVAL OF BLADDER LESION
6.00
1.00
51525
REMOVAL OF BLADDER LESION
21.23
1.00
51525
REMOVAL OF BLADDER LESION
22.10
1.00
51525
REMOVAL OF BLADDER LESION
24.56
1.00
Procedure Code Description
RVU
RVU Coeff Value
51530
REMOVAL OF BLADDER LESION
5.00
1.00
51530
REMOVAL OF BLADDER LESION
19.22
1.00
51530
REMOVAL OF BLADDER LESION
20.28
1.00
51530
REMOVAL OF BLADDER LESION
21.94
1.00
51535
REPAIR OF URETER LESION
5.00
1.00
51535
REPAIR OF URETER LESION
19.87
1.00
51535
REPAIR OF URETER LESION
21.10
1.00
51535
REPAIR OF URETER LESION
22.34
1.00
51550
PARTIAL REMOVAL OF BLADDER
6.00
1.00
51550
PARTIAL REMOVAL OF BLADDER
23.77
1.00
51550
PARTIAL REMOVAL OF BLADDER
24.68
1.00
51550
PARTIAL REMOVAL OF BLADDER
27.07
1.00
51555
PARTIAL REMOVAL OF BLADDER
7.00
1.00
51555
PARTIAL REMOVAL OF BLADDER
31.66
1.00
51555
PARTIAL REMOVAL OF BLADDER
32.79
1.00
51555
PARTIAL REMOVAL OF BLADDER
35.98
1.00
51565
REVISE BLADDER & URETER(S)
6.00
1.00
51565
REVISE BLADDER & URETER(S)
32.40
1.00
51565
REVISE BLADDER & URETER(S)
33.68
1.00
51565
REVISE BLADDER & URETER(S)
36.75
1.00
51570
REMOVAL OF BLADDER
6.00
1.00
51570
REMOVAL OF BLADDER
36.06
1.00
51570
REMOVAL OF BLADDER
37.54
1.00
51570
REMOVAL OF BLADDER
41.91
1.00
51575
REMOVAL OF BLADDER & NODES
7.00
1.00
51575
REMOVAL OF BLADDER & NODES
44.93
1.00
51575
REMOVAL OF BLADDER & NODES
46.66
1.00
51575
REMOVAL OF BLADDER & NODES
52.41
1.00
51580
REMOVE BLADDER/REVISE TRACT
8.00
1.00
51580
REMOVE BLADDER/REVISE TRACT
46.10
1.00
51580
REMOVE BLADDER/REVISE TRACT
47.99
1.00
51580
REMOVE BLADDER/REVISE TRACT
54.62
1.00
51585
REMOVAL OF BLADDER & NODES
7.00
1.00
51585
REMOVAL OF BLADDER & NODES
51.74
1.00
51585
REMOVAL OF BLADDER & NODES
53.48
1.00
Procedure Code Description
RVU
RVU Coeff Value
51585
REMOVAL OF BLADDER & NODES
60.83
1.00
51590
REMOVE BLADDER/REVISE TRACT
7.00
1.00
51590
REMOVE BLADDER/REVISE TRACT
47.87
1.00
51590
REMOVE BLADDER/REVISE TRACT
49.57
1.00
51590
REMOVE BLADDER/REVISE TRACT
55.41
1.00
51595
REMOVE BLADDER/REVISE TRACT
7.00
1.00
51595
REMOVE BLADDER/REVISE TRACT
54.13
1.00
51595
REMOVE BLADDER/REVISE TRACT
55.70
1.00
51595
REMOVE BLADDER/REVISE TRACT
62.98
1.00
51596
REMOVE BLADDER/CREATE POUCH
8.00
1.00
51596
REMOVE BLADDER/CREATE POUCH
57.81
1.00
51596
REMOVE BLADDER/CREATE POUCH
59.51
1.00
51596
REMOVE BLADDER/CREATE POUCH
67.70
1.00
51597
REMOVAL OF PELVIC STRUCTURES
7.00
1.00
51597
REMOVAL OF PELVIC STRUCTURES
56.36
1.00
51597
REMOVAL OF PELVIC STRUCTURES
58.12
1.00
51597
REMOVAL OF PELVIC STRUCTURES
65.33
1.00
51600
INJECTION FOR BLADDER X-RAY
1.22
1.00
51600
INJECTION FOR BLADDER X-RAY
1.23
1.00
51600
INJECTION FOR BLADDER X-RAY
1.25
1.00
51600
INJECTION FOR BLADDER X-RAY
1.28
1.00
51605
PREPARATION FOR BLADDER XRAY
0.90
1.00
51605
PREPARATION FOR BLADDER XRAY
1.04
1.00
51605
PREPARATION FOR BLADDER XRAY
1.10
1.00
51610
INJECTION FOR BLADDER X-RAY
1.45
1.00
51610
INJECTION FOR BLADDER X-RAY
1.71
1.00
51610
INJECTION FOR BLADDER X-RAY
1.82
1.00
51610
INJECTION FOR BLADDER X-RAY
3.00
1.00
51700
IRRIGATION OF BLADDER
1.22
1.00
51700
IRRIGATION OF BLADDER
1.28
1.00
51700
IRRIGATION OF BLADDER
3.00
1.00
51701
INSERT BLADDER CATHETER
0.73
1.00
51701
INSERT BLADDER CATHETER
0.78
1.00
51702
INSERT TEMP BLADDER CATH
0.80
1.00
51702
INSERT TEMP BLADDER CATH
0.86
1.00
Procedure Code Description
RVU
RVU Coeff Value
51703
INSERT BLADDER CATH, COMPLEX
2.15
1.00
51703
INSERT BLADDER CATH, COMPLEX
2.35
1.00
51705
CHANGE OF BLADDER TUBE
1.62
1.00
51705
CHANGE OF BLADDER TUBE
1.70
1.00
51705
CHANGE OF BLADDER TUBE
1.91
1.00
51705
CHANGE OF BLADDER TUBE
3.00
1.00
51710
CHANGE OF BLADDER TUBE
2.37
1.00
51710
CHANGE OF BLADDER TUBE
2.72
1.00
51710
CHANGE OF BLADDER TUBE
2.88
1.00
51710
CHANGE OF BLADDER TUBE
3.00
1.00
51715
ENDOSCOPIC INJECTION/IMPLANT
5.22
1.00
51715
ENDOSCOPIC INJECTION/IMPLANT
5.37
1.00
51715
ENDOSCOPIC INJECTION/IMPLANT
5.74
1.00
51715
ENDOSCOPIC INJECTION/IMPLANT
6.00
1.00
51720
TREATMENT OF BLADDER LESION
2.41
1.00
51720
TREATMENT OF BLADDER LESION
2.81
1.00
51720
TREATMENT OF BLADDER LESION
3.00
1.00
51725
SIMPLE CYSTOMETROGRAM
6.21
1.00
51725
SIMPLE CYSTOMETROGRAM
7.44
1.00
51725
SIMPLE CYSTOMETROGRAM
8.93
1.00
51726
COMPLEX CYSTOMETROGRAM
3.00
1.00
51726
COMPLEX CYSTOMETROGRAM
8.83
1.00
51726
COMPLEX CYSTOMETROGRAM
9.02
1.00
51726
COMPLEX CYSTOMETROGRAM
9.73
1.00
51736
URINE FLOW MEASUREMENT
1.21
1.00
51736
URINE FLOW MEASUREMENT
1.25
1.00
51736
URINE FLOW MEASUREMENT
1.52
1.00
51741
ELECTRO-UROFLOWMETRY, FIRST
2.02
1.00
51741
ELECTRO-UROFLOWMETRY, FIRST
2.04
1.00
51741
ELECTRO-UROFLOWMETRY, FIRST
2.41
1.00
51741
ELECTRO-UROFLOWMETRY, FIRST
3.00
1.00
51772
URETHRA PRESSURE PROFILE
3.00
1.00
51772
URETHRA PRESSURE PROFILE
6.96
1.00
51772
URETHRA PRESSURE PROFILE
7.58
1.00
51772
URETHRA PRESSURE PROFILE
8.09
1.00
Procedure Code Description
RVU
RVU Coeff Value
51784
ANAL/URINARY MUSCLE STUDY
5.70
1.00
51784
ANAL/URINARY MUSCLE STUDY
5.80
1.00
51784
ANAL/URINARY MUSCLE STUDY
6.91
1.00
51785
ANAL/URINARY MUSCLE STUDY
6.18
1.00
51785
ANAL/URINARY MUSCLE STUDY
6.30
1.00
51785
ANAL/URINARY MUSCLE STUDY
6.92
1.00
51792
URINARY REFLEX STUDY
6.50
1.00
51792
URINARY REFLEX STUDY
6.74
1.00
51792
URINARY REFLEX STUDY
7.32
1.00
51795
URINE VOIDING PRESSURE STUDY
3.00
1.00
51795
URINE VOIDING PRESSURE STUDY
8.41
1.00
51795
URINE VOIDING PRESSURE STUDY
8.52
1.00
51795
URINE VOIDING PRESSURE STUDY
9.37
1.00
51797
INTRAABDOMINAL PRESSURE TEST
3.00
1.00
51797
INTRAABDOMINAL PRESSURE TEST
4.23
1.00
51797
INTRAABDOMINAL PRESSURE TEST
6.05
1.00
51797
INTRAABDOMINAL PRESSURE TEST
7.72
1.00
51798
US URINE CAPACITY MEASURE
0.44
1.00
51798
US URINE CAPACITY MEASURE
0.55
1.00
51798
US URINE CAPACITY MEASURE
0.60
1.00
51800
REVISION OF BLADDER/URETHRA
5.00
1.00
51800
REVISION OF BLADDER/URETHRA
26.49
1.00
51800
REVISION OF BLADDER/URETHRA
27.38
1.00
51800
REVISION OF BLADDER/URETHRA
29.88
1.00
51820
REVISION OF URINARY TRACT
6.00
1.00
51820
REVISION OF URINARY TRACT
28.07
1.00
51820
REVISION OF URINARY TRACT
29.90
1.00
51820
REVISION OF URINARY TRACT
30.57
1.00
51840
ATTACH BLADDER/URETHRA
6.00
1.00
51840
ATTACH BLADDER/URETHRA
17.31
1.00
51840
ATTACH BLADDER/URETHRA
17.89
1.00
51840
ATTACH BLADDER/URETHRA
18.27
1.00
51841
ATTACH BLADDER/URETHRA
5.00
1.00
51841
ATTACH BLADDER/URETHRA
20.63
1.00
51841
ATTACH BLADDER/URETHRA
21.67
1.00
Procedure Code Description 51841
ATTACH BLADDER/URETHRA
51845
RVU
RVU Coeff Value
22.05
1.00
REPAIR BLADDER NECK
6.00
1.00
51845
REPAIR BLADDER NECK
15.34
1.00
51845
REPAIR BLADDER NECK
16.48
1.00
51845
REPAIR BLADDER NECK
16.60
1.00
51860
REPAIR OF BLADDER WOUND
4.00
1.00
51860
REPAIR OF BLADDER WOUND
18.97
1.00
51860
REPAIR OF BLADDER WOUND
20.25
1.00
51860
REPAIR OF BLADDER WOUND
20.35
1.00
51865
REPAIR OF BLADDER WOUND
6.00
1.00
51865
REPAIR OF BLADDER WOUND
23.07
1.00
51865
REPAIR OF BLADDER WOUND
24.23
1.00
51865
REPAIR OF BLADDER WOUND
25.14
1.00
51880
REPAIR OF BLADDER OPENING
3.00
1.00
51880
REPAIR OF BLADDER OPENING
12.37
1.00
51880
REPAIR OF BLADDER OPENING
13.20
1.00
51880
REPAIR OF BLADDER OPENING
13.50
1.00
51900
REPAIR BLADDER/VAGINA LESION
5.00
1.00
51900
REPAIR BLADDER/VAGINA LESION
20.22
1.00
51900
REPAIR BLADDER/VAGINA LESION
21.46
1.00
51900
REPAIR BLADDER/VAGINA LESION
23.34
1.00
51920
CLOSE BLADDER-UTERUS FISTULA
5.00
1.00
51920
CLOSE BLADDER-UTERUS FISTULA
18.58
1.00
51920
CLOSE BLADDER-UTERUS FISTULA
19.49
1.00
51920
CLOSE BLADDER-UTERUS FISTULA
21.60
1.00
51925
HYSTERECTOMY/BLADDER REPAIR
6.00
1.00
51925
HYSTERECTOMY/BLADDER REPAIR
25.97
1.00
51925
HYSTERECTOMY/BLADDER REPAIR
26.37
1.00
51925
HYSTERECTOMY/BLADDER REPAIR
28.32
1.00
51940
CORRECTION OF BLADDER DEFECT
7.00
1.00
51940
CORRECTION OF BLADDER DEFECT
43.13
1.00
51940
CORRECTION OF BLADDER DEFECT
45.83
1.00
51940
CORRECTION OF BLADDER DEFECT
46.00
1.00
51960
REVISION OF BLADDER & BOWEL
6.00
1.00
51960
REVISION OF BLADDER & BOWEL
34.55
1.00
Procedure Code Description
RVU
RVU Coeff Value
51960
REVISION OF BLADDER & BOWEL
36.61
1.00
51960
REVISION OF BLADDER & BOWEL
39.67
1.00
51980
CONSTRUCT BLADDER OPENING
5.00
1.00
51980
CONSTRUCT BLADDER OPENING
17.72
1.00
51980
CONSTRUCT BLADDER OPENING
18.66
1.00
51980
CONSTRUCT BLADDER OPENING
20.34
1.00
51990
LAPARO URETHRAL SUSPENSION
6.00
1.00
51990
LAPARO URETHRAL SUSPENSION
19.89
1.00
51990
LAPARO URETHRAL SUSPENSION
20.05
1.00
51990
LAPARO URETHRAL SUSPENSION
21.06
1.00
51992
LAPARO SLING OPERATION
6.00
1.00
51992
LAPARO SLING OPERATION
21.35
1.00
51992
LAPARO SLING OPERATION
21.38
1.00
51992
LAPARO SLING OPERATION
22.93
1.00
52000
CYSTOSCOPY
2.91
1.00
52000
CYSTOSCOPY
3.00
1.00
52000
CYSTOSCOPY
3.28
1.00
52000
CYSTOSCOPY
3.40
1.00
52000
CYSTOSCOPY
3.60
1.00
52001
CYSTOSCOPY, REMOVAL OF CLOTS
3.00
1.00
52001
CYSTOSCOPY, REMOVAL OF CLOTS
7.70
1.00
52001
CYSTOSCOPY, REMOVAL OF CLOTS
8.10
1.00
52001
CYSTOSCOPY, REMOVAL OF CLOTS
8.37
1.00
52005
CYSTOSCOPY & URETER CATHETER
3.00
1.00
52005
CYSTOSCOPY & URETER CATHETER
3.44
1.00
52005
CYSTOSCOPY & URETER CATHETER
3.45
1.00
52005
CYSTOSCOPY & URETER CATHETER
3.85
1.00
52007
CYSTOSCOPY AND BIOPSY
3.00
1.00
52007
CYSTOSCOPY AND BIOPSY
4.37
1.00
52007
CYSTOSCOPY AND BIOPSY
4.39
1.00
52007
CYSTOSCOPY AND BIOPSY
4.82
1.00
52010
CYSTOSCOPY & DUCT CATHETER
3.00
1.00
52010
CYSTOSCOPY & DUCT CATHETER
4.35
1.00
52010
CYSTOSCOPY & DUCT CATHETER
4.37
1.00
52010
CYSTOSCOPY & DUCT CATHETER
4.67
1.00
Procedure Code Description
RVU
RVU Coeff Value
52204
CYSTOSCOPY W/BIOPSY(S)
3.00
1.00
52204
CYSTOSCOPY W/BIOPSY(S)
3.45
1.00
52204
CYSTOSCOPY W/BIOPSY(S)
3.46
1.00
52204
CYSTOSCOPY W/BIOPSY(S)
3.79
1.00
52204
CYSTOSCOPY W/BIOPSY(S)
3.90
1.00
52204
CYSTOSCOPY W/BIOPSY(S)
4.08
1.00
52214
CYSTOSCOPY AND TREATMENT
3.00
1.00
52214
CYSTOSCOPY AND TREATMENT
5.29
1.00
52214
CYSTOSCOPY AND TREATMENT
5.30
1.00
52214
CYSTOSCOPY AND TREATMENT
6.32
1.00
52224
CYSTOSCOPY AND TREATMENT
4.50
1.00
52224
CYSTOSCOPY AND TREATMENT
4.51
1.00
52224
CYSTOSCOPY AND TREATMENT
4.93
1.00
52234
CYSTOSCOPY AND TREATMENT
3.00
1.00
52234
CYSTOSCOPY AND TREATMENT
6.57
1.00
52234
CYSTOSCOPY AND TREATMENT
6.58
1.00
52234
CYSTOSCOPY AND TREATMENT
7.19
1.00
52235
CYSTOSCOPY AND TREATMENT
3.00
1.00
52235
CYSTOSCOPY AND TREATMENT
7.72
1.00
52235
CYSTOSCOPY AND TREATMENT
7.73
1.00
52235
CYSTOSCOPY AND TREATMENT
8.43
1.00
52240
CYSTOSCOPY AND TREATMENT
5.00
1.00
52240
CYSTOSCOPY AND TREATMENT
13.67
1.00
52240
CYSTOSCOPY AND TREATMENT
13.71
1.00
52240
CYSTOSCOPY AND TREATMENT
14.74
1.00
52250
CYSTOSCOPY AND RADIOTRACER
3.00
1.00
52250
CYSTOSCOPY AND RADIOTRACER
6.47
1.00
52250
CYSTOSCOPY AND RADIOTRACER
6.48
1.00
52250
CYSTOSCOPY AND RADIOTRACER
7.06
1.00
52260
CYSTOSCOPY AND TREATMENT
3.00
1.00
52260
CYSTOSCOPY AND TREATMENT
5.61
1.00
52260
CYSTOSCOPY AND TREATMENT
5.62
1.00
52260
CYSTOSCOPY AND TREATMENT
6.09
1.00
52265
CYSTOSCOPY AND TREATMENT
4.26
1.00
52265
CYSTOSCOPY AND TREATMENT
4.28
1.00
Procedure Code Description
RVU
RVU Coeff Value
52265
CYSTOSCOPY AND TREATMENT
4.59
1.00
52270
CYSTOSCOPY & REVISE URETHRA
3.00
1.00
52270
CYSTOSCOPY & REVISE URETHRA
4.85
1.00
52270
CYSTOSCOPY & REVISE URETHRA
4.91
1.00
52270
CYSTOSCOPY & REVISE URETHRA
5.30
1.00
52275
CYSTOSCOPY & REVISE URETHRA
3.00
1.00
52275
CYSTOSCOPY & REVISE URETHRA
6.70
1.00
52275
CYSTOSCOPY & REVISE URETHRA
6.76
1.00
52275
CYSTOSCOPY & REVISE URETHRA
7.26
1.00
52276
CYSTOSCOPY AND TREATMENT
3.00
1.00
52276
CYSTOSCOPY AND TREATMENT
7.14
1.00
52276
CYSTOSCOPY AND TREATMENT
7.20
1.00
52276
CYSTOSCOPY AND TREATMENT
7.75
1.00
52277
CYSTOSCOPY AND TREATMENT
3.00
1.00
52277
CYSTOSCOPY AND TREATMENT
8.86
1.00
52277
CYSTOSCOPY AND TREATMENT
8.88
1.00
52277
CYSTOSCOPY AND TREATMENT
9.47
1.00
52281
CYSTOSCOPY AND TREATMENT
3.00
1.00
52281
CYSTOSCOPY AND TREATMENT
4.07
1.00
52281
CYSTOSCOPY AND TREATMENT
4.09
1.00
52281
CYSTOSCOPY AND TREATMENT
4.49
1.00
52282
CYSTOSCOPY, IMPLANT STENT
3.00
1.00
52282
CYSTOSCOPY, IMPLANT STENT
9.07
1.00
52282
CYSTOSCOPY, IMPLANT STENT
9.09
1.00
52282
CYSTOSCOPY, IMPLANT STENT
9.77
1.00
52283
CYSTOSCOPY AND TREATMENT
3.00
1.00
52283
CYSTOSCOPY AND TREATMENT
5.37
1.00
52283
CYSTOSCOPY AND TREATMENT
5.39
1.00
52283
CYSTOSCOPY AND TREATMENT
5.83
1.00
52285
CYSTOSCOPY AND TREATMENT
3.00
1.00
52285
CYSTOSCOPY AND TREATMENT
5.20
1.00
52285
CYSTOSCOPY AND TREATMENT
5.21
1.00
52285
CYSTOSCOPY AND TREATMENT
5.65
1.00
52290
CYSTOSCOPY AND TREATMENT
3.00
1.00
52290
CYSTOSCOPY AND TREATMENT
6.55
1.00
Procedure Code Description
RVU
RVU Coeff Value
52290
CYSTOSCOPY AND TREATMENT
6.57
1.00
52290
CYSTOSCOPY AND TREATMENT
7.13
1.00
52300
CYSTOSCOPY AND TREATMENT
3.00
1.00
52300
CYSTOSCOPY AND TREATMENT
7.58
1.00
52300
CYSTOSCOPY AND TREATMENT
7.60
1.00
52300
CYSTOSCOPY AND TREATMENT
8.19
1.00
52301
CYSTOSCOPY AND TREATMENT
3.00
1.00
52301
CYSTOSCOPY AND TREATMENT
7.94
1.00
52301
CYSTOSCOPY AND TREATMENT
7.97
1.00
52301
CYSTOSCOPY AND TREATMENT
8.63
1.00
52305
CYSTOSCOPY AND TREATMENT
3.00
1.00
52305
CYSTOSCOPY AND TREATMENT
7.52
1.00
52305
CYSTOSCOPY AND TREATMENT
7.53
1.00
52305
CYSTOSCOPY AND TREATMENT
8.14
1.00
52310
CYSTOSCOPY AND TREATMENT
3.00
1.00
52310
CYSTOSCOPY AND TREATMENT
4.03
1.00
52310
CYSTOSCOPY AND TREATMENT
4.06
1.00
52310
CYSTOSCOPY AND TREATMENT
4.41
1.00
52315
CYSTOSCOPY AND TREATMENT
3.00
1.00
52315
CYSTOSCOPY AND TREATMENT
7.40
1.00
52315
CYSTOSCOPY AND TREATMENT
7.41
1.00
52315
CYSTOSCOPY AND TREATMENT
8.02
1.00
52317
REMOVE BLADDER STONE
3.00
1.00
52317
REMOVE BLADDER STONE
9.46
1.00
52317
REMOVE BLADDER STONE
9.47
1.00
52318
REMOVE BLADDER STONE
3.00
1.00
52318
REMOVE BLADDER STONE
12.90
1.00
52318
REMOVE BLADDER STONE
12.93
1.00
52318
REMOVE BLADDER STONE
13.87
1.00
52320
CYSTOSCOPY AND TREATMENT
3.00
1.00
52320
CYSTOSCOPY AND TREATMENT
6.66
1.00
52320
CYSTOSCOPY AND TREATMENT
6.67
1.00
52320
CYSTOSCOPY AND TREATMENT
7.20
1.00
52325
CYSTOSCOPY, STONE REMOVAL
3.00
1.00
52325
CYSTOSCOPY, STONE REMOVAL
8.70
1.00
Procedure Code Description
RVU
RVU Coeff Value
52325
CYSTOSCOPY, STONE REMOVAL
8.71
1.00
52325
CYSTOSCOPY, STONE REMOVAL
9.37
1.00
52327
CYSTOSCOPY, INJECT MATERIAL
3.00
1.00
52327
CYSTOSCOPY, INJECT MATERIAL
7.38
1.00
52327
CYSTOSCOPY, INJECT MATERIAL
7.40
1.00
52327
CYSTOSCOPY, INJECT MATERIAL
7.67
1.00
52330
CYSTOSCOPY AND TREATMENT
3.00
1.00
52330
CYSTOSCOPY AND TREATMENT
7.14
1.00
52330
CYSTOSCOPY AND TREATMENT
7.15
1.00
52330
CYSTOSCOPY AND TREATMENT
7.31
1.00
52330
CYSTOSCOPY AND TREATMENT
7.44
1.00
52330
CYSTOSCOPY AND TREATMENT
7.71
1.00
52332
CYSTOSCOPY AND TREATMENT
3.00
1.00
52332
CYSTOSCOPY AND TREATMENT
4.07
1.00
52332
CYSTOSCOPY AND TREATMENT
4.09
1.00
52332
CYSTOSCOPY AND TREATMENT
4.10
1.00
52334
CREATE PASSAGE TO KIDNEY
3.00
1.00
52334
CREATE PASSAGE TO KIDNEY
6.91
1.00
52334
CREATE PASSAGE TO KIDNEY
6.92
1.00
52334
CREATE PASSAGE TO KIDNEY
7.49
1.00
52341
CYSTO W/URETER STRICTURE TX
3.00
1.00
52341
CYSTO W/URETER STRICTURE TX
8.53
1.00
52341
CYSTO W/URETER STRICTURE TX
8.63
1.00
52341
CYSTO W/URETER STRICTURE TX
8.66
1.00
52342
CYSTO W/UP STRICTURE TX
3.00
1.00
52342
CYSTO W/UP STRICTURE TX
9.27
1.00
52342
CYSTO W/UP STRICTURE TX
9.31
1.00
52342
CYSTO W/UP STRICTURE TX
9.32
1.00
52343
CYSTO W/RENAL STRICTURE TX
3.00
1.00
52343
CYSTO W/RENAL STRICTURE TX
10.31
1.00
52343
CYSTO W/RENAL STRICTURE TX
10.33
1.00
52344
CYSTO/URETERO, STRICTURE TX
3.00
1.00
52344
CYSTO/URETERO, STRICTURE TX
11.04
1.00
52344
CYSTO/URETERO, STRICTURE TX
11.06
1.00
52344
CYSTO/URETERO, STRICTURE TX
11.18
1.00
Procedure Code Description
RVU
RVU Coeff Value
52345
CYSTO/URETERO W/UP STRICTURE
3.00
1.00
52345
CYSTO/URETERO W/UP STRICTURE
11.73
1.00
52345
CYSTO/URETERO W/UP STRICTURE
11.75
1.00
52345
CYSTO/URETERO W/UP STRICTURE
11.92
1.00
52346
CYSTOURETERO W/RENAL STRICT
3.00
1.00
52346
CYSTOURETERO W/RENAL STRICT
13.18
1.00
52346
CYSTOURETERO W/RENAL STRICT
13.20
1.00
52346
CYSTOURETERO W/RENAL STRICT
13.45
1.00
52347
CYSTOSCOPY, RESECT DUCTS
3.00
1.00
52351
CYSTOURETERO & OR PYELOSCOPE
3.00
1.00
52351
CYSTOURETERO & OR PYELOSCOPE
8.41
1.00
52351
CYSTOURETERO & OR PYELOSCOPE
8.42
1.00
52351
CYSTOURETERO & OR PYELOSCOPE
9.16
1.00
52352
CYSTOURETERO W/STONE REMOVE
3.00
1.00
52352
CYSTOURETERO W/STONE REMOVE
9.87
1.00
52352
CYSTOURETERO W/STONE REMOVE
9.89
1.00
52352
CYSTOURETERO W/STONE REMOVE
10.76
1.00
52353
CYSTOURETERO W/LITHOTRIPSY
3.00
1.00
52353
CYSTOURETERO W/LITHOTRIPSY
11.39
1.00
52353
CYSTOURETERO W/LITHOTRIPSY
11.41
1.00
52353
CYSTOURETERO W/LITHOTRIPSY
12.38
1.00
52354
CYSTOURETERO W/BIOPSY
3.00
1.00
52354
CYSTOURETERO W/BIOPSY
10.53
1.00
52354
CYSTOURETERO W/BIOPSY
10.54
1.00
52354
CYSTOURETERO W/BIOPSY
11.44
1.00
52355
CYSTOURETERO W/EXCISE TUMOR
3.00
1.00
52355
CYSTOURETERO W/EXCISE TUMOR
12.59
1.00
52355
CYSTOURETERO W/EXCISE TUMOR
12.62
1.00
52355
CYSTOURETERO W/EXCISE TUMOR
13.64
1.00
52400
CYSTOURETERO W/CONGEN REPR
3.00
1.00
52400
CYSTOURETERO W/CONGEN REPR
14.03
1.00
52400
CYSTOURETERO W/CONGEN REPR
14.17
1.00
52400
CYSTOURETERO W/CONGEN REPR
14.59
1.00
52402
CYSTOURETHRO CUT EJACUL DUCT
7.86
1.00
52450
INCISION OF PROSTATE
11.75
1.00
Procedure Code Description
RVU
RVU Coeff Value
52450
INCISION OF PROSTATE
11.89
1.00
52450
INCISION OF PROSTATE
13.36
1.00
52450
INCISION OF PROSTATE
999.99
1.00
52500
REVISION OF BLADDER NECK
4.00
1.00
52500
REVISION OF BLADDER NECK
12.88
1.00
52500
REVISION OF BLADDER NECK
13.02
1.00
52500
REVISION OF BLADDER NECK
13.97
1.00
52510
DILATION PROSTATIC URETHRA
10.33
1.00
52510
DILATION PROSTATIC URETHRA
10.36
1.00
52510
DILATION PROSTATIC URETHRA
11.55
1.00
52510
DILATION PROSTATIC URETHRA
999.99
1.00
52601
PROSTATECTOMY (TURP)
5.00
1.00
52601
PROSTATECTOMY (TURP)
18.34
1.00
52601
PROSTATECTOMY (TURP)
18.39
1.00
52601
PROSTATECTOMY (TURP)
23.63
1.00
52606
CONTROL POSTOP BLEEDING
5.00
1.00
52606
CONTROL POSTOP BLEEDING
12.18
1.00
52606
CONTROL POSTOP BLEEDING
12.29
1.00
52606
CONTROL POSTOP BLEEDING
13.93
1.00
52612
PROSTATECTOMY, FIRST STAGE
5.00
1.00
52612
PROSTATECTOMY, FIRST STAGE
12.29
1.00
52612
PROSTATECTOMY, FIRST STAGE
12.32
1.00
52612
PROSTATECTOMY, FIRST STAGE
14.44
1.00
52614
PROSTATECTOMY, SECOND STAGE
5.00
1.00
52614
PROSTATECTOMY, SECOND STAGE
10.67
1.00
52614
PROSTATECTOMY, SECOND STAGE
10.70
1.00
52614
PROSTATECTOMY, SECOND STAGE
12.65
1.00
52620
REMOVE RESIDUAL PROSTATE
5.00
1.00
52620
REMOVE RESIDUAL PROSTATE
10.08
1.00
52620
REMOVE RESIDUAL PROSTATE
11.46
1.00
52630
REMOVE PROSTATE REGROWTH
5.00
1.00
52630
REMOVE PROSTATE REGROWTH
10.89
1.00
52630
REMOVE PROSTATE REGROWTH
10.99
1.00
52630
REMOVE PROSTATE REGROWTH
12.68
1.00
52640
RELIEVE BLADDER CONTRACTURE
5.00
1.00
Procedure Code Description
RVU
RVU Coeff Value
52640
RELIEVE BLADDER CONTRACTURE
8.71
1.00
52640
RELIEVE BLADDER CONTRACTURE
10.06
1.00
52640
RELIEVE BLADDER CONTRACTURE
10.11
1.00
52647
LASER SURGERY OF PROSTATE
5.00
1.00
52647
LASER SURGERY OF PROSTATE
15.54
1.00
52647
LASER SURGERY OF PROSTATE
15.61
1.00
52647
LASER SURGERY OF PROSTATE
15.65
1.00
52647
LASER SURGERY OF PROSTATE
17.04
1.00
52647
LASER SURGERY OF PROSTATE
17.59
1.00
52647
LASER SURGERY OF PROSTATE
18.45
1.00
52648
LASER SURGERY OF PROSTATE
5.00
1.00
52648
LASER SURGERY OF PROSTATE
16.65
1.00
52648
LASER SURGERY OF PROSTATE
16.83
1.00
52648
LASER SURGERY OF PROSTATE
19.69
1.00
52649
PROSTATE LASER ENUCLEATION
28.14
1.00
52700
DRAINAGE OF PROSTATE ABSCESS
5.00
1.00
52700
DRAINAGE OF PROSTATE ABSCESS
10.45
1.00
52700
DRAINAGE OF PROSTATE ABSCESS
10.49
1.00
52700
DRAINAGE OF PROSTATE ABSCESS
12.38
1.00
53000
INCISION OF URETHRA
3.00
1.00
53000
INCISION OF URETHRA
4.01
1.00
53000
INCISION OF URETHRA
4.24
1.00
53000
INCISION OF URETHRA
4.64
1.00
53010
INCISION OF URETHRA
3.00
1.00
53010
INCISION OF URETHRA
6.89
1.00
53010
INCISION OF URETHRA
7.92
1.00
53010
INCISION OF URETHRA
8.29
1.00
53020
INCISION OF URETHRA
2.54
1.00
53020
INCISION OF URETHRA
2.57
1.00
53020
INCISION OF URETHRA
2.82
1.00
53020
INCISION OF URETHRA
3.00
1.00
53025
INCISION OF URETHRA
1.65
1.00
53025
INCISION OF URETHRA
1.72
1.00
53025
INCISION OF URETHRA
1.85
1.00
53025
INCISION OF URETHRA
3.00
1.00
Procedure Code Description
RVU
RVU Coeff Value
53040
DRAINAGE OF URETHRA ABSCESS
3.00
1.00
53040
DRAINAGE OF URETHRA ABSCESS
11.20
1.00
53040
DRAINAGE OF URETHRA ABSCESS
13.21
1.00
53040
DRAINAGE OF URETHRA ABSCESS
13.98
1.00
53060
DRAINAGE OF URETHRA ABSCESS
3.00
1.00
53060
DRAINAGE OF URETHRA ABSCESS
4.36
1.00
53060
DRAINAGE OF URETHRA ABSCESS
4.40
1.00
53060
DRAINAGE OF URETHRA ABSCESS
5.53
1.00
53080
DRAINAGE OF URINARY LEAKAGE
3.00
1.00
53080
DRAINAGE OF URINARY LEAKAGE
12.43
1.00
53080
DRAINAGE OF URINARY LEAKAGE
12.96
1.00
53080
DRAINAGE OF URINARY LEAKAGE
13.93
1.00
53085
DRAINAGE OF URINARY LEAKAGE
5.00
1.00
53085
DRAINAGE OF URINARY LEAKAGE
17.64
1.00
53085
DRAINAGE OF URINARY LEAKAGE
18.69
1.00
53085
DRAINAGE OF URINARY LEAKAGE
19.57
1.00
53200
BIOPSY OF URETHRA
3.00
1.00
53200
BIOPSY OF URETHRA
3.71
1.00
53200
BIOPSY OF URETHRA
3.78
1.00
53200
BIOPSY OF URETHRA
4.06
1.00
53210
REMOVAL OF URETHRA
5.00
1.00
53210
REMOVAL OF URETHRA
19.51
1.00
53210
REMOVAL OF URETHRA
20.87
1.00
53210
REMOVAL OF URETHRA
22.01
1.00
53215
REMOVAL OF URETHRA
5.00
1.00
53215
REMOVAL OF URETHRA
23.45
1.00
53215
REMOVAL OF URETHRA
24.59
1.00
53215
REMOVAL OF URETHRA
26.74
1.00
53220
TREATMENT OF URETHRA LESION
3.00
1.00
53220
TREATMENT OF URETHRA LESION
11.36
1.00
53220
TREATMENT OF URETHRA LESION
12.52
1.00
53220
TREATMENT OF URETHRA LESION
12.85
1.00
53230
REMOVAL OF URETHRA LESION
3.00
1.00
53230
REMOVAL OF URETHRA LESION
15.13
1.00
53230
REMOVAL OF URETHRA LESION
15.98
1.00
Procedure Code Description
RVU
RVU Coeff Value
53230
REMOVAL OF URETHRA LESION
17.15
1.00
53235
REMOVAL OF URETHRA LESION
3.00
1.00
53235
REMOVAL OF URETHRA LESION
15.86
1.00
53235
REMOVAL OF URETHRA LESION
16.74
1.00
53235
REMOVAL OF URETHRA LESION
18.23
1.00
53240
SURGERY FOR URETHRA POUCH
3.00
1.00
53240
SURGERY FOR URETHRA POUCH
10.59
1.00
53240
SURGERY FOR URETHRA POUCH
11.72
1.00
53240
SURGERY FOR URETHRA POUCH
12.26
1.00
53250
REMOVAL OF URETHRA GLAND
3.00
1.00
53250
REMOVAL OF URETHRA GLAND
9.68
1.00
53250
REMOVAL OF URETHRA GLAND
10.48
1.00
53250
REMOVAL OF URETHRA GLAND
11.38
1.00
53260
TREATMENT OF URETHRA LESION
3.00
1.00
53260
TREATMENT OF URETHRA LESION
5.02
1.00
53260
TREATMENT OF URETHRA LESION
5.06
1.00
53260
TREATMENT OF URETHRA LESION
5.45
1.00
53265
TREATMENT OF URETHRA LESION
3.00
1.00
53265
TREATMENT OF URETHRA LESION
5.20
1.00
53265
TREATMENT OF URETHRA LESION
5.27
1.00
53265
TREATMENT OF URETHRA LESION
5.60
1.00
53270
REMOVAL OF URETHRA GLAND
3.00
1.00
53270
REMOVAL OF URETHRA GLAND
5.18
1.00
53270
REMOVAL OF URETHRA GLAND
5.21
1.00
53270
REMOVAL OF URETHRA GLAND
5.82
1.00
53275
REPAIR OF URETHRA DEFECT
3.00
1.00
53275
REPAIR OF URETHRA DEFECT
7.14
1.00
53275
REPAIR OF URETHRA DEFECT
7.60
1.00
53275
REPAIR OF URETHRA DEFECT
7.85
1.00
53400
REVISE URETHRA, STAGE 1
3.00
1.00
53400
REVISE URETHRA, STAGE 1
19.88
1.00
53400
REVISE URETHRA, STAGE 1
21.04
1.00
53400
REVISE URETHRA, STAGE 1
22.91
1.00
53405
REVISE URETHRA, STAGE 2
3.00
1.00
53405
REVISE URETHRA, STAGE 2
22.01
1.00
Procedure Code Description
RVU
RVU Coeff Value
53405
REVISE URETHRA, STAGE 2
23.09
1.00
53405
REVISE URETHRA, STAGE 2
25.24
1.00
53410
RECONSTRUCTION OF URETHRA
4.00
1.00
53410
RECONSTRUCTION OF URETHRA
24.81
1.00
53410
RECONSTRUCTION OF URETHRA
25.86
1.00
53410
RECONSTRUCTION OF URETHRA
28.14
1.00
53415
RECONSTRUCTION OF URETHRA
3.00
1.00
53415
RECONSTRUCTION OF URETHRA
28.25
1.00
53415
RECONSTRUCTION OF URETHRA
29.56
1.00
53415
RECONSTRUCTION OF URETHRA
32.46
1.00
53420
RECONSTRUCT URETHRA, STAGE 1
3.00
1.00
53420
RECONSTRUCT URETHRA, STAGE 1
21.60
1.00
53420
RECONSTRUCT URETHRA, STAGE 1
23.05
1.00
53420
RECONSTRUCT URETHRA, STAGE 1
23.51
1.00
53425
RECONSTRUCT URETHRA, STAGE 2
3.00
1.00
53425
RECONSTRUCT URETHRA, STAGE 2
24.18
1.00
53425
RECONSTRUCT URETHRA, STAGE 2
25.44
1.00
53425
RECONSTRUCT URETHRA, STAGE 2
27.11
1.00
53430
RECONSTRUCTION OF URETHRA
3.00
1.00
53430
RECONSTRUCTION OF URETHRA
24.67
1.00
53430
RECONSTRUCTION OF URETHRA
25.97
1.00
53430
RECONSTRUCTION OF URETHRA
27.04
1.00
53431
RECONSTRUCT URETHRA/BLADDER
3.00
1.00
53431
RECONSTRUCT URETHRA/BLADDER
29.60
1.00
53431
RECONSTRUCT URETHRA/BLADDER
30.23
1.00
53431
RECONSTRUCT URETHRA/BLADDER
33.18
1.00
53440
MALE SLING PROCEDURE
3.00
1.00
53440
MALE SLING PROCEDURE
20.52
1.00
53440
MALE SLING PROCEDURE
20.68
1.00
53440
MALE SLING PROCEDURE
25.09
1.00
53442
REMOVE/REVISE MALE SLING
3.00
1.00
53442
REMOVE/REVISE MALE SLING
17.72
1.00
53442
REMOVE/REVISE MALE SLING
18.05
1.00
53442
REMOVE/REVISE MALE SLING
22.09
1.00
53444
INSERT TANDEM CUFF
3.00
1.00
Procedure Code Description
RVU
RVU Coeff Value
53444
INSERT TANDEM CUFF
20.35
1.00
53444
INSERT TANDEM CUFF
20.42
1.00
53444
INSERT TANDEM CUFF
22.84
1.00
53445
INSERT URO/VES NCK SPHINCTER
3.00
1.00
53445
INSERT URO/VES NCK SPHINCTER
22.31
1.00
53445
INSERT URO/VES NCK SPHINCTER
22.66
1.00
53445
INSERT URO/VES NCK SPHINCTER
25.21
1.00
53446
REMOVE URO SPHINCTER
3.00
1.00
53446
REMOVE URO SPHINCTER
16.29
1.00
53446
REMOVE URO SPHINCTER
16.72
1.00
53446
REMOVE URO SPHINCTER
18.43
1.00
53447
REMOVE/REPLACE UR SPHINCTER
3.00
1.00
53447
REMOVE/REPLACE UR SPHINCTER
20.83
1.00
53447
REMOVE/REPLACE UR SPHINCTER
20.90
1.00
53447
REMOVE/REPLACE UR SPHINCTER
23.32
1.00
53448
REMOV/REPLC UR SPHINCTR COMP
3.00
1.00
53448
REMOV/REPLC UR SPHINCTR COMP
31.93
1.00
53448
REMOV/REPLC UR SPHINCTR COMP
32.39
1.00
53448
REMOV/REPLC UR SPHINCTR COMP
36.84
1.00
53449
REPAIR URO SPHINCTER
3.00
1.00
53449
REPAIR URO SPHINCTER
15.23
1.00
53449
REPAIR URO SPHINCTER
16.17
1.00
53449
REPAIR URO SPHINCTER
17.52
1.00
53450
REVISION OF URETHRA
3.00
1.00
53450
REVISION OF URETHRA
9.98
1.00
53450
REVISION OF URETHRA
11.04
1.00
53450
REVISION OF URETHRA
11.65
1.00
53460
REVISION OF URETHRA
3.00
1.00
53460
REVISION OF URETHRA
11.45
1.00
53460
REVISION OF URETHRA
12.45
1.00
53460
REVISION OF URETHRA
13.09
1.00
53500
URETHRLYS, TRANSVAG W/ SCOPE
19.27
1.00
53500
URETHRLYS, TRANSVAG W/ SCOPE
21.07
1.00
53502
REPAIR OF URETHRA INJURY
4.00
1.00
53502
REPAIR OF URETHRA INJURY
12.33
1.00
Procedure Code Description
RVU
RVU Coeff Value
53502
REPAIR OF URETHRA INJURY
13.45
1.00
53502
REPAIR OF URETHRA INJURY
13.87
1.00
53505
REPAIR OF URETHRA INJURY
4.00
1.00
53505
REPAIR OF URETHRA INJURY
12.16
1.00
53505
REPAIR OF URETHRA INJURY
13.13
1.00
53505
REPAIR OF URETHRA INJURY
13.91
1.00
53510
REPAIR OF URETHRA INJURY
3.00
1.00
53510
REPAIR OF URETHRA INJURY
16.10
1.00
53510
REPAIR OF URETHRA INJURY
17.14
1.00
53510
REPAIR OF URETHRA INJURY
18.11
1.00
53515
REPAIR OF URETHRA INJURY
3.00
1.00
53515
REPAIR OF URETHRA INJURY
20.34
1.00
53515
REPAIR OF URETHRA INJURY
21.19
1.00
53515
REPAIR OF URETHRA INJURY
22.87
1.00
53520
REPAIR OF URETHRA DEFECT
4.00
1.00
53520
REPAIR OF URETHRA DEFECT
13.91
1.00
53520
REPAIR OF URETHRA DEFECT
14.71
1.00
53520
REPAIR OF URETHRA DEFECT
15.88
1.00
53600
DILATE URETHRA STRICTURE
1.72
1.00
53600
DILATE URETHRA STRICTURE
1.73
1.00
53600
DILATE URETHRA STRICTURE
1.87
1.00
53600
DILATE URETHRA STRICTURE
3.00
1.00
53601
DILATE URETHRA STRICTURE
1.43
1.00
53601
DILATE URETHRA STRICTURE
1.56
1.00
53601
DILATE URETHRA STRICTURE
3.00
1.00
53605
DILATE URETHRA STRICTURE
1.78
1.00
53605
DILATE URETHRA STRICTURE
1.79
1.00
53605
DILATE URETHRA STRICTURE
1.88
1.00
53605
DILATE URETHRA STRICTURE
3.00
1.00
53620
DILATE URETHRA STRICTURE
2.34
1.00
53620
DILATE URETHRA STRICTURE
2.54
1.00
53620
DILATE URETHRA STRICTURE
3.00
1.00
53621
DILATE URETHRA STRICTURE
1.94
1.00
53621
DILATE URETHRA STRICTURE
1.95
1.00
53621
DILATE URETHRA STRICTURE
2.11
1.00
Procedure Code Description
RVU
RVU Coeff Value
53621
DILATE URETHRA STRICTURE
3.00
1.00
53660
DILATION OF URETHRA
1.08
1.00
53660
DILATION OF URETHRA
1.09
1.00
53660
DILATION OF URETHRA
1.19
1.00
53660
DILATION OF URETHRA
4.00
1.00
53661
DILATION OF URETHRA
1.07
1.00
53661
DILATION OF URETHRA
1.17
1.00
53661
DILATION OF URETHRA
3.00
1.00
53665
DILATION OF URETHRA
1.07
1.00
53665
DILATION OF URETHRA
1.08
1.00
53665
DILATION OF URETHRA
1.10
1.00
53665
DILATION OF URETHRA
3.00
1.00
53850
PROSTATIC MICROWAVE THERMOTX
3.00
1.00
53850
PROSTATIC MICROWAVE THERMOTX
14.26
1.00
53850
PROSTATIC MICROWAVE THERMOTX
14.42
1.00
53850
PROSTATIC MICROWAVE THERMOTX
16.28
1.00
53852
PROSTATIC RF THERMOTX
3.00
1.00
53852
PROSTATIC RF THERMOTX
14.89
1.00
53852
PROSTATIC RF THERMOTX
15.26
1.00
53852
PROSTATIC RF THERMOTX
17.72
1.00
53853
PROSTATIC WATER THERMOTHER
3.00
1.00
53853
PROSTATIC WATER THERMOTHER
8.74
1.00
53853
PROSTATIC WATER THERMOTHER
8.81
1.00
53853
PROSTATIC WATER THERMOTHER
9.51
1.00
54000
SLITTING OF PREPUCE
3.00
1.00
54000
SLITTING OF PREPUCE
3.04
1.00
54001
SLITTING OF PREPUCE
3.00
1.00
54001
SLITTING OF PREPUCE
4.34
1.00
54015
DRAIN PENIS LESION
3.00
1.00
54015
DRAIN PENIS LESION
8.70
1.00
54050
DESTRUCTION, PENIS LESION(S)
1.81
1.00
54050
DESTRUCTION, PENIS LESION(S)
3.00
1.00
54055
DESTRUCTION, PENIS LESION(S)
2.68
1.00
54055
DESTRUCTION, PENIS LESION(S)
3.00
1.00
54056
CRYOSURGERY, PENIS LESION(S)
1.84
1.00
Procedure Code Description
RVU
RVU Coeff Value
54056
CRYOSURGERY, PENIS LESION(S)
3.00
1.00
54057
LASER SURG, PENIS LESION(S)
2.56
1.00
54057
LASER SURG, PENIS LESION(S)
3.00
1.00
54060
EXCISION OF PENIS LESION(S)
3.00
1.00
54060
EXCISION OF PENIS LESION(S)
3.61
1.00
54065
DESTRUCTION, PENIS LESION(S)
3.00
1.00
54065
DESTRUCTION, PENIS LESION(S)
4.57
1.00
54100
BIOPSY OF PENIS
2.76
1.00
54100
BIOPSY OF PENIS
3.00
1.00
54105
BIOPSY OF PENIS
3.00
1.00
54105
BIOPSY OF PENIS
5.78
1.00
54110
TREATMENT OF PENIS LESION
3.00
1.00
54110
TREATMENT OF PENIS LESION
17.59
1.00
54111
TREAT PENIS LESION, GRAFT
3.00
1.00
54111
TREAT PENIS LESION, GRAFT
22.74
1.00
54112
TREAT PENIS LESION, GRAFT
3.00
1.00
54112
TREAT PENIS LESION, GRAFT
25.66
1.00
54115
TREATMENT OF PENIS LESION
3.00
1.00
54115
TREATMENT OF PENIS LESION
12.60
1.00
54120
PARTIAL REMOVAL OF PENIS
4.00
1.00
54120
PARTIAL REMOVAL OF PENIS
17.80
1.00
54125
REMOVAL OF PENIS
4.00
1.00
54125
REMOVAL OF PENIS
22.77
1.00
54130
REMOVE PENIS & NODES
6.00
1.00
54130
REMOVE PENIS & NODES
32.27
1.00
54135
REMOVE PENIS & NODES
8.00
1.00
54135
REMOVE PENIS & NODES
40.94
1.00
54150
CIRCUMCISION W/REGIONL BLOCK
3.86
1.00
54152
CIRCUMCISION
3.00
1.00
54152
CIRCUMCISION
4.12
1.00
54160
CIRCUMCISION, NEONATE
3.00
1.00
54160
CIRCUMCISION, NEONATE
4.39
1.00
54161
CIRCUM 28 DAYS OR OLDER
3.00
1.00
54161
CIRCUM 28 DAYS OR OLDER
5.39
1.00
54162
LYSIS PENIL CIRCUMIC LESION
3.00
1.00
Procedure Code Description
RVU
RVU Coeff Value
54162
LYSIS PENIL CIRCUMIC LESION
5.50
1.00
54163
REPAIR OF CIRCUMCISION
3.00
1.00
54163
REPAIR OF CIRCUMCISION
5.27
1.00
54200
TREATMENT OF PENIS LESION
1.49
1.00
54205
TREATMENT OF PENIS LESION
3.00
1.00
54205
TREATMENT OF PENIS LESION
14.87
1.00
54220
TREATMENT OF PENIS LESION
3.59
1.00
54230
PREPARE PENIS STUDY
1.86
1.00
54300
REVISION OF PENIS
3.00
1.00
54300
REVISION OF PENIS
19.09
1.00
54304
REVISION OF PENIS
3.00
1.00
54304
REVISION OF PENIS
22.48
1.00
54308
RECONSTRUCTION OF URETHRA
3.00
1.00
54308
RECONSTRUCTION OF URETHRA
21.35
1.00
54312
RECONSTRUCTION OF URETHRA
3.00
1.00
54312
RECONSTRUCTION OF URETHRA
24.25
1.00
54316
RECONSTRUCTION OF URETHRA
3.00
1.00
54316
RECONSTRUCTION OF URETHRA
28.65
1.00
54318
RECONSTRUCTION OF URETHRA
3.00
1.00
54318
RECONSTRUCTION OF URETHRA
21.04
1.00
54322
RECONSTRUCTION OF URETHRA
3.00
1.00
54322
RECONSTRUCTION OF URETHRA
22.34
1.00
54324
RECONSTRUCTION OF URETHRA
3.00
1.00
54324
RECONSTRUCTION OF URETHRA
28.40
1.00
54326
RECONSTRUCTION OF URETHRA
3.00
1.00
54326
RECONSTRUCTION OF URETHRA
26.80
1.00
54328
REVISE PENIS/URETHRA
3.00
1.00
54328
REVISE PENIS/URETHRA
26.66
1.00
54332
REVISE PENIS/URETHRA
3.00
1.00
54332
REVISE PENIS/URETHRA
28.65
1.00
54336
REVISE PENIS/URETHRA
3.00
1.00
54336
REVISE PENIS/URETHRA
36.06
1.00
54340
SECONDARY URETHRAL SURGERY
3.00
1.00
54340
SECONDARY URETHRAL SURGERY
16.97
1.00
54344
SECONDARY URETHRAL SURGERY
3.00
1.00
Procedure Code Description
RVU
RVU Coeff Value
54344
SECONDARY URETHRAL SURGERY
27.38
1.00
54348
SECONDARY URETHRAL SURGERY
3.00
1.00
54348
SECONDARY URETHRAL SURGERY
29.42
1.00
54352
RECONSTRUCT URETHRA/PENIS
3.00
1.00
54352
RECONSTRUCT URETHRA/PENIS
40.89
1.00
54360
PENIS PLASTIC SURGERY
3.00
1.00
54360
PENIS PLASTIC SURGERY
20.50
1.00
54380
REPAIR PENIS
3.00
1.00
54380
REPAIR PENIS
23.84
1.00
54385
REPAIR PENIS
3.00
1.00
54385
REPAIR PENIS
28.29
1.00
54390
REPAIR PENIS AND BLADDER
6.00
1.00
54390
REPAIR PENIS AND BLADDER
35.91
1.00
54420
REVISION OF PENIS
3.00
1.00
54420
REVISION OF PENIS
19.61
1.00
54430
REVISION OF PENIS
3.00
1.00
54430
REVISION OF PENIS
18.02
1.00
54435
REVISION OF PENIS
3.00
1.00
54435
REVISION OF PENIS
11.49
1.00
54440
REPAIR OF PENIS
3.00
1.00
54450
PREPUTIAL STRETCHING
1.67
1.00
54450
PREPUTIAL STRETCHING
3.00
1.00
54500
BIOPSY OF TESTIS
1.83
1.00
54500
BIOPSY OF TESTIS
3.00
1.00
54505
BIOPSY OF TESTIS
3.00
1.00
54505
BIOPSY OF TESTIS
5.95
1.00
54512
EXCISE LESION TESTIS
3.00
1.00
54512
EXCISE LESION TESTIS
13.64
1.00
54520
REMOVAL OF TESTIS
3.00
1.00
54520
REMOVAL OF TESTIS
8.80
1.00
54522
ORCHIECTOMY, PARTIAL
4.00
1.00
54522
ORCHIECTOMY, PARTIAL
15.24
1.00
54530
REMOVAL OF TESTIS
3.00
1.00
54530
REMOVAL OF TESTIS
13.97
1.00
54535
EXTENSIVE TESTIS SURGERY
6.00
1.00
Procedure Code Description 54535
EXTENSIVE TESTIS SURGERY
54550
RVU
RVU Coeff Value
19.71
1.00
EXPLORATION FOR TESTIS
3.00
1.00
54550
EXPLORATION FOR TESTIS
12.65
1.00
54560
EXPLORATION FOR TESTIS
3.00
1.00
54560
EXPLORATION FOR TESTIS
18.26
1.00
54600
REDUCE TESTIS TORSION
3.00
1.00
54600
REDUCE TESTIS TORSION
11.34
1.00
54620
SUSPENSION OF TESTIS
3.00
1.00
54620
SUSPENSION OF TESTIS
7.98
1.00
54640
SUSPENSION OF TESTIS
4.00
1.00
54640
SUSPENSION OF TESTIS
11.33
1.00
54650
ORCHIOPEXY (FOWLER-STEPHENS)
4.00
1.00
54650
ORCHIOPEXY (FOWLER-STEPHENS)
18.85
1.00
54660
REVISION OF TESTIS
999.99
1.00
54670
REPAIR TESTIS INJURY
3.00
1.00
54670
REPAIR TESTIS INJURY
10.65
1.00
54680
RELOCATION OF TESTIS(ES)
3.00
1.00
54680
RELOCATION OF TESTIS(ES)
20.65
1.00
54690
LAPAROSCOPY, ORCHIECTOMY
6.00
1.00
54690
LAPAROSCOPY, ORCHIECTOMY
18.27
1.00
54692
LAPAROSCOPY, ORCHIOPEXY
6.00
1.00
54692
LAPAROSCOPY, ORCHIOPEXY
19.22
1.00
54700
DRAINAGE OF SCROTUM
3.00
1.00
54700
DRAINAGE OF SCROTUM
6.72
1.00
54800
BIOPSY OF EPIDIDYMIS
3.00
1.00
54800
BIOPSY OF EPIDIDYMIS
3.26
1.00
54820
EXPLORATION OF EPIDIDYMIS
3.00
1.00
54820
EXPLORATION OF EPIDIDYMIS
8.73
1.00
54830
REMOVE EPIDIDYMIS LESION
3.00
1.00
54830
REMOVE EPIDIDYMIS LESION
9.05
1.00
54840
REMOVE EPIDIDYMIS LESION
3.00
1.00
54840
REMOVE EPIDIDYMIS LESION
8.75
1.00
54860
REMOVAL OF EPIDIDYMIS
3.00
1.00
54860
REMOVAL OF EPIDIDYMIS
10.50
1.00
54861
REMOVAL OF EPIDIDYMIS
3.00
1.00
Procedure Code Description 54861
REMOVAL OF EPIDIDYMIS
54900
RVU
RVU Coeff Value
14.06
1.00
FUSION OF SPERMATIC DUCTS
3.00
1.00
54900
FUSION OF SPERMATIC DUCTS
20.76
1.00
54901
FUSION OF SPERMATIC DUCTS
3.00
1.00
54901
FUSION OF SPERMATIC DUCTS
28.26
1.00
55000
DRAINAGE OF HYDROCELE
2.01
1.00
55000
DRAINAGE OF HYDROCELE
3.00
1.00
55040
REMOVAL OF HYDROCELE
3.00
1.00
55040
REMOVAL OF HYDROCELE
8.81
1.00
55041
REMOVAL OF HYDROCELES
3.00
1.00
55041
REMOVAL OF HYDROCELES
12.35
1.00
55060
REPAIR OF HYDROCELE
4.00
1.00
55060
REPAIR OF HYDROCELE
9.08
1.00
55100
DRAINAGE OF SCROTUM ABSCESS
3.00
1.00
55100
DRAINAGE OF SCROTUM ABSCESS
5.50
1.00
55110
EXPLORE SCROTUM
3.00
1.00
55110
EXPLORE SCROTUM
9.28
1.00
55120
REMOVAL OF SCROTUM LESION
3.00
1.00
55120
REMOVAL OF SCROTUM LESION
8.47
1.00
55150
REMOVAL OF SCROTUM
3.00
1.00
55150
REMOVAL OF SCROTUM
11.91
1.00
55175
REVISION OF SCROTUM
3.00
1.00
55175
REVISION OF SCROTUM
8.88
1.00
55180
REVISION OF SCROTUM
3.00
1.00
55180
REVISION OF SCROTUM
17.43
1.00
55250
REMOVAL OF SPERM DUCT(S)
3.00
1.00
55250
REMOVAL OF SPERM DUCT(S)
6.42
1.00
55450
LIGATION OF SPERM DUCT
3.00
1.00
55450
LIGATION OF SPERM DUCT
6.79
1.00
55500
REMOVAL OF HYDROCELE
3.00
1.00
55500
REMOVAL OF HYDROCELE
9.46
1.00
55520
REMOVAL OF SPERM CORD LESION
3.00
1.00
55520
REMOVAL OF SPERM CORD LESION
10.23
1.00
55530
REVISE SPERMATIC CORD VEINS
3.00
1.00
55530
REVISE SPERMATIC CORD VEINS
9.45
1.00
Procedure Code Description
RVU
RVU Coeff Value
55535
REVISE SPERMATIC CORD VEINS
6.00
1.00
55535
REVISE SPERMATIC CORD VEINS
10.69
1.00
55540
REVISE HERNIA & SPERM VEINS
3.00
1.00
55540
REVISE HERNIA & SPERM VEINS
12.61
1.00
55550
LAPARO LIGATE SPERMATIC VEIN
6.00
1.00
55550
LAPARO LIGATE SPERMATIC VEIN
10.54
1.00
55600
INCISE SPERM DUCT POUCH
3.00
1.00
55600
INCISE SPERM DUCT POUCH
10.58
1.00
55605
INCISE SPERM DUCT POUCH
3.00
1.00
55605
INCISE SPERM DUCT POUCH
13.40
1.00
55650
REMOVE SPERM DUCT POUCH
4.00
1.00
55650
REMOVE SPERM DUCT POUCH
18.33
1.00
55680
REMOVE SPERM POUCH LESION
6.00
1.00
55680
REMOVE SPERM POUCH LESION
8.98
1.00
55700
BIOPSY OF PROSTATE
2.40
1.00
55700
BIOPSY OF PROSTATE
3.00
1.00
55705
BIOPSY OF PROSTATE
4.00
1.00
55705
BIOPSY OF PROSTATE
8.13
1.00
55720
DRAINAGE OF PROSTATE ABSCESS
4.00
1.00
55720
DRAINAGE OF PROSTATE ABSCESS
13.38
1.00
55725
DRAINAGE OF PROSTATE ABSCESS
4.00
1.00
55725
DRAINAGE OF PROSTATE ABSCESS
15.04
1.00
55801
REMOVAL OF PROSTATE
4.00
1.00
55801
REMOVAL OF PROSTATE
27.70
1.00
55810
EXTENSIVE PROSTATE SURGERY
4.00
1.00
55810
EXTENSIVE PROSTATE SURGERY
34.72
1.00
55812
EXTENSIVE PROSTATE SURGERY
4.00
1.00
55812
EXTENSIVE PROSTATE SURGERY
42.17
1.00
55815
EXTENSIVE PROSTATE SURGERY
4.00
1.00
55815
EXTENSIVE PROSTATE SURGERY
46.15
1.00
55821
REMOVAL OF PROSTATE
6.00
1.00
55821
REMOVAL OF PROSTATE
22.43
1.00
55831
REMOVAL OF PROSTATE
4.00
1.00
55831
REMOVAL OF PROSTATE
24.37
1.00
55840
EXTENSIVE PROSTATE SURGERY
4.00
1.00
Procedure Code Description
RVU
RVU Coeff Value
55840
EXTENSIVE PROSTATE SURGERY
35.33
1.00
55842
EXTENSIVE PROSTATE SURGERY
4.00
1.00
55842
EXTENSIVE PROSTATE SURGERY
37.71
1.00
55845
EXTENSIVE PROSTATE SURGERY
4.00
1.00
55845
EXTENSIVE PROSTATE SURGERY
43.40
1.00
55859
PERCUT/NEEDLE INSERT, PROS
6.00
1.00
55859
PERCUT/NEEDLE INSERT, PROS
20.12
1.00
55860
SURGICAL EXPOSURE, PROSTATE
6.00
1.00
55860
SURGICAL EXPOSURE, PROSTATE
22.85
1.00
55862
EXTENSIVE PROSTATE SURGERY
6.00
1.00
55862
EXTENSIVE PROSTATE SURGERY
28.72
1.00
55865
EXTENSIVE PROSTATE SURGERY
6.00
1.00
55865
EXTENSIVE PROSTATE SURGERY
34.74
1.00
55866
LAPARO RADICAL PROSTATECTOMY
43.90
1.00
55873
CRYOABLATE PROSTATE
4.00
1.00
55873
CRYOABLATE PROSTATE
29.95
1.00
56405
I & D OF VULVA/PERINEUM
2.81
1.00
56405
I & D OF VULVA/PERINEUM
3.00
1.00
56420
DRAINAGE OF GLAND ABSCESS
2.76
1.00
56420
DRAINAGE OF GLAND ABSCESS
3.00
1.00
56440
SURGERY FOR VULVA LESION
3.00
1.00
56440
SURGERY FOR VULVA LESION
5.34
1.00
56441
LYSIS OF LABIAL LESION(S)
3.00
1.00
56441
LYSIS OF LABIAL LESION(S)
3.95
1.00
56501
DESTROY, VULVA LESIONS, SIM
2.97
1.00
56501
DESTROY, VULVA LESIONS, SIM
3.00
1.00
56515
DESTROY VULVA LESION/S COMPL
3.00
1.00
56515
DESTROY VULVA LESION/S COMPL
5.18
1.00
56605
BIOPSY OF VULVA/PERINEUM
1.68
1.00
56605
BIOPSY OF VULVA/PERINEUM
3.00
1.00
56606
BIOPSY OF VULVA/PERINEUM
0.83
1.00
56606
BIOPSY OF VULVA/PERINEUM
999.99
1.00
56620
PARTIAL REMOVAL OF VULVA
3.00
1.00
56620
PARTIAL REMOVAL OF VULVA
13.08
1.00
56625
COMPLETE REMOVAL OF VULVA
3.00
1.00
Procedure Code Description 56625
COMPLETE REMOVAL OF VULVA
56630
RVU
RVU Coeff Value
15.02
1.00
EXTENSIVE VULVA SURGERY
3.00
1.00
56630
EXTENSIVE VULVA SURGERY
21.19
1.00
56631
EXTENSIVE VULVA SURGERY
7.00
1.00
56631
EXTENSIVE VULVA SURGERY
28.10
1.00
56632
EXTENSIVE VULVA SURGERY
4.00
1.00
56632
EXTENSIVE VULVA SURGERY
32.55
1.00
56633
EXTENSIVE VULVA SURGERY
4.00
1.00
56633
EXTENSIVE VULVA SURGERY
27.40
1.00
56634
EXTENSIVE VULVA SURGERY
4.00
1.00
56634
EXTENSIVE VULVA SURGERY
30.61
1.00
56637
EXTENSIVE VULVA SURGERY
4.00
1.00
56637
EXTENSIVE VULVA SURGERY
36.79
1.00
56640
EXTENSIVE VULVA SURGERY
5.00
1.00
56640
EXTENSIVE VULVA SURGERY
36.67
1.00
56700
PARTIAL REMOVAL OF HYMEN
3.00
1.00
56700
PARTIAL REMOVAL OF HYMEN
4.46
1.00
56720
INCISION OF HYMEN
1.16
1.00
56720
INCISION OF HYMEN
3.00
1.00
56740
REMOVE VAGINA GLAND LESION
3.00
1.00
56740
REMOVE VAGINA GLAND LESION
7.52
1.00
56800
REPAIR OF VAGINA
3.00
1.00
56800
REPAIR OF VAGINA
6.87
1.00
56805
REPAIR CLITORIS
29.80
1.00
56805
REPAIR CLITORIS
999.99
1.00
56810
REPAIR OF PERINEUM
3.00
1.00
56810
REPAIR OF PERINEUM
7.26
1.00
56820
EXAM OF VULVA W/SCOPE
2.25
1.00
56821
EXAM/BIOPSY OF VULVA W/SCOPE
3.10
1.00
57000
EXPLORATION OF VAGINA
3.00
1.00
57000
EXPLORATION OF VAGINA
5.44
1.00
57010
DRAINAGE OF PELVIC ABSCESS
6.00
1.00
57010
DRAINAGE OF PELVIC ABSCESS
10.39
1.00
57020
DRAINAGE OF PELVIC FLUID
2.28
1.00
57020
DRAINAGE OF PELVIC FLUID
3.00
1.00
Procedure Code Description
RVU
RVU Coeff Value
57022
I & D VAGINAL HEMATOMA, PP
3.00
1.00
57022
I & D VAGINAL HEMATOMA, PP
4.83
1.00
57023
I & D VAG HEMATOMA, NON-OB
3.00
1.00
57023
I & D VAG HEMATOMA, NON-OB
7.88
1.00
57061
DESTROY VAG LESIONS, SIMPLE
2.54
1.00
57061
DESTROY VAG LESIONS, SIMPLE
3.00
1.00
57065
DESTROY VAG LESIONS, COMPLEX
3.00
1.00
57065
DESTROY VAG LESIONS, COMPLEX
5.10
1.00
57100
BIOPSY OF VAGINA
1.80
1.00
57100
BIOPSY OF VAGINA
3.00
1.00
57105
BIOPSY OF VAGINA
3.00
1.00
57105
BIOPSY OF VAGINA
3.17
1.00
57106
REMOVE VAGINA WALL, PARTIAL
5.00
1.00
57106
REMOVE VAGINA WALL, PARTIAL
10.81
1.00
57107
REMOVE VAGINA TISSUE, PART
5.00
1.00
57107
REMOVE VAGINA TISSUE, PART
35.45
1.00
57109
VAGINECTOMY PARTIAL W/NODES
5.00
1.00
57109
VAGINECTOMY PARTIAL W/NODES
40.50
1.00
57110
REMOVE VAGINA WALL, COMPLETE
5.00
1.00
57110
REMOVE VAGINA WALL, COMPLETE
22.93
1.00
57111
REMOVE VAGINA TISSUE, COMPL
5.00
1.00
57111
REMOVE VAGINA TISSUE, COMPL
42.01
1.00
57112
VAGINECTOMY W/NODES, COMPL
5.00
1.00
57112
VAGINECTOMY W/NODES, COMPL
43.58
1.00
57120
CLOSURE OF VAGINA
4.00
1.00
57120
CLOSURE OF VAGINA
12.75
1.00
57130
REMOVE VAGINA LESION
3.00
1.00
57130
REMOVE VAGINA LESION
4.69
1.00
57135
REMOVE VAGINA LESION
4.00
1.00
57135
REMOVE VAGINA LESION
5.06
1.00
57150
TREAT VAGINA INFECTION
0.83
1.00
57155
INSERT UTERI TANDEMS/OVOIDS
10.54
1.00
57160
INSERT PESSARY/OTHER DEVICE
1.38
1.00
57170
FITTING OF DIAPHRAGM/CAP
1.34
1.00
57180
TREAT VAGINAL BLEEDING
3.15
1.00
Procedure Code Description
RVU
RVU Coeff Value
57200
REPAIR OF VAGINA
3.00
1.00
57200
REPAIR OF VAGINA
7.43
1.00
57210
REPAIR VAGINA/PERINEUM
4.00
1.00
57210
REPAIR VAGINA/PERINEUM
9.34
1.00
57220
REVISION OF URETHRA
3.00
1.00
57220
REVISION OF URETHRA
8.07
1.00
57230
REPAIR OF URETHRAL LESION
3.00
1.00
57230
REPAIR OF URETHRAL LESION
9.68
1.00
57240
REPAIR BLADDER & VAGINA
4.00
1.00
57240
REPAIR BLADDER & VAGINA
10.50
1.00
57250
REPAIR RECTUM & VAGINA
4.00
1.00
57250
REPAIR RECTUM & VAGINA
9.88
1.00
57260
REPAIR OF VAGINA
4.00
1.00
57260
REPAIR OF VAGINA
14.24
1.00
57265
EXTENSIVE REPAIR OF VAGINA
4.00
1.00
57265
EXTENSIVE REPAIR OF VAGINA
18.86
1.00
57268
REPAIR OF BOWEL BULGE
4.00
1.00
57268
REPAIR OF BOWEL BULGE
11.90
1.00
57270
REPAIR OF BOWEL POUCH
5.00
1.00
57270
REPAIR OF BOWEL POUCH
19.88
1.00
57280
SUSPENSION OF VAGINA
5.00
1.00
57280
SUSPENSION OF VAGINA
24.21
1.00
57282
COLPOPEXY, EXTRAPERITONEAL
6.00
1.00
57282
COLPOPEXY, EXTRAPERITONEAL
15.30
1.00
57284
REPAIR PARAVAG DEFECT, OPEN
6.00
1.00
57284
REPAIR PARAVAG DEFECT, OPEN
20.99
1.00
57287
REVISE/REMOVE SLING REPAIR
6.00
1.00
57287
REVISE/REMOVE SLING REPAIR
17.05
1.00
57288
REPAIR BLADDER DEFECT
5.00
1.00
57288
REPAIR BLADDER DEFECT
19.93
1.00
57289
REPAIR BLADDER & VAGINA
5.00
1.00
57289
REPAIR BLADDER & VAGINA
18.79
1.00
57291
CONSTRUCTION OF VAGINA
6.00
1.00
57291
CONSTRUCTION OF VAGINA
14.02
1.00
57292
CONSTRUCT VAGINA WITH GRAFT
6.00
1.00
Procedure Code Description
RVU
RVU Coeff Value
57292
CONSTRUCT VAGINA WITH GRAFT
21.76
1.00
57300
REPAIR RECTUM-VAGINA FISTULA
4.00
1.00
57300
REPAIR RECTUM-VAGINA FISTULA
13.16
1.00
57305
REPAIR RECTUM-VAGINA FISTULA
6.00
1.00
57305
REPAIR RECTUM-VAGINA FISTULA
21.59
1.00
57307
FISTULA REPAIR & COLOSTOMY
6.00
1.00
57307
FISTULA REPAIR & COLOSTOMY
25.07
1.00
57308
FISTULA REPAIR, TRANSPERINE
4.00
1.00
57308
FISTULA REPAIR, TRANSPERINE
16.74
1.00
57310
REPAIR URETHROVAGINAL LESION
4.00
1.00
57310
REPAIR URETHROVAGINAL LESION
11.52
1.00
57311
REPAIR URETHROVAGINAL LESION
3.00
1.00
57311
REPAIR URETHROVAGINAL LESION
13.34
1.00
57320
REPAIR BLADDER-VAGINA LESION
4.00
1.00
57320
REPAIR BLADDER-VAGINA LESION
13.56
1.00
57330
REPAIR BLADDER-VAGINA LESION
6.00
1.00
57330
REPAIR BLADDER-VAGINA LESION
19.50
1.00
57335
REPAIR VAGINA
29.36
1.00
57335
REPAIR VAGINA
999.99
1.00
57400
DILATION OF VAGINA
3.00
1.00
57400
DILATION OF VAGINA
3.63
1.00
57410
PELVIC EXAMINATION
2.92
1.00
57410
PELVIC EXAMINATION
3.00
1.00
57415
REMOVE VAGINAL FOREIGN BODY
3.00
1.00
57415
REMOVE VAGINAL FOREIGN BODY
4.23
1.00
57420
EXAM OF VAGINA W/SCOPE
2.39
1.00
57421
EXAM/BIOPSY OF VAG W/SCOPE
3.31
1.00
57452
EXAM OF CERVIX W/SCOPE
2.25
1.00
57452
EXAM OF CERVIX W/SCOPE
3.00
1.00
57454
BX/CURETT OF CERVIX W/SCOPE
3.00
1.00
57454
BX/CURETT OF CERVIX W/SCOPE
3.48
1.00
57455
BIOPSY OF CERVIX W/SCOPE
3.01
1.00
57456
ENDOCERV CURETTAGE W/SCOPE
2.82
1.00
57460
BX OF CERVIX W/SCOPE, LEEP
3.00
1.00
57460
BX OF CERVIX W/SCOPE, LEEP
4.36
1.00
Procedure Code Description
RVU
RVU Coeff Value
57461
CONZ OF CERVIX W/SCOPE, LEEP
5.22
1.00
57500
BIOPSY OF CERVIX
1.56
1.00
57500
BIOPSY OF CERVIX
3.00
1.00
57505
ENDOCERVICAL CURETTAGE
2.47
1.00
57505
ENDOCERVICAL CURETTAGE
3.00
1.00
57510
CAUTERIZATION OF CERVIX
3.59
1.00
57510
CAUTERIZATION OF CERVIX
4.00
1.00
57511
CRYOCAUTERY OF CERVIX
2.83
1.00
57511
CRYOCAUTERY OF CERVIX
4.00
1.00
57513
LASER SURGERY OF CERVIX
3.00
1.00
57513
LASER SURGERY OF CERVIX
3.59
1.00
57520
CONIZATION OF CERVIX
3.00
1.00
57520
CONIZATION OF CERVIX
7.21
1.00
57522
CONIZATION OF CERVIX
3.00
1.00
57522
CONIZATION OF CERVIX
6.19
1.00
57530
REMOVAL OF CERVIX
3.00
1.00
57530
REMOVAL OF CERVIX
8.80
1.00
57531
REMOVAL OF CERVIX, RADICAL
3.00
1.00
57531
REMOVAL OF CERVIX, RADICAL
43.99
1.00
57540
REMOVAL OF RESIDUAL CERVIX
5.00
1.00
57540
REMOVAL OF RESIDUAL CERVIX
19.57
1.00
57545
REMOVE CERVIX/REPAIR PELVIS
6.00
1.00
57545
REMOVE CERVIX/REPAIR PELVIS
20.92
1.00
57550
REMOVAL OF RESIDUAL CERVIX
5.00
1.00
57550
REMOVAL OF RESIDUAL CERVIX
9.86
1.00
57555
REMOVE CERVIX/REPAIR VAGINA
4.00
1.00
57555
REMOVE CERVIX/REPAIR VAGINA
15.44
1.00
57556
REMOVE CERVIX, REPAIR BOWEL
4.00
1.00
57556
REMOVE CERVIX, REPAIR BOWEL
14.00
1.00
57700
REVISION OF CERVIX
4.00
1.00
57700
REVISION OF CERVIX
6.32
1.00
57720
REVISION OF CERVIX
4.00
1.00
57720
REVISION OF CERVIX
7.74
1.00
57800
DILATION OF CERVICAL CANAL
1.33
1.00
57800
DILATION OF CERVICAL CANAL
3.00
1.00
Procedure Code Description
RVU
RVU Coeff Value
57820
D & C OF RESIDUAL CERVIX
2.95
1.00
57820
D & C OF RESIDUAL CERVIX
3.00
1.00
58100
BIOPSY OF UTERUS LINING
2.35
1.00
58100
BIOPSY OF UTERUS LINING
3.00
1.00
58120
DILATION AND CURETTAGE
5.57
1.00
58120
DILATION AND CURETTAGE
6.00
1.00
58140
MYOMECTOMY ABDOM METHOD
6.00
1.00
58140
MYOMECTOMY ABDOM METHOD
23.07
1.00
58145
MYOMECTOMY VAG METHOD
5.00
1.00
58145
MYOMECTOMY VAG METHOD
13.68
1.00
58146
MYOMECTOMY ABDOM COMPLEX
29.61
1.00
58150
TOTAL HYSTERECTOMY
6.00
1.00
58150
TOTAL HYSTERECTOMY
24.70
1.00
58152
TOTAL HYSTERECTOMY
6.00
1.00
58152
TOTAL HYSTERECTOMY
32.40
1.00
58180
PARTIAL HYSTERECTOMY
6.00
1.00
58180
PARTIAL HYSTERECTOMY
24.68
1.00
58200
EXTENSIVE HYSTERECTOMY
6.00
1.00
58200
EXTENSIVE HYSTERECTOMY
34.34
1.00
58210
EXTENSIVE HYSTERECTOMY
8.00
1.00
58210
EXTENSIVE HYSTERECTOMY
45.72
1.00
58240
REMOVAL OF PELVIS CONTENTS
7.00
1.00
58240
REMOVAL OF PELVIS CONTENTS
60.63
1.00
58260
VAGINAL HYSTERECTOMY
6.00
1.00
58260
VAGINAL HYSTERECTOMY
20.89
1.00
58262
VAG HYST INCLUDING T/O
6.00
1.00
58262
VAG HYST INCLUDING T/O
23.62
1.00
58263
VAG HYST W/T/O & VAG REPAIR
6.00
1.00
58263
VAG HYST W/T/O & VAG REPAIR
25.56
1.00
58267
VAG HYST W/URINARY REPAIR
7.00
1.00
58267
VAG HYST W/URINARY REPAIR
27.07
1.00
58270
VAG HYST W/ENTEROCELE REPAIR
5.00
1.00
58270
VAG HYST W/ENTEROCELE REPAIR
22.82
1.00
58275
HYSTERECTOMY/REVISE VAGINA
6.00
1.00
58275
HYSTERECTOMY/REVISE VAGINA
24.99
1.00
Procedure Code Description
RVU
RVU Coeff Value
58280
HYSTERECTOMY/REVISE VAGINA
5.00
1.00
58280
HYSTERECTOMY/REVISE VAGINA
26.76
1.00
58285
EXTENSIVE HYSTERECTOMY
7.00
1.00
58285
EXTENSIVE HYSTERECTOMY
34.99
1.00
58290
VAG HYST COMPLEX
29.60
1.00
58291
VAG HYST INCL T/O, COMPLEX
32.55
1.00
58292
VAG HYST T/O & REPAIR, COMPL
34.48
1.00
58293
VAG HYST W/URO REPAIR, COMPL
35.82
1.00
58294
VAG HYST W/ENTEROCELE, COMPL
31.75
1.00
58300
INSERT INTRAUTERINE DEVICE
1.50
1.00
58301
REMOVE INTRAUTERINE DEVICE
1.90
1.00
58301
REMOVE INTRAUTERINE DEVICE
3.00
1.00
58340
CATHETER FOR HYSTEROGRAPHY
1.28
1.00
58340
CATHETER FOR HYSTEROGRAPHY
3.00
1.00
58346
INSERT HEYMAN UTERI CAPSULE
11.26
1.00
58353
ENDOMETR ABLATE, THERMAL
4.00
1.00
58353
ENDOMETR ABLATE, THERMAL
6.16
1.00
58400
SUSPENSION OF UTERUS
5.00
1.00
58400
SUSPENSION OF UTERUS
10.91
1.00
58410
SUSPENSION OF UTERUS
5.00
1.00
58410
SUSPENSION OF UTERUS
20.37
1.00
58520
REPAIR OF RUPTURED UTERUS
5.00
1.00
58520
REPAIR OF RUPTURED UTERUS
19.02
1.00
58540
REVISION OF UTERUS
6.00
1.00
58540
REVISION OF UTERUS
22.82
1.00
58545
LAPAROSCOPIC MYOMECTOMY
23.81
1.00
58546
LAPARO-MYOMECTOMY, COMPLEX
30.00
1.00
58550
LAPARO-ASST VAG HYSTERECTOMY
6.00
1.00
58550
LAPARO-ASST VAG HYSTERECTOMY
22.84
1.00
58551
LAPAROSCOPY, REMOVE MYOMA
6.00
1.00
58552
LAPARO-VAG HYST INCL T/O
23.19
1.00
58553
LAPARO-VAG HYST, COMPLEX
29.80
1.00
58554
LAPARO-VAG HYST W/T/O, COMPL
29.49
1.00
58555
HYSTEROSCOPY, DX, SEP PROC
5.16
1.00
58555
HYSTEROSCOPY, DX, SEP PROC
6.00
1.00
Procedure Code Description
RVU
RVU Coeff Value
58558
HYSTEROSCOPY, BIOPSY
6.00
1.00
58558
HYSTEROSCOPY, BIOPSY
7.36
1.00
58559
HYSTEROSCOPY, LYSIS
6.00
1.00
58559
HYSTEROSCOPY, LYSIS
9.48
1.00
58560
HYSTEROSCOPY, RESECT SEPTUM
6.00
1.00
58560
HYSTEROSCOPY, RESECT SEPTUM
10.76
1.00
58561
HYSTEROSCOPY, REMOVE MYOMA
6.00
1.00
58561
HYSTEROSCOPY, REMOVE MYOMA
15.30
1.00
58562
HYSTEROSCOPY, REMOVE FB
6.00
1.00
58562
HYSTEROSCOPY, REMOVE FB
8.00
1.00
58563
HYSTEROSCOPY, ABLATION
6.00
1.00
58563
HYSTEROSCOPY, ABLATION
9.50
1.00
58600
DIVISION OF FALLOPIAN TUBE
5.00
1.00
58600
DIVISION OF FALLOPIAN TUBE
9.27
1.00
58605
DIVISION OF FALLOPIAN TUBE
5.00
1.00
58605
DIVISION OF FALLOPIAN TUBE
8.45
1.00
58611
LIGATE OVIDUCT(S) ADD-ON
2.11
1.00
58615
OCCLUDE FALLOPIAN TUBE(S)
6.00
1.00
58615
OCCLUDE FALLOPIAN TUBE(S)
7.41
1.00
58660
LAPAROSCOPY, LYSIS
6.00
1.00
58660
LAPAROSCOPY, LYSIS
18.03
1.00
58661
LAPAROSCOPY, REMOVE ADNEXA
6.00
1.00
58661
LAPAROSCOPY, REMOVE ADNEXA
17.44
1.00
58662
LAPAROSCOPY, EXCISE LESIONS
6.00
1.00
58662
LAPAROSCOPY, EXCISE LESIONS
18.51
1.00
58670
LAPAROSCOPY, TUBAL CAUTERY
6.00
1.00
58670
LAPAROSCOPY, TUBAL CAUTERY
9.77
1.00
58671
LAPAROSCOPY, TUBAL BLOCK
6.00
1.00
58671
LAPAROSCOPY, TUBAL BLOCK
9.79
1.00
58672
LAPAROSCOPY, FIMBRIOPLASTY
6.00
1.00
58672
LAPAROSCOPY, FIMBRIOPLASTY
20.62
1.00
58673
LAPAROSCOPY, SALPINGOSTOMY
6.00
1.00
58673
LAPAROSCOPY, SALPINGOSTOMY
22.00
1.00
58700
REMOVAL OF FALLOPIAN TUBE
6.00
1.00
58700
REMOVAL OF FALLOPIAN TUBE
18.49
1.00
Procedure Code Description
RVU
RVU Coeff Value
58720
REMOVAL OF OVARY/TUBE(S)
6.00
1.00
58720
REMOVAL OF OVARY/TUBE(S)
18.25
1.00
58740
ADHESIOLYSIS TUBE, OVARY
6.00
1.00
58740
ADHESIOLYSIS TUBE, OVARY
21.58
1.00
58770
CREATE NEW TUBAL OPENING
6.00
1.00
58770
CREATE NEW TUBAL OPENING
22.36
1.00
58800
DRAINAGE OF OVARIAN CYST(S)
6.00
1.00
58800
DRAINAGE OF OVARIAN CYST(S)
8.86
1.00
58805
DRAINAGE OF OVARIAN CYST(S)
5.00
1.00
58805
DRAINAGE OF OVARIAN CYST(S)
9.91
1.00
58820
DRAIN OVARY ABSCESS, OPEN
5.00
1.00
58820
DRAIN OVARY ABSCESS, OPEN
7.85
1.00
58822
DRAIN OVARY ABSCESS, PERCUT
5.00
1.00
58822
DRAIN OVARY ABSCESS, PERCUT
16.09
1.00
58823
DRAIN PELVIC ABSCESS, PERCUT
5.88
1.00
58823
DRAIN PELVIC ABSCESS, PERCUT
6.00
1.00
58825
TRANSPOSITION, OVARY(S)
6.00
1.00
58825
TRANSPOSITION, OVARY(S)
17.34
1.00
58900
BIOPSY OF OVARY(S)
6.00
1.00
58900
BIOPSY OF OVARY(S)
10.08
1.00
58920
PARTIAL REMOVAL OF OVARY(S)
5.00
1.00
58920
PARTIAL REMOVAL OF OVARY(S)
17.62
1.00
58925
REMOVAL OF OVARIAN CYST(S)
6.00
1.00
58925
REMOVAL OF OVARIAN CYST(S)
18.04
1.00
58940
REMOVAL OF OVARY(S)
6.00
1.00
58940
REMOVAL OF OVARY(S)
11.96
1.00
58943
REMOVAL OF OVARY(S)
6.00
1.00
58943
REMOVAL OF OVARY(S)
29.73
1.00
58950
RESECT OVARIAN MALIGNANCY
6.00
1.00
58950
RESECT OVARIAN MALIGNANCY
27.48
1.00
58951
RESECT OVARIAN MALIGNANCY
8.00
1.00
58951
RESECT OVARIAN MALIGNANCY
35.90
1.00
58952
RESECT OVARIAN MALIGNANCY
39.99
1.00
58953
TAH, RAD DISSECT FOR DEBULK
8.00
1.00
58953
TAH, RAD DISSECT FOR DEBULK
50.38
1.00
Procedure Code Description
RVU
RVU Coeff Value
58954
TAH RAD DEBULK/LYMPH REMOVE
8.00
1.00
58954
TAH RAD DEBULK/LYMPH REMOVE
54.71
1.00
58960
EXPLORATION OF ABDOMEN
6.00
1.00
58960
EXPLORATION OF ABDOMEN
24.24
1.00
58999
GENITAL SURGERY PROCEDURE
999.99
1.00
61000
REMOVE CRANIAL CAVITY FLUID
2.69
1.00
61000
REMOVE CRANIAL CAVITY FLUID
2.70
1.00
61000
REMOVE CRANIAL CAVITY FLUID
2.84
1.00
61000
REMOVE CRANIAL CAVITY FLUID
4.00
1.00
61001
REMOVE CRANIAL CAVITY FLUID
2.72
1.00
61001
REMOVE CRANIAL CAVITY FLUID
2.73
1.00
61001
REMOVE CRANIAL CAVITY FLUID
2.79
1.00
61001
REMOVE CRANIAL CAVITY FLUID
4.00
1.00
61020
REMOVE BRAIN CAVITY FLUID
3.15
1.00
61020
REMOVE BRAIN CAVITY FLUID
3.17
1.00
61020
REMOVE BRAIN CAVITY FLUID
3.38
1.00
61020
REMOVE BRAIN CAVITY FLUID
7.00
1.00
61026
INJECTION INTO BRAIN CANAL
3.35
1.00
61026
INJECTION INTO BRAIN CANAL
3.37
1.00
61026
INJECTION INTO BRAIN CANAL
5.00
1.00
61050
REMOVE BRAIN CANAL FLUID
2.82
1.00
61050
REMOVE BRAIN CANAL FLUID
2.91
1.00
61050
REMOVE BRAIN CANAL FLUID
2.93
1.00
61050
REMOVE BRAIN CANAL FLUID
5.00
1.00
61055
INJECTION INTO BRAIN CANAL
3.64
1.00
61055
INJECTION INTO BRAIN CANAL
3.65
1.00
61055
INJECTION INTO BRAIN CANAL
3.68
1.00
61055
INJECTION INTO BRAIN CANAL
5.00
1.00
61070
BRAIN CANAL SHUNT PROCEDURE
2.02
1.00
61070
BRAIN CANAL SHUNT PROCEDURE
2.03
1.00
61070
BRAIN CANAL SHUNT PROCEDURE
2.14
1.00
61105
TWIST DRILL HOLE
9.00
1.00
61105
TWIST DRILL HOLE
10.23
1.00
61105
TWIST DRILL HOLE
10.35
1.00
61105
TWIST DRILL HOLE
11.17
1.00
Procedure Code Description
RVU
RVU Coeff Value
61107
DRILL SKULL FOR IMPLANTATION
4.00
1.00
61107
DRILL SKULL FOR IMPLANTATION
8.37
1.00
61107
DRILL SKULL FOR IMPLANTATION
9.40
1.00
61107
DRILL SKULL FOR IMPLANTATION
9.54
1.00
61108
DRILL SKULL FOR DRAINAGE
9.00
1.00
61108
DRILL SKULL FOR DRAINAGE
19.52
1.00
61108
DRILL SKULL FOR DRAINAGE
19.77
1.00
61108
DRILL SKULL FOR DRAINAGE
22.18
1.00
61120
BURR HOLE FOR PUNCTURE
4.00
1.00
61120
BURR HOLE FOR PUNCTURE
16.69
1.00
61120
BURR HOLE FOR PUNCTURE
16.93
1.00
61120
BURR HOLE FOR PUNCTURE
18.16
1.00
61140
PIERCE SKULL FOR BIOPSY
9.00
1.00
61140
PIERCE SKULL FOR BIOPSY
29.16
1.00
61140
PIERCE SKULL FOR BIOPSY
29.59
1.00
61140
PIERCE SKULL FOR BIOPSY
31.65
1.00
61150
PIERCE SKULL FOR DRAINAGE
9.00
1.00
61150
PIERCE SKULL FOR DRAINAGE
31.75
1.00
61150
PIERCE SKULL FOR DRAINAGE
32.20
1.00
61150
PIERCE SKULL FOR DRAINAGE
33.83
1.00
61151
PIERCE SKULL FOR DRAINAGE
5.00
1.00
61151
PIERCE SKULL FOR DRAINAGE
22.88
1.00
61151
PIERCE SKULL FOR DRAINAGE
23.20
1.00
61151
PIERCE SKULL FOR DRAINAGE
24.46
1.00
61154
PIERCE SKULL & REMOVE CLOT
11.00
1.00
61154
PIERCE SKULL & REMOVE CLOT
27.74
1.00
61154
PIERCE SKULL & REMOVE CLOT
28.15
1.00
61154
PIERCE SKULL & REMOVE CLOT
31.74
1.00
61156
PIERCE SKULL FOR DRAINAGE
9.00
1.00
61156
PIERCE SKULL FOR DRAINAGE
29.81
1.00
61156
PIERCE SKULL FOR DRAINAGE
30.28
1.00
61156
PIERCE SKULL FOR DRAINAGE
31.64
1.00
61210
PIERCE SKULL, IMPLANT DEVICE
7.00
1.00
61210
PIERCE SKULL, IMPLANT DEVICE
9.77
1.00
61210
PIERCE SKULL, IMPLANT DEVICE
10.78
1.00
Procedure Code Description 61210
PIERCE SKULL, IMPLANT DEVICE
61215
RVU
RVU Coeff Value
10.94
1.00
INSERT BRAIN-FLUID DEVICE
3.00
1.00
61215
INSERT BRAIN-FLUID DEVICE
9.97
1.00
61215
INSERT BRAIN-FLUID DEVICE
10.09
1.00
61215
INSERT BRAIN-FLUID DEVICE
12.09
1.00
61250
PIERCE SKULL & EXPLORE
7.00
1.00
61250
PIERCE SKULL & EXPLORE
19.45
1.00
61250
PIERCE SKULL & EXPLORE
19.71
1.00
61250
PIERCE SKULL & EXPLORE
21.35
1.00
61253
PIERCE SKULL & EXPLORE
9.00
1.00
61253
PIERCE SKULL & EXPLORE
22.49
1.00
61253
PIERCE SKULL & EXPLORE
22.81
1.00
61253
PIERCE SKULL & EXPLORE
23.36
1.00
61304
OPEN SKULL FOR EXPLORATION
11.00
1.00
61304
OPEN SKULL FOR EXPLORATION
39.47
1.00
61304
OPEN SKULL FOR EXPLORATION
40.03
1.00
61304
OPEN SKULL FOR EXPLORATION
41.77
1.00
61305
OPEN SKULL FOR EXPLORATION
15.00
1.00
61305
OPEN SKULL FOR EXPLORATION
47.56
1.00
61305
OPEN SKULL FOR EXPLORATION
48.27
1.00
61305
OPEN SKULL FOR EXPLORATION
50.13
1.00
61312
OPEN SKULL FOR DRAINAGE
11.00
1.00
61312
OPEN SKULL FOR DRAINAGE
44.98
1.00
61312
OPEN SKULL FOR DRAINAGE
45.63
1.00
61312
OPEN SKULL FOR DRAINAGE
52.01
1.00
61313
OPEN SKULL FOR DRAINAGE
11.00
1.00
61313
OPEN SKULL FOR DRAINAGE
45.20
1.00
61313
OPEN SKULL FOR DRAINAGE
45.85
1.00
61313
OPEN SKULL FOR DRAINAGE
49.85
1.00
61314
OPEN SKULL FOR DRAINAGE
11.00
1.00
61314
OPEN SKULL FOR DRAINAGE
41.57
1.00
61314
OPEN SKULL FOR DRAINAGE
42.09
1.00
61314
OPEN SKULL FOR DRAINAGE
46.24
1.00
61315
OPEN SKULL FOR DRAINAGE
11.00
1.00
61315
OPEN SKULL FOR DRAINAGE
49.72
1.00
Procedure Code Description
RVU
RVU Coeff Value
61315
OPEN SKULL FOR DRAINAGE
50.49
1.00
61315
OPEN SKULL FOR DRAINAGE
52.64
1.00
61316
IMPLT CRAN BONE FLAP TO ABDO
2.30
1.00
61316
IMPLT CRAN BONE FLAP TO ABDO
2.39
1.00
61316
IMPLT CRAN BONE FLAP TO ABDO
2.48
1.00
61320
OPEN SKULL FOR DRAINAGE
11.00
1.00
61320
OPEN SKULL FOR DRAINAGE
45.98
1.00
61320
OPEN SKULL FOR DRAINAGE
46.65
1.00
61320
OPEN SKULL FOR DRAINAGE
48.68
1.00
61321
OPEN SKULL FOR DRAINAGE
11.00
1.00
61321
OPEN SKULL FOR DRAINAGE
50.40
1.00
61321
OPEN SKULL FOR DRAINAGE
51.09
1.00
61321
OPEN SKULL FOR DRAINAGE
53.31
1.00
61322
DECOMPRESSIVE CRANIOTOMY
48.37
1.00
61322
DECOMPRESSIVE CRANIOTOMY
49.93
1.00
61322
DECOMPRESSIVE CRANIOTOMY
59.08
1.00
61323
DECOMPRESSIVE LOBECTOMY
50.07
1.00
61323
DECOMPRESSIVE LOBECTOMY
51.61
1.00
61323
DECOMPRESSIVE LOBECTOMY
60.19
1.00
61330
DECOMPRESS EYE SOCKET
11.00
1.00
61330
DECOMPRESS EYE SOCKET
40.00
1.00
61330
DECOMPRESS EYE SOCKET
40.20
1.00
61330
DECOMPRESS EYE SOCKET
40.21
1.00
61332
EXPLORE/BIOPSY EYE SOCKET
11.00
1.00
61332
EXPLORE/BIOPSY EYE SOCKET
47.30
1.00
61332
EXPLORE/BIOPSY EYE SOCKET
47.40
1.00
61332
EXPLORE/BIOPSY EYE SOCKET
47.91
1.00
61333
EXPLORE ORBIT/REMOVE LESION
11.00
1.00
61333
EXPLORE ORBIT/REMOVE LESION
46.21
1.00
61333
EXPLORE ORBIT/REMOVE LESION
46.27
1.00
61333
EXPLORE ORBIT/REMOVE LESION
47.47
1.00
61334
EXPLORE ORBIT/REMOVE OBJECT
11.00
1.00
61334
EXPLORE ORBIT/REMOVE OBJECT
30.54
1.00
61334
EXPLORE ORBIT/REMOVE OBJECT
32.22
1.00
61334
EXPLORE ORBIT/REMOVE OBJECT
32.58
1.00
Procedure Code Description
RVU
RVU Coeff Value
61340
SUBTEMPORAL DECOMPRESSION
11.00
1.00
61340
SUBTEMPORAL DECOMPRESSION
33.73
1.00
61340
SUBTEMPORAL DECOMPRESSION
34.20
1.00
61340
SUBTEMPORAL DECOMPRESSION
36.23
1.00
61343
INCISE SKULL (PRESS RELIEF)
11.00
1.00
61343
INCISE SKULL (PRESS RELIEF)
53.78
1.00
61343
INCISE SKULL (PRESS RELIEF)
53.89
1.00
61343
INCISE SKULL (PRESS RELIEF)
56.02
1.00
61345
RELIEVE CRANIAL PRESSURE
11.00
1.00
61345
RELIEVE CRANIAL PRESSURE
48.94
1.00
61345
RELIEVE CRANIAL PRESSURE
51.84
1.00
61440
INCISE SKULL FOR SURGERY
11.00
1.00
61440
INCISE SKULL FOR SURGERY
47.50
1.00
61440
INCISE SKULL FOR SURGERY
47.59
1.00
61440
INCISE SKULL FOR SURGERY
50.75
1.00
61450
INCISE SKULL FOR SURGERY
11.00
1.00
61450
INCISE SKULL FOR SURGERY
46.42
1.00
61450
INCISE SKULL FOR SURGERY
46.59
1.00
61450
INCISE SKULL FOR SURGERY
47.82
1.00
61458
INCISE SKULL FOR BRAIN WOUND
11.00
1.00
61458
INCISE SKULL FOR BRAIN WOUND
49.16
1.00
61458
INCISE SKULL FOR BRAIN WOUND
49.20
1.00
61458
INCISE SKULL FOR BRAIN WOUND
51.28
1.00
61460
INCISE SKULL FOR SURGERY
11.00
1.00
61460
INCISE SKULL FOR SURGERY
51.03
1.00
61460
INCISE SKULL FOR SURGERY
51.05
1.00
61460
INCISE SKULL FOR SURGERY
51.61
1.00
61470
INCISE SKULL FOR SURGERY
11.00
1.00
61470
INCISE SKULL FOR SURGERY
45.54
1.00
61470
INCISE SKULL FOR SURGERY
45.77
1.00
61470
INCISE SKULL FOR SURGERY
48.00
1.00
61480
INCISE SKULL FOR SURGERY
11.00
1.00
61480
INCISE SKULL FOR SURGERY
46.95
1.00
61480
INCISE SKULL FOR SURGERY
48.02
1.00
61480
INCISE SKULL FOR SURGERY
48.47
1.00
Procedure Code Description
RVU
RVU Coeff Value
61490
INCISE SKULL FOR SURGERY
11.00
1.00
61490
INCISE SKULL FOR SURGERY
46.49
1.00
61490
INCISE SKULL FOR SURGERY
46.59
1.00
61490
INCISE SKULL FOR SURGERY
48.62
1.00
61500
REMOVAL OF SKULL LESION
9.00
1.00
61500
REMOVAL OF SKULL LESION
32.67
1.00
61500
REMOVAL OF SKULL LESION
32.94
1.00
61500
REMOVAL OF SKULL LESION
34.12
1.00
61501
REMOVE INFECTED SKULL BONE
11.00
1.00
61501
REMOVE INFECTED SKULL BONE
27.24
1.00
61501
REMOVE INFECTED SKULL BONE
27.44
1.00
61501
REMOVE INFECTED SKULL BONE
29.15
1.00
61510
REMOVAL OF BRAIN LESION
11.00
1.00
61510
REMOVAL OF BRAIN LESION
51.44
1.00
61510
REMOVAL OF BRAIN LESION
52.13
1.00
61510
REMOVAL OF BRAIN LESION
55.24
1.00
61512
REMOVE BRAIN LINING LESION
11.00
1.00
61512
REMOVE BRAIN LINING LESION
62.95
1.00
61512
REMOVE BRAIN LINING LESION
63.41
1.00
61512
REMOVE BRAIN LINING LESION
65.33
1.00
61514
REMOVAL OF BRAIN ABSCESS
11.00
1.00
61514
REMOVAL OF BRAIN ABSCESS
45.85
1.00
61514
REMOVAL OF BRAIN ABSCESS
45.90
1.00
61514
REMOVAL OF BRAIN ABSCESS
48.43
1.00
61516
REMOVAL OF BRAIN LESION
11.00
1.00
61516
REMOVAL OF BRAIN LESION
44.47
1.00
61516
REMOVAL OF BRAIN LESION
44.86
1.00
61516
REMOVAL OF BRAIN LESION
47.24
1.00
61517
IMPLT BRAIN CHEMOTX ADD-ON
2.02
1.00
61517
IMPLT BRAIN CHEMOTX ADD-ON
2.05
1.00
61517
IMPLT BRAIN CHEMOTX ADD-ON
2.30
1.00
61518
REMOVAL OF BRAIN LESION
11.00
1.00
61518
REMOVAL OF BRAIN LESION
67.07
1.00
61518
REMOVAL OF BRAIN LESION
67.54
1.00
61518
REMOVAL OF BRAIN LESION
70.26
1.00
Procedure Code Description
RVU
RVU Coeff Value
61519
REMOVE BRAIN LINING LESION
13.00
1.00
61519
REMOVE BRAIN LINING LESION
73.75
1.00
61519
REMOVE BRAIN LINING LESION
73.91
1.00
61519
REMOVE BRAIN LINING LESION
75.73
1.00
61520
REMOVAL OF BRAIN LESION
11.00
1.00
61520
REMOVAL OF BRAIN LESION
96.01
1.00
61520
REMOVAL OF BRAIN LESION
96.67
1.00
61520
REMOVAL OF BRAIN LESION
97.40
1.00
61521
REMOVAL OF BRAIN LESION
11.00
1.00
61521
REMOVAL OF BRAIN LESION
79.09
1.00
61521
REMOVAL OF BRAIN LESION
79.41
1.00
61521
REMOVAL OF BRAIN LESION
81.36
1.00
61522
REMOVAL OF BRAIN ABSCESS
13.00
1.00
61522
REMOVAL OF BRAIN ABSCESS
52.29
1.00
61522
REMOVAL OF BRAIN ABSCESS
52.31
1.00
61522
REMOVAL OF BRAIN ABSCESS
55.76
1.00
61524
REMOVAL OF BRAIN LESION
13.00
1.00
61524
REMOVAL OF BRAIN LESION
49.60
1.00
61524
REMOVAL OF BRAIN LESION
49.66
1.00
61524
REMOVAL OF BRAIN LESION
52.63
1.00
61526
REMOVAL OF BRAIN LESION
11.00
1.00
61526
REMOVAL OF BRAIN LESION
86.13
1.00
61526
REMOVAL OF BRAIN LESION
89.60
1.00
61526
REMOVAL OF BRAIN LESION
89.81
1.00
61530
REMOVAL OF BRAIN LESION
11.00
1.00
61530
REMOVAL OF BRAIN LESION
73.21
1.00
61530
REMOVAL OF BRAIN LESION
76.42
1.00
61530
REMOVAL OF BRAIN LESION
76.97
1.00
61531
IMPLANT BRAIN ELECTRODES
9.00
1.00
61531
IMPLANT BRAIN ELECTRODES
27.13
1.00
61531
IMPLANT BRAIN ELECTRODES
27.21
1.00
61531
IMPLANT BRAIN ELECTRODES
30.40
1.00
61533
IMPLANT BRAIN ELECTRODES
11.00
1.00
61533
IMPLANT BRAIN ELECTRODES
35.83
1.00
61533
IMPLANT BRAIN ELECTRODES
35.85
1.00
Procedure Code Description
RVU
RVU Coeff Value
61533
IMPLANT BRAIN ELECTRODES
38.48
1.00
61534
REMOVAL OF BRAIN LESION
11.00
1.00
61534
REMOVAL OF BRAIN LESION
38.10
1.00
61534
REMOVAL OF BRAIN LESION
38.25
1.00
61534
REMOVAL OF BRAIN LESION
41.43
1.00
61535
REMOVE BRAIN ELECTRODES
11.00
1.00
61535
REMOVE BRAIN ELECTRODES
21.83
1.00
61535
REMOVE BRAIN ELECTRODES
22.02
1.00
61535
REMOVE BRAIN ELECTRODES
24.73
1.00
61536
REMOVAL OF BRAIN LESION
11.00
1.00
61536
REMOVAL OF BRAIN LESION
63.22
1.00
61536
REMOVAL OF BRAIN LESION
63.40
1.00
61536
REMOVAL OF BRAIN LESION
66.21
1.00
61537
REMOVAL OF BRAIN TISSUE
45.90
1.00
61537
REMOVAL OF BRAIN TISSUE
60.45
1.00
61538
REMOVAL OF BRAIN TISSUE
11.00
1.00
61538
REMOVAL OF BRAIN TISSUE
48.51
1.00
61538
REMOVAL OF BRAIN TISSUE
48.64
1.00
61538
REMOVAL OF BRAIN TISSUE
64.64
1.00
61539
REMOVAL OF BRAIN TISSUE
11.00
1.00
61539
REMOVAL OF BRAIN TISSUE
57.67
1.00
61539
REMOVAL OF BRAIN TISSUE
57.86
1.00
61539
REMOVAL OF BRAIN TISSUE
59.93
1.00
61540
REMOVAL OF BRAIN TISSUE
55.42
1.00
61540
REMOVAL OF BRAIN TISSUE
56.40
1.00
61541
INCISION OF BRAIN TISSUE
11.00
1.00
61541
INCISION OF BRAIN TISSUE
51.26
1.00
61541
INCISION OF BRAIN TISSUE
51.72
1.00
61541
INCISION OF BRAIN TISSUE
53.68
1.00
61542
REMOVAL OF BRAIN TISSUE
11.00
1.00
61542
REMOVAL OF BRAIN TISSUE
56.58
1.00
61542
REMOVAL OF BRAIN TISSUE
56.71
1.00
61542
REMOVAL OF BRAIN TISSUE
58.53
1.00
61543
REMOVAL OF BRAIN TISSUE
11.00
1.00
61543
REMOVAL OF BRAIN TISSUE
52.85
1.00
Procedure Code Description
RVU
RVU Coeff Value
61543
REMOVAL OF BRAIN TISSUE
53.01
1.00
61543
REMOVAL OF BRAIN TISSUE
54.69
1.00
61544
REMOVE & TREAT BRAIN LESION
11.00
1.00
61544
REMOVE & TREAT BRAIN LESION
44.93
1.00
61544
REMOVE & TREAT BRAIN LESION
45.02
1.00
61544
REMOVE & TREAT BRAIN LESION
45.28
1.00
61545
EXCISION OF BRAIN TUMOR
11.00
1.00
61545
EXCISION OF BRAIN TUMOR
77.70
1.00
61545
EXCISION OF BRAIN TUMOR
78.77
1.00
61545
EXCISION OF BRAIN TUMOR
80.40
1.00
61546
REMOVAL OF PITUITARY GLAND
12.00
1.00
61546
REMOVAL OF PITUITARY GLAND
56.04
1.00
61546
REMOVAL OF PITUITARY GLAND
56.14
1.00
61546
REMOVAL OF PITUITARY GLAND
58.26
1.00
61548
REMOVAL OF PITUITARY GLAND
5.00
1.00
61548
REMOVAL OF PITUITARY GLAND
38.73
1.00
61548
REMOVAL OF PITUITARY GLAND
38.80
1.00
61548
REMOVAL OF PITUITARY GLAND
38.94
1.00
61550
RELEASE OF SKULL SEAMS
9.00
1.00
61550
RELEASE OF SKULL SEAMS
23.01
1.00
61550
RELEASE OF SKULL SEAMS
23.13
1.00
61550
RELEASE OF SKULL SEAMS
25.11
1.00
61552
RELEASE OF SKULL SEAMS
11.00
1.00
61552
RELEASE OF SKULL SEAMS
29.79
1.00
61552
RELEASE OF SKULL SEAMS
30.28
1.00
61552
RELEASE OF SKULL SEAMS
32.91
1.00
61556
INCISE SKULL/SUTURES
37.84
1.00
61556
INCISE SKULL/SUTURES
37.96
1.00
61556
INCISE SKULL/SUTURES
41.28
1.00
61556
INCISE SKULL/SUTURES
999.99
1.00
61557
INCISE SKULL/SUTURES
40.92
1.00
61557
INCISE SKULL/SUTURES
41.67
1.00
61557
INCISE SKULL/SUTURES
42.83
1.00
61557
INCISE SKULL/SUTURES
999.99
1.00
61558
EXCISION OF SKULL/SUTURES
42.57
1.00
Procedure Code Description
RVU
RVU Coeff Value
61558
EXCISION OF SKULL/SUTURES
42.94
1.00
61558
EXCISION OF SKULL/SUTURES
43.32
1.00
61558
EXCISION OF SKULL/SUTURES
999.99
1.00
61559
EXCISION OF SKULL/SUTURES
11.00
1.00
61559
EXCISION OF SKULL/SUTURES
59.32
1.00
61559
EXCISION OF SKULL/SUTURES
60.40
1.00
61559
EXCISION OF SKULL/SUTURES
61.34
1.00
61563
EXCISION OF SKULL TUMOR
47.36
1.00
61563
EXCISION OF SKULL TUMOR
47.50
1.00
61563
EXCISION OF SKULL TUMOR
48.75
1.00
61563
EXCISION OF SKULL TUMOR
999.99
1.00
61564
EXCISION OF SKULL TUMOR
59.63
1.00
61564
EXCISION OF SKULL TUMOR
60.69
1.00
61564
EXCISION OF SKULL TUMOR
61.81
1.00
61564
EXCISION OF SKULL TUMOR
999.99
1.00
61566
REMOVAL OF BRAIN TISSUE
54.86
1.00
61566
REMOVAL OF BRAIN TISSUE
56.66
1.00
61567
INCISION OF BRAIN TISSUE
62.67
1.00
61567
INCISION OF BRAIN TISSUE
63.32
1.00
61570
REMOVE FOREIGN BODY, BRAIN
11.00
1.00
61570
REMOVE FOREIGN BODY, BRAIN
43.57
1.00
61570
REMOVE FOREIGN BODY, BRAIN
44.08
1.00
61570
REMOVE FOREIGN BODY, BRAIN
46.42
1.00
61571
INCISE SKULL FOR BRAIN WOUND
15.00
1.00
61571
INCISE SKULL FOR BRAIN WOUND
47.32
1.00
61571
INCISE SKULL FOR BRAIN WOUND
47.87
1.00
61571
INCISE SKULL FOR BRAIN WOUND
49.97
1.00
61575
SKULL BASE/BRAINSTEM SURGERY
11.00
1.00
61575
SKULL BASE/BRAINSTEM SURGERY
59.31
1.00
61575
SKULL BASE/BRAINSTEM SURGERY
60.10
1.00
61575
SKULL BASE/BRAINSTEM SURGERY
60.58
1.00
61576
SKULL BASE/BRAINSTEM SURGERY
11.00
1.00
61576
SKULL BASE/BRAINSTEM SURGERY
87.67
1.00
61576
SKULL BASE/BRAINSTEM SURGERY
87.91
1.00
61576
SKULL BASE/BRAINSTEM SURGERY
93.90
1.00
Procedure Code Description
RVU
RVU Coeff Value
61580
CRANIOFACIAL APPROACH, SKULL
7.00
1.00
61580
CRANIOFACIAL APPROACH, SKULL
52.25
1.00
61580
CRANIOFACIAL APPROACH, SKULL
59.11
1.00
61580
CRANIOFACIAL APPROACH, SKULL
61.64
1.00
61581
CRANIOFACIAL APPROACH, SKULL
7.00
1.00
61581
CRANIOFACIAL APPROACH, SKULL
53.36
1.00
61581
CRANIOFACIAL APPROACH, SKULL
61.66
1.00
61581
CRANIOFACIAL APPROACH, SKULL
69.24
1.00
61582
CRANIOFACIAL APPROACH, SKULL
11.00
1.00
61582
CRANIOFACIAL APPROACH, SKULL
57.22
1.00
61582
CRANIOFACIAL APPROACH, SKULL
66.20
1.00
61582
CRANIOFACIAL APPROACH, SKULL
72.11
1.00
61583
CRANIOFACIAL APPROACH, SKULL
11.00
1.00
61583
CRANIOFACIAL APPROACH, SKULL
65.77
1.00
61583
CRANIOFACIAL APPROACH, SKULL
69.54
1.00
61583
CRANIOFACIAL APPROACH, SKULL
73.53
1.00
61584
ORBITOCRANIAL APPROACH/SKULL
11.00
1.00
61584
ORBITOCRANIAL APPROACH/SKULL
62.10
1.00
61584
ORBITOCRANIAL APPROACH/SKULL
66.89
1.00
61584
ORBITOCRANIAL APPROACH/SKULL
71.35
1.00
61585
ORBITOCRANIAL APPROACH/SKULL
11.00
1.00
61585
ORBITOCRANIAL APPROACH/SKULL
67.38
1.00
61585
ORBITOCRANIAL APPROACH/SKULL
72.48
1.00
61585
ORBITOCRANIAL APPROACH/SKULL
75.06
1.00
61586
RESECT NASOPHARYNX, SKULL
11.00
1.00
61586
RESECT NASOPHARYNX, SKULL
44.84
1.00
61586
RESECT NASOPHARYNX, SKULL
51.66
1.00
61586
RESECT NASOPHARYNX, SKULL
53.88
1.00
61590
INFRATEMPORAL APPROACH/SKULL
11.00
1.00
61590
INFRATEMPORAL APPROACH/SKULL
71.59
1.00
61590
INFRATEMPORAL APPROACH/SKULL
75.69
1.00
61590
INFRATEMPORAL APPROACH/SKULL
78.77
1.00
61591
INFRATEMPORAL APPROACH/SKULL
11.00
1.00
61591
INFRATEMPORAL APPROACH/SKULL
75.28
1.00
61591
INFRATEMPORAL APPROACH/SKULL
79.43
1.00
Procedure Code Description
RVU
RVU Coeff Value
61591
INFRATEMPORAL APPROACH/SKULL
79.66
1.00
61592
ORBITOCRANIAL APPROACH/SKULL
11.00
1.00
61592
ORBITOCRANIAL APPROACH/SKULL
70.80
1.00
61592
ORBITOCRANIAL APPROACH/SKULL
75.29
1.00
61592
ORBITOCRANIAL APPROACH/SKULL
80.59
1.00
61595
TRANSTEMPORAL APPROACH/SKULL
11.00
1.00
61595
TRANSTEMPORAL APPROACH/SKULL
51.94
1.00
61595
TRANSTEMPORAL APPROACH/SKULL
55.72
1.00
61595
TRANSTEMPORAL APPROACH/SKULL
59.60
1.00
61596
TRANSCOCHLEAR APPROACH/SKULL
11.00
1.00
61596
TRANSCOCHLEAR APPROACH/SKULL
61.89
1.00
61596
TRANSCOCHLEAR APPROACH/SKULL
65.18
1.00
61596
TRANSCOCHLEAR APPROACH/SKULL
65.30
1.00
61597
TRANSCONDYLAR APPROACH/SKULL
11.00
1.00
61597
TRANSCONDYLAR APPROACH/SKULL
65.81
1.00
61597
TRANSCONDYLAR APPROACH/SKULL
68.97
1.00
61597
TRANSCONDYLAR APPROACH/SKULL
72.96
1.00
61598
TRANSPETROSAL APPROACH/SKULL
11.00
1.00
61598
TRANSPETROSAL APPROACH/SKULL
58.66
1.00
61598
TRANSPETROSAL APPROACH/SKULL
62.26
1.00
61598
TRANSPETROSAL APPROACH/SKULL
64.02
1.00
61600
RESECT/EXCISE CRANIAL LESION
11.00
1.00
61600
RESECT/EXCISE CRANIAL LESION
44.93
1.00
61600
RESECT/EXCISE CRANIAL LESION
49.45
1.00
61600
RESECT/EXCISE CRANIAL LESION
53.74
1.00
61601
RESECT/EXCISE CRANIAL LESION
11.00
1.00
61601
RESECT/EXCISE CRANIAL LESION
50.50
1.00
61601
RESECT/EXCISE CRANIAL LESION
54.79
1.00
61601
RESECT/EXCISE CRANIAL LESION
59.52
1.00
61605
RESECT/EXCISE CRANIAL LESION
11.00
1.00
61605
RESECT/EXCISE CRANIAL LESION
50.34
1.00
61605
RESECT/EXCISE CRANIAL LESION
54.48
1.00
61605
RESECT/EXCISE CRANIAL LESION
55.90
1.00
61606
RESECT/EXCISE CRANIAL LESION
11.00
1.00
61606
RESECT/EXCISE CRANIAL LESION
69.01
1.00
Procedure Code Description
RVU
RVU Coeff Value
61606
RESECT/EXCISE CRANIAL LESION
72.21
1.00
61606
RESECT/EXCISE CRANIAL LESION
76.48
1.00
61607
RESECT/EXCISE CRANIAL LESION
11.00
1.00
61607
RESECT/EXCISE CRANIAL LESION
64.01
1.00
61607
RESECT/EXCISE CRANIAL LESION
66.96
1.00
61607
RESECT/EXCISE CRANIAL LESION
70.45
1.00
61608
RESECT/EXCISE CRANIAL LESION
11.00
1.00
61608
RESECT/EXCISE CRANIAL LESION
75.18
1.00
61608
RESECT/EXCISE CRANIAL LESION
78.73
1.00
61608
RESECT/EXCISE CRANIAL LESION
82.84
1.00
61609
TRANSECT ARTERY, SINUS
16.14
1.00
61609
TRANSECT ARTERY, SINUS
16.87
1.00
61609
TRANSECT ARTERY, SINUS
17.25
1.00
61610
TRANSECT ARTERY, SINUS
46.67
1.00
61610
TRANSECT ARTERY, SINUS
47.07
1.00
61610
TRANSECT ARTERY, SINUS
49.42
1.00
61611
TRANSECT ARTERY, SINUS
12.37
1.00
61611
TRANSECT ARTERY, SINUS
12.46
1.00
61611
TRANSECT ARTERY, SINUS
13.12
1.00
61612
TRANSECT ARTERY, SINUS
43.09
1.00
61612
TRANSECT ARTERY, SINUS
45.10
1.00
61612
TRANSECT ARTERY, SINUS
45.48
1.00
61613
REMOVE ANEURYSM, SINUS
11.00
1.00
61613
REMOVE ANEURYSM, SINUS
73.13
1.00
61613
REMOVE ANEURYSM, SINUS
77.17
1.00
61613
REMOVE ANEURYSM, SINUS
79.87
1.00
61615
RESECT/EXCISE LESION, SKULL
11.00
1.00
61615
RESECT/EXCISE LESION, SKULL
57.29
1.00
61615
RESECT/EXCISE LESION, SKULL
60.44
1.00
61615
RESECT/EXCISE LESION, SKULL
62.54
1.00
61616
RESECT/EXCISE LESION, SKULL
11.00
1.00
61616
RESECT/EXCISE LESION, SKULL
77.22
1.00
61616
RESECT/EXCISE LESION, SKULL
80.51
1.00
61616
RESECT/EXCISE LESION, SKULL
82.77
1.00
61618
REPAIR DURA
11.00
1.00
Procedure Code Description
RVU
RVU Coeff Value
61618
REPAIR DURA
30.99
1.00
61618
REPAIR DURA
31.36
1.00
61618
REPAIR DURA
32.85
1.00
61619
REPAIR DURA
11.00
1.00
61619
REPAIR DURA
37.11
1.00
61619
REPAIR DURA
37.51
1.00
61619
REPAIR DURA
37.76
1.00
61623
ENDOVASC TEMPORY VESSEL OCCL
14.69
1.00
61623
ENDOVASC TEMPORY VESSEL OCCL
14.78
1.00
61623
ENDOVASC TEMPORY VESSEL OCCL
15.00
1.00
61624
TRANSCATH OCCLUSION, CNS
15.00
1.00
61624
TRANSCATH OCCLUSION, CNS
28.43
1.00
61624
TRANSCATH OCCLUSION, CNS
28.44
1.00
61624
TRANSCATH OCCLUSION, CNS
29.81
1.00
61626
TRANSCATH OCCLUSION, NON-CNS
15.00
1.00
61626
TRANSCATH OCCLUSION, NON-CNS
23.15
1.00
61626
TRANSCATH OCCLUSION, NON-CNS
23.16
1.00
61626
TRANSCATH OCCLUSION, NON-CNS
24.17
1.00
61630
INTRACRANIAL ANGIOPLASTY
33.90
1.00
61635
INTRACRAN ANGIOPLSTY W/STENT
37.12
1.00
61640
DILATE IC VASOSPASM, INIT
17.16
1.00
61641
DILATE IC VASOSPASM ADD-ON
6.03
1.00
61642
DILATE IC VASOSPASM ADD-ON
12.06
1.00
61680
INTRACRANIAL VESSEL SURGERY
15.00
1.00
61680
INTRACRANIAL VESSEL SURGERY
55.19
1.00
61680
INTRACRANIAL VESSEL SURGERY
55.46
1.00
61680
INTRACRANIAL VESSEL SURGERY
57.78
1.00
61682
INTRACRANIAL VESSEL SURGERY
15.00
1.00
61682
INTRACRANIAL VESSEL SURGERY
108.27
1.00
61682
INTRACRANIAL VESSEL SURGERY
108.87
1.00
61682
INTRACRANIAL VESSEL SURGERY
109.16
1.00
61684
INTRACRANIAL VESSEL SURGERY
15.00
1.00
61684
INTRACRANIAL VESSEL SURGERY
70.80
1.00
61684
INTRACRANIAL VESSEL SURGERY
71.34
1.00
61684
INTRACRANIAL VESSEL SURGERY
72.39
1.00
Procedure Code Description
RVU
RVU Coeff Value
61686
INTRACRANIAL VESSEL SURGERY
15.00
1.00
61686
INTRACRANIAL VESSEL SURGERY
113.71
1.00
61686
INTRACRANIAL VESSEL SURGERY
115.19
1.00
61686
INTRACRANIAL VESSEL SURGERY
116.46
1.00
61690
INTRACRANIAL VESSEL SURGERY
15.00
1.00
61690
INTRACRANIAL VESSEL SURGERY
52.58
1.00
61690
INTRACRANIAL VESSEL SURGERY
52.72
1.00
61690
INTRACRANIAL VESSEL SURGERY
54.77
1.00
61692
INTRACRANIAL VESSEL SURGERY
15.00
1.00
61692
INTRACRANIAL VESSEL SURGERY
90.88
1.00
61692
INTRACRANIAL VESSEL SURGERY
91.67
1.00
61692
INTRACRANIAL VESSEL SURGERY
94.04
1.00
61697
BRAIN ANEURYSM REPR, COMPLX
15.00
1.00
61697
BRAIN ANEURYSM REPR, COMPLX
89.56
1.00
61697
BRAIN ANEURYSM REPR, COMPLX
91.00
1.00
61697
BRAIN ANEURYSM REPR, COMPLX
105.57
1.00
61698
BRAIN ANEURYSM REPR, COMPLX
15.00
1.00
61698
BRAIN ANEURYSM REPR, COMPLX
85.76
1.00
61698
BRAIN ANEURYSM REPR, COMPLX
87.19
1.00
61698
BRAIN ANEURYSM REPR, COMPLX
113.18
1.00
61700
BRAIN ANEURYSM REPR, SIMPLE
15.00
1.00
61700
BRAIN ANEURYSM REPR, SIMPLE
89.01
1.00
61700
BRAIN ANEURYSM REPR, SIMPLE
89.38
1.00
61700
BRAIN ANEURYSM REPR, SIMPLE
90.65
1.00
61702
INNER SKULL VESSEL SURGERY
15.00
1.00
61702
INNER SKULL VESSEL SURGERY
85.82
1.00
61702
INNER SKULL VESSEL SURGERY
86.25
1.00
61702
INNER SKULL VESSEL SURGERY
98.46
1.00
61703
CLAMP NECK ARTERY
15.00
1.00
61703
CLAMP NECK ARTERY
32.33
1.00
61703
CLAMP NECK ARTERY
33.87
1.00
61705
REVISE CIRCULATION TO HEAD
15.00
1.00
61705
REVISE CIRCULATION TO HEAD
62.92
1.00
61705
REVISE CIRCULATION TO HEAD
63.53
1.00
61705
REVISE CIRCULATION TO HEAD
65.30
1.00
Procedure Code Description
RVU
RVU Coeff Value
61708
REVISE CIRCULATION TO HEAD
15.00
1.00
61708
REVISE CIRCULATION TO HEAD
53.08
1.00
61708
REVISE CIRCULATION TO HEAD
53.35
1.00
61708
REVISE CIRCULATION TO HEAD
54.79
1.00
61710
REVISE CIRCULATION TO HEAD
15.00
1.00
61710
REVISE CIRCULATION TO HEAD
46.21
1.00
61710
REVISE CIRCULATION TO HEAD
46.62
1.00
61710
REVISE CIRCULATION TO HEAD
50.57
1.00
61711
FUSION OF SKULL ARTERIES
15.00
1.00
61711
FUSION OF SKULL ARTERIES
64.35
1.00
61711
FUSION OF SKULL ARTERIES
65.09
1.00
61711
FUSION OF SKULL ARTERIES
66.67
1.00
61720
INCISE SKULL/BRAIN SURGERY
11.00
1.00
61720
INCISE SKULL/BRAIN SURGERY
29.30
1.00
61720
INCISE SKULL/BRAIN SURGERY
31.00
1.00
61720
INCISE SKULL/BRAIN SURGERY
31.02
1.00
61735
INCISE SKULL/BRAIN SURGERY
11.00
1.00
61735
INCISE SKULL/BRAIN SURGERY
35.75
1.00
61735
INCISE SKULL/BRAIN SURGERY
37.35
1.00
61735
INCISE SKULL/BRAIN SURGERY
37.64
1.00
61750
INCISE SKULL/BRAIN BIOPSY
11.00
1.00
61750
INCISE SKULL/BRAIN BIOPSY
32.87
1.00
61750
INCISE SKULL/BRAIN BIOPSY
33.31
1.00
61750
INCISE SKULL/BRAIN BIOPSY
35.57
1.00
61751
BRAIN BIOPSY W/CT/MR GUIDE
7.00
1.00
61751
BRAIN BIOPSY W/CT/MR GUIDE
31.96
1.00
61751
BRAIN BIOPSY W/CT/MR GUIDE
32.76
1.00
61751
BRAIN BIOPSY W/CT/MR GUIDE
34.66
1.00
61760
IMPLANT BRAIN ELECTRODES
11.00
1.00
61760
IMPLANT BRAIN ELECTRODES
35.69
1.00
61760
IMPLANT BRAIN ELECTRODES
36.55
1.00
61760
IMPLANT BRAIN ELECTRODES
39.21
1.00
61770
INCISE SKULL FOR TREATMENT
11.00
1.00
61770
INCISE SKULL FOR TREATMENT
38.11
1.00
61770
INCISE SKULL FOR TREATMENT
38.58
1.00
Procedure Code Description 61770
INCISE SKULL FOR TREATMENT
61790
RVU
RVU Coeff Value
38.65
1.00
TREAT TRIGEMINAL NERVE
7.00
1.00
61790
TREAT TRIGEMINAL NERVE
18.70
1.00
61790
TREAT TRIGEMINAL NERVE
18.99
1.00
61790
TREAT TRIGEMINAL NERVE
21.53
1.00
61791
TREAT TRIGEMINAL TRACT
7.00
1.00
61791
TREAT TRIGEMINAL TRACT
26.90
1.00
61791
TREAT TRIGEMINAL TRACT
27.20
1.00
61791
TREAT TRIGEMINAL TRACT
27.79
1.00
61793
FOCUS RADIATION BEAM
11.00
1.00
61793
FOCUS RADIATION BEAM
31.60
1.00
61793
FOCUS RADIATION BEAM
31.68
1.00
61793
FOCUS RADIATION BEAM
32.05
1.00
61795
BRAIN SURGERY USING COMPUTER
6.47
1.00
61795
BRAIN SURGERY USING COMPUTER
6.94
1.00
61795
BRAIN SURGERY USING COMPUTER
7.05
1.00
61796
SRS, CRANIAL LESION SIMPLE
20.28
1.00
61797
SRS, CRAN LES SIMPLE, ADDL
5.54
1.00
61798
SRS, CRANIAL LESION COMPLEX
20.28
1.00
61799
SRS, CRAN LES COMPLEX, ADDL
7.66
1.00
61800
APPLY SRS HEADFRAME ADD-ON
3.93
1.00
61850
IMPLANT NEUROELECTRODES
9.00
1.00
61850
IMPLANT NEUROELECTRODES
22.70
1.00
61850
IMPLANT NEUROELECTRODES
22.77
1.00
61850
IMPLANT NEUROELECTRODES
24.74
1.00
61860
IMPLANT NEUROELECTRODES
11.00
1.00
61860
IMPLANT NEUROELECTRODES
37.79
1.00
61860
IMPLANT NEUROELECTRODES
37.84
1.00
61860
IMPLANT NEUROELECTRODES
39.35
1.00
61862
IMPLANT NEUROSTIMUL, SUBCORT
11.00
1.00
61862
IMPLANT NEUROSTIMUL, SUBCORT
35.39
1.00
61863
IMPLANT NEUROELECTRODE
32.97
1.00
61863
IMPLANT NEUROELECTRODE
38.40
1.00
61864
IMPLANT NEUROELECTRDE, ADDL
7.91
1.00
61864
IMPLANT NEUROELECTRDE, ADDL
11.82
1.00
Procedure Code Description
RVU
RVU Coeff Value
61867
IMPLANT NEUROELECTRODE
49.89
1.00
61867
IMPLANT NEUROELECTRODE
55.74
1.00
61868
IMPLANT NEUROELECTRDE, ADDÏL
13.15
1.00
61868
IMPLANT NEUROELECTRDE, ADDÏL
16.68
1.00
61870
IMPLANT NEUROELECTRODES
11.00
1.00
61870
IMPLANT NEUROELECTRODES
26.79
1.00
61870
IMPLANT NEUROELECTRODES
27.49
1.00
61870
IMPLANT NEUROELECTRODES
29.96
1.00
61875
IMPLANT NEUROELECTRODES
11.00
1.00
61875
IMPLANT NEUROELECTRODES
26.57
1.00
61875
IMPLANT NEUROELECTRODES
26.76
1.00
61875
IMPLANT NEUROELECTRODES
28.91
1.00
61880
REVISE/REMOVE NEUROELECTRODE
5.00
1.00
61880
REVISE/REMOVE NEUROELECTRODE
12.46
1.00
61880
REVISE/REMOVE NEUROELECTRODE
12.94
1.00
61880
REVISE/REMOVE NEUROELECTRODE
13.77
1.00
61885
INSRT/REDO NEUROSTIM 1 ARRAY
5.00
1.00
61885
INSRT/REDO NEUROSTIM 1 ARRAY
12.16
1.00
61885
INSRT/REDO NEUROSTIM 1 ARRAY
12.63
1.00
61885
INSRT/REDO NEUROSTIM 1 ARRAY
15.83
1.00
61886
IMPLANT NEUROSTIM ARRAYS
6.00
1.00
61886
IMPLANT NEUROSTIM ARRAYS
15.79
1.00
61886
IMPLANT NEUROSTIM ARRAYS
16.33
1.00
61886
IMPLANT NEUROSTIM ARRAYS
19.95
1.00
61888
REVISE/REMOVE NEURORECEIVER
5.00
1.00
61888
REVISE/REMOVE NEURORECEIVER
10.01
1.00
61888
REVISE/REMOVE NEURORECEIVER
10.10
1.00
61888
REVISE/REMOVE NEURORECEIVER
10.19
1.00
62000
TREAT SKULL FRACTURE
9.00
1.00
62000
TREAT SKULL FRACTURE
19.05
1.00
62000
TREAT SKULL FRACTURE
19.11
1.00
62000
TREAT SKULL FRACTURE
21.65
1.00
62005
TREAT SKULL FRACTURE
9.00
1.00
62005
TREAT SKULL FRACTURE
27.79
1.00
62005
TREAT SKULL FRACTURE
27.96
1.00
Procedure Code Description
RVU
RVU Coeff Value
62005
TREAT SKULL FRACTURE
31.31
1.00
62010
TREATMENT OF HEAD INJURY
11.00
1.00
62010
TREATMENT OF HEAD INJURY
36.14
1.00
62010
TREATMENT OF HEAD INJURY
36.41
1.00
62010
TREATMENT OF HEAD INJURY
38.38
1.00
62100
REPAIR BRAIN FLUID LEAKAGE
9.00
1.00
62100
REPAIR BRAIN FLUID LEAKAGE
39.76
1.00
62100
REPAIR BRAIN FLUID LEAKAGE
39.95
1.00
62100
REPAIR BRAIN FLUID LEAKAGE
40.65
1.00
62115
REDUCTION OF SKULL DEFECT
36.52
1.00
62115
REDUCTION OF SKULL DEFECT
37.88
1.00
62115
REDUCTION OF SKULL DEFECT
38.78
1.00
62115
REDUCTION OF SKULL DEFECT
999.99
1.00
62116
REDUCTION OF SKULL DEFECT
42.23
1.00
62116
REDUCTION OF SKULL DEFECT
42.82
1.00
62116
REDUCTION OF SKULL DEFECT
45.04
1.00
62116
REDUCTION OF SKULL DEFECT
999.99
1.00
62117
REDUCTION OF SKULL DEFECT
47.93
1.00
62117
REDUCTION OF SKULL DEFECT
48.03
1.00
62117
REDUCTION OF SKULL DEFECT
48.71
1.00
62117
REDUCTION OF SKULL DEFECT
999.99
1.00
62120
REPAIR SKULL CAVITY LESION
11.00
1.00
62120
REPAIR SKULL CAVITY LESION
40.80
1.00
62120
REPAIR SKULL CAVITY LESION
41.34
1.00
62120
REPAIR SKULL CAVITY LESION
45.20
1.00
62121
INCISE SKULL REPAIR
37.28
1.00
62121
INCISE SKULL REPAIR
37.60
1.00
62121
INCISE SKULL REPAIR
41.72
1.00
62121
INCISE SKULL REPAIR
999.99
1.00
62140
REPAIR OF SKULL DEFECT
11.00
1.00
62140
REPAIR OF SKULL DEFECT
24.72
1.00
62140
REPAIR OF SKULL DEFECT
24.99
1.00
62140
REPAIR OF SKULL DEFECT
26.54
1.00
62141
REPAIR OF SKULL DEFECT
9.00
1.00
62141
REPAIR OF SKULL DEFECT
27.43
1.00
Procedure Code Description
RVU
RVU Coeff Value
62141
REPAIR OF SKULL DEFECT
27.54
1.00
62141
REPAIR OF SKULL DEFECT
29.13
1.00
62142
REMOVE SKULL PLATE/FLAP
11.00
1.00
62142
REMOVE SKULL PLATE/FLAP
20.13
1.00
62142
REMOVE SKULL PLATE/FLAP
20.33
1.00
62142
REMOVE SKULL PLATE/FLAP
22.16
1.00
62143
REPLACE SKULL PLATE/FLAP
11.00
1.00
62143
REPLACE SKULL PLATE/FLAP
24.19
1.00
62143
REPLACE SKULL PLATE/FLAP
24.35
1.00
62143
REPLACE SKULL PLATE/FLAP
26.01
1.00
62145
REPAIR OF SKULL & BRAIN
11.00
1.00
62145
REPAIR OF SKULL & BRAIN
34.32
1.00
62145
REPAIR OF SKULL & BRAIN
34.34
1.00
62145
REPAIR OF SKULL & BRAIN
35.60
1.00
62146
REPAIR OF SKULL WITH GRAFT
29.33
1.00
62146
REPAIR OF SKULL WITH GRAFT
29.46
1.00
62146
REPAIR OF SKULL WITH GRAFT
30.47
1.00
62146
REPAIR OF SKULL WITH GRAFT
999.99
1.00
62147
REPAIR OF SKULL WITH GRAFT
35.08
1.00
62147
REPAIR OF SKULL WITH GRAFT
35.12
1.00
62147
REPAIR OF SKULL WITH GRAFT
36.19
1.00
62147
REPAIR OF SKULL WITH GRAFT
999.99
1.00
62148
RETR BONE FLAP TO FIX SKULL
3.25
1.00
62148
RETR BONE FLAP TO FIX SKULL
3.28
1.00
62148
RETR BONE FLAP TO FIX SKULL
3.34
1.00
62160
NEUROENDOSCOPY ADD-ON
4.68
1.00
62160
NEUROENDOSCOPY ADD-ON
4.77
1.00
62160
NEUROENDOSCOPY ADD-ON
5.04
1.00
62161
DISSECT BRAIN W/SCOPE
33.41
1.00
62161
DISSECT BRAIN W/SCOPE
33.99
1.00
62161
DISSECT BRAIN W/SCOPE
38.41
1.00
62162
REMOVE COLLOID CYST W/SCOPE
42.91
1.00
62162
REMOVE COLLOID CYST W/SCOPE
43.86
1.00
62162
REMOVE COLLOID CYST W/SCOPE
47.58
1.00
62163
NEUROENDOSCOPY W/FB REMOVAL
27.17
1.00
Procedure Code Description
RVU
RVU Coeff Value
62163
NEUROENDOSCOPY W/FB REMOVAL
27.79
1.00
62163
NEUROENDOSCOPY W/FB REMOVAL
30.88
1.00
62164
REMOVE BRAIN TUMOR W/SCOPE
46.39
1.00
62164
REMOVE BRAIN TUMOR W/SCOPE
47.32
1.00
62164
REMOVE BRAIN TUMOR W/SCOPE
50.42
1.00
62165
REMOVE PITUIT TUMOR W/SCOPE
36.31
1.00
62165
REMOVE PITUIT TUMOR W/SCOPE
36.86
1.00
62165
REMOVE PITUIT TUMOR W/SCOPE
38.74
1.00
62180
ESTABLISH BRAIN CAVITY SHUNT
11.00
1.00
62180
ESTABLISH BRAIN CAVITY SHUNT
38.28
1.00
62180
ESTABLISH BRAIN CAVITY SHUNT
38.58
1.00
62180
ESTABLISH BRAIN CAVITY SHUNT
40.09
1.00
62190
ESTABLISH BRAIN CAVITY SHUNT
6.00
1.00
62190
ESTABLISH BRAIN CAVITY SHUNT
20.79
1.00
62190
ESTABLISH BRAIN CAVITY SHUNT
20.98
1.00
62190
ESTABLISH BRAIN CAVITY SHUNT
22.81
1.00
62192
ESTABLISH BRAIN CAVITY SHUNT
6.00
1.00
62192
ESTABLISH BRAIN CAVITY SHUNT
22.86
1.00
62192
ESTABLISH BRAIN CAVITY SHUNT
22.98
1.00
62192
ESTABLISH BRAIN CAVITY SHUNT
24.32
1.00
62194
REPLACE/IRRIGATE CATHETER
6.00
1.00
62194
REPLACE/IRRIGATE CATHETER
8.30
1.00
62194
REPLACE/IRRIGATE CATHETER
8.41
1.00
62194
REPLACE/IRRIGATE CATHETER
9.82
1.00
62200
ESTABLISH BRAIN CAVITY SHUNT
11.00
1.00
62200
ESTABLISH BRAIN CAVITY SHUNT
33.61
1.00
62200
ESTABLISH BRAIN CAVITY SHUNT
33.64
1.00
62200
ESTABLISH BRAIN CAVITY SHUNT
34.79
1.00
62201
BRAIN CAVITY SHUNT W/SCOPE
27.15
1.00
62201
BRAIN CAVITY SHUNT W/SCOPE
27.37
1.00
62201
BRAIN CAVITY SHUNT W/SCOPE
29.77
1.00
62220
ESTABLISH BRAIN CAVITY SHUNT
9.00
1.00
62220
ESTABLISH BRAIN CAVITY SHUNT
24.05
1.00
62220
ESTABLISH BRAIN CAVITY SHUNT
24.18
1.00
62220
ESTABLISH BRAIN CAVITY SHUNT
25.61
1.00
Procedure Code Description
RVU
RVU Coeff Value
62223
ESTABLISH BRAIN CAVITY SHUNT
9.00
1.00
62223
ESTABLISH BRAIN CAVITY SHUNT
23.96
1.00
62223
ESTABLISH BRAIN CAVITY SHUNT
24.24
1.00
62223
ESTABLISH BRAIN CAVITY SHUNT
26.20
1.00
62225
REPLACE/IRRIGATE CATHETER
10.00
1.00
62225
REPLACE/IRRIGATE CATHETER
10.82
1.00
62225
REPLACE/IRRIGATE CATHETER
11.31
1.00
62225
REPLACE/IRRIGATE CATHETER
12.47
1.00
62230
REPLACE/REVISE BRAIN SHUNT
8.00
1.00
62230
REPLACE/REVISE BRAIN SHUNT
19.56
1.00
62230
REPLACE/REVISE BRAIN SHUNT
19.87
1.00
62230
REPLACE/REVISE BRAIN SHUNT
21.15
1.00
62252
CSF SHUNT REPROGRAM
2.39
1.00
62252
CSF SHUNT REPROGRAM
2.43
1.00
62252
CSF SHUNT REPROGRAM
2.60
1.00
62256
REMOVE BRAIN CAVITY SHUNT
5.00
1.00
62256
REMOVE BRAIN CAVITY SHUNT
12.93
1.00
62256
REMOVE BRAIN CAVITY SHUNT
13.39
1.00
62256
REMOVE BRAIN CAVITY SHUNT
14.64
1.00
62258
REPLACE BRAIN CAVITY SHUNT
9.00
1.00
62258
REPLACE BRAIN CAVITY SHUNT
26.77
1.00
62258
REPLACE BRAIN CAVITY SHUNT
26.79
1.00
62258
REPLACE BRAIN CAVITY SHUNT
28.47
1.00
62263
EPIDURAL LYSIS MULT SESSIONS
8.00
1.00
62263
EPIDURAL LYSIS MULT SESSIONS
8.99
1.00
62263
EPIDURAL LYSIS MULT SESSIONS
9.03
1.00
62263
EPIDURAL LYSIS MULT SESSIONS
9.78
1.00
62264
EPIDURAL LYSIS ON SINGLE DAY
5.98
1.00
62264
EPIDURAL LYSIS ON SINGLE DAY
6.05
1.00
62264
EPIDURAL LYSIS ON SINGLE DAY
6.18
1.00
62267
INTERDISCAL PERQ ASPIR, DX
4.38
1.00
62268
DRAIN SPINAL CORD CYST
7.10
1.00
62268
DRAIN SPINAL CORD CYST
7.26
1.00
62268
DRAIN SPINAL CORD CYST
7.74
1.00
62269
NEEDLE BIOPSY, SPINAL CORD
5.00
1.00
Procedure Code Description
RVU
RVU Coeff Value
62269
NEEDLE BIOPSY, SPINAL CORD
7.20
1.00
62269
NEEDLE BIOPSY, SPINAL CORD
7.37
1.00
62269
NEEDLE BIOPSY, SPINAL CORD
7.68
1.00
62270
SPINAL FLUID TAP, DIAGNOSTIC
1.69
1.00
62270
SPINAL FLUID TAP, DIAGNOSTIC
2.04
1.00
62270
SPINAL FLUID TAP, DIAGNOSTIC
6.00
1.00
62272
DRAIN CEREBRO SPINAL FLUID
2.13
1.00
62272
DRAIN CEREBRO SPINAL FLUID
2.15
1.00
62272
DRAIN CEREBRO SPINAL FLUID
2.19
1.00
62272
DRAIN CEREBRO SPINAL FLUID
3.00
1.00
62273
INJECT EPIDURAL PATCH
2.87
1.00
62273
INJECT EPIDURAL PATCH
2.89
1.00
62273
INJECT EPIDURAL PATCH
2.91
1.00
62273
INJECT EPIDURAL PATCH
999.99
1.00
62280
TREAT SPINAL CORD LESION
3.62
1.00
62280
TREAT SPINAL CORD LESION
3.72
1.00
62280
TREAT SPINAL CORD LESION
4.03
1.00
62281
TREAT SPINAL CORD LESION
3.54
1.00
62281
TREAT SPINAL CORD LESION
3.62
1.00
62281
TREAT SPINAL CORD LESION
3.85
1.00
62281
TREAT SPINAL CORD LESION
999.99
1.00
62282
TREAT SPINAL CANAL LESION
3.20
1.00
62282
TREAT SPINAL CANAL LESION
3.29
1.00
62282
TREAT SPINAL CANAL LESION
3.55
1.00
62284
INJECTION FOR MYELOGRAM
2.25
1.00
62284
INJECTION FOR MYELOGRAM
2.26
1.00
62284
INJECTION FOR MYELOGRAM
2.41
1.00
62284
INJECTION FOR MYELOGRAM
4.00
1.00
62287
PERCUTANEOUS DISKECTOMY
8.00
1.00
62287
PERCUTANEOUS DISKECTOMY
13.78
1.00
62287
PERCUTANEOUS DISKECTOMY
14.16
1.00
62287
PERCUTANEOUS DISKECTOMY
14.39
1.00
62290
INJECT FOR SPINE DISK X-RAY
3.00
1.00
62290
INJECT FOR SPINE DISK X-RAY
4.48
1.00
62290
INJECT FOR SPINE DISK X-RAY
4.49
1.00
Procedure Code Description
RVU
RVU Coeff Value
62290
INJECT FOR SPINE DISK X-RAY
4.52
1.00
62291
INJECT FOR SPINE DISK X-RAY
4.23
1.00
62291
INJECT FOR SPINE DISK X-RAY
4.25
1.00
62291
INJECT FOR SPINE DISK X-RAY
4.34
1.00
62291
INJECT FOR SPINE DISK X-RAY
5.00
1.00
62292
INJECTION INTO DISK LESION
5.00
1.00
62292
INJECTION INTO DISK LESION
12.83
1.00
62292
INJECTION INTO DISK LESION
13.13
1.00
62292
INJECTION INTO DISK LESION
13.55
1.00
62294
INJECTION INTO SPINAL ARTERY
18.46
1.00
62294
INJECTION INTO SPINAL ARTERY
19.36
1.00
62294
INJECTION INTO SPINAL ARTERY
20.60
1.00
62310
INJECT SPINE C/T
2.53
1.00
62310
INJECT SPINE C/T
2.54
1.00
62310
INJECT SPINE C/T
2.64
1.00
62311
INJECT SPINE L/S (CD)
2.08
1.00
62311
INJECT SPINE L/S (CD)
2.10
1.00
62311
INJECT SPINE L/S (CD)
2.19
1.00
62318
INJECT SPINE W/CATH, C/T
2.65
1.00
62318
INJECT SPINE W/CATH, C/T
2.68
1.00
62318
INJECT SPINE W/CATH, C/T
2.69
1.00
62319
INJECT SPINE W/CATH L/S (CD)
2.46
1.00
62319
INJECT SPINE W/CATH L/S (CD)
2.47
1.00
62319
INJECT SPINE W/CATH L/S (CD)
2.48
1.00
62350
IMPLANT SPINAL CANAL CATH
8.00
1.00
62350
IMPLANT SPINAL CANAL CATH
10.11
1.00
62350
IMPLANT SPINAL CANAL CATH
11.15
1.00
62350
IMPLANT SPINAL CANAL CATH
11.62
1.00
62351
IMPLANT SPINAL CANAL CATH
10.00
1.00
62351
IMPLANT SPINAL CANAL CATH
18.51
1.00
62351
IMPLANT SPINAL CANAL CATH
19.25
1.00
62351
IMPLANT SPINAL CANAL CATH
21.35
1.00
62355
REMOVE SPINAL CANAL CATHETER
7.57
1.00
62355
REMOVE SPINAL CANAL CATHETER
8.00
1.00
62355
REMOVE SPINAL CANAL CATHETER
8.74
1.00
Procedure Code Description
RVU
RVU Coeff Value
62355
REMOVE SPINAL CANAL CATHETER
9.21
1.00
62360
INSERT SPINE INFUSION DEVICE
5.11
1.00
62360
INSERT SPINE INFUSION DEVICE
5.58
1.00
62360
INSERT SPINE INFUSION DEVICE
7.17
1.00
62360
INSERT SPINE INFUSION DEVICE
8.00
1.00
62361
IMPLANT SPINE INFUSION PUMP
8.00
1.00
62361
IMPLANT SPINE INFUSION PUMP
9.42
1.00
62361
IMPLANT SPINE INFUSION PUMP
9.92
1.00
62361
IMPLANT SPINE INFUSION PUMP
10.00
1.00
62362
IMPLANT SPINE INFUSION PUMP
8.00
1.00
62362
IMPLANT SPINE INFUSION PUMP
10.66
1.00
62362
IMPLANT SPINE INFUSION PUMP
11.96
1.00
62362
IMPLANT SPINE INFUSION PUMP
12.45
1.00
62365
REMOVE SPINE INFUSION DEVICE
8.00
1.00
62365
REMOVE SPINE INFUSION DEVICE
8.40
1.00
62365
REMOVE SPINE INFUSION DEVICE
9.71
1.00
62365
REMOVE SPINE INFUSION DEVICE
10.09
1.00
62367
ANALYZE SPINE INFUSION PUMP
0.63
1.00
62367
ANALYZE SPINE INFUSION PUMP
0.64
1.00
62367
ANALYZE SPINE INFUSION PUMP
0.65
1.00
62368
ANALYZE SPINE INFUSION PUMP
0.99
1.00
62368
ANALYZE SPINE INFUSION PUMP
1.00
1.00
63001
REMOVAL OF SPINAL LAMINA
10.00
1.00
63001
REMOVAL OF SPINAL LAMINA
28.78
1.00
63001
REMOVAL OF SPINAL LAMINA
28.97
1.00
63001
REMOVAL OF SPINAL LAMINA
31.20
1.00
63003
REMOVAL OF SPINAL LAMINA
10.00
1.00
63003
REMOVAL OF SPINAL LAMINA
29.21
1.00
63003
REMOVAL OF SPINAL LAMINA
29.38
1.00
63003
REMOVAL OF SPINAL LAMINA
31.37
1.00
63005
REMOVAL OF SPINAL LAMINA
8.00
1.00
63005
REMOVAL OF SPINAL LAMINA
27.85
1.00
63005
REMOVAL OF SPINAL LAMINA
27.99
1.00
63005
REMOVAL OF SPINAL LAMINA
29.73
1.00
63011
REMOVAL OF SPINAL LAMINA
8.00
1.00
Procedure Code Description
RVU
RVU Coeff Value
63011
REMOVAL OF SPINAL LAMINA
24.48
1.00
63011
REMOVAL OF SPINAL LAMINA
24.55
1.00
63011
REMOVAL OF SPINAL LAMINA
28.16
1.00
63012
REMOVAL OF SPINAL LAMINA
28.56
1.00
63012
REMOVAL OF SPINAL LAMINA
28.74
1.00
63012
REMOVAL OF SPINAL LAMINA
30.27
1.00
63012
REMOVAL OF SPINAL LAMINA
999.99
1.00
63015
REMOVAL OF SPINAL LAMINA
10.00
1.00
63015
REMOVAL OF SPINAL LAMINA
35.55
1.00
63015
REMOVAL OF SPINAL LAMINA
35.84
1.00
63015
REMOVAL OF SPINAL LAMINA
37.56
1.00
63016
REMOVAL OF SPINAL LAMINA
10.00
1.00
63016
REMOVAL OF SPINAL LAMINA
35.04
1.00
63016
REMOVAL OF SPINAL LAMINA
35.33
1.00
63016
REMOVAL OF SPINAL LAMINA
38.52
1.00
63017
REMOVAL OF SPINAL LAMINA
8.00
1.00
63017
REMOVAL OF SPINAL LAMINA
29.62
1.00
63017
REMOVAL OF SPINAL LAMINA
29.79
1.00
63017
REMOVAL OF SPINAL LAMINA
31.39
1.00
63020
NECK SPINE DISK SURGERY
10.00
1.00
63020
NECK SPINE DISK SURGERY
27.78
1.00
63020
NECK SPINE DISK SURGERY
27.95
1.00
63020
NECK SPINE DISK SURGERY
29.79
1.00
63030
LOW BACK DISK SURGERY
8.00
1.00
63030
LOW BACK DISK SURGERY
22.96
1.00
63030
LOW BACK DISK SURGERY
23.04
1.00
63030
LOW BACK DISK SURGERY
24.73
1.00
63035
SPINAL DISK SURGERY ADD-ON
5.30
1.00
63035
SPINAL DISK SURGERY ADD-ON
5.35
1.00
63035
SPINAL DISK SURGERY ADD-ON
5.43
1.00
63040
LAMINOTOMY, SINGLE CERVICAL
10.00
1.00
63040
LAMINOTOMY, SINGLE CERVICAL
34.08
1.00
63040
LAMINOTOMY, SINGLE CERVICAL
34.33
1.00
63040
LAMINOTOMY, SINGLE CERVICAL
36.23
1.00
63042
LAMINOTOMY, SINGLE LUMBAR
8.00
1.00
Procedure Code Description
RVU
RVU Coeff Value
63042
LAMINOTOMY, SINGLE LUMBAR
32.29
1.00
63042
LAMINOTOMY, SINGLE LUMBAR
32.49
1.00
63042
LAMINOTOMY, SINGLE LUMBAR
33.89
1.00
63045
REMOVAL OF SPINAL LAMINA
10.00
1.00
63045
REMOVAL OF SPINAL LAMINA
30.45
1.00
63045
REMOVAL OF SPINAL LAMINA
30.68
1.00
63045
REMOVAL OF SPINAL LAMINA
32.34
1.00
63046
REMOVAL OF SPINAL LAMINA
10.00
1.00
63046
REMOVAL OF SPINAL LAMINA
29.23
1.00
63046
REMOVAL OF SPINAL LAMINA
29.43
1.00
63046
REMOVAL OF SPINAL LAMINA
30.83
1.00
63047
REMOVAL OF SPINAL LAMINA
8.00
1.00
63047
REMOVAL OF SPINAL LAMINA
27.45
1.00
63047
REMOVAL OF SPINAL LAMINA
27.59
1.00
63047
REMOVAL OF SPINAL LAMINA
28.14
1.00
63048
REMOVE SPINAL LAMINA ADD-ON
5.55
1.00
63048
REMOVE SPINAL LAMINA ADD-ON
5.63
1.00
63048
REMOVE SPINAL LAMINA ADD-ON
5.66
1.00
63050
CERVICAL LAMINOPLASTY
38.82
1.00
63051
C-LAMINOPLASTY W/GRAFT/PLATE
43.64
1.00
63055
DECOMPRESS SPINAL CORD
10.00
1.00
63055
DECOMPRESS SPINAL CORD
39.68
1.00
63055
DECOMPRESS SPINAL CORD
40.03
1.00
63055
DECOMPRESS SPINAL CORD
41.66
1.00
63056
DECOMPRESS SPINAL CORD
8.00
1.00
63056
DECOMPRESS SPINAL CORD
36.68
1.00
63056
DECOMPRESS SPINAL CORD
36.90
1.00
63056
DECOMPRESS SPINAL CORD
38.43
1.00
63057
DECOMPRESS SPINE CORD ADD-ON
8.71
1.00
63057
DECOMPRESS SPINE CORD ADD-ON
8.78
1.00
63057
DECOMPRESS SPINE CORD ADD-ON
8.87
1.00
63064
DECOMPRESS SPINAL CORD
8.00
1.00
63064
DECOMPRESS SPINAL CORD
44.26
1.00
63064
DECOMPRESS SPINAL CORD
44.71
1.00
63064
DECOMPRESS SPINAL CORD
45.53
1.00
Procedure Code Description
RVU
RVU Coeff Value
63066
DECOMPRESS SPINE CORD ADD-ON
5.35
1.00
63066
DECOMPRESS SPINE CORD ADD-ON
5.60
1.00
63066
DECOMPRESS SPINE CORD ADD-ON
5.69
1.00
63075
NECK SPINE DISK SURGERY
10.00
1.00
63075
NECK SPINE DISK SURGERY
35.61
1.00
63075
NECK SPINE DISK SURGERY
35.67
1.00
63075
NECK SPINE DISK SURGERY
35.96
1.00
63076
NECK SPINE DISK SURGERY
6.73
1.00
63076
NECK SPINE DISK SURGERY
6.94
1.00
63076
NECK SPINE DISK SURGERY
7.04
1.00
63077
SPINE DISK SURGERY, THORAX
10.00
1.00
63077
SPINE DISK SURGERY, THORAX
37.96
1.00
63077
SPINE DISK SURGERY, THORAX
38.32
1.00
63077
SPINE DISK SURGERY, THORAX
38.68
1.00
63078
SPINE DISK SURGERY, THORAX
5.32
1.00
63078
SPINE DISK SURGERY, THORAX
5.45
1.00
63078
SPINE DISK SURGERY, THORAX
5.52
1.00
63081
REMOVAL OF VERTEBRAL BODY
42.99
1.00
63081
REMOVAL OF VERTEBRAL BODY
43.40
1.00
63081
REMOVAL OF VERTEBRAL BODY
45.60
1.00
63082
REMOVE VERTEBRAL BODY ADD-ON
7.26
1.00
63082
REMOVE VERTEBRAL BODY ADD-ON
7.48
1.00
63082
REMOVE VERTEBRAL BODY ADD-ON
7.58
1.00
63085
REMOVAL OF VERTEBRAL BODY
47.45
1.00
63085
REMOVAL OF VERTEBRAL BODY
48.02
1.00
63085
REMOVAL OF VERTEBRAL BODY
48.26
1.00
63086
REMOVE VERTEBRAL BODY ADD-ON
5.11
1.00
63086
REMOVE VERTEBRAL BODY ADD-ON
5.37
1.00
63086
REMOVE VERTEBRAL BODY ADD-ON
5.45
1.00
63087
REMOVAL OF VERTEBRAL BODY
10.00
1.00
63087
REMOVAL OF VERTEBRAL BODY
61.37
1.00
63087
REMOVAL OF VERTEBRAL BODY
61.78
1.00
63087
REMOVAL OF VERTEBRAL BODY
62.05
1.00
63088
REMOVE VERTEBRAL BODY ADD-ON
7.00
1.00
63088
REMOVE VERTEBRAL BODY ADD-ON
7.33
1.00
Procedure Code Description
RVU
RVU Coeff Value
63088
REMOVE VERTEBRAL BODY ADD-ON
7.43
1.00
63088
REMOVE VERTEBRAL BODY ADD-ON
999.99
1.00
63090
REMOVAL OF VERTEBRAL BODY
8.00
1.00
63090
REMOVAL OF VERTEBRAL BODY
48.83
1.00
63090
REMOVAL OF VERTEBRAL BODY
49.28
1.00
63090
REMOVAL OF VERTEBRAL BODY
50.28
1.00
63091
REMOVE VERTEBRAL BODY ADD-ON
4.78
1.00
63091
REMOVE VERTEBRAL BODY ADD-ON
4.97
1.00
63091
REMOVE VERTEBRAL BODY ADD-ON
5.03
1.00
63101
REMOVAL OF VERTEBRAL BODY
56.98
1.00
63101
REMOVAL OF VERTEBRAL BODY
57.88
1.00
63102
REMOVAL OF VERTEBRAL BODY
56.98
1.00
63102
REMOVAL OF VERTEBRAL BODY
57.64
1.00
63103
REMOVE VERTEBRAL BODY ADD-ON
6.66
1.00
63103
REMOVE VERTEBRAL BODY ADD-ON
7.61
1.00
63170
INCISE SPINAL CORD TRACT(S)
10.00
1.00
63170
INCISE SPINAL CORD TRACT(S)
36.55
1.00
63170
INCISE SPINAL CORD TRACT(S)
37.41
1.00
63170
INCISE SPINAL CORD TRACT(S)
39.12
1.00
63172
DRAINAGE OF SPINAL CYST
32.65
1.00
63172
DRAINAGE OF SPINAL CYST
34.33
1.00
63172
DRAINAGE OF SPINAL CYST
35.26
1.00
63173
DRAINAGE OF SPINAL CYST
39.98
1.00
63173
DRAINAGE OF SPINAL CYST
41.35
1.00
63173
DRAINAGE OF SPINAL CYST
43.52
1.00
63180
REVISE SPINAL CORD LIGAMENTS
9.00
1.00
63180
REVISE SPINAL CORD LIGAMENTS
34.07
1.00
63180
REVISE SPINAL CORD LIGAMENTS
35.24
1.00
63180
REVISE SPINAL CORD LIGAMENTS
35.37
1.00
63182
REVISE SPINAL CORD LIGAMENTS
10.00
1.00
63182
REVISE SPINAL CORD LIGAMENTS
35.85
1.00
63182
REVISE SPINAL CORD LIGAMENTS
36.91
1.00
63182
REVISE SPINAL CORD LIGAMENTS
38.08
1.00
63185
INCISE SPINAL COLUMN/NERVES
11.00
1.00
63185
INCISE SPINAL COLUMN/NERVES
25.78
1.00
Procedure Code Description
RVU
RVU Coeff Value
63185
INCISE SPINAL COLUMN/NERVES
26.94
1.00
63185
INCISE SPINAL COLUMN/NERVES
28.55
1.00
63190
INCISE SPINAL COLUMN/NERVES
10.00
1.00
63190
INCISE SPINAL COLUMN/NERVES
31.20
1.00
63190
INCISE SPINAL COLUMN/NERVES
32.25
1.00
63190
INCISE SPINAL COLUMN/NERVES
32.83
1.00
63191
INCISE SPINAL COLUMN/NERVES
10.00
1.00
63191
INCISE SPINAL COLUMN/NERVES
32.35
1.00
63191
INCISE SPINAL COLUMN/NERVES
32.41
1.00
63191
INCISE SPINAL COLUMN/NERVES
33.35
1.00
63194
INCISE SPINAL COLUMN & CORD
10.00
1.00
63194
INCISE SPINAL COLUMN & CORD
35.89
1.00
63194
INCISE SPINAL COLUMN & CORD
36.55
1.00
63194
INCISE SPINAL COLUMN & CORD
37.17
1.00
63195
INCISE SPINAL COLUMN & CORD
11.00
1.00
63195
INCISE SPINAL COLUMN & CORD
34.20
1.00
63195
INCISE SPINAL COLUMN & CORD
35.25
1.00
63195
INCISE SPINAL COLUMN & CORD
38.14
1.00
63196
INCISE SPINAL COLUMN & CORD
8.00
1.00
63196
INCISE SPINAL COLUMN & CORD
40.61
1.00
63196
INCISE SPINAL COLUMN & CORD
41.47
1.00
63196
INCISE SPINAL COLUMN & CORD
44.89
1.00
63197
INCISE SPINAL COLUMN & CORD
10.00
1.00
63197
INCISE SPINAL COLUMN & CORD
38.80
1.00
63197
INCISE SPINAL COLUMN & CORD
39.38
1.00
63197
INCISE SPINAL COLUMN & CORD
42.75
1.00
63198
INCISE SPINAL COLUMN & CORD
8.00
1.00
63198
INCISE SPINAL COLUMN & CORD
40.37
1.00
63198
INCISE SPINAL COLUMN & CORD
41.49
1.00
63198
INCISE SPINAL COLUMN & CORD
47.51
1.00
63199
INCISE SPINAL COLUMN & CORD
10.00
1.00
63199
INCISE SPINAL COLUMN & CORD
48.61
1.00
63199
INCISE SPINAL COLUMN & CORD
48.80
1.00
63199
INCISE SPINAL COLUMN & CORD
48.87
1.00
63200
RELEASE OF SPINAL CORD
8.00
1.00
Procedure Code Description
RVU
RVU Coeff Value
63200
RELEASE OF SPINAL CORD
34.98
1.00
63200
RELEASE OF SPINAL CORD
35.89
1.00
63200
RELEASE OF SPINAL CORD
38.29
1.00
63250
REVISE SPINAL CORD VESSELS
15.00
1.00
63250
REVISE SPINAL CORD VESSELS
69.10
1.00
63250
REVISE SPINAL CORD VESSELS
69.96
1.00
63250
REVISE SPINAL CORD VESSELS
74.04
1.00
63251
REVISE SPINAL CORD VESSELS
10.00
1.00
63251
REVISE SPINAL CORD VESSELS
72.44
1.00
63251
REVISE SPINAL CORD VESSELS
73.45
1.00
63251
REVISE SPINAL CORD VESSELS
77.20
1.00
63252
REVISE SPINAL CORD VESSELS
8.00
1.00
63252
REVISE SPINAL CORD VESSELS
71.84
1.00
63252
REVISE SPINAL CORD VESSELS
72.81
1.00
63252
REVISE SPINAL CORD VESSELS
77.33
1.00
63265
EXCISE INTRASPINAL LESION
10.00
1.00
63265
EXCISE INTRASPINAL LESION
39.15
1.00
63265
EXCISE INTRASPINAL LESION
39.51
1.00
63265
EXCISE INTRASPINAL LESION
42.38
1.00
63266
EXCISE INTRASPINAL LESION
10.00
1.00
63266
EXCISE INTRASPINAL LESION
40.50
1.00
63266
EXCISE INTRASPINAL LESION
40.88
1.00
63266
EXCISE INTRASPINAL LESION
43.55
1.00
63267
EXCISE INTRASPINAL LESION
8.00
1.00
63267
EXCISE INTRASPINAL LESION
32.98
1.00
63267
EXCISE INTRASPINAL LESION
33.23
1.00
63267
EXCISE INTRASPINAL LESION
35.06
1.00
63268
EXCISE INTRASPINAL LESION
6.00
1.00
63268
EXCISE INTRASPINAL LESION
32.56
1.00
63268
EXCISE INTRASPINAL LESION
32.75
1.00
63268
EXCISE INTRASPINAL LESION
34.96
1.00
63270
EXCISE INTRASPINAL LESION
10.00
1.00
63270
EXCISE INTRASPINAL LESION
48.31
1.00
63270
EXCISE INTRASPINAL LESION
48.81
1.00
63270
EXCISE INTRASPINAL LESION
52.19
1.00
Procedure Code Description
RVU
RVU Coeff Value
63271
EXCISE INTRASPINAL LESION
48.68
1.00
63271
EXCISE INTRASPINAL LESION
49.22
1.00
63271
EXCISE INTRASPINAL LESION
52.52
1.00
63272
EXCISE INTRASPINAL LESION
10.00
1.00
63272
EXCISE INTRASPINAL LESION
45.66
1.00
63272
EXCISE INTRASPINAL LESION
46.12
1.00
63272
EXCISE INTRASPINAL LESION
48.33
1.00
63273
EXCISE INTRASPINAL LESION
6.00
1.00
63273
EXCISE INTRASPINAL LESION
44.26
1.00
63273
EXCISE INTRASPINAL LESION
44.77
1.00
63273
EXCISE INTRASPINAL LESION
45.60
1.00
63275
BIOPSY/EXCISE SPINAL TUMOR
10.00
1.00
63275
BIOPSY/EXCISE SPINAL TUMOR
42.71
1.00
63275
BIOPSY/EXCISE SPINAL TUMOR
43.11
1.00
63275
BIOPSY/EXCISE SPINAL TUMOR
45.50
1.00
63276
BIOPSY/EXCISE SPINAL TUMOR
10.00
1.00
63276
BIOPSY/EXCISE SPINAL TUMOR
42.31
1.00
63276
BIOPSY/EXCISE SPINAL TUMOR
42.71
1.00
63276
BIOPSY/EXCISE SPINAL TUMOR
45.35
1.00
63277
BIOPSY/EXCISE SPINAL TUMOR
8.00
1.00
63277
BIOPSY/EXCISE SPINAL TUMOR
37.87
1.00
63277
BIOPSY/EXCISE SPINAL TUMOR
38.20
1.00
63277
BIOPSY/EXCISE SPINAL TUMOR
39.78
1.00
63278
BIOPSY/EXCISE SPINAL TUMOR
6.00
1.00
63278
BIOPSY/EXCISE SPINAL TUMOR
37.42
1.00
63278
BIOPSY/EXCISE SPINAL TUMOR
37.77
1.00
63278
BIOPSY/EXCISE SPINAL TUMOR
38.82
1.00
63280
BIOPSY/EXCISE SPINAL TUMOR
10.00
1.00
63280
BIOPSY/EXCISE SPINAL TUMOR
50.95
1.00
63280
BIOPSY/EXCISE SPINAL TUMOR
51.68
1.00
63280
BIOPSY/EXCISE SPINAL TUMOR
53.94
1.00
63281
BIOPSY/EXCISE SPINAL TUMOR
10.00
1.00
63281
BIOPSY/EXCISE SPINAL TUMOR
50.36
1.00
63281
BIOPSY/EXCISE SPINAL TUMOR
51.07
1.00
63281
BIOPSY/EXCISE SPINAL TUMOR
53.32
1.00
Procedure Code Description
RVU
RVU Coeff Value
63282
BIOPSY/EXCISE SPINAL TUMOR
8.00
1.00
63282
BIOPSY/EXCISE SPINAL TUMOR
47.49
1.00
63282
BIOPSY/EXCISE SPINAL TUMOR
48.16
1.00
63282
BIOPSY/EXCISE SPINAL TUMOR
50.32
1.00
63283
BIOPSY/EXCISE SPINAL TUMOR
6.00
1.00
63283
BIOPSY/EXCISE SPINAL TUMOR
45.21
1.00
63283
BIOPSY/EXCISE SPINAL TUMOR
45.85
1.00
63283
BIOPSY/EXCISE SPINAL TUMOR
47.63
1.00
63285
BIOPSY/EXCISE SPINAL TUMOR
10.00
1.00
63285
BIOPSY/EXCISE SPINAL TUMOR
63.84
1.00
63285
BIOPSY/EXCISE SPINAL TUMOR
64.78
1.00
63285
BIOPSY/EXCISE SPINAL TUMOR
66.27
1.00
63286
BIOPSY/EXCISE SPINAL TUMOR
10.00
1.00
63286
BIOPSY/EXCISE SPINAL TUMOR
63.17
1.00
63286
BIOPSY/EXCISE SPINAL TUMOR
64.08
1.00
63286
BIOPSY/EXCISE SPINAL TUMOR
66.07
1.00
63287
BIOPSY/EXCISE SPINAL TUMOR
8.00
1.00
63287
BIOPSY/EXCISE SPINAL TUMOR
65.22
1.00
63287
BIOPSY/EXCISE SPINAL TUMOR
66.19
1.00
63287
BIOPSY/EXCISE SPINAL TUMOR
69.59
1.00
63290
BIOPSY/EXCISE SPINAL TUMOR
66.21
1.00
63290
BIOPSY/EXCISE SPINAL TUMOR
67.21
1.00
63290
BIOPSY/EXCISE SPINAL TUMOR
70.25
1.00
63295
REPAIR OF LAMINECTOMY DEFECT
8.34
1.00
63300
REMOVAL OF VERTEBRAL BODY
10.00
1.00
63300
REMOVAL OF VERTEBRAL BODY
44.05
1.00
63300
REMOVAL OF VERTEBRAL BODY
44.50
1.00
63300
REMOVAL OF VERTEBRAL BODY
46.91
1.00
63301
REMOVAL OF VERTEBRAL BODY
10.00
1.00
63301
REMOVAL OF VERTEBRAL BODY
48.47
1.00
63301
REMOVAL OF VERTEBRAL BODY
49.21
1.00
63301
REMOVAL OF VERTEBRAL BODY
52.15
1.00
63302
REMOVAL OF VERTEBRAL BODY
10.00
1.00
63302
REMOVAL OF VERTEBRAL BODY
49.22
1.00
63302
REMOVAL OF VERTEBRAL BODY
49.98
1.00
Procedure Code Description
RVU
RVU Coeff Value
63302
REMOVAL OF VERTEBRAL BODY
51.89
1.00
63303
REMOVAL OF VERTEBRAL BODY
8.00
1.00
63303
REMOVAL OF VERTEBRAL BODY
53.10
1.00
63303
REMOVAL OF VERTEBRAL BODY
53.65
1.00
63303
REMOVAL OF VERTEBRAL BODY
53.86
1.00
63304
REMOVAL OF VERTEBRAL BODY
10.00
1.00
63304
REMOVAL OF VERTEBRAL BODY
52.82
1.00
63304
REMOVAL OF VERTEBRAL BODY
53.31
1.00
63304
REMOVAL OF VERTEBRAL BODY
57.69
1.00
63305
REMOVAL OF VERTEBRAL BODY
10.00
1.00
63305
REMOVAL OF VERTEBRAL BODY
55.72
1.00
63305
REMOVAL OF VERTEBRAL BODY
56.54
1.00
63305
REMOVAL OF VERTEBRAL BODY
58.57
1.00
63306
REMOVAL OF VERTEBRAL BODY
10.00
1.00
63306
REMOVAL OF VERTEBRAL BODY
52.65
1.00
63306
REMOVAL OF VERTEBRAL BODY
52.89
1.00
63306
REMOVAL OF VERTEBRAL BODY
62.30
1.00
63307
REMOVAL OF VERTEBRAL BODY
8.00
1.00
63307
REMOVAL OF VERTEBRAL BODY
53.19
1.00
63307
REMOVAL OF VERTEBRAL BODY
53.50
1.00
63307
REMOVAL OF VERTEBRAL BODY
56.63
1.00
63308
REMOVE VERTEBRAL BODY ADD-ON
8.75
1.00
63308
REMOVE VERTEBRAL BODY ADD-ON
8.93
1.00
63308
REMOVE VERTEBRAL BODY ADD-ON
9.08
1.00
63600
REMOVE SPINAL CORD LESION
20.91
1.00
63600
REMOVE SPINAL CORD LESION
21.27
1.00
63600
REMOVE SPINAL CORD LESION
21.31
1.00
63610
STIMULATION OF SPINAL CORD
11.41
1.00
63610
STIMULATION OF SPINAL CORD
11.54
1.00
63610
STIMULATION OF SPINAL CORD
12.95
1.00
63615
REMOVE LESION OF SPINAL CORD
28.98
1.00
63615
REMOVE LESION OF SPINAL CORD
29.11
1.00
63615
REMOVE LESION OF SPINAL CORD
29.12
1.00
63620
SRS, SPINAL LESION
20.28
1.00
63621
SRS, SPINAL LESION, ADDL
6.37
1.00
Procedure Code Description
RVU
RVU Coeff Value
63650
IMPLANT NEUROELECTRODES
10.18
1.00
63650
IMPLANT NEUROELECTRODES
10.51
1.00
63650
IMPLANT NEUROELECTRODES
10.53
1.00
63655
IMPLANT NEUROELECTRODES
8.00
1.00
63655
IMPLANT NEUROELECTRODES
19.37
1.00
63655
IMPLANT NEUROELECTRODES
19.40
1.00
63655
IMPLANT NEUROELECTRODES
21.45
1.00
63660
REVISE/REMOVE NEUROELECTRODE
5.00
1.00
63660
REVISE/REMOVE NEUROELECTRODE
10.55
1.00
63660
REVISE/REMOVE NEUROELECTRODE
10.56
1.00
63660
REVISE/REMOVE NEUROELECTRODE
11.17
1.00
63685
INSRT/REDO SPINE N GENERATOR
5.00
1.00
63685
INSRT/REDO SPINE N GENERATOR
10.27
1.00
63685
INSRT/REDO SPINE N GENERATOR
12.28
1.00
63685
INSRT/REDO SPINE N GENERATOR
12.35
1.00
63688
REVISE/REMOVE NEURORECEIVER
7.00
1.00
63688
REVISE/REMOVE NEURORECEIVER
9.19
1.00
63688
REVISE/REMOVE NEURORECEIVER
9.77
1.00
63688
REVISE/REMOVE NEURORECEIVER
9.79
1.00
63700
REPAIR OF SPINAL HERNIATION
11.00
1.00
63700
REPAIR OF SPINAL HERNIATION
29.67
1.00
63700
REPAIR OF SPINAL HERNIATION
30.02
1.00
63700
REPAIR OF SPINAL HERNIATION
31.14
1.00
63702
REPAIR OF SPINAL HERNIATION
8.00
1.00
63702
REPAIR OF SPINAL HERNIATION
30.55
1.00
63702
REPAIR OF SPINAL HERNIATION
30.93
1.00
63702
REPAIR OF SPINAL HERNIATION
35.08
1.00
63704
REPAIR OF SPINAL HERNIATION
11.00
1.00
63704
REPAIR OF SPINAL HERNIATION
37.63
1.00
63704
REPAIR OF SPINAL HERNIATION
38.67
1.00
63704
REPAIR OF SPINAL HERNIATION
39.06
1.00
63706
REPAIR OF SPINAL HERNIATION
8.00
1.00
63706
REPAIR OF SPINAL HERNIATION
42.36
1.00
63706
REPAIR OF SPINAL HERNIATION
43.38
1.00
63706
REPAIR OF SPINAL HERNIATION
45.82
1.00
Procedure Code Description
RVU
RVU Coeff Value
63707
REPAIR SPINAL FLUID LEAKAGE
8.00
1.00
63707
REPAIR SPINAL FLUID LEAKAGE
21.23
1.00
63707
REPAIR SPINAL FLUID LEAKAGE
21.28
1.00
63707
REPAIR SPINAL FLUID LEAKAGE
22.98
1.00
63709
REPAIR SPINAL FLUID LEAKAGE
8.00
1.00
63709
REPAIR SPINAL FLUID LEAKAGE
26.51
1.00
63709
REPAIR SPINAL FLUID LEAKAGE
26.66
1.00
63709
REPAIR SPINAL FLUID LEAKAGE
27.93
1.00
63710
GRAFT REPAIR OF SPINE DEFECT
8.00
1.00
63710
GRAFT REPAIR OF SPINE DEFECT
26.11
1.00
63710
GRAFT REPAIR OF SPINE DEFECT
26.25
1.00
63710
GRAFT REPAIR OF SPINE DEFECT
28.01
1.00
63740
INSTALL SPINAL SHUNT
7.00
1.00
63740
INSTALL SPINAL SHUNT
21.27
1.00
63740
INSTALL SPINAL SHUNT
21.31
1.00
63740
INSTALL SPINAL SHUNT
23.79
1.00
63741
INSTALL SPINAL SHUNT
14.16
1.00
63741
INSTALL SPINAL SHUNT
14.29
1.00
63741
INSTALL SPINAL SHUNT
15.36
1.00
63741
INSTALL SPINAL SHUNT
999.99
1.00
63744
REVISION OF SPINAL SHUNT
5.00
1.00
63744
REVISION OF SPINAL SHUNT
15.19
1.00
63744
REVISION OF SPINAL SHUNT
16.19
1.00
63746
REMOVAL OF SPINAL SHUNT
5.00
1.00
63746
REMOVAL OF SPINAL SHUNT
11.61
1.00
63746
REMOVAL OF SPINAL SHUNT
11.62
1.00
63746
REMOVAL OF SPINAL SHUNT
14.10
1.00
64400
N BLOCK INJ, TRIGEMINAL
1.53
1.00
64400
N BLOCK INJ, TRIGEMINAL
1.55
1.00
64400
N BLOCK INJ, TRIGEMINAL
1.63
1.00
64400
N BLOCK INJ, TRIGEMINAL
5.00
1.00
64402
N BLOCK INJ, FACIAL
1.86
1.00
64402
N BLOCK INJ, FACIAL
5.00
1.00
64405
N BLOCK INJ, OCCIPITAL
1.80
1.00
64405
N BLOCK INJ, OCCIPITAL
1.81
1.00
Procedure Code Description
RVU
RVU Coeff Value
64405
N BLOCK INJ, OCCIPITAL
1.90
1.00
64405
N BLOCK INJ, OCCIPITAL
5.00
1.00
64408
N BLOCK INJ, VAGUS
2.17
1.00
64408
N BLOCK INJ, VAGUS
2.18
1.00
64408
N BLOCK INJ, VAGUS
2.30
1.00
64408
N BLOCK INJ, VAGUS
5.00
1.00
64410
N BLOCK INJ, PHRENIC
1.91
1.00
64410
N BLOCK INJ, PHRENIC
1.92
1.00
64410
N BLOCK INJ, PHRENIC
2.04
1.00
64410
N BLOCK INJ, PHRENIC
5.00
1.00
64412
N BLOCK INJ, SPINAL ACCESSOR
1.63
1.00
64412
N BLOCK INJ, SPINAL ACCESSOR
1.65
1.00
64412
N BLOCK INJ, SPINAL ACCESSOR
1.82
1.00
64412
N BLOCK INJ, SPINAL ACCESSOR
5.00
1.00
64413
N BLOCK INJ, CERVICAL PLEXUS
1.93
1.00
64413
N BLOCK INJ, CERVICAL PLEXUS
1.94
1.00
64413
N BLOCK INJ, CERVICAL PLEXUS
1.98
1.00
64413
N BLOCK INJ, CERVICAL PLEXUS
8.00
1.00
64415
N BLOCK INJ, BRACHIAL PLEXUS
1.92
1.00
64415
N BLOCK INJ, BRACHIAL PLEXUS
1.95
1.00
64415
N BLOCK INJ, BRACHIAL PLEXUS
1.97
1.00
64415
N BLOCK INJ, BRACHIAL PLEXUS
8.00
1.00
64416
N BLOCK CONT INFUSE, B PLEX
2.48
1.00
64416
N BLOCK CONT INFUSE, B PLEX
4.31
1.00
64416
N BLOCK CONT INFUSE, B PLEX
4.33
1.00
64417
N BLOCK INJ, AXILLARY
1.91
1.00
64417
N BLOCK INJ, AXILLARY
1.96
1.00
64417
N BLOCK INJ, AXILLARY
1.97
1.00
64417
N BLOCK INJ, AXILLARY
8.00
1.00
64418
N BLOCK INJ, SUPRASCAPULAR
1.76
1.00
64418
N BLOCK INJ, SUPRASCAPULAR
1.77
1.00
64418
N BLOCK INJ, SUPRASCAPULAR
1.89
1.00
64418
N BLOCK INJ, SUPRASCAPULAR
5.00
1.00
64420
N BLOCK INJ, INTERCOST, SNG
1.60
1.00
64420
N BLOCK INJ, INTERCOST, SNG
1.62
1.00
Procedure Code Description
RVU
RVU Coeff Value
64420
N BLOCK INJ, INTERCOST, SNG
1.71
1.00
64420
N BLOCK INJ, INTERCOST, SNG
5.00
1.00
64421
N BLOCK INJ, INTERCOST, MLT
2.24
1.00
64421
N BLOCK INJ, INTERCOST, MLT
2.25
1.00
64421
N BLOCK INJ, INTERCOST, MLT
2.34
1.00
64421
N BLOCK INJ, INTERCOST, MLT
7.00
1.00
64425
N BLOCK INJ, ILIO-ING/HYPOGI
2.34
1.00
64425
N BLOCK INJ, ILIO-ING/HYPOGI
2.35
1.00
64425
N BLOCK INJ, ILIO-ING/HYPOGI
2.43
1.00
64425
N BLOCK INJ, ILIO-ING/HYPOGI
5.00
1.00
64430
N BLOCK INJ, PUDENDAL
2.07
1.00
64430
N BLOCK INJ, PUDENDAL
2.08
1.00
64430
N BLOCK INJ, PUDENDAL
2.30
1.00
64430
N BLOCK INJ, PUDENDAL
5.00
1.00
64435
N BLOCK INJ, PARACERVICAL
2.22
1.00
64435
N BLOCK INJ, PARACERVICAL
2.25
1.00
64435
N BLOCK INJ, PARACERVICAL
2.26
1.00
64435
N BLOCK INJ, PARACERVICAL
5.00
1.00
64445
N BLOCK INJ, SCIATIC, SNG
1.94
1.00
64445
N BLOCK INJ, SCIATIC, SNG
1.95
1.00
64445
N BLOCK INJ, SCIATIC, SNG
2.09
1.00
64445
N BLOCK INJ, SCIATIC, SNG
5.00
1.00
64446
N BLK INJ, SCIATIC, CONT INF
2.44
1.00
64446
N BLK INJ, SCIATIC, CONT INF
4.48
1.00
64446
N BLK INJ, SCIATIC, CONT INF
4.53
1.00
64447
N BLOCK INJ FEM, SINGLE
1.83
1.00
64447
N BLOCK INJ FEM, SINGLE
2.10
1.00
64447
N BLOCK INJ FEM, SINGLE
2.11
1.00
64448
N BLOCK INJ FEM, CONT INF
2.16
1.00
64448
N BLOCK INJ FEM, CONT INF
4.12
1.00
64448
N BLOCK INJ FEM, CONT INF
4.13
1.00
64449
N BLOCK INJ, LUMBAR PLEXUS
2.40
1.00
64449
N BLOCK INJ, LUMBAR PLEXUS
4.07
1.00
64450
N BLOCK, OTHER PERIPHERAL
1.77
1.00
64450
N BLOCK, OTHER PERIPHERAL
1.78
1.00
Procedure Code Description
RVU
RVU Coeff Value
64450
N BLOCK, OTHER PERIPHERAL
1.89
1.00
64450
N BLOCK, OTHER PERIPHERAL
5.00
1.00
64455
N BLOCK INJ, PLANTAR DIGIT
1.08
1.00
64470
INJ PARAVERTEBRAL C/T
2.54
1.00
64470
INJ PARAVERTEBRAL C/T
2.55
1.00
64470
INJ PARAVERTEBRAL C/T
2.69
1.00
64470
INJ PARAVERTEBRAL C/T
5.00
1.00
64472
INJ PARAVERTEBRAL C/T ADD-ON
1.70
1.00
64472
INJ PARAVERTEBRAL C/T ADD-ON
1.71
1.00
64472
INJ PARAVERTEBRAL C/T ADD-ON
1.72
1.00
64472
INJ PARAVERTEBRAL C/T ADD-ON
5.00
1.00
64475
INJ PARAVERTEBRAL L/S
1.98
1.00
64475
INJ PARAVERTEBRAL L/S
1.99
1.00
64475
INJ PARAVERTEBRAL L/S
2.12
1.00
64475
INJ PARAVERTEBRAL L/S
5.00
1.00
64476
INJ PARAVERTEBRAL L/S ADD-ON
1.29
1.00
64476
INJ PARAVERTEBRAL L/S ADD-ON
1.30
1.00
64476
INJ PARAVERTEBRAL L/S ADD-ON
5.00
1.00
64479
INJ FORAMEN EPIDURAL C/T
3.07
1.00
64479
INJ FORAMEN EPIDURAL C/T
3.09
1.00
64479
INJ FORAMEN EPIDURAL C/T
3.18
1.00
64479
INJ FORAMEN EPIDURAL C/T
5.00
1.00
64480
INJ FORAMEN EPIDURAL ADD-ON
2.08
1.00
64480
INJ FORAMEN EPIDURAL ADD-ON
2.11
1.00
64480
INJ FORAMEN EPIDURAL ADD-ON
5.00
1.00
64483
INJ FORAMEN EPIDURAL L/S
2.69
1.00
64483
INJ FORAMEN EPIDURAL L/S
2.70
1.00
64483
INJ FORAMEN EPIDURAL L/S
2.80
1.00
64483
INJ FORAMEN EPIDURAL L/S
5.00
1.00
64484
INJ FORAMEN EPIDURAL ADD-ON
1.77
1.00
64484
INJ FORAMEN EPIDURAL ADD-ON
1.79
1.00
64484
INJ FORAMEN EPIDURAL ADD-ON
1.80
1.00
64484
INJ FORAMEN EPIDURAL ADD-ON
5.00
1.00
64505
N BLOCK, SPENOPALATINE GANGL
1.93
1.00
64505
N BLOCK, SPENOPALATINE GANGL
2.18
1.00
Procedure Code Description 64505
N BLOCK, SPENOPALATINE GANGL
64508
RVU
RVU Coeff Value
10.00
1.00
N BLOCK, CAROTID SINUS S/P
1.70
1.00
64508
N BLOCK, CAROTID SINUS S/P
1.80
1.00
64508
N BLOCK, CAROTID SINUS S/P
7.00
1.00
64510
N BLOCK, STELLATE GANGLION
1.67
1.00
64510
N BLOCK, STELLATE GANGLION
1.75
1.00
64510
N BLOCK, STELLATE GANGLION
7.00
1.00
64517
N BLOCK INJ, HYPOGAS PLXS
3.07
1.00
64517
N BLOCK INJ, HYPOGAS PLXS
3.20
1.00
64520
N BLOCK, LUMBAR/THORACIC
1.85
1.00
64520
N BLOCK, LUMBAR/THORACIC
1.86
1.00
64520
N BLOCK, LUMBAR/THORACIC
1.98
1.00
64520
N BLOCK, LUMBAR/THORACIC
7.00
1.00
64530
N BLOCK INJ, CELIAC PELUS
2.15
1.00
64530
N BLOCK INJ, CELIAC PELUS
2.16
1.00
64530
N BLOCK INJ, CELIAC PELUS
2.34
1.00
64530
N BLOCK INJ, CELIAC PELUS
10.00
1.00
64550
APPLY NEUROSTIMULATOR
0.24
1.00
64553
IMPLANT NEUROELECTRODES
3.75
1.00
64553
IMPLANT NEUROELECTRODES
4.07
1.00
64553
IMPLANT NEUROELECTRODES
4.38
1.00
64555
IMPLANT NEUROELECTRODES
3.02
1.00
64555
IMPLANT NEUROELECTRODES
3.60
1.00
64555
IMPLANT NEUROELECTRODES
4.01
1.00
64560
IMPLANT NEUROELECTRODES
3.24
1.00
64560
IMPLANT NEUROELECTRODES
3.87
1.00
64560
IMPLANT NEUROELECTRODES
4.14
1.00
64561
IMPLANT NEUROELECTRODES
4.00
1.00
64561
IMPLANT NEUROELECTRODES
10.02
1.00
64561
IMPLANT NEUROELECTRODES
10.63
1.00
64561
IMPLANT NEUROELECTRODES
10.85
1.00
64561
IMPLANT NEUROELECTRODES
11.22
1.00
64565
IMPLANT NEUROELECTRODES
2.50
1.00
64565
IMPLANT NEUROELECTRODES
3.06
1.00
64565
IMPLANT NEUROELECTRODES
3.12
1.00
Procedure Code Description
RVU
RVU Coeff Value
64573
IMPLANT NEUROELECTRODES
5.00
1.00
64573
IMPLANT NEUROELECTRODES
14.38
1.00
64573
IMPLANT NEUROELECTRODES
14.51
1.00
64573
IMPLANT NEUROELECTRODES
15.06
1.00
64575
IMPLANT NEUROELECTRODES
7.36
1.00
64575
IMPLANT NEUROELECTRODES
7.49
1.00
64575
IMPLANT NEUROELECTRODES
7.73
1.00
64577
IMPLANT NEUROELECTRODES
8.53
1.00
64577
IMPLANT NEUROELECTRODES
8.75
1.00
64577
IMPLANT NEUROELECTRODES
9.22
1.00
64580
IMPLANT NEUROELECTRODES
7.53
1.00
64580
IMPLANT NEUROELECTRODES
7.91
1.00
64580
IMPLANT NEUROELECTRODES
8.34
1.00
64581
IMPLANT NEUROELECTRODES
5.00
1.00
64581
IMPLANT NEUROELECTRODES
19.34
1.00
64581
IMPLANT NEUROELECTRODES
20.48
1.00
64581
IMPLANT NEUROELECTRODES
21.79
1.00
64585
REVISE/REMOVE NEUROELECTRODE
4.12
1.00
64585
REVISE/REMOVE NEUROELECTRODE
4.16
1.00
64585
REVISE/REMOVE NEUROELECTRODE
4.44
1.00
64590
INSRT/REDO PN/GASTR STIMUL
4.64
1.00
64590
INSRT/REDO PN/GASTR STIMUL
4.78
1.00
64590
INSRT/REDO PN/GASTR STIMUL
5.04
1.00
64595
REVISE/RMV PN/GASTR STIMUL
3.49
1.00
64595
REVISE/RMV PN/GASTR STIMUL
3.68
1.00
64595
REVISE/RMV PN/GASTR STIMUL
3.86
1.00
64600
INJECTION TREATMENT OF NERVE
4.00
1.00
64600
INJECTION TREATMENT OF NERVE
5.23
1.00
64600
INJECTION TREATMENT OF NERVE
5.35
1.00
64600
INJECTION TREATMENT OF NERVE
5.51
1.00
64605
INJECTION TREATMENT OF NERVE
5.00
1.00
64605
INJECTION TREATMENT OF NERVE
8.15
1.00
64605
INJECTION TREATMENT OF NERVE
8.29
1.00
64605
INJECTION TREATMENT OF NERVE
8.85
1.00
64610
INJECTION TREATMENT OF NERVE
5.00
1.00
Procedure Code Description
RVU
RVU Coeff Value
64610
INJECTION TREATMENT OF NERVE
11.86
1.00
64610
INJECTION TREATMENT OF NERVE
12.08
1.00
64610
INJECTION TREATMENT OF NERVE
12.60
1.00
64612
DESTROY NERVE, FACE MUSCLE
3.08
1.00
64612
DESTROY NERVE, FACE MUSCLE
3.15
1.00
64612
DESTROY NERVE, FACE MUSCLE
3.45
1.00
64612
DESTROY NERVE, FACE MUSCLE
999.99
1.00
64613
DESTROY NERVE, NECK MUSCLE
3.02
1.00
64613
DESTROY NERVE, NECK MUSCLE
3.07
1.00
64613
DESTROY NERVE, NECK MUSCLE
3.26
1.00
64613
DESTROY NERVE, NECK MUSCLE
999.99
1.00
64614
DESTROY NERVE, EXTREM MUSC
3.33
1.00
64614
DESTROY NERVE, EXTREM MUSC
3.43
1.00
64614
DESTROY NERVE, EXTREM MUSC
3.62
1.00
64614
DESTROY NERVE, EXTREM MUSC
4.00
1.00
64620
INJECTION TREATMENT OF NERVE
4.11
1.00
64620
INJECTION TREATMENT OF NERVE
4.23
1.00
64620
INJECTION TREATMENT OF NERVE
4.28
1.00
64620
INJECTION TREATMENT OF NERVE
10.00
1.00
64622
DESTR PARAVERTEBRL NERVE L/S
4.34
1.00
64622
DESTR PARAVERTEBRL NERVE L/S
4.44
1.00
64622
DESTR PARAVERTEBRL NERVE L/S
4.53
1.00
64622
DESTR PARAVERTEBRL NERVE L/S
8.00
1.00
64623
DESTR PARAVERTEBRAL N ADD-ON
1.28
1.00
64623
DESTR PARAVERTEBRAL N ADD-ON
1.29
1.00
64626
DESTR PARAVERTEBRL NERVE C/T
5.34
1.00
64626
DESTR PARAVERTEBRL NERVE C/T
5.40
1.00
64626
DESTR PARAVERTEBRL NERVE C/T
5.97
1.00
64627
DESTR PARAVERTEBRAL N ADD-ON
1.50
1.00
64627
DESTR PARAVERTEBRAL N ADD-ON
1.51
1.00
64627
DESTR PARAVERTEBRAL N ADD-ON
1.53
1.00
64630
INJECTION TREATMENT OF NERVE
4.38
1.00
64630
INJECTION TREATMENT OF NERVE
4.47
1.00
64630
INJECTION TREATMENT OF NERVE
4.98
1.00
64630
INJECTION TREATMENT OF NERVE
10.00
1.00
Procedure Code Description
RVU
RVU Coeff Value
64632
N BLOCK INJ, COMMON DIGIT
1.88
1.00
64640
INJECTION TREATMENT OF NERVE
4.56
1.00
64640
INJECTION TREATMENT OF NERVE
4.57
1.00
64640
INJECTION TREATMENT OF NERVE
4.59
1.00
64650
CHEMODENERV ECCRINE GLANDS
1.03
1.00
64653
CHEMODENERV ECCRINE GLANDS
1.29
1.00
64680
INJECTION TREATMENT OF NERVE
3.98
1.00
64680
INJECTION TREATMENT OF NERVE
4.08
1.00
64680
INJECTION TREATMENT OF NERVE
4.15
1.00
64681
INJECTION TREATMENT OF NERVE
5.59
1.00
64681
INJECTION TREATMENT OF NERVE
5.82
1.00
64702
REVISE FINGER/TOE NERVE
3.00
1.00
64702
REVISE FINGER/TOE NERVE
8.66
1.00
64702
REVISE FINGER/TOE NERVE
8.73
1.00
64702
REVISE FINGER/TOE NERVE
11.62
1.00
64704
REVISE HAND/FOOT NERVE
3.00
1.00
64704
REVISE HAND/FOOT NERVE
8.38
1.00
64704
REVISE HAND/FOOT NERVE
8.55
1.00
64704
REVISE HAND/FOOT NERVE
8.60
1.00
64708
REVISE ARM/LEG NERVE
3.00
1.00
64708
REVISE ARM/LEG NERVE
11.93
1.00
64708
REVISE ARM/LEG NERVE
12.06
1.00
64708
REVISE ARM/LEG NERVE
12.18
1.00
64712
REVISION OF SCIATIC NERVE
3.00
1.00
64712
REVISION OF SCIATIC NERVE
13.38
1.00
64712
REVISION OF SCIATIC NERVE
13.56
1.00
64712
REVISION OF SCIATIC NERVE
13.94
1.00
64713
REVISION OF ARM NERVE(S)
4.00
1.00
64713
REVISION OF ARM NERVE(S)
17.81
1.00
64713
REVISION OF ARM NERVE(S)
18.10
1.00
64713
REVISION OF ARM NERVE(S)
19.66
1.00
64714
REVISE LOW BACK NERVE(S)
8.00
1.00
64714
REVISE LOW BACK NERVE(S)
15.19
1.00
64714
REVISE LOW BACK NERVE(S)
15.32
1.00
64714
REVISE LOW BACK NERVE(S)
16.66
1.00
Procedure Code Description
RVU
RVU Coeff Value
64716
REVISION OF CRANIAL NERVE
6.00
1.00
64716
REVISION OF CRANIAL NERVE
11.87
1.00
64716
REVISION OF CRANIAL NERVE
12.27
1.00
64716
REVISION OF CRANIAL NERVE
13.18
1.00
64718
REVISE ULNAR NERVE AT ELBOW
3.00
1.00
64718
REVISE ULNAR NERVE AT ELBOW
12.16
1.00
64718
REVISE ULNAR NERVE AT ELBOW
12.90
1.00
64718
REVISE ULNAR NERVE AT ELBOW
14.34
1.00
64719
REVISE ULNAR NERVE AT WRIST
3.00
1.00
64719
REVISE ULNAR NERVE AT WRIST
9.96
1.00
64719
REVISE ULNAR NERVE AT WRIST
10.06
1.00
64719
REVISE ULNAR NERVE AT WRIST
10.25
1.00
64721
CARPAL TUNNEL SURGERY
3.00
1.00
64721
CARPAL TUNNEL SURGERY
9.94
1.00
64721
CARPAL TUNNEL SURGERY
10.45
1.00
64721
CARPAL TUNNEL SURGERY
10.52
1.00
64722
RELIEVE PRESSURE ON NERVE(S)
3.00
1.00
64722
RELIEVE PRESSURE ON NERVE(S)
8.14
1.00
64722
RELIEVE PRESSURE ON NERVE(S)
8.35
1.00
64722
RELIEVE PRESSURE ON NERVE(S)
8.46
1.00
64726
RELEASE FOOT/TOE NERVE
3.00
1.00
64726
RELEASE FOOT/TOE NERVE
7.49
1.00
64726
RELEASE FOOT/TOE NERVE
7.62
1.00
64726
RELEASE FOOT/TOE NERVE
7.84
1.00
64727
INTERNAL NERVE REVISION
4.92
1.00
64727
INTERNAL NERVE REVISION
5.04
1.00
64727
INTERNAL NERVE REVISION
5.09
1.00
64732
INCISION OF BROW NERVE
3.00
1.00
64732
INCISION OF BROW NERVE
8.82
1.00
64732
INCISION OF BROW NERVE
8.86
1.00
64732
INCISION OF BROW NERVE
9.82
1.00
64734
INCISION OF CHEEK NERVE
4.00
1.00
64734
INCISION OF CHEEK NERVE
9.40
1.00
64734
INCISION OF CHEEK NERVE
9.97
1.00
64734
INCISION OF CHEEK NERVE
10.55
1.00
Procedure Code Description
RVU
RVU Coeff Value
64736
INCISION OF CHIN NERVE
4.00
1.00
64736
INCISION OF CHIN NERVE
8.26
1.00
64736
INCISION OF CHIN NERVE
9.48
1.00
64736
INCISION OF CHIN NERVE
9.86
1.00
64738
INCISION OF JAW NERVE
4.00
1.00
64738
INCISION OF JAW NERVE
10.22
1.00
64738
INCISION OF JAW NERVE
11.35
1.00
64738
INCISION OF JAW NERVE
11.80
1.00
64740
INCISION OF TONGUE NERVE
5.00
1.00
64740
INCISION OF TONGUE NERVE
9.84
1.00
64740
INCISION OF TONGUE NERVE
10.49
1.00
64740
INCISION OF TONGUE NERVE
11.65
1.00
64742
INCISION OF FACIAL NERVE
4.00
1.00
64742
INCISION OF FACIAL NERVE
11.62
1.00
64742
INCISION OF FACIAL NERVE
11.78
1.00
64742
INCISION OF FACIAL NERVE
11.92
1.00
64744
INCISE NERVE, BACK OF HEAD
4.00
1.00
64744
INCISE NERVE, BACK OF HEAD
10.20
1.00
64744
INCISE NERVE, BACK OF HEAD
10.22
1.00
64744
INCISE NERVE, BACK OF HEAD
10.64
1.00
64746
INCISE DIAPHRAGM NERVE
4.00
1.00
64746
INCISE DIAPHRAGM NERVE
11.17
1.00
64746
INCISE DIAPHRAGM NERVE
11.33
1.00
64746
INCISE DIAPHRAGM NERVE
11.35
1.00
64752
INCISION OF VAGUS NERVE
4.00
1.00
64752
INCISION OF VAGUS NERVE
12.36
1.00
64752
INCISION OF VAGUS NERVE
12.59
1.00
64752
INCISION OF VAGUS NERVE
12.82
1.00
64760
INCISION OF VAGUS NERVE
4.00
1.00
64760
INCISION OF VAGUS NERVE
11.09
1.00
64760
INCISION OF VAGUS NERVE
11.49
1.00
64760
INCISION OF VAGUS NERVE
12.08
1.00
64761
INCISION OF PELVIS NERVE
5.00
1.00
64761
INCISION OF PELVIS NERVE
10.27
1.00
64761
INCISION OF PELVIS NERVE
10.30
1.00
Procedure Code Description 64761
INCISION OF PELVIS NERVE
64763
RVU
RVU Coeff Value
11.36
1.00
INCISE HIP/THIGH NERVE
3.00
1.00
64763
INCISE HIP/THIGH NERVE
13.09
1.00
64763
INCISE HIP/THIGH NERVE
13.77
1.00
64763
INCISE HIP/THIGH NERVE
13.87
1.00
64766
INCISE HIP/THIGH NERVE
6.00
1.00
64766
INCISE HIP/THIGH NERVE
15.11
1.00
64766
INCISE HIP/THIGH NERVE
15.34
1.00
64766
INCISE HIP/THIGH NERVE
15.96
1.00
64771
SEVER CRANIAL NERVE
4.00
1.00
64771
SEVER CRANIAL NERVE
14.29
1.00
64771
SEVER CRANIAL NERVE
14.51
1.00
64771
SEVER CRANIAL NERVE
15.07
1.00
64772
INCISION OF SPINAL NERVE
4.00
1.00
64772
INCISION OF SPINAL NERVE
13.30
1.00
64772
INCISION OF SPINAL NERVE
13.58
1.00
64772
INCISION OF SPINAL NERVE
14.56
1.00
64774
REMOVE SKIN NERVE LESION
3.00
1.00
64774
REMOVE SKIN NERVE LESION
9.55
1.00
64774
REMOVE SKIN NERVE LESION
9.69
1.00
64774
REMOVE SKIN NERVE LESION
10.42
1.00
64776
REMOVE DIGIT NERVE LESION
3.00
1.00
64776
REMOVE DIGIT NERVE LESION
9.54
1.00
64776
REMOVE DIGIT NERVE LESION
9.59
1.00
64776
REMOVE DIGIT NERVE LESION
10.03
1.00
64778
DIGIT NERVE SURGERY ADD-ON
4.88
1.00
64778
DIGIT NERVE SURGERY ADD-ON
5.03
1.00
64778
DIGIT NERVE SURGERY ADD-ON
5.07
1.00
64782
REMOVE LIMB NERVE LESION
3.00
1.00
64782
REMOVE LIMB NERVE LESION
10.74
1.00
64782
REMOVE LIMB NERVE LESION
10.92
1.00
64782
REMOVE LIMB NERVE LESION
11.80
1.00
64783
LIMB NERVE SURGERY ADD-ON
5.82
1.00
64783
LIMB NERVE SURGERY ADD-ON
6.09
1.00
64783
LIMB NERVE SURGERY ADD-ON
6.14
1.00
Procedure Code Description
RVU
RVU Coeff Value
64784
REMOVE NERVE LESION
4.00
1.00
64784
REMOVE NERVE LESION
17.67
1.00
64784
REMOVE NERVE LESION
17.79
1.00
64784
REMOVE NERVE LESION
18.38
1.00
64786
REMOVE SCIATIC NERVE LESION
4.00
1.00
64786
REMOVE SCIATIC NERVE LESION
27.76
1.00
64786
REMOVE SCIATIC NERVE LESION
27.81
1.00
64786
REMOVE SCIATIC NERVE LESION
27.96
1.00
64787
IMPLANT NERVE END
3.00
1.00
64787
IMPLANT NERVE END
6.68
1.00
64787
IMPLANT NERVE END
7.04
1.00
64787
IMPLANT NERVE END
7.10
1.00
64788
REMOVE SKIN NERVE LESION
3.00
1.00
64788
REMOVE SKIN NERVE LESION
8.63
1.00
64788
REMOVE SKIN NERVE LESION
8.72
1.00
64788
REMOVE SKIN NERVE LESION
9.80
1.00
64790
REMOVAL OF NERVE LESION
3.00
1.00
64790
REMOVAL OF NERVE LESION
20.28
1.00
64790
REMOVAL OF NERVE LESION
20.51
1.00
64790
REMOVAL OF NERVE LESION
21.20
1.00
64792
REMOVAL OF NERVE LESION
4.00
1.00
64792
REMOVAL OF NERVE LESION
25.65
1.00
64792
REMOVAL OF NERVE LESION
26.01
1.00
64792
REMOVAL OF NERVE LESION
27.41
1.00
64795
BIOPSY OF NERVE
5.03
1.00
64795
BIOPSY OF NERVE
5.08
1.00
64795
BIOPSY OF NERVE
5.21
1.00
64802
REMOVE SYMPATHETIC NERVES
6.00
1.00
64802
REMOVE SYMPATHETIC NERVES
15.36
1.00
64802
REMOVE SYMPATHETIC NERVES
15.45
1.00
64802
REMOVE SYMPATHETIC NERVES
15.49
1.00
64804
REMOVE SYMPATHETIC NERVES
8.00
1.00
64804
REMOVE SYMPATHETIC NERVES
23.66
1.00
64804
REMOVE SYMPATHETIC NERVES
23.85
1.00
64804
REMOVE SYMPATHETIC NERVES
23.98
1.00
Procedure Code Description
RVU
RVU Coeff Value
64809
REMOVE SYMPATHETIC NERVES
6.00
1.00
64809
REMOVE SYMPATHETIC NERVES
20.61
1.00
64809
REMOVE SYMPATHETIC NERVES
20.94
1.00
64809
REMOVE SYMPATHETIC NERVES
22.05
1.00
64818
REMOVE SYMPATHETIC NERVES
7.00
1.00
64818
REMOVE SYMPATHETIC NERVES
16.91
1.00
64818
REMOVE SYMPATHETIC NERVES
17.15
1.00
64818
REMOVE SYMPATHETIC NERVES
17.17
1.00
64820
REMOVE SYMPATHETIC NERVES
8.00
1.00
64820
REMOVE SYMPATHETIC NERVES
18.87
1.00
64820
REMOVE SYMPATHETIC NERVES
18.98
1.00
64820
REMOVE SYMPATHETIC NERVES
19.27
1.00
64821
REMOVE SYMPATHETIC NERVES
8.00
1.00
64821
REMOVE SYMPATHETIC NERVES
17.28
1.00
64821
REMOVE SYMPATHETIC NERVES
17.36
1.00
64821
REMOVE SYMPATHETIC NERVES
18.97
1.00
64822
REMOVE SYMPATHETIC NERVES
8.00
1.00
64822
REMOVE SYMPATHETIC NERVES
17.17
1.00
64822
REMOVE SYMPATHETIC NERVES
17.20
1.00
64822
REMOVE SYMPATHETIC NERVES
18.97
1.00
64823
REMOVE SYMPATHETIC NERVES
8.00
1.00
64823
REMOVE SYMPATHETIC NERVES
19.53
1.00
64823
REMOVE SYMPATHETIC NERVES
19.94
1.00
64823
REMOVE SYMPATHETIC NERVES
21.57
1.00
64831
REPAIR OF DIGIT NERVE
3.00
1.00
64831
REPAIR OF DIGIT NERVE
17.27
1.00
64831
REPAIR OF DIGIT NERVE
17.82
1.00
64831
REPAIR OF DIGIT NERVE
17.85
1.00
64832
REPAIR NERVE ADD-ON
9.07
1.00
64832
REPAIR NERVE ADD-ON
9.36
1.00
64832
REPAIR NERVE ADD-ON
9.42
1.00
64834
REPAIR OF HAND OR FOOT NERVE
3.00
1.00
64834
REPAIR OF HAND OR FOOT NERVE
18.60
1.00
64834
REPAIR OF HAND OR FOOT NERVE
18.73
1.00
64834
REPAIR OF HAND OR FOOT NERVE
19.08
1.00
Procedure Code Description
RVU
RVU Coeff Value
64835
REPAIR OF HAND OR FOOT NERVE
3.00
1.00
64835
REPAIR OF HAND OR FOOT NERVE
20.16
1.00
64835
REPAIR OF HAND OR FOOT NERVE
20.23
1.00
64835
REPAIR OF HAND OR FOOT NERVE
20.71
1.00
64836
REPAIR OF HAND OR FOOT NERVE
3.00
1.00
64836
REPAIR OF HAND OR FOOT NERVE
20.09
1.00
64836
REPAIR OF HAND OR FOOT NERVE
20.16
1.00
64836
REPAIR OF HAND OR FOOT NERVE
20.68
1.00
64837
REPAIR NERVE ADD-ON
10.08
1.00
64837
REPAIR NERVE ADD-ON
10.37
1.00
64837
REPAIR NERVE ADD-ON
10.46
1.00
64840
REPAIR OF LEG NERVE
3.00
1.00
64840
REPAIR OF LEG NERVE
22.22
1.00
64840
REPAIR OF LEG NERVE
22.32
1.00
64840
REPAIR OF LEG NERVE
23.34
1.00
64856
REPAIR/TRANSPOSE NERVE
3.00
1.00
64856
REPAIR/TRANSPOSE NERVE
24.91
1.00
64856
REPAIR/TRANSPOSE NERVE
25.01
1.00
64856
REPAIR/TRANSPOSE NERVE
26.02
1.00
64857
REPAIR ARM/LEG NERVE
3.00
1.00
64857
REPAIR ARM/LEG NERVE
26.12
1.00
64857
REPAIR ARM/LEG NERVE
26.21
1.00
64857
REPAIR ARM/LEG NERVE
27.20
1.00
64858
REPAIR SCIATIC NERVE
4.00
1.00
64858
REPAIR SCIATIC NERVE
30.09
1.00
64858
REPAIR SCIATIC NERVE
30.56
1.00
64858
REPAIR SCIATIC NERVE
31.63
1.00
64859
NERVE SURGERY
6.84
1.00
64859
NERVE SURGERY
7.01
1.00
64859
NERVE SURGERY
7.05
1.00
64861
REPAIR OF ARM NERVES
5.00
1.00
64861
REPAIR OF ARM NERVES
33.99
1.00
64861
REPAIR OF ARM NERVES
34.33
1.00
64861
REPAIR OF ARM NERVES
35.77
1.00
64862
REPAIR OF LOW BACK NERVES
6.00
1.00
Procedure Code Description
RVU
RVU Coeff Value
64862
REPAIR OF LOW BACK NERVES
34.17
1.00
64862
REPAIR OF LOW BACK NERVES
34.35
1.00
64862
REPAIR OF LOW BACK NERVES
35.13
1.00
64864
REPAIR OF FACIAL NERVE
5.00
1.00
64864
REPAIR OF FACIAL NERVE
21.99
1.00
64864
REPAIR OF FACIAL NERVE
22.20
1.00
64864
REPAIR OF FACIAL NERVE
22.35
1.00
64865
REPAIR OF FACIAL NERVE
11.00
1.00
64865
REPAIR OF FACIAL NERVE
26.70
1.00
64865
REPAIR OF FACIAL NERVE
26.74
1.00
64865
REPAIR OF FACIAL NERVE
29.54
1.00
64866
FUSION OF FACIAL/OTHER NERVE
11.00
1.00
64866
FUSION OF FACIAL/OTHER NERVE
26.71
1.00
64866
FUSION OF FACIAL/OTHER NERVE
26.79
1.00
64866
FUSION OF FACIAL/OTHER NERVE
30.87
1.00
64868
FUSION OF FACIAL/OTHER NERVE
11.00
1.00
64868
FUSION OF FACIAL/OTHER NERVE
24.58
1.00
64868
FUSION OF FACIAL/OTHER NERVE
24.76
1.00
64868
FUSION OF FACIAL/OTHER NERVE
26.88
1.00
64870
FUSION OF FACIAL/OTHER NERVE
5.00
1.00
64870
FUSION OF FACIAL/OTHER NERVE
26.02
1.00
64870
FUSION OF FACIAL/OTHER NERVE
26.16
1.00
64870
FUSION OF FACIAL/OTHER NERVE
26.17
1.00
64872
SUBSEQUENT REPAIR OF NERVE
3.00
1.00
64872
SUBSEQUENT REPAIR OF NERVE
3.20
1.00
64872
SUBSEQUENT REPAIR OF NERVE
3.31
1.00
64872
SUBSEQUENT REPAIR OF NERVE
3.37
1.00
64874
REPAIR & REVISE NERVE ADD-ON
4.00
1.00
64874
REPAIR & REVISE NERVE ADD-ON
4.70
1.00
64874
REPAIR & REVISE NERVE ADD-ON
4.86
1.00
64874
REPAIR & REVISE NERVE ADD-ON
4.93
1.00
64876
REPAIR NERVE/SHORTEN BONE
5.08
1.00
64876
REPAIR NERVE/SHORTEN BONE
5.12
1.00
64876
REPAIR NERVE/SHORTEN BONE
5.13
1.00
64885
NERVE GRAFT, HEAD OR NECK
29.10
1.00
Procedure Code Description
RVU
RVU Coeff Value
64885
NERVE GRAFT, HEAD OR NECK
30.20
1.00
64885
NERVE GRAFT, HEAD OR NECK
30.23
1.00
64885
NERVE GRAFT, HEAD OR NECK
999.99
1.00
64886
NERVE GRAFT, HEAD OR NECK
34.58
1.00
64886
NERVE GRAFT, HEAD OR NECK
35.55
1.00
64886
NERVE GRAFT, HEAD OR NECK
35.56
1.00
64886
NERVE GRAFT, HEAD OR NECK
999.99
1.00
64890
NERVE GRAFT, HAND OR FOOT
3.00
1.00
64890
NERVE GRAFT, HAND OR FOOT
27.14
1.00
64890
NERVE GRAFT, HAND OR FOOT
27.22
1.00
64890
NERVE GRAFT, HAND OR FOOT
28.03
1.00
64891
NERVE GRAFT, HAND OR FOOT
3.00
1.00
64891
NERVE GRAFT, HAND OR FOOT
25.27
1.00
64891
NERVE GRAFT, HAND OR FOOT
25.41
1.00
64891
NERVE GRAFT, HAND OR FOOT
28.67
1.00
64892
NERVE GRAFT, ARM OR LEG
3.00
1.00
64892
NERVE GRAFT, ARM OR LEG
25.40
1.00
64892
NERVE GRAFT, ARM OR LEG
25.48
1.00
64892
NERVE GRAFT, ARM OR LEG
27.35
1.00
64893
NERVE GRAFT, ARM OR LEG
3.00
1.00
64893
NERVE GRAFT, ARM OR LEG
27.42
1.00
64893
NERVE GRAFT, ARM OR LEG
27.60
1.00
64893
NERVE GRAFT, ARM OR LEG
28.79
1.00
64895
NERVE GRAFT, HAND OR FOOT
3.00
1.00
64895
NERVE GRAFT, HAND OR FOOT
31.11
1.00
64895
NERVE GRAFT, HAND OR FOOT
31.35
1.00
64895
NERVE GRAFT, HAND OR FOOT
33.59
1.00
64896
NERVE GRAFT, HAND OR FOOT
3.00
1.00
64896
NERVE GRAFT, HAND OR FOOT
33.45
1.00
64896
NERVE GRAFT, HAND OR FOOT
33.70
1.00
64896
NERVE GRAFT, HAND OR FOOT
37.18
1.00
64897
NERVE GRAFT, ARM OR LEG
3.00
1.00
64897
NERVE GRAFT, ARM OR LEG
31.79
1.00
64897
NERVE GRAFT, ARM OR LEG
32.11
1.00
64897
NERVE GRAFT, ARM OR LEG
32.54
1.00
Procedure Code Description
RVU
RVU Coeff Value
64898
NERVE GRAFT, ARM OR LEG
3.00
1.00
64898
NERVE GRAFT, ARM OR LEG
34.09
1.00
64898
NERVE GRAFT, ARM OR LEG
34.55
1.00
64898
NERVE GRAFT, ARM OR LEG
35.49
1.00
64901
NERVE GRAFT ADD-ON
15.97
1.00
64901
NERVE GRAFT ADD-ON
16.62
1.00
64901
NERVE GRAFT ADD-ON
16.68
1.00
64902
NERVE GRAFT ADD-ON
18.34
1.00
64902
NERVE GRAFT ADD-ON
19.06
1.00
64902
NERVE GRAFT ADD-ON
19.13
1.00
64905
NERVE PEDICLE TRANSFER
24.39
1.00
64905
NERVE PEDICLE TRANSFER
24.48
1.00
64905
NERVE PEDICLE TRANSFER
26.03
1.00
64907
NERVE PEDICLE TRANSFER
33.00
1.00
64907
NERVE PEDICLE TRANSFER
33.46
1.00
64907
NERVE PEDICLE TRANSFER
34.38
1.00
64910
NERVE REPAIR W/ALLOGRAFT
20.99
1.00
64911
NEURORRAPHY W/VEIN AUTOGRAFT
25.25
1.00
65091
REVISE EYE
4.00
1.00
65091
REVISE EYE
14.71
1.00
65091
REVISE EYE
16.49
1.00
65091
REVISE EYE
18.00
1.00
65093
REVISE EYE WITH IMPLANT
4.00
1.00
65093
REVISE EYE WITH IMPLANT
14.69
1.00
65093
REVISE EYE WITH IMPLANT
17.29
1.00
65093
REVISE EYE WITH IMPLANT
18.65
1.00
65101
REMOVAL OF EYE
4.00
1.00
65101
REMOVAL OF EYE
16.95
1.00
65101
REMOVAL OF EYE
18.04
1.00
65101
REMOVAL OF EYE
18.90
1.00
65103
REMOVE EYE/INSERT IMPLANT
4.00
1.00
65103
REMOVE EYE/INSERT IMPLANT
17.70
1.00
65103
REMOVE EYE/INSERT IMPLANT
18.79
1.00
65103
REMOVE EYE/INSERT IMPLANT
19.61
1.00
65105
REMOVE EYE/ATTACH IMPLANT
4.00
1.00
Procedure Code Description
RVU
RVU Coeff Value
65105
REMOVE EYE/ATTACH IMPLANT
19.53
1.00
65105
REMOVE EYE/ATTACH IMPLANT
20.41
1.00
65105
REMOVE EYE/ATTACH IMPLANT
21.07
1.00
65110
REMOVAL OF EYE
4.00
1.00
65110
REMOVAL OF EYE
28.52
1.00
65110
REMOVAL OF EYE
29.36
1.00
65110
REMOVAL OF EYE
29.92
1.00
65112
REMOVE EYE/REVISE SOCKET
6.00
1.00
65112
REMOVE EYE/REVISE SOCKET
33.70
1.00
65112
REMOVE EYE/REVISE SOCKET
34.40
1.00
65112
REMOVE EYE/REVISE SOCKET
34.88
1.00
65114
REMOVE EYE/REVISE SOCKET
4.00
1.00
65114
REMOVE EYE/REVISE SOCKET
34.92
1.00
65114
REMOVE EYE/REVISE SOCKET
35.73
1.00
65114
REMOVE EYE/REVISE SOCKET
35.97
1.00
65125
REVISE OCULAR IMPLANT
4.72
1.00
65125
REVISE OCULAR IMPLANT
6.26
1.00
65125
REVISE OCULAR IMPLANT
6.69
1.00
65125
REVISE OCULAR IMPLANT
999.99
1.00
65130
INSERT OCULAR IMPLANT
6.00
1.00
65130
INSERT OCULAR IMPLANT
16.77
1.00
65130
INSERT OCULAR IMPLANT
17.72
1.00
65130
INSERT OCULAR IMPLANT
18.65
1.00
65135
INSERT OCULAR IMPLANT
6.00
1.00
65135
INSERT OCULAR IMPLANT
17.08
1.00
65135
INSERT OCULAR IMPLANT
18.09
1.00
65135
INSERT OCULAR IMPLANT
19.05
1.00
65140
ATTACH OCULAR IMPLANT
6.00
1.00
65140
ATTACH OCULAR IMPLANT
18.61
1.00
65140
ATTACH OCULAR IMPLANT
19.25
1.00
65140
ATTACH OCULAR IMPLANT
20.04
1.00
65150
REVISE OCULAR IMPLANT
6.00
1.00
65150
REVISE OCULAR IMPLANT
13.50
1.00
65150
REVISE OCULAR IMPLANT
15.84
1.00
65150
REVISE OCULAR IMPLANT
17.26
1.00
Procedure Code Description
RVU
RVU Coeff Value
65155
REINSERT OCULAR IMPLANT
6.00
1.00
65155
REINSERT OCULAR IMPLANT
19.66
1.00
65155
REINSERT OCULAR IMPLANT
20.72
1.00
65155
REINSERT OCULAR IMPLANT
21.60
1.00
65175
REMOVAL OF OCULAR IMPLANT
5.00
1.00
65175
REMOVAL OF OCULAR IMPLANT
15.11
1.00
65175
REMOVAL OF OCULAR IMPLANT
16.23
1.00
65175
REMOVAL OF OCULAR IMPLANT
17.36
1.00
65205
REMOVE FOREIGN BODY FROM EYE
0.93
1.00
65205
REMOVE FOREIGN BODY FROM EYE
0.94
1.00
65205
REMOVE FOREIGN BODY FROM EYE
1.06
1.00
65210
REMOVE FOREIGN BODY FROM EYE
1.17
1.00
65210
REMOVE FOREIGN BODY FROM EYE
1.18
1.00
65210
REMOVE FOREIGN BODY FROM EYE
1.28
1.00
65210
REMOVE FOREIGN BODY FROM EYE
6.00
1.00
65220
REMOVE FOREIGN BODY FROM EYE
0.94
1.00
65220
REMOVE FOREIGN BODY FROM EYE
0.95
1.00
65220
REMOVE FOREIGN BODY FROM EYE
1.05
1.00
65220
REMOVE FOREIGN BODY FROM EYE
4.00
1.00
65222
REMOVE FOREIGN BODY FROM EYE
1.25
1.00
65222
REMOVE FOREIGN BODY FROM EYE
1.40
1.00
65222
REMOVE FOREIGN BODY FROM EYE
4.00
1.00
65235
REMOVE FOREIGN BODY FROM EYE
6.00
1.00
65235
REMOVE FOREIGN BODY FROM EYE
14.71
1.00
65235
REMOVE FOREIGN BODY FROM EYE
15.18
1.00
65235
REMOVE FOREIGN BODY FROM EYE
16.11
1.00
65260
REMOVE FOREIGN BODY FROM EYE
6.00
1.00
65260
REMOVE FOREIGN BODY FROM EYE
22.11
1.00
65260
REMOVE FOREIGN BODY FROM EYE
22.89
1.00
65260
REMOVE FOREIGN BODY FROM EYE
23.77
1.00
65265
REMOVE FOREIGN BODY FROM EYE
8.00
1.00
65265
REMOVE FOREIGN BODY FROM EYE
24.88
1.00
65265
REMOVE FOREIGN BODY FROM EYE
25.84
1.00
65265
REMOVE FOREIGN BODY FROM EYE
26.97
1.00
65270
REPAIR OF EYE WOUND
3.29
1.00
Procedure Code Description
RVU
RVU Coeff Value
65270
REPAIR OF EYE WOUND
4.24
1.00
65270
REPAIR OF EYE WOUND
4.29
1.00
65270
REPAIR OF EYE WOUND
8.00
1.00
65272
REPAIR OF EYE WOUND
4.00
1.00
65272
REPAIR OF EYE WOUND
7.30
1.00
65272
REPAIR OF EYE WOUND
7.90
1.00
65272
REPAIR OF EYE WOUND
7.98
1.00
65272
REPAIR OF EYE WOUND
7.99
1.00
65272
REPAIR OF EYE WOUND
8.62
1.00
65272
REPAIR OF EYE WOUND
9.21
1.00
65273
REPAIR OF EYE WOUND
5.00
1.00
65273
REPAIR OF EYE WOUND
8.78
1.00
65273
REPAIR OF EYE WOUND
9.51
1.00
65273
REPAIR OF EYE WOUND
10.19
1.00
65275
REPAIR OF EYE WOUND
4.00
1.00
65275
REPAIR OF EYE WOUND
10.44
1.00
65275
REPAIR OF EYE WOUND
10.69
1.00
65275
REPAIR OF EYE WOUND
11.32
1.00
65280
REPAIR OF EYE WOUND
6.00
1.00
65280
REPAIR OF EYE WOUND
15.40
1.00
65280
REPAIR OF EYE WOUND
15.60
1.00
65280
REPAIR OF EYE WOUND
16.18
1.00
65285
REPAIR OF EYE WOUND
6.00
1.00
65285
REPAIR OF EYE WOUND
24.03
1.00
65285
REPAIR OF EYE WOUND
25.88
1.00
65285
REPAIR OF EYE WOUND
26.87
1.00
65286
REPAIR OF EYE WOUND
11.32
1.00
65286
REPAIR OF EYE WOUND
13.27
1.00
65286
REPAIR OF EYE WOUND
13.33
1.00
65290
REPAIR OF EYE SOCKET WOUND
5.00
1.00
65290
REPAIR OF EYE SOCKET WOUND
11.32
1.00
65290
REPAIR OF EYE SOCKET WOUND
11.94
1.00
65290
REPAIR OF EYE SOCKET WOUND
12.18
1.00
65400
REMOVAL OF EYE LESION
4.00
1.00
65400
REMOVAL OF EYE LESION
13.21
1.00
Procedure Code Description
RVU
RVU Coeff Value
65400
REMOVAL OF EYE LESION
13.65
1.00
65400
REMOVAL OF EYE LESION
13.81
1.00
65410
BIOPSY OF CORNEA
2.19
1.00
65410
BIOPSY OF CORNEA
2.20
1.00
65410
BIOPSY OF CORNEA
2.46
1.00
65410
BIOPSY OF CORNEA
4.00
1.00
65420
REMOVAL OF EYE LESION
4.00
1.00
65420
REMOVAL OF EYE LESION
8.62
1.00
65420
REMOVAL OF EYE LESION
11.11
1.00
65420
REMOVAL OF EYE LESION
11.31
1.00
65426
REMOVAL OF EYE LESION
5.00
1.00
65426
REMOVAL OF EYE LESION
10.97
1.00
65426
REMOVAL OF EYE LESION
11.99
1.00
65426
REMOVAL OF EYE LESION
12.02
1.00
65430
CORNEAL SMEAR
2.20
1.00
65430
CORNEAL SMEAR
2.21
1.00
65430
CORNEAL SMEAR
2.46
1.00
65435
CURETTE/TREAT CORNEA
1.36
1.00
65435
CURETTE/TREAT CORNEA
1.64
1.00
65435
CURETTE/TREAT CORNEA
5.00
1.00
65436
CURETTE/TREAT CORNEA
6.00
1.00
65436
CURETTE/TREAT CORNEA
8.53
1.00
65436
CURETTE/TREAT CORNEA
9.22
1.00
65436
CURETTE/TREAT CORNEA
9.61
1.00
65450
TREATMENT OF CORNEAL LESION
5.00
1.00
65450
TREATMENT OF CORNEAL LESION
7.26
1.00
65450
TREATMENT OF CORNEAL LESION
9.76
1.00
65450
TREATMENT OF CORNEAL LESION
9.97
1.00
65600
REVISION OF CORNEA
4.00
1.00
65600
REVISION OF CORNEA
4.97
1.00
65600
REVISION OF CORNEA
6.67
1.00
65600
REVISION OF CORNEA
7.72
1.00
65710
CORNEAL TRANSPLANT
8.00
1.00
65710
CORNEAL TRANSPLANT
25.25
1.00
65710
CORNEAL TRANSPLANT
25.44
1.00
Procedure Code Description
RVU
RVU Coeff Value
65710
CORNEAL TRANSPLANT
25.56
1.00
65730
CORNEAL TRANSPLANT
8.00
1.00
65730
CORNEAL TRANSPLANT
26.58
1.00
65730
CORNEAL TRANSPLANT
26.77
1.00
65730
CORNEAL TRANSPLANT
28.30
1.00
65750
CORNEAL TRANSPLANT
8.00
1.00
65750
CORNEAL TRANSPLANT
28.70
1.00
65750
CORNEAL TRANSPLANT
29.04
1.00
65750
CORNEAL TRANSPLANT
29.72
1.00
65755
CORNEAL TRANSPLANT
28.53
1.00
65755
CORNEAL TRANSPLANT
28.83
1.00
65755
CORNEAL TRANSPLANT
29.51
1.00
65755
CORNEAL TRANSPLANT
999.99
1.00
65756
CORNEAL TRNSPL, ENDOTHELIAL
27.48
1.00
65767
CORNEAL TISSUE TRANSPLANT
5.00
1.00
65770
REVISE CORNEA WITH IMPLANT
8.00
1.00
65770
REVISE CORNEA WITH IMPLANT
32.67
1.00
65770
REVISE CORNEA WITH IMPLANT
32.81
1.00
65770
REVISE CORNEA WITH IMPLANT
33.31
1.00
65771
RADIAL KERATOTOMY
999.99
1.00
65772
CORRECTION OF ASTIGMATISM
5.00
1.00
65772
CORRECTION OF ASTIGMATISM
9.25
1.00
65772
CORRECTION OF ASTIGMATISM
10.70
1.00
65772
CORRECTION OF ASTIGMATISM
10.95
1.00
65775
CORRECTION OF ASTIGMATISM
5.00
1.00
65775
CORRECTION OF ASTIGMATISM
12.64
1.00
65775
CORRECTION OF ASTIGMATISM
13.40
1.00
65775
CORRECTION OF ASTIGMATISM
14.39
1.00
65780
OCULAR RECONST, TRANSPLANT
20.36
1.00
65780
OCULAR RECONST, TRANSPLANT
20.52
1.00
65781
OCULAR RECONST, TRANSPLANT
30.82
1.00
65781
OCULAR RECONST, TRANSPLANT
31.30
1.00
65782
OCULAR RECONST, TRANSPLANT
26.61
1.00
65782
OCULAR RECONST, TRANSPLANT
26.99
1.00
65800
DRAINAGE OF EYE
3.11
1.00
Procedure Code Description
RVU
RVU Coeff Value
65800
DRAINAGE OF EYE
3.18
1.00
65800
DRAINAGE OF EYE
3.39
1.00
65800
DRAINAGE OF EYE
6.00
1.00
65805
DRAINAGE OF EYE
3.11
1.00
65805
DRAINAGE OF EYE
3.19
1.00
65805
DRAINAGE OF EYE
3.40
1.00
65805
DRAINAGE OF EYE
6.00
1.00
65810
DRAINAGE OF EYE
6.00
1.00
65810
DRAINAGE OF EYE
10.72
1.00
65810
DRAINAGE OF EYE
13.14
1.00
65810
DRAINAGE OF EYE
13.71
1.00
65815
DRAINAGE OF EYE
4.00
1.00
65815
DRAINAGE OF EYE
10.87
1.00
65815
DRAINAGE OF EYE
12.77
1.00
65815
DRAINAGE OF EYE
13.13
1.00
65820
RELIEVE INNER EYE PRESSURE
4.00
1.00
65820
RELIEVE INNER EYE PRESSURE
17.27
1.00
65820
RELIEVE INNER EYE PRESSURE
19.09
1.00
65820
RELIEVE INNER EYE PRESSURE
19.16
1.00
65850
INCISION OF EYE
6.00
1.00
65850
INCISION OF EYE
19.64
1.00
65850
INCISION OF EYE
20.37
1.00
65850
INCISION OF EYE
20.92
1.00
65855
LASER SURGERY OF EYE
5.00
1.00
65855
LASER SURGERY OF EYE
6.93
1.00
65855
LASER SURGERY OF EYE
7.58
1.00
65855
LASER SURGERY OF EYE
8.10
1.00
65860
INCISE INNER EYE ADHESIONS
5.00
1.00
65860
INCISE INNER EYE ADHESIONS
6.01
1.00
65860
INCISE INNER EYE ADHESIONS
6.76
1.00
65860
INCISE INNER EYE ADHESIONS
6.97
1.00
65865
INCISE INNER EYE ADHESIONS
6.00
1.00
65865
INCISE INNER EYE ADHESIONS
10.99
1.00
65865
INCISE INNER EYE ADHESIONS
12.34
1.00
65865
INCISE INNER EYE ADHESIONS
12.51
1.00
Procedure Code Description
RVU
RVU Coeff Value
65870
INCISE INNER EYE ADHESIONS
4.00
1.00
65870
INCISE INNER EYE ADHESIONS
13.53
1.00
65870
INCISE INNER EYE ADHESIONS
13.56
1.00
65870
INCISE INNER EYE ADHESIONS
13.69
1.00
65875
INCISE INNER EYE ADHESIONS
6.00
1.00
65875
INCISE INNER EYE ADHESIONS
13.91
1.00
65875
INCISE INNER EYE ADHESIONS
14.27
1.00
65875
INCISE INNER EYE ADHESIONS
14.40
1.00
65880
INCISE INNER EYE ADHESIONS
6.00
1.00
65880
INCISE INNER EYE ADHESIONS
14.75
1.00
65880
INCISE INNER EYE ADHESIONS
15.11
1.00
65880
INCISE INNER EYE ADHESIONS
15.18
1.00
65900
REMOVE EYE LESION
6.00
1.00
65900
REMOVE EYE LESION
22.28
1.00
65900
REMOVE EYE LESION
22.97
1.00
65900
REMOVE EYE LESION
23.87
1.00
65920
REMOVE IMPLANT OF EYE
6.00
1.00
65920
REMOVE IMPLANT OF EYE
16.72
1.00
65920
REMOVE IMPLANT OF EYE
17.49
1.00
65920
REMOVE IMPLANT OF EYE
18.02
1.00
65930
REMOVE BLOOD CLOT FROM EYE
5.00
1.00
65930
REMOVE BLOOD CLOT FROM EYE
14.84
1.00
65930
REMOVE BLOOD CLOT FROM EYE
15.52
1.00
65930
REMOVE BLOOD CLOT FROM EYE
16.29
1.00
66020
INJECTION TREATMENT OF EYE
3.04
1.00
66020
INJECTION TREATMENT OF EYE
3.18
1.00
66020
INJECTION TREATMENT OF EYE
3.25
1.00
66020
INJECTION TREATMENT OF EYE
4.00
1.00
66030
INJECTION TREATMENT OF EYE
2.54
1.00
66030
INJECTION TREATMENT OF EYE
2.65
1.00
66030
INJECTION TREATMENT OF EYE
2.73
1.00
66030
INJECTION TREATMENT OF EYE
6.00
1.00
66130
REMOVE EYE LESION
5.00
1.00
66130
REMOVE EYE LESION
13.37
1.00
66130
REMOVE EYE LESION
14.48
1.00
Procedure Code Description
RVU
RVU Coeff Value
66130
REMOVE EYE LESION
14.97
1.00
66150
GLAUCOMA SURGERY
6.00
1.00
66150
GLAUCOMA SURGERY
18.55
1.00
66150
GLAUCOMA SURGERY
19.24
1.00
66150
GLAUCOMA SURGERY
19.83
1.00
66155
GLAUCOMA SURGERY
6.00
1.00
66155
GLAUCOMA SURGERY
18.47
1.00
66155
GLAUCOMA SURGERY
19.19
1.00
66155
GLAUCOMA SURGERY
19.75
1.00
66160
GLAUCOMA SURGERY
6.00
1.00
66160
GLAUCOMA SURGERY
21.29
1.00
66160
GLAUCOMA SURGERY
22.02
1.00
66160
GLAUCOMA SURGERY
22.48
1.00
66165
GLAUCOMA SURGERY
6.00
1.00
66165
GLAUCOMA SURGERY
18.06
1.00
66165
GLAUCOMA SURGERY
18.76
1.00
66165
GLAUCOMA SURGERY
19.35
1.00
66170
GLAUCOMA SURGERY
6.00
1.00
66170
GLAUCOMA SURGERY
25.17
1.00
66170
GLAUCOMA SURGERY
27.22
1.00
66170
GLAUCOMA SURGERY
29.16
1.00
66172
INCISION OF EYE
5.00
1.00
66172
INCISION OF EYE
30.75
1.00
66172
INCISION OF EYE
30.85
1.00
66172
INCISION OF EYE
34.20
1.00
66180
IMPLANT EYE SHUNT
26.78
1.00
66180
IMPLANT EYE SHUNT
27.09
1.00
66180
IMPLANT EYE SHUNT
27.16
1.00
66180
IMPLANT EYE SHUNT
999.99
1.00
66185
REVISE EYE SHUNT
16.69
1.00
66185
REVISE EYE SHUNT
16.71
1.00
66185
REVISE EYE SHUNT
17.10
1.00
66185
REVISE EYE SHUNT
999.99
1.00
66220
REPAIR EYE LESION
5.00
1.00
66220
REPAIR EYE LESION
16.71
1.00
Procedure Code Description
RVU
RVU Coeff Value
66220
REPAIR EYE LESION
16.88
1.00
66220
REPAIR EYE LESION
18.02
1.00
66225
REPAIR/GRAFT EYE LESION
5.00
1.00
66225
REPAIR/GRAFT EYE LESION
20.80
1.00
66225
REPAIR/GRAFT EYE LESION
20.88
1.00
66225
REPAIR/GRAFT EYE LESION
21.50
1.00
66250
FOLLOW-UP SURGERY OF EYE
7.00
1.00
66250
FOLLOW-UP SURGERY OF EYE
12.54
1.00
66250
FOLLOW-UP SURGERY OF EYE
12.69
1.00
66250
FOLLOW-UP SURGERY OF EYE
12.75
1.00
66500
INCISION OF IRIS
6.00
1.00
66500
INCISION OF IRIS
8.12
1.00
66500
INCISION OF IRIS
8.51
1.00
66500
INCISION OF IRIS
8.98
1.00
66505
INCISION OF IRIS
6.00
1.00
66505
INCISION OF IRIS
8.89
1.00
66505
INCISION OF IRIS
9.05
1.00
66505
INCISION OF IRIS
9.66
1.00
66600
REMOVE IRIS AND LESION
4.00
1.00
66600
REMOVE IRIS AND LESION
17.64
1.00
66600
REMOVE IRIS AND LESION
17.99
1.00
66600
REMOVE IRIS AND LESION
18.81
1.00
66605
REMOVAL OF IRIS
4.00
1.00
66605
REMOVAL OF IRIS
24.50
1.00
66605
REMOVAL OF IRIS
24.77
1.00
66605
REMOVAL OF IRIS
25.54
1.00
66625
REMOVAL OF IRIS
6.00
1.00
66625
REMOVAL OF IRIS
9.90
1.00
66625
REMOVAL OF IRIS
11.66
1.00
66625
REMOVAL OF IRIS
11.92
1.00
66630
REMOVAL OF IRIS
6.00
1.00
66630
REMOVAL OF IRIS
13.01
1.00
66630
REMOVAL OF IRIS
13.86
1.00
66630
REMOVAL OF IRIS
13.90
1.00
66635
REMOVAL OF IRIS
6.00
1.00
Procedure Code Description
RVU
RVU Coeff Value
66635
REMOVAL OF IRIS
12.95
1.00
66635
REMOVAL OF IRIS
13.14
1.00
66635
REMOVAL OF IRIS
13.17
1.00
66680
REPAIR IRIS & CILIARY BODY
4.00
1.00
66680
REPAIR IRIS & CILIARY BODY
11.71
1.00
66680
REPAIR IRIS & CILIARY BODY
11.72
1.00
66680
REPAIR IRIS & CILIARY BODY
11.76
1.00
66700
DESTRUCTION, CILIARY BODY
9.05
1.00
66700
DESTRUCTION, CILIARY BODY
9.10
1.00
66700
DESTRUCTION, CILIARY BODY
9.24
1.00
66700
DESTRUCTION, CILIARY BODY
999.99
1.00
66710
CILIARY TRANSSLERAL THERAPY
8.77
1.00
66710
CILIARY TRANSSLERAL THERAPY
8.84
1.00
66710
CILIARY TRANSSLERAL THERAPY
9.07
1.00
66710
CILIARY TRANSSLERAL THERAPY
999.99
1.00
66711
CILIARY ENDOSCOPIC ABLATION
14.52
1.00
66720
DESTRUCTION, CILIARY BODY
9.46
1.00
66720
DESTRUCTION, CILIARY BODY
9.60
1.00
66720
DESTRUCTION, CILIARY BODY
9.61
1.00
66720
DESTRUCTION, CILIARY BODY
999.99
1.00
66740
DESTRUCTION, CILIARY BODY
9.11
1.00
66740
DESTRUCTION, CILIARY BODY
9.20
1.00
66740
DESTRUCTION, CILIARY BODY
9.80
1.00
66740
DESTRUCTION, CILIARY BODY
999.99
1.00
66761
REVISION OF IRIS
6.00
1.00
66761
REVISION OF IRIS
8.21
1.00
66761
REVISION OF IRIS
8.48
1.00
66761
REVISION OF IRIS
9.40
1.00
66762
REVISION OF IRIS
6.00
1.00
66762
REVISION OF IRIS
8.73
1.00
66762
REVISION OF IRIS
9.01
1.00
66762
REVISION OF IRIS
9.72
1.00
66770
REMOVAL OF INNER EYE LESION
6.00
1.00
66770
REMOVAL OF INNER EYE LESION
9.86
1.00
66770
REMOVAL OF INNER EYE LESION
10.14
1.00
Procedure Code Description 66770
REMOVAL OF INNER EYE LESION
66820
RVU
RVU Coeff Value
11.02
1.00
INCISION, SECONDARY CATARACT
4.00
1.00
66820
INCISION, SECONDARY CATARACT
9.12
1.00
66820
INCISION, SECONDARY CATARACT
11.17
1.00
66820
INCISION, SECONDARY CATARACT
12.24
1.00
66821
AFTER CATARACT LASER SURGERY
5.00
1.00
66821
AFTER CATARACT LASER SURGERY
5.79
1.00
66821
AFTER CATARACT LASER SURGERY
6.35
1.00
66821
AFTER CATARACT LASER SURGERY
6.97
1.00
66825
REPOSITION INTRAOCULAR LENS
6.00
1.00
66825
REPOSITION INTRAOCULAR LENS
17.51
1.00
66825
REPOSITION INTRAOCULAR LENS
18.69
1.00
66825
REPOSITION INTRAOCULAR LENS
18.74
1.00
66830
REMOVAL OF LENS LESION
8.00
1.00
66830
REMOVAL OF LENS LESION
15.35
1.00
66830
REMOVAL OF LENS LESION
15.66
1.00
66830
REMOVAL OF LENS LESION
16.37
1.00
66840
REMOVAL OF LENS MATERIAL
14.96
1.00
66840
REMOVAL OF LENS MATERIAL
15.00
1.00
66840
REMOVAL OF LENS MATERIAL
15.26
1.00
66840
REMOVAL OF LENS MATERIAL
15.97
1.00
66850
REMOVAL OF LENS MATERIAL
4.00
1.00
66850
REMOVAL OF LENS MATERIAL
16.73
1.00
66850
REMOVAL OF LENS MATERIAL
17.28
1.00
66850
REMOVAL OF LENS MATERIAL
18.23
1.00
66852
REMOVAL OF LENS MATERIAL
18.08
1.00
66852
REMOVAL OF LENS MATERIAL
18.63
1.00
66852
REMOVAL OF LENS MATERIAL
19.51
1.00
66852
REMOVAL OF LENS MATERIAL
999.99
1.00
66920
EXTRACTION OF LENS
8.00
1.00
66920
EXTRACTION OF LENS
16.40
1.00
66920
EXTRACTION OF LENS
16.70
1.00
66920
EXTRACTION OF LENS
17.41
1.00
66930
EXTRACTION OF LENS
8.00
1.00
66930
EXTRACTION OF LENS
19.22
1.00
Procedure Code Description
RVU
RVU Coeff Value
66930
EXTRACTION OF LENS
19.27
1.00
66930
EXTRACTION OF LENS
19.78
1.00
66940
EXTRACTION OF LENS
8.00
1.00
66940
EXTRACTION OF LENS
17.35
1.00
66940
EXTRACTION OF LENS
17.40
1.00
66940
EXTRACTION OF LENS
17.96
1.00
66982
CATARACT SURGERY, COMPLEX
6.00
1.00
66982
CATARACT SURGERY, COMPLEX
23.15
1.00
66982
CATARACT SURGERY, COMPLEX
24.08
1.00
66982
CATARACT SURGERY, COMPLEX
24.72
1.00
66983
CATARACT SURG W/IOL, 1 STAGE
8.00
1.00
66983
CATARACT SURG W/IOL, 1 STAGE
15.24
1.00
66983
CATARACT SURG W/IOL, 1 STAGE
15.63
1.00
66983
CATARACT SURG W/IOL, 1 STAGE
16.95
1.00
66984
CATARACT SURG W/IOL, 1 STAGE
8.00
1.00
66984
CATARACT SURG W/IOL, 1 STAGE
17.71
1.00
66984
CATARACT SURG W/IOL, 1 STAGE
18.23
1.00
66984
CATARACT SURG W/IOL, 1 STAGE
18.33
1.00
66985
INSERT LENS PROSTHESIS
8.00
1.00
66985
INSERT LENS PROSTHESIS
15.54
1.00
66985
INSERT LENS PROSTHESIS
16.25
1.00
66985
INSERT LENS PROSTHESIS
17.52
1.00
66986
EXCHANGE LENS PROSTHESIS
21.34
1.00
66986
EXCHANGE LENS PROSTHESIS
21.49
1.00
66986
EXCHANGE LENS PROSTHESIS
22.07
1.00
66986
EXCHANGE LENS PROSTHESIS
999.99
1.00
66990
OPHTHALMIC ENDOSCOPE ADD-ON
2.20
1.00
66990
OPHTHALMIC ENDOSCOPE ADD-ON
2.27
1.00
67005
PARTIAL REMOVAL OF EYE FLUID
4.00
1.00
67005
PARTIAL REMOVAL OF EYE FLUID
8.57
1.00
67005
PARTIAL REMOVAL OF EYE FLUID
10.34
1.00
67005
PARTIAL REMOVAL OF EYE FLUID
10.83
1.00
67010
PARTIAL REMOVAL OF EYE FLUID
6.00
1.00
67010
PARTIAL REMOVAL OF EYE FLUID
10.34
1.00
67010
PARTIAL REMOVAL OF EYE FLUID
12.12
1.00
Procedure Code Description 67010
PARTIAL REMOVAL OF EYE FLUID
67015
RVU
RVU Coeff Value
12.54
1.00
RELEASE OF EYE FLUID
6.00
1.00
67015
RELEASE OF EYE FLUID
13.38
1.00
67015
RELEASE OF EYE FLUID
14.97
1.00
67015
RELEASE OF EYE FLUID
15.31
1.00
67025
REPLACE EYE FLUID
4.00
1.00
67025
REPLACE EYE FLUID
14.42
1.00
67025
REPLACE EYE FLUID
14.62
1.00
67025
REPLACE EYE FLUID
14.67
1.00
67027
IMPLANT EYE DRUG SYSTEM
6.00
1.00
67027
IMPLANT EYE DRUG SYSTEM
19.77
1.00
67027
IMPLANT EYE DRUG SYSTEM
20.02
1.00
67027
IMPLANT EYE DRUG SYSTEM
20.17
1.00
67028
INJECTION EYE DRUG
3.78
1.00
67028
INJECTION EYE DRUG
3.79
1.00
67028
INJECTION EYE DRUG
4.00
1.00
67028
INJECTION EYE DRUG
999.99
1.00
67030
INCISE INNER EYE STRANDS
4.00
1.00
67030
INCISE INNER EYE STRANDS
11.75
1.00
67030
INCISE INNER EYE STRANDS
11.87
1.00
67030
INCISE INNER EYE STRANDS
11.94
1.00
67031
LASER SURGERY, EYE STRANDS
5.00
1.00
67031
LASER SURGERY, EYE STRANDS
6.95
1.00
67031
LASER SURGERY, EYE STRANDS
7.93
1.00
67031
LASER SURGERY, EYE STRANDS
8.10
1.00
67036
REMOVAL OF INNER EYE FLUID
6.00
1.00
67036
REMOVAL OF INNER EYE FLUID
21.35
1.00
67036
REMOVAL OF INNER EYE FLUID
21.79
1.00
67036
REMOVAL OF INNER EYE FLUID
22.32
1.00
67038
STRIP RETINAL MEMBRANE
6.00
1.00
67038
STRIP RETINAL MEMBRANE
37.53
1.00
67038
STRIP RETINAL MEMBRANE
38.05
1.00
67038
STRIP RETINAL MEMBRANE
39.50
1.00
67039
LASER TREATMENT OF RETINA
6.00
1.00
67039
LASER TREATMENT OF RETINA
27.42
1.00
Procedure Code Description
RVU
RVU Coeff Value
67039
LASER TREATMENT OF RETINA
27.73
1.00
67039
LASER TREATMENT OF RETINA
28.58
1.00
67040
LASER TREATMENT OF RETINA
8.00
1.00
67040
LASER TREATMENT OF RETINA
31.50
1.00
67040
LASER TREATMENT OF RETINA
32.04
1.00
67040
LASER TREATMENT OF RETINA
32.98
1.00
67041
VIT FOR MACULAR PUCKER
30.85
1.00
67042
VIT FOR MACULAR HOLE
35.34
1.00
67043
VIT FOR MEMBRANE DISSECT
37.08
1.00
67101
REPAIR DETACHED RETINA
5.00
1.00
67101
REPAIR DETACHED RETINA
15.43
1.00
67101
REPAIR DETACHED RETINA
15.98
1.00
67101
REPAIR DETACHED RETINA
16.69
1.00
67105
REPAIR DETACHED RETINA
5.00
1.00
67105
REPAIR DETACHED RETINA
13.24
1.00
67105
REPAIR DETACHED RETINA
13.98
1.00
67105
REPAIR DETACHED RETINA
14.80
1.00
67107
REPAIR DETACHED RETINA
6.00
1.00
67107
REPAIR DETACHED RETINA
28.07
1.00
67107
REPAIR DETACHED RETINA
28.34
1.00
67107
REPAIR DETACHED RETINA
28.60
1.00
67108
REPAIR DETACHED RETINA
8.00
1.00
67108
REPAIR DETACHED RETINA
37.38
1.00
67108
REPAIR DETACHED RETINA
38.80
1.00
67108
REPAIR DETACHED RETINA
39.33
1.00
67110
REPAIR DETACHED RETINA
17.77
1.00
67110
REPAIR DETACHED RETINA
18.45
1.00
67110
REPAIR DETACHED RETINA
19.45
1.00
67110
REPAIR DETACHED RETINA
999.99
1.00
67112
REREPAIR DETACHED RETINA
6.00
1.00
67112
REREPAIR DETACHED RETINA
30.84
1.00
67112
REREPAIR DETACHED RETINA
32.22
1.00
67112
REREPAIR DETACHED RETINA
33.21
1.00
67113
REPAIR RETINAL DETACH, CPLX
40.60
1.00
67115
RELEASE ENCIRCLING MATERIAL
5.00
1.00
Procedure Code Description
RVU
RVU Coeff Value
67115
RELEASE ENCIRCLING MATERIAL
11.29
1.00
67115
RELEASE ENCIRCLING MATERIAL
11.99
1.00
67115
RELEASE ENCIRCLING MATERIAL
12.30
1.00
67120
REMOVE EYE IMPLANT MATERIAL
6.00
1.00
67120
REMOVE EYE IMPLANT MATERIAL
12.72
1.00
67120
REMOVE EYE IMPLANT MATERIAL
13.18
1.00
67120
REMOVE EYE IMPLANT MATERIAL
13.33
1.00
67121
REMOVE EYE IMPLANT MATERIAL
5.00
1.00
67121
REMOVE EYE IMPLANT MATERIAL
20.92
1.00
67121
REMOVE EYE IMPLANT MATERIAL
22.33
1.00
67121
REMOVE EYE IMPLANT MATERIAL
23.19
1.00
67141
TREATMENT OF RETINA
5.00
1.00
67141
TREATMENT OF RETINA
11.10
1.00
67141
TREATMENT OF RETINA
11.92
1.00
67141
TREATMENT OF RETINA
12.35
1.00
67145
TREATMENT OF RETINA
5.00
1.00
67145
TREATMENT OF RETINA
9.74
1.00
67145
TREATMENT OF RETINA
10.55
1.00
67145
TREATMENT OF RETINA
11.35
1.00
67208
TREATMENT OF RETINAL LESION
5.00
1.00
67208
TREATMENT OF RETINAL LESION
12.38
1.00
67208
TREATMENT OF RETINAL LESION
13.29
1.00
67208
TREATMENT OF RETINAL LESION
14.09
1.00
67210
TREATMENT OF RETINAL LESION
5.00
1.00
67210
TREATMENT OF RETINAL LESION
14.91
1.00
67210
TREATMENT OF RETINAL LESION
15.02
1.00
67210
TREATMENT OF RETINAL LESION
15.57
1.00
67218
TREATMENT OF RETINAL LESION
5.00
1.00
67218
TREATMENT OF RETINAL LESION
32.66
1.00
67218
TREATMENT OF RETINAL LESION
33.27
1.00
67218
TREATMENT OF RETINAL LESION
34.85
1.00
67220
TREATMENT OF CHOROID LESION
5.00
1.00
67220
TREATMENT OF CHOROID LESION
22.56
1.00
67220
TREATMENT OF CHOROID LESION
23.26
1.00
67220
TREATMENT OF CHOROID LESION
23.57
1.00
Procedure Code Description
RVU
RVU Coeff Value
67221
OCULAR PHOTODYNAMIC THER
5.00
1.00
67221
OCULAR PHOTODYNAMIC THER
5.23
1.00
67221
OCULAR PHOTODYNAMIC THER
6.00
1.00
67221
OCULAR PHOTODYNAMIC THER
6.05
1.00
67225
EYE PHOTODYNAMIC THER ADD-ON
0.68
1.00
67225
EYE PHOTODYNAMIC THER ADD-ON
0.69
1.00
67225
EYE PHOTODYNAMIC THER ADD-ON
0.70
1.00
67227
TREATMENT OF RETINAL LESION
5.00
1.00
67227
TREATMENT OF RETINAL LESION
12.27
1.00
67227
TREATMENT OF RETINAL LESION
13.13
1.00
67227
TREATMENT OF RETINAL LESION
13.99
1.00
67228
TREATMENT OF RETINAL LESION
5.00
1.00
67228
TREATMENT OF RETINAL LESION
20.45
1.00
67228
TREATMENT OF RETINAL LESION
21.74
1.00
67228
TREATMENT OF RETINAL LESION
24.40
1.00
67229
TR RETINAL LES PRETERM INF
26.71
1.00
67250
REINFORCE EYE WALL
5.00
1.00
67250
REINFORCE EYE WALL
18.19
1.00
67250
REINFORCE EYE WALL
19.45
1.00
67250
REINFORCE EYE WALL
20.69
1.00
67255
REINFORCE/GRAFT EYE WALL
5.00
1.00
67255
REINFORCE/GRAFT EYE WALL
19.43
1.00
67255
REINFORCE/GRAFT EYE WALL
20.26
1.00
67255
REINFORCE/GRAFT EYE WALL
21.09
1.00
67311
REVISE EYE MUSCLE
4.00
1.00
67311
REVISE EYE MUSCLE
13.07
1.00
67311
REVISE EYE MUSCLE
13.39
1.00
67311
REVISE EYE MUSCLE
13.78
1.00
67312
REVISE TWO EYE MUSCLES
4.00
1.00
67312
REVISE TWO EYE MUSCLES
16.09
1.00
67312
REVISE TWO EYE MUSCLES
16.47
1.00
67312
REVISE TWO EYE MUSCLES
16.50
1.00
67314
REVISE EYE MUSCLE
5.00
1.00
67314
REVISE EYE MUSCLE
14.54
1.00
67314
REVISE EYE MUSCLE
15.13
1.00
Procedure Code Description
RVU
RVU Coeff Value
67314
REVISE EYE MUSCLE
15.44
1.00
67316
REVISE TWO EYE MUSCLES
17.76
1.00
67316
REVISE TWO EYE MUSCLES
18.35
1.00
67316
REVISE TWO EYE MUSCLES
18.49
1.00
67316
REVISE TWO EYE MUSCLES
999.99
1.00
67318
REVISE EYE MUSCLE(S)
15.27
1.00
67318
REVISE EYE MUSCLE(S)
15.85
1.00
67318
REVISE EYE MUSCLE(S)
16.16
1.00
67318
REVISE EYE MUSCLE(S)
999.99
1.00
67320
REVISE EYE MUSCLE(S) ADD-ON
6.49
1.00
67320
REVISE EYE MUSCLE(S) ADD-ON
6.51
1.00
67320
REVISE EYE MUSCLE(S) ADD-ON
7.70
1.00
67331
EYE SURGERY FOLLOW-UP ADD-ON
6.17
1.00
67331
EYE SURGERY FOLLOW-UP ADD-ON
7.29
1.00
67332
REREVISE EYE MUSCLES ADD-ON
6.73
1.00
67332
REREVISE EYE MUSCLES ADD-ON
6.75
1.00
67332
REREVISE EYE MUSCLES ADD-ON
7.93
1.00
67334
REVISE EYE MUSCLE W/SUTURE
5.97
1.00
67334
REVISE EYE MUSCLE W/SUTURE
5.98
1.00
67334
REVISE EYE MUSCLE W/SUTURE
7.19
1.00
67335
EYE SUTURE DURING SURGERY
3.63
1.00
67335
EYE SUTURE DURING SURGERY
3.73
1.00
67335
EYE SUTURE DURING SURGERY
3.74
1.00
67340
REVISE EYE MUSCLE ADD-ON
7.38
1.00
67340
REVISE EYE MUSCLE ADD-ON
7.40
1.00
67340
REVISE EYE MUSCLE ADD-ON
8.57
1.00
67343
RELEASE EYE TISSUE
14.65
1.00
67343
RELEASE EYE TISSUE
15.00
1.00
67343
RELEASE EYE TISSUE
15.04
1.00
67343
RELEASE EYE TISSUE
999.99
1.00
67345
DESTROY NERVE OF EYE MUSCLE
4.43
1.00
67345
DESTROY NERVE OF EYE MUSCLE
4.49
1.00
67345
DESTROY NERVE OF EYE MUSCLE
4.99
1.00
67346
BIOPSY, EYE MUSCLE
4.78
1.00
67350
BIOPSY EYE MUSCLE
4.90
1.00
Procedure Code Description
RVU
RVU Coeff Value
67350
BIOPSY EYE MUSCLE
4.93
1.00
67350
BIOPSY EYE MUSCLE
5.00
1.00
67400
EXPLORE/BIOPSY EYE SOCKET
6.00
1.00
67400
EXPLORE/BIOPSY EYE SOCKET
21.64
1.00
67400
EXPLORE/BIOPSY EYE SOCKET
22.78
1.00
67400
EXPLORE/BIOPSY EYE SOCKET
23.58
1.00
67405
EXPLORE/DRAIN EYE SOCKET
6.00
1.00
67405
EXPLORE/DRAIN EYE SOCKET
18.41
1.00
67405
EXPLORE/DRAIN EYE SOCKET
19.44
1.00
67405
EXPLORE/DRAIN EYE SOCKET
20.59
1.00
67412
EXPLORE/TREAT EYE SOCKET
6.00
1.00
67412
EXPLORE/TREAT EYE SOCKET
20.02
1.00
67412
EXPLORE/TREAT EYE SOCKET
22.97
1.00
67412
EXPLORE/TREAT EYE SOCKET
25.36
1.00
67413
EXPLORE/TREAT EYE SOCKET
6.00
1.00
67413
EXPLORE/TREAT EYE SOCKET
20.04
1.00
67413
EXPLORE/TREAT EYE SOCKET
22.65
1.00
67413
EXPLORE/TREAT EYE SOCKET
23.78
1.00
67414
EXPLR/DECOMPRESS EYE SOCKET
25.70
1.00
67414
EXPLR/DECOMPRESS EYE SOCKET
27.98
1.00
67414
EXPLR/DECOMPRESS EYE SOCKET
30.62
1.00
67414
EXPLR/DECOMPRESS EYE SOCKET
999.99
1.00
67415
ASPIRATION, ORBITAL CONTENTS
2.54
1.00
67415
ASPIRATION, ORBITAL CONTENTS
2.64
1.00
67415
ASPIRATION, ORBITAL CONTENTS
6.00
1.00
67420
EXPLORE/TREAT EYE SOCKET
4.00
1.00
67420
EXPLORE/TREAT EYE SOCKET
38.29
1.00
67420
EXPLORE/TREAT EYE SOCKET
39.81
1.00
67420
EXPLORE/TREAT EYE SOCKET
41.00
1.00
67430
EXPLORE/TREAT EYE SOCKET
4.00
1.00
67430
EXPLORE/TREAT EYE SOCKET
29.12
1.00
67430
EXPLORE/TREAT EYE SOCKET
30.37
1.00
67430
EXPLORE/TREAT EYE SOCKET
31.48
1.00
67440
EXPLORE/DRAIN EYE SOCKET
6.00
1.00
67440
EXPLORE/DRAIN EYE SOCKET
28.03
1.00
Procedure Code Description
RVU
RVU Coeff Value
67440
EXPLORE/DRAIN EYE SOCKET
29.24
1.00
67440
EXPLORE/DRAIN EYE SOCKET
30.20
1.00
67445
EXPLR/DECOMPRESS EYE SOCKET
30.86
1.00
67445
EXPLR/DECOMPRESS EYE SOCKET
32.70
1.00
67445
EXPLR/DECOMPRESS EYE SOCKET
32.93
1.00
67445
EXPLR/DECOMPRESS EYE SOCKET
999.99
1.00
67450
EXPLORE/BIOPSY EYE SOCKET
4.00
1.00
67450
EXPLORE/BIOPSY EYE SOCKET
29.07
1.00
67450
EXPLORE/BIOPSY EYE SOCKET
29.99
1.00
67450
EXPLORE/BIOPSY EYE SOCKET
30.75
1.00
67500
INJECT/TREAT EYE SOCKET
1.02
1.00
67500
INJECT/TREAT EYE SOCKET
1.03
1.00
67500
INJECT/TREAT EYE SOCKET
1.92
1.00
67500
INJECT/TREAT EYE SOCKET
4.00
1.00
67505
INJECT/TREAT EYE SOCKET
1.07
1.00
67505
INJECT/TREAT EYE SOCKET
1.08
1.00
67505
INJECT/TREAT EYE SOCKET
1.86
1.00
67515
INJECT/TREAT EYE SOCKET
0.91
1.00
67515
INJECT/TREAT EYE SOCKET
2.02
1.00
67515
INJECT/TREAT EYE SOCKET
4.00
1.00
67550
INSERT EYE SOCKET IMPLANT
22.60
1.00
67550
INSERT EYE SOCKET IMPLANT
23.05
1.00
67550
INSERT EYE SOCKET IMPLANT
23.88
1.00
67560
REVISE EYE SOCKET IMPLANT
5.00
1.00
67560
REVISE EYE SOCKET IMPLANT
22.96
1.00
67560
REVISE EYE SOCKET IMPLANT
23.48
1.00
67560
REVISE EYE SOCKET IMPLANT
24.12
1.00
67570
DECOMPRESS OPTIC NERVE
26.97
1.00
67570
DECOMPRESS OPTIC NERVE
29.72
1.00
67570
DECOMPRESS OPTIC NERVE
31.40
1.00
67570
DECOMPRESS OPTIC NERVE
999.99
1.00
67700
DRAINAGE OF EYELID ABSCESS
1.99
1.00
67700
DRAINAGE OF EYELID ABSCESS
2.04
1.00
67700
DRAINAGE OF EYELID ABSCESS
2.66
1.00
67710
INCISION OF EYELID
1.54
1.00
Procedure Code Description
RVU
RVU Coeff Value
67710
INCISION OF EYELID
1.60
1.00
67710
INCISION OF EYELID
2.22
1.00
67710
INCISION OF EYELID
4.00
1.00
67715
INCISION OF EYELID FOLD
1.84
1.00
67715
INCISION OF EYELID FOLD
1.90
1.00
67715
INCISION OF EYELID FOLD
2.51
1.00
67715
INCISION OF EYELID FOLD
4.00
1.00
67800
REMOVE EYELID LESION
2.08
1.00
67800
REMOVE EYELID LESION
2.14
1.00
67800
REMOVE EYELID LESION
2.43
1.00
67800
REMOVE EYELID LESION
4.00
1.00
67801
REMOVE EYELID LESIONS
2.84
1.00
67801
REMOVE EYELID LESIONS
2.90
1.00
67801
REMOVE EYELID LESIONS
3.15
1.00
67801
REMOVE EYELID LESIONS
4.00
1.00
67805
REMOVE EYELID LESIONS
3.34
1.00
67805
REMOVE EYELID LESIONS
3.41
1.00
67805
REMOVE EYELID LESIONS
3.87
1.00
67805
REMOVE EYELID LESIONS
5.00
1.00
67808
REMOVE EYELID LESION(S)
4.00
1.00
67808
REMOVE EYELID LESION(S)
8.13
1.00
67808
REMOVE EYELID LESION(S)
8.39
1.00
67808
REMOVE EYELID LESION(S)
9.23
1.00
67810
BIOPSY OF EYELID
2.23
1.00
67810
BIOPSY OF EYELID
2.24
1.00
67810
BIOPSY OF EYELID
2.26
1.00
67810
BIOPSY OF EYELID
5.00
1.00
67820
REVISE EYELASHES
1.28
1.00
67820
REVISE EYELASHES
1.31
1.00
67820
REVISE EYELASHES
4.00
1.00
67825
REVISE EYELASHES
2.47
1.00
67825
REVISE EYELASHES
2.53
1.00
67825
REVISE EYELASHES
2.80
1.00
67825
REVISE EYELASHES
3.00
1.00
67830
REVISE EYELASHES
3.20
1.00
Procedure Code Description
RVU
RVU Coeff Value
67830
REVISE EYELASHES
3.73
1.00
67830
REVISE EYELASHES
3.88
1.00
67830
REVISE EYELASHES
5.00
1.00
67835
REVISE EYELASHES
5.00
1.00
67835
REVISE EYELASHES
10.22
1.00
67835
REVISE EYELASHES
10.43
1.00
67835
REVISE EYELASHES
10.82
1.00
67840
REMOVE EYELID LESION
3.08
1.00
67840
REMOVE EYELID LESION
3.14
1.00
67840
REMOVE EYELID LESION
3.71
1.00
67840
REMOVE EYELID LESION
6.00
1.00
67850
TREAT EYELID LESION
3.32
1.00
67850
TREAT EYELID LESION
3.66
1.00
67850
TREAT EYELID LESION
3.82
1.00
67850
TREAT EYELID LESION
5.00
1.00
67875
CLOSURE OF EYELID BY SUTURE
2.04
1.00
67875
CLOSURE OF EYELID BY SUTURE
2.31
1.00
67875
CLOSURE OF EYELID BY SUTURE
3.49
1.00
67875
CLOSURE OF EYELID BY SUTURE
999.99
1.00
67880
REVISION OF EYELID
4.00
1.00
67880
REVISION OF EYELID
7.09
1.00
67880
REVISION OF EYELID
8.27
1.00
67880
REVISION OF EYELID
8.39
1.00
67882
REVISION OF EYELID
4.00
1.00
67882
REVISION OF EYELID
9.90
1.00
67882
REVISION OF EYELID
10.81
1.00
67900
REPAIR BROW DEFECT
11.98
1.00
67900
REPAIR BROW DEFECT
12.81
1.00
67900
REPAIR BROW DEFECT
12.90
1.00
67900
REPAIR BROW DEFECT
999.99
1.00
67901
REPAIR EYELID DEFECT
4.00
1.00
67901
REPAIR EYELID DEFECT
13.48
1.00
67901
REPAIR EYELID DEFECT
13.76
1.00
67901
REPAIR EYELID DEFECT
14.09
1.00
67902
REPAIR EYELID DEFECT
4.00
1.00
Procedure Code Description
RVU
RVU Coeff Value
67902
REPAIR EYELID DEFECT
13.90
1.00
67902
REPAIR EYELID DEFECT
14.25
1.00
67902
REPAIR EYELID DEFECT
16.66
1.00
67903
REPAIR EYELID DEFECT
4.00
1.00
67903
REPAIR EYELID DEFECT
11.65
1.00
67903
REPAIR EYELID DEFECT
13.53
1.00
67903
REPAIR EYELID DEFECT
13.94
1.00
67904
REPAIR EYELID DEFECT
5.00
1.00
67904
REPAIR EYELID DEFECT
13.73
1.00
67904
REPAIR EYELID DEFECT
13.76
1.00
67904
REPAIR EYELID DEFECT
14.62
1.00
67906
REPAIR EYELID DEFECT
4.00
1.00
67906
REPAIR EYELID DEFECT
12.06
1.00
67906
REPAIR EYELID DEFECT
13.30
1.00
67906
REPAIR EYELID DEFECT
13.58
1.00
67908
REPAIR EYELID DEFECT
5.00
1.00
67908
REPAIR EYELID DEFECT
10.02
1.00
67908
REPAIR EYELID DEFECT
11.04
1.00
67908
REPAIR EYELID DEFECT
11.43
1.00
67909
REVISE EYELID DEFECT
5.00
1.00
67909
REVISE EYELID DEFECT
10.26
1.00
67909
REVISE EYELID DEFECT
11.78
1.00
67909
REVISE EYELID DEFECT
12.23
1.00
67911
REVISE EYELID DEFECT
5.00
1.00
67911
REVISE EYELID DEFECT
11.58
1.00
67911
REVISE EYELID DEFECT
12.18
1.00
67911
REVISE EYELID DEFECT
12.84
1.00
67912
CORRECTION EYELID W/IMPLANT
11.22
1.00
67912
CORRECTION EYELID W/IMPLANT
11.56
1.00
67914
REPAIR EYELID DEFECT
4.00
1.00
67914
REPAIR EYELID DEFECT
6.75
1.00
67914
REPAIR EYELID DEFECT
7.40
1.00
67914
REPAIR EYELID DEFECT
7.81
1.00
67915
REPAIR EYELID DEFECT
4.00
1.00
67915
REPAIR EYELID DEFECT
4.79
1.00
Procedure Code Description
RVU
RVU Coeff Value
67915
REPAIR EYELID DEFECT
5.92
1.00
67915
REPAIR EYELID DEFECT
5.96
1.00
67916
REPAIR EYELID DEFECT
4.00
1.00
67916
REPAIR EYELID DEFECT
10.07
1.00
67916
REPAIR EYELID DEFECT
10.86
1.00
67916
REPAIR EYELID DEFECT
11.26
1.00
67917
REPAIR EYELID DEFECT
4.00
1.00
67917
REPAIR EYELID DEFECT
11.15
1.00
67917
REPAIR EYELID DEFECT
12.46
1.00
67917
REPAIR EYELID DEFECT
12.87
1.00
67921
REPAIR EYELID DEFECT
4.00
1.00
67921
REPAIR EYELID DEFECT
6.31
1.00
67921
REPAIR EYELID DEFECT
6.89
1.00
67921
REPAIR EYELID DEFECT
7.31
1.00
67922
REPAIR EYELID DEFECT
4.00
1.00
67922
REPAIR EYELID DEFECT
5.74
1.00
67922
REPAIR EYELID DEFECT
6.35
1.00
67922
REPAIR EYELID DEFECT
6.71
1.00
67923
REPAIR EYELID DEFECT
4.00
1.00
67923
REPAIR EYELID DEFECT
10.86
1.00
67923
REPAIR EYELID DEFECT
11.54
1.00
67923
REPAIR EYELID DEFECT
12.06
1.00
67924
REPAIR EYELID DEFECT
4.00
1.00
67924
REPAIR EYELID DEFECT
10.50
1.00
67924
REPAIR EYELID DEFECT
11.71
1.00
67924
REPAIR EYELID DEFECT
11.98
1.00
67930
REPAIR EYELID WOUND
4.00
1.00
67930
REPAIR EYELID WOUND
5.79
1.00
67930
REPAIR EYELID WOUND
6.76
1.00
67930
REPAIR EYELID WOUND
6.83
1.00
67935
REPAIR EYELID WOUND
4.00
1.00
67935
REPAIR EYELID WOUND
10.60
1.00
67935
REPAIR EYELID WOUND
11.91
1.00
67935
REPAIR EYELID WOUND
12.51
1.00
67938
REMOVE EYELID FOREIGN BODY
1.90
1.00
Procedure Code Description
RVU
RVU Coeff Value
67938
REMOVE EYELID FOREIGN BODY
1.96
1.00
67938
REMOVE EYELID FOREIGN BODY
2.67
1.00
67938
REMOVE EYELID FOREIGN BODY
4.00
1.00
67950
REVISION OF EYELID
4.00
1.00
67950
REVISION OF EYELID
10.95
1.00
67950
REVISION OF EYELID
12.74
1.00
67950
REVISION OF EYELID
13.39
1.00
67961
REVISION OF EYELID
4.00
1.00
67961
REVISION OF EYELID
10.69
1.00
67961
REVISION OF EYELID
11.69
1.00
67961
REVISION OF EYELID
11.70
1.00
67966
REVISION OF EYELID
5.00
1.00
67966
REVISION OF EYELID
12.62
1.00
67966
REVISION OF EYELID
12.79
1.00
67966
REVISION OF EYELID
15.10
1.00
67971
RECONSTRUCTION OF EYELID
5.00
1.00
67971
RECONSTRUCTION OF EYELID
17.09
1.00
67971
RECONSTRUCTION OF EYELID
17.56
1.00
67971
RECONSTRUCTION OF EYELID
17.74
1.00
67973
RECONSTRUCTION OF EYELID
4.00
1.00
67973
RECONSTRUCTION OF EYELID
22.16
1.00
67973
RECONSTRUCTION OF EYELID
22.80
1.00
67973
RECONSTRUCTION OF EYELID
23.00
1.00
67974
RECONSTRUCTION OF EYELID
4.00
1.00
67974
RECONSTRUCTION OF EYELID
22.07
1.00
67974
RECONSTRUCTION OF EYELID
22.63
1.00
67974
RECONSTRUCTION OF EYELID
22.83
1.00
67975
RECONSTRUCTION OF EYELID
5.00
1.00
67975
RECONSTRUCTION OF EYELID
16.14
1.00
67975
RECONSTRUCTION OF EYELID
16.53
1.00
67975
RECONSTRUCTION OF EYELID
16.71
1.00
68020
INCISE/DRAIN EYELID LINING
2.06
1.00
68020
INCISE/DRAIN EYELID LINING
2.12
1.00
68020
INCISE/DRAIN EYELID LINING
2.57
1.00
68020
INCISE/DRAIN EYELID LINING
4.00
1.00
Procedure Code Description
RVU
RVU Coeff Value
68040
TREATMENT OF EYELID LESIONS
1.26
1.00
68040
TREATMENT OF EYELID LESIONS
1.27
1.00
68040
TREATMENT OF EYELID LESIONS
1.28
1.00
68040
TREATMENT OF EYELID LESIONS
4.00
1.00
68100
BIOPSY OF EYELID LINING
2.03
1.00
68100
BIOPSY OF EYELID LINING
2.33
1.00
68100
BIOPSY OF EYELID LINING
4.00
1.00
68110
REMOVE EYELID LINING LESION
3.19
1.00
68110
REMOVE EYELID LINING LESION
3.25
1.00
68110
REMOVE EYELID LINING LESION
3.44
1.00
68110
REMOVE EYELID LINING LESION
4.00
1.00
68115
REMOVE EYELID LINING LESION
3.55
1.00
68115
REMOVE EYELID LINING LESION
3.61
1.00
68115
REMOVE EYELID LINING LESION
4.00
1.00
68115
REMOVE EYELID LINING LESION
4.29
1.00
68130
REMOVE EYELID LINING LESION
4.00
1.00
68130
REMOVE EYELID LINING LESION
7.42
1.00
68130
REMOVE EYELID LINING LESION
9.43
1.00
68130
REMOVE EYELID LINING LESION
9.52
1.00
68135
REMOVE EYELID LINING LESION
2.77
1.00
68135
REMOVE EYELID LINING LESION
2.82
1.00
68135
REMOVE EYELID LINING LESION
3.51
1.00
68135
REMOVE EYELID LINING LESION
5.00
1.00
68200
TREAT EYELID BY INJECTION
0.74
1.00
68200
TREAT EYELID BY INJECTION
0.82
1.00
68200
TREAT EYELID BY INJECTION
4.00
1.00
68320
REVISE/GRAFT EYELID LINING
4.00
1.00
68320
REVISE/GRAFT EYELID LINING
10.72
1.00
68320
REVISE/GRAFT EYELID LINING
11.02
1.00
68320
REVISE/GRAFT EYELID LINING
12.22
1.00
68325
REVISE/GRAFT EYELID LINING
4.00
1.00
68325
REVISE/GRAFT EYELID LINING
13.82
1.00
68325
REVISE/GRAFT EYELID LINING
14.10
1.00
68325
REVISE/GRAFT EYELID LINING
15.23
1.00
68326
REVISE/GRAFT EYELID LINING
4.00
1.00
Procedure Code Description
RVU
RVU Coeff Value
68326
REVISE/GRAFT EYELID LINING
13.48
1.00
68326
REVISE/GRAFT EYELID LINING
13.78
1.00
68326
REVISE/GRAFT EYELID LINING
14.80
1.00
68328
REVISE/GRAFT EYELID LINING
4.00
1.00
68328
REVISE/GRAFT EYELID LINING
15.37
1.00
68328
REVISE/GRAFT EYELID LINING
15.68
1.00
68328
REVISE/GRAFT EYELID LINING
16.58
1.00
68330
REVISE EYELID LINING
4.00
1.00
68330
REVISE EYELID LINING
10.51
1.00
68330
REVISE EYELID LINING
10.55
1.00
68330
REVISE EYELID LINING
11.10
1.00
68335
REVISE/GRAFT EYELID LINING
4.00
1.00
68335
REVISE/GRAFT EYELID LINING
12.96
1.00
68335
REVISE/GRAFT EYELID LINING
14.32
1.00
68335
REVISE/GRAFT EYELID LINING
14.85
1.00
68340
SEPARATE EYELID ADHESIONS
4.00
1.00
68340
SEPARATE EYELID ADHESIONS
8.51
1.00
68340
SEPARATE EYELID ADHESIONS
9.08
1.00
68340
SEPARATE EYELID ADHESIONS
9.14
1.00
68360
REVISE EYELID LINING
6.00
1.00
68360
REVISE EYELID LINING
9.39
1.00
68360
REVISE EYELID LINING
9.77
1.00
68360
REVISE EYELID LINING
10.15
1.00
68362
REVISE EYELID LINING
4.00
1.00
68362
REVISE EYELID LINING
15.05
1.00
68362
REVISE EYELID LINING
15.40
1.00
68362
REVISE EYELID LINING
15.45
1.00
68371
HARVEST EYE TISSUE, ALOGRAFT
9.72
1.00
68371
HARVEST EYE TISSUE, ALOGRAFT
9.75
1.00
68400
INCISE/DRAIN TEAR GLAND
3.18
1.00
68400
INCISE/DRAIN TEAR GLAND
3.81
1.00
68400
INCISE/DRAIN TEAR GLAND
3.89
1.00
68400
INCISE/DRAIN TEAR GLAND
4.00
1.00
68420
INCISE/DRAIN TEAR SAC
4.00
1.00
68420
INCISE/DRAIN TEAR SAC
4.08
1.00
Procedure Code Description
RVU
RVU Coeff Value
68420
INCISE/DRAIN TEAR SAC
4.75
1.00
68420
INCISE/DRAIN TEAR SAC
4.84
1.00
68440
INCISE TEAR DUCT OPENING
1.42
1.00
68440
INCISE TEAR DUCT OPENING
1.48
1.00
68440
INCISE TEAR DUCT OPENING
2.23
1.00
68440
INCISE TEAR DUCT OPENING
4.00
1.00
68500
REMOVAL OF TEAR GLAND
4.00
1.00
68500
REMOVAL OF TEAR GLAND
21.21
1.00
68500
REMOVAL OF TEAR GLAND
21.88
1.00
68500
REMOVAL OF TEAR GLAND
22.43
1.00
68505
PARTIAL REMOVAL, TEAR GLAND
4.00
1.00
68505
PARTIAL REMOVAL, TEAR GLAND
22.20
1.00
68505
PARTIAL REMOVAL, TEAR GLAND
22.57
1.00
68505
PARTIAL REMOVAL, TEAR GLAND
22.78
1.00
68510
BIOPSY OF TEAR GLAND
4.00
1.00
68510
BIOPSY OF TEAR GLAND
6.93
1.00
68510
BIOPSY OF TEAR GLAND
6.95
1.00
68510
BIOPSY OF TEAR GLAND
6.99
1.00
68520
REMOVAL OF TEAR SAC
4.00
1.00
68520
REMOVAL OF TEAR SAC
15.01
1.00
68520
REMOVAL OF TEAR SAC
15.68
1.00
68520
REMOVAL OF TEAR SAC
15.88
1.00
68525
BIOPSY OF TEAR SAC
4.00
1.00
68525
BIOPSY OF TEAR SAC
6.43
1.00
68525
BIOPSY OF TEAR SAC
6.66
1.00
68525
BIOPSY OF TEAR SAC
6.68
1.00
68530
CLEARANCE OF TEAR DUCT
5.00
1.00
68530
CLEARANCE OF TEAR DUCT
6.16
1.00
68530
CLEARANCE OF TEAR DUCT
6.69
1.00
68530
CLEARANCE OF TEAR DUCT
6.82
1.00
68540
REMOVE TEAR GLAND LESION
4.00
1.00
68540
REMOVE TEAR GLAND LESION
20.23
1.00
68540
REMOVE TEAR GLAND LESION
20.91
1.00
68540
REMOVE TEAR GLAND LESION
21.45
1.00
68550
REMOVE TEAR GLAND LESION
5.00
1.00
Procedure Code Description
RVU
RVU Coeff Value
68550
REMOVE TEAR GLAND LESION
25.11
1.00
68550
REMOVE TEAR GLAND LESION
25.79
1.00
68550
REMOVE TEAR GLAND LESION
26.42
1.00
68700
REPAIR TEAR DUCTS
4.00
1.00
68700
REPAIR TEAR DUCTS
13.51
1.00
68700
REPAIR TEAR DUCTS
13.84
1.00
68700
REPAIR TEAR DUCTS
14.21
1.00
68705
REVISE TEAR DUCT OPENING
3.11
1.00
68705
REVISE TEAR DUCT OPENING
3.17
1.00
68705
REVISE TEAR DUCT OPENING
3.86
1.00
68705
REVISE TEAR DUCT OPENING
4.00
1.00
68720
CREATE TEAR SAC DRAIN
5.00
1.00
68720
CREATE TEAR SAC DRAIN
17.12
1.00
68720
CREATE TEAR SAC DRAIN
17.58
1.00
68720
CREATE TEAR SAC DRAIN
17.67
1.00
68745
CREATE TEAR DUCT DRAIN
4.00
1.00
68745
CREATE TEAR DUCT DRAIN
16.67
1.00
68745
CREATE TEAR DUCT DRAIN
17.30
1.00
68745
CREATE TEAR DUCT DRAIN
17.68
1.00
68750
CREATE TEAR DUCT DRAIN
4.00
1.00
68750
CREATE TEAR DUCT DRAIN
17.20
1.00
68750
CREATE TEAR DUCT DRAIN
17.79
1.00
68750
CREATE TEAR DUCT DRAIN
18.14
1.00
68760
CLOSE TEAR DUCT OPENING
2.99
1.00
68760
CLOSE TEAR DUCT OPENING
3.04
1.00
68760
CLOSE TEAR DUCT OPENING
3.38
1.00
68760
CLOSE TEAR DUCT OPENING
4.00
1.00
68761
CLOSE TEAR DUCT OPENING
2.37
1.00
68761
CLOSE TEAR DUCT OPENING
2.41
1.00
68761
CLOSE TEAR DUCT OPENING
2.74
1.00
68761
CLOSE TEAR DUCT OPENING
5.00
1.00
68770
CLOSE TEAR SYSTEM FISTULA
4.00
1.00
68770
CLOSE TEAR SYSTEM FISTULA
13.28
1.00
68770
CLOSE TEAR SYSTEM FISTULA
13.69
1.00
68770
CLOSE TEAR SYSTEM FISTULA
14.13
1.00
Procedure Code Description
RVU
RVU Coeff Value
68801
DILATE TEAR DUCT OPENING
1.54
1.00
68801
DILATE TEAR DUCT OPENING
1.59
1.00
68801
DILATE TEAR DUCT OPENING
2.45
1.00
68801
DILATE TEAR DUCT OPENING
4.00
1.00
68810
PROBE NASOLACRIMAL DUCT
2.86
1.00
68810
PROBE NASOLACRIMAL DUCT
2.92
1.00
68810
PROBE NASOLACRIMAL DUCT
4.39
1.00
68811
PROBE NASOLACRIMAL DUCT
4.00
1.00
68811
PROBE NASOLACRIMAL DUCT
4.77
1.00
68811
PROBE NASOLACRIMAL DUCT
4.83
1.00
68811
PROBE NASOLACRIMAL DUCT
4.84
1.00
68815
PROBE NASOLACRIMAL DUCT
4.00
1.00
68815
PROBE NASOLACRIMAL DUCT
6.01
1.00
68815
PROBE NASOLACRIMAL DUCT
6.05
1.00
68815
PROBE NASOLACRIMAL DUCT
6.17
1.00
68816
PROBE NL DUCT W/BALLOON
5.76
1.00
68840
EXPLORE/IRRIGATE TEAR DUCTS
2.23
1.00
68840
EXPLORE/IRRIGATE TEAR DUCTS
2.27
1.00
68840
EXPLORE/IRRIGATE TEAR DUCTS
2.59
1.00
68840
EXPLORE/IRRIGATE TEAR DUCTS
4.00
1.00
68850
INJECTION FOR TEAR SAC X-RAY
1.14
1.00
68850
INJECTION FOR TEAR SAC X-RAY
1.48
1.00
68850
INJECTION FOR TEAR SAC X-RAY
3.00
1.00
70010
CONTRAST X-RAY OF BRAIN
4.74
1.00
70010
CONTRAST X-RAY OF BRAIN
6.15
1.00
70010
CONTRAST X-RAY OF BRAIN
6.21
1.00
70015
CONTRAST X-RAY OF BRAIN
3.06
1.00
70015
CONTRAST X-RAY OF BRAIN
3.08
1.00
70015
CONTRAST X-RAY OF BRAIN
3.94
1.00
70030
X-RAY EYE FOR FOREIGN BODY
0.67
1.00
70030
X-RAY EYE FOR FOREIGN BODY
0.68
1.00
70030
X-RAY EYE FOR FOREIGN BODY
0.77
1.00
70100
X-RAY EXAM OF JAW
0.79
1.00
70100
X-RAY EXAM OF JAW
0.83
1.00
70110
X-RAY EXAM OF JAW
0.99
1.00
Procedure Code Description
RVU
RVU Coeff Value
70110
X-RAY EXAM OF JAW
1.00
1.00
70110
X-RAY EXAM OF JAW
1.08
1.00
70120
X-RAY EXAM OF MASTOIDS
0.90
1.00
70120
X-RAY EXAM OF MASTOIDS
0.91
1.00
70130
X-RAY EXAM OF MASTOIDS
1.29
1.00
70130
X-RAY EXAM OF MASTOIDS
1.30
1.00
70130
X-RAY EXAM OF MASTOIDS
1.50
1.00
70134
X-RAY EXAM OF MIDDLE EAR
1.25
1.00
70134
X-RAY EXAM OF MIDDLE EAR
1.29
1.00
70140
X-RAY EXAM OF FACIAL BONES
0.82
1.00
70140
X-RAY EXAM OF FACIAL BONES
0.91
1.00
70140
X-RAY EXAM OF FACIAL BONES
0.92
1.00
70150
X-RAY EXAM OF FACIAL BONES
1.17
1.00
70150
X-RAY EXAM OF FACIAL BONES
1.18
1.00
70150
X-RAY EXAM OF FACIAL BONES
1.20
1.00
70160
X-RAY EXAM OF NASAL BONES
0.78
1.00
70160
X-RAY EXAM OF NASAL BONES
0.87
1.00
70170
X-RAY EXAM OF TEAR DUCT
1.41
1.00
70170
X-RAY EXAM OF TEAR DUCT
1.42
1.00
70190
X-RAY EXAM OF EYE SOCKETS
0.94
1.00
70190
X-RAY EXAM OF EYE SOCKETS
0.95
1.00
70190
X-RAY EXAM OF EYE SOCKETS
0.97
1.00
70200
X-RAY EXAM OF EYE SOCKETS
1.21
1.00
70200
X-RAY EXAM OF EYE SOCKETS
1.22
1.00
70210
X-RAY EXAM OF SINUSES
0.82
1.00
70210
X-RAY EXAM OF SINUSES
0.89
1.00
70210
X-RAY EXAM OF SINUSES
0.90
1.00
70220
X-RAY EXAM OF SINUSES
1.07
1.00
70220
X-RAY EXAM OF SINUSES
1.17
1.00
70220
X-RAY EXAM OF SINUSES
1.18
1.00
70240
X-RAY EXAM, PITUITARY SADDLE
0.69
1.00
70240
X-RAY EXAM, PITUITARY SADDLE
0.70
1.00
70240
X-RAY EXAM, PITUITARY SADDLE
0.80
1.00
70250
X-RAY EXAM OF SKULL
0.98
1.00
70250
X-RAY EXAM OF SKULL
0.99
1.00
Procedure Code Description
RVU
RVU Coeff Value
70260
X-RAY EXAM OF SKULL
1.32
1.00
70260
X-RAY EXAM OF SKULL
1.41
1.00
70300
X-RAY EXAM OF TEETH
0.39
1.00
70300
X-RAY EXAM OF TEETH
0.43
1.00
70300
X-RAY EXAM OF TEETH
0.45
1.00
70310
X-RAY EXAM OF TEETH
0.67
1.00
70310
X-RAY EXAM OF TEETH
0.68
1.00
70310
X-RAY EXAM OF TEETH
0.92
1.00
70320
FULL MOUTH X-RAY OF TEETH
1.13
1.00
70320
FULL MOUTH X-RAY OF TEETH
1.15
1.00
70320
FULL MOUTH X-RAY OF TEETH
1.30
1.00
70328
X-RAY EXAM OF JAW JOINT
0.76
1.00
70328
X-RAY EXAM OF JAW JOINT
0.81
1.00
70330
X-RAY EXAM OF JAW JOINTS
1.21
1.00
70330
X-RAY EXAM OF JAW JOINTS
1.23
1.00
70330
X-RAY EXAM OF JAW JOINTS
1.29
1.00
70332
X-RAY EXAM OF JAW JOINT
2.33
1.00
70332
X-RAY EXAM OF JAW JOINT
2.94
1.00
70332
X-RAY EXAM OF JAW JOINT
2.98
1.00
70336
MAGNETIC IMAGE, JAW JOINT
7.00
1.00
70336
MAGNETIC IMAGE, JAW JOINT
13.71
1.00
70336
MAGNETIC IMAGE, JAW JOINT
13.87
1.00
70336
MAGNETIC IMAGE, JAW JOINT
14.14
1.00
70350
X-RAY HEAD FOR ORTHODONTIA
0.56
1.00
70350
X-RAY HEAD FOR ORTHODONTIA
0.64
1.00
70355
PANORAMIC X-RAY OF JAWS
0.63
1.00
70355
PANORAMIC X-RAY OF JAWS
0.88
1.00
70355
PANORAMIC X-RAY OF JAWS
0.90
1.00
70360
X-RAY EXAM OF NECK
0.67
1.00
70360
X-RAY EXAM OF NECK
0.68
1.00
70360
X-RAY EXAM OF NECK
0.74
1.00
70370
THROAT X-RAY & FLUOROSCOPY
1.80
1.00
70370
THROAT X-RAY & FLUOROSCOPY
1.82
1.00
70370
THROAT X-RAY & FLUOROSCOPY
2.03
1.00
70371
SPEECH EVALUATION, COMPLEX
2.69
1.00
Procedure Code Description
RVU
RVU Coeff Value
70371
SPEECH EVALUATION, COMPLEX
3.36
1.00
70371
SPEECH EVALUATION, COMPLEX
3.39
1.00
70373
CONTRAST X-RAY OF LARYNX
2.21
1.00
70373
CONTRAST X-RAY OF LARYNX
2.47
1.00
70373
CONTRAST X-RAY OF LARYNX
2.51
1.00
70380
X-RAY EXAM OF SALIVARY GLAND
0.94
1.00
70380
X-RAY EXAM OF SALIVARY GLAND
0.95
1.00
70380
X-RAY EXAM OF SALIVARY GLAND
1.01
1.00
70390
X-RAY EXAM OF SALIVARY DUCT
2.39
1.00
70390
X-RAY EXAM OF SALIVARY DUCT
2.43
1.00
70390
X-RAY EXAM OF SALIVARY DUCT
2.73
1.00
70450
CT HEAD/BRAIN W/O DYE
6.06
1.00
70450
CT HEAD/BRAIN W/O DYE
6.09
1.00
70450
CT HEAD/BRAIN W/O DYE
6.17
1.00
70450
CT HEAD/BRAIN W/O DYE
7.00
1.00
70460
CT HEAD/BRAIN W/DYE
7.45
1.00
70460
CT HEAD/BRAIN W/DYE
7.53
1.00
70460
CT HEAD/BRAIN W/DYE
7.83
1.00
70470
CT HEAD/BRAIN W/O & W/DYE
7.00
1.00
70470
CT HEAD/BRAIN W/O & W/DYE
9.11
1.00
70470
CT HEAD/BRAIN W/O & W/DYE
9.22
1.00
70470
CT HEAD/BRAIN W/O & W/DYE
9.48
1.00
70480
CT ORBIT/EAR/FOSSA W/O DYE
6.69
1.00
70480
CT ORBIT/EAR/FOSSA W/O DYE
6.76
1.00
70480
CT ORBIT/EAR/FOSSA W/O DYE
9.19
1.00
70481
CT ORBIT/EAR/FOSSA W/DYE
7.79
1.00
70481
CT ORBIT/EAR/FOSSA W/DYE
7.87
1.00
70481
CT ORBIT/EAR/FOSSA W/DYE
10.69
1.00
70482
CT ORBIT/EAR/FOSSA W/O&W/DYE
9.35
1.00
70482
CT ORBIT/EAR/FOSSA W/O&W/DYE
9.46
1.00
70482
CT ORBIT/EAR/FOSSA W/O&W/DYE
12.25
1.00
70486
CT MAXILLOFACIAL W/O DYE
6.49
1.00
70486
CT MAXILLOFACIAL W/O DYE
6.56
1.00
70486
CT MAXILLOFACIAL W/O DYE
7.78
1.00
70487
CT MAXILLOFACIAL W/DYE
7.68
1.00
Procedure Code Description
RVU
RVU Coeff Value
70487
CT MAXILLOFACIAL W/DYE
7.76
1.00
70487
CT MAXILLOFACIAL W/DYE
9.41
1.00
70488
CT MAXILLOFACIAL W/O & W/DYE
9.31
1.00
70488
CT MAXILLOFACIAL W/O & W/DYE
9.42
1.00
70488
CT MAXILLOFACIAL W/O & W/DYE
11.45
1.00
70490
CT SOFT TISSUE NECK W/O DYE
6.68
1.00
70490
CT SOFT TISSUE NECK W/O DYE
6.76
1.00
70490
CT SOFT TISSUE NECK W/O DYE
7.71
1.00
70491
CT SOFT TISSUE NECK W/DYE
7.79
1.00
70491
CT SOFT TISSUE NECK W/DYE
7.87
1.00
70491
CT SOFT TISSUE NECK W/DYE
9.25
1.00
70492
CT SFT TSUE NCK W/O & W/DYE
9.35
1.00
70492
CT SFT TSUE NCK W/O & W/DYE
9.46
1.00
70492
CT SFT TSUE NCK W/O & W/DYE
11.23
1.00
70496
CT ANGIOGRAPHY, HEAD
7.00
1.00
70496
CT ANGIOGRAPHY, HEAD
13.46
1.00
70496
CT ANGIOGRAPHY, HEAD
13.65
1.00
70496
CT ANGIOGRAPHY, HEAD
17.90
1.00
70498
CT ANGIOGRAPHY, NECK
13.47
1.00
70498
CT ANGIOGRAPHY, NECK
13.65
1.00
70498
CT ANGIOGRAPHY, NECK
17.98
1.00
70540
MRI ORBIT/FACE/NECK W/O DYE
7.00
1.00
70540
MRI ORBIT/FACE/NECK W/O DYE
13.33
1.00
70540
MRI ORBIT/FACE/NECK W/O DYE
13.47
1.00
70540
MRI ORBIT/FACE/NECK W/O DYE
15.24
1.00
70542
MRI ORBIT/FACE/NECK W/DYE
16.00
1.00
70542
MRI ORBIT/FACE/NECK W/DYE
16.17
1.00
70542
MRI ORBIT/FACE/NECK W/DYE
16.94
1.00
70543
MRI ORBT/FAC/NCK W/O & W/DYE
23.41
1.00
70543
MRI ORBT/FAC/NCK W/O & W/DYE
28.43
1.00
70543
MRI ORBT/FAC/NCK W/O & W/DYE
28.76
1.00
70544
MR ANGIOGRAPHY HEAD W/O DYE
7.00
1.00
70544
MR ANGIOGRAPHY HEAD W/O DYE
13.31
1.00
70544
MR ANGIOGRAPHY HEAD W/O DYE
13.48
1.00
70544
MR ANGIOGRAPHY HEAD W/O DYE
16.49
1.00
Procedure Code Description
RVU
RVU Coeff Value
70545
MR ANGIOGRAPHY HEAD W/DYE
7.00
1.00
70545
MR ANGIOGRAPHY HEAD W/DYE
13.31
1.00
70545
MR ANGIOGRAPHY HEAD W/DYE
13.48
1.00
70545
MR ANGIOGRAPHY HEAD W/DYE
16.42
1.00
70546
MR ANGIOGRAPH HEAD W/O&W/DYE
7.00
1.00
70546
MR ANGIOGRAPH HEAD W/O&W/DYE
25.30
1.00
70546
MR ANGIOGRAPH HEAD W/O&W/DYE
25.57
1.00
70546
MR ANGIOGRAPH HEAD W/O&W/DYE
26.04
1.00
70547
MR ANGIOGRAPHY NECK W/O DYE
13.31
1.00
70547
MR ANGIOGRAPHY NECK W/O DYE
13.48
1.00
70547
MR ANGIOGRAPHY NECK W/O DYE
16.45
1.00
70548
MR ANGIOGRAPHY NECK W/DYE
13.31
1.00
70548
MR ANGIOGRAPHY NECK W/DYE
13.48
1.00
70548
MR ANGIOGRAPHY NECK W/DYE
17.09
1.00
70549
MR ANGIOGRAPH NECK W/O&W/DYE
25.30
1.00
70549
MR ANGIOGRAPH NECK W/O&W/DYE
25.57
1.00
70549
MR ANGIOGRAPH NECK W/O&W/DYE
26.06
1.00
70551
MRI BRAIN W/O DYE
7.00
1.00
70551
MRI BRAIN W/O DYE
13.71
1.00
70551
MRI BRAIN W/O DYE
13.88
1.00
70551
MRI BRAIN W/O DYE
15.80
1.00
70552
MRI BRAIN W/DYE
16.44
1.00
70552
MRI BRAIN W/DYE
16.66
1.00
70552
MRI BRAIN W/DYE
17.67
1.00
70553
MRI BRAIN W/O & W/DYE
23.64
1.00
70553
MRI BRAIN W/O & W/DYE
29.14
1.00
70553
MRI BRAIN W/O & W/DYE
29.55
1.00
70554
FMRI BRAIN BY TECH
17.17
1.00
71010
CHEST X-RAY
0.66
1.00
71010
CHEST X-RAY
0.74
1.00
71015
CHEST X-RAY
0.81
1.00
71015
CHEST X-RAY
0.83
1.00
71020
CHEST X-RAY
0.88
1.00
71020
CHEST X-RAY
0.95
1.00
71020
CHEST X-RAY
0.96
1.00
Procedure Code Description
RVU
RVU Coeff Value
71021
CHEST X-RAY
1.06
1.00
71021
CHEST X-RAY
1.15
1.00
71021
CHEST X-RAY
1.16
1.00
71022
CHEST X-RAY
1.22
1.00
71022
CHEST X-RAY
1.27
1.00
71023
CHEST X-RAY AND FLUOROSCOPY
1.36
1.00
71023
CHEST X-RAY AND FLUOROSCOPY
1.37
1.00
71023
CHEST X-RAY AND FLUOROSCOPY
1.83
1.00
71030
CHEST X-RAY
1.24
1.00
71030
CHEST X-RAY
1.26
1.00
71030
CHEST X-RAY
1.28
1.00
71034
CHEST X-RAY AND FLUOROSCOPY
2.15
1.00
71034
CHEST X-RAY AND FLUOROSCOPY
2.16
1.00
71034
CHEST X-RAY AND FLUOROSCOPY
2.52
1.00
71035
CHEST X-RAY
0.79
1.00
71035
CHEST X-RAY
0.94
1.00
71040
CONTRAST X-RAY OF BRONCHI
2.33
1.00
71040
CONTRAST X-RAY OF BRONCHI
2.35
1.00
71040
CONTRAST X-RAY OF BRONCHI
2.63
1.00
71060
CONTRAST X-RAY OF BRONCHI
3.33
1.00
71060
CONTRAST X-RAY OF BRONCHI
3.37
1.00
71060
CONTRAST X-RAY OF BRONCHI
3.83
1.00
71090
X-RAY & PACEMAKER INSERTION
2.53
1.00
71090
X-RAY & PACEMAKER INSERTION
2.57
1.00
71100
X-RAY EXAM OF RIBS
0.90
1.00
71100
X-RAY EXAM OF RIBS
0.91
1.00
71101
X-RAY EXAM OF RIBS/CHEST
1.07
1.00
71101
X-RAY EXAM OF RIBS/CHEST
1.08
1.00
71110
X-RAY EXAM OF RIBS
1.12
1.00
71110
X-RAY EXAM OF RIBS
1.19
1.00
71110
X-RAY EXAM OF RIBS
1.21
1.00
71111
X-RAY EXAM OF RIBS/CHEST
1.38
1.00
71111
X-RAY EXAM OF RIBS/CHEST
1.39
1.00
71111
X-RAY EXAM OF RIBS/CHEST
1.43
1.00
71120
X-RAY EXAM OF BREASTBONE
0.90
1.00
Procedure Code Description
RVU
RVU Coeff Value
71120
X-RAY EXAM OF BREASTBONE
0.96
1.00
71120
X-RAY EXAM OF BREASTBONE
0.97
1.00
71130
X-RAY EXAM OF BREASTBONE
1.03
1.00
71130
X-RAY EXAM OF BREASTBONE
1.04
1.00
71130
X-RAY EXAM OF BREASTBONE
1.05
1.00
71250
CT THORAX W/O DYE
3.00
1.00
71250
CT THORAX W/O DYE
7.74
1.00
71250
CT THORAX W/O DYE
7.84
1.00
71250
CT THORAX W/O DYE
7.90
1.00
71260
CT THORAX W/DYE
9.06
1.00
71260
CT THORAX W/DYE
9.17
1.00
71260
CT THORAX W/DYE
9.48
1.00
71270
CT THORAX W/O & W/DYE
11.10
1.00
71270
CT THORAX W/O & W/DYE
11.24
1.00
71270
CT THORAX W/O & W/DYE
11.71
1.00
71275
CT ANGIOGRAPHY, CHEST
14.39
1.00
71275
CT ANGIOGRAPHY, CHEST
15.28
1.00
71275
CT ANGIOGRAPHY, CHEST
15.43
1.00
71550
MRI CHEST W/O DYE
7.00
1.00
71550
MRI CHEST W/O DYE
13.53
1.00
71550
MRI CHEST W/O DYE
13.68
1.00
71550
MRI CHEST W/O DYE
17.02
1.00
71551
MRI CHEST W/DYE
16.19
1.00
71551
MRI CHEST W/DYE
16.38
1.00
71551
MRI CHEST W/DYE
19.10
1.00
71552
MRI CHEST W/O & W/DYE
26.19
1.00
71552
MRI CHEST W/O & W/DYE
28.45
1.00
71552
MRI CHEST W/O & W/DYE
28.76
1.00
71555
MRI ANGIO CHEST W OR W/O DYE
14.16
1.00
71555
MRI ANGIO CHEST W OR W/O DYE
14.34
1.00
71555
MRI ANGIO CHEST W OR W/O DYE
16.78
1.00
72010
X-RAY EXAM OF SPINE
1.70
1.00
72010
X-RAY EXAM OF SPINE
1.73
1.00
72010
X-RAY EXAM OF SPINE
1.89
1.00
72020
X-RAY EXAM OF SPINE
0.64
1.00
Procedure Code Description
RVU
RVU Coeff Value
72020
X-RAY EXAM OF SPINE
0.65
1.00
72040
X-RAY EXAM OF NECK SPINE
0.93
1.00
72040
X-RAY EXAM OF NECK SPINE
0.94
1.00
72040
X-RAY EXAM OF NECK SPINE
1.01
1.00
72050
X-RAY EXAM OF NECK SPINE
1.38
1.00
72050
X-RAY EXAM OF NECK SPINE
1.43
1.00
72052
X-RAY EXAM OF NECK SPINE
1.67
1.00
72052
X-RAY EXAM OF NECK SPINE
1.69
1.00
72052
X-RAY EXAM OF NECK SPINE
1.79
1.00
72069
X-RAY EXAM OF TRUNK SPINE
0.83
1.00
72069
X-RAY EXAM OF TRUNK SPINE
0.95
1.00
72070
X-RAY EXAM OF THORACIC SPINE
0.93
1.00
72070
X-RAY EXAM OF THORACIC SPINE
0.98
1.00
72070
X-RAY EXAM OF THORACIC SPINE
0.99
1.00
72072
X-RAY EXAM OF THORACIC SPINE
1.06
1.00
72072
X-RAY EXAM OF THORACIC SPINE
1.08
1.00
72072
X-RAY EXAM OF THORACIC SPINE
1.09
1.00
72074
X-RAY EXAM OF THORACIC SPINE
1.24
1.00
72074
X-RAY EXAM OF THORACIC SPINE
1.26
1.00
72074
X-RAY EXAM OF THORACIC SPINE
1.27
1.00
72080
X-RAY EXAM OF TRUNK SPINE
0.97
1.00
72080
X-RAY EXAM OF TRUNK SPINE
1.02
1.00
72090
X-RAY EXAM OF TRUNK SPINE
1.10
1.00
72090
X-RAY EXAM OF TRUNK SPINE
1.27
1.00
72100
X-RAY EXAM OF LOWER SPINE
1.02
1.00
72100
X-RAY EXAM OF LOWER SPINE
1.06
1.00
72110
X-RAY EXAM OF LOWER SPINE
1.40
1.00
72110
X-RAY EXAM OF LOWER SPINE
1.48
1.00
72114
X-RAY EXAM OF LOWER SPINE
1.74
1.00
72114
X-RAY EXAM OF LOWER SPINE
1.77
1.00
72114
X-RAY EXAM OF LOWER SPINE
1.93
1.00
72120
X-RAY EXAM OF LOWER SPINE
1.26
1.00
72120
X-RAY EXAM OF LOWER SPINE
1.33
1.00
72125
CT NECK SPINE W/O DYE
7.74
1.00
72125
CT NECK SPINE W/O DYE
7.84
1.00
Procedure Code Description
RVU
RVU Coeff Value
72125
CT NECK SPINE W/O DYE
7.92
1.00
72126
CT NECK SPINE W/DYE
9.03
1.00
72126
CT NECK SPINE W/DYE
9.14
1.00
72126
CT NECK SPINE W/DYE
9.46
1.00
72127
CT NECK SPINE W/O & W/DYE
10.95
1.00
72127
CT NECK SPINE W/O & W/DYE
11.09
1.00
72127
CT NECK SPINE W/O & W/DYE
11.53
1.00
72128
CT CHEST SPINE W/O DYE
7.74
1.00
72128
CT CHEST SPINE W/O DYE
7.84
1.00
72128
CT CHEST SPINE W/O DYE
7.90
1.00
72129
CT CHEST SPINE W/DYE
9.03
1.00
72129
CT CHEST SPINE W/DYE
9.14
1.00
72129
CT CHEST SPINE W/DYE
9.47
1.00
72130
CT CHEST SPINE W/O & W/DYE
10.95
1.00
72130
CT CHEST SPINE W/O & W/DYE
11.09
1.00
72130
CT CHEST SPINE W/O & W/DYE
11.56
1.00
72131
CT LUMBAR SPINE W/O DYE
7.75
1.00
72131
CT LUMBAR SPINE W/O DYE
7.84
1.00
72131
CT LUMBAR SPINE W/O DYE
7.89
1.00
72132
CT LUMBAR SPINE W/DYE
9.04
1.00
72132
CT LUMBAR SPINE W/DYE
9.16
1.00
72132
CT LUMBAR SPINE W/DYE
9.46
1.00
72133
CT LUMBAR SPINE W/O & W/DYE
10.96
1.00
72133
CT LUMBAR SPINE W/O & W/DYE
11.10
1.00
72133
CT LUMBAR SPINE W/O & W/DYE
11.55
1.00
72141
MRI NECK SPINE W/O DYE
7.00
1.00
72141
MRI NECK SPINE W/O DYE
13.87
1.00
72141
MRI NECK SPINE W/O DYE
14.04
1.00
72141
MRI NECK SPINE W/O DYE
14.46
1.00
72142
MRI NECK SPINE W/DYE
16.64
1.00
72142
MRI NECK SPINE W/DYE
16.87
1.00
72142
MRI NECK SPINE W/DYE
17.84
1.00
72146
MRI CHEST SPINE W/O DYE
3.00
1.00
72146
MRI CHEST SPINE W/O DYE
14.84
1.00
72146
MRI CHEST SPINE W/O DYE
15.14
1.00
Procedure Code Description
RVU
RVU Coeff Value
72146
MRI CHEST SPINE W/O DYE
15.32
1.00
72147
MRI CHEST SPINE W/DYE
16.33
1.00
72147
MRI CHEST SPINE W/DYE
16.63
1.00
72147
MRI CHEST SPINE W/DYE
16.86
1.00
72148
MRI LUMBAR SPINE W/O DYE
14.66
1.00
72148
MRI LUMBAR SPINE W/O DYE
14.98
1.00
72148
MRI LUMBAR SPINE W/O DYE
15.17
1.00
72149
MRI LUMBAR SPINE W/DYE
16.45
1.00
72149
MRI LUMBAR SPINE W/DYE
16.68
1.00
72149
MRI LUMBAR SPINE W/DYE
17.64
1.00
72156
MRI NECK SPINE W/O & W/DYE
23.65
1.00
72156
MRI NECK SPINE W/O & W/DYE
29.43
1.00
72156
MRI NECK SPINE W/O & W/DYE
29.84
1.00
72157
MRI CHEST SPINE W/O & W/DYE
22.49
1.00
72157
MRI CHEST SPINE W/O & W/DYE
29.43
1.00
72157
MRI CHEST SPINE W/O & W/DYE
29.84
1.00
72158
MRI LUMBAR SPINE W/O & W/DYE
23.34
1.00
72158
MRI LUMBAR SPINE W/O & W/DYE
29.15
1.00
72158
MRI LUMBAR SPINE W/O & W/DYE
29.56
1.00
72159
MR ANGIO SPINE W/O&W/DYE
15.46
1.00
72159
MR ANGIO SPINE W/O&W/DYE
15.50
1.00
72159
MR ANGIO SPINE W/O&W/DYE
18.00
1.00
72170
X-RAY EXAM OF PELVIS
0.71
1.00
72170
X-RAY EXAM OF PELVIS
0.78
1.00
72190
X-RAY EXAM OF PELVIS
0.99
1.00
72190
X-RAY EXAM OF PELVIS
1.00
1.00
72190
X-RAY EXAM OF PELVIS
1.08
1.00
72191
CT ANGIOGRAPH PELV W/O&W/DYE
13.87
1.00
72191
CT ANGIOGRAPH PELV W/O&W/DYE
14.78
1.00
72191
CT ANGIOGRAPH PELV W/O&W/DYE
14.94
1.00
72192
CT PELVIS W/O DYE
7.52
1.00
72192
CT PELVIS W/O DYE
7.65
1.00
72192
CT PELVIS W/O DYE
7.75
1.00
72193
CT PELVIS W/DYE
8.72
1.00
72193
CT PELVIS W/DYE
8.83
1.00
Procedure Code Description 72193
CT PELVIS W/DYE
72194
RVU
RVU Coeff Value
9.00
1.00
CT PELVIS W/O & W/DYE
10.49
1.00
72194
CT PELVIS W/O & W/DYE
10.63
1.00
72194
CT PELVIS W/O & W/DYE
11.47
1.00
72195
MRI PELVIS W/O DYE
13.54
1.00
72195
MRI PELVIS W/O DYE
13.69
1.00
72195
MRI PELVIS W/O DYE
15.60
1.00
72196
MRI PELVIS W/DYE
7.00
1.00
72196
MRI PELVIS W/DYE
16.18
1.00
72196
MRI PELVIS W/DYE
16.37
1.00
72196
MRI PELVIS W/DYE
17.30
1.00
72197
MRI PELVIS W/O & W/DYE
23.77
1.00
72197
MRI PELVIS W/O & W/DYE
28.65
1.00
72197
MRI PELVIS W/O & W/DYE
29.00
1.00
72198
MR ANGIO PELVIS W/O & W/DYE
14.23
1.00
72198
MR ANGIO PELVIS W/O & W/DYE
14.41
1.00
72198
MR ANGIO PELVIS W/O & W/DYE
16.68
1.00
72200
X-RAY EXAM SACROILIAC JOINTS
0.78
1.00
72200
X-RAY EXAM SACROILIAC JOINTS
0.79
1.00
72202
X-RAY EXAM SACROILIAC JOINTS
0.91
1.00
72202
X-RAY EXAM SACROILIAC JOINTS
0.92
1.00
72202
X-RAY EXAM SACROILIAC JOINTS
0.96
1.00
72220
X-RAY EXAM OF TAILBONE
0.81
1.00
72220
X-RAY EXAM OF TAILBONE
0.84
1.00
72220
X-RAY EXAM OF TAILBONE
0.85
1.00
72240
CONTRAST X-RAY OF NECK SPINE
4.39
1.00
72240
CONTRAST X-RAY OF NECK SPINE
6.19
1.00
72240
CONTRAST X-RAY OF NECK SPINE
6.27
1.00
72255
CONTRAST X-RAY, THORAX SPINE
4.01
1.00
72255
CONTRAST X-RAY, THORAX SPINE
5.72
1.00
72255
CONTRAST X-RAY, THORAX SPINE
5.80
1.00
72265
CONTRAST X-RAY, LOWER SPINE
4.08
1.00
72265
CONTRAST X-RAY, LOWER SPINE
5.36
1.00
72265
CONTRAST X-RAY, LOWER SPINE
5.45
1.00
72270
CONTRAST X-RAY, SPINE
6.36
1.00
Procedure Code Description
RVU
RVU Coeff Value
72270
CONTRAST X-RAY, SPINE
8.17
1.00
72270
CONTRAST X-RAY, SPINE
8.27
1.00
72275
EPIDUROGRAPHY
2.90
1.00
72275
EPIDUROGRAPHY
3.26
1.00
72275
EPIDUROGRAPHY
3.32
1.00
72285
X-RAY C/T SPINE DISK
4.96
1.00
72285
X-RAY C/T SPINE DISK
10.30
1.00
72285
X-RAY C/T SPINE DISK
10.43
1.00
72295
X-RAY OF LOWER SPINE DISK
4.42
1.00
72295
X-RAY OF LOWER SPINE DISK
9.30
1.00
72295
X-RAY OF LOWER SPINE DISK
9.43
1.00
73000
X-RAY EXAM OF COLLAR BONE
0.75
1.00
73000
X-RAY EXAM OF COLLAR BONE
0.76
1.00
73010
X-RAY EXAM OF SHOULDER BLADE
0.77
1.00
73010
X-RAY EXAM OF SHOULDER BLADE
0.78
1.00
73020
X-RAY EXAM OF SHOULDER
0.64
1.00
73020
X-RAY EXAM OF SHOULDER
0.70
1.00
73030
X-RAY EXAM OF SHOULDER
0.82
1.00
73030
X-RAY EXAM OF SHOULDER
0.85
1.00
73030
X-RAY EXAM OF SHOULDER
0.86
1.00
73040
CONTRAST X-RAY OF SHOULDER
2.93
1.00
73040
CONTRAST X-RAY OF SHOULDER
2.94
1.00
73040
CONTRAST X-RAY OF SHOULDER
2.98
1.00
73050
X-RAY EXAM OF SHOULDERS
0.98
1.00
73050
X-RAY EXAM OF SHOULDERS
0.99
1.00
73050
X-RAY EXAM OF SHOULDERS
1.00
1.00
73060
X-RAY EXAM OF HUMERUS
0.80
1.00
73060
X-RAY EXAM OF HUMERUS
0.84
1.00
73060
X-RAY EXAM OF HUMERUS
0.85
1.00
73070
X-RAY EXAM OF ELBOW
0.73
1.00
73070
X-RAY EXAM OF ELBOW
0.75
1.00
73080
X-RAY EXAM OF ELBOW
0.84
1.00
73080
X-RAY EXAM OF ELBOW
0.85
1.00
73080
X-RAY EXAM OF ELBOW
0.94
1.00
73085
CONTRAST X-RAY OF ELBOW
2.65
1.00
Procedure Code Description
RVU
RVU Coeff Value
73085
CONTRAST X-RAY OF ELBOW
2.95
1.00
73085
CONTRAST X-RAY OF ELBOW
2.99
1.00
73090
X-RAY EXAM OF FOREARM
0.74
1.00
73090
X-RAY EXAM OF FOREARM
0.76
1.00
73092
X-RAY EXAM OF ARM, INFANT
0.73
1.00
73092
X-RAY EXAM OF ARM, INFANT
0.76
1.00
73100
X-RAY EXAM OF WRIST
0.75
1.00
73100
X-RAY EXAM OF WRIST
0.77
1.00
73110
X-RAY EXAM OF WRIST
0.79
1.00
73110
X-RAY EXAM OF WRIST
0.92
1.00
73115
CONTRAST X-RAY OF WRIST
2.41
1.00
73115
CONTRAST X-RAY OF WRIST
2.45
1.00
73115
CONTRAST X-RAY OF WRIST
2.80
1.00
73120
X-RAY EXAM OF HAND
0.73
1.00
73120
X-RAY EXAM OF HAND
0.74
1.00
73130
X-RAY EXAM OF HAND
0.79
1.00
73130
X-RAY EXAM OF HAND
0.84
1.00
73140
X-RAY EXAM OF FINGER(S)
0.61
1.00
73140
X-RAY EXAM OF FINGER(S)
0.62
1.00
73140
X-RAY EXAM OF FINGER(S)
0.78
1.00
73200
CT UPPER EXTREMITY W/O DYE
6.66
1.00
73200
CT UPPER EXTREMITY W/O DYE
6.73
1.00
73200
CT UPPER EXTREMITY W/O DYE
7.48
1.00
73201
CT UPPER EXTREMITY W/DYE
7.75
1.00
73201
CT UPPER EXTREMITY W/DYE
7.84
1.00
73201
CT UPPER EXTREMITY W/DYE
8.98
1.00
73202
CT UPPR EXTREMITY W/O&W/DYE
9.41
1.00
73202
CT UPPR EXTREMITY W/O&W/DYE
9.53
1.00
73202
CT UPPR EXTREMITY W/O&W/DYE
11.49
1.00
73206
CT ANGIO UPR EXTRM W/O&W/DYE
13.29
1.00
73206
CT ANGIO UPR EXTRM W/O&W/DYE
13.73
1.00
73206
CT ANGIO UPR EXTRM W/O&W/DYE
13.86
1.00
73218
MRI UPPER EXTREMITY W/O DYE
13.33
1.00
73218
MRI UPPER EXTREMITY W/O DYE
13.47
1.00
73218
MRI UPPER EXTREMITY W/O DYE
15.59
1.00
Procedure Code Description
RVU
RVU Coeff Value
73219
MRI UPPER EXTREMITY W/DYE
16.00
1.00
73219
MRI UPPER EXTREMITY W/DYE
16.17
1.00
73219
MRI UPPER EXTREMITY W/DYE
17.13
1.00
73220
MRI UPPR EXTREMITY W/O&W/DYE
7.00
1.00
73220
MRI UPPR EXTREMITY W/O&W/DYE
23.62
1.00
73220
MRI UPPR EXTREMITY W/O&W/DYE
28.45
1.00
73220
MRI UPPR EXTREMITY W/O&W/DYE
28.78
1.00
73221
MRI JOINT UPR EXTREM W/O DYE
7.00
1.00
73221
MRI JOINT UPR EXTREM W/O DYE
13.33
1.00
73221
MRI JOINT UPR EXTREM W/O DYE
13.47
1.00
73221
MRI JOINT UPR EXTREM W/O DYE
14.76
1.00
73222
MRI JOINT UPR EXTREM W/DYE
15.99
1.00
73222
MRI JOINT UPR EXTREM W/DYE
16.17
1.00
73222
MRI JOINT UPR EXTREM W/DYE
16.29
1.00
73223
MRI JOINT UPR EXTR W/O&W/DYE
22.60
1.00
73223
MRI JOINT UPR EXTR W/O&W/DYE
28.44
1.00
73223
MRI JOINT UPR EXTR W/O&W/DYE
28.76
1.00
73225
MR ANGIO UPR EXTR W/O&W/DYE
14.10
1.00
73225
MR ANGIO UPR EXTR W/O&W/DYE
14.14
1.00
73225
MR ANGIO UPR EXTR W/O&W/DYE
17.54
1.00
73500
X-RAY EXAM OF HIP
0.69
1.00
73500
X-RAY EXAM OF HIP
0.73
1.00
73510
X-RAY EXAM OF HIP
0.90
1.00
73510
X-RAY EXAM OF HIP
0.91
1.00
73510
X-RAY EXAM OF HIP
1.00
1.00
73520
X-RAY EXAM OF HIPS
1.07
1.00
73520
X-RAY EXAM OF HIPS
1.08
1.00
73525
CONTRAST X-RAY OF HIP
2.65
1.00
73525
CONTRAST X-RAY OF HIP
2.94
1.00
73525
CONTRAST X-RAY OF HIP
2.98
1.00
73530
X-RAY EXAM OF HIP
0.94
1.00
73540
X-RAY EXAM OF PELVIS & HIPS
0.89
1.00
73540
X-RAY EXAM OF PELVIS & HIPS
0.90
1.00
73540
X-RAY EXAM OF PELVIS & HIPS
1.00
1.00
73542
X-RAY EXAM, SACROILIAC JOINT
2.18
1.00
Procedure Code Description
RVU
RVU Coeff Value
73542
X-RAY EXAM, SACROILIAC JOINT
2.98
1.00
73542
X-RAY EXAM, SACROILIAC JOINT
3.01
1.00
73550
X-RAY EXAM OF THIGH
0.78
1.00
73550
X-RAY EXAM OF THIGH
0.84
1.00
73550
X-RAY EXAM OF THIGH
0.85
1.00
73560
X-RAY EXAM OF KNEE, 1 OR 2
0.77
1.00
73560
X-RAY EXAM OF KNEE, 1 OR 2
0.79
1.00
73562
X-RAY EXAM OF KNEE, 3
0.86
1.00
73562
X-RAY EXAM OF KNEE, 3
0.87
1.00
73562
X-RAY EXAM OF KNEE, 3
0.93
1.00
73564
X-RAY EXAM, KNEE, 4 OR MORE
0.97
1.00
73564
X-RAY EXAM, KNEE, 4 OR MORE
0.98
1.00
73564
X-RAY EXAM, KNEE, 4 OR MORE
1.08
1.00
73565
X-RAY EXAM OF KNEES
0.76
1.00
73565
X-RAY EXAM OF KNEES
0.82
1.00
73580
CONTRAST X-RAY OF KNEE JOINT
3.30
1.00
73580
CONTRAST X-RAY OF KNEE JOINT
3.48
1.00
73580
CONTRAST X-RAY OF KNEE JOINT
3.52
1.00
73590
X-RAY EXAM OF LOWER LEG
0.74
1.00
73590
X-RAY EXAM OF LOWER LEG
0.78
1.00
73592
X-RAY EXAM OF LEG, INFANT
0.74
1.00
73592
X-RAY EXAM OF LEG, INFANT
0.76
1.00
73600
X-RAY EXAM OF ANKLE
0.73
1.00
73600
X-RAY EXAM OF ANKLE
0.74
1.00
73610
X-RAY EXAM OF ANKLE
0.79
1.00
73610
X-RAY EXAM OF ANKLE
0.84
1.00
73615
CONTRAST X-RAY OF ANKLE
2.72
1.00
73615
CONTRAST X-RAY OF ANKLE
2.95
1.00
73615
CONTRAST X-RAY OF ANKLE
2.99
1.00
73620
X-RAY EXAM OF FOOT
0.71
1.00
73620
X-RAY EXAM OF FOOT
0.73
1.00
73620
X-RAY EXAM OF FOOT
0.74
1.00
73630
X-RAY EXAM OF FOOT
0.79
1.00
73630
X-RAY EXAM OF FOOT
0.83
1.00
73650
X-RAY EXAM OF HEEL
0.71
1.00
Procedure Code Description
RVU
RVU Coeff Value
73650
X-RAY EXAM OF HEEL
0.72
1.00
73660
X-RAY EXAM OF TOE(S)
0.61
1.00
73660
X-RAY EXAM OF TOE(S)
0.62
1.00
73660
X-RAY EXAM OF TOE(S)
0.74
1.00
73700
CT LOWER EXTREMITY W/O DYE
6.66
1.00
73700
CT LOWER EXTREMITY W/O DYE
6.73
1.00
73700
CT LOWER EXTREMITY W/O DYE
7.49
1.00
73701
CT LOWER EXTREMITY W/DYE
7.74
1.00
73701
CT LOWER EXTREMITY W/DYE
7.84
1.00
73701
CT LOWER EXTREMITY W/DYE
9.04
1.00
73702
CT LWR EXTREMITY W/O&W/DYE
9.39
1.00
73702
CT LWR EXTREMITY W/O&W/DYE
9.52
1.00
73702
CT LWR EXTREMITY W/O&W/DYE
11.52
1.00
73706
CT ANGIO LWR EXTR W/O&W/DYE
13.85
1.00
73706
CT ANGIO LWR EXTR W/O&W/DYE
13.98
1.00
73706
CT ANGIO LWR EXTR W/O&W/DYE
14.43
1.00
73718
MRI LOWER EXTREMITY W/O DYE
13.33
1.00
73718
MRI LOWER EXTREMITY W/O DYE
13.47
1.00
73718
MRI LOWER EXTREMITY W/O DYE
15.32
1.00
73719
MRI LOWER EXTREMITY W/DYE
15.99
1.00
73719
MRI LOWER EXTREMITY W/DYE
16.17
1.00
73719
MRI LOWER EXTREMITY W/DYE
16.95
1.00
73720
MRI LWR EXTREMITY W/O&W/DYE
7.00
1.00
73720
MRI LWR EXTREMITY W/O&W/DYE
23.61
1.00
73720
MRI LWR EXTREMITY W/O&W/DYE
28.44
1.00
73720
MRI LWR EXTREMITY W/O&W/DYE
28.78
1.00
73721
MRI JNT OF LWR EXTRE W/O DYE
7.00
1.00
73721
MRI JNT OF LWR EXTRE W/O DYE
13.33
1.00
73721
MRI JNT OF LWR EXTRE W/O DYE
13.47
1.00
73721
MRI JNT OF LWR EXTRE W/O DYE
15.01
1.00
73722
MRI JOINT OF LWR EXTR W/DYE
16.01
1.00
73722
MRI JOINT OF LWR EXTR W/DYE
16.18
1.00
73722
MRI JOINT OF LWR EXTR W/DYE
16.42
1.00
73723
MRI JOINT LWR EXTR W/O&W/DYE
22.55
1.00
73723
MRI JOINT LWR EXTR W/O&W/DYE
28.44
1.00
Procedure Code Description
RVU
RVU Coeff Value
73723
MRI JOINT LWR EXTR W/O&W/DYE
28.76
1.00
73725
MR ANG LWR EXT W OR W/O DYE
14.17
1.00
73725
MR ANG LWR EXT W OR W/O DYE
14.35
1.00
73725
MR ANG LWR EXT W OR W/O DYE
16.70
1.00
74000
X-RAY EXAM OF ABDOMEN
0.70
1.00
74000
X-RAY EXAM OF ABDOMEN
0.79
1.00
74010
X-RAY EXAM OF ABDOMEN
0.92
1.00
74010
X-RAY EXAM OF ABDOMEN
0.93
1.00
74010
X-RAY EXAM OF ABDOMEN
1.03
1.00
74020
X-RAY EXAM OF ABDOMEN
1.02
1.00
74020
X-RAY EXAM OF ABDOMEN
1.03
1.00
74020
X-RAY EXAM OF ABDOMEN
1.10
1.00
74022
X-RAY EXAM SERIES, ABDOMEN
1.22
1.00
74022
X-RAY EXAM SERIES, ABDOMEN
1.23
1.00
74022
X-RAY EXAM SERIES, ABDOMEN
1.33
1.00
74150
CT ABDOMEN W/O DYE
3.00
1.00
74150
CT ABDOMEN W/O DYE
7.52
1.00
74150
CT ABDOMEN W/O DYE
7.58
1.00
74150
CT ABDOMEN W/O DYE
7.61
1.00
74160
CT ABDOMEN W/DYE
3.00
1.00
74160
CT ABDOMEN W/DYE
8.88
1.00
74160
CT ABDOMEN W/DYE
8.98
1.00
74160
CT ABDOMEN W/DYE
10.08
1.00
74170
CT ABDOMEN W/O & W/DYE
3.00
1.00
74170
CT ABDOMEN W/O & W/DYE
10.75
1.00
74170
CT ABDOMEN W/O & W/DYE
10.87
1.00
74170
CT ABDOMEN W/O & W/DYE
13.19
1.00
74175
CT ANGIO ABDOM W/O & W/DYE
14.67
1.00
74175
CT ANGIO ABDOM W/O & W/DYE
14.90
1.00
74175
CT ANGIO ABDOM W/O & W/DYE
15.05
1.00
74181
MRI ABDOMEN W/O DYE
3.00
1.00
74181
MRI ABDOMEN W/O DYE
13.55
1.00
74181
MRI ABDOMEN W/O DYE
13.70
1.00
74181
MRI ABDOMEN W/O DYE
14.15
1.00
74182
MRI ABDOMEN W/DYE
16.19
1.00
Procedure Code Description
RVU
RVU Coeff Value
74182
MRI ABDOMEN W/DYE
16.37
1.00
74182
MRI ABDOMEN W/DYE
18.76
1.00
74183
MRI ABDOMEN W/O & W/DYE
23.79
1.00
74183
MRI ABDOMEN W/O & W/DYE
28.65
1.00
74183
MRI ABDOMEN W/O & W/DYE
29.00
1.00
74185
MRI ANGIO, ABDOM W ORW/O DYE
14.14
1.00
74185
MRI ANGIO, ABDOM W ORW/O DYE
14.32
1.00
74185
MRI ANGIO, ABDOM W ORW/O DYE
16.64
1.00
74190
X-RAY EXAM OF PERITONEUM
2.02
1.00
74190
X-RAY EXAM OF PERITONEUM
2.04
1.00
74210
CONTRST X-RAY EXAM OF THROAT
1.73
1.00
74210
CONTRST X-RAY EXAM OF THROAT
1.75
1.00
74210
CONTRST X-RAY EXAM OF THROAT
2.10
1.00
74220
CONTRAST X-RAY, ESOPHAGUS
1.87
1.00
74220
CONTRAST X-RAY, ESOPHAGUS
1.88
1.00
74220
CONTRAST X-RAY, ESOPHAGUS
2.38
1.00
74230
CINE/VID X-RAY, THROAT/ESOPH
2.09
1.00
74230
CINE/VID X-RAY, THROAT/ESOPH
2.11
1.00
74230
CINE/VID X-RAY, THROAT/ESOPH
2.45
1.00
74235
REMOVE ESOPHAGUS OBSTRUCTION
4.38
1.00
74235
REMOVE ESOPHAGUS OBSTRUCTION
4.40
1.00
74240
X-RAY EXAM, UPPER GI TRACT
2.47
1.00
74240
X-RAY EXAM, UPPER GI TRACT
2.50
1.00
74240
X-RAY EXAM, UPPER GI TRACT
2.95
1.00
74241
X-RAY EXAM, UPPER GI TRACT
2.50
1.00
74241
X-RAY EXAM, UPPER GI TRACT
2.53
1.00
74241
X-RAY EXAM, UPPER GI TRACT
3.14
1.00
74245
X-RAY EXAM, UPPER GI TRACT
3.74
1.00
74245
X-RAY EXAM, UPPER GI TRACT
3.78
1.00
74245
X-RAY EXAM, UPPER GI TRACT
4.71
1.00
74246
CONTRST X-RAY UPPR GI TRACT
2.66
1.00
74246
CONTRST X-RAY UPPR GI TRACT
2.71
1.00
74246
CONTRST X-RAY UPPR GI TRACT
3.38
1.00
74247
CONTRST X-RAY UPPR GI TRACT
2.71
1.00
74247
CONTRST X-RAY UPPR GI TRACT
2.76
1.00
Procedure Code Description
RVU
RVU Coeff Value
74247
CONTRST X-RAY UPPR GI TRACT
3.71
1.00
74249
CONTRST X-RAY UPPR GI TRACT
3.94
1.00
74249
CONTRST X-RAY UPPR GI TRACT
3.99
1.00
74249
CONTRST X-RAY UPPR GI TRACT
5.05
1.00
74250
X-RAY EXAM OF SMALL BOWEL
2.01
1.00
74250
X-RAY EXAM OF SMALL BOWEL
2.03
1.00
74250
X-RAY EXAM OF SMALL BOWEL
2.77
1.00
74251
X-RAY EXAM OF SMALL BOWEL
2.31
1.00
74251
X-RAY EXAM OF SMALL BOWEL
2.34
1.00
74251
X-RAY EXAM OF SMALL BOWEL
8.61
1.00
74260
X-RAY EXAM OF SMALL BOWEL
2.24
1.00
74260
X-RAY EXAM OF SMALL BOWEL
2.26
1.00
74260
X-RAY EXAM OF SMALL BOWEL
7.18
1.00
74270
CONTRAST X-RAY EXAM OF COLON
2.73
1.00
74270
CONTRAST X-RAY EXAM OF COLON
2.78
1.00
74270
CONTRAST X-RAY EXAM OF COLON
3.98
1.00
74280
CONTRAST X-RAY EXAM OF COLON
3.70
1.00
74280
CONTRAST X-RAY EXAM OF COLON
3.74
1.00
74280
CONTRAST X-RAY EXAM OF COLON
5.50
1.00
74283
CONTRAST X-RAY EXAM OF COLON
5.47
1.00
74283
CONTRAST X-RAY EXAM OF COLON
5.51
1.00
74283
CONTRAST X-RAY EXAM OF COLON
5.70
1.00
74290
CONTRAST X-RAY, GALLBLADDER
1.22
1.00
74290
CONTRAST X-RAY, GALLBLADDER
1.23
1.00
74290
CONTRAST X-RAY, GALLBLADDER
1.77
1.00
74291
CONTRAST X-RAYS, GALLBLADDER
0.71
1.00
74291
CONTRAST X-RAYS, GALLBLADDER
0.72
1.00
74291
CONTRAST X-RAYS, GALLBLADDER
1.52
1.00
74301
X-RAYS AT SURGERY ADD-ON
0.29
1.00
74301
X-RAYS AT SURGERY ADD-ON
0.30
1.00
74305
X-RAY BILE DUCTS/PANCREAS
1.40
1.00
74305
X-RAY BILE DUCTS/PANCREAS
1.42
1.00
74320
CONTRAST X-RAY OF BILE DUCTS
3.17
1.00
74320
CONTRAST X-RAY OF BILE DUCTS
4.01
1.00
74320
CONTRAST X-RAY OF BILE DUCTS
4.08
1.00
Procedure Code Description
RVU
RVU Coeff Value
74327
X-RAY BILE STONE REMOVAL
2.81
1.00
74327
X-RAY BILE STONE REMOVAL
2.85
1.00
74327
X-RAY BILE STONE REMOVAL
3.58
1.00
74328
X-RAY BILE DUCT ENDOSCOPY
4.24
1.00
74328
X-RAY BILE DUCT ENDOSCOPY
4.31
1.00
74329
X-RAY FOR PANCREAS ENDOSCOPY
4.24
1.00
74329
X-RAY FOR PANCREAS ENDOSCOPY
4.31
1.00
74330
X-RAY BILE/PANC ENDOSCOPY
4.52
1.00
74330
X-RAY BILE/PANC ENDOSCOPY
4.59
1.00
74340
X-RAY GUIDE FOR GI TUBE
3.47
1.00
74340
X-RAY GUIDE FOR GI TUBE
3.50
1.00
74350
X-RAY GUIDE, STOMACH TUBE
4.03
1.00
74350
X-RAY GUIDE, STOMACH TUBE
4.32
1.00
74350
X-RAY GUIDE, STOMACH TUBE
4.39
1.00
74355
X-RAY GUIDE, INTESTINAL TUBE
3.78
1.00
74355
X-RAY GUIDE, INTESTINAL TUBE
3.81
1.00
74360
X-RAY GUIDE, GI DILATION
4.02
1.00
74360
X-RAY GUIDE, GI DILATION
4.09
1.00
74363
X-RAY, BILE DUCT DILATION
7.56
1.00
74363
X-RAY, BILE DUCT DILATION
7.67
1.00
74400
CONTRST X-RAY, URINARY TRACT
2.44
1.00
74400
CONTRST X-RAY, URINARY TRACT
2.47
1.00
74400
CONTRST X-RAY, URINARY TRACT
3.01
1.00
74410
CONTRST X-RAY, URINARY TRACT
2.71
1.00
74410
CONTRST X-RAY, URINARY TRACT
2.74
1.00
74410
CONTRST X-RAY, URINARY TRACT
3.17
1.00
74415
CONTRST X-RAY, URINARY TRACT
2.89
1.00
74415
CONTRST X-RAY, URINARY TRACT
2.91
1.00
74415
CONTRST X-RAY, URINARY TRACT
3.63
1.00
74420
CONTRST X-RAY, URINARY TRACT
3.23
1.00
74420
CONTRST X-RAY, URINARY TRACT
3.26
1.00
74425
CONTRST X-RAY, URINARY TRACT
1.86
1.00
74425
CONTRST X-RAY, URINARY TRACT
1.88
1.00
74430
CONTRAST X-RAY, BLADDER
1.54
1.00
74430
CONTRAST X-RAY, BLADDER
1.57
1.00
Procedure Code Description
RVU
RVU Coeff Value
74430
CONTRAST X-RAY, BLADDER
2.15
1.00
74440
X-RAY, MALE GENITAL TRACT
1.70
1.00
74440
X-RAY, MALE GENITAL TRACT
1.71
1.00
74440
X-RAY, MALE GENITAL TRACT
2.31
1.00
74445
X-RAY EXAM OF PENIS
2.74
1.00
74445
X-RAY EXAM OF PENIS
2.76
1.00
74450
X-RAY, URETHRA/BLADDER
1.98
1.00
74450
X-RAY, URETHRA/BLADDER
2.00
1.00
74455
X-RAY, URETHRA/BLADDER
2.11
1.00
74455
X-RAY, URETHRA/BLADDER
2.14
1.00
74455
X-RAY, URETHRA/BLADDER
2.50
1.00
74470
X-RAY EXAM OF KIDNEY LESION
2.04
1.00
74470
X-RAY EXAM OF KIDNEY LESION
2.06
1.00
74475
X-RAY CONTROL, CATH INSERT
3.44
1.00
74475
X-RAY CONTROL, CATH INSERT
4.97
1.00
74475
X-RAY CONTROL, CATH INSERT
5.05
1.00
74480
X-RAY CONTROL, CATH INSERT
3.45
1.00
74480
X-RAY CONTROL, CATH INSERT
4.97
1.00
74480
X-RAY CONTROL, CATH INSERT
5.05
1.00
74485
X-RAY GUIDE, GU DILATION
3.28
1.00
74485
X-RAY GUIDE, GU DILATION
4.02
1.00
74485
X-RAY GUIDE, GU DILATION
4.10
1.00
74710
X-RAY MEASUREMENT OF PELVIS
1.21
1.00
74710
X-RAY MEASUREMENT OF PELVIS
1.57
1.00
74710
X-RAY MEASUREMENT OF PELVIS
1.59
1.00
74740
X-RAY, FEMALE GENITAL TRACT
1.89
1.00
74740
X-RAY, FEMALE GENITAL TRACT
1.91
1.00
74740
X-RAY, FEMALE GENITAL TRACT
2.14
1.00
74775
X-RAY EXAM OF PERINEUM
2.39
1.00
74775
X-RAY EXAM OF PERINEUM
2.40
1.00
74775
X-RAY EXAM OF PERINEUM
2.41
1.00
75552
HEART MRI FOR MORPH W/O DYE
13.87
1.00
75552
HEART MRI FOR MORPH W/O DYE
14.04
1.00
75552
HEART MRI FOR MORPH W/O DYE
15.64
1.00
75553
HEART MRI FOR MORPH W/DYE
14.42
1.00
Procedure Code Description
RVU
RVU Coeff Value
75553
HEART MRI FOR MORPH W/DYE
14.59
1.00
75553
HEART MRI FOR MORPH W/DYE
17.46
1.00
75554
CARDIAC MRI/FUNCTION
14.22
1.00
75554
CARDIAC MRI/FUNCTION
14.38
1.00
75554
CARDIAC MRI/FUNCTION
17.99
1.00
75555
CARDIAC MRI/LIMITED STUDY
14.12
1.00
75555
CARDIAC MRI/LIMITED STUDY
14.29
1.00
75555
CARDIAC MRI/LIMITED STUDY
18.04
1.00
75557
CARDIAC MRI FOR MORPH
14.36
1.00
75558
CARDIAC MRI FLOW/VELOCITY
17.47
1.00
75559
CARDIAC MRI W/STRESS IMG
20.74
1.00
75560
CARDIAC MRI FLOW/VEL/STRESS
22.71
1.00
75561
CARDIAC MRI FOR MORPH W/DYE
19.30
1.00
75562
CARD MRI FLOW/VEL W/DYE
22.51
1.00
75563
CARD MRI W/STRESS IMG & DYE
23.67
1.00
75564
HT MRI W/FLO/VEL/STRS & DYE
26.47
1.00
75600
CONTRAST X-RAY EXAM OF AORTA
8.95
1.00
75600
CONTRAST X-RAY EXAM OF AORTA
13.79
1.00
75600
CONTRAST X-RAY EXAM OF AORTA
13.99
1.00
75605
CONTRAST X-RAY EXAM OF AORTA
7.68
1.00
75605
CONTRAST X-RAY EXAM OF AORTA
14.69
1.00
75605
CONTRAST X-RAY EXAM OF AORTA
14.88
1.00
75625
CONTRAST X-RAY EXAM OF AORTA
7.58
1.00
75625
CONTRAST X-RAY EXAM OF AORTA
14.67
1.00
75625
CONTRAST X-RAY EXAM OF AORTA
14.87
1.00
75630
X-RAY AORTA, LEG ARTERIES
8.79
1.00
75630
X-RAY AORTA, LEG ARTERIES
16.16
1.00
75630
X-RAY AORTA, LEG ARTERIES
16.36
1.00
75635
CT ANGIO ABDOMINAL ARTERIES
16.68
1.00
75635
CT ANGIO ABDOMINAL ARTERIES
19.47
1.00
75635
CT ANGIO ABDOMINAL ARTERIES
19.67
1.00
75650
ARTERY X-RAYS, HEAD & NECK
8.12
1.00
75650
ARTERY X-RAYS, HEAD & NECK
15.16
1.00
75650
ARTERY X-RAYS, HEAD & NECK
15.35
1.00
75658
ARTERY X-RAYS, ARM
8.03
1.00
Procedure Code Description
RVU
RVU Coeff Value
75658
ARTERY X-RAYS, ARM
14.95
1.00
75658
ARTERY X-RAYS, ARM
15.14
1.00
75660
ARTERY X-RAYS, HEAD & NECK
8.17
1.00
75660
ARTERY X-RAYS, HEAD & NECK
14.92
1.00
75660
ARTERY X-RAYS, HEAD & NECK
15.11
1.00
75662
ARTERY X-RAYS, HEAD & NECK
9.35
1.00
75662
ARTERY X-RAYS, HEAD & NECK
15.44
1.00
75662
ARTERY X-RAYS, HEAD & NECK
15.64
1.00
75665
ARTERY X-RAYS, HEAD & NECK
8.39
1.00
75665
ARTERY X-RAYS, HEAD & NECK
14.92
1.00
75665
ARTERY X-RAYS, HEAD & NECK
15.11
1.00
75671
ARTERY X-RAYS, HEAD & NECK
9.47
1.00
75671
ARTERY X-RAYS, HEAD & NECK
15.40
1.00
75671
ARTERY X-RAYS, HEAD & NECK
15.60
1.00
75676
ARTERY X-RAYS, NECK
8.18
1.00
75676
ARTERY X-RAYS, NECK
14.93
1.00
75676
ARTERY X-RAYS, NECK
15.12
1.00
75680
ARTERY X-RAYS, NECK
9.10
1.00
75680
ARTERY X-RAYS, NECK
15.40
1.00
75680
ARTERY X-RAYS, NECK
15.60
1.00
75685
ARTERY X-RAYS, SPINE
8.19
1.00
75685
ARTERY X-RAYS, SPINE
14.91
1.00
75685
ARTERY X-RAYS, SPINE
15.10
1.00
75705
ARTERY X-RAYS, SPINE
9.42
1.00
75705
ARTERY X-RAYS, SPINE
16.14
1.00
75705
ARTERY X-RAYS, SPINE
16.33
1.00
75710
ARTERY X-RAYS, ARM/LEG
8.01
1.00
75710
ARTERY X-RAYS, ARM/LEG
14.69
1.00
75710
ARTERY X-RAYS, ARM/LEG
14.88
1.00
75716
ARTERY X-RAYS, ARMS/LEGS
8.91
1.00
75716
ARTERY X-RAYS, ARMS/LEGS
14.91
1.00
75716
ARTERY X-RAYS, ARMS/LEGS
15.10
1.00
75722
ARTERY X-RAYS, KIDNEY
7.91
1.00
75722
ARTERY X-RAYS, KIDNEY
14.69
1.00
75722
ARTERY X-RAYS, KIDNEY
14.89
1.00
Procedure Code Description
RVU
RVU Coeff Value
75724
ARTERY X-RAYS, KIDNEYS
9.18
1.00
75724
ARTERY X-RAYS, KIDNEYS
15.21
1.00
75724
ARTERY X-RAYS, KIDNEYS
15.40
1.00
75726
ARTERY X-RAYS, ABDOMEN
7.92
1.00
75726
ARTERY X-RAYS, ABDOMEN
14.67
1.00
75726
ARTERY X-RAYS, ABDOMEN
14.86
1.00
75731
ARTERY X-RAYS, ADRENAL GLAND
8.19
1.00
75731
ARTERY X-RAYS, ADRENAL GLAND
14.67
1.00
75731
ARTERY X-RAYS, ADRENAL GLAND
14.86
1.00
75733
ARTERY X-RAYS, ADRENALS
9.25
1.00
75733
ARTERY X-RAYS, ADRENALS
14.91
1.00
75733
ARTERY X-RAYS, ADRENALS
15.10
1.00
75736
ARTERY X-RAYS, PELVIS
7.99
1.00
75736
ARTERY X-RAYS, PELVIS
14.67
1.00
75736
ARTERY X-RAYS, PELVIS
14.86
1.00
75741
ARTERY X-RAYS, LUNG
7.68
1.00
75741
ARTERY X-RAYS, LUNG
14.91
1.00
75741
ARTERY X-RAYS, LUNG
15.10
1.00
75743
ARTERY X-RAYS, LUNGS
4.00
1.00
75743
ARTERY X-RAYS, LUNGS
8.39
1.00
75743
ARTERY X-RAYS, LUNGS
15.38
1.00
75743
ARTERY X-RAYS, LUNGS
15.57
1.00
75746
ARTERY X-RAYS, LUNG
7.75
1.00
75746
ARTERY X-RAYS, LUNG
14.67
1.00
75746
ARTERY X-RAYS, LUNG
14.86
1.00
75756
ARTERY X-RAYS, CHEST
8.21
1.00
75756
ARTERY X-RAYS, CHEST
14.73
1.00
75756
ARTERY X-RAYS, CHEST
14.92
1.00
75774
ARTERY X-RAY, EACH VESSEL
6.06
1.00
75774
ARTERY X-RAY, EACH VESSEL
13.60
1.00
75774
ARTERY X-RAY, EACH VESSEL
13.80
1.00
75790
VISUALIZE A-V SHUNT
3.96
1.00
75790
VISUALIZE A-V SHUNT
3.99
1.00
75790
VISUALIZE A-V SHUNT
4.84
1.00
75801
LYMPH VESSEL X-RAY, ARM/LEG
6.77
1.00
Procedure Code Description
RVU
RVU Coeff Value
75801
LYMPH VESSEL X-RAY, ARM/LEG
6.87
1.00
75803
LYMPH VESSEL X-RAY,ARMS/LEGS
7.25
1.00
75803
LYMPH VESSEL X-RAY,ARMS/LEGS
7.34
1.00
75805
LYMPH VESSEL X-RAY, TRUNK
7.47
1.00
75805
LYMPH VESSEL X-RAY, TRUNK
7.58
1.00
75807
LYMPH VESSEL X-RAY, TRUNK
7.96
1.00
75807
LYMPH VESSEL X-RAY, TRUNK
8.06
1.00
75809
NONVASCULAR SHUNT, X-RAY
1.47
1.00
75809
NONVASCULAR SHUNT, X-RAY
1.49
1.00
75809
NONVASCULAR SHUNT, X-RAY
2.39
1.00
75810
VEIN X-RAY, SPLEEN/LIVER
14.68
1.00
75810
VEIN X-RAY, SPLEEN/LIVER
14.87
1.00
75820
VEIN X-RAY, ARM/LEG
1.97
1.00
75820
VEIN X-RAY, ARM/LEG
1.98
1.00
75820
VEIN X-RAY, ARM/LEG
3.28
1.00
75822
VEIN X-RAY, ARMS/LEGS
3.01
1.00
75822
VEIN X-RAY, ARMS/LEGS
3.03
1.00
75822
VEIN X-RAY, ARMS/LEGS
4.02
1.00
75825
VEIN X-RAY, TRUNK
7.32
1.00
75825
VEIN X-RAY, TRUNK
14.68
1.00
75825
VEIN X-RAY, TRUNK
14.87
1.00
75827
VEIN X-RAY, CHEST
7.30
1.00
75827
VEIN X-RAY, CHEST
14.66
1.00
75827
VEIN X-RAY, CHEST
14.86
1.00
75831
VEIN X-RAY, KIDNEY
7.40
1.00
75831
VEIN X-RAY, KIDNEY
14.66
1.00
75831
VEIN X-RAY, KIDNEY
14.86
1.00
75833
VEIN X-RAY, KIDNEYS
8.24
1.00
75833
VEIN X-RAY, KIDNEYS
15.16
1.00
75833
VEIN X-RAY, KIDNEYS
15.35
1.00
75840
VEIN X-RAY, ADRENAL GLAND
7.34
1.00
75840
VEIN X-RAY, ADRENAL GLAND
14.69
1.00
75840
VEIN X-RAY, ADRENAL GLAND
14.88
1.00
75842
VEIN X-RAY, ADRENAL GLANDS
8.28
1.00
75842
VEIN X-RAY, ADRENAL GLANDS
15.15
1.00
Procedure Code Description 75842
VEIN X-RAY, ADRENAL GLANDS
75860
RVU
RVU Coeff Value
15.34
1.00
VEIN X-RAY, NECK
7.54
1.00
75860
VEIN X-RAY, NECK
14.69
1.00
75860
VEIN X-RAY, NECK
14.89
1.00
75870
VEIN X-RAY, SKULL
7.48
1.00
75870
VEIN X-RAY, SKULL
14.69
1.00
75870
VEIN X-RAY, SKULL
14.89
1.00
75872
VEIN X-RAY, SKULL
8.17
1.00
75872
VEIN X-RAY, SKULL
14.67
1.00
75872
VEIN X-RAY, SKULL
14.86
1.00
75880
VEIN X-RAY, EYE SOCKET
1.97
1.00
75880
VEIN X-RAY, EYE SOCKET
1.98
1.00
75880
VEIN X-RAY, EYE SOCKET
3.31
1.00
75885
VEIN X-RAY, LIVER
7.86
1.00
75885
VEIN X-RAY, LIVER
15.08
1.00
75885
VEIN X-RAY, LIVER
15.27
1.00
75887
VEIN X-RAY, LIVER
7.92
1.00
75887
VEIN X-RAY, LIVER
15.08
1.00
75887
VEIN X-RAY, LIVER
15.27
1.00
75889
VEIN X-RAY, LIVER
7.42
1.00
75889
VEIN X-RAY, LIVER
14.66
1.00
75889
VEIN X-RAY, LIVER
14.86
1.00
75891
VEIN X-RAY, LIVER
7.42
1.00
75891
VEIN X-RAY, LIVER
14.66
1.00
75891
VEIN X-RAY, LIVER
14.86
1.00
75893
VENOUS SAMPLING BY CATHETER
6.54
1.00
75893
VENOUS SAMPLING BY CATHETER
13.84
1.00
75893
VENOUS SAMPLING BY CATHETER
14.03
1.00
75894
X-RAYS, TRANSCATH THERAPY
26.91
1.00
75894
X-RAYS, TRANSCATH THERAPY
27.29
1.00
75894
X-RAYS, TRANSCATH THERAPY
27.31
1.00
75896
X-RAYS, TRANSCATH THERAPY
23.65
1.00
75896
X-RAYS, TRANSCATH THERAPY
23.99
1.00
75898
FOLLOW-UP ANGIOGRAPHY
3.38
1.00
75898
FOLLOW-UP ANGIOGRAPHY
3.40
1.00
Procedure Code Description
RVU
RVU Coeff Value
75900
INTRAVASCULAR CATH EXCHANGE
22.48
1.00
75900
INTRAVASCULAR CATH EXCHANGE
22.82
1.00
75901
REMOVE CVA DEVICE OBSTRUCT
2.67
1.00
75901
REMOVE CVA DEVICE OBSTRUCT
2.81
1.00
75901
REMOVE CVA DEVICE OBSTRUCT
4.82
1.00
75902
REMOVE CVA LUMEN OBSTRUCT
2.53
1.00
75902
REMOVE CVA LUMEN OBSTRUCT
2.68
1.00
75902
REMOVE CVA LUMEN OBSTRUCT
2.82
1.00
75940
X-RAY PLACEMENT, VEIN FILTER
13.84
1.00
75940
X-RAY PLACEMENT, VEIN FILTER
14.05
1.00
75945
INTRAVASCULAR US
5.33
1.00
75945
INTRAVASCULAR US
5.40
1.00
75946
INTRAVASCULAR US ADD-ON
2.96
1.00
75946
INTRAVASCULAR US ADD-ON
3.01
1.00
75952
ENDOVASC REPAIR ABDOM AORTA
6.31
1.00
75952
ENDOVASC REPAIR ABDOM AORTA
6.34
1.00
75952
ENDOVASC REPAIR ABDOM AORTA
6.41
1.00
75952
ENDOVASC REPAIR ABDOM AORTA
6.42
1.00
75952
ENDOVASC REPAIR ABDOM AORTA
6.81
1.00
75952
ENDOVASC REPAIR ABDOM AORTA
6.93
1.00
75953
ABDOM ANEURYSM ENDOVAS RPR
1.91
1.00
75953
ABDOM ANEURYSM ENDOVAS RPR
1.92
1.00
75953
ABDOM ANEURYSM ENDOVAS RPR
1.94
1.00
75953
ABDOM ANEURYSM ENDOVAS RPR
2.57
1.00
75953
ABDOM ANEURYSM ENDOVAS RPR
2.63
1.00
75954
ILIAC ANEURYSM ENDOVAS RPR
3.10
1.00
75954
ILIAC ANEURYSM ENDOVAS RPR
3.11
1.00
75954
ILIAC ANEURYSM ENDOVAS RPR
3.18
1.00
75960
TRANSCATH IV STENT RS&I
7.43
1.00
75960
TRANSCATH IV STENT RS&I
16.63
1.00
75960
TRANSCATH IV STENT RS&I
16.88
1.00
75961
RETRIEVAL, BROKEN CATHETER
11.54
1.00
75961
RETRIEVAL, BROKEN CATHETER
16.79
1.00
75961
RETRIEVAL, BROKEN CATHETER
16.95
1.00
75962
REPAIR ARTERIAL BLOCKAGE
7.94
1.00
Procedure Code Description
RVU
RVU Coeff Value
75962
REPAIR ARTERIAL BLOCKAGE
17.12
1.00
75962
REPAIR ARTERIAL BLOCKAGE
17.40
1.00
75964
REPAIR ARTERY BLOCKAGE, EACH
4.67
1.00
75964
REPAIR ARTERY BLOCKAGE, EACH
9.23
1.00
75964
REPAIR ARTERY BLOCKAGE, EACH
9.35
1.00
75966
REPAIR ARTERIAL BLOCKAGE
9.28
1.00
75966
REPAIR ARTERIAL BLOCKAGE
18.21
1.00
75966
REPAIR ARTERIAL BLOCKAGE
18.47
1.00
75968
REPAIR ARTERY BLOCKAGE, EACH
4.68
1.00
75968
REPAIR ARTERY BLOCKAGE, EACH
9.22
1.00
75968
REPAIR ARTERY BLOCKAGE, EACH
9.35
1.00
75970
VASCULAR BIOPSY
13.15
1.00
75970
VASCULAR BIOPSY
13.36
1.00
75978
REPAIR VENOUS BLOCKAGE
7.81
1.00
75978
REPAIR VENOUS BLOCKAGE
17.10
1.00
75978
REPAIR VENOUS BLOCKAGE
17.37
1.00
75980
CONTRAST XRAY EXAM BILE DUCT
7.62
1.00
75980
CONTRAST XRAY EXAM BILE DUCT
7.71
1.00
75984
XRAY CONTROL CATHETER CHANGE
3.02
1.00
75984
XRAY CONTROL CATHETER CHANGE
3.07
1.00
75984
XRAY CONTROL CATHETER CHANGE
3.16
1.00
75989
ABSCESS DRAINAGE UNDER X-RAY
4.00
1.00
75989
ABSCESS DRAINAGE UNDER X-RAY
4.91
1.00
75989
ABSCESS DRAINAGE UNDER X-RAY
4.97
1.00
75992
ATHERECTOMY, X-RAY EXAM
17.12
1.00
75992
ATHERECTOMY, X-RAY EXAM
17.38
1.00
75993
ATHERECTOMY, X-RAY EXAM
9.23
1.00
75993
ATHERECTOMY, X-RAY EXAM
9.36
1.00
75994
ATHERECTOMY, X-RAY EXAM
18.21
1.00
75994
ATHERECTOMY, X-RAY EXAM
18.47
1.00
75995
ATHERECTOMY, X-RAY EXAM
18.22
1.00
75995
ATHERECTOMY, X-RAY EXAM
18.48
1.00
75996
ATHERECTOMY, X-RAY EXAM
9.21
1.00
75996
ATHERECTOMY, X-RAY EXAM
9.34
1.00
75998
FLUOROGUIDE FOR VEIN DEVICE
1.93
1.00
Procedure Code Description
RVU
RVU Coeff Value
75998
FLUOROGUIDE FOR VEIN DEVICE
1.97
1.00
76000
FLUOROSCOPE EXAMINATION
1.59
1.00
76000
FLUOROSCOPE EXAMINATION
1.61
1.00
76000
FLUOROSCOPE EXAMINATION
2.64
1.00
76001
FLUOROSCOPE EXAM, EXTENSIVE
3.66
1.00
76001
FLUOROSCOPE EXAM, EXTENSIVE
3.69
1.00
76003
NEEDLE LOCALIZATION BY X-RAY
2.11
1.00
76003
NEEDLE LOCALIZATION BY X-RAY
2.13
1.00
76005
FLUOROGUIDE FOR SPINE INJECT
2.15
1.00
76005
FLUOROGUIDE FOR SPINE INJECT
2.16
1.00
76005
FLUOROGUIDE FOR SPINE INJECT
2.18
1.00
76006
X-RAY STRESS VIEW
0.64
1.00
76006
X-RAY STRESS VIEW
0.65
1.00
76010
X-RAY, NOSE TO RECTUM
0.77
1.00
76010
X-RAY, NOSE TO RECTUM
0.79
1.00
76012
PERCUT VERTEBROPLASTY FLUOR
1.88
1.00
76012
PERCUT VERTEBROPLASTY FLUOR
2.05
1.00
76013
PERCUT VERTEBROPLASTY, CT
1.93
1.00
76013
PERCUT VERTEBROPLASTY, CT
1.94
1.00
76013
PERCUT VERTEBROPLASTY, CT
2.40
1.00
76013
PERCUT VERTEBROPLASTY, CT
2.43
1.00
76020
X-RAYS FOR BONE AGE
0.80
1.00
76040
X-RAYS, BONE EVALUATION
1.20
1.00
76040
X-RAYS, BONE EVALUATION
1.21
1.00
76040
X-RAYS, BONE EVALUATION
1.24
1.00
76061
X-RAYS, BONE SURVEY
1.67
1.00
76061
X-RAYS, BONE SURVEY
1.68
1.00
76062
X-RAYS, BONE SURVEY
2.24
1.00
76062
X-RAYS, BONE SURVEY
2.26
1.00
76065
X-RAYS, BONE EVALUATION
1.73
1.00
76065
X-RAYS, BONE EVALUATION
1.74
1.00
76066
JOINT SURVEY, SINGLE VIEW
1.59
1.00
76066
JOINT SURVEY, SINGLE VIEW
1.60
1.00
76066
JOINT SURVEY, SINGLE VIEW
1.62
1.00
76070
CT BONE DENSITY, AXIAL
3.41
1.00
Procedure Code Description
RVU
RVU Coeff Value
76070
CT BONE DENSITY, AXIAL
3.46
1.00
76071
CT BONE DENSITY, PERIPHERAL
3.28
1.00
76071
CT BONE DENSITY, PERIPHERAL
3.31
1.00
76075
DXA BONE DENSITY, AXIAL
3.64
1.00
76075
DXA BONE DENSITY, AXIAL
3.68
1.00
76075
DXA BONE DENSITY, AXIAL
3.69
1.00
76076
DXA BONE DENSITY/PERIPHERAL
1.10
1.00
76076
DXA BONE DENSITY/PERIPHERAL
1.11
1.00
76076
DXA BONE DENSITY/PERIPHERAL
1.12
1.00
76077
DXA BONE DENSITY/V-FRACTURE
1.04
1.00
76078
RADIOGRAPHIC ABSORPTIOMETRY
1.07
1.00
76078
RADIOGRAPHIC ABSORPTIOMETRY
1.08
1.00
76078
RADIOGRAPHIC ABSORPTIOMETRY
1.09
1.00
76080
X-RAY EXAM OF FISTULA
1.76
1.00
76080
X-RAY EXAM OF FISTULA
1.83
1.00
76080
X-RAY EXAM OF FISTULA
1.86
1.00
76082
COMPUTER MAMMOGRAM ADD-ON
0.51
1.00
76082
COMPUTER MAMMOGRAM ADD-ON
0.52
1.00
76083
COMPUTER MAMMOGRAM ADD-ON
0.51
1.00
76083
COMPUTER MAMMOGRAM ADD-ON
0.52
1.00
76085
COMPUTER MAMMOGRAM ADD-ON
0.52
1.00
76086
X-RAY OF MAMMARY DUCT
3.23
1.00
76086
X-RAY OF MAMMARY DUCT
3.26
1.00
76086
X-RAY OF MAMMARY DUCT
3.27
1.00
76088
X-RAY OF MAMMARY DUCTS
4.43
1.00
76088
X-RAY OF MAMMARY DUCTS
4.48
1.00
76088
X-RAY OF MAMMARY DUCTS
4.49
1.00
76090
MAMMOGRAM, ONE BREAST
2.06
1.00
76090
MAMMOGRAM, ONE BREAST
2.07
1.00
76090
MAMMOGRAM, ONE BREAST
2.09
1.00
76091
MAMMOGRAM, BOTH BREASTS
2.56
1.00
76091
MAMMOGRAM, BOTH BREASTS
2.57
1.00
76091
MAMMOGRAM, BOTH BREASTS
2.58
1.00
76092
MAMM0GRAM, SCREENING
2.25
1.00
76092
MAMM0GRAM, SCREENING
2.26
1.00
Procedure Code Description
RVU
RVU Coeff Value
76092
MAMM0GRAM, SCREENING
2.27
1.00
76093
MAGNETIC IMAGE, BREAST
20.57
1.00
76093
MAGNETIC IMAGE, BREAST
20.82
1.00
76093
MAGNETIC IMAGE, BREAST
20.84
1.00
76094
MAGNETIC IMAGE, BOTH BREASTS
27.08
1.00
76094
MAGNETIC IMAGE, BOTH BREASTS
27.45
1.00
76094
MAGNETIC IMAGE, BOTH BREASTS
27.47
1.00
76095
STEREOTACTIC BREAST BIOPSY
9.66
1.00
76095
STEREOTACTIC BREAST BIOPSY
9.75
1.00
76095
STEREOTACTIC BREAST BIOPSY
9.78
1.00
76096
X-RAY OF NEEDLE WIRE, BREAST
2.14
1.00
76096
X-RAY OF NEEDLE WIRE, BREAST
2.17
1.00
76098
X-RAY EXAM, BREAST SPECIMEN
0.55
1.00
76098
X-RAY EXAM, BREAST SPECIMEN
0.65
1.00
76098
X-RAY EXAM, BREAST SPECIMEN
0.67
1.00
76100
X-RAY EXAM OF BODY SECTION
2.11
1.00
76100
X-RAY EXAM OF BODY SECTION
2.13
1.00
76100
X-RAY EXAM OF BODY SECTION
3.69
1.00
76101
COMPLEX BODY SECTION X-RAY
2.29
1.00
76101
COMPLEX BODY SECTION X-RAY
2.32
1.00
76101
COMPLEX BODY SECTION X-RAY
5.10
1.00
76102
COMPLEX BODY SECTION X-RAYS
2.62
1.00
76102
COMPLEX BODY SECTION X-RAYS
2.67
1.00
76102
COMPLEX BODY SECTION X-RAYS
6.84
1.00
76120
CINE/VIDEO X-RAYS
1.62
1.00
76120
CINE/VIDEO X-RAYS
1.65
1.00
76120
CINE/VIDEO X-RAYS
2.08
1.00
76125
CINE/VIDEO X-RAYS ADD-ON
1.20
1.00
76125
CINE/VIDEO X-RAYS ADD-ON
1.21
1.00
76150
X-RAY EXAM, DRY PROCESS
0.43
1.00
76150
X-RAY EXAM, DRY PROCESS
0.44
1.00
76150
X-RAY EXAM, DRY PROCESS
0.51
1.00
76355
CT SCAN FOR LOCALIZATION
10.26
1.00
76355
CT SCAN FOR LOCALIZATION
10.36
1.00
76355
CT SCAN FOR LOCALIZATION
10.39
1.00
Procedure Code Description
RVU
RVU Coeff Value
76360
CT SCAN FOR NEEDLE BIOPSY
10.17
1.00
76360
CT SCAN FOR NEEDLE BIOPSY
10.29
1.00
76360
CT SCAN FOR NEEDLE BIOPSY
10.30
1.00
76362
CT GUIDE FOR TISSUE ABLATION
14.96
1.00
76362
CT GUIDE FOR TISSUE ABLATION
15.21
1.00
76362
CT GUIDE FOR TISSUE ABLATION
15.26
1.00
76375
3D/HOLOGRAPH RECONSTR ADD-ON
3.89
1.00
76375
3D/HOLOGRAPH RECONSTR ADD-ON
3.94
1.00
76375
3D/HOLOGRAPH RECONSTR ADD-ON
3.95
1.00
76376
3D RENDER W/O POSTPROCESS
2.22
1.00
76377
3D RENDERING W/POSTPROCESS
3.16
1.00
76380
CAT SCAN FOLLOW-UP STUDY
4.98
1.00
76380
CAT SCAN FOLLOW-UP STUDY
5.05
1.00
76380
CAT SCAN FOLLOW-UP STUDY
5.68
1.00
76390
MR SPECTROSCOPY
12.80
1.00
76390
MR SPECTROSCOPY
13.54
1.00
76390
MR SPECTROSCOPY
13.59
1.00
76393
MR GUIDANCE FOR NEEDLE PLACE
13.71
1.00
76393
MR GUIDANCE FOR NEEDLE PLACE
13.87
1.00
76394
MRI FOR TISSUE ABLATION
18.33
1.00
76394
MRI FOR TISSUE ABLATION
18.66
1.00
76400
MAGNETIC IMAGE, BONE MARROW
7.00
1.00
76400
MAGNETIC IMAGE, BONE MARROW
13.86
1.00
76400
MAGNETIC IMAGE, BONE MARROW
14.01
1.00
76400
MAGNETIC IMAGE, BONE MARROW
14.03
1.00
76490
US FOR TISSUE ABLATION
7.20
1.00
77261
RADIATION THERAPY PLANNING
1.97
1.00
77261
RADIATION THERAPY PLANNING
1.99
1.00
77262
RADIATION THERAPY PLANNING
2.96
1.00
77262
RADIATION THERAPY PLANNING
2.97
1.00
77262
RADIATION THERAPY PLANNING
3.00
1.00
77263
RADIATION THERAPY PLANNING
4.39
1.00
77263
RADIATION THERAPY PLANNING
4.42
1.00
77263
RADIATION THERAPY PLANNING
4.44
1.00
77280
SET RADIATION THERAPY FIELD
4.57
1.00
Procedure Code Description
RVU
RVU Coeff Value
77280
SET RADIATION THERAPY FIELD
4.62
1.00
77280
SET RADIATION THERAPY FIELD
5.11
1.00
77285
SET RADIATION THERAPY FIELD
7.24
1.00
77285
SET RADIATION THERAPY FIELD
7.33
1.00
77285
SET RADIATION THERAPY FIELD
8.80
1.00
77290
SET RADIATION THERAPY FIELD
8.92
1.00
77290
SET RADIATION THERAPY FIELD
9.00
1.00
77290
SET RADIATION THERAPY FIELD
13.63
1.00
77295
SET RADIATION THERAPY FIELD
19.17
1.00
77295
SET RADIATION THERAPY FIELD
35.33
1.00
77295
SET RADIATION THERAPY FIELD
35.74
1.00
77300
RADIATION THERAPY DOSE PLAN
1.98
1.00
77300
RADIATION THERAPY DOSE PLAN
2.25
1.00
77300
RADIATION THERAPY DOSE PLAN
2.28
1.00
77301
RADIOTHERAPY DOSE PLAN, IMRT
40.26
1.00
77301
RADIOTHERAPY DOSE PLAN, IMRT
40.33
1.00
77301
RADIOTHERAPY DOSE PLAN, IMRT
59.80
1.00
77305
TELETX ISODOSE PLAN SIMPLE
2.05
1.00
77305
TELETX ISODOSE PLAN SIMPLE
2.91
1.00
77305
TELETX ISODOSE PLAN SIMPLE
2.95
1.00
77310
TELETX ISODOSE PLAN INTERMED
2.84
1.00
77310
TELETX ISODOSE PLAN INTERMED
3.88
1.00
77310
TELETX ISODOSE PLAN INTERMED
3.91
1.00
77315
TELETX ISODOSE PLAN COMPLEX
4.13
1.00
77315
TELETX ISODOSE PLAN COMPLEX
4.92
1.00
77321
SPECIAL TELETX PORT PLAN
3.42
1.00
77321
SPECIAL TELETX PORT PLAN
5.50
1.00
77321
SPECIAL TELETX PORT PLAN
5.58
1.00
77326
BRACHYTX ISODOSE CALC SIMP
3.74
1.00
77326
BRACHYTX ISODOSE CALC SIMP
3.78
1.00
77326
BRACHYTX ISODOSE CALC SIMP
3.96
1.00
77327
BRACHYTX ISODOSE CALC INTERM
5.52
1.00
77327
BRACHYTX ISODOSE CALC INTERM
5.56
1.00
77327
BRACHYTX ISODOSE CALC INTERM
5.64
1.00
77328
BRACHYTX ISODOSE PLAN COMPL
7.73
1.00
Procedure Code Description
RVU
RVU Coeff Value
77328
BRACHYTX ISODOSE PLAN COMPL
8.04
1.00
77328
BRACHYTX ISODOSE PLAN COMPL
8.08
1.00
77331
SPECIAL RADIATION DOSIMETRY
1.72
1.00
77331
SPECIAL RADIATION DOSIMETRY
1.73
1.00
77332
RADIATION TREATMENT AID(S)
2.13
1.00
77332
RADIATION TREATMENT AID(S)
2.15
1.00
77332
RADIATION TREATMENT AID(S)
2.16
1.00
77332
RADIATION TREATMENT AID(S)
2.17
1.00
77333
RADIATION TREATMENT AID(S)
1.93
1.00
77333
RADIATION TREATMENT AID(S)
2.74
1.00
77333
RADIATION TREATMENT AID(S)
3.15
1.00
77333
RADIATION TREATMENT AID(S)
3.17
1.00
77334
RADIATION TREATMENT AID(S)
4.40
1.00
77334
RADIATION TREATMENT AID(S)
4.90
1.00
77334
RADIATION TREATMENT AID(S)
5.08
1.00
77334
RADIATION TREATMENT AID(S)
5.12
1.00
77336
RADIATION PHYSICS CONSULT
1.74
1.00
77336
RADIATION PHYSICS CONSULT
3.10
1.00
77336
RADIATION PHYSICS CONSULT
3.15
1.00
77370
RADIATION PHYSICS CONSULT
3.27
1.00
77370
RADIATION PHYSICS CONSULT
3.62
1.00
77370
RADIATION PHYSICS CONSULT
3.68
1.00
77371
SRS, MULTISOURCE
30.24
1.00
77372
SRS, LINEAR BASED
22.43
1.00
77373
SBRT DELIVERY
41.51
1.00
77401
RADIATION TREATMENT DELIVERY
0.90
1.00
77401
RADIATION TREATMENT DELIVERY
1.85
1.00
77401
RADIATION TREATMENT DELIVERY
1.89
1.00
77402
RADIATION TREATMENT DELIVERY
1.85
1.00
77402
RADIATION TREATMENT DELIVERY
1.89
1.00
77402
RADIATION TREATMENT DELIVERY
3.76
1.00
77403
RADIATION TREATMENT DELIVERY
1.85
1.00
77403
RADIATION TREATMENT DELIVERY
1.89
1.00
77403
RADIATION TREATMENT DELIVERY
3.31
1.00
77404
RADIATION TREATMENT DELIVERY
1.85
1.00
Procedure Code Description
RVU
RVU Coeff Value
77404
RADIATION TREATMENT DELIVERY
1.89
1.00
77404
RADIATION TREATMENT DELIVERY
3.64
1.00
77406
RADIATION TREATMENT DELIVERY
1.85
1.00
77406
RADIATION TREATMENT DELIVERY
1.89
1.00
77406
RADIATION TREATMENT DELIVERY
3.67
1.00
77407
RADIATION TREATMENT DELIVERY
2.18
1.00
77407
RADIATION TREATMENT DELIVERY
2.21
1.00
77407
RADIATION TREATMENT DELIVERY
5.88
1.00
77408
RADIATION TREATMENT DELIVERY
2.18
1.00
77408
RADIATION TREATMENT DELIVERY
2.21
1.00
77408
RADIATION TREATMENT DELIVERY
4.43
1.00
77409
RADIATION TREATMENT DELIVERY
2.18
1.00
77409
RADIATION TREATMENT DELIVERY
2.21
1.00
77409
RADIATION TREATMENT DELIVERY
4.88
1.00
77411
RADIATION TREATMENT DELIVERY
2.18
1.00
77411
RADIATION TREATMENT DELIVERY
2.21
1.00
77411
RADIATION TREATMENT DELIVERY
4.85
1.00
77412
RADIATION TREATMENT DELIVERY
2.43
1.00
77412
RADIATION TREATMENT DELIVERY
2.47
1.00
77412
RADIATION TREATMENT DELIVERY
5.70
1.00
77413
RADIATION TREATMENT DELIVERY
2.43
1.00
77413
RADIATION TREATMENT DELIVERY
2.47
1.00
77413
RADIATION TREATMENT DELIVERY
5.74
1.00
77414
RADIATION TREATMENT DELIVERY
2.43
1.00
77414
RADIATION TREATMENT DELIVERY
2.47
1.00
77414
RADIATION TREATMENT DELIVERY
6.37
1.00
77416
RADIATION TREATMENT DELIVERY
2.43
1.00
77416
RADIATION TREATMENT DELIVERY
2.47
1.00
77416
RADIATION TREATMENT DELIVERY
6.40
1.00
77417
RADIOLOGY PORT FILM(S)
0.45
1.00
77417
RADIOLOGY PORT FILM(S)
0.62
1.00
77417
RADIOLOGY PORT FILM(S)
0.63
1.00
77418
RADIATION TX DELIVERY, IMRT
14.33
1.00
77418
RADIATION TX DELIVERY, IMRT
18.08
1.00
77418
RADIATION TX DELIVERY, IMRT
18.18
1.00
Procedure Code Description
RVU
RVU Coeff Value
77421
STEREOSCOPIC X-RAY GUIDANCE
3.14
1.00
77422
NEUTRON BEAM TX, SIMPLE
5.37
1.00
77423
NEUTRON BEAM TX, COMPLEX
6.16
1.00
77427
RADIATION TX MANAGEMENT, X5
4.53
1.00
77427
RADIATION TX MANAGEMENT, X5
4.57
1.00
77427
RADIATION TX MANAGEMENT, X5
5.22
1.00
77431
RADIATION THERAPY MANAGEMENT
2.57
1.00
77431
RADIATION THERAPY MANAGEMENT
2.59
1.00
77431
RADIATION THERAPY MANAGEMENT
2.67
1.00
77432
STEREOTACTIC RADIATION TRMT
11.11
1.00
77432
STEREOTACTIC RADIATION TRMT
11.23
1.00
77432
STEREOTACTIC RADIATION TRMT
11.32
1.00
77435
SBRT MANAGEMENT
18.43
1.00
77470
SPECIAL RADIATION TREATMENT
7.20
1.00
77470
SPECIAL RADIATION TREATMENT
14.48
1.00
77470
SPECIAL RADIATION TREATMENT
14.64
1.00
77620
HYPERTHERMIA TREATMENT
5.33
1.00
77620
HYPERTHERMIA TREATMENT
5.36
1.00
77620
HYPERTHERMIA TREATMENT
10.74
1.00
77750
INFUSE RADIOACTIVE MATERIALS
8.09
1.00
77750
INFUSE RADIOACTIVE MATERIALS
8.14
1.00
77750
INFUSE RADIOACTIVE MATERIALS
9.40
1.00
77761
APPLY INTRCAV RADIAT SIMPLE
3.00
1.00
77761
APPLY INTRCAV RADIAT SIMPLE
7.73
1.00
77761
APPLY INTRCAV RADIAT SIMPLE
7.75
1.00
77761
APPLY INTRCAV RADIAT SIMPLE
9.74
1.00
77762
APPLY INTRCAV RADIAT INTERM
3.00
1.00
77762
APPLY INTRCAV RADIAT INTERM
11.61
1.00
77762
APPLY INTRCAV RADIAT INTERM
11.62
1.00
77762
APPLY INTRCAV RADIAT INTERM
13.29
1.00
77763
APPLY INTRCAV RADIAT COMPL
3.00
1.00
77763
APPLY INTRCAV RADIAT COMPL
16.42
1.00
77763
APPLY INTRCAV RADIAT COMPL
16.45
1.00
77763
APPLY INTRCAV RADIAT COMPL
18.80
1.00
77776
APPLY INTERSTIT RADIAT SIMPL
8.16
1.00
Procedure Code Description
RVU
RVU Coeff Value
77776
APPLY INTERSTIT RADIAT SIMPL
8.21
1.00
77776
APPLY INTERSTIT RADIAT SIMPL
11.49
1.00
77777
APPLY INTERSTIT RADIAT INTER
14.68
1.00
77777
APPLY INTERSTIT RADIAT INTER
14.69
1.00
77777
APPLY INTERSTIT RADIAT INTER
15.92
1.00
77778
APPLY INTERSTIT RADIAT COMPL
20.70
1.00
77778
APPLY INTERSTIT RADIAT COMPL
20.76
1.00
77778
APPLY INTERSTIT RADIAT COMPL
22.77
1.00
77781
REMOTE AFTERLOADING HIGH INTENSITY
14.97
1.00
77781
REMOTE AFTERLOADING HIGH INTENSITY
23.40
1.00
77781
REMOTE AFTERLOADING HIGH INTENSITY
23.71
1.00
77782
REMOTE AFTERLOADING HIGH INTENSITY
19.99
1.00
77782
REMOTE AFTERLOADING HIGH INTENSITY
24.54
1.00
77782
REMOTE AFTERLOADING HIGH INTENSITY
24.85
1.00
77783
REMOTE AFTERLOADING HIGH INTENSITY
26.24
1.00
77783
REMOTE AFTERLOADING HIGH INTENSITY
26.52
1.00
77783
REMOTE AFTERLOADING HIGH INTENSITY
27.38
1.00
77784
REMOTE AFTERLOADING HIGH INTENSITY
28.82
1.00
77784
REMOTE AFTERLOADING HIGH INTENSITY
29.09
1.00
77784
REMOTE AFTERLOADING HIGH INTENSITY
40.41
1.00
77785
HDR BRACHYTX, 1 CHANNEL
5.16
1.00
77786
HDR BRACHYTX, 2-12 CHANNEL
15.47
1.00
77787
HDR BRACHYTX OVER 12 CHAN
22.99
1.00
77789
APPLY SURFACE RADIATION
2.00
1.00
77789
APPLY SURFACE RADIATION
2.01
1.00
77789
APPLY SURFACE RADIATION
2.89
1.00
77790
RADIATION HANDLING
1.96
1.00
77790
RADIATION HANDLING
1.97
1.00
77790
RADIATION HANDLING
2.42
1.00
78000
THYROID, SINGLE UPTAKE
1.29
1.00
78000
THYROID, SINGLE UPTAKE
1.30
1.00
78000
THYROID, SINGLE UPTAKE
1.90
1.00
78001
THYROID, MULTIPLE UPTAKES
1.72
1.00
78001
THYROID, MULTIPLE UPTAKES
1.74
1.00
78001
THYROID, MULTIPLE UPTAKES
2.41
1.00
Procedure Code Description
RVU
RVU Coeff Value
78003
THYROID SUPPRESS/STIMUL
1.47
1.00
78003
THYROID SUPPRESS/STIMUL
1.48
1.00
78003
THYROID SUPPRESS/STIMUL
2.10
1.00
78006
THYROID IMAGING WITH UPTAKE
3.16
1.00
78006
THYROID IMAGING WITH UPTAKE
3.20
1.00
78006
THYROID IMAGING WITH UPTAKE
5.92
1.00
78007
THYROID IMAGE, MULT UPTAKES
3.37
1.00
78007
THYROID IMAGE, MULT UPTAKES
3.42
1.00
78007
THYROID IMAGE, MULT UPTAKES
3.63
1.00
78010
THYROID IMAGING
2.45
1.00
78010
THYROID IMAGING
2.48
1.00
78010
THYROID IMAGING
4.13
1.00
78011
THYROID IMAGING WITH FLOW
3.14
1.00
78011
THYROID IMAGING WITH FLOW
3.17
1.00
78011
THYROID IMAGING WITH FLOW
4.70
1.00
78015
THYROID MET IMAGING
3.61
1.00
78015
THYROID MET IMAGING
3.67
1.00
78015
THYROID MET IMAGING
5.58
1.00
78016
THYROID MET IMAGING/STUDIES
4.76
1.00
78016
THYROID MET IMAGING/STUDIES
4.82
1.00
78016
THYROID MET IMAGING/STUDIES
8.46
1.00
78018
THYROID MET IMAGING, BODY
6.84
1.00
78018
THYROID MET IMAGING, BODY
6.94
1.00
78018
THYROID MET IMAGING, BODY
8.57
1.00
78020
THYROID MET UPTAKE
2.26
1.00
78020
THYROID MET UPTAKE
2.28
1.00
78020
THYROID MET UPTAKE
2.52
1.00
78070
PARATHYROID NUCLEAR IMAGING
3.04
1.00
78070
PARATHYROID NUCLEAR IMAGING
3.08
1.00
78070
PARATHYROID NUCLEAR IMAGING
4.73
1.00
78075
ADRENAL NUCLEAR IMAGING
6.68
1.00
78075
ADRENAL NUCLEAR IMAGING
6.79
1.00
78075
ADRENAL NUCLEAR IMAGING
11.11
1.00
78102
BONE MARROW IMAGING, LTD
2.90
1.00
78102
BONE MARROW IMAGING, LTD
2.93
1.00
Procedure Code Description
RVU
RVU Coeff Value
78102
BONE MARROW IMAGING, LTD
4.39
1.00
78103
BONE MARROW IMAGING, MULT
4.34
1.00
78103
BONE MARROW IMAGING, MULT
4.40
1.00
78103
BONE MARROW IMAGING, MULT
5.90
1.00
78104
BONE MARROW IMAGING, BODY
5.34
1.00
78104
BONE MARROW IMAGING, BODY
5.42
1.00
78104
BONE MARROW IMAGING, BODY
6.77
1.00
78110
PLASMA VOLUME, SINGLE
1.27
1.00
78110
PLASMA VOLUME, SINGLE
1.28
1.00
78110
PLASMA VOLUME, SINGLE
2.10
1.00
78111
PLASMA VOLUME, MULTIPLE
2.70
1.00
78111
PLASMA VOLUME, MULTIPLE
2.99
1.00
78111
PLASMA VOLUME, MULTIPLE
3.04
1.00
78120
RED CELL MASS, SINGLE
2.13
1.00
78120
RED CELL MASS, SINGLE
2.17
1.00
78120
RED CELL MASS, SINGLE
2.40
1.00
78121
RED CELL MASS, MULTIPLE
2.91
1.00
78121
RED CELL MASS, MULTIPLE
3.47
1.00
78121
RED CELL MASS, MULTIPLE
3.50
1.00
78130
RED CELL SURVIVAL STUDY
3.82
1.00
78130
RED CELL SURVIVAL STUDY
3.86
1.00
78130
RED CELL SURVIVAL STUDY
4.20
1.00
78135
RED CELL SURVIVAL KINETICS
5.97
1.00
78135
RED CELL SURVIVAL KINETICS
6.04
1.00
78135
RED CELL SURVIVAL KINETICS
8.74
1.00
78140
RED CELL SEQUESTRATION
4.09
1.00
78140
RED CELL SEQUESTRATION
4.94
1.00
78140
RED CELL SEQUESTRATION
5.01
1.00
78160
PLASMA IRON TURNOVER
4.29
1.00
78160
PLASMA IRON TURNOVER
4.34
1.00
78160
PLASMA IRON TURNOVER
4.36
1.00
78162
RADIOIRON ABSORPTION EXAM
3.97
1.00
78162
RADIOIRON ABSORPTION EXAM
4.03
1.00
78170
RED CELL IRON UTILIZATION
6.10
1.00
78170
RED CELL IRON UTILIZATION
6.16
1.00
Procedure Code Description
RVU
RVU Coeff Value
78170
RED CELL IRON UTILIZATION
6.21
1.00
78185
SPLEEN IMAGING
3.02
1.00
78185
SPLEEN IMAGING
3.06
1.00
78185
SPLEEN IMAGING
5.09
1.00
78190
KINETICS, STUDY OF PLATELET SURVIV
7.57
1.00
78190
KINETICS, STUDY OF PLATELET SURVIV
7.59
1.00
78190
KINETICS, STUDY OF PLATELET SURVIV
10.02
1.00
78191
PLATELET SURVIVAL
5.51
1.00
78191
PLATELET SURVIVAL
8.46
1.00
78191
PLATELET SURVIVAL
8.58
1.00
78195
LYMPH SYSTEM IMAGING
5.91
1.00
78195
LYMPH SYSTEM IMAGING
5.98
1.00
78195
LYMPH SYSTEM IMAGING
9.10
1.00
78201
LIVER IMAGING
3.07
1.00
78201
LIVER IMAGING
3.11
1.00
78201
LIVER IMAGING
4.70
1.00
78202
LIVER IMAGING WITH FLOW
3.70
1.00
78202
LIVER IMAGING WITH FLOW
3.74
1.00
78202
LIVER IMAGING WITH FLOW
5.42
1.00
78205
LIVER IMAGING (3D)
6.53
1.00
78205
LIVER IMAGING (3D)
7.13
1.00
78205
LIVER IMAGING (3D)
7.24
1.00
78206
LIVER IMAGE (3D) WITH FLOW
7.31
1.00
78206
LIVER IMAGE (3D) WITH FLOW
7.39
1.00
78206
LIVER IMAGE (3D) WITH FLOW
9.08
1.00
78215
LIVER AND SPLEEN IMAGING
3.73
1.00
78215
LIVER AND SPLEEN IMAGING
3.77
1.00
78215
LIVER AND SPLEEN IMAGING
5.02
1.00
78216
LIVER & SPLEEN IMAGE/FLOW
3.82
1.00
78216
LIVER & SPLEEN IMAGE/FLOW
4.40
1.00
78216
LIVER & SPLEEN IMAGE/FLOW
4.46
1.00
78220
LIVER FUNCTION STUDY
3.98
1.00
78220
LIVER FUNCTION STUDY
4.54
1.00
78220
LIVER FUNCTION STUDY
4.61
1.00
78223
HEPATOBILIARY IMAGING
4.98
1.00
Procedure Code Description
RVU
RVU Coeff Value
78223
HEPATOBILIARY IMAGING
5.04
1.00
78223
HEPATOBILIARY IMAGING
8.39
1.00
78230
SALIVARY GLAND IMAGING
2.90
1.00
78230
SALIVARY GLAND IMAGING
2.93
1.00
78230
SALIVARY GLAND IMAGING
4.28
1.00
78231
SERIAL SALIVARY IMAGING
3.67
1.00
78231
SERIAL SALIVARY IMAGING
4.02
1.00
78231
SERIAL SALIVARY IMAGING
4.08
1.00
78232
SALIVARY GLAND FUNCTION EXAM
3.74
1.00
78232
SALIVARY GLAND FUNCTION EXAM
4.32
1.00
78232
SALIVARY GLAND FUNCTION EXAM
4.38
1.00
78258
ESOPHAGEAL MOTILITY STUDY
4.02
1.00
78258
ESOPHAGEAL MOTILITY STUDY
4.06
1.00
78258
ESOPHAGEAL MOTILITY STUDY
5.95
1.00
78261
GASTRIC MUCOSA IMAGING
5.23
1.00
78261
GASTRIC MUCOSA IMAGING
5.31
1.00
78261
GASTRIC MUCOSA IMAGING
6.59
1.00
78262
GASTROESOPHAGEAL REFLUX EXAM
5.37
1.00
78262
GASTROESOPHAGEAL REFLUX EXAM
5.45
1.00
78262
GASTROESOPHAGEAL REFLUX EXAM
6.50
1.00
78264
GASTRIC EMPTYING STUDY
5.37
1.00
78264
GASTRIC EMPTYING STUDY
5.45
1.00
78264
GASTRIC EMPTYING STUDY
7.47
1.00
78270
VIT B-12 ABSORPTION EXAM
1.90
1.00
78270
VIT B-12 ABSORPTION EXAM
1.93
1.00
78270
VIT B-12 ABSORPTION EXAM
2.18
1.00
78271
VIT B-12 ABSRP EXAM, INT FAC
1.99
1.00
78271
VIT B-12 ABSRP EXAM, INT FAC
2.03
1.00
78271
VIT B-12 ABSRP EXAM, INT FAC
2.20
1.00
78272
VIT B-12 ABSORP, COMBINED
2.50
1.00
78272
VIT B-12 ABSORP, COMBINED
2.80
1.00
78272
VIT B-12 ABSORP, COMBINED
2.84
1.00
78278
ACUTE GI BLOOD LOSS IMAGING
6.44
1.00
78278
ACUTE GI BLOOD LOSS IMAGING
6.52
1.00
78278
ACUTE GI BLOOD LOSS IMAGING
9.00
1.00
Procedure Code Description
RVU
RVU Coeff Value
78282
GI PROTEIN LOSS EXAM
0.52
1.00
78282
GI PROTEIN LOSS EXAM
0.53
1.00
78282
GI PROTEIN LOSS EXAM
0.54
1.00
78290
MECKELÏS DIVERT EXAM
4.12
1.00
78290
MECKELÏS DIVERT EXAM
4.17
1.00
78290
MECKELÏS DIVERT EXAM
8.03
1.00
78291
LEVEEN/SHUNT PATENCY EXAM
4.41
1.00
78291
LEVEEN/SHUNT PATENCY EXAM
4.47
1.00
78291
LEVEEN/SHUNT PATENCY EXAM
6.55
1.00
78300
BONE IMAGING, LIMITED AREA
3.46
1.00
78300
BONE IMAGING, LIMITED AREA
3.51
1.00
78300
BONE IMAGING, LIMITED AREA
4.61
1.00
78305
BONE IMAGING, MULTIPLE AREAS
4.96
1.00
78305
BONE IMAGING, MULTIPLE AREAS
5.02
1.00
78305
BONE IMAGING, MULTIPLE AREAS
6.13
1.00
78306
BONE IMAGING, WHOLE BODY
5.64
1.00
78306
BONE IMAGING, WHOLE BODY
5.71
1.00
78306
BONE IMAGING, WHOLE BODY
6.79
1.00
78315
BONE IMAGING, 3 PHASE
6.39
1.00
78315
BONE IMAGING, 3 PHASE
6.47
1.00
78315
BONE IMAGING, 3 PHASE
9.01
1.00
78320
BONE IMAGING (3D)
6.99
1.00
78320
BONE IMAGING (3D)
7.59
1.00
78320
BONE IMAGING (3D)
7.70
1.00
78350
BONE MINERAL, SINGLE PHOTON
0.93
1.00
78350
BONE MINERAL, SINGLE PHOTON
1.10
1.00
78350
BONE MINERAL, SINGLE PHOTON
1.11
1.00
78351
BONE MINERAL, DUAL PHOTON
0.42
1.00
78351
BONE MINERAL, DUAL PHOTON
0.43
1.00
78414
NON-IMAGING HEART FUNCTION
0.60
1.00
78414
NON-IMAGING HEART FUNCTION
0.63
1.00
78428
CARDIAC SHUNT IMAGING
3.46
1.00
78428
CARDIAC SHUNT IMAGING
3.51
1.00
78428
CARDIAC SHUNT IMAGING
5.34
1.00
78445
VASCULAR FLOW IMAGING
2.63
1.00
Procedure Code Description
RVU
RVU Coeff Value
78445
VASCULAR FLOW IMAGING
2.66
1.00
78445
VASCULAR FLOW IMAGING
4.48
1.00
78455
VENOUS THROMBOSIS STUDY
5.16
1.00
78455
VENOUS THROMBOSIS STUDY
5.20
1.00
78455
VENOUS THROMBOSIS STUDY
5.23
1.00
78456
ACUTE VENOUS THROMBUS IMAGE
5.61
1.00
78456
ACUTE VENOUS THROMBUS IMAGE
5.69
1.00
78456
ACUTE VENOUS THROMBUS IMAGE
9.49
1.00
78457
VENOUS THROMBOSIS IMAGING
3.84
1.00
78457
VENOUS THROMBOSIS IMAGING
3.87
1.00
78457
VENOUS THROMBOSIS IMAGING
5.15
1.00
78458
VEN THROMBOSIS IMAGES, BILAT
5.43
1.00
78458
VEN THROMBOSIS IMAGES, BILAT
5.52
1.00
78458
VEN THROMBOSIS IMAGES, BILAT
5.70
1.00
78459
HEART MUSCLE IMAGING (PET)
2.13
1.00
78459
HEART MUSCLE IMAGING (PET)
7.61
1.00
78459
HEART MUSCLE IMAGING (PET)
8.99
1.00
78460
HEART MUSCLE BLOOD, SINGLE
3.65
1.00
78460
HEART MUSCLE BLOOD, SINGLE
3.70
1.00
78460
HEART MUSCLE BLOOD, SINGLE
5.16
1.00
78461
HEART MUSCLE BLOOD, MULTIPLE
5.84
1.00
78461
HEART MUSCLE BLOOD, MULTIPLE
6.64
1.00
78461
HEART MUSCLE BLOOD, MULTIPLE
6.71
1.00
78464
HEART IMAGE (3D), SINGLE
7.61
1.00
78464
HEART IMAGE (3D), SINGLE
8.87
1.00
78464
HEART IMAGE (3D), SINGLE
8.99
1.00
78465
HEART IMAGE (3D), MULTIPLE
13.45
1.00
78465
HEART IMAGE (3D), MULTIPLE
14.30
1.00
78465
HEART IMAGE (3D), MULTIPLE
14.49
1.00
78466
HEART INFARCT IMAGE
3.70
1.00
78466
HEART INFARCT IMAGE
3.74
1.00
78466
HEART INFARCT IMAGE
4.92
1.00
78468
HEART INFARCT IMAGE (EF)
4.92
1.00
78468
HEART INFARCT IMAGE (EF)
4.99
1.00
78468
HEART INFARCT IMAGE (EF)
6.21
1.00
Procedure Code Description
RVU
RVU Coeff Value
78469
HEART INFARCT IMAGE (3D)
6.69
1.00
78469
HEART INFARCT IMAGE (3D)
6.80
1.00
78469
HEART INFARCT IMAGE (3D)
7.08
1.00
78472
GATED HEART, PLANAR, SINGLE
7.10
1.00
78472
GATED HEART, PLANAR, SINGLE
7.21
1.00
78473
GATED HEART, MULTIPLE
9.86
1.00
78473
GATED HEART, MULTIPLE
10.62
1.00
78473
GATED HEART, MULTIPLE
10.75
1.00
78478
HEART WALL MOTION ADD-ON
1.65
1.00
78478
HEART WALL MOTION ADD-ON
2.50
1.00
78478
HEART WALL MOTION ADD-ON
2.53
1.00
78480
HEART FUNCTION ADD-ON
1.38
1.00
78480
HEART FUNCTION ADD-ON
2.50
1.00
78480
HEART FUNCTION ADD-ON
2.53
1.00
78481
HEART FIRST PASS, SINGLE
6.33
1.00
78481
HEART FIRST PASS, SINGLE
6.80
1.00
78481
HEART FIRST PASS, SINGLE
6.91
1.00
78483
HEART FIRST PASS, MULTIPLE
8.95
1.00
78483
HEART FIRST PASS, MULTIPLE
10.25
1.00
78483
HEART FIRST PASS, MULTIPLE
10.37
1.00
78491
HEART IMAGE (PET), SINGLE
2.15
1.00
78492
HEART IMAGE (PET), MULTIPLE
2.68
1.00
78494
HEART IMAGE, SPECT
7.86
1.00
78494
HEART IMAGE, SPECT
8.95
1.00
78494
HEART IMAGE, SPECT
9.05
1.00
78496
HEART FIRST PASS ADD-ON
3.29
1.00
78496
HEART FIRST PASS ADD-ON
8.00
1.00
78496
HEART FIRST PASS ADD-ON
8.10
1.00
78580
LUNG PERFUSION IMAGING
4.59
1.00
78580
LUNG PERFUSION IMAGING
4.65
1.00
78580
LUNG PERFUSION IMAGING
5.69
1.00
78584
LUNG V/Q IMAGE SINGLE BREATH
4.34
1.00
78584
LUNG V/Q IMAGE SINGLE BREATH
4.69
1.00
78584
LUNG V/Q IMAGE SINGLE BREATH
4.75
1.00
78585
LUNG V/Q IMAGING
7.38
1.00
Procedure Code Description
RVU
RVU Coeff Value
78585
LUNG V/Q IMAGING
7.47
1.00
78585
LUNG V/Q IMAGING
9.39
1.00
78586
AEROSOL LUNG IMAGE, SINGLE
3.26
1.00
78586
AEROSOL LUNG IMAGE, SINGLE
3.29
1.00
78586
AEROSOL LUNG IMAGE, SINGLE
4.34
1.00
78587
AEROSOL LUNG IMAGE, MULTIPLE
3.60
1.00
78587
AEROSOL LUNG IMAGE, MULTIPLE
3.63
1.00
78587
AEROSOL LUNG IMAGE, MULTIPLE
5.45
1.00
78588
PERFUSION LUNG IMAGE
4.85
1.00
78588
PERFUSION LUNG IMAGE
4.91
1.00
78588
PERFUSION LUNG IMAGE
8.68
1.00
78591
VENT IMAGE, 1 BREATH, 1 PROJ
3.52
1.00
78591
VENT IMAGE, 1 BREATH, 1 PROJ
3.56
1.00
78591
VENT IMAGE, 1 BREATH, 1 PROJ
4.40
1.00
78593
VENT IMAGE, 1 PROJ, GAS
4.26
1.00
78593
VENT IMAGE, 1 PROJ, GAS
4.32
1.00
78593
VENT IMAGE, 1 PROJ, GAS
5.19
1.00
78594
VENT IMAGE, MULT PROJ, GAS
5.91
1.00
78594
VENT IMAGE, MULT PROJ, GAS
5.97
1.00
78594
VENT IMAGE, MULT PROJ, GAS
6.08
1.00
78596
LUNG DIFFERENTIAL FUNCTION
9.11
1.00
78596
LUNG DIFFERENTIAL FUNCTION
9.22
1.00
78596
LUNG DIFFERENTIAL FUNCTION
10.10
1.00
78600
BRAIN IMAGE < 4 VIEWS
3.61
1.00
78600
BRAIN IMAGE < 4 VIEWS
3.64
1.00
78600
BRAIN IMAGE < 4 VIEWS
4.72
1.00
78601
BRAIN IMAGE W/FLOW < 4 VIEWS
4.25
1.00
78601
BRAIN IMAGE W/FLOW < 4 VIEWS
4.29
1.00
78601
BRAIN IMAGE W/FLOW < 4 VIEWS
5.62
1.00
78605
BRAIN IMAGE 4+ VIEWS
4.28
1.00
78605
BRAIN IMAGE 4+ VIEWS
4.33
1.00
78605
BRAIN IMAGE 4+ VIEWS
5.26
1.00
78606
BRAIN IMAGE W/FLOW 4 + VIEWS
4.91
1.00
78606
BRAIN IMAGE W/FLOW 4 + VIEWS
4.99
1.00
78606
BRAIN IMAGE W/FLOW 4 + VIEWS
8.22
1.00
Procedure Code Description
RVU
RVU Coeff Value
78607
BRAIN IMAGING (3D)
8.55
1.00
78607
BRAIN IMAGING (3D)
8.65
1.00
78607
BRAIN IMAGING (3D)
9.89
1.00
78610
BRAIN FLOW IMAGING ONLY
2.07
1.00
78610
BRAIN FLOW IMAGING ONLY
2.10
1.00
78610
BRAIN FLOW IMAGING ONLY
4.75
1.00
78615
CEREBRAL VASCULAR FLOW IMAGE
4.60
1.00
78615
CEREBRAL VASCULAR FLOW IMAGE
4.67
1.00
78615
CEREBRAL VASCULAR FLOW IMAGE
4.91
1.00
78630
CEREBROSPINAL FLUID SCAN
6.19
1.00
78630
CEREBROSPINAL FLUID SCAN
6.27
1.00
78630
CEREBROSPINAL FLUID SCAN
8.74
1.00
78635
CSF VENTRICULOGRAPHY
3.52
1.00
78635
CSF VENTRICULOGRAPHY
3.57
1.00
78635
CSF VENTRICULOGRAPHY
7.92
1.00
78645
CSF SHUNT EVALUATION
4.35
1.00
78645
CSF SHUNT EVALUATION
4.41
1.00
78645
CSF SHUNT EVALUATION
8.03
1.00
78647
CEREBROSPINAL FLUID SCAN
7.40
1.00
78647
CEREBROSPINAL FLUID SCAN
7.50
1.00
78647
CEREBROSPINAL FLUID SCAN
9.23
1.00
78650
CSF LEAKAGE IMAGING
5.67
1.00
78650
CSF LEAKAGE IMAGING
5.74
1.00
78650
CSF LEAKAGE IMAGING
8.52
1.00
78660
NUCLEAR EXAM OF TEAR FLOW
2.95
1.00
78660
NUCLEAR EXAM OF TEAR FLOW
2.97
1.00
78660
NUCLEAR EXAM OF TEAR FLOW
4.44
1.00
78700
KIDNEY IMAGING, MORPHOL
3.80
1.00
78700
KIDNEY IMAGING, MORPHOL
3.84
1.00
78700
KIDNEY IMAGING, MORPHOL
4.69
1.00
78701
KIDNEY IMAGING WITH FLOW
4.37
1.00
78701
KIDNEY IMAGING WITH FLOW
4.43
1.00
78701
KIDNEY IMAGING WITH FLOW
5.61
1.00
78704
IMAGING RENOGRAM
5.14
1.00
78704
IMAGING RENOGRAM
5.19
1.00
Procedure Code Description
RVU
RVU Coeff Value
78704
IMAGING RENOGRAM
5.21
1.00
78707
K FLOW/FUNCT IMAGE W/O DRUG
5.98
1.00
78707
K FLOW/FUNCT IMAGE W/O DRUG
6.05
1.00
78707
K FLOW/FUNCT IMAGE W/O DRUG
6.54
1.00
78708
K FLOW/FUNCT IMAGE W/DRUG
5.34
1.00
78708
K FLOW/FUNCT IMAGE W/DRUG
6.33
1.00
78708
K FLOW/FUNCT IMAGE W/DRUG
6.39
1.00
78709
K FLOW/FUNCT IMAGE, MULTIPLE
6.60
1.00
78709
K FLOW/FUNCT IMAGE, MULTIPLE
6.66
1.00
78709
K FLOW/FUNCT IMAGE, MULTIPLE
9.60
1.00
78710
KIDNEY IMAGING (3D)
6.48
1.00
78710
KIDNEY IMAGING (3D)
7.06
1.00
78710
KIDNEY IMAGING (3D)
7.16
1.00
78715
RENAL VASCULAR FLOW EXAM
2.07
1.00
78715
RENAL VASCULAR FLOW EXAM
2.10
1.00
78725
KIDNEY FUNCTION STUDY
2.38
1.00
78725
KIDNEY FUNCTION STUDY
2.42
1.00
78725
KIDNEY FUNCTION STUDY
2.73
1.00
78730
URINARY BLADDER RETENTION
2.03
1.00
78730
URINARY BLADDER RETENTION
2.05
1.00
78730
URINARY BLADDER RETENTION
2.10
1.00
78740
URETERAL REFLUX STUDY
2.99
1.00
78740
URETERAL REFLUX STUDY
3.02
1.00
78740
URETERAL REFLUX STUDY
5.56
1.00
78760
TESTICULAR IMAGING
3.71
1.00
78760
TESTICULAR IMAGING
3.74
1.00
78761
TESTICULAR IMAGING W/FLOW
4.31
1.00
78761
TESTICULAR IMAGING W/FLOW
4.37
1.00
78761
TESTICULAR IMAGING W/FLOW
5.59
1.00
78800
TUMOR IMAGING, LIMITED AREA
4.46
1.00
78800
TUMOR IMAGING, LIMITED AREA
4.51
1.00
78800
TUMOR IMAGING, LIMITED AREA
5.01
1.00
78801
TUMOR IMAGING, MULT AREAS
5.49
1.00
78801
TUMOR IMAGING, MULT AREAS
5.56
1.00
78801
TUMOR IMAGING, MULT AREAS
6.70
1.00
Procedure Code Description
RVU
RVU Coeff Value
78802
TUMOR IMAGING, WHOLE BODY
6.95
1.00
78802
TUMOR IMAGING, WHOLE BODY
7.05
1.00
78802
TUMOR IMAGING, WHOLE BODY
8.77
1.00
78803
TUMOR IMAGING (3D)
8.35
1.00
78803
TUMOR IMAGING (3D)
8.45
1.00
78803
TUMOR IMAGING (3D)
9.67
1.00
78804
TUMOR IMAGING, WHOLE BODY
6.07
1.00
78804
TUMOR IMAGING, WHOLE BODY
15.38
1.00
78805
ABSCESS IMAGING, LTD AREA
4.56
1.00
78805
ABSCESS IMAGING, LTD AREA
4.61
1.00
78805
ABSCESS IMAGING, LTD AREA
5.02
1.00
78806
ABSCESS IMAGING, WHOLE BODY
7.89
1.00
78806
ABSCESS IMAGING, WHOLE BODY
8.00
1.00
78806
ABSCESS IMAGING, WHOLE BODY
9.19
1.00
78807
NUCLEAR LOCALIZATION/ABSCESS
8.36
1.00
78807
NUCLEAR LOCALIZATION/ABSCESS
8.46
1.00
78807
NUCLEAR LOCALIZATION/ABSCESS
9.68
1.00
78808
IV INJ RA DRUG DX STUDY
1.23
1.00
78810
TUMOR IMAGING (PET)
2.77
1.00
79000
INIT HYPERTHYROID THERAPY
5.23
1.00
79000
INIT HYPERTHYROID THERAPY
5.24
1.00
79001
REPEAT HYPERTHYROID THERAPY
2.82
1.00
79001
REPEAT HYPERTHYROID THERAPY
2.84
1.00
79005
NUCLEAR RX, ORAL ADMIN
4.26
1.00
79005
NUCLEAR RX, ORAL ADMIN
5.24
1.00
79020
THYROID ABLATION
5.23
1.00
79020
THYROID ABLATION
5.25
1.00
79030
THYROID ABLATION, CARCINOMA
5.65
1.00
79030
THYROID ABLATION, CARCINOMA
5.67
1.00
79035
THYROID METASTATIC THERAPY
6.25
1.00
79035
THYROID METASTATIC THERAPY
6.27
1.00
79100
HEMATOPOETIC NUCLEAR THERAPY
4.58
1.00
79100
HEMATOPOETIC NUCLEAR THERAPY
4.60
1.00
79101
NUCLEAR RX, IV ADMIN
4.79
1.00
79200
NUCLEAR RX, INTRACAV ADMIN
4.86
1.00
Procedure Code Description
RVU
RVU Coeff Value
79200
NUCLEAR RX, INTRACAV ADMIN
5.51
1.00
79200
NUCLEAR RX, INTRACAV ADMIN
5.52
1.00
79300
NUCLR RX, INTERSTIT COLLOID
2.24
1.00
79300
NUCLR RX, INTERSTIT COLLOID
2.26
1.00
79300
NUCLR RX, INTERSTIT COLLOID
2.29
1.00
79300
NUCLR RX, INTERSTIT COLLOID
2.31
1.00
79400
NONHEMATO NUCLEAR THERAPY
5.47
1.00
79400
NONHEMATO NUCLEAR THERAPY
5.49
1.00
79403
HEMATOPOIETIC NUCLEAR TX
6.07
1.00
79403
HEMATOPOIETIC NUCLEAR TX
7.65
1.00
79403
HEMATOPOIETIC NUCLEAR TX
7.68
1.00
79420
INTRAVASCULAR NUCLEAR THER
2.07
1.00
79420
INTRAVASCULAR NUCLEAR THER
2.09
1.00
79440
NUCLEAR RX, INTRA-ARTICULAR
4.49
1.00
79440
NUCLEAR RX, INTRA-ARTICULAR
5.55
1.00
79440
NUCLEAR RX, INTRA-ARTICULAR
5.57
1.00
80048
METABOLIC PANEL TOTAL CA
1.00
1.00
80051
ELECTROLYTE PANEL
1.00
1.00
80053
COMPREHEN METABOLIC PANEL
1.00
1.00
80061
LIPID PANEL
1.00
1.00
80069
RENAL FUNCTION PANEL
1.00
1.00
80076
HEPATIC FUNCTION PANEL
1.00
1.00
90801
PSY DX INTERVIEW
3.62
1.00
90801
PSY DX INTERVIEW
3.81
1.00
90801
PSY DX INTERVIEW
3.82
1.00
90802
INTAC PSY DX INTERVIEW
3.91
1.00
90802
INTAC PSY DX INTERVIEW
4.07
1.00
90802
INTAC PSY DX INTERVIEW
4.09
1.00
90804
PSYTX, OFFICE, 20-30 MIN
1.54
1.00
90804
PSYTX, OFFICE, 20-30 MIN
1.63
1.00
90805
PSYTX, OFF, 20-30 MIN W/E&M
1.73
1.00
90805
PSYTX, OFF, 20-30 MIN W/E&M
1.83
1.00
90805
PSYTX, OFF, 20-30 MIN W/E&M
1.84
1.00
90806
PSYTX, OFF, 45-50 MIN
2.36
1.00
90806
PSYTX, OFF, 45-50 MIN
2.51
1.00
Procedure Code Description
RVU
RVU Coeff Value
90807
PSYTX, OFF, 45-50 MIN W/E&M
2.56
1.00
90807
PSYTX, OFF, 45-50 MIN W/E&M
2.71
1.00
90808
PSYTX, OFFICE, 75-80 MIN
3.55
1.00
90808
PSYTX, OFFICE, 75-80 MIN
3.78
1.00
90809
PSYTX, OFF, 75-80, W/E&M
3.66
1.00
90809
PSYTX, OFF, 75-80, W/E&M
3.95
1.00
90810
INTAC PSYTX, OFF, 20-30 MIN
1.64
1.00
90810
INTAC PSYTX, OFF, 20-30 MIN
1.78
1.00
90811
INTAC PSYTX, 20-30, W/E&M
1.84
1.00
90811
INTAC PSYTX, 20-30, W/E&M
1.98
1.00
90811
INTAC PSYTX, 20-30, W/E&M
1.99
1.00
90812
INTAC PSYTX, OFF, 45-50 MIN
2.44
1.00
90812
INTAC PSYTX, OFF, 45-50 MIN
2.67
1.00
90813
INTAC PSYTX, 45-50 MIN W/E&M
2.64
1.00
90813
INTAC PSYTX, 45-50 MIN W/E&M
2.86
1.00
90814
INTAC PSYTX, OFF, 75-80 MIN
3.66
1.00
90814
INTAC PSYTX, OFF, 75-80 MIN
3.97
1.00
90815
INTAC PSYTX, 75-80 W/E&M
3.79
1.00
90815
INTAC PSYTX, 75-80 W/E&M
4.09
1.00
90816
PSYTX, HOSP, 20-30 MIN
1.64
1.00
90816
PSYTX, HOSP, 20-30 MIN
1.75
1.00
90816
PSYTX, HOSP, 20-30 MIN
1.76
1.00
90817
PSYTX, HOSP, 20-30 MIN W/E&M
1.82
1.00
90817
PSYTX, HOSP, 20-30 MIN W/E&M
1.90
1.00
90817
PSYTX, HOSP, 20-30 MIN W/E&M
1.91
1.00
90818
PSYTX, HOSP, 45-50 MIN
2.44
1.00
90819
PSYTX, HOSP, 45-50 MIN W/E&M
2.62
1.00
90821
PSYTX, HOSP, 75-80 MIN
3.60
1.00
90822
PSYTX, HOSP, 75-80 MIN W/E&M
3.79
1.00
90823
INTAC PSYTX, HOSP, 20-30 MIN
1.77
1.00
90823
INTAC PSYTX, HOSP, 20-30 MIN
1.88
1.00
90824
INTAC PSYTX, HSP 20-30 W/E&M
1.97
1.00
90824
INTAC PSYTX, HSP 20-30 W/E&M
2.05
1.00
90824
INTAC PSYTX, HSP 20-30 W/E&M
2.06
1.00
90826
INTAC PSYTX, HOSP, 45-50 MIN
2.59
1.00
Procedure Code Description
RVU
RVU Coeff Value
90827
INTAC PSYTX, HSP 45-50 W/E&M
2.75
1.00
90828
INTAC PSYTX, HOSP, 75-80 MIN
3.74
1.00
90829
INTAC PSYTX, HSP 75-80 W/E&M
3.91
1.00
90845
PSYCHOANALYSIS
2.26
1.00
90845
PSYCHOANALYSIS
2.39
1.00
90845
PSYCHOANALYSIS
2.40
1.00
90846
FAMILY PSYTX W/O PATIENT
2.41
1.00
90846
FAMILY PSYTX W/O PATIENT
2.53
1.00
90847
FAMILY PSYTX W/PATIENT
2.89
1.00
90847
FAMILY PSYTX W/PATIENT
3.03
1.00
90849
MULTIPLE FAMILY GROUP PSYTX
0.83
1.00
90849
MULTIPLE FAMILY GROUP PSYTX
0.84
1.00
90853
GROUP PSYCHOTHERAPY
0.81
1.00
90853
GROUP PSYCHOTHERAPY
0.83
1.00
90857
INTAC GROUP PSYTX
0.87
1.00
90857
INTAC GROUP PSYTX
0.91
1.00
90862
MEDICATION MANAGEMENT
1.26
1.00
90862
MEDICATION MANAGEMENT
1.29
1.00
90862
MEDICATION MANAGEMENT
1.30
1.00
90870
ELECTROCONVULSIVE THERAPY
2.36
1.00
90870
ELECTROCONVULSIVE THERAPY
2.72
1.00
90870
ELECTROCONVULSIVE THERAPY
2.73
1.00
90870
ELECTROCONVULSIVE THERAPY
3.00
1.00
90871
ELECTROCONVULSIVE THERAPY
3.00
1.00
90871
ELECTROCONVULSIVE THERAPY
3.86
1.00
90875
PSYCHOPHYSIOLOGICAL THERAPY
1.70
1.00
90885
PSY EVALUATION OF RECORDS
1.29
1.00
90885
PSY EVALUATION OF RECORDS
1.36
1.00
90911
BIOFEEDBACK PERI/URO/RECTAL
1.25
1.00
90911
BIOFEEDBACK PERI/URO/RECTAL
1.27
1.00
90911
BIOFEEDBACK PERI/URO/RECTAL
1.29
1.00
90918
ESRD RELATED SERVICES, MONTH
16.45
1.00
90918
ESRD RELATED SERVICES, MONTH
18.86
1.00
90918
ESRD RELATED SERVICES, MONTH
19.04
1.00
90919
ESRD RELATED SERVICES, MONTH
12.10
1.00
Procedure Code Description
RVU
RVU Coeff Value
90919
ESRD RELATED SERVICES, MONTH
12.89
1.00
90919
ESRD RELATED SERVICES, MONTH
12.96
1.00
90920
ESRD RELATED SERVICES, MONTH
10.50
1.00
90920
ESRD RELATED SERVICES, MONTH
11.30
1.00
90920
ESRD RELATED SERVICES, MONTH
11.38
1.00
90921
ESRD RELATED SERVICES, MONTH
6.63
1.00
90921
ESRD RELATED SERVICES, MONTH
7.08
1.00
90921
ESRD RELATED SERVICES, MONTH
7.13
1.00
90922
ESRD RELATED SERVICES, DAY
0.55
1.00
90922
ESRD RELATED SERVICES, DAY
0.60
1.00
90923
ESRD RELATED SERVICES, DAY
0.40
1.00
90923
ESRD RELATED SERVICES, DAY
0.42
1.00
90924
ESRD RELATED SERVICES, DAY
0.35
1.00
90924
ESRD RELATED SERVICES, DAY
0.37
1.00
90925
ESRD RELATED SERVICES, DAY
0.23
1.00
90925
ESRD RELATED SERVICES, DAY
0.24
1.00
90935
HEMODIALYSIS, ONE EVALUATION
1.86
1.00
90935
HEMODIALYSIS, ONE EVALUATION
1.93
1.00
90935
HEMODIALYSIS, ONE EVALUATION
1.94
1.00
90937
HEMODIALYSIS, REPEATED EVAL
3.02
1.00
90937
HEMODIALYSIS, REPEATED EVAL
3.16
1.00
90937
HEMODIALYSIS, REPEATED EVAL
3.17
1.00
90945
DIALYSIS, ONE EVALUATION
1.91
1.00
90945
DIALYSIS, ONE EVALUATION
2.03
1.00
90945
DIALYSIS, ONE EVALUATION
2.04
1.00
90947
DIALYSIS, REPEATED EVAL
3.09
1.00
90947
DIALYSIS, REPEATED EVAL
3.24
1.00
90951
ESRD SERV, 4 VISITS P MO, <2
26.67
1.00
90954
ESRD SERV, 4 VSTS P MO, 2-11
21.85
1.00
90955
ESRD SRV 2-3 VSTS P MO, 2-11
12.39
1.00
90956
ESRD SRV, 1 VISIT P MO, 2-11
8.39
1.00
90957
ESRD SRV, 4 VSTS P MO, 12-19
17.55
1.00
90958
ESRD SRV 2-3 VSTS P MO 12-19
11.85
1.00
90959
ESRD SERV, 1 VST P MO, 12-19
7.77
1.00
90960
ESRD SRV, 4 VISITS P MO, 20+
7.81
1.00
Procedure Code Description
RVU
RVU Coeff Value
90961
ESRD SRV, 2-3 VSTS P MO, 20+
6.30
1.00
90962
ESRD SERV, 1 VISIT P MO, 20+
4.55
1.00
90963
ESRD HOME PT, SERV P MO, <2
15.06
1.00
90964
ESRD HOME PT SERV P MO, 2-11
12.55
1.00
90965
ESRD HOME PT SERV P MO 12-19
11.93
1.00
90966
ESRD HOME PT, SERV P MO, 20+
6.23
1.00
90967
ESRD HOME PT SERV P DAY, <2
0.54
1.00
90968
ESRD HOME PT SRV P DAY, 2-11
0.42
1.00
90969
ESRD HOME PT SRV P DAY 12-19
0.41
1.00
90970
ESRD HOME PT SERV P DAY, 20+
0.22
1.00
90997
HEMOPERFUSION
2.46
1.00
90997
HEMOPERFUSION
3.31
1.00
90997
HEMOPERFUSION
3.32
1.00
91000
ESOPHAGEAL INTUBATION
1.10
1.00
91000
ESOPHAGEAL INTUBATION
1.11
1.00
91000
ESOPHAGEAL INTUBATION
2.42
1.00
91010
ESOPHAGUS MOTILITY STUDY
4.08
1.00
91010
ESOPHAGUS MOTILITY STUDY
4.10
1.00
91010
ESOPHAGUS MOTILITY STUDY
5.13
1.00
91011
ESOPHAGUS MOTILITY STUDY
4.78
1.00
91011
ESOPHAGUS MOTILITY STUDY
4.82
1.00
91011
ESOPHAGUS MOTILITY STUDY
6.86
1.00
91012
ESOPHAGUS MOTILITY STUDY
4.89
1.00
91012
ESOPHAGUS MOTILITY STUDY
4.94
1.00
91012
ESOPHAGUS MOTILITY STUDY
6.97
1.00
91020
GASTRIC MOTILITY STUDIES
4.50
1.00
91020
GASTRIC MOTILITY STUDIES
4.60
1.00
91020
GASTRIC MOTILITY STUDIES
6.23
1.00
91022
DUODENAL MOTILITY STUDY
5.13
1.00
91030
ACID PERFUSION OF ESOPHAGUS
3.37
1.00
91030
ACID PERFUSION OF ESOPHAGUS
3.53
1.00
91030
ACID PERFUSION OF ESOPHAGUS
3.73
1.00
91032
ESOPHAGUS, ACID REFLUX TEST
3.74
1.00
91032
ESOPHAGUS, ACID REFLUX TEST
5.43
1.00
91033
PROLONGED ACID REFLUX TEST
4.08
1.00
Procedure Code Description
RVU
RVU Coeff Value
91033
PROLONGED ACID REFLUX TEST
5.63
1.00
91034
GASTROESOPHAGEAL REFLUX TEST
5.38
1.00
91034
GASTROESOPHAGEAL REFLUX TEST
6.33
1.00
91034
GASTROESOPHAGEAL REFLUX TEST
6.34
1.00
91035
G-ESOPH REFLX TST W/ELECTROD
12.51
1.00
91035
G-ESOPH REFLX TST W/ELECTROD
12.54
1.00
91035
G-ESOPH REFLX TST W/ELECTROD
12.63
1.00
91037
ESOPH IMPED FUNCTION TEST
4.02
1.00
91037
ESOPH IMPED FUNCTION TEST
4.03
1.00
91037
ESOPH IMPED FUNCTION TEST
4.32
1.00
91038
ESOPH IMPED FUNCT TEST > 1H
3.44
1.00
91038
ESOPH IMPED FUNCT TEST > 1H
3.45
1.00
91038
ESOPH IMPED FUNCT TEST > 1H
3.81
1.00
91040
ESOPH BALLOON DISTENSION TST
10.23
1.00
91040
ESOPH BALLOON DISTENSION TST
12.22
1.00
91040
ESOPH BALLOON DISTENSION TST
12.25
1.00
91052
GASTRIC ANALYSIS TEST
3.04
1.00
91052
GASTRIC ANALYSIS TEST
3.22
1.00
91052
GASTRIC ANALYSIS TEST
3.32
1.00
91055
GASTRIC INTUBATION FOR SMEAR
3.17
1.00
91055
GASTRIC INTUBATION FOR SMEAR
3.38
1.00
91055
GASTRIC INTUBATION FOR SMEAR
3.59
1.00
91060
GASTRIC SALINE LOAD TEST
0.79
1.00
91060
GASTRIC SALINE LOAD TEST
2.47
1.00
91065
BREATH HYDROGEN TEST
1.77
1.00
91065
BREATH HYDROGEN TEST
2.19
1.00
91065
BREATH HYDROGEN TEST
4.11
1.00
91100
PASS INTESTINE BLEEDING TUBE
1.43
1.00
91100
PASS INTESTINE BLEEDING TUBE
1.44
1.00
91100
PASS INTESTINE BLEEDING TUBE
1.45
1.00
91105
GASTRIC INTUBATION TREATMENT
0.47
1.00
91105
GASTRIC INTUBATION TREATMENT
0.48
1.00
91105
GASTRIC INTUBATION TREATMENT
0.49
1.00
91110
GI TRACT CAPSULE ENDOSCOPY
24.30
1.00
91110
GI TRACT CAPSULE ENDOSCOPY
24.86
1.00
Procedure Code Description
RVU
RVU Coeff Value
91111
ESOPHAGEAL CAPSULE ENDOSCOPY
18.97
1.00
91120
RECTAL SENSATION TEST
10.48
1.00
91122
ANAL PRESSURE RECORD
6.29
1.00
91122
ANAL PRESSURE RECORD
6.49
1.00
91122
ANAL PRESSURE RECORD
8.03
1.00
91132
ELECTROGASTROGRAPHY
0.72
1.00
91132
ELECTROGASTROGRAPHY
0.73
1.00
91132
ELECTROGASTROGRAPHY
0.74
1.00
91132
ELECTROGASTROGRAPHY
0.75
1.00
91132
ELECTROGASTROGRAPHY
0.78
1.00
91133
ELECTROGASTROGRAPHY W/TEST
0.92
1.00
91133
ELECTROGASTROGRAPHY W/TEST
0.93
1.00
91133
ELECTROGASTROGRAPHY W/TEST
0.94
1.00
91133
ELECTROGASTROGRAPHY W/TEST
1.00
1.00
92502
EAR AND THROAT EXAMINATION
2.53
1.00
92502
EAR AND THROAT EXAMINATION
2.71
1.00
92502
EAR AND THROAT EXAMINATION
2.81
1.00
92502
EAR AND THROAT EXAMINATION
3.00
1.00
92504
EAR MICROSCOPY EXAMINATION
0.26
1.00
92504
EAR MICROSCOPY EXAMINATION
0.28
1.00
92506
SPEECH/HEARING EVALUATION
1.21
1.00
92506
SPEECH/HEARING EVALUATION
1.31
1.00
92507
SPEECH/HEARING THERAPY
0.72
1.00
92507
SPEECH/HEARING THERAPY
0.78
1.00
92508
SPEECH/HEARING THERAPY
0.37
1.00
92508
SPEECH/HEARING THERAPY
0.39
1.00
92511
NASOPHARYNGOSCOPY
1.29
1.00
92511
NASOPHARYNGOSCOPY
1.57
1.00
92511
NASOPHARYNGOSCOPY
1.67
1.00
92512
NASAL FUNCTION STUDIES
0.75
1.00
92512
NASAL FUNCTION STUDIES
0.76
1.00
92516
FACIAL NERVE FUNCTION TEST
0.61
1.00
92516
FACIAL NERVE FUNCTION TEST
0.67
1.00
92520
LARYNGEAL FUNCTION STUDIES
1.07
1.00
92520
LARYNGEAL FUNCTION STUDIES
1.18
1.00
Procedure Code Description
RVU
RVU Coeff Value
92520
LARYNGEAL FUNCTION STUDIES
1.19
1.00
92526
ORAL FUNCTION THERAPY
0.75
1.00
92526
ORAL FUNCTION THERAPY
0.77
1.00
92526
ORAL FUNCTION THERAPY
0.78
1.00
92541
SPONTANEOUS NYSTAGMUS TEST
1.41
1.00
92541
SPONTANEOUS NYSTAGMUS TEST
1.55
1.00
92541
SPONTANEOUS NYSTAGMUS TEST
1.58
1.00
92542
POSITIONAL NYSTAGMUS TEST
1.42
1.00
92542
POSITIONAL NYSTAGMUS TEST
1.56
1.00
92542
POSITIONAL NYSTAGMUS TEST
1.64
1.00
92543
CALORIC VESTIBULAR TEST
0.65
1.00
92543
CALORIC VESTIBULAR TEST
0.75
1.00
92543
CALORIC VESTIBULAR TEST
0.76
1.00
92544
OPTOKINETIC NYSTAGMUS TEST
1.13
1.00
92544
OPTOKINETIC NYSTAGMUS TEST
1.26
1.00
92544
OPTOKINETIC NYSTAGMUS TEST
1.32
1.00
92545
OSCILLATING TRACKING TEST
1.05
1.00
92545
OSCILLATING TRACKING TEST
1.16
1.00
92545
OSCILLATING TRACKING TEST
1.24
1.00
92546
SINUSOIDAL ROTATIONAL TEST
2.12
1.00
92546
SINUSOIDAL ROTATIONAL TEST
2.22
1.00
92546
SINUSOIDAL ROTATIONAL TEST
2.57
1.00
92547
SUPPLEMENTAL ELECTRICAL TEST
0.16
1.00
92547
SUPPLEMENTAL ELECTRICAL TEST
1.21
1.00
92547
SUPPLEMENTAL ELECTRICAL TEST
1.39
1.00
92548
POSTUROGRAPHY
2.55
1.00
92548
POSTUROGRAPHY
3.84
1.00
92548
POSTUROGRAPHY
4.61
1.00
92551
PURE TONE HEARING TEST, AIR
0.29
1.00
92551
PURE TONE HEARING TEST, AIR
0.48
1.00
92552
PURE TONE AUDIOMETRY, AIR
0.48
1.00
92552
PURE TONE AUDIOMETRY, AIR
0.59
1.00
92553
AUDIOMETRY, AIR & BONE
0.71
1.00
92553
AUDIOMETRY, AIR & BONE
0.72
1.00
92553
AUDIOMETRY, AIR & BONE
0.79
1.00
Procedure Code Description
RVU
RVU Coeff Value
92555
SPEECH THRESHOLD AUDIOMETRY
0.41
1.00
92555
SPEECH THRESHOLD AUDIOMETRY
0.44
1.00
92556
SPEECH AUDIOMETRY, COMPLETE
0.62
1.00
92556
SPEECH AUDIOMETRY, COMPLETE
0.63
1.00
92556
SPEECH AUDIOMETRY, COMPLETE
0.68
1.00
92557
COMPREHENSIVE HEARING TEST
1.18
1.00
92557
COMPREHENSIVE HEARING TEST
1.28
1.00
92557
COMPREHENSIVE HEARING TEST
1.31
1.00
92561
BEKESY AUDIOMETRY, DIAGNOSIS
0.77
1.00
92561
BEKESY AUDIOMETRY, DIAGNOSIS
0.78
1.00
92562
LOUDNESS BALANCE TEST
0.44
1.00
92562
LOUDNESS BALANCE TEST
0.62
1.00
92563
TONE DECAY HEARING TEST
0.41
1.00
92563
TONE DECAY HEARING TEST
0.56
1.00
92564
SISI HEARING TEST
0.51
1.00
92564
SISI HEARING TEST
0.52
1.00
92564
SISI HEARING TEST
0.54
1.00
92565
STENGER TEST, PURE TONE
0.35
1.00
92565
STENGER TEST, PURE TONE
0.43
1.00
92567
TYMPANOMETRY
0.44
1.00
92567
TYMPANOMETRY
0.57
1.00
92567
TYMPANOMETRY
0.58
1.00
92568
ACOUSTIC REFL THRESHOLD TST
0.41
1.00
92568
ACOUSTIC REFL THRESHOLD TST
0.50
1.00
92569
ACOUSTIC REFLEX DECAY TEST
0.40
1.00
92569
ACOUSTIC REFLEX DECAY TEST
0.44
1.00
92571
FILTERED SPEECH HEARING TEST
0.42
1.00
92571
FILTERED SPEECH HEARING TEST
0.45
1.00
92572
STAGGERED SPONDAIC WORD TEST
0.10
1.00
92572
STAGGERED SPONDAIC WORD TEST
0.47
1.00
92573
LOMBARD TEST
0.38
1.00
92573
LOMBARD TEST
0.39
1.00
92575
SENSORINEURAL ACUITY TEST
0.32
1.00
92575
SENSORINEURAL ACUITY TEST
0.95
1.00
92576
SYNTHETIC SENTENCE TEST
0.49
1.00
Procedure Code Description
RVU
RVU Coeff Value
92576
SYNTHETIC SENTENCE TEST
0.58
1.00
92577
STENGER TEST, SPEECH
0.48
1.00
92577
STENGER TEST, SPEECH
0.78
1.00
92577
STENGER TEST, SPEECH
0.79
1.00
92579
VISUAL AUDIOMETRY (VRA)
0.78
1.00
92579
VISUAL AUDIOMETRY (VRA)
0.79
1.00
92579
VISUAL AUDIOMETRY (VRA)
1.13
1.00
92582
CONDITIONING PLAY AUDIOMETRY
0.78
1.00
92582
CONDITIONING PLAY AUDIOMETRY
0.79
1.00
92582
CONDITIONING PLAY AUDIOMETRY
1.12
1.00
92583
SELECT PICTURE AUDIOMETRY
0.91
1.00
92583
SELECT PICTURE AUDIOMETRY
0.96
1.00
92583
SELECT PICTURE AUDIOMETRY
0.97
1.00
92584
ELECTROCOCHLEOGRAPHY
1.86
1.00
92584
ELECTROCOCHLEOGRAPHY
2.64
1.00
92584
ELECTROCOCHLEOGRAPHY
2.70
1.00
92585
AUDITOR EVOKE POTENT, COMPRE
2.70
1.00
92585
AUDITOR EVOKE POTENT, COMPRE
2.74
1.00
92585
AUDITOR EVOKE POTENT, COMPRE
2.76
1.00
92585
AUDITOR EVOKE POTENT, COMPRE
4.00
1.00
92586
AUDITOR EVOKE POTENT, LIMIT
1.71
1.00
92586
AUDITOR EVOKE POTENT, LIMIT
1.96
1.00
92586
AUDITOR EVOKE POTENT, LIMIT
2.00
1.00
92587
EVOKED AUDITORY TEST
1.07
1.00
92587
EVOKED AUDITORY TEST
1.60
1.00
92587
EVOKED AUDITORY TEST
1.63
1.00
92588
EVOKED AUDITORY TEST
1.74
1.00
92588
EVOKED AUDITORY TEST
2.11
1.00
92588
EVOKED AUDITORY TEST
2.14
1.00
92589
AUDITORY FUNCTION TEST(S)
0.58
1.00
92589
AUDITORY FUNCTION TEST(S)
0.59
1.00
92950
HEART/LUNG RESUSCITATION CPR
4.91
1.00
92950
HEART/LUNG RESUSCITATION CPR
5.02
1.00
92950
HEART/LUNG RESUSCITATION CPR
10.00
1.00
92960
CARDIOVERSION ELECTRIC, EXT
3.19
1.00
Procedure Code Description
RVU
RVU Coeff Value
92960
CARDIOVERSION ELECTRIC, EXT
3.52
1.00
92960
CARDIOVERSION ELECTRIC, EXT
3.70
1.00
92960
CARDIOVERSION ELECTRIC, EXT
4.00
1.00
92970
CARDIOASSIST, INTERNAL
4.77
1.00
92970
CARDIOASSIST, INTERNAL
4.79
1.00
92970
CARDIOASSIST, INTERNAL
5.04
1.00
92971
CARDIOASSIST, EXTERNAL
2.69
1.00
92971
CARDIOASSIST, EXTERNAL
2.71
1.00
92971
CARDIOASSIST, EXTERNAL
2.87
1.00
92973
PERCUT CORONARY THROMBECTOMY
4.71
1.00
92973
PERCUT CORONARY THROMBECTOMY
4.72
1.00
92973
PERCUT CORONARY THROMBECTOMY
5.16
1.00
92974
CATH PLACE, CARDIO BRACHYTX
4.34
1.00
92974
CATH PLACE, CARDIO BRACHYTX
4.35
1.00
92974
CATH PLACE, CARDIO BRACHYTX
4.73
1.00
92975
DISSOLVE CLOT, HEART VESSEL
10.32
1.00
92975
DISSOLVE CLOT, HEART VESSEL
10.35
1.00
92975
DISSOLVE CLOT, HEART VESSEL
11.33
1.00
92977
DISSOLVE CLOT, HEART VESSEL
3.72
1.00
92977
DISSOLVE CLOT, HEART VESSEL
8.40
1.00
92977
DISSOLVE CLOT, HEART VESSEL
8.54
1.00
92978
INTRAVASC US, HEART ADD-ON
7.34
1.00
92978
INTRAVASC US, HEART ADD-ON
7.40
1.00
92979
INTRAVASC US, HEART ADD-ON
4.45
1.00
92979
INTRAVASC US, HEART ADD-ON
4.48
1.00
92980
INSERT INTRACORONARY STENT
21.75
1.00
92980
INSERT INTRACORONARY STENT
21.76
1.00
92980
INSERT INTRACORONARY STENT
23.51
1.00
92981
INSERT INTRACORONARY STENT
6.04
1.00
92981
INSERT INTRACORONARY STENT
6.05
1.00
92981
INSERT INTRACORONARY STENT
6.54
1.00
92982
CORONARY ARTERY DILATION
7.00
1.00
92982
CORONARY ARTERY DILATION
16.14
1.00
92982
CORONARY ARTERY DILATION
16.16
1.00
92982
CORONARY ARTERY DILATION
17.43
1.00
Procedure Code Description
RVU
RVU Coeff Value
92984
CORONARY ARTERY DILATION
4.30
1.00
92984
CORONARY ARTERY DILATION
4.67
1.00
92986
REVISION OF AORTIC VALVE
33.21
1.00
92986
REVISION OF AORTIC VALVE
34.76
1.00
92986
REVISION OF AORTIC VALVE
38.57
1.00
92987
REVISION OF MITRAL VALVE
34.54
1.00
92987
REVISION OF MITRAL VALVE
36.10
1.00
92987
REVISION OF MITRAL VALVE
39.93
1.00
92990
REVISION OF PULMONARY VALVE
26.48
1.00
92990
REVISION OF PULMONARY VALVE
28.03
1.00
92990
REVISION OF PULMONARY VALVE
30.72
1.00
92995
CORONARY ATHERECTOMY
17.75
1.00
92995
CORONARY ATHERECTOMY
17.77
1.00
92995
CORONARY ATHERECTOMY
19.21
1.00
92996
CORONARY ATHERECTOMY ADD-ON
4.72
1.00
92996
CORONARY ATHERECTOMY ADD-ON
4.73
1.00
92996
CORONARY ATHERECTOMY ADD-ON
5.00
1.00
92997
PUL ART BALLOON REPR, PERCUT
7.00
1.00
92997
PUL ART BALLOON REPR, PERCUT
17.59
1.00
92997
PUL ART BALLOON REPR, PERCUT
17.63
1.00
92998
PUL ART BALLOON REPR, PERCUT
8.57
1.00
92998
PUL ART BALLOON REPR, PERCUT
9.06
1.00
93000
ELECTROCARDIOGRAM, COMPLETE
0.58
1.00
93000
ELECTROCARDIOGRAM, COMPLETE
0.71
1.00
93005
ELECTROCARDIOGRAM, TRACING
0.33
1.00
93005
ELECTROCARDIOGRAM, TRACING
0.47
1.00
93010
ELECTROCARDIOGRAM REPORT
0.24
1.00
93010
ELECTROCARDIOGRAM REPORT
0.25
1.00
93015
CARDIOVASCULAR STRESS TEST
2.78
1.00
93015
CARDIOVASCULAR STRESS TEST
2.83
1.00
93015
CARDIOVASCULAR STRESS TEST
2.86
1.00
93017
CARDIOVASCULAR STRESS TEST
1.65
1.00
93017
CARDIOVASCULAR STRESS TEST
1.76
1.00
93017
CARDIOVASCULAR STRESS TEST
1.80
1.00
93018
CARDIOVASCULAR STRESS TEST
0.43
1.00
Procedure Code Description
RVU
RVU Coeff Value
93018
CARDIOVASCULAR STRESS TEST
0.45
1.00
93024
CARDIAC DRUG STRESS TEST
2.85
1.00
93024
CARDIAC DRUG STRESS TEST
2.87
1.00
93024
CARDIAC DRUG STRESS TEST
3.38
1.00
93025
MICROVOLT T-WAVE ASSESS
5.91
1.00
93025
MICROVOLT T-WAVE ASSESS
9.06
1.00
93025
MICROVOLT T-WAVE ASSESS
11.59
1.00
93040
RHYTHM ECG WITH REPORT
0.37
1.00
93040
RHYTHM ECG WITH REPORT
0.38
1.00
93041
RHYTHM ECG, TRACING
0.15
1.00
93041
RHYTHM ECG, TRACING
0.16
1.00
93042
RHYTHM ECG, REPORT
0.22
1.00
93224
ECG MONITOR/REPORT, 24 HRS
3.31
1.00
93224
ECG MONITOR/REPORT, 24 HRS
4.34
1.00
93224
ECG MONITOR/REPORT, 24 HRS
4.39
1.00
93225
ECG MONITOR/RECORD, 24 HRS
0.99
1.00
93225
ECG MONITOR/RECORD, 24 HRS
1.30
1.00
93225
ECG MONITOR/RECORD, 24 HRS
1.32
1.00
93226
ECG MONITOR/REPORT, 24 HRS
1.53
1.00
93226
ECG MONITOR/REPORT, 24 HRS
2.30
1.00
93226
ECG MONITOR/REPORT, 24 HRS
2.33
1.00
93227
ECG MONITOR/REVIEW, 24 HRS
0.74
1.00
93227
ECG MONITOR/REVIEW, 24 HRS
0.79
1.00
93228
REMOTE 30 DAY ECG REV/REPORT
0.71
1.00
93230
ECG MONITOR/REPORT, 24 HRS
3.39
1.00
93230
ECG MONITOR/REPORT, 24 HRS
4.62
1.00
93230
ECG MONITOR/REPORT, 24 HRS
4.68
1.00
93231
ECG MONITOR/RECORD, 24 HRS
1.00
1.00
93231
ECG MONITOR/RECORD, 24 HRS
1.60
1.00
93231
ECG MONITOR/RECORD, 24 HRS
1.63
1.00
93232
ECG MONITOR/REPORT, 24 HRS
1.63
1.00
93232
ECG MONITOR/REPORT, 24 HRS
2.28
1.00
93232
ECG MONITOR/REPORT, 24 HRS
2.31
1.00
93233
ECG MONITOR/REVIEW, 24 HRS
0.74
1.00
93233
ECG MONITOR/REVIEW, 24 HRS
0.76
1.00
Procedure Code Description
RVU
RVU Coeff Value
93235
ECG MONITOR/REPORT, 24 HRS
3.36
1.00
93235
ECG MONITOR/REPORT, 24 HRS
3.39
1.00
93235
ECG MONITOR/REPORT, 24 HRS
3.40
1.00
93236
ECG MONITOR/REPORT, 24 HRS
2.73
1.00
93236
ECG MONITOR/REPORT, 24 HRS
2.76
1.00
93236
ECG MONITOR/REPORT, 24 HRS
2.77
1.00
93237
ECG MONITOR/REVIEW, 24 HRS
0.63
1.00
93237
ECG MONITOR/REVIEW, 24 HRS
0.68
1.00
93268
ECG RECORD/REVIEW
7.36
1.00
93268
ECG RECORD/REVIEW
8.17
1.00
93268
ECG RECORD/REVIEW
8.27
1.00
93270
ECG RECORDING
0.60
1.00
93270
ECG RECORDING
1.30
1.00
93270
ECG RECORDING
1.32
1.00
93271
ECG/MONITORING AND ANALYSIS
6.00
1.00
93271
ECG/MONITORING AND ANALYSIS
6.14
1.00
93271
ECG/MONITORING AND ANALYSIS
6.22
1.00
93272
ECG/REVIEW, INTERPRET ONLY
0.73
1.00
93272
ECG/REVIEW, INTERPRET ONLY
0.76
1.00
93278
ECG/SIGNAL-AVERAGED
1.13
1.00
93278
ECG/SIGNAL-AVERAGED
1.59
1.00
93278
ECG/SIGNAL-AVERAGED
1.62
1.00
93279
PM DEVICE PROGR EVAL, SNGL
1.55
1.00
93281
PM DEVICE PROGR EVAL, MULTI
2.14
1.00
93282
ICD DEVICE PROG EVAL, 1 SNGL
1.98
1.00
93283
ICD DEVICE PROGR EVAL, DUAL
2.41
1.00
93284
ICD DEVICE PROGR EVAL, MULT
2.82
1.00
93285
ILR DEVICE EVAL PROGR
1.34
1.00
93286
PRE-OP PM DEVICE EVAL
0.76
1.00
93287
PRE-OP ICD DEVICE EVAL
1.00
1.00
93288
PM DEVICE EVAL IN PERSON
1.20
1.00
93289
ICD DEVICE INTERROGATE
1.84
1.00
93290
ICM DEVICE EVAL
0.89
1.00
93291
ILR DEVICE INTERROGATE
1.15
1.00
93292
WCD DEVICE INTERROGATE
1.04
1.00
Procedure Code Description
RVU
RVU Coeff Value
93293
PM PHONE R-STRIP DEVICE EVAL
1.66
1.00
93294
PM DEVICE INTERROGATE REMOTE
1.02
1.00
93295
ICD DEVICE INTERROGAT REMOTE
1.84
1.00
93296
PM/ICD REMOTE TECH SERV
1.01
1.00
93297
ICM DEVICE INTERROGAT REMOTE
0.71
1.00
93298
ILR DEVICE INTERROGAT REMOTE
0.82
1.00
93303
ECHO TRANSTHORACIC
5.86
1.00
93303
ECHO TRANSTHORACIC
5.93
1.00
93303
ECHO TRANSTHORACIC
6.05
1.00
93304
ECHO TRANSTHORACIC
3.10
1.00
93304
ECHO TRANSTHORACIC
3.13
1.00
93304
ECHO TRANSTHORACIC
3.74
1.00
93306
TTE W/DOPPLER, COMPLETE
7.42
1.00
93307
TTE W/O DOPPLER, COMPLETE
4.91
1.00
93307
TTE W/O DOPPLER, COMPLETE
5.34
1.00
93307
TTE W/O DOPPLER, COMPLETE
5.42
1.00
93308
TTE, F-UP OR LMTD
2.80
1.00
93308
TTE, F-UP OR LMTD
2.84
1.00
93308
TTE, F-UP OR LMTD
3.10
1.00
93312
ECHO TRANSESOPHAGEAL
3.00
1.00
93312
ECHO TRANSESOPHAGEAL
7.09
1.00
93312
ECHO TRANSESOPHAGEAL
7.17
1.00
93312
ECHO TRANSESOPHAGEAL
9.03
1.00
93313
ECHO TRANSESOPHAGEAL
1.15
1.00
93313
ECHO TRANSESOPHAGEAL
1.21
1.00
93313
ECHO TRANSESOPHAGEAL
1.22
1.00
93314
ECHO TRANSESOPHAGEAL
5.77
1.00
93314
ECHO TRANSESOPHAGEAL
5.85
1.00
93314
ECHO TRANSESOPHAGEAL
7.77
1.00
93315
ECHO TRANSESOPHAGEAL
3.88
1.00
93315
ECHO TRANSESOPHAGEAL
3.90
1.00
93315
ECHO TRANSESOPHAGEAL
3.91
1.00
93315
ECHO TRANSESOPHAGEAL
3.92
1.00
93315
ECHO TRANSESOPHAGEAL
3.97
1.00
93315
ECHO TRANSESOPHAGEAL
4.12
1.00
Procedure Code Description
RVU
RVU Coeff Value
93316
ECHO TRANSESOPHAGEAL
1.24
1.00
93316
ECHO TRANSESOPHAGEAL
1.25
1.00
93316
ECHO TRANSESOPHAGEAL
1.26
1.00
93317
ECHO TRANSESOPHAGEAL
2.56
1.00
93317
ECHO TRANSESOPHAGEAL
2.57
1.00
93317
ECHO TRANSESOPHAGEAL
2.58
1.00
93318
ECHO TRANSESOPHAGEAL INTRAOP
2.74
1.00
93318
ECHO TRANSESOPHAGEAL INTRAOP
2.75
1.00
93318
ECHO TRANSESOPHAGEAL INTRAOP
2.82
1.00
93318
ECHO TRANSESOPHAGEAL INTRAOP
2.93
1.00
93318
ECHO TRANSESOPHAGEAL INTRAOP
3.13
1.00
93320
DOPPLER ECHO EXAM, HEART
2.17
1.00
93320
DOPPLER ECHO EXAM, HEART
2.34
1.00
93320
DOPPLER ECHO EXAM, HEART
2.38
1.00
93321
DOPPLER ECHO EXAM, HEART
0.97
1.00
93321
DOPPLER ECHO EXAM, HEART
1.39
1.00
93321
DOPPLER ECHO EXAM, HEART
1.42
1.00
93325
DOPPLER COLOR FLOW ADD-ON
1.50
1.00
93325
DOPPLER COLOR FLOW ADD-ON
3.17
1.00
93325
DOPPLER COLOR FLOW ADD-ON
3.23
1.00
93350
STRESS TTE ONLY
3.94
1.00
93350
STRESS TTE ONLY
3.97
1.00
93350
STRESS TTE ONLY
5.87
1.00
93351
STRESS TTE COMPLETE
7.04
1.00
93352
ADMIN ECG CONTRAST AGENT
1.07
1.00
93501
RIGHT HEART CATHETERIZATION
22.06
1.00
93501
RIGHT HEART CATHETERIZATION
22.29
1.00
93501
RIGHT HEART CATHETERIZATION
22.37
1.00
93501
RIGHT HEART CATHETERIZATION
22.68
1.00
93503
INSERT/PLACE HEART CATHETER
3.11
1.00
93503
INSERT/PLACE HEART CATHETER
3.76
1.00
93503
INSERT/PLACE HEART CATHETER
3.78
1.00
93505
BIOPSY OF HEART LINING
8.43
1.00
93505
BIOPSY OF HEART LINING
8.49
1.00
93505
BIOPSY OF HEART LINING
20.70
1.00
Procedure Code Description
RVU
RVU Coeff Value
93508
CATH PLACEMENT, ANGIOGRAPHY
19.04
1.00
93508
CATH PLACEMENT, ANGIOGRAPHY
19.72
1.00
93508
CATH PLACEMENT, ANGIOGRAPHY
29.41
1.00
93510
LEFT HEART CATHETERIZATION
5.00
1.00
93510
LEFT HEART CATHETERIZATION
36.98
1.00
93510
LEFT HEART CATHETERIZATION
44.99
1.00
93510
LEFT HEART CATHETERIZATION
46.15
1.00
93510
LEFT HEART CATHETERIZATION
46.17
1.00
93511
LEFT HEART CATHETERIZATION
44.98
1.00
93511
LEFT HEART CATHETERIZATION
46.11
1.00
93514
LEFT HEART CATHETERIZATION
47.85
1.00
93514
LEFT HEART CATHETERIZATION
48.96
1.00
93524
LEFT HEART CATHETERIZATION
59.31
1.00
93524
LEFT HEART CATHETERIZATION
60.66
1.00
93526
RT & LT HEART CATHETERS
7.00
1.00
93526
RT & LT HEART CATHETERS
47.46
1.00
93526
RT & LT HEART CATHETERS
59.28
1.00
93526
RT & LT HEART CATHETERS
60.65
1.00
93526
RT & LT HEART CATHETERS
60.69
1.00
93527
RT & LT HEART CATHETERS
59.81
1.00
93527
RT & LT HEART CATHETERS
61.16
1.00
93528
RT & LT HEART CATHETERS
62.34
1.00
93528
RT & LT HEART CATHETERS
63.71
1.00
93529
RT, LT HEART CATHETERIZATION
56.15
1.00
93529
RT, LT HEART CATHETERIZATION
57.48
1.00
93530
RT HEART CATH, CONGENITAL
7.00
1.00
93530
RT HEART CATH, CONGENITAL
23.71
1.00
93530
RT HEART CATH, CONGENITAL
24.46
1.00
93531
R & L HEART CATH, CONGENITAL
7.00
1.00
93531
R & L HEART CATH, CONGENITAL
62.61
1.00
93531
R & L HEART CATH, CONGENITAL
63.96
1.00
93531
R & L HEART CATH, CONGENITAL
63.98
1.00
93532
R & L HEART CATH, CONGENITAL
7.00
1.00
93532
R & L HEART CATH, CONGENITAL
63.65
1.00
93532
R & L HEART CATH, CONGENITAL
64.99
1.00
Procedure Code Description
RVU
RVU Coeff Value
93533
R & L HEART CATH, CONGENITAL
7.00
1.00
93533
R & L HEART CATH, CONGENITAL
58.80
1.00
93533
R & L HEART CATH, CONGENITAL
60.12
1.00
93539
INJECTION, CARDIAC CATH
0.57
1.00
93539
INJECTION, CARDIAC CATH
0.61
1.00
93540
INJECTION, CARDIAC CATH
0.61
1.00
93540
INJECTION, CARDIAC CATH
0.66
1.00
93541
INJECTION FOR LUNG ANGIOGRAM
0.41
1.00
93541
INJECTION FOR LUNG ANGIOGRAM
0.42
1.00
93541
INJECTION FOR LUNG ANGIOGRAM
0.44
1.00
93541
INJECTION FOR LUNG ANGIOGRAM
999.99
1.00
93542
INJECTION FOR HEART X-RAYS
0.41
1.00
93542
INJECTION FOR HEART X-RAYS
0.42
1.00
93542
INJECTION FOR HEART X-RAYS
0.44
1.00
93543
INJECTION FOR HEART X-RAYS
0.42
1.00
93543
INJECTION FOR HEART X-RAYS
0.44
1.00
93544
INJECTION FOR AORTOGRAPHY
0.36
1.00
93544
INJECTION FOR AORTOGRAPHY
0.39
1.00
93545
INJECT FOR CORONARY X-RAYS
0.57
1.00
93545
INJECT FOR CORONARY X-RAYS
0.60
1.00
93545
INJECT FOR CORONARY X-RAYS
0.61
1.00
93555
IMAGING, CARDIAC CATH
3.27
1.00
93556
IMAGING, CARDIAC CATH
4.57
1.00
93556
IMAGING, CARDIAC CATH
11.46
1.00
93556
IMAGING, CARDIAC CATH
11.64
1.00
93561
CARDIAC OUTPUT MEASUREMENT
1.25
1.00
93561
CARDIAC OUTPUT MEASUREMENT
1.26
1.00
93562
CARDIAC OUTPUT MEASUREMENT
0.57
1.00
93562
CARDIAC OUTPUT MEASUREMENT
0.58
1.00
93571
HEART FLOW RESERVE MEASURE
7.36
1.00
93571
HEART FLOW RESERVE MEASURE
7.43
1.00
93572
HEART FLOW RESERVE MEASURE
4.50
1.00
93572
HEART FLOW RESERVE MEASURE
4.58
1.00
93580
TRANSCATH CLOSURE OF ASD
26.48
1.00
93580
TRANSCATH CLOSURE OF ASD
26.55
1.00
Procedure Code Description
RVU
RVU Coeff Value
93580
TRANSCATH CLOSURE OF ASD
28.25
1.00
93581
TRANSCATH CLOSURE OF VSD
35.41
1.00
93581
TRANSCATH CLOSURE OF VSD
35.42
1.00
93581
TRANSCATH CLOSURE OF VSD
37.00
1.00
93600
BUNDLE OF HIS RECORDING
5.13
1.00
93600
BUNDLE OF HIS RECORDING
5.17
1.00
93602
INTRA-ATRIAL RECORDING
4.24
1.00
93602
INTRA-ATRIAL RECORDING
4.28
1.00
93603
RIGHT VENTRICULAR RECORDING
4.83
1.00
93603
RIGHT VENTRICULAR RECORDING
4.87
1.00
93609
MAP TACHYCARDIA, ADD-ON
10.37
1.00
93609
MAP TACHYCARDIA, ADD-ON
10.46
1.00
93610
INTRA-ATRIAL PACING
5.79
1.00
93610
INTRA-ATRIAL PACING
5.85
1.00
93612
INTRAVENTRICULAR PACING
6.07
1.00
93612
INTRAVENTRICULAR PACING
6.12
1.00
93613
ELECTROPHYS MAP 3D, ADD-ON
10.24
1.00
93613
ELECTROPHYS MAP 3D, ADD-ON
10.38
1.00
93613
ELECTROPHYS MAP 3D, ADD-ON
10.96
1.00
93615
ESOPHAGEAL RECORDING
1.63
1.00
93615
ESOPHAGEAL RECORDING
1.64
1.00
93616
ESOPHAGEAL RECORDING
2.32
1.00
93616
ESOPHAGEAL RECORDING
2.33
1.00
93618
HEART RHYTHM PACING
10.34
1.00
93618
HEART RHYTHM PACING
10.42
1.00
93619
ELECTROPHYSIOLOGY EVALUATION
4.00
1.00
93619
ELECTROPHYSIOLOGY EVALUATION
18.68
1.00
93619
ELECTROPHYSIOLOGY EVALUATION
19.18
1.00
93620
ELECTROPHYSIOLOGY EVALUATION
16.79
1.00
93620
ELECTROPHYSIOLOGY EVALUATION
16.81
1.00
93620
ELECTROPHYSIOLOGY EVALUATION
17.15
1.00
93620
ELECTROPHYSIOLOGY EVALUATION
17.22
1.00
93620
ELECTROPHYSIOLOGY EVALUATION
17.59
1.00
93620
ELECTROPHYSIOLOGY EVALUATION
18.18
1.00
93621
ELECTROPHYSIOLOGY EVALUATION
2.99
1.00
Procedure Code Description
RVU
RVU Coeff Value
93621
ELECTROPHYSIOLOGY EVALUATION
3.07
1.00
93621
ELECTROPHYSIOLOGY EVALUATION
3.09
1.00
93621
ELECTROPHYSIOLOGY EVALUATION
3.10
1.00
93621
ELECTROPHYSIOLOGY EVALUATION
3.15
1.00
93621
ELECTROPHYSIOLOGY EVALUATION
3.29
1.00
93622
ELECTROPHYSIOLOGY EVALUATION
4.41
1.00
93622
ELECTROPHYSIOLOGY EVALUATION
4.53
1.00
93622
ELECTROPHYSIOLOGY EVALUATION
4.81
1.00
93622
ELECTROPHYSIOLOGY EVALUATION
5.00
1.00
93622
ELECTROPHYSIOLOGY EVALUATION
5.12
1.00
93623
STIMULATION, PACING HEART
4.05
1.00
93623
STIMULATION, PACING HEART
4.13
1.00
93623
STIMULATION, PACING HEART
4.15
1.00
93623
STIMULATION, PACING HEART
4.16
1.00
93623
STIMULATION, PACING HEART
4.27
1.00
93623
STIMULATION, PACING HEART
4.46
1.00
93624
ELECTROPHYSIOLOGIC STUDY
9.05
1.00
93624
ELECTROPHYSIOLOGIC STUDY
9.42
1.00
93631
HEART PACING, MAPPING
17.70
1.00
93631
HEART PACING, MAPPING
17.96
1.00
93640
EVALUATION HEART DEVICE
12.58
1.00
93640
EVALUATION HEART DEVICE
12.71
1.00
93641
ELECTROPHYSIOLOGY EVALUATION
16.10
1.00
93641
ELECTROPHYSIOLOGY EVALUATION
16.23
1.00
93642
ELECTROPHYSIOLOGY EVALUATION
13.11
1.00
93642
ELECTROPHYSIOLOGY EVALUATION
14.47
1.00
93642
ELECTROPHYSIOLOGY EVALUATION
14.91
1.00
93650
ABLATE HEART DYSRHYTHM FOCUS
15.25
1.00
93650
ABLATE HEART DYSRHYTHM FOCUS
15.60
1.00
93650
ABLATE HEART DYSRHYTHM FOCUS
16.69
1.00
93651
ABLATE HEART DYSRHYTHM FOCUS
23.59
1.00
93651
ABLATE HEART DYSRHYTHM FOCUS
23.61
1.00
93651
ABLATE HEART DYSRHYTHM FOCUS
25.39
1.00
93652
ABLATE HEART DYSRHYTHM FOCUS
25.67
1.00
93652
ABLATE HEART DYSRHYTHM FOCUS
27.63
1.00
Procedure Code Description
RVU
RVU Coeff Value
93660
TILT TABLE EVALUATION
4.40
1.00
93660
TILT TABLE EVALUATION
4.41
1.00
93660
TILT TABLE EVALUATION
4.75
1.00
93662
INTRACARDIAC ECG (ICE)
4.00
1.00
93662
INTRACARDIAC ECG (ICE)
4.27
1.00
93662
INTRACARDIAC ECG (ICE)
4.29
1.00
93662
INTRACARDIAC ECG (ICE)
4.40
1.00
93701
BIOIMPEDANCE, THORACIC
0.94
1.00
93701
BIOIMPEDANCE, THORACIC
1.21
1.00
93701
BIOIMPEDANCE, THORACIC
1.33
1.00
93720
TOTAL BODY PLETHYSMOGRAPHY
0.99
1.00
93720
TOTAL BODY PLETHYSMOGRAPHY
1.00
1.00
93720
TOTAL BODY PLETHYSMOGRAPHY
1.28
1.00
93721
PLETHYSMOGRAPHY TRACING
0.76
1.00
93721
PLETHYSMOGRAPHY TRACING
0.77
1.00
93721
PLETHYSMOGRAPHY TRACING
1.05
1.00
93722
PLETHYSMOGRAPHY REPORT
0.23
1.00
93724
ANALYZE PACEMAKER SYSTEM
9.28
1.00
93724
ANALYZE PACEMAKER SYSTEM
11.18
1.00
93724
ANALYZE PACEMAKER SYSTEM
11.24
1.00
93727
ANALYZE ILR SYSTEM
0.77
1.00
93727
ANALYZE ILR SYSTEM
0.78
1.00
93727
ANALYZE ILR SYSTEM
0.96
1.00
93731
ANALYZE PACEMAKER SYSTEM
1.17
1.00
93731
ANALYZE PACEMAKER SYSTEM
1.18
1.00
93731
ANALYZE PACEMAKER SYSTEM
1.22
1.00
93732
ANALYZE PACEMAKER SYSTEM
1.85
1.00
93732
ANALYZE PACEMAKER SYSTEM
1.87
1.00
93732
ANALYZE PACEMAKER SYSTEM
2.00
1.00
93733
TELEPHONE ANALY, PACEMAKER
1.03
1.00
93733
TELEPHONE ANALY, PACEMAKER
1.04
1.00
93733
TELEPHONE ANALY, PACEMAKER
1.10
1.00
93734
ANALYZE PACEMAKER SYSTEM
0.91
1.00
93734
ANALYZE PACEMAKER SYSTEM
1.01
1.00
93735
ANALYZE PACEMAKER SYSTEM
1.54
1.00
Procedure Code Description
RVU
RVU Coeff Value
93735
ANALYZE PACEMAKER SYSTEM
1.55
1.00
93735
ANALYZE PACEMAKER SYSTEM
1.64
1.00
93736
TELEPHONIC ANALY, PACEMAKER
0.90
1.00
93736
TELEPHONIC ANALY, PACEMAKER
0.91
1.00
93736
TELEPHONIC ANALY, PACEMAKER
1.01
1.00
93741
ANALYZE HT PACE DEVICE SNGL
1.84
1.00
93741
ANALYZE HT PACE DEVICE SNGL
1.85
1.00
93741
ANALYZE HT PACE DEVICE SNGL
1.86
1.00
93742
ANALYZE HT PACE DEVICE SNGL
2.00
1.00
93742
ANALYZE HT PACE DEVICE SNGL
2.07
1.00
93743
ANALYZE HT PACE DEVICE DUAL
2.24
1.00
93743
ANALYZE HT PACE DEVICE DUAL
2.25
1.00
93743
ANALYZE HT PACE DEVICE DUAL
2.26
1.00
93744
ANALYZE HT PACE DEVICE DUAL
2.38
1.00
93744
ANALYZE HT PACE DEVICE DUAL
2.39
1.00
93744
ANALYZE HT PACE DEVICE DUAL
2.49
1.00
93770
MEASURE VENOUS PRESSURE
0.24
1.00
93770
MEASURE VENOUS PRESSURE
0.26
1.00
93784
AMBULATORY BP MONITORING
1.17
1.00
93784
AMBULATORY BP MONITORING
1.81
1.00
93784
AMBULATORY BP MONITORING
1.96
1.00
93786
AMBULATORY BP RECORDING
0.82
1.00
93786
AMBULATORY BP RECORDING
0.92
1.00
93788
AMBULATORY BP ANALYSIS
0.46
1.00
93788
AMBULATORY BP ANALYSIS
0.52
1.00
93790
REVIEW/REPORT BP RECORDING
0.25
1.00
93790
REVIEW/REPORT BP RECORDING
0.52
1.00
93790
REVIEW/REPORT BP RECORDING
0.53
1.00
93797
CARDIAC REHAB
0.26
1.00
93797
CARDIAC REHAB
0.27
1.00
93798
CARDIAC REHAB/MONITOR
0.40
1.00
93798
CARDIAC REHAB/MONITOR
0.42
1.00
93875
EXTRACRANIAL STUDY
1.97
1.00
93875
EXTRACRANIAL STUDY
2.00
1.00
93875
EXTRACRANIAL STUDY
2.81
1.00
Procedure Code Description
RVU
RVU Coeff Value
93880
EXTRACRANIAL STUDY
5.18
1.00
93880
EXTRACRANIAL STUDY
5.23
1.00
93880
EXTRACRANIAL STUDY
6.89
1.00
93882
EXTRACRANIAL STUDY
3.57
1.00
93882
EXTRACRANIAL STUDY
3.68
1.00
93882
EXTRACRANIAL STUDY
4.54
1.00
93886
INTRACRANIAL STUDY
5.86
1.00
93886
INTRACRANIAL STUDY
6.04
1.00
93886
INTRACRANIAL STUDY
8.26
1.00
93888
INTRACRANIAL STUDY
3.96
1.00
93888
INTRACRANIAL STUDY
4.02
1.00
93888
INTRACRANIAL STUDY
5.63
1.00
93890
TRANSCRANIAL DOPPLER STUDY OF THE
6.35
1.00
93890
TRANSCRANIAL DOPPLER STUDY OF THE
6.36
1.00
93890
TRANSCRANIAL DOPPLER STUDY OF THE
7.26
1.00
93892
TCD, EMBOLI DETECT W/O INJ
7.95
1.00
93893
TCD, EMBOLI DETECT W/INJ
7.93
1.00
93922
EXTREMITY STUDY
2.26
1.00
93922
EXTREMITY STUDY
2.33
1.00
93922
EXTREMITY STUDY
3.34
1.00
93923
EXTREMITY STUDY
3.62
1.00
93923
EXTREMITY STUDY
3.72
1.00
93923
EXTREMITY STUDY
5.16
1.00
93924
EXTREMITY STUDY
4.43
1.00
93924
EXTREMITY STUDY
4.57
1.00
93924
EXTREMITY STUDY
6.35
1.00
93925
LOWER EXTREMITY STUDY
5.85
1.00
93925
LOWER EXTREMITY STUDY
5.86
1.00
93925
LOWER EXTREMITY STUDY
8.55
1.00
93926
LOWER EXTREMITY STUDY
4.00
1.00
93926
LOWER EXTREMITY STUDY
4.15
1.00
93926
LOWER EXTREMITY STUDY
5.46
1.00
93930
UPPER EXTREMITY STUDY
4.72
1.00
93930
UPPER EXTREMITY STUDY
4.74
1.00
93930
UPPER EXTREMITY STUDY
6.77
1.00
Procedure Code Description
RVU
RVU Coeff Value
93931
UPPER EXTREMITY STUDY
3.36
1.00
93931
UPPER EXTREMITY STUDY
3.39
1.00
93931
UPPER EXTREMITY STUDY
4.53
1.00
93965
EXTREMITY STUDY
2.32
1.00
93965
EXTREMITY STUDY
2.35
1.00
93965
EXTREMITY STUDY
3.41
1.00
93970
EXTREMITY STUDY
5.11
1.00
93970
EXTREMITY STUDY
7.04
1.00
93971
EXTREMITY STUDY
3.57
1.00
93971
EXTREMITY STUDY
3.62
1.00
93971
EXTREMITY STUDY
4.66
1.00
93975
VASCULAR STUDY
8.18
1.00
93975
VASCULAR STUDY
8.19
1.00
93975
VASCULAR STUDY
10.49
1.00
93976
VASCULAR STUDY
5.01
1.00
93976
VASCULAR STUDY
5.04
1.00
93976
VASCULAR STUDY
6.05
1.00
93978
VASCULAR STUDY
4.64
1.00
93978
VASCULAR STUDY
4.66
1.00
93978
VASCULAR STUDY
6.62
1.00
93979
VASCULAR STUDY
3.31
1.00
93979
VASCULAR STUDY
3.38
1.00
93979
VASCULAR STUDY
4.57
1.00
93980
PENILE VASCULAR STUDY
5.13
1.00
93980
PENILE VASCULAR STUDY
6.10
1.00
93980
PENILE VASCULAR STUDY
6.45
1.00
93981
PENILE VASCULAR STUDY
3.61
1.00
93981
PENILE VASCULAR STUDY
5.38
1.00
93981
PENILE VASCULAR STUDY
5.54
1.00
93982
ANEURYSM PRESSURE SENS STUDY
1.10
1.00
93990
DOPPLER FLOW TESTING
3.81
1.00
93990
DOPPLER FLOW TESTING
3.92
1.00
93990
DOPPLER FLOW TESTING
5.35
1.00
94010
BREATHING CAPACITY TEST
0.87
1.00
94010
BREATHING CAPACITY TEST
0.91
1.00
Procedure Code Description
RVU
RVU Coeff Value
94010
BREATHING CAPACITY TEST
1.08
1.00
94014
PATIENT RECORDED SPIROMETRY
1.01
1.00
94014
PATIENT RECORDED SPIROMETRY
1.32
1.00
94014
PATIENT RECORDED SPIROMETRY
1.34
1.00
94015
PATIENT RECORDED SPIROMETRY
0.30
1.00
94015
PATIENT RECORDED SPIROMETRY
0.61
1.00
94015
PATIENT RECORDED SPIROMETRY
0.65
1.00
94016
REVIEW PATIENT SPIROMETRY
0.69
1.00
94016
REVIEW PATIENT SPIROMETRY
0.71
1.00
94060
EVALUATION OF WHEEZING
1.50
1.00
94060
EVALUATION OF WHEEZING
1.60
1.00
94060
EVALUATION OF WHEEZING
1.89
1.00
94070
EVALUATION OF WHEEZING
1.67
1.00
94070
EVALUATION OF WHEEZING
3.71
1.00
94070
EVALUATION OF WHEEZING
5.04
1.00
94150
VITAL CAPACITY TEST
0.57
1.00
94150
VITAL CAPACITY TEST
0.62
1.00
94150
VITAL CAPACITY TEST
0.75
1.00
94200
LUNG FUNCTION TEST (MBC/MVV)
0.58
1.00
94200
LUNG FUNCTION TEST (MBC/MVV)
0.62
1.00
94200
LUNG FUNCTION TEST (MBC/MVV)
0.77
1.00
94240
RESIDUAL LUNG CAPACITY
0.97
1.00
94240
RESIDUAL LUNG CAPACITY
1.08
1.00
94240
RESIDUAL LUNG CAPACITY
2.20
1.00
94250
EXPIRED GAS COLLECTION
0.67
1.00
94250
EXPIRED GAS COLLECTION
0.78
1.00
94250
EXPIRED GAS COLLECTION
0.83
1.00
94260
THORACIC GAS VOLUME
0.72
1.00
94260
THORACIC GAS VOLUME
0.75
1.00
94260
THORACIC GAS VOLUME
0.87
1.00
94350
LUNG NITROGEN WASHOUT CURVE
0.96
1.00
94350
LUNG NITROGEN WASHOUT CURVE
1.06
1.00
94350
LUNG NITROGEN WASHOUT CURVE
2.26
1.00
94360
MEASURE AIRFLOW RESISTANCE
0.89
1.00
94360
MEASURE AIRFLOW RESISTANCE
1.02
1.00
Procedure Code Description
RVU
RVU Coeff Value
94360
MEASURE AIRFLOW RESISTANCE
1.20
1.00
94370
BREATH AIRWAY CLOSING VOLUME
0.92
1.00
94370
BREATH AIRWAY CLOSING VOLUME
1.01
1.00
94370
BREATH AIRWAY CLOSING VOLUME
2.25
1.00
94375
RESPIRATORY FLOW VOLUME LOOP
0.95
1.00
94375
RESPIRATORY FLOW VOLUME LOOP
1.01
1.00
94375
RESPIRATORY FLOW VOLUME LOOP
1.02
1.00
94400
CO2 BREATHING RESPONSE CURVE
1.31
1.00
94400
CO2 BREATHING RESPONSE CURVE
1.35
1.00
94400
CO2 BREATHING RESPONSE CURVE
1.46
1.00
94450
HYPOXIA RESPONSE CURVE
1.12
1.00
94450
HYPOXIA RESPONSE CURVE
1.39
1.00
94452
HAST W/REPORT
1.53
1.00
94453
HAST W/OXYGEN TITRATE
2.04
1.00
94610
SURFACTANT ADMIN THRU TUBE
1.79
1.00
94620
PULMONARY STRESS TEST/SIMPLE
1.99
1.00
94620
PULMONARY STRESS TEST/SIMPLE
3.18
1.00
94620
PULMONARY STRESS TEST/SIMPLE
3.21
1.00
94621
PULM STRESS TEST/COMPLEX
3.64
1.00
94621
PULM STRESS TEST/COMPLEX
3.67
1.00
94621
PULM STRESS TEST/COMPLEX
4.46
1.00
94640
AIRWAY INHALATION TREATMENT
0.34
1.00
94640
AIRWAY INHALATION TREATMENT
0.37
1.00
94640
AIRWAY INHALATION TREATMENT
0.72
1.00
94644
CBT, 1ST HOUR
0.94
1.00
94645
CBT, EACH ADDL HOUR
0.37
1.00
94662
NEG PRESS VENTILATION, CNP
1.02
1.00
94664
EVALUATE PT USE OF INHALER
0.36
1.00
94664
EVALUATE PT USE OF INHALER
0.41
1.00
94664
EVALUATE PT USE OF INHALER
0.55
1.00
94680
EXHALED AIR ANALYSIS, O2
1.59
1.00
94680
EXHALED AIR ANALYSIS, O2
2.22
1.00
94680
EXHALED AIR ANALYSIS, O2
2.23
1.00
94681
EXHALED AIR ANALYSIS, O2/CO2
1.74
1.00
94681
EXHALED AIR ANALYSIS, O2/CO2
2.95
1.00
Procedure Code Description
RVU
RVU Coeff Value
94681
EXHALED AIR ANALYSIS, O2/CO2
3.11
1.00
94690
EXHALED AIR ANALYSIS
1.39
1.00
94690
EXHALED AIR ANALYSIS
2.09
1.00
94690
EXHALED AIR ANALYSIS
2.24
1.00
94720
MONOXIDE DIFFUSING CAPACITY
1.33
1.00
94720
MONOXIDE DIFFUSING CAPACITY
1.42
1.00
94720
MONOXIDE DIFFUSING CAPACITY
1.87
1.00
94725
MEMBRANE DIFFUSION CAPACITY
1.85
1.00
94725
MEMBRANE DIFFUSION CAPACITY
2.93
1.00
94725
MEMBRANE DIFFUSION CAPACITY
3.31
1.00
94750
PULMONARY COMPLIANCE STUDY
1.63
1.00
94750
PULMONARY COMPLIANCE STUDY
1.95
1.00
94750
PULMONARY COMPLIANCE STUDY
2.34
1.00
94760
MEASURE BLOOD OXYGEN LEVEL
0.06
1.00
94760
MEASURE BLOOD OXYGEN LEVEL
0.08
1.00
94760
MEASURE BLOOD OXYGEN LEVEL
0.11
1.00
94761
MEASURE BLOOD OXYGEN LEVEL
0.13
1.00
94761
MEASURE BLOOD OXYGEN LEVEL
0.16
1.00
94761
MEASURE BLOOD OXYGEN LEVEL
0.22
1.00
94762
MEASURE BLOOD OXYGEN LEVEL
0.50
1.00
94762
MEASURE BLOOD OXYGEN LEVEL
0.82
1.00
94770
EXHALED CARBON DIOXIDE TEST
1.01
1.00
94770
EXHALED CARBON DIOXIDE TEST
1.90
1.00
95805
MULTIPLE SLEEP LATENCY TEST
11.69
1.00
95805
MULTIPLE SLEEP LATENCY TEST
18.55
1.00
95805
MULTIPLE SLEEP LATENCY TEST
19.33
1.00
95806
SLEEP STUDY, UNATTENDED
5.39
1.00
95806
SLEEP STUDY, UNATTENDED
5.85
1.00
95806
SLEEP STUDY, UNATTENDED
6.08
1.00
95807
SLEEP STUDY, ATTENDED
13.68
1.00
95807
SLEEP STUDY, ATTENDED
13.81
1.00
95807
SLEEP STUDY, ATTENDED
14.06
1.00
95808
POLYSOMNOGRAPHY, 1-3
16.09
1.00
95808
POLYSOMNOGRAPHY, 1-3
16.19
1.00
95808
POLYSOMNOGRAPHY, 1-3
17.89
1.00
Procedure Code Description
RVU
RVU Coeff Value
95810
POLYSOMNOGRAPHY, 4 OR MORE
21.10
1.00
95810
POLYSOMNOGRAPHY, 4 OR MORE
21.28
1.00
95810
POLYSOMNOGRAPHY, 4 OR MORE
21.29
1.00
95811
POLYSOMNOGRAPHY W/CPAP
21.96
1.00
95811
POLYSOMNOGRAPHY W/CPAP
22.83
1.00
95811
POLYSOMNOGRAPHY W/CPAP
23.44
1.00
95812
EEG, 41-60 MINUTES
5.15
1.00
95812
EEG, 41-60 MINUTES
5.93
1.00
95812
EEG, 41-60 MINUTES
6.52
1.00
95813
EEG, OVER 1 HOUR
6.84
1.00
95813
EEG, OVER 1 HOUR
7.68
1.00
95813
EEG, OVER 1 HOUR
7.99
1.00
95816
EEG, AWAKE AND DROWSY
4.37
1.00
95816
EEG, AWAKE AND DROWSY
4.87
1.00
95816
EEG, AWAKE AND DROWSY
5.98
1.00
95819
EEG, AWAKE AND ASLEEP
4.92
1.00
95819
EEG, AWAKE AND ASLEEP
5.51
1.00
95819
EEG, AWAKE AND ASLEEP
6.42
1.00
95822
EEG, COMA OR SLEEP ONLY
5.61
1.00
95822
EEG, COMA OR SLEEP ONLY
6.34
1.00
95822
EEG, COMA OR SLEEP ONLY
6.40
1.00
95824
EEG, CEREBRAL DEATH ONLY
1.02
1.00
95824
EEG, CEREBRAL DEATH ONLY
1.09
1.00
95824
EEG, CEREBRAL DEATH ONLY
1.11
1.00
95824
EEG, CEREBRAL DEATH ONLY
1.12
1.00
95827
EEG, ALL NIGHT RECORDING
3.93
1.00
95827
EEG, ALL NIGHT RECORDING
3.96
1.00
95827
EEG, ALL NIGHT RECORDING
10.33
1.00
95829
SURGERY ELECTROCORTICOGRAM
33.20
1.00
95829
SURGERY ELECTROCORTICOGRAM
37.89
1.00
95829
SURGERY ELECTROCORTICOGRAM
46.66
1.00
95831
LIMB MUSCLE TESTING, MANUAL
0.39
1.00
95831
LIMB MUSCLE TESTING, MANUAL
0.42
1.00
95832
HAND MUSCLE TESTING, MANUAL
0.41
1.00
95832
HAND MUSCLE TESTING, MANUAL
0.42
1.00
Procedure Code Description
RVU
RVU Coeff Value
95833
BODY MUSCLE TESTING, MANUAL
0.65
1.00
95833
BODY MUSCLE TESTING, MANUAL
0.71
1.00
95834
BODY MUSCLE TESTING, MANUAL
0.82
1.00
95834
BODY MUSCLE TESTING, MANUAL
0.90
1.00
95852
RANGE OF MOTION MEASUREMENTS
0.16
1.00
95852
RANGE OF MOTION MEASUREMENTS
0.17
1.00
95857
TENSILON TEST
0.74
1.00
95857
TENSILON TEST
0.78
1.00
95858
TENSILON TEST & MYOGRAM
2.71
1.00
95858
TENSILON TEST & MYOGRAM
2.72
1.00
95858
TENSILON TEST & MYOGRAM
2.75
1.00
95860
MUSCLE TEST, ONE LIMB
2.23
1.00
95860
MUSCLE TEST, ONE LIMB
2.47
1.00
95860
MUSCLE TEST, ONE LIMB
2.63
1.00
95861
MUSCLE TEST, 2 LIMBS
3.08
1.00
95861
MUSCLE TEST, 2 LIMBS
3.24
1.00
95863
MUSCLE TEST, 3 LIMBS
3.75
1.00
95863
MUSCLE TEST, 3 LIMBS
3.86
1.00
95864
MUSCLE TEST, 4 LIMBS
4.44
1.00
95864
MUSCLE TEST, 4 LIMBS
4.81
1.00
95864
MUSCLE TEST, 4 LIMBS
4.84
1.00
95865
MUSCLE TEST, LARYNX
3.10
1.00
95866
MUSCLE TEST, HEMIDIAPHRAGM
2.54
1.00
95867
MUSCLE TEST CRAN NERV UNILAT
1.79
1.00
95867
MUSCLE TEST CRAN NERV UNILAT
1.80
1.00
95867
MUSCLE TEST CRAN NERV UNILAT
1.94
1.00
95868
MUSCLE TEST CRAN NERVE BILAT
2.49
1.00
95868
MUSCLE TEST CRAN NERVE BILAT
2.66
1.00
95869
MUSCLE TEST, THOR PARASPINAL
0.78
1.00
95869
MUSCLE TEST, THOR PARASPINAL
1.24
1.00
95870
MUSCLE TEST, NONPARASPINAL
0.77
1.00
95870
MUSCLE TEST, NONPARASPINAL
0.78
1.00
95870
MUSCLE TEST, NONPARASPINAL
1.21
1.00
95873
GUIDE NERV DESTR, ELEC STIM
1.26
1.00
95874
GUIDE NERV DESTR, NEEDLE EMG
1.19
1.00
Procedure Code Description
RVU
RVU Coeff Value
95875
LIMB EXERCISE TEST
2.55
1.00
95875
LIMB EXERCISE TEST
2.67
1.00
95875
LIMB EXERCISE TEST
2.91
1.00
95900
MOTOR NERVE CONDUCTION TEST
1.45
1.00
95900
MOTOR NERVE CONDUCTION TEST
1.57
1.00
95900
MOTOR NERVE CONDUCTION TEST
1.74
1.00
95903
MOTOR NERVE CONDUCTION TEST
1.70
1.00
95903
MOTOR NERVE CONDUCTION TEST
1.71
1.00
95903
MOTOR NERVE CONDUCTION TEST
1.85
1.00
95904
SENSE NERVE CONDUCTION TEST
1.28
1.00
95904
SENSE NERVE CONDUCTION TEST
1.32
1.00
95904
SENSE NERVE CONDUCTION TEST
1.48
1.00
95920
INTRAOP NERVE TEST ADD-ON
4.16
1.00
95920
INTRAOP NERVE TEST ADD-ON
4.57
1.00
95920
INTRAOP NERVE TEST ADD-ON
4.60
1.00
95921
AUTONOMIC NERV FUNCTION TEST
1.66
1.00
95921
AUTONOMIC NERV FUNCTION TEST
1.67
1.00
95921
AUTONOMIC NERV FUNCTION TEST
2.01
1.00
95922
AUTONOMIC NERV FUNCTION TEST
1.79
1.00
95922
AUTONOMIC NERV FUNCTION TEST
1.80
1.00
95922
AUTONOMIC NERV FUNCTION TEST
2.41
1.00
95923
AUTONOMIC NERV FUNCTION TEST
3.04
1.00
95923
AUTONOMIC NERV FUNCTION TEST
3.16
1.00
95923
AUTONOMIC NERV FUNCTION TEST
3.87
1.00
95925
SOMATOSENSORY TESTING
1.75
1.00
95925
SOMATOSENSORY TESTING
1.76
1.00
95925
SOMATOSENSORY TESTING
3.22
1.00
95926
SOMATOSENSORY TESTING
1.76
1.00
95926
SOMATOSENSORY TESTING
1.77
1.00
95926
SOMATOSENSORY TESTING
3.16
1.00
95927
SOMATOSENSORY TESTING
1.79
1.00
95927
SOMATOSENSORY TESTING
1.80
1.00
95927
SOMATOSENSORY TESTING
3.24
1.00
95928
C MOTOR EVOKED, UPPR LIMBS
5.13
1.00
95929
C MOTOR EVOKED, LWR LIMBS
5.41
1.00
Procedure Code Description
RVU
RVU Coeff Value
95930
VISUAL EVOKED POTENTIAL TEST
1.55
1.00
95930
VISUAL EVOKED POTENTIAL TEST
1.80
1.00
95930
VISUAL EVOKED POTENTIAL TEST
2.84
1.00
95933
BLINK REFLEX TEST
1.69
1.00
95933
BLINK REFLEX TEST
1.70
1.00
95933
BLINK REFLEX TEST
1.76
1.00
95934
H-REFLEX TEST
0.98
1.00
95934
H-REFLEX TEST
0.99
1.00
95934
H-REFLEX TEST
1.31
1.00
95936
H-REFLEX TEST
1.05
1.00
95936
H-REFLEX TEST
1.16
1.00
95937
NEUROMUSCULAR JUNCTION TEST
1.30
1.00
95937
NEUROMUSCULAR JUNCTION TEST
1.57
1.00
95950
AMBULATORY EEG MONITORING
6.51
1.00
95950
AMBULATORY EEG MONITORING
6.58
1.00
95950
AMBULATORY EEG MONITORING
8.74
1.00
95951
EEG MONITORING/VIDEORECORD
8.27
1.00
95951
EEG MONITORING/VIDEORECORD
8.43
1.00
95951
EEG MONITORING/VIDEORECORD
8.65
1.00
95951
EEG MONITORING/VIDEORECORD
8.80
1.00
95951
EEG MONITORING/VIDEORECORD
8.82
1.00
95951
EEG MONITORING/VIDEORECORD
8.87
1.00
95953
EEG MONITORING/COMPUTER
11.06
1.00
95953
EEG MONITORING/COMPUTER
11.17
1.00
95953
EEG MONITORING/COMPUTER
11.27
1.00
95956
EEG MONITORING, CABLE/RADIO
17.78
1.00
95956
EEG MONITORING, CABLE/RADIO
19.24
1.00
95956
EEG MONITORING, CABLE/RADIO
19.42
1.00
95957
EEG DIGITAL ANALYSIS
4.71
1.00
95957
EEG DIGITAL ANALYSIS
4.74
1.00
95957
EEG DIGITAL ANALYSIS
7.11
1.00
95961
ELECTRODE STIMULATION, BRAIN
5.86
1.00
95961
ELECTRODE STIMULATION, BRAIN
5.89
1.00
95961
ELECTRODE STIMULATION, BRAIN
6.42
1.00
95962
ELECTRODE STIM, BRAIN ADD-ON
5.89
1.00
Procedure Code Description
RVU
RVU Coeff Value
95962
ELECTRODE STIM, BRAIN ADD-ON
6.16
1.00
95962
ELECTRODE STIM, BRAIN ADD-ON
6.19
1.00
95965
MEG, SPONTANEOUS
11.31
1.00
95965
MEG, SPONTANEOUS
11.42
1.00
95965
MEG, SPONTANEOUS
11.78
1.00
95965
MEG, SPONTANEOUS
11.86
1.00
95965
MEG, SPONTANEOUS
11.88
1.00
95966
MEG, EVOKED, SINGLE
5.62
1.00
95966
MEG, EVOKED, SINGLE
5.70
1.00
95966
MEG, EVOKED, SINGLE
5.89
1.00
95966
MEG, EVOKED, SINGLE
5.90
1.00
95967
MEG, EVOKED, EACH ADDÏL
4.81
1.00
95967
MEG, EVOKED, EACH ADDÏL
4.82
1.00
95967
MEG, EVOKED, EACH ADDÏL
4.83
1.00
95967
MEG, EVOKED, EACH ADDÏL
4.98
1.00
95967
MEG, EVOKED, EACH ADDÏL
4.99
1.00
95970
ANALYZE NEUROSTIM, NO PROG
0.61
1.00
95970
ANALYZE NEUROSTIM, NO PROG
0.63
1.00
95970
ANALYZE NEUROSTIM, NO PROG
0.64
1.00
95971
ANALYZE NEUROSTIM, SIMPLE
1.07
1.00
95971
ANALYZE NEUROSTIM, SIMPLE
1.08
1.00
95971
ANALYZE NEUROSTIM, SIMPLE
1.11
1.00
95972
ANALYZE NEUROSTIM, COMPLEX
2.11
1.00
95972
ANALYZE NEUROSTIM, COMPLEX
2.18
1.00
95972
ANALYZE NEUROSTIM, COMPLEX
2.20
1.00
95973
ANALYZE NEUROSTIM, COMPLEX
1.25
1.00
95973
ANALYZE NEUROSTIM, COMPLEX
1.34
1.00
95973
ANALYZE NEUROSTIM, COMPLEX
1.35
1.00
95974
CRANIAL NEUROSTIM, COMPLEX
4.10
1.00
95974
CRANIAL NEUROSTIM, COMPLEX
4.47
1.00
95975
CRANIAL NEUROSTIM, COMPLEX
2.37
1.00
95975
CRANIAL NEUROSTIM, COMPLEX
2.51
1.00
95975
CRANIAL NEUROSTIM, COMPLEX
2.52
1.00
95978
ANALYZE NEUROSTIM BRAIN/1H
4.81
1.00
95979
ANALYZ NEUROSTIM BRAIN ADDON
2.26
1.00
Procedure Code Description
RVU
RVU Coeff Value
95980
IO ANAL GAST N-STIM INIT
1.12
1.00
95981
IO ANAL GAST N-STIM SUBSQ
0.44
1.00
95982
IO GA N-STIM SUBSQ W/REPROG
0.90
1.00
95990
SPIN/BRAIN PUMP REFIL & MAIN
1.54
1.00
95990
SPIN/BRAIN PUMP REFIL & MAIN
1.56
1.00
95990
SPIN/BRAIN PUMP REFIL & MAIN
1.62
1.00
95991
SPIN/BRAIN PUMP REFIL & MAIN
1.01
1.00
95991
SPIN/BRAIN PUMP REFIL & MAIN
1.02
1.00
95992
CANALITH REPOSITIONING PROC
1.02
1.00
97001
PT EVALUATION
1.71
1.00
97001
PT EVALUATION
1.94
1.00
97002
PT RE-EVALUATION
0.86
1.00
97002
PT RE-EVALUATION
1.04
1.00
97003
OT EVALUATION
1.66
1.00
97003
OT EVALUATION
2.06
1.00
97004
OT RE-EVALUATION
0.82
1.00
97004
OT RE-EVALUATION
1.19
1.00
97010
HOT OR COLD PACKS THERAPY
0.12
1.00
97010
HOT OR COLD PACKS THERAPY
0.13
1.00
97012
MECHANICAL TRACTION THERAPY
0.40
1.00
97014
ELECTRIC STIMULATION THERAPY
0.37
1.00
97014
ELECTRIC STIMULATION THERAPY
0.38
1.00
97016
VASOPNEUMATIC DEVICE THERAPY
0.38
1.00
97016
VASOPNEUMATIC DEVICE THERAPY
0.42
1.00
97018
PARAFFIN BATH THERAPY
0.18
1.00
97018
PARAFFIN BATH THERAPY
0.22
1.00
97020
MICROWAVE THERAPY
0.13
1.00
97022
WHIRLPOOL THERAPY
0.40
1.00
97022
WHIRLPOOL THERAPY
0.48
1.00
97024
DIATHERMY EG, MICROWAVE
0.13
1.00
97024
DIATHERMY EG, MICROWAVE
0.15
1.00
97024
DIATHERMY EG, MICROWAVE
0.16
1.00
97026
INFRARED THERAPY
0.13
1.00
97026
INFRARED THERAPY
0.14
1.00
97028
ULTRAVIOLET THERAPY
0.16
1.00
Procedure Code Description
RVU
RVU Coeff Value
97028
ULTRAVIOLET THERAPY
0.17
1.00
97032
ELECTRICAL STIMULATION
0.42
1.00
97032
ELECTRICAL STIMULATION
0.44
1.00
97032
ELECTRICAL STIMULATION
0.45
1.00
97033
ELECTRIC CURRENT THERAPY
0.55
1.00
97033
ELECTRIC CURRENT THERAPY
0.56
1.00
97033
ELECTRIC CURRENT THERAPY
0.67
1.00
97034
CONTRAST BATH THERAPY
0.38
1.00
97034
CONTRAST BATH THERAPY
0.41
1.00
97035
ULTRASOUND THERAPY
0.32
1.00
97035
ULTRASOUND THERAPY
0.33
1.00
97036
HYDROTHERAPY
0.62
1.00
97036
HYDROTHERAPY
0.70
1.00
97039
PHYSICAL THERAPY TREATMENT
0.31
1.00
97039
PHYSICAL THERAPY TREATMENT
0.32
1.00
97110
THERAPEUTIC EXERCISES
0.76
1.00
97110
THERAPEUTIC EXERCISES
0.77
1.00
97110
THERAPEUTIC EXERCISES
0.78
1.00
97112
NEUROMUSCULAR REEDUCATION
0.77
1.00
97112
NEUROMUSCULAR REEDUCATION
0.78
1.00
97112
NEUROMUSCULAR REEDUCATION
0.80
1.00
97113
AQUATIC THERAPY/EXERCISES
0.81
1.00
97113
AQUATIC THERAPY/EXERCISES
0.88
1.00
97113
AQUATIC THERAPY/EXERCISES
0.95
1.00
97116
GAIT TRAINING THERAPY
0.66
1.00
97116
GAIT TRAINING THERAPY
0.67
1.00
97116
GAIT TRAINING THERAPY
0.68
1.00
97124
MASSAGE THERAPY
0.59
1.00
97124
MASSAGE THERAPY
0.60
1.00
97124
MASSAGE THERAPY
0.62
1.00
97139
PHYSICAL MEDICINE PROCEDURE
0.42
1.00
97139
PHYSICAL MEDICINE PROCEDURE
0.43
1.00
97140
MANUAL THERAPY
0.71
1.00
97140
MANUAL THERAPY
0.72
1.00
97150
GROUP THERAPEUTIC PROCEDURES
0.47
1.00
Procedure Code Description
RVU
RVU Coeff Value
97150
GROUP THERAPEUTIC PROCEDURES
0.49
1.00
97150
GROUP THERAPEUTIC PROCEDURES
0.50
1.00
97150
GROUP THERAPEUTIC PROCEDURES
100.00
1.00
97504
ORTHOTIC TRAINING
0.77
1.00
97504
ORTHOTIC TRAINING
0.81
1.00
97504
ORTHOTIC TRAINING
0.82
1.00
97520
PROSTHETIC TRAINING
0.74
1.00
97520
PROSTHETIC TRAINING
0.75
1.00
97530
THERAPEUTIC ACTIVITIES
0.77
1.00
97530
THERAPEUTIC ACTIVITIES
0.78
1.00
97530
THERAPEUTIC ACTIVITIES
0.82
1.00
97532
COGNITIVE SKILLS DEVELOPMENT
0.65
1.00
97532
COGNITIVE SKILLS DEVELOPMENT
0.66
1.00
97532
COGNITIVE SKILLS DEVELOPMENT
0.67
1.00
97532
COGNITIVE SKILLS DEVELOPMENT
100.00
1.00
97533
SENSORY INTEGRATION
0.69
1.00
97533
SENSORY INTEGRATION
0.72
1.00
97535
SELF CARE MNGMENT TRAINING
0.80
1.00
97535
SELF CARE MNGMENT TRAINING
0.82
1.00
97537
COMMUNITY/WORK REINTEGRATION
0.73
1.00
97537
COMMUNITY/WORK REINTEGRATION
0.74
1.00
97542
WHEELCHAIR MNGMENT TRAINING
0.74
1.00
97542
WHEELCHAIR MNGMENT TRAINING
0.75
1.00
97597
ACTIVE WOUND CARE/20 CM OR <
0.89
1.00
97598
ACTIVE WOUND CARE > 20 CM
1.18
1.00
97601
WOUND(S) CARE, SELECTIVE
1.04
1.00
97601
WOUND(S) CARE, SELECTIVE
1.07
1.00
97605
NEG PRESS WOUND TX, < 50 CM
0.72
1.00
97606
NEG PRESS WOUND TX, > 50 CM
0.79
1.00
97703
PROSTHETIC CHECKOUT
0.60
1.00
97703
PROSTHETIC CHECKOUT
0.68
1.00
97750
PHYSICAL PERFORMANCE TEST
0.77
1.00
97750
PHYSICAL PERFORMANCE TEST
0.78
1.00
97750
PHYSICAL PERFORMANCE TEST
0.80
1.00
97755
ASSISTIVE TECHNOLOGY ASSESS
0.92
1.00
Procedure Code Description
RVU
RVU Coeff Value
97755
ASSISTIVE TECHNOLOGY ASSESS
0.93
1.00
97760
ORTHOTIC MGMT AND TRAINING
0.89
1.00
97761
PROSTHETIC TRAINING
0.79
1.00
97762
C/O FOR ORTHOTIC/PROSTH USE
0.92
1.00
99288
DIRECT ADVANCED LIFE SUPPORT
999.99
1.00
99291
CRITICAL CARE, FIRST HOUR
5.44
1.00
99292
CRITICAL CARE, ADDÏL 30 MIN
2.72
1.00
99293
PED CRITICAL CARE, INITIAL
21.37
1.00
99293
PED CRITICAL CARE, INITIAL
21.78
1.00
99294
PED CRITICAL CARE, SUBSEQ
10.47
1.00
99294
PED CRITICAL CARE, SUBSEQ
10.76
1.00
99295
NEONATE CRIT CARE, INITIAL
24.59
1.00
99295
NEONATE CRIT CARE, INITIAL
24.67
1.00
99295
NEONATE CRIT CARE, INITIAL
24.69
1.00
99296
NEONATE CRITICAL CARE SUBSEQ
10.61
1.00
99296
NEONATE CRITICAL CARE SUBSEQ
10.82
1.00
99296
NEONATE CRITICAL CARE SUBSEQ
10.84
1.00
99298
IC FOR LBW INFANT < 1500 GM
3.72
1.00
99298
IC FOR LBW INFANT < 1500 GM
3.80
1.00
99298
IC FOR LBW INFANT < 1500 GM
3.81
1.00
99299
IC, LBW INFANT 1500-2500 GM
3.38
1.00
99299
IC, LBW INFANT 1500-2500 GM
3.57
1.00
99300
IC, INFANT PBW 2501-5000 GM
3.32
1.00
99301
NURSING FACILITY CARE
1.65
1.00
99301
NURSING FACILITY CARE
1.66
1.00
99301
NURSING FACILITY CARE
1.75
1.00
99302
NURSING FACILITY CARE
2.21
1.00
99302
NURSING FACILITY CARE
2.32
1.00
99303
NURSING FACILITY CARE
2.75
1.00
99303
NURSING FACILITY CARE
2.86
1.00
99311
NURSING FAC CARE, SUBSEQ
0.82
1.00
99311
NURSING FAC CARE, SUBSEQ
0.83
1.00
99311
NURSING FAC CARE, SUBSEQ
0.90
1.00
99312
NURSING FAC CARE, SUBSEQ
1.37
1.00
99312
NURSING FAC CARE, SUBSEQ
1.38
1.00
Procedure Code Description
RVU
RVU Coeff Value
99312
NURSING FAC CARE, SUBSEQ
1.49
1.00
99313
NURSING FAC CARE, SUBSEQ
1.94
1.00
99313
NURSING FAC CARE, SUBSEQ
1.95
1.00
99313
NURSING FAC CARE, SUBSEQ
2.10
1.00
99341
HOME VISIT, NEW PATIENT
1.55
1.00
99341
HOME VISIT, NEW PATIENT
1.61
1.00
99342
HOME VISIT, NEW PATIENT
2.26
1.00
99342
HOME VISIT, NEW PATIENT
2.42
1.00
99343
HOME VISIT, NEW PATIENT
3.30
1.00
99343
HOME VISIT, NEW PATIENT
3.60
1.00
99344
HOME VISIT, NEW PATIENT
4.33
1.00
99344
HOME VISIT, NEW PATIENT
4.68
1.00
99345
HOME VISIT, NEW PATIENT
5.36
1.00
99345
HOME VISIT, NEW PATIENT
5.72
1.00
99347
HOME VISIT, EST PATIENT
1.19
1.00
99347
HOME VISIT, EST PATIENT
1.27
1.00
99348
HOME VISIT, EST PATIENT
2.02
1.00
99349
HOME VISIT, EST PATIENT
3.13
1.00
99350
HOME VISIT, EST PATIENT
4.55
1.00
99350
HOME VISIT, EST PATIENT
4.56
1.00
99354
PROLONGED SERVICE, OFFICE
2.44
1.00
99354
PROLONGED SERVICE, OFFICE
2.50
1.00
99355
PROLONGED SERVICE, OFFICE
2.42
1.00
99355
PROLONGED SERVICE, OFFICE
2.46
1.00
99356
PROLONGED SERVICE, INPATIENT
2.37
1.00
99356
PROLONGED SERVICE, INPATIENT
2.40
1.00
99357
PROLONGED SERVICE, INPATIENT
2.38
1.00
99357
PROLONGED SERVICE, INPATIENT
2.41
1.00
99360
PHYSICIAN STANDBY SERVICES
2.44
1.00
99360
PHYSICIAN STANDBY SERVICES
2.50
1.00
99381
INIT PM E/M, NEW PAT, INF
1.69
1.00
99382
INIT PM E/M, NEW PAT 1-4 YRS
1.93
1.00
99383
PREV VISIT, NEW, AGE 5-11
1.93
1.00
99384
PREV VISIT, NEW, AGE 12-17
2.18
1.00
99385
PREV VISIT, NEW, AGE 18-39
2.18
1.00
Procedure Code Description
RVU
RVU Coeff Value
99386
PREV VISIT, NEW, AGE 40-64
2.67
1.00
99387
INIT PM E/M, NEW PAT 65+ YRS
2.92
1.00
99391
PER PM REEVAL, EST PAT, INF
1.45
1.00
99392
PREV VISIT, EST, AGE 1-4
1.69
1.00
99393
PREV VISIT, EST, AGE 5-11
1.69
1.00
99394
PREV VISIT, EST, AGE 12-17
1.93
1.00
99395
PREV VISIT, EST, AGE 18-39
1.93
1.00
99396
PREV VISIT, EST, AGE 40-64
2.18
1.00
99397
PER PM REEVAL EST PAT 65+ YR
2.43
1.00
99431
INITIAL CARE, NORMAL NEWBORN
1.54
1.00
99431
INITIAL CARE, NORMAL NEWBORN
1.60
1.00
99432
NEWBORN CARE, NOT IN HOSP
1.67
1.00
99432
NEWBORN CARE, NOT IN HOSP
1.73
1.00
99433
NORMAL NEWBORN CARE/HOSPITAL
0.83
1.00
99433
NORMAL NEWBORN CARE/HOSPITAL
0.84
1.00
99435
NEWBORN DISCHARGE DAY HOSP
2.10
1.00
99436
ATTENDANCE, BIRTH
1.96
1.00
99440
NEWBORN RESUSCITATION
3.85
1.00
99440
NEWBORN RESUSCITATION
3.99
1.00
99440
NEWBORN RESUSCITATION
4.00
1.00
G0030
PET IMAGING PREV PET SINGLE
8.87
1.00
G0030
PET IMAGING PREV PET SINGLE
8.95
1.00
G0030
PET IMAGING PREV PET SINGLE
8.99
1.00
G0031
PET IMAGING PREV PET MULTPLE
14.30
1.00
G0031
PET IMAGING PREV PET MULTPLE
14.45
1.00
G0031
PET IMAGING PREV PET MULTPLE
14.49
1.00
G0032
PET FOLLOW SPECT 78464 SINGL
8.87
1.00
G0032
PET FOLLOW SPECT 78464 SINGL
8.95
1.00
G0032
PET FOLLOW SPECT 78464 SINGL
8.99
1.00
G0033
PET FOLLOW SPECT 78464 MULT
14.30
1.00
G0033
PET FOLLOW SPECT 78464 MULT
14.45
1.00
G0033
PET FOLLOW SPECT 78464 MULT
14.49
1.00
G0034
PET FOLLOW SPECT 76865 SINGL
8.87
1.00
G0034
PET FOLLOW SPECT 76865 SINGL
8.95
1.00
G0034
PET FOLLOW SPECT 76865 SINGL
8.99
1.00
Procedure Code Description
RVU
RVU Coeff Value
G0035
PET FOLLOW SPECT 78465 MULT
14.30
1.00
G0035
PET FOLLOW SPECT 78465 MULT
14.45
1.00
G0035
PET FOLLOW SPECT 78465 MULT
14.49
1.00
G0036
PET FOLLOW CORNRY ANGIO SING
8.87
1.00
G0036
PET FOLLOW CORNRY ANGIO SING
8.95
1.00
G0036
PET FOLLOW CORNRY ANGIO SING
8.99
1.00
G0037
PET FOLLOW CORNRY ANGIO MULT
14.30
1.00
G0037
PET FOLLOW CORNRY ANGIO MULT
14.45
1.00
G0037
PET FOLLOW CORNRY ANGIO MULT
14.49
1.00
G0038
PET FOLLOW MYOCARD PERF SING
8.87
1.00
G0038
PET FOLLOW MYOCARD PERF SING
8.95
1.00
G0038
PET FOLLOW MYOCARD PERF SING
8.99
1.00
G0039
PET FOLLOW MYOCARD PERF MULT
14.30
1.00
G0039
PET FOLLOW MYOCARD PERF MULT
14.45
1.00
G0039
PET FOLLOW MYOCARD PERF MULT
14.49
1.00
G0040
PET FOLLOW STRESS ECHO SINGL
8.87
1.00
G0040
PET FOLLOW STRESS ECHO SINGL
8.95
1.00
G0040
PET FOLLOW STRESS ECHO SINGL
8.99
1.00
G0041
PET FOLLOW STRESS ECHO MULT
14.30
1.00
G0041
PET FOLLOW STRESS ECHO MULT
14.45
1.00
G0041
PET FOLLOW STRESS ECHO MULT
14.49
1.00
G0042
PET FOLLOW VENTRICULOGM SING
8.87
1.00
G0042
PET FOLLOW VENTRICULOGM SING
8.95
1.00
G0042
PET FOLLOW VENTRICULOGM SING
8.99
1.00
G0043
PET FOLLOW VENTRICULOGM MULT
14.30
1.00
G0043
PET FOLLOW VENTRICULOGM MULT
14.45
1.00
G0043
PET FOLLOW VENTRICULOGM MULT
14.49
1.00
G0044
PET FOLLOWING REST ECG SINGL
8.87
1.00
G0044
PET FOLLOWING REST ECG SINGL
8.95
1.00
G0044
PET FOLLOWING REST ECG SINGL
8.99
1.00
G0045
PET FOLLOWING REST ECG MULT
14.30
1.00
G0045
PET FOLLOWING REST ECG MULT
14.45
1.00
G0045
PET FOLLOWING REST ECG MULT
14.49
1.00
G0046
PET FOLLOW STRESS ECG SINGL
8.87
1.00
G0046
PET FOLLOW STRESS ECG SINGL
8.95
1.00
Procedure Code Description
RVU
RVU Coeff Value
G0046
PET FOLLOW STRESS ECG SINGL
8.99
1.00
G0047
PET FOLLOW STRESS ECG MULT
14.30
1.00
G0047
PET FOLLOW STRESS ECG MULT
14.45
1.00
G0047
PET FOLLOW STRESS ECG MULT
14.49
1.00
G0210
PET IMG WHOLEBODY DXLUNG
5.64
1.00
G0210
PET IMG WHOLEBODY DXLUNG
14.45
1.00
G0210
PET IMG WHOLEBODY DXLUNG
14.49
1.00
G0211
PET IMG WHOLBODY INIT LUNG
5.64
1.00
G0211
PET IMG WHOLBODY INIT LUNG
14.45
1.00
G0211
PET IMG WHOLBODY INIT LUNG
14.49
1.00
G0212
PET IMG WHOLEBOD RESTAG LUNG
5.64
1.00
G0212
PET IMG WHOLEBOD RESTAG LUNG
14.45
1.00
G0212
PET IMG WHOLEBOD RESTAG LUNG
14.49
1.00
G0213
PET IMG WHOLBODY DX
5.64
1.00
G0213
PET IMG WHOLBODY DX
14.45
1.00
G0213
PET IMG WHOLBODY DX
14.49
1.00
G0214
PET IMG WHOLEBOD INIT
5.64
1.00
G0214
PET IMG WHOLEBOD INIT
14.45
1.00
G0214
PET IMG WHOLEBOD INIT
14.49
1.00
G0215
PETIMG WHOLEBOD RESTAG
5.64
1.00
G0215
PETIMG WHOLEBOD RESTAG
14.45
1.00
G0215
PETIMG WHOLEBOD RESTAG
14.49
1.00
G0216
PET IMG WHOLEBOD DX MELANOMA
5.64
1.00
G0216
PET IMG WHOLEBOD DX MELANOMA
14.45
1.00
G0216
PET IMG WHOLEBOD DX MELANOMA
14.49
1.00
G0217
PET IMG WHOLEBOD INIT MELAN
5.64
1.00
G0217
PET IMG WHOLEBOD INIT MELAN
14.45
1.00
G0217
PET IMG WHOLEBOD INIT MELAN
14.49
1.00
G0218
PET IMG WHOLEBOD RESTAG MELA
5.64
1.00
G0218
PET IMG WHOLEBOD RESTAG MELA
14.45
1.00
G0218
PET IMG WHOLEBOD RESTAG MELA
14.49
1.00
G0220
PET IMG WHOLEBOD DX LYMPHOMA
5.64
1.00
G0220
PET IMG WHOLEBOD DX LYMPHOMA
14.45
1.00
G0220
PET IMG WHOLEBOD DX LYMPHOMA
14.49
1.00
G0221
PET IMAG WHOLBOD INIT LYMPHO
5.64
1.00
Procedure Code Description
RVU
RVU Coeff Value
G0221
PET IMAG WHOLBOD INIT LYMPHO
14.45
1.00
G0221
PET IMAG WHOLBOD INIT LYMPHO
14.49
1.00
G0222
PET IMAG WHOLBOD RESTA LYMPH
5.64
1.00
G0222
PET IMAG WHOLBOD RESTA LYMPH
14.45
1.00
G0222
PET IMAG WHOLBOD RESTA LYMPH
14.49
1.00
G0223
PET IMAG WHOLBOD REG DX HEAD
5.64
1.00
G0223
PET IMAG WHOLBOD REG DX HEAD
14.45
1.00
G0223
PET IMAG WHOLBOD REG DX HEAD
14.49
1.00
G0224
PET IMAG WHOLBOD REG INI HEA
5.64
1.00
G0224
PET IMAG WHOLBOD REG INI HEA
14.45
1.00
G0224
PET IMAG WHOLBOD REG INI HEA
14.49
1.00
G0225
PET WHOL RESTAG HEADNECKONLY
5.64
1.00
G0225
PET WHOL RESTAG HEADNECKONLY
14.45
1.00
G0225
PET WHOL RESTAG HEADNECKONLY
14.49
1.00
G0226
PET IMG WHOLBODY DX ESOPHAGL
5.64
1.00
G0226
PET IMG WHOLBODY DX ESOPHAGL
14.45
1.00
G0226
PET IMG WHOLBODY DX ESOPHAGL
14.49
1.00
G0227
PET IMG WHOLBOD INI ESOPHAGE
5.64
1.00
G0227
PET IMG WHOLBOD INI ESOPHAGE
14.45
1.00
G0227
PET IMG WHOLBOD INI ESOPHAGE
14.49
1.00
G0228
PET IMG WHOLBOD RESTG ESOPHA
5.64
1.00
G0228
PET IMG WHOLBOD RESTG ESOPHA
14.45
1.00
G0228
PET IMG WHOLBOD RESTG ESOPHA
14.49
1.00
G0229
PET IMG METABOLOC BRAIN PRES
5.64
1.00
G0229
PET IMG METABOLOC BRAIN PRES
14.45
1.00
G0229
PET IMG METABOLOC BRAIN PRES
14.49
1.00
G0230
PET MYOCARD VIABILITY POST
5.64
1.00
G0230
PET MYOCARD VIABILITY POST
14.45
1.00
G0230
PET MYOCARD VIABILITY POST
14.49
1.00
G0231
PET WHBD COLOREC; GAMMA CAM
5.64
1.00
G0231
PET WHBD COLOREC; GAMMA CAM
14.45
1.00
G0231
PET WHBD COLOREC; GAMMA CAM
14.49
1.00
G0232
PET WHBD LYMPHOMA; GAMMA CAM
5.64
1.00
G0232
PET WHBD LYMPHOMA; GAMMA CAM
14.45
1.00
G0232
PET WHBD LYMPHOMA; GAMMA CAM
14.49
1.00
Procedure Code Description
RVU
RVU Coeff Value
G0233
PET WHBD MELANOMA; GAMMA CAM
5.64
1.00
G0233
PET WHBD MELANOMA; GAMMA CAM
14.45
1.00
G0233
PET WHBD MELANOMA; GAMMA CAM
14.49
1.00
G0234
PET WHBD PULM NOD; GAMMA CAM
5.64
1.00
G0234
PET WHBD PULM NOD; GAMMA CAM
14.45
1.00
G0234
PET WHBD PULM NOD; GAMMA CAM
14.49
1.00
G0253
PET IMAGE BRST DECTION RECUR
14.45
1.00
G0253
PET IMAGE BRST DECTION RECUR
14.49
1.00
G0254
PET IMAGE BRST EVAL TO TX
14.45
1.00
G0254
PET IMAGE BRST EVAL TO TX
14.49
1.00
G0296
PET IMGE RESTAG THYROD CANCE
14.45
1.00
G0296
PET IMGE RESTAG THYROD CANCE
14.49
1.00
V2101
SINGLE VISN SPHERE 4.12-7.00
1.00
16.05
Maximum Allowable
0001F
9
HEART FAILURE COMPOSITE
$0.00
0001T
O
ENDOVAS REPR ABDO AO ANEURYS
$0.00
0002F
O
TOBACCO USE, SMOKING, ASSESS
$0.00
0002T
9
ENDOVAS REPR ABDO AO ANEURYS
$0.00
0003F
O
TOBACCO USE, NON-SMOKING
$0.00
0003T
O
CERVICOGRAPHY
$0.00
0004F
O
TOBACCO USE TXMNT COUNSELING
$0.00
0005F
9
OSTEOARTHRITIS COMPOSITE
$0.00
0005T
O
PERC CATH STENT/BRAIN CV ART
$0.00
0006F
O
STATIN THERAPY, PRESCRIBED
$0.00
0006T
O
PERC CATH STENT/BRAIN CV ART
$0.00
0007F
O
BETA-BLOCKER THX PRESCRIBED
$0.00
0007T
O
PERC CATH STENT/BRAIN CV ART
$0.00
0008F
O
ACE INHIBITOR THX PRESCRIBED
$0.00
0008T
O
UPPER GI ENDOSCOPY W/SUTURE
$0.00
0009F
O
ASSESS ANGINAL SYMPTOM/LEVEL
$0.00
0009T
O
ENDOMETRIAL CRYOABLATION
$0.00
00100
A
ANESTH, SALIVARY GLAND
$0.00
00102
A
ANESTH, REPAIR OF CLEFT LIP
$0.00
00103
A
ANESTH, BLEPHAROPLASTY
$0.00
00104
A
ANESTH, ELECTROSHOCK
$0.00
0010F
O
ASSESS ANGINAL SYMPTOM/LEVEL
$0.00
0010T
O
TB TEST, GAMMA INTERFERON
$0.00
0011F
O
ORAL ANTIPLAT THX PRESCRIBED
$0.00
00120
A
ANESTH, EAR SURGERY
$0.00
00124
A
ANESTH, EAR EXAM
$0.00
00126
A
ANESTH, TYMPANOTOMY
$0.00
0012F
9
CAP BACTERIAL ASSESS
$0.00
0012T
O
OSTEOCHONDRAL KNEE AUTOGRAFT
$0.00
0013T
O
OSTEOCHONDRAL KNEE ALLOGRAFT
$0.00
00140
A
ANESTH, PROCEDURES ON EYE
$0.00
00142
A
ANESTH, LENS SURGERY
$0.00
00144
A
ANESTH, CORNEAL TRANSPLANT
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
00145
A
ANESTH, VITREORETINAL SURG
$0.00
00147
A
ANESTH, IRIDECTOMY
$0.00
00148
A
ANESTH, EYE EXAM
$0.00
0014F
9
COMP PREOP ASSESS CAT SURG
$0.00
0014T
O
MENISCAL TRANSPLANTATION, MEDIAL OR
$0.00
0015F
9
MELAN FOLLOW-UP COMPLETE
$0.00
00160
A
ANESTH, NOSE/SINUS SURGERY
$0.00
00162
A
ANESTH, NOSE/SINUS SURGERY
$0.00
00164
A
ANESTH, BIOPSY OF NOSE
$0.00
0016T
9
THERMOTX CHOROID VASC LESION
$0.00
00170
A
ANESTH, PROCEDURE ON MOUTH
$0.00
00172
A
ANESTH, CLEFT PALATE REPAIR
$0.00
00174
A
ANESTH, PHARYNGEAL SURGERY
$0.00
00176
A
ANESTH, PHARYNGEAL SURGERY
$0.00
0017T
9
PHOTOCOAGULAT MACULAR DRUSEN
$0.00
0018T
O
TRANSCRANIAL MAGNETIC STIMUL
$0.00
00190
A
ANESTH, FACE/SKULL BONE SURG
$0.00
00192
A
ANESTH, FACIAL BONE SURGERY
$0.00
0019T
9
EXTRACORP SHOCK WAVE, MS, NOS
$0.00
0020T
O
EXTRACORP SHOCK WAVE TX, FT
$0.00
00210
A
ANESTH, CRANIAL SURG NOS
$0.00
00211
A
ANESTH, CRAN SURG, HEMOTOMA
$0.00
00212
A
ANESTH, SKULL DRAINAGE
$0.00
00214
A
ANESTH, SKULL DRAINAGE
$0.00
00215
A
ANESTH, SKULL REPAIR/FRACT
$0.00
00216
A
ANESTH, HEAD VESSEL SURGERY
$0.00
00218
A
ANESTH, SPECIAL HEAD SURGERY
$0.00
0021T
O
FETAL OXIMETRY, TRNSVAG/CERV
$0.00
00220
A
ANESTH, INTRCRN NERVE
$0.00
00222
A
ANESTH, HEAD NERVE SURGERY
$0.00
0023T
O
PHENOTYPE DRUG TEST, HIV 1
$0.00
0024T
O
TRANSCATH CARDIAC REDUCTION
$0.00
0025T
O
ULTRASONIC PACHYMETRY
$0.00
0026T
O
MEASURE REMNANT LIPOPROTEINS
$0.00
0027T
O
ENDOSCOPIC EPIDURAL LYSIS
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
0028T
O
DEXA BODY COMPOSITION STUDY
$0.00
0029T
O
MAGNETIC TX FOR INCONTINENCE
$0.00
00300
A
ANESTH, HEAD/NECK/PTRUNK
$0.00
0030T
9
ANTIPROTHROMBIN ANTIBODY
$0.00
0031T
O
SPECULOSCOPY
$0.00
00320
A
ANESTH, NECK ORGAN, 1 & OVER
$0.00
00322
A
ANESTH, BIOPSY OF THYROID
$0.00
00326
A
ANESTH, LARYNX/TRACH, < 1 YR
$0.00
0032T
O
SPECULOSCOPY W/DIRECT SAMPLE
$0.00
0033T
O
ENDOVASC TAA REPR INCL SUBCL
$0.00
0034T
O
ENDOVASC TAA REPR W/O SUBCL
$0.00
00350
A
ANESTH, NECK VESSEL SURGERY
$0.00
00352
A
ANESTH, NECK VESSEL SURGERY
$0.00
0035T
O
INSERT ENDOVASC PROSTH, TAA
$0.00
0036T
O
ENDOVASC PROSTH, TAA, ADD-ON
$0.00
0037T
O
ARTERY TRANSPOSE/ENDOVAS TAA
$0.00
0038T
O
RAD ENDOVASC TAA RPR W/COVER
$0.00
0039T
O
RAD S/I, ENDOVASC TAA REPAIR
$0.00
00400
A
ANESTH, SKIN, EXT/PER/ATRUNK
$0.00
00402
A
ANESTH, SURGERY OF BREAST
$0.00
00404
A
ANESTH, SURGERY OF BREAST
$0.00
00406
A
ANESTH, SURGERY OF BREAST
$0.00
0040T
O
RAD S/I, ENDOVASC TAA PROSTH
$0.00
00410
A
ANESTH, CORRECT HEART RHYTHM
$0.00
0041T
O
DETECT UR INFECT AGNT W/CPAS
$0.00
00420
9
ANESTH, SKIN SURGERY, BACK
$0.00
0042T
9
CT PERFUSION W/CONTRAST, CBF
$0.00
0043T
O
CO EXPIRED GAS ANALYSIS
$0.00
0044T
O
WHOLE BODY PHOTOGRAPHY
$0.00
00450
A
ANESTH, SURGERY OF SHOULDER
$0.00
00452
A
ANESTH, SURGERY OF SHOULDER
$0.00
00454
A
ANESTH, COLLAR BONE BIOPSY
$0.00
0045T
O
WHOLE BODY PHOTOGRAPHY
$0.00
0046T
O
CATH LAVAGE, MAMMARY DUCT(S)
$0.00
00470
A
ANESTH, REMOVAL OF RIB
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
00472
A
ANESTH, CHEST WALL REPAIR
$0.00
00474
A
ANESTH, SURGERY OF RIB(S)
$0.00
0047T
O
CATH LAVAGE, MAMMARY DUCT(S)
$0.00
0048T
9
IMPLANT VENTRICULAR DEVICE
$0.00
0049T
O
EXTERNAL CIRCULATION ASSIST
$0.00
00500
A
ANESTH, ESOPHAGEAL SURGERY
$0.00
0050T
9
REMOVAL CIRCULATION ASSIST
$0.00
0051T
9
IMPLANT TOTAL HEART SYSTEM
$0.00
00520
A
ANESTH, CHEST PROCEDURE
$0.00
00522
A
ANESTH, CHEST LINING BIOPSY
$0.00
00524
A
ANESTH, CHEST DRAINAGE
$0.00
00528
A
ANESTH, CHEST PARTITION VIEW
$0.00
00529
9
ANESTH, CHEST PARTITION VIEW
$0.00
0052T
9
REPLACE COMPONENT HEART SYST
$0.00
00530
A
ANESTH, PACEMAKER INSERTION
$0.00
00532
A
ANESTH, VASCULAR ACCESS
$0.00
00534
A
ANESTH, CARDIOVERTER/DEFIB
$0.00
00537
A
ANESTH, CARDIAC ELECTROPHYS
$0.00
00539
A
ANESTH,TRACHEOBRONCHIAL RECONSTRUC
$0.00
0053T
9
REPLACE COMPONENT HEART SYST
$0.00
00540
A
ANESTH, CHEST SURGERY
$0.00
00541
A
ANESTH, ONE LUNG VENTILATION
$0.00
00542
A
ANESTH, RELEASE OF LUNG
$0.00
00544
O
ANESTH, CHEST LINING REMOVAL
$0.00
00546
A
ANESTH, LUNG,CHEST WALL SURG
$0.00
00548
A
ANESTH, TRACHEA,BRONCHI SURG
$0.00
0054T
O
BONE SURGERY USING COMPUTER
$0.00
00550
A
ANESTH, STERNAL DEBRIDEMENT
$0.00
0055T
O
BONE SURGERY USING COMPUTER
$0.00
00560
A
ANESTH, HEART SURG W/O PUMP
$0.00
00561
A
ANESTH, HEART SURG < AGE 1
$0.00
00562
A
ANESTH HRT SURG W/PMP AGE 1+
$0.00
00563
A
ANESTH, HEART SURG W/ARREST
$0.00
00566
A
ANESTH, CABG W/O PUMP
$0.00
00567
A
ANESTH, CABG W/PUMP
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
0056T
O
BONE SURGERY USING COMPUTER
$0.00
0057T
O
UPPR GI SCOPE W/ THRML TXMNT
$0.00
00580
A
ANESTH, HEART/LUNG TRANSPLNT
$0.00
0058T
O
CRYOPRESERVATION, OVARY TISS
$0.00
0059T
O
CRYOPRESERVATION, OOCYTE
$0.00
00600
A
ANESTH, SPINE, CORD SURGERY
$0.00
00604
A
ANESTH, SITTING PROCEDURE
$0.00
0060T
O
ELECTRICAL IMPEDANCE SCAN
$0.00
0061T
O
DESTRUCTION OF TUMOR, BREAST
$0.00
00620
A
ANESTH, SPINE, CORD SURGERY
$0.00
00622
A
ANESTH, REMOVAL OF NERVES
$0.00
00625
A
ANES SPINE TRANTHOR W/O VENT
$0.00
00626
A
ANES, SPINE TRANSTHOR W/VENT
$0.00
0062T
9
REP INTRADISC ANNULUS;1 LEV
$0.00
00630
A
ANESTH, SPINE, CORD SURGERY
$0.00
00632
A
ANESTH, REMOVAL OF NERVES
$0.00
00634
5
ANESTH FOR CHEMONUCLEOLYSIS
$0.00
00635
A
ANESTH, LUMBAR PUNCTURE
$0.00
0063T
9
REP INTRADISC ANNULUS;>1LEV
$0.00
00640
A
ANESTH, SPINE MANIPULATION
$0.00
0064T
9
SPECTROSCOP EVAL EXPIRED GAS
$0.00
0065T
O
OCULAR PHOTOSCREEN BILAT
$0.00
0066T
9
CT COLONOGRAPHY;SCREEN
$0.00
00670
A
ANESTH, SPINE, CORD SURGERY
$0.00
0067T
9
CT COLONOGRAPHY;DX
$0.00
0068T
9
INTERP/REPT HEART SOUND
$0.00
0069T
9
ANALYSIS ONLY HEART SOUND
$0.00
00700
A
ANESTH, ABDOMINAL WALL SURG
$0.00
00702
A
ANESTH, FOR LIVER BIOPSY
$0.00
0070T
9
INTERP ONLY HEART SOUND
$0.00
0071T
9
U/S LEIOMYOMATA ABLATE <200
$0.00
0072T
9
U/S LEIOMYOMATA ABLATE >200
$0.00
00730
A
ANESTH, ABDOMINAL WALL SURG
$0.00
0073T
9
DELIVERY, COMP IMRT
$0.00
00740
A
ANESTH, UPPER GI VISUALIZE
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
0074T
O
ONLINE PHYSICIAN E/M
$0.00
00750
A
ANESTH, REPAIR OF HERNIA
$0.00
00752
A
ANESTH, REPAIR OF HERNIA
$0.00
00754
A
ANESTH, REPAIR OF HERNIA
$0.00
00756
A
ANESTH, REPAIR OF HERNIA
$0.00
0075T
9
PERQ STENT/CHEST VERT ART
$0.00
0076T
9
S&I STENT/CHEST VERT ART
$0.00
00770
A
ANESTH, BLOOD VESSEL REPAIR
$0.00
0077T
9
CEREB THERM PERFUSION PROBE
$0.00
0078T
9
ENDOVASC AORT REPR W/DEVICE
$0.00
00790
A
ANESTH, SURG UPPER ABDOMEN
$0.00
00792
A
ANESTH, HEMORR/EXCISE LIVER
$0.00
00794
A
ANESTH, PANCREAS REMOVAL
$0.00
00796
A
ANESTH, FOR LIVER TRANSPLANT
$0.00
00797
A
ANESTH, SURGERY FOR OBESITY
$0.00
0079T
9
ENDOVASC VISC EXTNSN REPR
$0.00
00800
A
ANESTH, ABDOMINAL WALL SURG
$0.00
00802
A
ANESTH, FAT LAYER REMOVAL
$0.00
00806
O
ANESTHESIA FOR LAPAROSCOPIC PROCEDU
$0.00
0080T
9
ENDOVASC AORT REPR RAD S&I
$0.00
00810
A
ANESTH, LOW INTESTINE SCOPE
$0.00
0081T
9
ENDOVASC VISC EXTNSN S&I
$0.00
00820
A
ANESTH, ABDOMINAL WALL SURG
$0.00
0082T
O
STEREOTACTIC RAD DELIVERY
$0.00
00830
A
ANESTH, REPAIR OF HERNIA
$0.00
00832
A
ANESTH, REPAIR OF HERNIA
$0.00
00834
A
ANESTH, HERNIA REPAIR< 1 YR
$0.00
00836
A
ANESTH HERNIA REPAIR PREEMIE
$0.00
0083T
O
STEREOTACTIC RAD TX MNGMT
$0.00
00840
A
ANESTH, SURG LOWER ABDOMEN
$0.00
00842
A
ANESTH, AMNIOCENTESIS
$0.00
00844
A
ANESTH, PELVIS SURGERY
$0.00
00846
A
ANESTH, HYSTERECTOMY
$0.00
00848
A
ANESTH, PELVIC ORGAN SURG
$0.00
0084T
9
TEMP PROSTATE URETHRAL STENT
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
00850
9
ANESTH, CESAREAN SECTION
$0.00
00851
A
ANESTH, TUBAL LIGATION
$0.00
00855
9
ANESTH, HYSTERECTOMY
$0.00
00857
9
ANALGESIA, LABOR & C-SECTION
$0.00
0085T
9
BREATH TEST HEART REJECT
$0.00
00860
A
ANESTH, SURGERY OF ABDOMEN
$0.00
00862
A
ANESTH, KIDNEY/URETER SURG
$0.00
00864
A
ANESTH, REMOVAL OF BLADDER
$0.00
00865
A
ANESTH, REMOVAL OF PROSTATE
$0.00
00866
A
ANESTH, REMOVAL OF ADRENAL
$0.00
00868
A
ANESTH, KIDNEY TRANSPLANT
$0.00
00869
O
ANESTH, VASECTOMY
$0.00
0086T
9
L VENTRICLE FILL PRESSURE
$0.00
00870
A
ANESTH, BLADDER STONE SURG
$0.00
00872
A
ANESTH KIDNEY STONE DESTRUCT
$0.00
00873
A
ANESTH KIDNEY STONE DESTRUCT
$0.00
0087T
9
SPERM EVAL HYALURONAN
$0.00
00880
A
ANESTH, ABDOMEN VESSEL SURG
$0.00
00882
A
ANESTH, MAJOR VEIN LIGATION
$0.00
00884
9
ANESTH, MAJOR VEIN REVISION
$0.00
0088T
O
RF TONGUE BASE VOL REDUXN
$0.00
0089T
O
ACTIGRAPHY TESTING, 3-DAY
$0.00
00900
9
ANESTH, PERINEAL PROCEDURE
$0.00
00902
A
ANESTH, ANORECTAL SURGERY
$0.00
00904
A
ANESTH, PERINEAL SURGERY
$0.00
00906
A
ANESTH, REMOVAL OF VULVA
$0.00
00908
A
ANESTH, REMOVAL OF PROSTATE
$0.00
0090T
O
CERVICAL ARTIFIC DISC
$0.00
00910
A
ANESTH, BLADDER SURGERY
$0.00
00912
A
ANESTH, BLADDER TUMOR SURG
$0.00
00914
A
ANESTH, REMOVAL OF PROSTATE
$0.00
00916
A
ANESTH, BLEEDING CONTROL
$0.00
00918
A
ANESTH, STONE REMOVAL
$0.00
0091T
O
LUMBAR ARTIFIC DISC
$0.00
00920
A
ANESTH, GENITALIA SURGERY
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
00921
A
ANESTH, VASECTOMY
$0.00
00922
A
ANESTH, SPERM DUCT SURGERY
$0.00
00924
A
ANESTH, TESTIS EXPLORATION
$0.00
00926
A
ANESTH, REMOVAL OF TESTIS
$0.00
00928
A
ANESTH, REMOVAL OF TESTIS
$0.00
0092T
9
ARTIFIC DISC ADDL
$0.00
00930
A
ANESTH, TESTIS SUSPENSION
$0.00
00932
A
ANESTH, AMPUTATION OF PENIS
$0.00
00934
A
ANESTH, PENIS, NODES REMOVAL
$0.00
00936
A
ANESTH, PENIS, NODES REMOVAL
$0.00
00938
9
ANESTH, INSERT PENIS DEVICE
$0.00
0093T
O
CERVICAL ARTIFIC DISKECTOMY
$0.00
00940
A
ANESTH, VAGINAL PROCEDURES
$0.00
00942
A
ANESTH, SURG ON VAG/URETHRAL
$0.00
00944
A
ANESTH, VAGINAL HYSTERECTOMY
$0.00
00946
9
ANESTH, VAGINAL DELIVERY
$0.00
00948
A
ANESTH, REPAIR OF CERVIX
$0.00
0094T
O
LUMBAR ARTIFIC DISKECTOMY
$0.00
00950
A
ANESTH, VAGINAL ENDOSCOPY
$0.00
00952
A
ANESTH, HYSTEROSCOPE/GRAPH
$0.00
00955
9
ANALGESIA, VAGINAL DELIVERY
$0.00
0095T
9
ARTIFIC DISKECTOMY ADDL
$0.00
0096T
O
REV CERVICAL ARTIFIC DISC
$0.00
0097T
O
REV LUMBAR ARTIFIC DISC
$0.00
0098T
9
REV ARTIFIC DISC ADDL
$0.00
0099T
9
IMPLANT CORNEAL RING
$0.00
01000
9
ANESTH, SKIN SURGERY, PELVIS
$0.00
0100T
9
PROSTH RETINA RECEIVE&GEN
$0.00
0101T
9
EXTRACORP SHOCKWV TX,HI ENRG
$0.00
0102T
9
EXTRACORP SHOCKWV TX,ANESTH
$0.00
0103T
9
HOLOTRANSCOBALAMIN
$0.00
0104T
9
AT REST CARDIO GAS REBREATHE
$0.00
0105T
9
EXERC CARDIO GAS REBREATHE
$0.00
0106T
9
TOUCH QUANT SENSORY TEST
$0.00
0107T
9
VIBRATE QUANT SENSORY TEST
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
0108T
9
COOL QUANT SENSORY TEST
$0.00
0109T
9
HEAT QUANT SENSORY TEST
$0.00
0110T
9
NOS QUANT SENSORY TEST
$0.00
01110
9
ANESTH, SKIN SURGERY, PELVIS
$0.00
01112
A
ANESTH, BONE ASPIRATE/BX
$0.00
0111T
9
RBC MEMBRANES FATTY ACIDS
$0.00
01120
A
ANESTH, PELVIS SURGERY
$0.00
01130
A
ANESTH, BODY CAST PROCEDURE
$0.00
01140
A
ANESTH, AMPUTATION AT PELVIS
$0.00
01150
A
ANESTH, PELVIC TUMOR SURGERY
$0.00
0115T
O
MED TX MNGMT 15 MIN
$0.00
01160
A
ANESTH, PELVIS PROCEDURE
$0.00
0116T
O
MED TX MNGMT SUBSQT
$0.00
01170
A
ANESTH, PELVIS SURGERY
$0.00
01173
A
ANESTH, FX REPAIR, PELVIS
$0.00
0117T
O
MED TX MNGMT ADDL 15 MIN
$0.00
01180
A
ANESTH, PELVIS NERVE REMOVAL
$0.00
01190
A
ANESTH, PELVIS NERVE REMOVAL
$0.00
01200
A
ANESTH, HIP JOINT PROCEDURE
$0.00
01202
A
ANESTH, ARTHROSCOPY OF HIP
$0.00
0120T
O
FIBROADENOMA CRYOABLATE, EA
$0.00
01210
A
ANESTH, HIP JOINT SURGERY
$0.00
01212
A
ANESTH, HIP DISARTICULATION
$0.00
01214
A
ANESTH, HIP ARTHROPLASTY
$0.00
01215
A
ANESTH, REVISE HIP REPAIR
$0.00
01220
A
ANESTH, PROCEDURE ON FEMUR
$0.00
01230
A
ANESTH, SURGERY OF FEMUR
$0.00
01232
A
ANESTH, AMPUTATION OF FEMUR
$0.00
01234
A
ANESTH, RADICAL FEMUR SURG
$0.00
0123T
9
SCLERAL FISTULIZATION
$0.00
01240
9
ANESTH, UPPER LEG SKIN SURG
$0.00
0124T
9
CONJUNCTIVAL DRUG PLACEMENT
$0.00
01250
A
ANESTH, UPPER LEG SURGERY
$0.00
01260
A
ANESTH, UPPER LEG VEINS SURG
$0.00
0126T
9
CHD RISK IMT STUDY
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
01270
A
ANESTH, THIGH ARTERIES SURG
$0.00
01272
A
ANESTH, FEMORAL ARTERY SURG
$0.00
01274
A
ANESTH, FEMORAL EMBOLECTOMY
$0.00
01300
9
ANESTH, SKIN SURGERY, KNEE
$0.00
0130T
9
CHRON CARE DRUG INVESTIGATN
$0.00
01320
A
ANESTH, KNEE AREA SURGERY
$0.00
0133T
O
ESOPHAGEAL IMPLANT INJEXN
$0.00
01340
A
ANESTH, KNEE AREA PROCEDURE
$0.00
0135T
O
PERQ CRYOABLATE RENAL TUMOR
$0.00
01360
A
ANESTH, KNEE AREA SURGERY
$0.00
0137T
O
PROSTATE SATURATION SAMPLING
$0.00
01380
A
ANESTH, KNEE JOINT PROCEDURE
$0.00
01382
A
ANESTH, DX KNEE ARTHROSCOPY
$0.00
01390
A
ANESTH, KNEE AREA PROCEDURE
$0.00
01392
A
ANESTH, KNEE AREA SURGERY
$0.00
01400
A
ANESTH, KNEE JOINT SURGERY
$0.00
01402
A
ANESTH, KNEE ARTHROPLASTY
$0.00
01404
A
ANESTH, AMPUTATION AT KNEE
$0.00
0140T
9
EXHALED BREATH CONDENSATE PH
$0.00
0141T
9
PERQ ISLET TRANSPLANT
$0.00
01420
A
ANESTH, KNEE JOINT CASTING
$0.00
0142T
9
OPEN ISLET TRANSPLANT
$0.00
01430
A
ANESTH, KNEE VEINS SURGERY
$0.00
01432
A
ANESTH, KNEE VESSEL SURG
$0.00
0143T
9
LAPAROSCOPIC ISLET TRANSPLNT
$0.00
01440
A
ANESTH, KNEE ARTERIES SURG
$0.00
01442
A
ANESTH, KNEE ARTERY SURG
$0.00
01444
A
ANESTH, KNEE ARTERY REPAIR
$0.00
0144T
9
CT HEART WO DYE; QUAL CALC
$0.00
0145T
9
CT HEART W/WO DYE FUNCT
$0.00
01460
9
ANESTH, LOWER LEG SKIN SURG
$0.00
01462
A
ANESTH, LOWER LEG PROCEDURE
$0.00
01464
A
ANESTH, ANKLE/FT ARTHROSCOPY
$0.00
0146T
9
CCTA W/WO DYE
$0.00
01470
A
ANESTH, LOWER LEG SURGERY
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
01472
A
ANESTH, ACHILLES TENDON SURG
$0.00
01474
A
ANESTH, LOWER LEG SURGERY
$0.00
0147T
9
CCTA W/WO, QUAN CALCIUM
$0.00
01480
A
ANESTH, LOWER LEG BONE SURG
$0.00
01482
A
ANESTH, RADICAL LEG SURGERY
$0.00
01484
A
ANESTH, LOWER LEG REVISION
$0.00
01486
A
ANESTH, ANKLE REPLACEMENT
$0.00
0148T
9
CCTA W/WO, STRXR
$0.00
01490
A
ANESTH, LOWER LEG CASTING
$0.00
0149T
9
CCTA W/WO, STRXR QUAN CALC
$0.00
01500
A
ANESTH, LEG ARTERIES SURG
$0.00
01502
A
ANESTH, LWR LEG EMBOLECTOMY
$0.00
0150T
9
CCTA W/WO, DISEASE STRXR
$0.00
0151T
9
CT HEART FUNCT ADD-ON
$0.00
01520
A
ANESTH, LOWER LEG VEIN SURG
$0.00
01522
A
ANESTH, LOWER LEG VEIN SURG
$0.00
0152T
9
COMPUTER CHEST ADD-ON
$0.00
0153T
O
TCATH SENSOR ANEURYSM SAC
$0.00
0154T
O
STUDY SENSOR ANEURYSM SAC
$0.00
0155T
9
LAP IMPL GAST CURVE ELECTRD
$0.00
0156T
9
LAP REMV GAST CURVE ELECTRD
$0.00
0157T
9
OPEN IMPL GAST CURVE ELECTRD
$0.00
0158T
9
OPEN REMV GAST CURVE ELECTRD
$0.00
0159T
9
CAD BREAST MRI
$0.00
01600
9
ANESTH, SHOULDER SKIN SURG
$0.00
0160T
9
TCRANIAL MAGN STIM TX PLAN
$0.00
01610
A
ANESTH, SURGERY OF SHOULDER
$0.00
0161T
9
TCRANIAL MAGN STIM TX DELIV
$0.00
01620
A
ANESTH, SHOULDER PROCEDURE
$0.00
01622
A
ANES DX SHOULDER ARTHROSCOPY
$0.00
0162T
O
ANAL PROGRAM GAST NEUROSTIM
$0.00
01630
A
ANESTH, SURGERY OF SHOULDER
$0.00
01632
A
ANESTH, SURGERY OF SHOULDER
$0.00
01634
A
ANESTH, SHOULDER JOINT AMPUT
$0.00
01636
A
ANESTH, FOREQUARTER AMPUT
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
01638
A
ANESTH, SHOULDER REPLACEMENT
$0.00
0163T
9
LUMB ARTIF DISKECTOMY ADDL
$0.00
0164T
9
REMOVE LUMB ARTIF DISC ADDL
$0.00
01650
A
ANESTH, SHOULDER ARTERY SURG
$0.00
01652
A
ANESTH, SHOULDER VESSEL SURG
$0.00
01654
A
ANESTH, SHOULDER VESSEL SURG
$0.00
01656
A
ANESTH, ARM-LEG VESSEL SURG
$0.00
0165T
9
REVISE LUMB ARTIF DISC ADDL
$0.00
0166T
9
TCATH VSD CLOSE W/O BYPASS
$0.00
01670
A
ANESTH, SHOULDER VEIN SURG
$0.00
0167T
9
TCATH VSD CLOSE W BYPASS
$0.00
01680
A
ANESTH, SHOULDER CASTING
$0.00
01682
A
ANESTH, AIRPLANE CAST
$0.00
0168T
9
RHINOPHOTOTX LIGHT APP BILAT
$0.00
0169T
9
PLACE STEREO CATH BRAIN
$0.00
01700
9
ANESTH, ELBOW AREA SKIN SURG
$0.00
0170T
9
ANORECTAL FISTULA PLUG RPR
$0.00
01710
A
ANESTH, ELBOW AREA SURGERY
$0.00
01712
A
ANESTH, UPPR ARM TENDON SURG
$0.00
01714
A
ANESTH, UPPR ARM TENDON SURG
$0.00
01716
A
ANESTH, BICEPS TENDON REPAIR
$0.00
0171T
9
LUMBAR SPINE PROCES DISTRACT
$0.00
0172T
9
LUMBAR SPINE PROCES ADDL
$0.00
01730
A
ANESTH, UPPR ARM PROCEDURE
$0.00
01732
A
ANESTH, DX ELBOW ARTHROSCOPY
$0.00
0173T
9
IOP MONIT IO PRESSURE
$0.00
01740
A
ANESTH, UPPER ARM SURGERY
$0.00
01742
A
ANESTH, HUMERUS SURGERY
$0.00
01744
A
ANESTH, HUMERUS REPAIR
$0.00
0174T
9
CAD CXR WITH INTERP
$0.00
01756
A
ANESTH, RADICAL HUMERUS SURG
$0.00
01758
A
ANESTH, HUMERAL LESION SURG
$0.00
0175T
9
CAD CXR REMOTE
$0.00
01760
A
ANESTH, ELBOW REPLACEMENT
$0.00
0176T
9
AQU CANAL DILAT W/O RETENT
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
01770
A
ANESTH, UPPR ARM ARTERY SURG
$0.00
01772
A
ANESTH, UPPR ARM EMBOLECTOMY
$0.00
0177T
9
AQU CANAL DILAT W RETENT
$0.00
01780
A
ANESTH, UPPER ARM VEIN SURG
$0.00
01782
A
ANESTH, UPPR ARM VEIN REPAIR
$0.00
0178T
9
64 LEAD ECG W I&R
$0.00
0179T
9
64 LEAD ECG W TRACING
$0.00
01800
9
ANESTH, LOWER ARM SKIN SURG
$0.00
0180T
9
64 LEAD ECG W I&R ONLY
$0.00
01810
A
ANESTH, LOWER ARM SURGERY
$0.00
0181T
9
CORNEAL HYSTERESIS
$0.00
01820
A
ANESTH, LOWER ARM PROCEDURE
$0.00
01829
A
ANESTH, DX WRIST ARTHROSCOPY
$0.00
0182T
9
HDR ELECT BRACHYTHERAPY
$0.00
01830
A
ANESTH, LOWER ARM SURGERY
$0.00
01832
A
ANESTH, WRIST REPLACEMENT
$0.00
0183T
9
WOUND ULTRASOUND
$0.00
01840
A
ANESTH, LWR ARM ARTERY SURG
$0.00
01842
A
ANESTH, LWR ARM EMBOLECTOMY
$0.00
01844
A
ANESTH, VASCULAR SHUNT SURG
$0.00
0184T
9
EXC RECTAL TUMOR ENDOSCOPIC
$0.00
01850
A
ANESTH, LOWER ARM VEIN SURG
$0.00
01852
A
ANESTH, LWR ARM VEIN REPAIR
$0.00
0185T
9
COMPTR PROBABILITY ANALYSIS
$0.00
01860
A
ANESTH, LOWER ARM CASTING
$0.00
0186T
9
SUPRACHOROIDAL DRUG DELIVERY
$0.00
0187T
9
OPHTHALMIC DX IMAGE ANTERIOR
$0.00
0188T
9
VIDEOCONF CRIT CARE 74 MIN
$0.00
0189T
9
VIDEOCONF CRIT CARE ADDL 30
$0.00
01900
9
ANESTH, UTERUS/TUBE INJECT
$0.00
01902
9
ANESTH, BURR HOLES, SKULL
$0.00
01904
9
ANESTH, SKULL X-RAY INJECT
$0.00
01905
O
ANES, SPINE INJECT, X-RAY/RE
$0.00
01906
9
ANESTH, LUMBAR MYELOGRAPHY
$0.00
01908
9
ANESTH, CERVICAL MYELOGRAPHY
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
0190T
9
PLACE INTRAOC RADIATION SRC
$0.00
01910
9
ANESTH, SKULL MYELOGRAPHY
$0.00
01912
9
ANESTH, LUMBAR DISKOGRAPHY
$0.00
01914
9
ANESTH, CERVICAL DISKOGRAPHY
$0.00
01916
A
ANESTH, DX ARTERIOGRAPHY
$0.00
01918
9
ANESTH, LIMB ARTERIOGRAM
$0.00
0191T
9
INSERT ANT SEGMENT DRAIN INT
$0.00
01920
A
ANESTH, CATHETERIZE HEART
$0.00
01921
9
ANESTH, VESSEL SURGERY
$0.00
01922
A
ANESTH, CAT OR MRI SCAN
$0.00
01924
A
ANES, THER INTERVEN RAD, ART
$0.00
01925
A
ANES, THER INTERVEN RAD, CAR
$0.00
01926
A
ANES, TX INTERV RAD HRT/CRAN
$0.00
0192T
9
INSERT ANT SEGMENT DRAIN EXT
$0.00
01930
A
ANES, THER INTERVEN RAD, VEI
$0.00
01931
A
ANES, THER INTERVEN RAD, TIP
$0.00
01932
A
ANES, TX INTERV RAD, TH VEIN
$0.00
01933
A
ANES, TX INTERV RAD, CRAN V
$0.00
01935
A
ANESTH, PERC IMG DX SP PROC
$0.00
01936
A
ANESTH, PERC IMG TX SP PROC
$0.00
0193T
9
RF BLADDER NECK MICROREMODEL
$0.00
0194T
9
PROCALCITONIN (PCT)
$0.00
01951
A
ANESTH, BURN, LESS 4 PERCENT
$0.00
01952
A
ANESTH, BURN, 4-9 PERCENT
$0.00
01953
5
ANESTH, BURN, EACH 9 PERCENT
$0.00
01958
A
ANESTH, ANTEPARTUM MANIPUL
$0.00
0195T
9
ARTHROD PRESAC INTERBODY
$0.00
01960
A
ANESTH, VAGINAL DELIVERY
$0.00
01961
A
ANESTH, CS DELIVERY
$0.00
01962
A
ANESTH, EMER HYSTERECTOMY
$0.00
01963
A
ANESTH, CS HYSTERECTOMY
$0.00
01964
O
ANESTH, ABORTION PROCEDURES
$0.00
01965
A
ANESTH, INC/MISSED AB PROC
$0.00
01966
A
ANESTH, INDUCED AB PROCEDURE
$0.00
01967
A
ANESTH/ANALG, VAG DELIVERY
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
01968
A
ANES/ANALG CS DELIVER ADD-ON
$0.00
01969
A
ANESTH/ANALG CS HYST ADD-ON
$0.00
0196T
9
ARTHROD PRESAC INTERBODY EAC
$0.00
0197T
9
INTRAFRACTION TRACK MOTION
$0.00
0198T
9
OCULAR BLOOD FLOW MEASURE
$0.00
01990
A
SUPPORT FOR ORGAN DONOR
$0.00
01991
A
ANESTH, NERVE BLOCK/INJ
$0.00
01992
A
ANESTH, N BLOCK/INJ, PRONE
$0.00
01995
O
REGIONAL ANESTHESIA LIMB
$0.00
01996
3
HOSP MANAGE CONT DRUG ADMIN
01999
5
UNLISTED ANESTH PROCEDURE
$0.00
0500F
9
INITIAL PRENATAL CARE VISIT
$0.00
0501F
9
PRENATAL FLOW SHEET
$0.00
0502F
9
SUBSEQUENT PRENATAL CARE
$0.00
0503F
9
POSTPARTUM CARE VISIT
$0.00
0505F
9
HEMODIALYSIS PLAN DOCÏD
$0.00
0507F
9
PERITON DIALYSIS PLAN DOCÏD
$0.00
0509F
9
URINE INCON PLAN DOCÏD
$0.00
0513F
9
ELEV BP PLAN OF CARE DOCÏD
$0.00
0514F
9
CARE PLAN HGB DOCÏD ESA PT
$0.00
0516F
9
ANEMIA PLAN OF CARE DOCÏD
$0.00
0517F
9
GLAUCOMA PLAN OF CARE DOCÏD
$0.00
0518F
9
FALL PLAN OF CARE DOCÏD
$0.00
0519F
9
PLANÏD CHEMO DOCÏD B/4 TXMNT
$0.00
0520F
9
RAD DOS LIMTS B/4 3D RAD
$0.00
0521F
9
PLAN OF CARE 4 PAIN DOCÏD
$0.00
0525F
9
INITIAL VISIT FOR EPISODE
$0.00
0526F
9
SUBS VISIT FOR EPISODE
$0.00
0528F
9
RCMND FLW-UP 10 YRS DOCD
$0.00
0529F
9
INTRVL 3+YRS PTS CLNSCP DOCD
$0.00
0535F
9
DYSPNEA MNGMNT PLAN DOCD
$0.00
0540F
9
GLUCO MNGMNT PLAN DOCD
$0.00
0575F
9
HIV RNA PLAN CARE DOCD
$0.00
10000
O
INCISION AND DRAINAGE OF INFECTED O
$0.00
10001
O
INCISION AND DRAINAGE OF INFECTED O
$0.00
$48.15
Procedure Code Pricing Action Code Description
Maximum Allowable
10002
O
INCISION AND DRAINAGE OF INFECTED O
$0.00
10003
O
INCISION AND DRAINAGE OF INFECTED O
$0.00
1000F
9
TOBACCO USE ASSESSED
$0.00
1000H
O
PART H-ONLY DME, SUPPLIES AND HEARI
$0.00
1001F
O
TOBACCO USE, NON-SMOKING
$0.00
10020
O
INCISION AND DRAINAGE OF FURUNCLE
$0.00
10021
3
FNA W/O IMAGE
$127.26
10022
3
FNA W/IMAGE
$130.85
1002F
9
ASSESS ANGINAL SYMPTOM/LEVEL
$0.00
1003F
9
LEVEL OF ACTIVITY ASSESS
$0.00
10040
3
ACNE SURGERY
1004F
9
CLIN SYMP VOL OVRLD ASSESS
$0.00
1005F
9
ASTHMA SYMPTOMS EVALUATE
$0.00
10060
3
DRAINAGE OF SKIN ABSCESS
$97.53
10061
3
DRAINAGE OF SKIN ABSCESS
$166.28
1006F
9
OSTEOARTHRITIS ASSESS
$0.00
1007F
9
ANTI-INFLM/ANLGSC OTC ASSESS
$0.00
10080
3
DRAINAGE OF PILONIDAL CYST
$146.46
10081
3
DRAINAGE OF PILONIDAL CYST
$228.59
1008F
9
GI/RENAL RISK ASSESS
$0.00
10100
O
INCISION AND DRAINAGE OF ONYCHIA OR
$0.00
10101
O
INCISION AND DRAINAGE OF ONYCHIA OR
$0.00
1010H
O
TRANSPORTATION IN VEHICLE OTHER THA
$0.00
1011H
O
TRANSPORTATION IN VEHICLE OTHER THA
$0.00
10120
3
REMOVE FOREIGN BODY
$120.03
10121
3
REMOVE FOREIGN BODY
$232.67
1012H
O
TRANSPORTATION IN VEHICLE OTHER THA
$0.00
1013H
O
TRANSPORTATION IN VEHICLE OTHER THA
$0.00
10140
3
DRAINAGE OF HEMATOMA/FLUID
10141
O
INCISION AND DRAINAGE OF HEMATOMA C
$0.00
1015F
9
COPD SYMPTOMS ASSESS
$0.00
1015H
O
SOCIAL WORK
$0.00
10160
3
PUNCTURE DRAINAGE OF LESION
1016H
O
PARENT TRAINING
10180
3
COMPLEX DRAINAGE, WOUND
$90.31
$137.58
$86.51 $0.00 $206.70
Procedure Code Pricing Action Code Description
Maximum Allowable
1018F
9
ASSESS DYSPNEA NOT PRESENT
$0.00
1019F
9
ASSESS DYSPNEA PRESENT
$0.00
1020H
O
INDIVIDUAL DEVELOPMENTAL SERVICES
$0.00
1021H
O
GROUP DEVELOPMENTAL SERVICES
$0.00
1022F
9
PNEUMO IMM STATUS ASSESS
$0.00
1022H
O
CO-TREAT/SIMULTANEOUS DEVELOPMENTAL
$0.00
1023H
O
DEVELOPMENTAL EVALUATION
$0.00
1026F
9
CO-MORBID CONDITION ASSESS
$0.00
1030F
9
INFLUENZA IMM STATUS ASSESS
$0.00
1034F
9
CURRENT TOBACCO SMOKER
$0.00
1035F
9
SMOKELESS TOBACCO USER
$0.00
1036F
9
TOBACCO NON-USER
$0.00
1038F
9
PERSISTENT ASTHMA
$0.00
1039F
9
INTERMITTENT ASTHMA
$0.00
1040F
9
SM-IV INFO MDD DOCD
$0.00
1050F
9
HISTORY OF MOLE CHANGES
$0.00
1055F
9
VISUAL FUNCT STATUS ASSESS
$0.00
1060F
9
DOC PERM/CONT/PAROX ATR. FIB
$0.00
1061F
9
DOC LACK PERM+CONT+PAROX FIB
$0.00
1065F
9
ISCHM STROKE SYMP LT3 HRSB/4
$0.00
1066F
9
ISCHM STROKE SYMP GE3 HRSB/4
$0.00
1070F
9
ALARM SYMP ASSESSED-ABSENT
$0.00
1071F
9
ALARM SYMP ASSESSED-1+ PRSNT
$0.00
1090F
9
PRES/ABSN URINE INCON ASSESS
$0.00
1091F
9
URINE INCON CHARACTERIZED
$0.00
11000
3
DEBRIDE INFECTED SKIN
$48.26
11001
3
DEBRIDE INFECTED SKIN ADD-ON
$20.18
11004
3
DEBRIDE GENITALIA & PERINEUM
$533.60
11005
3
DEBRIDE ABDOM WALL
$695.64
11006
3
DEBRIDE GENIT/PER/ABDOM WALL
$659.25
11008
3
REMOVE MESH FROM ABD WALL
$250.97
1100F
9
PTFALLS ASSESS-DOCÏD GE2+/YR
11010
3
DEBRIDE SKIN, FX
$418.79
11011
3
DEBRIDE SKIN/MUSCLE, FX
$466.00
11012
3
DEBRIDE SKIN/MUSCLE/BONE, FX
$635.98
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
1101F
9
PT FALLS ASSESS-DOCÏD LE1/YR
$0.00
11040
3
DEBRIDE SKIN, PARTIAL
$42.23
11041
3
DEBRIDE SKIN, FULL
$49.34
11042
3
DEBRIDE SKIN/TISSUE
$66.83
11043
3
DEBRIDE TISSUE/MUSCLE
$243.48
11044
3
DEBRIDE TISSUE/MUSCLE/BONE
$332.79
11050
O
PARING OR CURETTEMENT OF BENIGN HYP
$0.00
11051
O
PARING OR CURETTEMENT OF BENIGN HYP
$0.00
11052
O
PARING OR CURETTEMENT OF BENIGN HYP
$0.00
11055
3
TRIM SKIN LESION
$43.55
11056
3
TRIM SKIN LESIONS, 2 TO 4
$53.05
11057
3
TRIM SKIN LESIONS, OVER 4
$63.90
11060
O
SHAVING OF EPIDERMAL OR SUPERFICIAL
$0.00
11061
O
SHAVING OF EPIDERMAL OR SUPERFICIAL
$0.00
11062
O
SHAVING OF EPIDERMAL OR SPUERFICIAL
$0.00
11100
3
BIOPSY, SKIN LESION
$92.88
11101
3
BIOPSY, SKIN ADD-ON
$29.92
1110F
9
PT LFT INPT FAC W/IN 60 DAYS
$0.00
1111F
9
DSCHRG MED/CURRENT MED MERGE
$0.00
1116F
9
AURIC/PERI PAIN ASSESSED
$0.00
1118F
9
GERD SYMPS ASSESSED 12 MONTH
$0.00
1119F
9
INIT. EVAL FOR CONDITION
$0.00
11200
3
REMOVAL OF SKIN TAGS
$72.81
11201
3
REMOVE SKIN TAGS ADD-ON
$16.76
1121F
9
SUBS. EVAL FOR CONDITION
$0.00
1123F
9
ACP DISCUSS/DSCN MKR DOCÏD
$0.00
1124F
9
ACP DISCUSS-NO DSCNMKR DOCÏD
$0.00
1125F
9
AMNT PAIN NOTED; PAIN PRSNT
$0.00
1126F
9
AMNT PAIN NOTED; NONE PRSNT
$0.00
1127F
9
NEW EPISODE FOR CONDITION
$0.00
1128F
9
SUBS. EPISODE FOR CONDITION
$0.00
11300
3
SHAVE SKIN LESION
$60.72
11301
3
SHAVE SKIN LESION
$83.09
11302
3
SHAVE SKIN LESION
$99.35
11303
3
SHAVE SKIN LESION
$116.60
Procedure Code Pricing Action Code Description
Maximum Allowable
11305
3
SHAVE SKIN LESION
$62.22
11306
3
SHAVE SKIN LESION
$85.86
11307
3
SHAVE SKIN LESION
$101.57
11308
3
SHAVE SKIN LESION
$113.77
1130F
9
BK PAIN + FXN ASSESSED
11310
3
SHAVE SKIN LESION
$75.48
11311
3
SHAVE SKIN LESION
$95.66
11312
3
SHAVE SKIN LESION
$110.50
11313
3
SHAVE SKIN LESION
$137.93
1134F
9
EPSD BK PAIN FOR =< 6 WKS
$0.00
1135F
9
EPSD BK PAIN FOR > 6 WKS
$0.00
1136F
9
EPSD BK PAIN FOR <= 12 WKS
$0.00
1137F
9
EPSD BK PAIN FOR > 12 WKS
$0.00
11400
3
EXC TR-EXT B9+MARG 0.5 < CM
$103.15
11401
3
EXC TR-EXT B9+MARG 0.6-1 CM
$126.55
11402
3
EXC TR-EXT B9+MARG 1.1-2 CM
$141.11
11403
3
EXC TR-EXT B9+MARG 2.1-3 CM
$161.92
11404
3
EXC TR-EXT B9+MARG 3.1-4 CM
$184.36
11406
3
EXC TR-EXT B9+MARG > 4.0 CM
$258.85
11420
3
EXC H-F-NK-SP B9+MARG 0.5 <
$104.07
11421
3
EXC H-F-NK-SP B9+MARG 0.6-1
$134.80
11422
3
EXC H-F-NK-SP B9+MARG 1.1-2
$150.42
11423
3
EXC H-F-NK-SP B9+MARG 2.1-3
$174.94
11424
3
EXC H-F-NK-SP B9+MARG 3.1-4
$201.50
11426
3
EXC H-F-NK-SP B9+MARG > 4 CM
$287.64
11440
3
EXC FACE-MM B9+MARG 0.5 < CM
$114.16
11441
3
EXC FACE-MM B9+MARG 0.6-1 CM
$144.33
11442
3
EXC FACE-MM B9+MARG 1.1-2 CM
$162.50
11443
3
EXC FACE-MM B9+MARG 2.1-3 CM
$194.67
11444
3
EXC FACE-MM B9+MARG 3.1-4 CM
$245.07
11446
3
EXC FACE-MM B9+MARG > 4 CM
$332.73
11450
3
REMOVAL, SWEAT GLAND LESION
$308.53
11451
3
REMOVAL, SWEAT GLAND LESION
$402.91
11462
3
REMOVAL, SWEAT GLAND LESION
$305.01
11463
3
REMOVAL, SWEAT GLAND LESION
$414.61
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
11470
3
REMOVAL, SWEAT GLAND LESION
$338.17
11471
3
REMOVAL, SWEAT GLAND LESION
$424.61
1150F
9
DOC PT RSK DEATH W/IN 1YR
$0.00
1151F
9
DOC NO PT RSK DEATH W/IN 1YR
$0.00
1152F
9
DOC ADVNCD DIS COMFORT 1ST
$0.00
1153F
9
DOC ADVNCD DIS CMFRT NOT 1ST
$0.00
1157F
9
ADVNC CARE PLAN IN RCRD
$0.00
1158F
9
ADVNC CARE PLAN TLK DOCD
$0.00
1159F
9
MED LIST DOCD IN RCRD
$0.00
11600
3
EXC TR-EXT MLG+MARG 0.5 < CM
$158.31
11601
3
EXC TR-EXT MLG+MARG 0.6-1 CM
$195.59
11602
3
EXC TR-EXT MLG+MARG 1.1-2 CM
$214.93
11603
3
EXC TR-EXT MLG+MARG 2.1-3 CM
$243.68
11604
3
EXC TR-EXT MLG+MARG 3.1-4 CM
$268.97
11606
3
EXC TR-EXT MLG+MARG > 4 CM
$377.37
1160F
9
RVW MEDS BY RX/DR IN RCRD
11620
3
EXC H-F-NK-SP MLG+MARG 0.5 <
$161.75
11621
3
EXC H-F-NK-SP MLG+MARG 0.6-1
$197.42
11622
3
EXC H-F-NK-SP MLG+MARG 1.1-2
$223.37
11623
3
EXC H-F-NK-SP MLG+MARG 2.1-3
$260.17
11624
3
EXC H-F-NK-SP MLG+MARG 3.1-4
$292.28
11626
3
EXC H-F-NK-SP MLG+MAR > 4 CM
$355.26
11640
3
EXC FACE-MM MALIG+MARG 0.5 <
$169.22
11641
3
EXC FACE-MM MALIG+MARG 0.6-1
$207.88
11642
3
EXC FACE-MM MALIG+MARG 1.1-2
$239.47
11643
3
EXC FACE-MM MALIG+MARG 2.1-3
$280.83
11644
3
EXC FACE-MM MALIG+MARG 3.1-4
$346.28
11646
3
EXC FACE-MM MLG+MARG > 4 CM
$455.02
11700
O
DEBRIDEMENT OF NAILS, MANUAL; FIVE
$0.00
11701
O
DEBRIDEMENT OF NAILS, MANUAL; EACH
$0.00
1170F
9
FXNL STATUS ASSESSED
$0.00
11710
O
DEBRIDEMENT OF NAILS, ELECTRIC GRIN
$0.00
11711
O
DEBRIDEMENT OF NAILS, ELECTRIC GRIN
$0.00
11719
3
TRIM NAIL(S)
$19.12
11720
3
DEBRIDE NAIL, 1-5
$27.92
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
11721
3
DEBRIDE NAIL, 6 OR MORE
$39.83
11730
3
REMOVAL OF NAIL PLATE
$88.14
11731
O
REMOVAL OF SECOND NAIL PLATE
11732
3
REMOVE NAIL PLATE, ADD-ON
$40.91
11740
3
DRAIN BLOOD FROM UNDER NAIL
$40.43
11750
3
REMOVAL OF NAIL BED
$190.86
11752
3
REMOVE NAIL BED/FINGER TIP
$271.38
11755
3
BIOPSY, NAIL UNIT
$119.31
11760
3
REPAIR OF NAIL BED
$179.77
11762
3
RECONSTRUCTION OF NAIL BED
$239.80
11765
3
EXCISION OF NAIL FOLD, TOE
$115.28
11770
3
REMOVAL OF PILONIDAL LESION
$229.44
11771
3
REMOVAL OF PILONIDAL LESION
$469.52
11772
3
REMOVAL OF PILONIDAL LESION
$569.91
1180F
9
THROMBOEMB RISK ASSESSED
$0.00
11900
3
INJECTION INTO SKIN LESIONS
$50.49
11901
3
ADDED SKIN LESIONS INJECTION
$63.69
11920
3
CORRECT SKIN COLOR DEFECTS
$162.74
11921
3
CORRECT SKIN COLOR DEFECTS
$185.35
11922
3
CORRECT SKIN COLOR DEFECTS
$54.68
11950
3
THERAPY FOR CONTOUR DEFECTS
$67.69
11951
3
THERAPY FOR CONTOUR DEFECTS
$90.27
11952
3
THERAPY FOR CONTOUR DEFECTS
$127.08
11954
3
THERAPY FOR CONTOUR DEFECTS
$145.30
11960
3
INSERT TISSUE EXPANDER(S)
$818.94
11970
3
REPLACE TISSUE EXPANDER
$535.99
11971
3
REMOVE TISSUE EXPANDER(S)
$406.68
11975
5
INSERT CONTRACEPTIVE CAP
11976
3
REMOVAL OF CONTRACEPTIVE CAP
11977
5
REMOVAL/REINSERT CONTRA CAP
$0.00
11980
5
IMPLANT HORMONE PELLET(S)
$0.00
11981
5
INSERT DRUG IMPLANT DEVICE
$0.00
11982
3
REMOVE DRUG IMPLANT DEVICE
$142.73
11983
5
REMOVE/INSERT DRUG IMPLANT
$0.00
12001
3
REPAIR SUPERFICIAL WOUND(S)
$130.50
$0.00
$0.00 $134.82
Procedure Code Pricing Action Code Description
Maximum Allowable
12002
3
REPAIR SUPERFICIAL WOUND(S)
$138.92
12004
3
REPAIR SUPERFICIAL WOUND(S)
$163.80
12005
3
REPAIR SUPERFICIAL WOUND(S)
$204.03
12006
3
REPAIR SUPERFICIAL WOUND(S)
$253.02
12007
3
REPAIR SUPERFICIAL WOUND(S)
$286.66
12011
3
REPAIR SUPERFICIAL WOUND(S)
$138.80
12013
3
REPAIR SUPERFICIAL WOUND(S)
$153.04
12014
3
REPAIR SUPERFICIAL WOUND(S)
$180.27
12015
3
REPAIR SUPERFICIAL WOUND(S)
$226.28
12016
3
REPAIR SUPERFICIAL WOUND(S)
$270.19
12017
3
REPAIR SUPERFICIAL WOUND(S)
$238.35
12018
3
REPAIR SUPERFICIAL WOUND(S)
$295.75
12020
3
CLOSURE OF SPLIT WOUND
$237.58
12021
3
CLOSURE OF SPLIT WOUND
$140.25
12031
3
INTMD WND REPAIR S/TR/EXT
$210.65
12032
3
INTMD WND REPAIR S/TR/EXT
$272.13
12034
3
INTMD WND REPAIR S/TR/EXT
$267.07
12035
3
INTMD WND REPAIR S/TR/EXT
$326.00
12036
3
INTMD WND REPAIR S/TR/EXT
$356.80
12037
3
INTMD WND REPAIR S/TR/EXT
$402.29
12041
3
INTMD WND REPAIR N-HF/GENIT
$220.47
12042
3
INTMD WND REPAIR N-HG/GENIT
$257.24
12044
3
INTMD WND REPAIR N-HG/GENIT
$296.85
12045
3
INTMD WND REPAIR N-HG/GENIT
$328.44
12046
3
INTMD WND REPAIR N-HG/GENIT
$389.22
12047
3
INTMD WND REPAIR N-HG/GENIT
$417.40
12051
3
INTMD WND REPAIR FACE/MM
$237.22
12052
3
INTMD WND REPAIR FACE/MM
$269.01
12053
3
INTMD WND REPAIR FACE/MM
$295.55
12054
3
INTMD WND REPAIR, FACE/MM
$312.35
12055
3
INTMD WND REPAIR FACE/MM
$375.74
12056
3
INTMD WND REPAIR FACE/MM
$443.54
12057
3
INTMD WND REPAIR FACE/MM
$495.54
1220F
9
PT SCREENED FOR DEPRESSION
13100
3
REPAIR OF WOUND OR LESION
$0.00 $281.11
Procedure Code Pricing Action Code Description
Maximum Allowable
13101
3
REPAIR OF WOUND OR LESION
$355.18
13102
3
REPAIR WOUND/LESION ADD-ON
13120
3
REPAIR OF WOUND OR LESION
$291.98
13121
3
REPAIR OF WOUND OR LESION
$393.23
13122
3
REPAIR WOUND/LESION ADD-ON
$107.18
13131
3
REPAIR OF WOUND OR LESION
$322.07
13132
3
REPAIR OF WOUND OR LESION
$515.03
13133
3
REPAIR WOUND/LESION ADD-ON
$151.34
13150
3
REPAIR OF WOUND OR LESION
$320.64
13151
3
REPAIR OF WOUND OR LESION
$365.33
13152
3
REPAIR OF WOUND OR LESION
$503.07
13153
3
REPAIR WOUND/LESION ADD-ON
$166.22
13160
3
LATE CLOSURE OF WOUND
$725.82
13300
O
REPAIR OF WOUND OR LESION
14000
3
SKIN TISSUE REARRANGEMENT
$547.00
14001
3
SKIN TISSUE REARRANGEMENT
$710.01
14020
3
SKIN TISSUE REARRANGEMENT
$615.94
14021
3
SKIN TISSUE REARRANGEMENT
$779.22
14040
3
SKIN TISSUE REARRANGEMENT
$683.21
14041
3
SKIN TISSUE REARRANGEMENT
$849.88
14060
3
SKIN TISSUE REARRANGEMENT
$693.85
14061
3
SKIN TISSUE REARRANGEMENT
$910.83
14300
3
SKIN TISSUE REARRANGEMENT
$983.00
14350
3
SKIN TISSUE REARRANGEMENT
$674.97
15000
O
WOUND PREP, 1ST 100 SQ CM
$0.00
15001
O
WOUND PREP, ADDL 100 SQ CM
$0.00
15002
3
WOUND PREP, TRK/ARM/LEG
$296.71
15003
3
WOUND PREP, ADDL 100 CM
$64.49
15004
3
WOUND PREP, F/N/HF/G
$359.68
15005
3
WND PREP, F/N/HF/G, ADDL CM
$107.92
15040
3
HARVEST CULTURED SKIN GRAFT
$226.95
15050
3
SKIN PINCH GRAFT
$479.14
15100
3
SKIN SPLT GRFT, TRNK/ARM/LEG
$767.29
15101
3
SKIN SPLT GRFT T/A/L, ADD-ON
$169.63
15110
3
EPIDRM AUTOGRFT TRNK/ARM/LEG
$755.14
$95.85
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
15111
3
EPIDRM AUTOGRFT T/A/L ADD-ON
$109.68
15115
3
EPIDRM A-GRFT FACE/NCK/HF/G
$764.23
15116
3
EPIDRM A-GRFT F/N/HF/G ADDL
$149.00
15120
3
SKN SPLT A-GRFT FAC/NCK/HF/G
$833.15
15121
3
SKN SPLT A-GRFT F/N/HF/G ADD
$238.98
15130
3
DERM AUTOGRAFT, TRNK/ARM/LEG
$597.11
15131
3
DERM AUTOGRAFT T/A/L ADD-ON
15135
3
DERM AUTOGRAFT FACE/NCK/HF/G
15136
3
DERM AUTOGRAFT, F/N/HF/G ADD
$82.06
15150
3
CULT EPIDERM GRFT T/ARM/LEG
$621.77
15151
3
CULT EPIDERM GRFT T/A/L ADDL
$115.52
15152
3
CULT EPIDERM GRAFT T/A/L +%
$150.59
15155
3
CULT EPIDERM GRAFT, F/N/HF/G
$654.18
15156
3
CULT EPIDRM GRFT F/N/HFG ADD
$160.50
15157
3
CULT EPIDERM GRFT F/N/HFG +%
$177.18
15170
3
ACELL GRAFT TRUNK/ARMS/LEGS
$379.18
15171
3
ACELL GRAFT T/ARM/LEG ADD-ON
$84.71
15175
3
ACELLULAR GRAFT, F/N/HF/G
$481.52
15176
3
ACELL GRAFT, F/N/HF/G ADD-ON
$135.53
15200
3
SKIN FULL GRAFT, TRUNK
$712.99
15201
3
SKIN FULL GRAFT TRUNK ADD-ON
$132.32
15220
3
SKIN FULL GRAFT SCLP/ARM/LEG
$679.85
15221
3
SKIN FULL GRAFT ADD-ON
$123.25
15240
3
SKIN FULL GRFT FACE/GENIT/HF
$815.10
15241
3
SKIN FULL GRAFT ADD-ON
$164.40
15260
3
SKIN FULL GRAFT EEN & LIPS
$883.47
15261
3
SKIN FULL GRAFT ADD-ON
$191.57
15300
3
APPLY SKINALLOGRFT, T/ARM/LG
$304.72
15301
3
APPLY SKNALLOGRFT T/A/L ADDL
$57.20
15320
3
APPLY SKIN ALLOGRFT F/N/HF/G
$343.33
15321
3
APLY SKNALLOGRFT F/N/HFG ADD
$85.25
15330
3
APLY ACELL ALOGRFT T/ARM/LEG
$282.24
15331
3
APLY ACELL GRFT T/A/L ADD-ON
15335
3
APPLY ACELL GRAFT, F/N/HF/G
15336
3
APLY ACELL GRFT F/N/HF/G ADD
$89.32 $767.23
$57.20 $296.72 $79.56
Procedure Code Pricing Action Code Description
Maximum Allowable
15340
3
APPLY CULT SKIN SUBSTITUTE
$282.83
15341
3
APPLY CULT SKIN SUB ADD-ON
$42.23
15342
O
CULTURED SKIN GRAFT, 25 CM
$0.00
15343
O
CULTURE SKN GRAFT ADDL 25 CM
$0.00
15350
O
SKIN HOMOGRAFT
$0.00
15351
O
SKIN HOMOGRAFT ADD-ON
$0.00
15360
3
APPLY CULT DERM SUB, T/A/L
15361
3
APLY CULT DERM SUB T/A/L ADD
$64.04
15365
3
APPLY CULT DERM SUB F/N/HF/G
$315.27
15366
3
APPLY CULT DERM F/HF/G ADD
$78.81
15400
3
APPLY SKIN XENOGRAFT, T/A/L
$351.15
15401
3
APPLY SKN XENOGRFT T/A/L ADD
15410
O
FREE TRANSPLANTATION OF SKIN FLAP B
$0.00
15412
O
FREE TRANSPLANTATION OF SKIN FLAP B
$0.00
15414
O
FREE TRANSPLANTATION OF SKIN FLAP B
$0.00
15416
O
FREE TRANSPLANTATION OF SKIN FLAP B
$0.00
15420
3
APPLY SKIN XGRAFT, F/N/HF/G
$396.09
15421
3
APPLY SKN XGRFT F/N/HF/G ADD
$103.00
15430
3
APPLY ACELLULAR XENOGRAFT
$466.19
15431
6
APPLY ACELLULAR XGRAFT ADD
$0.00
15500
O
FORMATION OF TUBE PEDICLE WITHOUT T
$0.00
15505
O
FORMATION OF TUBE PEDICLE WITHOUT T
$0.00
15510
O
FORMATION OF TUBE PEDICLE WITHOUT T
$0.00
15515
O
FORMATION OF TUBE PEDICLE WITHOUT T
$0.00
15540
O
PRIMARY ATTACHMENT OF OPEN OR TUBED
$0.00
15545
O
PRIMARY ATTACHMENT OF OPEN OR TUBED
$0.00
15550
O
PRIMARY ATTACHMENT OF OPEN OR TUBED
$0.00
15555
O
PRIMARY ATTACHMENT OF OPEN OR TUBED
$0.00
15570
3
FORM SKIN PEDICLE FLAP
$783.20
15572
3
FORM SKIN PEDICLE FLAP
$759.58
15574
3
FORM SKIN PEDICLE FLAP
$801.38
15576
3
FORM SKIN PEDICLE FLAP
$712.61
15580
O
ATTACH SKIN PEDICLE GRAFT
15600
3
SKIN GRAFT
$291.70
15610
3
SKIN GRAFT
$292.24
$321.18
$84.19
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
15620
3
SKIN GRAFT
$387.30
15625
O
SKIN GRAFT
$0.00
15630
3
SKIN GRAFT
$409.21
15650
3
TRANSFER SKIN PEDICLE FLAP
$456.11
15700
O
EXCISION OF LESION AND/OR EXCISIONA
$0.00
15710
O
EXCISION OF LESION AND/OR EXCISIONA
$0.00
15720
O
EXCISION OF LESION AND/OR EXCISIONA
$0.00
15730
O
EXCISION OF LESION AND/OR EXCISIONA
$0.00
15731
3
FOREHEAD FLAP W/VASC PEDICLE
$1,008.10
15732
3
MUSCLE-SKIN GRAFT, HEAD/NECK
$1,332.34
15734
3
MUSCLE-SKIN GRAFT, TRUNK
$1,213.83
15736
3
MUSCLE-SKIN GRAFT, ARM
$1,214.45
15738
3
MUSCLE-SKIN GRAFT, LEG
$1,294.40
15740
3
ISLAND PEDICLE FLAP GRAFT
$903.99
15750
3
NEUROVASCULAR PEDICLE GRAFT
$819.07
15755
O
FREE FLAP (MICROVASCULAR TRANSFER)
15756
3
FREE MYO/SKIN FLAP MICROVASC
$2,150.81
15757
3
FREE SKIN FLAP, MICROVASC
$2,128.85
15758
3
FREE FASCIAL FLAP, MICROVASC
$2,130.66
15760
3
COMPOSITE SKIN GRAFT
$750.03
15770
3
DERMA-FAT-FASCIA GRAFT
$587.41
15775
3
HAIR TRANSPLANT PUNCH GRAFTS
$289.67
15776
3
HAIR TRANSPLANT PUNCH GRAFTS
$401.20
15780
3
ABRASION TREATMENT OF SKIN
$740.53
15781
3
ABRASION TREATMENT OF SKIN
$476.04
15782
3
ABRASION TREATMENT OF SKIN
$505.19
15783
3
ABRASION TREATMENT OF SKIN
$433.54
15786
3
ABRASION, LESION, SINGLE
$212.68
15787
3
ABRASION, LESIONS, ADD-ON
15788
9
CHEMICAL PEEL, FACE, EPIDERM
$0.00
15789
9
CHEMICAL PEEL, FACE, DERMAL
$0.00
15790
O
CHEMICAL PEEL (CHEMEXFOLIATION) TOT
$0.00
15791
O
CHEMICAL PEEL (CHEMEXFOLIATION) REG
$0.00
15792
9
CHEMICAL PEEL, NONFACIAL
$0.00
15793
9
CHEMICAL PEEL, NONFACIAL
$0.00
$0.00
$43.81
Procedure Code Pricing Action Code Description
Maximum Allowable
15810
O
SALABRASION
$0.00
15811
O
SALABRASION
$0.00
15819
3
PLASTIC SURGERY, NECK
$659.53
15820
3
REVISION OF LOWER EYELID
$473.80
15821
3
REVISION OF LOWER EYELID
$503.50
15822
3
REVISION OF UPPER EYELID
$371.52
15823
3
REVISION OF UPPER EYELID
$585.34
15824
9
REMOVAL OF FOREHEAD WRINKLES
$0.00
15825
5
REMOVAL OF NECK WRINKLES
$0.00
15826
5
REMOVAL OF BROW WRINKLES
$0.00
15828
5
REMOVAL OF FACE WRINKLES
$0.00
15829
5
REMOVAL OF SKIN WRINKLES
$0.00
15830
3
EXC SKIN ABD
15831
O
EXCISE EXCESSIVE SKIN TISSUE
$0.00
15832
3
EXCISE EXCESSIVE SKIN TISSUE
$797.56
15833
3
EXCISE EXCESSIVE SKIN TISSUE
$752.89
15834
3
EXCISE EXCESSIVE SKIN TISSUE
$748.78
15835
3
EXCISE EXCESSIVE SKIN TISSUE
$791.52
15836
3
EXCISE EXCESSIVE SKIN TISSUE
$660.31
15837
3
EXCISE EXCESSIVE SKIN TISSUE
$686.24
15838
3
EXCISE EXCESSIVE SKIN TISSUE
$515.60
15839
3
EXCISE EXCESSIVE SKIN TISSUE
$759.22
15840
3
GRAFT FOR FACE NERVE PALSY
$907.71
15841
3
GRAFT FOR FACE NERVE PALSY
$1,516.31
15842
3
FLAP FOR FACE NERVE PALSY
$2,393.91
15845
3
SKIN AND MUSCLE REPAIR, FACE
15847
6
EXC SKIN ABD ADD-ON
$0.00
15850
9
REMOVAL OF SUTURES
$0.00
15851
3
REMOVAL OF SUTURES
$83.55
15852
3
DRESSING CHANGE NOT FOR BURN
$43.61
15860
3
TEST FOR BLOOD FLOW IN GRAFT
15876
5
SUCTION ASSISTED LIPECTOMY
$0.00
15877
9
SUCTION ASSISTED LIPECTOMY
$0.00
15878
9
SUCTION ASSISTED LIPECTOMY
$0.00
15879
9
SUCTION ASSISTED LIPECTOMY
$0.00
$1,048.64
$851.27
$102.77
Procedure Code Pricing Action Code Description
Maximum Allowable
15920
3
REMOVAL OF TAIL BONE ULCER
$523.57
15922
3
REMOVAL OF TAIL BONE ULCER
$665.41
15931
3
REMOVE SACRUM PRESSURE SORE
$594.75
15933
3
REMOVE SACRUM PRESSURE SORE
$733.77
15934
3
REMOVE SACRUM PRESSURE SORE
$816.59
15935
3
REMOVE SACRUM PRESSURE SORE
$973.07
15936
3
REMOVE SACRUM PRESSURE SORE
$791.96
15937
3
REMOVE SACRUM PRESSURE SORE
$926.49
15940
3
REMOVE HIP PRESSURE SORE
$611.90
15941
3
REMOVE HIP PRESSURE SORE
$796.97
15944
3
REMOVE HIP PRESSURE SORE
$784.49
15945
3
REMOVE HIP PRESSURE SORE
$871.60
15946
3
REMOVE HIP PRESSURE SORE
$1,455.12
15950
3
REMOVE THIGH PRESSURE SORE
$507.96
15951
3
REMOVE THIGH PRESSURE SORE
$724.04
15952
3
REMOVE THIGH PRESSURE SORE
$760.90
15953
3
REMOVE THIGH PRESSURE SORE
$847.70
15954
O
EXCISION, TROCHANTERIC PRESSURE ULC
$0.00
15955
O
EXCISION, TROCHANTERIC PRESSURE ULC
$0.00
15956
3
REMOVE THIGH PRESSURE SORE
$1,019.44
15958
3
REMOVE THIGH PRESSURE SORE
$1,041.15
15960
O
EXCISION, HEEL PRESSURE ULCER, WITH
$0.00
15961
O
EXCISION, HEEL PRESSURE ULCER, WITH
$0.00
15964
O
EXCISION, HEEL PRESSURE ULCER, WITH
$0.00
15965
O
EXCISION, HEEL PRESSURE ULCER, WITH
$0.00
15966
O
EXCISION, HEEL PRESSURE ULCER, WITH
$0.00
15967
O
EXCISION, HEEL PRESSURE ULCER, WITH
$0.00
15970
O
EXCISION, LEG PRESSURE ULCER, WITH
$0.00
15971
O
EXCISION, LEG PRESSURE ULCER, WITH
$0.00
15972
O
EXCISION, LEG PRESSURE ULCER, WITH
$0.00
15973
O
EXCISION, LEG PRESSURE ULCER, WITH
$0.00
15974
O
EXCISION, LEG PRESSURE ULCER, WITH
$0.00
15975
O
EXCISION, LEG PRESSURE ULCER, WITH
$0.00
15980
O
EXCISION, KNEE PRESSURE ULCER, WITH
$0.00
15981
O
EXCISION, KNEE PRESSURE ULCER, WITH
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
15982
O
EXCISION, KNEE PRESSURE ULCER, WITH
$0.00
15983
O
EXCISION, KNEE PRESSURE ULCER, WITH
$0.00
15999
5
REMOVAL OF PRESSURE SORE
$0.00
16000
3
INITIAL TREATMENT OF BURN(S)
$61.45
16010
O
TREATMENT OF BURN(S)
$0.00
16015
O
TREATMENT OF BURN(S)
$0.00
16020
3
DRESS/DEBRID P-THICK BURN, S
$72.65
16025
3
DRESS/DEBRID P-THICK BURN, M
$130.93
16030
3
DRESS/DEBRID P-THICK BURN, L
$156.98
16035
3
INCISION OF BURN SCAB, INITI
$194.95
16036
3
ESCHAROTOMY; ADDÏL INCISION
16040
O
BURN WOUND EXCISION
$0.00
16041
O
BURN WOUND EXCISION
$0.00
16042
O
BURN WOUND EXCISION
$0.00
17000
3
DESTRUCT PREMALG LESION
17001
O
DESTRUCTION BY ANY METHOD, INCLUDIN
$0.00
17002
O
DESTRUCTION BY ANY METHOD, INCLUDIN
$0.00
17003
3
DESTRUCT PREMALG LES, 2-14
$6.81
17004
3
DESTROY PREMLG LESIONS 15+
17010
O
DESTRUCTION BY ANY METHOD, INCLUDIN
$0.00
17100
O
DESTRUCTION BY ANY METHOD, INCLUDIN
$0.00
17101
O
DESTRUCTION BY ANY METHOD, INCLUDIN
$0.00
17102
O
DESTRUCTION BY ANY METHOD, INCLUDIN
$0.00
17104
O
DESTRUCTION BY ANY METHOD, INCLUDIN
$0.00
17105
O
DESTRUCTION BY ANY METHOD, INCLUDIN
$0.00
17106
3
DESTRUCTION OF SKIN LESIONS
$308.56
17107
3
DESTRUCTION OF SKIN LESIONS
$408.96
17108
3
DESTRUCTION OF SKIN LESIONS
$521.92
17110
3
DESTRUCT B9 LESION, 1-14
17111
3
DESTRUCT LESION, 15 OR MORE
17200
O
ELECTROSURGICAL DESTRUCTION OF MULT
$0.00
17201
O
ELECTROSURGICAL DESTRUCTION OF MULT
$0.00
17250
3
CHEMICAL CAUTERY, TISSUE
$66.63
17260
3
DESTRUCTION OF SKIN LESIONS
$84.84
17261
3
DESTRUCTION OF SKIN LESIONS
$126.91
$77.62
$70.57
$157.14
$98.34 $116.49
Procedure Code Pricing Action Code Description
Maximum Allowable
17262
3
DESTRUCTION OF SKIN LESIONS
$154.37
17263
3
DESTRUCTION OF SKIN LESIONS
$170.25
17264
3
DESTRUCTION OF SKIN LESIONS
$182.13
17266
3
DESTRUCTION OF SKIN LESIONS
$206.64
17270
3
DESTRUCTION OF SKIN LESIONS
$131.53
17271
3
DESTRUCTION OF SKIN LESIONS
$145.24
17272
3
DESTRUCTION OF SKIN LESIONS
$166.20
17273
3
DESTRUCTION OF SKIN LESIONS
$185.32
17274
3
DESTRUCTION OF SKIN LESIONS
$219.15
17276
3
DESTRUCTION OF SKIN LESIONS
$253.48
17280
3
DESTRUCTION OF SKIN LESIONS
$123.58
17281
3
DESTRUCTION OF SKIN LESIONS
$157.39
17282
3
DESTRUCTION OF SKIN LESIONS
$182.38
17283
3
DESTRUCTION OF SKIN LESIONS
$220.06
17284
3
DESTRUCTION OF SKIN LESIONS
$255.70
17286
3
DESTRUCTION OF SKIN LESIONS
$322.76
17303
O
CHEMOSURGERY (MOHS' TECHNIQUE), FIR
$0.00
17304
O
1 STAGE MOHS, UP TO 5 SPEC
$0.00
17305
O
2 STAGE MOHS, UP TO 5 SPEC
$0.00
17306
O
3 STAGE MOHS, UP TO 5 SPEC
$0.00
17307
O
MOHS ADDL STAGE UP TO 5 SPEC
$0.00
17310
O
MOHS ANY STAGE > 5 SPEC EACH
$0.00
17311
3
MOHS, 1 STAGE, H/N/HF/G
$621.05
17312
3
MOHS ADDL STAGE
$372.81
17313
3
MOHS, 1 STAGE, T/A/L
$567.01
17314
3
MOHS, ADDL STAGE, T/A/L
$345.51
17315
3
MOHS SURG, ADDL BLOCK
$73.95
17340
3
CRYOTHERAPY OF SKIN
$43.51
17360
3
SKIN PEEL THERAPY
17380
9
HAIR REMOVAL BY ELECTROLYSIS
$0.00
17999
5
SKIN TISSUE PROCEDURE
$0.00
19000
3
DRAINAGE OF BREAST LESION
$103.29
19001
3
DRAIN BREAST LESION ADD-ON
$25.58
19020
3
INCISION OF BREAST LESION
$385.11
19030
3
INJECTION FOR BREAST X-RAY
$158.13
$117.96
Procedure Code Pricing Action Code Description
Maximum Allowable
19100
3
BX BREAST PERCUT W/O IMAGE
$125.74
19101
3
BIOPSY OF BREAST, OPEN
$286.00
19102
3
BX BREAST PERCUT W/IMAGE
$207.18
19103
3
BX BREAST PERCUT W/DEVICE
$186.74
19105
3
CRYOSURG ABLATE FA, EACH
19110
3
NIPPLE EXPLORATION
$398.32
19112
3
EXCISE BREAST DUCT FISTULA
$373.28
19120
3
REMOVAL OF BREAST LESION
$409.92
19125
3
EXCISION, BREAST LESION
$388.13
19126
3
EXCISION, ADDL BREAST LESION
$145.24
19140
O
REMOVAL OF BREAST TISSUE
$0.00
19160
O
PARTIAL MASTECTOMY
$0.00
19162
O
P-MASTECTOMY W/LN REMOVAL
$0.00
19180
O
REMOVAL OF BREAST
$0.00
19182
O
REMOVAL OF BREAST
$0.00
19200
O
REMOVAL OF BREAST
$0.00
19220
O
REMOVAL OF BREAST
$0.00
19240
O
REMOVAL OF BREAST
$0.00
19260
3
REMOVAL OF CHEST WALL LESION
$1,071.36
19271
3
REVISION OF CHEST WALL
$1,459.38
19272
3
EXTENSIVE CHEST WALL SURGERY
$1,615.78
19290
3
PLACE NEEDLE WIRE, BREAST
$64.44
19291
3
PLACE NEEDLE WIRE, BREAST
$66.36
19295
3
PLACE BREAST CLIP, PERCUT
$87.12
19296
3
PLACE PO BREAST CATH FOR RAD
19297
3
PLACE BREAST CATH FOR RAD
19298
3
PLACE BREAST RAD TUBE/CATHS
19300
9
REMOVAL OF BREAST TISSUE
19301
3
PARTICAL MASTECTOMY
$540.06
19302
3
P-MASTECTOMY W/LN REMOVAL
$773.89
19303
3
MAST, SIMPLE, COMPLETE
$834.83
19304
3
MAST, SUBQ
$486.28
19305
3
MAST, RADICAL
$965.49
19306
3
MAST, RAD, URBAN TYPE
$1,012.30
19307
3
MAST, MOD RAD
$1,018.19
$2,032.71
$3,631.74 $84.39 $1,226.63 $0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
19316
3
SUSPENSION OF BREAST
$695.26
19318
3
REDUCTION OF LARGE BREAST
19324
9
ENLARGE BREAST
$0.00
19325
9
ENLARGE BREAST WITH IMPLANT
$0.00
19328
3
REMOVAL OF BREAST IMPLANT
$435.80
19330
3
REMOVAL OF IMPLANT MATERIAL
$559.96
19340
3
IMMEDIATE BREAST PROSTHESIS
$361.79
19342
3
DELAYED BREAST PROSTHESIS
$823.27
19350
3
BREAST RECONSTRUCTION
$756.55
19355
9
CORRECT INVERTED NIPPLE(S)
19357
3
BREAST RECONSTRUCTION
19360
O
BREAST RECONSTRUCTION WITH MUSCLE O
19361
3
BREAST RECONSTR W/LAT FLAP
19362
O
BREAST RECONSTRUCTION WITH TRANSVER
19364
3
BREAST RECONSTRUCTION
$2,528.30
19366
3
BREAST RECONSTRUCTION
$1,245.94
19367
3
BREAST RECONSTRUCTION
$1,637.04
19368
3
BREAST RECONSTRUCTION
$2,027.37
19369
3
BREAST RECONSTRUCTION
$1,847.64
19370
3
SURGERY OF BREAST CAPSULE
$607.27
19371
3
REMOVAL OF BREAST CAPSULE
$700.29
19380
3
REVISE BREAST RECONSTRUCTION
$685.14
19396
3
DESIGN CUSTOM BREAST IMPLANT
$196.38
19499
5
BREAST SURGERY PROCEDURE
20000
3
INCISION OF ABSCESS
$183.40
20005
3
INCISION OF DEEP ABSCESS
$271.71
2000F
9
BLOOD PRESSURE MEASURE
$0.00
2001F
9
WEIGHT RECORD
$0.00
2002F
9
CLIN SIGN VOL OVRLD ASSESS
$0.00
2003F
O
AUSCULTATION HEART PERFORM
$0.00
2004F
9
INITIAL EXAM INVOLVED JOINTS
$0.00
20100
3
EXPLORE WOUND, NECK
$534.18
20101
3
EXPLORE WOUND, CHEST
$352.98
20102
3
EXPLORE WOUND, ABDOMEN
$412.80
20103
3
EXPLORE WOUND, EXTREMITY
$502.01
$1,023.98
$0.00 $1,383.73 $0.00 $1,484.53 $0.00
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
2010F
9
VITAL SIGNS RECORDED
$0.00
2014F
9
MENTAL STATUS ASSESS
$0.00
20150
3
EXCISE EPIPHYSEAL BAR
$870.81
2018F
9
HYDRATION STATUS ASSESS
$0.00
2019F
9
DILATED MACUL EXAM DONE
$0.00
20200
3
MUSCLE BIOPSY
$171.56
20205
3
DEEP MUSCLE BIOPSY
$233.49
20206
3
NEEDLE BIOPSY, MUSCLE
$241.14
2020F
9
DILATED FUNDUS EVAL DONE
$0.00
2021F
9
DILAT MACUL+ EXAM DONE
$0.00
20220
3
BONE BIOPSY, TROCAR/NEEDLE
$164.87
20225
3
BONE BIOPSY, TROCAR/NEEDLE
$112.76
2022F
9
DIL RETINA EXAM INTERP REV
20240
3
BONE BIOPSY, EXCISIONAL
$207.64
20245
3
BONE BIOPSY, EXCISIONAL
$566.98
2024F
9
7 FIELD PHOTO INTERP DOC REV
20250
3
OPEN BONE BIOPSY
$341.19
20251
3
OPEN BONE BIOPSY
$378.40
2026F
9
EYE IMAGE VALID TO DX REV
$0.00
2027F
9
OPTIC NERVE HEAD EVAL DONE
$0.00
2028F
9
FOOT EXAM PERFORMED
$0.00
2029F
9
COMPLETE PHYS SKIN EXAM DONE
$0.00
2030F
9
H2O STAT DOCÏD, NORMAL
$0.00
2031F
9
H2O STAT DOCÏD, DEHYDRATED
$0.00
2035F
9
TYMP MEMB MOTION EXAMÏD
$0.00
2040F
9
BK PN XM ON INIT VISIT DATE
$0.00
2044F
9
DOC MNTL TST B/4 BK TRXMNT
$0.00
20500
3
INJECTION OF SINUS TRACT
20501
3
INJECT SINUS TRACT FOR X-RAY
2050F
9
WOUND CHAR SIZE ETC DOCD
20520
3
REMOVAL OF FOREIGN BODY
$170.20
20525
3
REMOVAL OF FOREIGN BODY
$417.52
20526
3
THER INJECTION, CARP TUNNEL
$68.50
20550
3
INJ TENDON SHEATH/LIGAMENT
$52.99
20551
3
INJ TENDON ORIGIN/INSERTION
$52.38
$0.00
$0.00
$105.96 $38.84 $0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
20552
3
INJ TRIGGER POINT, 1/2 MUSCL
$47.71
20553
3
INJECT TRIGGER POINTS, =/> 3
$53.27
20555
3
PLACE NDL MUSC/TIS FOR RT
$310.86
20600
3
DRAIN/INJECT, JOINT/BURSA
$49.90
20605
3
DRAIN/INJECT, JOINT/BURSA
$53.58
20610
3
DRAIN/INJECT, JOINT/BURSA
$69.32
20612
3
ASPIRATE/INJ GANGLION CYST
$53.29
20615
3
TREATMENT OF BONE CYST
$195.30
20650
3
INSERT AND REMOVE BONE PIN
$177.30
20660
3
APPLY, REM FIXATION DEVICE
$229.54
20661
3
APPLICATION OF HEAD BRACE
$419.88
20662
3
APPLICATION OF PELVIS BRACE
$433.43
20663
3
APPLICATION OF THIGH BRACE
$401.18
20664
3
HALO BRACE APPLICATION
$685.24
20665
3
REMOVAL OF FIXATION DEVICE
$110.12
20670
3
REMOVAL OF SUPPORT IMPLANT
$135.41
20680
3
REMOVAL OF SUPPORT IMPLANT
$373.62
20690
3
APPLY BONE FIXATION DEVICE
$489.61
20692
3
APPLY BONE FIXATION DEVICE
$916.34
20693
3
ADJUST BONE FIXATION DEVICE
$415.39
20694
3
REMOVE BONE FIXATION DEVICE
$380.79
20696
3
COMP MULTIPLANE EXT FIXATION
$981.74
20697
3
COMP EXT FIXATE STRUT CHANGE
$1,223.25
20802
3
REPLANTATION, ARM, COMPLETE
$2,238.62
20804
O
REPLANTATION, ARM (INCLUDES SURGICA
20805
3
REPLANT FOREARM, COMPLETE
20806
O
REPLANTATION, FOREARM (INCLUDES RAD
20808
3
REPLANTATION HAND, COMPLETE
20812
O
REPLANTATION, HAND (INCLUDES HAND T
20816
3
REPLANTATION DIGIT, COMPLETE
20820
O
REPLANTATION, DIGIT, EXCLUDING THUM
20822
3
REPLANTATION DIGIT, COMPLETE
20823
O
REPLANTATION, DIGIT, EXCLUDING THUM
20824
3
REPLANTATION THUMB, COMPLETE
20826
O
REPLANTATION, THUMB (INCLUDES CARPO
$0.00 $2,744.46 $0.00 $3,732.20 $0.00 $2,070.54 $0.00 $1,756.93 $0.00 $2,061.98 $0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
20827
3
REPLANTATION THUMB, COMPLETE
$1,827.39
20828
O
REPLANTATION, THUMB (INCLUDES DISTA
$0.00
20832
O
REPLANTATION, LEG; COMPLETE AMPUTAT
$0.00
20834
O
REPLANTATION, LEG; INCOMPLETE AMPUT
$0.00
20838
3
REPLANTATION FOOT, COMPLETE
20840
O
REPLANTATION, FOOT; INCOMPLETE AMPU
20900
3
REMOVAL OF BONE FOR GRAFT
$381.50
20902
3
REMOVAL OF BONE FOR GRAFT
$333.45
20910
3
REMOVE CARTILAGE FOR GRAFT
$391.13
20912
3
REMOVE CARTILAGE FOR GRAFT
$438.20
20920
3
REMOVAL OF FASCIA FOR GRAFT
$369.22
20922
3
REMOVAL OF FASCIA FOR GRAFT
$548.83
20924
3
REMOVAL OF TENDON FOR GRAFT
$457.10
20926
3
REMOVAL OF TISSUE FOR GRAFT
$394.60
20930
9
SP BONE ALGRFT MORSEL ADD-ON
$0.00
20931
3
SP BONE ALGRFT STRUCT ADD-ON
$103.82
20936
9
SP BONE AGRFT LOCAL ADD-ON
20937
3
SP BONE AGRFT MORSEL ADD-ON
$158.11
20938
3
SP BONE AGRFT STRUCT ADD-ON
$171.69
20950
3
FLUID PRESSURE, MUSCLE
$222.84
20955
3
FIBULA BONE GRAFT, MICROVASC
$2,333.14
20956
3
ILIAC BONE GRAFT, MICROVASC
$2,435.55
20957
3
MT BONE GRAFT, MICROVASC
$2,316.85
20960
O
BONE GRAFT WITH MICROVASCULAR ANAST
20962
3
OTHER BONE GRAFT, MICROVASC
$2,388.58
20969
3
BONE/SKIN GRAFT, MICROVASC
$2,582.88
20970
3
BONE/SKIN GRAFT, ILIAC CREST
$2,596.85
20971
O
FREE OSTEOCUTANEOUS FLAP WITH MICRO
20972
3
BONE/SKIN GRAFT, METATARSAL
$2,362.07
20973
3
BONE/SKIN GRAFT, GREAT TOE
$2,477.55
20974
3
ELECTRICAL BONE STIMULATION
$59.17
20975
3
ELECTRICAL BONE STIMULATION
$163.18
20976
O
ELECTRICAL STIMULATION TO AID BONE
20979
3
US BONE STIMULATION
20982
3
ABLATE, BONE TUMOR(S) PERQ
$2,264.18 $0.00
$0.00
$0.00
$0.00
$0.00 $48.34 $3,475.81
Procedure Code Pricing Action Code Description
Maximum Allowable
20985
3
CPTR-ASST DIR MS PX
$140.03
20986
O
CPTR-ASST DIR MS PX IO IMG
$0.00
20987
O
CPTR-ASST DIR MS PX PRE IMG
$0.00
20999
5
MUSCULOSKELETAL SURGERY
$0.00
21010
3
INCISION OF JAW JOINT
$657.52
21015
3
RESECTION OF FACIAL TUMOR
$385.12
21025
3
EXCISION OF BONE, LOWER JAW
$795.07
21026
3
EXCISION OF FACIAL BONE(S)
$528.08
21029
3
CONTOUR OF FACE BONE LESION
$670.40
21030
3
EXCISE MAX/ZYGOMA B9 TUMOR
$441.41
21031
3
REMOVE EXOSTOSIS, MANDIBLE
$340.58
21032
3
REMOVE EXOSTOSIS, MAXILLA
$345.13
21034
3
EXCISE MAX/ZYGOMA MLG TUMOR
21040
3
EXCISE MANDIBLE LESION
21041
O
REMOVAL OF JAW BONE LESION
$0.00
21044
3
REMOVAL OF JAW BONE LESION
$794.66
21045
3
EXTENSIVE JAW SURGERY
21046
3
REMOVE MANDIBLE CYST COMPLEX
21047
3
EXCISE LWR JAW CYST W/REPAIR
$1,181.86
21048
3
REMOVE MAXILLA CYST COMPLEX
$995.38
21049
3
EXCIS UPPR JAW CYST W/REPAIR
21050
3
REMOVAL OF JAW JOINT
$781.81
21060
3
REMOVE JAW JOINT CARTILAGE
$713.16
21070
3
REMOVE CORONOID PROCESS
$580.41
21073
3
MNPJ OF TMJ W/ANESTH
$328.95
21076
3
PREPARE FACE/ORAL PROSTHESIS
$873.18
21077
3
PREPARE FACE/ORAL PROSTHESIS
$2,150.91
21079
3
PREPARE FACE/ORAL PROSTHESIS
$1,472.63
21080
3
PREPARE FACE/ORAL PROSTHESIS
$1,673.03
21081
3
PREPARE FACE/ORAL PROSTHESIS
$1,527.13
21082
3
PREPARE FACE/ORAL PROSTHESIS
$1,422.47
21083
3
PREPARE FACE/ORAL PROSTHESIS
$1,351.98
21084
3
PREPARE FACE/ORAL PROSTHESIS
$1,539.38
21085
3
PREPARE FACE/ORAL PROSTHESIS
$623.05
21086
3
PREPARE FACE/ORAL PROSTHESIS
$1,569.01
$1,194.92 $445.11
$1,106.86 $983.00
$1,143.60
Procedure Code Pricing Action Code Description
Maximum Allowable
21087
3
PREPARE FACE/ORAL PROSTHESIS
$1,563.28
21088
5
PREPARE FACE/ORAL PROSTHESIS
$0.00
21089
5
PREPARE FACE/ORAL PROSTHESIS
$0.00
21100
3
MAXILLOFACIAL FIXATION
$639.52
21110
3
INTERDENTAL FIXATION
$670.75
21116
3
INJECTION, JAW JOINT X-RAY
$136.12
21120
3
RECONSTRUCTION OF CHIN
$556.86
21121
3
RECONSTRUCTION OF CHIN
$691.58
21122
3
RECONSTRUCTION OF CHIN
$649.07
21123
3
RECONSTRUCTION OF CHIN
$774.62
21125
3
AUGMENTATION, LOWER JAW BONE
$2,753.42
21127
3
AUGMENTATION, LOWER JAW BONE
$3,278.07
21137
3
REDUCTION OF FOREHEAD
$650.58
21138
3
REDUCTION OF FOREHEAD
$812.19
21139
3
REDUCTION OF FOREHEAD
$910.46
21141
3
RECONSTRUCT MIDFACE, LEFORT
$1,222.45
21142
3
RECONSTRUCT MIDFACE, LEFORT
$1,205.28
21143
3
RECONSTRUCT MIDFACE, LEFORT
$1,251.54
21144
O
RECONSTRUCTION MIDFACE, LEFORT I; I
21145
3
RECONSTRUCT MIDFACE, LEFORT
$1,400.33
21146
3
RECONSTRUCT MIDFACE, LEFORT
$1,497.26
21147
3
RECONSTRUCT MIDFACE, LEFORT
$1,540.01
21150
3
RECONSTRUCT MIDFACE, LEFORT
$1,528.63
21151
3
RECONSTRUCT MIDFACE, LEFORT
$1,856.40
21154
3
RECONSTRUCT MIDFACE, LEFORT
$1,869.08
21155
3
RECONSTRUCT MIDFACE, LEFORT
$2,116.84
21159
3
RECONSTRUCT MIDFACE, LEFORT
$2,558.39
21160
3
RECONSTRUCT MIDFACE, LEFORT
$2,628.74
21172
3
RECONSTRUCT ORBIT/FOREHEAD
$1,617.79
21175
3
RECONSTRUCT ORBIT/FOREHEAD
$1,954.61
21179
3
RECONSTRUCT ENTIRE FOREHEAD
$1,340.86
21180
3
RECONSTRUCT ENTIRE FOREHEAD
$1,529.13
21181
3
CONTOUR CRANIAL BONE LESION
21182
3
RECONSTRUCT CRANIAL BONE
$1,856.89
21183
3
RECONSTRUCT CRANIAL BONE
$2,077.91
$0.00
$640.53
Procedure Code Pricing Action Code Description
Maximum Allowable
21184
3
RECONSTRUCT CRANIAL BONE
$2,219.37
21188
3
RECONSTRUCTION OF MIDFACE
$1,480.45
21193
3
RECONST LWR JAW W/O GRAFT
$1,126.43
21194
3
RECONST LWR JAW W/GRAFT
$1,286.04
21195
3
RECONST LWR JAW W/O FIXATION
$1,212.70
21196
3
RECONST LWR JAW W/FIXATION
$1,321.37
21198
3
RECONSTR LWR JAW SEGMENT
$1,041.31
21199
3
RECONSTR LWR JAW W/ADVANCE
21200
O
OSTEOTOMY (EG, FOR PROGNATHISM, MIC
$0.00
21202
O
OSTEOTOMY (EG, FOR PROGNATHISM, MIC
$0.00
21203
O
OSTEOTOMY (EG, FOR PROGNATHISM, MIC
$0.00
21204
O
OSTEOTOMY (EG, FOR PROGNATHISM, MIC
$0.00
21206
3
RECONSTRUCT UPPER JAW BONE
$1,025.51
21208
3
AUGMENTATION OF FACIAL BONES
$1,553.28
21209
3
REDUCTION OF FACIAL BONES
21210
3
FACE BONE GRAFT
21215
3
LOWER JAW BONE GRAFT
$776.10
21230
3
RIB CARTILAGE GRAFT
$693.44
21235
3
EAR CARTILAGE GRAFT
$648.51
21240
3
RECONSTRUCTION OF JAW JOINT
$1,003.06
21242
3
RECONSTRUCTION OF JAW JOINT
$919.51
21243
3
RECONSTRUCTION OF JAW JOINT
$1,508.01
21244
3
RECONSTRUCTION OF LOWER JAW
21245
3
RECONSTRUCTION OF JAW
$1,021.52
21246
3
RECONSTRUCTION OF JAW
$771.86
21247
3
RECONSTRUCT LOWER JAW BONE
21248
3
RECONSTRUCTION OF JAW
$959.96
21249
3
RECONSTRUCTION OF JAW
$1,328.84
21250
O
OSTEOPLASTY OF MAXILLA AND/OR OTHER
$0.00
21254
O
OSTEOPLASTY OF MAXILLA AND/OR OTHER
$0.00
21255
3
RECONSTRUCT LOWER JAW BONE
$1,305.54
21256
3
RECONSTRUCTION OF ORBIT
$1,058.83
21260
3
REVISE EYE SOCKETS
$1,199.53
21261
3
REVISE EYE SOCKETS
$2,040.55
21263
3
REVISE EYE SOCKETS
$1,835.87
$935.18
$731.65 $1,863.02
$944.00
$1,465.39
Procedure Code Pricing Action Code Description
Maximum Allowable
21267
3
REVISE EYE SOCKETS
$1,400.25
21268
3
REVISE EYE SOCKETS
$1,734.18
21270
3
AUGMENTATION, CHEEK BONE
$815.75
21275
3
REVISION, ORBITOFACIAL BONES
$728.93
21280
3
REVISION OF EYELID
$472.14
21282
3
REVISION OF EYELID
$313.18
21295
3
REVISION OF JAW MUSCLE/BONE
$157.23
21296
3
REVISION OF JAW MUSCLE/BONE
$381.69
21299
5
CRANIO/MAXILLOFACIAL SURGERY
$0.00
21300
O
TREATMENT OF SKULL FRACTURE
$0.00
21310
3
TREATMENT OF NOSE FRACTURE
$95.86
21315
3
TREATMENT OF NOSE FRACTURE
$233.70
21320
3
TREATMENT OF NOSE FRACTURE
$224.58
21325
3
TREATMENT OF NOSE FRACTURE
$422.39
21330
3
TREATMENT OF NOSE FRACTURE
$516.60
21335
3
TREATMENT OF NOSE FRACTURE
$664.06
21336
3
TREAT NASAL SEPTAL FRACTURE
$576.27
21337
3
TREAT NASAL SEPTAL FRACTURE
$348.72
21338
3
TREAT NASOETHMOID FRACTURE
$661.61
21339
3
TREAT NASOETHMOID FRACTURE
$735.41
21340
3
TREATMENT OF NOSE FRACTURE
$727.08
21343
3
TREATMENT OF SINUS FRACTURE
$1,037.07
21344
3
TREATMENT OF SINUS FRACTURE
$1,355.99
21345
3
TREAT NOSE/JAW FRACTURE
$718.70
21346
3
TREAT NOSE/JAW FRACTURE
$859.82
21347
3
TREAT NOSE/JAW FRACTURE
$996.21
21348
3
TREAT NOSE/JAW FRACTURE
$1,048.98
21355
3
TREAT CHEEK BONE FRACTURE
$390.63
21356
3
TREAT CHEEK BONE FRACTURE
$437.78
21360
3
TREAT CHEEK BONE FRACTURE
$476.35
21365
3
TREAT CHEEK BONE FRACTURE
$994.49
21366
3
TREAT CHEEK BONE FRACTURE
$1,104.46
21385
3
TREAT EYE SOCKET FRACTURE
$643.01
21386
3
TREAT EYE SOCKET FRACTURE
$598.64
21387
3
TREAT EYE SOCKET FRACTURE
$670.49
Procedure Code Pricing Action Code Description
Maximum Allowable
21390
3
TREAT EYE SOCKET FRACTURE
$692.58
21395
3
TREAT EYE SOCKET FRACTURE
$871.94
21400
3
TREAT EYE SOCKET FRACTURE
$157.83
21401
3
TREAT EYE SOCKET FRACTURE
$421.35
21406
3
TREAT EYE SOCKET FRACTURE
$485.75
21407
3
TREAT EYE SOCKET FRACTURE
$574.57
21408
3
TREAT EYE SOCKET FRACTURE
$789.31
21421
3
TREAT MOUTH ROOF FRACTURE
$650.29
21422
3
TREAT MOUTH ROOF FRACTURE
$603.12
21423
3
TREAT MOUTH ROOF FRACTURE
$715.57
21431
3
TREAT CRANIOFACIAL FRACTURE
$662.70
21432
3
TREAT CRANIOFACIAL FRACTURE
$601.22
21433
3
TREAT CRANIOFACIAL FRACTURE
$1,536.31
21435
3
TREAT CRANIOFACIAL FRACTURE
$1,213.02
21436
3
TREAT CRANIOFACIAL FRACTURE
$1,783.68
21440
3
TREAT DENTAL RIDGE FRACTURE
$474.58
21445
3
TREAT DENTAL RIDGE FRACTURE
$671.15
21450
3
TREAT LOWER JAW FRACTURE
$494.13
21451
3
TREAT LOWER JAW FRACTURE
$650.91
21452
3
TREAT LOWER JAW FRACTURE
$539.35
21453
3
TREAT LOWER JAW FRACTURE
$753.31
21454
3
TREAT LOWER JAW FRACTURE
$496.59
21455
O
CLOSED MANIPULATIVE TREATMENT BY IN
21461
3
TREAT LOWER JAW FRACTURE
$823.04
21462
3
TREAT LOWER JAW FRACTURE
$1,853.84
21465
3
TREAT LOWER JAW FRACTURE
$821.18
21470
3
TREAT LOWER JAW FRACTURE
$1,070.69
21480
3
RESET DISLOCATED JAW
$81.28
21485
3
RESET DISLOCATED JAW
$582.57
21490
3
REPAIR DISLOCATED JAW
$832.65
21493
O
TREAT HYOID BONE FRACTURE
$0.00
21494
O
TREAT HYOID BONE FRACTURE
$0.00
21495
3
TREAT HYOID BONE FRACTURE
$612.21
21497
3
INTERDENTAL WIRING
$588.77
21499
5
HEAD SURGERY PROCEDURE
$0.00
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
21501
3
DRAIN NECK/CHEST LESION
$388.90
21502
3
DRAIN CHEST LESION
$469.91
21510
3
DRAINAGE OF BONE LESION
$416.51
21550
3
BIOPSY OF NECK/CHEST
$229.01
21555
3
REMOVE LESION, NECK/CHEST
$382.49
21556
3
REMOVE LESION, NECK/CHEST
$371.30
21557
3
REMOVE TUMOR, NECK/CHEST
$523.58
21600
3
PARTIAL REMOVAL OF RIB
$497.73
21610
3
PARTIAL REMOVAL OF RIB
$963.44
21615
3
REMOVAL OF RIB
$608.35
21616
3
REMOVAL OF RIB AND NERVES
$777.96
21620
3
PARTIAL REMOVAL OF STERNUM
$472.33
21627
3
STERNAL DEBRIDEMENT
$496.93
21630
3
EXTENSIVE STERNUM SURGERY
$1,152.12
21632
3
EXTENSIVE STERNUM SURGERY
$1,138.03
21633
O
RADICAL RESECTION OF STERNUM; FOR O
21685
3
HYOID MYOTOMY & SUSPENSION
$899.84
21700
3
REVISION OF NECK MUSCLE
$382.61
21705
3
REVISION OF NECK MUSCLE/RIB
$586.66
21720
3
REVISION OF NECK MUSCLE
$369.28
21725
3
REVISION OF NECK MUSCLE
$480.13
21740
3
RECONSTRUCTION OF STERNUM
$989.78
21742
5
REPAIR STERN/NUSS W/O SCOPE
$0.00
21743
5
REPAIR STERNUM/NUSS W/SCOPE
$0.00
21750
3
REPAIR OF STERNUM SEPARATION
21800
3
TREATMENT OF RIB FRACTURE
$86.72
21805
3
TREATMENT OF RIB FRACTURE
$231.91
21810
3
TREATMENT OF RIB FRACTURE(S)
$450.97
21820
3
TREAT STERNUM FRACTURE
$115.72
21825
3
TREAT STERNUM FRACTURE
$512.55
21899
5
NECK/CHEST SURGERY PROCEDURE
21920
3
BIOPSY SOFT TISSUE OF BACK
$228.53
21925
3
BIOPSY SOFT TISSUE OF BACK
$373.66
21930
3
REMOVE LESION, BACK OR FLANK
$416.98
21935
3
REMOVE TUMOR, BACK
$0.00
$656.85
$0.00
$1,049.71
Procedure Code Pricing Action Code Description
Maximum Allowable
22010
3
I&D, P-SPINE, C/T/CERV-THOR
$812.16
22015
3
I&D, P-SPINE, L/S/LS
$807.75
22100
3
REMOVE PART OF NECK VERTEBRA
$734.09
22101
3
REMOVE PART, THORAX VERTEBRA
$732.18
22102
3
REMOVE PART, LUMBAR VERTEBRA
$729.24
22103
3
REMOVE EXTRA SPINE SEGMENT
$132.24
22105
O
PARTIAL RESECTION OF VERTEBRAL COMP
$0.00
22106
O
PARTIAL RESECTION OF VERTEBRAL COMP
$0.00
22107
O
PARTIAL RESECTION OF VERTEBRAL COMP
$0.00
22110
3
REMOVE PART OF NECK VERTEBRA
$911.11
22112
3
REMOVE PART, THORAX VERTEBRA
$881.24
22114
3
REMOVE PART, LUMBAR VERTEBRA
$904.94
22116
3
REMOVE EXTRA SPINE SEGMENT
$131.49
22140
O
RECONSTRUCTION OF SPINE WITH BONE G
$0.00
22141
O
RECONSTRUCTION OF SPINE WITH BONE G
$0.00
22142
O
RECONSTRUCTION OF SPINE WITH BONE G
$0.00
22145
O
RECONSTRUCTION OF SPINE FOLLOWING V
$0.00
22148
O
HARVESTING OF BONE AUTOGRAFT FOR VE
$0.00
22150
O
RECONSTRUCTION OF SPINE WITH PREFAB
$0.00
22151
O
RECONSTRUCTION OF SPINE WITH PREFAB
$0.00
22152
O
RECONSTRUCTION OF SPINE WITH PREFAB
$0.00
22206
3
CUT SPINE 3 COL, THOR
$2,160.60
22207
3
CUT SPINE 3 COL, LUMB
$2,132.62
22208
3
CUT SPINE 3 COL, ADDL SEG
22210
3
REVISION OF NECK SPINE
$1,590.80
22212
3
REVISION OF THORAX SPINE
$1,316.56
22214
3
REVISION OF LUMBAR SPINE
$1,324.89
22216
3
REVISE, EXTRA SPINE SEGMENT
22220
3
REVISION OF NECK SPINE
$1,432.03
22222
3
REVISION OF THORAX SPINE
$1,302.22
22224
3
REVISION OF LUMBAR SPINE
$1,417.53
22226
3
REVISE, EXTRA SPINE SEGMENT
22230
O
OSTEOTOMY OF SPINE, ANY APPROACH, E
22305
3
TREAT SPINE PROCESS FRACTURE
$165.01
22310
3
TREAT SPINE FRACTURE
$254.39
$542.31
$344.73
$343.25 $0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
22315
3
TREAT SPINE FRACTURE
$760.65
22318
3
TREAT ODONTOID FX W/O GRAFT
$1,430.46
22319
3
TREAT ODONTOID FX W/GRAFT
$1,570.90
22325
3
TREAT SPINE FRACTURE
$1,254.01
22326
3
TREAT NECK SPINE FRACTURE
$1,306.22
22327
3
TREAT THORAX SPINE FRACTURE
$1,296.57
22328
3
TREAT EACH ADD SPINE FX
$259.74
22505
3
MANIPULATION OF SPINE
$110.95
22520
3
PERCUT VERTEBROPLASTY THOR
$2,110.61
22521
3
PERCUT VERTEBROPLASTY LUMB
$2,056.31
22522
3
PERCUT VERTEBROPLASTY ADDÏL
$235.05
22523
3
PERCUT KYPHOPLASTY, THOR
$560.36
22524
3
PERCUT KYPHOPLASTY, LUMBAR
$536.90
22525
3
PERCUT KYPHOPLASTY, ADD-ON
$250.37
22526
9
IDET, SINGLE LEVEL
$0.00
22527
9
IDET, 1 OR MORE LEVELS
$0.00
22532
3
LAT THORAX SPINE FUSION
$1,559.30
22533
3
LAT LUMBAR SPINE FUSION
$1,469.78
22534
3
LAT THOR/LUMB, ADDÏL SEG
$340.13
22548
3
NECK SPINE FUSION
$1,660.29
22554
3
NECK SPINE FUSION
$1,149.95
22556
3
THORAX SPINE FUSION
$1,487.35
22558
3
LUMBAR SPINE FUSION
$1,366.37
22585
3
ADDITIONAL SPINAL FUSION
22590
3
SPINE & SKULL SPINAL FUSION
$1,380.62
22595
3
NECK SPINAL FUSION
$1,311.16
22600
3
NECK SPINE FUSION
$1,124.75
22610
3
THORAX SPINE FUSION
$1,110.11
22612
3
LUMBAR SPINE FUSION
$1,435.03
22614
3
SPINE FUSION, EXTRA SEGMENT
22625
O
ARTHRODESIS, LATERAL TRANSVERSE PRO
22630
3
LUMBAR SPINE FUSION
22632
3
SPINE FUSION, EXTRA SEGMENT
22650
O
ARTHRODESIS, POSTERIOR, POSTEROLATE
22800
3
FUSION OF SPINE
$314.09
$366.73 $0.00 $1,380.63 $297.88 $0.00 $1,220.47
Procedure Code Pricing Action Code Description
Maximum Allowable
22802
3
FUSION OF SPINE
$1,938.09
22804
3
FUSION OF SPINE
$2,238.20
22808
3
FUSION OF SPINE
$1,648.98
22810
3
FUSION OF SPINE
$1,837.86
22812
3
FUSION OF SPINE
$2,012.25
22818
3
KYPHECTOMY, 1-2 SEGMENTS
$2,027.13
22819
3
KYPHECTOMY, 3 OR MORE
$2,335.49
22820
O
HARVESTING OF BONE AUTOGRAFT THROUG
22830
3
EXPLORATION OF SPINAL FUSION
$728.28
22840
3
INSERT SPINE FIXATION DEVICE
$715.74
22841
9
INSERT SPINE FIXATION DEVICE
$0.00
22842
3
INSERT SPINE FIXATION DEVICE
$717.32
22843
3
INSERT SPINE FIXATION DEVICE
$763.61
22844
3
INSERT SPINE FIXATION DEVICE
$936.05
22845
3
INSERT SPINE FIXATION DEVICE
$684.49
22846
3
INSERT SPINE FIXATION DEVICE
$710.73
22847
3
INSERT SPINE FIXATION DEVICE
$784.28
22848
3
INSERT PELV FIXATION DEVICE
$341.06
22849
3
REINSERT SPINAL FIXATION
22850
3
REMOVE SPINE FIXATION DEVICE
$644.52
22851
3
APPLY SPINE PROSTH DEVICE
$381.60
22852
3
REMOVE SPINE FIXATION DEVICE
$616.33
22855
3
REMOVE SPINE FIXATION DEVICE
$998.74
22856
3
CERV ARTIFIC DISKECTOMY
$1,492.64
22857
3
LUMBAR ARTIF DISKECTOMY
$1,556.36
22861
3
REVISE CERV ARTIFIC DISC
$1,818.88
22862
3
REVISE LUMBAR ARTIF DISC
$1,794.55
22864
3
REMOVE CERV ARTIF DISC
$1,665.72
22865
3
REMOVE LUMB ARTIF DISC
$1,925.16
22899
5
SPINE SURGERY PROCEDURE
22900
3
REMOVE ABDOMINAL WALL LESION
22999
5
ABDOMEN SURGERY PROCEDURE
$0.00
23000
3
REMOVAL OF CALCIUM DEPOSITS
$472.62
23020
3
RELEASE SHOULDER JOINT
$622.19
23030
3
DRAIN SHOULDER LESION
$377.27
$0.00
$1,178.99
$0.00 $367.75
Procedure Code Pricing Action Code Description
Maximum Allowable
23031
3
DRAIN SHOULDER BURSA
$345.16
23035
3
DRAIN SHOULDER BONE LESION
$617.43
23040
3
EXPLORATORY SHOULDER SURGERY
$647.92
23044
3
EXPLORATORY SHOULDER SURGERY
$514.03
23065
3
BIOPSY SHOULDER TISSUES
$190.52
23066
3
BIOPSY SHOULDER TISSUES
$449.48
23075
3
REMOVAL OF SHOULDER LESION
$229.95
23076
3
REMOVAL OF SHOULDER LESION
$505.48
23077
3
REMOVE TUMOR OF SHOULDER
23100
3
BIOPSY OF SHOULDER JOINT
$437.75
23101
3
SHOULDER JOINT SURGERY
$402.39
23105
3
REMOVE SHOULDER JOINT LINING
$573.07
23106
3
INCISION OF COLLARBONE JOINT
$427.03
23107
3
EXPLORE TREAT SHOULDER JOINT
$595.35
23120
3
PARTIAL REMOVAL, COLLAR BONE
$515.58
23125
3
REMOVAL OF COLLAR BONE
$633.00
23130
3
REMOVE SHOULDER BONE, PART
$542.26
23140
3
REMOVAL OF BONE LESION
$460.86
23145
3
REMOVAL OF BONE LESION
$621.68
23146
3
REMOVAL OF BONE LESION
$540.10
23150
3
REMOVAL OF HUMERUS LESION
$588.26
23155
3
REMOVAL OF HUMERUS LESION
$712.60
23156
3
REMOVAL OF HUMERUS LESION
$605.64
23170
3
REMOVE COLLAR BONE LESION
$475.76
23172
3
REMOVE SHOULDER BLADE LESION
$488.16
23174
3
REMOVE HUMERUS LESION
$677.62
23180
3
REMOVE COLLAR BONE LESION
$616.93
23182
3
REMOVE SHOULDER BLADE LESION
$595.41
23184
3
REMOVE HUMERUS LESION
$671.76
23190
3
PARTIAL REMOVAL OF SCAPULA
$499.93
23195
3
REMOVAL OF HEAD OF HUMERUS
$677.90
23200
3
REMOVAL OF COLLAR BONE
$799.05
23210
3
REMOVAL OF SHOULDER BLADE
$836.12
23220
3
PARTIAL REMOVAL OF HUMERUS
$968.28
23221
3
PARTIAL REMOVAL OF HUMERUS
$1,129.37
$1,070.75
Procedure Code Pricing Action Code Description
Maximum Allowable
23222
3
PARTIAL REMOVAL OF HUMERUS
$1,537.23
23330
3
REMOVE SHOULDER FOREIGN BODY
$199.02
23331
3
REMOVE SHOULDER FOREIGN BODY
$528.01
23332
3
REMOVE SHOULDER FOREIGN BODY
$800.67
23350
3
INJECTION FOR SHOULDER X-RAY
$144.76
23395
3
MUSCLE TRANSFER,SHOULDER/ARM
$1,165.84
23397
3
MUSCLE TRANSFERS
$1,043.69
23400
3
FIXATION OF SHOULDER BLADE
$885.15
23405
3
INCISION OF TENDON & MUSCLE
$569.64
23406
3
INCISE TENDON(S) & MUSCLE(S)
$711.47
23410
3
REPAIR ROTATOR CUFF, ACUTE
$755.35
23412
3
REPAIR ROTATOR CUFF, CHRONIC
$789.33
23415
3
RELEASE OF SHOULDER LIGAMENT
$629.41
23420
3
REPAIR OF SHOULDER
$884.62
23430
3
REPAIR BICEPS TENDON
$669.60
23440
3
REMOVE/TRANSPLANT TENDON
$690.39
23450
3
REPAIR SHOULDER CAPSULE
$865.71
23455
3
REPAIR SHOULDER CAPSULE
$923.31
23460
3
REPAIR SHOULDER CAPSULE
$999.55
23462
3
REPAIR SHOULDER CAPSULE
$980.23
23465
3
REPAIR SHOULDER CAPSULE
$1,022.80
23466
3
REPAIR SHOULDER CAPSULE
$1,008.97
23470
3
RECONSTRUCT SHOULDER JOINT
$1,112.61
23472
3
RECONSTRUCT SHOULDER JOINT
$1,377.07
23480
3
REVISION OF COLLAR BONE
$744.30
23485
3
REVISION OF COLLAR BONE
$879.00
23490
3
REINFORCE CLAVICLE
$759.38
23491
3
REINFORCE SHOULDER BONES
$925.73
23500
3
TREAT CLAVICLE FRACTURE
$182.75
23505
3
TREAT CLAVICLE FRACTURE
$300.96
23510
O
TREATMENT OF OPEN CLAVICULAR FRACTU
23515
3
TREAT CLAVICLE FRACTURE
$632.24
23520
3
TREAT CLAVICLE DISLOCATION
$189.53
23525
3
TREAT CLAVICLE DISLOCATION
$294.49
23530
3
TREAT CLAVICLE DISLOCATION
$483.99
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
23532
3
TREAT CLAVICLE DISLOCATION
$557.68
23540
3
TREAT CLAVICLE DISLOCATION
$187.14
23545
3
TREAT CLAVICLE DISLOCATION
$270.47
23550
3
TREAT CLAVICLE DISLOCATION
$514.26
23552
3
TREAT CLAVICLE DISLOCATION
$592.11
23570
3
TREAT SHOULDER BLADE FX
$195.47
23575
3
TREAT SHOULDER BLADE FX
$333.65
23580
O
TREATMENT OF OPEN SCAPULAR FRACTURE
23585
3
TREAT SCAPULA FRACTURE
$856.16
23600
3
TREAT HUMERUS FRACTURE
$273.62
23605
3
TREAT HUMERUS FRACTURE
$403.69
23610
O
TREATMENT OF OPEN HUMERAL (SURGICAL
23615
3
TREAT HUMERUS FRACTURE
$785.07
23616
3
TREAT HUMERUS FRACTURE
$1,171.97
23620
3
TREAT HUMERUS FRACTURE
$225.41
23625
3
TREAT HUMERUS FRACTURE
$327.22
23630
3
TREAT HUMERUS FRACTURE
$674.19
23650
3
TREAT SHOULDER DISLOCATION
$253.97
23655
3
TREAT SHOULDER DISLOCATION
$337.62
23658
O
TREATMENT OF OPEN SHOULDER DISLOCAT
23660
3
TREAT SHOULDER DISLOCATION
$521.42
23665
3
TREAT DISLOCATION/FRACTURE
$364.10
23670
3
TREAT DISLOCATION/FRACTURE
$756.65
23675
3
TREAT DISLOCATION/FRACTURE
$475.44
23680
3
TREAT DISLOCATION/FRACTURE
$819.51
23700
3
FIXATION OF SHOULDER
$175.25
23800
3
FUSION OF SHOULDER JOINT
$931.36
23802
3
FUSION OF SHOULDER JOINT
$1,130.53
23900
3
AMPUTATION OF ARM & GIRDLE
$1,204.87
23920
3
AMPUTATION AT SHOULDER JOINT
$976.95
23921
3
AMPUTATION FOLLOW-UP SURGERY
$354.10
23929
5
SHOULDER SURGERY PROCEDURE
23930
3
DRAINAGE OF ARM LESION
$313.13
23931
3
DRAINAGE OF ARM BURSA
$245.16
23935
3
DRAIN ARM/ELBOW BONE LESION
$444.79
$0.00
$0.00
$0.00
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
24000
3
EXPLORATORY ELBOW SURGERY
$422.89
24006
3
RELEASE ELBOW JOINT
$639.62
24065
3
BIOPSY ARM/ELBOW SOFT TISSUE
$223.68
24066
3
BIOPSY ARM/ELBOW SOFT TISSUE
$518.43
24075
3
REMOVE ARM/ELBOW LESION
$420.75
24076
3
REMOVE ARM/ELBOW LESION
$424.54
24077
3
REMOVE TUMOR OF ARM/ELBOW
$733.56
24100
3
BIOPSY ELBOW JOINT LINING
$361.00
24101
3
EXPLORE/TREAT ELBOW JOINT
$444.78
24102
3
REMOVE ELBOW JOINT LINING
$551.58
24105
3
REMOVAL OF ELBOW BURSA
$299.19
24110
3
REMOVE HUMERUS LESION
$522.04
24115
3
REMOVE/GRAFT BONE LESION
$658.62
24116
3
REMOVE/GRAFT BONE LESION
$781.94
24120
3
REMOVE ELBOW LESION
$467.26
24125
3
REMOVE/GRAFT BONE LESION
$539.74
24126
3
REMOVE/GRAFT BONE LESION
$572.96
24130
3
REMOVAL OF HEAD OF RADIUS
$451.53
24134
3
REMOVAL OF ARM BONE LESION
$678.24
24136
3
REMOVE RADIUS BONE LESION
$535.61
24138
3
REMOVE ELBOW BONE LESION
$593.38
24140
3
PARTIAL REMOVAL OF ARM BONE
$646.38
24145
3
PARTIAL REMOVAL OF RADIUS
$542.10
24147
3
PARTIAL REMOVAL OF ELBOW
$563.64
24149
3
RADICAL RESECTION OF ELBOW
$1,041.12
24150
3
EXTENSIVE HUMERUS SURGERY
$881.83
24151
3
EXTENSIVE HUMERUS SURGERY
$1,013.28
24152
3
EXTENSIVE RADIUS SURGERY
$663.14
24153
3
EXTENSIVE RADIUS SURGERY
$709.37
24155
3
REMOVAL OF ELBOW JOINT
$767.54
24160
3
REMOVE ELBOW JOINT IMPLANT
$543.06
24164
3
REMOVE RADIUS HEAD IMPLANT
$443.85
24200
3
REMOVAL OF ARM FOREIGN BODY
$174.14
24201
3
REMOVAL OF ARM FOREIGN BODY
$487.00
24220
3
INJECTION FOR ELBOW X-RAY
$158.53
Procedure Code Pricing Action Code Description
Maximum Allowable
24300
3
MANIPULATE ELBOW W/ANESTH
$348.71
24301
3
MUSCLE/TENDON TRANSFER
$679.26
24305
3
ARM TENDON LENGTHENING
$518.86
24310
3
REVISION OF ARM TENDON
$424.82
24320
3
REPAIR OF ARM TENDON
$699.44
24330
3
REVISION OF ARM MUSCLES
$645.64
24331
3
REVISION OF ARM MUSCLES
$713.96
24332
3
TENOLYSIS, TRICEPS
$541.53
24340
3
REPAIR OF BICEPS TENDON
$550.69
24341
3
REPAIR ARM TENDON/MUSCLE
$648.56
24342
3
REPAIR OF RUPTURED TENDON
$709.71
24343
3
REPR ELBOW LAT LIGMNT W/TISS
$630.22
24344
3
RECONSTRUCT ELBOW LAT LIGMNT
$982.15
24345
3
REPR ELBW MED LIGMNT W/TISSU
$626.01
24346
3
RECONSTRUCT ELBOW MED LIGMNT
$984.39
24350
O
REPAIR OF TENNIS ELBOW
$0.00
24351
O
REPAIR OF TENNIS ELBOW
$0.00
24352
O
REPAIR OF TENNIS ELBOW
$0.00
24354
O
REPAIR OF TENNIS ELBOW
$0.00
24356
O
REVISION OF TENNIS ELBOW
$0.00
24357
3
REPAIR ELBOW, PERC
$395.07
24358
3
REPAIR ELBOW W/DEB, OPEN
$466.01
24359
3
REPAIR ELBOW DEB/ATTCH OPEN
$585.90
24360
3
RECONSTRUCT ELBOW JOINT
$815.80
24361
3
RECONSTRUCT ELBOW JOINT
$914.74
24362
3
RECONSTRUCT ELBOW JOINT
$967.31
24363
3
REPLACE ELBOW JOINT
24365
3
RECONSTRUCT HEAD OF RADIUS
$575.99
24366
3
RECONSTRUCT HEAD OF RADIUS
$616.89
24400
3
REVISION OF HUMERUS
$744.84
24410
3
REVISION OF HUMERUS
$950.96
24420
3
REVISION OF HUMERUS
$893.92
24430
3
REPAIR OF HUMERUS
$948.48
24435
3
REPAIR HUMERUS WITH GRAFT
$963.27
24470
3
REVISION OF ELBOW JOINT
$566.94
$1,355.58
Procedure Code Pricing Action Code Description
Maximum Allowable
24495
3
DECOMPRESSION OF FOREARM
$591.80
24498
3
REINFORCE HUMERUS
$791.00
24500
3
TREAT HUMERUS FRACTURE
$297.76
24505
3
TREAT HUMERUS FRACTURE
$432.24
24506
O
TREATMENT OF CLOSED HUMERAL SHAFT F
$0.00
24510
O
TREATMENT OF OPEN HUMERAL SHAFT FRA
$0.00
24515
3
TREAT HUMERUS FRACTURE
$793.22
24516
3
TREAT HUMERUS FRACTURE
$784.23
24530
3
TREAT HUMERUS FRACTURE
$320.54
24531
O
TREATMENT OF CLOSED HUMERAL SUPRACO
24535
3
TREAT HUMERUS FRACTURE
24536
O
TREATMENT OF CLOSED HUMERAL SUPRACO
24538
3
TREAT HUMERUS FRACTURE
24540
O
TREATMENT OF OPEN HUMERAL SUPRACOND
$0.00
24542
O
TREATMENT OF OPEN HUMERAL SUPRACOND
$0.00
24545
3
TREAT HUMERUS FRACTURE
$824.51
24546
3
TREAT HUMERUS FRACTURE
$958.78
24560
3
TREAT HUMERUS FRACTURE
$267.64
24565
3
TREAT HUMERUS FRACTURE
$444.55
24566
3
TREAT HUMERUS FRACTURE
$627.26
24570
O
TREATMENT OF OPEN HUMERAL EPICONDYL
24575
3
TREAT HUMERUS FRACTURE
$664.49
24576
3
TREAT HUMERUS FRACTURE
$281.71
24577
3
TREAT HUMERUS FRACTURE
$462.48
24578
O
TREATMENT OF OPEN HUMERAL CONDYLAR
24579
3
TREAT HUMERUS FRACTURE
24580
O
TREATMENT OF CLOSED COMMINUTED ELBO
$0.00
24581
O
TREATMENT OF CLOSED COMMINUTED ELBO
$0.00
24582
3
TREAT HUMERUS FRACTURE
24583
O
TREATMENT OF OPEN COMMINUTED ELBOW
$0.00
24585
O
OPEN TREATMENT OF CLOSED OR OPEN CO
$0.00
24586
3
TREAT ELBOW FRACTURE
$996.53
24587
3
TREAT ELBOW FRACTURE
$992.17
24588
O
OPEN TREATMENT OF CLOSED OR OPEN CO
24600
3
TREAT ELBOW DISLOCATION
$0.00 $540.59 $0.00 $669.58
$0.00
$0.00 $754.54
$699.81
$0.00 $313.18
Procedure Code Pricing Action Code Description
Maximum Allowable
24605
3
TREAT ELBOW DISLOCATION
$406.05
24610
O
TREATMENT OF OPEN ELBOW DISLOCATION
24615
3
TREAT ELBOW DISLOCATION
$645.96
24620
3
TREAT ELBOW FRACTURE
$490.13
24625
O
TREATMENT OF OPEN MONTEGGIA TYPE OF
24635
3
TREAT ELBOW FRACTURE
$680.84
24640
3
TREAT ELBOW DISLOCATION
$103.77
24650
3
TREAT RADIUS FRACTURE
$217.48
24655
3
TREAT RADIUS FRACTURE
$375.03
24660
O
TREATMENT OF OPEN RADIAL HEAD OR NE
24665
3
TREAT RADIUS FRACTURE
$581.88
24666
3
TREAT RADIUS FRACTURE
$660.46
24670
3
TREAT ULNAR FRACTURE
$244.33
24675
3
TREAT ULNAR FRACTURE
$396.14
24680
O
TREATMENT OF OPEN ULNAR FRACTURE, P
24685
3
TREAT ULNAR FRACTURE
$584.53
24800
3
FUSION OF ELBOW JOINT
$716.11
24802
3
FUSION/GRAFT OF ELBOW JOINT
$907.58
24900
3
AMPUTATION OF UPPER ARM
$647.21
24920
3
AMPUTATION OF UPPER ARM
$642.87
24925
3
AMPUTATION FOLLOW-UP SURGERY
$499.79
24930
3
AMPUTATION FOLLOW-UP SURGERY
$681.76
24931
3
AMPUTATE UPPER ARM & IMPLANT
$759.97
24935
3
REVISION OF AMPUTATION
$922.12
24940
5
REVISION OF UPPER ARM
$0.00
24999
5
UPPER ARM/ELBOW SURGERY
$0.00
25000
3
INCISION OF TENDON SHEATH
$311.35
25001
3
INCISE FLEXOR CARPI RADIALIS
$294.05
25005
O
TENDON SHEATH INCISION; AT WRIST FO
25020
3
DECOMPRESS FOREARM 1 SPACE
$515.49
25023
3
DECOMPRESS FOREARM 1 SPACE
$988.76
25024
3
DECOMPRESS FOREARM 2 SPACES
$689.74
25025
3
DECOMPRESS FOREARM 2 SPACES
$1,061.87
25028
3
DRAINAGE OF FOREARM LESION
$459.10
25031
3
DRAINAGE OF FOREARM BURSA
$337.12
$0.00
$0.00
$0.00
$0.00
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
25035
3
TREAT FOREARM BONE LESION
$582.72
25040
3
EXPLORE/TREAT WRIST JOINT
$514.18
25065
3
BIOPSY FOREARM SOFT TISSUES
$222.20
25066
3
BIOPSY FOREARM SOFT TISSUES
$337.73
25075
3
REMOVAL FOREARM LESION SUBCU
$295.40
25076
3
REMOVAL FOREARM LESION DEEP
$399.41
25077
3
REMOVE TUMOR, FOREARM/WRIST
$674.69
25085
3
INCISION OF WRIST CAPSULE
$415.01
25100
3
BIOPSY OF WRIST JOINT
$308.36
25101
3
EXPLORE/TREAT WRIST JOINT
$363.34
25105
3
REMOVE WRIST JOINT LINING
$441.38
25107
3
REMOVE WRIST JOINT CARTILAGE
$548.68
25109
3
EXCISE TENDON FOREARM/WRIST
$467.85
25110
3
REMOVE WRIST TENDON LESION
$323.48
25111
3
REMOVE WRIST TENDON LESION
$280.55
25112
3
REREMOVE WRIST TENDON LESION
$342.37
25115
3
REMOVE WRIST/FOREARM LESION
$723.46
25116
3
REMOVE WRIST/FOREARM LESION
$586.09
25118
3
EXCISE WRIST TENDON SHEATH
$343.57
25119
3
PARTIAL REMOVAL OF ULNA
$454.68
25120
3
REMOVAL OF FOREARM LESION
$500.30
25125
3
REMOVE/GRAFT FOREARM LESION
$581.72
25126
3
REMOVE/GRAFT FOREARM LESION
$587.40
25130
3
REMOVAL OF WRIST LESION
$403.01
25135
3
REMOVE & GRAFT WRIST LESION
$502.74
25136
3
REMOVE & GRAFT WRIST LESION
$444.61
25145
3
REMOVE FOREARM BONE LESION
$513.51
25150
3
PARTIAL REMOVAL OF ULNA
$521.13
25151
3
PARTIAL REMOVAL OF RADIUS
$577.54
25170
3
EXTENSIVE FOREARM SURGERY
$802.43
25210
3
REMOVAL OF WRIST BONE
$441.41
25215
3
REMOVAL OF WRIST BONES
$568.36
25230
3
PARTIAL REMOVAL OF RADIUS
$390.98
25240
3
PARTIAL REMOVAL OF ULNA
$396.71
25246
3
INJECTION FOR WRIST X-RAY
$160.82
Procedure Code Pricing Action Code Description
Maximum Allowable
25248
3
REMOVE FOREARM FOREIGN BODY
$394.95
25250
3
REMOVAL OF WRIST PROSTHESIS
$468.86
25251
3
REMOVAL OF WRIST PROSTHESIS
$639.68
25259
3
MANIPULATE WRIST W/ANESTHES
$349.85
25260
3
REPAIR FOREARM TENDON/MUSCLE
$612.88
25263
3
REPAIR FOREARM TENDON/MUSCLE
$611.89
25265
3
REPAIR FOREARM TENDON/MUSCLE
$725.36
25270
3
REPAIR FOREARM TENDON/MUSCLE
$492.57
25272
3
REPAIR FOREARM TENDON/MUSCLE
$553.90
25274
3
REPAIR FOREARM TENDON/MUSCLE
$655.74
25275
3
REPAIR FOREARM TENDON SHEATH
$602.78
25280
3
REVISE WRIST/FOREARM TENDON
$561.09
25290
3
INCISE WRIST/FOREARM TENDON
$477.03
25295
3
RELEASE WRIST/FOREARM TENDON
$522.66
25300
3
FUSION OF TENDONS AT WRIST
$614.44
25301
3
FUSION OF TENDONS AT WRIST
$584.98
25310
3
TRANSPLANT FOREARM TENDON
$607.38
25312
3
TRANSPLANT FOREARM TENDON
$702.42
25315
3
REVISE PALSY HAND TENDON(S)
$752.76
25316
3
REVISE PALSY HAND TENDON(S)
$869.84
25317
O
FLEXOR ORIGIN SLIDE FOR VOLKMANN CO
$0.00
25318
O
FLEXOR ORIGIN SLIDE FOR VOLKMANN CO
$0.00
25320
3
REPAIR/REVISE WRIST JOINT
25330
O
ARTHROPLASTY, WRIST;
$0.00
25331
O
ARTHROPLASTY, WRIST; WITH IMPLANT
$0.00
25332
3
REVISE WRIST JOINT
$762.88
25335
3
REALIGNMENT OF HAND
$866.14
25337
3
RECONSTRUCT ULNA/RADIOULNAR
$796.39
25350
3
REVISION OF RADIUS
$668.30
25355
3
REVISION OF RADIUS
$750.87
25360
3
REVISION OF ULNA
$648.68
25365
3
REVISE RADIUS & ULNA
$881.13
25370
3
REVISE RADIUS OR ULNA
$960.45
25375
3
REVISE RADIUS & ULNA
$926.96
25390
3
SHORTEN RADIUS OR ULNA
$755.16
$865.47
Procedure Code Pricing Action Code Description
Maximum Allowable
25391
3
LENGTHEN RADIUS OR ULNA
$958.51
25392
3
SHORTEN RADIUS & ULNA
$972.88
25393
3
LENGTHEN RADIUS & ULNA
25394
3
REPAIR CARPAL BONE, SHORTEN
$700.69
25400
3
REPAIR RADIUS OR ULNA
$792.03
25405
3
REPAIR/GRAFT RADIUS OR ULNA
25415
3
REPAIR RADIUS & ULNA
25420
3
REPAIR/GRAFT RADIUS & ULNA
25425
3
REPAIR/GRAFT RADIUS OR ULNA
25426
3
REPAIR/GRAFT RADIUS & ULNA
25430
3
VASC GRAFT INTO CARPAL BONE
$639.34
25431
3
REPAIR NONUNION CARPAL BONE
$707.57
25440
3
REPAIR/GRAFT WRIST BONE
$703.68
25441
3
RECONSTRUCT WRIST JOINT
$852.12
25442
3
RECONSTRUCT WRIST JOINT
$726.64
25443
3
RECONSTRUCT WRIST JOINT
$697.13
25444
3
RECONSTRUCT WRIST JOINT
$743.40
25445
3
RECONSTRUCT WRIST JOINT
$650.99
25446
3
WRIST REPLACEMENT
25447
3
REPAIR WRIST JOINT(S)
$734.88
25449
3
REMOVE WRIST JOINT IMPLANT
$938.10
25450
3
REVISION OF WRIST JOINT
$545.91
25455
3
REVISION OF WRIST JOINT
$621.57
25490
3
REINFORCE RADIUS
$687.12
25491
3
REINFORCE ULNA
$725.43
25492
3
REINFORCE RADIUS AND ULNA
$873.43
25500
3
TREAT FRACTURE OF RADIUS
$222.68
25505
3
TREAT FRACTURE OF RADIUS
$434.27
25510
O
TREATMENT OF OPEN RADIAL SHAFT FRAC
25515
3
TREAT FRACTURE OF RADIUS
$600.84
25520
3
TREAT FRACTURE OF RADIUS
$478.32
25525
3
TREAT FRACTURE OF RADIUS
$726.25
25526
3
TREAT FRACTURE OF RADIUS
$891.46
25530
3
TREAT FRACTURE OF ULNA
$216.23
25535
3
TREAT FRACTURE OF ULNA
$420.81
$1,092.72
$1,005.72 $945.57 $1,124.40 $974.20 $1,015.86
$1,070.43
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
25540
O
TREATMENT OF OPEN ULNAR SHAFT FRACT
$0.00
25545
3
TREAT FRACTURE OF ULNA
$562.76
25560
3
TREAT FRACTURE RADIUS & ULNA
$225.65
25565
3
TREAT FRACTURE RADIUS & ULNA
$454.44
25570
O
TREATMENT OF OPEN RADIAL AND ULNAR
25574
3
TREAT FRACTURE RADIUS & ULNA
$590.99
25575
3
TREAT FRACTURE RADIUS/ULNA
$803.56
25600
3
TREAT FRACTURE RADIUS/ULNA
$245.94
25605
3
TREAT FRACTURE RADIUS/ULNA
$533.62
25606
3
TREAT FX DISTAL RADIAL
$592.49
25607
3
TREAT FX RAD EXTRA-ARTICUL
$639.19
25608
3
TREAT FX RAD INTRA-ARTICUL
$728.68
25609
3
TREAT FX RADIAL 3+ FRAG
$929.83
25610
O
TREATMENT OF CLOSED, COMPLEX, DISTA
$0.00
25611
O
TREAT FRACTURE RADIUS/ULNA
$0.00
25615
O
TREATMENT OF OPEN DISTAL RADIAL FRA
$0.00
25620
O
TREAT FRACTURE RADIUS/ULNA
$0.00
25622
3
TREAT WRIST BONE FRACTURE
$252.37
25624
3
TREAT WRIST BONE FRACTURE
$398.85
25626
O
TREATMENT OF OPEN CARPAL SCAPHOID (
25628
3
TREAT WRIST BONE FRACTURE
$641.81
25630
3
TREAT WRIST BONE FRACTURE
$258.18
25635
3
TREAT WRIST BONE FRACTURE
$377.11
25640
O
TREATMENT OF OPEN CARPAL BONE FRACT
25645
3
TREAT WRIST BONE FRACTURE
$506.62
25650
3
TREAT WRIST BONE FRACTURE
$269.05
25651
3
PIN ULNAR STYLOID FRACTURE
$419.89
25652
3
TREAT FRACTURE ULNAR STYLOID
$552.32
25660
3
TREAT WRIST DISLOCATION
$350.63
25665
O
TREATMENT OF OPEN RADIOCARPAL OR IN
25670
3
TREAT WRIST DISLOCATION
$546.54
25671
3
PIN RADIOULNAR DISLOCATION
$462.02
25675
3
TREAT WRIST DISLOCATION
$370.93
25676
3
TREAT WRIST DISLOCATION
$566.22
25680
3
TREAT WRIST FRACTURE
$404.17
$0.00
$0.00
$0.00
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
25685
3
TREAT WRIST FRACTURE
$657.84
25690
3
TREAT WRIST DISLOCATION
$409.40
25695
3
TREAT WRIST DISLOCATION
$567.67
25800
3
FUSION OF WRIST JOINT
$671.57
25805
3
FUSION/GRAFT OF WRIST JOINT
$774.00
25810
3
FUSION/GRAFT OF WRIST JOINT
$781.41
25820
3
FUSION OF HAND BONES
$550.10
25825
3
FUSE HAND BONES WITH GRAFT
$677.48
25830
3
FUSION, RADIOULNAR JNT/ULNA
$849.11
25900
3
AMPUTATION OF FOREARM
$675.32
25905
3
AMPUTATION OF FOREARM
$667.34
25907
3
AMPUTATION FOLLOW-UP SURGERY
$583.26
25909
3
AMPUTATION FOLLOW-UP SURGERY
$656.44
25915
3
AMPUTATION OF FOREARM
$1,146.26
25920
3
AMPUTATE HAND AT WRIST
$616.55
25922
3
AMPUTATE HAND AT WRIST
$521.06
25924
3
AMPUTATION FOLLOW-UP SURGERY
$602.05
25927
3
AMPUTATION OF HAND
$702.18
25929
3
AMPUTATION FOLLOW-UP SURGERY
$503.21
25931
3
AMPUTATION FOLLOW-UP SURGERY
$640.34
25999
5
FOREARM OR WRIST SURGERY
26010
3
DRAINAGE OF FINGER ABSCESS
$222.73
26011
3
DRAINAGE OF FINGER ABSCESS
$340.13
26020
3
DRAIN HAND TENDON SHEATH
$378.10
26025
3
DRAINAGE OF PALM BURSA
$369.19
26030
3
DRAINAGE OF PALM BURSA(S)
$435.89
26034
3
TREAT HAND BONE LESION
$472.77
26035
3
DECOMPRESS FINGERS/HAND
$734.99
26037
3
DECOMPRESS FINGERS/HAND
$508.43
26040
3
RELEASE PALM CONTRACTURE
$271.38
26045
3
RELEASE PALM CONTRACTURE
$413.15
26055
3
INCISE FINGER TENDON SHEATH
$497.57
26060
3
INCISION OF FINGER TENDON
$232.42
26070
3
EXPLORE/TREAT HAND JOINT
$263.84
26075
3
EXPLORE/TREAT FINGER JOINT
$279.70
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
26080
3
EXPLORE/TREAT FINGER JOINT
$337.98
26100
3
BIOPSY HAND JOINT LINING
$283.79
26105
3
BIOPSY FINGER JOINT LINING
$290.48
26110
3
BIOPSY FINGER JOINT LINING
$278.92
26115
3
REMOVAL HAND LESION SUBCUT
$545.00
26116
3
REMOVAL HAND LESION, DEEP
$425.42
26117
3
REMOVE TUMOR, HAND/FINGER
$579.28
26121
3
RELEASE PALM CONTRACTURE
$532.89
26123
3
RELEASE PALM CONTRACTURE
$729.12
26125
3
RELEASE PALM CONTRACTURE
$259.53
26130
3
REMOVE WRIST JOINT LINING
$403.95
26135
3
REVISE FINGER JOINT, EACH
$491.29
26140
3
REVISE FINGER JOINT, EACH
$446.90
26145
3
TENDON EXCISION, PALM/FINGER
$454.20
26160
3
REMOVE TENDON SHEATH LESION
$497.33
26170
3
REMOVAL OF PALM TENDON, EACH
$357.36
26180
3
REMOVAL OF FINGER TENDON
$390.79
26185
3
REMOVE FINGER BONE
$467.08
26200
3
REMOVE HAND BONE LESION
$400.93
26205
3
REMOVE/GRAFT BONE LESION
$538.16
26210
3
REMOVAL OF FINGER LESION
$388.85
26215
3
REMOVE/GRAFT FINGER LESION
$493.40
26230
3
PARTIAL REMOVAL OF HAND BONE
$448.51
26235
3
PARTIAL REMOVAL, FINGER BONE
$440.59
26236
3
PARTIAL REMOVAL, FINGER BONE
$390.61
26250
3
EXTENSIVE HAND SURGERY
$520.14
26255
3
EXTENSIVE HAND SURGERY
$789.60
26260
3
EXTENSIVE FINGER SURGERY
$487.19
26261
3
EXTENSIVE FINGER SURGERY
$602.95
26262
3
PARTIAL REMOVAL OF FINGER
$407.01
26320
3
REMOVAL OF IMPLANT FROM HAND
$304.19
26340
3
MANIPULATE FINGER W/ANESTH
$274.88
26350
3
REPAIR FINGER/HAND TENDON
$637.00
26352
3
REPAIR/GRAFT HAND TENDON
$722.90
26356
3
REPAIR FINGER/HAND TENDON
$944.70
Procedure Code Pricing Action Code Description
Maximum Allowable
26357
3
REPAIR FINGER/HAND TENDON
$775.75
26358
3
REPAIR/GRAFT HAND TENDON
$820.24
26370
3
REPAIR FINGER/HAND TENDON
$688.63
26372
3
REPAIR/GRAFT HAND TENDON
$797.47
26373
3
REPAIR FINGER/HAND TENDON
$758.28
26390
3
REVISE HAND/FINGER TENDON
$742.23
26392
3
REPAIR/GRAFT HAND TENDON
$868.84
26410
3
REPAIR HAND TENDON
$506.75
26412
3
REPAIR/GRAFT HAND TENDON
$614.29
26415
3
EXCISION, HAND/FINGER TENDON
$643.45
26416
3
GRAFT HAND OR FINGER TENDON
$688.64
26418
3
REPAIR FINGER TENDON
$509.44
26420
3
REPAIR/GRAFT FINGER TENDON
$637.94
26426
3
REPAIR FINGER/HAND TENDON
$512.34
26428
3
REPAIR/GRAFT FINGER TENDON
$670.40
26432
3
REPAIR FINGER TENDON
$443.23
26433
3
REPAIR FINGER TENDON
$475.17
26434
3
REPAIR/GRAFT FINGER TENDON
$569.24
26437
3
REALIGNMENT OF TENDONS
$554.94
26440
3
RELEASE PALM/FINGER TENDON
$558.87
26442
3
RELEASE PALM & FINGER TENDON
$843.68
26445
3
RELEASE HAND/FINGER TENDON
$519.27
26449
3
RELEASE FOREARM/HAND TENDON
$676.13
26450
3
INCISION OF PALM TENDON
$358.19
26455
3
INCISION OF FINGER TENDON
$355.77
26460
3
INCISE HAND/FINGER TENDON
$346.03
26471
3
FUSION OF FINGER TENDONS
$546.68
26474
3
FUSION OF FINGER TENDONS
$524.72
26476
3
TENDON LENGTHENING
$510.83
26477
3
TENDON SHORTENING
$515.40
26478
3
LENGTHENING OF HAND TENDON
$559.28
26479
3
SHORTENING OF HAND TENDON
$553.17
26480
3
TRANSPLANT HAND TENDON
$673.43
26483
3
TRANSPLANT/GRAFT HAND TENDON
$759.27
26485
3
TRANSPLANT PALM TENDON
$727.80
Procedure Code Pricing Action Code Description
Maximum Allowable
26489
3
TRANSPLANT/GRAFT PALM TENDON
$784.93
26490
3
REVISE THUMB TENDON
$701.73
26492
3
TENDON TRANSFER WITH GRAFT
$781.68
26494
3
HAND TENDON/MUSCLE TRANSFER
$710.36
26496
3
REVISE THUMB TENDON
$769.99
26497
3
FINGER TENDON TRANSFER
$770.53
26498
3
FINGER TENDON TRANSFER
$1,027.69
26499
3
REVISION OF FINGER
$736.55
26500
3
HAND TENDON RECONSTRUCTION
$557.96
26502
3
HAND TENDON RECONSTRUCTION
$629.31
26504
O
HAND TENDON RECONSTRUCTION
$0.00
26508
3
RELEASE THUMB CONTRACTURE
$560.93
26510
3
THUMB TENDON TRANSFER
$532.33
26516
3
FUSION OF KNUCKLE JOINT
$627.46
26517
3
FUSION OF KNUCKLE JOINTS
$738.10
26518
3
FUSION OF KNUCKLE JOINTS
$744.93
26520
3
RELEASE KNUCKLE CONTRACTURE
$584.12
26525
3
RELEASE FINGER CONTRACTURE
$586.54
26527
O
ARTHROPLASTY, CARPOMETACARPAL JOINT
26530
3
REVISE KNUCKLE JOINT
$476.49
26531
3
REVISE KNUCKLE WITH IMPLANT
$554.60
26535
3
REVISE FINGER JOINT
$356.88
26536
3
REVISE/IMPLANT FINGER JOINT
$598.81
26540
3
REPAIR HAND JOINT
$589.49
26541
3
REPAIR HAND JOINT WITH GRAFT
$719.42
26542
3
REPAIR HAND JOINT WITH GRAFT
$609.36
26545
3
RECONSTRUCT FINGER JOINT
$620.25
26546
3
REPAIR NONUNION HAND
$869.97
26548
3
RECONSTRUCT FINGER JOINT
$682.36
26550
3
CONSTRUCT THUMB REPLACEMENT
$1,335.53
26551
3
GREAT TOE-HAND TRANSFER
$2,905.51
26552
O
RECONSTRUCTION THUMB WITH TOE
26553
3
SINGLE TRANSFER, TOE-HAND
$2,535.67
26554
3
DOUBLE TRANSFER, TOE-HAND
$3,321.88
26555
3
POSITIONAL CHANGE OF FINGER
$1,231.40
$0.00
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
26556
3
TOE JOINT TRANSFER
$2,619.72
26557
O
TOE TO FINGER TRANSFER; FIRST STAGE
$0.00
26558
O
TOE TO FINGER TRANSFER; EACH DELAY
$0.00
26559
O
TOE TO FINGER TRANSFER; SECOND STAG
$0.00
26560
3
REPAIR OF WEB FINGER
$507.95
26561
3
REPAIR OF WEB FINGER
$811.23
26562
3
REPAIR OF WEB FINGER
$1,180.23
26565
3
CORRECT METACARPAL FLAW
$603.76
26567
3
CORRECT FINGER DEFORMITY
$609.80
26568
3
LENGTHEN METACARPAL/FINGER
$802.63
26580
3
REPAIR HAND DEFORMITY
26585
O
REPAIR FINGER DEFORMITY
26587
3
RECONSTRUCT EXTRA FINGER
26590
3
REPAIR FINGER DEFORMITY
26591
3
REPAIR MUSCLES OF HAND
$390.07
26593
3
RELEASE MUSCLES OF HAND
$531.11
26596
3
EXCISION CONSTRICTING TISSUE
$654.94
26597
O
RELEASE OF SCAR CONTRACTURE
26600
3
TREAT METACARPAL FRACTURE
$235.19
26605
3
TREAT METACARPAL FRACTURE
$271.36
26607
3
TREAT METACARPAL FRACTURE
$387.58
26608
3
TREAT METACARPAL FRACTURE
$420.31
26610
O
TREATMENT OF OPEN METACARPAL FRACTU
26615
3
TREAT METACARPAL FRACTURE
$486.77
26641
3
TREAT THUMB DISLOCATION
$310.88
26645
3
TREAT THUMB FRACTURE
$355.09
26650
3
TREAT THUMB FRACTURE
$420.94
26655
O
TREATMENT OF OPEN CARPOMETACARPAL F
$0.00
26660
O
TREATMENT OF OPEN CARPOMETACARPAL F
$0.00
26665
3
TREAT THUMB FRACTURE
$540.26
26670
3
TREAT HAND DISLOCATION
$280.53
26675
3
TREAT HAND DISLOCATION
$379.01
26676
3
PIN HAND DISLOCATION
$440.78
26680
O
TREATMENT OF OPEN CARPOMETACARPAL D
26685
3
TREAT HAND DISLOCATION
$1,250.80 $0.00 $854.81 $1,136.96
$0.00
$0.00
$0.00 $499.67
Procedure Code Pricing Action Code Description
Maximum Allowable
26686
3
TREAT HAND DISLOCATION
$553.24
26700
3
TREAT KNUCKLE DISLOCATION
$267.36
26705
3
TREAT KNUCKLE DISLOCATION
$347.72
26706
3
PIN KNUCKLE DISLOCATION
$381.59
26710
O
TREATMENT OF OPEN METACARPOPHALANGE
26715
3
TREAT KNUCKLE DISLOCATION
$487.65
26720
3
TREAT FINGER FRACTURE, EACH
$162.99
26725
3
TREAT FINGER FRACTURE, EACH
$290.96
26727
3
TREAT FINGER FRACTURE, EACH
$413.23
26730
O
TREATMENT OF OPEN PHALANGEAL SHAFT
26735
3
TREAT FINGER FRACTURE, EACH
$507.72
26740
3
TREAT FINGER FRACTURE, EACH
$189.83
26742
3
TREAT FINGER FRACTURE, EACH
$318.52
26744
O
TREATMENT OF OPEN ARTICULAR FRACTUR
26746
3
TREAT FINGER FRACTURE, EACH
$620.70
26750
3
TREAT FINGER FRACTURE, EACH
$152.12
26755
3
TREAT FINGER FRACTURE, EACH
$267.19
26756
3
PIN FINGER FRACTURE, EACH
$364.57
26760
O
TREATMENT OF OPEN DISTAL PHALANGEAL
26765
3
TREAT FINGER FRACTURE, EACH
$413.23
26770
3
TREAT FINGER DISLOCATION
$227.09
26775
3
TREAT FINGER DISLOCATION
$324.73
26776
3
PIN FINGER DISLOCATION
$387.69
26780
O
TREATMENT OF OPEN INTERPHALANGEAL J
26785
3
TREAT FINGER DISLOCATION
$450.51
26820
3
THUMB FUSION WITH GRAFT
$703.34
26841
3
FUSION OF THUMB
$651.94
26842
3
THUMB FUSION WITH GRAFT
$707.46
26843
3
FUSION OF HAND JOINT
$655.08
26844
3
FUSION/GRAFT OF HAND JOINT
$730.38
26850
3
FUSION OF KNUCKLE
$621.18
26852
3
FUSION OF KNUCKLE WITH GRAFT
$711.45
26860
3
FUSION OF FINGER JOINT
$499.62
26861
3
FUSION OF FINGER JNT, ADD-ON
$97.85
26862
3
FUSION/GRAFT OF FINGER JOINT
$647.52
$0.00
$0.00
$0.00
$0.00
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
26863
3
FUSE/GRAFT ADDED JOINT
$218.24
26910
3
AMPUTATE METACARPAL BONE
$636.83
26951
3
AMPUTATION OF FINGER/THUMB
$551.78
26952
3
AMPUTATION OF FINGER/THUMB
$577.96
26989
5
HAND/FINGER SURGERY
26990
3
DRAINAGE OF PELVIS LESION
$552.66
26991
3
DRAINAGE OF PELVIS BURSA
$620.60
26992
3
DRAINAGE OF BONE LESION
$869.53
27000
3
INCISION OF HIP TENDON
$401.35
27001
3
INCISION OF HIP TENDON
$486.46
27003
3
INCISION OF HIP TENDON
$522.34
27005
3
INCISION OF HIP TENDON
$659.13
27006
3
INCISION OF HIP TENDONS
$666.14
27010
O
GLUTEAL-ILIOTIBIAL FASCIOTOMY (OBER
$0.00
27015
O
ILIAC CREST FASCIOTOMY (SOUTTER OR
$0.00
27025
3
INCISION OF HIP/THIGH FASCIA
$806.18
27027
3
BUTTOCK FASCIOTOMY
$786.14
27030
3
DRAINAGE OF HIP JOINT
$859.89
27033
3
EXPLORATION OF HIP JOINT
$890.35
27035
3
DENERVATION OF HIP JOINT
$994.29
27036
3
EXCISION OF HIP JOINT/MUSCLE
$910.49
27040
3
BIOPSY OF SOFT TISSUES
$303.84
27041
3
BIOPSY OF SOFT TISSUES
$621.78
27047
3
REMOVE HIP/PELVIS LESION
$553.69
27048
3
REMOVE HIP/PELVIS LESION
$427.04
27049
3
REMOVE TUMOR, HIP/PELVIS
$903.32
27050
3
BIOPSY OF SACROILIAC JOINT
$312.53
27052
3
BIOPSY OF HIP JOINT
$498.99
27054
3
REMOVAL OF HIP JOINT LINING
$612.56
27057
3
BUTTOCK FASCIOTOMY W/DBRDMT
$871.82
27060
3
REMOVAL OF ISCHIAL BURSA
$385.43
27062
3
REMOVE FEMUR LESION/BURSA
$403.11
27065
3
REMOVAL OF HIP BONE LESION
$449.54
27066
3
REMOVAL OF HIP BONE LESION
$730.06
27067
3
REMOVE/GRAFT HIP BONE LESION
$925.82
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
27070
3
PARTIAL REMOVAL OF HIP BONE
$764.99
27071
3
PARTIAL REMOVAL OF HIP BONE
$821.17
27075
3
EXTENSIVE HIP SURGERY
$2,108.04
27076
3
EXTENSIVE HIP SURGERY
$1,456.04
27077
3
EXTENSIVE HIP SURGERY
$2,436.63
27078
3
EXTENSIVE HIP SURGERY
$921.28
27079
3
EXTENSIVE HIP SURGERY
$880.47
27080
3
REMOVAL OF TAIL BONE
$442.74
27086
3
REMOVE HIP FOREIGN BODY
$218.09
27087
3
REMOVE HIP FOREIGN BODY
$569.85
27090
3
REMOVAL OF HIP PROSTHESIS
$754.46
27091
3
REMOVAL OF HIP PROSTHESIS
$1,459.52
27093
3
INJECTION FOR HIP X-RAY
$177.86
27095
3
INJECTION FOR HIP X-RAY
$214.83
27096
3
INJECT SACROILIAC JOINT
$162.86
27097
3
REVISION OF HIP TENDON
$601.56
27098
3
TRANSFER TENDON TO PELVIS
$560.78
27100
3
TRANSFER OF ABDOMINAL MUSCLE
$742.03
27105
3
TRANSFER OF SPINAL MUSCLE
$776.89
27110
3
TRANSFER OF ILIOPSOAS MUSCLE
$867.10
27111
3
TRANSFER OF ILIOPSOAS MUSCLE
$772.96
27120
3
RECONSTRUCTION OF HIP SOCKET
$1,175.08
27122
3
RECONSTRUCTION OF HIP SOCKET
$1,006.89
27125
3
PARTIAL HIP REPLACEMENT
$1,024.91
27126
O
PARTIAL HIP REPLACEMENT (HEMIARTHRO
$0.00
27127
O
PARTIAL HIP REPLACEMENT (HEMIARTHRO
$0.00
27130
3
TOTAL HIP ARTHROPLASTY
$1,321.42
27132
3
TOTAL HIP ARTHROPLASTY
$1,544.00
27134
3
REVISE HIP JOINT REPLACEMENT
$1,790.53
27137
3
REVISE HIP JOINT REPLACEMENT
$1,365.00
27138
3
REVISE HIP JOINT REPLACEMENT
$1,420.71
27140
3
TRANSPLANT FEMUR RIDGE
27146
3
INCISION OF HIP BONE
$1,151.97
27147
3
REVISION OF HIP BONE
$1,342.37
27151
3
INCISION OF HIP BONES
$1,396.78
$817.45
Procedure Code Pricing Action Code Description
Maximum Allowable
27156
3
REVISION OF HIP BONES
$1,565.52
27157
O
ACETABULAR AUGMENTATION (WILSON PRO
27158
3
REVISION OF PELVIS
$1,258.34
27161
3
INCISION OF NECK OF FEMUR
$1,114.62
27165
3
INCISION/FIXATION OF FEMUR
$1,244.99
27170
3
REPAIR/GRAFT FEMUR HEAD/NECK
$1,078.22
27175
3
TREAT SLIPPED EPIPHYSIS
$599.88
27176
3
TREAT SLIPPED EPIPHYSIS
$829.18
27177
3
TREAT SLIPPED EPIPHYSIS
$1,011.34
27178
3
TREAT SLIPPED EPIPHYSIS
$820.28
27179
3
REVISE HEAD/NECK OF FEMUR
$883.69
27181
3
TREAT SLIPPED EPIPHYSIS
$983.91
27185
3
REVISION OF FEMUR EPIPHYSIS
$624.15
27187
3
REINFORCE HIP BONES
$906.21
27190
O
TREATMENT OF CLOSED SACRAL FRACTURE
$0.00
27192
O
OPEN TREATMENT OF CLOSED OR OPEN SA
$0.00
27193
3
TREAT PELVIC RING FRACTURE
$415.27
27194
3
TREAT PELVIC RING FRACTURE
$646.34
27195
O
TREATMENT OF SACROILIAC AND/OR SYMP
$0.00
27196
O
TREATMENT OF SACROILIAC AND/OR SYMP
$0.00
27200
3
TREAT TAIL BONE FRACTURE
27201
O
TREATMENT OF OPEN COCCYGEAL FRACTUR
27202
3
TREAT TAIL BONE FRACTURE
27210
O
TREATMENT OF CLOSED ILIAC, PUBIC OR
$0.00
27212
O
TREATMENT OF OPEN ILIAC, PUBIC OR I
$0.00
27214
O
OPEN TREATMENT OF CLOSED OR OPEN IL
$0.00
27215
3
TREAT PELVIC FRACTURE(S)
$668.95
27216
3
TREAT PELVIC RING FRACTURE
$977.70
27217
3
TREAT PELVIC RING FRACTURE
$925.70
27218
3
TREAT PELVIC RING FRACTURE
$1,263.37
27220
3
TREAT HIP SOCKET FRACTURE
$468.01
27222
3
TREAT HIP SOCKET FRACTURE
$888.00
27224
O
OPEN TREATMENT OF CLOSED OR OPEN AC
$0.00
27225
O
OPEN TREATMENT OF CLOSED OR OPEN AC
$0.00
27226
3
TREAT HIP WALL FRACTURE
$0.00
$151.17 $0.00 $577.65
$944.13
Procedure Code Pricing Action Code Description
Maximum Allowable
27227
3
TREAT HIP FRACTURE(S)
$1,529.43
27228
3
TREAT HIP FRACTURE(S)
$1,751.41
27230
3
TREAT THIGH FRACTURE
$416.86
27232
3
TREAT THIGH FRACTURE
$704.50
27234
O
TREATMENT OF OPEN FEMORAL FRACTURE,
27235
3
TREAT THIGH FRACTURE
$828.64
27236
3
TREAT THIGH FRACTURE
$1,083.62
27238
3
TREAT THIGH FRACTURE
$402.92
27240
3
TREAT THIGH FRACTURE
$866.58
27242
O
TREATMENT OF OPEN INTERTROCHANTERIC
27244
3
TREAT THIGH FRACTURE
$1,114.67
27245
3
TREAT THIGH FRACTURE
$1,155.93
27246
3
TREAT THIGH FRACTURE
$341.10
27248
3
TREAT THIGH FRACTURE
$684.47
27250
3
TREAT HIP DISLOCATION
$214.95
27252
3
TREAT HIP DISLOCATION
$684.35
27253
3
TREAT HIP DISLOCATION
$860.99
27254
3
TREAT HIP DISLOCATION
$1,163.19
27255
O
OPEN TREATMENT OF CLOSED OR OPEN HI
27256
3
TREAT HIP DISLOCATION
$262.72
27257
3
TREAT HIP DISLOCATION
$304.57
27258
3
TREAT HIP DISLOCATION
$1,009.35
27259
3
TREAT HIP DISLOCATION
$1,415.26
27265
3
TREAT HIP DISLOCATION
$348.90
27266
3
TREAT HIP DISLOCATION
$520.91
27267
3
CLTX THIGH FX
$371.81
27268
3
CLTX THIGH FX W/MNPJ
$460.21
27269
3
OPTX THIGH FX
27275
3
MANIPULATION OF HIP JOINT
$161.79
27280
3
FUSION OF SACROILIAC JOINT
$934.32
27282
3
FUSION OF PUBIC BONES
$731.67
27284
3
FUSION OF HIP JOINT
$1,417.98
27286
3
FUSION OF HIP JOINT
$1,500.78
27290
3
AMPUTATION OF LEG AT HIP
$1,432.03
27295
3
AMPUTATION OF LEG AT HIP
$1,156.64
$0.00
$0.00
$0.00
$1,105.87
Procedure Code Pricing Action Code Description
Maximum Allowable
27299
5
PELVIS/HIP JOINT SURGERY
$0.00
27301
3
DRAIN THIGH/KNEE LESION
$585.66
27303
3
DRAINAGE OF BONE LESION
$574.97
27305
3
INCISE THIGH TENDON & FASCIA
$419.28
27306
3
INCISION OF THIGH TENDON
$339.58
27307
3
INCISION OF THIGH TENDONS
$417.93
27310
3
EXPLORATION OF KNEE JOINT
$655.61
27315
O
PARTIAL REMOVAL, THIGH NERVE
$0.00
27320
O
PARTIAL REMOVAL, THIGH NERVE
$0.00
27323
3
BIOPSY, THIGH SOFT TISSUES
$236.19
27324
3
BIOPSY, THIGH SOFT TISSUES
$341.63
27325
3
NEURECTOMY, HAMSTRING
$473.20
27326
3
NEURECTOMY, POPLITEAL
$436.79
27327
3
REMOVAL OF THIGH LESION
$399.42
27328
3
REMOVAL OF THIGH LESION
$376.60
27329
3
REMOVE TUMOR, THIGH/KNEE
$938.65
27330
3
BIOPSY, KNEE JOINT LINING
$358.23
27331
3
EXPLORE/TREAT KNEE JOINT
$423.42
27332
3
REMOVAL OF KNEE CARTILAGE
$574.46
27333
3
REMOVAL OF KNEE CARTILAGE
$520.49
27334
3
REMOVE KNEE JOINT LINING
$611.32
27335
3
REMOVE KNEE JOINT LINING
$691.56
27340
3
REMOVAL OF KNEECAP BURSA
$324.43
27345
3
REMOVAL OF KNEE CYST
$428.80
27347
3
REMOVE KNEE CYST
$459.74
27350
3
REMOVAL OF KNEECAP
$584.44
27355
3
REMOVE FEMUR LESION
$541.69
27356
3
REMOVE FEMUR LESION/GRAFT
$664.22
27357
3
REMOVE FEMUR LESION/GRAFT
$736.53
27358
3
REMOVE FEMUR LESION/FIXATION
$267.79
27360
3
PARTIAL REMOVAL, LEG BONE(S)
$766.90
27365
3
EXTENSIVE LEG SURGERY
27370
3
INJECTION FOR KNEE X-RAY
$152.31
27372
3
REMOVAL OF FOREIGN BODY
$527.33
27380
3
REPAIR OF KNEECAP TENDON
$530.84
$1,116.34
Procedure Code Pricing Action Code Description
Maximum Allowable
27381
3
REPAIR/GRAFT KNEECAP TENDON
$723.55
27385
3
REPAIR OF THIGH MUSCLE
$568.39
27386
3
REPAIR/GRAFT OF THIGH MUSCLE
$750.44
27390
3
INCISION OF THIGH TENDON
$393.53
27391
3
INCISION OF THIGH TENDONS
$512.80
27392
3
INCISION OF THIGH TENDONS
$631.82
27393
3
LENGTHENING OF THIGH TENDON
$454.58
27394
3
LENGTHENING OF THIGH TENDONS
$587.56
27395
3
LENGTHENING OF THIGH TENDONS
$795.76
27396
3
TRANSPLANT OF THIGH TENDON
$552.33
27397
3
TRANSPLANTS OF THIGH TENDONS
$813.34
27400
3
REVISE THIGH MUSCLES/TENDONS
$615.23
27403
3
REPAIR OF KNEE CARTILAGE
$578.18
27405
3
REPAIR OF KNEE LIGAMENT
$609.25
27407
3
REPAIR OF KNEE LIGAMENT
$695.50
27409
3
REPAIR OF KNEE LIGAMENTS
$874.90
27412
3
AUTOCHONDROCYTE IMPLANT KNEE
$1,514.53
27415
3
OSTEOCHONDRAL KNEE ALLOGRAFT
$1,268.26
27416
3
OSTEOCHONDRAL KNEE AUTOGRAFT
$876.41
27418
3
REPAIR DEGENERATED KNEECAP
$755.01
27420
3
REVISION OF UNSTABLE KNEECAP
$676.04
27422
3
REVISION OF UNSTABLE KNEECAP
$673.27
27424
3
REVISION/REMOVAL OF KNEECAP
$675.08
27425
3
LAT RETINACULAR RELEASE OPEN
$393.99
27427
3
RECONSTRUCTION, KNEE
$648.21
27428
3
RECONSTRUCTION, KNEE
$998.30
27429
3
RECONSTRUCTION, KNEE
$1,117.99
27430
3
REVISION OF THIGH MUSCLES
$669.03
27435
3
INCISION OF KNEE JOINT
$717.78
27437
3
REVISE KNEECAP
$594.89
27438
3
REVISE KNEECAP WITH IMPLANT
$762.22
27440
3
REVISION OF KNEE JOINT
$695.90
27441
3
REVISION OF KNEE JOINT
$718.46
27442
3
REVISION OF KNEE JOINT
$789.38
27443
3
REVISION OF KNEE JOINT
$739.43
Procedure Code Pricing Action Code Description
Maximum Allowable
27445
3
REVISION OF KNEE JOINT
$1,151.76
27446
3
REVISION OF KNEE JOINT
$1,021.41
27447
3
TOTAL KNEE ARTHROPLASTY
$1,414.96
27448
3
INCISION OF THIGH
$744.59
27450
3
INCISION OF THIGH
$928.01
27454
3
REALIGNMENT OF THIGH BONE
27455
3
REALIGNMENT OF KNEE
$857.56
27457
3
REALIGNMENT OF KNEE
$883.15
27465
3
SHORTENING OF THIGH BONE
$1,111.74
27466
3
LENGTHENING OF THIGH BONE
$1,079.15
27468
3
SHORTEN/LENGTHEN THIGHS
$1,221.98
27470
3
REPAIR OF THIGH
$1,076.12
27472
3
REPAIR/GRAFT OF THIGH
$1,163.30
27475
3
SURGERY TO STOP LEG GROWTH
$591.77
27477
3
SURGERY TO STOP LEG GROWTH
$663.34
27479
3
SURGERY TO STOP LEG GROWTH
$854.11
27485
3
SURGERY TO STOP LEG GROWTH
$605.58
27486
3
REVISE/REPLACE KNEE JOINT
$1,290.83
27487
3
REVISE/REPLACE KNEE JOINT
$1,628.27
27488
3
REMOVAL OF KNEE PROSTHESIS
$1,092.14
27495
3
REINFORCE THIGH
$1,034.62
27496
3
DECOMPRESSION OF THIGH/KNEE
$451.38
27497
3
DECOMPRESSION OF THIGH/KNEE
$489.78
27498
3
DECOMPRESSION OF THIGH/KNEE
$533.79
27499
3
DECOMPRESSION OF THIGH/KNEE
$592.32
27500
3
TREATMENT OF THIGH FRACTURE
$455.24
27501
3
TREATMENT OF THIGH FRACTURE
$447.18
27502
3
TREATMENT OF THIGH FRACTURE
$712.96
27503
3
TREATMENT OF THIGH FRACTURE
$725.99
27504
O
TREATMENT OF OPEN FEMORAL SHAFT FRA
27506
3
TREATMENT OF THIGH FRACTURE
$1,213.79
27507
3
TREATMENT OF THIGH FRACTURE
$899.27
27508
3
TREATMENT OF THIGH FRACTURE
$459.38
27509
3
TREATMENT OF THIGH FRACTURE
$578.24
27510
3
TREATMENT OF THIGH FRACTURE
$630.28
$1,170.29
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
27511
3
TREATMENT OF THIGH FRACTURE
$931.37
27512
O
TREATMENT OF OPEN FEMORAL FRACTURE,
27513
3
TREATMENT OF THIGH FRACTURE
$1,171.23
27514
3
TREATMENT OF THIGH FRACTURE
$941.92
27516
3
TREAT THIGH FX GROWTH PLATE
$430.07
27517
3
TREAT THIGH FX GROWTH PLATE
$605.23
27518
O
TREATMENT OF OPEN DISTAL FEMORAL EP
27519
3
TREAT THIGH FX GROWTH PLATE
$851.84
27520
3
TREAT KNEECAP FRACTURE
$271.62
27522
O
TREATMENT OF OPEN PATELLAR FRACTURE
27524
3
TREAT KNEECAP FRACTURE
$682.90
27530
3
TREAT KNEE FRACTURE
$340.81
27532
3
TREAT KNEE FRACTURE
$544.52
27534
O
TREATMENT OF OPEN TIBIAL FRACTURE,
27535
3
TREAT KNEE FRACTURE
$831.44
27536
3
TREAT KNEE FRACTURE
$1,081.80
27537
O
OPEN TREATMENT OF CLOSED OR OPEN TI
27538
3
TREAT KNEE FRACTURE(S)
$407.75
27540
3
TREAT KNEE FRACTURE
$755.12
27550
3
TREAT KNEE DISLOCATION
$430.61
27552
3
TREAT KNEE DISLOCATION
$557.25
27554
O
TREATMENT OF OPEN KNEE DISLOCATION,
27556
3
TREAT KNEE DISLOCATION
$837.65
27557
3
TREAT KNEE DISLOCATION
$1,002.08
27558
3
TREAT KNEE DISLOCATION
$1,124.00
27560
3
TREAT KNEECAP DISLOCATION
$315.72
27562
3
TREAT KNEECAP DISLOCATION
$411.24
27564
O
TREATMENT OF OPEN PATELLAR DISLOCAT
27566
3
TREAT KNEECAP DISLOCATION
$812.97
27570
3
FIXATION OF KNEE JOINT
$132.19
27580
3
FUSION OF KNEE
27590
3
AMPUTATE LEG AT THIGH
$752.64
27591
3
AMPUTATE LEG AT THIGH
$834.93
27592
3
AMPUTATE LEG AT THIGH
$639.10
27594
3
AMPUTATION FOLLOW-UP SURGERY
$462.92
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$1,317.71
Procedure Code Pricing Action Code Description
Maximum Allowable
27596
3
AMPUTATION FOLLOW-UP SURGERY
$669.71
27598
3
AMPUTATE LOWER LEG AT KNEE
$680.96
27599
5
LEG SURGERY PROCEDURE
27600
3
DECOMPRESSION OF LOWER LEG
$384.45
27601
3
DECOMPRESSION OF LOWER LEG
$398.91
27602
3
DECOMPRESSION OF LOWER LEG
$470.83
27603
3
DRAIN LOWER LEG LESION
$464.29
27604
3
DRAIN LOWER LEG BURSA
$407.29
27605
3
INCISION OF ACHILLES TENDON
$325.68
27606
3
INCISION OF ACHILLES TENDON
$270.20
27607
3
TREAT LOWER LEG BONE LESION
$556.58
27610
3
EXPLORE/TREAT ANKLE JOINT
$594.35
27612
3
EXPLORATION OF ANKLE JOINT
$518.50
27613
3
BIOPSY LOWER LEG SOFT TISSUE
$221.70
27614
3
BIOPSY LOWER LEG SOFT TISSUE
$498.54
27615
3
REMOVE TUMOR, LOWER LEG
$799.32
27618
3
REMOVE LOWER LEG LESION
$434.95
27619
3
REMOVE LOWER LEG LESION
$693.46
27620
3
EXPLORE/TREAT ANKLE JOINT
$418.39
27625
3
REMOVE ANKLE JOINT LINING
$540.87
27626
3
REMOVE ANKLE JOINT LINING
$584.10
27630
3
REMOVAL OF TENDON LESION
$477.20
27635
3
REMOVE LOWER LEG BONE LESION
$538.10
27637
3
REMOVE/GRAFT LEG BONE LESION
$682.33
27638
3
REMOVE/GRAFT LEG BONE LESION
$710.78
27640
3
PARTIAL REMOVAL OF TIBIA
$787.49
27641
3
PARTIAL REMOVAL OF FIBULA
$631.13
27645
3
EXTENSIVE LOWER LEG SURGERY
$955.12
27646
3
EXTENSIVE LOWER LEG SURGERY
$844.54
27647
3
EXTENSIVE ANKLE/HEEL SURGERY
$745.74
27648
3
INJECTION FOR ANKLE X-RAY
$146.76
27650
3
REPAIR ACHILLES TENDON
$614.81
27652
3
REPAIR/GRAFT ACHILLES TENDON
$676.16
27654
3
REPAIR OF ACHILLES TENDON
$660.27
27656
3
REPAIR LEG FASCIA DEFECT
$480.36
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
27658
3
REPAIR OF LEG TENDON, EACH
$348.77
27659
3
REPAIR OF LEG TENDON, EACH
$457.80
27664
3
REPAIR OF LEG TENDON, EACH
$332.64
27665
3
REPAIR OF LEG TENDON, EACH
$380.96
27675
3
REPAIR LOWER LEG TENDONS
$466.47
27676
3
REPAIR LOWER LEG TENDONS
$566.39
27680
3
RELEASE OF LOWER LEG TENDON
$395.19
27681
3
RELEASE OF LOWER LEG TENDONS
$470.76
27685
3
REVISION OF LOWER LEG TENDON
$565.24
27686
3
REVISE LOWER LEG TENDONS
$513.83
27687
3
REVISION OF CALF TENDON
$422.85
27690
3
REVISE LOWER LEG TENDON
$582.01
27691
3
REVISE LOWER LEG TENDON
$683.19
27692
3
REVISE ADDITIONAL LEG TENDON
$103.69
27695
3
REPAIR OF ANKLE LIGAMENT
$450.32
27696
3
REPAIR OF ANKLE LIGAMENTS
$537.07
27698
3
REPAIR OF ANKLE LIGAMENT
$603.20
27700
3
REVISION OF ANKLE JOINT
$569.85
27702
3
RECONSTRUCT ANKLE JOINT
$911.52
27703
3
RECONSTRUCTION, ANKLE JOINT
27704
3
REMOVAL OF ANKLE IMPLANT
$516.71
27705
3
INCISION OF TIBIA
$699.63
27707
3
INCISION OF FIBULA
$356.27
27709
3
INCISION OF TIBIA & FIBULA
27712
3
REALIGNMENT OF LOWER LEG
$997.23
27715
3
REVISION OF LOWER LEG
$973.69
27720
3
REPAIR OF TIBIA
$800.79
27722
3
REPAIR/GRAFT OF TIBIA
$798.70
27724
3
REPAIR/GRAFT OF TIBIA
$1,175.05
27725
3
REPAIR OF LOWER LEG
$1,093.94
27726
3
REPAIR FIBULA NONUNION
$832.66
27727
3
REPAIR OF LOWER LEG
$886.94
27730
3
REPAIR OF TIBIA EPIPHYSIS
$533.39
27732
3
REPAIR OF FIBULA EPIPHYSIS
$362.30
27734
3
REPAIR LOWER LEG EPIPHYSES
$542.49
$1,054.55
$1,019.97
Procedure Code Pricing Action Code Description
Maximum Allowable
27740
3
REPAIR OF LEG EPIPHYSES
$602.36
27742
3
REPAIR OF LEG EPIPHYSES
$633.53
27745
3
REINFORCE TIBIA
$687.07
27750
3
TREATMENT OF TIBIA FRACTURE
$293.45
27752
3
TREATMENT OF TIBIA FRACTURE
$472.08
27754
O
TREATMENT OF OPEN TIBIAL SHAFT FRAC
27756
3
TREATMENT OF TIBIA FRACTURE
$511.42
27758
3
TREATMENT OF TIBIA FRACTURE
$806.98
27759
3
TREATMENT OF TIBIA FRACTURE
$914.31
27760
3
CLTX MEDIAL ANKLE FX
$282.75
27762
3
CLTX MED ANKLE FX W/MNPJ
$422.67
27764
O
TREATMENT OF OPEN DISTAL TIBIAL FRA
27766
3
OPTX MEDIAL ANKLE FX
$550.67
27767
3
CLTX POST ANKLE FX
$224.45
27768
3
CLTX POST ANKLE FX W/MNPJ
$360.64
27769
3
OPTX POST ANKLE FX
$626.48
27780
3
TREATMENT OF FIBULA FRACTURE
$253.06
27781
3
TREATMENT OF FIBULA FRACTURE
$366.15
27782
O
TREATMENT OF OPEN PROXIMAL FIBULA O
27784
3
TREATMENT OF FIBULA FRACTURE
$624.03
27786
3
TREATMENT OF ANKLE FRACTURE
$268.07
27788
3
TREATMENT OF ANKLE FRACTURE
$369.28
27790
O
TREATMENT OF OPEN DISTAL FIBULAR FR
27792
3
TREATMENT OF ANKLE FRACTURE
27800
O
TREATMENT OF CLOSED TIBIA AND FIBUL
$0.00
27802
O
TREATMENT OF CLOSED TIBIA AND FIBUL
$0.00
27804
O
TREATMENT OF OPEN TIBIA AND FIBULA
$0.00
27806
O
OPEN TREATMENT OF CLOSED OR OPEN TI
$0.00
27808
3
TREATMENT OF ANKLE FRACTURE
$280.64
27810
3
TREATMENT OF ANKLE FRACTURE
$413.62
27812
O
TREATMENT OF OPEN BIMALLEOLAR ANKLE
27814
3
TREATMENT OF ANKLE FRACTURE
$704.51
27816
3
TREATMENT OF ANKLE FRACTURE
$265.44
27818
3
TREATMENT OF ANKLE FRACTURE
$426.09
27820
O
TREATMENT OF OPEN TRIMALLEOLAR ANKL
$0.00
$0.00
$0.00
$0.00 $630.95
$0.00
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
27822
3
TREATMENT OF ANKLE FRACTURE
$772.16
27823
3
TREATMENT OF ANKLE FRACTURE
$879.20
27824
3
TREAT LOWER LEG FRACTURE
$266.36
27825
3
TREAT LOWER LEG FRACTURE
$485.07
27826
3
TREAT LOWER LEG FRACTURE
$740.44
27827
3
TREAT LOWER LEG FRACTURE
$987.29
27828
3
TREAT LOWER LEG FRACTURE
$1,179.70
27829
3
TREAT LOWER LEG JOINT
$591.78
27830
3
TREAT LOWER LEG DISLOCATION
$309.49
27831
3
TREAT LOWER LEG DISLOCATION
$337.49
27832
3
TREAT LOWER LEG DISLOCATION
$636.00
27840
3
TREAT ANKLE DISLOCATION
$310.65
27842
3
TREAT ANKLE DISLOCATION
$435.00
27844
O
TREATMENT OF OPEN ANKLE DISLOCATION
27846
3
TREAT ANKLE DISLOCATION
$672.07
27848
3
TREAT ANKLE DISLOCATION
$760.76
27860
3
FIXATION OF ANKLE JOINT
$162.44
27870
3
FUSION OF ANKLE JOINT, OPEN
$958.56
27871
3
FUSION OF TIBIOFIBULAR JOINT
$630.19
27880
3
AMPUTATION OF LOWER LEG
$844.82
27881
3
AMPUTATION OF LOWER LEG
$816.48
27882
3
AMPUTATION OF LOWER LEG
$575.00
27884
3
AMPUTATION FOLLOW-UP SURGERY
$535.03
27886
3
AMPUTATION FOLLOW-UP SURGERY
$610.28
27888
3
AMPUTATION OF FOOT AT ANKLE
$645.75
27889
3
AMPUTATION OF FOOT AT ANKLE
$629.53
27892
3
DECOMPRESSION OF LEG
$495.46
27893
3
DECOMPRESSION OF LEG
$501.80
27894
3
DECOMPRESSION OF LEG
$769.89
27899
5
LEG/ANKLE SURGERY PROCEDURE
28001
3
DRAINAGE OF BURSA OF FOOT
$241.49
28002
3
TREATMENT OF FOOT INFECTION
$449.27
28003
3
TREATMENT OF FOOT INFECTION
$617.65
28005
3
TREAT FOOT BONE LESION
$569.75
28008
3
INCISION OF FOOT FASCIA
$381.13
$0.00
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
28010
3
INCISION OF TOE TENDON
$211.35
28011
3
INCISION OF TOE TENDONS
$299.17
28020
3
EXPLORATION OF FOOT JOINT
$452.80
28022
3
EXPLORATION OF FOOT JOINT
$417.92
28024
3
EXPLORATION OF TOE JOINT
$397.35
28030
O
REMOVAL OF FOOT NERVE
28035
3
DECOMPRESSION OF TIBIA NERVE
$455.55
28043
3
EXCISION OF FOOT LESION
$303.48
28045
3
EXCISION OF FOOT LESION
$425.86
28046
3
RESECTION OF TUMOR, FOOT
$772.64
28050
3
BIOPSY OF FOOT JOINT LINING
$400.58
28052
3
BIOPSY OF FOOT JOINT LINING
$369.35
28054
3
BIOPSY OF TOE JOINT LINING
$347.21
28055
3
NEURECTOMY, FOOT
$369.79
28060
3
PARTIAL REMOVAL, FOOT FASCIA
$448.71
28062
3
REMOVAL OF FOOT FASCIA
$527.49
28070
3
REMOVAL OF FOOT JOINT LINING
$445.17
28072
3
REMOVAL OF FOOT JOINT LINING
$439.43
28080
3
REMOVAL OF FOOT LESION
$431.05
28086
3
EXCISE FOOT TENDON SHEATH
$471.79
28088
3
EXCISE FOOT TENDON SHEATH
$400.58
28090
3
REMOVAL OF FOOT LESION
$403.84
28092
3
REMOVAL OF TOE LESIONS
$365.06
28100
3
REMOVAL OF ANKLE/HEEL LESION
$520.93
28102
3
REMOVE/GRAFT FOOT LESION
$518.63
28103
3
REMOVE/GRAFT FOOT LESION
$418.53
28104
3
REMOVAL OF FOOT LESION
$446.64
28106
3
REMOVE/GRAFT FOOT LESION
$441.69
28107
3
REMOVE/GRAFT FOOT LESION
$495.84
28108
3
REMOVAL OF TOE LESIONS
$376.09
28110
3
PART REMOVAL OF METATARSAL
$395.29
28111
3
PART REMOVAL OF METATARSAL
$449.38
28112
3
PART REMOVAL OF METATARSAL
$425.66
28113
3
PART REMOVAL OF METATARSAL
$508.41
28114
3
REMOVAL OF METATARSAL HEADS
$922.88
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
28116
3
REVISION OF FOOT
$658.77
28118
3
REMOVAL OF HEEL BONE
$511.80
28119
3
REMOVAL OF HEEL SPUR
$455.91
28120
3
PART REMOVAL OF ANKLE/HEEL
$506.52
28122
3
PARTIAL REMOVAL OF FOOT BONE
$587.56
28124
3
PARTIAL REMOVAL OF TOE
$417.61
28126
3
PARTIAL REMOVAL OF TOE
$338.01
28130
3
REMOVAL OF ANKLE BONE
$589.89
28140
3
REMOVAL OF METATARSAL
$553.13
28150
3
REMOVAL OF TOE
$376.56
28153
3
PARTIAL REMOVAL OF TOE
$351.24
28160
3
PARTIAL REMOVAL OF TOE
$360.50
28171
3
EXTENSIVE FOOT SURGERY
$576.84
28173
3
EXTENSIVE FOOT SURGERY
$658.21
28175
3
EXTENSIVE FOOT SURGERY
$483.46
28190
3
REMOVAL OF FOOT FOREIGN BODY
$215.78
28192
3
REMOVAL OF FOOT FOREIGN BODY
$413.28
28193
3
REMOVAL OF FOOT FOREIGN BODY
$473.58
28200
3
REPAIR OF FOOT TENDON
$413.33
28202
3
REPAIR/GRAFT OF FOOT TENDON
$548.54
28208
3
REPAIR OF FOOT TENDON
$398.11
28210
3
REPAIR/GRAFT OF FOOT TENDON
$511.33
28220
3
RELEASE OF FOOT TENDON
$392.86
28222
3
RELEASE OF FOOT TENDONS
$453.54
28225
3
RELEASE OF FOOT TENDON
$341.78
28226
3
RELEASE OF FOOT TENDONS
$410.48
28230
3
INCISION OF FOOT TENDON(S)
$377.59
28232
3
INCISION OF TOE TENDON
$335.35
28234
3
INCISION OF FOOT TENDON
$347.91
28236
O
TRANSFER OF TENDON, ANTERIOR TIBIAL
28238
3
REVISION OF FOOT TENDON
$601.32
28240
3
RELEASE OF BIG TOE
$388.52
28250
3
REVISION OF FOOT FASCIA
$493.63
28260
3
RELEASE OF MIDFOOT JOINT
$602.21
28261
3
REVISION OF FOOT TENDON
$871.62
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
28262
3
REVISION OF FOOT AND ANKLE
$1,219.90
28264
3
RELEASE OF MIDFOOT JOINT
$781.05
28270
3
RELEASE OF FOOT CONTRACTURE
$420.02
28272
3
RELEASE OF TOE JOINT, EACH
$343.45
28280
3
FUSION OF TOES
$460.95
28285
3
REPAIR OF HAMMERTOE
$406.94
28286
3
REPAIR OF HAMMERTOE
$397.64
28288
3
PARTIAL REMOVAL OF FOOT BONE
$509.72
28289
3
REPAIR HALLUX RIGIDUS
$643.29
28290
3
CORRECTION OF BUNION
$502.45
28292
3
CORRECTION OF BUNION
$683.52
28293
3
CORRECTION OF BUNION
$912.86
28294
3
CORRECTION OF BUNION
$660.23
28296
3
CORRECTION OF BUNION
$648.04
28297
3
CORRECTION OF BUNION
$731.81
28298
3
CORRECTION OF BUNION
$631.93
28299
3
CORRECTION OF BUNION
$810.29
28300
3
INCISION OF HEEL BONE
$616.18
28302
3
INCISION OF ANKLE BONE
$610.34
28304
3
INCISION OF MIDFOOT BONES
$701.43
28305
3
INCISE/GRAFT MIDFOOT BONES
$644.31
28306
3
INCISION OF METATARSAL
$527.08
28307
3
INCISION OF METATARSAL
$622.21
28308
3
INCISION OF METATARSAL
$477.46
28309
3
INCISION OF METATARSALS
$830.06
28310
3
REVISION OF BIG TOE
$469.92
28312
3
REVISION OF TOE
$430.88
28313
3
REPAIR DEFORMITY OF TOE
$452.30
28315
3
REMOVAL OF SESAMOID BONE
$414.97
28320
3
REPAIR OF FOOT BONES
$582.57
28322
3
REPAIR OF METATARSALS
$682.55
28340
3
RESECT ENLARGED TOE TISSUE
$543.44
28341
3
RESECT ENLARGED TOE
$625.44
28344
3
REPAIR EXTRA TOE(S)
$418.74
28345
3
REPAIR WEBBED TOE(S)
$504.23
Procedure Code Pricing Action Code Description
Maximum Allowable
28360
3
RECONSTRUCT CLEFT FOOT
$895.94
28400
3
TREATMENT OF HEEL FRACTURE
$213.05
28405
3
TREATMENT OF HEEL FRACTURE
$346.72
28406
3
TREATMENT OF HEEL FRACTURE
$475.97
28410
O
TREATMENT OF OPEN CALCANEAL FRACTUR
28415
3
TREAT HEEL FRACTURE
$1,044.31
28420
3
TREAT/GRAFT HEEL FRACTURE
$1,098.88
28430
3
TREATMENT OF ANKLE FRACTURE
$199.25
28435
3
TREATMENT OF ANKLE FRACTURE
$281.02
28436
3
TREATMENT OF ANKLE FRACTURE
$382.10
28440
O
TREATMENT OF OPEN TALUS FRACTURE, W
28445
3
TREAT ANKLE FRACTURE
28446
3
OSTEOCHONDRAL TALUS AUTOGRFT
28450
3
TREAT MIDFOOT FRACTURE, EACH
$184.35
28455
3
TREAT MIDFOOT FRACTURE, EACH
$255.47
28456
3
TREAT MIDFOOT FRACTURE
$245.61
28460
O
TREATMENT OF OPEN TARSAL BONE FRACT
28465
3
TREAT MIDFOOT FRACTURE, EACH
$560.26
28470
3
TREAT METATARSAL FRACTURE
$184.03
28475
3
TREAT METATARSAL FRACTURE
$233.13
28476
3
TREAT METATARSAL FRACTURE
$304.06
28480
O
TREATMENT OF OPEN METATARSAL FRACTU
28485
3
TREAT METATARSAL FRACTURE
$483.75
28490
3
TREAT BIG TOE FRACTURE
$118.80
28495
3
TREAT BIG TOE FRACTURE
$149.93
28496
3
TREAT BIG TOE FRACTURE
$366.14
28500
O
TREATMENT OF OPEN FRACTURE GREAT TO
28505
3
TREAT BIG TOE FRACTURE
$579.69
28510
3
TREATMENT OF TOE FRACTURE
$102.90
28515
3
TREATMENT OF TOE FRACTURE
$135.55
28520
O
TREATMENT OF OPEN FRACTURE, PHALANX
28525
3
TREAT TOE FRACTURE
28530
3
TREAT SESAMOID BONE FRACTURE
$99.25
28531
3
TREAT SESAMOID BONE FRACTURE
$323.00
28540
3
TREAT FOOT DISLOCATION
$175.92
$0.00
$0.00 $984.15 $1,077.80
$0.00
$0.00
$0.00
$0.00 $488.94
Procedure Code Pricing Action Code Description
Maximum Allowable
28545
3
TREAT FOOT DISLOCATION
$216.50
28546
3
TREAT FOOT DISLOCATION
$410.28
28550
O
TREATMENT OF OPEN TARSAL BONE DISLO
28555
3
REPAIR FOOT DISLOCATION
$758.15
28570
3
TREAT FOOT DISLOCATION
$152.04
28575
3
TREAT FOOT DISLOCATION
$290.96
28576
3
TREAT FOOT DISLOCATION
$318.59
28580
O
TREATMENT OF OPEN TALOTARSAL JOINT
28585
3
REPAIR FOOT DISLOCATION
$807.63
28600
3
TREAT FOOT DISLOCATION
$183.75
28605
3
TREAT FOOT DISLOCATION
$237.22
28606
3
TREAT FOOT DISLOCATION
$352.53
28610
O
TREATMENT OF OPEN TARSOMETATARSAL J
28615
3
REPAIR FOOT DISLOCATION
$705.87
28630
3
TREAT TOE DISLOCATION
$130.59
28635
3
TREAT TOE DISLOCATION
$156.16
28636
3
TREAT TOE DISLOCATION
$257.92
28640
O
TREATMENT OF OPEN METATARSOPHALANGE
28645
3
REPAIR TOE DISLOCATION
$548.13
28660
3
TREAT TOE DISLOCATION
$95.11
28665
3
TREAT TOE DISLOCATION
$138.78
28666
3
TREAT TOE DISLOCATION
$179.30
28670
O
TREATMENT OF OPEN INTERPHALANGEAL J
28675
3
REPAIR OF TOE DISLOCATION
28705
3
FUSION OF FOOT BONES
$1,212.27
28715
3
FUSION OF FOOT BONES
$898.20
28725
3
FUSION OF FOOT BONES
$739.12
28730
3
FUSION OF FOOT BONES
$773.80
28735
3
FUSION OF FOOT BONES
$739.53
28737
3
REVISION OF FOOT BONES
$655.51
28740
3
FUSION OF FOOT BONES
$580.33
28750
3
FUSION OF BIG TOE JOINT
$732.12
28755
3
FUSION OF BIG TOE JOINT
$441.11
28760
3
FUSION OF BIG TOE JOINT
$543.90
28800
3
AMPUTATION OF MIDFOOT
$529.65
$0.00
$0.00
$0.00
$0.00
$0.00 $500.55
Procedure Code Pricing Action Code Description
Maximum Allowable
28805
3
AMPUTATION THRU METATARSAL
$695.61
28810
3
AMPUTATION TOE & METATARSAL
$408.13
28820
3
AMPUTATION OF TOE
$467.01
28825
3
PARTIAL AMPUTATION OF TOE
$505.34
28890
3
HIGH ENERGY ESWT, PLANTAR F
$306.99
28899
5
FOOT/TOES SURGERY PROCEDURE
29000
3
APPLICATION OF BODY CAST
$237.38
29010
3
APPLICATION OF BODY CAST
$216.38
29015
3
APPLICATION OF BODY CAST
$209.66
29020
3
APPLICATION OF BODY CAST
$200.78
29025
3
APPLICATION OF BODY CAST
$227.92
29035
3
APPLICATION OF BODY CAST
$211.56
29040
3
APPLICATION OF BODY CAST
$203.67
29044
3
APPLICATION OF BODY CAST
$229.08
29046
3
APPLICATION OF BODY CAST
$249.99
29049
3
APPLICATION OF FIGURE EIGHT
29055
3
APPLICATION OF SHOULDER CAST
$181.34
29058
3
APPLICATION OF SHOULDER CAST
$97.47
29065
3
APPLICATION OF LONG ARM CAST
$82.38
29075
3
APPLICATION OF FOREARM CAST
$76.48
29085
3
APPLY HAND/WRIST CAST
$81.40
29086
3
APPLY FINGER CAST
$62.28
29105
3
APPLY LONG ARM SPLINT
$75.37
29125
3
APPLY FOREARM SPLINT
$58.62
29126
3
APPLY FOREARM SPLINT
$67.28
29130
3
APPLICATION OF FINGER SPLINT
$35.57
29131
3
APPLICATION OF FINGER SPLINT
$44.03
29200
3
STRAPPING OF CHEST
$47.11
29220
3
STRAPPING OF LOW BACK
$48.60
29240
3
STRAPPING OF SHOULDER
$52.68
29260
3
STRAPPING OF ELBOW OR WRIST
$45.62
29280
3
STRAPPING OF HAND OR FINGER
$44.08
29305
3
APPLICATION OF HIP CAST
$204.78
29325
3
APPLICATION OF HIP CASTS
$227.80
29345
3
APPLICATION OF LONG LEG CAST
$118.26
$0.00
$75.59
Procedure Code Pricing Action Code Description
Maximum Allowable
29355
3
APPLICATION OF LONG LEG CAST
$122.27
29358
3
APPLY LONG LEG CAST BRACE
$133.25
29365
3
APPLICATION OF LONG LEG CAST
$106.11
29405
3
APPLY SHORT LEG CAST
$78.09
29425
3
APPLY SHORT LEG CAST
$84.42
29435
3
APPLY SHORT LEG CAST
$103.53
29440
3
ADDITION OF WALKER TO CAST
29445
3
APPLY RIGID LEG CAST
$129.61
29450
3
APPLICATION OF LEG CAST
$136.62
29505
3
APPLICATION, LONG LEG SPLINT
$66.50
29515
3
APPLICATION LOWER LEG SPLINT
$62.26
29520
3
STRAPPING OF HIP
$44.41
29530
3
STRAPPING OF KNEE
$46.33
29540
3
STRAPPING OF ANKLE AND/OR FT
$38.15
29550
3
STRAPPING OF TOES
$37.09
29580
3
APPLICATION OF PASTE BOOT
$46.84
29590
3
APPLICATION OF FOOT SPLINT
$50.02
29700
3
REMOVAL/REVISION OF CAST
$56.67
29705
3
REMOVAL/REVISION OF CAST
$59.48
29710
3
REMOVAL/REVISION OF CAST
$104.07
29715
3
REMOVAL/REVISION OF CAST
$79.37
29720
3
REPAIR OF BODY CAST
$70.06
29730
3
WINDOWING OF CAST
$57.77
29740
3
WEDGING OF CAST
$82.79
29750
3
WEDGING OF CLUBFOOT CAST
$90.36
29799
5
CASTING/STRAPPING PROCEDURE
29800
3
JAW ARTHROSCOPY/SURGERY
$467.19
29804
3
JAW ARTHROSCOPY/SURGERY
$579.45
29805
3
SHOULDER ARTHROSCOPY, DX
$423.04
29806
3
SHOULDER ARTHROSCOPY/SURGERY
$967.17
29807
3
SHOULDER ARTHROSCOPY/SURGERY
$942.17
29815
O
SHOULDER ARTHROSCOPY
29819
3
SHOULDER ARTHROSCOPY/SURGERY
$530.11
29820
3
SHOULDER ARTHROSCOPY/SURGERY
$489.23
29821
3
SHOULDER ARTHROSCOPY/SURGERY
$534.30
$46.31
$0.00
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
29822
3
SHOULDER ARTHROSCOPY/SURGERY
$519.04
29823
3
SHOULDER ARTHROSCOPY/SURGERY
$567.81
29824
3
SHOULDER ARTHROSCOPY/SURGERY
$605.04
29825
3
SHOULDER ARTHROSCOPY/SURGERY
$529.38
29826
3
SHOULDER ARTHROSCOPY/SURGERY
$607.14
29827
3
ARTHROSCOP ROTATOR CUFF REPR
$991.35
29828
3
ARTHROSCOPY BICEPS TENODESIS
$829.33
29830
3
ELBOW ARTHROSCOPY
$408.07
29834
3
ELBOW ARTHROSCOPY/SURGERY
$444.69
29835
3
ELBOW ARTHROSCOPY/SURGERY
$456.37
29836
3
ELBOW ARTHROSCOPY/SURGERY
$524.48
29837
3
ELBOW ARTHROSCOPY/SURGERY
$478.40
29838
3
ELBOW ARTHROSCOPY/SURGERY
$534.70
29840
3
WRIST ARTHROSCOPY
$400.30
29843
3
WRIST ARTHROSCOPY/SURGERY
$430.10
29844
3
WRIST ARTHROSCOPY/SURGERY
$446.59
29845
3
WRIST ARTHROSCOPY/SURGERY
$509.76
29846
3
WRIST ARTHROSCOPY/SURGERY
$469.75
29847
3
WRIST ARTHROSCOPY/SURGERY
$487.71
29848
3
WRIST ENDOSCOPY/SURGERY
$444.71
29850
3
KNEE ARTHROSCOPY/SURGERY
$515.99
29851
3
KNEE ARTHROSCOPY/SURGERY
$850.91
29855
3
TIBIAL ARTHROSCOPY/SURGERY
$712.97
29856
3
TIBIAL ARTHROSCOPY/SURGERY
$911.82
29860
3
HIP ARTHROSCOPY, DX
$586.93
29861
3
HIP ARTHROSCOPY/SURGERY
$650.97
29862
3
HIP ARTHROSCOPY/SURGERY
$727.34
29863
3
HIP ARTHROSCOPY/SURGERY
$719.58
29866
3
AUTGRFT IMPLNT, KNEE W/SCOPE
$948.36
29867
3
ALLGRFT IMPLNT, KNEE W/SCOPE
$1,148.70
29868
3
MENISCAL TRNSPL, KNEE W/SCPE
$1,535.53
29870
3
KNEE ARTHROSCOPY, DX
$367.12
29871
3
KNEE ARTHROSCOPY/DRAINAGE
$461.33
29873
3
KNEE ARTHROSCOPY/SURGERY
$461.41
29874
3
KNEE ARTHROSCOPY/SURGERY
$483.65
Procedure Code Pricing Action Code Description
Maximum Allowable
29875
3
KNEE ARTHROSCOPY/SURGERY
$446.38
29876
3
KNEE ARTHROSCOPY/SURGERY
$586.23
29877
3
KNEE ARTHROSCOPY/SURGERY
$554.83
29879
3
KNEE ARTHROSCOPY/SURGERY
$593.58
29880
3
KNEE ARTHROSCOPY/SURGERY
$619.69
29881
3
KNEE ARTHROSCOPY/SURGERY
$577.57
29882
3
KNEE ARTHROSCOPY/SURGERY
$625.41
29883
3
KNEE ARTHROSCOPY/SURGERY
$763.55
29884
3
KNEE ARTHROSCOPY/SURGERY
$553.13
29885
3
KNEE ARTHROSCOPY/SURGERY
$670.97
29886
3
KNEE ARTHROSCOPY/SURGERY
$565.79
29887
3
KNEE ARTHROSCOPY/SURGERY
$667.10
29888
3
KNEE ARTHROSCOPY/SURGERY
$904.52
29889
3
KNEE ARTHROSCOPY/SURGERY
$1,105.23
29891
3
ANKLE ARTHROSCOPY/SURGERY
$629.03
29892
3
ANKLE ARTHROSCOPY/SURGERY
$642.45
29893
3
SCOPE, PLANTAR FASCIOTOMY
$527.39
29894
3
ANKLE ARTHROSCOPY/SURGERY
$471.84
29895
3
ANKLE ARTHROSCOPY/SURGERY
$456.37
29897
3
ANKLE ARTHROSCOPY/SURGERY
$478.28
29898
3
ANKLE ARTHROSCOPY/SURGERY
$534.21
29899
3
ANKLE ARTHROSCOPY/SURGERY
$960.63
29900
3
MCP JOINT ARTHROSCOPY, DX
$411.38
29901
3
MCP JOINT ARTHROSCOPY, SURG
$450.72
29902
3
MCP JOINT ARTHROSCOPY, SURG
$481.78
29904
3
SUBTALAR ARTHRO W/FB RMVL
$558.48
29905
3
SUBTALAR ARTHRO W/EXC
$601.32
29906
3
SUBTALAR ARTHRO W/DEB
$633.47
29907
3
SUBTALAR ARTHRO W/FUSION
$775.66
29909
O
ARTHROSCOPY OF JOINT
$0.00
29999
5
ARTHROSCOPY OF JOINT
$0.00
30000
3
DRAINAGE OF NOSE LESION
3000F
O
BLOOD PRESS
30020
3
DRAINAGE OF NOSE LESION
3002F
O
BLOOD PRESSURE > 140/90 MMHG
$204.06 $0.00 $197.40 $0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
3006F
9
CXR DOC REV
$0.00
30100
3
INTRANASAL BIOPSY
$124.00
30110
3
REMOVAL OF NOSE POLYP(S)
$199.48
30115
3
REMOVAL OF NOSE POLYP(S)
$385.58
30117
3
REMOVAL OF INTRANASAL LESION
$736.52
30118
3
REMOVAL OF INTRANASAL LESION
$693.85
3011F
9
LIPID PANEL DOC REV
30120
3
REVISION OF NOSE
$463.60
30124
3
REMOVAL OF NOSE LESION
$243.53
30125
3
REMOVAL OF NOSE LESION
$554.09
30130
3
EXCISE INFERIOR TURBINATE
$337.06
30140
3
RESECT INFERIOR TURBINATE
$385.62
3014F
9
SCREEN MAMMO DOC REV
30150
3
PARTIAL REMOVAL OF NOSE
$711.22
30160
3
REMOVAL OF NOSE
$714.27
3016F
9
PT SCRND UNHLTHY OH USE
$0.00
3017F
9
COLORECTAL CA SCREEN DOC REV
$0.00
3018F
9
PRE-PRXD RSK ET AL DOCD
$0.00
30200
3
INJECTION TREATMENT OF NOSE
3020F
9
LVF ASSESS
30210
3
NASAL SINUS THERAPY
3021F
9
LVEF MOD/SEVER DEPRS SYST
$0.00
30220
9
INSERT NASAL SEPTAL BUTTON
$0.00
3022F
9
LVEF =40% SYSTOLIC
$0.00
3023F
9
SPIROM DOC REV
$0.00
3025F
9
SPIROM FEV/FVC<70% W COPD
$0.00
3027F
9
SPIROM FEV/FVC=70%/ W/O COPD
$0.00
3028F
9
O2 SATURATION DOC REV
$0.00
30300
3
REMOVE NASAL FOREIGN BODY
$199.88
30310
3
REMOVE NASAL FOREIGN BODY
$183.65
30320
3
REMOVE NASAL FOREIGN BODY
$404.84
3035F
9
O2 SATURATION =88% /PA0 =55
$0.00
3037F
9
O2 SATURATION> 88% /PAO>55
$0.00
30400
3
RECONSTRUCTION OF NOSE
$932.41
3040F
9
FEV<40% PREDICTED VALUE
$0.00
$0.00
$0.00
$99.19 $0.00 $130.19
Procedure Code Pricing Action Code Description
Maximum Allowable
30410
3
RECONSTRUCTION OF NOSE
$1,103.64
30420
3
RECONSTRUCTION OF NOSE
$1,238.92
3042F
9
FEV= 40% PREDICTED VALUE
$0.00
30430
3
REVISION OF NOSE
$817.16
30435
9
REVISION OF NOSE
$0.00
3044F
9
HG A1C LEVEL LT 7.0%
$0.00
30450
3
REVISION OF NOSE
3045F
9
HG A1C LEVEL 7.09.0%
30460
3
REVISION OF NOSE
$688.59
30462
3
REVISION OF NOSE
$1,385.43
30465
3
REPAIR NASAL STENOSIS
3046F
9
HEMOGLOBIN A1C LEVEL > 9.0%
$0.00
3047F
O
HEMOGLOBIN A1C LEVEL = 9.0%
$0.00
3048F
9
LDL-C <100 MG/DL
$0.00
3049F
9
LDL-C 100-129 MG/DL
$0.00
3050F
9
LDL-C = 130 MG/DL
$0.00
30520
3
REPAIR OF NASAL SEPTUM
$541.21
30540
3
REPAIR NASAL DEFECT
$603.85
30545
3
REPAIR NASAL DEFECT
$872.65
30560
3
RELEASE OF NASAL ADHESIONS
$236.69
30580
3
REPAIR UPPER JAW FISTULA
$563.83
30600
3
REPAIR MOUTH/NOSE FISTULA
$519.10
3060F
9
POS MICROALBUMINURIA REV
$0.00
3061F
9
NEG MICROALBUMINURIA REV
$0.00
30620
3
INTRANASAL RECONSTRUCTION
3062F
9
POS MACROALBUMINURIA REV
30630
3
REPAIR NASAL SEPTUM DEFECT
3066F
9
NEPHROPATHY DOC TX
$0.00
3072F
9
LOW RISK FOR RETINOPATHY
$0.00
3073F
9
PRE-SURG EYE MEASURES DOCD
$0.00
3074F
9
SYST BP LT 130 MM HG
$0.00
3075F
9
SYST BP GE 130 - 139MM HG
$0.00
3076F
O
SYST BP < 140 MM HG
$0.00
3077F
9
SYST BP = 140 MM HG6 IT
$0.00
3078F
9
DIAST BP < 80 MM HG
$0.00
$1,425.18 $0.00
$883.20
$553.36 $0.00 $560.68
Procedure Code Pricing Action Code Description
Maximum Allowable
3079F
9
DIAST BP 80-89 MM HG
$0.00
30800
O
CAUTERIZATION TURBINATES, UNILATERA
$0.00
30801
3
ABLATE INF TURBINATE, SUPERF
$198.95
30802
3
CAUTERIZATION, INNER NOSE
$256.40
30805
O
CAUTERIZATION TURBINATES, UNILATERA
$0.00
3080F
9
DIAST BP = 90 MM HG
$0.00
30820
O
CRYOSURGERY OF TURBINATES, UNILATER
$0.00
3082F
9
KT/V LT1.2
$0.00
3083F
9
KT/V GE 1.2 AND <1.7
$0.00
3084F
9
KT/V GE 1.7
$0.00
3085F
9
SUICIDE RISK ASSESSED
$0.00
3088F
9
MDD, MILD
$0.00
3089F
9
MDD, MODERATE
$0.00
30901
3
CONTROL OF NOSEBLEED
$93.57
30903
3
CONTROL OF NOSEBLEED
$172.38
30905
3
CONTROL OF NOSEBLEED
$214.59
30906
3
REPEAT CONTROL OF NOSEBLEED
$246.51
3090F
9
MDD, SEVERE; W/O PSYCH
30915
3
LIGATION, NASAL SINUS ARTERY
3091F
9
MDD, SEVERE; W/ PSYCH
30920
3
LIGATION, UPPER JAW ARTERY
3092F
9
MDD, IN REMISSION
30930
3
THER FX, NASAL INF TURBINATE
3093F
9
DOC NEW DIAG 1ST/ADDL. MDD
$0.00
3095F
9
CENTRAL DEXA RESULTS DOCÏD
$0.00
3096F
9
CENTRAL DEXA ORDERED
$0.00
30999
5
NASAL SURGERY PROCEDURE
$0.00
31000
3
IRRIGATION, MAXILLARY SINUS
$158.21
31002
3
IRRIGATION, SPHENOID SINUS
$180.52
3100F
9
IMAGE TEST REF CAROT DIAM
$0.00
31020
3
EXPLORATION, MAXILLARY SINUS
$428.79
31030
3
EXPLORATION, MAXILLARY SINUS
$622.58
31032
3
EXPLORE SINUS, REMOVE POLYPS
$513.21
31040
3
EXPLORATION BEHIND UPPER JAW
$674.75
31050
3
EXPLORATION, SPHENOID SINUS
$443.66
$0.00 $519.80 $0.00 $747.91 $0.00 $109.25
Procedure Code Pricing Action Code Description
Maximum Allowable
31051
3
SPHENOID SINUS SURGERY
$579.43
31070
3
EXPLORATION OF FRONTAL SINUS
$390.11
31071
O
SINUSOTOMY FRONTAL; INTRANASAL
31075
3
EXPLORATION OF FRONTAL SINUS
$706.58
31080
3
REMOVAL OF FRONTAL SINUS
$911.99
31081
3
REMOVAL OF FRONTAL SINUS
$1,115.52
31084
3
REMOVAL OF FRONTAL SINUS
$1,065.05
31085
3
REMOVAL OF FRONTAL SINUS
$1,126.31
31086
3
REMOVAL OF FRONTAL SINUS
$1,007.82
31087
3
REMOVAL OF FRONTAL SINUS
$997.92
31090
3
EXPLORATION OF SINUSES
$899.70
3110F
9
PRES/ABSN HMRHG/LESION DOCÏD
$0.00
3111F
9
CT/MRI BRAIN DONE W/IN 24HRS
$0.00
3112F
9
CT/MRI BRAIN DONE GT24 HRS
$0.00
31200
3
REMOVAL OF ETHMOID SINUS
$480.24
31201
3
REMOVAL OF ETHMOID SINUS
$658.73
31205
3
REMOVAL OF ETHMOID SINUS
$772.10
3120F
9
12-LEAD ECG PERFORMED
31225
3
REMOVAL OF UPPER JAW
$1,658.38
31230
3
REMOVAL OF UPPER JAW
$1,857.84
31231
3
NASAL ENDOSCOPY, DX
$170.86
31233
3
NASAL/SINUS ENDOSCOPY, DX
$239.82
31235
3
NASAL/SINUS ENDOSCOPY, DX
$275.44
31237
3
NASAL/SINUS ENDOSCOPY, SURG
$296.58
31238
3
NASAL/SINUS ENDOSCOPY, SURG
$305.23
31239
3
NASAL/SINUS ENDOSCOPY, SURG
$603.48
31240
3
NASAL/SINUS ENDOSCOPY, SURG
$151.89
31245
O
NASAL/SINUS ENDOSCOPY, SURGICAL, WI
$0.00
31246
O
NASAL/SINUS ENDOSCOPY, SURGICAL, WI
$0.00
31247
O
NASAL/SINUS ENDOSCOPY, SURGICAL, WI
$0.00
31248
O
NASAL/SINUS ENDOSCOPY, SURGICAL, WI
$0.00
31249
O
NASAL/SINUS ENDOSCOPY, SURGICAL, WI
$0.00
31250
O
NASAL ENDOSCOPY, DIAGNOSTIC (INCLUD
$0.00
31251
O
NASAL/SINUS ENDOSCOPY, SURGICAL, WI
$0.00
31252
O
NASAL ENDOSCOPY, SURGICAL WITH NASA
$0.00
$0.00
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
31254
3
REVISION OF ETHMOID SINUS
$259.78
31255
3
REMOVAL OF ETHMOID SINUS
$383.42
31256
3
EXPLORATION MAXILLARY SINUS
$188.33
31258
O
NASAL ENDOSCOPY, SURGICAL WITH REMO
$0.00
31260
O
MAXILLARY SINUS ENDOSCOPY, DIAGNOST
$0.00
31261
O
NASAL/SINUS ENDOSCOPY, SURGICAL, WI
$0.00
31262
O
NASAL/SINUS ENDOSCOPY, SURGICAL, WI
$0.00
31263
O
MAXILLARY SINUS ENDOSCOPY, SURGICAL
$0.00
31264
O
NASAL/SINUS ENDOSCOPY, SURGICAL, WI
$0.00
31265
O
MAXILLARY SINUS ENDOSCOPY, SURGICAL
$0.00
31266
O
NASAL/SINUS ENDOSCOPY, SURGICAL, WI
$0.00
31267
3
ENDOSCOPY, MAXILLARY SINUS
31268
O
MAXILLARY SINUS ENDOSCOPY, SURGICAL
$0.00
31269
O
NASAL/SINUS ENDOSCOPY, SURGICAL, WI
$0.00
31270
O
SPHENOID ENDOSCOPY, DIAGNOSTIC
$0.00
31271
O
NASAL/SINUS ENDOSCOPY, SURGICAL, WI
$0.00
31275
O
SPHENOID ENDOSCOPY, SURGICAL;
$0.00
31276
3
SINUS ENDOSCOPY, SURGICAL
31277
O
SPHENOID ENDOSCOPY, SURGICAL WITH R
$0.00
31280
O
NASAL/SINUS ENDOSCOPY, SURGICAL, WI
$0.00
31281
O
NASAL/SINUS ENDOSCOPY, SURGICAL, WI
$0.00
31282
O
NASAL/SINUS ENDOSCOPY, SURGICAL, WI
$0.00
31283
O
NASAL/SINUS ENDOSCOPY, SURGICAL, WI
$0.00
31284
O
NASAL/SINUS ENDOSCOPY, SURGICAL, WI
$0.00
31285
O
SINUS ENDOSCOPY, TWO OR MORE SINUSE
$0.00
31286
O
NASAL/SINUS ENDOSCOPY, SURGICAL, WI
$0.00
31287
3
NASAL/SINUS ENDOSCOPY, SURG
$221.16
31288
3
NASAL/SINUS ENDOSCOPY, SURG
$256.41
31290
3
NASAL/SINUS ENDOSCOPY, SURG
$1,068.78
31291
3
NASAL/SINUS ENDOSCOPY, SURG
$1,126.31
31292
3
NASAL/SINUS ENDOSCOPY, SURG
$925.24
31293
3
NASAL/SINUS ENDOSCOPY, SURG
$1,007.79
31294
3
NASAL/SINUS ENDOSCOPY, SURG
$1,156.67
31299
5
SINUS SURGERY PROCEDURE
$0.00
31300
3
REMOVAL OF LARYNX LESION
$1,139.92
$302.95
$483.23
Procedure Code Pricing Action Code Description
Maximum Allowable
3130F
9
UPPER GI ENDOSCOPY PERFORMED
$0.00
31320
3
DIAGNOSTIC INCISION, LARYNX
3132F
9
DOC REF. UPPER GI ENDOSCOPY
31360
3
REMOVAL OF LARYNX
$1,814.36
31365
3
REMOVAL OF LARYNX
$2,268.78
31367
3
PARTIAL REMOVAL OF LARYNX
$1,963.12
31368
3
PARTIAL REMOVAL OF LARYNX
$2,193.12
31370
3
PARTIAL REMOVAL OF LARYNX
$1,848.31
31375
3
PARTIAL REMOVAL OF LARYNX
$1,748.20
31380
3
PARTIAL REMOVAL OF LARYNX
$1,723.01
31382
3
PARTIAL REMOVAL OF LARYNX
$1,886.43
31390
3
REMOVAL OF LARYNX & PHARYNX
$2,528.86
31395
3
RECONSTRUCT LARYNX & PHARYNX
$2,684.84
31400
3
REVISION OF LARYNX
3140F
9
UPPER GI ENDO SHOWS BARRTTÏS
$0.00
3141F
9
UPPER GI ENDO NOT BARRTTÏS
$0.00
31420
3
REMOVAL OF EPIGLOTTIS
3142F
9
BARIUM SWALLOW TEST ORDERED
31500
3
INSERT EMERGENCY AIRWAY
31502
3
CHANGE OF WINDPIPE AIRWAY
$33.30
31505
3
DIAGNOSTIC LARYNGOSCOPY
$75.50
3150F
9
FORCEPS ESOPH BIOPSY DONE
31510
3
LARYNGOSCOPY WITH BIOPSY
$192.23
31511
3
REMOVE FOREIGN BODY, LARYNX
$192.29
31512
3
REMOVAL OF LARYNX LESION
$189.93
31513
9
INJECTION INTO VOCAL CORD
$0.00
31515
3
LARYNGOSCOPY FOR ASPIRATION
$190.05
31520
3
DX LARYNGOSCOPY, NEWBORN
$144.33
31525
3
DX LARYNGOSCOPY EXCL NB
$228.05
31526
3
DX LARYNGOSCOPY W/OPER SCOPE
$149.00
31527
9
LARYNGOSCOPY FOR TREATMENT
31528
3
LARYNGOSCOPY AND DILATION
$135.83
31529
9
LARYNGOSCOPY AND DILATION
$0.00
31530
3
LARYNGOSCOPY W/FB REMOVAL
$187.26
31531
3
LARYNGOSCOPY W/FB & OP SCOPE
$201.79
$583.78 $0.00
$907.78
$758.99 $0.00 $104.34
$0.00
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
31535
3
LARYNGOSCOPY W/BIOPSY
$179.41
31536
3
LARYNGOSCOPY W/BX & OP SCOPE
$200.35
31540
3
LARYNGOSCOPY W/EXC OF TUMOR
$230.18
31541
3
LARYNSCOP W/TUMR EXC + SCOPE
$251.72
31545
3
REMOVE VC LESION W/SCOPE
$340.47
31546
3
REMOVE VC LESION SCOPE/GRAFT
$518.33
3155F
9
CYTOGEN TEST MARROW B/4 TX
31560
3
LARYNGOSCOP W/ARYTENOIDECTOM
$297.85
31561
3
LARYNSCOP, REMVE CART + SCOP
$326.35
31570
3
LARYNGOSCOPE W/VC INJ
$317.28
31571
3
LARYNGOSCOP W/VC INJ + SCOPE
$237.51
31575
3
DIAGNOSTIC LARYNGOSCOPY
$105.79
31576
3
LARYNGOSCOPY WITH BIOPSY
$205.74
31577
9
REMOVE FOREIGN BODY, LARYNX
31578
3
REMOVAL OF LARYNX LESION
$257.47
31579
3
DIAGNOSTIC LARYNGOSCOPY
$199.68
31580
3
REVISION OF LARYNX
$1,088.96
31582
3
REVISION OF LARYNX
$1,731.56
31584
3
TREAT LARYNX FRACTURE
$1,382.50
31585
O
TREAT LARYNX FRACTURE
$0.00
31586
O
TREAT LARYNX FRACTURE
$0.00
31587
3
REVISION OF LARYNX
$900.72
31588
3
REVISION OF LARYNX
$1,025.87
31590
9
REINNERVATE LARYNX
$0.00
31595
9
LARYNX NERVE SURGERY
$0.00
31599
5
LARYNX SURGERY PROCEDURE
$0.00
31600
3
INCISION OF WINDPIPE
$372.25
31601
3
INCISION OF WINDPIPE
$246.63
31603
3
INCISION OF WINDPIPE
$209.88
31605
3
INCISION OF WINDPIPE
$172.65
3160F
9
DOC FE+ STORES B/4 EPO THX
31610
3
INCISION OF WINDPIPE
$644.45
31611
3
SURGERY/SPEECH PROSTHESIS
$484.70
31612
3
PUNCTURE/CLEAR WINDPIPE
$73.99
31613
3
REPAIR WINDPIPE OPENING
$401.41
$0.00
$0.00
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
31614
9
REPAIR WINDPIPE OPENING
$0.00
31615
3
VISUALIZATION OF WINDPIPE
$168.35
31620
3
ENDOBRONCHIAL US ADD-ON
$266.73
31622
3
DX BRONCHOSCOPE/WASH
$139.15
31623
3
DX BRONCHOSCOPE/BRUSH
$326.38
31624
3
DX BRONCHOSCOPE/LAVAGE
$141.15
31625
3
BRONCHOSCOPY W/BIOPSY(S)
$326.24
31628
3
BRONCHOSCOPY/LUNG BX, EACH
$183.36
31629
3
BRONCHOSCOPY/NEEDLE BX, EACH
$196.20
31630
3
BRONCHOSCOPY DILATE/FX REPR
$196.31
31631
3
BRONCHOSCOPY, DILATE W/STENT
$221.25
31632
3
BRONCHOSCOPY/LUNG BX, ADDÏL
$71.80
31633
3
BRONCHOSCOPY/NEEDLE BX ADDÏL
$86.49
31635
3
BRONCHOSCOPY W/FB REMOVAL
$334.69
31636
3
BRONCHOSCOPY, BRONCH STENTS
$216.17
31637
3
BRONCHOSCOPY, STENT ADD-ON
$76.58
31638
3
BRONCHOSCOPY, REVISE STENT
$242.50
31640
3
BRONCHOSCOPY W/TUMOR EXCISE
$251.15
31641
3
BRONCHOSCOPY, TREAT BLOCKAGE
$248.04
31643
3
DIAG BRONCHOSCOPE/CATHETER
$170.18
31645
3
BRONCHOSCOPY, CLEAR AIRWAYS
$154.47
31646
3
BRONCHOSCOPY, RECLEAR AIRWAY
$133.83
31656
3
BRONCHOSCOPY, INJ FOR X-RAY
$304.81
31659
O
BRONCHOSCOPY; WITH OTHER BRONCHOSCO
$0.00
31700
O
INSERTION OF AIRWAY CATHETER
$0.00
31708
O
INSTILL AIRWAY CONTRAST DYE
$0.00
3170F
9
FLOW CYTO DONE B/4 TX
$0.00
31710
O
INSERTION OF AIRWAY CATHETER
$0.00
31715
3
INJECTION FOR BRONCHUS X-RAY
$53.55
31717
3
BRONCHIAL BRUSH BIOPSY
31719
O
TRANSTRACHEAL (PERCUTANEOUS) INTROD
31720
3
CLEARANCE OF AIRWAYS
$50.27
31725
3
CLEARANCE OF AIRWAYS
$90.41
31730
3
INTRO, WINDPIPE WIRE/TUBE
31750
3
REPAIR OF WINDPIPE
$286.15 $0.00
$818.94 $1,217.18
Procedure Code Pricing Action Code Description
Maximum Allowable
31755
3
REPAIR OF WINDPIPE
$1,545.80
31760
3
REPAIR OF WINDPIPE
$1,303.25
31766
3
RECONSTRUCTION OF WINDPIPE
$1,699.18
31770
3
REPAIR/GRAFT OF BRONCHUS
$1,259.06
31775
3
RECONSTRUCT BRONCHUS
$1,301.28
31780
3
RECONSTRUCT WINDPIPE
$1,102.49
31781
3
RECONSTRUCT WINDPIPE
$1,335.01
31785
3
REMOVE WINDPIPE LESION
$1,008.89
31786
3
REMOVE WINDPIPE LESION
$1,403.10
31800
3
REPAIR OF WINDPIPE INJURY
$637.05
31805
3
REPAIR OF WINDPIPE INJURY
$774.17
31820
3
CLOSURE OF WINDPIPE LESION
$387.94
31825
3
REPAIR OF WINDPIPE DEFECT
$542.00
31830
3
REVISE WINDPIPE SCAR
$390.90
31899
5
AIRWAYS SURGICAL PROCEDURE
$0.00
32000
O
DRAINAGE OF CHEST
$0.00
32001
O
TOTAL LUNG LAVAGE
$0.00
32002
O
TREATMENT OF COLLAPSED LUNG
$0.00
32005
O
TREAT LUNG LINING CHEMICALLY
$0.00
3200F
9
BARIUM SWALLOW TEST NOT REQ
$0.00
32019
O
INSERT PLEURAL CATHETER
$0.00
32020
O
INSERTION OF CHEST TUBE
$0.00
32035
3
EXPLORATION OF CHEST
$659.64
32036
3
EXPLORATION OF CHEST
$715.33
32095
3
BIOPSY THROUGH CHEST WALL
$586.88
32100
3
EXPLORATION/BIOPSY OF CHEST
$905.94
3210F
9
GRP A STREP TEST PERFORMED
$0.00
32110
3
EXPLORE/REPAIR CHEST
32120
3
RE-EXPLORATION OF CHEST
$812.59
32124
3
EXPLORE CHEST FREE ADHESIONS
$863.60
32140
3
REMOVAL OF LUNG LESION(S)
$923.67
32141
3
REMOVE/TREAT LUNG LESIONS
32150
3
REMOVAL OF LUNG LESION(S)
$930.72
32151
3
REMOVE LUNG FOREIGN BODY
$952.35
3215F
9
PT IMMUNITY TO HEP A DOCÏD
$1,363.70
$1,392.19
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
32160
3
OPEN CHEST HEART MASSAGE
$714.41
3216F
9
PT IMMUNITY TO HEP B DOCÏD
$0.00
3218F
9
RNA TSTNG HEP C DOCÏD-DONE
$0.00
32200
3
DRAIN, OPEN, LUNG LESION
32201
3
DRAIN, PERCUT, LUNG LESION
3220F
9
HEP C QUANT RNA TSTNG DOCÏD
32215
3
TREAT CHEST LINING
32220
3
RELEASE OF LUNG
32225
3
PARTIAL RELEASE OF LUNG
3230F
9
NOTE HRING TST W/IN 6 MON
32310
3
REMOVAL OF CHEST LINING
32315
O
PLEURECTOMY; PARTIAL
32320
3
FREE/REMOVE CHEST LINING
32400
3
NEEDLE BIOPSY CHEST LINING
$145.52
32402
3
OPEN BIOPSY CHEST LINING
$528.92
32405
3
BIOPSY, LUNG OR MEDIASTINUM
32420
3
PUNCTURE/CLEAR LUNG
$108.88
32421
3
THORACENTESIS FOR ASPIRATION
$151.96
32422
3
THORACENTESIS W/TUBE INSERT
$191.31
32440
3
REMOVAL OF LUNG
$1,500.02
32442
3
SLEEVE PNEUMONECTOMY
$2,779.09
32445
3
REMOVAL OF LUNG
$3,159.30
32450
O
PNEUMONECTOMY, EXTRAPLEURAL WITH EM
32480
3
PARTIAL REMOVAL OF LUNG
$1,415.56
32482
3
BILOBECTOMY
$1,510.12
32484
3
SEGMENTECTOMY
$1,364.75
32485
O
REMOVAL OF LUNG, OTHER THAN TOTAL P
32486
3
SLEEVE LOBECTOMY
$2,173.89
32488
3
COMPLETION PNEUMONECTOMY
$2,203.35
32490
O
LOBECTOMY, TOTAL OR SEGMENTAL WITH
32491
3
LUNG VOLUME REDUCTION
$1,406.70
32500
3
PARTIAL REMOVAL OF LUNG
$1,369.19
32501
3
REPAIR BRONCHUS ADD-ON
$238.27
32503
3
RESECT APICAL LUNG TUMOR
$1,727.34
32504
3
RESECT APICAL LUNG TUM/CHEST
$1,983.90
$1,045.13 $889.23 $0.00 $750.25 $1,498.45 $931.87 $0.00 $859.92 $0.00 $1,500.54
$98.96
$0.00
$0.00
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
3250F
9
NONPRIM LOC ANAT BX SITE TUM
$0.00
32520
O
REMOVE LUNG & REVISE CHEST
$0.00
32522
O
REMOVE LUNG & REVISE CHEST
$0.00
32525
O
REMOVE LUNG & REVISE CHEST
$0.00
32540
3
REMOVAL OF LUNG LESION
32545
O
EXTRAPLEURAL ENUCLEATION OF EMPYEMA
32550
3
INSERT PLEURAL CATH
$755.79
32551
3
INSERTION OF CHEST TUBE
$169.65
32560
3
TREAT LUNG LINING CHEMICALLY
$281.94
32601
3
THORACOSCOPY, DIAGNOSTIC
$297.11
32602
3
THORACOSCOPY, DIAGNOSTIC
$322.19
32603
3
THORACOSCOPY, DIAGNOSTIC
$417.32
32604
3
THORACOSCOPY, DIAGNOSTIC
$468.68
32605
3
THORACOSCOPY, DIAGNOSTIC
$369.96
32606
3
THORACOSCOPY, DIAGNOSTIC
$447.72
3260F
9
PT CAT/PN CAT/HIST GRD DOCÏD
32650
3
THORACOSCOPY, SURGICAL
$637.52
32651
3
THORACOSCOPY, SURGICAL
$1,004.00
32652
3
THORACOSCOPY, SURGICAL
$1,523.55
32653
3
THORACOSCOPY, SURGICAL
$973.07
32654
3
THORACOSCOPY, SURGICAL
$1,074.84
32655
3
THORACOSCOPY, SURGICAL
$888.90
32656
3
THORACOSCOPY, SURGICAL
$762.73
32657
3
THORACOSCOPY, SURGICAL
$752.60
32658
3
THORACOSCOPY, SURGICAL
$688.11
32659
3
THORACOSCOPY, SURGICAL
$699.24
3265F
9
RNA TSTNG HEPC VIR ORD/DOCÏD
32660
3
THORACOSCOPY, SURGICAL
$985.38
32661
3
THORACOSCOPY, SURGICAL
$768.14
32662
3
THORACOSCOPY, SURGICAL
$859.73
32663
3
THORACOSCOPY, SURGICAL
$1,321.27
32664
3
THORACOSCOPY, SURGICAL
$816.49
32665
3
THORACOSCOPY, SURGICAL
$1,143.60
3266F
9
HEPC GN TSTNG DOCÏD B/4TXMNT
$0.00
3268F
9
PSA/T/G1SC DOCÏD B/4 TXMNT
$0.00
$1,568.58 $0.00
$0.00
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
3269F
9
BONE SCN B/4 TXMNT/AFTR DX
$0.00
32700
O
THORACOSCOPY, EXPLORATORY (SEPARATE
$0.00
32705
O
THORACOSCOPY, EXPLORATORY (SEPARATE
$0.00
3270F
9
NO BONE SCN B/4 TXMNT/AFTRDX
$0.00
3271F
9
LOW RISK, PROSTATE CANCER
$0.00
3272F
9
MED. RISK, PROSTATE CANCER
$0.00
3273F
9
HIGH RISK, PROSTATE CANCER
$0.00
3274F
9
PROST CNCR RSK NOT LW/MD/HGH
$0.00
3278F
9
SERUM LVLS CA/IPTH/LPD ORD
$0.00
3279F
9
HGB LVL >/=13 G/DL
$0.00
32800
3
REPAIR LUNG HERNIA
3280F
9
HGB LVL 11-12.9 G/DL
32810
3
CLOSE CHEST AFTER DRAINAGE
32815
3
CLOSE BRONCHIAL FISTULA
3281F
9
HGB LVL <11 G/DL
32820
3
RECONSTRUCT INJURED CHEST
3284F
9
IOP DOWN >15% OF PRE-SVC LVL
$0.00
32850
9
DONOR PNEUMONECTOMY
$0.00
32851
3
LUNG TRANSPLANT, SINGLE
$2,451.44
32852
3
LUNG TRANSPLANT WITH BYPASS
$2,715.09
32853
3
LUNG TRANSPLANT, DOUBLE
$2,926.86
32854
3
LUNG TRANSPLANT WITH BYPASS
$3,189.02
32855
9
PREPARE DONOR LUNG, SINGLE
$0.00
32856
9
PREPARE DONOR LUNG, DOUBLE
$0.00
3285F
9
IOP DOWN <15% OF PRE-SVC LVL
$0.00
3288F
9
FALL RISK ASSESSMENT DOCÏD
$0.00
32900
3
REMOVAL OF RIB(S)
$1,289.30
32905
3
REVISE & REPAIR CHEST WALL
$1,271.91
32906
3
REVISE & REPAIR CHEST WALL
$1,578.79
3290F
9
PT=D(RH)- AND UNSENSITIZED
$0.00
3291F
9
PT=D(RH)+OR SENSITIZED
$0.00
3292F
9
HIV TSTNG ASKED/DOCÏD/REVWÏD
$0.00
32940
3
REVISION OF LUNG
32960
3
THERAPEUTIC PNEUMOTHORAX
$132.44
32997
3
TOTAL LUNG LAVAGE
$343.17
$877.63 $0.00 $849.64 $2,505.54 $0.00 $1,265.62
$1,165.45
Procedure Code Pricing Action Code Description
Maximum Allowable
32998
3
PERQ RF ABLATE TX, PUL TUMOR
$2,733.40
32999
5
CHEST SURGERY PROCEDURE
$0.00
3300F
9
AJCC STAGE DOCD B/4 THXPY
$0.00
33010
3
DRAINAGE OF HEART SAC
$120.37
33011
3
REPEAT DRAINAGE OF HEART SAC
$117.65
33015
3
INCISION OF HEART SAC
$512.75
3301F
9
CANCER STAGE DOCD METAST
33020
3
INCISION OF HEART SAC
$825.53
33025
3
INCISION OF HEART SAC
$762.21
3302F
O
AJCC STAGE 0 DOCÏD
33030
3
PARTIAL REMOVAL OF HEART SAC
$1,219.15
33031
3
PARTIAL REMOVAL OF HEART SAC
$1,360.49
3303F
O
AJCC STAGE IA DOCÏD
$0.00
3304F
O
AJCC STAGE IB DOCÏD
$0.00
33050
3
REMOVAL OF HEART SAC LESION
3305F
O
AJCC STAGE IC DOCÏD
$0.00
3306F
O
AJCC STAGE IIA DOCÏD
$0.00
3307F
O
AJCC STAGE IIB DOCÏD
$0.00
3308F
O
AJCC STAGE IIC DOCÏD
$0.00
3309F
O
AJCC STAGE IIIA DOCÏD
$0.00
33100
O
PERICARDIECTOMY (SEPARATE PROCEDURE
$0.00
3310F
O
AJCC STAGE IIIB DOCÏD
$0.00
3311F
O
AJCC STAGE IIIC DOCÏD
$0.00
33120
3
REMOVAL OF HEART LESION
3312F
O
AJCC STAGE IVA DOCÏD
33130
3
REMOVAL OF HEART LESION
3313F
O
AJCC STAGE IVB DOCÏD
33140
3
HEART REVASCULARIZE (TMR)
33141
3
HEART TMR W/OTHER PROCEDURE
3314F
O
AJCC STAGE IVC DOCÏD
$0.00
3315F
9
ER +OR PR +BREAST CANCER
$0.00
3316F
9
ER- OR PR- BREAST CANCER
$0.00
3317F
9
PATH RPT MALIG CANCER DOCÏD
$0.00
3318F
9
PATH RPT MALIG CANCER DOCÏD
$0.00
3319F
9
X-RAY/CT/ULTRSND ET AL ORDÏD
$0.00
$0.00
$0.00
$943.12
$1,488.23 $0.00 $1,310.86 $0.00 $1,494.68 $145.38
Procedure Code Pricing Action Code Description
Maximum Allowable
33200
O
INSERTION OF HEART PACEMAKER
$0.00
33201
O
INSERTION OF HEART PACEMAKER
$0.00
33202
3
INSERT EPICARD ELTRD, OPEN
$744.17
33203
3
INSERT EPICARD ELTRD, ENDO
$784.72
33206
3
INSERTION OF HEART PACEMAKER
$457.42
33207
3
INSERTION OF HEART PACEMAKER
$489.30
33208
3
INSERTION OF HEART PACEMAKER
$527.25
3320F
9
NO XRAY/CT/ ET AL ORDÏD
33210
3
INSERTION OF HEART ELECTRODE
$180.65
33211
3
INSERTION OF HEART ELECTRODE
$181.26
33212
3
INSERTION OF PULSE GENERATOR
$341.78
33213
3
INSERTION OF PULSE GENERATOR
$390.00
33214
3
UPGRADE OF PACEMAKER SYSTEM
$483.79
33215
3
REPOSITION PACING-DEFIB LEAD
$309.31
33216
3
INSERT LEAD PACE-DEFIB, ONE
$381.50
33217
3
INSERT LEAD PACE-DEFIB, DUAL
$378.19
33218
3
REPAIR LEAD PACE-DEFIB, ONE
$394.49
33219
O
REPAIR OF PACEMAKER WITH REPLACEMEN
$0.00
3321F
9
AJCC CNCR 0/IA MELAN DOCD
$0.00
33220
3
REPAIR LEAD PACE-DEFIB, DUAL
$398.09
33222
3
REVISE POCKET, PACEMAKER
$347.69
33223
3
REVISE POCKET, PACING-DEFIB
$420.16
33224
3
INSERT PACING LEAD & CONNECT
$510.85
33225
3
L VENTRIC PACING LEAD ADD-ON
$460.40
33226
3
REPOSITION L VENTRIC LEAD
$493.64
3322F
9
MELAN >AJCC STAGE 0 OR IA
$0.00
33232
O
REMOVAL OF PERMANENT PACEMAKER
$0.00
33233
3
REMOVAL OF PACEMAKER SYSTEM
$243.69
33234
3
REMOVAL OF PACEMAKER SYSTEM
$491.36
33235
3
REMOVAL PACEMAKER ELECTRODE
$635.57
33236
3
REMOVE ELECTRODE/THORACOTOMY
$747.65
33237
3
REMOVE ELECTRODE/THORACOTOMY
$826.70
33238
3
REMOVE ELECTRODE/THORACOTOMY
$890.80
33240
3
INSERT PULSE GENERATOR
$469.58
33241
3
REMOVE PULSE GENERATOR
$230.24
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
33242
O
REPAIR PULSE GENERATOR/LEADS
$0.00
33243
3
REMOVE ELTRD/THORACOTOMY
33244
3
REMOVE ELTRD, TRANSVEN
33245
O
INSERT EPIC ELTRD PACE-DEFIB
$0.00
33246
O
INSERT EPIC ELTRD/GENERATOR
$0.00
33247
O
INSERT/REPLACE LEADS
$0.00
33248
O
REVISION OR REMOVAL OF AUTOMATIC IM
$0.00
33249
3
ELTRD/INSERT PACE-DEFIB
33250
3
ABLATE HEART DYSRHYTHM FOCUS
$1,400.28
33251
3
ABLATE HEART DYSRHYTHM FOCUS
$1,551.30
33253
O
RECONSTRUCT ATRIA
33254
3
ABLATE ATRIA, LMTD
$1,306.65
33255
3
ABLATE ATRIA W/O BYPASS, EXT
$1,598.51
33256
3
ABLATE ATRIA W/BYPASS, EXTEN
$1,905.68
33257
3
ABLATE ATRIA, LMTD, ADD-ON
$552.15
33258
3
ABLATE ATRIA, X10SV, ADD-ON
$623.28
33259
3
ABLATE ATRIA W/BYPASS ADD-ON
$813.39
3325F
9
PREOP ASSES 4 CATARACT SURG
$0.00
33260
O
OPERATIVE ABLATION OF ARRHYTHMOGENI
$0.00
33261
3
ABLATE HEART DYSRHYTHM FOCUS
$1,543.51
33265
3
ABLATE ATRIA, LMTD, ENDO
$1,303.69
33266
3
ABLATE ATRIA, X10SV, ENDO
$1,787.93
33282
3
IMPLANT PAT-ACTIVE HT RECORD
$326.89
33284
3
REMOVE PAT-ACTIVE HT RECORD
$236.21
33300
3
REPAIR OF HEART WOUND
$2,207.25
33305
3
REPAIR OF HEART WOUND
$3,680.75
3330F
9
IMAGING STUDY ORDERED (BKP)
$0.00
33310
3
EXPLORATORY HEART SURGERY
$1,117.35
33315
3
EXPLORATORY HEART SURGERY
$1,420.23
3331F
9
BK IMAGING TST NOT ORDERED
33320
3
REPAIR MAJOR BLOOD VESSEL(S)
$1,013.03
33321
3
REPAIR MAJOR VESSEL
$1,142.16
33322
3
REPAIR MAJOR BLOOD VESSEL(S)
$1,326.19
33330
3
INSERT MAJOR VESSEL GRAFT
$1,337.46
33332
3
INSERT MAJOR VESSEL GRAFT
$1,337.08
$1,309.43 $863.22
$913.06
$0.00
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
33335
3
INSERT MAJOR VESSEL GRAFT
$1,804.33
33350
O
GREAT VESSEL REPAIR WITH OTHER MAJO
33400
3
REPAIR OF AORTIC VALVE
$2,173.52
33401
3
VALVULOPLASTY, OPEN
$1,441.40
33403
3
VALVULOPLASTY, W/CP BYPASS
$1,447.11
33404
3
PREPARE HEART-AORTA CONDUIT
$1,712.54
33405
3
REPLACEMENT OF AORTIC VALVE
$2,218.88
33406
3
REPLACEMENT OF AORTIC VALVE
$2,736.02
33407
O
VALVOTOMY, AORTIC VALVE (COMMISSURO
$0.00
33408
O
VALVOTOMY, AORTIC VALVE (COMMISSURO
$0.00
3340F
9
MAMMO ASSESS INC XRAY DOCD
$0.00
33410
3
REPLACEMENT OF AORTIC VALVE
$2,414.64
33411
3
REPLACEMENT OF AORTIC VALVE
$3,151.03
33412
3
REPLACEMENT OF AORTIC VALVE
$2,395.63
33413
3
REPLACEMENT OF AORTIC VALVE
$3,107.56
33414
3
REPAIR OF AORTIC VALVE
$2,078.06
33415
3
REVISION, SUBVALVULAR TISSUE
$1,924.68
33416
3
REVISE VENTRICLE MUSCLE
$1,934.82
33417
3
REPAIR OF AORTIC VALVE
$1,615.32
3341F
9
MAMMO ASSESS NEGATIVE DOCD
33420
3
REVISION OF MITRAL VALVE
$1,308.44
33422
3
REVISION OF MITRAL VALVE
$1,621.30
33425
3
REPAIR OF MITRAL VALVE
$2,522.20
33426
3
REPAIR OF MITRAL VALVE
$2,291.35
33427
3
REPAIR OF MITRAL VALVE
$2,390.98
3342F
9
MAMMO ASSESS BENGN DOCD
33430
3
REPLACEMENT OF MITRAL VALVE
$2,649.64
3343F
9
MAMMO PROBABLY BENGN DOCD
$0.00
3344F
9
MAMMO ASSESS SUSP, DOCD
$0.00
33452
O
VALVOTOMY, TRICUSPID VALVE, WITH CA
$0.00
3345F
9
MAMMO ASSESS HGHLYMALIG DOC
$0.00
33460
3
REVISION OF TRICUSPID VALVE
$2,243.90
33463
3
VALVULOPLASTY, TRICUSPID
$2,834.69
33464
3
VALVULOPLASTY, TRICUSPID
$2,285.23
33465
3
REPLACE TRICUSPID VALVE
$2,556.65
$0.00
$0.00
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
33468
3
REVISION OF TRICUSPID VALVE
$1,807.15
33470
3
REVISION OF PULMONARY VALVE
$1,141.46
33471
3
VALVOTOMY, PULMONARY VALVE
$1,273.04
33472
3
REVISION OF PULMONARY VALVE
$1,285.66
33474
3
REVISION OF PULMONARY VALVE
$1,967.72
33475
3
REPLACEMENT, PULMONARY VALVE
$2,218.68
33476
3
REVISION OF HEART CHAMBER
$1,405.46
33478
3
REVISION OF HEART CHAMBER
$1,512.32
33480
O
REPLACEMENT AND/OR REPAIR, DOUBLE V
$0.00
33481
O
SINGLE VALVE REPLACEMENT WITH COMMI
$0.00
33482
O
SINGLE VALVE REPLACEMENT WITH COMMI
$0.00
33483
O
DOUBLE VALVE REPLACEMENT
$0.00
33485
O
DOUBLE VALVE REPLACEMENT WITH COMMI
$0.00
33490
O
REPLACEMENT AND/OR REPAIR, TRIPLE V
$0.00
33492
O
TRIPLE VALVE REPLACEMENT
$0.00
33496
3
REPAIR, PROSTH VALVE CLOT
$1,616.85
33500
3
REPAIR HEART VESSEL FISTULA
$1,517.21
33501
3
REPAIR HEART VESSEL FISTULA
$1,053.23
33502
3
CORONARY ARTERY CORRECTION
$1,217.79
33503
3
CORONARY ARTERY GRAFT
$1,307.97
33504
3
CORONARY ARTERY GRAFT
$1,389.42
33505
3
REPAIR ARTERY W/TUNNEL
$1,906.10
33506
3
REPAIR ARTERY, TRANSLOCATION
$1,977.80
33507
3
REPAIR ART, INTRAMURAL
$1,674.15
33508
3
ENDOSCOPIC VEIN HARVEST
3350F
9
MAMMO BX PROVEN MALIG DOCD
33510
3
CABG, VEIN, SINGLE
$1,887.44
33511
3
CABG, VEIN, TWO
$2,059.76
33512
3
CABG, VEIN, THREE
$2,318.80
33513
3
CABG, VEIN, FOUR
$2,367.58
33514
3
CABG, VEIN, FIVE
$2,509.48
33516
3
CABG, VEIN, SIX OR MORE
$2,609.56
33517
3
CABG, ARTERY-VEIN, SINGLE
$179.02
33518
3
CABG, ARTERY-VEIN, TWO
$387.37
33519
3
CABG, ARTERY-VEIN, THREE
$516.97
$15.73 $0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
3351F
9
NEG SCRN DEP SYMP BY DEPTOOL
$0.00
33520
O
CORONARY ARTERY BYPASS, NONAUTOGENO
$0.00
33521
3
CABG, ARTERY-VEIN, FOUR
$625.80
33522
3
CABG, ARTERY-VEIN, FIVE
$712.09
33523
3
CABG, ART-VEIN, SIX OR MORE
$812.72
33525
O
CORONARY ARTERY BYPASS, NONAUTOGENO
$0.00
33528
O
CORONARY ARTERY BYPASS, NONAUTOGENO
$0.00
3352F
9
NO SIG DEP SYMP BY DEP TOOL
$0.00
33530
3
CORONARY ARTERY, BYPASS/REOP
33533
3
CABG, ARTERIAL, SINGLE
$1,838.58
33534
3
CABG, ARTERIAL, TWO
$2,136.77
33535
3
CABG, ARTERIAL, THREE
$2,371.58
33536
3
CABG, ARTERIAL, FOUR OR MORE
$2,539.90
3353F
9
MILD-MOD DEP SYMP BY DEPTOOL
33542
3
REMOVAL OF HEART LESION
$2,444.91
33545
3
REPAIR OF HEART DAMAGE
$2,884.20
33548
3
RESTORE/REMODEL, VENTRICLE
$2,833.80
3354F
9
CLIN SIG DEP SYM BY DEP TOOL
$0.00
33570
O
CORONARY ANGIOPLASTY (ENDARTERECTOM
$0.00
33572
3
OPEN CORONARY ENDARTERECTOMY
33575
O
CORONARY ANGIOPLASTY (ENDARTERECTOM
33600
3
CLOSURE OF VALVE
$1,645.44
33602
3
CLOSURE OF VALVE
$1,566.82
33606
3
ANASTOMOSIS/ARTERY-AORTA
$1,707.65
33608
3
REPAIR ANOMALY W/CONDUIT
$1,754.32
33610
3
REPAIR BY ENLARGEMENT
$1,711.04
33611
3
REPAIR DOUBLE VENTRICLE
$1,878.69
33612
3
REPAIR DOUBLE VENTRICLE
$1,939.67
33615
3
REPAIR, MODIFIED FONTAN
$1,935.57
33617
3
REPAIR SINGLE VENTRICLE
$2,074.27
33619
3
REPAIR SINGLE VENTRICLE
$2,539.95
33641
3
REPAIR HEART SEPTUM DEFECT
$1,543.78
33645
3
REVISION OF HEART VEINS
$1,522.49
33647
3
REPAIR HEART SEPTUM DEFECTS
$1,621.16
33649
O
REPAIR OF TRICUSPID ATRESIA (EG, FO
$492.51
$0.00
$227.48 $0.00
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
33660
3
REPAIR OF HEART DEFECTS
$1,695.05
33665
3
REPAIR OF HEART DEFECTS
$1,834.11
33670
3
REPAIR OF HEART CHAMBERS
$1,905.86
33675
3
CLOSE MULT VSD
$1,903.21
33676
3
CLOSE MULT VSD W/RESECTION
$1,981.75
33677
3
CL MULT VSD W/REM PUL BAND
$2,059.58
33681
3
REPAIR HEART SEPTUM DEFECT
$1,762.73
33684
3
REPAIR HEART SEPTUM DEFECT
$1,796.80
33688
3
REPAIR HEART SEPTUM DEFECT
$1,802.56
33690
3
REINFORCE PULMONARY ARTERY
$1,111.39
33692
3
REPAIR OF HEART DEFECTS
$1,699.89
33694
3
REPAIR OF HEART DEFECTS
$1,914.18
33696
O
COMPLETE REPAIR TETRALOGY OF FALLOT
33697
3
REPAIR OF HEART DEFECTS
33698
O
COMPLETE REPAIR TETRALOGY OF FALLOT
33702
3
REPAIR OF HEART DEFECTS
3370F
9
AJCC BRST CNCR STAGE 0 DOCD
33710
3
REPAIR OF HEART DEFECTS
$1,791.93
33720
3
REPAIR OF HEART DEFECT
$1,495.53
33722
3
REPAIR OF HEART DEFECT
$1,485.90
33724
3
REPAIR VENOUS ANOMALY
$1,517.70
33726
3
REPAIR PUL VENOUS STENOSIS
$1,980.21
3372F
9
AJCC BRST CNCR STAGE 1 +DOCD
33730
3
REPAIR HEART-VEIN DEFECT(S)
$1,884.99
33732
3
REPAIR HEART-VEIN DEFECT
$1,577.25
33735
3
REVISION OF HEART CHAMBER
$1,201.82
33736
3
REVISION OF HEART CHAMBER
$1,340.37
33737
3
REVISION OF HEART CHAMBER
$1,250.33
33738
O
ATRIAL SEPTECTOMY OR SEPTOSTOMY TRA
$0.00
33739
O
ATRIAL SEPTECTOMY OR SEPTOSTOMY BLA
$0.00
3374F
9
AJCC BRST CNCR STAGE 1 +DOCD
$0.00
33750
3
MAJOR VESSEL SHUNT
$1,262.34
33755
3
MAJOR VESSEL SHUNT
$1,242.32
33762
3
MAJOR VESSEL SHUNT
$1,240.18
33764
3
MAJOR VESSEL SHUNT & GRAFT
$1,221.17
$0.00 $2,065.09 $0.00 $1,475.09 $0.00
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
33766
3
MAJOR VESSEL SHUNT
$1,347.78
33767
3
MAJOR VESSEL SHUNT
$1,359.24
33768
3
CAVOPULMONARY SHUNTING
3376F
9
AJCC BRSTCNCR STAGE 2 DOCD
33770
3
REPAIR GREAT VESSELS DEFECT
$2,064.65
33771
3
REPAIR GREAT VESSELS DEFECT
$2,114.89
33774
3
REPAIR GREAT VESSELS DEFECT
$1,744.39
33775
3
REPAIR GREAT VESSELS DEFECT
$1,814.76
33776
3
REPAIR GREAT VESSELS DEFECT
$1,909.71
33777
3
REPAIR GREAT VESSELS DEFECT
$1,869.72
33778
3
REPAIR GREAT VESSELS DEFECT
$2,295.27
33779
3
REPAIR GREAT VESSELS DEFECT
$2,199.00
33780
3
REPAIR GREAT VESSELS DEFECT
$2,288.07
33781
3
REPAIR GREAT VESSELS DEFECT
$2,246.94
33786
3
REPAIR ARTERIAL TRUNK
$2,211.41
33788
3
REVISION OF PULMONARY ARTERY
$1,495.12
3378F
9
AJCC BRSTCNCR STAGE 3 DOCD
33800
3
AORTIC SUSPENSION
33802
3
REPAIR VESSEL DEFECT
$1,009.35
33803
3
REPAIR VESSEL DEFECT
$1,096.52
3380F
9
AJCC BRSTCNCR STAGE 4 DOCD
33813
3
REPAIR SEPTAL DEFECT
$1,248.46
33814
3
REPAIR SEPTAL DEFECT
$1,467.45
33820
3
REVISE MAJOR VESSEL
$940.45
33822
3
REVISE MAJOR VESSEL
$998.49
33824
3
REVISE MAJOR VESSEL
$1,128.75
3382F
9
AJCC CLN CNCR STAGE 0 DOCD
$0.00
33830
O
PATENT DUCTUS ARTERIOSUS LIGATION O
$0.00
33840
3
REMOVE AORTA CONSTRICTION
$1,139.47
33845
3
REMOVE AORTA CONSTRICTION
$1,318.59
3384F
9
AJCC CLN CNCR STAGE 1 DOCD
$0.00
33851
3
REMOVE AORTA CONSTRICTION
$1,209.70
33852
3
REPAIR SEPTAL DEFECT
$1,313.87
33853
3
REPAIR SEPTAL DEFECT
$1,813.85
33855
O
EXCISION OF COARCTATION OF AORTA, W
$413.47 $0.00
$0.00 $937.52
$0.00
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
33860
3
ASCENDING AORTIC GRAFT
$3,017.52
33861
3
ASCENDING AORTIC GRAFT
$2,354.27
33863
3
ASCENDING AORTIC GRAFT
$3,015.63
33864
3
ASCENDING AORTIC GRAFT
$3,100.20
33865
O
ASCENDING AORTA GRAFT, WITH CARDIOP
$0.00
3386F
9
AJCC CLN CNCR STAGE 2 DOCD
$0.00
33870
3
TRANSVERSE AORTIC ARCH GRAFT
$2,457.25
33875
3
THORACIC AORTIC GRAFT
$1,907.19
33877
3
THORACOABDOMINAL GRAFT
$3,381.99
33880
3
ENDOVASC TAA REPR INCL SUBCL
$1,753.49
33881
3
ENDOVASC TAA REPR W/O SUBCL
$1,505.60
33883
3
INSERT ENDOVASC PROSTH, TAA
$1,100.46
33884
3
ENDOVASC PROSTH, TAA, ADD-ON
$401.25
33886
3
ENDOVASC PROSTH, DELAYED
$945.53
33889
3
ARTERY TRANSPOSE/ENDOVAS TAA
$787.87
3388F
9
AJCC CLN CNCR STAGE 3 DOCD
33891
3
CAR-CAR BP GRFT/ENDOVAS TAA
3390F
9
AJCC CLN CNCR STAGE 4 DOCD
$0.00
33910
3
REMOVE LUNG ARTERY EMBOLI
$1,597.09
33915
3
REMOVE LUNG ARTERY EMBOLI
$1,275.60
33916
3
SURGERY OF GREAT VESSEL
$1,602.40
33917
3
REPAIR PULMONARY ARTERY
$1,451.01
33918
O
REPAIR PULMONARY ATRESIA
$0.00
33919
O
REPAIR PULMONARY ATRESIA
$0.00
33920
3
REPAIR PULMONARY ATRESIA
$1,747.21
33922
3
TRANSECT PULMONARY ARTERY
$1,322.95
33924
3
REMOVE PULMONARY SHUNT
33925
3
RPR PUL ART UNIFOCAL W/O CPB
$1,701.13
33926
3
REPR PUL ART, UNIFOCAL W/CPB
$2,256.60
33930
9
REMOVAL OF DONOR HEART/LUNG
$0.00
33933
9
PREPARE DONOR HEART/LUNG
$0.00
33935
3
TRANSPLANTATION, HEART/LUNG
33940
9
REMOVAL OF DONOR HEART
$0.00
33944
9
PREPARE DONOR HEART
$0.00
33945
3
TRANSPLANTATION OF HEART
$0.00 $985.29
$278.68
$3,346.95
$4,441.23
Procedure Code Pricing Action Code Description
Maximum Allowable
33960
3
EXTERNAL CIRCULATION ASSIST
$968.04
33961
3
EXTERNAL CIRCULATION ASSIST
$539.61
33967
3
INSERT IA PERCUT DEVICE
$266.75
33968
3
REMOVE AORTIC ASSIST DEVICE
33970
3
AORTIC CIRCULATION ASSIST
$357.37
33971
3
AORTIC CIRCULATION ASSIST
$688.83
33972
O
INTRA-AORTIC BALLOON COUNTERPULSATI
33973
3
INSERT BALLOON DEVICE
$520.94
33974
3
REMOVE INTRA-AORTIC BALLOON
$878.00
33975
3
IMPLANT VENTRICULAR DEVICE
$1,075.80
33976
3
IMPLANT VENTRICULAR DEVICE
$1,196.18
33977
3
REMOVE VENTRICULAR DEVICE
$1,162.00
33978
3
REMOVE VENTRICULAR DEVICE
$1,278.55
33979
3
INSERT INTRACORPOREAL DEVICE
$2,359.16
33980
3
REMOVE INTRACORPOREAL DEVICE
$3,473.72
33999
5
CARDIAC SURGERY PROCEDURE
34001
3
REMOVAL OF ARTERY CLOT
$932.57
34051
3
REMOVAL OF ARTERY CLOT
$936.72
34101
3
REMOVAL OF ARTERY CLOT
$594.53
34111
3
REMOVAL OF ARM ARTERY CLOT
$594.29
34151
3
REMOVAL OF ARTERY CLOT
$1,373.62
34201
3
REMOVAL OF ARTERY CLOT
$967.22
34203
3
REMOVAL OF LEG ARTERY CLOT
$950.03
34401
3
REMOVAL OF VEIN CLOT
$1,418.42
34421
3
REMOVAL OF VEIN CLOT
$720.20
34451
3
REMOVAL OF VEIN CLOT
$1,483.59
34471
3
REMOVAL OF VEIN CLOT
$1,037.86
34490
3
REMOVAL OF VEIN CLOT
$597.88
34501
3
REPAIR VALVE, FEMORAL VEIN
$926.98
34502
3
RECONSTRUCT VENA CAVA
3450F
9
DYSPNEA SCRND, NO-MILD DYSP
34510
3
TRANSPOSITION OF VEIN VALVE
3451F
9
DYSPNEA SCRND MOD-HIGH DYSP
34520
3
CROSS-OVER VEIN GRAFT
$1,009.57
3452F
9
DYSPNEA NOT SCREENED
$0.00
$34.16
$0.00
$0.00
$1,499.20 $0.00 $1,051.37 $0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
34530
3
LEG VEIN FUSION
$949.54
3455F
9
TB SCRNG DONE-INTERPD 6MON
$0.00
3470F
9
RA DISEASE ACTIVITY, LOW
$0.00
3471F
9
RA DISEASE ACTIVITY, MOD
$0.00
3472F
9
RA DISEASE ACTIVITY, HIGH
$0.00
3475F
9
DISEASE PROGN RA POOR DOCD
$0.00
3476F
9
DISEASE PROGN RA GOOD DOCD
$0.00
34800
3
ENDOVAS AAA REPR W/SM TUBE
$1,129.34
34802
3
ENDOVAS AAA REPR W/2-P PART
$1,232.87
34803
3
ENDOVAS AAA REPR W/3-P PART
$1,260.90
34804
3
ENDOVAS AAA REPR W/1-P PART
$1,232.15
34805
3
ENDOVAS AAA REPR W/LONG TUBE
$1,156.71
34806
3
ANEURYSM PRESS SENSOR ADD-ON
$104.46
34808
3
ENDOVAS ILIAC A DEVICE ADDON
$205.36
34812
3
XPOSE FOR ENDOPROSTH, FEMORL
$339.74
34813
3
FEMORAL ENDOVAS GRAFT ADD-ON
$236.02
34820
3
XPOSE FOR ENDOPROSTH, ILIAC
$487.88
34825
3
ENDOVASC EXTEND PROSTH, INIT
$691.51
34826
3
ENDOVASC EXTEN PROSTH, ADDÏL
$203.99
34830
3
OPEN AORTIC TUBE PROSTH REPR
$1,802.15
34831
3
OPEN AORTOILIAC PROSTH REPR
$1,908.20
34832
3
OPEN AORTOFEMOR PROSTH REPR
$1,936.08
34833
3
XPOSE FOR ENDOPROSTH, ILIAC
$607.47
34834
3
XPOSE, ENDOPROSTH, BRACHIAL
$275.58
34900
3
ENDOVASC ILIAC REPR W/GRAFT
$897.11
3490F
9
HISTORY - AIDS-DEFINING COND
$0.00
3491F
9
HIV UNSURE BABY OF HIV+MOMS
$0.00
3492F
9
HISTORY CD4+CELL COUNT <350
$0.00
3493F
9
NO HIST CD4+CELL CNT <350
$0.00
3494F
9
CD4+CELL COUNT <200CELLS/MM3
$0.00
3495F
9
CD4+CELL CNT 200-499 CELLS
$0.00
3496F
9
CD4+ CELL COUNT >=500 CELLS
$0.00
3497F
9
CD4+ CELL PERCENTAGE <15%
$0.00
3498F
9
CD4+ CELL PERCENTAGE >=15%
$0.00
35001
3
REPAIR DEFECT OF ARTERY
$1,119.07
Procedure Code Pricing Action Code Description
Maximum Allowable
35002
3
REPAIR ARTERY RUPTURE, NECK
$1,181.02
35005
3
REPAIR DEFECT OF ARTERY
$1,028.37
3500F
9
CD4 +CELL CNT/% DOCD AS DONE
35011
3
REPAIR DEFECT OF ARTERY
35013
3
REPAIR ARTERY RUPTURE, ARM
$1,217.33
35021
3
REPAIR DEFECT OF ARTERY
$1,195.32
35022
3
REPAIR ARTERY RUPTURE, CHEST
$1,350.10
3502F
9
HIV RNA VRL LD
$0.00
3503F
9
HIV RNA VRL LDNOT
$0.00
35045
3
REPAIR DEFECT OF ARM ARTERY
35081
3
REPAIR DEFECT OF ARTERY
$1,708.53
35082
3
REPAIR ARTERY RUPTURE, AORTA
$2,145.55
35091
3
REPAIR DEFECT OF ARTERY
$1,806.74
35092
3
REPAIR ARTERY RUPTURE, AORTA
$2,561.30
35102
3
REPAIR DEFECT OF ARTERY
$1,853.25
35103
3
REPAIR ARTERY RUPTURE, GROIN
$2,216.73
3510F
9
DOC TB SCRNG-RSLTS INTERPD
35111
3
REPAIR DEFECT OF ARTERY
$1,366.95
35112
3
REPAIR ARTERY RUPTURE,SPLEEN
$1,674.39
3511F
9
CHLMYD/GONRH TSTS DOCD DONE
$0.00
35121
3
REPAIR DEFECT OF ARTERY
$1,622.15
35122
3
REPAIR ARTERY RUPTURE, BELLY
$1,941.93
3512F
9
SYPH SCRNG DOCD AS DONE
35131
3
REPAIR DEFECT OF ARTERY
$1,384.33
35132
3
REPAIR ARTERY RUPTURE, GROIN
$1,671.90
3513F
9
HEP B SCRNG DOCD AS DONE
35141
3
REPAIR DEFECT OF ARTERY
$1,098.15
35142
3
REPAIR ARTERY RUPTURE, THIGH
$1,313.60
3514F
9
HEP C SCRNG DOCD AS DONE
35151
3
REPAIR DEFECT OF ARTERY
$1,238.17
35152
3
REPAIR ARTERY RUPTURE, KNEE
$1,437.76
3515F
9
PT HAS DOCD IMMUN TO HEP C
$0.00
35161
O
REPAIR DEFECT OF ARTERY
$0.00
35162
O
REPAIR ARTERY RUPTURE
$0.00
35180
3
REPAIR BLOOD VESSEL LESION
$0.00 $981.35
$954.51
$0.00
$0.00
$0.00
$0.00
$825.41
Procedure Code Pricing Action Code Description
Maximum Allowable
35182
3
REPAIR BLOOD VESSEL LESION
$1,691.77
35184
3
REPAIR BLOOD VESSEL LESION
$996.50
35188
3
REPAIR BLOOD VESSEL LESION
$836.90
35189
3
REPAIR BLOOD VESSEL LESION
$1,559.45
35190
3
REPAIR BLOOD VESSEL LESION
$730.58
35201
3
REPAIR BLOOD VESSEL LESION
$916.27
35206
3
REPAIR BLOOD VESSEL LESION
$748.73
35207
3
REPAIR BLOOD VESSEL LESION
$680.50
35211
3
REPAIR BLOOD VESSEL LESION
$1,330.39
35216
3
REPAIR BLOOD VESSEL LESION
$1,848.46
35221
3
REPAIR BLOOD VESSEL LESION
$1,367.42
35226
3
REPAIR BLOOD VESSEL LESION
$826.68
35231
3
REPAIR BLOOD VESSEL LESION
$1,148.98
35236
3
REPAIR BLOOD VESSEL LESION
$957.36
35241
3
REPAIR BLOOD VESSEL LESION
$1,389.55
35246
3
REPAIR BLOOD VESSEL LESION
$1,509.91
35251
3
REPAIR BLOOD VESSEL LESION
$1,625.32
35256
3
REPAIR BLOOD VESSEL LESION
$1,006.34
35261
3
REPAIR BLOOD VESSEL LESION
$1,017.82
35266
3
REPAIR BLOOD VESSEL LESION
$843.47
35271
3
REPAIR BLOOD VESSEL LESION
$1,328.32
35276
3
REPAIR BLOOD VESSEL LESION
$1,394.24
35281
3
REPAIR BLOOD VESSEL LESION
$1,553.97
35286
3
REPAIR BLOOD VESSEL LESION
$923.99
35301
3
RECHANNELING OF ARTERY
$1,035.69
35302
3
RECHANNELING OF ARTERY
$1,100.63
35303
3
RECHANNELING OF ARTERY
$1,211.03
35304
3
RECHANNELING OF ARTERY
$1,259.23
35305
3
RECHANNELING OF ARTERY
$1,209.56
35306
3
RECHANNELING OF ARTERY
$451.75
35311
3
RECHANNELING OF ARTERY
$1,484.11
35321
3
RECHANNELING OF ARTERY
$880.87
35331
3
RECHANNELING OF ARTERY
$1,453.65
35341
3
RECHANNELING OF ARTERY
$1,367.82
35351
3
RECHANNELING OF ARTERY
$1,271.09
Procedure Code Pricing Action Code Description
Maximum Allowable
35355
3
RECHANNELING OF ARTERY
$1,032.56
35361
3
RECHANNELING OF ARTERY
$1,564.71
35363
3
RECHANNELING OF ARTERY
$1,705.05
35371
3
RECHANNELING OF ARTERY
$814.38
35372
3
RECHANNELING OF ARTERY
$976.99
35381
O
RECHANNELING OF ARTERY
$0.00
35390
3
REOPERATION, CAROTID ADD-ON
$159.40
35400
3
ANGIOSCOPY
$150.78
35450
3
REPAIR ARTERIAL BLOCKAGE
$510.72
35452
3
REPAIR ARTERIAL BLOCKAGE
$354.50
35454
3
REPAIR ARTERIAL BLOCKAGE
$311.00
35456
3
REPAIR ARTERIAL BLOCKAGE
$376.31
35458
3
REPAIR ARTERIAL BLOCKAGE
$482.83
35459
3
REPAIR ARTERIAL BLOCKAGE
$443.50
35460
3
REPAIR VENOUS BLOCKAGE
$308.20
35470
3
REPAIR ARTERIAL BLOCKAGE
$455.07
35471
3
REPAIR ARTERIAL BLOCKAGE
$544.51
35472
3
REPAIR ARTERIAL BLOCKAGE
$372.61
35473
3
REPAIR ARTERIAL BLOCKAGE
$321.98
35474
3
REPAIR ARTERIAL BLOCKAGE
$389.07
35475
3
REPAIR ARTERIAL BLOCKAGE
$486.72
35476
3
REPAIR VENOUS BLOCKAGE
$310.88
35480
3
ATHERECTOMY, OPEN
$553.82
35481
3
ATHERECTOMY, OPEN
$399.59
35482
3
ATHERECTOMY, OPEN
$349.55
35483
3
ATHERECTOMY, OPEN
$421.65
35484
3
ATHERECTOMY, OPEN
$524.79
35485
3
ATHERECTOMY, OPEN
$488.68
35490
3
ATHERECTOMY, PERCUTANEOUS
$607.81
35491
3
ATHERECTOMY, PERCUTANEOUS
$407.25
35492
3
ATHERECTOMY, PERCUTANEOUS
$369.95
35493
3
ATHERECTOMY, PERCUTANEOUS
$450.76
35494
3
ATHERECTOMY, PERCUTANEOUS
$571.34
35495
3
ATHERECTOMY, PERCUTANEOUS
$522.04
35500
3
HARVEST VEIN FOR BYPASS
$318.96
Procedure Code Pricing Action Code Description
Maximum Allowable
35501
3
ARTERY BYPASS GRAFT
$1,543.09
35506
3
ARTERY BYPASS GRAFT
$1,312.33
35507
O
ARTERY BYPASS GRAFT
$0.00
35508
3
ARTERY BYPASS GRAFT
$1,356.18
35509
3
ARTERY BYPASS GRAFT
$1,483.07
3550F
9
LOW RSK THROMBOEMBOLISM
35510
3
ARTERY BYPASS GRAFT
$1,243.76
35511
3
ARTERY BYPASS GRAFT
$1,170.73
35512
3
ARTERY BYPASS GRAFT
$1,212.21
35515
3
ARTERY BYPASS GRAFT
$1,307.39
35516
3
ARTERY BYPASS GRAFT
$1,196.76
35518
3
ARTERY BYPASS GRAFT
$1,191.53
3551F
9
INTRMED RSK THROMBOEMBOLISM
35521
3
ARTERY BYPASS GRAFT
$1,253.17
35522
3
ARTERY BYPASS GRAFT
$1,184.66
35523
3
ARTERY BYPASS GRAFT
$1,255.32
35525
3
ARTERY BYPASS GRAFT
$1,111.79
35526
3
ARTERY BYPASS GRAFT
$1,641.15
3552F
9
HGH RISK FOR THROMBOEMBOLISM
35531
3
ARTERY BYPASS GRAFT
$1,999.52
35533
3
ARTERY BYPASS GRAFT
$1,549.05
35535
3
ARTERY BYPASS GRAFT
$1,985.29
35536
3
ARTERY BYPASS GRAFT
$1,723.98
35537
3
ARTERY BYPASS GRAFT
$2,138.07
35538
3
ARTERY BYPASS GRAFT
$2,399.99
35539
3
ARTERY BYPASS GRAFT
$2,224.20
35540
3
ARTERY BYPASS GRAFT
$2,491.69
35541
O
ARTERY BYPASS GRAFT
$0.00
35546
O
ARTERY BYPASS GRAFT
$0.00
35548
3
ARTERY BYPASS GRAFT
$1,188.86
35549
3
ARTERY BYPASS GRAFT
$1,292.31
35551
3
ARTERY BYPASS GRAFT
$1,472.68
35556
3
ARTERY BYPASS GRAFT
$1,366.78
35558
3
ARTERY BYPASS GRAFT
$1,211.36
3555F
9
PT INR MEASUREMENT PERFORMED
$0.00
$0.00
$0.00
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
35560
3
ARTERY BYPASS GRAFT
$1,761.11
35563
3
ARTERY BYPASS GRAFT
$1,349.89
35565
3
ARTERY BYPASS GRAFT
$1,308.13
35566
3
ARTERY BYPASS GRAFT
$1,639.46
35570
3
ARTERY BYPASS GRAFT
$1,534.82
35571
3
ARTERY BYPASS GRAFT
$1,327.03
35572
3
HARVEST FEMOROPOPLITEAL VEIN
35582
O
VEIN BYPASS GRAFT
$0.00
35583
3
VEIN BYPASS GRAFT
$1,411.21
35585
3
VEIN BYPASS GRAFT
$1,652.53
35587
3
VEIN BYPASS GRAFT
$1,368.63
35600
3
HARVEST ART FOR CABG ADD-ON
35601
3
ARTERY BYPASS GRAFT
$1,425.91
35606
3
ARTERY BYPASS GRAFT
$1,160.22
35612
3
ARTERY BYPASS GRAFT
$909.69
35616
3
ARTERY BYPASS GRAFT
$1,110.19
35621
3
ARTERY BYPASS GRAFT
$1,096.26
35623
3
BYPASS GRAFT, NOT VEIN
$1,345.37
35626
3
ARTERY BYPASS GRAFT
$1,545.84
35631
3
ARTERY BYPASS GRAFT
$1,839.45
35632
3
ARTERY BYPASS GRAFT
$1,885.04
35633
3
ARTERY BYPASS GRAFT
$2,035.24
35634
3
ARTERY BYPASS GRAFT
$1,844.95
35636
3
ARTERY BYPASS GRAFT
$1,633.74
35637
3
BYPASS GRAFT, WITH OTHER THAN VEIN
$1,689.45
35638
3
BYPASS GRAFT, WITH OTHER THAN VEIN
$1,726.54
35641
O
ARTERY BYPASS GRAFT
$0.00
35642
3
ARTERY BYPASS GRAFT
$1,025.47
35645
3
ARTERY BYPASS GRAFT
$970.74
35646
3
ARTERY BYPASS GRAFT
$1,705.45
35647
3
ARTERY BYPASS GRAFT
$1,544.11
35650
3
ARTERY BYPASS GRAFT
$1,056.31
35651
3
ARTERY BYPASS GRAFT
$1,367.89
35654
3
ARTERY BYPASS GRAFT
$1,362.85
35656
3
ARTERY BYPASS GRAFT
$1,074.48
$345.82
$254.65
Procedure Code Pricing Action Code Description
Maximum Allowable
35661
3
ARTERY BYPASS GRAFT
$1,076.10
35663
3
ARTERY BYPASS GRAFT
$1,247.02
35665
3
ARTERY BYPASS GRAFT
$1,168.20
35666
3
ARTERY BYPASS GRAFT
$1,260.75
35671
3
ARTERY BYPASS GRAFT
$1,111.04
35681
3
COMPOSITE BYPASS GRAFT
$79.69
35682
3
COMPOSITE BYPASS GRAFT
$355.55
35683
3
COMPOSITE BYPASS GRAFT
$419.39
35685
3
BYPASS GRAFT PATENCY/PATCH
$199.68
35686
3
BYPASS GRAFT/AV FIST PATENCY
$167.22
35691
3
ARTERIAL TRANSPOSITION
$978.84
35693
3
ARTERIAL TRANSPOSITION
$869.40
35694
3
ARTERIAL TRANSPOSITION
$1,011.46
35695
3
ARTERIAL TRANSPOSITION
$1,053.60
35697
3
REIMPLANT ARTERY EACH
$148.82
35700
3
REOPERATION, BYPASS GRAFT
$153.14
35701
3
EXPLORATION, CAROTID ARTERY
$526.14
3570F
9
RPRT BONE SCINT X-REFW/X-RAY
$0.00
35721
3
EXPLORATION, FEMORAL ARTERY
$447.03
3572F
9
PT CONSID POSS RISK FX
$0.00
3573F
9
PT NOT CONSID POSS RISK FX
$0.00
35741
3
EXPLORATION POPLITEAL ARTERY
$489.05
35761
3
EXPLORATION OF ARTERY/VEIN
$362.35
35800
3
EXPLORE NECK VESSELS
$465.04
35820
3
EXPLORE CHEST VESSELS
35840
3
EXPLORE ABDOMINAL VESSELS
$606.87
35860
3
EXPLORE LIMB VESSELS
$393.03
35870
3
REPAIR VESSEL GRAFT DEFECT
35875
3
REMOVAL OF CLOT IN GRAFT
$584.81
35876
3
REMOVAL OF CLOT IN GRAFT
$935.08
35879
3
REVISE GRAFT W/VEIN
$915.39
35881
3
REVISE GRAFT W/VEIN
$1,017.68
35883
3
REVISE GRAFT W/NONAUTO GRAFT
$1,185.13
35884
3
REVISE GRAFT W/VEIN
$1,249.56
35900
O
EXCISION OF INFECTED GRAFT
$1,813.15
$1,266.44
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
35901
3
EXCISION, GRAFT, NECK
$492.05
35903
3
EXCISION, GRAFT, EXTREMITY
$556.30
35905
3
EXCISION, GRAFT, THORAX
$1,722.14
35907
3
EXCISION, GRAFT, ABDOMEN
$1,896.49
35910
O
EXCISION OF INFECTED GRAFT WITH REV
36000
3
PLACE NEEDLE IN VEIN
36002
3
PSEUDOANEURYSM INJECTION TRT
36005
3
INJECTION EXT VENOGRAPHY
36010
3
PLACE CATHETER IN VEIN
$122.69
36011
3
PLACE CATHETER IN VEIN
$158.60
36012
3
PLACE CATHETER IN VEIN
$854.83
36013
3
PLACE CATHETER IN ARTERY
$790.73
36014
3
PLACE CATHETER IN ARTERY
$824.53
36015
3
PLACE CATHETER IN ARTERY
$903.89
36100
3
ESTABLISH ACCESS TO ARTERY
$522.68
36120
3
ESTABLISH ACCESS TO ARTERY
$433.06
36140
3
ESTABLISH ACCESS TO ARTERY
$102.28
36145
3
ARTERY TO VEIN SHUNT
36160
3
ESTABLISH ACCESS TO AORTA
$526.25
36200
3
PLACE CATHETER IN AORTA
$155.51
36215
3
PLACE CATHETER IN ARTERY
$242.85
36216
3
PLACE CATHETER IN ARTERY
$273.75
36217
3
PLACE CATHETER IN ARTERY
$327.74
36218
3
PLACE CATHETER IN ARTERY
$52.19
36230
O
SELECTIVE CATHETER PLACEMENT, CORON
36245
3
PLACE CATHETER IN ARTERY
$250.47
36246
3
PLACE CATHETER IN ARTERY
$272.84
36247
3
PLACE CATHETER IN ARTERY
$324.76
36248
3
PLACE CATHETER IN ARTERY
$161.99
36260
3
INSERTION OF INFUSION PUMP
$558.54
36261
3
REVISION OF INFUSION PUMP
$341.17
36262
3
REMOVAL OF INFUSION PUMP
$260.07
36299
5
VESSEL INJECTION PROCEDURE
$0.00
36400
3
BL DRAW < 3 YRS FEM/JUGULAR
$24.65
36405
3
BL DRAW < 3 YRS SCALP VEIN
$22.52
$0.00 $24.42 $163.95 $48.82
$99.97
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
36406
3
BL DRAW < 3 YRS OTHER VEIN
$16.29
36410
3
NON-ROUTINE BL DRAW > 3 YRS
$18.13
36415
3
ROUTINE VENIPUNCTURE
$15.00
36416
9
CAPILLARY BLOOD DRAW
$0.00
36420
3
VEIN ACCESS CUTDOWN < 1 YR
$47.01
36425
3
VEIN ACCESS CUTDOWN > 1 YR
$37.10
36430
3
BLOOD TRANSFUSION SERVICE
$36.19
36440
3
BL PUSH TRANSFUSE, 2 YR OR <
$49.56
36450
3
BL EXCHANGE/TRANSFUSE, NB
$114.30
36455
3
BL EXCHANGE/TRANSFUSE NON-NB
$124.81
36460
3
TRANSFUSION SERVICE, FETAL
$325.05
36468
5
INJECTION(S), SPIDER VEINS
$0.00
36469
9
INJECTION(S), SPIDER VEINS
$0.00
36470
3
INJECTION THERAPY OF VEIN
$131.66
36471
3
INJECTION THERAPY OF VEINS
$161.92
36475
3
ENDOVENOUS RF, 1ST VEIN
$330.34
36476
3
ENDOVENOUS RF, VEIN ADD-ON
$161.33
36478
3
ENDOVENOUS LASER, 1ST VEIN
$333.66
36479
3
ENDOVENOUS LASER VEIN ADDON
$162.44
36481
3
INSERTION OF CATHETER, VEIN
$404.20
36488
O
INSERTION OF CATHETER, VEIN
$0.00
36489
O
INSERTION OF CATHETER, VEIN
$0.00
36490
O
INSERTION OF CATHETER, VEIN
$0.00
36491
O
INSERTION OF CATHETER, VEIN
$0.00
36493
O
REPOSITIONING OF CVC
$0.00
36495
O
INSERTION OF IMPLANTABLE INTRAVENOU
$0.00
36496
O
REVISION OF IMPLANTABLE INTRAVENOUS
$0.00
36497
O
REMOVAL OF IMPLANTABLE INTRAVENOUS
$0.00
36500
3
INSERTION OF CATHETER, VEIN
$179.02
36510
3
INSERTION OF CATHETER, VEIN
$105.31
36511
3
APHERESIS WBC
$87.01
36512
3
APHERESIS RBC
$88.49
36513
3
APHERESIS PLATELETS
$91.39
36514
3
APHERESIS PLASMA
36515
3
APHERESIS, ADSORP/REINFUSE
$504.43 $1,888.62
Procedure Code Pricing Action Code Description
Maximum Allowable
36516
3
APHERESIS, SELECTIVE
$2,139.19
36520
O
PLASMA AND/OR CELL EXCHANGE
$0.00
36521
O
APHERESIS W/ ADSORP/REINFUSE
$0.00
36522
3
PHOTOPHERESIS
36530
O
INSERTION OF INFUSION PUMP
$0.00
36531
O
REVISION OF INFUSION PUMP
$0.00
36532
O
REMOVAL OF INFUSION PUMP
$0.00
36533
O
INSERTION OF ACCESS DEVICE
$0.00
36534
O
REVISION OF ACCESS DEVICE
$0.00
36535
O
REMOVAL OF ACCESS DEVICE
$0.00
36536
O
REMOVE CVA DEVICE OBSTRUCT
$0.00
36537
O
REMOVE CVA LUMEN OBSTRUCT
$0.00
36540
O
COLLECT BLOOD VENOUS DEVICE
$0.00
36550
O
DECLOT VASCULAR DEVICE
$0.00
36555
3
INSERT NON-TUNNEL CV CATH
$264.40
36556
3
INSERT NON-TUNNEL CV CATH
$116.81
36557
3
INSERT TUNNELED CV CATH
$290.90
36558
3
INSERT TUNNELED CV CATH
$276.92
36560
3
INSERT TUNNELED CV CATH
$343.83
36561
3
INSERT TUNNELED CV CATH
$332.68
36563
3
INSERT TUNNELED CV CATH
$345.19
36565
3
INSERT TUNNELED CV CATH
$937.90
36566
3
INSERT TUNNELED CV CATH
$3,524.15
36568
3
INSERT PICC CATH
$94.90
36569
3
INSERT PICC CATH
$95.10
36570
3
INSERT PICVAD CATH
$1,142.45
36571
3
INSERT PICVAD CATH
$298.79
36575
3
REPAIR TUNNELED CV CATH
$156.65
36576
3
REPAIR TUNNELED CV CATH
$346.64
36578
3
REPLACE TUNNELED CV CATH
$486.38
36580
3
REPLACE CVAD CATH
36581
3
REPLACE TUNNELED CV CATH
$196.60
36582
3
REPLACE TUNNELED CV CATH
$1,027.76
36583
3
REPLACE TUNNELED CV CATH
$1,028.06
36584
3
REPLACE PICC CATH
$98.66
$68.37
$222.30
Procedure Code Pricing Action Code Description
Maximum Allowable
36585
3
REPLACE PICVAD CATH
$1,056.35
36589
3
REMOVAL TUNNELED CV CATH
$160.44
36590
3
REMOVAL TUNNELED CV CATH
$261.54
36591
3
DRAW BLOOD OFF VENOUS DEVICE
$22.42
36592
3
COLLECT BLOOD FROM PICC
$24.64
36593
3
DECLOT VASCULAR DEVICE
$35.11
36595
3
MECH REMOV TUNNELED CV CATH
$593.61
36596
3
MECH REMOV TUNNELED CV CATH
$133.37
36597
3
REPOSITION VENOUS CATHETER
$124.40
36598
3
INJ W/FLUOR, EVAL CV DEVICE
$112.31
36600
3
WITHDRAWAL OF ARTERIAL BLOOD
$29.66
36620
3
INSERTION CATHETER, ARTERY
$49.06
36625
3
INSERTION CATHETER, ARTERY
$102.33
36640
3
INSERTION CATHETER, ARTERY
$115.56
36660
3
INSERTION CATHETER, ARTERY
$64.85
36680
3
INSERT NEEDLE, BONE CAVITY
$57.35
36800
3
INSERTION OF CANNULA
$152.71
36810
3
INSERTION OF CANNULA
$202.94
36815
3
INSERTION OF CANNULA
$143.79
36818
3
AV FUSE, UPPR ARM, CEPHALIC
$653.89
36819
3
AV FUSE, UPPR ARM, BASILIC
$769.33
36820
3
AV FUSION/FOREARM VEIN
$772.04
36821
3
AV FUSION DIRECT ANY SITE
$641.66
36822
3
INSERTION OF CANNULA(S)
$363.34
36823
3
INSERTION OF CANNULA(S)
$1,228.91
36825
3
ARTERY-VEIN AUTOGRAFT
$558.28
36830
3
ARTERY-VEIN NONAUTOGRAFT
$637.18
36831
3
OPEN THROMBECT AV FISTULA
$440.64
36832
3
AV FISTULA REVISION, OPEN
$562.04
36833
3
AV FISTULA REVISION
$634.79
36834
3
REPAIR A-V ANEURYSM
$596.20
36835
3
ARTERY TO VEIN SHUNT
$442.42
36838
3
DIST REVAS LIGATION, HEMO
36840
O
INSERTION MANDRIL
$0.00
36845
O
ANASTOMOSIS MANDRIL
$0.00
$1,133.72
Procedure Code Pricing Action Code Description
Maximum Allowable
36860
3
EXTERNAL CANNULA DECLOTTING
$184.27
36861
3
CANNULA DECLOTTING
$145.70
36870
3
PERCUT THROMBECT AV FISTULA
$300.39
37140
3
REVISION OF CIRCULATION
$1,296.53
37145
3
REVISION OF CIRCULATION
$1,400.42
37160
3
REVISION OF CIRCULATION
$1,216.87
37180
3
REVISION OF CIRCULATION
$1,362.65
37181
3
SPLICE SPLEEN/KIDNEY VEINS
$1,473.11
37182
3
INSERT HEPATIC SHUNT (TIPS)
$882.15
37183
3
REMOVE HEPATIC SHUNT (TIPS)
$419.52
37184
3
PRIM ART MECH THROMBECTOMY
$2,370.47
37185
3
PRIM ART M-THROMBECT ADD-ON
$782.91
37186
3
SEC ART M-THROMBECT ADD-ON
$1,599.48
37187
3
VENOUS MECH THROMBECTOMY
$419.32
37188
3
VENOUS M-THROMBECTOMY ADD-ON
37190
O
PLASTIC REPAIR OF ARTERIOVENOUS ANE
37195
3
THROMBOLYTIC THERAPY, STROKE
$326.02
37200
3
TRANSCATHETER BIOPSY
$234.13
37201
3
TRANSCATHETER THERAPY INFUSE
$277.91
37202
3
TRANSCATHETER THERAPY INFUSE
$334.92
37203
3
TRANSCATHETER RETRIEVAL
$266.56
37204
3
TRANSCATHETER OCCLUSION
$929.58
37205
3
TRANSCATH IV STENT, PERCUT
$437.82
37206
3
TRANSCATH IV STENT/PERC ADDL
$213.07
37207
3
TRANSCATH IV STENT, OPEN
$423.38
37208
3
TRANSCATH IV STENT/OPEN ADDL
$204.62
37209
3
CHANGE IV CATH AT THROMB TX
$114.66
37210
3
EMBOLIZATION UTERINE FIBROID
$554.72
37215
3
TRANSCATH STENT, CCA W/EPS
37216
3
TRANSCATH STENT, CCA W/O EPS
$998.72
37250
3
IV US FIRST VESSEL ADD-ON
$108.91
37251
3
IV US EACH ADD VESSEL ADD-ON
$80.95
37500
3
ENDOSCOPY LIGATE PERF VEINS
$665.93
37501
5
VASCULAR ENDOSCOPY PROCEDURE
37565
3
LIGATION OF NECK VEIN
$1,932.81 $0.00
$1,090.70
$0.00 $660.74
Procedure Code Pricing Action Code Description
Maximum Allowable
37600
3
LIGATION OF NECK ARTERY
$675.50
37605
3
LIGATION OF NECK ARTERY
$772.50
37606
3
LIGATION OF NECK ARTERY
$504.86
37607
3
LIGATION OF A-V FISTULA
$360.61
37609
3
TEMPORAL ARTERY PROCEDURE
$274.41
37615
3
LIGATION OF NECK ARTERY
$447.08
37616
3
LIGATION OF CHEST ARTERY
$1,037.34
37617
3
LIGATION OF ABDOMEN ARTERY
$1,232.18
37618
3
LIGATION OF EXTREMITY ARTERY
$357.70
37620
3
REVISION OF MAJOR VEIN
$646.08
37650
3
REVISION OF MAJOR VEIN
$487.77
37660
3
REVISION OF MAJOR VEIN
$1,153.91
37700
3
REVISE LEG VEIN
$240.23
37718
3
LIGATE/STRIP SHORT LEG VEIN
$394.29
37720
O
REMOVAL OF LEG VEIN
37722
3
LIGATE/STRIP LONG LEG VEIN
37730
O
REMOVAL OF LEG VEINS
37735
3
REMOVAL OF LEG VEINS/LESION
$605.87
37760
3
LIGATION, LEG VEINS, OPEN
$596.56
37765
3
PHLEB VEINS - EXTREM - TO 20
$429.45
37766
3
PHLEB VEINS - EXTREM 20+
$521.68
37780
3
REVISION OF LEG VEIN
$247.85
37785
3
LIGATE/DIVIDE/EXCISE VEIN
$334.61
37788
3
REVASCULARIZATION, PENIS
$1,323.87
37790
3
PENILE VENOUS OCCLUSION
$480.35
37799
5
VASCULAR SURGERY PROCEDURE
38100
3
REMOVAL OF SPLEEN, TOTAL
38101
3
REMOVAL OF SPLEEN, PARTIAL
38102
3
REMOVAL OF SPLEEN, TOTAL
38115
3
REPAIR OF RUPTURED SPLEEN
$1,109.70
38120
3
LAPAROSCOPY, SPLENECTOMY
$926.88
38129
5
LAPAROSCOPE PROC, SPLEEN
$0.00
38200
3
INJECTION FOR SPLEEN X-RAY
$133.93
38204
9
BL DONOR SEARCH MANAGEMENT
$0.00
38205
9
HARVEST ALLOGENIC STEM CELLS
$0.00
$0.00 $455.75 $0.00
$0.00 $997.96 $1,003.29 $238.39
Procedure Code Pricing Action Code Description
Maximum Allowable
38206
3
HARVEST AUTO STEM CELLS
$77.46
38207
9
CRYOPRESERVE STEM CELLS
$0.00
38208
9
THAW PRESERVED STEM CELLS
$0.00
38209
9
WASH HARVEST STEM CELLS
$0.00
38210
9
T-CELL DEPLETION OF HARVEST
$0.00
38211
9
TUMOR CELL DEPLETE OF HARVST
$0.00
38212
9
RBC DEPLETION OF HARVEST
$0.00
38213
9
PLATELET DEPLETE OF HARVEST
$0.00
38214
9
VOLUME DEPLETE OF HARVEST
$0.00
38215
9
HARVEST STEM CELL CONCENTRTE
$0.00
38220
3
BONE MARROW ASPIRATION
$148.85
38221
3
BONE MARROW BIOPSY
$164.88
38230
3
BONE MARROW COLLECTION
$299.49
38231
O
STEM CELL COLLECTION
38240
3
BONE MARROW/STEM TRANSPLANT
$120.02
38241
3
BONE MARROW/STEM TRANSPLANT
$120.77
38242
3
LYMPHOCYTE INFUSE TRANSPLANT
$91.49
38300
3
DRAINAGE, LYMPH NODE LESION
$244.59
38305
3
DRAINAGE, LYMPH NODE LESION
$413.38
38308
3
INCISION OF LYMPH CHANNELS
$395.80
38380
3
THORACIC DUCT PROCEDURE
$510.96
38381
3
THORACIC DUCT PROCEDURE
$759.15
38382
3
THORACIC DUCT PROCEDURE
$613.96
38500
3
BIOPSY/REMOVAL, LYMPH NODES
$284.38
38505
3
NEEDLE BIOPSY, LYMPH NODES
$120.53
38510
3
BIOPSY/REMOVAL, LYMPH NODES
$458.91
38520
3
BIOPSY/REMOVAL, LYMPH NODES
$413.78
38525
3
BIOPSY/REMOVAL, LYMPH NODES
$374.74
38530
3
BIOPSY/REMOVAL, LYMPH NODES
$481.72
38542
9
EXPLORE DEEP NODE(S), NECK
38550
3
REMOVAL, NECK/ARMPIT LESION
$427.26
38555
3
REMOVAL, NECK/ARMPIT LESION
$887.12
38562
3
REMOVAL, PELVIC LYMPH NODES
$637.84
38564
3
REMOVAL, ABDOMEN LYMPH NODES
$631.76
38570
3
LAPAROSCOPY, LYMPH NODE BIOP
$515.08
$0.00
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
38571
3
LAPAROSCOPY, LYMPHADENECTOMY
$810.54
38572
3
LAPAROSCOPY, LYMPHADENECTOMY
$888.19
38589
5
LAPAROSCOPE PROC, LYMPHATIC
38700
3
REMOVAL OF LYMPH NODES, NECK
$715.48
38720
3
REMOVAL OF LYMPH NODES, NECK
$1,186.81
38724
3
REMOVAL OF LYMPH NODES, NECK
$1,286.82
38740
3
REMOVE ARMPIT LYMPH NODES
$598.63
38745
3
REMOVE ARMPIT LYMPH NODES
$761.21
38746
3
REMOVE THORACIC LYMPH NODES
$249.68
38747
3
REMOVE ABDOMINAL LYMPH NODES
$242.96
38760
3
REMOVE GROIN LYMPH NODES
$751.01
38765
3
REMOVE GROIN LYMPH NODES
$1,166.02
38770
3
REMOVE PELVIS LYMPH NODES
$783.77
38780
3
REMOVE ABDOMEN LYMPH NODES
$987.04
38790
3
INJECT FOR LYMPHATIC X-RAY
$77.31
38792
3
IDENTIFY SENTINEL NODE
$37.77
38794
3
ACCESS THORACIC LYMPH DUCT
38999
5
BLOOD/LYMPH SYSTEM PROCEDURE
39000
3
EXPLORATION OF CHEST
$457.20
39010
3
EXPLORATION OF CHEST
$756.14
39020
O
MEDIASTINOTOMY WITH EXPLORATION, DR
39200
3
REMOVAL CHEST LESION
$836.75
39220
3
REMOVAL CHEST LESION
$1,077.45
39400
3
VISUALIZATION OF CHEST
39499
5
CHEST PROCEDURE
39501
3
REPAIR DIAPHRAGM LACERATION
$766.74
39502
3
REPAIR PARAESOPHAGEAL HERNIA
$918.91
39503
3
REPAIR OF DIAPHRAGM HERNIA
$5,337.56
39520
3
REPAIR OF DIAPHRAGM HERNIA
$918.94
39530
3
REPAIR OF DIAPHRAGM HERNIA
$878.99
39531
3
REPAIR OF DIAPHRAGM HERNIA
$917.71
39540
3
REPAIR OF DIAPHRAGM HERNIA
$782.73
39541
3
REPAIR OF DIAPHRAGM HERNIA
$844.30
39545
3
REVISION OF DIAPHRAGM
$833.87
39547
O
IMBRICATION OF DIAPHRAGM FOR EVENTR
$0.00
$294.53 $0.00
$0.00
$470.41 $0.00
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
39560
3
RESECT DIAPHRAGM, SIMPLE
$719.33
39561
3
RESECT DIAPHRAGM, COMPLEX
39599
5
DIAPHRAGM SURGERY PROCEDURE
$0.00
4000F
9
TOBACCO USE TXMNT COUNSELING
$0.00
4001F
9
TOBACCO USE TXMNT, PHARMACOL
$0.00
4002F
9
STATIN THERAPY, RX
$0.00
4003F
9
PT ED WRITE/ORAL, PTS W/ HF
$0.00
4005F
9
PHARM THX FOR OP RXÏD
$0.00
4006F
9
BETA-BLOCKER THERAPY RX
$0.00
4007F
O
ANTIOX VIT/MIN SUPP RXÏD
$0.00
4009F
9
ACE/ARB INHIBITOR THERAPY RX
$0.00
4011F
9
ORAL ANTIPLATELET THERAPY RX
$0.00
4012F
9
WARFARIN THERAPY RX
$0.00
4014F
9
WRITTEN DISCHARGE INSTR PRVD
$0.00
4015F
9
PERSIST ASTHMA MEDICINE CTRL
$0.00
4016F
9
ANTI-INFLM/ANLGSC AGENT RX
$0.00
4017F
9
GI PROPHYLAXIS FOR NSAID RX
$0.00
4018F
9
THERAPY EXERCISE JOINT RX
$0.00
4019F
9
DOC RECPT COUNSL VIT D/CALC+
$0.00
4025F
9
INHALED BRONCHODILATOR RX
$0.00
4030F
9
OXYGEN THERAPY RX
$0.00
4033F
9
PULMONARY REHAB REC
$0.00
4035F
9
INFLUENZA IMM REC
$0.00
4037F
9
INFLUENZA IMM ORDER/ADMIN
$0.00
4040F
9
PNEUMOC VAC/ADMIN/RCVD
$0.00
4041F
9
DOC ORDER CEFAZOLIN/CEFUROX
$0.00
4042F
9
DOC ANTIBIO NOT GIVEN
$0.00
4043F
9
DOC ORDER GIVEN STOP ANTIBIO
$0.00
4044F
9
DOC ORDER GIVEN VTE PROPHYLX
$0.00
4045F
9
EMPIRIC ANTIBIOTIC RX
$0.00
4046F
9
DOC ANTIBIO GIVEN B/4 SURG
$0.00
4047F
9
DOC ANTIBIO GIVEN B/4 SURG
$0.00
4048F
9
DOC ANTIBIO GIVEN B/4 SURG
$0.00
40490
3
BIOPSY OF LIP
4049F
9
DOC ORDER GIVEN STOP ANTIBIO
$1,119.75
$117.63 $0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
40500
3
PARTIAL EXCISION OF LIP
$444.79
4050F
9
HT CARE PLAN DOC
40510
3
PARTIAL EXCISION OF LIP
4051F
9
REFERRED FOR AN AV FISTULA
40520
3
PARTIAL EXCISION OF LIP
$442.16
40525
3
RECONSTRUCT LIP WITH FLAP
$504.89
40527
3
RECONSTRUCT LIP WITH FLAP
$596.01
4052F
9
HEMODIALYSIS VIA AV FISTULA
40530
3
PARTIAL REMOVAL OF LIP
4053F
9
HEMODIALYSIS VIA AV GRAFT
$0.00
4054F
9
HEMODIALYSIS VIA CATHETER
$0.00
4055F
9
PT. RCVNG PERITON DIALYSIS
$0.00
4056F
9
APPROP. ORAL REHYD. RECOMMD
$0.00
4058F
9
PED GASTRO ED GIVEN, CAREGVR
$0.00
4060F
9
PSYCH SVCS PROVIDED
$0.00
4062F
9
PT REFERRAL PSYCH DOCÏD
$0.00
4064F
9
ANTIDEPRESSANT RX
$0.00
40650
3
REPAIR LIP
$367.60
40652
3
REPAIR LIP
$432.65
40654
3
REPAIR LIP
$509.81
4065F
9
ANTIPSYCHOTIC RX
$0.00
4066F
9
ECT PROVIDED
$0.00
4067F
9
PT REFERRAL FOR ECT DOCÏD
$0.00
40700
3
REPAIR CLEFT LIP/NASAL
$843.25
40701
3
REPAIR CLEFT LIP/NASAL
$1,047.01
40702
3
REPAIR CLEFT LIP/NASAL
$810.63
4070F
9
DVT PROPHYLX RECVÏD DAY 2
40720
3
REPAIR CLEFT LIP/NASAL
4073F
9
ORAL ANTIPLAT THX RX DISCHRG
$0.00
4075F
9
ANTICOAG THX RX AT DISCHRG
$0.00
40761
3
REPAIR CLEFT LIP/NASAL
4077F
9
DOC T-PA ADMIN CONSIDERED
$0.00
40799
5
LIP SURGERY PROCEDURE
$0.00
4079F
9
DOC REHAB SVCS CONSIDERED
$0.00
40800
3
DRAINAGE OF MOUTH LESION
$0.00 $429.94 $0.00
$0.00 $487.43
$0.00 $895.82
$970.21
$178.73
Procedure Code Pricing Action Code Description
Maximum Allowable
40801
3
DRAINAGE OF MOUTH LESION
$273.03
40804
3
REMOVAL, FOREIGN BODY, MOUTH
$182.24
40805
3
REMOVAL, FOREIGN BODY, MOUTH
$286.01
40806
3
INCISION OF LIP FOLD
40808
3
BIOPSY OF MOUTH LESION
$160.90
40810
3
EXCISION OF MOUTH LESION
$178.57
40812
3
EXCISE/REPAIR MOUTH LESION
$250.43
40814
3
EXCISE/REPAIR MOUTH LESION
$336.45
40816
3
EXCISION OF MOUTH LESION
$354.39
40818
3
EXCISE ORAL MUCOSA FOR GRAFT
$312.59
40819
3
EXCISE LIP OR CHEEK FOLD
$268.27
40820
3
TREATMENT OF MOUTH LESION
$233.57
40830
3
REPAIR MOUTH LACERATION
$214.20
40831
3
REPAIR MOUTH LACERATION
$283.96
40840
3
RECONSTRUCTION OF MOUTH
$723.07
40842
3
RECONSTRUCTION OF MOUTH
$711.62
40843
3
RECONSTRUCTION OF MOUTH
$927.19
40844
3
RECONSTRUCTION OF MOUTH
$1,230.11
40845
3
RECONSTRUCTION OF MOUTH
$1,336.61
4084F
9
ASPIRIN RECVÏD W/IN 24 HRS
$0.00
40899
5
MOUTH SURGERY PROCEDURE
$0.00
4090F
9
PT RCVNG EPO THXPY
$0.00
4095F
9
PT NOT RCVNG EPO THXPY
$0.00
41000
3
DRAINAGE OF MOUTH LESION
$141.74
41005
3
DRAINAGE OF MOUTH LESION
$199.83
41006
3
DRAINAGE OF MOUTH LESION
$318.95
41007
3
DRAINAGE OF MOUTH LESION
$320.02
41008
3
DRAINAGE OF MOUTH LESION
$328.99
41009
3
DRAINAGE OF MOUTH LESION
$349.50
4100F
9
BIPHOS THXPY VEIN ORD/RECÏVD
41010
3
INCISION OF TONGUE FOLD
$179.65
41015
3
DRAINAGE OF MOUTH LESION
$375.79
41016
3
DRAINAGE OF MOUTH LESION
$385.84
41017
3
DRAINAGE OF MOUTH LESION
$388.79
41018
3
DRAINAGE OF MOUTH LESION
$444.71
$95.22
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
41019
3
PLACE NEEDLES H&N FOR RT
$460.53
41100
3
BIOPSY OF TONGUE
$149.76
41105
3
BIOPSY OF TONGUE
$149.96
41108
3
BIOPSY OF FLOOR OF MOUTH
$129.00
4110F
9
INT. MAM ART USED FOR CABG
41110
3
EXCISION OF TONGUE LESION
$185.71
41112
3
EXCISION OF TONGUE LESION
$292.39
41113
3
EXCISION OF TONGUE LESION
$320.25
41114
3
EXCISION OF TONGUE LESION
$578.10
41115
3
EXCISION OF TONGUE FOLD
$216.20
41116
3
EXCISION OF MOUTH LESION
$286.77
41120
3
PARTIAL REMOVAL OF TONGUE
$950.79
41130
3
PARTIAL REMOVAL OF TONGUE
$1,170.28
41135
3
TONGUE AND NECK SURGERY
$1,944.94
41140
3
REMOVAL OF TONGUE
$2,003.00
41145
3
TONGUE REMOVAL, NECK SURGERY
$2,506.10
41150
3
TONGUE, MOUTH, JAW SURGERY
$1,982.26
41153
3
TONGUE, MOUTH, NECK SURGERY
$2,147.63
41155
3
TONGUE, JAW, & NECK SURGERY
$2,666.21
4115F
9
BETA BLCKR ADMIN W/IN 24 HRS
$0.00
4120F
9
ANTIBIOT RXÏD/GIVEN
$0.00
4124F
9
ANTIBIOT NOT RXÏD/GIVEN
$0.00
41250
3
REPAIR TONGUE LACERATION
$201.57
41251
3
REPAIR TONGUE LACERATION
$208.00
41252
3
REPAIR TONGUE LACERATION
$272.77
4130F
9
TOPICAL PREP RX, AOE
$0.00
4131F
9
SYST ANTIMICROBIAL THX RX
$0.00
4132F
9
NO SYST ANTIMICROBIAL THX RX
$0.00
4133F
9
ANTIHIST/DECONG RX/RECOM
$0.00
4134F
9
NO ANTIHIST/DECONG RX/RECOM
$0.00
4135F
9
SYSTEMIC CORTICOSTEROIDS RX
$0.00
4136F
9
SYST CORTICOSTEROIDS NOT RX
$0.00
4148F
9
HEP A VAC INJXN ADMIN/RECVD
$0.00
4149F
9
HEP B VAC INJXN ADMIN/RECVD
$0.00
41500
3
FIXATION OF TONGUE
$0.00
$404.07
Procedure Code Pricing Action Code Description
Maximum Allowable
4150F
9
PT RECVNG ANTIVIR TXMNT HEPC
$0.00
41510
3
TONGUE TO LIP SURGERY
$370.98
41512
3
TONGUE SUSPENSION
$564.76
4151F
9
PT NOT RECVNG ANTIV HEP C
41520
3
RECONSTRUCTION, TONGUE FOLD
4152F
O
DOCÏD PEGINTF/RIB THXY CONSD
41530
3
TONGUE BASE VOL REDUCTION
4153F
9
COMBO PEGINTF/RIB RX
$0.00
4154F
O
HEP A VAC SERIES RECOMMENDED
$0.00
4155F
9
HEP A VAC SERIES PREV RECVD
$0.00
4156F
O
HEP B VAC SERIES RECOMMENDED
$0.00
4157F
9
HEP B VAC SERIES PREV RECVD
$0.00
4158F
9
PT EDU RE: ALCOH DRNKNG DONE
$0.00
41599
5
TONGUE AND MOUTH SURGERY
$0.00
4159F
9
CONTRCP TALK B/4 ANTIV TXMNT
$0.00
4163F
9
PT COUNS 4 TXMNT OPT PROST
$0.00
4164F
9
ADJV HRMNL THXPY RXÏD
$0.00
4165F
9
3D-CRT/IMRT RECEIVED
$0.00
4167F
9
HD BED TILTED, 1ST DAY VENT
$0.00
4168F
9
PT CARE, ICU&VENT W/IN 24HRS
$0.00
4169F
9
NO PT CARE ICU/VENT IN 24HRS
$0.00
4171F
9
PT. RCVNG ESA THXPY
$0.00
4172F
9
PT. NOT RCVNG ESA THXPY
$0.00
4174F
9
COUNS., POTENT. GLAUC IMPCT
$0.00
4175F
9
VIS OF >=20/40 W/IN 90 DAYS
$0.00
4176F
9
TALK RE UV LIGHT, PT/CRGVR
$0.00
4177F
9
TALK PT/CRGVR RE: AREDS,PREV
$0.00
4178F
9
ANTID GLBLN RCVÏD W/IN 26WKS
$0.00
4179F
9
TAMOXIFEN/AI PRESCRIBED
$0.00
41800
3
DRAINAGE OF GUM LESION
$201.39
41805
3
REMOVAL FOREIGN BODY, GUM
$207.83
41806
3
REMOVAL FOREIGN BODY,JAWBONE
$302.37
4180F
9
ADJV THXPYRXÏD/RCVÏD STG3A-C
$0.00
4181F
9
CONFORMAL RADN THXPY RCVD 00
$0.00
41820
5
EXCISION, GUM, EACH QUADRANT
$0.00
$0.00 $306.21 $0.00 $2,867.27
Procedure Code Pricing Action Code Description
Maximum Allowable
41821
5
EXCISION OF GUM FLAP
$0.00
41822
3
EXCISION OF GUM LESION
$253.70
41823
3
EXCISION OF GUM LESION
$377.59
41825
3
EXCISION OF GUM LESION
$181.98
41826
3
EXCISION OF GUM LESION
$254.95
41827
3
EXCISION OF GUM LESION
$377.94
41828
3
EXCISION OF GUM LESION
$269.56
4182F
9
NO CONFORMAL RADN THXPY
41830
3
REMOVAL OF GUM TISSUE
41850
5
TREATMENT OF GUM LESION
$0.00
4185F
9
CONTINUOUS PPI OR H2RA RCVÏD
$0.00
4186F
9
NO CONT. PPI OR H2RA RCVÏD
$0.00
41870
5
GUM GRAFT
$0.00
41872
3
REPAIR GUM
$320.81
41874
3
REPAIR TOOTH SOCKET
$325.23
4187F
9
ANTI RHEUM DRUGTHXPYRXÏD/GVN
$0.00
4188F
9
APPROP ACE/ARB TSTNG DONE
$0.00
41899
5
DENTAL SURGERY PROCEDURE
$0.00
4189F
9
APPROP DIGOXIN TSTNG DONE
$0.00
4190F
9
APPROP DIURETIC TSTNG DONE
$0.00
4191F
9
APPROP ANTICONVULS TSTNG
$0.00
4192F
9
PT NOT RCVNG GLUCOCO THXPY
$0.00
4193F
9
PT RCVNG<10MG DAILY PREDNISO
$0.00
4194F
9
PT RCVNG>10MG DAILY PREDNISO
$0.00
4195F
9
PT RCVNG ANTI-RHEUM THXPY RA
$0.00
4196F
9
PTNOT RCVNG ANTI-RHM THXPYRA
$0.00
42000
3
DRAINAGE MOUTH ROOF LESION
4200F
9
EXTERNAL BEAM TO PROST ONLY
$0.00
4201F
9
EXTRNL BEAM OTHER THAN PROST
$0.00
42100
3
BIOPSY ROOF OF MOUTH
$132.72
42104
3
EXCISION LESION, MOUTH ROOF
$185.16
42106
3
EXCISION LESION, MOUTH ROOF
$234.81
42107
3
EXCISION LESION, MOUTH ROOF
$406.50
4210F
9
ACE/ARB THXPY FOR >= 6 MONS
$0.00
42120
3
REMOVE PALATE/LESION
$0.00 $341.32
$139.97
$881.60
Procedure Code Pricing Action Code Description
Maximum Allowable
42140
3
EXCISION OF UVULA
$221.79
42145
3
REPAIR PALATE, PHARYNX/UVULA
$638.83
42160
3
TREATMENT MOUTH ROOF LESION
$214.03
42180
3
REPAIR PALATE
$216.34
42182
3
REPAIR PALATE
$295.43
42200
3
RECONSTRUCT CLEFT PALATE
$809.23
42205
3
RECONSTRUCT CLEFT PALATE
$861.80
4220F
9
DIGOXIN THXPY FOR >= 6 MONS
42210
3
RECONSTRUCT CLEFT PALATE
$972.99
42215
3
RECONSTRUCT CLEFT PALATE
$640.05
4221F
9
DIURETIC THXPY FOR >= 6 MONS
42220
3
RECONSTRUCT CLEFT PALATE
$497.13
42225
3
RECONSTRUCT CLEFT PALATE
$859.36
42226
3
LENGTHENING OF PALATE
$852.26
42227
3
LENGTHENING OF PALATE
$828.79
42235
3
REPAIR PALATE
$677.00
42260
3
REPAIR NOSE TO LIP FISTULA
$752.32
42280
9
PREPARATION, PALATE MOLD
$0.00
42281
3
INSERTION, PALATE PROSTHESIS
42299
5
PALATE/UVULA SURGERY
42300
3
DRAINAGE OF SALIVARY GLAND
$185.53
42305
3
DRAINAGE OF SALIVARY GLAND
$394.20
4230F
9
ANTICONV THXPY FOR >= 6 MONS
42310
3
DRAINAGE OF SALIVARY GLAND
$144.24
42320
3
DRAINAGE OF SALIVARY GLAND
$223.19
42325
O
CREATE SALIVARY CYST DRAIN
$0.00
42326
O
CREATE SALIVARY CYST DRAIN
$0.00
42330
3
REMOVAL OF SALIVARY STONE
$207.72
42335
3
REMOVAL OF SALIVARY STONE
$331.48
42340
3
REMOVAL OF SALIVARY STONE
$415.81
42400
3
BIOPSY OF SALIVARY GLAND
$98.81
42405
3
BIOPSY OF SALIVARY GLAND
$272.87
42408
3
EXCISION OF SALIVARY CYST
$406.99
42409
3
DRAINAGE OF SALIVARY CYST
$295.38
4240F
9
INSTR XRCZ 4BK PN >12 WEEKS
$0.00
$0.00
$181.34 $0.00
$0.00
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
42410
3
EXCISE PAROTID GLAND/LESION
$570.59
42415
3
EXCISE PAROTID GLAND/LESION
$1,028.35
42420
3
EXCISE PAROTID GLAND/LESION
$1,178.31
42425
3
EXCISE PAROTID GLAND/LESION
$776.59
42426
3
EXCISE PAROTID GLAND/LESION
$1,260.31
4242F
9
SPRVSD XRCZ BK PN >12 WEEKS
$0.00
42440
3
EXCISE SUBMAXILLARY GLAND
$429.48
42450
3
EXCISE SUBLINGUAL GLAND
$406.54
4245F
9
PT INSTR NRML LIFEST
$0.00
4248F
9
PT INSTR-NO BD REST>= 4 DAYS
$0.00
42500
3
REPAIR SALIVARY DUCT
$387.84
42505
3
REPAIR SALIVARY DUCT
$502.37
42507
3
PAROTID DUCT DIVERSION
$470.69
42508
3
PAROTID DUCT DIVERSION
$668.64
42509
3
PAROTID DUCT DIVERSION
$763.94
4250F
9
WRMNG 4 SURG - NORMOTHERMIA
42510
3
PAROTID DUCT DIVERSION
$578.65
42550
3
INJECTION FOR SALIVARY X-RAY
$139.51
42600
3
CLOSURE OF SALIVARY FISTULA
$436.12
4260F
9
WOUND SRFC CULTURETECH USED
$0.00
4261F
9
TECH OTHER THAN SURFC CULTR
$0.00
42650
3
DILATION OF SALIVARY DUCT
4265F
9
WET-DRY DRESSINGS RX-RECMD
42660
3
DILATION OF SALIVARY DUCT
$95.78
42665
3
LIGATION OF SALIVARY DUCT
$276.65
4266F
9
NO WET-DRY DRSSINGS RX-RECMD
$0.00
4267F
9
COMPRSSION THXPY PRESCRIBED
$0.00
4268F
9
PT ED RE COMP THXPY RCVD
$0.00
42699
5
SALIVARY SURGERY PROCEDURE
$0.00
4269F
9
APPROPOS MTHD OFFLOADING RXD
$0.00
42700
3
DRAINAGE OF TONSIL ABSCESS
$168.20
4270F
9
PT RCVNG ANTI R-VIRAL THXPY
$0.00
4271F
9
PT RCVNG ANTI R-VIRAL THXPY
$0.00
42720
3
DRAINAGE OF THROAT ABSCESS
$415.33
42725
3
DRAINAGE OF THROAT ABSCESS
$744.19
$0.00
$74.67 $0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
4274F
9
FLU IMMUNO ADMIND RCVD
$0.00
4275F
9
POTENT ANTIVIR THXPY RXD
$0.00
4279F
9
PCP PROPHYLAXIS RXD
$0.00
42800
3
BIOPSY OF THROAT
$141.01
42802
3
BIOPSY OF THROAT
$216.12
42804
3
BIOPSY OF UPPER NOSE/THROAT
$180.52
42806
3
BIOPSY OF UPPER NOSE/THROAT
$203.37
42808
3
EXCISE PHARYNX LESION
$205.40
42809
3
REMOVE PHARYNX FOREIGN BODY
$152.78
4280F
9
PCP PROPHYLAX RXD 3MON LOW %
42810
3
EXCISION OF NECK CYST
$346.69
42815
3
EXCISION OF NECK CYST
$508.11
42820
3
REMOVE TONSILS AND ADENOIDS
$267.73
42821
3
REMOVE TONSILS AND ADENOIDS
$279.60
42825
3
REMOVAL OF TONSILS
$240.19
42826
3
REMOVAL OF TONSILS
$231.86
42830
3
REMOVAL OF ADENOIDS
$189.39
42831
3
REMOVAL OF ADENOIDS
$204.47
42835
3
REMOVAL OF ADENOIDS
$170.74
42836
3
REMOVAL OF ADENOIDS
$222.61
42842
3
EXTENSIVE SURGERY OF THROAT
$885.02
42844
3
EXTENSIVE SURGERY OF THROAT
$1,242.75
42845
3
EXTENSIVE SURGERY OF THROAT
$2,026.30
42860
3
EXCISION OF TONSIL TAGS
$171.60
42870
3
EXCISION OF LINGUAL TONSIL
$525.48
42880
O
EXCISION NASOPHARYNGEAL LESION (EG,
42890
3
PARTIAL REMOVAL OF PHARYNX
$1,262.48
42892
3
REVISION OF PHARYNGEAL WALLS
$1,654.36
42894
3
REVISION OF PHARYNGEAL WALLS
$2,118.36
42900
3
REPAIR THROAT WOUND
4290F
9
PT SCRNED FOR INJ DRUG USE
$0.00
4293F
9
PT SCRND - HGH-RSK SEX BEHAV
$0.00
42950
3
RECONSTRUCTION OF THROAT
$725.88
42953
3
REPAIR THROAT, ESOPHAGUS
$894.27
42955
3
SURGICAL OPENING OF THROAT
$682.99
$0.00
$0.00
$318.26
Procedure Code Pricing Action Code Description
Maximum Allowable
42960
3
CONTROL THROAT BLEEDING
$155.45
42961
3
CONTROL THROAT BLEEDING
$386.02
42962
3
CONTROL THROAT BLEEDING
$477.72
42970
3
CONTROL NOSE/THROAT BLEEDING
$356.77
42971
3
CONTROL NOSE/THROAT BLEEDING
$420.79
42972
3
CONTROL NOSE/THROAT BLEEDING
$472.49
42999
5
THROAT SURGERY PROCEDURE
$0.00
43000
O
ESOPHAGOTOMY, CERVICAL APPROACH; WI
$0.00
4300F
9
PT RCVNG WARF THXPY
$0.00
4301F
9
PT NOT RCVNG WARF THXPY
$0.00
43020
3
INCISION OF ESOPHAGUS
$484.75
43030
3
THROAT MUSCLE SURGERY
$480.59
43040
O
ESOPHAGOTOMY, THORACIC APPROACH; WI
43045
3
INCISION OF ESOPHAGUS
4305F
9
PT ED RE FT CARE INSPCT RCVD
$0.00
4306F
9
PT TLK PSYCH & RX OPD ADDIC
$0.00
43100
3
EXCISION OF ESOPHAGUS LESION
$574.28
43101
3
EXCISION OF ESOPHAGUS LESION
$949.61
43105
O
WIDE EXCISION OF MALIGNANT LESION O
$0.00
43106
O
WIDE EXCISION OF MALIGNANT LESION O
$0.00
43107
3
REMOVAL OF ESOPHAGUS
$2,345.28
43108
3
REMOVAL OF ESOPHAGUS
$3,937.01
43110
O
ESOPHAGECTOMY (AT UPPER TWO-THIRDS
$0.00
43111
O
ESOPHAGECTOMY (AT UPPER TWO-THIRDS
$0.00
43112
3
REMOVAL OF ESOPHAGUS
$2,506.07
43113
3
REMOVAL OF ESOPHAGUS
$3,938.89
43115
O
ESOPHAGECTOMY (AT UPPER TWO-THIRDS
43116
3
PARTIAL REMOVAL OF ESOPHAGUS
$4,478.28
43117
3
PARTIAL REMOVAL OF ESOPHAGUS
$2,291.76
43118
3
PARTIAL REMOVAL OF ESOPHAGUS
$3,242.62
43119
O
TOTAL ESOPHAGECTOMY WITH GASTROPHAR
$0.00
43120
O
ESOPHAGOGASTRECTOMY (LOWER THIRD) A
$0.00
43121
3
PARTIAL REMOVAL OF ESOPHAGUS
$2,579.12
43122
3
PARTIAL REMOVAL OF ESOPHAGUS
$2,317.43
43123
3
PARTIAL REMOVAL OF ESOPHAGUS
$3,958.21
$0.00 $1,216.08
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
43124
3
REMOVAL OF ESOPHAGUS
$3,386.97
43130
3
REMOVAL OF ESOPHAGUS POUCH
$726.73
43135
3
REMOVAL OF ESOPHAGUS POUCH
$1,353.28
43136
O
DIVERTICULOPEXY OF HYPOPHARYNX, WIT
43200
3
ESOPHAGUS ENDOSCOPY
$199.31
43201
3
ESOPH SCOPE W/SUBMUCOUS INJ
$274.22
43202
3
ESOPHAGUS ENDOSCOPY, BIOPSY
$262.28
43204
3
ESOPH SCOPE W/SCLEROSIS INJ
$212.91
43205
3
ESOPHAGUS ENDOSCOPY/LIGATION
$213.51
4320F
9
PT TALK PSYCHSOC+RX OH DPND
43215
3
ESOPHAGUS ENDOSCOPY
$145.87
43216
3
ESOPHAGUS ENDOSCOPY/LESION
$184.09
43217
3
ESOPHAGUS ENDOSCOPY
$350.55
43219
3
ESOPHAGUS ENDOSCOPY
$162.38
43220
3
ESOPH ENDOSCOPY, DILATION
$120.16
43226
3
ESOPH ENDOSCOPY, DILATION
$134.02
43227
3
ESOPH ENDOSCOPY, REPAIR
$199.32
43228
3
ESOPH ENDOSCOPY, ABLATION
$212.75
43231
3
ESOPH ENDOSCOPY W/US EXAM
$181.24
43232
3
ESOPH ENDOSCOPY W/US FN BX
$249.59
43234
3
UPPER GI ENDOSCOPY, EXAM
$260.01
43235
3
UPPR GI ENDOSCOPY, DIAGNOSIS
$280.73
43236
3
UPPR GI SCOPE W/SUBMUC INJ
$349.68
43237
3
ENDOSCOPIC US EXAM, ESOPH
$228.32
43238
3
UPPR GI ENDOSCOPY W/US FN BX
$282.86
43239
3
UPPER GI ENDOSCOPY, BIOPSY
$324.85
43240
3
ESOPH ENDOSCOPE W/DRAIN CYST
$379.47
43241
3
UPPER GI ENDOSCOPY WITH TUBE
$148.23
43242
3
UPPR GI ENDOSCOPY W/US FN BX
$404.81
43243
3
UPPER GI ENDOSCOPY & INJECT
$255.15
43244
3
UPPER GI ENDOSCOPY/LIGATION
$282.88
43245
3
UPPR GI SCOPE DILATE STRICTR
$178.28
43246
3
PLACE GASTROSTOMY TUBE
$238.68
43247
3
OPERATIVE UPPER GI ENDOSCOPY
$190.85
43248
3
UPPR GI ENDOSCOPY/GUIDE WIRE
$180.56
$0.00
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
43249
3
ESOPH ENDOSCOPY, DILATION
$166.21
43250
3
UPPER GI ENDOSCOPY/TUMOR
$178.25
43251
3
OPERATIVE UPPER GI ENDOSCOPY
$207.57
43255
3
OPERATIVE UPPER GI ENDOSCOPY
$270.11
43256
3
UPPR GI ENDOSCOPY W/STENT
$242.61
43257
3
UPPR GI SCOPE W/THRML TXMNT
$297.60
43258
3
OPERATIVE UPPER GI ENDOSCOPY
$254.44
43259
3
ENDOSCOPIC ULTRASOUND EXAM
$289.97
43260
3
ENDO CHOLANGIOPANCREATOGRAPH
$331.98
43261
3
ENDO CHOLANGIOPANCREATOGRAPH
$348.96
43262
3
ENDO CHOLANGIOPANCREATOGRAPH
$409.76
43263
3
ENDO CHOLANGIOPANCREATOGRAPH
$405.45
43264
3
ENDO CHOLANGIOPANCREATOGRAPH
$491.86
43265
3
ENDO CHOLANGIOPANCREATOGRAPH
$551.93
43267
3
ENDO CHOLANGIOPANCREATOGRAPH
$407.91
43268
3
ENDO CHOLANGIOPANCREATOGRAPH
$414.93
43269
3
ENDO CHOLANGIOPANCREATOGRAPH
$454.17
43271
3
ENDO CHOLANGIOPANCREATOGRAPH
$409.39
43272
3
ENDO CHOLANGIOPANCREATOGRAPH
$408.64
43273
3
ENDOSCOPIC PANCREATOSCOPY
$123.80
43279
3
LAP MYOTOMY, HELLER
43280
3
LAPAROSCOPY, FUNDOPLASTY
43289
5
LAPAROSCOPE PROC, ESOPH
43300
3
REPAIR OF ESOPHAGUS
43305
3
REPAIR ESOPHAGUS AND FISTULA
$1,019.53
43310
3
REPAIR OF ESOPHAGUS
$1,418.73
43312
3
REPAIR ESOPHAGUS AND FISTULA
$1,565.78
43313
3
ESOPHAGOPLASTY CONGENITAL
$2,489.03
43314
3
TRACHEO-ESOPHAGOPLASTY CONG
$2,857.94
43320
3
FUSE ESOPHAGUS & STOMACH
$1,246.32
43321
O
ESOPHAGOGASTROSTOMY (CARDIOPLASTY),
43324
3
REVISE ESOPHAGUS & STOMACH
$1,207.62
43325
3
REVISE ESOPHAGUS & STOMACH
$1,188.75
43326
3
REVISE ESOPHAGUS & STOMACH
$1,213.25
43330
3
REPAIR OF ESOPHAGUS
$1,165.95
$1,147.30 $958.13 $0.00 $570.75
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
43331
3
REPAIR OF ESOPHAGUS
$1,266.20
43340
3
FUSE ESOPHAGUS & INTESTINE
$1,210.79
43341
3
FUSE ESOPHAGUS & INTESTINE
$1,335.63
43350
3
SURGICAL OPENING, ESOPHAGUS
$1,034.24
43351
3
SURGICAL OPENING, ESOPHAGUS
$1,215.58
43352
3
SURGICAL OPENING, ESOPHAGUS
$994.66
43360
3
GASTROINTESTINAL REPAIR
$2,124.60
43361
3
GASTROINTESTINAL REPAIR
$2,371.86
43400
3
LIGATE ESOPHAGUS VEINS
$1,467.69
43401
3
ESOPHAGUS SURGERY FOR VEINS
$1,381.79
43405
3
LIGATE/STAPLE ESOPHAGUS
$1,341.29
43410
3
REPAIR ESOPHAGUS WOUND
$919.48
43415
3
REPAIR ESOPHAGUS WOUND
$1,563.06
43420
3
REPAIR ESOPHAGUS OPENING
$919.47
43425
3
REPAIR ESOPHAGUS OPENING
$1,374.23
43450
3
DILATE ESOPHAGUS
43451
O
DILATION OF ESOPHAGUS, BY UNGUIDED
43453
3
DILATE ESOPHAGUS
43455
O
DILATION OF ESOPHAGUS, BY BALLOON O
43456
3
DILATE ESOPHAGUS
$147.65
43458
3
DILATE ESOPHAGUS
$363.91
43460
3
PRESSURE TREATMENT ESOPHAGUS
$209.04
43496
5
FREE JEJUNUM FLAP, MICROVASC
$0.00
43499
5
ESOPHAGUS SURGERY PROCEDURE
$0.00
43500
3
SURGICAL OPENING OF STOMACH
43501
3
SURGICAL REPAIR OF STOMACH
$1,177.74
43502
3
SURGICAL REPAIR OF STOMACH
$1,333.33
43510
3
SURGICAL OPENING OF STOMACH
$849.49
43520
3
INCISION OF PYLORIC MUSCLE
$620.99
43600
3
BIOPSY OF STOMACH
$101.19
43605
3
BIOPSY OF STOMACH
$727.51
43610
3
EXCISION OF STOMACH LESION
$858.97
43611
3
EXCISION OF STOMACH LESION
$1,068.92
43620
3
REMOVAL OF STOMACH
$1,739.94
43621
3
REMOVAL OF STOMACH
$1,979.44
$148.81 $0.00 $281.38 $0.00
$685.62
Procedure Code Pricing Action Code Description
Maximum Allowable
43622
3
REMOVAL OF STOMACH
$2,008.72
43625
O
GASTRECTOMY, TOTAL WITH REPAIR BY I
$0.00
43630
O
HEMIGASTRECTOMY OR DISTAL SUBTOTAL
$0.00
43631
3
REMOVAL OF STOMACH, PARTIAL
$1,277.07
43632
3
REMOVAL OF STOMACH, PARTIAL
$1,736.41
43633
3
REMOVAL OF STOMACH, PARTIAL
$1,652.94
43634
3
REMOVAL OF STOMACH, PARTIAL
$1,825.51
43635
3
REMOVAL OF STOMACH, PARTIAL
$101.89
43638
O
REMOVAL OF STOMACH, PARTIAL
$0.00
43639
O
REMOVAL OF STOMACH, PARTIAL
$0.00
43640
3
VAGOTOMY & PYLORUS REPAIR
$1,027.24
43641
3
VAGOTOMY & PYLORUS REPAIR
$1,035.93
43644
3
LAP GASTRIC BYPASS/ROUX-EN-Y
$1,519.51
43645
3
LAP GASTR BYPASS INCL SMLL I
$1,625.44
43647
6
LAP IMPL ELECTRODE, ANTRUM
$0.00
43648
6
LAP REVISE/REMV ELTRD ANTRUM
$0.00
43651
3
LAPAROSCOPY, VAGUS NERVE
$572.06
43652
3
LAPAROSCOPY, VAGUS NERVE
$669.13
43653
3
LAPAROSCOPY, GASTROSTOMY
$488.91
43659
5
LAPAROSCOPE PROC, STOM
$0.00
43750
O
PLACE GASTROSTOMY TUBE
$0.00
43752
3
NASAL/OROGASTRIC W/STENT
$39.78
43760
3
CHANGE GASTROSTOMY TUBE
$48.00
43761
3
REPOSITION GASTROSTOMY TUBE
$116.72
43770
3
LAP PLACE GASTR ADJ DEVICE
$975.76
43771
3
LAP REVISE GASTR ADJ DEVICE
43772
3
LAP RMVL GASTR ADJ DEVICE
43773
3
LAP REPLACE GASTR ADJ DEVICE
$1,113.15
43774
3
LAP RMVL GASTR ADJ ALL PARTS
$842.03
43800
3
RECONSTRUCTION OF PYLORUS
$815.44
43810
3
FUSION OF STOMACH AND BOWEL
$883.44
43820
3
FUSION OF STOMACH AND BOWEL
$1,143.25
43825
3
FUSION OF STOMACH AND BOWEL
$1,136.59
43830
3
PLACE GASTROSTOMY TUBE
$606.72
43831
3
PLACE GASTROSTOMY TUBE
$508.62
$1,112.17 $841.04
Procedure Code Pricing Action Code Description
Maximum Allowable
43832
3
PLACE GASTROSTOMY TUBE
$932.26
43840
3
REPAIR OF STOMACH LESION
$1,159.62
43842
3
V-BAND GASTROPLASTY
$1,131.27
43843
3
GASTROPLASTY W/O V-BAND
$1,108.00
43844
O
GASTRIC BYPASS, OTHER THAN WITH ROU
43845
3
GASTRIC RESTRICTIVE PROCEDURE
$1,714.11
43846
3
GASTRIC BYPASS FOR OBESITY
$1,428.81
43847
3
GASTRIC BYPASS INCL SMALL I
$1,560.20
43848
3
REVISION GASTROPLASTY
$1,693.47
43850
3
REVISE STOMACH-BOWEL FUSION
$1,417.76
43855
3
REVISE STOMACH-BOWEL FUSION
$1,481.94
43860
3
REVISE STOMACH-BOWEL FUSION
$1,439.90
43865
3
REVISE STOMACH-BOWEL FUSION
$1,497.61
43870
3
REPAIR STOMACH OPENING
43880
3
REPAIR STOMACH-BOWEL FISTULA
43881
6
IMPL/REDO ELECTRD, ANTRUM
$0.00
43882
6
REVISE/REMOVE ELECTRD ANTRUM
$0.00
43885
O
ANTERIOR GASTROPEXY FOR HIATAL HERN
$0.00
43886
3
REVISE GASTRIC PORT, OPEN
$293.92
43887
3
REMOVE GASTRIC PORT, OPEN
$275.75
43888
3
CHANGE GASTRIC PORT, OPEN
$388.63
43999
5
STOMACH SURGERY PROCEDURE
44005
3
FREEING OF BOWEL ADHESION
$961.57
44010
3
INCISION OF SMALL BOWEL
$756.75
44015
3
INSERT NEEDLE CATH BOWEL
$130.85
44020
3
EXPLORE SMALL INTESTINE
$850.17
44021
3
DECOMPRESS SMALL BOWEL
$860.28
44025
3
INCISION OF LARGE BOWEL
$865.57
44040
O
EXTERIORIZATION OF INTESTINE (MIKUL
44050
3
REDUCE BOWEL OBSTRUCTION
44055
3
CORRECT MALROTATION OF BOWEL
44100
3
BIOPSY OF BOWEL
$109.17
44110
3
EXCISE INTESTINE LESION(S)
$741.92
44111
3
EXCISION OF BOWEL LESION(S)
$863.35
44120
3
REMOVAL OF SMALL INTESTINE
$1,068.63
$0.00
$618.27 $1,406.92
$0.00
$0.00 $819.61 $1,311.07
Procedure Code Pricing Action Code Description
Maximum Allowable
44121
3
REMOVAL OF SMALL INTESTINE
$219.88
44125
3
REMOVAL OF SMALL INTESTINE
$1,037.95
44126
3
ENTERECTOMY W/O TAPER, CONG
$2,141.52
44127
3
ENTERECTOMY W/TAPER, CONG
$2,492.87
44128
3
ENTERECTOMY CONG, ADD-ON
44130
3
BOWEL TO BOWEL FUSION
44131
O
ENTEROENTEROSTOMY, ANASTOMOSIS OF I
$0.00
44132
9
ENTERECTOMY, CADAVER DONOR
$0.00
44133
5
ENTERECTOMY, LIVE DONOR
$0.00
44135
5
INTESTINE TRANSPLNT, CADAVER
$0.00
44136
5
INTESTINE TRANSPLANT, LIVE
$0.00
44137
6
REMOVE INTESTINAL ALLOGRAFT
$0.00
44139
3
MOBILIZATION OF COLON
44140
3
PARTIAL REMOVAL OF COLON
$1,181.78
44141
3
PARTIAL REMOVAL OF COLON
$1,557.02
44143
3
PARTIAL REMOVAL OF COLON
$1,456.75
44144
3
PARTIAL REMOVAL OF COLON
$1,528.69
44145
3
PARTIAL REMOVAL OF COLON
$1,471.84
44146
3
PARTIAL REMOVAL OF COLON
$1,842.07
44147
3
PARTIAL REMOVAL OF COLON
$1,656.54
44150
3
REMOVAL OF COLON
$1,617.01
44151
3
REMOVAL OF COLON/ILEOSTOMY
$1,847.82
44152
O
REMOVAL OF COLON/ILEOSTOMY
$0.00
44153
O
REMOVAL OF COLON/ILEOSTOMY
$0.00
44155
3
REMOVAL OF COLON/ILEOSTOMY
$1,810.13
44156
3
REMOVAL OF COLON/ILEOSTOMY
$1,989.96
44157
3
COLECTOMY W/ILEOANAL ANAST
$1,889.59
44158
3
COLECTOMY W/NEO-RECTUM POUCH
$1,936.57
44160
3
REMOVAL OF COLON
$1,088.83
44180
3
LAP, ENTEROLYSIS
$812.53
44186
3
LAP, JEJUNOSTOMY
$574.10
44187
3
LAP, ILEO/JEJUNO-STOMY
$968.00
44188
3
LAP, COLOSTOMY
44200
O
LAPAROSCOPY, ENTEROLYSIS
$0.00
44201
O
LAPAROSCOPY, JEJUNOSTOMY
$0.00
$220.97 $1,118.87
$110.05
$1,070.67
Procedure Code Pricing Action Code Description
Maximum Allowable
44202
3
LAP, ENTERECTOMY
$1,222.97
44203
3
LAP RESECT S/INTESTINE, ADDL
44204
3
LAPARO PARTIAL COLECTOMY
$1,364.84
44205
3
LAP COLECTOMY PART W/ILEUM
$1,191.86
44206
3
LAP PART COLECTOMY W/STOMA
$1,549.14
44207
3
L COLECTOMY/COLOPROCTOSTOMY
$1,625.81
44208
3
L COLECTOMY/COLOPROCTOSTOMY
$1,769.51
44209
O
LAPAROSCOPE PROC, INTESTINE
44210
3
LAPARO TOTAL PROCTOCOLECTOMY
$1,582.62
44211
3
LAP COLECTOMY W/PROCTECTOMY
$1,942.44
44212
3
LAPARO TOTAL PROCTOCOLECTOMY
$1,822.68
44213
3
LAP, MOBIL SPLENIC FL ADD-ON
44227
3
LAP, CLOSE ENTEROSTOMY
44238
5
LAPAROSCOPE PROC, INTESTINE
$0.00
44239
O
LAPAROSCOPE PROC, RECTUM
$0.00
44300
3
OPEN BOWEL TO SKIN
44305
O
ENTEROSTOMY OR CECOSTOMY, TUBE (EG,
44310
3
ILEOSTOMY/JEJUNOSTOMY
$920.39
44312
3
REVISION OF ILEOSTOMY
$525.14
44314
3
REVISION OF ILEOSTOMY
$892.06
44316
3
DEVISE BOWEL POUCH
$1,219.59
44320
3
COLOSTOMY
$1,050.13
44322
3
COLOSTOMY WITH BIOPSIES
$840.65
44340
3
REVISION OF COLOSTOMY
$528.93
44345
3
REVISION OF COLOSTOMY
$919.70
44346
3
REVISION OF COLOSTOMY
$1,031.83
44360
3
SMALL BOWEL ENDOSCOPY
$150.34
44361
3
SMALL BOWEL ENDOSCOPY/BIOPSY
$165.63
44363
3
SMALL BOWEL ENDOSCOPY
$195.88
44364
3
SMALL BOWEL ENDOSCOPY
$211.11
44365
3
SMALL BOWEL ENDOSCOPY
$187.99
44366
3
SMALL BOWEL ENDOSCOPY
$248.82
44369
3
SMALL BOWEL ENDOSCOPY
$254.10
44370
3
SMALL BOWEL ENDOSCOPY/STENT
$273.94
44372
3
SMALL BOWEL ENDOSCOPY
$241.78
$218.90
$0.00
$172.59 $1,477.64
$736.85 $0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
44373
3
SMALL BOWEL ENDOSCOPY
$195.88
44376
3
SMALL BOWEL ENDOSCOPY
$289.35
44377
3
SMALL BOWEL ENDOSCOPY/BIOPSY
$307.03
44378
3
SMALL BOWEL ENDOSCOPY
$393.70
44379
3
S BOWEL ENDOSCOPE W/STENT
$417.49
44380
3
SMALL BOWEL ENDOSCOPY
$65.69
44382
3
SMALL BOWEL ENDOSCOPY
$78.95
44383
3
ILEOSCOPY W/STENT
$168.87
44385
3
ENDOSCOPY OF BOWEL POUCH
$231.30
44386
3
ENDOSCOPY, BOWEL POUCH/BIOP
$322.34
44388
3
COLONOSCOPY
$319.95
44389
3
COLONOSCOPY WITH BIOPSY
$371.94
44390
3
COLONOSCOPY FOR FOREIGN BODY
$429.22
44391
3
COLONOSCOPY FOR BLEEDING
$480.86
44392
3
COLONOSCOPY & POLYPECTOMY
$402.35
44393
3
COLONOSCOPY, LESION REMOVAL
$466.97
44394
3
COLONOSCOPY W/SNARE
$470.96
44397
3
COLONOSCOPY W/STENT
$262.70
44500
9
INTRO, GASTROINTESTINAL TUBE
$0.00
44600
O
SUTURE OF INTESTINE (ENTERORRHAPHY)
$0.00
44602
3
SUTURE, SMALL INTESTINE
$1,210.79
44603
3
SUTURE, SMALL INTESTINE
$1,388.29
44604
3
SUTURE, LARGE INTESTINE
$932.41
44605
3
REPAIR OF BOWEL LESION
44610
O
SUTURE OF INTESTINE (ENTERORRHAPHY)
44615
3
INTESTINAL STRICTUROPLASTY
$947.82
44620
3
REPAIR BOWEL OPENING
$757.12
44625
3
REPAIR BOWEL OPENING
$896.18
44626
3
REPAIR BOWEL OPENING
$1,423.71
44640
3
REPAIR BOWEL-SKIN FISTULA
$1,242.41
44650
3
REPAIR BOWEL FISTULA
$1,292.19
44660
3
REPAIR BOWEL-BLADDER FISTULA
$1,254.79
44661
3
REPAIR BOWEL-BLADDER FISTULA
$1,404.86
44680
3
SURGICAL REVISION, INTESTINE
$936.04
44700
3
SUSPEND BOWEL W/PROSTHESIS
$906.18
$1,150.44 $0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
44701
3
INTRAOP COLON LAVAGE ADD-ON
$152.17
44715
9
PREPARE DONOR INTESTINE
$0.00
44720
9
PREP DONOR INTESTINE/VENOUS
$0.00
44721
9
PREP DONOR INTESTINE/ARTERY
$0.00
44799
5
UNLISTED PROCEDURE INTESTINE
$0.00
44800
3
EXCISION OF BOWEL POUCH
$668.19
44820
3
EXCISION OF MESENTERY LESION
$737.00
44850
3
REPAIR OF MESENTERY
$650.27
44899
5
BOWEL SURGERY PROCEDURE
44900
3
DRAIN APP ABSCESS, OPEN
$666.07
44901
3
DRAIN APP ABSCESS, PERCUT
$933.52
44950
3
APPENDECTOMY
$564.07
44955
3
APPENDECTOMY ADD-ON
44960
3
APPENDECTOMY
$759.21
44970
3
LAPAROSCOPY, APPENDECTOMY
$519.30
44979
5
LAPAROSCOPE PROC, APP
45000
3
DRAINAGE OF PELVIC ABSCESS
$363.79
45005
3
DRAINAGE OF RECTAL ABSCESS
$223.13
45020
3
DRAINAGE OF RECTAL ABSCESS
$474.13
45100
3
BIOPSY OF RECTUM
$253.35
45108
3
REMOVAL OF ANORECTAL LESION
$307.74
45110
3
REMOVAL OF RECTUM
45111
3
PARTIAL REMOVAL OF RECTUM
45112
3
REMOVAL OF RECTUM
$1,676.17
45113
3
PARTIAL PROCTECTOMY
$1,720.45
45114
3
PARTIAL REMOVAL OF RECTUM
$1,570.27
45116
3
PARTIAL REMOVAL OF RECTUM
$1,410.98
45119
3
REMOVE RECTUM W/RESERVOIR
$1,722.56
45120
3
REMOVAL OF RECTUM
$1,377.22
45121
3
REMOVAL OF RECTUM AND COLON
$1,506.52
45123
3
PARTIAL PROCTECTOMY
45126
3
PELVIC EXENTERATION
45130
3
EXCISION OF RECTAL PROLAPSE
$955.04
45135
3
EXCISION OF RECTAL PROLAPSE
$1,170.08
45136
3
EXCISE ILEOANAL RESERVIOR
$1,620.56
$0.00
$76.47
$0.00
$1,629.13 $956.93
$976.78 $2,546.97
Procedure Code Pricing Action Code Description
Maximum Allowable
45150
3
EXCISION OF RECTAL STRICTURE
$350.20
45160
3
EXCISION OF RECTAL LESION
$870.22
45170
3
EXCISION OF RECTAL LESION
$680.54
45180
O
EXCISION AND/OR ELECTRODESICCATION
45190
3
DESTRUCTION, RECTAL TUMOR
45300
3
PROCTOSIGMOIDOSCOPY DX
45302
O
PROCTOSIGMOIDOSCOPY; WITH COLLECTIO
45303
3
PROCTOSIGMOIDOSCOPY DILATE
$765.38
45305
3
PROCTOSIGMOIDOSCOPY W/BX
$158.96
45307
3
PROCTOSIGMOIDOSCOPY FB
$176.52
45308
3
PROCTOSIGMOIDOSCOPY REMOVAL
$161.98
45309
3
PROCTOSIGMOIDOSCOPY REMOVAL
$182.36
45310
O
PROCTOSIGMOIDOSCOPY; WITH REMOVAL O
45315
3
PROCTOSIGMOIDOSCOPY REMOVAL
$196.21
45317
3
PROCTOSIGMOIDOSCOPY BLEED
$189.31
45320
3
PROCTOSIGMOIDOSCOPY ABLATE
$190.92
45321
3
PROCTOSIGMOIDOSCOPY VOLVUL
$94.85
45327
3
PROCTOSIGMOIDOSCOPY W/STENT
$110.80
45330
3
DIAGNOSTIC SIGMOIDOSCOPY
$126.06
45331
3
SIGMOIDOSCOPY AND BIOPSY
$160.45
45332
3
SIGMOIDOSCOPY W/FB REMOVAL
$263.75
45333
3
SIGMOIDOSCOPY & POLYPECTOMY
$265.35
45334
3
SIGMOIDOSCOPY FOR BLEEDING
$156.32
45335
3
SIGMOIDOSCOPY W/SUBMUC INJ
$227.10
45336
O
SIGMOIDOSCOPY, FLEXIBLE FIBEROPTIC;
45337
3
SIGMOIDOSCOPY & DECOMPRESS
$133.73
45338
3
SIGMOIDOSCOPY W/TUMR REMOVE
$295.58
45339
3
SIGMOIDOSCOPY W/ABLATE TUMR
$305.51
45340
3
SIG W/BALLOON DILATION
$406.09
45341
3
SIGMOIDOSCOPY W/ULTRASOUND
$149.22
45342
3
SIGMOIDOSCOPY W/US GUIDE BX
$228.08
45345
3
SIGMOIDOSCOPY W/STENT
$165.68
45355
3
SURGICAL COLONOSCOPY
$190.25
45378
3
DIAGNOSTIC COLONOSCOPY
$369.74
45379
3
COLONOSCOPY W/FB REMOVAL
$469.39
$0.00 $593.32 $97.57 $0.00
$0.00
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
45380
3
COLONOSCOPY AND BIOPSY
$443.97
45381
3
COLONOSCOPY, SUBMUCOUS INJ
$432.35
45382
3
COLONOSCOPY/CONTROL BLEEDING
$585.46
45383
3
LESION REMOVAL COLONOSCOPY
$527.40
45384
3
LESION REMOVE COLONOSCOPY
$435.49
45385
3
LESION REMOVAL COLONOSCOPY
$500.04
45386
3
COLONOSCOPY DILATE STRICTURE
$620.37
45387
3
COLONOSCOPY W/STENT
$328.44
45391
3
COLONOSCOPY W/ENDOSCOPE US
$283.64
45392
3
COLONOSCOPY W/ENDOSCOPIC FNB
$358.75
45395
3
LAP, REMOVAL OF RECTUM
$1,761.52
45397
3
LAP, REMOVE RECTUM W/POUCH
$1,906.77
45400
3
LAPAROSCOPIC PROC
$1,015.96
45402
3
LAP PROCTOPEXY W/SIG RESECT
$1,357.77
45499
6
LAPAROSCOPE PROC, RECTUM
45500
3
REPAIR OF RECTUM
$448.85
45505
3
REPAIR OF RECTUM
$492.57
45520
3
TREATMENT OF RECTAL PROLAPSE
$114.02
45540
3
CORRECT RECTAL PROLAPSE
$937.08
45541
3
CORRECT RECTAL PROLAPSE
$806.79
45550
3
REPAIR RECTUM/REMOVE SIGMOID
45560
3
REPAIR OF RECTOCELE
$639.24
45562
3
EXPLORATION/REPAIR OF RECTUM
$979.24
45563
3
EXPLORATION/REPAIR OF RECTUM
$1,417.05
45800
3
REPAIR RECT/BLADDER FISTULA
$1,099.54
45805
3
REPAIR FISTULA W/COLOSTOMY
$1,241.48
45820
3
REPAIR RECTOURETHRAL FISTULA
$1,091.64
45825
3
REPAIR FISTULA W/COLOSTOMY
$1,314.34
45900
3
REDUCTION OF RECTAL PROLAPSE
$173.60
45905
3
DILATION OF ANAL SPHINCTER
$147.78
45910
3
DILATION OF RECTAL NARROWING
$174.88
45915
3
REMOVE RECTAL OBSTRUCTION
$275.39
45990
3
SURG DX EXAM, ANORECTAL
45999
5
RECTUM SURGERY PROCEDURE
$0.00
46000
O
FISTULOTOMY, SUBCUTANEOUS
$0.00
$0.00
$1,288.92
$96.86
Procedure Code Pricing Action Code Description
Maximum Allowable
46020
3
PLACEMENT OF SETON
$221.92
46030
3
REMOVAL OF RECTAL MARKER
$111.99
46040
3
INCISION OF RECTAL ABSCESS
$433.89
46045
3
INCISION OF RECTAL ABSCESS
$357.00
46050
3
INCISION OF ANAL ABSCESS
$156.77
46060
3
INCISION OF RECTAL ABSCESS
$393.21
46070
3
INCISION OF ANAL SEPTUM
$201.56
46080
3
INCISION OF ANAL SPHINCTER
$203.00
46083
3
INCISE EXTERNAL HEMORRHOID
$154.53
46200
3
REMOVAL OF ANAL FISSURE
$341.84
46210
3
REMOVAL OF ANAL CRYPT
$314.61
46211
3
REMOVAL OF ANAL CRYPTS
$424.68
46220
3
REMOVAL OF ANAL TAG
$164.80
46221
3
LIGATION OF HEMORRHOID(S)
$215.24
46230
3
REMOVAL OF ANAL TAGS
$225.08
46250
3
HEMORRHOIDECTOMY
$374.95
46255
3
HEMORRHOIDECTOMY
$417.87
46257
3
REMOVE HEMORRHOIDS & FISSURE
$352.14
46258
3
REMOVE HEMORRHOIDS & FISTULA
$384.90
46260
3
HEMORRHOIDECTOMY
$399.66
46261
3
REMOVE HEMORRHOIDS & FISSURE
$446.49
46262
3
REMOVE HEMORRHOIDS & FISTULA
$466.46
46270
3
REMOVAL OF ANAL FISTULA
$404.73
46275
3
REMOVAL OF ANAL FISTULA
$428.10
46280
3
REMOVAL OF ANAL FISTULA
$389.96
46281
O
CLOSURE OF ANAL FISTULA WITH RECTAL
46285
3
REMOVAL OF ANAL FISTULA
$415.83
46288
3
REPAIR ANAL FISTULA
$460.48
46320
3
REMOVAL OF HEMORRHOID CLOT
$148.34
46500
3
INJECTION INTO HEMORRHOID(S)
$181.11
46505
3
CHEMODENERVATION ANAL MUSC
$234.62
46600
3
DIAGNOSTIC ANOSCOPY
46602
O
ANOSCOPY FOR COLLECTION OF SPECIMEN
46604
3
ANOSCOPY AND DILATION
$458.56
46606
3
ANOSCOPY AND BIOPSY
$187.00
$0.00
$72.98 $0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
46608
3
ANOSCOPY, REMOVE FOR BODY
$193.00
46610
3
ANOSCOPY, REMOVE LESION
$190.93
46611
3
ANOSCOPY
$150.09
46612
3
ANOSCOPY, REMOVE LESIONS
$228.90
46614
3
ANOSCOPY, CONTROL BLEEDING
$115.21
46615
3
ANOSCOPY
$132.12
46700
3
REPAIR OF ANAL STRICTURE
$553.66
46705
3
REPAIR OF ANAL STRICTURE
$457.89
46706
3
REPR OF ANAL FISTULA W/GLUE
$146.80
46710
3
REPR PER/VAG POUCH SNGL PROC
$941.85
46712
3
REPR PER/VAG POUCH DBL PROC
46715
3
REP PERF ANOPER FISTU
46716
3
REP PERF ANOPER/VESTIB FISTU
$1,108.79
46730
3
CONSTRUCTION OF ABSENT ANUS
$1,670.41
46735
3
CONSTRUCTION OF ABSENT ANUS
$1,949.77
46740
3
CONSTRUCTION OF ABSENT ANUS
$1,790.53
46742
3
REPAIR OF IMPERFORATED ANUS
$2,115.75
46744
3
REPAIR OF CLOACAL ANOMALY
$3,013.24
46746
3
REPAIR OF CLOACAL ANOMALY
$3,486.32
46748
3
REPAIR OF CLOACAL ANOMALY
$3,638.02
46750
3
REPAIR OF ANAL SPHINCTER
$668.84
46751
3
REPAIR OF ANAL SPHINCTER
$557.22
46753
3
RECONSTRUCTION OF ANUS
$505.56
46754
3
REMOVAL OF SUTURE FROM ANUS
$243.89
46760
3
REPAIR OF ANAL SPHINCTER
$945.90
46761
3
REPAIR OF ANAL SPHINCTER
$817.42
46762
3
IMPLANT ARTIFICIAL SPHINCTER
$806.46
46900
3
DESTRUCTION, ANAL LESION(S)
$198.03
46910
3
DESTRUCTION, ANAL LESION(S)
$206.68
46916
3
CRYOSURGERY, ANAL LESION(S)
$204.76
46917
3
LASER SURGERY, ANAL LESIONS
$397.18
46922
3
EXCISION OF ANAL LESION(S)
$215.53
46924
3
DESTRUCTION, ANAL LESION(S)
$161.77
46930
3
DESTROY INTERNAL HEMORRHOIDS
$190.45
46934
O
DESTRUCTION OF HEMORRHOIDS
$1,918.19 $451.94
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
46935
O
DESTRUCTION OF HEMORRHOIDS
$0.00
46936
O
DESTRUCTION OF HEMORRHOIDS
$0.00
46937
3
CRYOTHERAPY OF RECTAL LESION
$220.74
46938
3
CRYOTHERAPY OF RECTAL LESION
$385.19
46940
3
TREATMENT OF ANAL FISSURE
$185.64
46942
3
TREATMENT OF ANAL FISSURE
$172.09
46945
3
LIGATION OF HEMORRHOIDS
$241.12
46946
3
LIGATION OF HEMORRHOIDS
$260.57
46947
3
HEMORRHOIDOPEXY BY STAPLING
$327.28
46999
5
ANUS SURGERY PROCEDURE
47000
3
NEEDLE BIOPSY OF LIVER
47001
3
NEEDLE BIOPSY, LIVER ADD-ON
$94.22
47010
3
OPEN DRAINAGE, LIVER LESION
$1,047.71
47011
3
PERCUT DRAIN, LIVER LESION
$189.26
47015
3
INJECT/ASPIRATE LIVER CYST
$993.71
47100
3
WEDGE BIOPSY OF LIVER
$729.22
47120
3
PARTIAL REMOVAL OF LIVER
$2,046.78
47122
3
EXTENSIVE REMOVAL OF LIVER
$3,042.64
47125
3
PARTIAL REMOVAL OF LIVER
$2,725.63
47130
3
PARTIAL REMOVAL OF LIVER
$2,930.41
47133
9
REMOVAL OF DONOR LIVER
$0.00
47134
O
PARTIAL REMOVAL, DONOR LIVER
$0.00
47135
3
TRANSPLANTATION OF LIVER
$4,314.50
47136
3
TRANSPLANTATION OF LIVER
$3,681.05
47140
9
PARTIAL REMOVAL, DONOR LIVER
$0.00
47141
9
PARTIAL REMOVAL, DONOR LIVER
$0.00
47142
9
PARTIAL REMOVAL, DONOR LIVER
$0.00
47143
9
PREP DONOR LIVER, WHOLE
$0.00
47144
9
PREP DONOR LIVER, 3-SEGMENT
$0.00
47145
9
PREP DONOR LIVER, LOBE SPLIT
$0.00
47146
9
PREP DONOR LIVER/VENOUS
$0.00
47147
9
PREP DONOR LIVER/ARTERIAL
$0.00
47300
3
SURGERY FOR LIVER LESION
47350
3
REPAIR LIVER WOUND
47355
O
HEPATORRHAPHY, SUTURE OF LIVER WOUN
$0.00 $310.35
$977.79 $1,199.36 $0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
47360
3
REPAIR LIVER WOUND
$1,630.71
47361
3
REPAIR LIVER WOUND
$2,678.15
47362
3
REPAIR LIVER WOUND
$1,244.22
47370
3
LAPARO ABLATE LIVER TUMOR RF
$1,096.11
47371
3
LAPARO ABLATE LIVER CRYOSURG
$1,117.27
47379
5
LAPAROSCOPE PROCEDURE, LIVER
$0.00
47380
3
OPEN ABLATE LIVER TUMOR RF
$1,281.15
47381
3
OPEN ABLATE LIVER TUMOR CRYO
$1,306.57
47382
3
PERCUT ABLATE LIVER RF
47399
5
LIVER SURGERY PROCEDURE
47400
3
INCISION OF LIVER DUCT
$1,859.80
47420
3
INCISION OF BILE DUCT
$1,174.25
47425
3
INCISION OF BILE DUCT
$1,185.87
47440
O
DUODENOCHOLEDOCHOTOMY, TRANSDUODENA
47460
3
INCISE BILE DUCT SPHINCTER
47480
3
INCISION OF GALLBLADDER
$747.24
47490
3
INCISION OF GALLBLADDER
$504.63
47500
3
INJECTION FOR LIVER X-RAYS
$100.65
47505
3
INJECTION FOR LIVER X-RAYS
$38.84
47510
3
INSERT CATHETER, BILE DUCT
$477.39
47511
3
INSERT BILE DUCT DRAIN
$598.29
47525
3
CHANGE BILE DUCT CATHETER
$505.86
47530
3
REVISE/REINSERT BILE TUBE
47550
3
BILE DUCT ENDOSCOPY ADD-ON
$150.77
47552
3
BILIARY ENDOSCOPY THRU SKIN
$324.25
47553
3
BILIARY ENDOSCOPY THRU SKIN
$323.78
47554
3
BILIARY ENDOSCOPY THRU SKIN
$474.32
47555
3
BILIARY ENDOSCOPY THRU SKIN
$388.53
47556
3
BILIARY ENDOSCOPY THRU SKIN
$439.51
47560
3
LAPAROSCOPY W/CHOLANGIO
$243.57
47561
3
LAPARO W/CHOLANGIO/BIOPSY
$264.52
47562
3
LAPAROSCOPIC CHOLECYSTECTOMY
$647.26
47563
3
LAPARO CHOLECYSTECTOMY/GRAPH
$662.22
47564
3
LAPARO CHOLECYSTECTOMY/EXPLR
$764.55
47570
3
LAPARO CHOLECYSTOENTEROSTOMY
$682.82
$811.29 $0.00
$0.00 $1,120.95
$1,384.58
Procedure Code Pricing Action Code Description
Maximum Allowable
47579
5
LAPAROSCOPE PROC, BILIARY
$0.00
47600
3
REMOVAL OF GALLBLADDER
$927.10
47605
3
REMOVAL OF GALLBLADDER
$858.18
47610
3
REMOVAL OF GALLBLADDER
$1,099.40
47612
3
REMOVAL OF GALLBLADDER
$1,110.63
47620
3
REMOVAL OF GALLBLADDER
$1,205.51
47630
3
REMOVE BILE DUCT STONE
$543.15
47700
3
EXPLORATION OF BILE DUCTS
$917.01
47701
3
BILE DUCT REVISION
47710
O
EXCISION OF BILE DUCT TUMOR, WITH R
47711
3
EXCISION OF BILE DUCT TUMOR
$1,365.15
47712
3
EXCISION OF BILE DUCT TUMOR
$1,747.02
47715
3
EXCISION OF BILE DUCT CYST
$1,147.85
47716
O
FUSION OF BILE DUCT CYST
$0.00
47719
O
FUSION OF BILE DUCT CYST
$0.00
47720
3
FUSE GALLBLADDER & BOWEL
$992.24
47721
3
FUSE UPPER GI STRUCTURES
$1,170.08
47740
3
FUSE GALLBLADDER & BOWEL
$1,130.68
47741
3
FUSE GALLBLADDER & BOWEL
$1,280.63
47760
3
FUSE BILE DUCTS AND BOWEL
$1,925.11
47765
3
FUSE LIVER DUCTS & BOWEL
$2,538.40
47780
3
FUSE BILE DUCTS AND BOWEL
$2,104.34
47785
3
FUSE BILE DUCTS AND BOWEL
$2,741.54
47800
3
RECONSTRUCTION OF BILE DUCTS
$1,378.47
47801
3
PLACEMENT, BILE DUCT SUPPORT
$977.42
47802
3
FUSE LIVER DUCT & INTESTINE
$1,323.72
47900
3
SUTURE BILE DUCT INJURY
$1,193.10
47999
5
BILE TRACT SURGERY PROCEDURE
48000
3
DRAINAGE OF ABDOMEN
$1,652.28
48001
3
PLACEMENT OF DRAIN, PANCREAS
$2,029.95
48005
O
RESECT/DEBRIDE PANCREAS
48020
3
REMOVAL OF PANCREATIC STONE
48100
3
BIOPSY OF PANCREAS, OPEN
$774.50
48102
3
NEEDLE BIOPSY, PANCREAS
$517.04
48105
3
RESECT/DEBRIDE PANCREAS
$1,576.73 $0.00
$0.00
$0.00 $1,020.27
$2,501.57
Procedure Code Pricing Action Code Description
Maximum Allowable
48120
3
REMOVAL OF PANCREAS LESION
$966.71
48140
3
PARTIAL REMOVAL OF PANCREAS
$1,368.22
48145
3
PARTIAL REMOVAL OF PANCREAS
$1,420.76
48146
3
PANCREATECTOMY
$1,622.69
48148
3
REMOVAL OF PANCREATIC DUCT
$1,077.45
48150
3
PARTIAL REMOVAL OF PANCREAS
$2,736.81
48151
O
PANCREATECTOMY, NEAR-TOTAL, WITH PR
48152
3
PANCREATECTOMY
$2,530.96
48153
3
PANCREATECTOMY
$2,732.90
48154
3
PANCREATECTOMY
$2,537.18
48155
3
REMOVAL OF PANCREAS
$1,574.61
48160
5
PANCREAS REMOVAL/TRANSPLANT
$0.00
48180
O
FUSE PANCREAS AND BOWEL
$0.00
48400
9
INJECTION, INTRAOP ADD-ON
$0.00
48500
3
SURGERY OF PANCREATIC CYST
$987.22
48510
3
DRAIN PANCREATIC PSEUDOCYST
$937.78
48511
3
DRAIN PANCREATIC PSEUDOCYST
$903.65
48520
3
FUSE PANCREAS CYST AND BOWEL
$955.73
48540
3
FUSE PANCREAS CYST AND BOWEL
$1,141.68
48545
3
PANCREATORRHAPHY
$1,156.20
48547
3
DUODENAL EXCLUSION
$1,558.50
48548
3
FUSE PANCREAS AND BOWEL
$1,460.38
48550
9
DONOR PANCREATECTOMY
$0.00
48551
9
PREP DONOR PANCREAS
$0.00
48552
9
PREP DONOR PANCREAS/VENOUS
$0.00
48554
3
TRANSPL ALLOGRAFT PANCREAS
$2,177.48
48556
3
REMOVAL, ALLOGRAFT PANCREAS
$1,083.79
48999
5
PANCREAS SURGERY PROCEDURE
$0.00
49000
3
EXPLORATION OF ABDOMEN
$680.97
49002
3
REOPENING OF ABDOMEN
$891.40
49010
3
EXPLORATION BEHIND ABDOMEN
$843.09
49020
3
DRAIN ABDOMINAL ABSCESS
$1,394.63
49021
3
DRAIN ABDOMINAL ABSCESS
$864.27
49040
3
DRAIN, OPEN, ABDOM ABSCESS
$874.47
49041
3
DRAIN, PERCUT, ABDOM ABSCESS
$881.47
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
49060
3
DRAIN, OPEN, RETROP ABSCESS
$978.92
49061
3
DRAIN, PERCUT, RETROPER ABSC
$189.26
49062
3
DRAIN TO PERITONEAL CAVITY
$666.05
49080
3
PUNCTURE, PERITONEAL CAVITY
$69.01
49081
3
REMOVAL OF ABDOMINAL FLUID
$152.18
49085
O
REMOVE ABDOMEN FOREIGN BODY
49180
3
BIOPSY, ABDOMINAL MASS
49200
O
REMOVAL OF ABDOMINAL LESION
$0.00
49201
O
REMOVE ABDOM LESION, COMPLEX
$0.00
49203
3
EXC ABD TUM 5 CM OR LESS
$1,065.96
49204
3
EXC ABD TUM OVER 5 CM
$1,360.38
49205
3
EXC ABD TUM OVER 10 CM
$1,557.22
49215
3
EXCISE SACRAL SPINE TUMOR
$1,952.41
49220
3
MULTIPLE SURGERY, ABDOMEN
$850.70
49250
3
EXCISION OF UMBILICUS
$509.14
49255
3
REMOVAL OF OMENTUM
$690.68
49300
O
PERITONEOSCOPY WITHOUT BIOPSY
$0.00
49301
O
PERITONEOSCOPY WITH BIOPSY
$0.00
49302
O
PERITONEOSCOPY WITH GUIDED TRANSHEP
$0.00
49303
O
PERITONEOSCOPY WITH GUIDED TRANSHEP
$0.00
49310
O
LAPAROSCOPY, SURGICAL; CHOLECYSTECT
$0.00
49311
O
LAPAROSCOPY, SURGICAL; CHOLECYSTECT
$0.00
49315
O
LAPAROSCOPY, SURGICAL;APPENDECTOMY
$0.00
49320
3
DIAG LAPARO SEPARATE PROC
$291.74
49321
3
LAPAROSCOPY, BIOPSY
$306.99
49322
3
LAPAROSCOPY, ASPIRATION
$333.51
49323
3
LAPARO DRAIN LYMPHOCELE
$566.35
49324
3
LAP INSERTION PERM IP CATH
$346.91
49325
3
LAP REVISION PERM IP CATH
$372.33
49326
3
LAP W/OMENTOPEXY ADD-ON
$170.74
49329
5
LAPARO PROC, ABDM/PER/OMENT
49400
3
AIR INJECTION INTO ABDOMEN
49401
O
PNEUMOPERITONEUM (SEPARATE PROCEDUR
49402
3
REMOVE FOREIGN BODY, ADBOMEN
$750.93
49419
3
INSRT ABDOM CATH FOR CHEMOTX
$402.98
$0.00 $162.93
$0.00 $169.49 $0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
49420
3
INSERT ABDOM DRAIN, TEMP
$127.99
49421
3
INSERT ABDOM DRAIN, PERM
$345.80
49422
3
REMOVE PERM CANNULA/CATHETER
$346.00
49423
3
EXCHANGE DRAINAGE CATHETER
$76.51
49424
3
ASSESS CYST, CONTRAST INJECT
$39.94
49425
3
INSERT ABDOMEN-VENOUS DRAIN
$675.92
49426
3
REVISE ABDOMEN-VENOUS SHUNT
$575.79
49427
3
INJECTION, ABDOMINAL SHUNT
49428
3
LIGATION OF SHUNT
$387.87
49429
3
REMOVAL OF SHUNT
$409.02
49435
3
INSERT SUBQ EXTEN TO IP CATH
$109.29
49436
3
EMBEDDED IP CATH EXIT-SITE
$162.36
49440
3
PLACE GASTROSTOMY TUBE PERC
$1,063.95
49441
3
PLACE DUOD/JEJ TUBE PERC
$1,154.92
49442
3
PLACE CECOSTOMY TUBE PERC
$1,035.62
49446
3
CHANGE G-TUBE TO G-J PERC
49450
3
REPLACE G/C TUBE PERC
$67.89
49451
3
REPLACE DUOD/JEJ TUBE PERC
$94.64
49452
3
REPLACE G-J TUBE PERC
$147.55
49460
3
FIX G/COLON TUBE W/DEVICE
$796.74
49465
3
FLUORO EXAM OF G/COLON TUBE
$165.95
49491
3
RPR HERN PREEMIE REDUC
$679.23
49492
3
RPR ING HERN PREMIE, BLOCKED
$829.29
49495
3
RPR ING HERNIA BABY, REDUC
$345.82
49496
3
RPR ING HERNIA BABY, BLOCKED
$524.68
49500
3
RPR ING HERNIA, INIT, REDUCE
$344.85
49501
3
RPR ING HERNIA, INIT BLOCKED
$520.75
49505
3
PRP I/HERN INIT REDUC >5 YR
$451.56
49507
3
PRP I/HERN INIT BLOCK >5 YR
$555.29
49510
O
REPAIR INGUINAL HERNIA, AGE 5 OR OV
$0.00
49515
O
REPAIR INGUINAL HERNIA, AGE 5 OR OV
$0.00
49520
3
REREPAIR ING HERNIA, REDUCE
$551.17
49521
3
REREPAIR ING HERNIA, BLOCKED
$671.65
49525
3
REPAIR ING HERNIA, SLIDING
$498.60
49530
O
REPAIR INGUINAL HERNIA, ANY AGE INC
$46.05
$968.12
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
49535
O
REPAIR INGUINAL HERNIA, ANY AGE STR
$0.00
49540
3
REPAIR LUMBAR HERNIA
$589.37
49550
3
RPR REM HERNIA, INIT, REDUCE
$500.99
49552
O
REPAIR FEMORAL HERNIA, HENRY APPROA
49553
3
RPR FEM HERNIA, INIT BLOCKED
$548.07
49555
3
REREPAIR FEM HERNIA, REDUCE
$521.53
49557
3
REREPAIR FEM HERNIA, BLOCKED
$632.83
49560
3
RPR VENTRAL HERN INIT, REDUC
$646.96
49561
3
RPR VENTRAL HERN INIT, BLOCK
$815.33
49565
3
REREPAIR VENTRL HERN, REDUCE
$670.80
49566
3
REREPAIR VENTRL HERN, BLOCK
$823.76
49568
3
HERNIA REPAIR W/MESH
$242.22
49570
3
RPR EPIGASTRIC HERN, REDUCE
$355.90
49572
3
RPR EPIGASTRIC HERN, BLOCKED
$440.31
49575
O
REPAIR EPIGASTRIC HERNIA, PROPERITO
49580
3
RPR UMBIL HERN, REDUC < 5 YR
49581
O
REPAIR UMBILICAL HERNIA AGE 5 OR OV
49582
3
RPR UMBIL HERN, BLOCK < 5 YR
$411.29
49585
3
RPR UMBIL HERN, REDUC > 5 YR
$382.42
49587
3
RPR UMBIL HERN, BLOCK > 5 YR
$452.72
49590
3
REPAIR SPIGELIAN HERNIA
$496.79
49600
3
REPAIR UMBILICAL LESION
$641.15
49605
3
REPAIR UMBILICAL LESION
$4,412.89
49606
3
REPAIR UMBILICAL LESION
$1,000.49
49610
3
REPAIR UMBILICAL LESION
$596.02
49611
3
REPAIR UMBILICAL LESION
$538.14
49650
3
LAP ING HERNIA REPAIR INIT
$372.01
49651
3
LAP ING HERNIA REPAIR RECUR
$480.68
49652
3
LAP VENT/ABD HERNIA REPAIR
$697.45
49653
3
LAP VENT/ABD HERN PROC COMP
$871.08
49654
3
LAP INC HERNIA REPAIR
$800.64
49655
3
LAP INC HERN REPAIR COMP
$963.71
49656
3
LAP INC HERNIA REPAIR RECUR
$803.52
49657
3
LAP INC HERN RECUR COMP
49659
5
LAPARO PROC, HERNIA REPAIR
$0.00
$0.00 $277.77 $0.00
$1,159.17 $0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
49900
3
REPAIR OF ABDOMINAL WALL
$713.91
49904
3
OMENTAL FLAP, EXTRA-ABDOM
49905
3
OMENTAL FLAP, INTRA-ABDOM
49906
5
FREE OMENTAL FLAP, MICROVASC
$0.00
49999
5
ABDOMEN SURGERY PROCEDURE
$0.00
50010
3
EXPLORATION OF KIDNEY
$699.38
50020
3
RENAL ABSCESS, OPEN DRAIN
$996.39
50021
3
RENAL ABSCESS, PERCUT DRAIN
$172.54
50040
3
DRAINAGE OF KIDNEY
$940.04
50045
3
EXPLORATION OF KIDNEY
$948.90
5005F
9
PT COUNSLD ON EXAM FOR MOLES
50060
3
REMOVAL OF KIDNEY STONE
$1,168.12
50065
3
INCISION OF KIDNEY
$1,227.03
50070
3
INCISION OF KIDNEY
$1,220.69
50075
3
REMOVAL OF KIDNEY STONE
$1,500.03
50080
3
REMOVAL OF KIDNEY STONE
$892.92
50081
3
REMOVAL OF KIDNEY STONE
$1,310.55
50100
3
REVISE KIDNEY BLOOD VESSELS
$953.23
5010F
9
MACUL+FNDNGS TO DR MNG DM
$0.00
50120
3
EXPLORATION OF KIDNEY
$967.29
50125
3
EXPLORE AND DRAIN KIDNEY
$999.91
50130
3
REMOVAL OF KIDNEY STONE
$1,058.70
50135
3
EXPLORATION OF KIDNEY
$1,146.04
5015F
9
DOC FX & TEST/TXMNT FOR OP
50200
3
BIOPSY OF KIDNEY
$144.77
50205
3
BIOPSY OF KIDNEY
$671.57
5020F
9
TXMNTS 2 MAIN DR BY 1 MON
50220
3
REMOVE KIDNEY, OPEN
$1,041.66
50225
3
REMOVAL KIDNEY OPEN, COMPLEX
$1,206.19
50230
3
REMOVAL KIDNEY OPEN, RADICAL
$1,307.75
50234
3
REMOVAL OF KIDNEY & URETER
$1,328.04
50236
3
REMOVAL OF KIDNEY & URETER
$1,503.71
50240
3
PARTIAL REMOVAL OF KIDNEY
$1,350.61
50250
3
CRYOABLATE RENAL MASS OPEN
$1,253.79
50280
3
REMOVAL OF KIDNEY LESION
$1,332.39 $323.40
$0.00
$0.00
$0.00
$963.26
Procedure Code Pricing Action Code Description
Maximum Allowable
50290
3
REMOVAL OF KIDNEY LESION
$887.63
50300
9
REMOVE CADAVER DONOR KIDNEY
50320
3
REMOVE KIDNEY, LIVING DONOR
50323
9
PREP CADAVER RENAL ALLOGRAFT
$0.00
50325
9
PREP DONOR RENAL GRAFT
$0.00
50327
9
PREP RENAL GRAFT/VENOUS
$0.00
50328
9
PREP RENAL GRAFT/ARTERIAL
$0.00
50329
9
PREP RENAL GRAFT/URETERAL
$0.00
50340
3
REMOVAL OF KIDNEY
50360
3
TRANSPLANTATION OF KIDNEY
$2,215.04
50365
3
TRANSPLANTATION OF KIDNEY
$2,494.92
50370
3
REMOVE TRANSPLANTED KIDNEY
$1,036.08
50380
3
REIMPLANTATION OF KIDNEY
$1,756.67
50382
3
CHANGE URETER STENT, PERCUT
$1,279.44
50384
3
REMOVE URETER STENT, PERCUT
$1,100.03
50385
3
CHANGE STENT VIA TRANSURETH
$1,253.56
50386
3
REMOVE STENT VIA TRANSURETH
$811.86
50387
3
CHANGE EXT/INT URETER STENT
$593.05
50389
3
REMOVE RENAL TUBE W/FLUORO
$344.15
50390
3
DRAINAGE OF KIDNEY LESION
$100.65
50391
3
INSTLL RX AGNT INTO RNAL TUB
$130.33
50392
3
INSERT KIDNEY DRAIN
$185.11
50393
3
INSERT URETERAL TUBE
$225.65
50394
3
INJECTION FOR KIDNEY X-RAY
$105.62
50395
3
CREATE PASSAGE TO KIDNEY
$186.45
50396
3
MEASURE KIDNEY PRESSURE
$120.69
50398
3
CHANGE KIDNEY TUBE
50400
3
REVISION OF KIDNEY/URETER
$1,179.30
50405
3
REVISION OF KIDNEY/URETER
$1,430.45
50500
3
REPAIR OF KIDNEY WOUND
$1,139.98
5050F
9
PLAN 2 MAIN DR. BY 1 MONTH
$0.00
50520
3
CLOSE KIDNEY-SKIN FISTULA
$1,057.71
50525
3
REPAIR RENAL-ABDOMEN FISTULA
$1,320.33
50526
3
REPAIR RENAL-ABDOMEN FISTULA
$1,380.59
50540
3
REVISION OF HORSESHOE KIDNEY
$1,154.63
$0.00 $1,313.00
$809.14
$75.51
Procedure Code Pricing Action Code Description
Maximum Allowable
50541
3
LAPARO ABLATE RENAL CYST
$941.71
50542
3
LAPARO ABLATE RENAL MASS
$1,194.99
50543
3
LAPARO PARTIAL NEPHRECTOMY
$1,524.46
50544
3
LAPAROSCOPY, PYELOPLASTY
$1,284.21
50545
3
LAPARO RADICAL NEPHRECTOMY
$1,378.44
50546
3
LAPAROSCOPIC NEPHRECTOMY
$1,223.08
50547
3
LAPARO REMOVAL DONOR KIDNEY
$1,467.30
50548
3
LAPARO REMOVE W/URETER
$1,389.60
50549
5
LAPAROSCOPE PROC, RENAL
50551
3
KIDNEY ENDOSCOPY
$379.03
50553
3
KIDNEY ENDOSCOPY
$395.32
50555
3
KIDNEY ENDOSCOPY & BIOPSY
$431.21
50557
3
KIDNEY ENDOSCOPY & TREATMENT
$440.09
50559
O
RENAL ENDOSCOPY/RADIOTRACER
$0.00
50561
3
KIDNEY ENDOSCOPY & TREATMENT
$498.98
50562
3
RENAL SCOPE W/TUMOR RESECT
$605.16
50570
3
KIDNEY ENDOSCOPY
$512.49
50572
3
KIDNEY ENDOSCOPY
$557.72
50574
3
KIDNEY ENDOSCOPY & BIOPSY
$588.99
50575
3
KIDNEY ENDOSCOPY
$744.77
50576
3
KIDNEY ENDOSCOPY & TREATMENT
$588.16
50578
O
RENAL ENDOSCOPY/RADIOTRACER
$0.00
50580
3
KIDNEY ENDOSCOPY & TREATMENT
$629.69
50590
3
FRAGMENTING OF KIDNEY STONE
$950.85
50592
3
PERC RF ABLATE RENAL TUMOR
$3,646.91
50593
3
PERC CRYO ABLATE RENAL TUM
$4,706.51
50600
3
EXPLORATION OF URETER
$955.78
50605
3
INSERT URETERAL SUPPORT
$919.94
5060F
9
FNDNGS MAMMO 2PT W/IN 3 DAYS
50610
3
REMOVAL OF URETER STONE
$975.82
50620
3
REMOVAL OF URETER STONE
$925.69
5062F
9
DOC F2FMAMMO FNDNG IN 5 DAYS
50630
3
REMOVAL OF URETER STONE
50650
3
REMOVAL OF URETER
$1,055.25
50660
3
REMOVAL OF URETER
$1,166.30
$0.00
$0.00
$0.00 $902.04
Procedure Code Pricing Action Code Description
Maximum Allowable
50684
3
INJECTION FOR URETER X-RAY
$50.91
50686
3
MEASURE URETER PRESSURE
$92.83
50688
3
CHANGE OF URETER TUBE/STENT
$81.18
50690
3
INJECTION FOR URETER X-RAY
$101.55
50700
3
REVISION OF URETER
$945.35
50715
3
RELEASE OF URETER
$1,114.00
50722
3
RELEASE OF URETER
$969.10
50725
3
RELEASE/REVISE URETER
50727
3
REVISE URETER
$511.76
50728
3
REVISE URETER
$703.07
50740
3
FUSION OF URETER & KIDNEY
$1,091.41
50750
3
FUSION OF URETER & KIDNEY
$1,187.12
50760
3
FUSION OF URETERS
$1,106.48
50770
3
SPLICING OF URETERS
$1,147.77
50780
3
REIMPLANT URETER IN BLADDER
$1,110.10
50782
3
REIMPLANT URETER IN BLADDER
$1,089.56
50783
3
REIMPLANT URETER IN BLADDER
$1,129.22
50785
3
REIMPLANT URETER IN BLADDER
$1,231.92
50800
3
IMPLANT URETER IN BOWEL
50810
3
FUSION OF URETER & BOWEL
$1,229.11
50815
3
URINE SHUNT TO INTESTINE
$1,248.52
50820
3
CONSTRUCT BOWEL BLADDER
$1,328.45
50825
3
CONSTRUCT BOWEL BLADDER
$1,685.83
50830
3
REVISE URINE FLOW
$1,828.94
50840
3
REPLACE URETER BY BOWEL
$1,256.66
50845
3
APPENDICO-VESICOSTOMY
$1,275.30
50860
3
TRANSPLANT URETER TO SKIN
$965.67
50900
3
REPAIR OF URETER
$849.62
50920
3
CLOSURE URETER/SKIN FISTULA
$898.80
50930
3
CLOSURE URETER/BOWEL FISTULA
50940
3
RELEASE OF URETER
50945
3
LAPAROSCOPY URETEROLITHOTOMY
$1,002.42
50947
3
LAPARO NEW URETER/BLADDER
$1,420.39
50948
3
LAPARO NEW URETER/BLADDER
$1,318.97
50949
5
LAPAROSCOPE PROC, URETER
$1,110.04
$936.78
$1,085.44 $903.89
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
50951
3
ENDOSCOPY OF URETER
$395.99
50953
3
ENDOSCOPY OF URETER
$417.78
50955
3
URETER ENDOSCOPY & BIOPSY
$462.34
50957
3
URETER ENDOSCOPY & TREATMENT
$449.36
50959
O
URETER ENDOSCOPY & TRACER
50961
3
URETER ENDOSCOPY & TREATMENT
$405.71
50970
3
URETER ENDOSCOPY
$386.66
50972
3
URETER ENDOSCOPY & CATHETER
$372.20
50974
3
URETER ENDOSCOPY & BIOPSY
$492.76
50976
3
URETER ENDOSCOPY & TREATMENT
$485.27
50978
O
URETER ENDOSCOPY & TRACER
50980
3
URETER ENDOSCOPY & TREATMENT
51000
O
DRAINAGE OF BLADDER
$0.00
51005
O
DRAINAGE OF BLADDER
$0.00
5100F
9
RSK FX REF W/N 24 HRS X-RAY
$0.00
51010
O
DRAINAGE OF BLADDER
$0.00
51020
3
INCISE & TREAT BLADDER
$474.40
51030
3
INCISE & TREAT BLADDER
$469.50
51040
3
INCISE & DRAIN BLADDER
$296.98
51045
3
INCISE BLADDER/DRAIN URETER
$472.50
51050
3
REMOVAL OF BLADDER STONE
$481.15
51060
3
REMOVAL OF URETER STONE
$592.40
51065
3
REMOVE URETER CALCULUS
$588.21
51080
3
DRAINAGE OF BLADDER ABSCESS
$412.51
51100
3
DRAIN BLADDER BY NEEDLE
51101
3
DRAIN BLADDER BY TROCAR/CATH
$127.95
51102
3
DRAIN BL W/CATH INSERTION
$240.73
51500
3
REMOVAL OF BLADDER CYST
$632.29
51520
3
REMOVAL OF BLADDER LESION
$596.34
51525
3
REMOVAL OF BLADDER LESION
$876.22
51530
3
REMOVAL OF BLADDER LESION
$780.69
51535
3
REPAIR OF URETER LESION
$792.90
51550
3
PARTIAL REMOVAL OF BLADDER
$962.61
51555
3
PARTIAL REMOVAL OF BLADDER
$1,279.62
51565
3
REVISE BLADDER & URETER(S)
$1,308.42
$0.00
$0.00 $371.27
$61.98
Procedure Code Pricing Action Code Description
Maximum Allowable
51570
3
REMOVAL OF BLADDER
$1,493.30
51575
3
REMOVAL OF BLADDER & NODES
$1,867.37
51580
3
REMOVE BLADDER/REVISE TRACT
$1,946.62
51585
3
REMOVAL OF BLADDER & NODES
$2,167.82
51590
3
REMOVE BLADDER/REVISE TRACT
$1,974.19
51595
3
REMOVE BLADDER/REVISE TRACT
$2,243.76
51596
3
REMOVE BLADDER/CREATE POUCH
$2,412.34
51597
3
REMOVAL OF PELVIC STRUCTURES
$2,325.93
51600
3
INJECTION FOR BLADDER X-RAY
$45.45
51605
3
PREPARATION FOR BLADDER XRAY
$39.36
51610
3
INJECTION FOR BLADDER X-RAY
51700
3
IRRIGATION OF BLADDER
$89.08
51701
3
INSERT BLADDER CATHETER
$62.08
51702
3
INSERT TEMP BLADDER CATH
$80.19
51703
3
INSERT BLADDER CATH, COMPLEX
$143.66
51705
3
CHANGE OF BLADDER TUBE
$115.76
51710
3
CHANGE OF BLADDER TUBE
$163.08
51715
3
ENDOSCOPIC INJECTION/IMPLANT
$300.32
51720
3
TREATMENT OF BLADDER LESION
$119.07
51725
3
SIMPLE CYSTOMETROGRAM
$225.65
51726
3
COMPLEX CYSTOMETROGRAM
$329.03
51736
3
URINE FLOW MEASUREMENT
51739
O
SOUND RECORDING OF EXTERNAL STREAM
51741
3
ELECTRO-UROFLOWMETRY, FIRST
51772
3
URETHRA PRESSURE PROFILE
$252.72
51784
3
ANAL/URINARY MUSCLE STUDY
$206.76
51785
3
ANAL/URINARY MUSCLE STUDY
$224.64
51792
3
URINARY REFLEX STUDY
$236.35
51795
3
URINE VOIDING PRESSURE STUDY
$310.24
51797
3
INTRAABDOMINAL PRESSURE TEST
$153.18
51798
3
US URINE CAPACITY MEASURE
51800
3
REVISION OF BLADDER/URETHRA
$1,064.35
51820
3
REVISION OF URINARY TRACT
$1,083.43
51840
3
ATTACH BLADDER/URETHRA
$647.72
51841
3
ATTACH BLADDER/URETHRA
$768.21
$113.51
$54.66 $0.00 $86.26
$21.14
Procedure Code Pricing Action Code Description
Maximum Allowable
51845
3
REPAIR BLADDER NECK
$590.99
51860
3
REPAIR OF BLADDER WOUND
$721.82
51865
3
REPAIR OF BLADDER WOUND
$894.04
51880
3
REPAIR OF BLADDER OPENING
$468.99
51900
3
REPAIR BLADDER/VAGINA LESION
$829.26
51920
3
CLOSE BLADDER-UTERUS FISTULA
$766.82
51925
3
HYSTERECTOMY/BLADDER REPAIR
$999.02
51940
3
CORRECTION OF BLADDER DEFECT
$1,635.00
51960
3
REVISION OF BLADDER & BOWEL
$1,414.27
51980
3
CONSTRUCT BLADDER OPENING
$725.42
51990
3
LAPARO URETHRAL SUSPENSION
$744.13
51992
3
LAPARO SLING OPERATION
$811.14
51999
6
LAPAROSCOPE PROC, BLA
52000
3
CYSTOSCOPY
$128.52
52001
3
CYSTOSCOPY, REMOVAL OF CLOTS
$394.88
52005
3
CYSTOSCOPY & URETER CATHETER
$298.76
52007
3
CYSTOSCOPY AND BIOPSY
$561.28
52010
3
CYSTOSCOPY & DUCT CATHETER
$416.85
52204
3
CYSTOSCOPY W/BIOPSY(S)
$145.42
52214
3
CYSTOSCOPY AND TREATMENT
$603.54
52224
3
CYSTOSCOPY AND TREATMENT
$865.04
52234
3
CYSTOSCOPY AND TREATMENT
$255.82
52235
3
CYSTOSCOPY AND TREATMENT
$299.86
52240
3
CYSTOSCOPY AND TREATMENT
$523.97
52250
3
CYSTOSCOPY AND RADIOTRACER
$251.30
52260
3
CYSTOSCOPY AND TREATMENT
$216.68
52265
3
CYSTOSCOPY AND TREATMENT
$439.00
52270
3
CYSTOSCOPY & REVISE URETHRA
$422.69
52275
3
CYSTOSCOPY & REVISE URETHRA
$578.12
52276
3
CYSTOSCOPY AND TREATMENT
$275.80
52277
3
CYSTOSCOPY AND TREATMENT
$336.78
52281
3
CYSTOSCOPY AND TREATMENT
$317.43
52282
3
CYSTOSCOPY, IMPLANT STENT
$347.45
52283
3
CYSTOSCOPY AND TREATMENT
$291.10
52285
3
CYSTOSCOPY AND TREATMENT
$293.48
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
52290
3
CYSTOSCOPY AND TREATMENT
$253.78
52300
3
CYSTOSCOPY AND TREATMENT
$291.30
52301
3
CYSTOSCOPY AND TREATMENT
$306.27
52305
3
CYSTOSCOPY AND TREATMENT
$289.44
52310
3
CYSTOSCOPY AND TREATMENT
$260.86
52315
3
CYSTOSCOPY AND TREATMENT
$461.25
52317
3
REMOVE BLADDER STONE
$345.49
52318
3
REMOVE BLADDER STONE
$492.98
52320
3
CYSTOSCOPY AND TREATMENT
$256.09
52325
3
CYSTOSCOPY, STONE REMOVAL
$333.09
52327
3
CYSTOSCOPY, INJECT MATERIAL
$550.37
52330
3
CYSTOSCOPY AND TREATMENT
$274.15
52332
3
CYSTOSCOPY AND TREATMENT
$149.06
52334
3
CREATE PASSAGE TO KIDNEY
$266.40
52335
O
ENDOSCOPY OF URINARY TRACT
$0.00
52336
O
CYSTOSCOPY, STONE REMOVAL
$0.00
52337
O
CYSTOSCOPY, STONE REMOVAL
$0.00
52338
O
CYSTOSCOPY AND TREATMENT
$0.00
52339
O
CYSTOSCOPY AND TREATMENT
$0.00
52340
O
CYSTOSCOPY AND TREATMENT
$0.00
52341
3
CYSTO W/URETER STRICTURE TX
$303.15
52342
3
CYSTO W/UP STRICTURE TX
$329.51
52343
3
CYSTO W/RENAL STRICTURE TX
$366.43
52344
3
CYSTO/URETERO, STRICTURE TX
$397.46
52345
3
CYSTO/URETERO W/UP STRICTURE
$423.81
52346
3
CYSTOURETERO W/RENAL STRICT
$478.19
52347
O
CYSTOSCOPY, RESECT DUCTS
52351
3
CYSTOURETERO & OR PYELOSCOPE
$326.09
52352
3
CYSTOURETERO W/STONE REMOVE
$382.94
52353
3
CYSTOURETERO W/LITHOTRIPSY
$440.44
52354
3
CYSTOURETERO W/BIOPSY
$407.12
52355
3
CYSTOURETERO W/EXCISE TUMOR
$485.20
52400
3
CYSTOURETERO W/CONGEN REPR
$499.14
52402
3
CYSTOURETHRO CUT EJACUL DUCT
$278.87
52450
3
INCISION OF PROSTATE
$477.48
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
52500
3
REVISION OF BLADDER NECK
$498.80
52510
O
DILATION PROSTATIC URETHRA
52601
3
PROSTATECTOMY (TURP)
52606
O
CONTROL POSTOP BLEEDING
$0.00
52612
O
PROSTATECTOMY, FIRST STAGE
$0.00
52614
O
PROSTATECTOMY, SECOND STAGE
$0.00
52620
O
REMOVE RESIDUAL PROSTATE
$0.00
52630
3
REMOVE PROSTATE REGROWTH
$452.70
52640
3
RELIEVE BLADDER CONTRACTURE
$310.05
52647
3
LASER SURGERY OF PROSTATE
$658.82
52648
3
LASER SURGERY OF PROSTATE
$2,301.11
52649
3
PROSTATE LASER ENUCLEATION
$1,004.71
52650
O
TRANSURETHRAL CRYOSURGICAL REMOVAL
52700
3
DRAINAGE OF PROSTATE ABSCESS
$442.31
53000
3
INCISION OF URETHRA
$151.83
53010
3
INCISION OF URETHRA
$297.99
53020
3
INCISION OF URETHRA
$100.38
53025
3
INCISION OF URETHRA
$65.95
53040
3
DRAINAGE OF URETHRA ABSCESS
$400.19
53060
3
DRAINAGE OF URETHRA ABSCESS
$176.46
53080
3
DRAINAGE OF URINARY LEAKAGE
$444.35
53085
3
DRAINAGE OF URINARY LEAKAGE
$626.53
53200
3
BIOPSY OF URETHRA
$158.72
53210
3
REMOVAL OF URETHRA
$785.34
53215
3
REMOVAL OF URETHRA
$953.62
53220
3
TREATMENT OF URETHRA LESION
$459.39
53230
3
REMOVAL OF URETHRA LESION
$611.80
53235
3
REMOVAL OF URETHRA LESION
$651.18
53240
3
SURGERY FOR URETHRA POUCH
$437.86
53250
3
REMOVAL OF URETHRA GLAND
$406.42
53260
3
TREATMENT OF URETHRA LESION
$202.66
53265
3
TREATMENT OF URETHRA LESION
$225.55
53270
3
REMOVAL OF URETHRA GLAND
$206.31
53275
3
REPAIR OF URETHRA DEFECT
$271.21
53400
3
REVISE URETHRA, STAGE 1
$816.97
$0.00 $843.59
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
53405
3
REVISE URETHRA, STAGE 2
$899.66
53410
3
RECONSTRUCTION OF URETHRA
$1,003.60
53415
3
RECONSTRUCTION OF URETHRA
$1,156.84
53420
3
RECONSTRUCT URETHRA, STAGE 1
$821.09
53425
3
RECONSTRUCT URETHRA, STAGE 2
$966.63
53430
3
RECONSTRUCTION OF URETHRA
$963.34
53431
3
RECONSTRUCT URETHRA/BLADDER
53440
3
MALE SLING PROCEDURE
$896.14
53442
3
REMOVE/REVISE MALE SLING
$789.59
53443
O
RECONSTRUCTION OF URETHRA
53444
3
INSERT TANDEM CUFF
$814.80
53445
3
INSERT URO/VES NCK SPHINCTER
$900.35
53446
3
REMOVE URO SPHINCTER
$658.54
53447
3
REMOVE/REPLACE UR SPHINCTER
$832.30
53448
3
REMOV/REPLC UR SPHINCTR COMP
53449
3
REPAIR URO SPHINCTER
$625.98
53450
3
REVISION OF URETHRA
$416.87
53460
3
REVISION OF URETHRA
$467.99
53500
3
URETHRLYS, TRANSVAG W/ SCOPE
$751.36
53502
3
REPAIR OF URETHRA INJURY
$494.64
53505
3
REPAIR OF URETHRA INJURY
$497.15
53510
3
REPAIR OF URETHRA INJURY
$646.53
53515
3
REPAIR OF URETHRA INJURY
$814.44
53520
3
REPAIR OF URETHRA DEFECT
$567.60
53600
3
DILATE URETHRA STRICTURE
$88.65
53601
3
DILATE URETHRA STRICTURE
$86.61
53605
3
DILATE URETHRA STRICTURE
$66.75
53620
3
DILATE URETHRA STRICTURE
$127.08
53621
3
DILATE URETHRA STRICTURE
$120.51
53640
O
PASSAGE OF FILIFORM AND FOLLOWER FO
53660
3
DILATION OF URETHRA
$75.37
53661
3
DILATION OF URETHRA
$74.99
53665
3
DILATION OF URETHRA
$38.95
53670
O
INSERT URINARY CATHETER
$0.00
53675
O
INSERT URINARY CATHETER
$0.00
$1,182.35
$0.00
$1,313.73
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
53800
O
TWO OR THREE GLASS TEST INCLUDING E
$0.00
53850
3
PROSTATIC MICROWAVE THERMOTX
$2,593.54
53852
3
PROSTATIC RF THERMOTX
$2,493.94
53853
O
PROSTATIC WATER THERMOTHER
$0.00
53899
5
UROLOGY SURGERY PROCEDURE
$0.00
54000
3
SLITTING OF PREPUCE
$161.16
54001
3
SLITTING OF PREPUCE
$197.55
54015
3
DRAIN PENIS LESION
$316.77
54050
3
DESTRUCTION, PENIS LESION(S)
$121.26
54055
3
DESTRUCTION, PENIS LESION(S)
$115.75
54056
3
CRYOSURGERY, PENIS LESION(S)
$126.69
54057
3
LASER SURG, PENIS LESION(S)
$139.61
54060
3
EXCISION OF PENIS LESION(S)
$188.15
54065
3
DESTRUCTION, PENIS LESION(S)
$205.65
54100
3
BIOPSY OF PENIS
$189.34
54105
3
BIOPSY OF PENIS
$283.74
54110
3
TREATMENT OF PENIS LESION
$636.85
54111
3
TREAT PENIS LESION, GRAFT
$822.39
54112
3
TREAT PENIS LESION, GRAFT
$965.18
54115
3
TREATMENT OF PENIS LESION
$460.31
54120
3
PARTIAL REMOVAL OF PENIS
$644.28
54125
3
REMOVAL OF PENIS
$829.74
54130
3
REMOVE PENIS & NODES
$1,227.46
54135
3
REMOVE PENIS & NODES
$1,557.30
54150
3
CIRCUMCISION W/REGIONL BLOCK
54152
O
CIRCUMCISION
54160
3
CIRCUMCISION, NEONATE
$148.23
54161
3
CIRCUM 28 DAYS OR OLDER
$201.46
54162
3
LYSIS PENIL CIRCUMIC LESION
$277.16
54163
3
REPAIR OF CIRCUMCISION
$222.44
54164
9
FRENULOTOMY OF PENIS
54200
3
TREATMENT OF PENIS LESION
$113.35
54205
3
TREATMENT OF PENIS LESION
$548.18
54220
3
TREATMENT OF PENIS LESION
$218.84
54230
3
PREPARE PENIS STUDY
$100.32
$99.46 $0.00
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
54231
O
DYNAMIC CAVERNOSOMETRY
$0.00
54235
O
PENILE INJECTION
$0.00
54240
O
PENIS STUDY
$0.00
54250
O
PENIS STUDY
$0.00
54300
3
REVISION OF PENIS
$664.09
54304
3
REVISION OF PENIS
$777.52
54308
3
RECONSTRUCTION OF URETHRA
$740.40
54312
3
RECONSTRUCTION OF URETHRA
$855.63
54316
3
RECONSTRUCTION OF URETHRA
$1,034.28
54318
3
RECONSTRUCTION OF URETHRA
$746.45
54322
3
RECONSTRUCTION OF URETHRA
$809.40
54324
3
RECONSTRUCTION OF URETHRA
$1,005.49
54326
3
RECONSTRUCTION OF URETHRA
$943.69
54328
3
REVISE PENIS/URETHRA
$958.11
54332
3
REVISE PENIS/URETHRA
$1,047.56
54336
3
REVISE PENIS/URETHRA
$1,186.22
54340
3
SECONDARY URETHRAL SURGERY
$576.67
54344
3
SECONDARY URETHRAL SURGERY
$992.76
54348
3
SECONDARY URETHRAL SURGERY
$1,053.65
54352
3
RECONSTRUCT URETHRA/PENIS
$1,484.40
54360
3
PENIS PLASTIC SURGERY
$746.12
54380
3
REPAIR PENIS
$826.80
54385
3
REPAIR PENIS
$1,000.79
54390
3
REPAIR PENIS AND BLADDER
$1,209.05
54400
O
INSERT SEMI-RIGID PROSTHESIS
$0.00
54401
O
INSERT SELF-CONTD PROSTHESIS
$0.00
54402
O
REMOVE PENIS PROSTHESIS
$0.00
54405
O
INSERT MULTI-COMP PENIS PROS
$0.00
54406
9
REMOVE MUTI-COMP PENIS PROS
$0.00
54407
O
REMOVE MULTI-COMP PROSTHESIS
$0.00
54408
9
REPAIR MULTI-COMP PENIS PROS
$0.00
54409
O
REVISE PENIS PROSTHESIS
$0.00
54410
9
REMOVE/REPLACE PENIS PROSTH
$0.00
54411
9
REMOV/REPLC PENIS PROS, COMP
$0.00
54415
9
REMOVE SELF-CONTD PENIS PROS
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
54416
9
REMV/REPL PENIS CONTAIN PROS
$0.00
54417
9
REMV/REPLC PENIS PROS, COMPL
$0.00
54420
3
REVISION OF PENIS
$725.93
54430
3
REVISION OF PENIS
$658.12
54435
3
REVISION OF PENIS
$426.80
54440
5
REPAIR OF PENIS
54450
3
PREPUTIAL STRETCHING
$75.22
54500
3
BIOPSY OF TESTIS
$77.67
54505
3
BIOPSY OF TESTIS
$218.46
54510
O
REMOVAL OF TESTIS LESION
54512
3
EXCISE LESION TESTIS
$547.38
54520
3
REMOVAL OF TESTIS
$332.31
54522
3
ORCHIECTOMY, PARTIAL
$593.65
54530
3
REMOVAL OF TESTIS
$518.27
54535
3
EXTENSIVE TESTIS SURGERY
$750.46
54550
3
EXPLORATION FOR TESTIS
$499.27
54560
3
EXPLORATION FOR TESTIS
$679.27
54600
3
REDUCE TESTIS TORSION
$462.08
54620
3
SUSPENSION OF TESTIS
$310.08
54640
3
SUSPENSION OF TESTIS
$475.03
54645
O
ORCHIOPEXY, ANY TYPE, WITH OR WITHO
54650
3
ORCHIOPEXY (FOWLER-STEPHENS)
54660
9
REVISION OF TESTIS
54670
3
REPAIR TESTIS INJURY
$413.15
54680
3
RELOCATION OF TESTIS(ES)
$800.66
54690
3
LAPAROSCOPY, ORCHIECTOMY
$645.62
54692
3
LAPAROSCOPY, ORCHIOPEXY
$791.05
54699
5
LAPAROSCOPE PROC, TESTIS
$0.00
54700
3
DRAINAGE OF SCROTUM
$215.40
54800
3
BIOPSY OF EPIDIDYMIS
$135.73
54820
O
EXPLORATION OF EPIDIDYMIS
54830
3
REMOVE EPIDIDYMIS LESION
$376.29
54840
3
REMOVE EPIDIDYMIS LESION
$330.34
54860
3
REMOVAL OF EPIDIDYMIS
$426.37
54861
3
REMOVAL OF EPIDIDYMIS
$575.95
$0.00
$0.00
$0.00 $725.83 $0.00
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
54865
3
EXPLORE EPIDIDYMIS
$363.41
54900
3
FUSION OF SPERMATIC DUCTS
$769.84
54901
3
FUSION OF SPERMATIC DUCTS
$1,098.53
55000
3
DRAINAGE OF HYDROCELE
$124.72
55040
3
REMOVAL OF HYDROCELE
$343.40
55041
3
REMOVAL OF HYDROCELES
$516.03
55060
3
REPAIR OF HYDROCELE
$383.97
55100
3
DRAINAGE OF SCROTUM ABSCESS
$220.72
55110
3
EXPLORE SCROTUM
$390.42
55120
3
REMOVAL OF SCROTUM LESION
$358.43
55150
3
REMOVAL OF SCROTUM
$494.49
55175
3
REVISION OF SCROTUM
$367.75
55180
3
REVISION OF SCROTUM
$697.80
55200
9
INCISION OF SPERM DUCT
55250
3
REMOVAL OF SPERM DUCT(S)
55300
9
PREPARE, SPERM DUCT X-RAY
$0.00
55400
9
REPAIR OF SPERM DUCT
$0.00
55450
3
LIGATION OF SPERM DUCT
$391.95
55500
3
REMOVAL OF HYDROCELE
$380.49
55520
3
REMOVAL OF SPERM CORD LESION
$390.66
55530
3
REVISE SPERMATIC CORD VEINS
$360.15
55535
3
REVISE SPERMATIC CORD VEINS
$435.05
55540
3
REVISE HERNIA & SPERM VEINS
$473.05
55550
3
LAPARO LIGATE SPERMATIC VEIN
$430.42
55559
5
LAPARO PROC, SPERMATIC CORD
$0.00
55600
3
INCISE SPERM DUCT POUCH
$434.43
55605
3
INCISE SPERM DUCT POUCH
$512.28
55650
3
REMOVE SPERM DUCT POUCH
$728.60
55680
3
REMOVE SPERM POUCH LESION
$345.59
55700
3
BIOPSY OF PROSTATE
$237.54
55705
3
BIOPSY OF PROSTATE
$275.96
55706
3
PROSTATE SATURATION SAMPLING
$391.41
55720
3
DRAINAGE OF PROSTATE ABSCESS
$472.46
55725
3
DRAINAGE OF PROSTATE ABSCESS
$599.76
55740
O
PROSTATOLITHOTOMY, REMOVAL OF PROST
$0.00 $231.48
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
55801
3
REMOVAL OF PROSTATE
$1,112.17
55810
3
EXTENSIVE PROSTATE SURGERY
$1,344.62
55812
3
EXTENSIVE PROSTATE SURGERY
$1,652.44
55815
3
EXTENSIVE PROSTATE SURGERY
$1,812.35
55821
3
REMOVAL OF PROSTATE
$895.13
55831
3
REMOVAL OF PROSTATE
$969.84
55840
3
EXTENSIVE PROSTATE SURGERY
$1,372.57
55842
3
EXTENSIVE PROSTATE SURGERY
$1,470.74
55845
3
EXTENSIVE PROSTATE SURGERY
$1,681.62
55859
O
PERCUT/NEEDLE INSERT, PROS
55860
3
SURGICAL EXPOSURE, PROSTATE
55862
3
EXTENSIVE PROSTATE SURGERY
$1,134.28
55865
3
EXTENSIVE PROSTATE SURGERY
$1,373.86
55866
3
LAPARO RADICAL PROSTATECTOMY
$1,787.09
55870
O
VAG HYST W/ENTEROCELE REPAIR
55873
3
CRYOABLATE PROSTATE
55875
3
TRANSPERI NEEDLE PLACE, PROS
$779.78
55876
3
PLACE RT DEVICE/MARKER, PROS
$145.80
55899
5
GENITAL SURGERY PROCEDURE
$0.00
55920
3
PLACE NEEDLES PELVIC FOR RT
$437.29
55970
9
SEX TRANSFORMATION, M TO F
$0.00
55980
9
SEX TRANSFORMATION, F TO M
$0.00
56000
O
INCISION AND DRAINAGE OF PERINEAL A
$0.00
56100
O
BIOPSY OF PERINEUM (SEPARATE PROCED
$0.00
56200
O
PERINEOPLASTY, REPAIR OF PERINEUM,
$0.00
56300
O
LAPAROSCOPY; DIAGNOSTIC
$0.00
56301
O
LAPAROSCOPY; TUBAL CAUTERY
$0.00
56302
O
LAPAROSCOPY; TUBAL BLOCK
$0.00
56303
O
LAPAROSCOPY; EXCISE LESIONS
$0.00
56304
O
LAPAROSCOPY; LYSIS
$0.00
56305
O
LAPAROSCOPY; BIOPSY
$0.00
56306
O
LAPAROSCOPY; ASPIRATION
$0.00
56307
O
LAPAROSCOPY; REMOVE ADNEXA
$0.00
56308
O
LAPAROSCOPY; HYSTERECTOMY
$0.00
56309
O
LAPAROSCOPY; REMOVE MYOMA
$0.00
$0.00 $897.87
$0.00 $1,170.77
Procedure Code Pricing Action Code Description
Maximum Allowable
56310
O
LAPAROSCOPIC ENTEROLYSIS
$0.00
56311
O
LAPAROSCOPIC LYMPH NODE BIOP
$0.00
56312
O
LAPAROSCOPIC LYMPHADENECTOMY
$0.00
56313
O
LAPAROSCOPIC LYMPHADENECTOMY
$0.00
56314
O
LAPAR; DRAIN LYMPHOCELE
$0.00
56315
O
LAPAROSCOPIC APPENDECTOMY
$0.00
56316
O
LAPAROSCOPIC HERNIA REPAIR
$0.00
56317
O
LAPAROSCOPIC HERNIA REPAIR
$0.00
56318
O
LAPAROSCOPIC ORCHIECTOMY
$0.00
56320
O
LAPAROSCOPY, SPERMATIC VEINS
$0.00
56321
O
LAPAROSCOPY; ADRENALECTOMY
$0.00
56322
O
LAPAROSCOPY, VAGUS NERVES
$0.00
56323
O
LAPAROSCOPY, VAGUS NERVES
$0.00
56324
O
LAPAROSCOPY, CHOLECYSTOENTER
$0.00
56340
O
LAPAROSCOPIC CHOLECYSTECTOMY
$0.00
56341
O
LAPAROSCOPIC CHOLECYSTECTOMY
$0.00
56342
O
LAPAROSCOPIC CHOLECYSTECTOMY
$0.00
56343
O
LAPAROSCOPIC SALPINGOSTOMY
$0.00
56344
O
LAPAROSCOPIC FIMBRIOPLASTY
$0.00
56345
O
LAPAROSCOPIC SPLENECTOMY
$0.00
56346
O
LAPAROSCOPIC GASTROSTOMY
$0.00
56347
O
LAPAROSCOPIC JEJUNOSTOMY
$0.00
56348
O
LAPARO; RESECT INTESTINE
$0.00
56349
O
LAPAROSCOPY; FUNDOPLASTY
$0.00
56350
O
HYSTEROSCOPY; DIAGNOSTIC
$0.00
56351
O
HYSTEROSCOPY; BIOPSY
$0.00
56352
O
HYSTEROSCOPY; LYSIS
$0.00
56353
O
HYSTEROSCOPY; RESECT SEPTUM
$0.00
56354
O
HYSTEROSCOPY; REMOVE MYOMA
$0.00
56355
O
HYSTEROSCOPY; REMOVE IMPACT
$0.00
56356
O
HYSTEROSCOPY; ABLATION
$0.00
56360
O
PERITONEOSCOPY; WITHOUT BIOPSY
$0.00
56361
O
PERITONEOSCOPY; WITH BIOPSY
$0.00
56362
O
LAPAROSCOPY W/CHOLANGIO
$0.00
56363
O
LAPAROSCOPY W/BIOPSY
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
56399
O
LAPAROSCOPY PROCEDURE
$0.00
56400
O
INCISION AND DRAINAGE, ABSCESS OF V
$0.00
56405
3
I & D OF VULVA/PERINEUM
$101.35
56420
3
DRAINAGE OF GLAND ABSCESS
$117.44
56440
3
SURGERY FOR VULVA LESION
$170.61
56441
3
LYSIS OF LABIAL LESION(S)
$140.60
56442
3
HYMENOTOMY
56501
3
DESTROY, VULVA LESIONS, SIM
$121.81
56515
3
DESTROY VULVA LESION/S COMPL
$207.13
56600
O
BIOPSY OF VULVA (SEPARATE PROCEDURE
56605
3
BIOPSY OF VULVA/PERINEUM
$78.28
56606
3
BIOPSY OF VULVA/PERINEUM
$36.12
56620
3
PARTIAL REMOVAL OF VULVA
$459.45
56625
3
COMPLETE REMOVAL OF VULVA
$551.67
56630
3
EXTENSIVE VULVA SURGERY
$805.41
56631
3
EXTENSIVE VULVA SURGERY
$1,024.51
56632
3
EXTENSIVE VULVA SURGERY
$1,186.63
56633
3
EXTENSIVE VULVA SURGERY
$1,050.05
56634
3
EXTENSIVE VULVA SURGERY
$1,109.56
56635
O
VULVECTOMY, RADICAL WITH INGUINOFEM
56637
3
EXTENSIVE VULVA SURGERY
$1,310.61
56640
3
EXTENSIVE VULVA SURGERY
$1,306.51
56680
O
CLITORIDECTOMY SIMPLE
$0.00
56685
O
CLITORIDECTOMY EXTENSIVE
$0.00
56700
3
PARTIAL REMOVAL OF HYMEN
$173.07
56710
O
PLASTIC REVISION OF HYMEN
$0.00
56720
O
INCISION OF HYMEN
$0.00
56740
3
REMOVE VAGINA GLAND LESION
$275.86
56800
3
REPAIR OF VAGINA
$227.17
56805
3
REPAIR CLITORIS
56810
3
REPAIR OF PERINEUM
$243.82
56820
3
EXAM OF VULVA W/SCOPE
$103.76
56821
3
EXAM/BIOPSY OF VULVA W/SCOPE
$138.77
57000
3
EXPLORATION OF VAGINA
$177.86
57010
3
DRAINAGE OF PELVIC ABSCESS
$399.83
$45.82
$0.00
$0.00
$1,067.46
Procedure Code Pricing Action Code Description
Maximum Allowable
57020
3
DRAINAGE OF PELVIC FLUID
$88.23
57022
3
I & D VAGINAL HEMATOMA, PP
$154.84
57023
3
I & D VAG HEMATOMA, NON-OB
$290.01
57061
3
DESTROY VAG LESIONS, SIMPLE
$106.28
57065
3
DESTROY VAG LESIONS, COMPLEX
$179.42
57100
3
BIOPSY OF VAGINA
$82.84
57105
3
BIOPSY OF VAGINA
$126.90
57106
3
REMOVE VAGINA WALL, PARTIAL
$440.96
57107
3
REMOVE VAGINA TISSUE, PART
57108
O
PARTIAL REMOVAL OF VAGINA
57109
3
VAGINECTOMY PARTIAL W/NODES
57110
3
REMOVE VAGINA WALL, COMPLETE
57111
3
REMOVE VAGINA TISSUE, COMPL
$1,502.36
57112
3
VAGINECTOMY W/NODES, COMPL
$1,594.58
57120
3
CLOSURE OF VAGINA
57126
9
COMPLEX CYSTOMETROGRAM (EG, CALIBRA
57130
3
REMOVE VAGINA LESION
$169.20
57135
3
REMOVE VAGINA LESION
$181.20
57150
3
TREAT VAGINA INFECTION
57155
3
INSERT UTERI TANDEMS/OVOIDS
$394.91
57160
3
INSERT PESSARY/OTHER DEVICE
$72.65
57170
3
FITTING OF DIAPHRAGM/CAP
$65.10
57180
3
TREAT VAGINAL BLEEDING
$133.46
57200
3
REPAIR OF VAGINA
$276.28
57210
3
REPAIR VAGINA/PERINEUM
$342.11
57220
3
REVISION OF URETHRA
$297.66
57230
3
REPAIR OF URETHRAL LESION
$372.00
57240
3
REPAIR BLADDER & VAGINA
$617.04
57250
3
REPAIR RECTUM & VAGINA
$602.97
57260
3
REPAIR OF VAGINA
$751.19
57265
3
EXTENSIVE REPAIR OF VAGINA
$839.43
57267
3
INSERT MESH/PELVIC FLR ADDON
$252.94
57268
3
REPAIR OF BOWEL BULGE
$448.16
57270
3
REPAIR OF BOWEL POUCH
$742.24
57280
3
SUSPENSION OF VAGINA
$902.57
$1,300.48 $0.00 $1,485.94 $837.88
$476.31 $0.00
$47.95
Procedure Code Pricing Action Code Description
Maximum Allowable
57282
3
COLPOPEXY, EXTRAPERITONEAL
$475.41
57283
3
COLPOPEXY, INTRAPERITONEAL
$640.48
57284
3
REPAIR PARAVAG DEFECT, OPEN
$782.57
57285
3
REPAIR PARAVAG DEFECT, VAG
$624.92
57287
3
REVISE/REMOVE SLING REPAIR
$659.79
57288
3
REPAIR BLADDER DEFECT
$692.63
57289
3
REPAIR BLADDER & VAGINA
$727.58
57291
3
CONSTRUCTION OF VAGINA
$505.66
57292
3
CONSTRUCT VAGINA WITH GRAFT
$772.65
57295
3
REVISE VAG GRAFT VIA VAGINA
$460.33
57296
3
REVISE VAG GRAFT, OPEN ABD
$882.80
57300
3
REPAIR RECTUM-VAGINA FISTULA
$494.18
57305
3
REPAIR RECTUM-VAGINA FISTULA
$823.77
57307
3
FISTULA REPAIR & COLOSTOMY
$921.68
57308
3
FISTULA REPAIR, TRANSPERINE
$589.25
57310
3
REPAIR URETHROVAGINAL LESION
$462.41
57311
3
REPAIR URETHROVAGINAL LESION
$527.45
57320
3
REPAIR BLADDER-VAGINA LESION
$525.49
57330
3
REPAIR BLADDER-VAGINA LESION
$744.91
57335
3
REPAIR VAGINA
57400
3
DILATION OF VAGINA
$126.91
57410
3
PELVIC EXAMINATION
$99.75
57415
3
REMOVE VAGINAL FOREIGN BODY
$149.14
57420
3
EXAM OF VAGINA W/SCOPE
$109.05
57421
3
EXAM/BIOPSY OF VAG W/SCOPE
$146.82
57423
3
REPAIR PARAVAG DEFECT, LAP
$863.06
57425
3
LAPAROSCOPY, SURG, COLPOPEXY
$910.02
57450
O
CULDOSCOPY, DIAGNOSTIC
$0.00
57451
O
CULDOSCOPY, DIAGNOSTIC WITH BIOPSY
$0.00
57452
3
EXAM OF CERVIX W/SCOPE
$102.65
57454
3
BX/CURETT OF CERVIX W/SCOPE
$144.69
57455
3
BIOPSY OF CERVIX W/SCOPE
$134.91
57456
3
ENDOCERV CURETTAGE W/SCOPE
$127.58
57460
3
BX OF CERVIX W/SCOPE, LEEP
$281.93
57461
3
CONZ OF CERVIX W/SCOPE, LEEP
$315.77
$1,084.35
Procedure Code Pricing Action Code Description
Maximum Allowable
57500
3
BIOPSY OF CERVIX
$124.87
57505
3
ENDOCERVICAL CURETTAGE
57510
3
CAUTERIZATION OF CERVIX
$124.43
57511
3
CRYOCAUTERY OF CERVIX
$135.87
57513
3
LASER SURGERY OF CERVIX
$134.02
57520
3
CONIZATION OF CERVIX
$287.70
57522
3
CONIZATION OF CERVIX
$246.03
57530
3
REMOVAL OF CERVIX
$319.88
57531
3
REMOVAL OF CERVIX, RADICAL
57540
3
REMOVAL OF RESIDUAL CERVIX
$723.69
57545
3
REMOVE CERVIX/REPAIR PELVIS
$763.33
57550
3
REMOVAL OF RESIDUAL CERVIX
$378.04
57555
3
REMOVE CERVIX/REPAIR VAGINA
$557.05
57556
3
REMOVE CERVIX, REPAIR BOWEL
$532.26
57558
3
D&C OF CERVICAL STUMP
$116.94
57700
3
REVISION OF CERVIX
$285.22
57720
3
REVISION OF CERVIX
$284.91
57800
3
DILATION OF CERVICAL CANAL
57820
O
D & C OF RESIDUAL CERVIX
$0.00
58100
3
BIOPSY OF UTERUS LINING
$103.35
58101
O
ENDOMETRIAL WASHINGS (EG, FOR CYTOL
$0.00
58102
O
OFFICE ENDOMETRIAL CURETTAGE
$0.00
58110
3
BX DONE W/COLPOSCOPY ADD-ON
$45.94
58120
3
DILATION AND CURETTAGE
$233.08
58140
3
MYOMECTOMY ABDOM METHOD
$847.93
58145
3
MYOMECTOMY VAG METHOD
$503.69
58146
3
MYOMECTOMY ABDOM COMPLEX
58150
3
TOTAL HYSTERECTOMY
$918.49
58152
3
TOTAL HYSTERECTOMY
$1,159.43
58180
3
PARTIAL HYSTERECTOMY
58200
3
EXTENSIVE HYSTERECTOMY
$1,213.89
58210
3
EXTENSIVE HYSTERECTOMY
$1,616.80
58240
3
REMOVAL OF PELVIS CONTENTS
$2,541.08
58260
3
VAGINAL HYSTERECTOMY
$767.84
58262
3
VAG HYST INCLUDING T/O
$857.65
$95.09
$1,578.50
$56.66
$1,079.67
$882.17
Procedure Code Pricing Action Code Description
Maximum Allowable
58263
3
VAG HYST W/T/O & VAG REPAIR
$923.97
58265
O
VAGINAL HYSTERECTOMY WITH PLASTIC R
58267
3
VAG HYST W/URINARY REPAIR
$981.65
58270
3
VAG HYST W/ENTEROCELE REPAIR
$822.21
58275
3
HYSTERECTOMY/REVISE VAGINA
$915.00
58280
3
HYSTERECTOMY/REVISE VAGINA
$978.73
58285
3
EXTENSIVE HYSTERECTOMY
$1,226.96
58290
3
VAG HYST COMPLEX
$1,074.60
58291
3
VAG HYST INCL T/O, COMPLEX
$1,167.74
58292
3
VAG HYST T/O & REPAIR, COMPL
$1,230.37
58293
3
VAG HYST W/URO REPAIR, COMPL
$1,277.26
58294
3
VAG HYST W/ENTEROCELE, COMPL
$1,134.94
58300
5
INSERT INTRAUTERINE DEVICE
58301
3
REMOVE INTRAUTERINE DEVICE
58310
9
ARTIFICIAL INSEMINATION
$0.00
58311
9
ARTIFICIAL INSEMINATION WITH SPERM
$0.00
58320
O
INSUFFLATION OF UTERUS AND TUBES WI
$0.00
58321
9
ARTIFICIAL INSEMINATION
$0.00
58322
9
ARTIFICIAL INSEMINATION
$0.00
58323
9
SPERM WASHING
$0.00
58340
3
CATHETER FOR HYSTEROGRAPHY
58345
9
REOPEN FALLOPIAN TUBE
58346
3
INSERT HEYMAN UTERI CAPSULE
58350
9
REOPEN FALLOPIAN TUBE
58353
3
ENDOMETR ABLATE, THERMAL
$205.90
58356
3
ENDOMETRIAL CRYOABLATION
$1,997.50
58400
3
SUSPENSION OF UTERUS
$417.03
58410
3
SUSPENSION OF UTERUS
$744.65
58520
3
REPAIR OF RUPTURED UTERUS
$727.04
58540
3
REVISION OF UTERUS
$843.98
58541
3
LSH, UTERUS 250 G OR LESS
$796.41
58542
3
LSH W/T/O UT 250 G OR LESS
$884.19
58543
3
LSH UTERUS ABOVE 250 G
$898.82
58544
3
LSH W/T/O UTERUS ABOVE 250 G
$971.03
58545
3
LAPAROSCOPIC MYOMECTOMY
$830.99
$0.00
$0.00 $90.39
$121.96 $0.00 $424.16 $0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
58546
3
LAPARO-MYOMECTOMY, COMPLEX
$1,052.70
58548
3
LAP RADICAL HYST
$1,640.76
58550
3
LAPARO-ASST VAG HYSTERECTOMY
58551
O
LAPAROSCOPY, REMOVE MYOMA
58552
3
LAPARO-VAG HYST INCL T/O
58553
3
LAPARO-VAG HYST, COMPLEX
$1,058.10
58554
3
LAPARO-VAG HYST W/T/O, COMPL
$1,212.61
58555
3
HYSTEROSCOPY, DX, SEP PROC
$225.81
58558
3
HYSTEROSCOPY, BIOPSY
$304.67
58559
3
HYSTEROSCOPY, LYSIS
$323.26
58560
3
HYSTEROSCOPY, RESECT SEPTUM
$365.30
58561
3
HYSTEROSCOPY, REMOVE MYOMA
$516.86
58562
3
HYSTEROSCOPY, REMOVE FB
$321.81
58563
3
HYSTEROSCOPY, ABLATION
$323.26
58565
3
HYSTEROSCOPY, STERILIZATION
$413.53
58570
3
TLH, UTERUS 250 G OR LESS
$854.87
58571
3
TLH W/T/O 250 G OR LESS
$938.91
58572
3
TLH, UTERUS OVER 250 G
$1,062.16
58573
3
TLH W/T/O UTERUS OVER 250 G
$1,201.89
58578
5
LAPARO PROC, UTERUS
$0.00
58579
5
HYSTEROSCOPE PROCEDURE
$0.00
58600
3
DIVISION OF FALLOPIAN TUBE
$337.61
58605
3
DIVISION OF FALLOPIAN TUBE
$307.11
58611
3
LIGATE OVIDUCT(S) ADD-ON
58615
3
OCCLUDE FALLOPIAN TUBE(S)
$232.32
58660
3
LAPAROSCOPY, LYSIS
$624.86
58661
3
LAPAROSCOPY, REMOVE ADNEXA
$600.05
58662
3
LAPAROSCOPY, EXCISE LESIONS
$657.08
58670
3
LAPAROSCOPY, TUBAL CAUTERY
$340.07
58671
3
LAPAROSCOPY, TUBAL BLOCK
$339.94
58672
3
LAPAROSCOPY, FIMBRIOPLASTY
$691.21
58673
3
LAPAROSCOPY, SALPINGOSTOMY
$751.77
58679
5
LAPARO PROC, OVIDUCT-OVARY
58700
3
REMOVAL OF FALLOPIAN TUBE
$707.96
58720
3
REMOVAL OF OVARY/TUBE(S)
$665.36
$821.14 $0.00 $905.78
$73.14
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
58740
3
ADHESIOLYSIS TUBE, OVARY
$811.15
58750
9
REPAIR OVIDUCT
$0.00
58752
9
REVISE OVARIAN TUBE(S)
$0.00
58760
9
FIMBRIOPLASTY
$0.00
58770
3
CREATE NEW TUBAL OPENING
$782.91
58800
3
DRAINAGE OF OVARIAN CYST(S)
$298.24
58805
3
DRAINAGE OF OVARIAN CYST(S)
$376.18
58820
3
DRAIN OVARY ABSCESS, OPEN
$291.05
58822
3
DRAIN OVARY ABSCESS, PERCUT
$654.76
58823
3
DRAIN PELVIC ABSCESS, PERCUT
$874.47
58825
3
TRANSPOSITION, OVARY(S)
$646.78
58900
3
BIOPSY OF OVARY(S)
$383.74
58920
3
PARTIAL REMOVAL OF OVARY(S)
$651.05
58925
3
REMOVAL OF OVARIAN CYST(S)
$678.84
58940
3
REMOVAL OF OVARY(S)
$465.40
58943
3
REMOVAL OF OVARY(S)
$1,036.51
58950
3
RESECT OVARIAN MALIGNANCY
$988.92
58951
3
RESECT OVARIAN MALIGNANCY
$1,274.51
58952
3
RESECT OVARIAN MALIGNANCY
$1,437.64
58953
3
TAH, RAD DISSECT FOR DEBULK
$1,782.84
58954
3
TAH RAD DEBULK/LYMPH REMOVE
$1,935.16
58956
3
BSO, OMENTECTOMY W/TAH
$1,250.78
58957
3
RESECT RECURRENT GYN MAL
$1,372.37
58958
3
RESECT RECUR GYN MAL W/LYM
$1,525.07
58960
3
EXPLORATION OF ABDOMEN
58970
9
RETRIEVAL OF OOCYTE
$0.00
58972
O
CULTURE AND FERTILIZATION OF OOCYTE
$0.00
58974
9
TRANSFER OF EMBRYO
$0.00
58976
9
TRANSFER OF EMBRYO
$0.00
58980
O
LAPAROSCOPY, SURGICAL
$0.00
58982
O
LAPAROSCOPY, SURGICAL WITH FULGURAT
$0.00
58983
O
LAPAROSCOPY, SURGICAL WITH OCCLUSIO
$0.00
58984
O
LAPAROSCOPY, SURGICAL WITH FULGURAT
$0.00
58985
O
LAPAROSCOPY, SURGICAL WITH LYSIS OF
$0.00
58986
O
LAPAROSCOPY, SURGICAL WITH BIOPSY (
$0.00
$854.85
Procedure Code Pricing Action Code Description
Maximum Allowable
58987
O
LAPAROSCOPY, SURGICAL WITH ASPIRATI
$0.00
58988
O
LAPAROSCOPY, SURGICAL WITH REMOVAL
$0.00
58990
O
HYSTEROSCOPY DIAGNOSTIC
$0.00
58992
O
HYSTEROSCOPY WITH LYSIS OF INTRAUTE
$0.00
58994
O
HYSTEROSCOPY WITH REMOVAL OF SUBMUC
$0.00
58996
O
HYSTEROSCOPY; WITH ENDOMETRIAL ABLA
$0.00
58999
5
GENITAL SURGERY PROCEDURE
$0.00
59000
3
AMNIOCENTESIS, DIAGNOSTIC
$121.54
59001
3
AMNIOCENTESIS, THERAPEUTIC
$173.02
59012
3
FETAL CORD PUNCTURE,PRENATAL
$190.27
59015
3
CHORION BIOPSY
$145.79
59020
3
FETAL CONTRACT STRESS TEST
$66.41
59025
3
FETAL NON-STRESS TEST
$43.97
59030
3
FETAL SCALP BLOOD SAMPLE
59050
3
FETAL MONITOR W/REPORT
$47.19
59051
3
FETAL MONITOR/INTERPRET ONLY
$39.02
59070
3
TRANSABDOM AMNIOINFUS W/US
$371.42
59072
3
UMBILICAL CORD OCCLUD W/US
$447.46
59074
3
FETAL FLUID DRAINAGE W/US
$351.46
59076
3
FETAL SHUNT PLACEMENT, W/US
$437.11
59100
3
REMOVE UTERUS LESION
$761.92
59120
3
TREAT ECTOPIC PREGNANCY
$728.31
59121
3
TREAT ECTOPIC PREGNANCY
$731.49
59130
3
TREAT ECTOPIC PREGNANCY
$853.15
59135
3
TREAT ECTOPIC PREGNANCY
$864.74
59136
3
TREAT ECTOPIC PREGNANCY
$807.15
59140
3
TREAT ECTOPIC PREGNANCY
$363.06
59150
3
TREAT ECTOPIC PREGNANCY
$708.02
59151
3
TREAT ECTOPIC PREGNANCY
$691.52
59160
3
D & C AFTER DELIVERY
$199.40
59200
3
INSERT CERVICAL DILATOR
59300
3
EPISIOTOMY OR VAGINAL REPAIR
$179.63
59320
3
REVISION OF CERVIX
$143.06
59325
3
REVISION OF CERVIX
$225.32
59350
3
REPAIR OF UTERUS
$258.54
$105.66
$69.76
Procedure Code Pricing Action Code Description
Maximum Allowable
59400
7
OBSTETRICAL CARE
$0.00
59409
3
OBSTETRICAL CARE
$717.47
59410
3
OBSTETRICAL CARE
$833.70
59412
9
ANTEPARTUM MANIPULATION
59414
3
DELIVER PLACENTA
59420
O
ANTEPARTUM CARE ONLY (SEPARATE PROC
$0.00
59425
9
ANTEPARTUM CARE ONLY
$0.00
59426
9
ANTEPARTUM CARE ONLY
$0.00
59430
3
CARE AFTER DELIVERY
59510
7
CESAREAN DELIVERY
59514
3
CESAREAN DELIVERY ONLY
$717.47
59515
3
CESAREAN DELIVERY
$833.70
59525
3
REMOVE UTERUS AFTER CESAREAN
$452.10
59610
9
VBAC DELIVERY
59612
3
VBAC DELIVERY ONLY
$717.47
59614
3
VBAC CARE AFTER DELIVERY
$833.70
59618
9
ATTEMPTED VBAC DELIVERY
$0.00
59620
3
ATTEMPTED VBAC DELIVERY ONLY
$717.47
59622
3
ATTEMPTED VBAC AFTER CARE
$833.70
59812
3
TREATMENT OF MISCARRIAGE
$290.55
59820
3
CARE OF MISCARRIAGE
$344.91
59821
3
TREATMENT OF MISCARRIAGE
$350.52
59830
3
TREAT UTERUS INFECTION
$402.08
59840
3
ABORTION
$201.48
59841
3
ABORTION
$349.65
59850
3
ABORTION
$359.82
59851
3
ABORTION
$369.77
59852
3
ABORTION
$519.36
59855
3
ABORTION
$383.63
59856
3
ABORTION
$452.57
59857
3
ABORTION
$541.56
59866
9
ABORTION (MPR)
59870
3
EVACUATE MOLE OF UTERUS
$433.90
59871
3
REMOVE CERCLAGE SUTURE
$125.07
59897
6
FETAL INVAS PX W/US
$0.00 $85.50
$130.24 $0.00
$0.00
$0.00
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
59898
5
LAPARO PROC, OB CARE/DELIVER
$0.00
59899
5
MATERNITY CARE PROCEDURE
$0.00
60000
3
DRAIN THYROID/TONGUE CYST
$145.95
60001
O
ASPIRATE/INJECT THYRIOD CYST
$0.00
6005F
9
CARE LEVEL RATIONALE DOC
$0.00
60100
3
BIOPSY OF THYROID
6010F
9
DYSPHAG TEST DONE B/4 EATING
$0.00
6015F
9
DYSPHAG TEST DONE B/4 EATING
$0.00
60200
3
REMOVE THYROID LESION
6020F
9
NPO (NOTHING-MOUTH) ORDERED
60210
3
PARTIAL THYROID EXCISION
$630.88
60212
3
PARTIAL THYROID EXCISION
$905.34
60220
3
PARTIAL REMOVAL OF THYROID
$691.52
60225
3
PARTIAL REMOVAL OF THYROID
$831.19
60240
3
REMOVAL OF THYROID
$878.96
60245
O
THYROIDECTOMY, SUBTOTAL OR PARTIAL;
$0.00
60246
O
THYROIDECTOMY, SUBTOTAL OR PARTIAL;
$0.00
60252
3
REMOVAL OF THYROID
$1,187.09
60254
3
EXTENSIVE THYROID SURGERY
$1,530.05
60260
3
REPEAT THYROID SURGERY
60270
3
REMOVAL OF THYROID
$1,249.20
60271
3
REMOVAL OF THYROID
$958.20
60280
3
REMOVE THYROID DUCT LESION
$398.83
60281
3
REMOVE THYROID DUCT LESION
$531.34
60300
3
ASPIR/INJ THYROID CYST
$102.89
6030F
9
MAX STERILE BARRIERS FOLLWD
$0.00
6040F
9
APPRO RAD DS DVCS TECHS DOCD
$0.00
6045F
9
RADXPS IN END RPRT4FLURO PXD
$0.00
60500
3
EXPLORE PARATHYROID GLANDS
60502
3
RE-EXPLORE PARATHYROIDS
$1,144.01
60505
3
EXPLORE PARATHYROID GLANDS
$1,257.06
60512
3
AUTOTRANSPLANT PARATHYROID
$222.38
60520
3
REMOVAL OF THYMUS GLAND
$939.24
60521
3
REMOVAL OF THYMUS GLAND
$1,079.13
60522
3
REMOVAL OF THYMUS GLAND
$1,300.92
$108.79
$590.91 $0.00
$991.53
$911.50
Procedure Code Pricing Action Code Description
Maximum Allowable
60540
3
EXPLORE ADRENAL GLAND
$991.39
60545
3
EXPLORE ADRENAL GLAND
$1,126.94
60600
3
REMOVE CAROTID BODY LESION
$1,308.04
60605
3
REMOVE CAROTID BODY LESION
$1,644.64
60650
3
LAPAROSCOPY ADRENALECTOMY
$1,102.63
60659
5
LAPARO PROC, ENDOCRINE
$0.00
60699
5
ENDOCRINE SURGERY PROCEDURE
$0.00
61000
3
REMOVE CRANIAL CAVITY FLUID
$101.35
61001
3
REMOVE CRANIAL CAVITY FLUID
$99.23
61020
3
REMOVE BRAIN CAVITY FLUID
$118.67
61026
3
INJECTION INTO BRAIN CANAL
$118.21
61050
3
REMOVE BRAIN CANAL FLUID
$100.96
61055
3
INJECTION INTO BRAIN CANAL
$129.76
61070
3
BRAIN CANAL SHUNT PROCEDURE
61105
3
TWIST DRILL HOLE
61106
O
DRILL SKULL FOR EXAM/SURGERY
61107
3
DRILL SKULL FOR IMPLANTATION
$286.49
61108
3
DRILL SKULL FOR DRAINAGE
$771.45
61120
3
BURR HOLE FOR PUNCTURE
$632.31
61130
O
PIERCE SKULL, EXAM/SURGERY
61140
3
PIERCE SKULL FOR BIOPSY
$1,095.40
61150
3
PIERCE SKULL FOR DRAINAGE
$1,171.29
61151
3
PIERCE SKULL FOR DRAINAGE
$848.57
61154
3
PIERCE SKULL & REMOVE CLOT
$1,097.78
61156
3
PIERCE SKULL FOR DRAINAGE
$1,093.26
61210
3
PIERCE SKULL, IMPLANT DEVICE
$334.48
61215
3
INSERT BRAIN-FLUID DEVICE
$423.46
61250
3
PIERCE SKULL & EXPLORE
$739.18
61253
3
PIERCE SKULL & EXPLORE
$812.98
61304
3
OPEN SKULL FOR EXPLORATION
$1,442.22
61305
3
OPEN SKULL FOR EXPLORATION
$1,738.88
61312
3
OPEN SKULL FOR DRAINAGE
$1,802.95
61313
3
OPEN SKULL FOR DRAINAGE
$1,724.56
61314
3
OPEN SKULL FOR DRAINAGE
$1,595.98
61315
3
OPEN SKULL FOR DRAINAGE
$1,816.51
$75.80 $389.12 $0.00
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
61316
3
IMPLT CRAN BONE FLAP TO ABDO
$78.76
61320
3
OPEN SKULL FOR DRAINAGE
$1,679.85
61321
3
OPEN SKULL FOR DRAINAGE
$1,840.45
61322
3
DECOMPRESSIVE CRANIOTOMY
$2,042.85
61323
3
DECOMPRESSIVE LOBECTOMY
$2,077.64
61330
3
DECOMPRESS EYE SOCKET
$1,425.29
61332
3
EXPLORE/BIOPSY EYE SOCKET
$1,650.65
61333
3
EXPLORE ORBIT/REMOVE LESION
$1,667.95
61334
3
EXPLORE ORBIT/REMOVE OBJECT
$1,082.21
61340
3
SUBTEMPORAL DECOMPRESSION
$1,251.75
61343
3
INCISE SKULL (PRESS RELIEF)
$1,932.50
61345
3
RELIEVE CRANIAL PRESSURE
$1,789.02
61440
3
INCISE SKULL FOR SURGERY
$1,751.24
61450
3
INCISE SKULL FOR SURGERY
$1,658.52
61458
3
INCISE SKULL FOR BRAIN WOUND
$1,768.92
61460
3
INCISE SKULL FOR SURGERY
$1,792.27
61470
3
INCISE SKULL FOR SURGERY
$1,663.82
61480
3
INCISE SKULL FOR SURGERY
$1,613.68
61490
3
INCISE SKULL FOR SURGERY
$1,673.98
61500
3
REMOVAL OF SKULL LESION
$1,184.43
61501
3
REMOVE INFECTED SKULL BONE
$1,015.76
61510
3
REMOVAL OF BRAIN LESION
$1,908.80
61512
3
REMOVE BRAIN LINING LESION
$2,251.46
61514
3
REMOVAL OF BRAIN ABSCESS
$1,671.92
61516
3
REMOVAL OF BRAIN LESION
$1,631.20
61517
3
IMPLT BRAIN CHEMOTX ADD-ON
61518
3
REMOVAL OF BRAIN LESION
$2,422.97
61519
3
REMOVE BRAIN LINING LESION
$2,608.02
61520
3
REMOVAL OF BRAIN LESION
$3,333.41
61521
3
REMOVAL OF BRAIN LESION
$2,801.88
61522
3
REMOVAL OF BRAIN ABSCESS
$1,923.54
61524
3
REMOVAL OF BRAIN LESION
$1,815.84
61526
3
REMOVAL OF BRAIN LESION
$3,025.69
61530
3
REMOVAL OF BRAIN LESION
$2,570.46
61531
3
IMPLANT BRAIN ELECTRODES
$1,054.49
$78.77
Procedure Code Pricing Action Code Description
Maximum Allowable
61533
3
IMPLANT BRAIN ELECTRODES
$1,329.62
61534
3
REMOVAL OF BRAIN LESION
$1,432.65
61535
3
REMOVE BRAIN ELECTRODES
61536
3
REMOVAL OF BRAIN LESION
$2,281.57
61537
3
REMOVAL OF BRAIN TISSUE
$2,099.67
61538
3
REMOVAL OF BRAIN TISSUE
$2,250.86
61539
3
REMOVAL OF BRAIN TISSUE
$2,065.21
61540
3
REMOVAL OF BRAIN TISSUE
$1,938.23
61541
3
INCISION OF BRAIN TISSUE
$1,860.65
61542
3
REMOVAL OF BRAIN TISSUE
$2,018.61
61543
3
REMOVAL OF BRAIN TISSUE
$1,885.05
61544
3
REMOVE & TREAT BRAIN LESION
$1,553.06
61545
3
EXCISION OF BRAIN TUMOR
$2,777.03
61546
3
REMOVAL OF PITUITARY GLAND
$2,012.97
61548
3
REMOVAL OF PITUITARY GLAND
$1,366.26
61550
3
RELEASE OF SKULL SEAMS
$896.49
61552
3
RELEASE OF SKULL SEAMS
$1,177.86
61553
O
CRANIECTOMY FOR CRANIOSTENOSIS EACH
$0.00
61555
O
RECONSTRUCTION OF SKULL BY MULTIPLE
$0.00
61556
3
INCISE SKULL/SUTURES
$1,435.99
61557
3
INCISE SKULL/SUTURES
$1,479.38
61558
3
EXCISION OF SKULL/SUTURES
$1,523.58
61559
3
EXCISION OF SKULL/SUTURES
$2,115.28
61561
O
RECONSTRUCTION OF SKULL BY ORBITAL
61563
3
EXCISION OF SKULL TUMOR
$1,700.03
61564
3
EXCISION OF SKULL TUMOR
$2,128.20
61566
3
REMOVAL OF BRAIN TISSUE
$1,964.54
61567
3
INCISION OF BRAIN TISSUE
$2,210.37
61570
3
REMOVE FOREIGN BODY, BRAIN
$1,607.08
61571
3
INCISE SKULL FOR BRAIN WOUND
$1,745.95
61575
3
SKULL BASE/BRAINSTEM SURGERY
$2,078.24
61576
3
SKULL BASE/BRAINSTEM SURGERY
$3,330.83
61580
3
CRANIOFACIAL APPROACH, SKULL
$2,192.58
61581
3
CRANIOFACIAL APPROACH, SKULL
$2,460.80
61582
3
CRANIOFACIAL APPROACH, SKULL
$2,529.00
$858.87
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
61583
3
CRANIOFACIAL APPROACH, SKULL
$2,551.18
61584
3
ORBITOCRANIAL APPROACH/SKULL
$2,484.97
61585
3
ORBITOCRANIAL APPROACH/SKULL
$2,631.08
61586
3
RESECT NASOPHARYNX, SKULL
$1,901.42
61590
3
INFRATEMPORAL APPROACH/SKULL
$2,785.17
61591
3
INFRATEMPORAL APPROACH/SKULL
$2,805.01
61592
3
ORBITOCRANIAL APPROACH/SKULL
$2,795.35
61595
3
TRANSTEMPORAL APPROACH/SKULL
$2,110.19
61596
3
TRANSCOCHLEAR APPROACH/SKULL
$2,316.93
61597
3
TRANSCONDYLAR APPROACH/SKULL
$2,532.05
61598
3
TRANSPETROSAL APPROACH/SKULL
$2,247.71
61600
3
RESECT/EXCISE CRANIAL LESION
$1,900.62
61601
3
RESECT/EXCISE CRANIAL LESION
$2,075.89
61605
3
RESECT/EXCISE CRANIAL LESION
$1,989.41
61606
3
RESECT/EXCISE CRANIAL LESION
$2,658.99
61607
3
RESECT/EXCISE CRANIAL LESION
$2,464.37
61608
3
RESECT/EXCISE CRANIAL LESION
$2,866.64
61609
3
TRANSECT ARTERY, SINUS
$551.19
61610
3
TRANSECT ARTERY, SINUS
$1,690.57
61611
3
TRANSECT ARTERY, SINUS
$426.91
61612
3
TRANSECT ARTERY, SINUS
$1,502.59
61613
3
REMOVE ANEURYSM, SINUS
$2,787.38
61615
3
RESECT/EXCISE LESION, SKULL
$2,206.58
61616
3
RESECT/EXCISE LESION, SKULL
$2,895.02
61618
3
REPAIR DURA
$1,143.13
61619
3
REPAIR DURA
$1,317.42
61623
3
ENDOVASC TEMPORY VESSEL OCCL
61624
3
TRANSCATH OCCLUSION, CNS
61626
3
TRANSCATH OCCLUSION, NON-CNS
61630
3
INTRACRANIAL ANGIOPLASTY
$1,199.75
61635
3
INTRACRAN ANGIOPLSTY W/STENT
$1,313.58
61640
3
DILATE IC VASOSPASM, INIT
$609.95
61641
3
DILATE IC VASOSPASM ADD-ON
$214.33
61642
3
DILATE IC VASOSPASM ADD-ON
$428.65
61680
3
INTRACRANIAL VESSEL SURGERY
$528.60 $1,051.73 $856.93
$1,992.70
Procedure Code Pricing Action Code Description
Maximum Allowable
61682
3
INTRACRANIAL VESSEL SURGERY
$3,739.92
61684
3
INTRACRANIAL VESSEL SURGERY
$2,490.92
61686
3
INTRACRANIAL VESSEL SURGERY
$4,005.03
61690
3
INTRACRANIAL VESSEL SURGERY
$1,896.06
61692
3
INTRACRANIAL VESSEL SURGERY
$3,234.74
61697
3
BRAIN ANEURYSM REPR, COMPLX
$3,657.69
61698
3
BRAIN ANEURYSM REPR, COMPLX
$3,935.37
61700
3
BRAIN ANEURYSM REPR, SIMPLE
$3,059.05
61702
3
INNER SKULL VESSEL SURGERY
$3,425.79
61703
3
CLAMP NECK ARTERY
$1,176.27
61705
3
REVISE CIRCULATION TO HEAD
$2,251.87
61708
3
REVISE CIRCULATION TO HEAD
$1,947.14
61710
3
REVISE CIRCULATION TO HEAD
$1,772.25
61711
3
FUSION OF SKULL ARTERIES
$2,295.21
61712
O
SKULL OR SPINE MICROSURGERY
61720
3
INCISE SKULL/BRAIN SURGERY
$1,025.30
61735
3
INCISE SKULL/BRAIN SURGERY
$1,258.72
61750
3
INCISE SKULL/BRAIN BIOPSY
$1,229.26
61751
3
BRAIN BIOPSY W/CT/MR GUIDE
$1,199.05
61760
3
IMPLANT BRAIN ELECTRODES
$1,351.63
61770
3
INCISE SKULL FOR TREATMENT
$1,334.23
61780
O
STEREOTACTIC LOCALIZATION, ANY METH
61790
3
TREAT TRIGEMINAL NERVE
$745.08
61791
3
TREAT TRIGEMINAL TRACT
$964.26
61793
O
FOCUS RADIATION BEAM
61795
3
BRAIN SURGERY USING COMPUTER
$223.94
61796
3
SRS, CRANIAL LESION SIMPLE
$702.09
61797
3
SRS, CRAN LES SIMPLE, ADDL
$191.15
61798
3
SRS, CRANIAL LESION COMPLEX
$702.09
61799
3
SRS, CRAN LES COMPLEX, ADDL
$264.24
61800
3
APPLY SRS HEADFRAME ADD-ON
$135.10
61850
3
IMPLANT NEUROELECTRODES
$856.38
61855
O
IMPLANT NEUROELECTRODES
$0.00
61860
3
IMPLANT NEUROELECTRODES
$1,363.01
61862
O
IMPLANT NEUROSTIMUL, SUBCORT
$0.00
$0.00
$0.00
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
61863
3
IMPLANT NEUROELECTRODE
$1,323.63
61864
3
IMPLANT NEUROELECTRDE, ADDL
61865
O
IMPLANT NEUROELECTRODES
61867
3
IMPLANT NEUROELECTRODE
61868
3
IMPLANT NEUROELECTRDE, ADDÏL
61870
3
IMPLANT NEUROELECTRODES
$1,037.23
61875
3
IMPLANT NEUROELECTRODES
$1,010.22
61880
3
REVISE/REMOVE NEUROELECTRODE
$479.00
61885
3
INSRT/REDO NEUROSTIM 1 ARRAY
$555.45
61886
3
IMPLANT NEUROSTIM ARRAYS
$699.92
61888
3
REVISE/REMOVE NEURORECEIVER
$349.67
62000
3
TREAT SKULL FRACTURE
$769.53
62005
3
TREAT SKULL FRACTURE
$1,085.55
62010
3
TREATMENT OF HEAD INJURY
$1,325.74
62100
3
REPAIR BRAIN FLUID LEAKAGE
$1,410.97
62115
3
REDUCTION OF SKULL DEFECT
$1,250.42
62116
3
REDUCTION OF SKULL DEFECT
$1,554.91
62117
3
REDUCTION OF SKULL DEFECT
$1,678.14
62120
3
REPAIR SKULL CAVITY LESION
$1,601.90
62121
3
INCISE SKULL REPAIR
$1,459.83
62140
3
REPAIR OF SKULL DEFECT
$918.20
62141
3
REPAIR OF SKULL DEFECT
$1,008.30
62142
3
REMOVE SKULL PLATE/FLAP
$769.26
62143
3
REPLACE SKULL PLATE/FLAP
$900.40
62145
3
REPAIR OF SKULL & BRAIN
$1,232.91
62146
3
REPAIR OF SKULL WITH GRAFT
$1,058.17
62147
3
REPAIR OF SKULL WITH GRAFT
$1,256.35
62148
3
RETR BONE FLAP TO FIX SKULL
$112.54
62160
3
NEUROENDOSCOPY ADD-ON
$172.61
62161
3
DISSECT BRAIN W/SCOPE
$1,326.45
62162
3
REMOVE COLLOID CYST W/SCOPE
$1,649.22
62163
3
NEUROENDOSCOPY W/FB REMOVAL
$1,069.22
62164
3
REMOVE BRAIN TUMOR W/SCOPE
$1,757.89
62165
3
REMOVE PITUIT TUMOR W/SCOPE
$1,364.53
62180
3
ESTABLISH BRAIN CAVITY SHUNT
$1,389.63
$360.82 $0.00 $1,949.47 $536.27
Procedure Code Pricing Action Code Description
Maximum Allowable
62190
3
ESTABLISH BRAIN CAVITY SHUNT
$791.96
62192
3
ESTABLISH BRAIN CAVITY SHUNT
$843.47
62194
3
REPLACE/IRRIGATE CATHETER
$344.07
62200
3
ESTABLISH BRAIN CAVITY SHUNT
$1,202.00
62201
3
BRAIN CAVITY SHUNT W/SCOPE
$1,033.11
62220
3
ESTABLISH BRAIN CAVITY SHUNT
$885.94
62223
3
ESTABLISH BRAIN CAVITY SHUNT
$910.61
62225
3
REPLACE/IRRIGATE CATHETER
$435.39
62230
3
REPLACE/REVISE BRAIN SHUNT
$732.65
62252
3
CSF SHUNT REPROGRAM
62256
3
REMOVE BRAIN CAVITY SHUNT
$509.85
62258
3
REPLACE BRAIN CAVITY SHUNT
$984.69
62263
3
EPIDURAL LYSIS MULT SESSIONS
$598.98
62264
3
EPIDURAL LYSIS ON SINGLE DAY
$365.91
62267
3
INTERDISCAL PERQ ASPIR, DX
$237.68
62268
3
DRAIN SPINAL CORD CYST
$434.42
62269
3
NEEDLE BIOPSY, SPINAL CORD
$471.46
62270
3
SPINAL FLUID TAP, DIAGNOSTIC
$144.41
62272
3
DRAIN CEREBRO SPINAL FLUID
$170.49
62273
3
INJECT EPIDURAL PATCH
$152.41
62274
O
INJECT SPINAL ANESTHETIC
$0.00
62275
O
INJECT SPINAL ANESTHETIC
$0.00
62276
O
INJECT SPINAL ANESTHETIC
$0.00
62277
O
INJECT SPINAL ANESTHETIC
$0.00
62278
O
INJECT SPINAL ANESTHETIC
$0.00
62279
O
INJECT SPINAL ANESTHETIC
$0.00
62280
3
TREAT SPINAL CORD LESION
$283.81
62281
3
TREAT SPINAL CORD LESION
$262.65
62282
3
TREAT SPINAL CANAL LESION
$272.93
62284
3
INJECTION FOR MYELOGRAM
$208.62
62287
3
PERCUTANEOUS DISKECTOMY
$504.98
62288
O
INJECTION INTO SPINAL CANAL
$0.00
62289
O
INJECTION INTO SPINAL CANAL
$0.00
62290
3
INJECT FOR SPINE DISK X-RAY
$303.11
62291
3
INJECT FOR SPINE DISK X-RAY
$283.61
$92.48
Procedure Code Pricing Action Code Description
Maximum Allowable
62292
3
INJECTION INTO DISK LESION
$452.37
62294
3
INJECTION INTO SPINAL ARTERY
$729.68
62298
O
INJECTION INTO SPINAL CANAL
62310
3
INJECT SPINE C/T
$200.16
62311
3
INJECT SPINE L/S (CD)
$176.98
62318
3
INJECT SPINE W/CATH, C/T
$214.04
62319
3
INJECT SPINE W/CATH L/S (CD)
$193.68
62350
3
IMPLANT SPINAL CANAL CATH
$353.08
62351
3
IMPLANT SPINAL CANAL CATH
$745.79
62355
3
REMOVE SPINAL CANAL CATHETER
$265.32
62360
3
INSERT SPINE INFUSION DEVICE
$255.37
62361
3
IMPLANT SPINE INFUSION PUMP
$352.38
62362
3
IMPLANT SPINE INFUSION PUMP
$371.28
62365
3
REMOVE SPINE INFUSION DEVICE
$293.68
62367
3
ANALYZE SPINE INFUSION PUMP
$35.61
62368
3
ANALYZE SPINE INFUSION PUMP
$50.79
63001
3
REMOVAL OF SPINAL LAMINA
$1,082.80
63003
3
REMOVAL OF SPINAL LAMINA
$1,089.45
63005
3
REMOVAL OF SPINAL LAMINA
$1,035.44
63010
O
LAMINECTOMY FOR EXPLORATION/DECOMPR
63011
3
REMOVAL OF SPINAL LAMINA
$977.62
63012
3
REMOVAL OF SPINAL LAMINA
$1,053.04
63015
3
REMOVAL OF SPINAL LAMINA
$1,301.12
63016
3
REMOVAL OF SPINAL LAMINA
$1,337.34
63017
3
REMOVAL OF SPINAL LAMINA
$1,091.93
63020
3
NECK SPINE DISK SURGERY
$1,033.13
63030
3
LOW BACK DISK SURGERY
$859.03
63035
3
SPINAL DISK SURGERY ADD-ON
$181.77
63040
3
LAMINOTOMY, SINGLE CERVICAL
$1,253.63
63042
3
LAMINOTOMY, SINGLE LUMBAR
$1,174.52
63043
5
LAMINOTOMY, ADDÏL CERVICAL
$0.00
63044
5
LAMINOTOMY, ADDÏL LUMBAR
$0.00
63045
3
REMOVAL OF SPINAL LAMINA
$1,121.71
63046
3
REMOVAL OF SPINAL LAMINA
$1,072.34
63047
3
REMOVAL OF SPINAL LAMINA
$979.39
$0.00
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
63048
3
REMOVE SPINAL LAMINA ADD-ON
$195.60
63050
3
CERVICAL LAMINOPLASTY
$1,347.41
63051
3
C-LAMINOPLASTY W/GRAFT/PLATE
$1,521.28
63055
3
DECOMPRESS SPINAL CORD
$1,442.44
63056
3
DECOMPRESS SPINAL CORD
$1,332.01
63057
3
DECOMPRESS SPINE CORD ADD-ON
63064
3
DECOMPRESS SPINAL CORD
63066
3
DECOMPRESS SPINE CORD ADD-ON
63075
3
NECK SPINE DISK SURGERY
$1,232.23
63076
3
NECK SPINE DISK SURGERY
$231.33
63077
3
SPINE DISK SURGERY, THORAX
$1,350.00
63078
3
SPINE DISK SURGERY, THORAX
$184.04
63081
3
REMOVAL OF VERTEBRAL BODY
63082
3
REMOVE VERTEBRAL BODY ADD-ON
63085
3
REMOVAL OF VERTEBRAL BODY
63086
3
REMOVE VERTEBRAL BODY ADD-ON
63087
3
REMOVAL OF VERTEBRAL BODY
63088
3
REMOVE VERTEBRAL BODY ADD-ON
63090
3
REMOVAL OF VERTEBRAL BODY
63091
3
REMOVE VERTEBRAL BODY ADD-ON
63101
3
REMOVAL OF VERTEBRAL BODY
$2,023.66
63102
3
REMOVAL OF VERTEBRAL BODY
$2,014.78
63103
3
REMOVE VERTEBRAL BODY ADD-ON
63170
3
INCISE SPINAL CORD TRACT(S)
$1,355.65
63172
3
DRAINAGE OF SPINAL CYST
$1,220.88
63173
3
DRAINAGE OF SPINAL CYST
$1,504.93
63180
3
REVISE SPINAL CORD LIGAMENTS
$1,226.12
63182
3
REVISE SPINAL CORD LIGAMENTS
$1,310.59
63185
3
INCISE SPINAL COLUMN/NERVES
$998.87
63190
3
INCISE SPINAL COLUMN/NERVES
$1,148.29
63191
3
INCISE SPINAL COLUMN/NERVES
$1,090.04
63194
3
INCISE SPINAL COLUMN & CORD
$1,304.51
63195
3
INCISE SPINAL COLUMN & CORD
$1,319.96
63196
3
INCISE SPINAL COLUMN & CORD
$1,553.35
63197
3
INCISE SPINAL COLUMN & CORD
$1,480.91
$299.65 $1,576.75 $184.79
$1,581.44 $249.75 $1,689.53 $177.30 $2,156.93 $242.79 $1,765.94 $166.73
$266.41
Procedure Code Pricing Action Code Description
Maximum Allowable
63198
3
INCISE SPINAL COLUMN & CORD
$1,635.80
63199
3
INCISE SPINAL COLUMN & CORD
$1,740.22
63200
3
RELEASE OF SPINAL CORD
$1,324.62
63250
3
REVISE SPINAL CORD VESSELS
$2,565.66
63251
3
REVISE SPINAL CORD VESSELS
$2,663.35
63252
3
REVISE SPINAL CORD VESSELS
$2,665.17
63265
3
EXCISE INTRASPINAL LESION
$1,466.64
63266
3
EXCISE INTRASPINAL LESION
$1,507.41
63267
3
EXCISE INTRASPINAL LESION
$1,215.34
63268
3
EXCISE INTRASPINAL LESION
$1,219.78
63270
3
EXCISE INTRASPINAL LESION
$1,803.86
63271
3
EXCISE INTRASPINAL LESION
$1,814.86
63272
3
EXCISE INTRASPINAL LESION
$1,672.31
63273
3
EXCISE INTRASPINAL LESION
$1,578.38
63275
3
BIOPSY/EXCISE SPINAL TUMOR
$1,574.65
63276
3
BIOPSY/EXCISE SPINAL TUMOR
$1,568.93
63277
3
BIOPSY/EXCISE SPINAL TUMOR
$1,377.75
63278
3
BIOPSY/EXCISE SPINAL TUMOR
$1,348.71
63280
3
BIOPSY/EXCISE SPINAL TUMOR
$1,862.12
63281
3
BIOPSY/EXCISE SPINAL TUMOR
$1,840.87
63282
3
BIOPSY/EXCISE SPINAL TUMOR
$1,737.56
63283
3
BIOPSY/EXCISE SPINAL TUMOR
$1,646.33
63285
3
BIOPSY/EXCISE SPINAL TUMOR
$2,283.40
63286
3
BIOPSY/EXCISE SPINAL TUMOR
$2,276.15
63287
3
BIOPSY/EXCISE SPINAL TUMOR
$2,400.90
63290
3
BIOPSY/EXCISE SPINAL TUMOR
$2,429.19
63295
3
REPAIR OF LAMINECTOMY DEFECT
63300
3
REMOVAL OF VERTEBRAL BODY
$1,623.41
63301
3
REMOVAL OF VERTEBRAL BODY
$1,818.81
63302
3
REMOVAL OF VERTEBRAL BODY
$1,807.89
63303
3
REMOVAL OF VERTEBRAL BODY
$1,888.92
63304
3
REMOVAL OF VERTEBRAL BODY
$2,007.54
63305
3
REMOVAL OF VERTEBRAL BODY
$2,046.22
63306
3
REMOVAL OF VERTEBRAL BODY
$2,150.90
63307
3
REMOVAL OF VERTEBRAL BODY
$1,992.47
$288.44
Procedure Code Pricing Action Code Description
Maximum Allowable
63308
3
REMOVE VERTEBRAL BODY ADD-ON
$300.23
63600
3
REMOVE SPINAL CORD LESION
$749.50
63610
3
STIMULATION OF SPINAL CORD
$1,244.66
63615
3
REMOVE LESION OF SPINAL CORD
$1,013.06
63620
3
SRS, SPINAL LESION
$702.09
63621
3
SRS, SPINAL LESION, ADDL
$219.77
63650
3
IMPLANT NEUROELECTRODES
$372.83
63652
O
PERCUTANEOUS IMPLANTATION OF NEUROS
63655
3
IMPLANT NEUROELECTRODES
63656
O
LAMINECTOMY FOR IMPLANTATION OF NEU
$0.00
63657
O
LAMINECTOMY FOR IMPLANTATION OF NEU
$0.00
63658
O
LAMINECTOMY FOR IMPLANTATION OF NEU
$0.00
63660
3
REVISE/REMOVE NEUROELECTRODE
$394.32
63685
3
INSRT/REDO SPINE N GENERATOR
$358.61
63688
3
REVISE/REMOVE NEURORECEIVER
$321.69
63690
O
ANALYSIS OF NEURORECEIVER
$0.00
63691
O
ANALYSIS OF NEURORECEIVER
$0.00
63700
3
REPAIR OF SPINAL HERNIATION
$1,083.94
63702
3
REPAIR OF SPINAL HERNIATION
$1,219.40
63704
3
REPAIR OF SPINAL HERNIATION
$1,357.02
63706
3
REPAIR OF SPINAL HERNIATION
$1,581.61
63707
3
REPAIR SPINAL FLUID LEAKAGE
$801.33
63709
3
REPAIR SPINAL FLUID LEAKAGE
$973.08
63710
3
GRAFT REPAIR OF SPINE DEFECT
$972.32
63740
3
INSTALL SPINAL SHUNT
$825.84
63741
3
INSTALL SPINAL SHUNT
$535.13
63744
3
REVISION OF SPINAL SHUNT
$562.89
63746
3
REMOVAL OF SPINAL SHUNT
$492.42
63750
O
INSERTION, SUBARACHNOID CATHETER WI
$0.00
63780
O
INSERTION OR REPLACEMENT, SUBARACHN
$0.00
64400
3
N BLOCK INJ, TRIGEMINAL
64402
3
N BLOCK INJ, FACIAL
64405
3
N BLOCK INJ, OCCIPITAL
64408
3
N BLOCK INJ, VAGUS
$109.35
64410
3
N BLOCK INJ, PHRENIC
$127.57
$0.00 $747.15
$98.27 $100.43 $94.56
Procedure Code Pricing Action Code Description
Maximum Allowable
64412
3
N BLOCK INJ, SPINAL ACCESSOR
$127.27
64413
3
N BLOCK INJ, CERVICAL PLEXUS
$105.18
64415
3
N BLOCK INJ, BRACHIAL PLEXUS
$119.75
64416
3
N BLOCK CONT INFUSE, B PLEX
$85.42
64417
3
N BLOCK INJ, AXILLARY
$121.01
64418
3
N BLOCK INJ, SUPRASCAPULAR
$123.53
64420
3
N BLOCK INJ, INTERCOST, SNG
$147.60
64421
3
N BLOCK INJ, INTERCOST, MLT
$217.95
64425
3
N BLOCK INJ, ILIO-ING/HYPOGI
$117.41
64430
3
N BLOCK INJ, PUDENDAL
$144.41
64435
3
N BLOCK INJ, PARACERVICAL
$133.66
64440
O
INJECTION FOR NERVE BLOCK
$0.00
64441
O
INJECTION FOR NERVE BLOCK
$0.00
64442
O
INJECTION FOR NERVE BLOCK
$0.00
64443
O
INJECT, NERVE BLOCK ADD-ON
$0.00
64445
3
N BLOCK INJ, SCIATIC, SNG
64446
3
N BLK INJ, SCIATIC, CONT INF
$85.37
64447
3
N BLOCK INJ FEM, SINGLE
$64.63
64448
3
N BLOCK INJ FEM, CONT INF
$75.50
64449
3
N BLOCK INJ, LUMBAR PLEXUS
$84.54
64450
3
N BLOCK, OTHER PERIPHERAL
$94.71
64455
3
N BLOCK INJ, PLANTAR DIGIT
$48.19
64470
3
INJ PARAVERTEBRAL C/T
$241.77
64472
3
INJ PARAVERTEBRAL C/T ADD-ON
$103.84
64475
3
INJ PARAVERTEBRAL L/S
$216.93
64476
3
INJ PARAVERTEBRAL L/S ADD-ON
64479
3
INJ FORAMEN EPIDURAL C/T
$255.62
64480
3
INJ FORAMEN EPIDURAL ADD-ON
$127.67
64483
3
INJ FORAMEN EPIDURAL L/S
$249.11
64484
3
INJ FORAMEN EPIDURAL ADD-ON
$125.61
64505
3
N BLOCK, SPENOPALATINE GANGL
64508
3
N BLOCK, CAROTID SINUS S/P
$131.17
64510
3
N BLOCK, STELLATE GANGLION
$130.31
64517
3
N BLOCK INJ, HYPOGAS PLXS
$155.57
64520
3
N BLOCK, LUMBAR/THORACIC
$171.05
$124.42
$87.35
$93.14
Procedure Code Pricing Action Code Description
Maximum Allowable
64530
3
N BLOCK INJ, CELIAC PELUS
$176.42
64550
3
APPLY NEUROSTIMULATOR
$14.44
64553
3
IMPLANT NEUROELECTRODES
$185.92
64555
3
IMPLANT NEUROELECTRODES
$197.67
64560
3
IMPLANT NEUROELECTRODES
$195.69
64561
3
IMPLANT NEUROELECTRODES
$399.44
64565
3
IMPLANT NEUROELECTRODES
$156.19
64573
3
IMPLANT NEUROELECTRODES
$525.89
64575
3
IMPLANT NEUROELECTRODES
$258.77
64577
3
IMPLANT NEUROELECTRODES
$321.61
64580
3
IMPLANT NEUROELECTRODES
$268.59
64581
3
IMPLANT NEUROELECTRODES
$774.44
64585
3
REVISE/REMOVE NEUROELECTRODE
$312.04
64590
3
INSRT/REDO PN/GASTR STIMUL
$292.15
64595
3
REVISE/RMV PN/GASTR STIMUL
$302.97
64600
3
INJECTION TREATMENT OF NERVE
$369.88
64605
3
INJECTION TREATMENT OF NERVE
$519.22
64610
3
INJECTION TREATMENT OF NERVE
$630.51
64612
3
DESTROY NERVE, FACE MUSCLE
$141.05
64613
3
DESTROY NERVE, NECK MUSCLE
$138.83
64614
3
DESTROY NERVE, EXTREM MUSC
$155.69
64620
3
INJECTION TREATMENT OF NERVE
$248.22
64622
3
DESTR PARAVERTEBRL NERVE L/S
$297.82
64623
3
DESTR PARAVERTEBRAL N ADD-ON
$110.76
64626
3
DESTR PARAVERTEBRL NERVE C/T
$346.12
64627
3
DESTR PARAVERTEBRAL N ADD-ON
$151.46
64630
3
INJECTION TREATMENT OF NERVE
$214.12
64632
3
N BLOCK INJ, COMMON DIGIT
64640
3
INJECTION TREATMENT OF NERVE
$210.92
64650
3
CHEMODENERV ECCRINE GLANDS
$61.57
64653
3
CHEMODENERV ECCRINE GLANDS
$71.44
64680
3
INJECTION TREATMENT OF NERVE
$282.02
64681
3
INJECTION TREATMENT OF NERVE
$363.61
64702
3
REVISE FINGER/TOE NERVE
$414.13
64704
3
REVISE HAND/FOOT NERVE
$304.32
$79.20
Procedure Code Pricing Action Code Description
Maximum Allowable
64708
3
REVISE ARM/LEG NERVE
$430.13
64712
3
REVISION OF SCIATIC NERVE
$493.15
64713
3
REVISION OF ARM NERVE(S)
$689.09
64714
3
REVISE LOW BACK NERVE(S)
$587.55
64716
3
REVISION OF CRANIAL NERVE
$470.60
64718
3
REVISE ULNAR NERVE AT ELBOW
$507.78
64719
3
REVISE ULNAR NERVE AT WRIST
$352.16
64721
3
CARPAL TUNNEL SURGERY
$372.34
64722
3
RELIEVE PRESSURE ON NERVE(S)
$300.66
64726
3
RELEASE FOOT/TOE NERVE
$264.68
64727
3
INTERNAL NERVE REVISION
$171.82
64732
3
INCISION OF BROW NERVE
$344.36
64734
3
INCISION OF CHEEK NERVE
$371.72
64736
3
INCISION OF CHIN NERVE
$351.43
64738
3
INCISION OF JAW NERVE
$414.47
64740
3
INCISION OF TONGUE NERVE
$414.17
64742
3
INCISION OF FACIAL NERVE
$422.85
64744
3
INCISE NERVE, BACK OF HEAD
$371.31
64746
3
INCISE DIAPHRAGM NERVE
$400.22
64752
3
INCISION OF VAGUS NERVE
$452.49
64755
9
INCISION OF STOMACH NERVES
64760
3
INCISION OF VAGUS NERVE
$426.81
64761
3
INCISION OF PELVIS NERVE
$404.51
64763
3
INCISE HIP/THIGH NERVE
$491.33
64766
3
INCISE HIP/THIGH NERVE
$564.72
64771
3
SEVER CRANIAL NERVE
$531.24
64772
3
INCISION OF SPINAL NERVE
$510.51
64774
3
REMOVE SKIN NERVE LESION
$368.56
64776
3
REMOVE DIGIT NERVE LESION
$354.10
64778
3
DIGIT NERVE SURGERY ADD-ON
$170.59
64782
3
REMOVE LIMB NERVE LESION
$416.72
64783
3
LIMB NERVE SURGERY ADD-ON
$203.95
64784
3
REMOVE NERVE LESION
$648.60
64786
3
REMOVE SCIATIC NERVE LESION
$972.42
64787
3
IMPLANT NERVE END
$234.11
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
64788
3
REMOVE SKIN NERVE LESION
$346.46
64790
3
REMOVAL OF NERVE LESION
$741.54
64792
3
REMOVAL OF NERVE LESION
$961.56
64795
3
BIOPSY OF NERVE
$175.48
64802
3
REMOVE SYMPATHETIC NERVES
$543.23
64804
3
REMOVE SYMPATHETIC NERVES
$827.25
64809
3
REMOVE SYMPATHETIC NERVES
$777.63
64818
3
REMOVE SYMPATHETIC NERVES
$603.59
64820
3
REMOVE SYMPATHETIC NERVES
$679.89
64821
3
REMOVE SYMPATHETIC NERVES
$614.32
64822
3
REMOVE SYMPATHETIC NERVES
$606.51
64823
3
REMOVE SYMPATHETIC NERVES
$688.26
64830
O
MICROREPAIR OF NERVE
64831
3
REPAIR OF DIGIT NERVE
$609.02
64832
3
REPAIR NERVE ADD-ON
$317.28
64834
3
REPAIR OF HAND OR FOOT NERVE
$672.13
64835
3
REPAIR OF HAND OR FOOT NERVE
$728.69
64836
3
REPAIR OF HAND OR FOOT NERVE
$728.37
64837
3
REPAIR NERVE ADD-ON
$352.32
64840
3
REPAIR OF LEG NERVE
$827.93
64856
3
REPAIR/TRANSPOSE NERVE
$915.80
64857
3
REPAIR ARM/LEG NERVE
$957.33
64858
3
REPAIR SCIATIC NERVE
64859
3
NERVE SURGERY
64861
3
REPAIR OF ARM NERVES
$1,243.60
64862
3
REPAIR OF LOW BACK NERVES
$1,216.70
64864
3
REPAIR OF FACIAL NERVE
$793.45
64865
3
REPAIR OF FACIAL NERVE
$1,052.87
64866
3
FUSION OF FACIAL/OTHER NERVE
$1,093.97
64868
3
FUSION OF FACIAL/OTHER NERVE
$956.87
64870
3
FUSION OF FACIAL/OTHER NERVE
$929.66
64872
3
SUBSEQUENT REPAIR OF NERVE
$112.07
64874
3
REPAIR & REVISE NERVE ADD-ON
$164.61
64876
3
REPAIR NERVE/SHORTEN BONE
$179.38
64885
3
NERVE GRAFT, HEAD OR NECK
$0.00
$1,104.07 $238.91
$1,033.01
Procedure Code Pricing Action Code Description
Maximum Allowable
64886
3
NERVE GRAFT, HEAD OR NECK
$1,225.65
64890
3
NERVE GRAFT, HAND OR FOOT
$986.46
64891
3
NERVE GRAFT, HAND OR FOOT
$1,017.46
64892
3
NERVE GRAFT, ARM OR LEG
$959.60
64893
3
NERVE GRAFT, ARM OR LEG
$1,009.62
64895
3
NERVE GRAFT, HAND OR FOOT
$1,183.24
64896
3
NERVE GRAFT, HAND OR FOOT
$1,306.37
64897
3
NERVE GRAFT, ARM OR LEG
$1,146.06
64898
3
NERVE GRAFT, ARM OR LEG
$1,250.19
64901
3
NERVE GRAFT ADD-ON
$559.99
64902
3
NERVE GRAFT ADD-ON
$643.28
64905
3
NERVE PEDICLE TRANSFER
$917.68
64907
3
NERVE PEDICLE TRANSFER
$1,205.21
64910
3
NERVE REPAIR W/ALLOGRAFT
$739.53
64911
3
NEURORRAPHY W/VEIN AUTOGRAFT
$891.09
64999
5
NERVOUS SYSTEM SURGERY
65091
3
REVISE EYE
$530.87
65093
3
REVISE EYE WITH IMPLANT
$530.11
65101
3
REMOVAL OF EYE
$612.09
65103
3
REMOVE EYE/INSERT IMPLANT
$638.89
65105
3
REMOVE EYE/ATTACH IMPLANT
$704.58
65110
3
REMOVAL OF EYE
$1,024.81
65112
3
REMOVE EYE/REVISE SOCKET
$1,206.53
65114
3
REMOVE EYE/REVISE SOCKET
$1,253.86
65125
3
REVISE OCULAR IMPLANT
$384.38
65130
3
INSERT OCULAR IMPLANT
$605.29
65135
3
INSERT OCULAR IMPLANT
$616.39
65140
3
ATTACH OCULAR IMPLANT
$671.41
65150
3
REVISE OCULAR IMPLANT
$487.26
65155
3
REINSERT OCULAR IMPLANT
$708.14
65175
3
REMOVAL OF OCULAR IMPLANT
$545.67
65205
3
REMOVE FOREIGN BODY FROM EYE
$47.90
65210
3
REMOVE FOREIGN BODY FROM EYE
$58.70
65220
3
REMOVE FOREIGN BODY FROM EYE
$49.12
65222
3
REMOVE FOREIGN BODY FROM EYE
$64.50
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
65230
O
REMOVAL OF FOREIGN BODY, INTRAOCULA
$0.00
65235
3
REMOVE FOREIGN BODY FROM EYE
65240
O
REMOVAL OF FOREIGN BODY, INTRAOCULA
$0.00
65245
O
REMOVAL OF FOREIGN BODY, INTRAOCULA
$0.00
65260
3
REMOVE FOREIGN BODY FROM EYE
$794.82
65265
3
REMOVE FOREIGN BODY FROM EYE
$894.39
65270
3
REPAIR OF EYE WOUND
$225.30
65272
3
REPAIR OF EYE WOUND
$287.38
65273
3
REPAIR OF EYE WOUND
$315.52
65275
3
REPAIR OF EYE WOUND
$462.62
65280
3
REPAIR OF EYE WOUND
$553.44
65285
3
REPAIR OF EYE WOUND
$862.24
65286
3
REPAIR OF EYE WOUND
$585.96
65290
3
REPAIR OF EYE SOCKET WOUND
$406.62
65300
O
DELIMITING KERATOTOMY
$0.00
65400
3
REMOVAL OF EYE LESION
$555.72
65410
3
BIOPSY OF CORNEA
$121.13
65420
3
REMOVAL OF EYE LESION
$430.87
65426
3
REMOVAL OF EYE LESION
$542.50
65430
3
CORNEAL SMEAR
$97.46
65435
3
CURETTE/TREAT CORNEA
$67.47
65436
3
CURETTE/TREAT CORNEA
$319.73
65450
3
TREATMENT OF CORNEAL LESION
$265.51
65600
3
REVISION OF CORNEA
$321.79
65710
3
CORNEAL TRANSPLANT
$915.18
65730
3
CORNEAL TRANSPLANT
$1,017.40
65750
3
CORNEAL TRANSPLANT
$1,030.91
65755
3
CORNEAL TRANSPLANT
$1,024.89
65756
3
CORNEAL TRNSPL, ENDOTHELIAL
65757
6
PREP CORNEAL ENDO ALLOGRAFT
$0.00
65760
5
REVISION OF CORNEA
$0.00
65765
5
REVISION OF CORNEA
$0.00
65767
5
CORNEAL TISSUE TRANSPLANT
$0.00
65770
3
REVISE CORNEA WITH IMPLANT
$1,177.70
65771
5
RADIAL KERATOTOMY
$579.93
$985.80
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
65772
3
CORRECTION OF ASTIGMATISM
$371.57
65775
3
CORRECTION OF ASTIGMATISM
$455.35
65780
3
OCULAR RECONST, TRANSPLANT
$734.11
65781
3
OCULAR RECONST, TRANSPLANT
$1,111.66
65782
3
OCULAR RECONST, TRANSPLANT
$959.32
65800
3
DRAINAGE OF EYE
$127.34
65805
3
DRAINAGE OF EYE
$139.18
65810
3
DRAINAGE OF EYE
$386.20
65815
3
DRAINAGE OF EYE
$530.77
65820
3
RELIEVE INNER EYE PRESSURE
$622.51
65825
O
GONIOTOMY WITH GONIOPUNCTURE
$0.00
65830
O
GONIOPUNCTURE, WITHOUT GONIOTOMY
$0.00
65850
3
INCISION OF EYE
$705.44
65855
3
LASER SURGERY OF EYE
$283.67
65860
3
INCISE INNER EYE ADHESIONS
$262.03
65865
3
INCISE INNER EYE ADHESIONS
$395.67
65870
3
INCISE INNER EYE ADHESIONS
$488.37
65875
3
INCISE INNER EYE ADHESIONS
$518.81
65880
3
INCISE INNER EYE ADHESIONS
$546.58
65900
3
REMOVE EYE LESION
$801.52
65920
3
REMOVE IMPLANT OF EYE
$648.84
65930
3
REMOVE BLOOD CLOT FROM EYE
$533.65
66020
3
INJECTION TREATMENT OF EYE
$156.31
66030
3
INJECTION TREATMENT OF EYE
$138.51
66130
3
REMOVE EYE LESION
$589.23
66150
3
GLAUCOMA SURGERY
$714.56
66155
3
GLAUCOMA SURGERY
$712.26
66160
3
GLAUCOMA SURGERY
$809.72
66165
3
GLAUCOMA SURGERY
$697.96
66170
3
GLAUCOMA SURGERY
$980.53
66172
3
INCISION OF EYE
66180
3
IMPLANT EYE SHUNT
$972.49
66185
3
REVISE EYE SHUNT
$615.44
66220
3
REPAIR EYE LESION
$601.48
66225
3
REPAIR/GRAFT EYE LESION
$772.41
$1,232.20
Procedure Code Pricing Action Code Description
Maximum Allowable
66250
3
FOLLOW-UP SURGERY OF EYE
$623.44
66500
3
INCISION OF IRIS
$293.23
66505
3
INCISION OF IRIS
$320.96
66600
3
REMOVE IRIS AND LESION
$677.60
66605
3
REMOVAL OF IRIS
$878.47
66625
3
REMOVAL OF IRIS
$356.21
66630
3
REMOVAL OF IRIS
$468.18
66635
3
REMOVAL OF IRIS
$472.87
66680
3
REPAIR IRIS & CILIARY BODY
$423.55
66682
9
REPAIR IRIS & CILIARY BODY
$0.00
66700
3
DESTRUCTION, CILIARY BODY
66701
O
CYCLODIATHERMY SUBSEQUENT
$0.00
66702
O
CILIARY BODY DESTRUCTION, ANY METHO
$0.00
66710
3
CILIARY TRANSSLERAL THERAPY
$365.64
66711
3
CILIARY ENDOSCOPIC ABLATION
$523.39
66720
3
DESTRUCTION, CILIARY BODY
$384.35
66721
O
CYCLOCRYOTHERAPY SUBSEQUENT
66740
3
DESTRUCTION, CILIARY BODY
66741
O
CYCLODIALYSIS SUBSEQUENT
66761
3
REVISION OF IRIS
$373.28
66762
3
REVISION OF IRIS
$390.91
66770
3
REMOVAL OF INNER EYE LESION
$433.98
66800
O
DISCISSION OF LENS CAPSULE INCISION
$0.00
66801
O
DISCISSION OF LENS CAPSULE INCISION
$0.00
66802
O
DISCISSION OF LENS CAPSULE LASER SU
$0.00
66820
3
INCISION, SECONDARY CATARACT
$329.85
66821
3
AFTER CATARACT LASER SURGERY
$267.68
66825
3
REPOSITION INTRAOCULAR LENS
$631.25
66830
3
REMOVAL OF LENS LESION
$589.07
66840
3
REMOVAL OF LENS MATERIAL
$574.25
66850
3
REMOVAL OF LENS MATERIAL
$655.37
66852
3
REMOVAL OF LENS MATERIAL
$701.10
66915
O
EXPRESSION OF LENS, LINEAR, ONE OR
66920
3
EXTRACTION OF LENS
$625.66
66930
3
EXTRACTION OF LENS
$710.83
$372.16
$0.00 $363.05 $0.00
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
66940
3
EXTRACTION OF LENS
$645.87
66982
3
CATARACT SURGERY, COMPLEX
$887.39
66983
3
CATARACT SURG W/IOL, 1 STAGE
$612.23
66984
3
CATARACT SURG W/IOL, 1 STAGE
$636.87
66985
3
INSERT LENS PROSTHESIS
$631.01
66986
3
EXCHANGE LENS PROSTHESIS
$771.53
66990
3
OPHTHALMIC ENDOSCOPE ADD-ON
66999
5
EYE SURGERY PROCEDURE
67005
3
PARTIAL REMOVAL OF EYE FLUID
$389.62
67010
3
PARTIAL REMOVAL OF EYE FLUID
$450.61
67015
3
RELEASE OF EYE FLUID
$481.59
67025
3
REPLACE EYE FLUID
$600.25
67027
3
IMPLANT EYE DRUG SYSTEM
$709.76
67028
3
INJECTION EYE DRUG
$179.81
67030
3
INCISE INNER EYE STRANDS
$431.00
67031
3
LASER SURGERY, EYE STRANDS
$318.75
67036
3
REMOVAL OF INNER EYE FLUID
$801.45
67038
O
STRIP RETINAL MEMBRANE
67039
3
LASER TREATMENT OF RETINA
$1,027.13
67040
3
LASER TREATMENT OF RETINA
$1,184.47
67041
3
VIT FOR MACULAR PUCKER
$1,105.87
67042
3
VIT FOR MACULAR HOLE
$1,266.18
67043
3
VIT FOR MEMBRANE DISSECT
$1,328.99
67101
3
REPAIR DETACHED RETINA
$642.64
67105
3
REPAIR DETACHED RETINA
$594.14
67107
3
REPAIR DETACHED RETINA
$1,008.06
67108
3
REPAIR DETACHED RETINA
$1,340.89
67109
O
REPAIR OF RETINAL DETACHMENT, ONE O
67110
3
REPAIR DETACHED RETINA
67112
3
REREPAIR DETACHED RETINA
$1,106.57
67113
3
REPAIR RETINAL DETACH, CPLX
$1,455.41
67115
3
RELEASE ENCIRCLING MATERIAL
$406.82
67120
3
REMOVE EYE IMPLANT MATERIAL
$542.61
67121
3
REMOVE EYE IMPLANT MATERIAL
$751.70
67141
3
TREATMENT OF RETINA
$429.52
$78.56 $0.00
$0.00
$0.00 $719.08
Procedure Code Pricing Action Code Description
Maximum Allowable
67145
3
TREATMENT OF RETINA
$432.88
67208
3
TREATMENT OF RETINAL LESION
$495.52
67210
3
TREATMENT OF RETINAL LESION
$577.95
67218
3
TREATMENT OF RETINAL LESION
$1,170.50
67220
3
TREATMENT OF CHOROID LESION
$887.55
67221
3
OCULAR PHOTODYNAMIC THER
$251.93
67225
3
EYE PHOTODYNAMIC THER ADD-ON
67227
3
TREATMENT OF RETINAL LESION
$504.92
67228
3
TREATMENT OF RETINAL LESION
$997.15
67229
3
TR RETINAL LES PRETERM INF
$958.47
67250
3
REINFORCE EYE WALL
$654.69
67255
3
REINFORCE/GRAFT EYE WALL
$700.29
67299
5
EYE SURGERY PROCEDURE
67311
3
REVISE EYE MUSCLE
$495.26
67312
3
REVISE TWO EYE MUSCLES
$591.60
67313
O
STRABISMUS SURGERY ON PATIENT NOT P
67314
3
REVISE EYE MUSCLE
$555.13
67316
3
REVISE TWO EYE MUSCLES
$663.95
67318
3
REVISE EYE MUSCLE(S)
$581.09
67320
3
REVISE EYE MUSCLE(S) ADD-ON
$275.14
67331
3
EYE SURGERY FOLLOW-UP ADD-ON
$260.44
67332
3
REREVISE EYE MUSCLES ADD-ON
$283.31
67334
3
REVISE EYE MUSCLE W/SUTURE
$256.98
67335
3
EYE SUTURE DURING SURGERY
$129.44
67340
3
REVISE EYE MUSCLE ADD-ON
$306.17
67343
3
RELEASE EYE TISSUE
$539.50
67345
3
DESTROY NERVE OF EYE MUSCLE
$196.71
67346
3
BIOPSY, EYE MUSCLE
$171.22
67350
O
BIOPSY EYE MUSCLE
$0.00
67399
5
EYE MUSCLE SURGERY PROCEDURE
$0.00
67400
3
EXPLORE/BIOPSY EYE SOCKET
$779.20
67405
3
EXPLORE/DRAIN EYE SOCKET
$663.78
67412
3
EXPLORE/TREAT EYE SOCKET
$721.34
67413
3
EXPLORE/TREAT EYE SOCKET
$721.92
67414
3
EXPLR/DECOMPRESS EYE SOCKET
$25.77
$0.00
$0.00
$1,101.61
Procedure Code Pricing Action Code Description
Maximum Allowable
67415
3
ASPIRATION, ORBITAL CONTENTS
$90.56
67420
3
EXPLORE/TREAT EYE SOCKET
$1,373.92
67430
3
EXPLORE/TREAT EYE SOCKET
$1,046.87
67440
3
EXPLORE/DRAIN EYE SOCKET
$1,009.18
67445
3
EXPLR/DECOMPRESS EYE SOCKET
$1,182.30
67450
3
EXPLORE/BIOPSY EYE SOCKET
$1,047.22
67500
3
INJECT/TREAT EYE SOCKET
$75.95
67505
3
INJECT/TREAT EYE SOCKET
$74.31
67515
3
INJECT/TREAT EYE SOCKET
$78.84
67550
3
INSERT EYE SOCKET IMPLANT
$811.93
67560
3
REVISE EYE SOCKET IMPLANT
$826.30
67570
3
DECOMPRESS OPTIC NERVE
$970.69
67599
5
ORBIT SURGERY PROCEDURE
67700
3
DRAINAGE OF EYELID ABSCESS
$225.88
67710
3
INCISION OF EYELID
$190.68
67715
3
INCISION OF EYELID FOLD
$200.66
67800
3
REMOVE EYELID LESION
$106.07
67801
3
REMOVE EYELID LESIONS
$135.88
67805
3
REMOVE EYELID LESIONS
$168.45
67808
3
REMOVE EYELID LESION(S)
$302.18
67810
3
BIOPSY OF EYELID
$193.71
67820
3
REVISE EYELASHES
$44.44
67825
3
REVISE EYELASHES
$107.54
67830
3
REVISE EYELASHES
$225.68
67835
3
REVISE EYELASHES
$367.26
67840
3
REMOVE EYELID LESION
$235.72
67850
3
TREAT EYELID LESION
$189.59
67875
3
CLOSURE OF EYELID BY SUTURE
$147.16
67880
3
REVISION OF EYELID
$379.08
67882
3
REVISION OF EYELID
$467.16
67900
3
REPAIR BROW DEFECT
$540.23
67901
3
REPAIR EYELID DEFECT
$583.04
67902
3
REPAIR EYELID DEFECT
$596.16
67903
3
REPAIR EYELID DEFECT
$516.48
67904
3
REPAIR EYELID DEFECT
$610.53
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
67906
3
REPAIR EYELID DEFECT
$431.43
67907
O
REPAIR OF BLEPHAROPTOSIS SUPERIOR R
67908
3
REPAIR EYELID DEFECT
$411.40
67909
3
REVISE EYELID DEFECT
$452.09
67911
3
REVISE EYELID DEFECT
$461.55
67912
3
CORRECTION EYELID W/IMPLANT
$769.11
67914
3
REPAIR EYELID DEFECT
$329.39
67915
3
REPAIR EYELID DEFECT
$295.26
67916
3
REPAIR EYELID DEFECT
$452.97
67917
3
REPAIR EYELID DEFECT
$494.67
67921
3
REPAIR EYELID DEFECT
$313.73
67922
3
REPAIR EYELID DEFECT
$285.92
67923
3
REPAIR EYELID DEFECT
$477.14
67924
3
REPAIR EYELID DEFECT
$494.27
67930
3
REPAIR EYELID WOUND
$310.63
67935
3
REPAIR EYELID WOUND
$503.66
67938
3
REMOVE EYELID FOREIGN BODY
$206.06
67950
3
REVISION OF EYELID
$486.79
67961
3
REVISION OF EYELID
$486.23
67966
3
REVISION OF EYELID
$638.66
67971
3
RECONSTRUCTION OF EYELID
$612.74
67973
3
RECONSTRUCTION OF EYELID
$793.50
67974
3
RECONSTRUCTION OF EYELID
$790.20
67975
3
RECONSTRUCTION OF EYELID
$578.82
67999
5
REVISION OF EYELID
68020
3
INCISE/DRAIN EYELID LINING
$99.54
68040
3
TREATMENT OF EYELID LESIONS
$55.36
68100
3
BIOPSY OF EYELID LINING
$146.04
68110
3
REMOVE EYELID LINING LESION
$189.97
68115
3
REMOVE EYELID LINING LESION
$263.90
68130
3
REMOVE EYELID LINING LESION
$452.48
68135
3
REMOVE EYELID LINING LESION
$130.73
68200
3
TREAT EYELID BY INJECTION
$35.73
68320
3
REVISE/GRAFT EYELID LINING
$599.28
68325
3
REVISE/GRAFT EYELID LINING
$546.92
$0.00
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
68326
3
REVISE/GRAFT EYELID LINING
$532.45
68328
3
REVISE/GRAFT EYELID LINING
$594.52
68330
3
REVISE EYELID LINING
$503.07
68335
3
REVISE/GRAFT EYELID LINING
$534.12
68340
3
SEPARATE EYELID ADHESIONS
$453.42
68360
3
REVISE EYELID LINING
$441.58
68362
3
REVISE EYELID LINING
$541.33
68371
3
HARVEST EYE TISSUE, ALOGRAFT
$348.60
68399
5
EYELID LINING SURGERY
68400
3
INCISE/DRAIN TEAR GLAND
$238.27
68420
3
INCISE/DRAIN TEAR SAC
$271.14
68440
3
INCISE TEAR DUCT OPENING
68500
3
REMOVAL OF TEAR GLAND
$806.66
68505
3
PARTIAL REMOVAL, TEAR GLAND
$811.93
68510
3
BIOPSY OF TEAR GLAND
$385.06
68520
3
REMOVAL OF TEAR SAC
$571.67
68525
3
BIOPSY OF TEAR SAC
$229.40
68530
3
CLEARANCE OF TEAR DUCT
$368.37
68540
3
REMOVE TEAR GLAND LESION
$771.51
68550
3
REMOVE TEAR GLAND LESION
$947.99
68700
3
REPAIR TEAR DUCTS
$498.03
68705
3
REVISE TEAR DUCT OPENING
$200.58
68720
3
CREATE TEAR SAC DRAIN
$632.13
68745
3
CREATE TEAR DUCT DRAIN
$634.88
68750
3
CREATE TEAR DUCT DRAIN
$652.86
68760
3
CLOSE TEAR DUCT OPENING
$170.06
68761
3
CLOSE TEAR DUCT OPENING
$123.59
68770
3
CLOSE TEAR SYSTEM FISTULA
$491.58
68800
O
DILATION OF LACRIMAL PUNCTUM, WITH
68801
3
DILATE TEAR DUCT OPENING
$102.79
68810
3
PROBE NASOLACRIMAL DUCT
$198.71
68811
3
PROBE NASOLACRIMAL DUCT
$171.71
68815
3
PROBE NASOLACRIMAL DUCT
$375.32
68816
3
PROBE NL DUCT W/BALLOON
$579.09
68820
O
PROBING OF NASOLACRIMAL DUCT, WITH
$0.00
$89.85
$0.00
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
68825
O
PROBING OF NASOLACRIMAL DUCT, WITH
$0.00
68830
O
PROBING OF NASOLACRIMAL DUCT, WITH
$0.00
68840
3
EXPLORE/IRRIGATE TEAR DUCTS
$104.13
68850
3
INJECTION FOR TEAR SAC X-RAY
$58.38
68899
5
TEAR DUCT SYSTEM SURGERY
69000
3
DRAIN EXTERNAL EAR LESION
$161.51
69005
3
DRAIN EXTERNAL EAR LESION
$190.73
69020
3
DRAIN OUTER EAR CANAL LESION
$206.58
69090
9
PIERCE EARLOBES
69100
3
BIOPSY OF EXTERNAL EAR
69105
3
BIOPSY OF EXTERNAL EAR CANAL
$126.33
69110
3
REMOVE EXTERNAL EAR, PARTIAL
$410.32
69120
3
REMOVAL OF EXTERNAL EAR
$361.57
69140
3
REMOVE EAR CANAL LESION(S)
$791.65
69145
3
REMOVE EAR CANAL LESION(S)
$345.59
69150
3
EXTENSIVE EAR CANAL SURGERY
$960.49
69155
3
EXTENSIVE EAR/NECK SURGERY
69200
3
CLEAR OUTER EAR CANAL
$109.92
69205
3
CLEAR OUTER EAR CANAL
$92.23
69210
O
REMOVE IMPACTED EAR WAX
$0.00
69220
3
CLEAN OUT MASTOID CAVITY
$123.39
69222
3
CLEAN OUT MASTOID CAVITY
$197.80
69300
3
REVISE EXTERNAL EAR
$586.47
69310
3
REBUILD OUTER EAR CANAL
$987.06
69320
3
REBUILD OUTER EAR CANAL
$1,404.47
69399
5
OUTER EAR SURGERY PROCEDURE
69400
3
INFLATE MIDDLE EAR CANAL
$128.20
69401
3
INFLATE MIDDLE EAR CANAL
$74.73
69405
3
CATHETERIZE MIDDLE EAR CANAL
69410
O
INSET MIDDLE EAR (BAFFLE)
69420
3
INCISION OF EARDRUM
$171.03
69421
3
INCISION OF EARDRUM
$137.86
69424
3
REMOVE VENTILATING TUBE
$116.35
69433
3
CREATE EARDRUM OPENING
$177.93
69436
3
CREATE EARDRUM OPENING
$149.62
$0.00
$0.00 $96.22
$1,539.45
$0.00
$233.56 $0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
69440
3
EXPLORATION OF MIDDLE EAR
$621.13
69450
9
EARDRUM REVISION
69501
3
MASTOIDECTOMY
$665.41
69502
3
MASTOIDECTOMY
$884.79
69505
3
REMOVE MASTOID STRUCTURES
$1,097.45
69511
3
EXTENSIVE MASTOID SURGERY
$1,128.07
69530
3
EXTENSIVE MASTOID SURGERY
$1,516.23
69535
3
REMOVE PART OF TEMPORAL BONE
$2,457.55
69540
3
REMOVE EAR LESION
$186.86
69550
3
REMOVE EAR LESION
$948.95
69552
3
REMOVE EAR LESION
$1,443.05
69554
3
REMOVE EAR LESION
$2,282.15
69601
3
MASTOID SURGERY REVISION
$954.16
69602
3
MASTOID SURGERY REVISION
$992.92
69603
3
MASTOID SURGERY REVISION
$1,160.08
69604
3
MASTOID SURGERY REVISION
$1,024.39
69605
3
MASTOID SURGERY REVISION
$1,431.95
69610
3
REPAIR OF EARDRUM
$355.84
69620
3
REPAIR OF EARDRUM
$627.12
69631
3
REPAIR EARDRUM STRUCTURES
$798.81
69632
3
REBUILD EARDRUM STRUCTURES
$980.06
69633
3
REBUILD EARDRUM STRUCTURES
$944.54
69635
3
REPAIR EARDRUM STRUCTURES
$1,112.91
69636
3
REBUILD EARDRUM STRUCTURES
$1,260.93
69637
3
REBUILD EARDRUM STRUCTURES
$1,255.27
69641
3
REVISE MIDDLE EAR & MASTOID
$948.69
69642
3
REVISE MIDDLE EAR & MASTOID
$1,222.84
69643
3
REVISE MIDDLE EAR & MASTOID
$1,116.78
69644
3
REVISE MIDDLE EAR & MASTOID
$1,355.96
69645
3
REVISE MIDDLE EAR & MASTOID
$1,328.65
69646
3
REVISE MIDDLE EAR & MASTOID
$1,411.43
69650
3
RELEASE MIDDLE EAR BONE
$722.45
69660
3
REVISE MIDDLE EAR BONE
$848.95
69661
9
REVISE MIDDLE EAR BONE
$0.00
69662
3
REVISE MIDDLE EAR BONE
$1,063.36
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
69666
3
REPAIR MIDDLE EAR STRUCTURES
$733.29
69667
3
REPAIR MIDDLE EAR STRUCTURES
$735.86
69670
3
REMOVE MASTOID AIR CELLS
$857.88
69676
3
REMOVE MIDDLE EAR NERVE
$757.33
69700
3
CLOSE MASTOID FISTULA
$630.99
69710
5
IMPLANT/REPLACE HEARING AID
69711
3
REMOVE/REPAIR HEARING AID
$789.21
69714
3
IMPLANT TEMPLE BONE W/STIMUL
$985.42
69715
3
TEMPLE BNE IMPLNT W/STIMULAT
$1,224.49
69717
3
TEMPLE BONE IMPLANT REVISION
$1,041.54
69718
3
REVISE TEMPLE BONE IMPLANT
$1,280.30
69720
3
RELEASE FACIAL NERVE
$1,070.85
69725
3
RELEASE FACIAL NERVE
$1,739.12
69740
3
REPAIR FACIAL NERVE
$1,075.92
69745
3
REPAIR FACIAL NERVE
$1,143.26
69799
5
MIDDLE EAR SURGERY PROCEDURE
69801
3
INCISE INNER EAR
$679.87
69802
3
INCISE INNER EAR
$951.60
69805
3
EXPLORE INNER EAR
$963.44
69806
3
EXPLORE INNER EAR
$866.20
69820
3
ESTABLISH INNER EAR WINDOW
$787.31
69840
3
REVISE INNER EAR WINDOW
$828.40
69905
3
REMOVE INNER EAR
$838.89
69910
3
REMOVE INNER EAR & MASTOID
$936.17
69915
3
INCISE INNER EAR NERVE
$1,415.40
69930
3
IMPLANT COCHLEAR DEVICE
$1,138.44
69949
5
INNER EAR SURGERY PROCEDURE
69950
3
INCISE INNER EAR NERVE
$1,675.03
69955
3
RELEASE FACIAL NERVE
$1,833.26
69960
3
RELEASE INNER EAR CANAL
$1,775.92
69970
3
REMOVE INNER EAR LESION
$1,983.90
69979
5
TEMPORAL BONE SURGERY
$0.00
69990
3
MICROSURGERY ADD-ON
$198.95
70010
3
CONTRAST X-RAY OF BRAIN
$170.26
70011
O
MYELOGRAPHY, POSTERIOR FOSSA COMPLE
$0.00
$0.00
$0.00
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
70015
3
CONTRAST X-RAY OF BRAIN
$142.11
70016
O
CISTERNOGRAPHY, POSITIVE CONTRAST C
70030
3
X-RAY EYE FOR FOREIGN BODY
$27.87
70100
3
X-RAY EXAM OF JAW
$30.08
7010F
9
PT INFO INTO RECALL SYSTEM
70110
3
X-RAY EXAM OF JAW
$38.96
70120
3
X-RAY EXAM OF MASTOIDS
$32.77
70130
3
X-RAY EXAM OF MASTOIDS
$54.13
70134
3
X-RAY EXAM OF MIDDLE EAR
$46.36
70140
3
X-RAY EXAM OF FACIAL BONES
$29.43
70150
3
X-RAY EXAM OF FACIAL BONES
$42.15
70160
3
X-RAY EXAM OF NASAL BONES
$31.57
70170
3
X-RAY EXAM OF TEAR DUCT
$0.00
70171
O
DACRYOCYSTOGRAPHY, NASOLACRIMAL DUC
$0.00
70190
3
X-RAY EXAM OF EYE SOCKETS
$34.96
70200
3
X-RAY EXAM OF EYE SOCKETS
$43.61
7020F
9
MAMMO ASSESS CAT IN DBASE
$0.00
70210
3
X-RAY EXAM OF SINUSES
$29.46
70220
3
X-RAY EXAM OF SINUSES
$38.47
70240
3
X-RAY EXAM, PITUITARY SADDLE
$28.95
70250
3
X-RAY EXAM OF SKULL
$35.65
7025F
9
PT INFOSYS ALARM 4 NXT MAMMO
70260
3
X-RAY EXAM OF SKULL
$47.34
70300
3
X-RAY EXAM OF TEETH
$13.91
70310
3
X-RAY EXAM OF TEETH
$33.43
70320
3
FULL MOUTH X-RAY OF TEETH
$43.07
70328
3
X-RAY EXAM OF JAW JOINT
$29.33
70330
3
X-RAY EXAM OF JAW JOINTS
$46.62
70332
3
X-RAY EXAM OF JAW JOINT
$83.65
70333
O
TEMPOROMANDIBULAR JOINT ARTHROGRAPH
70336
3
MAGNETIC IMAGE, JAW JOINT
70350
3
X-RAY HEAD FOR ORTHODONTIA
$20.10
70355
3
PANORAMIC X-RAY OF JAWS
$22.39
70360
3
X-RAY EXAM OF NECK
$26.75
70370
3
THROAT X-RAY & FLUOROSCOPY
$73.62
$0.00
$0.00
$0.00
$0.00 $425.18
Procedure Code Pricing Action Code Description
Maximum Allowable
70371
3
SPEECH EVALUATION, COMPLEX
$96.33
70373
3
CONTRAST X-RAY OF LARYNX
$79.47
70374
O
LARYNGOGRAPHY, CONTRAST COMPLETE PR
70380
3
X-RAY EXAM OF SALIVARY GLAND
$36.48
70390
3
X-RAY EXAM OF SALIVARY DUCT
$98.77
70391
O
SIALOGRAPHY COMPLETE PROCEDURE
70450
3
CT HEAD/BRAIN W/O DYE
$219.23
70460
3
CT HEAD/BRAIN W/DYE
$283.53
70470
3
CT HEAD/BRAIN W/O & W/DYE
$343.32
70480
3
CT ORBIT/EAR/FOSSA W/O DYE
$261.48
70481
3
CT ORBIT/EAR/FOSSA W/DYE
$381.20
70482
3
CT ORBIT/EAR/FOSSA W/O&W/DYE
$417.80
70486
3
CT MAXILLOFACIAL W/O DYE
$253.88
70487
3
CT MAXILLOFACIAL W/DYE
$341.61
70488
3
CT MAXILLOFACIAL W/O & W/DYE
$415.97
70490
3
CT SOFT TISSUE NECK W/O DYE
$261.21
70491
3
CT SOFT TISSUE NECK W/DYE
$335.59
70492
3
CT SFT TSUE NCK W/O & W/DYE
$407.80
70496
3
CT ANGIOGRAPHY, HEAD
$444.88
70498
3
CT ANGIOGRAPHY, NECK
$445.24
70540
3
MRI ORBIT/FACE/NECK W/O DYE
$420.92
70541
O
MAGNETIC IMAGE, HEAD (MRA)
70542
3
MRI ORBIT/FACE/NECK W/DYE
$514.55
70543
3
MRI ORBT/FAC/NCK W/O & W/DYE
$652.35
70544
3
MR ANGIOGRAPHY HEAD W/O DYE
$412.18
70545
3
MR ANGIOGRAPHY HEAD W/DYE
$492.34
70546
3
MR ANGIOGRAPH HEAD W/O&W/DYE
$637.80
70547
3
MR ANGIOGRAPHY NECK W/O DYE
$412.04
70548
3
MR ANGIOGRAPHY NECK W/DYE
$492.60
70549
3
MR ANGIOGRAPH NECK W/O&W/DYE
$637.80
70551
3
MRI BRAIN W/O DYE
$426.20
70552
3
MRI BRAIN W/DYE
$520.88
70553
3
MRI BRAIN W/O & W/DYE
$658.38
70554
3
FMRI BRAIN BY TECH
$620.22
70555
3
FMRI BRAIN BY PHYS/PSYCH
$0.00
$0.00
$0.00
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
70557
3
MRI BRAIN W/O DYE
$0.00
70558
3
MRI BRAIN W/DYE
$0.00
70559
3
MRI BRAIN W/O & W/DYE
$0.00
71010
3
CHEST X-RAY
$23.78
71015
3
CHEST X-RAY
$29.29
71020
3
CHEST X-RAY
$31.61
71021
3
CHEST X-RAY
$38.07
71022
3
CHEST X-RAY
$45.79
71023
3
CHEST X-RAY AND FLUOROSCOPY
$66.40
71030
3
CHEST X-RAY
$46.16
71034
3
CHEST X-RAY AND FLUOROSCOPY
$91.30
71035
3
CHEST X-RAY
$34.14
71036
O
X-RAY GUIDANCE FOR BIOPSY
$0.00
71037
O
NEEDLE BIOPSY OF INTRATHORACIC LESI
$0.00
71038
O
X-RAY GUIDANCE FOR BIOPSY
$0.00
71040
3
CONTRAST X-RAY OF BRONCHI
$95.09
71041
O
BRONCHOGRAPHY, UNILATERAL COMPLETE
71060
3
CONTRAST X-RAY OF BRONCHI
71061
O
BRONCHOGRAPHY, BILATERAL COMPLETE P
$0.00
71090
3
X-RAY & PACEMAKER INSERTION
$0.00
71100
3
X-RAY EXAM OF RIBS
$32.35
71101
3
X-RAY EXAM OF RIBS/CHEST
$38.95
71110
3
X-RAY EXAM OF RIBS
$40.30
71111
3
X-RAY EXAM OF RIBS/CHEST
$51.56
71120
3
X-RAY EXAM OF BREASTBONE
$32.38
71130
3
X-RAY EXAM OF BREASTBONE
$37.16
71250
3
CT THORAX W/O DYE
$254.31
71260
3
CT THORAX W/DYE
$343.49
71270
3
CT THORAX W/O & W/DYE
$413.50
71275
3
CT ANGIOGRAPHY, CHEST
$453.94
71550
3
MRI CHEST W/O DYE
$426.20
71551
3
MRI CHEST W/DYE
$519.96
71552
3
MRI CHEST W/O & W/DYE
$660.83
71555
3
MRI ANGIO CHEST W OR W/O DYE
$523.84
72010
3
X-RAY EXAM OF SPINE
$0.00 $138.60
$68.28
Procedure Code Pricing Action Code Description
Maximum Allowable
72020
3
X-RAY EXAM OF SPINE
$23.45
72040
3
X-RAY EXAM OF NECK SPINE
$36.42
72050
3
X-RAY EXAM OF NECK SPINE
$51.58
72052
3
X-RAY EXAM OF NECK SPINE
$64.69
72069
3
X-RAY EXAM OF TRUNK SPINE
$34.46
72070
3
X-RAY EXAM OF THORACIC SPINE
$33.46
72072
3
X-RAY EXAM OF THORACIC SPINE
$38.14
72074
3
X-RAY EXAM OF THORACIC SPINE
$44.66
72080
3
X-RAY EXAM OF TRUNK SPINE
$34.94
72090
3
X-RAY EXAM OF TRUNK SPINE
$45.95
72100
3
X-RAY EXAM OF LOWER SPINE
$38.27
72110
3
X-RAY EXAM OF LOWER SPINE
$53.42
72114
3
X-RAY EXAM OF LOWER SPINE
$69.86
72120
3
X-RAY EXAM OF LOWER SPINE
$47.99
72125
3
CT NECK SPINE W/O DYE
$254.31
72126
3
CT NECK SPINE W/DYE
$342.77
72127
3
CT NECK SPINE W/O & W/DYE
$407.72
72128
3
CT CHEST SPINE W/O DYE
$254.31
72129
3
CT CHEST SPINE W/DYE
$343.15
72130
3
CT CHEST SPINE W/O & W/DYE
$408.09
72131
3
CT LUMBAR SPINE W/O DYE
$254.31
72132
3
CT LUMBAR SPINE W/DYE
$342.77
72133
3
CT LUMBAR SPINE W/O & W/DYE
$408.09
72141
3
MRI NECK SPINE W/O DYE
$430.96
72142
3
MRI NECK SPINE W/DYE
$527.60
72146
3
MRI CHEST SPINE W/O DYE
$431.06
72147
3
MRI CHEST SPINE W/DYE
$527.19
72148
3
MRI LUMBAR SPINE W/O DYE
$424.93
72149
3
MRI LUMBAR SPINE W/DYE
$520.88
72156
3
MRI NECK SPINE W/O & W/DYE
$668.83
72157
3
MRI CHEST SPINE W/O & W/DYE
$668.42
72158
3
MRI LUMBAR SPINE W/O & W/DYE
$658.13
72159
3
MR ANGIO SPINE W/O&W/DYE
$653.63
72170
3
X-RAY EXAM OF PELVIS
$25.65
72190
3
X-RAY EXAM OF PELVIS
$39.02
Procedure Code Pricing Action Code Description
Maximum Allowable
72191
3
CT ANGIOGRAPH PELV W/O&W/DYE
$448.15
72192
3
CT PELVIS W/O DYE
$250.94
72193
3
CT PELVIS W/DYE
$325.97
72194
3
CT PELVIS W/O & W/DYE
$405.71
72195
3
MRI PELVIS W/O DYE
$425.81
72196
3
MRI PELVIS W/DYE
$520.17
72197
3
MRI PELVIS W/O & W/DYE
$657.47
72198
3
MR ANGIO PELVIS W/O & W/DYE
$522.74
72200
3
X-RAY EXAM SACROILIAC JOINTS
$28.61
72202
3
X-RAY EXAM SACROILIAC JOINTS
$34.60
72220
3
X-RAY EXAM OF TAILBONE
$29.09
72240
3
CONTRAST X-RAY OF NECK SPINE
72241
O
MYELOGRAPHY, CERVICAL COMPLETE PROC
72255
3
CONTRAST X-RAY, THORAX SPINE
72256
O
MYELOGRAPHY, THORACIC COMPLETE PROC
72265
3
CONTRAST X-RAY, LOWER SPINE
72266
O
MYELOGRAPHY, LUMBOSACRAL COMPLETE P
72270
3
CONTRAST X-RAY, SPINE
72271
O
MYELOGRAPHY, ENTIRE SPINAL CANAL CO
72275
3
EPIDUROGRAPHY
$102.89
72285
3
X-RAY C/T SPINE DISK
$175.44
72286
O
DISKOGRAPHY, CERVICAL COMPLETE PROC
$0.00
72291
3
PERQ VERTEBROPLASTY, FLUOR
$0.00
72292
3
PERQ VERTEBROPLASTY, CT
$0.00
72295
3
X-RAY OF LOWER SPINE DISK
$156.40
72296
O
DISKOGRAPHY, LUMBAR COMPLETE PROCED
73000
3
X-RAY EXAM OF COLLAR BONE
$27.14
73010
3
X-RAY EXAM OF SHOULDER BLADE
$27.87
73020
3
X-RAY EXAM OF SHOULDER
$23.09
73030
3
X-RAY EXAM OF SHOULDER
$29.44
73040
3
CONTRAST X-RAY OF SHOULDER
73041
O
RADIOLOGIC EXAMINATION, SHOULDER, A
73050
3
X-RAY EXAM OF SHOULDERS
$35.34
73060
3
X-RAY EXAM OF HUMERUS
$28.71
73070
3
X-RAY EXAM OF ELBOW
$26.41
$157.41 $0.00 $143.75 $0.00 $146.43 $0.00 $228.42 $0.00
$0.00
$105.84 $0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
73080
3
X-RAY EXAM OF ELBOW
$33.89
73085
3
CONTRAST X-RAY OF ELBOW
$95.48
73086
O
RADIOLOGIC EXAMINATION, ELBOW, ARTH
73090
3
X-RAY EXAM OF FOREARM
$26.77
73092
3
X-RAY EXAM OF ARM, INFANT
$27.51
73100
3
X-RAY EXAM OF WRIST
$27.88
73110
3
X-RAY EXAM OF WRIST
$33.41
73115
3
CONTRAST X-RAY OF WRIST
73116
O
RADIOLOGIC EXAMINATION, WRIST, ARTH
73120
3
X-RAY EXAM OF HAND
$26.40
73130
3
X-RAY EXAM OF HAND
$30.46
73140
3
X-RAY EXAM OF FINGER(S)
$28.28
73200
3
CT UPPER EXTREMITY W/O DYE
$251.22
73201
3
CT UPPER EXTREMITY W/DYE
$325.88
73202
3
CT UPPR EXTREMITY W/O&W/DYE
$406.24
73206
3
CT ANGIO UPR EXTRM W/O&W/DYE
$448.63
73218
3
MRI UPPER EXTREMITY W/O DYE
$420.68
73219
3
MRI UPPER EXTREMITY W/DYE
$514.91
73220
3
MRI UPPR EXTREMITY W/O&W/DYE
$652.85
73221
3
MRI JOINT UPR EXTREM W/O DYE
$420.79
73222
3
MRI JOINT UPR EXTREM W/DYE
$514.28
73223
3
MRI JOINT UPR EXTR W/O&W/DYE
$652.08
73225
3
MR ANGIO UPR EXTR W/O&W/DYE
$637.36
73500
3
X-RAY EXAM OF HIP
$24.91
73510
3
X-RAY EXAM OF HIP
$36.06
73520
3
X-RAY EXAM OF HIPS
$38.96
73525
3
CONTRAST X-RAY OF HIP
$95.35
73526
O
RADIOLOGIC EXAMINATION, HIP, ARTHRO
$0.00
73530
3
X-RAY EXAM OF HIP
$0.00
73540
3
X-RAY EXAM OF PELVIS & HIPS
$36.07
73542
3
X-RAY EXAM, SACROILIAC JOINT
$77.92
73550
3
X-RAY EXAM OF THIGH
$27.98
73560
3
X-RAY EXAM OF KNEE, 1 OR 2
$27.87
73562
3
X-RAY EXAM OF KNEE, 3
$33.51
73564
3
X-RAY EXAM, KNEE, 4 OR MORE
$39.00
$0.00
$101.29 $0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
73565
3
X-RAY EXAM OF KNEES
$29.71
73580
3
CONTRAST X-RAY OF KNEE JOINT
73581
O
RADIOLOGIC EXAMINATION, KNEE, ARTHR
73590
3
X-RAY EXAM OF LOWER LEG
$26.75
73592
3
X-RAY EXAM OF LEG, INFANT
$27.51
73600
3
X-RAY EXAM OF ANKLE
$26.40
73610
3
X-RAY EXAM OF ANKLE
$30.46
73615
3
CONTRAST X-RAY OF ANKLE
$97.94
73616
O
RADIOLOGIC EXAMINATION, ANKLE, ARTH
73620
3
X-RAY EXAM OF FOOT
$25.67
73630
3
X-RAY EXAM OF FOOT
$30.09
73650
3
X-RAY EXAM OF HEEL
$26.03
73660
3
X-RAY EXAM OF TOE(S)
$26.80
73700
3
CT LOWER EXTREMITY W/O DYE
$251.22
73701
3
CT LOWER EXTREMITY W/DYE
$328.10
73702
3
CT LWR EXTREMITY W/O&W/DYE
$406.60
73706
3
CT ANGIO LWR EXTR W/O&W/DYE
$453.48
73718
3
MRI LOWER EXTREMITY W/O DYE
$420.92
73719
3
MRI LOWER EXTREMITY W/DYE
$514.55
73720
3
MRI LWR EXTREMITY W/O&W/DYE
$652.85
73721
3
MRI JNT OF LWR EXTRE W/O DYE
$420.79
73722
3
MRI JOINT OF LWR EXTR W/DYE
$514.78
73723
3
MRI JOINT LWR EXTR W/O&W/DYE
$652.08
73725
3
MR ANG LWR EXT W OR W/O DYE
$524.06
74000
3
X-RAY EXAM OF ABDOMEN
$25.26
74010
3
X-RAY EXAM OF ABDOMEN
$37.14
74020
3
X-RAY EXAM OF ABDOMEN
$39.68
74022
3
X-RAY EXAM SERIES, ABDOMEN
$47.99
74150
3
CT ABDOMEN W/O DYE
$255.75
74160
3
CT ABDOMEN W/DYE
$365.64
74170
3
CT ABDOMEN W/O & W/DYE
$415.38
74175
3
CT ANGIO ABDOM W/O & W/DYE
$453.10
74181
3
MRI ABDOMEN W/O DYE
$425.66
74182
3
MRI ABDOMEN W/DYE
$520.57
74183
3
MRI ABDOMEN W/O & W/DYE
$657.47
$119.13 $0.00
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
74185
3
MRI ANGIO, ABDOM W ORW/O DYE
$522.61
74190
3
X-RAY EXAM OF PERITONEUM
74210
3
CONTRST X-RAY EXAM OF THROAT
$76.16
74220
3
CONTRAST X-RAY, ESOPHAGUS
$86.38
74230
3
CINE/VID X-RAY, THROAT/ESOPH
$88.75
74235
3
REMOVE ESOPHAGUS OBSTRUCTION
74240
3
X-RAY EXAM, UPPER GI TRACT
$106.78
74241
3
X-RAY EXAM, UPPER GI TRACT
$113.81
74245
3
X-RAY EXAM, UPPER GI TRACT
$170.79
74246
3
CONTRST X-RAY UPPR GI TRACT
$122.42
74247
3
CONTRST X-RAY UPPR GI TRACT
$123.90
74249
3
CONTRST X-RAY UPPR GI TRACT
$183.24
74250
3
X-RAY EXAM OF SMALL BOWEL
$100.66
74251
3
X-RAY EXAM OF SMALL BOWEL
$180.87
74260
3
X-RAY EXAM OF SMALL BOWEL
$114.82
74270
3
CONTRAST X-RAY EXAM OF COLON
$124.03
74280
3
CONTRAST X-RAY EXAM OF COLON
$194.73
74283
3
CONTRAST X-RAY EXAM OF COLON
$190.35
74290
3
CONTRAST X-RAY, GALLBLADDER
$64.26
74291
3
CONTRAST X-RAYS, GALLBLADDER
$55.56
74300
O
X-RAY BILE DUCTS/PANCREAS
$0.00
74301
3
X-RAYS AT SURGERY ADD-ON
$0.00
74305
3
X-RAY BILE DUCTS/PANCREAS
$0.00
74320
3
CONTRAST X-RAY OF BILE DUCTS
74321
O
CHOLANGIOGRAPHY, PERCUTANEOUS, TRAN
74327
3
X-RAY BILE STONE REMOVAL
74328
3
X-RAY BILE DUCT ENDOSCOPY
$0.00
74329
3
X-RAY FOR PANCREAS ENDOSCOPY
$0.00
74330
3
X-RAY BILE/PANC ENDOSCOPY
$0.00
74340
3
X-RAY GUIDE FOR GI TUBE
$0.00
74350
O
X-RAY GUIDE, STOMACH TUBE
$0.00
74351
O
PERCUTANEOUS PLACEMENT OF GASTROSTO
$0.00
74355
3
X-RAY GUIDE, INTESTINAL TUBE
$0.00
74356
O
PERCUTANEOUS PLACEMENT OF ENTEROCLY
$0.00
74360
3
X-RAY GUIDE, GI DILATION
$0.00
$0.00
$0.00
$114.06 $0.00 $129.67
Procedure Code Pricing Action Code Description
Maximum Allowable
74361
O
INTRALUMINAL DILATION OF STRICTURES
$0.00
74363
3
X-RAY, BILE DUCT DILATION
$0.00
74400
3
CONTRST X-RAY, URINARY TRACT
74405
O
CONTRAST X-RAY URINARY TRACT
74410
3
CONTRST X-RAY, URINARY TRACT
$114.91
74415
3
CONTRST X-RAY, URINARY TRACT
$131.78
74420
3
CONTRST X-RAY, URINARY TRACT
$0.00
74425
3
CONTRST X-RAY, URINARY TRACT
$0.00
74426
O
UROGRAPHY, ANTEGRADE, (PYELOSTOGRAM
$0.00
74430
3
CONTRAST X-RAY, BLADDER
74431
O
CYSTOGRAPHY, MINIMUM OF THREE VIEWS
74440
3
X-RAY, MALE GENITAL TRACT
74441
O
VASOGRAPHY, VESICULOGRAPHY, OR EPID
$0.00
74445
3
X-RAY EXAM OF PENIS
$0.00
74446
O
CORPORA CAVERNOSOGRAPHY COMPLETE PR
$0.00
74450
3
X-RAY, URETHRA/BLADDER
$0.00
74451
O
URETHROCYSTOGRAPHY, RETROGRADE COMP
$0.00
74455
3
X-RAY, URETHRA/BLADDER
74456
O
URETHROCYSTOGRAPHY, VOIDING COMPLET
$0.00
74470
3
X-RAY EXAM OF KIDNEY LESION
$0.00
74471
O
RADIOLOGIC EXAMINATION, RENAL CYST
$0.00
74475
3
X-RAY CONTROL, CATH INSERT
74476
O
INTRODUCTION OF INTRACATHETER OR CA
74480
3
X-RAY CONTROL, CATH INSERT
74481
O
INTRODUCTION OF URETERAL CATHETER O
74485
3
X-RAY GUIDE, GU DILATION
74486
O
DILATION OF NEPHROSTOMY OR URETERS
74710
3
X-RAY MEASUREMENT OF PELVIS
$43.28
74740
3
X-RAY, FEMALE GENITAL TRACT
$77.48
74741
O
HYSTEROSALPINGOGRAPHY COMPLETE PROC
$0.00
74742
9
X-RAY, FALLOPIAN TUBE
$0.00
74775
3
X-RAY EXAM OF PERINEUM
$0.00
75120
O
RADIOLOGIC EXAMINATION, HAND; TWO V
$0.00
75500
O
ANGIOCARDIOGRAPHY BY CINERADIOGRAPH
$0.00
75501
O
ANGIOCARDIOGRAPHY BY CINERADIOGRAPH
$0.00
$108.99 $0.00
$78.05 $0.00 $83.89
$90.45
$123.39 $0.00 $123.76 $0.00 $117.99 $0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
75505
O
ANGIOCARDIOGRAPHY BY SERIALOGRAPHY,
$0.00
75506
O
ANGIOCARDIOGRAPHY BY SERIALOGRAPHY,
$0.00
75507
O
ANGIOCARDIOGRAPHY BY SERIALOGRAPHY,
$0.00
75509
O
ANGIOCARDIOGRAPHY BY SERIALOGRAPHY,
$0.00
75519
O
CARDIAC RADIOGRAPHY, SELECTIVE CARD
$0.00
75520
O
CARDIAC RADIOGRAPHY, SELECTIVE CARD
$0.00
75523
O
CARDIAC RADIOGRAPHY, SELECTIVE CARD
$0.00
75524
O
CARDIAC RADIOGRAPHY, SELECTIVE CARD
$0.00
75527
O
CARDIAC RADIOGRAPHY, SELECTIVE CARD
$0.00
75528
O
CARDIAC RADIOGRAPHY, SELECTIVE CARD
$0.00
75552
O
HEART MRI FOR MORPH W/O DYE
$0.00
75553
O
HEART MRI FOR MORPH W/DYE
$0.00
75554
O
CARDIAC MRI/FUNCTION
$0.00
75555
O
CARDIAC MRI/LIMITED STUDY
$0.00
75556
O
CARDIAC MRI/FLOW MAPPING
$0.00
75557
3
CARDIAC MRI FOR MORPH
$470.10
75558
3
CARDIAC MRI FLOW/VELOCITY
$628.75
75559
3
CARDIAC MRI W/STRESS IMG
$507.87
75560
3
CARDIAC MRI FLOW/VEL/STRESS
$822.90
75561
3
CARDIAC MRI FOR MORPH W/DYE
$676.46
75562
3
CARD MRI FLOW/VEL W/DYE
$815.28
75563
3
CARD MRI W/STRESS IMG & DYE
$705.54
75564
3
HT MRI W/FLO/VEL/STRS & DYE
$958.74
75600
3
CONTRAST X-RAY EXAM OF AORTA
$321.57
75601
O
AORTOGRAPHY, THORACIC, WITHOUT SERI
75605
3
CONTRAST X-RAY EXAM OF AORTA
75606
O
AORTOGRAPHY, THORACIC, BY SERIALOGR
75625
3
CONTRAST X-RAY EXAM OF AORTA
75626
O
AORTOGRAPHY, ABDOMINAL, TRANSLUMBAR
$0.00
75627
O
AORTOGRAPHY, ABDOMINAL, CATHETER, B
$0.00
75628
O
AORTOGRAPHY, ABDOMINAL, CATHETER, B
$0.00
75630
3
X-RAY AORTA, LEG ARTERIES
75631
O
AORTOGRAPHY, ABDOMINAL PLUS BILATER
75635
3
CT ANGIO ABDOMINAL ARTERIES
$480.58
75650
3
ARTERY X-RAYS, HEAD & NECK
$289.00
$0.00 $273.42 $0.00 $269.60
$312.36 $0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
75651
O
ANGIOGRAPHY, CERVICOCEREBRAL, CATHE
$0.00
75652
O
ANGIOGRAPHY, CERVICOCEREBRAL, SELEC
$0.00
75653
O
ANGIOGRAPHY, CERVICOCEREBRAL, SELEC
$0.00
75654
O
ANGIOGRAPHY, CERVICOCEREBRAL, SELEC
$0.00
75655
O
ANGIOGRAPHY, CERVICOCEREBRAL, SELEC
$0.00
75656
O
ANGIOGRAPHY, CERVICOCEREBRAL, SELEC
$0.00
75657
O
ANGIOGRAPHY, CERVICOCEREBRAL, SELEC
$0.00
75658
3
ARTERY X-RAYS, ARM
75659
O
ANGIOGRAPHY, BRACHIAL, RETROGRADE C
75660
3
ARTERY X-RAYS, HEAD & NECK
75661
O
ANGIOGRAPHY, EXTERNAL CAROTID, CERE
75662
3
ARTERY X-RAYS, HEAD & NECK
75663
O
ANGIOGRAPHY, EXTERNAL CAROTID, CERE
75665
3
ARTERY X-RAYS, HEAD & NECK
75667
O
ANGIOGRAPHY, CAROTID, CEREBRAL, UNI
$0.00
75669
O
ANGIOGRAPHY, CAROTID, CEREBRAL, UNI
$0.00
75671
3
ARTERY X-RAYS, HEAD & NECK
75672
O
ANGIOGRAPHY, CAROTID, CEREBRAL, BIL
$0.00
75673
O
ANGIOGRAPHY, CAROTID, CEREBRAL, BIL
$0.00
75676
3
ARTERY X-RAYS, NECK
75677
O
ANGIOGRAPHY, CAROTID, CERVICAL, UNI
$0.00
75678
O
ANGIOGRAPHY, CAROTID, CERVICAL, UNI
$0.00
75680
3
ARTERY X-RAYS, NECK
75681
O
ANGIOGRAPHY, CAROTID, CERVICAL, BIL
$0.00
75682
O
ANGIOGRAPHY, CAROTID, CERVICAL, BIL
$0.00
75685
3
ARTERY X-RAYS, SPINE
75686
O
ANGIOGRAPHY, VERTEBRAL DIRECT PUNCT
$0.00
75687
O
ANGIOGRAPHY, VERTEBRAL CATHETER, CO
$0.00
75690
O
ANGIOGRAPHY, VERTEBRAL, CERVICAL, U
$0.00
75692
O
ANGIOGRAPHY, VERTEBRAL, CERVICAL, U
$0.00
75695
O
ANGIOGRAPHY, VERTEBRAL, CERVICAL, B
$0.00
75697
O
ANGIOGRAPHY, VERTEBRAL, CERVICAL, B
$0.00
75705
3
ARTERY X-RAYS, SPINE
75706
O
ANGIOGRAPHY, SPINAL, SELECTIVE COMP
75710
3
ARTERY X-RAYS, ARM/LEG
$285.90 $0.00 $291.20 $0.00 $334.40 $0.00 $298.94
$338.70
$291.44
$325.02
$291.94
$335.42 $0.00 $285.37
Procedure Code Pricing Action Code Description
Maximum Allowable
75711
O
ANGIOGRAPHY, EXTREMITY, UNILATERAL
$0.00
75712
O
ANGIOGRAPHY, EXTREMITY, UNILATERAL
$0.00
75716
3
ARTERY X-RAYS, ARMS/LEGS
75717
O
ANGIOGRAPHY, EXTREMITY, BILATERAL W
$0.00
75718
O
ANGIOGRAPHY, EXTREMITY, BILATERAL B
$0.00
75722
3
ARTERY X-RAYS, KIDNEY
75723
O
ANGIOGRAPHY, RENAL, UNILATERAL, SEL
75724
3
ARTERY X-RAYS, KIDNEYS
75725
O
ANGIOGRAPHY, RENAL, BILATERAL, SELE
75726
3
ARTERY X-RAYS, ABDOMEN
75727
O
ANGIOGRAPHY, VISCERAL SELECTIVE (WI
$0.00
75728
O
ANGIOGRAPHY, VISCERAL SUPRASELECTIV
$0.00
75731
3
ARTERY X-RAYS, ADRENAL GLAND
75732
O
ANGIOGRAPHY, ADRENAL, UNILATERAL, S
75733
3
ARTERY X-RAYS, ADRENALS
75734
O
ANGIOGRAPHY, ADRENAL, BILATERAL, SE
75736
3
ARTERY X-RAYS, PELVIS
75737
O
ANGIOGRAPHY, PELVIC SELECTIVE, COMP
$0.00
75738
O
ANGIOGRAPHY, PELVIC SUPRASELECTIVE,
$0.00
75741
3
ARTERY X-RAYS, LUNG
75742
O
ANGIOGRAPHY, PULMONARY, UNILATERAL,
75743
3
ARTERY X-RAYS, LUNGS
75744
O
ANGIOGRAPHY, PULMONARY, BILATERAL,
75746
3
ARTERY X-RAYS, LUNG
75747
O
ANGIOGRAPHY, PULMONARY CATHETER, NO
$0.00
75748
O
ANGIOGRAPHY, PULMONARY VENOUS INJEC
$0.00
75750
O
ANGIOGRAPHY, CORONARY, ROOT INJECTI
$0.00
75751
O
ANGIOGRAPHY, CORONARY, ROOT INJECTI
$0.00
75752
O
ANGIOGRAPHY, CORONARY, UNILATERAL S
$0.00
75753
O
ANGIOGRAPHY, CORONARY, UNILATERAL S
$0.00
75754
O
ANGIOGRAPHY, CORONARY, BILATERAL SE
$0.00
75755
O
ANGIOGRAPHY, CORONARY, BILATERAL SE
$0.00
75756
3
ARTERY X-RAYS, CHEST
75757
O
ANGIOGRAPHY, INTERNAL MAMMARY COMPL
$0.00
75762
O
ANGIOGRAPHY, CORONARY BYPASS, UNILA
$0.00
$318.43
$281.93 $0.00 $328.45 $0.00 $282.30
$292.15 $0.00 $331.13 $0.00 $284.76
$273.09 $0.00 $298.77 $0.00 $276.01
$293.15
Procedure Code Pricing Action Code Description
Maximum Allowable
75764
O
ANGIOGRAPHY, CORONARY BYPASS, UNILA
$0.00
75766
O
ANGIOGRAPHY, CORONARY BYPASS, MULTI
$0.00
75767
O
ANGIOGRAPHY, CORONARY BYPASS, MULTI
$0.00
75774
3
ARTERY X-RAY, EACH VESSEL
75775
O
ANGIOGRAPHY, SELECTIVE, EACH ADDITI
75790
3
VISUALIZE A-V SHUNT
75801
3
LYMPH VESSEL X-RAY, ARM/LEG
$0.00
75802
O
LYMPHANGIOGRAPHY, EXTREMITY ONLY, U
$0.00
75803
3
LYMPH VESSEL X-RAY,ARMS/LEGS
$0.00
75804
O
LYMPHANGIOGRAPHY, EXTREMITY ONLY, B
$0.00
75805
3
LYMPH VESSEL X-RAY, TRUNK
$0.00
75806
O
LYMPHANGIOGRAPHY, PELVIC/ABDOMINAL,
$0.00
75807
3
LYMPH VESSEL X-RAY, TRUNK
$0.00
75808
O
LYMPHANGIOGRAPHY, PELVIC/ABDOMINAL,
$0.00
75809
3
NONVASCULAR SHUNT, X-RAY
75810
3
VEIN X-RAY, SPLEEN/LIVER
$0.00
75811
O
SPLENOPORTOGRAPHY COMPLETE PROCEDUR
$0.00
75820
3
VEIN X-RAY, ARM/LEG
75821
O
VENOGRAPHY, EXTREMITY, UNILATERAL C
75822
3
VEIN X-RAY, ARMS/LEGS
75823
O
VENOGRAPHY, EXTREMITY, BILATERAL CO
75825
3
VEIN X-RAY, TRUNK
75826
O
VENOGRAPHY, CAVAL, INFERIOR, WITH S
75827
3
VEIN X-RAY, CHEST
75828
O
VENOGRAPHY, CAVAL, SUPERIOR, WITH S
75831
3
VEIN X-RAY, KIDNEY
75832
O
VENOGRAPHY, RENAL, UNILATERAL, SELE
75833
3
VEIN X-RAY, KIDNEYS
75834
O
VENOGRAPHY, RENAL, BILATERAL, SELEC
75840
3
VEIN X-RAY, ADRENAL GLAND
75841
O
VENOGRAPHY, ADRENAL, UNILATERAL, SE
75842
3
VEIN X-RAY, ADRENAL GLANDS
75843
O
VENOGRAPHY, ADRENAL, BILATERAL, SEL
75860
3
VEIN X-RAY, NECK
75861
O
VENOGRAPHY, SINUS OR JUGULAR, CATHE
$214.88 $0.00 $174.45
$86.87
$119.23 $0.00 $145.62 $0.00 $259.86 $0.00 $259.38 $0.00 $262.94 $0.00 $293.18 $0.00 $260.59 $0.00 $294.91 $0.00 $268.37 $0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
75870
3
VEIN X-RAY, SKULL
$266.03
75871
O
VENOGRAPHY, SUPERIOR SAGITTAL SINUS
75872
3
VEIN X-RAY, SKULL
75873
O
VENOGRAPHY, EPIDURAL COMPLETE PROCE
75880
3
VEIN X-RAY, EYE SOCKET
75881
O
VENOGRAPHY, ORBITAL COMPLETE PROCED
75885
3
VEIN X-RAY, LIVER
75886
O
PERCUTANEOUS TRANSHEPATIC PORTOGRAP
75887
3
VEIN X-RAY, LIVER
75888
O
PERCUTANEOUS TRANSHEPATIC PORTOGRAP
75889
3
VEIN X-RAY, LIVER
75890
O
HEPATIC VENOGRAPHY WEDGED OR FREE,
75891
3
VEIN X-RAY, LIVER
75892
O
HEPATIC VENOGRAPHY, WEDGED OR FREE,
75893
3
VENOUS SAMPLING BY CATHETER
75894
3
X-RAYS, TRANSCATH THERAPY
$0.00
75895
O
TRANSCATHETER THERAPY, EMBOLIZATION
$0.00
75896
3
X-RAYS, TRANSCATH THERAPY
$0.00
75897
O
TRANSCATHETER THERAPY, INFUSION (EG
$0.00
75898
3
FOLLOW-UP ANGIOGRAPHY
$0.00
75900
3
INTRAVASCULAR CATH EXCHANGE
$0.00
75901
3
REMOVE CVA DEVICE OBSTRUCT
$166.54
75902
3
REMOVE CVA LUMEN OBSTRUCT
$92.72
75940
3
X-RAY PLACEMENT, VEIN FILTER
$0.00
75941
O
PERCUTANEOUS PLACEMENT OF IVC FILTE
$0.00
75945
3
INTRAVASCULAR US
$0.00
75946
3
INTRAVASCULAR US ADD-ON
$0.00
75950
O
TRANSCATHETER INTRAVASCULAR OCCLUSI
$0.00
75951
O
TRANSCATHETER INTRAVASCULAR OCCLUSI
$0.00
75952
3
ENDOVASC REPAIR ABDOM AORTA
$0.00
75953
3
ABDOM ANEURYSM ENDOVAS RPR
$0.00
75954
3
ILIAC ANEURYSM ENDOVAS RPR
$0.00
75955
O
TRANSCATHETER INTRAVASCULAR OCCLUSI
$0.00
75956
3
ENDOVASCULAR REPAIR OF DESCENDING
$0.00
75957
3
XRAY, ENDOVASC THOR AO REPR
$0.00
$0.00 $290.36 $0.00 $120.33 $0.00 $279.57 $0.00 $281.80 $0.00 $263.81 $0.00 $263.81 $0.00 $232.41
Procedure Code Pricing Action Code Description
Maximum Allowable
75958
3
XRAY, PLACE PROX EXT THOR AO
$0.00
75959
3
XRAY, PLACE DIST EXT THOR AO
$0.00
75960
3
TRANSCATH IV STENT RS&I
$263.01
75961
3
RETRIEVAL, BROKEN CATHETER
$411.90
75962
3
REPAIR ARTERIAL BLOCKAGE
$281.70
75963
O
PERCUTANEOUS TRANSLUMINAL ANGIOPLAS
75964
3
REPAIR ARTERY BLOCKAGE, EACH
75965
O
PERCUTANEOUS TRANSLUMINAL ANGIOPLAS
75966
3
REPAIR ARTERIAL BLOCKAGE
75967
O
PERCUTANEOUS TRANSLUMINAL ANGIOPLAS
75968
3
REPAIR ARTERY BLOCKAGE, EACH
75969
O
PERCUTANEOUS TRANSLUMINAL ANGIOPLAS
$0.00
75970
3
VASCULAR BIOPSY
$0.00
75971
O
TRANSCATHETER BIOPSY COMPLETE PROCE
$0.00
75978
3
REPAIR VENOUS BLOCKAGE
75979
O
PERCUTANEOUS TRANSLUMINAL ANGIOPLAS
$0.00
75980
3
CONTRAST XRAY EXAM BILE DUCT
$0.00
75981
O
PERCUTANEOUS TRANSHEPATIC BILIARY D
$0.00
75982
9
CONTRAST XRAY EXAM BILE DUCT
$0.00
75983
O
PERCUTANEOUS PLACEMENT OF DRAINAGE
$0.00
75984
3
XRAY CONTROL CATHETER CHANGE
75985
O
CHANGE OF PERCUTANEOUS DRAINAGE CAT
75989
3
ABSCESS DRAINAGE UNDER X-RAY
75990
O
RADIOLOGICAL GUIDANCE FOR PERCUTANE
$0.00
75992
3
ATHERECTOMY, X-RAY EXAM
$0.00
75993
3
ATHERECTOMY, X-RAY EXAM
$0.00
75994
3
ATHERECTOMY, X-RAY EXAM
$0.00
75995
3
ATHERECTOMY, X-RAY EXAM
$0.00
75996
3
ATHERECTOMY, X-RAY EXAM
$0.00
75998
O
FLUOROGUIDE FOR VEIN DEVICE
$0.00
76000
3
FLUOROSCOPE EXAMINATION
76001
3
FLUOROSCOPE EXAM, EXTENSIVE
$0.00
76003
O
NEEDLE LOCALIZATION BY X-RAY
$0.00
76005
O
FLUOROGUIDE FOR SPINE INJECT
$0.00
76006
O
X-RAY STRESS VIEW
$0.00
$0.00 $166.23 $0.00 $329.90 $0.00 $166.73
$277.02
$114.12 $0.00 $143.55
$93.02
Procedure Code Pricing Action Code Description
Maximum Allowable
76010
3
X-RAY, NOSE TO RECTUM
$27.85
76012
O
PERCUT VERTEBROPLASTY FLUOR
$0.00
76013
O
PERCUT VERTEBROPLASTY, CT
$0.00
76020
O
X-RAYS FOR BONE AGE
$0.00
76040
O
X-RAYS, BONE EVALUATION
$0.00
76061
O
X-RAYS, BONE SURVEY
$0.00
76062
O
X-RAYS, BONE SURVEY
$0.00
76065
O
X-RAYS, BONE EVALUATION
$0.00
76066
O
JOINT SURVEY, SINGLE VIEW
$0.00
76070
O
CT BONE DENSITY, AXIAL
$0.00
76071
O
CT BONE DENSITY, PERIPHERAL
$0.00
76075
O
DXA BONE DENSITY, AXIAL
$0.00
76076
O
DXA BONE DENSITY/PERIPHERAL
$0.00
76077
O
DXA BONE DENSITY/V-FRACTURE
$0.00
76078
O
RADIOGRAPHIC ABSORPTIOMETRY
$0.00
76080
3
X-RAY EXAM OF FISTULA
76081
O
RADIOLOGIC EXAMINATION, FISTULA OR
$0.00
76082
O
COMPUTER MAMMOGRAM ADD-ON
$0.00
76083
O
COMPUTER MAMMOGRAM ADD-ON
$0.00
76085
O
COMPUTER MAMMOGRAM ADD-ON
$0.00
76086
O
X-RAY OF MAMMARY DUCT
$0.00
76087
O
MAMMARY DUCTOGRAM OR GALACTOGRAM, S
$0.00
76088
O
X-RAY OF MAMMARY DUCTS
$0.00
76089
O
MAMMARY DUCTOGRAM OR GALACTOGRAM, M
$0.00
76090
O
MAMMOGRAM, ONE BREAST
$0.00
76091
O
MAMMOGRAM, BOTH BREASTS
$0.00
76092
O
MAMM0GRAM, SCREENING
$0.00
76093
O
MAGNETIC IMAGE, BREAST
$0.00
76094
O
MAGNETIC IMAGE, BOTH BREASTS
$0.00
76095
O
STEREOTACTIC BREAST BIOPSY
$0.00
76096
O
X-RAY OF NEEDLE WIRE, BREAST
$0.00
76097
O
LOCALIZATION OF BREAST NODULE OR CA
$0.00
76098
3
X-RAY EXAM, BREAST SPECIMEN
$19.75
76100
3
X-RAY EXAM OF BODY SECTION
$104.72
76101
3
COMPLEX BODY SECTION X-RAY
$186.41
$63.36
Procedure Code Pricing Action Code Description
Maximum Allowable
76102
3
COMPLEX BODY SECTION X-RAYS
$231.62
76120
3
CINE/VIDEO X-RAYS
76125
3
CINE/VIDEO X-RAYS ADD-ON
76140
3
X-RAY CONSULTATION
$38.59
76150
3
X-RAY EXAM, DRY PROCESS
$18.59
76350
5
SPECIAL X-RAY CONTRAST STUDY
$0.00
76355
O
CT SCAN FOR LOCALIZATION
$0.00
76360
O
CT SCAN FOR NEEDLE BIOPSY
$0.00
76361
O
COMPUTERIZED TOMOGRAPHY GUIDANCE FO
$0.00
76362
O
CT GUIDE FOR TISSUE ABLATION
$0.00
76365
O
CAT SCAN FOR CYST ASPIRATION
$0.00
76366
O
COMPUTERIZED TOMOGRAPHY GUIDANCE FO
$0.00
76370
O
CT SCAN FOR THERAPY GUIDE
$0.00
76375
O
3D/HOLOGRAPH RECONSTR ADD-ON
$0.00
76376
3
3D RENDER W/O POSTPROCESS
76377
3
3D RENDERING W/POSTPROCESS
$110.78
76380
3
CAT SCAN FOLLOW-UP STUDY
$155.31
76390
3
MR SPECTROSCOPY
$462.91
76393
O
MR GUIDANCE FOR NEEDLE PLACE
$0.00
76394
O
MRI FOR TISSUE ABLATION
$0.00
76400
O
MAGNETIC IMAGE, BONE MARROW
$0.00
76490
O
US FOR TISSUE ABLATION
$0.00
76496
5
FLUOROSCOPIC PROCEDURE
$0.00
76497
5
CT PROCEDURE
$0.00
76498
5
MRI PROCEDURE
$0.00
76499
5
RADIOGRAPHIC PROCEDURE
$0.00
76506
3
ECHO EXAM OF HEAD
76510
3
OPHTH US, B & QUANT A
76511
3
OPHTH US, QUANT A ONLY
$96.25
76512
3
OPHTH US, B W/NON-QUANT A
$90.07
76513
3
ECHO EXAM OF EYE, WATER BATH
$83.40
76514
3
ECHO EXAM OF EYE, THICKNESS
$12.47
76516
3
ECHO EXAM OF EYE
$66.69
76519
3
ECHO EXAM OF EYE
$71.49
76529
3
ECHO EXAM OF EYE
$67.50
$75.39 $0.00
$80.53
$95.64 $147.63
Procedure Code Pricing Action Code Description
Maximum Allowable
76536
3
US EXAM OF HEAD AND NECK
$110.40
76604
3
US EXAM, CHEST
$86.14
76645
3
US EXAM, BREAST(S)
$90.35
76700
3
US EXAM, ABDOM, COMPLETE
$136.43
76705
3
ECHO EXAM OF ABDOMEN
$103.58
76770
3
US EXAM ABDO BACK WALL, COMP
$130.73
76775
3
US EXAM ABDO BACK WALL, LIM
$111.72
76776
3
US EXAM K TRANSPL W/DOPPLER
$145.49
76778
O
US EXAM KIDNEY TRANSPLANT
76800
3
US EXAM, SPINAL CANAL
$122.25
76801
3
OB US < 14 WKS, SINGLE FETUS
$130.53
76802
3
OB US < 14 WKS, ADDÏL FETUS
76805
3
OB US >/= 14 WKS, SNGL FETUS
$145.69
76810
3
OB US >/= 14 WKS, ADDL FETUS
$99.67
76811
3
OB US, DETAILED, SNGL FETUS
$203.47
76812
3
OB US, DETAILED, ADDL FETUS
$147.70
76813
3
OB US NUCHAL MEAS, 1 GEST
$126.95
76814
3
OB US NUCHAL MEAS, ADD-ON
$82.08
76815
3
OB US, LIMITED, FETUS(S)
$90.56
76816
3
OB US, FOLLOW-UP, PER FETUS
$105.00
76817
3
TRANSVAGINAL US, OBSTETRIC
$99.94
76818
3
FETAL BIOPHYS PROFILE W/NST
$120.24
76819
3
FETAL BIOPHYS PROFIL W/O NST
$93.11
76820
3
UMBILICAL ARTERY ECHO
$53.63
76821
3
MIDDLE CEREBRAL ARTERY ECHO
$97.00
76825
3
ECHO EXAM OF FETAL HEART
$207.81
76826
3
ECHO EXAM OF FETAL HEART
$114.76
76827
3
ECHO EXAM OF FETAL HEART
$71.40
76828
3
ECHO EXAM OF FETAL HEART
$52.60
76830
3
TRANSVAGINAL US, NON-OB
$119.83
76831
3
ECHO EXAM, UTERUS
$119.80
76855
O
ECHOGRAPHY, PELVIC AREA (DOPPLER)
76856
3
US EXAM, PELVIC, COMPLETE
76857
3
US EXAM, PELVIC, LIMITED
76870
3
US EXAM, SCROTUM
$0.00
$73.05
$0.00 $120.57 $83.28 $119.52
Procedure Code Pricing Action Code Description
Maximum Allowable
76872
3
US, TRANSRECTAL
$134.99
76873
3
ECHOGRAP TRANS R, PROS STUDY
$176.36
76880
3
US EXAM, EXTREMITY
$125.39
76885
3
US EXAM INFANT HIPS, DYNAMIC
$100.32
76886
3
US EXAM INFANT HIPS, STATIC
76925
O
ECHOGRAPHY, PERIPHERAL VASCULAR SYS
$0.00
76926
O
ECHOGRAPHY, HEAD AND TRUNK, VASCULA
$0.00
76930
3
ECHO GUIDE, CARDIOCENTESIS
76931
O
ULTRASONIC GUIDANCE FOR PERICARDIOC
$0.00
76932
3
ECHO GUIDE FOR HEART BIOPSY
$0.00
76933
O
ULTRASONIC GUIDANCE FOR ENDOMYOCARD
$0.00
76934
O
ECHO GUIDE FOR CHEST TAP
$0.00
76935
O
ULTRASONIC GUIDANCE FOR THORACENTES
$0.00
76936
3
ECHO GUIDE FOR ARTERY REPAIR
76937
3
US GUIDE, VASCULAR ACCESS
76938
O
ECHO EXAM FOR DRAINAGE
$0.00
76939
O
ULTRASONIC GUIDANCE FOR CYST (ANY L
$0.00
76940
3
US GUIDE, TISSUE ABLATION
$0.00
76941
3
ECHO GUIDE FOR TRANSFUSION
$0.00
76942
3
ECHO GUIDE FOR BIOPSY
76943
O
ULTRASONIC GUIDANCE FOR NEEDLE BIOP
$0.00
76945
3
ECHO GUIDE, VILLUS SAMPLING
$0.00
76946
3
ECHO GUIDE FOR AMNIOCENTESIS
76947
O
ULTRASONIC GUIDANCE FOR AMNIOCENTES
$0.00
76948
9
ECHO GUIDE, OVA ASPIRATION
$0.00
76949
O
ULTRASONIC GUIDANCE FOR ASPIRATION
$0.00
76950
3
ECHO GUIDANCE RADIOTHERAPY
$70.44
76960
O
ECHO GUIDANCE RADIOTHERAPY
$0.00
76965
3
ECHO GUIDANCE RADIOTHERAPY
$146.22
76970
3
ULTRASOUND EXAM FOLLOW-UP
$82.39
76975
3
GI ENDOSCOPIC ULTRASOUND
76977
3
US BONE DENSITY MEASURE
76986
O
ULTRASOUND GUIDE INTRAOPER
$0.00
76998
3
US GUIDE, INTRAOP
$0.00
76999
5
ECHO EXAMINATION PROCEDURE
$0.00
$93.69
$98.18
$196.13 $35.65
$186.03
$44.18
$0.00 $13.95
Procedure Code Pricing Action Code Description
Maximum Allowable
77001
3
FLUOROGUIDE FOR VEIN DEVICE
$104.58
77002
3
NEEDLE LOCALIZATION BY XRAY
$70.63
77003
3
FLUOROGUIDE FOR SPINE INJECT
$58.59
77011
3
CT SCAN FOR LOCALIZATION
$684.12
77012
3
CT SCAN FOR NEEDLE BIOPSY
$198.01
77013
3
CT GUIDE FOR TISSUE ABLATION
77014
3
CT SCAN FOR THERAPY GUIDE
$186.01
77021
3
MR GUIDANCE FOR NEEDLE PLACE
$449.00
77022
3
MRI FOR TISSUE ABLATION
77031
3
STEREOTACT GUIDE FOR BRST BX
77032
3
GUIDANCE FOR NEEDLE, BREAST
$59.51
77051
3
COMPUTER DX MAMMOGRAM ADD-ON
$12.24
77052
3
COMP SCREEN MAMMOGRAM ADD-ON
$12.24
77053
3
X-RAY OF MAMMARY DUCT
$76.22
77054
3
X-RAY OF MAMMARY DUCTS
$102.82
77055
3
MAMMOGRAM, ONE BREAST
$84.85
77056
3
MAMMOGRAM, BOTH BREASTS
77057
3
MAMMOGRAM, SCREENING
77058
3
MRI, ONE BREAST
$846.16
77059
3
MRI, BOTH BREASTS
$908.55
77071
3
X-RAY STRESS VIEW
$39.01
77072
3
X-RAYS FOR BONE AGE
$23.40
77073
3
X-RAYS, BONE LENGTH STUDIES
$37.34
77074
3
X-RAYS, BONE SURVEY, LIMITED
$68.65
77075
3
X-RAYS, BONE SURVEY COMPLETE
$99.71
77076
3
X-RAYS, BONE SURVEY, INFANT
$92.74
77077
3
JOINT SURVEY, SINGLE VIEW
$42.20
77078
3
CT BONE DENSITY, AXIAL
$85.16
77079
3
CT BONE DENSITY, PERIPHERAL
$57.73
77080
3
DXA BONE DENSITY, AXIAL
$70.98
77081
3
DXA BONE DENSITY/PERIPHERAL
$30.01
77082
3
DXA BONE DENSITY, VERT FX
$28.96
77083
3
RADIOGRAPHIC ABSORPTIOMETRY
$26.33
77084
3
MAGNETIC IMAGE, BONE MARROW
$432.47
77261
3
RADIATION THERAPY PLANNING
$0.00
$0.00 $191.70
$107.66 $81.39
$70.21
Procedure Code Pricing Action Code Description
Maximum Allowable
77262
3
RADIATION THERAPY PLANNING
$105.39
77263
3
RADIATION THERAPY PLANNING
$156.34
77280
3
SET RADIATION THERAPY FIELD
$185.19
77285
3
SET RADIATION THERAPY FIELD
$319.50
77290
3
SET RADIATION THERAPY FIELD
$496.39
77295
3
SET RADIATION THERAPY FIELD
$680.86
77299
5
RADIATION THERAPY PLANNING
$0.00
77300
3
RADIATION THERAPY DOSE PLAN
77301
3
RADIOTHERAPY DOSE PLAN, IMRT
77305
3
TELETX ISODOSE PLAN SIMPLE
77310
3
TELETX ISODOSE PLAN INTERMED
$101.36
77315
3
TELETX ISODOSE PLAN COMPLEX
$147.90
77321
3
SPECIAL TELETX PORT PLAN
$121.88
77326
3
BRACHYTX ISODOSE CALC SIMP
$142.91
77327
3
BRACHYTX ISODOSE CALC INTERM
$203.55
77328
3
BRACHYTX ISODOSE PLAN COMPL
$278.52
77331
3
SPECIAL RADIATION DOSIMETRY
$62.10
77332
3
RADIATION TREATMENT AID(S)
$77.89
77333
3
RADIATION TREATMENT AID(S)
$68.36
77334
3
RADIATION TREATMENT AID(S)
$158.14
77336
3
RADIATION PHYSICS CONSULT
$62.25
77370
3
RADIATION PHYSICS CONSULT
$118.55
77371
3
SRS, MULTISOURCE
$1,188.49
77372
3
SRS, LINEAR BASED
$827.57
77373
3
SBRT DELIVERY
77380
O
PROTON BEAM DELIVERY
$0.00
77381
O
PROTON BEAM TREATMENT
$0.00
77399
5
EXTERNAL RADIATION DOSIMETRY
$0.00
77400
O
DAILY MEGAVOLTAGE TREATMENT MANAGEM
$0.00
77401
3
RADIATION TREATMENT DELIVERY
$31.84
77402
3
RADIATION TREATMENT DELIVERY
$137.58
77403
3
RADIATION TREATMENT DELIVERY
$120.94
77404
3
RADIATION TREATMENT DELIVERY
$133.14
77405
O
DAILY MEGAVOLTAGE TREATMENT MANAGEM
77406
3
RADIATION TREATMENT DELIVERY
$71.14 $2,176.54 $72.97
$1,532.98
$0.00 $134.25
Procedure Code Pricing Action Code Description
Maximum Allowable
77407
3
RADIATION TREATMENT DELIVERY
$215.83
77408
3
RADIATION TREATMENT DELIVERY
$162.22
77409
3
RADIATION TREATMENT DELIVERY
$178.86
77410
O
DAILY MEGAVOLTAGE TREATMENT MANAGEM
77411
3
RADIATION TREATMENT DELIVERY
$177.75
77412
3
RADIATION TREATMENT DELIVERY
$209.04
77413
3
RADIATION TREATMENT DELIVERY
$210.52
77414
3
RADIATION TREATMENT DELIVERY
$233.82
77415
O
THERAPEUTIC RADIOLOGY TREATMENT POR
77416
3
RADIATION TREATMENT DELIVERY
77417
3
RADIOLOGY PORT FILM(S)
77418
3
RADIATION TX DELIVERY, IMRT
77419
O
WEEKLY RADIATION THERAPY
$0.00
77420
O
WEEKLY RADIATION THERAPY
$0.00
77421
3
STEREOSCOPIC X-RAY GUIDANCE
$114.04
77422
3
NEUTRON BEAM TX, SIMPLE
$196.84
77423
3
NEUTRON BEAM TX, COMPLEX
$226.05
77425
O
WEEKLY RADIATION THERAPY
$0.00
77427
3
RADIATION TX MANAGEMENT, X5
77430
O
WEEKLY RADIATION THERAPY
77431
3
RADIATION THERAPY MANAGEMENT
77432
3
STEREOTACTIC RADIATION TRMT
$395.62
77435
3
SBRT MANAGEMENT
$656.58
77465
O
DAILY KILOVOLTAGE TREATMENT MANAGEM
77470
3
SPECIAL RADIATION TREATMENT
77499
5
RADIATION THERAPY MANAGEMENT
$0.00
77520
5
PROTON TRMT, SIMPLE W/O COMP
$0.00
77522
5
PROTON TRMT, SIMPLE W/COMP
$0.00
77523
5
PROTON TRMT, INTERMEDIATE
$0.00
77525
5
PROTON TREATMENT, COMPLEX
$0.00
77600
9
HYPERTHERMIA TREATMENT
$0.00
77605
9
HYPERTHERMIA TREATMENT
$0.00
77610
9
HYPERTHERMIA TREATMENT
$0.00
77615
9
HYPERTHERMIA TREATMENT
$0.00
77620
3
HYPERTHERMIA TREATMENT
$390.46
$0.00
$0.00 $234.93 $16.12 $528.10
$186.20 $0.00 $95.31
$0.00 $254.51
Procedure Code Pricing Action Code Description
Maximum Allowable
77750
3
INFUSE RADIOACTIVE MATERIALS
$337.26
77761
3
APPLY INTRCAV RADIAT SIMPLE
$351.09
77762
3
APPLY INTRCAV RADIAT INTERM
$478.01
77763
3
APPLY INTRCAV RADIAT COMPL
$675.84
77776
3
APPLY INTERSTIT RADIAT SIMPL
$411.61
77777
3
APPLY INTERSTIT RADIAT INTER
$571.38
77778
3
APPLY INTERSTIT RADIAT COMPL
$817.02
77781
O
REMOTE AFTERLOADING HIGH INTENSITY
$0.00
77782
O
REMOTE AFTERLOADING HIGH INTENSITY
$0.00
77783
O
REMOTE AFTERLOADING HIGH INTENSITY
$0.00
77784
O
REMOTE AFTERLOADING HIGH INTENSITY
$0.00
77785
3
HDR BRACHYTX, 1 CHANNEL
$186.42
77786
3
HDR BRACHYTX, 2-12 CHANNEL
$561.94
77787
3
HDR BRACHYTX OVER 12 CHAN
$834.94
77789
3
APPLY SURFACE RADIATION
$104.40
77790
3
RADIATION HANDLING
77799
5
RADIUM/RADIOISOTOPE THERAPY
78000
3
THYROID, SINGLE UPTAKE
$69.10
78001
3
THYROID, MULTIPLE UPTAKES
$87.74
78003
3
THYROID SUPPRESS/STIMUL
$76.32
78006
3
THYROID IMAGING WITH UPTAKE
$216.32
78007
3
THYROID IMAGE, MULT UPTAKES
$131.51
78010
3
THYROID IMAGING
$150.52
78011
3
THYROID IMAGING WITH FLOW
$161.03
78015
3
THYROID MET IMAGING
$203.26
78016
3
THYROID MET IMAGING/STUDIES
$309.03
78017
O
THYROID MET IMAGING, MULT
$0.00
78018
3
THYROID MET IMAGING, BODY
$311.48
78020
3
THYROID MET UPTAKE
78070
3
PARATHYROID NUCLEAR IMAGING
$171.91
78075
3
ADRENAL NUCLEAR IMAGING
$405.67
78099
5
ENDOCRINE NUCLEAR PROCEDURE
78102
3
BONE MARROW IMAGING, LTD
$159.80
78103
3
BONE MARROW IMAGING, MULT
$214.60
78104
3
BONE MARROW IMAGING, BODY
$246.05
$87.26 $0.00
$90.35
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
78110
3
PLASMA VOLUME, SINGLE
$76.49
78111
3
PLASMA VOLUME, MULTIPLE
$97.60
78120
3
RED CELL MASS, SINGLE
$86.89
78121
3
RED CELL MASS, MULTIPLE
78122
9
BLOOD VOLUME
78130
3
RED CELL SURVIVAL STUDY
$152.31
78135
3
RED CELL SURVIVAL KINETICS
$318.70
78140
3
RED CELL SEQUESTRATION
$147.33
78160
O
PLASMA IRON TURNOVER
$0.00
78162
O
RADIOIRON ABSORPTION EXAM
$0.00
78170
O
RED CELL IRON UTILIZATION
$0.00
78172
O
TOTAL BODY IRON ESTIMATION
$0.00
78185
3
SPLEEN IMAGING
78186
O
SPLEEN IMAGING ONLY WITH VASCULAR F
78190
3
KINETICS, STUDY OF PLATELET SURVIV
$221.42
78191
3
PLATELET SURVIVAL
$197.75
78192
O
WHITE BLOOD CELL LOCALIZATION LIMIT
$0.00
78193
O
WHITE BLOOD CELL LOCALIZATION WHOLE
$0.00
78195
3
LYMPH SYSTEM IMAGING
78199
5
BLOOD/LYMPH NUCLEAR EXAM
78201
3
LIVER IMAGING
$171.26
78202
3
LIVER IMAGING WITH FLOW
$197.68
78205
3
LIVER IMAGING (3D)
$236.12
78206
3
LIVER IMAGE (3D) WITH FLOW
$329.23
78215
3
LIVER AND SPLEEN IMAGING
$182.91
78216
3
LIVER & SPLEEN IMAGE/FLOW
$137.93
78220
3
LIVER FUNCTION STUDY
$143.81
78223
3
HEPATOBILIARY IMAGING
$306.16
78225
O
LIVER-LUNG IMAGING (EG, SUBPHRENIC
78230
3
SALIVARY GLAND IMAGING
$155.73
78231
3
SERIAL SALIVARY IMAGING
$132.56
78232
3
SALIVARY GLAND FUNCTION EXAM
$135.09
78258
3
ESOPHAGEAL MOTILITY STUDY
$216.85
78261
3
GASTRIC MUCOSA IMAGING
$239.53
78262
3
GASTROESOPHAGEAL REFLUX EXAM
$236.22
$105.24 $0.00
$185.74 $0.00
$327.24 $0.00
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
78264
3
GASTRIC EMPTYING STUDY
$271.96
78267
5
BREATH TST ATTAIN/ANAL C-14
$0.00
78268
5
BREATH TEST ANALYSIS, C-14
$0.00
78270
3
VIT B-12 ABSORPTION EXAM
$78.92
78271
3
VIT B-12 ABSRP EXAM, INT FAC
$79.65
78272
3
VIT B-12 ABSORP, COMBINED
$90.28
78276
O
GASTROINTESTINAL ASPIRATE BLOOD LOS
78278
3
ACUTE GI BLOOD LOSS IMAGING
78280
O
GASTROINTESTINAL BLOOD LOSS STUDY (
$0.00
78282
3
GI PROTEIN LOSS EXAM
$0.00
78290
3
MECKELÏS DIVERT EXAM
$281.87
78291
3
LEVEEN/SHUNT PATENCY EXAM
$238.47
78299
5
GI NUCLEAR PROCEDURE
78300
3
BONE IMAGING, LIMITED AREA
$167.46
78305
3
BONE IMAGING, MULTIPLE AREAS
$222.62
78306
3
BONE IMAGING, WHOLE BODY
$246.59
78310
O
BONE IMAGING VASCULAR FLOW ONLY
78315
3
BONE IMAGING, 3 PHASE
$300.61
78320
3
BONE IMAGING (3D)
$252.59
78350
3
BONE MINERAL, SINGLE PHOTON
$33.33
78351
3
BONE MINERAL, DUAL PHOTON
$15.02
78380
O
JOINT IMAGING LIMITED AREA
$0.00
78381
O
JOINT IMAGING MULTIPLE AREAS
$0.00
78399
5
MUSCULOSKELETAL NUCLEAR EXAM
$0.00
78414
3
NON-IMAGING HEART FUNCTION
$0.00
78415
O
CARDIAC BLOOD POOL IMAGING, FUNCTIO
$0.00
78425
O
CARDIAC REGURGITANT INDEX
$0.00
78428
3
CARDIAC SHUNT IMAGING
78435
O
CARDIAC FLOW IMAGING (IE, ANGIOCARD
78445
3
VASCULAR FLOW IMAGING
78455
O
VENOUS THROMBOSIS STUDY
78456
3
ACUTE VENOUS THROMBUS IMAGE
$242.74
78457
3
VENOUS THROMBOSIS IMAGING
$187.24
78458
3
VEN THROMBOSIS IMAGES, BILAT
$206.37
78459
3
HEART MUSCLE IMAGING (PET)
$274.66
$0.00 $296.34
$0.00
$0.00
$194.38 $0.00 $163.34 $0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
78460
3
HEART MUSCLE BLOOD, SINGLE
$187.49
78461
3
HEART MUSCLE BLOOD, MULTIPLE
$210.48
78464
3
HEART IMAGE (3D), SINGLE
$274.66
78465
3
HEART IMAGE (3D), MULTIPLE
$486.74
78466
3
HEART INFARCT IMAGE
$178.83
78467
O
MYOCARDIAL IMAGING, INFARCT AVID, A
78468
3
HEART INFARCT IMAGE (EF)
$225.74
78469
3
HEART INFARCT IMAGE (3D)
$256.58
78470
O
CARDIAC OUTPUT
$0.00
78471
O
CARDIAC BLOOD POOL IMAGING, GATED E
$0.00
78472
3
GATED HEART, PLANAR, SINGLE
$260.93
78473
3
GATED HEART, MULTIPLE
$356.48
78474
O
CARDIAC BLOOD POOL IMAGING, GATED E
$0.00
78475
O
CARDIAC BLOOD POOL IMAGING, GATED E
$0.00
78476
O
CARDIAC BLOOD POOL IMAGING, GATED E
$0.00
78477
O
CARDIAC BLOOD POOL IMAGING, GATED E
$0.00
78478
3
HEART WALL MOTION ADD-ON
78479
O
CARDIAC BLOOD POOL IMAGING, GATED E
78480
3
HEART FUNCTION ADD-ON
78481
3
HEART FIRST PASS, SINGLE
$228.78
78483
3
HEART FIRST PASS, MULTIPLE
$323.09
78484
O
CARDIAC BLOOD POOL IMAGING, FIRST P
$0.00
78485
O
CARDIAC BLOOD POOL IMAGING, FIRST P
$0.00
78486
O
CARDIAC BLOOD POOL IMAGING, FIRST P
$0.00
78487
O
CARDIAC BLOOD POOL IMAGING, FIRST P
$0.00
78489
O
CARDIAC BLOOD POOL IMAGING, FIRST P
$0.00
78491
3
HEART IMAGE (PET), SINGLE
$323.62
78492
3
HEART IMAGE (PET), MULTIPLE
$323.62
78494
3
HEART IMAGE, SPECT
$284.57
78496
3
HEART FIRST PASS ADD-ON
$116.86
78499
5
CARDIOVASCULAR NUCLEAR EXAM
78580
3
LUNG PERFUSION IMAGING
78581
O
PULMONARY PERFUSION IMAGING GASEOUS
$0.00
78582
O
PULMONARY PERFUSION IMAGING GASEOUS
$0.00
78584
3
LUNG V/Q IMAGE SINGLE BREATH
$0.00
$58.82 $0.00 $49.09
$0.00 $206.72
$156.50
Procedure Code Pricing Action Code Description
Maximum Allowable
78585
3
LUNG V/Q IMAGING
$341.26
78586
3
AEROSOL LUNG IMAGE, SINGLE
$157.88
78587
3
AEROSOL LUNG IMAGE, MULTIPLE
$198.80
78588
3
PERFUSION LUNG IMAGE
$316.57
78591
3
VENT IMAGE, 1 BREATH, 1 PROJ
$160.09
78593
3
VENT IMAGE, 1 PROJ, GAS
$188.67
78594
3
VENT IMAGE, MULT PROJ, GAS
$220.62
78596
3
LUNG DIFFERENTIAL FUNCTION
$366.37
78599
5
RESPIRATORY NUCLEAR EXAM
$0.00
78600
3
BRAIN IMAGE < 4 VIEWS
$171.88
78601
3
BRAIN IMAGE W/FLOW < 4 VIEWS
$204.55
78605
3
BRAIN IMAGE 4+ VIEWS
$191.21
78606
3
BRAIN IMAGE W/FLOW 4 + VIEWS
$299.99
78607
3
BRAIN IMAGING (3D)
$358.93
78608
3
BRAIN IMAGING (PET)
$323.62
78609
3
BRAIN IMAGING (PET)
$323.62
78610
3
BRAIN FLOW IMAGING ONLY
$173.81
78615
O
CEREBRAL VASCULAR FLOW IMAGE
78630
3
CEREBROSPINAL FLUID SCAN
$318.38
78635
3
CSF VENTRICULOGRAPHY
$289.97
78645
3
CSF SHUNT EVALUATION
$218.43
78647
3
CEREBROSPINAL FLUID SCAN
$335.58
78650
3
CSF LEAKAGE IMAGING
$310.73
78652
O
CSF LEAKAGE DETECTION AND LOCALIZAT
$0.00
78655
O
RADIOPHARMACEUTICAL IDENTIFICATION
$0.00
78660
3
NUCLEAR EXAM OF TEAR FLOW
78699
5
NERVOUS SYSTEM NUCLEAR EXAM
78700
3
KIDNEY IMAGING, MORPHOL
$170.50
78701
3
KIDNEY IMAGING WITH FLOW
$204.20
78704
O
IMAGING RENOGRAM
78707
3
K FLOW/FUNCT IMAGE W/O DRUG
$237.09
78708
3
K FLOW/FUNCT IMAGE W/DRUG
$192.29
78709
3
K FLOW/FUNCT IMAGE, MULTIPLE
$349.41
78710
3
KIDNEY IMAGING (3D)
$234.34
78715
O
RENAL VASCULAR FLOW EXAM
$0.00
$161.67 $0.00
$0.00
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
78725
3
KIDNEY FUNCTION STUDY
$98.77
78726
O
KIDNEY FUNCTION STUDY INCLUDING PHA
$0.00
78727
O
KIDNEY TRANSPLANT EVALUATION
$0.00
78730
3
URINARY BLADDER RETENTION
78740
3
URETERAL REFLUX STUDY
78760
O
TESTICULAR IMAGING
78761
3
TESTICULAR IMAGING W/FLOW
78799
5
GENITOURINARY NUCLEAR EXAM
78800
3
TUMOR IMAGING, LIMITED AREA
$181.55
78801
3
TUMOR IMAGING, MULT AREAS
$243.22
78802
3
TUMOR IMAGING, WHOLE BODY
$318.75
78803
3
TUMOR IMAGING (3D)
$350.96
78804
3
TUMOR IMAGING, WHOLE BODY
$562.87
78805
3
ABSCESS IMAGING, LTD AREA
$181.96
78806
3
ABSCESS IMAGING, WHOLE BODY
$333.63
78807
3
NUCLEAR LOCALIZATION/ABSCESS
$351.46
78808
3
IV INJ RA DRUG DX STUDY
78810
O
TUMOR IMAGING (PET)
$0.00
78811
3
PET IMAGE, LTD AREA
$0.00
78812
3
PET IMAGE, SKULL-THIGH
$0.00
78813
3
PET IMAGE, FULL BODY
$0.00
78814
3
PET IMAGE W/CT, LMTD
$0.00
78815
3
PET IMAGE W/CT, SKULL-THIGH
$0.00
78816
3
PET IMAGE W/CT, FULL BODY
$0.00
78890
O
NUCLEAR MEDICINE DATA PROC
$0.00
78891
O
NUCLEAR MED DATA PROC
$0.00
78990
O
PROVIDE DIAG RADIONUCLIDE(S)
$0.00
78999
5
NUCLEAR DIAGNOSTIC EXAM
$0.00
79000
O
INIT HYPERTHYROID THERAPY
$0.00
79001
O
REPEAT HYPERTHYROID THERAPY
$0.00
79005
3
NUCLEAR RX, ORAL ADMIN
79020
O
THYROID ABLATION
$0.00
79030
O
THYROID ABLATION, CARCINOMA
$0.00
79035
O
THYROID METASTATIC THERAPY
$0.00
79100
O
HEMATOPOETIC NUCLEAR THERAPY
$0.00
$76.16 $202.90 $0.00 $203.19 $0.00
$44.73
$152.41
Procedure Code Pricing Action Code Description
Maximum Allowable
79101
3
NUCLEAR RX, IV ADMIN
$171.80
79200
3
NUCLEAR RX, INTRACAV ADMIN
$174.22
79300
3
NUCLR RX, INTERSTIT COLLOID
$0.00
79400
O
NONHEMATO NUCLEAR THERAPY
$0.00
79403
3
HEMATOPOIETIC NUCLEAR TX
79420
O
INTRAVASCULAR NUCLEAR THER
79440
3
NUCLEAR RX, INTRA-ARTICULAR
79445
3
NUCLEAR RX, INTRA-ARTERIAL
$0.00
79900
O
PROVIDE THER RADIOPHARM(S)
$0.00
79999
5
NUCLEAR MEDICINE THERAPY
$0.00
80002
O
AUTOMATED MULTICHANNEL TEST 1 OR 2
$0.00
80003
O
AUTOMATED MULTICHANNEL TEST 3 CLINI
$0.00
80004
O
AUTOMATED MULTICHANNEL TEST 4 CLINI
$0.00
80005
O
AUTOMATED MULTICHANNEL TEST 5 CLINI
$0.00
80006
O
AUTOMATED MULTICHANNEL TEST 6 CLINI
$0.00
80007
O
AUTOMATED MULTICHANNEL TEST 7 CLINI
$0.00
80008
O
AUTOMATED MULTICHANNEL TEST 8 CLINI
$0.00
80009
O
AUTOMATED MULTICHANNEL TEST 9 CLINI
$0.00
80010
O
AUTOMATED MULTICHANNEL TEST 10 CLIN
$0.00
80011
O
AUTOMATED MULTICHANNEL TEST 11 CLIN
$0.00
80012
O
AUTOMATED MULTICHANNEL TEST 12 CLIN
$0.00
80016
O
AUTOMATED MULTICHANNEL TEST 13-16 C
$0.00
80018
O
AUTOMATED MULTICHANNEL TEST 17-18 C
$0.00
80019
O
AUTOMATED MULTICHANNEL TEST; 19 CLI
$0.00
80031
O
THERAPEUTIC QUANTITATIVE DRUG MONIT
$0.00
80032
O
THERAPEUTIC QUANTITATIVE DRUG MONIT
$0.00
80033
O
THERAPEUTIC QUANTITATIVE DRUG MONIT
$0.00
80034
O
THERAPEUTIC QUANTITATIVE DRUG MONIT
$0.00
80040
O
SERUM RADIOIMMUNOASSAY FOR CIRCULAT
$0.00
80042
O
SERUM ANTIMICROBIAL LEVEL, BIOASSAY
$0.00
80047
3
METABOLIC PANEL IONIZED CA
$12.11
80048
3
METABOLIC PANEL TOTAL CA
$12.11
80049
9
METABOLIC PANEL, BASIC
$0.00
80050
3
GENERAL HEALTH PANEL
$16.32
80051
3
ELECTROLYTE PANEL
$10.04
$218.51 $0.00 $160.68
Procedure Code Pricing Action Code Description
Maximum Allowable
80052
9
PRE-MARITAL PROFILE
$0.00
80053
3
COMPREHEN METABOLIC PANEL
$15.13
80054
9
COMPREHEN METABOLIC PANEL
$0.00
80055
3
OBSTETRIC PANEL
80056
9
AMENORRHEA PROFILE
$0.00
80057
9
MALE INFERTILITY AND/OR GYNECOMASTI
$0.00
80058
O
HEPATIC FUNCTION PANEL
$0.00
80059
O
HEPATITIS PANEL
$0.00
80060
O
HYPERTENSION PANEL
$0.00
80061
3
LIPID PANEL
80062
O
CARDIAC EVALUATION (INCLUDING CORON
$0.00
80063
O
CARDIAC INJURY PANEL
$0.00
80064
O
CARDIAC INJURY PANEL WITH CREATINE
$0.00
80065
O
METABOLIC PANEL
$0.00
80066
O
MALABSORPTION PANEL
$0.00
80067
O
PULMONARY (LUNG FUNCTION) PANEL
$0.00
80068
O
LUNG MATURITY PROFILE
$0.00
80069
3
RENAL FUNCTION PANEL
$12.43
80070
O
THYROID PANEL
$0.00
80071
O
THYROID PANEL WITH THYROTROPIN RELE
$0.00
80072
O
ARTHRITIS PANEL
$0.00
80073
O
RENAL PANEL
$0.00
80074
3
ACUTE HEPATITIS PANEL
80075
O
PARATHYROID PANEL
80076
3
HEPATIC FUNCTION PANEL
80080
O
PROSTATIC PANEL
$0.00
80082
O
PANCREATIC PANEL
$0.00
80084
O
PITUITARY PANEL
$0.00
80085
O
MICROCYTIC ANEMIA PANEL
$0.00
80086
O
MACROCYTIC ANEMIA PANEL
$0.00
80088
O
TRANSITION PANEL (FOR MANAGEMENT OF
$0.00
80089
O
MUSCLE PANEL
$0.00
80090
O
TORCH ANTIBODY PANEL
$0.00
80091
O
THYROID PANEL
$0.00
80092
O
THYROID PANEL W/TSH
$0.00
$23.08
$19.18
$67.88 $0.00 $11.69
Procedure Code Pricing Action Code Description
Maximum Allowable
80099
O
UNLISTED PANEL
$0.00
80100
3
DRUG SCREEN, QUALITATE/MULTI
$20.81
80101
3
DRUG SCREEN, SINGLE
$19.71
80102
3
DRUG CONFIRMATION
$18.95
80103
5
DRUG ANALYSIS, TISSUE PREP
80150
3
ASSAY OF AMIKACIN
$21.57
80152
3
ASSAY OF AMITRIPTYLINE
$25.62
80154
3
ASSAY OF BENZODIAZEPINES
$22.97
80156
3
ASSAY, CARBAMAZEPINE, TOTAL
$20.83
80157
3
ASSAY, CARBAMAZEPINE, FREE
$18.97
80158
3
ASSAY OF CYCLOSPORINE
$25.83
80160
3
ASSAY OF DESIPRAMINE
$24.63
80162
3
ASSAY OF DIGOXIN
$19.00
80164
3
ASSAY, DIPROPYLACETIC ACID
$19.38
80166
3
ASSAY OF DOXEPIN
$22.19
80168
3
ASSAY OF ETHOSUXIMIDE
$21.56
80170
3
ASSAY OF GENTAMICIN
$23.45
80172
3
ASSAY OF GOLD
$23.30
80173
3
ASSAY OF HALOPERIDOL
$20.83
80174
3
ASSAY OF IMIPRAMINE
$24.63
80176
3
ASSAY OF LIDOCAINE
$21.02
80178
3
ASSAY OF LITHIUM
80182
3
ASSAY OF NORTRIPTYLINE
$19.38
80184
3
ASSAY OF PHENOBARBITAL
$16.39
80185
3
ASSAY OF PHENYTOIN, TOTAL
$18.97
80186
3
ASSAY OF PHENYTOIN, FREE
$19.70
80188
3
ASSAY OF PRIMIDONE
$23.75
80190
3
ASSAY OF PROCAINAMIDE
$23.97
80192
3
ASSAY OF PROCAINAMIDE
$23.97
80194
3
ASSAY OF QUINIDINE
$20.88
80195
3
ASSAY OF SIROLIMUS
$19.64
80196
3
ASSAY OF SALICYLATE
$10.15
80197
3
ASSAY OF TACROLIMUS
$19.64
80198
3
ASSAY OF THEOPHYLLINE
$20.25
80200
3
ASSAY OF TOBRAMYCIN
$23.06
$0.00
$9.46
Procedure Code Pricing Action Code Description
Maximum Allowable
80201
3
ASSAY OF TOPIRAMATE
$17.05
80202
3
ASSAY OF VANCOMYCIN
$19.38
80299
3
QUANTITATIVE ASSAY, DRUG
$19.59
80400
3
ACTH STIMULATION PANEL
$46.67
80402
3
ACTH STIMULATION PANEL
$124.40
80406
3
ACTH STIMULATION PANEL
$111.97
80408
3
ALDOSTERONE SUPPRESSION EVAL
$179.58
80410
3
CALCITONIN STIMUL PANEL
80412
3
CRH STIMULATION PANEL
80414
3
TESTOSTERONE RESPONSE
$73.89
80415
3
ESTRADIOL RESPONSE PANEL
$79.97
80416
3
RENIN STIMULATION PANEL
$188.87
80417
3
RENIN STIMULATION PANEL
$62.96
80418
3
PITUITARY EVALUATION PANEL
$829.32
80420
3
DEXAMETHASONE PANEL
$102.74
80422
3
GLUCAGON TOLERANCE PANEL
$65.91
80424
3
GLUCAGON TOLERANCE PANEL
$72.27
80426
3
GONADOTROPIN HORMONE PANEL
80428
3
GROWTH HORMONE PANEL
$95.41
80430
3
GROWTH HORMONE PANEL
$112.26
80432
3
INSULIN SUPPRESSION PANEL
$193.30
80434
3
INSULIN TOLERANCE PANEL
$144.75
80435
3
INSULIN TOLERANCE PANEL
$147.34
80436
3
METYRAPONE PANEL
$130.44
80438
3
TRH STIMULATION PANEL
$72.12
80439
3
TRH STIMULATION PANEL
$96.16
80440
3
TRH STIMULATION PANEL
$83.20
80500
3
LAB PATHOLOGY CONSULTATION
$22.88
80502
3
LAB PATHOLOGY CONSULTATION
$76.36
81000
3
URINALYSIS, NONAUTO W/SCOPE
$4.52
81001
3
URINALYSIS, AUTO W/SCOPE
$4.52
81002
3
URINALYSIS NONAUTO W/O SCOPE
$3.67
81003
3
URINALYSIS, AUTO, W/O SCOPE
$3.21
81004
O
URINALYSIS COMPONENTS, SINGLE, NOT
$0.00
81005
3
URINALYSIS
$3.10
$64.30 $471.63
$212.39
Procedure Code Pricing Action Code Description
Maximum Allowable
81007
3
URINE SCREEN FOR BACTERIA
$3.68
81010
O
URINALYSIS CONCENTRATION AND DILUTI
$0.00
81011
O
URINALYSIS WATER DEPRIVATION TEST
$0.00
81012
O
URINALYSIS WATER DEPRIVATION TEST W
$0.00
81015
3
MICROSCOPIC EXAM OF URINE
$4.34
81020
3
URINALYSIS, GLASS TEST
$4.40
81025
3
URINE PREGNANCY TEST
$9.06
81030
O
QUANTITATIVE SEDIMENT ANALYSIS AND
$0.00
81050
3
URINALYSIS, VOLUME MEASURE
$4.12
81099
5
URINALYSIS TEST PROCEDURE
$0.00
82000
3
ASSAY OF BLOOD ACETALDEHYDE
$17.73
82003
3
ASSAY OF ACETAMINOPHEN
$28.96
82005
O
ACETOACETIC ACID
$0.00
82009
3
TEST FOR ACETONE/KETONES
$6.46
82010
3
ACETONE ASSAY
82011
O
ACETYLSALICYLIC ACID QUANTITATIVE
$0.00
82012
O
ACETYLSALICYLIC ACID QUALITATIVE
$0.00
82013
3
ACETYLCHOLINESTERASE ASSAY
82015
O
ACIDITY, TITRATABLE, URINE
82016
3
ACYLCARNITINES, QUAL
$19.84
82017
3
ACYLCARNITINES, QUANT
$24.14
82024
3
ASSAY OF ACTH
$55.27
82030
3
ASSAY OF ADP & AMP
$36.92
82035
O
ADENOSINE 5'-TRIPHOSPHATE, BLOOD
$0.00
82040
3
ASSAY OF SERUM ALBUMIN
$7.09
82042
3
ASSAY OF URINE ALBUMIN
$2.52
82043
3
MICROALBUMIN, QUANTITATIVE
$8.28
82044
3
MICROALBUMIN, SEMIQUANT
$3.64
82045
3
ALBUMIN, ISCHEMIA MODIFIED
$48.57
82055
3
ASSAY OF ETHANOL
$15.46
82060
O
ALCOHOL (ETHANOL), BLOOD BY GAS-LIQ
$0.00
82065
O
ALCOHOL (ETHANOL), URINE CHEMICAL
$0.00
82070
O
ALCOHOL (ETHANOL), URINE BY GAS-LIQ
$0.00
82072
O
ALCOHOL (ETHANOL) GELATION
$0.00
82075
3
ASSAY OF BREATH ETHANOL
$11.69
$12.37 $0.00
$17.25
Procedure Code Pricing Action Code Description
Maximum Allowable
82076
O
ALCOHOL ISOPROPYL
$0.00
82078
O
ALCOHOL METHYL
$0.00
82085
3
ASSAY OF ALDOLASE
82086
O
ALDOLASE, BLOOD COLORIMETRIC
$0.00
82087
O
ALDOSTERONE DOUBLE ISOTOPE TECHNIQU
$0.00
82088
3
ASSAY OF ALDOSTERONE
$58.31
82089
O
ALDOSTERONE RIA, URINE
$0.00
82091
O
ALDOSTERONE SALINE INFUSION TEST
$0.00
82095
O
ALKALOIDS, TISSUE SCREENING
$0.00
82096
O
ALKALOIDS, TISSUE QUANTITATIVE
$0.00
82100
O
ALKALOIDS, URINE SCREENING
$0.00
82101
3
ASSAY OF URINE ALKALOIDS
$42.95
82103
3
ALPHA-1-ANTITRYPSIN, TOTAL
$19.22
82104
3
ALPHA-1-ANTITRYPSIN, PHENO
$20.69
82105
3
ALPHA-FETOPROTEIN, SERUM
$24.00
82106
3
ALPHA-FETOPROTEIN, AMNIOTIC
$24.00
82107
3
ALPHA-FETOPROTEIN L3
$90.65
82108
3
ASSAY OF ALUMINUM
$36.46
82112
O
AMIKACIN
$0.00
82120
3
AMINES, VAGINAL FLUID QUAL
$5.38
82126
O
AMINO ACID NITROGEN, ALPHA
$0.00
82127
3
AMINO ACID, SINGLE QUAL
$19.84
82128
3
AMINO ACIDS, MULT QUAL
$19.84
82130
O
AMINO ACIDS ANALYSIS
82131
3
AMINO ACIDS, SINGLE QUANT
82134
O
AMINOHIPPURATE, PARA (PAH)
$0.00
82135
3
ASSAY, AMINOLEVULINIC ACID
$23.56
82136
3
AMINO ACIDS, QUANT, 2-5
$24.14
82137
O
AMINOPHYLLINE
$0.00
82138
O
AMITRIPTYLINE
$0.00
82139
3
AMINO ACIDS, QUAN, 6 OR MORE
$24.14
82140
3
ASSAY OF AMMONIA
$20.85
82141
O
AMMONIA URINE
$0.00
82142
O
AMMONIUM CHLORIDE LOADING TEST
$0.00
82143
3
AMNIOTIC FLUID SCAN
$9.83
$13.89
$0.00 $24.14
Procedure Code Pricing Action Code Description
Maximum Allowable
82145
3
ASSAY OF AMPHETAMINES
$22.25
82150
3
ASSAY OF AMYLASE
82154
3
ANDROSTANEDIOL GLUCURONIDE
82156
O
AMYLASE, URINE (DIASTASE)
82157
3
ASSAY OF ANDROSTENEDIONE
82159
O
ANDROSTERONE
82160
3
ASSAY OF ANDROSTERONE
$35.78
82163
3
ASSAY OF ANGIOTENSIN II
$29.37
82164
3
ANGIOTENSIN I ENZYME TEST
$20.88
82165
O
ANILINE
$0.00
82168
O
ANTIHISTAMINES
$0.00
82170
O
ANTIMONY, URINE
$0.00
82172
3
ASSAY OF APOLIPOPROTEIN
$22.17
82173
O
ARGININE TOLERANCE TEST
$0.00
82175
3
ASSAY OF ARSENIC
$27.15
82180
3
ASSAY OF ASCORBIC ACID
$14.14
82190
3
ATOMIC ABSORPTION
$21.33
82205
3
ASSAY OF BARBITURATES
$16.39
82210
O
BARBITURATES QUANTITATIVE AND IDENT
$0.00
82225
O
BARIUM
$0.00
82230
O
BERYLLIUM, URINE
$0.00
82231
O
BETA-2 MICROGLOBULIN, RIA URINE
$0.00
82232
3
ASSAY OF BETA-2 PROTEIN
82235
O
BICARBONATE EXCRETION, URINE
$0.00
82236
O
BICARBONATE LOADING TEST
$0.00
82239
3
BILE ACIDS, TOTAL
$24.51
82240
3
BILE ACIDS, CHOLYLGLYCINE
$38.03
82245
O
BILE PIGMENTS, URINE
$0.00
82247
3
BILIRUBIN, TOTAL
$7.18
82248
3
BILIRUBIN, DIRECT
$7.18
82250
O
ASSAY BILIRUBIN
$0.00
82251
O
ASSAY OF BILIRUBIN
$0.00
82252
3
FECAL BILIRUBIN TEST
$6.51
82260
O
BILIRUBIN URINE, QUANTITATIVE
$0.00
82261
3
ASSAY OF BIOTINIDASE
$9.27 $41.26 $0.00 $41.89 $0.00
$23.15
$24.14
Procedure Code Pricing Action Code Description
Maximum Allowable
82265
O
BILIRUBIN AMNIOTIC FLUID, QUANTITAT
$0.00
82268
O
BISMUTH
$0.00
82270
3
OCCULT BLOOD, FECES
$4.66
82271
3
OCCULT BLOOD, OTHER SOURCES
$4.66
82272
3
OCCULT BLD FECES, 1-3 TESTS
$4.66
82273
O
TEST FOR BLOOD, OTHER SOURCE
$0.00
82274
3
ASSAY TEST FOR BLOOD, FECAL
82280
O
BORIC ACID BLOOD
$0.00
82285
O
BORIC ACID URINE
$0.00
82286
3
ASSAY OF BRADYKININ
$9.86
82290
O
BROMIDES BLOOD
$0.00
82291
O
BROMIDES URINE
$0.00
82300
3
ASSAY OF CADMIUM
82305
O
CAFFEINE
82306
3
ASSAY OF VITAMIN D
$42.36
82307
3
ASSAY OF VITAMIN D
$46.11
82308
3
ASSAY OF CALCITONIN
$21.43
82310
3
ASSAY OF CALCIUM
$7.38
82315
O
CALCIUM, BLOOD FLUOROMETRIC
$0.00
82320
O
CALCIUM, BLOOD EMISSION FLAME PHOTO
$0.00
82325
O
CALCIUM, BLOOD ATOMIC ABSORPTION FL
$0.00
82330
3
ASSAY OF CALCIUM
$9.07
82331
3
CALCIUM INFUSION TEST
$7.41
82335
O
CALCIUM, URINE QUALITATIVE (SULKOWI
$0.00
82340
3
ASSAY OF CALCIUM IN URINE
$8.63
82355
3
CALCULUS ANALYSIS, QUAL
$16.55
82360
3
CALCULUS ASSAY, QUANT
$18.42
82365
3
CALCULUS SPECTROSCOPY
$18.45
82370
3
X-RAY ASSAY, CALCULUS
$17.92
82372
O
CARBAMAZEPINE, SERUM
$0.00
82373
3
ASSAY, C-D TRANSFER MEASURE
$25.84
82374
3
ASSAY, BLOOD CARBON DIOXIDE
$7.00
82375
3
CARBOXYHEMOGLOBIN; QUANTITATIVE
82376
3
ASSAY, CARBOXYHB, QUAL
82378
3
CARCINOEMBRYONIC ANTIGEN
$22.76
$33.11 $0.00
$17.64 $7.86 $27.15
Procedure Code Pricing Action Code Description
Maximum Allowable
82379
3
ASSAY OF CARNITINE
$24.14
82380
3
ASSAY OF CAROTENE
$13.20
82382
3
ASSAY, URINE CATECHOLAMINES
$24.60
82383
3
ASSAY, BLOOD CATECHOLAMINES
$35.86
82384
3
ASSAY, THREE CATECHOLAMINES
$36.13
82387
3
ASSAY OF CATHEPSIN-D
$29.77
82390
3
ASSAY OF CERULOPLASMIN
$15.37
82397
3
CHEMILUMINESCENT ASSAY
$20.22
82400
O
CHLORAL HYDRATE BLOOD
$0.00
82405
O
CHLORAL HYDRATE URINE
$0.00
82415
3
ASSAY OF CHLORAMPHENICOL
$18.13
82418
O
CHLORAZEPATE DIPOTASSIUM
$0.00
82420
O
CHLORDIAZEPOXIDE BLOOD
$0.00
82425
O
CHLORDIAZEPOXIDE URINE
$0.00
82435
3
ASSAY OF BLOOD CHLORIDE
$6.57
82436
3
ASSAY OF URINE CHLORIDE
$7.19
82437
O
CHLORIDES SWEAT (WITHOUT IONTOPHORE
$0.00
82438
3
ASSAY, OTHER FLUID CHLORIDES
$7.00
82441
3
TEST FOR CHLOROHYDROCARBONS
$8.58
82443
O
CHLOROTHIAZIDE-HYDROCHLOROTHIAZIDE
$0.00
82465
3
ASSAY, BLD/SERUM CHOLESTEROL
$6.23
82470
O
CHOLESTEROL, SERUM TOTAL AND ESTERS
$0.00
82480
3
ASSAY, SERUM CHOLINESTERASE
$11.28
82482
3
ASSAY, RBC CHOLINESTERASE
$11.00
82484
O
CHOLINESTERASE SERUM AND RBC
82485
3
ASSAY, CHONDROITIN SULFATE
$29.55
82486
3
GAS/LIQUID CHROMATOGRAPHY
$25.84
82487
3
PAPER CHROMATOGRAPHY
$22.84
82488
3
PAPER CHROMATOGRAPHY
$30.58
82489
3
THIN LAYER CHROMATOGRAPHY
$26.46
82491
3
CHROMOTOGRAPHY, QUANT, SING
$25.84
82492
3
CHROMOTOGRAPHY, QUANT, MULT
$25.84
82495
3
ASSAY OF CHROMIUM
$29.02
82507
3
ASSAY OF CITRATE
$39.79
82512
O
CLONAZEPAM
$0.00
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
82520
3
ASSAY OF COCAINE
$19.96
82523
3
COLLAGEN CROSSLINKS
$15.53
82525
3
ASSAY OF COPPER
$17.76
82526
O
COPPER URINE
82528
3
ASSAY OF CORTICOSTERONE
82529
O
CORTISOL FLUOROMETRIC, PLASMA
82530
3
CORTISOL, FREE
82531
O
CORTISOL CPB, PLASMA
$0.00
82532
O
CORTISOL CPB, URINE
$0.00
82533
3
TOTAL CORTISOL
82534
O
CORTISOL RIA, URINE
$0.00
82536
O
CORTISOL AFTER ADRENOCORTICOTROPIC
$0.00
82537
O
CORTISOL 48 HOURS AFTER CONTINUOUS
$0.00
82538
O
CORTISOL AFTER METYRAPONE TARTRATE
$0.00
82539
O
CORTISOL DEXAMETHASONE SUPPRESSION
$0.00
82540
3
ASSAY OF CREATINE
$6.62
82541
3
COLUMN CHROMOTOGRAPHY, QUAL
$25.84
82542
3
COLUMN CHROMOTOGRAPHY, QUANT
$25.84
82543
3
COLUMN CHROMOTOGRAPH/ISOTOPE
$25.84
82544
3
COLUMN CHROMOTOGRAPH/ISOTOPE
$25.84
82545
O
CREATINE URINE
$0.00
82546
O
CREATINE AND CREATININE
$0.00
82550
3
ASSAY OF CK (CPK)
$9.32
82552
3
ASSAY OF CPK IN BLOOD
$19.17
82553
3
CREATINE, MB FRACTION
$10.86
82554
3
CREATINE, ISOFORMS
$16.98
82555
O
CREATINE PHOSPHOKINASE (CPK), BLOOD
$0.00
82565
3
ASSAY OF CREATININE
$6.57
82570
3
ASSAY OF URINE CREATININE
$7.41
82575
3
CREATININE CLEARANCE TEST
$13.51
82585
3
ASSAY OF CRYOFIBRINOGEN
$12.27
82595
3
ASSAY OF CRYOGLOBULIN
82600
3
ASSAY OF CYANIDE
82601
O
CYANIDE TISSUE
$0.00
82606
O
CYANOCOBALAMIN (VITAMIN B-12) BIOAS
$0.00
$0.00 $32.20 $0.00 $23.92
$23.33
$9.26 $27.76
Procedure Code Pricing Action Code Description
Maximum Allowable
82607
3
VITAMIN B-12
$21.57
82608
3
B-12 BINDING CAPACITY
$20.49
82610
3
CYSTATIN C
$19.45
82614
O
CYSTINE, BLOOD, QUALITATIVE
82615
3
TEST FOR URINE CYSTINES
82620
O
CYSTINE AND HOMOCYSTINE, URINE QUAN
$0.00
82624
O
CYSTINE AMINOPEPTIDASE
$0.00
82626
3
DEHYDROEPIANDROSTERONE
$36.16
82627
3
DEHYDROEPIANDROSTERONE
$31.81
82628
O
DESIPRAMINE
82633
3
DESOXYCORTICOSTERONE
$44.33
82634
3
DEOXYCORTISOL
$41.89
82635
O
DIACETIC ACID
$0.00
82636
O
DIAZEPAM
$0.00
82638
3
ASSAY OF DIBUCAINE NUMBER
82639
O
DICUMAROL
$0.00
82640
O
DIGITOXIN (DIGITALIS) BLOOD, RIA
$0.00
82641
O
DIGITOXIN (DIGITALIS) URINE
$0.00
82643
O
DIGOXIN, RIA
$0.00
82646
3
ASSAY OF DIHYDROCODEINONE
$29.55
82649
3
ASSAY OF DIHYDROMORPHINONE
$36.78
82651
3
ASSAY OF DIHYDROTESTOSTERONE
$36.94
82652
3
ASSAY OF DIHYDROXYVITAMIN D
$55.08
82654
3
ASSAY OF DIMETHADIONE
$19.82
82656
3
ELASTASE, PANCREATIC (EL-1), FECAL
$15.76
82657
3
ENZYME CELL ACTIVITY
$25.84
82658
3
ENZYME CELL ACTIVITY, RA
$25.84
82660
O
DRUG SCREEN (AMPHETAMINES, BARBITUR
82664
3
ELECTROPHORETIC TEST
$49.16
82666
3
ASSAY OF EPIANDROSTERONE
$30.74
82668
3
ASSAY OF ERYTHROPOIETIN
$24.89
82670
3
ASSAY OF ESTRADIOL
$39.98
82671
3
ASSAY OF ESTROGENS
$46.21
82672
3
ASSAY OF ESTROGEN
$14.26
82673
O
ESTRIOL FLUOROMETRIC
$0.00 $11.68
$0.00
$16.65
$0.00
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
82674
O
ESTRIOL GLC
$0.00
82676
O
ESTRIOL CHEMICAL
$0.00
82677
3
ASSAY OF ESTRIOL
$34.60
82678
O
ESTRONE CHEMICAL
$0.00
82679
3
ASSAY OF ESTRONE
$33.58
82690
3
ASSAY OF ETHCHLORVYNOL
$24.74
82691
O
ETHCHLORVYNOL URINE
$0.00
82692
O
ETHOSUXIMIDE
$0.00
82693
3
ASSAY OF ETHYLENE GLYCOL
82694
O
ETIOCHOLANOLONE
82696
3
ASSAY OF ETIOCHOLANOLONE
82705
3
FATS/LIPIDS, FECES, QUAL
$7.28
82710
3
FATS/LIPIDS, FECES, QUANT
$4.12
82715
3
ASSAY OF FECAL FAT
82720
O
FATTY ACIDS, BLOOD ESTERIFIED
82725
3
ASSAY OF BLOOD FATTY ACIDS
$19.05
82726
3
LONG CHAIN FATTY ACIDS
$25.84
82727
O
FERRIC CHLORIDE, URINE
$0.00
82728
3
ASSAY OF FERRITIN
82730
O
FIBRINOGEN, QUANTITATIVE
82731
3
ASSAY OF FETAL FIBRONECTIN
$90.65
82735
3
ASSAY OF FLUORIDE
$26.54
82740
O
FLUORIDE URINE
$0.00
82741
O
FLUCYTOSINE (5-FLUOROCYTOSINE)
$0.00
82742
3
ASSAY OF FLURAZEPAM
82745
O
FOLIC ACID (FOLATE), BLOOD BIOASSAY
82746
3
BLOOD FOLIC ACID SERUM
$21.04
82747
3
ASSAY OF FOLIC ACID, RBC
$24.65
82750
O
FORMIMINOGLUTAMIC ACID (FIGLU), URI
$0.00
82755
O
FREE RADICAL ASSAY TECHNIQUE FOR DR
$0.00
82756
O
FREE THYROXINE INDEX (T-7)
$0.00
82757
3
ASSAY OF SEMEN FRUCTOSE
$24.81
82759
3
ASSAY OF RBC GALACTOKINASE
$30.74
82760
3
ASSAY OF GALACTOSE
$16.02
82763
O
GALACTOSE TOLERANCE TEST
$18.44 $0.00 $33.74
$12.51 $0.00
$19.49 $0.00
$22.50 $0.00
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
82765
O
GALACTOSE URINE
$0.00
82775
3
ASSAY GALACTOSE TRANSFERASE
$30.14
82776
3
GALACTOSE TRANSFERASE TEST
$12.00
82780
O
GALLIUM
82784
3
ASSAY OF GAMMAGLOBULIN IGM
$13.31
82785
3
ASSAY OF GAMMAGLOBULIN IGE
$23.57
82786
O
GAMMAGLOBULIN, SALT PRECIPITATION M
82787
3
IGG 1, 2, 3 OR 4, EACH
82790
O
GASES, BLOOD, OXYGEN SATURATION BY
$0.00
82791
O
GASES, BLOOD, OXYGEN SATURATION BY
$0.00
82792
O
GASES, BLOOD, OXYGEN SATURATION QUA
$0.00
82793
O
GASES, BLOOD, OXYGEN SATURATION BY
$0.00
82795
O
GASES, BLOOD, OXYGEN SATURATION BY
$0.00
82800
3
BLOOD PH
82801
O
GASES, BLOOD PCO2
$0.00
82802
O
GASES, BLOOD PH, PCO2 BY ELECTRODE
$0.00
82803
3
BLOOD GASES: PH, PO2 & PCO2
82804
O
GASES, BLOOD PO2 BY ELECTRODE
82805
3
BLOOD GASES W/02 SATURATION
$40.60
82810
3
BLOOD GASES, O2 SAT ONLY
$12.49
82812
O
GASES, BLOOD PO2 BY MANOMETRY
$0.00
82817
O
GASES, BLOOD PH, PCO2 BY TONOMETRY
$0.00
82820
3
HEMOGLOBIN-OXYGEN AFFINITY
82926
3
ASSAY OF GASTRIC ACID
$7.80
82927
O
GASTRIC ACID, FREE AND TOTAL EACH A
$0.00
82928
3
ASSAY OF GASTRIC ACID
$9.37
82929
O
GASTRIC ACID, FREE OR TOTAL EACH AD
$0.00
82931
O
GASTRIC ACID, PH TITRATION SINGLE S
$0.00
82932
O
GASTRIC ACID, PH TITRATION EACH ADD
$0.00
82938
3
GASTRIN TEST
$25.31
82941
3
ASSAY OF GASTRIN
$25.24
82942
O
GLOBULIN, SERUM
$0.00
82943
3
ASSAY OF GLUCAGON
82944
O
GLUCOSAMINE
$0.00
82945
3
GLUCOSE OTHER FLUID
$5.62
$0.00
$0.00 $11.48
$12.12
$27.69 $0.00
$14.30
$20.44
Procedure Code Pricing Action Code Description
Maximum Allowable
82946
3
GLUCAGON TOLERANCE TEST
$21.57
82947
3
ASSAY, GLUCOSE, BLOOD QUANT
$5.62
82948
3
REAGENT STRIP/BLOOD GLUCOSE
$4.54
82949
O
GLUCOSE FERMENTATION
$0.00
82950
3
GLUCOSE TEST
$6.79
82951
3
GLUCOSE TOLERANCE TEST (GTT)
82952
3
GTT-ADDED SAMPLES
82953
3
GLUCOSE-TOLBUTAMIDE TEST
82954
O
GLUCOSE, URINE
82955
3
ASSAY OF G6PD ENZYME
$13.88
82960
3
TEST FOR G6PD ENZYME
$8.66
82961
O
GLUCOSE TOLERANCE TEST, INTRAVENOUS
$0.00
82962
3
GLUCOSE BLOOD TEST
$3.35
82963
3
ASSAY OF GLUCOSIDASE
$30.74
82965
3
ASSAY OF GDH ENZYME
$11.06
82975
3
ASSAY OF GLUTAMINE
$22.67
82977
3
ASSAY OF GGT
$9.58
82978
3
ASSAY OF GLUTATHIONE
$8.53
82979
3
ASSAY, RBC GLUTATHIONE
$9.86
82980
3
ASSAY OF GLUTETHIMIDE
$26.22
82985
3
GLYCATED PROTEIN
$21.57
82995
O
GOLD, BLOOD
$0.00
83000
O
GONADOTROPIN, PITUITARY, FOLLICLE S
$0.00
83001
3
GONADOTROPIN (FSH)
$26.60
83002
3
GONADOTROPIN (LH)
$26.50
83003
3
ASSAY, GROWTH HORMONE (HGH)
$23.85
83004
O
GROWTH HORMONE, HUMAN (HGH) (SOMATO
83008
3
ASSAY OF GUANOSINE
$24.02
83009
3
H PYLORI (C-13), BLOOD
$96.38
83010
3
ASSAY OF HAPTOGLOBIN, QUANT
$18.00
83011
O
HAPTOGLOBIN QUANTITATIVE, ELECTROPH
83012
3
ASSAY OF HAPTOGLOBINS
$24.60
83013
3
H PYLORI (C-13), BREATH
$96.38
83014
3
H PYLORI DRUG ADMIN
$11.25
83015
3
HEAVY METAL SCREEN
$26.95
$18.42 $4.12 $21.68 $0.00
$0.00
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
83018
3
QUANTITATIVE SCREEN, METALS
$31.42
83019
O
BREATH ISOTOPE TEST
83020
3
HEMOGLOBIN ELECTROPHORESIS
$18.42
83021
3
HEMOGLOBIN CHROMOTOGRAPHY
$25.84
83026
3
HEMOGLOBIN, COPPER SULFATE
$3.38
83030
3
FETAL HEMOGLOBIN, CHEMICAL
$11.84
83033
3
FETAL HEMOGLOBIN ASSAY, QUAL
83036
3
GLYCOSYLATED HEMOGLOBIN TEST
$13.89
83037
3
GLYCOSYLATED HB, HOME DEVICE
$13.89
83040
O
HEMOGLOBIN METHEMOGLOBIN, ELECTROPH
$0.00
83045
3
BLOOD METHEMOGLOBIN TEST
$7.10
83050
3
BLOOD METHEMOGLOBIN ASSAY
$10.48
83051
3
ASSAY OF PLASMA HEMOGLOBIN
$4.12
83052
O
HEMOGLOBIN SICKLE, TURBIDIMETRIC
$0.00
83053
O
HEMOGLOBIN SOLUBILITY, S-D, ETC
$0.00
83055
3
BLOOD SULFHEMOGLOBIN TEST
$4.12
83060
3
BLOOD SULFHEMOGLOBIN ASSAY
83065
3
ASSAY OF HEMOGLOBIN HEAT
$9.86
83068
3
HEMOGLOBIN STABILITY SCREEN
$3.36
83069
3
ASSAY OF URINE HEMOGLOBIN
$5.64
83070
3
ASSAY OF HEMOSIDERIN, QUAL
$6.79
83071
3
ASSAY OF HEMOSIDERIN, QUANT
$9.18
83080
3
ASSAY OF B HEXOSAMINIDASE
$24.14
83086
O
HISTIDINE BLOOD, QUALITATIVE
$0.00
83087
O
HISTIDINE URINE, QUALITATIVE
$0.00
83088
3
ASSAY OF HISTAMINE
$42.26
83090
3
ASSAY OF HOMOCYSTINE
$24.14
83093
O
HOMOGENTISIC ACID BLOOD, QUALITATIV
$0.00
83094
O
HOMOGENTISIC ACID URINE, QUALITATIV
$0.00
83095
O
HOMOGENTISIC ACID URINE, QUANTITATI
$0.00
83150
3
ASSAY OF FOR HVA
83485
O
HYDROXYBUTYRIC DEHYDROGENASE, ALPHA
$0.00
83486
O
HYDROXYBUTYRIC DEHYDROGENASE, ALPHA
$0.00
83491
3
ASSAY OF CORTICOSTEROIDS
83492
O
HYDROXYCORTICOSTEROIDS, 17- (17-OHC
$0.00
$8.25
$11.84
$27.69
$25.06 $0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
83493
O
HYDROXYCORTICOSTEROIDS, 17- (17-OHC
$0.00
83494
O
HYDROXYCORTICOSTEROIDS, 17- (17-OHC
$0.00
83495
O
HYDROXYCORTICOSTEROIDS, 17- (17-OHC
$0.00
83496
O
HYDROXYCORTICOSTEROIDS, 17- (17-OHC
$0.00
83497
3
ASSAY OF 5-HIAA
$18.45
83498
3
ASSAY OF PROGESTERONE
$38.87
83499
3
ASSAY OF PROGESTERONE
$20.77
83500
3
ASSAY, FREE HYDROXYPROLINE
$32.41
83505
3
ASSAY, TOTAL HYDROXYPROLINE
$34.78
83510
O
HYDROXYPROLINE, URINE FREE AND TOTA
83516
3
IMMUNOASSAY, NONANTIBODY
$15.76
83518
3
IMMUNOASSAY, DIPSTICK
$12.13
83519
3
IMMUNOASSAY, NONANTIBODY
$19.34
83520
3
IMMUNOASSAY, RIA
$18.53
83523
O
IMIPRAMINE
$0.00
83524
O
INDICAN, URINE
$0.00
83525
3
ASSAY OF INSULIN
83526
O
INSULIN TOLERANCE TEST
83527
3
ASSAY OF INSULIN
$18.53
83528
3
ASSAY OF INTRINSIC FACTOR
$22.76
83530
O
INULIN CLEARANCE
$0.00
83540
3
ASSAY OF IRON
$9.27
83545
O
IRON, SERUM AUTOMATED
$0.00
83546
O
IRON, SERUM RADIOACTIVE UPTAKE METH
$0.00
83550
3
IRON BINDING TEST
83555
O
IRON BINDING CAPACITY, SERUM AUTOMA
$0.00
83565
O
IRON BINDING CAPACITY, SERUM RADIOA
$0.00
83570
3
ASSAY OF IDH ENZYME
83571
O
ISOCITRIC DEHYDROGENASE (IDH), BLOO
$0.00
83576
O
ISONICOTINIC ACID HYDRAZIDE (INH)
$0.00
83578
O
KANAMYCIN
$0.00
83582
3
ASSAY OF KETOGENIC STEROIDS
83583
O
KETOGENIC STEROIDS, URINE 11-DESOXY
$0.00
83584
O
KETOGLUTARATE, ALPHA
$0.00
83586
3
ASSAY 17- KETOSTEROIDS
$0.00
$16.36 $0.00
$12.51
$10.76
$20.28
$18.32
Procedure Code Pricing Action Code Description
Maximum Allowable
83587
O
KETOSTEROIDS, 17- (17-KS), BLOOD FR
$0.00
83588
O
KETOSTEROIDS, 17- (17-KS), BLOOD RI
$0.00
83589
O
KETOSTEROIDS, 17- (17-KS), URINE TO
$0.00
83590
O
KETOSTEROIDS, 17- (17-KS), URINE FR
$0.00
83593
3
FRACTIONATION, KETOSTEROIDS
83597
O
KETOSTEROIDS, 17- (17-KS), URINE 11
$0.00
83599
O
KETOSTEROIDS, 17-OH, RIA
$0.00
83600
O
KYNURENIC ACID
$0.00
83605
3
ASSAY OF LACTIC ACID
83610
O
LACTIC DEHYDROGENASE (LDH), RIA
$0.00
83615
3
LACTATE (LD) (LDH) ENZYME
$8.02
83620
O
LACTIC DEHYDROGENASE (LDH), BLOOD C
$0.00
83624
O
LACTIC DEHYDROGENASE (LDH), BLOOD H
$0.00
83625
3
ASSAY OF LDH ENZYMES
83626
O
LACTIC DEHYDROGENASE (LDH), BLOOD I
$0.00
83628
O
LACTIC DEHYDROGENASE, LIVER (LLDH)
$0.00
83629
O
LACTIC DEHYDROGENASE (LDH), URINE
$0.00
83630
3
LACTOFERRIN, FECAL (QUAL)
$28.09
83631
3
LACTOFERRIN, FECAL; QUANTITATIVE
$28.09
83632
3
PLACENTAL LACTOGEN
$28.92
83633
3
TEST URINE FOR LACTOSE
83634
3
ASSAY OF URINE FOR LACTOSE
83645
O
LEAD, SCREENING BLOOD
$0.00
83650
O
LEAD, SCREENING URINE
$0.00
83655
3
ASSAY OF LEAD
83660
O
LEAD, QUANTITATIVE URINE
83661
3
L/S RATIO, FETAL LUNG
$31.45
83662
3
FOAM STABILITY, FETAL LUNG
$27.07
83663
3
FLUORO POLARIZE, FETAL LUNG
$27.07
83664
3
LAMELLAR BDY, FETAL LUNG
$27.07
83670
3
ASSAY OF LAP ENZYME
$13.11
83675
O
LEUCINE AMINOPEPTIDASE (LAP), BLOOD
$0.00
83680
O
LEUCINE AMINOPEPTIDASE (LAP), URINE
$0.00
83681
O
LEUCINE TOLERANCE TEST
$0.00
83685
O
LIDOCAINE
$0.00
$37.63
$15.28
$18.32
$7.88 $16.49
$17.32 $0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
83690
3
ASSAY OF LIPASE
$9.86
83695
3
ASSAY OF LIPOPROTEIN(A)
$18.53
83698
3
ASSAY LIPOPROTEIN PLA2
$48.57
83700
3
LIPOPROTEIN, BLOOD; ELECTROPHORETI
$16.11
83701
3
LIPOPROTEIN BLD, HR FRACTION
$35.52
83704
3
LIPOPROTEIN, BLD, BY NMR
$45.15
83705
O
LIPIDS, BLOOD FRACTIONATED (CHOLEST
$0.00
83715
O
ASSAY OF BLOOD LIPOPROTEINS
$0.00
83716
O
ASSAY OF BLOOD LIPOPROTEINS
$0.00
83717
O
ASSAY BLOOD LIPOPROTEINS
$0.00
83718
3
ASSAY OF LIPOPROTEIN
$11.72
83719
3
ASSAY OF BLOOD LIPOPROTEIN
$16.65
83720
O
LIPOPROTEIN CHOLESTEROL FRACTIONATI
83721
3
ASSAY OF BLOOD LIPOPROTEIN
$13.65
83725
O
LITHIUM, BLOOD, QUANTITATIVE
$0.00
83727
3
ASSAY OF LRH HORMONE
83728
O
LYSERGIC ACID DIETHYLAMIDE (LSD), R
$0.00
83730
O
MACROGLOBULINS (SIA TEST)
$0.00
83735
3
ASSAY OF MAGNESIUM
$9.58
83740
O
MAGNESIUM, BLOOD FLUOROMETRIC
$0.00
83750
O
MAGNESIUM, BLOOD ATOMIC ABSORPTION
$0.00
83755
O
MAGNESIUM, URINE CHEMICAL
$0.00
83760
O
MAGNESIUM, URINE FLUOROMETRIC
$0.00
83765
O
MAGNESIUM, URINE ATOMIC ABSORPTION
$0.00
83775
3
ASSAY OF MD ENZYME
$10.55
83785
3
ASSAY OF MANGANESE
$15.57
83788
3
MASS SPECTROMETRY QUAL
$25.84
83789
3
MASS SPECTROMETRY QUANT
$25.84
83790
O
MANNITOL CLEARANCE
$0.00
83795
O
MELANIN, URINE, QUALITATIVE
$0.00
83799
O
MEPERIDINE, QUANTITATIVE
$0.00
83805
3
ASSAY OF MEPROBAMATE
$25.23
83825
3
ASSAY OF MERCURY
$23.27
83830
O
MERCURY, QUANTITATIVE URINE
83835
3
ASSAY OF METANEPHRINES
$0.00
$24.60
$0.00 $24.25
Procedure Code Pricing Action Code Description
Maximum Allowable
83840
3
ASSAY OF METHADONE
$23.30
83842
O
METHAPYRILENE
$0.00
83845
O
METHAQUALONE
$0.00
83857
3
ASSAY OF METHEMALBUMIN
$15.37
83858
3
ASSAY OF METHSUXIMIDE
$21.21
83859
O
METHYPRYLON
$0.00
83860
O
MORPHINE SCREENING
$0.00
83861
O
MORPHINE QUANTITATIVE
$0.00
83862
O
MORPHINE RIA
$0.00
83864
3
MUCOPOLYSACCHARIDES
83865
O
MUCOPOLYSACCHARIDES, ACID, URINE QU
83866
3
MUCOPOLYSACCHARIDES SCREEN
83872
3
ASSAY SYNOVIAL FLUID MUCIN
83873
3
ASSAY OF CSF PROTEIN
$24.62
83874
3
ASSAY OF MYOGLOBIN
$18.48
83875
O
MYOGLOBIN, URINE
83876
3
ASSAY, MYELOPEROXIDASE
$18.53
83880
3
NATRIURETIC PEPTIDE
$48.57
83883
3
ASSAY, NEPHELOMETRY NOT SPEC
$19.45
83885
3
ASSAY OF NICKEL
$35.05
83887
3
ASSAY OF NICOTINE
$33.89
83890
3
MOLECULE ISOLATE
$5.73
83891
3
MOLECULE ISOLATE NUCLEIC
$5.73
83892
3
MOLECULAR DIAGNOSTICS
$5.73
83893
3
MOLECULE DOT/SLOT/BLOT
$5.73
83894
3
MOLECULE GEL ELECTROPHOR
$5.73
83895
O
NITROGEN, TOTAL URINE, 24-HOUR SPEC
$0.00
83896
3
MOLECULAR DIAGNOSTICS
$5.73
83897
3
MOLECULE NUCLEIC TRANSFER
$5.73
83898
3
MOLECULE NUCLEIC AMPLI, EACH
$23.98
83900
3
MOLECULE NUCLEIC AMPLI 2 SEQ
$47.97
83901
3
MOLECULE NUCLEIC AMPLI ADDON
$23.98
83902
3
MOLECULAR DIAGNOSTICS
$20.31
83903
3
MOLECULE MUTATION SCAN
$23.98
83904
3
MOLECULE MUTATION IDENTIFY
$23.98
$28.49 $0.00 $14.10 $8.39
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
83905
3
MOLECULE MUTATION IDENTIFY
$23.98
83906
3
MOLECULE MUTATION IDENTIFY
$23.98
83907
3
LYSE CELLS FOR NUCLEIC EXT
$19.11
83908
3
NUCLEIC ACID, SIGNAL AMPLI
$23.98
83909
3
NUCLEIC ACID, HIGH RESOLUTE
$23.98
83910
O
NONPROTEIN NITROGEN (NPN), BLOOD
$0.00
83912
3
GENETIC EXAMINATION
$5.73
83913
3
NUCLEIC ACID PROBE, WITH ELECTROPHO
$19.11
83914
3
MUTATION IDENT OLA/SBCE/ASPE
$23.98
83915
3
ASSAY OF NUCLEOTIDASE
$15.96
83916
3
OLIGOCLONAL BANDS
$28.77
83917
O
ORGANIC ACIDS SCREEN, QUALITATIVE
83918
3
ORGANIC ACIDS, TOTAL, QUANT
$23.56
83919
3
ORGANIC ACIDS, QUAL, EACH
$23.56
83920
O
ORNITHINE CARBAMYL TRANSFERASE (OCT
83921
3
ORGANIC ACID, SINGLE, QUANT
$23.56
83925
3
ASSAY OF OPIATES
$27.84
83930
3
ASSAY OF BLOOD OSMOLALITY
$9.46
83935
3
ASSAY OF URINE OSMOLALITY
$9.75
83937
3
ASSAY OF OSTEOCALCIN
83938
O
OUABAIN
83945
3
ASSAY OF OXALATE
83946
O
OXAZEPAM
$0.00
83947
O
OXYBUTYRIC ACID, BETA
$0.00
83948
O
OXYCODINONE
$0.00
83949
O
OXYTOCINASE, RIA
$0.00
83950
3
ONCOPROTEIN, HER-2/NEU
$90.65
83951
3
ONCOPROTEIN, DCP
$90.65
83965
O
PARALDEHYDE, BLOOD, QUANTITATIVE
83970
3
ASSAY OF PARATHORMONE
83971
O
PENICILLIN, URINE
$0.00
83972
O
PENTAZOCINE
$0.00
83973
O
PENTOSE, URINE, QUALITATIVE
$0.00
83975
O
PEPSINOGEN, BLOOD
$0.00
83985
O
PESTICIDE OTHER THAN CHLORINATED HY
$0.00
$0.00
$0.00
$42.72 $0.00 $18.42
$0.00 $59.06
Procedure Code Pricing Action Code Description
Maximum Allowable
83986
3
ASSAY OF BODY FLUID ACIDITY
$3.36
83992
3
ASSAY FOR PHENCYCLIDINE
$21.03
83993
3
ASSAY FOR CALPROTECTIN FECAL
$28.09
83995
O
PHENOL, BLOOD OR URINE
$0.00
84005
O
PHENOLSULFONPHTHALEIN (PSP) TEST, U
$0.00
84021
O
PHENOTHIAZINE, URINE QUALITATIVE, C
$0.00
84022
3
ASSAY OF PHENOTHIAZINE
84030
3
ASSAY OF BLOOD PKU
$7.88
84031
O
PHENYLALANINE (PKU), BLOOD FLUOROME
$0.00
84033
O
PHENYLBUTAZONE
$0.00
84035
3
ASSAY OF PHENYLKETONES
$5.23
84037
O
PHENYLKETONES URINE, QUALITATIVE
$0.00
84038
O
PHENYLPROPANOLAMINE
$0.00
84039
O
PHENYLPYRUVIC ACID BLOOD
$0.00
84040
O
PHENYLPYRUVIC ACID URINE
$0.00
84045
O
PHENYTOIN
$0.00
84060
3
ASSAY ACID PHOSPHATASE
$8.25
84061
3
PHOSPHATASE, FORENSIC EXAM
$8.25
84065
O
PHOSPHATASE, ACID PROSTATIC FRACTIO
$0.00
84066
3
ASSAY PROSTATE PHOSPHATASE
84075
3
ASSAY ALKALINE PHOSPHATASE
$6.53
84078
3
ASSAY ALKALINE PHOSPHATASE
$10.45
84080
3
ASSAY ALKALINE PHOSPHATASES
$21.16
84081
3
AMNIOTIC FLUID ENZYME TEST
$23.64
84082
O
PHOSPHATES, TUBULAR REABSORPTION OF
$0.00
84083
O
PHOSPHOGLUCOMUTASE, ISOENZYMES
$0.00
84085
3
ASSAY OF RBC PG6D ENZYME
$9.64
84087
3
ASSAY PHOSPHOHEXOSE ENZYMES
84090
O
PHOSPHOLIPIDS, BLOOD
$0.00
84100
3
ASSAY OF PHOSPHORUS
$6.79
84105
3
ASSAY OF URINE PHOSPHORUS
$7.41
84106
3
TEST FOR PORPHOBILINOGEN
$6.13
84110
3
ASSAY OF PORPHOBILINOGEN
$11.05
84118
O
PORPHYRINS, COPRO-, URINE QUANTITAT
84119
3
TEST URINE FOR PORPHYRINS
$22.29
$13.42
$14.77
$0.00 $12.32
Procedure Code Pricing Action Code Description
Maximum Allowable
84120
3
ASSAY OF URINE PORPHYRINS
$20.89
84121
O
PORPHYRINS URO-, COPRO- AND PORPHOB
84126
3
ASSAY OF FECES PORPHYRINS
$36.45
84127
3
ASSAY OF FECES PORPHYRINS
$16.67
84128
O
PORPHYRINS, PLASMA
$0.00
84132
3
ASSAY OF SERUM POTASSIUM
$6.57
84133
3
ASSAY OF URINE POTASSIUM
$6.15
84134
3
ASSAY OF PREALBUMIN
$20.87
84135
3
ASSAY OF PREGNANEDIOL
$27.38
84136
O
PREGNANEDIOL OTHER METHOD (SPECIFY)
84138
3
ASSAY OF PREGNANETRIOL
84139
O
PREGNANETRIOL OTHER METHOD (SPECIFY
84140
3
ASSAY OF PREGNENOLONE
84141
O
PRIMIDONE
$0.00
84142
O
PROCAINAMIDE
$0.00
84143
3
ASSAY OF 17-HYDROXYPREGNENO
$32.65
84144
3
ASSAY OF PROGESTERONE
$29.85
84146
3
ASSAY OF PROLACTIN
$27.73
84147
O
PROPOXYPHENE
$0.00
84149
O
PROPRANOLOL
$0.00
84150
3
ASSAY OF PROSTAGLANDIN
$35.72
84152
3
ASSAY OF PSA, COMPLEXED
$26.31
84153
3
ASSAY OF PSA, TOTAL
$26.31
84154
3
ASSAY OF PSA, FREE
$26.31
84155
3
ASSAY OF PROTEIN, SERUM
$4.78
84156
3
ASSAY OF PROTEIN, URINE
$4.78
84157
3
ASSAY OF PROTEIN, OTHER
$4.78
84160
3
ASSAY OF PROTEIN, ANY SOURCE
$7.41
84163
3
PAPPA, SERUM
$20.76
84165
3
PROTEIN E-PHORESIS, SERUM
$15.37
84166
3
PROTEIN E-PHORESIS/URINE/CSF
$25.52
84170
O
PROTEIN, TOTAL, AND ALBUMIN/GLOBULI
$0.00
84175
O
PROTEIN;ELECTROPHORESIS,OTHER SOURC
$0.00
84176
O
PROTEIN, SPECIAL STUDIES (EG, MONOC
$0.00
84180
O
PROTEIN, URINE QUANTITATIVE, 24-HOU
$0.00
$0.00
$0.00 $27.10 $0.00 $29.59
Procedure Code Pricing Action Code Description
Maximum Allowable
84181
3
WESTERN BLOT TEST
$24.37
84182
3
PROTEIN, WESTERN BLOT TEST
$25.75
84185
O
PROTEIN, URINE BENCE-JONES
$0.00
84190
O
PROTEIN, URINE ELECTROPHORETIC FRAC
$0.00
84195
O
PROTEIN, SPINAL FLUID SEMI-QUANTITA
$0.00
84200
O
PROTEIN, SPINAL FLUID ELECTROPHORET
$0.00
84201
O
PROTIRELIN, THYROTROPIN RELEASING H
$0.00
84202
3
ASSAY RBC PROTOPORPHYRIN
$20.53
84203
3
TEST RBC PROTOPORPHYRIN
$12.32
84205
O
PROTRIPTYLENE
84206
3
ASSAY OF PROINSULIN
$11.17
84207
3
ASSAY OF VITAMIN B-6
$40.20
84208
O
PYROPHOSPHATE VS URATE, CRYSTALS (P
84210
3
ASSAY OF PYRUVATE
$15.53
84220
3
ASSAY OF PYRUVATE KINASE
$13.49
84228
3
ASSAY OF QUININE
$16.65
84230
O
QUINIDINE, BLOOD
$0.00
84231
O
RADIOIMMUNOASSAY (RIA) NOT ELSEWHER
$0.00
84232
O
RELEASING FACTOR
$0.00
84233
3
ASSAY OF ESTROGEN
$90.65
84234
3
ASSAY OF PROGESTERONE
$92.83
84235
3
ASSAY OF ENDOCRINE HORMONE
$74.88
84236
O
RECEPTOR ASSAY PROGESTERONE AND EST
84238
3
ASSAY, NONENDOCRINE RECEPTOR
$52.32
84244
3
ASSAY OF RENIN
$31.48
84246
O
RENIN (ANGIOTENSIN I) FUROSEMIDE TE
84252
3
ASSAY OF VITAMIN B-2
$28.22
84255
3
ASSAY OF SELENIUM
$36.52
84260
3
ASSAY OF SEROTONIN
$44.33
84270
3
ASSAY OF SEX HORMONE GLOBUL
$28.22
84275
3
ASSAY OF SIALIC ACID
$19.22
84285
3
ASSAY OF SILICA
$33.69
84295
3
ASSAY OF SERUM SODIUM
$6.65
84300
3
ASSAY OF URINE SODIUM
$6.96
84302
3
ASSAY OF SWEAT SODIUM
$6.96
$0.00
$0.00
$0.00
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
84305
3
ASSAY OF SOMATOMEDIN
$28.10
84307
3
ASSAY OF SOMATOSTATIN
$26.17
84310
O
SORBITOL DEHYDROGENASE, SERUM
84311
3
SPECTROPHOTOMETRY
84315
3
BODY FLUID SPECIFIC GRAVITY
$3.59
84318
O
STERCOBILIN, QUALITATIVE, FECES
$0.00
84324
O
STRYCHNINE
$0.00
84375
3
CHROMATOGRAM ASSAY, SUGARS
84376
3
SUGARS, SINGLE, QUAL
$7.88
84377
3
SUGARS, MULTIPLE, QUAL
$7.88
84378
3
SUGARS, SINGLE, QUANT
$16.49
84379
3
SUGARS MULTIPLE QUANT
$16.49
84392
3
ASSAY OF URINE SULFATE
$6.79
84395
O
SULFONAMIDE, BLOOD, CHEMICAL
$0.00
84402
3
ASSAY OF TESTOSTERONE
$36.44
84403
3
ASSAY OF TOTAL TESTOSTERONE
$36.95
84405
O
TESTOSTERONE, URINE, RIA
$0.00
84406
O
TESTOSTERONE, BINDING PROTEIN
$0.00
84407
O
TETRACAINE
$0.00
84408
O
TETRAHYDROCANNABINOL THC (MARIJUANA
$0.00
84409
O
TETRAHYDROCORTISONE OR TETRAHYDROCO
$0.00
84410
O
THALLIUM, BLOOD OR URINE
$0.00
84420
O
THEOPHYLLINE, BLOOD OR SALIVA
$0.00
84425
3
ASSAY OF VITAMIN B-1
84430
3
ASSAY OF THIOCYANATE
84432
3
ASSAY OF THYROGLOBULIN
84434
O
THIORIDAZINE
$0.00
84435
O
THYROXINE, (T-4), CPB OR RESIN UPTA
$0.00
84436
3
ASSAY OF TOTAL THYROXINE
$9.83
84437
3
ASSAY OF NEONATAL THYROXINE
$9.26
84439
3
ASSAY OF FREE THYROXINE
$12.91
84442
3
ASSAY OF THYROID ACTIVITY
$21.16
84443
3
ASSAY THYROID STIM HORMONE
$24.04
84444
O
THYROTROPIN RELEASING FACTOR (TRF)
84445
3
ASSAY OF TSI
$0.00 $10.00
$28.05
$30.39 $6.53 $22.98
$0.00 $72.76
Procedure Code Pricing Action Code Description
Maximum Allowable
84446
3
ASSAY OF VITAMIN E
$20.29
84447
O
TOXICOLOGY, SCREEN GENERAL
$0.00
84448
O
TOXICOLOGY, SCREEN SEDATIVE (ACID A
$0.00
84449
3
ASSAY OF TRANSCORTIN
84450
3
TRANSFERASE (AST) (SGOT)
$7.40
84455
O
TRANSAMINASE, GLUTAMIC OXALOACETIC
$0.00
84460
3
ALANINE AMINO (ALT) (SGPT)
$7.58
84465
O
TRANSAMINASE, GLUTAMIC PYRUVIC (SGP
$0.00
84466
3
ASSAY OF TRANSFERRIN
84472
O
TRICHLOROETHANOL
$0.00
84474
O
TRICHLOROACETIC ACID
$0.00
84476
O
TRIFLUOPERAZINE
$0.00
84478
3
ASSAY OF TRIGLYCERIDES
$8.23
84479
3
ASSAY OF THYROID (T3 OR T4)
$9.26
84480
3
ASSAY, TRIIODOTHYRONINE (T3)
$20.29
84481
3
FREE ASSAY (FT-3)
$24.25
84482
3
T3 REVERSE
$22.55
84483
O
TRIMETHADIONE
84484
3
ASSAY OF TROPONIN, QUANT
$12.47
84485
3
ASSAY DUODENAL FLUID TRYPSIN
$10.74
84488
3
TEST FECES FOR TRYPSIN
$10.45
84490
3
ASSAY OF FECES FOR TRYPSIN
$10.89
84510
3
ASSAY OF TYROSINE
$14.88
84512
3
ASSAY OF TROPONIN, QUAL
$10.55
84520
3
ASSAY OF UREA NITROGEN
$5.64
84525
3
UREA NITROGEN SEMI-QUANT
$5.38
84540
3
ASSAY OF URINE/UREA-N
$6.79
84545
3
UREA-N CLEARANCE TEST
$9.45
84550
3
ASSAY OF BLOOD/URIC ACID
$6.46
84555
O
URIC ACID URICASE, ULTRAVIOLET METH
$0.00
84560
3
ASSAY OF URINE/URIC ACID
$4.95
84565
O
UROBILIN, URINE QUALITATIVE
$0.00
84570
O
UROBILIN, URINE QUANTITATIVE, TIMED
$0.00
84575
O
UROBILIN, FECES, QUANTITATIVE
$0.00
84577
3
ASSAY OF FECES/UROBILINOGEN
$17.86
$25.75
$18.27
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
84578
3
TEST URINE UROBILINOGEN
$4.12
84580
3
ASSAY OF URINE UROBILINOGEN
$10.15
84583
3
ASSAY OF URINE UROBILINOGEN
$7.19
84584
O
UROPEPSIN, URINE
$0.00
84585
3
ASSAY OF URINE VMA
$22.19
84586
3
ASSAY OF VIP
$50.56
84588
3
ASSAY OF VASOPRESSIN
$48.57
84589
O
VISCOSITY
84590
3
ASSAY OF VITAMIN A
$16.59
84591
3
ASSAY OF NOS VITAMIN
$16.59
84595
O
VITAMIN A, BLOOD INCLUDING CAROTENE
84597
3
ASSAY OF VITAMIN K
$19.61
84600
3
ASSAY OF VOLATILES
$23.00
84605
O
VOLUME, BLOOD, DYE METHOD (EVANS BL
$0.00
84610
O
VOLUME, BLOOD, DYE METHOD (EVANS BL
$0.00
84613
O
WARFARIN
$0.00
84615
O
XANTHURENIC ACID
$0.00
84620
3
XYLOSE TOLERANCE TEST
$6.65
84630
3
ASSAY OF ZINC
84635
O
ZINC, QUANTITATIVE URINE
84681
3
ASSAY OF C-PEPTIDE
84695
O
GENTAMICIN
84702
3
CHORIONIC GONADOTROPIN TEST
$20.76
84703
3
CHORIONIC GONADOTROPIN ASSAY
$10.75
84704
3
HCG, FREE BETACHAIN TEST
$20.76
84800
O
THYROID STIMULATING HORMONE (TSH),
$0.00
84810
O
TOBRAMYCIN
$0.00
84830
9
OVULATION TESTS
$0.00
84999
5
CLINICAL CHEMISTRY TEST
$0.00
85000
O
BLEEDING TIME DUKE
$0.00
85002
3
BLEEDING TIME TEST
$6.44
85004
3
AUTOMATED DIFF WBC COUNT
$9.26
85005
O
BLOOD COUNT BASOPHIL COUNT, DIRECT
$0.00
85007
3
BL SMEAR W/DIFF WBC COUNT
$4.92
85008
3
BL SMEAR W/O DIFF WBC COUNT
$4.92
$0.00
$0.00
$16.30 $0.00 $29.77 $0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
85009
3
MANUAL DIFF WBC COUNT B-COAT
$5.32
85012
O
BLOOD COUNT EOSINOPHIL COUNT, DIREC
$0.00
85013
3
SPUN MICROHEMATOCRIT
$3.39
85014
3
HEMATOCRIT
$3.39
85018
3
HEMOGLOBIN
$3.39
85021
O
AUTOMATED HEMOGRAM
$0.00
85022
O
AUTOMATED HEMOGRAM
$0.00
85023
O
AUTOMATED HEMOGRAM
$0.00
85024
O
AUTOMATED HEMOGRAM
$0.00
85025
3
COMPLETE CBC W/AUTO DIFF WBC
85027
3
COMPLETE CBC, AUTOMATED
$9.26
85029
O
AUTOMATED HEMOGRAM
$0.00
85030
O
AUTOMATED HEMOGRAM
$0.00
85031
O
MANUAL HEMOGRAM, CBC
$0.00
85032
3
MANUAL CELL COUNT, EACH
$6.15
85041
3
AUTOMATED RBC COUNT
$4.12
85044
3
MANUAL RETICULOCYTE COUNT
$6.15
85045
3
AUTOMATED RETICULOCYTE COUNT
$5.73
85046
3
RETICYTE/HGB CONCENTRATE
$7.99
85048
3
AUTOMATED LEUKOCYTE COUNT
$3.64
85049
3
AUTOMATED PLATELET COUNT
$6.40
85055
3
RETICULATED PLATELET ASSAY
$38.31
85060
3
BLOOD SMEAR INTERPRETATION
$25.45
85095
O
BONE MARROW ASPIRATION
85097
3
BONE MARROW INTERPRETATION
85100
O
BONE MARROW SMEAR AND/OR CELL BLOCK
$0.00
85101
O
BONE MARROW SMEAR AND/OR CELL BLOCK
$0.00
85102
O
BONE MARROW BIOPSY
$0.00
85103
O
BONE MARROW BIOPSY, NEEDLE OR TROCA
$0.00
85105
O
BONE MARROW BIOPSY, NEEDLE OR TROCA
$0.00
85109
O
BONE MARROW BIOPSY, NEEDLE OR TROCA
$0.00
85130
3
CHROMOGENIC SUBSTRATE ASSAY
85170
3
BLOOD CLOT RETRACTION
$5.17
85171
O
CLOT RETRACTION QUANTITATIVE
$0.00
85172
O
CLOT RETRACTION INHIBITION BY DRUGS
$0.00
$11.12
$0.00 $104.59
$17.02
Procedure Code Pricing Action Code Description
Maximum Allowable
85175
3
BLOOD CLOT LYSIS TIME
$6.51
85210
3
BLOOD CLOT FACTOR II TEST
$8.25
85220
3
BLOOD CLOT FACTOR V TEST
$25.25
85230
3
BLOOD CLOT FACTOR VII TEST
$25.62
85240
3
BLOOD CLOT FACTOR VIII TEST
$25.62
85242
O
CLOTTING FACTOR VIII (AHG), TWO STA
85244
3
BLOOD CLOT FACTOR VIII TEST
$29.21
85245
3
BLOOD CLOT FACTOR VIII TEST
$32.84
85246
3
BLOOD CLOT FACTOR VIII TEST
$32.84
85247
3
BLOOD CLOT FACTOR VIII TEST
$32.84
85250
3
BLOOD CLOT FACTOR IX TEST
$27.23
85260
3
BLOOD CLOT FACTOR X TEST
$25.62
85270
3
BLOOD CLOT FACTOR XI TEST
$25.62
85280
3
BLOOD CLOT FACTOR XII TEST
$27.69
85290
3
BLOOD CLOT FACTOR XIII TEST
$11.58
85291
3
BLOOD CLOT FACTOR XIII TEST
$11.58
85292
3
BLOOD CLOT FACTOR ASSAY
$27.10
85293
3
BLOOD CLOT FACTOR ASSAY
$27.10
85300
3
ANTITHROMBIN III TEST
$13.85
85301
3
ANTITHROMBIN III TEST
$15.47
85302
3
BLOOD CLOT INHIBITOR ANTIGEN
$17.20
85303
3
BLOOD CLOT INHIBITOR TEST
$19.79
85305
3
BLOOD CLOT INHIBITOR ASSAY
$16.59
85306
3
BLOOD CLOT INHIBITOR TEST
$21.92
85307
3
ASSAY ACTIVATED PROTEIN C
$21.92
85310
O
CLOTTING INHIBITORS OR ANTICOAGULAN
$0.00
85311
O
CLOTTING INHIBITORS OR ANTICOAGULAN
$0.00
85320
O
CLOTTING INHIBITORS OR ANTICOAGULAN
$0.00
85330
O
CLOTTING INHIBITORS OR ANTICOAGULAN
$0.00
85335
3
FACTOR INHIBITOR TEST
$18.42
85337
3
THROMBOMODULIN
$14.92
85340
O
CLOTTING INHIBITORS OR ANTICOAGULAN
$0.00
85341
O
CLOTTING INHIBITORS OR ANTICOAGULAN
$0.00
85345
3
COAGULATION TIME
$4.78
85347
3
COAGULATION TIME
$6.10
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
85348
3
COAGULATION TIME
$5.33
85360
3
EUGLOBULIN LYSIS
$12.00
85362
3
FIBRIN DEGRADATION PRODUCTS
$9.86
85363
O
FIBRIN DEGRADATION (SPLIT) PRODUCTS
$0.00
85364
O
FIBRIN DEGRADATION (SPLIT) PRODUCTS
$0.00
85365
O
FIBRIN DEGRADATION (SPLIT) PRODUCTS
$0.00
85366
3
FIBRINOGEN TEST
85367
O
FIBRIN DEGRADATION (SPLIT) PRODUCTS
$0.00
85368
O
FIBRIN DEGRADATION (SPLIT) PRODUCTS
$0.00
85369
O
FIBRIN DEGRADATION (SPLIT) PRODUCTS
$0.00
85370
3
FIBRINOGEN TEST
85371
O
FIBRINOGEN, SEMIQUANTITATIVE LATEX
$0.00
85372
O
FIBRINOGEN, SEMIQUANTITATIVE TURBID
$0.00
85376
O
FIBRINOGEN THROMBIN WITH PLASMA DIL
$0.00
85377
O
FIBRINOGEN THROMBIN TIME DILUTION
$0.00
85378
3
FIBRIN DEGRADE, SEMIQUANT
$10.20
85379
3
FIBRIN DEGRADATION, QUANT
$11.58
85380
3
FIBRIN DEGRADATION, VTE
$11.58
85384
3
FIBRINOGEN
$12.15
85385
3
FIBRINOGEN
$12.15
85390
3
FIBRINOLYSINS SCREEN
$7.39
85392
O
FIBRINOLYSINS WITH EACA CONTROL
$0.00
85395
O
FIBRINOLYSINS SEMIQUANTITATIVE
$0.00
85396
3
CLOTTING ASSAY, WHOLE BLOOD
$21.84
85397
3
CLOTTING FUNCT ACTIVITY
$32.84
85398
O
FIBRINOLYSIS, QUANTITATIVE
85400
3
FIBRINOLYTIC PLASMIN
$12.65
85410
3
FIBRINOLYTIC ANTIPLASMIN
$11.03
85415
3
FIBRINOLYTIC PLASMINOGEN
$20.79
85420
3
FIBRINOLYTIC PLASMINOGEN
$9.36
85421
3
FIBRINOLYTIC PLASMINOGEN
$14.57
85426
O
FIBRINOLYTIC MECHANISMS VON WILLEBR
$0.00
85441
3
HEINZ BODIES, DIRECT
$6.02
85445
3
HEINZ BODIES, INDUCED
$8.25
85460
3
HEMOGLOBIN, FETAL
$12.32
$11.58
$0.00
$11.07
Procedure Code Pricing Action Code Description
Maximum Allowable
85461
3
HEMOGLOBIN, FETAL
$9.50
85475
3
HEMOLYSIN
$11.17
85520
3
HEPARIN ASSAY
$18.73
85525
3
HEPARIN NEUTRALIZATION
$16.95
85530
3
HEPARIN-PROTAMINE TOLERANCE
$20.29
85535
O
IRON STAIN, BLOOD CELLS
$0.00
85536
3
IRON STAIN PERIPHERAL BLOOD
$9.26
85538
O
LEDER STAIN (ESTERASE) BLOOD OR BON
$0.00
85540
3
WBC ALKALINE PHOSPHATASE
85544
O
LUPUS ERYTHEMATOSUS (LE) CELL PREP
85547
3
RBC MECHANICAL FRAGILITY
85548
O
MORPHOLOGY OF RED BLOOD CELLS, ONLY
85549
3
MURAMIDASE
85555
3
RBC OSMOTIC FRAGILITY
$9.56
85556
O
OSMOTIC FRAGILITY, RBC INCUBATED, Q
$0.00
85557
3
RBC OSMOTIC FRAGILITY
$19.11
85560
O
PEROXIDASE STAIN, WBC
$0.00
85575
O
PLATELET; IN VITRO AGGREGATION,EACH
$0.00
85576
3
BLOOD PLATELET AGGREGATION
85577
O
PLATELET RETENTION (IN VITRO), GLAS
$0.00
85580
O
PLATELET COUNT (REES-ECKER)
$0.00
85585
O
BLOOD PLATELET ESTIMATION
$0.00
85590
O
PLATELET COUNT, MANUAL
$0.00
85595
O
PLATELET COUNT, AUTOMATED
$0.00
85597
3
PLATELET NEUTRALIZATION
85610
3
PROTHROMBIN TIME
$5.63
85611
3
PROTHROMBIN TEST
$5.64
85612
3
VIPER VENOM PROTHROMBIN TIME
$13.69
85613
3
RUSSELL VIPER VENOM, DILUTED
$13.69
85615
O
PROTHROMBIN UTILIZATION (CONSUMPTIO
$0.00
85618
O
PROTHROMBIN-PROCONVERTIN, P&P (OWRE
$0.00
85630
O
RED BLOOD CELL SIZE (PRICE-JONES)
$0.00
85632
O
RED BLOOD CELL PEROXIDE HEMOLYSIS
$0.00
85635
3
REPTILASE TEST
85650
O
SEDIMENTATION RATE (ESR) WINTROBE T
$12.31 $0.00 $12.31 $0.00 $20.77
$30.74
$25.72
$10.01 $0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
85651
3
RBC SED RATE, NONAUTOMATED
$5.08
85652
3
RBC SED RATE, AUTOMATED
$3.86
85660
3
RBC SICKLE CELL TEST
$6.46
85665
O
STREPTOKINASE TITER (PLASMINOGEN AC
$0.00
85667
O
T-CELL DEPLETION (ANY METHOD) OF BO
$0.00
85670
3
THROMBIN TIME, PLASMA
$8.27
85675
3
THROMBIN TIME, TITER
$9.80
85700
O
THROMBOPLASTIN GENERATION TEST SCRE
$0.00
85705
3
THROMBOPLASTIN INHIBITION
85710
O
THROMBOPLASTIN GENERATION TEST DEFI
$0.00
85711
O
THROMBOPLASTIN GENERATION TEST WITH
$0.00
85720
O
THROMBOPLASTIN GENERATION TEST ALL
$0.00
85730
3
THROMBOPLASTIN TIME, PARTIAL
$8.58
85732
3
THROMBOPLASTIN TIME, PARTIAL
$9.26
85810
3
BLOOD VISCOSITY EXAMINATION
$16.71
85820
O
VISCOSITY SERUM OR PLASMA
$0.00
85999
5
HEMATOLOGY PROCEDURE
$0.00
86000
3
AGGLUTININS, FEBRILE
$9.99
86001
3
ALLERGEN SPECIFIC IGG
$7.47
86002
O
AGGLUTININS FEBRILE PANEL (TYPHOID
$0.00
86003
3
ALLERGEN SPECIFIC IGE
$7.47
86004
O
AGGLUTININS WARM
$0.00
86005
3
ALLERGEN SPECIFIC IGE
$4.15
86006
O
ANTIBODY, NON-RBC QUALITATIVE FIRST
$0.00
86007
O
ANTIBODY, NON-RBC QUALITATIVE EACH
$0.00
86008
O
ANTIBODY, NON-RBC, QUANTITATIVE FIR
$0.00
86009
O
ANTIBODY, NON-RBC, QUANTITATIVE EAC
$0.00
86011
O
ANTIBODY, DETECTION, LEUKOCYTE ANTI
$0.00
86012
O
ANTIBODY ABSORPTION, COLD AUTO ABSO
$0.00
86013
O
ANTIBODY ABSORPTION, COLD AUTO ABSO
$0.00
86014
O
ANTIBODY, PLATELET ANTIBODIES (AGGL
$0.00
86016
O
ANTIBODY SCREEN, RBC, EACH SERUM
$0.00
86019
O
ANTIBODY (RBC) ELUTION, ANY METHOD,
$0.00
86021
3
WBC ANTIBODY IDENTIFICATION
$19.03
86022
3
PLATELET ANTIBODIES
$19.03
$12.18
Procedure Code Pricing Action Code Description
Maximum Allowable
86023
3
IMMUNOGLOBULIN ASSAY
$17.83
86024
O
ANTIBODY IDENTIFICATION RBC ANTIBOD
$0.00
86031
O
ANTIHUMAN GLOBULIN TEST DIRECT (COO
$0.00
86032
O
ANTIHUMAN GLOBULIN TEST INDIRECT, Q
$0.00
86033
O
ANTIHUMAN GLOBULIN TEST INDIRECT, T
$0.00
86034
O
ANTIHUMAN GLOBULIN TEST ENZYME TECH
$0.00
86038
3
ANTINUCLEAR ANTIBODIES
$17.30
86039
3
ANTINUCLEAR ANTIBODIES (ANA)
$15.97
86060
3
ANTISTREPTOLYSIN O, TITER
$10.45
86063
3
ANTISTREPTOLYSIN O, SCREEN
$8.27
86064
O
B CELLS, TOTAL COUNT
$0.00
86066
O
ANTITRYPSIN, ALPHA-1 PI (PROTEASE I
$0.00
86067
O
ANTITRYPSIN, ALPHA-1 OTHER METHOD (
$0.00
86068
O
BLOOD COMPATIBILITY TEST CROSSMATCH
$0.00
86070
O
BLOOD COMPATIBILITY TEST CROSSMATCH
$0.00
86077
9
PHYSICIAN BLOOD BANK SERVICE
$0.00
86078
9
PHYSICIAN BLOOD BANK SERVICE
$0.00
86079
9
PHYSICIAN BLOOD BANK SERVICE
$0.00
86080
O
BLOOD TYPING ABO ONLY
$0.00
86082
O
BLOOD TYPING ABO AND RHO(D)
$0.00
86083
O
BLOOD TYPING ABO, RH(D) AND RBC ANT
$0.00
86084
O
BLOOD TYPING ANTIGEN SCREENING FOR
$0.00
86085
O
BLOOD TYPING ANTIGEN SCREENING FOR
$0.00
86095
O
BLOOD TYPING RBC ANTIGENS, OTHER TH
$0.00
86100
O
BLOOD TYPING RHO(D) ONLY
$0.00
86105
O
BLOOD TYPING RH GENOTYPING, COMPLET
$0.00
86115
O
BLOOD TYPING ANTI-RH IMMUNOGLOBULIN
$0.00
86128
O
COLLECTION, PROCESSING AND STORAGE
$0.00
86130
O
COLLECTION AND PROCESSING FOR TRANS
$0.00
86140
3
C-REACTIVE PROTEIN
$7.41
86141
3
C-REACTIVE PROTEIN, HS
$18.53
86146
3
GLYCOPROTEIN ANTIBODY
$36.40
86147
3
CARDIOLIPIN ANTIBODY
$36.40
86148
3
PHOSPHOLIPID ANTIBODY
$14.20
86149
O
CARCINOEMBRYONIC ANTIGEN (CEA) GEL
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
86151
O
CARCINOEMBRYONIC ANTIGEN (CEA) RIA
$0.00
86155
3
CHEMOTAXIS ASSAY
86156
3
COLD AGGLUTININ, SCREEN
86157
3
COLD AGGLUTININ, TITER
86158
O
COMPLEMENT C'1 ESTERASE
$0.00
86159
O
COMPLEMENT C'2 ESTERASE
$0.00
86160
3
COMPLEMENT, ANTIGEN
$17.18
86161
3
COMPLEMENT/FUNCTION ACTIVITY
$17.18
86162
3
COMPLEMENT, TOTAL (CH50)
$29.08
86163
O
COMPLEMENT C'3 ESTERASE
$0.00
86164
O
COMPLEMENT C'4 ESTERASE
$0.00
86171
3
COMPLEMENT FIXATION, EACH
$10.11
86185
3
COUNTERIMMUNOELECTROPHORESIS
$12.80
86200
3
CCP ANTIBODY
$18.53
86215
3
DEOXYRIBONUCLEASE, ANTIBODY
$18.96
86225
3
DNA ANTIBODY
$19.66
86226
3
DNA ANTIBODY, SINGLE STRAND
$17.33
86235
3
NUCLEAR ANTIGEN ANTIBODY
$25.66
86243
3
FC RECEPTOR
$29.36
86244
O
FETO-PROTEIN, ALPHA-1, RIA OR EIA
$0.00
86255
3
FLUORESCENT ANTIBODY, SCREEN
$17.25
86256
3
FLUORESCENT ANTIBODY, TITER
$12.51
86265
O
FROZEN BLOOD, PREPARATION FOR FREEZ
$0.00
86266
O
FROZEN BLOOD, PREPARATION FOR FREEZ
$0.00
86267
O
FROZEN BLOOD, PREPARATION FOR FREEZ
$0.00
86277
3
GROWTH HORMONE ANTIBODY
$22.52
86280
3
HEMAGGLUTINATION INHIBITION
$11.72
86281
O
HEMOLYSINS, ACID (FOR PAROXYSMAL HE
$0.00
86282
O
HEMOLYSINS AND AGGLUTININS, AUTO, S
$0.00
86283
O
HEMOLYSINS AND AGGLUTININS, AUTO, S
$0.00
86287
O
HEPATITIS B SURFACE ANTIGEN (HBSAG)
$0.00
86288
O
HEPATITIS B CORE ANTIGEN (HBCAG), R
$0.00
86289
O
HEPATITIS B CORE ANTIBODY (HBCAB);
$0.00
86290
O
HEPATITIS B CORE ANTIBODY (HBCAB);
$0.00
86291
O
HEPATITIS B SURFACE ANTIBODY (HBSAB
$0.00
$22.86 $9.13 $11.53
Procedure Code Pricing Action Code Description
Maximum Allowable
86293
O
HEPATITIS BE ANTIGEN (HBEAG)
$0.00
86294
3
IMMUNOASSAY, TUMOR, QUAL
86295
O
HEPATITIS BE ANTIBODY (HBEAB)
$0.00
86296
O
HEPATITIS A ANTIBODY (HAAB); IGG AN
$0.00
86298
O
HEPATITIS A ANTIBODY (HAAB) (EG, RI
$0.00
86299
O
HEPATITIS A ANTIBODY (HAAB); IGM AN
$0.00
86300
3
IMMUNOASSAY, TUMOR, CA 15-3
$29.77
86301
3
IMMUNOASSAY, TUMOR, CA 19-9
$29.77
86302
O
HEPATITIS C ANTIBODY;
$0.00
86303
O
HEPATITIS C ANTIBODY; CONFIRMATORY
$0.00
86304
3
IMMUNOASSAY, TUMOR, CA 125
86305
O
HETEROPHILE ANTIBODIES QUANTITATIVE
$0.00
86306
O
HEPATITIS, DELTA AGENT
$0.00
86308
3
HETEROPHILE ANTIBODIES
$7.41
86309
3
HETEROPHILE ANTIBODIES
$8.79
86310
3
HETEROPHILE ANTIBODIES
$10.55
86311
O
HIV, ANTIGEN
$0.00
86312
O
HIV (HTLV-III) ANTIBODY DETECTION I
$0.00
86313
O
IMMUNOASSAY FOR INFECTIOUS AGENT AN
$0.00
86314
O
HIV (HTLV-III) ANTIBODY DETECTION C
$0.00
86315
O
IMMUNOASSAY FOR INFECTIOUS AGENT AN
$0.00
86316
3
IMMUNOASSAY, TUMOR OTHER
$29.77
86317
3
IMMUNOASSAY,INFECTIOUS AGENT
$21.45
86318
3
IMMUNOASSAY,INFECTIOUS AGENT
$18.53
86319
O
IMMUNOASSAY TECHNIQUE FOR DRUGS
86320
3
SERUM IMMUNOELECTROPHORESIS
$32.07
86325
3
OTHER IMMUNOELECTROPHORESIS
$30.50
86327
3
IMMUNOELECTROPHORESIS ASSAY
$32.47
86329
3
IMMUNODIFFUSION
$20.10
86331
3
IMMUNODIFFUSION OUCHTERLONY
$17.15
86332
3
IMMUNE COMPLEX ASSAY
$34.88
86333
O
IMMUNE COMPLEX ASSAY RAJI CELL
86334
3
IMMUNOFIX E-PHORESIS, SERUM
$31.97
86335
3
IMMUNOFIXATION ELECTROPHORESIS; OT
$41.99
86336
3
INHIBIN A
$22.29
$25.04
$29.77
$0.00
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
86337
3
INSULIN ANTIBODIES
$20.91
86338
O
INSULIN FACTOR ANTIBODIES, RIA
86340
3
INTRINSIC FACTOR ANTIBODY
$21.57
86341
3
ISLET CELL ANTIBODY
$28.31
86342
O
IRRADIATION OF BLOOD PRODUCTS, EACH
86343
3
LEUKOCYTE HISTAMINE RELEASE
$17.84
86344
3
LEUKOCYTE PHAGOCYTOSIS
$11.43
86349
O
LEUKOCYTE TRANSFUSION (LEUKAPHERESI
86353
3
LYMPHOCYTE TRANSFORMATION
$70.15
86355
3
B CELLS, TOTAL COUNT
$53.98
86356
3
MONONUCLEAR CELL ANTIGEN
$38.31
86357
3
NATURAL KILLER (NK) CELLS, TOTAL C
$53.98
86358
O
LYMPHOCYTES B-CELL EVALUATION
86359
3
T CELLS, TOTAL COUNT
$53.98
86360
3
T CELL, ABSOLUTE COUNT/RATIO
$67.23
86361
3
T CELL, ABSOLUTE COUNT
$38.31
86367
3
STEM CELLS, TOTAL COUNT
$53.98
86376
3
MICROSOMAL ANTIBODY
$20.83
86377
O
MICROSOMAL ANTIBODY (THYROID) OTHER
86378
3
MIGRATION INHIBITORY FACTOR
86379
O
NK CELLS, TOTAL COUNT
86382
3
NEUTRALIZATION TEST, VIRAL
$24.20
86384
3
NITROBLUE TETRAZOLIUM DYE
$16.30
86385
O
PATERNITY TESTING, ABO+RH FACTORS+M
$0.00
86386
O
PATERNITY TESTING, ABO+RH FACTORS+M
$0.00
86403
3
PARTICLE AGGLUTINATION TEST
86404
O
POOLING OF PLATELETS OR OTHER BLOOD
$0.00
86405
O
PRECIPITIN TEST FOR BLOOD (SPECIES
$0.00
86406
3
PARTICLE AGGLUTINATION TEST
86410
O
PRETREATMENT OF RBC'S FOR USE IN RB
$0.00
86411
O
PRETREATMENT OF RBC'S FOR USE IN RB
$0.00
86412
O
PRETREATMENT OF RBC'S FOR USE IN RB
$0.00
86417
O
PRETREATMENT OF SERUM FOR USE IN RB
$0.00
86418
O
PRETREATMENT OF SERUM FOR USE IN RB
$0.00
86419
O
PRETREATMENT OF SERUM FOR USE IN RB
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00 $28.18 $0.00
$14.58
$15.22
Procedure Code Pricing Action Code Description
Maximum Allowable
86420
O
PRETREATMENT OF SERUM FOR USE IN RB
$0.00
86421
O
RADIOALLERGOSORBENT TEST, IN VITRO
$0.00
86422
9
RADIOALLERGOSORBENT TEST, IN VITRO
$0.00
86423
O
RADIOIMMUNOSORBENT TEST (RIST) IGE,
$0.00
86430
3
RHEUMATOID FACTOR TEST
$8.12
86431
3
RHEUMATOID FACTOR, QUANT
$8.12
86455
O
SKIN TEST ANERGY TESTING, ONE OR MO
$0.00
86480
3
TB TEST, CELL IMMUN MEASURE
86485
5
SKIN TEST, CANDIDA
$0.00
86486
6
SKIN TEST, NOS ANTIGEN
$0.00
86490
3
COCCIDIOIDOMYCOSIS SKIN TEST
$11.81
86510
3
HISTOPLASMOSIS SKIN TEST
$12.97
86540
O
SKIN TEST MUMPS
$0.00
86580
3
TB INTRADERMAL TEST
$5.00
86585
O
TB TINE TEST
$0.00
86586
O
SKIN TEST, UNLISTED
$0.00
86587
O
STEM CELLS (IE, CD34), TOTAL COUNT
$0.00
86588
O
STREPTOCOLLUS, DIRECT SCREEN
$0.00
86590
3
STREPTOKINASE, ANTIBODY
86592
3
BLOOD SEROLOGY, QUALITATIVE
$5.87
86593
3
BLOOD SEROLOGY, QUANTITATIVE
$6.25
86594
O
THYROID AUTOANTIBODIES
$0.00
86595
O
TISSUE CULTURE
$0.00
86600
O
TOXOPLASMOSIS, DYE TEST
$0.00
86602
3
ANTINOMYCES ANTIBODY
$14.55
86603
3
ADENOVIRUS ANTIBODY
$18.41
86606
3
ASPERGILLUS ANTIBODY
$21.54
86609
3
BACTERIUM ANTIBODY
$18.43
86611
3
BARTONELLA ANTIBODY
$14.55
86612
3
BLASTOMYCES ANTIBODY
$18.46
86615
3
BORDETELLA ANTIBODY
$18.87
86617
3
LYME DISEASE ANTIBODY
$22.16
86618
3
LYME DISEASE ANTIBODY
$24.37
86619
3
BORRELIA ANTIBODY
$19.15
86622
3
BRUCELLA ANTIBODY
$11.70
$88.68
$15.79
Procedure Code Pricing Action Code Description
Maximum Allowable
86625
3
CAMPYLOBACTER ANTIBODY
$18.78
86628
3
CANDIDA ANTIBODY
$17.18
86630
O
TRANSFER FACTOR TEST (TFT)
86631
3
CHLAMYDIA ANTIBODY
$10.11
86632
3
CHLAMYDIA IGM ANTIBODY
$18.16
86635
3
COCCIDIOIDES ANTIBODY
$16.42
86638
3
Q FEVER ANTIBODY
$17.35
86641
3
CRYPTOCOCCUS ANTIBODY
$20.63
86644
3
CMV ANTIBODY
$20.60
86645
3
CMV ANTIBODY, IGM
$24.11
86648
3
DIPHTHERIA ANTIBODY
$21.77
86650
O
TREPONEMA ANTIBODIES, FLUORESCENT,
86651
3
ENCEPHALITIS ANTIBODY
$18.87
86652
3
ENCEPHALITIS ANTIBODY
$18.87
86653
3
ENCEPHALITIS ANTIBODY
$18.87
86654
3
ENCEPHALITIS ANTIBODY
$18.87
86658
3
ENTEROVIRUS ANTIBODY
$18.65
86662
O
TREPONEMA PALLIDUM TEST, OTHER, SPE
86663
3
EPSTEIN-BARR ANTIBODY
$18.78
86664
3
EPSTEIN-BARR ANTIBODY
$21.89
86665
3
EPSTEIN-BARR ANTIBODY
$25.95
86666
3
EHRLICHIA ANTIBODY
$14.55
86668
3
FRANCISELLA TULARENSIS
$14.88
86671
3
FUNGUS ANTIBODY
$17.54
86674
3
GIARDIA LAMBLIA ANTIBODY
$21.07
86677
3
HELICOBACTER PYLORI
$20.77
86681
O
ADRENAL CORTEX ANTIBODIES, RIA
86682
3
HELMINTH ANTIBODY
86683
O
HEMOGLOBIN, FECAL ANTIBODY
86684
3
HEMOPHILUS INFLUENZA
86685
O
ANTI-ACHR (ACETYLCHOLINE RECEPTOR)
86687
3
HTLV-I ANTIBODY
$12.00
86688
3
HTLV-II ANTIBODY
$15.11
86689
3
HTLV/HIV CONFIRMATORY TEST
$27.69
86692
3
HEPATITIS, DELTA AGENT
$24.56
$0.00
$0.00
$0.00
$0.00 $18.61 $0.00 $22.67 $0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
86694
3
HERPES SIMPLEX TEST
$20.60
86695
3
HERPES SIMPLEX TEST
$18.87
86696
3
HERPES SIMPLEX TYPE 2
$27.69
86698
3
HISTOPLASMA
$17.88
86701
3
HIV-1
$12.70
86702
3
HIV-2
$15.11
86703
3
HIV-1/HIV-2, SINGLE ASSAY
$19.62
86704
3
HEP B CORE ANTIBODY, TOTAL
$17.25
86705
3
HEP B CORE ANTIBODY, IGM
$16.84
86706
3
HEP B SURFACE ANTIBODY
$15.37
86707
3
HEP BE ANTIBODY
$16.55
86708
3
HEP A ANTIBODY, TOTAL
$17.73
86709
3
HEP A ANTIBODY, IGM
$16.11
86710
3
INFLUENZA VIRUS ANTIBODY
$19.40
86713
3
LEGIONELLA ANTIBODY
$21.90
86717
3
LEISHMANIA ANTIBODY
$17.53
86720
3
LEPTOSPIRA ANTIBODY
$18.87
86723
3
LISTERIA MONOCYTOGENES AB
$18.87
86727
3
LYMPH CHORIOMENINGITIS AB
$18.41
86729
3
LYMPHO VENEREUM ANTIBODY
$10.11
86732
3
MUCORMYCOSIS ANTIBODY
$18.87
86735
3
MUMPS ANTIBODY
$18.68
86738
3
MYCOPLASMA ANTIBODY
$18.95
86741
3
NEISSERIA MENINGITIDIS
$18.87
86744
3
NOCARDIA ANTIBODY
$18.87
86747
3
PARVOVIRUS ANTIBODY
$21.51
86750
3
MALARIA ANTIBODY
$18.87
86753
3
PROTOZOA ANTIBODY NOS
$17.73
86756
3
RESPIRATORY VIRUS ANTIBODY
$18.44
86757
3
RICKETTSIA ANTIBODY
$27.69
86759
3
ROTAVIRUS ANTIBODY
$18.87
86762
3
RUBELLA ANTIBODY
$20.60
86765
3
RUBEOLA ANTIBODY
$14.01
86768
3
SALMONELLA ANTIBODY
$18.87
86771
3
SHIGELLA ANTIBODY
$18.87
Procedure Code Pricing Action Code Description
Maximum Allowable
86774
3
TETANUS ANTIBODY
$21.18
86777
3
TOXOPLASMA ANTIBODY
$20.60
86778
3
TOXOPLASMA ANTIBODY, IGM
$20.61
86781
3
TREPONEMA PALLIDUM, CONFIRM
$18.95
86784
3
TRICHINELLA ANTIBODY
$17.97
86787
3
VARICELLA-ZOSTER ANTIBODY
$18.43
86788
3
WEST NILE VIRUS AB, IGM
$24.11
86789
3
WEST NILE VIRUS ANTIBODY
$20.60
86790
3
VIRUS ANTIBODY NOS
$18.43
86793
3
YERSINIA ANTIBODY
$12.42
86800
3
THYROGLOBULIN ANTIBODY
$22.76
86803
3
HEPATITIS C AB TEST
$20.42
86804
3
HEP C AB TEST, CONFIRM
$22.16
86805
3
LYMPHOCYTOTOXICITY ASSAY
$48.17
86806
3
LYMPHOCYTOTOXICITY ASSAY
$48.17
86807
3
CYTOTOXIC ANTIBODY SCREENING
$56.61
86808
3
CYTOTOXIC ANTIBODY SCREENING
$42.46
86812
3
HLA TYPING, A, B, OR C
$36.93
86813
3
HLA TYPING, A, B, OR C
$82.97
86816
3
HLA TYPING, DR/DQ
$39.86
86817
3
HLA TYPING, DR/DQ
$92.12
86821
3
LYMPHOCYTE CULTURE, MIXED
$80.79
86822
3
LYMPHOCYTE CULTURE, PRIMED
$52.31
86849
5
IMMUNOLOGY PROCEDURE
86850
3
RBC ANTIBODY SCREEN
$15.00
86860
5
RBC ANTIBODY ELUTION
$0.00
86870
3
RBC ANTIBODY IDENTIFICATION
86880
3
COOMBS TEST, DIRECT
$7.68
86885
3
COOMBS TEST, INDIRECT, QUAL
$8.18
86886
3
COOMBS TEST, INDIRECT, TITER
$7.41
86890
5
AUTOLOGOUS BLOOD PROCESS
$0.00
86891
5
AUTOLOGOUS BLOOD, OP SALVAGE
$0.00
86900
3
BLOOD TYPING, ABO
$4.26
86901
3
BLOOD TYPING, RH (D)
$4.26
86903
3
BLOOD TYPING, ANTIGEN SCREEN
$0.00
$15.00
$13.50
Procedure Code Pricing Action Code Description
Maximum Allowable
86904
3
BLOOD TYPING, PATIENT SERUM
$13.60
86905
3
BLOOD TYPING, RBC ANTIGENS
$5.47
86906
3
BLOOD TYPING, RH PHENOTYPE
$11.08
86910
9
BLOOD TYPING, PATERNITY TEST
$0.00
86911
9
BLOOD TYPING, ANTIGEN SYSTEM
$0.00
86915
O
BONE MARROW/STEM CELL PREP
$0.00
86920
3
COMPATIBILITY TEST, SPIN
$36.00
86921
3
COMPATIBILITY TEST, INCUBATE
$36.00
86922
3
COMPATIBILITY TEST, ANTIGLOB
$36.00
86923
6
COMPATIBILITY TEST, ELECTRIC
$0.00
86927
5
PLASMA, FRESH FROZEN
$0.00
86930
5
FROZEN BLOOD PREP
$0.00
86931
5
FROZEN BLOOD THAW
$0.00
86932
5
FROZEN BLOOD FREEZE/THAW
$0.00
86940
3
HEMOLYSINS/AGGLUTININS, AUTO
$8.73
86941
3
HEMOLYSINS/AGGLUTININS
$17.02
86945
3
BLOOD PRODUCT/IRRADIATION
$42.00
86950
5
LEUKACYTE TRANSFUSION
$0.00
86960
6
VOL REDUCTION OF BLOOD/PROD
$0.00
86965
5
POOLING BLOOD PLATELETS
$0.00
86970
5
RBC PRETREATMENT
$0.00
86971
5
RBC PRETREATMENT
$0.00
86972
5
RBC PRETREATMENT
$0.00
86975
5
RBC PRETREATMENT, SERUM
$0.00
86976
5
RBC PRETREATMENT, SERUM
$0.00
86977
5
RBC PRETREATMENT, SERUM
$0.00
86978
5
RBC PRETREATMENT, SERUM
$0.00
86985
5
SPLIT BLOOD OR PRODUCTS
$0.00
86999
5
TRANSFUSION PROCEDURE
$0.00
87001
3
SMALL ANIMAL INOCULATION
$18.91
87003
3
SMALL ANIMAL INOCULATION
$24.09
87015
3
SPECIMEN CONCENTRATION
$9.56
87040
3
BLOOD CULTURE FOR BACTERIA
$14.77
87045
3
FECES CULTURE, BACTERIA
$13.49
87046
3
STOOL CULTR, BACTERIA, EACH
$13.49
Procedure Code Pricing Action Code Description
Maximum Allowable
87060
O
NOSE/THROAT CULTURE, BACT
$0.00
87070
3
CULTURE, BACTERIA, OTHER
$12.32
87071
3
CULTURE BACTERI AEROBIC OTHR
$13.49
87072
O
CULTURE OF SPECIMEN BY KIT
87073
3
CULTURE BACTERIA ANAEROBIC
$13.49
87075
3
CULTR BACTERIA, EXCEPT BLOOD
$13.53
87076
3
CULTURE ANAEROBE IDENT, EACH
$11.56
87077
3
CULTURE AEROBIC IDENTIFY
$11.56
87081
3
CULTURE SCREEN ONLY
$9.50
87082
O
CULTURE OF SPECIMEN BY KIT
$0.00
87083
O
CULTURE OF SPECIMEN BY KIT
$0.00
87084
3
CULTURE OF SPECIMEN BY KIT
$12.32
87085
O
CULTURE OF SPECIMEN BY KIT
$0.00
87086
3
URINE CULTURE/COLONY COUNT
87087
O
URINE BACTERIA CULTURE
$0.00
87088
3
URINE BACTERIA CULTURE
$11.58
87101
3
SKIN FUNGI CULTURE
$11.03
87102
3
FUNGUS ISOLATION CULTURE
$12.01
87103
3
BLOOD FUNGUS CULTURE
$12.91
87106
3
FUNGI IDENTIFICATION, YEAST
$14.77
87107
3
FUNGI IDENTIFICATION, MOLD
$14.77
87109
3
MYCOPLASMA
$22.02
87110
3
CHLAMYDIA CULTURE
$28.03
87116
3
MYCOBACTERIA CULTURE
$15.46
87117
O
MYCOBACTERIA CULTURE
$0.00
87118
3
MYCOBACTERIC IDENTIFICATION
87140
3
CULTURE TYPE IMMUNOFLUORESC
87143
3
CULTURE TYPING, GLC/HPLC
87145
O
CULTURE TYPING, PHAGE METHOD
$0.00
87147
3
CULTURE TYPE, IMMUNOLOGIC
$7.41
87149
3
CULTURE TYPE, NUCLEIC ACID
$28.68
87151
O
CULTURE TYPING, SEROLOGIC
$0.00
87152
3
CULTURE TYPE PULSE FIELD GEL
$7.49
87155
O
CULTURE TYPING, PRECIPITIN
$0.00
87158
3
CULTURE TYPING, ADDED METHOD
$7.49
$0.00
$11.55
$15.66 $6.92 $17.92
Procedure Code Pricing Action Code Description
Maximum Allowable
87163
O
SPECIAL MICROBIOLOGY CULTURE
$0.00
87164
3
DARK FIELD EXAMINATION
$15.37
87166
3
DARK FIELD EXAMINATION
$16.16
87168
3
MACROSCOPIC EXAM ARTHROPOD
$6.11
87169
3
MACROSCOPIC EXAM PARASITE
$6.11
87172
3
PINWORM EXAM
$6.11
87174
O
ENDOTOXIN, BACTERIAL
$0.00
87175
O
ASSAY, ENDOTOXIN, BACTERIAL
$0.00
87176
3
TISSUE HOMOGENIZATION, CULTR
$8.42
87177
3
OVA AND PARASITES SMEARS
87178
O
MICROBIAL IDENTIFICATION, NUCLEIC A
$0.00
87179
O
MICROBIAL IDENTIFICATION, NUCLEIC A
$0.00
87181
3
MICROBE SUSCEPTIBLE, DIFFUSE
$6.79
87184
3
MICROBE SUSCEPTIBLE, DISK
$9.87
87185
3
MICROBE SUSCEPTIBLE, ENZYME
$6.79
87186
3
MICROBE SUSCEPTIBLE, MIC
$12.37
87187
3
MICROBE SUSCEPTIBLE, MLC
$14.83
87188
3
MICROBE SUSCEPT, MACROBROTH
$9.18
87190
3
MICROBE SUSCEPT, MYCOBACTERI
$8.08
87192
O
ANTIBIOTIC SENSITIVITY, EACH
$0.00
87197
3
BACTERICIDAL LEVEL, SERUM
$16.63
87198
O
CYTOMEGALOVIRUS ANTIBODY DFA
$0.00
87199
O
ENTEROVIRUS ANTIBODY, DFA
$0.00
87205
3
SMEAR, GRAM STAIN
$6.11
87206
3
SMEAR, FLUORESCENT/ACID STAI
$6.92
87207
3
SMEAR, SPECIAL STAIN
$8.25
87208
O
SMEAR, STAIN & INTERPRET
$0.00
87209
3
SMEAR, COMPLEX STAIN
87210
3
SMEAR, WET MOUNT, SALINE/INK
$6.11
87211
O
SMEAR, STAIN & INTERPRET
$0.00
87220
3
TISSUE EXAM FOR FUNGI
$4.95
87230
3
ASSAY, TOXIN OR ANTITOXIN
$24.96
87250
3
VIRUS INOCULATE, EGGS/ANIMAL
$27.98
87252
3
VIRUS INOCULATION, TISSUE
$37.30
87253
3
VIRUS INOCULATE TISSUE, ADDL
$28.90
$12.73
$24.76
Procedure Code Pricing Action Code Description
Maximum Allowable
87254
3
VIRUS INOCULATION, SHELL VIA
$27.98
87255
3
GENET VIRUS ISOLATE, HSV
$48.45
87260
3
ADENOVIRUS AG, IF
$15.76
87265
3
PERTUSSIS AG, IF
$15.76
87267
3
ENTEROVIRUS ANTIBODY, DFA
$15.76
87269
3
GIARDIA AG, IF
$15.76
87270
3
CHLAMYDIA TRACHOMATIS AG, IF
$15.76
87271
3
CYTOMEGALOVIRUS DFA
$15.76
87272
3
CRYPTOSPORIDIUM AG, IF
$15.76
87273
3
HERPES SIMPLEX 2, AG, IF
$15.76
87274
3
HERPES SIMPLEX 1, AG, IF
$15.76
87275
3
INFLUENZA B, AG, IF
$15.76
87276
3
INFLUENZA A, AG, IF
$15.76
87277
3
LEGIONELLA MICDADEI, AG, IF
$15.76
87278
3
LEGION PNEUMOPHILIA AG, IF
$15.76
87279
3
PARAINFLUENZA, AG, IF
$15.76
87280
3
RESPIRATORY SYNCYTIAL AG, IF
$15.76
87281
3
PNEUMOCYSTIS CARINII, AG, IF
$15.76
87283
3
RUBEOLA, AG, IF
$15.76
87285
3
TREPONEMA PALLIDUM, AG, IF
$15.76
87290
3
VARICELLA ZOSTER, AG, IF
$15.76
87299
3
ANTIBODY DETECTION, NOS, IF
$15.76
87300
3
AG DETECTION, POLYVAL, IF
$15.76
87301
3
ADENOVIRUS AG, EIA
$15.76
87305
3
ASPERGILLUS AG, EIA
$15.76
87320
3
CHYLMD TRACH AG, EIA
$15.76
87324
3
CLOSTRIDIUM AG, EIA
$15.76
87327
3
CRYPTOCOCCUS NEOFORM AG, EIA
$15.76
87328
3
CRYPTOSPORIDIUM AG, EIA
$15.76
87329
3
GIARDIA AG, EIA
$15.76
87332
3
CYTOMEGALOVIRUS AG, EIA
$15.76
87335
3
E COLI 0157 AG, EIA
$15.76
87336
3
ENTAMOEB HIST DISPR, AG, EIA
$15.76
87337
3
ENTAMOEB HIST GROUP, AG, EIA
$15.76
87338
3
HPYLORI, STOOL, EIA
$15.76
Procedure Code Pricing Action Code Description
Maximum Allowable
87339
3
H PYLORI AG, EIA
$15.76
87340
3
HEPATITIS B SURFACE AG, EIA
$14.51
87341
3
HEPATITIS B SURFACE, AG, EIA
$14.51
87350
3
HEPATITIS BE AG, EIA
$16.49
87380
3
HEPATITIS DELTA AG, EIA
$23.50
87385
3
HISTOPLASMA CAPSUL AG, EIA
$15.76
87390
3
HIV-1 AG, EIA
$25.24
87391
3
HIV-2 AG, EIA
$25.24
87400
3
INFLUENZA A/B, AG, EIA
$15.76
87420
3
RESP SYNCYTIAL AG, EIA
$15.76
87425
3
ROTAVIRUS AG, EIA
$15.76
87427
3
SHIGA-LIKE TOXIN AG, EIA
$15.76
87430
3
STREP A AG, EIA
$15.76
87449
3
AG DETECT NOS, EIA, MULT
$15.76
87450
3
AG DETECT NOS, EIA, SINGLE
$13.71
87451
3
AG DETECT POLYVAL, EIA, MULT
$13.71
87470
3
BARTONELLA, DNA, DIR PROBE
$28.68
87471
3
BARTONELLA, DNA, AMP PROBE
$50.23
87472
3
BARTONELLA, DNA, QUANT
$40.60
87475
3
LYME DIS, DNA, DIR PROBE
$28.68
87476
3
LYME DIS, DNA, AMP PROBE
$50.23
87477
3
LYME DIS, DNA, QUANT
$40.60
87480
3
CANDIDA, DNA, DIR PROBE
$28.68
87481
3
CANDIDA, DNA, AMP PROBE
$50.23
87482
3
CANDIDA, DNA, QUANT
$40.60
87485
3
CHYLMD PNEUM, DNA, DIR PROBE
$28.68
87486
3
CHYLMD PNEUM, DNA, AMP PROBE
$50.23
87487
3
CHYLMD PNEUM, DNA, QUANT
$40.60
87490
3
CHYLMD TRACH, DNA, DIR PROBE
$28.68
87491
3
CHYLMD TRACH, DNA, AMP PROBE
$50.23
87492
3
CHYLMD TRACH, DNA, QUANT
$40.60
87495
3
CYTOMEG, DNA, DIR PROBE
$28.68
87496
3
CYTOMEG, DNA, AMP PROBE
$50.23
87497
3
CYTOMEG, DNA, QUANT
$40.60
87498
3
ENTEROVIRUS, DNA, AMP PROBE
$50.23
Procedure Code Pricing Action Code Description
Maximum Allowable
87500
3
VANOMYCIN, DNA, AMP PROBE
$50.23
87510
3
GARDNER VAG, DNA, DIR PROBE
$28.68
87511
3
GARDNER VAG, DNA, AMP PROBE
$50.23
87512
3
GARDNER VAG, DNA, QUANT
$40.60
87515
3
HEPATITIS B, DNA, DIR PROBE
$28.68
87516
3
HEPATITIS B, DNA, AMP PROBE
$50.23
87517
3
HEPATITIS B, DNA, QUANT
$40.60
87520
3
HEPATITIS C, RNA, DIR PROBE
$28.68
87521
3
HEPATITIS C, RNA, AMP PROBE
$50.23
87522
3
HEPATITIS C, RNA, QUANT
$40.60
87525
3
HEPATITIS G, DNA, DIR PROBE
$28.68
87526
3
HEPATITIS G, DNA, AMP PROBE
$50.23
87527
3
HEPATITIS G, DNA, QUANT
$40.60
87528
3
HSV, DNA, DIR PROBE
$28.68
87529
3
HSV, DNA, AMP PROBE
$50.23
87530
3
HSV, DNA, QUANT
$40.60
87531
3
HHV-6, DNA, DIR PROBE
$28.68
87532
3
HHV-6, DNA, AMP PROBE
$50.23
87533
3
HHV-6, DNA, QUANT
$40.60
87534
3
HIV-1, DNA, DIR PROBE
$28.68
87535
3
HIV-1, DNA, AMP PROBE
$50.23
87536
3
HIV-1, DNA, QUANT
87537
3
HIV-2, DNA, DIR PROBE
$28.68
87538
3
HIV-2, DNA, AMP PROBE
$50.23
87539
3
HIV-2, DNA, QUANT
$40.60
87540
3
LEGION PNEUMO, DNA, DIR PROB
$28.68
87541
3
LEGION PNEUMO, DNA, AMP PROB
$50.23
87542
3
LEGION PNEUMO, DNA, QUANT
$40.60
87550
3
MYCOBACTERIA, DNA, DIR PROBE
$28.68
87551
3
MYCOBACTERIA, DNA, AMP PROBE
$50.23
87552
3
MYCOBACTERIA, DNA, QUANT
$40.60
87555
3
M.TUBERCULO, DNA, DIR PROBE
$28.68
87556
3
M.TUBERCULO, DNA, AMP PROBE
$50.23
87557
3
M.TUBERCULO, DNA, QUANT
$40.60
87560
3
M.AVIUM-INTRA, DNA, DIR PROB
$28.68
$121.76
Procedure Code Pricing Action Code Description
Maximum Allowable
87561
3
M.AVIUM-INTRA, DNA, AMP PROB
$50.23
87562
3
M.AVIUM-INTRA, DNA, QUANT
$40.60
87580
3
M.PNEUMON, DNA, DIR PROBE
$28.68
87581
3
M.PNEUMON, DNA, AMP PROBE
$50.23
87582
3
M.PNEUMON, DNA, QUANT
$40.60
87590
3
N.GONORRHOEAE, DNA, DIR PROB
$28.68
87591
3
N.GONORRHOEAE, DNA, AMP PROB
$50.23
87592
3
N.GONORRHOEAE, DNA, QUANT
$40.60
87620
3
HPV, DNA, DIR PROBE
$28.68
87621
3
HPV, DNA, AMP PROBE
$50.23
87622
3
HPV, DNA, QUANT
$40.60
87640
3
STAPH A, DNA, AMP PROBE
$50.23
87641
3
MR-STAPH, DNA, AMP PROBE
$50.23
87650
3
STREP A, DNA, DIR PROBE
$28.68
87651
3
STREP A, DNA, AMP PROBE
$50.23
87652
3
STREP A, DNA, QUANT
$40.60
87653
3
STREP B, DNA, AMP PROBE
$50.23
87660
3
TRICHOMONAS VAGIN, DIR PROBE
$28.68
87797
3
DETECT AGENT NOS, DNA, DIR
$28.68
87798
3
DETECT AGENT NOS, DNA, AMP
$50.23
87799
3
DETECT AGENT NOS, DNA, QUANT
$61.29
87800
3
DETECT AGNT MULT, DNA, DIREC
$57.39
87801
3
DETECT AGNT MULT, DNA, AMPLI
$100.44
87802
3
STREP B ASSAY W/OPTIC
$15.76
87803
3
CLOSTRIDIUM TOXIN A W/OPTIC
$15.76
87804
3
INFLUENZA ASSAY W/OPTIC
$15.76
87807
3
INFECTIOUS AGENT ANTIGEN DETECTION
$15.76
87808
3
TRICHOMONAS ASSAY W/OPTIC
$15.76
87809
3
ADENOVIRUS ASSAY W/OPTIC
$15.76
87810
3
CHYLMD TRACH ASSAY W/OPTIC
$15.76
87850
3
N. GONORRHOEAE ASSAY W/OPTIC
$15.76
87880
3
STREP A ASSAY W/OPTIC
$15.76
87899
3
AGENT NOS ASSAY W/OPTIC
$15.76
87900
3
PHENOTYPE, INFECT AGENT DRUG
$186.50
87901
3
GENOTYPE, DNA, HIV REVERSE T
$368.36
Procedure Code Pricing Action Code Description
Maximum Allowable
87902
3
GENOTYPE, DNA, HEPATITIS C
$368.36
87903
3
PHENOTYPE, DNA HIV W/CULTURE
$699.16
87904
3
PHENOTYPE, DNA HIV W/CLT ADD
$37.30
87905
3
SIALIDASE ENZYME ASSAY
$8.99
87999
5
MICROBIOLOGY PROCEDURE
$0.00
88000
9
AUTOPSY (NECROPSY), GROSS
$0.00
88005
9
AUTOPSY (NECROPSY), GROSS
$0.00
88007
9
AUTOPSY (NECROPSY), GROSS
$0.00
88012
9
AUTOPSY (NECROPSY), GROSS
$0.00
88014
9
AUTOPSY (NECROPSY), GROSS
$0.00
88016
9
AUTOPSY (NECROPSY), GROSS
$0.00
88020
9
AUTOPSY (NECROPSY), COMPLETE
$0.00
88025
9
AUTOPSY (NECROPSY), COMPLETE
$0.00
88027
9
AUTOPSY (NECROPSY), COMPLETE
$0.00
88028
9
AUTOPSY (NECROPSY), COMPLETE
$0.00
88029
9
AUTOPSY (NECROPSY), COMPLETE
$0.00
88036
9
LIMITED AUTOPSY
$0.00
88037
9
LIMITED AUTOPSY
$0.00
88040
9
FORENSIC AUTOPSY (NECROPSY)
$0.00
88045
9
CORONERÏS AUTOPSY (NECROPSY)
$0.00
88099
9
NECROPSY (AUTOPSY) PROCEDURE
$0.00
88104
3
CYTOPATH FL NONGYN, SMEARS
$51.49
88106
3
CYTOPATH FL NONGYN, FILTER
$46.46
88107
3
CYTOPATH FL NONGYN, SM/FLTR
$68.58
88108
3
CYTOPATH, CONCENTRATE TECH
$53.81
88112
3
CYTOPATH, CELL ENHANCE TECH
$123.81
88125
3
FORENSIC CYTOPATHOLOGY
$20.54
88130
3
SEX CHROMATIN IDENTIFICATION
$21.53
88140
3
SEX CHROMATIN IDENTIFICATION
$11.44
88141
3
CYTOPATH, C/V, INTERPRET
$23.24
88142
3
CYTOPATH, C/V, THIN LAYER
$28.99
88143
3
CYTOPATH C/V THIN LAYER REDO
$28.99
88144
O
CYTOPATH, C/V, THIN LYR REDO
$0.00
88145
O
CYTOPATH, C/V, THIN LYR SEL
$0.00
88147
3
CYTOPATH, C/V, AUTOMATED
$16.29
Procedure Code Pricing Action Code Description
Maximum Allowable
88148
3
CYTOPATH, C/V, AUTO RESCREEN
$21.75
88150
3
CYTOPATH, C/V, MANUAL
$15.11
88151
O
CYTOPATHOLOGY, SMEARS, CERVICAL OR
88152
3
CYTOPATH, C/V, AUTO REDO
$15.11
88153
3
CYTOPATH, C/V, REDO
$15.11
88154
3
CYTOPATH, C/V, SELECT
$15.11
88155
3
CYTOPATH, C/V, INDEX ADD-ON
$8.58
88156
O
CYTOPATH CERV/VAG TBS
$0.00
88157
O
CYTOPATHOLOGY, SMEARS, CERVICAL OR
$0.00
88158
O
CYTOPATH CERV/VAG TBS AUTO
$0.00
88160
3
CYTOPATH SMEAR, OTHER SOURCE
$55.77
88161
3
CYTOPATH SMEAR, OTHER SOURCE
$54.23
88162
3
CYTOPATH SMEAR, OTHER SOURCE
$56.99
88164
3
CYTOPATH TBS, C/V, MANUAL
$15.11
88165
3
CYTOPATH TBS, C/V, REDO
$15.11
88166
3
CYTOPATH TBS, C/V, AUTO REDO
$15.11
88167
3
CYTOPATH TBS, C/V, SELECT
$15.11
88170
O
FINE NEEDLE ASPIRATION
$0.00
88171
O
FINE NEEDLE ASPIRATION
$0.00
88172
3
CYTOPATHOLOGY EVAL OF FNA
$49.53
88173
3
CYTOPATH EVAL, FNA, REPORT
$122.91
88174
3
CYTOPATH, C/V AUTO, IN FLUID
$30.57
88175
3
CYTOPATH C/V AUTO FLUID REDO
$37.91
88180
O
CELL MARKER STUDY
$0.00
88182
3
CELL MARKER STUDY
$93.14
88184
3
FLOWCYTOMETRY/ TC, 1 MARKER
$49.26
88185
3
FLOWCYTOMETRY/TC, ADD-ON
$24.22
88187
3
FLOWCYTOMETRY/READ, 2-8
$63.03
88188
3
FLOWCYTOMETRY/READ, 9-15
$83.19
88189
3
FLOWCYTOMETRY/READ, 16 & >
$109.59
88199
5
CYTOPATHOLOGY PROCEDURE
$0.00
88230
3
TISSUE CULTURE, LYMPHOCYTE
$166.70
88233
3
TISSUE CULTURE, SKIN/BIOPSY
$201.37
88235
3
TISSUE CULTURE, PLACENTA
$210.70
88237
3
TISSUE CULTURE, BONE MARROW
$180.72
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
88239
3
TISSUE CULTURE, TUMOR
$211.08
88240
3
CELL CRYOPRESERVE/STORAGE
$14.46
88241
3
FROZEN CELL PREPARATION
$14.46
88245
3
CHROMOSOME ANALYSIS, 20-25
$213.00
88248
3
CHROMOSOME ANALYSIS, 50-100
$247.78
88249
3
CHROMOSOME ANALYSIS, 100
$247.78
88250
O
CHROMOSOME ANALYSIS
$0.00
88260
O
CHROMOSOME ANALYSIS: 5 CELLS
$0.00
88261
3
CHROMOSOME ANALYSIS, 5
$252.89
88262
3
CHROMOSOME ANALYSIS, 15-20
$178.34
88263
3
CHROMOSOME ANALYSIS, 45
$215.03
88264
3
CHROMOSOME ANALYSIS, 20-25
$178.34
88267
3
CHROMOSOME ANALYS, PLACENTA
$257.22
88269
3
CHROMOSOME ANALYS, AMNIOTIC
$237.98
88271
3
CYTOGENETICS, DNA PROBE
$30.64
88272
3
CYTOGENETICS, 3-5
$38.31
88273
3
CYTOGENETICS, 10-30
$45.97
88274
3
CYTOGENETICS, 25-99
$49.80
88275
3
CYTOGENETICS, 100-300
$57.47
88280
3
CHROMOSOME KARYOTYPE STUDY
$35.91
88283
3
CHROMOSOME BANDING STUDY
$98.15
88285
3
CHROMOSOME COUNT, ADDITIONAL
$27.19
88289
3
CHROMOSOME STUDY, ADDITIONAL
$49.27
88291
3
CYTO/MOLECULAR REPORT
$31.20
88299
5
CYTOGENETIC STUDY
88300
3
SURGICAL PATH, GROSS
$14.46
88302
3
TISSUE EXAM BY PATHOLOGIST
$32.51
88304
3
TISSUE EXAM BY PATHOLOGIST
$42.89
88305
3
TISSUE EXAM BY PATHOLOGIST
$97.57
88307
3
TISSUE EXAM BY PATHOLOGIST
$166.79
88309
3
TISSUE EXAM BY PATHOLOGIST
$217.13
88311
3
DECALCIFY TISSUE
$17.46
88312
3
SPECIAL STAINS
$73.61
88313
3
SPECIAL STAINS
$51.85
88314
3
HISTOCHEMICAL STAIN
$52.71
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
88317
O
INTERPRETATION AND REPORT BY TREATI
$0.00
88318
3
CHEMICAL HISTOCHEMISTRY
$47.79
88319
3
ENZYME HISTOCHEMISTRY
$94.40
88321
3
MICROSLIDE CONSULTATION
$82.65
88323
9
MICROSLIDE CONSULTATION
$0.00
88325
3
COMPREHENSIVE REVIEW OF DATA
88329
3
PATH CONSULT INTROP
$50.44
88331
3
PATH CONSULT INTRAOP, 1 BLOC
$85.84
88332
3
PATH CONSULT INTRAOP, ADDÏL
$42.97
88333
3
INTRAOP CYTO PATH CONSULT, 1
$90.40
88334
3
INTRAOP CYTO PATH CONSULT, 2
$52.97
88342
3
IMMUNOHISTOCHEMISTRY
$86.31
88346
3
IMMUNOFLUORESCENT STUDY
$90.16
88347
3
IMMUNOFLUORESCENT STUDY
$102.53
88348
3
ELECTRON MICROSCOPY
$388.66
88349
3
SCANNING ELECTRON MICROSCOPY
$417.97
88355
3
ANALYSIS, SKELETAL MUSCLE
$175.05
88356
3
ANALYSIS, NERVE
$231.50
88358
3
ANALYSIS, TUMOR
$63.47
88360
3
TUMOR IMMUNOHISTOCHEM/MANUAL
$106.57
88361
3
TUMOR IMMUNOHISTOCHEM/COMPUT
$141.54
88362
3
NERVE TEASING PREPARATIONS
$256.79
88365
3
INSITU HYBRIDIZATION (FISH)
$122.58
88367
3
INSITU HYBRIDIZATION, AUTO
$200.25
88368
3
INSITU HYBRIDIZATION, MANUAL
$143.52
88371
3
PROTEIN, WESTERN BLOT TISSUE
$31.79
88372
3
PROTEIN ANALYSIS W/PROBE
$32.56
88380
5
MICRODISSECTION, LASER
$0.00
88381
6
MICRODISSECTION, MANUAL
$0.00
88384
3
EVAL MOLECULAR PROBES, 11-50
$326.65
88385
3
EVAL MOLECUL PROBES, 51-250
$335.50
88386
3
EVAL MOLECUL PROBES, 251-500
$349.50
88399
5
SURGICAL PATHOLOGY PROCEDURE
$0.00
88400
O
BILIRUBIN TOTAL TRANSCUT
$0.00
88720
3
BILIRUBIN TOTAL TRANSCUT
$7.18
$199.53
Procedure Code Pricing Action Code Description
Maximum Allowable
88740
3
TRANSCUTANEOUS CARBOXYHB
$7.18
88741
3
TRANSCUTANEOUS METHB
$7.18
89049
6
CHCT FOR MAL HYPERTHERMIA
$0.00
89050
3
BODY FLUID CELL COUNT
$6.76
89051
3
BODY FLUID CELL COUNT
$7.88
89055
3
LEUKOCYTE ASSESSMENT, FECAL
$6.11
89060
3
EXAM,SYNOVIAL FLUID CRYSTALS
$10.23
89100
3
SAMPLE INTESTINAL CONTENTS
$85.26
89105
3
SAMPLE INTESTINAL CONTENTS
$106.19
89125
3
SPECIMEN FAT STAIN
89130
3
SAMPLE STOMACH CONTENTS
$84.96
89132
3
SAMPLE STOMACH CONTENTS
$64.72
89135
3
SAMPLE STOMACH CONTENTS
$92.70
89136
3
SAMPLE STOMACH CONTENTS
$70.12
89140
3
SAMPLE STOMACH CONTENTS
$116.57
89141
3
SAMPLE STOMACH CONTENTS
$138.65
89160
3
EXAM FECES FOR MEAT FIBERS
$5.27
89190
3
NASAL SMEAR FOR EOSINOPHILS
$6.79
89205
O
OCCULT BLOOD, ANY SOURCE EXCEPT FEC
$0.00
89220
3
SPUTUM SPECIMEN COLLECTION
89225
3
STARCH GRANULES, FECES
$4.78
89230
3
COLLECT SWEAT FOR TEST
$17.60
89235
3
WATER LOAD TEST
$7.88
89240
6
PATHOLOGY LAB PROCEDURE
$0.00
89250
9
CULTR OOCYTE/EMBRYO <4 DAYS
$0.00
89251
9
CULTR OOCYTE/EMBRYO <4 DAYS
$0.00
89252
O
ASSIST OOCYTE FERTILIZATION
$0.00
89253
9
EMBRYO HATCHING
$0.00
89254
9
OOCYTE IDENTIFICATION
$0.00
89255
9
PREPARE EMBRYO FOR TRANSFER
$0.00
89256
O
PREPARE CRYOPRESERVED EMBRYO
$0.00
89257
9
SPERM IDENTIFICATION
$0.00
89258
9
CRYOPRESERVATION; EMBRYO(S)
$0.00
89259
9
CRYOPRESERVATION, SPERM
$0.00
89260
9
SPERM ISOLATION, SIMPLE
$0.00
$6.17
$16.06
Procedure Code Pricing Action Code Description
Maximum Allowable
89261
9
SPERM ISOLATION, COMPLEX
$0.00
89264
9
IDENTIFY SPERM TISSUE
$0.00
89268
9
INSEMINATION OF OOCYTES
$0.00
89272
9
EXTENDED CULTURE OF OOCYTES
$0.00
89280
9
ASSIST OOCYTE FERTILIZATION
$0.00
89281
9
ASSIST OOCYTE FERTILIZATION
$0.00
89290
9
BIOPSY, OOCYTE POLAR BODY
$0.00
89291
9
BIOPSY, OOCYTE POLAR BODY
$0.00
89300
9
SEMEN ANALYSIS W/HUHNER
$0.00
89310
3
SEMEN ANALYSIS W/COUNT
$12.32
89320
3
SEMEN ANAL VOL/COUNT/MOT
$17.25
89321
3
SEMEN ANAL, SPERM DETECTION
$17.25
89322
3
SEMEN ANAL, STRICT CRITERIA
$22.18
89325
3
SPERM ANTIBODY TEST
$15.27
89329
9
SPERM EVALUATION TEST
$0.00
89330
9
EVALUATION, CERVICAL MUCUS
$0.00
89331
3
RETROGRADE EJACULATION ANAL
$28.03
89335
9
CRYOPRESERVE TESTICULAR TISS
$0.00
89342
9
STORAGE/YEAR; EMBRYO(S)
$0.00
89343
9
STORAGE/YEAR; SPERM/SEMEN
$0.00
89344
9
STORAGE/YEAR; REPROD TISSUE
$0.00
89346
9
STORAGE/YEAR; OOCYTE(S)
$0.00
89350
O
SPUTUM SPECIMEN COLLECTION
$0.00
89352
9
THAWING CRYOPRESRVED; EMBRYO
$0.00
89353
9
THAWING CRYOPRESRVED; SPERM
$0.00
89354
9
THAW CRYOPRSVRD; REPROD TISS
$0.00
89355
O
EXAM FECES FOR STARCH
$0.00
89356
9
THAWING CRYOPRESRVED; OOCYTE
$0.00
89360
O
COLLECT SWEAT FOR TEST
$0.00
89365
O
WATER LOAD TEST
$0.00
89399
O
PATHOLOGY LAB PROCEDURE
$0.00
90000
O
OFFICE AND OTHER OUTPATIENT MEDICAL
$0.00
90010
O
OFFICE AND OTHER OUTPATIENT MEDICAL
$0.00
90015
O
OFFICE AND OTHER OUTPATIENT MEDICAL
$0.00
90017
O
OFFICE AND OTHER OUTPATIENT MEDICAL
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
90020
O
OFFICE AND OTHER OUTPATIENT MEDICAL
$0.00
90030
O
OFFICE AND OTHER OUTPATIENT MEDICAL
$0.00
90040
O
OFFICE AND OTHER OUTPATIENT MEDICAL
$0.00
90050
O
OFFICE AND OTHER OUTPATIENT MEDICAL
$0.00
90060
O
OFFICE AND OTHER OUTPATIENT MEDICAL
$0.00
90070
O
OFFICE AND OTHER OUTPATIENT MEDICAL
$0.00
90080
O
OFFICE AND OTHER OUTPATIENT MEDICAL
$0.00
90100
O
HOME MEDICAL SERVICE, NEW PATIENT B
$0.00
90110
O
HOME MEDICAL SERVICE, NEW PATIENT L
$0.00
90115
O
HOME MEDICAL SERVICE, NEW PATIENT I
$0.00
90117
O
HOME MEDICAL SERVICE, NEW PATIENT E
$0.00
90130
O
HOME MEDICAL SERVICE, ESTABLISHED P
$0.00
90140
O
HOME MEDICAL SERVICE, ESTABLISHED P
$0.00
90150
O
HOME MEDICAL SERVICE, ESTABLISHED P
$0.00
90160
O
HOME MEDICAL SERVICE, ESTABLISHED P
$0.00
90170
O
HOME MEDICAL SERVICE, ESTABLISHED P
$0.00
90200
O
INITIAL HOSPITAL CARE BRIEF HISTORY
$0.00
90215
O
INITIAL HOSPITAL CARE INTERMEDIATE
$0.00
90220
O
INITIAL HOSPITAL CARE COMPREHENSIVE
$0.00
90225
O
HISTORY AND EXAMINATION OF THE NORM
$0.00
90240
O
SUBSEQUENT HOSPITAL CARE, EACH DAY
$0.00
90250
O
SUBSEQUENT HOSPITAL CARE, EACH DAY
$0.00
90260
O
SUBSEQUENT HOSPITAL CARE, EACH DAY
$0.00
90270
O
SUBSEQUENT HOSPITAL CARE, EACH DAY
$0.00
90280
O
SUBSEQUENT HOSPITAL CARE, EACH DAY
$0.00
90281
5
HUMAN IG, IM
$0.00
90282
O
SUBSEQUENT HOSPITAL CARE, EACH DAY
$0.00
90283
5
HUMAN IG, IV
$0.00
90284
6
HUMAN IG, SC
$0.00
90287
5
BOTULINUM ANTITOXIN
$0.00
90288
5
BOTULISM IG, IV
$0.00
90291
5
CMV IG, IV
$0.00
90292
O
HOSPITAL DISCHARGE DAY MANAGEMENT
$0.00
90296
5
DIPHTHERIA ANTITOXIN
$0.00
90300
O
INITIAL CARE, SKILLED NURSING FACIL
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
90315
O
INITIAL CARE, SKILLED NURSING FACIL
$0.00
90320
O
INITIAL CARE, SKILLED NURSING FACIL
$0.00
90340
O
SUBSEQUENT CARE, SKILLED NURSING FA
$0.00
90350
O
SUBSEQUENT CARE, SKILLED NURSING FA
$0.00
90360
O
SUBSEQUENT CARE, SKILLED NURSING FA
$0.00
90370
O
SUBSEQUENT CARE, SKILLED NURSING FA
$0.00
90371
5
HEP B IG, IM
$0.00
90375
5
RABIES IG, IM/SC
$0.00
90376
5
RABIES IG, HEAT TREATED
$0.00
90378
5
RSV IG, IM, 50MG
$0.00
90379
5
RSV IG, IV
$0.00
90384
5
RH IG, FULL-DOSE, IM
$0.00
90385
5
RH IG, MINIDOSE, IM
$0.00
90386
5
RH IG, IV
$0.00
90389
5
TETANUS IG, IM
$0.00
90393
5
VACCINA IG, IM
$0.00
90396
5
VARICELLA-ZOSTER IG, IM
$0.00
90399
5
IMMUNE GLOBULIN
$0.00
90400
O
REST HOME (EG, BOARDING HOME), DOMI
$0.00
90410
O
REST HOME (EG, BOARDING HOME), DOMI
$0.00
90415
O
REST HOME (EG, BOARDING HOME), DOMI
$0.00
90420
O
REST HOME (EG, BOARDING HOME), DOMI
$0.00
90430
O
REST HOME (EG, BOARDING HOME), DOMI
$0.00
90440
O
REST HOME (EG, BOARDING HOME), DOMI
$0.00
90450
O
REST HOME (EG, BOARDING HOME), DOMI
$0.00
90460
O
REST HOME (EG, BOARDING HOME), DOMI
$0.00
90465
9
IMMUNE ADMIN 1 INJ, < 8 YRS
$0.00
90466
9
IMMUNE ADMIN ADDL INJ, < 8 Y
$0.00
90467
9
IMMUNE ADMIN O OR N, < 8 YRS
$0.00
90468
9
IMMUNE ADMIN O/N, ADDL < 8 Y
$0.00
90470
O
REST HOME (EG, BOARDING HOME), DOMI
$0.00
90471
9
IMMUNIZATION ADMIN
$0.00
90472
9
IMMUNIZATION ADMIN, EACH ADD
$0.00
90473
9
IMMUNE ADMIN ORAL/NASAL
$0.00
90474
9
IMMUNE ADMIN ORAL/NASAL ADDL
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
90476
5
ADENOVIRUS VACCINE, TYPE 4
$0.00
90477
5
ADENOVIRUS VACCINE, TYPE 7
$0.00
90500
O
EMERGENCY DEPARTMENT SERVICE, NEW P
$0.00
90505
O
EMERGENCY DEPARTMENT SERVICE, NEW P
$0.00
90510
O
EMERGENCY DEPARTMENT SERVICE, NEW P
$0.00
90515
O
EMERGENCY DEPARTMENT SERVICE, NEW P
$0.00
90517
O
EMERGENCY DEPARTMENT SERVICE, NEW P
$0.00
90520
O
EMERGENCY DEPARTMENT SERVICE, NEW P
$0.00
90530
O
EMERGENCY DEPARTMENT SERVICE, ESTAB
$0.00
90540
O
EMERGENCY DEPARTMENT SERVICE, ESTAB
$0.00
90550
O
EMERGENCY DEPARTMENT SERVICE, ESTAB
$0.00
90560
O
EMERGENCY DEPARTMENT SERVICE, ESTAB
$0.00
90570
O
EMERGENCY DEPARTMENT SERVICE, ESTAB
$0.00
90580
O
EMERGENCY DEPARTMENT SERVICE, ESTAB
$0.00
90581
5
ANTHRAX VACCINE, SC
$0.00
90585
5
BCG VACCINE, PERCUT
$0.00
90586
5
BCG VACCINE, INTRAVESICAL
$0.00
90590
9
PHYSICIAN DIRECTION OF EMERGENCY ME
$0.00
90592
9
CHOLERA VACCINE, ORAL
$0.00
90600
O
INITIAL CONSULTATION LIMITED
$0.00
90605
O
INITIAL CONSULTATION INTERMEDIATE
$0.00
90610
O
INITIAL CONSULTATION EXTENDED
$0.00
90620
O
INITIAL CONSULTATION COMPREHENSIVE
$0.00
90630
O
INITIAL CONSULTATION COMPLEX
$0.00
90632
3
HEP A VACCINE, ADULT IM
90633
5
HEP A VACC, PED/ADOL, 2 DOSE
$0.00
90634
5
HEP A VACC, PED/ADOL, 3 DOSE
$0.00
90636
6
HEP A/HEP B VACC, ADULT IM
$0.00
90640
9
FOLLOW-UP CONSULTATION BRIEF
$0.00
90641
9
FOLLOW-UP CONSULTATION LIMITED
$0.00
90642
9
FOLLOW-UP CONSULTATION INTERMEDIATE
$0.00
90643
9
FOLLOW-UP CONSULTATION COMPLEX
$0.00
90645
5
HIB VACCINE, HBOC, IM
$0.00
90646
5
HIB VACCINE, PRP-D, IM
$0.00
90647
5
HIB VACCINE, PRP-OMP, IM
$0.00
$48.22
Procedure Code Pricing Action Code Description
Maximum Allowable
90648
5
HIB VACCINE, PRP-T, IM
$0.00
90650
9
HPV VACCINE TYPES 16, 18, BIVALENT
$0.00
90651
9
CONFIRMATORY CONSULTATION INTERMEDI
$0.00
90652
9
CONFIRMATORY CONSULTATION EXTENDED
$0.00
90653
9
CONFIRMATORY CONSULTATION COMPREHEN
$0.00
90654
9
CONFIRMATORY CONSULTATION COMPLEX
$0.00
90655
5
FLU VACCINE NO PRESERV 6-35M
$0.00
90656
5
FLU VACCINE NO PRESERV 3 & >
$0.00
90657
5
FLU VACCINE, 3 YRS, IM
$0.00
90658
3
FLU VACCINE, 3 YRS & >, IM
90659
O
FLU VACCINE, WHOLE, IM
$0.00
90660
5
FLU VACCINE, NASAL
$0.00
90661
9
FLU VACC CELL CULT PRSV FREE
$0.00
90662
9
FLU VACC PRSV FREE INC ANTIG
$0.00
90663
9
FLU VACC PANDEMIC
$0.00
90665
3
LYME DISEASE VACCINE, IM
90669
5
PNEUMOCOCCAL VACC, PED <5
$0.00
90675
5
RABIES VACCINE, IM
$0.00
90676
5
RABIES VACCINE, ID
$0.00
90680
5
ROTOVIRUS VACC 3 DOSE, ORAL
$0.00
90681
6
ROTAVIRUS VACCINE, HUMAN, ATTENUAT
$0.00
90690
9
TYPHOID VACCINE, ORAL
$0.00
90691
9
TYPHOID VACCINE, IM
$0.00
90692
9
TYPHOID VACCINE, H-P, SC/ID
$0.00
90693
9
TYPHOID VACCINE, AKD, SC
$0.00
90696
6
DIPTHERIA,TETANUS TOXOIDS,ACELLULA
$0.00
90698
6
DTAP-HIB-IP VACCINE, IM
$0.00
90699
O
UNLISTED MEDICAL SERVICE, GENERAL
$0.00
90700
5
DTAP VACCINE, < 7 YRS, IM
$0.00
90701
5
DTP VACCINE, IM
$0.00
90702
5
DT VACCINE < 7, IM
$0.00
90703
3
TETANUS VACCINE, IM
90704
5
MUMPS VACCINE, SC
$0.00
90705
5
MEASLES VACCINE, SC
$0.00
90706
5
RUBELLA VACCINE, SC
$0.00
$13.22
$53.35
$22.47
Procedure Code Pricing Action Code Description
Maximum Allowable
90707
3
MMR VACCINE, SC
$44.73
90708
5
MEASLES-RUBELLA VACCINE, SC
$0.00
90709
O
RUBELLA & MUMPS VACCINE, SC
$0.00
90710
5
MMRV VACCINE, SC
$0.00
90711
O
COMBINED VACCINE
$0.00
90712
5
ORAL POLIOVIRUS VACCINE
$0.00
90713
6
POLIOVIRUS, IPV, SC/IM
$0.00
90714
3
TD VACCINE NO PRSRV >/= 7 IM
$19.98
90715
3
TDAP VACCINE >7 IM
$35.05
90716
6
CHICKEN POX VACCINE, SC
$0.00
90717
9
YELLOW FEVER VACCINE, SC
$0.00
90718
3
TD VACCINE > 7, IM
90719
5
DIPHTHERIA VACCINE, IM
$0.00
90720
5
DTP/HIB VACCINE, IM
$0.00
90721
6
DTAP/HIB VACCINE, IM
$0.00
90723
5
DTAP-HEP B-IPV VACCINE, IM
$0.00
90724
O
INFLUENZA IMMUNIZATION
$0.00
90725
9
CHOLERA VACCINE, INJECTABLE
$0.00
90726
O
RABIES IMMUNIZATION
$0.00
90727
9
PLAGUE VACCINE, IM
$0.00
90728
O
BCG IMMUNIZATION
$0.00
90730
O
HEPATITIS A VACCINE
$0.00
90731
O
IMMUNIZATION, ACTIVE; HEPATITIS B V
$0.00
90732
3
PNEUMOCOCCAL VACCINE
$12.85
90733
3
MENINGOCOCCAL VACCINE, SC
$12.85
90734
3
MENINGOCOCCAL VACCINE, IM
$41.00
90735
9
ENCEPHALITIS VACCINE, SC
$0.00
90736
6
ZOSTER VACC, SC
$0.00
90737
O
INFLUENZA B IMMUNIZATION
$0.00
90738
9
JAPANESE ENCEPHALITIS VIRUS VACCIN
$0.00
90740
5
HEPB VACC, ILL PAT 3 DOSE IM
$0.00
90741
O
PASSIVE IMMUNIZATION, ISG
$0.00
90742
O
SPECIAL PASSIVE IMMUNIZATION
$0.00
90743
5
HEP B VACC, ADOL, 2 DOSE, IM
$0.00
90744
5
HEPB VACC PED/ADOL 3 DOSE IM
$0.00
$13.85
Procedure Code Pricing Action Code Description
Maximum Allowable
90745
O
HEPB VACCINE, ADOL/RISK, IM
$0.00
90746
3
HEP B VACCINE, ADULT, IM
90747
5
HEPB VACC, ILL PAT 4 DOSE IM
$0.00
90748
6
HEP B/HIB VACCINE, IM
$0.00
90749
5
VACCINE TOXOID
$0.00
90750
9
INITIAL HISTORY AND EXAMINATION REL
$0.00
90751
9
INITIAL HISTORY AND EXAMINATION REL
$0.00
90752
O
INITIAL HISTORY AND EXAMINATION REL
$0.00
90753
O
INITIAL HISTORY AND EXAMINATION REL
$0.00
90754
O
INITIAL HISTORY AND EXAMINATION REL
$0.00
90755
9
INFANT CARE TO ONE YEAR OF AGE, WIT
$0.00
90757
O
NEWBORN CARE, IN OTHER THAN HOSPITA
$0.00
90760
O
HYDRATION IV INFUSION, INIT
$0.00
90761
O
HYDRATE IV INFUSION, ADD-ON
$0.00
90762
O
INTERVAL HISTORY AND EXAMINATION RE
$0.00
90763
O
INTERVAL HISTORY AND EXAMINATION RE
$0.00
90764
O
INTERVAL HISTORY AND EXAMINATION RE
$0.00
90765
O
THER/PROPH/DIAG IV INF, INIT
$0.00
90766
O
THER/PROPH/DG IV INF, ADD-ON
$0.00
90767
O
TX/PROPH/DG ADDL SEQ IV INF
$0.00
90768
O
THER/DIAG CONCURRENT INF
$0.00
90769
O
SC THER INFUSION, UP TO 1 HR
$0.00
90770
O
SC THER INFUSION, ADDL HR
$0.00
90771
O
SC THER INFUSION, RESET PUMP
$0.00
90772
O
THER/PROPH/DIAG INJ, SC/IM
$0.00
90773
O
THER/PROPH/DIAG INJ, IA
$0.00
90774
O
THERAPEUTIC, PROPHYLACTIC OR DIAG
$0.00
90775
O
TX/PRO/DX INJ NEW DRUG ADDON
$0.00
90776
O
TX/PRO/DX INJ SAME DRUG ADON
$0.00
90778
O
CIRCADIAN RESPIRATORY PATTERN RECOR
$0.00
90779
O
THER/PROP/DIAG INJ/INF PROC
$0.00
90780
O
IV INFUSION THERAPY, 1 HOUR
$0.00
90781
O
IV INFUSION, ADDITIONAL HOUR
$0.00
90782
O
INJECTION, SC/IM
$0.00
90783
O
INJECTION, IA
$0.00
$59.71
Procedure Code Pricing Action Code Description
Maximum Allowable
90784
O
INJECTION, IV
$0.00
90788
O
INJECTION OF ANTIBIOTIC
$0.00
90798
O
INTRAVENOUS THERAPY FOR SEVERE OR I
$0.00
90799
O
THER/PROPHYLACTIC/DX INJECT
$0.00
90801
3
PSY DX INTERVIEW
$152.51
90802
3
INTAC PSY DX INTERVIEW
$162.48
90804
3
PSYTX, OFFICE, 20-30 MIN
$66.73
90805
3
PSYTX, OFF, 20-30 MIN W/E&M
$74.29
90806
3
PSYTX, OFF, 45-50 MIN
$92.92
90807
3
PSYTX, OFF, 45-50 MIN W/E&M
$104.22
90808
3
PSYTX, OFFICE, 75-80 MIN
$136.47
90809
3
PSYTX, OFF, 75-80, W/E&M
$147.38
90810
3
INTAC PSYTX, OFF, 20-30 MIN
$70.72
90811
3
INTAC PSYTX, 20-30, W/E&M
$82.55
90812
3
INTAC PSYTX, OFF, 45-50 MIN
$101.32
90813
3
INTAC PSYTX, 45-50 MIN W/E&M
$112.62
90814
3
INTAC PSYTX, OFF, 75-80 MIN
$146.81
90815
3
INTAC PSYTX, 75-80 W/E&M
$155.78
90816
3
PSYTX, HOSP, 20-30 MIN
$61.63
90817
3
PSYTX, HOSP, 20-30 MIN W/E&M
$68.41
90818
3
PSYTX, HOSP, 45-50 MIN
$91.72
90819
3
PSYTX, HOSP, 45-50 MIN W/E&M
$98.36
90820
9
INTERACTIVE MEDICAL PSYCHIATRIC DIA
90821
3
PSYTX, HOSP, 75-80 MIN
$135.26
90822
3
PSYTX, HOSP, 75-80 MIN W/E&M
$142.15
90823
3
INTAC PSYTX, HOSP, 20-30 MIN
$66.53
90824
3
INTAC PSYTX, HSP 20-30 W/E&M
$73.95
90825
9
PSYCHIATRIC EVALUATION OF HOSPITAL
90826
3
INTAC PSYTX, HOSP, 45-50 MIN
$97.25
90827
3
INTAC PSYTX, HSP 45-50 W/E&M
$103.26
90828
3
INTAC PSYTX, HOSP, 75-80 MIN
$140.55
90829
3
INTAC PSYTX, HSP 75-80 W/E&M
$146.80
90830
O
PSYCHOLOGICAL TESTING (INCLUDES PSY
$0.00
90835
9
NARCOSYNTHESIS FOR PSYCHIATRIC DIAG
$0.00
90841
9
INDIVIDUAL MEDICAL PSYCHOTHERAPY BY
$0.00
$0.00
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
90842
9
INDIVIDUAL MEDICAL PSYCHOTHERAPY BY
$0.00
90843
9
INDIVIDUAL MEDICAL PSYCHOTHERAPY BY
$0.00
90844
9
INDIVIDUAL MEDICAL PSYCHOTHERAPY BY
$0.00
90845
3
PSYCHOANALYSIS
$81.19
90846
3
FAMILY PSYTX W/O PATIENT
$86.69
90847
3
FAMILY PSYTX W/PATIENT
90849
3
MULTIPLE FAMILY GROUP PSYTX
$32.65
90853
3
GROUP PSYCHOTHERAPY
$30.94
90855
9
INTERACTIVE INDIVIDUAL MEDICAL PSYC
90857
3
INTAC GROUP PSYTX
$34.95
90862
3
MEDICATION MANAGEMENT
$55.13
90865
9
NARCOSYNTHESIS
90870
3
ELECTROCONVULSIVE THERAPY
$137.28
90871
O
ELECTROCONVULSIVE THERAPY
$0.00
90875
9
PSYCHOPHYSIOLOGICAL THERAPY
$0.00
90876
9
PSYCHOPHYSIOLOGICAL THERAPY
$0.00
90880
9
HYPNOTHERAPY
$0.00
90882
9
ENVIRONMENTAL MANIPULATION
$0.00
90885
3
PSY EVALUATION OF RECORDS
90887
9
CONSULTATION WITH FAMILY
$0.00
90889
9
PREPARATION OF REPORT
$0.00
90899
O
PSYCHIATRIC SERVICE/THERAPY
$0.00
90900
O
BIOFEEDBACK TRAINING; BY ELECTROMYO
$0.00
90901
9
BIOFEEDBACK TRAIN, ANY METH
$0.00
90902
O
BIOFEEDBACK TRAINING; IN CONDUCTION
$0.00
90904
O
BIOFEEDBACK TRAINING; REGULATION OF
$0.00
90906
9
BIOFEEDBACK TRAINING REGULATION OF
$0.00
90908
O
BIOFEEDBACK TRAINING; BY ELECTROENC
$0.00
90910
O
BIOFEEDBACK TRAINING; BY ELECTRO-OC
$0.00
90911
3
BIOFEEDBACK PERI/URO/RECTAL
$86.11
90915
O
BIOFEEDBACK TRAINING; OTHER
$0.00
90918
O
ESRD RELATED SERVICES, MONTH
$0.00
90919
O
ESRD RELATED SERVICES, MONTH
$0.00
90920
O
ESRD RELATED SERVICES, MONTH
$0.00
90921
O
ESRD RELATED SERVICES, MONTH
$0.00
$107.90
$0.00
$0.00
$47.71
Procedure Code Pricing Action Code Description
Maximum Allowable
90922
O
ESRD RELATED SERVICES, DAY
$0.00
90923
O
ESRD RELATED SERVICES, DAY
$0.00
90924
O
ESRD RELATED SERVICES, DAY
$0.00
90925
O
ESRD RELATED SERVICES, DAY
$0.00
90935
3
HEMODIALYSIS, ONE EVALUATION
$65.99
90937
3
HEMODIALYSIS, REPEATED EVAL
$108.13
90939
O
HEMODIALYSIS STUDY, TRANSCUT
$0.00
90940
5
HEMODIALYSIS ACCESS STUDY
$0.00
90945
3
DIALYSIS, ONE EVALUATION
$68.51
90947
3
DIALYSIS, REPEATED EVAL
$110.66
90951
3
ESRD SERV, 4 VISITS P MO, <2
$955.25
90952
6
ESRD SERV, 2-3 VSTS P MO, <2
$0.00
90953
6
ESRD SERV, 1 VISIT P MO, <2
$0.00
90954
3
ESRD SERV, 4 VSTS P MO, 2-11
$780.77
90955
3
ESRD SRV 2-3 VSTS P MO, 2-11
$443.17
90956
3
ESRD SRV, 1 VISIT P MO, 2-11
$300.22
90957
3
ESRD SRV, 4 VSTS P MO, 12-19
$628.02
90958
3
ESRD SRV 2-3 VSTS P MO 12-19
$424.14
90959
3
ESRD SERV, 1 VST P MO, 12-19
$278.25
90960
3
ESRD SRV, 4 VISITS P MO, 20+
$280.12
90961
3
ESRD SRV, 2-3 VSTS P MO, 20+
$225.83
90962
3
ESRD SERV, 1 VISIT P MO, 20+
$163.02
90963
3
ESRD HOME PT, SERV P MO, <2
$539.04
90964
3
ESRD HOME PT SERV P MO, 2-11
$448.39
90965
3
ESRD HOME PT SERV P MO 12-19
$426.55
90966
3
ESRD HOME PT, SERV P MO, 20+
$223.24
90967
3
ESRD HOME PT SERV P DAY, <2
$19.40
90968
3
ESRD HOME PT SRV P DAY, 2-11
$15.02
90969
3
ESRD HOME PT SRV P DAY 12-19
$14.67
90970
3
ESRD HOME PT SERV P DAY, 20+
$7.83
90988
O
SUPERVISION OF HEMODIALYSIS IN HOSP
$0.00
90989
9
DIALYSIS TRAINING, COMPLETE
$0.00
90990
O
HEMODIALYSIS TRAINING AND/OR COUNSE
$0.00
90991
O
HOME HEMODIALYSIS CARE, OUTPATIENT,
$0.00
90992
9
PERITONEAL DIALYSIS TRAINING AND/OR
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
90993
9
DIALYSIS TRAINING, INCOMPL
$0.00
90994
O
SUPERVISION OF CHRONIC AMBULATORY P
$0.00
90995
O
END STAGE RENAL DISEASE (ESRD) RELA
$0.00
90997
3
HEMOPERFUSION
90998
O
END STAGE RENAL DISEASE (ESRD) RELA
$0.00
90999
5
DIALYSIS PROCEDURE
$0.00
91000
3
ESOPHAGEAL INTUBATION
91010
3
ESOPHAGUS MOTILITY STUDY
$186.55
91011
3
ESOPHAGUS MOTILITY STUDY
$250.08
91012
3
ESOPHAGUS MOTILITY STUDY
$254.19
91020
3
GASTRIC MOTILITY STUDIES
$226.86
91022
3
DUODENAL MOTILITY STUDY
$186.19
91030
3
ACID PERFUSION OF ESOPHAGUS
$135.99
91032
O
ESOPHAGUS, ACID REFLUX TEST
$0.00
91033
O
PROLONGED ACID REFLUX TEST
$0.00
91034
3
GASTROESOPHAGEAL REFLUX TEST
$196.15
91035
3
G-ESOPH REFLX TST W/ELECTROD
$463.42
91037
3
ESOPH IMPED FUNCTION TEST
$156.96
91038
3
ESOPH IMPED FUNCT TEST > 1H
$137.94
91040
3
ESOPH BALLOON DISTENSION TST
$375.46
91052
3
GASTRIC ANALYSIS TEST
$121.12
91055
3
GASTRIC INTUBATION FOR SMEAR
$130.65
91060
O
GASTRIC SALINE LOAD TEST
91065
3
BREATH HYDROGEN TEST
91100
O
PASS INTESTINE BLEEDING TUBE
91105
3
GASTRIC INTUBATION TREATMENT
91110
3
GI TRACT CAPSULE ENDOSCOPY
$891.82
91111
3
ESOPHAGEAL CAPSULE ENDOSCOPY
$699.46
91120
3
RECTAL SENSATION TEST
$384.83
91122
3
ANAL PRESSURE RECORD
$227.62
91123
3
IRRIGATE FECAL IMPACTION
91132
3
ELECTROGASTROGRAPHY
$0.00
91133
3
ELECTROGASTROGRAPHY W/TEST
$0.00
91299
5
GASTROENTEROLOGY PROCEDURE
$0.00
92002
3
EYE EXAM, NEW PATIENT
$87.90
$88.04
$0.00 $64.80 $0.00 $78.27
$92.29
$67.41
Procedure Code Pricing Action Code Description
Maximum Allowable
92004
3
EYE EXAM, NEW PATIENT
$126.63
92012
3
EYE EXAM ESTABLISHED PAT
92014
3
EYE EXAM & TREATMENT
92015
3
REFRACTION
92018
3
NEW EYE EXAM & TREATMENT
92019
3
EYE EXAM & TREATMENT
$63.06
92020
3
SPECIAL EYE EVALUATION
$23.81
92025
3
CORNEAL TOPOGRAPHY
$31.11
92060
3
SPECIAL EYE EVALUATION
$53.84
92065
3
ORTHOPTIC/PLEOPTIC TRAINING
$42.54
92070
9
FITTING OF CONTACT LENS
92081
3
VISUAL FIELD EXAMINATION(S)
$48.47
92082
3
VISUAL FIELD EXAMINATION(S)
$64.27
92083
3
VISUAL FIELD EXAMINATION(S)
$73.43
92100
3
SERIAL TONOMETRY EXAM(S)
$81.05
92120
3
TONOGRAPHY & EYE EVALUATION
$66.77
92130
3
WATER PROVOCATION TONOGRAPHY
$73.79
92135
3
OPHTH DX IMAGING POST SEG
$42.56
92136
3
OPHTHALMIC BIOMETRY
$75.93
92140
3
GLAUCOMA PROVOCATIVE TESTS
$52.49
92225
3
SPECIAL EYE EXAM, INITIAL
$22.69
92226
3
SPECIAL EYE EXAM, SUBSEQUENT
$20.53
92230
3
EYE EXAM WITH PHOTOS
$55.19
92235
3
EYE EXAM WITH PHOTOS
$117.75
92240
3
ICG ANGIOGRAPHY
$201.68
92250
3
EYE EXAM WITH PHOTOS
$66.11
92260
3
OPHTHALMOSCOPY/DYNAMOMETRY
$16.26
92265
3
EYE MUSCLE EVALUATION
$71.05
92270
3
ELECTRO-OCULOGRAPHY
$81.90
92275
3
ELECTRORETINOGRAPHY
$122.70
92280
O
VISUALLY EVOKED POTENTIAL (RESPONSE
92283
3
COLOR VISION EXAMINATION
$42.04
92284
3
DARK ADAPTATION EYE EXAM
$56.38
92285
3
EYE PHOTOGRAPHY
$38.68
92286
3
INTERNAL EYE PHOTOGRAPHY
$71.07 $103.59 $31.57 $126.87
$0.00
$0.00
$110.32
Procedure Code Pricing Action Code Description
Maximum Allowable
92287
3
INTERNAL EYE PHOTOGRAPHY
$104.48
92310
9
CONTACT LENS FITTING
$0.00
92311
O
CONTACT LENS FITTING
$0.00
92312
O
CONTACT LENS FITTING
$0.00
92313
9
CONTACT LENS FITTING
$0.00
92314
9
PRESCRIPTION OF CONTACT LENS
$0.00
92315
O
PRESCRIPTION OF CONTACT LENS
$0.00
92316
O
PRESCRIPTION OF CONTACT LENS
$0.00
92317
9
PRESCRIPTION OF CONTACT LENS
$0.00
92325
9
MODIFICATION OF CONTACT LENS
$0.00
92326
9
REPLACEMENT OF CONTACT LENS
$0.00
92330
O
FITTING OF ARTIFICIAL EYE
$0.00
92335
O
FITTING OF ARTIFICIAL EYE
$0.00
92340
9
FITTING OF SPECTACLES
$0.00
92341
9
FITTING OF SPECTACLES
$0.00
92342
9
FITTING OF SPECTACLES
$0.00
92352
9
SPECIAL SPECTACLES FITTING
$0.00
92353
9
SPECIAL SPECTACLES FITTING
$0.00
92354
9
SPECIAL SPECTACLES FITTING
$0.00
92355
9
SPECIAL SPECTACLES FITTING
$0.00
92358
9
EYE PROSTHESIS SERVICE
$0.00
92370
9
REPAIR & ADJUST SPECTACLES
$0.00
92371
9
REPAIR & ADJUST SPECTACLES
$0.00
92390
O
SUPPLY OF SPECTACLES
$0.00
92391
O
SUPPLY OF CONTACT LENSES
$0.00
92392
O
SUPPLY OF LOW VISION AIDS
$0.00
92393
O
SUPPLY OF ARTIFICIAL EYE
$0.00
92395
O
SUPPLY OF SPECTACLES
$0.00
92396
O
SUPPLY OF CONTACT LENSES
$0.00
92499
5
EYE SERVICE OR PROCEDURE
$0.00
92502
3
EAR AND THROAT EXAMINATION
$91.02
92504
3
EAR MICROSCOPY EXAMINATION
$27.74
92506
3
SPEECH/HEARING EVALUATION
92507
3
SPEECH/HEARING THERAPY
$61.95
92508
3
SPEECH/HEARING THERAPY
$29.50
$149.39
Procedure Code Pricing Action Code Description
Maximum Allowable
92510
O
REHAB FOR EAR IMPLANT
$0.00
92511
3
NASOPHARYNGOSCOPY
92512
3
NASAL FUNCTION STUDIES
$57.84
92516
3
FACIAL NERVE FUNCTION TEST
$59.97
92520
3
LARYNGEAL FUNCTION STUDIES
$58.57
92525
O
ORAL FUNCTION EVALUATION
92526
3
ORAL FUNCTION THERAPY
92531
5
SPONTANEOUS NYSTAGMUS STUDY
$0.00
92532
5
POSITIONAL NYSTAGMUS TEST
$0.00
92533
5
CALORIC VESTIBULAR TEST
$0.00
92534
5
OPTOKINETIC NYSTAGMUS TEST
$0.00
92541
3
SPONTANEOUS NYSTAGMUS TEST
$57.40
92542
3
POSITIONAL NYSTAGMUS TEST
$59.84
92543
3
CALORIC VESTIBULAR TEST
$27.71
92544
3
OPTOKINETIC NYSTAGMUS TEST
$48.09
92545
3
OSCILLATING TRACKING TEST
$45.17
92546
3
SINUSOIDAL ROTATIONAL TEST
$81.33
92547
3
SUPPLEMENTAL ELECTRICAL TEST
92548
3
POSTUROGRAPHY
$91.71
92551
3
PURE TONE HEARING TEST, AIR
$10.59
92552
3
PURE TONE AUDIOMETRY, AIR
$21.30
92553
3
AUDIOMETRY, AIR & BONE
$28.43
92555
3
SPEECH THRESHOLD AUDIOMETRY
$15.75
92556
3
SPEECH AUDIOMETRY, COMPLETE
$24.36
92557
3
COMPREHENSIVE HEARING TEST
$43.91
92559
9
GROUP AUDIOMETRIC TESTING
$0.00
92560
5
BEKESY AUDIOMETRY, SCREEN
$0.00
92561
3
BEKESY AUDIOMETRY, DIAGNOSIS
$27.69
92562
3
LOUDNESS BALANCE TEST
$22.40
92563
3
TONE DECAY HEARING TEST
$20.19
92564
3
SISI HEARING TEST
$19.32
92565
3
STENGER TEST, PURE TONE
$12.42
92566
O
IMPEDANCE TESTING
92567
3
TYMPANOMETRY
$17.09
92568
3
ACOUSTIC REFL THRESHOLD TST
$17.61
$146.82
$0.00 $79.28
$5.14
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
92569
3
ACOUSTIC REFLEX DECAY TEST
$14.02
92571
3
FILTERED SPEECH HEARING TEST
$16.12
92572
3
STAGGERED SPONDAIC WORD TEST
$17.25
92573
O
LOMBARD TEST
$0.00
92574
O
SWINGING STORY TEST
$0.00
92575
3
SENSORINEURAL ACUITY TEST
$34.86
92576
3
SYNTHETIC SENTENCE TEST
$20.80
92577
3
STENGER TEST, SPEECH
$16.84
92578
O
DELAYED AUDITORY FEEDBACK TEST
92579
3
VISUAL AUDIOMETRY (VRA)
92580
O
ELECTRODERMAL AUDIOMETRY
$0.00
92581
O
EVOKED RESPONSE (EEG) AUDIOMETRY
$0.00
92582
3
CONDITIONING PLAY AUDIOMETRY
$40.63
92583
3
SELECT PICTURE AUDIOMETRY
$32.60
92584
3
ELECTROCOCHLEOGRAPHY
$66.03
92585
3
AUDITOR EVOKE POTENT, COMPRE
$99.22
92586
3
AUDITOR EVOKE POTENT, LIMIT
$61.40
92587
3
EVOKED AUDITORY TEST
$37.84
92588
3
EVOKED AUDITORY TEST
$62.06
92589
O
AUDITORY FUNCTION TEST(S)
$0.00
92590
9
HEARING AID EXAM, ONE EAR
$0.00
92591
9
HEARING AID EXAM, BOTH EARS
$0.00
92592
9
HEARING AID CHECK, ONE EAR
$0.00
92593
9
HEARING AID CHECK, BOTH EARS
$0.00
92594
9
ELECTRO HEARNG AID TEST, ONE
$0.00
92595
9
ELECTRO HEARNG AID TST, BOTH
$0.00
92596
9
EAR PROTECTOR EVALUATION
$0.00
92597
9
ORAL SPEECH DEVICE EVAL
$0.00
92598
9
MODIFY ORAL SPEECH DEVICE
$0.00
92599
O
ENT PROCEDURE/SERVICE
$0.00
92601
3
COCHLEAR IMPLT F/UP EXAM < 7
92602
3
REPROGRAM COCHLEAR IMPLT < 7
92603
3
COCHLEAR IMPLT F/UP EXAM 7 >
92604
3
REPROGRAM COCHLEAR IMPLT 7 >
$81.10
92605
5
EVAL FOR NONSPEECH DEVICE RX
$0.00
$0.00 $43.09
$151.89 $95.09 $136.43
Procedure Code Pricing Action Code Description
Maximum Allowable
92606
5
NON-SPEECH DEVICE SERVICE
$0.00
92607
3
EX FOR SPEECH DEVICE RX, 1HR
$153.52
92608
3
EX FOR SPEECH DEVICE RX ADDL
$29.29
92609
3
USE OF SPEECH DEVICE SERVICE
$81.56
92610
3
EVALUATE SWALLOWING FUNCTION
$78.82
92611
3
MOTION FLUOROSCOPY/SWALLOW
$85.84
92612
3
ENDOSCOPY SWALLOW TST (FEES)
$153.18
92613
3
ENDOSCOPY SWALLOW TST (FEES)
$37.29
92614
3
LARYNGOSCOPIC SENSORY TEST
$136.18
92615
3
EVAL LARYNGOSCOPY SENSE TST
$33.32
92616
3
FEES W/LARYNGEAL SENSE TEST
$186.93
92617
3
INTERPRT FEES/LARYNGEAL TEST
$40.89
92620
9
AUDITORY FUNCTION, 60 MIN
$0.00
92621
9
AUDITORY FUNCTION, + 15 MIN
$0.00
92625
9
TINNITUS ASSESSMENT
$0.00
92626
9
EVAL AUD REHAB STATUS
$0.00
92627
9
EVAL AUD STATUS REHAB ADD-ON
$0.00
92630
9
AUD REHAB PRE-LING HEAR LOSS
$0.00
92633
9
AUD REHAB POSTLING HEAR LOSS
$0.00
92640
3
AUD BRAINSTEM IMPLT PROGRAMG
$73.71
92700
5
ENT PROCEDURE/SERVICE
92950
3
HEART/LUNG RESUSCITATION CPR
92953
9
TEMPORARY EXTERNAL PACING
$0.00
92960
3
CARDIOVERSION ELECTRIC, EXT
$257.69
92961
9
CARDIOVERSION, ELECTRIC, INT
$0.00
92970
3
CARDIOASSIST, INTERNAL
$179.91
92971
3
CARDIOASSIST, EXTERNAL
$103.14
92973
3
PERCUT CORONARY THROMBECTOMY
$183.72
92974
3
CATH PLACE, CARDIO BRACHYTX
$168.43
92975
3
DISSOLVE CLOT, HEART VESSEL
$403.43
92977
3
DISSOLVE CLOT, HEART VESSEL
$131.55
92978
3
INTRAVASC US, HEART ADD-ON
$0.00
92979
3
INTRAVASC US, HEART ADD-ON
$0.00
92980
3
INSERT INTRACORONARY STENT
$837.46
92981
3
INSERT INTRACORONARY STENT
$232.88
$0.00 $268.58
Procedure Code Pricing Action Code Description
Maximum Allowable
92982
3
CORONARY ARTERY DILATION
$620.97
92984
3
CORONARY ARTERY DILATION
$166.25
92986
3
REVISION OF AORTIC VALVE
$1,378.25
92987
3
REVISION OF MITRAL VALVE
$1,426.53
92990
3
REVISION OF PULMONARY VALVE
$1,097.73
92992
5
REVISION OF HEART CHAMBER
$0.00
92993
5
REVISION OF HEART CHAMBER
$0.00
92995
3
CORONARY ATHERECTOMY
$684.35
92996
3
CORONARY ATHERECTOMY ADD-ON
$179.53
92997
3
PUL ART BALLOON REPR, PERCUT
$631.78
92998
3
PUL ART BALLOON REPR, PERCUT
$323.91
93000
3
ELECTROCARDIOGRAM, COMPLETE
$20.84
93005
3
ELECTROCARDIOGRAM, TRACING
$11.94
93010
3
ELECTROCARDIOGRAM REPORT
$8.90
93012
9
TRANSMISSION OF ECG
$0.00
93014
9
REPORT ON TRANSMITTED ECG
$0.00
93015
3
CARDIOVASCULAR STRESS TEST
$100.03
93016
9
CARDIOVASCULAR STRESS TEST
$0.00
93017
3
CARDIOVASCULAR STRESS TEST
$59.57
93018
3
CARDIOVASCULAR STRESS TEST
$16.14
93024
3
CARDIAC DRUG STRESS TEST
$121.95
93025
3
MICROVOLT T-WAVE ASSESS
$215.75
93040
3
RHYTHM ECG WITH REPORT
$13.22
93041
3
RHYTHM ECG, TRACING
$5.42
93042
3
RHYTHM ECG, REPORT
$7.80
93201
O
PHONOCARDIOGRAM WITH OR WITHOUT ECG
$0.00
93202
O
PHONOCARDIOGRAM WITH OR WITHOUT ECG
$0.00
93204
O
PHONOCARDIOGRAM WITH OR WITHOUT ECG
$0.00
93205
O
PHONOCARDIOGRAM WITH ECG LEAD, WITH
$0.00
93208
O
PHONOCARDIOGRAM WITH ECG LEAD, WITH
$0.00
93209
O
PHONOCARDIOGRAM WITH ECG LEAD, WITH
$0.00
93210
O
PHONOCARDIOGRAM, INTRACARDIAC
$0.00
93220
O
VECTORCARDIOGRAM (VCG), WITH OR WIT
$0.00
93221
O
VECTORCARDIOGRAM (VCG), WITH OR WIT
$0.00
93222
O
VECTORCARDIOGRAM (VCG), WITH OR WIT
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
93224
3
ECG MONITOR/REPORT, 24 HRS
$118.61
93225
3
ECG MONITOR/RECORD, 24 HRS
$35.56
93226
3
ECG MONITOR/REPORT, 24 HRS
$54.74
93227
3
ECG MONITOR/REVIEW, 24 HRS
$28.30
93228
3
REMOTE 30 DAY ECG REV/REPORT
$25.34
93229
6
REMOTE 30 DAY ECG TECH SUPP
93230
3
ECG MONITOR/REPORT, 24 HRS
$121.30
93231
3
ECG MONITOR/RECORD, 24 HRS
$35.54
93232
3
ECG MONITOR/REPORT, 24 HRS
$58.57
93233
3
ECG MONITOR/REVIEW, 24 HRS
$27.20
93235
3
ECG MONITOR/REPORT, 24 HRS
$124.39
93236
3
ECG MONITOR/REPORT, 24 HRS
$101.38
93237
3
ECG MONITOR/REVIEW, 24 HRS
$24.32
93255
O
APEXCARDIOGRAPHY
$0.00
93268
3
ECG RECORD/REVIEW
$267.82
93270
3
ECG RECORDING
93271
3
ECG/MONITORING AND ANALYSIS
93272
3
ECG/REVIEW, INTERPRET ONLY
$27.20
93278
3
ECG/SIGNAL-AVERAGED
$39.91
93279
3
PM DEVICE PROGR EVAL, SNGL
$55.72
93280
O
CARDIAC FLUOROSCOPY
93281
3
PM DEVICE PROGR EVAL, MULTI
$77.22
93282
3
ICD DEVICE PROG EVAL, 1 SNGL
$71.24
93283
3
ICD DEVICE PROGR EVAL, DUAL
$86.76
93284
3
ICD DEVICE PROGR EVAL, MULT
$101.68
93285
3
ILR DEVICE EVAL PROGR
$48.12
93286
3
PRE-OP PM DEVICE EVAL
$27.20
93287
3
PRE-OP ICD DEVICE EVAL
$35.76
93288
3
PM DEVICE EVAL IN PERSON
$43.18
93289
3
ICD DEVICE INTERROGATE
$66.41
93290
3
ICM DEVICE EVAL
$31.60
93291
3
ILR DEVICE INTERROGATE
$41.34
93292
3
WCD DEVICE INTERROGATE
$37.27
93293
3
PM PHONE R-STRIP DEVICE EVAL
$59.29
93294
3
PM DEVICE INTERROGATE REMOTE
$36.51
$0.00
$21.14 $219.48
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
93295
3
ICD DEVICE INTERROGAT REMOTE
$66.06
93296
3
PM/ICD REMOTE TECH SERV
$37.21
93297
3
ICM DEVICE INTERROGAT REMOTE
$25.34
93298
3
ILR DEVICE INTERROGAT REMOTE
$29.41
93299
6
ICM/ILR REMOTE TECH SERV
93303
3
ECHO TRANSTHORACIC
$218.56
93304
3
ECHO TRANSTHORACIC
$135.40
93306
3
TTE W/DOPPLER, COMPLETE
$267.90
93307
3
TTE W/O DOPPLER, COMPLETE
$177.01
93308
3
TTE, F-UP OR LMTD
$112.00
93312
3
ECHO TRANSESOPHAGEAL
$326.31
93313
3
ECHO TRANSESOPHAGEAL
$40.56
93314
3
ECHO TRANSESOPHAGEAL
$281.43
93315
3
ECHO TRANSESOPHAGEAL
$0.00
93316
3
ECHO TRANSESOPHAGEAL
$44.76
93317
3
ECHO TRANSESOPHAGEAL
$0.00
93318
3
ECHO TRANSESOPHAGEAL INTRAOP
$0.00
93320
3
DOPPLER ECHO EXAM, HEART
$78.07
93321
3
DOPPLER ECHO EXAM, HEART
$34.51
93325
3
DOPPLER COLOR FLOW ADD-ON
$52.51
93350
3
STRESS TTE ONLY
$212.88
93351
3
STRESS TTE COMPLETE
$255.25
93352
3
ADMIN ECG CONTRAST AGENT
93501
3
RIGHT HEART CATHETERIZATION
$803.84
93503
3
INSERT/PLACE HEART CATHETER
$108.78
93505
3
BIOPSY OF HEART LINING
$753.91
93508
3
CATH PLACEMENT, ANGIOGRAPHY
$1,070.17
93510
3
LEFT HEART CATHETERIZATION
$1,327.90
93511
3
LEFT HEART CATHETERIZATION
$0.00
93514
3
LEFT HEART CATHETERIZATION
$0.00
93524
3
LEFT HEART CATHETERIZATION
$0.00
93526
3
RT & LT HEART CATHETERS
$1,702.25
93527
3
RT & LT HEART CATHETERS
$0.00
93528
3
RT & LT HEART CATHETERS
$0.00
93529
3
RT, LT HEART CATHETERIZATION
$0.00
$0.00
$38.81
Procedure Code Pricing Action Code Description
Maximum Allowable
93530
3
RT HEART CATH, CONGENITAL
$0.00
93531
3
R & L HEART CATH, CONGENITAL
$0.00
93532
3
R & L HEART CATH, CONGENITAL
$0.00
93533
3
R & L HEART CATH, CONGENITAL
$0.00
93536
O
INSERT CIRCULATION ASSI
$0.00
93539
3
INJECTION, CARDIAC CATH
$81.45
93540
3
INJECTION, CARDIAC CATH
$244.09
93541
3
INJECTION FOR LUNG ANGIOGRAM
93542
3
INJECTION FOR HEART X-RAYS
$148.14
93543
3
INJECTION FOR HEART X-RAYS
$80.85
93544
3
INJECTION FOR AORTOGRAPHY
$58.71
93545
3
INJECT FOR CORONARY X-RAYS
$21.92
93546
O
COMBINED LEFT HEART CATHETERIZATION
$0.00
93547
O
COMBINED LEFT HEART CATHETERIZATION
$0.00
93548
O
COMBINED LEFT HEART CATHETERIZATION
$0.00
93549
O
COMBINED RIGHT AND LEFT HEART CATHE
$0.00
93550
O
COMBINED RIGHT AND LEFT HEART CATHE
$0.00
93551
O
SELECTIVE OPACIFICATION OF AORTOCOR
$0.00
93552
O
COMBINED LEFT HEART CATHETERIZATION
$0.00
93553
O
COMBINED LEFT HEART CATHETERIZATION
$0.00
93555
3
IMAGING, CARDIAC CATH
$115.08
93556
3
IMAGING, CARDIAC CATH
$160.91
93561
3
CARDIAC OUTPUT MEASUREMENT
$0.00
93562
3
CARDIAC OUTPUT MEASUREMENT
$0.00
93571
3
HEART FLOW RESERVE MEASURE
$0.00
93572
3
HEART FLOW RESERVE MEASURE
$0.00
93580
3
TRANSCATH CLOSURE OF ASD
$1,005.95
93581
3
TRANSCATH CLOSURE OF VSD
$1,315.39
93600
3
BUNDLE OF HIS RECORDING
$0.00
93602
3
INTRA-ATRIAL RECORDING
$0.00
93603
3
RIGHT VENTRICULAR RECORDING
$0.00
93607
O
LEFT VENTRICULAR RECORDING
$0.00
93609
3
MAP TACHYCARDIA, ADD-ON
$0.00
93610
3
INTRA-ATRIAL PACING
$0.00
93612
3
INTRAVENTRICULAR PACING
$0.00
$15.78
Procedure Code Pricing Action Code Description
Maximum Allowable
93613
3
ELECTROPHYS MAP 3D, ADD-ON
$390.19
93615
3
ESOPHAGEAL RECORDING
$0.00
93616
3
ESOPHAGEAL RECORDING
$0.00
93618
3
HEART RHYTHM PACING
$0.00
93619
3
ELECTROPHYSIOLOGY EVALUATION
$0.00
93620
3
ELECTROPHYSIOLOGY EVALUATION
$0.00
93621
3
ELECTROPHYSIOLOGY EVALUATION
$0.00
93622
3
ELECTROPHYSIOLOGY EVALUATION
$0.00
93623
3
STIMULATION, PACING HEART
$0.00
93624
3
ELECTROPHYSIOLOGIC STUDY
$0.00
93631
3
HEART PACING, MAPPING
$0.00
93640
3
EVALUATION HEART DEVICE
$0.00
93641
3
ELECTROPHYSIOLOGY EVALUATION
$0.00
93642
3
ELECTROPHYSIOLOGY EVALUATION
$471.24
93650
3
ABLATE HEART DYSRHYTHM FOCUS
$594.58
93651
3
ABLATE HEART DYSRHYTHM FOCUS
$903.92
93652
3
ABLATE HEART DYSRHYTHM FOCUS
$983.68
93660
3
TILT TABLE EVALUATION
$172.24
93662
3
INTRACARDIAC ECG (ICE)
$0.00
93668
9
PERIPHERAL VASCULAR REHAB
$0.00
93701
3
BIOIMPEDANCE, THORACIC
$34.28
93720
3
TOTAL BODY PLETHYSMOGRAPHY
$46.21
93721
3
PLETHYSMOGRAPHY TRACING
$38.04
93722
3
PLETHYSMOGRAPHY REPORT
$8.16
93724
3
ANALYZE PACEMAKER SYSTEM
93727
O
ANALYZE ILR SYSTEM
$0.00
93731
O
ANALYZE PACEMAKER SYSTEM
$0.00
93732
O
ANALYZE PACEMAKER SYSTEM
$0.00
93733
O
TELEPHONE ANALY, PACEMAKER
$0.00
93734
O
ANALYZE PACEMAKER SYSTEM
$0.00
93735
O
ANALYZE PACEMAKER SYSTEM
$0.00
93736
O
TELEPHONIC ANALY, PACEMAKER
$0.00
93737
O
ANALYZE CARDIO/DEFIBRILLATOR
$0.00
93738
O
ANALYZE CARDIO/DEFIBRILLATOR
$0.00
93740
O
TEMPERATURE GRADIENT STUDIES
$0.00
$331.98
Procedure Code Pricing Action Code Description
Maximum Allowable
93741
O
ANALYZE HT PACE DEVICE SNGL
$0.00
93742
O
ANALYZE HT PACE DEVICE SNGL
$0.00
93743
O
ANALYZE HT PACE DEVICE DUAL
$0.00
93744
O
ANALYZE HT PACE DEVICE DUAL
$0.00
93745
3
SET-UP CARDIOVERT-DEFIBRILL
$215.95
93760
O
CEPHALIC THERMOGRAM
$0.00
93762
O
PERIPHERAL THERMOGRAM
$0.00
93770
3
MEASURE VENOUS PRESSURE
$8.42
93784
3
AMBULATORY BP MONITORING
$66.06
93786
3
AMBULATORY BP RECORDING
$30.18
93788
3
AMBULATORY BP ANALYSIS
$16.88
93790
3
REVIEW/REPORT BP RECORDING
$18.99
93797
3
CARDIAC REHAB
$18.13
93798
3
CARDIAC REHAB/MONITOR
$26.15
93799
5
CARDIOVASCULAR PROCEDURE
$0.00
93850
O
NON-INVASIVE STUDIES OF CEREBRAL AR
$0.00
93860
O
NON-INVASIVE STUDIES OF CAROTID ART
$0.00
93870
O
NON-INVASIVE STUDIES OF CAROTID ART
$0.00
93875
3
EXTRACRANIAL STUDY
$102.06
93880
3
EXTRACRANIAL STUDY
$184.41
93882
3
EXTRACRANIAL STUDY
$163.97
93886
3
INTRACRANIAL STUDY
$200.50
93888
3
INTRACRANIAL STUDY
$94.15
93890
3
TRANSCRANIAL DOPPLER STUDY OF THE
$147.23
93892
3
TCD, EMBOLI DETECT W/O INJ
$154.19
93893
3
TCD, EMBOLI DETECT W/INJ
$154.57
93910
O
NON-INVASIVE STUDIES OF LOWER EXTRE
$0.00
93920
O
NON-INVASIVE PHYSIOLOGIC STUDIES OF
$0.00
93921
O
NON-INVASIVE PHYSIOLOGIC STUDIES OF
$0.00
93922
3
EXTREMITY STUDY
$121.23
93923
3
EXTREMITY STUDY
$186.84
93924
3
EXTREMITY STUDY
$230.25
93925
3
LOWER EXTREMITY STUDY
$183.37
93926
3
LOWER EXTREMITY STUDY
$118.20
93930
3
UPPER EXTREMITY STUDY
$177.06
Procedure Code Pricing Action Code Description
Maximum Allowable
93931
3
UPPER EXTREMITY STUDY
$113.60
93950
O
NON-INVASIVE STUDIES OF EXTREMITY V
$0.00
93960
O
QUANTITATIVE VENOUS FLOW STUDIES (E
$0.00
93965
3
EXTREMITY STUDY
$123.81
93970
3
EXTREMITY STUDY
$187.73
93971
3
EXTREMITY STUDY
$120.57
93975
3
VASCULAR STUDY
$245.61
93976
3
VASCULAR STUDY
$213.69
93978
3
VASCULAR STUDY
$186.29
93979
3
VASCULAR STUDY
$120.10
93980
3
PENILE VASCULAR STUDY
$182.65
93981
3
PENILE VASCULAR STUDY
$128.63
93982
3
ANEURYSM PRESSURE SENS STUDY
93990
3
DOPPLER FLOW TESTING
94002
9
VENT MGMT INPAT, INIT DAY
$0.00
94003
9
VENT MGMT INPAT, SUBQ DAY
$0.00
94004
9
VENT MGMT NF PER DAY
$0.00
94005
9
HOME VENT MGMT SUPERVISION
$0.00
94010
3
BREATHING CAPACITY TEST
$33.05
94014
3
PATIENT RECORDED SPIROMETRY
$48.51
94015
3
PATIENT RECORDED SPIROMETRY
$23.90
94016
3
REVIEW PATIENT SPIROMETRY
$24.61
94060
3
EVALUATION OF WHEEZING
$57.86
94070
3
EVALUATION OF WHEEZING
$59.31
94150
3
VITAL CAPACITY TEST
$22.58
94160
O
VITAL CAPACITY SCREENING TESTS: TOT
94200
3
LUNG FUNCTION TEST (MBC/MVV)
$22.39
94240
3
RESIDUAL LUNG CAPACITY
$38.83
94250
3
EXPIRED GAS COLLECTION
$24.37
94260
3
THORACIC GAS VOLUME
$31.35
94350
3
LUNG NITROGEN WASHOUT CURVE
$34.52
94360
3
MEASURE AIRFLOW RESISTANCE
$43.13
94370
3
BREATH AIRWAY CLOSING VOLUME
$33.30
94375
3
RESPIRATORY FLOW VOLUME LOOP
$36.94
94400
3
CO2 BREATHING RESPONSE CURVE
$52.31
$40.17 $110.87
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
94450
3
HYPOXIA RESPONSE CURVE
$50.37
94452
3
HAST W/REPORT
$55.66
94453
3
HAST W/OXYGEN TITRATE
$74.40
94610
3
SURFACTANT ADMIN THRU TUBE
$61.36
94620
3
PULMONARY STRESS TEST/SIMPLE
$71.09
94621
3
PULM STRESS TEST/COMPLEX
94640
3
AIRWAY INHALATION TREATMENT
$13.42
94642
3
AEROSOL INHALATION TREATMENT
$34.88
94644
3
CBT, 1ST HOUR
$34.50
94645
3
CBT, EACH ADDL HOUR
$13.42
94650
O
PRESSURE BREATHING (IPPB)
$0.00
94651
O
PRESSURE BREATHING (IPPB)
$0.00
94652
O
PRESSURE BREATHING (IPPB)
$0.00
94656
O
INITIAL VENTILATOR MGMT
$0.00
94657
O
CONTINUED VENTILATOR MGMT
$0.00
94660
9
POS AIRWAY PRESSURE, CPAP
$0.00
94662
9
NEG PRESS VENTILATION, CNP
$0.00
94664
3
EVALUATE PT USE OF INHALER
$14.64
94665
O
AEROSOL OR VAPOR INHALATIONS
$0.00
94667
9
CHEST WALL MANIPULATION
$0.00
94668
9
CHEST WALL MANIPULATION
$0.00
94680
3
EXHALED AIR ANALYSIS, O2
$57.56
94681
3
EXHALED AIR ANALYSIS, O2/CO2
$62.39
94690
3
EXHALED AIR ANALYSIS
$50.66
94700
O
ANALYSIS OF ARTERIAL BLOOD GAS (OXY
$0.00
94705
O
ANALYSIS OF ARTERIAL BLOOD GAS (OXY
$0.00
94710
O
ANALYSIS OF ARTERIAL BLOOD GAS (OXY
$0.00
94715
O
HEMOGLOBIN-OXYGEN AFFINITY (PO2 FOR
$0.00
94720
3
MONOXIDE DIFFUSING CAPACITY
$51.26
94725
3
MEMBRANE DIFFUSION CAPACITY
$66.39
94750
3
PULMONARY COMPLIANCE STUDY
$71.16
94760
3
MEASURE BLOOD OXYGEN LEVEL
$2.70
94761
3
MEASURE BLOOD OXYGEN LEVEL
$5.14
94762
3
MEASURE BLOOD OXYGEN LEVEL
$29.02
94770
3
EXHALED CARBON DIOXIDE TEST
$36.11
$161.05
Procedure Code Pricing Action Code Description
Maximum Allowable
94772
3
BREATH RECORDING, INFANT
$167.00
94774
9
PED HOME APNEA REC, COMPL
$0.00
94775
9
PED HOME APNEA REC, HK-UP
$0.00
94776
9
PED HOME APNEA REC, DOWNLD
$0.00
94777
9
PED HOME APNEA REC, REPORT
$0.00
94799
O
PULMONARY SERVICE/PROCEDURE
$0.00
95000
O
PERCUTANEOUS TESTS (SCRATCH, PUNCTU
$0.00
95001
O
PERCUTANEOUS TESTS (SCRATCH, PUNCTU
$0.00
95002
O
PERCUTANEOUS TESTS (SCRATCH, PUNCTU
$0.00
95003
O
PERCUTANEOUS TESTS (SCRATCH, PUNCTU
$0.00
95004
3
PERCUT ALLERGY SKIN TESTS
$5.77
95005
O
PERCUTANEOUS TESTS (SCRATCH, PUNCTU
$0.00
95006
O
PERCUTANEOUS TESTS (SCRATCH, PUNCTU
$0.00
95007
O
PERCUTANEOUS TESTS (SCRATCH, PUNCTU
$0.00
95010
3
PERCUT ALLERGY TITRATE TEST
95011
O
PERCUTANEOUS TESTS (SCRATCH, PUNCTU
95012
3
EXHALED NITRIC OXIDE MEAS
95014
O
INTRACUTANEOUS (INTRADERMAL) TESTS,
95015
3
ID ALLERGY TITRATE-DRUG/BUG
95016
O
INTRACUTANEOUS (INTRADERMAL) TESTS,
$0.00
95017
O
INTRACUTANEOUS (INTRADERMAL) TESTS,
$0.00
95018
O
INTRACUTANEOUS (INTRADERMAL) TESTS,
$0.00
95020
O
INTRACUTANEOUS (INTRADERMAL) TESTS
$0.00
95021
O
INTRACUTANEOUS (INTRADERMAL) TESTS
$0.00
95022
O
INTRACUTANEOUS (INTRADERMAL) TESTS
$0.00
95023
O
INTRACUTANEOUS (INTRADERMAL) TESTS
$0.00
95024
3
ID ALLERGY TEST, DRUG/BUG
$6.88
95027
3
ID ALLERGY TITRATE-AIRBORNE
$4.66
95028
3
ID ALLERGY TEST-DELAYED TYPE
95030
O
INTRACUTANEOUS (INTRADERMAL) TESTS
$0.00
95031
O
INTRACUTANEOUS (INTRADERMAL) TESTS
$0.00
95032
O
INTRACUTANEOUS (INTRADERMAL) TESTS
$0.00
95033
O
INTRACUTANEOUS (INTRADERMAL) TESTS
$0.00
95034
O
INTRACUTANEOUS (INTRADERMAL) TESTS
$0.00
95040
O
PATCH OR APPLICATION TESTS UP TO 10
$0.00
$17.06 $0.00 $19.84 $0.00 $12.62
$10.96
Procedure Code Pricing Action Code Description
Maximum Allowable
95041
O
PATCH OR APPLICATION TESTS 11-20 TE
$0.00
95042
O
PATCH OR APPLICATION TESTS 21-30 TE
$0.00
95043
O
PATCH OR APPLICATION TESTS MORE THA
$0.00
95044
3
ALLERGY PATCH TESTS
$6.15
95050
9
PHOTO PATCH TESTS UP TO 10 TESTS
$0.00
95051
9
PHOTO PATCH TESTS MORE THAN 10 TEST
$0.00
95052
3
PHOTO PATCH TEST
$6.90
95056
3
PHOTOSENSITIVITY TESTS
$35.00
95060
3
EYE ALLERGY TESTS
$23.40
95065
3
NOSE ALLERGY TEST
$21.32
95070
3
BRONCHIAL ALLERGY TESTS
$43.37
95071
3
BRONCHIAL ALLERGY TESTS
$53.71
95075
3
INGESTION CHALLENGE TEST
$62.02
95078
O
PROVOCATIVE TESTING
$0.00
95080
9
PASSIVE TRANSFER TESTS UP TO 10 TES
$0.00
95081
9
PASSIVE TRANSFER TESTS 11-20 TESTS
$0.00
95082
9
PASSIVE TRANSFER TESTS MORE THAN 20
$0.00
95105
O
MEDICAL CONFERENCE SERVICES (EG, US
$0.00
95115
3
IMMUNOTHERAPY, ONE INJECTION
$10.46
95117
3
IMMUNOTHERAPY INJECTIONS
$12.68
95120
9
IMMUNOTHERAPY, ONE INJECTION
$0.00
95125
9
IMMUNOTHERAPY, MANY ANTIGENS
$0.00
95130
9
IMMUNOTHERAPY, INSECT VENOM
$0.00
95131
9
IMMUNOTHERAPY, INSECT VENOMS
$0.00
95132
9
IMMUNOTHERAPY, INSECT VENOMS
$0.00
95133
9
IMMUNOTHERAPY, INSECT VENOMS
$0.00
95134
9
IMMUNOTHERAPY, INSECT VENOMS
$0.00
95135
9
PROFESSIONAL SERVICES FOR THE SUPER
$0.00
95140
9
PROFESSIONAL SERVICES FOR THE SUPER
$0.00
95144
3
ANTIGEN THERAPY SERVICES
$11.62
95145
3
ANTIGEN THERAPY SERVICES
$15.33
95146
3
ANTIGEN THERAPY SERVICES
$25.30
95147
3
ANTIGEN THERAPY SERVICES
$24.57
95148
3
ANTIGEN THERAPY SERVICES
$34.55
95149
3
ANTIGEN THERAPY SERVICES
$45.27
Procedure Code Pricing Action Code Description
Maximum Allowable
95150
9
PROFESSIONAL SERVICE FOR THE SUPERV
$0.00
95155
O
PROFESSIONAL SERVICE FOR THE SUPERV
$0.00
95165
3
ANTIGEN THERAPY SERVICES
$11.62
95170
3
ANTIGEN THERAPY SERVICES
$9.04
95180
3
RAPID DESENSITIZATION
95199
5
ALLERGY IMMUNOLOGY SERVICES
95250
3
GLUCOSE MONITORING, CONT
95251
3
GLUC MONITOR, CONT, PHYS I&R
95803
9
ACTIGRAPHY TESTING
95805
3
MULTIPLE SLEEP LATENCY TEST
95806
9
SLEEP STUDY, UNATTENDED
95807
3
SLEEP STUDY, ATTENDED
$497.21
95808
3
POLYSOMNOGRAPHY, 1-3
$650.98
95810
3
POLYSOMNOGRAPHY, 4 OR MORE
$774.72
95811
3
POLYSOMNOGRAPHY W/CPAP
$853.98
95812
3
EEG, 41-60 MINUTES
$237.50
95813
3
EEG, OVER 1 HOUR
$290.66
95816
3
EEG, AWAKE AND DROWSY
$217.67
95817
O
ELECTROENCEPHALOGRAM (EEG) INCLUDIN
95819
3
EEG, AWAKE AND ASLEEP
95821
O
ELECTROENCEPHALOGRAM (EEG) INCLUDIN
95822
3
EEG, COMA OR SLEEP ONLY
95823
O
ELECTROENCEPHALOGRAM (EEG); PHYSICA
$0.00
95824
3
EEG, CEREBRAL DEATH ONLY
$0.00
95826
O
ELECTROENCEPHALOGRAM (EEG); INTRACE
$0.00
95827
3
EEG, ALL NIGHT RECORDING
95828
O
POLYSOMNOGRAPHY (RECORDING, ANALYSI
95829
3
SURGERY ELECTROCORTICOGRAM
95830
9
INSERT ELECTRODES FOR EEG
95831
3
LIMB MUSCLE TESTING, MANUAL
$25.40
95832
3
HAND MUSCLE TESTING, MANUAL
$23.78
95833
3
BODY MUSCLE TESTING, MANUAL
$35.03
95834
3
BODY MUSCLE TESTING, MANUAL
$41.39
95842
O
MUSCLE TESTING, ELECTRICAL: REACTIO
$0.00
95851
9
RANGE OF MOTION MEASUREMENTS
$0.00
$139.34 $0.00 $131.49 $39.36 $0.00 $424.27 $0.00
$0.00 $233.94 $0.00 $232.81
$378.10 $0.00 $1,213.27 $0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
95852
3
RANGE OF MOTION MEASUREMENTS
$12.67
95857
3
TENSILON TEST
$40.87
95858
O
TENSILON TEST & MYOGRAM
95860
3
MUSCLE TEST, ONE LIMB
95861
3
MUSCLE TEST, 2 LIMBS
$116.19
95863
3
MUSCLE TEST, 3 LIMBS
$138.44
95864
3
MUSCLE TEST, 4 LIMBS
$158.96
95865
3
MUSCLE TEST, LARYNX
$111.24
95866
3
MUSCLE TEST, HEMIDIAPHRAGM
$91.06
95867
3
MUSCLE TEST CRAN NERV UNILAT
$69.83
95868
3
MUSCLE TEST CRAN NERVE BILAT
$95.58
95869
3
MUSCLE TEST, THOR PARASPINAL
$44.86
95870
3
MUSCLE TEST, NONPARASPINAL
$43.76
95872
9
MUSCLE TEST, ONE FIBER
95873
3
GUIDE NERV DESTR, ELEC STIM
$45.61
95874
3
GUIDE NERV DESTR, NEEDLE EMG
$43.02
95875
3
LIMB EXERCISE TEST
$91.48
95880
O
ASSESSMENT OF APHASIA (INCLUDES ASS
$0.00
95881
O
DEVELOPMENTAL TESTING (INCLUDES ASS
$0.00
95882
O
NEUROBEHAVIORAL STATUS EXAM (CLINIC
$0.00
95883
O
NEUROPSYCHOLOGICAL TESTING BATTERY
$0.00
95900
3
MOTOR NERVE CONDUCTION TEST
$52.57
95903
3
MOTOR NERVE CONDUCTION TEST
$61.46
95904
3
SENSE NERVE CONDUCTION TEST
$46.38
95920
3
INTRAOP NERVE TEST ADD-ON
95921
3
AUTONOMIC NERV FUNCTION TEST
$72.42
95922
3
AUTONOMIC NERV FUNCTION TEST
$87.00
95923
3
AUTONOMIC NERV FUNCTION TEST
$114.81
95925
3
SOMATOSENSORY TESTING
$117.08
95926
3
SOMATOSENSORY TESTING
$114.99
95927
3
SOMATOSENSORY TESTING
$117.82
95928
3
C MOTOR EVOKED, UPPR LIMBS
$186.63
95929
3
C MOTOR EVOKED, LWR LIMBS
$196.99
95930
3
VISUAL EVOKED POTENTIAL TEST
$104.17
95933
3
BLINK REFLEX TEST
$0.00 $80.35
$0.00
$148.20
$63.04
Procedure Code Pricing Action Code Description
Maximum Allowable
95934
3
H-REFLEX TEST
$47.29
95935
O
''H'' OR ''F'' REFLEX STUDY, BY ELE
95936
3
H-REFLEX TEST
$41.55
95937
3
NEUROMUSCULAR JUNCTION TEST
$55.94
95950
3
AMBULATORY EEG MONITORING
95951
3
EEG MONITORING/VIDEORECORD
$0.00
95952
9
MONITORING FOR LOCALIZATION OF CERE
$0.00
95953
3
EEG MONITORING/COMPUTER
95954
9
EEG MONITORING/GIVING DRUGS
$0.00
95955
9
EEG DURING SURGERY
$0.00
95956
3
EEG MONITORING, CABLE/RADIO
$706.49
95957
3
EEG DIGITAL ANALYSIS
$257.43
95958
9
EEG MONITORING/FUNCTION TEST
95961
3
ELECTRODE STIMULATION, BRAIN
$226.53
95962
3
ELECTRODE STIM, BRAIN ADD-ON
$208.72
95965
3
MEG, SPONTANEOUS
$0.00
95966
3
MEG, EVOKED, SINGLE
$0.00
95967
3
MEG, EVOKED, EACH ADDÏL
$0.00
95970
3
ANALYZE NEUROSTIM, NO PROG
$49.33
95971
3
ANALYZE NEUROSTIM, SIMPLE
$56.17
95972
3
ANALYZE NEUROSTIM, COMPLEX
$99.84
95973
3
ANALYZE NEUROSTIM, COMPLEX
$54.52
95974
3
CRANIAL NEUROSTIM, COMPLEX
$167.24
95975
3
CRANIAL NEUROSTIM, COMPLEX
$92.46
95978
3
ANALYZE NEUROSTIM BRAIN/1H
$198.89
95979
3
ANALYZ NEUROSTIM BRAIN ADDON
$88.98
95980
3
IO ANAL GAST N-STIM INIT
$39.50
95981
3
IO ANAL GAST N-STIM SUBSQ
$27.47
95982
3
IO GA N-STIM SUBSQ W/REPROG
$42.54
95990
3
SPIN/BRAIN PUMP REFIL & MAIN
$59.11
95991
3
SPIN/BRAIN PUMP REFIL & MAIN
$86.99
95992
3
CANALITH REPOSITIONING PROC
$40.59
95999
5
NEUROLOGICAL PROCEDURE
$0.00
96000
9
MOTION ANALYSIS, VIDEO/3D
$0.00
96001
9
MOTION TEST W/FT PRESS MEAS
$0.00
$0.00
$234.77
$397.02
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
96002
9
DYNAMIC SURFACE EMG
$0.00
96003
9
DYNAMIC FINE WIRE EMG
$0.00
96004
9
PHYS REVIEW OF MOTION TESTS
$0.00
96020
3
FUNCTIONAL BRAIN MAPPING
$0.00
96040
9
GENETIC COUNSELING, 30 MIN
$0.00
96100
O
PSYCHOLOGICAL TESTING
$0.00
96101
3
PSYCHO TESTING BY PSYCH/PHYS
$83.56
96102
9
PSYCHO TESTING BY TECHNICIAN
$0.00
96103
9
PSYCHO TESTING ADMIN BY COMP
$0.00
96105
9
ASSESSMENT OF APHASIA
$0.00
96110
3
DEVELOPMENTAL TEST, LIM
96111
7
DEVELOPMENTAL TEST, EXTEND
$0.00
96115
O
NEUROBEHAVIOR STATUS EXAM
$0.00
96116
9
NEUROBEHAVIORAL STATUS EXAM
$0.00
96117
O
NEUROPSYCH TEST BATTERY
$0.00
96118
3
NEUROPSYCH TST BY PSYCH/PHYS
96119
9
NEUROPSYCH TESTING BY TEC
$0.00
96120
9
NEUROPSYCH TST ADMIN W/COMP
$0.00
96125
9
COGNITIVE TEST BY HC PRO
$0.00
96150
9
ASSESS HLTH/BEHAVE, INIT
$0.00
96151
9
ASSESS HLTH/BEHAVE, SUBSEQ
$0.00
96152
9
INTERVENE HLTH/BEHAVE, INDIV
$0.00
96153
9
INTERVENE HLTH/BEHAVE, GROUP
$0.00
96154
7
INTERV HLTH/BEHAV, FAM W/PT
$0.00
96155
7
INTERV HLTH/BEHAV FAM NO PT
$0.00
96360
3
HYDRATION IV INFUSION, INIT
$56.93
96361
3
HYDRATE IV INFUSION, ADD-ON
$16.38
96365
3
THER/PROPH/DIAG IV INF, INIT
$69.44
96366
3
THER/PROPH/DIAG IV INF ADDON
$21.81
96367
3
TX/PROPH/DG ADDL SEQ IV INF
$34.74
96368
3
THER/DIAG CONCURRENT INF
$20.34
96369
3
SC THER INFUSION, UP TO 1 HR
96370
3
SC THER INFUSION, ADDL HR
$15.52
96371
3
SC THER INFUSION, RESET PUMP
$74.19
96372
9
THER/PROPH/DIAG INJ, SC/IM
$10.97
$106.27
$152.39
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
96373
9
THER/PROPH/DIAG INJ, IA
$0.00
96374
9
THER/PROPH/DIAG INJ, IV PUSH
$0.00
96375
9
TX/PRO/DX INJ NEW DRUG ADDON
$0.00
96376
6
TX/PRO/DX INJ NEW DRUG ADON
$0.00
96379
9
THER/PROP/DIAG INJ/INF PROC
$0.00
96400
O
CHEMOTHERAPY, SC/IM
$0.00
96401
3
CHEMO, ANTI-NEOPL, SQ/IM
$68.75
96402
3
CHEMO HORMON ANTINEOPL SQ/IM
$37.35
96405
3
CHEMO INTRALESIONAL, UP TO 7
$85.48
96406
3
CHEMO INTRALESIONAL OVER 7
$118.04
96408
O
CHEMOTHERAPY, PUSH TECHNIQUE
96409
3
CHEMO, IV PUSH, SNGL DRUG
96410
O
CHEMOTHERAPY,INFUSION METHOD
96411
3
CHEMO, IV PUSH, ADDL DRUG
96412
O
CHEMO, INFUSE METHOD ADD-ON
96413
3
CHEMO, IV INFUSION, 1 HR
96414
O
CHEMO, INFUSE METHOD ADD-ON
96415
3
CHEMO, IV INFUSION, ADDL HR
96416
3
CHEMO PROLONG INFUSE W/PUMP
96417
3
CHEMO IV INFUS EACH ADDL SEQ
96420
3
CHEMO, IA, PUSH TECNIQUE
$109.29
96422
3
CHEMO IA INFUSION UP TO 1 HR
$176.95
96423
3
CHEMO IA INFUSE EACH ADDL HR
96425
3
CHEMOTHERAPY,INFUSION METHOD
$174.36
96440
3
CHEMOTHERAPY, INTRACAVITARY
$607.84
96445
3
CHEMOTHERAPY, INTRACAVITARY
$287.89
96450
3
CHEMOTHERAPY, INTO CNS
$210.26
96520
O
PORT PUMP REFILL & MAIN
96521
3
REFILL/MAINT, PORTABLE PUMP
$129.10
96522
3
REFILL/MAINT PUMP/RESVR SYST
$109.51
96523
3
IRRIG DRUG DELIVERY DEVICE
96530
O
SYST PUMP REFILL & MAIN
96542
3
CHEMOTHERAPY INJECTION
96545
O
PROVIDE CHEMOTHERAPY AGENT
$0.00
96549
5
CHEMOTHERAPY, UNSPECIFIED
$0.00
$0.00 $113.53 $0.00 $64.42 $0.00 $149.82 $0.00 $33.24 $163.59 $74.25
$79.02
$0.00
$25.70 $0.00 $135.69
Procedure Code Pricing Action Code Description
Maximum Allowable
96567
3
PHOTODYNAMIC TX, SKIN
$119.27
96570
3
PHOTODYNAMIC TX, 30 MIN
$56.73
96571
3
PHOTODYNAMIC TX, ADDL 15 MIN
$27.40
96900
3
ULTRAVIOLET LIGHT THERAPY
$19.71
96902
3
TRICHOGRAM
$20.81
96904
9
WHOLE BODY PHOTOGRAPHY
96910
3
PHOTOCHEMOTHERAPY WITH UV-B
$63.81
96912
3
PHOTOCHEMOTHERAPY WITH UV-A
$81.79
96913
3
PHOTOCHEMOTHERAPY, UV-A OR B
$113.31
96920
3
LASER TX, SKIN < 250 SQ CM
$162.46
96921
3
LASER TX, SKIN 250-500 SQ CM
$158.99
96922
3
LASER TX, SKIN > 500 SQ CM
$234.97
96999
5
DERMATOLOGICAL PROCEDURE
97001
3
PT EVALUATION
$69.59
97002
3
PT RE-EVALUATION
$37.45
97003
3
OT EVALUATION
$73.89
97004
3
OT RE-EVALUATION
$42.99
97005
9
ATHLETIC TRAIN EVAL
$0.00
97006
9
ATHLETIC TRAIN REEVAL
$0.00
97010
3
HOT OR COLD PACKS THERAPY
$4.61
97012
3
MECHANICAL TRACTION THERAPY
$14.35
97014
3
ELECTRIC STIMULATION THERAPY
$13.33
97016
3
VASOPNEUMATIC DEVICE THERAPY
$15.17
97018
3
PARAFFIN BATH THERAPY
$7.93
97020
O
MICROWAVE THERAPY
$0.00
97022
3
WHIRLPOOL THERAPY
$17.40
97024
3
DIATHERMY EG, MICROWAVE
$5.34
97026
3
INFRARED THERAPY
$4.97
97028
3
ULTRAVIOLET THERAPY
$6.06
97032
3
ELECTRICAL STIMULATION
$16.20
97033
3
ELECTRIC CURRENT THERAPY
$24.32
97034
3
CONTRAST BATH THERAPY
$14.77
97035
3
ULTRASOUND THERAPY
$11.44
97036
3
HYDROTHERAPY
$25.40
97039
3
PHYSICAL THERAPY TREATMENT
$11.27
$0.00
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
97110
3
THERAPEUTIC EXERCISES
$28.02
97112
3
NEUROMUSCULAR REEDUCATION
$28.89
97113
3
AQUATIC THERAPY/EXERCISES
$34.45
97114
O
PHYSICAL MEDICINE TREATMENT TO ONE
97116
3
GAIT TRAINING THERAPY
97118
O
PHYSICAL MEDICINE TREATMENT TO ONE
$0.00
97120
O
PHYSICAL MEDICINE TREATMENT TO ONE
$0.00
97122
O
MANUAL TRACTION THERAPY
$0.00
97124
3
MASSAGE THERAPY
97126
O
PHYSICAL MEDICINE TREATMENT TO ONE
$0.00
97128
O
PHYSICAL MEDICINE TREATMENT TO ONE
$0.00
97139
3
PHYSICAL MEDICINE PROCEDURE
$15.30
97140
3
MANUAL THERAPY
$25.96
97145
O
PHYSICAL MEDICINE TREATMENT TO ONE
97150
3
GROUP THERAPEUTIC PROCEDURES
97220
O
HUBBARD TANK; INITIAL 30 MINUTES, E
$0.00
97221
O
HUBBARD TANK; EACH ADDITIONAL 15 MI
$0.00
97240
O
POOL THERAPY OR HUBBARD TANK WITH T
$0.00
97241
O
POOL THERAPY OR HUBBARD TANK WITH T
$0.00
97250
O
MYOFASCIAL RELEASE
$0.00
97260
O
REGIONAL MANIPULATION
$0.00
97261
O
SUPPLEMENTAL MANIPULATIONS
$0.00
97265
O
JOINT MOBILIZATION
$0.00
97500
O
ORTHOTICS TRAINING (DYNAMIC BRACING
$0.00
97501
O
ORTHOTICS TRAINING (DYNAMIC BRACING
$0.00
97504
O
ORTHOTIC TRAINING
$0.00
97520
O
PROSTHETIC TRAINING
$0.00
97521
O
PROSTHETIC TRAINING; EACH ADDITIONA
$0.00
97530
3
THERAPEUTIC ACTIVITIES
97531
O
KINETIC ACTIVITIES TO INCREASE COOR
97532
3
COGNITIVE SKILLS DEVELOPMENT
$24.10
97533
3
SENSORY INTEGRATION
$25.94
97535
3
SELF CARE MNGMENT TRAINING
$29.63
97537
3
COMMUNITY/WORK REINTEGRATION
$26.68
97540
O
TRAINING IN ACTIVITIES OF DAILY LIV
$0.00
$0.00 $24.52
$22.36
$0.00 $17.65
$29.65 $0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
97541
O
TRAINING IN ACTIVITIES OF DAILY LIV
$0.00
97542
3
WHEELCHAIR MNGMENT TRAINING
97545
O
WORK HARDENING
$0.00
97546
O
WORK HARDENING ADD-ON
$0.00
97597
3
ACTIVE WOUND CARE/20 CM OR <
$58.53
97598
3
ACTIVE WOUND CARE > 20 CM
$72.30
97601
O
WOUND(S) CARE, SELECTIVE
$0.00
97602
9
WOUND(S) CARE NON-SELECTIVE
$0.00
97605
3
NEG PRESS WOUND TX, < 50 CM
$34.55
97606
3
NEG PRESS WOUND TX, > 50 CM
$36.95
97700
O
OFFICE VISIT, INCLUDING ONE OF THE
$0.00
97701
O
OFFICE VISIT, INCLUDING ONE OF THE
$0.00
97703
O
PROSTHETIC CHECKOUT
$0.00
97720
O
EXTREMITY TESTING FOR STRENGTH, DEX
$0.00
97721
O
EXTREMITY TESTING FOR STRENGTH, DEX
$0.00
97750
3
PHYSICAL PERFORMANCE TEST
97752
O
MUSCLE TESTING WITH TORQUE CURVES D
97755
3
ASSISTIVE TECHNOLOGY ASSESS
$32.99
97760
3
ORTHOTIC MGMT AND TRAINING
$31.96
97761
3
PROSTHETIC TRAINING
$28.39
97762
3
C/O FOR ORTHOTIC/PROSTH USE
$33.45
97770
O
COGNITIVE SKILLS DEVELOPMENT
$0.00
97780
O
ACUPUNCTURE W/O STIMUL
$0.00
97781
O
ACUPUNCTURE W/STIMUL
$0.00
97799
5
PHYSICAL MEDICINE PROCEDURE
$0.00
97802
7
MEDICAL NUTRITION, INDIV, IN
$0.00
97803
7
MED NUTRITION, INDIV, SUBSEQ
$0.00
97804
9
MEDICAL NUTRITION, GROUP
$0.00
97810
9
ACUPUNCT W/O STIMUL 15 MIN
$0.00
97811
9
ACUPUNCT W/O STIMUL ADDL 15M
$0.00
97813
9
ACUPUNCT W/STIMUL 15 MIN
$0.00
97814
9
ACUPUNCT W/STIMUL ADDL 15M
$0.00
98900
O
MEDICAL CONFERENCE BY PHYSICIAN REG
$0.00
98902
O
MEDICAL CONFERENCE BY PHYSICIAN REG
$0.00
98910
O
MEDICAL CONFERENCE BY PHYSICIAN WIT
$0.00
$27.04
$28.76 $0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
98912
O
MEDICAL CONFERENCE BY PHYSICIAN WIT
$0.00
98920
9
TELEPHONE CALL BY A PHYSICIAN TO PA
$0.00
98921
9
TELEPHONE CALL BY A PHYSICIAN TO PA
$0.00
98922
9
TELEPHONE CALL BY A PHYSICIAN TO PA
$0.00
98925
3
OSTEOPATHIC MANIPULATION
$27.66
98926
3
OSTEOPATHIC MANIPULATION
$37.99
98927
3
OSTEOPATHIC MANIPULATION
$49.19
98928
3
OSTEOPATHIC MANIPULATION
$57.73
98929
3
OSTEOPATHIC MANIPULATION
$66.28
98940
9
CHIROPRACTIC MANIPULATION
$0.00
98941
9
CHIROPRACTIC MANIPULATION
$0.00
98942
9
CHIROPRACTIC MANIPULATION
$0.00
98943
9
CHIROPRACTIC MANIPULATION
$0.00
98960
9
SELF-MGMT EDUC & TRAIN, 1 PT
$0.00
98961
9
SELF-MGMT EDUC/TRAIN, 2-4 PT
$0.00
98962
9
SELF-MGMT EDUC/TRAIN, 5-8 PT
$0.00
98966
9
HC PRO PHONE CALL 5-10 MIN
$0.00
98967
9
HC PRO PHONE CALL 11-20 MIN
$0.00
98968
9
HC PRO PHONE CALL 21-30 MIN
$0.00
98969
9
ONLINE SERVICE BY HC PRO
$0.00
99000
9
SPECIMEN HANDLING
$0.00
99001
3
SPECIMEN HANDLING
$3.10
99002
9
DEVICE HANDLING
$0.00
99024
9
POSTOP FOLLOW-UP VISIT
$0.00
99025
O
INITIAL SURGICAL EVALUATION
$0.00
99026
9
IN-HOSPITAL ON CALL SERVICE
$0.00
99027
9
OUT-OF-HOSP ON CALL SERVICE
$0.00
99050
3
MEDICAL SERVICES AFTER HRS
$20.00
99051
9
MED SERV, EVE/WKEND/HOLIDAY
$0.00
99052
O
MEDICAL SERVICES AT NIGHT
$0.00
99053
9
MED SERV 10PM-8AM, 24 HR FAC
$0.00
99054
O
MEDICAL SERVCS, UNUSUAL HRS
$0.00
99056
O
MED SERVICE OUT OF OFFICE
$0.00
99058
9
OFFICE EMERGENCY CARE
$0.00
99060
9
OUT OF OFFICE EMERG MED SERV
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
99062
O
EMERGENCY CARE FACILITY SERVICES: W
$0.00
99064
O
EMERGENCY CARE FACILITY SERVICES: W
$0.00
99065
O
EMERGENCY CARE FACILITY SERVICES: W
$0.00
99070
O
SPECIAL SUPPLIES
$0.00
99071
9
PATIENT EDUCATION MATERIALS
$0.00
99075
9
MEDICAL TESTIMONY
$0.00
99078
9
GROUP HEALTH EDUCATION
$0.00
99080
9
SPECIAL REPORTS OR FORMS
$0.00
99082
9
UNUSUAL PHYSICIAN TRAVEL
$0.00
99090
9
COMPUTER DATA ANALYSIS
$0.00
99091
9
COLLECT/REVIEW DATA FROM PT
$0.00
99100
9
SPECIAL ANESTHESIA SERVICE
$0.00
99116
9
ANESTHESIA WITH HYPOTHERMIA
$0.00
99135
9
SPECIAL ANESTHESIA PROCEDURE
$0.00
99140
9
EMERGENCY ANESTHESIA
$0.00
99141
O
SEDATION, IV/IM OR INHALANT
$0.00
99142
O
SEDATION, ORAL/RECTAL/NASAL
$0.00
99143
9
MOD CS BY SAME PHYS, < 5 YRS
$0.00
99144
9
MOD CS BY SAME PHYS, 5 YRS +
$0.00
99145
9
MOD CS BY SAME PHYS ADD-ON
$0.00
99148
3
MOD CS DIFF PHYS < 5 YRS
$112.36
99149
3
MOD CS DIFF PHYS 5 YRS +
$112.36
99150
3
MODERATE SEDATION SERVICES (OTHER
99151
O
PROLONGED PHYSICIAN ATTENDANCE REQU
$0.00
99152
O
NEWBORN RESUSCITATION: CARE OF THE
$0.00
99160
O
CRITICAL CARE, INITIAL, INCLUDING T
$0.00
99162
O
CRITICAL CARE, INITIAL, INCLUDING T
$0.00
99170
3
ANOGENITAL EXAM, CHILD
99171
O
CRITICAL CARE, SUBSEQUENT FOLLOW-UP
$0.00
99172
O
OCULAR FUNCTION SCREEN
$0.00
99173
3
VISUAL ACUITY SCREEN
$2.46
99174
3
OCULAR PHOTOSCREENING WITH INTERPR
$25.75
99175
3
INDUCTION OF VOMITING
$25.32
99178
O
ADMINISTRATION AND MEDICAL INTERPRE
$0.00
99180
O
HYPERBARIC OXYGEN PRESSURIZATION IN
$0.00
$56.18
$142.46
Procedure Code Pricing Action Code Description
Maximum Allowable
99182
O
HYPERBARIC OXYGEN PRESSURIZATION SU
$0.00
99183
3
HYPERBARIC OXYGEN THERAPY
99185
3
REGIONAL HYPOTHERMIA
$57.15
99186
3
TOTAL BODY HYPOTHERMIA
$72.53
99190
9
SPECIAL PUMP SERVICES
$0.00
99191
9
SPECIAL PUMP SERVICES
$0.00
99192
9
SPECIAL PUMP SERVICES
$0.00
99195
3
PHLEBOTOMY
99199
5
SPECIAL SERVICE/PROC/REPORT
$0.00
99201
3
OFFICE/OUTPATIENT VISIT, NEW
$36.76
99202
3
OFFICE/OUTPATIENT VISIT, NEW
$63.33
99203
3
OFFICE/OUTPATIENT VISIT, NEW
$91.44
99204
3
OFFICE/OUTPATIENT VISIT, NEW
$140.89
99205
3
OFFICE/OUTPATIENT VISIT, NEW
$177.71
99211
3
OFFICE/OUTPATIENT VISIT, EST
$18.88
99212
3
OFFICE/OUTPATIENT VISIT, EST
$37.13
99213
3
OFFICE/OUTPATIENT VISIT, EST
$61.32
99214
3
OFFICE/OUTPATIENT VISIT, EST
$92.24
99215
3
OFFICE/OUTPATIENT VISIT, EST
$124.40
99217
3
OBSERVATION CARE DISCHARGE
$66.03
99218
3
OBSERVATION CARE
$61.97
99219
3
OBSERVATION CARE
$102.53
99220
3
OBSERVATION CARE
$143.84
99221
3
INITIAL HOSPITAL CARE
$88.82
99222
3
INITIAL HOSPITAL CARE
$121.24
99223
3
INITIAL HOSPITAL CARE
$178.49
99231
3
SUBSEQUENT HOSPITAL CARE
$36.75
99232
3
SUBSEQUENT HOSPITAL CARE
$66.16
99233
3
SUBSEQUENT HOSPITAL CARE
$94.72
99234
3
OBSERV/HOSP SAME DATE
$125.65
99235
3
OBSERV/HOSP SAME DATE
$164.88
99236
3
OBSERV/HOSP SAME DATE
$204.84
99238
3
HOSPITAL DISCHARGE DAY
$65.80
99239
3
HOSPITAL DISCHARGE DAY
$95.45
99241
3
OFFICE CONSULTATION
$48.47
$189.12
$71.83
Procedure Code Pricing Action Code Description
Maximum Allowable
99242
3
OFFICE CONSULTATION
$90.21
99243
3
OFFICE CONSULTATION
$123.90
99244
3
OFFICE CONSULTATION
$183.10
99245
3
OFFICE CONSULTATION
$224.78
99251
3
INPATIENT CONSULTATION
$48.02
99252
3
INPATIENT CONSULTATION
$74.62
99253
3
INPATIENT CONSULTATION
$113.33
99254
3
INPATIENT CONSULTATION
$163.93
99255
3
INPATIENT CONSULTATION
$199.75
99261
O
FOLLOW-UP INPATIENT CONSULT
$0.00
99262
O
FOLLOW-UP INPATIENT CONSULT
$0.00
99263
O
FOLLOW-UP INPATIENT CONSULT
$0.00
99271
O
CONFIRMATORY CONSULTATION
$0.00
99272
O
CONFIRMATORY CONSULTATION
$0.00
99273
O
CONFIRMATORY CONSULTATION
$0.00
99274
O
CONFIRMATORY CONSULTATION
$0.00
99275
O
CONFIRMATORY CONSULTATION
$0.00
99281
3
EMERGENCY DEPT VISIT
$19.88
99282
3
EMERGENCY DEPT VISIT
$38.69
99283
3
EMERGENCY DEPT VISIT
$60.03
99284
3
EMERGENCY DEPT VISIT
$112.21
99285
3
EMERGENCY DEPT VISIT
$166.82
99288
9
DIRECT ADVANCED LIFE SUPPORT
$0.00
99289
O
PED CRIT CARE TRANSPORT
$0.00
99290
O
PED CRIT CARE TRANSPORT ADDL
$0.00
99291
3
CRITICAL CARE, FIRST HOUR
$251.98
99292
3
CRITICAL CARE, ADDÏL 30 MIN
$113.36
99293
O
PED CRITICAL CARE, INITIAL
$0.00
99294
O
PED CRITICAL CARE, SUBSEQ
$0.00
99295
O
NEONATE CRIT CARE, INITIAL
$0.00
99296
O
NEONATE CRITICAL CARE SUBSEQ
$0.00
99297
O
NEONATAL CRITICAL CARE
$0.00
99298
O
IC FOR LBW INFANT < 1500 GM
$0.00
99299
O
IC, LBW INFANT 1500-2500 GM
$0.00
99300
O
IC, INFANT PBW 2501-5000 GM
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
99301
O
NURSING FACILITY CARE
$0.00
99302
O
NURSING FACILITY CARE
$0.00
99303
O
NURSING FACILITY CARE
$0.00
99304
3
NURSING FACILITY CARE, INIT
$79.43
99305
3
NURSING FACILITY CARE, INIT
$110.86
99306
3
NURSING FACILITY CARE, INIT
$142.27
99307
3
NURSING FAC CARE, SUBSEQ
$39.34
99308
3
NURSING FAC CARE, SUBSEQ
$60.15
99309
3
NURSING FAC CARE, SUBSEQ
$79.75
99310
3
NURSING FAC CARE, SUBSEQ
$117.69
99311
O
NURSING FAC CARE, SUBSEQ
$0.00
99312
O
NURSING FAC CARE, SUBSEQ
$0.00
99313
O
NURSING FAC CARE, SUBSEQ
$0.00
99315
9
NURSING FAC DISCHARGE DAY
$0.00
99316
9
NURSING FAC DISCHARGE DAY
$0.00
99318
3
ANNUAL NURSING FAC ASSESSMNT
99321
O
REST HOME VISIT, NEW PATIENT
$0.00
99322
O
REST HOME VISIT, NEW PATIENT
$0.00
99323
O
REST HOME VISIT, NEW PATIENT
$0.00
99324
9
DOMICIL/R-HOME VISIT NEW PAT
$0.00
99325
9
DOMICIL/R-HOME VISIT NEW PAT
$0.00
99326
9
DOMICIL/R-HOME VISIT NEW PAT
$0.00
99327
9
DOMICIL/R-HOME VISIT NEW PAT
$0.00
99328
9
DOMICIL/R-HOME VISIT NEW PAT
$0.00
99331
O
REST HOME VISIT, EST PAT
$0.00
99332
O
REST HOME VISIT, EST PAT
$0.00
99333
O
REST HOME VISIT, EST PAT
$0.00
99334
9
DOMICIL/R-HOME VISIT EST PAT
$0.00
99335
9
DOMICIL/R-HOME VISIT EST PAT
$0.00
99336
9
DOMICIL/R-HOME VISIT EST PAT
$0.00
99337
9
DOMICIL/R-HOME VISIT EST PAT
$0.00
99339
9
DOMICIL/R-HOME CARE SUPERVIS
$0.00
99340
9
DOMICIL/R-HOME CARE SUPERVIS
$0.00
99341
3
HOME VISIT, NEW PATIENT
$53.56
99342
3
HOME VISIT, NEW PATIENT
$77.80
$83.01
Procedure Code Pricing Action Code Description
Maximum Allowable
99343
3
HOME VISIT, NEW PATIENT
$124.97
99344
3
HOME VISIT, NEW PATIENT
$163.83
99345
3
HOME VISIT, NEW PATIENT
$196.94
99347
3
HOME VISIT, EST PATIENT
$52.22
99348
3
HOME VISIT, EST PATIENT
$78.63
99349
3
HOME VISIT, EST PATIENT
$114.26
99350
3
HOME VISIT, EST PATIENT
$159.14
99351
O
HOME VISIT FOR THE EVALUATION AND M
$0.00
99352
O
HOME VISIT FOR THE EVALUATION AND M
$0.00
99353
O
HOME VISIT FOR THE EVALUATION AND M
$0.00
99354
3
PROLONGED SERVICE, OFFICE
$91.04
99355
3
PROLONGED SERVICE, OFFICE
$90.07
99356
3
PROLONGED SERVICE, INPATIENT
$82.75
99357
3
PROLONGED SERVICE, INPATIENT
$83.36
99358
9
PROLONGED SERV, W/O CONTACT
$0.00
99359
9
PROLONGED SERV, W/O CONTACT
$0.00
99360
3
PHYSICIAN STANDBY SERVICES
$58.87
99361
O
PHYSICIAN/TEAM CONFERENCE
$0.00
99362
O
PHYSICIAN/TEAM CONFERENCE
$0.00
99363
9
ANTICOAG MGMT, INIT
$0.00
99364
9
ANTICOAG MGMT, SUBSEQ
$0.00
99366
9
TEAM CONF W/PAT BY HC PRO
$0.00
99367
9
TEAM CONF W/O PAT BY PHYS
$0.00
99368
9
TEAM CONF W/O PAT BY HC PRO
$0.00
99371
O
PHYSICIAN PHONE CONSULTATION
$0.00
99372
O
PHYSICIAN PHONE CONSULTATION
$0.00
99373
O
PHYSICIAN PHONE CONSULTATION
$0.00
99374
9
HOME HEALTH CARE SUPERVISION
$0.00
99375
9
HOME HEALTH CARE SUPERVISION
$0.00
99376
9
PHYSICIAN SUPERVISION OF PATIENTS U
$0.00
99377
9
HOSPICE CARE SUPERVISION
$0.00
99378
9
HOSPICE CARE SUPERVISION
$0.00
99379
9
NURSING FAC CARE SUPERVISION
$0.00
99380
9
NURSING FAC CARE SUPERVISION
$0.00
99381
3
INIT PM E/M, NEW PAT, INF
$90.68
Procedure Code Pricing Action Code Description
Maximum Allowable
99382
3
INIT PM E/M, NEW PAT 1-4 YRS
$98.60
99383
3
PREV VISIT, NEW, AGE 5-11
$97.86
99384
3
PREV VISIT, NEW, AGE 12-17
$106.39
99385
3
PREV VISIT, NEW, AGE 18-39
$106.39
99386
3
PREV VISIT, NEW, AGE 40-64
$124.31
99387
3
INIT PM E/M, NEW PAT 65+ YRS
$136.29
99391
3
PER PM REEVAL, EST PAT, INF
$75.49
99392
3
PREV VISIT, EST, AGE 1-4
$84.02
99393
3
PREV VISIT, EST, AGE 5-11
$83.65
99394
3
PREV VISIT, EST, AGE 12-17
$91.94
99395
3
PREV VISIT, EST, AGE 18-39
$92.32
99396
3
PREV VISIT, EST, AGE 40-64
$100.84
99397
3
PER PM REEVAL EST PAT 65+ YR
$113.19
99401
7
PREVENTIVE COUNSELING, INDIV
$0.00
99402
7
PREVENTIVE COUNSELING, INDIV
$0.00
99403
7
PREVENTIVE COUNSELING, INDIV
$0.00
99404
7
PREVENTIVE COUNSELING, INDIV
$0.00
99406
9
BEHAV CHNG SMOKING 3-10 MIN
$0.00
99407
9
BEHAV CHNG SMOKING > 10 MIN
$0.00
99408
9
AUDIT/DAST, 15-30 MIN
$0.00
99409
9
AUDIT/DAST, OVER 30 MIN
$0.00
99411
9
PREVENTIVE COUNSELING, GROUP
$0.00
99412
9
PREVENTIVE COUNSELING, GROUP
$0.00
99420
9
HEALTH RISK ASSESSMENT TEST
$0.00
99429
9
UNLISTED PREVENTIVE SERVICE
$0.00
99431
O
INITIAL CARE, NORMAL NEWBORN
$0.00
99432
O
NEWBORN CARE, NOT IN HOSP
$0.00
99433
O
NORMAL NEWBORN CARE/HOSPITAL
$0.00
99435
O
NEWBORN DISCHARGE DAY HOSP
$0.00
99436
O
ATTENDANCE, BIRTH
$0.00
99438
9
INFANT CARE TO ONE YEAR OF AGE, WIT
$0.00
99440
O
NEWBORN RESUSCITATION
$0.00
99441
9
PHONE E/M BY PHYS 5-10 MIN
$0.00
99442
9
PHONE E/M BY PHYS 11-20 MIN
$0.00
99443
9
PHONE E/M BY PHYS 21-30 MIN
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
99444
9
ONLINE E/M BY PHYS
$0.00
99450
9
BASIC LIFE DISABILITY EXAM
$0.00
99455
9
WORK RELATED DISABILITY EXAM
$0.00
99456
9
DISABILITY EXAMINATION
$0.00
99460
3
INIT NB EM PER DAY, HOSP
$55.58
99461
3
INIT NB EM PER DAY, NON-FAC
$84.04
99462
3
SBSQ NB EM PER DAY, HOSP
$29.65
99463
3
SAME DAY NB DISCHARGE
$74.64
99464
3
ATTENDANCE AT DELIVERY
$69.83
99465
3
NB RESUSCITATION
$143.44
99466
3
PED CRIT CARE TRANSPORT
$228.67
99467
3
PED CRIT CARE TRANSPORT ADDL
$114.15
99468
3
NEONATE CRIT CARE, INITIAL
$854.56
99469
3
NEONATE CRIT CARE, SUBSQ
$374.89
99471
3
PED CRITICAL CARE, INITIAL
$763.14
99472
3
PED CRITICAL CARE, SUBSQ
$378.01
99475
3
PED CRIT CARE AGE 2-5, INIT
$525.56
99476
3
PED CRIT CARE AGE 2-5, SUBSQ
$313.16
99477
3
INIT DAY HOSP NEONATE CARE
$333.60
99478
3
IC, LBW INF < 1500 GM SUBSQ
$135.98
99479
3
IC LBW INF 1500-2500 G SUBSQ
$119.42
99480
3
IC INF PBW 2501-5000 G SUBSQ
$114.87
99499
5
UNLISTED E&M SERVICE
$0.00
99500
9
HOME VISIT, PRENATAL
$0.00
99501
9
HOME VISIT, POSTNATAL
$0.00
99502
9
HOME VISIT, NB CARE
$0.00
99503
9
HOME VISIT, RESP THERAPY
$0.00
99504
9
HOME VISIT MECH VENTILATOR
$0.00
99505
9
HOME VISIT, STOMA CARE
$0.00
99506
9
HOME VISIT, IM INJECTION
$0.00
99507
9
HOME VISIT, CATH MAINTAIN
$0.00
99508
9
HOME VISIT, SLEEP STUDIES
$0.00
99509
9
HOME VISIT DAY LIFE ACTIVITY
$0.00
99510
7
HOME VISIT, SING/M/FAM COUNS
$0.00
99511
9
HOME VISIT, FECAL/ENEMA MGMT
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
99512
9
HOME VISIT FOR HEMODIALYSIS
$0.00
99539
9
HOME VISIT, NOS
$0.00
99551
O
HOME INFUS, PAIN MGMT, IV/SC
$0.00
99552
O
HM INFUS PAIN MGMT, EPID/ITH
$0.00
99553
O
HOME INFUSE, TOCOLYTIC TX
$0.00
99554
O
HOME INFUS, HORMONE/PLATELET
$0.00
99555
O
HOME INFUSE, CHEMOTHERAPHY
$0.00
99556
O
HOME INFUS, ANTIBIO/FUNG/VIR
$0.00
99557
O
HOME INFUSE, ANTICOAGULANT
$0.00
99558
O
HOME INFUSE, IMMUNOTHERAPY
$0.00
99559
O
HOME INFUS, PERITON DIALYSIS
$0.00
99560
O
HOME INFUS, ENTERO NUTRITION
$0.00
99561
O
HOME INFUSE, HYDRATION TX
$0.00
99562
O
HOME INFUS, PARENT NUTRITION
$0.00
99563
O
HOME ADMIN, PENTAMIDINE
$0.00
99564
O
HME INFUS, ANTIHEMOPHIL AGNT
$0.00
99565
O
HOME INFUS, PROTEINASE INHIB
$0.00
99566
O
HOME INFUSE, IV THERAPY
$0.00
99567
O
HOME INFUSE, SYMPATH AGENT
$0.00
99568
O
HOME INFUS, MISC DRUG, DAILY
$0.00
99569
O
HOME INFUSE, EACH ADDL TX
$0.00
99600
9
HOME VISIT NOS
$0.00
99601
9
HOME INFUSION/VISIT, 2 HRS
$0.00
99602
9
HOME INFUSION, EACH ADDTL HR
$0.00
99605
9
MTMS BY PHARM, NP, 15 MIN
$0.00
99606
9
MTMS BY PHARM, EST, 15 MIN
$0.00
99607
9
MTMS BY PHARM, ADDL 15 MIN
$0.00
A0010
9
AMBULANCE SERVICE, BASIC LIFE SUPPO
$0.00
A0020
9
AMBULANCE SERVICE, (BLS) PER MILE,
$0.00
A0021
9
OUTSIDE STATE AMBULANCE SERV
$0.00
A0030
9
AIR AMBULANCE SERVICE
$0.00
A0040
O
HELICOPTER AMBULANCE SERVICE
$0.00
A0050
9
WATER AMB SERVICE EMERGENCY
$0.00
A0060
9
AMBULANCE SERVICE, WAITING TIME, ON
$0.00
A0070
O
AMBULANCE SERVICE, OXYGEN, ADMINIST
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
A0080
9
NONINTEREST ESCORT IN NON ER
$0.00
A0090
3
INTEREST ESCORT IN NON ER
$0.20
A0100
7
NONEMERGENCY TRANSPORT TAXI
$0.00
A0110
7
NONEMERGENCY TRANSPORT BUS
$0.00
A0120
7
NONER TRANSPORT MINI-BUS
$0.00
A0130
3
NONER TRANSPORT WHEELCH VAN
A0140
5
NONEMERGENCY TRANSPORT AIR
$0.00
A0150
O
NON-EMERGENCY TRANSPORTATION, AMBUL
$0.00
A0160
9
NONER TRANSPORT CASE WORKER
$0.00
A0170
5
TRANSPORT PARKING FEES/TOLLS
$0.00
A0180
5
NONER TRANSPORT LODGNG RECIP
$0.00
A0190
5
NONER TRANSPORT MEALS RECIP
$0.00
A0200
5
NONER TRANSPORT LODGNG ESCRT
$0.00
A0210
5
NONER TRANSPORT MEALS ESCORT
$0.00
A0215
9
AMBULANCE SERVICE, MISCELLANEOUS DI
$0.00
A0220
9
AMBULANCE SERVICE, ADVANCED LIFE SU
$0.00
A0221
9
AMBULANCE SERVICE, (ALS) PER MILE,
$0.00
A0222
9
AMBULANCE SERVICE, RETURN TRIP, TRA
$0.00
A0223
9
AMBULANCE SERVICE, ADVANCED LIFE SU
$0.00
A0225
3
NEONATAL EMERGENCY TRANSPORT
A0300
9
AMBULANCE BASIC NON-EMER ALL
$0.00
A0302
9
AMBULANCE BASIC EMERGENY ALL
$0.00
A0304
9
AMB ADV NON-ER NO SERV ALL
$0.00
A0306
9
AMB ADV NON-ER SPEC SERV ALL
$0.00
A0308
9
AMB ADV ER NO SPEC SERV ALL
$0.00
A0310
9
AMB ADV ER SPEC SERV ALL
$0.00
A0320
9
AMB BASIC NON-ER + SUPPLIES
$0.00
A0322
9
AMB BASIC EMERG + SUPPLIES
$0.00
A0324
9
ADV NON-ER SERV SEP MILEAGE
$0.00
A0326
9
ADV NON-ER NO SERV SEP MILE
$0.00
A0328
9
ADV ER NO SERV SEP MILEAGE
$0.00
A0330
9
ADV ER SPEC SERV SEP MILE
$0.00
A0340
9
AMB BASIC NON-ER + MILEAGE
$0.00
A0342
9
AMBUL BASIC EMER + MILEAGE
$0.00
A0344
9
AMB ADV NON-ER NO SERV +MILE
$0.00
$11.01
$95.00
Procedure Code Pricing Action Code Description
Maximum Allowable
A0346
9
AMB ADV NON-ER SERV + MILE
$0.00
A0348
9
ADV EMER NO SPEC SERV + MILE
$0.00
A0350
9
ADV EMER SPEC SERV + MILEAGE
$0.00
A0360
9
BASIC NON-ER SEP MILE & SUPP
$0.00
A0362
9
BASIC EMER SEP MILE & SUPPLY
$0.00
A0364
9
ADV NON-ER NO SERV SEP MI&SU
$0.00
A0366
9
ADV NON-ER SERV SEP MIL&SUPP
$0.00
A0368
9
ADV ER NO SERV SEP MILE&SUPP
$0.00
A0370
9
ADV ER SPEC SERV SEP MI&SUPP
$0.00
A0380
3
BASIC LIFE SUPPORT MILEAGE
$1.50
A0382
9
BASIC SUPPORT ROUTINE SUPPLS
$0.00
A0384
9
BLS DEFIBRILLATION SUPPLIES
$0.00
A0390
3
ADVANCED LIFE SUPPORT MILEAG
$1.50
A0392
9
ALS DEFIBRILLATION SUPPLIES
$0.00
A0394
9
ALS IV DRUG THERAPY SUPPLIES
$0.00
A0396
9
ALS ESOPHAGEAL INTUB SUPPLS
$0.00
A0398
9
ALS ROUTINE DISPOSBLE SUPPLS
$0.00
A0420
9
AMBULANCE WAITING 1/2 HR
$0.00
A0422
3
AMBULANCE 02 LIFE SUSTAINING
$12.00
A0424
5
EXTRA AMBULANCE ATTENDANT
$0.00
A0425
9
GROUND MILEAGE
$0.00
A0426
3
ALS 1
$35.00
A0427
3
ALS1-EMERGENCY
$55.00
A0428
3
BLS
$35.00
A0429
3
BLS-EMERGENCY
$55.00
A0430
9
FIXED WING AIR TRANSPORT
A0431
3
ROTARY WING AIR TRANSPORT
$2,124.00
A0432
9
PI VOLUNTEER AMBULANCE CO
$0.00
A0433
9
ALS 2
$0.00
A0434
9
SPECIALTY CARE TRANSPORT
$0.00
A0435
9
FIXED WING AIR MILEAGE
$0.00
A0436
3
ROTARY WING AIR MILEAGE
A0800
O
AMB TRANS 7PM-7AM
$0.00
A0888
9
NONCOVERED AMBULANCE MILEAGE
$0.00
A0998
9
AMBULANCE RESPONSE/TREATMENT
$0.00
$0.00
$12.80
Procedure Code Pricing Action Code Description
Maximum Allowable
A0999
9
UNLISTED AMBULANCE SERVICE
$0.00
A2000
9
MANIPULATION OF SPINE BY CHIROPRACT
$0.00
A4190
O
TRANSPARENT FILM, EACH
$0.00
A4200
O
GAUZE PADS, MEDICATED OR NON-MEDICA
$0.00
A4202
O
GAUZE, ELASTIC, ALL TYPES, PER ROLL
$0.00
A4203
O
GAUZE, NON-ELASTIC, PER ROLL
$0.00
A4204
O
ABSORPTIVE DRESSING (E.G. HYDROCOLL
$0.00
A4205
O
NON-ABSORPTIVE DRESSING (E.G. HYDRO
$0.00
A4206
3
1 CC STERILE SYRINGE&NEEDLE
$0.22
A4207
3
2 CC STERILE SYRINGE&NEEDLE
$0.20
A4208
3
3 CC STERILE SYRINGE&NEEDLE
$0.18
A4209
3
5+ CC STERILE SYRINGE&NEEDLE
$0.36
A4210
3
NONNEEDLE INJECTION DEVICE
$1.50
A4211
O
SUPP FOR SELF-ADM INJECTIONS
$0.00
A4212
5
NON CORING NEEDLE OR STYLET
$0.00
A4213
3
20+ CC SYRINGE ONLY
$0.68
A4214
O
30 CC STERILE WATER/SALINE
$0.00
A4215
5
STERILE NEEDLE
$0.00
A4216
3
STERILE WATER/SALINE, 10 ML
$0.54
A4217
3
STERILE WATER/SALINE, 500 ML
$3.13
A4218
6
STERILE SALINE OR WATER
$0.00
A4220
9
INFUSION PUMP REFILL KIT
$0.00
A4221
3
MAINT DRUG INFUS CATH PER WK
$22.52
A4222
3
INFUSION SUPPLIES WITH PUMP
$46.50
A4223
6
INFUSION SUPPLIES W/O PUMP
$0.00
A4230
3
INFUS INSULIN PUMP NON NEEDL
$10.07
A4231
5
INFUSION INSULIN PUMP NEEDLE
$0.00
A4232
3
SYRINGE W/NEEDLE INSULIN 3CC
$2.54
A4233
6
ALKALIN BATT FOR GLUCOSE MON
$0.00
A4234
6
J-CELL BATT FOR GLUCOSE MON
$0.00
A4235
3
LITHIUM BATT FOR GLUCOSE MON
$2.34
A4236
6
SILVR OXIDE BATT GLUCOSE MON
$0.00
A4244
3
ALCOHOL OR PEROXIDE PER PINT
$1.00
A4245
3
ALCOHOL WIPES PER BOX
$10.00
A4246
3
BETADINE/PHISOHEX SOLUTION
$10.00
Procedure Code Pricing Action Code Description
Maximum Allowable
A4247
3
BETADINE/IODINE SWABS/WIPES
$8.00
A4248
6
CHLORHEXIDINE ANTISEPT
$0.00
A4250
3
URINE REAGENT STRIPS/TABLETS
A4252
6
BLOOD KETONE TEST OR STRIP
$0.00
A4253
9
BLOOD GLUCOSE/REAGENT STRIPS
$0.00
A4254
O
BATTERY FOR GLUCOSE MONITOR
$0.00
A4255
9
GLUCOSE MONITOR PLATFORMS
$0.00
A4256
9
CALIBRATOR SOLUTION/CHIPS
$0.00
A4257
9
REPLACE LENSSHIELD CARTRIDGE
$0.00
A4258
9
LANCET DEVICE EACH
$0.00
A4259
9
LANCETS PER BOX
$0.00
A4260
O
LEVONORGESTREL (CONTRACEPTIVE) IMP
$0.00
A4261
9
CERVICAL CAP CONTRACEPTIVE
$0.00
A4262
9
TEMPORARY TEAR DUCT PLUG
$0.00
A4263
9
PERMANENT TEAR DUCT PLUG
$0.00
A4265
9
PARAFFIN
$0.00
A4266
9
DIAPHRAGM
$0.00
A4267
9
MALE CONDOM
$0.00
A4268
9
FEMALE CONDOM
$0.00
A4269
9
SPERMICIDE
$0.00
A4270
9
DISPOSABLE ENDOSCOPE SHEATH
$0.00
A4280
3
BRST PRSTHS ADHSV ATTCHMNT
$4.62
A4281
5
REPLACEMENT BREASTPUMP TUBE
$0.00
A4282
5
REPLACEMENT BREASTPUMP ADPT
$0.00
A4283
5
REPLACEMENT BREASTPUMP CAP
$0.00
A4284
5
REPLCMNT BREAST PUMP SHIELD
$0.00
A4285
5
REPLCMNT BREAST PUMP BOTTLE
$0.00
A4286
5
REPLCMNT BREASTPUMP LOK RING
$0.00
A4290
5
SACRAL NERVE STIM TEST LEAD
$0.00
A4300
9
CATH IMPL VASC ACCESS PORTAL
$0.00
A4301
9
IMPLANTABLE ACCESS SYST PERC
$0.00
A4305
3
DRUG DELIVERY SYSTEM >=50 ML
$17.04
A4306
3
DRUG DELIVERY SYSTEM <=50 ML
$29.64
A4310
3
INSERT TRAY W/O BAG/CATH
A4311
3
CATHETER W/O BAG 2-WAY LATEX
$17.25
$6.81 $12.04
Procedure Code Pricing Action Code Description
Maximum Allowable
A4312
3
CATH W/O BAG 2-WAY SILICONE
$14.62
A4313
3
CATHETER W/BAG 3-WAY
$17.31
A4314
3
CATH W/DRAINAGE 2-WAY LATEX
$22.90
A4315
3
CATH W/DRAINAGE 2-WAY SILCNE
$24.61
A4316
3
CATH W/DRAINAGE 3-WAY
$25.71
A4319
O
STERILE H2O IRRIGATION SOLUT
$0.00
A4320
3
IRRIGATION TRAY
$4.81
A4321
9
CATH THERAPEUTIC IRRIG AGENT
$0.00
A4322
3
IRRIGATION SYRINGE
$2.81
A4323
O
SALINE IRRIGATION SOLUTION
$0.00
A4324
O
MALE EXT CATH W/ADH COATING
$0.00
A4325
O
MALE EXT CATH W/ADH STRIP
$0.00
A4326
3
MALE EXTERNAL CATHETER
$10.29
A4327
3
FEM URINARY COLLECT DEV CUP
$40.32
A4328
3
FEM URINARY COLLECT POUCH
$9.97
A4329
O
EXTERNAL CATHETER START SET
$0.00
A4330
3
STOOL COLLECTION POUCH
$6.82
A4331
3
EXTENSION DRAINAGE TUBING
$3.04
A4332
3
LUBE STERILE PACKET
$0.12
A4333
3
URINARY CATH ANCHOR DEVICE
$2.10
A4334
3
URINARY CATH LEG STRAP
$4.71
A4335
5
INCONTINENCE SUPPLY
$0.00
A4338
3
INDWELLING CATHETER LATEX
$10.08
A4340
3
INDWELLING CATHETER SPECIAL
$30.28
A4344
3
CATH INDW FOLEY 2 WAY SILICN
$12.99
A4346
3
CATH INDW FOLEY 3 WAY
$16.26
A4347
O
MALE EXTERNAL CATHETER
$0.00
A4348
O
MALE EXT CATH EXTENDED WEAR
$0.00
A4349
3
DISPOSABLE MALE EXTERNAL CAT
$2.02
A4350
9
CATHETER CARE KIT
$0.00
A4351
3
STRAIGHT TIP URINE CATHETER
$1.66
A4352
3
COUDE TIP URINARY CATHETER
$6.12
A4353
3
INTERMITTENT URINARY CATH
$6.66
A4354
3
CATH INSERTION TRAY W/BAG
$11.16
A4355
3
BLADDER IRRIGATION TUBING
$8.50
Procedure Code Pricing Action Code Description
Maximum Allowable
A4356
3
EXT URETH CLMP OR COMPR DVC
$43.52
A4357
3
BEDSIDE DRAINAGE BAG
$8.77
A4358
3
URINARY LEG OR ABDOMEN BAG
$6.33
A4359
O
URINARY SUSPENSORY W/O LEG B
$0.00
A4360
9
ADULT INCONTINENCE GARMENT
$0.00
A4361
3
OSTOMY FACE PLATE
$17.42
A4362
3
SOLID SKIN BARRIER
$3.30
A4363
6
OSTOMY CLAMP
$0.00
A4364
3
ADHESIVE, LIQUID OR EQUAL
$2.80
A4365
3
ADHESIVE REMOVER WIPES
$10.80
A4366
6
OSTOMY VENT
$0.00
A4367
3
OSTOMY BELT
$7.01
A4368
9
OSTOMY FILTER
$0.00
A4369
3
SKIN BARRIER LIQUID PER OZ
$2.30
A4370
O
SKIN BARRIER PASTE PER OZ
$0.00
A4371
3
SKIN BARRIER POWDER PER OZ
$3.48
A4372
3
SKIN BARRIER SOLID 4X4 EQUIV
$3.98
A4373
3
SKIN BARRIER WITH FLANGE
$5.99
A4374
O
SKIN BARRIER EXTENDED WEAR
$0.00
A4375
3
DRAINABLE PLASTIC PCH W FCPL
$16.38
A4376
3
DRAINABLE RUBBER PCH W FCPLT
$45.38
A4377
3
DRAINABLE PLSTIC PCH W/O FP
A4378
3
DRAINABLE RUBBER PCH W/O FP
$29.33
A4379
3
URINARY PLASTIC POUCH W FCPL
$14.33
A4380
3
URINARY RUBBER POUCH W FCPLT
$35.60
A4381
3
URINARY PLASTIC POUCH W/O FP
$4.40
A4382
3
URINARY HVY PLSTC PCH W/O FP
$23.48
A4383
3
URINARY RUBBER POUCH W/O FP
$26.89
A4384
3
OSTOMY FACEPLT/SILICONE RING
$9.18
A4385
3
OST SKN BARRIER SLD EXT WEAR
$4.86
A4386
O
OST SKN BARRIER W FLNG EX WR
$0.00
A4387
3
OST CLSD POUCH W ATT ST BARR
$3.83
A4388
3
DRAINABLE PCH W EX WEAR BARR
$4.16
A4389
3
DRAINABLE PCH W ST WEAR BARR
$5.93
A4390
3
DRAINABLE PCH EX WEAR CONVEX
$9.17
$4.09
Procedure Code Pricing Action Code Description
Maximum Allowable
A4391
3
URINARY POUCH W EX WEAR BARR
$6.74
A4392
3
URINARY POUCH W ST WEAR BARR
$6.34
A4393
3
URINE PCH W EX WEAR BAR CONV
$8.75
A4394
3
OSTOMY POUCH LIQ DEODORANT
$2.46
A4395
3
OSTOMY POUCH SOLID DEODORANT
$0.05
A4396
3
PERISTOMAL HERNIA SUPPRT BLT
A4397
3
IRRIGATION SUPPLY SLEEVE
A4398
3
OSTOMY IRRIGATION BAG
$13.17
A4399
3
OSTOMY IRRIG CONE/CATH W BRS
$11.70
A4400
3
OSTOMY IRRIGATION SET
$46.62
A4402
3
LUBRICANT PER OUNCE
$1.32
A4404
3
OSTOMY RING EACH
$1.52
A4405
3
NONPECTIN BASED OSTOMY PASTE
$3.40
A4406
3
PECTIN BASED OSTOMY PASTE
$5.74
A4407
3
EXT WEAR OST SKN BARR <=4SQÊ
$8.76
A4408
3
EXT WEAR OST SKN BARR >4SQÊ
$9.87
A4409
3
OST SKN BARR CONVEX <=4 SQ I
$6.22
A4410
3
OST SKN BARR EXTND >4 SQ
$9.04
A4411
6
OST SKN BARR EXTND =4SQ
$0.00
A4412
6
OST POUCH DRAIN HIGH OUTPUT
$0.00
A4413
3
2 PC DRAINABLE OST POUCH
$5.50
A4414
3
OST SKNBAR W/O CONV<=4 SQ IN
$4.93
A4415
3
OST SKN BARR W/O CONV >4 SQI
$6.00
A4416
3
OST PCH CLSD W BARRIER/FILTR
$2.75
A4417
6
OST PCH W BAR/BLTINCONV/FLTR
$0.00
A4418
6
OST PCH CLSD W/O BAR W FILTR
$0.00
A4419
3
OST PCH FOR BAR W FLANGE/FLT
$1.74
A4420
6
OST PCH CLSD FOR BAR W LK FL
$0.00
A4421
3
OSTOMY SUPPLY MISC
A4422
3
OST POUCH ABSORBENT MATERIAL
$0.12
A4423
3
OST PCH FOR BAR W LK FL/FLTR
$1.86
A4424
3
OST PCH DRAIN W BAR & FILTER
$4.75
A4425
3
OST PCH DRAIN FOR BARRIER FL
$3.58
A4426
3
OST PCH DRAIN 2 PIECE SYSTEM
$2.73
A4427
3
OST PCH DRAIN/BARR LK FLNG/F
$2.78
$38.61 $4.57
$200.00
Procedure Code Pricing Action Code Description
Maximum Allowable
A4428
3
URINE OST POUCH W FAUCET/TAP
$6.51
A4429
3
URINE OST POUCH W BLTINCONV
$8.25
A4430
3
OST URINE PCH W B/BLTIN CONV
$8.52
A4431
3
OST PCH URINE W BARRIER/TAPV
$6.22
A4432
3
OS PCH URINE W BAR/FANGE/TAP
$3.59
A4433
3
URINE OST PCH BAR W LOCK FLN
$3.34
A4434
3
OST PCH URINE W LOCK FLNG/FT
$3.76
A4450
3
NON-WATERPROOF TAPE
$0.09
A4452
3
WATERPROOF TAPE
$0.36
A4454
O
TAPE ALL TYPES ALL SIZES
$0.00
A4455
3
ADHESIVE REMOVER PER OUNCE
$1.33
A4458
5
REUSABLE ENEMA BAG
$0.00
A4460
O
ELASTIC COMPRESSION BANDAGE
$0.00
A4461
6
SURGICL DRESS HOLD NON-REUSE
$0.00
A4462
O
ABDMNL DRSSNG HOLDER/BINDER
$0.00
A4463
6
SURGICAL DRESS HOLDER REUSE
$0.00
A4464
O
JOINT SUPPORT DEVICE/GARMENT
$0.00
A4465
9
NON-ELASTIC EXTREMITY BINDER
$0.00
A4470
5
GRAVLEE JET WASHER
$0.00
A4480
3
VABRA ASPIRATOR
A4481
9
TRACHEOSTOMA FILTER
$0.00
A4483
3
MOISTURE EXCHANGER
$2.86
A4490
3
ABOVE KNEE SURGICAL STOCKING
$60.00
A4495
3
THIGH LENGTH SURG STOCKING
$60.00
A4500
3
BELOW KNEE SURGICAL STOCKING
$30.00
A4510
3
FULL LENGTH SURG STOCKING
$60.00
A4520
9
INCONTINENCE GARMENT ANYTYPE
$0.00
A4521
O
ADULT SIZE DIAPER SM EACH
$0.00
A4522
O
ADULT SIZE DIAPER MED EACH
$0.00
A4523
O
ADULT SIZE DIAPER LG EACH
$0.00
A4524
O
ADULT SIZE DIAPER XL EACH
$0.00
A4525
O
ADULT SIZE BRIEF SM EACH
$0.00
A4526
O
ADULT SIZE BRIEF MED EACH
$0.00
A4527
O
ADULT SIZE BRIEF LG EACH
$0.00
A4528
O
ADULT SIZE BRIEF XL EACH
$0.00
$20.00
Procedure Code Pricing Action Code Description
Maximum Allowable
A4529
O
CHILD SIZE DIAPER SM/MED EA
$0.00
A4530
O
CHILD SIZE DIAPER LG EACH
$0.00
A4531
O
CHILD SIZE BRIEF SM/MED EACH
$0.00
A4532
O
CHILD SIZE BRIEF LG EACH
$0.00
A4533
O
YOUTH SIZE DIAPER EACH
$0.00
A4534
9
YOUTH SIZE BRIEF EACH
$0.00
A4535
O
DISP INCONT LINER/SHIELD EA
$0.00
A4536
O
PROT UNDERWR WSHBL ANY SZ EA
$0.00
A4537
O
UNDER PAD REUSABLE ANY SZ EA
$0.00
A4538
O
REUSABLE DIAPER FROM DPR SVC
$0.00
A4550
9
SURGICAL TRAYS
$0.00
A4554
3
DISPOSABLE UNDERPADS
$0.20
A4555
9
PRIMARY SURGICAL DRESSING KIT, (E.G
$0.00
A4556
5
ELECTRODES, PAIR
$0.00
A4557
3
LEAD WIRES, PAIR
A4558
3
CONDUCTIVE GEL OR PASTE
$4.44
A4559
9
COUPLING GEL OR PASTE
$0.00
A4560
O
PESSARY
$0.00
A4561
3
PESSARY RUBBER, ANY TYPE
$17.78
A4562
3
PESSARY, NON RUBBER,ANY TYPE
$44.25
A4565
3
SLINGS
$60.00
A4570
3
SPLINT
$50.00
A4572
O
RIB BELT
$0.00
A4575
9
HYPERBARIC O2 CHAMBER DISPS
$0.00
A4580
O
CAST SUPPLIES (PLASTER)
$0.00
A4581
9
SUPPLIES RISSER JACKET
$0.00
A4590
O
SPECIAL CASTING MATERIAL
$0.00
A4595
3
TENS SUPPL 2 LEAD PER MONTH
$27.56
A4600
6
SLEEVE, INTER LIMB COMP DEV
$0.00
A4601
6
LITH ION BATT, NON-PROS USE
$0.00
A4604
3
TUBING WITH HEATING ELEMENT
A4605
6
TRACH SUCTION CATH CLOSE SYS
$0.00
A4606
5
OXYGEN PROBE USED W OXIMETER
$0.00
A4608
3
TRANSTRACHEAL OXYGEN CATH
A4609
O
TRACH SUCTION CATH CLSED SYS
$17.16
$66.81
$58.32 $0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
A4610
O
TRACH SUCTION CATH CLSED SYS
$0.00
A4611
3
HEAVY DUTY BATTERY
A4612
3
BATTERY CABLES
A4613
3
BATTERY CHARGER
A4614
3
HAND-HELD PEFR METER
$22.75
A4615
3
CANNULA NASAL
$20.00
A4616
3
TUBING (OXYGEN) PER FOOT
$1.00
A4617
3
MOUTH PIECE
$5.00
A4618
3
BREATHING CIRCUITS
$8.51
A4619
3
FACE TENT
$1.21
A4620
3
VARIABLE CONCENTRATION MASK
$20.00
A4621
O
TRACHEOTOMY MASK OR COLLAR
$0.00
A4622
O
TRACHEOSTOMY OR LARNGECTOMY
$0.00
A4623
3
TRACHEOSTOMY INNER CANNULA
$6.25
A4624
3
TRACHEAL SUCTION TUBE
$2.25
A4625
3
TRACH CARE KIT FOR NEW TRACH
$6.61
A4626
3
TRACHEOSTOMY CLEANING BRUSH
$3.05
A4627
9
SPACER BAG/RESERVOIR
$0.00
A4628
3
OROPHARYNGEAL SUCTION CATH
$3.51
A4629
3
TRACHEOSTOMY CARE KIT
$4.42
A4630
3
REPL BAT T.E.N.S. OWN BY PT
$5.45
A4631
O
WHEELCHAIR BATTERY
$0.00
A4632
O
INFUS PUMP RPLCEMNT BATTERY
$0.00
A4633
3
UVL REPLACEMENT BULB
A4634
5
REPLACEMENT BULB TH LIGHTBOX
$0.00
A4635
3
UNDERARM CRUTCH PAD
$4.16
A4636
3
HANDGRIP FOR CANE ETC
$3.42
A4637
3
REPL TIP CANE/CRUTCH/WALKER
$1.90
A4638
6
REPL BATT PULSE GEN SYS
$0.00
A4639
3
INFRARED HT SYS REPLCMNT PAD
A4640
3
ALTERNATING PRESSURE PAD
$51.49
A4641
9
RADIOPHARM DX AGENT NOC
$0.00
A4642
9
IN111 SATUMOMAB
$0.00
A4643
O
HIGH DOSE CONTRAST MRI
$0.00
A4644
O
CONTRAST 100-199 MGS IODINE
$0.00
$187.94 $65.00 $137.96
$41.04
$287.21
Procedure Code Pricing Action Code Description
Maximum Allowable
A4645
O
CONTRAST 200-299 MGS IODINE
$0.00
A4646
O
CONTRAST 300-399 MGS IODINE
$0.00
A4647
O
SUPP- PARAMAGNETIC CONTR MAT
$0.00
A4648
9
TISSUE MARKER, IMPLANTABLE, ANY TY
$0.00
A4649
9
SURGICAL SUPPLIES
$0.00
A4650
9
IMPLANTABLE RADIATION DOSIMETER, E
$0.00
A4651
9
CALIBRATED MICROCAP TUBE
$0.00
A4652
9
MICROCAPILLARY TUBE SEALANT
$0.00
A4653
5
PD CATHETER ANCHOR BELT
$0.00
A4655
9
ESRD SYRINGE/NEEDLE
$0.00
A4656
O
NEEDLE ANY SIZE
$0.00
A4657
9
SYRINGE W/WO NEEDLE
$0.00
A4660
3
SPHYG/BP APP W CUFF AND STET
$20.00
A4663
3
DIALYSIS BLOOD PRESSURE CUFF
$6.27
A4670
5
AUTOMATIC BP MONITOR, DIAL
$0.00
A4671
6
DISPOSABLE CYCLER SET
$0.00
A4672
6
DRAINAGE EXT LINE, DIALYSIS
$0.00
A4673
6
EXT LINE W EASY LOCK CONNECT
$0.00
A4674
6
CHEM/ANTISEPT SOLUTION, 8OZ
$0.00
A4680
9
ACTIFICIAL CARBON FILTER, EA
$0.00
A4690
9
DIALYZER, EACH
$0.00
A4700
9
STANDARD DIALYSATE SOLUTION
$0.00
A4705
9
BICARB DIALYSATE SOLUTION
$0.00
A4706
9
BICARBONATE CONC SOL PER GAL
$0.00
A4707
9
BICARBONATE CONC POW PER PAC
$0.00
A4708
9
ACETATE CONC SOL PER GALLON
$0.00
A4709
9
ACID CONC SOL PER GALLON
$0.00
A4712
O
STERILE WATER INJ PER 10 ML
$0.00
A4714
9
TREATED WATER PER GALLON
$0.00
A4719
9
¾Y SET¾ TUBING
$0.00
A4720
9
DIALYSAT SOL FLD VOL > 249CC
$0.00
A4721
9
DIALYSAT SOL FLD VOL > 999CC
$0.00
A4722
9
DIALYS SOL FLD VOL > 1999CC
$0.00
A4723
9
DIALYS SOL FLD VOL > 2999CC
$0.00
A4724
9
DIALYS SOL FLD VOL > 3999CC
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
A4725
9
DIALYS SOL FLD VOL > 4999CC
$0.00
A4726
9
DIALYS SOL FLD VOL > 5999CC
$0.00
A4728
6
DIALYSATE SOLUTION, NON-DEX
$0.00
A4730
9
FISTULA CANNULATION SET, EA
$0.00
A4735
9
LOCAL/TOPICAL ANESTHETICS
$0.00
A4736
9
TOPICAL ANESTHETIC, PER GRAM
$0.00
A4737
9
INJ ANESTHETIC PER 10 ML
$0.00
A4740
9
SHUNT ACCESSORY
$0.00
A4750
9
ART OR VENOUS BLOOD TUBING
$0.00
A4755
9
COMB ART/VENOUS BLOOD TUBING
$0.00
A4760
9
DIALYSATE SOL TEST KIT, EACH
$0.00
A4765
9
DIALYSATE CONC POW PER PACK
$0.00
A4766
9
DIALYSATE CONC SOL ADD 10 ML
$0.00
A4770
9
BLOOD COLLECTION TUBE/VACUUM
$0.00
A4771
9
SERUM CLOTTING TIME TUBE
$0.00
A4772
9
BLOOD GLUCOSE TEST STRIPS
$0.00
A4773
9
OCCULT BLOOD TEST STRIPS
$0.00
A4774
9
AMMONIA TEST STRIPS
$0.00
A4780
9
ESRD STERILIZING AGENT
$0.00
A4790
9
ESRD CLEANSING AGENTS
$0.00
A4800
9
HEPARIN/ANTIDOTE DIALYSIS
$0.00
A4801
9
HEPARIN PER 1000 UNITS
$0.00
A4802
9
PROTAMINE SULFATE PER 50 MG
$0.00
A4820
9
SUPPLIES HEMODIALYSIS KIT
$0.00
A4850
9
RUBBER TIPPED HEMOSTATS
$0.00
A4860
9
DISPOSABLE CATHETER TIPS
$0.00
A4870
9
PLUMB/ELEC WK HM HEMO EQUIP
$0.00
A4880
9
WATER STORAGE TANKS
$0.00
A4890
9
REPAIR/MAINT CONT HEMO EQUIP
$0.00
A4900
9
CAPD SUPPLY KIT
$0.00
A4901
9
CCPD SUPPLY KIT
$0.00
A4905
9
IPD SUPPLY KIT
$0.00
A4910
9
ESRD NONMEDICAL SUPPLIES
$0.00
A4911
9
DRAIN BAG/BOTTLE
$0.00
A4912
9
GOMCO DRAIN BOTTLE
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
A4913
9
MISC DIALYSIS SUPPLIES NOC
$0.00
A4914
9
PREPARATION KIT
$0.00
A4918
9
VENOUS PRESSURE CLAMP
$0.00
A4919
9
SUPP DIALYSIS DIALYZER HOLDE
$0.00
A4920
9
HARVARD PRESSURE CLAMP
$0.00
A4921
9
MEASURING CYLINDER
$0.00
A4927
3
NON-STERILE GLOVES
$6.19
A4928
9
SURGICAL MASK
$0.00
A4929
9
TOURNIQUET FOR DIALYSIS, EA
$0.00
A4930
3
STERILE, GLOVES PER PAIR
$0.44
A4931
9
REUSABLE ORAL THERMOMETER
$0.00
A4932
9
REUSABLE RECTAL THERMOMETER
$0.00
A5051
3
POUCH CLSD W BARR ATTACHED
$2.21
A5052
3
CLSD OSTOMY POUCH W/O BARR
$1.59
A5053
3
CLSD OSTOMY POUCH FACEPLATE
$1.66
A5054
3
CLSD OSTOMY POUCH W/FLANGE
$1.37
A5055
3
STOMA CAP
$1.35
A5061
3
POUCH DRAINABLE W BARRIER AT
$2.58
A5062
3
DRNBLE OSTOMY POUCH W/O BARR
$2.12
A5063
3
DRAIN OSTOMY POUCH W/FLANGE
$2.09
A5064
O
DRAIN OSTOMY POUCH W/FCEPLTE
$0.00
A5065
O
DRAIN OSTOMY POUCH ON FCPLTE
$0.00
A5071
3
URINARY POUCH W/BARRIER
$4.15
A5072
3
URINARY POUCH W/O BARRIER
$3.36
A5073
3
URINARY POUCH ON BARR W/FLNG
$3.04
A5074
O
URINARY POUCH W/FACEPLATE
$0.00
A5075
O
URINARY POUCH ON FACEPLATE
$0.00
A5081
3
CONTINENT STOMA PLUG
$3.14
A5082
3
CONTINENT STOMA CATHETER
A5083
6
STOMA ABSORPTIVE COVER
$0.00
A5093
3
OSTOMY ACCESSORY CONVEX INSE
$1.85
A5102
3
BEDSIDE DRAIN BTL W/WO TUBE
$21.39
A5105
3
URINARY SUSPENSORY
$38.88
A5112
3
URINARY LEG BAG
$28.07
A5113
3
LATEX LEG STRAP
$4.48
$11.34
Procedure Code Pricing Action Code Description
Maximum Allowable
A5114
3
FOAM/FABRIC LEG STRAP
$8.52
A5119
O
SKIN BARRIER WIPES BOX PR 50
$0.00
A5120
3
SKIN BARRIER, WIPE OR SWAB
$0.23
A5121
3
SOLID SKIN BARRIER 6X6
$6.24
A5122
3
SOLID SKIN BARRIER 8X8
$10.42
A5123
O
SKIN BARRIER WITH FLANGE
$0.00
A5126
3
DISK/FOAM PAD +OR- ADHESIVE
$1.26
A5131
3
APPLIANCE CLEANER
A5149
O
INCONTINENCE/OSTOMY SUPPLY
A5200
3
PERCUTANEOUS CATHETER ANCHOR
A5500
5
DIAB SHOE FOR DENSITY INSERT
$0.00
A5501
5
DIABETIC CUSTOM MOLDED SHOE
$0.00
A5502
9
DIABETIC SHOE DENSITY INSERT
$0.00
A5503
5
DIABETIC SHOE W/ROLLER/ROCKR
$0.00
A5504
5
DIABETIC SHOE WITH WEDGE
$0.00
A5505
5
DIAB SHOE W/METATARSAL BAR
$0.00
A5506
5
DIABETIC SHOE W/OFF SET HEEL
$0.00
A5507
5
MODIFICATION DIABETIC SHOE
$0.00
A5508
5
DIABETIC DELUXE SHOE
$0.00
A5509
O
DIRECT HEAT FORM SHOE INSERT
$0.00
A5510
5
COMPRESSION FORM SHOE INSERT
$0.00
A5511
O
CUSTOM FAB MOLDED SHOE INSER
$0.00
A5512
6
MULTI DEN INSERT DIRECT FORM
$0.00
A5513
6
MULTI DEN INSERT CUSTOM MOLD
$0.00
A6000
5
WOUND WARMING WOUND COVER
$0.00
A6010
3
COLLAGEN BASED WOUND FILLER
$30.62
A6011
3
COLLAGEN GEL/PASTE WOUND FIL
$2.28
A6020
O
COLLAGEN WOUND DRESSING
$0.00
A6021
3
COLLAGEN DRESSING <=16 SQ IN
$20.05
A6022
3
COLLAGEN DRSG>6<=48 SQ IN
$20.05
A6023
3
COLLAGEN DRESSING >48 SQ IN
$181.51
A6024
3
COLLAGEN DSG WOUND FILLER
$5.90
A6025
9
SILICONE GEL SHEET, EACH
$0.00
A6154
9
WOUND POUCH EACH
$0.00
A6196
3
ALGINATE DRESSING <=16 SQ IN
$7.01
$15.13 $0.00 $10.78
Procedure Code Pricing Action Code Description
Maximum Allowable
A6197
3
ALGINATE DRSG >16 <=48 SQ IN
$15.68
A6198
3
ALGINATE DRESSING > 48 SQ IN
$15.68
A6199
3
ALGINATE DRSG WOUND FILLER
$5.04
A6200
3
COMPOS DRSG <=16 NO BORDER
$9.06
A6201
3
COMPOS DRSG >16<=48 NO BDR
$19.84
A6202
3
COMPOS DRSG >48 NO BORDER
$33.27
A6203
3
COMPOSITE DRSG <= 16 SQ IN
$3.19
A6204
3
COMPOSITE DRSG >16<=48 SQ IN
$5.94
A6205
3
COMPOSITE DRSG > 48 SQ IN
$5.94
A6206
3
CONTACT LAYER <= 16 SQ IN
$2.07
A6207
3
CONTACT LAYER >16<= 48 SQ IN
$7.00
A6208
3
CONTACT LAYER > 48 SQ IN
$7.00
A6209
3
FOAM DRSG <=16 SQ IN W/O BDR
$7.14
A6210
3
FOAM DRG >16<=48 SQ IN W/O B
$19.00
A6211
3
FOAM DRG > 48 SQ IN W/O BRDR
$28.01
A6212
3
FOAM DRG <=16 SQ IN W/BORDER
$9.25
A6213
3
FOAM DRG >16<=48 SQ IN W/BDR
$9.82
A6214
3
FOAM DRG > 48 SQ IN W/BORDER
$9.82
A6215
5
FOAM DRESSING WOUND FILLER
$0.00
A6216
3
NON-STERILE GAUZE<=16 SQ IN
$0.05
A6217
3
NON-STERILE GAUZE>16<=48 SQ
$0.41
A6218
3
NON-STERILE GAUZE > 48 SQ IN
$0.41
A6219
3
GAUZE <= 16 SQ IN W/BORDER
$0.91
A6220
3
GAUZE >16 <=48 SQ IN W/BORDR
$2.46
A6221
3
GAUZE > 48 SQ IN W/BORDER
$2.46
A6222
3
GAUZE <=16 IN NO W/SAL W/O B
$2.03
A6223
3
GAUZE >16<=48 NO W/SAL W/O B
$2.30
A6224
3
GAUZE > 48 IN NO W/SAL W/O B
$3.44
A6228
3
GAUZE <= 16 SQ IN WATER/SAL
$2.30
A6229
3
GAUZE >16<=48 SQ IN WATR/SAL
$3.44
A6230
3
GAUZE > 48 SQ IN WATER/SALNE
$3.44
A6231
3
HYDROGEL DSG<=16 SQ IN
$4.45
A6232
3
HYDROGEL DSG>16<=48 SQ IN
$6.57
A6233
3
HYDROGEL DRESSING >48 SQ IN
$18.30
A6234
3
HYDROCOLLD DRG <=16 W/O BDR
$6.24
Procedure Code Pricing Action Code Description
Maximum Allowable
A6235
3
HYDROCOLLD DRG >16<=48 W/O B
$16.05
A6236
3
HYDROCOLLD DRG > 48 IN W/O B
$25.99
A6237
3
HYDROCOLLD DRG <=16 IN W/BDR
$7.54
A6238
3
HYDROCOLLD DRG >16<=48 W/BDR
$21.74
A6239
3
HYDROCOLLD DRG > 48 IN W/BDR
$21.74
A6240
3
HYDROCOLLD DRG FILLER PASTE
$11.68
A6241
3
HYDROCOLLOID DRG FILLER DRY
$2.45
A6242
3
HYDROGEL DRG <=16 IN W/O BDR
$5.79
A6243
3
HYDROGEL DRG >16<=48 W/O BDR
$11.75
A6244
3
HYDROGEL DRG >48 IN W/O BDR
$37.46
A6245
3
HYDROGEL DRG <= 16 IN W/BDR
$6.93
A6246
3
HYDROGEL DRG >16<=48 IN W/B
$9.46
A6247
3
HYDROGEL DRG > 48 SQ IN W/B
$22.68
A6248
3
HYDROGEL DRSG GEL FILLER
$15.49
A6250
9
SKIN SEAL PROTECT MOISTURIZR
$0.00
A6251
3
ABSORPT DRG <=16 SQ IN W/O B
$1.90
A6252
3
ABSORPT DRG >16 <=48 W/O BDR
$3.10
A6253
3
ABSORPT DRG > 48 SQ IN W/O B
$6.05
A6254
3
ABSORPT DRG <=16 SQ IN W/BDR
$1.16
A6255
3
ABSORPT DRG >16<=48 IN W/BDR
$2.89
A6256
3
ABSORPT DRG > 48 SQ IN W/BDR
$2.89
A6257
3
TRANSPARENT FILM <= 16 SQ IN
$1.46
A6258
3
TRANSPARENT FILM >16<=48 IN
$4.10
A6259
3
TRANSPARENT FILM > 48 SQ IN
$10.43
A6260
9
WOUND CLEANSER ANY TYPE/SIZE
$0.00
A6261
5
WOUND FILLER GEL/PASTE /OZ
$0.00
A6262
5
WOUND FILLER DRY FORM / GRAM
$0.00
A6263
O
NON-STERILE ELASTIC GAUZE/YD
$0.00
A6264
O
NON-STERILE NO ELASTIC GAUZE
$0.00
A6265
O
TAPE PER 18 SQ INCHES
$0.00
A6266
3
IMPREG GAUZE NO H20/SAL/YARD
$1.83
A6402
3
STERILE GAUZE <= 16 SQ IN
$0.12
A6403
3
STERILE GAUZE>16 <= 48 SQ IN
$0.41
A6404
3
STERILE GAUZE > 48 SQ IN
$0.41
A6405
O
STERILE ELASTIC GAUZE /YD
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
A6406
O
STERILE NON-ELASTIC GAUZE/YD
$0.00
A6407
3
PACKING STRIPS, NON-IMPREG
$1.88
A6410
5
STERILE EYE PAD
$0.00
A6411
5
NON-STERILE EYE PAD
$0.00
A6412
5
OCCLUSIVE EYE PATCH
$0.00
A6413
9
ADHESIVE BANDAGE, FIRST-AID
$0.00
A6421
O
PAD BANDAGE >=3 <5IN W /ROLL
$0.00
A6422
O
CONF BANDAGE NS >=3<5ÊW/ROLL
$0.00
A6424
O
CONF BANDAGE NS >=5ÊW /ROLL
$0.00
A6426
O
CONF BANDAGE S >=3<5Ê W/ROLL
$0.00
A6428
O
CONF BANDAGE S >=5Ê W /ROLL
$0.00
A6430
O
LT COMPRES BDG >=3<5ÊW /ROLL
$0.00
A6432
O
LT COMPRES BDG >=5ÊW /ROLL
$0.00
A6434
O
MO COMPRES BDG >=3<5ÊW /ROLL
$0.00
A6436
O
HI COMPRES BDG >=3<5ÊW /ROLL
$0.00
A6438
O
SELF-ADHER BDG >=3<5ÊW /ROLL
$0.00
A6440
O
ZINC PASTE BDG >=3<5ÊW /ROLL
$0.00
A6441
3
PAD BAND W>=3" <5"/YD
$0.67
A6442
3
CONFORM BAND N/S W<3"/YD
$0.17
A6443
3
CONFORM BAND N/S W>=3"<5"/YD
$0.29
A6444
6
CONFORM BAND N/S W>=5"/YD
$0.00
A6445
3
CONFORM BAND S W <3"/YD
$0.32
A6446
3
CONFORM BAND S W>=3" <5"/YD
$0.41
A6447
3
CONFORM BAND S W >=5"/YD
$0.67
A6448
3
LT COMPRES BAND <3"/YD
$1.16
A6449
3
LT COMPRES BAND >=3" <5"/YD
$1.75
A6450
6
LT COMPRES BAND >=5"/YD
$0.00
A6451
6
MOD COMPRES BAND W>=3"<5"/YD
$0.00
A6452
3
HIGH COMPRES BAND W>=3"<5"YD
$5.91
A6453
3
SELF-ADHER BAND W <3"/YD
$0.61
A6454
3
SELF-ADHER BAND W>=3" <5"/YD
$0.77
A6455
3
SELF-ADHER BAND >=5"/YD
$1.39
A6456
3
ZINC PASTE BAND W >=3"<5"/YD
$1.28
A6457
3
TUBULAR DRESSING
$1.14
A6501
5
COMPRES BURNGARMENT BODYSUIT
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
A6502
5
COMPRES BURNGARMENT CHINSTRP
$0.00
A6503
5
COMPRES BURNGARMENT FACEHOOD
$0.00
A6504
5
CMPRSBURNGARMENT GLOVE-WRIST
$0.00
A6505
5
CMPRSBURNGARMENT GLOVE-ELBOW
$0.00
A6506
5
CMPRSBURNGRMNT GLOVE-AXILLA
$0.00
A6507
5
CMPRS BURNGARMENT FOOT-KNEE
$0.00
A6508
5
CMPRS BURNGARMENT FOOT-THIGH
$0.00
A6509
5
COMPRES BURN GARMENT JACKET
$0.00
A6510
5
COMPRES BURN GARMENT LEOTARD
$0.00
A6511
5
COMPRES BURN GARMENT PANTY
$0.00
A6512
5
COMPRES BURN GARMENT, NOC
$0.00
A6513
6
COMPRESS BURN MASK FACE/NECK
$0.00
A6530
6
COMPRESSION STOCKING BK18-30
$0.00
A6531
6
COMPRESSION STOCKING BK30-40
$0.00
A6532
6
COMPRESSION STOCKING BK40-50
$0.00
A6533
6
GC STOCKING THIGHLNGTH 18-30
$0.00
A6534
6
GC STOCKING THIGHLNGTH 30-40
$0.00
A6535
6
GC STOCKING THIGHLNGTH 40-50
$0.00
A6536
6
GC STOCKING FULL LNGTH 18-30
$0.00
A6537
6
GC STOCKING FULL LNGTH 30-40
$0.00
A6538
6
GC STOCKING FULL LNGTH 40-50
$0.00
A6539
6
GC STOCKING WAISTLNGTH 18-30
$0.00
A6540
6
GC STOCKING WAISTLNGTH 30-40
$0.00
A6541
6
GC STOCKING WAISTLNGTH 40-50
$0.00
A6542
6
GC STOCKING CUSTOM MADE
$0.00
A6543
6
GC STOCKING LYMPHEDEMA
$0.00
A6544
6
GC STOCKING GARTER BELT
$0.00
A6545
6
GRAD COMP NON-ELASTIC BK
$0.00
A6549
6
G COMPRESSION STOCKING
$0.00
A6550
6
NEG PRES WOUND THER DRSG SET
$0.00
A6551
O
NEG PRESS WOUND THER CANISTR
$0.00
A7000
3
DISPOSABLE CANISTER FOR PUMP
$7.97
A7001
3
NONDISPOSABLE PUMP CANISTER
$28.55
A7002
3
TUBING USED W SUCTION PUMP
$3.31
A7003
3
NEBULIZER ADMINISTRATION SET
$2.61
Procedure Code Pricing Action Code Description
Maximum Allowable
A7004
3
DISPOSABLE NEBULIZER SML VOL
$1.47
A7005
3
NONDISPOSABLE NEBULIZER SET
$26.59
A7006
3
FILTERED NEBULIZER ADMIN SET
$7.78
A7007
3
LG VOL NEBULIZER DISPOSABLE
$3.80
A7008
3
DISPOSABLE NEBULIZER PREFILL
$10.52
A7009
3
NEBULIZER RESERVOIR BOTTLE
$36.26
A7010
3
DISPOSABLE CORRUGATED TUBING
$22.31
A7011
5
NONDISPOS CORRUGATED TUBING
$0.00
A7012
3
NEBULIZER WATER COLLEC DEVIC
$3.42
A7013
3
DISPOSABLE COMPRESSOR FILTER
$0.71
A7014
3
COMPRESSOR NONDISPOS FILTER
$3.87
A7015
3
AEROSOL MASK USED W NEBULIZE
$1.57
A7016
3
NEBULIZER DOME & MOUTHPIECE
$6.24
A7017
3
NEBULIZER NOT USED W OXYGEN
$128.23
A7018
3
WATER DISTILLED W/NEBULIZER
$0.37
A7019
O
SALINE SOLUTION DISPENSER
$0.00
A7020
O
STERILE H2O OR NSS W LGV NEB
$0.00
A7025
3
REPLACE CHEST COMPRESS VEST
$434.94
A7026
3
REPLACE CHST CMPRSS SYS HOSE
$28.75
A7027
6
COMBINATION ORAL/NASAL MASK
$0.00
A7028
6
REPL ORAL CUSHION COMBO MASK
$0.00
A7029
6
REPL NASAL PILLOW COMB MASK
$0.00
A7030
3
CPAP FULL FACE MASK
A7031
3
REPLACEMENT FACEMASK INTERFA
$69.77
A7032
3
REPLACEMENT NASAL CUSHION
$40.53
A7033
3
REPLACEMENT NASAL PILLOWS
$28.41
A7034
3
NASAL APPLICATION DEVICE
A7035
3
POS AIRWAY PRESS HEADGEAR
$35.42
A7036
3
POS AIRWAY PRESS CHINSTRAP
$18.20
A7037
3
POS AIRWAY PRESSURE TUBING
$39.21
A7038
3
POS AIRWAY PRESSURE FILTER
$4.58
A7039
3
FILTER, NON DISPOSABLE W PAP
$15.33
A7040
6
ONE WAY CHEST DRAIN VALVE
$0.00
A7041
6
WATER SEAL DRAIN CONTAINER
$0.00
A7042
9
IMPLANTED PLEURAL CATHETER
$0.00
$188.64
$117.64
Procedure Code Pricing Action Code Description
Maximum Allowable
A7043
5
VACUUM DRAINAGEBOTTLE/TUBING
$0.00
A7044
3
PAP ORAL INTERFACE
A7045
3
REPL EXHALATION PORT FOR PAP
$19.47
A7046
6
REPL WATER CHAMBER, PAP DEV
$0.00
A7501
3
TRACHEOSTOMA VALVE W DIAPHRA
$100.18
A7502
3
REPLACEMENT DIAPHRAGM/FPLATE
$47.61
A7503
3
HMES FILTER HOLDER OR CAP
$10.81
A7504
3
TRACHEOSTOMA HMES FILTER
$0.64
A7505
3
HMES OR TRACH VALVE HOUSING
$4.46
A7506
3
HMES/TRACHVALVE ADHESIVEDISK
$0.32
A7507
3
INTEGRATED FILTER & HOLDER
$2.37
A7508
3
HOUSING & INTEGRATED ADHESIV
$2.74
A7509
3
HEAT & MOISTURE EXCHANGE SYS
$1.34
A7520
6
TRACH/LARYN TUBE NON-CUFFED
$0.00
A7521
6
TRACH/LARYN TUBE CUFFED
$0.00
A7522
6
TRACH/LARYN TUBE STAINLESS
$0.00
A7523
6
TRACHEOSTOMY SHOWER PROTECT
$0.00
A7524
6
TRACHEOSTOMA STENT/STUD/BTTN
$0.00
A7525
3
TRACHEOSTOMY MASK
$2.07
A7526
3
TRACHEOSTOMY TUBE COLLAR
$3.37
A7527
6
TRACH/LARYN TUBE PLUG/STOP
$0.00
A8000
6
SOFT PROTECT HELMET PREFAB
$0.00
A8001
6
HARD PROTECT HELMET PREFAB
$0.00
A8002
6
SOFT PROTECT HELMET CUSTOM
$0.00
A8003
6
HARD PROTECT HELMET CUSTOM
$0.00
A8004
6
REPL SOFT INTERFACE, HELMET
$0.00
A9150
9
MISC/EXPER NON-PRESCRIPT DRU
$0.00
A9152
9
SINGLE VITAMIN NOS
$0.00
A9153
9
MULTI-VITAMIN NOS
$0.00
A9155
6
ARTIFICIAL SALIVA
$0.00
A9160
9
PODIATRIST NON-COVERED SERVI
$0.00
A9170
9
CHIROPRACTOR NON-COVERED SER
$0.00
A9180
9
PEDICULOSIS (LICE INFESTATION) TRE
$0.00
A9190
9
MISC/EXPE PERSONAL COMFORT I
$0.00
A9250
9
NURSING HOME RENTALS
$0.00
$120.91
Procedure Code Pricing Action Code Description
Maximum Allowable
A9260
9
NON-CERTIFIED PHYSICAL THERAPISTS
$0.00
A9270
9
NON-COVERED ITEM OR SERVICE
$0.00
A9274
6
EXT AMB INSULIN DELIVERY SYS
$0.00
A9275
9
DISP HOME GLUCOSE MONITOR
$0.00
A9276
9
DISPOSABLE SENSOR, CGM SYS
$0.00
A9277
9
EXTERNAL TRANSMITTER, CGM
$0.00
A9278
9
EXTERNAL RECEIVER, CGM SYS
$0.00
A9279
9
MONITORING FEATURE/DEVICENOC
$0.00
A9280
6
ALERT OR ALARM DEVICE, NOC
$0.00
A9281
9
REACHING/GRABBING DEVICE
$0.00
A9282
9
WIG ANY TYPE
$0.00
A9283
6
FOOT PRESS OFF LOAD SUPP DEV
$0.00
A9284
9
NON-ELECTRONIC SPIROMETER
$0.00
A9290
9
DESCRIPTION OF SERVICE DOES NOT IND
$0.00
A9300
O
EXERCISE EQUIPMENT
$0.00
A9500
9
TC99M SESTAMIBI
$0.00
A9501
9
TECHNETIUM TC-99M TEBOROXIME
$0.00
A9502
9
TC99M TETROFOSMIN
$0.00
A9503
9
TC99M MEDRONATE
$0.00
A9504
9
TC99M APCITIDE
$0.00
A9505
9
TL201 THALLIUM
$0.00
A9507
9
IN111 CAPROMAB
$0.00
A9508
9
I131 IODOBENGUATE, DX
$0.00
A9509
9
IODINE I-123 SOD IODIDE MIL
$0.00
A9510
9
TC99M DISOFENIN
$0.00
A9511
O
TECHNETIUM TC 99M DEPREOTIDE
$0.00
A9512
9
TC99M PERTECHNETATE
$0.00
A9513
O
TECHNETIUM TC-99M MEBROFENIN
$0.00
A9514
O
TECHNETIUMTC99MPYROPHOSPHATE
$0.00
A9515
O
TECHNETIUM TC-99M PENTETATE
$0.00
A9516
9
IODINE I-123 SOD IODIDE MIC
$0.00
A9517
9
I131 IODIDE CAP, RX
$0.00
A9518
O
I-131 SODIUM IODIDE SOLUTION
$0.00
A9519
O
TECHNETIUMTC-99MMACROAG ALBU
$0.00
A9520
O
TECHNETIUMTC-99M SULFUR CLLD
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
A9521
9
TC99M EXAMETAZIME
$0.00
A9522
O
INDIUM111IBRITUMOMABTIUXETAN
$0.00
A9523
O
YTTRIUM90IBRITUMOMABTIUXETAN
$0.00
A9524
9
I131 SERUM ALBUMIN, DX
$0.00
A9525
O
LOW/ISO-OSMOLAR CONTRAST MAT
$0.00
A9526
9
NITROGEN N-13 AMMONIA
$0.00
A9527
9
IODINE I-125 SODIUM IODIDE
$0.00
A9528
9
IODINE I-131 IODIDE CAP, DX
$0.00
A9529
9
I131 IODIDE SOL, DX
$0.00
A9530
9
I131 IODIDE SOL, RX
$0.00
A9531
9
I131 MAX 100UCI
$0.00
A9532
9
I125 SERUM ALBUMIN, DX
$0.00
A9533
O
I-131 TOSITUMOMAB DIAGNOSTIC
$0.00
A9534
O
I-131 TOSITUMOMAB THERAPEUT
$0.00
A9535
9
INJECTION, METHYLENE BLUE
$0.00
A9536
9
TC99M DEPREOTIDE
$0.00
A9537
9
TC99M MEBROFENIN
$0.00
A9538
9
TC99M PYROPHOSPHATE
$0.00
A9539
9
TC99M PENTETATE
$0.00
A9540
9
TC99M MAA
$0.00
A9541
9
TC99M SULFUR COLLOID
$0.00
A9542
9
IN111 IBRITUMOMAB, DX
$0.00
A9543
9
Y90 IBRITUMOMAB, RX
$0.00
A9544
9
I131 TOSITUMOMAB, DX
$0.00
A9545
9
I131 TOSITUMOMAB, RX
$0.00
A9546
9
CO57/58
$0.00
A9547
9
IN111 OXYQUINOLINE
$0.00
A9548
9
IN111 PENTETATE
$0.00
A9549
O
TC99M ARCITUMOMAB
$0.00
A9550
9
TC99M GLUCEPTATE
$0.00
A9551
9
TC99M SUCCIMER
$0.00
A9552
9
F18 FDG
$0.00
A9553
9
CR51 CHROMATE
$0.00
A9554
9
I125 IOTHALAMATE, DX
$0.00
A9555
9
RB82 RUBIDIUM
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
A9556
9
GA67 GALLIUM
$0.00
A9557
9
TC99M BICISATE
$0.00
A9558
9
XE133 XENON 10MCI
$0.00
A9559
9
CO57 CYANO
$0.00
A9560
9
TC99M LABELED RBC
$0.00
A9561
9
TC99M OXIDRONATE
$0.00
A9562
9
TC99M MERTIATIDE
$0.00
A9563
9
P32 NA PHOSPHATE
$0.00
A9564
9
P32 CHROMIC PHOSPHATE
$0.00
A9565
O
IN111 PENTETREOTIDE
$0.00
A9566
9
TC99M FANOLESOMAB
$0.00
A9567
9
TECHNETIUM TC-99M AEROSOL
$0.00
A9568
9
TECHNETIUM TC99M ARCITUMOMAB
$0.00
A9569
9
TECHNETIUM TC-99M AUTO WBC
$0.00
A9570
9
INDIUM IN-111 AUTO WBC
$0.00
A9571
9
INDIUM IN-111 AUTO PLATELET
$0.00
A9572
9
INDIUM IN-111 PENTETREOTIDE
$0.00
A9576
9
INJ PROHANCE MULTIPACK
$0.00
A9577
9
INJ MULTIHANCE
$0.00
A9578
9
INJ MULTIHANCE MULTIPACK
$0.00
A9579
9
GAD-BASE MR CONTRAST NOS,1ML
$0.00
A9580
9
SODIUM FLUORIDE F-18
$0.00
A9600
9
SR89 STRONTIUM
$0.00
A9603
9
I-131SODIUMIODIDECAP PER MCI
$0.00
A9605
9
SM 153 LEXIDRONM
$0.00
A9698
9
NON-RAD CONTRAST MATERIALNOC
$0.00
A9699
9
RADIOPHARM RX AGENT NOC
$0.00
A9700
9
ECHOCARDIOGRAPHY CONTRAST
$0.00
A9900
5
SUPPLY/ACCESSORY/SERVICE
$0.00
A9901
9
DELIVERY/SET UP/DISPENSING
$0.00
A9999
5
MISC DME SUPPLY OR ACCESS, NOS
$0.00
ASC0001
7
AMBULATORY SURGICAL CENTER
$0.00
ASC0002
7
AMBULATORY SURGICAL CENTER
$0.00
ASC0003
7
AMBULATORY SURGICAL CENTER
$0.00
ASC0004
7
AMBULATORY SURGICAL CENTER
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
ASC0005
7
AMBULATORY SURGICAL CENTER
$0.00
ASC0006
7
AMBULATORY SURGICAL CENTER
$0.00
ASC0007
7
AMBULATORY SURGICAL CENTER
$0.00
ASC0008
7
AMBULATORY SURGICAL CENTER
$0.00
ASC0009
7
AMBULATORY SURGICAL CENTER
$0.00
B4034
3
ENTER FEED SUPKIT SYR BY DAY
$5.60
B4035
3
ENTERAL FEED SUPP PUMP PER D
$10.67
B4036
3
ENTERAL FEED SUP KIT GRAV BY
$7.31
B4081
3
ENTERAL NG TUBING W/ STYLET
$19.78
B4082
3
ENTERAL NG TUBING W/O STYLET
$14.73
B4083
3
ENTERAL STOMACH TUBE LEVINE
$2.25
B4084
O
GASTROSTOMY/JEJUNOSTOMY TUBI
$0.00
B4085
9
GASTROSTOMY TUBE W/RING EACH
$0.00
B4086
O
GASTROSTOMY/JEJUNOSTOMY TUBE
$0.00
B4087
6
GASTRO/JEJUNO TUBE, STD
$0.00
B4088
6
GASTRO/JEJUNO TUBE, LOW-PRO
$0.00
B4100
5
FOOD THICKENER ORAL
$0.00
B4102
6
EF ADULT FLUIDS AND ELECTRO
$0.00
B4103
6
EF PED FLUID AND ELECTROLYTE
$0.00
B4104
6
ADDITIVE FOR ENTERAL FORMULA
$0.00
B4149
6
EF BLENDERIZED FOODS
$0.00
B4150
3
EF COMPLET W/INTACT NUTRIENT
$0.61
B4151
O
ENTERAL FORMULAE CAT1NATURAL
$0.00
B4152
3
EF CALORIE DENSE>/=1.5KCAL
$0.51
B4153
3
EF HYDROLYZED/AMINO ACIDS
$1.74
B4154
3
EF SPEC METABOLIC NONINHERIT
$1.12
B4155
3
EF INCOMPLETE/MODULAR
$0.89
B4156
O
ENTERAL FORMULAE CATEGORY VI
$0.00
B4157
6
EF SPECIAL METABOLIC INHERIT
$0.00
B4158
3
EF PED COMPLETE INTACT NUT
$0.65
B4159
6
EF PED COMPLETE SOY BASED
$0.00
B4160
6
EF PED CALORIC DENSE>/=0.7KC
$0.00
B4161
3
EF PED HYDROLYZED/AMINO ACID
$1.80
B4162
6
EF PED SPECMETABOLIC INHERIT
$0.00
B4164
9
PARENTERAL 50% DEXTROSE SOLU
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
B4168
9
PARENTERAL SOL AMINO ACID 3.
$0.00
B4172
9
PARENTERAL SOL AMINO ACID 5.
$0.00
B4176
9
PARENTERAL SOL AMINO ACID 7-
$0.00
B4178
9
PARENTERAL SOL AMINO ACID >
$0.00
B4180
9
PARENTERAL SOL CARB > 50%
$0.00
B4184
O
PARENTERAL SOL LIPIDS 10%
$0.00
B4185
6
PARENTERAL SOL 10 GM LIPIDS
$0.00
B4186
O
PARENTERAL SOL LIPIDS 20%
$0.00
B4189
9
PARENTERAL SOL AMINO ACID &
$0.00
B4193
9
PARENTERAL SOL 52-73 GM PROT
$0.00
B4197
9
PARENTERAL SOL 74-100 GM PRO
$0.00
B4199
9
PARENTERAL SOL > 100GM PROTE
$0.00
B4216
9
PARENTERAL NUTRITION ADDITIV
$0.00
B4220
3
PARENTERAL SUPPLY KIT PREMIX
$8.09
B4222
O
PARENTERAL SUPPLY KIT HOMEMI
$0.00
B4224
3
PARENTERAL ADMINISTRATION KI
$25.29
B5000
9
PARENTERAL SOL RENAL-AMIROSY
$0.00
B5100
9
PARENTERAL SOL HEPATIC-FREAM
$0.00
B5200
9
PARENTERAL SOL STRES-BRNCH C
$0.00
B9000
3
ENTER INFUSION PUMP W/O ALRM
$988.00
B9002
3
ENTERAL INFUSION PUMP W/ ALA
$988.00
B9004
3
PARENTERAL INFUS PUMP PORTAB
$2,551.22
B9006
3
PARENTERAL INFUS PUMP STATIO
$1,970.80
B9998
5
ENTERAL SUPP NOT OTHERWISE C
$0.00
B9999
5
PARENTERAL SUPP NOT OTHRWS C
$0.00
BONUS
O
MCO SPECIFIC CODE: SMART START OUT
$0.00
C1000
9
PERCLOSCLOSR PROSTARARTVAS
$0.00
C1001
9
ACUNAV-DIAGNSTIC ULTRSND CA
$0.00
C1003
9
CATH, ABLATION, LIVEWIRE TC
$0.00
C1004
9
FAST-CATH,SWARTZ,SAFL,CSTA
$0.00
C1006
9
ARRAY POST CHAMB IOL
$0.00
C1007
9
AMS 700/AMBICOR PROSTHESIS
$0.00
C1008
9
UROLUME-IMPLT URETHRAL STNT
$0.00
C1009
9
PLASMA,CRYOPRECIPITATE-REDUC
$0.00
C1010
O
BLOOD, L/R, CMV-NEG
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
C1011
O
PLATELETS, HLA-M, L/R, UNIT
$0.00
C1012
9
PLATELET CONC, L/R, IRRAD
$0.00
C1013
9
PLATELET CONC, L/R, UNIT
$0.00
C1014
9
PLATELET,APH/PHER, L/R, UNIT
$0.00
C1015
O
PLT, PHER,L/R,CMV, IRRAD
$0.00
C1016
O
BLOOD,L/R,FROZ/DEGLY/WASHED
$0.00
C1017
O
PLT, APH/PHER,L/R,CMV-NEG
$0.00
C1018
O
BLOOD, L/R, IRRADIATED
$0.00
C1019
9
PLT, APH/PHER, L/R, IRRAD
$0.00
C1020
O
RBC, FRZ/DEG/WSH, L/R, IRRAD
$0.00
C1021
O
RBC, L/R, CMV NEG, IRRAD
$0.00
C1022
O
PLASMA, FRZ WITHIN 24 HOUR
$0.00
C1024
9
QUINOPRISTIN 10ML/DALFOPRIS
$0.00
C1025
9
MARINR CS CATH
$0.00
C1026
9
RF PERFRMR CATH 5F RF MARINR
$0.00
C1027
9
MAGIC X/SHORT RADIUS 14MM
$0.00
C1028
9
PRCIS TWST TRSNSVG ANCH SYS
$0.00
C1029
9
CRE GUIDED BALLOON DIL CATH
$0.00
C1030
9
CTHTR:MRSHAL,BLU MAX UTR DMD
$0.00
C1031
9
MR COMP/MOD LEVEEN NED ELECT
$0.00
C1033
9
SONICATH MDL 37-410
$0.00
C1034
9
SURPASS, LONG30 SURPASS-CATH
$0.00
C1035
9
CATH, ULTRA ICE
$0.00
C1036
9
R PORT/RESERVOIR IMPL DEV
$0.00
C1037
9
VAXCELCHRONIC DIALYSIS CATH
$0.00
C1038
9
ULTRACROSS IMAGING CATH
$0.00
C1039
9
WALLSTENT, RP/TRACH
$0.00
C1040
9
WALLSTENT, TIPS
$0.00
C1042
9
WALLSTENT, BILIARY
$0.00
C1043
9
ATHERECTOMY SYS, CORONARY
$0.00
C1045
9
I-131 MIBG(IOBEN-SULFATE)0.5
$0.00
C1047
9
NOGA/NAVI-STAR CATH
$0.00
C1048
9
NEUROCYBERNETICPROS:GEN
$0.00
C1050
9
PROSORBA COLUMN
$0.00
C1051
9
OASIS THROMBECTOMY CATH
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
C1053
9
ENSITE 3000 CATHETER
$0.00
C1054
9
HYDROLYSER THROMB CATH 6/7F
$0.00
C1055
9
TRANSESOPH 210, 210-S CATH
$0.00
C1056
9
THERMACHOICE II CATH
$0.00
C1057
9
MICROMARK TISSUE MARKER
$0.00
C1058
9
TC 99M OXIDRONATE, PER VIAL
$0.00
C1059
9
CARTICEL,AUTO CULT-CHNDR CYT
$0.00
C1060
9
ACS MULTI-LINK TRISTAR STENT
$0.00
C1061
9
ACS VIKING GUIDING CATH
$0.00
C1063
9
ENDOTAK ENDURANCE EZ,RX LEAD
$0.00
C1064
9
I-131 CAP, EACH ADD MCI
$0.00
C1065
9
I-131 SOL, EACH ADD MCI
$0.00
C1066
9
IN 111 SATUMOMAB PENDETIDE
$0.00
C1067
9
MEGALINK BILIARY STENT
$0.00
C1068
9
PULSAR DDD PMKR
$0.00
C1069
9
DISCOVERY DR, PMKR
$0.00
C1071
9
PULSAR MAX, PULSAR SR PMKR
$0.00
C1072
9
GUIDANT:BLLN DIL CATH
$0.00
C1073
9
MORCELLATOR
$0.00
C1074
9
RX/OTW VIATRAC-PERI DIL CATH
$0.00
C1075
9
GUIDANT:LEAD,PMKR
$0.00
C1076
9
VENTAK MINI SC DEFIB
$0.00
C1077
9
VENTAK VR,PRIZM VR, SC DEFIB
$0.00
C1078
9
VENTAK:PRIZM,AV III DR DEFIB
$0.00
C1079
O
CO 57/58 PER 0.5 UCI
$0.00
C1080
O
I-131 TOSITUMOMAB, DX
$0.00
C1081
O
I-131 TOSITUMOMAB, TX
$0.00
C1082
O
IN-111 IBRITUMOMAB TIUXETAN
$0.00
C1083
O
YTTRIUM 90 IBRITUMOMAB TIUXE
$0.00
C1084
9
DENILEUKIN DIFTITOX, 300 MCG
$0.00
C1086
9
TEMOZOLOMIDE, 5 MG
$0.00
C1087
9
I-123 PER 100 UCI
$0.00
C1088
9
LASER OPTIC TR SYS
$0.00
C1089
9
CO 57, 0.5 MCI
$0.00
C1090
9
IN 111 CHLORIDE, PER MCI
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
C1091
O
IN111 OXYQUINOLINE,PER0.5MCI
$0.00
C1092
O
IN 111 PENTETATE PER 0.5 MCI
$0.00
C1093
O
TC99M FANOLESOMAB
$0.00
C1094
9
TC99MALBUMIN AGGR,PER 1.0MCI
$0.00
C1095
9
TC 99M DEPREOTIDE, PER VIAL
$0.00
C1096
9
TC 99M EXAMETAZIME, PER DOSE
$0.00
C1097
9
TC 99M MEBROFENIN, PER VIAL
$0.00
C1098
9
TC 99M PENTETATE, PER VIAL
$0.00
C1099
9
TC 99M PYROPHOSPHATE,PER VIA
$0.00
C1100
9
MEDTRONIC AVE GT1 GUIDEWIRE
$0.00
C1101
9
MEDTRONIC AVE ZUMA GUIDECATH
$0.00
C1102
9
SYNERGY NEUROSTIM GENRTR
$0.00
C1103
9
MICRO JEWEL DEFIBRILLATOR
$0.00
C1104
9
RF CONDUCTR ABLATION CATH
$0.00
C1105
9
SIGMA 300VDD PMKR
$0.00
C1106
9
SYNERGYEX PT PROGRMR
$0.00
C1107
9
TORQR,SOLOIST CATH
$0.00
C1109
9
IMPLANTABLE ANCHOR:ETHICON
$0.00
C1110
9
STABLE MAPPER,CATH ELECTR
$0.00
C1111
9
ANEURXAORT-UNI-ILIAC STNT
$0.00
C1112
9
ANEURX STENT GRAFT/DEL CATH
$0.00
C1113
9
TLNT ENDO SPRNG STNT GRFT SY
$0.00
C1114
9
TALNTSPRGSTNT+GRAF ENDO PROS
$0.00
C1115
9
5038S, 5038 5038L PACE LEAD
$0.00
C1116
9
CAPSURESP PACING LEAD
$0.00
C1117
9
ANCURE ENDOGRAFT DEL SYS
$0.00
C1118
9
SIGMA300DR LEGIIDR, PMKR
$0.00
C1119
9
SPRINT6932,6943 DEFIB LEAD
$0.00
C1120
9
SPRINT6942,6945 DEFIB LEAD
$0.00
C1121
9
GEM DEFIBRILLATOR
$0.00
C1122
O
TC 99M ARCITUMOMAB PER VIAL
$0.00
C1123
9
GEM II VR DEFIBRILLATOR
$0.00
C1124
9
INTERSTIM TEST STIM KIT
$0.00
C1125
9
KAPPA 400SR,TOPAZ II SR PMKR
$0.00
C1126
9
KAPPA 700 DR, PMKR
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
C1127
9
KAPPA 700SR, SC PMKR
$0.00
C1128
9
KAPPA 700D, RUBY IID PMKR
$0.00
C1129
9
KAPPA 700VDD, PMKR
$0.00
C1130
9
SIGMA200D, LGCY IID DC PMKR
$0.00
C1131
9
SIGMA 200DR, PMKR
$0.00
C1132
9
SIGMA 200 SR LEG II:SC PA
$0.00
C1133
9
SIGMA SR, VITA SR, PMKR
$0.00
C1134
9
SIGMA 300D PMKR
$0.00
C1135
9
ENTITY DR 5326L/R, DC, PMKR
$0.00
C1136
9
AFFINITY DR 5330L/R, DC, PMK
$0.00
C1137
9
CARDIOSEAL IMPLANT SYS
$0.00
C1143
9
ADDVENT MOD 2060BL, VDD
$0.00
C1144
9
AFNTY SP 5130,INTEGRITY SR
$0.00
C1145
9
ANGIO-SEAL 6FR,8FR
$0.00
C1146
9
VETT TUBE
$0.00
C1147
9
AV PLUS DX 1368:LEAD
$0.00
C1148
9
CONTOUR MD SC DEFIB
$0.00
C1149
9
ENTITY DC 5226R,PMKR
$0.00
C1151
9
PASSIVEPLUS DX LEAD, 10MDLS
$0.00
C1152
9
LIFESITE ACCESS SYSTEM
$0.00
C1153
9
REGENCY SC+2402L PMKR
$0.00
C1154
9
SPL:SPO1,02,04-DEFIB LEAD
$0.00
C1155
9
REPLIFORM 8 SQ CM
$0.00
C1156
9
TR1102TRSR+2260L,2264L,5131
$0.00
C1157
9
TRILOGY DCT 23/8L PMKR
$0.00
C1158
9
TVL LEAD SV01,SV02,SV04
$0.00
C1159
9
TVL RV02, RV06,RV07:LEAD
$0.00
C1160
9
TVL-ADX 1559:LEAD
$0.00
C1161
9
TENDRIL DX, 1388 PACING LEAD
$0.00
C1162
9
TEMPODR TRILOGYDR+DC PMKR
$0.00
C1163
9
TENDRIL SDX, 1488T LEAD
$0.00
C1164
9
IODINE-125 BRACHYTX SEED
$0.00
C1166
O
CYTARABINE LIPOSOMAL, 10 MG
$0.00
C1167
O
EPIRUBICIN HCL, 2 MG
$0.00
C1170
9
ABBI DISP BIOPSY DEVICE
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
C1171
9
AUTOSUTURE SITE MARKER STPLE
$0.00
C1172
9
SPACEMAKER DISSECT BALLOON
$0.00
C1173
9
COR STNTS540,S670,O-WIRE STN
$0.00
C1174
9
BARD BRACHYTX NEEDLE
$0.00
C1175
9
MIBB DISP BIOPSY DEVICE
$0.00
C1176
9
MAMMOTOME HH PROBE W/VAC SYS
$0.00
C1177
9
11-G MAMMOTOME PROBE
$0.00
C1178
O
BUSULFAN IV, 6 MG
$0.00
C1179
9
14-G MAMMOTOME PROBE
$0.00
C1180
9
VIGOR SR, SC, PMKR
$0.00
C1181
9
MERIDIAN SSI, SC, PMKR
$0.00
C1182
9
PULSAR SSI, SC, PMKR
$0.00
C1183
9
JADE IIS, SIGMA 300S, SC, PM
$0.00
C1184
9
SIGMA 200S, SC, PMKR
$0.00
C1188
9
I-131 CAP, PER 1-5 MCI
$0.00
C1200
O
TC 99M SODIUM GLUCOHEPTONAT
$0.00
C1201
O
TC 99M SUCCIMER, PER VIAL
$0.00
C1202
9
TC 99M SULFUR COLLOID, VIAL
$0.00
C1203
9
VERTEPORFIN FOR INJ
$0.00
C1205
9
TC 99M DISOFENIN, PER VIAL
$0.00
C1207
O
OCTREOTIDE ACETATE DEPOT 1MG
$0.00
C1300
9
HYPERBARIC OXYGEN
$0.00
C1302
9
SQ01: LEAD
$0.00
C1303
9
CAPSURE FIX 6940/4068-110
$0.00
C1304
9
SONCATH MDL 37-416,-418
$0.00
C1305
O
APLIGRAF
$0.00
C1306
9
NEUROCYBERNETICPROS:LEAD
$0.00
C1311
9
TRILOGY DR+/DAO PMKR
$0.00
C1312
9
MAGIC WALLSTENT--MINI
$0.00
C1313
9
MAGIC MEDIUM,RADIUS 31MM
$0.00
C1314
9
MAGIC WALLSTENT--LONG
$0.00
C1315
9
VIGOR DR, MERIDIAN DR PMKR
$0.00
C1316
9
MERIDIAN DDD PMKR
$0.00
C1317
9
DISCOVERY SR, PMKR
$0.00
C1318
9
MERIDIAN SR PMKR
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
C1319
9
WALLSTENT: ENTERAL--60MM
$0.00
C1320
9
WALLSTENT: ILIAC
$0.00
C1321
9
PALATE/BASE OF TONGUE ELECTR
$0.00
C1322
9
TURBINATE SOMNOPLASTY ELECTR
$0.00
C1323
9
VAPR/T DISP ELECTRODE
$0.00
C1324
9
LIGASURE DISPOSABLE ELECTROD
$0.00
C1325
9
PALLADIUM-103 SEED
$0.00
C1326
9
ANGIO-JET RHEOLYTIC THROMB
$0.00
C1328
9
ANS RENEW NS TRNSMTR
$0.00
C1329
9
VERSAPOINT DISP ELECTRODE
$0.00
C1333
9
PALMAZ CORINTHIAN BIL STENT
$0.00
C1334
9
CROWN,MINI-CROWN,CROSSLC
$0.00
C1335
9
MESH, PROLENE
$0.00
C1336
9
CONSTANT FLOW IMP PUMP
$0.00
C1337
9
ISOMED 8472-20/35/60
$0.00
C1348
9
I-131 SOL, PER 1-6 MCI
$0.00
C1350
9
PROSTASEED I-125, PER SOURCE
$0.00
C1351
9
CAPSURE FIX LEAD
$0.00
C1352
9
GEM II DR
$0.00
C1353
9
ITREL INTERSTM NEUROSTIM+EXT
$0.00
C1354
9
KAPPA 400DR,DIAMOND II 820DR
$0.00
C1355
9
KAPPA 600DR, VITA DR
$0.00
C1356
9
PROFILE MD V-186HV3 SC DEFIB
$0.00
C1357
9
ANGSTROM MD V-190HV3 SC DEF
$0.00
C1358
9
AFFINITY DC 5230R, PMKR
$0.00
C1359
9
PULSAR,PULSAR MAX DR, PMKR
$0.00
C1360
9
OCULAR PHOTODYNAMIC TX
$0.00
C1361
9
REVEAL CARDIAC RECORDER
$0.00
C1362
9
HERCULINK,OTW,SDS BIL STNT
$0.00
C1363
9
GEM DR, DC, DEFIB
$0.00
C1364
9
PHOTON DR V-230HV3 DC DEFIB
$0.00
C1365
9
GUIDEWIRE, HI-TORQUE14/18/35
$0.00
C1366
9
GUIDEWIRE,PTCA,HI-TORQUE
$0.00
C1367
9
GUIDE WIRE, HI-TORQUECROSSIT
$0.00
C1368
9
ON-Q PAIN MGT SYS
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
C1369
9
ANS RENEW STIM SYS RECVR
$0.00
C1370
9
TENSION-FREE VAGINAL TAPE
$0.00
C1371
9
SYMP NITINOL TRANSHEP BIL SY
$0.00
C1372
9
CORDIS NITINOL BIL STENT
$0.00
C1375
9
STENT, CORONARY, NIR
$0.00
C1376
9
ANS RENEW STIM SYS LEAD
$0.00
C1377
9
SPECIFY 3988 NEURO LEAD
$0.00
C1378
9
INTERSTIM TX 3080/3886 LEAD
$0.00
C1379
9
PISCES-QUAD 3887 LEAD
$0.00
C1420
9
STAPLETAC2 BONEW/DERMIS
$0.00
C1421
9
STAPLETAC2 BONE WO DERMIS
$0.00
C1450
9
ORTHOSPHERE ARTHROPLASTY
$0.00
C1451
9
ORTHOSPHERE ARTHROPLASTY KIT
$0.00
C1500
9
ATHERECTOMY SYS, PERIPHERAL
$0.00
C1700
9
AUTHEN MICK TP BRACHY NEEDLE
$0.00
C1701
9
MEDTEC MT-BT-5201-25 NEEDLE
$0.00
C1702
9
WWMT BRACHY NEEDLE
$0.00
C1703
9
MENTOR PROSTATE BRACHY
$0.00
C1704
9
MT-BT-5001-25/5051-25
$0.00
C1705
9
BEST FLEXI BRACHY NEEDLE
$0.00
C1706
9
INDIGO PROSTATE SEEDING NDL
$0.00
C1707
9
VARISOURCE IMPLT NDL
$0.00
C1708
9
UROMED PROSTATE SEED NDL
$0.00
C1709
9
REMINGTON BRACHYTX NEEDLE
$0.00
C1710
9
US BIOPSY PROSTATE NEEDLE
$0.00
C1711
9
MD TECH BRACHYTX NEEDLE
$0.00
C1712
9
IMAGYN BRACHYTX NEEDLE
$0.00
C1713
9
ANCHOR/SCREW BN/BN,TIS/BN
$0.00
C1714
9
CATH, TRANS ATHERECTOMY, DIR
$0.00
C1715
9
BRACHYTHERAPY NEEDLE
$0.00
C1716
9
BRACHYTX, NON-STR, GOLD-198
$0.00
C1717
O
BRACHYTX, NON-STR,HDR IR-192
$0.00
C1718
O
BRACHYTX SOURCE, IODINE 125
$0.00
C1719
9
BRACHYTX, NS, NON-HDRIR-192
$0.00
C1720
O
BRACHYTX SOUR, PALLADIUM 103
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
C1721
9
AICD, DUAL CHAMBER
$0.00
C1722
9
AICD, SINGLE CHAMBER
$0.00
C1724
9
CATH, TRANS ATHEREC,ROTATION
$0.00
C1725
9
CATH, TRANSLUMIN NON-LASER
$0.00
C1726
9
CATH, BAL DIL, NON-VASCULAR
$0.00
C1727
9
CATH, BAL TIS DIS, NON-VAS
$0.00
C1728
9
CATH, BRACHYTX SEED ADM
$0.00
C1729
9
CATH, DRAINAGE
$0.00
C1730
9
CATH, EP, 19 OR FEW ELECT
$0.00
C1731
9
CATH, EP, 20 OR MORE ELEC
$0.00
C1732
9
CATH, EP, DIAG/ABL, 3D/VECT
$0.00
C1733
9
CATH, EP, OTHR THAN COOL-TIP
$0.00
C1750
9
CATH, HEMODIALYSIS,LONG-TERM
$0.00
C1751
9
CATH, INF, PER/CENT/MIDLINE
$0.00
C1752
9
CATH,HEMODIALYSIS,SHORT-TERM
$0.00
C1753
9
CATH, INTRAVAS ULTRASOUND
$0.00
C1754
9
CATHETER, INTRADISCAL
$0.00
C1755
9
CATHETER, INTRASPINAL
$0.00
C1756
9
CATH, PACING, TRANSESOPH
$0.00
C1757
9
CATH, THROMBECTOMY/EMBOLECT
$0.00
C1758
9
CATHETER, URETERAL
$0.00
C1759
9
CATH, INTRA ECHOCARDIOGRAPHY
$0.00
C1760
9
CLOSURE DEV, VASC
$0.00
C1762
9
CONN TISS, HUMAN(INC FASCIA)
$0.00
C1763
9
CONN TISS, NON-HUMAN
$0.00
C1764
9
EVENT RECORDER, CARDIAC
$0.00
C1765
9
ADHESION BARRIER
$0.00
C1766
9
INTRO/SHEATH,STRBLE,NON-PEEL
$0.00
C1767
9
GENERATOR, NEURO NON-RECHARG
$0.00
C1768
9
GRAFT, VASCULAR
$0.00
C1769
9
GUIDE WIRE
$0.00
C1770
9
IMAGING COIL, MR, INSERTABLE
$0.00
C1771
9
REP DEV, URINARY, W/SLING
$0.00
C1772
9
INFUSION PUMP, PROGRAMMABLE
$0.00
C1773
9
RET DEV, INSERTABLE
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
C1775
O
FDG, PER DOSE (4-40 MCI/ML)
$0.00
C1776
9
JOINT DEVICE (IMPLANTABLE)
$0.00
C1777
9
LEAD, AICD, ENDO SINGLE COIL
$0.00
C1778
9
LEAD, NEUROSTIMULATOR
$0.00
C1779
9
LEAD, PMKR, TRANSVENOUS VDD
$0.00
C1780
9
LENS, INTRAOCULAR (NEW TECH)
$0.00
C1781
9
MESH (IMPLANTABLE)
$0.00
C1782
9
MORCELLATOR
$0.00
C1783
9
OCULAR IMP, AQUEOUS DRAIN DE
$0.00
C1784
9
OCULAR DEV, INTRAOP, DET RET
$0.00
C1785
9
PMKR, DUAL, RATE-RESP
$0.00
C1786
9
PMKR, SINGLE, RATE-RESP
$0.00
C1787
9
PATIENT PROGR, NEUROSTIM
$0.00
C1788
9
PORT, INDWELLING, IMP
$0.00
C1789
9
PROSTHESIS, BREAST, IMP
$0.00
C1790
9
IRIDIUM 192 HDR
$0.00
C1791
9
ONCOSEED, RAPID STRAND I-125
$0.00
C1792
9
UROMED I-125 BRACHY SEED
$0.00
C1793
9
BARD INTERSOURCE P-103 SEED
$0.00
C1794
9
BARD ISOSEED P-103 SEED
$0.00
C1795
9
BARD BRACHYSOURCE I-125
$0.00
C1796
9
SOURCETECH MED I-125
$0.00
C1797
9
DRAXIMAGE I-125 SEED
$0.00
C1798
9
SYNCOR I-125 PHARMASEED
$0.00
C1799
9
I-PLANT I-125 BRACHYTX SEED
$0.00
C1800
9
PD-103 BRACHYTX SEED
$0.00
C1801
9
IOGOLD I-125 BRACHYTX SEED
$0.00
C1802
9
IRIDIUM 192 BRACHYTX SEEDS
$0.00
C1803
9
BEST IODINE 125 BRACHYTX SDS
$0.00
C1804
9
BEST PALLADIUM 103 SEEDS
$0.00
C1805
9
ISOSTAR IODINE-125 SEEDS
$0.00
C1806
9
BEST GOLD 198 BRACHYTX SEED
$0.00
C1810
9
D114S DILATATION CATH
$0.00
C1811
9
SUGICAL DYNAMICS ANCHORS
$0.00
C1812
9
OBL ANCHORS
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
C1813
9
PROSTHESIS, PENILE, INFLATAB
$0.00
C1814
9
RETINAL TAMP, SILICONE OIL
$0.00
C1815
9
PROS, URINARY SPH, IMP
$0.00
C1816
9
RECEIVER/TRANSMITTER, NEURO
$0.00
C1817
9
SEPTAL DEFECT IMP SYS
$0.00
C1818
9
INTEGRATED KERATOPROSTHESIS
$0.00
C1819
9
TISSUE LOCALIZATION-EXCISION
$0.00
C1820
9
GENERATOR NEURO RECHG BAT SY
$0.00
C1821
9
INTERSPINOUS IMPLANT
$0.00
C1850
9
REPLIFORM 14/21 SQ CM
$0.00
C1851
9
REPLIFORM 24/28 SQ CM
$0.00
C1852
9
TRANSCYTE, PER 247 SQ CM
$0.00
C1853
9
SUSPEND, PER 8/14 SQ CM
$0.00
C1854
9
SUSPEND, PER 24/28 SQ CM
$0.00
C1855
9
SUSPEND, PER 36 SQ CM
$0.00
C1856
9
SUSPEND, PER 48 SQ CM
$0.00
C1857
9
SUSPEND, PER 84 SQ CM
$0.00
C1858
9
DURADERM, PER 8/14 SQ CM
$0.00
C1859
9
DURADERM, PER 21/24/28 SQ CM
$0.00
C1860
9
DURADERM, PER 48 SQ CM
$0.00
C1861
9
DURADERM, PER 36 SQ CM
$0.00
C1862
9
DURADERM, PER 72 SQ CM
$0.00
C1863
9
DURADERM, PER 84 SQ CM
$0.00
C1864
9
SPERMATEX, PER 13.44 SQ CM
$0.00
C1865
9
FASLATA, PER 8/14 SQ CM
$0.00
C1866
9
FASLATA, PER 24/28 SQ CM
$0.00
C1867
9
FASLATA, PER 36/48 SQ CM
$0.00
C1868
9
FASLATA, PER 96 SQ CM
$0.00
C1869
9
GORE THYROPLASTY DEVICE
$0.00
C1870
9
DERMMATRIX, PER 16 SQ CM
$0.00
C1871
9
DERMMATRIX, 32 OR 64 SQ CM
$0.00
C1872
9
DERMAGRAFT, PER 37.5 SQ CM
$0.00
C1873
9
BARD 3DMAX MESH
$0.00
C1874
9
STENT, COATED/COV W/DEL SYS
$0.00
C1875
9
STENT, COATED/COV W/O DEL SY
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
C1876
9
STENT, NON-COA/NON-COV W/DEL
$0.00
C1877
9
STENT, NON-COAT/COV W/O DEL
$0.00
C1878
9
MATRL FOR VOCAL CORD
$0.00
C1879
O
TISSUE MARKER, IMPLANTABLE
$0.00
C1880
9
VENA CAVA FILTER
$0.00
C1881
9
DIALYSIS ACCESS SYSTEM
$0.00
C1882
9
AICD, OTHER THAN SING/DUAL
$0.00
C1883
9
ADAPT/EXT, PACING/NEURO LEAD
$0.00
C1884
9
EMBOLIZATION PROTECT SYST
$0.00
C1885
9
CATH, TRANSLUMIN ANGIO LASER
$0.00
C1887
9
CATHETER, GUIDING
$0.00
C1888
9
ENDOVAS NON-CARDIAC ABL CATH
$0.00
C1891
9
INFUSION PUMP,NON-PROG, PERM
$0.00
C1892
9
INTRO/SHEATH,FIXED,PEEL-AWAY
$0.00
C1893
9
INTRO/SHEATH, FIXED,NON-PEEL
$0.00
C1894
9
INTRO/SHEATH, NON-LASER
$0.00
C1895
9
LEAD, AICD, ENDO DUAL COIL
$0.00
C1896
9
LEAD, AICD, NON SING/DUAL
$0.00
C1897
9
LEAD, NEUROSTIM TEST KIT
$0.00
C1898
9
LEAD, PMKR, OTHER THAN TRANS
$0.00
C1899
9
LEAD, PMKR/AICD COMBINATION
$0.00
C1900
9
LEAD, CORONARY VENOUS
$0.00
C1925
9
INJECTION, RISPERIDONE
$0.00
C1929
9
MAVERICK PTCA CATH
$0.00
C1930
9
COYOTE DIL CATH, 20/30/40MM
$0.00
C1931
9
TALON DIL CATH
$0.00
C1932
9
SCIMED REMEDY DIL CATH
$0.00
C1933
9
OPTI-PLAST XL/CENTURION CATH
$0.00
C1934
9
ULTRAVERSE 3.5F BAL DIL CATH
$0.00
C1935
9
WORKHORSE PTA BAL CATH
$0.00
C1936
9
UROMAX ULTRA BAL DIL CATH
$0.00
C1937
9
SYNERGY/EXPLORER CATH
$0.00
C1938
9
UROFORCE BAL DIL CATH
$0.00
C1939
9
RAPTUR, NINJA PTCA DIL CATH
$0.00
C1940
9
POWERFLEX,OPTA 5/LP BAL CATH
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
C1941
9
JUPITER PTA DIL CATH
$0.00
C1942
9
CORDIS MAXI LD PTA BAL CATH
$0.00
C1943
9
RXCROSSSAIL OTW OPENSAIL
$0.00
C1944
9
RAPID EXCHANGE BIL DIL CATH
$0.00
C1945
9
SAVVY PTA DIL CATH
$0.00
C1946
9
R1S RAPID DIL CATH
$0.00
C1947
9
GAZELLE BAL DIL CATH
$0.00
C1948
9
ORACLE MEGASONICS CATH
$0.00
C1949
9
ORACLE MEGASONICS CATH
$0.00
C1979
9
VISIONS PV/AVANAR US CATH
$0.00
C1980
9
ATLANTIS SR CORONARY CATH
$0.00
C1981
9
PTCA CATHETERS
$0.00
C2000
9
ORBITER ST STEERABLE CATH
$0.00
C2001
9
CONSTELLATION DIAG CATH
$0.00
C2002
9
IRVINE 5F INQUIRY EP CATH
$0.00
C2003
9
IRVINE 6F INQUIRY EP CATH
$0.00
C2004
9
EP CATH--OCTAPOLAR
$0.00
C2005
9
EP TIP CATH--HEXAPOLAR
$0.00
C2006
9
EP CATH--DECAPOLAR
$0.00
C2007
9
IRVINE 6F LUMA-CATH EP CATH
$0.00
C2008
9
LUMA-CATH EP CATH 81910-15
$0.00
C2009
9
IRVINE 7F LUMA-CATH EP CATH
$0.00
C2010
9
FIXED CURVE EP CATH
$0.00
C2011
9
DEFLECTABLE TIP CATH--QUAD
$0.00
C2012
9
CELSIUS ABLN CATH
$0.00
C2013
9
CELSIUS LARGE ABLN CATH
$0.00
C2014
9
CELSIUS II ASYM ABLN CATH
$0.00
C2015
9
CELSIUS II SYM ABLN CATH
$0.00
C2016
9
NAVI-STAR DS, NAVI-STAR THER
$0.00
C2017
9
NAVI-STAR ABLN CATH
$0.00
C2018
9
POLARIS T ABLATION CATH
$0.00
C2019
9
EP DEFLECTABLE CATH
$0.00
C2020
9
BLAZER II XP ABLN CATH
$0.00
C2021
9
SILVERFLEX EP CATH
$0.00
C2022
9
CP CHILLI COOLED ABLN CATH
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
C2023
9
CHILLI CLD ABLNCATH-STD,LG
$0.00
C2100
9
CP CS REFERENCE CATH
$0.00
C2101
9
CP RV REFERENCE CATH
$0.00
C2102
9
CP RADII 7F EP CATH
$0.00
C2103
9
CP RADII 7F EP CATH W/TRACK
$0.00
C2104
9
LASSO DEFLECTABLE CATH
$0.00
C2151
9
VERIPATH GUIDING CATH
$0.00
C2152
9
CORDIS VISTA BRITE TIP CATH
$0.00
C2153
9
BARD VIKING CATH
$0.00
C2200
9
ARROW-TREROTOLA PTD CATH
$0.00
C2300
9
VARISOURCE STND CATH
$0.00
C2597
9
CLINICATH 16/18 SGL/DBL
$0.00
C2598
9
CLINICATH 18/20/24G--SINGLE
$0.00
C2599
9
CLINICATH 16/18 DOUBLE
$0.00
C2600
9
GOLD PROBE CATHETER
$0.00
C2601
9
BARD DL URETERAL CATH
$0.00
C2602
9
VITESSE LASER CATH 1.4/1.7MM
$0.00
C2603
9
VITESSE LASER CATH 2.0MM
$0.00
C2604
9
VITESSE E LASER CATH 2.0MM
$0.00
C2605
9
EXTREME LASER CATH
$0.00
C2606
9
SPINECATH XL CATHETER
$0.00
C2607
9
SPINECATH INTRADISCAL CATH
$0.00
C2608
9
SCIMED 6F WISEGUIDE CATHETER
$0.00
C2609
9
FLEXIMA BIL DRAINAGE CATH
$0.00
C2610
9
FLEXTIPPLUS INTRASPINAL CATH
$0.00
C2611
9
ALGOLINE INTRASPINAL CATH
$0.00
C2612
9
INDURA CATHETER
$0.00
C2614
9
PROBE, PERC LUMB DISC
$0.00
C2615
9
SEALANT, PULMONARY, LIQUID
$0.00
C2616
9
BRACHYTX, NON-STR,YTTRIUM-90
$0.00
C2617
9
STENT, NON-COR, TEM W/O DEL
$0.00
C2618
9
PROBE, CRYOABLATION
$0.00
C2619
9
PMKR, DUAL, NON RATE-RESP
$0.00
C2620
9
PMKR, SINGLE, NON RATE-RESP
$0.00
C2621
9
PMKR, OTHER THAN SING/DUAL
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
C2622
9
PROSTHESIS, PENILE, NON-INF
$0.00
C2625
9
STENT, NON-COR, TEM W/DEL SY
$0.00
C2626
9
INFUSION PUMP, NON-PROG,TEMP
$0.00
C2627
9
CATH, SUPRAPUBIC/CYSTOSCOPIC
$0.00
C2628
9
CATHETER, OCCLUSION
$0.00
C2629
9
INTRO/SHEATH, LASER
$0.00
C2630
9
CATH, EP, COOL-TIP
$0.00
C2631
9
REP DEV, URINARY, W/O SLING
$0.00
C2632
O
BRACHYTX SOL, I-125, PER MCI
$0.00
C2633
O
BRACHYTX SOURCE, CESIUM-131
$0.00
C2634
9
BRACHYTX, NON-STR, HA, I-125
$0.00
C2635
9
BRACHYTX, NON-STR, HA, P-103
$0.00
C2636
9
BRACHY LINEAR, NON-STR,P-103
$0.00
C2637
9
BRACHY,NON-STR,YTTERBIUM-169
$0.00
C2638
9
BRACHYTX, STRANDED, I-125
$0.00
C2639
9
BRACHYTX, NON-STRANDED,I-125
$0.00
C2640
9
BRACHYTX, STRANDED, P-103
$0.00
C2641
9
BRACHYTX, NON-STRANDED,P-103
$0.00
C2642
9
BRACHYTX, STRANDED, C-131
$0.00
C2643
9
BRACHYTX, NON-STRANDED,C-131
$0.00
C2676
9
RSPONSE CV CATHETER
$0.00
C2698
9
BRACHYTX, STRANDED, NOS
$0.00
C2699
9
BRACHYTX, NON-STRANDED, NOS
$0.00
C2700
9
MYCROPHYLAX PLUS SC DEFIB
$0.00
C2701
9
PHYLAX XM SC DEFIB
$0.00
C2702
9
VENTAK PRIZM 2 VR DEFIB
$0.00
C2703
9
VENTAK PRIZM VR HE DEFIB
$0.00
C2704
9
VENTAK MINI IV+ DEFIB
$0.00
C2801
9
DEFENDER IV DR 612 DC DEFIB
$0.00
C2802
9
PHYLAX AV
$0.00
C2803
9
VENTAK PRIZM DR HE DEFIB
$0.00
C2804
9
VENTAK PRIZM 2 DR DEFIB
$0.00
C2805
9
JEWEL AF 7250 DEFIB
$0.00
C2806
9
GEM VR 7227 DEFIB
$0.00
C2807
9
CONTAK CD 1823
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
C2808
9
CONTAK TR 1241
$0.00
C3001
9
KAINOX SL/RV DEFIB LEAD
$0.00
C3002
9
EASYTRAK DEFIB LEAD
$0.00
C3003
9
ENDOTAK SQ ARAY XP LEAD
$0.00
C3004
9
INTERVENE DEFIB LEAD
$0.00
C3400
9
SILTEX SPECTRUM,CONTOUR PROF
$0.00
C3401
9
SALINE-FILLED SPECTRUM
$0.00
C3500
9
ALPHA I INF PRO
$0.00
C3510
9
AMS 800 URINARY PROS
$0.00
C3551
9
CHOICE/PT GRAPHIX/LUGE/TROOP
$0.00
C3552
9
HI-TORQUE WHISPER
$0.00
C3553
9
CORDIS GUIDEWIRES
$0.00
C3554
9
JINDO GUIDEWIRE
$0.00
C3555
9
WHOLEY HI-TORQUE PLUS GW
$0.00
C3556
9
WAVE/FLOWWIRE GUIDEWIRE
$0.00
C3557
9
HYTEK GUIDEWIRE
$0.00
C3800
9
SYNCHROMED EL INFUSION PUMP
$0.00
C3801
9
ARROW/MICROJECT PCA SYS
$0.00
C3851
9
ELASTIC UV IOLAA-4203T/TF/TL
$0.00
C4000
9
OPUS G 4621, 4624 SC PMKR
$0.00
C4001
9
OPUS S 4121/4124 SC PMKR
$0.00
C4002
9
TALENT 113 SC PMKR
$0.00
C4003
9
KAIROS SR SC PMKR
$0.00
C4004
9
ACTROS SR, ACTROSSR-B SC PMK
$0.00
C4005
9
PHILOS SR/SR-B SC PMKR
$0.00
C4006
9
PULSAR MAX II SR PMKR
$0.00
C4007
9
MARATHON SR PMKR
$0.00
C4008
9
DISCOVERY II SSI PMKR
$0.00
C4009
9
DISCOVERY II SR PMKR
$0.00
C4300
9
INTEGRITY AFX DR 5342 PMKR
$0.00
C4301
9
INTEGRITY AFX DR 5346 PMKR
$0.00
C4302
9
AFFINITY VDR 5430 PMKR
$0.00
C4303
9
BRIO 112 DC PMKR
$0.00
C4304
9
BRIO212,TALENT213/223DCPMKR
$0.00
C4305
9
BRIO 222 DC PMKR
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
C4306
9
BRIO 220 DC PMKR
$0.00
C4307
9
KAIROS DR DC PMKR
$0.00
C4308
9
INOS2, INOS2+ DC PMKR
$0.00
C4309
9
ACTROS DR,D,DR-A,SLR DC PMKR
$0.00
C4310
9
ACTROS DR-B DC PMKR
$0.00
C4311
9
PHILOS DR/DR-B/SLR DC PMKR
$0.00
C4312
9
PULSAR MAX II DR PMKR
$0.00
C4313
9
MARATHON DR PMKR
$0.00
C4314
9
MOMENTUM DR PMKR
$0.00
C4315
9
SELECTION AFM PMKR
$0.00
C4316
9
DISCOVERY II DR
$0.00
C4317
9
DISCOVERY II DDD
$0.00
C4600
9
SYNOX,POLYROX,ELOX,RETROX
$0.00
C4601
9
AESCULA LV PMKR LEAD
$0.00
C4602
9
TENDRIL SDX, 1488K PMKR LEAD
$0.00
C4603
9
OSCOR PR/FLEXION PMKR LEAD
$0.00
C4604
9
CRYSTALLINEACTFIX,CAPSUREFIX
$0.00
C4605
9
CAPSURE EPI PMKR LEAD
$0.00
C4606
9
FLEXTEND PMKR LEAD
$0.00
C4607
9
FINELINEII/EZ, THINLINEII/EZ
$0.00
C5000
9
BX VELOCITY W/HEPACOAT
$0.00
C5001
9
MEMOTHERM BIL STENT, SM, MED
$0.00
C5002
9
MEMOTHERM BIL STENT, LARGE
$0.00
C5003
9
MEMOTHERM BIL STENT, X-LARGE
$0.00
C5004
9
PALMAZCORINTHIAN IQ BIL STNT
$0.00
C5005
9
PALMAZCORINTHIAN IQ TRANS/BI
$0.00
C5006
9
PALMAZTRANS BIL STENTSYS-MED
$0.00
C5007
9
PALMAZTRANS XL BIL ST-40MM
$0.00
C5008
9
PALMAZTRANS XL BIL ST-50MM
$0.00
C5009
9
VISTAFLEX BILIARY STENT
$0.00
C5010
9
RAPID EXCHANGE BIL STENT SYS
$0.00
C5011
9
INTRASTENT, INTRASTENT LP
$0.00
C5012
9
INTRASTENT DOUBLESTRUT LD
$0.00
C5013
9
INTRASTENT DOUBLESTRUT, XS
$0.00
C5014
9
AVE BRIDGE STENTSYS10/17/28
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
C5015
9
AVE/X3 BRIDGE SYS, 40-100
$0.00
C5016
9
BILIARY STENT SINGLE USE COV
$0.00
C5017
9
WALLSTENTRP-BIL-20/40/60/68
$0.00
C5018
9
WALLSTENTRP BIL--80/94MM
$0.00
C5019
9
FLEXIMA BIL STENT SYS
$0.00
C5020
9
SMART NITINOL STENT--20MM
$0.00
C5021
9
SMART NITINOL STENT--40/60MM
$0.00
C5022
9
SMART NITINOL STENT--80MM
$0.00
C5023
9
BX VELOCITY STENT--8/13MM
$0.00
C5024
9
BX VELOCITY STENT
$0.00
C5025
9
BX VELOCITY STENT--23MM
$0.00
C5026
9
BX VELOCITY STENT--28/33MM
$0.00
C5027
9
BX VELOCITY W/HEP--8/13MM
$0.00
C5028
9
BX VELOCITY W/HEP--18MM
$0.00
C5029
9
BX VELOCITY W/HEP--23MM
$0.00
C5030
9
STENT, CORONARY, S660 9/12MM
$0.00
C5031
9
STENT, CORONARY, S660 15/18
$0.00
C5032
9
STENT,CORONARY, S660 24/30
$0.00
C5033
9
NIROYAL STNT SYS, 9MM
$0.00
C5034
9
NIROYAL STENT SYS, 12/15MM
$0.00
C5035
9
NIROYAL STENT SYS, 18MM
$0.00
C5036
9
NIROYAL STENT SYS, 25MM
$0.00
C5037
9
NIROYAL STENT SYS, 31MM
$0.00
C5038
9
BX VELOCITY STNT W/RAPTOR
$0.00
C5039
9
INTRACOIL PERIP STENT--40MM
$0.00
C5040
9
INTRACOIL PERIPH STENT--60MM
$0.00
C5041
9
BESTENT OVER-THE-WIRE24/30MM
$0.00
C5042
9
BESTENT OVER-THE-WIRE 18MM
$0.00
C5043
9
BESTENT OVER-THE-WIRE 15MM
$0.00
C5044
9
BESTENT OVER-THE-WIRE 9/12MM
$0.00
C5045
9
MULTILINK TETRA COR STENT SY
$0.00
C5046
9
RADIUS 20MM COR STENT
$0.00
C5047
9
NIROYAL ELITE COR STENT SYS
$0.00
C5048
9
GR II CORONARY STENT
$0.00
C5130
9
WILSON-COOK Z-STENT
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
C5131
9
BARD COLORECTAL STENT--60MM
$0.00
C5132
9
BARD COLORECTAL STENT--80MM
$0.00
C5133
9
BARD COLORECTAL STENT-100MM
$0.00
C5134
9
ENTERAL WALLSTENT--90MM
$0.00
C5279
9
CONTOUR/PERCUFLEX STENT
$0.00
C5280
9
INLAY DBL URETERAL STENT
$0.00
C5281
9
WALLGRAFT TRACH SYS 70MM
$0.00
C5282
9
WALLGRAFT TRACH SYS 20/30/50
$0.00
C5283
9
WALLSTENT/RP TIPS--80MM
$0.00
C5284
9
WALLSTENT TRACHULTRAFLEX
$0.00
C5600
9
CLOSURE DEV, VASOSEAL ES
$0.00
C5601
9
VASOSEAL 1000
$0.00
C6001
9
COMPOSIX MESH 8/18 IN
$0.00
C6002
9
COMPOSIX MESH 32 IN
$0.00
C6003
9
COMPOSIX MESH 48 IN
$0.00
C6004
9
COMPOSIX MESH 80 IN
$0.00
C6005
9
COMPOSIX MESH 140 IN
$0.00
C6006
9
COMPOSIX MESH 144 IN
$0.00
C6012
9
PELVICOL COLLAGEN 8/14 SQ CM
$0.00
C6013
9
PELVICOL COLLAGEN 21/24/28
$0.00
C6014
9
PELVICOL COLLAGEN 40 SQ CM
$0.00
C6015
9
PELVICOL COLLAGEN 48 SQ CM
$0.00
C6016
9
PELVICOL COLLAGEN 96 SQ CM
$0.00
C6017
9
GORE-TEX DUALMESH 75/96 SQCM
$0.00
C6018
9
GORE-TEX DUALMESH 150SQCM
$0.00
C6019
9
GORE-TEX DUALMESH 285 SQCM
$0.00
C6020
9
GORE-TEX DUALMESH 432SQCM
$0.00
C6021
9
GORE-TEX DUALMESH 600 SQCM
$0.00
C6022
9
GORE-TEX DUALMESH 884 SQCM
$0.00
C6023
9
GORE-TEXPLUS 1MM,75/96 SQCM
$0.00
C6024
9
GORE-TEXPLUS 1MM, 150 SQ CM
$0.00
C6025
9
GORE-TEXPLUS 1MM, 285 SQ CM
$0.00
C6026
9
GORE-TEXPLUS 1MM, 432 SQCM
$0.00
C6027
9
GORE-TEXPLUS 1MM, 600 SQCM
$0.00
C6028
9
GORE-TEXPLUS 1MM,884 SQ CM
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
C6029
9
GORE-TEXPLUS 2MM, 150 SQ CM
$0.00
C6030
9
GORE-TEXPLUS 2MM, 285 SQ CM
$0.00
C6031
9
GORE-TEXPLUS 2MM, 432 SQ CM
$0.00
C6032
9
GORE-TEXPLUS 2MM, 600 SQ CM
$0.00
C6033
9
GORE-TEXPLUS 2MM,884 SQ CM
$0.00
C6034
9
BARD EPTFE: 150 SQ CM-2MM
$0.00
C6035
9
BARD EPTFE150SQCM-1MM,75-2MM
$0.00
C6036
9
BARD EPTFE: 50/75SQCM-1,2MM
$0.00
C6037
9
BARD EPFTE: 300SQ CM-1MM
$0.00
C6038
9
BARD EPTFE: 600SQ CM-1MM
$0.00
C6039
9
BARD EPTFE: 884 CM--1MM
$0.00
C6040
9
BARD EPTFE: 600SQ CM-2MM
$0.00
C6041
9
BARD EPTFE: 884SQ CM-2MM
$0.00
C6050
9
FEMALE SLING SYS W/WO MATRL
$0.00
C6051
9
STRATASIS SLING, 20/40CM
$0.00
C6052
9
STRATASIS SLING, 60CM
$0.00
C6053
9
SURGISIS SOFT GRAFT
$0.00
C6054
9
SURGISIS ENCHANCED GRAFT
$0.00
C6055
9
SURGISIS ENHANCED TISSUE
$0.00
C6056
9
SURGISIS SOFT TISSUE GRAFT
$0.00
C6057
9
SURGISIS HERNIA GRAFT
$0.00
C6058
9
SURGIPRO HERNIA PLUG,MED/LG
$0.00
C6080
9
MALE SLING SYS W/WO MATRL
$0.00
C6200
9
EXXCEL SFT EPTFE VAS GRAFT
$0.00
C6201
9
IMPRA VENAFLO-10/20CM
$0.00
C6202
9
IMPRA VENAFLO-30/40CM
$0.00
C6203
9
IMPRA VENAFLO-50CM/VT45
$0.00
C6204
9
IMPRA VENAFLO-STEPPED
$0.00
C6205
9
IMPRA CARBOFLO-10CM
$0.00
C6206
9
IMPRA CARBOFLO-20CM
$0.00
C6207
9
IMPRA CARBOFLO-30/34/40CM
$0.00
C6208
9
IMPRA CARBOFLO-40/50CM
$0.00
C6209
9
IMPRA CARBOFLO-CTRFLEX
$0.00
C6210
9
EXXCEL EPTFE VAS GRAFT
$0.00
C6300
9
VANGUARD III ENDOVAS GRAFT
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
C6500
9
PREFACE GUIDING SHEATH
$0.00
C6501
9
SOFT TIP SHEATHS
$0.00
C6525
9
SPECTRANETICS LASER SHEATH
$0.00
C6600
9
MICRO LITHO FLEX PROBES
$0.00
C6650
9
FAST-CATH GUIDING INTRODUCER
$0.00
C6651
9
SEAL-AWAYGUIDING INTRODUCER
$0.00
C6652
9
BARD EXCALIBUR INTRODUCER
$0.00
C6700
9
FOCAL SEAL-L
$0.00
C8099
9
SPECTRANETICS LEAD LOCK DEV
$0.00
C8100
9
ADHESION BARRIER, ADCON-L
$0.00
C8102
9
SURGIVISION ESOPH COIL
$0.00
C8103
9
CAPIO CAPTURING DEV
$0.00
C8500
9
ATHEROCATH-GTO
$0.00
C8501
9
VIGOR SSI, SC, PMKR
$0.00
C8502
9
LIVEWIRE STEERABLE EP CATH
$0.00
C8503
9
SYNCHROMED VAS CATH
$0.00
C8504
9
VASOSEAL HEMOSTASIS DEV
$0.00
C8505
9
SYNCHROMED INFUSION PUMP
$0.00
C8506
9
PMKR LEADS 4057M,4058M
$0.00
C8507
9
6721L/M/S,6939 LEAD
$0.00
C8508
9
CAPSURE 4965 DEFIB LEAD
$0.00
C8509
9
TRANSVENE 6933/6937 LEAD
$0.00
C8510
9
DP-3238 DEFIB LEAD
$0.00
C8511
9
ENDOTAK DSP DEFIB LEAD
$0.00
C8512
9
ON-POINT,PISCES-QUAD LEAD
$0.00
C8513
9
PISCES,RESUME II LEAD
$0.00
C8514
9
DURA II PENILE PROSTHESIS
$0.00
C8516
9
MENTOR ACU-FORM/MAL PROS
$0.00
C8518
9
VIGOR DDD DC PMKR
$0.00
C8519
9
VISTA DDD C PMKR
$0.00
C8520
9
LEGACY II S, SC, PMKR
$0.00
C8521
9
MEDTRONIC MATTRIX RCVR/TRMR
$0.00
C8522
9
PALMAZ BAL STENT
$0.00
C8523
9
WALLSTENT TRANS BIL
$0.00
C8524
9
WALLSTENT ESOP
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
C8525
9
WALLSTENT ESOPH--DOUBLE
$0.00
C8526
9
OPTIPLAST XT PTA CATH
$0.00
C8528
9
MS CLASSIQUE BL DIL CATH
$0.00
C8529
9
CRISTA CATH II DEF 20-POLE
$0.00
C8530
9
GEL-FILLED/SMOOTH MAMMARY PR
$0.00
C8531
9
WILSON-COOK ESOPH Z-STENT
$0.00
C8532
9
ULTRAFLEX ESOPHAGEAL PROS
$0.00
C8533
9
SYNCHROMED VAS CATH 8700A/V
$0.00
C8534
9
AMS 650 PENILE PROSTHESIS
$0.00
C8535
9
ZA/SPIRAL Z BIL STENT
$0.00
C8536
9
ESOPH Z METAL STENT
$0.00
C8539
9
QUANTUM DIL BALLOON
$0.00
C8540
9
FLEX-EZ BAL DILATOR
$0.00
C8541
9
CARSON/PASSPRT DIL CATH
$0.00
C8542
9
URETHRAMAX DIL CATH
$0.00
C8543
9
AMPLATZ RENAL DIL
$0.00
C8550
9
LIVEWIRE 5F, 7F EP CATH
$0.00
C8551
9
LIVEWIRE 7F DUO-DECAPOLAR
$0.00
C8552
9
SANTURO FIXED CURVE CATH
$0.00
C8597
9
WISDOM ST GUIDEWIRE
$0.00
C8598
9
SV GUIDEWIRE-5/8/14CM
$0.00
C8599
9
STABILIZER XS GUIDEWIRE
$0.00
C8600
9
SHINOBI PLUS GUIDEWIRE
$0.00
C8650
9
XL CHECK-FLO INTRODUCER
$0.00
C8724
9
OCTAD NEURO LEAD
$0.00
C8725
9
SYMMIX NEURO LEAD
$0.00
C8748
9
ENDOTAK SQ PATCH DEFIB LEAD
$0.00
C8749
9
ENDOTAK SQ ARRAY DEFIB LEAD
$0.00
C8750
9
UNITY VDDR DC PMKR
$0.00
C8775
9
2188 COR PMKR LEAD
$0.00
C8776
9
INNOMEDICA PMKR LEAD
$0.00
C8777
9
UNIPASS PMKR LEAD
$0.00
C8800
9
LG PALMAZ BIL STENT
$0.00
C8801
9
GIANTURCO BIL Z STENT
$0.00
C8802
9
OASIS STENT INTRO SYS
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
C8830
9
GIANTURCO-ROUBIN COR SNT
$0.00
C8890
9
PERFLUORON, 2ML
$0.00
C8891
9
PERFLUORON, 5/7ML
$0.00
C8900
9
MRA W/CONT, ABD
$0.00
C8901
9
MRA W/O CONT, ABD
$0.00
C8902
9
MRA W/O FOL W/CONT, ABD
$0.00
C8903
9
MRI W/CONT, BREAST, UNI
$0.00
C8904
9
MRI W/O CONT, BREAST, UNI
$0.00
C8905
9
MRI W/O FOL W/CONT, BRST, UN
$0.00
C8906
9
MRI W/CONT, BREAST, BI
$0.00
C8907
9
MRI W/O CONT, BREAST, BI
$0.00
C8908
9
MRI W/O FOL W/CONT, BREAST,
$0.00
C8909
9
MRA W/CONT, CHEST
$0.00
C8910
9
MRA W/O CONT, CHEST
$0.00
C8911
9
MRA W/O FOL W/CONT, CHEST
$0.00
C8912
9
MRA W/CONT, LWR EXT
$0.00
C8913
9
MRA W/O CONT, LWR EXT
$0.00
C8914
9
MRA W/O FOL W/CONT, LWR EXT
$0.00
C8918
9
MRA W/CONT, PELVIS
$0.00
C8919
9
MRA W/O CONT, PELVIS
$0.00
C8920
9
MRA W/O FOL W/CONT, PELVIS
$0.00
C8921
9
TTE W OR W/O FOL W/CONT, COM
$0.00
C8922
9
TTE W OR W/O FOL W/CONT, F/U
$0.00
C8923
9
2D TTE W OR W/O FOL W/CON,CO
$0.00
C8924
9
2D TTE W OR W/O FOL W/CON,FU
$0.00
C8925
9
2D TEE W OR W/O FOL W/CON,IN
$0.00
C8926
9
TEE W OR W/O FOL W/CONT,CONG
$0.00
C8927
9
TEE W OR W/O FOL W/CONT, MON
$0.00
C8928
9
TTE W OR W/O FOL W/CON,STRES
$0.00
C8929
9
TTE W OR WO FOL WCON,DOPPLER
$0.00
C8930
9
TTE W OR W/O CONTR, CONT ECG
$0.00
C8950
O
INTRAVENOUS INFUSION FOR THERAPY/
$0.00
C8951
O
INTRAVENOUS INFUSION FOR THERAPY/
$0.00
C8952
O
THERAPEUTIC, PROPHYLACTIC OR DIAGN
$0.00
C8953
O
CHEMOTHERAPY ADMINISTRATION, INTRA
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
C8954
O
CHEMOTHERAPY ADMINISTRATION, INTRA
$0.00
C8955
O
CHEMOTHERAPY ADMINISTRATION, INTRA
$0.00
C8956
9
REFILLING AND MAINTENANCE OF PORTA
$0.00
C8957
9
INTRAVENOUS INFUSION FOR THERAPY/
$0.00
C9000
O
NA CHROMATECR51, PER 0.25MCI
$0.00
C9001
9
LINEZOLID INJ, 200MG
$0.00
C9002
9
TENECTEPLASE, 50MG/VIAL
$0.00
C9003
O
PALIVIZUMAB, PER 50 MG
$0.00
C9004
9
GEMTUZUMAB OZOGAMICIN INJ,5M
$0.00
C9005
9
RETEPLASE INJ, HALF-KIT,18.8
$0.00
C9006
9
TACROLIMUS INJ, PER 5 MG
$0.00
C9007
O
BACLOFEN INTRATHECAL KIT-1AM
$0.00
C9008
O
BACLOFEN REFILL KIT-500MCG
$0.00
C9009
O
BACLOFEN REFILL KIT-2000MCG
$0.00
C9010
O
BACLOFEN REFILL KIT--4000MCG
$0.00
C9011
9
CAFFEINE CITRATE, INJ, 1ML
$0.00
C9013
O
CO 57 COBALTOUS CHLORIDE
$0.00
C9019
9
CASPOFUNGIN ACETATE, 5 MG
$0.00
C9020
9
SIROLIMUS TABLET, 1 MG
$0.00
C9100
9
IODINATED I-131 ALBUMIN
$0.00
C9102
O
51 NA CHROMATE, 50MCI
$0.00
C9103
O
NA IOTHALAMATE I-125, 10 UCI
$0.00
C9104
9
ANTI-THYMOCYTE GLOBULIN,25MG
$0.00
C9105
O
HEP B IMM GLOB, PER 1 ML
$0.00
C9106
9
SIROLIMUS 1MG/ML
$0.00
C9107
9
TINZAPARIN SODIUM, 2ML VIAL
$0.00
C9108
9
THYROTROPIN ALFA, 1.1 MG
$0.00
C9109
O
TIROFIBAN HCL, 6.25 MG
$0.00
C9110
9
ALEMTUZUMAB, PER 10MG/ML
$0.00
C9111
O
INJ, BIVALIRUDIN, 250MG VIAL
$0.00
C9112
O
PERFLUTREN LIPID MICRO, 2ML
$0.00
C9113
9
INJ PANTOPRAZOLE SODIUM, VIA
$0.00
C9114
9
NESIRITIDE, PER 1.5 MG VIAL
$0.00
C9115
9
INJ, ZOLEDRONIC ACID, 2 MG
$0.00
C9116
O
ERTAPENEM SODIUM, PER 1 GM
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
C9119
O
INJECTION, PEGFILGRASTIM
$0.00
C9120
O
INJECTION, FULVESTRANT
$0.00
C9121
9
INJECTION, ARGATROBAN
$0.00
C9123
O
TRANSCYTE, PER 247 SQ CM
$0.00
C9124
O
INJECTION, DAPTOMYCIN
$0.00
C9125
O
INJECTION, RISPERIDONE
$0.00
C9126
O
INJECTION, NATALIZUMAB
$0.00
C9200
O
ORCEL, PER 36 CM2
$0.00
C9201
O
DERMAGRAFT, PER 37.5 SQ CM
$0.00
C9202
O
OCTAFLUOROPROPANE
$0.00
C9203
O
PERFLEXANE LIPID MICRO
$0.00
C9205
O
OXALIPLATIN
$0.00
C9206
O
INTEGRA, PER CM2
$0.00
C9207
O
INJECTION, BORTEZOMIB
$0.00
C9208
O
INJECTION, AGALSIDASE BETA
$0.00
C9209
O
INJECTION, LARONIDASE
$0.00
C9210
O
INJECTION, PALONOSETRON HCL
$0.00
C9211
O
INJ, ALEFACEPT, IV
$0.00
C9212
O
INJ, ALEFACEPT, IM
$0.00
C9213
O
INJECTION, PEMETREXED
$0.00
C9214
O
INJECTION, BEVACIZUMAB
$0.00
C9215
O
INJECTION, CETUXIMAB
$0.00
C9216
O
ABARELIX, INJECT SUSPENSION
$0.00
C9217
O
INJECTION, OMALIZUMAB
$0.00
C9218
O
INJECTION, AZACITIDINE
$0.00
C9220
O
SODIUM HYALURONATE
$0.00
C9221
O
GRAFTJACKET REG MATRIX
$0.00
C9222
O
GRAFTJACKET SFTTIS
$0.00
C9224
O
INJECTION, GALSULFASE
$0.00
C9225
O
FLUOCINOLONE ACETONIDE
$0.00
C9227
O
INJECTION, MICAFUNGIN SODIUM, PER
$0.00
C9228
O
INJECTION, TIGECYCLINE, PER 1 MG
$0.00
C9229
O
INJECTION, IBANDRONATE SODIUM, PER
$0.00
C9230
O
INJECTION, ABATACEPT, PER 10 MG
$0.00
C9231
O
INJECTION, DECITABINE, PER 1 MG
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
C9232
O
INJECTION, IDURSULFASE
$0.00
C9233
O
INJECTION, RANIBIZUMAB
$0.00
C9234
O
INJ, ALGLUCOSIDASE ALFA
$0.00
C9235
O
INJECTION, PANITUMUMAB
$0.00
C9238
O
INJ, LEVETIRACETAM
$0.00
C9239
O
INJ, TEMSIROLIMUS
$0.00
C9241
O
INJ DORIPENEM 10 MG
$0.00
C9245
9
INJECTION, ROMIPLOSTIM
$0.00
C9246
9
INJ, GADOXETATE DISODIUM
$0.00
C9247
9
INJ, IOBENGUANE, I-123, DX
$0.00
C9248
9
INJ, CLEVIDIPINE BUTYRATE
$0.00
C9350
O
POROUS COLLAGEN TUBE PER CM
$0.00
C9351
O
ACELLULAR DERM TISSUE PERCM2
$0.00
C9352
9
NEURAGEN NERVE GUIDE, PER CM
$0.00
C9353
9
NEURAWRAP NERVE PROTECTOR,CM
$0.00
C9356
9
TENOGLIDE TENDON PROT, CM2
$0.00
C9358
9
SURGIMEND, 0.5CM2
$0.00
C9359
9
IMPLANT, BONE VOID FILLER
$0.00
C9399
9
UNCLASSIFIED DRUGS OR BIOLOGICALS
$0.00
C9400
O
THALLOUS CHLORIDE, BRAND
$0.00
C9401
O
STRONTIUM-89 CHLORIDE,BRAND
$0.00
C9402
O
TH I131 SO IODIDE CAP, BRAND
$0.00
C9403
O
DX I131 SO IODIDE CAP, BRAND
$0.00
C9404
O
DX I131 SO IODIDE SOL, BRAND
$0.00
C9405
O
TH I131 SO IODIDE SOL, BRAND
$0.00
C9408
9
FDG, BRAND, PER DOSE
$0.00
C9410
O
DEXRAZOXANE HCL INJ, BRAND
$0.00
C9411
O
PAMIDRONATE DISODIUM, BRAND
$0.00
C9412
O
GANCICLOVIR IMPLANT, BRAND
$0.00
C9413
O
SODIUM HYALURONATE INJ, BRAND
$0.00
C9414
O
ETOPOSIDE ORAL, BRAND
$0.00
C9415
O
DOXORUBIC HCL CHEMO, BRAND
$0.00
C9416
9
BCG LIVE INTRAVESICAL, BRAND
$0.00
C9417
O
BLEOMYCIN SULFATE INJ, BRAND
$0.00
C9418
O
CISPLATIN INJ, BRAND
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
C9419
O
INJ CLADRIBINE, BRAND
$0.00
C9420
O
CYCLOPHOSPHAMIDE INJ, BRAND
$0.00
C9421
O
CYCLOPHOSPHAMIDE LYO, BRAND
$0.00
C9422
O
CYTARABINE HCL INJ, BRAND
$0.00
C9423
O
DACARBAZINE INJ, BRAND
$0.00
C9424
O
DAUNORUBICIN, BRAND
$0.00
C9425
O
ETOPOSIDE INJ, BRAND
$0.00
C9426
O
FLOXURIDINE INJ, BRAND
$0.00
C9427
O
IFOSFOMIDE INJ, BRAND
$0.00
C9428
O
MESNA INJECTION, BRAND
$0.00
C9429
O
IDARUBICIN HCL INJ, BRAND
$0.00
C9430
O
LEUPROLIDE ACETATE INJ, BRAN
$0.00
C9431
O
PACLITAXEL INJ, BRAND
$0.00
C9432
O
MITOMYCIN INJ, BRAND
$0.00
C9433
O
THIOTEPA INJ, BRAND
$0.00
C9434
9
GALLIUM GA 67, BRAND
$0.00
C9435
O
GONADORELIN HYDROCH, BRAND
$0.00
C9436
O
AZATHIOPRINE PARENTERAL,BRND
$0.00
C9437
O
CARMUS BISCHL NITRO INJ
$0.00
C9438
O
CYCLOSPORINE ORAL, BRAND
$0.00
C9439
O
DIETHYLSTILBESTROL INJECTION
$0.00
C9500
9
PLATELETS, IRRAD, EA UNIT
$0.00
C9501
9
PLATELETS, PHERESIS, EA UNIT
$0.00
C9502
9
PLATELETS, PHER/IRRAD, EA UN
$0.00
C9503
O
FRESH FROZEN PLASMA, EA UNIT
$0.00
C9504
9
RBC, DEGLYCEROLIZED, EA UNIT
$0.00
C9505
9
RBC, IRRADIATED, EACH UNIT
$0.00
C9700
9
WATER INDUCED THERMO
$0.00
C9701
O
STRETTA SYSTEM
$0.00
C9702
9
CHKMATE/NOVOST/GALILEO BRACH
$0.00
C9703
O
BARD ENDOSCOPIC SUTURING SYS
$0.00
C9704
O
INJ INERT SUBS UPPER GI
$0.00
C9708
9
PREVIEW TX PLANNING SOFTWARE
$0.00
C9711
O
H.E.L.P. APHERESIS SYSTEM
$0.00
C9712
O
INSERT PH CAPSULE, GERD
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
C9713
O
NON-CONTACT LASER VAP PROSTA
$0.00
C9714
O
BREAST INTERS RAD TX, IMMED
$0.00
C9715
O
BREAST INTERS RAD TX, DELAY
$0.00
C9716
9
RADIOFREQUENCY ENERGY TO ANUS
$0.00
C9718
O
KYPHOPLASTY, FIRST VERTEBRA
$0.00
C9719
O
KYPHOPLASTY, EACH ADDL
$0.00
C9720
O
HE ESW TX, TENNIS ELBOW
$0.00
C9721
O
HE ESW TX, PLANTAR FASCIITIS
$0.00
C9722
O
KV IMAGING W/IR TRACKING
$0.00
C9723
O
DYN IR PERF IMG
$0.00
C9724
9
EPS GAST CARDIA PLIC
$0.00
C9725
9
PLACE ENDORECTAL APP
$0.00
C9726
9
RXT BREAST APPL PLACE/REMOV
$0.00
C9727
9
INSERT PALATE IMPLANTS
$0.00
C9728
9
PLACE DEVICE/MARKER, NON PRO
$0.00
C9898
9
INPNT STAY RADIOLABELED ITEM
$0.00
C9899
9
INPT IMPLANT PROS DEV,NO COV
$0.00
CEDCL
O
MCO SPECIFIC CODE: SMART START COM
$0.00
CEDRV
O
MCO SPECIFIC CODE: SMART START CHI
$0.00
D0110
O
INITIAL ORAL EXAMINATION
$0.00
D0120
1
PERIODIC ORAL EVALUATION
$0.00
D0130
O
EMERGENCY ORAL EXAMINATION
$0.00
D0140
1
LIMIT ORAL EVAL PROBLM FOCUS
$0.00
D0145
1
ORAL EVALUATION, PT < 3YRS
$0.00
D0150
1
COMPREHENSVE ORAL EVALUATION
$0.00
D0160
1
EXTENSV ORAL EVAL PROB FOCUS
$0.00
D0170
1
RE-EVAL,EST PT,PROBLEM FOCUS
$0.00
D0180
9
COMP PERIODONTAL EVALUATION
$0.00
D0210
1
INTRAOR COMPLETE FILM SERIES
$0.00
D0220
1
INTRAORAL PERIAPICAL FIRST F
$0.00
D0230
1
INTRAORAL PERIAPICAL EA ADD
$0.00
D0240
1
INTRAORAL OCCLUSAL FILM
$0.00
D0250
1
EXTRAORAL FIRST FILM
$0.00
D0260
1
EXTRAORAL EA ADDITIONAL FILM
$0.00
D0270
1
DENTAL BITEWING SINGLE FILM
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
D0272
1
DENTAL BITEWINGS TWO FILMS
$0.00
D0273
1
BITEWINGS - THREE FILMS
$0.00
D0274
1
DENTAL BITEWINGS FOUR FILMS
$0.00
D0275
9
BITEWINGS-EACH ADDITIONAL FILM
$0.00
D0277
1
VERT BITEWINGS-SEV TO EIGHT
$0.00
D0290
1
DENTAL FILM SKULL/FACIAL BON
$0.00
D0310
1
DENTAL SALIOGRAPHY
$0.00
D0320
1
DENTAL TMJ ARTHROGRAM INCL I
$0.00
D0321
1
DENTAL OTHER TMJ FILMS
$0.00
D0322
1
DENTAL TOMOGRAPHIC SURVEY
$0.00
D0330
1
DENTAL PANORAMIC FILM
$0.00
D0340
1
DENTAL CEPHALOMETRIC FILM
$0.00
D0350
9
ORAL/FACIAL PHOTO IMAGES
$0.00
D0360
1
CONE BEAM CT
$0.00
D0362
1
CONE BEAM, TWO DIMENSIONAL
$0.00
D0363
1
CONE BEAM, THREE DIMENSIONAL
$0.00
D0410
9
BACTERIOLOGIC STUDIES FOR DETERMINA
$0.00
D0415
9
COLLECTION OF MICROORGANISMS
$0.00
D0416
9
VIRAL CULTURE
$0.00
D0417
9
COLLECT & PREP SALIVA SAMPLE
$0.00
D0418
9
ANALYSIS OF SALIVA SAMPLE
$0.00
D0420
9
CARIES SUSCEPTIBILITY TESTS
$0.00
D0421
9
GEN TST SUSCEPT ORAL DISEASE
$0.00
D0425
9
CARRIES SUSCEPTIBILITY TESTS
$0.00
D0431
9
DIAG TST DETECT MUCOS ABNORM
$0.00
D0460
1
PULP VITALITY TEST
$0.00
D0470
1
DIAGNOSTIC CASTS
$0.00
D0471
9
DIAGNOSTIC PHOTOGRAPHS
$0.00
D0472
1
GROSS EXAM, PREP & REPORT
$0.00
D0473
1
MICRO EXAM, PREP & REPORT
$0.00
D0474
1
MICRO W EXAM OF SURG MARGINS
$0.00
D0475
9
DECALCIFICATION PROCEDURE
$0.00
D0476
9
SPEC STAINS FOR MICROORGANIS
$0.00
D0477
9
SPEC STAINS NOT FOR MICROORG
$0.00
D0478
9
IMMUNOHISTOCHEMICAL STAINS
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
D0479
9
TISSUE IN-SITU HYBRIDIZATION
$0.00
D0480
1
CYTOPATH SMEAR PREP & REPORT
$0.00
D0481
9
ELECTRON MICROSCOPY DIAGNOST
$0.00
D0482
9
DIRECT IMMUNOFLUORESCENCE
$0.00
D0483
9
INDIRECT IMMUNOFLUORESCENCE
$0.00
D0484
9
CONSULT SLIDES PREP ELSEWHER
$0.00
D0485
9
CONSULT INC PREP OF SLIDES
$0.00
D0486
9
ACCESSION OF BRUSH BIOPSY
$0.00
D0501
O
HISTOPATHOLOGIC EXAMINATIONS
$0.00
D0502
1
OTHER ORAL PATHOLOGY PROCEDU
$0.00
D0999
1
UNSPECIFIED DIAGNOSTIC PROCE
$0.00
D1110
1
DENTAL PROPHYLAXIS ADULT
$0.00
D1120
1
DENTAL PROPHYLAXIS CHILD
$0.00
D1201
O
TOPICAL FLUOR W PROPHY CHILD
$0.00
D1202
9
TOPICAL APPLICATION OF FLUORIDE (IN
$0.00
D1203
1
TOPICAL APP FLUORIDE CHILD
$0.00
D1204
1
TOPICAL APP FLUORIDE ADULT
$0.00
D1205
O
TOPICAL FLUORIDE W/ PROPHY A
$0.00
D1206
1
TOPICAL FLUORIDE VARNISH
$0.00
D1310
9
NUTRI COUNSEL-CONTROL CARIES
$0.00
D1320
1
TOBACCO COUNSELING
$0.00
D1330
9
ORAL HYGIENE INSTRUCTION
$0.00
D1351
1
DENTAL SEALANT PER TOOTH
$0.00
D1510
1
SPACE MAINTAINER FXD UNILAT
$0.00
D1515
1
FIXED BILAT SPACE MAINTAINER
$0.00
D1520
1
REMOVE UNILAT SPACE MAINTAIN
$0.00
D1525
1
REMOVE BILAT SPACE MAINTAIN
$0.00
D1550
1
RECEMENT SPACE MAINTAINER
$0.00
D1555
1
REMOVE FIX SPACE MAINTAINER
$0.00
D2110
O
AMALGAM ONE SURFACE PRIMARY
$0.00
D2120
O
AMALGAM TWO SURFACES PRIMARY
$0.00
D2130
O
AMALGAM THREE SURFACES PRIMA
$0.00
D2131
O
AMALGAM FOUR/MORE SURF PRIMA
$0.00
D2140
1
AMALGAM ONE SURFACE PERMANEN
$0.00
D2150
1
AMALGAM TWO SURFACES PERMANE
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
D2160
1
AMALGAM THREE SURFACES PERMA
$0.00
D2161
1
AMALGAM 4 OR > SURFACES PERM
$0.00
D2210
9
SILCATE CEMENT PER RESTORAT
$0.00
D2330
1
RESIN ONE SURFACE-ANTERIOR
$0.00
D2331
1
RESIN TWO SURFACES-ANTERIOR
$0.00
D2332
1
RESIN THREE SURFACES-ANTERIO
$0.00
D2335
1
RESIN 4/> SURF OR W INCIS AN
$0.00
D2336
O
COMPOSITE RESIN CROWN
$0.00
D2337
O
COMPO RESIN CROWN ANT-PERM
$0.00
D2380
O
RESIN ONE SURF POSTER PRIMAR
$0.00
D2381
O
RESIN TWO SURF POSTER PRIMAR
$0.00
D2382
O
RESIN THREE/MORE SURF POST P
$0.00
D2385
O
RESIN ONE SURF POSTER PERMAN
$0.00
D2386
O
RESIN TWO SURF POSTER PERMAN
$0.00
D2387
O
RESIN THREE/MORE SURF POST P
$0.00
D2388
O
RESIN FOUR/MORE, POST PERM
$0.00
D2390
1
ANT RESIN-BASED CMPST CROWN
$0.00
D2391
1
POST 1 SRFC RESINBASED CMPST
$0.00
D2392
1
POST 2 SRFC RESINBASED CMPST
$0.00
D2393
1
POST 3 SRFC RESINBASED CMPST
$0.00
D2394
1
POST >=4SRFC RESINBASE CMPST
$0.00
D2410
9
DENTAL GOLD FOIL ONE SURFACE
$0.00
D2420
9
DENTAL GOLD FOIL TWO SURFACE
$0.00
D2430
9
DENTAL GOLD FOIL THREE SURFA
$0.00
D2510
9
DENTAL INLAY METALIC 1 SURF
$0.00
D2520
9
DENTAL INLAY METALLIC 2 SURF
$0.00
D2530
9
DENTAL INLAY METL 3/MORE SUR
$0.00
D2540
O
ONLAY-METALLIC-PER TOOTH (IN ADDITI
$0.00
D2542
9
DENTAL ONLAY METALLIC 2 SURF
$0.00
D2543
9
DENTAL ONLAY METALLIC 3 SURF
$0.00
D2544
9
DENTAL ONLAY METL 4/MORE SUR
$0.00
D2610
9
INLAY PORCELAIN/CERAMIC 1 SU
$0.00
D2620
9
INLAY PORCELAIN/CERAMIC 2 SU
$0.00
D2630
9
DENTAL ONLAY PORC 3/MORE SUR
$0.00
D2642
9
DENTAL ONLAY PORCELIN 2 SURF
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
D2643
9
DENTAL ONLAY PORCELIN 3 SURF
$0.00
D2644
9
DENTAL ONLAY PORC 4/MORE SUR
$0.00
D2650
9
DENTAL INLAY RESIN ONE SURFACE
$0.00
D2651
9
DENTAL INLAY RESIN 2 SURFACES
$0.00
D2652
9
DENTAL INLAY RESIN 3 OR MORE SURFA
$0.00
D2662
9
DENTAL ONLAY RESIN 2 SURFACE
$0.00
D2663
9
DENTAL ONLAY RESIN 3 SURFACE
$0.00
D2664
9
DENTAL ONLAY RESIN 4/MRE SUR
$0.00
D2710
1
CROWN RESIN-BASED INDIRECT
$0.00
D2712
1
CROWN 3/4 RESIN-BASED COMPOS
$0.00
D2720
9
CROWN RESIN W/ HIGH NOBLE ME
$0.00
D2721
1
CROWN RESIN W/ BASE METAL
$0.00
D2722
1
CROWN RESIN W/ NOBLE METAL
$0.00
D2740
9
CROWN PORCELAIN/CERAMIC SUBS
$0.00
D2750
9
CROWN PORCELAIN W/ H NOBLE M
$0.00
D2751
1
CROWN PORCELAIN FUSED BASE M
$0.00
D2752
1
CROWN PORCELAIN W/ NOBLE MET
$0.00
D2780
9
CROWN 3/4 CAST HI NOBLE MET
$0.00
D2781
1
CROWN 3/4 CAST BASE METAL
$0.00
D2782
1
CROWN 3/4 CAST NOBLE METAL
$0.00
D2783
9
CROWN 3/4 PORCELAIN/CERAMIC
$0.00
D2790
9
CROWN FULL CAST HIGH NOBLE M
$0.00
D2791
1
CROWN FULL CAST BASE METAL
$0.00
D2792
1
CROWN FULL CAST NOBLE METAL
$0.00
D2794
9
CROWN-TITANIUM
$0.00
D2799
1
PROVISIONAL CROWN
$0.00
D2810
9
CROWN 3/4 CAST METALLIC
$0.00
D2910
1
RECEMENT INLAY ONLAY OR PART
$0.00
D2915
1
RECEMENT CAST OR PREFAB POST
$0.00
D2920
1
DENTAL RECEMENT CROWN
$0.00
D2930
1
PREFAB STNLSS STEEL CRWN PRI
$0.00
D2931
1
PREFAB STNLSS STEEL CROWN PE
$0.00
D2932
1
PREFABRICATED RESIN CROWN
$0.00
D2933
1
PREFAB STAINLESS STEEL CROWN
$0.00
D2934
1
PREFAB STEEL CROWN PRIMARY
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
D2940
1
DENTAL SEDATIVE FILLING
$0.00
D2950
1
CORE BUILD-UP INCL ANY PINS
$0.00
D2951
1
TOOTH PIN RETENTION
$0.00
D2952
1
POST AND CORE CAST + CROWN
$0.00
D2953
1
EACH ADDTNL CAST POST
$0.00
D2954
1
PREFAB POST/CORE + CROWN
$0.00
D2955
1
POST REMOVAL
$0.00
D2957
1
EACH ADDTNL PREFAB POST
$0.00
D2960
9
LAMINATE LABIAL VENEER
$0.00
D2961
9
LAMINATE LABIAL VENEER
$0.00
D2962
9
LAMINATE LABIAL VENEER
$0.00
D2970
1
TEMPORARY- FRACTURED TOOTH
$0.00
D2971
9
ADD PROC CONSTRUCT NEW CROWN
$0.00
D2975
9
COPING
$0.00
D2980
1
CROWN REPAIR
$0.00
D2999
1
DENTAL UNSPEC RESTORATIVE PR
$0.00
D3110
1
PULP CAP DIRECT
$0.00
D3120
1
PULP CAP INDIRECT
$0.00
D3220
1
THERAPEUTIC PULPOTOMY
$0.00
D3221
1
GROSS PULPAL DEBRIDEMENT
$0.00
D3222
1
PART PULP FOR APEXOGENESIS
$0.00
D3230
1
PULPAL THERAPY ANTERIOR PRIM
$0.00
D3240
1
PULPAL THERAPY POSTERIOR PRI
$0.00
D3310
1
END THXPY, ANTERIOR TOOTH
$0.00
D3320
1
END THXPY, BICUSPID TOOTH
$0.00
D3330
1
END THXPY, MOLAR
$0.00
D3331
9
NON-SURG TX ROOT CANAL OBS
$0.00
D3332
1
INCOMPLETE ENDODONTIC TX
$0.00
D3333
1
INTERNAL ROOT REPAIR
$0.00
D3340
9
FOUR OR MORE CANALS (EXCLUDING FINA
$0.00
D3346
1
RETREAT ROOT CANAL ANTERIOR
$0.00
D3347
1
RETREAT ROOT CANAL BICUSPID
$0.00
D3348
1
RETREAT ROOT CANAL MOLAR
$0.00
D3350
9
APEXIFICATION (PER TREATMENT VISIT)
$0.00
D3351
1
APEXIFICATION/RECALC INITIAL
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
D3352
1
APEXIFICATION/RECALC INTERIM
$0.00
D3353
1
APEXIFICATION/RECALC FINAL
$0.00
D3410
1
APICOECT/PERIRAD SURG ANTER
$0.00
D3411
9
APICOECTOMY (PER TOOTH) - EACH ADDI
$0.00
D3421
1
ROOT SURGERY BICUSPID
$0.00
D3425
1
ROOT SURGERY MOLAR
$0.00
D3426
1
ROOT SURGERY EA ADD ROOT
$0.00
D3430
1
RETROGRADE FILLING
$0.00
D3440
9
APICAL CURETTAGE
$0.00
D3450
1
ROOT AMPUTATION
$0.00
D3460
9
ENDODONTIC ENDOSSEOUS IMPLAN
$0.00
D3470
1
INTENTIONAL REPLANTATION
$0.00
D3910
1
ISOLATION- TOOTH W RUBB DAM
$0.00
D3920
9
TOOTH SPLITTING
$0.00
D3940
9
RECALCIFICATION OR REPAIR (PERFORAT
$0.00
D3950
9
CANAL PREP/FITTING OF DOWEL
$0.00
D3960
9
BLEACHING OF DISCOLORED TOOT
$0.00
D3999
1
ENDODONTIC PROCEDURE
$0.00
D4210
1
GINGIVECTOMY/PLASTY PER QUAD
$0.00
D4211
1
GINGIVECTOMY/PLASTY PER TOOT
$0.00
D4220
O
GINGIVAL CURETTAGE PER QUADR
$0.00
D4230
1
ANA CROWN EXP 4 OR> PER QUAD
$0.00
D4231
1
ANA CROWN EXP 1-3 PER QUAD
$0.00
D4240
1
GINGIVAL FLAP PROC W/ PLANIN
$0.00
D4241
1
GNGVL FLAP W ROOTPLAN 1-3 TH
$0.00
D4245
1
APICALLY POSITIONED FLAP
$0.00
D4249
1
CROWN LENGTHEN HARD TISSUE
$0.00
D4260
1
OSSEOUS SURGERY PER QUADRANT
$0.00
D4261
1
OSSEOUS SURGL-3TEETHPERQUAD
$0.00
D4262
O
BONE REPLACEMENT GRAFT-MULTIPLE SIT
$0.00
D4263
1
BONE REPLCE GRAFT FIRST SITE
$0.00
D4264
1
BONE REPLCE GRAFT EACH ADD
$0.00
D4265
1
BIO MTRLS TO AID SOFT/OS REG
$0.00
D4266
1
GUIDED TISS REGEN RESORBLE
$0.00
D4267
1
GUIDED TISS REGEN NONRESORB
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
D4268
1
SURGICAL REVISION PROCEDURE
$0.00
D4270
1
PEDICLE SOFT TISSUE GRAFT PR
$0.00
D4271
1
FREE SOFT TISSUE GRAFT PROC
$0.00
D4272
9
APICALLY REPOSITIONING FLAP PROCEDU
$0.00
D4273
1
SUBEPITHELIAL TISSUE GRAFT
$0.00
D4274
1
DISTAL/PROXIMAL WEDGE PROC
$0.00
D4275
1
SOFT TISSUE ALLOGRAFT
$0.00
D4276
1
CON TISSUE W DBLE PED GRAFT
$0.00
D4320
1
PROVISION SPLNT INTRACORONAL
$0.00
D4321
1
PROVISIONAL SPLINT EXTRACORO
$0.00
D4340
9
PERIODONTAL SCALING AND ROOT PLANIN
$0.00
D4341
1
PERIODONTAL SCALING & ROOT
$0.00
D4342
1
PERIODONTAL SCALING 1-3TEETH
$0.00
D4355
1
FULL MOUTH DEBRIDEMENT
$0.00
D4381
1
LOCALIZED DELIVERY ANTIMICRO
$0.00
D4910
1
PERIODONTAL MAINT PROCEDURES
$0.00
D4920
1
UNSCHEDULED DRESSING CHANGE
$0.00
D4999
1
UNSPECIFIED PERIODONTAL PROC
$0.00
D5110
1
DENTURES COMPLETE MAXILLARY
$0.00
D5120
1
DENTURES COMPLETE MANDIBLE
$0.00
D5130
1
DENTURES IMMEDIAT MAXILLARY
$0.00
D5140
1
DENTURES IMMEDIAT MANDIBLE
$0.00
D5211
1
DENTURES MAXILL PART RESIN
$0.00
D5212
1
DENTURES MAND PART RESIN
$0.00
D5213
1
DENTURES MAXILL PART METAL
$0.00
D5214
1
DENTURES MANDIBL PART METAL
$0.00
D5215
9
UPPER PARTIAL - HIGH NOBLE CAST BAS
$0.00
D5216
9
LOWER PARTIAL - HIGH NOBLE CAST BAS
$0.00
D5225
1
MAXILLARY PART DENTURE FLEX
$0.00
D5226
1
MANDIBULAR PART DENTURE FLEX
$0.00
D5280
9
REMOVABLE UNILATERAL PARTIAL DENTUR
$0.00
D5281
9
REMOVABLE PARTIAL DENTURE
$0.00
D5410
1
DENTURES ADJUST CMPLT MAXIL
$0.00
D5411
1
DENTURES ADJUST CMPLT MAND
$0.00
D5421
1
DENTURES ADJUST PART MAXILL
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
D5422
1
DENTURES ADJUST PART MANDBL
$0.00
D5510
1
DENTUR REPR BROKEN COMPL BAS
$0.00
D5520
1
REPLACE DENTURE TEETH COMPLT
$0.00
D5610
1
DENTURES REPAIR RESIN BASE
$0.00
D5620
1
REP PART DENTURE CAST FRAME
$0.00
D5630
1
REP PARTIAL DENTURE CLASP
$0.00
D5640
1
REPLACE PART DENTURE TEETH
$0.00
D5650
1
ADD TOOTH TO PARTIAL DENTURE
$0.00
D5660
1
ADD CLASP TO PARTIAL DENTURE
$0.00
D5670
1
REPLC TTH&ACRLC ON MTL FRMWK
$0.00
D5671
1
REPLC TTH&ACRLC MANDIBULAR
$0.00
D5710
9
DENTURES REBASE CMPLT MAXIL
$0.00
D5711
9
DENTURES REBASE CMPLT MAND
$0.00
D5720
9
DENTURES REBASE PART MAXILL
$0.00
D5721
9
DENTURES REBASE PART MANDBL
$0.00
D5730
1
DENTURE RELN CMPLT MAXIL CH
$0.00
D5731
1
DENTURE RELN CMPLT MAND CHR
$0.00
D5740
1
DENTURE RELN PART MAXIL CHR
$0.00
D5741
1
DENTURE RELN PART MAND CHR
$0.00
D5750
1
DENTURE RELN CMPLT MAX LAB
$0.00
D5751
1
DENTURE RELN CMPLT MAND LAB
$0.00
D5760
1
DENTURE RELN PART MAXIL LAB
$0.00
D5761
1
DENTURE RELN PART MAND LAB
$0.00
D5810
1
DENTURE INTERM CMPLT MAXILL
$0.00
D5811
1
DENTURE INTERM CMPLT MANDBL
$0.00
D5820
1
DENTURE INTERM PART MAXILL
$0.00
D5821
1
DENTURE INTERM PART MANDBL
$0.00
D5850
1
DENTURE TISS CONDITN MAXILL
$0.00
D5851
1
DENTURE TISS CONDTIN MANDBL
$0.00
D5860
9
OVERDENTURE COMPLETE
$0.00
D5861
9
OVERDENTURE PARTIAL
$0.00
D5862
9
PRECISION ATTACHMENT
$0.00
D5867
9
REPLACEMENT OF PRECISION ATT
$0.00
D5875
9
PROSTHESIS MODIFICATION
$0.00
D5899
1
REMOVABLE PROSTHODONTIC PROC
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
D5911
1
FACIAL MOULAGE SECTIONAL
$0.00
D5912
1
FACIAL MOULAGE COMPLETE
$0.00
D5913
1
NASAL PROSTHESIS
$0.00
D5914
1
AURICULAR PROSTHESIS
$0.00
D5915
1
ORBITAL PROSTHESIS
$0.00
D5916
1
OCULAR PROSTHESIS
$0.00
D5917
9
COMPOSITE FACIAL PROSTHESIS
$0.00
D5918
9
REPLACEMENT PROSTHESIS
$0.00
D5919
1
FACIAL PROSTHESIS
$0.00
D5920
9
OCULAR IMPLANT
$0.00
D5921
9
ORBITAL IMPLANT
$0.00
D5922
1
NASAL SEPTAL PROSTHESIS
$0.00
D5923
1
OCULAR PROSTHESIS INTERIM
$0.00
D5924
1
CRANIAL PROSTHESIS
$0.00
D5925
1
FACIAL AUGMENTATION IMPLANT
$0.00
D5926
1
REPLACEMENT NASAL PROSTHESIS
$0.00
D5927
1
AURICULAR REPLACEMENT
$0.00
D5928
1
ORBITAL REPLACEMENT
$0.00
D5929
1
FACIAL REPLACEMENT
$0.00
D5931
1
SURGICAL OBTURATOR
$0.00
D5932
1
POSTSURGICAL OBTURATOR
$0.00
D5933
1
REFITTING OF OBTURATOR
$0.00
D5934
1
MANDIBULAR FLANGE PROSTHESIS
$0.00
D5935
1
MANDIBULAR DENTURE PROSTH
$0.00
D5936
1
TEMP OBTURATOR PROSTHESIS
$0.00
D5937
1
TRISMUS APPLIANCE
$0.00
D5951
1
FEEDING AID
$0.00
D5952
1
PEDIATRIC SPEECH AID
$0.00
D5953
1
ADULT SPEECH AID
$0.00
D5954
1
SUPERIMPOSED PROSTHESIS
$0.00
D5955
1
PALATAL LIFT PROSTHESIS
$0.00
D5956
9
OBTURATOR
$0.00
D5957
9
SPEECH BULB
$0.00
D5958
1
INTRAORAL CON DEF INTER PLT
$0.00
D5959
1
INTRAORAL CON DEF MOD PALAT
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
D5960
1
MODIFY SPEECH AID PROSTHESIS
$0.00
D5971
9
SIMPLE IMPLANT
$0.00
D5972
9
COMPLEX IMPLANT
$0.00
D5973
9
SUBPERIOSTEAL IMPLANT
$0.00
D5974
9
ENDOSSEOUS IMPLANT (IN THE BONE)
$0.00
D5976
9
MANDIBULAR STAPLE IMPLANT
$0.00
D5982
9
SURGICAL STENT
$0.00
D5983
9
RADIATION APPLICATOR
$0.00
D5984
9
RADIATION SHIELD
$0.00
D5985
9
RADIATION CONE LOCATOR
$0.00
D5986
1
FLUORIDE APPLICATOR
$0.00
D5987
1
COMMISSURE SPLINT
$0.00
D5988
1
SURGICAL SPLINT
$0.00
D5991
1
TOPICAL MEDICAMENT CARRIER
$0.00
D5999
1
MAXILLOFACIAL PROSTHESIS
$0.00
D6010
9
ODONTICS ENDOSTEAL IMPLANT
$0.00
D6012
9
ENDOSTEAL IMPLANT
$0.00
D6020
O
ODONTICS ABUTMENT PLACEMENT
$0.00
D6040
9
SURGICAL PLACEMENT:EPOSTEAL IMPLAN
$0.00
D6050
9
SURGICAL PLACEMENT TRANSOSTEAL
$0.00
D6053
9
IMPLNT/ABTMNT SPPRT REMV DNT
$0.00
D6054
9
IMPLNT/ABTMNT SPPRT REMVPRTL
$0.00
D6055
9
DENTAL IMPLANT SUPPORTED BAR
$0.00
D6056
9
PREFABRICATED ABUTMENT
$0.00
D6057
9
CUSTOM ABUTMENT
$0.00
D6058
9
ABUTMENT SUPPORTED CROWN
$0.00
D6059
9
ABUTMENT SUPPORTED MTL CROWN
$0.00
D6060
9
ABUTMENT SUPPORTED MTL CROWN
$0.00
D6061
9
ABUTMENT SUPPORTED MTL CROWN
$0.00
D6062
9
ABUTMENT SUPPORTED MTL CROWN
$0.00
D6063
9
ABUTMENT SUPPORTED MTL CROWN
$0.00
D6064
9
ABUTMENT SUPPORTED MTL CROWN
$0.00
D6065
9
IMPLANT SUPPORTED CROWN
$0.00
D6066
9
IMPLANT SUPPORTED MTL CROWN
$0.00
D6067
9
IMPLANT SUPPORTED MTL CROWN
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
D6068
9
ABUTMENT SUPPORTED RETAINER
$0.00
D6069
9
ABUTMENT SUPPORTED RETAINER
$0.00
D6070
9
ABUTMENT SUPPORTED RETAINER
$0.00
D6071
9
ABUTMENT SUPPORTED RETAINER
$0.00
D6072
9
ABUTMENT SUPPORTED RETAINER
$0.00
D6073
9
ABUTMENT SUPPORTED RETAINER
$0.00
D6074
9
ABUTMENT SUPPORTED RETAINER
$0.00
D6075
9
IMPLANT SUPPORTED RETAINER
$0.00
D6076
9
IMPLANT SUPPORTED RETAINER
$0.00
D6077
9
IMPLANT SUPPORTED RETAINER
$0.00
D6078
9
IMPLNT/ABUT SUPRTD FIXD DENT
$0.00
D6079
9
IMPLNT/ABUT SUPRTD FIXD DENT
$0.00
D6080
9
IMPLANT MAINTENANCE PROCEDURES INC
$0.00
D6090
9
REPAIR IMPLANT SUPPORTED PROSTHESI
$0.00
D6091
9
REPL SEMI/PRECISION ATTACH
$0.00
D6092
9
RECEMENT SUPP CROWN
$0.00
D6093
9
RECEMENT SUPP PART DENTURE
$0.00
D6094
9
ABUT SUPPORT CROWN TITANIUM
$0.00
D6095
9
ODONTICS REPR ABUTMENT
$0.00
D6100
9
IMPLANT REMOVAL, BY REPORT.
$0.00
D6190
9
RADIO/SURGICAL IMPLANT INDEX
$0.00
D6194
9
ABUT SUPPORT RETAINER TITANI
$0.00
D6199
9
UNSPECIFIED IMPLANT PROCEDURE, BY
$0.00
D6205
9
PONTIC-INDIRECT RESIN BASED
$0.00
D6210
9
PROSTHODONT HIGH NOBLE METAL
$0.00
D6211
1
BRIDGE BASE METAL CAST
$0.00
D6212
1
BRIDGE NOBLE METAL CAST
$0.00
D6214
9
PONTIC TITANIUM
$0.00
D6240
9
BRIDGE PORCELAIN HIGH NOBLE
$0.00
D6241
1
BRIDGE PORCELAIN BASE METAL
$0.00
D6242
1
BRIDGE PORCELAIN NOBEL METAL
$0.00
D6245
9
BRIDGE PORCELAIN/CERAMIC
$0.00
D6250
9
BRIDGE RESIN W/HIGH NOBLE
$0.00
D6251
1
BRIDGE RESIN BASE METAL
$0.00
D6252
1
BRIDGE RESIN W/NOBLE METAL
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
D6253
9
PROVISIONAL PONTIC
$0.00
D6519
9
INLAY/ONLAY PORCE/CERAMIC
$0.00
D6520
9
DENTAL RETAINER TWO SURFACES
$0.00
D6530
9
RETAINER METALLIC 3+ SURFACE
$0.00
D6540
O
ONLAY-METALLIC-PER TOOTH (IN ADDITI
$0.00
D6543
9
DENTAL RETAINR ONLAY 3 SURF
$0.00
D6544
9
DENTAL RETAINR ONLAY 4/MORE
$0.00
D6545
1
DENTAL RETAINR CAST METL
$0.00
D6548
9
PORCELAIN/CERAMIC RETAINER
$0.00
D6600
9
PORCELAIN/CERAMIC INLAY 2SRF
$0.00
D6601
9
PORC/CERAM INLAY >= 3 SURFAC
$0.00
D6602
9
CST HGH NBLE MTL INLAY 2 SRF
$0.00
D6603
9
CST HGH NBLE MTL INLAY >=3SR
$0.00
D6604
9
CST BSE MTL INLAY 2 SURFACES
$0.00
D6605
9
CST BSE MTL INLAY >= 3 SURFA
$0.00
D6606
9
CAST NOBLE METAL INLAY 2 SUR
$0.00
D6607
9
CST NOBLE MTL INLAY >=3 SURF
$0.00
D6608
9
ONLAY PORC/CRMC 2 SURFACES
$0.00
D6609
9
ONLAY PORC/CRMC >=3 SURFACES
$0.00
D6610
9
ONLAY CST HGH NBL MTL 2 SRFC
$0.00
D6611
9
ONLAY CST HGH NBL MTL >=3SRF
$0.00
D6612
9
ONLAY CST BASE MTL 2 SURFACE
$0.00
D6613
9
ONLAY CST BASE MTL >=3 SURFA
$0.00
D6614
9
ONLAY CST NBL MTL 2 SURFACES
$0.00
D6615
9
ONLAY CST NBL MTL >=3 SURFAC
$0.00
D6624
9
INLAY TITANIUM
$0.00
D6634
9
ONLAY TITANIUM
$0.00
D6710
9
CROWN-INDIRECT RESIN BASED
$0.00
D6720
9
RETAIN CROWN RESIN W HI NBLE
$0.00
D6721
1
CROWN RESIN W/BASE METAL
$0.00
D6722
1
CROWN RESIN W/NOBLE METAL
$0.00
D6740
9
CROWN PORCELAIN/CERAMIC
$0.00
D6750
9
CROWN PORCELAIN HIGH NOBLE
$0.00
D6751
1
CROWN PORCELAIN BASE METAL
$0.00
D6752
1
CROWN PORCELAIN NOBLE METAL
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
D6780
9
CROWN 3/4 HIGH NOBLE METAL
$0.00
D6781
9
CROWN 3/4 CAST BASED METAL
$0.00
D6782
9
CROWN 3/4 CAST NOBLE METAL
$0.00
D6783
9
CROWN 3/4 PORCELAIN/CERAMIC
$0.00
D6790
9
CROWN FULL HIGH NOBLE METAL
$0.00
D6791
1
CROWN FULL BASE METAL CAST
$0.00
D6792
1
CROWN FULL NOBLE METAL CAST
$0.00
D6793
9
PROVISIONAL RETAINER CROWN
$0.00
D6794
9
CROWN TITANIUM
$0.00
D6920
9
DENTAL CONNECTOR BAR
$0.00
D6930
1
DENTAL RECEMENT BRIDGE
$0.00
D6940
9
STRESS BREAKER
$0.00
D6950
9
PRECISION ATTACHMENT
$0.00
D6970
9
POST & CORE PLUS RETAINER
$0.00
D6971
O
CAST POST BRIDGE RETAINER
$0.00
D6972
1
PREFAB POST & CORE PLUS RETA
$0.00
D6973
9
CORE BUILD UP FOR RETAINER, INCLUD
$0.00
D6975
9
COPING METAL
$0.00
D6976
9
EACH ADDTNL CAST POST
$0.00
D6977
9
EACH ADDTL PREFAB POST
$0.00
D6980
1
BRIDGE REPAIR
$0.00
D6985
1
PEDIATRIC PARTIAL DENTURE FX
$0.00
D6999
1
FIXED PROSTHODONTIC PROC
$0.00
D7110
O
ORAL SURGERY SINGLE TOOTH
$0.00
D7111
1
EXTRACTION CORONAL REMNANTS
$0.00
D7120
O
EACH ADD TOOTH EXTRACTION
$0.00
D7130
O
TOOTH ROOT REMOVAL
$0.00
D7140
1
EXTRACTION ERUPTED TOOTH/EXR
$0.00
D7210
1
REM IMP TOOTH W MUCOPER FLP
$0.00
D7220
1
IMPACT TOOTH REMOV SOFT TISS
$0.00
D7230
1
IMPACT TOOTH REMOV PART BONY
$0.00
D7240
1
IMPACT TOOTH REMOV COMP BONY
$0.00
D7241
1
IMPACT TOOTH REM BONY W/COMP
$0.00
D7250
1
TOOTH ROOT REMOVAL
$0.00
D7260
1
ORAL ANTRAL FISTULA CLOSURE
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
D7261
1
PRIMARY CLOSURE SINUS PERF
$0.00
D7270
1
TOOTH REIMPLANTATION
$0.00
D7271
O
TOOTH IMPLANTATION
$0.00
D7272
1
TOOTH TRANSPLANTATION
$0.00
D7280
1
EXPOSURE IMPACT TOOTH ORTHOD
$0.00
D7281
O
EXPOSURE TOOTH AID ERUPTION
$0.00
D7282
1
MOBILIZE ERUPTED/MALPOS TOOT
$0.00
D7283
1
PLACE DEVICE IMPACTED TOOTH
$0.00
D7285
9
BIOPSY OF ORAL TISSUE HARD
$0.00
D7286
9
BIOPSY OF ORAL TISSUE SOFT
$0.00
D7287
9
EXFOLIATIVE CYTOLOG COLLECT
$0.00
D7288
9
BRUSH BIOPSY
$0.00
D7290
1
REPOSITIONING OF TEETH
$0.00
D7291
1
TRANSSEPTAL FIBEROTOMY
$0.00
D7292
9
SCREW RETAINED PLATE
$0.00
D7293
9
TEMP ANCHORAGE DEV W FLAP
$0.00
D7294
9
TEMP ANCHORAGE DEV W/O FLAP
$0.00
D7310
1
ALVEOPLASTY W/ EXTRACTION
$0.00
D7311
1
ALVEOLOPLASTY W/EXTRACT 1-3
$0.00
D7320
1
ALVEOPLASTY W/O EXTRACTION
$0.00
D7321
1
ALVEOLOPLASTY NOT W/EXTRACTS
$0.00
D7340
1
VESTIBULOPLASTY RIDGE EXTENS
$0.00
D7350
1
VESTIBULOPLASTY EXTEN GRAFT
$0.00
D7410
9
RAD EXC LESION UP TO 1.25 CM
$0.00
D7411
9
EXCISION BENIGN LESION>1.25C
$0.00
D7412
9
EXCISION BENIGN LESION COMPL
$0.00
D7413
9
EXCISION MALIG LESION<=1.25C
$0.00
D7414
9
EXCISION MALIG LESION>1.25CM
$0.00
D7415
9
EXCISION MALIG LES COMPLICAT
$0.00
D7420
9
LESION > 1.25 CM
$0.00
D7430
9
EXC BENIGN TUMOR TO 1.25 CM
$0.00
D7431
9
BENIGN TUMOR EXC > 1.25 CM
$0.00
D7440
9
MALIG TUMOR EXC TO 1.25 CM
$0.00
D7441
9
MALIG TUMOR > 1.25 CM
$0.00
D7450
9
REM ODONTOGEN CYST TO 1.25CM
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
D7451
9
REM ODONTOGEN CYST > 1.25 CM
$0.00
D7460
9
REM NONODONTO CYST TO 1.25CM
$0.00
D7461
9
REM NONODONTO CYST > 1.25 CM
$0.00
D7465
9
LESION DESTRUCTION
$0.00
D7470
9
REM EXOSTOSIS MAXILLA/MANDIB
$0.00
D7471
9
REM EXOSTOSIS ANY SITE
$0.00
D7472
9
REMOVAL OF TORUS PALATINUS
$0.00
D7473
9
REMOVE TORUS MANDIBULARIS
$0.00
D7480
9
PARTIAL OSTECTOMY
$0.00
D7485
9
SURG REDUCT OSSEOUSTUBEROSIT
$0.00
D7490
9
MAXILLA OR MANDIBLE RESECTIO
$0.00
D7510
1
I&D ABSC INTRAORAL SOFT TISS
$0.00
D7511
1
INCISION/DRAIN ABSCESS INTRA
$0.00
D7520
1
I&D ABSCESS EXTRAORAL
$0.00
D7521
1
INCISION/DRAIN ABSCESS EXTRA
$0.00
D7530
1
REMOVAL FB SKIN/AREOLAR TISS
$0.00
D7540
1
REMOVAL OF FB REACTION
$0.00
D7550
1
REMOVAL OF SLOUGHED OFF BONE
$0.00
D7560
1
MAXILLARY SINUSOTOMY
$0.00
D7610
9
MAXILLA OPEN REDUCT SIMPLE
$0.00
D7620
9
CLSD REDUCT SIMPL MAXILLA FX
$0.00
D7630
9
OPEN RED SIMPL MANDIBLE FX
$0.00
D7640
9
CLSD RED SIMPL MANDIBLE FX
$0.00
D7650
9
OPEN RED SIMP MALAR/ZYGOM FX
$0.00
D7660
9
CLSD RED SIMP MALAR/ZYGOM FX
$0.00
D7670
9
CLOSD RDUCTN SPLINT ALVEOLUS
$0.00
D7671
9
ALVEOLUS OPEN REDUCTION
$0.00
D7680
9
REDUCT SIMPLE FACIAL BONE FX
$0.00
D7710
9
MAXILLA OPEN REDUCT COMPOUND
$0.00
D7720
9
CLSD REDUCT COMPD MAXILLA FX
$0.00
D7730
9
OPEN REDUCT COMPD MANDBLE FX
$0.00
D7740
9
CLSD REDUCT COMPD MANDBLE FX
$0.00
D7750
9
OPEN RED COMP MALAR/ZYGMA FX
$0.00
D7760
9
CLSD RED COMP MALAR/ZYGMA FX
$0.00
D7770
9
OPEN REDUC COMPD ALVEOLUS FX
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
D7771
9
ALVEOLUS CLSD REDUC STBLZ TE
$0.00
D7780
9
REDUCT COMPND FACIAL BONE FX
$0.00
D7810
9
TMJ OPEN REDUCT-DISLOCATION
$0.00
D7820
9
CLOSED TMP MANIPULATION
$0.00
D7830
9
TMJ MANIPULATION UNDER ANEST
$0.00
D7840
9
REMOVAL OF TMJ CONDYLE
$0.00
D7850
9
TMJ MENISCECTOMY
$0.00
D7852
9
DISC REPAIR
$0.00
D7854
9
SYNOVECTOMY
$0.00
D7856
9
MYOTOMY
$0.00
D7858
9
JOINT RECONSTRUCTION
$0.00
D7860
9
TMJ CUTTING INTO JOINT
$0.00
D7865
9
ARTHROPLASTY
$0.00
D7870
9
TMJ ASPIRATION JOINT FLUID
$0.00
D7871
9
LYSIS + LAVAGE W CATHETERS
$0.00
D7872
9
ARTHROSCOPY- DIAGNOSIS WITH
$0.00
D7873
9
ARTHOSCOPY- SURGICAL: LAVAGE AND
$0.00
D7874
9
ARTHROSCOPY- SURGICAL: DISC REPOSI
$0.00
D7875
9
ARTHROSCOPY- SURGICAL: SYNOVECTOMY
$0.00
D7876
9
ARTHROSCOPY- SURGICAL: DISCECTOMY
$0.00
D7877
9
ARTHROSCOPY- SURGICAL DEBRIDEMENT
$0.00
D7880
1
OCCLUSAL ORTHOTIC APPLIANCE
$0.00
D7899
1
TMJ UNSPECIFIED THERAPY
$0.00
D7910
1
DENT SUTUR RECENT WND TO 5CM
$0.00
D7911
1
DENTAL SUTURE WOUND TO 5 CM
$0.00
D7912
1
SUTURE COMPLICATE WND > 5 CM
$0.00
D7920
9
DENTAL SKIN GRAFT
$0.00
D7940
9
RESHAPING BONE ORTHOGNATHIC
$0.00
D7941
9
BONE CUTTING RAMUS CLOSED
$0.00
D7942
9
BONE CUTTING RAMUS OPEN
$0.00
D7943
9
CUTTING RAMUS OPEN W/GRAFT
$0.00
D7944
9
BONE CUTTING SEGMENTED
$0.00
D7945
9
BONE CUTTING BODY MANDIBLE
$0.00
D7946
9
RECONSTRUCTION MAXILLA TOTAL
$0.00
D7947
9
RECONSTRUCT MAXILLA SEGMENT
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
D7948
9
RECONSTRUCT MIDFACE NO GRAFT
$0.00
D7949
9
RECONSTRUCT MIDFACE W/GRAFT
$0.00
D7950
9
MANDIBLE GRAFT
$0.00
D7951
9
SINUS AUG W BONE/BONE SUP
$0.00
D7953
9
BONE REPLACEMENT GRAFT
$0.00
D7955
9
REPAIR MAXILLOFACIAL DEFECTS
$0.00
D7960
1
FRENULECTOMY/FRENULOTOMY
$0.00
D7963
1
FRENULOPLASTY
$0.00
D7970
1
EXCISION HYPERPLASTIC TISSUE
$0.00
D7971
1
EXCISION PERICORONAL GINGIVA
$0.00
D7972
9
SURG REDCT FIBROUS TUBEROSIT
$0.00
D7980
9
SIALOLITHOTOMY
$0.00
D7981
9
EXCISION OF SALIVARY GLAND
$0.00
D7982
9
SIALODOCHOPLASTY
$0.00
D7983
9
CLOSURE OF SALIVARY FISTULA
$0.00
D7990
9
EMERGENCY TRACHEOTOMY
$0.00
D7991
9
DENTAL CORONOIDECTOMY
$0.00
D7992
9
EMINENECTOMY
$0.00
D7993
O
IMPLANT-FACIAL BONES (HOMOLOGOUS, H
$0.00
D7994
O
IMPLANT-OTHER THAN FACIAL BONES
$0.00
D7995
9
SYNTHETIC GRAFT FACIAL BONES
$0.00
D7996
9
IMPLANT MANDIBLE FOR AUGMENT
$0.00
D7997
1
APPLIANCE REMOVAL
$0.00
D7998
9
INTRAORAL PLACE OF FIX DEV
$0.00
D7999
1
ORAL SURGERY PROCEDURE
$0.00
D8010
1
LIMITED DENTAL TX PRIMARY
$0.00
D8020
1
LIMITED DENTAL TX TRANSITION
$0.00
D8030
1
LIMITED DENTAL TX ADOLESCENT
$0.00
D8040
1
LIMITED DENTAL TX ADULT
$0.00
D8050
1
INTERCEP DENTAL TX PRIMARY
$0.00
D8060
1
INTERCEP DENTAL TX TRANSITN
$0.00
D8070
1
COMPRE DENTAL TX TRANSITION
$0.00
D8080
3
COMPRE DENTAL TX ADOLESCENT
D8090
1
COMPRE DENTAL TX ADULT
$0.00
D8110
O
REMOVABLE APPLIANCE THERAPY
$0.00
$1,585.00
Procedure Code Pricing Action Code Description
Maximum Allowable
D8120
O
FIXED APPLIANCE THERAPY
$0.00
D8210
1
ORTHODONTIC REM APPLIANCE TX
$0.00
D8220
1
FIXED APPLIANCE THERAPY HABT
$0.00
D8360
O
REMOVABLE APPLIANCE THERAPY
$0.00
D8370
O
FIXED APPLIANCE THERAPY
$0.00
D8460
O
CLASS I MALOCCLUSION
$0.00
D8470
O
CLASS II MALOCCLUSION
$0.00
D8480
O
CLASS III MALOCCLUSION
$0.00
D8560
O
CLASS I MALOCCLUSION
$0.00
D8570
O
CLASS II MALOCCLUSION
$0.00
D8580
O
CLASS III MALOCCLUSION
$0.00
D8650
O
TREATMENT OF THE ATYPICAL OR EXTEND
$0.00
D8660
3
PREORTHODONTIC TX VISIT
$225.00
D8670
3
PERIODIC ORTHODONTC TX VISIT
$465.00
D8680
1
ORTHODONTIC RETENTION
$0.00
D8690
1
ORTHODONTIC TREATMENT
$0.00
D8691
1
REPAIR ORTHO APPLIANCE
$0.00
D8692
1
REPLACEMENT RETAINER
$0.00
D8693
9
REBOND/CEMENT/REPAIR RETAIN
$0.00
D8750
O
POST-TREATMENT STABILIZATION
$0.00
D8999
1
ORTHODONTIC PROCEDURE
$0.00
D9110
1
TX DENTAL PAIN MINOR PROC
$0.00
D9120
1
FIX PARTIAL DENTURE SECTION
$0.00
D9210
1
DENT ANESTHESIA W/O SURGERY
$0.00
D9211
9
REGIONAL BLOCK ANESTHESIA
$0.00
D9212
9
TRIGEMINAL BLOCK ANESTHESIA
$0.00
D9215
9
LOCAL ANESTHESIA
$0.00
D9220
1
GENERAL ANESTHESIA
$0.00
D9221
1
GENERAL ANESTHESIA EA AD 15M
$0.00
D9230
1
ANALGESIA
$0.00
D9240
9
INTRAVENOUS SEDATION
$0.00
D9241
1
INTRAVENOUS SEDATION
$0.00
D9242
1
IV SEDATION EA AD 30 M
$0.00
D9248
1
SEDATION (NON-IV)
$0.00
D9310
1
DENTAL CONSULTATION
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
D9410
9
DENTAL HOUSE CALL
$0.00
D9420
9
HOSPITAL CALL
$0.00
D9430
9
OFFICE VISIT DURING HOURS
$0.00
D9440
1
OFFICE VISIT AFTER HOURS
$0.00
D9450
9
CASE PRESENTATION TX PLAN
$0.00
D9610
1
DENT THERAPEUTIC DRUG INJECT
$0.00
D9612
1
THERA PAR DRUGS 2 OR > ADMIN
$0.00
D9630
9
OTHER DRUGS/MEDICAMENTS
$0.00
D9910
1
DENT APPL DESENSITIZING MED
$0.00
D9911
1
APPL DESENSITIZING RESIN
$0.00
D9920
1
BEHAVIOR MANAGEMENT
$0.00
D9930
1
TREATMENT OF COMPLICATIONS
$0.00
D9940
1
DENTAL OCCLUSAL GUARD
$0.00
D9941
9
FABRICATION ATHLETIC GUARD
$0.00
D9942
9
REPAIR/RELINE OCCLUSAL GUARD
$0.00
D9950
9
OCCLUSION ANALYSIS
$0.00
D9951
9
LIMITED OCCLUSAL ADJUSTMENT
$0.00
D9952
9
COMPLETE OCCLUSAL ADJUSTMENT
$0.00
D9960
9
COMPLETION OF CLAIM FORM
$0.00
D9970
9
ENAMEL MICROABRASION
$0.00
D9971
9
ODONTOPLASTY 1-2 TEETH
$0.00
D9972
9
EXTRNL BLEACHING PER ARCH
$0.00
D9973
9
EXTRNL BLEACHING PER TOOTH
$0.00
D9974
9
INTRNL BLEACHING PER TOOTH
$0.00
D9999
1
ADJUNCTIVE PROCEDURE
$0.00
DCD03
O
MCO SPECIFIC CODE: DEVELOPMENTAL CE
$0.00
DCP01
O
MCO SPECIFIC CODE: PARENT INFANT PR
$0.00
DCT02
O
MCO SPECIFIC CODE: TODDLER PROGRAM
$0.00
E0100
3
CANE ADJUST/FIXED WITH TIP
$20.16
E0105
3
CANE ADJUST/FIXED QUAD/3 PRO
$46.99
E0110
3
CRUTCH FOREARM PAIR
$69.54
E0111
3
CRUTCH FOREARM EACH
$50.95
E0112
3
CRUTCH UNDERARM PAIR WOOD
$35.40
E0113
3
CRUTCH UNDERARM EACH WOOD
$20.21
E0114
3
CRUTCH UNDERARM PAIR NO WOOD
$45.15
Procedure Code Pricing Action Code Description
Maximum Allowable
E0116
3
CRUTCH UNDERARM EACH NO WOOD
$22.76
E0117
5
UNDERARM SPRINGASSIST CRUTCH
$0.00
E0118
6
CRUTCH SUBSTITUTE
$0.00
E0130
3
WALKER RIGID ADJUST/FIXED HT
$57.13
E0135
3
WALKER FOLDING ADJUST/FIXED
$77.57
E0140
6
WALKER W TRUNK SUPPORT
E0141
3
RIGID WHEELED WALKER ADJ/FIX
E0142
O
WALKER RIGID WHEELED WITH SE
E0143
3
WALKER FOLDING WHEELED W/O S
$115.02
E0144
3
ENCLOSED WALKER W REAR SEAT
$304.66
E0145
O
WALKER WHLED SEAT/CRUTCH ATT
$0.00
E0146
O
FOLDING WALKER WHEELS W SEAT
$0.00
E0147
3
WALKER VARIABLE WHEEL RESIST
$549.91
E0148
3
HEAVYDUTY WALKER NO WHEELS
$121.55
E0149
3
HEAVY DUTY WHEELED WALKER
$213.53
E0150
9
UNDERARM PAD, CRUTCH, REPLACEMENT,
$0.00
E0151
9
HANDGRIP, CANE, CRUTCH, OR WALKER R
$0.00
E0152
9
TIP, CANE OR CRUTCH WALKER REPLACEM
$0.00
E0153
3
FOREARM CRUTCH PLATFORM ATTA
$66.38
E0154
3
WALKER PLATFORM ATTACHMENT
$66.38
E0155
3
WALKER WHEEL ATTACHMENT,PAIR
$30.20
E0156
3
WALKER SEAT ATTACHMENT
$25.29
E0157
3
WALKER CRUTCH ATTACHMENT
$66.61
E0158
3
WALKER LEG EXTENDERS SET OF4
$30.78
E0159
9
BRAKE FOR WHEELED WALKER
$0.00
E0160
3
SITZ TYPE BATH OR EQUIPMENT
$31.62
E0161
3
SITZ BATH/EQUIPMENT W/FAUCET
$25.09
E0162
3
SITZ BATH CHAIR
E0163
3
COMMODE CHAIR WITH FIXED ARM
$98.08
E0164
O
COMMODE CHAIR MOBILE FIXED A
$0.00
E0165
3
COMMODE CHAIR WITH DETACHARM
E0166
O
COMMODE CHAIR MOBILE DETACH
E0167
3
COMMODE CHAIR PAIL OR PAN
E0168
3
HEAVYDUTY/WIDE COMMODE CHAIR
E0169
O
SEATLIFT INCORP COMMODECHAIR
$0.00 $110.30 $0.00
$139.39
$144.20 $0.00 $10.11 $144.38 $0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
E0170
6
COMMODE CHAIR ELECTRIC
$0.00
E0171
6
COMMODE CHAIR NON-ELECTRIC
$0.00
E0172
6
SEAT LIFT MECHANISM TOILET
$0.00
E0175
3
COMMODE CHAIR FOOT REST
$53.86
E0176
O
AIR PRESSRE PAD/CUSHION NONP
$0.00
E0177
O
WATER PRESS PAD/CUSHION NONP
$0.00
E0178
O
GEL PRESSRE PAD/CUSHION NONP
$0.00
E0179
O
DRY PRESSRE PAD/CUSHION NONP
$0.00
E0180
O
PRESS PAD ALTERNATING W PUMP
$0.00
E0181
3
PRESS PAD ALTERNATING W/ PUM
$304.20
E0182
3
REPLACE PUMP, ALT PRESS PAD
$235.90
E0183
9
FLOTATION PAD FOR WHEELCHAIR
E0184
3
DRY PRESSURE MATTRESS
$186.27
E0185
3
GEL PRESSURE MATTRESS PAD
$306.01
E0186
3
AIR PRESSURE MATTRESS
$182.80
E0187
3
WATER PRESSURE MATTRESS
$209.20
E0188
3
SYNTHETIC SHEEPSKIN PAD
$23.85
E0189
3
LAMBSWOOL SHEEPSKIN PAD
$36.30
E0190
6
POSITIONING CUSHION
$0.00
E0191
3
PROTECTOR HEEL OR ELBOW
$9.56
E0192
O
PAD WHEELCHR LOW PRESS/POSIT
$0.00
E0193
3
POWERED AIR FLOTATION BED
E0194
3
AIR FLUIDIZED BED
$0.00
E0195
9
REPLACEMENT PAD FOR USE WITH MEDICA
$0.00
E0196
3
GEL PRESSURE MATTRESS
$287.60
E0197
3
AIR PRESSURE PAD FOR MATTRES
$211.98
E0198
3
WATER PRESSURE PAD FOR MATTR
$211.98
E0199
3
DRY PRESSURE PAD FOR MATTRES
$30.66
E0200
3
HEAT LAMP WITHOUT STAND
$75.85
E0202
3
PHOTOTHERAPY LIGHT W/ PHOTOM
E0203
5
THERAPEUTIC LIGHTBOX TABLETP
E0205
3
HEAT LAMP WITH STAND
E0210
3
ELECTRIC HEAT PAD STANDARD
$31.22
E0215
3
ELECTRIC HEAT PAD MOIST
$67.77
E0217
3
WATER CIRC HEAT PAD W PUMP
$0.00
$6,956.30
$564.10 $0.00 $157.81
$403.72
Procedure Code Pricing Action Code Description
Maximum Allowable
E0218
9
WATER CIRC COLD PAD W PUMP
$0.00
E0220
3
HOT WATER BOTTLE
$6.89
E0221
5
INFRARED HEATING PAD SYSTEM
$0.00
E0225
3
HYDROCOLLATOR UNIT
E0230
3
ICE CAP OR COLLAR
$6.89
E0231
5
WOUND WARMING DEVICE
$0.00
E0232
5
WARMING CARD FOR NWT
$0.00
E0235
3
PARAFFIN BATH UNIT PORTABLE
$155.40
E0236
3
PUMP FOR WATER CIRCULATING P
$358.90
E0237
O
WATER CIRCULATING HEAT/COLD PAD WIT
E0238
3
HEAT PAD NON-ELECTRIC MOIST
E0239
3
HYDROCOLLATOR UNIT PORTABLE
E0240
6
BATH/SHOWER CHAIR
$0.00
E0241
5
BATH TUB WALL RAIL
$0.00
E0242
5
BATH TUB RAIL FLOOR
$0.00
E0243
5
TOILET RAIL
$0.00
E0244
5
TOILET SEAT RAISED
$0.00
E0245
5
TUB STOOL OR BENCH
$0.00
E0246
5
TRANSFER TUB RAIL ATTACHMENT
$0.00
E0247
6
TRANS BENCH W/WO COMM OPEN
$0.00
E0248
6
HDTRANS BENCH W/WO COMM OPEN
$0.00
E0249
3
PAD WATER CIRCULATING HEAT U
$95.29
E0250
3
HOSP BED FIXED HT W/ MATTRES
$880.70
E0251
3
HOSP BED FIXD HT W/O MATTRES
$667.40
E0252
9
HOSPITAL BED, FIXED HEIGHT, WITH MA
E0255
3
HOSPITAL BED VAR HT W/ MATTR
$1,058.30
E0256
3
HOSPITAL BED VAR HT W/O MATT
$706.90
E0260
3
HOSP BED SEMI-ELECTR W/ MATT
$1,512.70
E0261
3
HOSP BED SEMI-ELECTR W/O MAT
$1,233.60
E0265
3
HOSP BED TOTAL ELECTR W/ MAT
$1,800.70
E0266
3
HOSP BED TOTAL ELEC W/O MATT
$1,359.80
E0270
9
HOSPITAL BED INSTITUTIONAL T
E0271
3
MATTRESS INNERSPRING
$212.42
E0272
3
MATTRESS FOAM RUBBER
$186.47
E0273
5
BED BOARD
$316.04
$0.00 $25.87 $430.35
$0.00
$0.00
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
E0274
5
OVER-BED TABLE
$0.00
E0275
3
BED PAN STANDARD
$14.64
E0276
3
BED PAN FRACTURE
$12.73
E0277
3
POWERED PRES-REDU AIR MATTRS
E0280
3
BED CRADLE
E0290
3
HOSP BED FX HT W/O RAILS W/M
$673.30
E0291
3
HOSP BED FX HT W/O RAIL W/O
$489.00
E0292
3
HOSP BED VAR HT W/O RAIL W/O
$701.60
E0293
3
HOSP BED VAR HT W/O RAIL W/
$644.30
E0294
3
HOSP BED SEMI-ELECT W/ MATTR
$1,177.20
E0295
3
HOSP BED SEMI-ELECT W/O MATT
$1,147.10
E0296
3
HOSP BED TOTAL ELECT W/ MATT
$1,479.10
E0297
3
HOSP BED TOTAL ELECT W/O MAT
$1,077.10
E0298
O
HEAVYDUTY/XTRA WIDE HOSP BED
$0.00
E0300
6
ENCLOSED PED CRIB HOSP GRADE
$0.00
E0301
6
HD HOSP BED, 350-600 LBS
$0.00
E0302
6
EX HD HOSP BED > 600 LBS
$0.00
E0303
6
HOSP BED HVY DTY XTRA WIDE
$0.00
E0304
6
HOSP BED XTRA HVY DTY X WIDE
$0.00
E0305
3
RAILS BED SIDE HALF LENGTH
$160.00
E0310
3
RAILS BED SIDE FULL LENGTH
$185.74
E0315
9
BED ACCESSORY BRD/TBL/SUPPRT
$0.00
E0316
5
BED SAFETY ENCLOSURE
$0.00
E0325
3
URINAL MALE JUG-TYPE
$9.67
E0326
3
URINAL FEMALE JUG-TYPE
$9.48
E0328
6
PED HOSPITAL BED, MANUAL
$0.00
E0329
6
PED HOSPITAL BED SEMI/ELECT
$0.00
E0350
9
CONTROL UNIT BOWEL SYSTEM
$0.00
E0352
9
DISPOSABLE PACK W/BOWEL SYST
$0.00
E0370
9
AIR ELEVATOR FOR HEEL
$0.00
E0371
5
NONPOWER MATTRESS OVERLAY
$0.00
E0372
3
POWERED AIR MATTRESS OVERLAY
$0.00
E0373
5
NONPOWERED PRESSURE MATTRESS
$0.00
E0400
O
OXYGEN CONTENTS, GASEOUS, PER CUBIC
$0.00
E0405
O
OXYGEN CONTENTS, GASEOUS, PER 100 C
$0.00
$1.00 $35.40
Procedure Code Pricing Action Code Description
Maximum Allowable
E0410
O
OXYGEN CONTENTS, LIQUID, PER POUND
$0.00
E0415
O
OXYGEN CONTENTS, LIQUID, PER 100 PO
$0.00
E0416
O
OXYGEN REFILL FOR PORTABLE GASEOUS
$0.00
E0424
3
STATIONARY COMPRESSED GAS 02
$1.00
E0425
5
GAS SYSTEM STATIONARY COMPRE
$0.00
E0430
5
OXYGEN SYSTEM GAS PORTABLE
$0.00
E0431
3
PORTABLE GASEOUS 02
$0.00
E0434
3
PORTABLE LIQUID 02
$1.00
E0435
5
OXYGEN SYSTEM LIQUID PORTABL
$0.00
E0439
3
STATIONARY LIQUID 02
$1.00
E0440
5
OXYGEN SYSTEM LIQUID STATION
$0.00
E0441
3
OXYGEN CONTENTS, GASEOUS
$148.00
E0442
3
OXYGEN CONTENTS, LIQUID
$148.00
E0443
3
PORTABLE 02 CONTENTS, GAS
$18.31
E0444
3
PORTABLE 02 CONTENTS, LIQUID
$18.31
E0445
3
OXIMETER NON-INVASIVE
$1.00
E0450
3
VOL CONTROL VENT INVASIV INT
$1.00
E0451
O
VOLUME VENTILATOR; PORTABLE (INCLUD
$0.00
E0452
O
INTERMIT ASSIS DEVICE W CPAP
$0.00
E0453
9
VENTILATOR 12 HRS/LESS PER D
$0.00
E0454
O
PRESSURE VENTILATOR
$0.00
E0455
O
OXYGEN TENT EXCL CROUP/PED T
$0.00
E0457
3
CHEST SHELL
$0.00
E0458
9
NEGATIVE PRESSURE PUMP
$0.00
E0459
3
CHEST WRAP
E0460
O
NEG PRESS VENT PORTABL/STATN
$0.00
E0461
5
VOL CONTROL VENT NONINV INT
$0.00
E0462
3
ROCKING BED W/ OR W/O SIDE R
$2,625.00
E0463
6
PRESS SUPP VENT INVASIVE INT
$0.00
E0464
6
PRESS SUPP VENT NONINV INT
$0.00
E0470
3
RAD W/O BACKUP NON-INV INTFC
$0.00
E0471
3
RAD W/BACKUP NON INV INTRFC
$0.00
E0472
6
RAD W BACKUP INVASIVE INTRFC
$0.00
E0480
3
PERCUSSOR ELECT/PNEUM HOME M
E0481
5
INTRPULMNRY PERCUSS VENT SYS
$458.40
$395.80 $0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
E0482
5
COUGH STIMULATING DEVICE
$0.00
E0483
5
CHEST COMPRESSION GEN SYSTEM
$0.00
E0484
3
NON-ELEC OSCILLATORY PEP DVC
$36.92
E0485
6
ORAL DEVICE/APPLIANCE PREFAB
$0.00
E0486
6
ORAL DEVICE/APPLIANCE CUSFAB
$0.00
E0487
6
ELECTRONIC SPIROMETER
$0.00
E0500
3
IPPB ALL TYPES
$0.00
E0505
9
IPPB MACHINES WITH MANUAL VALVES EL
$0.00
E0510
9
IPPB MACHINES WITH AUTOMATIC VALVES
$0.00
E0515
9
IPPB MACHINES WITH AUTOMATIC VALVES
$0.00
E0550
3
HUMIDIF EXTENS SUPPLE W IPPB
$451.60
E0555
9
HUMIDIFIER FOR USE W/ REGULA
$0.00
E0560
3
HUMIDIFIER SUPPLEMENTAL W/ I
$164.09
E0561
3
HUMIDIFIER NONHEATED W PAP
$107.00
E0562
3
HUMIDIFIER HEATED USED W PAP
$301.22
E0565
3
COMPRESSOR AIR POWER SOURCE
$467.20
E0570
3
NEBULIZER WITH COMPRESSION
$177.80
E0571
5
AEROSOL COMPRESSOR FOR SVNEB
$0.00
E0572
5
AEROSOL COMPRESSOR ADJUST PR
$0.00
E0574
5
ULTRASONIC GENERATOR W SVNEB
$0.00
E0575
3
NEBULIZER ULTRASONIC
E0580
9
NEBULIZER FOR USE W/ REGULAT
E0585
3
NEBULIZER W/ COMPRESSOR & HE
E0590
O
DISPENSING FEE DME NEB DRUG
$0.00
E0600
3
SUCTION PUMP PORTAB HOM MODL
$1.00
E0601
3
CONT AIRWAY PRESSURE DEVICE
$0.00
E0602
9
MANUAL BREAST PUMP
$0.00
E0603
3
ELECTRIC BREAST PUMP
E0604
5
HOSP GRADE ELEC BREAST PUMP
E0605
3
VAPORIZER ROOM TYPE
E0606
3
DRAINAGE BOARD POSTURAL
E0607
9
BLOOD GLUCOSE MONITOR HOME
$0.00
E0608
O
APNEA MONITOR
$0.00
E0609
O
BLOOD GLUC MON W/SPECIAL FEA
$0.00
E0610
3
PACEMAKER MONITR AUDIBLE/VIS
$227.56
$530.00 $0.00 $315.90
$742.80 $0.00 $25.29 $175.60
Procedure Code Pricing Action Code Description
Maximum Allowable
E0615
3
PACEMAKER MONITR DIGITAL/VIS
$403.28
E0616
9
CARDIAC EVENT RECORDER
$0.00
E0617
5
AUTOMATIC EXT DEFIBRILLATOR
$0.00
E0618
3
APNEA MONITOR
E0619
3
APNEA MONITOR W RECORDER
$1.00
E0620
9
CAP BLD SKIN PIERCING LASER
$0.00
E0621
3
PATIENT LIFT SLING OR SEAT
E0625
5
PATIENT LIFT BATHROOM OR TOI
E0627
3
SEAT LIFT INCORP LIFT-CHAIR
$316.39
E0628
3
SEAT LIFT FOR PT FURN-ELECTR
$316.39
E0629
3
SEAT LIFT FOR PT FURN-NON-EL
$316.39
E0630
3
PATIENT LIFT HYDRAULIC
$917.70
E0635
3
PATIENT LIFT ELECTRIC
$936.90
E0636
5
PT SUPPORT & POSITIONING SYS
$0.00
E0637
6
COMBINATION SIT TO STAND SYS
$0.00
E0638
6
STANDING FRAME SYS
$0.00
E0639
6
MOVEABLE PATIENT LIFT SYSTEM
$0.00
E0640
6
FIXED PATIENT LIFT SYSTEM
$0.00
E0641
6
MULTI-POSITION STND FRAM SYS
$0.00
E0642
6
DYNAMIC STANDING FRAME
$0.00
E0650
3
PNEUMA COMPRESOR NON-SEGMENT
$689.02
E0651
3
PNEUM COMPRESSOR SEGMENTAL
$878.65
E0652
3
PNEUM COMPRES W/CAL PRESSURE
E0655
3
PNEUMATIC APPLIANCE HALF ARM
E0656
6
SEGMENTAL PNEUMATIC TRUNK
$0.00
E0657
6
SEGMENTAL PNEUMATIC CHEST
$0.00
E0660
3
PNEUMATIC APPLIANCE FULL LEG
$139.07
E0665
3
PNEUMATIC APPLIANCE FULL ARM
$111.40
E0666
3
PNEUMATIC APPLIANCE HALF LEG
$112.29
E0667
3
SEG PNEUMATIC APPL FULL LEG
$309.75
E0668
3
SEG PNEUMATIC APPL FULL ARM
$359.33
E0669
3
SEG PNEUMATIC APPLI HALF LEG
$166.53
E0670
O
SEGMENTAL PNEUMATIC APPLIANCE FOR U
$0.00
E0671
9
PRESSURE PNEUM APPL FULL LEG
$0.00
E0672
9
PRESSURE PNEUM APPL FULL ARM
$0.00
$3,000.00
$91.83 $0.00
$5,012.71 $87.76
Procedure Code Pricing Action Code Description
Maximum Allowable
E0673
9
PRESSURE PNEUM APPL HALF LEG
$0.00
E0675
6
PNEUMATIC COMPRESSION DEVICE
$0.00
E0676
6
INTER LIMB COMPRESS DEV NOS
$0.00
E0690
O
ULTRAVIOLET CABINET
$0.00
E0691
5
UVL PNL 2 SQ FT OR LESS
$0.00
E0692
5
UVL SYS PANEL 4 FT
$0.00
E0693
5
UVL SYS PANEL 6 FT
$0.00
E0694
5
UVL MD CABINET SYS 6 FT
$0.00
E0700
5
SAFETY EQUIPMENT
$0.00
E0701
O
HELMET W FACE GUARD PREFAB
$0.00
E0705
6
TRANSFER DEVICE
$0.00
E0710
5
RESTRAINTS ANY TYPE
$0.00
E0720
3
TENS TWO LEAD
$314.34
E0730
3
TENS FOUR LEAD
$354.51
E0731
3
CONDUCTIVE GARMENT FOR TENS/
$341.24
E0740
9
INCONTINENCE TREATMENT SYSTM
$0.00
E0744
3
NEUROMUSCULAR STIM FOR SCOLI
$824.90
E0745
3
NEUROMUSCULAR STIM FOR SHOCK
$806.30
E0746
O
ELECTROMYOGRAPH BIOFEEDBACK
$0.00
E0747
3
ELEC OSTEOGEN STIM NOT SPINE
$3,774.74
E0748
3
ELEC OSTEOGEN STIM SPINAL
$3,890.70
E0749
O
ELEC OSTEOGEN STIM IMPLANTED
$0.00
E0750
O
IMPLANTABLE ELECTRICAL NERVE STIMUL
$0.00
E0751
9
PULSE GENERATOR OR RECEIVER
$0.00
E0752
O
NEUROSTIMULATOR ELECTRODE
$0.00
E0753
9
NEUROSTIMULATOR ELECTRODES
$0.00
E0754
O
PULSEGENERATOR PT PROGRAMMER
$0.00
E0755
5
ELECTRONIC SALIVARY REFLEX S
$0.00
E0756
O
IMPLANTABLE PULSE GENERATOR
$0.00
E0757
O
IMPLANTABLE RF RECEIVER
$0.00
E0758
O
EXTERNAL RF TRANSMITTER
$0.00
E0759
O
REPLACE RDFRQUNCY TRANSMITTR
$0.00
E0760
9
OSTEOGEN ULTRASOUND STIMLTOR
$0.00
E0761
5
NONTHERM ELECTROMGNTC DEVICE
$0.00
E0762
6
TRANS ELEC JT STIM DEV SYS
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
E0764
6
FUNCTIONAL NEUROMUSCULARSTIM
$0.00
E0765
5
NERVE STIMULATOR FOR TX N&V
$0.00
E0769
6
ELECTRIC WOUND TREATMENT DEV
$0.00
E0770
6
FUNCTIONAL ELECTRIC STIM NOS
$0.00
E0776
3
IV POLE
E0779
3
AMB INFUSION PUMP MECHANICAL
$15.67
E0780
3
MECH AMB INFUSION PUMP <8HRS
$9.92
E0781
3
EXTERNAL AMBULATORY INFUS PU
$2,484.00
E0782
O
NON-PROGRAMBLE INFUSION PUMP
$0.00
E0783
9
PROGRAMMABLE INFUSION PUMP
$0.00
E0784
5
EXT AMB INFUSN PUMP INSULIN
$0.00
E0785
9
REPLACEMENT IMPL PUMP CATHET
$0.00
E0786
9
IMPLANTABLE PUMP REPLACEMENT
$0.00
E0791
3
PARENTERAL INFUSION PUMP STA
E0830
5
AMBULATORY TRACTION DEVICE
E0840
3
TRACT FRAME ATTACH HEADBOARD
E0849
6
CERVICAL PNEUM TRAC EQUIP
E0850
3
TRACTION STAND FREE STANDING
$85.43
E0855
3
CERVICAL TRACTION EQUIPMENT
$480.86
E0856
6
CERVIC COLLAR W AIR BLADDER
E0860
3
TRACT EQUIP CERVICAL TRACT
E0870
3
TRACT FRAME ATTACH FOOTBOARD
$100.51
E0880
3
TRAC STAND FREE STAND EXTREM
$102.09
E0890
3
TRACTION FRAME ATTACH PELVIC
$97.91
E0900
3
TRAC STAND FREE STAND PELVIC
$104.19
E0910
3
TRAPEZE BAR ATTACHED TO BED
$180.20
E0911
6
HD TRAPEZE BAR ATTACH TO BED
$0.00
E0912
6
HD TRAPEZE BAR FREE STANDING
$0.00
E0920
3
FRACTURE FRAME ATTACHED TO B
$415.70
E0930
3
FRACTURE FRAME FREE STANDING
$372.00
E0935
5
CONT PAS MOTION EXERCISE DEV
$0.00
E0936
6
CPM DEVICE, OTHER THAN KNEE
$0.00
E0940
3
TRAPEZE BAR FREE STANDING
$313.20
E0941
3
GRAVITY ASSISTED TRACTION DE
$363.00
E0942
3
CERVICAL HEAD HARNESS/HALTER
$136.96
$2,421.20 $0.00 $59.59 $0.00
$0.00 $36.86
$18.99
Procedure Code Pricing Action Code Description
Maximum Allowable
E0943
O
CERVICAL PILLOW
$0.00
E0944
3
PELVIC BELT/HARNESS/BOOT
$43.89
E0945
3
BELT/HARNESS EXTREMITY
$42.41
E0946
3
FRACTURE FRAME DUAL W CROSS
$532.90
E0947
3
FRACTURE FRAME ATTACHMNTS PE
$580.20
E0948
3
FRACTURE FRAME ATTACHMNTS CE
$561.19
E0950
3
TRAY
$99.45
E0951
3
LOOP HEEL
$18.02
E0952
3
TOE LOOP/HOLDER, EACH
$18.02
E0953
O
PNEUMATIC TIRE
$0.00
E0954
O
WHEELCHAIR SEMI-PNEUMATIC CA
$0.00
E0955
6
CUSHIONED HEADREST
$0.00
E0956
6
W/C LATERAL TRUNK/HIP SUPPOR
$0.00
E0957
6
W/C MEDIAL THIGH SUPPORT
$0.00
E0958
3
WHLCHR ATT- CONV 1 ARM DRIVE
E0959
3
AMPUTEE ADAPTER
E0960
6
W/C SHOULDER HARNESS/STRAPS
E0961
3
WHEELCHAIR BRAKE EXTENSION
E0962
O
WHEELCHAIR 1 INCH CUSHION
$0.00
E0963
O
WHEELCHAIR 2 INCH CUSHION
$0.00
E0964
O
WHEELCHAIR 3 INCH CUSHION
$0.00
E0965
O
WHEELCHAIR 4 INCH CUSHION
$0.00
E0966
3
WHEELCHAIR HEAD REST EXTENSI
$61.94
E0967
3
MANUAL WC HAND RIM W PROJECT
$126.41
E0968
3
WHEELCHAIR COMMODE SEAT
$161.60
E0969
3
WHEELCHAIR NARROWING DEVICE
$139.86
E0970
3
WHEELCHAIR NO. 2 FOOTPLATES
$46.08
E0971
3
WHEELCHAIR ANTI-TIPPING DEVI
$62.90
E0972
O
TRANSFER BOARD OR DEVICE
E0973
3
W/CH ACCESS DET ADJ ARMREST
E0974
3
W/CH ACCESS ANTI-ROLLBACK
E0975
O
WHEELCHAIR REINFORCED SEAT U
$0.00
E0976
O
WHEELCHAIR REINFORCED BACK U
$0.00
E0977
O
WHEELCHAIR WEDGE CUSHION
$0.00
E0978
3
W/C ACC,SAF BELT PELV STRAP
$42.81
$393.10 $84.59 $0.00 $27.82
$0.00 $109.99 $75.59
Procedure Code Pricing Action Code Description
Maximum Allowable
E0979
O
WHEELCHAIR BELT WITH VELCRO
$0.00
E0980
3
WHEELCHAIR SAFETY VEST
E0981
6
SEAT UPHOLSTERY, REPLACEMENT
$0.00
E0982
6
BACK UPHOLSTERY, REPLACEMENT
$0.00
E0983
6
ADD PWR JOYSTICK
$0.00
E0984
6
ADD PWR TILLER
$0.00
E0985
6
W/C SEAT LIFT MECHANISM
$0.00
E0986
6
MAN W/C PUSH-RIM POW ASSIST
$0.00
E0990
3
WHELLCHAIR ELEVATING LEG RES
E0991
O
WHEELCHAIR UPHOLSTRY SEAT
E0992
3
WHEELCHAIR SOLID SEAT INSERT
$88.48
E0993
O
WHEELCHAIR BACK UPHOLSTERY
$0.00
E0994
3
WHEELCHAIR ARM REST
$15.18
E0995
3
WHEELCHAIR CALF REST
$25.29
E0996
O
WHEELCHAIR TIRE SOLID
$0.00
E0997
O
WHEELCHAIR CASTER W/ A FORK
$0.00
E0998
O
WHEELCHAIR CASTER W/O A FORK
$0.00
E0999
O
WHEELCHR PNEUMATIC TIRE W/WH
$0.00
E1000
O
WHEELCHAIR TIRE PNEUMATIC CA
$0.00
E1001
O
WHEELCHAIR WHEEL
$0.00
E1002
6
PWR SEAT TILT
$0.00
E1003
6
PWR SEAT RECLINE
$0.00
E1004
6
PWR SEAT RECLINE MECH
$0.00
E1005
6
WHEELCHAIR ACCESSORY, POWER SEAT
$0.00
E1006
6
PWR SEAT COMBO W/O SHEAR
$0.00
E1007
3
PWR SEAT COMBO W/SHEAR
$8,741.27
E1008
3
PWR SEAT COMBO PWR SHEAR
$8,742.05
E1009
6
ADD MECH LEG ELEVATION
$0.00
E1010
6
ADD PWR LEG ELEVATION
$0.00
E1011
5
PED WC MODIFY WIDTH ADJUSTM
$0.00
E1012
O
INT SEAT SYS PLANAR PED W/C
$0.00
E1013
O
INT SEAT SYS CONTOUR PED W/C
$0.00
E1014
5
RECLINING BACK ADD PED W/C
$0.00
E1015
5
SHOCK ABSORBER FOR MAN W/C
$0.00
E1016
5
SHOCK ABSORBER FOR POWER W/C
$0.00
$31.62
$112.35 $0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
E1017
5
HD SHCK ABSRBR FOR HD MAN WC
$0.00
E1018
5
HD SHCK ABSRBER FOR HD POWWC
$0.00
E1020
5
RESIDUAL LIMB SUPPORT SYSTEM
$0.00
E1025
O
PEDWC LAT/THOR SUP NOCONTOUR
$0.00
E1026
O
PEDWC CONTOURED LAT/THOR SUP
$0.00
E1027
O
PED WC LAT/ANT SUPPORT
$0.00
E1028
3
W/C MANUAL SWINGAWAY
E1029
6
W/C VENT TRAY FIXED
$0.00
E1030
6
W/C VENT TRAY GIMBALED
$0.00
E1031
3
ROLLABOUT CHAIR WITH CASTERS
E1035
5
PATIENT TRANSFER SYSTEM
$0.00
E1037
5
TRANSPORT CHAIR, PED SIZE
$0.00
E1038
5
TRANSPORT CHAIR PT WT<=300LB
$0.00
E1039
6
TRANSPORT CHAIR PT WT >300LB
$0.00
E1050
3
WHELCHR FXD FULL LENGTH ARMS
E1060
3
WHEELCHAIR DETACHABLE ARMS
E1065
O
WHEELCHAIR POWER ATTACHMENT
$0.00
E1066
O
WHEELCHAIR BATTERY CHARGER
$0.00
E1069
O
WHEELCHAIR DEEP CYCLE BATTER
$0.00
E1070
3
WHEELCHAIR DETACHABLE FOOT R
$838.60
E1083
3
HEMI-WHEELCHAIR FIXED ARMS
$709.40
E1084
3
HEMI-WHEELCHAIR DETACHABLE A
$883.70
E1085
3
HEMI-WHEELCHAIR FIXED ARMS
$623.40
E1086
3
HEMI-WHEELCHAIR DETACHABLE A
$757.10
E1087
3
WHEELCHAIR LIGHTWT FIXED ARM
$1,139.60
E1088
3
WHEELCHAIR LIGHTWEIGHT DET A
$1,358.29
E1089
3
WHEELCHAIR LIGHTWT FIXED ARM
$1,082.80
E1090
3
WHEELCHAIR LIGHTWEIGHT DET A
$1,042.60
E1091
3
WHEELCHAIR YOUTH
E1092
3
WHEELCHAIR WIDE W/ LEG RESTS
$1,157.70
E1093
3
WHEELCHAIR WIDE W/ FOOT REST
$995.60
E1100
3
WHCHR S-RECL FXD ARM LEG RES
$935.10
E1110
3
WHEELCHAIR SEMI-RECL DETACH
$778.30
E1130
3
WHLCHR STAND FXD ARM FT REST
$420.70
E1140
3
WHEELCHAIR STANDARD DETACH A
$647.00
$206.54
$455.00
$917.40 $1,135.60
$751.00
Procedure Code Pricing Action Code Description
Maximum Allowable
E1150
3
WHEELCHAIR STANDARD W/ LEG R
$735.00
E1160
3
WHEELCHAIR FIXED ARMS
$563.00
E1161
5
MANUAL ADULT WC W TILTINSPAC
E1170
3
WHLCHR AMPU FXD ARM LEG REST
$804.60
E1171
3
WHEELCHAIR AMPUTEE W/O LEG R
$643.40
E1172
3
WHEELCHAIR AMPUTEE DETACH AR
$827.40
E1180
3
WHEELCHAIR AMPUTEE W/ FOOT R
$776.00
E1190
3
WHEELCHAIR AMPUTEE W/ LEG RE
$1,054.70
E1195
3
WHEELCHAIR AMPUTEE HEAVY DUT
$961.90
E1200
3
WHEELCHAIR AMPUTEE FIXED ARM
$689.20
E1210
O
WHLCHR MOTO FUL ARM LEG REST
$0.00
E1211
O
WHEELCHAIR MOTORIZED W/ DET
$0.00
E1212
O
WHEELCHAIR MOTORIZED W FULL
$0.00
E1213
O
WHEELCHAIR MOTORIZED W/ DET
$0.00
E1220
5
WHLCHR SPECIAL SIZE/CONSTRC
$0.00
E1221
3
WHEELCHAIR SPEC SIZE W FOOT
$428.10
E1222
3
WHEELCHAIR SPEC SIZE W/ LEG
$610.70
E1223
3
WHEELCHAIR SPEC SIZE W FOOT
$666.80
E1224
3
WHEELCHAIR SPEC SIZE W/ LEG
$731.10
E1225
3
MANUAL SEMI-RECLINING BACK
$407.20
E1226
3
MANUAL FULLY RECLINING BACK
$522.01
E1227
3
WHEELCHAIR SPEC SZ SPEC HT A
$265.23
E1228
3
WHEELCHAIR SPEC SZ SPEC HT B
$214.50
E1229
6
PEDIATRIC WHEELCHAIR NOS
E1230
3
POWER OPERATED VEHICLE
E1231
5
RIGID PED W/C TILT-IN-SPACE
$0.00
E1232
5
FOLDING PED WC TILT-IN-SPACE
$0.00
E1233
5
RIG PED WC TLTNSPC W/O SEAT
$0.00
E1234
5
FLD PED WC TLTNSPC W/O SEAT
$0.00
E1235
5
RIGID PED WC ADJUSTABLE
$0.00
E1236
5
FOLDING PED WC ADJUSTABLE
$0.00
E1237
5
RGD PED WC ADJSTABL W/O SEAT
$0.00
E1238
5
FLD PED WC ADJSTABL W/O SEAT
$0.00
E1239
6
PED POWER WHEELCHAIR NOS
$0.00
E1240
3
WHCHR LITWT DET ARM LEG REST
$0.00
$0.00 $1,946.92
$928.10
Procedure Code Pricing Action Code Description
Maximum Allowable
E1250
3
WHEELCHAIR LIGHTWT FIXED ARM
$684.70
E1260
3
WHEELCHAIR LIGHTWT FOOT REST
$713.70
E1270
3
WHEELCHAIR LIGHTWEIGHT LEG R
$604.40
E1280
3
WHCHR H-DUTY DET ARM LEG RES
$1,005.00
E1285
3
WHEELCHAIR HEAVY DUTY FIXED
$923.50
E1290
3
WHEELCHAIR HVY DUTY DETACH A
$958.20
E1295
3
WHEELCHAIR HEAVY DUTY FIXED
$1,046.20
E1296
3
WHEELCHAIR SPECIAL SEAT HEIG
$399.82
E1297
3
WHEELCHAIR SPECIAL SEAT DEPT
$85.07
E1298
3
WHEELCHAIR SPEC SEAT DEPTH/W
$365.36
E1300
5
WHIRLPOOL PORTABLE
E1310
3
WHIRLPOOL NON-PORTABLE
E1340
3
REPAIR FOR DME, PER 15 MIN
E1350
O
REPAIR OR NON-ROUTINE SERVICE (E.G.
$0.00
E1353
5
OXYGEN SUPPLIES REGULATOR
$0.00
E1354
6
WHEELED CART, PORT CYL/CONC
$0.00
E1355
3
OXYGEN SUPPLIES STAND/RACK
$46.67
E1356
O
BREATHING CIRCUITS
$0.00
E1357
6
BATTERY CHARGER, PORT CONC
$0.00
E1358
6
DC POWER ADAPTER, PORT CONC
$0.00
E1372
3
OXY SUPPL HEATER FOR NEBULIZ
$155.98
E1375
O
OXYGEN SUPPL NEBULIZER PORTA
$0.00
E1377
O
OXYGEN CONCENTRATOR TO 244 C
$0.00
E1378
O
OXYGEN CONCENTRATOR TO 488 C
$0.00
E1379
O
OXYGEN CONCENTRATOR TO 732 C
$0.00
E1380
O
OXYGEN CONCENTRATOR TO 976 C
$0.00
E1381
O
OXYGEN CONCENTRAT TO 1220 CU
$0.00
E1382
O
OXYGEN CONCENTRAT TO 1464 CU
$0.00
E1383
O
OXYGEN CONCENTRAT TO 1708 CU
$0.00
E1384
O
OXYGEN CONCENTRAT TO 1952 CU
$0.00
E1385
O
OXYGEN CONCENTRATOR > 1952 C
$0.00
E1388
O
OXYGEN CONCENTRATOR, EQUIVALENT TO
$0.00
E1389
O
OXYGEN CONCENTRATOR, EQUIVALENT TO
$0.00
E1390
3
OXYGEN CONCENTRATOR
$0.00
E1391
6
OXYGEN CONCENTRATOR
$0.00
$0.00 $2,054.39 $25.00
Procedure Code Pricing Action Code Description
Maximum Allowable
E1392
6
PORTABLE OXYGEN CONCENTRATOR
$0.00
E1393
O
OXYGEN CONCENTRATOR, EQUIVALENT TO
$0.00
E1394
O
OXYGEN CONCENTRATOR, EQUIVALENT TO
$0.00
E1395
O
OXYGEN CONCENTRATOR, EQUIVALENT TO
$0.00
E1396
O
OXYGEN CONCENTRATOR, EQUIVALENT TO
$0.00
E1399
3
DURABLE MEDICAL EQUIPMENT MI
$325.00
E1400
9
OXYGEN CONCENTRATOR < 2 LITE
$0.00
E1401
O
OXYGEN CONCENTRATOR 2-3 LITE
$0.00
E1402
O
OXYGEN CONCENTRATOR 3-4 LITE
$0.00
E1403
O
OXYGEN CONCENTRATOR 4-5 LITE
$0.00
E1404
9
OXYGEN CONCENTRATOR > 5 LITE
$0.00
E1405
5
O2/WATER VAPOR ENRICH W/HEAT
$0.00
E1406
5
O2/WATER VAPOR ENRICH W/O HE
$0.00
E1500
9
CENTRIFUGE
$0.00
E1510
5
KIDNEY DIALYSATE DELIVRY SYS
$0.00
E1520
5
HEPARIN INFUSION PUMP
$0.00
E1530
5
REPLACEMENT AIR BUBBLE DETEC
$0.00
E1540
5
REPLACEMENT PRESSURE ALARM
$0.00
E1550
5
BATH CONDUCTIVITY METER
$0.00
E1560
5
REPLACE BLOOD LEAK DETECTOR
$0.00
E1570
5
ADJUSTABLE CHAIR FOR ESRD PT
$0.00
E1575
5
TRANSDUCER PROTECT/FLD BAR
$0.00
E1580
5
UNIPUNCTURE CONTROL SYSTEM
$0.00
E1590
5
HEMODIALYSIS MACHINE
$0.00
E1592
5
AUTO INTERM PERITONEAL DIALY
$0.00
E1594
5
CYCLER DIALYSIS MACHINE
$0.00
E1600
5
DELI/INSTALL CHRG HEMO EQUIP
$0.00
E1610
5
REVERSE OSMOSIS H2O PURI SYS
$0.00
E1615
5
DEIONIZER H2O PURI SYSTEM
$0.00
E1620
5
REPLACEMENT BLOOD PUMP
$0.00
E1625
5
WATER SOFTENING SYSTEM
$0.00
E1630
5
RECIPROCATING PERITONEAL DIA
$0.00
E1632
5
WEARABLE ARTIFICIAL KIDNEY
$0.00
E1634
6
PERITONEAL DIALYSIS CLAMP
$0.00
E1635
5
COMPACT TRAVEL HEMODIALYZER
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
E1636
5
SORBENT CARTRIDGES PER 10
$0.00
E1637
9
HEMOSTATS FOR DIALYSIS, EACH
$0.00
E1638
9
PERI DIALYSIS HEATING PAD
$0.00
E1639
9
DIALYSIS SCALE
$0.00
E1640
O
REPLACEMENT COMPONENTS FOR D
$0.00
E1699
5
DIALYSIS EQUIPMENT NOC
$0.00
E1700
O
JAW MOTION REHAB SYSTEM
$0.00
E1701
O
REPL CUSHIONS FOR JAW MOTION
$0.00
E1702
O
REPL MEASR SCALES JAW MOTION
$0.00
E1800
9
ADJUST ELBOW EXT/FLEX DEVICE
$0.00
E1801
9
SPS ELBOW DEVICE
$0.00
E1802
5
ADJST FOREARM PRO/SUP DEVICE
$0.00
E1805
9
ADJUST WRIST EXT/FLEX DEVICE
$0.00
E1806
9
SPS WRIST DEVICE
$0.00
E1810
9
ADJUST KNEE EXT/FLEX DEVICE
$0.00
E1811
9
SPS KNEE DEVICE
$0.00
E1812
6
KNEE EXT/FLEX W ACT RES CTRL
$0.00
E1815
9
ADJUST ANKLE EXT/FLEX DEVICE
$0.00
E1816
9
SPS ANKLE DEVICE
$0.00
E1818
9
SPS FOREARM DEVICE
$0.00
E1820
9
SOFT INTERFACE MATERIAL
$0.00
E1821
9
REPLACEMENT INTERFACE SPSD
$0.00
E1825
9
ADJUST FINGER EXT/FLEX DEVC
$0.00
E1830
9
ADJUST TOE EXT/FLEX DEVICE
$0.00
E1840
9
ADJ SHOULDER EXT/FLEX DEVICE
$0.00
E1841
6
STATIC STR SHLDR DEV ROM ADJ
$0.00
E1900
O
SPEECH COMMUNICATION DEVICE
$0.00
E1902
5
AAC NON-ELECTRONIC BOARD
$0.00
E2000
3
GASTRIC SUCTION PUMP HME MDL
$1.00
E2100
5
BLD GLUCOSE MONITOR W VOICE
$0.00
E2101
5
BLD GLUCOSE MONITOR W LANCE
$0.00
E2120
6
PULSE GEN SYS TX ENDOLYMP FL
$0.00
E2201
6
MAN W/CH ACC SEAT W>=20"<24"
$0.00
E2202
6
SEAT WIDTH 24-27 IN
$0.00
E2203
6
FRAME DEPTH LESS THAN 22 IN
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
E2204
6
FRAME DEPTH 22 TO 25 IN
$0.00
E2205
6
MANUAL WC ACCESSORY, HANDRIM
$0.00
E2206
3
COMPLETE WHEEL LOCK ASSEMBLY
$40.68
E2207
6
CRUTCH AND CANE HOLDER
$0.00
E2208
6
CYLINDER TANK CARRIER
$0.00
E2209
6
ARM TROUGH EACH
$0.00
E2210
6
WHEELCHAIR BEARINGS
$0.00
E2211
6
PNEUMATIC PROPULSION TIRE
$0.00
E2212
6
PNEUMATIC PROP TIRE TUBE
$0.00
E2213
6
PNEUMATIC PROP TIRE INSERT
$0.00
E2214
6
PNEUMATIC CASTER TIRE EACH
$0.00
E2215
6
PNEUMATIC CASTER TIRE TUBE
$0.00
E2216
6
FOAM FILLED PROPULSION TIRE
$0.00
E2217
6
FOAM FILLED CASTER TIRE EACH
$0.00
E2218
6
FOAM PROPULSION TIRE EACH
$0.00
E2219
6
FOAM CASTER TIRE ANY SIZE EA
$0.00
E2220
6
SOLID PROPULSION TIRE EACH
$0.00
E2221
6
SOLID CASTER TIRE EACH
$0.00
E2222
6
SOLID CASTER INTEGRATED WHL
$0.00
E2223
6
VALVE REPLACEMENT ONLY EACH
$0.00
E2224
6
PROPULSION WHL EXCLUDES TIRE
$0.00
E2225
6
CASTER WHEEL EXCLUDES TIRE
$0.00
E2226
6
CASTER FORK REPLACEMENT ONLY
$0.00
E2227
6
GEAR REDUCTION DRIVE WHEEL
$0.00
E2228
6
MWC ACC, WHEELCHAIR BRAKE
$0.00
E2230
6
MANUAL STANDING SYSTEM
$0.00
E2231
6
SOLID SEAT SUPPORT BASE
$0.00
E2291
6
PLANAR BACK FOR PED SIZE WC
$0.00
E2292
6
PLANAR SEAT FOR PED SIZE WC
$0.00
E2293
6
CONTOUR BACK FOR PED SIZE WC
$0.00
E2294
6
CONTOUR SEAT FOR PED SIZE WC
$0.00
E2295
6
PED DYNAMIC SEATING FRAME
$0.00
E2300
6
PWR SEAT ELEVATION SYS
$0.00
E2301
6
PWR STANDING
$0.00
E2310
6
ELECTRO CONNECT BTW CONTROL
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
E2311
3
ELECTRO CONNECT BTW 2 SYS
$2,369.20
E2312
6
MINI-PROP REMOTE JOYSTICK
$0.00
E2313
6
PWC HARNESS, EXPAND CONTROL
$0.00
E2320
O
HAND CHIN CONTROL
$0.00
E2321
6
HAND INTERFACE JOYSTICK
$0.00
E2322
6
MULT MECH SWITCHES
$0.00
E2323
6
SPECIAL JOYSTICK HANDLE
$0.00
E2324
6
CHIN CUP INTERFACE
$0.00
E2325
6
SIP AND PUFF INTERFACE
$0.00
E2326
6
BREATH TUBE KIT
$0.00
E2327
6
HEAD CONTROL INTERFACE MECH
$0.00
E2328
6
HEAD/EXTREMITY CONTROL INTER
$0.00
E2329
6
HEAD CONTROL NONPROPORTIONAL
$0.00
E2330
6
HEAD CONTROL PROXIMITY SWITC
$0.00
E2331
6
ATTENDANT CONTROL
$0.00
E2340
6
W/C WDTH 20-23 IN SEAT FRAME
$0.00
E2341
6
W/C WDTH 24-27 IN SEAT FRAME
$0.00
E2342
6
W/C DPTH 20-21 IN SEAT FRAME
$0.00
E2343
6
W/C DPTH 22-25 IN SEAT FRAME
$0.00
E2351
6
ELECTRONIC SGD INTERFACE
$0.00
E2360
3
22NF NONSEALED LEADACID
$112.34
E2361
3
22NF SEALED LEADACID BATTERY
$139.47
E2362
3
GR24 NONSEALED LEADACID
E2363
3
GR24 SEALED LEADACID BATTERY
$186.00
E2364
3
U1NONSEALED LEADACID BATTERY
$112.34
E2365
3
U1 SEALED LEADACID BATTERY
$112.17
E2366
3
BATTERY CHARGER, SINGLE MODE
$263.62
E2367
3
BATTERY CHARGER, DUAL MODE
$419.07
E2368
6
POWER WC MOTOR REPLACEMENT
$0.00
E2369
6
PWR WC GEAR BOX REPLACEMENT
$0.00
E2370
6
PWR WC MOTOR/GEAR BOX COMBO
$0.00
E2371
6
GR27 SEALED LEADACID BATTERY
$0.00
E2372
6
GR27 NON-SEALED LEADACID
$0.00
E2373
6
HAND/CHIN CTRL SPEC JOYSTICK
$0.00
E2374
6
HAND/CHIN CTRL STD JOYSTICK
$0.00
$91.98
Procedure Code Pricing Action Code Description
Maximum Allowable
E2375
6
NON-EXPANDABLE CONTROLLER
$0.00
E2376
6
EXPANDABLE CONTROLLER, REPL
$0.00
E2377
6
EXPANDABLE CONTROLLER, INITL
$0.00
E2381
6
PNEUM DRIVE WHEEL TIRE
$0.00
E2382
6
TUBE, PNEUM WHEEL DRIVE TIRE
$0.00
E2383
6
INSERT, PNEUM WHEEL DRIVE
$0.00
E2384
6
PNEUMATIC CASTER TIRE
$0.00
E2385
6
TUBE, PNEUMATIC CASTER TIRE
$0.00
E2386
6
FOAM FILLED DRIVE WHEEL TIRE
$0.00
E2387
6
FOAM FILLED CASTER TIRE
$0.00
E2388
6
FOAM DRIVE WHEEL TIRE
$0.00
E2389
6
FOAM CASTER TIRE
$0.00
E2390
6
SOLID DRIVE WHEEL TIRE
$0.00
E2391
6
SOLID CASTER TIRE
$0.00
E2392
6
SOLID CASTER TIRE, INTEGRATE
$0.00
E2393
6
VALVE, PNEUMATIC TIRE TUBE
$0.00
E2394
6
DRIVE WHEEL EXCLUDES TIRE
$0.00
E2395
6
CASTER WHEEL EXCLUDES TIRE
$0.00
E2396
6
CASTER FORK
$0.00
E2397
6
PWC ACC, LITH-BASED BATTERY
$0.00
E2399
6
NOC INTERFACE
$0.00
E2402
6
NEG PRESS WOUND THERAPY PUMP
$0.00
E2500
6
SGD DIGITIZED PRE-REC <=8MIN
$0.00
E2502
6
SGD PREREC MSG >8MIN <=20MIN
$0.00
E2504
6
SGD PREREC MSG>20MIN <=40MIN
$0.00
E2506
6
SGD PREREC MSG > 40 MIN
$0.00
E2508
6
SGD SPELLING PHYS CONTACT
$0.00
E2510
6
SGD W MULTI METHODS MSG/ACCS
$0.00
E2511
6
SGD SFTWRE PRGRM FOR PC/PDA
$0.00
E2512
6
SGD ACCESSORY, MOUNTING SYS
$0.00
E2599
6
SGD ACCESSORY NOC
$0.00
E2601
6
GEN W/C CUSHION WDTH < 22 IN
$0.00
E2602
6
GEN W/C CUSHION WDTH >=22 IN
$0.00
E2603
6
SKIN PROTECT WC CUS WD <22IN
$0.00
E2604
6
SKIN PROTECT WC CUS WD>=22IN
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
E2605
6
POSITION WC CUSH WDTH <22 IN
$0.00
E2606
6
POSITION WC CUSH WDTH>=22 IN
$0.00
E2607
6
SKIN PRO/POS WC CUS WD <22IN
$0.00
E2608
6
SKIN PRO/POS WC CUS WD>=22IN
$0.00
E2609
6
CUSTOM FABRICATE W/C CUSHION
$0.00
E2610
6
POWERED W/C CUSHION
$0.00
E2611
6
GEN USE BACK CUSH WDTH <22IN
$0.00
E2612
6
GEN USE BACK CUSH WDTH>=22IN
$0.00
E2613
6
POSITION BACK CUSH WD <22IN
$0.00
E2614
6
POSITION BACK CUSH WD>=22IN
$0.00
E2615
6
POS BACK POST/LAT WDTH <22IN
$0.00
E2616
6
POS BACK POST/LAT WDTH>=22IN
$0.00
E2617
6
CUSTOM FAB W/C BACK CUSHION
$0.00
E2618
O
WC ACC SOLID SEAT SUPP BASE
$0.00
E2619
6
REPLACE COVER W/C SEAT CUSH
$0.00
E2620
6
WC PLANAR BACK CUSH WD <22IN
$0.00
E2621
6
WC PLANAR BACK CUSH WD>=22IN
$0.00
E4610
9
LANCET DEVICE
$0.00
E8000
6
POSTERIOR GAIT TRAINER
$0.00
E8001
6
UPRIGHT GAIT TRAINER
$0.00
E8002
6
ANTERIOR GAIT TRAINER
$0.00
EDUCW
O
MCO SPECIFIC CODE: SMART START INDI
$0.00
EDURN
O
MCO SPECIFIC CODE: SMART START INDI
$0.00
EDUSW
O
MCO SPECIFIC CODE: SMART START INDI
$0.00
EXRCL
O
MCO SPECIFIC CODE: SMART START PRE
$0.00
FS001
O
MCO SPECIFIC CODE: FULL BABY FIRST
$0.00
FS002
O
MCO SPECIFIC CODE: LATE REFERRAL BA
$0.00
FS003
O
MCO SPECIFIC CODE: PARTIAL BABY FIR
$0.00
FS100
O
MCO SPECIFIC CODE: PREGNANT MOTHER
$0.00
FS104
O
MCO SPECIFIC CODE: SMART START, PRE
$0.00
FS105
O
MCO SPECIFIC CODE: SMART START, PRE
$0.00
FS106
O
MCO SPECIFIC CODE: SMART START, PRE
$0.00
FS107
O
MCO SPECIFIC CODE: SMART START, PRE
$0.00
FS108
O
MCO SPECIFIC CODE: SMART START, PRE
$0.00
FS109
O
MCO SPECIFIC CODE: SMART START, PRE
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
FS110
O
MCO SPECIFIC CODE: RESOURCE MOTHER'
$0.00
FS111
O
MCO SPECIFIC CODE: RESOURCE MOTHER'
$0.00
FS112
O
MCO SPECIFIC CODE: RSEOURCE MOTHER'
$0.00
FS912
O
MCO SPECIFIC CODE: NEOCATE 1+, 100
$0.00
FS913
O
MCO SPECIFIC CODE: NEOCATE 1+, 8 OU
$0.00
G0001
O
DRAWING BLOOD FOR SPECIMEN
$0.00
G0002
9
TEMPORARY URINARY CATHETER
$0.00
G0004
9
ECG TRANSM PHYS REVIEW & INT
$0.00
G0005
9
ECG 24 HOUR RECORDING
$0.00
G0006
9
ECG TRANSMISSION & ANALYSIS
$0.00
G0007
9
ECG PHY REVIEW & INTERPRET
$0.00
G0008
9
ADMIN INFLUENZA VIRUS VAC
$0.00
G0009
9
ADMIN PNEUMOCOCCAL VACCINE
$0.00
G0010
9
ADMIN HEPATITIS B VACCINE
$0.00
G0015
9
POST SYMPTOM ECG TRACING
$0.00
G0016
9
POST SYMPTOM ECG MD REVIEW
$0.00
G0020
O
IMPRESSION AND CUSTOM PREPARATION;
$0.00
G0021
O
IMPRESSION AND CUSTOM PREPARATION;
$0.00
G0025
O
COLLAGEN SKIN TEST KIT
$0.00
G0026
O
FECAL LEUKOCYTE EXAMINATION
$0.00
G0027
9
SEMEN ANALYSIS
$0.00
G0030
O
PET IMAGING PREV PET SINGLE
$0.00
G0031
O
PET IMAGING PREV PET MULTPLE
$0.00
G0032
O
PET FOLLOW SPECT 78464 SINGL
$0.00
G0033
O
PET FOLLOW SPECT 78464 MULT
$0.00
G0034
O
PET FOLLOW SPECT 76865 SINGL
$0.00
G0035
O
PET FOLLOW SPECT 78465 MULT
$0.00
G0036
O
PET FOLLOW CORNRY ANGIO SING
$0.00
G0037
O
PET FOLLOW CORNRY ANGIO MULT
$0.00
G0038
O
PET FOLLOW MYOCARD PERF SING
$0.00
G0039
O
PET FOLLOW MYOCARD PERF MULT
$0.00
G0040
O
PET FOLLOW STRESS ECHO SINGL
$0.00
G0041
O
PET FOLLOW STRESS ECHO MULT
$0.00
G0042
O
PET FOLLOW VENTRICULOGM SING
$0.00
G0043
O
PET FOLLOW VENTRICULOGM MULT
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
G0044
O
PET FOLLOWING REST ECG SINGL
$0.00
G0045
O
PET FOLLOWING REST ECG MULT
$0.00
G0046
O
PET FOLLOW STRESS ECG SINGL
$0.00
G0047
O
PET FOLLOW STRESS ECG MULT
$0.00
G0050
9
RESIDUAL URINE BY ULTRASOUND
$0.00
G0051
9
DESTRUCTION BY ANY METHOD, INCLUDIN
$0.00
G0052
9
DESTRUCTION BY ANY METHOD, INCLUDIN
$0.00
G0053
9
DESTRUCTION BY ANY METHOD, INCLUDIN
$0.00
G0054
O
BLOOD CHOLESTEROL TEST, BY CHOLESTE
$0.00
G0055
O
GLUCOSE POST DOSE (INCLUDES GLUCOSE
$0.00
G0056
O
GLUCOSE TOLERANCE TEST (GTT), BY DI
$0.00
G0057
O
GLUCOSE TOLERANCE TEST (GTT), BY DI
$0.00
G0058
O
AUTOMATED MULTICHANNEL TEST; 20 CLI
$0.00
G0059
O
AUTOMATED MULTICHANNEL TEST; 21 CLI
$0.00
G0060
O
AUTOMATED MULTICHANNEL TEST, 22 CLI
$0.00
G0061
O
LUNG VOLUME REDUCTION SURGERY (REDU
$0.00
G0062
9
PERIPHERAL SKELETAL BONE MINERAL DE
$0.00
G0063
9
CENTRAL SKELETAL BONE MINERAL DENSI
$0.00
G0064
9
PHYSICIAN SUPERVISION OF A PATIENT
$0.00
G0065
9
PHYSICIAN SUPERVISION OF A HOSPICE
$0.00
G0066
9
PHYSICIAN SUPERVISION OF A NURSING
$0.00
G0071
9
INDIVIDUAL PSYCHOTHERAPY, INSIGHT O
$0.00
G0072
9
INDIVIDUAL PSYCHOTHERAPY, INSIGHT O
$0.00
G0073
9
INDIVIDUAL PSYCHOTHERAPY, INSIGHT O
$0.00
G0074
9
INDIVIDUAL PSYCHOTHERAPY, INSIGHT O
$0.00
G0075
9
INDIVIDUAL PSYCHOTHERAPY, INSIGHT O
$0.00
G0076
9
INDIVIDUAL PSYCHOTHERAPY, INSIGHT O
$0.00
G0077
9
INDIVIDUAL PSYCHOTHERAPY, INTERACTI
$0.00
G0078
9
INDIVIDUAL PSYCHOTHERAPY, INTERACTI
$0.00
G0079
9
INDIVIDUAL PSYCHOTHERAPY, INTERACTI
$0.00
G0080
9
INDIVIDUAL PSYCHOTHERAPY, INTERACTI
$0.00
G0081
9
INDIVIDUAL PSYCHOTHERAPY, INTERACTI
$0.00
G0082
9
INDIVIDUAL PSYCHOTHERAPY, INTERACTI
$0.00
G0083
9
INDIVIDUAL PSYCHOTHERAPY, INSIGHT O
$0.00
G0084
9
INDIVIDUAL PSYCHOTHERAPY, INSIGHT O
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
G0085
9
INDIVIDUAL PSYCHOTHERAPY, INSIGHT O
$0.00
G0086
9
INDIVIDUAL PSYCHOTHERAPY, INSIGHT O
$0.00
G0087
9
INDIVIDUAL PSYCHOTHERAPY, INSIGHT O
$0.00
G0088
9
INDIVIDUAL PSYCHOTHERAPY, INSIGHT O
$0.00
G0089
9
INDIVIDUAL PSYCHOTHERAPY, INTERACTI
$0.00
G0090
9
INDIVIDUAL PSYCHOTHERAPY, INTERACTI
$0.00
G0091
9
INDIVIDUAL PSYCHOTHERAPY, INTERACTI
$0.00
G0092
9
INDIVIDUAL PSYCHOTHERAPY, INTERACTI
$0.00
G0093
9
INDIVIDUAL PSYCHOTHERAPY, INTERACTI
$0.00
G0094
9
INDIVIDUAL PSYCHOTHERAPY, INTERACTI
$0.00
G0101
9
CA SCREEN;PELVIC/BREAST EXAM
$0.00
G0102
9
PROSTATE CA SCREENING; DRE
$0.00
G0103
9
PSA, TOTAL SCREENING
$0.00
G0104
9
CA SCREEN;FLEXI SIGMOIDSCOPE
$0.00
G0105
9
COLORECTAL SCRN; HI RISK IND
$0.00
G0106
9
COLON CA SCREEN;BARIUM ENEMA
$0.00
G0107
O
CA SCREEN; FECAL BLOOD TEST
$0.00
G0108
9
DIAB MANAGE TRN PER INDIV
$0.00
G0109
9
DIAB MANAGE TRN IND/GROUP
$0.00
G0110
O
NETT PULM-REHAB EDUC; IND
$0.00
G0111
O
NETT PULM-REHAB EDUC; GROUP
$0.00
G0112
O
NETT;NUTRITION GUID, INITIAL
$0.00
G0113
O
NETT;NUTRITION GUID,SUBSEQNT
$0.00
G0114
O
NETT; PSYCHOSOCIAL CONSULT
$0.00
G0115
O
NETT; PSYCHOLOGICAL TESTING
$0.00
G0116
O
NETT; PSYCHOSOCIAL COUNSEL
$0.00
G0117
9
GLAUCOMA SCRN HGH RISK DIREC
$0.00
G0118
9
GLAUCOMA SCRN HGH RISK DIREC
$0.00
G0120
9
COLON CA SCRN; BARIUM ENEMA
$0.00
G0121
9
COLON CA SCRN NOT HI RSK IND
$0.00
G0122
9
COLON CA SCRN; BARIUM ENEMA
$0.00
G0123
3
SCREEN CERV/VAG THIN LAYER
$28.00
G0124
9
SCREEN C/V THIN LAYER BY MD
$0.00
G0125
O
PET IMAGE PULMONARY NODULE
$0.00
G0126
9
LUNG IMAGE (PET) STAGING
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
G0127
9
TRIM NAIL(S)
$0.00
G0128
9
CORF SKILLED NURSING SERVICE
$0.00
G0129
9
PARTIAL HOSP PROG SERVICE
$0.00
G0130
9
SINGLE ENERGY X-RAY STUDY
$0.00
G0131
9
CT SCAN, BONE DENSITY STUDY
$0.00
G0132
9
CT SCAN, BONE DENSITY STUDY
$0.00
G0141
9
SCR C/V CYTO,AUTOSYS AND MD
$0.00
G0143
9
SCR C/V CYTO,THINLAYER,RESCR
$0.00
G0144
9
SCR C/V CYTO,THINLAYER,RESCR
$0.00
G0145
9
SCR C/V CYTO,THINLAYER,RESCR
$0.00
G0147
9
SCR C/V CYTO, AUTOMATED SYS
$0.00
G0148
9
SCR C/V CYTO, AUTOSYS, RESCR
$0.00
G0151
7
HHCP-SERV OF PT,EA 15 MIN
$0.00
G0152
7
HHCP-SERV OF OT,EA 15 MIN
$0.00
G0153
7
HHCP-SVS OF S/L PATH,EA 15MN
$0.00
G0154
7
HHCP-SVS OF RN,EA 15 MIN
$0.00
G0155
9
HHCP-SVS OF CSW,EA 15 MIN
$0.00
G0156
7
HHCP-SVS OF AIDE,EA 15 MIN
$0.00
G0159
9
PERC DECLOT DIALYSIS GRAFT
$0.00
G0160
9
CRYO. ABLATION, PROSTATE
$0.00
G0161
9
ECHO GUIDE FOR CRYO PROBES
$0.00
G0163
9
PET FOR REC OF COLORECTAL CA
$0.00
G0164
9
PET FOR LYMPHOMA STAGING
$0.00
G0165
9
PET,REC OF MELANOMA/MET CA
$0.00
G0166
9
EXTRNL COUNTERPULSE, PER TX
$0.00
G0167
O
HYPERBARIC OZ TX;NO MD REQRD
$0.00
G0168
9
WOUND CLOSURE BY ADHESIVE
$0.00
G0169
9
REMOVAL TISSUE; NO ANESTHSIA
$0.00
G0170
9
SKIN BIOGRAFT
$0.00
G0171
9
SKIN BIOGRAFT ADD-ON
$0.00
G0172
9
PHP;TRAIN & ED, PER DAY
$0.00
G0173
9
LINEAR ACC STEREO RADSUR COM
$0.00
G0174
9
INTENSITYMODULATEDRADIATION
$0.00
G0175
7
OPPS SERVICE,SCHED TEAM CONF
$0.00
G0176
3
OPPS/PHP;ACTIVITY THERAPY
$10,128.26
Procedure Code Pricing Action Code Description
Maximum Allowable
G0177
O
OPPS/PHP; TRAIN & EDUC SERV
$0.00
G0178
9
INTENSITYMODULATEDRADIATION
$0.00
G0179
9
MD RECERTIFICATION HHA PT
$0.00
G0180
9
MD CERTIFICATION HHA PATIENT
$0.00
G0181
9
HOME HEALTH CARE SUPERVISION
$0.00
G0182
9
HOSPICE CARE SUPERVISION
$0.00
G0183
9
DESTRUCTION OF LOCALIZED LESION OF
$0.00
G0184
9
OCULAR PHOTDYNAMICTX 2ND EYE
$0.00
G0185
9
TRANSPUPPILLARY THERMOTX
$0.00
G0186
9
DSTRY EYE LESN,FDR VSSL TECH
$0.00
G0187
9
DSTRY MCLR DRUSEN,PHOTOCOAG
$0.00
G0188
9
XRAY LWR EXTRMTY-FULL LNGTH
$0.00
G0190
9
IMMUNIZATION ADMINISTRATION
$0.00
G0191
9
IMMUNIZATION ADMIN,EACH ADD
$0.00
G0192
9
IMMUNIZATION ORAL/INTRANASAL
$0.00
G0193
9
ENDOSCOPICSTUDYSWALLOWFUNCTN
$0.00
G0194
9
SENSORYTESTINGENDOSCOPICSTUD
$0.00
G0195
9
CLINICALEVALSWALLOWINGFUNCT
$0.00
G0196
9
EVALOFSWALLOWINGWITHRADIOOPA
$0.00
G0197
9
EVALOFPTFORPRESCIPSPEECHDEVI
$0.00
G0198
9
PATIENTADAPATION&TRAINFORSPE
$0.00
G0199
9
REEVALUATIONOFPATIENTUSESPEC
$0.00
G0200
9
EVALOFPATIENTPRESCIPOFVOICEP
$0.00
G0201
9
MODIFORTRAININGINUSEVOICEPRO
$0.00
G0202
3
SCREENINGMAMMOGRAPHYDIGITAL
$136.60
G0204
3
DIAGNOSTICMAMMOGRAPHYDIGITAL
$154.48
G0206
3
DIAGNOSTICMAMMOGRAPHYDIGITAL
$123.32
G0210
O
PET IMG WHOLEBODY DXLUNG
$0.00
G0211
O
PET IMG WHOLBODY INIT LUNG
$0.00
G0212
O
PET IMG WHOLEBOD RESTAG LUNG
$0.00
G0213
O
PET IMG WHOLBODY DX
$0.00
G0214
O
PET IMG WHOLEBOD INIT
$0.00
G0215
O
PETIMG WHOLEBOD RESTAG
$0.00
G0216
O
PET IMG WHOLEBOD DX MELANOMA
$0.00
G0217
O
PET IMG WHOLEBOD INIT MELAN
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
G0218
O
PET IMG WHOLEBOD RESTAG MELA
$0.00
G0219
9
PET IMG WHOLBOD MELANO NONCO
$0.00
G0220
O
PET IMG WHOLEBOD DX LYMPHOMA
$0.00
G0221
O
PET IMAG WHOLBOD INIT LYMPHO
$0.00
G0222
O
PET IMAG WHOLBOD RESTA LYMPH
$0.00
G0223
O
PET IMAG WHOLBOD REG DX HEAD
$0.00
G0224
O
PET IMAG WHOLBOD REG INI HEA
$0.00
G0225
O
PET WHOL RESTAG HEADNECKONLY
$0.00
G0226
O
PET IMG WHOLBODY DX ESOPHAGL
$0.00
G0227
O
PET IMG WHOLBOD INI ESOPHAGE
$0.00
G0228
O
PET IMG WHOLBOD RESTG ESOPHA
$0.00
G0229
O
PET IMG METABOLOC BRAIN PRES
$0.00
G0230
O
PET MYOCARD VIABILITY POST
$0.00
G0231
O
PET WHBD COLOREC; GAMMA CAM
$0.00
G0232
O
PET WHBD LYMPHOMA; GAMMA CAM
$0.00
G0233
O
PET WHBD MELANOMA; GAMMA CAM
$0.00
G0234
O
PET WHBD PULM NOD; GAMMA CAM
$0.00
G0235
6
PET NOT OTHERWISE SPECIFIED
$0.00
G0236
O
DIGITAL FILM CONVERT DIAG MA
$0.00
G0237
9
THERAPEUTIC PROCD STRG ENDUR
$0.00
G0238
9
OTH RESP PROC, INDIV
$0.00
G0239
9
OTH RESP PROC, GROUP
$0.00
G0240
9
CRITIC CARE BY MD TRANSPORT
$0.00
G0241
9
EACH ADDITIONAL 30 MINUTES
$0.00
G0242
O
MULTISOURCE PHOTON STER PLAN
$0.00
G0243
O
MULTISOUR PHOTON STERO TREAT
$0.00
G0244
O
OBSERV CARE BY FACILITY TOPT
$0.00
G0245
9
INITIAL FOOT EXAM PT LOPS
$0.00
G0246
9
FOLLOWUP EVAL OF FOOT PT LOP
$0.00
G0247
9
ROUTINE FOOTCARE PT W LOPS
$0.00
G0248
9
DEMONSTRATE USE HOME INR MON
$0.00
G0249
9
PROVIDE INR TEST MATER/EQUIP
$0.00
G0250
9
MD INR TEST REVIE INTER MGMT
$0.00
G0251
9
LINEAR ACC BASED STERO RADIO
$0.00
G0252
3
PET IMAGING INITIAL DX
$521.95
Procedure Code Pricing Action Code Description
Maximum Allowable
G0253
O
PET IMAGE BRST DECTION RECUR
$0.00
G0254
O
PET IMAGE BRST EVAL TO TX
$0.00
G0255
5
CURRENT PERCEP THRESHOLD TST
$0.00
G0256
O
PROSTATE BRACHY W PALLADIUM
$0.00
G0257
5
UNSCHED DIALYSIS ESRD PT HOS
$0.00
G0258
O
IV INFUSION DURING OBS STAY
$0.00
G0259
5
INJECT FOR SACROILIAC JOINT
$0.00
G0260
5
INJ FOR SACROILIAC JT ANESTH
$0.00
G0261
O
PROSTATE BRACHY W IODINE SEE
$0.00
G0262
O
SM INTESTINAL IMAGE CAPSULE
$0.00
G0263
O
ADM WITH CHF, CP, ASTHMA
$0.00
G0264
O
ASSMT OTR CHF, CP, ASTHMA
$0.00
G0265
O
CRYOPRESEVATION FREEZE+STORA
$0.00
G0266
O
THAWING + EXPANSION FROZ CEL
$0.00
G0267
O
BONE MARROW OR PSC HARVEST
$0.00
G0268
9
REMOVAL OF IMPACTED WAX MD
$0.00
G0269
5
OCCLUSIVE DEVICE IN VEIN ART
$0.00
G0270
5
MNT SUBS TX FOR CHANGE DX
$0.00
G0271
5
GROUP MNT 2 OR MORE 30 MINS
$0.00
G0272
O
NASO/ORO GASTRIC TUBE PL MD
$0.00
G0273
O
PRETX PLANNING, NON-HODGKINS
$0.00
G0274
O
RADIOPHARM TX, NON-HODGKINS
$0.00
G0275
3
RENAL ANGIO, CARDIAC CATH
$13.49
G0278
3
ILIAC ART ANGIO,CARDIAC CATH
$13.85
G0279
O
EXCORP SHOCK TX, ELBOW EPI
$0.00
G0280
O
EXCORP SHOCK TX OTHER THAN
$0.00
G0281
5
ELEC STIM UNATTEND FOR PRESS
$0.00
G0282
5
ELECT STIM WOUND CARE NOT PD
$0.00
G0283
9
ELEC STIM OTHER THAN WOUND
$0.00
G0288
3
RECON, CTA FOR SURG PLAN
G0289
3
ARTHRO, LOOSE BODY + CHONDRO
G0290
5
DRUG-ELUTING STENTS, SINGLE
$0.00
G0291
5
DRUG-ELUTING STENTS,EACH ADD
$0.00
G0292
O
ADM EXP DRUGS,CLINICAL TRIAL
$0.00
G0293
9
NON-COV SURG PROC,CLIN TRIAL
$0.00
$234.70 $84.90
Procedure Code Pricing Action Code Description
Maximum Allowable
G0294
9
NON-COV PROC, CLINICAL TRIAL
$0.00
G0295
9
ELECTROMAGNETIC THERAPY ONC
$0.00
G0296
O
PET IMGE RESTAG THYROD CANCE
$0.00
G0297
O
INSERT SINGLE CHAMBER/CD
$0.00
G0298
O
INSERT DUAL CHAMBER/CD
$0.00
G0299
O
INSER/REPOS SINGLE ICD+LEADS
$0.00
G0300
O
INSERT REPOSIT LEAD DUAL+GEN
$0.00
G0302
9
PRE-OP SERVICE LVRS COMPLETE
$0.00
G0303
9
PRE-OP SERVICE LVRS 10-15DOS
$0.00
G0304
9
PRE-OP SERVICE LVRS 1-9 DOS
$0.00
G0305
9
POST OP SERVICE LVRS MIN 6
$0.00
G0306
9
CBC/DIFFWBC W/O PLATELET
$0.00
G0307
9
CBC WITHOUT PLATELET
$0.00
G0308
O
ESRD RELATED SVC 4+MO < 2YRS
$0.00
G0309
O
ESRD RELATED SVC 2-3MO <2YRS
$0.00
G0310
O
ESRD RELATED SVC 1 VST <2YRS
$0.00
G0311
O
ESRD RELATED SVS 4+MO 2-11YR
$0.00
G0312
O
ESRD RELATE SVS 2-3 MO 2-11Y
$0.00
G0313
O
ESRD RELATED SVS 1 MON 2-11Y
$0.00
G0314
O
ESRD RELATED SVS 4+ MO 12-19
$0.00
G0315
O
ESRD RELATED SVS 2-3MO/12-19
$0.00
G0316
O
ESRD RELATED SVS 1VIS/12-19Y
$0.00
G0317
O
ESRD RELATED SVS 4+MO 20+YRS
$0.00
G0318
O
ESRD RELATED SVS 2-3 MO 20+Y
$0.00
G0319
O
ESRD RELATED SVS 1VISIT 20+Y
$0.00
G0320
O
ESD RELATED SVS HOME UNDR 2
$0.00
G0321
O
ESRDRELATEDSVS HOME MO 2-11Y
$0.00
G0322
O
ESRD RELATED SVS HOM MO12-19
$0.00
G0323
O
ESRD RELATED SVS HOME MO 20+
$0.00
G0324
O
ESRD RELATE SVS HOME/DY<2Y
$0.00
G0325
O
ESRD RELATE HOME/DAY/ 2-11YR
$0.00
G0326
O
ESRD RELATE HOME/DY 12-19YR
$0.00
G0327
O
ESRD RELATE HOME/DY 20+YRS
$0.00
G0328
5
FECAL BLOOD SCRN IMMUNOASSAY
$0.00
G0329
9
ELECTROMAGNTIC TX FOR ULCERS
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
G0332
O
PREADMIN IV IMMUNOGLOBULIN
$0.00
G0333
9
DISPENSE FEE INITIAL 30 DAY
$0.00
G0336
O
PET IMAGING BRAIN ALZHEIMERS
$0.00
G0337
9
HOSPICE EVALUATION PREELECTI
$0.00
G0338
O
LINEAR ACCELERATOR STERO PLN
$0.00
G0339
9
ROBOT LIN-RADSURG COM, FIRST
$0.00
G0340
9
ROBOT LINEAR STERORADIO MAX5
$0.00
G0341
9
PERCUTANEOUS ISLET CELLTRANS
$0.00
G0342
9
LAPAROSCOPY ISLET CELL TRANS
$0.00
G0343
9
LAPAROTOMY ISLET CELL TRANSP
$0.00
G0344
O
INITIAL PREVENTIVE EXAM
$0.00
G0345
O
IV INFUSE HYDRATION, INITIAL
$0.00
G0346
O
EACH ADDITIONAL INFUSE HOUR
$0.00
G0347
O
IV INFUSION THERAPY/DIAGNOST
$0.00
G0348
O
EACH ADDITIONAL HR UP TO 8HR
$0.00
G0349
O
ADDITIONAL SEQUENTIAL INFUSE
$0.00
G0350
O
CONCURRENT INFUSION
$0.00
G0351
O
THERAPEUTIC/DIAGNOSTIC INJEC
$0.00
G0353
O
IV PUSH,SINGLE ORINITIAL DRU
$0.00
G0354
O
EACH ADDITION SEQUENTIAL IV
$0.00
G0355
O
CHEMO ADMINISRATE SUBCUT/IM
$0.00
G0356
O
HORMONAL ANTI-NEOPLASTIC
$0.00
G0357
O
IV PUSH SINGLE/INITIAL SUBST
$0.00
G0358
O
IV PUSH EACH ADDITIONAL DRUG
$0.00
G0359
O
CHEMOTHERAPY IV ONE HR INITI
$0.00
G0360
O
EACH ADDITIONAL HR 1-8 HRS
$0.00
G0361
O
PROLONG CHEMO INFUSE>8HRS PU
$0.00
G0362
O
EACH ADD SEQUENTIAL INFUSION
$0.00
G0363
O
IRRIGATE IMPLANTED VENOUS DE
$0.00
G0364
3
BONE MARROW ASPIRATE &BIOPSY
G0365
9
VESSEL MAPPING HEMO ACCESS
$0.00
G0366
O
EKG FOR INITIAL PREVENT EXAM
$0.00
G0367
O
EKG TRACING FOR INITIAL PREV
$0.00
G0368
O
EKG INTERPRET & REPORT PREVE
$0.00
G0369
O
SUPPLYING FEE FOR THE INITIAL SUPP
$0.00
$12.24
Procedure Code Pricing Action Code Description
Maximum Allowable
G0370
O
SUPPLYING FEE FOR EACH SUPPLIED PR
$0.00
G0371
O
DISPENSING FEE FOR A 30 DAY PERIOD
$0.00
G0372
9
MD SERVICE REQUIRED FOR PMD
$0.00
G0374
O
DISPENSING FEE FOR EACH DISPENSED
$0.00
G0375
O
SMOKE/TOBACCO COUNSELNG 3-10
$0.00
G0376
O
SMOKE/TOBACCO COUNSELING >10
$0.00
G0378
9
HOSPITAL OBSERVATION PER HR
$0.00
G0379
9
DIRECT ADMIT HOSPITAL OBSERV
$0.00
G0380
9
LEV 1 HOSP TYPE B ED VISIT
$0.00
G0381
9
LEV 2 HOSP TYPE B ED VISIT
$0.00
G0382
9
LEV 3 HOSP TYPE B ED VISIT
$0.00
G0383
9
LEV 4 HOSP TYPE B ED VISIT
$0.00
G0384
9
LEV 5 HOSP TYPE B ED VISIT
$0.00
G0389
6
ULTRASOUND EXAM AAA SCREEN
$0.00
G0390
9
TRAUMA RESPONS W/HOSP CRITI
$0.00
G0392
3
AV FISTULA OR GRAFT ARTERIAL
$476.40
G0393
3
AV FISTULA OR GRAFT VENOUS
$304.63
G0394
O
BLOOD OCCULT TEST,COLORECTAL
$0.00
G0396
9
ALCOHOL/SUBS INTERV 15-30MN
$0.00
G0397
9
ALCOHOL/SUBS INTERV >30 MIN
$0.00
G0398
9
HOME SLEEP TEST/TYPE 2 PORTA
$0.00
G0399
9
HOME SLEEP TEST/TYPE 3 PORTA
$0.00
G0400
9
HOME SLEEP TEST/TYPE 4 PORTA
$0.00
G0402
9
INITIAL PREVENTIVE EXAM
$0.00
G0403
9
EKG FOR INITIAL PREVENT EXAM
$0.00
G0404
9
EKG TRACING FOR INITIAL PREV
$0.00
G0405
9
EKG INTERPRET & REPORT PREVE
$0.00
G0406
9
TELHEALTH INPT CONSULT 15MIN
$0.00
G0407
9
TELHEATH INPT CONSULT 25MIN
$0.00
G0408
9
TELHEALTH INPT CONSULT 35MIN
$0.00
G0409
9
CORF RELATED SERV 15 MINS EA
$0.00
G0410
9
GRP PSYCH PARTIAL HOSP 45-50
$0.00
G0411
9
INTER ACTIVE GRP PSYCH PARTI
$0.00
G0412
9
OPEN TX ILIAC SPINE UNI/BIL
$0.00
G0413
9
PELVIC RING FRACTURE UNI/BIL
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
G0414
9
PELVIC RING FX TREAT INT FIX
$0.00
G0415
9
OPEN TX POST PELVIC FXCTURE
$0.00
G0416
6
SAT BIOPSY PROSTATE 1-20 SPC
$0.00
G0417
6
SAT BIOPSY PROSTATE 21-40
$0.00
G0418
6
SAT BIOPSY PROSTATE 41-60
$0.00
G0419
6
SAT BIOPSY PROSTATE: >60
$0.00
G3001
6
ADMIN + SUPPLY, TOSITUMOMAB
$0.00
G8006
9
AMI PT RECD ASPIRIN AT ARRIV
$0.00
G8007
9
AMI PT DID NOT RECEIV ASPIRI
$0.00
G8008
9
AMI PT INELIGIBLE FOR ASPIRI
$0.00
G8009
9
AMI PT RECD BBLOCK AT ARR
$0.00
G8010
9
AMI PT DID NOT REC BBLOCK
$0.00
G8011
9
AMI PT INELIG BBLOC AT ARRIV
$0.00
G8012
9
PNEUM PT RECV ANTIBIOTIC 4 H
$0.00
G8013
9
PNEUM PT W/O ANTIBIOTIC 4 HR
$0.00
G8014
9
PNEUM PT NOT ELIG ANTIBIOTIC
$0.00
G8015
9
DIABETIC PT W/ HBA1C>9%
$0.00
G8016
9
DIABETIC PT W/ HBA1C
$0.00
G8017
9
DM PT INELIG FOR HBA1C MEASU
$0.00
G8018
9
CARE NOT PROVIDED FOR HBA1C
$0.00
G8019
9
DIABETIC PT W/LDL>= 100MG/DL
$0.00
G8020
9
DIAB PT W/LDL< 100MG/DL
$0.00
G8021
9
DIAB PT INELIG FOR LDL MEAS
$0.00
G8022
9
CARE NOT PROVIDED FOR LDL
$0.00
G8023
9
DM PT W BP>=140/80
$0.00
G8024
9
DIABETIC PT WBP<140/80
$0.00
G8025
9
DIABETIC PT INELIG FOR BP ME
$0.00
G8026
9
DIABET PT W NO CARE RE BP ME
$0.00
G8027
9
HF P W/LVSD ON ACE-I/ARB
$0.00
G8028
9
HF PT W/LVSD NOT ON ACE-I/AR
$0.00
G8029
9
HF PT NOT ELIG FOR ACE-I/ARB
$0.00
G8030
9
HF PT W/LVSD ON BBLOCKER
$0.00
G8031
9
HF PT W/LVSD NOT ON BBLOCKER
$0.00
G8032
9
HF PT NOT ELIG FOR BBLOCKER
$0.00
G8033
9
PMI-CAD PT ON BBLOCKER
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
G8034
9
PMI-CAD PT NOT ON BBLOCKER
$0.00
G8035
9
PMI-CAD PT INELIG BBLOCKER
$0.00
G8036
9
AMI-CAD PT DOC ON ANTIPLATEL
$0.00
G8037
9
AMI-CAD PT NOT DOCU ON ANTIP
$0.00
G8038
9
AMI-CAD INELIG ANTIPLATE MEA
$0.00
G8039
9
CAD PT W/LDL>100MG/DL
$0.00
G8040
9
CAD PT W/LDL
$0.00
G8041
9
CAD PT NOT ELIGIBLE FOR LDL
$0.00
G8051
9
OSTEOPOROSIS ASSESS
$0.00
G8052
9
OSTEOPOR PT NOT ASSESS
$0.00
G8053
9
PT INELIG FOR OSTEOPOR MEAS
$0.00
G8054
9
FALLS ASSESS NOT DOCUM 12 MO
$0.00
G8055
9
FALLS ASSESS W/ 12 MON
$0.00
G8056
9
NOT ELIG FOR FALLS ASSESSMEN
$0.00
G8057
9
HEARING ASSESS RECEIVE
$0.00
G8058
9
PT W/O HEARING ASSESS
$0.00
G8059
9
PT INELIG FOR HEARING ASSESS
$0.00
G8060
9
URINARY INCONT PT ASSESS
$0.00
G8061
9
PT NOT ASSESS FOR URINARY IN
$0.00
G8062
9
PT NOT ELIG FOR URINARY INCO
$0.00
G8075
9
ESRD PT W/ DIALY OF URR>=65%
$0.00
G8076
9
ESRD PT W/ DIALY OF URR<65%
$0.00
G8077
9
ESRD PT NOT ELIG FOR URR/KTV
$0.00
G8078
9
ESRD PT W/HCT>OR=33
$0.00
G8079
9
ESRD PT W/HCT<33
$0.00
G8080
9
ESRD PT INELIG FOR HCT/HGB
$0.00
G8081
9
ESRD PT W/ AUTO AV FISTULA
$0.00
G8082
9
ESRD PT W OTHER FISTULA
$0.00
G8085
9
ESRD PT INELIG AUTO AV FISTU
$0.00
G8093
9
COPD PT REC SMOKING CESSAT
$0.00
G8094
9
COPD PT W/O SMOKE CESSAT INT
$0.00
G8099
9
OSTEOPO PT GIVEN CA+VITD SUP
$0.00
G8100
9
OSTEOP PT INELIG FOR CA+VITD
$0.00
G8103
9
NEW DX OSTEO PT W/ANTIRESORP
$0.00
G8104
9
OSTEO PT INELIG FOR ANTIRESO
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
G8106
9
BONE DENS MEAS TEST PERF
$0.00
G8107
9
BONE DENS MEAS TEST INELIG
$0.00
G8108
9
PT RECEIV INFLUENZA VACC
$0.00
G8109
9
PT W/O INFLUENZA VACC
$0.00
G8110
9
PT INELIG FOR INFLUENZA VACC
$0.00
G8111
9
PT RECEIV MAMMOGRAM
$0.00
G8112
9
PT NOT DOC MAMMOGRAM
$0.00
G8113
9
PT INELIGIBLE MAMMOGRAPHY
$0.00
G8114
9
CARE NOT PROVIDED FOR MAMOGR
$0.00
G8115
9
PT RECEIV PNEUMO VACC
$0.00
G8116
9
PT DID NOT REC PNEUMO VACC
$0.00
G8117
9
PT WAS INELIG FOR PNEUMO VAC
$0.00
G8126
9
PT TREAT W/ANTIDEPRESS12WKS
$0.00
G8127
9
PT NOT TREAT W/ANTIDEPRES12W
$0.00
G8128
9
PT INELIG FOR ANTIDEPRES MED
$0.00
G8129
9
PT TREAT W/ANTIDEPRES FOR 6M
$0.00
G8130
9
PT NOT TREAT W/ANTIDEPRES 6M
$0.00
G8131
9
PT INELIG FOR ANTIDEPRES MED
$0.00
G8152
9
PT W/AB 1 HR PRIOR TO INCISI
$0.00
G8153
9
PT NOT DOC FOR AB 1 HR PRIOR
$0.00
G8154
9
PT INELIGI FOR AB THERAPY
$0.00
G8155
9
PT RECD THROMBOEMB PROPHYLAX
$0.00
G8156
9
PT DID NOT REC THROMBOEMBO
$0.00
G8157
9
PT INELIGI FOR THROMBOLISM
$0.00
G8158
O
PT RECD CABG W/ IMA
$0.00
G8159
9
PT W/CABG W/O IMA
$0.00
G8160
O
PT INELIG FOR CABG W/IMA
$0.00
G8161
O
ISO CABG PT REC PREOP BBLOCK
$0.00
G8162
9
ISO CABG PT W/O PREOP BBLOCK
$0.00
G8163
O
ISO CABG PT INELIG FOR PREO
$0.00
G8164
9
ISO CABG PT W/PROLNG INTUB
$0.00
G8165
9
ISO CABG PT W/O PROLNG INTUB
$0.00
G8166
9
ISO CABG REQ SURG REXPO
$0.00
G8167
9
ISO CABG W/O SURG EXPLO
$0.00
G8170
9
CEA/EXT BYPASS PT ON ASPIRIN
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
G8171
9
PT W/CAROT ENDARCT/EXT BYPAS
$0.00
G8172
9
CEA/EXT BYPASS PT NOT ON ASP
$0.00
G8182
9
CAD PT CARE NOT PROV LDL
$0.00
G8183
9
HF/ATRIAL FIB PT ON WARFARIN
$0.00
G8184
9
HF/ATRIAL FIB PT INELIG WARF
$0.00
G8185
9
OSTEOARTH PT W/ ASSESS PAIN
$0.00
G8186
9
OSTEOARTH PT INELIG ASSESS
$0.00
G8191
O
ANTIBIOTIC GIVEN PRIOR SURG
$0.00
G8192
O
ANTIB GIVEN PRIOR SURG INCIS
$0.00
G8193
9
ANTIBIO NOT DOC PRIOR SURG
$0.00
G8194
O
PT NOT ELIG FOR ANTIBIOTIC
$0.00
G8195
O
ANTIBIOTIC GIVEN PRIOR SURG
$0.00
G8196
9
ANTIBIO NOT DOCUM PRIOR SURG
$0.00
G8197
O
ANTIB ORDER PRIOR TO SURG
$0.00
G8198
O
CEFAZOLIN DOCUMENTED ORDERED
$0.00
G8199
O
CEFAZOLIN GIVEN PROPHYLAXIS
$0.00
G8200
9
CEFAZOLIN NOT DOCUM PROPHY
$0.00
G8201
O
PT NOT ELIGI FOR CEFAZOLIN
$0.00
G8202
O
ORDER GIVEN TO D/C ANTIBIO
$0.00
G8203
O
ANTIB WAS D/C 24HRS SURG TIM
$0.00
G8204
9
MD NOT DOC ORDER TO D/C ANTI
$0.00
G8205
O
PT NOT ELIGI FOR PROPH ANTIB
$0.00
G8206
O
MD DOC PROPHYLACTIC AB GIVEN
$0.00
G8207
O
CLINI DOC ORDER TO D/C ANTIB
$0.00
G8208
O
CLINI DOC AB WAS D/C 48 H
$0.00
G8209
9
CLINICIAN DID NOT DOC
$0.00
G8210
O
CLINI DOC PT INELIGIB ANTI
$0.00
G8211
O
CLINI DOC PROPH AB GIV
$0.00
G8212
O
CLINI ORDER GIVEN FOR VTE
$0.00
G8213
O
CLINI GIVEN VTE PROP
$0.00
G8214
9
CLINI NOT DOC ORDER VTE
$0.00
G8215
O
CLINI DOC PT INELIG VTE
$0.00
G8216
O
PT RECEIVED DVT PROPHYLAXIS
$0.00
G8217
9
PT NOT RECEIVED DVT PROPH
$0.00
G8218
O
PT INELIG DVT PROPHYLAXIS
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
G8219
9
RECEIVED DVT PROPH DAY 2
$0.00
G8220
9
PT NOT REC DVT PROPH DAY 2
$0.00
G8221
9
PT INELIG FOR DVT PROPH
$0.00
G8222
O
PT PRESCRIBE PLATELET AT D/C
$0.00
G8223
9
PT NOT DOC FOR PRESC ANTIPLA
$0.00
G8224
O
PT INELIG FOR ANTIPLAT PROPH
$0.00
G8225
O
PT PRESCRIB ANTICOAG AT D/C
$0.00
G8226
9
PT NO PRESCR ANTICOA AT D/C
$0.00
G8227
O
PT NOT DOC TO HAVE PERM/AF
$0.00
G8228
O
CLIN PT INELIG ANTICOAG D/C
$0.00
G8229
O
PT DOC TO HAVE ADMIN T-PA
$0.00
G8230
O
PT INELIG T-PA ISCH STROK>3H
$0.00
G8231
9
PT NOT DOC FOR ADMIN T-PA
$0.00
G8232
O
PT RECEIVED DYSPHAGIA SCREEN
$0.00
G8234
9
PT NOT DOC DYSPHAGIA SCREEN
$0.00
G8235
O
PT RECEIVED NPO
$0.00
G8236
O
PT INELIG DYSPHAGIA SCREEN
$0.00
G8237
O
PT DOC REC REHAB SERV
$0.00
G8238
9
PT NOT DOC TO REC REHAB SERV
$0.00
G8239
O
INTER CAROTID STENOSIS <30%
$0.00
G8240
9
INTER CAROTID STENOSIS30-99%
$0.00
G8241
O
PT INELIG CANDIDATE ITO MEAS
$0.00
G8242
O
PT DOC TO HAVE CT/MRI W/LES
$0.00
G8243
9
PT NOT DOC MRI/CT W/O LESION
$0.00
G8245
O
CLINI DOC PRESE/ABS ALARM
$0.00
G8246
9
PT INELIG HX W NEW/CHG MOLE
$0.00
G8247
O
PT W/ALARM SYMP UPPER ENDO
$0.00
G8248
9
PT W/ONE ALARM SYMP NOT DOC
$0.00
G8249
O
PT INELIG FOR UPPER ENDO
$0.00
G8250
O
PT W/BARRETTS ESOPH ENDO RE
$0.00
G8251
9
PT NOT DOC W/BARRETTS, ENDO
$0.00
G8252
O
PT INELIG FOR ESOPHAG BIOP
$0.00
G8253
O
PT REC ORDER FOR BARIUM
$0.00
G8254
9
PT W/NO DOC ORDER FOR BARIUM
$0.00
G8255
O
CLINI DOC PT INELIG BAR SWAL
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
G8256
O
CLINI DOC REV D/C MEDS W/MED
$0.00
G8257
9
PT NOT DOC REV MEDS D/C
$0.00
G8258
O
PT INELIG FOR D/C MEDS REV
$0.00
G8259
O
PT DOC TO HAV DECISION MAKER
$0.00
G8260
9
PT NOT DOC TO HAVE DEC MAKER
$0.00
G8261
O
CLIN DOC PT INELIG DEC MAKER
$0.00
G8262
O
PT DOC ASSESS URINY INCON
$0.00
G8263
9
PT NOT DOC ASSESS URINARY IN
$0.00
G8264
O
PT INELIG ASSESS URINARY INC
$0.00
G8265
O
PT DOC REC CHARC URIN INCON
$0.00
G8266
9
PT NOT DOC CHARC URIN INCON
$0.00
G8267
O
PT DOC REC PLAN URINARY INCO
$0.00
G8268
9
PT NOT DOC REC CARE URIN INC
$0.00
G8269
O
CLIN NOT PROV CARE URIN INCO
$0.00
G8270
O
PT RECEIV SCREEN FOR FALL
$0.00
G8271
9
PT NO DOC SCREEN FALL
$0.00
G8272
O
CLIN DOC PT INELIG FALL RISK
$0.00
G8273
O
CLIN NOT PROV CARE SCRE FALL
$0.00
G8274
9
CLINI NOT DOC PRES/ABS ALARM
$0.00
G8275
O
PT HX W/ NEW MOLES
$0.00
G8276
9
PT NOT DOC MOLE CHANGE
$0.00
G8277
O
PT INELIG FOR ASSESS MOLE
$0.00
G8278
O
PT DOC REC PE SKIN
$0.00
G8279
9
PT NOT DOC REC PE
$0.00
G8280
O
PT INELIG PE SKIN
$0.00
G8281
O
PT REC COUNSEL FOR SELF-EXAM
$0.00
G8282
9
PT NOT DOC TO REC COUNS
$0.00
G8283
O
PT INELIG FOR COUNSEL
$0.00
G8284
O
PT DOC TO REC PRES OSTEO
$0.00
G8285
9
PT DID NOT REC PRES OSTEO
$0.00
G8286
O
PT INELIG TO REC PRES OSTEO
$0.00
G8287
O
CLIN NOT PROV CARE FOR PHARM
$0.00
G8288
O
PT DOC REC CA/VIT D
$0.00
G8289
9
PT NOT DOC REC CA/VIT D
$0.00
G8290
O
CLIN DOC PT INELIG CA/VIT D
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
G8291
O
CLIN NO PRO CARE PT CA/VIT D
$0.00
G8292
O
COPD PT W/SPIR RESULTS
$0.00
G8293
9
COPD PT W/O SPIR RESULTS
$0.00
G8294
O
COPD PT INELIG SPIR RESULTS
$0.00
G8295
O
COPD PT DOC BRONCH THER
$0.00
G8296
9
COPD PT NOT DOC BRONCH THER
$0.00
G8297
O
COPD PT INELIG BRONCH THERAP
$0.00
G8298
9
PT DOC OPTIC NERVE EVAL
$0.00
G8299
9
PT NOT DOC OPTIC NERV EVAL
$0.00
G8300
O
PT INELIG FOR OPTIC NERV EVA
$0.00
G8301
O
CLIN NOT PROV CARE POAG
$0.00
G8302
9
PT DOC W/ TARGET IOP
$0.00
G8303
9
PT NOT DOC W/ IOP
$0.00
G8304
9
CLIN DOC PT INELIG IOP
$0.00
G8305
9
CLIN NOT PROV CARE POAG
$0.00
G8306
9
POAG W/ IOP REC CARE PLAN
$0.00
G8307
9
POAG W/ IOP NO CARE PLAN
$0.00
G8308
9
POAG W/ IOP NOT DOC PLAN
$0.00
G8309
O
PT DOC REC ANTIOXIDANT
$0.00
G8310
9
PT NOT DOC REC ANTIOX
$0.00
G8311
O
PT INELIG FOR ANTIOXIDANT
$0.00
G8312
O
CLIN NO PROV CARE FOR ANTIOX
$0.00
G8313
O
PT DOC REC MACULAR EXAM
$0.00
G8314
9
PT NOT DOC TO REC MAC EXAM
$0.00
G8315
O
CLIN DOC PT INELIG MAC EXAM
$0.00
G8316
O
CLIN NO PRO CARE FOR MAC DEG
$0.00
G8317
O
PT DOC TO HAVE VISUAL FUNC
$0.00
G8318
9
PT DOC NOT HAVE VISUAL FUNC
$0.00
G8319
O
PT INELIG FOR VIS FUNC STAT
$0.00
G8320
O
CLIN NOT PROV CARE CATARAC
$0.00
G8321
O
PT DOC TO PRE AXIAL LENG
$0.00
G8322
9
PT NOT DOC PRE AXIAL LENG
$0.00
G8323
O
PT INELIG FOR PRE SURG AXIAL
$0.00
G8324
O
CLIN NOT PROV CARE FOR IOL
$0.00
G8325
O
PT REC FUND EXAM PRIOR SURG
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
G8326
9
PT NOT DOC REC FUNDUS EXAM
$0.00
G8327
O
PT INELIG FOR PRE SURG FUNDU
$0.00
G8328
O
CLIN NOT PROV CARE FUND EVAL
$0.00
G8329
O
PT DOC REC DILATED MACULAR
$0.00
G8330
9
PT NOT DOC REC DILATED MAC
$0.00
G8331
O
PT INELIG DILATE FUNDUS
$0.00
G8332
O
CLIN PROV NO CARE DIABETIC R
$0.00
G8333
O
PT DOC TO HAVE MACULAR EXAM
$0.00
G8334
9
DOC OF MACULAR NOT GIV MD
$0.00
G8335
O
CLIN DOC PT INELIG MACULAR
$0.00
G8336
O
CLIN DID NOT PRO CARE DIABET
$0.00
G8337
O
CLIN DOC PT WAS TEST OSTEO
$0.00
G8338
9
CLIN NOT DOC PT TEST OSTEO
$0.00
G8339
O
PT INELIG FOR TEST OSTEO
$0.00
G8340
O
PT DOC HAVE DEXA
$0.00
G8341
9
PT NOT DOC FOR DEXA
$0.00
G8342
O
CLIN DOC PT INELIG DEXA
$0.00
G8343
O
CLIN NOT PROV CARE DEXA
$0.00
G8344
O
PT DOC HAVE DEXA PERFORM
$0.00
G8345
9
PT NOT DOC HAVE DEXA
$0.00
G8346
O
CLIN DOC PT INELIG DEXA
$0.00
G8347
O
CLIN NOT PROV CARE DEXA
$0.00
G8351
9
PT NOT DOC ECG
$0.00
G8354
9
PT NOT REC ASPIRIN PRIOR ER
$0.00
G8357
9
PT NOT DOC TO HAVE ECG
$0.00
G8360
9
PT NOT DOC VITAL SIGNS RECOR
$0.00
G8362
9
PT NOT DOC 02 SAT ASSESS
$0.00
G8365
9
PT NOT DOC MENTAL STATUS
$0.00
G8367
9
PT NOT DOC HAVE EMPIRIC AB
$0.00
G8370
9
ASTHMA PT W SURVEY NOT DOCUM
$0.00
G8371
9
CHEMOTHER NOT REC STG3 COLON
$0.00
G8372
9
CHEMOTHER REC STG3 COLON CA
$0.00
G8373
9
CHEMO PLAN DOCUMEN PRIOR CHE
$0.00
G8374
9
CHEMO PLAN NOT DOC PRIOR CHE
$0.00
G8375
9
CLL PT W/O DOC FLOW CYTOMETR
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
G8376
9
BRST CA PT INELIG TAMOXIFEN
$0.00
G8377
9
MD DOC COLON CA PT INELIG CH
$0.00
G8378
9
MD DOC PT INELIG RADIATION
$0.00
G8379
9
DOC RADIAT TX RECOM 12MO OV
$0.00
G8380
9
PT W STGIC-3BRST CA NOT REC
$0.00
G8381
9
PT W STGIC-3BRST CA REC TAM
$0.00
G8382
9
MM PT W/O DOC IV BISPHOPHON
$0.00
G8383
9
NO DOC RADIATION REC 12MO OV
$0.00
G8384
9
BASE CYTOGEN TEST MDS NOTPER
$0.00
G8385
9
DIABET PT NO DO HGB A1C 12M
$0.00
G8386
9
DIABET PT NODOC LDLIPROTEI
$0.00
G8387
9
ESRD PT W HCT/HGB NOT DOCUME
$0.00
G8388
9
ESRD PT W URR/KTV NOTDOC ELI
$0.00
G8389
9
MDS PT NO DOC FE ST PRIO EPO
$0.00
G8390
9
DIABETIC W/O DOCUMENT BP 12M
$0.00
G8391
9
PT W ASTHMA NO DOC MED OR TX
$0.00
G8395
9
LVEF>=40% DOC NORMAL OR MILD
$0.00
G8396
9
LVEF NOT PERFORMED
$0.00
G8397
9
DIL MACULA/FUNDUS EXAM/W DOC
$0.00
G8398
9
DIL MACULAR/FUNDUS NOT PERFO
$0.00
G8399
9
PT W/DXA DOCUMENT OR ORDER
$0.00
G8400
9
PT W/DXA NO DOCUMENT OR ORDE
$0.00
G8401
9
PT INELIG OSTEO SCREEN MEASU
$0.00
G8402
9
SMOKE PREVEN INTERVEN COUNSE
$0.00
G8403
9
SMOKE PREVEN NOCOUNSEL
$0.00
G8404
9
LOW EXTEMITY NEUR EXAM DOCUM
$0.00
G8405
9
LOW EXTEMITY NEUR NOT PERFOR
$0.00
G8406
9
PT INELIG LOWER EXTREM NEURO
$0.00
G8407
9
ABI DOCUMENTED
$0.00
G8408
9
ABI NOT DOCUMENTED
$0.00
G8409
9
PT INELIG FOR ABI MEASURE
$0.00
G8410
9
EVAL ON FOOT DOCUMENTED
$0.00
G8415
9
EVAL ON FOOT NOT PERFORMED
$0.00
G8416
9
PT INELIG FOOTWEAR EVALUATIO
$0.00
G8417
9
CALC BMI ABV UP PARAM F/U
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
G8418
9
CALC BMI BLW LOW PARAM F/U
$0.00
G8419
9
CALC BMI OUT NRM PARAM NOF/U
$0.00
G8420
9
CALC BMI NORM PARAMETERS
$0.00
G8421
9
BMI NOT CALCULATED
$0.00
G8422
9
PT INELIG BMI CALCULATION
$0.00
G8423
9
PT SCREEN FLU VAC & COUNSEL
$0.00
G8424
9
FLU VACCINE NOT SCREEN
$0.00
G8425
9
FLU VACCINE SCREEN NOT CURRE
$0.00
G8426
9
PT NOT APPROP SCREEN & COUNC
$0.00
G8427
9
DOC MEDS VERIFIED W/PT OR RE
$0.00
G8428
9
MEDS DOCUMENT W/O VERIFICA
$0.00
G8429
9
INCOMPLETE DOC PT ON MEDS
$0.00
G8430
9
PT INELIG MED CHECK
$0.00
G8431
9
POS CLIN DEPRES SCRN F/U DOC
$0.00
G8432
9
CLIN DEPRESSION SCREEN NOT D
$0.00
G8433
9
PT INELIG; SCRN CLIN DEP
$0.00
G8434
9
COGNITIVE IMPAIRMENT SCREEN
$0.00
G8435
9
COGNITIVE SCREEN NOT DOCUMEN
$0.00
G8436
9
PT INELIG FOR COGNITIVE IMPA
$0.00
G8437
9
CARE PLAN DEVELOP & DOCUMENT
$0.00
G8438
9
PT INELIG FOR DEVLP CARE PLN
$0.00
G8439
9
CARE PLAN DEVELP & NOT DOCUM
$0.00
G8440
9
PAIN ASSESS F/U PLN DOCUMENT
$0.00
G8441
9
NO DOCUMENT OF PAIN ASSESS
$0.00
G8442
9
PT INELIG PAIN ASSESSMENT
$0.00
G8443
9
PRESCRIPTION BY E-PRESCRIB S
$0.00
G8445
9
PRESCRIP NOT GEN AT ENCOUNTE
$0.00
G8446
9
SOME PRESCRIB PRINT OR CALL
$0.00
G8447
9
PT VIS DOC USE CCHIT CER EHR
$0.00
G8448
9
PT VIS DOC W/NON-CCHIT EHR
$0.00
G8449
9
PT NOT DOC W/EMR DUE TO SYST
$0.00
G8450
9
BETA-BLOC RX PT W/ABN LVEF
$0.00
G8451
9
PT W/ABN LVEF INELIG B-BLOC
$0.00
G8452
9
PT W/ABN LVEF B-BLOC NO RX
$0.00
G8453
9
TOB USE CESS INT COUNSEL
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
G8454
9
TOB USE CESS INT NO COUNSEL
$0.00
G8455
9
CURRENT TOBACCO SMOKER
$0.00
G8456
9
SMOKELESS TOBACCO USER
$0.00
G8457
9
CUR TOBACCO NON-USER
$0.00
G8458
9
PT INELIG GENO NO ANTVIR TX
$0.00
G8459
9
DOC PT REC ANTIVIR TREAT
$0.00
G8460
9
PT INELIG RNA NO ANTVIR TX
$0.00
G8461
9
PT REC ANTIVIR TREAT HEP C
$0.00
G8462
9
PT INELIG COUNS NO ANTVIR TX
$0.00
G8463
9
PT REC ANTIVIRAL TREAT DOC
$0.00
G8464
9
PT INELIG; LO TO NO DTER RSK
$0.00
G8465
9
HIGH RISK RECURRENCE PRO CA
$0.00
G8466
9
PT INELIG SUIC; MDD REMIS
$0.00
G8467
9
NEW DX INIT/REC EPISODE MDD
$0.00
G8468
9
ACE/ARB RX PT W/ABN LVEF
$0.00
G8469
9
PT W/ABN LVEF INELIG ACE/ARB
$0.00
G8470
9
PT W/ NORMAL LVEF
$0.00
G8471
9
LVEF NOT PERFORMED/DOC
$0.00
G8472
9
ACE/ARB NO RX PT W/ABN LVEF
$0.00
G8473
9
ACE/ARB THXPY RX'D
$0.00
G8474
9
ACE/ARB NOT RX'D; DOC REAS
$0.00
G8475
9
ACE/ARB THXPY NOT RX'D
$0.00
G8476
9
BP SYS <130 AND DIAS <80
$0.00
G8477
9
BP SYS>=130 AND/OR DIAS >=80
$0.00
G8478
9
BP NOT PERFORMED/DOC
$0.00
G8479
9
MD RX'D ACE/ARB THXPY
$0.00
G8480
9
PT INELIG ACE/ARB THXPY
$0.00
G8481
9
MD NOT RX'D ACE/ARB THXPY
$0.00
G8482
9
FLU IMMUNIZE ORDER/ADMIN
$0.00
G8483
9
FLU IMM NO ORD/ADMIN DOC REA
$0.00
G8484
9
FLU IMMUNIZE NO ORDER/ADMIN
$0.00
G8485
9
REPORT, DIABETES MEASURES
$0.00
G8486
9
REPORT, PREV CARE MEASURES
$0.00
G8487
9
REPORT CKD MEASURES
$0.00
G8488
9
REPORT ESRD MEASURES
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
G8489
9
CAD MEASURES GRP
$0.00
G8490
9
RA MEASURES GRP
$0.00
G8491
9
HIV/AIDS MEASURES GRP
$0.00
G8492
9
PREV CARE MEASURES GRP
$0.00
G8493
9
BACK PAIN MEASURES GRP
$0.00
G8494
9
DM MEAS QUAL ACT PERFORM
$0.00
G8495
9
CKD MEAS QUAL ACT PERFORM
$0.00
G8496
9
PC MEAS QUAL ACT PERFORM
$0.00
G8497
9
CABG MEAS QUAL ACT PERFORM
$0.00
G8498
9
CAD MEAS QUAL ACT PERFORM
$0.00
G8499
9
RA MEAS QUAL ACT PERFORM
$0.00
G8500
9
HIV MEAS QUAL ACT PERFORM
$0.00
G8501
9
PERIO MEAS QUAL ACT PERFORM
$0.00
G8502
9
BP MEAS QUAL ACT PERFORM
$0.00
G8503
9
DOC PROPH ANTIBX W/IN 1 HR
$0.00
G8504
9
DOC ORD PRO ANTBX W/IN 1 HR
$0.00
G8505
9
NO DOC PROPH ANTIBX W/IN 1HR
$0.00
G8506
9
PT REC ACE/ARB
$0.00
G8507
9
PT INELIG PT VERIF MEDS
$0.00
G8508
9
PT INELIG; PAIN ASSES NO F/U
$0.00
G8509
9
PAIN ASSESS NO F/U PLN DOC
$0.00
G8510
9
PT INELIG NEG SCRN DEPRES
$0.00
G8511
9
CLIN DEPRES SCRN NO F/U DOC
$0.00
G8512
9
PAIN SEV QUANT PRESENT
$0.00
G8513
9
ABI MEAS & DOC
$0.00
G8514
9
PT INELIG; ABI MEASURE
$0.00
G8515
9
NO ABI MEASUREMENT
$0.00
G8516
9
SCRN FAL RSK >2 FAL OR W/INJ
$0.00
G8517
9
SCRN FALL RSK; <2 FALLS
$0.00
G8518
9
CLIN STG B/F LUN/ESO CA SURG
$0.00
G8519
9
PT IN; CLIN CA STG B/F SURG
$0.00
G8520
9
CLIN STG B/F SURG NOT DOC
$0.00
G8521
9
ANTPLT RECD 48 HRS & DISCH
$0.00
G8522
9
PT INELIG; ANTIPLT THERAPY
$0.00
G8523
9
ANTPLT NOT RECD REAS NO SPEC
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
G8524
9
PATCH CLOSURE CONV CEA
$0.00
G8525
9
NO PATCH CLOSURE CEA
$0.00
G8526
9
NO PATCH CLOSURE CONV CEA
$0.00
G8527
9
DOC ORD ANTIMIC PROPHY
$0.00
G8528
9
PT INELIG; PROPH ANTIBIOT
$0.00
G8529
9
NO DOC ORD ANTIMIC PROPHY
$0.00
G8530
9
AUTO AV FISTULA RECD
$0.00
G8531
9
PT INELIG; AUTO AV FISTULA
$0.00
G8532
9
NO AUTO AV FISTULA; NO REAS
$0.00
G8533
9
PARTIC IN CLIN DATA BASE REG
$0.00
G8534
9
DOC ELDER MAL SCRN F/U PLAN
$0.00
G8535
9
PT INELIG NO ELD MAL SCRN
$0.00
G8536
9
NO DOC ELDER MAL SCRN
$0.00
G8537
9
PT INELIG ELDMAL SCRN NO F/U
$0.00
G8538
9
ELD MAL SCRN NO F/U PLN
$0.00
G8539
9
CUR FUNCT ASSESS & CARE PLN
$0.00
G8540
9
PT INELIG FUNCT ASSESS
$0.00
G8541
9
NO DOC CUR FUNCT ASSESS
$0.00
G8542
9
PT INELIG FUNC ASSES NO PLN
$0.00
G8543
9
CUR FUNCT ASSES; NO CARE PLN
$0.00
G8544
9
CABG MEASURES GRP
$0.00
G9001
7
MCCD, INITIAL RATE
$0.00
G9002
7
MCCD,MAINTENANCE RATE
$0.00
G9003
9
MCCD, RISK ADJ HI, INITIAL
$0.00
G9004
9
MCCD, RISK ADJ LO, INITIAL
$0.00
G9005
7
MCCD, RISK ADJ, MAINTENANCE
$0.00
G9006
7
MCCD, HOME MONITORING
$0.00
G9007
7
MCCD, SCH TEAM CONF
$0.00
G9008
7
MCCD,PHYS COOR-CARE OVRSGHT
$0.00
G9009
7
MCCD, RISK ADJ, LEVEL 3
$0.00
G9010
9
MCCD, RISK ADJ, LEVEL 4
$0.00
G9011
7
MCCD, RISK ADJ, LEVEL 5
$0.00
G9012
7
OTHER SPECIFIED CASE MGMT
$0.00
G9013
9
ESRD DEMO BUNDLE LEVEL I
$0.00
G9014
9
ESRD DEMO BUNDLE-LEVEL II
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
G9016
9
DEMO-SMOKING CESSATION COUN
$0.00
G9017
9
AMANTADINE HCL 100MG ORAL
$0.00
G9018
9
ZANAMIVIR,INHALATION PWD 10M
$0.00
G9019
9
OSELTAMIVIR PHOSPHATE 75MG
$0.00
G9020
9
RIMANTADINE HCL 100MG ORAL
$0.00
G9021
O
CHEMOTHERAPY ASSESSMENT FOR NAUSEA
$0.00
G9022
O
CHEMOTHERAPY ASSESSMENT FOR NAUSEA
$0.00
G9023
O
CHEMOTHERAPY ASSESSMENT FOR NAUSEA
$0.00
G9024
O
CHEMOTHERAPY ASSESSMENT FOR NAUSEA
$0.00
G9025
O
CHEMOTHERAPY ASSESSMENT FOR PAIN
$0.00
G9026
O
CHEMOTHERAPY ASSESSMENT FOR PAIN
$0.00
G9027
O
CHEMOTHERAPY ASSESSMENT FOR PAIN
$0.00
G9028
O
CHEMOTHERAPY ASSESSMENT FOR PAIN
$0.00
G9029
O
CHEMOTHERAPY ASSESSMENT FOR LACK O
$0.00
G9030
O
CHEMOTHERAPY ASSESSMENT FOR LACK O
$0.00
G9031
O
CHEMOTHERAPY ASSESSMENT FOR LACK O
$0.00
G9032
O
CHEMOTHERAPY ASSESSMENT FOR LACK O
$0.00
G9033
9
AMANTADINE HCL ORAL BRAND
$0.00
G9034
9
SERVICES PROVIDED BY OCCUPATIONAL
$0.00
G9035
9
SERVICES PROVIDED BY ORIENTATION
$0.00
G9036
9
SERVICES PROVIDED BY LOW VISION TH
$0.00
G9037
9
SERVICES PROVIDED BY REHABILITATIO
$0.00
G9041
9
LOW VISION REHAB OCCUPATIONA
$0.00
G9042
9
LOW VISION REHAB ORIENT/MOBI
$0.00
G9043
9
LOW VISION LOWVISION THERAPI
$0.00
G9044
9
LOW VISION REHABILATE TEACHE
$0.00
G9050
9
ONCOLOGY WORK-UP EVALUATION
$0.00
G9051
9
ONCOLOGY TX DECISION-MGMT
$0.00
G9052
9
ONC SURVEILLANCE FOR DISEASE
$0.00
G9053
9
ONC EXPECTANT MANAGEMENT PT
$0.00
G9054
9
ONC SUPERVISION PALLIATIVE
$0.00
G9055
9
ONC VISIT UNSPECIFIED NOS
$0.00
G9056
9
ONC PRAC MGMT ADHERES GUIDE
$0.00
G9057
9
ONC PRACT MGMT DIFFERS TRIAL
$0.00
G9058
9
ONC PRAC MGMT DISAGREE W/GUI
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
G9059
9
ONC PRAC MGMT PT OPT ALTERNA
$0.00
G9060
9
ONC PRAC MGMT DIF PT COMORB
$0.00
G9061
9
ONC PRAC COND NOADD BY GUIDE
$0.00
G9062
9
ONC PRAC GUIDE DIFFERS NOS
$0.00
G9063
9
ONC DX NSCLC STGI NO DX PROG
$0.00
G9064
9
ONC DX NSCLC STG2 NO DX PROG
$0.00
G9065
9
ONC DX NSCLC STG3A NODX PROG
$0.00
G9066
9
ONC DX NSCLC STG3B-4 METASTA
$0.00
G9067
9
ONC DX NSCLC DX UNKNOWN NOS
$0.00
G9068
9
ONC DX NSCLC/SCLC LIMITED
$0.00
G9069
9
ONC DX SCLC/NSCLC EXT AT DX
$0.00
G9070
9
ONC DX SCLC/NSCLC EXT UNKNWN
$0.00
G9071
9
ONC DX BRST STG1 2B NO DX PR
$0.00
G9072
9
ONC DX BRST STG1-2 NOPROGRES
$0.00
G9073
9
ONC DX BRST STG3-W/PROGRES
$0.00
G9074
9
ONC DX BRST STG3-NOPROGRESS
$0.00
G9075
9
ONC DX BRST METASTIC/ RECUR
$0.00
G9076
O
ONC DX BRST UNKNOWN NOS
$0.00
G9077
9
ONC DX PROSTATE T1NO PROGRES
$0.00
G9078
9
ONC DX PROSTATE T2NO PROGRES
$0.00
G9079
9
ONC DX PROSTATE T3B-T4NOPROG
$0.00
G9080
9
ONC DX PROSTATE W/RISE PSA
$0.00
G9081
O
ONC DX PROSTATE METS NO CAST
$0.00
G9082
O
ONC DX PROSTATE CASTRATE MET
$0.00
G9083
9
ONC DX PROSTATE UNKNWN NOS
$0.00
G9084
9
ONC DX COLON T1-3,N1-2,NO PR
$0.00
G9085
9
ONC DX COLON T4, N0 W/O PROG
$0.00
G9086
9
ONC DX COLON T1-4 NO DX PROG
$0.00
G9087
9
ONC DX COLON RADIOLG EVID DX
$0.00
G9088
9
ONC DX COLON M1/METS W/O RAD
$0.00
G9089
9
ONC DX COLON EXTENT UNKNOWN
$0.00
G9090
9
ONC DX RECTAL T1-2 NO PROGR
$0.00
G9091
9
ONC DX RECTAL T3 N0 NO PROG
$0.00
G9092
9
ONC DX RECTAL T1-3,N1-2NOPRG
$0.00
G9093
9
ONC DX RECTAL T4,N,M0 NO PRG
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
G9094
9
ONC DX RECTAL M1 W/METS PROG
$0.00
G9095
9
ONC DX RECTAL EXTENT UNKNWN
$0.00
G9096
9
ONC DX ESOPHAG T1-T3 NOPROG
$0.00
G9097
9
ONC DX ESOPHAGEAL T4 NO PROG
$0.00
G9098
9
ONC DX ESOPHAGEAL METS RECUR
$0.00
G9099
9
ONC DX ESOPHAGEAL UNKNOWN
$0.00
G9100
9
ONC DX GASTRIC NO RECURRENCE
$0.00
G9101
9
ONC DX GASTRIC P R1-R2NOPROG
$0.00
G9102
9
ONC DX GASTRIC UNRESECTABLE
$0.00
G9103
9
ONC DX GASTRIC RECURRENT
$0.00
G9104
9
ONC DX GASTRIC UNKNOWN NOS
$0.00
G9105
9
ONC DX PANCREATC P R0 RES NO
$0.00
G9106
9
ONC DX PANCREATC P R1/R2 NO
$0.00
G9107
9
ONC DX PANCREATIC UNRESECTAB
$0.00
G9108
9
ONC DX PANCREATIC UNKNWN NOS
$0.00
G9109
9
ONC DX HEAD/NECK T1-T2NO PRG
$0.00
G9110
9
ONC DX HEAD/NECK T3-4 NOPROG
$0.00
G9111
9
ONC DX HEAD/NECK M1 METS REC
$0.00
G9112
9
ONC DX HEAD/NECK EXT UNKNOWN
$0.00
G9113
9
ONC DX OVARIAN STG1A-B NO PR
$0.00
G9114
9
ONC DX OVARIAN STG1A-B OR 2
$0.00
G9115
9
ONC DX OVARIAN STG3/4 NOPROG
$0.00
G9116
9
ONC DX OVARIAN RECURRENCE
$0.00
G9117
9
ONC DX OVARIAN UNKNOWN NOS
$0.00
G9118
O
ONC DX NHL STG 1-2 NOT RELAP
$0.00
G9119
O
ONC DX NHL STG 3-4 NOT RELAP
$0.00
G9120
O
ONC DX NHL TRANS TO LG BCELL
$0.00
G9121
O
ONC NHLSTG 1-2 NO RELAP NO
$0.00
G9122
O
ONC DX NHL STG 3/4NO RELAP
$0.00
G9123
9
ONC DX NHL LGE BCELL RELAP
$0.00
G9124
9
ONC DX NHL RELAPSE/REFRACTOR
$0.00
G9125
9
ONC DX NHL STG UNKNOWN
$0.00
G9126
9
ONC DX OVARIAN STG IA/B
$0.00
G9127
O
ONC DX MULTI MYELOMA STAGE I
$0.00
G9128
9
ONC DX MULT MYELOMA STG2 HIG
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
G9129
9
ONC DX MULT MYELOMA UNKWN OP
$0.00
G9130
9
ONC DX MULTI MYELOMA UNKNOWN
$0.00
G9131
9
ONC DX BRST UNKNOWN NOS
$0.00
G9132
9
ONC DX PROSTATE METS NO CAST
$0.00
G9133
9
ONC DX PROSTATE CLINICAL MET
$0.00
G9134
9
ONC NHLSTG 1-2 NO RELAP NO
$0.00
G9135
9
ONC DX NHL STG 3-4 NOT RELAP
$0.00
G9136
9
ONC DX NHL TRANS TO LG BCELL
$0.00
G9137
9
ONC DX NHL RELAPSE/REFRACTOR
$0.00
G9138
9
ONC DX NHL STG UNKNOWN
$0.00
G9139
9
ONC DX CML DX STATUS UNKNOWN
$0.00
G9140
9
FRONTIER EXTENDED STAY DEMO
$0.00
H0001
7
ALCOHOL AND/OR DRUG ASSESS
$0.00
H0002
7
ALCOHOL AND/OR DRUG SCREENIN
$0.00
H0003
9
ALCOHOL AND/OR DRUG SCREENIN
$0.00
H0004
9
ALCOHOL AND/OR DRUG SERVICES
$0.00
H0005
7
ALCOHOL AND/OR DRUG SERVICES
$0.00
H0006
9
ALCOHOL AND/OR DRUG SERVICES
$0.00
H0007
7
ALCOHOL AND/OR DRUG SERVICES
$0.00
H0008
9
ALCOHOL AND/OR DRUG SERVICES
$0.00
H0009
9
ALCOHOL AND/OR DRUG SERVICES
$0.00
H0010
9
ALCOHOL AND/OR DRUG SERVICES
$0.00
H0011
9
ALCOHOL AND/OR DRUG SERVICES
$0.00
H0012
9
ALCOHOL AND/OR DRUG SERVICES
$0.00
H0013
9
ALCOHOL AND/OR DRUG SERVICES
$0.00
H0014
9
ALCOHOL AND/OR DRUG SERVICES
$0.00
H0015
7
ALCOHOL AND/OR DRUG SERVICES
$0.00
H0016
9
ALCOHOL AND/OR DRUG SERVICES
$0.00
H0017
7
ALCOHOL AND/OR DRUG SERVICES
$0.00
H0018
7
ALCOHOL AND/OR DRUG SERVICES
$0.00
H0019
7
ALCOHOL AND/OR DRUG SERVICES
$0.00
H0020
3
ALCOHOL AND/OR DRUG SERVICES
$4.00
H0021
9
ALCOHOL AND/OR DRUG TRAINING
$0.00
H0022
9
ALCOHOL AND/OR DRUG INTERVEN
$0.00
H0023
9
ALCOHOL AND/OR DRUG OUTREACH
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
H0024
9
ALCOHOL AND/OR DRUG PREVENTI
$0.00
H0025
9
ALCOHOL AND/OR DRUG PREVENTI
$0.00
H0026
9
ALCOHOL AND/OR DRUG PREVENTI
$0.00
H0027
9
ALCOHOL AND/OR DRUG PREVENTI
$0.00
H0028
9
ALCOHOL AND/OR DRUG PREVENTI
$0.00
H0029
9
ALCOHOL AND/OR DRUG PREVENTI
$0.00
H0030
9
ALCOHOL AND/OR DRUG HOTLINE
$0.00
H0031
7
MH HEALTH ASSESS BY NON-MD
$0.00
H0032
7
MH SVC PLAN DEV BY NON-MD
$0.00
H0033
9
ORAL MED ADM DIRECT OBSERVE
$0.00
H0034
9
MED TRNG & SUPPORT PER 15MIN
$0.00
H0035
9
MH PARTIAL HOSP TX UNDER 24H
$0.00
H0036
9
COMM PSY FACE-FACE PER 15MIN
$0.00
H0037
7
COMM PSY SUP TX PGM PER DIEM
$0.00
H0038
9
SELF-HELP/PEER SVC PER 15MIN
$0.00
H0039
7
ASSER COM TX FACE-FACE/15MIN
$0.00
H0040
9
ASSERT COMM TX PGM PER DIEM
$0.00
H0041
9
FOS C CHLD NON-THER PER DIEM
$0.00
H0042
9
FOS C CHLD NON-THER PER MON
$0.00
H0043
7
SUPPORTED HOUSING, PER DIEM
$0.00
H0044
9
SUPPORTED HOUSING, PER MONTH
$0.00
H0045
9
RESPITE NOT-IN-HOME PER DIEM
$0.00
H0046
7
MENTAL HEALTH SERVICE, NOS
$0.00
H0047
9
ALCOHOL/DRUG ABUSE SVC NOS
$0.00
H0048
9
SPEC COLL NON-BLOOD:A/D TEST
$0.00
H0049
9
ALCOHOL/DRUG SCREENING
$0.00
H0050
9
ALCOHOL/DRUG SERVICE 15 MIN
$0.00
H1000
9
PRENATAL CARE ATRISK ASSESSM
$0.00
H1001
9
ANTEPARTUM MANAGEMENT
$0.00
H1002
9
CARECOORDINATION PRENATAL
$0.00
H1003
9
PRENATAL AT RISK EDUCATION
$0.00
H1004
9
FOLLOW UP HOME VISIT/PRENTAL
$0.00
H1005
9
PRENATALCARE ENHANCED SRV PK
$0.00
H1010
9
NONMED FAMILY PLANNING ED
$0.00
H1011
9
FAMILY ASSESSMENT
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
H2000
9
COMP MULTIDISIPLN EVALUATION
$0.00
H2001
9
REHABILITATION PROGRAM 1/2 D
$0.00
H2010
9
COMPREHENSIVE MED SVC 15 MIN
$0.00
H2011
7
CRISIS INTERVEN SVC, 15 MIN
$0.00
H2012
7
BEHAV HLTH DAY TREAT, PER HR
$0.00
H2013
9
PSYCH HLTH FAC SVC, PER DIEM
$0.00
H2014
9
SKILLS TRAIN AND DEV, 15 MIN
$0.00
H2015
9
COMP COMM SUPP SVC, 15 MIN
$0.00
H2016
7
COMP COMM SUPP SVC, PER DIEM
$0.00
H2017
9
PSYSOC REHAB SVC, PER 15 MIN
$0.00
H2018
7
PSYSOC REHAB SVC, PER DIEM
$0.00
H2019
9
THER BEHAV SVC, PER 15 MIN
$0.00
H2020
7
THER BEHAV SVC, PER DIEM
$0.00
H2021
9
COM WRAP-AROUND SV, 15 MIN
$0.00
H2022
9
COM WRAP-AROUND SV, PER DIEM
$0.00
H2023
9
SUPPPORTED EMPLOY, PER 15 MIN
$0.00
H2024
7
SUPPORTED EMPLOY, PER DIEM
$0.00
H2025
9
SUPP MAINT EMPLOY, 15 MIN
$0.00
H2026
9
SUPP MAINT EMPLOY, PER DIEM
$0.00
H2027
7
PSYCHOED SVC, PER 15 MIN
$0.00
H2028
9
SEX OFFEND TX SVC, 15 MIN
$0.00
H2029
9
SEX OFFEND TX SVC, PER DIEM
$0.00
H2030
9
MH CLUBHOUSE SVC, PER 15 MIN
$0.00
H2031
9
MH CLUBHOUSE SVC, PER DIEM
$0.00
H2032
9
ACTIVITY THERAPY, PER 15 MIN
$0.00
H2033
9
MULTISYS THER/JUVENILE 15MIN
$0.00
H2034
9
A/D HALFWAY HOUSE, PER DIEM
$0.00
H2035
7
A/D TX PROGRAM, PER HOUR
$0.00
H2036
7
A/D TX PROGRAM, PER DIEM
$0.00
H2037
9
DEV DELAY PREV DP CH, 15 MIN
$0.00
H5010
9
THERAPY, INDIVIDUAL, BY SOCIAL WORK
$0.00
H5020
9
PSYCHOTHERAPY, GROUP (MAXIMUM 8 PER
$0.00
H5025
9
PSYCHOTHERAPY, GROUP (MAXIMUM 8 PER
$0.00
H5030
9
OTHER SERVICES BY SOCIAL WORKER, PS
$0.00
H5040
9
RESIDENTIAL CARE IN PUBLIC INSTITUT
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
H5050
9
RESIDENTIAL CARE IN PRIVATE INSTITU
$0.00
H5060
9
PUBLIC SPECIAL SCHOOLS OR DAY CARE
$0.00
H5090
9
SPECIAL CLASS PRIVATE
$0.00
H5100
9
SPECIAL CLASS PRIVATE PROPRIETARY
$0.00
H5110
9
SUMMER TREATMENT CAMP
$0.00
H5120
9
SPECIALIZED CARE NURSING HOME, CONV
$0.00
H5130
9
VISITING TEACHER SERVICES
$0.00
H5160
9
READING THERAPY
$0.00
H5170
9
OTHER SPECIAL EDUCATION OR VOCATION
$0.00
H5180
9
TRANSPORTATION FOR HANDICAPPED
$0.00
H5190
9
NURSING CARE, HOME
$0.00
H5200
9
NURSING CARE, OTHER
$0.00
H5220
9
REHABILITATIVE EVALUATION, 0-20 MIN
$0.00
H5230
9
REHABILITATIVE EVALUATION, 21-40 MI
$0.00
H5240
9
REHABILITATIVE EVALUATION, 41-60 MI
$0.00
H5299
9
REHABILITATIVE EVALUATION, NOT OTHE
$0.00
H5300
9
OCCUPATIONAL THERAPY, EXCLUDING INI
$0.00
HI010
O
MCO SPECIFIC CODE: HOME INFUSION PA
$0.00
HI011
O
MCO SPECIFIC CODE: HOME INFUSION PA
$0.00
HI012
O
MCO SPECIFIC CODE: HOME INFUSION PA
$0.00
HI013
O
MCO SPECIFIC CODE: HOME INFUSION PA
$0.00
HI014
O
MCO SPECIFIC CODE: HOME INFUSION PA
$0.00
HI020
O
MCO SPECIFIC CODE: HOME INFUSION PA
$0.00
HI021
O
MCO SPECIFIC: HOME INFUSION PACKAGE
$0.00
HI022
O
MCO SPECIFIC CODE: HOME INFUSION PA
$0.00
HI023
O
MCO SPECIFIC CODE: HOME INFUSION PA
$0.00
HI024
O
MCO SPECIFIC CODE: HOME INFUSION PA
$0.00
HI030
O
MCO SPECIFIC CODE: HOME INFUSION PA
$0.00
HI031
O
MCO SCPECIFIC CODE: HOME INFUSION P
$0.00
HI032
O
MCO SPECIFIC CODE: HOME INFUSION PA
$0.00
HI033
O
MCO SPECIFIC CODE: HOME INFUSION PA
$0.00
HI034
O
MCO SPECIFIC CODE: HOME INFUSION PA
$0.00
HI040
O
MCO SPECIFIC CODE: HOME INFUSION PA
$0.00
HI041
O
MCO SPECIFIC CODE: HOME INFUSION PA
$0.00
HI042
O
MCO SPECIFIC CODE: HOME INFUSION PA
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
HI043
O
MCO SPECIFIC CODE: HOME INFUSION PA
$0.00
HI044
O
MCO SPECIFIC CODE: HOME INFUSION PA
$0.00
HI050
O
MCO SPECIFIC CODE: HOME INFUSION PA
$0.00
HI060
O
MCO SPECIFIC CODE: HOME INFUSION PA
$0.00
HI070
O
MCO SPECIFIC CODE: HOME INFUSION PA
$0.00
HI080
O
MCO SPECIFIC CODE: HOME INFUSION, S
$0.00
HI081
O
MCO SPECIFIC CODE: HOME INFUSION, S
$0.00
HI082
O
MCO SPECIFIC CODE: HOME INFUSION, S
$0.00
HI090
O
MCO SPECIFIC CODE: HOME INFUSION PA
$0.00
HI091
O
MCO SPECIFIC CODE: HOME INFUSION PA
$0.00
HI092
O
MCO SPECIFIC CODE: HOME INFUSION PA
$0.00
HI093
O
MCO SPECIFIC CODE: HOME INFUSION PA
$0.00
HI094
O
MCO SPECIFIC CODE: HOME INFUSION PA
$0.00
HI100
O
MCO SPECIFIC CODE: HOME INFUSION PA
$0.00
HI110
O
MCO SPECIFIC CODE: HOME INFUSION PA
$0.00
HI120
O
MCO SPECIFIC CODE: HOME INFUSION, E
$0.00
HI130
O
MCO SPECIFIC CODE: HOME INFUSION PA
$0.00
HI140
O
MCO SPECIFIC CODE: HOME INFUSION PA
$0.00
HI160
O
MCO SPECIFIC CODE: HOME INFUSION PA
$0.00
HI170
O
MCO SPECIFIC CODE: HOME INFUSION PA
$0.00
HI171
O
MCO SPECIFIC CODE: HOME INFUSION PA
$0.00
HI172
O
MCO SPECIFIC CODE: HOME INFUSION PA
$0.00
HI180
O
MCO SPECIFIC CODE: HOME INFUSION PA
$0.00
HI190
O
MCO SPECIFIC CODE: HOME INFUSION PA
$0.00
HM1CW
O
MCO SPECIFIC CODE: SMART START INIT
$0.00
HM1RN
O
MCO SPECIFIC CODE: SMART START INIT
$0.00
HM1SW
O
MCO SPECIFIC CODE: SMART START INIT
$0.00
HM2CW
O
MCO SPECIFIC CODE: SMART START POST
$0.00
HM2RN
O
MCO SPECIFIC CODE: SMART START POST
$0.00
HM2SW
O
MCO SPECIFIC CODE: SMART START POST
$0.00
J0110
O
ADMINISTRATION OF INJECTION, INCLUD
$0.00
J0120
5
TETRACYCLIN INJECTION
$0.00
J0128
6
ABARELIX INJECTION
$0.00
J0129
3
ABATACEPT INJECTION
$19.04
J0130
3
ABCIXIMAB INJECTION
$444.32
Procedure Code Pricing Action Code Description
Maximum Allowable
J0132
5
ACETYLCYSTEINE INJECTION
$0.00
J0133
5
ACYCLOVIR INJECTION
$0.00
J0135
6
ADALIMUMAB INJECTION
$0.00
J0150
3
INJECTION ADENOSINE 6 MG
$9.62
J0151
5
ADENOSINE INJECTION
$0.00
J0152
3
ADENOSINE INJECTION
$37.63
J0170
3
ADRENALIN EPINEPHRIN INJECT
$0.67
J0180
6
AGALSIDASE BETA INJECTION
$0.00
J0190
5
INJ BIPERIDEN LACTATE/5 MG
$0.00
J0200
9
ALATROFLOXACIN MESYLATE
$0.00
J0205
5
ALGLUCERASE INJECTION
$0.00
J0207
3
AMIFOSTINE
J0210
5
METHYLDOPATE HCL INJECTION
$0.00
J0215
6
ALEFACEPT
$0.00
J0220
3
INJECTION, ALGLUCOSIDASE ALFA,
J0230
O
INJECTION, ALLERGY DESENSITIZATION,
$0.00
J0240
O
INJECTION, ALLERGY DESENSITIZATION,
$0.00
J0256
5
ALPHA 1 PROTEINASE INHIBITOR
$0.00
J0270
9
ALPROSTADIL FOR INJECTION
$0.00
J0275
9
ALPROSTADIL URETHRAL SUPPOS
$0.00
J0278
5
AMIKACIN SULFATE INJECTION
$0.00
J0280
3
AMINOPHYLLIN 250 MG INJ
$0.42
J0282
5
AMIODARONE HCL
$0.00
J0285
5
AMPHOTERICIN B
$0.00
J0286
O
AMPHOTERICIN B LIPID COMPLEX
$0.00
J0287
3
AMPHOTERICIN B LIPID COMPLEX
$10.58
J0288
5
AMPHO B CHOLESTERYL SULFATE
$0.00
J0289
3
AMPHOTERICIN B LIPOSOME INJ
J0290
3
AMPICILLIN 500 MG INJ
$1.34
J0295
3
AMPICILLIN SODIUM PER 1.5 GM
$3.12
J0300
5
AMOBARBITAL 125 MG INJ
$0.00
J0330
3
SUCCINYCHOLINE CHLORIDE INJ
$0.14
J0340
O
NANDROLON PHENPROPIONATE INJ
$0.00
J0348
3
ANIDULAFUNGIN INJECTION
$1.28
J0350
5
INJECTION ANISTREPLASE 30 U
$0.00
$188.30
$123.84
$15.59
Procedure Code Pricing Action Code Description
Maximum Allowable
J0360
5
HYDRALAZINE HCL INJECTION
$0.00
J0364
3
APOMORPHINE HYDROCHLORIDE
$3.71
J0365
5
APROTONIN, 10,000 KIU
$0.00
J0380
5
INJ METARAMINOL BITARTRATE
$0.00
J0390
5
CHLOROQUINE INJECTION
$0.00
J0395
5
ARBUTAMINE HCL INJECTION
$0.00
J0400
3
INJECTION, ARIPIPRAZOLE, INTRAMUSC
$0.29
J0456
3
AZITHROMYCIN
$9.17
J0460
3
ATROPINE SULFATE INJECTION
$0.28
J0470
5
DIMECAPROL INJECTION
$0.00
J0475
6
BACLOFEN 10 MG INJECTION
$0.00
J0476
3
BACLOFEN INTRATHECAL TRIAL
J0480
5
BASILIXIMAB
$0.00
J0500
5
DICYCLOMINE INJECTION
$0.00
J0510
O
BENZQUINAMIDE INJECTION
$0.00
J0515
5
INJ BENZTROPINE MESYLATE
$0.00
J0520
5
BETHANECHOL CHLORIDE INJECT
$0.00
J0530
5
PENICILLIN G BENZATHINE INJ
$0.00
J0540
5
PENICILLIN G BENZATHINE INJ
$0.00
J0550
5
PENICILLIN G BENZATHINE INJ
$0.00
J0560
5
PENICILLIN G BENZATHINE INJ
$0.00
J0570
3
PENICILLIN G BENZATHINE INJ
$13.60
J0580
5
PENICILLIN G BENZATHINE INJ
$0.00
J0583
6
BIVALIRUDIN
$0.00
J0585
3
BOTULINUM TOXIN A PER UNIT
$5.41
J0587
3
BOTULINUM TOXIN TYPE B
$8.87
J0590
O
ETHYLNOREPINEPHRINE HCL INJ
$0.00
J0592
5
BUPRENORPHINE HYDROCHLORIDE
$0.00
J0594
3
BUSULFAN INJECTION
$9.53
J0595
6
BUTORPHANOL TARTRATE 1 MG
$0.00
J0600
5
EDETATE CALCIUM DISODIUM INJ
$0.00
J0610
3
CALCIUM GLUCONATE INJECTION
$0.29
J0620
5
CALCIUM GLYCER & LACT/10 ML
$0.00
J0630
5
CALCITONIN SALMON INJECTION
$0.00
J0635
O
CALCITRIOL INJECTION
$0.00
$69.97
Procedure Code Pricing Action Code Description
Maximum Allowable
J0636
5
INJ CALCITRIOL PER 0.1 MCG
$0.00
J0637
5
CASPOFUNGIN ACETATE
$0.00
J0640
3
LEUCOVORIN CALCIUM INJECTION
$1.95
J0641
3
LEVOLEUCOVORIN INJECTION
$1.05
J0670
3
INJ MEPIVACAINE HCL/10 ML
$1.82
J0680
O
INJECTION, DESLANOSIDE, UP TO 0.4 M
$0.00
J0690
3
CEFAZOLIN SODIUM INJECTION
$0.59
J0692
3
CEFEPIME HCL FOR INJECTION
$5.25
J0694
3
CEFOXITIN SODIUM INJECTION
$6.45
J0695
O
CEFONOCID SODIUM INJECTION
$0.00
J0696
3
CEFTRIAXONE SODIUM INJECTION
$13.78
J0697
5
STERILE CEFUROXIME INJECTION
$0.00
J0698
5
CEFOTAXIME SODIUM INJECTION
$0.00
J0700
O
INJECTION, BETAMETHASONE, UP TO 6 M
$0.00
J0702
3
BETAMETHASONE ACET&SOD PHOSP
$6.08
J0704
5
BETAMETHASONE SOD PHOSP/4 MG
$0.00
J0706
5
CAFFEINE CITRATE INJECTION
$0.00
J0710
5
CEPHAPIRIN SODIUM INJECTION
$0.00
J0713
5
INJ CEFTAZIDIME PER 500 MG
$0.00
J0715
5
CEFTIZOXIME SODIUM / 500 MG
$0.00
J0720
5
CHLORAMPHENICOL SODIUM INJEC
$0.00
J0725
5
CHORIONIC GONADOTROPIN/1000U
$0.00
J0730
O
CHLORPHENIRAMIN MALEATE INJ
$0.00
J0735
5
CLONIDINE HYDROCHLORIDE
$0.00
J0740
3
CIDOFOVIR INJECTION
J0743
3
CILASTATIN SODIUM INJECTION
J0744
3
CIPROFLOXACIN IV
$1.66
J0745
5
INJ CODEINE PHOSPHATE /30 MG
$0.00
J0760
6
COLCHICINE INJECTION
$0.00
J0770
5
COLISTIMETHATE SODIUM INJ
$0.00
J0780
5
PROCHLORPERAZINE INJECTION
$0.00
J0790
O
INJECTION, NIKETHAMIDE, UP TO 1.5 M
$0.00
J0795
5
CORTICORELIN OVINE TRIFLUTAL
$0.00
J0800
3
CORTICOTROPIN INJECTION
J0810
O
CORTISONE INJECTION
$761.41 $13.68
$2,425.07 $0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
J0820
O
INJECTION, CORTIGEL 40, UP TO 40 UN
$0.00
J0830
O
INJECTION, CORTROPHIN ZINC HYDROXID
$0.00
J0835
3
INJ COSYNTROPIN PER 0.25 MG
J0840
O
INJECTION, WARFARIN SODIUM, UP TO 5
J0850
3
CYTOMEGALOVIRUS IMM IV /VIAL
J0878
3
DAPTOMYCIN INJECTION
$0.38
J0880
O
DARBEPOETIN ALFA INJECTION
$0.00
J0881
3
DARBEPOETIN ALFA, NON-ESRD
$3.06
J0882
5
DARBEPOETIN ALFA, ESRD USE
$0.00
J0885
3
EPOETIN ALFA, NON-ESRD
$9.20
J0886
5
EPOETIN ALFA 1000 UNITS ESRD
$0.00
J0894
3
DECITABINE INJECTION
J0895
5
DEFEROXAMINE MESYLATE INJ
$0.00
J0900
5
TESTOSTERONE ENANTHATE INJ
$0.00
J0945
5
BROMPHENIRAMINE MALEATE INJ
$0.00
J0970
5
ESTRADIOL VALERATE INJECTION
$0.00
J1000
5
DEPO-ESTRADIOL CYPIONATE INJ
$0.00
J1020
3
METHYLPREDNISOLONE 20 MG INJ
$1.88
J1030
3
METHYLPREDNISOLONE 40 MG INJ
$4.14
J1040
3
METHYLPREDNISOLONE 80 MG INJ
$10.57
J1050
5
MEDROXYPROGESTERONE INJ
$0.00
J1051
3
MEDROXYPROGESTERONE INJ
$7.28
J1055
3
MEDRXYPROGESTER ACETATE INJ
$28.91
J1056
3
MA/EC CONTRACEPTIVEINJECTION
$22.50
J1060
5
TESTOSTERONE CYPIONATE 1 ML
$0.00
J1070
5
TESTOSTERONE CYPIONAT 100 MG
$0.00
J1080
5
TESTOSTERONE CYPIONAT 200 MG
$0.00
J1090
O
TESTOSTERONE CYPIONATE 50 MG
$0.00
J1094
6
INJ DEXAMETHASONE ACETATE
$0.00
J1095
5
INJ DEXAMETHASONE ACETATE
$0.00
J1100
3
DEXAMETHASONE SODIUM PHOS
$0.09
J1110
3
INJ DIHYDROERGOTAMINE MESYLT
$22.69
J1120
5
ACETAZOLAMID SODIUM INJECTIO
$0.00
J1155
O
INJECTION, DIGITOXIN
$0.00
J1160
5
DIGOXIN INJECTION
$0.00
$98.20 $0.00 $878.83
$27.68
Procedure Code Pricing Action Code Description
Maximum Allowable
J1162
5
DIGOXIN IMMUNE FAB (OVINE)
$0.00
J1165
5
PHENYTOIN SODIUM INJECTION
$0.00
J1170
6
HYDROMORPHONE INJECTION
$0.00
J1180
5
DYPHYLLINE INJECTION
$0.00
J1190
5
DEXRAZOXANE HCL INJECTION
$0.00
J1200
3
DIPHENHYDRAMINE HCL INJECTIO
$0.73
J1205
5
CHLOROTHIAZIDE SODIUM INJ
$0.00
J1212
5
DIMETHYL SULFOXIDE 50% 50 ML
$0.00
J1230
5
METHADONE INJECTION
$0.00
J1240
5
DIMENHYDRINATE INJECTION
$0.00
J1245
3
DIPYRIDAMOLE INJECTION
$7.52
J1250
3
INJ DOBUTAMINE HCL/250 MG
$3.25
J1260
3
DOLASETRON MESYLATE
$4.63
J1265
5
DOPAMINE INJECTION
$0.00
J1267
3
DORIPENEM INJECTION
$0.65
J1270
5
INJECTION, DOXERCALCIFEROL
$0.00
J1300
3
ECULIZUMAB INJECTION
J1320
5
AMITRIPTYLINE INJECTION
J1324
3
ENFUVIRTIDE INJECTION
$26.04
J1325
3
EPOPROSTENOL INJECTION
$11.93
J1327
5
EPTIFIBATIDE INJECTION
$0.00
J1330
5
ERGONOVINE MALEATE INJECTION
$0.00
J1335
3
ERTAPENEM INJECTION
J1340
O
INJECTION, AQUEOUS OR SALINE PLACEB
$0.00
J1350
O
INJECTION, ERYTHROMYCIN-IM, UP TO 1
$0.00
J1360
O
INJECTION, ERTHROMYCIN-IV, UP TO 50
$0.00
J1362
O
ERYTHROMYCIN GLUCEP / 250 MG
$0.00
J1364
5
ERYTHRO LACTOBIONATE /500 MG
$0.00
J1380
5
ESTRADIOL VALERATE 10 MG INJ
$0.00
J1390
5
ESTRADIOL VALERATE 20 MG INJ
$0.00
J1410
3
INJ ESTROGEN CONJUGATE 25 MG
$78.49
J1430
3
ETHANOLAMINE OLEATE 100 MG
$79.46
J1435
5
INJECTION ESTRONE PER 1 MG
$0.00
J1436
5
ETIDRONATE DISODIUM INJ
$0.00
J1438
5
ETANERCEPT INJECTION
$0.00
$176.19 $0.00
$26.07
Procedure Code Pricing Action Code Description
Maximum Allowable
J1440
3
FILGRASTIM 300 MCG INJECITON
$202.11
J1441
3
FILGRASTIM 480 MCG INJECTION
$274.45
J1450
5
FLUCONAZOLE
$0.00
J1451
5
FOMEPIZOLE, 15 MG
$0.00
J1452
5
INTRAOCULAR FOMIVIRSEN NA
$0.00
J1453
3
FOSAPREPITANT INJECTION
$1.57
J1455
3
FOSCARNET SODIUM INJECTION
J1457
6
GALLIUM NITRATE INJECTION
J1458
3
GALSULFASE INJECTION
$326.65
J1459
3
INJ IVIG PRIVIGEN 500 MG
$34.15
J1460
5
GAMMA GLOBULIN 1 CC INJ
$0.00
J1470
5
GAMMA GLOBULIN 2 CC INJ
$0.00
J1480
5
GAMMA GLOBULIN 3 CC INJ
$0.00
J1490
5
GAMMA GLOBULIN 4 CC INJ
$0.00
J1500
5
GAMMA GLOBULIN 5 CC INJ
$0.00
J1510
5
GAMMA GLOBULIN 6 CC INJ
$0.00
J1520
5
GAMMA GLOBULIN 7 CC INJ
$0.00
J1530
5
GAMMA GLOBULIN 8 CC INJ
$0.00
J1540
5
GAMMA GLOBULIN 9 CC INJ
$0.00
J1550
5
GAMMA GLOBULIN 10 CC INJ
$0.00
J1560
5
GAMMA GLOBULIN > 10 CC INJ
$0.00
J1561
3
IMMUNE GLOBULIN 500 MG
J1562
3
VIVAGLOBIN, INJ
$7.02
J1563
O
IV IMMUNE GLOBULIN
$0.00
J1564
O
IMMUNE GLOBULIN 10 MG
$0.00
J1565
5
RSV-IVIG
$0.00
J1566
5
IMMUNE GLOBULIN, POWDER
$0.00
J1567
O
IMMUNE GLOBULIN, LIQUID
$0.00
J1568
3
OCTAGAM INJECTION
$36.87
J1569
3
GAMMAGARD LIQUID INJECTION
$35.38
J1570
6
GANCICLOVIR SODIUM INJECTION
J1571
3
HEPAGAM B IM INJECTION
$44.09
J1572
3
FLEBOGAMMA INJECTION
$35.60
J1573
3
HEPAGAM B INTRAVENOUS, INJ
$44.09
J1580
3
GARAMYCIN GENTAMICIN INJ
$10.61 $0.00
$35.53
$0.00
$0.69
Procedure Code Pricing Action Code Description
Maximum Allowable
J1590
5
GATIFLOXACIN INJECTION
$0.00
J1595
3
INJECTION GLATIRAMER ACETATE
J1600
5
GOLD SODIUM THIOMALEATE INJ
$0.00
J1610
5
GLUCAGON HYDROCHLORIDE/1 MG
$0.00
J1620
5
GONADORELIN HYDROCH/ 100 MCG
$0.00
J1625
O
INJECTION, GRANISETRON HYDROCHLORID
$0.00
J1626
3
GRANISETRON HCL INJECTION
$3.45
J1630
5
HALOPERIDOL INJECTION
$0.00
J1631
5
HALOPERIDOL DECANOATE INJ
$0.00
J1640
5
INJECTION, HEMIN, 1 MG
$0.00
J1642
3
INJ HEPARIN SODIUM PER 10 U
$0.02
J1644
3
INJ HEPARIN SODIUM PER 1000U
$0.11
J1645
5
DALTEPARIN SODIUM
$0.00
J1650
3
INJ ENOXAPARIN SODIUM
$6.20
J1652
5
FONDAPARINUX SODIUM
$0.00
J1655
3
TINZAPARIN SODIUM INJECTION
$2.12
J1660
O
INJECTION, HISTAMINE, UP TO 2.75 MG
$0.00
J1670
5
TETANUS IMMUNE GLOBULIN INJ
$0.00
J1675
5
HISTRELIN ACETATE
$0.00
J1690
O
PREDNISOLONE TEBUTATE INJ
$0.00
J1700
5
HYDROCORTISONE ACETATE INJ
$0.00
J1710
5
HYDROCORTISONE SODIUM PH INJ
$0.00
J1720
3
HYDROCORTISONE SODIUM SUCC I
$2.10
J1730
5
DIAZOXIDE INJECTION
$0.00
J1739
O
HYDROXYPROGESTERONE CAP 125
$0.00
J1740
3
IBANDRONATE SODIUM INJECTION
J1741
O
HYDROXYPROGESTERONE CAP 250
$0.00
J1742
5
IBUTILIDE FUMARATE INJECTION
$0.00
J1743
3
IDURSULFASE INJECTION
J1745
3
INFLIXIMAB INJECTION
J1750
6
IRON DEXTRAN
$0.00
J1751
O
IRON DEXTRAN 165 INJECTION
$0.00
J1752
O
IRON DEXTRAN 267 INJECTION
$0.00
J1755
O
IRON SUCROSE INJECTION
$0.00
J1756
3
IRON SUCROSE INJECTION
$0.37
$67.64
$138.96
$452.09 $57.08
Procedure Code Pricing Action Code Description
Maximum Allowable
J1760
O
IRON DEXTRAN 2 CC INJ
$0.00
J1770
O
IRON DEXTRAN 5 CC INJ
$0.00
J1780
O
IRON DEXTRAN 10 CC INJ
$0.00
J1785
5
INJECTION IMIGLUCERASE /UNIT
$0.00
J1790
5
DROPERIDOL INJECTION
$0.00
J1800
5
PROPRANOLOL INJECTION
$0.00
J1810
5
DROPERIDOL/FENTANYL INJ
$0.00
J1815
3
INSULIN INJECTION
$0.19
J1817
5
INSULIN FOR INSULIN PUMP USE
$0.00
J1820
O
INSULIN INJECTION
$0.00
J1825
3
INTERFERON BETA-1A
J1830
5
INTERFERON BETA-1B / .25 MG
$0.00
J1835
5
INTRACONAZOLE INJECTION
$0.00
J1840
5
KANAMYCIN SULFATE 500 MG INJ
$0.00
J1850
5
KANAMYCIN SULFATE 75 MG INJ
$0.00
J1885
3
KETOROLAC TROMETHAMINE INJ
$0.30
J1890
5
CEPHALOTHIN SODIUM INJECTION
$0.00
J1910
O
KUTAPRESSIN INJECTION
$0.00
J1930
6
INJECTION, LANREOTIDE, 1 MG
$0.00
J1931
3
LARONIDASE INJECTION
$24.96
J1940
3
FUROSEMIDE INJECTION
$0.21
J1945
5
LEPIRUDIN
$0.00
J1950
5
LEUPROLIDE ACETATE /3.75 MG
$0.00
J1953
3
LEVETIRACETAM INJECTION
$0.43
J1955
5
INJ LEVOCARNITINE PER 1 GM
$0.00
J1956
3
LEVOFLOXACIN INJECTION
$5.97
J1960
5
LEVORPHANOL TARTRATE INJ
$0.00
J1970
O
METHOTRIMEPRAZINE INJECTION
$0.00
J1980
5
HYOSCYAMINE SULFATE INJ
$0.00
J1990
5
CHLORDIAZEPOXIDE INJECTION
$0.00
J2000
O
LIDOCAINE INJECTION
$0.00
J2001
3
LIDOCAINE INJECTION
$0.02
J2010
5
LINCOMYCIN INJECTION
$0.00
J2020
5
LINEZOLID INJECTION
$0.00
J2050
O
INJECTION, LIVER, UP TO 20 MCG
$0.00
$542.32
Procedure Code Pricing Action Code Description
Maximum Allowable
J2060
3
LORAZEPAM INJECTION
$0.75
J2100
O
INJECTION, LUMINAL SODIUM, UP TO 12
$0.00
J2150
3
MANNITOL INJECTION
$0.91
J2160
O
INJECTION, CYCLIZINE LACTATE, UP TO
$0.00
J2170
3
MECASERMIN INJECTION
J2175
3
MEPERIDINE HYDROCHL /100 MG
$0.54
J2180
5
MEPERIDINE/PROMETHAZINE INJ
$0.00
J2185
6
MEROPENEM
$0.00
J2190
O
INJECTION, MERSALYL WITH THEOPHYLLI
$0.00
J2210
5
METHYLERGONOVIN MALEATE INJ
$0.00
J2220
5
INJECTION, METHYLANDROSTENEDIOL, AL
$0.00
J2240
O
METOCURINE IODIDE INJECTION
$0.00
J2248
3
MICAFUNGIN SODIUM INJECTION
$1.96
J2250
3
INJ MIDAZOLAM HYDROCHLORIDE
$0.16
J2260
5
INJECTION, MILRINONE LACTATE 5MG
$0.00
J2270
3
MORPHINE SULFATE INJECTION
$0.26
J2271
5
MORPHINE SO4 INJECTION 100MG
$0.00
J2275
5
MORPHINE SULFATE INJECTION
$0.00
J2278
5
ZICONOTIDE INJECTION
$0.00
J2280
6
INJ, MOXIFLOXACIN 100 MG
$0.00
J2300
3
INJ NALBUPHINE HYDROCHLORIDE
$1.55
J2310
3
INJ NALOXONE HYDROCHLORIDE
$3.72
J2315
3
NALTREXONE, DEPOT FORM
$1.88
J2320
5
NANDROLONE DECANOATE 50 MG
$0.00
J2321
5
NANDROLONE DECANOATE 100 MG
$0.00
J2322
5
NANDROLONE DECANOATE 200 MG
$0.00
J2323
3
NATALIZUMAB INJECTION
$7.91
J2324
O
NESIRITIDE
$0.00
J2325
5
NESIRITIDE INJECTION
$0.00
J2330
O
THIOTHIXENE INJECTION
$0.00
J2350
O
NIACINAMIDE/NIACIN INJECTION
$0.00
J2352
O
OCTREOTIDE ACETATE INJECTION
$0.00
J2353
6
OCTREOTIDE INJECTION, DEPOT
$0.00
J2354
6
OCTREOTIDE INJ, NON-DEPOT
$0.00
J2355
5
OPRELVEKIN INJECTION
$0.00
$17.65
Procedure Code Pricing Action Code Description
Maximum Allowable
J2357
3
OMALIZUMAB INJECTION
$18.23
J2360
5
ORPHENADRINE INJECTION
$0.00
J2370
5
PHENYLEPHRINE HCL INJECTION
$0.00
J2400
5
CHLOROPROCAINE HCL INJECTION
$0.00
J2405
3
ONDANSETRON HCL INJECTION
$0.21
J2410
5
OXYMORPHONE HCL INJECTION
$0.00
J2425
5
PALIFERMIN INJECTION
$0.00
J2430
5
PAMIDRONATE DISODIUM /30 MG
$0.00
J2440
5
PAPAVERIN HCL INJECTION
$0.00
J2460
5
OXYTETRACYCLINE INJECTION
$0.00
J2469
3
PALONOSETRON HCL
J2480
O
HYDROCHLORIDES OF OPIUM INJ
$0.00
J2490
O
INJECTION, PARALDEHYDE, UP TO 5 ML
$0.00
J2495
O
INJECTION, TRIDIHEXETHYL CHLORIDE P
$0.00
J2500
O
PARICALCITOL
$0.00
J2501
5
PARICALCITOL
$0.00
J2503
5
PEGAPTANIB SODIUM INJECTION
$0.00
J2504
5
PEGADEMASE BOVINE, 25 IU
$0.00
J2505
3
INJECTION, PEGFILGRASTIM 6MG
J2510
5
PENICILLIN G PROCAINE INJ
$0.00
J2512
O
INJ PENTAGASTRIN PER 2 ML
$0.00
J2513
5
PENTASTARCH 10% SOLUTION
$0.00
J2515
3
PENTOBARBITAL SODIUM INJ
$9.17
J2520
5
INJECTION, THIOPENTAL SODIUM
$0.00
J2540
3
PENICILLIN G POTASSIUM INJ
$0.79
J2543
5
PIPERACILLIN/TAZOBACTAM
$0.00
J2545
9
PENTAMIDINE NON-COMP UNIT
$0.00
J2550
3
PROMETHAZINE HCL INJECTION
$1.36
J2560
5
PHENOBARBITAL SODIUM INJ
$0.00
J2590
5
OXYTOCIN INJECTION
$0.00
J2595
O
INJECTION, VASOPRESSIN TANNATE
$0.00
J2597
5
INJ DESMOPRESSIN ACETATE
$0.00
J2600
O
INJECTION, POSTERIOR PITUITARY, UP
$0.00
J2640
O
PREDNISOLONE SODIUM PH INJ
$0.00
J2650
5
PREDNISOLONE ACETATE INJ
$0.00
$16.64
$2,176.15
Procedure Code Pricing Action Code Description
Maximum Allowable
J2670
5
TOTAZOLINE HCL INJECTION
$0.00
J2672
O
INJECTION, PROPANTHELINE BROMIDE
$0.00
J2675
O
INJ PROGESTERONE PER 50 MG
$0.00
J2680
5
FLUPHENAZINE DECANOATE 25 MG
$0.00
J2690
5
PROCAINAMIDE HCL INJECTION
$0.00
J2700
3
OXACILLIN SODIUM INJECITON
$1.82
J2710
5
NEOSTIGMINE METHYLSLFTE INJ
$0.00
J2720
5
INJ PROTAMINE SULFATE/10 MG
$0.00
J2724
6
PROTEIN C CONCENTRATE
$0.00
J2725
5
INJ PROTIRELIN PER 250 MCG
$0.00
J2730
5
PRALIDOXIME CHLORIDE INJ
$0.00
J2760
9
PHENTOLAINE MESYLATE INJ
$0.00
J2765
3
METOCLOPRAMIDE HCL INJECTION
$1.30
J2770
5
QUINUPRISTIN/DALFOPRISTIN
$0.00
J2778
3
RANIBIZUMAB INJECTION
J2780
3
RANITIDINE HYDROCHLORIDE INJ
$0.99
J2783
6
RASBURICASE
$0.00
J2785
3
REGADENOSON INJECTION
$47.40
J2788
3
RHO D IMMUNE GLOBULIN 50 MCG
$23.50
J2790
3
RHO D IMMUNE GLOBULIN INJ
$86.26
J2791
6
RHOPHYLAC INJECTION
J2792
3
RHO(D) IMMUNE GLOBULIN H, SD
J2794
6
RISPERIDONE, LONG ACTING
$0.00
J2795
5
ROPIVACAINE HCL INJECTION
$0.00
J2800
5
METHOCARBAMOL INJECTION
$0.00
J2805
5
SINCALIDE INJECTION
$0.00
J2810
5
INJ THEOPHYLLINE PER 40 MG
$0.00
J2820
3
SARGRAMOSTIM INJECTION
J2825
O
INJECTION, SARRACENIA PURPUREA PLAN
$0.00
J2850
5
INJ SECRETIN SYNTHETIC HUMAN
$0.00
J2860
O
SECOBARBITAL SODIUM INJ
$0.00
J2910
5
AUROTHIOGLUCOSE INJECITON
$0.00
J2914
O
INJECTION, SODIUM SALICYLATE
$0.00
J2915
O
NA FERRIC GLUCONATE COMPLEX
$0.00
J2916
5
NA FERRIC GLUCONATE COMPLEX
$0.00
$406.60
$0.00 $16.39
$24.07
Procedure Code Pricing Action Code Description
Maximum Allowable
J2920
3
METHYLPREDNISOLONE INJECTION
$1.70
J2930
3
METHYLPREDNISOLONE INJECTION
$2.95
J2940
5
SOMATREM INJECTION
$0.00
J2941
5
SOMATROPIN INJECTION
$0.00
J2950
5
PROMAZINE HCL INJECITON
$0.00
J2970
O
METHICILLIN SODIUM INJECTION
$0.00
J2993
5
RETEPLASE INJECTION
$0.00
J2994
9
RETEPLASE DOUBLE BOLUS
$0.00
J2995
5
INJ STREPTOKINASE /250000 IU
$0.00
J2996
O
ALTEPLASE RECOMBINANT INJ
$0.00
J2997
3
ALTEPLASE RECOMBINANT
$34.10
J3000
3
STREPTOMYCIN INJECTION
$4.61
J3005
O
INJECTION, STRONTIUM-89 CHLORIDE, P
$0.00
J3010
3
FENTANYL CITRATE INJECITON
$0.18
J3030
5
SUMATRIPTAN SUCCINATE / 6 MG
$0.00
J3050
O
INJECTION, DECAMETHONIUM BROMIDE, U
$0.00
J3070
5
PENTAZOCINE INJECTION
$0.00
J3080
O
CHLORPROTHIXENE INJECTION
$0.00
J3100
O
TENECTEPLASE INJECTION
$0.00
J3101
9
TENECTEPLASE INJECTION
$0.00
J3105
5
TERBUTALINE SULFATE INJ
$0.00
J3110
6
TERIPARATIDE INJECTION
$0.00
J3120
5
TESTOSTERONE ENANTHATE INJ
$0.00
J3130
5
TESTOSTERONE ENANTHATE INJ
$0.00
J3140
5
TESTOSTERONE SUSPENSION INJ
$0.00
J3150
5
TESTOSTERON PROPIONATE INJ
$0.00
J3180
O
INJECTION, TETANUS TOXOID, UP TO 1
$0.00
J3230
5
CHLORPROMAZINE HCL INJECTION
$0.00
J3240
5
THYROTROPIN INJECTION
$0.00
J3243
6
TIGECYCLINE INJECTION
$0.00
J3245
O
TIROFIBAN HYDROCHLORIDE
$0.00
J3246
6
TIROFIBAN HCL
$0.00
J3250
5
TRIMETHOBENZAMIDE HCL INJ
$0.00
J3260
5
TOBRAMYCIN SULFATE INJECTION
$0.00
J3265
5
INJECTION TORSEMIDE 10 MG/ML
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
J3270
O
IMIPRAMINE HCL INJECTION
$0.00
J3280
5
THIETHYLPERAZINE MALEATE INJ
$0.00
J3285
5
TREPROSTINIL INJECTION
$0.00
J3300
6
INJECTION, TRIAMCINOLONE ACETONIDE,
$0.00
J3301
3
TRIAMCINOLONE ACET INJ NOS
$1.40
J3302
5
TRIAMCINOLONE DIACETATE INJ
$0.00
J3303
3
TRIAMCINOLONE HEXACETONL INJ
$1.33
J3305
5
INJ TRIMETREXATE GLUCORONATE
$0.00
J3310
5
PERPHENAZINE INJECITON
$0.00
J3315
5
TRIPTORELIN PAMOATE
$0.00
J3320
5
SPECTINOMYCN DI-HCL INJ
$0.00
J3340
O
INJECTION, CRYPTENAMINE ACETATE, UP
$0.00
J3350
5
UREA INJECTION
$0.00
J3355
9
UROFOLLITROPIN, 75 IU
$0.00
J3360
5
DIAZEPAM INJECTION
$0.00
J3364
5
UROKINASE 5000 IU INJECTION
$0.00
J3365
5
UROKINASE 250,000 IU INJ
$0.00
J3370
3
VANCOMYCIN HCL INJECITON
$3.08
J3380
O
INJECTION, ISOXSUPRINE HCL, UP TO 1
$0.00
J3390
O
METHOXAMINE INJECTION
$0.00
J3395
O
VERTEPORFIN INJECTION
$0.00
J3396
6
VERTEPORFIN INJECTION
$0.00
J3400
5
TRIFLUPROMAZINE HCL INJ
$0.00
J3410
3
HYDROXYZINE HCL INJECITON
$0.25
J3411
3
THIAMINE HCL 100 MG
$2.63
J3415
6
PYRIDOXINE HCL 100 MG
$0.00
J3420
3
VITAMIN B12 INJECTION
$0.13
J3430
5
VITAMIN K PHYTONADIONE INJ
$0.00
J3450
O
MEPHENTERMINE SULFATE INJ
$0.00
J3465
6
INJECTION, VORICONAZOLE
$0.00
J3470
5
HYALURONIDASE INJECTION
$0.00
J3471
5
OVINE, UP TO 999 USP UNITS
$0.00
J3472
5
OVINE, 1000 USP UNITS
$0.00
J3473
3
HYALURONIDASE RECOMBINANT
$0.48
J3475
3
INJ MAGNESIUM SULFATE
$0.05
Procedure Code Pricing Action Code Description
Maximum Allowable
J3480
3
INJ POTASSIUM CHLORIDE
$0.02
J3485
5
ZIDOVUDINE
$0.00
J3486
3
ZIPRASIDONE MESYLATE
$5.38
J3487
3
ZOLEDRONIC ACID
$5.36
J3488
3
RECLAST INJECTION
J3490
5
DRUGS UNCLASSIFIED INJECTION
$0.00
J3500
O
VITAMIN THERAPY
$0.00
J3520
5
EDETATE DISODIUM PER 150 MG
$0.00
J3530
9
NASAL VACCINE INHALATION
$0.00
J3535
9
METERED DOSE INHALER DRUG
$0.00
J3540
O
AUTOGENOUS BLOOD EXTRACT, INTRAVENO
$0.00
J3550
O
INTRA-ARTERIAL OXYGEN INJECTION
$0.00
J3560
O
ADRENAL CORTEX EXTRACT
$0.00
J3570
9
LAETRILE AMYGDALIN VIT B17
$0.00
J3590
5
UNCLASSIFIED BIOLOGICS
$0.00
J6015
O
TYPHUS
$0.00
J7010
O
VIAL OF ALLERGY VACCINE, SINGLE DOS
$0.00
J7020
O
VIAL OF ALLERGY VACCINE, MULTIPLE D
$0.00
J7030
3
NORMAL SALINE SOLUTION INFUS
$218.51
J7040
3
NORMAL SALINE SOLUTION INFUS
$1.08
J7042
3
5% DEXTROSE/NORMAL SALINE
$0.54
J7050
3
NORMAL SALINE SOLUTION INFUS
$0.27
J7051
O
STERILE SALINE/WATER
$0.00
J7060
3
5% DEXTROSE/WATER
$1.09
J7070
5
D5W INFUSION
$0.00
J7080
O
INFUSION, ALBUMISOL 5%, 500 ML VIAL
$0.00
J7090
O
INFUSION, ALBUMISOL 25%, 50 ML VIAL
$0.00
J7100
5
DEXTRAN 40 INFUSION
$0.00
J7110
5
DEXTRAN 75 INFUSION
$0.00
J7120
5
RINGERS LACTATE INFUSION
$0.00
J7130
5
HYPERTONIC SALINE SOLUTION
$0.00
J7140
9
PRESCRIPTION DRUG, ORAL, DISPENSED
$0.00
J7150
9
PRESCRIPTION DRUG, ORAL CHEMOTHERAP
$0.00
J7186
6
ANTIHEMOPHILIC VIII/VWF COMP
$0.00
J7187
3
HUMATE-P, INJ
$0.86
$215.21
Procedure Code Pricing Action Code Description
Maximum Allowable
J7188
O
INJ VONWILLEBRAND FACTOR IU
$0.00
J7189
5
FACTOR VIIA
$0.00
J7190
5
FACTOR VIII
$0.00
J7191
5
FACTOR VIII (PORCINE)
$0.00
J7192
5
FACTOR VIII RECOMBINANT
$0.00
J7193
5
FACTOR IX NON-RECOMBINANT
$0.00
J7194
5
FACTOR IX COMPLEX
$0.00
J7195
5
FACTOR IX RECOMBINANT
$0.00
J7196
O
OTHR HEMOPHILIA CLOT FACTORS
$0.00
J7198
5
ANTI-INHIBITOR
$0.00
J7199
5
HEMOPHILIA CLOT FACTOR NOC
$0.00
J7300
9
INTRAUT COPPER CONTRACEPTIVE
$0.00
J7302
3
LEVONORGESTREL IU CONTRACEPT
J7303
6
CONTRACEPTIVE VAGINAL RING
$0.00
J7304
9
CONTRACEPTIVE HORMONE PATCH
$0.00
J7306
9
LEVONORGESTREL IMPLANT SYS
$0.00
J7307
3
ETONOGESTREL IMPLANT SYSTEM
J7308
9
AMINOLEVULINIC ACID HCL TOP
$0.00
J7310
9
GANCICLOVIR LONG ACT IMPLANT
$0.00
J7311
9
FLUOCINOLONE ACETONIDE IMPLT
$0.00
J7315
O
SODIUM HYALURONATE INJECTION
$0.00
J7316
O
SODIUM HYALURONATE INJECTION
$0.00
J7317
O
SODIUM HYALURONATE INJECTION
$0.00
J7319
O
SODIUM HYALURONATE INJECTION
$0.00
J7321
3
HYALGAN/SUPARTZ INJ PER DOSE
$97.39
J7322
3
SYNVISC INJ PER DOSE
$182.84
J7323
3
EUFLEXXA INJ PER DOSE
$111.01
J7324
3
ORTHOVISC INJ PER DOSE
$178.09
J7330
9
CULTURED CHONDROCYTES IMPLNT
$0.00
J7340
O
METABOLIC ACTIVE D/E TISSUE
$0.00
J7341
O
NON-HUMAN, METABOLIC TISSUE
$0.00
J7342
O
METABOLICALLY ACTIVE TISSUE
$0.00
J7343
O
NONMETABOLIC ACT D/E TISSUE
$0.00
J7344
O
NONMETABOLIC ACTIVE TISSUE
$0.00
J7345
O
NON-HUMAN, NON-METAB TISSUE
$0.00
$468.71
$483.70
Procedure Code Pricing Action Code Description
Maximum Allowable
J7346
O
INJECTABLE HUMAN TISSUE
$0.00
J7347
O
INTEGRA MATRIX TISSUE
$0.00
J7348
O
TISSUEMEND TISSUE
$0.00
J7349
O
PRIMATRIX TISSUE
$0.00
J7350
O
INJECTABLE HUMAN TISSUE
$0.00
J7500
9
AZATHIOPRINE ORAL 50MG
$0.00
J7501
5
AZATHIOPRINE PARENTERAL
$0.00
J7502
9
CYCLOSPORINE ORAL 100 MG
$0.00
J7503
O
CYCLOSPORINE PARENTERAL
$0.00
J7504
5
LYMPHOCYTE IMMUNE GLOBULIN
$0.00
J7505
5
MONOCLONAL ANTIBODIES
$0.00
J7506
9
PREDNISONE ORAL
$0.00
J7507
9
TACROLIMUS ORAL PER 1 MG
$0.00
J7508
O
TACROLIMUS ORAL PER 5 MG
$0.00
J7509
9
METHYLPREDNISOLONE ORAL
$0.00
J7510
9
PREDNISOLONE ORAL PER 5 MG
$0.00
J7511
5
ANTITHYMOCYTE GLOBULN RABBIT
$0.00
J7513
5
DACLIZUMAB, PARENTERAL
$0.00
J7515
9
CYCLOSPORINE ORAL 25 MG
$0.00
J7516
5
CYCLOSPORIN PARENTERAL 250MG
$0.00
J7517
9
MYCOPHENOLATE MOFETIL ORAL
$0.00
J7518
9
MYCOPHENOLIC ACID
$0.00
J7520
9
SIROLIMUS, ORAL
$0.00
J7525
5
TACROLIMUS INJECTION
$0.00
J7599
5
IMMUNOSUPPRESSIVE DRUG NOC
$0.00
J7602
O
ALBUTEROL INH NON-COMP CON
$0.00
J7603
O
ALBUTEROL INH NON-COMP U D
$0.00
J7604
9
ACETYLCYSTEINE COMP UNIT
$0.00
J7605
9
ARFORMOTEROL NON-COMP UNIT
$0.00
J7606
9
FORMOTEROL FUMARATE, INH
$0.00
J7607
9
LEVALBUTEROL COMP CON
$0.00
J7608
9
ACETYLCYSTEINE NON-COMP UNIT
$0.00
J7609
9
ALBUTEROL COMP UNIT
$0.00
J7610
9
ALBUTEROL COMP CON
$0.00
J7611
9
ALBUTEROL NON-COMP CON
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
J7612
9
LEVALBUTEROL NON-COMP CON
$0.00
J7613
9
ALBUTEROL NON-COMP UNIT
$0.00
J7614
9
LEVALBUTEROL NON-COMP UNIT
$0.00
J7615
9
LEVALBUTEROL COMP UNIT
$0.00
J7616
O
ALBUTEROL COMPOUND SOLUTION
$0.00
J7617
O
LEVALBUTEROL COMPOUNDED SOL
$0.00
J7618
O
ALBUTEROL INH SOL CON
$0.00
J7619
O
ALBUTEROL INH SOL U D
$0.00
J7620
9
ALBUTEROL IPRATROP NON-COMP
$0.00
J7621
O
(LEVO)ALBUTEROL/IPRA-BROMIDE
$0.00
J7622
9
BECLOMETHASONE COMP UNIT
$0.00
J7624
9
BETAMETHASONE COMP UNIT
$0.00
J7625
O
ALBUTEROL SULFATE .5% INJ
$0.00
J7626
9
BUDESONIDE NON-COMP UNIT
$0.00
J7627
9
BUDESONIDE COMP UNIT
$0.00
J7628
9
BITOLTEROL MESYLATE COMP CON
$0.00
J7629
9
BITOLTEROL MESYLATE COMP UNT
$0.00
J7630
O
CROMOLYN SODIUM INJECITON
$0.00
J7631
9
CROMOLYN SODIUM NONCOMP UNIT
$0.00
J7632
9
CROMOLYN SODIUM COMP UNIT
$0.00
J7633
9
BUDESONIDE NON-COMP CON
$0.00
J7634
9
BUDESONIDE COMP CON
$0.00
J7635
9
ATROPINE COMP CON
$0.00
J7636
9
ATROPINE COMP UNIT
$0.00
J7637
9
DEXAMETHASONE COMP CON
$0.00
J7638
9
DEXAMETHASONE COMP UNIT
$0.00
J7639
9
DORNASE ALFA NON-COMP UNIT
$0.00
J7640
9
FORMOTEROL COMP UNIT
$0.00
J7641
9
FLUNISOLIDE COMP UNIT
$0.00
J7642
9
GLYCOPYRROLATE COMP CON
$0.00
J7643
9
GLYCOPYRROLATE COMP UNIT
$0.00
J7644
9
IPRATROPIUM BROMIDE NON-COMP
$0.00
J7645
9
IPRATROPIUM BROMIDE
$0.00
J7647
9
ISOETHARINE COMP CON
$0.00
J7648
9
ISOETHARINE NON-COMP CON
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
J7649
9
ISOETHARINE NON-COMP UNIT
$0.00
J7650
9
ISOETHARINE COMP UNIT
$0.00
J7651
O
ISOETHARINE HCL .125% INJ
$0.00
J7652
O
ISOETHARINE HCL .167% INJ
$0.00
J7653
O
ISOETHARINE HCL .2%/ INJ
$0.00
J7654
O
ISOETHARINE HCL .25% INJ
$0.00
J7655
O
ISOETHARINE HCL 1% INJ
$0.00
J7657
9
ISOPROTERENOL COMP CON
$0.00
J7658
9
ISOPROTERENOL NON-COMP CON
$0.00
J7659
9
ISOPROTERENOL NON-COMP UNIT
$0.00
J7660
9
ISOPROTERENOL COMP UNIT
$0.00
J7665
O
ISOPROTERENOL HCL 1% INJ
$0.00
J7667
9
METAPROTERENOL COMP CON
$0.00
J7668
9
METAPROTERENOL NON-COMP CON
$0.00
J7669
9
METAPROTERENOL NON-COMP UNIT
$0.00
J7670
9
METAPROTERENOL COMP UNIT
$0.00
J7672
O
METAPROTERENOL SULFATE .6%
$0.00
J7674
9
METHACHOLINE CHLORIDE, NEB
$0.00
J7675
O
METAPROTERENOL SULFATE 5%
$0.00
J7676
9
PENTAMIDINE COMP UNIT DOSE
$0.00
J7680
9
TERBUTALINE SULF COMP CON
$0.00
J7681
9
TERBUTALINE SULF COMP UNIT
$0.00
J7682
9
TOBRAMYCIN NON-COMP UNIT
$0.00
J7683
9
TRIAMCINOLONE COMP CON
$0.00
J7684
9
TRIAMCINOLONE COMP UNIT
$0.00
J7685
9
TOBRAMYCIN COMP UNIT
$0.00
J7699
O
INHALATION SOLUTION FOR DME
$0.00
J7799
O
NON-INHALATION DRUG FOR DME
$0.00
J8498
9
ANTIEMETIC RECTAL/SUPP NOS
$0.00
J8499
9
ORAL PRESCRIP DRUG NON CHEMO
$0.00
J8501
9
ORAL APREPITANT
$0.00
J8510
9
ORAL BUSULFAN
$0.00
J8515
9
CABERGOLINE, ORAL 0.25MG
$0.00
J8520
9
CAPECITABINE, ORAL, 150 MG
$0.00
J8521
9
CAPECITABINE, ORAL, 500 MG
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
J8530
9
CYCLOPHOSPHAMIDE ORAL 25 MG
$0.00
J8540
9
ORAL DEXAMETHASONE
$0.00
J8560
9
ETOPOSIDE ORAL 50 MG
$0.00
J8565
9
GEFITINIB ORAL
$0.00
J8597
9
ANTIEMETIC DRUG ORAL NOS
$0.00
J8600
9
MELPHALAN ORAL 2 MG
$0.00
J8610
9
METHOTREXATE ORAL 2.5 MG
$0.00
J8650
9
NABILONE ORAL
$0.00
J8700
9
TEMOZOLMIDE
$0.00
J8705
9
TOPOTECAN ORAL
$0.00
J8999
9
ORAL PRESCRIPTION DRUG CHEMO
$0.00
J9000
3
DOXORUBICIN HCL INJECTION
$3.79
J9001
3
DOXORUBICIN HCL LIPOSOME INJ
J9010
O
ALEMTUZUMAB INJECTION
$0.00
J9015
5
ALDESLEUKIN INJECTION
$0.00
J9017
5
ARSENIC TRIOXIDE INJECTION
$0.00
J9020
3
ASPARAGINASE INJECTION
J9025
3
AZACITIDINE INJECTION
$4.64
J9027
5
CLOFARABINE INJECTION
$0.00
J9031
3
BCG LIVE INTRAVESICAL VAC
J9033
3
BENDAMUSTINE INJECTION
$18.58
J9035
3
BEVACIZUMAB INJECTION
$57.39
J9040
3
BLEOMYCIN SULFATE INJECTION
$24.24
J9041
3
BORTEZOMIB INJECTION
$36.11
J9045
3
CARBOPLATIN INJECTION
$5.75
J9050
5
CARMUSTINE INJECTION
$0.00
J9055
3
CETUXIMAB INJECTION
J9060
3
CISPLATIN 10 MG INJECITON
$2.23
J9062
3
CISPLATIN 50 MG INJECITON
$11.14
J9065
5
INJ CLADRIBINE PER 1 MG
$0.00
J9070
5
CYCLOPHOSPHAMIDE 100 MG INJ
$0.00
J9080
5
CYCLOPHOSPHAMIDE 200 MG INJ
$0.00
J9090
3
CYCLOPHOSPHAMIDE 500 MG INJ
$14.50
J9091
3
CYCLOPHOSPHAMIDE 1.0 GRM INJ
$29.00
J9092
5
CYCLOPHOSPHAMIDE 2.0 GRM INJ
$0.00
$441.25
$57.68
$125.35
$49.54
Procedure Code Pricing Action Code Description
Maximum Allowable
J9093
3
CYCLOPHOSPHAMIDE LYOPHILIZED
$5.16
J9094
5
CYCLOPHOSPHAMIDE LYOPHILIZED
$0.00
J9095
5
CYCLOPHOSPHAMIDE LYOPHILIZED
$0.00
J9096
5
CYCLOPHOSPHAMIDE LYOPHILIZED
$0.00
J9097
5
CYCLOPHOSPHAMIDE LYOPHILIZED
$0.00
J9098
6
CYTARABINE LIPOSOME INJ
$0.00
J9100
3
CYTARABINE HCL 100 MG INJ
$0.88
J9110
3
CYTARABINE HCL 500 MG INJ
$6.83
J9120
5
DACTINOMYCIN INJECTION
$0.00
J9130
3
DACARBAZINE 100 MG INJ
$4.39
J9140
3
DACARBAZINE 200 MG INJ
$8.54
J9150
3
DAUNORUBICIN INJECTION
$16.26
J9151
5
DAUNORUBICIN CITRATE INJ
$0.00
J9160
5
DENILEUKIN DIFTITOX INJ
$0.00
J9165
5
DIETHYLSTILBESTROL INJECTION
$0.00
J9170
3
DOCETAXEL INJECTION
J9175
5
ELLIOTTS B SOLUTION PER ML
$0.00
J9178
6
INJ, EPIRUBICIN HCL, 2 MG
$0.00
J9180
O
EPIRUBICIN HCL INJECTION
$0.00
J9181
3
ETOPOSIDE INJECTION
$0.48
J9182
O
ETOPOSIDE 100 MG INJ
$0.00
J9185
5
FLUDARABINE PHOSPHATE INJ
$0.00
J9190
3
FLUOROURACIL INJECTION
$1.55
J9200
5
FLOXURIDINE INJECTION
$0.00
J9201
3
GEMCITABINE HCL INJECTION
$138.19
J9202
3
GOSERELIN ACETATE IMPLANT
$182.99
J9206
3
IRINOTECAN INJECTION
$21.72
J9207
3
IXABEPILONE INJECTION
$63.46
J9208
5
IFOSFOMIDE INJECTION
$0.00
J9209
5
MESNA INJECTION
$0.00
J9211
5
IDARUBICIN HCL INJECTION
$0.00
J9212
5
INTERFERON ALFACON-1 INJ
$0.00
J9213
5
INTERFERON ALFA-2A INJ
$0.00
J9214
3
INTERFERON ALFA-2B INJ
$14.71
J9215
5
INTERFERON ALFA-N3 INJ
$0.00
$336.94
Procedure Code Pricing Action Code Description
Maximum Allowable
J9216
5
INTERFERON GAMMA 1-B INJ
$0.00
J9217
3
LEUPROLIDE ACETATE SUSPNSION
J9218
5
LEUPROLIDE ACETATE INJECITON
$0.00
J9219
5
LEUPROLIDE ACETATE IMPLANT
$0.00
J9225
5
VANTAS IMPLANT
$0.00
J9226
6
SUPPRELIN LA IMPLANT
$0.00
J9230
5
MECHLORETHAMINE HCL INJ
$0.00
J9240
O
MEDROXYPROGESTERONE ACETATE, 100 MG
$0.00
J9245
5
INJ MELPHALAN HYDROCHL 50 MG
$0.00
J9250
5
METHOTREXATE SODIUM INJ
$0.00
J9260
3
METHOTREXATE SODIUM INJ
$1.69
J9261
3
NELARABINE INJECTION
J9263
3
OXALIPLATIN
$9.57
J9264
3
PACLITAXEL PROTEIN BOUND
$9.07
J9265
3
PACLITAXEL INJECTION
$5.28
J9266
5
PEGASPARGASE INJECTION
$0.00
J9268
5
PENTOSTATIN INJECTION
$0.00
J9270
5
PLICAMYCIN (MITHRAMYCIN) INJ
$0.00
J9280
3
MITOMYCIN 5 MG INJ
$15.64
J9290
5
MITOMYCIN 20 MG INJ
$0.00
J9291
5
MITOMYCIN 40 MG INJ
$0.00
J9293
5
MITOXANTRONE HYDROCHL / 5 MG
$0.00
J9295
O
POLYESTRADIOL PHOSPHATE 40 MG
$0.00
J9300
5
GEMTUZUMAB OZOGAMICIN INJ
$0.00
J9303
3
PANITUMUMAB INJECTION
$83.56
J9305
6
PEMETREXED INJECTION
$0.00
J9310
3
RITUXIMAB INJECTION
J9320
5
STREPTOZOCIN INJECTION
$0.00
J9330
3
TEMSIROLIMUS INJECTION
$48.53
J9340
5
THIOTEPA INJECTION
J9350
3
TOPOTECAN INJECTION
J9355
3
TRASTUZUMAB INJECTION
J9357
5
VALRUBICIN INJECTION
$0.00
J9360
3
VINBLASTINE SULFATE INJ
$0.79
J9370
3
VINCRISTINE SULFATE 1 MG INJ
$5.68
$515.00
$96.96
$535.32
$0.00 $939.34 $61.64
Procedure Code Pricing Action Code Description
Maximum Allowable
J9375
3
VINCRISTINE SULFATE 2 MG INJ
$11.36
J9380
5
VINCRISTINE SULFATE 5 MG INJ
$0.00
J9390
3
VINORELBINE TARTRATE INJ
$19.64
J9395
3
INJECTION, FULVESTRANT
$81.38
J9600
5
PORFIMER SODIUM INJECTION
$0.00
J9999
5
CHEMOTHERAPY DRUG
$0.00
K0001
3
STANDARD WHEELCHAIR
K0002
5
STND HEMI (LOW SEAT) WHLCHR
$0.00
K0003
3
LIGHTWEIGHT WHEELCHAIR
$0.00
K0004
3
HIGH STRENGTH LTWT WHLCHR
$1.00
K0005
3
ULTRALIGHTWEIGHT WHEELCHAIR
K0006
5
HEAVY DUTY WHEELCHAIR
$0.00
K0007
5
EXTRA HEAVY DUTY WHEELCHAIR
$0.00
K0008
9
CSTM MANUAL WHEELCHAIR/BASE
$0.00
K0009
5
OTHER MANUAL WHEELCHAIR/BASE
$0.00
K0010
5
STND WT FRAME POWER WHLCHR
$0.00
K0011
5
STND WT PWR WHLCHR W CONTROL
$0.00
K0012
5
LTWT PORTBL POWER WHLCHR
$0.00
K0013
9
CUSTOM POWER WHLCHR BASE
$0.00
K0014
5
OTHER POWER WHLCHR BASE
$0.00
K0015
3
DETACH NON-ADJUS HGHT ARMRST
$180.80
K0016
O
DETACH ADJUST ARMRST CMPLETE
$0.00
K0017
3
DETACH ADJUST ARMREST BASE
$50.85
K0018
3
DETACH ADJUST ARMRST UPPER
$28.41
K0019
3
ARM PAD EACH
$14.58
K0020
3
FIXED ADJUST ARMREST PAIR
$46.23
K0021
O
ANTI-TIPPING DEVICE EACH
$0.00
K0022
O
REINFORCED BACK UPHOLSTERY
$0.00
K0023
O
PLANR BACK INSRT FOAM W/STRP
$0.00
K0024
O
PLNR BACK INSRT FOAM W/HRDWR
$0.00
K0025
O
HOOK-ON HEADREST EXTENSION
$0.00
K0026
O
BACK UPHOLST LGTWT WHLCHR
$0.00
K0027
O
BACK UPHOLST OTHER WHLCHR
$0.00
K0028
O
MANUAL FULLY RECLINING BACK
$0.00
K0029
O
REINFORCED SEAT UPHOLSTERY
$0.00
$532.70
$1,839.61
Procedure Code Pricing Action Code Description
Maximum Allowable
K0030
O
SOLID PLNR SEAT SNGL DNSFOAM
$0.00
K0031
O
SAFETY BELT/PELVIC STRAP
$0.00
K0032
O
SEAT UPHOLS LGTWT WHLCHR
$0.00
K0033
O
SEAT UPHOLSTERY OTHER WHLCHR
$0.00
K0034
O
HEEL LOOP EACH
$0.00
K0035
O
HEEL LOOP WITH ANKLE STRAP
$0.00
K0036
O
TOE LOOP EACH
$0.00
K0037
3
HIGH MOUNT FLIP-UP FOOTREST
$47.93
K0038
3
LEG STRAP EACH
$24.14
K0039
3
LEG STRAP H STYLE EACH
$53.61
K0040
3
ADJUSTABLE ANGLE FOOTPLATE
$74.30
K0041
3
LARGE SIZE FOOTPLATE EACH
$52.65
K0042
3
STANDARD SIZE FOOTPLATE EACH
$36.25
K0043
3
FTRST LOWER EXTENSION TUBE
$19.44
K0044
3
FTRST UPPER HANGER BRACKET
$16.56
K0045
3
FOOTREST COMPLETE ASSEMBLY
$56.34
K0046
3
ELEVAT LEGRST LOW EXTENSION
$19.44
K0047
3
ELEVAT LEGRST UP HANGR BRACK
$76.10
K0048
O
ELEVATE LEGREST COMPLETE
$0.00
K0049
O
CALF PAD EACH
$0.00
K0050
3
RATCHET ASSEMBLY
$32.34
K0051
3
CAM RELESE ASSEM FTRST/LGRST
$52.35
K0052
3
SWINGAWAY DETACH FOOTREST
$91.98
K0053
3
ELEVATE FOOTREST ARTICULATE
$101.51
K0054
O
SEAT WDTH 10-12/15/17/20 WC
$0.00
K0055
O
SEAT DPTH 15/17/18 LTWT WC
$0.00
K0056
3
SEAT HT <17 OR >=21 LTWT WC
$94.63
K0057
O
SEAT WDTH 19/20 HVY DTY WC
$0.00
K0058
O
SEAT DPTH 17/18 POWER WC
$0.00
K0059
O
PLASTIC COATED HANDRIM EACH
$0.00
K0060
O
STEEL HANDRIM EACH
$0.00
K0061
O
ALUMINUM HANDRIM EACH
$0.00
K0062
O
HANDRIM 8-10 VERT/OBLIQ PROJ
$0.00
K0063
O
HNDRM 12-16 VERT/OBLIQ PROJ
$0.00
K0064
O
ZERO PRESSURE TUBE FLAT FREE
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
K0065
3
SPOKE PROTECTORS
$44.24
K0066
O
SOLID TIRE ANY SIZE EACH
$0.00
K0067
O
PNEUMATIC TIRE ANY SIZE EACH
$0.00
K0068
O
PNEUMATIC TIRE TUBE EACH
$0.00
K0069
3
REAR WHL COMPLETE SOLID TIRE
K0070
3
REAR WHL COMPL PNEUM TIRE
$182.26
K0071
3
FRONT CASTR COMPL PNEUM TIRE
$108.71
K0072
3
FRNT CSTR CMPL SEM-PNEUM TIR
$65.43
K0073
3
CASTER PIN LOCK EACH
$34.63
K0074
O
PNEUMATIC CASTER TIRE EACH
$0.00
K0075
O
SEMI-PNEUMATIC CASTER TIRE
$0.00
K0076
O
SOLID CASTER TIRE EACH
$0.00
K0077
3
FRONT CASTER ASSEM COMPLETE
K0078
O
PNEUMATIC CASTER TIRE TUBE
$0.00
K0079
O
WHEEL LOCK EXTENSION PAIR
$0.00
K0080
O
ANTI-ROLLBACK DEVICE PAIR
$0.00
K0081
O
WHEEL LOCK ASSEMBLY COMPLETE
$0.00
K0082
O
22 NF NONSEALED LEADACID
$0.00
K0083
O
22NF SEALED LEADACID BATTERY
$0.00
K0084
O
GR24 NONSEALED LEADACID
$0.00
K0085
O
GR 24 SEALED LEAD ACID BATTERY
$0.00
K0086
O
U1NONSEALED LEADACID BATTERY
$0.00
K0087
O
U1 SEALED LEADACID BATTERY
$0.00
K0088
O
BATTERY CHARGER, SINGLE MODE
$0.00
K0089
O
BATTERY CHARGER, DUAL MODE
$0.00
K0090
O
REAR TIRE POWER WHEELCHAIR
$0.00
K0091
O
REAR TIRE TUBE POWER WHLCHR
$0.00
K0092
O
REAR ASSEM CMPLT POWR WHLCHR
$0.00
K0093
O
REAR ZERO PRESSURE TIRE TUBE
$0.00
K0094
O
WHEEL TIRE FOR POWER BASE
$0.00
K0095
O
WHEEL TIRE TUBE EACH BASE
$0.00
K0096
O
WHEEL ASSEM POWR BASE COMPLT
$0.00
K0097
O
WHEEL ZERO PRESURE TIRE TUBE
$0.00
K0098
3
DRIVE BELT POWER WHEELCHAIR
$27.07
K0099
O
PWR WHEELCHAIR FRONT CASTER
$99.42
$58.56
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
K0100
O
AMPUTEE ADAPTER PAIR
$0.00
K0101
O
ONE-ARM DRIVE ATTACHMENT
$0.00
K0102
O
CRUTCH AND CANE HOLDER
$0.00
K0103
O
TRANSFER BOARD < 25"
$0.00
K0104
O
CYLINDER TANK CARRIER
$0.00
K0105
3
IV HANGER
K0106
O
ARM TROUGH EACH
$0.00
K0107
O
WHEELCHAIR TRAY
$0.00
K0108
5
W/C COMPONENT-ACCESSORY NOS
$0.00
K0109
9
CUSTOMIZE WHLCHR BASE FRAME
$0.00
K0110
9
SUPPLIES FOR MAINTENANCE OF DRUG IN
$0.00
K0111
9
SUPPLIES FOR EXTERNAL DRUG INFUSION
$0.00
K0112
O
TRUNK VEST SUPPRT INNR FRAME
$0.00
K0113
O
TRUNK VEST SUPRT W/O INR FRM
$0.00
K0114
O
WHLCHR BACK SUPRT INR FRAME
$0.00
K0115
O
BACK MODULE ORTHOTIC SYSTEM
$0.00
K0116
O
BACK & SEAT MODUL ORTHOT SYS
$0.00
K0117
O
UNLISTED ITEM, ORTHOTIC SEATING, BA
$0.00
K0118
O
TENS SUPPLIES - ONE MONTH SUPPLY FO
$0.00
K0119
9
AZATHIOPRINE ORAL TAB 50 MG
$0.00
K0120
9
AZATHIOPRINE PRENTRL 100 MG
$0.00
K0121
9
CYCLOSPORINE ORAL 25 MG
$0.00
K0122
9
CYCLOSPORINE PRENTRL 250 MG
$0.00
K0123
9
IMUN/ANTITYMOCYT GLOB 250 MG
$0.00
K0124
9
MONOCLONAL ANTIBODIES - PARENTERAL,
$0.00
K0125
9
PREDNISONE - ORAL, 5 MG
$0.00
K0126
9
REPLACE SOFT INTERFACE MATERIAL, MU
$0.00
K0127
9
REPLACE SOFT INTERFACE MATERIAL, AN
$0.00
K0128
9
REPLACE SOFT INTERFACE MATERIAL, FO
$0.00
K0129
9
ANKLE CONTRACTURE SPLINT
$0.00
K0130
9
FOOT DROP SPLINT, RECUMBENT POSITIO
$0.00
K0131
O
SPRING-POWERED DEVICE FOR LANCET
$0.00
K0132
O
MALE EXTERNAL CATHETER WITH OR WITH
$0.00
K0133
O
INTERMITTENT URINARY CATHETER, DISP
$0.00
K0134
O
INTERMITTENT URINARY CATHETER, DISP
$0.00
$98.94
Procedure Code Pricing Action Code Description
Maximum Allowable
K0135
O
INTERMITTENT URINARY CATHETER, REUS
$0.00
K0136
O
INTERMITTENT URINARY CATHETER, REUS
$0.00
K0137
9
SKIN BARRIER LIQUID PER OZ
$0.00
K0138
9
SKIN BARRIER PASTE PER OZ
$0.00
K0139
9
SKIN BARRIER POWDER PER OZ
$0.00
K0140
9
ACETYLCYSTEINE, COMPOUNDED, PER MG,
$0.00
K0141
9
ALBUTEROL SULFATE, COMPOUNDED, PER
$0.00
K0142
9
CROMOLYN SODIUM, COMPOUNDED, PER MG
$0.00
K0143
9
ISOETHARINE HYDROCHLORIDE, COMPOUND
$0.00
K0144
9
ISOPROTHERENOL HYDROCHLORIDE, COMPO
$0.00
K0145
9
METAPROTERENOL, COMPOUNDED, PER MG,
$0.00
K0146
9
TERBUTALINE, COMPOUNDED, PER MG, IN
$0.00
K0147
O
GASTROSTOMY TUBE, SILICONE WITH SLI
$0.00
K0148
O
HYDROGEL DRESSING, EACH
$0.00
K0149
O
HYDROCOLLOID DRESSING, EACH
$0.00
K0150
O
ALGINATE DRESSING, EACH
$0.00
K0151
O
FOAM DRESSING, EACH
$0.00
K0152
9
PASTES, POWDERS, GRANULES, BEADS, C
$0.00
K0153
O
COMPOSITE DRESSING, EACH
$0.00
K0154
9
WOUND POUCH, EACH
$0.00
K0162
O
PROGRESSIVE LENS, EACH LENS
$0.00
K0163
9
VACUUM ERECTION SYSTEM
$0.00
K0164
O
OROPHARYNGEAL SUCTION CATHETER, EAC
$0.00
K0165
O
TRACHEOSTOMY CARE KIT FOR ESTABLISH
$0.00
K0166
O
METHYLPREDNISOLONE - ORAL, 4 MG
$0.00
K0167
O
PREDNISOLONE - ORAL, 5 MG
$0.00
K0168
9
DISPOSABLE NEBULIZER SET
$0.00
K0169
9
DISPOSABLE NEBULIZER SMALL
$0.00
K0170
9
NON DISPOSABLE NEBULIZER SET
$0.00
K0171
9
FILTERED NEBULIZER SET
$0.00
K0172
9
DISPOSABLE NEBULIZER UNFILL
$0.00
K0173
9
DISPOSABLE NEBULIZER PREFILL
$0.00
K0174
9
RESERVOIR BOTTLE W NEBULIZER
$0.00
K0175
9
DISPOSABLE CORRUGATED TUBING
$0.00
K0176
9
NON DISPOS CORRUGATED TUBING
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
K0177
9
WATER COLLEC DEV W NEBULIZER
$0.00
K0178
9
DISPOSBL FILTER W COMPRESSOR
$0.00
K0179
9
NON-DISPOS FILTER W/COMPRESS
$0.00
K0180
9
AEROSOL MASK WITH NEBULIZER
$0.00
K0181
9
DOME & MOUTHPIECE W/ NEBULIZ
$0.00
K0182
9
WATER DISTILLED W/ NEBULIZER
$0.00
K0183
O
NASAL APPLICATION DEVICE
$0.00
K0184
O
NASAL PILLOW OR FACE SEAL
$0.00
K0185
O
POS AIRWAY PRESSURE HEADGEAR
$0.00
K0186
O
POS AIRWAY PRSSURE CHINSTRAP
$0.00
K0187
O
POS AIRWAY PRESSURE TUBING
$0.00
K0188
O
POS AIRWAY PRESSURE FILTER
$0.00
K0189
O
FILTER NONDISPOSABLE W PAP
$0.00
K0190
9
DISPOSABLE CANISTER W/PUMP
$0.00
K0191
9
NON-DISPOSBL CANISTER W/PUMP
$0.00
K0192
9
TUBING USED W/ SUCTION PUMP
$0.00
K0193
9
AIRWAY PRESSURE DEV/W HMDFER
$0.00
K0194
9
ASSIST DEVICE W/HUMIDIFIER
$0.00
K0195
3
ELEVATING WHLCHAIR LEG RESTS
$0.00
K0196
9
ALGINATE DRESSING, WOUND COVER, PAD
$0.00
K0197
9
ALGINATE DRESSING, WOUND COVER, PAD
$0.00
K0198
9
ALGINATE DRESSING, WOUND COVER, PAD
$0.00
K0199
9
ALGINATE DRESSING, WOUND FILLER, PE
$0.00
K0203
9
COMPOSITE DRESSING, PAD SIZE 16 SQ.
$0.00
K0204
9
COMPOSITE DRESSING, PAD SIZE MORE T
$0.00
K0205
9
COMPOSITE DRESSING, PAD SIZE MORE T
$0.00
K0206
9
CONTACT LAYER, 16 SQ. IN. OR LESS,
$0.00
K0207
9
CONTACT LAYER, MORE THAN 16 BUT LES
$0.00
K0208
9
CONTACT LAYER, MORE THAN 48 SQ. IN.
$0.00
K0209
9
FOAM DRESSING, WOUND COVER, PAD SIZ
$0.00
K0210
9
FOAM DRESSING, WOUND COVER, PAD SIZ
$0.00
K0211
9
FOAM DRESSING, WOUND COVER, PAD SIZ
$0.00
K0212
9
FOAM DRESSING, WOUND COVER, PAD SIZ
$0.00
K0213
9
FOAM DRESSING, WOUND COVER, PAD SIZ
$0.00
K0214
9
FOAM DRESSING, WOUND COVER, PAD SIZ
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
K0215
9
FOAM DRESSING, WOUND FILLER, PER GR
$0.00
K0216
9
GAUZE, NON-IMPREGNATED, NON-STERILE
$0.00
K0217
9
GAUZE, NON-IMPREGNATED, NON-STERILE
$0.00
K0218
9
GAUZE, NON-IMPREGNATED, NON-STERILE
$0.00
K0219
9
GAUZE, NON-IMPREGNATED, PAD SIZE 16
$0.00
K0220
9
GAUZE, NON-IMPREGNATED, PAD SIZE MO
$0.00
K0221
9
GAUZE, NON-IMPREGNATED, PAD SIZE MO
$0.00
K0222
9
GAUZE, IMPREGNATED, OTHER THAN WATE
$0.00
K0223
9
GAUZE, IMPREGNATED, OTHER THAN WATE
$0.00
K0224
9
GAUZE, IMPREGNATED, OTHER THAN WATE
$0.00
K0228
9
GAUZE, IMPREGNATED, WATER OR NORMAL
$0.00
K0229
9
GAUZE, IMPREGNATED, WATER OR NORMAL
$0.00
K0230
9
GAUZE, IMPREGNATED, WATER OR NORMAL
$0.00
K0234
9
HYDROCOLLOID DRESSING, WOUND COVER,
$0.00
K0235
9
HYDROCOLLOID DRESSING, WOUND COVER,
$0.00
K0236
9
HYDROCOLLOID DRESSING, WOUND COVER,
$0.00
K0237
9
HYDROCOLLOID DRESSING, WOUND COVER,
$0.00
K0238
9
HYDROCOLLOID DRESSING, WOUND COVER,
$0.00
K0239
9
HYDROCOLLOID DRESSING, WOUND COVER,
$0.00
K0240
9
HYDROCOLLOID DRESSING, WOUND FILLER
$0.00
K0241
9
HYDROCOLLOID DRESSING, WOUND FILLER
$0.00
K0242
9
HYDROGEL DRESSING, WOUND COVER, PAD
$0.00
K0243
9
HYDROGEL DRESSING, WOUND COVER, PAD
$0.00
K0244
9
HYDROGEL DRESSING, WOUND COVER, PAD
$0.00
K0245
9
HYDROGEL DRESSING, WOUND COVER, PAD
$0.00
K0246
9
HYDROGEL DRESSING, WOUND COVER, PAD
$0.00
K0247
9
HYDROGEL DRESSING, WOUND COVER, PAD
$0.00
K0248
9
HYDROGEL DRESSING, WOUND FILLER, GE
$0.00
K0249
9
HYDROGEL DRESSING, WOUND FILLER, DR
$0.00
K0250
9
SKIN SEALANTS, PROTECTANTS, MOISTUR
$0.00
K0251
9
SPECIALTY ABSORPTIVE DRESSING, WOUN
$0.00
K0252
9
SPECIALTY ABSORPTIVE DRESSING, WOUN
$0.00
K0253
9
SPECIALTY ABSORPTIVE DRESSING, WOUN
$0.00
K0254
9
SPECIALTY ABSORPTIVE DRESSING, WOUN
$0.00
K0255
9
SPECIALTY ABSORPTIVE DRESSING, WOUN
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
K0256
9
SPECIALTY ABSORPTIVE DRESSING, WOUN
$0.00
K0257
9
TRANSPARENT FILM, 16 SQ. IN. OR LES
$0.00
K0258
9
TRANSPARENT FILM, MORE THAN 16 BUT
$0.00
K0259
9
TRANSPARENT FILM, MORE THAN 48 SQ.
$0.00
K0260
9
WOUND CLEANSERS, ANY TYPE, ANY SIZE
$0.00
K0261
9
WOUND FILLER, NOT ELSEWHERE CLASSIF
$0.00
K0262
9
WOUND FILLER, NOT ELSEWHERE CLASSIF
$0.00
K0263
9
GAUZE, ELASTIC, NON-STERILE, ALL T
$0.00
K0264
9
GAUZE, NON-ELASTIC, NON-STERILE, PE
$0.00
K0265
9
TAPE, ALL TYPES, PER 18 SQUARE INCH
$0.00
K0266
9
GAUZE, IMPREGNATED, OTHER THAN WATE
$0.00
K0267
O
REPLACEMENT BATTERY, ANY TYPE, FOR
$0.00
K0268
O
HUMIDIFIER NONHEATED W PAP
$0.00
K0269
9
AEROSOL COMPRESSOR CPAP DEV
$0.00
K0270
9
ULTRASONIC GENERATOR W NEBUL
$0.00
K0271
9
POUCH, DRAINABLE; WITH FACEPLATE AT
$0.00
K0272
9
POUCH, DRAINABLE; WITHOUT FACEPLATE
$0.00
K0273
9
POUCH, URINARY; WITH FACEPLATE ATTA
$0.00
K0274
9
POUCH, URINARY; WITHOUT FACEPLATE A
$0.00
K0275
9
OSTOMY FACEPLATE; CONVEX; REUSABLE;
$0.00
K0276
9
OSTOMY FACEPLATE; CONVEX; CUSTOM FI
$0.00
K0277
9
SKIN BARRIER SOLID 4X4 EQUIV
$0.00
K0278
9
SKIN BARRIER WITH FLANGE
$0.00
K0279
9
SKIN BARRIER EXTENDED WEAR
$0.00
K0280
9
EXTENSION DRAINAGE TUBING
$0.00
K0281
9
LUBRICANT CATHETER INSERTION
$0.00
K0283
9
SALINE SOLUTION DISPENSER
$0.00
K0284
9
EXTERNAL INFUSION PUMP REUSE
$0.00
K0285
9
REPAIR OF PROSTHETIC DEVICE, LABOR
$0.00
K0400
9
SKIN SUPPORT ATTACHMENT EACH
$0.00
K0401
9
DIABETIC DELUXE SHOE
$0.00
K0402
9
GAUZE, NON-IMPREGNATED, STERILE, PA
$0.00
K0403
9
GAUZE, NON-IMPREGNATED, STERILE, PA
$0.00
K0404
9
GAUZE, NON-IMPREGNATED, STERILE, PA
$0.00
K0405
9
GAUZE, ELASTIC, STERILE, ALL TYPES,
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
K0406
9
GAUZE, NON-ELASTIC, STERILE, PER LI
$0.00
K0407
9
URINARY CATH SKIN ATTACHMENT
$0.00
K0408
9
URINARY CATH LEG STRAP
$0.00
K0409
9
STERILE H2O IRRIGATION SOLUT
$0.00
K0410
9
MALE EXT CATH W/ADH COATING
$0.00
K0411
9
MALE EXT CATH W/ADH STRIP
$0.00
K0412
9
MYCOPHENOLATE MOFETIL 25O MG
$0.00
K0413
O
NON-POWERED, ADVANCED PRESSURE-REDU
$0.00
K0414
O
POWERED AIR OVERLAY FOR MATTRESS, S
$0.00
K0415
O
RX ANTIEMETIC DRG, ORAL NOS
$0.00
K0416
O
RX ANTIEMETIC DRG,RECTAL NOS
$0.00
K0417
9
MECH INFUS PUMP SHT TRM DRUG
$0.00
K0418
9
ORAL CYCLOSPORIN
$0.00
K0419
9
DRAINABLE PLSTIC PCH W FCPLT
$0.00
K0420
9
DRAINABLE RUBBER PCH W FCPLT
$0.00
K0421
9
DRAINABLE PLSTIC PCH W/O FP
$0.00
K0422
9
DRAINABLE RUBBER PCH W/O FP
$0.00
K0423
9
URINARY PLSTIC POUCH W FCPLT
$0.00
K0424
9
URINARY RUBBER POUCH W FCPLT
$0.00
K0425
9
URINARY PLSTIC POUCH W/O FP
$0.00
K0426
9
URINARY HVY PLSTC PCH W/O FP
$0.00
K0427
9
URINARY RUBBER POUCH W/O FP
$0.00
K0428
9
OSTOMY FACEPLT/SILICONE RING
$0.00
K0429
9
SKIN BARRIER SOLID EXT WEAR
$0.00
K0430
9
SKIN BARRIER W FLANG EX WEAR
$0.00
K0431
9
CLOSED POUCH W ST WEAR BAR
$0.00
K0432
9
DRAINABLE PCH W EX WEAR BAR
$0.00
K0433
9
DRAINABLE PCH W ST WEAR BAR
$0.00
K0434
9
DRAINABLE PCH EX WEAR CONVEX
$0.00
K0435
9
URINARY POUCH W EX WEAR BAR
$0.00
K0436
9
URINARY POUCH W ST WEAR BAR
$0.00
K0437
9
URINE PCH W EX WEAR BAR CONV
$0.00
K0438
9
OSTOMY POUCH LIQ DEODORANT
$0.00
K0439
9
OSTOMY POUCH SOLID DEODORANT
$0.00
K0440
9
NASAL PROSTHESIS
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
K0441
9
MIDFACIAL PROSTHESIS
$0.00
K0442
9
ORBITAL PROSTHESIS
$0.00
K0443
9
UPPER FACIAL PROSTHESIS
$0.00
K0444
9
HEMI-FACIAL PROSTHESIS
$0.00
K0445
9
AURICULAR PROSTHESIS
$0.00
K0446
9
PARTIAL FACIAL PROSTHESIS
$0.00
K0447
9
NASAL SEPTAL PROSTHESIS
$0.00
K0448
9
UNSPEC MAXILLOFACIAL PROSTH
$0.00
K0449
9
REPAIR MAXILLOFACIAL PROSTH
$0.00
K0450
9
LIQ ADHES FOR FACIAL PROSTH
$0.00
K0451
9
ADHESIVE REMOVER WIPES
$0.00
K0452
O
WHEELCHAIR BEARINGS
$0.00
K0453
9
AMPHOTERICIN B
$0.00
K0455
9
PUMP UNINTERRUPTED INFUSION
$0.00
K0456
O
HEAVYDUTY/XTRA WIDE HOSP BED
$0.00
K0457
O
HEAVYDUTY/WIDE COMMODE CHAIR
$0.00
K0458
O
HEAVYDUTY WALKER NO WHEELS
$0.00
K0459
O
HEAVY DUTY WHEELED WALKER
$0.00
K0460
O
WC POWER ADD-ON JOYSTICK
$0.00
K0461
O
WC POWER ADD-ON TILLER CNTRL
$0.00
K0462
9
TEMPORARY REPLACEMENT EQPMNT
$0.00
K0501
9
AEROSOL COMPRESSOR FOR SVNEB
$0.00
K0503
9
ACETYLCYSTEINE INH SOL U D
$0.00
K0504
9
ALBUTEROL INH SOL CON
$0.00
K0505
9
ALBUTEROL INH SOL U D
$0.00
K0506
9
ATROPINE INH SOL CON
$0.00
K0507
9
ATROPINE INH SOL U D
$0.00
K0508
9
BITOLTEROL MES INH SOL CON
$0.00
K0509
9
BITOLTEROL MES INH SOL U D
$0.00
K0511
9
CROMOLYN SODIUM INH SOL U D
$0.00
K0512
9
DEXAMETHASONE INH SOL CON
$0.00
K0513
9
DEXAMETHASONE INH SOL U D
$0.00
K0514
9
DORNASE ALPHA INH SOL U D
$0.00
K0515
9
GLYCOPYRROLATE INH SOL CON
$0.00
K0516
9
GLYCOPYRROLATE INH SOL U D
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
K0518
9
IPRATROPIUM BROM INH SOL U D
$0.00
K0519
9
ISOETHARINE HCL INH SOL CON
$0.00
K0520
9
ISOETHARINE HCL INH SOL U D
$0.00
K0521
9
ISOPROTERENOLHCL INH SOL CON
$0.00
K0522
9
ISOPROTERENOLHCL INH SOL U D
$0.00
K0523
9
METAPROTERENOL INH SOL CON
$0.00
K0524
9
METAPROTERENOL INH SOL U D
$0.00
K0525
9
TERBUTALINE SO4 INH SOL CON
$0.00
K0526
9
TERBUTALINE SO4 INH SOL U D
$0.00
K0527
9
TRIAMCINOLONE INH SOL CON
$0.00
K0528
9
TRIAMCINOLONE INH SOL U D
$0.00
K0529
9
STERILE H20 OR NSS W LV NEB
$0.00
K0530
9
NEBULIZER NOT USED W OXYGEN
$0.00
K0531
O
HEATED HUMIDIFIER USED W PAP
$0.00
K0532
O
NONINVASIVE ASSIST WO BACKUP
$0.00
K0533
O
NONINVASIVE ASSIST W BACKUP
$0.00
K0534
O
INVASIVE ASSIST W BACKUP
$0.00
K0538
O
NEG PRESSURE WND THRPY PUMP
$0.00
K0539
O
NEG PRES WND THRPY DSG SET
$0.00
K0540
O
NEG PRES WND THRP CANISTER
$0.00
K0541
O
SGD PRERECORDED MSG <= 8 MIN
$0.00
K0542
O
SGD PRERECORDED MSG > 8 MIN
$0.00
K0543
O
SGD MSG FORMED BY SPELLING
$0.00
K0544
O
SGD W MULTI METHODS MSG/ACCS
$0.00
K0545
O
SGD SFTWRE PRGRM FOR PC/PDA
$0.00
K0546
O
SGD ACCESSORY,MOUNTING SYSTM
$0.00
K0547
O
SGD ACCESSORY NOC
$0.00
K0549
O
HOSPITAL BED, HEAVY DUTY, EXTRA WI
$0.00
K0550
O
HOSPITAL BED, EXTRA HEAVY DUTY, EX
$0.00
K0551
9
RESIDUAL LIMB SUPPORT SYSTEM
$0.00
K0552
6
SUPPLY/EXT INF PUMP SYR TYPE
$0.00
K0556
O
SOCKET INSERT W LOCK MECH
$0.00
K0557
O
SOCKET INSERT W/O LOCK MECH
$0.00
K0558
O
INTL CUSTM CONG/ATYP INSERT
$0.00
K0559
O
INITIAL CUSTOM SOCKET INSERT
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
K0561
9
NONPECTIN BASED OSTOMY PASTE
$0.00
K0562
9
PECTIN BASED OSTOMY PASTE
$0.00
K0563
O
OSTOMY SKIN BARRIER WITH FLANGE (S
$0.00
K0565
O
OSTOMY SKIN BARRIER WITH FLANGE (S
$0.00
K0570
O
BUILT IN CONVEXITY, 4X INCHES OR S
$0.00
K0572
O
TAPE, NON WATERPROOF, PER 18 SQUAR
$0.00
K0573
O
TAPE, WATERPROOF, PER 18 SQUARE IN
$0.00
K0581
O
OST PCH CLSD W BARRIER/FILTR
$0.00
K0582
O
OST PCH W BAR/BLTINCONV/FLTR
$0.00
K0583
O
OST PCH CLSD W/O BAR W FILTR
$0.00
K0584
O
OST PCH FOR BAR W FLANGE/FLT
$0.00
K0585
O
OST PCH CLSD FOR BAR W LK FL
$0.00
K0586
O
OST PCH FOR BAR W LK FL/FLTR
$0.00
K0587
O
OST PCH DRAIN W BAR & FILTER
$0.00
K0588
O
OST PCH DRAIN FOR BARRIER FL
$0.00
K0589
O
OST PCH DRAIN 2 PIECE SYSTEM
$0.00
K0590
O
OST PCH DRAIN/BARR LK FLNG/F
$0.00
K0591
O
URINE OST POUCH W FAUCET/TAP
$0.00
K0592
O
URINE OST POUCH W BLTINCONV
$0.00
K0593
O
OST URINE PCH W B/BLTIN CONV
$0.00
K0594
O
OST PCH URINE W BARRIER/TAPV
$0.00
K0595
O
OS PCH URINE W BAR/FANGE/TAP
$0.00
K0596
O
URINE OST PCH BAR W LOCK FLN
$0.00
K0597
O
OST PCH URINE W LOCK FLNG/FT
$0.00
K0600
O
FUNCTIONAL NEUROMUSCULARSTIM
$0.00
K0601
6
REPL BATT SILVER OXIDE 1.5 V
$0.00
K0602
6
REPL BATT SILVER OXIDE 3 V
$0.00
K0603
6
REPL BATT ALKALINE 1.5 V
$0.00
K0604
6
REPL BATT LITHIUM 3.6 V
$0.00
K0605
6
REPL BATT LITHIUM 4.5 V
$0.00
K0606
6
AED GARMENT W ELEC ANALYSIS
$0.00
K0607
6
REPL BATT FOR AED
$0.00
K0608
6
REPL GARMENT FOR AED
$0.00
K0609
6
REPL ELECTRODE FOR AED
$0.00
K0618
O
TLSO 2 PIECE RIGID SHELL
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
K0619
O
TLSO 3 PIECE RIGID SHELL
$0.00
K0620
O
TUBULAR ELASTIC DRESSING
$0.00
K0627
O
CERVICAL PNEUM TRAC EQUIP
$0.00
K0628
O
MULT DENS INSERT DIRECT FORM
$0.00
K0629
O
MULT DENS INSERT CUSTOM MOLD
$0.00
K0630
O
SIO FLEX PELVISACRAL PREFAB
$0.00
K0631
O
SIO FLEX PELVISACRAL CUSTOM
$0.00
K0632
O
SIO PANEL PREFAB
$0.00
K0633
O
SIO PANEL CUSTOM
$0.00
K0634
O
LO FLEXIBLE L1 BELOW L5 PRE
$0.00
K0635
O
LO SAG STAYS/PANELS PRE-FAB
$0.00
K0636
O
LO SAGITT RIGID PANEL PREFAB
$0.00
K0637
O
LO FLEX W/O RIGID STAYS PRE
$0.00
K0638
O
LSO FLEX W/RIGID STAYS CUST
$0.00
K0639
O
LSO POST RIGID PANEL PRE
$0.00
K0640
O
LSO SAG-CORO RIGID FRAME PRE
$0.00
K0641
O
LSO SAG-COR RIGID FRAME CUST
$0.00
K0642
O
LSO FLEXION CONTROL PREFAB
$0.00
K0643
O
LSO FLEXION CONTROL CUSTOM
$0.00
K0644
O
LSO SAGIT RIGID PANEL PREFAB
$0.00
K0645
O
LSO SAGITTAL RIGID PANEL CUS
$0.00
K0646
O
LSO SAG-CORONAL PANEL PREFAB
$0.00
K0647
O
LSO SAG-CORONAL PANEL CUSTOM
$0.00
K0648
O
LSO S/C SHELL/PANEL PREFAB
$0.00
K0649
O
LSO S/C SHELL/PANEL CUSTOM
$0.00
K0650
O
GEN W/C CUSHION WIDTH LESS THAN 22
$0.00
K0651
O
GEN W/C CUSHION WIDTH GREATER THAN
$0.00
K0652
O
SKIN PROTECT W/C CUS WD LESS THAN2
$0.00
K0653
O
SKIN PROTECT W/C CUS WD GREATER TH
$0.00
K0654
O
POSITION W/C CUSH WIDTH LESS THAN2
$0.00
K0655
O
POSITION W/C CUSH WIDTH GREATER TH
$0.00
K0656
O
SKIN PRO/POS W/C CUS WD LESS THAN2
$0.00
K0657
O
SKIN PRO/POS W/C CUS WD GREATER TH
$0.00
K0658
O
CUSTOM FABRICATE W/C CUSHION
$0.00
K0659
O
POWERED W/C CUSHION
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
K0660
O
GEN USE BACK CUSH WIDTH LESS THAN2
$0.00
K0661
O
GEN USE BACK CUSH WIDTH GREATER TH
$0.00
K0662
O
POSITION BACK CUSH WDTH LESS THAN2
$0.00
K0663
O
POSITION BACK CUSH WDTH GREATER TH
$0.00
K0664
O
POS BACK POST/LAT WIDTH LESS THAN2
$0.00
K0665
O
POS BACK POST/LAT WIDTH GREATER TH
$0.00
K0666
O
CUSTOM FAB W/C BACK CUSHION
$0.00
K0667
O
MT HARDWRE MAN/LIGHT PWR W/C
$0.00
K0668
O
REP ACE COVER W/C SEAT CUSH
$0.00
K0669
6
SEAT/BACK CUS NO SADMERC VER
$0.00
K0670
O
STANCE PHASE ONLY
$0.00
K0672
6
REMOVABLE SOFT INTERFACE LE
$0.00
K0730
6
CTRL DOSE INH DRUG DELIV SYS
$0.00
K0733
6
12-24HR SEALED LEAD ACID
$0.00
K0734
6
ADJ SKIN PRO W/C CUS WD<22IN
$0.00
K0735
6
ADJ SKIN PRO WC CUS WD>=22IN
$0.00
K0736
6
ADJ SKIN PRO/POS WC CUS<22IN
$0.00
K0737
6
ADJ SKIN PRO/POS WC CUS>=22Ê
$0.00
K0738
6
PORTABLE GAS OXYGEN SYSTEM
$0.00
K0800
6
POV GROUP 1 STD UP TO 300LBS
$0.00
K0801
6
POV GROUP 1 HD 301-450 LBS
$0.00
K0802
6
POV GROUP 1 VHD 451-600 LBS
$0.00
K0806
6
POV GROUP 2 STD UP TO 300LBS
$0.00
K0807
6
POV GROUP 2 HD 301-450 LBS
$0.00
K0808
6
POV GROUP 2 VHD 451-600 LBS
$0.00
K0812
6
POWER OPERATED VEHICLE NOC
$0.00
K0813
6
PWC GP 1 STD PORT SEAT/BACK
$0.00
K0814
6
PWC GP 1 STD PORT CAP CHAIR
$0.00
K0815
6
PWC GP 1 STD SEAT/BACK
$0.00
K0816
6
PWC GP 1 STD CAP CHAIR
$0.00
K0820
6
PWC GP 2 STD PORT SEAT/BACK
$0.00
K0821
6
PWC GP 2 STD PORT CAP CHAIR
$0.00
K0822
6
PWC GP 2 STD SEAT/BACK
$0.00
K0823
6
PWC GP 2 STD CAP CHAIR
$0.00
K0824
6
PWC GP 2 HD SEAT/BACK
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
K0825
6
PWC GP 2 HD CAP CHAIR
$0.00
K0826
6
PWC GP 2 VHD SEAT/BACK
$0.00
K0827
6
PWC GP VHD CAP CHAIR
$0.00
K0828
6
PWC GP 2 XTRA HD SEAT/BACK
$0.00
K0829
6
PWC GP 2 XTRA HD CAP CHAIR
$0.00
K0830
6
PWC GP2 STD SEAT ELEVATE S/B
$0.00
K0831
6
PWC GP2 STD SEAT ELEVATE CAP
$0.00
K0835
6
PWC GP2 STD SING POW OPT S/B
$0.00
K0836
6
PWC GP2 STD SING POW OPT CAP
$0.00
K0837
6
PWC GP 2 HD SING POW OPT S/B
$0.00
K0838
6
PWC GP 2 HD SING POW OPT CAP
$0.00
K0839
6
PWC GP2 VHD SING POW OPT S/B
$0.00
K0840
6
PWC GP2 XHD SING POW OPT S/B
$0.00
K0841
6
PWC GP2 STD MULT POW OPT S/B
$0.00
K0842
6
PWC GP2 STD MULT POW OPT CAP
$0.00
K0843
6
PWC GP2 HD MULT POW OPT S/B
$0.00
K0848
6
PWC GP 3 STD SEAT/BACK
$0.00
K0849
6
PWC GP 3 STD CAP CHAIR
$0.00
K0850
6
PWC GP 3 HD SEAT/BACK
$0.00
K0851
6
PWC GP 3 HD CAP CHAIR
$0.00
K0852
6
PWC GP 3 VHD SEAT/BACK
$0.00
K0853
6
PWC GP 3 VHD CAP CHAIR
$0.00
K0854
6
PWC GP 3 XHD SEAT/BACK
$0.00
K0855
6
PWC GP 3 XHD CAP CHAIR
$0.00
K0856
6
PWC GP3 STD SING POW OPT S/B
$0.00
K0857
6
PWC GP3 STD SING POW OPT CAP
$0.00
K0858
6
PWC GP3 HD SING POW OPT S/B
$0.00
K0859
6
PWC GP3 HD SING POW OPT CAP
$0.00
K0860
6
PWC GP3 VHD SING POW OPT S/B
$0.00
K0861
6
PWC GP3 STD MULT POW OPT S/B
$0.00
K0862
6
PWC GP3 HD MULT POW OPT S/B
$0.00
K0863
6
PWC GP3 VHD MULT POW OPT S/B
$0.00
K0864
6
PWC GP3 XHD MULT POW OPT S/B
$0.00
K0868
6
PWC GP 4 STD SEAT/BACK
$0.00
K0869
6
PWC GP 4 STD CAP CHAIR
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
K0870
6
PWC GP 4 HD SEAT/BACK
$0.00
K0871
6
PWC GP 4 VHD SEAT/BACK
$0.00
K0877
6
PWC GP4 STD SING POW OPT S/B
$0.00
K0878
6
PWC GP4 STD SING POW OPT CAP
$0.00
K0879
6
PWC GP4 HD SING POW OPT S/B
$0.00
K0880
6
PWC GP4 VHD SING POW OPT S/B
$0.00
K0884
6
PWC GP4 STD MULT POW OPT S/B
$0.00
K0885
6
PWC GP4 STD MULT POW OPT CAP
$0.00
K0886
6
PWC GP4 HD MULT POW S/B
$0.00
K0890
6
PWC GP5 PED SING POW OPT S/B
$0.00
K0891
6
PWC GP5 PED MULT POW OPT S/B
$0.00
K0898
6
POWER WHEELCHAIR NOC
$0.00
K0899
9
POW MOBIL DEV NO SADMERC
$0.00
KKEVL
O
MCO SPECIFIC CODE: DPH KIDS KARE IN
$0.00
KKTX1
O
MCO SPECIFIC CODE: DPH KIDS KARE TE
$0.00
KKTX2
O
MCO SPECIFIC CODE: DPH KIDS KARE TE
$0.00
L0100
O
CRANIAL ORTHOSIS/HELMET MOLD
$0.00
L0101
O
ONE-ARM DRIVE ATTACHMENT, EACH
$0.00
L0110
O
CRANIAL ORTHOSIS/HELMET NONM
$0.00
L0112
6
CRANIAL CERVICAL ORTHOSIS
$0.00
L0113
6
CRANIAL CERVICAL TORTICOLLIS
$0.00
L0120
3
CERV FLEXIBLE NON-ADJUSTABLE
$20.07
L0130
3
FLEX THERMOPLASTIC COLLAR MO
$141.92
L0140
3
CERVICAL SEMI-RIGID ADJUSTAB
$46.91
L0150
3
CERV SEMI-RIG ADJ MOLDED CHN
$86.11
L0160
3
CERV SEMI-RIG WIRE OCC/MAND
$112.45
L0170
3
CERVICAL COLLAR MOLDED TO PT
$463.04
L0172
3
CERV COL THERMPLAS FOAM 2 PI
$100.39
L0174
3
CERV COL FOAM 2 PIECE W THOR
$197.24
L0180
3
CER POST COL OCC/MAN SUP ADJ
$273.50
L0190
3
CERV COLLAR SUPP ADJ CERV BA
$355.67
L0200
3
CERV COL SUPP ADJ BAR & THOR
$370.78
L0210
3
THORACIC RIB BELT
L0220
3
THOR RIB BELT CUSTOM FABRICA
L0300
O
TLSO FLEX SURGICAL SUPPORT
$34.05 $101.25 $0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
L0310
O
TLSO FLEXIBLE CUSTOM FABRICA
$0.00
L0315
O
TLSO FLEX ELAS RIGID POST PA
$0.00
L0317
O
TLSO FLEX HYPEXT ELAS POST P
$0.00
L0320
O
TLSO A-P CONTRL W APRON FRNT
$0.00
L0321
O
TLSO ANTI-POST-CNTRL PREFAB
$0.00
L0330
O
TLSO ANT-POS-LATERAL CONTROL
$0.00
L0331
O
TLSO ANT-POST-LAT CNTRL PRFB
$0.00
L0340
O
TLSO A-P-L-ROTARY WITH APRON
$0.00
L0350
O
TLSO FLEX COMPRESS JACKET CU
$0.00
L0360
O
TLSO FLEX COMPRESS JACKET MO
$0.00
L0370
O
TLSO A-P-L-ROTARY HYPEREXTEN
$0.00
L0380
O
TLSO A-P-L-ROT W/ POS EXTENS
$0.00
L0390
O
TLSO A-P-L CONTROL MOLDED
$0.00
L0391
O
TLSO ANT-POST-LAT-ROT CNTRL
$0.00
L0400
O
TLSO A-P-L W INTERFACE MATER
$0.00
L0410
O
TLSO A-P-L TWO PIECE CONSTR
$0.00
L0420
O
TLSO A-P-L 2 PIECE W INTERFA
$0.00
L0430
6
TLSO A-P-L W INTERFACE CUSTM
$0.00
L0440
O
TLSO A-P-L OVERLAP FRNT CUST
$0.00
L0450
5
TLSO FLEX PREFAB THORACIC
$0.00
L0452
5
TLSO FLEX CUSTOM FAB THORACI
$0.00
L0454
5
TLSO FLEX PREFAB SACROCOC-T9
$0.00
L0456
5
TLSO FLEX PREFAB
$0.00
L0458
5
TLSO 2MOD SYMPHIS-XIPHO PRE
$0.00
L0460
5
TLSO2MOD SYMPHYSIS-STERN PRE
$0.00
L0462
3
TLSO 3MOD SACRO-SCAP PRE
$1,050.90
L0464
5
TLSO 4MOD SACRO-SCAP PRE
$0.00
L0466
5
TLSO RIGID FRAME PRE SOFT AP
$0.00
L0468
5
TLSO RIGID FRAME PREFAB PELV
$0.00
L0470
5
TLSO RIGID FRAME PRE SUBCLAV
$0.00
L0472
5
TLSO RIGID FRAME HYPEREX PRE
$0.00
L0474
5
TLSO RIGID FRAME PRE PELVIC
$0.00
L0476
O
TLSO FLEXION COMPRES JAC PRE
$0.00
L0478
O
TLSO FLEXION COMPRES JAC CUS
$0.00
L0480
5
TLSO RIGID PLASTIC CUSTOM FA
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
L0482
5
TLSO RIGID LINED CUSTOM FAB
$0.00
L0484
5
TLSO RIGID PLASTIC CUST FAB
$0.00
L0486
5
TLSO RIGIDLINED CUST FAB TWO
$0.00
L0488
5
TLSO RIGID LINED PRE ONE PIE
$0.00
L0490
5
TLSO RIGID PLASTIC PRE ONE
$0.00
L0491
6
TLSO 2 PIECE RIGID SHELL
$0.00
L0492
6
TLSO 3 PIECE RIGID SHELL
$0.00
L0500
O
LSO FLEX SURGICAL SUPPORT
$0.00
L0510
O
LSO FLEXIBLE CUSTOM FABRICAT
$0.00
L0515
O
LSO FLEX ELAS W/ RIG POST PA
$0.00
L0520
O
LSO A-P-L CONTROL WITH APRON
$0.00
L0530
O
LSO ANT-POS CONTROL W APRON
$0.00
L0540
O
LSO LUMBAR FLEXION A-P-L
$0.00
L0550
O
LSO A-P-L CONTROL MOLDED
$0.00
L0560
O
LSO A-P-L W INTERFACE
$0.00
L0561
O
PREFAB LSO
$0.00
L0565
O
LSO A-P-L CONTROL CUSTOM
$0.00
L0600
O
SACROILIAC FLEX SURG SUPPORT
$0.00
L0610
O
SACROILIAC FLEXIBLE CUSTM FA
$0.00
L0620
O
SACROILIAC SEMI-RIG W APRON
$0.00
L0621
6
SIO FLEX PELVISACRAL PREFAB
$0.00
L0622
6
SIO FLEX PELVISACRAL CUSTOM
$0.00
L0623
6
SIO PANEL PREFAB
$0.00
L0624
6
SIO PANEL CUSTOM
$0.00
L0625
6
LO FLEXIBL L1-BELOW L5 PRE
$0.00
L0626
6
LO SAG STAYS/PANELS PRE-FAB
$0.00
L0627
6
LO SAGITT RIGID PANEL PREFAB
$0.00
L0628
6
LO FLEX W/O RIGID STAYS PRE
$0.00
L0629
6
LSO FLEX W/RIGID STAYS CUST
$0.00
L0630
3
LSO POST RIGID PANEL PRE
L0631
6
LSO SAG-CORO RIGID FRAME PRE
$0.00
L0632
6
LSO SAG RIGID FRAME CUST
$0.00
L0633
6
LSO FLEXION CONTROL PREFAB
$0.00
L0634
6
LSO FLEXION CONTROL CUSTOM
$0.00
L0635
6
LSO SAGIT RIGID PANEL PREFAB
$0.00
$127.26
Procedure Code Pricing Action Code Description
Maximum Allowable
L0636
6
LSO SAGITTAL RIGID PANEL CUS
$0.00
L0637
6
LSO SAG-CORONAL PANEL PREFAB
$0.00
L0638
6
LSO SAG-CORONAL PANEL CUSTOM
$0.00
L0639
6
LSO S/C SHELL/PANEL PREFAB
$0.00
L0640
6
LSO S/C SHELL/PANEL CUSTOM
$0.00
L0700
3
CTLSO A-P-L CONTROL MOLDED
$1,467.79
L0710
3
CTLSO A-P-L CONTROL W/ INTER
$1,499.54
L0810
3
HALO CERVICAL INTO JCKT VEST
$1,875.37
L0820
3
HALO CERVICAL INTO BODY JACK
$1,683.27
L0830
3
HALO CERV INTO MILWAUKEE TYP
$2,372.22
L0859
6
MRI COMPATIBLE SYSTEM
$0.00
L0860
O
MAGNETIC RESONANC IMAGE COMP
$0.00
L0861
6
HALO REPL LINER/INTERFACE
$0.00
L0900
O
TORSO/PTOSIS SUPPORT
$0.00
L0910
O
TORSO & PTOSIS SUPP CUSTM FA
$0.00
L0920
O
TORSO/PENDULOUS ABD SUPPORT
$0.00
L0930
O
PENDULOUS ABDOMEN SUPP CUSTM
$0.00
L0940
O
TORSO/POSTSURGICAL SUPPORT
$0.00
L0950
O
POST SURG SUPPORT CUSTOM FAB
$0.00
L0960
O
POST SURGICAL SUPPORT PADS
$0.00
L0970
3
TLSO CORSET FRONT
$96.55
L0972
3
LSO CORSET FRONT
$86.71
L0974
3
TLSO FULL CORSET
$128.76
L0976
3
LSO FULL CORSET
$114.81
L0978
3
AXILLARY CRUTCH EXTENSION
$151.56
L0980
3
PERONEAL STRAPS PAIR
$16.53
L0982
3
STOCKING SUPP GRIPS SET OF F
$11.69
L0984
3
PROTECTIVE BODY SOCK EACH
$48.54
L0986
O
SPINAL ORTH ABDM PNL PREFAB
$0.00
L0999
5
ADD TO SPINAL ORTHOSIS NOS
$0.00
L1000
3
CTLSO MILWAUKE INITIAL MODEL
L1001
6
CTLSO INFANT IMMOBILIZER
$0.00
L1005
5
TENSION BASED SCOLIOSIS ORTH
$0.00
L1010
3
CTLSO AXILLA SLING
$48.19
L1020
3
KYPHOSIS PAD
$62.06
$1,472.64
Procedure Code Pricing Action Code Description
Maximum Allowable
L1025
3
KYPHOSIS PAD FLOATING
$118.46
L1030
3
LUMBAR BOLSTER PAD
$45.67
L1040
3
LUMBAR OR LUMBAR RIB PAD
$59.77
L1050
3
STERNAL PAD
$72.03
L1060
3
THORACIC PAD
$86.42
L1070
3
TRAPEZIUS SLING
$84.40
L1080
3
OUTRIGGER
$47.48
L1085
3
OUTRIGGER BIL W/ VERT EXTENS
L1090
3
LUMBAR SLING
L1100
3
RING FLANGE PLASTIC/LEATHER
$135.65
L1110
3
RING FLANGE PLAS/LEATHER MOL
$183.38
L1120
3
COVERS FOR UPRIGHT EACH
L1200
3
FURNSH INITIAL ORTHOSIS ONLY
L1210
3
LATERAL THORACIC EXTENSION
$187.88
L1220
3
ANTERIOR THORACIC EXTENSION
$179.47
L1230
3
MILWAUKEE TYPE SUPERSTRUCTUR
$460.04
L1240
3
LUMBAR DEROTATION PAD
$62.18
L1250
3
ANTERIOR ASIS PAD
$62.18
L1260
3
ANTERIOR THORACIC DEROTATION
$63.50
L1270
3
ABDOMINAL PAD
$64.52
L1280
3
RIB GUSSET (ELASTIC) EACH
$74.19
L1290
3
LATERAL TROCHANTERIC PAD
$58.74
L1300
3
BODY JACKET MOLD TO PATIENT
$1,322.50
L1310
3
POST-OPERATIVE BODY JACKET
$1,358.90
L1499
5
SPINAL ORTHOSIS NOS
L1500
3
THKAO MOBILITY FRAME
L1510
3
THKAO STANDING FRAME
L1520
3
THKAO SWIVEL WALKER
L1600
3
ABDUCT HIP FLEX FREJKA W CVR
$92.52
L1610
3
ABDUCT HIP FLEX FREJKA COVR
$40.82
L1620
3
ABDUCT HIP FLEX PAVLIK HARNE
$115.65
L1630
3
ABDUCT CONTROL HIP SEMI-FLEX
$121.67
L1640
3
PELV BAND/SPREAD BAR THIGH C
$370.37
L1650
3
HO ABDUCTION HIP ADJUSTABLE
$187.41
L1652
5
HO BI THIGHCUFFS W SPRDR BAR
$128.42 $84.96
$31.00 $1,124.98
$0.00 $1,363.82 $862.81 $1,638.02
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
L1660
3
HO ABDUCTION STATIC PLASTIC
$122.87
L1680
3
PELVIC & HIP CONTROL THIGH C
$874.83
L1685
3
POST-OP HIP ABDUCT CUSTOM FA
$892.79
L1686
3
HO POST-OP HIP ABDUCTION
$824.39
L1690
3
COMBINATION BILATERAL HO
$1,449.30
L1700
3
LEG PERTHES ORTH TORONTO TYP
$1,096.46
L1710
3
LEGG PERTHES ORTH NEWINGTON
$1,283.53
L1720
3
LEGG PERTHES ORTHOSIS TRILAT
$946.12
L1730
3
LEGG PERTHES ORTH SCOTTISH R
$812.63
L1750
O
LEGG PERTHES SLING
L1755
3
LEGG PERTHES PATTEN BOTTOM T
L1800
3
KNEE ORTHOSES ELAS W STAYS
$52.19
L1810
3
KO ELASTIC WITH JOINTS
$70.71
L1815
3
ELASTIC WITH CONDYLAR PADS
$74.89
L1820
3
KO ELAS W/ CONDYLE PADS & JO
$109.56
L1825
3
KO ELASTIC KNEE CAP
$48.39
L1830
3
KO IMMOBILIZER CANVAS LONGIT
$66.62
L1831
6
KNEE ORTH POS LOCKING JOINT
$0.00
L1832
3
KO ADJ JNT POS RIGID SUPPORT
$507.82
L1834
3
KO W/0 JOINT RIGID MOLDED TO
$557.35
L1836
5
RIGID KO WO JOINTS
L1840
3
KO DEROT ANT CRUCIATE CUSTOM
$742.41
L1843
3
KO SINGLE UPRIGHT CUSTOM FIT
$672.48
L1844
3
KO W/ADJ JT ROT CNTRL MOLDED
$1,165.61
L1845
3
KO W/ ADJ FLEX/EXT ROTAT CUS
$697.85
L1846
3
KO W ADJ FLEX/EXT ROTAT MOLD
$791.83
L1847
3
KO ADJUSTABLE W AIR CHAMBERS
$431.07
L1850
3
KO SWEDISH TYPE
$218.25
L1855
O
KO PLAS DOUB UPRIGHT JNT MOL
$0.00
L1858
O
KO POLYCENTRIC PNEUMATIC PAD
$0.00
L1860
3
KO SUPRACONDYLAR SOCKET MOLD
L1870
O
KO DOUB UPRIGHT LACERS MOLDE
$0.00
L1880
O
KO DOUB UPRIGHT CUFFS/LACERS
$0.00
L1885
O
KNEE UPRIGHT W/RESISTANCE
$0.00
L1900
3
AFO SPRNG WIR DRSFLX CALF BD
$0.00 $1,289.59
$0.00
$770.45
$193.70
Procedure Code Pricing Action Code Description
Maximum Allowable
L1901
5
PREFAB ANKLE ORTHOSIS
$0.00
L1902
3
AFO ANKLE GAUNTLET
L1904
3
AFO MOLDED ANKLE GAUNTLET
L1906
3
AFO MULTILIGAMENTUS ANKLE SU
L1907
6
AFO SUPRAMALLEOLAR CUSTOM
$0.00
L1910
3
AFO SING BAR CLASP ATTACH SH
$196.12
L1920
3
AFO SING UPRIGHT W/ ADJUST S
$251.01
L1930
3
AFO PLASTIC
$169.85
L1932
6
AFO RIG ANT TIB PREFAB TCF/=
L1940
3
AFO MOLDED TO PATIENT PLASTI
$355.08
L1945
3
AFO MOLDED PLAS RIG ANT TIB
$848.95
L1950
3
AFO SPIRAL MOLDED TO PT PLAS
$562.89
L1951
6
AFO SPIRAL PREFABRICATED
L1960
3
AFO POS SOLID ANK PLASTIC MO
$424.55
L1970
3
AFO PLASTIC MOLDED W/ANKLE J
$510.90
L1971
6
AFO W/ANKLE JOINT, PREFAB
L1980
3
AFO SING SOLID STIRRUP CALF
$263.51
L1990
3
AFO DOUB SOLID STIRRUP CALF
$320.05
L2000
3
KAFO SING FRE STIRR THI/CALF
$758.23
L2005
6
KAFO SNG/DBL MECHANICAL ACT
L2010
3
KAFO SNG SOLID STIRRUP W/O J
$707.32
L2020
3
KAFO DBL SOLID STIRRUP BAND/
$890.63
L2030
3
KAFO DBL SOLID STIRRUP W/O J
$808.48
L2034
6
KAFO PLA SIN UP W/WO K/A CUS
$0.00
L2035
3
KAFO PLASTIC PEDIATRIC SIZE
L2036
3
KAFO PLAS DOUB FREE KNEE MOL
$1,380.47
L2037
3
KAFO PLAS SING FREE KNEE MOL
$1,287.91
L2038
3
KAFO W/O JOINT MULTI-AXIS AN
$1,308.30
L2039
O
KAFO,PLSTIC,MEDLAT ROTAT CON
$0.00
L2040
3
HKAFO TORSION BIL ROT STRAPS
$158.68
L2050
3
HKAFO TORSION CABLE HIP PELV
$342.03
L2060
3
HKAFO TORSION BALL BEARING J
$416.86
L2070
3
HKAFO TORSION UNILAT ROT STR
$107.04
L2080
3
HKAFO UNILAT TORSION CABLE
$258.25
L2090
3
HKAFO UNILAT TORSION BALL BR
$314.84
$66.93 $402.52 $86.35
$0.00
$0.00
$0.00
$0.00
$131.14
Procedure Code Pricing Action Code Description
Maximum Allowable
L2102
O
AFO TIBIAL FX CAST PLSTR MOL
$0.00
L2104
O
AFO TIB FX CAST SYNTHETIC MO
$0.00
L2106
3
AFO TIB FX CAST PLASTER MOLD
$488.18
L2108
3
AFO TIB FX CAST MOLDED TO PT
$850.00
L2112
3
AFO TIBIAL FRACTURE SOFT
$390.97
L2114
3
AFO TIB FX SEMI-RIGID
$490.39
L2116
3
AFO TIBIAL FRACTURE RIGID
$564.23
L2122
O
KAFO FEM FX CAST PLASTER MOL
$0.00
L2124
O
KAFO FEM FX CAST SYNTHET MOL
$0.00
L2126
3
KAFO FEM FX CAST THERMOPLAS
$943.82
L2128
3
KAFO FEM FX CAST MOLDED TO P
$1,336.53
L2132
3
KAFO FEMORAL FX CAST SOFT
$724.60
L2134
3
KAFO FEM FX CAST SEMI-RIGID
$773.23
L2136
3
KAFO FEMORAL FX CAST RIGID
$922.89
L2180
3
PLAS SHOE INSERT W ANK JOINT
$86.13
L2182
3
DROP LOCK KNEE
$71.37
L2184
3
LIMITED MOTION KNEE JOINT
$97.56
L2186
3
ADJ MOTION KNEE JNT LERMAN T
$135.31
L2188
3
QUADRILATERAL BRIM
$259.14
L2190
3
WAIST BELT
L2192
3
PELVIC BAND & BELT THIGH FLA
$294.02
L2200
3
LIMITED ANKLE MOTION EA JNT
$34.14
L2210
3
DORSIFLEXION ASSIST EACH JOI
$49.41
L2220
3
DORSI & PLANTAR FLEX ASS/RES
$58.80
L2230
3
SPLIT FLAT CALIPER STIRR & P
$55.09
L2232
6
ROCKER BOTTOM, CONTACT AFO
$0.00
L2240
3
ROUND CALIPER AND PLATE ATTA
$68.19
L2250
3
FOOT PLATE MOLDED STIRRUP AT
$276.47
L2260
3
REINFORCED SOLID STIRRUP
$143.93
L2265
3
LONG TONGUE STIRRUP
$84.55
L2270
3
VARUS/VALGUS STRAP PADDED/LI
$39.65
L2275
3
PLASTIC MOD LOW EXT PAD/LINE
$93.48
L2280
3
MOLDED INNER BOOT
$326.87
L2300
3
ABDUCTION BAR JOINTED ADJUST
$204.94
L2310
3
ABDUCTION BAR-STRAIGHT
$102.64
$66.96
Procedure Code Pricing Action Code Description
Maximum Allowable
L2320
3
NON-MOLDED LACER
$147.73
L2330
3
LACER MOLDED TO PATIENT MODE
$309.23
L2335
3
ANTERIOR SWING BAND
$190.92
L2340
3
PRE-TIBIAL SHELL MOLDED TO P
$413.33
L2350
3
PROSTHETIC TYPE SOCKET MOLDE
$713.86
L2360
3
EXTENDED STEEL SHANK
L2370
3
PATTEN BOTTOM
$240.71
L2375
3
TORSION ANK & HALF SOLID STI
$101.69
L2380
3
TORSION STRAIGHT KNEE JOINT
$88.39
L2385
3
STRAIGHT KNEE JOINT HEAVY DU
$96.17
L2387
6
ADD LE POLY KNEE CUSTOM KAFO
$0.00
L2390
3
OFFSET KNEE JOINT EACH
L2395
3
OFFSET KNEE JOINT HEAVY DUTY
$112.34
L2397
3
SUSPENSION SLEEVE LOWER EXT
$87.53
L2405
3
KNEE JOINT DROP LOCK EA JNT
$65.34
L2415
3
KNEE JOINT CAM LOCK EACH JOI
$91.03
L2425
3
KNEE DISC/DIAL LOCK/ADJ FLEX
$107.43
L2430
3
KNEE JNT RATCHET LOCK EA JNT
$107.43
L2435
O
KNEE JOINT POLYCENTRIC JOINT
$0.00
L2492
3
KNEE LIFT LOOP DROP LOCK RIN
$97.54
L2500
3
THI/GLUT/ISCHIA WGT BEARING
$233.34
L2510
3
TH/WGHT BEAR QUAD-LAT BRIM M
$523.55
L2520
3
TH/WGHT BEAR QUAD-LAT BRIM C
$345.37
L2525
3
TH/WGHT BEAR NAR M-L BRIM MO
$931.80
L2526
3
TH/WGHT BEAR NAR M-L BRIM CU
$531.72
L2530
3
THIGH/WGHT BEAR LACER NON-MO
$168.70
L2540
3
THIGH/WGHT BEAR LACER MOLDED
$303.55
L2550
3
THIGH/WGHT BEAR HIGH ROLL CU
$206.21
L2570
3
HIP CLEVIS TYPE 2 POSIT JNT
$341.99
L2580
3
PELVIC CONTROL PELVIC SLING
$333.23
L2600
3
HIP CLEVIS/THRUST BEARING FR
$182.48
L2610
3
HIP CLEVIS/THRUST BEARING LO
$193.28
L2620
3
PELVIC CONTROL HIP HEAVY DUT
$217.32
L2622
3
HIP JOINT ADJUSTABLE FLEXION
$246.37
L2624
3
HIP ADJ FLEX EXT ABDUCT CONT
$237.76
$37.15
$80.51
Procedure Code Pricing Action Code Description
Maximum Allowable
L2627
3
PLASTIC MOLD RECIPRO HIP & C
$1,297.39
L2628
3
METAL FRAME RECIPRO HIP & CA
$1,276.17
L2630
3
PELVIC CONTROL BAND & BELT U
$177.79
L2640
3
PELVIC CONTROL BAND & BELT B
$241.29
L2650
3
PELV & THOR CONTROL GLUTEAL
$102.75
L2660
3
THORACIC CONTROL THORACIC BA
$133.82
L2670
3
THORAC CONT PARASPINAL UPRIG
$129.79
L2680
3
THORAC CONT LAT SUPPORT UPRI
$120.23
L2750
3
PLATING CHROME/NICKEL PR BAR
$60.02
L2755
3
CARBON GRAPHITE LAMINATION
$97.91
L2760
3
EXTENSION PER EXTENSION PER
$43.62
L2768
5
ORTHO SIDEBAR DISCONNECT
L2770
3
LOW EXT ORTHOSIS PER BAR/JNT
$44.33
L2780
3
NON-CORROSIVE FINISH
$48.59
L2785
3
DROP LOCK RETAINER EACH
$22.86
L2795
3
KNEE CONTROL FULL KNEECAP
$61.97
L2800
3
KNEE CAP MEDIAL OR LATERAL P
$95.24
L2810
3
KNEE CONTROL CONDYLAR PAD
$74.77
L2820
3
SOFT INTERFACE BELOW KNEE SE
$62.35
L2830
3
SOFT INTERFACE ABOVE KNEE SE
$67.46
L2840
3
TIBIAL LENGTH SOCK FX OR EQU
$39.88
L2850
3
FEMORAL LGTH SOCK FX OR EQUA
$44.46
L2860
O
TORSION MECHANISM KNEE/ANKLE
$0.00
L2999
5
LOWER EXTREMITY ORTHOSIS NOS
$0.00
L3000
3
FT INSERT UCB BERKELEY SHELL
L3001
5
FOOT INSERT REMOV MOLDED SPE
$0.00
L3002
5
FOOT INSERT PLASTAZOTE OR EQ
$0.00
L3003
5
FOOT INSERT SILICONE GEL EAC
$0.00
L3010
5
FOOT LONGITUDINAL ARCH SUPPO
$0.00
L3020
3
FOOT LONGITUD/METATARSAL SUP
$155.91
L3030
5
FOOT ARCH SUPPORT REMOV PREM
$0.00
L3031
6
FOOT LAMIN/PREPREG COMPOSITE
$0.00
L3040
5
FT ARCH SUPRT PREMOLD LONGIT
$0.00
L3050
5
FOOT ARCH SUPP PREMOLD METAT
$0.00
L3060
5
FOOT ARCH SUPP LONGITUD/META
$0.00
$0.00
$80.00
Procedure Code Pricing Action Code Description
Maximum Allowable
L3070
5
ARCH SUPRT ATT TO SHO LONGIT
$0.00
L3080
5
ARCH SUPP ATT TO SHOE METATA
$0.00
L3090
5
ARCH SUPP ATT TO SHOE LONG/M
$0.00
L3100
5
HALLUS-VALGUS NGHT DYNAMIC S
$0.00
L3140
5
ABDUCTION ROTATION BAR SHOE
$0.00
L3150
5
ABDUCT ROTATION BAR W/O SHOE
$0.00
L3160
5
SHOE STYLED POSITIONING DEV
$0.00
L3170
5
FOOT PLASTIC HEEL STABILIZER
$0.00
L3201
5
OXFORD W SUPINAT/PRONAT INF
$0.00
L3202
5
OXFORD W/ SUPINAT/PRONATOR C
$0.00
L3203
5
OXFORD W/ SUPINATOR/PRONATOR
$0.00
L3204
5
HIGHTOP W/ SUPP/PRONATOR INF
$0.00
L3206
5
HIGHTOP W/ SUPP/PRONATOR CHI
$0.00
L3207
5
HIGHTOP W/ SUPP/PRONATOR JUN
$0.00
L3208
5
SURGICAL BOOT EACH INFANT
$0.00
L3209
5
SURGICAL BOOT EACH CHILD
$0.00
L3211
5
SURGICAL BOOT EACH JUNIOR
$0.00
L3212
5
BENESCH BOOT PAIR INFANT
$0.00
L3213
5
BENESCH BOOT PAIR CHILD
$0.00
L3214
5
BENESCH BOOT PAIR JUNIOR
$0.00
L3215
3
ORTHOPEDIC FTWEAR LADIES OXF
$86.72
L3216
5
ORTHOPED LADIES SHOES DPTH I
$0.00
L3217
5
LADIES SHOES HIGHTOP DEPTH I
$0.00
L3218
O
LADIES SURGICAL BOOT EACH
$0.00
L3219
3
ORTHOPEDIC MENS SHOES OXFORD
L3221
5
ORTHOPEDIC MENS SHOES DPTH I
$0.00
L3222
5
MENS SHOES HIGHTOP DEPTH INL
$0.00
L3223
O
MENS SURGICAL BOOT EACH
$0.00
L3224
3
WOMAN'S SHOE OXFORD BRACE
$47.77
L3225
3
MAN'S SHOE OXFORD BRACE
$49.05
L3230
5
CUSTOM SHOES DEPTH INLAY
$0.00
L3250
5
CUSTOM MOLD SHOE REMOV PROST
$0.00
L3251
5
SHOE MOLDED TO PT SILICONE S
$0.00
L3252
5
SHOE MOLDED PLASTAZOTE CUST
$0.00
L3253
5
SHOE MOLDED PLASTAZOTE CUST
$0.00
$89.02
Procedure Code Pricing Action Code Description
Maximum Allowable
L3254
5
ORTH FOOT NON-STNDARD SIZE/W
$0.00
L3255
5
ORTH FOOT NON-STANDARD SIZE/
$0.00
L3257
5
ORTH FOOT ADD CHARGE SPLIT S
$0.00
L3260
5
AMBULATORY SURGICAL BOOT EAC
$0.00
L3265
5
PLASTAZOTE SANDAL EACH
$0.00
L3300
5
SHO LIFT TAPER TO METATARSAL
$0.00
L3310
5
SHOE LIFT ELEV HEEL/SOLE NEO
$0.00
L3320
5
SHOE LIFT ELEV HEEL/SOLE COR
$0.00
L3330
5
LIFTS ELEVATION METAL EXTENS
$0.00
L3332
5
SHOE LIFTS TAPERED TO ONE-HA
$0.00
L3334
5
SHOE LIFTS ELEVATION HEEL /I
$0.00
L3340
5
SHOE WEDGE SACH
$0.00
L3350
5
SHOE HEEL WEDGE
$0.00
L3360
5
SHOE SOLE WEDGE OUTSIDE SOLE
$0.00
L3370
5
SHOE SOLE WEDGE BETWEEN SOLE
$0.00
L3380
5
SHOE CLUBFOOT WEDGE
$0.00
L3390
5
SHOE OUTFLARE WEDGE
$0.00
L3400
5
SHOE METATARSAL BAR WEDGE RO
$0.00
L3410
5
SHOE METATARSAL BAR BETWEEN
$0.00
L3420
5
FULL SOLE/HEEL WEDGE BTWEEN
$0.00
L3430
5
SHO HEEL COUNT PLAST REINFOR
$0.00
L3440
5
HEEL LEATHER REINFORCED
$0.00
L3450
5
SHOE HEEL SACH CUSHION TYPE
$0.00
L3455
5
SHOE HEEL NEW LEATHER STANDA
$0.00
L3460
5
SHOE HEEL NEW RUBBER STANDAR
$0.00
L3465
5
SHOE HEEL THOMAS WITH WEDGE
$0.00
L3470
5
SHOE HEEL THOMAS EXTEND TO B
$0.00
L3480
5
SHOE HEEL PAD & DEPRESS FOR
$0.00
L3485
5
SHOE HEEL PAD REMOVABLE FOR
$0.00
L3500
5
ORTHO SHOE ADD LEATHER INSOL
$0.00
L3510
5
ORTHOPEDIC SHOE ADD RUB INSL
$0.00
L3520
5
O SHOE ADD FELT W LEATH INSL
$0.00
L3530
5
ORTHO SHOE ADD HALF SOLE
$0.00
L3540
5
ORTHO SHOE ADD FULL SOLE
$0.00
L3550
5
O SHOE ADD STANDARD TOE TAP
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
L3560
5
O SHOE ADD HORSESHOE TOE TAP
$0.00
L3570
5
O SHOE ADD INSTEP EXTENSION
$0.00
L3580
5
O SHOE ADD INSTEP VELCRO CLO
$0.00
L3590
5
O SHOE CONVERT TO SOF COUNTE
$0.00
L3595
5
ORTHO SHOE ADD MARCH BAR
$0.00
L3600
5
TRANS SHOE CALIP PLATE EXIST
$0.00
L3610
3
TRANS SHOE CALIPER PLATE NEW
L3620
5
TRANS SHOE SOLID STIRRUP EXI
$0.00
L3630
5
TRANS SHOE SOLID STIRRUP NEW
$0.00
L3640
5
SHOE DENNIS BROWNE SPLINT BO
$0.00
L3649
5
ORTHOPEDIC SHOE MODIFICA NOS
$0.00
L3650
3
SHLDER FIG 8 ABDUCT RESTRAIN
L3651
5
PREFAB SHOULDER ORTHOSIS
$0.00
L3652
5
PREFAB DBL SHOULDER ORTHOSIS
$0.00
L3660
3
ABDUCT RESTRAINER CANVAS&WEB
$72.21
L3670
3
ACROMIO/CLAVICULAR CANVAS&WE
$95.42
L3671
6
SO CAP DESIGN W/O JNTS CF
$0.00
L3672
6
SO AIRPLANE W/O JNTS CF
$0.00
L3673
6
SO AIRPLANE W/JOINT CF
$0.00
L3675
3
CANVAS VEST SO
L3677
5
SO HARD PLASTIC STABILIZER
L3700
3
ELBOW ORTHOSES ELAS W STAYS
$49.04
L3701
3
PREFAB ELBOW ORTHOSIS
$14.56
L3702
6
EO W/O JOINTS CF
L3710
3
ELBOW ELASTIC WITH METAL JOI
$109.80
L3720
3
FOREARM/ARM CUFFS FREE MOTIO
$489.89
L3730
3
FOREARM/ARM CUFFS EXT/FLEX A
$633.36
L3740
3
CUFFS ADJ LOCK W/ ACTIVE CON
$750.90
L3760
3
EO WITHJOINT, PREFABRICATED
$341.11
L3762
5
RIGID EO WO JOINTS
$0.00
L3763
6
EWHO RIGID W/O JNTS CF
$0.00
L3764
6
EWHO W/JOINT(S) CF
$0.00
L3765
6
EWHFO RIGID W/O JNTS CF
$0.00
L3766
6
EWHFO W/JOINT(S) CF
$0.00
L3800
O
WHFO SHORT OPPONEN NO ATTACH
$0.00
$30.00
$47.75
$119.70 $0.00
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
L3805
O
WHFO LONG OPPONENS NO ATTACH
$0.00
L3806
6
WHFO W/JOINT(S) CUSTOM FAB
$0.00
L3807
3
WHFO,NO JOINT, PREFABRICATED
L3808
6
WHFO, RIGID W/O JOINTS
$0.00
L3810
O
WHFO THUMB ABDUCTION BAR
$0.00
L3815
O
WHFO SECOND M.P. ABDUCTION A
$0.00
L3820
O
WHFO IP EXT ASST W/ MP EXT S
$0.00
L3825
O
WHFO M.P. EXTENSION STOP
$0.00
L3830
O
WHFO M.P. EXTENSION ASSIST
$0.00
L3835
O
WHFO M.P. SPRING EXTENSION A
$0.00
L3840
O
WHFO SPRING SWIVEL THUMB
$0.00
L3845
O
WHFO THUMB IP EXT ASS W/ MP
$0.00
L3850
O
ACTION WRIST W/ DORSIFLEX AS
$0.00
L3855
O
WHFO ADJ M.P. FLEXION CONTRO
$0.00
L3860
O
WHFO ADJ M.P. FLEX CTRL & I.
$0.00
L3890
O
TORSION MECHANISM WRIST/ELBO
$0.00
L3900
3
HINGE EXTENSION/FLEX WRIST/F
L3901
3
HINGE EXT/FLEX WRIST FINGER
L3902
O
WHFO EXT POWER COMPRESS GAS
L3904
3
WHFO ELECTRIC CUSTOM FITTED
L3905
6
WHO W/NONTORSION JNT(S) CF
L3906
3
WHO W/O JOINTS CF
L3907
O
WHFO WRST GAUNTLT THMB SPICA
L3908
3
WRIST COCK-UP NON-MOLDED
L3909
5
PREFAB WRIST ORTHOSIS
$0.00
L3910
O
WHFO SWANSON DESIGN
$0.00
L3911
5
PREFAB HAND FINGER ORTHOSIS
$0.00
L3912
3
FLEX GLOVE W/ELASTIC FINGER
L3913
6
HFO W/O JOINTS CF
$0.00
L3914
O
WHO WRIST EXTENSION COCK-UP
$0.00
L3915
6
WHO W NONTOR JNT(S) PREFAB
$0.00
L3916
O
WHFO WRIST EXTENS W/ OUTRIGG
$0.00
L3917
6
PREFAB METACARPL FX ORTHOSIS
$0.00
L3918
O
HFO KNUCKLE BENDER
$0.00
L3919
6
HO W/O JOINTS CF
$0.00
$170.55
$994.57 $1,129.43 $0.00 $2,057.53 $0.00 $300.34 $0.00 $47.27
$81.88
Procedure Code Pricing Action Code Description
Maximum Allowable
L3920
O
KNUCKLE BENDER WITH OUTRIGGE
$0.00
L3921
6
HFO W/JOINT(S) CF
$0.00
L3922
O
KNUCKLE BEND 2 SEG TO FLEX J
$0.00
L3923
3
HFO W/O JOINTS PF
L3924
O
OPPENHEIMER
$0.00
L3925
6
FO PIP/DIP WITH JOINT/SPRING
$0.00
L3926
O
THOMAS SUSPENSION
$0.00
L3927
6
FO PIP/DIP W/O JOINT/SPRING
$0.00
L3928
O
FINGER EXTENSION W/ CLOCK SP
$0.00
L3929
6
HFO NONTORSION JOINT, PREFAB
$0.00
L3930
O
FINGER EXTENSION WITH WRIST
$0.00
L3931
6
WHFO NONTORSION JOINT PREFAB
$0.00
L3932
O
SAFETY PIN SPRING WIRE
$0.00
L3933
6
FO W/O JOINTS CF
$0.00
L3934
O
SAFETY PIN MODIFIED
$0.00
L3935
6
FO NONTORSION JOINT CF
$0.00
L3936
O
PALMER
$0.00
L3938
O
DORSAL WRIST
$0.00
L3940
O
DORSAL WRIST W/ OUTRIGGER AT
$0.00
L3942
O
REVERSE KNUCKLE BENDER
$0.00
L3944
O
REVERSE KNUCKLE BEND W/ OUTR
$0.00
L3946
O
HFO COMPOSITE ELASTIC
$0.00
L3948
O
FINGER KNUCKLE BENDER
$0.00
L3950
O
OPPENHEIMER W/ KNUCKLE BEND
$0.00
L3952
O
OPPENHEIMER W/ REV KNUCKLE 2
$0.00
L3954
O
SPREADING HAND
$0.00
L3956
5
ADD JOINT UPPER EXT ORTHOSIS
$0.00
L3960
3
SEWHO AIRPLAN DESIG ABDU POS
$516.83
L3961
6
SEWHO CAP DESIGN W/O JNTS CF
$0.00
L3962
3
SEWHO ERBS PALSEY DESIGN ABD
$504.11
L3963
O
MOLDED W/ ARTICULATING ELBOW
$0.00
L3964
3
SEO MOBILE ARM SUP ATT TO WC
$594.21
L3965
3
ARM SUPP ATT TO WC RANCHO TY
$948.19
L3966
3
MOBILE ARM SUPPORTS RECLININ
$714.31
L3967
6
SEWHO AIRPLANE W/O JNTS CF
$25.99
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
L3968
3
FRICTION DAMPENING ARM SUPP
$903.93
L3969
3
MONOSUSPENSION ARM/HAND SUPP
$615.05
L3970
3
ELEVAT PROXIMAL ARM SUPPORT
$252.86
L3971
6
SEWHO CAP DESIGN W/JNT(S) CF
$0.00
L3972
3
OFFSET/LAT ROCKER ARM W/ ELA
$160.79
L3973
6
SEWHO AIRPLANE W/JNT(S) CF
L3974
3
MOBILE ARM SUPPORT SUPINATOR
L3975
6
SEWHFO CAP DESIGN W/O JNT CF
$0.00
L3976
6
SEWHFO AIRPLANE W/O JNTS CF
$0.00
L3977
6
SEWHFO CAP DESGN W/JNT(S) CF
$0.00
L3978
6
SEWHFO AIRPLANE W/JNT(S) CF
$0.00
L3980
3
UPP EXT FX ORTHOSIS HUMERAL
$224.99
L3982
3
UPPER EXT FX ORTHOSIS RAD/UL
$262.29
L3984
3
UPPER EXT FX ORTHOSIS WRIST
$241.83
L3985
O
FOREARM HAND FX ORTH W/ WR H
$0.00
L3986
O
HUMERAL RAD/ULNA WRIST FX OR
$0.00
L3995
3
SOCK FRACTURE OR EQUAL EACH
$25.05
L3999
5
UPPER LIMB ORTHOSIS NOS
L4000
3
REPL GIRDLE MILWAUKEE ORTH
L4002
6
REPLACE STRAP, ANY ORTHOSIS
L4010
3
REPLACE TRILATERAL SOCKET BR
$481.87
L4020
3
REPLACE QUADLAT SOCKET BRIM
$673.89
L4030
3
REPLACE SOCKET BRIM CUST FIT
$362.50
L4040
3
REPLACE MOLDED THIGH LACER
$295.81
L4045
3
REPLACE NON-MOLDED THIGH LAC
$235.52
L4050
3
REPLACE MOLDED CALF LACER
$296.42
L4055
3
REPLACE NON-MOLDED CALF LACE
$191.94
L4060
3
REPLACE HIGH ROLL CUFF
$228.18
L4070
3
REPLACE PROX & DIST UPRIGHT
$202.07
L4080
3
REPL MET BAND KAFO-AFO PROX
$82.87
L4090
3
REPL MET BAND KAFO-AFO CALF/
$65.40
L4100
3
REPL LEATH CUFF KAFO PROX TH
$85.87
L4110
3
REPL LEATH CUFF KAFO-AFO CAL
$64.70
L4130
3
REPLACE PRETIBIAL SHELL
L4200
O
REPAIR OF ORTHOTIC DEVICE, HOURLY R
$0.00 $136.38
$0.00 $988.41 $0.00
$362.78 $0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
L4205
3
ORTHO DVC REPAIR PER 15 MIN
$6.25
L4210
5
ORTH DEV REPAIR/REPL MINOR P
$0.00
L4310
O
MULT-PODUS/EQ ORTH PREP MGMT
$0.00
L4320
O
LOW EXT MGMT SYS FT POS AFO
$0.00
L4350
3
ANKLE CONTROL ORTHOSI PREFAB
$71.87
L4360
3
PNEUMATI WALKING BOOT PREFAB
$220.93
L4370
3
PNEUMATIC FULL LEG SPLINT
$146.11
L4380
3
PNEUMATIC KNEE SPLINT
L4386
3
NON-PNEUM WALK BOOT PREFAB
L4390
O
REPLACE MULTI-PODUS SPLINT
$0.00
L4392
3
REPLACE AFO SOFT INTERFACE
$17.63
L4394
3
REPLACE FOOT DROP SPINT
$12.87
L4396
3
STATIC AFO
L4398
3
FOOT DROP SPLINT RECUMBENT
$57.91
L5000
3
SHO INSERT W ARCH TOE FILLER
$426.36
L5010
3
MOLD SOCKET ANK HGT W/ TOE F
$931.27
L5020
3
TIBIAL TUBERCLE HGT W/ TOE F
$1,515.92
L5050
3
ANK SYMES MOLD SCKT SACH FT
$1,755.51
L5060
3
SYMES MET FR LEATH SOCKET AR
$2,112.77
L5100
3
MOLDED SOCKET SHIN SACH FOOT
$1,828.78
L5105
3
PLAST SOCKET JTS/THGH LACER
$2,902.64
L5150
3
MOLD SCKT EXT KNEE SHIN SACH
$2,686.23
L5160
3
MOLD SOCKET BENT KNEE SHIN S
$2,921.76
L5200
3
KNE SING AXIS FRIC SHIN SACH
$2,545.10
L5210
3
NO KNEE/ANKLE JOINTS W/ FT B
$1,856.19
L5220
3
NO KNEE JOINT WITH ARTIC ALI
$2,109.89
L5230
3
FEM FOCAL DEFIC CONSTANT FRI
$2,909.97
L5250
3
HIP CANAD SING AXI CONS FRIC
$3,968.93
L5270
3
TILT TABLE LOCKING HIP SING
$3,934.16
L5280
3
HEMIPELVECT CANAD SING AXIS
$3,894.82
L5300
O
BK SACH SOFT COVER & FINISH
$0.00
L5301
5
BK MOLD SOCKET SACH FT ENDO
$0.00
L5310
O
KNEE DISART SACH SOFT CV/FIN
$0.00
L5311
5
KNEE DISART, SACH FT, ENDO
$0.00
L5320
O
AK OPEN END SACH SOFT CV/FIN
$0.00
$82.45 $124.58
$125.77
Procedure Code Pricing Action Code Description
Maximum Allowable
L5321
5
AK OPEN END SACH
$0.00
L5330
O
HIP CANADIAN SACH SFT CV/FIN
$0.00
L5331
5
HIP DISART CANADIAN SACH FT
$0.00
L5340
O
HEMIPELVECTOMY CANAD CV/FIN
$0.00
L5341
5
HEMIPELVECTOMY CANADIAN SACH
$0.00
L5400
3
POSTOP DRESS & 1 CAST CHG BK
$920.64
L5410
3
POSTOP DSG BK EA ADD CAST CH
$403.36
L5420
3
POSTOP DSG & 1 CAST CHG AK/D
L5430
3
POSTOP DSG AK EA ADD CAST CH
$513.24
L5450
3
POSTOP APP NON-WGT BEAR DSG
$328.33
L5460
3
POSTOP APP NON-WGT BEAR DSG
$483.92
L5500
3
INIT BK PTB PLASTER DIRECT
$982.44
L5505
3
INIT AK ISCHAL PLSTR DIRECT
$1,330.47
L5510
3
PREP BK PTB PLASTER MOLDED
$1,113.65
L5520
3
PERP BK PTB THERMOPLS DIRECT
$1,100.03
L5530
3
PREP BK PTB THERMOPLS MOLDED
$1,392.40
L5535
3
PREP BK PTB OPEN END SOCKET
$1,372.22
L5540
3
PREP BK PTB LAMINATED SOCKET
$1,448.99
L5560
3
PREP AK ISCHIAL PLAST MOLDED
$1,486.72
L5570
3
PREP AK ISCHIAL DIRECT FORM
$1,545.67
L5580
3
PREP AK ISCHIAL THERMO MOLD
$1,804.46
L5585
3
PREP AK ISCHIAL OPEN END
$1,957.15
L5590
3
PREP AK ISCHIAL LAMINATED
$1,838.87
L5595
3
HIP DISARTIC SACH THERMOPLS
$3,232.24
L5600
3
HIP DISART SACH LAMINAT MOLD
$3,525.47
L5610
3
ABOVE KNEE HYDRACADENCE
$1,583.72
L5611
3
AK 4 BAR LINK W/FRIC SWING
$1,232.45
L5613
3
AK 4 BAR LING W/HYDRAUL SWIG
$1,874.64
L5614
3
4-BAR LINK ABOVE KNEE W/SWNG
$1,267.18
L5616
3
AK UNIV MULTIPLEX SYS FRICT
$1,038.91
L5617
3
AK/BK SELF-ALIGNING UNIT EA
$420.17
L5618
3
TEST SOCKET SYMES
$242.04
L5620
3
TEST SOCKET BELOW KNEE
$212.67
L5622
3
TEST SOCKET KNEE DISARTICULA
$324.80
L5624
3
TEST SOCKET ABOVE KNEE
$309.88
$1,162.72
Procedure Code Pricing Action Code Description
Maximum Allowable
L5626
3
TEST SOCKET HIP DISARTICULAT
$435.56
L5628
3
TEST SOCKET HEMIPELVECTOMY
$412.54
L5629
3
BELOW KNEE ACRYLIC SOCKET
$315.05
L5630
3
SYME TYP EXPANDABL WALL SCKT
$343.30
L5631
3
AK/KNEE DISARTIC ACRYLIC SOC
$410.52
L5632
3
SYMES TYPE PTB BRIM DESIGN S
$169.85
L5634
3
SYMES TYPE POSTER OPENING SO
$232.68
L5636
3
SYMES TYPE MEDIAL OPENING SO
$194.91
L5637
3
BELOW KNEE TOTAL CONTACT
$260.35
L5638
3
BELOW KNEE LEATHER SOCKET
$372.27
L5639
3
BELOW KNEE WOOD SOCKET
$873.31
L5640
3
KNEE DISARTICULAT LEATHER SO
$531.69
L5642
3
ABOVE KNEE LEATHER SOCKET
$476.00
L5643
3
HIP FLEX INNER SOCKET EXT FR
L5644
3
ABOVE KNEE WOOD SOCKET
$451.81
L5645
3
BK FLEX INNER SOCKET EXT FRA
$610.34
L5646
3
BELOW KNEE CUSHION SOCKET
$419.12
L5647
3
BELOW KNEE SUCTION SOCKET
$608.48
L5648
3
ABOVE KNEE CUSHION SOCKET
$503.62
L5649
3
ISCH CONTAINMT/NARROW M-L SO
L5650
3
TOT CONTACT AK/KNEE DISART S
$373.43
L5651
3
AK FLEX INNER SOCKET EXT FRA
$918.63
L5652
3
SUCTION SUSP AK/KNEE DISART
$333.50
L5653
3
KNEE DISART EXPAND WALL SOCK
$445.19
L5654
3
SOCKET INSERT SYMES
$253.68
L5655
3
SOCKET INSERT BELOW KNEE
$214.80
L5656
3
SOCKET INSERT KNEE ARTICULAT
$302.59
L5658
3
SOCKET INSERT ABOVE KNEE
$294.67
L5660
O
SOCK INSRT SYME SILICONE GEL
L5661
3
MULTI-DUROMETER SYMES
L5662
O
SOCKET INSERT BK SILICONE GE
$0.00
L5663
O
SOCK KNEE DISARTIC SILICONE
$0.00
L5664
O
SOCKET INSERT AK SILICONE GE
$0.00
L5665
3
MULTI-DUROMETER BELOW KNEE
$391.67
L5666
3
BELOW KNEE CUFF SUSPENSION
$58.20
$1,190.58
$1,528.91
$0.00 $512.05
Procedure Code Pricing Action Code Description
Maximum Allowable
L5667
O
SOCKET INSERT W LOCK LOWER
$0.00
L5668
3
SOCKET INSERT W/O LOCK LOWER
L5669
O
BELOW KNEE SOCKET W/O LOCK
L5670
3
BK MOLDED SUPRACONDYLAR SUSP
L5671
5
BK/AK LOCKING MECHANISM
L5672
3
BK REMOVABLE MEDIAL BRIM SUS
L5673
6
SOCKET INSERT W LOCK MECH
$0.00
L5674
O
BK SUSPENSION SLEEVE
$0.00
L5675
O
BK HEAVY DUTY SUSP SLEEVE
$0.00
L5676
3
BK KNEE JOINTS SINGLE AXIS P
$277.19
L5677
3
BK KNEE JOINTS POLYCENTRIC P
$377.16
L5678
3
BK JOINT COVERS PAIR
L5679
6
SOCKET INSERT W/O LOCK MECH
L5680
3
BK THIGH LACER NON-MOLDED
L5681
6
INTL CUSTM CONG/LATYP INSERT
L5682
3
BK THIGH LACER GLUT/ISCHIA M
L5683
6
INITIAL CUSTOM SOCKET INSERT
L5684
3
BK FORK STRAP
L5685
6
BELOW KNEE SUS/SEAL SLEEVE
L5686
3
BK BACK CHECK
$49.66
L5688
3
BK WAIST BELT WEBBING
$46.72
L5690
3
BK WAIST BELT PADDED AND LIN
$90.49
L5692
3
AK PELVIC CONTROL BELT LIGHT
$105.02
L5694
3
AK PELVIC CONTROL BELT PAD/L
$138.77
L5695
3
AK SLEEVE SUSP NEOPRENE/EQUA
$145.59
L5696
3
AK/KNEE DISARTIC PELVIC JOIN
$159.10
L5697
3
AK/KNEE DISARTIC PELVIC BAND
$64.62
L5698
3
AK/KNEE DISARTIC SILESIAN BA
$80.36
L5699
3
SHOULDER HARNESS
L5700
3
REPLACE SOCKET BELOW KNEE
$2,203.73
L5701
3
REPLACE SOCKET ABOVE KNEE
$2,733.93
L5702
3
REPLACE SOCKET HIP
$3,445.70
L5703
6
SYMES ANKLE W/O (SACH) FOOT
L5704
3
CUSTOM SHAPE COVER BK
$449.33
L5705
3
CUSTOM SHAPE COVER AK
$823.79
$77.71 $0.00 $236.56 $0.00 $289.06
$30.37 $0.00 $264.93 $0.00 $478.39 $0.00 $36.81 $0.00
$142.63
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
L5706
3
CUSTOM SHAPE CVR KNEE DISART
$803.52
L5707
3
CUSTOM SHAPE CVR HIP DISART
$1,079.50
L5710
3
KNE-SHIN EXO SNG AXI MNL LOC
$275.12
L5711
3
KNEE-SHIN EXO MNL LOCK ULTRA
$417.34
L5712
3
KNEE-SHIN EXO FRICT SWG & ST
$329.61
L5714
3
KNEE-SHIN EXO VARIABLE FRICT
$339.91
L5716
3
KNEE-SHIN EXO MECH STANCE PH
$557.52
L5718
3
KNEE-SHIN EXO FRCT SWG & STA
$696.84
L5722
3
KNEE-SHIN PNEUM SWG FRCT EXO
$727.18
L5724
3
KNEE-SHIN EXO FLUID SWING PH
$1,154.61
L5726
3
KNEE-SHIN EXT JNTS FLD SWG E
$1,516.14
L5728
3
KNEE-SHIN FLUID SWG & STANCE
$1,888.89
L5780
3
KNEE-SHIN PNEUM/HYDRA PNEUM
$910.73
L5781
5
LOWER LIMB PROS VACUUM PUMP
$0.00
L5782
5
HD LOW LIMB PROS VACUUM PUMP
$0.00
L5785
3
EXOSKELETAL BK ULTRALT MATER
$397.43
L5790
3
EXOSKELETAL AK ULTRA-LIGHT M
$550.01
L5795
3
EXOSKEL HIP ULTRA-LIGHT MATE
$821.31
L5810
3
ENDOSKEL KNEE-SHIN MNL LOCK
$382.08
L5811
3
ENDO KNEE-SHIN MNL LCK ULTRA
$557.88
L5812
3
ENDO KNEE-SHIN FRCT SWG & ST
$432.41
L5814
3
ENDO KNEE-SHIN HYDRAL SWG PH
$2,788.88
L5816
3
ENDO KNEE-SHIN POLYC MCH STA
$650.54
L5818
3
ENDO KNEE-SHIN FRCT SWG & ST
$734.59
L5822
3
ENDO KNEE-SHIN PNEUM SWG FRC
$1,425.17
L5824
3
ENDO KNEE-SHIN FLUID SWING P
$1,173.08
L5826
3
MINIATURE KNEE JOINT
$2,368.56
L5828
3
ENDO KNEE-SHIN FLUID SWG/STA
$2,236.15
L5830
3
ENDO KNEE-SHIN PNEUM/SWG PHA
$1,588.87
L5840
3
MULTI-AXIAL KNEE/SHIN SYSTEM
$2,801.79
L5845
3
KNEE-SHIN SYS STANCE FLEXION
$1,345.96
L5846
O
KNEE-SHIN SYS MICROPROCESSOR
$0.00
L5847
O
MICROPROCESSOR CNTRL FEATURE
$0.00
L5848
5
KNEE-SHIN SYS HYDRAUL STANCE
$0.00
L5850
3
ENDO AK/HIP KNEE EXTENS ASSI
$101.61
Procedure Code Pricing Action Code Description
Maximum Allowable
L5855
3
MECH HIP EXTENSION ASSIST
$236.23
L5856
6
ELEC KNEE-SHIN SWING/STANCE
$0.00
L5857
6
ELEC KNEE-SHIN SWING ONLY
$0.00
L5858
6
STANCE PHASE ONLY
$0.00
L5910
3
ENDO BELOW KNEE ALIGNABLE SY
$279.01
L5920
3
ENDO AK/HIP ALIGNABLE SYSTEM
$405.87
L5925
3
ABOVE KNEE MANUAL LOCK
$257.02
L5930
3
HIGH ACTIVITY KNEE FRAME
$2,527.60
L5940
3
ENDO BK ULTRA-LIGHT MATERIAL
$383.70
L5950
3
ENDO AK ULTRA-LIGHT MATERIAL
$648.20
L5960
3
ENDO HIP ULTRA-LIGHT MATERIA
$776.46
L5962
3
BELOW KNEE FLEX COVER SYSTEM
$449.63
L5964
3
ABOVE KNEE FLEX COVER SYSTEM
$805.38
L5966
3
HIP FLEXIBLE COVER SYSTEM
$1,037.45
L5968
3
MULTIAXIAL ANKLE W DORSIFLEX
$2,728.85
L5970
3
FOOT EXTERNAL KEEL SACH FOOT
L5971
6
SACH FOOT, REPLACEMENT
L5972
3
FLEXIBLE KEEL FOOT
$269.59
L5974
3
FOOT SINGLE AXIS ANKLE/FOOT
$227.45
L5975
3
COMBO ANKLE/FOOT PROSTHESIS
$348.14
L5976
3
ENERGY STORING FOOT
$428.39
L5978
3
FT PROSTH MULTIAXIAL ANKL/FT
$223.23
L5979
3
MULTI-AXIAL ANKLE/FT PROSTH
$1,791.29
L5980
3
FLEX FOOT SYSTEM
$2,836.17
L5981
3
FLEX-WALK SYS LOW EXT PROSTH
$2,451.49
L5982
3
EXOSKELETAL AXIAL ROTATION U
$442.22
L5984
3
ENDOSKELETAL AXIAL ROTATION
$438.30
L5985
3
LWR EXT DYNAMIC PROSTH PYLON
$212.05
L5986
3
MULTI-AXIAL ROTATION UNIT
$487.29
L5987
3
SHANK FT W VERT LOAD PYLON
$5,402.07
L5988
3
VERTICAL SHOCK REDUCING PYLO
$1,500.16
L5989
O
PYLON W ELCTRNC FORCE SENSOR
$0.00
L5990
5
USER ADJUSTABLE HEEL HEIGHT
$0.00
L5993
O
HEAVY DUTY FEATURE, FOOT
$0.00
L5994
O
HEAVY DUTY FEATURE, KNEE
$0.00
$167.93 $0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
L5995
O
LOWER EXT PROS HEAVYDUTY FEA
$0.00
L5999
5
LOWR EXTREMITY PROSTHES NOS
$0.00
L6000
3
PAR HAND ROBIN-AIDS THUM REM
$1,016.37
L6010
3
HAND ROBIN-AIDS LITTLE/RING
$1,131.05
L6020
3
PART HAND ROBIN-AIDS NO FING
$1,054.53
L6025
5
PART HAND DISART MYOELECTRIC
L6050
3
WRST MLD SCK FLX HNG TRI PAD
$1,453.10
L6055
3
WRST MOLD SOCK W/EXP INTERFA
$2,309.76
L6100
3
ELB MOLD SOCK FLEX HINGE PAD
$1,472.21
L6110
3
ELBOW MOLD SOCK SUSPENSION T
$1,561.53
L6120
3
ELBOW MOLD DOUB SPLT SOC STE
$1,819.73
L6130
3
ELBOW STUMP ACTIVATED LOCK H
$1,980.21
L6200
3
ELBOW MOLD OUTSID LOCK HINGE
$2,086.82
L6205
3
ELBOW MOLDED W/ EXPAND INTER
$3,477.47
L6250
3
ELBOW INTER LOC ELBOW FORARM
$2,054.13
L6300
3
SHLDER DISART INT LOCK ELBOW
$2,849.88
L6310
3
SHOULDER PASSIVE RESTOR COMP
$2,343.65
L6320
3
SHOULDER PASSIVE RESTOR CAP
$1,307.24
L6350
3
THORACIC INTERN LOCK ELBOW
$2,996.21
L6360
3
THORACIC PASSIVE RESTOR COMP
$2,459.71
L6370
3
THORACIC PASSIVE RESTOR CAP
$1,851.78
L6380
3
POSTOP DSG CAST CHG WRST/ELB
$1,000.12
L6382
3
POSTOP DSG CAST CHG ELB DIS/
$1,196.80
L6384
3
POSTOP DSG CAST CHG SHLDER/T
$1,460.42
L6386
3
POSTOP EA CAST CHG & REALIGN
$350.22
L6388
3
POSTOP APPLICAT RIGID DSG ON
$336.28
L6400
3
BELOW ELBOW PROSTH TISS SHAP
$1,778.70
L6450
3
ELB DISART PROSTH TISS SHAP
$2,358.38
L6500
3
ABOVE ELBOW PROSTH TISS SHAP
$2,360.31
L6550
3
SHLDR DISAR PROSTH TISS SHAP
$2,916.91
L6570
3
SCAP THORAC PROSTH TISS SHAP
$3,539.21
L6580
3
WRIST/ELBOW BOWDEN CABLE MOL
$1,235.42
L6582
3
WRIST/ELBOW BOWDEN CBL DIR F
$1,052.79
L6584
3
ELBOW FAIR LEAD CABLE MOLDED
$1,705.33
L6586
3
ELBOW FAIR LEAD CABLE DIR FO
$1,491.81
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
L6588
3
SHDR FAIR LEAD CABLE MOLDED
$2,462.65
L6590
3
SHDR FAIR LEAD CABLE DIRECT
$2,252.61
L6600
3
POLYCENTRIC HINGE PAIR
$151.99
L6605
3
SINGLE PIVOT HINGE PAIR
$141.87
L6610
3
FLEXIBLE METAL HINGE PAIR
$127.35
L6611
6
ADDITIONAL SWITCH, EXT POWER
$0.00
L6615
3
DISCONNECT LOCKING WRIST UNI
$157.03
L6616
3
DISCONNECT INSERT LOCKING WR
$66.15
L6620
3
FLEXION/EXTENSION WRIST UNIT
$246.46
L6621
6
FLEX/EXT WRIST W/WO FRICTION
$0.00
L6623
3
SPRING-ASS ROT WRST W/ LATCH
L6624
6
FLEX/EXT/ROTATION WRIST UNIT
$0.00
L6625
3
ROTATION WRST W/ CABLE LOCK
$410.51
L6628
3
QUICK DISCONN HOOK ADAPTER O
$419.48
L6629
3
LAMINATION COLLAR W/ COUPLIN
$111.91
L6630
3
STAINLESS STEEL ANY WRIST
$164.86
L6632
3
LATEX SUSPENSION SLEEVE EACH
L6635
3
LIFT ASSIST FOR ELBOW
$152.70
L6637
3
NUDGE CONTROL ELBOW LOCK
$316.97
L6638
5
ELEC LOCK ON MANUAL PW ELBOW
$0.00
L6639
6
HEAVY DUTY ELBOW FEATURE
$0.00
L6640
3
SHOULDER ABDUCTION JOINT PAI
$216.31
L6641
3
EXCURSION AMPLIFIER PULLEY T
$143.76
L6642
3
EXCURSION AMPLIFIER LEVER TY
$204.69
L6645
3
SHOULDER FLEXION-ABDUCTION J
$248.55
L6646
5
MULTIPO LOCKING SHOULDER JNT
$0.00
L6647
5
SHOULDER LOCK ACTUATOR
$0.00
L6648
5
EXT PWRD SHLDER LOCK/UNLOCK
$0.00
L6650
3
SHOULDER UNIVERSAL JOINT
L6655
3
STANDARD CONTROL CABLE EXTRA
$57.46
L6660
3
HEAVY DUTY CONTROL CABLE
$70.21
L6665
3
TEFLON OR EQUAL CABLE LINING
$40.14
L6670
3
HOOK TO HAND CABLE ADAPTER
$38.06
L6672
3
HARNESS CHEST/SHLDER SADDLE
$128.98
L6675
3
HARNESS FIGURE OF 8 SING CON
$91.86
$564.15
$54.98
$258.92
Procedure Code Pricing Action Code Description
Maximum Allowable
L6676
3
HARNESS FIGURE OF 8 DUAL CON
$92.77
L6677
6
UE TRIPLE CONTROL HARNESS
L6680
3
TEST SOCK WRIST DISART/BEL E
$177.47
L6682
3
TEST SOCK ELBW DISART/ABOVE
$198.90
L6684
3
TEST SOCKET SHLDR DISART/THO
$266.63
L6686
3
SUCTION SOCKET
$495.85
L6687
3
FRAME TYP SOCKET BEL ELBOW/W
$441.23
L6688
3
FRAME TYP SOCK ABOVE ELB/DIS
$426.80
L6689
3
FRAME TYP SOCKET SHOULDER DI
$515.42
L6690
3
FRAME TYP SOCK INTERSCAP-THO
$558.16
L6691
3
REMOVABLE INSERT EACH
$333.79
L6692
3
SILICONE GEL INSERT OR EQUAL
$427.78
L6693
3
LOCKINGELBOW FOREARM CNTRBAL
L6694
6
ELBOW SOCKET INS USE W/LOCK
$0.00
L6695
6
ELBOW SOCKET INS USE W/O LCK
$0.00
L6696
6
CUS ELBO SKT IN FOR CON/ATYP
$0.00
L6697
6
CUS ELBO SKT IN NOT CON/ATYP
$0.00
L6698
6
BELOW/ABOVE ELBOW LOCK MECH
$0.00
L6700
O
TERMINAL DEVICE MODEL #3
$0.00
L6703
6
TERM DEV, PASSIVE HAND MITT
$0.00
L6704
6
TERM DEV, SPORT/REC/WORK ATT
$0.00
L6705
O
TERMINAL DEVICE MODEL #5
$0.00
L6706
6
TERM DEV MECH HOOK VOL OPEN
$0.00
L6707
6
TERM DEV MECH HOOK VOL CLOSE
$0.00
L6708
6
TERM DEV MECH HAND VOL OPEN
$0.00
L6709
6
TERM DEV MECH HAND VOL CLOSE
$0.00
L6710
O
TERMINAL DEVICE MODEL #5X
$0.00
L6711
6
PED TERM DEV, HOOK, VOL OPEN
$0.00
L6712
6
PED TERM DEV, HOOK, VOL CLOS
$0.00
L6713
6
PED TERM DEV, HAND, VOL OPEN
$0.00
L6714
6
PED TERM DEV, HAND, VOL CLOS
$0.00
L6715
O
TERMINAL DEVICE MODEL #5XA
$0.00
L6720
O
TERMINAL DEVICE MODEL #6
$0.00
L6721
6
HOOK/HAND, HVY DTY, VOL OPEN
$0.00
L6722
6
HOOK/HAND, HVY DTY, VOL CLOS
$0.00
$0.00
$2,131.93
Procedure Code Pricing Action Code Description
Maximum Allowable
L6725
O
TERMINAL DEVICE MODEL #7
$0.00
L6730
O
TERMINAL DEVICE MODEL #7LO
$0.00
L6735
O
TERMINAL DEVICE MODEL #8
$0.00
L6740
O
TERMINAL DEVICE MODEL #8X
$0.00
L6745
O
TERMINAL DEVICE MODEL #88X
$0.00
L6750
O
TERMINAL DEVICE MODEL #10P
$0.00
L6755
O
TERMINAL DEVICE MODEL #10X
$0.00
L6765
O
TERMINAL DEVICE MODEL #12P
$0.00
L6770
O
TERMINAL DEVICE MODEL #99X
$0.00
L6775
O
TERMINAL DEVICE MODEL#555
$0.00
L6780
O
TERMINAL DEVICE MODEL #SS555
$0.00
L6790
O
HOOKS-ACCU HOOK OR EQUAL
$0.00
L6795
O
HOOKS-2 LOAD OR EQUAL
$0.00
L6800
O
HOOKS-APRL VC OR EQUAL
$0.00
L6805
3
TERM DEV MODIFIER WRIST UNIT
L6806
O
TRS GRIP VC OR EQUAL
$0.00
L6807
O
TERM DEVICE GRIP1/2 OR EQUAL
$0.00
L6808
O
TERM DEVICE INFANT OR CHILD
$0.00
L6809
O
TRS SUPER SPORT PASSIVE
$0.00
L6810
3
TERM DEV PRECISION PINCH DEV
L6825
O
HANDS DORRANCE VO
$0.00
L6830
O
HAND APRL VC
$0.00
L6835
O
HAND SIERRA VO
$0.00
L6840
O
HAND BECKER IMPERIAL
$0.00
L6845
O
HAND BECKER LOCK GRIP
$0.00
L6850
O
TERM DVC-HAND BECKER PLYLITE
$0.00
L6855
O
HAND ROBIN-AIDS VO
$0.00
L6860
O
HAND ROBIN-AIDS VO SOFT
$0.00
L6865
O
HAND PASSIVE HAND
$0.00
L6867
O
HAND DETROIT INFANT HAND
$0.00
L6868
O
PASSIVE INF HAND STEEPER/HOS
$0.00
L6870
O
HAND CHILD MITT
$0.00
L6872
O
HAND NYU CHILD HAND
$0.00
L6873
O
HAND MECH INF STEEPER OR EQU
$0.00
L6875
O
HAND BOCK VC
$0.00
$275.35
$150.10
Procedure Code Pricing Action Code Description
Maximum Allowable
L6880
O
HAND BOCK VO
$0.00
L6881
5
TERM DEV AUTO GRASP FEATURE
$0.00
L6882
9
MICROPROCESSOR CONTROL UPLMB
$0.00
L6883
6
REPLC SOCKT BELOW E/W DISA
$0.00
L6884
6
REPLC SOCKT ABOVE ELBOW DISA
$0.00
L6885
6
REPLC SOCKT SHLDR DIS/INTERC
$0.00
L6890
3
PREFAB GLOVE FOR TERM DEVICE
$130.10
L6895
3
CUSTOM GLOVE FOR TERM DEVICE
$473.54
L6900
3
HAND RESTORAT THUMB/1 FINGER
$1,228.99
L6905
3
HAND RESTORATION MULTIPLE FI
$1,206.52
L6910
3
HAND RESTORATION NO FINGERS
$1,238.56
L6915
3
HAND RESTORATION REPLACMNT G
L6920
3
WRIST DISARTICUL SWITCH CTRL
$5,896.34
L6925
3
WRIST DISART MYOELECTRONIC C
$6,464.09
L6930
3
BELOW ELBOW SWITCH CONTROL
$5,578.08
L6935
3
BELOW ELBOW MYOELECTRONIC CT
$6,600.69
L6940
3
ELBOW DISARTICULATION SWITCH
$7,272.04
L6945
3
ELBOW DISART MYOELECTRONIC C
$8,133.63
L6950
3
ABOVE ELBOW SWITCH CONTROL
$7,706.82
L6955
3
ABOVE ELBOW MYOELECTRONIC CT
$9,372.94
L6960
3
SHLDR DISARTIC SWITCH CONTRO
$9,950.82
L6965
3
SHLDR DISARTIC MYOELECTRONIC
$11,398.65
L6970
3
INTERSCAPULAR-THOR SWITCH CT
$12,251.26
L6975
3
INTERSCAP-THOR MYOELECTRONIC
$13,525.58
L7007
6
ADULT ELECTRIC HAND
$0.00
L7008
6
PEDIATRIC ELECTRIC HAND
$0.00
L7009
6
ADULT ELECTRIC HOOK
$0.00
L7010
O
HAND OTTO BACK STEEPER/EQ SW
$0.00
L7015
O
HAND SYS TEKNIK VILLAGE SWIT
$0.00
L7020
O
ELECTRONIC GREIFER SWITCH CT
$0.00
L7025
O
ELECTRON HAND MYOELECTRONIC
$0.00
L7030
O
HAND SYS TEKNIK VILL MYOELEC
$0.00
L7035
O
ELECTRON GREIFER MYOELECTRO
$0.00
L7040
3
PREHENSILE ACTUATOR
$2,225.23
L7045
3
PEDIATRIC ELECTRIC HOOK
$1,236.40
$478.87
Procedure Code Pricing Action Code Description
Maximum Allowable
L7160
O
ELECTRONIC ELBOW, BOSTON OR EQUAL,
$0.00
L7165
O
ELECTRONIC ELBOW, BOSTON OR EQUAL,
$0.00
L7170
3
ELECTRONIC ELBOW HOSMER SWIT
L7180
3
ELECTRONIC ELBOW SEQUENTIAL
L7181
6
ELECTRONIC ELBO SIMULTANEOUS
L7185
3
ELECTRON ELBOW ADOLESCENT SW
$4,592.13
L7186
3
ELECTRON ELBOW CHILD SWITCH
$7,012.55
L7190
3
ELBOW ADOLESCENT MYOELECTRON
$5,978.78
L7191
3
ELBOW CHILD MYOELECTRONIC CT
$7,553.10
L7260
3
ELECTRON WRIST ROTATOR OTTO
$1,945.02
L7261
3
ELECTRON WRIST ROTATOR UTAH
$3,581.46
L7266
3
SERVO CONTROL STEEPER OR EQU
$757.35
L7272
3
ANALOGUE CONTROL UNB OR EQUA
$1,688.10
L7274
3
PROPORTIONAL CTL 12 VOLT UTA
$5,406.56
L7360
3
SIX VOLT BAT OTTO BOCK/EQ EA
$228.56
L7362
3
BATTERY CHRGR SIX VOLT OTTO
$205.92
L7364
3
TWELVE VOLT BATTERY UTAH/EQU
$380.62
L7366
3
BATTERY CHRGR 12 VOLT UTAH/E
$512.77
L7367
5
REPLACEMNT LITHIUM IONBATTER
$0.00
L7368
5
LITHIUM ION BATTERY CHARGER
$0.00
L7400
6
ADD UE PROST BE/WD, ULTLITE
$0.00
L7401
6
ADD UE PROST A/E ULTLITE MAT
$0.00
L7402
6
ADD UE PROST S/D ULTLITE MAT
$0.00
L7403
6
ADD UE PROST B/E ACRYLIC
$0.00
L7404
6
ADD UE PROST A/E ACRYLIC
$0.00
L7405
6
ADD UE PROST S/D ACRYLIC
$0.00
L7499
5
UPPER EXTREMITY PROSTHES NOS
$0.00
L7500
5
PROSTHETIC DVC REPAIR HOURLY
$0.00
L7510
5
PROSTHETIC DEVICE REPAIR REP
$0.00
L7520
3
REPAIR PROSTHESIS PER 15 MIN
$6.25
L7600
6
PROSTHETIC DONNING SLEEVE
$0.00
L7611
O
PED TERM DEV, HOOK, VOL OPEN
$0.00
L7612
O
PED TERM DEV, HOOK, VOL CLOS
$0.00
L7613
O
PED TERM DEV, HAND, VOL OPEN
$0.00
L7614
O
PED TERM DEV, HAND, VOL CLOS
$0.00
$4,485.23 $26,708.37 $0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
L7621
O
HOOK/HAND, HVY DTY, VOL OPEN
$0.00
L7622
O
HOOK/HAND, HVY DTY, VOL CLOS
$0.00
L7900
9
VACUUM ERECTION SYSTEM
$0.00
L8000
3
MASTECTOMY BRA
L8001
5
BREAST PROSTHESIS BRA & FORM
$0.00
L8002
5
BRST PRSTH BRA & BILAT FORM
$0.00
L8010
3
MASTECTOMY SLEEVE
$46.39
L8015
3
EXT BREASTPROSTHESIS GARMENT
$45.02
L8020
3
MASTECTOMY FORM
$191.37
L8030
3
BREAST PROSTHESIS SILICONE/E
$247.69
L8035
3
CUSTOM BREAST PROSTHESIS
L8039
5
BREAST PROSTHESIS NOS
L8040
3
NASAL PROSTHESIS
$1,294.46
L8041
3
MIDFACIAL PROSTHESIS
$1,560.25
L8042
3
ORBITAL PROSTHESIS
$1,753.08
L8043
3
UPPER FACIAL PROSTHESIS
$1,963.45
L8044
3
HEMI-FACIAL PROSTHESIS
$2,173.82
L8045
3
AURICULAR PROSTHESIS
$1,517.49
L8046
3
PARTIAL FACIAL PROSTHESIS
$1,402.47
L8047
3
NASAL SEPTAL PROSTHESIS
L8048
5
UNSPEC MAXILLOFACIAL PROSTH
$0.00
L8049
3
REPAIR MAXILLOFACIAL PROSTH
$15.69
L8100
O
COMPRESSION STOCKING BK18-30
$0.00
L8110
O
COMPRESSION STOCKING BK30-40
$0.00
L8120
O
COMPRESSION STOCKING BK40-50
$0.00
L8130
O
GC STOCKING THIGHLNGTH 18-30
$0.00
L8140
O
GC STOCKING THIGHLNGTH 30-40
$0.00
L8150
O
GC STOCKING THIGHLNGTH 40-50
$0.00
L8160
O
GC STOCKING FULL LNGTH 18-30
$0.00
L8170
O
GC STOCKING FULL LNGTH 30-40
$0.00
L8180
O
GC STOCKING FULL LNGTH 40-50
$0.00
L8190
O
GC STOCKING WAISTLNGTH 18-30
$0.00
L8195
O
GC STOCKING WAISTLNGTH 30-40
$0.00
L8200
O
GC STOCKING WAISTLNGTH 40-50
$0.00
L8210
O
GC STOCKING CUSTOM MADE
$0.00
$27.93
$2,751.16 $0.00
$718.77
Procedure Code Pricing Action Code Description
Maximum Allowable
L8220
O
GC STOCKING LYMPHEDEMA
$0.00
L8230
O
GC STOCKING GARTER BELT
$0.00
L8239
O
G COMPRESSION STOCKING NOS
$0.00
L8300
3
TRUSS SINGLE W/ STANDARD PAD
$64.52
L8310
3
TRUSS DOUBLE W/ STANDARD PAD
$101.87
L8320
3
TRUSS ADDITION TO STD PAD WA
$45.67
L8330
3
TRUSS ADD TO STD PAD SCROTAL
$37.77
L8400
3
SHEATH BELOW KNEE
$13.28
L8410
3
SHEATH ABOVE KNEE
$17.75
L8415
3
SHEATH UPPER LIMB
$17.44
L8417
3
PROS SHEATH/SOCK W GEL CUSHN
$56.42
L8420
3
PROSTHETIC SOCK MULTI PLY BK
$15.68
L8430
3
PROSTHETIC SOCK MULTI PLY AK
$16.93
L8435
3
PROS SOCK MULTI PLY UPPER LM
$16.09
L8440
3
SHRINKER BELOW KNEE
$31.99
L8460
3
SHRINKER ABOVE KNEE
$50.98
L8465
3
SHRINKER UPPER LIMB
$45.15
L8470
3
PROS SOCK SINGLE PLY BK
$5.11
L8480
3
PROS SOCK SINGLE PLY AK
$7.04
L8485
3
PROS SOCK SINGLE PLY UPPER L
$8.84
L8490
O
AIR SEAL SUCTION RETEN SYSTM
$0.00
L8499
5
UNLISTED MISC PROSTHETIC SER
$0.00
L8500
3
ARTIFICIAL LARYNX
L8501
3
TRACHEOSTOMY SPEAKING VALVE
L8505
5
ARTIFICIAL LARYNX, ACCESSORY
$0.00
L8507
5
TRACH-ESOPH VOICE PROS PT IN
$0.00
L8509
5
TRACH-ESOPH VOICE PROS MD IN
$0.00
L8510
5
VOICE AMPLIFIER
$0.00
L8511
6
INDWELLING TRACH INSERT
$0.00
L8512
6
GEL CAP FOR TRACH VOICE PROS
$0.00
L8513
6
TRACH PROS CLEANING DEVICE
$0.00
L8514
6
REPL TRACH PUNCTURE DILATOR
$0.00
L8515
6
GEL CAP APP DEVICE FOR TRACH
$0.00
L8603
9
COLLAGEN IMP URINARY 2.5 ML
$0.00
L8604
9
DEXTRANOMER/HYALURONIC ACID
$0.00
$673.10 $92.40
Procedure Code Pricing Action Code Description
Maximum Allowable
L8606
3
SYNTHETIC IMPLNT URINARY 1ML
$166.75
L8609
6
ARTIFICIAL CORNEA
$0.00
L8614
9
COCHLEAR DEVICE,
$0.00
L8615
6
COCH IMPLANT HEADSET REPLACE
$0.00
L8616
6
COCH IMPLANT MICROPHONE REPL
$0.00
L8617
6
COCH IMPLANT TRANS COIL REPL
$0.00
L8618
6
COCH IMPLANT TRAN CABLE REPL
$0.00
L8619
3
REPLACE COCHLEAR PROCESSOR
$6,403.44
L8620
O
REPL LITHIUM ION BATTERY
$0.00
L8621
6
REPL ZINC AIR BATTERY
$0.00
L8622
6
REPL ALKALINE BATTERY
$0.00
L8623
6
LITH ION BATT CID,NON-EARLVL
$0.00
L8624
6
LITH ION BATT CID, EAR LEVEL
$0.00
L8630
9
METACARPOPHALANGEAL JOINT IMPLANT
$0.00
L8631
9
MCP JOINT REPL 2 PC OR MORE
$0.00
L8641
9
METATARSAL JOINT IMPLANT
$0.00
L8642
9
HALLUX IMPLANT
$0.00
L8658
9
INTERPHALANGEAL JOINT SPACER, SILI
$0.00
L8659
9
INTERPHALANGEAL JOINT REPL
$0.00
L8670
9
VASCULAR GRAFT MATERIAL, SYNTHETIC
$0.00
L8680
9
IMPLANTABLE NEUROSTIMULATOR ELECTR
$0.00
L8681
6
PT PRGRM FOR IMPLT NEUROSTIM
$0.00
L8682
6
IMPLT NEUROSTIM RADIOFQ REC
$0.00
L8683
6
RADIOFQ TRSMTR FOR IMPLT NEU
$0.00
L8684
6
RADIOF TRSMTR IMPLT SCRL NEU
$0.00
L8685
9
IMPLT NROSTM PLS GEN SNG REC
$0.00
L8686
9
IMPLT NROSTM PLS GEN SNG NON
$0.00
L8687
9
IMPLT NROSTM PLS GEN DUA REC
$0.00
L8688
9
IMPLT NROSTM PLS GEN DUA NON
$0.00
L8689
6
EXTERNAL RECHARG SYS INTERN
$0.00
L8690
9
AUD OSSEO DEV, INT/EXT COMP
$0.00
L8691
6
AUD OSSEO DEV EXT SND PROCES
$0.00
L8695
6
EXTERNAL RECHARG SYS EXTERN
$0.00
L8699
9
PROSTHETIC IMPLANT NOS
$0.00
L9900
5
O&P SUPPLY/ACCESSORY/SERVICE
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
L9999
O
SALES TAX, ORTHOTIC/PROSTHETIC/OTHE
$0.00
M0005
9
OFFICE VISITS WITH TWO OR MORE MODA
$0.00
M0006
9
OFFICE VISITS WITH ONE OF THE ABOVE
$0.00
M0007
9
OFFICE VISITS INCLUDING COMBINATION
$0.00
M0008
9
OFFICE VISIT INCLUDING COMBINATION
$0.00
M0009
9
NOT OTHERWISE CLASSIFIED, OFFICE VI
$0.00
M0019
9
NOT OTHERWISE CLASSIFIED, HOME VISI
$0.00
M0021
9
PER DIEM INPATIENT HOSPITAL CARE WH
$0.00
M0022
9
I.C.U. CARE FOLLOW-UP WHEN ONE OR
$0.00
M0023
9
ROUTINE NEWBORN CARE, INHOSPITAL, I
$0.00
M0024
9
CHEMOTHERAPY(FOR MALIGNANCIES, FOLL
$0.00
M0029
9
NOT OTHERWISE CLASSIFIED, HOSPITAL
$0.00
M0039
9
NOT OTHERWISE CLASSIFIED, SNF, ECF,
$0.00
M0049
9
NOT OTHERWISE CLASSIFIED, NH, BOARD
$0.00
M0059
9
NOT OTHERWISE CLASSIFIED, EMERGENCY
$0.00
M0064
9
BRIEF OFFICE VISIT FOR THE SOLE PU
$0.00
M0070
9
INSULIN SHOCK THERAPY, HYPOGLYCEMIA
$0.00
M0071
9
ORTHOMOLECULAR THERAPY
$0.00
M0072
9
IMMUNOTHERAPY FOR MALIGNANT DISEASE
$0.00
M0075
9
CELLULAR THERAPY
$0.00
M0076
9
PROLOTHERAPY
$0.00
M0080
9
HYPERTHERMIA THERAPY (TO INCLUDE SY
$0.00
M0100
9
INTRAGASTRIC HYPOTHERMIA
$0.00
M0101
9
FOOT CARE HYGIENIC/PM
$0.00
M0260
9
TONSILLECTOMY, WITH OR WITHOUT ADEN
$0.00
M0261
9
TONSILLECTOMY, WITH OR WITHOUT ADEN
$0.00
M0300
9
IV CHELATIONTHERAPY
$0.00
M0301
9
FABRIC WRAPPING OF ANEURYSM
$0.00
M0520
9
ELECTRONIC PACEMAKER ANALYSIS, PULS
$0.00
M0525
9
SINGLE LEAD EKG WITH ANALYSIS OF PA
$0.00
M0526
9
COMPUTER TRACING AND INTERPRETATION
$0.00
M0530
9
CARDIAC EVENTS RECORDER, ELECTROCAR
$0.00
M0535
9
CARDIAC EVENTS RECORDER, ELECTROCAR
$0.00
M0540
9
SIGNAL-AVERAGING EKG
$0.00
M0560
9
PNEUMOPLETHYSMOGRAPHY VENOUS OCCLUS
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
M0575
9
ELECTROENCEPHALOGRAM (EEG), INTERPR
$0.00
M0580
9
TRANSTELEPHONIC ELECTROENCEPHALOGRA
$0.00
M0585
9
ACHILLES REFLEX RESPONSE, ELECTRICA
$0.00
M0590
9
MONITORING ECG, EEG OR PRESSURE IN
$0.00
M0601
9
PSYCHOLOGICAL TESTING, WITH WRITTEN
$0.00
M0702
9
BRIEF, OSTEOPATHIC MANIPULATIVE THE
$0.00
M0704
9
LIMITED, OSTEOPATHIC MANIPULATIVE T
$0.00
M0706
9
INTERMEDIATE OSTEOPATHIC MANIPULATI
$0.00
M0708
9
EXTENDED OSTEOPATHIC MANIPULATIVE T
$0.00
M0710
9
COMPREHENSIVE OSTEOPATHIC MANIPULAT
$0.00
M0722
9
BRIEF INPATIENT HOSPITAL OMT (UP TO
$0.00
M0724
9
LIMITED INPATIENT HOSPITAL OMT (UP
$0.00
M0726
9
INTERMEDIATE INPATIENT HOSPITAL OMT
$0.00
M0728
9
EXTENDED INPATIENT HOSPITAL OMT (UP
$0.00
M0730
9
COMPREHENSIVE INPATIENT HOSPITAL OM
$0.00
M0799
9
PHYSICAL MEDICINE, NOT OTHERWISE CL
$0.00
M0900
9
EXCISION, REVISION OR REMOVAL OF A-
$0.00
M0910
9
INSERTION CATHETERS FEMORAL VEIN, U
$0.00
M0945
9
OUTPATIENT DIALYSIS RELATED PHYSICI
$0.00
M0974
9
SELF DIALYSIS TRAINING, ANY MODE, C
$0.00
M0978
9
SELF DIALYSIS TRAINING, ANY MODE, C
$0.00
ORVCW
O
MCO SPECIFIC CODE: SMART START OUR
$0.00
ORVRN
O
MCO SPECIFIC CODE: SMART START OUTR
$0.00
ORVSW
O
MCO SPECIFIC CODE: SMART START OUTR
$0.00
P2028
9
CEPHALIN FLOCULATION TEST
$0.00
P2029
9
CONGO RED BLOOD TEST
$0.00
P2031
9
HAIR ANALYSIS
$0.00
P2032
9
ICTERUS INDEX, BLOOD
$0.00
P2033
9
BLOOD THYMOL TURBIDITY
$0.00
P2038
9
BLOOD MUCOPROTEIN
$0.00
P3000
9
SCREEN PAP BY TECH W MD SUPV
$0.00
P3001
9
SCREENING PAP SMEAR BY PHYS
$0.00
P7001
9
CULTURE BACTERIAL URINE
$0.00
P7020
9
VACCINE, AUTOGENOUS (MEDICAL NECESS
$0.00
P9005
9
ADMINISTRATION FEE CHARGE BY A PROV
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
P9006
9
MULTIPLE PATHOLOGY SERVICES
$0.00
P9007
9
HANDLING CHARGE FOR PURCHASED LAB S
$0.00
P9010
9
WHOLE BLOOD FOR TRANSFUSION
$0.00
P9011
9
BLOOD SPLIT UNIT
$0.00
P9012
9
CRYOPRECIPITATE EACH UNIT
$0.00
P9013
9
UNIT/S BLOOD FIBRINOGEN
$0.00
P9014
9
GAMMA GLOBULIN 1 ML
$0.00
P9015
9
RH IMMUNE GLOBULIN 1 ML
$0.00
P9016
9
RBC LEUKOCYTES REDUCED
$0.00
P9017
9
PLASMA 1 DONOR FRZ W/IN 8 HR
$0.00
P9018
9
PLASMA PROTEIN FRACT, UNIT
$0.00
P9019
9
PLATELETS, EACH UNIT
$0.00
P9020
9
PLAELET RICH PLASMA UNIT
$0.00
P9021
9
RED BLOOD CELLS UNIT
$0.00
P9022
9
WASHED RED BLOOD CELLS UNIT
$0.00
P9023
9
FROZEN PLASMA, POOLED, SD
$0.00
P9024
9
FACTOR VIII DILUTION, EACH BOTTLE.
$0.00
P9031
9
PLATELETS LEUKOCYTES REDUCED
$0.00
P9032
9
PLATELETS, IRRADIATED
$0.00
P9033
9
PLATELETS LEUKOREDUCED IRRAD
$0.00
P9034
9
PLATELETS, PHERESIS
$0.00
P9035
9
PLATELET PHERES LEUKOREDUCED
$0.00
P9036
9
PLATELET PHERESIS IRRADIATED
$0.00
P9037
9
PLATE PHERES LEUKOREDU IRRAD
$0.00
P9038
9
RBC IRRADIATED
$0.00
P9039
9
RBC DEGLYCEROLIZED
$0.00
P9040
9
RBC LEUKOREDUCED IRRADIATED
$0.00
P9041
9
ALBUMIN (HUMAN),5%, 50ML
$0.00
P9042
9
ALBUMIN (HUMAN), 25%
$0.00
P9043
9
PLASMA PROTEIN FRACT,5%,50ML
$0.00
P9044
9
CRYOPRECIPITATEREDUCEDPLASMA
$0.00
P9045
9
ALBUMIN (HUMAN), 5%, 250 ML
$0.00
P9046
9
ALBUMIN (HUMAN), 25%, 20 ML
$0.00
P9047
9
ALBUMIN (HUMAN), 25%, 50ML
$0.00
P9048
9
PLASMAPROTEIN FRACT,5%,250ML
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
P9050
9
GRANULOCYTES, PHERESIS UNIT
$0.00
P9051
9
BLOOD, L/R, CMV-NEG
$0.00
P9052
9
PLATELETS, HLA-M, L/R, UNIT
$0.00
P9053
9
PLT, PHER, L/R CMV-NEG, IRR
$0.00
P9054
9
BLOOD, L/R, FROZ/DEGLY/WASH
$0.00
P9055
9
PLT, APH/PHER, L/R, CMV-NEG
$0.00
P9056
9
BLOOD, L/R, IRRADIATED
$0.00
P9057
9
RBC, FRZ/DEG/WSH, L/R, IRRAD
$0.00
P9058
9
RBC, L/R, CMV-NEG, IRRAD
$0.00
P9059
9
PLASMA, FRZ BETWEEN 8-24HOUR
$0.00
P9060
9
FR FRZ PLASMA DONOR RETESTED
$0.00
P9603
9
ONE-WAY ALLOW PRORATED MILES
$0.00
P9604
9
ONE-WAY ALLOW PRORATED TRIP
$0.00
P9605
O
ROUTINE VENIPUNCTURE FOR COLLECTION
$0.00
P9610
9
URINE SPECIMEN COLLECT SINGL
$0.00
P9612
9
CATHETERIZE FOR URINE SPEC
$0.00
P9615
9
URINE SPECIMEN COLLECT MULT
$0.00
PEDCL
O
MCO SPECIFIC CODE: SMART START PREN
$0.00
Q0033
9
LINOZ V. BOWEN AMBULANCE REIMBURSE
$0.00
Q0034
9
ADMIN OF INFLUENZA VACCINE
$0.00
Q0035
9
CARDIOKYMOGRAPHY
$0.00
Q0036
O
OXYGEN CONCENTRATOR, HIGH HUMIDITY
$0.00
Q0037
5
OXYGEN AND WATER VAPOR ENRICHING SY
$0.00
Q0038
O
OXYGEN CONTENTS, GASEOUS, PER UNIT
$0.00
Q0039
9
OXYGEN CONTENTS, LIQUID, PER UNIT,
$0.00
Q0040
O
PORTABLE OXYGEN CONTENTS, GASEOUS P
$0.00
Q0041
O
PORTABLE OXYGEN CONTENTS, LIQUID, P
$0.00
Q0042
O
STATIONARY COMPRESSED GAS SYSTEM RE
$0.00
Q0043
O
STATIONARY LIQUID OXYGEN SYSTEM REN
$0.00
Q0045
9
ANESTHESIA FOR IRIDECTOMY
$0.00
Q0046
9
PORTABLE LIQUID OXYGEN SYSTEM RENTA
$0.00
Q0047
9
ANESTHESIA FOR BLEPHAROPLASTY
$0.00
Q0066
9
ASSESSMENT OF CARDIAC OUTPUT BY ELE
$0.00
Q0068
9
EXTRACORPEAL PLASMAPHERESIS
$0.00
Q0081
9
INFUSION THER OTHER THAN CHE
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
Q0082
9
ACTIVITY THERAPY W/PARTIAL H
$0.00
Q0083
9
CHEMO BY OTHER THAN INFUSION
$0.00
Q0084
9
CHEMOTHERAPY BY INFUSION
$0.00
Q0085
9
CHEMO BY BOTH INFUSION AND O
$0.00
Q0086
O
PHYSICAL THERAPY EVALUATION/
$0.00
Q0091
9
OBTAINING SCREEN PAP SMEAR
$0.00
Q0092
O
SET UP PORT XRAY EQUIPMENT
$0.00
Q0093
O
FILGRASTIM (G-CSF), PER 100 MCG
$0.00
Q0094
O
SARGRAMOSTIM (GM-CSF), PER 250 MCG
$0.00
Q0095
O
URINE PREGNANCY TESTS, VISUAL COLOR
$0.00
Q0096
O
OVULATION TEST KITS, VISUAL COLOR C
$0.00
Q0097
O
HEMOGLOBIN; BY COPPER SULFATE METHO
$0.00
Q0098
O
GLUCOSE, BLOOD; BY GLUCOSE MONITORI
$0.00
Q0100
O
URINALYSIS BY DIP STICK OR TABLET F
$0.00
Q0101
O
MICROHEMATOCRIT, SPUN
$0.00
Q0102
O
SEDIMENTATION RATE, ERYTHROCYTE; NO
$0.00
Q0103
9
PHYSICAL THERAPY EVALUATION, INITIA
$0.00
Q0104
9
PHYSICAL THERAPY RE-EVALUATION, PER
$0.00
Q0109
9
OCCUPATIONAL THERAPY EVALUATION, IN
$0.00
Q0110
9
OCCUPATIONAL THERAPY RE-EVALUATION,
$0.00
Q0111
O
WET MOUNTS/ W PREPARATIONS
$0.00
Q0112
O
POTASSIUM HYDROXIDE PREPS
$0.00
Q0113
O
PINWORM EXAMINATIONS
$0.00
Q0114
9
FERN TEST
$0.00
Q0115
9
POST-COITAL MUCOUS EXAM
$0.00
Q0116
O
HEMOGLOBIN BY SINGLE ANALYTE INSTRU
$0.00
Q0117
9
FOR DIABETICS ONLY, FITTING (INCLUD
$0.00
Q0118
9
FOR DIABETICS ONLY, FITTING (INCLUD
$0.00
Q0119
9
FOR DIABETICS ONLY, MULTIPLE DENSIT
$0.00
Q0120
9
FOR DIABETICS ONLY, MODIFICATION (I
$0.00
Q0121
9
FOR DIABETICS ONLY, MODIFICATION (I
$0.00
Q0122
9
FOR DIABETICS ONLY, MODIFICATION (I
$0.00
Q0123
9
FOR DIABETICS ONLY, MODIFICATION (I
$0.00
Q0132
9
DISPENSING FEE DME NEB DRUG
$0.00
Q0136
O
NON ESRD EPOETIN ALPHA INJ
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
Q0137
O
INJECTION, DARBEPOETIN ALFA
$0.00
Q0138
O
INJECTION, DEXAMETHASONE ACETATE, 1
$0.00
Q0144
9
AZITHROMYCIN DIHYDRATE, ORAL
$0.00
Q0156
9
HUMAN ALBUMIN 5%
$0.00
Q0157
O
HUMAN ALBUMIN 25%
$0.00
Q0160
9
FACTOR IX NON-RECOMBINANT
$0.00
Q0161
9
FACTOR IX RECOMBINANT
$0.00
Q0163
9
DIPHENHYDRAMINE HCL 50MG
$0.00
Q0164
9
PROCHLORPERAZINE MALEATE 5MG
$0.00
Q0165
9
PROCHLORPERAZINE MALEATE10MG
$0.00
Q0166
9
GRANISETRON HCL 1 MG ORAL
$0.00
Q0167
9
DRONABINOL 2.5MG ORAL
$0.00
Q0168
9
DRONABINOL 5MG ORAL
$0.00
Q0169
9
PROMETHAZINE HCL 12.5MG ORAL
$0.00
Q0170
9
PROMETHAZINE HCL 25 MG ORAL
$0.00
Q0171
9
CHLORPROMAZINE HCL 10MG ORAL
$0.00
Q0172
9
CHLORPROMAZINE HCL 25MG ORAL
$0.00
Q0173
9
TRIMETHOBENZAMIDE HCL 250MG
$0.00
Q0174
9
THIETHYLPERAZINE MALEATE10MG
$0.00
Q0175
9
PERPHENAZINE 4MG ORAL
$0.00
Q0176
9
PERPHENAZINE 8MG ORAL
$0.00
Q0177
9
HYDROXYZINE PAMOATE 25MG
$0.00
Q0178
9
HYDROXYZINE PAMOATE 50MG
$0.00
Q0179
9
ONDANSETRON HCL 8 MG ORAL
$0.00
Q0180
9
DOLASETRON MESYLATE ORAL
$0.00
Q0181
9
UNSPECIFIED ORAL ANTI-EMETIC
$0.00
Q0182
O
NONMETABOLIC ACT D/E TISSUE
$0.00
Q0183
O
NONMETABOLIC ACTIVE TISSUE
$0.00
Q0184
9
METABOLICALLY ACTIVE TISSUE
$0.00
Q0185
9
METABOLIC ACTIVE D/E TISSUE
$0.00
Q0186
9
PARAMEDIC INTERCEPT, RURAL
$0.00
Q0187
O
FACTOR VIIA RECOMBINANT
$0.00
Q0480
9
DRIVER PNEUMATIC VAD, REP
$0.00
Q0481
9
MICROPRCSR CU ELEC VAD, REP
$0.00
Q0482
9
MICROPRCSR CU COMBO VAD, REP
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
Q0483
9
MONITOR ELEC VAD, REP
$0.00
Q0484
9
MONITOR ELEC OR COMB VAD REP
$0.00
Q0485
9
MONITOR CABLE ELEC VAD, REP
$0.00
Q0486
9
MON CABLE ELEC/PNEUM VAD REP
$0.00
Q0487
9
LEADS ANY TYPE VAD, REP ONLY
$0.00
Q0488
9
PWR PACK BASE ELEC VAD, REP
$0.00
Q0489
9
PWR PCK BASE COMBO VAD, REP
$0.00
Q0490
9
EMR PWR SOURCE ELEC VAD, REP
$0.00
Q0491
9
EMR PWR SOURCE COMBO VAD REP
$0.00
Q0492
9
EMR PWR CBL ELEC VAD, REP
$0.00
Q0493
9
EMR PWR CBL COMBO VAD, REP
$0.00
Q0494
9
EMR HD PMP ELEC/COMBO, REP
$0.00
Q0495
9
CHARGER ELEC/COMBO VAD, REP
$0.00
Q0496
9
BATTERY ELEC/COMBO VAD, REP
$0.00
Q0497
9
BAT CLPS ELEC/COMB VAD, REP
$0.00
Q0498
9
HOLSTER ELEC/COMBO VAD, REP
$0.00
Q0499
9
BELT/VEST ELEC/COMBO VAD REP
$0.00
Q0500
9
FILTERS ELEC/COMBO VAD, REP
$0.00
Q0501
9
SHWR COV ELEC/COMBO VAD, REP
$0.00
Q0502
9
MOBILITY CART PNEUM VAD, REP
$0.00
Q0503
9
BATTERY PNEUM VAD REPLACEMNT
$0.00
Q0504
9
PWR ADPT PNEUM VAD, REP VEH
$0.00
Q0505
9
MISCL SUPPLY/ACCESSORY VAD
$0.00
Q0510
9
DISPENS FEE IMMUNOSUPRESSIVE
$0.00
Q0511
9
SUP FEE ANTIEM,ANTICA,IMMUNO
$0.00
Q0512
9
PX SUP FEE ANTI-CAN SUB PRES
$0.00
Q0513
9
DISP FEE INHAL DRUGS/30 DAYS
$0.00
Q0514
9
DISP FEE INHAL DRUGS/90 DAYS
$0.00
Q0515
5
SERMORELIN ACETATE INJECTION
$0.00
Q1001
O
NTIOL CATEGORY 1
$0.00
Q1002
O
NTIOL CATEGORY 2
$0.00
Q1003
9
NTIOL CATEGORY 3
$0.00
Q1004
9
NTIOL CATEGORY 4
$0.00
Q1005
9
NTIOL CATEGORY 5
$0.00
Q2001
O
ORAL CABERGOLINE 0.5 MG
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
Q2002
O
ELLIOTTS B SOLUTION PER ML
$0.00
Q2003
O
APROTININ, 10,000 KIU
$0.00
Q2004
5
BLADDER CALCULI IRRIG SOL
$0.00
Q2005
O
CORTICORELIN OVINE TRIFLUTAT
$0.00
Q2006
O
DIGOXIN IMMUNE FAB (OVINE)
$0.00
Q2007
O
ETHANOLAMINE OLEATE 100 MG
$0.00
Q2008
O
FOMEPIZOLE, 15 MG
$0.00
Q2009
5
FOSPHENYTOIN, 50 MG
$0.00
Q2010
O
GLATIRAMER ACETATE, PER DOSE
$0.00
Q2011
O
HEMIN, PER 1 MG
$0.00
Q2012
O
PEGADEMASE BOVINE, 25 IU
$0.00
Q2013
O
PENTASTARCH 10% SOLUTION
$0.00
Q2014
O
SERMORELIN ACETATE, 0.5 MG
$0.00
Q2015
O
SOMATREM, 5 MG
$0.00
Q2016
O
SOMATROPIN, 1 MG
$0.00
Q2017
5
TENIPOSIDE, 50 MG
$0.00
Q2018
O
UROFOLLITROPIN, 75 IU
$0.00
Q2019
O
BASILIXIMAB
$0.00
Q2020
O
HISTRELIN ACETATE
$0.00
Q2021
O
LEPIRUDIN
$0.00
Q2022
O
VONWILLEBRANDFACTRCMPLXPERIU
$0.00
Q3000
O
RUBIDIUM RB 82
$0.00
Q3001
5
BRACHYTHERAPY RADIOELEMENTS
$0.00
Q3002
O
GALLIUM GA 67
$0.00
Q3003
O
TECHNETIUM TC99M BICISATE
$0.00
Q3004
O
XENON XE 133
$0.00
Q3005
O
TECHNETIUM TC99M MERTIATIDE
$0.00
Q3006
O
TECHNETIUM TC99M GLUCEPATATE
$0.00
Q3007
O
SODIUM PHOSPHATE P32
$0.00
Q3008
O
INDIUM 111-IN PENTETREOTIDE
$0.00
Q3009
O
TECHNETIUM TC99M OXIDRONATE
$0.00
Q3010
O
TECHNETIUM TC99MLABELEDRBCS
$0.00
Q3011
O
CHROMIC PHOSPHATE P32
$0.00
Q3012
O
CYANOCOBALAMIN COBALT CO57
$0.00
Q3014
9
TELEHEALTH FACILITY FEE
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
Q3017
9
ALS ASSESSMENT
$0.00
Q3019
O
ALS EMER TRANS NO ALS SERV
$0.00
Q3020
O
ALS NONEMER TRANS NO ALS SER
$0.00
Q3021
5
PED HEPATITIS B VACCINE INJ
$0.00
Q3022
5
HEPATITIS B VACCINE ADULT DS
$0.00
Q3023
5
INJECTION HEPATITIS BVACCINE
$0.00
Q3025
5
IM INJ INTERFERON BETA 1-A
$0.00
Q3026
5
SUBC INJ INTERFERON BETA-1A
$0.00
Q3031
9
COLLAGEN SKIN TEST
$0.00
Q4001
9
CAST SUP BODY CAST PLASTER
$0.00
Q4002
9
CAST SUP BODY CAST FIBERGLAS
$0.00
Q4003
9
CAST SUP SHOULDER CAST PLSTR
$0.00
Q4004
9
CAST SUP SHOULDER CAST FBRGL
$0.00
Q4005
9
CAST SUP LONG ARM ADULT PLST
$0.00
Q4006
9
CAST SUP LONG ARM ADULT FBRG
$0.00
Q4007
9
CAST SUP LONG ARM PED PLSTER
$0.00
Q4008
9
CAST SUP LONG ARM PED FBRGLS
$0.00
Q4009
9
CAST SUP SHT ARM ADULT PLSTR
$0.00
Q4010
9
CAST SUP SHT ARM ADULT FBRGL
$0.00
Q4011
9
CAST SUP SHT ARM PED PLASTER
$0.00
Q4012
9
CAST SUP SHT ARM PED FBRGLAS
$0.00
Q4013
9
CAST SUP GAUNTLET PLASTER
$0.00
Q4014
9
CAST SUP GAUNTLET FIBERGLASS
$0.00
Q4015
9
CAST SUP GAUNTLET PED PLSTER
$0.00
Q4016
9
CAST SUP GAUNTLET PED FBRGLS
$0.00
Q4017
9
CAST SUP LNG ARM SPLINT PLST
$0.00
Q4018
9
CAST SUP LNG ARM SPLINT FBRG
$0.00
Q4019
9
CAST SUP LNG ARM SPLNT PED P
$0.00
Q4020
9
CAST SUP LNG ARM SPLNT PED F
$0.00
Q4021
9
CAST SUP SHT ARM SPLINT PLST
$0.00
Q4022
9
CAST SUP SHT ARM SPLINT FBRG
$0.00
Q4023
9
CAST SUP SHT ARM SPLNT PED P
$0.00
Q4024
9
CAST SUP SHT ARM SPLNT PED F
$0.00
Q4025
9
CAST SUP HIP SPICA PLASTER
$0.00
Q4026
9
CAST SUP HIP SPICA FIBERGLAS
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
Q4027
9
CAST SUP HIP SPICA PED PLSTR
$0.00
Q4028
9
CAST SUP HIP SPICA PED FBRGL
$0.00
Q4029
9
CAST SUP LONG LEG PLASTER
$0.00
Q4030
9
CAST SUP LONG LEG FIBERGLASS
$0.00
Q4031
9
CAST SUP LNG LEG PED PLASTER
$0.00
Q4032
9
CAST SUP LNG LEG PED FBRGLS
$0.00
Q4033
9
CAST SUP LNG LEG CYLINDER PL
$0.00
Q4034
9
CAST SUP LNG LEG CYLINDER FB
$0.00
Q4035
9
CAST SUP LNGLEG CYLNDR PED P
$0.00
Q4036
9
CAST SUP LNGLEG CYLNDR PED F
$0.00
Q4037
9
CAST SUP SHRT LEG PLASTER
$0.00
Q4038
9
CAST SUP SHRT LEG FIBERGLASS
$0.00
Q4039
9
CAST SUP SHRT LEG PED PLSTER
$0.00
Q4040
9
CAST SUP SHRT LEG PED FBRGLS
$0.00
Q4041
9
CAST SUP LNG LEG SPLNT PLSTR
$0.00
Q4042
9
CAST SUP LNG LEG SPLNT FBRGL
$0.00
Q4043
9
CAST SUP LNG LEG SPLNT PED P
$0.00
Q4044
9
CAST SUP LNG LEG SPLNT PED F
$0.00
Q4045
9
CAST SUP SHT LEG SPLNT PLSTR
$0.00
Q4046
9
CAST SUP SHT LEG SPLNT FBRGL
$0.00
Q4047
9
CAST SUP SHT LEG SPLNT PED P
$0.00
Q4048
9
CAST SUP SHT LEG SPLNT PED F
$0.00
Q4049
9
FINGER SPLINT, STATIC
$0.00
Q4050
9
CAST SUPPLIES UNLISTED
$0.00
Q4051
9
SPLINT SUPPLIES MISC
$0.00
Q4054
O
DARBEPOETIN ALFA, ESRD USE
$0.00
Q4055
O
EPOETIN ALFA, ESRD USE
$0.00
Q4075
O
ACYCLOVIR, 5 MG
$0.00
Q4076
O
DOPAMINE HCL, 40 MG
$0.00
Q4077
O
TREPROSTINIL, 1 MG
$0.00
Q4079
O
NATALIZUMAB INJECTION
$0.00
Q4080
9
ILOPROST NON-COMP UNIT DOSE
$0.00
Q4081
6
EPOETIN ALFA, 100 UNITS ESRD
$0.00
Q4082
9
DRUG/BIO NOC PART B DRUG CAP
$0.00
Q4083
O
HYALURONAN OR DERIVATIVE, HYALGAN
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
Q4084
O
HYALURONAN OR DERIVATIVE, SYNVISC,
$0.00
Q4085
O
HYALURONAN OR DERIVATIVE, EUFLEXXA
$0.00
Q4086
O
HYALURONAN OR DERIVATIVE, ORTHVISC
$0.00
Q4096
O
INJECTION, VON WILLEBRAND FACTOR C
$0.00
Q4097
O
INJECTION, IMMUNE GLOBULIN (PRIVIG
$0.00
Q4098
O
INJECTION, IRON DEXTRAN, 50 MG
$0.00
Q4099
O
FORMOTEROL FUMARATE INHALATION UD
$0.00
Q4100
9
SKIN SUBSTITUTE, NOS
$0.00
Q4101
9
APLIGRAF SKIN SUB
$0.00
Q4102
9
OASIS WOUND MATRIX SKIN SUB
$0.00
Q4103
9
OASIS BURN MATRIX SKIN SUB
$0.00
Q4104
9
INTEGRA BMWD SKIN SUB
$0.00
Q4105
9
INTEGRA DRT SKIN SUB
$0.00
Q4106
9
DERMAGRAFT SKIN SUB
$0.00
Q4107
9
GRAFTJACKET SKIN SUB
$0.00
Q4108
9
INTEGRA MATRIX SKIN SUB
$0.00
Q4109
9
TISSUEMEND SKIN SUB
$0.00
Q4110
9
PRIMATRIX SKIN SUB
$0.00
Q4111
9
GAMMAGRAFT SKIN SUB
$0.00
Q4112
9
CYMETRA ALLOGRAFT
$0.00
Q4113
9
GRAFTJACKET EXPRESS ALLOGRAF
$0.00
Q4114
9
INTEGRA FLOWABLE WOUND MATRI
$0.00
Q5001
9
HOSPICE IN PATIENT HOME
$0.00
Q5002
9
HOSPICE IN ASSISTED LIVING
$0.00
Q5003
9
HOSPICE IN LT/NON-SKILLED NF
$0.00
Q5004
9
HOSPICE IN SNF
$0.00
Q5005
9
HOSPICE, INPATIENT HOSPITAL
$0.00
Q5006
9
HOSPICE IN HOSPICE FACILITY
$0.00
Q5007
9
HOSPICE IN LTCH
$0.00
Q5008
9
HOSPICE IN INPATIENT PSYCH
$0.00
Q5009
9
HOSPICE CARE, NOS
$0.00
Q9920
O
EPOETIN WITH HCT <= 20
$0.00
Q9921
O
EPOETIN WITH HCT = 21
$0.00
Q9922
O
EPOETIN WITH HCT = 22
$0.00
Q9923
O
EPOETIN WITH HCT = 23
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
Q9924
O
EPOETIN WITH HCT = 24
$0.00
Q9925
O
EPOETIN WITH HCT = 25
$0.00
Q9926
O
EPOETIN WITH HCT = 26
$0.00
Q9927
O
EPOETIN WITH HCT = 27
$0.00
Q9928
O
EPOETIN WITH HCT = 28
$0.00
Q9929
O
EPOETIN WITH HCT = 29
$0.00
Q9930
O
EPOETIN WITH HCT = 30
$0.00
Q9931
O
EPOETIN WITH HCT = 31
$0.00
Q9932
O
EPOETIN WITH HCT = 32
$0.00
Q9933
O
EPOETIN WITH HCT = 33
$0.00
Q9934
O
EPOETIN WITH HCT = 34
$0.00
Q9935
O
EPOETIN WITH HCT = 35
$0.00
Q9936
O
EPOETIN WITH HCT = 36
$0.00
Q9937
O
EPOETIN WITH HCT = 37
$0.00
Q9938
O
EPOETIN WITH HCT = 38
$0.00
Q9939
O
EPOETIN WITH HCT = 39
$0.00
Q9940
O
EPOETIN WITH HCT >= 40
$0.00
Q9945
O
LOCM <=149 MG/ML IODINE, 1ML
$0.00
Q9946
O
LOCM 150-199MG/ML IODINE,1ML
$0.00
Q9947
O
LOCM 200-249MG/ML IODINE,1ML
$0.00
Q9948
O
LOCM 250-299MG/ML IODINE,1ML
$0.00
Q9949
O
LOCM 300-349MG/ML IODINE,1ML
$0.00
Q9950
O
LOCM 350-399MG/ML IODINE,1ML
$0.00
Q9951
9
LOCM >= 400 MG/ML IODINE,1ML
$0.00
Q9952
O
INJ GAD-BASE MR CONTRAST,1ML
$0.00
Q9953
9
INJ FE-BASED MR CONTRAST,1ML
$0.00
Q9954
9
ORAL MR CONTRAST, 100 ML
$0.00
Q9955
5
INJ PERFLEXANE LIP MICROS,ML
$0.00
Q9956
5
INJ OCTAFLUOROPROPANE MIC,ML
$0.00
Q9957
5
INJ PERFLUTREN LIP MICROS,ML
$0.00
Q9958
9
HOCM <=149 MG/ML IODINE, 1ML
$0.00
Q9959
9
HOCM 150-199MG/ML IODINE,1ML
$0.00
Q9960
9
HOCM 200-249MG/ML IODINE,1ML
$0.00
Q9961
9
HOCM 250-299MG/ML IODINE,1ML
$0.00
Q9962
9
HOCM 300-349MG/ML IODINE,1ML
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
Q9963
9
HOCM 350-399MG/ML IODINE,1ML
$0.00
Q9964
9
HOCM>= 400MG/ML IODINE, 1ML
$0.00
Q9965
9
LOCM 100-199MG/ML IODINE,1ML
$0.00
Q9966
9
LOCM 200-299MG/ML IODINE,1ML
$0.00
Q9967
9
LOCM 300-399MG/ML IODINE,1ML
$0.00
R0059
9
NOT OTHERWISE CLASSIFIED, CHEST
$0.00
R0065
9
CIRCULATION TIME, RADIONUCLIDE STUD
$0.00
R0070
9
TRANSPORT PORTABLE X-RAY
$0.00
R0075
9
TRANSPORT PORT X-RAY MULTIPL
$0.00
R0076
9
TRANSPORT PORTABLE EKG
$0.00
R0085
9
MULTIPLE RADIOLOGY SERVICES
$0.00
S0009
O
INJECTION, BUTORPHANOL TARTR
$0.00
S0010
O
INJECTION, SOMATREM, 5 MG
$0.00
S0011
O
INJECTION, SOMATROPIN, 5 MG
$0.00
S0012
9
BUTORPHANOL TARTRATE, NASAL
$0.00
S0014
9
TACRINE HYDROCHLORIDE, 10 MG
$0.00
S0016
O
INJECTION, AMIKACIN SULFATE
$0.00
S0017
5
INJECTION, AMINOCAPROIC ACID
$0.00
S0020
3
INJECTION, BUPIVICAINE HYDRO
$1.69
S0021
5
INJECTION, CEFOPERAZONE SOD
$0.00
S0023
5
INJECTION, CIMETIDINE HYDROC
$0.00
S0024
O
INJECTION, CIPROFLOXACIN
$0.00
S0028
5
INJECTION, FAMOTIDINE, 20 MG
$0.00
S0029
O
INJECTION, FLUCONAZOLE
$0.00
S0030
5
INJECTION, METRONIDAZOLE
$0.00
S0032
5
INJECTION, NAFCILLIN SODIUM
$0.00
S0034
5
INJECTION, OFLOXACIN, 400 MG
$0.00
S0039
5
INJECTION, SULFAMETHOXAZOLE
$0.00
S0040
5
INJECTION, TICARCILLIN DISOD
$0.00
S0071
O
INJECTION, ACYCLOVIR SODIUM
$0.00
S0072
O
INJECTION, AMIKACIN SULFATE
$0.00
S0073
5
INJECTION, AZTREONAM, 500 MG
$0.00
S0074
5
INJECTION, CEFOTETAN DISODIU
$0.00
S0077
5
INJECTION, CLINDAMYCIN PHOSP
$0.00
S0078
5
INJECTION, FOSPHENYTOIN SODI
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
S0079
O
OCTREOTIDE 100 MCG
$0.00
S0080
5
INJECTION, PENTAMIDINE ISETH
$0.00
S0081
5
INJECTION, PIPERACILLIN SODI
$0.00
S0085
O
INJECTION, GATIFLOXACIN
$0.00
S0086
O
INJECTION, VERTEPORFIN, 15MG
$0.00
S0087
O
ALEMTUZUMAB 30 MG
$0.00
S0088
9
IMATINIB 100 MG
$0.00
S0090
9
SILDENAFIL CITRATE, 25 MG
$0.00
S0091
5
GRANISETRON 1MG
$0.00
S0092
9
HYDROMORPHONE 250 MG
$0.00
S0093
9
MORPHINE 500 MG
$0.00
S0096
O
INJECTION, ITRACONAZOLE, 200
$0.00
S0097
O
INJECTION, IBUTILIDE FUMARAT
$0.00
S0098
O
INJECTION, SODIUM FERRIC GLU
$0.00
S0104
9
ZIDOVUDINE ORAL 100 MG
$0.00
S0106
9
BUPROPION HCL SR 60 TABLETS
$0.00
S0107
O
INJ, OMALIZUMAB 25 MG
$0.00
S0108
9
MERCAPTOPURINE 50 MG
$0.00
S0109
9
METHADONE ORAL 5 MG
$0.00
S0114
O
TREPROSTINIL SODIUM INJECT
$0.00
S0115
O
BORTEZOMIB 3.5 MG
$0.00
S0116
O
BEVACIZUMAB, 100MG
$0.00
S0117
9
TRETINOIN TOPICAL 5G
$0.00
S0118
O
ZICONOTIDE INJ
$0.00
S0122
9
INJ MENOTROPINS 75 IU
$0.00
S0124
O
INJ UROFOLLITROPIN 75 IU
$0.00
S0126
9
INJ FOLLITROPIN ALFA 75 IU
$0.00
S0128
9
INJ FOLLITROPIN BETA 75 IU
$0.00
S0130
O
INJ C GONADOTROPIN 5000 IU
$0.00
S0132
9
INJ GANIRELIX ACETAT 250 MCG
$0.00
S0133
O
HISTRELIN IMPLANT
$0.00
S0135
5
PEGFILGRASTIM INJECTION 6MG
$0.00
S0136
9
CLOZAPINE, 25 MG
$0.00
S0137
9
DIDANOSINE, 25 MG
$0.00
S0138
9
FINASTERIDE, 5 MG
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
S0139
9
MINOXIDIL, 10 MG
$0.00
S0140
9
SAQUINAVIR, 200 MG
$0.00
S0141
O
ZALCITABINE, 0.375 MG
$0.00
S0142
9
COLISTIMETHATE INH SOL MG
$0.00
S0143
O
AZTREONAM, INH SOL GRAM
$0.00
S0145
5
PEG INTERFERON ALFA-2A/180
$0.00
S0146
5
PEG INTERFERON ALFA-2B/10
$0.00
S0147
O
ALGLUCOSIDASE ALFA 20 MG
$0.00
S0155
5
EPOPROSTENOL DILUTANT
$0.00
S0156
5
EXEMESTANE, 25 MG
$0.00
S0157
9
BECAPLERMIN GEL 1%, 0.5 GM
$0.00
S0158
O
INJECTION LARONIDASE
$0.00
S0159
O
INJECTION AGALSIDASE
$0.00
S0160
9
DEXTROAMPHETAMINE
$0.00
S0161
5
CALCITROL
$0.00
S0162
5
INJECTION EFALIZUMAB
$0.00
S0163
O
INJECTION RISPERIDONELA
$0.00
S0164
5
INJECTION PANTOPRAZOLE
$0.00
S0165
O
INJECTION ABARELIX
$0.00
S0166
9
INJ OLANZAPINE 2.5MG
$0.00
S0167
O
INJ APOMORPHINE HCL 1MG
$0.00
S0168
O
INJ AZACITIDINE 100 MG
$0.00
S0170
9
ANASTROZOLE 1 MG
$0.00
S0171
5
BUMETANIDE 0.5 MG
$0.00
S0172
9
CHLORAMBUCIL 2 MG
$0.00
S0173
O
DEXAMETHASONE 4 MG
$0.00
S0174
9
DOLASETRON 50 MG
$0.00
S0175
9
FLUTAMIDE 125 MG
$0.00
S0176
9
HYDROXYUREA 500 MG
$0.00
S0177
9
LEVAMISOLE 50 MG
$0.00
S0178
9
LOMUSTINE 10 MG
$0.00
S0179
9
MEGESTROL 20 MG
$0.00
S0180
O
ETONOGESTREL IMPLANT SYSTEM
$0.00
S0181
9
ONDANSETRON 4 MG
$0.00
S0182
9
PROCARBAZINE 5 MG
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
S0183
9
PROCHLORPERAZINE 5 MG
$0.00
S0187
9
TAMOXIFEN 10 MG
$0.00
S0189
9
TESTOSTERONE PELLET 75 MG
$0.00
S0190
5
MIFEPRISTONE, ORAL, 200 MG
$0.00
S0191
5
MISOPROSTOL, ORAL, 200 MCG
$0.00
S0194
9
VITAMIN SUPPL 100 CAPS
$0.00
S0195
5
PNEUMOCOCCAL CONJUGATE VAC
$0.00
S0196
9
POLY-L-LACTIC ACID 1ML FACE
$0.00
S0197
9
PRENATAL VITAMINS 30 DAY
$0.00
S0198
O
INJ PEGAPTANIB 0.3 MG
$0.00
S0199
9
MEDICALLY INDUCED ABORTION BY ORAL
$0.00
S0201
9
PARTIAL HOSPITALIZATION SERV
$0.00
S0206
9
SURGERY IN OFFICE
$0.00
S0207
9
PARAMEDICINTERCEP NONHOSPALS
$0.00
S0208
9
PARAMED INTRCEPT NONVOL
$0.00
S0209
3
WC VAN MILEAGE PER MI
$0.42
S0215
3
NONEMERG TRANSP MILEAGE
$0.42
S0220
6
MEDICAL CONFERENCE BY PHYSIC
$0.00
S0221
6
MEDICAL CONFERENCE, 60 MIN
$0.00
S0250
9
COMP GERIATR ASSMT TEAM
$0.00
S0255
9
HOSPICE REFER VISIT NONMD
$0.00
S0257
9
END OF LIFE COUNSELING
$0.00
S0260
9
H&P FOR SURGERY
$0.00
S0265
9
GENETIC COUNSEL 15 MINS
$0.00
S0270
9
HOME STD CASE RATE 30 DAYS
$0.00
S0271
9
HOME HOSPICE CASE 30 DAYS
$0.00
S0272
9
HOME EPISODIC CASE 30 DAYS
$0.00
S0273
9
MD HOME VISIT OUTSIDE CAP
$0.00
S0274
9
NURSE PRACTR VISIT OUTS CAP
$0.00
S0302
9
COMPLETED EPSDT
$0.00
S0310
9
HOSPITALIST VISIT
$0.00
S0315
9
DISEASE MANAGEMENT PROGRAM
$0.00
S0316
9
FOLLOW-UP/REASSESSMENT
$0.00
S0317
9
DISEASE MGMT PER DIEM
$0.00
S0320
9
RN TELEPHONE CALLS TO DMP
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
S0340
9
LIFESTYLE MOD 1ST STAGE
$0.00
S0341
9
LIFESTYLE MOD 2 OR 3 STAGE
$0.00
S0342
9
LIFESTYLE MOD 4TH STAGE
$0.00
S0345
9
HOME ECG MONITRNG GLOBAL 24H
$0.00
S0346
9
HOME ECG MONITRNG TECH 24HR
$0.00
S0347
9
HOME ECG MONITRNG PROF 24HR
$0.00
S0390
5
ROUT FOOT CARE PER VISIT
$0.00
S0395
9
IMPRESSION CASTING FT
$0.00
S0400
9
GLOBAL ESWL KIDNEY
$0.00
S0500
6
DISPOS CONT LENS
$0.00
S0504
9
SINGL PRSCRP LENS
$0.00
S0506
9
BIFOC PRSCP LENS
$0.00
S0508
9
TRIFOC PRSCRP LENS
$0.00
S0510
9
NON-PRSCRP LENS
$0.00
S0512
6
DAILY CONT LENS
$0.00
S0514
9
COLOR CONT LENS
$0.00
S0515
9
SCLERAL LENS LIQUID BANDAGE
$0.00
S0516
6
SAFETY FRAMES
$0.00
S0518
9
SUNGLASS FRAMES
$0.00
S0580
3
POLYCARB LENS
$18.96
S0581
6
NONSTND LENS
$0.00
S0590
9
MISC INTEGRAL LENS SERV
$0.00
S0592
6
COMP CONT LENS EVAL
$0.00
S0595
9
NEW LENSES IN PTS OLD FRAME
$0.00
S0601
9
SCREENING PROCTOSCOPY
$0.00
S0605
9
DIGITAL RECTAL EXAMINATION,
$0.00
S0610
3
ANNUAL GYNECOLOGICAL EXAMINA
$63.33
S0612
3
ANNUAL GYNECOLOGICAL EXAMINA
$61.32
S0613
9
ANN BREAST EXAM
$0.00
S0618
9
AUDIOMETRY FOR HEARING AID
$0.00
S0620
6
ROUTINE OPHTHALMOLOGICAL EXA
$0.00
S0621
6
ROUTINE OPHTHALMOLOGICAL EXA
$0.00
S0622
9
PHYS EXAM FOR COLLEGE
$0.00
S0625
9
DIGITAL SCREENING RETINA
$0.00
S0630
9
REMOVAL OF SUTURES
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
S0800
9
LASER IN SITU KERATOMILEUSIS
$0.00
S0810
9
PHOTOREFRACTIVE KERATECTOMY
$0.00
S0812
9
PHOTOTHERAP KERATECT
$0.00
S0820
O
COMPUTERIZED CORNEAL TOPOGRA
$0.00
S0830
O
ULTRASOUND PACHYMETRY
$0.00
S1001
9
DELUXE ITEM
$0.00
S1002
9
CUSTOM ITEM
$0.00
S1015
9
IV TUBING EXTENSION SET
$0.00
S1016
9
NON-PVC INTRAVENOUS ADMINIST
$0.00
S1025
O
INHAL NITRIC OXIDE NEONATE
$0.00
S1030
9
GLUC MONITOR PURCHASE
$0.00
S1031
9
GLUC MONITOR RENTAL
$0.00
S1040
6
CRANIAL REMOLDING ORTHOSIS
$0.00
S2050
9
DONOR ENTERECTOMY, WITH PREP
$0.00
S2052
9
TRANSPLANTATION OF SMALL INT
$0.00
S2053
9
TRANSPLANTATION OF SMALL INT
$0.00
S2054
9
TRANSPLANTATION OF MULTIVISC
$0.00
S2055
9
HARVESTING OF DONOR MULTIVIS
$0.00
S2060
9
LOBAR LUNG TRANSPLANTATION
$0.00
S2061
9
DONOR LOBECTOMY (LUNG)
$0.00
S2065
9
SIMULT PANC KIDN TRANS
$0.00
S2066
9
BREAST GAP FLAP RECONST
$0.00
S2067
9
BREAST "STACKED" DIEP/GAP
$0.00
S2068
9
BREAST DIEP OR SIEA FLAP
$0.00
S2070
9
CYSTO LASER TX URETERAL CALC
$0.00
S2075
O
LAP INC/VENT HERNIA REPAIR
$0.00
S2076
O
LAP UMBILICAL HERNIA REPAIR
$0.00
S2077
O
LAP MESH IMPLANT HERN REP
$0.00
S2078
O
LAP SUPRACERV HYSTERECTOMY
$0.00
S2079
9
LAP ESOPHAGOMYOTOMY
$0.00
S2080
9
LAUP
$0.00
S2082
O
LAP ADJUSTABLE GASTRIC BAND
$0.00
S2083
9
ADJUSTMENT GASTRIC BAND
$0.00
S2085
O
LAPAROSCOP GASTRIC BYPASS
$0.00
S2090
O
OPEN CRYOSURG RENAL
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
S2091
O
PERC CRYOSURG RENAL
$0.00
S2095
9
TRANSCATH EMBOLIZ MICROSPHER
$0.00
S2102
9
ISLET CELL TISSUE TRANSPLANT
$0.00
S2103
9
ADRENAL TISSUE TRANSPLANT
$0.00
S2107
5
ADOPTIVE IMMUNOTHERAPY
$0.00
S2109
9
AUTOLOGOUS CHONDROCYTE TRANS
$0.00
S2112
9
KNEE ARTHROSCP HARV
$0.00
S2113
O
ARTHRO CHONDROCYTE IMPLANT
$0.00
S2114
O
ARTHROSC SH TENODESIS BICEPS
$0.00
S2115
9
PERIACETABULAR OSTEOTOMY
$0.00
S2117
9
ARTHROEREISIS, SUBTALAR
$0.00
S2118
9
TOTAL HIP RESURFACING
$0.00
S2120
9
LOW DENSITY LIPOPROTEIN(LDL)
$0.00
S2130
O
ERA OF REFLUX SAPHENOUS VEIN
$0.00
S2131
O
LASER ABLAT SAPHENOUS VEIN
$0.00
S2135
O
NEUROLYSIS INTERSPACE FOOT
$0.00
S2140
9
CORD BLOOD HARVESTING
$0.00
S2142
9
CORD BLOOD-DERIVED STEM-CELL
$0.00
S2150
9
BMT HARV/TRANSPL 28D PKG
$0.00
S2152
9
SOLID ORGAN TRANSPL PKG
$0.00
S2180
9
DONOR LEUKOCYTE INFUSION
$0.00
S2190
9
SUBCUTANEOUS IMPLANTATION OF
$0.00
S2202
9
ECHOSCLEROTHERAPY
$0.00
S2204
9
TRANSMYOCARDIAL LASER REVASC
$0.00
S2205
9
MINIMALLY INVASIVE DIRECT CO
$0.00
S2206
9
MINIMALLY INVASIVE DIRECT CO
$0.00
S2207
9
MINIMALLY INVASIVE DIRECT CO
$0.00
S2208
9
MINIMALLY INVASIVE DIRECT CO
$0.00
S2209
9
MINIMALLY INVASIVE DIRECT CO
$0.00
S2210
9
CRYOSURGICAL ABLATION (IN SI
$0.00
S2211
O
TRANSV CAROTID STENT PLACEMT
$0.00
S2213
O
IMPLANT GASTRIC STIM
$0.00
S2215
O
UGI ENDOSCOPY INJ IMPLANT
$0.00
S2220
9
THROMBECTOMY, CORONARY
$0.00
S2225
9
MYRINGOTOMY LASER-ASSIST
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
S2230
9
IMPLANT SEMI-IMP HEAR
$0.00
S2235
9
IMPLANT AUDITORY BRAIN IMP
$0.00
S2250
O
UTERINE ARTERY EMBOLIZ
$0.00
S2260
9
INDUCED ABORTION 17-24 WEEKS
$0.00
S2262
O
ABORTION MATERNAL INDIC 25W
$0.00
S2265
9
INDUCED ABORTION 25-28 WKS
$0.00
S2266
9
INDUCED ABORTION 29-31 WKS
$0.00
S2267
9
INDUCED ABORTION 32 OR MORE
$0.00
S2270
9
INSERTION VAGINAL CYLINDER
$0.00
S2300
9
ARTHROSCOPY, SHOULDER, SURGI
$0.00
S2325
6
HIP CORE DECOMPRESSION
$0.00
S2340
9
CHEMODENERVATION OF ABDUCTOR
$0.00
S2341
9
CHEMODENERV ADDUCT VOCAL
$0.00
S2342
9
NASAL ENDOSCOP PO DEBRID
$0.00
S2344
9
ENDOSC BALLOON SINUPLASTY
$0.00
S2348
9
DECOMPRESS DISC RF LUMBAR
$0.00
S2350
9
DISKECTOMY, ANTERIOR, WITH D
$0.00
S2351
9
DISKECTOMY, ANTERIOR, WITH D
$0.00
S2360
9
VERTEBROPLAST CERV 1ST
$0.00
S2361
9
VERTEBROPLAST CERV ADDL
$0.00
S2362
O
KYPHOPLASTY, FIRST VERTEBRA
$0.00
S2363
O
KYPHOPLASTY, EACH ADDL
$0.00
S2370
O
INTRADISCAL ELECTROTHERMAL
$0.00
S2371
O
EACH ADDITIONAL INTERSPACE
$0.00
S2400
5
FETAL SURG CONGEN HERNIA
$0.00
S2401
9
FETAL SURG URIN TRAC OBSTR
$0.00
S2402
9
FETAL SURG CONG CYST MALF
$0.00
S2403
9
FETAL SURG PULMON SEQUEST
$0.00
S2404
9
FETAL SURG MYELOMENINGO
$0.00
S2405
5
FETAL SURG SACROCOC TERATOMA
$0.00
S2409
9
FETAL SURG NOC
$0.00
S2411
9
FETOSCOP LASER THER TTTS
$0.00
S2900
9
ROBOTIC SURGICAL SYSTEM
$0.00
S3000
9
BILAT DIL RETINAL EXAM
$0.00
S3005
9
EVAL SELF-ASSESS DEPRESSION
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
S3600
9
STAT LAB
$0.00
S3601
9
STAT LAB HOME/NF
$0.00
S3620
9
NEWBORN METABOLIC SCREENING
$0.00
S3625
9
MATERNAL TRIPLE SCREEN TEST
$0.00
S3626
9
MATERNAL SERUM QUAD SCREEN
$0.00
S3628
6
PLACENTAL ALPHA MICROGLOBULIN-1RAP
$0.00
S3630
9
EOSINOPHIL BLOOD COUNT
$0.00
S3645
9
HIV-1 ANTIBODY TESTING OF OR
$0.00
S3650
9
SALIVA TEST, HORMONE LEVEL;
$0.00
S3652
9
SALIVA TEST, HORMONE LEVEL;
$0.00
S3655
9
ANTISPERM ANTIBODIES TEST
$0.00
S3700
9
BLADDER TUMOR-ASSOCIATED
$0.00
S3701
O
NMP-22 ASSAY
$0.00
S3708
9
GASTROINTESTINAL FAT ABSORPT
$0.00
S3711
9
CIRCULATING TUMOR CELL TEST
$0.00
S3800
9
GENETIC TESTING ALS
$0.00
S3818
9
BRCA1 GENE ANAL
$0.00
S3819
9
BRCA2 GENE ANAL
$0.00
S3820
9
COMP BRCA1/BRCA2
$0.00
S3822
9
SING MUTATION BRST/OVAR
$0.00
S3823
9
3 MUTATION BRST/OVAR
$0.00
S3828
9
COMP MLH1 GENE
$0.00
S3829
9
COMP MLH2 GENE
$0.00
S3830
9
GENE TEST HNPCC COMP
$0.00
S3831
9
GENE TEST HNPCC SINGLE
$0.00
S3833
9
COMP APC SEQUENCE
$0.00
S3834
9
SING MUTATION APC
$0.00
S3835
9
GENE TEST CYSTIC FIBROSIS
$0.00
S3837
9
GENE TEST HEMOCHROMATO
$0.00
S3840
9
DNA ANALYSIS RET-ONCOGENE
$0.00
S3841
9
GENE TEST RETINOBLASTOMA
$0.00
S3842
9
GENE TEST HIPPEL-LINDAU
$0.00
S3843
9
DNA ANALYSIS FACTOR V
$0.00
S3844
9
DNA ANALYSIS DEAFNESS
$0.00
S3845
9
GENE TEST ALPHA-THALASSEMIA
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
S3846
9
GENE TEST BETA-THALASSEMIA
$0.00
S3847
9
GENE TEST TAY-SACHS
$0.00
S3848
9
GENE TEST GAUCHER
$0.00
S3849
9
GENE TEST NIEMANN-PICK
$0.00
S3850
9
GENE TEST SICKLE CELL
$0.00
S3851
9
GENE TEST CANAVAN
$0.00
S3852
9
DNA ANALYSIS APOE ALZHEIMER
$0.00
S3853
9
GENE TEST MYO MUSCLR DYST
$0.00
S3854
9
GENE PROFILE PANEL BREAST
$0.00
S3855
9
GENE TEST PRESENILIN-1 GENE
$0.00
S3860
9
GENET TEST CARDIAC ION-COMP
$0.00
S3861
9
GENETIC TEST BRUGADA
$0.00
S3862
9
GENET TEST CARDIAC ION-SPEC
$0.00
S3890
9
FECAL DNA ANALYSIS
$0.00
S3900
9
SURFACE EMG
$0.00
S3902
9
BALLISTOCARDIOGRAM
$0.00
S3904
9
MASTERS TWO STEP
$0.00
S3905
9
AUTO HANDHELD DIAG NERV TEST
$0.00
S3906
9
TRANSFUSION, DIRECT, BLOOD
$0.00
S4005
9
INTERIM LABOR FACILITY GLOBA
$0.00
S4011
9
IVF PACKAGE
$0.00
S4013
9
COMPL GIFT CASE RATE
$0.00
S4014
9
COMPL ZIFT CASE RATE
$0.00
S4015
9
COMPLETE IVF NOS CASE RATE
$0.00
S4016
9
FROZEN IVF CASE RATE
$0.00
S4017
9
IVF CANC A STIM CASE RATE
$0.00
S4018
9
F EMB TRNS CANC CASE RATE
$0.00
S4020
9
IVF CANC A ASPIR CASE RATE
$0.00
S4021
9
IVF CANC P ASPIR CASE RATE
$0.00
S4022
9
ASST OOCYTE FERT CASE RATE
$0.00
S4023
9
INCOMPL DONOR EGG CASE RATE
$0.00
S4025
9
DONOR SERV IVF CASE RATE
$0.00
S4026
9
PROCURE DONOR SPERM
$0.00
S4027
9
STORE PREV FROZ EMBRYOS
$0.00
S4028
9
MICROSURG EPI SPERM ASP
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
S4030
9
SPERM PROCURE INIT VISIT
$0.00
S4031
9
SPERM PROCURE SUBS VISIT
$0.00
S4035
9
STIMULATED IUI CASE RATE
$0.00
S4036
O
INTRAVAG CULT CASE RATE
$0.00
S4037
9
CRYO EMBRYO TRANSF CASE RATE
$0.00
S4040
9
MONIT STORE CRYO EMBRYO 30 D
$0.00
S4042
9
OVULATION MGMT PER CYCLE
$0.00
S4386
O
EARLY INTERVENTION
$0.00
S4516
O
MULTI-DISCIPLINARY ASSESSMENT/EVALU
$0.00
S4518
5
ENVIROMENTAL LEAD TESTING
$0.00
S4981
9
INSERT LEVONORGESTREL IUS
$0.00
S4989
9
CONTRACEPT IUD
$0.00
S4990
9
NICOTINE PATCH LEGEND
$0.00
S4991
9
NICOTINE PATCH NONLEGEND
$0.00
S4993
9
CONTRACEPTIVE PILLS FOR BC
$0.00
S4995
9
SMOKING CESSATION GUM
$0.00
S5000
9
PRESCRIPTION DRUG, GENERIC
$0.00
S5001
9
PRESCRIPTION DRUG,BRAND NAME
$0.00
S5002
9
FAT EMULSION 10% IN 250 ML
$0.00
S5003
9
FAT EMULSION 20% IN 250 ML
$0.00
S5010
9
5% DEXTROSE AND 0.45% SALINE
$0.00
S5011
9
5% DEXTROSE IN LACTATED RING
$0.00
S5012
9
5% DEXTROSE WITH POTASSIUM
$0.00
S5013
9
5%DEXTROSE/0.45%SALINE1000ML
$0.00
S5014
9
D5W/0.45NS W KCL AND MGS04
$0.00
S5016
9
ANTIBIOTIC ADMIN SUPPLIES W/
$0.00
S5017
9
ANTIBIOTIC ADMINSUPPLIES W/O
$0.00
S5018
9
PAIN THERAPY ADMIN SUPPLIES
$0.00
S5019
9
CHEMOTHERAPY ADMIN SUPPLIES
$0.00
S5020
9
CHEMOTHERAPY ADMIN SUPPLIES
$0.00
S5021
9
HYDRATION THERAPY ADMIN SUPP
$0.00
S5022
9
GROWTH HORMONE THERAPY
$0.00
S5025
9
INFUSION PUMP RENTAL,PERDIEM
$0.00
S5035
9
HIT ROUTINE DEVICE MAINT
$0.00
S5036
9
HIT DEVICE REPAIR
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
S5100
9
ADULT DAYCARE SERVICES 15 MIN
$0.00
S5101
7
ADULT DAY CARE PER HALF DAY
$0.00
S5102
7
ADULY DAY CARE PER DIEM
$0.00
S5105
7
CENTERBASED DAYCARE PERDIEM
$0.00
S5108
9
HOMECARE TRAIN PT 15 MIN
$0.00
S5109
9
HOMECARE TRAIN PT SESSION
$0.00
S5110
9
FAMILY HOMECARE TRAINING 15M
$0.00
S5111
9
FAMILY HOMECARE TRAIN SESSION
$0.00
S5115
9
NONFAMILY HOMECARE TRAIN 15M
$0.00
S5116
9
NON FAMILY HC TRAIN SESSION
$0.00
S5120
9
CHORE SERVICES PER 15 MIN
$0.00
S5121
9
CHORE SERVICES PER DIEM
$0.00
S5125
9
ATTENDANT CARE SERVICES 15 M
$0.00
S5126
9
ATTENDANT CARE SERVICE 15M
$0.00
S5130
7
HOMAKER SERVICE NOS PER 15M
$0.00
S5131
9
HOMEMAKER SERVICE NOS PER 15 M
$0.00
S5135
9
ADULT COMPANION CARE PER 15M
$0.00
S5136
9
ADULT COMPANION CARE PER DIEM
$0.00
S5140
7
ADULT FOSTER CARE PER DIEM
$0.00
S5141
9
ADULT FOSTER CARE PER MONTH
$0.00
S5145
7
CHILD FOSTERCARE TH PER DIEM
$0.00
S5146
9
THER FOSTERCARE CHILD MONTH
$0.00
S5150
9
UNSKILLED RESPITE CARE 15M
$0.00
S5151
9
UNSKILLED RESPIT CARE DIEM
$0.00
S5160
7
EMERGENCY RESPONSE SYSTEM ERS INST
$0.00
S5161
7
EMERGENCY RESPONSE SYSTEM ERS PER
$0.00
S5162
7
EMERGENCY RESPONSE SYSTEM PURCHASE
$0.00
S5165
5
HOME MODIFICATIONS PER SERV
$0.00
S5170
9
HOMEDELIVERED PREPARED MEAL
$0.00
S5175
9
LAUNDRY SERV EXT PROF ORDER
$0.00
S5180
9
HH RESPIRATORY THRPY IN EVAL
$0.00
S5181
9
HH RESIRATORY THRPY NOS DAY
$0.00
S5185
9
MED REMINDER SER PER MONTH
$0.00
S5190
6
WELLNESS ASSESSMENT BY NONPH
$0.00
S5199
9
PERSONAL CARE ITEM NOS EACH
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
S5497
9
HIT CATH CARE NOC
$0.00
S5498
9
HIT SIMPLE CATH CARE
$0.00
S5501
9
HIT COMPLEX CATH CARE
$0.00
S5502
9
HIT INTERIM CATH CARE
$0.00
S5503
9
MAINTENANCE OF IMPLANTED VAS
$0.00
S5517
9
HIT DECLOTTING KIT
$0.00
S5518
9
HIT CATH REPAIR KIT
$0.00
S5520
9
HIT PICC INSERT KIT
$0.00
S5521
9
HIT MIDLINE CATH INSERT KIT
$0.00
S5522
9
HIT PICC INSERT NO SUPP
$0.00
S5523
9
HIP MIDLINE CATH INSERT KIT
$0.00
S5550
6
INSULIN RAPID 5 U
$0.00
S5551
6
INSULIN MOST RAPID 5 U
$0.00
S5552
6
INSULIN INTERMED 5 U
$0.00
S5553
6
INSULIN LONG ACTING 5 U
$0.00
S5560
6
INSULIN REUSE PEN 1.5 ML
$0.00
S5561
6
INSULIN REUSE PEN 3 ML
$0.00
S5565
9
INSULIN CARTRIDGE 150 U
$0.00
S5566
9
INSULIN CARTRIDGE 300 U
$0.00
S5570
9
INSULIN DISPOS PEN 1.5 ML
$0.00
S5571
9
INSULIN DISPOS PEN 3 ML
$0.00
S8001
9
RADIOFREQUENCY STIMULATION
$0.00
S8004
O
WHOLEBODY RADIOPHARM TRGCELL
$0.00
S8030
9
TANTALUM RING APPLICATION
$0.00
S8035
9
MAGNETIC SOURCE IMAGING
$0.00
S8037
9
MRCP
$0.00
S8040
9
TOPOGRAPHIC BRAIN MAPPING
$0.00
S8042
5
MRI LOW FIELD
$0.00
S8048
9
ISOLATED LIMB PERFUSION
$0.00
S8049
9
INTRAOPERATIVE RADIATION THE
$0.00
S8055
9
US GUIDANCE FETAL REDUCT
$0.00
S8060
9
SUPPLY OF CONTRAST MATERIAL
$0.00
S8075
O
CAD OF DIGITAL MAMMOGR
$0.00
S8080
9
SCINTIMAMMOGRAPHY
$0.00
S8085
9
FLUORINE-18 FLUORODEOXYGLUCO
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
S8092
9
ELECTRON BEAM COMPUTED TOMOG
$0.00
S8093
O
CT ANGIOGRAPHY CORONARY
$0.00
S8095
O
WIG (FOR MEDICALLY-INDUCED H
$0.00
S8096
9
PORTABLE PEAK FLOW METER
$0.00
S8097
9
ASTHMA KIT
$0.00
S8100
9
SPACER WITHOUT MASK
$0.00
S8101
9
SPACER WITH MASK
$0.00
S8105
O
OXIMETER FOR MEASURING BLOOD
$0.00
S8110
9
PEAK EXPIRATORY FLOW RATE (P
$0.00
S8120
9
O2 CONTENTS GAS CUBIC FT
$0.00
S8121
9
O2 CONTENTS LIQUID LB
$0.00
S8180
O
TRACH SHOWER PROTECTOR
$0.00
S8181
O
TRACH TUBE HOLDER
$0.00
S8182
O
HUMIDIFIER NON-SERVO
$0.00
S8183
O
HUMIDIFIER DUAL SERVO
$0.00
S8185
9
FLUTTER DEVICE
$0.00
S8186
9
SWIVEL ADAPTOR
$0.00
S8189
9
TRACH SUPPLY NOC
$0.00
S8190
9
ELECTRONIC SPIROMETER
$0.00
S8200
9
CHEST COMPRESSION VEST
$0.00
S8205
9
CHEST COMPRESSION SYSTEM GEN
$0.00
S8210
9
MUCUS TRAP
$0.00
S8260
O
ORAL ORTHOTIC FOR TREATMENT
$0.00
S8262
5
MANDIB ORTHO REPOS DEVICE
$0.00
S8265
5
HABERMAN FEEDER
$0.00
S8270
9
ENURESIS ALARM
$0.00
S8300
9
SACRAL NERVE STIMULATION TES
$0.00
S8301
9
INFECT CONTROL SUPPLIES NOS
$0.00
S8400
9
INCONTINENCE PANTS, EACH
$0.00
S8401
O
CHILD-SIZE DIAPER
$0.00
S8402
9
DIAPERS, EACH
$0.00
S8403
O
ADULT-SIZE PULL-UP BRIEF
$0.00
S8404
9
CHILD-SIZE PULL-UP BRIEF
$0.00
S8405
O
INCONTINENCE LINERS, EACH
$0.00
S8415
9
SUPPLIES FOR HOME DELIVERY
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
S8420
9
CUSTOM GRADIENT SLEEV/GLOV
$0.00
S8421
9
READY GRADIENT SLEEV/GLOV
$0.00
S8422
9
CUSTOM GRAD SLEEVE MED
$0.00
S8423
9
CUSTOM GRAD SLEEVE HEAVY
$0.00
S8424
9
READY GRADIENT SLEEVE
$0.00
S8425
9
CUSTOM GRAD GLOVE MED
$0.00
S8426
9
CUSTOM GRAD GLOVE HEAVY
$0.00
S8427
9
READY GRADIENT GLOVE
$0.00
S8428
9
READY GRADIENT GAUNTLET
$0.00
S8429
9
GRADIENT PRESSURE WRAP
$0.00
S8430
9
PADDING FOR COMPRSSN BDG
$0.00
S8431
9
COMPRESSION BANDAGE
$0.00
S8433
O
SKIN SUPPORT/BREAST PROSTH
$0.00
S8450
9
SPLINT DIGIT
$0.00
S8451
9
SPLINT WRIST OR ANKLE
$0.00
S8452
9
SPLINT ELBOW
$0.00
S8460
9
CAMISOLE POST-MAST
$0.00
S8490
9
100 INSULIN SYRINGES
$0.00
S8940
9
HIPPOTHERAPY PER SESSION
$0.00
S8945
O
PT PHONOPHORESIS 30 MINS
$0.00
S8948
6
LOW-LEVEL LASER TRMT 15 MIN
$0.00
S8950
9
COMPLEX LYMPHEDEMA THERAPY,
$0.00
S8990
9
PT OR MANIP FOR MAINT
$0.00
S8999
9
RESUSCITATION BAG
$0.00
S9001
9
HOME UTERINE MONITOR WITH OR
$0.00
S9007
9
ULTRAFILTRATION MONITOR
$0.00
S9015
9
AUTOMATED EEG MONITORING
$0.00
S9022
O
DIGITAL SUBTRACTION ANGIOGRA
$0.00
S9023
9
XENON REGIONAL CEREBRAL BLOO
$0.00
S9024
9
PARANASAL SINUS ULTRASOUND
$0.00
S9025
9
OMNICARDIOGRAM/CARDIOINTEGRA
$0.00
S9033
9
GAIT ANALYSIS
$0.00
S9034
5
ESWL FOR GALLSTONES
$0.00
S9035
9
MEDICAL EQUIPMENT OR SUPPLIE
$0.00
S9055
9
PROCUREN OR OTHER GROWTH FAC
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
S9056
9
COMA STIMULATION PER DIEM
$0.00
S9061
9
MEDICAL SUPPLIES AND EQUIPME
$0.00
S9075
9
SMOKING CESSATION TREATMENT
$0.00
S9083
7
URGENT CARE CENTER GLOBAL
$0.00
S9085
9
MENISCAL ALLOGRAFT TRANSPLAN
$0.00
S9088
9
SERVICES PROVIDED IN URGENT
$0.00
S9090
9
VERTEBRAL AXIAL DECOMPRESSIO
$0.00
S9092
O
CANOLITH REPOSITIONING
$0.00
S9097
9
HOME VISIT WOUND CARE
$0.00
S9098
9
HOME PHOTOTHERAPY VISIT
$0.00
S9105
5
EVALUATION BY OCULARIST
$0.00
S9109
9
CHF TELEMONITORING MONTH
$0.00
S9117
9
BACK SCHOOL VISIT
$0.00
S9122
7
HOME HEALTH AIDE OR CERTIFIE
$0.00
S9123
3
NURSING CARE IN HOME RN
$51.50
S9124
3
NURSING CARE, IN THE HOME; B
$46.14
S9125
7
RESPITE CARE, IN THE HOME, P
$0.00
S9126
9
HOSPICE CARE, IN THE HOME, P
$0.00
S9127
7
SOCIAL WORK VISIT, IN THE HO
$0.00
S9128
3
SPEECH THERAPY, IN THE HOME,
$43.50
S9129
3
OCCUPATIONAL THERAPY, IN THE
$43.50
S9131
3
PT IN THE HOME PER DIEM
$43.50
S9140
9
DIABETIC MANAGEMENT PROGRAM,
$0.00
S9141
9
DIABETIC MANAGEMENT PROGRAM,
$0.00
S9145
5
INSULIN PUMP INITIATION
$0.00
S9152
9
SPEECH THERAPY, RE-EVAL
$0.00
S9200
9
NURSING SERVICES AND ALL NEC
$0.00
S9208
9
HOME MGMT PRETERM LABOR
$0.00
S9209
9
HOME MGMT PPROM
$0.00
S9210
9
NURSING SERVICES AND ALL NEC
$0.00
S9211
5
HOME MGMT GEST HYPERTENSION
$0.00
S9212
9
HM POSTPAR HYPER PER DIEM
$0.00
S9213
9
HM PREECLAMP PER DIEM
$0.00
S9214
9
HM GEST DM PER DIEM
$0.00
S9216
9
GEST HYPER W NURS DIEM
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
S9217
9
POSTPAR HYPER W NURS DIEM
$0.00
S9218
9
PREECLAMP W NURS DIEM
$0.00
S9220
9
NURSING SERVICES AND ALL NEC
$0.00
S9225
9
NURSING SERVICES AND ALL NEC
$0.00
S9230
9
NURSING SERVICES AND ALL NEC
$0.00
S9300
9
NURSING SERVICES AND ALL NEC
$0.00
S9308
9
NURSING SERVICES AND ALL NEC
$0.00
S9310
9
NURSING SERVICES AND ALL NEC
$0.00
S9325
9
HIT PAIN MGMT PER DIEM
$0.00
S9326
9
HIT CONT PAIN PER DIEM
$0.00
S9327
9
HIT INT PAIN PER DIEM
$0.00
S9328
9
HIT PAIN IMP PUMP DIEM
$0.00
S9329
9
HIT CHEMO PER DIEM
$0.00
S9330
9
HIT CONT CHEM DIEM
$0.00
S9331
9
HIT INTERMIT CHEMO DIEM
$0.00
S9335
9
HT HEMODIALYSIS DIEM
$0.00
S9336
9
HIT CONT ANTICOAG DIEM
$0.00
S9338
9
HIT IMMUNOTHERAPY DIEM
$0.00
S9339
9
HIT PERITON DIALYSIS DIEM
$0.00
S9340
9
HIT ENTERAL PER DIEM
$0.00
S9341
9
HIT ENTERAL GRAV DIEM
$0.00
S9342
9
HIT ENTERAL PUMP DIEM
$0.00
S9343
9
HIT ENTERAL BOLUS NURS
$0.00
S9345
9
HIT ANTI-HEMOPHIL DIEM
$0.00
S9346
9
HIT ALPHA-1-PROTEINAS DIEM
$0.00
S9347
9
HIT LONGTERM INFUSION DIEM
$0.00
S9348
9
HIT SYMPATHOMIM DIEM
$0.00
S9349
9
HIT TOCOLYSIS DIEM
$0.00
S9351
9
HIT CONT ANTIEMETIC DIEM
$0.00
S9353
9
HIT CONT INSULIN DIEM
$0.00
S9355
9
HIT CHELATION DIEM
$0.00
S9357
9
HIT ENZYME REPLACE DIEM
$0.00
S9359
9
HIT ANTI-TNF PER DIEM
$0.00
S9361
9
HIT DIURETIC INFUS DIEM
$0.00
S9363
9
HIT ANTI-SPASMOTIC DIEM
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
S9364
9
HIT TPN TOTAL DIEM
$0.00
S9365
9
HIT TPN 1 LITER DIEM
$0.00
S9366
9
HIT TPN 2 LITER DIEM
$0.00
S9367
9
HIT TPN 3 LITER DIEM
$0.00
S9368
9
HIT TPN OVER 3L DIEM
$0.00
S9370
9
HT INJ ANTIEMETIC DIEM
$0.00
S9372
9
HT INJ ANTICOAG DIEM
$0.00
S9373
9
HIT HYDRA TOTAL DIEM
$0.00
S9374
9
HIT HYDRA 1 LITER DIEM
$0.00
S9375
9
HIT HYDRA 2 LITER DIEM
$0.00
S9376
9
HIT HYDRA 3 LITER DIEM
$0.00
S9377
9
HIT HYDRA OVER 3L DIEM
$0.00
S9379
9
HIT NOC PER DIEM
$0.00
S9381
9
HIT HIGH RISK/ESCORT
$0.00
S9395
9
NURSING SERVICES AND ALL NEC
$0.00
S9401
9
ANTICOAG CLINIC PER SESSION
$0.00
S9420
9
NURSING SERVICES AND ALL NEC
$0.00
S9423
9
NURSING SERVICES, PATIENT AS
$0.00
S9425
9
NURSING SERVICES AND ALL NEC
$0.00
S9430
9
PHARMACY COMP/DISP SERV
$0.00
S9433
9
MEDICAL FOOD ORAL 100% NUTR
$0.00
S9434
6
MOD SOLID FOOD SUPPL
$0.00
S9435
9
MEDICAL FOODS FOR INBORN ERR
$0.00
S9436
9
LAMAZE CLASS
$0.00
S9437
9
CHILDBIRTH REFRESHER CLASS
$0.00
S9438
9
CESAREAN BIRTH CLASS
$0.00
S9439
9
VBAC CLASS
$0.00
S9441
9
ASTHMA EDUCATION
$0.00
S9442
9
BIRTHING CLASS
$0.00
S9443
9
LACTATION CLASS
$0.00
S9444
9
PARENTING CLASS
$0.00
S9445
7
PT EDUCATION NOC INDIVID
$0.00
S9446
9
PT EDUCATION NOC GROUP
$0.00
S9447
9
INFANT SAFETY CLASS
$0.00
S9449
9
WEIGHT MGMT CLASS
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
S9451
9
EXERCISE CLASS
$0.00
S9452
9
NUTRITION CLASS
$0.00
S9453
9
SMOKING CESSATION CLASS
$0.00
S9454
9
STRESS MGMT CLASS
$0.00
S9455
9
DIABETIC MANAGEMENT PROGRAM,
$0.00
S9460
9
DIABETIC MANAGEMENT PROGRAM,
$0.00
S9465
9
DIABETIC MANAGEMENT PROGRAM,
$0.00
S9470
3
NUTRITIONAL COUNSELING, DIET
$44.00
S9472
9
CARDIAC REHABILITATION PROGR
$0.00
S9473
9
PULMONARY REHABILITATION PRO
$0.00
S9474
9
ENTEROSTOMAL THERAPY BY A RE
$0.00
S9475
9
AMBULATORY SETTING SUBSTANCE
$0.00
S9476
9
VESTIBULAR REHAB PER DIEM
$0.00
S9480
9
INTENSIVE OUTPATIENT PSYCHIA
$0.00
S9482
9
FAMILY STABILIZATION 15 MIN
$0.00
S9484
7
CRISIS INTERVENTION PER HOUR
$0.00
S9485
9
CRISIS INTERVENTION MENTAL H
$0.00
S9490
9
HIT CORTICOSEROID DIEM
$0.00
S9494
9
HIT ANTIBIOTIC TOTAL DIEM
$0.00
S9497
9
HIT ANTIBIOTIC Q3H DIEM
$0.00
S9500
9
HIT ANTIBIOTIC Q24H DIEM
$0.00
S9501
9
HIT ANTIBIOTIC Q12H DIEM
$0.00
S9502
9
HIT ANTIBIOTIC Q8H DIEM
$0.00
S9503
9
HIT ANTIBIOTIC Q6H DIEM
$0.00
S9504
9
HIT ANTIBIOTIC Q4H DIEM
$0.00
S9524
O
NURSING SERVICES RELATED TO
$0.00
S9526
9
SKILLED NURSING VISITS FOR
$0.00
S9527
9
INSERTION OF A PERIPHERALLY
$0.00
S9528
9
INSERTION OF MIDLINE CENTRAL
$0.00
S9529
9
VENIPUNCTURE HOME/SNF
$0.00
S9533
9
PAIN MANAGEMENT, INTRAVENOUS
$0.00
S9535
9
ADMINISTRATION OF HEMATOPOIE
$0.00
S9537
9
HT HEM HORM INJ DIEM
$0.00
S9538
9
HIT BLOOD PRODUCTS DIEM
$0.00
S9539
9
ADMINISTRATION OF ANTIBIOTIC
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
S9542
9
HT INJ NOC PER DIEM
$0.00
S9543
O
ADMINISTRATION OF MEDICATION
$0.00
S9545
9
ADMINISTRATION OF IMMUNE GLO
$0.00
S9546
O
HOME INF BLOOD PROD NURS SER
$0.00
S9550
9
HOME IV THERAPY, HYDRATION
$0.00
S9555
9
ADDITIONAL HOME INFUSION
$0.00
S9558
9
HT INJ GROWTH HORM DIEM
$0.00
S9559
9
HIT INJ INTERFERON DIEM
$0.00
S9560
9
HT INJ HORMONE DIEM
$0.00
S9562
9
PALIVIZUMAB HOME INJ PERDIEM
$0.00
S9590
9
IN HOME IRRIGATION THERAPY
$0.00
S9800
9
HT RN PER HOUR
$0.00
S9802
O
SPECIALTY DRUG ADMIN/NSG SRV
$0.00
S9803
O
EACH ADDITIONAL HOUR
$0.00
S9806
O
RN INFUSION SUITE VISIT
$0.00
S9810
9
HT PHARM PER HOUR
$0.00
S9900
9
CHRISTIAN SCI PRACT VISIT
$0.00
S9970
9
HEALTH CLUB MEMBERSHIP YR
$0.00
S9975
9
TRANSPLANT RELATED PER DIEM
$0.00
S9976
9
LODGING PER DIEM
$0.00
S9977
9
MEALS PER DIEM
$0.00
S9981
9
MED RECORD COPY ADMIN
$0.00
S9982
9
MED RECORD COPY PER PAGE
$0.00
S9986
9
NOT MEDICALLY NECESSARY SVC
$0.00
S9988
9
SERV PART OF PHASE I TRIAL
$0.00
S9989
9
SERVICES OUTSIDE US
$0.00
S9990
9
SERVICES PROVIDED AS PART OF
$0.00
S9991
9
SERVICES PROVIDED AS PART OF
$0.00
S9992
9
TRANSPORTATION COSTS TO AND
$0.00
S9994
9
LODGING COSTS (E.G. HOTEL CH
$0.00
S9996
9
MEALS FOR CLINICAL TRIAL PAR
$0.00
S9999
9
SALES TAX
$0.00
SARCW
O
MCO SPECIFIC CODE: SMART START SUBS
$0.00
SARRN
O
MCO SPECIFIC CODE: SMART START SUBS
$0.00
SARSW
O
MCO SPECIFIC CODE: SMART START SUBS
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
T1000
7
PRIVATE DUTY/INDEPENDENT NSG
$0.00
T1001
7
NURSING ASSESSMENT/EVALUATN
$0.00
T1002
3
RN SERVICES UP TO 15 MINUTES
$19.00
T1003
9
LPN/LVN SERVICES UP TO 15MIN
$0.00
T1004
9
NSG AIDE SERVICE UP TO 15MIN
$0.00
T1005
7
RESPITE CARE SERVICE 15 MIN
$0.00
T1006
9
FAMILY/COUPLE COUNSELING
$0.00
T1007
9
TREATMENT PLAN DEVELOPMENT
$0.00
T1008
O
DAY TREATMENT FOR INDIVIDUAL
$0.00
T1009
9
CHILD SITTING SERVICES
$0.00
T1010
9
MEALS WHEN RECEIVE SERVICES
$0.00
T1011
O
ALCOHOL/SUBSTANCE ABUSE NOC
$0.00
T1012
9
ALCOHOL/SUBSTANCE ABUSE SKIL
$0.00
T1013
9
SIGN LANG/ORAL INTERPRETER
$0.00
T1014
9
TELEHEALTH TRANSMIT, PER MIN
$0.00
T1015
9
CLINIC SERVICE
$0.00
T1016
9
CASE MANAGEMENT
$0.00
T1017
9
TARGETED CASE MANAGEMENT
$0.00
T1018
9
SCHOOL-BASED IEP SER BUNDLED
$0.00
T1019
9
PERSONAL CARE SER PER 15 MIN
$0.00
T1020
9
PERSONAL CARE SER PER DIEM
$0.00
T1021
9
HH AIDE OR CN AIDE PER VISIT
$0.00
T1022
9
CONTRACTED SERVICES PER DAY
$0.00
T1023
7
PROGRAM INTAKE ASSESSMENT
$0.00
T1024
3
TEAM EVALUATION & MANAGEMENT
T1025
9
PED COMPR CARE PKG, PER DIEM
$0.00
T1026
9
PED COMPR CARE PKG, PER HOUR
$0.00
T1027
9
FAMILY TRAINING & COUNSELING
$0.00
T1028
9
HOME ENVIRONMENT ASSESSMENT
$0.00
T1029
5
DWELLING LEAD INVESTIGATION
$0.00
T1030
9
RN HOME CARE PER DIEM
$0.00
T1031
9
LPN HOME CARE PER DIEM
$0.00
T1500
O
REUSABLE DIAPER/PANT
$0.00
T1502
9
MEDICATION ADMIN VISIT
$0.00
T1503
9
MED ADMIN, NOT ORAL/INJECT
$0.00
$1,429.81
Procedure Code Pricing Action Code Description
Maximum Allowable
T1999
9
NOC RETAIL ITEMS ANDSUPPLIES
$0.00
T2001
3
NONEMERGENCY TRANSPORTATION ATTEND
T2002
7
N-ET; PER DIEM
T2003
3
NON-EMERGENCY TRANSPORTATION; ENCOU
T2004
9
N-ET; COMMERC CARRIER PASS
$0.00
T2005
9
N-ET; STRETCHER VAN
$0.00
T2006
O
AMB RESPONSE & TRT, NO TRANS
$0.00
T2007
9
NON-EMER TRANSPORT WAIT TIME
$0.00
T2010
9
PASRR LEVEL I
$0.00
T2011
9
PASRR LEVEL II
$0.00
T2012
9
HABIL. ED. WAIVER; PER DIEM
$0.00
T2013
9
HABIL. ED. WAIVER, PER HOUR
$0.00
T2014
7
HABIL. PREVOC WAIVER, PER D
$0.00
T2015
7
HABIL. PREVOC WAIVER PER HR
$0.00
T2016
7
HABIL., RES. WAIVER PER DIEM
$0.00
T2017
9
HABIL., RES. WAIVER 15 MIN
$0.00
T2018
7
HABIL. SUP EMPL WAIVER/DAY
$0.00
T2019
9
HABIL. SUP EMPL WAIVER 15 MIN
$0.00
T2020
7
DAY HABIL WAIVER PER DIEM
$0.00
T2021
7
DAY HABIL WAIVER PER 15 MIN
$0.00
T2022
7
CASE MANAGEMENT, PER MONTH
$0.00
T2023
9
TARGETED CASE MGMT PER MONTH
$0.00
T2024
9
SERV ASMNT/CARE PLAN WAIVER
$0.00
T2025
7
WAIVER SERVICE, NOS
$0.00
T2026
9
SPECIAL CHILDCARE WAIVER/D
$0.00
T2027
9
SPEC CHILDCARE WAIVER 15 MIN
$0.00
T2028
9
SPECIAL SUPPLY, NOS WAIVER
$0.00
T2029
9
SPECIAL MED EQUIP, NOS WAIVER
$0.00
T2030
9
ASSIST LIVING WAIVER/MONTH
$0.00
T2031
9
ASSIST LIVING WAIVER/D
$0.00
T2032
9
RES CARE, NOS WAIVER/MONTH
$0.00
T2033
7
RES, NOS WAIVER PER DIEM
$0.00
T2034
9
CRISIS INTERVEN WAIVER/D
$0.00
T2035
9
UTILITY SERVICES WAIVER
$0.00
T2036
9
CAMP OVERNITE WAIVER/SESSION
$0.00
$10.10 $0.00 $10.10
Procedure Code Pricing Action Code Description
Maximum Allowable
T2037
9
CAMP DAY WAIVER/SESSION
$0.00
T2038
9
COMM TRANS WAIVER/SERVICE
$0.00
T2039
9
VEHICLE MOD WAIVER/SERVICE
$0.00
T2040
9
FINANCIAL MGT WAIVER/15 MIN
$0.00
T2041
9
SUPPORT BROKER WAIVER/15 MIN
$0.00
T2042
9
HOSPICE ROUTINE HOME CARE
$0.00
T2043
9
HOSPICE CONTINUOUS HOME CARE
$0.00
T2044
9
HOSPICE RESPITE CARE
$0.00
T2045
9
HOSPICE GENERAL CARE
$0.00
T2046
9
HOSPICE LONG TERM CARE, R&B
$0.00
T2048
9
BH LTC RES R&B, PER DIEM
$0.00
T2049
9
N-ET; STRETCHER VAN, MILEAGE
$0.00
T2101
9
BREAST MILK PROC/STORE/DIST
$0.00
T4521
3
ADULT SIZE BRIEF/DIAPER SM
$0.50
T4522
3
ADULT SIZE BRIEF/DIAPER MED
$0.50
T4523
3
ADULT SIZE BRIEF/DIAPER LG
$0.74
T4524
3
ADULT SIZE BRIEF/DIAPER XL
$0.88
T4525
3
ADULT SIZE PULL-ON SM
$0.50
T4526
3
ADULT SIZE PULL-ON MED
$0.50
T4527
3
ADULT SIZE PULL-ON LG
$0.74
T4528
3
ADULT SIZE PULL-ON XL
$0.88
T4529
3
PED SIZE BRIEF/DIAPER SM/MED
$0.25
T4530
3
PED SIZE BRIEF/DIAPER LG
$0.37
T4531
3
PED SIZE PULL-ON SM/MED
$0.25
T4532
3
PED SIZE PULL-ON LG
$0.37
T4533
3
YOUTH SIZE BRIEF/DIAPER
$0.47
T4534
3
YOUTH SIZE PULL-ON
$0.47
T4535
3
DISPOSABLE LINER/SHIELD/PAD
$0.33
T4536
9
REUSABLE PULL-ON ANY SIZE
$0.00
T4537
9
REUSABLE UNDERPAD BED SIZE
$0.00
T4538
9
DIAPER SERV REUSABLE DIAPER
$0.00
T4539
9
REUSE DIAPER/BRIEF ANY SIZE
$0.00
T4540
9
REUSABLE UNDERPAD CHAIR SIZE
$0.00
T4541
3
LARGE DISPOSABLE UNDERPAD
$0.54
T4542
3
SMALL DISPOSABLE UNDERPAD
$0.20
Procedure Code Pricing Action Code Description
Maximum Allowable
T4543
6
DISP BARIATRIC BRIEF/DIAPER
$0.00
T5001
6
POSITION SEAT SPEC ORTH NEED
$0.00
T5999
9
SUPPLY, NOS
$0.00
TBEVL
O
MCO SPECIFIC CODE: DPH INITIAL EVAL
$0.00
TBTXA
O
MCO SPECIFIC CODE: DPH TB TREATMENT
$0.00
TBTXS
O
MCO SPECIFIC CODE: DPH TB TREATMENT
$0.00
TI10H
O
PART C SPECIFIC CODE: INTERPERIODIC
$0.00
TI11H
O
PART C SPECIFIC CODE: INTERPERIODIC
$0.00
TI12H
O
PART C SPECIFIC CODE: INTERPERIODIC
$0.00
TI13H
7
PART C SPECIFIC CODE: INTERPERIODIC
$0.00
TI420
O
MCO SPECIFIC CODE: INTERPERIODIC CO
$0.00
TI42H
O
INTERPERIODIC CONSULTATION BY A PHY
$0.00
TI430
O
MCO SPECIFIC CODE: INTERPERIODIC CO
$0.00
TI43H
O
INTERPERIODIC CONSULTATION BY A OCC
$0.00
TI440
O
MCO SPECIFIC CODE: INTERPERIODIC CO
$0.00
TI44H
O
INTERPERIODIC CONSULTATION BY A SPE
$0.00
TV10H
O
PART C SPECIFIC CODE: TREATMENT VIS
$0.00
TV11H
O
PART C SPECIFIC CODE: TREATMENT VIS
$0.00
TV12H
O
PART C SPECIFIC CODE: TREATMENT VIS
$0.00
TV420
O
MCO SPECIFIC CODE: TRANSDISCIPLINAR
$0.00
TV42H
O
TRANSDISCIPLINARY VISIT BY A PHYSIC
$0.00
TV430
O
MCO SPECIFIC CODE: TRANSDISCIPLINAR
$0.00
TV43H
O
TRANSDISCIPLINARY VISIT BY A OCCUPA
$0.00
TV440
O
MCO SPECIFIC CODE: TRANSDISCIPLINAR
$0.00
TV44H
O
TRANSDISCIPLINARY VISIT BY A SPEECH
$0.00
V2020
3
VISION SVCS FRAMES PURCHASES
V2025
6
EYEGLASSES DELUX FRAMES
V2100
3
LENS SPHER SINGLE PLANO 4.00
$38.15
V2101
3
SINGLE VISN SPHERE 4.12-7.00
$40.00
V2102
3
SINGL VISN SPHERE 7.12-20.00
$58.93
V2103
3
SPHEROCYLINDR 4.00D/12-2.00D
$35.97
V2104
3
SPHEROCYLINDR 4.00D/2.12-4D
$38.98
V2105
3
SPHEROCYLINDER 4.00D/4.25-6D
$43.37
V2106
3
SPHEROCYLINDER 4.00D/>6.00D
$48.13
V2107
3
SPHEROCYLINDER 4.25D/12-2D
$44.62
$49.74 $0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
V2108
3
SPHEROCYLINDER 4.25D/2.12-4D
$47.40
V2109
3
SPHEROCYLINDER 4.25D/4.25-6D
$52.44
V2110
3
SPHEROCYLINDER 4.25D/OVER 6D
$51.74
V2111
3
SPHEROCYLINDR 7.25D/.25-2.25
$53.06
V2112
3
SPHEROCYLINDR 7.25D/2.25-4D
$58.86
V2113
3
SPHEROCYLINDR 7.25D/4.25-6D
$1.79
V2114
3
SPHEROCYLINDER OVER 12.00D
$71.89
V2115
3
LENS LENTICULAR BIFOCAL
$63.63
V2116
O
NONASPHERIC LENS BIFOCAL
$0.00
V2117
O
ASPHERIC LENS BIFOCAL
$0.00
V2118
3
LENS ANISEIKONIC SINGLE
$77.56
V2121
6
LENTICULAR LENS, SINGLE
$0.00
V2199
6
LENS SINGLE VISION NOT OTH C
$0.00
V2200
3
LENS SPHER BIFOC PLANO 4.00D
$52.57
V2201
3
LENS SPHERE BIFOCAL 4.12-7.0
$57.57
V2202
3
LENS SPHERE BIFOCAL 7.12-20.
$69.55
V2203
3
LENS SPHCYL BIFOCAL 4.00D/.1
$54.25
V2204
3
LENS SPHCY BIFOCAL 4.00D/2.1
$57.19
V2205
3
LENS SPHCY BIFOCAL 4.00D/4.2
$61.83
V2206
3
LENS SPHCY BIFOCAL 4.00D/OVE
$66.43
V2207
3
LENS SPHCY BIFOCAL 4.25-7D/.
$58.71
V2208
3
LENS SPHCY BIFOCAL 4.25-7/2.
$62.97
V2209
3
LENS SPHCY BIFOCAL 4.25-7/4.
$67.36
V2210
3
LENS SPHCY BIFOCAL 4.25-7/OV
$75.32
V2211
3
LENS SPHCY BIFO 7.25-12/.25-
$72.60
V2212
3
LENS SPHCYL BIFO 7.25-12/2.2
$72.60
V2213
3
LENS SPHCYL BIFO 7.25-12/4.2
$68.64
V2214
3
LENS SPHCYL BIFOCAL OVER 12.
$88.57
V2215
3
LENS LENTICULAR BIFOCAL
$75.38
V2216
O
LENS LENTICULAR NONASPHERIC
$0.00
V2217
O
LENS LENTICULAR ASPHERIC BIF
$0.00
V2218
3
LENS ANISEIKONIC BIFOCAL
V2219
3
LENS BIFOCAL SEG WIDTH OVER
$47.09
V2220
3
LENS BIFOCAL ADD OVER 3.25D
$38.19
V2221
6
LENTICULAR LENS, BIFOCAL
$106.98
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
V2299
6
LENS BIFOCAL SPECIALITY
$0.00
V2300
3
LENS SPHERE TRIFOCAL 4.00D
$62.84
V2301
3
LENS SPHERE TRIFOCAL 4.12-7.
$73.64
V2302
3
LENS SPHERE TRIFOCAL 7.12-20
$86.73
V2303
3
LENS SPHCY TRIFOCAL 4.0/.12-
$57.57
V2304
3
LENS SPHCY TRIFOCAL 4.0/2.25
$67.29
V2305
3
LENS SPHCY TRIFOCAL 4.0/4.25
$77.94
V2306
3
LENS SPHCYL TRIFOCAL 4.00/>6
$82.73
V2307
3
LENS SPHCY TRIFOCAL 4.25-7/.
$76.36
V2308
3
LENS SPHC TRIFOCAL 4.25-7/2.
$79.36
V2309
3
LENS SPHC TRIFOCAL 4.25-7/4.
$82.96
V2310
3
LENS SPHC TRIFOCAL 4.25-7/>6
$88.00
V2311
3
LENS SPHC TRIFO 7.25-12/.25-
$79.49
V2312
3
LENS SPHC TRIFO 7.25-12/2.25
$79.95
V2313
3
LENS SPHC TRIFO 7.25-12/4.25
$82.94
V2314
3
LENS SPHCYL TRIFOCAL OVER 12
V2315
3
LENS LENTICULAR TRIFOCAL
V2316
O
LENS LENTICULAR NONASPHERIC
$0.00
V2317
O
LENS LENTICULAR ASPHERIC TRI
$0.00
V2318
3
LENS ANISEIKONIC TRIFOCAL
V2319
3
LENS TRIFOCAL SEG WIDTH > 28
$52.52
V2320
3
LENS TRIFOCAL ADD OVER 3.25D
$55.41
V2321
6
LENTICULAR LENS, TRIFOCAL
$0.00
V2399
6
LENS TRIFOCAL SPECIALITY
$0.00
V2410
3
LENS VARIAB ASPHERICITY SING
$82.58
V2430
3
LENS VARIABLE ASPHERICITY BI
$92.26
V2499
6
VARIABLE ASPHERICITY LENS
V2500
3
CONTACT LENS PMMA SPHERICAL
$85.97
V2501
3
CNTCT LENS PMMA-TORIC/PRISM
$116.84
V2502
3
CONTACT LENS PMMA BIFOCAL
$153.78
V2503
3
CNTCT LENS PMMA COLOR VISION
$148.27
V2510
3
CNTCT GAS PERMEABLE SPHERICL
$116.23
V2511
3
CNTCT TORIC PRISM BALLAST
$150.69
V2512
3
CNTCT LENS GAS PERMBL BIFOCL
$185.42
V2513
3
CONTACT LENS EXTENDED WEAR
$151.11
$106.56 $94.65
$148.07
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
V2520
3
CONTACT LENS HYDROPHILIC
$107.68
V2521
3
CNTCT LENS HYDROPHILIC TORIC
$169.90
V2522
3
CNTCT LENS HYDROPHIL BIFOCL
$151.60
V2523
3
CNTCT LENS HYDROPHIL EXTEND
$149.83
V2530
3
CONTACT LENS GAS IMPERMEABLE
$202.40
V2531
3
CONTACT LENS GAS PERMEABLE
$421.66
V2599
6
CONTACT LENS/ES OTHER TYPE
$0.00
V2600
6
HAND HELD LOW VISION AIDS
$0.00
V2610
6
SINGLE LENS SPECTACLE MOUNT
$0.00
V2615
6
TELESCOP/OTHR COMPOUND LENS
$0.00
V2620
9
PROSTHETIC, EYE, GLASS, STOCK
$0.00
V2621
9
PROSTHETIC, EYE PLASTIC, STOCK
$0.00
V2622
9
PROSTHETIC, EYE, GLASS, CUSTOM
$0.00
V2623
3
PLASTIC EYE PROSTH CUSTOM
V2624
3
POLISHING ARTIFICAL EYE
V2625
3
ENLARGEMNT OF EYE PROSTHESIS
$293.59
V2626
3
REDUCTION OF EYE PROSTHESIS
$158.26
V2627
3
SCLERAL COVER SHELL
$1,022.12
V2628
3
FABRICATION & FITTING
$241.34
V2629
6
PROSTHETIC EYE OTHER TYPE
$0.00
V2630
6
ANTER CHAMBER INTRAOCUL LENS
$0.00
V2631
6
IRIS SUPPORT INTRAOCLR LENS
$0.00
V2632
6
POST CHMBR INTRAOCULAR LENS
$0.00
V2700
3
BALANCE LENS
V2702
9
DELUXE LENS FEATURE
V2710
3
GLASS/PLASTIC SLAB OFF PRISM
V2715
3
PRISM LENS/ES
V2718
3
FRESNELL PRISM PRESS-ON LENS
$23.48
V2730
3
SPECIAL BASE CURVE
$16.73
V2740
O
ROSE TINT PLASTIC
$0.00
V2741
O
NON-ROSE TINT PLASTIC
$0.00
V2742
O
ROSE TINT GLASS
$0.00
V2743
O
NON-ROSE TINT GLASS
$0.00
V2744
5
TINT PHOTOCHROMATIC LENS/ES
$0.00
V2745
9
TINT, ANY COLOR/SOLID/GRAD
$0.00
$712.05 $64.39
$42.70 $0.00 $59.65 $9.76
Procedure Code Pricing Action Code Description
Maximum Allowable
V2750
5
ANTI-REFLECTIVE COATING
$0.00
V2755
9
UV LENS/ES
$0.00
V2756
9
EYE GLASS CASE
$0.00
V2760
3
SCRATCH RESISTANT COATING
V2761
9
MIRROR COATING
$0.00
V2762
9
POLARIZATION, ANY LENS
$0.00
V2770
9
OCCLUDER LENS/ES
$0.00
V2780
9
OVERSIZE LENS/ES
$0.00
V2781
9
PROGRESSIVE LENS PER LENS
$0.00
V2782
6
LENS, 1.54-1.65 P/1.60-1.79G
$0.00
V2783
6
LENS, >= 1.66 P/>=1.80 G
$0.00
V2784
3
LENS POLYCARB OR EQUAL
V2785
6
CORNEAL TISSUE PROCESSING
$0.00
V2786
9
OCCUPATIONAL MULTIFOCAL LENS
$0.00
V2787
9
ASTIGMATISM-CORRECT FUNCTION
$0.00
V2788
9
PRESBYOPIA-CORRECT FUNCTION
$0.00
V2790
6
AMNIOTIC MEMBRANE
$0.00
V2797
9
VIS ITEM/SVC IN OTHER CODE
$0.00
V2799
6
MISCELLANEOUS VISION SERVICE
$0.00
V5000
9
BASIC AUDIOLOGIC ASSESSMENT - HEARI
$0.00
V5001
9
COMPREHENSIVE AUDIOLOGIC ASSESSMENT
$0.00
V5002
9
ASSESSMENT OF VESTIBULAR AND/OR AUD
$0.00
V5003
9
ASSESSMENT OF VESTIBULAR AND/OR AUD
$0.00
V5008
3
HEARING SCREENING
V5010
9
ASSESSMENT FOR HEARING AID
$0.00
V5011
9
HEARING AID FITTING/CHECKING
$0.00
V5012
9
COMPLETE COCHLEAR IMPLANT REHABILIT
$0.00
V5014
5
HEARING AID REPAIR/MODIFYING
$0.00
V5016
9
UNLISTED AUDIOLOGIC PROCEDURE (SPEC
$0.00
V5020
9
CONFORMITY EVALUATION
$0.00
V5030
5
BODY-WORN HEARING AID AIR
$0.00
V5040
5
BODY-WORN HEARING AID BONE
$0.00
V5050
5
HEARING AID MONAURAL IN EAR
$0.00
V5060
5
BEHIND EAR HEARING AID
$0.00
V5070
5
GLASSES AIR CONDUCTION
$0.00
$16.31
$37.16
$16.00
Procedure Code Pricing Action Code Description
Maximum Allowable
V5080
5
GLASSES BONE CONDUCTION
$0.00
V5090
3
HEARING AID DISPENSING FEE
V5095
5
IMPLANT MID EAR HEARING PROS
$0.00
V5100
5
BODY-WORN BILAT HEARING AID
$0.00
V5110
9
HEARING AID DISPENSING FEE
$0.00
V5120
5
BODY-WORN BINAUR HEARING AID
$0.00
V5130
5
IN EAR BINAURAL HEARING AID
$0.00
V5140
5
BEHIND EAR BINAUR HEARING AI
$0.00
V5150
5
GLASSES BINAURAL HEARING AID
$0.00
V5160
9
DISPENSING FEE BINAURAL
$0.00
V5170
5
WITHIN EAR CROS HEARING AID
$0.00
V5180
5
BEHIND EAR CROS HEARING AID
$0.00
V5190
5
GLASSES CROS HEARING AID
$0.00
V5200
9
CROS HEARING AID DISPENS FEE
$0.00
V5210
5
IN EAR BICROS HEARING AID
$0.00
V5220
5
BEHIND EAR BICROS HEARING AI
$0.00
V5230
5
GLASSES BICROS HEARING AID
$0.00
V5240
9
DISPENSING FEE BICROS
$0.00
V5241
9
DISPENSING FEE, MONAURAL
$0.00
V5242
5
HEARING AID, MONAURAL, CIC
$0.00
V5243
5
HEARING AID, MONAURAL, ITC
$0.00
V5244
5
HEARING AID, PROG, MON, CIC
$0.00
V5245
5
HEARING AID, PROG, MON, ITC
$0.00
V5246
5
HEARING AID, PROG, MON, ITE
$0.00
V5247
5
HEARING AID, PROG, MON, BTE
$0.00
V5248
5
HEARING AID, BINAURAL, CIC
$0.00
V5249
5
HEARING AID, BINAURAL, ITC
$0.00
V5250
5
HEARING AID, PROG, BIN, CIC
$0.00
V5251
5
HEARING AID, PROG, BIN, ITC
$0.00
V5252
5
HEARING AID, PROG, BIN, ITE
$0.00
V5253
5
HEARING AID, PROG, BIN, BTE
$0.00
V5254
5
HEARING ID, DIGIT, MON, CIC
$0.00
V5255
5
HEARING AID, DIGIT, MON, ITC
$0.00
V5256
5
HEARING AID, DIGIT, MON, ITE
$0.00
V5257
5
HEARING AID, DIGIT, MON, BTE
$0.00
$400.00
Procedure Code Pricing Action Code Description
Maximum Allowable
V5258
5
HEARING AID, DIGIT, BIN, CIC
$0.00
V5259
5
HEARING AID, DIGIT, BIN, ITC
$0.00
V5260
5
HEARING AID, DIGIT, BIN, ITE
$0.00
V5261
5
HEARING AID, DIGIT, BIN, BTE
$0.00
V5262
5
HEARING AID, DISP, MONAURAL
$0.00
V5263
5
HEARING AID, DISP, BINAURAL
$0.00
V5264
9
EAR MOLD/INSERT
$0.00
V5265
9
EAR MOLD/INSERT, DISP
$0.00
V5266
5
BATTERY FOR HEARING DEVICE
$0.00
V5267
5
HEARING AID SUPPLY/ACCESSORY
$0.00
V5268
9
ALD TELEPHONE AMPLIFIER
$0.00
V5269
9
ALERTING DEVICE, ANY TYPE
$0.00
V5270
9
ALD, TV AMPLIFIER, ANY TYPE
$0.00
V5271
9
ALD, TV CAPTION DECODER
$0.00
V5272
9
TDD
$0.00
V5273
9
ALD FOR COCHLEAR IMPLANT
$0.00
V5274
9
ALD UNSPECIFIED
$0.00
V5275
9
EAR IMPRESSION
$0.00
V5298
5
HEARING AID NOC
$0.00
V5299
9
HEARING SERVICE
$0.00
V5301
9
BASIC ASSESSMENT OF SPECIFIC SINGLE
$0.00
V5310
9
COMPREHENSIVE ASSESSMENT OF SPEECH,
$0.00
V5321
9
ASSESSMENT FOR ORAL OR LARYNGEAL PR
$0.00
V5322
9
ASSESSMENT FOR AUGMENTATIVE COMMUNI
$0.00
V5330
9
TREATMENT FOR SPEECH, LANGUAGE, ORA
$0.00
V5335
9
REPAIR/MODIFICATION OF ORAL OR LARY
$0.00
V5336
5
REPAIR COMMUNICATION DEVICE
$0.00
V5360
9
UNLISTED SPEECH-LANGUAGE SERVICE (S
$0.00
V5362
3
SPEECH SCREENING
$16.00
V5363
3
LANGUAGE SCREENING
$16.00
V5364
3
DYSPHAGIA SCREENING
$16.00
W5950
O
MCO SPECIFIC CODE: INTAKE/RISK ASSE
$0.00
W9026
O
HOSPITAL VISIT,INITIAL,OUTPATIENT;E
$0.00
W9045
O
ER SUPPORT SERVICES,SPECIAL NON-EME
$0.00
W9047
O
ER SUPPORT SERVICES, SPECIAL EMERGE
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
W9049
O
HOSPITAL OUTPATIENT CLINIC VISIT
$0.00
W9057
O
RURAL HEALTH CLINIC VISIT
$0.00
WW101
O
OFFICE VISIT COPAY
$0.00
WW102
O
EMERGENCY ROOM COPAY
$0.00
WW103
O
VISION CARE COPAY
$0.00
WW104
O
TRANSPORTATION COPAY
$0.00
WW105
O
INPATIENT HOSPITAL VISIT OR PROCEDU
$0.00
WW106
O
OUTPATIENT HOSPITAL CO-PAY, EXCLUDI
$0.00
WW201
O
INJECTION, AMPICILLIN SODIUM AND SU
$0.00
WW202
O
INJECTION, AMPICILLIN SODIUM AND SU
$0.00
WW203
O
INJECTION, LEUCOVORIN CALCIUM, UP T
$0.00
WW204
O
INJECTION, CYTOVENE, UP TO 500 MG
$0.00
WW205
O
INJECTION, HEPARIN SODIUM, UP TO 50
$0.00
WW206
O
INJECTION, HEPARIN SODIUM, UP TO 10
$0.00
WW207
O
INJECTION, HEPARIN SODIUM, UP TO 20
$0.00
WW208
O
INJECTION, PROMETHAZINE HCL, UP TO
$0.00
WW209
O
INJECTION, NALBUPHINE, UP TO 20 MG.
$0.00
WW210
O
INJECTION, LORAZEPAN, UP TO 2 MG.
$0.00
WW211
O
INJECTION, CEFTAZADIME, UP TO 500 M
$0.00
WW212
O
INJECTION, CEFTAZADIME, UP TO 1,000
$0.00
WW213
O
INFECTION, STINGING INSECT VENOM, S
$0.00
WW214
O
INJECTION, STINGING INSECT VENOM, M
$0.00
WW215
O
INJECTION, POISON IVY/ OAK, PROPHYL
$0.00
WW216
O
INJECTION, LONG ACTING ADRENALIN, U
$0.00
WW217
O
INJECTION, LEUPROLIDE ACETATE DEPOT
$0.00
WW218
O
INJECTION, LEUPROLIDE ACETATE DEPOT
$0.00
WW219
O
INJECTION, HEPARIN SODIUM FLUSH, UP
$0.00
WW220
O
INJECTION, KETOROLAC TROMETHAMINE,
$0.00
WW221
O
INJECTION, KETOROLAC TROMETHAMINE,
$0.00
WW222
O
INJECTION, MARCAINE HCL, UP TO 10CC
$0.00
WW223
O
INJECTION, ONDANSETRON HCL, UP TO 1
$0.00
WW224
O
IMMUNIZATION, ACTIVE; DIPHTHEIA AND
$0.00
WW225
O
INJECTION, DEPO-PROVERA, 150 MG/ML
$0.00
WW226
O
IMMUNIZATION, ACTIVE; DPT AND HIB
$0.00
WW227
O
INJECTION, MIDAZOLAM, UP TO 10 MG.
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
WW228
O
INJECTION, FLUMAZENIL, UP TO 0.5 MG
$0.00
WW229
O
INJECTION, NALOXONE HCL, UP TO O.4
$0.00
WW230
O
INJECTION, KYTRIL, 1MG/ML
$0.00
WW231
O
INJECTION, HEPARIN SODIUM, PER 100
$0.00
WW232
O
INJECTION, DEXAMETHASONE ACETATE, 1
$0.00
WW301
O
ROUTINE GYNECOLOGICAL EVALUATION IN
$0.00
WW302
O
ROUTINE GYNECOLOGICAL EVALUATION IN
$0.00
WW303
O
INITIAL ANTEPARTUM CARE
$0.00
WW304
O
USE OF A BIRTHING CENTER FACILITY F
$0.00
WW305
O
USE OF A BIRTHING CENTER FACILITY W
$0.00
WW310
O
INSERTION OF HORMONAL CONTRACEPTIVE
$0.00
WW311
O
REMOVAL OF HORMONAL CONTRACEPTIVE I
$0.00
WW312
O
PROVISION AND INSERTION OF VAGINAL
$0.00
WW313
O
INSERTION OF VAGINAL RING CONTAININ
$0.00
WW351
O
HOSPITAL BASED EMERGENCY ROOM PHYSI
$0.00
WW401
O
METHADONE CLINIC SERVICES
$0.00
WW402
O
OPIOID MEDICATION DISPENSING FOR IN
$0.00
WW403
O
OPIOID THERAPY PHYSICAL EVALUATION
$0.00
WW404
O
OPIOID DOSAGE MONITORING FOR INDIVI
$0.00
WW430
O
CHRONIC RENAL DISEASE PROGRAM-NEPRO
$0.00
WW451
O
INSERTION OF AN EPIDURAL OR SUBARAC
$0.00
WW452
O
RE-INJECTION OF A NARCOTIC INTO AN
$0.00
WW453
O
MAINTENANCE OF INTRAVENOUS ACCESS C
$0.00
WW501
O
VISION PROGRAM UNDER EPSDT - ROUTIN
$0.00
WW502
O
VISION PROGRAM UNDER EPSDT - PROVIS
$0.00
WW503
O
VISION PROGRAM UNDER EPSDT - PROVIS
$0.00
WW504
O
EPSDT/VISION-CONTACT LENS TO CORREC
$0.00
WW505
O
VISION PROGRAM UNDER EPSDT-PROVISIO
$0.00
WW506
O
VISION PROGRAM UNDER EPSDT-STOCK SI
$0.00
WW507
O
VISION PROGRAM UNDER EPSDT-PROVISIO
$0.00
WW508
O
VISION PROGRAM UNDER EPSDT-STOCK SI
$0.00
WW509
O
VISION PROGRAM UNDER EPSDT-PROVISIO
$0.00
WW510
O
VISION PROGRAM UNDER EPSDT-NON-STOC
$0.00
WW511
O
VISION PROGRAM UNDER EPSDT-PROVISIO
$0.00
WW512
O
VISION PROGRAM UNDER EPSDT-NON-STOC
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
WW513
O
VISION PROGRAM UNDER EPSDT-PROVISIO
$0.00
WW514
O
VISION PROGRAM UNDER EPSDT-BIFOCAL
$0.00
WW515
O
VISION PROGARM UNDER EPSDT-PROVISIO
$0.00
WW516
O
VISION PROGRAM UNDER EPSDT-BIFOCAL
$0.00
WW517
O
VISION PROGRAM UNDER EPSDT-PROVISIO
$0.00
WW518
O
VISION PROGRAM UNDER EPSDT-BIFOCAL
$0.00
WW519
O
VISION PROGRAM UNDER EPSDT-REPLACEM
$0.00
WW520
O
VISION PROGRAM UNDER EPSDT-POLYCARB
$0.00
WW521
O
VISION PROGRAM UNDER EPSDT-PHOTO GR
$0.00
WW522
O
VISION PROGRAM UNDER EPSDT-REPLACEM
$0.00
WW523
O
VISION PROGRAM UNDER EPSDT-REPLACEM
$0.00
WW524
O
VISION PROGRAM UNDER EPSDT-UNLISTED
$0.00
WW531
O
EPSDT SCREENING WITHOUT TREATMENT R
$0.00
WW532
O
EPSDT SCREENING WITHOUT TREATMENT R
$0.00
WW533
O
EPSDT SCREENING WITHOUT TREATMENT R
$0.00
WW534
O
EPSDT SCREENING WITHOUT TREATMENT R
$0.00
WW535
O
EPSDT SCREENING WITHOUT TREATMENT R
$0.00
WW536
O
EPSDT SCREENING WITH TREATMENT REFE
$0.00
WW537
O
EPSDT SCREENING WITH TREATMENT REFE
$0.00
WW538
O
EPSDT SCREENING WITH TREATMENT REFE
$0.00
WW539
O
EPSDT SCREENING WITH TREATMENT REFE
$0.00
WW540
O
EPSDT SCREENING WITH TREATMENT REFE
$0.00
WW571
O
DPH SPECIAL DENTAL CLINIC REFERRALS
$0.00
WW572
O
EPSDT - TOTAL YEARLY DENTAL CARE FO
$0.00
WW573
O
DENTAL CARE FOR INDIVIDUALS, EPSDT,
$0.00
WW574
O
DENTAL SERVICES FOR SPECIAL NEEDS P
$0.00
WW575
O
ENVIRONMENTAL INSPECTION FOR SOURCE
$0.00
WW601
O
POTENTIAL ACUITY METER (PAM)
$0.00
WW651
O
COMMUNITY SUPPORT SERVICES - MENTAL
$0.00
WW652
O
PSYCHOSOCIAL REHABILITATION CENTER
$0.00
WW653
O
RESIDENTIAL REHABILITATION MENTAL H
$0.00
WW654
O
PERSONAL CARE-DADAMH APPROVED C.S.S
$0.00
WW655
O
COMMUNITY SUPPORT SERVICES-ALCOHOL
$0.00
WW660
O
PHYS SERVICE DADAMH COMM MENTAL HEA
$0.00
WW661
O
PHYS SUPERVISED DADAMH COMM MENTAL
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
WW663
O
PHYS SUPERVISED DADAMH CMHC SERVICE
$0.00
WW664
O
PHYSICIAN SERVICE - DADAMH COMMUNIT
$0.00
WW665
O
PHYS. SUPERVISED DADAMH COMMUNITY M
$0.00
WW668
O
EPSDT BEHAVIORAL HEALTH SERVICES, A
$0.00
WW701
O
PRIVATE DUTY NURSE, EMPLOYED BY AGE
$0.00
WW702
O
EPSDT EXTENDED PRIVATE DUTY NURSE,E
$0.00
WW703
O
PRIVATE DUTY NURSE,SELF-EMPLOYED,PE
$0.00
WW704
O
PRIVATE DUTY NURSE,SELF-EMPLOYED, P
$0.00
WW705
O
PRIVATE DUTY NURSE, SELF-EMPLOYED,
$0.00
WW706
O
PRIVATE DUTY NURSE, SELF-EMPLOYED,
$0.00
WW707
O
PRIVATE DUTY NURSE,SELF-EMPLOYED,PE
$0.00
WW708
O
PRIVATE DUTY NURSE,SELF-EMPLOYED,PE
$0.00
WW709
O
PRIVATE DUTY NURSE,SELF-EMPLOYED, P
$0.00
WW710
O
PRIVATE DUTY NURSE,SELF-EMPLOYED,PE
$0.00
WW711
O
PRIVATE DUTY NURSE,SELF-EMPLOYED,PE
$0.00
WW712
O
PRIVATE DUTY NURSE,SELF-EMPLOYED, P
$0.00
WW713
O
EPSDT EXTENDED PRIVATE DUTY NURSE,S
$0.00
WW714
O
EPSDT EXTENDED PRIVATE DUTY NURSE,S
$0.00
WW715
O
EPSDT EXTENDED PRIVATE DUTY NURSE,S
$0.00
WW716
O
EPSDT EXTENDED PRIVATE DUTY NURSE,S
$0.00
WW717
O
EPSDT EXTENDED PRIVATE DUTY NURSE,S
$0.00
WW718
O
EPSDT EXTENDED PRIVATE DUTY NURSE,S
$0.00
WW719
O
EPSDT EXTENDED PRIVATE DUTY NURSE,S
$0.00
WW720
O
EPSDT EXTENDED PRIVATE DUTY NURSE,S
$0.00
WW721
O
EPSDT EXTENDED PRIVATE DUTY NURSE,S
$0.00
WW722
O
EPSDT EXTENDED PRIVATE DUTY NURSE,S
$0.00
WW751
O
'PULMONARY EVALUATION AND DIAGNOSTI
$0.00
WW752
O
MULTICHANNEL RECORDING OF 3 TO 5 PH
$0.00
WW753
O
MULTICHANNEL RECORDING OF 6 TO 12 P
$0.00
WW754
O
4 HR OVERNIGHT GROWTH HORMONE TEST;
$0.00
WW755
O
12 HR OVERNIGHT GROWTH HORMONE TEST
$0.00
WW797
O
ENTERAL FORMULAE NOC
$0.00
WW798
O
DISPOSABLE INCONTINENCE PRODUCTS ME
$0.00
WW799
O
DIAPERS THAT ARE MEDICALLY NECESSAR
$0.00
WW800
O
EPSDT NON-STATE PLAN SUPPLIES FOR U
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
WW801
O
MISCELLANEOUS SUPPLIES
$0.00
WW802
O
EPSDT
$0.00
WW803
O
NEEDLE WASTE UNIT (ALL SIZES) - IV
$0.00
WW804
O
INJECTION CAPS
$0.00
WW805
O
HUBER NEEDLE (ALL SIZES)
$0.00
WW806
O
SYRINGES (ALL TYPES)
$0.00
WW808
O
ADMINISTRATION SET-INCLUDES TUBING
$0.00
WW809
O
IV TUBING - ALL SIZES & TYPES
$0.00
WW810
O
CLAMP SCISSORS
$0.00
WW811
O
INTRAVENOUS CATHETER -ANGIO CATH, B
$0.00
WW812
O
IV START KIT
$0.00
WW813
O
IV CATHETER DRESSING KIT
$0.00
WW814
O
PEAK EXPIRATORY FLOW METER, EPSDT,
$0.00
WW815
O
MOUTHPIECE FOR PEAK FLOW METER, BOX
$0.00
WW816
O
LANCET DEVICE
$0.00
WW821
O
FEDERALLY QUALIFIED HEALTH CENTER E
$0.00
WW822
O
LINE MAINTENANCE-WEEKLY-SINGLE LUME
$0.00
WW823
O
LINE MAINTENANCE-WEEKLY-DOUBLE LUME
$0.00
WW824
O
LINE MAINTENANCE-WEEKLY-TRIPLE LUME
$0.00
WW825
O
PROTECTED NEEDLE HOUSING
$0.00
WW826
O
THERMOMETER-MERCURY
$0.00
WW827
O
HIBICLENS- 4 OZ
$0.00
WW828
O
TUBEX HOLDER
$0.00
WW829
O
CHEMO SPILL KIT-INCLUDES SAFETY GLA
$0.00
WW830
O
VIAL ADAPTER
$0.00
WW831
O
PICC INSERTION TRAY
$0.00
WW838
O
ENURESIS ALARM FOR AGES 4-20
$0.00
WW839
O
PHOTOTHERAPY BLANKET
$0.00
WW840
9
CARBON ELECTRODES FOR APNEA MONITOR
$0.00
WW841
O
STICKY ELECTRODES FOR APNEA MONITOR
$0.00
WW842
O
FOAM/VELCRO BELT FOR USE WITH CARBO
$0.00
WW843
9
LEAD WIRES FOR APNEA MONITOR-1 SET
$0.00
WW844
O
PULSE OXIMETER
$0.00
WW845
O
OXIBANDS - FOR USE WITH PULSE OXIME
$0.00
WW846
O
OXISENSOR / PROBE - FOR USE WITH PU
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
WW847
O
MEMORY MONITOR - RENTAL - INCLUDES
$0.00
WW848
O
SKIN LEVEL GASTROSTOMY KIT
$0.00
WW849
O
ADAPTER FOR SKIN LEVEL GASTROSTOMY
$0.00
WW850
O
OXYGEN CONTENT, LIQUID, PER POUND
$0.00
WW851
O
OXYGEN CONTENT, GASEOUS, PER EACH D
$0.00
WW852
O
OXYGEN CONTENT, GASEOUS, PER EACH E
$0.00
WW853
O
OXYGEN CONTENT, GASEOUS, PER EACH H
$0.00
WW854
O
OXYGEN CONTENT, GASEOUS, PER EACH M
$0.00
WW855
O
OXYGEN CONTENT, GASEOUS, PER EACH C
$0.00
WW856
O
STATIONARY COMPRESSED GAS SYSTEM; I
$0.00
WW858
O
STATIONARY LIQUID OXYGEN SYSTEM, IN
$0.00
WW860
O
OXYGEN CONCENTRATOR
$0.00
WW870
O
REPAIR OF PATIENT OWNED DURABLE MED
$0.00
WW871
O
EPSDT NON-STATE PLAN ORTHOTIC/PROST
$0.00
WW880
O
ARGININGE POWDER
$0.00
WW881
O
SPECIAL NEEDS EQUIPMENT - MISCELLAN
$0.00
WW900
O
HEARING ASSESSMENT-EPSDT SCHOOL BAS
$0.00
WW901
O
VISION ASSESSMENT-EPSDT SCHOOL BASE
$0.00
WW902
O
IMMUNIZATION ASSESSMENT-EPSDT SCHOO
$0.00
WW903
O
DEVELOPMENTAL/ORTHOPEDIC ASSESSMENT
$0.00
WW904
O
DENTAL ASSESSMENT-EPSDT SCHOOL BASE
$0.00
WW905
O
HEALTH EDUCATION ASSESSMENT-EPSDT S
$0.00
WW906
O
DENTAL HEALTH EDUCATION-EPSDT SCHOO
$0.00
WW910
O
INDIVIDUAL NURSING TREATMENT-EPSDT
$0.00
WW920
O
OCCUPATIONAL THERAPY EVALUATION-EPS
$0.00
WW921
O
INDIVIDUAL OCCUPATIONAL THERAPY TRE
$0.00
WW922
O
GROUP OCCUPATIONAL THERAPY TREATMEN
$0.00
WW930
O
PHYSICAL THERAPY ASSESSMENT-EPSDT S
$0.00
WW931
O
INDIVIDUAL PHYSICAL THERAPY TREATME
$0.00
WW932
O
GROUP PHYSICAL THERAPY TREATMENT-EP
$0.00
WW936
O
ICT PLACEMENT FOR 0-0-S RTC-BASED B
$0.00
WW937
O
ICT PLACEMENT FOR 0-0-S RTC-BASED B
$0.00
WW938
O
ICT PLACEMENT FOR O-O-S RTC-BASED B
$0.00
WW939
O
ICT PLACEMENT FOR 0-0-S RTC-BASED B
$0.00
WW940
O
MENTAL HEALTH TREATMENT ASSESSMENT-
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
WW941
O
INDIVIDUAL MENTAL HEALTH TREATMENT
$0.00
WW942
O
GROUP MENTAL HEALTH TREATMENT THERA
$0.00
WW943
O
FAMILY MENTAL HEALTH TREATMENT THER
$0.00
WW944
O
INDIVIDUAL MENTAL HEALTH CO-TREATME
$0.00
WW945
O
GROUP MENTAL HEALTH CO-TREATMENT TH
$0.00
WW946
O
FAMILY MENTAL HEALTH CO-TREATMENT T
$0.00
WW947
O
MENTAL HEALTH CASE CONSULTATION-EPS
$0.00
WW948
O
AU CLAIR BEHAVIORAL THERAPY, EPSDT
$0.00
WW950
O
SPEECH, LANGUAGE AND HEARING ASSESS
$0.00
WW951
O
INDIVIDUAL SPEECH/LANGUAGE THERAPY-
$0.00
WW952
O
INDIVIDUAL HEARING THERAPY-EPSDT SC
$0.00
WW953
O
GROUP SPEECH/LANGUAGE THERAPY-EPSDT
$0.00
WW954
O
INDIVUDUAL SPEECH/LANGUAGE CO-TREAT
$0.00
WW955
O
INDIVIDUAL HEARING CO-TREATMENT THE
$0.00
WW956
O
GROUP SPEECH/LANGAUAGE CO-TREATMENT
$0.00
WW960
O
TRANSPORTATION,ROUND TRIP-EPSDT SCH
$0.00
WW967
O
ASSESSMENT OF HIGHER CEREBRAL FUNCT
$0.00
WW968
O
PDDN EARLY INTERVENTION THERAPIES,
$0.00
WW969
O
EARLY INTERVENTION MULTI-DISCIPLINA
$0.00
WW970
O
CHILD DEVELOPMENT ORIENTED FAMILY T
$0.00
WW975
O
MENTAL HEALTH TREATMENT EVALUATION,
$0.00
WW976
O
INDIVIDUAL MENTAL HEALTH TREATMENT
$0.00
WW980
O
SPEECH/LANGUAGE/HEARING SCREEN, EPS
$0.00
WW981
O
SPEECH/LANGUAGE/HEARING COMPREHENSI
$0.00
WW982
O
SPEECH/LANGUAGE/HEARING INDIVIDUAL
$0.00
WW983
O
GROUP SPEECH/LANGUAGE/HEARING THERA
$0.00
WW985
O
OCCUPATIONAL THERAPY SCREEN, EPSDT,
$0.00
WW986
O
OCCUPATIONAL THERAPY EVALUATION, CO
$0.00
WW987
O
OCCUPATIONAL THERAPY TREATMENT, IND
$0.00
WW990
O
PHYSICAL THERAPY SCREEN, EPSDT, AGE
$0.00
WW991
O
PHYSICAL THERAPY EVALUATION, COMPRE
$0.00
WW992
O
INDIVIDUAL PHYSICAL THERAPY TREATME
$0.00
WW995
O
INITIAL NUTRITION CONSULTATION
$0.00
WW996
O
NUTRITION COUNSELING
$0.00
WW997
O
ASTHMA REHABILITATION CASE MANAGEME
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
WW998
O
NURSING SERVICES, INTERMITTENT, EPS
$0.00
WW999
O
EPSDT CASE MANAGEMENT SERVICE FOR C
$0.00
X0019
O
MCO SPECIFIC CODE: PRIVATE DUTY NUR
$0.00
YY001
O
NURSING HOME ANCILLARIES - OXYGEN H
$0.00
YY002
O
NURSING HOME ANCILLARIES - OXYGEN P
$0.00
YY003
O
NURSING HOME ANCILLARIES - OXYGEN C
$0.00
YY004
O
NURSING HOME ANCILLARIES - PHYSICAL
$0.00
YY005
O
NURSING HOME ANCILLARIES - PHYSICAL
$0.00
YY006
O
NURSING HOME ANCILLARIES - SPEECH T
$0.00
YY007
O
NURSING HOME ANCILLARIES - SPEECH T
$0.00
YY008
O
NURSING HOME ANCILLARIES - OCCUPATI
$0.00
YY009
O
NURSING HOME ANCILLARIES - OCCUPATI
$0.00
YY101
O
EXTENDED PREGNANCY-PER FIFTEEN MINU
$0.00
YY102
O
EXTENDED PREGNANCY-NUTRITION PER FI
$0.00
YY103
O
EXTENDED PREGNANCY-SOCIAL WORK PER
$0.00
YY201
O
HOSPICE - ROUTINE HOME CARE PER DAY
$0.00
YY202
O
HOSPICE - CONTINUOUS HOME CARE PER
$0.00
YY203
O
HOSPICE - INPATIENT RESPIT CARE PER
$0.00
YY204
O
HOSPICE - GENERAL INPATIENT CARE PE
$0.00
YY205
O
HOSPICE - NURSING HOME ROOM AND BOA
$0.00
YY301
O
FAMILY AND CHILDREN'S SERVICES CLIN
$0.00
YY302
O
FAMILY AND CHILDREN'S SERVICES NURS
$0.00
YY303
O
FAMILY AND CHILDREN'S SERVICES NURS
$0.00
YY304
O
FAMILY AND CHILDREN'S SERVICES EPSD
$0.00
YY401
O
DPH SPECIALTY AUDIOLOGY CLINIC VISI
$0.00
YY402
O
DPH SPECIALTY CARDIAC CLINIC VISIT
$0.00
YY403
O
DPH SPECIALTY ORTHOPEDIC CLINIC VIS
$0.00
YY404
O
DPH SPECIALTY NEUROLOGY CLINIC VISI
$0.00
YY405
O
DPH SPECIALTY SPEECH CLINIC VISIT
$0.00
YY406
O
DPH GENERAL MEDICAL CLINIC VISIT
$0.00
YY407
O
DPH URINALYSIS
$0.00
YY408
O
DPH PRENATAL CLINIC VISIT
$0.00
YY409
O
DPH TUBERCULOSIS CLINIC VISIT
$0.00
YY410
O
DPH STD CLINIC VISIT
$0.00
YY411
O
DPH ENHANCED CARE FOR AT-RISK CHILD
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
YY431
O
DPH - SPECIALTY FAMILY PLANNING CLI
$0.00
YY432
O
DPH - SPECIALTY FAMILY PLANNING CLI
$0.00
YY433
O
DPH - SPECIALTY FAMILY PLANNING CLI
$0.00
YY434
O
DPH FAMILY PLANNING CLINIC VISIT -
$0.00
YY441
O
DPH - SUPPLIED DIAPHRAGM
$0.00
YY442
O
DPH - SUPPLIED FOAM
$0.00
YY443
O
DPH - SUPPLIED BIRTH CONTROL PILLS
$0.00
YY444
O
DPH - SUPPLIED IUD
$0.00
YY445
O
DPH - SUPPLIED PREGNANCY TEST
$0.00
YY471
O
DPH - HEALTH SCREENING - AGE 35 TO
$0.00
YY472
O
DPH - HEALTH SCREENING - AGE 50 TO
$0.00
YY473
O
DPH - HEALTH SCREENING - AGE 60 AND
$0.00
YY501
O
TRANSPORTATION IN VEHICLE OTHER THA
$0.00
YY502
O
TRANSPORTATION IN VEHICLE OTHER THA
$0.00
YY503
O
TRANSPORTATION IN VEHICLE OTHER THA
$0.00
YY504
O
TRANSPORTATION IN VEHICLE OTHER THA
$0.00
YY505
O
TRANSPORTATION IN VEHICLE OTHER THA
$0.00
YY506
O
AMBULANCE - EMERGENCY TRANSPORT (ON
$0.00
YY507
O
AMBULANCE - EMERGENCY TRANSPORT (ON
$0.00
YY508
O
AMBULANCE - NON-EMERGENCY TRANSPORT
$0.00
YY509
O
AMBULANCE, NON-EMERGENCY TRANSPORT,
$0.00
YY510
O
AMBULANCE, NON-EMERGENCY TRANSPORT,
$0.00
YY511
O
ADDITIONAL AMBULANCE CREW(S) NECESS
$0.00
YY512
O
CHRONIC RENAL DISEASE PROGRAM MILEA
$0.00
YY513
O
AMBULANCE, NEONATAL EMERGENCY TRANS
$0.00
YY514
O
AMBULANCE, NEONATAL EMERGENCY TRANS
$0.00
YY515
O
TRANSPORTATION IN VEHICLE OTHER THA
$0.00
YY516
O
TRANSPORTATION IN VEHICLE OTHER THA
$0.00
YY517
O
TRANSPORTATION IN VEHICLE OTHER THA
$0.00
YY518
O
TRANSPORTATION-TAXI SERVICE-METERED
$0.00
YY519
O
TRANSPORTATION IN VEHICLE OTHER THA
$0.00
YY520
O
TRANSPORTATION IN VEHICLE OTHER THA
$0.00
YY521
O
TRANSPORTATION IN VEHICLE OTHER THA
$0.00
YY522
O
TRANSPORTATION IN VEHICLE OTHER THA
$0.00
YY523
O
TRANSPORTATION IN VEHICLE OTHER THA
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
YY524
O
TRANSPORTATION IN VEHICLE OTHER THA
$0.00
YY525
O
TRANSPORTATION IN VEHICLE OTHER THA
$0.00
YY526
O
TRANSPORTATION IN VEHICLE OTHER THA
$0.00
YY560
O
HCBS WAIVER FOR THE MENTALLY RETARD
$0.00
YY561
O
HCBS WAIVER FOR THE MENTALLY RETARD
$0.00
YY562
O
HCBS WAIVER FOR THE MENTALLY RETARD
$0.00
YY563
O
HCBS WAIVER FOR THE MENTALLY RETARD
$0.00
YY564
O
HCBS WAIVER FOR THE MENTALLY RETARD
$0.00
YY565
O
HCBS WAIVER FOR THE MENTALLY RETARD
$0.00
YY566
O
HCBS WAIVER FOR THE MENTALLY RETARD
$0.00
YY577
O
HCBS WAIVER FOR THE MENTALLY RETARD
$0.00
YY578
O
HCBS WAIVER FOR THE MENTALLY RETARD
$0.00
YY579
O
HCBS WAIVER FOR THE MENTALLY RETARD
$0.00
YY580
O
HCBS WAIVER FOR THE MENTALLY RETARD
$0.00
YY581
O
HCBS WAIVER FOR THE MENTALLY RETARD
$0.00
YY582
O
HCBS WAIVER FOR THE MENTALLY RETARD
$0.00
YY583
O
HCBS WAIVER FOR THE MENTALLY RETARD
$0.00
YY584
O
HCBS WAIVER FOR THE MENTALLY RETARD
$0.00
YY585
O
HCBS WAIVER FOR THE MENTALLY RETARD
$0.00
YY586
O
HCBS WAIVER FOR THE MENTALLY RETARD
$0.00
YY587
O
HCBS WAIVER FOR THE MENTALLY RETARD
$0.00
YY599
O
HOME AND COMMUNITY-BASED SERVICES W
$0.00
YY600
O
HOME AND COMMUNITY-BASED SERVICES W
$0.00
YY601
O
HCBS WAIVER FOR THE MENTALLY RETARD
$0.00
YY602
O
HCBS WAIVER FOR THE MENTALLY RETARD
$0.00
YY603
O
HCBS WAIVER FOR THE MENTALLY RETARD
$0.00
YY604
O
HCBS WAIVER FOR THE MENTALLY RETARD
$0.00
YY605
O
HCBS WAIVER FOR THE MENTALLY RETARD
$0.00
YY606
O
HOME AND COMMUNITY - BASED SERVICES
$0.00
YY607
O
HCBS WAIVER FOR MENTALLY RETARDED R
$0.00
YY608
O
HCBS WAIVER FOR THE MENTALLY-RETARD
$0.00
YY609
O
HCBS WAIVER FOR THE MENTALLY RETARD
$0.00
YY610
O
HCBS WAIVER FOR THE MENTALLY RETARD
$0.00
YY611
O
HCBS WAIVER FOR THE MENTALLY RETARD
$0.00
YY612
O
HCBS WAIVER FOR THE MENTALLY RETARD
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
YY613
O
HCBS WAIVER FOR THE MENTALLY RETARD
$0.00
YY614
O
HOME AND COMMUNITY-BASED SERVICES F
$0.00
YY615
O
HCBS WAIVER FOR THE MENTALLY RETARD
$0.00
YY616
O
HCBS WAIVER FOR THE MENTALLY RETARD
$0.00
YY617
O
HOME AND COMMUNITY-BASED WAIVER FOR
$0.00
YY618
O
HCBS WAIVER FOR THE MENTALLY RETARD
$0.00
YY619
O
HCBS WAIVER FOR THE MENTALLY RETARD
$0.00
YY620
O
HCBS WAIVER FOR THE MENTALLY RETARD
$0.00
YY621
O
HCBS WAIVER FOR THE MENTALLY RETARD
$0.00
YY629
O
HOME AND COMMUNITY-BASED SERVICES W
$0.00
YY630
O
HOME AND COMMUNITY-BASED SERVICES W
$0.00
YY631
O
HOME AND COMMUNITY-BASED SERVICES W
$0.00
YY632
O
HOME AND COMMUNITY-BASED SERVICES W
$0.00
YY633
O
HOME AND COMMUNITY-BASED SERVICES W
$0.00
YY634
O
HOME AND COMMUNITY-BASED SERVICES W
$0.00
YY635
O
HOME AND COMMUNITY-BASED SERVICES W
$0.00
YY636
O
HOME AND COMMUNITY-BASED SERVICES W
$0.00
YY637
O
HOME AND COMMUNITY-BASED SERVICES W
$0.00
YY638
O
HOME AND COMMUNITY-BASED SERVICES W
$0.00
YY639
O
HOME AND COMMUNITY-BASED SERVICES W
$0.00
YY640
O
HOME AND COMMUNITY-BASED SERVICES W
$0.00
YY641
O
HOME AND COMMUNITY-BASED SERVICES W
$0.00
YY642
O
HOME AND COMMUNITY-BASED SERVICES W
$0.00
YY643
O
HOME AND COMMUNITY-BASED SERVICES W
$0.00
YY644
O
HOME & COMMUNITY-BASED SERVICES WAI
$0.00
YY645
O
HOME & COMMUNITY-BASED WAIVER FOR A
$0.00
YY646
O
HOME & COMMUNITY BASED WAIVER FOR A
$0.00
YY647
O
HOME & COMMUNITY-BASED WAIVER FOR A
$0.00
YY648
O
HOME&COMMUNITY-BASED WAIVER FOR AID
$0.00
YY649
O
HOME & COMMUNITY-BASED WAIVER FOR A
$0.00
YY650
O
HOME AND COMMUNITY-BASED SERVICES W
$0.00
YY651
O
HOME AND COMMUNITY - BASED SERVICES
$0.00
YY652
O
AGED AND DISABLED WAIVER - EMERGENC
$0.00
YY653
O
HOME AND COMMUNITY - BASED SERVICES
$0.00
YY654
O
HOME AND COMMUNITY - BASED SERVICES
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
YY655
O
HOME AND COMMUNITY - BASED SERVICES
$0.00
YY656
O
HOME AND COMMUNITY-BASED SERVICES W
$0.00
YY657
O
HOME AND COMMUNITY - BASED SERVICES
$0.00
YY658
O
HOME AND COMMUNITY - BASED SERVICES
$0.00
YY659
O
HOME AND COMMUNITY - BASED SERVICES
$0.00
YY660
O
HOME AND COMMUNITY-BASED SERVICES W
$0.00
YY661
O
HCBS-A/D-WAIVER-DURABLE MEDICAL EQU
$0.00
YY662
O
HOME AND COMMUNITY-BASED WAIVER FOR
$0.00
YY663
O
HOME AND COMMUNITY-BASED WAIVER FOR
$0.00
YY664
O
HOME & COMMUNITY BASED SERVICES FOR
$0.00
YY701
O
HOME HEALTH-SKILLED NURSE VISIT-PLA
$0.00
YY702
O
HOME HEALTH - NURSE AIDE - PER 15 M
$0.00
YY703
O
HOME HEALTH - PHYSICAL THERAPY EVAL
$0.00
YY704
O
HOME HEALTH - PHYSICAL THERAPY TREA
$0.00
YY705
O
HOME HEALTH - OCCUPATIONAL THERAPY
$0.00
YY706
O
HOME HEALTH - OCCUPATIONAL THERAPY
$0.00
YY707
O
HOME HEALTH - SPEECH THERAPY EVALUA
$0.00
YY708
O
HOME HEALTH - SPEECH THERAPY TREATM
$0.00
YY709
O
HOME HEALTH- MEDICALLY NECESSARY SU
$0.00
YY710
O
HOME HEALTH-SKILLED NURSE VISIT-ADU
$0.00
YY711
O
HOME HEALTH-NURSE AIDE-ADULT FOSTER
$0.00
YY712
O
HOME HEALTH-PHYSICAL THERAPY EVALUA
$0.00
YY713
O
HOME HEALTH-PHYSICAL THERAPY TREATM
$0.00
YY714
O
HOME HEALTH-OCCUPATIONAL THERAPY EV
$0.00
YY715
O
HOME HEALTH-OCCUPATIONAL THERAPY TR
$0.00
YY716
O
HOME HEALTH-SPEECH THERAPY EVALUATI
$0.00
YY717
O
HOME HEALTH-SPEECH THERAPY TREATMEN
$0.00
YY718
O
HOME HEALTH-NURSE AIDE-HCBS/WAIVER
$0.00
YY719
O
HOME HEALTH-SKILLED NURSE VISIT-HCB
$0.00
YY720
O
HOME HEALTH-PHYSICAL THERAPY EVALUA
$0.00
YY721
O
HOME HEALTH-PHYSICAL THERAPY TREATM
$0.00
YY722
O
HOME HEALTH-OCCUPATIONAL THERAPY EV
$0.00
YY723
O
HOME HEALTH-OCCUPATIONAL THERAPY TR
$0.00
YY724
O
HOME HEALTH-SPEECH THERAPY EVALUATI
$0.00
YY725
O
HOME HEALTH-SPEECH THERAPY TREATMEN
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
YY726
O
HOME HEALTH-SKILLED NURSE VISIT-IN
$0.00
YY727
O
HOME HEALTH-SKILLED NURSE VISIT-ASS
$0.00
YY728
O
HOME HEALTH-NURSE AIDE-ASSISTED LIV
$0.00
YY740
O
MH/SA ASSESSMENT, EPSDT-DSCYF, AGE
$0.00
YY741
O
CLINICAL COORDINATION, EPSDT-DSCYF,
$0.00
YY742
O
CLINICAL BEHAVIORAL GUIDANCE,PERIOD
$0.00
YY750
O
MENTAL HEALTH CRISIS SERVICES, EPSD
$0.00
YY751
O
CENTER-BASED INDIVIDUAL OUTPATIENT
$0.00
YY752
O
MEDICATION MONITORING OR PSYCHIATRI
$0.00
YY753
O
CENTER-BASED OUTPATIENT GROUP MENTA
$0.00
YY754
O
RTC-BASED INDIVIDUAL OUT-PT MENTAL
$0.00
YY755
O
MENTAL HEALTH DAY TREATMENT, EPSDT-
$0.00
YY756
O
RTC-BASED INDIVIDUAL MENTAL HEALTH
$0.00
YY757
O
RTC-BASED INDIVIDUAL MENTAL HEALTH
$0.00
YY758
O
RTC-BASED INDIVIDUAL MENTAL HEALTH
$0.00
YY760
O
DRUG/ALCOHOL INTENSIVE INDIVIDUAL D
$0.00
YY761
O
DRUG/ALCOHOL INDIVIDUAL OUTPATIENT
$0.00
YY762
O
DRUG/ALCOHOL GROUP OUTPATIENT SERVI
$0.00
YY763
O
DRUG/ALCOHOL TREATMENT PROGRAM IN A
$0.00
YY764
7
DRUG\ALCOHOL PARTIAL DAY TREATMENT
$0.00
YY765
O
MENTAL HEALTH/SUBSTANCE ABUSE SERVI
$0.00
YY801
O
PRESCRIBED PEDIATRIC EXTENDED CARE
$0.00
YY802
O
PRESCRIBED PEDIATRIC EXTENDED CARE
$0.00
YY803
O
PRESCRIBED PEDIATRIC EXTENDED CARE(
$0.00
YY804
O
PRESCRIBED PEDIATRIC EXTENDED CARE
$0.00
YY805
O
PRESCRIBED PEDIATRIC EXTENDED CARE
$0.00
YY806
O
PRESCRIBED PEDIATRIC EXTENDED CARE
$0.00
YY807
O
PRESCRIBED PEDIATRIC EXTENDED CARE
$0.00
YY808
O
PRESCRIBED PEDIATRIC EXTENDED CARE
$0.00
YY822
O
VFC IMMUNIZATION CODE CREATED FOR L
$0.00
YY850
O
DAY HEALTH & REHAB FOR MR & DD CLIE
$0.00
YY851
O
DAY HEALTH & REHAB FOR MR & DD CLIE
$0.00
YY852
O
DAY HEALTH AND REHABILITATION FOR N
$0.00
YY853
O
DAY HEALTH AND REHABILITATION FOR N
$0.00
YY921
O
MONTHLY CAPITATED RATE, PEDIATRIC M
$0.00
Procedure Code Pricing Action Code Description
Maximum Allowable
Z0402
O
PORTABLE OXYGEN REFILL (13 TO 28 CU
$0.00
Z0406
O
H TANK REFILL (151-282 CU. FT.)
$0.00
Z0445
O
OXYGEN CONCENTRATOR
$0.00
Z0526
O
WARM-N-FORM ORTHOSIS
$0.00
Z3255
O
ORTHOPEDIC SHOES ATTACHED TO BRACE
$0.00
Z4442
O
TRACHEOSTOMY SUCTION KIT
$0.00
Z4443
O
TRACHEOSTOMY SUCTION CATHETER
$0.00
ZE001
O
MCO SPECIFIC CODE: HOME INFUSION SE
$0.00
ZE002
O
MCO SPECIFIC CODE: HOME INFUSION SE
$0.00
ZH003
O
MCO SPECIFIC CODE: HOME INFUSION SE
$0.00
ZH004
O
MCO SPECIFIC CODE: HOME INFUSION SE
$0.00
ZH005
O
MCO SPECIFIC CODE: HOME INFUSION SE
$0.00
ZH010
O
MCO SPECIFIC CODE: HOME INFUSION SE
$0.00
ZH011
O
MCO SPECIFIC CODE: HOME INFUSION SE
$0.00
ZH020
O
MCO SPECIFIC CODE: HOME INFUSION SE
$0.00
ZH021
O
MCO SPECIFIC CODE: HOME INFUSION SE
$0.00
ZM001
O
MCO SPECIFIC CODE: HOME INFUSION SE
$0.00
ZR001
O
MCO SPECIFIC CODE: HOME INFUSION SE
$0.00
ZR002
O
MCO SPECIFIC CODE: HOME INFUSION SE
$0.00
Pricing Action Codes Pricing Action Code Pricing Action Description 1
PAY PERCENTAGE OF BILLED AMOUNT.
3
LOWER OF BILLED OR ALLOWED AMOUNT.
5
MANUAL PRICE - INDIVIDUAL CONSIDERATION. SET EDIT TO SUSPEND.
6
MANUAL PRICE - NO REASONABLE CHARGE ESTABLISHED. SET EDIT TO SUSPEND.
7
ONLY LEVEL I PRICING SHOULD BE USED. SET EDIT TO SUSPEND.
9
NON-COVERED. SET EDIT TO AUTODENY.
A
LOWER OF BILLED AMOUNT OR ((RVU + BILLED UNITS) X CONVERSION FACTOR DOLLAR AMOUNT)
O
OBSOLETE. SET EDIT TO AUTODENY.
SUSPEND.
FACTOR DOLLAR AMOUNT) .
Procedure Modifier Pricing Procedure Code Procedure Code Modifier Pricing Action Code Modifier Price 11975
26
5
$120.18
11977
26
5
$215.89
11980
26
5
$95.19
11981
26
5
$124.16
11983
26
5
$219.93
51725
26
3
$77.91
51725
TC
3
$147.74
51726
26
3
$88.62
51726
TC
3
$240.40
51736
26
3
$31.87
51736
TC
3
$22.79
51741
26
3
$59.54
51741
TC
3
$26.72
51772
26
3
$82.57
51772
TC
3
$170.16
51784
26
3
$78.63
51784
TC
3
$128.14
51785
26
3
$78.75
51785
TC
3
$145.88
51792
26
3
$56.52
51792
TC
3
$179.84
51795
26
3
$78.99
51795
TC
3
$231.25
51797
26
3
$45.14
51797
TC
3
$108.05
58300
26
5
$73.72
59020
26
3
$35.18
59020
TC
3
$31.23
59025
26
3
$28.34
59025
TC
3
$15.64
62252
26
3
$42.45
62252
TC
3
$50.02
70010
26
3
$59.62
Procedure Code Procedure Code Modifier Pricing Action Code Modifier Price 70010
TC
3
$110.64
70015
26
3
$61.07
70015
TC
3
$81.04
70030
26
3
$8.54
70030
TC
3
$19.34
70100
26
3
$8.89
70100
TC
3
$21.19
70110
26
3
$12.50
70110
TC
3
$26.47
70120
26
3
$8.89
70120
TC
3
$23.88
70130
26
3
$17.06
70130
TC
3
$37.06
70134
26
3
$17.06
70134
TC
3
$29.29
70140
26
3
$9.25
70140
TC
3
$20.19
70150
26
3
$12.86
70150
TC
3
$29.29
70160
26
3
$8.54
70160
TC
3
$23.03
70170
26
3
$15.02
70190
26
3
$10.33
70190
TC
3
$24.62
70200
26
3
$13.95
70200
TC
3
$29.66
70210
26
3
$8.54
70210
TC
3
$20.92
70220
26
3
$12.13
70220
TC
3
$26.34
70240
26
3
$9.61
70240
TC
3
$19.34
70250
26
3
$11.77
70250
TC
3
$23.88
70260
26
3
$16.70
Procedure Code Procedure Code Modifier Pricing Action Code Modifier Price 70260
TC
3
$30.64
70300
26
3
$5.29
70300
TC
3
$8.61
70310
26
3
$8.17
70310
TC
3
$25.25
70320
26
3
$11.05
70320
TC
3
$32.02
70328
26
3
$8.89
70328
TC
3
$20.44
70330
26
3
$12.14
70330
TC
3
$34.48
70332
26
3
$26.43
70332
TC
3
$57.22
70336
26
3
$74.53
70336
TC
3
$350.65
70350
26
3
$8.54
70350
TC
3
$11.57
70355
26
3
$9.98
70355
TC
3
$12.42
70360
26
3
$8.54
70360
TC
3
$18.23
70370
26
3
$15.74
70370
TC
3
$57.87
70371
26
3
$40.95
70371
TC
3
$55.37
70373
26
3
$20.64
70373
TC
3
$58.83
70380
26
3
$8.54
70380
TC
3
$27.95
70390
26
3
$19.24
70390
TC
3
$79.54
70450
26
3
$43.16
70450
TC
3
$176.06
70460
26
3
$57.10
70460
TC
3
$226.43
Procedure Code Procedure Code Modifier Pricing Action Code Modifier Price 70470
26
3
$64.20
70470
TC
3
$279.12
70480
26
3
$64.55
70480
TC
3
$196.93
70481
26
3
$69.61
70481
TC
3
$311.59
70482
26
3
$72.84
70482
TC
3
$344.95
70486
26
3
$57.47
70486
TC
3
$196.41
70487
26
3
$66.01
70487
TC
3
$275.60
70488
26
3
$71.40
70488
TC
3
$344.57
70490
26
3
$64.93
70490
TC
3
$196.28
70491
26
3
$69.61
70491
TC
3
$265.99
70492
26
3
$72.84
70492
TC
3
$334.95
70496
26
3
$88.86
70496
TC
3
$356.02
70498
26
3
$89.22
70498
TC
3
$356.02
70540
26
3
$67.80
70540
TC
3
$353.13
70542
26
3
$81.38
70542
TC
3
$433.17
70543
26
3
$108.06
70543
TC
3
$544.28
70544
26
3
$60.35
70544
TC
3
$351.83
70545
26
3
$60.35
70545
TC
3
$431.99
70546
26
3
$90.64
Procedure Code Procedure Code Modifier Pricing Action Code Modifier Price 70546
TC
3
$547.16
70547
26
3
$60.35
70547
TC
3
$351.70
70548
26
3
$60.35
70548
TC
3
$432.26
70549
26
3
$90.64
70549
TC
3
$547.16
70551
26
3
$74.53
70551
TC
3
$351.68
70552
26
3
$89.92
70552
TC
3
$430.96
70553
26
3
$118.89
70553
TC
3
$539.49
70554
26
3
$107.37
70554
TC
3
$512.84
70555
26
3
$129.63
70557
26
3
$147.32
70558
26
3
$160.74
70559
26
3
$163.43
71010
26
3
$8.89
71010
TC
3
$14.90
71015
26
3
$10.33
71015
TC
3
$18.96
71020
26
3
$11.05
71020
TC
3
$20.55
71021
26
3
$13.21
71021
TC
3
$24.86
71022
26
3
$15.39
71022
TC
3
$30.41
71023
26
3
$19.36
71023
TC
3
$47.04
71030
26
3
$15.39
71030
TC
3
$30.77
71034
26
3
$24.68
71034
TC
3
$66.62
Procedure Code Procedure Code Modifier Pricing Action Code Modifier Price 71035
26
3
$9.26
71035
TC
3
$24.88
71040
26
3
$29.20
71040
TC
3
$65.88
71060
26
3
$37.14
71060
TC
3
$101.46
71090
26
3
$29.39
71100
26
3
$11.05
71100
TC
3
$21.30
71101
26
3
$13.21
71101
TC
3
$25.73
71110
26
3
$13.21
71110
TC
3
$27.08
71111
26
3
$15.74
71111
TC
3
$35.82
71120
26
3
$9.98
71120
TC
3
$22.40
71130
26
3
$11.05
71130
TC
3
$26.10
71250
26
3
$58.55
71250
TC
3
$195.76
71260
26
3
$62.51
71260
TC
3
$280.98
71270
26
3
$69.61
71270
TC
3
$343.89
71275
26
3
$97.38
71275
TC
3
$356.54
71550
26
3
$73.21
71550
TC
3
$353.00
71551
26
3
$86.66
71551
TC
3
$433.30
71552
26
3
$114.58
71552
TC
3
$546.25
71555
26
3
$92.11
71555
TC
3
$431.74
Procedure Code Procedure Code Modifier Pricing Action Code Modifier Price 72010
26
3
$21.74
72010
TC
3
$46.54
72020
26
3
$7.82
72020
TC
3
$15.64
72040
26
3
$11.05
72040
TC
3
$25.36
72050
26
3
$15.39
72050
TC
3
$36.19
72052
26
3
$18.15
72052
TC
3
$46.54
72069
26
3
$11.05
72069
TC
3
$23.40
72070
26
3
$11.05
72070
TC
3
$22.40
72072
26
3
$11.05
72072
TC
3
$27.08
72074
26
3
$11.05
72074
TC
3
$33.60
72080
26
3
$11.05
72080
TC
3
$23.88
72090
26
3
$14.31
72090
TC
3
$31.64
72100
26
3
$11.05
72100
TC
3
$27.20
72110
26
3
$15.39
72110
TC
3
$38.04
72114
26
3
$18.15
72114
TC
3
$51.71
72120
26
3
$11.05
72120
TC
3
$36.93
72125
26
3
$58.55
72125
TC
3
$195.76
72126
26
3
$61.43
72126
TC
3
$281.35
72127
26
3
$63.83
Procedure Code Procedure Code Modifier Pricing Action Code Modifier Price 72127
TC
3
$343.89
72128
26
3
$58.55
72128
TC
3
$195.76
72129
26
3
$61.80
72129
TC
3
$281.35
72130
26
3
$64.20
72130
TC
3
$343.89
72131
26
3
$58.55
72131
TC
3
$195.76
72132
26
3
$61.80
72132
TC
3
$280.98
72133
26
3
$64.20
72133
TC
3
$343.89
72141
26
3
$80.29
72141
TC
3
$350.65
72142
26
3
$96.65
72142
TC
3
$430.96
72146
26
3
$80.66
72146
TC
3
$350.40
72147
26
3
$97.02
72147
TC
3
$430.17
72148
26
3
$74.53
72148
TC
3
$350.40
72149
26
3
$89.92
72149
TC
3
$430.96
72156
26
3
$129.22
72156
TC
3
$539.60
72157
26
3
$129.60
72157
TC
3
$538.82
72158
26
3
$118.52
72158
TC
3
$539.60
72159
26
3
$90.01
72159
TC
3
$563.62
72170
26
3
$8.54
72170
TC
3
$17.12
Procedure Code Procedure Code Modifier Pricing Action Code Modifier Price 72190
26
3
$10.70
72190
TC
3
$28.32
72191
26
3
$91.74
72191
TC
3
$356.42
72192
26
3
$55.31
72192
TC
3
$195.64
72193
26
3
$58.55
72193
TC
3
$267.42
72194
26
3
$61.43
72194
TC
3
$344.28
72195
26
3
$73.21
72195
TC
3
$352.61
72196
26
3
$87.40
72196
TC
3
$432.78
72197
26
3
$113.84
72197
TC
3
$543.64
72198
26
3
$91.01
72198
TC
3
$431.74
72200
26
3
$8.54
72200
TC
3
$20.07
72202
26
3
$9.61
72202
TC
3
$24.99
72220
26
3
$8.54
72220
TC
3
$20.55
72240
26
3
$45.68
72240
TC
3
$111.73
72255
26
3
$44.57
72255
TC
3
$99.18
72265
26
3
$41.71
72265
TC
3
$104.72
72270
26
3
$67.08
72270
TC
3
$161.34
72275
26
3
$35.88
72275
TC
3
$67.01
72285
26
3
$55.70
Procedure Code Procedure Code Modifier Pricing Action Code Modifier Price 72285
TC
3
$119.74
72291
26
3
$68.06
72292
26
3
$70.95
72295
26
3
$40.71
72295
TC
3
$115.69
73000
26
3
$8.17
73000
TC
3
$18.96
73010
26
3
$8.54
73010
TC
3
$19.34
73020
26
3
$7.45
73020
TC
3
$15.64
73030
26
3
$9.26
73030
TC
3
$20.19
73040
26
3
$27.17
73040
TC
3
$78.66
73050
26
3
$10.35
73050
TC
3
$24.99
73060
26
3
$8.54
73060
TC
3
$20.19
73070
26
3
$7.45
73070
TC
3
$18.96
73080
26
3
$8.54
73080
TC
3
$25.36
73085
26
3
$26.80
73085
TC
3
$68.69
73090
26
3
$7.80
73090
TC
3
$18.96
73092
26
3
$7.80
73092
TC
3
$19.71
73100
26
3
$8.17
73100
TC
3
$19.71
73110
26
3
$8.54
73110
TC
3
$24.88
73115
26
3
$27.17
73115
TC
3
$74.12
Procedure Code Procedure Code Modifier Pricing Action Code Modifier Price 73120
26
3
$7.80
73120
TC
3
$18.59
73130
26
3
$8.54
73130
TC
3
$21.92
73140
26
3
$6.73
73140
TC
3
$21.55
73200
26
3
$54.94
73200
TC
3
$196.28
73201
26
3
$58.55
73201
TC
3
$267.33
73202
26
3
$61.43
73202
TC
3
$344.80
73206
26
3
$92.47
73206
TC
3
$356.15
73218
26
3
$67.42
73218
TC
3
$353.26
73219
26
3
$81.38
73219
TC
3
$433.53
73220
26
3
$108.43
73220
TC
3
$544.42
73221
26
3
$67.80
73221
TC
3
$353.00
73222
26
3
$81.38
73222
TC
3
$432.91
73223
26
3
$108.06
73223
TC
3
$544.03
73225
26
3
$86.40
73225
TC
3
$550.96
73500
26
3
$8.54
73500
TC
3
$16.38
73510
26
3
$10.70
73510
TC
3
$25.36
73520
26
3
$12.86
73520
TC
3
$26.10
73525
26
3
$27.41
Procedure Code Procedure Code Modifier Pricing Action Code Modifier Price 73525
TC
3
$67.94
73530
26
3
$14.67
73540
26
3
$9.98
73540
TC
3
$26.10
73542
26
3
$27.71
73542
TC
3
$50.20
73550
26
3
$8.54
73550
TC
3
$19.44
73560
26
3
$8.54
73560
TC
3
$19.34
73562
26
3
$9.26
73562
TC
3
$24.26
73564
26
3
$11.05
73564
TC
3
$27.95
73565
26
3
$8.90
73565
TC
3
$20.82
73580
26
3
$27.41
73580
TC
3
$91.72
73590
26
3
$8.54
73590
TC
3
$18.23
73592
26
3
$7.80
73592
TC
3
$19.71
73600
26
3
$7.80
73600
TC
3
$18.59
73610
26
3
$8.54
73610
TC
3
$21.92
73615
26
3
$27.04
73615
TC
3
$70.90
73620
26
3
$7.80
73620
TC
3
$17.86
73630
26
3
$8.54
73630
TC
3
$21.55
73650
26
3
$7.80
73650
TC
3
$18.23
73660
26
3
$6.36
Procedure Code Procedure Code Modifier Pricing Action Code Modifier Price 73660
TC
3
$20.44
73700
26
3
$54.94
73700
TC
3
$196.28
73701
26
3
$58.92
73701
TC
3
$269.19
73702
26
3
$61.80
73702
TC
3
$344.80
73706
26
3
$97.17
73706
TC
3
$356.31
73718
26
3
$67.80
73718
TC
3
$353.13
73719
26
3
$81.38
73719
TC
3
$433.17
73720
26
3
$108.43
73720
TC
3
$544.42
73721
26
3
$67.80
73721
TC
3
$353.00
73722
26
3
$81.75
73722
TC
3
$433.03
73723
26
3
$108.43
73723
TC
3
$543.66
73725
26
3
$92.09
73725
TC
3
$431.97
74000
26
3
$8.89
74000
TC
3
$16.38
74010
26
3
$11.42
74010
TC
3
$25.73
74020
26
3
$13.58
74020
TC
3
$26.10
74022
26
3
$16.11
74022
TC
3
$31.88
74150
26
3
$59.99
74150
TC
3
$195.76
74160
26
3
$64.56
74160
TC
3
$301.07
Procedure Code Procedure Code Modifier Pricing Action Code Modifier Price 74170
26
3
$70.69
74170
TC
3
$344.70
74175
26
3
$96.43
74175
TC
3
$356.68
74181
26
3
$73.58
74181
TC
3
$352.08
74182
26
3
$87.40
74182
TC
3
$433.17
74183
26
3
$113.84
74183
TC
3
$543.64
74185
26
3
$91.01
74185
TC
3
$431.60
74190
26
3
$24.28
74210
26
3
$18.52
74210
TC
3
$57.63
74220
26
3
$23.21
74220
TC
3
$63.18
74230
26
3
$26.81
74230
TC
3
$61.94
74235
26
3
$61.47
74240
26
3
$34.99
74240
TC
3
$71.79
74241
26
3
$34.61
74241
TC
3
$79.18
74245
26
3
$46.05
74245
TC
3
$124.75
74246
26
3
$34.99
74246
TC
3
$87.43
74247
26
3
$34.99
74247
TC
3
$88.91
74249
26
3
$46.05
74249
TC
3
$137.19
74250
26
3
$23.56
74250
TC
3
$77.10
74251
26
3
$34.99
Procedure Code Procedure Code Modifier Pricing Action Code Modifier Price 74251
TC
3
$145.88
74260
26
3
$25.00
74260
TC
3
$89.82
74270
26
3
$34.99
74270
TC
3
$89.04
74280
26
3
$50.02
74280
TC
3
$144.72
74283
26
3
$101.69
74283
TC
3
$88.65
74290
26
3
$16.11
74290
TC
3
$48.15
74291
26
3
$9.98
74291
TC
3
$45.58
74300
26
O
$18.66
74301
26
3
$10.70
74305
26
3
$21.40
74320
26
3
$27.54
74320
TC
3
$86.52
74327
26
3
$35.71
74327
TC
3
$93.95
74328
26
3
$35.71
74329
26
3
$35.71
74330
26
3
$45.69
74340
26
3
$27.17
74355
26
3
$38.60
74360
26
3
$28.28
74363
26
3
$44.97
74400
26
3
$24.65
74400
TC
3
$84.34
74410
26
3
$25.01
74410
TC
3
$89.89
74415
26
3
$24.65
74415
TC
3
$107.13
74420
26
3
$18.52
74425
26
3
$18.52
Procedure Code Procedure Code Modifier Pricing Action Code Modifier Price 74430
26
3
$16.35
74430
TC
3
$61.70
74440
26
3
$19.24
74440
TC
3
$64.66
74445
26
3
$59.05
74450
26
3
$17.08
74455
26
3
$17.08
74455
TC
3
$73.38
74470
26
3
$27.54
74475
26
3
$27.54
74475
TC
3
$95.85
74480
26
3
$27.54
74480
TC
3
$96.22
74485
26
3
$27.78
74485
TC
3
$90.22
74710
26
3
$17.43
74710
TC
3
$25.84
74740
26
3
$19.24
74740
TC
3
$58.24
74775
26
3
$31.38
75600
26
3
$26.49
75600
TC
3
$295.08
75605
26
3
$59.68
75605
TC
3
$213.74
75625
26
3
$58.07
75625
TC
3
$211.52
75630
26
3
$92.85
75630
TC
3
$219.51
75635
26
3
$123.52
75635
TC
3
$357.06
75650
26
3
$76.36
75650
TC
3
$212.63
75658
26
3
$65.49
75658
TC
3
$220.39
75660
26
3
$67.10
Procedure Code Procedure Code Modifier Pricing Action Code Modifier Price 75660
TC
3
$224.10
75662
26
3
$86.27
75662
TC
3
$248.13
75665
26
3
$67.45
75665
TC
3
$231.49
75671
26
3
$85.02
75671
TC
3
$253.67
75676
26
3
$66.97
75676
TC
3
$224.46
75680
26
3
$85.40
75680
TC
3
$239.62
75685
26
3
$67.10
75685
TC
3
$224.83
75705
26
3
$112.07
75705
TC
3
$223.35
75710
26
3
$58.31
75710
TC
3
$227.06
75716
26
3
$66.97
75716
TC
3
$251.45
75722
26
3
$59.31
75722
TC
3
$222.62
75724
26
3
$80.69
75724
TC
3
$247.75
75726
26
3
$58.20
75726
TC
3
$224.10
75731
26
3
$61.40
75731
TC
3
$230.75
75733
26
3
$71.54
75733
TC
3
$259.58
75736
26
3
$58.81
75736
TC
3
$225.94
75741
26
3
$67.10
75741
TC
3
$205.98
75743
26
3
$85.40
75743
TC
3
$213.38
Procedure Code Procedure Code Modifier Pricing Action Code Modifier Price 75746
26
3
$57.83
75746
TC
3
$218.18
75756
26
3
$62.03
75756
TC
3
$231.12
75774
26
3
$18.52
75774
TC
3
$196.36
75790
26
3
$91.20
75790
TC
3
$83.25
75801
26
3
$40.10
75803
26
3
$59.64
75805
26
3
$41.60
75807
26
3
$59.64
75809
26
3
$23.56
75809
TC
3
$63.31
75810
26
3
$58.57
75820
26
3
$36.08
75820
TC
3
$83.14
75822
26
3
$53.50
75822
TC
3
$92.13
75825
26
3
$57.58
75825
TC
3
$202.28
75827
26
3
$56.35
75827
TC
3
$203.02
75831
26
3
$57.70
75831
TC
3
$205.24
75833
26
3
$74.63
75833
TC
3
$218.55
75840
26
3
$56.83
75840
TC
3
$203.76
75842
26
3
$75.63
75842
TC
3
$219.28
75860
26
3
$59.07
75860
TC
3
$209.31
75870
26
3
$57.47
75870
TC
3
$208.56
Procedure Code Procedure Code Modifier Pricing Action Code Modifier Price 75872
26
3
$60.73
75872
TC
3
$229.64
75880
26
3
$34.60
75880
TC
3
$85.73
75885
26
3
$73.60
75885
TC
3
$205.98
75887
26
3
$73.60
75887
TC
3
$208.20
75889
26
3
$58.20
75889
TC
3
$205.60
75891
26
3
$58.20
75891
TC
3
$205.60
75893
26
3
$27.17
75893
TC
3
$205.24
75894
26
3
$66.85
75896
26
3
$67.24
75898
26
3
$84.67
75900
26
3
$24.88
75901
26
3
$24.65
75901
TC
3
$141.89
75902
26
3
$19.59
75902
TC
3
$73.13
75940
26
3
$27.28
75945
26
3
$20.80
75946
26
3
$20.30
75952
26
3
$223.25
75953
26
3
$67.61
75954
26
3
$110.25
75956
26
3
$349.86
75957
26
3
$299.53
75958
26
3
$197.75
75959
26
3
$173.88
75960
26
3
$42.33
75960
TC
3
$220.69
75961
26
3
$214.61
Procedure Code Procedure Code Modifier Pricing Action Code Modifier Price 75961
TC
3
$197.29
75962
26
3
$27.41
75962
TC
3
$254.29
75964
26
3
$18.38
75964
TC
3
$147.83
75966
26
3
$68.58
75966
TC
3
$261.31
75968
26
3
$18.88
75968
TC
3
$147.83
75970
26
3
$42.44
75978
26
3
$26.80
75978
TC
3
$250.22
75980
26
3
$73.23
75984
26
3
$36.80
75984
TC
3
$77.32
75989
26
3
$60.36
75989
TC
3
$83.19
75992
26
3
$28.15
75993
26
3
$18.52
75994
26
3
$61.80
75995
26
3
$65.76
75996
26
3
$18.15
76000
26
3
$8.54
76000
TC
3
$84.50
76001
26
3
$34.38
76010
26
3
$9.26
76010
TC
3
$18.59
76080
26
3
$27.54
76080
TC
3
$35.82
76098
26
3
$8.17
76098
TC
3
$11.57
76100
26
3
$29.20
76100
TC
3
$75.51
76101
26
3
$28.84
76101
TC
3
$157.56
Procedure Code Procedure Code Modifier Pricing Action Code Modifier Price 76102
26
3
$28.47
76102
TC
3
$203.15
76120
26
3
$18.87
76120
TC
3
$56.53
76125
26
3
$14.33
76376
26
3
$10.58
76376
TC
3
$69.94
76377
26
3
$40.87
76377
TC
3
$69.91
76380
26
3
$49.28
76380
TC
3
$106.03
76390
26
3
$69.08
76390
TC
3
$393.83
76506
26
3
$32.46
76506
TC
3
$63.18
76510
26
3
$79.40
76510
TC
3
$68.23
76511
26
3
$47.99
76511
TC
3
$48.27
76512
26
3
$48.12
76512
TC
3
$41.95
76513
26
3
$32.94
76513
TC
3
$50.46
76514
26
3
$8.90
76514
TC
3
$3.57
76516
26
3
$27.30
76516
TC
3
$39.39
76519
26
3
$27.67
76519
TC
3
$43.83
76529
26
3
$28.98
76529
TC
3
$38.51
76536
26
3
$27.52
76536
TC
3
$82.89
76604
26
3
$27.53
76604
TC
3
$58.61
Procedure Code Procedure Code Modifier Pricing Action Code Modifier Price 76645
26
3
$27.17
76645
TC
3
$63.18
76700
26
3
$40.62
76700
TC
3
$95.80
76705
26
3
$29.94
76705
TC
3
$73.64
76770
26
3
$37.14
76770
TC
3
$93.58
76775
26
3
$29.95
76775
TC
3
$81.77
76776
26
3
$38.23
76776
TC
3
$107.26
76800
26
3
$53.41
76800
TC
3
$68.84
76801
26
3
$49.27
76801
TC
3
$81.25
76802
26
3
$40.97
76802
TC
3
$32.09
76805
26
3
$48.90
76805
TC
3
$96.78
76810
26
3
$48.18
76810
TC
3
$51.49
76811
26
3
$92.60
76811
TC
3
$110.87
76812
26
3
$86.59
76812
TC
3
$61.10
76813
26
3
$56.67
76813
TC
3
$70.28
76814
26
3
$47.67
76814
TC
3
$34.41
76815
26
3
$32.08
76815
TC
3
$58.49
76816
26
3
$41.69
76816
TC
3
$63.31
76817
26
3
$36.76
Procedure Code Procedure Code Modifier Pricing Action Code Modifier Price 76817
TC
3
$63.18
76818
26
3
$51.29
76818
TC
3
$68.94
76819
26
3
$37.85
76819
TC
3
$55.26
76820
26
3
$24.50
76820
TC
3
$29.13
76821
26
3
$34.23
76821
TC
3
$62.77
76825
26
3
$81.68
76825
TC
3
$126.12
76826
26
3
$39.99
76826
TC
3
$74.77
76827
26
3
$28.23
76827
TC
3
$43.18
76828
26
3
$27.38
76828
TC
3
$25.21
76830
26
3
$34.25
76830
TC
3
$85.58
76831
26
3
$34.95
76831
TC
3
$84.84
76856
26
3
$34.61
76856
TC
3
$85.96
76857
26
3
$19.60
76857
TC
3
$63.68
76870
26
3
$32.46
76870
TC
3
$87.06
76872
26
3
$35.97
76872
TC
3
$99.02
76873
26
3
$78.25
76873
TC
3
$98.11
76880
26
3
$28.82
76880
TC
3
$96.56
76885
26
3
$37.14
76885
TC
3
$63.18
Procedure Code Procedure Code Modifier Pricing Action Code Modifier Price 76886
26
3
$30.63
76886
TC
3
$63.05
76930
26
3
$36.25
76930
TC
3
$61.92
76932
26
3
$36.25
76936
26
3
$101.21
76936
TC
3
$94.91
76937
26
3
$15.50
76937
TC
3
$20.14
76940
26
3
$104.41
76941
26
3
$65.83
76942
26
3
$33.91
76942
TC
3
$152.13
76945
26
3
$32.79
76946
26
3
$18.49
76946
TC
3
$25.69
76950
26
3
$28.84
76950
TC
3
$41.61
76965
26
3
$68.66
76965
TC
3
$77.57
76970
26
3
$19.21
76970
TC
3
$63.18
76975
26
3
$41.37
76977
26
3
$2.76
76977
TC
3
$11.18
76998
26
3
$60.42
77001
26
3
$18.99
77001
TC
3
$85.58
77002
26
3
$26.43
77002
TC
3
$44.20
77003
26
3
$27.70
77003
TC
3
$30.88
77011
26
3
$60.34
77011
TC
3
$623.79
77012
26
3
$58.92
Procedure Code Procedure Code Modifier Pricing Action Code Modifier Price 77012
TC
3
$139.09
77013
26
3
$203.09
77014
26
3
$42.05
77014
TC
3
$143.95
77021
26
3
$76.46
77021
TC
3
$372.54
77022
26
3
$212.35
77031
26
3
$80.05
77031
TC
3
$111.65
77032
26
3
$28.25
77032
TC
3
$31.25
77051
26
3
$3.13
77051
TC
3
$9.11
77052
26
3
$3.13
77052
TC
3
$9.11
77280
26
3
$34.85
77280
TC
3
$150.35
77285
26
3
$52.03
77285
TC
3
$267.46
77290
26
3
$77.25
77290
TC
3
$419.14
77295
26
3
$225.76
77295
TC
3
$455.09
77300
26
3
$30.63
77300
TC
3
$40.49
77301
26
3
$395.67
77301
TC
3
$1,780.88
77305
26
3
$34.85
77305
TC
3
$38.13
77310
26
3
$52.03
77310
TC
3
$49.33
77315
26
3
$77.25
77315
TC
3
$70.64
77321
26
3
$46.98
77321
TC
3
$74.91
Procedure Code Procedure Code Modifier Pricing Action Code Modifier Price 77326
26
3
$45.89
77326
TC
3
$97.02
77327
26
3
$68.73
77327
TC
3
$134.82
77328
26
3
$103.57
77328
TC
3
$174.95
77331
26
3
$43.14
77331
TC
3
$18.96
77332
26
3
$26.67
77332
TC
3
$51.21
77333
26
3
$41.70
77333
TC
3
$26.67
77334
26
3
$61.28
77334
TC
3
$96.87
77421
26
3
$19.22
77421
TC
3
$94.82
77470
26
3
$103.57
77470
TC
3
$150.93
77620
26
3
$77.55
77620
TC
3
$312.91
77750
26
3
$244.63
77750
TC
3
$92.63
77761
26
3
$187.64
77761
TC
3
$163.44
77762
26
3
$283.80
77762
TC
3
$194.22
77763
26
3
$425.95
77763
TC
3
$249.89
77776
26
3
$235.10
77776
TC
3
$176.51
77777
26
3
$375.70
77777
TC
3
$195.68
77778
26
3
$556.92
77778
TC
3
$260.09
77789
26
3
$56.60
Procedure Code Procedure Code Modifier Pricing Action Code Modifier Price 77789
TC
3
$47.80
77790
26
3
$52.03
77790
TC
3
$35.23
78000
26
3
$9.61
78000
TC
3
$59.49
78001
26
3
$13.23
78001
TC
3
$74.51
78003
26
3
$16.46
78003
TC
3
$59.85
78006
26
3
$24.65
78006
TC
3
$191.67
78007
26
3
$25.37
78007
TC
3
$106.13
78010
26
3
$19.59
78010
TC
3
$130.93
78011
26
3
$22.84
78011
TC
3
$138.19
78015
26
3
$33.91
78015
TC
3
$169.35
78016
26
3
$41.48
78016
TC
3
$267.55
78018
26
3
$43.52
78018
TC
3
$267.96
78020
26
3
$30.42
78020
TC
3
$59.92
78070
26
3
$41.72
78070
TC
3
$130.18
78075
26
3
$37.51
78075
TC
3
$368.16
78102
26
3
$27.90
78102
TC
3
$131.91
78103
26
3
$37.87
78103
TC
3
$176.73
78104
26
3
$40.77
78104
TC
3
$205.29
Procedure Code Procedure Code Modifier Pricing Action Code Modifier Price 78110
26
3
$9.61
78110
TC
3
$66.88
78111
26
3
$11.43
78111
TC
3
$86.17
78120
26
3
$11.79
78120
TC
3
$75.10
78121
26
3
$16.11
78121
TC
3
$89.13
78122
26
9
$23.48
78130
26
3
$31.02
78130
TC
3
$121.29
78135
26
3
$32.46
78135
TC
3
$286.23
78140
26
3
$31.02
78140
TC
3
$116.32
78185
26
3
$20.32
78185
TC
3
$165.41
78190
26
3
$54.55
78190
TC
3
$166.87
78191
26
3
$30.65
78191
TC
3
$167.10
78195
26
3
$60.96
78195
TC
3
$266.29
78201
26
3
$21.75
78201
TC
3
$149.52
78202
26
3
$25.36
78202
TC
3
$172.31
78205
26
3
$36.07
78205
TC
3
$200.05
78206
26
3
$48.57
78206
TC
3
$280.66
78215
26
3
$24.65
78215
TC
3
$158.26
78216
26
3
$28.62
78216
TC
3
$109.31
Procedure Code Procedure Code Modifier Pricing Action Code Modifier Price 78220
26
3
$24.65
78220
TC
3
$119.17
78223
26
3
$42.43
78223
TC
3
$263.72
78230
26
3
$22.47
78230
TC
3
$133.25
78231
26
3
$26.09
78231
TC
3
$106.49
78232
26
3
$23.93
78232
TC
3
$111.16
78258
26
3
$37.89
78258
TC
3
$178.97
78261
26
3
$34.99
78261
TC
3
$204.55
78262
26
3
$33.89
78262
TC
3
$202.33
78264
26
3
$39.32
78264
TC
3
$232.64
78270
26
3
$9.98
78270
TC
3
$68.94
78271
26
3
$9.60
78271
TC
3
$70.05
78272
26
3
$12.85
78272
TC
3
$77.43
78278
26
3
$50.02
78278
TC
3
$246.32
78282
26
3
$19.24
78290
26
3
$34.63
78290
TC
3
$247.23
78291
26
3
$44.61
78291
TC
3
$193.86
78300
26
3
$31.38
78300
TC
3
$136.08
78305
26
3
$41.71
78305
TC
3
$180.91
Procedure Code Procedure Code Modifier Pricing Action Code Modifier Price 78306
26
3
$43.52
78306
TC
3
$203.07
78315
26
3
$51.46
78315
TC
3
$249.16
78320
26
3
$52.54
78320
TC
3
$200.05
78350
26
3
$10.69
78350
TC
3
$22.64
78414
26
3
$21.36
78428
26
3
$41.16
78428
TC
3
$153.22
78445
26
3
$24.65
78445
TC
3
$138.69
78456
26
3
$53.70
78456
TC
3
$189.04
78457
26
3
$38.58
78457
TC
3
$148.66
78458
26
3
$45.69
78458
TC
3
$160.68
78459
26
3
$58.03
78459
TC
3
$216.65
78460
26
3
$43.89
78460
TC
3
$143.61
78461
26
3
$62.90
78461
TC
3
$147.59
78464
26
3
$58.03
78464
TC
3
$216.65
78465
26
3
$78.51
78465
TC
3
$408.23
78466
26
3
$36.09
78466
TC
3
$142.74
78468
26
3
$42.98
78468
TC
3
$182.75
78469
26
3
$48.38
78469
TC
3
$208.20
Procedure Code Procedure Code Modifier Pricing Action Code Modifier Price 78472
26
3
$51.14
78472
TC
3
$209.79
78473
26
3
$78.00
78473
TC
3
$278.48
78478
26
3
$27.21
78478
TC
3
$31.61
78480
26
3
$17.48
78480
TC
3
$31.61
78481
26
3
$53.12
78481
TC
3
$175.67
78483
26
3
$80.71
78483
TC
3
$242.37
78491
26
3
$55.17
78491
TC
3
$268.45
78492
26
3
$55.17
78492
TC
3
$268.45
78494
26
3
$62.57
78494
TC
3
$221.99
78496
26
3
$26.85
78496
TC
3
$90.00
78580
26
3
$37.51
78580
TC
3
$169.21
78584
26
3
$50.02
78584
TC
3
$106.49
78585
26
3
$55.31
78585
TC
3
$285.95
78586
26
3
$20.32
78586
TC
3
$137.56
78587
26
3
$25.01
78587
TC
3
$173.79
78588
26
3
$55.31
78588
TC
3
$261.26
78591
26
3
$20.32
78591
TC
3
$139.78
78593
26
3
$24.65
Procedure Code Procedure Code Modifier Pricing Action Code Modifier Price 78593
TC
3
$164.03
78594
26
3
$26.81
78594
TC
3
$193.80
78596
26
3
$62.85
78596
TC
3
$303.53
78600
26
3
$22.49
78600
TC
3
$149.39
78601
26
3
$25.73
78601
TC
3
$178.82
78605
26
3
$27.19
78605
TC
3
$164.03
78606
26
3
$32.46
78606
TC
3
$267.53
78607
26
3
$62.16
78607
TC
3
$296.76
78608
26
3
$55.17
78608
TC
3
$268.45
78609
26
3
$55.17
78609
TC
3
$268.45
78610
26
3
$15.77
78610
TC
3
$158.04
78630
26
3
$34.63
78630
TC
3
$283.75
78635
26
3
$31.15
78635
TC
3
$258.83
78645
26
3
$28.98
78645
TC
3
$189.45
78647
26
3
$45.32
78647
TC
3
$290.26
78650
26
3
$31.02
78650
TC
3
$279.71
78660
26
3
$26.81
78660
TC
3
$134.86
78700
26
3
$22.84
78700
TC
3
$147.66
Procedure Code Procedure Code Modifier Pricing Action Code Modifier Price 78701
26
3
$24.65
78701
TC
3
$179.56
78707
26
3
$48.57
78707
TC
3
$188.52
78708
26
3
$61.45
78708
TC
3
$130.84
78709
26
3
$71.42
78709
TC
3
$277.99
78710
26
3
$33.55
78710
TC
3
$200.79
78725
26
3
$18.87
78725
TC
3
$79.91
78730
26
3
$8.80
78730
TC
3
$67.36
78740
26
3
$29.22
78740
TC
3
$173.69
78761
26
3
$36.07
78761
TC
3
$167.12
78800
26
3
$33.05
78800
TC
3
$148.50
78801
26
3
$40.15
78801
TC
3
$203.07
78802
26
3
$43.52
78802
TC
3
$275.23
78803
26
3
$55.31
78803
TC
3
$295.66
78804
26
3
$54.35
78804
TC
3
$508.52
78805
26
3
$36.79
78805
TC
3
$145.18
78806
26
3
$43.52
78806
TC
3
$290.11
78807
26
3
$55.44
78807
TC
3
$296.02
78811
26
3
$79.11
Procedure Code Procedure Code Modifier Pricing Action Code Modifier Price 78812
26
3
$98.59
78813
26
3
$102.20
78814
26
3
$111.94
78815
26
3
$123.84
78816
26
3
$127.10
79005
26
3
$89.90
79005
TC
3
$62.50
79101
26
3
$103.75
79101
TC
3
$68.05
79200
26
3
$101.00
79200
TC
3
$73.23
79300
26
3
$81.73
79403
26
3
$114.96
79403
TC
3
$103.55
79440
26
3
$100.75
79440
TC
3
$59.92
79445
26
3
$122.28
83020
26
3
$20.56
83912
26
3
$5.60
84165
26
3
$20.56
84166
26
3
$19.93
84181
26
3
$19.79
84182
26
3
$20.95
85390
26
3
$20.17
85576
26
3
$20.56
86255
26
3
$20.56
86256
26
3
$20.56
86320
26
3
$20.56
86325
26
3
$20.56
86327
26
3
$23.62
86334
26
3
$20.56
86335
26
3
$19.02
87164
26
3
$19.01
87207
26
3
$20.95
88104
26
3
$31.57
Procedure Code Procedure Code Modifier Pricing Action Code Modifier Price 88104
TC
3
$19.92
88106
26
3
$31.57
88106
TC
3
$14.90
88107
26
3
$43.25
88107
TC
3
$25.33
88108
26
3
$31.57
88108
TC
3
$22.24
88112
26
3
$66.40
88112
TC
3
$57.41
88125
26
3
$14.83
88125
TC
3
$5.71
88160
26
3
$28.12
88160
TC
3
$27.65
88161
26
3
$28.12
88161
TC
3
$26.10
88162
26
3
$43.25
88162
TC
3
$13.74
88172
26
3
$33.86
88172
TC
3
$15.67
88173
26
3
$77.87
88173
TC
3
$45.04
88182
26
3
$43.63
88182
TC
3
$49.50
88300
26
3
$4.89
88300
TC
3
$9.57
88302
26
3
$7.56
88302
TC
3
$24.94
88304
26
3
$12.53
88304
TC
3
$30.35
88305
26
3
$42.27
88305
TC
3
$55.30
88307
26
3
$89.26
88307
TC
3
$77.54
88309
26
3
$128.39
88309
TC
3
$88.75
Procedure Code Procedure Code Modifier Pricing Action Code Modifier Price 88311
26
3
$13.68
88311
TC
3
$3.78
88312
26
3
$30.42
88312
TC
3
$43.19
88313
26
3
$13.68
88313
TC
3
$38.17
88314
26
3
$25.45
88314
TC
3
$27.26
88318
26
3
$23.62
88318
TC
3
$23.87
88319
26
3
$29.65
88319
TC
3
$64.75
88331
26
3
$66.87
88331
TC
3
$18.97
88332
26
3
$33.09
88332
TC
3
$9.87
88333
26
3
$59.71
88333
TC
3
$30.69
88334
26
3
$34.67
88334
TC
3
$18.30
88342
26
3
$47.84
88342
TC
3
$38.47
88346
26
3
$48.22
88346
TC
3
$41.95
88347
26
3
$47.83
88347
TC
3
$54.70
88348
26
3
$84.37
88348
TC
3
$304.29
88349
26
3
$43.25
88349
TC
3
$374.71
88355
26
3
$103.70
88355
TC
3
$71.36
88356
26
3
$167.57
88356
TC
3
$63.93
88358
26
3
$55.97
Procedure Code Procedure Code Modifier Pricing Action Code Modifier Price 88358
TC
3
$7.51
88360
26
3
$59.52
88360
TC
3
$47.05
88361
26
3
$55.20
88361
TC
3
$86.34
88362
26
3
$120.90
88362
TC
3
$135.89
88365
26
3
$52.43
88365
TC
3
$70.16
88367
26
3
$69.42
88367
TC
3
$130.83
88368
26
3
$75.29
88368
TC
3
$68.23
88371
26
3
$19.40
88372
26
3
$20.95
88384
26
3
$67.70
88384
TC
3
$258.95
88385
26
3
$84.63
88385
TC
3
$250.87
88386
26
3
$106.44
88386
TC
3
$243.06
89060
26
3
$20.95
91000
26
3
$35.68
91000
TC
3
$52.37
91010
26
3
$66.07
91010
TC
3
$120.48
91011
26
3
$81.15
91011
TC
3
$168.91
91012
26
3
$78.01
91012
TC
3
$176.18
91020
26
3
$75.69
91020
TC
3
$151.17
91022
26
3
$77.91
91022
TC
3
$108.28
91030
26
3
$49.00
Procedure Code Procedure Code Modifier Pricing Action Code Modifier Price 91030
TC
3
$86.99
91034
26
3
$51.25
91034
TC
3
$144.88
91035
26
3
$83.76
91035
TC
3
$379.65
91037
26
3
$52.00
91037
TC
3
$104.96
91038
26
3
$58.86
91038
TC
3
$79.08
91040
26
3
$53.48
91040
TC
3
$321.98
91052
26
3
$40.04
91052
TC
3
$81.08
91055
26
3
$45.51
91055
TC
3
$85.14
91065
26
3
$10.35
91065
TC
3
$54.46
91110
26
3
$192.49
91110
TC
3
$699.32
91120
26
3
$48.17
91120
TC
3
$336.66
91122
26
3
$89.29
91122
TC
3
$138.34
91132
26
3
$27.93
91133
26
3
$35.76
92060
26
3
$34.75
92060
TC
3
$19.09
92065
26
3
$17.53
92065
TC
3
$25.01
92081
26
3
$17.91
92081
TC
3
$30.56
92082
26
3
$21.87
92082
TC
3
$42.39
92083
26
3
$25.13
92083
TC
3
$48.30
Procedure Code Procedure Code Modifier Pricing Action Code Modifier Price 92135
26
3
$17.92
92135
TC
3
$24.64
92136
26
3
$27.67
92136
TC
3
$48.27
92235
26
3
$41.62
92235
TC
3
$76.12
92240
26
3
$56.66
92240
TC
3
$145.02
92250
26
3
$21.87
92250
TC
3
$44.24
92265
26
3
$39.14
92265
TC
3
$31.91
92270
26
3
$39.64
92270
TC
3
$42.26
92275
26
3
$51.60
92275
TC
3
$71.10
92283
26
3
$8.54
92283
TC
3
$33.52
92284
26
3
$11.41
92284
TC
3
$44.97
92285
26
3
$10.35
92285
TC
3
$28.34
92286
26
3
$33.31
92286
TC
3
$77.01
92541
26
3
$19.95
92541
TC
3
$37.45
92542
26
3
$16.46
92542
TC
3
$43.37
92543
26
3
$5.29
92543
TC
3
$22.42
92544
26
3
$12.86
92544
TC
3
$35.23
92545
26
3
$11.42
92545
TC
3
$33.75
92546
26
3
$14.30
Procedure Code Procedure Code Modifier Pricing Action Code Modifier Price 92546
TC
3
$67.03
92548
26
3
$25.00
92548
TC
3
$66.71
92585
26
3
$25.24
92585
TC
3
$73.97
92587
26
3
$6.73
92587
TC
3
$31.11
92588
26
3
$17.91
92588
TC
3
$44.15
92978
26
3
$99.03
92979
26
3
$79.88
93024
26
3
$62.73
93024
TC
3
$59.22
93025
26
3
$40.83
93025
TC
3
$174.92
93278
26
3
$12.87
93278
TC
3
$27.04
93303
26
3
$68.48
93303
TC
3
$150.07
93304
26
3
$38.74
93304
TC
3
$96.65
93307
26
3
$49.49
93307
TC
3
$127.52
93308
26
3
$29.03
93308
TC
3
$82.98
93312
26
3
$115.29
93312
TC
3
$211.03
93314
26
3
$65.22
93314
TC
3
$216.21
93315
26
3
$147.72
93317
26
3
$91.35
93318
26
3
$111.18
93320
26
3
$20.47
93320
TC
3
$57.59
93321
26
3
$8.18
Procedure Code Procedure Code Modifier Pricing Action Code Modifier Price 93321
TC
3
$26.32
93325
26
3
$3.85
93325
TC
3
$48.66
93350
26
3
$79.99
93350
TC
3
$132.89
93501
26
3
$167.67
93501
TC
3
$636.17
93505
26
3
$242.46
93505
TC
3
$511.45
93508
26
3
$233.09
93508
TC
3
$837.08
93510
26
3
$245.85
93510
TC
3
$1,082.05
93511
26
3
$285.00
93514
26
3
$391.97
93524
26
3
$392.96
93526
26
3
$338.74
93526
TC
3
$1,363.51
93527
26
3
$410.28
93528
26
3
$486.58
93529
26
3
$271.87
93530
26
3
$231.32
93531
26
3
$452.78
93532
26
3
$536.56
93533
26
3
$361.24
93555
26
3
$44.45
93555
TC
3
$70.63
93556
26
3
$45.54
93556
TC
3
$115.38
93561
26
3
$23.52
93562
26
3
$7.44
93571
26
3
$98.67
93572
26
3
$77.56
93600
26
3
$117.67
93602
26
3
$117.17
Procedure Code Procedure Code Modifier Pricing Action Code Modifier Price 93603
26
3
$117.41
93609
26
3
$277.65
93610
26
3
$166.54
93612
26
3
$165.67
93615
26
3
$53.47
93616
26
3
$68.35
93618
26
3
$238.55
93619
26
3
$412.08
93620
26
3
$647.42
93621
26
3
$117.09
93622
26
3
$171.14
93623
26
3
$158.76
93624
26
3
$270.75
93631
26
3
$396.51
93640
26
3
$194.77
93641
26
3
$329.69
93642
26
3
$270.77
93642
TC
3
$200.47
93660
26
3
$103.36
93660
TC
3
$68.87
93662
26
3
$153.23
93701
26
3
$8.90
93701
TC
3
$25.38
93724
26
3
$265.97
93724
TC
3
$66.01
93770
26
3
$7.80
93770
TC
3
$0.61
93875
26
3
$11.05
93875
TC
3
$90.99
93880
26
3
$30.54
93880
TC
3
$153.88
93882
26
3
$20.06
93882
TC
3
$143.91
93886
26
3
$46.49
93886
TC
3
$154.01
Procedure Code Procedure Code Modifier Pricing Action Code Modifier Price 93888
26
3
$31.49
93888
TC
3
$62.66
93890
26
3
$49.37
93890
TC
3
$97.85
93892
26
3
$56.21
93892
TC
3
$97.98
93893
26
3
$56.59
93893
TC
3
$97.98
93922
26
3
$12.37
93922
TC
3
$108.85
93923
26
3
$22.59
93923
TC
3
$164.25
93924
26
3
$25.72
93924
TC
3
$204.53
93925
26
3
$29.08
93925
TC
3
$154.29
93926
26
3
$19.70
93926
TC
3
$98.50
93930
26
3
$23.31
93930
TC
3
$153.74
93931
26
3
$15.49
93931
TC
3
$98.11
93965
26
3
$17.42
93965
TC
3
$106.40
93970
26
3
$34.24
93970
TC
3
$153.49
93971
26
3
$22.72
93971
TC
3
$97.85
93975
26
3
$91.46
93975
TC
3
$154.13
93976
26
3
$60.70
93976
TC
3
$152.99
93978
26
3
$32.80
93978
TC
3
$153.49
93979
26
3
$21.99
Procedure Code Procedure Code Modifier Pricing Action Code Modifier Price 93979
TC
3
$98.11
93980
26
3
$64.70
93980
TC
3
$117.95
93981
26
3
$22.12
93981
TC
3
$106.52
93990
26
3
$12.24
93990
TC
3
$98.63
94010
26
3
$8.16
94010
TC
3
$24.88
94060
26
3
$14.28
94060
TC
3
$43.58
94070
26
3
$28.08
94070
TC
3
$31.23
94150
26
3
$3.85
94150
TC
3
$18.73
94200
26
3
$5.28
94200
TC
3
$17.12
94240
26
3
$12.12
94240
TC
3
$26.71
94250
26
3
$5.28
94250
TC
3
$19.09
94260
26
3
$6.00
94260
TC
3
$25.36
94350
26
3
$12.12
94350
TC
3
$22.40
94360
26
3
$12.12
94360
TC
3
$31.02
94370
26
3
$12.12
94370
TC
3
$21.19
94375
26
3
$14.28
94375
TC
3
$22.66
94400
26
3
$19.08
94400
TC
3
$33.23
94450
26
3
$18.47
94450
TC
3
$31.91
Procedure Code Procedure Code Modifier Pricing Action Code Modifier Price 94452
26
3
$14.51
94452
TC
3
$41.15
94453
26
3
$18.84
94453
TC
3
$55.57
94620
26
3
$30.24
94620
TC
3
$40.85
94621
26
3
$69.56
94621
TC
3
$91.49
94680
26
3
$12.12
94680
TC
3
$45.43
94681
26
3
$9.23
94681
TC
3
$53.16
94690
26
3
$3.48
94690
TC
3
$47.18
94720
26
3
$12.12
94720
TC
3
$39.15
94725
26
3
$12.12
94725
TC
3
$54.26
94750
26
3
$10.67
94750
TC
3
$60.49
94770
26
3
$7.08
94770
TC
3
$29.04
95805
26
3
$90.04
95805
TC
3
$334.23
95807
26
3
$78.98
95807
TC
3
$418.22
95808
26
3
$126.65
95808
TC
3
$524.33
95810
26
3
$166.83
95810
TC
3
$607.88
95811
26
3
$179.30
95811
TC
3
$674.68
95812
26
3
$52.97
95812
TC
3
$184.53
95813
26
3
$84.31
Procedure Code Procedure Code Modifier Pricing Action Code Modifier Price 95813
TC
3
$206.35
95816
26
3
$52.97
95816
TC
3
$164.70
95819
26
3
$52.97
95819
TC
3
$180.97
95822
26
3
$52.97
95822
TC
3
$179.84
95824
26
3
$36.28
95827
26
3
$52.36
95827
TC
3
$325.74
95829
26
3
$307.37
95829
TC
3
$905.90
95860
26
3
$48.44
95860
TC
3
$31.91
95861
26
3
$77.41
95861
TC
3
$38.78
95863
26
3
$92.64
95863
TC
3
$45.81
95864
26
3
$99.15
95864
TC
3
$59.81
95865
26
3
$79.83
95865
TC
3
$31.41
95866
26
3
$63.35
95866
TC
3
$27.70
95867
26
3
$39.30
95867
TC
3
$30.54
95868
26
3
$58.53
95868
TC
3
$37.06
95869
26
3
$18.50
95869
TC
3
$26.36
95870
26
3
$18.50
95870
TC
3
$25.25
95873
26
3
$19.62
95873
TC
3
$25.99
95874
26
3
$18.87
Procedure Code Procedure Code Modifier Pricing Action Code Modifier Price 95874
TC
3
$24.14
95875
26
3
$54.18
95875
TC
3
$37.30
95900
26
3
$21.03
95900
TC
3
$31.54
95903
26
3
$29.56
95903
TC
3
$31.91
95904
26
3
$17.06
95904
TC
3
$29.32
95920
26
3
$105.49
95920
TC
3
$42.72
95921
26
3
$43.85
95921
TC
3
$28.58
95922
26
3
$46.96
95922
TC
3
$40.04
95923
26
3
$44.45
95923
TC
3
$70.35
95925
26
3
$26.91
95925
TC
3
$90.17
95926
26
3
$26.67
95926
TC
3
$88.32
95927
26
3
$27.28
95927
TC
3
$90.54
95928
26
3
$73.16
95928
TC
3
$113.48
95929
26
3
$73.53
95929
TC
3
$123.46
95930
26
3
$17.42
95930
TC
3
$86.75
95933
26
3
$29.44
95933
TC
3
$33.60
95934
26
3
$25.36
95934
TC
3
$21.92
95936
26
3
$27.40
95936
TC
3
$14.16
Procedure Code Procedure Code Modifier Pricing Action Code Modifier Price 95937
26
3
$33.28
95937
TC
3
$22.66
95950
26
3
$73.99
95950
TC
3
$160.78
95951
26
3
$294.18
95953
26
3
$160.82
95953
TC
3
$236.20
95956
26
3
$151.23
95956
TC
3
$555.26
95957
26
3
$97.42
95957
TC
3
$160.00
95961
26
3
$155.34
95961
TC
3
$71.19
95962
26
3
$161.19
95962
TC
3
$47.52
95965
26
3
$402.28
95966
26
3
$200.37
95967
26
3
$171.43
A7017
RR
3
$12.82
A7017
UE
3
$96.17
B9000
RR
3
$125.00
B9000
UE
3
$741.00
B9002
RR
3
$125.00
B9002
UE
3
$741.00
B9004
RR
3
$403.88
B9004
UE
3
$1,913.41
B9006
RR
3
$400.00
B9006
UE
3
$1,478.10
E0100
RR
3
$4.84
E0100
UE
3
$16.08
E0105
RR
3
$7.46
E0105
UE
3
$32.84
E0110
RR
3
$15.31
E0110
UE
3
$52.16
E0111
RR
3
$8.06
Procedure Code Procedure Code Modifier Pricing Action Code Modifier Price E0111
UE
3
$39.32
E0112
RR
3
$9.50
E0112
UE
3
$27.00
E0113
RR
3
$4.92
E0113
UE
3
$15.18
E0114
RR
3
$8.20
E0114
UE
3
$34.12
E0116
RR
3
$5.17
E0116
UE
3
$17.07
E0130
RR
3
$16.10
E0130
UE
3
$51.20
E0135
RR
3
$16.51
E0135
UE
3
$56.91
E0141
RR
3
$21.39
E0141
UE
3
$82.73
E0143
RR
3
$20.66
E0143
UE
3
$86.08
E0144
RR
3
$25.91
E0144
UE
3
$194.21
E0147
RR
3
$54.98
E0147
UE
3
$412.45
E0148
RR
3
$12.17
E0148
UE
3
$91.15
E0149
RR
3
$21.35
E0149
UE
3
$160.14
E0153
RR
3
$7.49
E0153
UE
3
$49.77
E0154
RR
3
$8.19
E0154
UE
3
$49.77
E0155
RR
3
$3.68
E0155
UE
3
$23.01
E0156
RR
3
$3.23
E0156
UE
3
$18.99
E0157
RR
3
$8.60
E0157
UE
3
$49.97
Procedure Code Procedure Code Modifier Pricing Action Code Modifier Price E0158
RR
3
$3.39
E0158
UE
3
$23.24
E0160
RR
3
$4.14
E0160
UE
3
$23.70
E0161
RR
3
$3.41
E0161
UE
3
$18.80
E0162
RR
3
$14.62
E0162
UE
3
$108.10
E0163
RR
3
$23.37
E0163
UE
3
$81.36
E0165
RR
3
$15.32
E0165
UE
3
$96.45
E0167
RR
3
$1.21
E0167
UE
3
$7.58
E0168
RR
3
$14.50
E0168
UE
3
$108.28
E0175
RR
3
$5.39
E0175
UE
3
$39.64
E0181
RR
3
$22.47
E0181
UE
3
$201.60
E0182
RR
3
$25.05
E0182
UE
3
$216.38
E0183
UE
9
$233.34
E0184
RR
3
$23.50
E0184
UE
3
$142.86
E0185
RR
3
$42.99
E0185
UE
3
$234.85
E0186
RR
3
$19.42
E0187
RR
3
$22.21
E0188
UE
3
$14.04
E0189
RR
3
$3.63
E0189
UE
3
$23.31
E0191
RR
3
$0.97
E0191
UE
3
$7.14
E0193
RR
3
$806.39
Procedure Code Procedure Code Modifier Pricing Action Code Modifier Price E0193
UE
3
$5,217.23
E0194
RR
3
$3,113.39
E0196
RR
3
$30.54
E0197
RR
3
$29.25
E0197
UE
3
$186.21
E0198
RR
3
$21.96
E0198
UE
3
$160.86
E0199
RR
3
$3.06
E0199
UE
3
$23.00
E0200
RR
3
$10.29
E0200
UE
3
$56.90
E0202
RR
3
$59.90
E0202
UE
3
$673.58
E0205
RR
3
$20.42
E0205
UE
3
$118.35
E0210
RR
3
$2.94
E0210
UE
3
$23.42
E0215
RR
3
$7.09
E0215
UE
3
$50.83
E0217
RR
3
$44.96
E0217
UE
3
$302.77
E0225
RR
3
$31.15
E0225
UE
3
$237.02
E0235
RR
3
$16.51
E0235
UE
3
$148.28
E0236
RR
3
$38.12
E0238
RR
3
$2.60
E0238
UE
3
$19.02
E0239
RR
3
$43.04
E0239
UE
3
$322.78
E0249
RR
3
$10.47
E0249
UE
3
$71.46
E0250
RR
3
$93.53
E0250
UE
3
$712.05
E0251
RR
3
$70.87
Procedure Code Procedure Code Modifier Pricing Action Code Modifier Price E0251
UE
3
$601.88
E0255
RR
3
$112.39
E0255
UE
3
$688.88
E0256
RR
3
$75.06
E0260
RR
3
$160.65
E0260
UE
3
$1,083.60
E0261
RR
3
$131.01
E0265
RR
3
$191.23
E0265
UE
3
$1,412.85
E0266
RR
3
$144.42
E0266
UE
3
$938.40
E0271
RR
3
$22.07
E0271
UE
3
$165.95
E0272
RR
3
$20.21
E0272
UE
3
$139.85
E0275
RR
3
$1.52
E0275
UE
3
$10.98
E0276
RR
3
$1.49
E0276
UE
3
$10.07
E0277
RR
3
$642.27
E0280
RR
3
$3.93
E0280
UE
3
$26.55
E0290
RR
3
$71.50
E0291
RR
3
$51.95
E0292
RR
3
$74.50
E0293
RR
3
$68.41
E0294
RR
3
$124.99
E0295
RR
3
$121.83
E0296
RR
3
$157.09
E0297
RR
3
$114.39
E0305
RR
3
$17.02
E0305
UE
3
$104.02
E0310
RR
3
$21.78
E0310
UE
3
$140.55
E0325
UE
3
$6.40
Procedure Code Procedure Code Modifier Pricing Action Code Modifier Price E0326
RR
3
$1.14
E0326
UE
3
$7.07
E0371
RR
5
$415.05
E0372
RR
3
$503.67
E0373
RR
5
$576.95
E0424
RR
3
$230.17
E0431
RR
3
$36.19
E0434
RR
3
$36.19
E0439
RR
3
$230.17
E0445
RR
3
$195.00
E0450
RR
3
$850.00
E0451
UE
O
$4,296.56
E0453
RR
9
$520.64
E0457
RR
3
$58.79
E0459
RR
3
$48.69
E0462
RR
3
$278.78
E0462
UE
3
$1,831.27
E0480
RR
3
$42.04
E0480
UE
3
$289.20
E0484
RR
3
$3.69
E0484
UE
3
$27.70
E0500
RR
3
$98.86
E0550
RR
3
$47.95
E0550
UE
3
$373.50
E0560
RR
3
$19.23
E0560
UE
3
$123.07
E0565
RR
3
$49.61
E0565
UE
3
$318.83
E0570
RR
3
$18.88
E0571
RR
5
$28.12
E0572
RR
5
$35.76
E0574
RR
5
$37.81
E0575
RR
3
$94.83
E0585
RR
3
$33.55
E0600
RR
3
$43.80
Procedure Code Procedure Code Modifier Pricing Action Code Modifier Price E0601
RR
3
$99.59
E0603
RR
3
$74.28
E0605
RR
3
$2.94
E0605
UE
3
$20.82
E0606
RR
3
$18.66
E0610
RR
3
$24.00
E0610
UE
3
$170.69
E0615
RR
3
$55.97
E0615
UE
3
$302.46
E0618
RR
3
$300.00
E0619
RR
3
$330.00
E0621
RR
3
$8.85
E0621
UE
3
$69.23
E0627
RR
3
$31.64
E0627
UE
3
$237.27
E0628
RR
3
$31.64
E0628
UE
3
$237.27
E0629
RR
3
$31.64
E0629
UE
3
$237.27
E0630
RR
3
$97.47
E0630
UE
3
$662.78
E0635
RR
3
$99.50
E0635
UE
3
$637.65
E0650
RR
3
$85.01
E0650
UE
3
$516.77
E0651
RR
3
$87.87
E0651
UE
3
$658.99
E0652
RR
3
$501.26
E0652
UE
3
$3,759.53
E0655
RR
3
$12.13
E0655
UE
3
$65.91
E0660
RR
3
$15.91
E0660
UE
3
$104.30
E0665
RR
3
$13.46
E0665
UE
3
$83.66
Procedure Code Procedure Code Modifier Pricing Action Code Modifier Price E0666
RR
3
$13.62
E0666
UE
3
$84.24
E0667
RR
3
$30.98
E0667
UE
3
$232.30
E0668
RR
3
$35.46
E0668
UE
3
$269.50
E0669
RR
3
$16.66
E0669
UE
3
$124.90
E0720
RR
3
$29.59
E0730
RR
3
$33.38
E0730
UE
3
$265.88
E0744
RR
3
$87.60
E0744
UE
3
$632.40
E0745
RR
3
$85.64
E0745
UE
3
$603.75
E0746
UE
O
$521.09
E0776
RR
3
$17.84
E0776
UE
3
$100.76
E0781
RR
3
$215.39
E0781
UE
3
$1,335.90
E0782
UE
O
$2,774.69
E0791
RR
3
$257.13
E0791
UE
3
$1,391.93
E0840
RR
3
$15.61
E0840
UE
3
$44.67
E0850
RR
3
$12.65
E0850
UE
3
$64.08
E0855
RR
3
$48.08
E0855
UE
3
$360.64
E0860
RR
3
$6.23
E0860
UE
3
$28.23
E0870
RR
3
$12.65
E0870
UE
3
$75.39
E0880
RR
3
$18.86
E0880
UE
3
$77.27
Procedure Code Procedure Code Modifier Pricing Action Code Modifier Price E0890
RR
3
$30.34
E0890
UE
3
$78.87
E0900
RR
3
$26.43
E0900
UE
3
$78.17
E0910
RR
3
$19.13
E0910
UE
3
$131.93
E0920
RR
3
$44.14
E0920
UE
3
$292.05
E0930
RR
3
$39.52
E0930
UE
3
$254.40
E0935
RR
5
$21.75
E0940
RR
3
$33.26
E0940
UE
3
$217.20
E0941
RR
3
$38.56
E0941
UE
3
$278.40
E0942
RR
3
$2.24
E0942
UE
3
$14.22
E0944
RR
3
$4.40
E0944
UE
3
$32.92
E0945
RR
3
$4.24
E0945
UE
3
$32.83
E0946
RR
3
$56.60
E0946
UE
3
$408.08
E0947
RR
3
$60.17
E0947
UE
3
$435.14
E0948
RR
3
$56.10
E0948
UE
3
$395.78
E0950
RR
3
$9.96
E0950
UE
3
$74.59
E0951
RR
3
$1.81
E0951
UE
3
$13.52
E0952
RR
3
$1.81
E0952
UE
3
$13.52
E0958
RR
3
$41.74
E0958
UE
3
$278.25
Procedure Code Procedure Code Modifier Pricing Action Code Modifier Price E0959
RR
3
$8.50
E0959
UE
3
$64.02
E0961
RR
3
$2.78
E0961
UE
3
$20.86
E0966
RR
3
$6.19
E0966
UE
3
$46.45
E0967
RR
3
$12.65
E0967
UE
3
$94.83
E0968
RR
3
$17.15
E0968
UE
3
$111.15
E0969
RR
3
$13.99
E0969
UE
3
$104.89
E0970
RR
3
$4.11
E0970
UE
3
$34.56
E0971
RR
3
$7.14
E0971
UE
3
$47.17
E0973
RR
3
$10.47
E0973
UE
3
$82.50
E0974
RR
3
$7.95
E0974
UE
3
$56.69
E0978
RR
3
$4.26
E0978
UE
3
$32.12
E0980
RR
3
$3.15
E0980
UE
3
$23.59
E0990
RR
3
$12.65
E0990
UE
3
$87.77
E0992
RR
3
$8.85
E0992
UE
3
$66.38
E0994
RR
3
$1.52
E0994
UE
3
$11.37
E0995
RR
3
$2.54
E0995
UE
3
$18.99
E1031
RR
3
$48.32
E1031
UE
3
$352.50
E1050
RR
3
$97.43
Procedure Code Procedure Code Modifier Pricing Action Code Modifier Price E1050
UE
3
$651.53
E1060
RR
3
$120.61
E1060
UE
3
$769.57
E1070
RR
3
$89.06
E1070
UE
3
$544.05
E1083
RR
3
$75.33
E1083
UE
3
$462.83
E1084
RR
3
$93.85
E1084
UE
3
$590.70
E1085
RR
3
$66.21
E1085
UE
3
$443.55
E1086
RR
3
$80.40
E1086
UE
3
$540.83
E1087
RR
3
$121.03
E1087
UE
3
$855.90
E1088
RR
3
$144.24
E1088
UE
3
$890.63
E1089
RR
3
$114.99
E1089
UE
3
$798.38
E1090
RR
3
$110.73
E1090
UE
3
$633.38
E1091
RR
3
$79.76
E1091
UE
3
$640.80
E1092
RR
3
$122.94
E1092
UE
3
$896.93
E1093
RR
3
$105.74
E1093
UE
3
$763.13
E1100
RR
3
$99.32
E1100
UE
3
$627.53
E1110
RR
3
$82.66
E1110
UE
3
$541.05
E1130
RR
3
$44.67
E1130
UE
3
$316.05
E1140
RR
3
$68.73
E1140
UE
3
$498.08
Procedure Code Procedure Code Modifier Pricing Action Code Modifier Price E1150
RR
3
$78.04
E1150
UE
3
$581.48
E1160
RR
3
$59.79
E1160
UE
3
$420.00
E1170
RR
3
$85.45
E1170
UE
3
$522.98
E1171
RR
3
$68.33
E1171
UE
3
$480.08
E1172
RR
3
$87.87
E1172
UE
3
$537.75
E1180
RR
3
$82.41
E1180
UE
3
$497.33
E1190
RR
3
$112.01
E1190
UE
3
$693.08
E1195
RR
3
$102.16
E1195
UE
3
$562.95
E1200
RR
3
$73.20
E1200
UE
3
$447.97
E1221
RR
3
$45.45
E1222
RR
3
$64.85
E1223
RR
3
$70.81
E1223
UE
3
$477.15
E1224
RR
3
$77.64
E1225
RR
3
$43.24
E1228
RR
3
$22.79
E1230
RR
3
$194.69
E1230
UE
3
$1,454.64
E1240
RR
3
$98.55
E1240
UE
3
$641.18
E1250
RR
3
$72.71
E1250
UE
3
$441.68
E1260
RR
3
$75.79
E1260
UE
3
$467.33
E1270
RR
3
$64.19
E1270
UE
3
$407.63
Procedure Code Procedure Code Modifier Pricing Action Code Modifier Price E1280
RR
3
$106.74
E1280
UE
3
$681.23
E1285
RR
3
$98.07
E1285
UE
3
$592.05
E1290
RR
3
$101.77
E1290
UE
3
$566.33
E1295
RR
3
$111.11
E1295
UE
3
$679.95
E1296
RR
3
$40.61
E1296
UE
3
$299.87
E1297
RR
3
$9.44
E1297
UE
3
$63.79
E1298
RR
3
$36.55
E1298
UE
3
$274.02
E1310
RR
3
$175.72
E1310
UE
3
$1,540.80
E1353
RR
5
$308.71
E1355
RR
3
$4.67
E1355
UE
3
$35.00
E1372
RR
3
$22.66
E1372
UE
3
$115.46
E1390
RR
3
$230.17
E1405
RR
5
$263.04
E1406
RR
5
$248.37
E2000
RR
3
$50.57
G0202
26
3
$33.81
G0202
TC
3
$102.79
G0204
26
3
$42.24
G0204
TC
3
$112.23
G0206
26
3
$33.81
G0206
TC
3
$89.51
G0252
26
3
$74.46
G0252
TC
3
$447.50
K0001
RR
3
$53.27
K0001
UE
3
$399.52
Procedure Code Procedure Code Modifier Pricing Action Code Modifier Price K0002
RR
5
$81.43
K0003
RR
3
$76.15
K0004
RR
3
$113.03
K0005
RR
3
$183.95
K0005
UE
3
$1,379.69
K0006
RR
5
$106.07
K0015
RR
3
$18.09
K0015
UE
3
$135.60
K0017
RR
3
$5.08
K0017
UE
3
$38.14
K0018
RR
3
$2.83
K0018
UE
3
$21.33
K0019
RR
3
$1.63
K0019
UE
3
$12.19
K0020
RR
3
$4.63
K0020
UE
3
$34.66
K0037
RR
3
$4.28
K0037
UE
3
$35.95
K0038
RR
3
$2.41
K0038
UE
3
$18.11
K0039
RR
3
$5.37
K0039
UE
3
$40.21
K0040
RR
3
$7.41
K0040
UE
3
$55.71
K0041
RR
3
$5.28
K0042
RR
3
$3.61
K0042
UE
3
$27.18
K0043
RR
3
$1.94
K0043
UE
3
$14.59
K0044
RR
3
$1.66
K0044
UE
3
$12.41
K0045
RR
3
$5.64
K0045
UE
3
$42.26
K0046
RR
3
$1.94
K0046
UE
3
$14.59
Procedure Code Procedure Code Modifier Pricing Action Code Modifier Price K0047
RR
3
$7.64
K0047
UE
3
$57.06
K0050
RR
3
$3.22
K0050
UE
3
$24.26
K0051
RR
3
$5.26
K0051
UE
3
$39.24
K0052
RR
3
$9.19
K0052
UE
3
$68.98
K0053
RR
3
$10.14
K0053
UE
3
$76.13
K0056
RR
3
$9.47
K0056
UE
3
$70.98
K0065
RR
3
$4.43
K0065
UE
3
$33.18
K0069
RR
3
$9.94
K0069
UE
3
$74.56
K0070
RR
3
$15.50
K0070
UE
3
$136.70
K0071
RR
3
$10.87
K0071
UE
3
$81.52
K0072
RR
3
$6.54
K0072
UE
3
$49.07
K0073
RR
3
$3.46
K0073
UE
3
$25.97
K0077
RR
3
$5.85
K0077
UE
3
$43.91
K0098
RR
3
$2.71
K0098
UE
3
$20.29
K0105
RR
3
$9.88
K0105
UE
3
$74.20
K0193
RR
9
$107.84
K0195
RR
3
$21.07
Q0037
RR
5
$275.35
Procedure Percentage Pricing Procedure Code
Description
Pricing Percent
D0120
PERIODIC ORAL EVALUATION
80%
D0140
LIMIT ORAL EVAL PROBLM FOCUS
80%
D0145
ORAL EVALUATION, PT < 3YRS
80%
D0150
COMPREHENSVE ORAL EVALUATION
80%
D0160
EXTENSV ORAL EVAL PROB FOCUS
80%
D0170
RE-EVAL,EST PT,PROBLEM FOCUS
80%
D0210
INTRAOR COMPLETE FILM SERIES
80%
D0220
INTRAORAL PERIAPICAL FIRST F
80%
D0230
INTRAORAL PERIAPICAL EA ADD
80%
D0240
INTRAORAL OCCLUSAL FILM
80%
D0250
EXTRAORAL FIRST FILM
80%
D0260
EXTRAORAL EA ADDITIONAL FILM
80%
D0270
DENTAL BITEWING SINGLE FILM
80%
D0272
DENTAL BITEWINGS TWO FILMS
80%
D0273
BITEWINGS - THREE FILMS
80%
D0274
DENTAL BITEWINGS FOUR FILMS
80%
D0277
VERT BITEWINGS-SEV TO EIGHT
80%
D0290
DENTAL FILM SKULL/FACIAL BON
80%
D0310
DENTAL SALIOGRAPHY
80%
D0320
DENTAL TMJ ARTHROGRAM INCL I
80%
D0321
DENTAL OTHER TMJ FILMS
80%
D0322
DENTAL TOMOGRAPHIC SURVEY
80%
D0330
DENTAL PANORAMIC FILM
80%
D0340
DENTAL CEPHALOMETRIC FILM
80%
D0360
CONE BEAM CT
80%
D0362
CONE BEAM, TWO DIMENSIONAL
80%
D0363
CONE BEAM, THREE DIMENSIONAL
80%
D0460
PULP VITALITY TEST
80%
D0470
DIAGNOSTIC CASTS
80%
D0472
GROSS EXAM, PREP & REPORT
80%
D0473
MICRO EXAM, PREP & REPORT
80%
D0474
MICRO W EXAM OF SURG MARGINS
80%
D0480
CYTOPATH SMEAR PREP & REPORT
80%
Procedure Code
Description
Pricing Percent
D0502
OTHER ORAL PATHOLOGY PROCEDU
80%
D0999
UNSPECIFIED DIAGNOSTIC PROCE
80%
D1110
DENTAL PROPHYLAXIS ADULT
80%
D1120
DENTAL PROPHYLAXIS CHILD
80%
D1203
TOPICAL APP FLUORIDE CHILD
80%
D1204
TOPICAL APP FLUORIDE ADULT
80%
D1206
TOPICAL FLUORIDE VARNISH
80%
D1320
TOBACCO COUNSELING
80%
D1351
DENTAL SEALANT PER TOOTH
80%
D1510
SPACE MAINTAINER FXD UNILAT
80%
D1515
FIXED BILAT SPACE MAINTAINER
80%
D1520
REMOVE UNILAT SPACE MAINTAIN
80%
D1525
REMOVE BILAT SPACE MAINTAIN
80%
D1550
RECEMENT SPACE MAINTAINER
80%
D1555
REMOVE FIX SPACE MAINTAINER
80%
D2140
AMALGAM ONE SURFACE PERMANEN
80%
D2150
AMALGAM TWO SURFACES PERMANE
80%
D2160
AMALGAM THREE SURFACES PERMA
80%
D2161
AMALGAM 4 OR > SURFACES PERM
80%
D2330
RESIN ONE SURFACE-ANTERIOR
80%
D2331
RESIN TWO SURFACES-ANTERIOR
80%
D2332
RESIN THREE SURFACES-ANTERIO
80%
D2335
RESIN 4/> SURF OR W INCIS AN
80%
D2390
ANT RESIN-BASED CMPST CROWN
80%
D2391
POST 1 SRFC RESINBASED CMPST
80%
D2392
POST 2 SRFC RESINBASED CMPST
80%
D2393
POST 3 SRFC RESINBASED CMPST
80%
D2394
POST >=4SRFC RESINBASE CMPST
80%
D2710
CROWN RESIN-BASED INDIRECT
80%
D2712
CROWN 3/4 RESIN-BASED COMPOS
80%
D2721
CROWN RESIN W/ BASE METAL
80%
D2722
CROWN RESIN W/ NOBLE METAL
80%
D2751
CROWN PORCELAIN FUSED BASE M
80%
D2752
CROWN PORCELAIN W/ NOBLE MET
80%
D2781
CROWN 3/4 CAST BASE METAL
80%
Procedure Code
Description
Pricing Percent
D2782
CROWN 3/4 CAST NOBLE METAL
80%
D2791
CROWN FULL CAST BASE METAL
80%
D2792
CROWN FULL CAST NOBLE METAL
80%
D2799
PROVISIONAL CROWN
80%
D2910
RECEMENT INLAY ONLAY OR PART
80%
D2915
RECEMENT CAST OR PREFAB POST
80%
D2920
DENTAL RECEMENT CROWN
80%
D2930
PREFAB STNLSS STEEL CRWN PRI
80%
D2931
PREFAB STNLSS STEEL CROWN PE
80%
D2932
PREFABRICATED RESIN CROWN
80%
D2933
PREFAB STAINLESS STEEL CROWN
80%
D2934
PREFAB STEEL CROWN PRIMARY
80%
D2940
DENTAL SEDATIVE FILLING
80%
D2950
CORE BUILD-UP INCL ANY PINS
80%
D2951
TOOTH PIN RETENTION
80%
D2952
POST AND CORE CAST + CROWN
80%
D2953
EACH ADDTNL CAST POST
80%
D2954
PREFAB POST/CORE + CROWN
80%
D2955
POST REMOVAL
80%
D2957
EACH ADDTNL PREFAB POST
80%
D2970
TEMPORARY- FRACTURED TOOTH
80%
D2980
CROWN REPAIR
80%
D2999
DENTAL UNSPEC RESTORATIVE PR
80%
D3110
PULP CAP DIRECT
80%
D3120
PULP CAP INDIRECT
80%
D3220
THERAPEUTIC PULPOTOMY
80%
D3221
GROSS PULPAL DEBRIDEMENT
80%
D3222
PART PULP FOR APEXOGENESIS
80%
D3230
PULPAL THERAPY ANTERIOR PRIM
80%
D3240
PULPAL THERAPY POSTERIOR PRI
80%
D3310
END THXPY, ANTERIOR TOOTH
80%
D3320
END THXPY, BICUSPID TOOTH
80%
D3330
END THXPY, MOLAR
80%
D3332
INCOMPLETE ENDODONTIC TX
80%
D3333
INTERNAL ROOT REPAIR
80%
Procedure Code
Description
Pricing Percent
D3346
RETREAT ROOT CANAL ANTERIOR
80%
D3347
RETREAT ROOT CANAL BICUSPID
80%
D3348
RETREAT ROOT CANAL MOLAR
80%
D3351
APEXIFICATION/RECALC INITIAL
80%
D3352
APEXIFICATION/RECALC INTERIM
80%
D3353
APEXIFICATION/RECALC FINAL
80%
D3410
APICOECT/PERIRAD SURG ANTER
80%
D3421
ROOT SURGERY BICUSPID
80%
D3425
ROOT SURGERY MOLAR
80%
D3426
ROOT SURGERY EA ADD ROOT
80%
D3430
RETROGRADE FILLING
80%
D3450
ROOT AMPUTATION
80%
D3470
INTENTIONAL REPLANTATION
80%
D3910
ISOLATION- TOOTH W RUBB DAM
80%
D3999
ENDODONTIC PROCEDURE
80%
D4210
GINGIVECTOMY/PLASTY PER QUAD
80%
D4211
GINGIVECTOMY/PLASTY PER TOOT
80%
D4230
ANA CROWN EXP 4 OR> PER QUAD
80%
D4231
ANA CROWN EXP 1-3 PER QUAD
80%
D4240
GINGIVAL FLAP PROC W/ PLANIN
80%
D4241
GNGVL FLAP W ROOTPLAN 1-3 TH
80%
D4245
APICALLY POSITIONED FLAP
80%
D4249
CROWN LENGTHEN HARD TISSUE
80%
D4260
OSSEOUS SURGERY PER QUADRANT
80%
D4261
OSSEOUS SURGL-3TEETHPERQUAD
80%
D4263
BONE REPLCE GRAFT FIRST SITE
80%
D4264
BONE REPLCE GRAFT EACH ADD
80%
D4265
BIO MTRLS TO AID SOFT/OS REG
80%
D4266
GUIDED TISS REGEN RESORBLE
80%
D4267
GUIDED TISS REGEN NONRESORB
80%
D4268
SURGICAL REVISION PROCEDURE
80%
D4270
PEDICLE SOFT TISSUE GRAFT PR
80%
D4271
FREE SOFT TISSUE GRAFT PROC
80%
D4273
SUBEPITHELIAL TISSUE GRAFT
80%
D4274
DISTAL/PROXIMAL WEDGE PROC
80%
Procedure Code
Description
Pricing Percent
D4275
SOFT TISSUE ALLOGRAFT
80%
D4276
CON TISSUE W DBLE PED GRAFT
80%
D4320
PROVISION SPLNT INTRACORONAL
80%
D4321
PROVISIONAL SPLINT EXTRACORO
80%
D4341
PERIODONTAL SCALING & ROOT
80%
D4342
PERIODONTAL SCALING 1-3TEETH
80%
D4355
FULL MOUTH DEBRIDEMENT
80%
D4381
LOCALIZED DELIVERY ANTIMICRO
80%
D4910
PERIODONTAL MAINT PROCEDURES
80%
D4920
UNSCHEDULED DRESSING CHANGE
80%
D4999
UNSPECIFIED PERIODONTAL PROC
80%
D5110
DENTURES COMPLETE MAXILLARY
80%
D5120
DENTURES COMPLETE MANDIBLE
80%
D5130
DENTURES IMMEDIAT MAXILLARY
80%
D5140
DENTURES IMMEDIAT MANDIBLE
80%
D5211
DENTURES MAXILL PART RESIN
80%
D5212
DENTURES MAND PART RESIN
80%
D5213
DENTURES MAXILL PART METAL
80%
D5214
DENTURES MANDIBL PART METAL
80%
D5225
MAXILLARY PART DENTURE FLEX
80%
D5226
MANDIBULAR PART DENTURE FLEX
80%
D5410
DENTURES ADJUST CMPLT MAXIL
80%
D5411
DENTURES ADJUST CMPLT MAND
80%
D5421
DENTURES ADJUST PART MAXILL
80%
D5422
DENTURES ADJUST PART MANDBL
80%
D5510
DENTUR REPR BROKEN COMPL BAS
80%
D5520
REPLACE DENTURE TEETH COMPLT
80%
D5610
DENTURES REPAIR RESIN BASE
80%
D5620
REP PART DENTURE CAST FRAME
80%
D5630
REP PARTIAL DENTURE CLASP
80%
D5640
REPLACE PART DENTURE TEETH
80%
D5650
ADD TOOTH TO PARTIAL DENTURE
80%
D5660
ADD CLASP TO PARTIAL DENTURE
80%
D5670
REPLC TTH&ACRLC ON MTL FRMWK
80%
D5671
REPLC TTH&ACRLC MANDIBULAR
80%
Procedure Code
Description
Pricing Percent
D5730
DENTURE RELN CMPLT MAXIL CH
80%
D5731
DENTURE RELN CMPLT MAND CHR
80%
D5740
DENTURE RELN PART MAXIL CHR
80%
D5741
DENTURE RELN PART MAND CHR
80%
D5750
DENTURE RELN CMPLT MAX LAB
80%
D5751
DENTURE RELN CMPLT MAND LAB
80%
D5760
DENTURE RELN PART MAXIL LAB
80%
D5761
DENTURE RELN PART MAND LAB
80%
D5810
DENTURE INTERM CMPLT MAXILL
80%
D5811
DENTURE INTERM CMPLT MANDBL
80%
D5820
DENTURE INTERM PART MAXILL
80%
D5821
DENTURE INTERM PART MANDBL
80%
D5850
DENTURE TISS CONDITN MAXILL
80%
D5851
DENTURE TISS CONDTIN MANDBL
80%
D5899
REMOVABLE PROSTHODONTIC PROC
80%
D5911
FACIAL MOULAGE SECTIONAL
80%
D5912
FACIAL MOULAGE COMPLETE
80%
D5913
NASAL PROSTHESIS
80%
D5914
AURICULAR PROSTHESIS
80%
D5915
ORBITAL PROSTHESIS
80%
D5916
OCULAR PROSTHESIS
80%
D5919
FACIAL PROSTHESIS
80%
D5922
NASAL SEPTAL PROSTHESIS
80%
D5923
OCULAR PROSTHESIS INTERIM
80%
D5924
CRANIAL PROSTHESIS
80%
D5925
FACIAL AUGMENTATION IMPLANT
80%
D5926
REPLACEMENT NASAL PROSTHESIS
80%
D5927
AURICULAR REPLACEMENT
80%
D5928
ORBITAL REPLACEMENT
80%
D5929
FACIAL REPLACEMENT
80%
D5931
SURGICAL OBTURATOR
80%
D5932
POSTSURGICAL OBTURATOR
80%
D5933
REFITTING OF OBTURATOR
80%
D5934
MANDIBULAR FLANGE PROSTHESIS
80%
D5935
MANDIBULAR DENTURE PROSTH
80%
Procedure Code
Description
Pricing Percent
D5936
TEMP OBTURATOR PROSTHESIS
80%
D5937
TRISMUS APPLIANCE
80%
D5951
FEEDING AID
80%
D5952
PEDIATRIC SPEECH AID
80%
D5953
ADULT SPEECH AID
80%
D5954
SUPERIMPOSED PROSTHESIS
80%
D5955
PALATAL LIFT PROSTHESIS
80%
D5958
INTRAORAL CON DEF INTER PLT
80%
D5959
INTRAORAL CON DEF MOD PALAT
80%
D5960
MODIFY SPEECH AID PROSTHESIS
80%
D5986
FLUORIDE APPLICATOR
80%
D5987
COMMISSURE SPLINT
80%
D5988
SURGICAL SPLINT
80%
D5991
TOPICAL MEDICAMENT CARRIER
80%
D5999
MAXILLOFACIAL PROSTHESIS
80%
D6211
BRIDGE BASE METAL CAST
80%
D6212
BRIDGE NOBLE METAL CAST
80%
D6241
BRIDGE PORCELAIN BASE METAL
80%
D6242
BRIDGE PORCELAIN NOBEL METAL
80%
D6251
BRIDGE RESIN BASE METAL
80%
D6252
BRIDGE RESIN W/NOBLE METAL
80%
D6545
DENTAL RETAINR CAST METL
80%
D6721
CROWN RESIN W/BASE METAL
80%
D6722
CROWN RESIN W/NOBLE METAL
80%
D6751
CROWN PORCELAIN BASE METAL
80%
D6752
CROWN PORCELAIN NOBLE METAL
80%
D6791
CROWN FULL BASE METAL CAST
80%
D6792
CROWN FULL NOBLE METAL CAST
80%
D6930
DENTAL RECEMENT BRIDGE
80%
D6972
PREFAB POST & CORE PLUS RETA
80%
D6980
BRIDGE REPAIR
80%
D6985
PEDIATRIC PARTIAL DENTURE FX
80%
D6999
FIXED PROSTHODONTIC PROC
80%
D7111
EXTRACTION CORONAL REMNANTS
80%
D7140
EXTRACTION ERUPTED TOOTH/EXR
80%
Procedure Code
Description
Pricing Percent
D7210
REM IMP TOOTH W MUCOPER FLP
80%
D7220
IMPACT TOOTH REMOV SOFT TISS
80%
D7230
IMPACT TOOTH REMOV PART BONY
80%
D7240
IMPACT TOOTH REMOV COMP BONY
80%
D7241
IMPACT TOOTH REM BONY W/COMP
80%
D7250
TOOTH ROOT REMOVAL
80%
D7260
ORAL ANTRAL FISTULA CLOSURE
80%
D7261
PRIMARY CLOSURE SINUS PERF
80%
D7270
TOOTH REIMPLANTATION
80%
D7272
TOOTH TRANSPLANTATION
80%
D7280
EXPOSURE IMPACT TOOTH ORTHOD
80%
D7282
MOBILIZE ERUPTED/MALPOS TOOT
80%
D7283
PLACE DEVICE IMPACTED TOOTH
80%
D7290
REPOSITIONING OF TEETH
80%
D7291
TRANSSEPTAL FIBEROTOMY
80%
D7310
ALVEOPLASTY W/ EXTRACTION
80%
D7311
ALVEOLOPLASTY W/EXTRACT 1-3
80%
D7320
ALVEOPLASTY W/O EXTRACTION
80%
D7321
ALVEOLOPLASTY NOT W/EXTRACTS
80%
D7340
VESTIBULOPLASTY RIDGE EXTENS
80%
D7350
VESTIBULOPLASTY EXTEN GRAFT
80%
D7510
I&D ABSC INTRAORAL SOFT TISS
80%
D7511
INCISION/DRAIN ABSCESS INTRA
80%
D7520
I&D ABSCESS EXTRAORAL
80%
D7521
INCISION/DRAIN ABSCESS EXTRA
80%
D7530
REMOVAL FB SKIN/AREOLAR TISS
80%
D7540
REMOVAL OF FB REACTION
80%
D7550
REMOVAL OF SLOUGHED OFF BONE
80%
D7560
MAXILLARY SINUSOTOMY
80%
D7880
OCCLUSAL ORTHOTIC APPLIANCE
80%
D7899
TMJ UNSPECIFIED THERAPY
80%
D7910
DENT SUTUR RECENT WND TO 5CM
80%
D7911
DENTAL SUTURE WOUND TO 5 CM
80%
D7912
SUTURE COMPLICATE WND > 5 CM
80%
D7960
FRENULECTOMY/FRENULOTOMY
80%
Procedure Code
Description
Pricing Percent
D7963
FRENULOPLASTY
80%
D7970
EXCISION HYPERPLASTIC TISSUE
80%
D7971
EXCISION PERICORONAL GINGIVA
80%
D7997
APPLIANCE REMOVAL
80%
D7999
ORAL SURGERY PROCEDURE
80%
D8010
LIMITED DENTAL TX PRIMARY
80%
D8020
LIMITED DENTAL TX TRANSITION
80%
D8030
LIMITED DENTAL TX ADOLESCENT
80%
D8040
LIMITED DENTAL TX ADULT
80%
D8050
INTERCEP DENTAL TX PRIMARY
80%
D8060
INTERCEP DENTAL TX TRANSITN
80%
D8070
COMPRE DENTAL TX TRANSITION
80%
D8090
COMPRE DENTAL TX ADULT
80%
D8210
ORTHODONTIC REM APPLIANCE TX
80%
D8220
FIXED APPLIANCE THERAPY HABT
80%
D8680
ORTHODONTIC RETENTION
80%
D8690
ORTHODONTIC TREATMENT
80%
D8691
REPAIR ORTHO APPLIANCE
80%
D8692
REPLACEMENT RETAINER
80%
D8999
ORTHODONTIC PROCEDURE
80%
D9110
TX DENTAL PAIN MINOR PROC
80%
D9120
FIX PARTIAL DENTURE SECTION
80%
D9210
DENT ANESTHESIA W/O SURGERY
80%
D9220
GENERAL ANESTHESIA
80%
D9221
GENERAL ANESTHESIA EA AD 15M
80%
D9230
ANALGESIA
80%
D9241
INTRAVENOUS SEDATION
80%
D9242
IV SEDATION EA AD 30 M
80%
D9248
SEDATION (NON-IV)
80%
D9310
DENTAL CONSULTATION
80%
D9440
OFFICE VISIT AFTER HOURS
80%
D9610
DENT THERAPEUTIC DRUG INJECT
80%
D9612
THERA PAR DRUGS 2 OR > ADMIN
80%
D9910
DENT APPL DESENSITIZING MED
80%
D9911
APPL DESENSITIZING RESIN
80%
Procedure Code
Description
Pricing Percent
D9920
BEHAVIOR MANAGEMENT
80%
D9930
TREATMENT OF COMPLICATIONS
80%
D9940
DENTAL OCCLUSAL GUARD
80%
D9999
ADJUNCTIVE PROCEDURE
80%
Procedure RVU Pricing Procedure Code Description
RVU
RVU Coeff Value
00100
ANESTH, SALIVARY GLAND
5.00
16.05
00102
ANESTH, REPAIR OF CLEFT LIP
6.00
16.05
00103
ANESTH, BLEPHAROPLASTY
5.00
16.05
00104
ANESTH, ELECTROSHOCK
4.00
16.05
00120
ANESTH, EAR SURGERY
4.00
16.05
00124
ANESTH, EAR EXAM
4.00
16.05
00126
ANESTH, TYMPANOTOMY
4.00
16.05
00140
ANESTH, PROCEDURES ON EYE
5.00
16.05
00142
ANESTH, LENS SURGERY
6.00
16.05
00144
ANESTH, CORNEAL TRANSPLANT
6.00
16.05
00145
ANESTH, VITREORETINAL SURG
6.00
16.05
00147
ANESTH, IRIDECTOMY
4.00
16.05
00148
ANESTH, EYE EXAM
4.00
16.05
00160
ANESTH, NOSE/SINUS SURGERY
5.00
16.05
00162
ANESTH, NOSE/SINUS SURGERY
7.00
16.05
00164
ANESTH, BIOPSY OF NOSE
4.00
16.05
00170
ANESTH, PROCEDURE ON MOUTH
5.00
16.05
00172
ANESTH, CLEFT PALATE REPAIR
6.00
16.05
00174
ANESTH, PHARYNGEAL SURGERY
6.00
16.05
00176
ANESTH, PHARYNGEAL SURGERY
7.00
16.05
00190
ANESTH, FACE/SKULL BONE SURG
5.00
16.05
00192
ANESTH, FACIAL BONE SURGERY
7.00
16.05
00210
ANESTH, CRANIAL SURG NOS
11.00
16.05
00211
ANESTH, CRAN SURG, HEMOTOMA
10.00
16.05
00212
ANESTH, SKULL DRAINAGE
5.00
16.05
00214
ANESTH, SKULL DRAINAGE
9.00
16.05
00215
ANESTH, SKULL REPAIR/FRACT
9.00
16.05
00216
ANESTH, HEAD VESSEL SURGERY
15.00
16.05
00218
ANESTH, SPECIAL HEAD SURGERY
13.00
16.05
00220
ANESTH, INTRCRN NERVE
10.00
16.05
00222
ANESTH, HEAD NERVE SURGERY
6.00
16.05
00300
ANESTH, HEAD/NECK/PTRUNK
5.00
16.05
00320
ANESTH, NECK ORGAN, 1 & OVER
6.00
16.05
Procedure Code Description
RVU
RVU Coeff Value
00322
ANESTH, BIOPSY OF THYROID
3.00
16.05
00326
ANESTH, LARYNX/TRACH, < 1 YR
7.00
16.05
00350
ANESTH, NECK VESSEL SURGERY
10.00
16.05
00352
ANESTH, NECK VESSEL SURGERY
5.00
16.05
00400
ANESTH, SKIN, EXT/PER/ATRUNK
3.00
16.05
00402
ANESTH, SURGERY OF BREAST
5.00
16.05
00404
ANESTH, SURGERY OF BREAST
5.00
16.05
00406
ANESTH, SURGERY OF BREAST
13.00
16.05
00410
ANESTH, CORRECT HEART RHYTHM
4.00
16.05
00450
ANESTH, SURGERY OF SHOULDER
5.00
16.05
00452
ANESTH, SURGERY OF SHOULDER
6.00
16.05
00454
ANESTH, COLLAR BONE BIOPSY
3.00
16.05
00470
ANESTH, REMOVAL OF RIB
6.00
16.05
00472
ANESTH, CHEST WALL REPAIR
10.00
16.05
00474
ANESTH, SURGERY OF RIB(S)
13.00
16.05
00500
ANESTH, ESOPHAGEAL SURGERY
15.00
16.05
00520
ANESTH, CHEST PROCEDURE
6.00
16.05
00522
ANESTH, CHEST LINING BIOPSY
4.00
16.05
00524
ANESTH, CHEST DRAINAGE
4.00
16.05
00528
ANESTH, CHEST PARTITION VIEW
8.00
16.05
00530
ANESTH, PACEMAKER INSERTION
4.00
16.05
00532
ANESTH, VASCULAR ACCESS
4.00
16.05
00534
ANESTH, CARDIOVERTER/DEFIB
7.00
16.05
00537
ANESTH, CARDIAC ELECTROPHYS
10.00
16.05
00539
ANESTH,TRACHEOBRONCHIAL RECONSTRUC
18.00
16.05
00540
ANESTH, CHEST SURGERY
13.00
16.05
00541
ANESTH, ONE LUNG VENTILATION
15.00
16.05
00542
ANESTH, RELEASE OF LUNG
15.00
16.05
00544
ANESTH, CHEST LINING REMOVAL
15.00
16.05
00546
ANESTH, LUNG,CHEST WALL SURG
15.00
16.05
00548
ANESTH, TRACHEA,BRONCHI SURG
17.00
16.05
00550
ANESTH, STERNAL DEBRIDEMENT
10.00
16.05
00560
ANESTH, HEART SURG W/O PUMP
15.00
16.05
00561
ANESTH, HEART SURG < AGE 1
25.00
16.05
00562
ANESTH HRT SURG W/PMP AGE 1+
20.00
16.05
Procedure Code Description
RVU
RVU Coeff Value
00563
ANESTH, HEART SURG W/ARREST
25.00
16.05
00566
ANESTH, CABG W/O PUMP
25.00
16.05
00567
ANESTH, CABG W/PUMP
18.00
16.05
00580
ANESTH, HEART/LUNG TRANSPLNT
20.00
16.05
00600
ANESTH, SPINE, CORD SURGERY
10.00
16.05
00604
ANESTH, SITTING PROCEDURE
13.00
16.05
00620
ANESTH, SPINE, CORD SURGERY
10.00
16.05
00622
ANESTH, REMOVAL OF NERVES
13.00
16.05
00625
ANES SPINE TRANTHOR W/O VENT
13.00
16.05
00626
ANES, SPINE TRANSTHOR W/VENT
15.00
16.05
00630
ANESTH, SPINE, CORD SURGERY
8.00
16.05
00632
ANESTH, REMOVAL OF NERVES
7.00
16.05
00635
ANESTH, LUMBAR PUNCTURE
4.00
16.05
00640
ANESTH, SPINE MANIPULATION
3.00
16.05
00670
ANESTH, SPINE, CORD SURGERY
13.00
16.05
00700
ANESTH, ABDOMINAL WALL SURG
4.00
16.05
00702
ANESTH, FOR LIVER BIOPSY
4.00
16.05
00730
ANESTH, ABDOMINAL WALL SURG
5.00
16.05
00740
ANESTH, UPPER GI VISUALIZE
5.00
16.05
00750
ANESTH, REPAIR OF HERNIA
4.00
16.05
00752
ANESTH, REPAIR OF HERNIA
6.00
16.05
00754
ANESTH, REPAIR OF HERNIA
7.00
16.05
00756
ANESTH, REPAIR OF HERNIA
7.00
16.05
00770
ANESTH, BLOOD VESSEL REPAIR
15.00
16.05
00790
ANESTH, SURG UPPER ABDOMEN
7.00
16.05
00792
ANESTH, HEMORR/EXCISE LIVER
7.00
16.05
00794
ANESTH, PANCREAS REMOVAL
13.00
16.05
00796
ANESTH, FOR LIVER TRANSPLANT
30.00
16.05
00797
ANESTH, SURGERY FOR OBESITY
10.00
16.05
00800
ANESTH, ABDOMINAL WALL SURG
4.00
16.05
00802
ANESTH, FAT LAYER REMOVAL
5.00
16.05
00810
ANESTH, LOW INTESTINE SCOPE
5.00
16.05
00820
ANESTH, ABDOMINAL WALL SURG
5.00
16.05
00830
ANESTH, REPAIR OF HERNIA
4.00
16.05
00832
ANESTH, REPAIR OF HERNIA
6.00
16.05
Procedure Code Description
RVU
RVU Coeff Value
00834
ANESTH, HERNIA REPAIR< 1 YR
5.00
16.05
00836
ANESTH HERNIA REPAIR PREEMIE
6.00
16.05
00840
ANESTH, SURG LOWER ABDOMEN
6.00
16.05
00842
ANESTH, AMNIOCENTESIS
4.00
16.05
00844
ANESTH, PELVIS SURGERY
7.00
16.05
00846
ANESTH, HYSTERECTOMY
8.00
16.05
00848
ANESTH, PELVIC ORGAN SURG
8.00
16.05
00851
ANESTH, TUBAL LIGATION
6.00
16.05
00860
ANESTH, SURGERY OF ABDOMEN
6.00
16.05
00862
ANESTH, KIDNEY/URETER SURG
7.00
16.05
00864
ANESTH, REMOVAL OF BLADDER
8.00
16.05
00865
ANESTH, REMOVAL OF PROSTATE
7.00
16.05
00866
ANESTH, REMOVAL OF ADRENAL
10.00
16.05
00868
ANESTH, KIDNEY TRANSPLANT
10.00
16.05
00869
ANESTH, VASECTOMY
3.00
16.05
00870
ANESTH, BLADDER STONE SURG
5.00
16.05
00872
ANESTH KIDNEY STONE DESTRUCT
7.00
16.05
00873
ANESTH KIDNEY STONE DESTRUCT
5.00
16.05
00880
ANESTH, ABDOMEN VESSEL SURG
15.00
16.05
00882
ANESTH, MAJOR VEIN LIGATION
10.00
16.05
00902
ANESTH, ANORECTAL SURGERY
5.00
16.05
00904
ANESTH, PERINEAL SURGERY
7.00
16.05
00906
ANESTH, REMOVAL OF VULVA
4.00
16.05
00908
ANESTH, REMOVAL OF PROSTATE
6.00
16.05
00910
ANESTH, BLADDER SURGERY
3.00
16.05
00910
ANESTH, BLADDER SURGERY
4.00
16.05
00912
ANESTH, BLADDER TUMOR SURG
5.00
16.05
00914
ANESTH, REMOVAL OF PROSTATE
5.00
16.05
00916
ANESTH, BLEEDING CONTROL
5.00
16.05
00918
ANESTH, STONE REMOVAL
5.00
16.05
00920
ANESTH, GENITALIA SURGERY
3.00
16.05
00921
ANESTH, VASECTOMY
3.00
16.05
00922
ANESTH, SPERM DUCT SURGERY
6.00
16.05
00924
ANESTH, TESTIS EXPLORATION
4.00
16.05
00926
ANESTH, REMOVAL OF TESTIS
4.00
16.05
Procedure Code Description
RVU
RVU Coeff Value
00928
ANESTH, REMOVAL OF TESTIS
6.00
16.05
00930
ANESTH, TESTIS SUSPENSION
4.00
16.05
00932
ANESTH, AMPUTATION OF PENIS
4.00
16.05
00934
ANESTH, PENIS, NODES REMOVAL
6.00
16.05
00936
ANESTH, PENIS, NODES REMOVAL
8.00
16.05
00940
ANESTH, VAGINAL PROCEDURES
3.00
16.05
00942
ANESTH, SURG ON VAG/URETHRAL
4.00
16.05
00944
ANESTH, VAGINAL HYSTERECTOMY
6.00
16.05
00948
ANESTH, REPAIR OF CERVIX
4.00
16.05
00950
ANESTH, VAGINAL ENDOSCOPY
5.00
16.05
00952
ANESTH, HYSTEROSCOPE/GRAPH
4.00
16.05
01112
ANESTH, BONE ASPIRATE/BX
5.00
16.05
01120
ANESTH, PELVIS SURGERY
6.00
16.05
01130
ANESTH, BODY CAST PROCEDURE
3.00
16.05
01140
ANESTH, AMPUTATION AT PELVIS
15.00
16.05
01150
ANESTH, PELVIC TUMOR SURGERY
10.00
16.05
01160
ANESTH, PELVIS PROCEDURE
4.00
16.05
01170
ANESTH, PELVIS SURGERY
8.00
16.05
01173
ANESTH, FX REPAIR, PELVIS
12.00
16.05
01180
ANESTH, PELVIS NERVE REMOVAL
3.00
16.05
01190
ANESTH, PELVIS NERVE REMOVAL
4.00
16.05
01200
ANESTH, HIP JOINT PROCEDURE
4.00
16.05
01202
ANESTH, ARTHROSCOPY OF HIP
4.00
16.05
01210
ANESTH, HIP JOINT SURGERY
6.00
16.05
01212
ANESTH, HIP DISARTICULATION
10.00
16.05
01214
ANESTH, HIP ARTHROPLASTY
8.00
16.05
01215
ANESTH, REVISE HIP REPAIR
10.00
16.05
01220
ANESTH, PROCEDURE ON FEMUR
4.00
16.05
01230
ANESTH, SURGERY OF FEMUR
6.00
16.05
01232
ANESTH, AMPUTATION OF FEMUR
5.00
16.05
01234
ANESTH, RADICAL FEMUR SURG
8.00
16.05
01250
ANESTH, UPPER LEG SURGERY
4.00
16.05
01250
ANESTH, UPPER LEG SURGERY
8.00
16.05
01260
ANESTH, UPPER LEG VEINS SURG
3.00
16.05
01270
ANESTH, THIGH ARTERIES SURG
8.00
16.05
Procedure Code Description
RVU
RVU Coeff Value
01272
ANESTH, FEMORAL ARTERY SURG
4.00
16.05
01274
ANESTH, FEMORAL EMBOLECTOMY
6.00
16.05
01320
ANESTH, KNEE AREA SURGERY
4.00
16.05
01340
ANESTH, KNEE AREA PROCEDURE
4.00
16.05
01360
ANESTH, KNEE AREA SURGERY
5.00
16.05
01380
ANESTH, KNEE JOINT PROCEDURE
3.00
16.05
01382
ANESTH, DX KNEE ARTHROSCOPY
3.00
16.05
01390
ANESTH, KNEE AREA PROCEDURE
3.00
16.05
01392
ANESTH, KNEE AREA SURGERY
4.00
16.05
01400
ANESTH, KNEE JOINT SURGERY
4.00
16.05
01402
ANESTH, KNEE ARTHROPLASTY
7.00
16.05
01404
ANESTH, AMPUTATION AT KNEE
5.00
16.05
01420
ANESTH, KNEE JOINT CASTING
3.00
16.05
01430
ANESTH, KNEE VEINS SURGERY
3.00
16.05
01432
ANESTH, KNEE VESSEL SURG
6.00
16.05
01440
ANESTH, KNEE ARTERIES SURG
8.00
16.05
01442
ANESTH, KNEE ARTERY SURG
8.00
16.05
01444
ANESTH, KNEE ARTERY REPAIR
8.00
16.05
01462
ANESTH, LOWER LEG PROCEDURE
3.00
16.05
01464
ANESTH, ANKLE/FT ARTHROSCOPY
3.00
16.05
01470
ANESTH, LOWER LEG SURGERY
3.00
16.05
01472
ANESTH, ACHILLES TENDON SURG
5.00
16.05
01474
ANESTH, LOWER LEG SURGERY
5.00
16.05
01480
ANESTH, LOWER LEG BONE SURG
3.00
16.05
01482
ANESTH, RADICAL LEG SURGERY
4.00
16.05
01484
ANESTH, LOWER LEG REVISION
4.00
16.05
01486
ANESTH, ANKLE REPLACEMENT
7.00
16.05
01490
ANESTH, LOWER LEG CASTING
3.00
16.05
01500
ANESTH, LEG ARTERIES SURG
8.00
16.05
01502
ANESTH, LWR LEG EMBOLECTOMY
6.00
16.05
01520
ANESTH, LOWER LEG VEIN SURG
3.00
16.05
01522
ANESTH, LOWER LEG VEIN SURG
5.00
16.05
01610
ANESTH, SURGERY OF SHOULDER
5.00
16.05
01620
ANESTH, SHOULDER PROCEDURE
4.00
16.05
01622
ANES DX SHOULDER ARTHROSCOPY
4.00
16.05
Procedure Code Description
RVU
RVU Coeff Value
01630
ANESTH, SURGERY OF SHOULDER
5.00
16.05
01632
ANESTH, SURGERY OF SHOULDER
6.00
16.05
01634
ANESTH, SHOULDER JOINT AMPUT
9.00
16.05
01636
ANESTH, FOREQUARTER AMPUT
15.00
16.05
01638
ANESTH, SHOULDER REPLACEMENT
10.00
16.05
01650
ANESTH, SHOULDER ARTERY SURG
6.00
16.05
01652
ANESTH, SHOULDER VESSEL SURG
10.00
16.05
01654
ANESTH, SHOULDER VESSEL SURG
8.00
16.05
01656
ANESTH, ARM-LEG VESSEL SURG
10.00
16.05
01670
ANESTH, SHOULDER VEIN SURG
4.00
16.05
01680
ANESTH, SHOULDER CASTING
3.00
16.05
01682
ANESTH, AIRPLANE CAST
4.00
16.05
01710
ANESTH, ELBOW AREA SURGERY
3.00
16.05
01712
ANESTH, UPPR ARM TENDON SURG
5.00
16.05
01714
ANESTH, UPPR ARM TENDON SURG
5.00
16.05
01716
ANESTH, BICEPS TENDON REPAIR
5.00
16.05
01730
ANESTH, UPPR ARM PROCEDURE
3.00
16.05
01732
ANESTH, DX ELBOW ARTHROSCOPY
3.00
16.05
01740
ANESTH, UPPER ARM SURGERY
4.00
16.05
01742
ANESTH, HUMERUS SURGERY
5.00
16.05
01744
ANESTH, HUMERUS REPAIR
5.00
16.05
01756
ANESTH, RADICAL HUMERUS SURG
6.00
16.05
01758
ANESTH, HUMERAL LESION SURG
5.00
16.05
01760
ANESTH, ELBOW REPLACEMENT
7.00
16.05
01770
ANESTH, UPPR ARM ARTERY SURG
6.00
16.05
01772
ANESTH, UPPR ARM EMBOLECTOMY
6.00
16.05
01780
ANESTH, UPPER ARM VEIN SURG
3.00
16.05
01782
ANESTH, UPPR ARM VEIN REPAIR
4.00
16.05
01810
ANESTH, LOWER ARM SURGERY
3.00
16.05
01820
ANESTH, LOWER ARM PROCEDURE
3.00
16.05
01829
ANESTH, DX WRIST ARTHROSCOPY
3.00
16.05
01830
ANESTH, LOWER ARM SURGERY
3.00
16.05
01832
ANESTH, WRIST REPLACEMENT
6.00
16.05
01840
ANESTH, LWR ARM ARTERY SURG
6.00
16.05
01842
ANESTH, LWR ARM EMBOLECTOMY
6.00
16.05
Procedure Code Description
RVU
RVU Coeff Value
01844
ANESTH, VASCULAR SHUNT SURG
6.00
16.05
01850
ANESTH, LOWER ARM VEIN SURG
3.00
16.05
01852
ANESTH, LWR ARM VEIN REPAIR
4.00
16.05
01860
ANESTH, LOWER ARM CASTING
3.00
16.05
01905
ANES, SPINE INJECT, X-RAY/RE
5.00
16.05
01916
ANESTH, DX ARTERIOGRAPHY
6.00
16.05
01920
ANESTH, CATHETERIZE HEART
7.00
16.05
01922
ANESTH, CAT OR MRI SCAN
7.00
16.05
01924
ANES, THER INTERVEN RAD, ART
6.00
16.05
01925
ANES, THER INTERVEN RAD, CAR
8.00
16.05
01926
ANES, TX INTERV RAD HRT/CRAN
10.00
16.05
01930
ANES, THER INTERVEN RAD, VEI
5.00
16.05
01931
ANES, THER INTERVEN RAD, TIP
6.00
16.05
01932
ANES, TX INTERV RAD, TH VEIN
8.00
16.05
01933
ANES, TX INTERV RAD, CRAN V
10.00
16.05
01935
ANESTH, PERC IMG DX SP PROC
5.00
16.05
01936
ANESTH, PERC IMG TX SP PROC
5.00
16.05
01951
ANESTH, BURN, LESS 4 PERCENT
3.00
16.05
01952
ANESTH, BURN, 4-9 PERCENT
5.00
16.05
01958
ANESTH, ANTEPARTUM MANIPUL
5.00
16.05
01960
ANESTH, VAGINAL DELIVERY
5.00
16.05
01961
ANESTH, CS DELIVERY
3.00
16.05
01961
ANESTH, CS DELIVERY
7.00
16.05
01962
ANESTH, EMER HYSTERECTOMY
5.00
16.05
01963
ANESTH, CS HYSTERECTOMY
8.00
16.05
01964
ANESTH, ABORTION PROCEDURES
4.00
16.05
01965
ANESTH, INC/MISSED AB PROC
4.00
16.05
01966
ANESTH, INDUCED AB PROCEDURE
4.00
16.05
01967
ANESTH/ANALG, VAG DELIVERY
5.00
16.05
01968
ANES/ANALG CS DELIVER ADD-ON
3.00
16.05
01969
ANESTH/ANALG CS HYST ADD-ON
5.00
16.05
01990
SUPPORT FOR ORGAN DONOR
7.00
16.05
01991
ANESTH, NERVE BLOCK/INJ
3.00
16.05
01992
ANESTH, N BLOCK/INJ, PRONE
5.00
16.05
01995
REGIONAL ANESTHESIA LIMB
5.00
16.05
Procedure Code Description
RVU
RVU Coeff Value
10040
ACNE SURGERY
1.92
1.00
10040
ACNE SURGERY
1.94
1.00
10040
ACNE SURGERY
2.19
1.00
10040
ACNE SURGERY
4.00
1.00
10060
DRAINAGE OF SKIN ABSCESS
1.92
1.00
10060
DRAINAGE OF SKIN ABSCESS
2.21
1.00
10060
DRAINAGE OF SKIN ABSCESS
2.35
1.00
10060
DRAINAGE OF SKIN ABSCESS
3.00
1.00
10061
DRAINAGE OF SKIN ABSCESS
3.98
1.00
10061
DRAINAGE OF SKIN ABSCESS
4.00
1.00
10061
DRAINAGE OF SKIN ABSCESS
4.12
1.00
10061
DRAINAGE OF SKIN ABSCESS
4.18
1.00
10080
DRAINAGE OF PILONIDAL CYST
1.99
1.00
10080
DRAINAGE OF PILONIDAL CYST
2.40
1.00
10080
DRAINAGE OF PILONIDAL CYST
2.42
1.00
10080
DRAINAGE OF PILONIDAL CYST
4.00
1.00
10081
DRAINAGE OF PILONIDAL CYST
4.00
1.00
10081
DRAINAGE OF PILONIDAL CYST
4.19
1.00
10120
REMOVE FOREIGN BODY
1.68
1.00
10120
REMOVE FOREIGN BODY
1.75
1.00
10120
REMOVE FOREIGN BODY
2.30
1.00
10120
REMOVE FOREIGN BODY
3.00
1.00
10121
REMOVE FOREIGN BODY
3.00
1.00
10121
REMOVE FOREIGN BODY
4.72
1.00
10121
REMOVE FOREIGN BODY
4.73
1.00
10121
REMOVE FOREIGN BODY
4.87
1.00
10140
DRAINAGE OF HEMATOMA/FLUID
2.55
1.00
10140
DRAINAGE OF HEMATOMA/FLUID
2.62
1.00
10140
DRAINAGE OF HEMATOMA/FLUID
3.00
1.00
10140
DRAINAGE OF HEMATOMA/FLUID
3.02
1.00
10160
PUNCTURE DRAINAGE OF LESION
1.73
1.00
10160
PUNCTURE DRAINAGE OF LESION
1.79
1.00
10160
PUNCTURE DRAINAGE OF LESION
2.43
1.00
10160
PUNCTURE DRAINAGE OF LESION
2.44
1.00
10160
PUNCTURE DRAINAGE OF LESION
3.00
1.00
Procedure Code Description
RVU
RVU Coeff Value
10180
COMPLEX DRAINAGE, WOUND
3.00
1.00
10180
COMPLEX DRAINAGE, WOUND
3.77
1.00
10180
COMPLEX DRAINAGE, WOUND
4.48
1.00
10180
COMPLEX DRAINAGE, WOUND
4.63
1.00
11000
DEBRIDE INFECTED SKIN
0.85
1.00
11000
DEBRIDE INFECTED SKIN
0.88
1.00
11000
DEBRIDE INFECTED SKIN
0.89
1.00
11000
DEBRIDE INFECTED SKIN
3.00
1.00
11001
DEBRIDE INFECTED SKIN ADD-ON
0.43
1.00
11004
DEBRIDE GENITALIA & PERINEUM
15.03
1.00
11005
DEBRIDE ABDOM WALL
19.63
1.00
11006
DEBRIDE GENIT/PER/ABDOM WALL
18.72
1.00
11008
REMOVE MESH FROM ABD WALL
7.17
1.00
11010
DEBRIDE SKIN, FX
3.00
1.00
11010
DEBRIDE SKIN, FX
6.61
1.00
11010
DEBRIDE SKIN, FX
7.06
1.00
11010
DEBRIDE SKIN, FX
7.34
1.00
11011
DEBRIDE SKIN/MUSCLE, FX
3.00
1.00
11011
DEBRIDE SKIN/MUSCLE, FX
7.89
1.00
11011
DEBRIDE SKIN/MUSCLE, FX
7.95
1.00
11011
DEBRIDE SKIN/MUSCLE, FX
8.08
1.00
11012
DEBRIDE SKIN/MUSCLE/BONE, FX
5.00
1.00
11012
DEBRIDE SKIN/MUSCLE/BONE, FX
11.47
1.00
11012
DEBRIDE SKIN/MUSCLE/BONE, FX
11.80
1.00
11012
DEBRIDE SKIN/MUSCLE/BONE, FX
12.00
1.00
11040
DEBRIDE SKIN, PARTIAL
0.73
1.00
11040
DEBRIDE SKIN, PARTIAL
0.76
1.00
11040
DEBRIDE SKIN, PARTIAL
0.77
1.00
11040
DEBRIDE SKIN, PARTIAL
3.00
1.00
11041
DEBRIDE SKIN, FULL
0.92
1.00
11041
DEBRIDE SKIN, FULL
1.21
1.00
11041
DEBRIDE SKIN, FULL
1.22
1.00
11041
DEBRIDE SKIN, FULL
3.00
1.00
11042
DEBRIDE SKIN/TISSUE
1.23
1.00
11042
DEBRIDE SKIN/TISSUE
1.68
1.00
Procedure Code Description
RVU
RVU Coeff Value
11042
DEBRIDE SKIN/TISSUE
3.00
1.00
11043
DEBRIDE TISSUE/MUSCLE
3.00
1.00
11043
DEBRIDE TISSUE/MUSCLE
5.26
1.00
11043
DEBRIDE TISSUE/MUSCLE
5.28
1.00
11043
DEBRIDE TISSUE/MUSCLE
5.95
1.00
11044
DEBRIDE TISSUE/MUSCLE/BONE
3.00
1.00
11044
DEBRIDE TISSUE/MUSCLE/BONE
7.24
1.00
11044
DEBRIDE TISSUE/MUSCLE/BONE
7.31
1.00
11044
DEBRIDE TISSUE/MUSCLE/BONE
8.19
1.00
11055
TRIM SKIN LESION
0.61
1.00
11055
TRIM SKIN LESION
0.62
1.00
11055
TRIM SKIN LESION
0.63
1.00
11056
TRIM SKIN LESIONS, 2 TO 4
0.86
1.00
11056
TRIM SKIN LESIONS, 2 TO 4
0.89
1.00
11056
TRIM SKIN LESIONS, 2 TO 4
0.90
1.00
11057
TRIM SKIN LESIONS, OVER 4
1.12
1.00
11057
TRIM SKIN LESIONS, OVER 4
1.15
1.00
11057
TRIM SKIN LESIONS, OVER 4
1.16
1.00
11100
BIOPSY, SKIN LESION
1.23
1.00
11100
BIOPSY, SKIN LESION
1.24
1.00
11100
BIOPSY, SKIN LESION
3.00
1.00
11101
BIOPSY, SKIN ADD-ON
0.62
1.00
11101
BIOPSY, SKIN ADD-ON
0.63
1.00
11101
BIOPSY, SKIN ADD-ON
0.64
1.00
11200
REMOVAL OF SKIN TAGS
1.12
1.00
11200
REMOVAL OF SKIN TAGS
1.59
1.00
11200
REMOVAL OF SKIN TAGS
1.70
1.00
11200
REMOVAL OF SKIN TAGS
3.00
1.00
11201
REMOVE SKIN TAGS ADD-ON
0.43
1.00
11300
SHAVE SKIN LESION
0.76
1.00
11300
SHAVE SKIN LESION
0.77
1.00
11301
SHAVE SKIN LESION
1.27
1.00
11301
SHAVE SKIN LESION
1.28
1.00
11301
SHAVE SKIN LESION
1.29
1.00
11302
SHAVE SKIN LESION
1.57
1.00
Procedure Code Description
RVU
RVU Coeff Value
11302
SHAVE SKIN LESION
1.58
1.00
11302
SHAVE SKIN LESION
1.60
1.00
11303
SHAVE SKIN LESION
1.83
1.00
11303
SHAVE SKIN LESION
1.84
1.00
11303
SHAVE SKIN LESION
1.88
1.00
11305
SHAVE SKIN LESION
0.97
1.00
11305
SHAVE SKIN LESION
0.98
1.00
11305
SHAVE SKIN LESION
0.99
1.00
11305
SHAVE SKIN LESION
3.00
1.00
11306
SHAVE SKIN LESION
1.46
1.00
11306
SHAVE SKIN LESION
1.47
1.00
11306
SHAVE SKIN LESION
3.00
1.00
11307
SHAVE SKIN LESION
1.69
1.00
11307
SHAVE SKIN LESION
1.72
1.00
11307
SHAVE SKIN LESION
3.00
1.00
11308
SHAVE SKIN LESION
2.08
1.00
11308
SHAVE SKIN LESION
2.09
1.00
11308
SHAVE SKIN LESION
3.00
1.00
11310
SHAVE SKIN LESION
1.10
1.00
11310
SHAVE SKIN LESION
1.11
1.00
11311
SHAVE SKIN LESION
1.59
1.00
11311
SHAVE SKIN LESION
1.60
1.00
11311
SHAVE SKIN LESION
1.61
1.00
11312
SHAVE SKIN LESION
1.82
1.00
11312
SHAVE SKIN LESION
1.83
1.00
11312
SHAVE SKIN LESION
1.85
1.00
11313
SHAVE SKIN LESION
2.45
1.00
11313
SHAVE SKIN LESION
2.48
1.00
11400
EXC TR-EXT B9+MARG 0.5 < CM
1.81
1.00
11400
EXC TR-EXT B9+MARG 0.5 < CM
1.86
1.00
11400
EXC TR-EXT B9+MARG 0.5 < CM
1.87
1.00
11400
EXC TR-EXT B9+MARG 0.5 < CM
3.00
1.00
11401
EXC TR-EXT B9+MARG 0.6-1 CM
2.37
1.00
11401
EXC TR-EXT B9+MARG 0.6-1 CM
2.40
1.00
11401
EXC TR-EXT B9+MARG 0.6-1 CM
2.48
1.00
Procedure Code Description
RVU
RVU Coeff Value
11401
EXC TR-EXT B9+MARG 0.6-1 CM
3.00
1.00
11402
EXC TR-EXT B9+MARG 1.1-2 CM
2.75
1.00
11402
EXC TR-EXT B9+MARG 1.1-2 CM
2.77
1.00
11402
EXC TR-EXT B9+MARG 1.1-2 CM
3.00
1.00
11403
EXC TR-EXT B9+MARG 2.1-3 CM
3.00
1.00
11403
EXC TR-EXT B9+MARG 2.1-3 CM
3.30
1.00
11403
EXC TR-EXT B9+MARG 2.1-3 CM
3.31
1.00
11403
EXC TR-EXT B9+MARG 2.1-3 CM
3.50
1.00
11404
EXC TR-EXT B9+MARG 3.1-4 CM
3.00
1.00
11404
EXC TR-EXT B9+MARG 3.1-4 CM
3.66
1.00
11404
EXC TR-EXT B9+MARG 3.1-4 CM
3.69
1.00
11404
EXC TR-EXT B9+MARG 3.1-4 CM
3.90
1.00
11406
EXC TR-EXT B9+MARG > 4.0 CM
3.00
1.00
11406
EXC TR-EXT B9+MARG > 4.0 CM
4.69
1.00
11406
EXC TR-EXT B9+MARG > 4.0 CM
4.73
1.00
11406
EXC TR-EXT B9+MARG > 4.0 CM
5.82
1.00
11420
EXC H-F-NK-SP B9+MARG 0.5 <
2.02
1.00
11420
EXC H-F-NK-SP B9+MARG 0.5 <
2.06
1.00
11420
EXC H-F-NK-SP B9+MARG 0.5 <
3.00
1.00
11421
EXC H-F-NK-SP B9+MARG 0.6-1
2.67
1.00
11421
EXC H-F-NK-SP B9+MARG 0.6-1
2.71
1.00
11421
EXC H-F-NK-SP B9+MARG 0.6-1
2.73
1.00
11421
EXC H-F-NK-SP B9+MARG 0.6-1
3.00
1.00
11422
EXC H-F-NK-SP B9+MARG 1.1-2
3.00
1.00
11422
EXC H-F-NK-SP B9+MARG 1.1-2
3.14
1.00
11422
EXC H-F-NK-SP B9+MARG 1.1-2
3.15
1.00
11422
EXC H-F-NK-SP B9+MARG 1.1-2
3.30
1.00
11423
EXC H-F-NK-SP B9+MARG 2.1-3
3.00
1.00
11423
EXC H-F-NK-SP B9+MARG 2.1-3
3.67
1.00
11423
EXC H-F-NK-SP B9+MARG 2.1-3
3.68
1.00
11423
EXC H-F-NK-SP B9+MARG 2.1-3
3.85
1.00
11424
EXC H-F-NK-SP B9+MARG 3.1-4
3.00
1.00
11424
EXC H-F-NK-SP B9+MARG 3.1-4
4.28
1.00
11424
EXC H-F-NK-SP B9+MARG 3.1-4
4.29
1.00
11424
EXC H-F-NK-SP B9+MARG 3.1-4
4.44
1.00
Procedure Code Description
RVU
RVU Coeff Value
11426
EXC H-F-NK-SP B9+MARG > 4 CM
3.00
1.00
11426
EXC H-F-NK-SP B9+MARG > 4 CM
6.27
1.00
11426
EXC H-F-NK-SP B9+MARG > 4 CM
6.29
1.00
11426
EXC H-F-NK-SP B9+MARG > 4 CM
6.79
1.00
11440
EXC FACE-MM B9+MARG 0.5 < CM
2.42
1.00
11440
EXC FACE-MM B9+MARG 0.5 < CM
2.49
1.00
11440
EXC FACE-MM B9+MARG 0.5 < CM
2.55
1.00
11440
EXC FACE-MM B9+MARG 0.5 < CM
4.00
1.00
11441
EXC FACE-MM B9+MARG 0.6-1 CM
3.00
1.00
11441
EXC FACE-MM B9+MARG 0.6-1 CM
3.12
1.00
11441
EXC FACE-MM B9+MARG 0.6-1 CM
3.18
1.00
11442
EXC FACE-MM B9+MARG 1.1-2 CM
3.47
1.00
11442
EXC FACE-MM B9+MARG 1.1-2 CM
3.52
1.00
11442
EXC FACE-MM B9+MARG 1.1-2 CM
3.55
1.00
11442
EXC FACE-MM B9+MARG 1.1-2 CM
4.00
1.00
11443
EXC FACE-MM B9+MARG 2.1-3 CM
4.00
1.00
11443
EXC FACE-MM B9+MARG 2.1-3 CM
4.34
1.00
11443
EXC FACE-MM B9+MARG 2.1-3 CM
4.37
1.00
11443
EXC FACE-MM B9+MARG 2.1-3 CM
4.39
1.00
11444
EXC FACE-MM B9+MARG 3.1-4 CM
3.00
1.00
11444
EXC FACE-MM B9+MARG 3.1-4 CM
5.63
1.00
11444
EXC FACE-MM B9+MARG 3.1-4 CM
5.67
1.00
11446
EXC FACE-MM B9+MARG > 4 CM
3.00
1.00
11446
EXC FACE-MM B9+MARG > 4 CM
7.62
1.00
11446
EXC FACE-MM B9+MARG > 4 CM
7.67
1.00
11446
EXC FACE-MM B9+MARG > 4 CM
7.96
1.00
11450
REMOVAL, SWEAT GLAND LESION
3.97
1.00
11450
REMOVAL, SWEAT GLAND LESION
4.00
1.00
11450
REMOVAL, SWEAT GLAND LESION
5.07
1.00
11450
REMOVAL, SWEAT GLAND LESION
5.82
1.00
11451
REMOVAL, SWEAT GLAND LESION
4.00
1.00
11451
REMOVAL, SWEAT GLAND LESION
5.77
1.00
11451
REMOVAL, SWEAT GLAND LESION
6.97
1.00
11451
REMOVAL, SWEAT GLAND LESION
7.71
1.00
11462
REMOVAL, SWEAT GLAND LESION
3.69
1.00
Procedure Code Description
RVU
RVU Coeff Value
11462
REMOVAL, SWEAT GLAND LESION
4.00
1.00
11462
REMOVAL, SWEAT GLAND LESION
4.81
1.00
11462
REMOVAL, SWEAT GLAND LESION
5.60
1.00
11463
REMOVAL, SWEAT GLAND LESION
4.00
1.00
11463
REMOVAL, SWEAT GLAND LESION
5.92
1.00
11463
REMOVAL, SWEAT GLAND LESION
7.11
1.00
11463
REMOVAL, SWEAT GLAND LESION
7.87
1.00
11470
REMOVAL, SWEAT GLAND LESION
4.00
1.00
11470
REMOVAL, SWEAT GLAND LESION
4.78
1.00
11470
REMOVAL, SWEAT GLAND LESION
5.88
1.00
11470
REMOVAL, SWEAT GLAND LESION
6.63
1.00
11471
REMOVAL, SWEAT GLAND LESION
4.00
1.00
11471
REMOVAL, SWEAT GLAND LESION
6.53
1.00
11471
REMOVAL, SWEAT GLAND LESION
7.66
1.00
11471
REMOVAL, SWEAT GLAND LESION
8.36
1.00
11600
EXC TR-EXT MLG+MARG 0.5 < CM
2.39
1.00
11600
EXC TR-EXT MLG+MARG 0.5 < CM
2.40
1.00
11600
EXC TR-EXT MLG+MARG 0.5 < CM
2.79
1.00
11600
EXC TR-EXT MLG+MARG 0.5 < CM
3.00
1.00
11601
EXC TR-EXT MLG+MARG 0.6-1 CM
3.00
1.00
11601
EXC TR-EXT MLG+MARG 0.6-1 CM
3.16
1.00
11601
EXC TR-EXT MLG+MARG 0.6-1 CM
3.17
1.00
11601
EXC TR-EXT MLG+MARG 0.6-1 CM
3.61
1.00
11602
EXC TR-EXT MLG+MARG 1.1-2 CM
3.00
1.00
11602
EXC TR-EXT MLG+MARG 1.1-2 CM
3.37
1.00
11602
EXC TR-EXT MLG+MARG 1.1-2 CM
3.38
1.00
11602
EXC TR-EXT MLG+MARG 1.1-2 CM
3.97
1.00
11603
EXC TR-EXT MLG+MARG 2.1-3 CM
3.00
1.00
11603
EXC TR-EXT MLG+MARG 2.1-3 CM
3.70
1.00
11603
EXC TR-EXT MLG+MARG 2.1-3 CM
3.71
1.00
11603
EXC TR-EXT MLG+MARG 2.1-3 CM
4.72
1.00
11604
EXC TR-EXT MLG+MARG 3.1-4 CM
3.00
1.00
11604
EXC TR-EXT MLG+MARG 3.1-4 CM
3.99
1.00
11604
EXC TR-EXT MLG+MARG 3.1-4 CM
4.02
1.00
11604
EXC TR-EXT MLG+MARG 3.1-4 CM
5.19
1.00
Procedure Code Description
RVU
RVU Coeff Value
11606
EXC TR-EXT MLG+MARG > 4 CM
3.00
1.00
11606
EXC TR-EXT MLG+MARG > 4 CM
5.47
1.00
11606
EXC TR-EXT MLG+MARG > 4 CM
5.51
1.00
11606
EXC TR-EXT MLG+MARG > 4 CM
7.70
1.00
11620
EXC H-F-NK-SP MLG+MARG 0.5 <
2.25
1.00
11620
EXC H-F-NK-SP MLG+MARG 0.5 <
2.26
1.00
11620
EXC H-F-NK-SP MLG+MARG 0.5 <
2.83
1.00
11620
EXC H-F-NK-SP MLG+MARG 0.5 <
3.00
1.00
11621
EXC H-F-NK-SP MLG+MARG 0.6-1
3.00
1.00
11621
EXC H-F-NK-SP MLG+MARG 0.6-1
3.15
1.00
11621
EXC H-F-NK-SP MLG+MARG 0.6-1
3.65
1.00
11622
EXC H-F-NK-SP MLG+MARG 1.1-2
3.00
1.00
11622
EXC H-F-NK-SP MLG+MARG 1.1-2
3.66
1.00
11622
EXC H-F-NK-SP MLG+MARG 1.1-2
4.21
1.00
11623
EXC H-F-NK-SP MLG+MARG 2.1-3
3.00
1.00
11623
EXC H-F-NK-SP MLG+MARG 2.1-3
4.43
1.00
11623
EXC H-F-NK-SP MLG+MARG 2.1-3
4.44
1.00
11623
EXC H-F-NK-SP MLG+MARG 2.1-3
5.19
1.00
11624
EXC H-F-NK-SP MLG+MARG 3.1-4
3.00
1.00
11624
EXC H-F-NK-SP MLG+MARG 3.1-4
5.12
1.00
11624
EXC H-F-NK-SP MLG+MARG 3.1-4
5.14
1.00
11624
EXC H-F-NK-SP MLG+MARG 3.1-4
5.91
1.00
11626
EXC H-F-NK-SP MLG+MAR > 4 CM
3.00
1.00
11626
EXC H-F-NK-SP MLG+MAR > 4 CM
7.09
1.00
11626
EXC H-F-NK-SP MLG+MAR > 4 CM
7.11
1.00
11626
EXC H-F-NK-SP MLG+MAR > 4 CM
7.43
1.00
11640
EXC FACE-MM MALIG+MARG 0.5 <
2.59
1.00
11640
EXC FACE-MM MALIG+MARG 0.5 <
2.99
1.00
11640
EXC FACE-MM MALIG+MARG 0.5 <
4.00
1.00
11641
EXC FACE-MM MALIG+MARG 0.6-1
3.88
1.00
11641
EXC FACE-MM MALIG+MARG 0.6-1
3.91
1.00
11641
EXC FACE-MM MALIG+MARG 0.6-1
4.00
1.00
11642
EXC FACE-MM MALIG+MARG 1.1-2
4.00
1.00
11642
EXC FACE-MM MALIG+MARG 1.1-2
4.54
1.00
11642
EXC FACE-MM MALIG+MARG 1.1-2
4.61
1.00
Procedure Code Description
RVU
RVU Coeff Value
11643
EXC FACE-MM MALIG+MARG 2.1-3
3.00
1.00
11643
EXC FACE-MM MALIG+MARG 2.1-3
5.35
1.00
11643
EXC FACE-MM MALIG+MARG 2.1-3
5.76
1.00
11644
EXC FACE-MM MALIG+MARG 3.1-4
3.00
1.00
11644
EXC FACE-MM MALIG+MARG 3.1-4
6.89
1.00
11644
EXC FACE-MM MALIG+MARG 3.1-4
6.92
1.00
11644
EXC FACE-MM MALIG+MARG 3.1-4
7.19
1.00
11646
EXC FACE-MM MLG+MARG > 4 CM
3.00
1.00
11646
EXC FACE-MM MLG+MARG > 4 CM
9.98
1.00
11646
EXC FACE-MM MLG+MARG > 4 CM
10.01
1.00
11646
EXC FACE-MM MLG+MARG > 4 CM
10.14
1.00
11719
TRIM NAIL(S)
0.24
1.00
11719
TRIM NAIL(S)
0.25
1.00
11720
DEBRIDE NAIL, 1-5
0.45
1.00
11720
DEBRIDE NAIL, 1-5
0.47
1.00
11720
DEBRIDE NAIL, 1-5
3.00
1.00
11721
DEBRIDE NAIL, 6 OR MORE
0.78
1.00
11721
DEBRIDE NAIL, 6 OR MORE
0.79
1.00
11721
DEBRIDE NAIL, 6 OR MORE
0.80
1.00
11721
DEBRIDE NAIL, 6 OR MORE
3.00
1.00
11730
REMOVAL OF NAIL PLATE
1.56
1.00
11730
REMOVAL OF NAIL PLATE
1.66
1.00
11730
REMOVAL OF NAIL PLATE
1.67
1.00
11730
REMOVAL OF NAIL PLATE
3.00
1.00
11732
REMOVE NAIL PLATE, ADD-ON
0.81
1.00
11732
REMOVE NAIL PLATE, ADD-ON
0.85
1.00
11740
DRAIN BLOOD FROM UNDER NAIL
0.54
1.00
11740
DRAIN BLOOD FROM UNDER NAIL
0.55
1.00
11740
DRAIN BLOOD FROM UNDER NAIL
0.81
1.00
11740
DRAIN BLOOD FROM UNDER NAIL
3.00
1.00
11750
REMOVAL OF NAIL BED
2.79
1.00
11750
REMOVAL OF NAIL BED
3.00
1.00
11750
REMOVAL OF NAIL BED
3.77
1.00
11750
REMOVAL OF NAIL BED
4.44
1.00
11752
REMOVE NAIL BED/FINGER TIP
3.00
1.00
Procedure Code Description
RVU
RVU Coeff Value
11752
REMOVE NAIL BED/FINGER TIP
4.76
1.00
11752
REMOVE NAIL BED/FINGER TIP
6.02
1.00
11752
REMOVE NAIL BED/FINGER TIP
6.65
1.00
11755
BIOPSY, NAIL UNIT
1.92
1.00
11755
BIOPSY, NAIL UNIT
1.93
1.00
11755
BIOPSY, NAIL UNIT
2.21
1.00
11755
BIOPSY, NAIL UNIT
3.00
1.00
11760
REPAIR OF NAIL BED
3.00
1.00
11760
REPAIR OF NAIL BED
3.33
1.00
11762
RECONSTRUCTION OF NAIL BED
3.00
1.00
11762
RECONSTRUCTION OF NAIL BED
5.09
1.00
11762
RECONSTRUCTION OF NAIL BED
5.11
1.00
11762
RECONSTRUCTION OF NAIL BED
5.12
1.00
11765
EXCISION OF NAIL FOLD, TOE
1.23
1.00
11765
EXCISION OF NAIL FOLD, TOE
1.27
1.00
11765
EXCISION OF NAIL FOLD, TOE
1.71
1.00
11765
EXCISION OF NAIL FOLD, TOE
3.00
1.00
11770
REMOVAL OF PILONIDAL LESION
4.00
1.00
11770
REMOVAL OF PILONIDAL LESION
4.08
1.00
11770
REMOVAL OF PILONIDAL LESION
4.41
1.00
11770
REMOVAL OF PILONIDAL LESION
4.49
1.00
11771
REMOVAL OF PILONIDAL LESION
4.00
1.00
11771
REMOVAL OF PILONIDAL LESION
9.74
1.00
11771
REMOVAL OF PILONIDAL LESION
10.21
1.00
11771
REMOVAL OF PILONIDAL LESION
10.40
1.00
11772
REMOVAL OF PILONIDAL LESION
4.00
1.00
11772
REMOVAL OF PILONIDAL LESION
11.66
1.00
11772
REMOVAL OF PILONIDAL LESION
12.02
1.00
11772
REMOVAL OF PILONIDAL LESION
13.57
1.00
11900
INJECTION INTO SKIN LESIONS
0.76
1.00
11900
INJECTION INTO SKIN LESIONS
0.79
1.00
11900
INJECTION INTO SKIN LESIONS
4.00
1.00
11901
ADDED SKIN LESIONS INJECTION
1.19
1.00
11901
ADDED SKIN LESIONS INJECTION
1.20
1.00
11901
ADDED SKIN LESIONS INJECTION
1.23
1.00
Procedure Code Description
RVU
RVU Coeff Value
11901
ADDED SKIN LESIONS INJECTION
4.00
1.00
11920
CORRECT SKIN COLOR DEFECTS
2.58
1.00
11920
CORRECT SKIN COLOR DEFECTS
2.60
1.00
11920
CORRECT SKIN COLOR DEFECTS
2.97
1.00
11921
CORRECT SKIN COLOR DEFECTS
3.14
1.00
11921
CORRECT SKIN COLOR DEFECTS
3.16
1.00
11921
CORRECT SKIN COLOR DEFECTS
3.50
1.00
11922
CORRECT SKIN COLOR DEFECTS
0.79
1.00
11922
CORRECT SKIN COLOR DEFECTS
0.80
1.00
11950
THERAPY FOR CONTOUR DEFECTS
1.30
1.00
11950
THERAPY FOR CONTOUR DEFECTS
1.31
1.00
11950
THERAPY FOR CONTOUR DEFECTS
1.32
1.00
11951
THERAPY FOR CONTOUR DEFECTS
1.81
1.00
11951
THERAPY FOR CONTOUR DEFECTS
1.82
1.00
11952
THERAPY FOR CONTOUR DEFECTS
2.56
1.00
11952
THERAPY FOR CONTOUR DEFECTS
2.58
1.00
11952
THERAPY FOR CONTOUR DEFECTS
2.63
1.00
11954
THERAPY FOR CONTOUR DEFECTS
2.97
1.00
11954
THERAPY FOR CONTOUR DEFECTS
2.98
1.00
11954
THERAPY FOR CONTOUR DEFECTS
2.99
1.00
11954
THERAPY FOR CONTOUR DEFECTS
3.00
1.00
11960
INSERT TISSUE EXPANDER(S)
5.00
1.00
11960
INSERT TISSUE EXPANDER(S)
20.65
1.00
11960
INSERT TISSUE EXPANDER(S)
20.90
1.00
11960
INSERT TISSUE EXPANDER(S)
22.98
1.00
11970
REPLACE TISSUE EXPANDER
12.81
1.00
11970
REPLACE TISSUE EXPANDER
14.08
1.00
11970
REPLACE TISSUE EXPANDER
15.13
1.00
11971
REMOVE TISSUE EXPANDER(S)
3.00
1.00
11971
REMOVE TISSUE EXPANDER(S)
6.20
1.00
11971
REMOVE TISSUE EXPANDER(S)
6.22
1.00
11971
REMOVE TISSUE EXPANDER(S)
6.25
1.00
11971
REMOVE TISSUE EXPANDER(S)
7.14
1.00
11971
REMOVE TISSUE EXPANDER(S)
7.45
1.00
11975
INSERT CONTRACEPTIVE CAP
2.17
1.00
Procedure Code Description
RVU
RVU Coeff Value
11975
INSERT CONTRACEPTIVE CAP
2.20
1.00
11975
INSERT CONTRACEPTIVE CAP
2.22
1.00
11976
REMOVAL OF CONTRACEPTIVE CAP
2.54
1.00
11976
REMOVAL OF CONTRACEPTIVE CAP
2.65
1.00
11976
REMOVAL OF CONTRACEPTIVE CAP
2.67
1.00
11976
REMOVAL OF CONTRACEPTIVE CAP
3.00
1.00
11977
REMOVAL/REINSERT CONTRA CAP
4.82
1.00
11977
REMOVAL/REINSERT CONTRA CAP
4.89
1.00
11977
REMOVAL/REINSERT CONTRA CAP
4.93
1.00
11980
IMPLANT HORMONE PELLET(S)
2.12
1.00
11980
IMPLANT HORMONE PELLET(S)
2.14
1.00
11981
INSERT DRUG IMPLANT DEVICE
2.20
1.00
11981
INSERT DRUG IMPLANT DEVICE
2.23
1.00
11981
INSERT DRUG IMPLANT DEVICE
2.33
1.00
11982
REMOVE DRUG IMPLANT DEVICE
2.65
1.00
11982
REMOVE DRUG IMPLANT DEVICE
2.73
1.00
11982
REMOVE DRUG IMPLANT DEVICE
2.83
1.00
11983
REMOVE/INSERT DRUG IMPLANT
4.89
1.00
11983
REMOVE/INSERT DRUG IMPLANT
4.97
1.00
11983
REMOVE/INSERT DRUG IMPLANT
5.14
1.00
12001
REPAIR SUPERFICIAL WOUND(S)
2.27
1.00
12001
REPAIR SUPERFICIAL WOUND(S)
2.35
1.00
12001
REPAIR SUPERFICIAL WOUND(S)
2.61
1.00
12001
REPAIR SUPERFICIAL WOUND(S)
3.00
1.00
12002
REPAIR SUPERFICIAL WOUND(S)
2.90
1.00
12002
REPAIR SUPERFICIAL WOUND(S)
2.93
1.00
12002
REPAIR SUPERFICIAL WOUND(S)
2.97
1.00
12002
REPAIR SUPERFICIAL WOUND(S)
3.00
1.00
12004
REPAIR SUPERFICIAL WOUND(S)
3.00
1.00
12004
REPAIR SUPERFICIAL WOUND(S)
3.41
1.00
12004
REPAIR SUPERFICIAL WOUND(S)
3.44
1.00
12004
REPAIR SUPERFICIAL WOUND(S)
3.50
1.00
12005
REPAIR SUPERFICIAL WOUND(S)
4.00
1.00
12005
REPAIR SUPERFICIAL WOUND(S)
4.25
1.00
12005
REPAIR SUPERFICIAL WOUND(S)
4.31
1.00
Procedure Code Description
RVU
RVU Coeff Value
12005
REPAIR SUPERFICIAL WOUND(S)
4.37
1.00
12006
REPAIR SUPERFICIAL WOUND(S)
3.00
1.00
12006
REPAIR SUPERFICIAL WOUND(S)
5.37
1.00
12006
REPAIR SUPERFICIAL WOUND(S)
5.51
1.00
12006
REPAIR SUPERFICIAL WOUND(S)
5.57
1.00
12007
REPAIR SUPERFICIAL WOUND(S)
3.00
1.00
12007
REPAIR SUPERFICIAL WOUND(S)
6.16
1.00
12007
REPAIR SUPERFICIAL WOUND(S)
6.32
1.00
12007
REPAIR SUPERFICIAL WOUND(S)
6.40
1.00
12011
REPAIR SUPERFICIAL WOUND(S)
2.34
1.00
12011
REPAIR SUPERFICIAL WOUND(S)
2.43
1.00
12011
REPAIR SUPERFICIAL WOUND(S)
2.70
1.00
12011
REPAIR SUPERFICIAL WOUND(S)
3.00
1.00
12013
REPAIR SUPERFICIAL WOUND(S)
3.08
1.00
12013
REPAIR SUPERFICIAL WOUND(S)
3.11
1.00
12013
REPAIR SUPERFICIAL WOUND(S)
3.15
1.00
12013
REPAIR SUPERFICIAL WOUND(S)
4.00
1.00
12014
REPAIR SUPERFICIAL WOUND(S)
3.71
1.00
12014
REPAIR SUPERFICIAL WOUND(S)
3.72
1.00
12014
REPAIR SUPERFICIAL WOUND(S)
3.77
1.00
12014
REPAIR SUPERFICIAL WOUND(S)
4.00
1.00
12015
REPAIR SUPERFICIAL WOUND(S)
4.00
1.00
12015
REPAIR SUPERFICIAL WOUND(S)
4.65
1.00
12015
REPAIR SUPERFICIAL WOUND(S)
4.70
1.00
12015
REPAIR SUPERFICIAL WOUND(S)
4.76
1.00
12016
REPAIR SUPERFICIAL WOUND(S)
4.00
1.00
12016
REPAIR SUPERFICIAL WOUND(S)
5.68
1.00
12016
REPAIR SUPERFICIAL WOUND(S)
5.80
1.00
12016
REPAIR SUPERFICIAL WOUND(S)
5.87
1.00
12017
REPAIR SUPERFICIAL WOUND(S)
4.00
1.00
12017
REPAIR SUPERFICIAL WOUND(S)
6.77
1.00
12017
REPAIR SUPERFICIAL WOUND(S)
7.00
1.00
12017
REPAIR SUPERFICIAL WOUND(S)
7.08
1.00
12018
REPAIR SUPERFICIAL WOUND(S)
4.00
1.00
12018
REPAIR SUPERFICIAL WOUND(S)
8.26
1.00
Procedure Code Description
RVU
RVU Coeff Value
12018
REPAIR SUPERFICIAL WOUND(S)
8.34
1.00
12018
REPAIR SUPERFICIAL WOUND(S)
8.41
1.00
12020
CLOSURE OF SPLIT WOUND
4.28
1.00
12020
CLOSURE OF SPLIT WOUND
4.66
1.00
12020
CLOSURE OF SPLIT WOUND
4.74
1.00
12021
CLOSURE OF SPLIT WOUND
3.05
1.00
12021
CLOSURE OF SPLIT WOUND
3.45
1.00
12021
CLOSURE OF SPLIT WOUND
3.48
1.00
12031
INTMD WND REPAIR S/TR/EXT
3.07
1.00
12031
INTMD WND REPAIR S/TR/EXT
3.14
1.00
12031
INTMD WND REPAIR S/TR/EXT
3.95
1.00
12031
INTMD WND REPAIR S/TR/EXT
4.00
1.00
12032
INTMD WND REPAIR S/TR/EXT
3.90
1.00
12032
INTMD WND REPAIR S/TR/EXT
4.00
1.00
12032
INTMD WND REPAIR S/TR/EXT
4.49
1.00
12032
INTMD WND REPAIR S/TR/EXT
4.85
1.00
12034
INTMD WND REPAIR S/TR/EXT
4.00
1.00
12034
INTMD WND REPAIR S/TR/EXT
4.57
1.00
12034
INTMD WND REPAIR S/TR/EXT
4.58
1.00
12034
INTMD WND REPAIR S/TR/EXT
5.08
1.00
12035
INTMD WND REPAIR S/TR/EXT
4.00
1.00
12035
INTMD WND REPAIR S/TR/EXT
5.40
1.00
12035
INTMD WND REPAIR S/TR/EXT
5.96
1.00
12035
INTMD WND REPAIR S/TR/EXT
5.99
1.00
12036
INTMD WND REPAIR S/TR/EXT
4.00
1.00
12036
INTMD WND REPAIR S/TR/EXT
6.91
1.00
12036
INTMD WND REPAIR S/TR/EXT
6.92
1.00
12036
INTMD WND REPAIR S/TR/EXT
6.94
1.00
12037
INTMD WND REPAIR S/TR/EXT
4.00
1.00
12037
INTMD WND REPAIR S/TR/EXT
7.96
1.00
12037
INTMD WND REPAIR S/TR/EXT
8.03
1.00
12037
INTMD WND REPAIR S/TR/EXT
8.09
1.00
12041
INTMD WND REPAIR N-HF/GENIT
3.37
1.00
12041
INTMD WND REPAIR N-HF/GENIT
3.45
1.00
12041
INTMD WND REPAIR N-HF/GENIT
4.00
1.00
Procedure Code Description
RVU
RVU Coeff Value
12041
INTMD WND REPAIR N-HF/GENIT
4.23
1.00
12042
INTMD WND REPAIR N-HG/GENIT
4.00
1.00
12042
INTMD WND REPAIR N-HG/GENIT
4.32
1.00
12042
INTMD WND REPAIR N-HG/GENIT
4.93
1.00
12044
INTMD WND REPAIR N-HG/GENIT
4.00
1.00
12044
INTMD WND REPAIR N-HG/GENIT
4.98
1.00
12044
INTMD WND REPAIR N-HG/GENIT
4.99
1.00
12044
INTMD WND REPAIR N-HG/GENIT
5.33
1.00
12045
INTMD WND REPAIR N-HG/GENIT
4.00
1.00
12045
INTMD WND REPAIR N-HG/GENIT
5.85
1.00
12045
INTMD WND REPAIR N-HG/GENIT
6.21
1.00
12045
INTMD WND REPAIR N-HG/GENIT
6.22
1.00
12046
INTMD WND REPAIR N-HG/GENIT
4.00
1.00
12046
INTMD WND REPAIR N-HG/GENIT
7.20
1.00
12046
INTMD WND REPAIR N-HG/GENIT
7.35
1.00
12046
INTMD WND REPAIR N-HG/GENIT
7.48
1.00
12047
INTMD WND REPAIR N-HG/GENIT
4.00
1.00
12047
INTMD WND REPAIR N-HG/GENIT
7.95
1.00
12047
INTMD WND REPAIR N-HG/GENIT
8.04
1.00
12047
INTMD WND REPAIR N-HG/GENIT
8.23
1.00
12051
INTMD WND REPAIR FACE/MM
4.00
1.00
12051
INTMD WND REPAIR FACE/MM
4.02
1.00
12051
INTMD WND REPAIR FACE/MM
4.04
1.00
12051
INTMD WND REPAIR FACE/MM
4.53
1.00
12052
INTMD WND REPAIR FACE/MM
4.00
1.00
12052
INTMD WND REPAIR FACE/MM
4.32
1.00
12052
INTMD WND REPAIR FACE/MM
5.30
1.00
12053
INTMD WND REPAIR FACE/MM
4.00
1.00
12053
INTMD WND REPAIR FACE/MM
4.86
1.00
12053
INTMD WND REPAIR FACE/MM
5.39
1.00
12054
INTMD WND REPAIR, FACE/MM
4.00
1.00
12054
INTMD WND REPAIR, FACE/MM
5.35
1.00
12054
INTMD WND REPAIR, FACE/MM
5.74
1.00
12055
INTMD WND REPAIR FACE/MM
4.00
1.00
12055
INTMD WND REPAIR FACE/MM
6.97
1.00
Procedure Code Description
RVU
RVU Coeff Value
12055
INTMD WND REPAIR FACE/MM
6.98
1.00
12055
INTMD WND REPAIR FACE/MM
7.02
1.00
12056
INTMD WND REPAIR FACE/MM
4.00
1.00
12056
INTMD WND REPAIR FACE/MM
8.59
1.00
12056
INTMD WND REPAIR FACE/MM
8.72
1.00
12056
INTMD WND REPAIR FACE/MM
8.82
1.00
12057
INTMD WND REPAIR FACE/MM
4.00
1.00
12057
INTMD WND REPAIR FACE/MM
9.80
1.00
12057
INTMD WND REPAIR FACE/MM
10.19
1.00
12057
INTMD WND REPAIR FACE/MM
10.31
1.00
13100
REPAIR OF WOUND OR LESION
4.00
1.00
13100
REPAIR OF WOUND OR LESION
5.15
1.00
13100
REPAIR OF WOUND OR LESION
5.17
1.00
13100
REPAIR OF WOUND OR LESION
5.92
1.00
13101
REPAIR OF WOUND OR LESION
3.00
1.00
13101
REPAIR OF WOUND OR LESION
6.40
1.00
13101
REPAIR OF WOUND OR LESION
6.43
1.00
13101
REPAIR OF WOUND OR LESION
6.86
1.00
13101
REPAIR OF WOUND OR LESION
6.87
1.00
13101
REPAIR OF WOUND OR LESION
7.17
1.00
13102
REPAIR WOUND/LESION ADD-ON
1.92
1.00
13102
REPAIR WOUND/LESION ADD-ON
1.93
1.00
13120
REPAIR OF WOUND OR LESION
3.00
1.00
13120
REPAIR OF WOUND OR LESION
5.40
1.00
13120
REPAIR OF WOUND OR LESION
5.41
1.00
13120
REPAIR OF WOUND OR LESION
6.18
1.00
13121
REPAIR OF WOUND OR LESION
3.00
1.00
13121
REPAIR OF WOUND OR LESION
6.94
1.00
13121
REPAIR OF WOUND OR LESION
6.97
1.00
13121
REPAIR OF WOUND OR LESION
8.12
1.00
13122
REPAIR WOUND/LESION ADD-ON
2.21
1.00
13131
REPAIR OF WOUND OR LESION
3.00
1.00
13131
REPAIR OF WOUND OR LESION
6.22
1.00
13131
REPAIR OF WOUND OR LESION
6.25
1.00
13131
REPAIR OF WOUND OR LESION
6.96
1.00
Procedure Code Description
RVU
RVU Coeff Value
13132
REPAIR OF WOUND OR LESION
3.00
1.00
13132
REPAIR OF WOUND OR LESION
9.50
1.00
13132
REPAIR OF WOUND OR LESION
9.52
1.00
13132
REPAIR OF WOUND OR LESION
10.43
1.00
13132
REPAIR OF WOUND OR LESION
10.45
1.00
13132
REPAIR OF WOUND OR LESION
11.69
1.00
13133
REPAIR WOUND/LESION ADD-ON
3.41
1.00
13133
REPAIR WOUND/LESION ADD-ON
3.42
1.00
13133
REPAIR WOUND/LESION ADD-ON
3.43
1.00
13150
REPAIR OF WOUND OR LESION
3.00
1.00
13150
REPAIR OF WOUND OR LESION
6.74
1.00
13150
REPAIR OF WOUND OR LESION
6.76
1.00
13150
REPAIR OF WOUND OR LESION
6.95
1.00
13151
REPAIR OF WOUND OR LESION
3.00
1.00
13151
REPAIR OF WOUND OR LESION
7.81
1.00
13151
REPAIR OF WOUND OR LESION
8.06
1.00
13152
REPAIR OF WOUND OR LESION
3.00
1.00
13152
REPAIR OF WOUND OR LESION
10.69
1.00
13152
REPAIR OF WOUND OR LESION
10.71
1.00
13152
REPAIR OF WOUND OR LESION
10.83
1.00
13153
REPAIR WOUND/LESION ADD-ON
3.72
1.00
13153
REPAIR WOUND/LESION ADD-ON
3.74
1.00
13160
LATE CLOSURE OF WOUND
3.00
1.00
13160
LATE CLOSURE OF WOUND
18.00
1.00
13160
LATE CLOSURE OF WOUND
19.04
1.00
13160
LATE CLOSURE OF WOUND
20.57
1.00
14000
SKIN TISSUE REARRANGEMENT
4.00
1.00
14000
SKIN TISSUE REARRANGEMENT
11.00
1.00
14000
SKIN TISSUE REARRANGEMENT
11.55
1.00
14000
SKIN TISSUE REARRANGEMENT
12.52
1.00
14001
SKIN TISSUE REARRANGEMENT
4.00
1.00
14001
SKIN TISSUE REARRANGEMENT
15.08
1.00
14001
SKIN TISSUE REARRANGEMENT
15.83
1.00
14001
SKIN TISSUE REARRANGEMENT
16.62
1.00
14020
SKIN TISSUE REARRANGEMENT
4.00
1.00
Procedure Code Description
RVU
RVU Coeff Value
14020
SKIN TISSUE REARRANGEMENT
12.44
1.00
14020
SKIN TISSUE REARRANGEMENT
13.17
1.00
14020
SKIN TISSUE REARRANGEMENT
14.32
1.00
14021
SKIN TISSUE REARRANGEMENT
4.00
1.00
14021
SKIN TISSUE REARRANGEMENT
17.87
1.00
14021
SKIN TISSUE REARRANGEMENT
18.49
1.00
14021
SKIN TISSUE REARRANGEMENT
18.61
1.00
14040
SKIN TISSUE REARRANGEMENT
4.00
1.00
14040
SKIN TISSUE REARRANGEMENT
15.38
1.00
14040
SKIN TISSUE REARRANGEMENT
15.47
1.00
14040
SKIN TISSUE REARRANGEMENT
16.24
1.00
14041
SKIN TISSUE REARRANGEMENT
4.00
1.00
14041
SKIN TISSUE REARRANGEMENT
20.04
1.00
14041
SKIN TISSUE REARRANGEMENT
21.01
1.00
14041
SKIN TISSUE REARRANGEMENT
21.11
1.00
14060
SKIN TISSUE REARRANGEMENT
4.00
1.00
14060
SKIN TISSUE REARRANGEMENT
16.89
1.00
14060
SKIN TISSUE REARRANGEMENT
16.93
1.00
14060
SKIN TISSUE REARRANGEMENT
17.15
1.00
14061
SKIN TISSUE REARRANGEMENT
4.00
1.00
14061
SKIN TISSUE REARRANGEMENT
21.37
1.00
14061
SKIN TISSUE REARRANGEMENT
22.68
1.00
14061
SKIN TISSUE REARRANGEMENT
22.81
1.00
14300
SKIN TISSUE REARRANGEMENT
4.00
1.00
14300
SKIN TISSUE REARRANGEMENT
21.97
1.00
14300
SKIN TISSUE REARRANGEMENT
22.00
1.00
14300
SKIN TISSUE REARRANGEMENT
24.00
1.00
14350
SKIN TISSUE REARRANGEMENT
3.00
1.00
14350
SKIN TISSUE REARRANGEMENT
17.06
1.00
14350
SKIN TISSUE REARRANGEMENT
18.03
1.00
14350
SKIN TISSUE REARRANGEMENT
19.09
1.00
15000
WOUND PREP, 1ST 100 SQ CM
3.00
1.00
15000
WOUND PREP, 1ST 100 SQ CM
6.59
1.00
15000
WOUND PREP, 1ST 100 SQ CM
6.64
1.00
15000
WOUND PREP, 1ST 100 SQ CM
6.72
1.00
Procedure Code Description
RVU
RVU Coeff Value
15001
WOUND PREP, ADDL 100 SQ CM
1.53
1.00
15001
WOUND PREP, ADDL 100 SQ CM
1.54
1.00
15001
WOUND PREP, ADDL 100 SQ CM
1.55
1.00
15002
WOUND PREP, TRK/ARM/LEG
5.87
1.00
15003
WOUND PREP, ADDL 100 CM
1.19
1.00
15004
WOUND PREP, F/N/HF/G
7.34
1.00
15005
WND PREP, F/N/HF/G, ADDL CM
2.36
1.00
15040
HARVEST CULTURED SKIN GRAFT
3.29
1.00
15050
SKIN PINCH GRAFT
3.00
1.00
15050
SKIN PINCH GRAFT
8.75
1.00
15050
SKIN PINCH GRAFT
9.58
1.00
15050
SKIN PINCH GRAFT
10.99
1.00
15100
SKIN SPLT GRFT, TRNK/ARM/LEG
4.00
1.00
15100
SKIN SPLT GRFT, TRNK/ARM/LEG
17.97
1.00
15100
SKIN SPLT GRFT, TRNK/ARM/LEG
18.08
1.00
15100
SKIN SPLT GRFT, TRNK/ARM/LEG
18.09
1.00
15101
SKIN SPLT GRFT T/A/L, ADD-ON
2.91
1.00
15101
SKIN SPLT GRFT T/A/L, ADD-ON
3.38
1.00
15101
SKIN SPLT GRFT T/A/L, ADD-ON
3.60
1.00
15110
EPIDRM AUTOGRFT TRNK/ARM/LEG
18.60
1.00
15111
EPIDRM AUTOGRFT T/A/L ADD-ON
2.81
1.00
15115
EPIDRM A-GRFT FACE/NCK/HF/G
19.20
1.00
15116
EPIDRM A-GRFT F/N/HF/G ADDL
3.87
1.00
15120
SKN SPLT A-GRFT FAC/NCK/HF/G
4.00
1.00
15120
SKN SPLT A-GRFT FAC/NCK/HF/G
18.68
1.00
15120
SKN SPLT A-GRFT FAC/NCK/HF/G
18.76
1.00
15120
SKN SPLT A-GRFT FAC/NCK/HF/G
19.75
1.00
15121
SKN SPLT A-GRFT F/N/HF/G ADD
4.45
1.00
15121
SKN SPLT A-GRFT F/N/HF/G ADD
4.79
1.00
15121
SKN SPLT A-GRFT F/N/HF/G ADD
4.87
1.00
15130
DERM AUTOGRAFT, TRNK/ARM/LEG
14.14
1.00
15131
DERM AUTOGRAFT T/A/L ADD-ON
2.30
1.00
15135
DERM AUTOGRAFT FACE/NCK/HF/G
19.38
1.00
15136
DERM AUTOGRAFT, F/N/HF/G ADD
2.18
1.00
15150
CULT EPIDERM GRFT T/ARM/LEG
16.15
1.00
Procedure Code Description
RVU
RVU Coeff Value
15151
CULT EPIDERM GRFT T/A/L ADDL
3.04
1.00
15152
CULT EPIDERM GRAFT T/A/L +%
4.00
1.00
15155
CULT EPIDERM GRAFT, F/N/HF/G
17.25
1.00
15156
CULT EPIDRM GRFT F/N/HFG ADD
4.33
1.00
15157
CULT EPIDERM GRFT F/N/HFG +%
4.70
1.00
15170
ACELL GRAFT TRUNK/ARMS/LEGS
9.25
1.00
15171
ACELL GRAFT T/ARM/LEG ADD-ON
2.30
1.00
15175
ACELLULAR GRAFT, F/N/HF/G
12.26
1.00
15176
ACELL GRAFT, F/N/HF/G ADD-ON
3.64
1.00
15200
SKIN FULL GRAFT, TRUNK
3.00
1.00
15200
SKIN FULL GRAFT, TRUNK
14.30
1.00
15200
SKIN FULL GRAFT, TRUNK
14.90
1.00
15200
SKIN FULL GRAFT, TRUNK
16.50
1.00
15201
SKIN FULL GRAFT TRUNK ADD-ON
2.08
1.00
15201
SKIN FULL GRAFT TRUNK ADD-ON
2.10
1.00
15201
SKIN FULL GRAFT TRUNK ADD-ON
2.11
1.00
15201
SKIN FULL GRAFT TRUNK ADD-ON
2.12
1.00
15201
SKIN FULL GRAFT TRUNK ADD-ON
2.13
1.00
15220
SKIN FULL GRAFT SCLP/ARM/LEG
3.00
1.00
15220
SKIN FULL GRAFT SCLP/ARM/LEG
14.73
1.00
15220
SKIN FULL GRAFT SCLP/ARM/LEG
15.11
1.00
15220
SKIN FULL GRAFT SCLP/ARM/LEG
15.59
1.00
15221
SKIN FULL GRAFT ADD-ON
1.89
1.00
15221
SKIN FULL GRAFT ADD-ON
1.90
1.00
15240
SKIN FULL GRFT FACE/GENIT/HF
3.00
1.00
15240
SKIN FULL GRFT FACE/GENIT/HF
16.85
1.00
15240
SKIN FULL GRFT FACE/GENIT/HF
17.64
1.00
15240
SKIN FULL GRFT FACE/GENIT/HF
19.87
1.00
15241
SKIN FULL GRAFT ADD-ON
2.96
1.00
15241
SKIN FULL GRAFT ADD-ON
2.97
1.00
15241
SKIN FULL GRAFT ADD-ON
2.99
1.00
15260
SKIN FULL GRAFT EEN & LIPS
4.00
1.00
15260
SKIN FULL GRAFT EEN & LIPS
19.40
1.00
15260
SKIN FULL GRAFT EEN & LIPS
19.59
1.00
15260
SKIN FULL GRAFT EEN & LIPS
21.43
1.00
Procedure Code Description
RVU
RVU Coeff Value
15261
SKIN FULL GRAFT ADD-ON
3.70
1.00
15261
SKIN FULL GRAFT ADD-ON
3.86
1.00
15261
SKIN FULL GRAFT ADD-ON
4.00
1.00
15300
APPLY SKINALLOGRFT, T/ARM/LG
7.38
1.00
15301
APPLY SKNALLOGRFT T/A/L ADDL
1.51
1.00
15320
APPLY SKIN ALLOGRFT F/N/HF/G
8.36
1.00
15321
APLY SKNALLOGRFT F/N/HFG ADD
2.27
1.00
15330
APLY ACELL ALOGRFT T/ARM/LEG
6.72
1.00
15331
APLY ACELL GRFT T/A/L ADD-ON
1.52
1.00
15335
APPLY ACELL GRAFT, F/N/HF/G
7.18
1.00
15336
APLY ACELL GRFT F/N/HF/G ADD
2.09
1.00
15340
APPLY CULT SKIN SUBSTITUTE
6.84
1.00
15341
APPLY CULT SKIN SUB ADD-ON
0.72
1.00
15342
CULTURED SKIN GRAFT, 25 CM
1.66
1.00
15342
CULTURED SKIN GRAFT, 25 CM
1.84
1.00
15342
CULTURED SKIN GRAFT, 25 CM
3.00
1.00
15343
CULTURE SKN GRAFT ADDL 25 CM
0.37
1.00
15350
SKIN HOMOGRAFT
3.00
1.00
15350
SKIN HOMOGRAFT
8.32
1.00
15350
SKIN HOMOGRAFT
8.76
1.00
15350
SKIN HOMOGRAFT
9.33
1.00
15351
SKIN HOMOGRAFT ADD-ON
1.50
1.00
15351
SKIN HOMOGRAFT ADD-ON
1.52
1.00
15360
APPLY CULT DERM SUB, T/A/L
7.70
1.00
15361
APLY CULT DERM SUB T/A/L ADD
1.66
1.00
15365
APPLY CULT DERM SUB F/N/HF/G
7.69
1.00
15366
APPLY CULT DERM F/HF/G ADD
2.07
1.00
15400
APPLY SKIN XENOGRAFT, T/A/L
3.00
1.00
15400
APPLY SKIN XENOGRAFT, T/A/L
8.57
1.00
15400
APPLY SKIN XENOGRAFT, T/A/L
8.87
1.00
15400
APPLY SKIN XENOGRAFT, T/A/L
9.24
1.00
15401
APPLY SKN XENOGRFT T/A/L ADD
1.50
1.00
15401
APPLY SKN XENOGRFT T/A/L ADD
1.57
1.00
15420
APPLY SKIN XGRAFT, F/N/HF/G
9.84
1.00
15421
APPLY SKN XGRFT F/N/HF/G ADD
2.24
1.00
Procedure Code Description 15430
APPLY ACELLULAR XENOGRAFT
15570
RVU
RVU Coeff Value
12.58
1.00
FORM SKIN PEDICLE FLAP
4.00
1.00
15570
FORM SKIN PEDICLE FLAP
16.24
1.00
15570
FORM SKIN PEDICLE FLAP
17.04
1.00
15570
FORM SKIN PEDICLE FLAP
18.10
1.00
15572
FORM SKIN PEDICLE FLAP
4.00
1.00
15572
FORM SKIN PEDICLE FLAP
16.00
1.00
15572
FORM SKIN PEDICLE FLAP
16.63
1.00
15572
FORM SKIN PEDICLE FLAP
18.28
1.00
15574
FORM SKIN PEDICLE FLAP
4.00
1.00
15574
FORM SKIN PEDICLE FLAP
17.64
1.00
15574
FORM SKIN PEDICLE FLAP
17.93
1.00
15574
FORM SKIN PEDICLE FLAP
19.29
1.00
15576
FORM SKIN PEDICLE FLAP
4.00
1.00
15576
FORM SKIN PEDICLE FLAP
15.70
1.00
15576
FORM SKIN PEDICLE FLAP
15.97
1.00
15576
FORM SKIN PEDICLE FLAP
16.88
1.00
15600
SKIN GRAFT
4.00
1.00
15600
SKIN GRAFT
4.44
1.00
15600
SKIN GRAFT
4.84
1.00
15600
SKIN GRAFT
5.04
1.00
15610
SKIN GRAFT
4.00
1.00
15610
SKIN GRAFT
5.29
1.00
15610
SKIN GRAFT
5.75
1.00
15610
SKIN GRAFT
5.97
1.00
15620
SKIN GRAFT
4.00
1.00
15620
SKIN GRAFT
6.61
1.00
15620
SKIN GRAFT
6.95
1.00
15620
SKIN GRAFT
7.87
1.00
15630
SKIN GRAFT
4.00
1.00
15630
SKIN GRAFT
7.21
1.00
15630
SKIN GRAFT
7.54
1.00
15630
SKIN GRAFT
8.59
1.00
15650
TRANSFER SKIN PEDICLE FLAP
4.00
1.00
15650
TRANSFER SKIN PEDICLE FLAP
8.06
1.00
Procedure Code Description
RVU
RVU Coeff Value
15650
TRANSFER SKIN PEDICLE FLAP
8.41
1.00
15650
TRANSFER SKIN PEDICLE FLAP
9.69
1.00
15731
FOREHEAD FLAP W/VASC PEDICLE
25.57
1.00
15732
MUSCLE-SKIN GRAFT, HEAD/NECK
4.00
1.00
15732
MUSCLE-SKIN GRAFT, HEAD/NECK
31.84
1.00
15732
MUSCLE-SKIN GRAFT, HEAD/NECK
32.04
1.00
15732
MUSCLE-SKIN GRAFT, HEAD/NECK
33.36
1.00
15734
MUSCLE-SKIN GRAFT, TRUNK
4.00
1.00
15734
MUSCLE-SKIN GRAFT, TRUNK
32.40
1.00
15734
MUSCLE-SKIN GRAFT, TRUNK
32.43
1.00
15734
MUSCLE-SKIN GRAFT, TRUNK
34.36
1.00
15734
MUSCLE-SKIN GRAFT, TRUNK
34.41
1.00
15734
MUSCLE-SKIN GRAFT, TRUNK
34.56
1.00
15736
MUSCLE-SKIN GRAFT, ARM
3.00
1.00
15736
MUSCLE-SKIN GRAFT, ARM
29.62
1.00
15736
MUSCLE-SKIN GRAFT, ARM
29.78
1.00
15736
MUSCLE-SKIN GRAFT, ARM
29.86
1.00
15738
MUSCLE-SKIN GRAFT, LEG
3.00
1.00
15738
MUSCLE-SKIN GRAFT, LEG
31.98
1.00
15738
MUSCLE-SKIN GRAFT, LEG
32.12
1.00
15738
MUSCLE-SKIN GRAFT, LEG
32.43
1.00
15740
ISLAND PEDICLE FLAP GRAFT
4.00
1.00
15740
ISLAND PEDICLE FLAP GRAFT
17.92
1.00
15740
ISLAND PEDICLE FLAP GRAFT
18.86
1.00
15740
ISLAND PEDICLE FLAP GRAFT
21.56
1.00
15750
NEUROVASCULAR PEDICLE GRAFT
4.00
1.00
15750
NEUROVASCULAR PEDICLE GRAFT
20.77
1.00
15750
NEUROVASCULAR PEDICLE GRAFT
21.83
1.00
15750
NEUROVASCULAR PEDICLE GRAFT
23.08
1.00
15756
FREE MYO/SKIN FLAP MICROVASC
4.00
1.00
15756
FREE MYO/SKIN FLAP MICROVASC
59.19
1.00
15756
FREE MYO/SKIN FLAP MICROVASC
59.62
1.00
15756
FREE MYO/SKIN FLAP MICROVASC
61.03
1.00
15757
FREE SKIN FLAP, MICROVASC
4.00
1.00
15757
FREE SKIN FLAP, MICROVASC
60.19
1.00
Procedure Code Description
RVU
RVU Coeff Value
15757
FREE SKIN FLAP, MICROVASC
60.56
1.00
15757
FREE SKIN FLAP, MICROVASC
60.97
1.00
15758
FREE FASCIAL FLAP, MICROVASC
4.00
1.00
15758
FREE FASCIAL FLAP, MICROVASC
60.35
1.00
15758
FREE FASCIAL FLAP, MICROVASC
60.62
1.00
15758
FREE FASCIAL FLAP, MICROVASC
61.02
1.00
15760
COMPOSITE SKIN GRAFT
4.00
1.00
15760
COMPOSITE SKIN GRAFT
16.08
1.00
15760
COMPOSITE SKIN GRAFT
16.62
1.00
15760
COMPOSITE SKIN GRAFT
17.77
1.00
15770
DERMA-FAT-FASCIA GRAFT
4.00
1.00
15770
DERMA-FAT-FASCIA GRAFT
14.38
1.00
15770
DERMA-FAT-FASCIA GRAFT
15.14
1.00
15770
DERMA-FAT-FASCIA GRAFT
16.55
1.00
15775
HAIR TRANSPLANT PUNCH GRAFTS
4.00
1.00
15775
HAIR TRANSPLANT PUNCH GRAFTS
5.74
1.00
15775
HAIR TRANSPLANT PUNCH GRAFTS
5.79
1.00
15775
HAIR TRANSPLANT PUNCH GRAFTS
6.06
1.00
15776
HAIR TRANSPLANT PUNCH GRAFTS
4.00
1.00
15776
HAIR TRANSPLANT PUNCH GRAFTS
8.65
1.00
15776
HAIR TRANSPLANT PUNCH GRAFTS
9.03
1.00
15776
HAIR TRANSPLANT PUNCH GRAFTS
9.06
1.00
15780
ABRASION TREATMENT OF SKIN
4.00
1.00
15780
ABRASION TREATMENT OF SKIN
14.28
1.00
15780
ABRASION TREATMENT OF SKIN
14.84
1.00
15780
ABRASION TREATMENT OF SKIN
16.22
1.00
15781
ABRASION TREATMENT OF SKIN
9.92
1.00
15781
ABRASION TREATMENT OF SKIN
10.52
1.00
15781
ABRASION TREATMENT OF SKIN
10.66
1.00
15782
ABRASION TREATMENT OF SKIN
8.68
1.00
15782
ABRASION TREATMENT OF SKIN
8.86
1.00
15782
ABRASION TREATMENT OF SKIN
10.25
1.00
15783
ABRASION TREATMENT OF SKIN
8.12
1.00
15783
ABRASION TREATMENT OF SKIN
8.76
1.00
15783
ABRASION TREATMENT OF SKIN
9.23
1.00
Procedure Code Description
RVU
RVU Coeff Value
15786
ABRASION, LESION, SINGLE
3.43
1.00
15786
ABRASION, LESION, SINGLE
3.46
1.00
15786
ABRASION, LESION, SINGLE
4.00
1.00
15787
ABRASION, LESIONS, ADD-ON
0.49
1.00
15787
ABRASION, LESIONS, ADD-ON
0.51
1.00
15810
SALABRASION
4.00
1.00
15810
SALABRASION
8.89
1.00
15810
SALABRASION
9.11
1.00
15810
SALABRASION
9.12
1.00
15811
SALABRASION
4.00
1.00
15811
SALABRASION
10.64
1.00
15811
SALABRASION
10.95
1.00
15811
SALABRASION
11.53
1.00
15819
PLASTIC SURGERY, NECK
16.82
1.00
15819
PLASTIC SURGERY, NECK
17.50
1.00
15819
PLASTIC SURGERY, NECK
18.53
1.00
15820
REVISION OF LOWER EYELID
4.00
1.00
15820
REVISION OF LOWER EYELID
10.70
1.00
15820
REVISION OF LOWER EYELID
10.84
1.00
15820
REVISION OF LOWER EYELID
11.92
1.00
15821
REVISION OF LOWER EYELID
4.00
1.00
15821
REVISION OF LOWER EYELID
11.44
1.00
15821
REVISION OF LOWER EYELID
11.60
1.00
15821
REVISION OF LOWER EYELID
12.64
1.00
15822
REVISION OF UPPER EYELID
4.00
1.00
15822
REVISION OF UPPER EYELID
8.90
1.00
15822
REVISION OF UPPER EYELID
9.07
1.00
15822
REVISION OF UPPER EYELID
9.15
1.00
15823
REVISION OF UPPER EYELID
4.00
1.00
15823
REVISION OF UPPER EYELID
13.50
1.00
15823
REVISION OF UPPER EYELID
13.67
1.00
15823
REVISION OF UPPER EYELID
14.99
1.00
15830
EXC SKIN ABD
29.96
1.00
15831
EXCISE EXCESSIVE SKIN TISSUE
4.00
1.00
15831
EXCISE EXCESSIVE SKIN TISSUE
21.39
1.00
Procedure Code Description
RVU
RVU Coeff Value
15831
EXCISE EXCESSIVE SKIN TISSUE
22.17
1.00
15831
EXCISE EXCESSIVE SKIN TISSUE
22.31
1.00
15832
EXCISE EXCESSIVE SKIN TISSUE
4.00
1.00
15832
EXCISE EXCESSIVE SKIN TISSUE
20.48
1.00
15832
EXCISE EXCESSIVE SKIN TISSUE
21.41
1.00
15832
EXCISE EXCESSIVE SKIN TISSUE
22.58
1.00
15833
EXCISE EXCESSIVE SKIN TISSUE
4.00
1.00
15833
EXCISE EXCESSIVE SKIN TISSUE
18.87
1.00
15833
EXCISE EXCESSIVE SKIN TISSUE
20.27
1.00
15833
EXCISE EXCESSIVE SKIN TISSUE
21.28
1.00
15834
EXCISE EXCESSIVE SKIN TISSUE
4.00
1.00
15834
EXCISE EXCESSIVE SKIN TISSUE
18.98
1.00
15834
EXCISE EXCESSIVE SKIN TISSUE
19.96
1.00
15834
EXCISE EXCESSIVE SKIN TISSUE
21.22
1.00
15835
EXCISE EXCESSIVE SKIN TISSUE
4.00
1.00
15835
EXCISE EXCESSIVE SKIN TISSUE
19.73
1.00
15835
EXCISE EXCESSIVE SKIN TISSUE
20.64
1.00
15835
EXCISE EXCESSIVE SKIN TISSUE
22.40
1.00
15836
EXCISE EXCESSIVE SKIN TISSUE
4.00
1.00
15836
EXCISE EXCESSIVE SKIN TISSUE
16.47
1.00
15836
EXCISE EXCESSIVE SKIN TISSUE
17.29
1.00
15836
EXCISE EXCESSIVE SKIN TISSUE
18.68
1.00
15837
EXCISE EXCESSIVE SKIN TISSUE
4.00
1.00
15837
EXCISE EXCESSIVE SKIN TISSUE
15.63
1.00
15837
EXCISE EXCESSIVE SKIN TISSUE
16.36
1.00
15837
EXCISE EXCESSIVE SKIN TISSUE
16.90
1.00
15838
EXCISE EXCESSIVE SKIN TISSUE
4.00
1.00
15838
EXCISE EXCESSIVE SKIN TISSUE
13.39
1.00
15838
EXCISE EXCESSIVE SKIN TISSUE
13.91
1.00
15838
EXCISE EXCESSIVE SKIN TISSUE
14.42
1.00
15839
EXCISE EXCESSIVE SKIN TISSUE
16.01
1.00
15839
EXCISE EXCESSIVE SKIN TISSUE
16.64
1.00
15839
EXCISE EXCESSIVE SKIN TISSUE
18.28
1.00
15840
GRAFT FOR FACE NERVE PALSY
4.00
1.00
15840
GRAFT FOR FACE NERVE PALSY
24.16
1.00
Procedure Code Description
RVU
RVU Coeff Value
15840
GRAFT FOR FACE NERVE PALSY
24.68
1.00
15840
GRAFT FOR FACE NERVE PALSY
25.51
1.00
15841
GRAFT FOR FACE NERVE PALSY
4.00
1.00
15841
GRAFT FOR FACE NERVE PALSY
40.42
1.00
15841
GRAFT FOR FACE NERVE PALSY
41.51
1.00
15841
GRAFT FOR FACE NERVE PALSY
42.77
1.00
15842
FLAP FOR FACE NERVE PALSY
4.00
1.00
15842
FLAP FOR FACE NERVE PALSY
64.73
1.00
15842
FLAP FOR FACE NERVE PALSY
65.72
1.00
15842
FLAP FOR FACE NERVE PALSY
67.85
1.00
15845
SKIN AND MUSCLE REPAIR, FACE
4.00
1.00
15845
SKIN AND MUSCLE REPAIR, FACE
21.84
1.00
15845
SKIN AND MUSCLE REPAIR, FACE
22.87
1.00
15845
SKIN AND MUSCLE REPAIR, FACE
23.78
1.00
15850
REMOVAL OF SUTURES
5.00
1.00
15851
REMOVAL OF SUTURES
1.18
1.00
15851
REMOVAL OF SUTURES
1.25
1.00
15851
REMOVAL OF SUTURES
1.26
1.00
15851
REMOVAL OF SUTURES
3.00
1.00
15852
DRESSING CHANGE NOT FOR BURN
1.24
1.00
15852
DRESSING CHANGE NOT FOR BURN
1.29
1.00
15852
DRESSING CHANGE NOT FOR BURN
1.30
1.00
15852
DRESSING CHANGE NOT FOR BURN
3.00
1.00
15860
TEST FOR BLOOD FLOW IN GRAFT
2.89
1.00
15860
TEST FOR BLOOD FLOW IN GRAFT
2.90
1.00
15860
TEST FOR BLOOD FLOW IN GRAFT
2.94
1.00
15920
REMOVAL OF TAIL BONE ULCER
4.00
1.00
15920
REMOVAL OF TAIL BONE ULCER
14.27
1.00
15920
REMOVAL OF TAIL BONE ULCER
14.55
1.00
15920
REMOVAL OF TAIL BONE ULCER
14.80
1.00
15922
REMOVAL OF TAIL BONE ULCER
4.00
1.00
15922
REMOVAL OF TAIL BONE ULCER
18.27
1.00
15922
REMOVAL OF TAIL BONE ULCER
18.48
1.00
15922
REMOVAL OF TAIL BONE ULCER
18.84
1.00
15931
REMOVE SACRUM PRESSURE SORE
4.00
1.00
Procedure Code Description
RVU
RVU Coeff Value
15931
REMOVE SACRUM PRESSURE SORE
15.75
1.00
15931
REMOVE SACRUM PRESSURE SORE
16.13
1.00
15931
REMOVE SACRUM PRESSURE SORE
16.86
1.00
15933
REMOVE SACRUM PRESSURE SORE
4.00
1.00
15933
REMOVE SACRUM PRESSURE SORE
19.97
1.00
15933
REMOVE SACRUM PRESSURE SORE
20.14
1.00
15933
REMOVE SACRUM PRESSURE SORE
20.77
1.00
15934
REMOVE SACRUM PRESSURE SORE
4.00
1.00
15934
REMOVE SACRUM PRESSURE SORE
22.33
1.00
15934
REMOVE SACRUM PRESSURE SORE
22.45
1.00
15934
REMOVE SACRUM PRESSURE SORE
23.17
1.00
15935
REMOVE SACRUM PRESSURE SORE
5.00
1.00
15935
REMOVE SACRUM PRESSURE SORE
26.09
1.00
15935
REMOVE SACRUM PRESSURE SORE
26.83
1.00
15935
REMOVE SACRUM PRESSURE SORE
27.58
1.00
15936
REMOVE SACRUM PRESSURE SORE
5.00
1.00
15936
REMOVE SACRUM PRESSURE SORE
22.31
1.00
15936
REMOVE SACRUM PRESSURE SORE
22.48
1.00
15936
REMOVE SACRUM PRESSURE SORE
22.49
1.00
15937
REMOVE SACRUM PRESSURE SORE
5.00
1.00
15937
REMOVE SACRUM PRESSURE SORE
25.97
1.00
15937
REMOVE SACRUM PRESSURE SORE
26.29
1.00
15940
REMOVE HIP PRESSURE SORE
4.00
1.00
15940
REMOVE HIP PRESSURE SORE
16.24
1.00
15940
REMOVE HIP PRESSURE SORE
16.74
1.00
15940
REMOVE HIP PRESSURE SORE
17.35
1.00
15941
REMOVE HIP PRESSURE SORE
6.00
1.00
15941
REMOVE HIP PRESSURE SORE
22.46
1.00
15941
REMOVE HIP PRESSURE SORE
22.47
1.00
15941
REMOVE HIP PRESSURE SORE
22.55
1.00
15944
REMOVE HIP PRESSURE SORE
4.00
1.00
15944
REMOVE HIP PRESSURE SORE
21.26
1.00
15944
REMOVE HIP PRESSURE SORE
21.60
1.00
15944
REMOVE HIP PRESSURE SORE
22.21
1.00
15945
REMOVE HIP PRESSURE SORE
4.00
1.00
Procedure Code Description
RVU
RVU Coeff Value
15945
REMOVE HIP PRESSURE SORE
23.58
1.00
15945
REMOVE HIP PRESSURE SORE
24.07
1.00
15945
REMOVE HIP PRESSURE SORE
24.68
1.00
15946
REMOVE HIP PRESSURE SORE
37.84
1.00
15946
REMOVE HIP PRESSURE SORE
38.75
1.00
15946
REMOVE HIP PRESSURE SORE
41.27
1.00
15946
REMOVE HIP PRESSURE SORE
999.99
1.00
15950
REMOVE THIGH PRESSURE SORE
4.00
1.00
15950
REMOVE THIGH PRESSURE SORE
13.49
1.00
15950
REMOVE THIGH PRESSURE SORE
13.96
1.00
15950
REMOVE THIGH PRESSURE SORE
14.37
1.00
15951
REMOVE THIGH PRESSURE SORE
6.00
1.00
15951
REMOVE THIGH PRESSURE SORE
19.85
1.00
15951
REMOVE THIGH PRESSURE SORE
20.02
1.00
15951
REMOVE THIGH PRESSURE SORE
20.49
1.00
15952
REMOVE THIGH PRESSURE SORE
3.00
1.00
15952
REMOVE THIGH PRESSURE SORE
19.97
1.00
15952
REMOVE THIGH PRESSURE SORE
20.64
1.00
15952
REMOVE THIGH PRESSURE SORE
21.55
1.00
15953
REMOVE THIGH PRESSURE SORE
6.00
1.00
15953
REMOVE THIGH PRESSURE SORE
22.80
1.00
15953
REMOVE THIGH PRESSURE SORE
23.34
1.00
15953
REMOVE THIGH PRESSURE SORE
24.01
1.00
15956
REMOVE THIGH PRESSURE SORE
4.00
1.00
15956
REMOVE THIGH PRESSURE SORE
27.56
1.00
15956
REMOVE THIGH PRESSURE SORE
28.33
1.00
15956
REMOVE THIGH PRESSURE SORE
28.91
1.00
15958
REMOVE THIGH PRESSURE SORE
4.00
1.00
15958
REMOVE THIGH PRESSURE SORE
27.86
1.00
15958
REMOVE THIGH PRESSURE SORE
28.59
1.00
15958
REMOVE THIGH PRESSURE SORE
29.51
1.00
16000
INITIAL TREATMENT OF BURN(S)
1.21
1.00
16000
INITIAL TREATMENT OF BURN(S)
1.22
1.00
16000
INITIAL TREATMENT OF BURN(S)
1.23
1.00
16000
INITIAL TREATMENT OF BURN(S)
3.00
1.00
Procedure Code Description
RVU
RVU Coeff Value
16010
TREATMENT OF BURN(S)
1.30
1.00
16010
TREATMENT OF BURN(S)
1.58
1.00
16010
TREATMENT OF BURN(S)
1.59
1.00
16010
TREATMENT OF BURN(S)
3.00
1.00
16015
TREATMENT OF BURN(S)
3.00
1.00
16015
TREATMENT OF BURN(S)
3.51
1.00
16015
TREATMENT OF BURN(S)
3.77
1.00
16015
TREATMENT OF BURN(S)
3.81
1.00
16020
DRESS/DEBRID P-THICK BURN, S
1.12
1.00
16020
DRESS/DEBRID P-THICK BURN, S
1.44
1.00
16020
DRESS/DEBRID P-THICK BURN, S
1.48
1.00
16025
DRESS/DEBRID P-THICK BURN, M
2.68
1.00
16025
DRESS/DEBRID P-THICK BURN, M
2.95
1.00
16025
DRESS/DEBRID P-THICK BURN, M
3.01
1.00
16030
DRESS/DEBRID P-THICK BURN, L
3.17
1.00
16030
DRESS/DEBRID P-THICK BURN, L
3.36
1.00
16030
DRESS/DEBRID P-THICK BURN, L
3.42
1.00
16035
INCISION OF BURN SCAB, INITI
5.00
1.00
16035
INCISION OF BURN SCAB, INITI
5.56
1.00
16035
INCISION OF BURN SCAB, INITI
5.61
1.00
16035
INCISION OF BURN SCAB, INITI
5.64
1.00
16036
ESCHAROTOMY; ADDÏL INCISION
2.22
1.00
16036
ESCHAROTOMY; ADDÏL INCISION
2.23
1.00
17000
DESTRUCT PREMALG LESION
0.90
1.00
17000
DESTRUCT PREMALG LESION
0.96
1.00
17000
DESTRUCT PREMALG LESION
1.35
1.00
17000
DESTRUCT PREMALG LESION
3.00
1.00
17003
DESTRUCT PREMALG LES, 2-14
0.12
1.00
17003
DESTRUCT PREMALG LES, 2-14
0.23
1.00
17004
DESTROY PREMLG LESIONS 15+
3.40
1.00
17004
DESTROY PREMLG LESIONS 15+
4.18
1.00
17004
DESTROY PREMLG LESIONS 15+
4.22
1.00
17106
DESTRUCTION OF SKIN LESIONS
7.07
1.00
17106
DESTRUCTION OF SKIN LESIONS
8.08
1.00
17106
DESTRUCTION OF SKIN LESIONS
8.26
1.00
Procedure Code Description
RVU
RVU Coeff Value
17107
DESTRUCTION OF SKIN LESIONS
9.41
1.00
17107
DESTRUCTION OF SKIN LESIONS
15.06
1.00
17107
DESTRUCTION OF SKIN LESIONS
15.24
1.00
17108
DESTRUCTION OF SKIN LESIONS
12.17
1.00
17108
DESTRUCTION OF SKIN LESIONS
21.75
1.00
17108
DESTRUCTION OF SKIN LESIONS
21.93
1.00
17110
DESTRUCT B9 LESION, 1-14
1.14
1.00
17110
DESTRUCT B9 LESION, 1-14
1.19
1.00
17110
DESTRUCT B9 LESION, 1-14
1.69
1.00
17110
DESTRUCT B9 LESION, 1-14
3.00
1.00
17111
DESTRUCT LESION, 15 OR MORE
1.52
1.00
17111
DESTRUCT LESION, 15 OR MORE
1.56
1.00
17111
DESTRUCT LESION, 15 OR MORE
2.10
1.00
17111
DESTRUCT LESION, 15 OR MORE
3.00
1.00
17250
CHEMICAL CAUTERY, TISSUE
0.88
1.00
17250
CHEMICAL CAUTERY, TISSUE
0.90
1.00
17250
CHEMICAL CAUTERY, TISSUE
0.93
1.00
17260
DESTRUCTION OF SKIN LESIONS
1.36
1.00
17260
DESTRUCTION OF SKIN LESIONS
1.40
1.00
17260
DESTRUCTION OF SKIN LESIONS
1.68
1.00
17260
DESTRUCTION OF SKIN LESIONS
3.00
1.00
17261
DESTRUCTION OF SKIN LESIONS
1.77
1.00
17261
DESTRUCTION OF SKIN LESIONS
1.82
1.00
17261
DESTRUCTION OF SKIN LESIONS
2.27
1.00
17261
DESTRUCTION OF SKIN LESIONS
3.00
1.00
17262
DESTRUCTION OF SKIN LESIONS
2.40
1.00
17262
DESTRUCTION OF SKIN LESIONS
2.44
1.00
17262
DESTRUCTION OF SKIN LESIONS
2.90
1.00
17262
DESTRUCTION OF SKIN LESIONS
3.00
1.00
17263
DESTRUCTION OF SKIN LESIONS
2.69
1.00
17263
DESTRUCTION OF SKIN LESIONS
2.75
1.00
17263
DESTRUCTION OF SKIN LESIONS
3.00
1.00
17263
DESTRUCTION OF SKIN LESIONS
3.21
1.00
17264
DESTRUCTION OF SKIN LESIONS
2.88
1.00
17264
DESTRUCTION OF SKIN LESIONS
2.93
1.00
Procedure Code Description
RVU
RVU Coeff Value
17264
DESTRUCTION OF SKIN LESIONS
3.00
1.00
17264
DESTRUCTION OF SKIN LESIONS
3.43
1.00
17266
DESTRUCTION OF SKIN LESIONS
3.00
1.00
17266
DESTRUCTION OF SKIN LESIONS
3.41
1.00
17266
DESTRUCTION OF SKIN LESIONS
3.46
1.00
17266
DESTRUCTION OF SKIN LESIONS
3.99
1.00
17270
DESTRUCTION OF SKIN LESIONS
1.98
1.00
17270
DESTRUCTION OF SKIN LESIONS
2.03
1.00
17270
DESTRUCTION OF SKIN LESIONS
2.45
1.00
17270
DESTRUCTION OF SKIN LESIONS
3.00
1.00
17271
DESTRUCTION OF SKIN LESIONS
2.26
1.00
17271
DESTRUCTION OF SKIN LESIONS
2.30
1.00
17271
DESTRUCTION OF SKIN LESIONS
2.76
1.00
17271
DESTRUCTION OF SKIN LESIONS
3.00
1.00
17272
DESTRUCTION OF SKIN LESIONS
2.69
1.00
17272
DESTRUCTION OF SKIN LESIONS
2.73
1.00
17272
DESTRUCTION OF SKIN LESIONS
3.00
1.00
17272
DESTRUCTION OF SKIN LESIONS
3.20
1.00
17273
DESTRUCTION OF SKIN LESIONS
3.00
1.00
17273
DESTRUCTION OF SKIN LESIONS
3.10
1.00
17273
DESTRUCTION OF SKIN LESIONS
3.15
1.00
17273
DESTRUCTION OF SKIN LESIONS
3.61
1.00
17274
DESTRUCTION OF SKIN LESIONS
3.00
1.00
17274
DESTRUCTION OF SKIN LESIONS
3.88
1.00
17274
DESTRUCTION OF SKIN LESIONS
3.92
1.00
17274
DESTRUCTION OF SKIN LESIONS
4.43
1.00
17276
DESTRUCTION OF SKIN LESIONS
3.00
1.00
17276
DESTRUCTION OF SKIN LESIONS
4.77
1.00
17276
DESTRUCTION OF SKIN LESIONS
4.82
1.00
17276
DESTRUCTION OF SKIN LESIONS
5.34
1.00
17280
DESTRUCTION OF SKIN LESIONS
1.75
1.00
17280
DESTRUCTION OF SKIN LESIONS
1.80
1.00
17280
DESTRUCTION OF SKIN LESIONS
2.23
1.00
17280
DESTRUCTION OF SKIN LESIONS
3.00
1.00
17281
DESTRUCTION OF SKIN LESIONS
2.61
1.00
Procedure Code Description
RVU
RVU Coeff Value
17281
DESTRUCTION OF SKIN LESIONS
2.66
1.00
17281
DESTRUCTION OF SKIN LESIONS
3.11
1.00
17282
DESTRUCTION OF SKIN LESIONS
3.11
1.00
17282
DESTRUCTION OF SKIN LESIONS
3.16
1.00
17282
DESTRUCTION OF SKIN LESIONS
3.61
1.00
17283
DESTRUCTION OF SKIN LESIONS
3.98
1.00
17283
DESTRUCTION OF SKIN LESIONS
4.02
1.00
17283
DESTRUCTION OF SKIN LESIONS
4.52
1.00
17284
DESTRUCTION OF SKIN LESIONS
4.84
1.00
17284
DESTRUCTION OF SKIN LESIONS
4.90
1.00
17284
DESTRUCTION OF SKIN LESIONS
5.39
1.00
17286
DESTRUCTION OF SKIN LESIONS
6.84
1.00
17286
DESTRUCTION OF SKIN LESIONS
6.89
1.00
17286
DESTRUCTION OF SKIN LESIONS
7.26
1.00
17304
1 STAGE MOHS, UP TO 5 SPEC
3.00
1.00
17304
1 STAGE MOHS, UP TO 5 SPEC
11.46
1.00
17304
1 STAGE MOHS, UP TO 5 SPEC
11.53
1.00
17304
1 STAGE MOHS, UP TO 5 SPEC
11.57
1.00
17305
2 STAGE MOHS, UP TO 5 SPEC
4.30
1.00
17305
2 STAGE MOHS, UP TO 5 SPEC
4.33
1.00
17305
2 STAGE MOHS, UP TO 5 SPEC
4.34
1.00
17306
3 STAGE MOHS, UP TO 5 SPEC
4.31
1.00
17306
3 STAGE MOHS, UP TO 5 SPEC
4.34
1.00
17306
3 STAGE MOHS, UP TO 5 SPEC
4.35
1.00
17307
MOHS ADDL STAGE UP TO 5 SPEC
3.00
1.00
17307
MOHS ADDL STAGE UP TO 5 SPEC
4.32
1.00
17307
MOHS ADDL STAGE UP TO 5 SPEC
4.36
1.00
17307
MOHS ADDL STAGE UP TO 5 SPEC
4.37
1.00
17310
MOHS ANY STAGE > 5 SPEC EACH
0.98
1.00
17310
MOHS ANY STAGE > 5 SPEC EACH
1.44
1.00
17310
MOHS ANY STAGE > 5 SPEC EACH
1.47
1.00
17310
MOHS ANY STAGE > 5 SPEC EACH
3.00
1.00
17311
MOHS, 1 STAGE, H/N/HF/G
9.70
1.00
17312
MOHS ADDL STAGE
5.16
1.00
17313
MOHS, 1 STAGE, T/A/L
8.71
1.00
Procedure Code Description
RVU
RVU Coeff Value
17314
MOHS, ADDL STAGE, T/A/L
4.79
1.00
17315
MOHS SURG, ADDL BLOCK
1.36
1.00
17340
CRYOTHERAPY OF SKIN
1.06
1.00
17340
CRYOTHERAPY OF SKIN
1.12
1.00
17340
CRYOTHERAPY OF SKIN
1.18
1.00
17340
CRYOTHERAPY OF SKIN
3.00
1.00
17360
SKIN PEEL THERAPY
2.21
1.00
17360
SKIN PEEL THERAPY
2.25
1.00
17360
SKIN PEEL THERAPY
2.51
1.00
17360
SKIN PEEL THERAPY
3.00
1.00
19000
DRAINAGE OF BREAST LESION
1.20
1.00
19000
DRAINAGE OF BREAST LESION
1.22
1.00
19000
DRAINAGE OF BREAST LESION
1.28
1.00
19000
DRAINAGE OF BREAST LESION
3.00
1.00
19001
DRAIN BREAST LESION ADD-ON
0.59
1.00
19001
DRAIN BREAST LESION ADD-ON
0.60
1.00
19001
DRAIN BREAST LESION ADD-ON
0.61
1.00
19020
INCISION OF BREAST LESION
3.00
1.00
19020
INCISION OF BREAST LESION
6.75
1.00
19020
INCISION OF BREAST LESION
7.15
1.00
19020
INCISION OF BREAST LESION
7.31
1.00
19030
INJECTION FOR BREAST X-RAY
2.11
1.00
19030
INJECTION FOR BREAST X-RAY
2.12
1.00
19030
INJECTION FOR BREAST X-RAY
2.19
1.00
19030
INJECTION FOR BREAST X-RAY
3.00
1.00
19100
BX BREAST PERCUT W/O IMAGE
1.80
1.00
19100
BX BREAST PERCUT W/O IMAGE
1.81
1.00
19100
BX BREAST PERCUT W/O IMAGE
3.00
1.00
19101
BIOPSY OF BREAST, OPEN
3.00
1.00
19101
BIOPSY OF BREAST, OPEN
5.10
1.00
19101
BIOPSY OF BREAST, OPEN
5.27
1.00
19101
BIOPSY OF BREAST, OPEN
5.43
1.00
19102
BX BREAST PERCUT W/IMAGE
2.81
1.00
19102
BX BREAST PERCUT W/IMAGE
2.82
1.00
19102
BX BREAST PERCUT W/IMAGE
2.87
1.00
Procedure Code Description
RVU
RVU Coeff Value
19102
BX BREAST PERCUT W/IMAGE
3.00
1.00
19103
BX BREAST PERCUT W/DEVICE
3.00
1.00
19103
BX BREAST PERCUT W/DEVICE
5.11
1.00
19103
BX BREAST PERCUT W/DEVICE
5.13
1.00
19103
BX BREAST PERCUT W/DEVICE
5.17
1.00
19103
BX BREAST PERCUT W/DEVICE
5.20
1.00
19103
BX BREAST PERCUT W/DEVICE
5.22
1.00
19103
BX BREAST PERCUT W/DEVICE
5.28
1.00
19105
CRYOSURG ABLATE FA, EACH
5.29
1.00
19110
NIPPLE EXPLORATION
3.00
1.00
19110
NIPPLE EXPLORATION
7.88
1.00
19110
NIPPLE EXPLORATION
8.09
1.00
19110
NIPPLE EXPLORATION
9.17
1.00
19112
EXCISE BREAST DUCT FISTULA
3.00
1.00
19112
EXCISE BREAST DUCT FISTULA
6.80
1.00
19112
EXCISE BREAST DUCT FISTULA
7.13
1.00
19112
EXCISE BREAST DUCT FISTULA
7.26
1.00
19120
REMOVAL OF BREAST LESION
3.00
1.00
19120
REMOVAL OF BREAST LESION
9.21
1.00
19120
REMOVAL OF BREAST LESION
9.31
1.00
19120
REMOVAL OF BREAST LESION
9.92
1.00
19125
EXCISION, BREAST LESION
3.00
1.00
19125
EXCISION, BREAST LESION
9.93
1.00
19125
EXCISION, BREAST LESION
10.09
1.00
19125
EXCISION, BREAST LESION
10.14
1.00
19125
EXCISION, BREAST LESION
10.76
1.00
19125
EXCISION, BREAST LESION
10.86
1.00
19125
EXCISION, BREAST LESION
11.00
1.00
19126
EXCISION, ADDL BREAST LESION
4.16
1.00
19126
EXCISION, ADDL BREAST LESION
4.25
1.00
19126
EXCISION, ADDL BREAST LESION
4.30
1.00
19140
REMOVAL OF BREAST TISSUE
3.00
1.00
19140
REMOVAL OF BREAST TISSUE
9.18
1.00
19140
REMOVAL OF BREAST TISSUE
9.22
1.00
19140
REMOVAL OF BREAST TISSUE
9.31
1.00
Procedure Code Description
RVU
RVU Coeff Value
19160
PARTIAL MASTECTOMY
3.00
1.00
19160
PARTIAL MASTECTOMY
10.17
1.00
19160
PARTIAL MASTECTOMY
10.20
1.00
19160
PARTIAL MASTECTOMY
11.12
1.00
19162
P-MASTECTOMY W/LN REMOVAL
3.00
1.00
19162
P-MASTECTOMY W/LN REMOVAL
21.55
1.00
19162
P-MASTECTOMY W/LN REMOVAL
21.65
1.00
19162
P-MASTECTOMY W/LN REMOVAL
22.79
1.00
19180
REMOVAL OF BREAST
3.00
1.00
19180
REMOVAL OF BREAST
14.91
1.00
19180
REMOVAL OF BREAST
15.00
1.00
19180
REMOVAL OF BREAST
15.61
1.00
19182
REMOVAL OF BREAST
3.00
1.00
19182
REMOVAL OF BREAST
13.48
1.00
19182
REMOVAL OF BREAST
13.50
1.00
19182
REMOVAL OF BREAST
13.52
1.00
19200
REMOVAL OF BREAST
5.00
1.00
19200
REMOVAL OF BREAST
25.33
1.00
19200
REMOVAL OF BREAST
25.37
1.00
19200
REMOVAL OF BREAST
26.07
1.00
19220
REMOVAL OF BREAST
5.00
1.00
19220
REMOVAL OF BREAST
25.88
1.00
19220
REMOVAL OF BREAST
26.02
1.00
19220
REMOVAL OF BREAST
26.40
1.00
19240
REMOVAL OF BREAST
5.00
1.00
19240
REMOVAL OF BREAST
26.21
1.00
19240
REMOVAL OF BREAST
26.32
1.00
19240
REMOVAL OF BREAST
26.36
1.00
19260
REMOVAL OF CHEST WALL LESION
13.00
1.00
19260
REMOVAL OF CHEST WALL LESION
26.21
1.00
19260
REMOVAL OF CHEST WALL LESION
28.70
1.00
19260
REMOVAL OF CHEST WALL LESION
30.32
1.00
19271
REVISION OF CHEST WALL
13.00
1.00
19271
REVISION OF CHEST WALL
32.48
1.00
19271
REVISION OF CHEST WALL
39.84
1.00
Procedure Code Description
RVU
RVU Coeff Value
19271
REVISION OF CHEST WALL
41.13
1.00
19272
EXTENSIVE CHEST WALL SURGERY
13.00
1.00
19272
EXTENSIVE CHEST WALL SURGERY
36.33
1.00
19272
EXTENSIVE CHEST WALL SURGERY
43.76
1.00
19272
EXTENSIVE CHEST WALL SURGERY
45.59
1.00
19290
PLACE NEEDLE WIRE, BREAST
1.75
1.00
19290
PLACE NEEDLE WIRE, BREAST
1.76
1.00
19290
PLACE NEEDLE WIRE, BREAST
1.77
1.00
19290
PLACE NEEDLE WIRE, BREAST
1.81
1.00
19291
PLACE NEEDLE WIRE, BREAST
0.87
1.00
19291
PLACE NEEDLE WIRE, BREAST
0.88
1.00
19291
PLACE NEEDLE WIRE, BREAST
0.90
1.00
19295
PLACE BREAST CLIP, PERCUT
2.36
1.00
19295
PLACE BREAST CLIP, PERCUT
2.66
1.00
19295
PLACE BREAST CLIP, PERCUT
2.78
1.00
19296
PLACE PO BREAST CATH FOR RAD
5.31
1.00
19297
PLACE BREAST CATH FOR RAD
2.40
1.00
19298
PLACE BREAST RAD TUBE/CATHS
8.70
1.00
19301
PARTICAL MASTECTOMY
15.22
1.00
19302
P-MASTECTOMY W/LN REMOVAL
22.03
1.00
19303
MAST, SIMPLE, COMPLETE
23.52
1.00
19304
MAST, SUBQ
13.78
1.00
19305
MAST, RADICAL
27.37
1.00
19306
MAST, RAD, URBAN TYPE
28.71
1.00
19307
MAST, MOD RAD
28.89
1.00
19316
SUSPENSION OF BREAST
5.00
1.00
19316
SUSPENSION OF BREAST
19.41
1.00
19316
SUSPENSION OF BREAST
19.65
1.00
19316
SUSPENSION OF BREAST
19.75
1.00
19318
REDUCTION OF LARGE BREAST
6.00
1.00
19318
REDUCTION OF LARGE BREAST
28.84
1.00
19318
REDUCTION OF LARGE BREAST
29.03
1.00
19318
REDUCTION OF LARGE BREAST
29.26
1.00
19328
REMOVAL OF BREAST IMPLANT
6.00
1.00
19328
REMOVAL OF BREAST IMPLANT
10.83
1.00
Procedure Code Description
RVU
RVU Coeff Value
19328
REMOVAL OF BREAST IMPLANT
11.48
1.00
19328
REMOVAL OF BREAST IMPLANT
12.32
1.00
19330
REMOVAL OF IMPLANT MATERIAL
6.00
1.00
19330
REMOVAL OF IMPLANT MATERIAL
13.60
1.00
19330
REMOVAL OF IMPLANT MATERIAL
14.63
1.00
19330
REMOVAL OF IMPLANT MATERIAL
15.87
1.00
19340
IMMEDIATE BREAST PROSTHESIS
10.20
1.00
19340
IMMEDIATE BREAST PROSTHESIS
10.26
1.00
19340
IMMEDIATE BREAST PROSTHESIS
10.37
1.00
19340
IMMEDIATE BREAST PROSTHESIS
999.99
1.00
19342
DELAYED BREAST PROSTHESIS
5.00
1.00
19342
DELAYED BREAST PROSTHESIS
20.24
1.00
19342
DELAYED BREAST PROSTHESIS
21.61
1.00
19342
DELAYED BREAST PROSTHESIS
23.33
1.00
19350
BREAST RECONSTRUCTION
6.00
1.00
19350
BREAST RECONSTRUCTION
16.67
1.00
19350
BREAST RECONSTRUCTION
17.17
1.00
19350
BREAST RECONSTRUCTION
17.21
1.00
19357
BREAST RECONSTRUCTION
6.00
1.00
19357
BREAST RECONSTRUCTION
29.94
1.00
19357
BREAST RECONSTRUCTION
34.34
1.00
19357
BREAST RECONSTRUCTION
39.15
1.00
19361
BREAST RECONSTR W/LAT FLAP
6.00
1.00
19361
BREAST RECONSTR W/LAT FLAP
31.61
1.00
19361
BREAST RECONSTR W/LAT FLAP
33.52
1.00
19361
BREAST RECONSTR W/LAT FLAP
41.96
1.00
19364
BREAST RECONSTRUCTION
5.00
1.00
19364
BREAST RECONSTRUCTION
69.30
1.00
19364
BREAST RECONSTRUCTION
70.13
1.00
19364
BREAST RECONSTRUCTION
72.00
1.00
19366
BREAST RECONSTRUCTION
5.00
1.00
19366
BREAST RECONSTRUCTION
33.82
1.00
19366
BREAST RECONSTRUCTION
35.22
1.00
19366
BREAST RECONSTRUCTION
35.57
1.00
19367
BREAST RECONSTRUCTION
5.00
1.00
Procedure Code Description
RVU
RVU Coeff Value
19367
BREAST RECONSTRUCTION
45.61
1.00
19367
BREAST RECONSTRUCTION
45.98
1.00
19367
BREAST RECONSTRUCTION
46.59
1.00
19368
BREAST RECONSTRUCTION
5.00
1.00
19368
BREAST RECONSTRUCTION
56.86
1.00
19368
BREAST RECONSTRUCTION
57.01
1.00
19368
BREAST RECONSTRUCTION
57.91
1.00
19369
BREAST RECONSTRUCTION
5.00
1.00
19369
BREAST RECONSTRUCTION
52.60
1.00
19369
BREAST RECONSTRUCTION
53.48
1.00
19369
BREAST RECONSTRUCTION
53.71
1.00
19370
SURGERY OF BREAST CAPSULE
6.00
1.00
19370
SURGERY OF BREAST CAPSULE
14.99
1.00
19370
SURGERY OF BREAST CAPSULE
16.03
1.00
19370
SURGERY OF BREAST CAPSULE
17.18
1.00
19371
REMOVAL OF BREAST CAPSULE
5.00
1.00
19371
REMOVAL OF BREAST CAPSULE
17.51
1.00
19371
REMOVAL OF BREAST CAPSULE
18.43
1.00
19371
REMOVAL OF BREAST CAPSULE
19.86
1.00
19380
REVISE BREAST RECONSTRUCTION
5.00
1.00
19380
REVISE BREAST RECONSTRUCTION
17.17
1.00
19380
REVISE BREAST RECONSTRUCTION
18.07
1.00
19380
REVISE BREAST RECONSTRUCTION
19.38
1.00
19396
DESIGN CUSTOM BREAST IMPLANT
3.42
1.00
19396
DESIGN CUSTOM BREAST IMPLANT
3.44
1.00
19396
DESIGN CUSTOM BREAST IMPLANT
3.45
1.00
22900
REMOVE ABDOMINAL WALL LESION
6.00
1.00
22900
REMOVE ABDOMINAL WALL LESION
9.77
1.00
22900
REMOVE ABDOMINAL WALL LESION
10.42
1.00
22900
REMOVE ABDOMINAL WALL LESION
10.67
1.00
23000
REMOVAL OF CALCIUM DEPOSITS
4.00
1.00
23000
REMOVAL OF CALCIUM DEPOSITS
9.07
1.00
23000
REMOVAL OF CALCIUM DEPOSITS
9.11
1.00
23000
REMOVAL OF CALCIUM DEPOSITS
12.24
1.00
23020
RELEASE SHOULDER JOINT
5.00
1.00
Procedure Code Description
RVU
RVU Coeff Value
23020
RELEASE SHOULDER JOINT
17.68
1.00
23020
RELEASE SHOULDER JOINT
17.98
1.00
23020
RELEASE SHOULDER JOINT
21.11
1.00
23030
DRAIN SHOULDER LESION
5.00
1.00
23030
DRAIN SHOULDER LESION
6.57
1.00
23030
DRAIN SHOULDER LESION
6.86
1.00
23030
DRAIN SHOULDER LESION
8.39
1.00
23031
DRAIN SHOULDER BURSA
3.00
1.00
23031
DRAIN SHOULDER BURSA
5.44
1.00
23031
DRAIN SHOULDER BURSA
5.83
1.00
23031
DRAIN SHOULDER BURSA
7.41
1.00
23035
DRAIN SHOULDER BONE LESION
5.00
1.00
23035
DRAIN SHOULDER BONE LESION
17.52
1.00
23035
DRAIN SHOULDER BONE LESION
18.55
1.00
23035
DRAIN SHOULDER BONE LESION
25.61
1.00
23040
EXPLORATORY SHOULDER SURGERY
5.00
1.00
23040
EXPLORATORY SHOULDER SURGERY
18.41
1.00
23040
EXPLORATORY SHOULDER SURGERY
18.58
1.00
23040
EXPLORATORY SHOULDER SURGERY
22.63
1.00
23044
EXPLORATORY SHOULDER SURGERY
5.00
1.00
23044
EXPLORATORY SHOULDER SURGERY
14.59
1.00
23044
EXPLORATORY SHOULDER SURGERY
14.78
1.00
23044
EXPLORATORY SHOULDER SURGERY
19.10
1.00
23065
BIOPSY SHOULDER TISSUES
3.00
1.00
23065
BIOPSY SHOULDER TISSUES
3.74
1.00
23065
BIOPSY SHOULDER TISSUES
3.98
1.00
23065
BIOPSY SHOULDER TISSUES
4.20
1.00
23066
BIOPSY SHOULDER TISSUES
5.00
1.00
23066
BIOPSY SHOULDER TISSUES
8.57
1.00
23066
BIOPSY SHOULDER TISSUES
8.82
1.00
23066
BIOPSY SHOULDER TISSUES
11.15
1.00
23075
REMOVAL OF SHOULDER LESION
3.00
1.00
23075
REMOVAL OF SHOULDER LESION
4.51
1.00
23075
REMOVAL OF SHOULDER LESION
5.85
1.00
23076
REMOVAL OF SHOULDER LESION
5.00
1.00
Procedure Code Description
RVU
RVU Coeff Value
23076
REMOVAL OF SHOULDER LESION
14.33
1.00
23076
REMOVAL OF SHOULDER LESION
14.45
1.00
23076
REMOVAL OF SHOULDER LESION
16.92
1.00
23077
REMOVE TUMOR OF SHOULDER
3.00
1.00
23077
REMOVE TUMOR OF SHOULDER
29.01
1.00
23077
REMOVE TUMOR OF SHOULDER
30.39
1.00
23077
REMOVE TUMOR OF SHOULDER
32.16
1.00
23100
BIOPSY OF SHOULDER JOINT
5.00
1.00
23100
BIOPSY OF SHOULDER JOINT
12.41
1.00
23100
BIOPSY OF SHOULDER JOINT
12.69
1.00
23100
BIOPSY OF SHOULDER JOINT
15.97
1.00
23101
SHOULDER JOINT SURGERY
4.00
1.00
23101
SHOULDER JOINT SURGERY
11.41
1.00
23101
SHOULDER JOINT SURGERY
11.89
1.00
23101
SHOULDER JOINT SURGERY
15.49
1.00
23105
REMOVE SHOULDER JOINT LINING
5.00
1.00
23105
REMOVE SHOULDER JOINT LINING
16.28
1.00
23105
REMOVE SHOULDER JOINT LINING
16.75
1.00
23105
REMOVE SHOULDER JOINT LINING
19.91
1.00
23106
INCISION OF COLLARBONE JOINT
4.00
1.00
23106
INCISION OF COLLARBONE JOINT
12.10
1.00
23106
INCISION OF COLLARBONE JOINT
12.71
1.00
23106
INCISION OF COLLARBONE JOINT
16.03
1.00
23107
EXPLORE TREAT SHOULDER JOINT
5.00
1.00
23107
EXPLORE TREAT SHOULDER JOINT
16.92
1.00
23107
EXPLORE TREAT SHOULDER JOINT
17.44
1.00
23107
EXPLORE TREAT SHOULDER JOINT
20.55
1.00
23120
PARTIAL REMOVAL, COLLAR BONE
5.00
1.00
23120
PARTIAL REMOVAL, COLLAR BONE
14.62
1.00
23120
PARTIAL REMOVAL, COLLAR BONE
14.77
1.00
23120
PARTIAL REMOVAL, COLLAR BONE
18.07
1.00
23125
REMOVAL OF COLLAR BONE
5.00
1.00
23125
REMOVAL OF COLLAR BONE
18.01
1.00
23125
REMOVAL OF COLLAR BONE
18.54
1.00
23125
REMOVAL OF COLLAR BONE
21.74
1.00
Procedure Code Description
RVU
RVU Coeff Value
23130
REMOVE SHOULDER BONE, PART
5.00
1.00
23130
REMOVE SHOULDER BONE, PART
15.38
1.00
23130
REMOVE SHOULDER BONE, PART
15.92
1.00
23130
REMOVE SHOULDER BONE, PART
18.81
1.00
23140
REMOVAL OF BONE LESION
4.00
1.00
23140
REMOVAL OF BONE LESION
13.08
1.00
23140
REMOVAL OF BONE LESION
13.28
1.00
23140
REMOVAL OF BONE LESION
16.35
1.00
23145
REMOVAL OF BONE LESION
5.00
1.00
23145
REMOVAL OF BONE LESION
17.65
1.00
23145
REMOVAL OF BONE LESION
18.16
1.00
23145
REMOVAL OF BONE LESION
22.38
1.00
23146
REMOVAL OF BONE LESION
4.00
1.00
23146
REMOVAL OF BONE LESION
15.35
1.00
23146
REMOVAL OF BONE LESION
16.29
1.00
23146
REMOVAL OF BONE LESION
20.31
1.00
23150
REMOVAL OF HUMERUS LESION
4.00
1.00
23150
REMOVAL OF HUMERUS LESION
16.67
1.00
23150
REMOVAL OF HUMERUS LESION
16.81
1.00
23150
REMOVAL OF HUMERUS LESION
19.99
1.00
23155
REMOVAL OF HUMERUS LESION
4.00
1.00
23155
REMOVAL OF HUMERUS LESION
20.24
1.00
23155
REMOVAL OF HUMERUS LESION
20.27
1.00
23155
REMOVAL OF HUMERUS LESION
24.17
1.00
23156
REMOVAL OF HUMERUS LESION
4.00
1.00
23156
REMOVAL OF HUMERUS LESION
17.21
1.00
23156
REMOVAL OF HUMERUS LESION
17.47
1.00
23156
REMOVAL OF HUMERUS LESION
20.60
1.00
23170
REMOVE COLLAR BONE LESION
5.00
1.00
23170
REMOVE COLLAR BONE LESION
13.50
1.00
23170
REMOVE COLLAR BONE LESION
14.22
1.00
23170
REMOVE COLLAR BONE LESION
18.87
1.00
23172
REMOVE SHOULDER BLADE LESION
5.00
1.00
23172
REMOVE SHOULDER BLADE LESION
13.80
1.00
23172
REMOVE SHOULDER BLADE LESION
14.45
1.00
Procedure Code Description 23172
REMOVE SHOULDER BLADE LESION
23174
RVU
RVU Coeff Value
18.55
1.00
REMOVE HUMERUS LESION
5.00
1.00
23174
REMOVE HUMERUS LESION
19.24
1.00
23174
REMOVE HUMERUS LESION
19.44
1.00
23174
REMOVE HUMERUS LESION
23.00
1.00
23180
REMOVE COLLAR BONE LESION
5.00
1.00
23180
REMOVE COLLAR BONE LESION
17.50
1.00
23180
REMOVE COLLAR BONE LESION
19.15
1.00
23180
REMOVE COLLAR BONE LESION
26.53
1.00
23182
REMOVE SHOULDER BLADE LESION
4.00
1.00
23182
REMOVE SHOULDER BLADE LESION
16.87
1.00
23182
REMOVE SHOULDER BLADE LESION
18.33
1.00
23182
REMOVE SHOULDER BLADE LESION
26.13
1.00
23184
REMOVE HUMERUS LESION
4.00
1.00
23184
REMOVE HUMERUS LESION
19.07
1.00
23184
REMOVE HUMERUS LESION
20.41
1.00
23184
REMOVE HUMERUS LESION
27.70
1.00
23190
PARTIAL REMOVAL OF SCAPULA
5.00
1.00
23190
PARTIAL REMOVAL OF SCAPULA
14.18
1.00
23190
PARTIAL REMOVAL OF SCAPULA
14.63
1.00
23190
PARTIAL REMOVAL OF SCAPULA
16.93
1.00
23195
REMOVAL OF HEAD OF HUMERUS
4.00
1.00
23195
REMOVAL OF HEAD OF HUMERUS
19.22
1.00
23195
REMOVAL OF HEAD OF HUMERUS
19.28
1.00
23195
REMOVAL OF HEAD OF HUMERUS
22.30
1.00
23200
REMOVAL OF COLLAR BONE
6.00
1.00
23200
REMOVAL OF COLLAR BONE
22.72
1.00
23200
REMOVAL OF COLLAR BONE
22.82
1.00
23200
REMOVAL OF COLLAR BONE
28.08
1.00
23210
REMOVAL OF SHOULDER BLADE
6.00
1.00
23210
REMOVAL OF SHOULDER BLADE
23.71
1.00
23210
REMOVAL OF SHOULDER BLADE
23.77
1.00
23210
REMOVAL OF SHOULDER BLADE
28.57
1.00
23220
PARTIAL REMOVAL OF HUMERUS
5.00
1.00
23220
PARTIAL REMOVAL OF HUMERUS
27.58
1.00
Procedure Code Description
RVU
RVU Coeff Value
23220
PARTIAL REMOVAL OF HUMERUS
27.86
1.00
23220
PARTIAL REMOVAL OF HUMERUS
32.32
1.00
23221
PARTIAL REMOVAL OF HUMERUS
5.00
1.00
23221
PARTIAL REMOVAL OF HUMERUS
32.24
1.00
23221
PARTIAL REMOVAL OF HUMERUS
32.58
1.00
23221
PARTIAL REMOVAL OF HUMERUS
37.38
1.00
23222
PARTIAL REMOVAL OF HUMERUS
5.00
1.00
23222
PARTIAL REMOVAL OF HUMERUS
43.79
1.00
23222
PARTIAL REMOVAL OF HUMERUS
43.82
1.00
23222
PARTIAL REMOVAL OF HUMERUS
48.31
1.00
23330
REMOVE SHOULDER FOREIGN BODY
3.00
1.00
23330
REMOVE SHOULDER FOREIGN BODY
3.75
1.00
23330
REMOVE SHOULDER FOREIGN BODY
3.98
1.00
23330
REMOVE SHOULDER FOREIGN BODY
5.80
1.00
23331
REMOVE SHOULDER FOREIGN BODY
5.00
1.00
23331
REMOVE SHOULDER FOREIGN BODY
14.98
1.00
23331
REMOVE SHOULDER FOREIGN BODY
15.39
1.00
23331
REMOVE SHOULDER FOREIGN BODY
18.46
1.00
23332
REMOVE SHOULDER FOREIGN BODY
5.00
1.00
23332
REMOVE SHOULDER FOREIGN BODY
22.78
1.00
23332
REMOVE SHOULDER FOREIGN BODY
22.86
1.00
23332
REMOVE SHOULDER FOREIGN BODY
25.64
1.00
23350
INJECTION FOR SHOULDER X-RAY
1.39
1.00
23350
INJECTION FOR SHOULDER X-RAY
1.43
1.00
23350
INJECTION FOR SHOULDER X-RAY
3.00
1.00
23395
MUSCLE TRANSFER,SHOULDER/ARM
5.00
1.00
23395
MUSCLE TRANSFER,SHOULDER/ARM
32.32
1.00
23395
MUSCLE TRANSFER,SHOULDER/ARM
33.18
1.00
23395
MUSCLE TRANSFER,SHOULDER/ARM
33.41
1.00
23397
MUSCLE TRANSFERS
29.75
1.00
23397
MUSCLE TRANSFERS
30.21
1.00
23397
MUSCLE TRANSFERS
32.98
1.00
23400
FIXATION OF SHOULDER BLADE
6.00
1.00
23400
FIXATION OF SHOULDER BLADE
25.21
1.00
23400
FIXATION OF SHOULDER BLADE
25.98
1.00
Procedure Code Description
RVU
RVU Coeff Value
23400
FIXATION OF SHOULDER BLADE
30.03
1.00
23405
INCISION OF TENDON & MUSCLE
5.00
1.00
23405
INCISION OF TENDON & MUSCLE
16.20
1.00
23405
INCISION OF TENDON & MUSCLE
16.72
1.00
23405
INCISION OF TENDON & MUSCLE
19.18
1.00
23406
INCISE TENDON(S) & MUSCLE(S)
5.00
1.00
23406
INCISE TENDON(S) & MUSCLE(S)
20.27
1.00
23406
INCISE TENDON(S) & MUSCLE(S)
20.97
1.00
23406
INCISE TENDON(S) & MUSCLE(S)
24.16
1.00
23410
REPAIR ROTATOR CUFF, ACUTE
4.00
1.00
23410
REPAIR ROTATOR CUFF, ACUTE
21.57
1.00
23410
REPAIR ROTATOR CUFF, ACUTE
23.90
1.00
23410
REPAIR ROTATOR CUFF, ACUTE
26.98
1.00
23412
REPAIR ROTATOR CUFF, CHRONIC
5.00
1.00
23412
REPAIR ROTATOR CUFF, CHRONIC
22.56
1.00
23412
REPAIR ROTATOR CUFF, CHRONIC
25.43
1.00
23412
REPAIR ROTATOR CUFF, CHRONIC
28.49
1.00
23415
RELEASE OF SHOULDER LIGAMENT
4.00
1.00
23415
RELEASE OF SHOULDER LIGAMENT
17.94
1.00
23415
RELEASE OF SHOULDER LIGAMENT
19.61
1.00
23415
RELEASE OF SHOULDER LIGAMENT
21.81
1.00
23420
REPAIR OF SHOULDER
4.00
1.00
23420
REPAIR OF SHOULDER
25.19
1.00
23420
REPAIR OF SHOULDER
26.30
1.00
23420
REPAIR OF SHOULDER
29.47
1.00
23430
REPAIR BICEPS TENDON
3.00
1.00
23430
REPAIR BICEPS TENDON
19.06
1.00
23430
REPAIR BICEPS TENDON
19.77
1.00
23430
REPAIR BICEPS TENDON
22.88
1.00
23440
REMOVE/TRANSPLANT TENDON
5.00
1.00
23440
REMOVE/TRANSPLANT TENDON
19.67
1.00
23440
REMOVE/TRANSPLANT TENDON
20.52
1.00
23440
REMOVE/TRANSPLANT TENDON
23.77
1.00
23450
REPAIR SHOULDER CAPSULE
5.00
1.00
23450
REPAIR SHOULDER CAPSULE
24.69
1.00
Procedure Code Description
RVU
RVU Coeff Value
23450
REPAIR SHOULDER CAPSULE
25.49
1.00
23450
REPAIR SHOULDER CAPSULE
28.56
1.00
23455
REPAIR SHOULDER CAPSULE
5.00
1.00
23455
REPAIR SHOULDER CAPSULE
26.34
1.00
23455
REPAIR SHOULDER CAPSULE
27.22
1.00
23455
REPAIR SHOULDER CAPSULE
30.26
1.00
23460
REPAIR SHOULDER CAPSULE
4.00
1.00
23460
REPAIR SHOULDER CAPSULE
28.50
1.00
23460
REPAIR SHOULDER CAPSULE
29.34
1.00
23460
REPAIR SHOULDER CAPSULE
32.00
1.00
23462
REPAIR SHOULDER CAPSULE
5.00
1.00
23462
REPAIR SHOULDER CAPSULE
27.95
1.00
23462
REPAIR SHOULDER CAPSULE
28.67
1.00
23462
REPAIR SHOULDER CAPSULE
31.59
1.00
23465
REPAIR SHOULDER CAPSULE
4.00
1.00
23465
REPAIR SHOULDER CAPSULE
29.07
1.00
23465
REPAIR SHOULDER CAPSULE
29.18
1.00
23465
REPAIR SHOULDER CAPSULE
31.77
1.00
23466
REPAIR SHOULDER CAPSULE
5.00
1.00
23466
REPAIR SHOULDER CAPSULE
27.88
1.00
23466
REPAIR SHOULDER CAPSULE
28.68
1.00
23466
REPAIR SHOULDER CAPSULE
30.06
1.00
23470
RECONSTRUCT SHOULDER JOINT
4.00
1.00
23470
RECONSTRUCT SHOULDER JOINT
31.74
1.00
23470
RECONSTRUCT SHOULDER JOINT
31.97
1.00
23470
RECONSTRUCT SHOULDER JOINT
32.14
1.00
23472
RECONSTRUCT SHOULDER JOINT
5.00
1.00
23472
RECONSTRUCT SHOULDER JOINT
38.11
1.00
23472
RECONSTRUCT SHOULDER JOINT
38.20
1.00
23472
RECONSTRUCT SHOULDER JOINT
39.29
1.00
23480
REVISION OF COLLAR BONE
5.00
1.00
23480
REVISION OF COLLAR BONE
21.20
1.00
23480
REVISION OF COLLAR BONE
21.81
1.00
23480
REVISION OF COLLAR BONE
24.90
1.00
23485
REVISION OF COLLAR BONE
5.00
1.00
Procedure Code Description
RVU
RVU Coeff Value
23485
REVISION OF COLLAR BONE
25.06
1.00
23485
REVISION OF COLLAR BONE
25.54
1.00
23485
REVISION OF COLLAR BONE
28.62
1.00
23490
REINFORCE CLAVICLE
5.00
1.00
23490
REINFORCE CLAVICLE
21.46
1.00
23490
REINFORCE CLAVICLE
21.99
1.00
23490
REINFORCE CLAVICLE
25.21
1.00
23491
REINFORCE SHOULDER BONES
5.00
1.00
23491
REINFORCE SHOULDER BONES
26.39
1.00
23491
REINFORCE SHOULDER BONES
27.30
1.00
23491
REINFORCE SHOULDER BONES
29.97
1.00
23500
TREAT CLAVICLE FRACTURE
3.00
1.00
23500
TREAT CLAVICLE FRACTURE
4.94
1.00
23500
TREAT CLAVICLE FRACTURE
4.96
1.00
23500
TREAT CLAVICLE FRACTURE
5.09
1.00
23505
TREAT CLAVICLE FRACTURE
4.00
1.00
23505
TREAT CLAVICLE FRACTURE
8.04
1.00
23505
TREAT CLAVICLE FRACTURE
8.05
1.00
23505
TREAT CLAVICLE FRACTURE
8.31
1.00
23515
TREAT CLAVICLE FRACTURE
5.00
1.00
23515
TREAT CLAVICLE FRACTURE
15.16
1.00
23515
TREAT CLAVICLE FRACTURE
16.87
1.00
23515
TREAT CLAVICLE FRACTURE
17.87
1.00
23520
TREAT CLAVICLE DISLOCATION
3.00
1.00
23520
TREAT CLAVICLE DISLOCATION
5.10
1.00
23520
TREAT CLAVICLE DISLOCATION
5.18
1.00
23520
TREAT CLAVICLE DISLOCATION
5.35
1.00
23525
TREAT CLAVICLE DISLOCATION
3.00
1.00
23525
TREAT CLAVICLE DISLOCATION
7.73
1.00
23525
TREAT CLAVICLE DISLOCATION
8.00
1.00
23525
TREAT CLAVICLE DISLOCATION
8.02
1.00
23530
TREAT CLAVICLE DISLOCATION
4.00
1.00
23530
TREAT CLAVICLE DISLOCATION
13.76
1.00
23530
TREAT CLAVICLE DISLOCATION
14.36
1.00
23530
TREAT CLAVICLE DISLOCATION
16.36
1.00
Procedure Code Description
RVU
RVU Coeff Value
23532
TREAT CLAVICLE DISLOCATION
5.00
1.00
23532
TREAT CLAVICLE DISLOCATION
15.84
1.00
23532
TREAT CLAVICLE DISLOCATION
16.28
1.00
23532
TREAT CLAVICLE DISLOCATION
17.74
1.00
23540
TREAT CLAVICLE DISLOCATION
4.00
1.00
23540
TREAT CLAVICLE DISLOCATION
4.98
1.00
23540
TREAT CLAVICLE DISLOCATION
5.04
1.00
23540
TREAT CLAVICLE DISLOCATION
5.17
1.00
23545
TREAT CLAVICLE DISLOCATION
4.00
1.00
23545
TREAT CLAVICLE DISLOCATION
6.97
1.00
23545
TREAT CLAVICLE DISLOCATION
7.10
1.00
23545
TREAT CLAVICLE DISLOCATION
7.33
1.00
23550
TREAT CLAVICLE DISLOCATION
4.00
1.00
23550
TREAT CLAVICLE DISLOCATION
14.60
1.00
23550
TREAT CLAVICLE DISLOCATION
14.74
1.00
23550
TREAT CLAVICLE DISLOCATION
16.55
1.00
23552
TREAT CLAVICLE DISLOCATION
5.00
1.00
23552
TREAT CLAVICLE DISLOCATION
16.82
1.00
23552
TREAT CLAVICLE DISLOCATION
17.12
1.00
23552
TREAT CLAVICLE DISLOCATION
18.66
1.00
23570
TREAT SHOULDER BLADE FX
4.00
1.00
23570
TREAT SHOULDER BLADE FX
5.29
1.00
23570
TREAT SHOULDER BLADE FX
5.45
1.00
23570
TREAT SHOULDER BLADE FX
5.56
1.00
23575
TREAT SHOULDER BLADE FX
4.00
1.00
23575
TREAT SHOULDER BLADE FX
8.85
1.00
23575
TREAT SHOULDER BLADE FX
8.93
1.00
23575
TREAT SHOULDER BLADE FX
8.96
1.00
23585
TREAT SCAPULA FRACTURE
5.00
1.00
23585
TREAT SCAPULA FRACTURE
18.06
1.00
23585
TREAT SCAPULA FRACTURE
19.79
1.00
23585
TREAT SCAPULA FRACTURE
24.17
1.00
23600
TREAT HUMERUS FRACTURE
4.00
1.00
23600
TREAT HUMERUS FRACTURE
7.06
1.00
23600
TREAT HUMERUS FRACTURE
7.11
1.00
Procedure Code Description
RVU
RVU Coeff Value
23600
TREAT HUMERUS FRACTURE
7.22
1.00
23605
TREAT HUMERUS FRACTURE
3.00
1.00
23605
TREAT HUMERUS FRACTURE
10.54
1.00
23605
TREAT HUMERUS FRACTURE
10.63
1.00
23605
TREAT HUMERUS FRACTURE
12.37
1.00
23615
TREAT HUMERUS FRACTURE
5.00
1.00
23615
TREAT HUMERUS FRACTURE
19.61
1.00
23615
TREAT HUMERUS FRACTURE
21.13
1.00
23615
TREAT HUMERUS FRACTURE
22.21
1.00
23616
TREAT HUMERUS FRACTURE
5.00
1.00
23616
TREAT HUMERUS FRACTURE
33.61
1.00
23616
TREAT HUMERUS FRACTURE
38.96
1.00
23616
TREAT HUMERUS FRACTURE
40.49
1.00
23620
TREAT HUMERUS FRACTURE
4.00
1.00
23620
TREAT HUMERUS FRACTURE
5.97
1.00
23620
TREAT HUMERUS FRACTURE
6.02
1.00
23620
TREAT HUMERUS FRACTURE
6.19
1.00
23625
TREAT HUMERUS FRACTURE
3.00
1.00
23625
TREAT HUMERUS FRACTURE
8.68
1.00
23625
TREAT HUMERUS FRACTURE
9.12
1.00
23625
TREAT HUMERUS FRACTURE
10.21
1.00
23630
TREAT HUMERUS FRACTURE
4.00
1.00
23630
TREAT HUMERUS FRACTURE
15.17
1.00
23630
TREAT HUMERUS FRACTURE
16.82
1.00
23630
TREAT HUMERUS FRACTURE
19.03
1.00
23650
TREAT SHOULDER DISLOCATION
6.50
1.00
23650
TREAT SHOULDER DISLOCATION
6.63
1.00
23650
TREAT SHOULDER DISLOCATION
7.28
1.00
23655
TREAT SHOULDER DISLOCATION
4.00
1.00
23655
TREAT SHOULDER DISLOCATION
9.35
1.00
23655
TREAT SHOULDER DISLOCATION
9.47
1.00
23655
TREAT SHOULDER DISLOCATION
9.53
1.00
23660
TREAT SHOULDER DISLOCATION
4.00
1.00
23660
TREAT SHOULDER DISLOCATION
14.81
1.00
23660
TREAT SHOULDER DISLOCATION
15.06
1.00
Procedure Code Description
RVU
RVU Coeff Value
23660
TREAT SHOULDER DISLOCATION
16.74
1.00
23665
TREAT DISLOCATION/FRACTURE
4.00
1.00
23665
TREAT DISLOCATION/FRACTURE
9.67
1.00
23665
TREAT DISLOCATION/FRACTURE
10.11
1.00
23665
TREAT DISLOCATION/FRACTURE
11.06
1.00
23670
TREAT DISLOCATION/FRACTURE
4.00
1.00
23670
TREAT DISLOCATION/FRACTURE
16.04
1.00
23670
TREAT DISLOCATION/FRACTURE
17.93
1.00
23670
TREAT DISLOCATION/FRACTURE
21.35
1.00
23675
TREAT DISLOCATION/FRACTURE
5.00
1.00
23675
TREAT DISLOCATION/FRACTURE
12.46
1.00
23675
TREAT DISLOCATION/FRACTURE
13.10
1.00
23675
TREAT DISLOCATION/FRACTURE
13.75
1.00
23680
TREAT DISLOCATION/FRACTURE
5.00
1.00
23680
TREAT DISLOCATION/FRACTURE
19.81
1.00
23680
TREAT DISLOCATION/FRACTURE
21.51
1.00
23680
TREAT DISLOCATION/FRACTURE
23.22
1.00
23700
FIXATION OF SHOULDER
4.00
1.00
23700
FIXATION OF SHOULDER
4.98
1.00
23700
FIXATION OF SHOULDER
5.24
1.00
23700
FIXATION OF SHOULDER
6.52
1.00
23800
FUSION OF SHOULDER JOINT
4.00
1.00
23800
FUSION OF SHOULDER JOINT
26.51
1.00
23800
FUSION OF SHOULDER JOINT
26.98
1.00
23800
FUSION OF SHOULDER JOINT
30.79
1.00
23802
FUSION OF SHOULDER JOINT
4.00
1.00
23802
FUSION OF SHOULDER JOINT
29.63
1.00
23802
FUSION OF SHOULDER JOINT
32.14
1.00
23802
FUSION OF SHOULDER JOINT
32.85
1.00
23900
AMPUTATION OF ARM & GIRDLE
15.00
1.00
23900
AMPUTATION OF ARM & GIRDLE
34.40
1.00
23900
AMPUTATION OF ARM & GIRDLE
34.58
1.00
23900
AMPUTATION OF ARM & GIRDLE
37.88
1.00
23920
AMPUTATION AT SHOULDER JOINT
9.00
1.00
23920
AMPUTATION AT SHOULDER JOINT
27.00
1.00
Procedure Code Description
RVU
RVU Coeff Value
23920
AMPUTATION AT SHOULDER JOINT
27.83
1.00
23920
AMPUTATION AT SHOULDER JOINT
30.55
1.00
23921
AMPUTATION FOLLOW-UP SURGERY
3.00
1.00
23921
AMPUTATION FOLLOW-UP SURGERY
10.04
1.00
23921
AMPUTATION FOLLOW-UP SURGERY
11.58
1.00
23921
AMPUTATION FOLLOW-UP SURGERY
13.17
1.00
23930
DRAINAGE OF ARM LESION
3.00
1.00
23930
DRAINAGE OF ARM LESION
5.50
1.00
23930
DRAINAGE OF ARM LESION
5.68
1.00
23930
DRAINAGE OF ARM LESION
7.31
1.00
23931
DRAINAGE OF ARM BURSA
3.00
1.00
23931
DRAINAGE OF ARM BURSA
3.96
1.00
23931
DRAINAGE OF ARM BURSA
4.23
1.00
23931
DRAINAGE OF ARM BURSA
5.88
1.00
23935
DRAIN ARM/ELBOW BONE LESION
3.00
1.00
23935
DRAIN ARM/ELBOW BONE LESION
12.61
1.00
23935
DRAIN ARM/ELBOW BONE LESION
13.22
1.00
23935
DRAIN ARM/ELBOW BONE LESION
20.54
1.00
24000
EXPLORATORY ELBOW SURGERY
3.00
1.00
24000
EXPLORATORY ELBOW SURGERY
11.98
1.00
24000
EXPLORATORY ELBOW SURGERY
12.10
1.00
24000
EXPLORATORY ELBOW SURGERY
12.76
1.00
24006
RELEASE ELBOW JOINT
5.00
1.00
24006
RELEASE ELBOW JOINT
18.15
1.00
24006
RELEASE ELBOW JOINT
18.52
1.00
24006
RELEASE ELBOW JOINT
19.28
1.00
24065
BIOPSY ARM/ELBOW SOFT TISSUE
3.00
1.00
24065
BIOPSY ARM/ELBOW SOFT TISSUE
4.03
1.00
24065
BIOPSY ARM/ELBOW SOFT TISSUE
4.17
1.00
24065
BIOPSY ARM/ELBOW SOFT TISSUE
5.57
1.00
24066
BIOPSY ARM/ELBOW SOFT TISSUE
3.00
1.00
24066
BIOPSY ARM/ELBOW SOFT TISSUE
10.08
1.00
24066
BIOPSY ARM/ELBOW SOFT TISSUE
10.21
1.00
24066
BIOPSY ARM/ELBOW SOFT TISSUE
12.64
1.00
24075
REMOVE ARM/ELBOW LESION
3.00
1.00
Procedure Code Description
RVU
RVU Coeff Value
24075
REMOVE ARM/ELBOW LESION
7.86
1.00
24075
REMOVE ARM/ELBOW LESION
8.10
1.00
24075
REMOVE ARM/ELBOW LESION
10.49
1.00
24076
REMOVE ARM/ELBOW LESION
3.00
1.00
24076
REMOVE ARM/ELBOW LESION
12.03
1.00
24076
REMOVE ARM/ELBOW LESION
12.22
1.00
24076
REMOVE ARM/ELBOW LESION
14.34
1.00
24077
REMOVE TUMOR OF ARM/ELBOW
6.00
1.00
24077
REMOVE TUMOR OF ARM/ELBOW
20.85
1.00
24077
REMOVE TUMOR OF ARM/ELBOW
21.98
1.00
24077
REMOVE TUMOR OF ARM/ELBOW
26.86
1.00
24100
BIOPSY ELBOW JOINT LINING
3.00
1.00
24100
BIOPSY ELBOW JOINT LINING
10.16
1.00
24100
BIOPSY ELBOW JOINT LINING
10.23
1.00
24100
BIOPSY ELBOW JOINT LINING
11.34
1.00
24101
EXPLORE/TREAT ELBOW JOINT
3.00
1.00
24101
EXPLORE/TREAT ELBOW JOINT
12.60
1.00
24101
EXPLORE/TREAT ELBOW JOINT
12.99
1.00
24101
EXPLORE/TREAT ELBOW JOINT
13.93
1.00
24102
REMOVE ELBOW JOINT LINING
3.00
1.00
24102
REMOVE ELBOW JOINT LINING
15.66
1.00
24102
REMOVE ELBOW JOINT LINING
16.16
1.00
24102
REMOVE ELBOW JOINT LINING
17.07
1.00
24105
REMOVAL OF ELBOW BURSA
3.00
1.00
24105
REMOVAL OF ELBOW BURSA
8.43
1.00
24105
REMOVAL OF ELBOW BURSA
8.54
1.00
24105
REMOVAL OF ELBOW BURSA
9.48
1.00
24110
REMOVE HUMERUS LESION
5.00
1.00
24110
REMOVE HUMERUS LESION
14.82
1.00
24110
REMOVE HUMERUS LESION
15.28
1.00
24110
REMOVE HUMERUS LESION
18.51
1.00
24115
REMOVE/GRAFT BONE LESION
5.00
1.00
24115
REMOVE/GRAFT BONE LESION
18.36
1.00
24115
REMOVE/GRAFT BONE LESION
18.74
1.00
24115
REMOVE/GRAFT BONE LESION
21.30
1.00
Procedure Code Description
RVU
RVU Coeff Value
24116
REMOVE/GRAFT BONE LESION
3.00
1.00
24116
REMOVE/GRAFT BONE LESION
22.28
1.00
24116
REMOVE/GRAFT BONE LESION
22.90
1.00
24116
REMOVE/GRAFT BONE LESION
26.04
1.00
24120
REMOVE ELBOW LESION
3.00
1.00
24120
REMOVE ELBOW LESION
13.25
1.00
24120
REMOVE ELBOW LESION
13.57
1.00
24120
REMOVE ELBOW LESION
14.47
1.00
24125
REMOVE/GRAFT BONE LESION
3.00
1.00
24125
REMOVE/GRAFT BONE LESION
15.12
1.00
24125
REMOVE/GRAFT BONE LESION
15.24
1.00
24125
REMOVE/GRAFT BONE LESION
16.05
1.00
24126
REMOVE/GRAFT BONE LESION
4.00
1.00
24126
REMOVE/GRAFT BONE LESION
16.19
1.00
24126
REMOVE/GRAFT BONE LESION
16.36
1.00
24126
REMOVE/GRAFT BONE LESION
17.24
1.00
24130
REMOVAL OF HEAD OF RADIUS
3.00
1.00
24130
REMOVAL OF HEAD OF RADIUS
12.79
1.00
24130
REMOVAL OF HEAD OF RADIUS
13.24
1.00
24130
REMOVAL OF HEAD OF RADIUS
14.17
1.00
24134
REMOVAL OF ARM BONE LESION
4.00
1.00
24134
REMOVAL OF ARM BONE LESION
19.26
1.00
24134
REMOVAL OF ARM BONE LESION
20.48
1.00
24134
REMOVAL OF ARM BONE LESION
27.50
1.00
24136
REMOVE RADIUS BONE LESION
3.00
1.00
24136
REMOVE RADIUS BONE LESION
15.25
1.00
24136
REMOVE RADIUS BONE LESION
15.39
1.00
24136
REMOVE RADIUS BONE LESION
16.42
1.00
24138
REMOVE ELBOW BONE LESION
3.00
1.00
24138
REMOVE ELBOW BONE LESION
16.80
1.00
24138
REMOVE ELBOW BONE LESION
17.06
1.00
24138
REMOVE ELBOW BONE LESION
17.20
1.00
24140
PARTIAL REMOVAL OF ARM BONE
4.00
1.00
24140
PARTIAL REMOVAL OF ARM BONE
18.33
1.00
24140
PARTIAL REMOVAL OF ARM BONE
20.14
1.00
Procedure Code Description 24140
PARTIAL REMOVAL OF ARM BONE
24145
RVU
RVU Coeff Value
27.97
1.00
PARTIAL REMOVAL OF RADIUS
3.00
1.00
24145
PARTIAL REMOVAL OF RADIUS
15.36
1.00
24145
PARTIAL REMOVAL OF RADIUS
16.94
1.00
24145
PARTIAL REMOVAL OF RADIUS
20.23
1.00
24147
PARTIAL REMOVAL OF ELBOW
4.00
1.00
24147
PARTIAL REMOVAL OF ELBOW
15.96
1.00
24147
PARTIAL REMOVAL OF ELBOW
17.42
1.00
24147
PARTIAL REMOVAL OF ELBOW
20.22
1.00
24149
RADICAL RESECTION OF ELBOW
4.00
1.00
24149
RADICAL RESECTION OF ELBOW
27.29
1.00
24149
RADICAL RESECTION OF ELBOW
27.88
1.00
24149
RADICAL RESECTION OF ELBOW
29.52
1.00
24150
EXTENSIVE HUMERUS SURGERY
6.00
1.00
24150
EXTENSIVE HUMERUS SURGERY
25.13
1.00
24150
EXTENSIVE HUMERUS SURGERY
25.53
1.00
24150
EXTENSIVE HUMERUS SURGERY
30.31
1.00
24151
EXTENSIVE HUMERUS SURGERY
6.00
1.00
24151
EXTENSIVE HUMERUS SURGERY
28.86
1.00
24151
EXTENSIVE HUMERUS SURGERY
29.87
1.00
24151
EXTENSIVE HUMERUS SURGERY
34.73
1.00
24152
EXTENSIVE RADIUS SURGERY
6.00
1.00
24152
EXTENSIVE RADIUS SURGERY
18.80
1.00
24152
EXTENSIVE RADIUS SURGERY
19.33
1.00
24152
EXTENSIVE RADIUS SURGERY
21.08
1.00
24153
EXTENSIVE RADIUS SURGERY
6.00
1.00
24153
EXTENSIVE RADIUS SURGERY
18.12
1.00
24153
EXTENSIVE RADIUS SURGERY
19.24
1.00
24153
EXTENSIVE RADIUS SURGERY
19.84
1.00
24155
REMOVAL OF ELBOW JOINT
4.00
1.00
24155
REMOVAL OF ELBOW JOINT
21.83
1.00
24155
REMOVAL OF ELBOW JOINT
21.84
1.00
24155
REMOVAL OF ELBOW JOINT
22.57
1.00
24160
REMOVE ELBOW JOINT IMPLANT
3.00
1.00
24160
REMOVE ELBOW JOINT IMPLANT
15.41
1.00
Procedure Code Description
RVU
RVU Coeff Value
24160
REMOVE ELBOW JOINT IMPLANT
15.85
1.00
24160
REMOVE ELBOW JOINT IMPLANT
15.88
1.00
24164
REMOVE RADIUS HEAD IMPLANT
4.00
1.00
24164
REMOVE RADIUS HEAD IMPLANT
12.58
1.00
24164
REMOVE RADIUS HEAD IMPLANT
12.89
1.00
24164
REMOVE RADIUS HEAD IMPLANT
13.02
1.00
24200
REMOVAL OF ARM FOREIGN BODY
3.00
1.00
24200
REMOVAL OF ARM FOREIGN BODY
3.40
1.00
24200
REMOVAL OF ARM FOREIGN BODY
3.61
1.00
24200
REMOVAL OF ARM FOREIGN BODY
5.26
1.00
24201
REMOVAL OF ARM FOREIGN BODY
3.00
1.00
24201
REMOVAL OF ARM FOREIGN BODY
9.19
1.00
24201
REMOVAL OF ARM FOREIGN BODY
9.57
1.00
24201
REMOVAL OF ARM FOREIGN BODY
12.18
1.00
24220
INJECTION FOR ELBOW X-RAY
1.83
1.00
24220
INJECTION FOR ELBOW X-RAY
1.84
1.00
24220
INJECTION FOR ELBOW X-RAY
1.89
1.00
24220
INJECTION FOR ELBOW X-RAY
3.00
1.00
24300
MANIPULATE ELBOW W/ANESTH
3.00
1.00
24300
MANIPULATE ELBOW W/ANESTH
9.77
1.00
24300
MANIPULATE ELBOW W/ANESTH
9.79
1.00
24300
MANIPULATE ELBOW W/ANESTH
9.81
1.00
24301
MUSCLE/TENDON TRANSFER
3.00
1.00
24301
MUSCLE/TENDON TRANSFER
19.30
1.00
24301
MUSCLE/TENDON TRANSFER
19.93
1.00
24301
MUSCLE/TENDON TRANSFER
20.72
1.00
24305
ARM TENDON LENGTHENING
3.00
1.00
24305
ARM TENDON LENGTHENING
14.69
1.00
24305
ARM TENDON LENGTHENING
15.30
1.00
24305
ARM TENDON LENGTHENING
16.22
1.00
24310
REVISION OF ARM TENDON
3.00
1.00
24310
REVISION OF ARM TENDON
12.03
1.00
24310
REVISION OF ARM TENDON
12.58
1.00
24310
REVISION OF ARM TENDON
15.25
1.00
24320
REPAIR OF ARM TENDON
3.00
1.00
Procedure Code Description
RVU
RVU Coeff Value
24320
REPAIR OF ARM TENDON
19.49
1.00
24320
REPAIR OF ARM TENDON
19.89
1.00
24320
REPAIR OF ARM TENDON
22.61
1.00
24330
REVISION OF ARM MUSCLES
3.00
1.00
24330
REVISION OF ARM MUSCLES
18.35
1.00
24330
REVISION OF ARM MUSCLES
18.91
1.00
24330
REVISION OF ARM MUSCLES
19.68
1.00
24331
REVISION OF ARM MUSCLES
3.00
1.00
24331
REVISION OF ARM MUSCLES
20.30
1.00
24331
REVISION OF ARM MUSCLES
20.93
1.00
24331
REVISION OF ARM MUSCLES
21.54
1.00
24332
TENOLYSIS, TRICEPS
3.00
1.00
24332
TENOLYSIS, TRICEPS
13.43
1.00
24332
TENOLYSIS, TRICEPS
14.95
1.00
24332
TENOLYSIS, TRICEPS
15.34
1.00
24340
REPAIR OF BICEPS TENDON
3.00
1.00
24340
REPAIR OF BICEPS TENDON
15.64
1.00
24340
REPAIR OF BICEPS TENDON
16.09
1.00
24340
REPAIR OF BICEPS TENDON
16.83
1.00
24341
REPAIR ARM TENDON/MUSCLE
3.00
1.00
24341
REPAIR ARM TENDON/MUSCLE
16.84
1.00
24341
REPAIR ARM TENDON/MUSCLE
16.94
1.00
24341
REPAIR ARM TENDON/MUSCLE
18.33
1.00
24342
REPAIR OF RUPTURED TENDON
4.00
1.00
24342
REPAIR OF RUPTURED TENDON
20.21
1.00
24342
REPAIR OF RUPTURED TENDON
20.85
1.00
24342
REPAIR OF RUPTURED TENDON
21.54
1.00
24343
REPR ELBOW LAT LIGMNT W/TISS
3.00
1.00
24343
REPR ELBOW LAT LIGMNT W/TISS
17.67
1.00
24343
REPR ELBOW LAT LIGMNT W/TISS
17.85
1.00
24343
REPR ELBOW LAT LIGMNT W/TISS
17.93
1.00
24344
RECONSTRUCT ELBOW LAT LIGMNT
3.00
1.00
24344
RECONSTRUCT ELBOW LAT LIGMNT
27.01
1.00
24344
RECONSTRUCT ELBOW LAT LIGMNT
27.50
1.00
24344
RECONSTRUCT ELBOW LAT LIGMNT
27.90
1.00
Procedure Code Description
RVU
RVU Coeff Value
24345
REPR ELBW MED LIGMNT W/TISSU
3.00
1.00
24345
REPR ELBW MED LIGMNT W/TISSU
17.67
1.00
24345
REPR ELBW MED LIGMNT W/TISSU
17.74
1.00
24345
REPR ELBW MED LIGMNT W/TISSU
17.83
1.00
24346
RECONSTRUCT ELBOW MED LIGMNT
3.00
1.00
24346
RECONSTRUCT ELBOW MED LIGMNT
27.01
1.00
24346
RECONSTRUCT ELBOW MED LIGMNT
27.36
1.00
24346
RECONSTRUCT ELBOW MED LIGMNT
27.95
1.00
24350
REPAIR OF TENNIS ELBOW
3.00
1.00
24350
REPAIR OF TENNIS ELBOW
11.60
1.00
24350
REPAIR OF TENNIS ELBOW
11.63
1.00
24350
REPAIR OF TENNIS ELBOW
12.41
1.00
24351
REPAIR OF TENNIS ELBOW
3.00
1.00
24351
REPAIR OF TENNIS ELBOW
12.69
1.00
24351
REPAIR OF TENNIS ELBOW
12.75
1.00
24351
REPAIR OF TENNIS ELBOW
13.66
1.00
24352
REPAIR OF TENNIS ELBOW
3.00
1.00
24352
REPAIR OF TENNIS ELBOW
13.54
1.00
24352
REPAIR OF TENNIS ELBOW
13.63
1.00
24352
REPAIR OF TENNIS ELBOW
14.52
1.00
24354
REPAIR OF TENNIS ELBOW
3.00
1.00
24354
REPAIR OF TENNIS ELBOW
13.54
1.00
24354
REPAIR OF TENNIS ELBOW
13.61
1.00
24354
REPAIR OF TENNIS ELBOW
14.51
1.00
24356
REVISION OF TENNIS ELBOW
3.00
1.00
24356
REVISION OF TENNIS ELBOW
13.92
1.00
24356
REVISION OF TENNIS ELBOW
14.02
1.00
24356
REVISION OF TENNIS ELBOW
14.91
1.00
24357
REPAIR ELBOW, PERC
11.17
1.00
24358
REPAIR ELBOW W/DEB, OPEN
13.20
1.00
24359
REPAIR ELBOW DEB/ATTCH OPEN
16.64
1.00
24360
RECONSTRUCT ELBOW JOINT
3.00
1.00
24360
RECONSTRUCT ELBOW JOINT
23.21
1.00
24360
RECONSTRUCT ELBOW JOINT
23.68
1.00
24360
RECONSTRUCT ELBOW JOINT
23.71
1.00
Procedure Code Description
RVU
RVU Coeff Value
24361
RECONSTRUCT ELBOW JOINT
3.00
1.00
24361
RECONSTRUCT ELBOW JOINT
25.99
1.00
24361
RECONSTRUCT ELBOW JOINT
26.67
1.00
24361
RECONSTRUCT ELBOW JOINT
26.85
1.00
24362
RECONSTRUCT ELBOW JOINT
3.00
1.00
24362
RECONSTRUCT ELBOW JOINT
27.26
1.00
24362
RECONSTRUCT ELBOW JOINT
27.59
1.00
24362
RECONSTRUCT ELBOW JOINT
29.32
1.00
24363
REPLACE ELBOW JOINT
7.00
1.00
24363
REPLACE ELBOW JOINT
32.54
1.00
24363
REPLACE ELBOW JOINT
35.03
1.00
24363
REPLACE ELBOW JOINT
38.48
1.00
24365
RECONSTRUCT HEAD OF RADIUS
3.00
1.00
24365
RECONSTRUCT HEAD OF RADIUS
16.36
1.00
24365
RECONSTRUCT HEAD OF RADIUS
16.81
1.00
24366
RECONSTRUCT HEAD OF RADIUS
3.00
1.00
24366
RECONSTRUCT HEAD OF RADIUS
17.53
1.00
24366
RECONSTRUCT HEAD OF RADIUS
18.09
1.00
24366
RECONSTRUCT HEAD OF RADIUS
18.10
1.00
24400
REVISION OF HUMERUS
5.00
1.00
24400
REVISION OF HUMERUS
21.20
1.00
24400
REVISION OF HUMERUS
21.80
1.00
24400
REVISION OF HUMERUS
25.58
1.00
24410
REVISION OF HUMERUS
5.00
1.00
24410
REVISION OF HUMERUS
27.13
1.00
24410
REVISION OF HUMERUS
27.51
1.00
24410
REVISION OF HUMERUS
30.82
1.00
24420
REVISION OF HUMERUS
5.00
1.00
24420
REVISION OF HUMERUS
25.40
1.00
24420
REVISION OF HUMERUS
26.28
1.00
24420
REVISION OF HUMERUS
32.53
1.00
24430
REPAIR OF HUMERUS
5.00
1.00
24430
REPAIR OF HUMERUS
24.71
1.00
24430
REPAIR OF HUMERUS
26.94
1.00
24430
REPAIR OF HUMERUS
27.79
1.00
Procedure Code Description
RVU
RVU Coeff Value
24435
REPAIR HUMERUS WITH GRAFT
5.00
1.00
24435
REPAIR HUMERUS WITH GRAFT
26.20
1.00
24435
REPAIR HUMERUS WITH GRAFT
27.35
1.00
24435
REPAIR HUMERUS WITH GRAFT
29.38
1.00
24470
REVISION OF ELBOW JOINT
4.00
1.00
24470
REVISION OF ELBOW JOINT
16.15
1.00
24470
REVISION OF ELBOW JOINT
17.83
1.00
24470
REVISION OF ELBOW JOINT
18.47
1.00
24495
DECOMPRESSION OF FOREARM
4.00
1.00
24495
DECOMPRESSION OF FOREARM
16.70
1.00
24495
DECOMPRESSION OF FOREARM
18.27
1.00
24495
DECOMPRESSION OF FOREARM
19.32
1.00
24498
REINFORCE HUMERUS
5.00
1.00
24498
REINFORCE HUMERUS
22.53
1.00
24498
REINFORCE HUMERUS
23.19
1.00
24498
REINFORCE HUMERUS
26.27
1.00
24500
TREAT HUMERUS FRACTURE
3.00
1.00
24500
TREAT HUMERUS FRACTURE
7.00
1.00
24500
TREAT HUMERUS FRACTURE
7.31
1.00
24500
TREAT HUMERUS FRACTURE
7.58
1.00
24505
TREAT HUMERUS FRACTURE
3.00
1.00
24505
TREAT HUMERUS FRACTURE
11.18
1.00
24505
TREAT HUMERUS FRACTURE
11.31
1.00
24505
TREAT HUMERUS FRACTURE
12.99
1.00
24515
TREAT HUMERUS FRACTURE
5.00
1.00
24515
TREAT HUMERUS FRACTURE
22.57
1.00
24515
TREAT HUMERUS FRACTURE
22.94
1.00
24515
TREAT HUMERUS FRACTURE
24.86
1.00
24516
TREAT HUMERUS FRACTURE
5.00
1.00
24516
TREAT HUMERUS FRACTURE
22.33
1.00
24516
TREAT HUMERUS FRACTURE
22.71
1.00
24516
TREAT HUMERUS FRACTURE
25.42
1.00
24530
TREAT HUMERUS FRACTURE
5.00
1.00
24530
TREAT HUMERUS FRACTURE
8.00
1.00
24530
TREAT HUMERUS FRACTURE
8.17
1.00
Procedure Code Description
RVU
RVU Coeff Value
24530
TREAT HUMERUS FRACTURE
8.94
1.00
24535
TREAT HUMERUS FRACTURE
3.00
1.00
24535
TREAT HUMERUS FRACTURE
14.26
1.00
24535
TREAT HUMERUS FRACTURE
14.42
1.00
24535
TREAT HUMERUS FRACTURE
14.72
1.00
24538
TREAT HUMERUS FRACTURE
3.00
1.00
24538
TREAT HUMERUS FRACTURE
19.01
1.00
24538
TREAT HUMERUS FRACTURE
19.62
1.00
24538
TREAT HUMERUS FRACTURE
21.53
1.00
24545
TREAT HUMERUS FRACTURE
3.00
1.00
24545
TREAT HUMERUS FRACTURE
20.63
1.00
24545
TREAT HUMERUS FRACTURE
22.30
1.00
24545
TREAT HUMERUS FRACTURE
23.38
1.00
24546
TREAT HUMERUS FRACTURE
5.00
1.00
24546
TREAT HUMERUS FRACTURE
27.39
1.00
24546
TREAT HUMERUS FRACTURE
29.61
1.00
24546
TREAT HUMERUS FRACTURE
31.70
1.00
24560
TREAT HUMERUS FRACTURE
3.00
1.00
24560
TREAT HUMERUS FRACTURE
6.31
1.00
24560
TREAT HUMERUS FRACTURE
6.43
1.00
24560
TREAT HUMERUS FRACTURE
6.67
1.00
24565
TREAT HUMERUS FRACTURE
3.00
1.00
24565
TREAT HUMERUS FRACTURE
11.64
1.00
24565
TREAT HUMERUS FRACTURE
11.84
1.00
24565
TREAT HUMERUS FRACTURE
12.35
1.00
24566
TREAT HUMERUS FRACTURE
3.00
1.00
24566
TREAT HUMERUS FRACTURE
17.22
1.00
24566
TREAT HUMERUS FRACTURE
17.72
1.00
24566
TREAT HUMERUS FRACTURE
19.23
1.00
24575
TREAT HUMERUS FRACTURE
4.00
1.00
24575
TREAT HUMERUS FRACTURE
18.95
1.00
24575
TREAT HUMERUS FRACTURE
20.53
1.00
24575
TREAT HUMERUS FRACTURE
20.68
1.00
24576
TREAT HUMERUS FRACTURE
3.00
1.00
24576
TREAT HUMERUS FRACTURE
6.55
1.00
Procedure Code Description
RVU
RVU Coeff Value
24576
TREAT HUMERUS FRACTURE
6.91
1.00
24576
TREAT HUMERUS FRACTURE
7.10
1.00
24577
TREAT HUMERUS FRACTURE
3.00
1.00
24577
TREAT HUMERUS FRACTURE
12.07
1.00
24577
TREAT HUMERUS FRACTURE
12.45
1.00
24577
TREAT HUMERUS FRACTURE
12.92
1.00
24579
TREAT HUMERUS FRACTURE
3.00
1.00
24579
TREAT HUMERUS FRACTURE
21.50
1.00
24579
TREAT HUMERUS FRACTURE
22.36
1.00
24579
TREAT HUMERUS FRACTURE
24.53
1.00
24582
TREAT HUMERUS FRACTURE
3.00
1.00
24582
TREAT HUMERUS FRACTURE
19.00
1.00
24582
TREAT HUMERUS FRACTURE
19.78
1.00
24582
TREAT HUMERUS FRACTURE
20.52
1.00
24586
TREAT ELBOW FRACTURE
4.00
1.00
24586
TREAT ELBOW FRACTURE
28.38
1.00
24586
TREAT ELBOW FRACTURE
28.41
1.00
24586
TREAT ELBOW FRACTURE
28.86
1.00
24587
TREAT ELBOW FRACTURE
4.00
1.00
24587
TREAT ELBOW FRACTURE
28.18
1.00
24587
TREAT ELBOW FRACTURE
28.25
1.00
24587
TREAT ELBOW FRACTURE
28.63
1.00
24600
TREAT ELBOW DISLOCATION
3.00
1.00
24600
TREAT ELBOW DISLOCATION
8.03
1.00
24600
TREAT ELBOW DISLOCATION
8.33
1.00
24600
TREAT ELBOW DISLOCATION
9.83
1.00
24605
TREAT ELBOW DISLOCATION
3.00
1.00
24605
TREAT ELBOW DISLOCATION
11.23
1.00
24605
TREAT ELBOW DISLOCATION
11.48
1.00
24605
TREAT ELBOW DISLOCATION
11.53
1.00
24615
TREAT ELBOW DISLOCATION
3.00
1.00
24615
TREAT ELBOW DISLOCATION
18.36
1.00
24615
TREAT ELBOW DISLOCATION
18.70
1.00
24615
TREAT ELBOW DISLOCATION
18.72
1.00
24620
TREAT ELBOW FRACTURE
3.00
1.00
Procedure Code Description
RVU
RVU Coeff Value
24620
TREAT ELBOW FRACTURE
13.87
1.00
24620
TREAT ELBOW FRACTURE
14.17
1.00
24620
TREAT ELBOW FRACTURE
14.59
1.00
24635
TREAT ELBOW FRACTURE
3.00
1.00
24635
TREAT ELBOW FRACTURE
19.51
1.00
24635
TREAT ELBOW FRACTURE
29.60
1.00
24635
TREAT ELBOW FRACTURE
31.67
1.00
24640
TREAT ELBOW DISLOCATION
2.13
1.00
24640
TREAT ELBOW DISLOCATION
2.20
1.00
24640
TREAT ELBOW DISLOCATION
3.00
1.00
24640
TREAT ELBOW DISLOCATION
3.15
1.00
24650
TREAT RADIUS FRACTURE
3.00
1.00
24650
TREAT RADIUS FRACTURE
5.23
1.00
24650
TREAT RADIUS FRACTURE
5.36
1.00
24650
TREAT RADIUS FRACTURE
5.51
1.00
24655
TREAT RADIUS FRACTURE
3.00
1.00
24655
TREAT RADIUS FRACTURE
9.69
1.00
24655
TREAT RADIUS FRACTURE
9.78
1.00
24655
TREAT RADIUS FRACTURE
10.39
1.00
24665
TREAT RADIUS FRACTURE
3.00
1.00
24665
TREAT RADIUS FRACTURE
16.51
1.00
24665
TREAT RADIUS FRACTURE
16.97
1.00
24665
TREAT RADIUS FRACTURE
18.99
1.00
24666
TREAT RADIUS FRACTURE
4.00
1.00
24666
TREAT RADIUS FRACTURE
18.76
1.00
24666
TREAT RADIUS FRACTURE
19.12
1.00
24666
TREAT RADIUS FRACTURE
21.29
1.00
24670
TREAT ULNAR FRACTURE
3.00
1.00
24670
TREAT ULNAR FRACTURE
5.95
1.00
24670
TREAT ULNAR FRACTURE
6.00
1.00
24670
TREAT ULNAR FRACTURE
6.16
1.00
24675
TREAT ULNAR FRACTURE
3.00
1.00
24675
TREAT ULNAR FRACTURE
10.31
1.00
24675
TREAT ULNAR FRACTURE
11.05
1.00
24685
TREAT ULNAR FRACTURE
3.00
1.00
Procedure Code Description
RVU
RVU Coeff Value
24685
TREAT ULNAR FRACTURE
16.62
1.00
24685
TREAT ULNAR FRACTURE
17.79
1.00
24685
TREAT ULNAR FRACTURE
20.11
1.00
24800
FUSION OF ELBOW JOINT
3.00
1.00
24800
FUSION OF ELBOW JOINT
20.32
1.00
24800
FUSION OF ELBOW JOINT
21.59
1.00
24800
FUSION OF ELBOW JOINT
22.55
1.00
24802
FUSION/GRAFT OF ELBOW JOINT
3.00
1.00
24802
FUSION/GRAFT OF ELBOW JOINT
25.86
1.00
24802
FUSION/GRAFT OF ELBOW JOINT
26.27
1.00
24802
FUSION/GRAFT OF ELBOW JOINT
27.14
1.00
24900
AMPUTATION OF UPPER ARM
4.00
1.00
24900
AMPUTATION OF UPPER ARM
18.36
1.00
24900
AMPUTATION OF UPPER ARM
18.38
1.00
24900
AMPUTATION OF UPPER ARM
21.99
1.00
24920
AMPUTATION OF UPPER ARM
4.00
1.00
24920
AMPUTATION OF UPPER ARM
18.29
1.00
24920
AMPUTATION OF UPPER ARM
18.52
1.00
24920
AMPUTATION OF UPPER ARM
23.58
1.00
24925
AMPUTATION FOLLOW-UP SURGERY
4.00
1.00
24925
AMPUTATION FOLLOW-UP SURGERY
14.16
1.00
24925
AMPUTATION FOLLOW-UP SURGERY
14.48
1.00
24925
AMPUTATION FOLLOW-UP SURGERY
17.70
1.00
24930
AMPUTATION FOLLOW-UP SURGERY
4.00
1.00
24930
AMPUTATION FOLLOW-UP SURGERY
19.23
1.00
24930
AMPUTATION FOLLOW-UP SURGERY
19.39
1.00
24930
AMPUTATION FOLLOW-UP SURGERY
23.26
1.00
24931
AMPUTATE UPPER ARM & IMPLANT
4.00
1.00
24931
AMPUTATE UPPER ARM & IMPLANT
20.69
1.00
24931
AMPUTATE UPPER ARM & IMPLANT
21.67
1.00
24931
AMPUTATE UPPER ARM & IMPLANT
23.51
1.00
24935
REVISION OF AMPUTATION
25.87
1.00
24935
REVISION OF AMPUTATION
26.24
1.00
24935
REVISION OF AMPUTATION
29.77
1.00
25000
INCISION OF TENDON SHEATH
3.00
1.00
Procedure Code Description
RVU
RVU Coeff Value
25000
INCISION OF TENDON SHEATH
8.73
1.00
25000
INCISION OF TENDON SHEATH
10.86
1.00
25000
INCISION OF TENDON SHEATH
11.42
1.00
25001
INCISE FLEXOR CARPI RADIALIS
3.00
1.00
25001
INCISE FLEXOR CARPI RADIALIS
8.00
1.00
25001
INCISE FLEXOR CARPI RADIALIS
8.20
1.00
25001
INCISE FLEXOR CARPI RADIALIS
8.27
1.00
25020
DECOMPRESS FOREARM 1 SPACE
3.00
1.00
25020
DECOMPRESS FOREARM 1 SPACE
14.47
1.00
25020
DECOMPRESS FOREARM 1 SPACE
16.77
1.00
25020
DECOMPRESS FOREARM 1 SPACE
18.06
1.00
25023
DECOMPRESS FOREARM 1 SPACE
4.00
1.00
25023
DECOMPRESS FOREARM 1 SPACE
27.92
1.00
25023
DECOMPRESS FOREARM 1 SPACE
30.22
1.00
25023
DECOMPRESS FOREARM 1 SPACE
31.84
1.00
25024
DECOMPRESS FOREARM 2 SPACES
3.00
1.00
25024
DECOMPRESS FOREARM 2 SPACES
18.51
1.00
25024
DECOMPRESS FOREARM 2 SPACES
18.82
1.00
25024
DECOMPRESS FOREARM 2 SPACES
19.49
1.00
25025
DECOMPRESS FOREARM 2 SPACES
3.00
1.00
25025
DECOMPRESS FOREARM 2 SPACES
29.15
1.00
25025
DECOMPRESS FOREARM 2 SPACES
29.96
1.00
25025
DECOMPRESS FOREARM 2 SPACES
30.47
1.00
25028
DRAINAGE OF FOREARM LESION
4.00
1.00
25028
DRAINAGE OF FOREARM LESION
12.88
1.00
25028
DRAINAGE OF FOREARM LESION
14.46
1.00
25028
DRAINAGE OF FOREARM LESION
16.03
1.00
25031
DRAINAGE OF FOREARM BURSA
3.00
1.00
25031
DRAINAGE OF FOREARM BURSA
9.48
1.00
25031
DRAINAGE OF FOREARM BURSA
12.98
1.00
25031
DRAINAGE OF FOREARM BURSA
14.78
1.00
25035
TREAT FOREARM BONE LESION
3.00
1.00
25035
TREAT FOREARM BONE LESION
16.45
1.00
25035
TREAT FOREARM BONE LESION
22.56
1.00
25035
TREAT FOREARM BONE LESION
25.21
1.00
Procedure Code Description
RVU
RVU Coeff Value
25040
EXPLORE/TREAT WRIST JOINT
3.00
1.00
25040
EXPLORE/TREAT WRIST JOINT
14.56
1.00
25040
EXPLORE/TREAT WRIST JOINT
15.67
1.00
25040
EXPLORE/TREAT WRIST JOINT
17.62
1.00
25065
BIOPSY FOREARM SOFT TISSUES
3.00
1.00
25065
BIOPSY FOREARM SOFT TISSUES
4.11
1.00
25065
BIOPSY FOREARM SOFT TISSUES
4.69
1.00
25065
BIOPSY FOREARM SOFT TISSUES
4.92
1.00
25066
BIOPSY FOREARM SOFT TISSUES
3.00
1.00
25066
BIOPSY FOREARM SOFT TISSUES
9.50
1.00
25066
BIOPSY FOREARM SOFT TISSUES
11.95
1.00
25066
BIOPSY FOREARM SOFT TISSUES
13.04
1.00
25075
REMOVAL FOREARM LESION SUBCU
3.00
1.00
25075
REMOVAL FOREARM LESION SUBCU
8.31
1.00
25075
REMOVAL FOREARM LESION SUBCU
10.34
1.00
25075
REMOVAL FOREARM LESION SUBCU
11.53
1.00
25076
REMOVAL FOREARM LESION DEEP
3.00
1.00
25076
REMOVAL FOREARM LESION DEEP
11.23
1.00
25076
REMOVAL FOREARM LESION DEEP
15.60
1.00
25076
REMOVAL FOREARM LESION DEEP
18.39
1.00
25077
REMOVE TUMOR, FOREARM/WRIST
3.00
1.00
25077
REMOVE TUMOR, FOREARM/WRIST
19.08
1.00
25077
REMOVE TUMOR, FOREARM/WRIST
23.76
1.00
25077
REMOVE TUMOR, FOREARM/WRIST
26.37
1.00
25085
INCISION OF WRIST CAPSULE
5.00
1.00
25085
INCISION OF WRIST CAPSULE
11.71
1.00
25085
INCISION OF WRIST CAPSULE
13.65
1.00
25085
INCISION OF WRIST CAPSULE
17.50
1.00
25100
BIOPSY OF WRIST JOINT
3.00
1.00
25100
BIOPSY OF WRIST JOINT
8.68
1.00
25100
BIOPSY OF WRIST JOINT
9.90
1.00
25100
BIOPSY OF WRIST JOINT
12.06
1.00
25101
EXPLORE/TREAT WRIST JOINT
3.00
1.00
25101
EXPLORE/TREAT WRIST JOINT
10.25
1.00
25101
EXPLORE/TREAT WRIST JOINT
11.36
1.00
Procedure Code Description
RVU
RVU Coeff Value
25101
EXPLORE/TREAT WRIST JOINT
13.31
1.00
25105
REMOVE WRIST JOINT LINING
3.00
1.00
25105
REMOVE WRIST JOINT LINING
12.46
1.00
25105
REMOVE WRIST JOINT LINING
14.25
1.00
25105
REMOVE WRIST JOINT LINING
17.87
1.00
25107
REMOVE WRIST JOINT CARTILAGE
3.00
1.00
25107
REMOVE WRIST JOINT CARTILAGE
15.44
1.00
25107
REMOVE WRIST JOINT CARTILAGE
15.82
1.00
25107
REMOVE WRIST JOINT CARTILAGE
18.87
1.00
25109
EXCISE TENDON FOREARM/WRIST
13.22
1.00
25110
REMOVE WRIST TENDON LESION
3.00
1.00
25110
REMOVE WRIST TENDON LESION
9.10
1.00
25110
REMOVE WRIST TENDON LESION
11.75
1.00
25110
REMOVE WRIST TENDON LESION
13.02
1.00
25111
REMOVE WRIST TENDON LESION
3.00
1.00
25111
REMOVE WRIST TENDON LESION
7.89
1.00
25111
REMOVE WRIST TENDON LESION
8.72
1.00
25111
REMOVE WRIST TENDON LESION
10.48
1.00
25112
REREMOVE WRIST TENDON LESION
3.00
1.00
25112
REREMOVE WRIST TENDON LESION
9.66
1.00
25112
REREMOVE WRIST TENDON LESION
10.60
1.00
25112
REREMOVE WRIST TENDON LESION
12.56
1.00
25115
REMOVE WRIST/FOREARM LESION
3.00
1.00
25115
REMOVE WRIST/FOREARM LESION
20.36
1.00
25115
REMOVE WRIST/FOREARM LESION
24.59
1.00
25115
REMOVE WRIST/FOREARM LESION
27.29
1.00
25116
REMOVE WRIST/FOREARM LESION
3.00
1.00
25116
REMOVE WRIST/FOREARM LESION
16.49
1.00
25116
REMOVE WRIST/FOREARM LESION
21.72
1.00
25116
REMOVE WRIST/FOREARM LESION
24.37
1.00
25118
EXCISE WRIST TENDON SHEATH
3.00
1.00
25118
EXCISE WRIST TENDON SHEATH
9.68
1.00
25118
EXCISE WRIST TENDON SHEATH
10.90
1.00
25118
EXCISE WRIST TENDON SHEATH
13.01
1.00
25119
PARTIAL REMOVAL OF ULNA
3.00
1.00
Procedure Code Description
RVU
RVU Coeff Value
25119
PARTIAL REMOVAL OF ULNA
12.84
1.00
25119
PARTIAL REMOVAL OF ULNA
14.76
1.00
25119
PARTIAL REMOVAL OF ULNA
18.38
1.00
25120
REMOVAL OF FOREARM LESION
3.00
1.00
25120
REMOVAL OF FOREARM LESION
14.09
1.00
25120
REMOVAL OF FOREARM LESION
19.51
1.00
25120
REMOVAL OF FOREARM LESION
22.22
1.00
25125
REMOVE/GRAFT FOREARM LESION
3.00
1.00
25125
REMOVE/GRAFT FOREARM LESION
16.36
1.00
25125
REMOVE/GRAFT FOREARM LESION
21.91
1.00
25125
REMOVE/GRAFT FOREARM LESION
24.89
1.00
25126
REMOVE/GRAFT FOREARM LESION
3.00
1.00
25126
REMOVE/GRAFT FOREARM LESION
16.59
1.00
25126
REMOVE/GRAFT FOREARM LESION
22.06
1.00
25126
REMOVE/GRAFT FOREARM LESION
24.48
1.00
25130
REMOVAL OF WRIST LESION
3.00
1.00
25130
REMOVAL OF WRIST LESION
11.36
1.00
25130
REMOVAL OF WRIST LESION
12.56
1.00
25130
REMOVAL OF WRIST LESION
14.36
1.00
25135
REMOVE & GRAFT WRIST LESION
3.00
1.00
25135
REMOVE & GRAFT WRIST LESION
14.19
1.00
25135
REMOVE & GRAFT WRIST LESION
15.48
1.00
25135
REMOVE & GRAFT WRIST LESION
17.05
1.00
25136
REMOVE & GRAFT WRIST LESION
3.00
1.00
25136
REMOVE & GRAFT WRIST LESION
12.59
1.00
25136
REMOVE & GRAFT WRIST LESION
13.34
1.00
25136
REMOVE & GRAFT WRIST LESION
15.05
1.00
25145
REMOVE FOREARM BONE LESION
3.00
1.00
25145
REMOVE FOREARM BONE LESION
14.46
1.00
25145
REMOVE FOREARM BONE LESION
19.82
1.00
25145
REMOVE FOREARM BONE LESION
22.92
1.00
25150
PARTIAL REMOVAL OF ULNA
3.00
1.00
25150
PARTIAL REMOVAL OF ULNA
14.74
1.00
25150
PARTIAL REMOVAL OF ULNA
16.65
1.00
25150
PARTIAL REMOVAL OF ULNA
20.33
1.00
Procedure Code Description
RVU
RVU Coeff Value
25151
PARTIAL REMOVAL OF RADIUS
3.00
1.00
25151
PARTIAL REMOVAL OF RADIUS
16.29
1.00
25151
PARTIAL REMOVAL OF RADIUS
21.58
1.00
25151
PARTIAL REMOVAL OF RADIUS
24.60
1.00
25170
EXTENSIVE FOREARM SURGERY
4.00
1.00
25170
EXTENSIVE FOREARM SURGERY
22.71
1.00
25170
EXTENSIVE FOREARM SURGERY
28.36
1.00
25170
EXTENSIVE FOREARM SURGERY
30.37
1.00
25210
REMOVAL OF WRIST BONE
3.00
1.00
25210
REMOVAL OF WRIST BONE
12.45
1.00
25210
REMOVAL OF WRIST BONE
13.72
1.00
25210
REMOVAL OF WRIST BONE
15.52
1.00
25215
REMOVAL OF WRIST BONES
3.00
1.00
25215
REMOVAL OF WRIST BONES
16.06
1.00
25215
REMOVAL OF WRIST BONES
18.00
1.00
25215
REMOVAL OF WRIST BONES
21.43
1.00
25230
PARTIAL REMOVAL OF RADIUS
3.00
1.00
25230
PARTIAL REMOVAL OF RADIUS
11.03
1.00
25230
PARTIAL REMOVAL OF RADIUS
12.24
1.00
25230
PARTIAL REMOVAL OF RADIUS
14.24
1.00
25240
PARTIAL REMOVAL OF ULNA
3.00
1.00
25240
PARTIAL REMOVAL OF ULNA
11.19
1.00
25240
PARTIAL REMOVAL OF ULNA
13.08
1.00
25240
PARTIAL REMOVAL OF ULNA
16.93
1.00
25246
INJECTION FOR WRIST X-RAY
2.01
1.00
25246
INJECTION FOR WRIST X-RAY
2.02
1.00
25246
INJECTION FOR WRIST X-RAY
2.08
1.00
25246
INJECTION FOR WRIST X-RAY
3.00
1.00
25248
REMOVE FOREARM FOREIGN BODY
3.00
1.00
25248
REMOVE FOREARM FOREIGN BODY
11.11
1.00
25248
REMOVE FOREARM FOREIGN BODY
14.53
1.00
25248
REMOVE FOREARM FOREIGN BODY
15.91
1.00
25250
REMOVAL OF WRIST PROSTHESIS
5.00
1.00
25250
REMOVAL OF WRIST PROSTHESIS
13.26
1.00
25250
REMOVAL OF WRIST PROSTHESIS
13.60
1.00
Procedure Code Description
RVU
RVU Coeff Value
25250
REMOVAL OF WRIST PROSTHESIS
13.63
1.00
25251
REMOVAL OF WRIST PROSTHESIS
5.00
1.00
25251
REMOVAL OF WRIST PROSTHESIS
18.07
1.00
25251
REMOVAL OF WRIST PROSTHESIS
18.77
1.00
25251
REMOVAL OF WRIST PROSTHESIS
18.80
1.00
25259
MANIPULATE WRIST W/ANESTHES
3.00
1.00
25259
MANIPULATE WRIST W/ANESTHES
9.71
1.00
25259
MANIPULATE WRIST W/ANESTHES
9.81
1.00
25259
MANIPULATE WRIST W/ANESTHES
9.82
1.00
25260
REPAIR FOREARM TENDON/MUSCLE
3.00
1.00
25260
REPAIR FOREARM TENDON/MUSCLE
17.26
1.00
25260
REPAIR FOREARM TENDON/MUSCLE
22.86
1.00
25260
REPAIR FOREARM TENDON/MUSCLE
25.89
1.00
25263
REPAIR FOREARM TENDON/MUSCLE
3.00
1.00
25263
REPAIR FOREARM TENDON/MUSCLE
17.23
1.00
25263
REPAIR FOREARM TENDON/MUSCLE
22.75
1.00
25263
REPAIR FOREARM TENDON/MUSCLE
25.75
1.00
25265
REPAIR FOREARM TENDON/MUSCLE
3.00
1.00
25265
REPAIR FOREARM TENDON/MUSCLE
20.47
1.00
25265
REPAIR FOREARM TENDON/MUSCLE
26.01
1.00
25265
REPAIR FOREARM TENDON/MUSCLE
28.78
1.00
25270
REPAIR FOREARM TENDON/MUSCLE
3.00
1.00
25270
REPAIR FOREARM TENDON/MUSCLE
13.86
1.00
25270
REPAIR FOREARM TENDON/MUSCLE
19.51
1.00
25270
REPAIR FOREARM TENDON/MUSCLE
22.93
1.00
25272
REPAIR FOREARM TENDON/MUSCLE
3.00
1.00
25272
REPAIR FOREARM TENDON/MUSCLE
15.61
1.00
25272
REPAIR FOREARM TENDON/MUSCLE
21.40
1.00
25272
REPAIR FOREARM TENDON/MUSCLE
24.67
1.00
25274
REPAIR FOREARM TENDON/MUSCLE
3.00
1.00
25274
REPAIR FOREARM TENDON/MUSCLE
18.51
1.00
25274
REPAIR FOREARM TENDON/MUSCLE
24.13
1.00
25274
REPAIR FOREARM TENDON/MUSCLE
27.06
1.00
25275
REPAIR FOREARM TENDON SHEATH
3.00
1.00
25275
REPAIR FOREARM TENDON SHEATH
17.06
1.00
Procedure Code Description
RVU
RVU Coeff Value
25275
REPAIR FOREARM TENDON SHEATH
17.07
1.00
25275
REPAIR FOREARM TENDON SHEATH
17.32
1.00
25280
REVISE WRIST/FOREARM TENDON
3.00
1.00
25280
REVISE WRIST/FOREARM TENDON
15.80
1.00
25280
REVISE WRIST/FOREARM TENDON
21.34
1.00
25280
REVISE WRIST/FOREARM TENDON
24.42
1.00
25290
INCISE WRIST/FOREARM TENDON
3.00
1.00
25290
INCISE WRIST/FOREARM TENDON
13.37
1.00
25290
INCISE WRIST/FOREARM TENDON
21.61
1.00
25290
INCISE WRIST/FOREARM TENDON
24.57
1.00
25295
RELEASE WRIST/FOREARM TENDON
3.00
1.00
25295
RELEASE WRIST/FOREARM TENDON
14.71
1.00
25295
RELEASE WRIST/FOREARM TENDON
20.17
1.00
25295
RELEASE WRIST/FOREARM TENDON
23.34
1.00
25300
FUSION OF TENDONS AT WRIST
3.00
1.00
25300
FUSION OF TENDONS AT WRIST
17.36
1.00
25300
FUSION OF TENDONS AT WRIST
18.60
1.00
25300
FUSION OF TENDONS AT WRIST
19.93
1.00
25301
FUSION OF TENDONS AT WRIST
3.00
1.00
25301
FUSION OF TENDONS AT WRIST
16.56
1.00
25301
FUSION OF TENDONS AT WRIST
17.85
1.00
25301
FUSION OF TENDONS AT WRIST
19.46
1.00
25310
TRANSPLANT FOREARM TENDON
3.00
1.00
25310
TRANSPLANT FOREARM TENDON
17.12
1.00
25310
TRANSPLANT FOREARM TENDON
22.79
1.00
25310
TRANSPLANT FOREARM TENDON
25.89
1.00
25312
TRANSPLANT FOREARM TENDON
3.00
1.00
25312
TRANSPLANT FOREARM TENDON
19.82
1.00
25312
TRANSPLANT FOREARM TENDON
25.35
1.00
25312
TRANSPLANT FOREARM TENDON
28.28
1.00
25315
REVISE PALSY HAND TENDON(S)
3.00
1.00
25315
REVISE PALSY HAND TENDON(S)
21.27
1.00
25315
REVISE PALSY HAND TENDON(S)
26.59
1.00
25315
REVISE PALSY HAND TENDON(S)
29.77
1.00
25316
REVISE PALSY HAND TENDON(S)
3.00
1.00
Procedure Code Description
RVU
RVU Coeff Value
25316
REVISE PALSY HAND TENDON(S)
24.57
1.00
25316
REVISE PALSY HAND TENDON(S)
31.07
1.00
25316
REVISE PALSY HAND TENDON(S)
33.78
1.00
25320
REPAIR/REVISE WRIST JOINT
3.00
1.00
25320
REPAIR/REVISE WRIST JOINT
23.55
1.00
25320
REPAIR/REVISE WRIST JOINT
23.59
1.00
25320
REPAIR/REVISE WRIST JOINT
24.39
1.00
25332
REVISE WRIST JOINT
3.00
1.00
25332
REVISE WRIST JOINT
21.67
1.00
25332
REVISE WRIST JOINT
22.21
1.00
25335
REALIGNMENT OF HAND
3.00
1.00
25335
REALIGNMENT OF HAND
24.55
1.00
25335
REALIGNMENT OF HAND
26.58
1.00
25335
REALIGNMENT OF HAND
29.49
1.00
25337
RECONSTRUCT ULNA/RADIOULNAR
3.00
1.00
25337
RECONSTRUCT ULNA/RADIOULNAR
22.49
1.00
25337
RECONSTRUCT ULNA/RADIOULNAR
22.80
1.00
25337
RECONSTRUCT ULNA/RADIOULNAR
25.33
1.00
25350
REVISION OF RADIUS
3.00
1.00
25350
REVISION OF RADIUS
18.89
1.00
25350
REVISION OF RADIUS
24.46
1.00
25350
REVISION OF RADIUS
26.93
1.00
25355
REVISION OF RADIUS
3.00
1.00
25355
REVISION OF RADIUS
21.27
1.00
25355
REVISION OF RADIUS
26.79
1.00
25355
REVISION OF RADIUS
29.21
1.00
25360
REVISION OF ULNA
3.00
1.00
25360
REVISION OF ULNA
18.33
1.00
25360
REVISION OF ULNA
24.00
1.00
25360
REVISION OF ULNA
26.49
1.00
25365
REVISE RADIUS & ULNA
3.00
1.00
25365
REVISE RADIUS & ULNA
25.02
1.00
25365
REVISE RADIUS & ULNA
30.32
1.00
25365
REVISE RADIUS & ULNA
32.58
1.00
25370
REVISE RADIUS OR ULNA
3.00
1.00
Procedure Code Description
RVU
RVU Coeff Value
25370
REVISE RADIUS OR ULNA
27.25
1.00
25370
REVISE RADIUS OR ULNA
31.91
1.00
25370
REVISE RADIUS OR ULNA
33.66
1.00
25375
REVISE RADIUS & ULNA
3.00
1.00
25375
REVISE RADIUS & ULNA
26.32
1.00
25375
REVISE RADIUS & ULNA
31.96
1.00
25375
REVISE RADIUS & ULNA
34.30
1.00
25390
SHORTEN RADIUS OR ULNA
3.00
1.00
25390
SHORTEN RADIUS OR ULNA
21.36
1.00
25390
SHORTEN RADIUS OR ULNA
26.95
1.00
25390
SHORTEN RADIUS OR ULNA
29.47
1.00
25391
LENGTHEN RADIUS OR ULNA
3.00
1.00
25391
LENGTHEN RADIUS OR ULNA
27.18
1.00
25391
LENGTHEN RADIUS OR ULNA
32.59
1.00
25391
LENGTHEN RADIUS OR ULNA
34.75
1.00
25392
SHORTEN RADIUS & ULNA
3.00
1.00
25392
SHORTEN RADIUS & ULNA
27.54
1.00
25392
SHORTEN RADIUS & ULNA
32.26
1.00
25392
SHORTEN RADIUS & ULNA
34.05
1.00
25393
LENGTHEN RADIUS & ULNA
3.00
1.00
25393
LENGTHEN RADIUS & ULNA
31.08
1.00
25393
LENGTHEN RADIUS & ULNA
35.99
1.00
25393
LENGTHEN RADIUS & ULNA
38.37
1.00
25394
REPAIR CARPAL BONE, SHORTEN
3.00
1.00
25394
REPAIR CARPAL BONE, SHORTEN
19.87
1.00
25394
REPAIR CARPAL BONE, SHORTEN
20.09
1.00
25394
REPAIR CARPAL BONE, SHORTEN
20.30
1.00
25400
REPAIR RADIUS OR ULNA
4.00
1.00
25400
REPAIR RADIUS OR ULNA
22.44
1.00
25400
REPAIR RADIUS OR ULNA
28.20
1.00
25400
REPAIR RADIUS OR ULNA
30.64
1.00
25405
REPAIR/GRAFT RADIUS OR ULNA
4.00
1.00
25405
REPAIR/GRAFT RADIUS OR ULNA
28.52
1.00
25405
REPAIR/GRAFT RADIUS OR ULNA
34.29
1.00
25405
REPAIR/GRAFT RADIUS OR ULNA
36.81
1.00
Procedure Code Description
RVU
RVU Coeff Value
25415
REPAIR RADIUS & ULNA
4.00
1.00
25415
REPAIR RADIUS & ULNA
26.80
1.00
25415
REPAIR RADIUS & ULNA
32.40
1.00
25415
REPAIR RADIUS & ULNA
34.61
1.00
25420
REPAIR/GRAFT RADIUS & ULNA
4.00
1.00
25420
REPAIR/GRAFT RADIUS & ULNA
31.90
1.00
25420
REPAIR/GRAFT RADIUS & ULNA
37.52
1.00
25420
REPAIR/GRAFT RADIUS & ULNA
39.87
1.00
25425
REPAIR/GRAFT RADIUS OR ULNA
3.00
1.00
25425
REPAIR/GRAFT RADIUS OR ULNA
27.54
1.00
25425
REPAIR/GRAFT RADIUS OR ULNA
37.21
1.00
25425
REPAIR/GRAFT RADIUS OR ULNA
41.62
1.00
25426
REPAIR/GRAFT RADIUS & ULNA
3.00
1.00
25426
REPAIR/GRAFT RADIUS & ULNA
28.92
1.00
25426
REPAIR/GRAFT RADIUS & ULNA
35.78
1.00
25426
REPAIR/GRAFT RADIUS & ULNA
38.17
1.00
25430
VASC GRAFT INTO CARPAL BONE
3.00
1.00
25430
VASC GRAFT INTO CARPAL BONE
17.81
1.00
25430
VASC GRAFT INTO CARPAL BONE
17.94
1.00
25430
VASC GRAFT INTO CARPAL BONE
18.06
1.00
25431
REPAIR NONUNION CARPAL BONE
3.00
1.00
25431
REPAIR NONUNION CARPAL BONE
17.38
1.00
25431
REPAIR NONUNION CARPAL BONE
19.33
1.00
25431
REPAIR NONUNION CARPAL BONE
20.17
1.00
25440
REPAIR/GRAFT WRIST BONE
3.00
1.00
25440
REPAIR/GRAFT WRIST BONE
19.96
1.00
25440
REPAIR/GRAFT WRIST BONE
21.53
1.00
25440
REPAIR/GRAFT WRIST BONE
23.10
1.00
25441
RECONSTRUCT WRIST JOINT
3.00
1.00
25441
RECONSTRUCT WRIST JOINT
24.22
1.00
25441
RECONSTRUCT WRIST JOINT
24.87
1.00
25441
RECONSTRUCT WRIST JOINT
24.97
1.00
25442
RECONSTRUCT WRIST JOINT
3.00
1.00
25442
RECONSTRUCT WRIST JOINT
20.56
1.00
25442
RECONSTRUCT WRIST JOINT
21.09
1.00
Procedure Code Description
RVU
RVU Coeff Value
25442
RECONSTRUCT WRIST JOINT
21.10
1.00
25443
RECONSTRUCT WRIST JOINT
3.00
1.00
25443
RECONSTRUCT WRIST JOINT
19.69
1.00
25443
RECONSTRUCT WRIST JOINT
20.58
1.00
25443
RECONSTRUCT WRIST JOINT
20.59
1.00
25444
RECONSTRUCT WRIST JOINT
3.00
1.00
25444
RECONSTRUCT WRIST JOINT
21.09
1.00
25444
RECONSTRUCT WRIST JOINT
21.75
1.00
25444
RECONSTRUCT WRIST JOINT
21.92
1.00
25445
RECONSTRUCT WRIST JOINT
3.00
1.00
25445
RECONSTRUCT WRIST JOINT
18.48
1.00
25445
RECONSTRUCT WRIST JOINT
19.07
1.00
25445
RECONSTRUCT WRIST JOINT
19.13
1.00
25446
WRIST REPLACEMENT
3.00
1.00
25446
WRIST REPLACEMENT
30.40
1.00
25446
WRIST REPLACEMENT
30.92
1.00
25446
WRIST REPLACEMENT
30.99
1.00
25447
REPAIR WRIST JOINT(S)
3.00
1.00
25447
REPAIR WRIST JOINT(S)
20.47
1.00
25447
REPAIR WRIST JOINT(S)
20.51
1.00
25447
REPAIR WRIST JOINT(S)
20.81
1.00
25449
REMOVE WRIST JOINT IMPLANT
3.00
1.00
25449
REMOVE WRIST JOINT IMPLANT
26.65
1.00
25449
REMOVE WRIST JOINT IMPLANT
27.15
1.00
25449
REMOVE WRIST JOINT IMPLANT
27.17
1.00
25450
REVISION OF WRIST JOINT
3.00
1.00
25450
REVISION OF WRIST JOINT
15.51
1.00
25450
REVISION OF WRIST JOINT
19.33
1.00
25450
REVISION OF WRIST JOINT
21.84
1.00
25455
REVISION OF WRIST JOINT
3.00
1.00
25455
REVISION OF WRIST JOINT
17.47
1.00
25455
REVISION OF WRIST JOINT
22.10
1.00
25455
REVISION OF WRIST JOINT
24.84
1.00
25490
REINFORCE RADIUS
3.00
1.00
25490
REINFORCE RADIUS
19.41
1.00
Procedure Code Description
RVU
RVU Coeff Value
25490
REINFORCE RADIUS
25.00
1.00
25490
REINFORCE RADIUS
27.44
1.00
25491
REINFORCE ULNA
3.00
1.00
25491
REINFORCE ULNA
20.52
1.00
25491
REINFORCE ULNA
26.44
1.00
25491
REINFORCE ULNA
28.95
1.00
25492
REINFORCE RADIUS AND ULNA
3.00
1.00
25492
REINFORCE RADIUS AND ULNA
24.80
1.00
25492
REINFORCE RADIUS AND ULNA
29.84
1.00
25492
REINFORCE RADIUS AND ULNA
32.01
1.00
25500
TREAT FRACTURE OF RADIUS
3.00
1.00
25500
TREAT FRACTURE OF RADIUS
5.50
1.00
25500
TREAT FRACTURE OF RADIUS
5.66
1.00
25500
TREAT FRACTURE OF RADIUS
5.69
1.00
25505
TREAT FRACTURE OF RADIUS
3.00
1.00
25505
TREAT FRACTURE OF RADIUS
11.28
1.00
25505
TREAT FRACTURE OF RADIUS
11.34
1.00
25505
TREAT FRACTURE OF RADIUS
11.71
1.00
25515
TREAT FRACTURE OF RADIUS
3.00
1.00
25515
TREAT FRACTURE OF RADIUS
17.10
1.00
25515
TREAT FRACTURE OF RADIUS
18.11
1.00
25515
TREAT FRACTURE OF RADIUS
20.40
1.00
25520
TREAT FRACTURE OF RADIUS
5.00
1.00
25520
TREAT FRACTURE OF RADIUS
12.92
1.00
25520
TREAT FRACTURE OF RADIUS
13.15
1.00
25520
TREAT FRACTURE OF RADIUS
13.54
1.00
25525
TREAT FRACTURE OF RADIUS
5.00
1.00
25525
TREAT FRACTURE OF RADIUS
20.74
1.00
25525
TREAT FRACTURE OF RADIUS
24.19
1.00
25525
TREAT FRACTURE OF RADIUS
25.84
1.00
25526
TREAT FRACTURE OF RADIUS
5.00
1.00
25526
TREAT FRACTURE OF RADIUS
25.32
1.00
25526
TREAT FRACTURE OF RADIUS
28.72
1.00
25526
TREAT FRACTURE OF RADIUS
30.18
1.00
25530
TREAT FRACTURE OF ULNA
3.00
1.00
Procedure Code Description
RVU
RVU Coeff Value
25530
TREAT FRACTURE OF ULNA
5.22
1.00
25530
TREAT FRACTURE OF ULNA
5.28
1.00
25530
TREAT FRACTURE OF ULNA
5.44
1.00
25535
TREAT FRACTURE OF ULNA
3.00
1.00
25535
TREAT FRACTURE OF ULNA
11.12
1.00
25535
TREAT FRACTURE OF ULNA
11.15
1.00
25535
TREAT FRACTURE OF ULNA
11.68
1.00
25545
TREAT FRACTURE OF ULNA
3.00
1.00
25545
TREAT FRACTURE OF ULNA
16.02
1.00
25545
TREAT FRACTURE OF ULNA
18.02
1.00
25545
TREAT FRACTURE OF ULNA
20.27
1.00
25560
TREAT FRACTURE RADIUS & ULNA
3.00
1.00
25560
TREAT FRACTURE RADIUS & ULNA
5.41
1.00
25560
TREAT FRACTURE RADIUS & ULNA
5.61
1.00
25560
TREAT FRACTURE RADIUS & ULNA
5.66
1.00
25565
TREAT FRACTURE RADIUS & ULNA
3.00
1.00
25565
TREAT FRACTURE RADIUS & ULNA
11.77
1.00
25565
TREAT FRACTURE RADIUS & ULNA
11.86
1.00
25565
TREAT FRACTURE RADIUS & ULNA
12.41
1.00
25574
TREAT FRACTURE RADIUS & ULNA
5.00
1.00
25574
TREAT FRACTURE RADIUS & ULNA
15.29
1.00
25574
TREAT FRACTURE RADIUS & ULNA
16.70
1.00
25574
TREAT FRACTURE RADIUS & ULNA
17.02
1.00
25575
TREAT FRACTURE RADIUS/ULNA
3.00
1.00
25575
TREAT FRACTURE RADIUS/ULNA
21.58
1.00
25575
TREAT FRACTURE RADIUS/ULNA
22.78
1.00
25575
TREAT FRACTURE RADIUS/ULNA
22.89
1.00
25600
TREAT FRACTURE RADIUS/ULNA
3.00
1.00
25600
TREAT FRACTURE RADIUS/ULNA
5.98
1.00
25600
TREAT FRACTURE RADIUS/ULNA
6.08
1.00
25600
TREAT FRACTURE RADIUS/ULNA
6.24
1.00
25605
TREAT FRACTURE RADIUS/ULNA
3.00
1.00
25605
TREAT FRACTURE RADIUS/ULNA
12.79
1.00
25605
TREAT FRACTURE RADIUS/ULNA
12.89
1.00
25605
TREAT FRACTURE RADIUS/ULNA
14.24
1.00
Procedure Code Description
RVU
RVU Coeff Value
25606
TREAT FX DISTAL RADIAL
16.74
1.00
25607
TREAT FX RAD EXTRA-ARTICUL
18.08
1.00
25608
TREAT FX RAD INTRA-ARTICUL
20.72
1.00
25609
TREAT FX RADIAL 3+ FRAG
26.46
1.00
25611
TREAT FRACTURE RADIUS/ULNA
3.00
1.00
25611
TREAT FRACTURE RADIUS/ULNA
17.90
1.00
25611
TREAT FRACTURE RADIUS/ULNA
18.09
1.00
25611
TREAT FRACTURE RADIUS/ULNA
19.22
1.00
25620
TREAT FRACTURE RADIUS/ULNA
4.00
1.00
25620
TREAT FRACTURE RADIUS/ULNA
17.23
1.00
25620
TREAT FRACTURE RADIUS/ULNA
17.24
1.00
25620
TREAT FRACTURE RADIUS/ULNA
19.63
1.00
25622
TREAT WRIST BONE FRACTURE
3.00
1.00
25622
TREAT WRIST BONE FRACTURE
6.02
1.00
25622
TREAT WRIST BONE FRACTURE
6.13
1.00
25622
TREAT WRIST BONE FRACTURE
6.37
1.00
25624
TREAT WRIST BONE FRACTURE
3.00
1.00
25624
TREAT WRIST BONE FRACTURE
10.16
1.00
25624
TREAT WRIST BONE FRACTURE
10.27
1.00
25624
TREAT WRIST BONE FRACTURE
10.63
1.00
25628
TREAT WRIST BONE FRACTURE
3.00
1.00
25628
TREAT WRIST BONE FRACTURE
17.60
1.00
25628
TREAT WRIST BONE FRACTURE
18.16
1.00
25628
TREAT WRIST BONE FRACTURE
19.52
1.00
25630
TREAT WRIST BONE FRACTURE
3.00
1.00
25630
TREAT WRIST BONE FRACTURE
6.27
1.00
25630
TREAT WRIST BONE FRACTURE
6.39
1.00
25630
TREAT WRIST BONE FRACTURE
6.56
1.00
25635
TREAT WRIST BONE FRACTURE
3.00
1.00
25635
TREAT WRIST BONE FRACTURE
8.74
1.00
25635
TREAT WRIST BONE FRACTURE
9.51
1.00
25635
TREAT WRIST BONE FRACTURE
9.53
1.00
25645
TREAT WRIST BONE FRACTURE
3.00
1.00
25645
TREAT WRIST BONE FRACTURE
14.37
1.00
25645
TREAT WRIST BONE FRACTURE
15.15
1.00
Procedure Code Description
RVU
RVU Coeff Value
25645
TREAT WRIST BONE FRACTURE
17.65
1.00
25650
TREAT WRIST BONE FRACTURE
3.00
1.00
25650
TREAT WRIST BONE FRACTURE
6.63
1.00
25650
TREAT WRIST BONE FRACTURE
6.72
1.00
25650
TREAT WRIST BONE FRACTURE
6.96
1.00
25651
PIN ULNAR STYLOID FRACTURE
3.00
1.00
25651
PIN ULNAR STYLOID FRACTURE
11.61
1.00
25651
PIN ULNAR STYLOID FRACTURE
11.77
1.00
25651
PIN ULNAR STYLOID FRACTURE
11.85
1.00
25652
TREAT FRACTURE ULNAR STYLOID
3.00
1.00
25652
TREAT FRACTURE ULNAR STYLOID
15.47
1.00
25652
TREAT FRACTURE ULNAR STYLOID
15.63
1.00
25652
TREAT FRACTURE ULNAR STYLOID
15.67
1.00
25660
TREAT WRIST DISLOCATION
3.00
1.00
25660
TREAT WRIST DISLOCATION
9.85
1.00
25660
TREAT WRIST DISLOCATION
10.12
1.00
25660
TREAT WRIST DISLOCATION
10.84
1.00
25670
TREAT WRIST DISLOCATION
3.00
1.00
25670
TREAT WRIST DISLOCATION
15.50
1.00
25670
TREAT WRIST DISLOCATION
16.28
1.00
25670
TREAT WRIST DISLOCATION
18.72
1.00
25671
PIN RADIOULNAR DISLOCATION
3.00
1.00
25671
PIN RADIOULNAR DISLOCATION
12.83
1.00
25671
PIN RADIOULNAR DISLOCATION
12.95
1.00
25671
PIN RADIOULNAR DISLOCATION
13.06
1.00
25675
TREAT WRIST DISLOCATION
3.00
1.00
25675
TREAT WRIST DISLOCATION
9.62
1.00
25675
TREAT WRIST DISLOCATION
9.96
1.00
25675
TREAT WRIST DISLOCATION
10.67
1.00
25676
TREAT WRIST DISLOCATION
3.00
1.00
25676
TREAT WRIST DISLOCATION
16.06
1.00
25676
TREAT WRIST DISLOCATION
16.68
1.00
25676
TREAT WRIST DISLOCATION
18.92
1.00
25680
TREAT WRIST FRACTURE
3.00
1.00
25680
TREAT WRIST FRACTURE
11.41
1.00
Procedure Code Description
RVU
RVU Coeff Value
25680
TREAT WRIST FRACTURE
11.47
1.00
25680
TREAT WRIST FRACTURE
13.08
1.00
25685
TREAT WRIST FRACTURE
3.00
1.00
25685
TREAT WRIST FRACTURE
18.69
1.00
25685
TREAT WRIST FRACTURE
19.15
1.00
25685
TREAT WRIST FRACTURE
21.47
1.00
25690
TREAT WRIST DISLOCATION
3.00
1.00
25690
TREAT WRIST DISLOCATION
11.57
1.00
25690
TREAT WRIST DISLOCATION
11.82
1.00
25690
TREAT WRIST DISLOCATION
13.49
1.00
25695
TREAT WRIST DISLOCATION
3.00
1.00
25695
TREAT WRIST DISLOCATION
16.10
1.00
25695
TREAT WRIST DISLOCATION
16.81
1.00
25695
TREAT WRIST DISLOCATION
19.27
1.00
25800
FUSION OF WRIST JOINT
3.00
1.00
25800
FUSION OF WRIST JOINT
19.05
1.00
25800
FUSION OF WRIST JOINT
20.42
1.00
25800
FUSION OF WRIST JOINT
21.98
1.00
25805
FUSION/GRAFT OF WRIST JOINT
3.00
1.00
25805
FUSION/GRAFT OF WRIST JOINT
21.96
1.00
25805
FUSION/GRAFT OF WRIST JOINT
23.32
1.00
25805
FUSION/GRAFT OF WRIST JOINT
24.60
1.00
25810
FUSION/GRAFT OF WRIST JOINT
3.00
1.00
25810
FUSION/GRAFT OF WRIST JOINT
22.08
1.00
25810
FUSION/GRAFT OF WRIST JOINT
22.12
1.00
25810
FUSION/GRAFT OF WRIST JOINT
23.28
1.00
25820
FUSION OF HAND BONES
3.00
1.00
25820
FUSION OF HAND BONES
15.56
1.00
25820
FUSION OF HAND BONES
16.48
1.00
25820
FUSION OF HAND BONES
18.09
1.00
25825
FUSE HAND BONES WITH GRAFT
3.00
1.00
25825
FUSE HAND BONES WITH GRAFT
19.14
1.00
25825
FUSE HAND BONES WITH GRAFT
19.93
1.00
25825
FUSE HAND BONES WITH GRAFT
21.13
1.00
25830
FUSION, RADIOULNAR JNT/ULNA
3.00
1.00
Procedure Code Description
RVU
RVU Coeff Value
25830
FUSION, RADIOULNAR JNT/ULNA
23.87
1.00
25830
FUSION, RADIOULNAR JNT/ULNA
26.26
1.00
25830
FUSION, RADIOULNAR JNT/ULNA
28.45
1.00
25900
AMPUTATION OF FOREARM
4.00
1.00
25900
AMPUTATION OF FOREARM
19.04
1.00
25900
AMPUTATION OF FOREARM
23.19
1.00
25900
AMPUTATION OF FOREARM
24.57
1.00
25905
AMPUTATION OF FOREARM
3.00
1.00
25905
AMPUTATION OF FOREARM
18.86
1.00
25905
AMPUTATION OF FOREARM
23.21
1.00
25905
AMPUTATION OF FOREARM
25.93
1.00
25907
AMPUTATION FOLLOW-UP SURGERY
3.00
1.00
25907
AMPUTATION FOLLOW-UP SURGERY
16.43
1.00
25907
AMPUTATION FOLLOW-UP SURGERY
21.22
1.00
25907
AMPUTATION FOLLOW-UP SURGERY
24.00
1.00
25909
AMPUTATION FOLLOW-UP SURGERY
3.00
1.00
25909
AMPUTATION FOLLOW-UP SURGERY
18.57
1.00
25909
AMPUTATION FOLLOW-UP SURGERY
23.00
1.00
25909
AMPUTATION FOLLOW-UP SURGERY
25.65
1.00
25915
AMPUTATION OF FOREARM
5.00
1.00
25915
AMPUTATION OF FOREARM
32.62
1.00
25915
AMPUTATION OF FOREARM
39.47
1.00
25915
AMPUTATION OF FOREARM
42.63
1.00
25920
AMPUTATE HAND AT WRIST
3.00
1.00
25920
AMPUTATE HAND AT WRIST
17.45
1.00
25920
AMPUTATE HAND AT WRIST
17.95
1.00
25920
AMPUTATE HAND AT WRIST
19.65
1.00
25922
AMPUTATE HAND AT WRIST
3.00
1.00
25922
AMPUTATE HAND AT WRIST
14.74
1.00
25922
AMPUTATE HAND AT WRIST
15.78
1.00
25922
AMPUTATE HAND AT WRIST
17.41
1.00
25924
AMPUTATION FOLLOW-UP SURGERY
3.00
1.00
25924
AMPUTATION FOLLOW-UP SURGERY
17.04
1.00
25924
AMPUTATION FOLLOW-UP SURGERY
17.96
1.00
25924
AMPUTATION FOLLOW-UP SURGERY
19.78
1.00
Procedure Code Description
RVU
RVU Coeff Value
25927
AMPUTATION OF HAND
5.00
1.00
25927
AMPUTATION OF HAND
19.74
1.00
25927
AMPUTATION OF HAND
22.17
1.00
25927
AMPUTATION OF HAND
24.00
1.00
25929
AMPUTATION FOLLOW-UP SURGERY
3.00
1.00
25929
AMPUTATION FOLLOW-UP SURGERY
14.27
1.00
25929
AMPUTATION FOLLOW-UP SURGERY
14.71
1.00
25929
AMPUTATION FOLLOW-UP SURGERY
16.31
1.00
25931
AMPUTATION FOLLOW-UP SURGERY
3.00
1.00
25931
AMPUTATION FOLLOW-UP SURGERY
17.99
1.00
25931
AMPUTATION FOLLOW-UP SURGERY
20.92
1.00
25931
AMPUTATION FOLLOW-UP SURGERY
23.78
1.00
26010
DRAINAGE OF FINGER ABSCESS
3.00
1.00
26010
DRAINAGE OF FINGER ABSCESS
3.29
1.00
26010
DRAINAGE OF FINGER ABSCESS
3.37
1.00
26010
DRAINAGE OF FINGER ABSCESS
3.46
1.00
26011
DRAINAGE OF FINGER ABSCESS
3.00
1.00
26011
DRAINAGE OF FINGER ABSCESS
4.62
1.00
26011
DRAINAGE OF FINGER ABSCESS
4.80
1.00
26011
DRAINAGE OF FINGER ABSCESS
4.92
1.00
26020
DRAIN HAND TENDON SHEATH
3.00
1.00
26020
DRAIN HAND TENDON SHEATH
10.57
1.00
26020
DRAIN HAND TENDON SHEATH
10.65
1.00
26020
DRAIN HAND TENDON SHEATH
10.94
1.00
26025
DRAINAGE OF PALM BURSA
3.00
1.00
26025
DRAINAGE OF PALM BURSA
10.42
1.00
26025
DRAINAGE OF PALM BURSA
10.60
1.00
26025
DRAINAGE OF PALM BURSA
10.89
1.00
26030
DRAINAGE OF PALM BURSA(S)
4.00
1.00
26030
DRAINAGE OF PALM BURSA(S)
12.32
1.00
26030
DRAINAGE OF PALM BURSA(S)
12.50
1.00
26030
DRAINAGE OF PALM BURSA(S)
12.79
1.00
26034
TREAT HAND BONE LESION
3.00
1.00
26034
TREAT HAND BONE LESION
13.06
1.00
26034
TREAT HAND BONE LESION
13.36
1.00
Procedure Code Description 26034
TREAT HAND BONE LESION
26035
RVU
RVU Coeff Value
13.44
1.00
DECOMPRESS FINGERS/HAND
3.00
1.00
26035
DECOMPRESS FINGERS/HAND
18.62
1.00
26035
DECOMPRESS FINGERS/HAND
18.95
1.00
26035
DECOMPRESS FINGERS/HAND
20.77
1.00
26037
DECOMPRESS FINGERS/HAND
3.00
1.00
26037
DECOMPRESS FINGERS/HAND
14.40
1.00
26037
DECOMPRESS FINGERS/HAND
14.60
1.00
26037
DECOMPRESS FINGERS/HAND
14.89
1.00
26040
RELEASE PALM CONTRACTURE
3.00
1.00
26040
RELEASE PALM CONTRACTURE
7.53
1.00
26040
RELEASE PALM CONTRACTURE
7.64
1.00
26040
RELEASE PALM CONTRACTURE
7.86
1.00
26045
RELEASE PALM CONTRACTURE
3.00
1.00
26045
RELEASE PALM CONTRACTURE
11.60
1.00
26045
RELEASE PALM CONTRACTURE
11.69
1.00
26045
RELEASE PALM CONTRACTURE
12.00
1.00
26055
INCISE FINGER TENDON SHEATH
3.00
1.00
26055
INCISE FINGER TENDON SHEATH
6.64
1.00
26055
INCISE FINGER TENDON SHEATH
6.97
1.00
26055
INCISE FINGER TENDON SHEATH
7.30
1.00
26060
INCISION OF FINGER TENDON
3.00
1.00
26060
INCISION OF FINGER TENDON
6.44
1.00
26060
INCISION OF FINGER TENDON
6.54
1.00
26060
INCISION OF FINGER TENDON
6.68
1.00
26070
EXPLORE/TREAT HAND JOINT
3.00
1.00
26070
EXPLORE/TREAT HAND JOINT
7.36
1.00
26070
EXPLORE/TREAT HAND JOINT
7.43
1.00
26070
EXPLORE/TREAT HAND JOINT
7.46
1.00
26075
EXPLORE/TREAT FINGER JOINT
3.00
1.00
26075
EXPLORE/TREAT FINGER JOINT
7.86
1.00
26075
EXPLORE/TREAT FINGER JOINT
7.88
1.00
26075
EXPLORE/TREAT FINGER JOINT
8.02
1.00
26080
EXPLORE/TREAT FINGER JOINT
3.00
1.00
26080
EXPLORE/TREAT FINGER JOINT
9.34
1.00
Procedure Code Description
RVU
RVU Coeff Value
26080
EXPLORE/TREAT FINGER JOINT
9.52
1.00
26080
EXPLORE/TREAT FINGER JOINT
9.64
1.00
26100
BIOPSY HAND JOINT LINING
3.00
1.00
26100
BIOPSY HAND JOINT LINING
7.99
1.00
26100
BIOPSY HAND JOINT LINING
8.02
1.00
26100
BIOPSY HAND JOINT LINING
8.30
1.00
26105
BIOPSY FINGER JOINT LINING
3.00
1.00
26105
BIOPSY FINGER JOINT LINING
8.09
1.00
26105
BIOPSY FINGER JOINT LINING
8.19
1.00
26105
BIOPSY FINGER JOINT LINING
8.41
1.00
26110
BIOPSY FINGER JOINT LINING
3.00
1.00
26110
BIOPSY FINGER JOINT LINING
7.77
1.00
26110
BIOPSY FINGER JOINT LINING
7.85
1.00
26110
BIOPSY FINGER JOINT LINING
8.03
1.00
26115
REMOVAL HAND LESION SUBCUT
3.00
1.00
26115
REMOVAL HAND LESION SUBCUT
8.77
1.00
26115
REMOVAL HAND LESION SUBCUT
8.90
1.00
26115
REMOVAL HAND LESION SUBCUT
9.10
1.00
26116
REMOVAL HAND LESION, DEEP
3.00
1.00
26116
REMOVAL HAND LESION, DEEP
11.88
1.00
26116
REMOVAL HAND LESION, DEEP
11.99
1.00
26116
REMOVAL HAND LESION, DEEP
12.27
1.00
26117
REMOVE TUMOR, HAND/FINGER
3.00
1.00
26117
REMOVE TUMOR, HAND/FINGER
16.40
1.00
26117
REMOVE TUMOR, HAND/FINGER
16.50
1.00
26117
REMOVE TUMOR, HAND/FINGER
16.79
1.00
26121
RELEASE PALM CONTRACTURE
3.00
1.00
26121
RELEASE PALM CONTRACTURE
15.08
1.00
26121
RELEASE PALM CONTRACTURE
15.20
1.00
26121
RELEASE PALM CONTRACTURE
15.56
1.00
26123
RELEASE PALM CONTRACTURE
3.00
1.00
26123
RELEASE PALM CONTRACTURE
19.11
1.00
26123
RELEASE PALM CONTRACTURE
19.43
1.00
26123
RELEASE PALM CONTRACTURE
20.58
1.00
26125
RELEASE PALM CONTRACTURE
7.42
1.00
Procedure Code Description
RVU
RVU Coeff Value
26125
RELEASE PALM CONTRACTURE
7.69
1.00
26125
RELEASE PALM CONTRACTURE
7.75
1.00
26130
REMOVE WRIST JOINT LINING
3.00
1.00
26130
REMOVE WRIST JOINT LINING
11.19
1.00
26130
REMOVE WRIST JOINT LINING
11.44
1.00
26130
REMOVE WRIST JOINT LINING
11.49
1.00
26135
REVISE FINGER JOINT, EACH
3.00
1.00
26135
REVISE FINGER JOINT, EACH
13.90
1.00
26135
REVISE FINGER JOINT, EACH
14.03
1.00
26135
REVISE FINGER JOINT, EACH
14.39
1.00
26140
REVISE FINGER JOINT, EACH
3.00
1.00
26140
REVISE FINGER JOINT, EACH
12.62
1.00
26140
REVISE FINGER JOINT, EACH
12.68
1.00
26140
REVISE FINGER JOINT, EACH
13.05
1.00
26145
TENDON EXCISION, PALM/FINGER
3.00
1.00
26145
TENDON EXCISION, PALM/FINGER
12.84
1.00
26145
TENDON EXCISION, PALM/FINGER
12.87
1.00
26145
TENDON EXCISION, PALM/FINGER
13.22
1.00
26160
REMOVE TENDON SHEATH LESION
3.00
1.00
26160
REMOVE TENDON SHEATH LESION
7.40
1.00
26160
REMOVE TENDON SHEATH LESION
7.66
1.00
26160
REMOVE TENDON SHEATH LESION
7.96
1.00
26170
REMOVAL OF PALM TENDON, EACH
3.00
1.00
26170
REMOVAL OF PALM TENDON, EACH
10.07
1.00
26170
REMOVAL OF PALM TENDON, EACH
10.09
1.00
26170
REMOVAL OF PALM TENDON, EACH
10.36
1.00
26180
REMOVAL OF FINGER TENDON
3.00
1.00
26180
REMOVAL OF FINGER TENDON
10.92
1.00
26180
REMOVAL OF FINGER TENDON
11.02
1.00
26180
REMOVAL OF FINGER TENDON
11.29
1.00
26185
REMOVE FINGER BONE
3.00
1.00
26185
REMOVE FINGER BONE
11.54
1.00
26185
REMOVE FINGER BONE
11.96
1.00
26185
REMOVE FINGER BONE
13.13
1.00
26200
REMOVE HAND BONE LESION
3.00
1.00
Procedure Code Description
RVU
RVU Coeff Value
26200
REMOVE HAND BONE LESION
11.34
1.00
26200
REMOVE HAND BONE LESION
11.36
1.00
26200
REMOVE HAND BONE LESION
11.65
1.00
26205
REMOVE/GRAFT BONE LESION
3.00
1.00
26205
REMOVE/GRAFT BONE LESION
15.24
1.00
26205
REMOVE/GRAFT BONE LESION
15.34
1.00
26205
REMOVE/GRAFT BONE LESION
15.68
1.00
26210
REMOVAL OF FINGER LESION
3.00
1.00
26210
REMOVAL OF FINGER LESION
10.91
1.00
26210
REMOVAL OF FINGER LESION
10.97
1.00
26210
REMOVAL OF FINGER LESION
11.27
1.00
26215
REMOVE/GRAFT FINGER LESION
3.00
1.00
26215
REMOVE/GRAFT FINGER LESION
13.93
1.00
26215
REMOVE/GRAFT FINGER LESION
13.94
1.00
26215
REMOVE/GRAFT FINGER LESION
14.28
1.00
26230
PARTIAL REMOVAL OF HAND BONE
3.00
1.00
26230
PARTIAL REMOVAL OF HAND BONE
12.70
1.00
26230
PARTIAL REMOVAL OF HAND BONE
12.85
1.00
26230
PARTIAL REMOVAL OF HAND BONE
13.18
1.00
26235
PARTIAL REMOVAL, FINGER BONE
3.00
1.00
26235
PARTIAL REMOVAL, FINGER BONE
12.46
1.00
26235
PARTIAL REMOVAL, FINGER BONE
12.59
1.00
26235
PARTIAL REMOVAL, FINGER BONE
12.87
1.00
26236
PARTIAL REMOVAL, FINGER BONE
3.00
1.00
26236
PARTIAL REMOVAL, FINGER BONE
11.03
1.00
26236
PARTIAL REMOVAL, FINGER BONE
11.15
1.00
26236
PARTIAL REMOVAL, FINGER BONE
11.39
1.00
26250
EXTENSIVE HAND SURGERY
3.00
1.00
26250
EXTENSIVE HAND SURGERY
14.70
1.00
26250
EXTENSIVE HAND SURGERY
15.03
1.00
26255
EXTENSIVE HAND SURGERY
3.00
1.00
26255
EXTENSIVE HAND SURGERY
22.38
1.00
26255
EXTENSIVE HAND SURGERY
22.74
1.00
26255
EXTENSIVE HAND SURGERY
23.03
1.00
26260
EXTENSIVE FINGER SURGERY
3.00
1.00
Procedure Code Description
RVU
RVU Coeff Value
26260
EXTENSIVE FINGER SURGERY
13.77
1.00
26260
EXTENSIVE FINGER SURGERY
13.84
1.00
26260
EXTENSIVE FINGER SURGERY
14.16
1.00
26261
EXTENSIVE FINGER SURGERY
3.00
1.00
26261
EXTENSIVE FINGER SURGERY
16.15
1.00
26261
EXTENSIVE FINGER SURGERY
16.32
1.00
26261
EXTENSIVE FINGER SURGERY
17.02
1.00
26262
PARTIAL REMOVAL OF FINGER
3.00
1.00
26262
PARTIAL REMOVAL OF FINGER
11.51
1.00
26262
PARTIAL REMOVAL OF FINGER
11.55
1.00
26262
PARTIAL REMOVAL OF FINGER
11.79
1.00
26320
REMOVAL OF IMPLANT FROM HAND
3.00
1.00
26320
REMOVAL OF IMPLANT FROM HAND
8.57
1.00
26320
REMOVAL OF IMPLANT FROM HAND
8.81
1.00
26320
REMOVAL OF IMPLANT FROM HAND
8.97
1.00
26340
MANIPULATE FINGER W/ANESTH
3.00
1.00
26340
MANIPULATE FINGER W/ANESTH
7.44
1.00
26340
MANIPULATE FINGER W/ANESTH
7.60
1.00
26340
MANIPULATE FINGER W/ANESTH
7.66
1.00
26350
REPAIR FINGER/HAND TENDON
3.00
1.00
26350
REPAIR FINGER/HAND TENDON
17.76
1.00
26350
REPAIR FINGER/HAND TENDON
22.35
1.00
26350
REPAIR FINGER/HAND TENDON
26.75
1.00
26352
REPAIR/GRAFT HAND TENDON
3.00
1.00
26352
REPAIR/GRAFT HAND TENDON
20.21
1.00
26352
REPAIR/GRAFT HAND TENDON
24.87
1.00
26352
REPAIR/GRAFT HAND TENDON
29.11
1.00
26356
REPAIR FINGER/HAND TENDON
3.00
1.00
26356
REPAIR FINGER/HAND TENDON
26.32
1.00
26356
REPAIR FINGER/HAND TENDON
28.16
1.00
26356
REPAIR FINGER/HAND TENDON
30.55
1.00
26357
REPAIR FINGER/HAND TENDON
3.00
1.00
26357
REPAIR FINGER/HAND TENDON
21.74
1.00
26357
REPAIR FINGER/HAND TENDON
26.33
1.00
26357
REPAIR FINGER/HAND TENDON
30.79
1.00
Procedure Code Description
RVU
RVU Coeff Value
26358
REPAIR/GRAFT HAND TENDON
3.00
1.00
26358
REPAIR/GRAFT HAND TENDON
22.98
1.00
26358
REPAIR/GRAFT HAND TENDON
27.85
1.00
26358
REPAIR/GRAFT HAND TENDON
31.95
1.00
26370
REPAIR FINGER/HAND TENDON
3.00
1.00
26370
REPAIR FINGER/HAND TENDON
19.26
1.00
26370
REPAIR FINGER/HAND TENDON
24.14
1.00
26370
REPAIR FINGER/HAND TENDON
28.68
1.00
26372
REPAIR/GRAFT HAND TENDON
3.00
1.00
26372
REPAIR/GRAFT HAND TENDON
22.36
1.00
26372
REPAIR/GRAFT HAND TENDON
27.35
1.00
26372
REPAIR/GRAFT HAND TENDON
31.82
1.00
26373
REPAIR FINGER/HAND TENDON
3.00
1.00
26373
REPAIR FINGER/HAND TENDON
21.22
1.00
26373
REPAIR FINGER/HAND TENDON
26.20
1.00
26373
REPAIR FINGER/HAND TENDON
30.70
1.00
26390
REVISE HAND/FINGER TENDON
3.00
1.00
26390
REVISE HAND/FINGER TENDON
20.88
1.00
26390
REVISE HAND/FINGER TENDON
24.41
1.00
26390
REVISE HAND/FINGER TENDON
27.03
1.00
26392
REPAIR/GRAFT HAND TENDON
3.00
1.00
26392
REPAIR/GRAFT HAND TENDON
24.40
1.00
26392
REPAIR/GRAFT HAND TENDON
29.42
1.00
26392
REPAIR/GRAFT HAND TENDON
34.07
1.00
26410
REPAIR HAND TENDON
3.00
1.00
26410
REPAIR HAND TENDON
14.12
1.00
26410
REPAIR HAND TENDON
17.90
1.00
26410
REPAIR HAND TENDON
21.50
1.00
26412
REPAIR/GRAFT HAND TENDON
3.00
1.00
26412
REPAIR/GRAFT HAND TENDON
17.17
1.00
26412
REPAIR/GRAFT HAND TENDON
21.18
1.00
26412
REPAIR/GRAFT HAND TENDON
24.50
1.00
26415
EXCISION, HAND/FINGER TENDON
3.00
1.00
26415
EXCISION, HAND/FINGER TENDON
18.03
1.00
26415
EXCISION, HAND/FINGER TENDON
21.54
1.00
Procedure Code Description
RVU
RVU Coeff Value
26415
EXCISION, HAND/FINGER TENDON
25.01
1.00
26416
GRAFT HAND OR FINGER TENDON
3.00
1.00
26416
GRAFT HAND OR FINGER TENDON
19.22
1.00
26416
GRAFT HAND OR FINGER TENDON
26.02
1.00
26416
GRAFT HAND OR FINGER TENDON
29.13
1.00
26418
REPAIR FINGER TENDON
3.00
1.00
26418
REPAIR FINGER TENDON
14.16
1.00
26418
REPAIR FINGER TENDON
17.79
1.00
26418
REPAIR FINGER TENDON
20.88
1.00
26420
REPAIR/GRAFT FINGER TENDON
3.00
1.00
26420
REPAIR/GRAFT FINGER TENDON
17.86
1.00
26420
REPAIR/GRAFT FINGER TENDON
22.02
1.00
26420
REPAIR/GRAFT FINGER TENDON
25.29
1.00
26426
REPAIR FINGER/HAND TENDON
3.00
1.00
26426
REPAIR FINGER/HAND TENDON
14.40
1.00
26426
REPAIR FINGER/HAND TENDON
20.85
1.00
26426
REPAIR FINGER/HAND TENDON
24.08
1.00
26428
REPAIR/GRAFT FINGER TENDON
3.00
1.00
26428
REPAIR/GRAFT FINGER TENDON
18.76
1.00
26428
REPAIR/GRAFT FINGER TENDON
22.79
1.00
26428
REPAIR/GRAFT FINGER TENDON
26.29
1.00
26432
REPAIR FINGER TENDON
3.00
1.00
26432
REPAIR FINGER TENDON
12.35
1.00
26432
REPAIR FINGER TENDON
15.28
1.00
26432
REPAIR FINGER TENDON
17.86
1.00
26433
REPAIR FINGER TENDON
3.00
1.00
26433
REPAIR FINGER TENDON
13.26
1.00
26433
REPAIR FINGER TENDON
16.60
1.00
26433
REPAIR FINGER TENDON
19.39
1.00
26434
REPAIR/GRAFT FINGER TENDON
3.00
1.00
26434
REPAIR/GRAFT FINGER TENDON
15.93
1.00
26434
REPAIR/GRAFT FINGER TENDON
19.00
1.00
26434
REPAIR/GRAFT FINGER TENDON
21.47
1.00
26437
REALIGNMENT OF TENDONS
3.00
1.00
26437
REALIGNMENT OF TENDONS
15.52
1.00
Procedure Code Description
RVU
RVU Coeff Value
26437
REALIGNMENT OF TENDONS
18.68
1.00
26437
REALIGNMENT OF TENDONS
20.96
1.00
26440
RELEASE PALM/FINGER TENDON
3.00
1.00
26440
RELEASE PALM/FINGER TENDON
15.55
1.00
26440
RELEASE PALM/FINGER TENDON
19.94
1.00
26440
RELEASE PALM/FINGER TENDON
24.51
1.00
26442
RELEASE PALM & FINGER TENDON
3.00
1.00
26442
RELEASE PALM & FINGER TENDON
23.56
1.00
26442
RELEASE PALM & FINGER TENDON
25.89
1.00
26442
RELEASE PALM & FINGER TENDON
29.41
1.00
26445
RELEASE HAND/FINGER TENDON
3.00
1.00
26445
RELEASE HAND/FINGER TENDON
14.42
1.00
26445
RELEASE HAND/FINGER TENDON
18.88
1.00
26445
RELEASE HAND/FINGER TENDON
23.56
1.00
26449
RELEASE FOREARM/HAND TENDON
3.00
1.00
26449
RELEASE FOREARM/HAND TENDON
18.94
1.00
26449
RELEASE FOREARM/HAND TENDON
24.39
1.00
26449
RELEASE FOREARM/HAND TENDON
27.86
1.00
26450
INCISION OF PALM TENDON
3.00
1.00
26450
INCISION OF PALM TENDON
10.02
1.00
26450
INCISION OF PALM TENDON
11.79
1.00
26450
INCISION OF PALM TENDON
12.70
1.00
26455
INCISION OF FINGER TENDON
3.00
1.00
26455
INCISION OF FINGER TENDON
9.95
1.00
26455
INCISION OF FINGER TENDON
11.70
1.00
26455
INCISION OF FINGER TENDON
12.56
1.00
26460
INCISE HAND/FINGER TENDON
3.00
1.00
26460
INCISE HAND/FINGER TENDON
9.67
1.00
26460
INCISE HAND/FINGER TENDON
11.30
1.00
26460
INCISE HAND/FINGER TENDON
12.10
1.00
26471
FUSION OF FINGER TENDONS
3.00
1.00
26471
FUSION OF FINGER TENDONS
15.29
1.00
26471
FUSION OF FINGER TENDONS
18.25
1.00
26471
FUSION OF FINGER TENDONS
20.52
1.00
26474
FUSION OF FINGER TENDONS
3.00
1.00
Procedure Code Description
RVU
RVU Coeff Value
26474
FUSION OF FINGER TENDONS
14.64
1.00
26474
FUSION OF FINGER TENDONS
17.98
1.00
26474
FUSION OF FINGER TENDONS
20.32
1.00
26476
TENDON LENGTHENING
3.00
1.00
26476
TENDON LENGTHENING
14.27
1.00
26476
TENDON LENGTHENING
17.29
1.00
26476
TENDON LENGTHENING
19.60
1.00
26477
TENDON SHORTENING
3.00
1.00
26477
TENDON SHORTENING
14.40
1.00
26477
TENDON SHORTENING
17.40
1.00
26477
TENDON SHORTENING
19.76
1.00
26478
LENGTHENING OF HAND TENDON
3.00
1.00
26478
LENGTHENING OF HAND TENDON
15.64
1.00
26478
LENGTHENING OF HAND TENDON
18.96
1.00
26478
LENGTHENING OF HAND TENDON
21.22
1.00
26479
SHORTENING OF HAND TENDON
3.00
1.00
26479
SHORTENING OF HAND TENDON
15.48
1.00
26479
SHORTENING OF HAND TENDON
18.73
1.00
26479
SHORTENING OF HAND TENDON
21.15
1.00
26480
TRANSPLANT HAND TENDON
3.00
1.00
26480
TRANSPLANT HAND TENDON
18.80
1.00
26480
TRANSPLANT HAND TENDON
23.37
1.00
26480
TRANSPLANT HAND TENDON
27.47
1.00
26483
TRANSPLANT/GRAFT HAND TENDON
3.00
1.00
26483
TRANSPLANT/GRAFT HAND TENDON
21.26
1.00
26483
TRANSPLANT/GRAFT HAND TENDON
25.64
1.00
26483
TRANSPLANT/GRAFT HAND TENDON
29.75
1.00
26485
TRANSPLANT PALM TENDON
3.00
1.00
26485
TRANSPLANT PALM TENDON
20.35
1.00
26485
TRANSPLANT PALM TENDON
24.83
1.00
26485
TRANSPLANT PALM TENDON
28.98
1.00
26489
TRANSPLANT/GRAFT PALM TENDON
3.00
1.00
26489
TRANSPLANT/GRAFT PALM TENDON
22.00
1.00
26489
TRANSPLANT/GRAFT PALM TENDON
23.26
1.00
26489
TRANSPLANT/GRAFT PALM TENDON
27.57
1.00
Procedure Code Description
RVU
RVU Coeff Value
26490
REVISE THUMB TENDON
3.00
1.00
26490
REVISE THUMB TENDON
19.69
1.00
26490
REVISE THUMB TENDON
22.83
1.00
26490
REVISE THUMB TENDON
25.00
1.00
26492
TENDON TRANSFER WITH GRAFT
3.00
1.00
26492
TENDON TRANSFER WITH GRAFT
21.96
1.00
26492
TENDON TRANSFER WITH GRAFT
25.02
1.00
26492
TENDON TRANSFER WITH GRAFT
26.96
1.00
26494
HAND TENDON/MUSCLE TRANSFER
3.00
1.00
26494
HAND TENDON/MUSCLE TRANSFER
19.95
1.00
26494
HAND TENDON/MUSCLE TRANSFER
23.43
1.00
26494
HAND TENDON/MUSCLE TRANSFER
25.74
1.00
26496
REVISE THUMB TENDON
3.00
1.00
26496
REVISE THUMB TENDON
21.66
1.00
26496
REVISE THUMB TENDON
24.60
1.00
26496
REVISE THUMB TENDON
26.63
1.00
26497
FINGER TENDON TRANSFER
3.00
1.00
26497
FINGER TENDON TRANSFER
21.66
1.00
26497
FINGER TENDON TRANSFER
24.93
1.00
26497
FINGER TENDON TRANSFER
27.06
1.00
26498
FINGER TENDON TRANSFER
3.00
1.00
26498
FINGER TENDON TRANSFER
29.01
1.00
26498
FINGER TENDON TRANSFER
32.63
1.00
26498
FINGER TENDON TRANSFER
34.45
1.00
26499
REVISION OF FINGER
3.00
1.00
26499
REVISION OF FINGER
20.70
1.00
26499
REVISION OF FINGER
23.60
1.00
26499
REVISION OF FINGER
26.94
1.00
26500
HAND TENDON RECONSTRUCTION
5.00
1.00
26500
HAND TENDON RECONSTRUCTION
15.61
1.00
26500
HAND TENDON RECONSTRUCTION
18.87
1.00
26500
HAND TENDON RECONSTRUCTION
21.60
1.00
26502
HAND TENDON RECONSTRUCTION
3.00
1.00
26502
HAND TENDON RECONSTRUCTION
17.66
1.00
26502
HAND TENDON RECONSTRUCTION
20.76
1.00
Procedure Code Description
RVU
RVU Coeff Value
26502
HAND TENDON RECONSTRUCTION
23.28
1.00
26504
HAND TENDON RECONSTRUCTION
3.00
1.00
26504
HAND TENDON RECONSTRUCTION
21.32
1.00
26504
HAND TENDON RECONSTRUCTION
21.48
1.00
26504
HAND TENDON RECONSTRUCTION
23.39
1.00
26508
RELEASE THUMB CONTRACTURE
3.00
1.00
26508
RELEASE THUMB CONTRACTURE
15.72
1.00
26508
RELEASE THUMB CONTRACTURE
19.03
1.00
26508
RELEASE THUMB CONTRACTURE
21.36
1.00
26510
THUMB TENDON TRANSFER
3.00
1.00
26510
THUMB TENDON TRANSFER
14.86
1.00
26510
THUMB TENDON TRANSFER
18.07
1.00
26510
THUMB TENDON TRANSFER
20.44
1.00
26516
FUSION OF KNUCKLE JOINT
3.00
1.00
26516
FUSION OF KNUCKLE JOINT
17.60
1.00
26516
FUSION OF KNUCKLE JOINT
20.88
1.00
26516
FUSION OF KNUCKLE JOINT
23.12
1.00
26517
FUSION OF KNUCKLE JOINTS
3.00
1.00
26517
FUSION OF KNUCKLE JOINTS
20.76
1.00
26517
FUSION OF KNUCKLE JOINTS
23.94
1.00
26517
FUSION OF KNUCKLE JOINTS
26.20
1.00
26518
FUSION OF KNUCKLE JOINTS
3.00
1.00
26518
FUSION OF KNUCKLE JOINTS
20.93
1.00
26518
FUSION OF KNUCKLE JOINTS
24.14
1.00
26518
FUSION OF KNUCKLE JOINTS
26.27
1.00
26520
RELEASE KNUCKLE CONTRACTURE
3.00
1.00
26520
RELEASE KNUCKLE CONTRACTURE
16.26
1.00
26520
RELEASE KNUCKLE CONTRACTURE
20.70
1.00
26520
RELEASE KNUCKLE CONTRACTURE
24.80
1.00
26525
RELEASE FINGER CONTRACTURE
3.00
1.00
26525
RELEASE FINGER CONTRACTURE
16.33
1.00
26525
RELEASE FINGER CONTRACTURE
20.86
1.00
26525
RELEASE FINGER CONTRACTURE
25.01
1.00
26530
REVISE KNUCKLE JOINT
3.00
1.00
26530
REVISE KNUCKLE JOINT
13.48
1.00
Procedure Code Description
RVU
RVU Coeff Value
26530
REVISE KNUCKLE JOINT
13.59
1.00
26530
REVISE KNUCKLE JOINT
13.74
1.00
26531
REVISE KNUCKLE WITH IMPLANT
3.00
1.00
26531
REVISE KNUCKLE WITH IMPLANT
15.68
1.00
26531
REVISE KNUCKLE WITH IMPLANT
15.87
1.00
26531
REVISE KNUCKLE WITH IMPLANT
16.11
1.00
26535
REVISE FINGER JOINT
3.00
1.00
26535
REVISE FINGER JOINT
9.59
1.00
26535
REVISE FINGER JOINT
9.72
1.00
26535
REVISE FINGER JOINT
10.08
1.00
26536
REVISE/IMPLANT FINGER JOINT
3.00
1.00
26536
REVISE/IMPLANT FINGER JOINT
16.75
1.00
26536
REVISE/IMPLANT FINGER JOINT
17.06
1.00
26536
REVISE/IMPLANT FINGER JOINT
17.49
1.00
26540
REPAIR HAND JOINT
3.00
1.00
26540
REPAIR HAND JOINT
16.51
1.00
26540
REPAIR HAND JOINT
19.75
1.00
26540
REPAIR HAND JOINT
22.13
1.00
26541
REPAIR HAND JOINT WITH GRAFT
3.00
1.00
26541
REPAIR HAND JOINT WITH GRAFT
20.20
1.00
26541
REPAIR HAND JOINT WITH GRAFT
23.79
1.00
26541
REPAIR HAND JOINT WITH GRAFT
25.99
1.00
26542
REPAIR HAND JOINT WITH GRAFT
3.00
1.00
26542
REPAIR HAND JOINT WITH GRAFT
17.07
1.00
26542
REPAIR HAND JOINT WITH GRAFT
20.21
1.00
26542
REPAIR HAND JOINT WITH GRAFT
22.43
1.00
26545
RECONSTRUCT FINGER JOINT
3.00
1.00
26545
RECONSTRUCT FINGER JOINT
17.38
1.00
26545
RECONSTRUCT FINGER JOINT
20.65
1.00
26545
RECONSTRUCT FINGER JOINT
23.23
1.00
26546
REPAIR NONUNION HAND
3.00
1.00
26546
REPAIR NONUNION HAND
24.39
1.00
26546
REPAIR NONUNION HAND
25.48
1.00
26546
REPAIR NONUNION HAND
26.21
1.00
26548
RECONSTRUCT FINGER JOINT
3.00
1.00
Procedure Code Description
RVU
RVU Coeff Value
26548
RECONSTRUCT FINGER JOINT
19.15
1.00
26548
RECONSTRUCT FINGER JOINT
22.59
1.00
26548
RECONSTRUCT FINGER JOINT
25.03
1.00
26550
CONSTRUCT THUMB REPLACEMENT
3.00
1.00
26550
CONSTRUCT THUMB REPLACEMENT
37.71
1.00
26550
CONSTRUCT THUMB REPLACEMENT
41.54
1.00
26550
CONSTRUCT THUMB REPLACEMENT
46.51
1.00
26551
GREAT TOE-HAND TRANSFER
3.00
1.00
26551
GREAT TOE-HAND TRANSFER
83.01
1.00
26551
GREAT TOE-HAND TRANSFER
88.14
1.00
26551
GREAT TOE-HAND TRANSFER
90.05
1.00
26553
SINGLE TRANSFER, TOE-HAND
3.00
1.00
26553
SINGLE TRANSFER, TOE-HAND
71.04
1.00
26553
SINGLE TRANSFER, TOE-HAND
71.82
1.00
26553
SINGLE TRANSFER, TOE-HAND
76.42
1.00
26554
DOUBLE TRANSFER, TOE-HAND
3.00
1.00
26554
DOUBLE TRANSFER, TOE-HAND
95.07
1.00
26554
DOUBLE TRANSFER, TOE-HAND
101.50
1.00
26554
DOUBLE TRANSFER, TOE-HAND
102.25
1.00
26555
POSITIONAL CHANGE OF FINGER
3.00
1.00
26555
POSITIONAL CHANGE OF FINGER
34.75
1.00
26555
POSITIONAL CHANGE OF FINGER
37.85
1.00
26555
POSITIONAL CHANGE OF FINGER
41.27
1.00
26556
TOE JOINT TRANSFER
3.00
1.00
26556
TOE JOINT TRANSFER
73.42
1.00
26556
TOE JOINT TRANSFER
88.20
1.00
26556
TOE JOINT TRANSFER
89.73
1.00
26560
REPAIR OF WEB FINGER
3.00
1.00
26560
REPAIR OF WEB FINGER
14.22
1.00
26560
REPAIR OF WEB FINGER
16.37
1.00
26560
REPAIR OF WEB FINGER
18.97
1.00
26561
REPAIR OF WEB FINGER
3.00
1.00
26561
REPAIR OF WEB FINGER
22.82
1.00
26561
REPAIR OF WEB FINGER
24.66
1.00
26561
REPAIR OF WEB FINGER
27.73
1.00
Procedure Code Description
RVU
RVU Coeff Value
26562
REPAIR OF WEB FINGER
3.00
1.00
26562
REPAIR OF WEB FINGER
33.26
1.00
26562
REPAIR OF WEB FINGER
33.75
1.00
26562
REPAIR OF WEB FINGER
35.35
1.00
26565
CORRECT METACARPAL FLAW
3.00
1.00
26565
CORRECT METACARPAL FLAW
16.91
1.00
26565
CORRECT METACARPAL FLAW
20.20
1.00
26565
CORRECT METACARPAL FLAW
22.53
1.00
26567
CORRECT FINGER DEFORMITY
3.00
1.00
26567
CORRECT FINGER DEFORMITY
17.09
1.00
26567
CORRECT FINGER DEFORMITY
20.21
1.00
26567
CORRECT FINGER DEFORMITY
22.54
1.00
26568
LENGTHEN METACARPAL/FINGER
3.00
1.00
26568
LENGTHEN METACARPAL/FINGER
22.54
1.00
26568
LENGTHEN METACARPAL/FINGER
26.49
1.00
26568
LENGTHEN METACARPAL/FINGER
30.59
1.00
26580
REPAIR HAND DEFORMITY
3.00
1.00
26580
REPAIR HAND DEFORMITY
33.89
1.00
26580
REPAIR HAND DEFORMITY
35.29
1.00
26580
REPAIR HAND DEFORMITY
35.51
1.00
26587
RECONSTRUCT EXTRA FINGER
3.00
1.00
26587
RECONSTRUCT EXTRA FINGER
19.93
1.00
26587
RECONSTRUCT EXTRA FINGER
24.14
1.00
26587
RECONSTRUCT EXTRA FINGER
24.43
1.00
26590
REPAIR FINGER DEFORMITY
3.00
1.00
26590
REPAIR FINGER DEFORMITY
32.35
1.00
26590
REPAIR FINGER DEFORMITY
33.92
1.00
26590
REPAIR FINGER DEFORMITY
36.74
1.00
26591
REPAIR MUSCLES OF HAND
3.00
1.00
26591
REPAIR MUSCLES OF HAND
10.83
1.00
26591
REPAIR MUSCLES OF HAND
14.14
1.00
26591
REPAIR MUSCLES OF HAND
17.42
1.00
26593
RELEASE MUSCLES OF HAND
3.00
1.00
26593
RELEASE MUSCLES OF HAND
14.82
1.00
26593
RELEASE MUSCLES OF HAND
17.58
1.00
Procedure Code Description 26593
RELEASE MUSCLES OF HAND
26596
RVU
RVU Coeff Value
19.73
1.00
EXCISION CONSTRICTING TISSUE
3.00
1.00
26596
EXCISION CONSTRICTING TISSUE
18.52
1.00
26596
EXCISION CONSTRICTING TISSUE
19.00
1.00
26596
EXCISION CONSTRICTING TISSUE
19.68
1.00
26600
TREAT METACARPAL FRACTURE
3.00
1.00
26600
TREAT METACARPAL FRACTURE
4.90
1.00
26600
TREAT METACARPAL FRACTURE
5.04
1.00
26600
TREAT METACARPAL FRACTURE
6.06
1.00
26605
TREAT METACARPAL FRACTURE
3.00
1.00
26605
TREAT METACARPAL FRACTURE
6.89
1.00
26605
TREAT METACARPAL FRACTURE
6.96
1.00
26605
TREAT METACARPAL FRACTURE
7.68
1.00
26607
TREAT METACARPAL FRACTURE
3.00
1.00
26607
TREAT METACARPAL FRACTURE
10.97
1.00
26607
TREAT METACARPAL FRACTURE
12.54
1.00
26607
TREAT METACARPAL FRACTURE
14.52
1.00
26608
TREAT METACARPAL FRACTURE
3.00
1.00
26608
TREAT METACARPAL FRACTURE
11.86
1.00
26608
TREAT METACARPAL FRACTURE
12.58
1.00
26608
TREAT METACARPAL FRACTURE
15.16
1.00
26615
TREAT METACARPAL FRACTURE
3.00
1.00
26615
TREAT METACARPAL FRACTURE
11.69
1.00
26615
TREAT METACARPAL FRACTURE
13.70
1.00
26615
TREAT METACARPAL FRACTURE
14.52
1.00
26641
TREAT THUMB DISLOCATION
3.00
1.00
26641
TREAT THUMB DISLOCATION
7.95
1.00
26641
TREAT THUMB DISLOCATION
8.02
1.00
26641
TREAT THUMB DISLOCATION
9.22
1.00
26645
TREAT THUMB FRACTURE
3.00
1.00
26645
TREAT THUMB FRACTURE
9.22
1.00
26645
TREAT THUMB FRACTURE
9.24
1.00
26645
TREAT THUMB FRACTURE
10.30
1.00
26650
TREAT THUMB FRACTURE
3.00
1.00
26650
TREAT THUMB FRACTURE
11.89
1.00
Procedure Code Description
RVU
RVU Coeff Value
26650
TREAT THUMB FRACTURE
13.40
1.00
26650
TREAT THUMB FRACTURE
15.73
1.00
26665
TREAT THUMB FRACTURE
3.00
1.00
26665
TREAT THUMB FRACTURE
15.19
1.00
26665
TREAT THUMB FRACTURE
15.56
1.00
26665
TREAT THUMB FRACTURE
18.09
1.00
26670
TREAT HAND DISLOCATION
7.10
1.00
26670
TREAT HAND DISLOCATION
7.14
1.00
26670
TREAT HAND DISLOCATION
8.80
1.00
26675
TREAT HAND DISLOCATION
3.00
1.00
26675
TREAT HAND DISLOCATION
9.72
1.00
26675
TREAT HAND DISLOCATION
9.77
1.00
26675
TREAT HAND DISLOCATION
9.90
1.00
26676
PIN HAND DISLOCATION
3.00
1.00
26676
PIN HAND DISLOCATION
12.43
1.00
26676
PIN HAND DISLOCATION
13.22
1.00
26676
PIN HAND DISLOCATION
15.58
1.00
26685
TREAT HAND DISLOCATION
3.00
1.00
26685
TREAT HAND DISLOCATION
14.13
1.00
26685
TREAT HAND DISLOCATION
14.38
1.00
26685
TREAT HAND DISLOCATION
17.07
1.00
26686
TREAT HAND DISLOCATION
3.00
1.00
26686
TREAT HAND DISLOCATION
15.67
1.00
26686
TREAT HAND DISLOCATION
16.23
1.00
26686
TREAT HAND DISLOCATION
18.72
1.00
26700
TREAT KNUCKLE DISLOCATION
3.00
1.00
26700
TREAT KNUCKLE DISLOCATION
6.98
1.00
26700
TREAT KNUCKLE DISLOCATION
7.00
1.00
26700
TREAT KNUCKLE DISLOCATION
7.06
1.00
26705
TREAT KNUCKLE DISLOCATION
3.00
1.00
26705
TREAT KNUCKLE DISLOCATION
9.01
1.00
26705
TREAT KNUCKLE DISLOCATION
9.02
1.00
26705
TREAT KNUCKLE DISLOCATION
9.10
1.00
26706
PIN KNUCKLE DISLOCATION
3.00
1.00
26706
PIN KNUCKLE DISLOCATION
10.78
1.00
Procedure Code Description
RVU
RVU Coeff Value
26706
PIN KNUCKLE DISLOCATION
10.97
1.00
26706
PIN KNUCKLE DISLOCATION
11.74
1.00
26715
TREAT KNUCKLE DISLOCATION
3.00
1.00
26715
TREAT KNUCKLE DISLOCATION
12.34
1.00
26715
TREAT KNUCKLE DISLOCATION
13.74
1.00
26715
TREAT KNUCKLE DISLOCATION
15.14
1.00
26720
TREAT FINGER FRACTURE, EACH
3.00
1.00
26720
TREAT FINGER FRACTURE, EACH
3.55
1.00
26720
TREAT FINGER FRACTURE, EACH
4.17
1.00
26720
TREAT FINGER FRACTURE, EACH
4.50
1.00
26725
TREAT FINGER FRACTURE, EACH
3.00
1.00
26725
TREAT FINGER FRACTURE, EACH
7.04
1.00
26725
TREAT FINGER FRACTURE, EACH
7.36
1.00
26725
TREAT FINGER FRACTURE, EACH
7.89
1.00
26727
TREAT FINGER FRACTURE, EACH
3.00
1.00
26727
TREAT FINGER FRACTURE, EACH
11.65
1.00
26727
TREAT FINGER FRACTURE, EACH
12.45
1.00
26727
TREAT FINGER FRACTURE, EACH
15.10
1.00
26735
TREAT FINGER FRACTURE, EACH
3.00
1.00
26735
TREAT FINGER FRACTURE, EACH
12.76
1.00
26735
TREAT FINGER FRACTURE, EACH
14.31
1.00
26735
TREAT FINGER FRACTURE, EACH
15.66
1.00
26740
TREAT FINGER FRACTURE, EACH
3.00
1.00
26740
TREAT FINGER FRACTURE, EACH
4.85
1.00
26740
TREAT FINGER FRACTURE, EACH
4.92
1.00
26740
TREAT FINGER FRACTURE, EACH
4.99
1.00
26742
TREAT FINGER FRACTURE, EACH
3.00
1.00
26742
TREAT FINGER FRACTURE, EACH
8.16
1.00
26742
TREAT FINGER FRACTURE, EACH
8.28
1.00
26742
TREAT FINGER FRACTURE, EACH
9.62
1.00
26746
TREAT FINGER FRACTURE, EACH
3.00
1.00
26746
TREAT FINGER FRACTURE, EACH
12.60
1.00
26746
TREAT FINGER FRACTURE, EACH
15.53
1.00
26746
TREAT FINGER FRACTURE, EACH
17.43
1.00
26750
TREAT FINGER FRACTURE, EACH
3.00
1.00
Procedure Code Description
RVU
RVU Coeff Value
26750
TREAT FINGER FRACTURE, EACH
4.01
1.00
26750
TREAT FINGER FRACTURE, EACH
4.14
1.00
26750
TREAT FINGER FRACTURE, EACH
4.30
1.00
26755
TREAT FINGER FRACTURE, EACH
3.00
1.00
26755
TREAT FINGER FRACTURE, EACH
6.54
1.00
26755
TREAT FINGER FRACTURE, EACH
6.57
1.00
26755
TREAT FINGER FRACTURE, EACH
6.60
1.00
26756
PIN FINGER FRACTURE, EACH
3.00
1.00
26756
PIN FINGER FRACTURE, EACH
10.26
1.00
26756
PIN FINGER FRACTURE, EACH
11.10
1.00
26756
PIN FINGER FRACTURE, EACH
13.84
1.00
26765
TREAT FINGER FRACTURE, EACH
3.00
1.00
26765
TREAT FINGER FRACTURE, EACH
9.56
1.00
26765
TREAT FINGER FRACTURE, EACH
11.60
1.00
26765
TREAT FINGER FRACTURE, EACH
12.65
1.00
26770
TREAT FINGER DISLOCATION
5.81
1.00
26770
TREAT FINGER DISLOCATION
5.90
1.00
26770
TREAT FINGER DISLOCATION
6.00
1.00
26775
TREAT FINGER DISLOCATION
3.00
1.00
26775
TREAT FINGER DISLOCATION
8.04
1.00
26775
TREAT FINGER DISLOCATION
8.20
1.00
26776
PIN FINGER DISLOCATION
3.00
1.00
26776
PIN FINGER DISLOCATION
10.92
1.00
26776
PIN FINGER DISLOCATION
11.76
1.00
26776
PIN FINGER DISLOCATION
14.44
1.00
26785
TREAT FINGER DISLOCATION
3.00
1.00
26785
TREAT FINGER DISLOCATION
9.66
1.00
26785
TREAT FINGER DISLOCATION
12.64
1.00
26785
TREAT FINGER DISLOCATION
12.69
1.00
26820
THUMB FUSION WITH GRAFT
3.00
1.00
26820
THUMB FUSION WITH GRAFT
19.76
1.00
26820
THUMB FUSION WITH GRAFT
23.22
1.00
26820
THUMB FUSION WITH GRAFT
25.59
1.00
26841
FUSION OF THUMB
3.00
1.00
26841
FUSION OF THUMB
18.29
1.00
Procedure Code Description
RVU
RVU Coeff Value
26841
FUSION OF THUMB
21.82
1.00
26841
FUSION OF THUMB
23.56
1.00
26842
THUMB FUSION WITH GRAFT
3.00
1.00
26842
THUMB FUSION WITH GRAFT
19.88
1.00
26842
THUMB FUSION WITH GRAFT
23.27
1.00
26842
THUMB FUSION WITH GRAFT
25.58
1.00
26843
FUSION OF HAND JOINT
3.00
1.00
26843
FUSION OF HAND JOINT
18.38
1.00
26843
FUSION OF HAND JOINT
21.47
1.00
26843
FUSION OF HAND JOINT
23.53
1.00
26844
FUSION/GRAFT OF HAND JOINT
3.00
1.00
26844
FUSION/GRAFT OF HAND JOINT
20.52
1.00
26844
FUSION/GRAFT OF HAND JOINT
23.75
1.00
26844
FUSION/GRAFT OF HAND JOINT
26.05
1.00
26850
FUSION OF KNUCKLE
3.00
1.00
26850
FUSION OF KNUCKLE
17.41
1.00
26850
FUSION OF KNUCKLE
20.59
1.00
26850
FUSION OF KNUCKLE
22.75
1.00
26852
FUSION OF KNUCKLE WITH GRAFT
3.00
1.00
26852
FUSION OF KNUCKLE WITH GRAFT
19.96
1.00
26852
FUSION OF KNUCKLE WITH GRAFT
22.97
1.00
26852
FUSION OF KNUCKLE WITH GRAFT
25.35
1.00
26860
FUSION OF FINGER JOINT
3.00
1.00
26860
FUSION OF FINGER JOINT
13.93
1.00
26860
FUSION OF FINGER JOINT
16.95
1.00
26860
FUSION OF FINGER JOINT
19.04
1.00
26861
FUSION OF FINGER JNT, ADD-ON
2.80
1.00
26861
FUSION OF FINGER JNT, ADD-ON
2.92
1.00
26861
FUSION OF FINGER JNT, ADD-ON
2.94
1.00
26862
FUSION/GRAFT OF FINGER JOINT
3.00
1.00
26862
FUSION/GRAFT OF FINGER JOINT
18.15
1.00
26862
FUSION/GRAFT OF FINGER JOINT
21.22
1.00
26862
FUSION/GRAFT OF FINGER JOINT
23.67
1.00
26863
FUSE/GRAFT ADDED JOINT
6.23
1.00
26863
FUSE/GRAFT ADDED JOINT
6.58
1.00
Procedure Code Description
RVU
RVU Coeff Value
26863
FUSE/GRAFT ADDED JOINT
6.63
1.00
26910
AMPUTATE METACARPAL BONE
3.00
1.00
26910
AMPUTATE METACARPAL BONE
17.89
1.00
26910
AMPUTATE METACARPAL BONE
20.38
1.00
26910
AMPUTATE METACARPAL BONE
22.57
1.00
26951
AMPUTATION OF FINGER/THUMB
3.00
1.00
26951
AMPUTATION OF FINGER/THUMB
15.37
1.00
26951
AMPUTATION OF FINGER/THUMB
15.88
1.00
26951
AMPUTATION OF FINGER/THUMB
18.21
1.00
26952
AMPUTATION OF FINGER/THUMB
3.00
1.00
26952
AMPUTATION OF FINGER/THUMB
16.18
1.00
26952
AMPUTATION OF FINGER/THUMB
19.42
1.00
26952
AMPUTATION OF FINGER/THUMB
21.30
1.00
33010
DRAINAGE OF HEART SAC
3.35
1.00
33010
DRAINAGE OF HEART SAC
3.36
1.00
33010
DRAINAGE OF HEART SAC
3.38
1.00
33010
DRAINAGE OF HEART SAC
4.00
1.00
33011
REPEAT DRAINAGE OF HEART SAC
3.31
1.00
33011
REPEAT DRAINAGE OF HEART SAC
3.39
1.00
33011
REPEAT DRAINAGE OF HEART SAC
3.40
1.00
33011
REPEAT DRAINAGE OF HEART SAC
4.00
1.00
33015
INCISION OF HEART SAC
10.00
1.00
33015
INCISION OF HEART SAC
11.96
1.00
33015
INCISION OF HEART SAC
12.54
1.00
33015
INCISION OF HEART SAC
14.38
1.00
33020
INCISION OF HEART SAC
20.00
1.00
33020
INCISION OF HEART SAC
21.24
1.00
33020
INCISION OF HEART SAC
22.12
1.00
33020
INCISION OF HEART SAC
23.46
1.00
33025
INCISION OF HEART SAC
20.00
1.00
33025
INCISION OF HEART SAC
20.27
1.00
33025
INCISION OF HEART SAC
21.47
1.00
33025
INCISION OF HEART SAC
21.71
1.00
33030
PARTIAL REMOVAL OF HEART SAC
15.00
1.00
33030
PARTIAL REMOVAL OF HEART SAC
31.16
1.00
Procedure Code Description
RVU
RVU Coeff Value
33030
PARTIAL REMOVAL OF HEART SAC
33.41
1.00
33030
PARTIAL REMOVAL OF HEART SAC
34.72
1.00
33031
PARTIAL REMOVAL OF HEART SAC
15.00
1.00
33031
PARTIAL REMOVAL OF HEART SAC
35.21
1.00
33031
PARTIAL REMOVAL OF HEART SAC
38.14
1.00
33031
PARTIAL REMOVAL OF HEART SAC
38.75
1.00
33050
REMOVAL OF HEART SAC LESION
20.00
1.00
33050
REMOVAL OF HEART SAC LESION
24.33
1.00
33050
REMOVAL OF HEART SAC LESION
26.40
1.00
33050
REMOVAL OF HEART SAC LESION
26.83
1.00
33120
REMOVAL OF HEART LESION
24.00
1.00
33120
REMOVAL OF HEART LESION
39.89
1.00
33120
REMOVAL OF HEART LESION
42.47
1.00
33120
REMOVAL OF HEART LESION
43.67
1.00
33130
REMOVAL OF HEART LESION
15.00
1.00
33130
REMOVAL OF HEART LESION
34.57
1.00
33130
REMOVAL OF HEART LESION
36.64
1.00
33130
REMOVAL OF HEART LESION
37.32
1.00
33140
HEART REVASCULARIZE (TMR)
20.00
1.00
33140
HEART REVASCULARIZE (TMR)
32.94
1.00
33140
HEART REVASCULARIZE (TMR)
33.65
1.00
33140
HEART REVASCULARIZE (TMR)
42.38
1.00
33141
HEART TMR W/OTHER PROCEDURE
4.26
1.00
33141
HEART TMR W/OTHER PROCEDURE
6.96
1.00
33141
HEART TMR W/OTHER PROCEDURE
7.08
1.00
33200
INSERTION OF HEART PACEMAKER
15.00
1.00
33200
INSERTION OF HEART PACEMAKER
20.85
1.00
33200
INSERTION OF HEART PACEMAKER
21.02
1.00
33200
INSERTION OF HEART PACEMAKER
23.37
1.00
33201
INSERTION OF HEART PACEMAKER
18.12
1.00
33201
INSERTION OF HEART PACEMAKER
18.35
1.00
33201
INSERTION OF HEART PACEMAKER
21.10
1.00
33202
INSERT EPICARD ELTRD, OPEN
21.17
1.00
33203
INSERT EPICARD ELTRD, ENDO
22.18
1.00
33206
INSERTION OF HEART PACEMAKER
6.00
1.00
Procedure Code Description
RVU
RVU Coeff Value
33206
INSERTION OF HEART PACEMAKER
11.83
1.00
33206
INSERTION OF HEART PACEMAKER
12.80
1.00
33206
INSERTION OF HEART PACEMAKER
12.86
1.00
33207
INSERTION OF HEART PACEMAKER
6.00
1.00
33207
INSERTION OF HEART PACEMAKER
13.48
1.00
33207
INSERTION OF HEART PACEMAKER
13.71
1.00
33207
INSERTION OF HEART PACEMAKER
14.84
1.00
33208
INSERTION OF HEART PACEMAKER
6.00
1.00
33208
INSERTION OF HEART PACEMAKER
13.63
1.00
33208
INSERTION OF HEART PACEMAKER
14.75
1.00
33208
INSERTION OF HEART PACEMAKER
15.10
1.00
33210
INSERTION OF HEART ELECTRODE
4.75
1.00
33210
INSERTION OF HEART ELECTRODE
4.76
1.00
33210
INSERTION OF HEART ELECTRODE
5.06
1.00
33210
INSERTION OF HEART ELECTRODE
6.00
1.00
33211
INSERTION OF HEART ELECTRODE
4.91
1.00
33211
INSERTION OF HEART ELECTRODE
4.92
1.00
33211
INSERTION OF HEART ELECTRODE
5.09
1.00
33211
INSERTION OF HEART ELECTRODE
6.00
1.00
33212
INSERTION OF PULSE GENERATOR
6.00
1.00
33212
INSERTION OF PULSE GENERATOR
9.46
1.00
33212
INSERTION OF PULSE GENERATOR
9.58
1.00
33212
INSERTION OF PULSE GENERATOR
10.58
1.00
33213
INSERTION OF PULSE GENERATOR
6.00
1.00
33213
INSERTION OF PULSE GENERATOR
10.69
1.00
33213
INSERTION OF PULSE GENERATOR
10.92
1.00
33213
INSERTION OF PULSE GENERATOR
11.89
1.00
33214
UPGRADE OF PACEMAKER SYSTEM
6.00
1.00
33214
UPGRADE OF PACEMAKER SYSTEM
13.36
1.00
33214
UPGRADE OF PACEMAKER SYSTEM
13.55
1.00
33214
UPGRADE OF PACEMAKER SYSTEM
14.46
1.00
33215
REPOSITION PACING-DEFIB LEAD
8.27
1.00
33215
REPOSITION PACING-DEFIB LEAD
8.36
1.00
33215
REPOSITION PACING-DEFIB LEAD
8.66
1.00
33216
INSERT LEAD PACE-DEFIB, ONE
6.00
1.00
Procedure Code Description
RVU
RVU Coeff Value
33216
INSERT LEAD PACE-DEFIB, ONE
10.50
1.00
33216
INSERT LEAD PACE-DEFIB, ONE
10.64
1.00
33216
INSERT LEAD PACE-DEFIB, ONE
11.46
1.00
33217
INSERT LEAD PACE-DEFIB, DUAL
6.00
1.00
33217
INSERT LEAD PACE-DEFIB, DUAL
10.50
1.00
33217
INSERT LEAD PACE-DEFIB, DUAL
10.56
1.00
33217
INSERT LEAD PACE-DEFIB, DUAL
11.69
1.00
33218
REPAIR LEAD PACE-DEFIB, ONE
6.00
1.00
33218
REPAIR LEAD PACE-DEFIB, ONE
10.28
1.00
33218
REPAIR LEAD PACE-DEFIB, ONE
10.52
1.00
33218
REPAIR LEAD PACE-DEFIB, ONE
11.00
1.00
33220
REPAIR LEAD PACE-DEFIB, DUAL
6.00
1.00
33220
REPAIR LEAD PACE-DEFIB, DUAL
10.32
1.00
33220
REPAIR LEAD PACE-DEFIB, DUAL
10.60
1.00
33220
REPAIR LEAD PACE-DEFIB, DUAL
11.10
1.00
33222
REVISE POCKET, PACEMAKER
3.00
1.00
33222
REVISE POCKET, PACEMAKER
9.43
1.00
33222
REVISE POCKET, PACEMAKER
9.72
1.00
33222
REVISE POCKET, PACEMAKER
9.78
1.00
33223
REVISE POCKET, PACING-DEFIB
6.00
1.00
33223
REVISE POCKET, PACING-DEFIB
11.62
1.00
33223
REVISE POCKET, PACING-DEFIB
11.74
1.00
33223
REVISE POCKET, PACING-DEFIB
12.31
1.00
33224
INSERT PACING LEAD & CONNECT
13.33
1.00
33224
INSERT PACING LEAD & CONNECT
13.49
1.00
33224
INSERT PACING LEAD & CONNECT
14.31
1.00
33225
L VENTRIC PACING LEAD ADD-ON
11.81
1.00
33225
L VENTRIC PACING LEAD ADD-ON
11.99
1.00
33225
L VENTRIC PACING LEAD ADD-ON
12.89
1.00
33226
REPOSITION L VENTRIC LEAD
12.84
1.00
33226
REPOSITION L VENTRIC LEAD
12.99
1.00
33226
REPOSITION L VENTRIC LEAD
13.85
1.00
33233
REMOVAL OF PACEMAKER SYSTEM
6.00
1.00
33233
REMOVAL OF PACEMAKER SYSTEM
6.78
1.00
33233
REMOVAL OF PACEMAKER SYSTEM
6.87
1.00
Procedure Code Description
RVU
RVU Coeff Value
33233
REMOVAL OF PACEMAKER SYSTEM
7.63
1.00
33234
REMOVAL OF PACEMAKER SYSTEM
6.00
1.00
33234
REMOVAL OF PACEMAKER SYSTEM
13.44
1.00
33234
REMOVAL OF PACEMAKER SYSTEM
13.75
1.00
33234
REMOVAL OF PACEMAKER SYSTEM
14.04
1.00
33235
REMOVAL PACEMAKER ELECTRODE
6.00
1.00
33235
REMOVAL PACEMAKER ELECTRODE
16.58
1.00
33235
REMOVAL PACEMAKER ELECTRODE
17.07
1.00
33235
REMOVAL PACEMAKER ELECTRODE
17.78
1.00
33236
REMOVE ELECTRODE/THORACOTOMY
6.00
1.00
33236
REMOVE ELECTRODE/THORACOTOMY
21.24
1.00
33236
REMOVE ELECTRODE/THORACOTOMY
21.86
1.00
33236
REMOVE ELECTRODE/THORACOTOMY
23.47
1.00
33237
REMOVE ELECTRODE/THORACOTOMY
6.00
1.00
33237
REMOVE ELECTRODE/THORACOTOMY
23.38
1.00
33237
REMOVE ELECTRODE/THORACOTOMY
23.42
1.00
33237
REMOVE ELECTRODE/THORACOTOMY
25.06
1.00
33238
REMOVE ELECTRODE/THORACOTOMY
6.00
1.00
33238
REMOVE ELECTRODE/THORACOTOMY
25.32
1.00
33238
REMOVE ELECTRODE/THORACOTOMY
25.34
1.00
33238
REMOVE ELECTRODE/THORACOTOMY
26.05
1.00
33240
INSERT PULSE GENERATOR
6.00
1.00
33240
INSERT PULSE GENERATOR
12.89
1.00
33240
INSERT PULSE GENERATOR
13.10
1.00
33240
INSERT PULSE GENERATOR
13.90
1.00
33241
REMOVE PULSE GENERATOR
6.00
1.00
33241
REMOVE PULSE GENERATOR
6.40
1.00
33241
REMOVE PULSE GENERATOR
6.48
1.00
33241
REMOVE PULSE GENERATOR
7.16
1.00
33243
REMOVE ELTRD/THORACOTOMY
6.00
1.00
33243
REMOVE ELTRD/THORACOTOMY
36.07
1.00
33243
REMOVE ELTRD/THORACOTOMY
36.94
1.00
33243
REMOVE ELTRD/THORACOTOMY
37.16
1.00
33244
REMOVE ELTRD, TRANSVEN
6.00
1.00
33244
REMOVE ELTRD, TRANSVEN
23.24
1.00
Procedure Code Description
RVU
RVU Coeff Value
33244
REMOVE ELTRD, TRANSVEN
23.97
1.00
33244
REMOVE ELTRD, TRANSVEN
24.16
1.00
33245
INSERT EPIC ELTRD PACE-DEFIB
13.00
1.00
33245
INSERT EPIC ELTRD PACE-DEFIB
23.85
1.00
33245
INSERT EPIC ELTRD PACE-DEFIB
24.21
1.00
33245
INSERT EPIC ELTRD PACE-DEFIB
26.60
1.00
33246
INSERT EPIC ELTRD/GENERATOR
13.00
1.00
33246
INSERT EPIC ELTRD/GENERATOR
33.62
1.00
33246
INSERT EPIC ELTRD/GENERATOR
33.77
1.00
33246
INSERT EPIC ELTRD/GENERATOR
37.29
1.00
33249
ELTRD/INSERT PACE-DEFIB
6.00
1.00
33249
ELTRD/INSERT PACE-DEFIB
23.66
1.00
33249
ELTRD/INSERT PACE-DEFIB
24.30
1.00
33249
ELTRD/INSERT PACE-DEFIB
25.47
1.00
33250
ABLATE HEART DYSRHYTHM FOCUS
34.17
1.00
33250
ABLATE HEART DYSRHYTHM FOCUS
37.28
1.00
33250
ABLATE HEART DYSRHYTHM FOCUS
39.86
1.00
33251
ABLATE HEART DYSRHYTHM FOCUS
39.49
1.00
33251
ABLATE HEART DYSRHYTHM FOCUS
41.82
1.00
33251
ABLATE HEART DYSRHYTHM FOCUS
44.19
1.00
33253
RECONSTRUCT ATRIA
15.00
1.00
33253
RECONSTRUCT ATRIA
49.36
1.00
33253
RECONSTRUCT ATRIA
49.39
1.00
33253
RECONSTRUCT ATRIA
51.53
1.00
33254
ABLATE ATRIA, LMTD
37.31
1.00
33255
ABLATE ATRIA W/O BYPASS, EXT
45.59
1.00
33256
ABLATE ATRIA W/BYPASS, EXTEN
54.45
1.00
33257
ABLATE ATRIA, LMTD, ADD-ON
15.57
1.00
33258
ABLATE ATRIA, X10SV, ADD-ON
17.61
1.00
33259
ABLATE ATRIA W/BYPASS ADD-ON
23.10
1.00
33261
ABLATE HEART DYSRHYTHM FOCUS
40.09
1.00
33261
ABLATE HEART DYSRHYTHM FOCUS
42.49
1.00
33261
ABLATE HEART DYSRHYTHM FOCUS
43.93
1.00
33265
ABLATE ATRIA, LMTD, ENDO
37.23
1.00
33266
ABLATE ATRIA, X10SV, ENDO
51.15
1.00
Procedure Code Description
RVU
RVU Coeff Value
33282
IMPLANT PAT-ACTIVE HT RECORD
6.00
1.00
33282
IMPLANT PAT-ACTIVE HT RECORD
8.74
1.00
33282
IMPLANT PAT-ACTIVE HT RECORD
9.08
1.00
33282
IMPLANT PAT-ACTIVE HT RECORD
9.47
1.00
33284
REMOVE PAT-ACTIVE HT RECORD
6.00
1.00
33284
REMOVE PAT-ACTIVE HT RECORD
6.36
1.00
33284
REMOVE PAT-ACTIVE HT RECORD
6.54
1.00
33284
REMOVE PAT-ACTIVE HT RECORD
7.12
1.00
33300
REPAIR OF HEART WOUND
15.00
1.00
33300
REPAIR OF HEART WOUND
29.50
1.00
33300
REPAIR OF HEART WOUND
31.91
1.00
33300
REPAIR OF HEART WOUND
62.14
1.00
33305
REPAIR OF HEART WOUND
15.00
1.00
33305
REPAIR OF HEART WOUND
35.34
1.00
33305
REPAIR OF HEART WOUND
37.65
1.00
33305
REPAIR OF HEART WOUND
103.23
1.00
33310
EXPLORATORY HEART SURGERY
15.00
1.00
33310
EXPLORATORY HEART SURGERY
30.86
1.00
33310
EXPLORATORY HEART SURGERY
31.81
1.00
33310
EXPLORATORY HEART SURGERY
33.20
1.00
33315
EXPLORATORY HEART SURGERY
20.00
1.00
33315
EXPLORATORY HEART SURGERY
36.79
1.00
33315
EXPLORATORY HEART SURGERY
39.01
1.00
33315
EXPLORATORY HEART SURGERY
40.44
1.00
33320
REPAIR MAJOR BLOOD VESSEL(S)
15.00
1.00
33320
REPAIR MAJOR BLOOD VESSEL(S)
27.06
1.00
33320
REPAIR MAJOR BLOOD VESSEL(S)
28.75
1.00
33320
REPAIR MAJOR BLOOD VESSEL(S)
29.89
1.00
33321
REPAIR MAJOR VESSEL
15.00
1.00
33321
REPAIR MAJOR VESSEL
32.61
1.00
33321
REPAIR MAJOR VESSEL
33.29
1.00
33321
REPAIR MAJOR VESSEL
35.62
1.00
33322
REPAIR MAJOR BLOOD VESSEL(S)
15.00
1.00
33322
REPAIR MAJOR BLOOD VESSEL(S)
34.06
1.00
33322
REPAIR MAJOR BLOOD VESSEL(S)
36.45
1.00
Procedure Code Description
RVU
RVU Coeff Value
33322
REPAIR MAJOR BLOOD VESSEL(S)
37.69
1.00
33330
INSERT MAJOR VESSEL GRAFT
15.00
1.00
33330
INSERT MAJOR VESSEL GRAFT
34.75
1.00
33330
INSERT MAJOR VESSEL GRAFT
36.85
1.00
33330
INSERT MAJOR VESSEL GRAFT
38.01
1.00
33332
INSERT MAJOR VESSEL GRAFT
15.00
1.00
33332
INSERT MAJOR VESSEL GRAFT
37.46
1.00
33332
INSERT MAJOR VESSEL GRAFT
38.05
1.00
33332
INSERT MAJOR VESSEL GRAFT
39.59
1.00
33335
INSERT MAJOR VESSEL GRAFT
15.00
1.00
33335
INSERT MAJOR VESSEL GRAFT
47.95
1.00
33335
INSERT MAJOR VESSEL GRAFT
50.03
1.00
33335
INSERT MAJOR VESSEL GRAFT
51.44
1.00
33400
REPAIR OF AORTIC VALVE
15.00
1.00
33400
REPAIR OF AORTIC VALVE
46.59
1.00
33400
REPAIR OF AORTIC VALVE
47.92
1.00
33400
REPAIR OF AORTIC VALVE
61.62
1.00
33401
VALVULOPLASTY, OPEN
15.00
1.00
33401
VALVULOPLASTY, OPEN
39.95
1.00
33401
VALVULOPLASTY, OPEN
40.71
1.00
33401
VALVULOPLASTY, OPEN
41.06
1.00
33403
VALVULOPLASTY, W/CP BYPASS
15.00
1.00
33403
VALVULOPLASTY, W/CP BYPASS
41.08
1.00
33403
VALVULOPLASTY, W/CP BYPASS
41.24
1.00
33403
VALVULOPLASTY, W/CP BYPASS
42.21
1.00
33404
PREPARE HEART-AORTA CONDUIT
20.00
1.00
33404
PREPARE HEART-AORTA CONDUIT
45.79
1.00
33404
PREPARE HEART-AORTA CONDUIT
47.07
1.00
33404
PREPARE HEART-AORTA CONDUIT
48.89
1.00
33405
REPLACEMENT OF AORTIC VALVE
15.00
1.00
33405
REPLACEMENT OF AORTIC VALVE
56.38
1.00
33405
REPLACEMENT OF AORTIC VALVE
57.97
1.00
33405
REPLACEMENT OF AORTIC VALVE
63.27
1.00
33406
REPLACEMENT OF AORTIC VALVE
15.00
1.00
33406
REPLACEMENT OF AORTIC VALVE
59.88
1.00
Procedure Code Description
RVU
RVU Coeff Value
33406
REPLACEMENT OF AORTIC VALVE
61.55
1.00
33406
REPLACEMENT OF AORTIC VALVE
77.68
1.00
33410
REPLACEMENT OF AORTIC VALVE
20.00
1.00
33410
REPLACEMENT OF AORTIC VALVE
52.57
1.00
33410
REPLACEMENT OF AORTIC VALVE
54.03
1.00
33410
REPLACEMENT OF AORTIC VALVE
68.51
1.00
33411
REPLACEMENT OF AORTIC VALVE
20.00
1.00
33411
REPLACEMENT OF AORTIC VALVE
58.38
1.00
33411
REPLACEMENT OF AORTIC VALVE
60.05
1.00
33411
REPLACEMENT OF AORTIC VALVE
89.23
1.00
33412
REPLACEMENT OF AORTIC VALVE
20.00
1.00
33412
REPLACEMENT OF AORTIC VALVE
66.43
1.00
33412
REPLACEMENT OF AORTIC VALVE
68.06
1.00
33412
REPLACEMENT OF AORTIC VALVE
68.51
1.00
33413
REPLACEMENT OF AORTIC VALVE
15.00
1.00
33413
REPLACEMENT OF AORTIC VALVE
67.86
1.00
33413
REPLACEMENT OF AORTIC VALVE
69.48
1.00
33413
REPLACEMENT OF AORTIC VALVE
88.35
1.00
33414
REPAIR OF AORTIC VALVE
15.00
1.00
33414
REPAIR OF AORTIC VALVE
49.10
1.00
33414
REPAIR OF AORTIC VALVE
52.12
1.00
33414
REPAIR OF AORTIC VALVE
59.13
1.00
33415
REVISION, SUBVALVULAR TISSUE
20.00
1.00
33415
REVISION, SUBVALVULAR TISSUE
43.14
1.00
33415
REVISION, SUBVALVULAR TISSUE
46.45
1.00
33415
REVISION, SUBVALVULAR TISSUE
54.76
1.00
33416
REVISE VENTRICLE MUSCLE
48.53
1.00
33416
REVISE VENTRICLE MUSCLE
50.61
1.00
33416
REVISE VENTRICLE MUSCLE
55.16
1.00
33417
REPAIR OF AORTIC VALVE
20.00
1.00
33417
REPAIR OF AORTIC VALVE
46.11
1.00
33417
REPAIR OF AORTIC VALVE
46.52
1.00
33417
REPAIR OF AORTIC VALVE
49.62
1.00
33420
REVISION OF MITRAL VALVE
15.00
1.00
33420
REVISION OF MITRAL VALVE
34.12
1.00
Procedure Code Description
RVU
RVU Coeff Value
33420
REVISION OF MITRAL VALVE
34.30
1.00
33420
REVISION OF MITRAL VALVE
36.89
1.00
33422
REVISION OF MITRAL VALVE
15.00
1.00
33422
REVISION OF MITRAL VALVE
42.27
1.00
33422
REVISION OF MITRAL VALVE
43.59
1.00
33422
REVISION OF MITRAL VALVE
46.23
1.00
33425
REPAIR OF MITRAL VALVE
15.00
1.00
33425
REPAIR OF MITRAL VALVE
42.58
1.00
33425
REPAIR OF MITRAL VALVE
43.68
1.00
33425
REPAIR OF MITRAL VALVE
71.32
1.00
33426
REPAIR OF MITRAL VALVE
53.29
1.00
33426
REPAIR OF MITRAL VALVE
54.83
1.00
33426
REPAIR OF MITRAL VALVE
65.19
1.00
33427
REPAIR OF MITRAL VALVE
62.89
1.00
33427
REPAIR OF MITRAL VALVE
64.57
1.00
33427
REPAIR OF MITRAL VALVE
68.31
1.00
33430
REPLACEMENT OF MITRAL VALVE
20.00
1.00
33430
REPLACEMENT OF MITRAL VALVE
53.99
1.00
33430
REPLACEMENT OF MITRAL VALVE
55.58
1.00
33430
REPLACEMENT OF MITRAL VALVE
75.16
1.00
33460
REVISION OF TRICUSPID VALVE
15.00
1.00
33460
REVISION OF TRICUSPID VALVE
38.58
1.00
33460
REVISION OF TRICUSPID VALVE
40.75
1.00
33460
REVISION OF TRICUSPID VALVE
63.40
1.00
33463
VALVULOPLASTY, TRICUSPID
15.00
1.00
33463
VALVULOPLASTY, TRICUSPID
42.39
1.00
33463
VALVULOPLASTY, TRICUSPID
43.66
1.00
33463
VALVULOPLASTY, TRICUSPID
79.94
1.00
33464
VALVULOPLASTY, TRICUSPID
15.00
1.00
33464
VALVULOPLASTY, TRICUSPID
45.08
1.00
33464
VALVULOPLASTY, TRICUSPID
46.27
1.00
33464
VALVULOPLASTY, TRICUSPID
64.76
1.00
33465
REPLACE TRICUSPID VALVE
15.00
1.00
33465
REPLACE TRICUSPID VALVE
46.15
1.00
33465
REPLACE TRICUSPID VALVE
48.20
1.00
Procedure Code Description
RVU
RVU Coeff Value
33465
REPLACE TRICUSPID VALVE
72.39
1.00
33468
REVISION OF TRICUSPID VALVE
15.00
1.00
33468
REVISION OF TRICUSPID VALVE
48.65
1.00
33468
REVISION OF TRICUSPID VALVE
51.41
1.00
33468
REVISION OF TRICUSPID VALVE
54.22
1.00
33470
REVISION OF PULMONARY VALVE
15.00
1.00
33470
REVISION OF PULMONARY VALVE
31.95
1.00
33470
REVISION OF PULMONARY VALVE
34.95
1.00
33470
REVISION OF PULMONARY VALVE
37.29
1.00
33471
VALVOTOMY, PULMONARY VALVE
15.00
1.00
33471
VALVOTOMY, PULMONARY VALVE
35.66
1.00
33471
VALVOTOMY, PULMONARY VALVE
36.39
1.00
33471
VALVOTOMY, PULMONARY VALVE
37.97
1.00
33472
REVISION OF PULMONARY VALVE
20.00
1.00
33472
REVISION OF PULMONARY VALVE
36.79
1.00
33472
REVISION OF PULMONARY VALVE
37.71
1.00
33472
REVISION OF PULMONARY VALVE
40.42
1.00
33474
REVISION OF PULMONARY VALVE
15.00
1.00
33474
REVISION OF PULMONARY VALVE
37.39
1.00
33474
REVISION OF PULMONARY VALVE
39.30
1.00
33474
REVISION OF PULMONARY VALVE
55.67
1.00
33475
REPLACEMENT, PULMONARY VALVE
15.00
1.00
33475
REPLACEMENT, PULMONARY VALVE
51.61
1.00
33475
REPLACEMENT, PULMONARY VALVE
54.51
1.00
33475
REPLACEMENT, PULMONARY VALVE
63.16
1.00
33476
REVISION OF HEART CHAMBER
15.00
1.00
33476
REVISION OF HEART CHAMBER
39.75
1.00
33476
REVISION OF HEART CHAMBER
40.65
1.00
33476
REVISION OF HEART CHAMBER
42.24
1.00
33478
REVISION OF HEART CHAMBER
15.00
1.00
33478
REVISION OF HEART CHAMBER
43.19
1.00
33478
REVISION OF HEART CHAMBER
44.12
1.00
33478
REVISION OF HEART CHAMBER
45.45
1.00
33496
REPAIR, PROSTH VALVE CLOT
15.00
1.00
33496
REPAIR, PROSTH VALVE CLOT
44.19
1.00
Procedure Code Description
RVU
RVU Coeff Value
33496
REPAIR, PROSTH VALVE CLOT
46.18
1.00
33496
REPAIR, PROSTH VALVE CLOT
47.87
1.00
33500
REPAIR HEART VESSEL FISTULA
40.43
1.00
33500
REPAIR HEART VESSEL FISTULA
42.21
1.00
33500
REPAIR HEART VESSEL FISTULA
43.33
1.00
33501
REPAIR HEART VESSEL FISTULA
15.00
1.00
33501
REPAIR HEART VESSEL FISTULA
28.56
1.00
33501
REPAIR HEART VESSEL FISTULA
29.81
1.00
33501
REPAIR HEART VESSEL FISTULA
30.38
1.00
33502
CORONARY ARTERY CORRECTION
15.00
1.00
33502
CORONARY ARTERY CORRECTION
34.72
1.00
33502
CORONARY ARTERY CORRECTION
35.19
1.00
33502
CORONARY ARTERY CORRECTION
40.59
1.00
33503
CORONARY ARTERY GRAFT
10.00
1.00
33503
CORONARY ARTERY GRAFT
33.29
1.00
33503
CORONARY ARTERY GRAFT
36.75
1.00
33503
CORONARY ARTERY GRAFT
37.25
1.00
33504
CORONARY ARTERY GRAFT
20.00
1.00
33504
CORONARY ARTERY GRAFT
39.61
1.00
33504
CORONARY ARTERY GRAFT
40.20
1.00
33504
CORONARY ARTERY GRAFT
44.62
1.00
33505
REPAIR ARTERY W/TUNNEL
15.00
1.00
33505
REPAIR ARTERY W/TUNNEL
41.65
1.00
33505
REPAIR ARTERY W/TUNNEL
46.72
1.00
33505
REPAIR ARTERY W/TUNNEL
53.61
1.00
33506
REPAIR ARTERY, TRANSLOCATION
15.00
1.00
33506
REPAIR ARTERY, TRANSLOCATION
53.96
1.00
33506
REPAIR ARTERY, TRANSLOCATION
56.40
1.00
33506
REPAIR ARTERY, TRANSLOCATION
58.38
1.00
33507
REPAIR ART, INTRAMURAL
47.76
1.00
33508
ENDOSCOPIC VEIN HARVEST
0.45
1.00
33510
CABG, VEIN, SINGLE
20.00
1.00
33510
CABG, VEIN, SINGLE
47.65
1.00
33510
CABG, VEIN, SINGLE
49.15
1.00
33510
CABG, VEIN, SINGLE
53.77
1.00
Procedure Code Description
RVU
RVU Coeff Value
33511
CABG, VEIN, TWO
20.00
1.00
33511
CABG, VEIN, TWO
49.55
1.00
33511
CABG, VEIN, TWO
51.14
1.00
33511
CABG, VEIN, TWO
58.60
1.00
33512
CABG, VEIN, THREE
20.00
1.00
33512
CABG, VEIN, THREE
52.25
1.00
33512
CABG, VEIN, THREE
53.89
1.00
33512
CABG, VEIN, THREE
65.83
1.00
33513
CABG, VEIN, FOUR
20.00
1.00
33513
CABG, VEIN, FOUR
52.90
1.00
33513
CABG, VEIN, FOUR
54.62
1.00
33513
CABG, VEIN, FOUR
67.27
1.00
33514
CABG, VEIN, FIVE
20.00
1.00
33514
CABG, VEIN, FIVE
54.28
1.00
33514
CABG, VEIN, FIVE
56.11
1.00
33514
CABG, VEIN, FIVE
71.16
1.00
33516
CABG, VEIN, SIX OR MORE
20.00
1.00
33516
CABG, VEIN, SIX OR MORE
57.53
1.00
33516
CABG, VEIN, SIX OR MORE
59.40
1.00
33516
CABG, VEIN, SIX OR MORE
74.05
1.00
33517
CABG, ARTERY-VEIN, SINGLE
3.73
1.00
33517
CABG, ARTERY-VEIN, SINGLE
3.80
1.00
33517
CABG, ARTERY-VEIN, SINGLE
5.10
1.00
33517
CABG, ARTERY-VEIN, SINGLE
20.00
1.00
33518
CABG, ARTERY-VEIN, TWO
7.04
1.00
33518
CABG, ARTERY-VEIN, TWO
7.17
1.00
33518
CABG, ARTERY-VEIN, TWO
11.00
1.00
33518
CABG, ARTERY-VEIN, TWO
20.00
1.00
33519
CABG, ARTERY-VEIN, THREE
10.32
1.00
33519
CABG, ARTERY-VEIN, THREE
10.51
1.00
33519
CABG, ARTERY-VEIN, THREE
14.70
1.00
33519
CABG, ARTERY-VEIN, THREE
20.00
1.00
33521
CABG, ARTERY-VEIN, FOUR
13.63
1.00
33521
CABG, ARTERY-VEIN, FOUR
13.89
1.00
33521
CABG, ARTERY-VEIN, FOUR
17.83
1.00
Procedure Code Description
RVU
RVU Coeff Value
33521
CABG, ARTERY-VEIN, FOUR
20.00
1.00
33522
CABG, ARTERY-VEIN, FIVE
16.94
1.00
33522
CABG, ARTERY-VEIN, FIVE
17.26
1.00
33522
CABG, ARTERY-VEIN, FIVE
20.00
1.00
33522
CABG, ARTERY-VEIN, FIVE
20.36
1.00
33523
CABG, ART-VEIN, SIX OR MORE
20.00
1.00
33523
CABG, ART-VEIN, SIX OR MORE
20.23
1.00
33523
CABG, ART-VEIN, SIX OR MORE
20.63
1.00
33523
CABG, ART-VEIN, SIX OR MORE
23.27
1.00
33530
CORONARY ARTERY, BYPASS/REOP
8.49
1.00
33530
CORONARY ARTERY, BYPASS/REOP
8.64
1.00
33530
CORONARY ARTERY, BYPASS/REOP
13.97
1.00
33530
CORONARY ARTERY, BYPASS/REOP
999.99
1.00
33533
CABG, ARTERIAL, SINGLE
20.00
1.00
33533
CABG, ARTERIAL, SINGLE
48.91
1.00
33533
CABG, ARTERIAL, SINGLE
50.41
1.00
33533
CABG, ARTERIAL, SINGLE
52.46
1.00
33534
CABG, ARTERIAL, TWO
20.00
1.00
33534
CABG, ARTERIAL, TWO
52.64
1.00
33534
CABG, ARTERIAL, TWO
54.32
1.00
33534
CABG, ARTERIAL, TWO
60.78
1.00
33535
CABG, ARTERIAL, THREE
20.00
1.00
33535
CABG, ARTERIAL, THREE
55.77
1.00
33535
CABG, ARTERIAL, THREE
57.46
1.00
33535
CABG, ARTERIAL, THREE
67.41
1.00
33536
CABG, ARTERIAL, FOUR OR MORE
20.00
1.00
33536
CABG, ARTERIAL, FOUR OR MORE
58.42
1.00
33536
CABG, ARTERIAL, FOUR OR MORE
59.79
1.00
33536
CABG, ARTERIAL, FOUR OR MORE
72.23
1.00
33542
REMOVAL OF HEART LESION
20.00
1.00
33542
REMOVAL OF HEART LESION
46.24
1.00
33542
REMOVAL OF HEART LESION
49.89
1.00
33542
REMOVAL OF HEART LESION
69.28
1.00
33545
REPAIR OF HEART DAMAGE
15.00
1.00
33545
REPAIR OF HEART DAMAGE
57.76
1.00
Procedure Code Description
RVU
RVU Coeff Value
33545
REPAIR OF HEART DAMAGE
61.19
1.00
33545
REPAIR OF HEART DAMAGE
81.75
1.00
33548
RESTORE/REMODEL, VENTRICLE
80.40
1.00
33572
OPEN CORONARY ENDARTERECTOMY
6.44
1.00
33572
OPEN CORONARY ENDARTERECTOMY
6.53
1.00
33572
OPEN CORONARY ENDARTERECTOMY
6.56
1.00
33600
CLOSURE OF VALVE
15.00
1.00
33600
CLOSURE OF VALVE
44.86
1.00
33600
CLOSURE OF VALVE
47.07
1.00
33600
CLOSURE OF VALVE
48.70
1.00
33602
CLOSURE OF VALVE
15.00
1.00
33602
CLOSURE OF VALVE
44.54
1.00
33602
CLOSURE OF VALVE
44.70
1.00
33602
CLOSURE OF VALVE
47.87
1.00
33606
ANASTOMOSIS/ARTERY-AORTA
15.00
1.00
33606
ANASTOMOSIS/ARTERY-AORTA
48.77
1.00
33606
ANASTOMOSIS/ARTERY-AORTA
48.79
1.00
33606
ANASTOMOSIS/ARTERY-AORTA
52.56
1.00
33608
REPAIR ANOMALY W/CONDUIT
15.00
1.00
33608
REPAIR ANOMALY W/CONDUIT
50.18
1.00
33608
REPAIR ANOMALY W/CONDUIT
50.26
1.00
33608
REPAIR ANOMALY W/CONDUIT
52.88
1.00
33610
REPAIR BY ENLARGEMENT
15.00
1.00
33610
REPAIR BY ENLARGEMENT
48.93
1.00
33610
REPAIR BY ENLARGEMENT
49.61
1.00
33610
REPAIR BY ENLARGEMENT
53.29
1.00
33611
REPAIR DOUBLE VENTRICLE
15.00
1.00
33611
REPAIR DOUBLE VENTRICLE
52.14
1.00
33611
REPAIR DOUBLE VENTRICLE
53.54
1.00
33611
REPAIR DOUBLE VENTRICLE
56.49
1.00
33612
REPAIR DOUBLE VENTRICLE
15.00
1.00
33612
REPAIR DOUBLE VENTRICLE
55.55
1.00
33612
REPAIR DOUBLE VENTRICLE
55.56
1.00
33612
REPAIR DOUBLE VENTRICLE
59.41
1.00
33615
REPAIR, MODIFIED FONTAN
15.00
1.00
Procedure Code Description
RVU
RVU Coeff Value
33615
REPAIR, MODIFIED FONTAN
52.89
1.00
33615
REPAIR, MODIFIED FONTAN
55.07
1.00
33615
REPAIR, MODIFIED FONTAN
55.95
1.00
33617
REPAIR SINGLE VENTRICLE
15.00
1.00
33617
REPAIR SINGLE VENTRICLE
57.98
1.00
33617
REPAIR SINGLE VENTRICLE
59.40
1.00
33617
REPAIR SINGLE VENTRICLE
63.00
1.00
33619
REPAIR SINGLE VENTRICLE
15.00
1.00
33619
REPAIR SINGLE VENTRICLE
71.55
1.00
33619
REPAIR SINGLE VENTRICLE
72.60
1.00
33619
REPAIR SINGLE VENTRICLE
76.95
1.00
33641
REPAIR HEART SEPTUM DEFECT
20.00
1.00
33641
REPAIR HEART SEPTUM DEFECT
34.22
1.00
33641
REPAIR HEART SEPTUM DEFECT
36.01
1.00
33641
REPAIR HEART SEPTUM DEFECT
43.88
1.00
33645
REVISION OF HEART VEINS
20.00
1.00
33645
REVISION OF HEART VEINS
40.56
1.00
33645
REVISION OF HEART VEINS
42.36
1.00
33645
REVISION OF HEART VEINS
43.45
1.00
33647
REPAIR HEART SEPTUM DEFECTS
20.00
1.00
33647
REPAIR HEART SEPTUM DEFECTS
46.00
1.00
33647
REPAIR HEART SEPTUM DEFECTS
46.61
1.00
33647
REPAIR HEART SEPTUM DEFECTS
49.75
1.00
33660
REPAIR OF HEART DEFECTS
15.00
1.00
33660
REPAIR OF HEART DEFECTS
46.94
1.00
33660
REPAIR OF HEART DEFECTS
48.49
1.00
33660
REPAIR OF HEART DEFECTS
50.19
1.00
33665
REPAIR OF HEART DEFECTS
15.00
1.00
33665
REPAIR OF HEART DEFECTS
47.07
1.00
33665
REPAIR OF HEART DEFECTS
50.08
1.00
33665
REPAIR OF HEART DEFECTS
52.18
1.00
33670
REPAIR OF HEART CHAMBERS
15.00
1.00
33670
REPAIR OF HEART CHAMBERS
50.97
1.00
33670
REPAIR OF HEART CHAMBERS
53.37
1.00
33670
REPAIR OF HEART CHAMBERS
54.41
1.00
Procedure Code Description
RVU
RVU Coeff Value
33675
CLOSE MULT VSD
54.42
1.00
33676
CLOSE MULT VSD W/RESECTION
56.75
1.00
33677
CL MULT VSD W/REM PUL BAND
58.99
1.00
33681
REPAIR HEART SEPTUM DEFECT
20.00
1.00
33681
REPAIR HEART SEPTUM DEFECT
49.59
1.00
33681
REPAIR HEART SEPTUM DEFECT
50.32
1.00
33681
REPAIR HEART SEPTUM DEFECT
52.21
1.00
33684
REPAIR HEART SEPTUM DEFECT
20.00
1.00
33684
REPAIR HEART SEPTUM DEFECT
47.87
1.00
33684
REPAIR HEART SEPTUM DEFECT
50.35
1.00
33684
REPAIR HEART SEPTUM DEFECT
50.94
1.00
33688
REPAIR HEART SEPTUM DEFECT
20.00
1.00
33688
REPAIR HEART SEPTUM DEFECT
45.84
1.00
33688
REPAIR HEART SEPTUM DEFECT
48.91
1.00
33688
REPAIR HEART SEPTUM DEFECT
51.58
1.00
33690
REINFORCE PULMONARY ARTERY
15.00
1.00
33690
REINFORCE PULMONARY ARTERY
31.43
1.00
33690
REINFORCE PULMONARY ARTERY
32.93
1.00
33690
REINFORCE PULMONARY ARTERY
35.76
1.00
33692
REPAIR OF HEART DEFECTS
15.00
1.00
33692
REPAIR OF HEART DEFECTS
48.64
1.00
33692
REPAIR OF HEART DEFECTS
49.27
1.00
33692
REPAIR OF HEART DEFECTS
51.99
1.00
33694
REPAIR OF HEART DEFECTS
15.00
1.00
33694
REPAIR OF HEART DEFECTS
53.42
1.00
33694
REPAIR OF HEART DEFECTS
54.82
1.00
33694
REPAIR OF HEART DEFECTS
56.68
1.00
33697
REPAIR OF HEART DEFECTS
15.00
1.00
33697
REPAIR OF HEART DEFECTS
56.38
1.00
33697
REPAIR OF HEART DEFECTS
58.55
1.00
33697
REPAIR OF HEART DEFECTS
60.15
1.00
33702
REPAIR OF HEART DEFECTS
15.00
1.00
33702
REPAIR OF HEART DEFECTS
42.10
1.00
33702
REPAIR OF HEART DEFECTS
43.31
1.00
33702
REPAIR OF HEART DEFECTS
46.84
1.00
Procedure Code Description
RVU
RVU Coeff Value
33710
REPAIR OF HEART DEFECTS
15.00
1.00
33710
REPAIR OF HEART DEFECTS
48.39
1.00
33710
REPAIR OF HEART DEFECTS
51.04
1.00
33710
REPAIR OF HEART DEFECTS
51.79
1.00
33720
REPAIR OF HEART DEFECT
15.00
1.00
33720
REPAIR OF HEART DEFECT
42.71
1.00
33720
REPAIR OF HEART DEFECT
42.75
1.00
33720
REPAIR OF HEART DEFECT
46.11
1.00
33722
REPAIR OF HEART DEFECT
15.00
1.00
33722
REPAIR OF HEART DEFECT
41.62
1.00
33722
REPAIR OF HEART DEFECT
46.89
1.00
33722
REPAIR OF HEART DEFECT
50.12
1.00
33724
REPAIR VENOUS ANOMALY
43.38
1.00
33726
REPAIR PUL VENOUS STENOSIS
56.57
1.00
33730
REPAIR HEART-VEIN DEFECT(S)
20.00
1.00
33730
REPAIR HEART-VEIN DEFECT(S)
51.87
1.00
33730
REPAIR HEART-VEIN DEFECT(S)
53.96
1.00
33730
REPAIR HEART-VEIN DEFECT(S)
55.12
1.00
33732
REPAIR HEART-VEIN DEFECT
15.00
1.00
33732
REPAIR HEART-VEIN DEFECT
44.92
1.00
33732
REPAIR HEART-VEIN DEFECT
44.97
1.00
33732
REPAIR HEART-VEIN DEFECT
48.14
1.00
33735
REVISION OF HEART CHAMBER
15.00
1.00
33735
REVISION OF HEART CHAMBER
32.79
1.00
33735
REVISION OF HEART CHAMBER
33.92
1.00
33735
REVISION OF HEART CHAMBER
34.76
1.00
33736
REVISION OF HEART CHAMBER
20.00
1.00
33736
REVISION OF HEART CHAMBER
38.15
1.00
33736
REVISION OF HEART CHAMBER
38.69
1.00
33736
REVISION OF HEART CHAMBER
41.78
1.00
33737
REVISION OF HEART CHAMBER
15.00
1.00
33737
REVISION OF HEART CHAMBER
35.71
1.00
33737
REVISION OF HEART CHAMBER
36.28
1.00
33737
REVISION OF HEART CHAMBER
39.55
1.00
33750
MAJOR VESSEL SHUNT
15.00
1.00
Procedure Code Description
RVU
RVU Coeff Value
33750
MAJOR VESSEL SHUNT
33.79
1.00
33750
MAJOR VESSEL SHUNT
35.29
1.00
33750
MAJOR VESSEL SHUNT
36.53
1.00
33755
MAJOR VESSEL SHUNT
15.00
1.00
33755
MAJOR VESSEL SHUNT
34.15
1.00
33755
MAJOR VESSEL SHUNT
35.50
1.00
33755
MAJOR VESSEL SHUNT
36.97
1.00
33762
MAJOR VESSEL SHUNT
15.00
1.00
33762
MAJOR VESSEL SHUNT
33.92
1.00
33762
MAJOR VESSEL SHUNT
35.40
1.00
33762
MAJOR VESSEL SHUNT
36.78
1.00
33764
MAJOR VESSEL SHUNT & GRAFT
15.00
1.00
33764
MAJOR VESSEL SHUNT & GRAFT
34.40
1.00
33764
MAJOR VESSEL SHUNT & GRAFT
34.84
1.00
33764
MAJOR VESSEL SHUNT & GRAFT
36.87
1.00
33766
MAJOR VESSEL SHUNT
15.00
1.00
33766
MAJOR VESSEL SHUNT
38.13
1.00
33766
MAJOR VESSEL SHUNT
38.54
1.00
33766
MAJOR VESSEL SHUNT
41.13
1.00
33767
MAJOR VESSEL SHUNT
20.00
1.00
33767
MAJOR VESSEL SHUNT
38.95
1.00
33767
MAJOR VESSEL SHUNT
40.06
1.00
33767
MAJOR VESSEL SHUNT
42.83
1.00
33768
CAVOPULMONARY SHUNTING
11.87
1.00
33770
REPAIR GREAT VESSELS DEFECT
20.00
1.00
33770
REPAIR GREAT VESSELS DEFECT
57.13
1.00
33770
REPAIR GREAT VESSELS DEFECT
59.17
1.00
33770
REPAIR GREAT VESSELS DEFECT
59.46
1.00
33771
REPAIR GREAT VESSELS DEFECT
20.00
1.00
33771
REPAIR GREAT VESSELS DEFECT
52.71
1.00
33771
REPAIR GREAT VESSELS DEFECT
54.27
1.00
33771
REPAIR GREAT VESSELS DEFECT
60.56
1.00
33774
REPAIR GREAT VESSELS DEFECT
20.00
1.00
33774
REPAIR GREAT VESSELS DEFECT
49.93
1.00
33774
REPAIR GREAT VESSELS DEFECT
50.20
1.00
Procedure Code Description
RVU
RVU Coeff Value
33774
REPAIR GREAT VESSELS DEFECT
51.74
1.00
33775
REPAIR GREAT VESSELS DEFECT
51.66
1.00
33775
REPAIR GREAT VESSELS DEFECT
51.94
1.00
33775
REPAIR GREAT VESSELS DEFECT
53.46
1.00
33776
REPAIR GREAT VESSELS DEFECT
54.60
1.00
33776
REPAIR GREAT VESSELS DEFECT
55.39
1.00
33776
REPAIR GREAT VESSELS DEFECT
57.03
1.00
33777
REPAIR GREAT VESSELS DEFECT
53.64
1.00
33777
REPAIR GREAT VESSELS DEFECT
53.80
1.00
33777
REPAIR GREAT VESSELS DEFECT
55.38
1.00
33778
REPAIR GREAT VESSELS DEFECT
62.75
1.00
33778
REPAIR GREAT VESSELS DEFECT
65.55
1.00
33778
REPAIR GREAT VESSELS DEFECT
65.69
1.00
33778
REPAIR GREAT VESSELS DEFECT
999.99
1.00
33779
REPAIR GREAT VESSELS DEFECT
54.54
1.00
33779
REPAIR GREAT VESSELS DEFECT
56.77
1.00
33779
REPAIR GREAT VESSELS DEFECT
61.95
1.00
33780
REPAIR GREAT VESSELS DEFECT
64.65
1.00
33780
REPAIR GREAT VESSELS DEFECT
67.10
1.00
33780
REPAIR GREAT VESSELS DEFECT
69.36
1.00
33781
REPAIR GREAT VESSELS DEFECT
55.88
1.00
33781
REPAIR GREAT VESSELS DEFECT
56.77
1.00
33781
REPAIR GREAT VESSELS DEFECT
64.32
1.00
33786
REPAIR ARTERIAL TRUNK
15.00
1.00
33786
REPAIR ARTERIAL TRUNK
61.39
1.00
33786
REPAIR ARTERIAL TRUNK
63.22
1.00
33786
REPAIR ARTERIAL TRUNK
63.86
1.00
33788
REVISION OF PULMONARY ARTERY
15.00
1.00
33788
REVISION OF PULMONARY ARTERY
42.61
1.00
33788
REVISION OF PULMONARY ARTERY
42.77
1.00
33788
REVISION OF PULMONARY ARTERY
45.32
1.00
33800
AORTIC SUSPENSION
10.00
1.00
33800
AORTIC SUSPENSION
25.77
1.00
33800
AORTIC SUSPENSION
26.80
1.00
33800
AORTIC SUSPENSION
29.80
1.00
Procedure Code Description
RVU
RVU Coeff Value
33802
REPAIR VESSEL DEFECT
15.00
1.00
33802
REPAIR VESSEL DEFECT
28.71
1.00
33802
REPAIR VESSEL DEFECT
28.81
1.00
33802
REPAIR VESSEL DEFECT
32.24
1.00
33803
REPAIR VESSEL DEFECT
15.00
1.00
33803
REPAIR VESSEL DEFECT
31.46
1.00
33803
REPAIR VESSEL DEFECT
32.58
1.00
33803
REPAIR VESSEL DEFECT
35.74
1.00
33813
REPAIR SEPTAL DEFECT
34.96
1.00
33813
REPAIR SEPTAL DEFECT
35.58
1.00
33813
REPAIR SEPTAL DEFECT
38.37
1.00
33814
REPAIR SEPTAL DEFECT
41.50
1.00
33814
REPAIR SEPTAL DEFECT
41.93
1.00
33814
REPAIR SEPTAL DEFECT
44.76
1.00
33820
REVISE MAJOR VESSEL
15.00
1.00
33820
REVISE MAJOR VESSEL
26.82
1.00
33820
REVISE MAJOR VESSEL
27.19
1.00
33820
REVISE MAJOR VESSEL
29.84
1.00
33822
REVISE MAJOR VESSEL
15.00
1.00
33822
REVISE MAJOR VESSEL
28.54
1.00
33822
REVISE MAJOR VESSEL
29.13
1.00
33822
REVISE MAJOR VESSEL
33.49
1.00
33824
REVISE MAJOR VESSEL
15.00
1.00
33824
REVISE MAJOR VESSEL
32.22
1.00
33824
REVISE MAJOR VESSEL
32.70
1.00
33824
REVISE MAJOR VESSEL
34.76
1.00
33840
REMOVE AORTA CONSTRICTION
15.00
1.00
33840
REMOVE AORTA CONSTRICTION
32.29
1.00
33840
REMOVE AORTA CONSTRICTION
33.81
1.00
33840
REMOVE AORTA CONSTRICTION
36.94
1.00
33845
REMOVE AORTA CONSTRICTION
15.00
1.00
33845
REMOVE AORTA CONSTRICTION
37.01
1.00
33845
REMOVE AORTA CONSTRICTION
37.56
1.00
33845
REMOVE AORTA CONSTRICTION
40.15
1.00
33851
REMOVE AORTA CONSTRICTION
15.00
1.00
Procedure Code Description
RVU
RVU Coeff Value
33851
REMOVE AORTA CONSTRICTION
34.57
1.00
33851
REMOVE AORTA CONSTRICTION
35.47
1.00
33851
REMOVE AORTA CONSTRICTION
38.93
1.00
33852
REPAIR SEPTAL DEFECT
37.11
1.00
33852
REPAIR SEPTAL DEFECT
38.97
1.00
33852
REPAIR SEPTAL DEFECT
42.24
1.00
33853
REPAIR SEPTAL DEFECT
20.00
1.00
33853
REPAIR SEPTAL DEFECT
51.69
1.00
33853
REPAIR SEPTAL DEFECT
51.72
1.00
33853
REPAIR SEPTAL DEFECT
54.85
1.00
33860
ASCENDING AORTIC GRAFT
20.00
1.00
33860
ASCENDING AORTIC GRAFT
59.68
1.00
33860
ASCENDING AORTIC GRAFT
61.20
1.00
33860
ASCENDING AORTIC GRAFT
85.63
1.00
33861
ASCENDING AORTIC GRAFT
20.00
1.00
33861
ASCENDING AORTIC GRAFT
64.86
1.00
33861
ASCENDING AORTIC GRAFT
66.42
1.00
33861
ASCENDING AORTIC GRAFT
67.39
1.00
33863
ASCENDING AORTIC GRAFT
20.00
1.00
33863
ASCENDING AORTIC GRAFT
69.28
1.00
33863
ASCENDING AORTIC GRAFT
70.74
1.00
33863
ASCENDING AORTIC GRAFT
85.85
1.00
33864
ASCENDING AORTIC GRAFT
88.23
1.00
33870
TRANSVERSE AORTIC ARCH GRAFT
20.00
1.00
33870
TRANSVERSE AORTIC ARCH GRAFT
68.56
1.00
33870
TRANSVERSE AORTIC ARCH GRAFT
69.92
1.00
33870
TRANSVERSE AORTIC ARCH GRAFT
70.33
1.00
33875
THORACIC AORTIC GRAFT
20.00
1.00
33875
THORACIC AORTIC GRAFT
52.11
1.00
33875
THORACIC AORTIC GRAFT
54.24
1.00
33875
THORACIC AORTIC GRAFT
54.50
1.00
33877
THORACOABDOMINAL GRAFT
15.00
1.00
33877
THORACOABDOMINAL GRAFT
65.08
1.00
33877
THORACOABDOMINAL GRAFT
69.42
1.00
33877
THORACOABDOMINAL GRAFT
95.87
1.00
Procedure Code Description
RVU
RVU Coeff Value
33880
ENDOVASC TAA REPR INCL SUBCL
49.55
1.00
33881
ENDOVASC TAA REPR W/O SUBCL
42.53
1.00
33883
INSERT ENDOVASC PROSTH, TAA
31.21
1.00
33884
ENDOVASC PROSTH, TAA, ADD-ON
11.43
1.00
33886
ENDOVASC PROSTH, DELAYED
26.81
1.00
33889
ARTERY TRANSPOSE/ENDOVAS TAA
22.61
1.00
33891
CAR-CAR BP GRFT/ENDOVAS TAA
28.28
1.00
33910
REMOVE LUNG ARTERY EMBOLI
20.00
1.00
33910
REMOVE LUNG ARTERY EMBOLI
39.76
1.00
33910
REMOVE LUNG ARTERY EMBOLI
41.93
1.00
33910
REMOVE LUNG ARTERY EMBOLI
45.49
1.00
33915
REMOVE LUNG ARTERY EMBOLI
15.00
1.00
33915
REMOVE LUNG ARTERY EMBOLI
32.12
1.00
33915
REMOVE LUNG ARTERY EMBOLI
34.59
1.00
33915
REMOVE LUNG ARTERY EMBOLI
35.84
1.00
33916
SURGERY OF GREAT VESSEL
40.89
1.00
33916
SURGERY OF GREAT VESSEL
43.81
1.00
33916
SURGERY OF GREAT VESSEL
45.58
1.00
33917
REPAIR PULMONARY ARTERY
15.00
1.00
33917
REPAIR PULMONARY ARTERY
40.55
1.00
33917
REPAIR PULMONARY ARTERY
41.39
1.00
33917
REPAIR PULMONARY ARTERY
43.61
1.00
33918
REPAIR PULMONARY ATRESIA
15.00
1.00
33918
REPAIR PULMONARY ATRESIA
42.60
1.00
33918
REPAIR PULMONARY ATRESIA
42.72
1.00
33918
REPAIR PULMONARY ATRESIA
45.46
1.00
33919
REPAIR PULMONARY ATRESIA
20.00
1.00
33919
REPAIR PULMONARY ATRESIA
61.76
1.00
33919
REPAIR PULMONARY ATRESIA
63.35
1.00
33919
REPAIR PULMONARY ATRESIA
65.16
1.00
33920
REPAIR PULMONARY ATRESIA
20.00
1.00
33920
REPAIR PULMONARY ATRESIA
49.89
1.00
33920
REPAIR PULMONARY ATRESIA
50.17
1.00
33920
REPAIR PULMONARY ATRESIA
52.46
1.00
33922
TRANSECT PULMONARY ARTERY
20.00
1.00
Procedure Code Description
RVU
RVU Coeff Value
33922
TRANSECT PULMONARY ARTERY
37.23
1.00
33922
TRANSECT PULMONARY ARTERY
37.68
1.00
33922
TRANSECT PULMONARY ARTERY
40.20
1.00
33924
REMOVE PULMONARY SHUNT
8.01
1.00
33924
REMOVE PULMONARY SHUNT
8.06
1.00
33924
REMOVE PULMONARY SHUNT
8.23
1.00
33925
RPR PUL ART UNIFOCAL W/O CPB
48.68
1.00
33926
REPR PUL ART, UNIFOCAL W/CPB
64.72
1.00
33935
TRANSPLANTATION, HEART/LUNG
20.00
1.00
33935
TRANSPLANTATION, HEART/LUNG
95.78
1.00
33935
TRANSPLANTATION, HEART/LUNG
97.00
1.00
33935
TRANSPLANTATION, HEART/LUNG
99.77
1.00
33945
TRANSPLANTATION OF HEART
20.00
1.00
33945
TRANSPLANTATION OF HEART
69.31
1.00
33945
TRANSPLANTATION OF HEART
70.24
1.00
33945
TRANSPLANTATION OF HEART
125.31
1.00
33960
EXTERNAL CIRCULATION ASSIST
26.46
1.00
33960
EXTERNAL CIRCULATION ASSIST
26.84
1.00
33960
EXTERNAL CIRCULATION ASSIST
27.77
1.00
33961
EXTERNAL CIRCULATION ASSIST
15.27
1.00
33961
EXTERNAL CIRCULATION ASSIST
16.05
1.00
33961
EXTERNAL CIRCULATION ASSIST
16.31
1.00
33967
INSERT IA PERCUT DEVICE
4.00
1.00
33967
INSERT IA PERCUT DEVICE
7.00
1.00
33967
INSERT IA PERCUT DEVICE
7.03
1.00
33967
INSERT IA PERCUT DEVICE
7.50
1.00
33968
REMOVE AORTIC ASSIST DEVICE
0.94
1.00
33968
REMOVE AORTIC ASSIST DEVICE
0.95
1.00
33968
REMOVE AORTIC ASSIST DEVICE
0.97
1.00
33970
AORTIC CIRCULATION ASSIST
9.74
1.00
33970
AORTIC CIRCULATION ASSIST
9.87
1.00
33970
AORTIC CIRCULATION ASSIST
10.18
1.00
33971
AORTIC CIRCULATION ASSIST
15.00
1.00
33971
AORTIC CIRCULATION ASSIST
16.92
1.00
33971
AORTIC CIRCULATION ASSIST
18.84
1.00
Procedure Code Description
RVU
RVU Coeff Value
33971
AORTIC CIRCULATION ASSIST
19.47
1.00
33973
INSERT BALLOON DEVICE
14.08
1.00
33973
INSERT BALLOON DEVICE
14.29
1.00
33973
INSERT BALLOON DEVICE
14.86
1.00
33973
INSERT BALLOON DEVICE
15.00
1.00
33974
REMOVE INTRA-AORTIC BALLOON
15.00
1.00
33974
REMOVE INTRA-AORTIC BALLOON
24.13
1.00
33974
REMOVE INTRA-AORTIC BALLOON
24.86
1.00
33974
REMOVE INTRA-AORTIC BALLOON
26.87
1.00
33975
IMPLANT VENTRICULAR DEVICE
15.00
1.00
33975
IMPLANT VENTRICULAR DEVICE
29.00
1.00
33975
IMPLANT VENTRICULAR DEVICE
29.35
1.00
33975
IMPLANT VENTRICULAR DEVICE
30.88
1.00
33976
IMPLANT VENTRICULAR DEVICE
15.00
1.00
33976
IMPLANT VENTRICULAR DEVICE
33.34
1.00
33976
IMPLANT VENTRICULAR DEVICE
33.95
1.00
33976
IMPLANT VENTRICULAR DEVICE
34.27
1.00
33977
REMOVE VENTRICULAR DEVICE
15.00
1.00
33977
REMOVE VENTRICULAR DEVICE
32.23
1.00
33977
REMOVE VENTRICULAR DEVICE
33.09
1.00
33977
REMOVE VENTRICULAR DEVICE
33.33
1.00
33978
REMOVE VENTRICULAR DEVICE
15.00
1.00
33978
REMOVE VENTRICULAR DEVICE
35.76
1.00
33978
REMOVE VENTRICULAR DEVICE
36.50
1.00
33978
REMOVE VENTRICULAR DEVICE
36.71
1.00
33979
INSERT INTRACORPOREAL DEVICE
15.00
1.00
33979
INSERT INTRACORPOREAL DEVICE
65.70
1.00
33979
INSERT INTRACORPOREAL DEVICE
67.80
1.00
33979
INSERT INTRACORPOREAL DEVICE
67.86
1.00
33980
REMOVE INTRACORPOREAL DEVICE
15.00
1.00
33980
REMOVE INTRACORPOREAL DEVICE
87.24
1.00
33980
REMOVE INTRACORPOREAL DEVICE
87.32
1.00
33980
REMOVE INTRACORPOREAL DEVICE
99.15
1.00
34001
REMOVAL OF ARTERY CLOT
10.00
1.00
34001
REMOVAL OF ARTERY CLOT
20.22
1.00
Procedure Code Description
RVU
RVU Coeff Value
34001
REMOVAL OF ARTERY CLOT
21.40
1.00
34001
REMOVAL OF ARTERY CLOT
26.47
1.00
34051
REMOVAL OF ARTERY CLOT
10.00
1.00
34051
REMOVAL OF ARTERY CLOT
24.02
1.00
34051
REMOVAL OF ARTERY CLOT
25.30
1.00
34051
REMOVAL OF ARTERY CLOT
26.68
1.00
34101
REMOVAL OF ARTERY CLOT
5.00
1.00
34101
REMOVAL OF ARTERY CLOT
15.82
1.00
34101
REMOVAL OF ARTERY CLOT
16.71
1.00
34101
REMOVAL OF ARTERY CLOT
16.94
1.00
34111
REMOVAL OF ARM ARTERY CLOT
10.00
1.00
34111
REMOVAL OF ARM ARTERY CLOT
15.62
1.00
34111
REMOVAL OF ARM ARTERY CLOT
16.40
1.00
34111
REMOVAL OF ARM ARTERY CLOT
16.93
1.00
34151
REMOVAL OF ARTERY CLOT
10.00
1.00
34151
REMOVAL OF ARTERY CLOT
37.08
1.00
34151
REMOVAL OF ARTERY CLOT
37.63
1.00
34151
REMOVAL OF ARTERY CLOT
39.29
1.00
34201
REMOVAL OF ARTERY CLOT
4.00
1.00
34201
REMOVAL OF ARTERY CLOT
16.08
1.00
34201
REMOVAL OF ARTERY CLOT
16.69
1.00
34201
REMOVAL OF ARTERY CLOT
27.32
1.00
34203
REMOVAL OF LEG ARTERY CLOT
8.00
1.00
34203
REMOVAL OF LEG ARTERY CLOT
25.33
1.00
34203
REMOVAL OF LEG ARTERY CLOT
26.22
1.00
34203
REMOVAL OF LEG ARTERY CLOT
27.12
1.00
34401
REMOVAL OF VEIN CLOT
10.00
1.00
34401
REMOVAL OF VEIN CLOT
36.25
1.00
34401
REMOVAL OF VEIN CLOT
37.13
1.00
34401
REMOVAL OF VEIN CLOT
40.34
1.00
34421
REMOVAL OF VEIN CLOT
6.00
1.00
34421
REMOVAL OF VEIN CLOT
18.83
1.00
34421
REMOVAL OF VEIN CLOT
19.46
1.00
34421
REMOVAL OF VEIN CLOT
20.47
1.00
34451
REMOVAL OF VEIN CLOT
10.00
1.00
Procedure Code Description
RVU
RVU Coeff Value
34451
REMOVAL OF VEIN CLOT
39.35
1.00
34451
REMOVAL OF VEIN CLOT
40.37
1.00
34451
REMOVAL OF VEIN CLOT
42.43
1.00
34471
REMOVAL OF VEIN CLOT
10.00
1.00
34471
REMOVAL OF VEIN CLOT
16.01
1.00
34471
REMOVAL OF VEIN CLOT
16.60
1.00
34471
REMOVAL OF VEIN CLOT
29.19
1.00
34490
REMOVAL OF VEIN CLOT
10.00
1.00
34490
REMOVAL OF VEIN CLOT
16.19
1.00
34490
REMOVAL OF VEIN CLOT
16.71
1.00
34490
REMOVAL OF VEIN CLOT
17.03
1.00
34501
REPAIR VALVE, FEMORAL VEIN
8.00
1.00
34501
REPAIR VALVE, FEMORAL VEIN
26.18
1.00
34501
REPAIR VALVE, FEMORAL VEIN
26.46
1.00
34501
REPAIR VALVE, FEMORAL VEIN
26.62
1.00
34502
RECONSTRUCT VENA CAVA
20.00
1.00
34502
RECONSTRUCT VENA CAVA
40.92
1.00
34502
RECONSTRUCT VENA CAVA
42.76
1.00
34502
RECONSTRUCT VENA CAVA
42.86
1.00
34510
TRANSPOSITION OF VEIN VALVE
3.00
1.00
34510
TRANSPOSITION OF VEIN VALVE
29.92
1.00
34510
TRANSPOSITION OF VEIN VALVE
30.33
1.00
34510
TRANSPOSITION OF VEIN VALVE
30.82
1.00
34520
CROSS-OVER VEIN GRAFT
3.00
1.00
34520
CROSS-OVER VEIN GRAFT
28.34
1.00
34520
CROSS-OVER VEIN GRAFT
28.66
1.00
34520
CROSS-OVER VEIN GRAFT
28.75
1.00
34530
LEG VEIN FUSION
3.00
1.00
34530
LEG VEIN FUSION
26.89
1.00
34530
LEG VEIN FUSION
27.44
1.00
34530
LEG VEIN FUSION
27.75
1.00
34800
ENDOVAS AAA REPR W/SM TUBE
7.00
1.00
34800
ENDOVAS AAA REPR W/SM TUBE
31.18
1.00
34800
ENDOVAS AAA REPR W/SM TUBE
31.73
1.00
34800
ENDOVAS AAA REPR W/SM TUBE
32.13
1.00
Procedure Code Description
RVU
RVU Coeff Value
34802
ENDOVAS AAA REPR W/2-P PART
7.00
1.00
34802
ENDOVAS AAA REPR W/2-P PART
34.34
1.00
34802
ENDOVAS AAA REPR W/2-P PART
34.79
1.00
34802
ENDOVAS AAA REPR W/2-P PART
34.96
1.00
34803
ENDOVAS AAA REPR W/3-P PART
35.64
1.00
34804
ENDOVAS AAA REPR W/1-P PART
7.00
1.00
34804
ENDOVAS AAA REPR W/1-P PART
34.34
1.00
34804
ENDOVAS AAA REPR W/1-P PART
34.80
1.00
34804
ENDOVAS AAA REPR W/1-P PART
34.93
1.00
34805
ENDOVAS AAA REPR W/LONG TUBE
32.75
1.00
34805
ENDOVAS AAA REPR W/LONG TUBE
33.30
1.00
34806
ANEURYSM PRESS SENSOR ADD-ON
3.00
1.00
34808
ENDOVAS ILIAC A DEVICE ADDON
5.82
1.00
34808
ENDOVAS ILIAC A DEVICE ADDON
5.85
1.00
34808
ENDOVAS ILIAC A DEVICE ADDON
5.90
1.00
34812
XPOSE FOR ENDOPROSTH, FEMORL
9.53
1.00
34812
XPOSE FOR ENDOPROSTH, FEMORL
9.57
1.00
34812
XPOSE FOR ENDOPROSTH, FEMORL
9.83
1.00
34812
XPOSE FOR ENDOPROSTH, FEMORL
15.00
1.00
34813
FEMORAL ENDOVAS GRAFT ADD-ON
6.74
1.00
34813
FEMORAL ENDOVAS GRAFT ADD-ON
6.78
1.00
34820
XPOSE FOR ENDOPROSTH, ILIAC
13.75
1.00
34820
XPOSE FOR ENDOPROSTH, ILIAC
13.83
1.00
34820
XPOSE FOR ENDOPROSTH, ILIAC
14.05
1.00
34820
XPOSE FOR ENDOPROSTH, ILIAC
15.00
1.00
34825
ENDOVASC EXTEND PROSTH, INIT
7.00
1.00
34825
ENDOVASC EXTEND PROSTH, INIT
18.81
1.00
34825
ENDOVASC EXTEND PROSTH, INIT
19.19
1.00
34825
ENDOVASC EXTEND PROSTH, INIT
19.58
1.00
34826
ENDOVASC EXTEN PROSTH, ADDÏL
5.81
1.00
34826
ENDOVASC EXTEN PROSTH, ADDÏL
5.83
1.00
34826
ENDOVASC EXTEN PROSTH, ADDÏL
5.85
1.00
34830
OPEN AORTIC TUBE PROSTH REPR
15.00
1.00
34830
OPEN AORTIC TUBE PROSTH REPR
48.24
1.00
34830
OPEN AORTIC TUBE PROSTH REPR
49.12
1.00
Procedure Code Description
RVU
RVU Coeff Value
34830
OPEN AORTIC TUBE PROSTH REPR
51.52
1.00
34831
OPEN AORTOILIAC PROSTH REPR
15.00
1.00
34831
OPEN AORTOILIAC PROSTH REPR
49.55
1.00
34831
OPEN AORTOILIAC PROSTH REPR
50.14
1.00
34831
OPEN AORTOILIAC PROSTH REPR
54.60
1.00
34832
OPEN AORTOFEMOR PROSTH REPR
15.00
1.00
34832
OPEN AORTOFEMOR PROSTH REPR
52.25
1.00
34832
OPEN AORTOFEMOR PROSTH REPR
53.02
1.00
34832
OPEN AORTOFEMOR PROSTH REPR
55.34
1.00
34833
XPOSE FOR ENDOPROSTH, ILIAC
17.33
1.00
34833
XPOSE FOR ENDOPROSTH, ILIAC
17.43
1.00
34833
XPOSE FOR ENDOPROSTH, ILIAC
17.68
1.00
34834
XPOSE, ENDOPROSTH, BRACHIAL
7.90
1.00
34834
XPOSE, ENDOPROSTH, BRACHIAL
8.16
1.00
34834
XPOSE, ENDOPROSTH, BRACHIAL
8.32
1.00
34900
ENDOVASC ILIAC REPR W/GRAFT
25.53
1.00
34900
ENDOVASC ILIAC REPR W/GRAFT
25.98
1.00
34900
ENDOVASC ILIAC REPR W/GRAFT
26.11
1.00
35001
REPAIR DEFECT OF ARTERY
6.00
1.00
35001
REPAIR DEFECT OF ARTERY
30.47
1.00
35001
REPAIR DEFECT OF ARTERY
31.95
1.00
35001
REPAIR DEFECT OF ARTERY
32.14
1.00
35002
REPAIR ARTERY RUPTURE, NECK
6.00
1.00
35002
REPAIR ARTERY RUPTURE, NECK
31.89
1.00
35002
REPAIR ARTERY RUPTURE, NECK
32.91
1.00
35002
REPAIR ARTERY RUPTURE, NECK
33.74
1.00
35005
REPAIR DEFECT OF ARTERY
10.00
1.00
35005
REPAIR DEFECT OF ARTERY
27.26
1.00
35005
REPAIR DEFECT OF ARTERY
28.61
1.00
35005
REPAIR DEFECT OF ARTERY
29.08
1.00
35011
REPAIR DEFECT OF ARTERY
10.00
1.00
35011
REPAIR DEFECT OF ARTERY
26.70
1.00
35011
REPAIR DEFECT OF ARTERY
27.56
1.00
35011
REPAIR DEFECT OF ARTERY
28.06
1.00
35013
REPAIR ARTERY RUPTURE, ARM
6.00
1.00
Procedure Code Description
RVU
RVU Coeff Value
35013
REPAIR ARTERY RUPTURE, ARM
32.65
1.00
35013
REPAIR ARTERY RUPTURE, ARM
34.00
1.00
35013
REPAIR ARTERY RUPTURE, ARM
34.79
1.00
35021
REPAIR DEFECT OF ARTERY
20.00
1.00
35021
REPAIR DEFECT OF ARTERY
30.19
1.00
35021
REPAIR DEFECT OF ARTERY
31.45
1.00
35021
REPAIR DEFECT OF ARTERY
34.08
1.00
35022
REPAIR ARTERY RUPTURE, CHEST
6.00
1.00
35022
REPAIR ARTERY RUPTURE, CHEST
34.60
1.00
35022
REPAIR ARTERY RUPTURE, CHEST
35.65
1.00
35022
REPAIR ARTERY RUPTURE, CHEST
38.49
1.00
35045
REPAIR DEFECT OF ARM ARTERY
6.00
1.00
35045
REPAIR DEFECT OF ARM ARTERY
26.63
1.00
35045
REPAIR DEFECT OF ARM ARTERY
27.28
1.00
35045
REPAIR DEFECT OF ARM ARTERY
27.43
1.00
35081
REPAIR DEFECT OF ARTERY
12.00
1.00
35081
REPAIR DEFECT OF ARTERY
42.86
1.00
35081
REPAIR DEFECT OF ARTERY
43.34
1.00
35081
REPAIR DEFECT OF ARTERY
48.74
1.00
35082
REPAIR ARTERY RUPTURE, AORTA
6.00
1.00
35082
REPAIR ARTERY RUPTURE, AORTA
57.17
1.00
35082
REPAIR ARTERY RUPTURE, AORTA
58.70
1.00
35082
REPAIR ARTERY RUPTURE, AORTA
61.35
1.00
35091
REPAIR DEFECT OF ARTERY
15.00
1.00
35091
REPAIR DEFECT OF ARTERY
51.86
1.00
35091
REPAIR DEFECT OF ARTERY
53.40
1.00
35091
REPAIR DEFECT OF ARTERY
53.91
1.00
35092
REPAIR ARTERY RUPTURE, AORTA
6.00
1.00
35092
REPAIR ARTERY RUPTURE, AORTA
66.24
1.00
35092
REPAIR ARTERY RUPTURE, AORTA
67.83
1.00
35092
REPAIR ARTERY RUPTURE, AORTA
73.23
1.00
35102
REPAIR DEFECT OF ARTERY
12.00
1.00
35102
REPAIR DEFECT OF ARTERY
46.53
1.00
35102
REPAIR DEFECT OF ARTERY
47.27
1.00
35102
REPAIR DEFECT OF ARTERY
52.92
1.00
Procedure Code Description
RVU
RVU Coeff Value
35103
REPAIR ARTERY RUPTURE, GROIN
6.00
1.00
35103
REPAIR ARTERY RUPTURE, GROIN
59.68
1.00
35103
REPAIR ARTERY RUPTURE, GROIN
60.93
1.00
35103
REPAIR ARTERY RUPTURE, GROIN
63.44
1.00
35111
REPAIR DEFECT OF ARTERY
15.00
1.00
35111
REPAIR DEFECT OF ARTERY
36.99
1.00
35111
REPAIR DEFECT OF ARTERY
37.65
1.00
35111
REPAIR DEFECT OF ARTERY
39.07
1.00
35112
REPAIR ARTERY RUPTURE,SPLEEN
6.00
1.00
35112
REPAIR ARTERY RUPTURE,SPLEEN
43.60
1.00
35112
REPAIR ARTERY RUPTURE,SPLEEN
44.32
1.00
35112
REPAIR ARTERY RUPTURE,SPLEEN
47.81
1.00
35121
REPAIR DEFECT OF ARTERY
7.00
1.00
35121
REPAIR DEFECT OF ARTERY
45.00
1.00
35121
REPAIR DEFECT OF ARTERY
45.91
1.00
35121
REPAIR DEFECT OF ARTERY
46.44
1.00
35122
REPAIR ARTERY RUPTURE, BELLY
6.00
1.00
35122
REPAIR ARTERY RUPTURE, BELLY
52.00
1.00
35122
REPAIR ARTERY RUPTURE, BELLY
53.08
1.00
35122
REPAIR ARTERY RUPTURE, BELLY
55.46
1.00
35131
REPAIR DEFECT OF ARTERY
12.00
1.00
35131
REPAIR DEFECT OF ARTERY
37.49
1.00
35131
REPAIR DEFECT OF ARTERY
38.30
1.00
35131
REPAIR DEFECT OF ARTERY
39.66
1.00
35132
REPAIR ARTERY RUPTURE, GROIN
6.00
1.00
35132
REPAIR ARTERY RUPTURE, GROIN
44.30
1.00
35132
REPAIR ARTERY RUPTURE, GROIN
45.37
1.00
35132
REPAIR ARTERY RUPTURE, GROIN
47.82
1.00
35141
REPAIR DEFECT OF ARTERY
5.00
1.00
35141
REPAIR DEFECT OF ARTERY
30.15
1.00
35141
REPAIR DEFECT OF ARTERY
30.91
1.00
35141
REPAIR DEFECT OF ARTERY
31.42
1.00
35142
REPAIR ARTERY RUPTURE, THIGH
6.00
1.00
35142
REPAIR ARTERY RUPTURE, THIGH
34.61
1.00
35142
REPAIR ARTERY RUPTURE, THIGH
35.78
1.00
Procedure Code Description 35142
REPAIR ARTERY RUPTURE, THIGH
35151
RVU
RVU Coeff Value
37.55
1.00
REPAIR DEFECT OF ARTERY
8.00
1.00
35151
REPAIR DEFECT OF ARTERY
34.11
1.00
35151
REPAIR DEFECT OF ARTERY
34.98
1.00
35151
REPAIR DEFECT OF ARTERY
35.42
1.00
35152
REPAIR ARTERY RUPTURE, KNEE
6.00
1.00
35152
REPAIR ARTERY RUPTURE, KNEE
37.97
1.00
35152
REPAIR ARTERY RUPTURE, KNEE
39.34
1.00
35152
REPAIR ARTERY RUPTURE, KNEE
41.08
1.00
35161
REPAIR DEFECT OF ARTERY
8.00
1.00
35161
REPAIR DEFECT OF ARTERY
29.67
1.00
35161
REPAIR DEFECT OF ARTERY
30.59
1.00
35162
REPAIR ARTERY RUPTURE
6.00
1.00
35162
REPAIR ARTERY RUPTURE
30.85
1.00
35162
REPAIR ARTERY RUPTURE
32.03
1.00
35180
REPAIR BLOOD VESSEL LESION
10.00
1.00
35180
REPAIR BLOOD VESSEL LESION
21.41
1.00
35180
REPAIR BLOOD VESSEL LESION
22.32
1.00
35180
REPAIR BLOOD VESSEL LESION
23.18
1.00
35182
REPAIR BLOOD VESSEL LESION
44.18
1.00
35182
REPAIR BLOOD VESSEL LESION
45.08
1.00
35182
REPAIR BLOOD VESSEL LESION
48.35
1.00
35184
REPAIR BLOOD VESSEL LESION
27.13
1.00
35184
REPAIR BLOOD VESSEL LESION
27.93
1.00
35184
REPAIR BLOOD VESSEL LESION
28.47
1.00
35188
REPAIR BLOOD VESSEL LESION
22.39
1.00
35188
REPAIR BLOOD VESSEL LESION
23.78
1.00
35188
REPAIR BLOOD VESSEL LESION
23.90
1.00
35189
REPAIR BLOOD VESSEL LESION
41.58
1.00
35189
REPAIR BLOOD VESSEL LESION
42.52
1.00
35189
REPAIR BLOOD VESSEL LESION
44.59
1.00
35190
REPAIR BLOOD VESSEL LESION
3.00
1.00
35190
REPAIR BLOOD VESSEL LESION
19.96
1.00
35190
REPAIR BLOOD VESSEL LESION
20.83
1.00
35190
REPAIR BLOOD VESSEL LESION
20.84
1.00
Procedure Code Description
RVU
RVU Coeff Value
35201
REPAIR BLOOD VESSEL LESION
10.00
1.00
35201
REPAIR BLOOD VESSEL LESION
24.33
1.00
35201
REPAIR BLOOD VESSEL LESION
25.55
1.00
35201
REPAIR BLOOD VESSEL LESION
26.17
1.00
35206
REPAIR BLOOD VESSEL LESION
5.00
1.00
35206
REPAIR BLOOD VESSEL LESION
21.09
1.00
35206
REPAIR BLOOD VESSEL LESION
21.37
1.00
35206
REPAIR BLOOD VESSEL LESION
21.80
1.00
35207
REPAIR BLOOD VESSEL LESION
5.00
1.00
35207
REPAIR BLOOD VESSEL LESION
19.03
1.00
35207
REPAIR BLOOD VESSEL LESION
19.29
1.00
35207
REPAIR BLOOD VESSEL LESION
21.06
1.00
35211
REPAIR BLOOD VESSEL LESION
15.00
1.00
35211
REPAIR BLOOD VESSEL LESION
36.20
1.00
35211
REPAIR BLOOD VESSEL LESION
37.93
1.00
35211
REPAIR BLOOD VESSEL LESION
38.72
1.00
35216
REPAIR BLOOD VESSEL LESION
15.00
1.00
35216
REPAIR BLOOD VESSEL LESION
30.38
1.00
35216
REPAIR BLOOD VESSEL LESION
32.59
1.00
35216
REPAIR BLOOD VESSEL LESION
52.15
1.00
35221
REPAIR BLOOD VESSEL LESION
6.00
1.00
35221
REPAIR BLOOD VESSEL LESION
36.27
1.00
35221
REPAIR BLOOD VESSEL LESION
36.49
1.00
35221
REPAIR BLOOD VESSEL LESION
39.06
1.00
35226
REPAIR BLOOD VESSEL LESION
5.00
1.00
35226
REPAIR BLOOD VESSEL LESION
23.01
1.00
35226
REPAIR BLOOD VESSEL LESION
23.58
1.00
35226
REPAIR BLOOD VESSEL LESION
24.29
1.00
35231
REPAIR BLOOD VESSEL LESION
10.00
1.00
35231
REPAIR BLOOD VESSEL LESION
30.56
1.00
35231
REPAIR BLOOD VESSEL LESION
31.37
1.00
35231
REPAIR BLOOD VESSEL LESION
32.80
1.00
35236
REPAIR BLOOD VESSEL LESION
8.00
1.00
35236
REPAIR BLOOD VESSEL LESION
26.47
1.00
35236
REPAIR BLOOD VESSEL LESION
27.19
1.00
Procedure Code Description
RVU
RVU Coeff Value
35236
REPAIR BLOOD VESSEL LESION
27.35
1.00
35241
REPAIR BLOOD VESSEL LESION
15.00
1.00
35241
REPAIR BLOOD VESSEL LESION
37.79
1.00
35241
REPAIR BLOOD VESSEL LESION
39.68
1.00
35241
REPAIR BLOOD VESSEL LESION
40.44
1.00
35246
REPAIR BLOOD VESSEL LESION
15.00
1.00
35246
REPAIR BLOOD VESSEL LESION
40.60
1.00
35246
REPAIR BLOOD VESSEL LESION
42.90
1.00
35246
REPAIR BLOOD VESSEL LESION
43.14
1.00
35251
REPAIR BLOOD VESSEL LESION
10.00
1.00
35251
REPAIR BLOOD VESSEL LESION
44.10
1.00
35251
REPAIR BLOOD VESSEL LESION
44.25
1.00
35251
REPAIR BLOOD VESSEL LESION
46.48
1.00
35256
REPAIR BLOOD VESSEL LESION
8.00
1.00
35256
REPAIR BLOOD VESSEL LESION
28.35
1.00
35256
REPAIR BLOOD VESSEL LESION
28.78
1.00
35256
REPAIR BLOOD VESSEL LESION
29.11
1.00
35261
REPAIR BLOOD VESSEL LESION
10.00
1.00
35261
REPAIR BLOOD VESSEL LESION
26.57
1.00
35261
REPAIR BLOOD VESSEL LESION
27.44
1.00
35261
REPAIR BLOOD VESSEL LESION
29.08
1.00
35266
REPAIR BLOOD VESSEL LESION
8.00
1.00
35266
REPAIR BLOOD VESSEL LESION
23.35
1.00
35266
REPAIR BLOOD VESSEL LESION
24.05
1.00
35266
REPAIR BLOOD VESSEL LESION
24.08
1.00
35271
REPAIR BLOOD VESSEL LESION
20.00
1.00
35271
REPAIR BLOOD VESSEL LESION
36.02
1.00
35271
REPAIR BLOOD VESSEL LESION
37.86
1.00
35271
REPAIR BLOOD VESSEL LESION
38.46
1.00
35276
REPAIR BLOOD VESSEL LESION
15.00
1.00
35276
REPAIR BLOOD VESSEL LESION
38.35
1.00
35276
REPAIR BLOOD VESSEL LESION
39.80
1.00
35276
REPAIR BLOOD VESSEL LESION
40.46
1.00
35281
REPAIR BLOOD VESSEL LESION
15.00
1.00
35281
REPAIR BLOOD VESSEL LESION
41.23
1.00
Procedure Code Description
RVU
RVU Coeff Value
35281
REPAIR BLOOD VESSEL LESION
41.91
1.00
35281
REPAIR BLOOD VESSEL LESION
44.43
1.00
35286
REPAIR BLOOD VESSEL LESION
7.00
1.00
35286
REPAIR BLOOD VESSEL LESION
25.90
1.00
35286
REPAIR BLOOD VESSEL LESION
26.25
1.00
35286
REPAIR BLOOD VESSEL LESION
26.39
1.00
35301
RECHANNELING OF ARTERY
6.00
1.00
35301
RECHANNELING OF ARTERY
29.19
1.00
35301
RECHANNELING OF ARTERY
29.61
1.00
35301
RECHANNELING OF ARTERY
29.86
1.00
35302
RECHANNELING OF ARTERY
31.53
1.00
35303
RECHANNELING OF ARTERY
34.69
1.00
35304
RECHANNELING OF ARTERY
36.08
1.00
35305
RECHANNELING OF ARTERY
34.65
1.00
35306
RECHANNELING OF ARTERY
13.00
1.00
35311
RECHANNELING OF ARTERY
15.00
1.00
35311
RECHANNELING OF ARTERY
40.67
1.00
35311
RECHANNELING OF ARTERY
42.07
1.00
35311
RECHANNELING OF ARTERY
42.30
1.00
35321
RECHANNELING OF ARTERY
6.00
1.00
35321
RECHANNELING OF ARTERY
24.08
1.00
35321
RECHANNELING OF ARTERY
25.03
1.00
35321
RECHANNELING OF ARTERY
25.17
1.00
35331
RECHANNELING OF ARTERY
12.00
1.00
35331
RECHANNELING OF ARTERY
39.73
1.00
35331
RECHANNELING OF ARTERY
40.71
1.00
35331
RECHANNELING OF ARTERY
41.59
1.00
35341
RECHANNELING OF ARTERY
12.00
1.00
35341
RECHANNELING OF ARTERY
38.39
1.00
35341
RECHANNELING OF ARTERY
39.20
1.00
35341
RECHANNELING OF ARTERY
39.44
1.00
35351
RECHANNELING OF ARTERY
12.00
1.00
35351
RECHANNELING OF ARTERY
34.92
1.00
35351
RECHANNELING OF ARTERY
35.37
1.00
35351
RECHANNELING OF ARTERY
36.38
1.00
Procedure Code Description
RVU
RVU Coeff Value
35355
RECHANNELING OF ARTERY
15.00
1.00
35355
RECHANNELING OF ARTERY
28.42
1.00
35355
RECHANNELING OF ARTERY
28.76
1.00
35355
RECHANNELING OF ARTERY
29.53
1.00
35361
RECHANNELING OF ARTERY
12.00
1.00
35361
RECHANNELING OF ARTERY
42.23
1.00
35361
RECHANNELING OF ARTERY
43.12
1.00
35361
RECHANNELING OF ARTERY
44.79
1.00
35363
RECHANNELING OF ARTERY
15.00
1.00
35363
RECHANNELING OF ARTERY
45.09
1.00
35363
RECHANNELING OF ARTERY
46.12
1.00
35363
RECHANNELING OF ARTERY
48.72
1.00
35371
RECHANNELING OF ARTERY
12.00
1.00
35371
RECHANNELING OF ARTERY
22.62
1.00
35371
RECHANNELING OF ARTERY
23.28
1.00
35371
RECHANNELING OF ARTERY
23.29
1.00
35372
RECHANNELING OF ARTERY
27.26
1.00
35372
RECHANNELING OF ARTERY
27.90
1.00
35372
RECHANNELING OF ARTERY
27.97
1.00
35381
RECHANNELING OF ARTERY
6.00
1.00
35381
RECHANNELING OF ARTERY
24.82
1.00
35381
RECHANNELING OF ARTERY
25.81
1.00
35381
RECHANNELING OF ARTERY
25.87
1.00
35390
REOPERATION, CAROTID ADD-ON
4.58
1.00
35390
REOPERATION, CAROTID ADD-ON
4.64
1.00
35390
REOPERATION, CAROTID ADD-ON
4.72
1.00
35400
ANGIOSCOPY
4.33
1.00
35400
ANGIOSCOPY
4.39
1.00
35400
ANGIOSCOPY
4.53
1.00
35450
REPAIR ARTERIAL BLOCKAGE
14.59
1.00
35450
REPAIR ARTERIAL BLOCKAGE
14.93
1.00
35450
REPAIR ARTERIAL BLOCKAGE
15.10
1.00
35452
REPAIR ARTERIAL BLOCKAGE
10.15
1.00
35452
REPAIR ARTERIAL BLOCKAGE
10.76
1.00
35452
REPAIR ARTERIAL BLOCKAGE
10.99
1.00
Procedure Code Description
RVU
RVU Coeff Value
35454
REPAIR ARTERIAL BLOCKAGE
8.92
1.00
35454
REPAIR ARTERIAL BLOCKAGE
9.48
1.00
35454
REPAIR ARTERIAL BLOCKAGE
9.68
1.00
35456
REPAIR ARTERIAL BLOCKAGE
10.79
1.00
35456
REPAIR ARTERIAL BLOCKAGE
11.38
1.00
35456
REPAIR ARTERIAL BLOCKAGE
11.62
1.00
35458
REPAIR ARTERIAL BLOCKAGE
13.82
1.00
35458
REPAIR ARTERIAL BLOCKAGE
14.50
1.00
35458
REPAIR ARTERIAL BLOCKAGE
14.80
1.00
35459
REPAIR ARTERIAL BLOCKAGE
12.71
1.00
35459
REPAIR ARTERIAL BLOCKAGE
13.18
1.00
35459
REPAIR ARTERIAL BLOCKAGE
13.42
1.00
35459
REPAIR ARTERIAL BLOCKAGE
999.99
1.00
35460
REPAIR VENOUS BLOCKAGE
8.83
1.00
35460
REPAIR VENOUS BLOCKAGE
9.33
1.00
35460
REPAIR VENOUS BLOCKAGE
9.51
1.00
35460
REPAIR VENOUS BLOCKAGE
999.99
1.00
35470
REPAIR ARTERIAL BLOCKAGE
12.71
1.00
35470
REPAIR ARTERIAL BLOCKAGE
12.84
1.00
35470
REPAIR ARTERIAL BLOCKAGE
13.02
1.00
35470
REPAIR ARTERIAL BLOCKAGE
13.07
1.00
35470
REPAIR ARTERIAL BLOCKAGE
999.99
1.00
35471
REPAIR ARTERIAL BLOCKAGE
14.85
1.00
35471
REPAIR ARTERIAL BLOCKAGE
15.04
1.00
35471
REPAIR ARTERIAL BLOCKAGE
15.10
1.00
35471
REPAIR ARTERIAL BLOCKAGE
15.30
1.00
35471
REPAIR ARTERIAL BLOCKAGE
999.99
1.00
35472
REPAIR ARTERIAL BLOCKAGE
10.24
1.00
35472
REPAIR ARTERIAL BLOCKAGE
10.56
1.00
35472
REPAIR ARTERIAL BLOCKAGE
10.61
1.00
35472
REPAIR ARTERIAL BLOCKAGE
999.99
1.00
35473
REPAIR ARTERIAL BLOCKAGE
8.97
1.00
35473
REPAIR ARTERIAL BLOCKAGE
9.00
1.00
35473
REPAIR ARTERIAL BLOCKAGE
9.09
1.00
35473
REPAIR ARTERIAL BLOCKAGE
9.33
1.00
Procedure Code Description
RVU
RVU Coeff Value
35473
REPAIR ARTERIAL BLOCKAGE
9.36
1.00
35473
REPAIR ARTERIAL BLOCKAGE
999.99
1.00
35474
REPAIR ARTERIAL BLOCKAGE
10.70
1.00
35474
REPAIR ARTERIAL BLOCKAGE
10.71
1.00
35474
REPAIR ARTERIAL BLOCKAGE
10.82
1.00
35474
REPAIR ARTERIAL BLOCKAGE
10.83
1.00
35474
REPAIR ARTERIAL BLOCKAGE
10.86
1.00
35474
REPAIR ARTERIAL BLOCKAGE
10.97
1.00
35474
REPAIR ARTERIAL BLOCKAGE
999.99
1.00
35475
REPAIR ARTERIAL BLOCKAGE
13.57
1.00
35475
REPAIR ARTERIAL BLOCKAGE
13.58
1.00
35475
REPAIR ARTERIAL BLOCKAGE
13.67
1.00
35475
REPAIR ARTERIAL BLOCKAGE
13.69
1.00
35475
REPAIR ARTERIAL BLOCKAGE
13.70
1.00
35475
REPAIR ARTERIAL BLOCKAGE
14.08
1.00
35475
REPAIR ARTERIAL BLOCKAGE
14.11
1.00
35475
REPAIR ARTERIAL BLOCKAGE
999.99
1.00
35476
REPAIR VENOUS BLOCKAGE
8.63
1.00
35476
REPAIR VENOUS BLOCKAGE
8.66
1.00
35476
REPAIR VENOUS BLOCKAGE
8.73
1.00
35476
REPAIR VENOUS BLOCKAGE
8.77
1.00
35476
REPAIR VENOUS BLOCKAGE
9.19
1.00
35476
REPAIR VENOUS BLOCKAGE
9.21
1.00
35476
REPAIR VENOUS BLOCKAGE
999.99
1.00
35480
ATHERECTOMY, OPEN
15.00
1.00
35480
ATHERECTOMY, OPEN
15.80
1.00
35480
ATHERECTOMY, OPEN
16.71
1.00
35480
ATHERECTOMY, OPEN
16.93
1.00
35481
ATHERECTOMY, OPEN
11.46
1.00
35481
ATHERECTOMY, OPEN
11.83
1.00
35481
ATHERECTOMY, OPEN
12.09
1.00
35481
ATHERECTOMY, OPEN
15.00
1.00
35482
ATHERECTOMY, OPEN
9.99
1.00
35482
ATHERECTOMY, OPEN
10.44
1.00
35482
ATHERECTOMY, OPEN
10.63
1.00
Procedure Code Description
RVU
RVU Coeff Value
35482
ATHERECTOMY, OPEN
15.00
1.00
35483
ATHERECTOMY, OPEN
8.00
1.00
35483
ATHERECTOMY, OPEN
12.08
1.00
35483
ATHERECTOMY, OPEN
12.38
1.00
35483
ATHERECTOMY, OPEN
12.61
1.00
35484
ATHERECTOMY, OPEN
8.00
1.00
35484
ATHERECTOMY, OPEN
14.99
1.00
35484
ATHERECTOMY, OPEN
15.76
1.00
35484
ATHERECTOMY, OPEN
16.01
1.00
35485
ATHERECTOMY, OPEN
8.00
1.00
35485
ATHERECTOMY, OPEN
14.01
1.00
35485
ATHERECTOMY, OPEN
14.57
1.00
35485
ATHERECTOMY, OPEN
14.82
1.00
35490
ATHERECTOMY, PERCUTANEOUS
6.00
1.00
35490
ATHERECTOMY, PERCUTANEOUS
16.43
1.00
35490
ATHERECTOMY, PERCUTANEOUS
17.06
1.00
35491
ATHERECTOMY, PERCUTANEOUS
10.00
1.00
35491
ATHERECTOMY, PERCUTANEOUS
11.42
1.00
35491
ATHERECTOMY, PERCUTANEOUS
11.49
1.00
35491
ATHERECTOMY, PERCUTANEOUS
11.53
1.00
35492
ATHERECTOMY, PERCUTANEOUS
10.00
1.00
35492
ATHERECTOMY, PERCUTANEOUS
10.28
1.00
35492
ATHERECTOMY, PERCUTANEOUS
10.35
1.00
35492
ATHERECTOMY, PERCUTANEOUS
10.38
1.00
35493
ATHERECTOMY, PERCUTANEOUS
5.00
1.00
35493
ATHERECTOMY, PERCUTANEOUS
12.43
1.00
35493
ATHERECTOMY, PERCUTANEOUS
12.47
1.00
35493
ATHERECTOMY, PERCUTANEOUS
12.66
1.00
35494
ATHERECTOMY, PERCUTANEOUS
8.00
1.00
35494
ATHERECTOMY, PERCUTANEOUS
15.38
1.00
35494
ATHERECTOMY, PERCUTANEOUS
15.40
1.00
35494
ATHERECTOMY, PERCUTANEOUS
16.01
1.00
35495
ATHERECTOMY, PERCUTANEOUS
8.00
1.00
35495
ATHERECTOMY, PERCUTANEOUS
14.46
1.00
35495
ATHERECTOMY, PERCUTANEOUS
14.49
1.00
Procedure Code Description 35495
ATHERECTOMY, PERCUTANEOUS
35500
RVU
RVU Coeff Value
14.68
1.00
HARVEST VEIN FOR BYPASS
9.15
1.00
35500
HARVEST VEIN FOR BYPASS
9.17
1.00
35500
HARVEST VEIN FOR BYPASS
9.23
1.00
35501
ARTERY BYPASS GRAFT
6.00
1.00
35501
ARTERY BYPASS GRAFT
28.95
1.00
35501
ARTERY BYPASS GRAFT
30.48
1.00
35501
ARTERY BYPASS GRAFT
44.15
1.00
35506
ARTERY BYPASS GRAFT
6.00
1.00
35506
ARTERY BYPASS GRAFT
30.13
1.00
35506
ARTERY BYPASS GRAFT
31.96
1.00
35506
ARTERY BYPASS GRAFT
37.35
1.00
35507
ARTERY BYPASS GRAFT
6.00
1.00
35507
ARTERY BYPASS GRAFT
30.03
1.00
35507
ARTERY BYPASS GRAFT
31.84
1.00
35507
ARTERY BYPASS GRAFT
31.93
1.00
35508
ARTERY BYPASS GRAFT
10.00
1.00
35508
ARTERY BYPASS GRAFT
28.84
1.00
35508
ARTERY BYPASS GRAFT
30.92
1.00
35508
ARTERY BYPASS GRAFT
38.53
1.00
35509
ARTERY BYPASS GRAFT
6.00
1.00
35509
ARTERY BYPASS GRAFT
27.73
1.00
35509
ARTERY BYPASS GRAFT
29.40
1.00
35509
ARTERY BYPASS GRAFT
42.43
1.00
35510
ARTERY BYPASS GRAFT
35.20
1.00
35510
ARTERY BYPASS GRAFT
35.24
1.00
35511
ARTERY BYPASS GRAFT
6.00
1.00
35511
ARTERY BYPASS GRAFT
31.63
1.00
35511
ARTERY BYPASS GRAFT
32.66
1.00
35511
ARTERY BYPASS GRAFT
33.43
1.00
35512
ARTERY BYPASS GRAFT
34.33
1.00
35512
ARTERY BYPASS GRAFT
34.57
1.00
35515
ARTERY BYPASS GRAFT
10.00
1.00
35515
ARTERY BYPASS GRAFT
28.84
1.00
35515
ARTERY BYPASS GRAFT
30.68
1.00
Procedure Code Description
RVU
RVU Coeff Value
35515
ARTERY BYPASS GRAFT
37.21
1.00
35516
ARTERY BYPASS GRAFT
6.00
1.00
35516
ARTERY BYPASS GRAFT
24.00
1.00
35516
ARTERY BYPASS GRAFT
25.41
1.00
35516
ARTERY BYPASS GRAFT
34.00
1.00
35518
ARTERY BYPASS GRAFT
4.00
1.00
35518
ARTERY BYPASS GRAFT
31.47
1.00
35518
ARTERY BYPASS GRAFT
32.34
1.00
35518
ARTERY BYPASS GRAFT
34.05
1.00
35521
ARTERY BYPASS GRAFT
6.00
1.00
35521
ARTERY BYPASS GRAFT
33.35
1.00
35521
ARTERY BYPASS GRAFT
34.24
1.00
35521
ARTERY BYPASS GRAFT
35.80
1.00
35522
ARTERY BYPASS GRAFT
33.56
1.00
35522
ARTERY BYPASS GRAFT
33.57
1.00
35523
ARTERY BYPASS GRAFT
35.51
1.00
35525
ARTERY BYPASS GRAFT
31.54
1.00
35525
ARTERY BYPASS GRAFT
32.05
1.00
35526
ARTERY BYPASS GRAFT
15.00
1.00
35526
ARTERY BYPASS GRAFT
44.13
1.00
35526
ARTERY BYPASS GRAFT
45.10
1.00
35526
ARTERY BYPASS GRAFT
46.72
1.00
35531
ARTERY BYPASS GRAFT
15.00
1.00
35531
ARTERY BYPASS GRAFT
53.24
1.00
35531
ARTERY BYPASS GRAFT
54.20
1.00
35531
ARTERY BYPASS GRAFT
57.21
1.00
35533
ARTERY BYPASS GRAFT
4.00
1.00
35533
ARTERY BYPASS GRAFT
41.71
1.00
35533
ARTERY BYPASS GRAFT
42.56
1.00
35533
ARTERY BYPASS GRAFT
44.25
1.00
35535
ARTERY BYPASS GRAFT
56.81
1.00
35536
ARTERY BYPASS GRAFT
10.00
1.00
35536
ARTERY BYPASS GRAFT
46.90
1.00
35536
ARTERY BYPASS GRAFT
47.81
1.00
35536
ARTERY BYPASS GRAFT
49.38
1.00
Procedure Code Description
RVU
RVU Coeff Value
35537
ARTERY BYPASS GRAFT
61.24
1.00
35538
ARTERY BYPASS GRAFT
68.73
1.00
35539
ARTERY BYPASS GRAFT
63.75
1.00
35540
ARTERY BYPASS GRAFT
71.42
1.00
35541
ARTERY BYPASS GRAFT
12.00
1.00
35541
ARTERY BYPASS GRAFT
39.26
1.00
35541
ARTERY BYPASS GRAFT
40.31
1.00
35541
ARTERY BYPASS GRAFT
40.69
1.00
35546
ARTERY BYPASS GRAFT
12.00
1.00
35546
ARTERY BYPASS GRAFT
38.86
1.00
35546
ARTERY BYPASS GRAFT
39.84
1.00
35546
ARTERY BYPASS GRAFT
40.08
1.00
35548
ARTERY BYPASS GRAFT
12.00
1.00
35548
ARTERY BYPASS GRAFT
33.08
1.00
35548
ARTERY BYPASS GRAFT
33.95
1.00
35548
ARTERY BYPASS GRAFT
33.96
1.00
35549
ARTERY BYPASS GRAFT
12.00
1.00
35549
ARTERY BYPASS GRAFT
35.93
1.00
35549
ARTERY BYPASS GRAFT
36.93
1.00
35549
ARTERY BYPASS GRAFT
37.07
1.00
35551
ARTERY BYPASS GRAFT
15.00
1.00
35551
ARTERY BYPASS GRAFT
40.75
1.00
35551
ARTERY BYPASS GRAFT
42.04
1.00
35551
ARTERY BYPASS GRAFT
42.08
1.00
35556
ARTERY BYPASS GRAFT
15.00
1.00
35556
ARTERY BYPASS GRAFT
33.48
1.00
35556
ARTERY BYPASS GRAFT
34.49
1.00
35556
ARTERY BYPASS GRAFT
38.95
1.00
35558
ARTERY BYPASS GRAFT
5.00
1.00
35558
ARTERY BYPASS GRAFT
31.77
1.00
35558
ARTERY BYPASS GRAFT
32.67
1.00
35558
ARTERY BYPASS GRAFT
34.59
1.00
35560
ARTERY BYPASS GRAFT
15.00
1.00
35560
ARTERY BYPASS GRAFT
47.51
1.00
35560
ARTERY BYPASS GRAFT
48.61
1.00
Procedure Code Description
RVU
RVU Coeff Value
35560
ARTERY BYPASS GRAFT
50.44
1.00
35563
ARTERY BYPASS GRAFT
12.00
1.00
35563
ARTERY BYPASS GRAFT
35.97
1.00
35563
ARTERY BYPASS GRAFT
36.76
1.00
35563
ARTERY BYPASS GRAFT
38.62
1.00
35565
ARTERY BYPASS GRAFT
5.00
1.00
35565
ARTERY BYPASS GRAFT
34.62
1.00
35565
ARTERY BYPASS GRAFT
35.40
1.00
35565
ARTERY BYPASS GRAFT
37.38
1.00
35566
ARTERY BYPASS GRAFT
5.00
1.00
35566
ARTERY BYPASS GRAFT
41.61
1.00
35566
ARTERY BYPASS GRAFT
41.97
1.00
35566
ARTERY BYPASS GRAFT
46.77
1.00
35570
ARTERY BYPASS GRAFT
43.86
1.00
35571
ARTERY BYPASS GRAFT
5.00
1.00
35571
ARTERY BYPASS GRAFT
37.51
1.00
35571
ARTERY BYPASS GRAFT
37.95
1.00
35571
ARTERY BYPASS GRAFT
38.10
1.00
35572
HARVEST FEMOROPOPLITEAL VEIN
9.91
1.00
35572
HARVEST FEMOROPOPLITEAL VEIN
9.93
1.00
35572
HARVEST FEMOROPOPLITEAL VEIN
10.02
1.00
35582
VEIN BYPASS GRAFT
3.00
1.00
35582
VEIN BYPASS GRAFT
41.33
1.00
35582
VEIN BYPASS GRAFT
42.46
1.00
35583
VEIN BYPASS GRAFT
3.00
1.00
35583
VEIN BYPASS GRAFT
35.29
1.00
35583
VEIN BYPASS GRAFT
35.60
1.00
35583
VEIN BYPASS GRAFT
40.21
1.00
35585
VEIN BYPASS GRAFT
3.00
1.00
35585
VEIN BYPASS GRAFT
44.54
1.00
35585
VEIN BYPASS GRAFT
45.89
1.00
35585
VEIN BYPASS GRAFT
47.19
1.00
35587
VEIN BYPASS GRAFT
3.00
1.00
35587
VEIN BYPASS GRAFT
38.87
1.00
35587
VEIN BYPASS GRAFT
39.13
1.00
Procedure Code Description 35587
VEIN BYPASS GRAFT
35600
RVU
RVU Coeff Value
39.50
1.00
HARVEST ART FOR CABG ADD-ON
7.17
1.00
35600
HARVEST ART FOR CABG ADD-ON
7.29
1.00
35600
HARVEST ART FOR CABG ADD-ON
7.31
1.00
35601
ARTERY BYPASS GRAFT
10.00
1.00
35601
ARTERY BYPASS GRAFT
26.91
1.00
35601
ARTERY BYPASS GRAFT
28.64
1.00
35601
ARTERY BYPASS GRAFT
40.78
1.00
35606
ARTERY BYPASS GRAFT
6.00
1.00
35606
ARTERY BYPASS GRAFT
28.63
1.00
35606
ARTERY BYPASS GRAFT
30.36
1.00
35606
ARTERY BYPASS GRAFT
33.08
1.00
35612
ARTERY BYPASS GRAFT
10.00
1.00
35612
ARTERY BYPASS GRAFT
24.20
1.00
35612
ARTERY BYPASS GRAFT
25.73
1.00
35612
ARTERY BYPASS GRAFT
25.90
1.00
35616
ARTERY BYPASS GRAFT
10.00
1.00
35616
ARTERY BYPASS GRAFT
24.32
1.00
35616
ARTERY BYPASS GRAFT
26.04
1.00
35616
ARTERY BYPASS GRAFT
31.53
1.00
35621
ARTERY BYPASS GRAFT
5.00
1.00
35621
ARTERY BYPASS GRAFT
30.35
1.00
35621
ARTERY BYPASS GRAFT
30.71
1.00
35621
ARTERY BYPASS GRAFT
31.38
1.00
35623
BYPASS GRAFT, NOT VEIN
5.00
1.00
35623
BYPASS GRAFT, NOT VEIN
35.89
1.00
35623
BYPASS GRAFT, NOT VEIN
36.80
1.00
35623
BYPASS GRAFT, NOT VEIN
38.47
1.00
35626
ARTERY BYPASS GRAFT
15.00
1.00
35626
ARTERY BYPASS GRAFT
41.57
1.00
35626
ARTERY BYPASS GRAFT
43.23
1.00
35626
ARTERY BYPASS GRAFT
44.22
1.00
35631
ARTERY BYPASS GRAFT
15.00
1.00
35631
ARTERY BYPASS GRAFT
50.24
1.00
35631
ARTERY BYPASS GRAFT
51.24
1.00
Procedure Code Description
RVU
RVU Coeff Value
35631
ARTERY BYPASS GRAFT
52.70
1.00
35632
ARTERY BYPASS GRAFT
53.94
1.00
35633
ARTERY BYPASS GRAFT
58.25
1.00
35634
ARTERY BYPASS GRAFT
52.79
1.00
35636
ARTERY BYPASS GRAFT
15.00
1.00
35636
ARTERY BYPASS GRAFT
43.98
1.00
35636
ARTERY BYPASS GRAFT
44.67
1.00
35636
ARTERY BYPASS GRAFT
46.69
1.00
35637
BYPASS GRAFT, WITH OTHER THAN VEIN
48.36
1.00
35638
BYPASS GRAFT, WITH OTHER THAN VEIN
49.41
1.00
35641
ARTERY BYPASS GRAFT
10.00
1.00
35641
ARTERY BYPASS GRAFT
37.67
1.00
35641
ARTERY BYPASS GRAFT
39.05
1.00
35641
ARTERY BYPASS GRAFT
39.15
1.00
35642
ARTERY BYPASS GRAFT
10.00
1.00
35642
ARTERY BYPASS GRAFT
27.68
1.00
35642
ARTERY BYPASS GRAFT
28.89
1.00
35642
ARTERY BYPASS GRAFT
29.17
1.00
35645
ARTERY BYPASS GRAFT
10.00
1.00
35645
ARTERY BYPASS GRAFT
27.07
1.00
35645
ARTERY BYPASS GRAFT
27.75
1.00
35645
ARTERY BYPASS GRAFT
28.05
1.00
35646
ARTERY BYPASS GRAFT
12.00
1.00
35646
ARTERY BYPASS GRAFT
47.63
1.00
35646
ARTERY BYPASS GRAFT
48.48
1.00
35646
ARTERY BYPASS GRAFT
48.79
1.00
35647
ARTERY BYPASS GRAFT
12.00
1.00
35647
ARTERY BYPASS GRAFT
43.04
1.00
35647
ARTERY BYPASS GRAFT
43.74
1.00
35647
ARTERY BYPASS GRAFT
44.16
1.00
35650
ARTERY BYPASS GRAFT
4.00
1.00
35650
ARTERY BYPASS GRAFT
28.41
1.00
35650
ARTERY BYPASS GRAFT
29.35
1.00
35650
ARTERY BYPASS GRAFT
30.20
1.00
35651
ARTERY BYPASS GRAFT
12.00
1.00
Procedure Code Description
RVU
RVU Coeff Value
35651
ARTERY BYPASS GRAFT
38.07
1.00
35651
ARTERY BYPASS GRAFT
38.94
1.00
35651
ARTERY BYPASS GRAFT
39.05
1.00
35654
ARTERY BYPASS GRAFT
4.00
1.00
35654
ARTERY BYPASS GRAFT
37.44
1.00
35654
ARTERY BYPASS GRAFT
38.19
1.00
35654
ARTERY BYPASS GRAFT
38.98
1.00
35656
ARTERY BYPASS GRAFT
5.00
1.00
35656
ARTERY BYPASS GRAFT
29.96
1.00
35656
ARTERY BYPASS GRAFT
30.73
1.00
35656
ARTERY BYPASS GRAFT
30.81
1.00
35661
ARTERY BYPASS GRAFT
8.00
1.00
35661
ARTERY BYPASS GRAFT
28.59
1.00
35661
ARTERY BYPASS GRAFT
29.74
1.00
35661
ARTERY BYPASS GRAFT
30.74
1.00
35663
ARTERY BYPASS GRAFT
15.00
1.00
35663
ARTERY BYPASS GRAFT
32.99
1.00
35663
ARTERY BYPASS GRAFT
33.86
1.00
35663
ARTERY BYPASS GRAFT
35.62
1.00
35665
ARTERY BYPASS GRAFT
15.00
1.00
35665
ARTERY BYPASS GRAFT
31.74
1.00
35665
ARTERY BYPASS GRAFT
32.57
1.00
35665
ARTERY BYPASS GRAFT
33.40
1.00
35666
ARTERY BYPASS GRAFT
4.00
1.00
35666
ARTERY BYPASS GRAFT
35.52
1.00
35666
ARTERY BYPASS GRAFT
36.00
1.00
35666
ARTERY BYPASS GRAFT
36.10
1.00
35671
ARTERY BYPASS GRAFT
8.00
1.00
35671
ARTERY BYPASS GRAFT
30.76
1.00
35671
ARTERY BYPASS GRAFT
31.40
1.00
35671
ARTERY BYPASS GRAFT
31.72
1.00
35681
COMPOSITE BYPASS GRAFT
2.29
1.00
35681
COMPOSITE BYPASS GRAFT
2.33
1.00
35681
COMPOSITE BYPASS GRAFT
2.35
1.00
35682
COMPOSITE BYPASS GRAFT
10.22
1.00
Procedure Code Description
RVU
RVU Coeff Value
35682
COMPOSITE BYPASS GRAFT
10.47
1.00
35682
COMPOSITE BYPASS GRAFT
10.59
1.00
35683
COMPOSITE BYPASS GRAFT
12.05
1.00
35683
COMPOSITE BYPASS GRAFT
12.36
1.00
35683
COMPOSITE BYPASS GRAFT
12.50
1.00
35685
BYPASS GRAFT PATENCY/PATCH
5.69
1.00
35685
BYPASS GRAFT PATENCY/PATCH
5.74
1.00
35685
BYPASS GRAFT PATENCY/PATCH
5.82
1.00
35686
BYPASS GRAFT/AV FIST PATENCY
4.72
1.00
35686
BYPASS GRAFT/AV FIST PATENCY
4.80
1.00
35686
BYPASS GRAFT/AV FIST PATENCY
4.82
1.00
35691
ARTERIAL TRANSPOSITION
10.00
1.00
35691
ARTERIAL TRANSPOSITION
27.65
1.00
35691
ARTERIAL TRANSPOSITION
28.00
1.00
35691
ARTERIAL TRANSPOSITION
28.95
1.00
35693
ARTERIAL TRANSPOSITION
10.00
1.00
35693
ARTERIAL TRANSPOSITION
23.75
1.00
35693
ARTERIAL TRANSPOSITION
24.82
1.00
35693
ARTERIAL TRANSPOSITION
25.27
1.00
35694
ARTERIAL TRANSPOSITION
10.00
1.00
35694
ARTERIAL TRANSPOSITION
28.95
1.00
35694
ARTERIAL TRANSPOSITION
29.12
1.00
35694
ARTERIAL TRANSPOSITION
30.34
1.00
35695
ARTERIAL TRANSPOSITION
10.00
1.00
35695
ARTERIAL TRANSPOSITION
29.13
1.00
35695
ARTERIAL TRANSPOSITION
30.13
1.00
35695
ARTERIAL TRANSPOSITION
30.37
1.00
35697
REIMPLANT ARTERY EACH
4.27
1.00
35697
REIMPLANT ARTERY EACH
4.44
1.00
35700
REOPERATION, BYPASS GRAFT
4.40
1.00
35700
REOPERATION, BYPASS GRAFT
4.47
1.00
35700
REOPERATION, BYPASS GRAFT
4.54
1.00
35700
REOPERATION, BYPASS GRAFT
8.00
1.00
35701
EXPLORATION, CAROTID ARTERY
6.00
1.00
35701
EXPLORATION, CAROTID ARTERY
13.73
1.00
Procedure Code Description
RVU
RVU Coeff Value
35701
EXPLORATION, CAROTID ARTERY
14.44
1.00
35701
EXPLORATION, CAROTID ARTERY
14.93
1.00
35721
EXPLORATION, FEMORAL ARTERY
5.00
1.00
35721
EXPLORATION, FEMORAL ARTERY
12.36
1.00
35721
EXPLORATION, FEMORAL ARTERY
12.71
1.00
35721
EXPLORATION, FEMORAL ARTERY
12.90
1.00
35741
EXPLORATION POPLITEAL ARTERY
4.00
1.00
35741
EXPLORATION POPLITEAL ARTERY
13.42
1.00
35741
EXPLORATION POPLITEAL ARTERY
13.91
1.00
35741
EXPLORATION POPLITEAL ARTERY
13.94
1.00
35761
EXPLORATION OF ARTERY/VEIN
10.15
1.00
35761
EXPLORATION OF ARTERY/VEIN
10.26
1.00
35761
EXPLORATION OF ARTERY/VEIN
10.39
1.00
35800
EXPLORE NECK VESSELS
4.00
1.00
35800
EXPLORE NECK VESSELS
11.71
1.00
35800
EXPLORE NECK VESSELS
12.64
1.00
35800
EXPLORE NECK VESSELS
13.18
1.00
35820
EXPLORE CHEST VESSELS
18.68
1.00
35820
EXPLORE CHEST VESSELS
20.00
1.00
35820
EXPLORE CHEST VESSELS
22.00
1.00
35820
EXPLORE CHEST VESSELS
50.96
1.00
35840
EXPLORE ABDOMINAL VESSELS
6.00
1.00
35840
EXPLORE ABDOMINAL VESSELS
15.93
1.00
35840
EXPLORE ABDOMINAL VESSELS
16.35
1.00
35840
EXPLORE ABDOMINAL VESSELS
17.25
1.00
35860
EXPLORE LIMB VESSELS
4.00
1.00
35860
EXPLORE LIMB VESSELS
9.72
1.00
35860
EXPLORE LIMB VESSELS
10.36
1.00
35860
EXPLORE LIMB VESSELS
11.13
1.00
35870
REPAIR VESSEL GRAFT DEFECT
6.00
1.00
35870
REPAIR VESSEL GRAFT DEFECT
34.59
1.00
35870
REPAIR VESSEL GRAFT DEFECT
34.93
1.00
35870
REPAIR VESSEL GRAFT DEFECT
36.13
1.00
35875
REMOVAL OF CLOT IN GRAFT
6.00
1.00
35875
REMOVAL OF CLOT IN GRAFT
16.52
1.00
Procedure Code Description
RVU
RVU Coeff Value
35875
REMOVAL OF CLOT IN GRAFT
16.67
1.00
35875
REMOVAL OF CLOT IN GRAFT
17.40
1.00
35876
REMOVAL OF CLOT IN GRAFT
8.00
1.00
35876
REMOVAL OF CLOT IN GRAFT
26.73
1.00
35876
REMOVAL OF CLOT IN GRAFT
26.83
1.00
35876
REMOVAL OF CLOT IN GRAFT
27.68
1.00
35879
REVISE GRAFT W/VEIN
8.00
1.00
35879
REVISE GRAFT W/VEIN
24.96
1.00
35879
REVISE GRAFT W/VEIN
25.36
1.00
35879
REVISE GRAFT W/VEIN
26.14
1.00
35881
REVISE GRAFT W/VEIN
8.00
1.00
35881
REVISE GRAFT W/VEIN
27.90
1.00
35881
REVISE GRAFT W/VEIN
28.46
1.00
35881
REVISE GRAFT W/VEIN
29.07
1.00
35883
REVISE GRAFT W/NONAUTO GRAFT
33.95
1.00
35884
REVISE GRAFT W/VEIN
35.82
1.00
35901
EXCISION, GRAFT, NECK
10.00
1.00
35901
EXCISION, GRAFT, NECK
13.99
1.00
35901
EXCISION, GRAFT, NECK
14.63
1.00
35901
EXCISION, GRAFT, NECK
14.91
1.00
35903
EXCISION, GRAFT, EXTREMITY
8.00
1.00
35903
EXCISION, GRAFT, EXTREMITY
15.82
1.00
35903
EXCISION, GRAFT, EXTREMITY
16.63
1.00
35903
EXCISION, GRAFT, EXTREMITY
18.50
1.00
35905
EXCISION, GRAFT, THORAX
15.00
1.00
35905
EXCISION, GRAFT, THORAX
47.05
1.00
35905
EXCISION, GRAFT, THORAX
48.52
1.00
35905
EXCISION, GRAFT, THORAX
49.26
1.00
35907
EXCISION, GRAFT, ABDOMEN
15.00
1.00
35907
EXCISION, GRAFT, ABDOMEN
51.68
1.00
35907
EXCISION, GRAFT, ABDOMEN
51.74
1.00
35907
EXCISION, GRAFT, ABDOMEN
54.27
1.00
36000
PLACE NEEDLE IN VEIN
0.24
1.00
36000
PLACE NEEDLE IN VEIN
0.26
1.00
36002
PSEUDOANEURYSM INJECTION TRT
3.06
1.00
Procedure Code Description
RVU
RVU Coeff Value
36002
PSEUDOANEURYSM INJECTION TRT
3.07
1.00
36005
INJECTION EXT VENOGRAPHY
1.31
1.00
36005
INJECTION EXT VENOGRAPHY
1.32
1.00
36005
INJECTION EXT VENOGRAPHY
1.35
1.00
36005
INJECTION EXT VENOGRAPHY
1.37
1.00
36010
PLACE CATHETER IN VEIN
3.40
1.00
36010
PLACE CATHETER IN VEIN
3.41
1.00
36010
PLACE CATHETER IN VEIN
3.42
1.00
36010
PLACE CATHETER IN VEIN
3.47
1.00
36010
PLACE CATHETER IN VEIN
5.00
1.00
36011
PLACE CATHETER IN VEIN
4.36
1.00
36011
PLACE CATHETER IN VEIN
4.38
1.00
36011
PLACE CATHETER IN VEIN
4.44
1.00
36011
PLACE CATHETER IN VEIN
4.47
1.00
36011
PLACE CATHETER IN VEIN
4.49
1.00
36011
PLACE CATHETER IN VEIN
999.99
1.00
36012
PLACE CATHETER IN VEIN
4.87
1.00
36012
PLACE CATHETER IN VEIN
5.04
1.00
36012
PLACE CATHETER IN VEIN
999.99
1.00
36013
PLACE CATHETER IN ARTERY
3.36
1.00
36013
PLACE CATHETER IN ARTERY
3.39
1.00
36013
PLACE CATHETER IN ARTERY
3.65
1.00
36013
PLACE CATHETER IN ARTERY
999.99
1.00
36014
PLACE CATHETER IN ARTERY
4.18
1.00
36014
PLACE CATHETER IN ARTERY
4.38
1.00
36014
PLACE CATHETER IN ARTERY
999.99
1.00
36015
PLACE CATHETER IN ARTERY
4.85
1.00
36015
PLACE CATHETER IN ARTERY
4.86
1.00
36015
PLACE CATHETER IN ARTERY
5.06
1.00
36015
PLACE CATHETER IN ARTERY
999.99
1.00
36100
ESTABLISH ACCESS TO ARTERY
4.00
1.00
36100
ESTABLISH ACCESS TO ARTERY
4.32
1.00
36100
ESTABLISH ACCESS TO ARTERY
4.34
1.00
36100
ESTABLISH ACCESS TO ARTERY
4.46
1.00
36120
ESTABLISH ACCESS TO ARTERY
2.79
1.00
Procedure Code Description
RVU
RVU Coeff Value
36120
ESTABLISH ACCESS TO ARTERY
2.80
1.00
36120
ESTABLISH ACCESS TO ARTERY
4.00
1.00
36140
ESTABLISH ACCESS TO ARTERY
2.79
1.00
36140
ESTABLISH ACCESS TO ARTERY
2.82
1.00
36140
ESTABLISH ACCESS TO ARTERY
2.84
1.00
36140
ESTABLISH ACCESS TO ARTERY
2.89
1.00
36145
ARTERY TO VEIN SHUNT
2.76
1.00
36145
ARTERY TO VEIN SHUNT
2.78
1.00
36145
ARTERY TO VEIN SHUNT
2.79
1.00
36145
ARTERY TO VEIN SHUNT
2.80
1.00
36145
ARTERY TO VEIN SHUNT
2.81
1.00
36145
ARTERY TO VEIN SHUNT
5.00
1.00
36160
ESTABLISH ACCESS TO AORTA
3.58
1.00
36160
ESTABLISH ACCESS TO AORTA
3.61
1.00
36160
ESTABLISH ACCESS TO AORTA
3.78
1.00
36160
ESTABLISH ACCESS TO AORTA
4.00
1.00
36200
PLACE CATHETER IN AORTA
4.21
1.00
36200
PLACE CATHETER IN AORTA
4.22
1.00
36200
PLACE CATHETER IN AORTA
4.28
1.00
36200
PLACE CATHETER IN AORTA
5.00
1.00
36215
PLACE CATHETER IN ARTERY
3.00
1.00
36215
PLACE CATHETER IN ARTERY
6.52
1.00
36215
PLACE CATHETER IN ARTERY
6.55
1.00
36215
PLACE CATHETER IN ARTERY
6.59
1.00
36215
PLACE CATHETER IN ARTERY
6.60
1.00
36215
PLACE CATHETER IN ARTERY
6.69
1.00
36215
PLACE CATHETER IN ARTERY
6.82
1.00
36216
PLACE CATHETER IN ARTERY
7.32
1.00
36216
PLACE CATHETER IN ARTERY
7.33
1.00
36216
PLACE CATHETER IN ARTERY
7.38
1.00
36216
PLACE CATHETER IN ARTERY
7.40
1.00
36216
PLACE CATHETER IN ARTERY
7.43
1.00
36216
PLACE CATHETER IN ARTERY
7.52
1.00
36216
PLACE CATHETER IN ARTERY
7.69
1.00
36216
PLACE CATHETER IN ARTERY
999.99
1.00
Procedure Code Description
RVU
RVU Coeff Value
36217
PLACE CATHETER IN ARTERY
8.82
1.00
36217
PLACE CATHETER IN ARTERY
8.83
1.00
36217
PLACE CATHETER IN ARTERY
8.90
1.00
36217
PLACE CATHETER IN ARTERY
8.91
1.00
36217
PLACE CATHETER IN ARTERY
8.92
1.00
36217
PLACE CATHETER IN ARTERY
9.03
1.00
36217
PLACE CATHETER IN ARTERY
9.23
1.00
36217
PLACE CATHETER IN ARTERY
999.99
1.00
36218
PLACE CATHETER IN ARTERY
1.41
1.00
36218
PLACE CATHETER IN ARTERY
1.42
1.00
36218
PLACE CATHETER IN ARTERY
1.43
1.00
36218
PLACE CATHETER IN ARTERY
1.44
1.00
36218
PLACE CATHETER IN ARTERY
1.47
1.00
36245
PLACE CATHETER IN ARTERY
3.00
1.00
36245
PLACE CATHETER IN ARTERY
6.60
1.00
36245
PLACE CATHETER IN ARTERY
6.66
1.00
36245
PLACE CATHETER IN ARTERY
6.68
1.00
36245
PLACE CATHETER IN ARTERY
6.76
1.00
36245
PLACE CATHETER IN ARTERY
6.88
1.00
36245
PLACE CATHETER IN ARTERY
7.04
1.00
36246
PLACE CATHETER IN ARTERY
7.37
1.00
36246
PLACE CATHETER IN ARTERY
7.48
1.00
36246
PLACE CATHETER IN ARTERY
7.49
1.00
36246
PLACE CATHETER IN ARTERY
7.56
1.00
36246
PLACE CATHETER IN ARTERY
7.69
1.00
36246
PLACE CATHETER IN ARTERY
999.99
1.00
36247
PLACE CATHETER IN ARTERY
8.78
1.00
36247
PLACE CATHETER IN ARTERY
8.79
1.00
36247
PLACE CATHETER IN ARTERY
8.91
1.00
36247
PLACE CATHETER IN ARTERY
8.93
1.00
36247
PLACE CATHETER IN ARTERY
9.01
1.00
36247
PLACE CATHETER IN ARTERY
9.16
1.00
36247
PLACE CATHETER IN ARTERY
999.99
1.00
36248
PLACE CATHETER IN ARTERY
1.42
1.00
36248
PLACE CATHETER IN ARTERY
1.43
1.00
Procedure Code Description
RVU
RVU Coeff Value
36248
PLACE CATHETER IN ARTERY
1.47
1.00
36260
INSERTION OF INFUSION PUMP
3.00
1.00
36260
INSERTION OF INFUSION PUMP
15.81
1.00
36260
INSERTION OF INFUSION PUMP
15.89
1.00
36260
INSERTION OF INFUSION PUMP
16.21
1.00
36261
REVISION OF INFUSION PUMP
9.28
1.00
36261
REVISION OF INFUSION PUMP
9.66
1.00
36261
REVISION OF INFUSION PUMP
9.70
1.00
36262
REMOVAL OF INFUSION PUMP
6.93
1.00
36262
REMOVAL OF INFUSION PUMP
7.30
1.00
36262
REMOVAL OF INFUSION PUMP
7.36
1.00
36400
BL DRAW < 3 YRS FEM/JUGULAR
0.48
1.00
36400
BL DRAW < 3 YRS FEM/JUGULAR
0.49
1.00
36405
BL DRAW < 3 YRS SCALP VEIN
0.40
1.00
36405
BL DRAW < 3 YRS SCALP VEIN
0.43
1.00
36406
BL DRAW < 3 YRS OTHER VEIN
0.24
1.00
36406
BL DRAW < 3 YRS OTHER VEIN
0.25
1.00
36410
NON-ROUTINE BL DRAW > 3 YRS
0.24
1.00
36420
VEIN ACCESS CUTDOWN < 1 YR
1.33
1.00
36420
VEIN ACCESS CUTDOWN < 1 YR
1.40
1.00
36420
VEIN ACCESS CUTDOWN < 1 YR
1.41
1.00
36425
VEIN ACCESS CUTDOWN > 1 YR
1.03
1.00
36425
VEIN ACCESS CUTDOWN > 1 YR
1.04
1.00
36425
VEIN ACCESS CUTDOWN > 1 YR
1.05
1.00
36430
BLOOD TRANSFUSION SERVICE
1.00
1.00
36430
BLOOD TRANSFUSION SERVICE
1.06
1.00
36430
BLOOD TRANSFUSION SERVICE
1.07
1.00
36440
BL PUSH TRANSFUSE, 2 YR OR <
1.40
1.00
36440
BL PUSH TRANSFUSE, 2 YR OR <
1.41
1.00
36440
BL PUSH TRANSFUSE, 2 YR OR <
1.43
1.00
36450
BL EXCHANGE/TRANSFUSE, NB
3.11
1.00
36450
BL EXCHANGE/TRANSFUSE, NB
3.13
1.00
36450
BL EXCHANGE/TRANSFUSE, NB
3.24
1.00
36455
BL EXCHANGE/TRANSFUSE NON-NB
3.38
1.00
36455
BL EXCHANGE/TRANSFUSE NON-NB
3.51
1.00
Procedure Code Description
RVU
RVU Coeff Value
36455
BL EXCHANGE/TRANSFUSE NON-NB
3.57
1.00
36460
TRANSFUSION SERVICE, FETAL
3.00
1.00
36460
TRANSFUSION SERVICE, FETAL
9.29
1.00
36460
TRANSFUSION SERVICE, FETAL
9.42
1.00
36460
TRANSFUSION SERVICE, FETAL
9.51
1.00
36470
INJECTION THERAPY OF VEIN
1.58
1.00
36470
INJECTION THERAPY OF VEIN
1.65
1.00
36470
INJECTION THERAPY OF VEIN
1.88
1.00
36471
INJECTION THERAPY OF VEINS
2.27
1.00
36471
INJECTION THERAPY OF VEINS
2.35
1.00
36471
INJECTION THERAPY OF VEINS
2.65
1.00
36475
ENDOVENOUS RF, 1ST VEIN
9.29
1.00
36475
ENDOVENOUS RF, 1ST VEIN
9.30
1.00
36475
ENDOVENOUS RF, 1ST VEIN
9.48
1.00
36475
ENDOVENOUS RF, 1ST VEIN
9.62
1.00
36475
ENDOVENOUS RF, 1ST VEIN
9.63
1.00
36476
ENDOVENOUS RF, VEIN ADD-ON
4.54
1.00
36476
ENDOVENOUS RF, VEIN ADD-ON
4.64
1.00
36476
ENDOVENOUS RF, VEIN ADD-ON
4.70
1.00
36478
ENDOVENOUS LASER, 1ST VEIN
9.38
1.00
36478
ENDOVENOUS LASER, 1ST VEIN
9.50
1.00
36478
ENDOVENOUS LASER, 1ST VEIN
9.62
1.00
36478
ENDOVENOUS LASER, 1ST VEIN
9.63
1.00
36479
ENDOVENOUS LASER VEIN ADDON
4.57
1.00
36479
ENDOVENOUS LASER VEIN ADDON
4.60
1.00
36479
ENDOVENOUS LASER VEIN ADDON
4.66
1.00
36479
ENDOVENOUS LASER VEIN ADDON
4.70
1.00
36481
INSERTION OF CATHETER, VEIN
10.19
1.00
36481
INSERTION OF CATHETER, VEIN
11.36
1.00
36481
INSERTION OF CATHETER, VEIN
999.99
1.00
36488
INSERTION OF CATHETER, VEIN
2.18
1.00
36488
INSERTION OF CATHETER, VEIN
999.99
1.00
36489
INSERTION OF CATHETER, VEIN
3.62
1.00
36489
INSERTION OF CATHETER, VEIN
4.00
1.00
36490
INSERTION OF CATHETER, VEIN
2.67
1.00
Procedure Code Description
RVU
RVU Coeff Value
36490
INSERTION OF CATHETER, VEIN
3.00
1.00
36491
INSERTION OF CATHETER, VEIN
2.32
1.00
36491
INSERTION OF CATHETER, VEIN
3.00
1.00
36493
REPOSITIONING OF CVC
2.13
1.00
36493
REPOSITIONING OF CVC
999.99
1.00
36500
INSERTION OF CATHETER, VEIN
4.92
1.00
36500
INSERTION OF CATHETER, VEIN
5.03
1.00
36500
INSERTION OF CATHETER, VEIN
5.05
1.00
36510
INSERTION OF CATHETER, VEIN
1.57
1.00
36510
INSERTION OF CATHETER, VEIN
1.77
1.00
36510
INSERTION OF CATHETER, VEIN
1.87
1.00
36511
APHERESIS WBC
2.44
1.00
36511
APHERESIS WBC
2.50
1.00
36511
APHERESIS WBC
2.52
1.00
36512
APHERESIS RBC
2.48
1.00
36512
APHERESIS RBC
2.50
1.00
36512
APHERESIS RBC
2.52
1.00
36513
APHERESIS PLATELETS
2.50
1.00
36513
APHERESIS PLATELETS
2.52
1.00
36513
APHERESIS PLATELETS
2.59
1.00
36514
APHERESIS PLASMA
2.42
1.00
36514
APHERESIS PLASMA
2.50
1.00
36514
APHERESIS PLASMA
2.52
1.00
36515
APHERESIS, ADSORP/REINFUSE
2.37
1.00
36515
APHERESIS, ADSORP/REINFUSE
2.50
1.00
36515
APHERESIS, ADSORP/REINFUSE
2.54
1.00
36516
APHERESIS, SELECTIVE
1.71
1.00
36516
APHERESIS, SELECTIVE
1.80
1.00
36516
APHERESIS, SELECTIVE
2.50
1.00
36522
PHOTOPHERESIS
2.77
1.00
36530
INSERTION OF INFUSION PUMP
3.00
1.00
36530
INSERTION OF INFUSION PUMP
10.46
1.00
36531
REVISION OF INFUSION PUMP
3.00
1.00
36531
REVISION OF INFUSION PUMP
8.56
1.00
36532
REMOVAL OF INFUSION PUMP
3.00
1.00
Procedure Code Description
RVU
RVU Coeff Value
36532
REMOVAL OF INFUSION PUMP
5.16
1.00
36533
INSERTION OF ACCESS DEVICE
3.00
1.00
36533
INSERTION OF ACCESS DEVICE
9.19
1.00
36534
REVISION OF ACCESS DEVICE
3.00
1.00
36534
REVISION OF ACCESS DEVICE
4.45
1.00
36535
REMOVAL OF ACCESS DEVICE
3.00
1.00
36535
REMOVAL OF ACCESS DEVICE
4.30
1.00
36536
REMOVE CVA DEVICE OBSTRUCT
5.30
1.00
36537
REMOVE CVA LUMEN OBSTRUCT
1.28
1.00
36540
COLLECT BLOOD VENOUS DEVICE
0.24
1.00
36550
DECLOT VASCULAR DEVICE
0.68
1.00
36550
DECLOT VASCULAR DEVICE
0.69
1.00
36550
DECLOT VASCULAR DEVICE
0.76
1.00
36555
INSERT NON-TUNNEL CV CATH
3.46
1.00
36555
INSERT NON-TUNNEL CV CATH
3.71
1.00
36556
INSERT NON-TUNNEL CV CATH
3.31
1.00
36556
INSERT NON-TUNNEL CV CATH
3.34
1.00
36556
INSERT NON-TUNNEL CV CATH
3.39
1.00
36556
INSERT NON-TUNNEL CV CATH
3.43
1.00
36557
INSERT TUNNELED CV CATH
8.15
1.00
36557
INSERT TUNNELED CV CATH
8.23
1.00
36557
INSERT TUNNELED CV CATH
8.24
1.00
36557
INSERT TUNNELED CV CATH
8.26
1.00
36557
INSERT TUNNELED CV CATH
8.32
1.00
36558
INSERT TUNNELED CV CATH
7.85
1.00
36558
INSERT TUNNELED CV CATH
7.91
1.00
36560
INSERT TUNNELED CV CATH
9.71
1.00
36560
INSERT TUNNELED CV CATH
9.73
1.00
36560
INSERT TUNNELED CV CATH
9.79
1.00
36560
INSERT TUNNELED CV CATH
9.85
1.00
36561
INSERT TUNNELED CV CATH
9.38
1.00
36561
INSERT TUNNELED CV CATH
9.40
1.00
36561
INSERT TUNNELED CV CATH
9.43
1.00
36561
INSERT TUNNELED CV CATH
9.45
1.00
36561
INSERT TUNNELED CV CATH
9.52
1.00
Procedure Code Description
RVU
RVU Coeff Value
36563
INSERT TUNNELED CV CATH
9.84
1.00
36563
INSERT TUNNELED CV CATH
9.85
1.00
36563
INSERT TUNNELED CV CATH
9.94
1.00
36563
INSERT TUNNELED CV CATH
10.02
1.00
36565
INSERT TUNNELED CV CATH
9.26
1.00
36565
INSERT TUNNELED CV CATH
9.45
1.00
36565
INSERT TUNNELED CV CATH
9.51
1.00
36565
INSERT TUNNELED CV CATH
9.52
1.00
36566
INSERT TUNNELED CV CATH
9.90
1.00
36566
INSERT TUNNELED CV CATH
10.12
1.00
36568
INSERT PICC CATH
2.60
1.00
36568
INSERT PICC CATH
2.62
1.00
36568
INSERT PICC CATH
2.67
1.00
36568
INSERT PICC CATH
2.72
1.00
36569
INSERT PICC CATH
2.55
1.00
36569
INSERT PICC CATH
2.58
1.00
36569
INSERT PICC CATH
2.63
1.00
36569
INSERT PICC CATH
2.70
1.00
36570
INSERT PICVAD CATH
8.54
1.00
36570
INSERT PICVAD CATH
8.70
1.00
36571
INSERT PICVAD CATH
8.46
1.00
36571
INSERT PICVAD CATH
8.50
1.00
36571
INSERT PICVAD CATH
8.51
1.00
36571
INSERT PICVAD CATH
8.58
1.00
36575
REPAIR TUNNELED CV CATH
1.12
1.00
36575
REPAIR TUNNELED CV CATH
1.52
1.00
36576
REPAIR TUNNELED CV CATH
5.08
1.00
36576
REPAIR TUNNELED CV CATH
5.54
1.00
36578
REPLACE TUNNELED CV CATH
5.81
1.00
36578
REPLACE TUNNELED CV CATH
6.28
1.00
36580
REPLACE CVAD CATH
1.88
1.00
36580
REPLACE CVAD CATH
1.91
1.00
36580
REPLACE CVAD CATH
1.92
1.00
36580
REPLACE CVAD CATH
1.96
1.00
36581
REPLACE TUNNELED CV CATH
5.47
1.00
Procedure Code Description
RVU
RVU Coeff Value
36581
REPLACE TUNNELED CV CATH
5.50
1.00
36581
REPLACE TUNNELED CV CATH
5.55
1.00
36581
REPLACE TUNNELED CV CATH
5.86
1.00
36582
REPLACE TUNNELED CV CATH
8.04
1.00
36582
REPLACE TUNNELED CV CATH
8.54
1.00
36583
REPLACE TUNNELED CV CATH
8.05
1.00
36583
REPLACE TUNNELED CV CATH
8.60
1.00
36584
REPLACE PICC CATH
1.90
1.00
36584
REPLACE PICC CATH
2.02
1.00
36585
REPLACE PICVAD CATH
7.56
1.00
36585
REPLACE PICVAD CATH
8.00
1.00
36589
REMOVAL TUNNELED CV CATH
3.82
1.00
36589
REMOVAL TUNNELED CV CATH
3.93
1.00
36590
REMOVAL TUNNELED CV CATH
5.35
1.00
36590
REMOVAL TUNNELED CV CATH
5.44
1.00
36591
DRAW BLOOD OFF VENOUS DEVICE
0.61
1.00
36592
COLLECT BLOOD FROM PICC
0.67
1.00
36593
DECLOT VASCULAR DEVICE
1.08
1.00
36595
MECH REMOV TUNNELED CV CATH
5.31
1.00
36595
MECH REMOV TUNNELED CV CATH
5.33
1.00
36596
MECH REMOV TUNNELED CV CATH
1.26
1.00
36596
MECH REMOV TUNNELED CV CATH
1.29
1.00
36597
REPOSITION VENOUS CATHETER
1.71
1.00
36597
REPOSITION VENOUS CATHETER
1.77
1.00
36598
INJ W/FLUOR, EVAL CV DEVICE
1.67
1.00
36600
WITHDRAWAL OF ARTERIAL BLOOD
0.42
1.00
36600
WITHDRAWAL OF ARTERIAL BLOOD
0.43
1.00
36600
WITHDRAWAL OF ARTERIAL BLOOD
999.99
1.00
36620
INSERTION CATHETER, ARTERY
1.39
1.00
36620
INSERTION CATHETER, ARTERY
1.45
1.00
36620
INSERTION CATHETER, ARTERY
1.46
1.00
36620
INSERTION CATHETER, ARTERY
999.99
1.00
36625
INSERTION CATHETER, ARTERY
2.80
1.00
36625
INSERTION CATHETER, ARTERY
2.82
1.00
36625
INSERTION CATHETER, ARTERY
2.93
1.00
Procedure Code Description
RVU
RVU Coeff Value
36640
INSERTION CATHETER, ARTERY
3.00
1.00
36640
INSERTION CATHETER, ARTERY
3.27
1.00
36640
INSERTION CATHETER, ARTERY
3.37
1.00
36660
INSERTION CATHETER, ARTERY
1.85
1.00
36660
INSERTION CATHETER, ARTERY
1.93
1.00
36660
INSERTION CATHETER, ARTERY
1.94
1.00
36680
INSERT NEEDLE, BONE CAVITY
1.63
1.00
36680
INSERT NEEDLE, BONE CAVITY
1.79
1.00
36680
INSERT NEEDLE, BONE CAVITY
1.90
1.00
36800
INSERTION OF CANNULA
4.00
1.00
36800
INSERTION OF CANNULA
4.30
1.00
36800
INSERTION OF CANNULA
4.36
1.00
36800
INSERTION OF CANNULA
4.45
1.00
36810
INSERTION OF CANNULA
5.00
1.00
36810
INSERTION OF CANNULA
5.78
1.00
36810
INSERTION OF CANNULA
6.13
1.00
36810
INSERTION OF CANNULA
6.61
1.00
36815
INSERTION OF CANNULA
4.00
1.00
36815
INSERTION OF CANNULA
4.10
1.00
36815
INSERTION OF CANNULA
4.14
1.00
36818
AV FUSE, UPPR ARM, CEPHALIC
18.75
1.00
36819
AV FUSE, UPPR ARM, BASILIC
5.00
1.00
36819
AV FUSE, UPPR ARM, BASILIC
21.97
1.00
36819
AV FUSE, UPPR ARM, BASILIC
21.98
1.00
36819
AV FUSE, UPPR ARM, BASILIC
22.26
1.00
36820
AV FUSION/FOREARM VEIN
6.00
1.00
36820
AV FUSION/FOREARM VEIN
21.99
1.00
36820
AV FUSION/FOREARM VEIN
22.05
1.00
36820
AV FUSION/FOREARM VEIN
22.26
1.00
36821
AV FUSION DIRECT ANY SITE
5.00
1.00
36821
AV FUSION DIRECT ANY SITE
14.80
1.00
36821
AV FUSION DIRECT ANY SITE
14.84
1.00
36821
AV FUSION DIRECT ANY SITE
18.19
1.00
36822
INSERTION OF CANNULA(S)
10.29
1.00
36822
INSERTION OF CANNULA(S)
10.66
1.00
Procedure Code Description
RVU
RVU Coeff Value
36822
INSERTION OF CANNULA(S)
13.19
1.00
36823
INSERTION OF CANNULA(S)
4.00
1.00
36823
INSERTION OF CANNULA(S)
33.08
1.00
36823
INSERTION OF CANNULA(S)
33.56
1.00
36823
INSERTION OF CANNULA(S)
35.02
1.00
36825
ARTERY-VEIN AUTOGRAFT
12.00
1.00
36825
ARTERY-VEIN AUTOGRAFT
15.91
1.00
36825
ARTERY-VEIN AUTOGRAFT
16.28
1.00
36825
ARTERY-VEIN AUTOGRAFT
16.41
1.00
36830
ARTERY-VEIN NONAUTOGRAFT
6.00
1.00
36830
ARTERY-VEIN NONAUTOGRAFT
18.22
1.00
36830
ARTERY-VEIN NONAUTOGRAFT
18.87
1.00
36830
ARTERY-VEIN NONAUTOGRAFT
19.36
1.00
36831
OPEN THROMBECT AV FISTULA
5.00
1.00
36831
OPEN THROMBECT AV FISTULA
12.57
1.00
36831
OPEN THROMBECT AV FISTULA
12.72
1.00
36831
OPEN THROMBECT AV FISTULA
12.91
1.00
36832
AV FISTULA REVISION, OPEN
5.00
1.00
36832
AV FISTULA REVISION, OPEN
16.06
1.00
36832
AV FISTULA REVISION, OPEN
16.63
1.00
36832
AV FISTULA REVISION, OPEN
17.16
1.00
36833
AV FISTULA REVISION
5.00
1.00
36833
AV FISTULA REVISION
18.15
1.00
36833
AV FISTULA REVISION
18.74
1.00
36833
AV FISTULA REVISION
19.24
1.00
36834
REPAIR A-V ANEURYSM
14.78
1.00
36834
REPAIR A-V ANEURYSM
15.00
1.00
36834
REPAIR A-V ANEURYSM
16.01
1.00
36834
REPAIR A-V ANEURYSM
16.98
1.00
36835
ARTERY TO VEIN SHUNT
12.47
1.00
36835
ARTERY TO VEIN SHUNT
12.49
1.00
36835
ARTERY TO VEIN SHUNT
12.56
1.00
36838
DIST REVAS LIGATION, HEMO
32.45
1.00
36838
DIST REVAS LIGATION, HEMO
32.95
1.00
36860
EXTERNAL CANNULA DECLOTTING
2.80
1.00
Procedure Code Description
RVU
RVU Coeff Value
36860
EXTERNAL CANNULA DECLOTTING
3.00
1.00
36860
EXTERNAL CANNULA DECLOTTING
3.45
1.00
36860
EXTERNAL CANNULA DECLOTTING
3.48
1.00
36861
CANNULA DECLOTTING
4.12
1.00
36861
CANNULA DECLOTTING
4.17
1.00
36861
CANNULA DECLOTTING
8.00
1.00
36870
PERCUT THROMBECT AV FISTULA
3.00
1.00
36870
PERCUT THROMBECT AV FISTULA
7.78
1.00
36870
PERCUT THROMBECT AV FISTULA
8.40
1.00
36870
PERCUT THROMBECT AV FISTULA
8.42
1.00
36870
PERCUT THROMBECT AV FISTULA
8.45
1.00
36870
PERCUT THROMBECT AV FISTULA
8.57
1.00
36870
PERCUT THROMBECT AV FISTULA
8.60
1.00
37140
REVISION OF CIRCULATION
11.00
1.00
37140
REVISION OF CIRCULATION
35.12
1.00
37140
REVISION OF CIRCULATION
35.52
1.00
37140
REVISION OF CIRCULATION
36.62
1.00
37145
REVISION OF CIRCULATION
15.00
1.00
37145
REVISION OF CIRCULATION
38.02
1.00
37145
REVISION OF CIRCULATION
38.49
1.00
37145
REVISION OF CIRCULATION
39.90
1.00
37160
REVISION OF CIRCULATION
15.00
1.00
37160
REVISION OF CIRCULATION
32.90
1.00
37160
REVISION OF CIRCULATION
33.48
1.00
37160
REVISION OF CIRCULATION
34.68
1.00
37180
REVISION OF CIRCULATION
15.00
1.00
37180
REVISION OF CIRCULATION
37.51
1.00
37180
REVISION OF CIRCULATION
38.09
1.00
37180
REVISION OF CIRCULATION
38.91
1.00
37181
SPLICE SPLEEN/KIDNEY VEINS
11.00
1.00
37181
SPLICE SPLEEN/KIDNEY VEINS
40.21
1.00
37181
SPLICE SPLEEN/KIDNEY VEINS
40.92
1.00
37181
SPLICE SPLEEN/KIDNEY VEINS
41.99
1.00
37182
INSERT HEPATIC SHUNT (TIPS)
24.78
1.00
37182
INSERT HEPATIC SHUNT (TIPS)
24.86
1.00
Procedure Code Description
RVU
RVU Coeff Value
37182
INSERT HEPATIC SHUNT (TIPS)
25.04
1.00
37183
REMOVE HEPATIC SHUNT (TIPS)
11.55
1.00
37183
REMOVE HEPATIC SHUNT (TIPS)
11.59
1.00
37183
REMOVE HEPATIC SHUNT (TIPS)
11.78
1.00
37184
PRIM ART MECH THROMBECTOMY
12.69
1.00
37185
PRIM ART M-THROMBECT ADD-ON
4.67
1.00
37186
SEC ART M-THROMBECT ADD-ON
7.18
1.00
37187
VENOUS MECH THROMBECTOMY
11.54
1.00
37187
VENOUS MECH THROMBECTOMY
11.61
1.00
37187
VENOUS MECH THROMBECTOMY
11.69
1.00
37187
VENOUS MECH THROMBECTOMY
11.79
1.00
37188
VENOUS M-THROMBECTOMY ADD-ON
8.54
1.00
37195
THROMBOLYTIC THERAPY, STROKE
8.40
1.00
37195
THROMBOLYTIC THERAPY, STROKE
8.54
1.00
37195
THROMBOLYTIC THERAPY, STROKE
15.00
1.00
37200
TRANSCATHETER BIOPSY
6.28
1.00
37200
TRANSCATHETER BIOPSY
6.30
1.00
37200
TRANSCATHETER BIOPSY
6.58
1.00
37200
TRANSCATHETER BIOPSY
999.99
1.00
37201
TRANSCATHETER THERAPY INFUSE
7.77
1.00
37201
TRANSCATHETER THERAPY INFUSE
7.80
1.00
37201
TRANSCATHETER THERAPY INFUSE
999.99
1.00
37202
TRANSCATHETER THERAPY INFUSE
9.16
1.00
37202
TRANSCATHETER THERAPY INFUSE
9.40
1.00
37202
TRANSCATHETER THERAPY INFUSE
999.99
1.00
37203
TRANSCATHETER RETRIEVAL
7.29
1.00
37203
TRANSCATHETER RETRIEVAL
7.35
1.00
37203
TRANSCATHETER RETRIEVAL
7.37
1.00
37203
TRANSCATHETER RETRIEVAL
7.48
1.00
37203
TRANSCATHETER RETRIEVAL
7.81
1.00
37203
TRANSCATHETER RETRIEVAL
7.83
1.00
37203
TRANSCATHETER RETRIEVAL
999.99
1.00
37204
TRANSCATHETER OCCLUSION
25.14
1.00
37204
TRANSCATHETER OCCLUSION
25.16
1.00
37204
TRANSCATHETER OCCLUSION
26.27
1.00
Procedure Code Description
RVU
RVU Coeff Value
37204
TRANSCATHETER OCCLUSION
999.99
1.00
37205
TRANSCATH IV STENT, PERCUT
12.33
1.00
37205
TRANSCATH IV STENT, PERCUT
12.37
1.00
37205
TRANSCATH IV STENT, PERCUT
12.50
1.00
37205
TRANSCATH IV STENT, PERCUT
12.53
1.00
37206
TRANSCATH IV STENT/PERC ADDL
5.83
1.00
37206
TRANSCATH IV STENT/PERC ADDL
5.93
1.00
37206
TRANSCATH IV STENT/PERC ADDL
6.01
1.00
37207
TRANSCATH IV STENT, OPEN
12.14
1.00
37207
TRANSCATH IV STENT, OPEN
12.51
1.00
37207
TRANSCATH IV STENT, OPEN
12.70
1.00
37208
TRANSCATH IV STENT/OPEN ADDL
5.88
1.00
37208
TRANSCATH IV STENT/OPEN ADDL
5.98
1.00
37208
TRANSCATH IV STENT/OPEN ADDL
6.04
1.00
37209
CHANGE IV CATH AT THROMB TX
3.15
1.00
37209
CHANGE IV CATH AT THROMB TX
3.23
1.00
37210
EMBOLIZATION UTERINE FIBROID
14.33
1.00
37210
EMBOLIZATION UTERINE FIBROID
14.88
1.00
37210
EMBOLIZATION UTERINE FIBROID
15.57
1.00
37215
TRANSCATH STENT, CCA W/EPS
30.54
1.00
37216
TRANSCATH STENT, CCA W/O EPS
28.01
1.00
37250
IV US FIRST VESSEL ADD-ON
3.04
1.00
37250
IV US FIRST VESSEL ADD-ON
3.06
1.00
37250
IV US FIRST VESSEL ADD-ON
3.09
1.00
37250
IV US FIRST VESSEL ADD-ON
999.99
1.00
37251
IV US EACH ADD VESSEL ADD-ON
2.31
1.00
37251
IV US EACH ADD VESSEL ADD-ON
2.32
1.00
37500
ENDOSCOPY LIGATE PERF VEINS
18.58
1.00
37500
ENDOSCOPY LIGATE PERF VEINS
18.94
1.00
37500
ENDOSCOPY LIGATE PERF VEINS
20.10
1.00
37565
LIGATION OF NECK VEIN
6.00
1.00
37565
LIGATION OF NECK VEIN
16.41
1.00
37565
LIGATION OF NECK VEIN
17.05
1.00
37565
LIGATION OF NECK VEIN
18.74
1.00
37600
LIGATION OF NECK ARTERY
5.00
1.00
Procedure Code Description
RVU
RVU Coeff Value
37600
LIGATION OF NECK ARTERY
17.95
1.00
37600
LIGATION OF NECK ARTERY
18.38
1.00
37600
LIGATION OF NECK ARTERY
19.18
1.00
37605
LIGATION OF NECK ARTERY
6.00
1.00
37605
LIGATION OF NECK ARTERY
20.36
1.00
37605
LIGATION OF NECK ARTERY
20.96
1.00
37605
LIGATION OF NECK ARTERY
22.07
1.00
37606
LIGATION OF NECK ARTERY
6.00
1.00
37606
LIGATION OF NECK ARTERY
11.81
1.00
37606
LIGATION OF NECK ARTERY
14.38
1.00
37607
LIGATION OF A-V FISTULA
10.00
1.00
37607
LIGATION OF A-V FISTULA
10.26
1.00
37607
LIGATION OF A-V FISTULA
10.48
1.00
37607
LIGATION OF A-V FISTULA
10.55
1.00
37609
TEMPORAL ARTERY PROCEDURE
5.00
1.00
37609
TEMPORAL ARTERY PROCEDURE
5.23
1.00
37609
TEMPORAL ARTERY PROCEDURE
5.27
1.00
37609
TEMPORAL ARTERY PROCEDURE
5.73
1.00
37615
LIGATION OF NECK ARTERY
6.00
1.00
37615
LIGATION OF NECK ARTERY
9.94
1.00
37615
LIGATION OF NECK ARTERY
10.53
1.00
37615
LIGATION OF NECK ARTERY
12.59
1.00
37616
LIGATION OF CHEST ARTERY
6.00
1.00
37616
LIGATION OF CHEST ARTERY
26.95
1.00
37616
LIGATION OF CHEST ARTERY
29.00
1.00
37616
LIGATION OF CHEST ARTERY
29.51
1.00
37617
LIGATION OF ABDOMEN ARTERY
6.00
1.00
37617
LIGATION OF ABDOMEN ARTERY
33.17
1.00
37617
LIGATION OF ABDOMEN ARTERY
33.29
1.00
37617
LIGATION OF ABDOMEN ARTERY
35.17
1.00
37618
LIGATION OF EXTREMITY ARTERY
4.00
1.00
37618
LIGATION OF EXTREMITY ARTERY
8.87
1.00
37618
LIGATION OF EXTREMITY ARTERY
9.07
1.00
37618
LIGATION OF EXTREMITY ARTERY
10.11
1.00
37620
REVISION OF MAJOR VEIN
7.00
1.00
Procedure Code Description
RVU
RVU Coeff Value
37620
REVISION OF MAJOR VEIN
16.71
1.00
37620
REVISION OF MAJOR VEIN
17.16
1.00
37620
REVISION OF MAJOR VEIN
18.18
1.00
37650
REVISION OF MAJOR VEIN
4.00
1.00
37650
REVISION OF MAJOR VEIN
13.01
1.00
37650
REVISION OF MAJOR VEIN
13.19
1.00
37650
REVISION OF MAJOR VEIN
13.83
1.00
37660
REVISION OF MAJOR VEIN
5.00
1.00
37660
REVISION OF MAJOR VEIN
31.48
1.00
37660
REVISION OF MAJOR VEIN
31.49
1.00
37660
REVISION OF MAJOR VEIN
32.83
1.00
37700
REVISE LEG VEIN
3.00
1.00
37700
REVISE LEG VEIN
6.81
1.00
37700
REVISE LEG VEIN
7.01
1.00
37700
REVISE LEG VEIN
7.27
1.00
37718
LIGATE/STRIP SHORT LEG VEIN
10.95
1.00
37720
REMOVAL OF LEG VEIN
3.00
1.00
37720
REMOVAL OF LEG VEIN
9.90
1.00
37720
REMOVAL OF LEG VEIN
10.12
1.00
37720
REMOVAL OF LEG VEIN
10.13
1.00
37722
LIGATE/STRIP LONG LEG VEIN
12.90
1.00
37730
REMOVAL OF LEG VEINS
3.00
1.00
37730
REMOVAL OF LEG VEINS
12.53
1.00
37730
REMOVAL OF LEG VEINS
12.59
1.00
37730
REMOVAL OF LEG VEINS
12.61
1.00
37735
REMOVAL OF LEG VEINS/LESION
4.00
1.00
37735
REMOVAL OF LEG VEINS/LESION
17.27
1.00
37735
REMOVAL OF LEG VEINS/LESION
17.46
1.00
37735
REMOVAL OF LEG VEINS/LESION
17.47
1.00
37760
LIGATION, LEG VEINS, OPEN
4.00
1.00
37760
LIGATION, LEG VEINS, OPEN
17.00
1.00
37760
LIGATION, LEG VEINS, OPEN
17.17
1.00
37760
LIGATION, LEG VEINS, OPEN
17.21
1.00
37765
PHLEB VEINS - EXTREM - TO 20
12.04
1.00
37765
PHLEB VEINS - EXTREM - TO 20
12.37
1.00
Procedure Code Description
RVU
RVU Coeff Value
37766
PHLEB VEINS - EXTREM 20+
14.60
1.00
37766
PHLEB VEINS - EXTREM 20+
15.03
1.00
37780
REVISION OF LEG VEIN
3.00
1.00
37780
REVISION OF LEG VEIN
7.02
1.00
37780
REVISION OF LEG VEIN
7.20
1.00
37780
REVISION OF LEG VEIN
7.21
1.00
37785
LIGATE/DIVIDE/EXCISE VEIN
3.00
1.00
37785
LIGATE/DIVIDE/EXCISE VEIN
6.96
1.00
37785
LIGATE/DIVIDE/EXCISE VEIN
7.04
1.00
37785
LIGATE/DIVIDE/EXCISE VEIN
7.10
1.00
37788
REVASCULARIZATION, PENIS
32.90
1.00
37788
REVASCULARIZATION, PENIS
34.86
1.00
37788
REVASCULARIZATION, PENIS
37.38
1.00
37788
REVASCULARIZATION, PENIS
999.99
1.00
37790
PENILE VENOUS OCCLUSION
3.00
1.00
37790
PENILE VENOUS OCCLUSION
13.48
1.00
37790
PENILE VENOUS OCCLUSION
13.62
1.00
37790
PENILE VENOUS OCCLUSION
15.08
1.00
40490
BIOPSY OF LIP
1.89
1.00
40490
BIOPSY OF LIP
1.90
1.00
40490
BIOPSY OF LIP
4.00
1.00
40500
PARTIAL EXCISION OF LIP
4.00
1.00
40500
PARTIAL EXCISION OF LIP
9.09
1.00
40500
PARTIAL EXCISION OF LIP
9.54
1.00
40500
PARTIAL EXCISION OF LIP
10.28
1.00
40510
PARTIAL EXCISION OF LIP
4.00
1.00
40510
PARTIAL EXCISION OF LIP
9.03
1.00
40510
PARTIAL EXCISION OF LIP
9.94
1.00
40510
PARTIAL EXCISION OF LIP
11.59
1.00
40520
PARTIAL EXCISION OF LIP
4.00
1.00
40520
PARTIAL EXCISION OF LIP
9.14
1.00
40520
PARTIAL EXCISION OF LIP
10.20
1.00
40520
PARTIAL EXCISION OF LIP
11.96
1.00
40525
RECONSTRUCT LIP WITH FLAP
4.00
1.00
40525
RECONSTRUCT LIP WITH FLAP
14.21
1.00
Procedure Code Description
RVU
RVU Coeff Value
40525
RECONSTRUCT LIP WITH FLAP
15.26
1.00
40525
RECONSTRUCT LIP WITH FLAP
16.59
1.00
40527
RECONSTRUCT LIP WITH FLAP
4.00
1.00
40527
RECONSTRUCT LIP WITH FLAP
16.77
1.00
40527
RECONSTRUCT LIP WITH FLAP
17.96
1.00
40527
RECONSTRUCT LIP WITH FLAP
19.19
1.00
40530
PARTIAL REMOVAL OF LIP
4.00
1.00
40530
PARTIAL REMOVAL OF LIP
10.35
1.00
40530
PARTIAL REMOVAL OF LIP
11.15
1.00
40530
PARTIAL REMOVAL OF LIP
12.11
1.00
40650
REPAIR LIP
4.00
1.00
40650
REPAIR LIP
7.27
1.00
40650
REPAIR LIP
7.80
1.00
40650
REPAIR LIP
8.76
1.00
40652
REPAIR LIP
4.00
1.00
40652
REPAIR LIP
8.89
1.00
40652
REPAIR LIP
9.95
1.00
40652
REPAIR LIP
11.45
1.00
40654
REPAIR LIP
5.00
1.00
40654
REPAIR LIP
10.78
1.00
40654
REPAIR LIP
11.84
1.00
40654
REPAIR LIP
13.29
1.00
40700
REPAIR CLEFT LIP/NASAL
6.00
1.00
40700
REPAIR CLEFT LIP/NASAL
23.40
1.00
40700
REPAIR CLEFT LIP/NASAL
23.61
1.00
40700
REPAIR CLEFT LIP/NASAL
24.04
1.00
40701
REPAIR CLEFT LIP/NASAL
8.00
1.00
40701
REPAIR CLEFT LIP/NASAL
29.26
1.00
40701
REPAIR CLEFT LIP/NASAL
29.47
1.00
40701
REPAIR CLEFT LIP/NASAL
29.91
1.00
40702
REPAIR CLEFT LIP/NASAL
8.00
1.00
40702
REPAIR CLEFT LIP/NASAL
22.71
1.00
40702
REPAIR CLEFT LIP/NASAL
22.83
1.00
40702
REPAIR CLEFT LIP/NASAL
23.59
1.00
40720
REPAIR CLEFT LIP/NASAL
8.00
1.00
Procedure Code Description
RVU
RVU Coeff Value
40720
REPAIR CLEFT LIP/NASAL
25.35
1.00
40720
REPAIR CLEFT LIP/NASAL
25.61
1.00
40720
REPAIR CLEFT LIP/NASAL
26.79
1.00
40761
REPAIR CLEFT LIP/NASAL
6.00
1.00
40761
REPAIR CLEFT LIP/NASAL
27.22
1.00
40761
REPAIR CLEFT LIP/NASAL
27.45
1.00
40761
REPAIR CLEFT LIP/NASAL
28.52
1.00
40799
LIP SURGERY PROCEDURE
999.99
1.00
40800
DRAINAGE OF MOUTH LESION
2.13
1.00
40800
DRAINAGE OF MOUTH LESION
2.42
1.00
40800
DRAINAGE OF MOUTH LESION
3.18
1.00
40800
DRAINAGE OF MOUTH LESION
4.00
1.00
40801
DRAINAGE OF MOUTH LESION
4.26
1.00
40801
DRAINAGE OF MOUTH LESION
4.78
1.00
40801
DRAINAGE OF MOUTH LESION
5.00
1.00
40801
DRAINAGE OF MOUTH LESION
5.55
1.00
40804
REMOVAL, FOREIGN BODY, MOUTH
2.36
1.00
40804
REMOVAL, FOREIGN BODY, MOUTH
2.47
1.00
40804
REMOVAL, FOREIGN BODY, MOUTH
3.21
1.00
40804
REMOVAL, FOREIGN BODY, MOUTH
5.00
1.00
40805
REMOVAL, FOREIGN BODY, MOUTH
4.61
1.00
40805
REMOVAL, FOREIGN BODY, MOUTH
4.88
1.00
40805
REMOVAL, FOREIGN BODY, MOUTH
5.00
1.00
40805
REMOVAL, FOREIGN BODY, MOUTH
5.75
1.00
40806
INCISION OF LIP FOLD
0.86
1.00
40806
INCISION OF LIP FOLD
1.19
1.00
40806
INCISION OF LIP FOLD
1.28
1.00
40806
INCISION OF LIP FOLD
3.00
1.00
40808
BIOPSY OF MOUTH LESION
2.05
1.00
40808
BIOPSY OF MOUTH LESION
2.12
1.00
40808
BIOPSY OF MOUTH LESION
2.67
1.00
40808
BIOPSY OF MOUTH LESION
4.00
1.00
40810
EXCISION OF MOUTH LESION
2.56
1.00
40810
EXCISION OF MOUTH LESION
2.63
1.00
40810
EXCISION OF MOUTH LESION
3.17
1.00
Procedure Code Description
RVU
RVU Coeff Value
40810
EXCISION OF MOUTH LESION
4.00
1.00
40812
EXCISE/REPAIR MOUTH LESION
4.00
1.00
40812
EXCISE/REPAIR MOUTH LESION
4.20
1.00
40812
EXCISE/REPAIR MOUTH LESION
4.30
1.00
40812
EXCISE/REPAIR MOUTH LESION
4.95
1.00
40814
EXCISE/REPAIR MOUTH LESION
5.00
1.00
40814
EXCISE/REPAIR MOUTH LESION
6.66
1.00
40814
EXCISE/REPAIR MOUTH LESION
7.01
1.00
40814
EXCISE/REPAIR MOUTH LESION
7.64
1.00
40816
EXCISION OF MOUTH LESION
4.00
1.00
40816
EXCISION OF MOUTH LESION
7.11
1.00
40816
EXCISION OF MOUTH LESION
7.38
1.00
40816
EXCISION OF MOUTH LESION
7.98
1.00
40818
EXCISE ORAL MUCOSA FOR GRAFT
4.00
1.00
40818
EXCISE ORAL MUCOSA FOR GRAFT
6.11
1.00
40818
EXCISE ORAL MUCOSA FOR GRAFT
6.66
1.00
40818
EXCISE ORAL MUCOSA FOR GRAFT
6.79
1.00
40819
EXCISE LIP OR CHEEK FOLD
4.00
1.00
40819
EXCISE LIP OR CHEEK FOLD
5.54
1.00
40819
EXCISE LIP OR CHEEK FOLD
5.86
1.00
40819
EXCISE LIP OR CHEEK FOLD
6.13
1.00
40820
TREATMENT OF MOUTH LESION
3.66
1.00
40820
TREATMENT OF MOUTH LESION
3.73
1.00
40820
TREATMENT OF MOUTH LESION
4.00
1.00
40820
TREATMENT OF MOUTH LESION
4.26
1.00
40830
REPAIR MOUTH LACERATION
3.99
1.00
40830
REPAIR MOUTH LACERATION
4.00
1.00
40830
REPAIR MOUTH LACERATION
4.40
1.00
40830
REPAIR MOUTH LACERATION
4.44
1.00
40831
REPAIR MOUTH LACERATION
4.00
1.00
40831
REPAIR MOUTH LACERATION
5.45
1.00
40831
REPAIR MOUTH LACERATION
5.62
1.00
40831
REPAIR MOUTH LACERATION
5.79
1.00
40840
RECONSTRUCTION OF MOUTH
3.00
1.00
40840
RECONSTRUCTION OF MOUTH
15.66
1.00
Procedure Code Description
RVU
RVU Coeff Value
40840
RECONSTRUCTION OF MOUTH
16.24
1.00
40840
RECONSTRUCTION OF MOUTH
17.03
1.00
40842
RECONSTRUCTION OF MOUTH
4.00
1.00
40842
RECONSTRUCTION OF MOUTH
15.38
1.00
40842
RECONSTRUCTION OF MOUTH
15.90
1.00
40842
RECONSTRUCTION OF MOUTH
16.60
1.00
40843
RECONSTRUCTION OF MOUTH
4.00
1.00
40843
RECONSTRUCTION OF MOUTH
20.25
1.00
40843
RECONSTRUCTION OF MOUTH
20.64
1.00
40843
RECONSTRUCTION OF MOUTH
21.70
1.00
40844
RECONSTRUCTION OF MOUTH
4.00
1.00
40844
RECONSTRUCTION OF MOUTH
26.59
1.00
40844
RECONSTRUCTION OF MOUTH
28.90
1.00
40844
RECONSTRUCTION OF MOUTH
29.71
1.00
40845
RECONSTRUCTION OF MOUTH
4.00
1.00
40845
RECONSTRUCTION OF MOUTH
30.99
1.00
40845
RECONSTRUCTION OF MOUTH
32.29
1.00
40845
RECONSTRUCTION OF MOUTH
33.87
1.00
41000
DRAINAGE OF MOUTH LESION
2.80
1.00
41000
DRAINAGE OF MOUTH LESION
2.81
1.00
41000
DRAINAGE OF MOUTH LESION
2.89
1.00
41000
DRAINAGE OF MOUTH LESION
4.00
1.00
41005
DRAINAGE OF MOUTH LESION
2.82
1.00
41005
DRAINAGE OF MOUTH LESION
2.99
1.00
41005
DRAINAGE OF MOUTH LESION
3.19
1.00
41005
DRAINAGE OF MOUTH LESION
5.00
1.00
41006
DRAINAGE OF MOUTH LESION
5.00
1.00
41006
DRAINAGE OF MOUTH LESION
6.56
1.00
41006
DRAINAGE OF MOUTH LESION
6.89
1.00
41006
DRAINAGE OF MOUTH LESION
6.98
1.00
41007
DRAINAGE OF MOUTH LESION
5.00
1.00
41007
DRAINAGE OF MOUTH LESION
6.36
1.00
41007
DRAINAGE OF MOUTH LESION
6.51
1.00
41007
DRAINAGE OF MOUTH LESION
6.68
1.00
41008
DRAINAGE OF MOUTH LESION
6.82
1.00
Procedure Code Description
RVU
RVU Coeff Value
41008
DRAINAGE OF MOUTH LESION
6.89
1.00
41008
DRAINAGE OF MOUTH LESION
7.00
1.00
41008
DRAINAGE OF MOUTH LESION
7.14
1.00
41009
DRAINAGE OF MOUTH LESION
5.00
1.00
41009
DRAINAGE OF MOUTH LESION
7.11
1.00
41009
DRAINAGE OF MOUTH LESION
7.41
1.00
41009
DRAINAGE OF MOUTH LESION
7.73
1.00
41010
INCISION OF TONGUE FOLD
2.73
1.00
41010
INCISION OF TONGUE FOLD
4.00
1.00
41010
INCISION OF TONGUE FOLD
4.38
1.00
41010
INCISION OF TONGUE FOLD
4.59
1.00
41015
DRAINAGE OF MOUTH LESION
5.00
1.00
41015
DRAINAGE OF MOUTH LESION
7.48
1.00
41015
DRAINAGE OF MOUTH LESION
8.36
1.00
41015
DRAINAGE OF MOUTH LESION
8.48
1.00
41016
DRAINAGE OF MOUTH LESION
5.00
1.00
41016
DRAINAGE OF MOUTH LESION
7.73
1.00
41016
DRAINAGE OF MOUTH LESION
8.47
1.00
41016
DRAINAGE OF MOUTH LESION
8.82
1.00
41017
DRAINAGE OF MOUTH LESION
4.00
1.00
41017
DRAINAGE OF MOUTH LESION
7.71
1.00
41017
DRAINAGE OF MOUTH LESION
8.59
1.00
41017
DRAINAGE OF MOUTH LESION
8.86
1.00
41018
DRAINAGE OF MOUTH LESION
5.00
1.00
41018
DRAINAGE OF MOUTH LESION
9.24
1.00
41018
DRAINAGE OF MOUTH LESION
9.76
1.00
41018
DRAINAGE OF MOUTH LESION
10.38
1.00
41019
PLACE NEEDLES H&N FOR RT
12.96
1.00
41100
BIOPSY OF TONGUE
2.79
1.00
41100
BIOPSY OF TONGUE
3.15
1.00
41100
BIOPSY OF TONGUE
3.19
1.00
41100
BIOPSY OF TONGUE
4.00
1.00
41105
BIOPSY OF TONGUE
2.82
1.00
41105
BIOPSY OF TONGUE
2.84
1.00
41105
BIOPSY OF TONGUE
2.85
1.00
Procedure Code Description
RVU
RVU Coeff Value
41105
BIOPSY OF TONGUE
4.00
1.00
41108
BIOPSY OF FLOOR OF MOUTH
2.23
1.00
41108
BIOPSY OF FLOOR OF MOUTH
2.27
1.00
41108
BIOPSY OF FLOOR OF MOUTH
4.00
1.00
41110
EXCISION OF TONGUE LESION
2.93
1.00
41110
EXCISION OF TONGUE LESION
2.97
1.00
41110
EXCISION OF TONGUE LESION
3.31
1.00
41110
EXCISION OF TONGUE LESION
4.00
1.00
41112
EXCISION OF TONGUE LESION
4.00
1.00
41112
EXCISION OF TONGUE LESION
5.64
1.00
41112
EXCISION OF TONGUE LESION
5.68
1.00
41112
EXCISION OF TONGUE LESION
6.30
1.00
41113
EXCISION OF TONGUE LESION
4.00
1.00
41113
EXCISION OF TONGUE LESION
6.36
1.00
41113
EXCISION OF TONGUE LESION
6.45
1.00
41113
EXCISION OF TONGUE LESION
7.01
1.00
41114
EXCISION OF TONGUE LESION
4.00
1.00
41114
EXCISION OF TONGUE LESION
14.55
1.00
41114
EXCISION OF TONGUE LESION
15.54
1.00
41114
EXCISION OF TONGUE LESION
16.22
1.00
41115
EXCISION OF TONGUE FOLD
3.75
1.00
41115
EXCISION OF TONGUE FOLD
4.41
1.00
41115
EXCISION OF TONGUE FOLD
4.47
1.00
41115
EXCISION OF TONGUE FOLD
6.00
1.00
41116
EXCISION OF MOUTH LESION
4.00
1.00
41116
EXCISION OF MOUTH LESION
5.42
1.00
41116
EXCISION OF MOUTH LESION
5.51
1.00
41116
EXCISION OF MOUTH LESION
6.01
1.00
41120
PARTIAL REMOVAL OF TONGUE
6.00
1.00
41120
PARTIAL REMOVAL OF TONGUE
18.18
1.00
41120
PARTIAL REMOVAL OF TONGUE
19.35
1.00
41120
PARTIAL REMOVAL OF TONGUE
26.36
1.00
41130
PARTIAL REMOVAL OF TONGUE
6.00
1.00
41130
PARTIAL REMOVAL OF TONGUE
20.47
1.00
41130
PARTIAL REMOVAL OF TONGUE
21.62
1.00
Procedure Code Description 41130
PARTIAL REMOVAL OF TONGUE
41135
RVU
RVU Coeff Value
32.50
1.00
TONGUE AND NECK SURGERY
6.00
1.00
41135
TONGUE AND NECK SURGERY
39.89
1.00
41135
TONGUE AND NECK SURGERY
40.74
1.00
41135
TONGUE AND NECK SURGERY
54.27
1.00
41140
REMOVAL OF TONGUE
6.00
1.00
41140
REMOVAL OF TONGUE
43.75
1.00
41140
REMOVAL OF TONGUE
44.67
1.00
41140
REMOVAL OF TONGUE
55.94
1.00
41145
TONGUE REMOVAL, NECK SURGERY
6.00
1.00
41145
TONGUE REMOVAL, NECK SURGERY
51.73
1.00
41145
TONGUE REMOVAL, NECK SURGERY
53.47
1.00
41145
TONGUE REMOVAL, NECK SURGERY
69.94
1.00
41150
TONGUE, MOUTH, JAW SURGERY
6.00
1.00
41150
TONGUE, MOUTH, JAW SURGERY
40.51
1.00
41150
TONGUE, MOUTH, JAW SURGERY
41.87
1.00
41150
TONGUE, MOUTH, JAW SURGERY
55.29
1.00
41153
TONGUE, MOUTH, NECK SURGERY
41.75
1.00
41153
TONGUE, MOUTH, NECK SURGERY
43.25
1.00
41153
TONGUE, MOUTH, NECK SURGERY
59.91
1.00
41155
TONGUE, JAW, & NECK SURGERY
8.00
1.00
41155
TONGUE, JAW, & NECK SURGERY
48.11
1.00
41155
TONGUE, JAW, & NECK SURGERY
49.71
1.00
41155
TONGUE, JAW, & NECK SURGERY
74.41
1.00
41250
REPAIR TONGUE LACERATION
3.58
1.00
41250
REPAIR TONGUE LACERATION
3.71
1.00
41250
REPAIR TONGUE LACERATION
3.77
1.00
41250
REPAIR TONGUE LACERATION
4.00
1.00
41251
REPAIR TONGUE LACERATION
4.17
1.00
41251
REPAIR TONGUE LACERATION
4.42
1.00
41251
REPAIR TONGUE LACERATION
4.45
1.00
41251
REPAIR TONGUE LACERATION
5.00
1.00
41252
REPAIR TONGUE LACERATION
4.00
1.00
41252
REPAIR TONGUE LACERATION
5.40
1.00
41252
REPAIR TONGUE LACERATION
5.53
1.00
Procedure Code Description
RVU
RVU Coeff Value
41252
REPAIR TONGUE LACERATION
5.54
1.00
41500
FIXATION OF TONGUE
5.00
1.00
41500
FIXATION OF TONGUE
7.64
1.00
41500
FIXATION OF TONGUE
8.30
1.00
41500
FIXATION OF TONGUE
11.16
1.00
41510
TONGUE TO LIP SURGERY
6.00
1.00
41510
TONGUE TO LIP SURGERY
6.80
1.00
41510
TONGUE TO LIP SURGERY
8.46
1.00
41510
TONGUE TO LIP SURGERY
10.22
1.00
41512
TONGUE SUSPENSION
15.66
1.00
41520
RECONSTRUCTION, TONGUE FOLD
4.00
1.00
41520
RECONSTRUCTION, TONGUE FOLD
5.95
1.00
41520
RECONSTRUCTION, TONGUE FOLD
6.18
1.00
41520
RECONSTRUCTION, TONGUE FOLD
6.38
1.00
41530
TONGUE BASE VOL REDUCTION
10.26
1.00
41800
DRAINAGE OF GUM LESION
2.63
1.00
41800
DRAINAGE OF GUM LESION
2.72
1.00
41800
DRAINAGE OF GUM LESION
3.22
1.00
41800
DRAINAGE OF GUM LESION
4.00
1.00
41805
REMOVAL FOREIGN BODY, GUM
3.28
1.00
41805
REMOVAL FOREIGN BODY, GUM
3.68
1.00
41805
REMOVAL FOREIGN BODY, GUM
4.09
1.00
41805
REMOVAL FOREIGN BODY, GUM
5.00
1.00
41806
REMOVAL FOREIGN BODY,JAWBONE
4.00
1.00
41806
REMOVAL FOREIGN BODY,JAWBONE
5.36
1.00
41806
REMOVAL FOREIGN BODY,JAWBONE
6.10
1.00
41806
REMOVAL FOREIGN BODY,JAWBONE
6.42
1.00
41820
EXCISION, GUM, EACH QUADRANT
4.00
1.00
41822
EXCISION OF GUM LESION
3.51
1.00
41822
EXCISION OF GUM LESION
3.93
1.00
41822
EXCISION OF GUM LESION
4.47
1.00
41822
EXCISION OF GUM LESION
5.00
1.00
41823
EXCISION OF GUM LESION
5.00
1.00
41823
EXCISION OF GUM LESION
6.59
1.00
41823
EXCISION OF GUM LESION
7.75
1.00
Procedure Code Description
RVU
RVU Coeff Value
41823
EXCISION OF GUM LESION
8.05
1.00
41825
EXCISION OF GUM LESION
3.18
1.00
41825
EXCISION OF GUM LESION
3.77
1.00
41825
EXCISION OF GUM LESION
3.78
1.00
41825
EXCISION OF GUM LESION
4.00
1.00
41826
EXCISION OF GUM LESION
5.00
1.00
41826
EXCISION OF GUM LESION
5.12
1.00
41826
EXCISION OF GUM LESION
5.14
1.00
41826
EXCISION OF GUM LESION
5.41
1.00
41827
EXCISION OF GUM LESION
5.00
1.00
41827
EXCISION OF GUM LESION
7.25
1.00
41827
EXCISION OF GUM LESION
7.55
1.00
41827
EXCISION OF GUM LESION
7.59
1.00
41828
EXCISION OF GUM LESION
4.00
1.00
41828
EXCISION OF GUM LESION
5.56
1.00
41828
EXCISION OF GUM LESION
5.71
1.00
41828
EXCISION OF GUM LESION
6.71
1.00
41830
REMOVAL OF GUM TISSUE
4.00
1.00
41830
REMOVAL OF GUM TISSUE
6.52
1.00
41830
REMOVAL OF GUM TISSUE
7.07
1.00
41830
REMOVAL OF GUM TISSUE
7.19
1.00
41872
REPAIR GUM
4.00
1.00
41872
REPAIR GUM
5.65
1.00
41872
REPAIR GUM
6.34
1.00
41872
REPAIR GUM
6.54
1.00
41874
REPAIR TOOTH SOCKET
4.00
1.00
41874
REPAIR TOOTH SOCKET
5.72
1.00
41874
REPAIR TOOTH SOCKET
6.47
1.00
41874
REPAIR TOOTH SOCKET
6.66
1.00
42000
DRAINAGE MOUTH ROOF LESION
2.60
1.00
42000
DRAINAGE MOUTH ROOF LESION
2.86
1.00
42000
DRAINAGE MOUTH ROOF LESION
5.00
1.00
42100
BIOPSY ROOF OF MOUTH
2.76
1.00
42100
BIOPSY ROOF OF MOUTH
2.79
1.00
42100
BIOPSY ROOF OF MOUTH
3.91
1.00
Procedure Code Description
RVU
RVU Coeff Value
42100
BIOPSY ROOF OF MOUTH
4.00
1.00
42104
EXCISION LESION, MOUTH ROOF
3.33
1.00
42104
EXCISION LESION, MOUTH ROOF
3.47
1.00
42104
EXCISION LESION, MOUTH ROOF
4.00
1.00
42104
EXCISION LESION, MOUTH ROOF
4.33
1.00
42106
EXCISION LESION, MOUTH ROOF
4.56
1.00
42106
EXCISION LESION, MOUTH ROOF
4.90
1.00
42106
EXCISION LESION, MOUTH ROOF
5.10
1.00
42106
EXCISION LESION, MOUTH ROOF
6.00
1.00
42107
EXCISION LESION, MOUTH ROOF
4.00
1.00
42107
EXCISION LESION, MOUTH ROOF
8.76
1.00
42107
EXCISION LESION, MOUTH ROOF
8.87
1.00
42107
EXCISION LESION, MOUTH ROOF
9.00
1.00
42120
REMOVE PALATE/LESION
4.00
1.00
42120
REMOVE PALATE/LESION
12.25
1.00
42120
REMOVE PALATE/LESION
12.72
1.00
42120
REMOVE PALATE/LESION
24.42
1.00
42140
EXCISION OF UVULA
3.00
1.00
42140
EXCISION OF UVULA
3.89
1.00
42140
EXCISION OF UVULA
4.13
1.00
42140
EXCISION OF UVULA
5.11
1.00
42145
REPAIR PALATE, PHARYNX/UVULA
5.00
1.00
42145
REPAIR PALATE, PHARYNX/UVULA
15.33
1.00
42145
REPAIR PALATE, PHARYNX/UVULA
16.11
1.00
42145
REPAIR PALATE, PHARYNX/UVULA
17.83
1.00
42160
TREATMENT MOUTH ROOF LESION
3.87
1.00
42160
TREATMENT MOUTH ROOF LESION
4.61
1.00
42160
TREATMENT MOUTH ROOF LESION
4.63
1.00
42160
TREATMENT MOUTH ROOF LESION
6.00
1.00
42180
REPAIR PALATE
4.69
1.00
42180
REPAIR PALATE
4.80
1.00
42180
REPAIR PALATE
4.85
1.00
42180
REPAIR PALATE
6.00
1.00
42182
REPAIR PALATE
6.00
1.00
42182
REPAIR PALATE
6.87
1.00
Procedure Code Description
RVU
RVU Coeff Value
42182
REPAIR PALATE
7.16
1.00
42182
REPAIR PALATE
7.21
1.00
42200
RECONSTRUCT CLEFT PALATE
6.00
1.00
42200
RECONSTRUCT CLEFT PALATE
22.16
1.00
42200
RECONSTRUCT CLEFT PALATE
22.75
1.00
42200
RECONSTRUCT CLEFT PALATE
23.11
1.00
42205
RECONSTRUCT CLEFT PALATE
6.00
1.00
42205
RECONSTRUCT CLEFT PALATE
23.34
1.00
42205
RECONSTRUCT CLEFT PALATE
23.61
1.00
42205
RECONSTRUCT CLEFT PALATE
24.32
1.00
42210
RECONSTRUCT CLEFT PALATE
6.00
1.00
42210
RECONSTRUCT CLEFT PALATE
25.25
1.00
42210
RECONSTRUCT CLEFT PALATE
26.50
1.00
42210
RECONSTRUCT CLEFT PALATE
27.58
1.00
42215
RECONSTRUCT CLEFT PALATE
6.00
1.00
42215
RECONSTRUCT CLEFT PALATE
17.52
1.00
42215
RECONSTRUCT CLEFT PALATE
18.07
1.00
42215
RECONSTRUCT CLEFT PALATE
18.47
1.00
42220
RECONSTRUCT CLEFT PALATE
6.00
1.00
42220
RECONSTRUCT CLEFT PALATE
13.14
1.00
42220
RECONSTRUCT CLEFT PALATE
13.94
1.00
42220
RECONSTRUCT CLEFT PALATE
14.16
1.00
42225
RECONSTRUCT CLEFT PALATE
6.00
1.00
42225
RECONSTRUCT CLEFT PALATE
18.09
1.00
42225
RECONSTRUCT CLEFT PALATE
19.44
1.00
42225
RECONSTRUCT CLEFT PALATE
23.87
1.00
42226
LENGTHENING OF PALATE
6.00
1.00
42226
LENGTHENING OF PALATE
18.75
1.00
42226
LENGTHENING OF PALATE
20.26
1.00
42226
LENGTHENING OF PALATE
23.75
1.00
42227
LENGTHENING OF PALATE
6.00
1.00
42227
LENGTHENING OF PALATE
17.69
1.00
42227
LENGTHENING OF PALATE
18.31
1.00
42227
LENGTHENING OF PALATE
23.09
1.00
42235
REPAIR PALATE
6.00
1.00
Procedure Code Description
RVU
RVU Coeff Value
42235
REPAIR PALATE
13.80
1.00
42235
REPAIR PALATE
14.54
1.00
42235
REPAIR PALATE
18.83
1.00
42260
REPAIR NOSE TO LIP FISTULA
6.00
1.00
42260
REPAIR NOSE TO LIP FISTULA
17.64
1.00
42260
REPAIR NOSE TO LIP FISTULA
17.65
1.00
42260
REPAIR NOSE TO LIP FISTULA
18.26
1.00
42281
INSERTION, PALATE PROSTHESIS
3.87
1.00
42300
DRAINAGE OF SALIVARY GLAND
3.87
1.00
42300
DRAINAGE OF SALIVARY GLAND
3.94
1.00
42300
DRAINAGE OF SALIVARY GLAND
3.97
1.00
42300
DRAINAGE OF SALIVARY GLAND
4.00
1.00
42305
DRAINAGE OF SALIVARY GLAND
5.00
1.00
42305
DRAINAGE OF SALIVARY GLAND
11.05
1.00
42305
DRAINAGE OF SALIVARY GLAND
11.56
1.00
42305
DRAINAGE OF SALIVARY GLAND
11.82
1.00
42310
DRAINAGE OF SALIVARY GLAND
3.16
1.00
42310
DRAINAGE OF SALIVARY GLAND
3.23
1.00
42310
DRAINAGE OF SALIVARY GLAND
3.32
1.00
42310
DRAINAGE OF SALIVARY GLAND
4.00
1.00
42320
DRAINAGE OF SALIVARY GLAND
4.00
1.00
42320
DRAINAGE OF SALIVARY GLAND
4.54
1.00
42320
DRAINAGE OF SALIVARY GLAND
4.65
1.00
42320
DRAINAGE OF SALIVARY GLAND
4.67
1.00
42325
CREATE SALIVARY CYST DRAIN
4.00
1.00
42325
CREATE SALIVARY CYST DRAIN
4.07
1.00
42325
CREATE SALIVARY CYST DRAIN
5.19
1.00
42325
CREATE SALIVARY CYST DRAIN
5.31
1.00
42326
CREATE SALIVARY CYST DRAIN
5.00
1.00
42326
CREATE SALIVARY CYST DRAIN
5.88
1.00
42326
CREATE SALIVARY CYST DRAIN
7.21
1.00
42326
CREATE SALIVARY CYST DRAIN
7.28
1.00
42330
REMOVAL OF SALIVARY STONE
3.42
1.00
42330
REMOVAL OF SALIVARY STONE
4.00
1.00
42330
REMOVAL OF SALIVARY STONE
4.21
1.00
Procedure Code Description
RVU
RVU Coeff Value
42330
REMOVAL OF SALIVARY STONE
4.26
1.00
42335
REMOVAL OF SALIVARY STONE
4.00
1.00
42335
REMOVAL OF SALIVARY STONE
6.60
1.00
42335
REMOVAL OF SALIVARY STONE
6.95
1.00
42335
REMOVAL OF SALIVARY STONE
7.20
1.00
42340
REMOVAL OF SALIVARY STONE
4.00
1.00
42340
REMOVAL OF SALIVARY STONE
8.69
1.00
42340
REMOVAL OF SALIVARY STONE
9.27
1.00
42340
REMOVAL OF SALIVARY STONE
9.74
1.00
42400
BIOPSY OF SALIVARY GLAND
1.23
1.00
42400
BIOPSY OF SALIVARY GLAND
1.51
1.00
42400
BIOPSY OF SALIVARY GLAND
1.57
1.00
42400
BIOPSY OF SALIVARY GLAND
4.00
1.00
42405
BIOPSY OF SALIVARY GLAND
4.00
1.00
42405
BIOPSY OF SALIVARY GLAND
5.87
1.00
42405
BIOPSY OF SALIVARY GLAND
6.06
1.00
42405
BIOPSY OF SALIVARY GLAND
6.87
1.00
42408
EXCISION OF SALIVARY CYST
4.00
1.00
42408
EXCISION OF SALIVARY CYST
8.44
1.00
42408
EXCISION OF SALIVARY CYST
9.00
1.00
42408
EXCISION OF SALIVARY CYST
9.42
1.00
42409
DRAINAGE OF SALIVARY CYST
4.00
1.00
42409
DRAINAGE OF SALIVARY CYST
5.72
1.00
42409
DRAINAGE OF SALIVARY CYST
6.14
1.00
42409
DRAINAGE OF SALIVARY CYST
6.40
1.00
42410
EXCISE PAROTID GLAND/LESION
4.00
1.00
42410
EXCISE PAROTID GLAND/LESION
16.07
1.00
42410
EXCISE PAROTID GLAND/LESION
16.90
1.00
42410
EXCISE PAROTID GLAND/LESION
17.98
1.00
42415
EXCISE PAROTID GLAND/LESION
5.00
1.00
42415
EXCISE PAROTID GLAND/LESION
28.92
1.00
42415
EXCISE PAROTID GLAND/LESION
29.64
1.00
42415
EXCISE PAROTID GLAND/LESION
30.62
1.00
42420
EXCISE PAROTID GLAND/LESION
6.00
1.00
42420
EXCISE PAROTID GLAND/LESION
33.15
1.00
Procedure Code Description
RVU
RVU Coeff Value
42420
EXCISE PAROTID GLAND/LESION
34.08
1.00
42420
EXCISE PAROTID GLAND/LESION
35.07
1.00
42425
EXCISE PAROTID GLAND/LESION
6.00
1.00
42425
EXCISE PAROTID GLAND/LESION
21.82
1.00
42425
EXCISE PAROTID GLAND/LESION
23.25
1.00
42425
EXCISE PAROTID GLAND/LESION
24.46
1.00
42426
EXCISE PAROTID GLAND/LESION
6.00
1.00
42426
EXCISE PAROTID GLAND/LESION
35.48
1.00
42426
EXCISE PAROTID GLAND/LESION
36.55
1.00
42426
EXCISE PAROTID GLAND/LESION
37.66
1.00
42440
EXCISE SUBMAXILLARY GLAND
3.00
1.00
42440
EXCISE SUBMAXILLARY GLAND
12.06
1.00
42440
EXCISE SUBMAXILLARY GLAND
12.64
1.00
42440
EXCISE SUBMAXILLARY GLAND
13.46
1.00
42450
EXCISE SUBLINGUAL GLAND
3.00
1.00
42450
EXCISE SUBLINGUAL GLAND
9.18
1.00
42450
EXCISE SUBLINGUAL GLAND
9.26
1.00
42450
EXCISE SUBLINGUAL GLAND
9.74
1.00
42500
REPAIR SALIVARY DUCT
4.00
1.00
42500
REPAIR SALIVARY DUCT
8.74
1.00
42500
REPAIR SALIVARY DUCT
8.83
1.00
42500
REPAIR SALIVARY DUCT
9.44
1.00
42505
REPAIR SALIVARY DUCT
5.00
1.00
42505
REPAIR SALIVARY DUCT
11.69
1.00
42505
REPAIR SALIVARY DUCT
12.06
1.00
42505
REPAIR SALIVARY DUCT
12.08
1.00
42507
PAROTID DUCT DIVERSION
5.00
1.00
42507
PAROTID DUCT DIVERSION
12.10
1.00
42507
PAROTID DUCT DIVERSION
12.75
1.00
42507
PAROTID DUCT DIVERSION
13.11
1.00
42508
PAROTID DUCT DIVERSION
5.00
1.00
42508
PAROTID DUCT DIVERSION
16.88
1.00
42508
PAROTID DUCT DIVERSION
17.86
1.00
42508
PAROTID DUCT DIVERSION
18.76
1.00
42509
PAROTID DUCT DIVERSION
5.00
1.00
Procedure Code Description
RVU
RVU Coeff Value
42509
PAROTID DUCT DIVERSION
21.38
1.00
42509
PAROTID DUCT DIVERSION
21.44
1.00
42509
PAROTID DUCT DIVERSION
22.43
1.00
42510
PAROTID DUCT DIVERSION
5.00
1.00
42510
PAROTID DUCT DIVERSION
14.94
1.00
42510
PAROTID DUCT DIVERSION
15.81
1.00
42510
PAROTID DUCT DIVERSION
16.16
1.00
42550
INJECTION FOR SALIVARY X-RAY
1.73
1.00
42550
INJECTION FOR SALIVARY X-RAY
1.74
1.00
42550
INJECTION FOR SALIVARY X-RAY
1.79
1.00
42600
CLOSURE OF SALIVARY FISTULA
4.00
1.00
42600
CLOSURE OF SALIVARY FISTULA
9.10
1.00
42600
CLOSURE OF SALIVARY FISTULA
9.74
1.00
42600
CLOSURE OF SALIVARY FISTULA
10.83
1.00
42650
DILATION OF SALIVARY DUCT
1.23
1.00
42650
DILATION OF SALIVARY DUCT
1.52
1.00
42650
DILATION OF SALIVARY DUCT
1.55
1.00
42650
DILATION OF SALIVARY DUCT
4.00
1.00
42660
DILATION OF SALIVARY DUCT
2.02
1.00
42660
DILATION OF SALIVARY DUCT
2.05
1.00
42660
DILATION OF SALIVARY DUCT
2.38
1.00
42660
DILATION OF SALIVARY DUCT
4.00
1.00
42665
LIGATION OF SALIVARY DUCT
5.00
1.00
42665
LIGATION OF SALIVARY DUCT
5.29
1.00
42665
LIGATION OF SALIVARY DUCT
5.70
1.00
42665
LIGATION OF SALIVARY DUCT
6.21
1.00
42700
DRAINAGE OF TONSIL ABSCESS
3.45
1.00
42700
DRAINAGE OF TONSIL ABSCESS
3.49
1.00
42700
DRAINAGE OF TONSIL ABSCESS
3.62
1.00
42700
DRAINAGE OF TONSIL ABSCESS
4.00
1.00
42720
DRAINAGE OF THROAT ABSCESS
4.00
1.00
42720
DRAINAGE OF THROAT ABSCESS
9.70
1.00
42720
DRAINAGE OF THROAT ABSCESS
10.22
1.00
42720
DRAINAGE OF THROAT ABSCESS
10.57
1.00
42725
DRAINAGE OF THROAT ABSCESS
4.00
1.00
Procedure Code Description
RVU
RVU Coeff Value
42725
DRAINAGE OF THROAT ABSCESS
19.66
1.00
42725
DRAINAGE OF THROAT ABSCESS
20.04
1.00
42725
DRAINAGE OF THROAT ABSCESS
20.86
1.00
42800
BIOPSY OF THROAT
2.85
1.00
42800
BIOPSY OF THROAT
2.91
1.00
42800
BIOPSY OF THROAT
4.00
1.00
42800
BIOPSY OF THROAT
4.11
1.00
42802
BIOPSY OF THROAT
3.46
1.00
42802
BIOPSY OF THROAT
3.61
1.00
42802
BIOPSY OF THROAT
4.00
1.00
42802
BIOPSY OF THROAT
4.35
1.00
42804
BIOPSY OF UPPER NOSE/THROAT
2.93
1.00
42804
BIOPSY OF UPPER NOSE/THROAT
3.14
1.00
42804
BIOPSY OF UPPER NOSE/THROAT
3.90
1.00
42806
BIOPSY OF UPPER NOSE/THROAT
3.44
1.00
42806
BIOPSY OF UPPER NOSE/THROAT
3.64
1.00
42806
BIOPSY OF UPPER NOSE/THROAT
4.00
1.00
42806
BIOPSY OF UPPER NOSE/THROAT
4.46
1.00
42808
EXCISE PHARYNX LESION
4.23
1.00
42808
EXCISE PHARYNX LESION
4.44
1.00
42808
EXCISE PHARYNX LESION
5.00
1.00
42808
EXCISE PHARYNX LESION
5.62
1.00
42809
REMOVE PHARYNX FOREIGN BODY
3.32
1.00
42809
REMOVE PHARYNX FOREIGN BODY
3.33
1.00
42809
REMOVE PHARYNX FOREIGN BODY
3.68
1.00
42809
REMOVE PHARYNX FOREIGN BODY
5.00
1.00
42810
EXCISION OF NECK CYST
4.00
1.00
42810
EXCISION OF NECK CYST
6.92
1.00
42810
EXCISION OF NECK CYST
7.25
1.00
42810
EXCISION OF NECK CYST
8.00
1.00
42815
EXCISION OF NECK CYST
4.00
1.00
42815
EXCISION OF NECK CYST
13.12
1.00
42815
EXCISION OF NECK CYST
14.18
1.00
42815
EXCISION OF NECK CYST
14.20
1.00
42820
REMOVE TONSILS AND ADENOIDS
5.00
1.00
Procedure Code Description
RVU
RVU Coeff Value
42820
REMOVE TONSILS AND ADENOIDS
7.49
1.00
42820
REMOVE TONSILS AND ADENOIDS
7.71
1.00
42820
REMOVE TONSILS AND ADENOIDS
8.44
1.00
42821
REMOVE TONSILS AND ADENOIDS
5.00
1.00
42821
REMOVE TONSILS AND ADENOIDS
7.83
1.00
42821
REMOVE TONSILS AND ADENOIDS
8.32
1.00
42821
REMOVE TONSILS AND ADENOIDS
8.82
1.00
42825
REMOVAL OF TONSILS
5.00
1.00
42825
REMOVAL OF TONSILS
6.70
1.00
42825
REMOVAL OF TONSILS
7.02
1.00
42825
REMOVAL OF TONSILS
7.35
1.00
42826
REMOVAL OF TONSILS
5.00
1.00
42826
REMOVAL OF TONSILS
6.48
1.00
42826
REMOVAL OF TONSILS
6.86
1.00
42826
REMOVAL OF TONSILS
7.36
1.00
42830
REMOVAL OF ADENOIDS
5.00
1.00
42830
REMOVAL OF ADENOIDS
5.17
1.00
42830
REMOVAL OF ADENOIDS
5.28
1.00
42830
REMOVAL OF ADENOIDS
5.41
1.00
42831
REMOVAL OF ADENOIDS
4.00
1.00
42831
REMOVAL OF ADENOIDS
5.45
1.00
42831
REMOVAL OF ADENOIDS
5.70
1.00
42831
REMOVAL OF ADENOIDS
5.80
1.00
42835
REMOVAL OF ADENOIDS
4.00
1.00
42835
REMOVAL OF ADENOIDS
4.77
1.00
42835
REMOVAL OF ADENOIDS
5.13
1.00
42835
REMOVAL OF ADENOIDS
5.62
1.00
42836
REMOVAL OF ADENOIDS
4.00
1.00
42836
REMOVAL OF ADENOIDS
6.22
1.00
42836
REMOVAL OF ADENOIDS
6.59
1.00
42836
REMOVAL OF ADENOIDS
7.08
1.00
42842
EXTENSIVE SURGERY OF THROAT
7.00
1.00
42842
EXTENSIVE SURGERY OF THROAT
16.23
1.00
42842
EXTENSIVE SURGERY OF THROAT
17.19
1.00
42842
EXTENSIVE SURGERY OF THROAT
24.59
1.00
Procedure Code Description
RVU
RVU Coeff Value
42844
EXTENSIVE SURGERY OF THROAT
7.00
1.00
42844
EXTENSIVE SURGERY OF THROAT
25.57
1.00
42844
EXTENSIVE SURGERY OF THROAT
26.71
1.00
42844
EXTENSIVE SURGERY OF THROAT
34.61
1.00
42845
EXTENSIVE SURGERY OF THROAT
7.00
1.00
42845
EXTENSIVE SURGERY OF THROAT
42.48
1.00
42845
EXTENSIVE SURGERY OF THROAT
43.49
1.00
42845
EXTENSIVE SURGERY OF THROAT
56.59
1.00
42860
EXCISION OF TONSIL TAGS
4.78
1.00
42860
EXCISION OF TONSIL TAGS
4.99
1.00
42860
EXCISION OF TONSIL TAGS
5.00
1.00
42860
EXCISION OF TONSIL TAGS
5.46
1.00
42870
EXCISION OF LINGUAL TONSIL
4.00
1.00
42870
EXCISION OF LINGUAL TONSIL
10.64
1.00
42870
EXCISION OF LINGUAL TONSIL
11.88
1.00
42870
EXCISION OF LINGUAL TONSIL
14.55
1.00
42890
PARTIAL REMOVAL OF PHARYNX
7.00
1.00
42890
PARTIAL REMOVAL OF PHARYNX
23.36
1.00
42890
PARTIAL REMOVAL OF PHARYNX
24.67
1.00
42890
PARTIAL REMOVAL OF PHARYNX
35.15
1.00
42892
REVISION OF PHARYNGEAL WALLS
7.00
1.00
42892
REVISION OF PHARYNGEAL WALLS
28.07
1.00
42892
REVISION OF PHARYNGEAL WALLS
29.31
1.00
42892
REVISION OF PHARYNGEAL WALLS
46.06
1.00
42894
REVISION OF PHARYNGEAL WALLS
7.00
1.00
42894
REVISION OF PHARYNGEAL WALLS
39.90
1.00
42894
REVISION OF PHARYNGEAL WALLS
41.49
1.00
42894
REVISION OF PHARYNGEAL WALLS
59.08
1.00
42900
REPAIR THROAT WOUND
5.00
1.00
42900
REPAIR THROAT WOUND
8.96
1.00
42900
REPAIR THROAT WOUND
9.40
1.00
42900
REPAIR THROAT WOUND
9.41
1.00
42950
RECONSTRUCTION OF THROAT
8.00
1.00
42950
RECONSTRUCTION OF THROAT
15.39
1.00
42950
RECONSTRUCTION OF THROAT
16.20
1.00
Procedure Code Description
RVU
RVU Coeff Value
42950
RECONSTRUCTION OF THROAT
20.16
1.00
42953
REPAIR THROAT, ESOPHAGUS
5.00
1.00
42953
REPAIR THROAT, ESOPHAGUS
17.36
1.00
42953
REPAIR THROAT, ESOPHAGUS
18.68
1.00
42953
REPAIR THROAT, ESOPHAGUS
24.81
1.00
42955
SURGICAL OPENING OF THROAT
5.00
1.00
42955
SURGICAL OPENING OF THROAT
13.72
1.00
42955
SURGICAL OPENING OF THROAT
14.55
1.00
42955
SURGICAL OPENING OF THROAT
19.02
1.00
42960
CONTROL THROAT BLEEDING
4.00
1.00
42960
CONTROL THROAT BLEEDING
4.35
1.00
42960
CONTROL THROAT BLEEDING
4.54
1.00
42960
CONTROL THROAT BLEEDING
4.61
1.00
42961
CONTROL THROAT BLEEDING
10.79
1.00
42961
CONTROL THROAT BLEEDING
10.91
1.00
42961
CONTROL THROAT BLEEDING
11.26
1.00
42962
CONTROL THROAT BLEEDING
5.00
1.00
42962
CONTROL THROAT BLEEDING
13.37
1.00
42962
CONTROL THROAT BLEEDING
13.48
1.00
42962
CONTROL THROAT BLEEDING
13.83
1.00
42970
CONTROL NOSE/THROAT BLEEDING
4.00
1.00
42970
CONTROL NOSE/THROAT BLEEDING
9.48
1.00
42970
CONTROL NOSE/THROAT BLEEDING
9.57
1.00
42970
CONTROL NOSE/THROAT BLEEDING
9.98
1.00
42971
CONTROL NOSE/THROAT BLEEDING
11.71
1.00
42971
CONTROL NOSE/THROAT BLEEDING
11.78
1.00
42971
CONTROL NOSE/THROAT BLEEDING
12.47
1.00
42972
CONTROL NOSE/THROAT BLEEDING
5.00
1.00
42972
CONTROL NOSE/THROAT BLEEDING
13.25
1.00
42972
CONTROL NOSE/THROAT BLEEDING
13.28
1.00
42972
CONTROL NOSE/THROAT BLEEDING
13.31
1.00
43020
INCISION OF ESOPHAGUS
6.00
1.00
43020
INCISION OF ESOPHAGUS
13.69
1.00
43020
INCISION OF ESOPHAGUS
14.62
1.00
43020
INCISION OF ESOPHAGUS
15.25
1.00
Procedure Code Description
RVU
RVU Coeff Value
43030
THROAT MUSCLE SURGERY
6.00
1.00
43030
THROAT MUSCLE SURGERY
13.51
1.00
43030
THROAT MUSCLE SURGERY
14.22
1.00
43030
THROAT MUSCLE SURGERY
15.22
1.00
43045
INCISION OF ESOPHAGUS
15.00
1.00
43045
INCISION OF ESOPHAGUS
33.35
1.00
43045
INCISION OF ESOPHAGUS
33.44
1.00
43045
INCISION OF ESOPHAGUS
34.53
1.00
43100
EXCISION OF ESOPHAGUS LESION
6.00
1.00
43100
EXCISION OF ESOPHAGUS LESION
16.18
1.00
43100
EXCISION OF ESOPHAGUS LESION
16.40
1.00
43100
EXCISION OF ESOPHAGUS LESION
17.18
1.00
43101
EXCISION OF ESOPHAGUS LESION
6.00
1.00
43101
EXCISION OF ESOPHAGUS LESION
26.34
1.00
43101
EXCISION OF ESOPHAGUS LESION
26.67
1.00
43101
EXCISION OF ESOPHAGUS LESION
27.07
1.00
43107
REMOVAL OF ESOPHAGUS
15.00
1.00
43107
REMOVAL OF ESOPHAGUS
61.05
1.00
43107
REMOVAL OF ESOPHAGUS
61.31
1.00
43107
REMOVAL OF ESOPHAGUS
66.75
1.00
43108
REMOVAL OF ESOPHAGUS
15.00
1.00
43108
REMOVAL OF ESOPHAGUS
53.00
1.00
43108
REMOVAL OF ESOPHAGUS
53.82
1.00
43108
REMOVAL OF ESOPHAGUS
110.69
1.00
43112
REMOVAL OF ESOPHAGUS
15.00
1.00
43112
REMOVAL OF ESOPHAGUS
66.10
1.00
43112
REMOVAL OF ESOPHAGUS
66.66
1.00
43112
REMOVAL OF ESOPHAGUS
71.41
1.00
43113
REMOVAL OF ESOPHAGUS
15.00
1.00
43113
REMOVAL OF ESOPHAGUS
55.64
1.00
43113
REMOVAL OF ESOPHAGUS
56.08
1.00
43113
REMOVAL OF ESOPHAGUS
110.77
1.00
43116
PARTIAL REMOVAL OF ESOPHAGUS
15.00
1.00
43116
PARTIAL REMOVAL OF ESOPHAGUS
51.14
1.00
43116
PARTIAL REMOVAL OF ESOPHAGUS
52.66
1.00
Procedure Code Description
RVU
RVU Coeff Value
43116
PARTIAL REMOVAL OF ESOPHAGUS
125.31
1.00
43117
PARTIAL REMOVAL OF ESOPHAGUS
15.00
1.00
43117
PARTIAL REMOVAL OF ESOPHAGUS
60.55
1.00
43117
PARTIAL REMOVAL OF ESOPHAGUS
60.60
1.00
43117
PARTIAL REMOVAL OF ESOPHAGUS
65.27
1.00
43118
PARTIAL REMOVAL OF ESOPHAGUS
15.00
1.00
43118
PARTIAL REMOVAL OF ESOPHAGUS
51.31
1.00
43118
PARTIAL REMOVAL OF ESOPHAGUS
52.16
1.00
43118
PARTIAL REMOVAL OF ESOPHAGUS
91.39
1.00
43121
PARTIAL REMOVAL OF ESOPHAGUS
15.00
1.00
43121
PARTIAL REMOVAL OF ESOPHAGUS
45.99
1.00
43121
PARTIAL REMOVAL OF ESOPHAGUS
46.05
1.00
43121
PARTIAL REMOVAL OF ESOPHAGUS
72.85
1.00
43122
PARTIAL REMOVAL OF ESOPHAGUS
15.00
1.00
43122
PARTIAL REMOVAL OF ESOPHAGUS
60.37
1.00
43122
PARTIAL REMOVAL OF ESOPHAGUS
60.56
1.00
43122
PARTIAL REMOVAL OF ESOPHAGUS
66.06
1.00
43123
PARTIAL REMOVAL OF ESOPHAGUS
15.00
1.00
43123
PARTIAL REMOVAL OF ESOPHAGUS
52.11
1.00
43123
PARTIAL REMOVAL OF ESOPHAGUS
52.98
1.00
43123
PARTIAL REMOVAL OF ESOPHAGUS
111.30
1.00
43124
REMOVAL OF ESOPHAGUS
15.00
1.00
43124
REMOVAL OF ESOPHAGUS
44.00
1.00
43124
REMOVAL OF ESOPHAGUS
45.21
1.00
43124
REMOVAL OF ESOPHAGUS
95.23
1.00
43130
REMOVAL OF ESOPHAGUS POUCH
13.00
1.00
43130
REMOVAL OF ESOPHAGUS POUCH
20.48
1.00
43130
REMOVAL OF ESOPHAGUS POUCH
20.63
1.00
43130
REMOVAL OF ESOPHAGUS POUCH
21.67
1.00
43135
REMOVAL OF ESOPHAGUS POUCH
13.00
1.00
43135
REMOVAL OF ESOPHAGUS POUCH
26.47
1.00
43135
REMOVAL OF ESOPHAGUS POUCH
27.86
1.00
43135
REMOVAL OF ESOPHAGUS POUCH
38.30
1.00
43200
ESOPHAGUS ENDOSCOPY
2.74
1.00
43200
ESOPHAGUS ENDOSCOPY
2.82
1.00
Procedure Code Description
RVU
RVU Coeff Value
43200
ESOPHAGUS ENDOSCOPY
2.88
1.00
43200
ESOPHAGUS ENDOSCOPY
4.00
1.00
43201
ESOPH SCOPE W/SUBMUCOUS INJ
3.44
1.00
43201
ESOPH SCOPE W/SUBMUCOUS INJ
3.48
1.00
43201
ESOPH SCOPE W/SUBMUCOUS INJ
3.50
1.00
43202
ESOPHAGUS ENDOSCOPY, BIOPSY
2.99
1.00
43202
ESOPHAGUS ENDOSCOPY, BIOPSY
3.00
1.00
43202
ESOPHAGUS ENDOSCOPY, BIOPSY
3.04
1.00
43202
ESOPHAGUS ENDOSCOPY, BIOPSY
3.14
1.00
43204
ESOPH SCOPE W/SCLEROSIS INJ
4.00
1.00
43204
ESOPH SCOPE W/SCLEROSIS INJ
5.52
1.00
43204
ESOPH SCOPE W/SCLEROSIS INJ
5.62
1.00
43204
ESOPH SCOPE W/SCLEROSIS INJ
5.99
1.00
43205
ESOPHAGUS ENDOSCOPY/LIGATION
5.00
1.00
43205
ESOPHAGUS ENDOSCOPY/LIGATION
5.54
1.00
43205
ESOPHAGUS ENDOSCOPY/LIGATION
5.64
1.00
43205
ESOPHAGUS ENDOSCOPY/LIGATION
6.00
1.00
43215
ESOPHAGUS ENDOSCOPY
4.00
1.00
43215
ESOPHAGUS ENDOSCOPY
4.03
1.00
43215
ESOPHAGUS ENDOSCOPY
4.11
1.00
43216
ESOPHAGUS ENDOSCOPY/LESION
3.73
1.00
43216
ESOPHAGUS ENDOSCOPY/LESION
3.76
1.00
43216
ESOPHAGUS ENDOSCOPY/LESION
3.83
1.00
43216
ESOPHAGUS ENDOSCOPY/LESION
5.00
1.00
43217
ESOPHAGUS ENDOSCOPY
4.32
1.00
43217
ESOPHAGUS ENDOSCOPY
4.40
1.00
43217
ESOPHAGUS ENDOSCOPY
4.52
1.00
43217
ESOPHAGUS ENDOSCOPY
6.00
1.00
43219
ESOPHAGUS ENDOSCOPY
4.36
1.00
43219
ESOPHAGUS ENDOSCOPY
4.57
1.00
43219
ESOPHAGUS ENDOSCOPY
6.00
1.00
43220
ESOPH ENDOSCOPY, DILATION
3.23
1.00
43220
ESOPH ENDOSCOPY, DILATION
3.32
1.00
43220
ESOPH ENDOSCOPY, DILATION
3.38
1.00
43220
ESOPH ENDOSCOPY, DILATION
4.00
1.00
Procedure Code Description
RVU
RVU Coeff Value
43226
ESOPH ENDOSCOPY, DILATION
3.54
1.00
43226
ESOPH ENDOSCOPY, DILATION
3.63
1.00
43226
ESOPH ENDOSCOPY, DILATION
3.77
1.00
43226
ESOPH ENDOSCOPY, DILATION
6.00
1.00
43227
ESOPH ENDOSCOPY, REPAIR
5.28
1.00
43227
ESOPH ENDOSCOPY, REPAIR
5.38
1.00
43227
ESOPH ENDOSCOPY, REPAIR
5.61
1.00
43227
ESOPH ENDOSCOPY, REPAIR
6.00
1.00
43228
ESOPH ENDOSCOPY, ABLATION
5.64
1.00
43228
ESOPH ENDOSCOPY, ABLATION
5.74
1.00
43228
ESOPH ENDOSCOPY, ABLATION
6.00
1.00
43231
ESOPH ENDOSCOPY W/US EXAM
4.76
1.00
43231
ESOPH ENDOSCOPY W/US EXAM
4.96
1.00
43231
ESOPH ENDOSCOPY W/US EXAM
5.00
1.00
43231
ESOPH ENDOSCOPY W/US EXAM
5.09
1.00
43232
ESOPH ENDOSCOPY W/US FN BX
5.00
1.00
43232
ESOPH ENDOSCOPY W/US FN BX
6.62
1.00
43232
ESOPH ENDOSCOPY W/US FN BX
6.84
1.00
43232
ESOPH ENDOSCOPY W/US FN BX
7.02
1.00
43234
UPPER GI ENDOSCOPY, EXAM
3.07
1.00
43234
UPPER GI ENDOSCOPY, EXAM
3.18
1.00
43234
UPPER GI ENDOSCOPY, EXAM
5.00
1.00
43235
UPPR GI ENDOSCOPY, DIAGNOSIS
3.58
1.00
43235
UPPR GI ENDOSCOPY, DIAGNOSIS
3.62
1.00
43235
UPPR GI ENDOSCOPY, DIAGNOSIS
3.88
1.00
43235
UPPR GI ENDOSCOPY, DIAGNOSIS
5.00
1.00
43236
UPPR GI SCOPE W/SUBMUC INJ
4.32
1.00
43236
UPPR GI SCOPE W/SUBMUC INJ
4.35
1.00
43236
UPPR GI SCOPE W/SUBMUC INJ
4.71
1.00
43237
ENDOSCOPIC US EXAM, ESOPH
5.86
1.00
43237
ENDOSCOPIC US EXAM, ESOPH
6.46
1.00
43238
UPPR GI ENDOSCOPY W/US FN BX
7.26
1.00
43238
UPPR GI ENDOSCOPY W/US FN BX
7.97
1.00
43239
UPPER GI ENDOSCOPY, BIOPSY
4.00
1.00
43239
UPPER GI ENDOSCOPY, BIOPSY
4.24
1.00
Procedure Code Description
RVU
RVU Coeff Value
43239
UPPER GI ENDOSCOPY, BIOPSY
4.27
1.00
43239
UPPER GI ENDOSCOPY, BIOPSY
4.59
1.00
43240
ESOPH ENDOSCOPE W/DRAIN CYST
5.00
1.00
43240
ESOPH ENDOSCOPE W/DRAIN CYST
9.92
1.00
43240
ESOPH ENDOSCOPE W/DRAIN CYST
9.93
1.00
43240
ESOPH ENDOSCOPE W/DRAIN CYST
10.69
1.00
43241
UPPER GI ENDOSCOPY WITH TUBE
3.87
1.00
43241
UPPER GI ENDOSCOPY WITH TUBE
3.90
1.00
43241
UPPER GI ENDOSCOPY WITH TUBE
4.17
1.00
43241
UPPER GI ENDOSCOPY WITH TUBE
5.00
1.00
43242
UPPR GI ENDOSCOPY W/US FN BX
5.00
1.00
43242
UPPR GI ENDOSCOPY W/US FN BX
10.43
1.00
43242
UPPR GI ENDOSCOPY W/US FN BX
11.38
1.00
43243
UPPER GI ENDOSCOPY & INJECT
5.00
1.00
43243
UPPER GI ENDOSCOPY & INJECT
6.64
1.00
43243
UPPER GI ENDOSCOPY & INJECT
6.65
1.00
43243
UPPER GI ENDOSCOPY & INJECT
7.17
1.00
43244
UPPER GI ENDOSCOPY/LIGATION
5.00
1.00
43244
UPPER GI ENDOSCOPY/LIGATION
7.29
1.00
43244
UPPER GI ENDOSCOPY/LIGATION
7.30
1.00
43244
UPPER GI ENDOSCOPY/LIGATION
7.95
1.00
43245
UPPR GI SCOPE DILATE STRICTR
4.70
1.00
43245
UPPR GI SCOPE DILATE STRICTR
4.74
1.00
43245
UPPR GI SCOPE DILATE STRICTR
5.00
1.00
43245
UPPR GI SCOPE DILATE STRICTR
5.02
1.00
43246
PLACE GASTROSTOMY TUBE
5.00
1.00
43246
PLACE GASTROSTOMY TUBE
6.32
1.00
43246
PLACE GASTROSTOMY TUBE
6.35
1.00
43246
PLACE GASTROSTOMY TUBE
6.72
1.00
43247
OPERATIVE UPPER GI ENDOSCOPY
4.98
1.00
43247
OPERATIVE UPPER GI ENDOSCOPY
5.00
1.00
43247
OPERATIVE UPPER GI ENDOSCOPY
5.01
1.00
43247
OPERATIVE UPPER GI ENDOSCOPY
5.37
1.00
43248
UPPR GI ENDOSCOPY/GUIDE WIRE
4.65
1.00
43248
UPPR GI ENDOSCOPY/GUIDE WIRE
4.68
1.00
Procedure Code Description
RVU
RVU Coeff Value
43248
UPPR GI ENDOSCOPY/GUIDE WIRE
5.00
1.00
43248
UPPR GI ENDOSCOPY/GUIDE WIRE
5.07
1.00
43249
ESOPH ENDOSCOPY, DILATION
4.31
1.00
43249
ESOPH ENDOSCOPY, DILATION
4.33
1.00
43249
ESOPH ENDOSCOPY, DILATION
4.67
1.00
43249
ESOPH ENDOSCOPY, DILATION
6.00
1.00
43250
UPPER GI ENDOSCOPY/TUMOR
4.72
1.00
43250
UPPER GI ENDOSCOPY/TUMOR
4.76
1.00
43250
UPPER GI ENDOSCOPY/TUMOR
5.00
1.00
43250
UPPER GI ENDOSCOPY/TUMOR
5.02
1.00
43251
OPERATIVE UPPER GI ENDOSCOPY
5.00
1.00
43251
OPERATIVE UPPER GI ENDOSCOPY
5.42
1.00
43251
OPERATIVE UPPER GI ENDOSCOPY
5.45
1.00
43251
OPERATIVE UPPER GI ENDOSCOPY
5.84
1.00
43255
OPERATIVE UPPER GI ENDOSCOPY
5.00
1.00
43255
OPERATIVE UPPER GI ENDOSCOPY
6.97
1.00
43255
OPERATIVE UPPER GI ENDOSCOPY
7.59
1.00
43256
UPPR GI ENDOSCOPY W/STENT
5.00
1.00
43256
UPPR GI ENDOSCOPY W/STENT
6.35
1.00
43256
UPPR GI ENDOSCOPY W/STENT
6.39
1.00
43256
UPPR GI ENDOSCOPY W/STENT
6.82
1.00
43257
UPPR GI SCOPE W/THRML TXMNT
8.36
1.00
43258
OPERATIVE UPPER GI ENDOSCOPY
5.00
1.00
43258
OPERATIVE UPPER GI ENDOSCOPY
6.62
1.00
43258
OPERATIVE UPPER GI ENDOSCOPY
6.65
1.00
43258
OPERATIVE UPPER GI ENDOSCOPY
7.15
1.00
43259
ENDOSCOPIC ULTRASOUND EXAM
5.00
1.00
43259
ENDOSCOPIC ULTRASOUND EXAM
7.06
1.00
43259
ENDOSCOPIC ULTRASOUND EXAM
7.50
1.00
43259
ENDOSCOPIC ULTRASOUND EXAM
8.14
1.00
43260
ENDO CHOLANGIOPANCREATOGRAPH
4.00
1.00
43260
ENDO CHOLANGIOPANCREATOGRAPH
8.59
1.00
43260
ENDO CHOLANGIOPANCREATOGRAPH
8.67
1.00
43260
ENDO CHOLANGIOPANCREATOGRAPH
9.33
1.00
43261
ENDO CHOLANGIOPANCREATOGRAPH
5.00
1.00
Procedure Code Description
RVU
RVU Coeff Value
43261
ENDO CHOLANGIOPANCREATOGRAPH
9.03
1.00
43261
ENDO CHOLANGIOPANCREATOGRAPH
9.11
1.00
43261
ENDO CHOLANGIOPANCREATOGRAPH
9.81
1.00
43262
ENDO CHOLANGIOPANCREATOGRAPH
5.00
1.00
43262
ENDO CHOLANGIOPANCREATOGRAPH
10.60
1.00
43262
ENDO CHOLANGIOPANCREATOGRAPH
10.69
1.00
43262
ENDO CHOLANGIOPANCREATOGRAPH
11.52
1.00
43263
ENDO CHOLANGIOPANCREATOGRAPH
5.00
1.00
43263
ENDO CHOLANGIOPANCREATOGRAPH
10.40
1.00
43263
ENDO CHOLANGIOPANCREATOGRAPH
10.50
1.00
43263
ENDO CHOLANGIOPANCREATOGRAPH
11.40
1.00
43264
ENDO CHOLANGIOPANCREATOGRAPH
5.00
1.00
43264
ENDO CHOLANGIOPANCREATOGRAPH
12.73
1.00
43264
ENDO CHOLANGIOPANCREATOGRAPH
12.80
1.00
43264
ENDO CHOLANGIOPANCREATOGRAPH
13.83
1.00
43265
ENDO CHOLANGIOPANCREATOGRAPH
14.24
1.00
43265
ENDO CHOLANGIOPANCREATOGRAPH
14.33
1.00
43265
ENDO CHOLANGIOPANCREATOGRAPH
15.52
1.00
43267
ENDO CHOLANGIOPANCREATOGRAPH
5.00
1.00
43267
ENDO CHOLANGIOPANCREATOGRAPH
10.59
1.00
43267
ENDO CHOLANGIOPANCREATOGRAPH
10.69
1.00
43267
ENDO CHOLANGIOPANCREATOGRAPH
11.47
1.00
43268
ENDO CHOLANGIOPANCREATOGRAPH
5.00
1.00
43268
ENDO CHOLANGIOPANCREATOGRAPH
10.69
1.00
43268
ENDO CHOLANGIOPANCREATOGRAPH
11.66
1.00
43269
ENDO CHOLANGIOPANCREATOGRAPH
5.00
1.00
43269
ENDO CHOLANGIOPANCREATOGRAPH
11.64
1.00
43269
ENDO CHOLANGIOPANCREATOGRAPH
11.73
1.00
43269
ENDO CHOLANGIOPANCREATOGRAPH
12.77
1.00
43271
ENDO CHOLANGIOPANCREATOGRAPH
5.00
1.00
43271
ENDO CHOLANGIOPANCREATOGRAPH
10.59
1.00
43271
ENDO CHOLANGIOPANCREATOGRAPH
10.68
1.00
43271
ENDO CHOLANGIOPANCREATOGRAPH
11.51
1.00
43272
ENDO CHOLANGIOPANCREATOGRAPH
5.00
1.00
43272
ENDO CHOLANGIOPANCREATOGRAPH
10.60
1.00
Procedure Code Description
RVU
RVU Coeff Value
43272
ENDO CHOLANGIOPANCREATOGRAPH
10.69
1.00
43272
ENDO CHOLANGIOPANCREATOGRAPH
11.49
1.00
43273
ENDOSCOPIC PANCREATOSCOPY
3.48
1.00
43279
LAP MYOTOMY, HELLER
32.69
1.00
43280
LAPAROSCOPY, FUNDOPLASTY
6.00
1.00
43280
LAPAROSCOPY, FUNDOPLASTY
26.67
1.00
43280
LAPAROSCOPY, FUNDOPLASTY
27.21
1.00
43280
LAPAROSCOPY, FUNDOPLASTY
27.32
1.00
43300
REPAIR OF ESOPHAGUS
13.00
1.00
43300
REPAIR OF ESOPHAGUS
16.14
1.00
43300
REPAIR OF ESOPHAGUS
16.67
1.00
43300
REPAIR OF ESOPHAGUS
17.24
1.00
43305
REPAIR ESOPHAGUS AND FISTULA
19.00
1.00
43305
REPAIR ESOPHAGUS AND FISTULA
28.72
1.00
43305
REPAIR ESOPHAGUS AND FISTULA
29.78
1.00
43305
REPAIR ESOPHAGUS AND FISTULA
31.45
1.00
43310
REPAIR OF ESOPHAGUS
12.00
1.00
43310
REPAIR OF ESOPHAGUS
40.34
1.00
43310
REPAIR OF ESOPHAGUS
40.52
1.00
43310
REPAIR OF ESOPHAGUS
43.23
1.00
43312
REPAIR ESOPHAGUS AND FISTULA
15.00
1.00
43312
REPAIR ESOPHAGUS AND FISTULA
44.46
1.00
43312
REPAIR ESOPHAGUS AND FISTULA
44.74
1.00
43312
REPAIR ESOPHAGUS AND FISTULA
50.00
1.00
43313
ESOPHAGOPLASTY CONGENITAL
15.00
1.00
43313
ESOPHAGOPLASTY CONGENITAL
70.86
1.00
43313
ESOPHAGOPLASTY CONGENITAL
71.91
1.00
43313
ESOPHAGOPLASTY CONGENITAL
72.37
1.00
43314
TRACHEO-ESOPHAGOPLASTY CONG
15.00
1.00
43314
TRACHEO-ESOPHAGOPLASTY CONG
78.91
1.00
43314
TRACHEO-ESOPHAGOPLASTY CONG
79.48
1.00
43314
TRACHEO-ESOPHAGOPLASTY CONG
81.42
1.00
43320
FUSE ESOPHAGUS & STOMACH
13.00
1.00
43320
FUSE ESOPHAGUS & STOMACH
31.09
1.00
43320
FUSE ESOPHAGUS & STOMACH
31.97
1.00
Procedure Code Description 43320
FUSE ESOPHAGUS & STOMACH
43324
RVU
RVU Coeff Value
35.45
1.00
REVISE ESOPHAGUS & STOMACH
7.00
1.00
43324
REVISE ESOPHAGUS & STOMACH
31.43
1.00
43324
REVISE ESOPHAGUS & STOMACH
31.77
1.00
43324
REVISE ESOPHAGUS & STOMACH
34.40
1.00
43325
REVISE ESOPHAGUS & STOMACH
7.00
1.00
43325
REVISE ESOPHAGUS & STOMACH
30.86
1.00
43325
REVISE ESOPHAGUS & STOMACH
31.56
1.00
43325
REVISE ESOPHAGUS & STOMACH
33.82
1.00
43326
REVISE ESOPHAGUS & STOMACH
31.27
1.00
43326
REVISE ESOPHAGUS & STOMACH
32.07
1.00
43326
REVISE ESOPHAGUS & STOMACH
34.56
1.00
43326
REVISE ESOPHAGUS & STOMACH
999.99
1.00
43330
REPAIR OF ESOPHAGUS
13.00
1.00
43330
REPAIR OF ESOPHAGUS
30.16
1.00
43330
REPAIR OF ESOPHAGUS
30.85
1.00
43330
REPAIR OF ESOPHAGUS
33.20
1.00
43331
REPAIR OF ESOPHAGUS
15.00
1.00
43331
REPAIR OF ESOPHAGUS
32.26
1.00
43331
REPAIR OF ESOPHAGUS
33.19
1.00
43331
REPAIR OF ESOPHAGUS
36.05
1.00
43340
FUSE ESOPHAGUS & INTESTINE
13.00
1.00
43340
FUSE ESOPHAGUS & INTESTINE
30.46
1.00
43340
FUSE ESOPHAGUS & INTESTINE
31.75
1.00
43340
FUSE ESOPHAGUS & INTESTINE
34.38
1.00
43341
FUSE ESOPHAGUS & INTESTINE
15.00
1.00
43341
FUSE ESOPHAGUS & INTESTINE
33.46
1.00
43341
FUSE ESOPHAGUS & INTESTINE
35.07
1.00
43341
FUSE ESOPHAGUS & INTESTINE
37.96
1.00
43350
SURGICAL OPENING, ESOPHAGUS
13.00
1.00
43350
SURGICAL OPENING, ESOPHAGUS
25.65
1.00
43350
SURGICAL OPENING, ESOPHAGUS
27.10
1.00
43350
SURGICAL OPENING, ESOPHAGUS
29.12
1.00
43351
SURGICAL OPENING, ESOPHAGUS
15.00
1.00
43351
SURGICAL OPENING, ESOPHAGUS
29.99
1.00
Procedure Code Description
RVU
RVU Coeff Value
43351
SURGICAL OPENING, ESOPHAGUS
30.47
1.00
43351
SURGICAL OPENING, ESOPHAGUS
34.48
1.00
43352
SURGICAL OPENING, ESOPHAGUS
6.00
1.00
43352
SURGICAL OPENING, ESOPHAGUS
25.23
1.00
43352
SURGICAL OPENING, ESOPHAGUS
26.26
1.00
43352
SURGICAL OPENING, ESOPHAGUS
28.22
1.00
43360
GASTROINTESTINAL REPAIR
15.00
1.00
43360
GASTROINTESTINAL REPAIR
54.42
1.00
43360
GASTROINTESTINAL REPAIR
55.24
1.00
43360
GASTROINTESTINAL REPAIR
60.55
1.00
43361
GASTROINTESTINAL REPAIR
15.00
1.00
43361
GASTROINTESTINAL REPAIR
61.67
1.00
43361
GASTROINTESTINAL REPAIR
62.40
1.00
43361
GASTROINTESTINAL REPAIR
67.26
1.00
43400
LIGATE ESOPHAGUS VEINS
12.00
1.00
43400
LIGATE ESOPHAGUS VEINS
31.79
1.00
43400
LIGATE ESOPHAGUS VEINS
32.53
1.00
43400
LIGATE ESOPHAGUS VEINS
41.24
1.00
43401
ESOPHAGUS SURGERY FOR VEINS
15.00
1.00
43401
ESOPHAGUS SURGERY FOR VEINS
33.71
1.00
43401
ESOPHAGUS SURGERY FOR VEINS
34.17
1.00
43401
ESOPHAGUS SURGERY FOR VEINS
39.33
1.00
43405
LIGATE/STAPLE ESOPHAGUS
15.00
1.00
43405
LIGATE/STAPLE ESOPHAGUS
31.15
1.00
43405
LIGATE/STAPLE ESOPHAGUS
31.57
1.00
43405
LIGATE/STAPLE ESOPHAGUS
38.10
1.00
43410
REPAIR ESOPHAGUS WOUND
7.00
1.00
43410
REPAIR ESOPHAGUS WOUND
22.53
1.00
43410
REPAIR ESOPHAGUS WOUND
23.55
1.00
43410
REPAIR ESOPHAGUS WOUND
26.02
1.00
43415
REPAIR ESOPHAGUS WOUND
12.00
1.00
43415
REPAIR ESOPHAGUS WOUND
39.08
1.00
43415
REPAIR ESOPHAGUS WOUND
39.18
1.00
43415
REPAIR ESOPHAGUS WOUND
44.48
1.00
43420
REPAIR ESOPHAGUS OPENING
7.00
1.00
Procedure Code Description
RVU
RVU Coeff Value
43420
REPAIR ESOPHAGUS OPENING
22.85
1.00
43420
REPAIR ESOPHAGUS OPENING
24.13
1.00
43420
REPAIR ESOPHAGUS OPENING
25.93
1.00
43425
REPAIR ESOPHAGUS OPENING
13.00
1.00
43425
REPAIR ESOPHAGUS OPENING
33.48
1.00
43425
REPAIR ESOPHAGUS OPENING
34.28
1.00
43425
REPAIR ESOPHAGUS OPENING
39.07
1.00
43450
DILATE ESOPHAGUS
2.07
1.00
43450
DILATE ESOPHAGUS
2.19
1.00
43450
DILATE ESOPHAGUS
2.37
1.00
43450
DILATE ESOPHAGUS
5.00
1.00
43453
DILATE ESOPHAGUS
2.26
1.00
43453
DILATE ESOPHAGUS
2.39
1.00
43453
DILATE ESOPHAGUS
2.57
1.00
43453
DILATE ESOPHAGUS
6.00
1.00
43456
DILATE ESOPHAGUS
3.00
1.00
43456
DILATE ESOPHAGUS
3.75
1.00
43456
DILATE ESOPHAGUS
3.89
1.00
43456
DILATE ESOPHAGUS
3.97
1.00
43456
DILATE ESOPHAGUS
4.04
1.00
43456
DILATE ESOPHAGUS
4.15
1.00
43458
DILATE ESOPHAGUS
4.46
1.00
43458
DILATE ESOPHAGUS
4.60
1.00
43458
DILATE ESOPHAGUS
4.85
1.00
43458
DILATE ESOPHAGUS
5.00
1.00
43460
PRESSURE TREATMENT ESOPHAGUS
4.00
1.00
43460
PRESSURE TREATMENT ESOPHAGUS
5.51
1.00
43460
PRESSURE TREATMENT ESOPHAGUS
5.53
1.00
43460
PRESSURE TREATMENT ESOPHAGUS
5.89
1.00
43496
FREE JEJUNUM FLAP, MICROVASC
5.00
1.00
43500
SURGICAL OPENING OF STOMACH
7.00
1.00
43500
SURGICAL OPENING OF STOMACH
16.97
1.00
43500
SURGICAL OPENING OF STOMACH
17.04
1.00
43500
SURGICAL OPENING OF STOMACH
19.48
1.00
43501
SURGICAL REPAIR OF STOMACH
7.00
1.00
Procedure Code Description
RVU
RVU Coeff Value
43501
SURGICAL REPAIR OF STOMACH
30.19
1.00
43501
SURGICAL REPAIR OF STOMACH
30.24
1.00
43501
SURGICAL REPAIR OF STOMACH
33.54
1.00
43502
SURGICAL REPAIR OF STOMACH
15.00
1.00
43502
SURGICAL REPAIR OF STOMACH
34.73
1.00
43502
SURGICAL REPAIR OF STOMACH
34.82
1.00
43502
SURGICAL REPAIR OF STOMACH
38.01
1.00
43510
SURGICAL OPENING OF STOMACH
7.00
1.00
43510
SURGICAL OPENING OF STOMACH
20.74
1.00
43510
SURGICAL OPENING OF STOMACH
21.51
1.00
43510
SURGICAL OPENING OF STOMACH
24.00
1.00
43520
INCISION OF PYLORIC MUSCLE
7.00
1.00
43520
INCISION OF PYLORIC MUSCLE
16.29
1.00
43520
INCISION OF PYLORIC MUSCLE
16.64
1.00
43520
INCISION OF PYLORIC MUSCLE
17.65
1.00
43600
BIOPSY OF STOMACH
2.85
1.00
43600
BIOPSY OF STOMACH
3.04
1.00
43600
BIOPSY OF STOMACH
3.07
1.00
43600
BIOPSY OF STOMACH
5.00
1.00
43605
BIOPSY OF STOMACH
6.00
1.00
43605
BIOPSY OF STOMACH
18.30
1.00
43605
BIOPSY OF STOMACH
18.40
1.00
43605
BIOPSY OF STOMACH
20.69
1.00
43610
EXCISION OF STOMACH LESION
6.00
1.00
43610
EXCISION OF STOMACH LESION
22.15
1.00
43610
EXCISION OF STOMACH LESION
22.43
1.00
43610
EXCISION OF STOMACH LESION
24.46
1.00
43611
EXCISION OF STOMACH LESION
7.00
1.00
43611
EXCISION OF STOMACH LESION
27.08
1.00
43611
EXCISION OF STOMACH LESION
27.15
1.00
43611
EXCISION OF STOMACH LESION
30.42
1.00
43620
REMOVAL OF STOMACH
7.00
1.00
43620
REMOVAL OF STOMACH
44.62
1.00
43620
REMOVAL OF STOMACH
45.02
1.00
43620
REMOVAL OF STOMACH
49.59
1.00
Procedure Code Description
RVU
RVU Coeff Value
43621
REMOVAL OF STOMACH
7.00
1.00
43621
REMOVAL OF STOMACH
45.59
1.00
43621
REMOVAL OF STOMACH
45.97
1.00
43621
REMOVAL OF STOMACH
56.28
1.00
43622
REMOVAL OF STOMACH
7.00
1.00
43622
REMOVAL OF STOMACH
48.13
1.00
43622
REMOVAL OF STOMACH
48.49
1.00
43622
REMOVAL OF STOMACH
57.18
1.00
43631
REMOVAL OF STOMACH, PARTIAL
7.00
1.00
43631
REMOVAL OF STOMACH, PARTIAL
34.03
1.00
43631
REMOVAL OF STOMACH, PARTIAL
34.17
1.00
43631
REMOVAL OF STOMACH, PARTIAL
36.41
1.00
43632
REMOVAL OF STOMACH, PARTIAL
7.00
1.00
43632
REMOVAL OF STOMACH, PARTIAL
34.05
1.00
43632
REMOVAL OF STOMACH, PARTIAL
34.18
1.00
43632
REMOVAL OF STOMACH, PARTIAL
49.19
1.00
43633
REMOVAL OF STOMACH, PARTIAL
7.00
1.00
43633
REMOVAL OF STOMACH, PARTIAL
34.79
1.00
43633
REMOVAL OF STOMACH, PARTIAL
34.91
1.00
43633
REMOVAL OF STOMACH, PARTIAL
46.89
1.00
43634
REMOVAL OF STOMACH, PARTIAL
7.00
1.00
43634
REMOVAL OF STOMACH, PARTIAL
37.71
1.00
43634
REMOVAL OF STOMACH, PARTIAL
37.85
1.00
43634
REMOVAL OF STOMACH, PARTIAL
51.77
1.00
43635
REMOVAL OF STOMACH, PARTIAL
2.92
1.00
43635
REMOVAL OF STOMACH, PARTIAL
2.99
1.00
43635
REMOVAL OF STOMACH, PARTIAL
3.01
1.00
43635
REMOVAL OF STOMACH, PARTIAL
999.99
1.00
43638
REMOVAL OF STOMACH, PARTIAL
7.00
1.00
43638
REMOVAL OF STOMACH, PARTIAL
43.01
1.00
43638
REMOVAL OF STOMACH, PARTIAL
43.60
1.00
43638
REMOVAL OF STOMACH, PARTIAL
44.59
1.00
43639
REMOVAL OF STOMACH, PARTIAL
7.00
1.00
43639
REMOVAL OF STOMACH, PARTIAL
43.97
1.00
43639
REMOVAL OF STOMACH, PARTIAL
44.14
1.00
Procedure Code Description 43639
REMOVAL OF STOMACH, PARTIAL
43640
RVU
RVU Coeff Value
45.14
1.00
VAGOTOMY & PYLORUS REPAIR
7.00
1.00
43640
VAGOTOMY & PYLORUS REPAIR
26.05
1.00
43640
VAGOTOMY & PYLORUS REPAIR
26.11
1.00
43640
VAGOTOMY & PYLORUS REPAIR
29.23
1.00
43641
VAGOTOMY & PYLORUS REPAIR
7.00
1.00
43641
VAGOTOMY & PYLORUS REPAIR
26.43
1.00
43641
VAGOTOMY & PYLORUS REPAIR
26.50
1.00
43641
VAGOTOMY & PYLORUS REPAIR
29.47
1.00
43644
LAP GASTRIC BYPASS/ROUX-EN-Y
43.19
1.00
43645
LAP GASTR BYPASS INCL SMLL I
46.26
1.00
43651
LAPAROSCOPY, VAGUS NERVE
6.00
1.00
43651
LAPAROSCOPY, VAGUS NERVE
15.77
1.00
43651
LAPAROSCOPY, VAGUS NERVE
16.17
1.00
43651
LAPAROSCOPY, VAGUS NERVE
16.28
1.00
43652
LAPAROSCOPY, VAGUS NERVE
6.00
1.00
43652
LAPAROSCOPY, VAGUS NERVE
18.77
1.00
43652
LAPAROSCOPY, VAGUS NERVE
19.04
1.00
43652
LAPAROSCOPY, VAGUS NERVE
19.05
1.00
43653
LAPAROSCOPY, GASTROSTOMY
6.00
1.00
43653
LAPAROSCOPY, GASTROSTOMY
12.74
1.00
43653
LAPAROSCOPY, GASTROSTOMY
12.88
1.00
43653
LAPAROSCOPY, GASTROSTOMY
13.86
1.00
43750
PLACE GASTROSTOMY TUBE
3.00
1.00
43750
PLACE GASTROSTOMY TUBE
7.17
1.00
43750
PLACE GASTROSTOMY TUBE
7.44
1.00
43750
PLACE GASTROSTOMY TUBE
7.60
1.00
43752
NASAL/OROGASTRIC W/STENT
0.96
1.00
43752
NASAL/OROGASTRIC W/STENT
1.11
1.00
43752
NASAL/OROGASTRIC W/STENT
3.00
1.00
43760
CHANGE GASTROSTOMY TUBE
1.36
1.00
43760
CHANGE GASTROSTOMY TUBE
1.38
1.00
43760
CHANGE GASTROSTOMY TUBE
1.63
1.00
43760
CHANGE GASTROSTOMY TUBE
3.00
1.00
43761
REPOSITION GASTROSTOMY TUBE
2.89
1.00
Procedure Code Description
RVU
RVU Coeff Value
43761
REPOSITION GASTROSTOMY TUBE
2.91
1.00
43761
REPOSITION GASTROSTOMY TUBE
2.92
1.00
43770
LAP PLACE GASTR ADJ DEVICE
27.76
1.00
43771
LAP REVISE GASTR ADJ DEVICE
31.67
1.00
43772
LAP RMVL GASTR ADJ DEVICE
23.95
1.00
43773
LAP REPLACE GASTR ADJ DEVICE
31.70
1.00
43774
LAP RMVL GASTR ADJ ALL PARTS
23.95
1.00
43800
RECONSTRUCTION OF PYLORUS
7.00
1.00
43800
RECONSTRUCTION OF PYLORUS
20.90
1.00
43800
RECONSTRUCTION OF PYLORUS
21.20
1.00
43800
RECONSTRUCTION OF PYLORUS
23.21
1.00
43810
FUSION OF STOMACH AND BOWEL
7.00
1.00
43810
FUSION OF STOMACH AND BOWEL
22.19
1.00
43810
FUSION OF STOMACH AND BOWEL
22.49
1.00
43810
FUSION OF STOMACH AND BOWEL
25.14
1.00
43820
FUSION OF STOMACH AND BOWEL
7.00
1.00
43820
FUSION OF STOMACH AND BOWEL
23.22
1.00
43820
FUSION OF STOMACH AND BOWEL
23.51
1.00
43820
FUSION OF STOMACH AND BOWEL
32.39
1.00
43825
FUSION OF STOMACH AND BOWEL
6.00
1.00
43825
FUSION OF STOMACH AND BOWEL
29.02
1.00
43825
FUSION OF STOMACH AND BOWEL
29.06
1.00
43825
FUSION OF STOMACH AND BOWEL
32.36
1.00
43830
PLACE GASTROSTOMY TUBE
6.00
1.00
43830
PLACE GASTROSTOMY TUBE
15.13
1.00
43830
PLACE GASTROSTOMY TUBE
15.23
1.00
43830
PLACE GASTROSTOMY TUBE
17.21
1.00
43831
PLACE GASTROSTOMY TUBE
7.00
1.00
43831
PLACE GASTROSTOMY TUBE
12.93
1.00
43831
PLACE GASTROSTOMY TUBE
13.35
1.00
43831
PLACE GASTROSTOMY TUBE
14.40
1.00
43832
PLACE GASTROSTOMY TUBE
6.00
1.00
43832
PLACE GASTROSTOMY TUBE
23.84
1.00
43832
PLACE GASTROSTOMY TUBE
24.19
1.00
43832
PLACE GASTROSTOMY TUBE
26.49
1.00
Procedure Code Description
RVU
RVU Coeff Value
43840
REPAIR OF STOMACH LESION
7.00
1.00
43840
REPAIR OF STOMACH LESION
23.78
1.00
43840
REPAIR OF STOMACH LESION
23.80
1.00
43840
REPAIR OF STOMACH LESION
32.85
1.00
43842
V-BAND GASTROPLASTY
7.00
1.00
43842
V-BAND GASTROPLASTY
28.41
1.00
43842
V-BAND GASTROPLASTY
31.19
1.00
43842
V-BAND GASTROPLASTY
32.16
1.00
43843
GASTROPLASTY W/O V-BAND
7.00
1.00
43843
GASTROPLASTY W/O V-BAND
28.59
1.00
43843
GASTROPLASTY W/O V-BAND
30.99
1.00
43843
GASTROPLASTY W/O V-BAND
31.54
1.00
43845
GASTRIC RESTRICTIVE PROCEDURE
48.90
1.00
43846
GASTRIC BYPASS FOR OBESITY
7.00
1.00
43846
GASTRIC BYPASS FOR OBESITY
36.74
1.00
43846
GASTRIC BYPASS FOR OBESITY
39.24
1.00
43846
GASTRIC BYPASS FOR OBESITY
40.68
1.00
43847
GASTRIC BYPASS INCL SMALL I
7.00
1.00
43847
GASTRIC BYPASS INCL SMALL I
40.78
1.00
43847
GASTRIC BYPASS INCL SMALL I
43.92
1.00
43847
GASTRIC BYPASS INCL SMALL I
44.46
1.00
43848
REVISION GASTROPLASTY
7.00
1.00
43848
REVISION GASTROPLASTY
44.48
1.00
43848
REVISION GASTROPLASTY
47.69
1.00
43848
REVISION GASTROPLASTY
48.26
1.00
43850
REVISE STOMACH-BOWEL FUSION
6.00
1.00
43850
REVISE STOMACH-BOWEL FUSION
36.83
1.00
43850
REVISE STOMACH-BOWEL FUSION
36.93
1.00
43850
REVISE STOMACH-BOWEL FUSION
40.42
1.00
43855
REVISE STOMACH-BOWEL FUSION
6.00
1.00
43855
REVISE STOMACH-BOWEL FUSION
38.90
1.00
43855
REVISE STOMACH-BOWEL FUSION
38.92
1.00
43855
REVISE STOMACH-BOWEL FUSION
42.26
1.00
43860
REVISE STOMACH-BOWEL FUSION
6.00
1.00
43860
REVISE STOMACH-BOWEL FUSION
37.33
1.00
Procedure Code Description
RVU
RVU Coeff Value
43860
REVISE STOMACH-BOWEL FUSION
37.44
1.00
43860
REVISE STOMACH-BOWEL FUSION
41.04
1.00
43865
REVISE STOMACH-BOWEL FUSION
6.00
1.00
43865
REVISE STOMACH-BOWEL FUSION
39.52
1.00
43865
REVISE STOMACH-BOWEL FUSION
39.63
1.00
43865
REVISE STOMACH-BOWEL FUSION
42.71
1.00
43870
REPAIR STOMACH OPENING
6.00
1.00
43870
REPAIR STOMACH OPENING
15.09
1.00
43870
REPAIR STOMACH OPENING
15.45
1.00
43870
REPAIR STOMACH OPENING
17.55
1.00
43880
REPAIR STOMACH-BOWEL FISTULA
7.00
1.00
43880
REPAIR STOMACH-BOWEL FISTULA
36.92
1.00
43880
REPAIR STOMACH-BOWEL FISTULA
37.26
1.00
43880
REPAIR STOMACH-BOWEL FISTULA
40.11
1.00
43886
REVISE GASTRIC PORT, OPEN
8.19
1.00
43887
REMOVE GASTRIC PORT, OPEN
7.78
1.00
43888
CHANGE GASTRIC PORT, OPEN
10.93
1.00
44005
FREEING OF BOWEL ADHESION
6.00
1.00
44005
FREEING OF BOWEL ADHESION
24.66
1.00
44005
FREEING OF BOWEL ADHESION
24.82
1.00
44005
FREEING OF BOWEL ADHESION
27.38
1.00
44010
INCISION OF SMALL BOWEL
7.00
1.00
44010
INCISION OF SMALL BOWEL
19.27
1.00
44010
INCISION OF SMALL BOWEL
19.89
1.00
44010
INCISION OF SMALL BOWEL
21.52
1.00
44015
INSERT NEEDLE CATH BOWEL
3.00
1.00
44015
INSERT NEEDLE CATH BOWEL
3.75
1.00
44015
INSERT NEEDLE CATH BOWEL
3.78
1.00
44015
INSERT NEEDLE CATH BOWEL
3.81
1.00
44020
EXPLORE SMALL INTESTINE
6.00
1.00
44020
EXPLORE SMALL INTESTINE
21.40
1.00
44020
EXPLORE SMALL INTESTINE
21.59
1.00
44020
EXPLORE SMALL INTESTINE
24.19
1.00
44021
DECOMPRESS SMALL BOWEL
6.00
1.00
44021
DECOMPRESS SMALL BOWEL
21.50
1.00
Procedure Code Description
RVU
RVU Coeff Value
44021
DECOMPRESS SMALL BOWEL
22.10
1.00
44021
DECOMPRESS SMALL BOWEL
24.47
1.00
44025
INCISION OF LARGE BOWEL
5.00
1.00
44025
INCISION OF LARGE BOWEL
21.79
1.00
44025
INCISION OF LARGE BOWEL
21.98
1.00
44025
INCISION OF LARGE BOWEL
24.63
1.00
44050
REDUCE BOWEL OBSTRUCTION
5.00
1.00
44050
REDUCE BOWEL OBSTRUCTION
21.40
1.00
44050
REDUCE BOWEL OBSTRUCTION
21.60
1.00
44050
REDUCE BOWEL OBSTRUCTION
23.34
1.00
44055
CORRECT MALROTATION OF BOWEL
6.00
1.00
44055
CORRECT MALROTATION OF BOWEL
32.34
1.00
44055
CORRECT MALROTATION OF BOWEL
32.52
1.00
44055
CORRECT MALROTATION OF BOWEL
37.34
1.00
44100
BIOPSY OF BOWEL
3.08
1.00
44100
BIOPSY OF BOWEL
3.19
1.00
44100
BIOPSY OF BOWEL
3.25
1.00
44100
BIOPSY OF BOWEL
4.00
1.00
44110
EXCISE INTESTINE LESION(S)
6.00
1.00
44110
EXCISE INTESTINE LESION(S)
18.27
1.00
44110
EXCISE INTESTINE LESION(S)
18.50
1.00
44110
EXCISE INTESTINE LESION(S)
21.08
1.00
44111
EXCISION OF BOWEL LESION(S)
6.00
1.00
44111
EXCISION OF BOWEL LESION(S)
21.91
1.00
44111
EXCISION OF BOWEL LESION(S)
22.56
1.00
44111
EXCISION OF BOWEL LESION(S)
24.56
1.00
44120
REMOVAL OF SMALL INTESTINE
6.00
1.00
44120
REMOVAL OF SMALL INTESTINE
25.85
1.00
44120
REMOVAL OF SMALL INTESTINE
25.91
1.00
44120
REMOVAL OF SMALL INTESTINE
30.39
1.00
44121
REMOVAL OF SMALL INTESTINE
6.30
1.00
44121
REMOVAL OF SMALL INTESTINE
6.47
1.00
44121
REMOVAL OF SMALL INTESTINE
6.52
1.00
44125
REMOVAL OF SMALL INTESTINE
6.00
1.00
44125
REMOVAL OF SMALL INTESTINE
26.62
1.00
Procedure Code Description
RVU
RVU Coeff Value
44125
REMOVAL OF SMALL INTESTINE
26.67
1.00
44125
REMOVAL OF SMALL INTESTINE
29.54
1.00
44126
ENTERECTOMY W/O TAPER, CONG
6.00
1.00
44126
ENTERECTOMY W/O TAPER, CONG
50.04
1.00
44126
ENTERECTOMY W/O TAPER, CONG
53.65
1.00
44126
ENTERECTOMY W/O TAPER, CONG
60.98
1.00
44127
ENTERECTOMY W/TAPER, CONG
6.00
1.00
44127
ENTERECTOMY W/TAPER, CONG
57.22
1.00
44127
ENTERECTOMY W/TAPER, CONG
61.69
1.00
44127
ENTERECTOMY W/TAPER, CONG
71.10
1.00
44128
ENTERECTOMY CONG, ADD-ON
6.34
1.00
44128
ENTERECTOMY CONG, ADD-ON
6.52
1.00
44128
ENTERECTOMY CONG, ADD-ON
6.63
1.00
44130
BOWEL TO BOWEL FUSION
6.00
1.00
44130
BOWEL TO BOWEL FUSION
22.21
1.00
44130
BOWEL TO BOWEL FUSION
22.29
1.00
44130
BOWEL TO BOWEL FUSION
31.66
1.00
44133
ENTERECTOMY, LIVE DONOR
6.00
1.00
44136
INTESTINE TRANSPLANT, LIVE
6.00
1.00
44139
MOBILIZATION OF COLON
3.15
1.00
44139
MOBILIZATION OF COLON
3.22
1.00
44139
MOBILIZATION OF COLON
3.24
1.00
44140
PARTIAL REMOVAL OF COLON
6.00
1.00
44140
PARTIAL REMOVAL OF COLON
32.00
1.00
44140
PARTIAL REMOVAL OF COLON
32.24
1.00
44140
PARTIAL REMOVAL OF COLON
33.67
1.00
44141
PARTIAL REMOVAL OF COLON
6.00
1.00
44141
PARTIAL REMOVAL OF COLON
31.66
1.00
44141
PARTIAL REMOVAL OF COLON
31.98
1.00
44141
PARTIAL REMOVAL OF COLON
44.00
1.00
44143
PARTIAL REMOVAL OF COLON
6.00
1.00
44143
PARTIAL REMOVAL OF COLON
35.90
1.00
44143
PARTIAL REMOVAL OF COLON
36.20
1.00
44143
PARTIAL REMOVAL OF COLON
41.40
1.00
44144
PARTIAL REMOVAL OF COLON
6.00
1.00
Procedure Code Description
RVU
RVU Coeff Value
44144
PARTIAL REMOVAL OF COLON
33.12
1.00
44144
PARTIAL REMOVAL OF COLON
33.47
1.00
44144
PARTIAL REMOVAL OF COLON
43.35
1.00
44145
PARTIAL REMOVAL OF COLON
6.00
1.00
44145
PARTIAL REMOVAL OF COLON
39.68
1.00
44145
PARTIAL REMOVAL OF COLON
39.93
1.00
44145
PARTIAL REMOVAL OF COLON
41.92
1.00
44146
PARTIAL REMOVAL OF COLON
6.00
1.00
44146
PARTIAL REMOVAL OF COLON
42.86
1.00
44146
PARTIAL REMOVAL OF COLON
43.13
1.00
44146
PARTIAL REMOVAL OF COLON
52.20
1.00
44147
PARTIAL REMOVAL OF COLON
6.00
1.00
44147
PARTIAL REMOVAL OF COLON
31.30
1.00
44147
PARTIAL REMOVAL OF COLON
31.52
1.00
44147
PARTIAL REMOVAL OF COLON
46.83
1.00
44150
REMOVAL OF COLON
6.00
1.00
44150
REMOVAL OF COLON
38.20
1.00
44150
REMOVAL OF COLON
38.54
1.00
44150
REMOVAL OF COLON
45.81
1.00
44151
REMOVAL OF COLON/ILEOSTOMY
7.00
1.00
44151
REMOVAL OF COLON/ILEOSTOMY
42.40
1.00
44151
REMOVAL OF COLON/ILEOSTOMY
42.76
1.00
44151
REMOVAL OF COLON/ILEOSTOMY
52.37
1.00
44152
REMOVAL OF COLON/ILEOSTOMY
7.00
1.00
44152
REMOVAL OF COLON/ILEOSTOMY
42.13
1.00
44152
REMOVAL OF COLON/ILEOSTOMY
42.32
1.00
44152
REMOVAL OF COLON/ILEOSTOMY
42.92
1.00
44153
REMOVAL OF COLON/ILEOSTOMY
7.00
1.00
44153
REMOVAL OF COLON/ILEOSTOMY
47.66
1.00
44153
REMOVAL OF COLON/ILEOSTOMY
47.91
1.00
44153
REMOVAL OF COLON/ILEOSTOMY
48.49
1.00
44155
REMOVAL OF COLON/ILEOSTOMY
6.00
1.00
44155
REMOVAL OF COLON/ILEOSTOMY
43.68
1.00
44155
REMOVAL OF COLON/ILEOSTOMY
43.99
1.00
44155
REMOVAL OF COLON/ILEOSTOMY
51.26
1.00
Procedure Code Description
RVU
RVU Coeff Value
44156
REMOVAL OF COLON/ILEOSTOMY
7.00
1.00
44156
REMOVAL OF COLON/ILEOSTOMY
48.17
1.00
44156
REMOVAL OF COLON/ILEOSTOMY
48.58
1.00
44156
REMOVAL OF COLON/ILEOSTOMY
56.46
1.00
44157
COLECTOMY W/ILEOANAL ANAST
53.68
1.00
44158
COLECTOMY W/NEO-RECTUM POUCH
55.03
1.00
44160
REMOVAL OF COLON
6.00
1.00
44160
REMOVAL OF COLON
28.41
1.00
44160
REMOVAL OF COLON
28.63
1.00
44160
REMOVAL OF COLON
30.98
1.00
44180
LAP, ENTEROLYSIS
23.14
1.00
44186
LAP, JEJUNOSTOMY
16.32
1.00
44187
LAP, ILEO/JEJUNO-STOMY
27.45
1.00
44188
LAP, COLOSTOMY
30.39
1.00
44200
LAPAROSCOPY, ENTEROLYSIS
6.00
1.00
44200
LAPAROSCOPY, ENTEROLYSIS
22.28
1.00
44200
LAPAROSCOPY, ENTEROLYSIS
22.41
1.00
44200
LAPAROSCOPY, ENTEROLYSIS
22.46
1.00
44201
LAPAROSCOPY, JEJUNOSTOMY
6.00
1.00
44201
LAPAROSCOPY, JEJUNOSTOMY
15.38
1.00
44201
LAPAROSCOPY, JEJUNOSTOMY
15.64
1.00
44201
LAPAROSCOPY, JEJUNOSTOMY
15.70
1.00
44202
LAP, ENTERECTOMY
6.00
1.00
44202
LAP, ENTERECTOMY
33.34
1.00
44202
LAP, ENTERECTOMY
33.60
1.00
44202
LAP, ENTERECTOMY
34.86
1.00
44203
LAP RESECT S/INTESTINE, ADDL
6.27
1.00
44203
LAP RESECT S/INTESTINE, ADDL
6.47
1.00
44203
LAP RESECT S/INTESTINE, ADDL
6.49
1.00
44204
LAPARO PARTIAL COLECTOMY
6.00
1.00
44204
LAPARO PARTIAL COLECTOMY
37.84
1.00
44204
LAPARO PARTIAL COLECTOMY
38.12
1.00
44204
LAPARO PARTIAL COLECTOMY
38.89
1.00
44205
LAP COLECTOMY PART W/ILEUM
6.00
1.00
44205
LAP COLECTOMY PART W/ILEUM
33.53
1.00
Procedure Code Description
RVU
RVU Coeff Value
44205
LAP COLECTOMY PART W/ILEUM
33.77
1.00
44205
LAP COLECTOMY PART W/ILEUM
33.97
1.00
44206
LAP PART COLECTOMY W/STOMA
40.24
1.00
44206
LAP PART COLECTOMY W/STOMA
40.77
1.00
44206
LAP PART COLECTOMY W/STOMA
44.11
1.00
44207
L COLECTOMY/COLOPROCTOSTOMY
44.04
1.00
44207
L COLECTOMY/COLOPROCTOSTOMY
44.23
1.00
44207
L COLECTOMY/COLOPROCTOSTOMY
46.33
1.00
44208
L COLECTOMY/COLOPROCTOSTOMY
47.62
1.00
44208
L COLECTOMY/COLOPROCTOSTOMY
47.87
1.00
44208
L COLECTOMY/COLOPROCTOSTOMY
50.36
1.00
44210
LAPARO TOTAL PROCTOCOLECTOMY
42.16
1.00
44210
LAPARO TOTAL PROCTOCOLECTOMY
42.46
1.00
44210
LAPARO TOTAL PROCTOCOLECTOMY
45.01
1.00
44211
LAP COLECTOMY W/PROCTECTOMY
52.35
1.00
44211
LAP COLECTOMY W/PROCTECTOMY
52.50
1.00
44211
LAP COLECTOMY W/PROCTECTOMY
55.24
1.00
44212
LAPARO TOTAL PROCTOCOLECTOMY
48.92
1.00
44212
LAPARO TOTAL PROCTOCOLECTOMY
49.06
1.00
44212
LAPARO TOTAL PROCTOCOLECTOMY
51.78
1.00
44213
LAP, MOBIL SPLENIC FL ADD-ON
4.94
1.00
44227
LAP, CLOSE ENTEROSTOMY
42.11
1.00
44300
OPEN BOWEL TO SKIN
6.00
1.00
44300
OPEN BOWEL TO SKIN
18.62
1.00
44300
OPEN BOWEL TO SKIN
18.68
1.00
44300
OPEN BOWEL TO SKIN
20.95
1.00
44310
ILEOSTOMY/JEJUNOSTOMY
6.00
1.00
44310
ILEOSTOMY/JEJUNOSTOMY
23.96
1.00
44310
ILEOSTOMY/JEJUNOSTOMY
24.02
1.00
44310
ILEOSTOMY/JEJUNOSTOMY
26.18
1.00
44312
REVISION OF ILEOSTOMY
5.00
1.00
44312
REVISION OF ILEOSTOMY
12.65
1.00
44312
REVISION OF ILEOSTOMY
12.69
1.00
44312
REVISION OF ILEOSTOMY
14.84
1.00
44314
REVISION OF ILEOSTOMY
6.00
1.00
Procedure Code Description
RVU
RVU Coeff Value
44314
REVISION OF ILEOSTOMY
22.75
1.00
44314
REVISION OF ILEOSTOMY
22.82
1.00
44314
REVISION OF ILEOSTOMY
25.30
1.00
44316
DEVISE BOWEL POUCH
6.00
1.00
44316
DEVISE BOWEL POUCH
31.21
1.00
44316
DEVISE BOWEL POUCH
31.36
1.00
44316
DEVISE BOWEL POUCH
34.61
1.00
44320
COLOSTOMY
5.00
1.00
44320
COLOSTOMY
26.75
1.00
44320
COLOSTOMY
26.86
1.00
44320
COLOSTOMY
29.86
1.00
44322
COLOSTOMY WITH BIOPSIES
6.00
1.00
44322
COLOSTOMY WITH BIOPSIES
21.91
1.00
44322
COLOSTOMY WITH BIOPSIES
22.08
1.00
44322
COLOSTOMY WITH BIOPSIES
23.72
1.00
44340
REVISION OF COLOSTOMY
5.00
1.00
44340
REVISION OF COLOSTOMY
12.63
1.00
44340
REVISION OF COLOSTOMY
12.70
1.00
44340
REVISION OF COLOSTOMY
14.96
1.00
44345
REVISION OF COLOSTOMY
6.00
1.00
44345
REVISION OF COLOSTOMY
23.57
1.00
44345
REVISION OF COLOSTOMY
23.68
1.00
44345
REVISION OF COLOSTOMY
26.14
1.00
44346
REVISION OF COLOSTOMY
6.00
1.00
44346
REVISION OF COLOSTOMY
25.73
1.00
44346
REVISION OF COLOSTOMY
25.84
1.00
44346
REVISION OF COLOSTOMY
29.31
1.00
44360
SMALL BOWEL ENDOSCOPY
3.88
1.00
44360
SMALL BOWEL ENDOSCOPY
4.09
1.00
44360
SMALL BOWEL ENDOSCOPY
4.22
1.00
44360
SMALL BOWEL ENDOSCOPY
6.00
1.00
44361
SMALL BOWEL ENDOSCOPY/BIOPSY
4.26
1.00
44361
SMALL BOWEL ENDOSCOPY/BIOPSY
4.47
1.00
44361
SMALL BOWEL ENDOSCOPY/BIOPSY
4.65
1.00
44361
SMALL BOWEL ENDOSCOPY/BIOPSY
6.00
1.00
Procedure Code Description
RVU
RVU Coeff Value
44363
SMALL BOWEL ENDOSCOPY
5.12
1.00
44363
SMALL BOWEL ENDOSCOPY
5.33
1.00
44363
SMALL BOWEL ENDOSCOPY
5.51
1.00
44363
SMALL BOWEL ENDOSCOPY
6.00
1.00
44364
SMALL BOWEL ENDOSCOPY
5.50
1.00
44364
SMALL BOWEL ENDOSCOPY
5.71
1.00
44364
SMALL BOWEL ENDOSCOPY
5.93
1.00
44364
SMALL BOWEL ENDOSCOPY
6.00
1.00
44365
SMALL BOWEL ENDOSCOPY
4.91
1.00
44365
SMALL BOWEL ENDOSCOPY
5.12
1.00
44365
SMALL BOWEL ENDOSCOPY
5.28
1.00
44365
SMALL BOWEL ENDOSCOPY
6.00
1.00
44366
SMALL BOWEL ENDOSCOPY
6.00
1.00
44366
SMALL BOWEL ENDOSCOPY
6.43
1.00
44366
SMALL BOWEL ENDOSCOPY
6.64
1.00
44366
SMALL BOWEL ENDOSCOPY
6.99
1.00
44369
SMALL BOWEL ENDOSCOPY
6.00
1.00
44369
SMALL BOWEL ENDOSCOPY
6.55
1.00
44369
SMALL BOWEL ENDOSCOPY
6.76
1.00
44369
SMALL BOWEL ENDOSCOPY
7.14
1.00
44370
SMALL BOWEL ENDOSCOPY/STENT
5.00
1.00
44370
SMALL BOWEL ENDOSCOPY/STENT
7.03
1.00
44370
SMALL BOWEL ENDOSCOPY/STENT
7.16
1.00
44370
SMALL BOWEL ENDOSCOPY/STENT
7.70
1.00
44372
SMALL BOWEL ENDOSCOPY
6.48
1.00
44372
SMALL BOWEL ENDOSCOPY
6.68
1.00
44372
SMALL BOWEL ENDOSCOPY
6.81
1.00
44373
SMALL BOWEL ENDOSCOPY
5.17
1.00
44373
SMALL BOWEL ENDOSCOPY
5.41
1.00
44373
SMALL BOWEL ENDOSCOPY
5.51
1.00
44376
SMALL BOWEL ENDOSCOPY
6.00
1.00
44376
SMALL BOWEL ENDOSCOPY
7.64
1.00
44376
SMALL BOWEL ENDOSCOPY
7.85
1.00
44376
SMALL BOWEL ENDOSCOPY
8.15
1.00
44377
SMALL BOWEL ENDOSCOPY/BIOPSY
6.00
1.00
Procedure Code Description
RVU
RVU Coeff Value
44377
SMALL BOWEL ENDOSCOPY/BIOPSY
8.01
1.00
44377
SMALL BOWEL ENDOSCOPY/BIOPSY
8.24
1.00
44377
SMALL BOWEL ENDOSCOPY/BIOPSY
8.63
1.00
44378
SMALL BOWEL ENDOSCOPY
6.00
1.00
44378
SMALL BOWEL ENDOSCOPY
10.28
1.00
44378
SMALL BOWEL ENDOSCOPY
10.49
1.00
44378
SMALL BOWEL ENDOSCOPY
11.07
1.00
44379
S BOWEL ENDOSCOPE W/STENT
5.00
1.00
44379
S BOWEL ENDOSCOPE W/STENT
10.85
1.00
44379
S BOWEL ENDOSCOPE W/STENT
10.96
1.00
44379
S BOWEL ENDOSCOPE W/STENT
11.76
1.00
44380
SMALL BOWEL ENDOSCOPY
1.71
1.00
44380
SMALL BOWEL ENDOSCOPY
1.84
1.00
44380
SMALL BOWEL ENDOSCOPY
1.91
1.00
44380
SMALL BOWEL ENDOSCOPY
6.00
1.00
44382
SMALL BOWEL ENDOSCOPY
2.03
1.00
44382
SMALL BOWEL ENDOSCOPY
2.22
1.00
44382
SMALL BOWEL ENDOSCOPY
2.23
1.00
44382
SMALL BOWEL ENDOSCOPY
6.00
1.00
44383
ILEOSCOPY W/STENT
4.38
1.00
44383
ILEOSCOPY W/STENT
4.49
1.00
44383
ILEOSCOPY W/STENT
4.74
1.00
44383
ILEOSCOPY W/STENT
6.00
1.00
44385
ENDOSCOPY OF BOWEL POUCH
2.83
1.00
44385
ENDOSCOPY OF BOWEL POUCH
2.90
1.00
44385
ENDOSCOPY OF BOWEL POUCH
2.92
1.00
44385
ENDOSCOPY OF BOWEL POUCH
6.00
1.00
44386
ENDOSCOPY, BOWEL POUCH/BIOP
3.33
1.00
44386
ENDOSCOPY, BOWEL POUCH/BIOP
3.36
1.00
44386
ENDOSCOPY, BOWEL POUCH/BIOP
3.42
1.00
44386
ENDOSCOPY, BOWEL POUCH/BIOP
6.00
1.00
44388
COLONOSCOPY
4.20
1.00
44388
COLONOSCOPY
4.38
1.00
44388
COLONOSCOPY
4.42
1.00
44388
COLONOSCOPY
6.00
1.00
Procedure Code Description
RVU
RVU Coeff Value
44389
COLONOSCOPY WITH BIOPSY
4.63
1.00
44389
COLONOSCOPY WITH BIOPSY
4.82
1.00
44389
COLONOSCOPY WITH BIOPSY
4.93
1.00
44389
COLONOSCOPY WITH BIOPSY
6.00
1.00
44390
COLONOSCOPY FOR FOREIGN BODY
5.60
1.00
44390
COLONOSCOPY FOR FOREIGN BODY
5.78
1.00
44390
COLONOSCOPY FOR FOREIGN BODY
5.91
1.00
44390
COLONOSCOPY FOR FOREIGN BODY
6.00
1.00
44391
COLONOSCOPY FOR BLEEDING
6.00
1.00
44391
COLONOSCOPY FOR BLEEDING
6.28
1.00
44391
COLONOSCOPY FOR BLEEDING
6.31
1.00
44391
COLONOSCOPY FOR BLEEDING
6.73
1.00
44392
COLONOSCOPY & POLYPECTOMY
5.61
1.00
44392
COLONOSCOPY & POLYPECTOMY
5.79
1.00
44392
COLONOSCOPY & POLYPECTOMY
5.82
1.00
44392
COLONOSCOPY & POLYPECTOMY
6.00
1.00
44393
COLONOSCOPY, LESION REMOVAL
6.00
1.00
44393
COLONOSCOPY, LESION REMOVAL
7.04
1.00
44393
COLONOSCOPY, LESION REMOVAL
7.23
1.00
44393
COLONOSCOPY, LESION REMOVAL
7.41
1.00
44394
COLONOSCOPY W/SNARE
5.00
1.00
44394
COLONOSCOPY W/SNARE
6.48
1.00
44394
COLONOSCOPY W/SNARE
6.67
1.00
44394
COLONOSCOPY W/SNARE
6.86
1.00
44397
COLONOSCOPY W/STENT
6.00
1.00
44397
COLONOSCOPY W/STENT
7.05
1.00
44397
COLONOSCOPY W/STENT
7.10
1.00
44397
COLONOSCOPY W/STENT
7.40
1.00
44602
SUTURE, SMALL INTESTINE
6.00
1.00
44602
SUTURE, SMALL INTESTINE
23.72
1.00
44602
SUTURE, SMALL INTESTINE
23.73
1.00
44602
SUTURE, SMALL INTESTINE
34.32
1.00
44603
SUTURE, SMALL INTESTINE
6.00
1.00
44603
SUTURE, SMALL INTESTINE
27.57
1.00
44603
SUTURE, SMALL INTESTINE
27.62
1.00
Procedure Code Description
RVU
RVU Coeff Value
44603
SUTURE, SMALL INTESTINE
39.34
1.00
44604
SUTURE, LARGE INTESTINE
6.00
1.00
44604
SUTURE, LARGE INTESTINE
24.14
1.00
44604
SUTURE, LARGE INTESTINE
24.21
1.00
44604
SUTURE, LARGE INTESTINE
26.57
1.00
44605
REPAIR OF BOWEL LESION
6.00
1.00
44605
REPAIR OF BOWEL LESION
29.73
1.00
44605
REPAIR OF BOWEL LESION
29.82
1.00
44605
REPAIR OF BOWEL LESION
32.74
1.00
44615
INTESTINAL STRICTUROPLASTY
6.00
1.00
44615
INTESTINAL STRICTUROPLASTY
24.21
1.00
44615
INTESTINAL STRICTUROPLASTY
24.31
1.00
44615
INTESTINAL STRICTUROPLASTY
26.97
1.00
44620
REPAIR BOWEL OPENING
5.00
1.00
44620
REPAIR BOWEL OPENING
18.73
1.00
44620
REPAIR BOWEL OPENING
18.81
1.00
44620
REPAIR BOWEL OPENING
21.49
1.00
44625
REPAIR BOWEL OPENING
5.00
1.00
44625
REPAIR BOWEL OPENING
22.84
1.00
44625
REPAIR BOWEL OPENING
22.95
1.00
44625
REPAIR BOWEL OPENING
25.47
1.00
44626
REPAIR BOWEL OPENING
6.00
1.00
44626
REPAIR BOWEL OPENING
37.98
1.00
44626
REPAIR BOWEL OPENING
38.24
1.00
44626
REPAIR BOWEL OPENING
40.59
1.00
44640
REPAIR BOWEL-SKIN FISTULA
5.00
1.00
44640
REPAIR BOWEL-SKIN FISTULA
31.93
1.00
44640
REPAIR BOWEL-SKIN FISTULA
32.00
1.00
44640
REPAIR BOWEL-SKIN FISTULA
35.39
1.00
44650
REPAIR BOWEL FISTULA
6.00
1.00
44650
REPAIR BOWEL FISTULA
33.19
1.00
44650
REPAIR BOWEL FISTULA
33.27
1.00
44650
REPAIR BOWEL FISTULA
36.82
1.00
44660
REPAIR BOWEL-BLADDER FISTULA
6.00
1.00
44660
REPAIR BOWEL-BLADDER FISTULA
31.06
1.00
Procedure Code Description
RVU
RVU Coeff Value
44660
REPAIR BOWEL-BLADDER FISTULA
31.10
1.00
44660
REPAIR BOWEL-BLADDER FISTULA
35.49
1.00
44661
REPAIR BOWEL-BLADDER FISTULA
6.00
1.00
44661
REPAIR BOWEL-BLADDER FISTULA
36.14
1.00
44661
REPAIR BOWEL-BLADDER FISTULA
36.22
1.00
44661
REPAIR BOWEL-BLADDER FISTULA
39.90
1.00
44680
SURGICAL REVISION, INTESTINE
5.00
1.00
44680
SURGICAL REVISION, INTESTINE
23.41
1.00
44680
SURGICAL REVISION, INTESTINE
23.51
1.00
44680
SURGICAL REVISION, INTESTINE
26.62
1.00
44700
SUSPEND BOWEL W/PROSTHESIS
6.00
1.00
44700
SUSPEND BOWEL W/PROSTHESIS
24.20
1.00
44700
SUSPEND BOWEL W/PROSTHESIS
24.24
1.00
44700
SUSPEND BOWEL W/PROSTHESIS
25.74
1.00
44701
INTRAOP COLON LAVAGE ADD-ON
4.35
1.00
44701
INTRAOP COLON LAVAGE ADD-ON
4.38
1.00
44701
INTRAOP COLON LAVAGE ADD-ON
4.41
1.00
44800
EXCISION OF BOWEL POUCH
5.00
1.00
44800
EXCISION OF BOWEL POUCH
17.84
1.00
44800
EXCISION OF BOWEL POUCH
17.98
1.00
44800
EXCISION OF BOWEL POUCH
18.99
1.00
44820
EXCISION OF MESENTERY LESION
6.00
1.00
44820
EXCISION OF MESENTERY LESION
18.75
1.00
44820
EXCISION OF MESENTERY LESION
18.84
1.00
44820
EXCISION OF MESENTERY LESION
20.95
1.00
44850
REPAIR OF MESENTERY
6.00
1.00
44850
REPAIR OF MESENTERY
16.86
1.00
44850
REPAIR OF MESENTERY
16.95
1.00
44850
REPAIR OF MESENTERY
18.48
1.00
44900
DRAIN APP ABSCESS, OPEN
5.00
1.00
44900
DRAIN APP ABSCESS, OPEN
15.85
1.00
44900
DRAIN APP ABSCESS, OPEN
15.87
1.00
44900
DRAIN APP ABSCESS, OPEN
18.90
1.00
44901
DRAIN APP ABSCESS, PERCUT
4.00
1.00
44901
DRAIN APP ABSCESS, PERCUT
4.70
1.00
Procedure Code Description
RVU
RVU Coeff Value
44901
DRAIN APP ABSCESS, PERCUT
4.83
1.00
44901
DRAIN APP ABSCESS, PERCUT
8.06
1.00
44950
APPENDECTOMY
6.00
1.00
44950
APPENDECTOMY
15.38
1.00
44950
APPENDECTOMY
15.40
1.00
44950
APPENDECTOMY
16.07
1.00
44955
APPENDECTOMY ADD-ON
2.19
1.00
44955
APPENDECTOMY ADD-ON
2.24
1.00
44955
APPENDECTOMY ADD-ON
2.25
1.00
44960
APPENDECTOMY
6.00
1.00
44960
APPENDECTOMY
18.95
1.00
44960
APPENDECTOMY
19.01
1.00
44960
APPENDECTOMY
21.59
1.00
44970
LAPAROSCOPY, APPENDECTOMY
6.00
1.00
44970
LAPAROSCOPY, APPENDECTOMY
13.80
1.00
44970
LAPAROSCOPY, APPENDECTOMY
13.98
1.00
44970
LAPAROSCOPY, APPENDECTOMY
14.76
1.00
45000
DRAINAGE OF PELVIC ABSCESS
4.00
1.00
45000
DRAINAGE OF PELVIC ABSCESS
7.94
1.00
45000
DRAINAGE OF PELVIC ABSCESS
7.97
1.00
45000
DRAINAGE OF PELVIC ABSCESS
10.23
1.00
45005
DRAINAGE OF RECTAL ABSCESS
3.74
1.00
45005
DRAINAGE OF RECTAL ABSCESS
3.83
1.00
45005
DRAINAGE OF RECTAL ABSCESS
3.90
1.00
45005
DRAINAGE OF RECTAL ABSCESS
5.00
1.00
45020
DRAINAGE OF RECTAL ABSCESS
5.00
1.00
45020
DRAINAGE OF RECTAL ABSCESS
8.51
1.00
45020
DRAINAGE OF RECTAL ABSCESS
13.30
1.00
45100
BIOPSY OF RECTUM
4.00
1.00
45100
BIOPSY OF RECTUM
6.46
1.00
45100
BIOPSY OF RECTUM
6.50
1.00
45100
BIOPSY OF RECTUM
7.14
1.00
45108
REMOVAL OF ANORECTAL LESION
4.00
1.00
45108
REMOVAL OF ANORECTAL LESION
8.21
1.00
45108
REMOVAL OF ANORECTAL LESION
8.24
1.00
Procedure Code Description
RVU
RVU Coeff Value
45108
REMOVAL OF ANORECTAL LESION
8.70
1.00
45110
REMOVAL OF RECTUM
6.00
1.00
45110
REMOVAL OF RECTUM
42.77
1.00
45110
REMOVAL OF RECTUM
43.19
1.00
45110
REMOVAL OF RECTUM
46.27
1.00
45111
PARTIAL REMOVAL OF RECTUM
6.00
1.00
45111
PARTIAL REMOVAL OF RECTUM
25.43
1.00
45111
PARTIAL REMOVAL OF RECTUM
25.60
1.00
45111
PARTIAL REMOVAL OF RECTUM
27.21
1.00
45112
REMOVAL OF RECTUM
7.00
1.00
45112
REMOVAL OF RECTUM
44.96
1.00
45112
REMOVAL OF RECTUM
45.14
1.00
45112
REMOVAL OF RECTUM
47.65
1.00
45113
PARTIAL PROCTECTOMY
7.00
1.00
45113
PARTIAL PROCTECTOMY
45.69
1.00
45113
PARTIAL PROCTECTOMY
45.79
1.00
45113
PARTIAL PROCTECTOMY
48.87
1.00
45114
PARTIAL REMOVAL OF RECTUM
7.00
1.00
45114
PARTIAL REMOVAL OF RECTUM
40.79
1.00
45114
PARTIAL REMOVAL OF RECTUM
41.04
1.00
45114
PARTIAL REMOVAL OF RECTUM
44.68
1.00
45116
PARTIAL REMOVAL OF RECTUM
7.00
1.00
45116
PARTIAL REMOVAL OF RECTUM
36.80
1.00
45116
PARTIAL REMOVAL OF RECTUM
37.03
1.00
45116
PARTIAL REMOVAL OF RECTUM
40.10
1.00
45119
REMOVE RECTUM W/RESERVOIR
7.00
1.00
45119
REMOVE RECTUM W/RESERVOIR
45.82
1.00
45119
REMOVE RECTUM W/RESERVOIR
45.90
1.00
45119
REMOVE RECTUM W/RESERVOIR
48.89
1.00
45120
REMOVAL OF RECTUM
7.00
1.00
45120
REMOVAL OF RECTUM
37.19
1.00
45120
REMOVAL OF RECTUM
37.50
1.00
45120
REMOVAL OF RECTUM
39.15
1.00
45121
REMOVAL OF RECTUM AND COLON
7.00
1.00
45121
REMOVAL OF RECTUM AND COLON
41.04
1.00
Procedure Code Description
RVU
RVU Coeff Value
45121
REMOVAL OF RECTUM AND COLON
41.39
1.00
45121
REMOVAL OF RECTUM AND COLON
42.86
1.00
45123
PARTIAL PROCTECTOMY
6.00
1.00
45123
PARTIAL PROCTECTOMY
24.77
1.00
45123
PARTIAL PROCTECTOMY
24.83
1.00
45123
PARTIAL PROCTECTOMY
27.70
1.00
45126
PELVIC EXENTERATION
8.00
1.00
45126
PELVIC EXENTERATION
67.80
1.00
45126
PELVIC EXENTERATION
68.37
1.00
45126
PELVIC EXENTERATION
72.05
1.00
45130
EXCISION OF RECTAL PROLAPSE
4.00
1.00
45130
EXCISION OF RECTAL PROLAPSE
24.49
1.00
45130
EXCISION OF RECTAL PROLAPSE
24.57
1.00
45130
EXCISION OF RECTAL PROLAPSE
27.08
1.00
45135
EXCISION OF RECTAL PROLAPSE
6.00
1.00
45135
EXCISION OF RECTAL PROLAPSE
29.34
1.00
45135
EXCISION OF RECTAL PROLAPSE
29.56
1.00
45135
EXCISION OF RECTAL PROLAPSE
33.22
1.00
45136
EXCISE ILEOANAL RESERVIOR
4.00
1.00
45136
EXCISE ILEOANAL RESERVIOR
42.33
1.00
45136
EXCISE ILEOANAL RESERVIOR
43.06
1.00
45136
EXCISE ILEOANAL RESERVIOR
45.85
1.00
45150
EXCISION OF RECTAL STRICTURE
4.00
1.00
45150
EXCISION OF RECTAL STRICTURE
9.19
1.00
45150
EXCISION OF RECTAL STRICTURE
9.21
1.00
45150
EXCISION OF RECTAL STRICTURE
9.88
1.00
45160
EXCISION OF RECTAL LESION
6.00
1.00
45160
EXCISION OF RECTAL LESION
23.17
1.00
45160
EXCISION OF RECTAL LESION
23.27
1.00
45160
EXCISION OF RECTAL LESION
24.67
1.00
45170
EXCISION OF RECTAL LESION
4.00
1.00
45170
EXCISION OF RECTAL LESION
17.77
1.00
45170
EXCISION OF RECTAL LESION
17.81
1.00
45170
EXCISION OF RECTAL LESION
19.30
1.00
45190
DESTRUCTION, RECTAL TUMOR
4.00
1.00
Procedure Code Description
RVU
RVU Coeff Value
45190
DESTRUCTION, RECTAL TUMOR
15.33
1.00
45190
DESTRUCTION, RECTAL TUMOR
15.62
1.00
45190
DESTRUCTION, RECTAL TUMOR
16.79
1.00
45300
PROCTOSIGMOIDOSCOPY DX
0.66
1.00
45300
PROCTOSIGMOIDOSCOPY DX
0.75
1.00
45300
PROCTOSIGMOIDOSCOPY DX
1.26
1.00
45300
PROCTOSIGMOIDOSCOPY DX
4.00
1.00
45303
PROCTOSIGMOIDOSCOPY DILATE
0.76
1.00
45303
PROCTOSIGMOIDOSCOPY DILATE
0.86
1.00
45303
PROCTOSIGMOIDOSCOPY DILATE
2.14
1.00
45303
PROCTOSIGMOIDOSCOPY DILATE
4.00
1.00
45305
PROCTOSIGMOIDOSCOPY W/BX
1.55
1.00
45305
PROCTOSIGMOIDOSCOPY W/BX
1.64
1.00
45305
PROCTOSIGMOIDOSCOPY W/BX
1.95
1.00
45305
PROCTOSIGMOIDOSCOPY W/BX
4.00
1.00
45307
PROCTOSIGMOIDOSCOPY FB
1.51
1.00
45307
PROCTOSIGMOIDOSCOPY FB
1.62
1.00
45307
PROCTOSIGMOIDOSCOPY FB
2.45
1.00
45307
PROCTOSIGMOIDOSCOPY FB
4.00
1.00
45308
PROCTOSIGMOIDOSCOPY REMOVAL
1.35
1.00
45308
PROCTOSIGMOIDOSCOPY REMOVAL
1.45
1.00
45308
PROCTOSIGMOIDOSCOPY REMOVAL
2.08
1.00
45308
PROCTOSIGMOIDOSCOPY REMOVAL
4.00
1.00
45309
PROCTOSIGMOIDOSCOPY REMOVAL
2.46
1.00
45309
PROCTOSIGMOIDOSCOPY REMOVAL
2.97
1.00
45309
PROCTOSIGMOIDOSCOPY REMOVAL
3.08
1.00
45309
PROCTOSIGMOIDOSCOPY REMOVAL
4.00
1.00
45315
PROCTOSIGMOIDOSCOPY REMOVAL
2.19
1.00
45315
PROCTOSIGMOIDOSCOPY REMOVAL
2.29
1.00
45315
PROCTOSIGMOIDOSCOPY REMOVAL
2.76
1.00
45315
PROCTOSIGMOIDOSCOPY REMOVAL
4.00
1.00
45317
PROCTOSIGMOIDOSCOPY BLEED
2.32
1.00
45317
PROCTOSIGMOIDOSCOPY BLEED
2.42
1.00
45317
PROCTOSIGMOIDOSCOPY BLEED
2.90
1.00
45317
PROCTOSIGMOIDOSCOPY BLEED
4.00
1.00
Procedure Code Description
RVU
RVU Coeff Value
45320
PROCTOSIGMOIDOSCOPY ABLATE
2.44
1.00
45320
PROCTOSIGMOIDOSCOPY ABLATE
2.55
1.00
45320
PROCTOSIGMOIDOSCOPY ABLATE
2.77
1.00
45320
PROCTOSIGMOIDOSCOPY ABLATE
4.00
1.00
45321
PROCTOSIGMOIDOSCOPY VOLVUL
1.85
1.00
45321
PROCTOSIGMOIDOSCOPY VOLVUL
1.96
1.00
45321
PROCTOSIGMOIDOSCOPY VOLVUL
2.67
1.00
45321
PROCTOSIGMOIDOSCOPY VOLVUL
4.00
1.00
45327
PROCTOSIGMOIDOSCOPY W/STENT
2.47
1.00
45327
PROCTOSIGMOIDOSCOPY W/STENT
2.61
1.00
45327
PROCTOSIGMOIDOSCOPY W/STENT
3.12
1.00
45327
PROCTOSIGMOIDOSCOPY W/STENT
5.00
1.00
45330
DIAGNOSTIC SIGMOIDOSCOPY
1.53
1.00
45330
DIAGNOSTIC SIGMOIDOSCOPY
1.54
1.00
45330
DIAGNOSTIC SIGMOIDOSCOPY
1.64
1.00
45330
DIAGNOSTIC SIGMOIDOSCOPY
4.00
1.00
45331
SIGMOIDOSCOPY AND BIOPSY
1.75
1.00
45331
SIGMOIDOSCOPY AND BIOPSY
1.86
1.00
45331
SIGMOIDOSCOPY AND BIOPSY
1.99
1.00
45331
SIGMOIDOSCOPY AND BIOPSY
4.00
1.00
45332
SIGMOIDOSCOPY W/FB REMOVAL
2.65
1.00
45332
SIGMOIDOSCOPY W/FB REMOVAL
2.77
1.00
45332
SIGMOIDOSCOPY W/FB REMOVAL
2.92
1.00
45332
SIGMOIDOSCOPY W/FB REMOVAL
4.00
1.00
45333
SIGMOIDOSCOPY & POLYPECTOMY
2.66
1.00
45333
SIGMOIDOSCOPY & POLYPECTOMY
2.78
1.00
45333
SIGMOIDOSCOPY & POLYPECTOMY
2.90
1.00
45333
SIGMOIDOSCOPY & POLYPECTOMY
4.00
1.00
45334
SIGMOIDOSCOPY FOR BLEEDING
3.97
1.00
45334
SIGMOIDOSCOPY FOR BLEEDING
4.00
1.00
45334
SIGMOIDOSCOPY FOR BLEEDING
4.10
1.00
45334
SIGMOIDOSCOPY FOR BLEEDING
4.39
1.00
45335
SIGMOIDOSCOPY W/SUBMUC INJ
2.08
1.00
45335
SIGMOIDOSCOPY W/SUBMUC INJ
2.22
1.00
45335
SIGMOIDOSCOPY W/SUBMUC INJ
2.42
1.00
Procedure Code Description
RVU
RVU Coeff Value
45337
SIGMOIDOSCOPY & DECOMPRESS
3.46
1.00
45337
SIGMOIDOSCOPY & DECOMPRESS
3.59
1.00
45337
SIGMOIDOSCOPY & DECOMPRESS
3.77
1.00
45337
SIGMOIDOSCOPY & DECOMPRESS
4.00
1.00
45338
SIGMOIDOSCOPY W/TUMR REMOVE
3.44
1.00
45338
SIGMOIDOSCOPY W/TUMR REMOVE
3.57
1.00
45338
SIGMOIDOSCOPY W/TUMR REMOVE
3.77
1.00
45338
SIGMOIDOSCOPY W/TUMR REMOVE
4.00
1.00
45339
SIGMOIDOSCOPY W/ABLATE TUMR
4.00
1.00
45339
SIGMOIDOSCOPY W/ABLATE TUMR
4.54
1.00
45339
SIGMOIDOSCOPY W/ABLATE TUMR
4.67
1.00
45339
SIGMOIDOSCOPY W/ABLATE TUMR
4.99
1.00
45340
SIG W/BALLOON DILATION
2.49
1.00
45340
SIG W/BALLOON DILATION
2.80
1.00
45340
SIG W/BALLOON DILATION
3.05
1.00
45341
SIGMOIDOSCOPY W/ULTRASOUND
3.96
1.00
45341
SIGMOIDOSCOPY W/ULTRASOUND
4.17
1.00
45341
SIGMOIDOSCOPY W/ULTRASOUND
4.19
1.00
45341
SIGMOIDOSCOPY W/ULTRASOUND
5.00
1.00
45342
SIGMOIDOSCOPY W/US GUIDE BX
5.00
1.00
45342
SIGMOIDOSCOPY W/US GUIDE BX
5.93
1.00
45342
SIGMOIDOSCOPY W/US GUIDE BX
6.10
1.00
45342
SIGMOIDOSCOPY W/US GUIDE BX
6.41
1.00
45345
SIGMOIDOSCOPY W/STENT
4.30
1.00
45345
SIGMOIDOSCOPY W/STENT
4.47
1.00
45345
SIGMOIDOSCOPY W/STENT
4.66
1.00
45345
SIGMOIDOSCOPY W/STENT
5.00
1.00
45355
SURGICAL COLONOSCOPY
4.00
1.00
45355
SURGICAL COLONOSCOPY
5.02
1.00
45355
SURGICAL COLONOSCOPY
5.22
1.00
45355
SURGICAL COLONOSCOPY
5.39
1.00
45378
DIAGNOSTIC COLONOSCOPY
4.00
1.00
45378
DIAGNOSTIC COLONOSCOPY
5.51
1.00
45378
DIAGNOSTIC COLONOSCOPY
5.62
1.00
45378
DIAGNOSTIC COLONOSCOPY
5.77
1.00
Procedure Code Description
RVU
RVU Coeff Value
45379
COLONOSCOPY W/FB REMOVAL
4.00
1.00
45379
COLONOSCOPY W/FB REMOVAL
6.84
1.00
45379
COLONOSCOPY W/FB REMOVAL
7.02
1.00
45379
COLONOSCOPY W/FB REMOVAL
7.23
1.00
45380
COLONOSCOPY AND BIOPSY
4.00
1.00
45380
COLONOSCOPY AND BIOPSY
6.46
1.00
45380
COLONOSCOPY AND BIOPSY
6.65
1.00
45380
COLONOSCOPY AND BIOPSY
6.95
1.00
45381
COLONOSCOPY, SUBMUCOUS INJ
6.11
1.00
45381
COLONOSCOPY, SUBMUCOUS INJ
6.13
1.00
45381
COLONOSCOPY, SUBMUCOUS INJ
6.57
1.00
45382
COLONOSCOPY/CONTROL BLEEDING
4.00
1.00
45382
COLONOSCOPY/CONTROL BLEEDING
8.19
1.00
45382
COLONOSCOPY/CONTROL BLEEDING
8.24
1.00
45382
COLONOSCOPY/CONTROL BLEEDING
8.87
1.00
45383
LESION REMOVAL COLONOSCOPY
4.00
1.00
45383
LESION REMOVAL COLONOSCOPY
8.52
1.00
45383
LESION REMOVAL COLONOSCOPY
8.69
1.00
45383
LESION REMOVAL COLONOSCOPY
8.94
1.00
45384
LESION REMOVE COLONOSCOPY
4.00
1.00
45384
LESION REMOVE COLONOSCOPY
6.85
1.00
45384
LESION REMOVE COLONOSCOPY
7.03
1.00
45384
LESION REMOVE COLONOSCOPY
7.22
1.00
45385
LESION REMOVAL COLONOSCOPY
4.00
1.00
45385
LESION REMOVAL COLONOSCOPY
7.72
1.00
45385
LESION REMOVAL COLONOSCOPY
7.90
1.00
45385
LESION REMOVAL COLONOSCOPY
8.25
1.00
45386
COLONOSCOPY DILATE STRICTURE
6.63
1.00
45386
COLONOSCOPY DILATE STRICTURE
6.65
1.00
45386
COLONOSCOPY DILATE STRICTURE
7.10
1.00
45387
COLONOSCOPY W/STENT
5.00
1.00
45387
COLONOSCOPY W/STENT
8.65
1.00
45387
COLONOSCOPY W/STENT
8.76
1.00
45387
COLONOSCOPY W/STENT
9.25
1.00
45391
COLONOSCOPY W/ENDOSCOPE US
7.99
1.00
Procedure Code Description
RVU
RVU Coeff Value
45392
COLONOSCOPY W/ENDOSCOPIC FNB
10.07
1.00
45395
LAP, REMOVAL OF RECTUM
50.02
1.00
45397
LAP, REMOVE RECTUM W/POUCH
54.08
1.00
45400
LAPAROSCOPIC PROC
28.84
1.00
45402
LAP PROCTOPEXY W/SIG RESECT
38.60
1.00
45500
REPAIR OF RECTUM
4.00
1.00
45500
REPAIR OF RECTUM
11.55
1.00
45500
REPAIR OF RECTUM
11.99
1.00
45500
REPAIR OF RECTUM
12.66
1.00
45505
REPAIR OF RECTUM
4.00
1.00
45505
REPAIR OF RECTUM
11.78
1.00
45505
REPAIR OF RECTUM
12.04
1.00
45505
REPAIR OF RECTUM
13.90
1.00
45520
TREATMENT OF RECTAL PROLAPSE
0.78
1.00
45520
TREATMENT OF RECTAL PROLAPSE
0.79
1.00
45520
TREATMENT OF RECTAL PROLAPSE
0.98
1.00
45520
TREATMENT OF RECTAL PROLAPSE
3.00
1.00
45540
CORRECT RECTAL PROLAPSE
5.00
1.00
45540
CORRECT RECTAL PROLAPSE
24.52
1.00
45540
CORRECT RECTAL PROLAPSE
25.34
1.00
45540
CORRECT RECTAL PROLAPSE
26.60
1.00
45541
CORRECT RECTAL PROLAPSE
4.00
1.00
45541
CORRECT RECTAL PROLAPSE
20.44
1.00
45541
CORRECT RECTAL PROLAPSE
21.06
1.00
45541
CORRECT RECTAL PROLAPSE
22.86
1.00
45550
REPAIR RECTUM/REMOVE SIGMOID
5.00
1.00
45550
REPAIR RECTUM/REMOVE SIGMOID
34.17
1.00
45550
REPAIR RECTUM/REMOVE SIGMOID
34.73
1.00
45550
REPAIR RECTUM/REMOVE SIGMOID
36.61
1.00
45560
REPAIR OF RECTOCELE
4.00
1.00
45560
REPAIR OF RECTOCELE
16.56
1.00
45560
REPAIR OF RECTOCELE
17.20
1.00
45560
REPAIR OF RECTOCELE
18.07
1.00
45562
EXPLORATION/REPAIR OF RECTUM
4.00
1.00
45562
EXPLORATION/REPAIR OF RECTUM
23.80
1.00
Procedure Code Description
RVU
RVU Coeff Value
45562
EXPLORATION/REPAIR OF RECTUM
23.83
1.00
45562
EXPLORATION/REPAIR OF RECTUM
27.73
1.00
45563
EXPLORATION/REPAIR OF RECTUM
7.00
1.00
45563
EXPLORATION/REPAIR OF RECTUM
36.21
1.00
45563
EXPLORATION/REPAIR OF RECTUM
36.26
1.00
45563
EXPLORATION/REPAIR OF RECTUM
40.30
1.00
45800
REPAIR RECT/BLADDER FISTULA
4.00
1.00
45800
REPAIR RECT/BLADDER FISTULA
26.61
1.00
45800
REPAIR RECT/BLADDER FISTULA
26.82
1.00
45800
REPAIR RECT/BLADDER FISTULA
31.07
1.00
45805
REPAIR FISTULA W/COLOSTOMY
6.00
1.00
45805
REPAIR FISTULA W/COLOSTOMY
32.12
1.00
45805
REPAIR FISTULA W/COLOSTOMY
32.16
1.00
45805
REPAIR FISTULA W/COLOSTOMY
35.07
1.00
45820
REPAIR RECTOURETHRAL FISTULA
4.00
1.00
45820
REPAIR RECTOURETHRAL FISTULA
27.56
1.00
45820
REPAIR RECTOURETHRAL FISTULA
27.80
1.00
45820
REPAIR RECTOURETHRAL FISTULA
30.76
1.00
45825
REPAIR FISTULA W/COLOSTOMY
6.00
1.00
45825
REPAIR FISTULA W/COLOSTOMY
32.30
1.00
45825
REPAIR FISTULA W/COLOSTOMY
32.35
1.00
45825
REPAIR FISTULA W/COLOSTOMY
37.17
1.00
45900
REDUCTION OF RECTAL PROLAPSE
3.00
1.00
45900
REDUCTION OF RECTAL PROLAPSE
3.80
1.00
45900
REDUCTION OF RECTAL PROLAPSE
4.34
1.00
45900
REDUCTION OF RECTAL PROLAPSE
4.90
1.00
45905
DILATION OF ANAL SPHINCTER
3.00
1.00
45905
DILATION OF ANAL SPHINCTER
3.38
1.00
45905
DILATION OF ANAL SPHINCTER
3.90
1.00
45905
DILATION OF ANAL SPHINCTER
4.17
1.00
45910
DILATION OF RECTAL NARROWING
3.00
1.00
45910
DILATION OF RECTAL NARROWING
4.06
1.00
45910
DILATION OF RECTAL NARROWING
4.63
1.00
45910
DILATION OF RECTAL NARROWING
4.93
1.00
45915
REMOVE RECTAL OBSTRUCTION
4.00
1.00
Procedure Code Description
RVU
RVU Coeff Value
45915
REMOVE RECTAL OBSTRUCTION
4.41
1.00
45915
REMOVE RECTAL OBSTRUCTION
4.52
1.00
45915
REMOVE RECTAL OBSTRUCTION
5.51
1.00
45990
SURG DX EXAM, ANORECTAL
2.74
1.00
46020
PLACEMENT OF SETON
3.00
1.00
46020
PLACEMENT OF SETON
5.03
1.00
46020
PLACEMENT OF SETON
5.45
1.00
46020
PLACEMENT OF SETON
5.50
1.00
46030
REMOVAL OF RECTAL MARKER
2.07
1.00
46030
REMOVAL OF RECTAL MARKER
2.17
1.00
46030
REMOVAL OF RECTAL MARKER
2.53
1.00
46030
REMOVAL OF RECTAL MARKER
4.00
1.00
46040
INCISION OF RECTAL ABSCESS
3.00
1.00
46040
INCISION OF RECTAL ABSCESS
8.49
1.00
46040
INCISION OF RECTAL ABSCESS
8.70
1.00
46040
INCISION OF RECTAL ABSCESS
9.79
1.00
46045
INCISION OF RECTAL ABSCESS
4.00
1.00
46045
INCISION OF RECTAL ABSCESS
7.49
1.00
46045
INCISION OF RECTAL ABSCESS
7.71
1.00
46045
INCISION OF RECTAL ABSCESS
10.04
1.00
46050
INCISION OF ANAL ABSCESS
2.18
1.00
46050
INCISION OF ANAL ABSCESS
2.29
1.00
46050
INCISION OF ANAL ABSCESS
2.62
1.00
46050
INCISION OF ANAL ABSCESS
3.00
1.00
46060
INCISION OF RECTAL ABSCESS
3.00
1.00
46060
INCISION OF RECTAL ABSCESS
9.61
1.00
46060
INCISION OF RECTAL ABSCESS
9.92
1.00
46060
INCISION OF RECTAL ABSCESS
11.08
1.00
46070
INCISION OF ANAL SEPTUM
4.00
1.00
46070
INCISION OF ANAL SEPTUM
4.92
1.00
46070
INCISION OF ANAL SEPTUM
5.38
1.00
46070
INCISION OF ANAL SEPTUM
5.67
1.00
46080
INCISION OF ANAL SPHINCTER
3.00
1.00
46080
INCISION OF ANAL SPHINCTER
3.90
1.00
46080
INCISION OF ANAL SPHINCTER
3.95
1.00
Procedure Code Description
RVU
RVU Coeff Value
46080
INCISION OF ANAL SPHINCTER
4.32
1.00
46083
INCISE EXTERNAL HEMORRHOID
2.49
1.00
46083
INCISE EXTERNAL HEMORRHOID
2.64
1.00
46083
INCISE EXTERNAL HEMORRHOID
3.05
1.00
46200
REMOVAL OF ANAL FISSURE
3.00
1.00
46200
REMOVAL OF ANAL FISSURE
6.07
1.00
46200
REMOVAL OF ANAL FISSURE
6.20
1.00
46200
REMOVAL OF ANAL FISSURE
7.38
1.00
46210
REMOVAL OF ANAL CRYPT
3.00
1.00
46210
REMOVAL OF ANAL CRYPT
5.10
1.00
46210
REMOVAL OF ANAL CRYPT
5.12
1.00
46210
REMOVAL OF ANAL CRYPT
6.21
1.00
46211
REMOVAL OF ANAL CRYPTS
3.00
1.00
46211
REMOVAL OF ANAL CRYPTS
7.50
1.00
46211
REMOVAL OF ANAL CRYPTS
7.64
1.00
46211
REMOVAL OF ANAL CRYPTS
9.05
1.00
46220
REMOVAL OF ANAL TAG
2.25
1.00
46220
REMOVAL OF ANAL TAG
2.67
1.00
46220
REMOVAL OF ANAL TAG
2.83
1.00
46220
REMOVAL OF ANAL TAG
3.00
1.00
46221
LIGATION OF HEMORRHOID(S)
3.23
1.00
46221
LIGATION OF HEMORRHOID(S)
3.30
1.00
46221
LIGATION OF HEMORRHOID(S)
4.48
1.00
46230
REMOVAL OF ANAL TAGS
3.00
1.00
46230
REMOVAL OF ANAL TAGS
4.12
1.00
46230
REMOVAL OF ANAL TAGS
4.24
1.00
46230
REMOVAL OF ANAL TAGS
4.44
1.00
46250
HEMORRHOIDECTOMY
3.00
1.00
46250
HEMORRHOIDECTOMY
6.86
1.00
46250
HEMORRHOIDECTOMY
6.97
1.00
46250
HEMORRHOIDECTOMY
7.47
1.00
46255
HEMORRHOIDECTOMY
4.00
1.00
46255
HEMORRHOIDECTOMY
7.88
1.00
46255
HEMORRHOIDECTOMY
7.98
1.00
46255
HEMORRHOIDECTOMY
8.51
1.00
Procedure Code Description
RVU
RVU Coeff Value
46257
REMOVE HEMORRHOIDS & FISSURE
4.00
1.00
46257
REMOVE HEMORRHOIDS & FISSURE
9.01
1.00
46257
REMOVE HEMORRHOIDS & FISSURE
9.04
1.00
46257
REMOVE HEMORRHOIDS & FISSURE
9.94
1.00
46258
REMOVE HEMORRHOIDS & FISTULA
4.00
1.00
46258
REMOVE HEMORRHOIDS & FISTULA
9.56
1.00
46258
REMOVE HEMORRHOIDS & FISTULA
9.80
1.00
46258
REMOVE HEMORRHOIDS & FISTULA
10.86
1.00
46260
HEMORRHOIDECTOMY
3.00
1.00
46260
HEMORRHOIDECTOMY
10.44
1.00
46260
HEMORRHOIDECTOMY
10.97
1.00
46260
HEMORRHOIDECTOMY
11.30
1.00
46261
REMOVE HEMORRHOIDS & FISSURE
4.00
1.00
46261
REMOVE HEMORRHOIDS & FISSURE
11.57
1.00
46261
REMOVE HEMORRHOIDS & FISSURE
11.82
1.00
46261
REMOVE HEMORRHOIDS & FISSURE
12.61
1.00
46262
REMOVE HEMORRHOIDS & FISTULA
4.00
1.00
46262
REMOVE HEMORRHOIDS & FISTULA
12.20
1.00
46262
REMOVE HEMORRHOIDS & FISTULA
12.52
1.00
46262
REMOVE HEMORRHOIDS & FISTULA
13.17
1.00
46270
REMOVAL OF ANAL FISTULA
3.00
1.00
46270
REMOVAL OF ANAL FISTULA
6.52
1.00
46270
REMOVAL OF ANAL FISTULA
6.64
1.00
46270
REMOVAL OF ANAL FISTULA
8.93
1.00
46275
REMOVAL OF ANAL FISTULA
3.00
1.00
46275
REMOVAL OF ANAL FISTULA
7.60
1.00
46275
REMOVAL OF ANAL FISTULA
7.72
1.00
46275
REMOVAL OF ANAL FISTULA
9.58
1.00
46280
REMOVAL OF ANAL FISTULA
3.00
1.00
46280
REMOVAL OF ANAL FISTULA
9.88
1.00
46280
REMOVAL OF ANAL FISTULA
10.17
1.00
46280
REMOVAL OF ANAL FISTULA
10.99
1.00
46285
REMOVAL OF ANAL FISTULA
4.00
1.00
46285
REMOVAL OF ANAL FISTULA
6.84
1.00
46285
REMOVAL OF ANAL FISTULA
7.03
1.00
Procedure Code Description
RVU
RVU Coeff Value
46285
REMOVAL OF ANAL FISTULA
9.43
1.00
46288
REPAIR ANAL FISTULA
4.00
1.00
46288
REPAIR ANAL FISTULA
11.56
1.00
46288
REPAIR ANAL FISTULA
11.92
1.00
46288
REPAIR ANAL FISTULA
12.99
1.00
46320
REMOVAL OF HEMORRHOID CLOT
2.63
1.00
46320
REMOVAL OF HEMORRHOID CLOT
2.69
1.00
46320
REMOVAL OF HEMORRHOID CLOT
3.00
1.00
46320
REMOVAL OF HEMORRHOID CLOT
3.29
1.00
46500
INJECTION INTO HEMORRHOID(S)
2.30
1.00
46500
INJECTION INTO HEMORRHOID(S)
2.37
1.00
46500
INJECTION INTO HEMORRHOID(S)
3.00
1.00
46500
INJECTION INTO HEMORRHOID(S)
3.04
1.00
46505
CHEMODENERVATION ANAL MUSC
5.50
1.00
46600
DIAGNOSTIC ANOSCOPY
0.69
1.00
46600
DIAGNOSTIC ANOSCOPY
0.93
1.00
46600
DIAGNOSTIC ANOSCOPY
0.97
1.00
46600
DIAGNOSTIC ANOSCOPY
3.00
1.00
46604
ANOSCOPY AND DILATION
1.69
1.00
46604
ANOSCOPY AND DILATION
1.86
1.00
46604
ANOSCOPY AND DILATION
2.06
1.00
46604
ANOSCOPY AND DILATION
4.00
1.00
46606
ANOSCOPY AND BIOPSY
1.16
1.00
46606
ANOSCOPY AND BIOPSY
1.33
1.00
46606
ANOSCOPY AND BIOPSY
1.85
1.00
46606
ANOSCOPY AND BIOPSY
4.00
1.00
46608
ANOSCOPY, REMOVE FOR BODY
2.06
1.00
46608
ANOSCOPY, REMOVE FOR BODY
2.11
1.00
46608
ANOSCOPY, REMOVE FOR BODY
2.35
1.00
46608
ANOSCOPY, REMOVE FOR BODY
4.00
1.00
46610
ANOSCOPY, REMOVE LESION
1.91
1.00
46610
ANOSCOPY, REMOVE LESION
2.04
1.00
46610
ANOSCOPY, REMOVE LESION
2.09
1.00
46610
ANOSCOPY, REMOVE LESION
4.00
1.00
46611
ANOSCOPY
2.12
1.00
Procedure Code Description
RVU
RVU Coeff Value
46611
ANOSCOPY
2.60
1.00
46611
ANOSCOPY
2.79
1.00
46611
ANOSCOPY
3.00
1.00
46612
ANOSCOPY, REMOVE LESIONS
2.53
1.00
46612
ANOSCOPY, REMOVE LESIONS
3.36
1.00
46612
ANOSCOPY, REMOVE LESIONS
3.56
1.00
46612
ANOSCOPY, REMOVE LESIONS
4.00
1.00
46614
ANOSCOPY, CONTROL BLEEDING
1.81
1.00
46614
ANOSCOPY, CONTROL BLEEDING
2.84
1.00
46614
ANOSCOPY, CONTROL BLEEDING
3.05
1.00
46614
ANOSCOPY, CONTROL BLEEDING
4.00
1.00
46615
ANOSCOPY
2.59
1.00
46615
ANOSCOPY
3.00
1.00
46615
ANOSCOPY
3.85
1.00
46615
ANOSCOPY
4.06
1.00
46700
REPAIR OF ANAL STRICTURE
5.00
1.00
46700
REPAIR OF ANAL STRICTURE
14.04
1.00
46700
REPAIR OF ANAL STRICTURE
14.33
1.00
46700
REPAIR OF ANAL STRICTURE
15.63
1.00
46705
REPAIR OF ANAL STRICTURE
5.00
1.00
46705
REPAIR OF ANAL STRICTURE
11.52
1.00
46705
REPAIR OF ANAL STRICTURE
11.69
1.00
46705
REPAIR OF ANAL STRICTURE
12.95
1.00
46706
REPR OF ANAL FISTULA W/GLUE
3.80
1.00
46706
REPR OF ANAL FISTULA W/GLUE
3.84
1.00
46706
REPR OF ANAL FISTULA W/GLUE
4.15
1.00
46710
REPR PER/VAG POUCH SNGL PROC
26.53
1.00
46712
REPR PER/VAG POUCH DBL PROC
54.39
1.00
46715
REP PERF ANOPER FISTU
4.00
1.00
46715
REP PERF ANOPER FISTU
11.75
1.00
46715
REP PERF ANOPER FISTU
12.19
1.00
46715
REP PERF ANOPER FISTU
12.80
1.00
46716
REP PERF ANOPER/VESTIB FISTU
4.00
1.00
46716
REP PERF ANOPER/VESTIB FISTU
23.75
1.00
46716
REP PERF ANOPER/VESTIB FISTU
24.60
1.00
Procedure Code Description
RVU
RVU Coeff Value
46716
REP PERF ANOPER/VESTIB FISTU
31.12
1.00
46730
CONSTRUCTION OF ABSENT ANUS
5.00
1.00
46730
CONSTRUCTION OF ABSENT ANUS
41.01
1.00
46730
CONSTRUCTION OF ABSENT ANUS
41.20
1.00
46730
CONSTRUCTION OF ABSENT ANUS
47.06
1.00
46735
CONSTRUCTION OF ABSENT ANUS
6.00
1.00
46735
CONSTRUCTION OF ABSENT ANUS
48.88
1.00
46735
CONSTRUCTION OF ABSENT ANUS
48.89
1.00
46735
CONSTRUCTION OF ABSENT ANUS
55.06
1.00
46740
CONSTRUCTION OF ABSENT ANUS
6.00
1.00
46740
CONSTRUCTION OF ABSENT ANUS
44.53
1.00
46740
CONSTRUCTION OF ABSENT ANUS
45.57
1.00
46740
CONSTRUCTION OF ABSENT ANUS
50.40
1.00
46742
REPAIR OF IMPERFORATED ANUS
4.00
1.00
46742
REPAIR OF IMPERFORATED ANUS
56.43
1.00
46742
REPAIR OF IMPERFORATED ANUS
56.46
1.00
46742
REPAIR OF IMPERFORATED ANUS
59.68
1.00
46744
REPAIR OF CLOACAL ANOMALY
4.00
1.00
46744
REPAIR OF CLOACAL ANOMALY
76.33
1.00
46744
REPAIR OF CLOACAL ANOMALY
76.46
1.00
46744
REPAIR OF CLOACAL ANOMALY
85.71
1.00
46746
REPAIR OF CLOACAL ANOMALY
4.00
1.00
46746
REPAIR OF CLOACAL ANOMALY
86.36
1.00
46746
REPAIR OF CLOACAL ANOMALY
86.63
1.00
46746
REPAIR OF CLOACAL ANOMALY
99.18
1.00
46748
REPAIR OF CLOACAL ANOMALY
4.00
1.00
46748
REPAIR OF CLOACAL ANOMALY
91.26
1.00
46748
REPAIR OF CLOACAL ANOMALY
92.73
1.00
46748
REPAIR OF CLOACAL ANOMALY
101.96
1.00
46750
REPAIR OF ANAL SPHINCTER
4.00
1.00
46750
REPAIR OF ANAL SPHINCTER
16.16
1.00
46750
REPAIR OF ANAL SPHINCTER
16.57
1.00
46750
REPAIR OF ANAL SPHINCTER
18.88
1.00
46751
REPAIR OF ANAL SPHINCTER
4.00
1.00
46751
REPAIR OF ANAL SPHINCTER
15.21
1.00
Procedure Code Description
RVU
RVU Coeff Value
46751
REPAIR OF ANAL SPHINCTER
15.71
1.00
46751
REPAIR OF ANAL SPHINCTER
15.93
1.00
46753
RECONSTRUCTION OF ANUS
3.00
1.00
46753
RECONSTRUCTION OF ANUS
12.86
1.00
46753
RECONSTRUCTION OF ANUS
12.88
1.00
46753
RECONSTRUCTION OF ANUS
14.30
1.00
46754
REMOVAL OF SUTURE FROM ANUS
3.68
1.00
46754
REMOVAL OF SUTURE FROM ANUS
4.00
1.00
46754
REMOVAL OF SUTURE FROM ANUS
4.04
1.00
46754
REMOVAL OF SUTURE FROM ANUS
5.21
1.00
46760
REPAIR OF ANAL SPHINCTER
4.00
1.00
46760
REPAIR OF ANAL SPHINCTER
22.36
1.00
46760
REPAIR OF ANAL SPHINCTER
22.56
1.00
46760
REPAIR OF ANAL SPHINCTER
26.72
1.00
46761
REPAIR OF ANAL SPHINCTER
4.00
1.00
46761
REPAIR OF ANAL SPHINCTER
20.89
1.00
46761
REPAIR OF ANAL SPHINCTER
21.25
1.00
46761
REPAIR OF ANAL SPHINCTER
23.12
1.00
46762
IMPLANT ARTIFICIAL SPHINCTER
4.00
1.00
46762
IMPLANT ARTIFICIAL SPHINCTER
19.11
1.00
46762
IMPLANT ARTIFICIAL SPHINCTER
19.14
1.00
46762
IMPLANT ARTIFICIAL SPHINCTER
22.74
1.00
46900
DESTRUCTION, ANAL LESION(S)
2.79
1.00
46900
DESTRUCTION, ANAL LESION(S)
2.86
1.00
46900
DESTRUCTION, ANAL LESION(S)
3.00
1.00
46900
DESTRUCTION, ANAL LESION(S)
3.41
1.00
46910
DESTRUCTION, ANAL LESION(S)
3.00
1.00
46910
DESTRUCTION, ANAL LESION(S)
3.13
1.00
46910
DESTRUCTION, ANAL LESION(S)
3.27
1.00
46910
DESTRUCTION, ANAL LESION(S)
3.46
1.00
46916
CRYOSURGERY, ANAL LESION(S)
3.37
1.00
46916
CRYOSURGERY, ANAL LESION(S)
3.57
1.00
46916
CRYOSURGERY, ANAL LESION(S)
3.62
1.00
46917
LASER SURGERY, ANAL LESIONS
3.17
1.00
46917
LASER SURGERY, ANAL LESIONS
3.30
1.00
Procedure Code Description
RVU
RVU Coeff Value
46917
LASER SURGERY, ANAL LESIONS
3.54
1.00
46922
EXCISION OF ANAL LESION(S)
3.00
1.00
46922
EXCISION OF ANAL LESION(S)
3.16
1.00
46922
EXCISION OF ANAL LESION(S)
3.28
1.00
46922
EXCISION OF ANAL LESION(S)
3.46
1.00
46924
DESTRUCTION, ANAL LESION(S)
4.00
1.00
46924
DESTRUCTION, ANAL LESION(S)
4.36
1.00
46924
DESTRUCTION, ANAL LESION(S)
4.44
1.00
46924
DESTRUCTION, ANAL LESION(S)
4.47
1.00
46924
DESTRUCTION, ANAL LESION(S)
4.56
1.00
46924
DESTRUCTION, ANAL LESION(S)
4.65
1.00
46930
DESTROY INTERNAL HEMORRHOIDS
3.81
1.00
46934
DESTRUCTION OF HEMORRHOIDS
4.00
1.00
46934
DESTRUCTION OF HEMORRHOIDS
6.51
1.00
46934
DESTRUCTION OF HEMORRHOIDS
7.02
1.00
46934
DESTRUCTION OF HEMORRHOIDS
7.35
1.00
46935
DESTRUCTION OF HEMORRHOIDS
3.00
1.00
46935
DESTRUCTION OF HEMORRHOIDS
3.46
1.00
46935
DESTRUCTION OF HEMORRHOIDS
3.83
1.00
46935
DESTRUCTION OF HEMORRHOIDS
3.85
1.00
46936
DESTRUCTION OF HEMORRHOIDS
3.00
1.00
46936
DESTRUCTION OF HEMORRHOIDS
6.30
1.00
46936
DESTRUCTION OF HEMORRHOIDS
6.61
1.00
46936
DESTRUCTION OF HEMORRHOIDS
7.42
1.00
46937
CRYOTHERAPY OF RECTAL LESION
4.00
1.00
46937
CRYOTHERAPY OF RECTAL LESION
4.05
1.00
46937
CRYOTHERAPY OF RECTAL LESION
4.32
1.00
46937
CRYOTHERAPY OF RECTAL LESION
4.58
1.00
46938
CRYOTHERAPY OF RECTAL LESION
4.00
1.00
46938
CRYOTHERAPY OF RECTAL LESION
7.83
1.00
46938
CRYOTHERAPY OF RECTAL LESION
8.31
1.00
46938
CRYOTHERAPY OF RECTAL LESION
8.93
1.00
46940
TREATMENT OF ANAL FISSURE
3.00
1.00
46940
TREATMENT OF ANAL FISSURE
3.30
1.00
46940
TREATMENT OF ANAL FISSURE
3.62
1.00
Procedure Code Description
RVU
RVU Coeff Value
46940
TREATMENT OF ANAL FISSURE
3.64
1.00
46942
TREATMENT OF ANAL FISSURE
2.87
1.00
46942
TREATMENT OF ANAL FISSURE
3.00
1.00
46942
TREATMENT OF ANAL FISSURE
3.23
1.00
46945
LIGATION OF HEMORRHOIDS
3.93
1.00
46945
LIGATION OF HEMORRHOIDS
4.00
1.00
46945
LIGATION OF HEMORRHOIDS
4.16
1.00
46945
LIGATION OF HEMORRHOIDS
5.14
1.00
46946
LIGATION OF HEMORRHOIDS
4.00
1.00
46946
LIGATION OF HEMORRHOIDS
4.70
1.00
46946
LIGATION OF HEMORRHOIDS
5.25
1.00
46946
LIGATION OF HEMORRHOIDS
5.45
1.00
46947
HEMORRHOIDOPEXY BY STAPLING
9.30
1.00
47000
NEEDLE BIOPSY OF LIVER
2.64
1.00
47000
NEEDLE BIOPSY OF LIVER
2.75
1.00
47000
NEEDLE BIOPSY OF LIVER
3.00
1.00
47001
NEEDLE BIOPSY, LIVER ADD-ON
2.70
1.00
47001
NEEDLE BIOPSY, LIVER ADD-ON
2.75
1.00
47001
NEEDLE BIOPSY, LIVER ADD-ON
2.77
1.00
47010
OPEN DRAINAGE, LIVER LESION
12.00
1.00
47010
OPEN DRAINAGE, LIVER LESION
25.32
1.00
47010
OPEN DRAINAGE, LIVER LESION
26.32
1.00
47010
OPEN DRAINAGE, LIVER LESION
29.62
1.00
47011
PERCUT DRAIN, LIVER LESION
5.11
1.00
47011
PERCUT DRAIN, LIVER LESION
5.32
1.00
47011
PERCUT DRAIN, LIVER LESION
8.25
1.00
47011
PERCUT DRAIN, LIVER LESION
10.00
1.00
47015
INJECT/ASPIRATE LIVER CYST
7.00
1.00
47015
INJECT/ASPIRATE LIVER CYST
23.69
1.00
47015
INJECT/ASPIRATE LIVER CYST
23.81
1.00
47015
INJECT/ASPIRATE LIVER CYST
28.14
1.00
47100
WEDGE BIOPSY OF LIVER
6.00
1.00
47100
WEDGE BIOPSY OF LIVER
18.65
1.00
47100
WEDGE BIOPSY OF LIVER
18.72
1.00
47100
WEDGE BIOPSY OF LIVER
20.69
1.00
Procedure Code Description
RVU
RVU Coeff Value
47120
PARTIAL REMOVAL OF LIVER
12.00
1.00
47120
PARTIAL REMOVAL OF LIVER
53.49
1.00
47120
PARTIAL REMOVAL OF LIVER
54.34
1.00
47120
PARTIAL REMOVAL OF LIVER
58.30
1.00
47122
EXTENSIVE REMOVAL OF LIVER
13.00
1.00
47122
EXTENSIVE REMOVAL OF LIVER
81.01
1.00
47122
EXTENSIVE REMOVAL OF LIVER
82.16
1.00
47122
EXTENSIVE REMOVAL OF LIVER
86.82
1.00
47125
PARTIAL REMOVAL OF LIVER
13.00
1.00
47125
PARTIAL REMOVAL OF LIVER
72.63
1.00
47125
PARTIAL REMOVAL OF LIVER
73.79
1.00
47125
PARTIAL REMOVAL OF LIVER
77.77
1.00
47130
PARTIAL REMOVAL OF LIVER
13.00
1.00
47130
PARTIAL REMOVAL OF LIVER
78.60
1.00
47130
PARTIAL REMOVAL OF LIVER
79.70
1.00
47130
PARTIAL REMOVAL OF LIVER
83.62
1.00
47134
PARTIAL REMOVAL, DONOR LIVER
13.00
1.00
47134
PARTIAL REMOVAL, DONOR LIVER
56.69
1.00
47135
TRANSPLANTATION OF LIVER
13.00
1.00
47135
TRANSPLANTATION OF LIVER
122.99
1.00
47135
TRANSPLANTATION OF LIVER
123.28
1.00
47135
TRANSPLANTATION OF LIVER
132.17
1.00
47136
TRANSPLANTATION OF LIVER
13.00
1.00
47136
TRANSPLANTATION OF LIVER
104.36
1.00
47136
TRANSPLANTATION OF LIVER
104.89
1.00
47136
TRANSPLANTATION OF LIVER
117.36
1.00
47300
SURGERY FOR LIVER LESION
7.00
1.00
47300
SURGERY FOR LIVER LESION
23.52
1.00
47300
SURGERY FOR LIVER LESION
23.58
1.00
47300
SURGERY FOR LIVER LESION
27.75
1.00
47350
REPAIR LIVER WOUND
13.00
1.00
47350
REPAIR LIVER WOUND
29.97
1.00
47350
REPAIR LIVER WOUND
30.02
1.00
47350
REPAIR LIVER WOUND
34.10
1.00
47360
REPAIR LIVER WOUND
13.00
1.00
Procedure Code Description
RVU
RVU Coeff Value
47360
REPAIR LIVER WOUND
40.61
1.00
47360
REPAIR LIVER WOUND
41.14
1.00
47360
REPAIR LIVER WOUND
46.34
1.00
47361
REPAIR LIVER WOUND
13.00
1.00
47361
REPAIR LIVER WOUND
69.44
1.00
47361
REPAIR LIVER WOUND
69.80
1.00
47361
REPAIR LIVER WOUND
76.26
1.00
47362
REPAIR LIVER WOUND
13.00
1.00
47362
REPAIR LIVER WOUND
28.75
1.00
47362
REPAIR LIVER WOUND
29.27
1.00
47362
REPAIR LIVER WOUND
35.32
1.00
47370
LAPARO ABLATE LIVER TUMOR RF
7.00
1.00
47370
LAPARO ABLATE LIVER TUMOR RF
28.87
1.00
47370
LAPARO ABLATE LIVER TUMOR RF
30.26
1.00
47370
LAPARO ABLATE LIVER TUMOR RF
31.24
1.00
47371
LAPARO ABLATE LIVER CRYOSURG
7.00
1.00
47371
LAPARO ABLATE LIVER CRYOSURG
28.88
1.00
47371
LAPARO ABLATE LIVER CRYOSURG
30.26
1.00
47371
LAPARO ABLATE LIVER CRYOSURG
31.83
1.00
47380
OPEN ABLATE LIVER TUMOR RF
7.00
1.00
47380
OPEN ABLATE LIVER TUMOR RF
33.39
1.00
47380
OPEN ABLATE LIVER TUMOR RF
34.86
1.00
47380
OPEN ABLATE LIVER TUMOR RF
36.48
1.00
47381
OPEN ABLATE LIVER TUMOR CRYO
7.00
1.00
47381
OPEN ABLATE LIVER TUMOR CRYO
33.92
1.00
47381
OPEN ABLATE LIVER TUMOR CRYO
35.24
1.00
47381
OPEN ABLATE LIVER TUMOR CRYO
37.17
1.00
47382
PERCUT ABLATE LIVER RF
4.00
1.00
47382
PERCUT ABLATE LIVER RF
22.58
1.00
47382
PERCUT ABLATE LIVER RF
22.64
1.00
47382
PERCUT ABLATE LIVER RF
22.79
1.00
47400
INCISION OF LIVER DUCT
7.00
1.00
47400
INCISION OF LIVER DUCT
48.19
1.00
47400
INCISION OF LIVER DUCT
48.75
1.00
47400
INCISION OF LIVER DUCT
52.60
1.00
Procedure Code Description
RVU
RVU Coeff Value
47420
INCISION OF BILE DUCT
7.00
1.00
47420
INCISION OF BILE DUCT
30.72
1.00
47420
INCISION OF BILE DUCT
30.73
1.00
47420
INCISION OF BILE DUCT
33.42
1.00
47425
INCISION OF BILE DUCT
6.00
1.00
47425
INCISION OF BILE DUCT
30.60
1.00
47425
INCISION OF BILE DUCT
30.65
1.00
47425
INCISION OF BILE DUCT
33.74
1.00
47460
INCISE BILE DUCT SPHINCTER
4.00
1.00
47460
INCISE BILE DUCT SPHINCTER
27.93
1.00
47460
INCISE BILE DUCT SPHINCTER
28.24
1.00
47460
INCISE BILE DUCT SPHINCTER
31.78
1.00
47480
INCISION OF GALLBLADDER
7.00
1.00
47480
INCISION OF GALLBLADDER
17.80
1.00
47480
INCISION OF GALLBLADDER
18.25
1.00
47480
INCISION OF GALLBLADDER
21.15
1.00
47490
INCISION OF GALLBLADDER
3.00
1.00
47490
INCISION OF GALLBLADDER
13.45
1.00
47490
INCISION OF GALLBLADDER
14.07
1.00
47490
INCISION OF GALLBLADDER
15.05
1.00
47500
INJECTION FOR LIVER X-RAYS
2.71
1.00
47500
INJECTION FOR LIVER X-RAYS
2.83
1.00
47500
INJECTION FOR LIVER X-RAYS
4.00
1.00
47505
INJECTION FOR LIVER X-RAYS
1.05
1.00
47505
INJECTION FOR LIVER X-RAYS
1.09
1.00
47510
INSERT CATHETER, BILE DUCT
4.00
1.00
47510
INSERT CATHETER, BILE DUCT
12.88
1.00
47510
INSERT CATHETER, BILE DUCT
13.26
1.00
47510
INSERT CATHETER, BILE DUCT
13.34
1.00
47511
INSERT BILE DUCT DRAIN
16.14
1.00
47511
INSERT BILE DUCT DRAIN
16.76
1.00
47511
INSERT BILE DUCT DRAIN
21.34
1.00
47511
INSERT BILE DUCT DRAIN
999.99
1.00
47525
CHANGE BILE DUCT CATHETER
3.22
1.00
47525
CHANGE BILE DUCT CATHETER
9.04
1.00
Procedure Code Description
RVU
RVU Coeff Value
47525
CHANGE BILE DUCT CATHETER
9.09
1.00
47530
REVISE/REINSERT BILE TUBE
3.00
1.00
47530
REVISE/REINSERT BILE TUBE
10.03
1.00
47530
REVISE/REINSERT BILE TUBE
10.51
1.00
47530
REVISE/REINSERT BILE TUBE
11.07
1.00
47550
BILE DUCT ENDOSCOPY ADD-ON
4.32
1.00
47550
BILE DUCT ENDOSCOPY ADD-ON
4.36
1.00
47550
BILE DUCT ENDOSCOPY ADD-ON
4.41
1.00
47552
BILIARY ENDOSCOPY THRU SKIN
5.00
1.00
47552
BILIARY ENDOSCOPY THRU SKIN
8.90
1.00
47552
BILIARY ENDOSCOPY THRU SKIN
8.94
1.00
47552
BILIARY ENDOSCOPY THRU SKIN
9.12
1.00
47553
BILIARY ENDOSCOPY THRU SKIN
5.00
1.00
47553
BILIARY ENDOSCOPY THRU SKIN
9.10
1.00
47553
BILIARY ENDOSCOPY THRU SKIN
9.29
1.00
47553
BILIARY ENDOSCOPY THRU SKIN
9.30
1.00
47554
BILIARY ENDOSCOPY THRU SKIN
5.00
1.00
47554
BILIARY ENDOSCOPY THRU SKIN
13.24
1.00
47554
BILIARY ENDOSCOPY THRU SKIN
13.32
1.00
47554
BILIARY ENDOSCOPY THRU SKIN
13.47
1.00
47555
BILIARY ENDOSCOPY THRU SKIN
5.00
1.00
47555
BILIARY ENDOSCOPY THRU SKIN
10.92
1.00
47555
BILIARY ENDOSCOPY THRU SKIN
10.96
1.00
47555
BILIARY ENDOSCOPY THRU SKIN
10.98
1.00
47556
BILIARY ENDOSCOPY THRU SKIN
12.33
1.00
47556
BILIARY ENDOSCOPY THRU SKIN
12.34
1.00
47556
BILIARY ENDOSCOPY THRU SKIN
12.35
1.00
47556
BILIARY ENDOSCOPY THRU SKIN
999.99
1.00
47560
LAPAROSCOPY W/CHOLANGIO
6.00
1.00
47560
LAPAROSCOPY W/CHOLANGIO
6.98
1.00
47560
LAPAROSCOPY W/CHOLANGIO
7.22
1.00
47560
LAPAROSCOPY W/CHOLANGIO
7.30
1.00
47561
LAPARO W/CHOLANGIO/BIOPSY
6.00
1.00
47561
LAPARO W/CHOLANGIO/BIOPSY
7.56
1.00
47561
LAPARO W/CHOLANGIO/BIOPSY
7.80
1.00
Procedure Code Description
RVU
RVU Coeff Value
47561
LAPARO W/CHOLANGIO/BIOPSY
7.89
1.00
47562
LAPAROSCOPIC CHOLECYSTECTOMY
6.00
1.00
47562
LAPAROSCOPIC CHOLECYSTECTOMY
17.23
1.00
47562
LAPAROSCOPIC CHOLECYSTECTOMY
17.43
1.00
47562
LAPAROSCOPIC CHOLECYSTECTOMY
18.41
1.00
47563
LAPARO CHOLECYSTECTOMY/GRAPH
6.00
1.00
47563
LAPARO CHOLECYSTECTOMY/GRAPH
18.42
1.00
47563
LAPARO CHOLECYSTECTOMY/GRAPH
18.70
1.00
47563
LAPARO CHOLECYSTECTOMY/GRAPH
18.87
1.00
47564
LAPARO CHOLECYSTECTOMY/EXPLR
6.00
1.00
47564
LAPARO CHOLECYSTECTOMY/EXPLR
21.75
1.00
47564
LAPARO CHOLECYSTECTOMY/EXPLR
21.82
1.00
47564
LAPARO CHOLECYSTECTOMY/EXPLR
21.92
1.00
47570
LAPARO CHOLECYSTOENTEROSTOMY
6.00
1.00
47570
LAPARO CHOLECYSTOENTEROSTOMY
19.36
1.00
47570
LAPARO CHOLECYSTOENTEROSTOMY
19.47
1.00
47570
LAPARO CHOLECYSTOENTEROSTOMY
19.49
1.00
47600
REMOVAL OF GALLBLADDER
7.00
1.00
47600
REMOVAL OF GALLBLADDER
21.16
1.00
47600
REMOVAL OF GALLBLADDER
21.41
1.00
47600
REMOVAL OF GALLBLADDER
26.29
1.00
47605
REMOVAL OF GALLBLADDER
7.00
1.00
47605
REMOVAL OF GALLBLADDER
22.73
1.00
47605
REMOVAL OF GALLBLADDER
22.97
1.00
47605
REMOVAL OF GALLBLADDER
24.43
1.00
47610
REMOVAL OF GALLBLADDER
7.00
1.00
47610
REMOVAL OF GALLBLADDER
28.72
1.00
47610
REMOVAL OF GALLBLADDER
29.02
1.00
47610
REMOVAL OF GALLBLADDER
31.31
1.00
47612
REMOVAL OF GALLBLADDER
7.00
1.00
47612
REMOVAL OF GALLBLADDER
28.62
1.00
47612
REMOVAL OF GALLBLADDER
28.83
1.00
47612
REMOVAL OF GALLBLADDER
31.62
1.00
47620
REMOVAL OF GALLBLADDER
7.00
1.00
47620
REMOVAL OF GALLBLADDER
31.33
1.00
Procedure Code Description
RVU
RVU Coeff Value
47620
REMOVAL OF GALLBLADDER
31.53
1.00
47620
REMOVAL OF GALLBLADDER
34.34
1.00
47630
REMOVE BILE DUCT STONE
7.00
1.00
47630
REMOVE BILE DUCT STONE
12.65
1.00
47630
REMOVE BILE DUCT STONE
14.45
1.00
47630
REMOVE BILE DUCT STONE
15.24
1.00
47700
EXPLORATION OF BILE DUCTS
7.00
1.00
47700
EXPLORATION OF BILE DUCTS
24.77
1.00
47700
EXPLORATION OF BILE DUCTS
25.53
1.00
47700
EXPLORATION OF BILE DUCTS
26.08
1.00
47701
BILE DUCT REVISION
7.00
1.00
47701
BILE DUCT REVISION
42.97
1.00
47701
BILE DUCT REVISION
43.87
1.00
47701
BILE DUCT REVISION
44.90
1.00
47711
EXCISION OF BILE DUCT TUMOR
7.00
1.00
47711
EXCISION OF BILE DUCT TUMOR
35.40
1.00
47711
EXCISION OF BILE DUCT TUMOR
36.03
1.00
47711
EXCISION OF BILE DUCT TUMOR
38.86
1.00
47712
EXCISION OF BILE DUCT TUMOR
7.00
1.00
47712
EXCISION OF BILE DUCT TUMOR
45.91
1.00
47712
EXCISION OF BILE DUCT TUMOR
46.54
1.00
47712
EXCISION OF BILE DUCT TUMOR
49.76
1.00
47715
EXCISION OF BILE DUCT CYST
7.00
1.00
47715
EXCISION OF BILE DUCT CYST
29.14
1.00
47715
EXCISION OF BILE DUCT CYST
29.18
1.00
47715
EXCISION OF BILE DUCT CYST
32.64
1.00
47716
FUSION OF BILE DUCT CYST
7.00
1.00
47716
FUSION OF BILE DUCT CYST
26.00
1.00
47716
FUSION OF BILE DUCT CYST
26.05
1.00
47716
FUSION OF BILE DUCT CYST
26.39
1.00
47719
FUSION OF BILE DUCT CYST
29.07
1.00
47720
FUSE GALLBLADDER & BOWEL
7.00
1.00
47720
FUSE GALLBLADDER & BOWEL
25.08
1.00
47720
FUSE GALLBLADDER & BOWEL
25.76
1.00
47720
FUSE GALLBLADDER & BOWEL
28.19
1.00
Procedure Code Description
RVU
RVU Coeff Value
47721
FUSE UPPER GI STRUCTURES
7.00
1.00
47721
FUSE UPPER GI STRUCTURES
29.69
1.00
47721
FUSE UPPER GI STRUCTURES
30.35
1.00
47721
FUSE UPPER GI STRUCTURES
33.27
1.00
47740
FUSE GALLBLADDER & BOWEL
7.00
1.00
47740
FUSE GALLBLADDER & BOWEL
28.82
1.00
47740
FUSE GALLBLADDER & BOWEL
29.47
1.00
47740
FUSE GALLBLADDER & BOWEL
32.14
1.00
47741
FUSE GALLBLADDER & BOWEL
7.00
1.00
47741
FUSE GALLBLADDER & BOWEL
32.86
1.00
47741
FUSE GALLBLADDER & BOWEL
33.49
1.00
47741
FUSE GALLBLADDER & BOWEL
36.44
1.00
47760
FUSE BILE DUCTS AND BOWEL
7.00
1.00
47760
FUSE BILE DUCTS AND BOWEL
39.40
1.00
47760
FUSE BILE DUCTS AND BOWEL
39.99
1.00
47760
FUSE BILE DUCTS AND BOWEL
54.55
1.00
47765
FUSE LIVER DUCTS & BOWEL
7.00
1.00
47765
FUSE LIVER DUCTS & BOWEL
38.36
1.00
47765
FUSE LIVER DUCTS & BOWEL
39.43
1.00
47765
FUSE LIVER DUCTS & BOWEL
71.56
1.00
47780
FUSE BILE DUCTS AND BOWEL
7.00
1.00
47780
FUSE BILE DUCTS AND BOWEL
40.48
1.00
47780
FUSE BILE DUCTS AND BOWEL
40.94
1.00
47780
FUSE BILE DUCTS AND BOWEL
59.56
1.00
47785
FUSE BILE DUCTS AND BOWEL
7.00
1.00
47785
FUSE BILE DUCTS AND BOWEL
47.38
1.00
47785
FUSE BILE DUCTS AND BOWEL
48.36
1.00
47785
FUSE BILE DUCTS AND BOWEL
77.47
1.00
47800
RECONSTRUCTION OF BILE DUCTS
7.00
1.00
47800
RECONSTRUCTION OF BILE DUCTS
35.75
1.00
47800
RECONSTRUCTION OF BILE DUCTS
36.40
1.00
47800
RECONSTRUCTION OF BILE DUCTS
39.24
1.00
47801
PLACEMENT, BILE DUCT SUPPORT
7.00
1.00
47801
PLACEMENT, BILE DUCT SUPPORT
24.31
1.00
47801
PLACEMENT, BILE DUCT SUPPORT
25.89
1.00
Procedure Code Description 47801
PLACEMENT, BILE DUCT SUPPORT
47802
RVU
RVU Coeff Value
27.43
1.00
FUSE LIVER DUCT & INTESTINE
7.00
1.00
47802
FUSE LIVER DUCT & INTESTINE
33.50
1.00
47802
FUSE LIVER DUCT & INTESTINE
34.52
1.00
47802
FUSE LIVER DUCT & INTESTINE
37.64
1.00
47900
SUTURE BILE DUCT INJURY
7.00
1.00
47900
SUTURE BILE DUCT INJURY
30.79
1.00
47900
SUTURE BILE DUCT INJURY
31.46
1.00
47900
SUTURE BILE DUCT INJURY
33.95
1.00
48000
DRAINAGE OF ABDOMEN
7.00
1.00
48000
DRAINAGE OF ABDOMEN
41.20
1.00
48000
DRAINAGE OF ABDOMEN
41.79
1.00
48000
DRAINAGE OF ABDOMEN
46.98
1.00
48001
PLACEMENT OF DRAIN, PANCREAS
4.00
1.00
48001
PLACEMENT OF DRAIN, PANCREAS
51.64
1.00
48001
PLACEMENT OF DRAIN, PANCREAS
52.05
1.00
48001
PLACEMENT OF DRAIN, PANCREAS
57.88
1.00
48005
RESECT/DEBRIDE PANCREAS
7.00
1.00
48005
RESECT/DEBRIDE PANCREAS
61.42
1.00
48005
RESECT/DEBRIDE PANCREAS
61.47
1.00
48005
RESECT/DEBRIDE PANCREAS
64.24
1.00
48020
REMOVAL OF PANCREATIC STONE
7.00
1.00
48020
REMOVAL OF PANCREATIC STONE
24.44
1.00
48020
REMOVAL OF PANCREATIC STONE
24.67
1.00
48020
REMOVAL OF PANCREATIC STONE
28.98
1.00
48100
BIOPSY OF PANCREAS, OPEN
7.00
1.00
48100
BIOPSY OF PANCREAS, OPEN
19.16
1.00
48100
BIOPSY OF PANCREAS, OPEN
20.14
1.00
48100
BIOPSY OF PANCREAS, OPEN
22.00
1.00
48102
NEEDLE BIOPSY, PANCREAS
7.00
1.00
48102
NEEDLE BIOPSY, PANCREAS
7.02
1.00
48102
NEEDLE BIOPSY, PANCREAS
7.26
1.00
48102
NEEDLE BIOPSY, PANCREAS
7.36
1.00
48105
RESECT/DEBRIDE PANCREAS
71.26
1.00
48120
REMOVAL OF PANCREAS LESION
7.00
1.00
Procedure Code Description
RVU
RVU Coeff Value
48120
REMOVAL OF PANCREAS LESION
24.36
1.00
48120
REMOVAL OF PANCREAS LESION
24.56
1.00
48120
REMOVAL OF PANCREAS LESION
27.50
1.00
48140
PARTIAL REMOVAL OF PANCREAS
7.00
1.00
48140
PARTIAL REMOVAL OF PANCREAS
35.07
1.00
48140
PARTIAL REMOVAL OF PANCREAS
35.57
1.00
48140
PARTIAL REMOVAL OF PANCREAS
38.95
1.00
48145
PARTIAL REMOVAL OF PANCREAS
7.00
1.00
48145
PARTIAL REMOVAL OF PANCREAS
36.60
1.00
48145
PARTIAL REMOVAL OF PANCREAS
37.45
1.00
48145
PARTIAL REMOVAL OF PANCREAS
40.46
1.00
48146
PANCREATECTOMY
8.00
1.00
48146
PANCREATECTOMY
41.38
1.00
48146
PANCREATECTOMY
42.12
1.00
48146
PANCREATECTOMY
46.14
1.00
48148
REMOVAL OF PANCREATIC DUCT
7.00
1.00
48148
REMOVAL OF PANCREATIC DUCT
26.93
1.00
48148
REMOVAL OF PANCREATIC DUCT
27.93
1.00
48148
REMOVAL OF PANCREATIC DUCT
30.63
1.00
48150
PARTIAL REMOVAL OF PANCREAS
7.00
1.00
48150
PARTIAL REMOVAL OF PANCREAS
72.92
1.00
48150
PARTIAL REMOVAL OF PANCREAS
73.81
1.00
48150
PARTIAL REMOVAL OF PANCREAS
78.01
1.00
48152
PANCREATECTOMY
8.00
1.00
48152
PANCREATECTOMY
66.94
1.00
48152
PANCREATECTOMY
68.07
1.00
48152
PANCREATECTOMY
72.12
1.00
48153
PANCREATECTOMY
8.00
1.00
48153
PANCREATECTOMY
72.87
1.00
48153
PANCREATECTOMY
73.87
1.00
48153
PANCREATECTOMY
77.90
1.00
48154
PANCREATECTOMY
8.00
1.00
48154
PANCREATECTOMY
67.36
1.00
48154
PANCREATECTOMY
68.33
1.00
48154
PANCREATECTOMY
72.31
1.00
Procedure Code Description
RVU
RVU Coeff Value
48155
REMOVAL OF PANCREAS
7.00
1.00
48155
REMOVAL OF PANCREAS
39.19
1.00
48155
REMOVAL OF PANCREAS
40.42
1.00
48155
REMOVAL OF PANCREAS
44.72
1.00
48180
FUSE PANCREAS AND BOWEL
7.00
1.00
48180
FUSE PANCREAS AND BOWEL
37.60
1.00
48180
FUSE PANCREAS AND BOWEL
37.81
1.00
48180
FUSE PANCREAS AND BOWEL
38.12
1.00
48500
SURGERY OF PANCREATIC CYST
7.00
1.00
48500
SURGERY OF PANCREATIC CYST
23.87
1.00
48500
SURGERY OF PANCREATIC CYST
24.29
1.00
48500
SURGERY OF PANCREATIC CYST
28.02
1.00
48510
DRAIN PANCREATIC PSEUDOCYST
7.00
1.00
48510
DRAIN PANCREATIC PSEUDOCYST
22.87
1.00
48510
DRAIN PANCREATIC PSEUDOCYST
23.12
1.00
48510
DRAIN PANCREATIC PSEUDOCYST
26.58
1.00
48511
DRAIN PANCREATIC PSEUDOCYST
4.00
1.00
48511
DRAIN PANCREATIC PSEUDOCYST
5.51
1.00
48511
DRAIN PANCREATIC PSEUDOCYST
5.76
1.00
48511
DRAIN PANCREATIC PSEUDOCYST
7.89
1.00
48520
FUSE PANCREAS CYST AND BOWEL
7.00
1.00
48520
FUSE PANCREAS CYST AND BOWEL
24.02
1.00
48520
FUSE PANCREAS CYST AND BOWEL
24.21
1.00
48520
FUSE PANCREAS CYST AND BOWEL
27.18
1.00
48540
FUSE PANCREAS CYST AND BOWEL
7.00
1.00
48540
FUSE PANCREAS CYST AND BOWEL
30.05
1.00
48540
FUSE PANCREAS CYST AND BOWEL
30.16
1.00
48540
FUSE PANCREAS CYST AND BOWEL
32.53
1.00
48545
PANCREATORRHAPHY
7.00
1.00
48545
PANCREATORRHAPHY
28.14
1.00
48545
PANCREATORRHAPHY
28.47
1.00
48545
PANCREATORRHAPHY
32.85
1.00
48547
DUODENAL EXCLUSION
7.00
1.00
48547
DUODENAL EXCLUSION
38.92
1.00
48547
DUODENAL EXCLUSION
39.11
1.00
Procedure Code Description
RVU
RVU Coeff Value
48547
DUODENAL EXCLUSION
44.37
1.00
48548
FUSE PANCREAS AND BOWEL
41.59
1.00
48554
TRANSPL ALLOGRAFT PANCREAS
7.00
1.00
48554
TRANSPL ALLOGRAFT PANCREAS
49.41
1.00
48554
TRANSPL ALLOGRAFT PANCREAS
55.42
1.00
48554
TRANSPL ALLOGRAFT PANCREAS
61.61
1.00
48556
REMOVAL, ALLOGRAFT PANCREAS
7.00
1.00
48556
REMOVAL, ALLOGRAFT PANCREAS
25.69
1.00
48556
REMOVAL, ALLOGRAFT PANCREAS
25.81
1.00
48556
REMOVAL, ALLOGRAFT PANCREAS
30.69
1.00
49000
EXPLORATION OF ABDOMEN
5.00
1.00
49000
EXPLORATION OF ABDOMEN
18.49
1.00
49000
EXPLORATION OF ABDOMEN
18.91
1.00
49000
EXPLORATION OF ABDOMEN
19.37
1.00
49002
REOPENING OF ABDOMEN
5.00
1.00
49002
REOPENING OF ABDOMEN
16.82
1.00
49002
REOPENING OF ABDOMEN
17.51
1.00
49002
REOPENING OF ABDOMEN
25.18
1.00
49010
EXPLORATION BEHIND ABDOMEN
6.00
1.00
49010
EXPLORATION BEHIND ABDOMEN
19.68
1.00
49010
EXPLORATION BEHIND ABDOMEN
20.43
1.00
49010
EXPLORATION BEHIND ABDOMEN
23.87
1.00
49020
DRAIN ABDOMINAL ABSCESS
6.00
1.00
49020
DRAIN ABDOMINAL ABSCESS
34.63
1.00
49020
DRAIN ABDOMINAL ABSCESS
35.56
1.00
49020
DRAIN ABDOMINAL ABSCESS
39.61
1.00
49021
DRAIN ABDOMINAL ABSCESS
4.00
1.00
49021
DRAIN ABDOMINAL ABSCESS
4.68
1.00
49021
DRAIN ABDOMINAL ABSCESS
4.86
1.00
49021
DRAIN ABDOMINAL ABSCESS
8.82
1.00
49040
DRAIN, OPEN, ABDOM ABSCESS
7.00
1.00
49040
DRAIN, OPEN, ABDOM ABSCESS
20.98
1.00
49040
DRAIN, OPEN, ABDOM ABSCESS
22.55
1.00
49040
DRAIN, OPEN, ABDOM ABSCESS
24.80
1.00
49041
DRAIN, PERCUT, ABDOM ABSCESS
4.00
1.00
Procedure Code Description
RVU
RVU Coeff Value
49041
DRAIN, PERCUT, ABDOM ABSCESS
5.52
1.00
49041
DRAIN, PERCUT, ABDOM ABSCESS
5.75
1.00
49041
DRAIN, PERCUT, ABDOM ABSCESS
9.79
1.00
49060
DRAIN, OPEN, RETROP ABSCESS
7.00
1.00
49060
DRAIN, OPEN, RETROP ABSCESS
24.25
1.00
49060
DRAIN, OPEN, RETROP ABSCESS
26.21
1.00
49060
DRAIN, OPEN, RETROP ABSCESS
27.71
1.00
49061
DRAIN, PERCUT, RETROPER ABSC
4.00
1.00
49061
DRAIN, PERCUT, RETROPER ABSC
5.08
1.00
49061
DRAIN, PERCUT, RETROPER ABSC
5.11
1.00
49061
DRAIN, PERCUT, RETROPER ABSC
5.12
1.00
49061
DRAIN, PERCUT, RETROPER ABSC
5.18
1.00
49061
DRAIN, PERCUT, RETROPER ABSC
5.32
1.00
49061
DRAIN, PERCUT, RETROPER ABSC
9.49
1.00
49062
DRAIN TO PERITONEAL CAVITY
4.00
1.00
49062
DRAIN TO PERITONEAL CAVITY
18.14
1.00
49062
DRAIN TO PERITONEAL CAVITY
18.91
1.00
49062
DRAIN TO PERITONEAL CAVITY
19.51
1.00
49080
PUNCTURE, PERITONEAL CAVITY
1.88
1.00
49080
PUNCTURE, PERITONEAL CAVITY
1.89
1.00
49080
PUNCTURE, PERITONEAL CAVITY
1.90
1.00
49080
PUNCTURE, PERITONEAL CAVITY
1.94
1.00
49080
PUNCTURE, PERITONEAL CAVITY
7.00
1.00
49081
REMOVAL OF ABDOMINAL FLUID
1.83
1.00
49081
REMOVAL OF ABDOMINAL FLUID
1.90
1.00
49081
REMOVAL OF ABDOMINAL FLUID
4.00
1.00
49085
REMOVE ABDOMEN FOREIGN BODY
7.00
1.00
49085
REMOVE ABDOMEN FOREIGN BODY
18.74
1.00
49085
REMOVE ABDOMEN FOREIGN BODY
19.25
1.00
49085
REMOVE ABDOMEN FOREIGN BODY
19.58
1.00
49180
BIOPSY, ABDOMINAL MASS
2.39
1.00
49180
BIOPSY, ABDOMINAL MASS
2.40
1.00
49180
BIOPSY, ABDOMINAL MASS
2.49
1.00
49180
BIOPSY, ABDOMINAL MASS
5.00
1.00
49200
REMOVAL OF ABDOMINAL LESION
5.00
1.00
Procedure Code Description
RVU
RVU Coeff Value
49200
REMOVAL OF ABDOMINAL LESION
16.42
1.00
49200
REMOVAL OF ABDOMINAL LESION
17.16
1.00
49200
REMOVAL OF ABDOMINAL LESION
17.44
1.00
49201
REMOVE ABDOM LESION, COMPLEX
6.00
1.00
49201
REMOVE ABDOM LESION, COMPLEX
23.69
1.00
49201
REMOVE ABDOM LESION, COMPLEX
24.43
1.00
49201
REMOVE ABDOM LESION, COMPLEX
24.87
1.00
49203
EXC ABD TUM 5 CM OR LESS
30.30
1.00
49204
EXC ABD TUM OVER 5 CM
38.70
1.00
49205
EXC ABD TUM OVER 10 CM
44.32
1.00
49215
EXCISE SACRAL SPINE TUMOR
6.00
1.00
49215
EXCISE SACRAL SPINE TUMOR
50.53
1.00
49215
EXCISE SACRAL SPINE TUMOR
50.72
1.00
49215
EXCISE SACRAL SPINE TUMOR
55.61
1.00
49220
MULTIPLE SURGERY, ABDOMEN
6.00
1.00
49220
MULTIPLE SURGERY, ABDOMEN
23.37
1.00
49220
MULTIPLE SURGERY, ABDOMEN
24.02
1.00
49220
MULTIPLE SURGERY, ABDOMEN
24.20
1.00
49250
EXCISION OF UMBILICUS
6.00
1.00
49250
EXCISION OF UMBILICUS
13.68
1.00
49250
EXCISION OF UMBILICUS
14.27
1.00
49250
EXCISION OF UMBILICUS
14.45
1.00
49255
REMOVAL OF OMENTUM
5.00
1.00
49255
REMOVAL OF OMENTUM
18.13
1.00
49255
REMOVAL OF OMENTUM
18.75
1.00
49255
REMOVAL OF OMENTUM
19.60
1.00
49320
DIAG LAPARO SEPARATE PROC
6.00
1.00
49320
DIAG LAPARO SEPARATE PROC
8.29
1.00
49320
DIAG LAPARO SEPARATE PROC
8.33
1.00
49320
DIAG LAPARO SEPARATE PROC
8.61
1.00
49321
LAPAROSCOPY, BIOPSY
6.00
1.00
49321
LAPAROSCOPY, BIOPSY
8.68
1.00
49321
LAPAROSCOPY, BIOPSY
8.73
1.00
49321
LAPAROSCOPY, BIOPSY
8.92
1.00
49322
LAPAROSCOPY, ASPIRATION
6.00
1.00
Procedure Code Description
RVU
RVU Coeff Value
49322
LAPAROSCOPY, ASPIRATION
9.37
1.00
49322
LAPAROSCOPY, ASPIRATION
9.47
1.00
49322
LAPAROSCOPY, ASPIRATION
9.69
1.00
49323
LAPARO DRAIN LYMPHOCELE
6.00
1.00
49323
LAPARO DRAIN LYMPHOCELE
14.39
1.00
49323
LAPARO DRAIN LYMPHOCELE
15.05
1.00
49323
LAPARO DRAIN LYMPHOCELE
16.08
1.00
49324
LAP INSERTION PERM IP CATH
9.85
1.00
49325
LAP REVISION PERM IP CATH
10.60
1.00
49326
LAP W/OMENTOPEXY ADD-ON
4.89
1.00
49400
AIR INJECTION INTO ABDOMEN
2.71
1.00
49400
AIR INJECTION INTO ABDOMEN
2.79
1.00
49400
AIR INJECTION INTO ABDOMEN
2.80
1.00
49400
AIR INJECTION INTO ABDOMEN
6.00
1.00
49402
REMOVE FOREIGN BODY, ADBOMEN
21.35
1.00
49419
INSRT ABDOM CATH FOR CHEMOTX
10.86
1.00
49419
INSRT ABDOM CATH FOR CHEMOTX
11.01
1.00
49419
INSRT ABDOM CATH FOR CHEMOTX
11.42
1.00
49420
INSERT ABDOM DRAIN, TEMP
3.32
1.00
49420
INSERT ABDOM DRAIN, TEMP
3.50
1.00
49420
INSERT ABDOM DRAIN, TEMP
3.61
1.00
49420
INSERT ABDOM DRAIN, TEMP
4.00
1.00
49421
INSERT ABDOM DRAIN, PERM
4.00
1.00
49421
INSERT ABDOM DRAIN, PERM
9.39
1.00
49421
INSERT ABDOM DRAIN, PERM
9.81
1.00
49421
INSERT ABDOM DRAIN, PERM
10.15
1.00
49422
REMOVE PERM CANNULA/CATHETER
4.00
1.00
49422
REMOVE PERM CANNULA/CATHETER
9.81
1.00
49422
REMOVE PERM CANNULA/CATHETER
9.86
1.00
49422
REMOVE PERM CANNULA/CATHETER
9.91
1.00
49423
EXCHANGE DRAINAGE CATHETER
2.06
1.00
49423
EXCHANGE DRAINAGE CATHETER
2.09
1.00
49423
EXCHANGE DRAINAGE CATHETER
2.15
1.00
49423
EXCHANGE DRAINAGE CATHETER
2.21
1.00
49423
EXCHANGE DRAINAGE CATHETER
4.00
1.00
Procedure Code Description
RVU
RVU Coeff Value
49424
ASSESS CYST, CONTRAST INJECT
1.08
1.00
49424
ASSESS CYST, CONTRAST INJECT
1.10
1.00
49424
ASSESS CYST, CONTRAST INJECT
1.12
1.00
49424
ASSESS CYST, CONTRAST INJECT
1.23
1.00
49424
ASSESS CYST, CONTRAST INJECT
1.24
1.00
49425
INSERT ABDOMEN-VENOUS DRAIN
4.00
1.00
49425
INSERT ABDOMEN-VENOUS DRAIN
18.46
1.00
49425
INSERT ABDOMEN-VENOUS DRAIN
19.23
1.00
49425
INSERT ABDOMEN-VENOUS DRAIN
19.27
1.00
49426
REVISE ABDOMEN-VENOUS SHUNT
7.00
1.00
49426
REVISE ABDOMEN-VENOUS SHUNT
15.56
1.00
49426
REVISE ABDOMEN-VENOUS SHUNT
16.37
1.00
49426
REVISE ABDOMEN-VENOUS SHUNT
16.63
1.00
49427
INJECTION, ABDOMINAL SHUNT
1.30
1.00
49427
INJECTION, ABDOMINAL SHUNT
1.42
1.00
49427
INJECTION, ABDOMINAL SHUNT
1.43
1.00
49428
LIGATION OF SHUNT
4.00
1.00
49428
LIGATION OF SHUNT
9.53
1.00
49428
LIGATION OF SHUNT
9.71
1.00
49428
LIGATION OF SHUNT
11.00
1.00
49429
REMOVAL OF SHUNT
4.00
1.00
49429
REMOVAL OF SHUNT
11.65
1.00
49429
REMOVAL OF SHUNT
11.67
1.00
49429
REMOVAL OF SHUNT
11.81
1.00
49435
INSERT SUBQ EXTEN TO IP CATH
3.13
1.00
49436
EMBEDDED IP CATH EXIT-SITE
4.58
1.00
49440
PLACE GASTROSTOMY TUBE PERC
6.58
1.00
49441
PLACE DUOD/JEJ TUBE PERC
7.18
1.00
49442
PLACE CECOSTOMY TUBE PERC
5.93
1.00
49446
CHANGE G-TUBE TO G-J PERC
4.77
1.00
49450
REPLACE G/C TUBE PERC
1.88
1.00
49450
REPLACE G/C TUBE PERC
1.91
1.00
49451
REPLACE DUOD/JEJ TUBE PERC
2.59
1.00
49451
REPLACE DUOD/JEJ TUBE PERC
2.66
1.00
49452
REPLACE G-J TUBE PERC
4.04
1.00
Procedure Code Description
RVU
RVU Coeff Value
49452
REPLACE G-J TUBE PERC
4.15
1.00
49460
FIX G/COLON TUBE W/DEVICE
1.36
1.00
49465
FLUORO EXAM OF G/COLON TUBE
0.89
1.00
49491
RPR HERN PREEMIE REDUC
4.00
1.00
49491
RPR HERN PREEMIE REDUC
17.51
1.00
49491
RPR HERN PREEMIE REDUC
17.74
1.00
49491
RPR HERN PREEMIE REDUC
19.28
1.00
49492
RPR ING HERN PREMIE, BLOCKED
4.00
1.00
49492
RPR ING HERN PREMIE, BLOCKED
21.78
1.00
49492
RPR ING HERN PREMIE, BLOCKED
21.92
1.00
49492
RPR ING HERN PREMIE, BLOCKED
23.58
1.00
49495
RPR ING HERNIA BABY, REDUC
4.00
1.00
49495
RPR ING HERNIA BABY, REDUC
9.58
1.00
49495
RPR ING HERNIA BABY, REDUC
9.82
1.00
49495
RPR ING HERNIA BABY, REDUC
9.95
1.00
49496
RPR ING HERNIA BABY, BLOCKED
4.00
1.00
49496
RPR ING HERNIA BABY, BLOCKED
14.26
1.00
49496
RPR ING HERNIA BABY, BLOCKED
14.88
1.00
49496
RPR ING HERNIA BABY, BLOCKED
15.82
1.00
49500
RPR ING HERNIA, INIT, REDUCE
4.00
1.00
49500
RPR ING HERNIA, INIT, REDUCE
9.17
1.00
49500
RPR ING HERNIA, INIT, REDUCE
9.28
1.00
49500
RPR ING HERNIA, INIT, REDUCE
9.77
1.00
49501
RPR ING HERNIA, INIT BLOCKED
4.00
1.00
49501
RPR ING HERNIA, INIT BLOCKED
14.03
1.00
49501
RPR ING HERNIA, INIT BLOCKED
14.07
1.00
49501
RPR ING HERNIA, INIT BLOCKED
14.79
1.00
49505
PRP I/HERN INIT REDUC >5 YR
4.00
1.00
49505
PRP I/HERN INIT REDUC >5 YR
12.24
1.00
49505
PRP I/HERN INIT REDUC >5 YR
12.26
1.00
49505
PRP I/HERN INIT REDUC >5 YR
12.84
1.00
49507
PRP I/HERN INIT BLOCK >5 YR
4.00
1.00
49507
PRP I/HERN INIT BLOCK >5 YR
15.10
1.00
49507
PRP I/HERN INIT BLOCK >5 YR
15.80
1.00
49507
PRP I/HERN INIT BLOCK >5 YR
16.41
1.00
Procedure Code Description
RVU
RVU Coeff Value
49520
REREPAIR ING HERNIA, REDUCE
4.00
1.00
49520
REREPAIR ING HERNIA, REDUCE
15.12
1.00
49520
REREPAIR ING HERNIA, REDUCE
15.69
1.00
49520
REREPAIR ING HERNIA, REDUCE
15.81
1.00
49521
REREPAIR ING HERNIA, BLOCKED
4.00
1.00
49521
REREPAIR ING HERNIA, BLOCKED
18.48
1.00
49521
REREPAIR ING HERNIA, BLOCKED
18.69
1.00
49521
REREPAIR ING HERNIA, BLOCKED
19.14
1.00
49525
REPAIR ING HERNIA, SLIDING
4.00
1.00
49525
REPAIR ING HERNIA, SLIDING
13.58
1.00
49525
REPAIR ING HERNIA, SLIDING
14.14
1.00
49525
REPAIR ING HERNIA, SLIDING
14.18
1.00
49540
REPAIR LUMBAR HERNIA
4.00
1.00
49540
REPAIR LUMBAR HERNIA
16.27
1.00
49540
REPAIR LUMBAR HERNIA
16.78
1.00
49540
REPAIR LUMBAR HERNIA
16.80
1.00
49550
RPR REM HERNIA, INIT, REDUCE
4.00
1.00
49550
RPR REM HERNIA, INIT, REDUCE
13.68
1.00
49550
RPR REM HERNIA, INIT, REDUCE
13.80
1.00
49550
RPR REM HERNIA, INIT, REDUCE
14.25
1.00
49553
RPR FEM HERNIA, INIT BLOCKED
4.00
1.00
49553
RPR FEM HERNIA, INIT BLOCKED
14.89
1.00
49553
RPR FEM HERNIA, INIT BLOCKED
15.11
1.00
49553
RPR FEM HERNIA, INIT BLOCKED
15.59
1.00
49555
REREPAIR FEM HERNIA, REDUCE
4.00
1.00
49555
REREPAIR FEM HERNIA, REDUCE
14.29
1.00
49555
REREPAIR FEM HERNIA, REDUCE
14.84
1.00
49555
REREPAIR FEM HERNIA, REDUCE
14.99
1.00
49557
REREPAIR FEM HERNIA, BLOCKED
4.00
1.00
49557
REREPAIR FEM HERNIA, BLOCKED
17.33
1.00
49557
REREPAIR FEM HERNIA, BLOCKED
17.54
1.00
49557
REREPAIR FEM HERNIA, BLOCKED
18.02
1.00
49560
RPR VENTRAL HERN INIT, REDUC
4.00
1.00
49560
RPR VENTRAL HERN INIT, REDUC
17.97
1.00
49560
RPR VENTRAL HERN INIT, REDUC
18.43
1.00
Procedure Code Description
RVU
RVU Coeff Value
49560
RPR VENTRAL HERN INIT, REDUC
18.52
1.00
49561
RPR VENTRAL HERN INIT, BLOCK
6.00
1.00
49561
RPR VENTRAL HERN INIT, BLOCK
21.82
1.00
49561
RPR VENTRAL HERN INIT, BLOCK
22.01
1.00
49561
RPR VENTRAL HERN INIT, BLOCK
23.23
1.00
49565
REREPAIR VENTRL HERN, REDUCE
4.00
1.00
49565
REREPAIR VENTRL HERN, REDUCE
18.04
1.00
49565
REREPAIR VENTRL HERN, REDUCE
18.68
1.00
49565
REREPAIR VENTRL HERN, REDUCE
19.09
1.00
49566
REREPAIR VENTRL HERN, BLOCK
6.00
1.00
49566
REREPAIR VENTRL HERN, BLOCK
22.06
1.00
49566
REREPAIR VENTRL HERN, BLOCK
22.24
1.00
49566
REREPAIR VENTRL HERN, BLOCK
23.47
1.00
49568
HERNIA REPAIR W/MESH
6.00
1.00
49568
HERNIA REPAIR W/MESH
6.94
1.00
49568
HERNIA REPAIR W/MESH
7.10
1.00
49568
HERNIA REPAIR W/MESH
7.16
1.00
49570
RPR EPIGASTRIC HERN, REDUCE
4.00
1.00
49570
RPR EPIGASTRIC HERN, REDUCE
9.48
1.00
49570
RPR EPIGASTRIC HERN, REDUCE
9.62
1.00
49570
RPR EPIGASTRIC HERN, REDUCE
10.09
1.00
49572
RPR EPIGASTRIC HERN, BLOCKED
6.00
1.00
49572
RPR EPIGASTRIC HERN, BLOCKED
10.92
1.00
49572
RPR EPIGASTRIC HERN, BLOCKED
11.22
1.00
49572
RPR EPIGASTRIC HERN, BLOCKED
12.48
1.00
49580
RPR UMBIL HERN, REDUC < 5 YR
5.00
1.00
49580
RPR UMBIL HERN, REDUC < 5 YR
7.15
1.00
49580
RPR UMBIL HERN, REDUC < 5 YR
7.37
1.00
49580
RPR UMBIL HERN, REDUC < 5 YR
7.85
1.00
49582
RPR UMBIL HERN, BLOCK < 5 YR
4.00
1.00
49582
RPR UMBIL HERN, BLOCK < 5 YR
10.86
1.00
49582
RPR UMBIL HERN, BLOCK < 5 YR
11.67
1.00
49582
RPR UMBIL HERN, BLOCK < 5 YR
12.08
1.00
49585
RPR UMBIL HERN, REDUC > 5 YR
4.00
1.00
49585
RPR UMBIL HERN, REDUC > 5 YR
10.21
1.00
Procedure Code Description
RVU
RVU Coeff Value
49585
RPR UMBIL HERN, REDUC > 5 YR
10.80
1.00
49585
RPR UMBIL HERN, REDUC > 5 YR
10.85
1.00
49587
RPR UMBIL HERN, BLOCK > 5 YR
4.00
1.00
49587
RPR UMBIL HERN, BLOCK > 5 YR
12.11
1.00
49587
RPR UMBIL HERN, BLOCK > 5 YR
12.36
1.00
49587
RPR UMBIL HERN, BLOCK > 5 YR
12.86
1.00
49590
REPAIR SPIGELIAN HERNIA
4.00
1.00
49590
REPAIR SPIGELIAN HERNIA
13.55
1.00
49590
REPAIR SPIGELIAN HERNIA
14.13
1.00
49600
REPAIR UMBILICAL LESION
5.00
1.00
49600
REPAIR UMBILICAL LESION
17.69
1.00
49600
REPAIR UMBILICAL LESION
18.16
1.00
49600
REPAIR UMBILICAL LESION
18.19
1.00
49605
REPAIR UMBILICAL LESION
6.00
1.00
49605
REPAIR UMBILICAL LESION
107.64
1.00
49605
REPAIR UMBILICAL LESION
108.46
1.00
49605
REPAIR UMBILICAL LESION
125.57
1.00
49606
REPAIR UMBILICAL LESION
7.00
1.00
49606
REPAIR UMBILICAL LESION
28.56
1.00
49606
REPAIR UMBILICAL LESION
29.02
1.00
49606
REPAIR UMBILICAL LESION
29.88
1.00
49610
REPAIR UMBILICAL LESION
7.00
1.00
49610
REPAIR UMBILICAL LESION
16.67
1.00
49610
REPAIR UMBILICAL LESION
16.86
1.00
49610
REPAIR UMBILICAL LESION
18.04
1.00
49611
REPAIR UMBILICAL LESION
7.00
1.00
49611
REPAIR UMBILICAL LESION
15.14
1.00
49611
REPAIR UMBILICAL LESION
16.94
1.00
49611
REPAIR UMBILICAL LESION
19.21
1.00
49650
LAP ING HERNIA REPAIR INIT
6.00
1.00
49650
LAP ING HERNIA REPAIR INIT
10.14
1.00
49650
LAP ING HERNIA REPAIR INIT
10.26
1.00
49650
LAP ING HERNIA REPAIR INIT
10.60
1.00
49651
LAP ING HERNIA REPAIR RECUR
6.00
1.00
49651
LAP ING HERNIA REPAIR RECUR
13.33
1.00
Procedure Code Description
RVU
RVU Coeff Value
49651
LAP ING HERNIA REPAIR RECUR
13.36
1.00
49651
LAP ING HERNIA REPAIR RECUR
13.68
1.00
49652
LAP VENT/ABD HERNIA REPAIR
19.87
1.00
49653
LAP VENT/ABD HERN PROC COMP
24.80
1.00
49654
LAP INC HERNIA REPAIR
22.80
1.00
49655
LAP INC HERN REPAIR COMP
27.45
1.00
49656
LAP INC HERNIA REPAIR RECUR
22.89
1.00
49657
LAP INC HERN RECUR COMP
33.05
1.00
49900
REPAIR OF ABDOMINAL WALL
5.00
1.00
49900
REPAIR OF ABDOMINAL WALL
20.02
1.00
49900
REPAIR OF ABDOMINAL WALL
20.16
1.00
49900
REPAIR OF ABDOMINAL WALL
20.29
1.00
49904
OMENTAL FLAP, EXTRA-ABDOM
37.73
1.00
49904
OMENTAL FLAP, EXTRA-ABDOM
37.79
1.00
49904
OMENTAL FLAP, EXTRA-ABDOM
37.89
1.00
49905
OMENTAL FLAP, INTRA-ABDOM
9.23
1.00
49905
OMENTAL FLAP, INTRA-ABDOM
9.50
1.00
49905
OMENTAL FLAP, INTRA-ABDOM
9.58
1.00
49906
FREE OMENTAL FLAP, MICROVASC
4.00
1.00
50010
EXPLORATION OF KIDNEY
6.00
1.00
50010
EXPLORATION OF KIDNEY
17.33
1.00
50010
EXPLORATION OF KIDNEY
18.25
1.00
50010
EXPLORATION OF KIDNEY
19.65
1.00
50020
RENAL ABSCESS, OPEN DRAIN
6.00
1.00
50020
RENAL ABSCESS, OPEN DRAIN
24.41
1.00
50020
RENAL ABSCESS, OPEN DRAIN
28.02
1.00
50020
RENAL ABSCESS, OPEN DRAIN
29.20
1.00
50021
RENAL ABSCESS, PERCUT DRAIN
4.64
1.00
50021
RENAL ABSCESS, PERCUT DRAIN
4.66
1.00
50021
RENAL ABSCESS, PERCUT DRAIN
4.73
1.00
50021
RENAL ABSCESS, PERCUT DRAIN
4.85
1.00
50021
RENAL ABSCESS, PERCUT DRAIN
6.00
1.00
50021
RENAL ABSCESS, PERCUT DRAIN
13.51
1.00
50040
DRAINAGE OF KIDNEY
6.00
1.00
50040
DRAINAGE OF KIDNEY
24.33
1.00
Procedure Code Description
RVU
RVU Coeff Value
50040
DRAINAGE OF KIDNEY
26.34
1.00
50040
DRAINAGE OF KIDNEY
26.59
1.00
50045
EXPLORATION OF KIDNEY
6.00
1.00
50045
EXPLORATION OF KIDNEY
23.52
1.00
50045
EXPLORATION OF KIDNEY
24.40
1.00
50045
EXPLORATION OF KIDNEY
26.66
1.00
50060
REMOVAL OF KIDNEY STONE
6.00
1.00
50060
REMOVAL OF KIDNEY STONE
28.67
1.00
50060
REMOVAL OF KIDNEY STONE
29.57
1.00
50060
REMOVAL OF KIDNEY STONE
32.77
1.00
50065
INCISION OF KIDNEY
6.00
1.00
50065
INCISION OF KIDNEY
28.36
1.00
50065
INCISION OF KIDNEY
29.93
1.00
50065
INCISION OF KIDNEY
34.49
1.00
50070
INCISION OF KIDNEY
6.00
1.00
50070
INCISION OF KIDNEY
30.16
1.00
50070
INCISION OF KIDNEY
31.05
1.00
50070
INCISION OF KIDNEY
34.25
1.00
50075
REMOVAL OF KIDNEY STONE
6.00
1.00
50075
REMOVAL OF KIDNEY STONE
37.31
1.00
50075
REMOVAL OF KIDNEY STONE
38.46
1.00
50075
REMOVAL OF KIDNEY STONE
42.11
1.00
50080
REMOVAL OF KIDNEY STONE
7.00
1.00
50080
REMOVAL OF KIDNEY STONE
23.58
1.00
50080
REMOVAL OF KIDNEY STONE
25.04
1.00
50080
REMOVAL OF KIDNEY STONE
25.73
1.00
50081
REMOVAL OF KIDNEY STONE
7.00
1.00
50081
REMOVAL OF KIDNEY STONE
33.69
1.00
50081
REMOVAL OF KIDNEY STONE
35.33
1.00
50081
REMOVAL OF KIDNEY STONE
36.77
1.00
50100
REVISE KIDNEY BLOOD VESSELS
6.00
1.00
50100
REVISE KIDNEY BLOOD VESSELS
26.04
1.00
50100
REVISE KIDNEY BLOOD VESSELS
27.09
1.00
50100
REVISE KIDNEY BLOOD VESSELS
27.39
1.00
50120
EXPLORATION OF KIDNEY
6.00
1.00
Procedure Code Description
RVU
RVU Coeff Value
50120
EXPLORATION OF KIDNEY
24.11
1.00
50120
EXPLORATION OF KIDNEY
25.03
1.00
50120
EXPLORATION OF KIDNEY
27.16
1.00
50125
EXPLORE AND DRAIN KIDNEY
6.00
1.00
50125
EXPLORE AND DRAIN KIDNEY
24.91
1.00
50125
EXPLORE AND DRAIN KIDNEY
25.95
1.00
50125
EXPLORE AND DRAIN KIDNEY
28.14
1.00
50130
REMOVAL OF KIDNEY STONE
6.00
1.00
50130
REMOVAL OF KIDNEY STONE
25.89
1.00
50130
REMOVAL OF KIDNEY STONE
26.74
1.00
50130
REMOVAL OF KIDNEY STONE
29.69
1.00
50135
EXPLORATION OF KIDNEY
6.00
1.00
50135
EXPLORATION OF KIDNEY
28.55
1.00
50135
EXPLORATION OF KIDNEY
29.41
1.00
50135
EXPLORATION OF KIDNEY
32.15
1.00
50200
BIOPSY OF KIDNEY
3.00
1.00
50200
BIOPSY OF KIDNEY
3.67
1.00
50200
BIOPSY OF KIDNEY
3.68
1.00
50200
BIOPSY OF KIDNEY
4.06
1.00
50205
BIOPSY OF KIDNEY
6.00
1.00
50205
BIOPSY OF KIDNEY
17.66
1.00
50205
BIOPSY OF KIDNEY
18.45
1.00
50205
BIOPSY OF KIDNEY
19.03
1.00
50220
REMOVE KIDNEY, OPEN
6.00
1.00
50220
REMOVE KIDNEY, OPEN
25.96
1.00
50220
REMOVE KIDNEY, OPEN
26.88
1.00
50220
REMOVE KIDNEY, OPEN
29.27
1.00
50225
REMOVAL KIDNEY OPEN, COMPLEX
6.00
1.00
50225
REMOVAL KIDNEY OPEN, COMPLEX
30.08
1.00
50225
REMOVAL KIDNEY OPEN, COMPLEX
30.95
1.00
50225
REMOVAL KIDNEY OPEN, COMPLEX
33.88
1.00
50230
REMOVAL KIDNEY OPEN, RADICAL
6.00
1.00
50230
REMOVAL KIDNEY OPEN, RADICAL
32.50
1.00
50230
REMOVAL KIDNEY OPEN, RADICAL
33.46
1.00
50230
REMOVAL KIDNEY OPEN, RADICAL
36.71
1.00
Procedure Code Description
RVU
RVU Coeff Value
50234
REMOVAL OF KIDNEY & URETER
7.00
1.00
50234
REMOVAL OF KIDNEY & URETER
33.06
1.00
50234
REMOVAL OF KIDNEY & URETER
33.91
1.00
50234
REMOVAL OF KIDNEY & URETER
37.28
1.00
50236
REMOVAL OF KIDNEY & URETER
6.00
1.00
50236
REMOVAL OF KIDNEY & URETER
38.04
1.00
50236
REMOVAL OF KIDNEY & URETER
39.57
1.00
50236
REMOVAL OF KIDNEY & URETER
42.19
1.00
50240
PARTIAL REMOVAL OF KIDNEY
7.00
1.00
50240
PARTIAL REMOVAL OF KIDNEY
34.11
1.00
50240
PARTIAL REMOVAL OF KIDNEY
35.69
1.00
50240
PARTIAL REMOVAL OF KIDNEY
37.88
1.00
50250
CRYOABLATE RENAL MASS OPEN
35.14
1.00
50280
REMOVAL OF KIDNEY LESION
6.00
1.00
50280
REMOVAL OF KIDNEY LESION
23.73
1.00
50280
REMOVAL OF KIDNEY LESION
24.61
1.00
50280
REMOVAL OF KIDNEY LESION
27.04
1.00
50290
REMOVAL OF KIDNEY LESION
6.00
1.00
50290
REMOVAL OF KIDNEY LESION
22.70
1.00
50290
REMOVAL OF KIDNEY LESION
23.64
1.00
50290
REMOVAL OF KIDNEY LESION
25.04
1.00
50320
REMOVE KIDNEY, LIVING DONOR
6.00
1.00
50320
REMOVE KIDNEY, LIVING DONOR
34.23
1.00
50320
REMOVE KIDNEY, LIVING DONOR
34.29
1.00
50320
REMOVE KIDNEY, LIVING DONOR
37.09
1.00
50340
REMOVAL OF KIDNEY
6.00
1.00
50340
REMOVAL OF KIDNEY
20.45
1.00
50340
REMOVAL OF KIDNEY
22.37
1.00
50340
REMOVAL OF KIDNEY
22.93
1.00
50360
TRANSPLANTATION OF KIDNEY
6.00
1.00
50360
TRANSPLANTATION OF KIDNEY
50.82
1.00
50360
TRANSPLANTATION OF KIDNEY
51.93
1.00
50360
TRANSPLANTATION OF KIDNEY
62.61
1.00
50365
TRANSPLANTATION OF KIDNEY
6.00
1.00
50365
TRANSPLANTATION OF KIDNEY
59.53
1.00
Procedure Code Description
RVU
RVU Coeff Value
50365
TRANSPLANTATION OF KIDNEY
61.39
1.00
50365
TRANSPLANTATION OF KIDNEY
70.57
1.00
50370
REMOVE TRANSPLANTED KIDNEY
6.00
1.00
50370
REMOVE TRANSPLANTED KIDNEY
22.74
1.00
50370
REMOVE TRANSPLANTED KIDNEY
24.45
1.00
50370
REMOVE TRANSPLANTED KIDNEY
29.24
1.00
50380
REIMPLANTATION OF KIDNEY
6.00
1.00
50380
REIMPLANTATION OF KIDNEY
36.05
1.00
50380
REIMPLANTATION OF KIDNEY
36.16
1.00
50380
REIMPLANTATION OF KIDNEY
49.39
1.00
50382
CHANGE URETER STENT, PERCUT
8.03
1.00
50384
REMOVE URETER STENT, PERCUT
7.31
1.00
50385
CHANGE STENT VIA TRANSURETH
6.86
1.00
50386
REMOVE STENT VIA TRANSURETH
5.18
1.00
50387
CHANGE EXT/INT URETER STENT
2.91
1.00
50389
REMOVE RENAL TUBE W/FLUORO
1.60
1.00
50390
DRAINAGE OF KIDNEY LESION
2.71
1.00
50390
DRAINAGE OF KIDNEY LESION
2.83
1.00
50390
DRAINAGE OF KIDNEY LESION
5.00
1.00
50391
INSTLL RX AGNT INTO RNAL TUB
2.89
1.00
50392
INSERT KIDNEY DRAIN
4.66
1.00
50392
INSERT KIDNEY DRAIN
5.00
1.00
50392
INSERT KIDNEY DRAIN
5.19
1.00
50393
INSERT URETERAL TUBE
5.00
1.00
50393
INSERT URETERAL TUBE
5.72
1.00
50393
INSERT URETERAL TUBE
5.73
1.00
50393
INSERT URETERAL TUBE
6.33
1.00
50394
INJECTION FOR KIDNEY X-RAY
1.06
1.00
50394
INJECTION FOR KIDNEY X-RAY
1.43
1.00
50394
INJECTION FOR KIDNEY X-RAY
5.00
1.00
50395
CREATE PASSAGE TO KIDNEY
4.66
1.00
50395
CREATE PASSAGE TO KIDNEY
4.67
1.00
50395
CREATE PASSAGE TO KIDNEY
5.00
1.00
50395
CREATE PASSAGE TO KIDNEY
5.23
1.00
50396
MEASURE KIDNEY PRESSURE
3.06
1.00
Procedure Code Description
RVU
RVU Coeff Value
50396
MEASURE KIDNEY PRESSURE
3.07
1.00
50396
MEASURE KIDNEY PRESSURE
3.38
1.00
50396
MEASURE KIDNEY PRESSURE
5.00
1.00
50398
CHANGE KIDNEY TUBE
2.01
1.00
50398
CHANGE KIDNEY TUBE
2.02
1.00
50398
CHANGE KIDNEY TUBE
2.07
1.00
50398
CHANGE KIDNEY TUBE
999.99
1.00
50400
REVISION OF KIDNEY/URETER
7.00
1.00
50400
REVISION OF KIDNEY/URETER
28.65
1.00
50400
REVISION OF KIDNEY/URETER
29.90
1.00
50400
REVISION OF KIDNEY/URETER
33.09
1.00
50405
REVISION OF KIDNEY/URETER
7.00
1.00
50405
REVISION OF KIDNEY/URETER
36.05
1.00
50405
REVISION OF KIDNEY/URETER
36.82
1.00
50405
REVISION OF KIDNEY/URETER
40.18
1.00
50500
REPAIR OF KIDNEY WOUND
10.00
1.00
50500
REPAIR OF KIDNEY WOUND
30.06
1.00
50500
REPAIR OF KIDNEY WOUND
31.61
1.00
50500
REPAIR OF KIDNEY WOUND
32.25
1.00
50520
CLOSE KIDNEY-SKIN FISTULA
6.00
1.00
50520
CLOSE KIDNEY-SKIN FISTULA
27.47
1.00
50520
CLOSE KIDNEY-SKIN FISTULA
28.53
1.00
50520
CLOSE KIDNEY-SKIN FISTULA
29.76
1.00
50525
REPAIR RENAL-ABDOMEN FISTULA
6.00
1.00
50525
REPAIR RENAL-ABDOMEN FISTULA
34.22
1.00
50525
REPAIR RENAL-ABDOMEN FISTULA
35.77
1.00
50525
REPAIR RENAL-ABDOMEN FISTULA
37.17
1.00
50526
REPAIR RENAL-ABDOMEN FISTULA
13.00
1.00
50526
REPAIR RENAL-ABDOMEN FISTULA
36.81
1.00
50526
REPAIR RENAL-ABDOMEN FISTULA
38.91
1.00
50526
REPAIR RENAL-ABDOMEN FISTULA
39.07
1.00
50540
REVISION OF HORSESHOE KIDNEY
6.00
1.00
50540
REVISION OF HORSESHOE KIDNEY
29.99
1.00
50540
REVISION OF HORSESHOE KIDNEY
31.18
1.00
50540
REVISION OF HORSESHOE KIDNEY
32.41
1.00
Procedure Code Description
RVU
RVU Coeff Value
50541
LAPARO ABLATE RENAL CYST
6.00
1.00
50541
LAPARO ABLATE RENAL CYST
23.36
1.00
50541
LAPARO ABLATE RENAL CYST
23.58
1.00
50541
LAPARO ABLATE RENAL CYST
26.43
1.00
50542
LAPARO ABLATE RENAL MASS
29.70
1.00
50542
LAPARO ABLATE RENAL MASS
29.74
1.00
50542
LAPARO ABLATE RENAL MASS
33.52
1.00
50543
LAPARO PARTIAL NEPHRECTOMY
37.34
1.00
50543
LAPARO PARTIAL NEPHRECTOMY
37.37
1.00
50543
LAPARO PARTIAL NEPHRECTOMY
42.78
1.00
50544
LAPAROSCOPY, PYELOPLASTY
6.00
1.00
50544
LAPAROSCOPY, PYELOPLASTY
32.37
1.00
50544
LAPAROSCOPY, PYELOPLASTY
32.54
1.00
50544
LAPAROSCOPY, PYELOPLASTY
36.07
1.00
50545
LAPARO RADICAL NEPHRECTOMY
7.00
1.00
50545
LAPARO RADICAL NEPHRECTOMY
34.67
1.00
50545
LAPARO RADICAL NEPHRECTOMY
34.93
1.00
50545
LAPARO RADICAL NEPHRECTOMY
38.72
1.00
50546
LAPAROSCOPIC NEPHRECTOMY
6.00
1.00
50546
LAPAROSCOPIC NEPHRECTOMY
29.80
1.00
50546
LAPAROSCOPIC NEPHRECTOMY
30.40
1.00
50546
LAPAROSCOPIC NEPHRECTOMY
34.36
1.00
50547
LAPARO REMOVAL DONOR KIDNEY
6.00
1.00
50547
LAPARO REMOVAL DONOR KIDNEY
38.33
1.00
50547
LAPARO REMOVAL DONOR KIDNEY
38.36
1.00
50547
LAPARO REMOVAL DONOR KIDNEY
41.54
1.00
50548
LAPARO REMOVE W/URETER
6.00
1.00
50548
LAPARO REMOVE W/URETER
35.07
1.00
50548
LAPARO REMOVE W/URETER
35.27
1.00
50548
LAPARO REMOVE W/URETER
39.04
1.00
50551
KIDNEY ENDOSCOPY
6.00
1.00
50551
KIDNEY ENDOSCOPY
7.77
1.00
50551
KIDNEY ENDOSCOPY
7.79
1.00
50551
KIDNEY ENDOSCOPY
8.61
1.00
50553
KIDNEY ENDOSCOPY
8.34
1.00
Procedure Code Description
RVU
RVU Coeff Value
50553
KIDNEY ENDOSCOPY
8.35
1.00
50553
KIDNEY ENDOSCOPY
9.08
1.00
50555
KIDNEY ENDOSCOPY & BIOPSY
6.00
1.00
50555
KIDNEY ENDOSCOPY & BIOPSY
9.08
1.00
50555
KIDNEY ENDOSCOPY & BIOPSY
9.09
1.00
50555
KIDNEY ENDOSCOPY & BIOPSY
9.95
1.00
50557
KIDNEY ENDOSCOPY & TREATMENT
6.00
1.00
50557
KIDNEY ENDOSCOPY & TREATMENT
9.19
1.00
50557
KIDNEY ENDOSCOPY & TREATMENT
9.20
1.00
50557
KIDNEY ENDOSCOPY & TREATMENT
10.11
1.00
50559
RENAL ENDOSCOPY/RADIOTRACER
9.29
1.00
50559
RENAL ENDOSCOPY/RADIOTRACER
9.36
1.00
50561
KIDNEY ENDOSCOPY & TREATMENT
6.00
1.00
50561
KIDNEY ENDOSCOPY & TREATMENT
10.54
1.00
50561
KIDNEY ENDOSCOPY & TREATMENT
10.55
1.00
50561
KIDNEY ENDOSCOPY & TREATMENT
11.55
1.00
50562
RENAL SCOPE W/TUMOR RESECT
15.75
1.00
50562
RENAL SCOPE W/TUMOR RESECT
15.78
1.00
50562
RENAL SCOPE W/TUMOR RESECT
16.99
1.00
50570
KIDNEY ENDOSCOPY
6.00
1.00
50570
KIDNEY ENDOSCOPY
13.23
1.00
50570
KIDNEY ENDOSCOPY
13.27
1.00
50570
KIDNEY ENDOSCOPY
14.42
1.00
50572
KIDNEY ENDOSCOPY
6.00
1.00
50572
KIDNEY ENDOSCOPY
14.40
1.00
50572
KIDNEY ENDOSCOPY
14.43
1.00
50572
KIDNEY ENDOSCOPY
15.73
1.00
50574
KIDNEY ENDOSCOPY & BIOPSY
6.00
1.00
50574
KIDNEY ENDOSCOPY & BIOPSY
15.31
1.00
50574
KIDNEY ENDOSCOPY & BIOPSY
15.35
1.00
50574
KIDNEY ENDOSCOPY & BIOPSY
16.57
1.00
50575
KIDNEY ENDOSCOPY
6.00
1.00
50575
KIDNEY ENDOSCOPY
19.42
1.00
50575
KIDNEY ENDOSCOPY
19.45
1.00
50575
KIDNEY ENDOSCOPY
20.96
1.00
Procedure Code Description
RVU
RVU Coeff Value
50576
KIDNEY ENDOSCOPY & TREATMENT
6.00
1.00
50576
KIDNEY ENDOSCOPY & TREATMENT
15.25
1.00
50576
KIDNEY ENDOSCOPY & TREATMENT
15.28
1.00
50576
KIDNEY ENDOSCOPY & TREATMENT
16.55
1.00
50578
RENAL ENDOSCOPY/RADIOTRACER
6.00
1.00
50578
RENAL ENDOSCOPY/RADIOTRACER
15.75
1.00
50578
RENAL ENDOSCOPY/RADIOTRACER
15.78
1.00
50580
KIDNEY ENDOSCOPY & TREATMENT
6.00
1.00
50580
KIDNEY ENDOSCOPY & TREATMENT
16.46
1.00
50580
KIDNEY ENDOSCOPY & TREATMENT
16.48
1.00
50580
KIDNEY ENDOSCOPY & TREATMENT
17.72
1.00
50590
FRAGMENTING OF KIDNEY STONE
7.00
1.00
50590
FRAGMENTING OF KIDNEY STONE
14.57
1.00
50590
FRAGMENTING OF KIDNEY STONE
14.76
1.00
50590
FRAGMENTING OF KIDNEY STONE
16.14
1.00
50592
PERC RF ABLATE RENAL TUMOR
10.44
1.00
50593
PERC CRYO ABLATE RENAL TUM
13.25
1.00
50600
EXPLORATION OF URETER
5.00
1.00
50600
EXPLORATION OF URETER
24.00
1.00
50600
EXPLORATION OF URETER
24.94
1.00
50600
EXPLORATION OF URETER
26.82
1.00
50605
INSERT URETERAL SUPPORT
7.00
1.00
50605
INSERT URETERAL SUPPORT
23.80
1.00
50605
INSERT URETERAL SUPPORT
24.85
1.00
50605
INSERT URETERAL SUPPORT
25.95
1.00
50610
REMOVAL OF URETER STONE
5.00
1.00
50610
REMOVAL OF URETER STONE
24.44
1.00
50610
REMOVAL OF URETER STONE
25.44
1.00
50610
REMOVAL OF URETER STONE
27.47
1.00
50620
REMOVAL OF URETER STONE
5.00
1.00
50620
REMOVAL OF URETER STONE
22.86
1.00
50620
REMOVAL OF URETER STONE
23.71
1.00
50620
REMOVAL OF URETER STONE
25.96
1.00
50630
REMOVAL OF URETER STONE
5.00
1.00
50630
REMOVAL OF URETER STONE
22.57
1.00
Procedure Code Description
RVU
RVU Coeff Value
50630
REMOVAL OF URETER STONE
23.44
1.00
50630
REMOVAL OF URETER STONE
25.32
1.00
50650
REMOVAL OF URETER
5.00
1.00
50650
REMOVAL OF URETER
26.17
1.00
50650
REMOVAL OF URETER
27.31
1.00
50650
REMOVAL OF URETER
29.60
1.00
50660
REMOVAL OF URETER
6.00
1.00
50660
REMOVAL OF URETER
29.20
1.00
50660
REMOVAL OF URETER
30.31
1.00
50660
REMOVAL OF URETER
32.73
1.00
50684
INJECTION FOR URETER X-RAY
1.05
1.00
50684
INJECTION FOR URETER X-RAY
1.06
1.00
50684
INJECTION FOR URETER X-RAY
1.32
1.00
50684
INJECTION FOR URETER X-RAY
1.36
1.00
50684
INJECTION FOR URETER X-RAY
1.42
1.00
50686
MEASURE URETER PRESSURE
2.27
1.00
50686
MEASURE URETER PRESSURE
2.60
1.00
50686
MEASURE URETER PRESSURE
7.00
1.00
50688
CHANGE OF URETER TUBE/STENT
2.26
1.00
50688
CHANGE OF URETER TUBE/STENT
2.92
1.00
50688
CHANGE OF URETER TUBE/STENT
2.99
1.00
50690
INJECTION FOR URETER X-RAY
1.60
1.00
50690
INJECTION FOR URETER X-RAY
1.61
1.00
50690
INJECTION FOR URETER X-RAY
2.00
1.00
50700
REVISION OF URETER
5.00
1.00
50700
REVISION OF URETER
23.53
1.00
50700
REVISION OF URETER
24.82
1.00
50700
REVISION OF URETER
26.57
1.00
50715
RELEASE OF URETER
5.00
1.00
50715
RELEASE OF URETER
29.93
1.00
50715
RELEASE OF URETER
31.57
1.00
50715
RELEASE OF URETER
32.29
1.00
50722
RELEASE OF URETER
5.00
1.00
50722
RELEASE OF URETER
26.06
1.00
50722
RELEASE OF URETER
27.32
1.00
Procedure Code Description 50722
RELEASE OF URETER
50725
RVU
RVU Coeff Value
27.48
1.00
RELEASE/REVISE URETER
5.00
1.00
50725
RELEASE/REVISE URETER
28.51
1.00
50725
RELEASE/REVISE URETER
29.79
1.00
50725
RELEASE/REVISE URETER
31.23
1.00
50727
REVISE URETER
6.00
1.00
50727
REVISE URETER
13.99
1.00
50727
REVISE URETER
14.33
1.00
50727
REVISE URETER
14.48
1.00
50728
REVISE URETER
6.00
1.00
50728
REVISE URETER
19.77
1.00
50728
REVISE URETER
19.78
1.00
50728
REVISE URETER
20.45
1.00
50740
FUSION OF URETER & KIDNEY
5.00
1.00
50740
FUSION OF URETER & KIDNEY
28.15
1.00
50740
FUSION OF URETER & KIDNEY
29.00
1.00
50740
FUSION OF URETER & KIDNEY
30.88
1.00
50750
FUSION OF URETER & KIDNEY
5.00
1.00
50750
FUSION OF URETER & KIDNEY
29.25
1.00
50750
FUSION OF URETER & KIDNEY
30.38
1.00
50750
FUSION OF URETER & KIDNEY
33.30
1.00
50760
FUSION OF URETERS
5.00
1.00
50760
FUSION OF URETERS
27.85
1.00
50760
FUSION OF URETERS
29.04
1.00
50760
FUSION OF URETERS
31.14
1.00
50770
SPLICING OF URETERS
5.00
1.00
50770
SPLICING OF URETERS
29.24
1.00
50770
SPLICING OF URETERS
30.31
1.00
50770
SPLICING OF URETERS
32.26
1.00
50780
REIMPLANT URETER IN BLADDER
5.00
1.00
50780
REIMPLANT URETER IN BLADDER
27.64
1.00
50780
REIMPLANT URETER IN BLADDER
28.78
1.00
50780
REIMPLANT URETER IN BLADDER
31.22
1.00
50782
REIMPLANT URETER IN BLADDER
7.00
1.00
50782
REIMPLANT URETER IN BLADDER
30.69
1.00
Procedure Code Description
RVU
RVU Coeff Value
50782
REIMPLANT URETER IN BLADDER
30.70
1.00
50782
REIMPLANT URETER IN BLADDER
31.73
1.00
50783
REIMPLANT URETER IN BLADDER
7.00
1.00
50783
REIMPLANT URETER IN BLADDER
31.50
1.00
50783
REIMPLANT URETER IN BLADDER
31.93
1.00
50783
REIMPLANT URETER IN BLADDER
32.08
1.00
50785
REIMPLANT URETER IN BLADDER
5.00
1.00
50785
REIMPLANT URETER IN BLADDER
30.64
1.00
50785
REIMPLANT URETER IN BLADDER
31.78
1.00
50785
REIMPLANT URETER IN BLADDER
34.57
1.00
50800
IMPLANT URETER IN BOWEL
6.00
1.00
50800
IMPLANT URETER IN BOWEL
22.60
1.00
50800
IMPLANT URETER IN BOWEL
24.43
1.00
50800
IMPLANT URETER IN BOWEL
26.30
1.00
50810
FUSION OF URETER & BOWEL
7.00
1.00
50810
FUSION OF URETER & BOWEL
31.74
1.00
50810
FUSION OF URETER & BOWEL
34.11
1.00
50810
FUSION OF URETER & BOWEL
34.81
1.00
50815
URINE SHUNT TO INTESTINE
7.00
1.00
50815
URINE SHUNT TO INTESTINE
30.41
1.00
50815
URINE SHUNT TO INTESTINE
32.22
1.00
50815
URINE SHUNT TO INTESTINE
35.05
1.00
50820
CONSTRUCT BOWEL BLADDER
7.00
1.00
50820
CONSTRUCT BOWEL BLADDER
32.66
1.00
50820
CONSTRUCT BOWEL BLADDER
34.60
1.00
50820
CONSTRUCT BOWEL BLADDER
37.40
1.00
50825
CONSTRUCT BOWEL BLADDER
7.00
1.00
50825
CONSTRUCT BOWEL BLADDER
41.97
1.00
50825
CONSTRUCT BOWEL BLADDER
44.11
1.00
50825
CONSTRUCT BOWEL BLADDER
47.35
1.00
50830
REVISE URINE FLOW
7.00
1.00
50830
REVISE URINE FLOW
46.54
1.00
50830
REVISE URINE FLOW
48.28
1.00
50830
REVISE URINE FLOW
51.43
1.00
50840
REPLACE URETER BY BOWEL
7.00
1.00
Procedure Code Description
RVU
RVU Coeff Value
50840
REPLACE URETER BY BOWEL
30.42
1.00
50840
REPLACE URETER BY BOWEL
32.18
1.00
50840
REPLACE URETER BY BOWEL
35.25
1.00
50845
APPENDICO-VESICOSTOMY
6.00
1.00
50845
APPENDICO-VESICOSTOMY
31.25
1.00
50845
APPENDICO-VESICOSTOMY
31.77
1.00
50845
APPENDICO-VESICOSTOMY
35.79
1.00
50860
TRANSPLANT URETER TO SKIN
5.00
1.00
50860
TRANSPLANT URETER TO SKIN
23.45
1.00
50860
TRANSPLANT URETER TO SKIN
24.60
1.00
50860
TRANSPLANT URETER TO SKIN
27.14
1.00
50900
REPAIR OF URETER
6.00
1.00
50900
REPAIR OF URETER
21.14
1.00
50900
REPAIR OF URETER
22.00
1.00
50900
REPAIR OF URETER
23.88
1.00
50920
CLOSURE URETER/SKIN FISTULA
6.00
1.00
50920
CLOSURE URETER/SKIN FISTULA
22.11
1.00
50920
CLOSURE URETER/SKIN FISTULA
23.12
1.00
50920
CLOSURE URETER/SKIN FISTULA
25.19
1.00
50930
CLOSURE URETER/BOWEL FISTULA
6.00
1.00
50930
CLOSURE URETER/BOWEL FISTULA
28.77
1.00
50930
CLOSURE URETER/BOWEL FISTULA
29.77
1.00
50930
CLOSURE URETER/BOWEL FISTULA
30.48
1.00
50940
RELEASE OF URETER
7.00
1.00
50940
RELEASE OF URETER
22.37
1.00
50940
RELEASE OF URETER
23.20
1.00
50940
RELEASE OF URETER
25.42
1.00
50945
LAPAROSCOPY URETEROLITHOTOMY
6.00
1.00
50945
LAPAROSCOPY URETEROLITHOTOMY
25.14
1.00
50945
LAPAROSCOPY URETEROLITHOTOMY
25.32
1.00
50945
LAPAROSCOPY URETEROLITHOTOMY
28.19
1.00
50947
LAPARO NEW URETER/BLADDER
6.00
1.00
50947
LAPARO NEW URETER/BLADDER
36.39
1.00
50947
LAPARO NEW URETER/BLADDER
36.52
1.00
50947
LAPARO NEW URETER/BLADDER
40.04
1.00
Procedure Code Description
RVU
RVU Coeff Value
50948
LAPARO NEW URETER/BLADDER
6.00
1.00
50948
LAPARO NEW URETER/BLADDER
33.18
1.00
50948
LAPARO NEW URETER/BLADDER
33.30
1.00
50948
LAPARO NEW URETER/BLADDER
37.07
1.00
50951
ENDOSCOPY OF URETER
6.00
1.00
50951
ENDOSCOPY OF URETER
8.11
1.00
50951
ENDOSCOPY OF URETER
8.12
1.00
50951
ENDOSCOPY OF URETER
8.98
1.00
50953
ENDOSCOPY OF URETER
6.00
1.00
50953
ENDOSCOPY OF URETER
8.67
1.00
50953
ENDOSCOPY OF URETER
8.68
1.00
50953
ENDOSCOPY OF URETER
9.88
1.00
50955
URETER ENDOSCOPY & BIOPSY
6.00
1.00
50955
URETER ENDOSCOPY & BIOPSY
9.39
1.00
50955
URETER ENDOSCOPY & BIOPSY
9.42
1.00
50955
URETER ENDOSCOPY & BIOPSY
10.68
1.00
50957
URETER ENDOSCOPY & TREATMENT
6.00
1.00
50957
URETER ENDOSCOPY & TREATMENT
9.43
1.00
50957
URETER ENDOSCOPY & TREATMENT
9.44
1.00
50957
URETER ENDOSCOPY & TREATMENT
10.36
1.00
50959
URETER ENDOSCOPY & TRACER
5.98
1.00
50959
URETER ENDOSCOPY & TRACER
6.03
1.00
50961
URETER ENDOSCOPY & TREATMENT
6.00
1.00
50961
URETER ENDOSCOPY & TREATMENT
8.39
1.00
50961
URETER ENDOSCOPY & TREATMENT
8.40
1.00
50961
URETER ENDOSCOPY & TREATMENT
9.27
1.00
50970
URETER ENDOSCOPY
3.00
1.00
50970
URETER ENDOSCOPY
9.93
1.00
50970
URETER ENDOSCOPY
9.95
1.00
50970
URETER ENDOSCOPY
10.88
1.00
50972
URETER ENDOSCOPY & CATHETER
3.00
1.00
50972
URETER ENDOSCOPY & CATHETER
9.60
1.00
50972
URETER ENDOSCOPY & CATHETER
9.62
1.00
50972
URETER ENDOSCOPY & CATHETER
10.47
1.00
50974
URETER ENDOSCOPY & BIOPSY
6.00
1.00
Procedure Code Description
RVU
RVU Coeff Value
50974
URETER ENDOSCOPY & BIOPSY
12.71
1.00
50974
URETER ENDOSCOPY & BIOPSY
12.73
1.00
50974
URETER ENDOSCOPY & BIOPSY
13.86
1.00
50976
URETER ENDOSCOPY & TREATMENT
6.00
1.00
50976
URETER ENDOSCOPY & TREATMENT
12.56
1.00
50976
URETER ENDOSCOPY & TREATMENT
12.58
1.00
50976
URETER ENDOSCOPY & TREATMENT
13.66
1.00
50978
URETER ENDOSCOPY & TRACER
6.00
1.00
50978
URETER ENDOSCOPY & TRACER
7.12
1.00
50978
URETER ENDOSCOPY & TRACER
7.14
1.00
50980
URETER ENDOSCOPY & TREATMENT
6.00
1.00
50980
URETER ENDOSCOPY & TREATMENT
9.52
1.00
50980
URETER ENDOSCOPY & TREATMENT
9.53
1.00
50980
URETER ENDOSCOPY & TREATMENT
10.44
1.00
51000
DRAINAGE OF BLADDER
1.08
1.00
51000
DRAINAGE OF BLADDER
3.00
1.00
51005
DRAINAGE OF BLADDER
1.45
1.00
51005
DRAINAGE OF BLADDER
1.46
1.00
51005
DRAINAGE OF BLADDER
3.00
1.00
51010
DRAINAGE OF BLADDER
3.00
1.00
51010
DRAINAGE OF BLADDER
5.69
1.00
51010
DRAINAGE OF BLADDER
5.84
1.00
51010
DRAINAGE OF BLADDER
6.55
1.00
51020
INCISE & TREAT BLADDER
5.00
1.00
51020
INCISE & TREAT BLADDER
11.19
1.00
51020
INCISE & TREAT BLADDER
12.21
1.00
51020
INCISE & TREAT BLADDER
13.25
1.00
51030
INCISE & TREAT BLADDER
5.00
1.00
51030
INCISE & TREAT BLADDER
11.36
1.00
51030
INCISE & TREAT BLADDER
12.55
1.00
51030
INCISE & TREAT BLADDER
13.16
1.00
51040
INCISE & DRAIN BLADDER
5.00
1.00
51040
INCISE & DRAIN BLADDER
7.59
1.00
51040
INCISE & DRAIN BLADDER
8.29
1.00
51040
INCISE & DRAIN BLADDER
8.47
1.00
Procedure Code Description
RVU
RVU Coeff Value
51045
INCISE BLADDER/DRAIN URETER
5.00
1.00
51045
INCISE BLADDER/DRAIN URETER
11.39
1.00
51045
INCISE BLADDER/DRAIN URETER
12.70
1.00
51045
INCISE BLADDER/DRAIN URETER
13.22
1.00
51050
REMOVAL OF BLADDER STONE
5.00
1.00
51050
REMOVAL OF BLADDER STONE
11.17
1.00
51050
REMOVAL OF BLADDER STONE
11.87
1.00
51050
REMOVAL OF BLADDER STONE
13.45
1.00
51060
REMOVAL OF URETER STONE
5.00
1.00
51060
REMOVAL OF URETER STONE
14.11
1.00
51060
REMOVAL OF URETER STONE
15.04
1.00
51060
REMOVAL OF URETER STONE
16.57
1.00
51065
REMOVE URETER CALCULUS
5.00
1.00
51065
REMOVE URETER CALCULUS
13.95
1.00
51065
REMOVE URETER CALCULUS
14.88
1.00
51065
REMOVE URETER CALCULUS
16.46
1.00
51080
DRAINAGE OF BLADDER ABSCESS
5.00
1.00
51080
DRAINAGE OF BLADDER ABSCESS
10.03
1.00
51080
DRAINAGE OF BLADDER ABSCESS
11.45
1.00
51080
DRAINAGE OF BLADDER ABSCESS
11.53
1.00
51100
DRAIN BLADDER BY NEEDLE
1.11
1.00
51101
DRAIN BLADDER BY TROCAR/CATH
1.50
1.00
51102
DRAIN BL W/CATH INSERTION
4.36
1.00
51500
REMOVAL OF BLADDER CYST
6.00
1.00
51500
REMOVAL OF BLADDER CYST
16.26
1.00
51500
REMOVAL OF BLADDER CYST
16.87
1.00
51500
REMOVAL OF BLADDER CYST
17.83
1.00
51520
REMOVAL OF BLADDER LESION
5.00
1.00
51520
REMOVAL OF BLADDER LESION
14.77
1.00
51520
REMOVAL OF BLADDER LESION
15.74
1.00
51520
REMOVAL OF BLADDER LESION
16.71
1.00
51525
REMOVAL OF BLADDER LESION
6.00
1.00
51525
REMOVAL OF BLADDER LESION
21.23
1.00
51525
REMOVAL OF BLADDER LESION
22.10
1.00
51525
REMOVAL OF BLADDER LESION
24.56
1.00
Procedure Code Description
RVU
RVU Coeff Value
51530
REMOVAL OF BLADDER LESION
5.00
1.00
51530
REMOVAL OF BLADDER LESION
19.22
1.00
51530
REMOVAL OF BLADDER LESION
20.28
1.00
51530
REMOVAL OF BLADDER LESION
21.94
1.00
51535
REPAIR OF URETER LESION
5.00
1.00
51535
REPAIR OF URETER LESION
19.87
1.00
51535
REPAIR OF URETER LESION
21.10
1.00
51535
REPAIR OF URETER LESION
22.34
1.00
51550
PARTIAL REMOVAL OF BLADDER
6.00
1.00
51550
PARTIAL REMOVAL OF BLADDER
23.77
1.00
51550
PARTIAL REMOVAL OF BLADDER
24.68
1.00
51550
PARTIAL REMOVAL OF BLADDER
27.07
1.00
51555
PARTIAL REMOVAL OF BLADDER
7.00
1.00
51555
PARTIAL REMOVAL OF BLADDER
31.66
1.00
51555
PARTIAL REMOVAL OF BLADDER
32.79
1.00
51555
PARTIAL REMOVAL OF BLADDER
35.98
1.00
51565
REVISE BLADDER & URETER(S)
6.00
1.00
51565
REVISE BLADDER & URETER(S)
32.40
1.00
51565
REVISE BLADDER & URETER(S)
33.68
1.00
51565
REVISE BLADDER & URETER(S)
36.75
1.00
51570
REMOVAL OF BLADDER
6.00
1.00
51570
REMOVAL OF BLADDER
36.06
1.00
51570
REMOVAL OF BLADDER
37.54
1.00
51570
REMOVAL OF BLADDER
41.91
1.00
51575
REMOVAL OF BLADDER & NODES
7.00
1.00
51575
REMOVAL OF BLADDER & NODES
44.93
1.00
51575
REMOVAL OF BLADDER & NODES
46.66
1.00
51575
REMOVAL OF BLADDER & NODES
52.41
1.00
51580
REMOVE BLADDER/REVISE TRACT
8.00
1.00
51580
REMOVE BLADDER/REVISE TRACT
46.10
1.00
51580
REMOVE BLADDER/REVISE TRACT
47.99
1.00
51580
REMOVE BLADDER/REVISE TRACT
54.62
1.00
51585
REMOVAL OF BLADDER & NODES
7.00
1.00
51585
REMOVAL OF BLADDER & NODES
51.74
1.00
51585
REMOVAL OF BLADDER & NODES
53.48
1.00
Procedure Code Description
RVU
RVU Coeff Value
51585
REMOVAL OF BLADDER & NODES
60.83
1.00
51590
REMOVE BLADDER/REVISE TRACT
7.00
1.00
51590
REMOVE BLADDER/REVISE TRACT
47.87
1.00
51590
REMOVE BLADDER/REVISE TRACT
49.57
1.00
51590
REMOVE BLADDER/REVISE TRACT
55.41
1.00
51595
REMOVE BLADDER/REVISE TRACT
7.00
1.00
51595
REMOVE BLADDER/REVISE TRACT
54.13
1.00
51595
REMOVE BLADDER/REVISE TRACT
55.70
1.00
51595
REMOVE BLADDER/REVISE TRACT
62.98
1.00
51596
REMOVE BLADDER/CREATE POUCH
8.00
1.00
51596
REMOVE BLADDER/CREATE POUCH
57.81
1.00
51596
REMOVE BLADDER/CREATE POUCH
59.51
1.00
51596
REMOVE BLADDER/CREATE POUCH
67.70
1.00
51597
REMOVAL OF PELVIC STRUCTURES
7.00
1.00
51597
REMOVAL OF PELVIC STRUCTURES
56.36
1.00
51597
REMOVAL OF PELVIC STRUCTURES
58.12
1.00
51597
REMOVAL OF PELVIC STRUCTURES
65.33
1.00
51600
INJECTION FOR BLADDER X-RAY
1.22
1.00
51600
INJECTION FOR BLADDER X-RAY
1.23
1.00
51600
INJECTION FOR BLADDER X-RAY
1.25
1.00
51600
INJECTION FOR BLADDER X-RAY
1.28
1.00
51605
PREPARATION FOR BLADDER XRAY
0.90
1.00
51605
PREPARATION FOR BLADDER XRAY
1.04
1.00
51605
PREPARATION FOR BLADDER XRAY
1.10
1.00
51610
INJECTION FOR BLADDER X-RAY
1.45
1.00
51610
INJECTION FOR BLADDER X-RAY
1.71
1.00
51610
INJECTION FOR BLADDER X-RAY
1.82
1.00
51610
INJECTION FOR BLADDER X-RAY
3.00
1.00
51700
IRRIGATION OF BLADDER
1.22
1.00
51700
IRRIGATION OF BLADDER
1.28
1.00
51700
IRRIGATION OF BLADDER
3.00
1.00
51701
INSERT BLADDER CATHETER
0.73
1.00
51701
INSERT BLADDER CATHETER
0.78
1.00
51702
INSERT TEMP BLADDER CATH
0.80
1.00
51702
INSERT TEMP BLADDER CATH
0.86
1.00
Procedure Code Description
RVU
RVU Coeff Value
51703
INSERT BLADDER CATH, COMPLEX
2.15
1.00
51703
INSERT BLADDER CATH, COMPLEX
2.35
1.00
51705
CHANGE OF BLADDER TUBE
1.62
1.00
51705
CHANGE OF BLADDER TUBE
1.70
1.00
51705
CHANGE OF BLADDER TUBE
1.91
1.00
51705
CHANGE OF BLADDER TUBE
3.00
1.00
51710
CHANGE OF BLADDER TUBE
2.37
1.00
51710
CHANGE OF BLADDER TUBE
2.72
1.00
51710
CHANGE OF BLADDER TUBE
2.88
1.00
51710
CHANGE OF BLADDER TUBE
3.00
1.00
51715
ENDOSCOPIC INJECTION/IMPLANT
5.22
1.00
51715
ENDOSCOPIC INJECTION/IMPLANT
5.37
1.00
51715
ENDOSCOPIC INJECTION/IMPLANT
5.74
1.00
51715
ENDOSCOPIC INJECTION/IMPLANT
6.00
1.00
51720
TREATMENT OF BLADDER LESION
2.41
1.00
51720
TREATMENT OF BLADDER LESION
2.81
1.00
51720
TREATMENT OF BLADDER LESION
3.00
1.00
51725
SIMPLE CYSTOMETROGRAM
6.21
1.00
51725
SIMPLE CYSTOMETROGRAM
7.44
1.00
51725
SIMPLE CYSTOMETROGRAM
8.93
1.00
51726
COMPLEX CYSTOMETROGRAM
3.00
1.00
51726
COMPLEX CYSTOMETROGRAM
8.83
1.00
51726
COMPLEX CYSTOMETROGRAM
9.02
1.00
51726
COMPLEX CYSTOMETROGRAM
9.73
1.00
51736
URINE FLOW MEASUREMENT
1.21
1.00
51736
URINE FLOW MEASUREMENT
1.25
1.00
51736
URINE FLOW MEASUREMENT
1.52
1.00
51741
ELECTRO-UROFLOWMETRY, FIRST
2.02
1.00
51741
ELECTRO-UROFLOWMETRY, FIRST
2.04
1.00
51741
ELECTRO-UROFLOWMETRY, FIRST
2.41
1.00
51741
ELECTRO-UROFLOWMETRY, FIRST
3.00
1.00
51772
URETHRA PRESSURE PROFILE
3.00
1.00
51772
URETHRA PRESSURE PROFILE
6.96
1.00
51772
URETHRA PRESSURE PROFILE
7.58
1.00
51772
URETHRA PRESSURE PROFILE
8.09
1.00
Procedure Code Description
RVU
RVU Coeff Value
51784
ANAL/URINARY MUSCLE STUDY
5.70
1.00
51784
ANAL/URINARY MUSCLE STUDY
5.80
1.00
51784
ANAL/URINARY MUSCLE STUDY
6.91
1.00
51785
ANAL/URINARY MUSCLE STUDY
6.18
1.00
51785
ANAL/URINARY MUSCLE STUDY
6.30
1.00
51785
ANAL/URINARY MUSCLE STUDY
6.92
1.00
51792
URINARY REFLEX STUDY
6.50
1.00
51792
URINARY REFLEX STUDY
6.74
1.00
51792
URINARY REFLEX STUDY
7.32
1.00
51795
URINE VOIDING PRESSURE STUDY
3.00
1.00
51795
URINE VOIDING PRESSURE STUDY
8.41
1.00
51795
URINE VOIDING PRESSURE STUDY
8.52
1.00
51795
URINE VOIDING PRESSURE STUDY
9.37
1.00
51797
INTRAABDOMINAL PRESSURE TEST
3.00
1.00
51797
INTRAABDOMINAL PRESSURE TEST
4.23
1.00
51797
INTRAABDOMINAL PRESSURE TEST
6.05
1.00
51797
INTRAABDOMINAL PRESSURE TEST
7.72
1.00
51798
US URINE CAPACITY MEASURE
0.44
1.00
51798
US URINE CAPACITY MEASURE
0.55
1.00
51798
US URINE CAPACITY MEASURE
0.60
1.00
51800
REVISION OF BLADDER/URETHRA
5.00
1.00
51800
REVISION OF BLADDER/URETHRA
26.49
1.00
51800
REVISION OF BLADDER/URETHRA
27.38
1.00
51800
REVISION OF BLADDER/URETHRA
29.88
1.00
51820
REVISION OF URINARY TRACT
6.00
1.00
51820
REVISION OF URINARY TRACT
28.07
1.00
51820
REVISION OF URINARY TRACT
29.90
1.00
51820
REVISION OF URINARY TRACT
30.57
1.00
51840
ATTACH BLADDER/URETHRA
6.00
1.00
51840
ATTACH BLADDER/URETHRA
17.31
1.00
51840
ATTACH BLADDER/URETHRA
17.89
1.00
51840
ATTACH BLADDER/URETHRA
18.27
1.00
51841
ATTACH BLADDER/URETHRA
5.00
1.00
51841
ATTACH BLADDER/URETHRA
20.63
1.00
51841
ATTACH BLADDER/URETHRA
21.67
1.00
Procedure Code Description 51841
ATTACH BLADDER/URETHRA
51845
RVU
RVU Coeff Value
22.05
1.00
REPAIR BLADDER NECK
6.00
1.00
51845
REPAIR BLADDER NECK
15.34
1.00
51845
REPAIR BLADDER NECK
16.48
1.00
51845
REPAIR BLADDER NECK
16.60
1.00
51860
REPAIR OF BLADDER WOUND
4.00
1.00
51860
REPAIR OF BLADDER WOUND
18.97
1.00
51860
REPAIR OF BLADDER WOUND
20.25
1.00
51860
REPAIR OF BLADDER WOUND
20.35
1.00
51865
REPAIR OF BLADDER WOUND
6.00
1.00
51865
REPAIR OF BLADDER WOUND
23.07
1.00
51865
REPAIR OF BLADDER WOUND
24.23
1.00
51865
REPAIR OF BLADDER WOUND
25.14
1.00
51880
REPAIR OF BLADDER OPENING
3.00
1.00
51880
REPAIR OF BLADDER OPENING
12.37
1.00
51880
REPAIR OF BLADDER OPENING
13.20
1.00
51880
REPAIR OF BLADDER OPENING
13.50
1.00
51900
REPAIR BLADDER/VAGINA LESION
5.00
1.00
51900
REPAIR BLADDER/VAGINA LESION
20.22
1.00
51900
REPAIR BLADDER/VAGINA LESION
21.46
1.00
51900
REPAIR BLADDER/VAGINA LESION
23.34
1.00
51920
CLOSE BLADDER-UTERUS FISTULA
5.00
1.00
51920
CLOSE BLADDER-UTERUS FISTULA
18.58
1.00
51920
CLOSE BLADDER-UTERUS FISTULA
19.49
1.00
51920
CLOSE BLADDER-UTERUS FISTULA
21.60
1.00
51925
HYSTERECTOMY/BLADDER REPAIR
6.00
1.00
51925
HYSTERECTOMY/BLADDER REPAIR
25.97
1.00
51925
HYSTERECTOMY/BLADDER REPAIR
26.37
1.00
51925
HYSTERECTOMY/BLADDER REPAIR
28.32
1.00
51940
CORRECTION OF BLADDER DEFECT
7.00
1.00
51940
CORRECTION OF BLADDER DEFECT
43.13
1.00
51940
CORRECTION OF BLADDER DEFECT
45.83
1.00
51940
CORRECTION OF BLADDER DEFECT
46.00
1.00
51960
REVISION OF BLADDER & BOWEL
6.00
1.00
51960
REVISION OF BLADDER & BOWEL
34.55
1.00
Procedure Code Description
RVU
RVU Coeff Value
51960
REVISION OF BLADDER & BOWEL
36.61
1.00
51960
REVISION OF BLADDER & BOWEL
39.67
1.00
51980
CONSTRUCT BLADDER OPENING
5.00
1.00
51980
CONSTRUCT BLADDER OPENING
17.72
1.00
51980
CONSTRUCT BLADDER OPENING
18.66
1.00
51980
CONSTRUCT BLADDER OPENING
20.34
1.00
51990
LAPARO URETHRAL SUSPENSION
6.00
1.00
51990
LAPARO URETHRAL SUSPENSION
19.89
1.00
51990
LAPARO URETHRAL SUSPENSION
20.05
1.00
51990
LAPARO URETHRAL SUSPENSION
21.06
1.00
51992
LAPARO SLING OPERATION
6.00
1.00
51992
LAPARO SLING OPERATION
21.35
1.00
51992
LAPARO SLING OPERATION
21.38
1.00
51992
LAPARO SLING OPERATION
22.93
1.00
52000
CYSTOSCOPY
2.91
1.00
52000
CYSTOSCOPY
3.00
1.00
52000
CYSTOSCOPY
3.28
1.00
52000
CYSTOSCOPY
3.40
1.00
52000
CYSTOSCOPY
3.60
1.00
52001
CYSTOSCOPY, REMOVAL OF CLOTS
3.00
1.00
52001
CYSTOSCOPY, REMOVAL OF CLOTS
7.70
1.00
52001
CYSTOSCOPY, REMOVAL OF CLOTS
8.10
1.00
52001
CYSTOSCOPY, REMOVAL OF CLOTS
8.37
1.00
52005
CYSTOSCOPY & URETER CATHETER
3.00
1.00
52005
CYSTOSCOPY & URETER CATHETER
3.44
1.00
52005
CYSTOSCOPY & URETER CATHETER
3.45
1.00
52005
CYSTOSCOPY & URETER CATHETER
3.85
1.00
52007
CYSTOSCOPY AND BIOPSY
3.00
1.00
52007
CYSTOSCOPY AND BIOPSY
4.37
1.00
52007
CYSTOSCOPY AND BIOPSY
4.39
1.00
52007
CYSTOSCOPY AND BIOPSY
4.82
1.00
52010
CYSTOSCOPY & DUCT CATHETER
3.00
1.00
52010
CYSTOSCOPY & DUCT CATHETER
4.35
1.00
52010
CYSTOSCOPY & DUCT CATHETER
4.37
1.00
52010
CYSTOSCOPY & DUCT CATHETER
4.67
1.00
Procedure Code Description
RVU
RVU Coeff Value
52204
CYSTOSCOPY W/BIOPSY(S)
3.00
1.00
52204
CYSTOSCOPY W/BIOPSY(S)
3.45
1.00
52204
CYSTOSCOPY W/BIOPSY(S)
3.46
1.00
52204
CYSTOSCOPY W/BIOPSY(S)
3.79
1.00
52204
CYSTOSCOPY W/BIOPSY(S)
3.90
1.00
52204
CYSTOSCOPY W/BIOPSY(S)
4.08
1.00
52214
CYSTOSCOPY AND TREATMENT
3.00
1.00
52214
CYSTOSCOPY AND TREATMENT
5.29
1.00
52214
CYSTOSCOPY AND TREATMENT
5.30
1.00
52214
CYSTOSCOPY AND TREATMENT
6.32
1.00
52224
CYSTOSCOPY AND TREATMENT
4.50
1.00
52224
CYSTOSCOPY AND TREATMENT
4.51
1.00
52224
CYSTOSCOPY AND TREATMENT
4.93
1.00
52234
CYSTOSCOPY AND TREATMENT
3.00
1.00
52234
CYSTOSCOPY AND TREATMENT
6.57
1.00
52234
CYSTOSCOPY AND TREATMENT
6.58
1.00
52234
CYSTOSCOPY AND TREATMENT
7.19
1.00
52235
CYSTOSCOPY AND TREATMENT
3.00
1.00
52235
CYSTOSCOPY AND TREATMENT
7.72
1.00
52235
CYSTOSCOPY AND TREATMENT
7.73
1.00
52235
CYSTOSCOPY AND TREATMENT
8.43
1.00
52240
CYSTOSCOPY AND TREATMENT
5.00
1.00
52240
CYSTOSCOPY AND TREATMENT
13.67
1.00
52240
CYSTOSCOPY AND TREATMENT
13.71
1.00
52240
CYSTOSCOPY AND TREATMENT
14.74
1.00
52250
CYSTOSCOPY AND RADIOTRACER
3.00
1.00
52250
CYSTOSCOPY AND RADIOTRACER
6.47
1.00
52250
CYSTOSCOPY AND RADIOTRACER
6.48
1.00
52250
CYSTOSCOPY AND RADIOTRACER
7.06
1.00
52260
CYSTOSCOPY AND TREATMENT
3.00
1.00
52260
CYSTOSCOPY AND TREATMENT
5.61
1.00
52260
CYSTOSCOPY AND TREATMENT
5.62
1.00
52260
CYSTOSCOPY AND TREATMENT
6.09
1.00
52265
CYSTOSCOPY AND TREATMENT
4.26
1.00
52265
CYSTOSCOPY AND TREATMENT
4.28
1.00
Procedure Code Description
RVU
RVU Coeff Value
52265
CYSTOSCOPY AND TREATMENT
4.59
1.00
52270
CYSTOSCOPY & REVISE URETHRA
3.00
1.00
52270
CYSTOSCOPY & REVISE URETHRA
4.85
1.00
52270
CYSTOSCOPY & REVISE URETHRA
4.91
1.00
52270
CYSTOSCOPY & REVISE URETHRA
5.30
1.00
52275
CYSTOSCOPY & REVISE URETHRA
3.00
1.00
52275
CYSTOSCOPY & REVISE URETHRA
6.70
1.00
52275
CYSTOSCOPY & REVISE URETHRA
6.76
1.00
52275
CYSTOSCOPY & REVISE URETHRA
7.26
1.00
52276
CYSTOSCOPY AND TREATMENT
3.00
1.00
52276
CYSTOSCOPY AND TREATMENT
7.14
1.00
52276
CYSTOSCOPY AND TREATMENT
7.20
1.00
52276
CYSTOSCOPY AND TREATMENT
7.75
1.00
52277
CYSTOSCOPY AND TREATMENT
3.00
1.00
52277
CYSTOSCOPY AND TREATMENT
8.86
1.00
52277
CYSTOSCOPY AND TREATMENT
8.88
1.00
52277
CYSTOSCOPY AND TREATMENT
9.47
1.00
52281
CYSTOSCOPY AND TREATMENT
3.00
1.00
52281
CYSTOSCOPY AND TREATMENT
4.07
1.00
52281
CYSTOSCOPY AND TREATMENT
4.09
1.00
52281
CYSTOSCOPY AND TREATMENT
4.49
1.00
52282
CYSTOSCOPY, IMPLANT STENT
3.00
1.00
52282
CYSTOSCOPY, IMPLANT STENT
9.07
1.00
52282
CYSTOSCOPY, IMPLANT STENT
9.09
1.00
52282
CYSTOSCOPY, IMPLANT STENT
9.77
1.00
52283
CYSTOSCOPY AND TREATMENT
3.00
1.00
52283
CYSTOSCOPY AND TREATMENT
5.37
1.00
52283
CYSTOSCOPY AND TREATMENT
5.39
1.00
52283
CYSTOSCOPY AND TREATMENT
5.83
1.00
52285
CYSTOSCOPY AND TREATMENT
3.00
1.00
52285
CYSTOSCOPY AND TREATMENT
5.20
1.00
52285
CYSTOSCOPY AND TREATMENT
5.21
1.00
52285
CYSTOSCOPY AND TREATMENT
5.65
1.00
52290
CYSTOSCOPY AND TREATMENT
3.00
1.00
52290
CYSTOSCOPY AND TREATMENT
6.55
1.00
Procedure Code Description
RVU
RVU Coeff Value
52290
CYSTOSCOPY AND TREATMENT
6.57
1.00
52290
CYSTOSCOPY AND TREATMENT
7.13
1.00
52300
CYSTOSCOPY AND TREATMENT
3.00
1.00
52300
CYSTOSCOPY AND TREATMENT
7.58
1.00
52300
CYSTOSCOPY AND TREATMENT
7.60
1.00
52300
CYSTOSCOPY AND TREATMENT
8.19
1.00
52301
CYSTOSCOPY AND TREATMENT
3.00
1.00
52301
CYSTOSCOPY AND TREATMENT
7.94
1.00
52301
CYSTOSCOPY AND TREATMENT
7.97
1.00
52301
CYSTOSCOPY AND TREATMENT
8.63
1.00
52305
CYSTOSCOPY AND TREATMENT
3.00
1.00
52305
CYSTOSCOPY AND TREATMENT
7.52
1.00
52305
CYSTOSCOPY AND TREATMENT
7.53
1.00
52305
CYSTOSCOPY AND TREATMENT
8.14
1.00
52310
CYSTOSCOPY AND TREATMENT
3.00
1.00
52310
CYSTOSCOPY AND TREATMENT
4.03
1.00
52310
CYSTOSCOPY AND TREATMENT
4.06
1.00
52310
CYSTOSCOPY AND TREATMENT
4.41
1.00
52315
CYSTOSCOPY AND TREATMENT
3.00
1.00
52315
CYSTOSCOPY AND TREATMENT
7.40
1.00
52315
CYSTOSCOPY AND TREATMENT
7.41
1.00
52315
CYSTOSCOPY AND TREATMENT
8.02
1.00
52317
REMOVE BLADDER STONE
3.00
1.00
52317
REMOVE BLADDER STONE
9.46
1.00
52317
REMOVE BLADDER STONE
9.47
1.00
52318
REMOVE BLADDER STONE
3.00
1.00
52318
REMOVE BLADDER STONE
12.90
1.00
52318
REMOVE BLADDER STONE
12.93
1.00
52318
REMOVE BLADDER STONE
13.87
1.00
52320
CYSTOSCOPY AND TREATMENT
3.00
1.00
52320
CYSTOSCOPY AND TREATMENT
6.66
1.00
52320
CYSTOSCOPY AND TREATMENT
6.67
1.00
52320
CYSTOSCOPY AND TREATMENT
7.20
1.00
52325
CYSTOSCOPY, STONE REMOVAL
3.00
1.00
52325
CYSTOSCOPY, STONE REMOVAL
8.70
1.00
Procedure Code Description
RVU
RVU Coeff Value
52325
CYSTOSCOPY, STONE REMOVAL
8.71
1.00
52325
CYSTOSCOPY, STONE REMOVAL
9.37
1.00
52327
CYSTOSCOPY, INJECT MATERIAL
3.00
1.00
52327
CYSTOSCOPY, INJECT MATERIAL
7.38
1.00
52327
CYSTOSCOPY, INJECT MATERIAL
7.40
1.00
52327
CYSTOSCOPY, INJECT MATERIAL
7.67
1.00
52330
CYSTOSCOPY AND TREATMENT
3.00
1.00
52330
CYSTOSCOPY AND TREATMENT
7.14
1.00
52330
CYSTOSCOPY AND TREATMENT
7.15
1.00
52330
CYSTOSCOPY AND TREATMENT
7.31
1.00
52330
CYSTOSCOPY AND TREATMENT
7.44
1.00
52330
CYSTOSCOPY AND TREATMENT
7.71
1.00
52332
CYSTOSCOPY AND TREATMENT
3.00
1.00
52332
CYSTOSCOPY AND TREATMENT
4.07
1.00
52332
CYSTOSCOPY AND TREATMENT
4.09
1.00
52332
CYSTOSCOPY AND TREATMENT
4.10
1.00
52334
CREATE PASSAGE TO KIDNEY
3.00
1.00
52334
CREATE PASSAGE TO KIDNEY
6.91
1.00
52334
CREATE PASSAGE TO KIDNEY
6.92
1.00
52334
CREATE PASSAGE TO KIDNEY
7.49
1.00
52341
CYSTO W/URETER STRICTURE TX
3.00
1.00
52341
CYSTO W/URETER STRICTURE TX
8.53
1.00
52341
CYSTO W/URETER STRICTURE TX
8.63
1.00
52341
CYSTO W/URETER STRICTURE TX
8.66
1.00
52342
CYSTO W/UP STRICTURE TX
3.00
1.00
52342
CYSTO W/UP STRICTURE TX
9.27
1.00
52342
CYSTO W/UP STRICTURE TX
9.31
1.00
52342
CYSTO W/UP STRICTURE TX
9.32
1.00
52343
CYSTO W/RENAL STRICTURE TX
3.00
1.00
52343
CYSTO W/RENAL STRICTURE TX
10.31
1.00
52343
CYSTO W/RENAL STRICTURE TX
10.33
1.00
52344
CYSTO/URETERO, STRICTURE TX
3.00
1.00
52344
CYSTO/URETERO, STRICTURE TX
11.04
1.00
52344
CYSTO/URETERO, STRICTURE TX
11.06
1.00
52344
CYSTO/URETERO, STRICTURE TX
11.18
1.00
Procedure Code Description
RVU
RVU Coeff Value
52345
CYSTO/URETERO W/UP STRICTURE
3.00
1.00
52345
CYSTO/URETERO W/UP STRICTURE
11.73
1.00
52345
CYSTO/URETERO W/UP STRICTURE
11.75
1.00
52345
CYSTO/URETERO W/UP STRICTURE
11.92
1.00
52346
CYSTOURETERO W/RENAL STRICT
3.00
1.00
52346
CYSTOURETERO W/RENAL STRICT
13.18
1.00
52346
CYSTOURETERO W/RENAL STRICT
13.20
1.00
52346
CYSTOURETERO W/RENAL STRICT
13.45
1.00
52347
CYSTOSCOPY, RESECT DUCTS
3.00
1.00
52351
CYSTOURETERO & OR PYELOSCOPE
3.00
1.00
52351
CYSTOURETERO & OR PYELOSCOPE
8.41
1.00
52351
CYSTOURETERO & OR PYELOSCOPE
8.42
1.00
52351
CYSTOURETERO & OR PYELOSCOPE
9.16
1.00
52352
CYSTOURETERO W/STONE REMOVE
3.00
1.00
52352
CYSTOURETERO W/STONE REMOVE
9.87
1.00
52352
CYSTOURETERO W/STONE REMOVE
9.89
1.00
52352
CYSTOURETERO W/STONE REMOVE
10.76
1.00
52353
CYSTOURETERO W/LITHOTRIPSY
3.00
1.00
52353
CYSTOURETERO W/LITHOTRIPSY
11.39
1.00
52353
CYSTOURETERO W/LITHOTRIPSY
11.41
1.00
52353
CYSTOURETERO W/LITHOTRIPSY
12.38
1.00
52354
CYSTOURETERO W/BIOPSY
3.00
1.00
52354
CYSTOURETERO W/BIOPSY
10.53
1.00
52354
CYSTOURETERO W/BIOPSY
10.54
1.00
52354
CYSTOURETERO W/BIOPSY
11.44
1.00
52355
CYSTOURETERO W/EXCISE TUMOR
3.00
1.00
52355
CYSTOURETERO W/EXCISE TUMOR
12.59
1.00
52355
CYSTOURETERO W/EXCISE TUMOR
12.62
1.00
52355
CYSTOURETERO W/EXCISE TUMOR
13.64
1.00
52400
CYSTOURETERO W/CONGEN REPR
3.00
1.00
52400
CYSTOURETERO W/CONGEN REPR
14.03
1.00
52400
CYSTOURETERO W/CONGEN REPR
14.17
1.00
52400
CYSTOURETERO W/CONGEN REPR
14.59
1.00
52402
CYSTOURETHRO CUT EJACUL DUCT
7.86
1.00
52450
INCISION OF PROSTATE
11.75
1.00
Procedure Code Description
RVU
RVU Coeff Value
52450
INCISION OF PROSTATE
11.89
1.00
52450
INCISION OF PROSTATE
13.36
1.00
52450
INCISION OF PROSTATE
999.99
1.00
52500
REVISION OF BLADDER NECK
4.00
1.00
52500
REVISION OF BLADDER NECK
12.88
1.00
52500
REVISION OF BLADDER NECK
13.02
1.00
52500
REVISION OF BLADDER NECK
13.97
1.00
52510
DILATION PROSTATIC URETHRA
10.33
1.00
52510
DILATION PROSTATIC URETHRA
10.36
1.00
52510
DILATION PROSTATIC URETHRA
11.55
1.00
52510
DILATION PROSTATIC URETHRA
999.99
1.00
52601
PROSTATECTOMY (TURP)
5.00
1.00
52601
PROSTATECTOMY (TURP)
18.34
1.00
52601
PROSTATECTOMY (TURP)
18.39
1.00
52601
PROSTATECTOMY (TURP)
23.63
1.00
52606
CONTROL POSTOP BLEEDING
5.00
1.00
52606
CONTROL POSTOP BLEEDING
12.18
1.00
52606
CONTROL POSTOP BLEEDING
12.29
1.00
52606
CONTROL POSTOP BLEEDING
13.93
1.00
52612
PROSTATECTOMY, FIRST STAGE
5.00
1.00
52612
PROSTATECTOMY, FIRST STAGE
12.29
1.00
52612
PROSTATECTOMY, FIRST STAGE
12.32
1.00
52612
PROSTATECTOMY, FIRST STAGE
14.44
1.00
52614
PROSTATECTOMY, SECOND STAGE
5.00
1.00
52614
PROSTATECTOMY, SECOND STAGE
10.67
1.00
52614
PROSTATECTOMY, SECOND STAGE
10.70
1.00
52614
PROSTATECTOMY, SECOND STAGE
12.65
1.00
52620
REMOVE RESIDUAL PROSTATE
5.00
1.00
52620
REMOVE RESIDUAL PROSTATE
10.08
1.00
52620
REMOVE RESIDUAL PROSTATE
11.46
1.00
52630
REMOVE PROSTATE REGROWTH
5.00
1.00
52630
REMOVE PROSTATE REGROWTH
10.89
1.00
52630
REMOVE PROSTATE REGROWTH
10.99
1.00
52630
REMOVE PROSTATE REGROWTH
12.68
1.00
52640
RELIEVE BLADDER CONTRACTURE
5.00
1.00
Procedure Code Description
RVU
RVU Coeff Value
52640
RELIEVE BLADDER CONTRACTURE
8.71
1.00
52640
RELIEVE BLADDER CONTRACTURE
10.06
1.00
52640
RELIEVE BLADDER CONTRACTURE
10.11
1.00
52647
LASER SURGERY OF PROSTATE
5.00
1.00
52647
LASER SURGERY OF PROSTATE
15.54
1.00
52647
LASER SURGERY OF PROSTATE
15.61
1.00
52647
LASER SURGERY OF PROSTATE
15.65
1.00
52647
LASER SURGERY OF PROSTATE
17.04
1.00
52647
LASER SURGERY OF PROSTATE
17.59
1.00
52647
LASER SURGERY OF PROSTATE
18.45
1.00
52648
LASER SURGERY OF PROSTATE
5.00
1.00
52648
LASER SURGERY OF PROSTATE
16.65
1.00
52648
LASER SURGERY OF PROSTATE
16.83
1.00
52648
LASER SURGERY OF PROSTATE
19.69
1.00
52649
PROSTATE LASER ENUCLEATION
28.14
1.00
52700
DRAINAGE OF PROSTATE ABSCESS
5.00
1.00
52700
DRAINAGE OF PROSTATE ABSCESS
10.45
1.00
52700
DRAINAGE OF PROSTATE ABSCESS
10.49
1.00
52700
DRAINAGE OF PROSTATE ABSCESS
12.38
1.00
53000
INCISION OF URETHRA
3.00
1.00
53000
INCISION OF URETHRA
4.01
1.00
53000
INCISION OF URETHRA
4.24
1.00
53000
INCISION OF URETHRA
4.64
1.00
53010
INCISION OF URETHRA
3.00
1.00
53010
INCISION OF URETHRA
6.89
1.00
53010
INCISION OF URETHRA
7.92
1.00
53010
INCISION OF URETHRA
8.29
1.00
53020
INCISION OF URETHRA
2.54
1.00
53020
INCISION OF URETHRA
2.57
1.00
53020
INCISION OF URETHRA
2.82
1.00
53020
INCISION OF URETHRA
3.00
1.00
53025
INCISION OF URETHRA
1.65
1.00
53025
INCISION OF URETHRA
1.72
1.00
53025
INCISION OF URETHRA
1.85
1.00
53025
INCISION OF URETHRA
3.00
1.00
Procedure Code Description
RVU
RVU Coeff Value
53040
DRAINAGE OF URETHRA ABSCESS
3.00
1.00
53040
DRAINAGE OF URETHRA ABSCESS
11.20
1.00
53040
DRAINAGE OF URETHRA ABSCESS
13.21
1.00
53040
DRAINAGE OF URETHRA ABSCESS
13.98
1.00
53060
DRAINAGE OF URETHRA ABSCESS
3.00
1.00
53060
DRAINAGE OF URETHRA ABSCESS
4.36
1.00
53060
DRAINAGE OF URETHRA ABSCESS
4.40
1.00
53060
DRAINAGE OF URETHRA ABSCESS
5.53
1.00
53080
DRAINAGE OF URINARY LEAKAGE
3.00
1.00
53080
DRAINAGE OF URINARY LEAKAGE
12.43
1.00
53080
DRAINAGE OF URINARY LEAKAGE
12.96
1.00
53080
DRAINAGE OF URINARY LEAKAGE
13.93
1.00
53085
DRAINAGE OF URINARY LEAKAGE
5.00
1.00
53085
DRAINAGE OF URINARY LEAKAGE
17.64
1.00
53085
DRAINAGE OF URINARY LEAKAGE
18.69
1.00
53085
DRAINAGE OF URINARY LEAKAGE
19.57
1.00
53200
BIOPSY OF URETHRA
3.00
1.00
53200
BIOPSY OF URETHRA
3.71
1.00
53200
BIOPSY OF URETHRA
3.78
1.00
53200
BIOPSY OF URETHRA
4.06
1.00
53210
REMOVAL OF URETHRA
5.00
1.00
53210
REMOVAL OF URETHRA
19.51
1.00
53210
REMOVAL OF URETHRA
20.87
1.00
53210
REMOVAL OF URETHRA
22.01
1.00
53215
REMOVAL OF URETHRA
5.00
1.00
53215
REMOVAL OF URETHRA
23.45
1.00
53215
REMOVAL OF URETHRA
24.59
1.00
53215
REMOVAL OF URETHRA
26.74
1.00
53220
TREATMENT OF URETHRA LESION
3.00
1.00
53220
TREATMENT OF URETHRA LESION
11.36
1.00
53220
TREATMENT OF URETHRA LESION
12.52
1.00
53220
TREATMENT OF URETHRA LESION
12.85
1.00
53230
REMOVAL OF URETHRA LESION
3.00
1.00
53230
REMOVAL OF URETHRA LESION
15.13
1.00
53230
REMOVAL OF URETHRA LESION
15.98
1.00
Procedure Code Description
RVU
RVU Coeff Value
53230
REMOVAL OF URETHRA LESION
17.15
1.00
53235
REMOVAL OF URETHRA LESION
3.00
1.00
53235
REMOVAL OF URETHRA LESION
15.86
1.00
53235
REMOVAL OF URETHRA LESION
16.74
1.00
53235
REMOVAL OF URETHRA LESION
18.23
1.00
53240
SURGERY FOR URETHRA POUCH
3.00
1.00
53240
SURGERY FOR URETHRA POUCH
10.59
1.00
53240
SURGERY FOR URETHRA POUCH
11.72
1.00
53240
SURGERY FOR URETHRA POUCH
12.26
1.00
53250
REMOVAL OF URETHRA GLAND
3.00
1.00
53250
REMOVAL OF URETHRA GLAND
9.68
1.00
53250
REMOVAL OF URETHRA GLAND
10.48
1.00
53250
REMOVAL OF URETHRA GLAND
11.38
1.00
53260
TREATMENT OF URETHRA LESION
3.00
1.00
53260
TREATMENT OF URETHRA LESION
5.02
1.00
53260
TREATMENT OF URETHRA LESION
5.06
1.00
53260
TREATMENT OF URETHRA LESION
5.45
1.00
53265
TREATMENT OF URETHRA LESION
3.00
1.00
53265
TREATMENT OF URETHRA LESION
5.20
1.00
53265
TREATMENT OF URETHRA LESION
5.27
1.00
53265
TREATMENT OF URETHRA LESION
5.60
1.00
53270
REMOVAL OF URETHRA GLAND
3.00
1.00
53270
REMOVAL OF URETHRA GLAND
5.18
1.00
53270
REMOVAL OF URETHRA GLAND
5.21
1.00
53270
REMOVAL OF URETHRA GLAND
5.82
1.00
53275
REPAIR OF URETHRA DEFECT
3.00
1.00
53275
REPAIR OF URETHRA DEFECT
7.14
1.00
53275
REPAIR OF URETHRA DEFECT
7.60
1.00
53275
REPAIR OF URETHRA DEFECT
7.85
1.00
53400
REVISE URETHRA, STAGE 1
3.00
1.00
53400
REVISE URETHRA, STAGE 1
19.88
1.00
53400
REVISE URETHRA, STAGE 1
21.04
1.00
53400
REVISE URETHRA, STAGE 1
22.91
1.00
53405
REVISE URETHRA, STAGE 2
3.00
1.00
53405
REVISE URETHRA, STAGE 2
22.01
1.00
Procedure Code Description
RVU
RVU Coeff Value
53405
REVISE URETHRA, STAGE 2
23.09
1.00
53405
REVISE URETHRA, STAGE 2
25.24
1.00
53410
RECONSTRUCTION OF URETHRA
4.00
1.00
53410
RECONSTRUCTION OF URETHRA
24.81
1.00
53410
RECONSTRUCTION OF URETHRA
25.86
1.00
53410
RECONSTRUCTION OF URETHRA
28.14
1.00
53415
RECONSTRUCTION OF URETHRA
3.00
1.00
53415
RECONSTRUCTION OF URETHRA
28.25
1.00
53415
RECONSTRUCTION OF URETHRA
29.56
1.00
53415
RECONSTRUCTION OF URETHRA
32.46
1.00
53420
RECONSTRUCT URETHRA, STAGE 1
3.00
1.00
53420
RECONSTRUCT URETHRA, STAGE 1
21.60
1.00
53420
RECONSTRUCT URETHRA, STAGE 1
23.05
1.00
53420
RECONSTRUCT URETHRA, STAGE 1
23.51
1.00
53425
RECONSTRUCT URETHRA, STAGE 2
3.00
1.00
53425
RECONSTRUCT URETHRA, STAGE 2
24.18
1.00
53425
RECONSTRUCT URETHRA, STAGE 2
25.44
1.00
53425
RECONSTRUCT URETHRA, STAGE 2
27.11
1.00
53430
RECONSTRUCTION OF URETHRA
3.00
1.00
53430
RECONSTRUCTION OF URETHRA
24.67
1.00
53430
RECONSTRUCTION OF URETHRA
25.97
1.00
53430
RECONSTRUCTION OF URETHRA
27.04
1.00
53431
RECONSTRUCT URETHRA/BLADDER
3.00
1.00
53431
RECONSTRUCT URETHRA/BLADDER
29.60
1.00
53431
RECONSTRUCT URETHRA/BLADDER
30.23
1.00
53431
RECONSTRUCT URETHRA/BLADDER
33.18
1.00
53440
MALE SLING PROCEDURE
3.00
1.00
53440
MALE SLING PROCEDURE
20.52
1.00
53440
MALE SLING PROCEDURE
20.68
1.00
53440
MALE SLING PROCEDURE
25.09
1.00
53442
REMOVE/REVISE MALE SLING
3.00
1.00
53442
REMOVE/REVISE MALE SLING
17.72
1.00
53442
REMOVE/REVISE MALE SLING
18.05
1.00
53442
REMOVE/REVISE MALE SLING
22.09
1.00
53444
INSERT TANDEM CUFF
3.00
1.00
Procedure Code Description
RVU
RVU Coeff Value
53444
INSERT TANDEM CUFF
20.35
1.00
53444
INSERT TANDEM CUFF
20.42
1.00
53444
INSERT TANDEM CUFF
22.84
1.00
53445
INSERT URO/VES NCK SPHINCTER
3.00
1.00
53445
INSERT URO/VES NCK SPHINCTER
22.31
1.00
53445
INSERT URO/VES NCK SPHINCTER
22.66
1.00
53445
INSERT URO/VES NCK SPHINCTER
25.21
1.00
53446
REMOVE URO SPHINCTER
3.00
1.00
53446
REMOVE URO SPHINCTER
16.29
1.00
53446
REMOVE URO SPHINCTER
16.72
1.00
53446
REMOVE URO SPHINCTER
18.43
1.00
53447
REMOVE/REPLACE UR SPHINCTER
3.00
1.00
53447
REMOVE/REPLACE UR SPHINCTER
20.83
1.00
53447
REMOVE/REPLACE UR SPHINCTER
20.90
1.00
53447
REMOVE/REPLACE UR SPHINCTER
23.32
1.00
53448
REMOV/REPLC UR SPHINCTR COMP
3.00
1.00
53448
REMOV/REPLC UR SPHINCTR COMP
31.93
1.00
53448
REMOV/REPLC UR SPHINCTR COMP
32.39
1.00
53448
REMOV/REPLC UR SPHINCTR COMP
36.84
1.00
53449
REPAIR URO SPHINCTER
3.00
1.00
53449
REPAIR URO SPHINCTER
15.23
1.00
53449
REPAIR URO SPHINCTER
16.17
1.00
53449
REPAIR URO SPHINCTER
17.52
1.00
53450
REVISION OF URETHRA
3.00
1.00
53450
REVISION OF URETHRA
9.98
1.00
53450
REVISION OF URETHRA
11.04
1.00
53450
REVISION OF URETHRA
11.65
1.00
53460
REVISION OF URETHRA
3.00
1.00
53460
REVISION OF URETHRA
11.45
1.00
53460
REVISION OF URETHRA
12.45
1.00
53460
REVISION OF URETHRA
13.09
1.00
53500
URETHRLYS, TRANSVAG W/ SCOPE
19.27
1.00
53500
URETHRLYS, TRANSVAG W/ SCOPE
21.07
1.00
53502
REPAIR OF URETHRA INJURY
4.00
1.00
53502
REPAIR OF URETHRA INJURY
12.33
1.00
Procedure Code Description
RVU
RVU Coeff Value
53502
REPAIR OF URETHRA INJURY
13.45
1.00
53502
REPAIR OF URETHRA INJURY
13.87
1.00
53505
REPAIR OF URETHRA INJURY
4.00
1.00
53505
REPAIR OF URETHRA INJURY
12.16
1.00
53505
REPAIR OF URETHRA INJURY
13.13
1.00
53505
REPAIR OF URETHRA INJURY
13.91
1.00
53510
REPAIR OF URETHRA INJURY
3.00
1.00
53510
REPAIR OF URETHRA INJURY
16.10
1.00
53510
REPAIR OF URETHRA INJURY
17.14
1.00
53510
REPAIR OF URETHRA INJURY
18.11
1.00
53515
REPAIR OF URETHRA INJURY
3.00
1.00
53515
REPAIR OF URETHRA INJURY
20.34
1.00
53515
REPAIR OF URETHRA INJURY
21.19
1.00
53515
REPAIR OF URETHRA INJURY
22.87
1.00
53520
REPAIR OF URETHRA DEFECT
4.00
1.00
53520
REPAIR OF URETHRA DEFECT
13.91
1.00
53520
REPAIR OF URETHRA DEFECT
14.71
1.00
53520
REPAIR OF URETHRA DEFECT
15.88
1.00
53600
DILATE URETHRA STRICTURE
1.72
1.00
53600
DILATE URETHRA STRICTURE
1.73
1.00
53600
DILATE URETHRA STRICTURE
1.87
1.00
53600
DILATE URETHRA STRICTURE
3.00
1.00
53601
DILATE URETHRA STRICTURE
1.43
1.00
53601
DILATE URETHRA STRICTURE
1.56
1.00
53601
DILATE URETHRA STRICTURE
3.00
1.00
53605
DILATE URETHRA STRICTURE
1.78
1.00
53605
DILATE URETHRA STRICTURE
1.79
1.00
53605
DILATE URETHRA STRICTURE
1.88
1.00
53605
DILATE URETHRA STRICTURE
3.00
1.00
53620
DILATE URETHRA STRICTURE
2.34
1.00
53620
DILATE URETHRA STRICTURE
2.54
1.00
53620
DILATE URETHRA STRICTURE
3.00
1.00
53621
DILATE URETHRA STRICTURE
1.94
1.00
53621
DILATE URETHRA STRICTURE
1.95
1.00
53621
DILATE URETHRA STRICTURE
2.11
1.00
Procedure Code Description
RVU
RVU Coeff Value
53621
DILATE URETHRA STRICTURE
3.00
1.00
53660
DILATION OF URETHRA
1.08
1.00
53660
DILATION OF URETHRA
1.09
1.00
53660
DILATION OF URETHRA
1.19
1.00
53660
DILATION OF URETHRA
4.00
1.00
53661
DILATION OF URETHRA
1.07
1.00
53661
DILATION OF URETHRA
1.17
1.00
53661
DILATION OF URETHRA
3.00
1.00
53665
DILATION OF URETHRA
1.07
1.00
53665
DILATION OF URETHRA
1.08
1.00
53665
DILATION OF URETHRA
1.10
1.00
53665
DILATION OF URETHRA
3.00
1.00
53850
PROSTATIC MICROWAVE THERMOTX
3.00
1.00
53850
PROSTATIC MICROWAVE THERMOTX
14.26
1.00
53850
PROSTATIC MICROWAVE THERMOTX
14.42
1.00
53850
PROSTATIC MICROWAVE THERMOTX
16.28
1.00
53852
PROSTATIC RF THERMOTX
3.00
1.00
53852
PROSTATIC RF THERMOTX
14.89
1.00
53852
PROSTATIC RF THERMOTX
15.26
1.00
53852
PROSTATIC RF THERMOTX
17.72
1.00
53853
PROSTATIC WATER THERMOTHER
3.00
1.00
53853
PROSTATIC WATER THERMOTHER
8.74
1.00
53853
PROSTATIC WATER THERMOTHER
8.81
1.00
53853
PROSTATIC WATER THERMOTHER
9.51
1.00
54000
SLITTING OF PREPUCE
3.00
1.00
54000
SLITTING OF PREPUCE
3.04
1.00
54001
SLITTING OF PREPUCE
3.00
1.00
54001
SLITTING OF PREPUCE
4.34
1.00
54015
DRAIN PENIS LESION
3.00
1.00
54015
DRAIN PENIS LESION
8.70
1.00
54050
DESTRUCTION, PENIS LESION(S)
1.81
1.00
54050
DESTRUCTION, PENIS LESION(S)
3.00
1.00
54055
DESTRUCTION, PENIS LESION(S)
2.68
1.00
54055
DESTRUCTION, PENIS LESION(S)
3.00
1.00
54056
CRYOSURGERY, PENIS LESION(S)
1.84
1.00
Procedure Code Description
RVU
RVU Coeff Value
54056
CRYOSURGERY, PENIS LESION(S)
3.00
1.00
54057
LASER SURG, PENIS LESION(S)
2.56
1.00
54057
LASER SURG, PENIS LESION(S)
3.00
1.00
54060
EXCISION OF PENIS LESION(S)
3.00
1.00
54060
EXCISION OF PENIS LESION(S)
3.61
1.00
54065
DESTRUCTION, PENIS LESION(S)
3.00
1.00
54065
DESTRUCTION, PENIS LESION(S)
4.57
1.00
54100
BIOPSY OF PENIS
2.76
1.00
54100
BIOPSY OF PENIS
3.00
1.00
54105
BIOPSY OF PENIS
3.00
1.00
54105
BIOPSY OF PENIS
5.78
1.00
54110
TREATMENT OF PENIS LESION
3.00
1.00
54110
TREATMENT OF PENIS LESION
17.59
1.00
54111
TREAT PENIS LESION, GRAFT
3.00
1.00
54111
TREAT PENIS LESION, GRAFT
22.74
1.00
54112
TREAT PENIS LESION, GRAFT
3.00
1.00
54112
TREAT PENIS LESION, GRAFT
25.66
1.00
54115
TREATMENT OF PENIS LESION
3.00
1.00
54115
TREATMENT OF PENIS LESION
12.60
1.00
54120
PARTIAL REMOVAL OF PENIS
4.00
1.00
54120
PARTIAL REMOVAL OF PENIS
17.80
1.00
54125
REMOVAL OF PENIS
4.00
1.00
54125
REMOVAL OF PENIS
22.77
1.00
54130
REMOVE PENIS & NODES
6.00
1.00
54130
REMOVE PENIS & NODES
32.27
1.00
54135
REMOVE PENIS & NODES
8.00
1.00
54135
REMOVE PENIS & NODES
40.94
1.00
54150
CIRCUMCISION W/REGIONL BLOCK
3.86
1.00
54152
CIRCUMCISION
3.00
1.00
54152
CIRCUMCISION
4.12
1.00
54160
CIRCUMCISION, NEONATE
3.00
1.00
54160
CIRCUMCISION, NEONATE
4.39
1.00
54161
CIRCUM 28 DAYS OR OLDER
3.00
1.00
54161
CIRCUM 28 DAYS OR OLDER
5.39
1.00
54162
LYSIS PENIL CIRCUMIC LESION
3.00
1.00
Procedure Code Description
RVU
RVU Coeff Value
54162
LYSIS PENIL CIRCUMIC LESION
5.50
1.00
54163
REPAIR OF CIRCUMCISION
3.00
1.00
54163
REPAIR OF CIRCUMCISION
5.27
1.00
54200
TREATMENT OF PENIS LESION
1.49
1.00
54205
TREATMENT OF PENIS LESION
3.00
1.00
54205
TREATMENT OF PENIS LESION
14.87
1.00
54220
TREATMENT OF PENIS LESION
3.59
1.00
54230
PREPARE PENIS STUDY
1.86
1.00
54300
REVISION OF PENIS
3.00
1.00
54300
REVISION OF PENIS
19.09
1.00
54304
REVISION OF PENIS
3.00
1.00
54304
REVISION OF PENIS
22.48
1.00
54308
RECONSTRUCTION OF URETHRA
3.00
1.00
54308
RECONSTRUCTION OF URETHRA
21.35
1.00
54312
RECONSTRUCTION OF URETHRA
3.00
1.00
54312
RECONSTRUCTION OF URETHRA
24.25
1.00
54316
RECONSTRUCTION OF URETHRA
3.00
1.00
54316
RECONSTRUCTION OF URETHRA
28.65
1.00
54318
RECONSTRUCTION OF URETHRA
3.00
1.00
54318
RECONSTRUCTION OF URETHRA
21.04
1.00
54322
RECONSTRUCTION OF URETHRA
3.00
1.00
54322
RECONSTRUCTION OF URETHRA
22.34
1.00
54324
RECONSTRUCTION OF URETHRA
3.00
1.00
54324
RECONSTRUCTION OF URETHRA
28.40
1.00
54326
RECONSTRUCTION OF URETHRA
3.00
1.00
54326
RECONSTRUCTION OF URETHRA
26.80
1.00
54328
REVISE PENIS/URETHRA
3.00
1.00
54328
REVISE PENIS/URETHRA
26.66
1.00
54332
REVISE PENIS/URETHRA
3.00
1.00
54332
REVISE PENIS/URETHRA
28.65
1.00
54336
REVISE PENIS/URETHRA
3.00
1.00
54336
REVISE PENIS/URETHRA
36.06
1.00
54340
SECONDARY URETHRAL SURGERY
3.00
1.00
54340
SECONDARY URETHRAL SURGERY
16.97
1.00
54344
SECONDARY URETHRAL SURGERY
3.00
1.00
Procedure Code Description
RVU
RVU Coeff Value
54344
SECONDARY URETHRAL SURGERY
27.38
1.00
54348
SECONDARY URETHRAL SURGERY
3.00
1.00
54348
SECONDARY URETHRAL SURGERY
29.42
1.00
54352
RECONSTRUCT URETHRA/PENIS
3.00
1.00
54352
RECONSTRUCT URETHRA/PENIS
40.89
1.00
54360
PENIS PLASTIC SURGERY
3.00
1.00
54360
PENIS PLASTIC SURGERY
20.50
1.00
54380
REPAIR PENIS
3.00
1.00
54380
REPAIR PENIS
23.84
1.00
54385
REPAIR PENIS
3.00
1.00
54385
REPAIR PENIS
28.29
1.00
54390
REPAIR PENIS AND BLADDER
6.00
1.00
54390
REPAIR PENIS AND BLADDER
35.91
1.00
54420
REVISION OF PENIS
3.00
1.00
54420
REVISION OF PENIS
19.61
1.00
54430
REVISION OF PENIS
3.00
1.00
54430
REVISION OF PENIS
18.02
1.00
54435
REVISION OF PENIS
3.00
1.00
54435
REVISION OF PENIS
11.49
1.00
54440
REPAIR OF PENIS
3.00
1.00
54450
PREPUTIAL STRETCHING
1.67
1.00
54450
PREPUTIAL STRETCHING
3.00
1.00
54500
BIOPSY OF TESTIS
1.83
1.00
54500
BIOPSY OF TESTIS
3.00
1.00
54505
BIOPSY OF TESTIS
3.00
1.00
54505
BIOPSY OF TESTIS
5.95
1.00
54512
EXCISE LESION TESTIS
3.00
1.00
54512
EXCISE LESION TESTIS
13.64
1.00
54520
REMOVAL OF TESTIS
3.00
1.00
54520
REMOVAL OF TESTIS
8.80
1.00
54522
ORCHIECTOMY, PARTIAL
4.00
1.00
54522
ORCHIECTOMY, PARTIAL
15.24
1.00
54530
REMOVAL OF TESTIS
3.00
1.00
54530
REMOVAL OF TESTIS
13.97
1.00
54535
EXTENSIVE TESTIS SURGERY
6.00
1.00
Procedure Code Description 54535
EXTENSIVE TESTIS SURGERY
54550
RVU
RVU Coeff Value
19.71
1.00
EXPLORATION FOR TESTIS
3.00
1.00
54550
EXPLORATION FOR TESTIS
12.65
1.00
54560
EXPLORATION FOR TESTIS
3.00
1.00
54560
EXPLORATION FOR TESTIS
18.26
1.00
54600
REDUCE TESTIS TORSION
3.00
1.00
54600
REDUCE TESTIS TORSION
11.34
1.00
54620
SUSPENSION OF TESTIS
3.00
1.00
54620
SUSPENSION OF TESTIS
7.98
1.00
54640
SUSPENSION OF TESTIS
4.00
1.00
54640
SUSPENSION OF TESTIS
11.33
1.00
54650
ORCHIOPEXY (FOWLER-STEPHENS)
4.00
1.00
54650
ORCHIOPEXY (FOWLER-STEPHENS)
18.85
1.00
54660
REVISION OF TESTIS
999.99
1.00
54670
REPAIR TESTIS INJURY
3.00
1.00
54670
REPAIR TESTIS INJURY
10.65
1.00
54680
RELOCATION OF TESTIS(ES)
3.00
1.00
54680
RELOCATION OF TESTIS(ES)
20.65
1.00
54690
LAPAROSCOPY, ORCHIECTOMY
6.00
1.00
54690
LAPAROSCOPY, ORCHIECTOMY
18.27
1.00
54692
LAPAROSCOPY, ORCHIOPEXY
6.00
1.00
54692
LAPAROSCOPY, ORCHIOPEXY
19.22
1.00
54700
DRAINAGE OF SCROTUM
3.00
1.00
54700
DRAINAGE OF SCROTUM
6.72
1.00
54800
BIOPSY OF EPIDIDYMIS
3.00
1.00
54800
BIOPSY OF EPIDIDYMIS
3.26
1.00
54820
EXPLORATION OF EPIDIDYMIS
3.00
1.00
54820
EXPLORATION OF EPIDIDYMIS
8.73
1.00
54830
REMOVE EPIDIDYMIS LESION
3.00
1.00
54830
REMOVE EPIDIDYMIS LESION
9.05
1.00
54840
REMOVE EPIDIDYMIS LESION
3.00
1.00
54840
REMOVE EPIDIDYMIS LESION
8.75
1.00
54860
REMOVAL OF EPIDIDYMIS
3.00
1.00
54860
REMOVAL OF EPIDIDYMIS
10.50
1.00
54861
REMOVAL OF EPIDIDYMIS
3.00
1.00
Procedure Code Description 54861
REMOVAL OF EPIDIDYMIS
54900
RVU
RVU Coeff Value
14.06
1.00
FUSION OF SPERMATIC DUCTS
3.00
1.00
54900
FUSION OF SPERMATIC DUCTS
20.76
1.00
54901
FUSION OF SPERMATIC DUCTS
3.00
1.00
54901
FUSION OF SPERMATIC DUCTS
28.26
1.00
55000
DRAINAGE OF HYDROCELE
2.01
1.00
55000
DRAINAGE OF HYDROCELE
3.00
1.00
55040
REMOVAL OF HYDROCELE
3.00
1.00
55040
REMOVAL OF HYDROCELE
8.81
1.00
55041
REMOVAL OF HYDROCELES
3.00
1.00
55041
REMOVAL OF HYDROCELES
12.35
1.00
55060
REPAIR OF HYDROCELE
4.00
1.00
55060
REPAIR OF HYDROCELE
9.08
1.00
55100
DRAINAGE OF SCROTUM ABSCESS
3.00
1.00
55100
DRAINAGE OF SCROTUM ABSCESS
5.50
1.00
55110
EXPLORE SCROTUM
3.00
1.00
55110
EXPLORE SCROTUM
9.28
1.00
55120
REMOVAL OF SCROTUM LESION
3.00
1.00
55120
REMOVAL OF SCROTUM LESION
8.47
1.00
55150
REMOVAL OF SCROTUM
3.00
1.00
55150
REMOVAL OF SCROTUM
11.91
1.00
55175
REVISION OF SCROTUM
3.00
1.00
55175
REVISION OF SCROTUM
8.88
1.00
55180
REVISION OF SCROTUM
3.00
1.00
55180
REVISION OF SCROTUM
17.43
1.00
55250
REMOVAL OF SPERM DUCT(S)
3.00
1.00
55250
REMOVAL OF SPERM DUCT(S)
6.42
1.00
55450
LIGATION OF SPERM DUCT
3.00
1.00
55450
LIGATION OF SPERM DUCT
6.79
1.00
55500
REMOVAL OF HYDROCELE
3.00
1.00
55500
REMOVAL OF HYDROCELE
9.46
1.00
55520
REMOVAL OF SPERM CORD LESION
3.00
1.00
55520
REMOVAL OF SPERM CORD LESION
10.23
1.00
55530
REVISE SPERMATIC CORD VEINS
3.00
1.00
55530
REVISE SPERMATIC CORD VEINS
9.45
1.00
Procedure Code Description
RVU
RVU Coeff Value
55535
REVISE SPERMATIC CORD VEINS
6.00
1.00
55535
REVISE SPERMATIC CORD VEINS
10.69
1.00
55540
REVISE HERNIA & SPERM VEINS
3.00
1.00
55540
REVISE HERNIA & SPERM VEINS
12.61
1.00
55550
LAPARO LIGATE SPERMATIC VEIN
6.00
1.00
55550
LAPARO LIGATE SPERMATIC VEIN
10.54
1.00
55600
INCISE SPERM DUCT POUCH
3.00
1.00
55600
INCISE SPERM DUCT POUCH
10.58
1.00
55605
INCISE SPERM DUCT POUCH
3.00
1.00
55605
INCISE SPERM DUCT POUCH
13.40
1.00
55650
REMOVE SPERM DUCT POUCH
4.00
1.00
55650
REMOVE SPERM DUCT POUCH
18.33
1.00
55680
REMOVE SPERM POUCH LESION
6.00
1.00
55680
REMOVE SPERM POUCH LESION
8.98
1.00
55700
BIOPSY OF PROSTATE
2.40
1.00
55700
BIOPSY OF PROSTATE
3.00
1.00
55705
BIOPSY OF PROSTATE
4.00
1.00
55705
BIOPSY OF PROSTATE
8.13
1.00
55720
DRAINAGE OF PROSTATE ABSCESS
4.00
1.00
55720
DRAINAGE OF PROSTATE ABSCESS
13.38
1.00
55725
DRAINAGE OF PROSTATE ABSCESS
4.00
1.00
55725
DRAINAGE OF PROSTATE ABSCESS
15.04
1.00
55801
REMOVAL OF PROSTATE
4.00
1.00
55801
REMOVAL OF PROSTATE
27.70
1.00
55810
EXTENSIVE PROSTATE SURGERY
4.00
1.00
55810
EXTENSIVE PROSTATE SURGERY
34.72
1.00
55812
EXTENSIVE PROSTATE SURGERY
4.00
1.00
55812
EXTENSIVE PROSTATE SURGERY
42.17
1.00
55815
EXTENSIVE PROSTATE SURGERY
4.00
1.00
55815
EXTENSIVE PROSTATE SURGERY
46.15
1.00
55821
REMOVAL OF PROSTATE
6.00
1.00
55821
REMOVAL OF PROSTATE
22.43
1.00
55831
REMOVAL OF PROSTATE
4.00
1.00
55831
REMOVAL OF PROSTATE
24.37
1.00
55840
EXTENSIVE PROSTATE SURGERY
4.00
1.00
Procedure Code Description
RVU
RVU Coeff Value
55840
EXTENSIVE PROSTATE SURGERY
35.33
1.00
55842
EXTENSIVE PROSTATE SURGERY
4.00
1.00
55842
EXTENSIVE PROSTATE SURGERY
37.71
1.00
55845
EXTENSIVE PROSTATE SURGERY
4.00
1.00
55845
EXTENSIVE PROSTATE SURGERY
43.40
1.00
55859
PERCUT/NEEDLE INSERT, PROS
6.00
1.00
55859
PERCUT/NEEDLE INSERT, PROS
20.12
1.00
55860
SURGICAL EXPOSURE, PROSTATE
6.00
1.00
55860
SURGICAL EXPOSURE, PROSTATE
22.85
1.00
55862
EXTENSIVE PROSTATE SURGERY
6.00
1.00
55862
EXTENSIVE PROSTATE SURGERY
28.72
1.00
55865
EXTENSIVE PROSTATE SURGERY
6.00
1.00
55865
EXTENSIVE PROSTATE SURGERY
34.74
1.00
55866
LAPARO RADICAL PROSTATECTOMY
43.90
1.00
55873
CRYOABLATE PROSTATE
4.00
1.00
55873
CRYOABLATE PROSTATE
29.95
1.00
56405
I & D OF VULVA/PERINEUM
2.81
1.00
56405
I & D OF VULVA/PERINEUM
3.00
1.00
56420
DRAINAGE OF GLAND ABSCESS
2.76
1.00
56420
DRAINAGE OF GLAND ABSCESS
3.00
1.00
56440
SURGERY FOR VULVA LESION
3.00
1.00
56440
SURGERY FOR VULVA LESION
5.34
1.00
56441
LYSIS OF LABIAL LESION(S)
3.00
1.00
56441
LYSIS OF LABIAL LESION(S)
3.95
1.00
56501
DESTROY, VULVA LESIONS, SIM
2.97
1.00
56501
DESTROY, VULVA LESIONS, SIM
3.00
1.00
56515
DESTROY VULVA LESION/S COMPL
3.00
1.00
56515
DESTROY VULVA LESION/S COMPL
5.18
1.00
56605
BIOPSY OF VULVA/PERINEUM
1.68
1.00
56605
BIOPSY OF VULVA/PERINEUM
3.00
1.00
56606
BIOPSY OF VULVA/PERINEUM
0.83
1.00
56606
BIOPSY OF VULVA/PERINEUM
999.99
1.00
56620
PARTIAL REMOVAL OF VULVA
3.00
1.00
56620
PARTIAL REMOVAL OF VULVA
13.08
1.00
56625
COMPLETE REMOVAL OF VULVA
3.00
1.00
Procedure Code Description 56625
COMPLETE REMOVAL OF VULVA
56630
RVU
RVU Coeff Value
15.02
1.00
EXTENSIVE VULVA SURGERY
3.00
1.00
56630
EXTENSIVE VULVA SURGERY
21.19
1.00
56631
EXTENSIVE VULVA SURGERY
7.00
1.00
56631
EXTENSIVE VULVA SURGERY
28.10
1.00
56632
EXTENSIVE VULVA SURGERY
4.00
1.00
56632
EXTENSIVE VULVA SURGERY
32.55
1.00
56633
EXTENSIVE VULVA SURGERY
4.00
1.00
56633
EXTENSIVE VULVA SURGERY
27.40
1.00
56634
EXTENSIVE VULVA SURGERY
4.00
1.00
56634
EXTENSIVE VULVA SURGERY
30.61
1.00
56637
EXTENSIVE VULVA SURGERY
4.00
1.00
56637
EXTENSIVE VULVA SURGERY
36.79
1.00
56640
EXTENSIVE VULVA SURGERY
5.00
1.00
56640
EXTENSIVE VULVA SURGERY
36.67
1.00
56700
PARTIAL REMOVAL OF HYMEN
3.00
1.00
56700
PARTIAL REMOVAL OF HYMEN
4.46
1.00
56720
INCISION OF HYMEN
1.16
1.00
56720
INCISION OF HYMEN
3.00
1.00
56740
REMOVE VAGINA GLAND LESION
3.00
1.00
56740
REMOVE VAGINA GLAND LESION
7.52
1.00
56800
REPAIR OF VAGINA
3.00
1.00
56800
REPAIR OF VAGINA
6.87
1.00
56805
REPAIR CLITORIS
29.80
1.00
56805
REPAIR CLITORIS
999.99
1.00
56810
REPAIR OF PERINEUM
3.00
1.00
56810
REPAIR OF PERINEUM
7.26
1.00
56820
EXAM OF VULVA W/SCOPE
2.25
1.00
56821
EXAM/BIOPSY OF VULVA W/SCOPE
3.10
1.00
57000
EXPLORATION OF VAGINA
3.00
1.00
57000
EXPLORATION OF VAGINA
5.44
1.00
57010
DRAINAGE OF PELVIC ABSCESS
6.00
1.00
57010
DRAINAGE OF PELVIC ABSCESS
10.39
1.00
57020
DRAINAGE OF PELVIC FLUID
2.28
1.00
57020
DRAINAGE OF PELVIC FLUID
3.00
1.00
Procedure Code Description
RVU
RVU Coeff Value
57022
I & D VAGINAL HEMATOMA, PP
3.00
1.00
57022
I & D VAGINAL HEMATOMA, PP
4.83
1.00
57023
I & D VAG HEMATOMA, NON-OB
3.00
1.00
57023
I & D VAG HEMATOMA, NON-OB
7.88
1.00
57061
DESTROY VAG LESIONS, SIMPLE
2.54
1.00
57061
DESTROY VAG LESIONS, SIMPLE
3.00
1.00
57065
DESTROY VAG LESIONS, COMPLEX
3.00
1.00
57065
DESTROY VAG LESIONS, COMPLEX
5.10
1.00
57100
BIOPSY OF VAGINA
1.80
1.00
57100
BIOPSY OF VAGINA
3.00
1.00
57105
BIOPSY OF VAGINA
3.00
1.00
57105
BIOPSY OF VAGINA
3.17
1.00
57106
REMOVE VAGINA WALL, PARTIAL
5.00
1.00
57106
REMOVE VAGINA WALL, PARTIAL
10.81
1.00
57107
REMOVE VAGINA TISSUE, PART
5.00
1.00
57107
REMOVE VAGINA TISSUE, PART
35.45
1.00
57109
VAGINECTOMY PARTIAL W/NODES
5.00
1.00
57109
VAGINECTOMY PARTIAL W/NODES
40.50
1.00
57110
REMOVE VAGINA WALL, COMPLETE
5.00
1.00
57110
REMOVE VAGINA WALL, COMPLETE
22.93
1.00
57111
REMOVE VAGINA TISSUE, COMPL
5.00
1.00
57111
REMOVE VAGINA TISSUE, COMPL
42.01
1.00
57112
VAGINECTOMY W/NODES, COMPL
5.00
1.00
57112
VAGINECTOMY W/NODES, COMPL
43.58
1.00
57120
CLOSURE OF VAGINA
4.00
1.00
57120
CLOSURE OF VAGINA
12.75
1.00
57130
REMOVE VAGINA LESION
3.00
1.00
57130
REMOVE VAGINA LESION
4.69
1.00
57135
REMOVE VAGINA LESION
4.00
1.00
57135
REMOVE VAGINA LESION
5.06
1.00
57150
TREAT VAGINA INFECTION
0.83
1.00
57155
INSERT UTERI TANDEMS/OVOIDS
10.54
1.00
57160
INSERT PESSARY/OTHER DEVICE
1.38
1.00
57170
FITTING OF DIAPHRAGM/CAP
1.34
1.00
57180
TREAT VAGINAL BLEEDING
3.15
1.00
Procedure Code Description
RVU
RVU Coeff Value
57200
REPAIR OF VAGINA
3.00
1.00
57200
REPAIR OF VAGINA
7.43
1.00
57210
REPAIR VAGINA/PERINEUM
4.00
1.00
57210
REPAIR VAGINA/PERINEUM
9.34
1.00
57220
REVISION OF URETHRA
3.00
1.00
57220
REVISION OF URETHRA
8.07
1.00
57230
REPAIR OF URETHRAL LESION
3.00
1.00
57230
REPAIR OF URETHRAL LESION
9.68
1.00
57240
REPAIR BLADDER & VAGINA
4.00
1.00
57240
REPAIR BLADDER & VAGINA
10.50
1.00
57250
REPAIR RECTUM & VAGINA
4.00
1.00
57250
REPAIR RECTUM & VAGINA
9.88
1.00
57260
REPAIR OF VAGINA
4.00
1.00
57260
REPAIR OF VAGINA
14.24
1.00
57265
EXTENSIVE REPAIR OF VAGINA
4.00
1.00
57265
EXTENSIVE REPAIR OF VAGINA
18.86
1.00
57268
REPAIR OF BOWEL BULGE
4.00
1.00
57268
REPAIR OF BOWEL BULGE
11.90
1.00
57270
REPAIR OF BOWEL POUCH
5.00
1.00
57270
REPAIR OF BOWEL POUCH
19.88
1.00
57280
SUSPENSION OF VAGINA
5.00
1.00
57280
SUSPENSION OF VAGINA
24.21
1.00
57282
COLPOPEXY, EXTRAPERITONEAL
6.00
1.00
57282
COLPOPEXY, EXTRAPERITONEAL
15.30
1.00
57284
REPAIR PARAVAG DEFECT, OPEN
6.00
1.00
57284
REPAIR PARAVAG DEFECT, OPEN
20.99
1.00
57287
REVISE/REMOVE SLING REPAIR
6.00
1.00
57287
REVISE/REMOVE SLING REPAIR
17.05
1.00
57288
REPAIR BLADDER DEFECT
5.00
1.00
57288
REPAIR BLADDER DEFECT
19.93
1.00
57289
REPAIR BLADDER & VAGINA
5.00
1.00
57289
REPAIR BLADDER & VAGINA
18.79
1.00
57291
CONSTRUCTION OF VAGINA
6.00
1.00
57291
CONSTRUCTION OF VAGINA
14.02
1.00
57292
CONSTRUCT VAGINA WITH GRAFT
6.00
1.00
Procedure Code Description
RVU
RVU Coeff Value
57292
CONSTRUCT VAGINA WITH GRAFT
21.76
1.00
57300
REPAIR RECTUM-VAGINA FISTULA
4.00
1.00
57300
REPAIR RECTUM-VAGINA FISTULA
13.16
1.00
57305
REPAIR RECTUM-VAGINA FISTULA
6.00
1.00
57305
REPAIR RECTUM-VAGINA FISTULA
21.59
1.00
57307
FISTULA REPAIR & COLOSTOMY
6.00
1.00
57307
FISTULA REPAIR & COLOSTOMY
25.07
1.00
57308
FISTULA REPAIR, TRANSPERINE
4.00
1.00
57308
FISTULA REPAIR, TRANSPERINE
16.74
1.00
57310
REPAIR URETHROVAGINAL LESION
4.00
1.00
57310
REPAIR URETHROVAGINAL LESION
11.52
1.00
57311
REPAIR URETHROVAGINAL LESION
3.00
1.00
57311
REPAIR URETHROVAGINAL LESION
13.34
1.00
57320
REPAIR BLADDER-VAGINA LESION
4.00
1.00
57320
REPAIR BLADDER-VAGINA LESION
13.56
1.00
57330
REPAIR BLADDER-VAGINA LESION
6.00
1.00
57330
REPAIR BLADDER-VAGINA LESION
19.50
1.00
57335
REPAIR VAGINA
29.36
1.00
57335
REPAIR VAGINA
999.99
1.00
57400
DILATION OF VAGINA
3.00
1.00
57400
DILATION OF VAGINA
3.63
1.00
57410
PELVIC EXAMINATION
2.92
1.00
57410
PELVIC EXAMINATION
3.00
1.00
57415
REMOVE VAGINAL FOREIGN BODY
3.00
1.00
57415
REMOVE VAGINAL FOREIGN BODY
4.23
1.00
57420
EXAM OF VAGINA W/SCOPE
2.39
1.00
57421
EXAM/BIOPSY OF VAG W/SCOPE
3.31
1.00
57452
EXAM OF CERVIX W/SCOPE
2.25
1.00
57452
EXAM OF CERVIX W/SCOPE
3.00
1.00
57454
BX/CURETT OF CERVIX W/SCOPE
3.00
1.00
57454
BX/CURETT OF CERVIX W/SCOPE
3.48
1.00
57455
BIOPSY OF CERVIX W/SCOPE
3.01
1.00
57456
ENDOCERV CURETTAGE W/SCOPE
2.82
1.00
57460
BX OF CERVIX W/SCOPE, LEEP
3.00
1.00
57460
BX OF CERVIX W/SCOPE, LEEP
4.36
1.00
Procedure Code Description
RVU
RVU Coeff Value
57461
CONZ OF CERVIX W/SCOPE, LEEP
5.22
1.00
57500
BIOPSY OF CERVIX
1.56
1.00
57500
BIOPSY OF CERVIX
3.00
1.00
57505
ENDOCERVICAL CURETTAGE
2.47
1.00
57505
ENDOCERVICAL CURETTAGE
3.00
1.00
57510
CAUTERIZATION OF CERVIX
3.59
1.00
57510
CAUTERIZATION OF CERVIX
4.00
1.00
57511
CRYOCAUTERY OF CERVIX
2.83
1.00
57511
CRYOCAUTERY OF CERVIX
4.00
1.00
57513
LASER SURGERY OF CERVIX
3.00
1.00
57513
LASER SURGERY OF CERVIX
3.59
1.00
57520
CONIZATION OF CERVIX
3.00
1.00
57520
CONIZATION OF CERVIX
7.21
1.00
57522
CONIZATION OF CERVIX
3.00
1.00
57522
CONIZATION OF CERVIX
6.19
1.00
57530
REMOVAL OF CERVIX
3.00
1.00
57530
REMOVAL OF CERVIX
8.80
1.00
57531
REMOVAL OF CERVIX, RADICAL
3.00
1.00
57531
REMOVAL OF CERVIX, RADICAL
43.99
1.00
57540
REMOVAL OF RESIDUAL CERVIX
5.00
1.00
57540
REMOVAL OF RESIDUAL CERVIX
19.57
1.00
57545
REMOVE CERVIX/REPAIR PELVIS
6.00
1.00
57545
REMOVE CERVIX/REPAIR PELVIS
20.92
1.00
57550
REMOVAL OF RESIDUAL CERVIX
5.00
1.00
57550
REMOVAL OF RESIDUAL CERVIX
9.86
1.00
57555
REMOVE CERVIX/REPAIR VAGINA
4.00
1.00
57555
REMOVE CERVIX/REPAIR VAGINA
15.44
1.00
57556
REMOVE CERVIX, REPAIR BOWEL
4.00
1.00
57556
REMOVE CERVIX, REPAIR BOWEL
14.00
1.00
57700
REVISION OF CERVIX
4.00
1.00
57700
REVISION OF CERVIX
6.32
1.00
57720
REVISION OF CERVIX
4.00
1.00
57720
REVISION OF CERVIX
7.74
1.00
57800
DILATION OF CERVICAL CANAL
1.33
1.00
57800
DILATION OF CERVICAL CANAL
3.00
1.00
Procedure Code Description
RVU
RVU Coeff Value
57820
D & C OF RESIDUAL CERVIX
2.95
1.00
57820
D & C OF RESIDUAL CERVIX
3.00
1.00
58100
BIOPSY OF UTERUS LINING
2.35
1.00
58100
BIOPSY OF UTERUS LINING
3.00
1.00
58120
DILATION AND CURETTAGE
5.57
1.00
58120
DILATION AND CURETTAGE
6.00
1.00
58140
MYOMECTOMY ABDOM METHOD
6.00
1.00
58140
MYOMECTOMY ABDOM METHOD
23.07
1.00
58145
MYOMECTOMY VAG METHOD
5.00
1.00
58145
MYOMECTOMY VAG METHOD
13.68
1.00
58146
MYOMECTOMY ABDOM COMPLEX
29.61
1.00
58150
TOTAL HYSTERECTOMY
6.00
1.00
58150
TOTAL HYSTERECTOMY
24.70
1.00
58152
TOTAL HYSTERECTOMY
6.00
1.00
58152
TOTAL HYSTERECTOMY
32.40
1.00
58180
PARTIAL HYSTERECTOMY
6.00
1.00
58180
PARTIAL HYSTERECTOMY
24.68
1.00
58200
EXTENSIVE HYSTERECTOMY
6.00
1.00
58200
EXTENSIVE HYSTERECTOMY
34.34
1.00
58210
EXTENSIVE HYSTERECTOMY
8.00
1.00
58210
EXTENSIVE HYSTERECTOMY
45.72
1.00
58240
REMOVAL OF PELVIS CONTENTS
7.00
1.00
58240
REMOVAL OF PELVIS CONTENTS
60.63
1.00
58260
VAGINAL HYSTERECTOMY
6.00
1.00
58260
VAGINAL HYSTERECTOMY
20.89
1.00
58262
VAG HYST INCLUDING T/O
6.00
1.00
58262
VAG HYST INCLUDING T/O
23.62
1.00
58263
VAG HYST W/T/O & VAG REPAIR
6.00
1.00
58263
VAG HYST W/T/O & VAG REPAIR
25.56
1.00
58267
VAG HYST W/URINARY REPAIR
7.00
1.00
58267
VAG HYST W/URINARY REPAIR
27.07
1.00
58270
VAG HYST W/ENTEROCELE REPAIR
5.00
1.00
58270
VAG HYST W/ENTEROCELE REPAIR
22.82
1.00
58275
HYSTERECTOMY/REVISE VAGINA
6.00
1.00
58275
HYSTERECTOMY/REVISE VAGINA
24.99
1.00
Procedure Code Description
RVU
RVU Coeff Value
58280
HYSTERECTOMY/REVISE VAGINA
5.00
1.00
58280
HYSTERECTOMY/REVISE VAGINA
26.76
1.00
58285
EXTENSIVE HYSTERECTOMY
7.00
1.00
58285
EXTENSIVE HYSTERECTOMY
34.99
1.00
58290
VAG HYST COMPLEX
29.60
1.00
58291
VAG HYST INCL T/O, COMPLEX
32.55
1.00
58292
VAG HYST T/O & REPAIR, COMPL
34.48
1.00
58293
VAG HYST W/URO REPAIR, COMPL
35.82
1.00
58294
VAG HYST W/ENTEROCELE, COMPL
31.75
1.00
58300
INSERT INTRAUTERINE DEVICE
1.50
1.00
58301
REMOVE INTRAUTERINE DEVICE
1.90
1.00
58301
REMOVE INTRAUTERINE DEVICE
3.00
1.00
58340
CATHETER FOR HYSTEROGRAPHY
1.28
1.00
58340
CATHETER FOR HYSTEROGRAPHY
3.00
1.00
58346
INSERT HEYMAN UTERI CAPSULE
11.26
1.00
58353
ENDOMETR ABLATE, THERMAL
4.00
1.00
58353
ENDOMETR ABLATE, THERMAL
6.16
1.00
58400
SUSPENSION OF UTERUS
5.00
1.00
58400
SUSPENSION OF UTERUS
10.91
1.00
58410
SUSPENSION OF UTERUS
5.00
1.00
58410
SUSPENSION OF UTERUS
20.37
1.00
58520
REPAIR OF RUPTURED UTERUS
5.00
1.00
58520
REPAIR OF RUPTURED UTERUS
19.02
1.00
58540
REVISION OF UTERUS
6.00
1.00
58540
REVISION OF UTERUS
22.82
1.00
58545
LAPAROSCOPIC MYOMECTOMY
23.81
1.00
58546
LAPARO-MYOMECTOMY, COMPLEX
30.00
1.00
58550
LAPARO-ASST VAG HYSTERECTOMY
6.00
1.00
58550
LAPARO-ASST VAG HYSTERECTOMY
22.84
1.00
58551
LAPAROSCOPY, REMOVE MYOMA
6.00
1.00
58552
LAPARO-VAG HYST INCL T/O
23.19
1.00
58553
LAPARO-VAG HYST, COMPLEX
29.80
1.00
58554
LAPARO-VAG HYST W/T/O, COMPL
29.49
1.00
58555
HYSTEROSCOPY, DX, SEP PROC
5.16
1.00
58555
HYSTEROSCOPY, DX, SEP PROC
6.00
1.00
Procedure Code Description
RVU
RVU Coeff Value
58558
HYSTEROSCOPY, BIOPSY
6.00
1.00
58558
HYSTEROSCOPY, BIOPSY
7.36
1.00
58559
HYSTEROSCOPY, LYSIS
6.00
1.00
58559
HYSTEROSCOPY, LYSIS
9.48
1.00
58560
HYSTEROSCOPY, RESECT SEPTUM
6.00
1.00
58560
HYSTEROSCOPY, RESECT SEPTUM
10.76
1.00
58561
HYSTEROSCOPY, REMOVE MYOMA
6.00
1.00
58561
HYSTEROSCOPY, REMOVE MYOMA
15.30
1.00
58562
HYSTEROSCOPY, REMOVE FB
6.00
1.00
58562
HYSTEROSCOPY, REMOVE FB
8.00
1.00
58563
HYSTEROSCOPY, ABLATION
6.00
1.00
58563
HYSTEROSCOPY, ABLATION
9.50
1.00
58600
DIVISION OF FALLOPIAN TUBE
5.00
1.00
58600
DIVISION OF FALLOPIAN TUBE
9.27
1.00
58605
DIVISION OF FALLOPIAN TUBE
5.00
1.00
58605
DIVISION OF FALLOPIAN TUBE
8.45
1.00
58611
LIGATE OVIDUCT(S) ADD-ON
2.11
1.00
58615
OCCLUDE FALLOPIAN TUBE(S)
6.00
1.00
58615
OCCLUDE FALLOPIAN TUBE(S)
7.41
1.00
58660
LAPAROSCOPY, LYSIS
6.00
1.00
58660
LAPAROSCOPY, LYSIS
18.03
1.00
58661
LAPAROSCOPY, REMOVE ADNEXA
6.00
1.00
58661
LAPAROSCOPY, REMOVE ADNEXA
17.44
1.00
58662
LAPAROSCOPY, EXCISE LESIONS
6.00
1.00
58662
LAPAROSCOPY, EXCISE LESIONS
18.51
1.00
58670
LAPAROSCOPY, TUBAL CAUTERY
6.00
1.00
58670
LAPAROSCOPY, TUBAL CAUTERY
9.77
1.00
58671
LAPAROSCOPY, TUBAL BLOCK
6.00
1.00
58671
LAPAROSCOPY, TUBAL BLOCK
9.79
1.00
58672
LAPAROSCOPY, FIMBRIOPLASTY
6.00
1.00
58672
LAPAROSCOPY, FIMBRIOPLASTY
20.62
1.00
58673
LAPAROSCOPY, SALPINGOSTOMY
6.00
1.00
58673
LAPAROSCOPY, SALPINGOSTOMY
22.00
1.00
58700
REMOVAL OF FALLOPIAN TUBE
6.00
1.00
58700
REMOVAL OF FALLOPIAN TUBE
18.49
1.00
Procedure Code Description
RVU
RVU Coeff Value
58720
REMOVAL OF OVARY/TUBE(S)
6.00
1.00
58720
REMOVAL OF OVARY/TUBE(S)
18.25
1.00
58740
ADHESIOLYSIS TUBE, OVARY
6.00
1.00
58740
ADHESIOLYSIS TUBE, OVARY
21.58
1.00
58770
CREATE NEW TUBAL OPENING
6.00
1.00
58770
CREATE NEW TUBAL OPENING
22.36
1.00
58800
DRAINAGE OF OVARIAN CYST(S)
6.00
1.00
58800
DRAINAGE OF OVARIAN CYST(S)
8.86
1.00
58805
DRAINAGE OF OVARIAN CYST(S)
5.00
1.00
58805
DRAINAGE OF OVARIAN CYST(S)
9.91
1.00
58820
DRAIN OVARY ABSCESS, OPEN
5.00
1.00
58820
DRAIN OVARY ABSCESS, OPEN
7.85
1.00
58822
DRAIN OVARY ABSCESS, PERCUT
5.00
1.00
58822
DRAIN OVARY ABSCESS, PERCUT
16.09
1.00
58823
DRAIN PELVIC ABSCESS, PERCUT
5.88
1.00
58823
DRAIN PELVIC ABSCESS, PERCUT
6.00
1.00
58825
TRANSPOSITION, OVARY(S)
6.00
1.00
58825
TRANSPOSITION, OVARY(S)
17.34
1.00
58900
BIOPSY OF OVARY(S)
6.00
1.00
58900
BIOPSY OF OVARY(S)
10.08
1.00
58920
PARTIAL REMOVAL OF OVARY(S)
5.00
1.00
58920
PARTIAL REMOVAL OF OVARY(S)
17.62
1.00
58925
REMOVAL OF OVARIAN CYST(S)
6.00
1.00
58925
REMOVAL OF OVARIAN CYST(S)
18.04
1.00
58940
REMOVAL OF OVARY(S)
6.00
1.00
58940
REMOVAL OF OVARY(S)
11.96
1.00
58943
REMOVAL OF OVARY(S)
6.00
1.00
58943
REMOVAL OF OVARY(S)
29.73
1.00
58950
RESECT OVARIAN MALIGNANCY
6.00
1.00
58950
RESECT OVARIAN MALIGNANCY
27.48
1.00
58951
RESECT OVARIAN MALIGNANCY
8.00
1.00
58951
RESECT OVARIAN MALIGNANCY
35.90
1.00
58952
RESECT OVARIAN MALIGNANCY
39.99
1.00
58953
TAH, RAD DISSECT FOR DEBULK
8.00
1.00
58953
TAH, RAD DISSECT FOR DEBULK
50.38
1.00
Procedure Code Description
RVU
RVU Coeff Value
58954
TAH RAD DEBULK/LYMPH REMOVE
8.00
1.00
58954
TAH RAD DEBULK/LYMPH REMOVE
54.71
1.00
58960
EXPLORATION OF ABDOMEN
6.00
1.00
58960
EXPLORATION OF ABDOMEN
24.24
1.00
58999
GENITAL SURGERY PROCEDURE
999.99
1.00
61000
REMOVE CRANIAL CAVITY FLUID
2.69
1.00
61000
REMOVE CRANIAL CAVITY FLUID
2.70
1.00
61000
REMOVE CRANIAL CAVITY FLUID
2.84
1.00
61000
REMOVE CRANIAL CAVITY FLUID
4.00
1.00
61001
REMOVE CRANIAL CAVITY FLUID
2.72
1.00
61001
REMOVE CRANIAL CAVITY FLUID
2.73
1.00
61001
REMOVE CRANIAL CAVITY FLUID
2.79
1.00
61001
REMOVE CRANIAL CAVITY FLUID
4.00
1.00
61020
REMOVE BRAIN CAVITY FLUID
3.15
1.00
61020
REMOVE BRAIN CAVITY FLUID
3.17
1.00
61020
REMOVE BRAIN CAVITY FLUID
3.38
1.00
61020
REMOVE BRAIN CAVITY FLUID
7.00
1.00
61026
INJECTION INTO BRAIN CANAL
3.35
1.00
61026
INJECTION INTO BRAIN CANAL
3.37
1.00
61026
INJECTION INTO BRAIN CANAL
5.00
1.00
61050
REMOVE BRAIN CANAL FLUID
2.82
1.00
61050
REMOVE BRAIN CANAL FLUID
2.91
1.00
61050
REMOVE BRAIN CANAL FLUID
2.93
1.00
61050
REMOVE BRAIN CANAL FLUID
5.00
1.00
61055
INJECTION INTO BRAIN CANAL
3.64
1.00
61055
INJECTION INTO BRAIN CANAL
3.65
1.00
61055
INJECTION INTO BRAIN CANAL
3.68
1.00
61055
INJECTION INTO BRAIN CANAL
5.00
1.00
61070
BRAIN CANAL SHUNT PROCEDURE
2.02
1.00
61070
BRAIN CANAL SHUNT PROCEDURE
2.03
1.00
61070
BRAIN CANAL SHUNT PROCEDURE
2.14
1.00
61105
TWIST DRILL HOLE
9.00
1.00
61105
TWIST DRILL HOLE
10.23
1.00
61105
TWIST DRILL HOLE
10.35
1.00
61105
TWIST DRILL HOLE
11.17
1.00
Procedure Code Description
RVU
RVU Coeff Value
61107
DRILL SKULL FOR IMPLANTATION
4.00
1.00
61107
DRILL SKULL FOR IMPLANTATION
8.37
1.00
61107
DRILL SKULL FOR IMPLANTATION
9.40
1.00
61107
DRILL SKULL FOR IMPLANTATION
9.54
1.00
61108
DRILL SKULL FOR DRAINAGE
9.00
1.00
61108
DRILL SKULL FOR DRAINAGE
19.52
1.00
61108
DRILL SKULL FOR DRAINAGE
19.77
1.00
61108
DRILL SKULL FOR DRAINAGE
22.18
1.00
61120
BURR HOLE FOR PUNCTURE
4.00
1.00
61120
BURR HOLE FOR PUNCTURE
16.69
1.00
61120
BURR HOLE FOR PUNCTURE
16.93
1.00
61120
BURR HOLE FOR PUNCTURE
18.16
1.00
61140
PIERCE SKULL FOR BIOPSY
9.00
1.00
61140
PIERCE SKULL FOR BIOPSY
29.16
1.00
61140
PIERCE SKULL FOR BIOPSY
29.59
1.00
61140
PIERCE SKULL FOR BIOPSY
31.65
1.00
61150
PIERCE SKULL FOR DRAINAGE
9.00
1.00
61150
PIERCE SKULL FOR DRAINAGE
31.75
1.00
61150
PIERCE SKULL FOR DRAINAGE
32.20
1.00
61150
PIERCE SKULL FOR DRAINAGE
33.83
1.00
61151
PIERCE SKULL FOR DRAINAGE
5.00
1.00
61151
PIERCE SKULL FOR DRAINAGE
22.88
1.00
61151
PIERCE SKULL FOR DRAINAGE
23.20
1.00
61151
PIERCE SKULL FOR DRAINAGE
24.46
1.00
61154
PIERCE SKULL & REMOVE CLOT
11.00
1.00
61154
PIERCE SKULL & REMOVE CLOT
27.74
1.00
61154
PIERCE SKULL & REMOVE CLOT
28.15
1.00
61154
PIERCE SKULL & REMOVE CLOT
31.74
1.00
61156
PIERCE SKULL FOR DRAINAGE
9.00
1.00
61156
PIERCE SKULL FOR DRAINAGE
29.81
1.00
61156
PIERCE SKULL FOR DRAINAGE
30.28
1.00
61156
PIERCE SKULL FOR DRAINAGE
31.64
1.00
61210
PIERCE SKULL, IMPLANT DEVICE
7.00
1.00
61210
PIERCE SKULL, IMPLANT DEVICE
9.77
1.00
61210
PIERCE SKULL, IMPLANT DEVICE
10.78
1.00
Procedure Code Description 61210
PIERCE SKULL, IMPLANT DEVICE
61215
RVU
RVU Coeff Value
10.94
1.00
INSERT BRAIN-FLUID DEVICE
3.00
1.00
61215
INSERT BRAIN-FLUID DEVICE
9.97
1.00
61215
INSERT BRAIN-FLUID DEVICE
10.09
1.00
61215
INSERT BRAIN-FLUID DEVICE
12.09
1.00
61250
PIERCE SKULL & EXPLORE
7.00
1.00
61250
PIERCE SKULL & EXPLORE
19.45
1.00
61250
PIERCE SKULL & EXPLORE
19.71
1.00
61250
PIERCE SKULL & EXPLORE
21.35
1.00
61253
PIERCE SKULL & EXPLORE
9.00
1.00
61253
PIERCE SKULL & EXPLORE
22.49
1.00
61253
PIERCE SKULL & EXPLORE
22.81
1.00
61253
PIERCE SKULL & EXPLORE
23.36
1.00
61304
OPEN SKULL FOR EXPLORATION
11.00
1.00
61304
OPEN SKULL FOR EXPLORATION
39.47
1.00
61304
OPEN SKULL FOR EXPLORATION
40.03
1.00
61304
OPEN SKULL FOR EXPLORATION
41.77
1.00
61305
OPEN SKULL FOR EXPLORATION
15.00
1.00
61305
OPEN SKULL FOR EXPLORATION
47.56
1.00
61305
OPEN SKULL FOR EXPLORATION
48.27
1.00
61305
OPEN SKULL FOR EXPLORATION
50.13
1.00
61312
OPEN SKULL FOR DRAINAGE
11.00
1.00
61312
OPEN SKULL FOR DRAINAGE
44.98
1.00
61312
OPEN SKULL FOR DRAINAGE
45.63
1.00
61312
OPEN SKULL FOR DRAINAGE
52.01
1.00
61313
OPEN SKULL FOR DRAINAGE
11.00
1.00
61313
OPEN SKULL FOR DRAINAGE
45.20
1.00
61313
OPEN SKULL FOR DRAINAGE
45.85
1.00
61313
OPEN SKULL FOR DRAINAGE
49.85
1.00
61314
OPEN SKULL FOR DRAINAGE
11.00
1.00
61314
OPEN SKULL FOR DRAINAGE
41.57
1.00
61314
OPEN SKULL FOR DRAINAGE
42.09
1.00
61314
OPEN SKULL FOR DRAINAGE
46.24
1.00
61315
OPEN SKULL FOR DRAINAGE
11.00
1.00
61315
OPEN SKULL FOR DRAINAGE
49.72
1.00
Procedure Code Description
RVU
RVU Coeff Value
61315
OPEN SKULL FOR DRAINAGE
50.49
1.00
61315
OPEN SKULL FOR DRAINAGE
52.64
1.00
61316
IMPLT CRAN BONE FLAP TO ABDO
2.30
1.00
61316
IMPLT CRAN BONE FLAP TO ABDO
2.39
1.00
61316
IMPLT CRAN BONE FLAP TO ABDO
2.48
1.00
61320
OPEN SKULL FOR DRAINAGE
11.00
1.00
61320
OPEN SKULL FOR DRAINAGE
45.98
1.00
61320
OPEN SKULL FOR DRAINAGE
46.65
1.00
61320
OPEN SKULL FOR DRAINAGE
48.68
1.00
61321
OPEN SKULL FOR DRAINAGE
11.00
1.00
61321
OPEN SKULL FOR DRAINAGE
50.40
1.00
61321
OPEN SKULL FOR DRAINAGE
51.09
1.00
61321
OPEN SKULL FOR DRAINAGE
53.31
1.00
61322
DECOMPRESSIVE CRANIOTOMY
48.37
1.00
61322
DECOMPRESSIVE CRANIOTOMY
49.93
1.00
61322
DECOMPRESSIVE CRANIOTOMY
59.08
1.00
61323
DECOMPRESSIVE LOBECTOMY
50.07
1.00
61323
DECOMPRESSIVE LOBECTOMY
51.61
1.00
61323
DECOMPRESSIVE LOBECTOMY
60.19
1.00
61330
DECOMPRESS EYE SOCKET
11.00
1.00
61330
DECOMPRESS EYE SOCKET
40.00
1.00
61330
DECOMPRESS EYE SOCKET
40.20
1.00
61330
DECOMPRESS EYE SOCKET
40.21
1.00
61332
EXPLORE/BIOPSY EYE SOCKET
11.00
1.00
61332
EXPLORE/BIOPSY EYE SOCKET
47.30
1.00
61332
EXPLORE/BIOPSY EYE SOCKET
47.40
1.00
61332
EXPLORE/BIOPSY EYE SOCKET
47.91
1.00
61333
EXPLORE ORBIT/REMOVE LESION
11.00
1.00
61333
EXPLORE ORBIT/REMOVE LESION
46.21
1.00
61333
EXPLORE ORBIT/REMOVE LESION
46.27
1.00
61333
EXPLORE ORBIT/REMOVE LESION
47.47
1.00
61334
EXPLORE ORBIT/REMOVE OBJECT
11.00
1.00
61334
EXPLORE ORBIT/REMOVE OBJECT
30.54
1.00
61334
EXPLORE ORBIT/REMOVE OBJECT
32.22
1.00
61334
EXPLORE ORBIT/REMOVE OBJECT
32.58
1.00
Procedure Code Description
RVU
RVU Coeff Value
61340
SUBTEMPORAL DECOMPRESSION
11.00
1.00
61340
SUBTEMPORAL DECOMPRESSION
33.73
1.00
61340
SUBTEMPORAL DECOMPRESSION
34.20
1.00
61340
SUBTEMPORAL DECOMPRESSION
36.23
1.00
61343
INCISE SKULL (PRESS RELIEF)
11.00
1.00
61343
INCISE SKULL (PRESS RELIEF)
53.78
1.00
61343
INCISE SKULL (PRESS RELIEF)
53.89
1.00
61343
INCISE SKULL (PRESS RELIEF)
56.02
1.00
61345
RELIEVE CRANIAL PRESSURE
11.00
1.00
61345
RELIEVE CRANIAL PRESSURE
48.94
1.00
61345
RELIEVE CRANIAL PRESSURE
51.84
1.00
61440
INCISE SKULL FOR SURGERY
11.00
1.00
61440
INCISE SKULL FOR SURGERY
47.50
1.00
61440
INCISE SKULL FOR SURGERY
47.59
1.00
61440
INCISE SKULL FOR SURGERY
50.75
1.00
61450
INCISE SKULL FOR SURGERY
11.00
1.00
61450
INCISE SKULL FOR SURGERY
46.42
1.00
61450
INCISE SKULL FOR SURGERY
46.59
1.00
61450
INCISE SKULL FOR SURGERY
47.82
1.00
61458
INCISE SKULL FOR BRAIN WOUND
11.00
1.00
61458
INCISE SKULL FOR BRAIN WOUND
49.16
1.00
61458
INCISE SKULL FOR BRAIN WOUND
49.20
1.00
61458
INCISE SKULL FOR BRAIN WOUND
51.28
1.00
61460
INCISE SKULL FOR SURGERY
11.00
1.00
61460
INCISE SKULL FOR SURGERY
51.03
1.00
61460
INCISE SKULL FOR SURGERY
51.05
1.00
61460
INCISE SKULL FOR SURGERY
51.61
1.00
61470
INCISE SKULL FOR SURGERY
11.00
1.00
61470
INCISE SKULL FOR SURGERY
45.54
1.00
61470
INCISE SKULL FOR SURGERY
45.77
1.00
61470
INCISE SKULL FOR SURGERY
48.00
1.00
61480
INCISE SKULL FOR SURGERY
11.00
1.00
61480
INCISE SKULL FOR SURGERY
46.95
1.00
61480
INCISE SKULL FOR SURGERY
48.02
1.00
61480
INCISE SKULL FOR SURGERY
48.47
1.00
Procedure Code Description
RVU
RVU Coeff Value
61490
INCISE SKULL FOR SURGERY
11.00
1.00
61490
INCISE SKULL FOR SURGERY
46.49
1.00
61490
INCISE SKULL FOR SURGERY
46.59
1.00
61490
INCISE SKULL FOR SURGERY
48.62
1.00
61500
REMOVAL OF SKULL LESION
9.00
1.00
61500
REMOVAL OF SKULL LESION
32.67
1.00
61500
REMOVAL OF SKULL LESION
32.94
1.00
61500
REMOVAL OF SKULL LESION
34.12
1.00
61501
REMOVE INFECTED SKULL BONE
11.00
1.00
61501
REMOVE INFECTED SKULL BONE
27.24
1.00
61501
REMOVE INFECTED SKULL BONE
27.44
1.00
61501
REMOVE INFECTED SKULL BONE
29.15
1.00
61510
REMOVAL OF BRAIN LESION
11.00
1.00
61510
REMOVAL OF BRAIN LESION
51.44
1.00
61510
REMOVAL OF BRAIN LESION
52.13
1.00
61510
REMOVAL OF BRAIN LESION
55.24
1.00
61512
REMOVE BRAIN LINING LESION
11.00
1.00
61512
REMOVE BRAIN LINING LESION
62.95
1.00
61512
REMOVE BRAIN LINING LESION
63.41
1.00
61512
REMOVE BRAIN LINING LESION
65.33
1.00
61514
REMOVAL OF BRAIN ABSCESS
11.00
1.00
61514
REMOVAL OF BRAIN ABSCESS
45.85
1.00
61514
REMOVAL OF BRAIN ABSCESS
45.90
1.00
61514
REMOVAL OF BRAIN ABSCESS
48.43
1.00
61516
REMOVAL OF BRAIN LESION
11.00
1.00
61516
REMOVAL OF BRAIN LESION
44.47
1.00
61516
REMOVAL OF BRAIN LESION
44.86
1.00
61516
REMOVAL OF BRAIN LESION
47.24
1.00
61517
IMPLT BRAIN CHEMOTX ADD-ON
2.02
1.00
61517
IMPLT BRAIN CHEMOTX ADD-ON
2.05
1.00
61517
IMPLT BRAIN CHEMOTX ADD-ON
2.30
1.00
61518
REMOVAL OF BRAIN LESION
11.00
1.00
61518
REMOVAL OF BRAIN LESION
67.07
1.00
61518
REMOVAL OF BRAIN LESION
67.54
1.00
61518
REMOVAL OF BRAIN LESION
70.26
1.00
Procedure Code Description
RVU
RVU Coeff Value
61519
REMOVE BRAIN LINING LESION
13.00
1.00
61519
REMOVE BRAIN LINING LESION
73.75
1.00
61519
REMOVE BRAIN LINING LESION
73.91
1.00
61519
REMOVE BRAIN LINING LESION
75.73
1.00
61520
REMOVAL OF BRAIN LESION
11.00
1.00
61520
REMOVAL OF BRAIN LESION
96.01
1.00
61520
REMOVAL OF BRAIN LESION
96.67
1.00
61520
REMOVAL OF BRAIN LESION
97.40
1.00
61521
REMOVAL OF BRAIN LESION
11.00
1.00
61521
REMOVAL OF BRAIN LESION
79.09
1.00
61521
REMOVAL OF BRAIN LESION
79.41
1.00
61521
REMOVAL OF BRAIN LESION
81.36
1.00
61522
REMOVAL OF BRAIN ABSCESS
13.00
1.00
61522
REMOVAL OF BRAIN ABSCESS
52.29
1.00
61522
REMOVAL OF BRAIN ABSCESS
52.31
1.00
61522
REMOVAL OF BRAIN ABSCESS
55.76
1.00
61524
REMOVAL OF BRAIN LESION
13.00
1.00
61524
REMOVAL OF BRAIN LESION
49.60
1.00
61524
REMOVAL OF BRAIN LESION
49.66
1.00
61524
REMOVAL OF BRAIN LESION
52.63
1.00
61526
REMOVAL OF BRAIN LESION
11.00
1.00
61526
REMOVAL OF BRAIN LESION
86.13
1.00
61526
REMOVAL OF BRAIN LESION
89.60
1.00
61526
REMOVAL OF BRAIN LESION
89.81
1.00
61530
REMOVAL OF BRAIN LESION
11.00
1.00
61530
REMOVAL OF BRAIN LESION
73.21
1.00
61530
REMOVAL OF BRAIN LESION
76.42
1.00
61530
REMOVAL OF BRAIN LESION
76.97
1.00
61531
IMPLANT BRAIN ELECTRODES
9.00
1.00
61531
IMPLANT BRAIN ELECTRODES
27.13
1.00
61531
IMPLANT BRAIN ELECTRODES
27.21
1.00
61531
IMPLANT BRAIN ELECTRODES
30.40
1.00
61533
IMPLANT BRAIN ELECTRODES
11.00
1.00
61533
IMPLANT BRAIN ELECTRODES
35.83
1.00
61533
IMPLANT BRAIN ELECTRODES
35.85
1.00
Procedure Code Description
RVU
RVU Coeff Value
61533
IMPLANT BRAIN ELECTRODES
38.48
1.00
61534
REMOVAL OF BRAIN LESION
11.00
1.00
61534
REMOVAL OF BRAIN LESION
38.10
1.00
61534
REMOVAL OF BRAIN LESION
38.25
1.00
61534
REMOVAL OF BRAIN LESION
41.43
1.00
61535
REMOVE BRAIN ELECTRODES
11.00
1.00
61535
REMOVE BRAIN ELECTRODES
21.83
1.00
61535
REMOVE BRAIN ELECTRODES
22.02
1.00
61535
REMOVE BRAIN ELECTRODES
24.73
1.00
61536
REMOVAL OF BRAIN LESION
11.00
1.00
61536
REMOVAL OF BRAIN LESION
63.22
1.00
61536
REMOVAL OF BRAIN LESION
63.40
1.00
61536
REMOVAL OF BRAIN LESION
66.21
1.00
61537
REMOVAL OF BRAIN TISSUE
45.90
1.00
61537
REMOVAL OF BRAIN TISSUE
60.45
1.00
61538
REMOVAL OF BRAIN TISSUE
11.00
1.00
61538
REMOVAL OF BRAIN TISSUE
48.51
1.00
61538
REMOVAL OF BRAIN TISSUE
48.64
1.00
61538
REMOVAL OF BRAIN TISSUE
64.64
1.00
61539
REMOVAL OF BRAIN TISSUE
11.00
1.00
61539
REMOVAL OF BRAIN TISSUE
57.67
1.00
61539
REMOVAL OF BRAIN TISSUE
57.86
1.00
61539
REMOVAL OF BRAIN TISSUE
59.93
1.00
61540
REMOVAL OF BRAIN TISSUE
55.42
1.00
61540
REMOVAL OF BRAIN TISSUE
56.40
1.00
61541
INCISION OF BRAIN TISSUE
11.00
1.00
61541
INCISION OF BRAIN TISSUE
51.26
1.00
61541
INCISION OF BRAIN TISSUE
51.72
1.00
61541
INCISION OF BRAIN TISSUE
53.68
1.00
61542
REMOVAL OF BRAIN TISSUE
11.00
1.00
61542
REMOVAL OF BRAIN TISSUE
56.58
1.00
61542
REMOVAL OF BRAIN TISSUE
56.71
1.00
61542
REMOVAL OF BRAIN TISSUE
58.53
1.00
61543
REMOVAL OF BRAIN TISSUE
11.00
1.00
61543
REMOVAL OF BRAIN TISSUE
52.85
1.00
Procedure Code Description
RVU
RVU Coeff Value
61543
REMOVAL OF BRAIN TISSUE
53.01
1.00
61543
REMOVAL OF BRAIN TISSUE
54.69
1.00
61544
REMOVE & TREAT BRAIN LESION
11.00
1.00
61544
REMOVE & TREAT BRAIN LESION
44.93
1.00
61544
REMOVE & TREAT BRAIN LESION
45.02
1.00
61544
REMOVE & TREAT BRAIN LESION
45.28
1.00
61545
EXCISION OF BRAIN TUMOR
11.00
1.00
61545
EXCISION OF BRAIN TUMOR
77.70
1.00
61545
EXCISION OF BRAIN TUMOR
78.77
1.00
61545
EXCISION OF BRAIN TUMOR
80.40
1.00
61546
REMOVAL OF PITUITARY GLAND
12.00
1.00
61546
REMOVAL OF PITUITARY GLAND
56.04
1.00
61546
REMOVAL OF PITUITARY GLAND
56.14
1.00
61546
REMOVAL OF PITUITARY GLAND
58.26
1.00
61548
REMOVAL OF PITUITARY GLAND
5.00
1.00
61548
REMOVAL OF PITUITARY GLAND
38.73
1.00
61548
REMOVAL OF PITUITARY GLAND
38.80
1.00
61548
REMOVAL OF PITUITARY GLAND
38.94
1.00
61550
RELEASE OF SKULL SEAMS
9.00
1.00
61550
RELEASE OF SKULL SEAMS
23.01
1.00
61550
RELEASE OF SKULL SEAMS
23.13
1.00
61550
RELEASE OF SKULL SEAMS
25.11
1.00
61552
RELEASE OF SKULL SEAMS
11.00
1.00
61552
RELEASE OF SKULL SEAMS
29.79
1.00
61552
RELEASE OF SKULL SEAMS
30.28
1.00
61552
RELEASE OF SKULL SEAMS
32.91
1.00
61556
INCISE SKULL/SUTURES
37.84
1.00
61556
INCISE SKULL/SUTURES
37.96
1.00
61556
INCISE SKULL/SUTURES
41.28
1.00
61556
INCISE SKULL/SUTURES
999.99
1.00
61557
INCISE SKULL/SUTURES
40.92
1.00
61557
INCISE SKULL/SUTURES
41.67
1.00
61557
INCISE SKULL/SUTURES
42.83
1.00
61557
INCISE SKULL/SUTURES
999.99
1.00
61558
EXCISION OF SKULL/SUTURES
42.57
1.00
Procedure Code Description
RVU
RVU Coeff Value
61558
EXCISION OF SKULL/SUTURES
42.94
1.00
61558
EXCISION OF SKULL/SUTURES
43.32
1.00
61558
EXCISION OF SKULL/SUTURES
999.99
1.00
61559
EXCISION OF SKULL/SUTURES
11.00
1.00
61559
EXCISION OF SKULL/SUTURES
59.32
1.00
61559
EXCISION OF SKULL/SUTURES
60.40
1.00
61559
EXCISION OF SKULL/SUTURES
61.34
1.00
61563
EXCISION OF SKULL TUMOR
47.36
1.00
61563
EXCISION OF SKULL TUMOR
47.50
1.00
61563
EXCISION OF SKULL TUMOR
48.75
1.00
61563
EXCISION OF SKULL TUMOR
999.99
1.00
61564
EXCISION OF SKULL TUMOR
59.63
1.00
61564
EXCISION OF SKULL TUMOR
60.69
1.00
61564
EXCISION OF SKULL TUMOR
61.81
1.00
61564
EXCISION OF SKULL TUMOR
999.99
1.00
61566
REMOVAL OF BRAIN TISSUE
54.86
1.00
61566
REMOVAL OF BRAIN TISSUE
56.66
1.00
61567
INCISION OF BRAIN TISSUE
62.67
1.00
61567
INCISION OF BRAIN TISSUE
63.32
1.00
61570
REMOVE FOREIGN BODY, BRAIN
11.00
1.00
61570
REMOVE FOREIGN BODY, BRAIN
43.57
1.00
61570
REMOVE FOREIGN BODY, BRAIN
44.08
1.00
61570
REMOVE FOREIGN BODY, BRAIN
46.42
1.00
61571
INCISE SKULL FOR BRAIN WOUND
15.00
1.00
61571
INCISE SKULL FOR BRAIN WOUND
47.32
1.00
61571
INCISE SKULL FOR BRAIN WOUND
47.87
1.00
61571
INCISE SKULL FOR BRAIN WOUND
49.97
1.00
61575
SKULL BASE/BRAINSTEM SURGERY
11.00
1.00
61575
SKULL BASE/BRAINSTEM SURGERY
59.31
1.00
61575
SKULL BASE/BRAINSTEM SURGERY
60.10
1.00
61575
SKULL BASE/BRAINSTEM SURGERY
60.58
1.00
61576
SKULL BASE/BRAINSTEM SURGERY
11.00
1.00
61576
SKULL BASE/BRAINSTEM SURGERY
87.67
1.00
61576
SKULL BASE/BRAINSTEM SURGERY
87.91
1.00
61576
SKULL BASE/BRAINSTEM SURGERY
93.90
1.00
Procedure Code Description
RVU
RVU Coeff Value
61580
CRANIOFACIAL APPROACH, SKULL
7.00
1.00
61580
CRANIOFACIAL APPROACH, SKULL
52.25
1.00
61580
CRANIOFACIAL APPROACH, SKULL
59.11
1.00
61580
CRANIOFACIAL APPROACH, SKULL
61.64
1.00
61581
CRANIOFACIAL APPROACH, SKULL
7.00
1.00
61581
CRANIOFACIAL APPROACH, SKULL
53.36
1.00
61581
CRANIOFACIAL APPROACH, SKULL
61.66
1.00
61581
CRANIOFACIAL APPROACH, SKULL
69.24
1.00
61582
CRANIOFACIAL APPROACH, SKULL
11.00
1.00
61582
CRANIOFACIAL APPROACH, SKULL
57.22
1.00
61582
CRANIOFACIAL APPROACH, SKULL
66.20
1.00
61582
CRANIOFACIAL APPROACH, SKULL
72.11
1.00
61583
CRANIOFACIAL APPROACH, SKULL
11.00
1.00
61583
CRANIOFACIAL APPROACH, SKULL
65.77
1.00
61583
CRANIOFACIAL APPROACH, SKULL
69.54
1.00
61583
CRANIOFACIAL APPROACH, SKULL
73.53
1.00
61584
ORBITOCRANIAL APPROACH/SKULL
11.00
1.00
61584
ORBITOCRANIAL APPROACH/SKULL
62.10
1.00
61584
ORBITOCRANIAL APPROACH/SKULL
66.89
1.00
61584
ORBITOCRANIAL APPROACH/SKULL
71.35
1.00
61585
ORBITOCRANIAL APPROACH/SKULL
11.00
1.00
61585
ORBITOCRANIAL APPROACH/SKULL
67.38
1.00
61585
ORBITOCRANIAL APPROACH/SKULL
72.48
1.00
61585
ORBITOCRANIAL APPROACH/SKULL
75.06
1.00
61586
RESECT NASOPHARYNX, SKULL
11.00
1.00
61586
RESECT NASOPHARYNX, SKULL
44.84
1.00
61586
RESECT NASOPHARYNX, SKULL
51.66
1.00
61586
RESECT NASOPHARYNX, SKULL
53.88
1.00
61590
INFRATEMPORAL APPROACH/SKULL
11.00
1.00
61590
INFRATEMPORAL APPROACH/SKULL
71.59
1.00
61590
INFRATEMPORAL APPROACH/SKULL
75.69
1.00
61590
INFRATEMPORAL APPROACH/SKULL
78.77
1.00
61591
INFRATEMPORAL APPROACH/SKULL
11.00
1.00
61591
INFRATEMPORAL APPROACH/SKULL
75.28
1.00
61591
INFRATEMPORAL APPROACH/SKULL
79.43
1.00
Procedure Code Description
RVU
RVU Coeff Value
61591
INFRATEMPORAL APPROACH/SKULL
79.66
1.00
61592
ORBITOCRANIAL APPROACH/SKULL
11.00
1.00
61592
ORBITOCRANIAL APPROACH/SKULL
70.80
1.00
61592
ORBITOCRANIAL APPROACH/SKULL
75.29
1.00
61592
ORBITOCRANIAL APPROACH/SKULL
80.59
1.00
61595
TRANSTEMPORAL APPROACH/SKULL
11.00
1.00
61595
TRANSTEMPORAL APPROACH/SKULL
51.94
1.00
61595
TRANSTEMPORAL APPROACH/SKULL
55.72
1.00
61595
TRANSTEMPORAL APPROACH/SKULL
59.60
1.00
61596
TRANSCOCHLEAR APPROACH/SKULL
11.00
1.00
61596
TRANSCOCHLEAR APPROACH/SKULL
61.89
1.00
61596
TRANSCOCHLEAR APPROACH/SKULL
65.18
1.00
61596
TRANSCOCHLEAR APPROACH/SKULL
65.30
1.00
61597
TRANSCONDYLAR APPROACH/SKULL
11.00
1.00
61597
TRANSCONDYLAR APPROACH/SKULL
65.81
1.00
61597
TRANSCONDYLAR APPROACH/SKULL
68.97
1.00
61597
TRANSCONDYLAR APPROACH/SKULL
72.96
1.00
61598
TRANSPETROSAL APPROACH/SKULL
11.00
1.00
61598
TRANSPETROSAL APPROACH/SKULL
58.66
1.00
61598
TRANSPETROSAL APPROACH/SKULL
62.26
1.00
61598
TRANSPETROSAL APPROACH/SKULL
64.02
1.00
61600
RESECT/EXCISE CRANIAL LESION
11.00
1.00
61600
RESECT/EXCISE CRANIAL LESION
44.93
1.00
61600
RESECT/EXCISE CRANIAL LESION
49.45
1.00
61600
RESECT/EXCISE CRANIAL LESION
53.74
1.00
61601
RESECT/EXCISE CRANIAL LESION
11.00
1.00
61601
RESECT/EXCISE CRANIAL LESION
50.50
1.00
61601
RESECT/EXCISE CRANIAL LESION
54.79
1.00
61601
RESECT/EXCISE CRANIAL LESION
59.52
1.00
61605
RESECT/EXCISE CRANIAL LESION
11.00
1.00
61605
RESECT/EXCISE CRANIAL LESION
50.34
1.00
61605
RESECT/EXCISE CRANIAL LESION
54.48
1.00
61605
RESECT/EXCISE CRANIAL LESION
55.90
1.00
61606
RESECT/EXCISE CRANIAL LESION
11.00
1.00
61606
RESECT/EXCISE CRANIAL LESION
69.01
1.00
Procedure Code Description
RVU
RVU Coeff Value
61606
RESECT/EXCISE CRANIAL LESION
72.21
1.00
61606
RESECT/EXCISE CRANIAL LESION
76.48
1.00
61607
RESECT/EXCISE CRANIAL LESION
11.00
1.00
61607
RESECT/EXCISE CRANIAL LESION
64.01
1.00
61607
RESECT/EXCISE CRANIAL LESION
66.96
1.00
61607
RESECT/EXCISE CRANIAL LESION
70.45
1.00
61608
RESECT/EXCISE CRANIAL LESION
11.00
1.00
61608
RESECT/EXCISE CRANIAL LESION
75.18
1.00
61608
RESECT/EXCISE CRANIAL LESION
78.73
1.00
61608
RESECT/EXCISE CRANIAL LESION
82.84
1.00
61609
TRANSECT ARTERY, SINUS
16.14
1.00
61609
TRANSECT ARTERY, SINUS
16.87
1.00
61609
TRANSECT ARTERY, SINUS
17.25
1.00
61610
TRANSECT ARTERY, SINUS
46.67
1.00
61610
TRANSECT ARTERY, SINUS
47.07
1.00
61610
TRANSECT ARTERY, SINUS
49.42
1.00
61611
TRANSECT ARTERY, SINUS
12.37
1.00
61611
TRANSECT ARTERY, SINUS
12.46
1.00
61611
TRANSECT ARTERY, SINUS
13.12
1.00
61612
TRANSECT ARTERY, SINUS
43.09
1.00
61612
TRANSECT ARTERY, SINUS
45.10
1.00
61612
TRANSECT ARTERY, SINUS
45.48
1.00
61613
REMOVE ANEURYSM, SINUS
11.00
1.00
61613
REMOVE ANEURYSM, SINUS
73.13
1.00
61613
REMOVE ANEURYSM, SINUS
77.17
1.00
61613
REMOVE ANEURYSM, SINUS
79.87
1.00
61615
RESECT/EXCISE LESION, SKULL
11.00
1.00
61615
RESECT/EXCISE LESION, SKULL
57.29
1.00
61615
RESECT/EXCISE LESION, SKULL
60.44
1.00
61615
RESECT/EXCISE LESION, SKULL
62.54
1.00
61616
RESECT/EXCISE LESION, SKULL
11.00
1.00
61616
RESECT/EXCISE LESION, SKULL
77.22
1.00
61616
RESECT/EXCISE LESION, SKULL
80.51
1.00
61616
RESECT/EXCISE LESION, SKULL
82.77
1.00
61618
REPAIR DURA
11.00
1.00
Procedure Code Description
RVU
RVU Coeff Value
61618
REPAIR DURA
30.99
1.00
61618
REPAIR DURA
31.36
1.00
61618
REPAIR DURA
32.85
1.00
61619
REPAIR DURA
11.00
1.00
61619
REPAIR DURA
37.11
1.00
61619
REPAIR DURA
37.51
1.00
61619
REPAIR DURA
37.76
1.00
61623
ENDOVASC TEMPORY VESSEL OCCL
14.69
1.00
61623
ENDOVASC TEMPORY VESSEL OCCL
14.78
1.00
61623
ENDOVASC TEMPORY VESSEL OCCL
15.00
1.00
61624
TRANSCATH OCCLUSION, CNS
15.00
1.00
61624
TRANSCATH OCCLUSION, CNS
28.43
1.00
61624
TRANSCATH OCCLUSION, CNS
28.44
1.00
61624
TRANSCATH OCCLUSION, CNS
29.81
1.00
61626
TRANSCATH OCCLUSION, NON-CNS
15.00
1.00
61626
TRANSCATH OCCLUSION, NON-CNS
23.15
1.00
61626
TRANSCATH OCCLUSION, NON-CNS
23.16
1.00
61626
TRANSCATH OCCLUSION, NON-CNS
24.17
1.00
61630
INTRACRANIAL ANGIOPLASTY
33.90
1.00
61635
INTRACRAN ANGIOPLSTY W/STENT
37.12
1.00
61640
DILATE IC VASOSPASM, INIT
17.16
1.00
61641
DILATE IC VASOSPASM ADD-ON
6.03
1.00
61642
DILATE IC VASOSPASM ADD-ON
12.06
1.00
61680
INTRACRANIAL VESSEL SURGERY
15.00
1.00
61680
INTRACRANIAL VESSEL SURGERY
55.19
1.00
61680
INTRACRANIAL VESSEL SURGERY
55.46
1.00
61680
INTRACRANIAL VESSEL SURGERY
57.78
1.00
61682
INTRACRANIAL VESSEL SURGERY
15.00
1.00
61682
INTRACRANIAL VESSEL SURGERY
108.27
1.00
61682
INTRACRANIAL VESSEL SURGERY
108.87
1.00
61682
INTRACRANIAL VESSEL SURGERY
109.16
1.00
61684
INTRACRANIAL VESSEL SURGERY
15.00
1.00
61684
INTRACRANIAL VESSEL SURGERY
70.80
1.00
61684
INTRACRANIAL VESSEL SURGERY
71.34
1.00
61684
INTRACRANIAL VESSEL SURGERY
72.39
1.00
Procedure Code Description
RVU
RVU Coeff Value
61686
INTRACRANIAL VESSEL SURGERY
15.00
1.00
61686
INTRACRANIAL VESSEL SURGERY
113.71
1.00
61686
INTRACRANIAL VESSEL SURGERY
115.19
1.00
61686
INTRACRANIAL VESSEL SURGERY
116.46
1.00
61690
INTRACRANIAL VESSEL SURGERY
15.00
1.00
61690
INTRACRANIAL VESSEL SURGERY
52.58
1.00
61690
INTRACRANIAL VESSEL SURGERY
52.72
1.00
61690
INTRACRANIAL VESSEL SURGERY
54.77
1.00
61692
INTRACRANIAL VESSEL SURGERY
15.00
1.00
61692
INTRACRANIAL VESSEL SURGERY
90.88
1.00
61692
INTRACRANIAL VESSEL SURGERY
91.67
1.00
61692
INTRACRANIAL VESSEL SURGERY
94.04
1.00
61697
BRAIN ANEURYSM REPR, COMPLX
15.00
1.00
61697
BRAIN ANEURYSM REPR, COMPLX
89.56
1.00
61697
BRAIN ANEURYSM REPR, COMPLX
91.00
1.00
61697
BRAIN ANEURYSM REPR, COMPLX
105.57
1.00
61698
BRAIN ANEURYSM REPR, COMPLX
15.00
1.00
61698
BRAIN ANEURYSM REPR, COMPLX
85.76
1.00
61698
BRAIN ANEURYSM REPR, COMPLX
87.19
1.00
61698
BRAIN ANEURYSM REPR, COMPLX
113.18
1.00
61700
BRAIN ANEURYSM REPR, SIMPLE
15.00
1.00
61700
BRAIN ANEURYSM REPR, SIMPLE
89.01
1.00
61700
BRAIN ANEURYSM REPR, SIMPLE
89.38
1.00
61700
BRAIN ANEURYSM REPR, SIMPLE
90.65
1.00
61702
INNER SKULL VESSEL SURGERY
15.00
1.00
61702
INNER SKULL VESSEL SURGERY
85.82
1.00
61702
INNER SKULL VESSEL SURGERY
86.25
1.00
61702
INNER SKULL VESSEL SURGERY
98.46
1.00
61703
CLAMP NECK ARTERY
15.00
1.00
61703
CLAMP NECK ARTERY
32.33
1.00
61703
CLAMP NECK ARTERY
33.87
1.00
61705
REVISE CIRCULATION TO HEAD
15.00
1.00
61705
REVISE CIRCULATION TO HEAD
62.92
1.00
61705
REVISE CIRCULATION TO HEAD
63.53
1.00
61705
REVISE CIRCULATION TO HEAD
65.30
1.00
Procedure Code Description
RVU
RVU Coeff Value
61708
REVISE CIRCULATION TO HEAD
15.00
1.00
61708
REVISE CIRCULATION TO HEAD
53.08
1.00
61708
REVISE CIRCULATION TO HEAD
53.35
1.00
61708
REVISE CIRCULATION TO HEAD
54.79
1.00
61710
REVISE CIRCULATION TO HEAD
15.00
1.00
61710
REVISE CIRCULATION TO HEAD
46.21
1.00
61710
REVISE CIRCULATION TO HEAD
46.62
1.00
61710
REVISE CIRCULATION TO HEAD
50.57
1.00
61711
FUSION OF SKULL ARTERIES
15.00
1.00
61711
FUSION OF SKULL ARTERIES
64.35
1.00
61711
FUSION OF SKULL ARTERIES
65.09
1.00
61711
FUSION OF SKULL ARTERIES
66.67
1.00
61720
INCISE SKULL/BRAIN SURGERY
11.00
1.00
61720
INCISE SKULL/BRAIN SURGERY
29.30
1.00
61720
INCISE SKULL/BRAIN SURGERY
31.00
1.00
61720
INCISE SKULL/BRAIN SURGERY
31.02
1.00
61735
INCISE SKULL/BRAIN SURGERY
11.00
1.00
61735
INCISE SKULL/BRAIN SURGERY
35.75
1.00
61735
INCISE SKULL/BRAIN SURGERY
37.35
1.00
61735
INCISE SKULL/BRAIN SURGERY
37.64
1.00
61750
INCISE SKULL/BRAIN BIOPSY
11.00
1.00
61750
INCISE SKULL/BRAIN BIOPSY
32.87
1.00
61750
INCISE SKULL/BRAIN BIOPSY
33.31
1.00
61750
INCISE SKULL/BRAIN BIOPSY
35.57
1.00
61751
BRAIN BIOPSY W/CT/MR GUIDE
7.00
1.00
61751
BRAIN BIOPSY W/CT/MR GUIDE
31.96
1.00
61751
BRAIN BIOPSY W/CT/MR GUIDE
32.76
1.00
61751
BRAIN BIOPSY W/CT/MR GUIDE
34.66
1.00
61760
IMPLANT BRAIN ELECTRODES
11.00
1.00
61760
IMPLANT BRAIN ELECTRODES
35.69
1.00
61760
IMPLANT BRAIN ELECTRODES
36.55
1.00
61760
IMPLANT BRAIN ELECTRODES
39.21
1.00
61770
INCISE SKULL FOR TREATMENT
11.00
1.00
61770
INCISE SKULL FOR TREATMENT
38.11
1.00
61770
INCISE SKULL FOR TREATMENT
38.58
1.00
Procedure Code Description 61770
INCISE SKULL FOR TREATMENT
61790
RVU
RVU Coeff Value
38.65
1.00
TREAT TRIGEMINAL NERVE
7.00
1.00
61790
TREAT TRIGEMINAL NERVE
18.70
1.00
61790
TREAT TRIGEMINAL NERVE
18.99
1.00
61790
TREAT TRIGEMINAL NERVE
21.53
1.00
61791
TREAT TRIGEMINAL TRACT
7.00
1.00
61791
TREAT TRIGEMINAL TRACT
26.90
1.00
61791
TREAT TRIGEMINAL TRACT
27.20
1.00
61791
TREAT TRIGEMINAL TRACT
27.79
1.00
61793
FOCUS RADIATION BEAM
11.00
1.00
61793
FOCUS RADIATION BEAM
31.60
1.00
61793
FOCUS RADIATION BEAM
31.68
1.00
61793
FOCUS RADIATION BEAM
32.05
1.00
61795
BRAIN SURGERY USING COMPUTER
6.47
1.00
61795
BRAIN SURGERY USING COMPUTER
6.94
1.00
61795
BRAIN SURGERY USING COMPUTER
7.05
1.00
61796
SRS, CRANIAL LESION SIMPLE
20.28
1.00
61797
SRS, CRAN LES SIMPLE, ADDL
5.54
1.00
61798
SRS, CRANIAL LESION COMPLEX
20.28
1.00
61799
SRS, CRAN LES COMPLEX, ADDL
7.66
1.00
61800
APPLY SRS HEADFRAME ADD-ON
3.93
1.00
61850
IMPLANT NEUROELECTRODES
9.00
1.00
61850
IMPLANT NEUROELECTRODES
22.70
1.00
61850
IMPLANT NEUROELECTRODES
22.77
1.00
61850
IMPLANT NEUROELECTRODES
24.74
1.00
61860
IMPLANT NEUROELECTRODES
11.00
1.00
61860
IMPLANT NEUROELECTRODES
37.79
1.00
61860
IMPLANT NEUROELECTRODES
37.84
1.00
61860
IMPLANT NEUROELECTRODES
39.35
1.00
61862
IMPLANT NEUROSTIMUL, SUBCORT
11.00
1.00
61862
IMPLANT NEUROSTIMUL, SUBCORT
35.39
1.00
61863
IMPLANT NEUROELECTRODE
32.97
1.00
61863
IMPLANT NEUROELECTRODE
38.40
1.00
61864
IMPLANT NEUROELECTRDE, ADDL
7.91
1.00
61864
IMPLANT NEUROELECTRDE, ADDL
11.82
1.00
Procedure Code Description
RVU
RVU Coeff Value
61867
IMPLANT NEUROELECTRODE
49.89
1.00
61867
IMPLANT NEUROELECTRODE
55.74
1.00
61868
IMPLANT NEUROELECTRDE, ADDÏL
13.15
1.00
61868
IMPLANT NEUROELECTRDE, ADDÏL
16.68
1.00
61870
IMPLANT NEUROELECTRODES
11.00
1.00
61870
IMPLANT NEUROELECTRODES
26.79
1.00
61870
IMPLANT NEUROELECTRODES
27.49
1.00
61870
IMPLANT NEUROELECTRODES
29.96
1.00
61875
IMPLANT NEUROELECTRODES
11.00
1.00
61875
IMPLANT NEUROELECTRODES
26.57
1.00
61875
IMPLANT NEUROELECTRODES
26.76
1.00
61875
IMPLANT NEUROELECTRODES
28.91
1.00
61880
REVISE/REMOVE NEUROELECTRODE
5.00
1.00
61880
REVISE/REMOVE NEUROELECTRODE
12.46
1.00
61880
REVISE/REMOVE NEUROELECTRODE
12.94
1.00
61880
REVISE/REMOVE NEUROELECTRODE
13.77
1.00
61885
INSRT/REDO NEUROSTIM 1 ARRAY
5.00
1.00
61885
INSRT/REDO NEUROSTIM 1 ARRAY
12.16
1.00
61885
INSRT/REDO NEUROSTIM 1 ARRAY
12.63
1.00
61885
INSRT/REDO NEUROSTIM 1 ARRAY
15.83
1.00
61886
IMPLANT NEUROSTIM ARRAYS
6.00
1.00
61886
IMPLANT NEUROSTIM ARRAYS
15.79
1.00
61886
IMPLANT NEUROSTIM ARRAYS
16.33
1.00
61886
IMPLANT NEUROSTIM ARRAYS
19.95
1.00
61888
REVISE/REMOVE NEURORECEIVER
5.00
1.00
61888
REVISE/REMOVE NEURORECEIVER
10.01
1.00
61888
REVISE/REMOVE NEURORECEIVER
10.10
1.00
61888
REVISE/REMOVE NEURORECEIVER
10.19
1.00
62000
TREAT SKULL FRACTURE
9.00
1.00
62000
TREAT SKULL FRACTURE
19.05
1.00
62000
TREAT SKULL FRACTURE
19.11
1.00
62000
TREAT SKULL FRACTURE
21.65
1.00
62005
TREAT SKULL FRACTURE
9.00
1.00
62005
TREAT SKULL FRACTURE
27.79
1.00
62005
TREAT SKULL FRACTURE
27.96
1.00
Procedure Code Description
RVU
RVU Coeff Value
62005
TREAT SKULL FRACTURE
31.31
1.00
62010
TREATMENT OF HEAD INJURY
11.00
1.00
62010
TREATMENT OF HEAD INJURY
36.14
1.00
62010
TREATMENT OF HEAD INJURY
36.41
1.00
62010
TREATMENT OF HEAD INJURY
38.38
1.00
62100
REPAIR BRAIN FLUID LEAKAGE
9.00
1.00
62100
REPAIR BRAIN FLUID LEAKAGE
39.76
1.00
62100
REPAIR BRAIN FLUID LEAKAGE
39.95
1.00
62100
REPAIR BRAIN FLUID LEAKAGE
40.65
1.00
62115
REDUCTION OF SKULL DEFECT
36.52
1.00
62115
REDUCTION OF SKULL DEFECT
37.88
1.00
62115
REDUCTION OF SKULL DEFECT
38.78
1.00
62115
REDUCTION OF SKULL DEFECT
999.99
1.00
62116
REDUCTION OF SKULL DEFECT
42.23
1.00
62116
REDUCTION OF SKULL DEFECT
42.82
1.00
62116
REDUCTION OF SKULL DEFECT
45.04
1.00
62116
REDUCTION OF SKULL DEFECT
999.99
1.00
62117
REDUCTION OF SKULL DEFECT
47.93
1.00
62117
REDUCTION OF SKULL DEFECT
48.03
1.00
62117
REDUCTION OF SKULL DEFECT
48.71
1.00
62117
REDUCTION OF SKULL DEFECT
999.99
1.00
62120
REPAIR SKULL CAVITY LESION
11.00
1.00
62120
REPAIR SKULL CAVITY LESION
40.80
1.00
62120
REPAIR SKULL CAVITY LESION
41.34
1.00
62120
REPAIR SKULL CAVITY LESION
45.20
1.00
62121
INCISE SKULL REPAIR
37.28
1.00
62121
INCISE SKULL REPAIR
37.60
1.00
62121
INCISE SKULL REPAIR
41.72
1.00
62121
INCISE SKULL REPAIR
999.99
1.00
62140
REPAIR OF SKULL DEFECT
11.00
1.00
62140
REPAIR OF SKULL DEFECT
24.72
1.00
62140
REPAIR OF SKULL DEFECT
24.99
1.00
62140
REPAIR OF SKULL DEFECT
26.54
1.00
62141
REPAIR OF SKULL DEFECT
9.00
1.00
62141
REPAIR OF SKULL DEFECT
27.43
1.00
Procedure Code Description
RVU
RVU Coeff Value
62141
REPAIR OF SKULL DEFECT
27.54
1.00
62141
REPAIR OF SKULL DEFECT
29.13
1.00
62142
REMOVE SKULL PLATE/FLAP
11.00
1.00
62142
REMOVE SKULL PLATE/FLAP
20.13
1.00
62142
REMOVE SKULL PLATE/FLAP
20.33
1.00
62142
REMOVE SKULL PLATE/FLAP
22.16
1.00
62143
REPLACE SKULL PLATE/FLAP
11.00
1.00
62143
REPLACE SKULL PLATE/FLAP
24.19
1.00
62143
REPLACE SKULL PLATE/FLAP
24.35
1.00
62143
REPLACE SKULL PLATE/FLAP
26.01
1.00
62145
REPAIR OF SKULL & BRAIN
11.00
1.00
62145
REPAIR OF SKULL & BRAIN
34.32
1.00
62145
REPAIR OF SKULL & BRAIN
34.34
1.00
62145
REPAIR OF SKULL & BRAIN
35.60
1.00
62146
REPAIR OF SKULL WITH GRAFT
29.33
1.00
62146
REPAIR OF SKULL WITH GRAFT
29.46
1.00
62146
REPAIR OF SKULL WITH GRAFT
30.47
1.00
62146
REPAIR OF SKULL WITH GRAFT
999.99
1.00
62147
REPAIR OF SKULL WITH GRAFT
35.08
1.00
62147
REPAIR OF SKULL WITH GRAFT
35.12
1.00
62147
REPAIR OF SKULL WITH GRAFT
36.19
1.00
62147
REPAIR OF SKULL WITH GRAFT
999.99
1.00
62148
RETR BONE FLAP TO FIX SKULL
3.25
1.00
62148
RETR BONE FLAP TO FIX SKULL
3.28
1.00
62148
RETR BONE FLAP TO FIX SKULL
3.34
1.00
62160
NEUROENDOSCOPY ADD-ON
4.68
1.00
62160
NEUROENDOSCOPY ADD-ON
4.77
1.00
62160
NEUROENDOSCOPY ADD-ON
5.04
1.00
62161
DISSECT BRAIN W/SCOPE
33.41
1.00
62161
DISSECT BRAIN W/SCOPE
33.99
1.00
62161
DISSECT BRAIN W/SCOPE
38.41
1.00
62162
REMOVE COLLOID CYST W/SCOPE
42.91
1.00
62162
REMOVE COLLOID CYST W/SCOPE
43.86
1.00
62162
REMOVE COLLOID CYST W/SCOPE
47.58
1.00
62163
NEUROENDOSCOPY W/FB REMOVAL
27.17
1.00
Procedure Code Description
RVU
RVU Coeff Value
62163
NEUROENDOSCOPY W/FB REMOVAL
27.79
1.00
62163
NEUROENDOSCOPY W/FB REMOVAL
30.88
1.00
62164
REMOVE BRAIN TUMOR W/SCOPE
46.39
1.00
62164
REMOVE BRAIN TUMOR W/SCOPE
47.32
1.00
62164
REMOVE BRAIN TUMOR W/SCOPE
50.42
1.00
62165
REMOVE PITUIT TUMOR W/SCOPE
36.31
1.00
62165
REMOVE PITUIT TUMOR W/SCOPE
36.86
1.00
62165
REMOVE PITUIT TUMOR W/SCOPE
38.74
1.00
62180
ESTABLISH BRAIN CAVITY SHUNT
11.00
1.00
62180
ESTABLISH BRAIN CAVITY SHUNT
38.28
1.00
62180
ESTABLISH BRAIN CAVITY SHUNT
38.58
1.00
62180
ESTABLISH BRAIN CAVITY SHUNT
40.09
1.00
62190
ESTABLISH BRAIN CAVITY SHUNT
6.00
1.00
62190
ESTABLISH BRAIN CAVITY SHUNT
20.79
1.00
62190
ESTABLISH BRAIN CAVITY SHUNT
20.98
1.00
62190
ESTABLISH BRAIN CAVITY SHUNT
22.81
1.00
62192
ESTABLISH BRAIN CAVITY SHUNT
6.00
1.00
62192
ESTABLISH BRAIN CAVITY SHUNT
22.86
1.00
62192
ESTABLISH BRAIN CAVITY SHUNT
22.98
1.00
62192
ESTABLISH BRAIN CAVITY SHUNT
24.32
1.00
62194
REPLACE/IRRIGATE CATHETER
6.00
1.00
62194
REPLACE/IRRIGATE CATHETER
8.30
1.00
62194
REPLACE/IRRIGATE CATHETER
8.41
1.00
62194
REPLACE/IRRIGATE CATHETER
9.82
1.00
62200
ESTABLISH BRAIN CAVITY SHUNT
11.00
1.00
62200
ESTABLISH BRAIN CAVITY SHUNT
33.61
1.00
62200
ESTABLISH BRAIN CAVITY SHUNT
33.64
1.00
62200
ESTABLISH BRAIN CAVITY SHUNT
34.79
1.00
62201
BRAIN CAVITY SHUNT W/SCOPE
27.15
1.00
62201
BRAIN CAVITY SHUNT W/SCOPE
27.37
1.00
62201
BRAIN CAVITY SHUNT W/SCOPE
29.77
1.00
62220
ESTABLISH BRAIN CAVITY SHUNT
9.00
1.00
62220
ESTABLISH BRAIN CAVITY SHUNT
24.05
1.00
62220
ESTABLISH BRAIN CAVITY SHUNT
24.18
1.00
62220
ESTABLISH BRAIN CAVITY SHUNT
25.61
1.00
Procedure Code Description
RVU
RVU Coeff Value
62223
ESTABLISH BRAIN CAVITY SHUNT
9.00
1.00
62223
ESTABLISH BRAIN CAVITY SHUNT
23.96
1.00
62223
ESTABLISH BRAIN CAVITY SHUNT
24.24
1.00
62223
ESTABLISH BRAIN CAVITY SHUNT
26.20
1.00
62225
REPLACE/IRRIGATE CATHETER
10.00
1.00
62225
REPLACE/IRRIGATE CATHETER
10.82
1.00
62225
REPLACE/IRRIGATE CATHETER
11.31
1.00
62225
REPLACE/IRRIGATE CATHETER
12.47
1.00
62230
REPLACE/REVISE BRAIN SHUNT
8.00
1.00
62230
REPLACE/REVISE BRAIN SHUNT
19.56
1.00
62230
REPLACE/REVISE BRAIN SHUNT
19.87
1.00
62230
REPLACE/REVISE BRAIN SHUNT
21.15
1.00
62252
CSF SHUNT REPROGRAM
2.39
1.00
62252
CSF SHUNT REPROGRAM
2.43
1.00
62252
CSF SHUNT REPROGRAM
2.60
1.00
62256
REMOVE BRAIN CAVITY SHUNT
5.00
1.00
62256
REMOVE BRAIN CAVITY SHUNT
12.93
1.00
62256
REMOVE BRAIN CAVITY SHUNT
13.39
1.00
62256
REMOVE BRAIN CAVITY SHUNT
14.64
1.00
62258
REPLACE BRAIN CAVITY SHUNT
9.00
1.00
62258
REPLACE BRAIN CAVITY SHUNT
26.77
1.00
62258
REPLACE BRAIN CAVITY SHUNT
26.79
1.00
62258
REPLACE BRAIN CAVITY SHUNT
28.47
1.00
62263
EPIDURAL LYSIS MULT SESSIONS
8.00
1.00
62263
EPIDURAL LYSIS MULT SESSIONS
8.99
1.00
62263
EPIDURAL LYSIS MULT SESSIONS
9.03
1.00
62263
EPIDURAL LYSIS MULT SESSIONS
9.78
1.00
62264
EPIDURAL LYSIS ON SINGLE DAY
5.98
1.00
62264
EPIDURAL LYSIS ON SINGLE DAY
6.05
1.00
62264
EPIDURAL LYSIS ON SINGLE DAY
6.18
1.00
62267
INTERDISCAL PERQ ASPIR, DX
4.38
1.00
62268
DRAIN SPINAL CORD CYST
7.10
1.00
62268
DRAIN SPINAL CORD CYST
7.26
1.00
62268
DRAIN SPINAL CORD CYST
7.74
1.00
62269
NEEDLE BIOPSY, SPINAL CORD
5.00
1.00
Procedure Code Description
RVU
RVU Coeff Value
62269
NEEDLE BIOPSY, SPINAL CORD
7.20
1.00
62269
NEEDLE BIOPSY, SPINAL CORD
7.37
1.00
62269
NEEDLE BIOPSY, SPINAL CORD
7.68
1.00
62270
SPINAL FLUID TAP, DIAGNOSTIC
1.69
1.00
62270
SPINAL FLUID TAP, DIAGNOSTIC
2.04
1.00
62270
SPINAL FLUID TAP, DIAGNOSTIC
6.00
1.00
62272
DRAIN CEREBRO SPINAL FLUID
2.13
1.00
62272
DRAIN CEREBRO SPINAL FLUID
2.15
1.00
62272
DRAIN CEREBRO SPINAL FLUID
2.19
1.00
62272
DRAIN CEREBRO SPINAL FLUID
3.00
1.00
62273
INJECT EPIDURAL PATCH
2.87
1.00
62273
INJECT EPIDURAL PATCH
2.89
1.00
62273
INJECT EPIDURAL PATCH
2.91
1.00
62273
INJECT EPIDURAL PATCH
999.99
1.00
62280
TREAT SPINAL CORD LESION
3.62
1.00
62280
TREAT SPINAL CORD LESION
3.72
1.00
62280
TREAT SPINAL CORD LESION
4.03
1.00
62281
TREAT SPINAL CORD LESION
3.54
1.00
62281
TREAT SPINAL CORD LESION
3.62
1.00
62281
TREAT SPINAL CORD LESION
3.85
1.00
62281
TREAT SPINAL CORD LESION
999.99
1.00
62282
TREAT SPINAL CANAL LESION
3.20
1.00
62282
TREAT SPINAL CANAL LESION
3.29
1.00
62282
TREAT SPINAL CANAL LESION
3.55
1.00
62284
INJECTION FOR MYELOGRAM
2.25
1.00
62284
INJECTION FOR MYELOGRAM
2.26
1.00
62284
INJECTION FOR MYELOGRAM
2.41
1.00
62284
INJECTION FOR MYELOGRAM
4.00
1.00
62287
PERCUTANEOUS DISKECTOMY
8.00
1.00
62287
PERCUTANEOUS DISKECTOMY
13.78
1.00
62287
PERCUTANEOUS DISKECTOMY
14.16
1.00
62287
PERCUTANEOUS DISKECTOMY
14.39
1.00
62290
INJECT FOR SPINE DISK X-RAY
3.00
1.00
62290
INJECT FOR SPINE DISK X-RAY
4.48
1.00
62290
INJECT FOR SPINE DISK X-RAY
4.49
1.00
Procedure Code Description
RVU
RVU Coeff Value
62290
INJECT FOR SPINE DISK X-RAY
4.52
1.00
62291
INJECT FOR SPINE DISK X-RAY
4.23
1.00
62291
INJECT FOR SPINE DISK X-RAY
4.25
1.00
62291
INJECT FOR SPINE DISK X-RAY
4.34
1.00
62291
INJECT FOR SPINE DISK X-RAY
5.00
1.00
62292
INJECTION INTO DISK LESION
5.00
1.00
62292
INJECTION INTO DISK LESION
12.83
1.00
62292
INJECTION INTO DISK LESION
13.13
1.00
62292
INJECTION INTO DISK LESION
13.55
1.00
62294
INJECTION INTO SPINAL ARTERY
18.46
1.00
62294
INJECTION INTO SPINAL ARTERY
19.36
1.00
62294
INJECTION INTO SPINAL ARTERY
20.60
1.00
62310
INJECT SPINE C/T
2.53
1.00
62310
INJECT SPINE C/T
2.54
1.00
62310
INJECT SPINE C/T
2.64
1.00
62311
INJECT SPINE L/S (CD)
2.08
1.00
62311
INJECT SPINE L/S (CD)
2.10
1.00
62311
INJECT SPINE L/S (CD)
2.19
1.00
62318
INJECT SPINE W/CATH, C/T
2.65
1.00
62318
INJECT SPINE W/CATH, C/T
2.68
1.00
62318
INJECT SPINE W/CATH, C/T
2.69
1.00
62319
INJECT SPINE W/CATH L/S (CD)
2.46
1.00
62319
INJECT SPINE W/CATH L/S (CD)
2.47
1.00
62319
INJECT SPINE W/CATH L/S (CD)
2.48
1.00
62350
IMPLANT SPINAL CANAL CATH
8.00
1.00
62350
IMPLANT SPINAL CANAL CATH
10.11
1.00
62350
IMPLANT SPINAL CANAL CATH
11.15
1.00
62350
IMPLANT SPINAL CANAL CATH
11.62
1.00
62351
IMPLANT SPINAL CANAL CATH
10.00
1.00
62351
IMPLANT SPINAL CANAL CATH
18.51
1.00
62351
IMPLANT SPINAL CANAL CATH
19.25
1.00
62351
IMPLANT SPINAL CANAL CATH
21.35
1.00
62355
REMOVE SPINAL CANAL CATHETER
7.57
1.00
62355
REMOVE SPINAL CANAL CATHETER
8.00
1.00
62355
REMOVE SPINAL CANAL CATHETER
8.74
1.00
Procedure Code Description
RVU
RVU Coeff Value
62355
REMOVE SPINAL CANAL CATHETER
9.21
1.00
62360
INSERT SPINE INFUSION DEVICE
5.11
1.00
62360
INSERT SPINE INFUSION DEVICE
5.58
1.00
62360
INSERT SPINE INFUSION DEVICE
7.17
1.00
62360
INSERT SPINE INFUSION DEVICE
8.00
1.00
62361
IMPLANT SPINE INFUSION PUMP
8.00
1.00
62361
IMPLANT SPINE INFUSION PUMP
9.42
1.00
62361
IMPLANT SPINE INFUSION PUMP
9.92
1.00
62361
IMPLANT SPINE INFUSION PUMP
10.00
1.00
62362
IMPLANT SPINE INFUSION PUMP
8.00
1.00
62362
IMPLANT SPINE INFUSION PUMP
10.66
1.00
62362
IMPLANT SPINE INFUSION PUMP
11.96
1.00
62362
IMPLANT SPINE INFUSION PUMP
12.45
1.00
62365
REMOVE SPINE INFUSION DEVICE
8.00
1.00
62365
REMOVE SPINE INFUSION DEVICE
8.40
1.00
62365
REMOVE SPINE INFUSION DEVICE
9.71
1.00
62365
REMOVE SPINE INFUSION DEVICE
10.09
1.00
62367
ANALYZE SPINE INFUSION PUMP
0.63
1.00
62367
ANALYZE SPINE INFUSION PUMP
0.64
1.00
62367
ANALYZE SPINE INFUSION PUMP
0.65
1.00
62368
ANALYZE SPINE INFUSION PUMP
0.99
1.00
62368
ANALYZE SPINE INFUSION PUMP
1.00
1.00
63001
REMOVAL OF SPINAL LAMINA
10.00
1.00
63001
REMOVAL OF SPINAL LAMINA
28.78
1.00
63001
REMOVAL OF SPINAL LAMINA
28.97
1.00
63001
REMOVAL OF SPINAL LAMINA
31.20
1.00
63003
REMOVAL OF SPINAL LAMINA
10.00
1.00
63003
REMOVAL OF SPINAL LAMINA
29.21
1.00
63003
REMOVAL OF SPINAL LAMINA
29.38
1.00
63003
REMOVAL OF SPINAL LAMINA
31.37
1.00
63005
REMOVAL OF SPINAL LAMINA
8.00
1.00
63005
REMOVAL OF SPINAL LAMINA
27.85
1.00
63005
REMOVAL OF SPINAL LAMINA
27.99
1.00
63005
REMOVAL OF SPINAL LAMINA
29.73
1.00
63011
REMOVAL OF SPINAL LAMINA
8.00
1.00
Procedure Code Description
RVU
RVU Coeff Value
63011
REMOVAL OF SPINAL LAMINA
24.48
1.00
63011
REMOVAL OF SPINAL LAMINA
24.55
1.00
63011
REMOVAL OF SPINAL LAMINA
28.16
1.00
63012
REMOVAL OF SPINAL LAMINA
28.56
1.00
63012
REMOVAL OF SPINAL LAMINA
28.74
1.00
63012
REMOVAL OF SPINAL LAMINA
30.27
1.00
63012
REMOVAL OF SPINAL LAMINA
999.99
1.00
63015
REMOVAL OF SPINAL LAMINA
10.00
1.00
63015
REMOVAL OF SPINAL LAMINA
35.55
1.00
63015
REMOVAL OF SPINAL LAMINA
35.84
1.00
63015
REMOVAL OF SPINAL LAMINA
37.56
1.00
63016
REMOVAL OF SPINAL LAMINA
10.00
1.00
63016
REMOVAL OF SPINAL LAMINA
35.04
1.00
63016
REMOVAL OF SPINAL LAMINA
35.33
1.00
63016
REMOVAL OF SPINAL LAMINA
38.52
1.00
63017
REMOVAL OF SPINAL LAMINA
8.00
1.00
63017
REMOVAL OF SPINAL LAMINA
29.62
1.00
63017
REMOVAL OF SPINAL LAMINA
29.79
1.00
63017
REMOVAL OF SPINAL LAMINA
31.39
1.00
63020
NECK SPINE DISK SURGERY
10.00
1.00
63020
NECK SPINE DISK SURGERY
27.78
1.00
63020
NECK SPINE DISK SURGERY
27.95
1.00
63020
NECK SPINE DISK SURGERY
29.79
1.00
63030
LOW BACK DISK SURGERY
8.00
1.00
63030
LOW BACK DISK SURGERY
22.96
1.00
63030
LOW BACK DISK SURGERY
23.04
1.00
63030
LOW BACK DISK SURGERY
24.73
1.00
63035
SPINAL DISK SURGERY ADD-ON
5.30
1.00
63035
SPINAL DISK SURGERY ADD-ON
5.35
1.00
63035
SPINAL DISK SURGERY ADD-ON
5.43
1.00
63040
LAMINOTOMY, SINGLE CERVICAL
10.00
1.00
63040
LAMINOTOMY, SINGLE CERVICAL
34.08
1.00
63040
LAMINOTOMY, SINGLE CERVICAL
34.33
1.00
63040
LAMINOTOMY, SINGLE CERVICAL
36.23
1.00
63042
LAMINOTOMY, SINGLE LUMBAR
8.00
1.00
Procedure Code Description
RVU
RVU Coeff Value
63042
LAMINOTOMY, SINGLE LUMBAR
32.29
1.00
63042
LAMINOTOMY, SINGLE LUMBAR
32.49
1.00
63042
LAMINOTOMY, SINGLE LUMBAR
33.89
1.00
63045
REMOVAL OF SPINAL LAMINA
10.00
1.00
63045
REMOVAL OF SPINAL LAMINA
30.45
1.00
63045
REMOVAL OF SPINAL LAMINA
30.68
1.00
63045
REMOVAL OF SPINAL LAMINA
32.34
1.00
63046
REMOVAL OF SPINAL LAMINA
10.00
1.00
63046
REMOVAL OF SPINAL LAMINA
29.23
1.00
63046
REMOVAL OF SPINAL LAMINA
29.43
1.00
63046
REMOVAL OF SPINAL LAMINA
30.83
1.00
63047
REMOVAL OF SPINAL LAMINA
8.00
1.00
63047
REMOVAL OF SPINAL LAMINA
27.45
1.00
63047
REMOVAL OF SPINAL LAMINA
27.59
1.00
63047
REMOVAL OF SPINAL LAMINA
28.14
1.00
63048
REMOVE SPINAL LAMINA ADD-ON
5.55
1.00
63048
REMOVE SPINAL LAMINA ADD-ON
5.63
1.00
63048
REMOVE SPINAL LAMINA ADD-ON
5.66
1.00
63050
CERVICAL LAMINOPLASTY
38.82
1.00
63051
C-LAMINOPLASTY W/GRAFT/PLATE
43.64
1.00
63055
DECOMPRESS SPINAL CORD
10.00
1.00
63055
DECOMPRESS SPINAL CORD
39.68
1.00
63055
DECOMPRESS SPINAL CORD
40.03
1.00
63055
DECOMPRESS SPINAL CORD
41.66
1.00
63056
DECOMPRESS SPINAL CORD
8.00
1.00
63056
DECOMPRESS SPINAL CORD
36.68
1.00
63056
DECOMPRESS SPINAL CORD
36.90
1.00
63056
DECOMPRESS SPINAL CORD
38.43
1.00
63057
DECOMPRESS SPINE CORD ADD-ON
8.71
1.00
63057
DECOMPRESS SPINE CORD ADD-ON
8.78
1.00
63057
DECOMPRESS SPINE CORD ADD-ON
8.87
1.00
63064
DECOMPRESS SPINAL CORD
8.00
1.00
63064
DECOMPRESS SPINAL CORD
44.26
1.00
63064
DECOMPRESS SPINAL CORD
44.71
1.00
63064
DECOMPRESS SPINAL CORD
45.53
1.00
Procedure Code Description
RVU
RVU Coeff Value
63066
DECOMPRESS SPINE CORD ADD-ON
5.35
1.00
63066
DECOMPRESS SPINE CORD ADD-ON
5.60
1.00
63066
DECOMPRESS SPINE CORD ADD-ON
5.69
1.00
63075
NECK SPINE DISK SURGERY
10.00
1.00
63075
NECK SPINE DISK SURGERY
35.61
1.00
63075
NECK SPINE DISK SURGERY
35.67
1.00
63075
NECK SPINE DISK SURGERY
35.96
1.00
63076
NECK SPINE DISK SURGERY
6.73
1.00
63076
NECK SPINE DISK SURGERY
6.94
1.00
63076
NECK SPINE DISK SURGERY
7.04
1.00
63077
SPINE DISK SURGERY, THORAX
10.00
1.00
63077
SPINE DISK SURGERY, THORAX
37.96
1.00
63077
SPINE DISK SURGERY, THORAX
38.32
1.00
63077
SPINE DISK SURGERY, THORAX
38.68
1.00
63078
SPINE DISK SURGERY, THORAX
5.32
1.00
63078
SPINE DISK SURGERY, THORAX
5.45
1.00
63078
SPINE DISK SURGERY, THORAX
5.52
1.00
63081
REMOVAL OF VERTEBRAL BODY
42.99
1.00
63081
REMOVAL OF VERTEBRAL BODY
43.40
1.00
63081
REMOVAL OF VERTEBRAL BODY
45.60
1.00
63082
REMOVE VERTEBRAL BODY ADD-ON
7.26
1.00
63082
REMOVE VERTEBRAL BODY ADD-ON
7.48
1.00
63082
REMOVE VERTEBRAL BODY ADD-ON
7.58
1.00
63085
REMOVAL OF VERTEBRAL BODY
47.45
1.00
63085
REMOVAL OF VERTEBRAL BODY
48.02
1.00
63085
REMOVAL OF VERTEBRAL BODY
48.26
1.00
63086
REMOVE VERTEBRAL BODY ADD-ON
5.11
1.00
63086
REMOVE VERTEBRAL BODY ADD-ON
5.37
1.00
63086
REMOVE VERTEBRAL BODY ADD-ON
5.45
1.00
63087
REMOVAL OF VERTEBRAL BODY
10.00
1.00
63087
REMOVAL OF VERTEBRAL BODY
61.37
1.00
63087
REMOVAL OF VERTEBRAL BODY
61.78
1.00
63087
REMOVAL OF VERTEBRAL BODY
62.05
1.00
63088
REMOVE VERTEBRAL BODY ADD-ON
7.00
1.00
63088
REMOVE VERTEBRAL BODY ADD-ON
7.33
1.00
Procedure Code Description
RVU
RVU Coeff Value
63088
REMOVE VERTEBRAL BODY ADD-ON
7.43
1.00
63088
REMOVE VERTEBRAL BODY ADD-ON
999.99
1.00
63090
REMOVAL OF VERTEBRAL BODY
8.00
1.00
63090
REMOVAL OF VERTEBRAL BODY
48.83
1.00
63090
REMOVAL OF VERTEBRAL BODY
49.28
1.00
63090
REMOVAL OF VERTEBRAL BODY
50.28
1.00
63091
REMOVE VERTEBRAL BODY ADD-ON
4.78
1.00
63091
REMOVE VERTEBRAL BODY ADD-ON
4.97
1.00
63091
REMOVE VERTEBRAL BODY ADD-ON
5.03
1.00
63101
REMOVAL OF VERTEBRAL BODY
56.98
1.00
63101
REMOVAL OF VERTEBRAL BODY
57.88
1.00
63102
REMOVAL OF VERTEBRAL BODY
56.98
1.00
63102
REMOVAL OF VERTEBRAL BODY
57.64
1.00
63103
REMOVE VERTEBRAL BODY ADD-ON
6.66
1.00
63103
REMOVE VERTEBRAL BODY ADD-ON
7.61
1.00
63170
INCISE SPINAL CORD TRACT(S)
10.00
1.00
63170
INCISE SPINAL CORD TRACT(S)
36.55
1.00
63170
INCISE SPINAL CORD TRACT(S)
37.41
1.00
63170
INCISE SPINAL CORD TRACT(S)
39.12
1.00
63172
DRAINAGE OF SPINAL CYST
32.65
1.00
63172
DRAINAGE OF SPINAL CYST
34.33
1.00
63172
DRAINAGE OF SPINAL CYST
35.26
1.00
63173
DRAINAGE OF SPINAL CYST
39.98
1.00
63173
DRAINAGE OF SPINAL CYST
41.35
1.00
63173
DRAINAGE OF SPINAL CYST
43.52
1.00
63180
REVISE SPINAL CORD LIGAMENTS
9.00
1.00
63180
REVISE SPINAL CORD LIGAMENTS
34.07
1.00
63180
REVISE SPINAL CORD LIGAMENTS
35.24
1.00
63180
REVISE SPINAL CORD LIGAMENTS
35.37
1.00
63182
REVISE SPINAL CORD LIGAMENTS
10.00
1.00
63182
REVISE SPINAL CORD LIGAMENTS
35.85
1.00
63182
REVISE SPINAL CORD LIGAMENTS
36.91
1.00
63182
REVISE SPINAL CORD LIGAMENTS
38.08
1.00
63185
INCISE SPINAL COLUMN/NERVES
11.00
1.00
63185
INCISE SPINAL COLUMN/NERVES
25.78
1.00
Procedure Code Description
RVU
RVU Coeff Value
63185
INCISE SPINAL COLUMN/NERVES
26.94
1.00
63185
INCISE SPINAL COLUMN/NERVES
28.55
1.00
63190
INCISE SPINAL COLUMN/NERVES
10.00
1.00
63190
INCISE SPINAL COLUMN/NERVES
31.20
1.00
63190
INCISE SPINAL COLUMN/NERVES
32.25
1.00
63190
INCISE SPINAL COLUMN/NERVES
32.83
1.00
63191
INCISE SPINAL COLUMN/NERVES
10.00
1.00
63191
INCISE SPINAL COLUMN/NERVES
32.35
1.00
63191
INCISE SPINAL COLUMN/NERVES
32.41
1.00
63191
INCISE SPINAL COLUMN/NERVES
33.35
1.00
63194
INCISE SPINAL COLUMN & CORD
10.00
1.00
63194
INCISE SPINAL COLUMN & CORD
35.89
1.00
63194
INCISE SPINAL COLUMN & CORD
36.55
1.00
63194
INCISE SPINAL COLUMN & CORD
37.17
1.00
63195
INCISE SPINAL COLUMN & CORD
11.00
1.00
63195
INCISE SPINAL COLUMN & CORD
34.20
1.00
63195
INCISE SPINAL COLUMN & CORD
35.25
1.00
63195
INCISE SPINAL COLUMN & CORD
38.14
1.00
63196
INCISE SPINAL COLUMN & CORD
8.00
1.00
63196
INCISE SPINAL COLUMN & CORD
40.61
1.00
63196
INCISE SPINAL COLUMN & CORD
41.47
1.00
63196
INCISE SPINAL COLUMN & CORD
44.89
1.00
63197
INCISE SPINAL COLUMN & CORD
10.00
1.00
63197
INCISE SPINAL COLUMN & CORD
38.80
1.00
63197
INCISE SPINAL COLUMN & CORD
39.38
1.00
63197
INCISE SPINAL COLUMN & CORD
42.75
1.00
63198
INCISE SPINAL COLUMN & CORD
8.00
1.00
63198
INCISE SPINAL COLUMN & CORD
40.37
1.00
63198
INCISE SPINAL COLUMN & CORD
41.49
1.00
63198
INCISE SPINAL COLUMN & CORD
47.51
1.00
63199
INCISE SPINAL COLUMN & CORD
10.00
1.00
63199
INCISE SPINAL COLUMN & CORD
48.61
1.00
63199
INCISE SPINAL COLUMN & CORD
48.80
1.00
63199
INCISE SPINAL COLUMN & CORD
48.87
1.00
63200
RELEASE OF SPINAL CORD
8.00
1.00
Procedure Code Description
RVU
RVU Coeff Value
63200
RELEASE OF SPINAL CORD
34.98
1.00
63200
RELEASE OF SPINAL CORD
35.89
1.00
63200
RELEASE OF SPINAL CORD
38.29
1.00
63250
REVISE SPINAL CORD VESSELS
15.00
1.00
63250
REVISE SPINAL CORD VESSELS
69.10
1.00
63250
REVISE SPINAL CORD VESSELS
69.96
1.00
63250
REVISE SPINAL CORD VESSELS
74.04
1.00
63251
REVISE SPINAL CORD VESSELS
10.00
1.00
63251
REVISE SPINAL CORD VESSELS
72.44
1.00
63251
REVISE SPINAL CORD VESSELS
73.45
1.00
63251
REVISE SPINAL CORD VESSELS
77.20
1.00
63252
REVISE SPINAL CORD VESSELS
8.00
1.00
63252
REVISE SPINAL CORD VESSELS
71.84
1.00
63252
REVISE SPINAL CORD VESSELS
72.81
1.00
63252
REVISE SPINAL CORD VESSELS
77.33
1.00
63265
EXCISE INTRASPINAL LESION
10.00
1.00
63265
EXCISE INTRASPINAL LESION
39.15
1.00
63265
EXCISE INTRASPINAL LESION
39.51
1.00
63265
EXCISE INTRASPINAL LESION
42.38
1.00
63266
EXCISE INTRASPINAL LESION
10.00
1.00
63266
EXCISE INTRASPINAL LESION
40.50
1.00
63266
EXCISE INTRASPINAL LESION
40.88
1.00
63266
EXCISE INTRASPINAL LESION
43.55
1.00
63267
EXCISE INTRASPINAL LESION
8.00
1.00
63267
EXCISE INTRASPINAL LESION
32.98
1.00
63267
EXCISE INTRASPINAL LESION
33.23
1.00
63267
EXCISE INTRASPINAL LESION
35.06
1.00
63268
EXCISE INTRASPINAL LESION
6.00
1.00
63268
EXCISE INTRASPINAL LESION
32.56
1.00
63268
EXCISE INTRASPINAL LESION
32.75
1.00
63268
EXCISE INTRASPINAL LESION
34.96
1.00
63270
EXCISE INTRASPINAL LESION
10.00
1.00
63270
EXCISE INTRASPINAL LESION
48.31
1.00
63270
EXCISE INTRASPINAL LESION
48.81
1.00
63270
EXCISE INTRASPINAL LESION
52.19
1.00
Procedure Code Description
RVU
RVU Coeff Value
63271
EXCISE INTRASPINAL LESION
48.68
1.00
63271
EXCISE INTRASPINAL LESION
49.22
1.00
63271
EXCISE INTRASPINAL LESION
52.52
1.00
63272
EXCISE INTRASPINAL LESION
10.00
1.00
63272
EXCISE INTRASPINAL LESION
45.66
1.00
63272
EXCISE INTRASPINAL LESION
46.12
1.00
63272
EXCISE INTRASPINAL LESION
48.33
1.00
63273
EXCISE INTRASPINAL LESION
6.00
1.00
63273
EXCISE INTRASPINAL LESION
44.26
1.00
63273
EXCISE INTRASPINAL LESION
44.77
1.00
63273
EXCISE INTRASPINAL LESION
45.60
1.00
63275
BIOPSY/EXCISE SPINAL TUMOR
10.00
1.00
63275
BIOPSY/EXCISE SPINAL TUMOR
42.71
1.00
63275
BIOPSY/EXCISE SPINAL TUMOR
43.11
1.00
63275
BIOPSY/EXCISE SPINAL TUMOR
45.50
1.00
63276
BIOPSY/EXCISE SPINAL TUMOR
10.00
1.00
63276
BIOPSY/EXCISE SPINAL TUMOR
42.31
1.00
63276
BIOPSY/EXCISE SPINAL TUMOR
42.71
1.00
63276
BIOPSY/EXCISE SPINAL TUMOR
45.35
1.00
63277
BIOPSY/EXCISE SPINAL TUMOR
8.00
1.00
63277
BIOPSY/EXCISE SPINAL TUMOR
37.87
1.00
63277
BIOPSY/EXCISE SPINAL TUMOR
38.20
1.00
63277
BIOPSY/EXCISE SPINAL TUMOR
39.78
1.00
63278
BIOPSY/EXCISE SPINAL TUMOR
6.00
1.00
63278
BIOPSY/EXCISE SPINAL TUMOR
37.42
1.00
63278
BIOPSY/EXCISE SPINAL TUMOR
37.77
1.00
63278
BIOPSY/EXCISE SPINAL TUMOR
38.82
1.00
63280
BIOPSY/EXCISE SPINAL TUMOR
10.00
1.00
63280
BIOPSY/EXCISE SPINAL TUMOR
50.95
1.00
63280
BIOPSY/EXCISE SPINAL TUMOR
51.68
1.00
63280
BIOPSY/EXCISE SPINAL TUMOR
53.94
1.00
63281
BIOPSY/EXCISE SPINAL TUMOR
10.00
1.00
63281
BIOPSY/EXCISE SPINAL TUMOR
50.36
1.00
63281
BIOPSY/EXCISE SPINAL TUMOR
51.07
1.00
63281
BIOPSY/EXCISE SPINAL TUMOR
53.32
1.00
Procedure Code Description
RVU
RVU Coeff Value
63282
BIOPSY/EXCISE SPINAL TUMOR
8.00
1.00
63282
BIOPSY/EXCISE SPINAL TUMOR
47.49
1.00
63282
BIOPSY/EXCISE SPINAL TUMOR
48.16
1.00
63282
BIOPSY/EXCISE SPINAL TUMOR
50.32
1.00
63283
BIOPSY/EXCISE SPINAL TUMOR
6.00
1.00
63283
BIOPSY/EXCISE SPINAL TUMOR
45.21
1.00
63283
BIOPSY/EXCISE SPINAL TUMOR
45.85
1.00
63283
BIOPSY/EXCISE SPINAL TUMOR
47.63
1.00
63285
BIOPSY/EXCISE SPINAL TUMOR
10.00
1.00
63285
BIOPSY/EXCISE SPINAL TUMOR
63.84
1.00
63285
BIOPSY/EXCISE SPINAL TUMOR
64.78
1.00
63285
BIOPSY/EXCISE SPINAL TUMOR
66.27
1.00
63286
BIOPSY/EXCISE SPINAL TUMOR
10.00
1.00
63286
BIOPSY/EXCISE SPINAL TUMOR
63.17
1.00
63286
BIOPSY/EXCISE SPINAL TUMOR
64.08
1.00
63286
BIOPSY/EXCISE SPINAL TUMOR
66.07
1.00
63287
BIOPSY/EXCISE SPINAL TUMOR
8.00
1.00
63287
BIOPSY/EXCISE SPINAL TUMOR
65.22
1.00
63287
BIOPSY/EXCISE SPINAL TUMOR
66.19
1.00
63287
BIOPSY/EXCISE SPINAL TUMOR
69.59
1.00
63290
BIOPSY/EXCISE SPINAL TUMOR
66.21
1.00
63290
BIOPSY/EXCISE SPINAL TUMOR
67.21
1.00
63290
BIOPSY/EXCISE SPINAL TUMOR
70.25
1.00
63295
REPAIR OF LAMINECTOMY DEFECT
8.34
1.00
63300
REMOVAL OF VERTEBRAL BODY
10.00
1.00
63300
REMOVAL OF VERTEBRAL BODY
44.05
1.00
63300
REMOVAL OF VERTEBRAL BODY
44.50
1.00
63300
REMOVAL OF VERTEBRAL BODY
46.91
1.00
63301
REMOVAL OF VERTEBRAL BODY
10.00
1.00
63301
REMOVAL OF VERTEBRAL BODY
48.47
1.00
63301
REMOVAL OF VERTEBRAL BODY
49.21
1.00
63301
REMOVAL OF VERTEBRAL BODY
52.15
1.00
63302
REMOVAL OF VERTEBRAL BODY
10.00
1.00
63302
REMOVAL OF VERTEBRAL BODY
49.22
1.00
63302
REMOVAL OF VERTEBRAL BODY
49.98
1.00
Procedure Code Description
RVU
RVU Coeff Value
63302
REMOVAL OF VERTEBRAL BODY
51.89
1.00
63303
REMOVAL OF VERTEBRAL BODY
8.00
1.00
63303
REMOVAL OF VERTEBRAL BODY
53.10
1.00
63303
REMOVAL OF VERTEBRAL BODY
53.65
1.00
63303
REMOVAL OF VERTEBRAL BODY
53.86
1.00
63304
REMOVAL OF VERTEBRAL BODY
10.00
1.00
63304
REMOVAL OF VERTEBRAL BODY
52.82
1.00
63304
REMOVAL OF VERTEBRAL BODY
53.31
1.00
63304
REMOVAL OF VERTEBRAL BODY
57.69
1.00
63305
REMOVAL OF VERTEBRAL BODY
10.00
1.00
63305
REMOVAL OF VERTEBRAL BODY
55.72
1.00
63305
REMOVAL OF VERTEBRAL BODY
56.54
1.00
63305
REMOVAL OF VERTEBRAL BODY
58.57
1.00
63306
REMOVAL OF VERTEBRAL BODY
10.00
1.00
63306
REMOVAL OF VERTEBRAL BODY
52.65
1.00
63306
REMOVAL OF VERTEBRAL BODY
52.89
1.00
63306
REMOVAL OF VERTEBRAL BODY
62.30
1.00
63307
REMOVAL OF VERTEBRAL BODY
8.00
1.00
63307
REMOVAL OF VERTEBRAL BODY
53.19
1.00
63307
REMOVAL OF VERTEBRAL BODY
53.50
1.00
63307
REMOVAL OF VERTEBRAL BODY
56.63
1.00
63308
REMOVE VERTEBRAL BODY ADD-ON
8.75
1.00
63308
REMOVE VERTEBRAL BODY ADD-ON
8.93
1.00
63308
REMOVE VERTEBRAL BODY ADD-ON
9.08
1.00
63600
REMOVE SPINAL CORD LESION
20.91
1.00
63600
REMOVE SPINAL CORD LESION
21.27
1.00
63600
REMOVE SPINAL CORD LESION
21.31
1.00
63610
STIMULATION OF SPINAL CORD
11.41
1.00
63610
STIMULATION OF SPINAL CORD
11.54
1.00
63610
STIMULATION OF SPINAL CORD
12.95
1.00
63615
REMOVE LESION OF SPINAL CORD
28.98
1.00
63615
REMOVE LESION OF SPINAL CORD
29.11
1.00
63615
REMOVE LESION OF SPINAL CORD
29.12
1.00
63620
SRS, SPINAL LESION
20.28
1.00
63621
SRS, SPINAL LESION, ADDL
6.37
1.00
Procedure Code Description
RVU
RVU Coeff Value
63650
IMPLANT NEUROELECTRODES
10.18
1.00
63650
IMPLANT NEUROELECTRODES
10.51
1.00
63650
IMPLANT NEUROELECTRODES
10.53
1.00
63655
IMPLANT NEUROELECTRODES
8.00
1.00
63655
IMPLANT NEUROELECTRODES
19.37
1.00
63655
IMPLANT NEUROELECTRODES
19.40
1.00
63655
IMPLANT NEUROELECTRODES
21.45
1.00
63660
REVISE/REMOVE NEUROELECTRODE
5.00
1.00
63660
REVISE/REMOVE NEUROELECTRODE
10.55
1.00
63660
REVISE/REMOVE NEUROELECTRODE
10.56
1.00
63660
REVISE/REMOVE NEUROELECTRODE
11.17
1.00
63685
INSRT/REDO SPINE N GENERATOR
5.00
1.00
63685
INSRT/REDO SPINE N GENERATOR
10.27
1.00
63685
INSRT/REDO SPINE N GENERATOR
12.28
1.00
63685
INSRT/REDO SPINE N GENERATOR
12.35
1.00
63688
REVISE/REMOVE NEURORECEIVER
7.00
1.00
63688
REVISE/REMOVE NEURORECEIVER
9.19
1.00
63688
REVISE/REMOVE NEURORECEIVER
9.77
1.00
63688
REVISE/REMOVE NEURORECEIVER
9.79
1.00
63700
REPAIR OF SPINAL HERNIATION
11.00
1.00
63700
REPAIR OF SPINAL HERNIATION
29.67
1.00
63700
REPAIR OF SPINAL HERNIATION
30.02
1.00
63700
REPAIR OF SPINAL HERNIATION
31.14
1.00
63702
REPAIR OF SPINAL HERNIATION
8.00
1.00
63702
REPAIR OF SPINAL HERNIATION
30.55
1.00
63702
REPAIR OF SPINAL HERNIATION
30.93
1.00
63702
REPAIR OF SPINAL HERNIATION
35.08
1.00
63704
REPAIR OF SPINAL HERNIATION
11.00
1.00
63704
REPAIR OF SPINAL HERNIATION
37.63
1.00
63704
REPAIR OF SPINAL HERNIATION
38.67
1.00
63704
REPAIR OF SPINAL HERNIATION
39.06
1.00
63706
REPAIR OF SPINAL HERNIATION
8.00
1.00
63706
REPAIR OF SPINAL HERNIATION
42.36
1.00
63706
REPAIR OF SPINAL HERNIATION
43.38
1.00
63706
REPAIR OF SPINAL HERNIATION
45.82
1.00
Procedure Code Description
RVU
RVU Coeff Value
63707
REPAIR SPINAL FLUID LEAKAGE
8.00
1.00
63707
REPAIR SPINAL FLUID LEAKAGE
21.23
1.00
63707
REPAIR SPINAL FLUID LEAKAGE
21.28
1.00
63707
REPAIR SPINAL FLUID LEAKAGE
22.98
1.00
63709
REPAIR SPINAL FLUID LEAKAGE
8.00
1.00
63709
REPAIR SPINAL FLUID LEAKAGE
26.51
1.00
63709
REPAIR SPINAL FLUID LEAKAGE
26.66
1.00
63709
REPAIR SPINAL FLUID LEAKAGE
27.93
1.00
63710
GRAFT REPAIR OF SPINE DEFECT
8.00
1.00
63710
GRAFT REPAIR OF SPINE DEFECT
26.11
1.00
63710
GRAFT REPAIR OF SPINE DEFECT
26.25
1.00
63710
GRAFT REPAIR OF SPINE DEFECT
28.01
1.00
63740
INSTALL SPINAL SHUNT
7.00
1.00
63740
INSTALL SPINAL SHUNT
21.27
1.00
63740
INSTALL SPINAL SHUNT
21.31
1.00
63740
INSTALL SPINAL SHUNT
23.79
1.00
63741
INSTALL SPINAL SHUNT
14.16
1.00
63741
INSTALL SPINAL SHUNT
14.29
1.00
63741
INSTALL SPINAL SHUNT
15.36
1.00
63741
INSTALL SPINAL SHUNT
999.99
1.00
63744
REVISION OF SPINAL SHUNT
5.00
1.00
63744
REVISION OF SPINAL SHUNT
15.19
1.00
63744
REVISION OF SPINAL SHUNT
16.19
1.00
63746
REMOVAL OF SPINAL SHUNT
5.00
1.00
63746
REMOVAL OF SPINAL SHUNT
11.61
1.00
63746
REMOVAL OF SPINAL SHUNT
11.62
1.00
63746
REMOVAL OF SPINAL SHUNT
14.10
1.00
64400
N BLOCK INJ, TRIGEMINAL
1.53
1.00
64400
N BLOCK INJ, TRIGEMINAL
1.55
1.00
64400
N BLOCK INJ, TRIGEMINAL
1.63
1.00
64400
N BLOCK INJ, TRIGEMINAL
5.00
1.00
64402
N BLOCK INJ, FACIAL
1.86
1.00
64402
N BLOCK INJ, FACIAL
5.00
1.00
64405
N BLOCK INJ, OCCIPITAL
1.80
1.00
64405
N BLOCK INJ, OCCIPITAL
1.81
1.00
Procedure Code Description
RVU
RVU Coeff Value
64405
N BLOCK INJ, OCCIPITAL
1.90
1.00
64405
N BLOCK INJ, OCCIPITAL
5.00
1.00
64408
N BLOCK INJ, VAGUS
2.17
1.00
64408
N BLOCK INJ, VAGUS
2.18
1.00
64408
N BLOCK INJ, VAGUS
2.30
1.00
64408
N BLOCK INJ, VAGUS
5.00
1.00
64410
N BLOCK INJ, PHRENIC
1.91
1.00
64410
N BLOCK INJ, PHRENIC
1.92
1.00
64410
N BLOCK INJ, PHRENIC
2.04
1.00
64410
N BLOCK INJ, PHRENIC
5.00
1.00
64412
N BLOCK INJ, SPINAL ACCESSOR
1.63
1.00
64412
N BLOCK INJ, SPINAL ACCESSOR
1.65
1.00
64412
N BLOCK INJ, SPINAL ACCESSOR
1.82
1.00
64412
N BLOCK INJ, SPINAL ACCESSOR
5.00
1.00
64413
N BLOCK INJ, CERVICAL PLEXUS
1.93
1.00
64413
N BLOCK INJ, CERVICAL PLEXUS
1.94
1.00
64413
N BLOCK INJ, CERVICAL PLEXUS
1.98
1.00
64413
N BLOCK INJ, CERVICAL PLEXUS
8.00
1.00
64415
N BLOCK INJ, BRACHIAL PLEXUS
1.92
1.00
64415
N BLOCK INJ, BRACHIAL PLEXUS
1.95
1.00
64415
N BLOCK INJ, BRACHIAL PLEXUS
1.97
1.00
64415
N BLOCK INJ, BRACHIAL PLEXUS
8.00
1.00
64416
N BLOCK CONT INFUSE, B PLEX
2.48
1.00
64416
N BLOCK CONT INFUSE, B PLEX
4.31
1.00
64416
N BLOCK CONT INFUSE, B PLEX
4.33
1.00
64417
N BLOCK INJ, AXILLARY
1.91
1.00
64417
N BLOCK INJ, AXILLARY
1.96
1.00
64417
N BLOCK INJ, AXILLARY
1.97
1.00
64417
N BLOCK INJ, AXILLARY
8.00
1.00
64418
N BLOCK INJ, SUPRASCAPULAR
1.76
1.00
64418
N BLOCK INJ, SUPRASCAPULAR
1.77
1.00
64418
N BLOCK INJ, SUPRASCAPULAR
1.89
1.00
64418
N BLOCK INJ, SUPRASCAPULAR
5.00
1.00
64420
N BLOCK INJ, INTERCOST, SNG
1.60
1.00
64420
N BLOCK INJ, INTERCOST, SNG
1.62
1.00
Procedure Code Description
RVU
RVU Coeff Value
64420
N BLOCK INJ, INTERCOST, SNG
1.71
1.00
64420
N BLOCK INJ, INTERCOST, SNG
5.00
1.00
64421
N BLOCK INJ, INTERCOST, MLT
2.24
1.00
64421
N BLOCK INJ, INTERCOST, MLT
2.25
1.00
64421
N BLOCK INJ, INTERCOST, MLT
2.34
1.00
64421
N BLOCK INJ, INTERCOST, MLT
7.00
1.00
64425
N BLOCK INJ, ILIO-ING/HYPOGI
2.34
1.00
64425
N BLOCK INJ, ILIO-ING/HYPOGI
2.35
1.00
64425
N BLOCK INJ, ILIO-ING/HYPOGI
2.43
1.00
64425
N BLOCK INJ, ILIO-ING/HYPOGI
5.00
1.00
64430
N BLOCK INJ, PUDENDAL
2.07
1.00
64430
N BLOCK INJ, PUDENDAL
2.08
1.00
64430
N BLOCK INJ, PUDENDAL
2.30
1.00
64430
N BLOCK INJ, PUDENDAL
5.00
1.00
64435
N BLOCK INJ, PARACERVICAL
2.22
1.00
64435
N BLOCK INJ, PARACERVICAL
2.25
1.00
64435
N BLOCK INJ, PARACERVICAL
2.26
1.00
64435
N BLOCK INJ, PARACERVICAL
5.00
1.00
64445
N BLOCK INJ, SCIATIC, SNG
1.94
1.00
64445
N BLOCK INJ, SCIATIC, SNG
1.95
1.00
64445
N BLOCK INJ, SCIATIC, SNG
2.09
1.00
64445
N BLOCK INJ, SCIATIC, SNG
5.00
1.00
64446
N BLK INJ, SCIATIC, CONT INF
2.44
1.00
64446
N BLK INJ, SCIATIC, CONT INF
4.48
1.00
64446
N BLK INJ, SCIATIC, CONT INF
4.53
1.00
64447
N BLOCK INJ FEM, SINGLE
1.83
1.00
64447
N BLOCK INJ FEM, SINGLE
2.10
1.00
64447
N BLOCK INJ FEM, SINGLE
2.11
1.00
64448
N BLOCK INJ FEM, CONT INF
2.16
1.00
64448
N BLOCK INJ FEM, CONT INF
4.12
1.00
64448
N BLOCK INJ FEM, CONT INF
4.13
1.00
64449
N BLOCK INJ, LUMBAR PLEXUS
2.40
1.00
64449
N BLOCK INJ, LUMBAR PLEXUS
4.07
1.00
64450
N BLOCK, OTHER PERIPHERAL
1.77
1.00
64450
N BLOCK, OTHER PERIPHERAL
1.78
1.00
Procedure Code Description
RVU
RVU Coeff Value
64450
N BLOCK, OTHER PERIPHERAL
1.89
1.00
64450
N BLOCK, OTHER PERIPHERAL
5.00
1.00
64455
N BLOCK INJ, PLANTAR DIGIT
1.08
1.00
64470
INJ PARAVERTEBRAL C/T
2.54
1.00
64470
INJ PARAVERTEBRAL C/T
2.55
1.00
64470
INJ PARAVERTEBRAL C/T
2.69
1.00
64470
INJ PARAVERTEBRAL C/T
5.00
1.00
64472
INJ PARAVERTEBRAL C/T ADD-ON
1.70
1.00
64472
INJ PARAVERTEBRAL C/T ADD-ON
1.71
1.00
64472
INJ PARAVERTEBRAL C/T ADD-ON
1.72
1.00
64472
INJ PARAVERTEBRAL C/T ADD-ON
5.00
1.00
64475
INJ PARAVERTEBRAL L/S
1.98
1.00
64475
INJ PARAVERTEBRAL L/S
1.99
1.00
64475
INJ PARAVERTEBRAL L/S
2.12
1.00
64475
INJ PARAVERTEBRAL L/S
5.00
1.00
64476
INJ PARAVERTEBRAL L/S ADD-ON
1.29
1.00
64476
INJ PARAVERTEBRAL L/S ADD-ON
1.30
1.00
64476
INJ PARAVERTEBRAL L/S ADD-ON
5.00
1.00
64479
INJ FORAMEN EPIDURAL C/T
3.07
1.00
64479
INJ FORAMEN EPIDURAL C/T
3.09
1.00
64479
INJ FORAMEN EPIDURAL C/T
3.18
1.00
64479
INJ FORAMEN EPIDURAL C/T
5.00
1.00
64480
INJ FORAMEN EPIDURAL ADD-ON
2.08
1.00
64480
INJ FORAMEN EPIDURAL ADD-ON
2.11
1.00
64480
INJ FORAMEN EPIDURAL ADD-ON
5.00
1.00
64483
INJ FORAMEN EPIDURAL L/S
2.69
1.00
64483
INJ FORAMEN EPIDURAL L/S
2.70
1.00
64483
INJ FORAMEN EPIDURAL L/S
2.80
1.00
64483
INJ FORAMEN EPIDURAL L/S
5.00
1.00
64484
INJ FORAMEN EPIDURAL ADD-ON
1.77
1.00
64484
INJ FORAMEN EPIDURAL ADD-ON
1.79
1.00
64484
INJ FORAMEN EPIDURAL ADD-ON
1.80
1.00
64484
INJ FORAMEN EPIDURAL ADD-ON
5.00
1.00
64505
N BLOCK, SPENOPALATINE GANGL
1.93
1.00
64505
N BLOCK, SPENOPALATINE GANGL
2.18
1.00
Procedure Code Description 64505
N BLOCK, SPENOPALATINE GANGL
64508
RVU
RVU Coeff Value
10.00
1.00
N BLOCK, CAROTID SINUS S/P
1.70
1.00
64508
N BLOCK, CAROTID SINUS S/P
1.80
1.00
64508
N BLOCK, CAROTID SINUS S/P
7.00
1.00
64510
N BLOCK, STELLATE GANGLION
1.67
1.00
64510
N BLOCK, STELLATE GANGLION
1.75
1.00
64510
N BLOCK, STELLATE GANGLION
7.00
1.00
64517
N BLOCK INJ, HYPOGAS PLXS
3.07
1.00
64517
N BLOCK INJ, HYPOGAS PLXS
3.20
1.00
64520
N BLOCK, LUMBAR/THORACIC
1.85
1.00
64520
N BLOCK, LUMBAR/THORACIC
1.86
1.00
64520
N BLOCK, LUMBAR/THORACIC
1.98
1.00
64520
N BLOCK, LUMBAR/THORACIC
7.00
1.00
64530
N BLOCK INJ, CELIAC PELUS
2.15
1.00
64530
N BLOCK INJ, CELIAC PELUS
2.16
1.00
64530
N BLOCK INJ, CELIAC PELUS
2.34
1.00
64530
N BLOCK INJ, CELIAC PELUS
10.00
1.00
64550
APPLY NEUROSTIMULATOR
0.24
1.00
64553
IMPLANT NEUROELECTRODES
3.75
1.00
64553
IMPLANT NEUROELECTRODES
4.07
1.00
64553
IMPLANT NEUROELECTRODES
4.38
1.00
64555
IMPLANT NEUROELECTRODES
3.02
1.00
64555
IMPLANT NEUROELECTRODES
3.60
1.00
64555
IMPLANT NEUROELECTRODES
4.01
1.00
64560
IMPLANT NEUROELECTRODES
3.24
1.00
64560
IMPLANT NEUROELECTRODES
3.87
1.00
64560
IMPLANT NEUROELECTRODES
4.14
1.00
64561
IMPLANT NEUROELECTRODES
4.00
1.00
64561
IMPLANT NEUROELECTRODES
10.02
1.00
64561
IMPLANT NEUROELECTRODES
10.63
1.00
64561
IMPLANT NEUROELECTRODES
10.85
1.00
64561
IMPLANT NEUROELECTRODES
11.22
1.00
64565
IMPLANT NEUROELECTRODES
2.50
1.00
64565
IMPLANT NEUROELECTRODES
3.06
1.00
64565
IMPLANT NEUROELECTRODES
3.12
1.00
Procedure Code Description
RVU
RVU Coeff Value
64573
IMPLANT NEUROELECTRODES
5.00
1.00
64573
IMPLANT NEUROELECTRODES
14.38
1.00
64573
IMPLANT NEUROELECTRODES
14.51
1.00
64573
IMPLANT NEUROELECTRODES
15.06
1.00
64575
IMPLANT NEUROELECTRODES
7.36
1.00
64575
IMPLANT NEUROELECTRODES
7.49
1.00
64575
IMPLANT NEUROELECTRODES
7.73
1.00
64577
IMPLANT NEUROELECTRODES
8.53
1.00
64577
IMPLANT NEUROELECTRODES
8.75
1.00
64577
IMPLANT NEUROELECTRODES
9.22
1.00
64580
IMPLANT NEUROELECTRODES
7.53
1.00
64580
IMPLANT NEUROELECTRODES
7.91
1.00
64580
IMPLANT NEUROELECTRODES
8.34
1.00
64581
IMPLANT NEUROELECTRODES
5.00
1.00
64581
IMPLANT NEUROELECTRODES
19.34
1.00
64581
IMPLANT NEUROELECTRODES
20.48
1.00
64581
IMPLANT NEUROELECTRODES
21.79
1.00
64585
REVISE/REMOVE NEUROELECTRODE
4.12
1.00
64585
REVISE/REMOVE NEUROELECTRODE
4.16
1.00
64585
REVISE/REMOVE NEUROELECTRODE
4.44
1.00
64590
INSRT/REDO PN/GASTR STIMUL
4.64
1.00
64590
INSRT/REDO PN/GASTR STIMUL
4.78
1.00
64590
INSRT/REDO PN/GASTR STIMUL
5.04
1.00
64595
REVISE/RMV PN/GASTR STIMUL
3.49
1.00
64595
REVISE/RMV PN/GASTR STIMUL
3.68
1.00
64595
REVISE/RMV PN/GASTR STIMUL
3.86
1.00
64600
INJECTION TREATMENT OF NERVE
4.00
1.00
64600
INJECTION TREATMENT OF NERVE
5.23
1.00
64600
INJECTION TREATMENT OF NERVE
5.35
1.00
64600
INJECTION TREATMENT OF NERVE
5.51
1.00
64605
INJECTION TREATMENT OF NERVE
5.00
1.00
64605
INJECTION TREATMENT OF NERVE
8.15
1.00
64605
INJECTION TREATMENT OF NERVE
8.29
1.00
64605
INJECTION TREATMENT OF NERVE
8.85
1.00
64610
INJECTION TREATMENT OF NERVE
5.00
1.00
Procedure Code Description
RVU
RVU Coeff Value
64610
INJECTION TREATMENT OF NERVE
11.86
1.00
64610
INJECTION TREATMENT OF NERVE
12.08
1.00
64610
INJECTION TREATMENT OF NERVE
12.60
1.00
64612
DESTROY NERVE, FACE MUSCLE
3.08
1.00
64612
DESTROY NERVE, FACE MUSCLE
3.15
1.00
64612
DESTROY NERVE, FACE MUSCLE
3.45
1.00
64612
DESTROY NERVE, FACE MUSCLE
999.99
1.00
64613
DESTROY NERVE, NECK MUSCLE
3.02
1.00
64613
DESTROY NERVE, NECK MUSCLE
3.07
1.00
64613
DESTROY NERVE, NECK MUSCLE
3.26
1.00
64613
DESTROY NERVE, NECK MUSCLE
999.99
1.00
64614
DESTROY NERVE, EXTREM MUSC
3.33
1.00
64614
DESTROY NERVE, EXTREM MUSC
3.43
1.00
64614
DESTROY NERVE, EXTREM MUSC
3.62
1.00
64614
DESTROY NERVE, EXTREM MUSC
4.00
1.00
64620
INJECTION TREATMENT OF NERVE
4.11
1.00
64620
INJECTION TREATMENT OF NERVE
4.23
1.00
64620
INJECTION TREATMENT OF NERVE
4.28
1.00
64620
INJECTION TREATMENT OF NERVE
10.00
1.00
64622
DESTR PARAVERTEBRL NERVE L/S
4.34
1.00
64622
DESTR PARAVERTEBRL NERVE L/S
4.44
1.00
64622
DESTR PARAVERTEBRL NERVE L/S
4.53
1.00
64622
DESTR PARAVERTEBRL NERVE L/S
8.00
1.00
64623
DESTR PARAVERTEBRAL N ADD-ON
1.28
1.00
64623
DESTR PARAVERTEBRAL N ADD-ON
1.29
1.00
64626
DESTR PARAVERTEBRL NERVE C/T
5.34
1.00
64626
DESTR PARAVERTEBRL NERVE C/T
5.40
1.00
64626
DESTR PARAVERTEBRL NERVE C/T
5.97
1.00
64627
DESTR PARAVERTEBRAL N ADD-ON
1.50
1.00
64627
DESTR PARAVERTEBRAL N ADD-ON
1.51
1.00
64627
DESTR PARAVERTEBRAL N ADD-ON
1.53
1.00
64630
INJECTION TREATMENT OF NERVE
4.38
1.00
64630
INJECTION TREATMENT OF NERVE
4.47
1.00
64630
INJECTION TREATMENT OF NERVE
4.98
1.00
64630
INJECTION TREATMENT OF NERVE
10.00
1.00
Procedure Code Description
RVU
RVU Coeff Value
64632
N BLOCK INJ, COMMON DIGIT
1.88
1.00
64640
INJECTION TREATMENT OF NERVE
4.56
1.00
64640
INJECTION TREATMENT OF NERVE
4.57
1.00
64640
INJECTION TREATMENT OF NERVE
4.59
1.00
64650
CHEMODENERV ECCRINE GLANDS
1.03
1.00
64653
CHEMODENERV ECCRINE GLANDS
1.29
1.00
64680
INJECTION TREATMENT OF NERVE
3.98
1.00
64680
INJECTION TREATMENT OF NERVE
4.08
1.00
64680
INJECTION TREATMENT OF NERVE
4.15
1.00
64681
INJECTION TREATMENT OF NERVE
5.59
1.00
64681
INJECTION TREATMENT OF NERVE
5.82
1.00
64702
REVISE FINGER/TOE NERVE
3.00
1.00
64702
REVISE FINGER/TOE NERVE
8.66
1.00
64702
REVISE FINGER/TOE NERVE
8.73
1.00
64702
REVISE FINGER/TOE NERVE
11.62
1.00
64704
REVISE HAND/FOOT NERVE
3.00
1.00
64704
REVISE HAND/FOOT NERVE
8.38
1.00
64704
REVISE HAND/FOOT NERVE
8.55
1.00
64704
REVISE HAND/FOOT NERVE
8.60
1.00
64708
REVISE ARM/LEG NERVE
3.00
1.00
64708
REVISE ARM/LEG NERVE
11.93
1.00
64708
REVISE ARM/LEG NERVE
12.06
1.00
64708
REVISE ARM/LEG NERVE
12.18
1.00
64712
REVISION OF SCIATIC NERVE
3.00
1.00
64712
REVISION OF SCIATIC NERVE
13.38
1.00
64712
REVISION OF SCIATIC NERVE
13.56
1.00
64712
REVISION OF SCIATIC NERVE
13.94
1.00
64713
REVISION OF ARM NERVE(S)
4.00
1.00
64713
REVISION OF ARM NERVE(S)
17.81
1.00
64713
REVISION OF ARM NERVE(S)
18.10
1.00
64713
REVISION OF ARM NERVE(S)
19.66
1.00
64714
REVISE LOW BACK NERVE(S)
8.00
1.00
64714
REVISE LOW BACK NERVE(S)
15.19
1.00
64714
REVISE LOW BACK NERVE(S)
15.32
1.00
64714
REVISE LOW BACK NERVE(S)
16.66
1.00
Procedure Code Description
RVU
RVU Coeff Value
64716
REVISION OF CRANIAL NERVE
6.00
1.00
64716
REVISION OF CRANIAL NERVE
11.87
1.00
64716
REVISION OF CRANIAL NERVE
12.27
1.00
64716
REVISION OF CRANIAL NERVE
13.18
1.00
64718
REVISE ULNAR NERVE AT ELBOW
3.00
1.00
64718
REVISE ULNAR NERVE AT ELBOW
12.16
1.00
64718
REVISE ULNAR NERVE AT ELBOW
12.90
1.00
64718
REVISE ULNAR NERVE AT ELBOW
14.34
1.00
64719
REVISE ULNAR NERVE AT WRIST
3.00
1.00
64719
REVISE ULNAR NERVE AT WRIST
9.96
1.00
64719
REVISE ULNAR NERVE AT WRIST
10.06
1.00
64719
REVISE ULNAR NERVE AT WRIST
10.25
1.00
64721
CARPAL TUNNEL SURGERY
3.00
1.00
64721
CARPAL TUNNEL SURGERY
9.94
1.00
64721
CARPAL TUNNEL SURGERY
10.45
1.00
64721
CARPAL TUNNEL SURGERY
10.52
1.00
64722
RELIEVE PRESSURE ON NERVE(S)
3.00
1.00
64722
RELIEVE PRESSURE ON NERVE(S)
8.14
1.00
64722
RELIEVE PRESSURE ON NERVE(S)
8.35
1.00
64722
RELIEVE PRESSURE ON NERVE(S)
8.46
1.00
64726
RELEASE FOOT/TOE NERVE
3.00
1.00
64726
RELEASE FOOT/TOE NERVE
7.49
1.00
64726
RELEASE FOOT/TOE NERVE
7.62
1.00
64726
RELEASE FOOT/TOE NERVE
7.84
1.00
64727
INTERNAL NERVE REVISION
4.92
1.00
64727
INTERNAL NERVE REVISION
5.04
1.00
64727
INTERNAL NERVE REVISION
5.09
1.00
64732
INCISION OF BROW NERVE
3.00
1.00
64732
INCISION OF BROW NERVE
8.82
1.00
64732
INCISION OF BROW NERVE
8.86
1.00
64732
INCISION OF BROW NERVE
9.82
1.00
64734
INCISION OF CHEEK NERVE
4.00
1.00
64734
INCISION OF CHEEK NERVE
9.40
1.00
64734
INCISION OF CHEEK NERVE
9.97
1.00
64734
INCISION OF CHEEK NERVE
10.55
1.00
Procedure Code Description
RVU
RVU Coeff Value
64736
INCISION OF CHIN NERVE
4.00
1.00
64736
INCISION OF CHIN NERVE
8.26
1.00
64736
INCISION OF CHIN NERVE
9.48
1.00
64736
INCISION OF CHIN NERVE
9.86
1.00
64738
INCISION OF JAW NERVE
4.00
1.00
64738
INCISION OF JAW NERVE
10.22
1.00
64738
INCISION OF JAW NERVE
11.35
1.00
64738
INCISION OF JAW NERVE
11.80
1.00
64740
INCISION OF TONGUE NERVE
5.00
1.00
64740
INCISION OF TONGUE NERVE
9.84
1.00
64740
INCISION OF TONGUE NERVE
10.49
1.00
64740
INCISION OF TONGUE NERVE
11.65
1.00
64742
INCISION OF FACIAL NERVE
4.00
1.00
64742
INCISION OF FACIAL NERVE
11.62
1.00
64742
INCISION OF FACIAL NERVE
11.78
1.00
64742
INCISION OF FACIAL NERVE
11.92
1.00
64744
INCISE NERVE, BACK OF HEAD
4.00
1.00
64744
INCISE NERVE, BACK OF HEAD
10.20
1.00
64744
INCISE NERVE, BACK OF HEAD
10.22
1.00
64744
INCISE NERVE, BACK OF HEAD
10.64
1.00
64746
INCISE DIAPHRAGM NERVE
4.00
1.00
64746
INCISE DIAPHRAGM NERVE
11.17
1.00
64746
INCISE DIAPHRAGM NERVE
11.33
1.00
64746
INCISE DIAPHRAGM NERVE
11.35
1.00
64752
INCISION OF VAGUS NERVE
4.00
1.00
64752
INCISION OF VAGUS NERVE
12.36
1.00
64752
INCISION OF VAGUS NERVE
12.59
1.00
64752
INCISION OF VAGUS NERVE
12.82
1.00
64760
INCISION OF VAGUS NERVE
4.00
1.00
64760
INCISION OF VAGUS NERVE
11.09
1.00
64760
INCISION OF VAGUS NERVE
11.49
1.00
64760
INCISION OF VAGUS NERVE
12.08
1.00
64761
INCISION OF PELVIS NERVE
5.00
1.00
64761
INCISION OF PELVIS NERVE
10.27
1.00
64761
INCISION OF PELVIS NERVE
10.30
1.00
Procedure Code Description 64761
INCISION OF PELVIS NERVE
64763
RVU
RVU Coeff Value
11.36
1.00
INCISE HIP/THIGH NERVE
3.00
1.00
64763
INCISE HIP/THIGH NERVE
13.09
1.00
64763
INCISE HIP/THIGH NERVE
13.77
1.00
64763
INCISE HIP/THIGH NERVE
13.87
1.00
64766
INCISE HIP/THIGH NERVE
6.00
1.00
64766
INCISE HIP/THIGH NERVE
15.11
1.00
64766
INCISE HIP/THIGH NERVE
15.34
1.00
64766
INCISE HIP/THIGH NERVE
15.96
1.00
64771
SEVER CRANIAL NERVE
4.00
1.00
64771
SEVER CRANIAL NERVE
14.29
1.00
64771
SEVER CRANIAL NERVE
14.51
1.00
64771
SEVER CRANIAL NERVE
15.07
1.00
64772
INCISION OF SPINAL NERVE
4.00
1.00
64772
INCISION OF SPINAL NERVE
13.30
1.00
64772
INCISION OF SPINAL NERVE
13.58
1.00
64772
INCISION OF SPINAL NERVE
14.56
1.00
64774
REMOVE SKIN NERVE LESION
3.00
1.00
64774
REMOVE SKIN NERVE LESION
9.55
1.00
64774
REMOVE SKIN NERVE LESION
9.69
1.00
64774
REMOVE SKIN NERVE LESION
10.42
1.00
64776
REMOVE DIGIT NERVE LESION
3.00
1.00
64776
REMOVE DIGIT NERVE LESION
9.54
1.00
64776
REMOVE DIGIT NERVE LESION
9.59
1.00
64776
REMOVE DIGIT NERVE LESION
10.03
1.00
64778
DIGIT NERVE SURGERY ADD-ON
4.88
1.00
64778
DIGIT NERVE SURGERY ADD-ON
5.03
1.00
64778
DIGIT NERVE SURGERY ADD-ON
5.07
1.00
64782
REMOVE LIMB NERVE LESION
3.00
1.00
64782
REMOVE LIMB NERVE LESION
10.74
1.00
64782
REMOVE LIMB NERVE LESION
10.92
1.00
64782
REMOVE LIMB NERVE LESION
11.80
1.00
64783
LIMB NERVE SURGERY ADD-ON
5.82
1.00
64783
LIMB NERVE SURGERY ADD-ON
6.09
1.00
64783
LIMB NERVE SURGERY ADD-ON
6.14
1.00
Procedure Code Description
RVU
RVU Coeff Value
64784
REMOVE NERVE LESION
4.00
1.00
64784
REMOVE NERVE LESION
17.67
1.00
64784
REMOVE NERVE LESION
17.79
1.00
64784
REMOVE NERVE LESION
18.38
1.00
64786
REMOVE SCIATIC NERVE LESION
4.00
1.00
64786
REMOVE SCIATIC NERVE LESION
27.76
1.00
64786
REMOVE SCIATIC NERVE LESION
27.81
1.00
64786
REMOVE SCIATIC NERVE LESION
27.96
1.00
64787
IMPLANT NERVE END
3.00
1.00
64787
IMPLANT NERVE END
6.68
1.00
64787
IMPLANT NERVE END
7.04
1.00
64787
IMPLANT NERVE END
7.10
1.00
64788
REMOVE SKIN NERVE LESION
3.00
1.00
64788
REMOVE SKIN NERVE LESION
8.63
1.00
64788
REMOVE SKIN NERVE LESION
8.72
1.00
64788
REMOVE SKIN NERVE LESION
9.80
1.00
64790
REMOVAL OF NERVE LESION
3.00
1.00
64790
REMOVAL OF NERVE LESION
20.28
1.00
64790
REMOVAL OF NERVE LESION
20.51
1.00
64790
REMOVAL OF NERVE LESION
21.20
1.00
64792
REMOVAL OF NERVE LESION
4.00
1.00
64792
REMOVAL OF NERVE LESION
25.65
1.00
64792
REMOVAL OF NERVE LESION
26.01
1.00
64792
REMOVAL OF NERVE LESION
27.41
1.00
64795
BIOPSY OF NERVE
5.03
1.00
64795
BIOPSY OF NERVE
5.08
1.00
64795
BIOPSY OF NERVE
5.21
1.00
64802
REMOVE SYMPATHETIC NERVES
6.00
1.00
64802
REMOVE SYMPATHETIC NERVES
15.36
1.00
64802
REMOVE SYMPATHETIC NERVES
15.45
1.00
64802
REMOVE SYMPATHETIC NERVES
15.49
1.00
64804
REMOVE SYMPATHETIC NERVES
8.00
1.00
64804
REMOVE SYMPATHETIC NERVES
23.66
1.00
64804
REMOVE SYMPATHETIC NERVES
23.85
1.00
64804
REMOVE SYMPATHETIC NERVES
23.98
1.00
Procedure Code Description
RVU
RVU Coeff Value
64809
REMOVE SYMPATHETIC NERVES
6.00
1.00
64809
REMOVE SYMPATHETIC NERVES
20.61
1.00
64809
REMOVE SYMPATHETIC NERVES
20.94
1.00
64809
REMOVE SYMPATHETIC NERVES
22.05
1.00
64818
REMOVE SYMPATHETIC NERVES
7.00
1.00
64818
REMOVE SYMPATHETIC NERVES
16.91
1.00
64818
REMOVE SYMPATHETIC NERVES
17.15
1.00
64818
REMOVE SYMPATHETIC NERVES
17.17
1.00
64820
REMOVE SYMPATHETIC NERVES
8.00
1.00
64820
REMOVE SYMPATHETIC NERVES
18.87
1.00
64820
REMOVE SYMPATHETIC NERVES
18.98
1.00
64820
REMOVE SYMPATHETIC NERVES
19.27
1.00
64821
REMOVE SYMPATHETIC NERVES
8.00
1.00
64821
REMOVE SYMPATHETIC NERVES
17.28
1.00
64821
REMOVE SYMPATHETIC NERVES
17.36
1.00
64821
REMOVE SYMPATHETIC NERVES
18.97
1.00
64822
REMOVE SYMPATHETIC NERVES
8.00
1.00
64822
REMOVE SYMPATHETIC NERVES
17.17
1.00
64822
REMOVE SYMPATHETIC NERVES
17.20
1.00
64822
REMOVE SYMPATHETIC NERVES
18.97
1.00
64823
REMOVE SYMPATHETIC NERVES
8.00
1.00
64823
REMOVE SYMPATHETIC NERVES
19.53
1.00
64823
REMOVE SYMPATHETIC NERVES
19.94
1.00
64823
REMOVE SYMPATHETIC NERVES
21.57
1.00
64831
REPAIR OF DIGIT NERVE
3.00
1.00
64831
REPAIR OF DIGIT NERVE
17.27
1.00
64831
REPAIR OF DIGIT NERVE
17.82
1.00
64831
REPAIR OF DIGIT NERVE
17.85
1.00
64832
REPAIR NERVE ADD-ON
9.07
1.00
64832
REPAIR NERVE ADD-ON
9.36
1.00
64832
REPAIR NERVE ADD-ON
9.42
1.00
64834
REPAIR OF HAND OR FOOT NERVE
3.00
1.00
64834
REPAIR OF HAND OR FOOT NERVE
18.60
1.00
64834
REPAIR OF HAND OR FOOT NERVE
18.73
1.00
64834
REPAIR OF HAND OR FOOT NERVE
19.08
1.00
Procedure Code Description
RVU
RVU Coeff Value
64835
REPAIR OF HAND OR FOOT NERVE
3.00
1.00
64835
REPAIR OF HAND OR FOOT NERVE
20.16
1.00
64835
REPAIR OF HAND OR FOOT NERVE
20.23
1.00
64835
REPAIR OF HAND OR FOOT NERVE
20.71
1.00
64836
REPAIR OF HAND OR FOOT NERVE
3.00
1.00
64836
REPAIR OF HAND OR FOOT NERVE
20.09
1.00
64836
REPAIR OF HAND OR FOOT NERVE
20.16
1.00
64836
REPAIR OF HAND OR FOOT NERVE
20.68
1.00
64837
REPAIR NERVE ADD-ON
10.08
1.00
64837
REPAIR NERVE ADD-ON
10.37
1.00
64837
REPAIR NERVE ADD-ON
10.46
1.00
64840
REPAIR OF LEG NERVE
3.00
1.00
64840
REPAIR OF LEG NERVE
22.22
1.00
64840
REPAIR OF LEG NERVE
22.32
1.00
64840
REPAIR OF LEG NERVE
23.34
1.00
64856
REPAIR/TRANSPOSE NERVE
3.00
1.00
64856
REPAIR/TRANSPOSE NERVE
24.91
1.00
64856
REPAIR/TRANSPOSE NERVE
25.01
1.00
64856
REPAIR/TRANSPOSE NERVE
26.02
1.00
64857
REPAIR ARM/LEG NERVE
3.00
1.00
64857
REPAIR ARM/LEG NERVE
26.12
1.00
64857
REPAIR ARM/LEG NERVE
26.21
1.00
64857
REPAIR ARM/LEG NERVE
27.20
1.00
64858
REPAIR SCIATIC NERVE
4.00
1.00
64858
REPAIR SCIATIC NERVE
30.09
1.00
64858
REPAIR SCIATIC NERVE
30.56
1.00
64858
REPAIR SCIATIC NERVE
31.63
1.00
64859
NERVE SURGERY
6.84
1.00
64859
NERVE SURGERY
7.01
1.00
64859
NERVE SURGERY
7.05
1.00
64861
REPAIR OF ARM NERVES
5.00
1.00
64861
REPAIR OF ARM NERVES
33.99
1.00
64861
REPAIR OF ARM NERVES
34.33
1.00
64861
REPAIR OF ARM NERVES
35.77
1.00
64862
REPAIR OF LOW BACK NERVES
6.00
1.00
Procedure Code Description
RVU
RVU Coeff Value
64862
REPAIR OF LOW BACK NERVES
34.17
1.00
64862
REPAIR OF LOW BACK NERVES
34.35
1.00
64862
REPAIR OF LOW BACK NERVES
35.13
1.00
64864
REPAIR OF FACIAL NERVE
5.00
1.00
64864
REPAIR OF FACIAL NERVE
21.99
1.00
64864
REPAIR OF FACIAL NERVE
22.20
1.00
64864
REPAIR OF FACIAL NERVE
22.35
1.00
64865
REPAIR OF FACIAL NERVE
11.00
1.00
64865
REPAIR OF FACIAL NERVE
26.70
1.00
64865
REPAIR OF FACIAL NERVE
26.74
1.00
64865
REPAIR OF FACIAL NERVE
29.54
1.00
64866
FUSION OF FACIAL/OTHER NERVE
11.00
1.00
64866
FUSION OF FACIAL/OTHER NERVE
26.71
1.00
64866
FUSION OF FACIAL/OTHER NERVE
26.79
1.00
64866
FUSION OF FACIAL/OTHER NERVE
30.87
1.00
64868
FUSION OF FACIAL/OTHER NERVE
11.00
1.00
64868
FUSION OF FACIAL/OTHER NERVE
24.58
1.00
64868
FUSION OF FACIAL/OTHER NERVE
24.76
1.00
64868
FUSION OF FACIAL/OTHER NERVE
26.88
1.00
64870
FUSION OF FACIAL/OTHER NERVE
5.00
1.00
64870
FUSION OF FACIAL/OTHER NERVE
26.02
1.00
64870
FUSION OF FACIAL/OTHER NERVE
26.16
1.00
64870
FUSION OF FACIAL/OTHER NERVE
26.17
1.00
64872
SUBSEQUENT REPAIR OF NERVE
3.00
1.00
64872
SUBSEQUENT REPAIR OF NERVE
3.20
1.00
64872
SUBSEQUENT REPAIR OF NERVE
3.31
1.00
64872
SUBSEQUENT REPAIR OF NERVE
3.37
1.00
64874
REPAIR & REVISE NERVE ADD-ON
4.00
1.00
64874
REPAIR & REVISE NERVE ADD-ON
4.70
1.00
64874
REPAIR & REVISE NERVE ADD-ON
4.86
1.00
64874
REPAIR & REVISE NERVE ADD-ON
4.93
1.00
64876
REPAIR NERVE/SHORTEN BONE
5.08
1.00
64876
REPAIR NERVE/SHORTEN BONE
5.12
1.00
64876
REPAIR NERVE/SHORTEN BONE
5.13
1.00
64885
NERVE GRAFT, HEAD OR NECK
29.10
1.00
Procedure Code Description
RVU
RVU Coeff Value
64885
NERVE GRAFT, HEAD OR NECK
30.20
1.00
64885
NERVE GRAFT, HEAD OR NECK
30.23
1.00
64885
NERVE GRAFT, HEAD OR NECK
999.99
1.00
64886
NERVE GRAFT, HEAD OR NECK
34.58
1.00
64886
NERVE GRAFT, HEAD OR NECK
35.55
1.00
64886
NERVE GRAFT, HEAD OR NECK
35.56
1.00
64886
NERVE GRAFT, HEAD OR NECK
999.99
1.00
64890
NERVE GRAFT, HAND OR FOOT
3.00
1.00
64890
NERVE GRAFT, HAND OR FOOT
27.14
1.00
64890
NERVE GRAFT, HAND OR FOOT
27.22
1.00
64890
NERVE GRAFT, HAND OR FOOT
28.03
1.00
64891
NERVE GRAFT, HAND OR FOOT
3.00
1.00
64891
NERVE GRAFT, HAND OR FOOT
25.27
1.00
64891
NERVE GRAFT, HAND OR FOOT
25.41
1.00
64891
NERVE GRAFT, HAND OR FOOT
28.67
1.00
64892
NERVE GRAFT, ARM OR LEG
3.00
1.00
64892
NERVE GRAFT, ARM OR LEG
25.40
1.00
64892
NERVE GRAFT, ARM OR LEG
25.48
1.00
64892
NERVE GRAFT, ARM OR LEG
27.35
1.00
64893
NERVE GRAFT, ARM OR LEG
3.00
1.00
64893
NERVE GRAFT, ARM OR LEG
27.42
1.00
64893
NERVE GRAFT, ARM OR LEG
27.60
1.00
64893
NERVE GRAFT, ARM OR LEG
28.79
1.00
64895
NERVE GRAFT, HAND OR FOOT
3.00
1.00
64895
NERVE GRAFT, HAND OR FOOT
31.11
1.00
64895
NERVE GRAFT, HAND OR FOOT
31.35
1.00
64895
NERVE GRAFT, HAND OR FOOT
33.59
1.00
64896
NERVE GRAFT, HAND OR FOOT
3.00
1.00
64896
NERVE GRAFT, HAND OR FOOT
33.45
1.00
64896
NERVE GRAFT, HAND OR FOOT
33.70
1.00
64896
NERVE GRAFT, HAND OR FOOT
37.18
1.00
64897
NERVE GRAFT, ARM OR LEG
3.00
1.00
64897
NERVE GRAFT, ARM OR LEG
31.79
1.00
64897
NERVE GRAFT, ARM OR LEG
32.11
1.00
64897
NERVE GRAFT, ARM OR LEG
32.54
1.00
Procedure Code Description
RVU
RVU Coeff Value
64898
NERVE GRAFT, ARM OR LEG
3.00
1.00
64898
NERVE GRAFT, ARM OR LEG
34.09
1.00
64898
NERVE GRAFT, ARM OR LEG
34.55
1.00
64898
NERVE GRAFT, ARM OR LEG
35.49
1.00
64901
NERVE GRAFT ADD-ON
15.97
1.00
64901
NERVE GRAFT ADD-ON
16.62
1.00
64901
NERVE GRAFT ADD-ON
16.68
1.00
64902
NERVE GRAFT ADD-ON
18.34
1.00
64902
NERVE GRAFT ADD-ON
19.06
1.00
64902
NERVE GRAFT ADD-ON
19.13
1.00
64905
NERVE PEDICLE TRANSFER
24.39
1.00
64905
NERVE PEDICLE TRANSFER
24.48
1.00
64905
NERVE PEDICLE TRANSFER
26.03
1.00
64907
NERVE PEDICLE TRANSFER
33.00
1.00
64907
NERVE PEDICLE TRANSFER
33.46
1.00
64907
NERVE PEDICLE TRANSFER
34.38
1.00
64910
NERVE REPAIR W/ALLOGRAFT
20.99
1.00
64911
NEURORRAPHY W/VEIN AUTOGRAFT
25.25
1.00
65091
REVISE EYE
4.00
1.00
65091
REVISE EYE
14.71
1.00
65091
REVISE EYE
16.49
1.00
65091
REVISE EYE
18.00
1.00
65093
REVISE EYE WITH IMPLANT
4.00
1.00
65093
REVISE EYE WITH IMPLANT
14.69
1.00
65093
REVISE EYE WITH IMPLANT
17.29
1.00
65093
REVISE EYE WITH IMPLANT
18.65
1.00
65101
REMOVAL OF EYE
4.00
1.00
65101
REMOVAL OF EYE
16.95
1.00
65101
REMOVAL OF EYE
18.04
1.00
65101
REMOVAL OF EYE
18.90
1.00
65103
REMOVE EYE/INSERT IMPLANT
4.00
1.00
65103
REMOVE EYE/INSERT IMPLANT
17.70
1.00
65103
REMOVE EYE/INSERT IMPLANT
18.79
1.00
65103
REMOVE EYE/INSERT IMPLANT
19.61
1.00
65105
REMOVE EYE/ATTACH IMPLANT
4.00
1.00
Procedure Code Description
RVU
RVU Coeff Value
65105
REMOVE EYE/ATTACH IMPLANT
19.53
1.00
65105
REMOVE EYE/ATTACH IMPLANT
20.41
1.00
65105
REMOVE EYE/ATTACH IMPLANT
21.07
1.00
65110
REMOVAL OF EYE
4.00
1.00
65110
REMOVAL OF EYE
28.52
1.00
65110
REMOVAL OF EYE
29.36
1.00
65110
REMOVAL OF EYE
29.92
1.00
65112
REMOVE EYE/REVISE SOCKET
6.00
1.00
65112
REMOVE EYE/REVISE SOCKET
33.70
1.00
65112
REMOVE EYE/REVISE SOCKET
34.40
1.00
65112
REMOVE EYE/REVISE SOCKET
34.88
1.00
65114
REMOVE EYE/REVISE SOCKET
4.00
1.00
65114
REMOVE EYE/REVISE SOCKET
34.92
1.00
65114
REMOVE EYE/REVISE SOCKET
35.73
1.00
65114
REMOVE EYE/REVISE SOCKET
35.97
1.00
65125
REVISE OCULAR IMPLANT
4.72
1.00
65125
REVISE OCULAR IMPLANT
6.26
1.00
65125
REVISE OCULAR IMPLANT
6.69
1.00
65125
REVISE OCULAR IMPLANT
999.99
1.00
65130
INSERT OCULAR IMPLANT
6.00
1.00
65130
INSERT OCULAR IMPLANT
16.77
1.00
65130
INSERT OCULAR IMPLANT
17.72
1.00
65130
INSERT OCULAR IMPLANT
18.65
1.00
65135
INSERT OCULAR IMPLANT
6.00
1.00
65135
INSERT OCULAR IMPLANT
17.08
1.00
65135
INSERT OCULAR IMPLANT
18.09
1.00
65135
INSERT OCULAR IMPLANT
19.05
1.00
65140
ATTACH OCULAR IMPLANT
6.00
1.00
65140
ATTACH OCULAR IMPLANT
18.61
1.00
65140
ATTACH OCULAR IMPLANT
19.25
1.00
65140
ATTACH OCULAR IMPLANT
20.04
1.00
65150
REVISE OCULAR IMPLANT
6.00
1.00
65150
REVISE OCULAR IMPLANT
13.50
1.00
65150
REVISE OCULAR IMPLANT
15.84
1.00
65150
REVISE OCULAR IMPLANT
17.26
1.00
Procedure Code Description
RVU
RVU Coeff Value
65155
REINSERT OCULAR IMPLANT
6.00
1.00
65155
REINSERT OCULAR IMPLANT
19.66
1.00
65155
REINSERT OCULAR IMPLANT
20.72
1.00
65155
REINSERT OCULAR IMPLANT
21.60
1.00
65175
REMOVAL OF OCULAR IMPLANT
5.00
1.00
65175
REMOVAL OF OCULAR IMPLANT
15.11
1.00
65175
REMOVAL OF OCULAR IMPLANT
16.23
1.00
65175
REMOVAL OF OCULAR IMPLANT
17.36
1.00
65205
REMOVE FOREIGN BODY FROM EYE
0.93
1.00
65205
REMOVE FOREIGN BODY FROM EYE
0.94
1.00
65205
REMOVE FOREIGN BODY FROM EYE
1.06
1.00
65210
REMOVE FOREIGN BODY FROM EYE
1.17
1.00
65210
REMOVE FOREIGN BODY FROM EYE
1.18
1.00
65210
REMOVE FOREIGN BODY FROM EYE
1.28
1.00
65210
REMOVE FOREIGN BODY FROM EYE
6.00
1.00
65220
REMOVE FOREIGN BODY FROM EYE
0.94
1.00
65220
REMOVE FOREIGN BODY FROM EYE
0.95
1.00
65220
REMOVE FOREIGN BODY FROM EYE
1.05
1.00
65220
REMOVE FOREIGN BODY FROM EYE
4.00
1.00
65222
REMOVE FOREIGN BODY FROM EYE
1.25
1.00
65222
REMOVE FOREIGN BODY FROM EYE
1.40
1.00
65222
REMOVE FOREIGN BODY FROM EYE
4.00
1.00
65235
REMOVE FOREIGN BODY FROM EYE
6.00
1.00
65235
REMOVE FOREIGN BODY FROM EYE
14.71
1.00
65235
REMOVE FOREIGN BODY FROM EYE
15.18
1.00
65235
REMOVE FOREIGN BODY FROM EYE
16.11
1.00
65260
REMOVE FOREIGN BODY FROM EYE
6.00
1.00
65260
REMOVE FOREIGN BODY FROM EYE
22.11
1.00
65260
REMOVE FOREIGN BODY FROM EYE
22.89
1.00
65260
REMOVE FOREIGN BODY FROM EYE
23.77
1.00
65265
REMOVE FOREIGN BODY FROM EYE
8.00
1.00
65265
REMOVE FOREIGN BODY FROM EYE
24.88
1.00
65265
REMOVE FOREIGN BODY FROM EYE
25.84
1.00
65265
REMOVE FOREIGN BODY FROM EYE
26.97
1.00
65270
REPAIR OF EYE WOUND
3.29
1.00
Procedure Code Description
RVU
RVU Coeff Value
65270
REPAIR OF EYE WOUND
4.24
1.00
65270
REPAIR OF EYE WOUND
4.29
1.00
65270
REPAIR OF EYE WOUND
8.00
1.00
65272
REPAIR OF EYE WOUND
4.00
1.00
65272
REPAIR OF EYE WOUND
7.30
1.00
65272
REPAIR OF EYE WOUND
7.90
1.00
65272
REPAIR OF EYE WOUND
7.98
1.00
65272
REPAIR OF EYE WOUND
7.99
1.00
65272
REPAIR OF EYE WOUND
8.62
1.00
65272
REPAIR OF EYE WOUND
9.21
1.00
65273
REPAIR OF EYE WOUND
5.00
1.00
65273
REPAIR OF EYE WOUND
8.78
1.00
65273
REPAIR OF EYE WOUND
9.51
1.00
65273
REPAIR OF EYE WOUND
10.19
1.00
65275
REPAIR OF EYE WOUND
4.00
1.00
65275
REPAIR OF EYE WOUND
10.44
1.00
65275
REPAIR OF EYE WOUND
10.69
1.00
65275
REPAIR OF EYE WOUND
11.32
1.00
65280
REPAIR OF EYE WOUND
6.00
1.00
65280
REPAIR OF EYE WOUND
15.40
1.00
65280
REPAIR OF EYE WOUND
15.60
1.00
65280
REPAIR OF EYE WOUND
16.18
1.00
65285
REPAIR OF EYE WOUND
6.00
1.00
65285
REPAIR OF EYE WOUND
24.03
1.00
65285
REPAIR OF EYE WOUND
25.88
1.00
65285
REPAIR OF EYE WOUND
26.87
1.00
65286
REPAIR OF EYE WOUND
11.32
1.00
65286
REPAIR OF EYE WOUND
13.27
1.00
65286
REPAIR OF EYE WOUND
13.33
1.00
65290
REPAIR OF EYE SOCKET WOUND
5.00
1.00
65290
REPAIR OF EYE SOCKET WOUND
11.32
1.00
65290
REPAIR OF EYE SOCKET WOUND
11.94
1.00
65290
REPAIR OF EYE SOCKET WOUND
12.18
1.00
65400
REMOVAL OF EYE LESION
4.00
1.00
65400
REMOVAL OF EYE LESION
13.21
1.00
Procedure Code Description
RVU
RVU Coeff Value
65400
REMOVAL OF EYE LESION
13.65
1.00
65400
REMOVAL OF EYE LESION
13.81
1.00
65410
BIOPSY OF CORNEA
2.19
1.00
65410
BIOPSY OF CORNEA
2.20
1.00
65410
BIOPSY OF CORNEA
2.46
1.00
65410
BIOPSY OF CORNEA
4.00
1.00
65420
REMOVAL OF EYE LESION
4.00
1.00
65420
REMOVAL OF EYE LESION
8.62
1.00
65420
REMOVAL OF EYE LESION
11.11
1.00
65420
REMOVAL OF EYE LESION
11.31
1.00
65426
REMOVAL OF EYE LESION
5.00
1.00
65426
REMOVAL OF EYE LESION
10.97
1.00
65426
REMOVAL OF EYE LESION
11.99
1.00
65426
REMOVAL OF EYE LESION
12.02
1.00
65430
CORNEAL SMEAR
2.20
1.00
65430
CORNEAL SMEAR
2.21
1.00
65430
CORNEAL SMEAR
2.46
1.00
65435
CURETTE/TREAT CORNEA
1.36
1.00
65435
CURETTE/TREAT CORNEA
1.64
1.00
65435
CURETTE/TREAT CORNEA
5.00
1.00
65436
CURETTE/TREAT CORNEA
6.00
1.00
65436
CURETTE/TREAT CORNEA
8.53
1.00
65436
CURETTE/TREAT CORNEA
9.22
1.00
65436
CURETTE/TREAT CORNEA
9.61
1.00
65450
TREATMENT OF CORNEAL LESION
5.00
1.00
65450
TREATMENT OF CORNEAL LESION
7.26
1.00
65450
TREATMENT OF CORNEAL LESION
9.76
1.00
65450
TREATMENT OF CORNEAL LESION
9.97
1.00
65600
REVISION OF CORNEA
4.00
1.00
65600
REVISION OF CORNEA
4.97
1.00
65600
REVISION OF CORNEA
6.67
1.00
65600
REVISION OF CORNEA
7.72
1.00
65710
CORNEAL TRANSPLANT
8.00
1.00
65710
CORNEAL TRANSPLANT
25.25
1.00
65710
CORNEAL TRANSPLANT
25.44
1.00
Procedure Code Description
RVU
RVU Coeff Value
65710
CORNEAL TRANSPLANT
25.56
1.00
65730
CORNEAL TRANSPLANT
8.00
1.00
65730
CORNEAL TRANSPLANT
26.58
1.00
65730
CORNEAL TRANSPLANT
26.77
1.00
65730
CORNEAL TRANSPLANT
28.30
1.00
65750
CORNEAL TRANSPLANT
8.00
1.00
65750
CORNEAL TRANSPLANT
28.70
1.00
65750
CORNEAL TRANSPLANT
29.04
1.00
65750
CORNEAL TRANSPLANT
29.72
1.00
65755
CORNEAL TRANSPLANT
28.53
1.00
65755
CORNEAL TRANSPLANT
28.83
1.00
65755
CORNEAL TRANSPLANT
29.51
1.00
65755
CORNEAL TRANSPLANT
999.99
1.00
65756
CORNEAL TRNSPL, ENDOTHELIAL
27.48
1.00
65767
CORNEAL TISSUE TRANSPLANT
5.00
1.00
65770
REVISE CORNEA WITH IMPLANT
8.00
1.00
65770
REVISE CORNEA WITH IMPLANT
32.67
1.00
65770
REVISE CORNEA WITH IMPLANT
32.81
1.00
65770
REVISE CORNEA WITH IMPLANT
33.31
1.00
65771
RADIAL KERATOTOMY
999.99
1.00
65772
CORRECTION OF ASTIGMATISM
5.00
1.00
65772
CORRECTION OF ASTIGMATISM
9.25
1.00
65772
CORRECTION OF ASTIGMATISM
10.70
1.00
65772
CORRECTION OF ASTIGMATISM
10.95
1.00
65775
CORRECTION OF ASTIGMATISM
5.00
1.00
65775
CORRECTION OF ASTIGMATISM
12.64
1.00
65775
CORRECTION OF ASTIGMATISM
13.40
1.00
65775
CORRECTION OF ASTIGMATISM
14.39
1.00
65780
OCULAR RECONST, TRANSPLANT
20.36
1.00
65780
OCULAR RECONST, TRANSPLANT
20.52
1.00
65781
OCULAR RECONST, TRANSPLANT
30.82
1.00
65781
OCULAR RECONST, TRANSPLANT
31.30
1.00
65782
OCULAR RECONST, TRANSPLANT
26.61
1.00
65782
OCULAR RECONST, TRANSPLANT
26.99
1.00
65800
DRAINAGE OF EYE
3.11
1.00
Procedure Code Description
RVU
RVU Coeff Value
65800
DRAINAGE OF EYE
3.18
1.00
65800
DRAINAGE OF EYE
3.39
1.00
65800
DRAINAGE OF EYE
6.00
1.00
65805
DRAINAGE OF EYE
3.11
1.00
65805
DRAINAGE OF EYE
3.19
1.00
65805
DRAINAGE OF EYE
3.40
1.00
65805
DRAINAGE OF EYE
6.00
1.00
65810
DRAINAGE OF EYE
6.00
1.00
65810
DRAINAGE OF EYE
10.72
1.00
65810
DRAINAGE OF EYE
13.14
1.00
65810
DRAINAGE OF EYE
13.71
1.00
65815
DRAINAGE OF EYE
4.00
1.00
65815
DRAINAGE OF EYE
10.87
1.00
65815
DRAINAGE OF EYE
12.77
1.00
65815
DRAINAGE OF EYE
13.13
1.00
65820
RELIEVE INNER EYE PRESSURE
4.00
1.00
65820
RELIEVE INNER EYE PRESSURE
17.27
1.00
65820
RELIEVE INNER EYE PRESSURE
19.09
1.00
65820
RELIEVE INNER EYE PRESSURE
19.16
1.00
65850
INCISION OF EYE
6.00
1.00
65850
INCISION OF EYE
19.64
1.00
65850
INCISION OF EYE
20.37
1.00
65850
INCISION OF EYE
20.92
1.00
65855
LASER SURGERY OF EYE
5.00
1.00
65855
LASER SURGERY OF EYE
6.93
1.00
65855
LASER SURGERY OF EYE
7.58
1.00
65855
LASER SURGERY OF EYE
8.10
1.00
65860
INCISE INNER EYE ADHESIONS
5.00
1.00
65860
INCISE INNER EYE ADHESIONS
6.01
1.00
65860
INCISE INNER EYE ADHESIONS
6.76
1.00
65860
INCISE INNER EYE ADHESIONS
6.97
1.00
65865
INCISE INNER EYE ADHESIONS
6.00
1.00
65865
INCISE INNER EYE ADHESIONS
10.99
1.00
65865
INCISE INNER EYE ADHESIONS
12.34
1.00
65865
INCISE INNER EYE ADHESIONS
12.51
1.00
Procedure Code Description
RVU
RVU Coeff Value
65870
INCISE INNER EYE ADHESIONS
4.00
1.00
65870
INCISE INNER EYE ADHESIONS
13.53
1.00
65870
INCISE INNER EYE ADHESIONS
13.56
1.00
65870
INCISE INNER EYE ADHESIONS
13.69
1.00
65875
INCISE INNER EYE ADHESIONS
6.00
1.00
65875
INCISE INNER EYE ADHESIONS
13.91
1.00
65875
INCISE INNER EYE ADHESIONS
14.27
1.00
65875
INCISE INNER EYE ADHESIONS
14.40
1.00
65880
INCISE INNER EYE ADHESIONS
6.00
1.00
65880
INCISE INNER EYE ADHESIONS
14.75
1.00
65880
INCISE INNER EYE ADHESIONS
15.11
1.00
65880
INCISE INNER EYE ADHESIONS
15.18
1.00
65900
REMOVE EYE LESION
6.00
1.00
65900
REMOVE EYE LESION
22.28
1.00
65900
REMOVE EYE LESION
22.97
1.00
65900
REMOVE EYE LESION
23.87
1.00
65920
REMOVE IMPLANT OF EYE
6.00
1.00
65920
REMOVE IMPLANT OF EYE
16.72
1.00
65920
REMOVE IMPLANT OF EYE
17.49
1.00
65920
REMOVE IMPLANT OF EYE
18.02
1.00
65930
REMOVE BLOOD CLOT FROM EYE
5.00
1.00
65930
REMOVE BLOOD CLOT FROM EYE
14.84
1.00
65930
REMOVE BLOOD CLOT FROM EYE
15.52
1.00
65930
REMOVE BLOOD CLOT FROM EYE
16.29
1.00
66020
INJECTION TREATMENT OF EYE
3.04
1.00
66020
INJECTION TREATMENT OF EYE
3.18
1.00
66020
INJECTION TREATMENT OF EYE
3.25
1.00
66020
INJECTION TREATMENT OF EYE
4.00
1.00
66030
INJECTION TREATMENT OF EYE
2.54
1.00
66030
INJECTION TREATMENT OF EYE
2.65
1.00
66030
INJECTION TREATMENT OF EYE
2.73
1.00
66030
INJECTION TREATMENT OF EYE
6.00
1.00
66130
REMOVE EYE LESION
5.00
1.00
66130
REMOVE EYE LESION
13.37
1.00
66130
REMOVE EYE LESION
14.48
1.00
Procedure Code Description
RVU
RVU Coeff Value
66130
REMOVE EYE LESION
14.97
1.00
66150
GLAUCOMA SURGERY
6.00
1.00
66150
GLAUCOMA SURGERY
18.55
1.00
66150
GLAUCOMA SURGERY
19.24
1.00
66150
GLAUCOMA SURGERY
19.83
1.00
66155
GLAUCOMA SURGERY
6.00
1.00
66155
GLAUCOMA SURGERY
18.47
1.00
66155
GLAUCOMA SURGERY
19.19
1.00
66155
GLAUCOMA SURGERY
19.75
1.00
66160
GLAUCOMA SURGERY
6.00
1.00
66160
GLAUCOMA SURGERY
21.29
1.00
66160
GLAUCOMA SURGERY
22.02
1.00
66160
GLAUCOMA SURGERY
22.48
1.00
66165
GLAUCOMA SURGERY
6.00
1.00
66165
GLAUCOMA SURGERY
18.06
1.00
66165
GLAUCOMA SURGERY
18.76
1.00
66165
GLAUCOMA SURGERY
19.35
1.00
66170
GLAUCOMA SURGERY
6.00
1.00
66170
GLAUCOMA SURGERY
25.17
1.00
66170
GLAUCOMA SURGERY
27.22
1.00
66170
GLAUCOMA SURGERY
29.16
1.00
66172
INCISION OF EYE
5.00
1.00
66172
INCISION OF EYE
30.75
1.00
66172
INCISION OF EYE
30.85
1.00
66172
INCISION OF EYE
34.20
1.00
66180
IMPLANT EYE SHUNT
26.78
1.00
66180
IMPLANT EYE SHUNT
27.09
1.00
66180
IMPLANT EYE SHUNT
27.16
1.00
66180
IMPLANT EYE SHUNT
999.99
1.00
66185
REVISE EYE SHUNT
16.69
1.00
66185
REVISE EYE SHUNT
16.71
1.00
66185
REVISE EYE SHUNT
17.10
1.00
66185
REVISE EYE SHUNT
999.99
1.00
66220
REPAIR EYE LESION
5.00
1.00
66220
REPAIR EYE LESION
16.71
1.00
Procedure Code Description
RVU
RVU Coeff Value
66220
REPAIR EYE LESION
16.88
1.00
66220
REPAIR EYE LESION
18.02
1.00
66225
REPAIR/GRAFT EYE LESION
5.00
1.00
66225
REPAIR/GRAFT EYE LESION
20.80
1.00
66225
REPAIR/GRAFT EYE LESION
20.88
1.00
66225
REPAIR/GRAFT EYE LESION
21.50
1.00
66250
FOLLOW-UP SURGERY OF EYE
7.00
1.00
66250
FOLLOW-UP SURGERY OF EYE
12.54
1.00
66250
FOLLOW-UP SURGERY OF EYE
12.69
1.00
66250
FOLLOW-UP SURGERY OF EYE
12.75
1.00
66500
INCISION OF IRIS
6.00
1.00
66500
INCISION OF IRIS
8.12
1.00
66500
INCISION OF IRIS
8.51
1.00
66500
INCISION OF IRIS
8.98
1.00
66505
INCISION OF IRIS
6.00
1.00
66505
INCISION OF IRIS
8.89
1.00
66505
INCISION OF IRIS
9.05
1.00
66505
INCISION OF IRIS
9.66
1.00
66600
REMOVE IRIS AND LESION
4.00
1.00
66600
REMOVE IRIS AND LESION
17.64
1.00
66600
REMOVE IRIS AND LESION
17.99
1.00
66600
REMOVE IRIS AND LESION
18.81
1.00
66605
REMOVAL OF IRIS
4.00
1.00
66605
REMOVAL OF IRIS
24.50
1.00
66605
REMOVAL OF IRIS
24.77
1.00
66605
REMOVAL OF IRIS
25.54
1.00
66625
REMOVAL OF IRIS
6.00
1.00
66625
REMOVAL OF IRIS
9.90
1.00
66625
REMOVAL OF IRIS
11.66
1.00
66625
REMOVAL OF IRIS
11.92
1.00
66630
REMOVAL OF IRIS
6.00
1.00
66630
REMOVAL OF IRIS
13.01
1.00
66630
REMOVAL OF IRIS
13.86
1.00
66630
REMOVAL OF IRIS
13.90
1.00
66635
REMOVAL OF IRIS
6.00
1.00
Procedure Code Description
RVU
RVU Coeff Value
66635
REMOVAL OF IRIS
12.95
1.00
66635
REMOVAL OF IRIS
13.14
1.00
66635
REMOVAL OF IRIS
13.17
1.00
66680
REPAIR IRIS & CILIARY BODY
4.00
1.00
66680
REPAIR IRIS & CILIARY BODY
11.71
1.00
66680
REPAIR IRIS & CILIARY BODY
11.72
1.00
66680
REPAIR IRIS & CILIARY BODY
11.76
1.00
66700
DESTRUCTION, CILIARY BODY
9.05
1.00
66700
DESTRUCTION, CILIARY BODY
9.10
1.00
66700
DESTRUCTION, CILIARY BODY
9.24
1.00
66700
DESTRUCTION, CILIARY BODY
999.99
1.00
66710
CILIARY TRANSSLERAL THERAPY
8.77
1.00
66710
CILIARY TRANSSLERAL THERAPY
8.84
1.00
66710
CILIARY TRANSSLERAL THERAPY
9.07
1.00
66710
CILIARY TRANSSLERAL THERAPY
999.99
1.00
66711
CILIARY ENDOSCOPIC ABLATION
14.52
1.00
66720
DESTRUCTION, CILIARY BODY
9.46
1.00
66720
DESTRUCTION, CILIARY BODY
9.60
1.00
66720
DESTRUCTION, CILIARY BODY
9.61
1.00
66720
DESTRUCTION, CILIARY BODY
999.99
1.00
66740
DESTRUCTION, CILIARY BODY
9.11
1.00
66740
DESTRUCTION, CILIARY BODY
9.20
1.00
66740
DESTRUCTION, CILIARY BODY
9.80
1.00
66740
DESTRUCTION, CILIARY BODY
999.99
1.00
66761
REVISION OF IRIS
6.00
1.00
66761
REVISION OF IRIS
8.21
1.00
66761
REVISION OF IRIS
8.48
1.00
66761
REVISION OF IRIS
9.40
1.00
66762
REVISION OF IRIS
6.00
1.00
66762
REVISION OF IRIS
8.73
1.00
66762
REVISION OF IRIS
9.01
1.00
66762
REVISION OF IRIS
9.72
1.00
66770
REMOVAL OF INNER EYE LESION
6.00
1.00
66770
REMOVAL OF INNER EYE LESION
9.86
1.00
66770
REMOVAL OF INNER EYE LESION
10.14
1.00
Procedure Code Description 66770
REMOVAL OF INNER EYE LESION
66820
RVU
RVU Coeff Value
11.02
1.00
INCISION, SECONDARY CATARACT
4.00
1.00
66820
INCISION, SECONDARY CATARACT
9.12
1.00
66820
INCISION, SECONDARY CATARACT
11.17
1.00
66820
INCISION, SECONDARY CATARACT
12.24
1.00
66821
AFTER CATARACT LASER SURGERY
5.00
1.00
66821
AFTER CATARACT LASER SURGERY
5.79
1.00
66821
AFTER CATARACT LASER SURGERY
6.35
1.00
66821
AFTER CATARACT LASER SURGERY
6.97
1.00
66825
REPOSITION INTRAOCULAR LENS
6.00
1.00
66825
REPOSITION INTRAOCULAR LENS
17.51
1.00
66825
REPOSITION INTRAOCULAR LENS
18.69
1.00
66825
REPOSITION INTRAOCULAR LENS
18.74
1.00
66830
REMOVAL OF LENS LESION
8.00
1.00
66830
REMOVAL OF LENS LESION
15.35
1.00
66830
REMOVAL OF LENS LESION
15.66
1.00
66830
REMOVAL OF LENS LESION
16.37
1.00
66840
REMOVAL OF LENS MATERIAL
14.96
1.00
66840
REMOVAL OF LENS MATERIAL
15.00
1.00
66840
REMOVAL OF LENS MATERIAL
15.26
1.00
66840
REMOVAL OF LENS MATERIAL
15.97
1.00
66850
REMOVAL OF LENS MATERIAL
4.00
1.00
66850
REMOVAL OF LENS MATERIAL
16.73
1.00
66850
REMOVAL OF LENS MATERIAL
17.28
1.00
66850
REMOVAL OF LENS MATERIAL
18.23
1.00
66852
REMOVAL OF LENS MATERIAL
18.08
1.00
66852
REMOVAL OF LENS MATERIAL
18.63
1.00
66852
REMOVAL OF LENS MATERIAL
19.51
1.00
66852
REMOVAL OF LENS MATERIAL
999.99
1.00
66920
EXTRACTION OF LENS
8.00
1.00
66920
EXTRACTION OF LENS
16.40
1.00
66920
EXTRACTION OF LENS
16.70
1.00
66920
EXTRACTION OF LENS
17.41
1.00
66930
EXTRACTION OF LENS
8.00
1.00
66930
EXTRACTION OF LENS
19.22
1.00
Procedure Code Description
RVU
RVU Coeff Value
66930
EXTRACTION OF LENS
19.27
1.00
66930
EXTRACTION OF LENS
19.78
1.00
66940
EXTRACTION OF LENS
8.00
1.00
66940
EXTRACTION OF LENS
17.35
1.00
66940
EXTRACTION OF LENS
17.40
1.00
66940
EXTRACTION OF LENS
17.96
1.00
66982
CATARACT SURGERY, COMPLEX
6.00
1.00
66982
CATARACT SURGERY, COMPLEX
23.15
1.00
66982
CATARACT SURGERY, COMPLEX
24.08
1.00
66982
CATARACT SURGERY, COMPLEX
24.72
1.00
66983
CATARACT SURG W/IOL, 1 STAGE
8.00
1.00
66983
CATARACT SURG W/IOL, 1 STAGE
15.24
1.00
66983
CATARACT SURG W/IOL, 1 STAGE
15.63
1.00
66983
CATARACT SURG W/IOL, 1 STAGE
16.95
1.00
66984
CATARACT SURG W/IOL, 1 STAGE
8.00
1.00
66984
CATARACT SURG W/IOL, 1 STAGE
17.71
1.00
66984
CATARACT SURG W/IOL, 1 STAGE
18.23
1.00
66984
CATARACT SURG W/IOL, 1 STAGE
18.33
1.00
66985
INSERT LENS PROSTHESIS
8.00
1.00
66985
INSERT LENS PROSTHESIS
15.54
1.00
66985
INSERT LENS PROSTHESIS
16.25
1.00
66985
INSERT LENS PROSTHESIS
17.52
1.00
66986
EXCHANGE LENS PROSTHESIS
21.34
1.00
66986
EXCHANGE LENS PROSTHESIS
21.49
1.00
66986
EXCHANGE LENS PROSTHESIS
22.07
1.00
66986
EXCHANGE LENS PROSTHESIS
999.99
1.00
66990
OPHTHALMIC ENDOSCOPE ADD-ON
2.20
1.00
66990
OPHTHALMIC ENDOSCOPE ADD-ON
2.27
1.00
67005
PARTIAL REMOVAL OF EYE FLUID
4.00
1.00
67005
PARTIAL REMOVAL OF EYE FLUID
8.57
1.00
67005
PARTIAL REMOVAL OF EYE FLUID
10.34
1.00
67005
PARTIAL REMOVAL OF EYE FLUID
10.83
1.00
67010
PARTIAL REMOVAL OF EYE FLUID
6.00
1.00
67010
PARTIAL REMOVAL OF EYE FLUID
10.34
1.00
67010
PARTIAL REMOVAL OF EYE FLUID
12.12
1.00
Procedure Code Description 67010
PARTIAL REMOVAL OF EYE FLUID
67015
RVU
RVU Coeff Value
12.54
1.00
RELEASE OF EYE FLUID
6.00
1.00
67015
RELEASE OF EYE FLUID
13.38
1.00
67015
RELEASE OF EYE FLUID
14.97
1.00
67015
RELEASE OF EYE FLUID
15.31
1.00
67025
REPLACE EYE FLUID
4.00
1.00
67025
REPLACE EYE FLUID
14.42
1.00
67025
REPLACE EYE FLUID
14.62
1.00
67025
REPLACE EYE FLUID
14.67
1.00
67027
IMPLANT EYE DRUG SYSTEM
6.00
1.00
67027
IMPLANT EYE DRUG SYSTEM
19.77
1.00
67027
IMPLANT EYE DRUG SYSTEM
20.02
1.00
67027
IMPLANT EYE DRUG SYSTEM
20.17
1.00
67028
INJECTION EYE DRUG
3.78
1.00
67028
INJECTION EYE DRUG
3.79
1.00
67028
INJECTION EYE DRUG
4.00
1.00
67028
INJECTION EYE DRUG
999.99
1.00
67030
INCISE INNER EYE STRANDS
4.00
1.00
67030
INCISE INNER EYE STRANDS
11.75
1.00
67030
INCISE INNER EYE STRANDS
11.87
1.00
67030
INCISE INNER EYE STRANDS
11.94
1.00
67031
LASER SURGERY, EYE STRANDS
5.00
1.00
67031
LASER SURGERY, EYE STRANDS
6.95
1.00
67031
LASER SURGERY, EYE STRANDS
7.93
1.00
67031
LASER SURGERY, EYE STRANDS
8.10
1.00
67036
REMOVAL OF INNER EYE FLUID
6.00
1.00
67036
REMOVAL OF INNER EYE FLUID
21.35
1.00
67036
REMOVAL OF INNER EYE FLUID
21.79
1.00
67036
REMOVAL OF INNER EYE FLUID
22.32
1.00
67038
STRIP RETINAL MEMBRANE
6.00
1.00
67038
STRIP RETINAL MEMBRANE
37.53
1.00
67038
STRIP RETINAL MEMBRANE
38.05
1.00
67038
STRIP RETINAL MEMBRANE
39.50
1.00
67039
LASER TREATMENT OF RETINA
6.00
1.00
67039
LASER TREATMENT OF RETINA
27.42
1.00
Procedure Code Description
RVU
RVU Coeff Value
67039
LASER TREATMENT OF RETINA
27.73
1.00
67039
LASER TREATMENT OF RETINA
28.58
1.00
67040
LASER TREATMENT OF RETINA
8.00
1.00
67040
LASER TREATMENT OF RETINA
31.50
1.00
67040
LASER TREATMENT OF RETINA
32.04
1.00
67040
LASER TREATMENT OF RETINA
32.98
1.00
67041
VIT FOR MACULAR PUCKER
30.85
1.00
67042
VIT FOR MACULAR HOLE
35.34
1.00
67043
VIT FOR MEMBRANE DISSECT
37.08
1.00
67101
REPAIR DETACHED RETINA
5.00
1.00
67101
REPAIR DETACHED RETINA
15.43
1.00
67101
REPAIR DETACHED RETINA
15.98
1.00
67101
REPAIR DETACHED RETINA
16.69
1.00
67105
REPAIR DETACHED RETINA
5.00
1.00
67105
REPAIR DETACHED RETINA
13.24
1.00
67105
REPAIR DETACHED RETINA
13.98
1.00
67105
REPAIR DETACHED RETINA
14.80
1.00
67107
REPAIR DETACHED RETINA
6.00
1.00
67107
REPAIR DETACHED RETINA
28.07
1.00
67107
REPAIR DETACHED RETINA
28.34
1.00
67107
REPAIR DETACHED RETINA
28.60
1.00
67108
REPAIR DETACHED RETINA
8.00
1.00
67108
REPAIR DETACHED RETINA
37.38
1.00
67108
REPAIR DETACHED RETINA
38.80
1.00
67108
REPAIR DETACHED RETINA
39.33
1.00
67110
REPAIR DETACHED RETINA
17.77
1.00
67110
REPAIR DETACHED RETINA
18.45
1.00
67110
REPAIR DETACHED RETINA
19.45
1.00
67110
REPAIR DETACHED RETINA
999.99
1.00
67112
REREPAIR DETACHED RETINA
6.00
1.00
67112
REREPAIR DETACHED RETINA
30.84
1.00
67112
REREPAIR DETACHED RETINA
32.22
1.00
67112
REREPAIR DETACHED RETINA
33.21
1.00
67113
REPAIR RETINAL DETACH, CPLX
40.60
1.00
67115
RELEASE ENCIRCLING MATERIAL
5.00
1.00
Procedure Code Description
RVU
RVU Coeff Value
67115
RELEASE ENCIRCLING MATERIAL
11.29
1.00
67115
RELEASE ENCIRCLING MATERIAL
11.99
1.00
67115
RELEASE ENCIRCLING MATERIAL
12.30
1.00
67120
REMOVE EYE IMPLANT MATERIAL
6.00
1.00
67120
REMOVE EYE IMPLANT MATERIAL
12.72
1.00
67120
REMOVE EYE IMPLANT MATERIAL
13.18
1.00
67120
REMOVE EYE IMPLANT MATERIAL
13.33
1.00
67121
REMOVE EYE IMPLANT MATERIAL
5.00
1.00
67121
REMOVE EYE IMPLANT MATERIAL
20.92
1.00
67121
REMOVE EYE IMPLANT MATERIAL
22.33
1.00
67121
REMOVE EYE IMPLANT MATERIAL
23.19
1.00
67141
TREATMENT OF RETINA
5.00
1.00
67141
TREATMENT OF RETINA
11.10
1.00
67141
TREATMENT OF RETINA
11.92
1.00
67141
TREATMENT OF RETINA
12.35
1.00
67145
TREATMENT OF RETINA
5.00
1.00
67145
TREATMENT OF RETINA
9.74
1.00
67145
TREATMENT OF RETINA
10.55
1.00
67145
TREATMENT OF RETINA
11.35
1.00
67208
TREATMENT OF RETINAL LESION
5.00
1.00
67208
TREATMENT OF RETINAL LESION
12.38
1.00
67208
TREATMENT OF RETINAL LESION
13.29
1.00
67208
TREATMENT OF RETINAL LESION
14.09
1.00
67210
TREATMENT OF RETINAL LESION
5.00
1.00
67210
TREATMENT OF RETINAL LESION
14.91
1.00
67210
TREATMENT OF RETINAL LESION
15.02
1.00
67210
TREATMENT OF RETINAL LESION
15.57
1.00
67218
TREATMENT OF RETINAL LESION
5.00
1.00
67218
TREATMENT OF RETINAL LESION
32.66
1.00
67218
TREATMENT OF RETINAL LESION
33.27
1.00
67218
TREATMENT OF RETINAL LESION
34.85
1.00
67220
TREATMENT OF CHOROID LESION
5.00
1.00
67220
TREATMENT OF CHOROID LESION
22.56
1.00
67220
TREATMENT OF CHOROID LESION
23.26
1.00
67220
TREATMENT OF CHOROID LESION
23.57
1.00
Procedure Code Description
RVU
RVU Coeff Value
67221
OCULAR PHOTODYNAMIC THER
5.00
1.00
67221
OCULAR PHOTODYNAMIC THER
5.23
1.00
67221
OCULAR PHOTODYNAMIC THER
6.00
1.00
67221
OCULAR PHOTODYNAMIC THER
6.05
1.00
67225
EYE PHOTODYNAMIC THER ADD-ON
0.68
1.00
67225
EYE PHOTODYNAMIC THER ADD-ON
0.69
1.00
67225
EYE PHOTODYNAMIC THER ADD-ON
0.70
1.00
67227
TREATMENT OF RETINAL LESION
5.00
1.00
67227
TREATMENT OF RETINAL LESION
12.27
1.00
67227
TREATMENT OF RETINAL LESION
13.13
1.00
67227
TREATMENT OF RETINAL LESION
13.99
1.00
67228
TREATMENT OF RETINAL LESION
5.00
1.00
67228
TREATMENT OF RETINAL LESION
20.45
1.00
67228
TREATMENT OF RETINAL LESION
21.74
1.00
67228
TREATMENT OF RETINAL LESION
24.40
1.00
67229
TR RETINAL LES PRETERM INF
26.71
1.00
67250
REINFORCE EYE WALL
5.00
1.00
67250
REINFORCE EYE WALL
18.19
1.00
67250
REINFORCE EYE WALL
19.45
1.00
67250
REINFORCE EYE WALL
20.69
1.00
67255
REINFORCE/GRAFT EYE WALL
5.00
1.00
67255
REINFORCE/GRAFT EYE WALL
19.43
1.00
67255
REINFORCE/GRAFT EYE WALL
20.26
1.00
67255
REINFORCE/GRAFT EYE WALL
21.09
1.00
67311
REVISE EYE MUSCLE
4.00
1.00
67311
REVISE EYE MUSCLE
13.07
1.00
67311
REVISE EYE MUSCLE
13.39
1.00
67311
REVISE EYE MUSCLE
13.78
1.00
67312
REVISE TWO EYE MUSCLES
4.00
1.00
67312
REVISE TWO EYE MUSCLES
16.09
1.00
67312
REVISE TWO EYE MUSCLES
16.47
1.00
67312
REVISE TWO EYE MUSCLES
16.50
1.00
67314
REVISE EYE MUSCLE
5.00
1.00
67314
REVISE EYE MUSCLE
14.54
1.00
67314
REVISE EYE MUSCLE
15.13
1.00
Procedure Code Description
RVU
RVU Coeff Value
67314
REVISE EYE MUSCLE
15.44
1.00
67316
REVISE TWO EYE MUSCLES
17.76
1.00
67316
REVISE TWO EYE MUSCLES
18.35
1.00
67316
REVISE TWO EYE MUSCLES
18.49
1.00
67316
REVISE TWO EYE MUSCLES
999.99
1.00
67318
REVISE EYE MUSCLE(S)
15.27
1.00
67318
REVISE EYE MUSCLE(S)
15.85
1.00
67318
REVISE EYE MUSCLE(S)
16.16
1.00
67318
REVISE EYE MUSCLE(S)
999.99
1.00
67320
REVISE EYE MUSCLE(S) ADD-ON
6.49
1.00
67320
REVISE EYE MUSCLE(S) ADD-ON
6.51
1.00
67320
REVISE EYE MUSCLE(S) ADD-ON
7.70
1.00
67331
EYE SURGERY FOLLOW-UP ADD-ON
6.17
1.00
67331
EYE SURGERY FOLLOW-UP ADD-ON
7.29
1.00
67332
REREVISE EYE MUSCLES ADD-ON
6.73
1.00
67332
REREVISE EYE MUSCLES ADD-ON
6.75
1.00
67332
REREVISE EYE MUSCLES ADD-ON
7.93
1.00
67334
REVISE EYE MUSCLE W/SUTURE
5.97
1.00
67334
REVISE EYE MUSCLE W/SUTURE
5.98
1.00
67334
REVISE EYE MUSCLE W/SUTURE
7.19
1.00
67335
EYE SUTURE DURING SURGERY
3.63
1.00
67335
EYE SUTURE DURING SURGERY
3.73
1.00
67335
EYE SUTURE DURING SURGERY
3.74
1.00
67340
REVISE EYE MUSCLE ADD-ON
7.38
1.00
67340
REVISE EYE MUSCLE ADD-ON
7.40
1.00
67340
REVISE EYE MUSCLE ADD-ON
8.57
1.00
67343
RELEASE EYE TISSUE
14.65
1.00
67343
RELEASE EYE TISSUE
15.00
1.00
67343
RELEASE EYE TISSUE
15.04
1.00
67343
RELEASE EYE TISSUE
999.99
1.00
67345
DESTROY NERVE OF EYE MUSCLE
4.43
1.00
67345
DESTROY NERVE OF EYE MUSCLE
4.49
1.00
67345
DESTROY NERVE OF EYE MUSCLE
4.99
1.00
67346
BIOPSY, EYE MUSCLE
4.78
1.00
67350
BIOPSY EYE MUSCLE
4.90
1.00
Procedure Code Description
RVU
RVU Coeff Value
67350
BIOPSY EYE MUSCLE
4.93
1.00
67350
BIOPSY EYE MUSCLE
5.00
1.00
67400
EXPLORE/BIOPSY EYE SOCKET
6.00
1.00
67400
EXPLORE/BIOPSY EYE SOCKET
21.64
1.00
67400
EXPLORE/BIOPSY EYE SOCKET
22.78
1.00
67400
EXPLORE/BIOPSY EYE SOCKET
23.58
1.00
67405
EXPLORE/DRAIN EYE SOCKET
6.00
1.00
67405
EXPLORE/DRAIN EYE SOCKET
18.41
1.00
67405
EXPLORE/DRAIN EYE SOCKET
19.44
1.00
67405
EXPLORE/DRAIN EYE SOCKET
20.59
1.00
67412
EXPLORE/TREAT EYE SOCKET
6.00
1.00
67412
EXPLORE/TREAT EYE SOCKET
20.02
1.00
67412
EXPLORE/TREAT EYE SOCKET
22.97
1.00
67412
EXPLORE/TREAT EYE SOCKET
25.36
1.00
67413
EXPLORE/TREAT EYE SOCKET
6.00
1.00
67413
EXPLORE/TREAT EYE SOCKET
20.04
1.00
67413
EXPLORE/TREAT EYE SOCKET
22.65
1.00
67413
EXPLORE/TREAT EYE SOCKET
23.78
1.00
67414
EXPLR/DECOMPRESS EYE SOCKET
25.70
1.00
67414
EXPLR/DECOMPRESS EYE SOCKET
27.98
1.00
67414
EXPLR/DECOMPRESS EYE SOCKET
30.62
1.00
67414
EXPLR/DECOMPRESS EYE SOCKET
999.99
1.00
67415
ASPIRATION, ORBITAL CONTENTS
2.54
1.00
67415
ASPIRATION, ORBITAL CONTENTS
2.64
1.00
67415
ASPIRATION, ORBITAL CONTENTS
6.00
1.00
67420
EXPLORE/TREAT EYE SOCKET
4.00
1.00
67420
EXPLORE/TREAT EYE SOCKET
38.29
1.00
67420
EXPLORE/TREAT EYE SOCKET
39.81
1.00
67420
EXPLORE/TREAT EYE SOCKET
41.00
1.00
67430
EXPLORE/TREAT EYE SOCKET
4.00
1.00
67430
EXPLORE/TREAT EYE SOCKET
29.12
1.00
67430
EXPLORE/TREAT EYE SOCKET
30.37
1.00
67430
EXPLORE/TREAT EYE SOCKET
31.48
1.00
67440
EXPLORE/DRAIN EYE SOCKET
6.00
1.00
67440
EXPLORE/DRAIN EYE SOCKET
28.03
1.00
Procedure Code Description
RVU
RVU Coeff Value
67440
EXPLORE/DRAIN EYE SOCKET
29.24
1.00
67440
EXPLORE/DRAIN EYE SOCKET
30.20
1.00
67445
EXPLR/DECOMPRESS EYE SOCKET
30.86
1.00
67445
EXPLR/DECOMPRESS EYE SOCKET
32.70
1.00
67445
EXPLR/DECOMPRESS EYE SOCKET
32.93
1.00
67445
EXPLR/DECOMPRESS EYE SOCKET
999.99
1.00
67450
EXPLORE/BIOPSY EYE SOCKET
4.00
1.00
67450
EXPLORE/BIOPSY EYE SOCKET
29.07
1.00
67450
EXPLORE/BIOPSY EYE SOCKET
29.99
1.00
67450
EXPLORE/BIOPSY EYE SOCKET
30.75
1.00
67500
INJECT/TREAT EYE SOCKET
1.02
1.00
67500
INJECT/TREAT EYE SOCKET
1.03
1.00
67500
INJECT/TREAT EYE SOCKET
1.92
1.00
67500
INJECT/TREAT EYE SOCKET
4.00
1.00
67505
INJECT/TREAT EYE SOCKET
1.07
1.00
67505
INJECT/TREAT EYE SOCKET
1.08
1.00
67505
INJECT/TREAT EYE SOCKET
1.86
1.00
67515
INJECT/TREAT EYE SOCKET
0.91
1.00
67515
INJECT/TREAT EYE SOCKET
2.02
1.00
67515
INJECT/TREAT EYE SOCKET
4.00
1.00
67550
INSERT EYE SOCKET IMPLANT
22.60
1.00
67550
INSERT EYE SOCKET IMPLANT
23.05
1.00
67550
INSERT EYE SOCKET IMPLANT
23.88
1.00
67560
REVISE EYE SOCKET IMPLANT
5.00
1.00
67560
REVISE EYE SOCKET IMPLANT
22.96
1.00
67560
REVISE EYE SOCKET IMPLANT
23.48
1.00
67560
REVISE EYE SOCKET IMPLANT
24.12
1.00
67570
DECOMPRESS OPTIC NERVE
26.97
1.00
67570
DECOMPRESS OPTIC NERVE
29.72
1.00
67570
DECOMPRESS OPTIC NERVE
31.40
1.00
67570
DECOMPRESS OPTIC NERVE
999.99
1.00
67700
DRAINAGE OF EYELID ABSCESS
1.99
1.00
67700
DRAINAGE OF EYELID ABSCESS
2.04
1.00
67700
DRAINAGE OF EYELID ABSCESS
2.66
1.00
67710
INCISION OF EYELID
1.54
1.00
Procedure Code Description
RVU
RVU Coeff Value
67710
INCISION OF EYELID
1.60
1.00
67710
INCISION OF EYELID
2.22
1.00
67710
INCISION OF EYELID
4.00
1.00
67715
INCISION OF EYELID FOLD
1.84
1.00
67715
INCISION OF EYELID FOLD
1.90
1.00
67715
INCISION OF EYELID FOLD
2.51
1.00
67715
INCISION OF EYELID FOLD
4.00
1.00
67800
REMOVE EYELID LESION
2.08
1.00
67800
REMOVE EYELID LESION
2.14
1.00
67800
REMOVE EYELID LESION
2.43
1.00
67800
REMOVE EYELID LESION
4.00
1.00
67801
REMOVE EYELID LESIONS
2.84
1.00
67801
REMOVE EYELID LESIONS
2.90
1.00
67801
REMOVE EYELID LESIONS
3.15
1.00
67801
REMOVE EYELID LESIONS
4.00
1.00
67805
REMOVE EYELID LESIONS
3.34
1.00
67805
REMOVE EYELID LESIONS
3.41
1.00
67805
REMOVE EYELID LESIONS
3.87
1.00
67805
REMOVE EYELID LESIONS
5.00
1.00
67808
REMOVE EYELID LESION(S)
4.00
1.00
67808
REMOVE EYELID LESION(S)
8.13
1.00
67808
REMOVE EYELID LESION(S)
8.39
1.00
67808
REMOVE EYELID LESION(S)
9.23
1.00
67810
BIOPSY OF EYELID
2.23
1.00
67810
BIOPSY OF EYELID
2.24
1.00
67810
BIOPSY OF EYELID
2.26
1.00
67810
BIOPSY OF EYELID
5.00
1.00
67820
REVISE EYELASHES
1.28
1.00
67820
REVISE EYELASHES
1.31
1.00
67820
REVISE EYELASHES
4.00
1.00
67825
REVISE EYELASHES
2.47
1.00
67825
REVISE EYELASHES
2.53
1.00
67825
REVISE EYELASHES
2.80
1.00
67825
REVISE EYELASHES
3.00
1.00
67830
REVISE EYELASHES
3.20
1.00
Procedure Code Description
RVU
RVU Coeff Value
67830
REVISE EYELASHES
3.73
1.00
67830
REVISE EYELASHES
3.88
1.00
67830
REVISE EYELASHES
5.00
1.00
67835
REVISE EYELASHES
5.00
1.00
67835
REVISE EYELASHES
10.22
1.00
67835
REVISE EYELASHES
10.43
1.00
67835
REVISE EYELASHES
10.82
1.00
67840
REMOVE EYELID LESION
3.08
1.00
67840
REMOVE EYELID LESION
3.14
1.00
67840
REMOVE EYELID LESION
3.71
1.00
67840
REMOVE EYELID LESION
6.00
1.00
67850
TREAT EYELID LESION
3.32
1.00
67850
TREAT EYELID LESION
3.66
1.00
67850
TREAT EYELID LESION
3.82
1.00
67850
TREAT EYELID LESION
5.00
1.00
67875
CLOSURE OF EYELID BY SUTURE
2.04
1.00
67875
CLOSURE OF EYELID BY SUTURE
2.31
1.00
67875
CLOSURE OF EYELID BY SUTURE
3.49
1.00
67875
CLOSURE OF EYELID BY SUTURE
999.99
1.00
67880
REVISION OF EYELID
4.00
1.00
67880
REVISION OF EYELID
7.09
1.00
67880
REVISION OF EYELID
8.27
1.00
67880
REVISION OF EYELID
8.39
1.00
67882
REVISION OF EYELID
4.00
1.00
67882
REVISION OF EYELID
9.90
1.00
67882
REVISION OF EYELID
10.81
1.00
67900
REPAIR BROW DEFECT
11.98
1.00
67900
REPAIR BROW DEFECT
12.81
1.00
67900
REPAIR BROW DEFECT
12.90
1.00
67900
REPAIR BROW DEFECT
999.99
1.00
67901
REPAIR EYELID DEFECT
4.00
1.00
67901
REPAIR EYELID DEFECT
13.48
1.00
67901
REPAIR EYELID DEFECT
13.76
1.00
67901
REPAIR EYELID DEFECT
14.09
1.00
67902
REPAIR EYELID DEFECT
4.00
1.00
Procedure Code Description
RVU
RVU Coeff Value
67902
REPAIR EYELID DEFECT
13.90
1.00
67902
REPAIR EYELID DEFECT
14.25
1.00
67902
REPAIR EYELID DEFECT
16.66
1.00
67903
REPAIR EYELID DEFECT
4.00
1.00
67903
REPAIR EYELID DEFECT
11.65
1.00
67903
REPAIR EYELID DEFECT
13.53
1.00
67903
REPAIR EYELID DEFECT
13.94
1.00
67904
REPAIR EYELID DEFECT
5.00
1.00
67904
REPAIR EYELID DEFECT
13.73
1.00
67904
REPAIR EYELID DEFECT
13.76
1.00
67904
REPAIR EYELID DEFECT
14.62
1.00
67906
REPAIR EYELID DEFECT
4.00
1.00
67906
REPAIR EYELID DEFECT
12.06
1.00
67906
REPAIR EYELID DEFECT
13.30
1.00
67906
REPAIR EYELID DEFECT
13.58
1.00
67908
REPAIR EYELID DEFECT
5.00
1.00
67908
REPAIR EYELID DEFECT
10.02
1.00
67908
REPAIR EYELID DEFECT
11.04
1.00
67908
REPAIR EYELID DEFECT
11.43
1.00
67909
REVISE EYELID DEFECT
5.00
1.00
67909
REVISE EYELID DEFECT
10.26
1.00
67909
REVISE EYELID DEFECT
11.78
1.00
67909
REVISE EYELID DEFECT
12.23
1.00
67911
REVISE EYELID DEFECT
5.00
1.00
67911
REVISE EYELID DEFECT
11.58
1.00
67911
REVISE EYELID DEFECT
12.18
1.00
67911
REVISE EYELID DEFECT
12.84
1.00
67912
CORRECTION EYELID W/IMPLANT
11.22
1.00
67912
CORRECTION EYELID W/IMPLANT
11.56
1.00
67914
REPAIR EYELID DEFECT
4.00
1.00
67914
REPAIR EYELID DEFECT
6.75
1.00
67914
REPAIR EYELID DEFECT
7.40
1.00
67914
REPAIR EYELID DEFECT
7.81
1.00
67915
REPAIR EYELID DEFECT
4.00
1.00
67915
REPAIR EYELID DEFECT
4.79
1.00
Procedure Code Description
RVU
RVU Coeff Value
67915
REPAIR EYELID DEFECT
5.92
1.00
67915
REPAIR EYELID DEFECT
5.96
1.00
67916
REPAIR EYELID DEFECT
4.00
1.00
67916
REPAIR EYELID DEFECT
10.07
1.00
67916
REPAIR EYELID DEFECT
10.86
1.00
67916
REPAIR EYELID DEFECT
11.26
1.00
67917
REPAIR EYELID DEFECT
4.00
1.00
67917
REPAIR EYELID DEFECT
11.15
1.00
67917
REPAIR EYELID DEFECT
12.46
1.00
67917
REPAIR EYELID DEFECT
12.87
1.00
67921
REPAIR EYELID DEFECT
4.00
1.00
67921
REPAIR EYELID DEFECT
6.31
1.00
67921
REPAIR EYELID DEFECT
6.89
1.00
67921
REPAIR EYELID DEFECT
7.31
1.00
67922
REPAIR EYELID DEFECT
4.00
1.00
67922
REPAIR EYELID DEFECT
5.74
1.00
67922
REPAIR EYELID DEFECT
6.35
1.00
67922
REPAIR EYELID DEFECT
6.71
1.00
67923
REPAIR EYELID DEFECT
4.00
1.00
67923
REPAIR EYELID DEFECT
10.86
1.00
67923
REPAIR EYELID DEFECT
11.54
1.00
67923
REPAIR EYELID DEFECT
12.06
1.00
67924
REPAIR EYELID DEFECT
4.00
1.00
67924
REPAIR EYELID DEFECT
10.50
1.00
67924
REPAIR EYELID DEFECT
11.71
1.00
67924
REPAIR EYELID DEFECT
11.98
1.00
67930
REPAIR EYELID WOUND
4.00
1.00
67930
REPAIR EYELID WOUND
5.79
1.00
67930
REPAIR EYELID WOUND
6.76
1.00
67930
REPAIR EYELID WOUND
6.83
1.00
67935
REPAIR EYELID WOUND
4.00
1.00
67935
REPAIR EYELID WOUND
10.60
1.00
67935
REPAIR EYELID WOUND
11.91
1.00
67935
REPAIR EYELID WOUND
12.51
1.00
67938
REMOVE EYELID FOREIGN BODY
1.90
1.00
Procedure Code Description
RVU
RVU Coeff Value
67938
REMOVE EYELID FOREIGN BODY
1.96
1.00
67938
REMOVE EYELID FOREIGN BODY
2.67
1.00
67938
REMOVE EYELID FOREIGN BODY
4.00
1.00
67950
REVISION OF EYELID
4.00
1.00
67950
REVISION OF EYELID
10.95
1.00
67950
REVISION OF EYELID
12.74
1.00
67950
REVISION OF EYELID
13.39
1.00
67961
REVISION OF EYELID
4.00
1.00
67961
REVISION OF EYELID
10.69
1.00
67961
REVISION OF EYELID
11.69
1.00
67961
REVISION OF EYELID
11.70
1.00
67966
REVISION OF EYELID
5.00
1.00
67966
REVISION OF EYELID
12.62
1.00
67966
REVISION OF EYELID
12.79
1.00
67966
REVISION OF EYELID
15.10
1.00
67971
RECONSTRUCTION OF EYELID
5.00
1.00
67971
RECONSTRUCTION OF EYELID
17.09
1.00
67971
RECONSTRUCTION OF EYELID
17.56
1.00
67971
RECONSTRUCTION OF EYELID
17.74
1.00
67973
RECONSTRUCTION OF EYELID
4.00
1.00
67973
RECONSTRUCTION OF EYELID
22.16
1.00
67973
RECONSTRUCTION OF EYELID
22.80
1.00
67973
RECONSTRUCTION OF EYELID
23.00
1.00
67974
RECONSTRUCTION OF EYELID
4.00
1.00
67974
RECONSTRUCTION OF EYELID
22.07
1.00
67974
RECONSTRUCTION OF EYELID
22.63
1.00
67974
RECONSTRUCTION OF EYELID
22.83
1.00
67975
RECONSTRUCTION OF EYELID
5.00
1.00
67975
RECONSTRUCTION OF EYELID
16.14
1.00
67975
RECONSTRUCTION OF EYELID
16.53
1.00
67975
RECONSTRUCTION OF EYELID
16.71
1.00
68020
INCISE/DRAIN EYELID LINING
2.06
1.00
68020
INCISE/DRAIN EYELID LINING
2.12
1.00
68020
INCISE/DRAIN EYELID LINING
2.57
1.00
68020
INCISE/DRAIN EYELID LINING
4.00
1.00
Procedure Code Description
RVU
RVU Coeff Value
68040
TREATMENT OF EYELID LESIONS
1.26
1.00
68040
TREATMENT OF EYELID LESIONS
1.27
1.00
68040
TREATMENT OF EYELID LESIONS
1.28
1.00
68040
TREATMENT OF EYELID LESIONS
4.00
1.00
68100
BIOPSY OF EYELID LINING
2.03
1.00
68100
BIOPSY OF EYELID LINING
2.33
1.00
68100
BIOPSY OF EYELID LINING
4.00
1.00
68110
REMOVE EYELID LINING LESION
3.19
1.00
68110
REMOVE EYELID LINING LESION
3.25
1.00
68110
REMOVE EYELID LINING LESION
3.44
1.00
68110
REMOVE EYELID LINING LESION
4.00
1.00
68115
REMOVE EYELID LINING LESION
3.55
1.00
68115
REMOVE EYELID LINING LESION
3.61
1.00
68115
REMOVE EYELID LINING LESION
4.00
1.00
68115
REMOVE EYELID LINING LESION
4.29
1.00
68130
REMOVE EYELID LINING LESION
4.00
1.00
68130
REMOVE EYELID LINING LESION
7.42
1.00
68130
REMOVE EYELID LINING LESION
9.43
1.00
68130
REMOVE EYELID LINING LESION
9.52
1.00
68135
REMOVE EYELID LINING LESION
2.77
1.00
68135
REMOVE EYELID LINING LESION
2.82
1.00
68135
REMOVE EYELID LINING LESION
3.51
1.00
68135
REMOVE EYELID LINING LESION
5.00
1.00
68200
TREAT EYELID BY INJECTION
0.74
1.00
68200
TREAT EYELID BY INJECTION
0.82
1.00
68200
TREAT EYELID BY INJECTION
4.00
1.00
68320
REVISE/GRAFT EYELID LINING
4.00
1.00
68320
REVISE/GRAFT EYELID LINING
10.72
1.00
68320
REVISE/GRAFT EYELID LINING
11.02
1.00
68320
REVISE/GRAFT EYELID LINING
12.22
1.00
68325
REVISE/GRAFT EYELID LINING
4.00
1.00
68325
REVISE/GRAFT EYELID LINING
13.82
1.00
68325
REVISE/GRAFT EYELID LINING
14.10
1.00
68325
REVISE/GRAFT EYELID LINING
15.23
1.00
68326
REVISE/GRAFT EYELID LINING
4.00
1.00
Procedure Code Description
RVU
RVU Coeff Value
68326
REVISE/GRAFT EYELID LINING
13.48
1.00
68326
REVISE/GRAFT EYELID LINING
13.78
1.00
68326
REVISE/GRAFT EYELID LINING
14.80
1.00
68328
REVISE/GRAFT EYELID LINING
4.00
1.00
68328
REVISE/GRAFT EYELID LINING
15.37
1.00
68328
REVISE/GRAFT EYELID LINING
15.68
1.00
68328
REVISE/GRAFT EYELID LINING
16.58
1.00
68330
REVISE EYELID LINING
4.00
1.00
68330
REVISE EYELID LINING
10.51
1.00
68330
REVISE EYELID LINING
10.55
1.00
68330
REVISE EYELID LINING
11.10
1.00
68335
REVISE/GRAFT EYELID LINING
4.00
1.00
68335
REVISE/GRAFT EYELID LINING
12.96
1.00
68335
REVISE/GRAFT EYELID LINING
14.32
1.00
68335
REVISE/GRAFT EYELID LINING
14.85
1.00
68340
SEPARATE EYELID ADHESIONS
4.00
1.00
68340
SEPARATE EYELID ADHESIONS
8.51
1.00
68340
SEPARATE EYELID ADHESIONS
9.08
1.00
68340
SEPARATE EYELID ADHESIONS
9.14
1.00
68360
REVISE EYELID LINING
6.00
1.00
68360
REVISE EYELID LINING
9.39
1.00
68360
REVISE EYELID LINING
9.77
1.00
68360
REVISE EYELID LINING
10.15
1.00
68362
REVISE EYELID LINING
4.00
1.00
68362
REVISE EYELID LINING
15.05
1.00
68362
REVISE EYELID LINING
15.40
1.00
68362
REVISE EYELID LINING
15.45
1.00
68371
HARVEST EYE TISSUE, ALOGRAFT
9.72
1.00
68371
HARVEST EYE TISSUE, ALOGRAFT
9.75
1.00
68400
INCISE/DRAIN TEAR GLAND
3.18
1.00
68400
INCISE/DRAIN TEAR GLAND
3.81
1.00
68400
INCISE/DRAIN TEAR GLAND
3.89
1.00
68400
INCISE/DRAIN TEAR GLAND
4.00
1.00
68420
INCISE/DRAIN TEAR SAC
4.00
1.00
68420
INCISE/DRAIN TEAR SAC
4.08
1.00
Procedure Code Description
RVU
RVU Coeff Value
68420
INCISE/DRAIN TEAR SAC
4.75
1.00
68420
INCISE/DRAIN TEAR SAC
4.84
1.00
68440
INCISE TEAR DUCT OPENING
1.42
1.00
68440
INCISE TEAR DUCT OPENING
1.48
1.00
68440
INCISE TEAR DUCT OPENING
2.23
1.00
68440
INCISE TEAR DUCT OPENING
4.00
1.00
68500
REMOVAL OF TEAR GLAND
4.00
1.00
68500
REMOVAL OF TEAR GLAND
21.21
1.00
68500
REMOVAL OF TEAR GLAND
21.88
1.00
68500
REMOVAL OF TEAR GLAND
22.43
1.00
68505
PARTIAL REMOVAL, TEAR GLAND
4.00
1.00
68505
PARTIAL REMOVAL, TEAR GLAND
22.20
1.00
68505
PARTIAL REMOVAL, TEAR GLAND
22.57
1.00
68505
PARTIAL REMOVAL, TEAR GLAND
22.78
1.00
68510
BIOPSY OF TEAR GLAND
4.00
1.00
68510
BIOPSY OF TEAR GLAND
6.93
1.00
68510
BIOPSY OF TEAR GLAND
6.95
1.00
68510
BIOPSY OF TEAR GLAND
6.99
1.00
68520
REMOVAL OF TEAR SAC
4.00
1.00
68520
REMOVAL OF TEAR SAC
15.01
1.00
68520
REMOVAL OF TEAR SAC
15.68
1.00
68520
REMOVAL OF TEAR SAC
15.88
1.00
68525
BIOPSY OF TEAR SAC
4.00
1.00
68525
BIOPSY OF TEAR SAC
6.43
1.00
68525
BIOPSY OF TEAR SAC
6.66
1.00
68525
BIOPSY OF TEAR SAC
6.68
1.00
68530
CLEARANCE OF TEAR DUCT
5.00
1.00
68530
CLEARANCE OF TEAR DUCT
6.16
1.00
68530
CLEARANCE OF TEAR DUCT
6.69
1.00
68530
CLEARANCE OF TEAR DUCT
6.82
1.00
68540
REMOVE TEAR GLAND LESION
4.00
1.00
68540
REMOVE TEAR GLAND LESION
20.23
1.00
68540
REMOVE TEAR GLAND LESION
20.91
1.00
68540
REMOVE TEAR GLAND LESION
21.45
1.00
68550
REMOVE TEAR GLAND LESION
5.00
1.00
Procedure Code Description
RVU
RVU Coeff Value
68550
REMOVE TEAR GLAND LESION
25.11
1.00
68550
REMOVE TEAR GLAND LESION
25.79
1.00
68550
REMOVE TEAR GLAND LESION
26.42
1.00
68700
REPAIR TEAR DUCTS
4.00
1.00
68700
REPAIR TEAR DUCTS
13.51
1.00
68700
REPAIR TEAR DUCTS
13.84
1.00
68700
REPAIR TEAR DUCTS
14.21
1.00
68705
REVISE TEAR DUCT OPENING
3.11
1.00
68705
REVISE TEAR DUCT OPENING
3.17
1.00
68705
REVISE TEAR DUCT OPENING
3.86
1.00
68705
REVISE TEAR DUCT OPENING
4.00
1.00
68720
CREATE TEAR SAC DRAIN
5.00
1.00
68720
CREATE TEAR SAC DRAIN
17.12
1.00
68720
CREATE TEAR SAC DRAIN
17.58
1.00
68720
CREATE TEAR SAC DRAIN
17.67
1.00
68745
CREATE TEAR DUCT DRAIN
4.00
1.00
68745
CREATE TEAR DUCT DRAIN
16.67
1.00
68745
CREATE TEAR DUCT DRAIN
17.30
1.00
68745
CREATE TEAR DUCT DRAIN
17.68
1.00
68750
CREATE TEAR DUCT DRAIN
4.00
1.00
68750
CREATE TEAR DUCT DRAIN
17.20
1.00
68750
CREATE TEAR DUCT DRAIN
17.79
1.00
68750
CREATE TEAR DUCT DRAIN
18.14
1.00
68760
CLOSE TEAR DUCT OPENING
2.99
1.00
68760
CLOSE TEAR DUCT OPENING
3.04
1.00
68760
CLOSE TEAR DUCT OPENING
3.38
1.00
68760
CLOSE TEAR DUCT OPENING
4.00
1.00
68761
CLOSE TEAR DUCT OPENING
2.37
1.00
68761
CLOSE TEAR DUCT OPENING
2.41
1.00
68761
CLOSE TEAR DUCT OPENING
2.74
1.00
68761
CLOSE TEAR DUCT OPENING
5.00
1.00
68770
CLOSE TEAR SYSTEM FISTULA
4.00
1.00
68770
CLOSE TEAR SYSTEM FISTULA
13.28
1.00
68770
CLOSE TEAR SYSTEM FISTULA
13.69
1.00
68770
CLOSE TEAR SYSTEM FISTULA
14.13
1.00
Procedure Code Description
RVU
RVU Coeff Value
68801
DILATE TEAR DUCT OPENING
1.54
1.00
68801
DILATE TEAR DUCT OPENING
1.59
1.00
68801
DILATE TEAR DUCT OPENING
2.45
1.00
68801
DILATE TEAR DUCT OPENING
4.00
1.00
68810
PROBE NASOLACRIMAL DUCT
2.86
1.00
68810
PROBE NASOLACRIMAL DUCT
2.92
1.00
68810
PROBE NASOLACRIMAL DUCT
4.39
1.00
68811
PROBE NASOLACRIMAL DUCT
4.00
1.00
68811
PROBE NASOLACRIMAL DUCT
4.77
1.00
68811
PROBE NASOLACRIMAL DUCT
4.83
1.00
68811
PROBE NASOLACRIMAL DUCT
4.84
1.00
68815
PROBE NASOLACRIMAL DUCT
4.00
1.00
68815
PROBE NASOLACRIMAL DUCT
6.01
1.00
68815
PROBE NASOLACRIMAL DUCT
6.05
1.00
68815
PROBE NASOLACRIMAL DUCT
6.17
1.00
68816
PROBE NL DUCT W/BALLOON
5.76
1.00
68840
EXPLORE/IRRIGATE TEAR DUCTS
2.23
1.00
68840
EXPLORE/IRRIGATE TEAR DUCTS
2.27
1.00
68840
EXPLORE/IRRIGATE TEAR DUCTS
2.59
1.00
68840
EXPLORE/IRRIGATE TEAR DUCTS
4.00
1.00
68850
INJECTION FOR TEAR SAC X-RAY
1.14
1.00
68850
INJECTION FOR TEAR SAC X-RAY
1.48
1.00
68850
INJECTION FOR TEAR SAC X-RAY
3.00
1.00
70010
CONTRAST X-RAY OF BRAIN
4.74
1.00
70010
CONTRAST X-RAY OF BRAIN
6.15
1.00
70010
CONTRAST X-RAY OF BRAIN
6.21
1.00
70015
CONTRAST X-RAY OF BRAIN
3.06
1.00
70015
CONTRAST X-RAY OF BRAIN
3.08
1.00
70015
CONTRAST X-RAY OF BRAIN
3.94
1.00
70030
X-RAY EYE FOR FOREIGN BODY
0.67
1.00
70030
X-RAY EYE FOR FOREIGN BODY
0.68
1.00
70030
X-RAY EYE FOR FOREIGN BODY
0.77
1.00
70100
X-RAY EXAM OF JAW
0.79
1.00
70100
X-RAY EXAM OF JAW
0.83
1.00
70110
X-RAY EXAM OF JAW
0.99
1.00
Procedure Code Description
RVU
RVU Coeff Value
70110
X-RAY EXAM OF JAW
1.00
1.00
70110
X-RAY EXAM OF JAW
1.08
1.00
70120
X-RAY EXAM OF MASTOIDS
0.90
1.00
70120
X-RAY EXAM OF MASTOIDS
0.91
1.00
70130
X-RAY EXAM OF MASTOIDS
1.29
1.00
70130
X-RAY EXAM OF MASTOIDS
1.30
1.00
70130
X-RAY EXAM OF MASTOIDS
1.50
1.00
70134
X-RAY EXAM OF MIDDLE EAR
1.25
1.00
70134
X-RAY EXAM OF MIDDLE EAR
1.29
1.00
70140
X-RAY EXAM OF FACIAL BONES
0.82
1.00
70140
X-RAY EXAM OF FACIAL BONES
0.91
1.00
70140
X-RAY EXAM OF FACIAL BONES
0.92
1.00
70150
X-RAY EXAM OF FACIAL BONES
1.17
1.00
70150
X-RAY EXAM OF FACIAL BONES
1.18
1.00
70150
X-RAY EXAM OF FACIAL BONES
1.20
1.00
70160
X-RAY EXAM OF NASAL BONES
0.78
1.00
70160
X-RAY EXAM OF NASAL BONES
0.87
1.00
70170
X-RAY EXAM OF TEAR DUCT
1.41
1.00
70170
X-RAY EXAM OF TEAR DUCT
1.42
1.00
70190
X-RAY EXAM OF EYE SOCKETS
0.94
1.00
70190
X-RAY EXAM OF EYE SOCKETS
0.95
1.00
70190
X-RAY EXAM OF EYE SOCKETS
0.97
1.00
70200
X-RAY EXAM OF EYE SOCKETS
1.21
1.00
70200
X-RAY EXAM OF EYE SOCKETS
1.22
1.00
70210
X-RAY EXAM OF SINUSES
0.82
1.00
70210
X-RAY EXAM OF SINUSES
0.89
1.00
70210
X-RAY EXAM OF SINUSES
0.90
1.00
70220
X-RAY EXAM OF SINUSES
1.07
1.00
70220
X-RAY EXAM OF SINUSES
1.17
1.00
70220
X-RAY EXAM OF SINUSES
1.18
1.00
70240
X-RAY EXAM, PITUITARY SADDLE
0.69
1.00
70240
X-RAY EXAM, PITUITARY SADDLE
0.70
1.00
70240
X-RAY EXAM, PITUITARY SADDLE
0.80
1.00
70250
X-RAY EXAM OF SKULL
0.98
1.00
70250
X-RAY EXAM OF SKULL
0.99
1.00
Procedure Code Description
RVU
RVU Coeff Value
70260
X-RAY EXAM OF SKULL
1.32
1.00
70260
X-RAY EXAM OF SKULL
1.41
1.00
70300
X-RAY EXAM OF TEETH
0.39
1.00
70300
X-RAY EXAM OF TEETH
0.43
1.00
70300
X-RAY EXAM OF TEETH
0.45
1.00
70310
X-RAY EXAM OF TEETH
0.67
1.00
70310
X-RAY EXAM OF TEETH
0.68
1.00
70310
X-RAY EXAM OF TEETH
0.92
1.00
70320
FULL MOUTH X-RAY OF TEETH
1.13
1.00
70320
FULL MOUTH X-RAY OF TEETH
1.15
1.00
70320
FULL MOUTH X-RAY OF TEETH
1.30
1.00
70328
X-RAY EXAM OF JAW JOINT
0.76
1.00
70328
X-RAY EXAM OF JAW JOINT
0.81
1.00
70330
X-RAY EXAM OF JAW JOINTS
1.21
1.00
70330
X-RAY EXAM OF JAW JOINTS
1.23
1.00
70330
X-RAY EXAM OF JAW JOINTS
1.29
1.00
70332
X-RAY EXAM OF JAW JOINT
2.33
1.00
70332
X-RAY EXAM OF JAW JOINT
2.94
1.00
70332
X-RAY EXAM OF JAW JOINT
2.98
1.00
70336
MAGNETIC IMAGE, JAW JOINT
7.00
1.00
70336
MAGNETIC IMAGE, JAW JOINT
13.71
1.00
70336
MAGNETIC IMAGE, JAW JOINT
13.87
1.00
70336
MAGNETIC IMAGE, JAW JOINT
14.14
1.00
70350
X-RAY HEAD FOR ORTHODONTIA
0.56
1.00
70350
X-RAY HEAD FOR ORTHODONTIA
0.64
1.00
70355
PANORAMIC X-RAY OF JAWS
0.63
1.00
70355
PANORAMIC X-RAY OF JAWS
0.88
1.00
70355
PANORAMIC X-RAY OF JAWS
0.90
1.00
70360
X-RAY EXAM OF NECK
0.67
1.00
70360
X-RAY EXAM OF NECK
0.68
1.00
70360
X-RAY EXAM OF NECK
0.74
1.00
70370
THROAT X-RAY & FLUOROSCOPY
1.80
1.00
70370
THROAT X-RAY & FLUOROSCOPY
1.82
1.00
70370
THROAT X-RAY & FLUOROSCOPY
2.03
1.00
70371
SPEECH EVALUATION, COMPLEX
2.69
1.00
Procedure Code Description
RVU
RVU Coeff Value
70371
SPEECH EVALUATION, COMPLEX
3.36
1.00
70371
SPEECH EVALUATION, COMPLEX
3.39
1.00
70373
CONTRAST X-RAY OF LARYNX
2.21
1.00
70373
CONTRAST X-RAY OF LARYNX
2.47
1.00
70373
CONTRAST X-RAY OF LARYNX
2.51
1.00
70380
X-RAY EXAM OF SALIVARY GLAND
0.94
1.00
70380
X-RAY EXAM OF SALIVARY GLAND
0.95
1.00
70380
X-RAY EXAM OF SALIVARY GLAND
1.01
1.00
70390
X-RAY EXAM OF SALIVARY DUCT
2.39
1.00
70390
X-RAY EXAM OF SALIVARY DUCT
2.43
1.00
70390
X-RAY EXAM OF SALIVARY DUCT
2.73
1.00
70450
CT HEAD/BRAIN W/O DYE
6.06
1.00
70450
CT HEAD/BRAIN W/O DYE
6.09
1.00
70450
CT HEAD/BRAIN W/O DYE
6.17
1.00
70450
CT HEAD/BRAIN W/O DYE
7.00
1.00
70460
CT HEAD/BRAIN W/DYE
7.45
1.00
70460
CT HEAD/BRAIN W/DYE
7.53
1.00
70460
CT HEAD/BRAIN W/DYE
7.83
1.00
70470
CT HEAD/BRAIN W/O & W/DYE
7.00
1.00
70470
CT HEAD/BRAIN W/O & W/DYE
9.11
1.00
70470
CT HEAD/BRAIN W/O & W/DYE
9.22
1.00
70470
CT HEAD/BRAIN W/O & W/DYE
9.48
1.00
70480
CT ORBIT/EAR/FOSSA W/O DYE
6.69
1.00
70480
CT ORBIT/EAR/FOSSA W/O DYE
6.76
1.00
70480
CT ORBIT/EAR/FOSSA W/O DYE
9.19
1.00
70481
CT ORBIT/EAR/FOSSA W/DYE
7.79
1.00
70481
CT ORBIT/EAR/FOSSA W/DYE
7.87
1.00
70481
CT ORBIT/EAR/FOSSA W/DYE
10.69
1.00
70482
CT ORBIT/EAR/FOSSA W/O&W/DYE
9.35
1.00
70482
CT ORBIT/EAR/FOSSA W/O&W/DYE
9.46
1.00
70482
CT ORBIT/EAR/FOSSA W/O&W/DYE
12.25
1.00
70486
CT MAXILLOFACIAL W/O DYE
6.49
1.00
70486
CT MAXILLOFACIAL W/O DYE
6.56
1.00
70486
CT MAXILLOFACIAL W/O DYE
7.78
1.00
70487
CT MAXILLOFACIAL W/DYE
7.68
1.00
Procedure Code Description
RVU
RVU Coeff Value
70487
CT MAXILLOFACIAL W/DYE
7.76
1.00
70487
CT MAXILLOFACIAL W/DYE
9.41
1.00
70488
CT MAXILLOFACIAL W/O & W/DYE
9.31
1.00
70488
CT MAXILLOFACIAL W/O & W/DYE
9.42
1.00
70488
CT MAXILLOFACIAL W/O & W/DYE
11.45
1.00
70490
CT SOFT TISSUE NECK W/O DYE
6.68
1.00
70490
CT SOFT TISSUE NECK W/O DYE
6.76
1.00
70490
CT SOFT TISSUE NECK W/O DYE
7.71
1.00
70491
CT SOFT TISSUE NECK W/DYE
7.79
1.00
70491
CT SOFT TISSUE NECK W/DYE
7.87
1.00
70491
CT SOFT TISSUE NECK W/DYE
9.25
1.00
70492
CT SFT TSUE NCK W/O & W/DYE
9.35
1.00
70492
CT SFT TSUE NCK W/O & W/DYE
9.46
1.00
70492
CT SFT TSUE NCK W/O & W/DYE
11.23
1.00
70496
CT ANGIOGRAPHY, HEAD
7.00
1.00
70496
CT ANGIOGRAPHY, HEAD
13.46
1.00
70496
CT ANGIOGRAPHY, HEAD
13.65
1.00
70496
CT ANGIOGRAPHY, HEAD
17.90
1.00
70498
CT ANGIOGRAPHY, NECK
13.47
1.00
70498
CT ANGIOGRAPHY, NECK
13.65
1.00
70498
CT ANGIOGRAPHY, NECK
17.98
1.00
70540
MRI ORBIT/FACE/NECK W/O DYE
7.00
1.00
70540
MRI ORBIT/FACE/NECK W/O DYE
13.33
1.00
70540
MRI ORBIT/FACE/NECK W/O DYE
13.47
1.00
70540
MRI ORBIT/FACE/NECK W/O DYE
15.24
1.00
70542
MRI ORBIT/FACE/NECK W/DYE
16.00
1.00
70542
MRI ORBIT/FACE/NECK W/DYE
16.17
1.00
70542
MRI ORBIT/FACE/NECK W/DYE
16.94
1.00
70543
MRI ORBT/FAC/NCK W/O & W/DYE
23.41
1.00
70543
MRI ORBT/FAC/NCK W/O & W/DYE
28.43
1.00
70543
MRI ORBT/FAC/NCK W/O & W/DYE
28.76
1.00
70544
MR ANGIOGRAPHY HEAD W/O DYE
7.00
1.00
70544
MR ANGIOGRAPHY HEAD W/O DYE
13.31
1.00
70544
MR ANGIOGRAPHY HEAD W/O DYE
13.48
1.00
70544
MR ANGIOGRAPHY HEAD W/O DYE
16.49
1.00
Procedure Code Description
RVU
RVU Coeff Value
70545
MR ANGIOGRAPHY HEAD W/DYE
7.00
1.00
70545
MR ANGIOGRAPHY HEAD W/DYE
13.31
1.00
70545
MR ANGIOGRAPHY HEAD W/DYE
13.48
1.00
70545
MR ANGIOGRAPHY HEAD W/DYE
16.42
1.00
70546
MR ANGIOGRAPH HEAD W/O&W/DYE
7.00
1.00
70546
MR ANGIOGRAPH HEAD W/O&W/DYE
25.30
1.00
70546
MR ANGIOGRAPH HEAD W/O&W/DYE
25.57
1.00
70546
MR ANGIOGRAPH HEAD W/O&W/DYE
26.04
1.00
70547
MR ANGIOGRAPHY NECK W/O DYE
13.31
1.00
70547
MR ANGIOGRAPHY NECK W/O DYE
13.48
1.00
70547
MR ANGIOGRAPHY NECK W/O DYE
16.45
1.00
70548
MR ANGIOGRAPHY NECK W/DYE
13.31
1.00
70548
MR ANGIOGRAPHY NECK W/DYE
13.48
1.00
70548
MR ANGIOGRAPHY NECK W/DYE
17.09
1.00
70549
MR ANGIOGRAPH NECK W/O&W/DYE
25.30
1.00
70549
MR ANGIOGRAPH NECK W/O&W/DYE
25.57
1.00
70549
MR ANGIOGRAPH NECK W/O&W/DYE
26.06
1.00
70551
MRI BRAIN W/O DYE
7.00
1.00
70551
MRI BRAIN W/O DYE
13.71
1.00
70551
MRI BRAIN W/O DYE
13.88
1.00
70551
MRI BRAIN W/O DYE
15.80
1.00
70552
MRI BRAIN W/DYE
16.44
1.00
70552
MRI BRAIN W/DYE
16.66
1.00
70552
MRI BRAIN W/DYE
17.67
1.00
70553
MRI BRAIN W/O & W/DYE
23.64
1.00
70553
MRI BRAIN W/O & W/DYE
29.14
1.00
70553
MRI BRAIN W/O & W/DYE
29.55
1.00
70554
FMRI BRAIN BY TECH
17.17
1.00
71010
CHEST X-RAY
0.66
1.00
71010
CHEST X-RAY
0.74
1.00
71015
CHEST X-RAY
0.81
1.00
71015
CHEST X-RAY
0.83
1.00
71020
CHEST X-RAY
0.88
1.00
71020
CHEST X-RAY
0.95
1.00
71020
CHEST X-RAY
0.96
1.00
Procedure Code Description
RVU
RVU Coeff Value
71021
CHEST X-RAY
1.06
1.00
71021
CHEST X-RAY
1.15
1.00
71021
CHEST X-RAY
1.16
1.00
71022
CHEST X-RAY
1.22
1.00
71022
CHEST X-RAY
1.27
1.00
71023
CHEST X-RAY AND FLUOROSCOPY
1.36
1.00
71023
CHEST X-RAY AND FLUOROSCOPY
1.37
1.00
71023
CHEST X-RAY AND FLUOROSCOPY
1.83
1.00
71030
CHEST X-RAY
1.24
1.00
71030
CHEST X-RAY
1.26
1.00
71030
CHEST X-RAY
1.28
1.00
71034
CHEST X-RAY AND FLUOROSCOPY
2.15
1.00
71034
CHEST X-RAY AND FLUOROSCOPY
2.16
1.00
71034
CHEST X-RAY AND FLUOROSCOPY
2.52
1.00
71035
CHEST X-RAY
0.79
1.00
71035
CHEST X-RAY
0.94
1.00
71040
CONTRAST X-RAY OF BRONCHI
2.33
1.00
71040
CONTRAST X-RAY OF BRONCHI
2.35
1.00
71040
CONTRAST X-RAY OF BRONCHI
2.63
1.00
71060
CONTRAST X-RAY OF BRONCHI
3.33
1.00
71060
CONTRAST X-RAY OF BRONCHI
3.37
1.00
71060
CONTRAST X-RAY OF BRONCHI
3.83
1.00
71090
X-RAY & PACEMAKER INSERTION
2.53
1.00
71090
X-RAY & PACEMAKER INSERTION
2.57
1.00
71100
X-RAY EXAM OF RIBS
0.90
1.00
71100
X-RAY EXAM OF RIBS
0.91
1.00
71101
X-RAY EXAM OF RIBS/CHEST
1.07
1.00
71101
X-RAY EXAM OF RIBS/CHEST
1.08
1.00
71110
X-RAY EXAM OF RIBS
1.12
1.00
71110
X-RAY EXAM OF RIBS
1.19
1.00
71110
X-RAY EXAM OF RIBS
1.21
1.00
71111
X-RAY EXAM OF RIBS/CHEST
1.38
1.00
71111
X-RAY EXAM OF RIBS/CHEST
1.39
1.00
71111
X-RAY EXAM OF RIBS/CHEST
1.43
1.00
71120
X-RAY EXAM OF BREASTBONE
0.90
1.00
Procedure Code Description
RVU
RVU Coeff Value
71120
X-RAY EXAM OF BREASTBONE
0.96
1.00
71120
X-RAY EXAM OF BREASTBONE
0.97
1.00
71130
X-RAY EXAM OF BREASTBONE
1.03
1.00
71130
X-RAY EXAM OF BREASTBONE
1.04
1.00
71130
X-RAY EXAM OF BREASTBONE
1.05
1.00
71250
CT THORAX W/O DYE
3.00
1.00
71250
CT THORAX W/O DYE
7.74
1.00
71250
CT THORAX W/O DYE
7.84
1.00
71250
CT THORAX W/O DYE
7.90
1.00
71260
CT THORAX W/DYE
9.06
1.00
71260
CT THORAX W/DYE
9.17
1.00
71260
CT THORAX W/DYE
9.48
1.00
71270
CT THORAX W/O & W/DYE
11.10
1.00
71270
CT THORAX W/O & W/DYE
11.24
1.00
71270
CT THORAX W/O & W/DYE
11.71
1.00
71275
CT ANGIOGRAPHY, CHEST
14.39
1.00
71275
CT ANGIOGRAPHY, CHEST
15.28
1.00
71275
CT ANGIOGRAPHY, CHEST
15.43
1.00
71550
MRI CHEST W/O DYE
7.00
1.00
71550
MRI CHEST W/O DYE
13.53
1.00
71550
MRI CHEST W/O DYE
13.68
1.00
71550
MRI CHEST W/O DYE
17.02
1.00
71551
MRI CHEST W/DYE
16.19
1.00
71551
MRI CHEST W/DYE
16.38
1.00
71551
MRI CHEST W/DYE
19.10
1.00
71552
MRI CHEST W/O & W/DYE
26.19
1.00
71552
MRI CHEST W/O & W/DYE
28.45
1.00
71552
MRI CHEST W/O & W/DYE
28.76
1.00
71555
MRI ANGIO CHEST W OR W/O DYE
14.16
1.00
71555
MRI ANGIO CHEST W OR W/O DYE
14.34
1.00
71555
MRI ANGIO CHEST W OR W/O DYE
16.78
1.00
72010
X-RAY EXAM OF SPINE
1.70
1.00
72010
X-RAY EXAM OF SPINE
1.73
1.00
72010
X-RAY EXAM OF SPINE
1.89
1.00
72020
X-RAY EXAM OF SPINE
0.64
1.00
Procedure Code Description
RVU
RVU Coeff Value
72020
X-RAY EXAM OF SPINE
0.65
1.00
72040
X-RAY EXAM OF NECK SPINE
0.93
1.00
72040
X-RAY EXAM OF NECK SPINE
0.94
1.00
72040
X-RAY EXAM OF NECK SPINE
1.01
1.00
72050
X-RAY EXAM OF NECK SPINE
1.38
1.00
72050
X-RAY EXAM OF NECK SPINE
1.43
1.00
72052
X-RAY EXAM OF NECK SPINE
1.67
1.00
72052
X-RAY EXAM OF NECK SPINE
1.69
1.00
72052
X-RAY EXAM OF NECK SPINE
1.79
1.00
72069
X-RAY EXAM OF TRUNK SPINE
0.83
1.00
72069
X-RAY EXAM OF TRUNK SPINE
0.95
1.00
72070
X-RAY EXAM OF THORACIC SPINE
0.93
1.00
72070
X-RAY EXAM OF THORACIC SPINE
0.98
1.00
72070
X-RAY EXAM OF THORACIC SPINE
0.99
1.00
72072
X-RAY EXAM OF THORACIC SPINE
1.06
1.00
72072
X-RAY EXAM OF THORACIC SPINE
1.08
1.00
72072
X-RAY EXAM OF THORACIC SPINE
1.09
1.00
72074
X-RAY EXAM OF THORACIC SPINE
1.24
1.00
72074
X-RAY EXAM OF THORACIC SPINE
1.26
1.00
72074
X-RAY EXAM OF THORACIC SPINE
1.27
1.00
72080
X-RAY EXAM OF TRUNK SPINE
0.97
1.00
72080
X-RAY EXAM OF TRUNK SPINE
1.02
1.00
72090
X-RAY EXAM OF TRUNK SPINE
1.10
1.00
72090
X-RAY EXAM OF TRUNK SPINE
1.27
1.00
72100
X-RAY EXAM OF LOWER SPINE
1.02
1.00
72100
X-RAY EXAM OF LOWER SPINE
1.06
1.00
72110
X-RAY EXAM OF LOWER SPINE
1.40
1.00
72110
X-RAY EXAM OF LOWER SPINE
1.48
1.00
72114
X-RAY EXAM OF LOWER SPINE
1.74
1.00
72114
X-RAY EXAM OF LOWER SPINE
1.77
1.00
72114
X-RAY EXAM OF LOWER SPINE
1.93
1.00
72120
X-RAY EXAM OF LOWER SPINE
1.26
1.00
72120
X-RAY EXAM OF LOWER SPINE
1.33
1.00
72125
CT NECK SPINE W/O DYE
7.74
1.00
72125
CT NECK SPINE W/O DYE
7.84
1.00
Procedure Code Description
RVU
RVU Coeff Value
72125
CT NECK SPINE W/O DYE
7.92
1.00
72126
CT NECK SPINE W/DYE
9.03
1.00
72126
CT NECK SPINE W/DYE
9.14
1.00
72126
CT NECK SPINE W/DYE
9.46
1.00
72127
CT NECK SPINE W/O & W/DYE
10.95
1.00
72127
CT NECK SPINE W/O & W/DYE
11.09
1.00
72127
CT NECK SPINE W/O & W/DYE
11.53
1.00
72128
CT CHEST SPINE W/O DYE
7.74
1.00
72128
CT CHEST SPINE W/O DYE
7.84
1.00
72128
CT CHEST SPINE W/O DYE
7.90
1.00
72129
CT CHEST SPINE W/DYE
9.03
1.00
72129
CT CHEST SPINE W/DYE
9.14
1.00
72129
CT CHEST SPINE W/DYE
9.47
1.00
72130
CT CHEST SPINE W/O & W/DYE
10.95
1.00
72130
CT CHEST SPINE W/O & W/DYE
11.09
1.00
72130
CT CHEST SPINE W/O & W/DYE
11.56
1.00
72131
CT LUMBAR SPINE W/O DYE
7.75
1.00
72131
CT LUMBAR SPINE W/O DYE
7.84
1.00
72131
CT LUMBAR SPINE W/O DYE
7.89
1.00
72132
CT LUMBAR SPINE W/DYE
9.04
1.00
72132
CT LUMBAR SPINE W/DYE
9.16
1.00
72132
CT LUMBAR SPINE W/DYE
9.46
1.00
72133
CT LUMBAR SPINE W/O & W/DYE
10.96
1.00
72133
CT LUMBAR SPINE W/O & W/DYE
11.10
1.00
72133
CT LUMBAR SPINE W/O & W/DYE
11.55
1.00
72141
MRI NECK SPINE W/O DYE
7.00
1.00
72141
MRI NECK SPINE W/O DYE
13.87
1.00
72141
MRI NECK SPINE W/O DYE
14.04
1.00
72141
MRI NECK SPINE W/O DYE
14.46
1.00
72142
MRI NECK SPINE W/DYE
16.64
1.00
72142
MRI NECK SPINE W/DYE
16.87
1.00
72142
MRI NECK SPINE W/DYE
17.84
1.00
72146
MRI CHEST SPINE W/O DYE
3.00
1.00
72146
MRI CHEST SPINE W/O DYE
14.84
1.00
72146
MRI CHEST SPINE W/O DYE
15.14
1.00
Procedure Code Description
RVU
RVU Coeff Value
72146
MRI CHEST SPINE W/O DYE
15.32
1.00
72147
MRI CHEST SPINE W/DYE
16.33
1.00
72147
MRI CHEST SPINE W/DYE
16.63
1.00
72147
MRI CHEST SPINE W/DYE
16.86
1.00
72148
MRI LUMBAR SPINE W/O DYE
14.66
1.00
72148
MRI LUMBAR SPINE W/O DYE
14.98
1.00
72148
MRI LUMBAR SPINE W/O DYE
15.17
1.00
72149
MRI LUMBAR SPINE W/DYE
16.45
1.00
72149
MRI LUMBAR SPINE W/DYE
16.68
1.00
72149
MRI LUMBAR SPINE W/DYE
17.64
1.00
72156
MRI NECK SPINE W/O & W/DYE
23.65
1.00
72156
MRI NECK SPINE W/O & W/DYE
29.43
1.00
72156
MRI NECK SPINE W/O & W/DYE
29.84
1.00
72157
MRI CHEST SPINE W/O & W/DYE
22.49
1.00
72157
MRI CHEST SPINE W/O & W/DYE
29.43
1.00
72157
MRI CHEST SPINE W/O & W/DYE
29.84
1.00
72158
MRI LUMBAR SPINE W/O & W/DYE
23.34
1.00
72158
MRI LUMBAR SPINE W/O & W/DYE
29.15
1.00
72158
MRI LUMBAR SPINE W/O & W/DYE
29.56
1.00
72159
MR ANGIO SPINE W/O&W/DYE
15.46
1.00
72159
MR ANGIO SPINE W/O&W/DYE
15.50
1.00
72159
MR ANGIO SPINE W/O&W/DYE
18.00
1.00
72170
X-RAY EXAM OF PELVIS
0.71
1.00
72170
X-RAY EXAM OF PELVIS
0.78
1.00
72190
X-RAY EXAM OF PELVIS
0.99
1.00
72190
X-RAY EXAM OF PELVIS
1.00
1.00
72190
X-RAY EXAM OF PELVIS
1.08
1.00
72191
CT ANGIOGRAPH PELV W/O&W/DYE
13.87
1.00
72191
CT ANGIOGRAPH PELV W/O&W/DYE
14.78
1.00
72191
CT ANGIOGRAPH PELV W/O&W/DYE
14.94
1.00
72192
CT PELVIS W/O DYE
7.52
1.00
72192
CT PELVIS W/O DYE
7.65
1.00
72192
CT PELVIS W/O DYE
7.75
1.00
72193
CT PELVIS W/DYE
8.72
1.00
72193
CT PELVIS W/DYE
8.83
1.00
Procedure Code Description 72193
CT PELVIS W/DYE
72194
RVU
RVU Coeff Value
9.00
1.00
CT PELVIS W/O & W/DYE
10.49
1.00
72194
CT PELVIS W/O & W/DYE
10.63
1.00
72194
CT PELVIS W/O & W/DYE
11.47
1.00
72195
MRI PELVIS W/O DYE
13.54
1.00
72195
MRI PELVIS W/O DYE
13.69
1.00
72195
MRI PELVIS W/O DYE
15.60
1.00
72196
MRI PELVIS W/DYE
7.00
1.00
72196
MRI PELVIS W/DYE
16.18
1.00
72196
MRI PELVIS W/DYE
16.37
1.00
72196
MRI PELVIS W/DYE
17.30
1.00
72197
MRI PELVIS W/O & W/DYE
23.77
1.00
72197
MRI PELVIS W/O & W/DYE
28.65
1.00
72197
MRI PELVIS W/O & W/DYE
29.00
1.00
72198
MR ANGIO PELVIS W/O & W/DYE
14.23
1.00
72198
MR ANGIO PELVIS W/O & W/DYE
14.41
1.00
72198
MR ANGIO PELVIS W/O & W/DYE
16.68
1.00
72200
X-RAY EXAM SACROILIAC JOINTS
0.78
1.00
72200
X-RAY EXAM SACROILIAC JOINTS
0.79
1.00
72202
X-RAY EXAM SACROILIAC JOINTS
0.91
1.00
72202
X-RAY EXAM SACROILIAC JOINTS
0.92
1.00
72202
X-RAY EXAM SACROILIAC JOINTS
0.96
1.00
72220
X-RAY EXAM OF TAILBONE
0.81
1.00
72220
X-RAY EXAM OF TAILBONE
0.84
1.00
72220
X-RAY EXAM OF TAILBONE
0.85
1.00
72240
CONTRAST X-RAY OF NECK SPINE
4.39
1.00
72240
CONTRAST X-RAY OF NECK SPINE
6.19
1.00
72240
CONTRAST X-RAY OF NECK SPINE
6.27
1.00
72255
CONTRAST X-RAY, THORAX SPINE
4.01
1.00
72255
CONTRAST X-RAY, THORAX SPINE
5.72
1.00
72255
CONTRAST X-RAY, THORAX SPINE
5.80
1.00
72265
CONTRAST X-RAY, LOWER SPINE
4.08
1.00
72265
CONTRAST X-RAY, LOWER SPINE
5.36
1.00
72265
CONTRAST X-RAY, LOWER SPINE
5.45
1.00
72270
CONTRAST X-RAY, SPINE
6.36
1.00
Procedure Code Description
RVU
RVU Coeff Value
72270
CONTRAST X-RAY, SPINE
8.17
1.00
72270
CONTRAST X-RAY, SPINE
8.27
1.00
72275
EPIDUROGRAPHY
2.90
1.00
72275
EPIDUROGRAPHY
3.26
1.00
72275
EPIDUROGRAPHY
3.32
1.00
72285
X-RAY C/T SPINE DISK
4.96
1.00
72285
X-RAY C/T SPINE DISK
10.30
1.00
72285
X-RAY C/T SPINE DISK
10.43
1.00
72295
X-RAY OF LOWER SPINE DISK
4.42
1.00
72295
X-RAY OF LOWER SPINE DISK
9.30
1.00
72295
X-RAY OF LOWER SPINE DISK
9.43
1.00
73000
X-RAY EXAM OF COLLAR BONE
0.75
1.00
73000
X-RAY EXAM OF COLLAR BONE
0.76
1.00
73010
X-RAY EXAM OF SHOULDER BLADE
0.77
1.00
73010
X-RAY EXAM OF SHOULDER BLADE
0.78
1.00
73020
X-RAY EXAM OF SHOULDER
0.64
1.00
73020
X-RAY EXAM OF SHOULDER
0.70
1.00
73030
X-RAY EXAM OF SHOULDER
0.82
1.00
73030
X-RAY EXAM OF SHOULDER
0.85
1.00
73030
X-RAY EXAM OF SHOULDER
0.86
1.00
73040
CONTRAST X-RAY OF SHOULDER
2.93
1.00
73040
CONTRAST X-RAY OF SHOULDER
2.94
1.00
73040
CONTRAST X-RAY OF SHOULDER
2.98
1.00
73050
X-RAY EXAM OF SHOULDERS
0.98
1.00
73050
X-RAY EXAM OF SHOULDERS
0.99
1.00
73050
X-RAY EXAM OF SHOULDERS
1.00
1.00
73060
X-RAY EXAM OF HUMERUS
0.80
1.00
73060
X-RAY EXAM OF HUMERUS
0.84
1.00
73060
X-RAY EXAM OF HUMERUS
0.85
1.00
73070
X-RAY EXAM OF ELBOW
0.73
1.00
73070
X-RAY EXAM OF ELBOW
0.75
1.00
73080
X-RAY EXAM OF ELBOW
0.84
1.00
73080
X-RAY EXAM OF ELBOW
0.85
1.00
73080
X-RAY EXAM OF ELBOW
0.94
1.00
73085
CONTRAST X-RAY OF ELBOW
2.65
1.00
Procedure Code Description
RVU
RVU Coeff Value
73085
CONTRAST X-RAY OF ELBOW
2.95
1.00
73085
CONTRAST X-RAY OF ELBOW
2.99
1.00
73090
X-RAY EXAM OF FOREARM
0.74
1.00
73090
X-RAY EXAM OF FOREARM
0.76
1.00
73092
X-RAY EXAM OF ARM, INFANT
0.73
1.00
73092
X-RAY EXAM OF ARM, INFANT
0.76
1.00
73100
X-RAY EXAM OF WRIST
0.75
1.00
73100
X-RAY EXAM OF WRIST
0.77
1.00
73110
X-RAY EXAM OF WRIST
0.79
1.00
73110
X-RAY EXAM OF WRIST
0.92
1.00
73115
CONTRAST X-RAY OF WRIST
2.41
1.00
73115
CONTRAST X-RAY OF WRIST
2.45
1.00
73115
CONTRAST X-RAY OF WRIST
2.80
1.00
73120
X-RAY EXAM OF HAND
0.73
1.00
73120
X-RAY EXAM OF HAND
0.74
1.00
73130
X-RAY EXAM OF HAND
0.79
1.00
73130
X-RAY EXAM OF HAND
0.84
1.00
73140
X-RAY EXAM OF FINGER(S)
0.61
1.00
73140
X-RAY EXAM OF FINGER(S)
0.62
1.00
73140
X-RAY EXAM OF FINGER(S)
0.78
1.00
73200
CT UPPER EXTREMITY W/O DYE
6.66
1.00
73200
CT UPPER EXTREMITY W/O DYE
6.73
1.00
73200
CT UPPER EXTREMITY W/O DYE
7.48
1.00
73201
CT UPPER EXTREMITY W/DYE
7.75
1.00
73201
CT UPPER EXTREMITY W/DYE
7.84
1.00
73201
CT UPPER EXTREMITY W/DYE
8.98
1.00
73202
CT UPPR EXTREMITY W/O&W/DYE
9.41
1.00
73202
CT UPPR EXTREMITY W/O&W/DYE
9.53
1.00
73202
CT UPPR EXTREMITY W/O&W/DYE
11.49
1.00
73206
CT ANGIO UPR EXTRM W/O&W/DYE
13.29
1.00
73206
CT ANGIO UPR EXTRM W/O&W/DYE
13.73
1.00
73206
CT ANGIO UPR EXTRM W/O&W/DYE
13.86
1.00
73218
MRI UPPER EXTREMITY W/O DYE
13.33
1.00
73218
MRI UPPER EXTREMITY W/O DYE
13.47
1.00
73218
MRI UPPER EXTREMITY W/O DYE
15.59
1.00
Procedure Code Description
RVU
RVU Coeff Value
73219
MRI UPPER EXTREMITY W/DYE
16.00
1.00
73219
MRI UPPER EXTREMITY W/DYE
16.17
1.00
73219
MRI UPPER EXTREMITY W/DYE
17.13
1.00
73220
MRI UPPR EXTREMITY W/O&W/DYE
7.00
1.00
73220
MRI UPPR EXTREMITY W/O&W/DYE
23.62
1.00
73220
MRI UPPR EXTREMITY W/O&W/DYE
28.45
1.00
73220
MRI UPPR EXTREMITY W/O&W/DYE
28.78
1.00
73221
MRI JOINT UPR EXTREM W/O DYE
7.00
1.00
73221
MRI JOINT UPR EXTREM W/O DYE
13.33
1.00
73221
MRI JOINT UPR EXTREM W/O DYE
13.47
1.00
73221
MRI JOINT UPR EXTREM W/O DYE
14.76
1.00
73222
MRI JOINT UPR EXTREM W/DYE
15.99
1.00
73222
MRI JOINT UPR EXTREM W/DYE
16.17
1.00
73222
MRI JOINT UPR EXTREM W/DYE
16.29
1.00
73223
MRI JOINT UPR EXTR W/O&W/DYE
22.60
1.00
73223
MRI JOINT UPR EXTR W/O&W/DYE
28.44
1.00
73223
MRI JOINT UPR EXTR W/O&W/DYE
28.76
1.00
73225
MR ANGIO UPR EXTR W/O&W/DYE
14.10
1.00
73225
MR ANGIO UPR EXTR W/O&W/DYE
14.14
1.00
73225
MR ANGIO UPR EXTR W/O&W/DYE
17.54
1.00
73500
X-RAY EXAM OF HIP
0.69
1.00
73500
X-RAY EXAM OF HIP
0.73
1.00
73510
X-RAY EXAM OF HIP
0.90
1.00
73510
X-RAY EXAM OF HIP
0.91
1.00
73510
X-RAY EXAM OF HIP
1.00
1.00
73520
X-RAY EXAM OF HIPS
1.07
1.00
73520
X-RAY EXAM OF HIPS
1.08
1.00
73525
CONTRAST X-RAY OF HIP
2.65
1.00
73525
CONTRAST X-RAY OF HIP
2.94
1.00
73525
CONTRAST X-RAY OF HIP
2.98
1.00
73530
X-RAY EXAM OF HIP
0.94
1.00
73540
X-RAY EXAM OF PELVIS & HIPS
0.89
1.00
73540
X-RAY EXAM OF PELVIS & HIPS
0.90
1.00
73540
X-RAY EXAM OF PELVIS & HIPS
1.00
1.00
73542
X-RAY EXAM, SACROILIAC JOINT
2.18
1.00
Procedure Code Description
RVU
RVU Coeff Value
73542
X-RAY EXAM, SACROILIAC JOINT
2.98
1.00
73542
X-RAY EXAM, SACROILIAC JOINT
3.01
1.00
73550
X-RAY EXAM OF THIGH
0.78
1.00
73550
X-RAY EXAM OF THIGH
0.84
1.00
73550
X-RAY EXAM OF THIGH
0.85
1.00
73560
X-RAY EXAM OF KNEE, 1 OR 2
0.77
1.00
73560
X-RAY EXAM OF KNEE, 1 OR 2
0.79
1.00
73562
X-RAY EXAM OF KNEE, 3
0.86
1.00
73562
X-RAY EXAM OF KNEE, 3
0.87
1.00
73562
X-RAY EXAM OF KNEE, 3
0.93
1.00
73564
X-RAY EXAM, KNEE, 4 OR MORE
0.97
1.00
73564
X-RAY EXAM, KNEE, 4 OR MORE
0.98
1.00
73564
X-RAY EXAM, KNEE, 4 OR MORE
1.08
1.00
73565
X-RAY EXAM OF KNEES
0.76
1.00
73565
X-RAY EXAM OF KNEES
0.82
1.00
73580
CONTRAST X-RAY OF KNEE JOINT
3.30
1.00
73580
CONTRAST X-RAY OF KNEE JOINT
3.48
1.00
73580
CONTRAST X-RAY OF KNEE JOINT
3.52
1.00
73590
X-RAY EXAM OF LOWER LEG
0.74
1.00
73590
X-RAY EXAM OF LOWER LEG
0.78
1.00
73592
X-RAY EXAM OF LEG, INFANT
0.74
1.00
73592
X-RAY EXAM OF LEG, INFANT
0.76
1.00
73600
X-RAY EXAM OF ANKLE
0.73
1.00
73600
X-RAY EXAM OF ANKLE
0.74
1.00
73610
X-RAY EXAM OF ANKLE
0.79
1.00
73610
X-RAY EXAM OF ANKLE
0.84
1.00
73615
CONTRAST X-RAY OF ANKLE
2.72
1.00
73615
CONTRAST X-RAY OF ANKLE
2.95
1.00
73615
CONTRAST X-RAY OF ANKLE
2.99
1.00
73620
X-RAY EXAM OF FOOT
0.71
1.00
73620
X-RAY EXAM OF FOOT
0.73
1.00
73620
X-RAY EXAM OF FOOT
0.74
1.00
73630
X-RAY EXAM OF FOOT
0.79
1.00
73630
X-RAY EXAM OF FOOT
0.83
1.00
73650
X-RAY EXAM OF HEEL
0.71
1.00
Procedure Code Description
RVU
RVU Coeff Value
73650
X-RAY EXAM OF HEEL
0.72
1.00
73660
X-RAY EXAM OF TOE(S)
0.61
1.00
73660
X-RAY EXAM OF TOE(S)
0.62
1.00
73660
X-RAY EXAM OF TOE(S)
0.74
1.00
73700
CT LOWER EXTREMITY W/O DYE
6.66
1.00
73700
CT LOWER EXTREMITY W/O DYE
6.73
1.00
73700
CT LOWER EXTREMITY W/O DYE
7.49
1.00
73701
CT LOWER EXTREMITY W/DYE
7.74
1.00
73701
CT LOWER EXTREMITY W/DYE
7.84
1.00
73701
CT LOWER EXTREMITY W/DYE
9.04
1.00
73702
CT LWR EXTREMITY W/O&W/DYE
9.39
1.00
73702
CT LWR EXTREMITY W/O&W/DYE
9.52
1.00
73702
CT LWR EXTREMITY W/O&W/DYE
11.52
1.00
73706
CT ANGIO LWR EXTR W/O&W/DYE
13.85
1.00
73706
CT ANGIO LWR EXTR W/O&W/DYE
13.98
1.00
73706
CT ANGIO LWR EXTR W/O&W/DYE
14.43
1.00
73718
MRI LOWER EXTREMITY W/O DYE
13.33
1.00
73718
MRI LOWER EXTREMITY W/O DYE
13.47
1.00
73718
MRI LOWER EXTREMITY W/O DYE
15.32
1.00
73719
MRI LOWER EXTREMITY W/DYE
15.99
1.00
73719
MRI LOWER EXTREMITY W/DYE
16.17
1.00
73719
MRI LOWER EXTREMITY W/DYE
16.95
1.00
73720
MRI LWR EXTREMITY W/O&W/DYE
7.00
1.00
73720
MRI LWR EXTREMITY W/O&W/DYE
23.61
1.00
73720
MRI LWR EXTREMITY W/O&W/DYE
28.44
1.00
73720
MRI LWR EXTREMITY W/O&W/DYE
28.78
1.00
73721
MRI JNT OF LWR EXTRE W/O DYE
7.00
1.00
73721
MRI JNT OF LWR EXTRE W/O DYE
13.33
1.00
73721
MRI JNT OF LWR EXTRE W/O DYE
13.47
1.00
73721
MRI JNT OF LWR EXTRE W/O DYE
15.01
1.00
73722
MRI JOINT OF LWR EXTR W/DYE
16.01
1.00
73722
MRI JOINT OF LWR EXTR W/DYE
16.18
1.00
73722
MRI JOINT OF LWR EXTR W/DYE
16.42
1.00
73723
MRI JOINT LWR EXTR W/O&W/DYE
22.55
1.00
73723
MRI JOINT LWR EXTR W/O&W/DYE
28.44
1.00
Procedure Code Description
RVU
RVU Coeff Value
73723
MRI JOINT LWR EXTR W/O&W/DYE
28.76
1.00
73725
MR ANG LWR EXT W OR W/O DYE
14.17
1.00
73725
MR ANG LWR EXT W OR W/O DYE
14.35
1.00
73725
MR ANG LWR EXT W OR W/O DYE
16.70
1.00
74000
X-RAY EXAM OF ABDOMEN
0.70
1.00
74000
X-RAY EXAM OF ABDOMEN
0.79
1.00
74010
X-RAY EXAM OF ABDOMEN
0.92
1.00
74010
X-RAY EXAM OF ABDOMEN
0.93
1.00
74010
X-RAY EXAM OF ABDOMEN
1.03
1.00
74020
X-RAY EXAM OF ABDOMEN
1.02
1.00
74020
X-RAY EXAM OF ABDOMEN
1.03
1.00
74020
X-RAY EXAM OF ABDOMEN
1.10
1.00
74022
X-RAY EXAM SERIES, ABDOMEN
1.22
1.00
74022
X-RAY EXAM SERIES, ABDOMEN
1.23
1.00
74022
X-RAY EXAM SERIES, ABDOMEN
1.33
1.00
74150
CT ABDOMEN W/O DYE
3.00
1.00
74150
CT ABDOMEN W/O DYE
7.52
1.00
74150
CT ABDOMEN W/O DYE
7.58
1.00
74150
CT ABDOMEN W/O DYE
7.61
1.00
74160
CT ABDOMEN W/DYE
3.00
1.00
74160
CT ABDOMEN W/DYE
8.88
1.00
74160
CT ABDOMEN W/DYE
8.98
1.00
74160
CT ABDOMEN W/DYE
10.08
1.00
74170
CT ABDOMEN W/O & W/DYE
3.00
1.00
74170
CT ABDOMEN W/O & W/DYE
10.75
1.00
74170
CT ABDOMEN W/O & W/DYE
10.87
1.00
74170
CT ABDOMEN W/O & W/DYE
13.19
1.00
74175
CT ANGIO ABDOM W/O & W/DYE
14.67
1.00
74175
CT ANGIO ABDOM W/O & W/DYE
14.90
1.00
74175
CT ANGIO ABDOM W/O & W/DYE
15.05
1.00
74181
MRI ABDOMEN W/O DYE
3.00
1.00
74181
MRI ABDOMEN W/O DYE
13.55
1.00
74181
MRI ABDOMEN W/O DYE
13.70
1.00
74181
MRI ABDOMEN W/O DYE
14.15
1.00
74182
MRI ABDOMEN W/DYE
16.19
1.00
Procedure Code Description
RVU
RVU Coeff Value
74182
MRI ABDOMEN W/DYE
16.37
1.00
74182
MRI ABDOMEN W/DYE
18.76
1.00
74183
MRI ABDOMEN W/O & W/DYE
23.79
1.00
74183
MRI ABDOMEN W/O & W/DYE
28.65
1.00
74183
MRI ABDOMEN W/O & W/DYE
29.00
1.00
74185
MRI ANGIO, ABDOM W ORW/O DYE
14.14
1.00
74185
MRI ANGIO, ABDOM W ORW/O DYE
14.32
1.00
74185
MRI ANGIO, ABDOM W ORW/O DYE
16.64
1.00
74190
X-RAY EXAM OF PERITONEUM
2.02
1.00
74190
X-RAY EXAM OF PERITONEUM
2.04
1.00
74210
CONTRST X-RAY EXAM OF THROAT
1.73
1.00
74210
CONTRST X-RAY EXAM OF THROAT
1.75
1.00
74210
CONTRST X-RAY EXAM OF THROAT
2.10
1.00
74220
CONTRAST X-RAY, ESOPHAGUS
1.87
1.00
74220
CONTRAST X-RAY, ESOPHAGUS
1.88
1.00
74220
CONTRAST X-RAY, ESOPHAGUS
2.38
1.00
74230
CINE/VID X-RAY, THROAT/ESOPH
2.09
1.00
74230
CINE/VID X-RAY, THROAT/ESOPH
2.11
1.00
74230
CINE/VID X-RAY, THROAT/ESOPH
2.45
1.00
74235
REMOVE ESOPHAGUS OBSTRUCTION
4.38
1.00
74235
REMOVE ESOPHAGUS OBSTRUCTION
4.40
1.00
74240
X-RAY EXAM, UPPER GI TRACT
2.47
1.00
74240
X-RAY EXAM, UPPER GI TRACT
2.50
1.00
74240
X-RAY EXAM, UPPER GI TRACT
2.95
1.00
74241
X-RAY EXAM, UPPER GI TRACT
2.50
1.00
74241
X-RAY EXAM, UPPER GI TRACT
2.53
1.00
74241
X-RAY EXAM, UPPER GI TRACT
3.14
1.00
74245
X-RAY EXAM, UPPER GI TRACT
3.74
1.00
74245
X-RAY EXAM, UPPER GI TRACT
3.78
1.00
74245
X-RAY EXAM, UPPER GI TRACT
4.71
1.00
74246
CONTRST X-RAY UPPR GI TRACT
2.66
1.00
74246
CONTRST X-RAY UPPR GI TRACT
2.71
1.00
74246
CONTRST X-RAY UPPR GI TRACT
3.38
1.00
74247
CONTRST X-RAY UPPR GI TRACT
2.71
1.00
74247
CONTRST X-RAY UPPR GI TRACT
2.76
1.00
Procedure Code Description
RVU
RVU Coeff Value
74247
CONTRST X-RAY UPPR GI TRACT
3.71
1.00
74249
CONTRST X-RAY UPPR GI TRACT
3.94
1.00
74249
CONTRST X-RAY UPPR GI TRACT
3.99
1.00
74249
CONTRST X-RAY UPPR GI TRACT
5.05
1.00
74250
X-RAY EXAM OF SMALL BOWEL
2.01
1.00
74250
X-RAY EXAM OF SMALL BOWEL
2.03
1.00
74250
X-RAY EXAM OF SMALL BOWEL
2.77
1.00
74251
X-RAY EXAM OF SMALL BOWEL
2.31
1.00
74251
X-RAY EXAM OF SMALL BOWEL
2.34
1.00
74251
X-RAY EXAM OF SMALL BOWEL
8.61
1.00
74260
X-RAY EXAM OF SMALL BOWEL
2.24
1.00
74260
X-RAY EXAM OF SMALL BOWEL
2.26
1.00
74260
X-RAY EXAM OF SMALL BOWEL
7.18
1.00
74270
CONTRAST X-RAY EXAM OF COLON
2.73
1.00
74270
CONTRAST X-RAY EXAM OF COLON
2.78
1.00
74270
CONTRAST X-RAY EXAM OF COLON
3.98
1.00
74280
CONTRAST X-RAY EXAM OF COLON
3.70
1.00
74280
CONTRAST X-RAY EXAM OF COLON
3.74
1.00
74280
CONTRAST X-RAY EXAM OF COLON
5.50
1.00
74283
CONTRAST X-RAY EXAM OF COLON
5.47
1.00
74283
CONTRAST X-RAY EXAM OF COLON
5.51
1.00
74283
CONTRAST X-RAY EXAM OF COLON
5.70
1.00
74290
CONTRAST X-RAY, GALLBLADDER
1.22
1.00
74290
CONTRAST X-RAY, GALLBLADDER
1.23
1.00
74290
CONTRAST X-RAY, GALLBLADDER
1.77
1.00
74291
CONTRAST X-RAYS, GALLBLADDER
0.71
1.00
74291
CONTRAST X-RAYS, GALLBLADDER
0.72
1.00
74291
CONTRAST X-RAYS, GALLBLADDER
1.52
1.00
74301
X-RAYS AT SURGERY ADD-ON
0.29
1.00
74301
X-RAYS AT SURGERY ADD-ON
0.30
1.00
74305
X-RAY BILE DUCTS/PANCREAS
1.40
1.00
74305
X-RAY BILE DUCTS/PANCREAS
1.42
1.00
74320
CONTRAST X-RAY OF BILE DUCTS
3.17
1.00
74320
CONTRAST X-RAY OF BILE DUCTS
4.01
1.00
74320
CONTRAST X-RAY OF BILE DUCTS
4.08
1.00
Procedure Code Description
RVU
RVU Coeff Value
74327
X-RAY BILE STONE REMOVAL
2.81
1.00
74327
X-RAY BILE STONE REMOVAL
2.85
1.00
74327
X-RAY BILE STONE REMOVAL
3.58
1.00
74328
X-RAY BILE DUCT ENDOSCOPY
4.24
1.00
74328
X-RAY BILE DUCT ENDOSCOPY
4.31
1.00
74329
X-RAY FOR PANCREAS ENDOSCOPY
4.24
1.00
74329
X-RAY FOR PANCREAS ENDOSCOPY
4.31
1.00
74330
X-RAY BILE/PANC ENDOSCOPY
4.52
1.00
74330
X-RAY BILE/PANC ENDOSCOPY
4.59
1.00
74340
X-RAY GUIDE FOR GI TUBE
3.47
1.00
74340
X-RAY GUIDE FOR GI TUBE
3.50
1.00
74350
X-RAY GUIDE, STOMACH TUBE
4.03
1.00
74350
X-RAY GUIDE, STOMACH TUBE
4.32
1.00
74350
X-RAY GUIDE, STOMACH TUBE
4.39
1.00
74355
X-RAY GUIDE, INTESTINAL TUBE
3.78
1.00
74355
X-RAY GUIDE, INTESTINAL TUBE
3.81
1.00
74360
X-RAY GUIDE, GI DILATION
4.02
1.00
74360
X-RAY GUIDE, GI DILATION
4.09
1.00
74363
X-RAY, BILE DUCT DILATION
7.56
1.00
74363
X-RAY, BILE DUCT DILATION
7.67
1.00
74400
CONTRST X-RAY, URINARY TRACT
2.44
1.00
74400
CONTRST X-RAY, URINARY TRACT
2.47
1.00
74400
CONTRST X-RAY, URINARY TRACT
3.01
1.00
74410
CONTRST X-RAY, URINARY TRACT
2.71
1.00
74410
CONTRST X-RAY, URINARY TRACT
2.74
1.00
74410
CONTRST X-RAY, URINARY TRACT
3.17
1.00
74415
CONTRST X-RAY, URINARY TRACT
2.89
1.00
74415
CONTRST X-RAY, URINARY TRACT
2.91
1.00
74415
CONTRST X-RAY, URINARY TRACT
3.63
1.00
74420
CONTRST X-RAY, URINARY TRACT
3.23
1.00
74420
CONTRST X-RAY, URINARY TRACT
3.26
1.00
74425
CONTRST X-RAY, URINARY TRACT
1.86
1.00
74425
CONTRST X-RAY, URINARY TRACT
1.88
1.00
74430
CONTRAST X-RAY, BLADDER
1.54
1.00
74430
CONTRAST X-RAY, BLADDER
1.57
1.00
Procedure Code Description
RVU
RVU Coeff Value
74430
CONTRAST X-RAY, BLADDER
2.15
1.00
74440
X-RAY, MALE GENITAL TRACT
1.70
1.00
74440
X-RAY, MALE GENITAL TRACT
1.71
1.00
74440
X-RAY, MALE GENITAL TRACT
2.31
1.00
74445
X-RAY EXAM OF PENIS
2.74
1.00
74445
X-RAY EXAM OF PENIS
2.76
1.00
74450
X-RAY, URETHRA/BLADDER
1.98
1.00
74450
X-RAY, URETHRA/BLADDER
2.00
1.00
74455
X-RAY, URETHRA/BLADDER
2.11
1.00
74455
X-RAY, URETHRA/BLADDER
2.14
1.00
74455
X-RAY, URETHRA/BLADDER
2.50
1.00
74470
X-RAY EXAM OF KIDNEY LESION
2.04
1.00
74470
X-RAY EXAM OF KIDNEY LESION
2.06
1.00
74475
X-RAY CONTROL, CATH INSERT
3.44
1.00
74475
X-RAY CONTROL, CATH INSERT
4.97
1.00
74475
X-RAY CONTROL, CATH INSERT
5.05
1.00
74480
X-RAY CONTROL, CATH INSERT
3.45
1.00
74480
X-RAY CONTROL, CATH INSERT
4.97
1.00
74480
X-RAY CONTROL, CATH INSERT
5.05
1.00
74485
X-RAY GUIDE, GU DILATION
3.28
1.00
74485
X-RAY GUIDE, GU DILATION
4.02
1.00
74485
X-RAY GUIDE, GU DILATION
4.10
1.00
74710
X-RAY MEASUREMENT OF PELVIS
1.21
1.00
74710
X-RAY MEASUREMENT OF PELVIS
1.57
1.00
74710
X-RAY MEASUREMENT OF PELVIS
1.59
1.00
74740
X-RAY, FEMALE GENITAL TRACT
1.89
1.00
74740
X-RAY, FEMALE GENITAL TRACT
1.91
1.00
74740
X-RAY, FEMALE GENITAL TRACT
2.14
1.00
74775
X-RAY EXAM OF PERINEUM
2.39
1.00
74775
X-RAY EXAM OF PERINEUM
2.40
1.00
74775
X-RAY EXAM OF PERINEUM
2.41
1.00
75552
HEART MRI FOR MORPH W/O DYE
13.87
1.00
75552
HEART MRI FOR MORPH W/O DYE
14.04
1.00
75552
HEART MRI FOR MORPH W/O DYE
15.64
1.00
75553
HEART MRI FOR MORPH W/DYE
14.42
1.00
Procedure Code Description
RVU
RVU Coeff Value
75553
HEART MRI FOR MORPH W/DYE
14.59
1.00
75553
HEART MRI FOR MORPH W/DYE
17.46
1.00
75554
CARDIAC MRI/FUNCTION
14.22
1.00
75554
CARDIAC MRI/FUNCTION
14.38
1.00
75554
CARDIAC MRI/FUNCTION
17.99
1.00
75555
CARDIAC MRI/LIMITED STUDY
14.12
1.00
75555
CARDIAC MRI/LIMITED STUDY
14.29
1.00
75555
CARDIAC MRI/LIMITED STUDY
18.04
1.00
75557
CARDIAC MRI FOR MORPH
14.36
1.00
75558
CARDIAC MRI FLOW/VELOCITY
17.47
1.00
75559
CARDIAC MRI W/STRESS IMG
20.74
1.00
75560
CARDIAC MRI FLOW/VEL/STRESS
22.71
1.00
75561
CARDIAC MRI FOR MORPH W/DYE
19.30
1.00
75562
CARD MRI FLOW/VEL W/DYE
22.51
1.00
75563
CARD MRI W/STRESS IMG & DYE
23.67
1.00
75564
HT MRI W/FLO/VEL/STRS & DYE
26.47
1.00
75600
CONTRAST X-RAY EXAM OF AORTA
8.95
1.00
75600
CONTRAST X-RAY EXAM OF AORTA
13.79
1.00
75600
CONTRAST X-RAY EXAM OF AORTA
13.99
1.00
75605
CONTRAST X-RAY EXAM OF AORTA
7.68
1.00
75605
CONTRAST X-RAY EXAM OF AORTA
14.69
1.00
75605
CONTRAST X-RAY EXAM OF AORTA
14.88
1.00
75625
CONTRAST X-RAY EXAM OF AORTA
7.58
1.00
75625
CONTRAST X-RAY EXAM OF AORTA
14.67
1.00
75625
CONTRAST X-RAY EXAM OF AORTA
14.87
1.00
75630
X-RAY AORTA, LEG ARTERIES
8.79
1.00
75630
X-RAY AORTA, LEG ARTERIES
16.16
1.00
75630
X-RAY AORTA, LEG ARTERIES
16.36
1.00
75635
CT ANGIO ABDOMINAL ARTERIES
16.68
1.00
75635
CT ANGIO ABDOMINAL ARTERIES
19.47
1.00
75635
CT ANGIO ABDOMINAL ARTERIES
19.67
1.00
75650
ARTERY X-RAYS, HEAD & NECK
8.12
1.00
75650
ARTERY X-RAYS, HEAD & NECK
15.16
1.00
75650
ARTERY X-RAYS, HEAD & NECK
15.35
1.00
75658
ARTERY X-RAYS, ARM
8.03
1.00
Procedure Code Description
RVU
RVU Coeff Value
75658
ARTERY X-RAYS, ARM
14.95
1.00
75658
ARTERY X-RAYS, ARM
15.14
1.00
75660
ARTERY X-RAYS, HEAD & NECK
8.17
1.00
75660
ARTERY X-RAYS, HEAD & NECK
14.92
1.00
75660
ARTERY X-RAYS, HEAD & NECK
15.11
1.00
75662
ARTERY X-RAYS, HEAD & NECK
9.35
1.00
75662
ARTERY X-RAYS, HEAD & NECK
15.44
1.00
75662
ARTERY X-RAYS, HEAD & NECK
15.64
1.00
75665
ARTERY X-RAYS, HEAD & NECK
8.39
1.00
75665
ARTERY X-RAYS, HEAD & NECK
14.92
1.00
75665
ARTERY X-RAYS, HEAD & NECK
15.11
1.00
75671
ARTERY X-RAYS, HEAD & NECK
9.47
1.00
75671
ARTERY X-RAYS, HEAD & NECK
15.40
1.00
75671
ARTERY X-RAYS, HEAD & NECK
15.60
1.00
75676
ARTERY X-RAYS, NECK
8.18
1.00
75676
ARTERY X-RAYS, NECK
14.93
1.00
75676
ARTERY X-RAYS, NECK
15.12
1.00
75680
ARTERY X-RAYS, NECK
9.10
1.00
75680
ARTERY X-RAYS, NECK
15.40
1.00
75680
ARTERY X-RAYS, NECK
15.60
1.00
75685
ARTERY X-RAYS, SPINE
8.19
1.00
75685
ARTERY X-RAYS, SPINE
14.91
1.00
75685
ARTERY X-RAYS, SPINE
15.10
1.00
75705
ARTERY X-RAYS, SPINE
9.42
1.00
75705
ARTERY X-RAYS, SPINE
16.14
1.00
75705
ARTERY X-RAYS, SPINE
16.33
1.00
75710
ARTERY X-RAYS, ARM/LEG
8.01
1.00
75710
ARTERY X-RAYS, ARM/LEG
14.69
1.00
75710
ARTERY X-RAYS, ARM/LEG
14.88
1.00
75716
ARTERY X-RAYS, ARMS/LEGS
8.91
1.00
75716
ARTERY X-RAYS, ARMS/LEGS
14.91
1.00
75716
ARTERY X-RAYS, ARMS/LEGS
15.10
1.00
75722
ARTERY X-RAYS, KIDNEY
7.91
1.00
75722
ARTERY X-RAYS, KIDNEY
14.69
1.00
75722
ARTERY X-RAYS, KIDNEY
14.89
1.00
Procedure Code Description
RVU
RVU Coeff Value
75724
ARTERY X-RAYS, KIDNEYS
9.18
1.00
75724
ARTERY X-RAYS, KIDNEYS
15.21
1.00
75724
ARTERY X-RAYS, KIDNEYS
15.40
1.00
75726
ARTERY X-RAYS, ABDOMEN
7.92
1.00
75726
ARTERY X-RAYS, ABDOMEN
14.67
1.00
75726
ARTERY X-RAYS, ABDOMEN
14.86
1.00
75731
ARTERY X-RAYS, ADRENAL GLAND
8.19
1.00
75731
ARTERY X-RAYS, ADRENAL GLAND
14.67
1.00
75731
ARTERY X-RAYS, ADRENAL GLAND
14.86
1.00
75733
ARTERY X-RAYS, ADRENALS
9.25
1.00
75733
ARTERY X-RAYS, ADRENALS
14.91
1.00
75733
ARTERY X-RAYS, ADRENALS
15.10
1.00
75736
ARTERY X-RAYS, PELVIS
7.99
1.00
75736
ARTERY X-RAYS, PELVIS
14.67
1.00
75736
ARTERY X-RAYS, PELVIS
14.86
1.00
75741
ARTERY X-RAYS, LUNG
7.68
1.00
75741
ARTERY X-RAYS, LUNG
14.91
1.00
75741
ARTERY X-RAYS, LUNG
15.10
1.00
75743
ARTERY X-RAYS, LUNGS
4.00
1.00
75743
ARTERY X-RAYS, LUNGS
8.39
1.00
75743
ARTERY X-RAYS, LUNGS
15.38
1.00
75743
ARTERY X-RAYS, LUNGS
15.57
1.00
75746
ARTERY X-RAYS, LUNG
7.75
1.00
75746
ARTERY X-RAYS, LUNG
14.67
1.00
75746
ARTERY X-RAYS, LUNG
14.86
1.00
75756
ARTERY X-RAYS, CHEST
8.21
1.00
75756
ARTERY X-RAYS, CHEST
14.73
1.00
75756
ARTERY X-RAYS, CHEST
14.92
1.00
75774
ARTERY X-RAY, EACH VESSEL
6.06
1.00
75774
ARTERY X-RAY, EACH VESSEL
13.60
1.00
75774
ARTERY X-RAY, EACH VESSEL
13.80
1.00
75790
VISUALIZE A-V SHUNT
3.96
1.00
75790
VISUALIZE A-V SHUNT
3.99
1.00
75790
VISUALIZE A-V SHUNT
4.84
1.00
75801
LYMPH VESSEL X-RAY, ARM/LEG
6.77
1.00
Procedure Code Description
RVU
RVU Coeff Value
75801
LYMPH VESSEL X-RAY, ARM/LEG
6.87
1.00
75803
LYMPH VESSEL X-RAY,ARMS/LEGS
7.25
1.00
75803
LYMPH VESSEL X-RAY,ARMS/LEGS
7.34
1.00
75805
LYMPH VESSEL X-RAY, TRUNK
7.47
1.00
75805
LYMPH VESSEL X-RAY, TRUNK
7.58
1.00
75807
LYMPH VESSEL X-RAY, TRUNK
7.96
1.00
75807
LYMPH VESSEL X-RAY, TRUNK
8.06
1.00
75809
NONVASCULAR SHUNT, X-RAY
1.47
1.00
75809
NONVASCULAR SHUNT, X-RAY
1.49
1.00
75809
NONVASCULAR SHUNT, X-RAY
2.39
1.00
75810
VEIN X-RAY, SPLEEN/LIVER
14.68
1.00
75810
VEIN X-RAY, SPLEEN/LIVER
14.87
1.00
75820
VEIN X-RAY, ARM/LEG
1.97
1.00
75820
VEIN X-RAY, ARM/LEG
1.98
1.00
75820
VEIN X-RAY, ARM/LEG
3.28
1.00
75822
VEIN X-RAY, ARMS/LEGS
3.01
1.00
75822
VEIN X-RAY, ARMS/LEGS
3.03
1.00
75822
VEIN X-RAY, ARMS/LEGS
4.02
1.00
75825
VEIN X-RAY, TRUNK
7.32
1.00
75825
VEIN X-RAY, TRUNK
14.68
1.00
75825
VEIN X-RAY, TRUNK
14.87
1.00
75827
VEIN X-RAY, CHEST
7.30
1.00
75827
VEIN X-RAY, CHEST
14.66
1.00
75827
VEIN X-RAY, CHEST
14.86
1.00
75831
VEIN X-RAY, KIDNEY
7.40
1.00
75831
VEIN X-RAY, KIDNEY
14.66
1.00
75831
VEIN X-RAY, KIDNEY
14.86
1.00
75833
VEIN X-RAY, KIDNEYS
8.24
1.00
75833
VEIN X-RAY, KIDNEYS
15.16
1.00
75833
VEIN X-RAY, KIDNEYS
15.35
1.00
75840
VEIN X-RAY, ADRENAL GLAND
7.34
1.00
75840
VEIN X-RAY, ADRENAL GLAND
14.69
1.00
75840
VEIN X-RAY, ADRENAL GLAND
14.88
1.00
75842
VEIN X-RAY, ADRENAL GLANDS
8.28
1.00
75842
VEIN X-RAY, ADRENAL GLANDS
15.15
1.00
Procedure Code Description 75842
VEIN X-RAY, ADRENAL GLANDS
75860
RVU
RVU Coeff Value
15.34
1.00
VEIN X-RAY, NECK
7.54
1.00
75860
VEIN X-RAY, NECK
14.69
1.00
75860
VEIN X-RAY, NECK
14.89
1.00
75870
VEIN X-RAY, SKULL
7.48
1.00
75870
VEIN X-RAY, SKULL
14.69
1.00
75870
VEIN X-RAY, SKULL
14.89
1.00
75872
VEIN X-RAY, SKULL
8.17
1.00
75872
VEIN X-RAY, SKULL
14.67
1.00
75872
VEIN X-RAY, SKULL
14.86
1.00
75880
VEIN X-RAY, EYE SOCKET
1.97
1.00
75880
VEIN X-RAY, EYE SOCKET
1.98
1.00
75880
VEIN X-RAY, EYE SOCKET
3.31
1.00
75885
VEIN X-RAY, LIVER
7.86
1.00
75885
VEIN X-RAY, LIVER
15.08
1.00
75885
VEIN X-RAY, LIVER
15.27
1.00
75887
VEIN X-RAY, LIVER
7.92
1.00
75887
VEIN X-RAY, LIVER
15.08
1.00
75887
VEIN X-RAY, LIVER
15.27
1.00
75889
VEIN X-RAY, LIVER
7.42
1.00
75889
VEIN X-RAY, LIVER
14.66
1.00
75889
VEIN X-RAY, LIVER
14.86
1.00
75891
VEIN X-RAY, LIVER
7.42
1.00
75891
VEIN X-RAY, LIVER
14.66
1.00
75891
VEIN X-RAY, LIVER
14.86
1.00
75893
VENOUS SAMPLING BY CATHETER
6.54
1.00
75893
VENOUS SAMPLING BY CATHETER
13.84
1.00
75893
VENOUS SAMPLING BY CATHETER
14.03
1.00
75894
X-RAYS, TRANSCATH THERAPY
26.91
1.00
75894
X-RAYS, TRANSCATH THERAPY
27.29
1.00
75894
X-RAYS, TRANSCATH THERAPY
27.31
1.00
75896
X-RAYS, TRANSCATH THERAPY
23.65
1.00
75896
X-RAYS, TRANSCATH THERAPY
23.99
1.00
75898
FOLLOW-UP ANGIOGRAPHY
3.38
1.00
75898
FOLLOW-UP ANGIOGRAPHY
3.40
1.00
Procedure Code Description
RVU
RVU Coeff Value
75900
INTRAVASCULAR CATH EXCHANGE
22.48
1.00
75900
INTRAVASCULAR CATH EXCHANGE
22.82
1.00
75901
REMOVE CVA DEVICE OBSTRUCT
2.67
1.00
75901
REMOVE CVA DEVICE OBSTRUCT
2.81
1.00
75901
REMOVE CVA DEVICE OBSTRUCT
4.82
1.00
75902
REMOVE CVA LUMEN OBSTRUCT
2.53
1.00
75902
REMOVE CVA LUMEN OBSTRUCT
2.68
1.00
75902
REMOVE CVA LUMEN OBSTRUCT
2.82
1.00
75940
X-RAY PLACEMENT, VEIN FILTER
13.84
1.00
75940
X-RAY PLACEMENT, VEIN FILTER
14.05
1.00
75945
INTRAVASCULAR US
5.33
1.00
75945
INTRAVASCULAR US
5.40
1.00
75946
INTRAVASCULAR US ADD-ON
2.96
1.00
75946
INTRAVASCULAR US ADD-ON
3.01
1.00
75952
ENDOVASC REPAIR ABDOM AORTA
6.31
1.00
75952
ENDOVASC REPAIR ABDOM AORTA
6.34
1.00
75952
ENDOVASC REPAIR ABDOM AORTA
6.41
1.00
75952
ENDOVASC REPAIR ABDOM AORTA
6.42
1.00
75952
ENDOVASC REPAIR ABDOM AORTA
6.81
1.00
75952
ENDOVASC REPAIR ABDOM AORTA
6.93
1.00
75953
ABDOM ANEURYSM ENDOVAS RPR
1.91
1.00
75953
ABDOM ANEURYSM ENDOVAS RPR
1.92
1.00
75953
ABDOM ANEURYSM ENDOVAS RPR
1.94
1.00
75953
ABDOM ANEURYSM ENDOVAS RPR
2.57
1.00
75953
ABDOM ANEURYSM ENDOVAS RPR
2.63
1.00
75954
ILIAC ANEURYSM ENDOVAS RPR
3.10
1.00
75954
ILIAC ANEURYSM ENDOVAS RPR
3.11
1.00
75954
ILIAC ANEURYSM ENDOVAS RPR
3.18
1.00
75960
TRANSCATH IV STENT RS&I
7.43
1.00
75960
TRANSCATH IV STENT RS&I
16.63
1.00
75960
TRANSCATH IV STENT RS&I
16.88
1.00
75961
RETRIEVAL, BROKEN CATHETER
11.54
1.00
75961
RETRIEVAL, BROKEN CATHETER
16.79
1.00
75961
RETRIEVAL, BROKEN CATHETER
16.95
1.00
75962
REPAIR ARTERIAL BLOCKAGE
7.94
1.00
Procedure Code Description
RVU
RVU Coeff Value
75962
REPAIR ARTERIAL BLOCKAGE
17.12
1.00
75962
REPAIR ARTERIAL BLOCKAGE
17.40
1.00
75964
REPAIR ARTERY BLOCKAGE, EACH
4.67
1.00
75964
REPAIR ARTERY BLOCKAGE, EACH
9.23
1.00
75964
REPAIR ARTERY BLOCKAGE, EACH
9.35
1.00
75966
REPAIR ARTERIAL BLOCKAGE
9.28
1.00
75966
REPAIR ARTERIAL BLOCKAGE
18.21
1.00
75966
REPAIR ARTERIAL BLOCKAGE
18.47
1.00
75968
REPAIR ARTERY BLOCKAGE, EACH
4.68
1.00
75968
REPAIR ARTERY BLOCKAGE, EACH
9.22
1.00
75968
REPAIR ARTERY BLOCKAGE, EACH
9.35
1.00
75970
VASCULAR BIOPSY
13.15
1.00
75970
VASCULAR BIOPSY
13.36
1.00
75978
REPAIR VENOUS BLOCKAGE
7.81
1.00
75978
REPAIR VENOUS BLOCKAGE
17.10
1.00
75978
REPAIR VENOUS BLOCKAGE
17.37
1.00
75980
CONTRAST XRAY EXAM BILE DUCT
7.62
1.00
75980
CONTRAST XRAY EXAM BILE DUCT
7.71
1.00
75984
XRAY CONTROL CATHETER CHANGE
3.02
1.00
75984
XRAY CONTROL CATHETER CHANGE
3.07
1.00
75984
XRAY CONTROL CATHETER CHANGE
3.16
1.00
75989
ABSCESS DRAINAGE UNDER X-RAY
4.00
1.00
75989
ABSCESS DRAINAGE UNDER X-RAY
4.91
1.00
75989
ABSCESS DRAINAGE UNDER X-RAY
4.97
1.00
75992
ATHERECTOMY, X-RAY EXAM
17.12
1.00
75992
ATHERECTOMY, X-RAY EXAM
17.38
1.00
75993
ATHERECTOMY, X-RAY EXAM
9.23
1.00
75993
ATHERECTOMY, X-RAY EXAM
9.36
1.00
75994
ATHERECTOMY, X-RAY EXAM
18.21
1.00
75994
ATHERECTOMY, X-RAY EXAM
18.47
1.00
75995
ATHERECTOMY, X-RAY EXAM
18.22
1.00
75995
ATHERECTOMY, X-RAY EXAM
18.48
1.00
75996
ATHERECTOMY, X-RAY EXAM
9.21
1.00
75996
ATHERECTOMY, X-RAY EXAM
9.34
1.00
75998
FLUOROGUIDE FOR VEIN DEVICE
1.93
1.00
Procedure Code Description
RVU
RVU Coeff Value
75998
FLUOROGUIDE FOR VEIN DEVICE
1.97
1.00
76000
FLUOROSCOPE EXAMINATION
1.59
1.00
76000
FLUOROSCOPE EXAMINATION
1.61
1.00
76000
FLUOROSCOPE EXAMINATION
2.64
1.00
76001
FLUOROSCOPE EXAM, EXTENSIVE
3.66
1.00
76001
FLUOROSCOPE EXAM, EXTENSIVE
3.69
1.00
76003
NEEDLE LOCALIZATION BY X-RAY
2.11
1.00
76003
NEEDLE LOCALIZATION BY X-RAY
2.13
1.00
76005
FLUOROGUIDE FOR SPINE INJECT
2.15
1.00
76005
FLUOROGUIDE FOR SPINE INJECT
2.16
1.00
76005
FLUOROGUIDE FOR SPINE INJECT
2.18
1.00
76006
X-RAY STRESS VIEW
0.64
1.00
76006
X-RAY STRESS VIEW
0.65
1.00
76010
X-RAY, NOSE TO RECTUM
0.77
1.00
76010
X-RAY, NOSE TO RECTUM
0.79
1.00
76012
PERCUT VERTEBROPLASTY FLUOR
1.88
1.00
76012
PERCUT VERTEBROPLASTY FLUOR
2.05
1.00
76013
PERCUT VERTEBROPLASTY, CT
1.93
1.00
76013
PERCUT VERTEBROPLASTY, CT
1.94
1.00
76013
PERCUT VERTEBROPLASTY, CT
2.40
1.00
76013
PERCUT VERTEBROPLASTY, CT
2.43
1.00
76020
X-RAYS FOR BONE AGE
0.80
1.00
76040
X-RAYS, BONE EVALUATION
1.20
1.00
76040
X-RAYS, BONE EVALUATION
1.21
1.00
76040
X-RAYS, BONE EVALUATION
1.24
1.00
76061
X-RAYS, BONE SURVEY
1.67
1.00
76061
X-RAYS, BONE SURVEY
1.68
1.00
76062
X-RAYS, BONE SURVEY
2.24
1.00
76062
X-RAYS, BONE SURVEY
2.26
1.00
76065
X-RAYS, BONE EVALUATION
1.73
1.00
76065
X-RAYS, BONE EVALUATION
1.74
1.00
76066
JOINT SURVEY, SINGLE VIEW
1.59
1.00
76066
JOINT SURVEY, SINGLE VIEW
1.60
1.00
76066
JOINT SURVEY, SINGLE VIEW
1.62
1.00
76070
CT BONE DENSITY, AXIAL
3.41
1.00
Procedure Code Description
RVU
RVU Coeff Value
76070
CT BONE DENSITY, AXIAL
3.46
1.00
76071
CT BONE DENSITY, PERIPHERAL
3.28
1.00
76071
CT BONE DENSITY, PERIPHERAL
3.31
1.00
76075
DXA BONE DENSITY, AXIAL
3.64
1.00
76075
DXA BONE DENSITY, AXIAL
3.68
1.00
76075
DXA BONE DENSITY, AXIAL
3.69
1.00
76076
DXA BONE DENSITY/PERIPHERAL
1.10
1.00
76076
DXA BONE DENSITY/PERIPHERAL
1.11
1.00
76076
DXA BONE DENSITY/PERIPHERAL
1.12
1.00
76077
DXA BONE DENSITY/V-FRACTURE
1.04
1.00
76078
RADIOGRAPHIC ABSORPTIOMETRY
1.07
1.00
76078
RADIOGRAPHIC ABSORPTIOMETRY
1.08
1.00
76078
RADIOGRAPHIC ABSORPTIOMETRY
1.09
1.00
76080
X-RAY EXAM OF FISTULA
1.76
1.00
76080
X-RAY EXAM OF FISTULA
1.83
1.00
76080
X-RAY EXAM OF FISTULA
1.86
1.00
76082
COMPUTER MAMMOGRAM ADD-ON
0.51
1.00
76082
COMPUTER MAMMOGRAM ADD-ON
0.52
1.00
76083
COMPUTER MAMMOGRAM ADD-ON
0.51
1.00
76083
COMPUTER MAMMOGRAM ADD-ON
0.52
1.00
76085
COMPUTER MAMMOGRAM ADD-ON
0.52
1.00
76086
X-RAY OF MAMMARY DUCT
3.23
1.00
76086
X-RAY OF MAMMARY DUCT
3.26
1.00
76086
X-RAY OF MAMMARY DUCT
3.27
1.00
76088
X-RAY OF MAMMARY DUCTS
4.43
1.00
76088
X-RAY OF MAMMARY DUCTS
4.48
1.00
76088
X-RAY OF MAMMARY DUCTS
4.49
1.00
76090
MAMMOGRAM, ONE BREAST
2.06
1.00
76090
MAMMOGRAM, ONE BREAST
2.07
1.00
76090
MAMMOGRAM, ONE BREAST
2.09
1.00
76091
MAMMOGRAM, BOTH BREASTS
2.56
1.00
76091
MAMMOGRAM, BOTH BREASTS
2.57
1.00
76091
MAMMOGRAM, BOTH BREASTS
2.58
1.00
76092
MAMM0GRAM, SCREENING
2.25
1.00
76092
MAMM0GRAM, SCREENING
2.26
1.00
Procedure Code Description
RVU
RVU Coeff Value
76092
MAMM0GRAM, SCREENING
2.27
1.00
76093
MAGNETIC IMAGE, BREAST
20.57
1.00
76093
MAGNETIC IMAGE, BREAST
20.82
1.00
76093
MAGNETIC IMAGE, BREAST
20.84
1.00
76094
MAGNETIC IMAGE, BOTH BREASTS
27.08
1.00
76094
MAGNETIC IMAGE, BOTH BREASTS
27.45
1.00
76094
MAGNETIC IMAGE, BOTH BREASTS
27.47
1.00
76095
STEREOTACTIC BREAST BIOPSY
9.66
1.00
76095
STEREOTACTIC BREAST BIOPSY
9.75
1.00
76095
STEREOTACTIC BREAST BIOPSY
9.78
1.00
76096
X-RAY OF NEEDLE WIRE, BREAST
2.14
1.00
76096
X-RAY OF NEEDLE WIRE, BREAST
2.17
1.00
76098
X-RAY EXAM, BREAST SPECIMEN
0.55
1.00
76098
X-RAY EXAM, BREAST SPECIMEN
0.65
1.00
76098
X-RAY EXAM, BREAST SPECIMEN
0.67
1.00
76100
X-RAY EXAM OF BODY SECTION
2.11
1.00
76100
X-RAY EXAM OF BODY SECTION
2.13
1.00
76100
X-RAY EXAM OF BODY SECTION
3.69
1.00
76101
COMPLEX BODY SECTION X-RAY
2.29
1.00
76101
COMPLEX BODY SECTION X-RAY
2.32
1.00
76101
COMPLEX BODY SECTION X-RAY
5.10
1.00
76102
COMPLEX BODY SECTION X-RAYS
2.62
1.00
76102
COMPLEX BODY SECTION X-RAYS
2.67
1.00
76102
COMPLEX BODY SECTION X-RAYS
6.84
1.00
76120
CINE/VIDEO X-RAYS
1.62
1.00
76120
CINE/VIDEO X-RAYS
1.65
1.00
76120
CINE/VIDEO X-RAYS
2.08
1.00
76125
CINE/VIDEO X-RAYS ADD-ON
1.20
1.00
76125
CINE/VIDEO X-RAYS ADD-ON
1.21
1.00
76150
X-RAY EXAM, DRY PROCESS
0.43
1.00
76150
X-RAY EXAM, DRY PROCESS
0.44
1.00
76150
X-RAY EXAM, DRY PROCESS
0.51
1.00
76355
CT SCAN FOR LOCALIZATION
10.26
1.00
76355
CT SCAN FOR LOCALIZATION
10.36
1.00
76355
CT SCAN FOR LOCALIZATION
10.39
1.00
Procedure Code Description
RVU
RVU Coeff Value
76360
CT SCAN FOR NEEDLE BIOPSY
10.17
1.00
76360
CT SCAN FOR NEEDLE BIOPSY
10.29
1.00
76360
CT SCAN FOR NEEDLE BIOPSY
10.30
1.00
76362
CT GUIDE FOR TISSUE ABLATION
14.96
1.00
76362
CT GUIDE FOR TISSUE ABLATION
15.21
1.00
76362
CT GUIDE FOR TISSUE ABLATION
15.26
1.00
76375
3D/HOLOGRAPH RECONSTR ADD-ON
3.89
1.00
76375
3D/HOLOGRAPH RECONSTR ADD-ON
3.94
1.00
76375
3D/HOLOGRAPH RECONSTR ADD-ON
3.95
1.00
76376
3D RENDER W/O POSTPROCESS
2.22
1.00
76377
3D RENDERING W/POSTPROCESS
3.16
1.00
76380
CAT SCAN FOLLOW-UP STUDY
4.98
1.00
76380
CAT SCAN FOLLOW-UP STUDY
5.05
1.00
76380
CAT SCAN FOLLOW-UP STUDY
5.68
1.00
76390
MR SPECTROSCOPY
12.80
1.00
76390
MR SPECTROSCOPY
13.54
1.00
76390
MR SPECTROSCOPY
13.59
1.00
76393
MR GUIDANCE FOR NEEDLE PLACE
13.71
1.00
76393
MR GUIDANCE FOR NEEDLE PLACE
13.87
1.00
76394
MRI FOR TISSUE ABLATION
18.33
1.00
76394
MRI FOR TISSUE ABLATION
18.66
1.00
76400
MAGNETIC IMAGE, BONE MARROW
7.00
1.00
76400
MAGNETIC IMAGE, BONE MARROW
13.86
1.00
76400
MAGNETIC IMAGE, BONE MARROW
14.01
1.00
76400
MAGNETIC IMAGE, BONE MARROW
14.03
1.00
76490
US FOR TISSUE ABLATION
7.20
1.00
77261
RADIATION THERAPY PLANNING
1.97
1.00
77261
RADIATION THERAPY PLANNING
1.99
1.00
77262
RADIATION THERAPY PLANNING
2.96
1.00
77262
RADIATION THERAPY PLANNING
2.97
1.00
77262
RADIATION THERAPY PLANNING
3.00
1.00
77263
RADIATION THERAPY PLANNING
4.39
1.00
77263
RADIATION THERAPY PLANNING
4.42
1.00
77263
RADIATION THERAPY PLANNING
4.44
1.00
77280
SET RADIATION THERAPY FIELD
4.57
1.00
Procedure Code Description
RVU
RVU Coeff Value
77280
SET RADIATION THERAPY FIELD
4.62
1.00
77280
SET RADIATION THERAPY FIELD
5.11
1.00
77285
SET RADIATION THERAPY FIELD
7.24
1.00
77285
SET RADIATION THERAPY FIELD
7.33
1.00
77285
SET RADIATION THERAPY FIELD
8.80
1.00
77290
SET RADIATION THERAPY FIELD
8.92
1.00
77290
SET RADIATION THERAPY FIELD
9.00
1.00
77290
SET RADIATION THERAPY FIELD
13.63
1.00
77295
SET RADIATION THERAPY FIELD
19.17
1.00
77295
SET RADIATION THERAPY FIELD
35.33
1.00
77295
SET RADIATION THERAPY FIELD
35.74
1.00
77300
RADIATION THERAPY DOSE PLAN
1.98
1.00
77300
RADIATION THERAPY DOSE PLAN
2.25
1.00
77300
RADIATION THERAPY DOSE PLAN
2.28
1.00
77301
RADIOTHERAPY DOSE PLAN, IMRT
40.26
1.00
77301
RADIOTHERAPY DOSE PLAN, IMRT
40.33
1.00
77301
RADIOTHERAPY DOSE PLAN, IMRT
59.80
1.00
77305
TELETX ISODOSE PLAN SIMPLE
2.05
1.00
77305
TELETX ISODOSE PLAN SIMPLE
2.91
1.00
77305
TELETX ISODOSE PLAN SIMPLE
2.95
1.00
77310
TELETX ISODOSE PLAN INTERMED
2.84
1.00
77310
TELETX ISODOSE PLAN INTERMED
3.88
1.00
77310
TELETX ISODOSE PLAN INTERMED
3.91
1.00
77315
TELETX ISODOSE PLAN COMPLEX
4.13
1.00
77315
TELETX ISODOSE PLAN COMPLEX
4.92
1.00
77321
SPECIAL TELETX PORT PLAN
3.42
1.00
77321
SPECIAL TELETX PORT PLAN
5.50
1.00
77321
SPECIAL TELETX PORT PLAN
5.58
1.00
77326
BRACHYTX ISODOSE CALC SIMP
3.74
1.00
77326
BRACHYTX ISODOSE CALC SIMP
3.78
1.00
77326
BRACHYTX ISODOSE CALC SIMP
3.96
1.00
77327
BRACHYTX ISODOSE CALC INTERM
5.52
1.00
77327
BRACHYTX ISODOSE CALC INTERM
5.56
1.00
77327
BRACHYTX ISODOSE CALC INTERM
5.64
1.00
77328
BRACHYTX ISODOSE PLAN COMPL
7.73
1.00
Procedure Code Description
RVU
RVU Coeff Value
77328
BRACHYTX ISODOSE PLAN COMPL
8.04
1.00
77328
BRACHYTX ISODOSE PLAN COMPL
8.08
1.00
77331
SPECIAL RADIATION DOSIMETRY
1.72
1.00
77331
SPECIAL RADIATION DOSIMETRY
1.73
1.00
77332
RADIATION TREATMENT AID(S)
2.13
1.00
77332
RADIATION TREATMENT AID(S)
2.15
1.00
77332
RADIATION TREATMENT AID(S)
2.16
1.00
77332
RADIATION TREATMENT AID(S)
2.17
1.00
77333
RADIATION TREATMENT AID(S)
1.93
1.00
77333
RADIATION TREATMENT AID(S)
2.74
1.00
77333
RADIATION TREATMENT AID(S)
3.15
1.00
77333
RADIATION TREATMENT AID(S)
3.17
1.00
77334
RADIATION TREATMENT AID(S)
4.40
1.00
77334
RADIATION TREATMENT AID(S)
4.90
1.00
77334
RADIATION TREATMENT AID(S)
5.08
1.00
77334
RADIATION TREATMENT AID(S)
5.12
1.00
77336
RADIATION PHYSICS CONSULT
1.74
1.00
77336
RADIATION PHYSICS CONSULT
3.10
1.00
77336
RADIATION PHYSICS CONSULT
3.15
1.00
77370
RADIATION PHYSICS CONSULT
3.27
1.00
77370
RADIATION PHYSICS CONSULT
3.62
1.00
77370
RADIATION PHYSICS CONSULT
3.68
1.00
77371
SRS, MULTISOURCE
30.24
1.00
77372
SRS, LINEAR BASED
22.43
1.00
77373
SBRT DELIVERY
41.51
1.00
77401
RADIATION TREATMENT DELIVERY
0.90
1.00
77401
RADIATION TREATMENT DELIVERY
1.85
1.00
77401
RADIATION TREATMENT DELIVERY
1.89
1.00
77402
RADIATION TREATMENT DELIVERY
1.85
1.00
77402
RADIATION TREATMENT DELIVERY
1.89
1.00
77402
RADIATION TREATMENT DELIVERY
3.76
1.00
77403
RADIATION TREATMENT DELIVERY
1.85
1.00
77403
RADIATION TREATMENT DELIVERY
1.89
1.00
77403
RADIATION TREATMENT DELIVERY
3.31
1.00
77404
RADIATION TREATMENT DELIVERY
1.85
1.00
Procedure Code Description
RVU
RVU Coeff Value
77404
RADIATION TREATMENT DELIVERY
1.89
1.00
77404
RADIATION TREATMENT DELIVERY
3.64
1.00
77406
RADIATION TREATMENT DELIVERY
1.85
1.00
77406
RADIATION TREATMENT DELIVERY
1.89
1.00
77406
RADIATION TREATMENT DELIVERY
3.67
1.00
77407
RADIATION TREATMENT DELIVERY
2.18
1.00
77407
RADIATION TREATMENT DELIVERY
2.21
1.00
77407
RADIATION TREATMENT DELIVERY
5.88
1.00
77408
RADIATION TREATMENT DELIVERY
2.18
1.00
77408
RADIATION TREATMENT DELIVERY
2.21
1.00
77408
RADIATION TREATMENT DELIVERY
4.43
1.00
77409
RADIATION TREATMENT DELIVERY
2.18
1.00
77409
RADIATION TREATMENT DELIVERY
2.21
1.00
77409
RADIATION TREATMENT DELIVERY
4.88
1.00
77411
RADIATION TREATMENT DELIVERY
2.18
1.00
77411
RADIATION TREATMENT DELIVERY
2.21
1.00
77411
RADIATION TREATMENT DELIVERY
4.85
1.00
77412
RADIATION TREATMENT DELIVERY
2.43
1.00
77412
RADIATION TREATMENT DELIVERY
2.47
1.00
77412
RADIATION TREATMENT DELIVERY
5.70
1.00
77413
RADIATION TREATMENT DELIVERY
2.43
1.00
77413
RADIATION TREATMENT DELIVERY
2.47
1.00
77413
RADIATION TREATMENT DELIVERY
5.74
1.00
77414
RADIATION TREATMENT DELIVERY
2.43
1.00
77414
RADIATION TREATMENT DELIVERY
2.47
1.00
77414
RADIATION TREATMENT DELIVERY
6.37
1.00
77416
RADIATION TREATMENT DELIVERY
2.43
1.00
77416
RADIATION TREATMENT DELIVERY
2.47
1.00
77416
RADIATION TREATMENT DELIVERY
6.40
1.00
77417
RADIOLOGY PORT FILM(S)
0.45
1.00
77417
RADIOLOGY PORT FILM(S)
0.62
1.00
77417
RADIOLOGY PORT FILM(S)
0.63
1.00
77418
RADIATION TX DELIVERY, IMRT
14.33
1.00
77418
RADIATION TX DELIVERY, IMRT
18.08
1.00
77418
RADIATION TX DELIVERY, IMRT
18.18
1.00
Procedure Code Description
RVU
RVU Coeff Value
77421
STEREOSCOPIC X-RAY GUIDANCE
3.14
1.00
77422
NEUTRON BEAM TX, SIMPLE
5.37
1.00
77423
NEUTRON BEAM TX, COMPLEX
6.16
1.00
77427
RADIATION TX MANAGEMENT, X5
4.53
1.00
77427
RADIATION TX MANAGEMENT, X5
4.57
1.00
77427
RADIATION TX MANAGEMENT, X5
5.22
1.00
77431
RADIATION THERAPY MANAGEMENT
2.57
1.00
77431
RADIATION THERAPY MANAGEMENT
2.59
1.00
77431
RADIATION THERAPY MANAGEMENT
2.67
1.00
77432
STEREOTACTIC RADIATION TRMT
11.11
1.00
77432
STEREOTACTIC RADIATION TRMT
11.23
1.00
77432
STEREOTACTIC RADIATION TRMT
11.32
1.00
77435
SBRT MANAGEMENT
18.43
1.00
77470
SPECIAL RADIATION TREATMENT
7.20
1.00
77470
SPECIAL RADIATION TREATMENT
14.48
1.00
77470
SPECIAL RADIATION TREATMENT
14.64
1.00
77620
HYPERTHERMIA TREATMENT
5.33
1.00
77620
HYPERTHERMIA TREATMENT
5.36
1.00
77620
HYPERTHERMIA TREATMENT
10.74
1.00
77750
INFUSE RADIOACTIVE MATERIALS
8.09
1.00
77750
INFUSE RADIOACTIVE MATERIALS
8.14
1.00
77750
INFUSE RADIOACTIVE MATERIALS
9.40
1.00
77761
APPLY INTRCAV RADIAT SIMPLE
3.00
1.00
77761
APPLY INTRCAV RADIAT SIMPLE
7.73
1.00
77761
APPLY INTRCAV RADIAT SIMPLE
7.75
1.00
77761
APPLY INTRCAV RADIAT SIMPLE
9.74
1.00
77762
APPLY INTRCAV RADIAT INTERM
3.00
1.00
77762
APPLY INTRCAV RADIAT INTERM
11.61
1.00
77762
APPLY INTRCAV RADIAT INTERM
11.62
1.00
77762
APPLY INTRCAV RADIAT INTERM
13.29
1.00
77763
APPLY INTRCAV RADIAT COMPL
3.00
1.00
77763
APPLY INTRCAV RADIAT COMPL
16.42
1.00
77763
APPLY INTRCAV RADIAT COMPL
16.45
1.00
77763
APPLY INTRCAV RADIAT COMPL
18.80
1.00
77776
APPLY INTERSTIT RADIAT SIMPL
8.16
1.00
Procedure Code Description
RVU
RVU Coeff Value
77776
APPLY INTERSTIT RADIAT SIMPL
8.21
1.00
77776
APPLY INTERSTIT RADIAT SIMPL
11.49
1.00
77777
APPLY INTERSTIT RADIAT INTER
14.68
1.00
77777
APPLY INTERSTIT RADIAT INTER
14.69
1.00
77777
APPLY INTERSTIT RADIAT INTER
15.92
1.00
77778
APPLY INTERSTIT RADIAT COMPL
20.70
1.00
77778
APPLY INTERSTIT RADIAT COMPL
20.76
1.00
77778
APPLY INTERSTIT RADIAT COMPL
22.77
1.00
77781
REMOTE AFTERLOADING HIGH INTENSITY
14.97
1.00
77781
REMOTE AFTERLOADING HIGH INTENSITY
23.40
1.00
77781
REMOTE AFTERLOADING HIGH INTENSITY
23.71
1.00
77782
REMOTE AFTERLOADING HIGH INTENSITY
19.99
1.00
77782
REMOTE AFTERLOADING HIGH INTENSITY
24.54
1.00
77782
REMOTE AFTERLOADING HIGH INTENSITY
24.85
1.00
77783
REMOTE AFTERLOADING HIGH INTENSITY
26.24
1.00
77783
REMOTE AFTERLOADING HIGH INTENSITY
26.52
1.00
77783
REMOTE AFTERLOADING HIGH INTENSITY
27.38
1.00
77784
REMOTE AFTERLOADING HIGH INTENSITY
28.82
1.00
77784
REMOTE AFTERLOADING HIGH INTENSITY
29.09
1.00
77784
REMOTE AFTERLOADING HIGH INTENSITY
40.41
1.00
77785
HDR BRACHYTX, 1 CHANNEL
5.16
1.00
77786
HDR BRACHYTX, 2-12 CHANNEL
15.47
1.00
77787
HDR BRACHYTX OVER 12 CHAN
22.99
1.00
77789
APPLY SURFACE RADIATION
2.00
1.00
77789
APPLY SURFACE RADIATION
2.01
1.00
77789
APPLY SURFACE RADIATION
2.89
1.00
77790
RADIATION HANDLING
1.96
1.00
77790
RADIATION HANDLING
1.97
1.00
77790
RADIATION HANDLING
2.42
1.00
78000
THYROID, SINGLE UPTAKE
1.29
1.00
78000
THYROID, SINGLE UPTAKE
1.30
1.00
78000
THYROID, SINGLE UPTAKE
1.90
1.00
78001
THYROID, MULTIPLE UPTAKES
1.72
1.00
78001
THYROID, MULTIPLE UPTAKES
1.74
1.00
78001
THYROID, MULTIPLE UPTAKES
2.41
1.00
Procedure Code Description
RVU
RVU Coeff Value
78003
THYROID SUPPRESS/STIMUL
1.47
1.00
78003
THYROID SUPPRESS/STIMUL
1.48
1.00
78003
THYROID SUPPRESS/STIMUL
2.10
1.00
78006
THYROID IMAGING WITH UPTAKE
3.16
1.00
78006
THYROID IMAGING WITH UPTAKE
3.20
1.00
78006
THYROID IMAGING WITH UPTAKE
5.92
1.00
78007
THYROID IMAGE, MULT UPTAKES
3.37
1.00
78007
THYROID IMAGE, MULT UPTAKES
3.42
1.00
78007
THYROID IMAGE, MULT UPTAKES
3.63
1.00
78010
THYROID IMAGING
2.45
1.00
78010
THYROID IMAGING
2.48
1.00
78010
THYROID IMAGING
4.13
1.00
78011
THYROID IMAGING WITH FLOW
3.14
1.00
78011
THYROID IMAGING WITH FLOW
3.17
1.00
78011
THYROID IMAGING WITH FLOW
4.70
1.00
78015
THYROID MET IMAGING
3.61
1.00
78015
THYROID MET IMAGING
3.67
1.00
78015
THYROID MET IMAGING
5.58
1.00
78016
THYROID MET IMAGING/STUDIES
4.76
1.00
78016
THYROID MET IMAGING/STUDIES
4.82
1.00
78016
THYROID MET IMAGING/STUDIES
8.46
1.00
78018
THYROID MET IMAGING, BODY
6.84
1.00
78018
THYROID MET IMAGING, BODY
6.94
1.00
78018
THYROID MET IMAGING, BODY
8.57
1.00
78020
THYROID MET UPTAKE
2.26
1.00
78020
THYROID MET UPTAKE
2.28
1.00
78020
THYROID MET UPTAKE
2.52
1.00
78070
PARATHYROID NUCLEAR IMAGING
3.04
1.00
78070
PARATHYROID NUCLEAR IMAGING
3.08
1.00
78070
PARATHYROID NUCLEAR IMAGING
4.73
1.00
78075
ADRENAL NUCLEAR IMAGING
6.68
1.00
78075
ADRENAL NUCLEAR IMAGING
6.79
1.00
78075
ADRENAL NUCLEAR IMAGING
11.11
1.00
78102
BONE MARROW IMAGING, LTD
2.90
1.00
78102
BONE MARROW IMAGING, LTD
2.93
1.00
Procedure Code Description
RVU
RVU Coeff Value
78102
BONE MARROW IMAGING, LTD
4.39
1.00
78103
BONE MARROW IMAGING, MULT
4.34
1.00
78103
BONE MARROW IMAGING, MULT
4.40
1.00
78103
BONE MARROW IMAGING, MULT
5.90
1.00
78104
BONE MARROW IMAGING, BODY
5.34
1.00
78104
BONE MARROW IMAGING, BODY
5.42
1.00
78104
BONE MARROW IMAGING, BODY
6.77
1.00
78110
PLASMA VOLUME, SINGLE
1.27
1.00
78110
PLASMA VOLUME, SINGLE
1.28
1.00
78110
PLASMA VOLUME, SINGLE
2.10
1.00
78111
PLASMA VOLUME, MULTIPLE
2.70
1.00
78111
PLASMA VOLUME, MULTIPLE
2.99
1.00
78111
PLASMA VOLUME, MULTIPLE
3.04
1.00
78120
RED CELL MASS, SINGLE
2.13
1.00
78120
RED CELL MASS, SINGLE
2.17
1.00
78120
RED CELL MASS, SINGLE
2.40
1.00
78121
RED CELL MASS, MULTIPLE
2.91
1.00
78121
RED CELL MASS, MULTIPLE
3.47
1.00
78121
RED CELL MASS, MULTIPLE
3.50
1.00
78130
RED CELL SURVIVAL STUDY
3.82
1.00
78130
RED CELL SURVIVAL STUDY
3.86
1.00
78130
RED CELL SURVIVAL STUDY
4.20
1.00
78135
RED CELL SURVIVAL KINETICS
5.97
1.00
78135
RED CELL SURVIVAL KINETICS
6.04
1.00
78135
RED CELL SURVIVAL KINETICS
8.74
1.00
78140
RED CELL SEQUESTRATION
4.09
1.00
78140
RED CELL SEQUESTRATION
4.94
1.00
78140
RED CELL SEQUESTRATION
5.01
1.00
78160
PLASMA IRON TURNOVER
4.29
1.00
78160
PLASMA IRON TURNOVER
4.34
1.00
78160
PLASMA IRON TURNOVER
4.36
1.00
78162
RADIOIRON ABSORPTION EXAM
3.97
1.00
78162
RADIOIRON ABSORPTION EXAM
4.03
1.00
78170
RED CELL IRON UTILIZATION
6.10
1.00
78170
RED CELL IRON UTILIZATION
6.16
1.00
Procedure Code Description
RVU
RVU Coeff Value
78170
RED CELL IRON UTILIZATION
6.21
1.00
78185
SPLEEN IMAGING
3.02
1.00
78185
SPLEEN IMAGING
3.06
1.00
78185
SPLEEN IMAGING
5.09
1.00
78190
KINETICS, STUDY OF PLATELET SURVIV
7.57
1.00
78190
KINETICS, STUDY OF PLATELET SURVIV
7.59
1.00
78190
KINETICS, STUDY OF PLATELET SURVIV
10.02
1.00
78191
PLATELET SURVIVAL
5.51
1.00
78191
PLATELET SURVIVAL
8.46
1.00
78191
PLATELET SURVIVAL
8.58
1.00
78195
LYMPH SYSTEM IMAGING
5.91
1.00
78195
LYMPH SYSTEM IMAGING
5.98
1.00
78195
LYMPH SYSTEM IMAGING
9.10
1.00
78201
LIVER IMAGING
3.07
1.00
78201
LIVER IMAGING
3.11
1.00
78201
LIVER IMAGING
4.70
1.00
78202
LIVER IMAGING WITH FLOW
3.70
1.00
78202
LIVER IMAGING WITH FLOW
3.74
1.00
78202
LIVER IMAGING WITH FLOW
5.42
1.00
78205
LIVER IMAGING (3D)
6.53
1.00
78205
LIVER IMAGING (3D)
7.13
1.00
78205
LIVER IMAGING (3D)
7.24
1.00
78206
LIVER IMAGE (3D) WITH FLOW
7.31
1.00
78206
LIVER IMAGE (3D) WITH FLOW
7.39
1.00
78206
LIVER IMAGE (3D) WITH FLOW
9.08
1.00
78215
LIVER AND SPLEEN IMAGING
3.73
1.00
78215
LIVER AND SPLEEN IMAGING
3.77
1.00
78215
LIVER AND SPLEEN IMAGING
5.02
1.00
78216
LIVER & SPLEEN IMAGE/FLOW
3.82
1.00
78216
LIVER & SPLEEN IMAGE/FLOW
4.40
1.00
78216
LIVER & SPLEEN IMAGE/FLOW
4.46
1.00
78220
LIVER FUNCTION STUDY
3.98
1.00
78220
LIVER FUNCTION STUDY
4.54
1.00
78220
LIVER FUNCTION STUDY
4.61
1.00
78223
HEPATOBILIARY IMAGING
4.98
1.00
Procedure Code Description
RVU
RVU Coeff Value
78223
HEPATOBILIARY IMAGING
5.04
1.00
78223
HEPATOBILIARY IMAGING
8.39
1.00
78230
SALIVARY GLAND IMAGING
2.90
1.00
78230
SALIVARY GLAND IMAGING
2.93
1.00
78230
SALIVARY GLAND IMAGING
4.28
1.00
78231
SERIAL SALIVARY IMAGING
3.67
1.00
78231
SERIAL SALIVARY IMAGING
4.02
1.00
78231
SERIAL SALIVARY IMAGING
4.08
1.00
78232
SALIVARY GLAND FUNCTION EXAM
3.74
1.00
78232
SALIVARY GLAND FUNCTION EXAM
4.32
1.00
78232
SALIVARY GLAND FUNCTION EXAM
4.38
1.00
78258
ESOPHAGEAL MOTILITY STUDY
4.02
1.00
78258
ESOPHAGEAL MOTILITY STUDY
4.06
1.00
78258
ESOPHAGEAL MOTILITY STUDY
5.95
1.00
78261
GASTRIC MUCOSA IMAGING
5.23
1.00
78261
GASTRIC MUCOSA IMAGING
5.31
1.00
78261
GASTRIC MUCOSA IMAGING
6.59
1.00
78262
GASTROESOPHAGEAL REFLUX EXAM
5.37
1.00
78262
GASTROESOPHAGEAL REFLUX EXAM
5.45
1.00
78262
GASTROESOPHAGEAL REFLUX EXAM
6.50
1.00
78264
GASTRIC EMPTYING STUDY
5.37
1.00
78264
GASTRIC EMPTYING STUDY
5.45
1.00
78264
GASTRIC EMPTYING STUDY
7.47
1.00
78270
VIT B-12 ABSORPTION EXAM
1.90
1.00
78270
VIT B-12 ABSORPTION EXAM
1.93
1.00
78270
VIT B-12 ABSORPTION EXAM
2.18
1.00
78271
VIT B-12 ABSRP EXAM, INT FAC
1.99
1.00
78271
VIT B-12 ABSRP EXAM, INT FAC
2.03
1.00
78271
VIT B-12 ABSRP EXAM, INT FAC
2.20
1.00
78272
VIT B-12 ABSORP, COMBINED
2.50
1.00
78272
VIT B-12 ABSORP, COMBINED
2.80
1.00
78272
VIT B-12 ABSORP, COMBINED
2.84
1.00
78278
ACUTE GI BLOOD LOSS IMAGING
6.44
1.00
78278
ACUTE GI BLOOD LOSS IMAGING
6.52
1.00
78278
ACUTE GI BLOOD LOSS IMAGING
9.00
1.00
Procedure Code Description
RVU
RVU Coeff Value
78282
GI PROTEIN LOSS EXAM
0.52
1.00
78282
GI PROTEIN LOSS EXAM
0.53
1.00
78282
GI PROTEIN LOSS EXAM
0.54
1.00
78290
MECKELÏS DIVERT EXAM
4.12
1.00
78290
MECKELÏS DIVERT EXAM
4.17
1.00
78290
MECKELÏS DIVERT EXAM
8.03
1.00
78291
LEVEEN/SHUNT PATENCY EXAM
4.41
1.00
78291
LEVEEN/SHUNT PATENCY EXAM
4.47
1.00
78291
LEVEEN/SHUNT PATENCY EXAM
6.55
1.00
78300
BONE IMAGING, LIMITED AREA
3.46
1.00
78300
BONE IMAGING, LIMITED AREA
3.51
1.00
78300
BONE IMAGING, LIMITED AREA
4.61
1.00
78305
BONE IMAGING, MULTIPLE AREAS
4.96
1.00
78305
BONE IMAGING, MULTIPLE AREAS
5.02
1.00
78305
BONE IMAGING, MULTIPLE AREAS
6.13
1.00
78306
BONE IMAGING, WHOLE BODY
5.64
1.00
78306
BONE IMAGING, WHOLE BODY
5.71
1.00
78306
BONE IMAGING, WHOLE BODY
6.79
1.00
78315
BONE IMAGING, 3 PHASE
6.39
1.00
78315
BONE IMAGING, 3 PHASE
6.47
1.00
78315
BONE IMAGING, 3 PHASE
9.01
1.00
78320
BONE IMAGING (3D)
6.99
1.00
78320
BONE IMAGING (3D)
7.59
1.00
78320
BONE IMAGING (3D)
7.70
1.00
78350
BONE MINERAL, SINGLE PHOTON
0.93
1.00
78350
BONE MINERAL, SINGLE PHOTON
1.10
1.00
78350
BONE MINERAL, SINGLE PHOTON
1.11
1.00
78351
BONE MINERAL, DUAL PHOTON
0.42
1.00
78351
BONE MINERAL, DUAL PHOTON
0.43
1.00
78414
NON-IMAGING HEART FUNCTION
0.60
1.00
78414
NON-IMAGING HEART FUNCTION
0.63
1.00
78428
CARDIAC SHUNT IMAGING
3.46
1.00
78428
CARDIAC SHUNT IMAGING
3.51
1.00
78428
CARDIAC SHUNT IMAGING
5.34
1.00
78445
VASCULAR FLOW IMAGING
2.63
1.00
Procedure Code Description
RVU
RVU Coeff Value
78445
VASCULAR FLOW IMAGING
2.66
1.00
78445
VASCULAR FLOW IMAGING
4.48
1.00
78455
VENOUS THROMBOSIS STUDY
5.16
1.00
78455
VENOUS THROMBOSIS STUDY
5.20
1.00
78455
VENOUS THROMBOSIS STUDY
5.23
1.00
78456
ACUTE VENOUS THROMBUS IMAGE
5.61
1.00
78456
ACUTE VENOUS THROMBUS IMAGE
5.69
1.00
78456
ACUTE VENOUS THROMBUS IMAGE
9.49
1.00
78457
VENOUS THROMBOSIS IMAGING
3.84
1.00
78457
VENOUS THROMBOSIS IMAGING
3.87
1.00
78457
VENOUS THROMBOSIS IMAGING
5.15
1.00
78458
VEN THROMBOSIS IMAGES, BILAT
5.43
1.00
78458
VEN THROMBOSIS IMAGES, BILAT
5.52
1.00
78458
VEN THROMBOSIS IMAGES, BILAT
5.70
1.00
78459
HEART MUSCLE IMAGING (PET)
2.13
1.00
78459
HEART MUSCLE IMAGING (PET)
7.61
1.00
78459
HEART MUSCLE IMAGING (PET)
8.99
1.00
78460
HEART MUSCLE BLOOD, SINGLE
3.65
1.00
78460
HEART MUSCLE BLOOD, SINGLE
3.70
1.00
78460
HEART MUSCLE BLOOD, SINGLE
5.16
1.00
78461
HEART MUSCLE BLOOD, MULTIPLE
5.84
1.00
78461
HEART MUSCLE BLOOD, MULTIPLE
6.64
1.00
78461
HEART MUSCLE BLOOD, MULTIPLE
6.71
1.00
78464
HEART IMAGE (3D), SINGLE
7.61
1.00
78464
HEART IMAGE (3D), SINGLE
8.87
1.00
78464
HEART IMAGE (3D), SINGLE
8.99
1.00
78465
HEART IMAGE (3D), MULTIPLE
13.45
1.00
78465
HEART IMAGE (3D), MULTIPLE
14.30
1.00
78465
HEART IMAGE (3D), MULTIPLE
14.49
1.00
78466
HEART INFARCT IMAGE
3.70
1.00
78466
HEART INFARCT IMAGE
3.74
1.00
78466
HEART INFARCT IMAGE
4.92
1.00
78468
HEART INFARCT IMAGE (EF)
4.92
1.00
78468
HEART INFARCT IMAGE (EF)
4.99
1.00
78468
HEART INFARCT IMAGE (EF)
6.21
1.00
Procedure Code Description
RVU
RVU Coeff Value
78469
HEART INFARCT IMAGE (3D)
6.69
1.00
78469
HEART INFARCT IMAGE (3D)
6.80
1.00
78469
HEART INFARCT IMAGE (3D)
7.08
1.00
78472
GATED HEART, PLANAR, SINGLE
7.10
1.00
78472
GATED HEART, PLANAR, SINGLE
7.21
1.00
78473
GATED HEART, MULTIPLE
9.86
1.00
78473
GATED HEART, MULTIPLE
10.62
1.00
78473
GATED HEART, MULTIPLE
10.75
1.00
78478
HEART WALL MOTION ADD-ON
1.65
1.00
78478
HEART WALL MOTION ADD-ON
2.50
1.00
78478
HEART WALL MOTION ADD-ON
2.53
1.00
78480
HEART FUNCTION ADD-ON
1.38
1.00
78480
HEART FUNCTION ADD-ON
2.50
1.00
78480
HEART FUNCTION ADD-ON
2.53
1.00
78481
HEART FIRST PASS, SINGLE
6.33
1.00
78481
HEART FIRST PASS, SINGLE
6.80
1.00
78481
HEART FIRST PASS, SINGLE
6.91
1.00
78483
HEART FIRST PASS, MULTIPLE
8.95
1.00
78483
HEART FIRST PASS, MULTIPLE
10.25
1.00
78483
HEART FIRST PASS, MULTIPLE
10.37
1.00
78491
HEART IMAGE (PET), SINGLE
2.15
1.00
78492
HEART IMAGE (PET), MULTIPLE
2.68
1.00
78494
HEART IMAGE, SPECT
7.86
1.00
78494
HEART IMAGE, SPECT
8.95
1.00
78494
HEART IMAGE, SPECT
9.05
1.00
78496
HEART FIRST PASS ADD-ON
3.29
1.00
78496
HEART FIRST PASS ADD-ON
8.00
1.00
78496
HEART FIRST PASS ADD-ON
8.10
1.00
78580
LUNG PERFUSION IMAGING
4.59
1.00
78580
LUNG PERFUSION IMAGING
4.65
1.00
78580
LUNG PERFUSION IMAGING
5.69
1.00
78584
LUNG V/Q IMAGE SINGLE BREATH
4.34
1.00
78584
LUNG V/Q IMAGE SINGLE BREATH
4.69
1.00
78584
LUNG V/Q IMAGE SINGLE BREATH
4.75
1.00
78585
LUNG V/Q IMAGING
7.38
1.00
Procedure Code Description
RVU
RVU Coeff Value
78585
LUNG V/Q IMAGING
7.47
1.00
78585
LUNG V/Q IMAGING
9.39
1.00
78586
AEROSOL LUNG IMAGE, SINGLE
3.26
1.00
78586
AEROSOL LUNG IMAGE, SINGLE
3.29
1.00
78586
AEROSOL LUNG IMAGE, SINGLE
4.34
1.00
78587
AEROSOL LUNG IMAGE, MULTIPLE
3.60
1.00
78587
AEROSOL LUNG IMAGE, MULTIPLE
3.63
1.00
78587
AEROSOL LUNG IMAGE, MULTIPLE
5.45
1.00
78588
PERFUSION LUNG IMAGE
4.85
1.00
78588
PERFUSION LUNG IMAGE
4.91
1.00
78588
PERFUSION LUNG IMAGE
8.68
1.00
78591
VENT IMAGE, 1 BREATH, 1 PROJ
3.52
1.00
78591
VENT IMAGE, 1 BREATH, 1 PROJ
3.56
1.00
78591
VENT IMAGE, 1 BREATH, 1 PROJ
4.40
1.00
78593
VENT IMAGE, 1 PROJ, GAS
4.26
1.00
78593
VENT IMAGE, 1 PROJ, GAS
4.32
1.00
78593
VENT IMAGE, 1 PROJ, GAS
5.19
1.00
78594
VENT IMAGE, MULT PROJ, GAS
5.91
1.00
78594
VENT IMAGE, MULT PROJ, GAS
5.97
1.00
78594
VENT IMAGE, MULT PROJ, GAS
6.08
1.00
78596
LUNG DIFFERENTIAL FUNCTION
9.11
1.00
78596
LUNG DIFFERENTIAL FUNCTION
9.22
1.00
78596
LUNG DIFFERENTIAL FUNCTION
10.10
1.00
78600
BRAIN IMAGE < 4 VIEWS
3.61
1.00
78600
BRAIN IMAGE < 4 VIEWS
3.64
1.00
78600
BRAIN IMAGE < 4 VIEWS
4.72
1.00
78601
BRAIN IMAGE W/FLOW < 4 VIEWS
4.25
1.00
78601
BRAIN IMAGE W/FLOW < 4 VIEWS
4.29
1.00
78601
BRAIN IMAGE W/FLOW < 4 VIEWS
5.62
1.00
78605
BRAIN IMAGE 4+ VIEWS
4.28
1.00
78605
BRAIN IMAGE 4+ VIEWS
4.33
1.00
78605
BRAIN IMAGE 4+ VIEWS
5.26
1.00
78606
BRAIN IMAGE W/FLOW 4 + VIEWS
4.91
1.00
78606
BRAIN IMAGE W/FLOW 4 + VIEWS
4.99
1.00
78606
BRAIN IMAGE W/FLOW 4 + VIEWS
8.22
1.00
Procedure Code Description
RVU
RVU Coeff Value
78607
BRAIN IMAGING (3D)
8.55
1.00
78607
BRAIN IMAGING (3D)
8.65
1.00
78607
BRAIN IMAGING (3D)
9.89
1.00
78610
BRAIN FLOW IMAGING ONLY
2.07
1.00
78610
BRAIN FLOW IMAGING ONLY
2.10
1.00
78610
BRAIN FLOW IMAGING ONLY
4.75
1.00
78615
CEREBRAL VASCULAR FLOW IMAGE
4.60
1.00
78615
CEREBRAL VASCULAR FLOW IMAGE
4.67
1.00
78615
CEREBRAL VASCULAR FLOW IMAGE
4.91
1.00
78630
CEREBROSPINAL FLUID SCAN
6.19
1.00
78630
CEREBROSPINAL FLUID SCAN
6.27
1.00
78630
CEREBROSPINAL FLUID SCAN
8.74
1.00
78635
CSF VENTRICULOGRAPHY
3.52
1.00
78635
CSF VENTRICULOGRAPHY
3.57
1.00
78635
CSF VENTRICULOGRAPHY
7.92
1.00
78645
CSF SHUNT EVALUATION
4.35
1.00
78645
CSF SHUNT EVALUATION
4.41
1.00
78645
CSF SHUNT EVALUATION
8.03
1.00
78647
CEREBROSPINAL FLUID SCAN
7.40
1.00
78647
CEREBROSPINAL FLUID SCAN
7.50
1.00
78647
CEREBROSPINAL FLUID SCAN
9.23
1.00
78650
CSF LEAKAGE IMAGING
5.67
1.00
78650
CSF LEAKAGE IMAGING
5.74
1.00
78650
CSF LEAKAGE IMAGING
8.52
1.00
78660
NUCLEAR EXAM OF TEAR FLOW
2.95
1.00
78660
NUCLEAR EXAM OF TEAR FLOW
2.97
1.00
78660
NUCLEAR EXAM OF TEAR FLOW
4.44
1.00
78700
KIDNEY IMAGING, MORPHOL
3.80
1.00
78700
KIDNEY IMAGING, MORPHOL
3.84
1.00
78700
KIDNEY IMAGING, MORPHOL
4.69
1.00
78701
KIDNEY IMAGING WITH FLOW
4.37
1.00
78701
KIDNEY IMAGING WITH FLOW
4.43
1.00
78701
KIDNEY IMAGING WITH FLOW
5.61
1.00
78704
IMAGING RENOGRAM
5.14
1.00
78704
IMAGING RENOGRAM
5.19
1.00
Procedure Code Description
RVU
RVU Coeff Value
78704
IMAGING RENOGRAM
5.21
1.00
78707
K FLOW/FUNCT IMAGE W/O DRUG
5.98
1.00
78707
K FLOW/FUNCT IMAGE W/O DRUG
6.05
1.00
78707
K FLOW/FUNCT IMAGE W/O DRUG
6.54
1.00
78708
K FLOW/FUNCT IMAGE W/DRUG
5.34
1.00
78708
K FLOW/FUNCT IMAGE W/DRUG
6.33
1.00
78708
K FLOW/FUNCT IMAGE W/DRUG
6.39
1.00
78709
K FLOW/FUNCT IMAGE, MULTIPLE
6.60
1.00
78709
K FLOW/FUNCT IMAGE, MULTIPLE
6.66
1.00
78709
K FLOW/FUNCT IMAGE, MULTIPLE
9.60
1.00
78710
KIDNEY IMAGING (3D)
6.48
1.00
78710
KIDNEY IMAGING (3D)
7.06
1.00
78710
KIDNEY IMAGING (3D)
7.16
1.00
78715
RENAL VASCULAR FLOW EXAM
2.07
1.00
78715
RENAL VASCULAR FLOW EXAM
2.10
1.00
78725
KIDNEY FUNCTION STUDY
2.38
1.00
78725
KIDNEY FUNCTION STUDY
2.42
1.00
78725
KIDNEY FUNCTION STUDY
2.73
1.00
78730
URINARY BLADDER RETENTION
2.03
1.00
78730
URINARY BLADDER RETENTION
2.05
1.00
78730
URINARY BLADDER RETENTION
2.10
1.00
78740
URETERAL REFLUX STUDY
2.99
1.00
78740
URETERAL REFLUX STUDY
3.02
1.00
78740
URETERAL REFLUX STUDY
5.56
1.00
78760
TESTICULAR IMAGING
3.71
1.00
78760
TESTICULAR IMAGING
3.74
1.00
78761
TESTICULAR IMAGING W/FLOW
4.31
1.00
78761
TESTICULAR IMAGING W/FLOW
4.37
1.00
78761
TESTICULAR IMAGING W/FLOW
5.59
1.00
78800
TUMOR IMAGING, LIMITED AREA
4.46
1.00
78800
TUMOR IMAGING, LIMITED AREA
4.51
1.00
78800
TUMOR IMAGING, LIMITED AREA
5.01
1.00
78801
TUMOR IMAGING, MULT AREAS
5.49
1.00
78801
TUMOR IMAGING, MULT AREAS
5.56
1.00
78801
TUMOR IMAGING, MULT AREAS
6.70
1.00
Procedure Code Description
RVU
RVU Coeff Value
78802
TUMOR IMAGING, WHOLE BODY
6.95
1.00
78802
TUMOR IMAGING, WHOLE BODY
7.05
1.00
78802
TUMOR IMAGING, WHOLE BODY
8.77
1.00
78803
TUMOR IMAGING (3D)
8.35
1.00
78803
TUMOR IMAGING (3D)
8.45
1.00
78803
TUMOR IMAGING (3D)
9.67
1.00
78804
TUMOR IMAGING, WHOLE BODY
6.07
1.00
78804
TUMOR IMAGING, WHOLE BODY
15.38
1.00
78805
ABSCESS IMAGING, LTD AREA
4.56
1.00
78805
ABSCESS IMAGING, LTD AREA
4.61
1.00
78805
ABSCESS IMAGING, LTD AREA
5.02
1.00
78806
ABSCESS IMAGING, WHOLE BODY
7.89
1.00
78806
ABSCESS IMAGING, WHOLE BODY
8.00
1.00
78806
ABSCESS IMAGING, WHOLE BODY
9.19
1.00
78807
NUCLEAR LOCALIZATION/ABSCESS
8.36
1.00
78807
NUCLEAR LOCALIZATION/ABSCESS
8.46
1.00
78807
NUCLEAR LOCALIZATION/ABSCESS
9.68
1.00
78808
IV INJ RA DRUG DX STUDY
1.23
1.00
78810
TUMOR IMAGING (PET)
2.77
1.00
79000
INIT HYPERTHYROID THERAPY
5.23
1.00
79000
INIT HYPERTHYROID THERAPY
5.24
1.00
79001
REPEAT HYPERTHYROID THERAPY
2.82
1.00
79001
REPEAT HYPERTHYROID THERAPY
2.84
1.00
79005
NUCLEAR RX, ORAL ADMIN
4.26
1.00
79005
NUCLEAR RX, ORAL ADMIN
5.24
1.00
79020
THYROID ABLATION
5.23
1.00
79020
THYROID ABLATION
5.25
1.00
79030
THYROID ABLATION, CARCINOMA
5.65
1.00
79030
THYROID ABLATION, CARCINOMA
5.67
1.00
79035
THYROID METASTATIC THERAPY
6.25
1.00
79035
THYROID METASTATIC THERAPY
6.27
1.00
79100
HEMATOPOETIC NUCLEAR THERAPY
4.58
1.00
79100
HEMATOPOETIC NUCLEAR THERAPY
4.60
1.00
79101
NUCLEAR RX, IV ADMIN
4.79
1.00
79200
NUCLEAR RX, INTRACAV ADMIN
4.86
1.00
Procedure Code Description
RVU
RVU Coeff Value
79200
NUCLEAR RX, INTRACAV ADMIN
5.51
1.00
79200
NUCLEAR RX, INTRACAV ADMIN
5.52
1.00
79300
NUCLR RX, INTERSTIT COLLOID
2.24
1.00
79300
NUCLR RX, INTERSTIT COLLOID
2.26
1.00
79300
NUCLR RX, INTERSTIT COLLOID
2.29
1.00
79300
NUCLR RX, INTERSTIT COLLOID
2.31
1.00
79400
NONHEMATO NUCLEAR THERAPY
5.47
1.00
79400
NONHEMATO NUCLEAR THERAPY
5.49
1.00
79403
HEMATOPOIETIC NUCLEAR TX
6.07
1.00
79403
HEMATOPOIETIC NUCLEAR TX
7.65
1.00
79403
HEMATOPOIETIC NUCLEAR TX
7.68
1.00
79420
INTRAVASCULAR NUCLEAR THER
2.07
1.00
79420
INTRAVASCULAR NUCLEAR THER
2.09
1.00
79440
NUCLEAR RX, INTRA-ARTICULAR
4.49
1.00
79440
NUCLEAR RX, INTRA-ARTICULAR
5.55
1.00
79440
NUCLEAR RX, INTRA-ARTICULAR
5.57
1.00
80048
METABOLIC PANEL TOTAL CA
1.00
1.00
80051
ELECTROLYTE PANEL
1.00
1.00
80053
COMPREHEN METABOLIC PANEL
1.00
1.00
80061
LIPID PANEL
1.00
1.00
80069
RENAL FUNCTION PANEL
1.00
1.00
80076
HEPATIC FUNCTION PANEL
1.00
1.00
90801
PSY DX INTERVIEW
3.62
1.00
90801
PSY DX INTERVIEW
3.81
1.00
90801
PSY DX INTERVIEW
3.82
1.00
90802
INTAC PSY DX INTERVIEW
3.91
1.00
90802
INTAC PSY DX INTERVIEW
4.07
1.00
90802
INTAC PSY DX INTERVIEW
4.09
1.00
90804
PSYTX, OFFICE, 20-30 MIN
1.54
1.00
90804
PSYTX, OFFICE, 20-30 MIN
1.63
1.00
90805
PSYTX, OFF, 20-30 MIN W/E&M
1.73
1.00
90805
PSYTX, OFF, 20-30 MIN W/E&M
1.83
1.00
90805
PSYTX, OFF, 20-30 MIN W/E&M
1.84
1.00
90806
PSYTX, OFF, 45-50 MIN
2.36
1.00
90806
PSYTX, OFF, 45-50 MIN
2.51
1.00
Procedure Code Description
RVU
RVU Coeff Value
90807
PSYTX, OFF, 45-50 MIN W/E&M
2.56
1.00
90807
PSYTX, OFF, 45-50 MIN W/E&M
2.71
1.00
90808
PSYTX, OFFICE, 75-80 MIN
3.55
1.00
90808
PSYTX, OFFICE, 75-80 MIN
3.78
1.00
90809
PSYTX, OFF, 75-80, W/E&M
3.66
1.00
90809
PSYTX, OFF, 75-80, W/E&M
3.95
1.00
90810
INTAC PSYTX, OFF, 20-30 MIN
1.64
1.00
90810
INTAC PSYTX, OFF, 20-30 MIN
1.78
1.00
90811
INTAC PSYTX, 20-30, W/E&M
1.84
1.00
90811
INTAC PSYTX, 20-30, W/E&M
1.98
1.00
90811
INTAC PSYTX, 20-30, W/E&M
1.99
1.00
90812
INTAC PSYTX, OFF, 45-50 MIN
2.44
1.00
90812
INTAC PSYTX, OFF, 45-50 MIN
2.67
1.00
90813
INTAC PSYTX, 45-50 MIN W/E&M
2.64
1.00
90813
INTAC PSYTX, 45-50 MIN W/E&M
2.86
1.00
90814
INTAC PSYTX, OFF, 75-80 MIN
3.66
1.00
90814
INTAC PSYTX, OFF, 75-80 MIN
3.97
1.00
90815
INTAC PSYTX, 75-80 W/E&M
3.79
1.00
90815
INTAC PSYTX, 75-80 W/E&M
4.09
1.00
90816
PSYTX, HOSP, 20-30 MIN
1.64
1.00
90816
PSYTX, HOSP, 20-30 MIN
1.75
1.00
90816
PSYTX, HOSP, 20-30 MIN
1.76
1.00
90817
PSYTX, HOSP, 20-30 MIN W/E&M
1.82
1.00
90817
PSYTX, HOSP, 20-30 MIN W/E&M
1.90
1.00
90817
PSYTX, HOSP, 20-30 MIN W/E&M
1.91
1.00
90818
PSYTX, HOSP, 45-50 MIN
2.44
1.00
90819
PSYTX, HOSP, 45-50 MIN W/E&M
2.62
1.00
90821
PSYTX, HOSP, 75-80 MIN
3.60
1.00
90822
PSYTX, HOSP, 75-80 MIN W/E&M
3.79
1.00
90823
INTAC PSYTX, HOSP, 20-30 MIN
1.77
1.00
90823
INTAC PSYTX, HOSP, 20-30 MIN
1.88
1.00
90824
INTAC PSYTX, HSP 20-30 W/E&M
1.97
1.00
90824
INTAC PSYTX, HSP 20-30 W/E&M
2.05
1.00
90824
INTAC PSYTX, HSP 20-30 W/E&M
2.06
1.00
90826
INTAC PSYTX, HOSP, 45-50 MIN
2.59
1.00
Procedure Code Description
RVU
RVU Coeff Value
90827
INTAC PSYTX, HSP 45-50 W/E&M
2.75
1.00
90828
INTAC PSYTX, HOSP, 75-80 MIN
3.74
1.00
90829
INTAC PSYTX, HSP 75-80 W/E&M
3.91
1.00
90845
PSYCHOANALYSIS
2.26
1.00
90845
PSYCHOANALYSIS
2.39
1.00
90845
PSYCHOANALYSIS
2.40
1.00
90846
FAMILY PSYTX W/O PATIENT
2.41
1.00
90846
FAMILY PSYTX W/O PATIENT
2.53
1.00
90847
FAMILY PSYTX W/PATIENT
2.89
1.00
90847
FAMILY PSYTX W/PATIENT
3.03
1.00
90849
MULTIPLE FAMILY GROUP PSYTX
0.83
1.00
90849
MULTIPLE FAMILY GROUP PSYTX
0.84
1.00
90853
GROUP PSYCHOTHERAPY
0.81
1.00
90853
GROUP PSYCHOTHERAPY
0.83
1.00
90857
INTAC GROUP PSYTX
0.87
1.00
90857
INTAC GROUP PSYTX
0.91
1.00
90862
MEDICATION MANAGEMENT
1.26
1.00
90862
MEDICATION MANAGEMENT
1.29
1.00
90862
MEDICATION MANAGEMENT
1.30
1.00
90870
ELECTROCONVULSIVE THERAPY
2.36
1.00
90870
ELECTROCONVULSIVE THERAPY
2.72
1.00
90870
ELECTROCONVULSIVE THERAPY
2.73
1.00
90870
ELECTROCONVULSIVE THERAPY
3.00
1.00
90871
ELECTROCONVULSIVE THERAPY
3.00
1.00
90871
ELECTROCONVULSIVE THERAPY
3.86
1.00
90875
PSYCHOPHYSIOLOGICAL THERAPY
1.70
1.00
90885
PSY EVALUATION OF RECORDS
1.29
1.00
90885
PSY EVALUATION OF RECORDS
1.36
1.00
90911
BIOFEEDBACK PERI/URO/RECTAL
1.25
1.00
90911
BIOFEEDBACK PERI/URO/RECTAL
1.27
1.00
90911
BIOFEEDBACK PERI/URO/RECTAL
1.29
1.00
90918
ESRD RELATED SERVICES, MONTH
16.45
1.00
90918
ESRD RELATED SERVICES, MONTH
18.86
1.00
90918
ESRD RELATED SERVICES, MONTH
19.04
1.00
90919
ESRD RELATED SERVICES, MONTH
12.10
1.00
Procedure Code Description
RVU
RVU Coeff Value
90919
ESRD RELATED SERVICES, MONTH
12.89
1.00
90919
ESRD RELATED SERVICES, MONTH
12.96
1.00
90920
ESRD RELATED SERVICES, MONTH
10.50
1.00
90920
ESRD RELATED SERVICES, MONTH
11.30
1.00
90920
ESRD RELATED SERVICES, MONTH
11.38
1.00
90921
ESRD RELATED SERVICES, MONTH
6.63
1.00
90921
ESRD RELATED SERVICES, MONTH
7.08
1.00
90921
ESRD RELATED SERVICES, MONTH
7.13
1.00
90922
ESRD RELATED SERVICES, DAY
0.55
1.00
90922
ESRD RELATED SERVICES, DAY
0.60
1.00
90923
ESRD RELATED SERVICES, DAY
0.40
1.00
90923
ESRD RELATED SERVICES, DAY
0.42
1.00
90924
ESRD RELATED SERVICES, DAY
0.35
1.00
90924
ESRD RELATED SERVICES, DAY
0.37
1.00
90925
ESRD RELATED SERVICES, DAY
0.23
1.00
90925
ESRD RELATED SERVICES, DAY
0.24
1.00
90935
HEMODIALYSIS, ONE EVALUATION
1.86
1.00
90935
HEMODIALYSIS, ONE EVALUATION
1.93
1.00
90935
HEMODIALYSIS, ONE EVALUATION
1.94
1.00
90937
HEMODIALYSIS, REPEATED EVAL
3.02
1.00
90937
HEMODIALYSIS, REPEATED EVAL
3.16
1.00
90937
HEMODIALYSIS, REPEATED EVAL
3.17
1.00
90945
DIALYSIS, ONE EVALUATION
1.91
1.00
90945
DIALYSIS, ONE EVALUATION
2.03
1.00
90945
DIALYSIS, ONE EVALUATION
2.04
1.00
90947
DIALYSIS, REPEATED EVAL
3.09
1.00
90947
DIALYSIS, REPEATED EVAL
3.24
1.00
90951
ESRD SERV, 4 VISITS P MO, <2
26.67
1.00
90954
ESRD SERV, 4 VSTS P MO, 2-11
21.85
1.00
90955
ESRD SRV 2-3 VSTS P MO, 2-11
12.39
1.00
90956
ESRD SRV, 1 VISIT P MO, 2-11
8.39
1.00
90957
ESRD SRV, 4 VSTS P MO, 12-19
17.55
1.00
90958
ESRD SRV 2-3 VSTS P MO 12-19
11.85
1.00
90959
ESRD SERV, 1 VST P MO, 12-19
7.77
1.00
90960
ESRD SRV, 4 VISITS P MO, 20+
7.81
1.00
Procedure Code Description
RVU
RVU Coeff Value
90961
ESRD SRV, 2-3 VSTS P MO, 20+
6.30
1.00
90962
ESRD SERV, 1 VISIT P MO, 20+
4.55
1.00
90963
ESRD HOME PT, SERV P MO, <2
15.06
1.00
90964
ESRD HOME PT SERV P MO, 2-11
12.55
1.00
90965
ESRD HOME PT SERV P MO 12-19
11.93
1.00
90966
ESRD HOME PT, SERV P MO, 20+
6.23
1.00
90967
ESRD HOME PT SERV P DAY, <2
0.54
1.00
90968
ESRD HOME PT SRV P DAY, 2-11
0.42
1.00
90969
ESRD HOME PT SRV P DAY 12-19
0.41
1.00
90970
ESRD HOME PT SERV P DAY, 20+
0.22
1.00
90997
HEMOPERFUSION
2.46
1.00
90997
HEMOPERFUSION
3.31
1.00
90997
HEMOPERFUSION
3.32
1.00
91000
ESOPHAGEAL INTUBATION
1.10
1.00
91000
ESOPHAGEAL INTUBATION
1.11
1.00
91000
ESOPHAGEAL INTUBATION
2.42
1.00
91010
ESOPHAGUS MOTILITY STUDY
4.08
1.00
91010
ESOPHAGUS MOTILITY STUDY
4.10
1.00
91010
ESOPHAGUS MOTILITY STUDY
5.13
1.00
91011
ESOPHAGUS MOTILITY STUDY
4.78
1.00
91011
ESOPHAGUS MOTILITY STUDY
4.82
1.00
91011
ESOPHAGUS MOTILITY STUDY
6.86
1.00
91012
ESOPHAGUS MOTILITY STUDY
4.89
1.00
91012
ESOPHAGUS MOTILITY STUDY
4.94
1.00
91012
ESOPHAGUS MOTILITY STUDY
6.97
1.00
91020
GASTRIC MOTILITY STUDIES
4.50
1.00
91020
GASTRIC MOTILITY STUDIES
4.60
1.00
91020
GASTRIC MOTILITY STUDIES
6.23
1.00
91022
DUODENAL MOTILITY STUDY
5.13
1.00
91030
ACID PERFUSION OF ESOPHAGUS
3.37
1.00
91030
ACID PERFUSION OF ESOPHAGUS
3.53
1.00
91030
ACID PERFUSION OF ESOPHAGUS
3.73
1.00
91032
ESOPHAGUS, ACID REFLUX TEST
3.74
1.00
91032
ESOPHAGUS, ACID REFLUX TEST
5.43
1.00
91033
PROLONGED ACID REFLUX TEST
4.08
1.00
Procedure Code Description
RVU
RVU Coeff Value
91033
PROLONGED ACID REFLUX TEST
5.63
1.00
91034
GASTROESOPHAGEAL REFLUX TEST
5.38
1.00
91034
GASTROESOPHAGEAL REFLUX TEST
6.33
1.00
91034
GASTROESOPHAGEAL REFLUX TEST
6.34
1.00
91035
G-ESOPH REFLX TST W/ELECTROD
12.51
1.00
91035
G-ESOPH REFLX TST W/ELECTROD
12.54
1.00
91035
G-ESOPH REFLX TST W/ELECTROD
12.63
1.00
91037
ESOPH IMPED FUNCTION TEST
4.02
1.00
91037
ESOPH IMPED FUNCTION TEST
4.03
1.00
91037
ESOPH IMPED FUNCTION TEST
4.32
1.00
91038
ESOPH IMPED FUNCT TEST > 1H
3.44
1.00
91038
ESOPH IMPED FUNCT TEST > 1H
3.45
1.00
91038
ESOPH IMPED FUNCT TEST > 1H
3.81
1.00
91040
ESOPH BALLOON DISTENSION TST
10.23
1.00
91040
ESOPH BALLOON DISTENSION TST
12.22
1.00
91040
ESOPH BALLOON DISTENSION TST
12.25
1.00
91052
GASTRIC ANALYSIS TEST
3.04
1.00
91052
GASTRIC ANALYSIS TEST
3.22
1.00
91052
GASTRIC ANALYSIS TEST
3.32
1.00
91055
GASTRIC INTUBATION FOR SMEAR
3.17
1.00
91055
GASTRIC INTUBATION FOR SMEAR
3.38
1.00
91055
GASTRIC INTUBATION FOR SMEAR
3.59
1.00
91060
GASTRIC SALINE LOAD TEST
0.79
1.00
91060
GASTRIC SALINE LOAD TEST
2.47
1.00
91065
BREATH HYDROGEN TEST
1.77
1.00
91065
BREATH HYDROGEN TEST
2.19
1.00
91065
BREATH HYDROGEN TEST
4.11
1.00
91100
PASS INTESTINE BLEEDING TUBE
1.43
1.00
91100
PASS INTESTINE BLEEDING TUBE
1.44
1.00
91100
PASS INTESTINE BLEEDING TUBE
1.45
1.00
91105
GASTRIC INTUBATION TREATMENT
0.47
1.00
91105
GASTRIC INTUBATION TREATMENT
0.48
1.00
91105
GASTRIC INTUBATION TREATMENT
0.49
1.00
91110
GI TRACT CAPSULE ENDOSCOPY
24.30
1.00
91110
GI TRACT CAPSULE ENDOSCOPY
24.86
1.00
Procedure Code Description
RVU
RVU Coeff Value
91111
ESOPHAGEAL CAPSULE ENDOSCOPY
18.97
1.00
91120
RECTAL SENSATION TEST
10.48
1.00
91122
ANAL PRESSURE RECORD
6.29
1.00
91122
ANAL PRESSURE RECORD
6.49
1.00
91122
ANAL PRESSURE RECORD
8.03
1.00
91132
ELECTROGASTROGRAPHY
0.72
1.00
91132
ELECTROGASTROGRAPHY
0.73
1.00
91132
ELECTROGASTROGRAPHY
0.74
1.00
91132
ELECTROGASTROGRAPHY
0.75
1.00
91132
ELECTROGASTROGRAPHY
0.78
1.00
91133
ELECTROGASTROGRAPHY W/TEST
0.92
1.00
91133
ELECTROGASTROGRAPHY W/TEST
0.93
1.00
91133
ELECTROGASTROGRAPHY W/TEST
0.94
1.00
91133
ELECTROGASTROGRAPHY W/TEST
1.00
1.00
92502
EAR AND THROAT EXAMINATION
2.53
1.00
92502
EAR AND THROAT EXAMINATION
2.71
1.00
92502
EAR AND THROAT EXAMINATION
2.81
1.00
92502
EAR AND THROAT EXAMINATION
3.00
1.00
92504
EAR MICROSCOPY EXAMINATION
0.26
1.00
92504
EAR MICROSCOPY EXAMINATION
0.28
1.00
92506
SPEECH/HEARING EVALUATION
1.21
1.00
92506
SPEECH/HEARING EVALUATION
1.31
1.00
92507
SPEECH/HEARING THERAPY
0.72
1.00
92507
SPEECH/HEARING THERAPY
0.78
1.00
92508
SPEECH/HEARING THERAPY
0.37
1.00
92508
SPEECH/HEARING THERAPY
0.39
1.00
92511
NASOPHARYNGOSCOPY
1.29
1.00
92511
NASOPHARYNGOSCOPY
1.57
1.00
92511
NASOPHARYNGOSCOPY
1.67
1.00
92512
NASAL FUNCTION STUDIES
0.75
1.00
92512
NASAL FUNCTION STUDIES
0.76
1.00
92516
FACIAL NERVE FUNCTION TEST
0.61
1.00
92516
FACIAL NERVE FUNCTION TEST
0.67
1.00
92520
LARYNGEAL FUNCTION STUDIES
1.07
1.00
92520
LARYNGEAL FUNCTION STUDIES
1.18
1.00
Procedure Code Description
RVU
RVU Coeff Value
92520
LARYNGEAL FUNCTION STUDIES
1.19
1.00
92526
ORAL FUNCTION THERAPY
0.75
1.00
92526
ORAL FUNCTION THERAPY
0.77
1.00
92526
ORAL FUNCTION THERAPY
0.78
1.00
92541
SPONTANEOUS NYSTAGMUS TEST
1.41
1.00
92541
SPONTANEOUS NYSTAGMUS TEST
1.55
1.00
92541
SPONTANEOUS NYSTAGMUS TEST
1.58
1.00
92542
POSITIONAL NYSTAGMUS TEST
1.42
1.00
92542
POSITIONAL NYSTAGMUS TEST
1.56
1.00
92542
POSITIONAL NYSTAGMUS TEST
1.64
1.00
92543
CALORIC VESTIBULAR TEST
0.65
1.00
92543
CALORIC VESTIBULAR TEST
0.75
1.00
92543
CALORIC VESTIBULAR TEST
0.76
1.00
92544
OPTOKINETIC NYSTAGMUS TEST
1.13
1.00
92544
OPTOKINETIC NYSTAGMUS TEST
1.26
1.00
92544
OPTOKINETIC NYSTAGMUS TEST
1.32
1.00
92545
OSCILLATING TRACKING TEST
1.05
1.00
92545
OSCILLATING TRACKING TEST
1.16
1.00
92545
OSCILLATING TRACKING TEST
1.24
1.00
92546
SINUSOIDAL ROTATIONAL TEST
2.12
1.00
92546
SINUSOIDAL ROTATIONAL TEST
2.22
1.00
92546
SINUSOIDAL ROTATIONAL TEST
2.57
1.00
92547
SUPPLEMENTAL ELECTRICAL TEST
0.16
1.00
92547
SUPPLEMENTAL ELECTRICAL TEST
1.21
1.00
92547
SUPPLEMENTAL ELECTRICAL TEST
1.39
1.00
92548
POSTUROGRAPHY
2.55
1.00
92548
POSTUROGRAPHY
3.84
1.00
92548
POSTUROGRAPHY
4.61
1.00
92551
PURE TONE HEARING TEST, AIR
0.29
1.00
92551
PURE TONE HEARING TEST, AIR
0.48
1.00
92552
PURE TONE AUDIOMETRY, AIR
0.48
1.00
92552
PURE TONE AUDIOMETRY, AIR
0.59
1.00
92553
AUDIOMETRY, AIR & BONE
0.71
1.00
92553
AUDIOMETRY, AIR & BONE
0.72
1.00
92553
AUDIOMETRY, AIR & BONE
0.79
1.00
Procedure Code Description
RVU
RVU Coeff Value
92555
SPEECH THRESHOLD AUDIOMETRY
0.41
1.00
92555
SPEECH THRESHOLD AUDIOMETRY
0.44
1.00
92556
SPEECH AUDIOMETRY, COMPLETE
0.62
1.00
92556
SPEECH AUDIOMETRY, COMPLETE
0.63
1.00
92556
SPEECH AUDIOMETRY, COMPLETE
0.68
1.00
92557
COMPREHENSIVE HEARING TEST
1.18
1.00
92557
COMPREHENSIVE HEARING TEST
1.28
1.00
92557
COMPREHENSIVE HEARING TEST
1.31
1.00
92561
BEKESY AUDIOMETRY, DIAGNOSIS
0.77
1.00
92561
BEKESY AUDIOMETRY, DIAGNOSIS
0.78
1.00
92562
LOUDNESS BALANCE TEST
0.44
1.00
92562
LOUDNESS BALANCE TEST
0.62
1.00
92563
TONE DECAY HEARING TEST
0.41
1.00
92563
TONE DECAY HEARING TEST
0.56
1.00
92564
SISI HEARING TEST
0.51
1.00
92564
SISI HEARING TEST
0.52
1.00
92564
SISI HEARING TEST
0.54
1.00
92565
STENGER TEST, PURE TONE
0.35
1.00
92565
STENGER TEST, PURE TONE
0.43
1.00
92567
TYMPANOMETRY
0.44
1.00
92567
TYMPANOMETRY
0.57
1.00
92567
TYMPANOMETRY
0.58
1.00
92568
ACOUSTIC REFL THRESHOLD TST
0.41
1.00
92568
ACOUSTIC REFL THRESHOLD TST
0.50
1.00
92569
ACOUSTIC REFLEX DECAY TEST
0.40
1.00
92569
ACOUSTIC REFLEX DECAY TEST
0.44
1.00
92571
FILTERED SPEECH HEARING TEST
0.42
1.00
92571
FILTERED SPEECH HEARING TEST
0.45
1.00
92572
STAGGERED SPONDAIC WORD TEST
0.10
1.00
92572
STAGGERED SPONDAIC WORD TEST
0.47
1.00
92573
LOMBARD TEST
0.38
1.00
92573
LOMBARD TEST
0.39
1.00
92575
SENSORINEURAL ACUITY TEST
0.32
1.00
92575
SENSORINEURAL ACUITY TEST
0.95
1.00
92576
SYNTHETIC SENTENCE TEST
0.49
1.00
Procedure Code Description
RVU
RVU Coeff Value
92576
SYNTHETIC SENTENCE TEST
0.58
1.00
92577
STENGER TEST, SPEECH
0.48
1.00
92577
STENGER TEST, SPEECH
0.78
1.00
92577
STENGER TEST, SPEECH
0.79
1.00
92579
VISUAL AUDIOMETRY (VRA)
0.78
1.00
92579
VISUAL AUDIOMETRY (VRA)
0.79
1.00
92579
VISUAL AUDIOMETRY (VRA)
1.13
1.00
92582
CONDITIONING PLAY AUDIOMETRY
0.78
1.00
92582
CONDITIONING PLAY AUDIOMETRY
0.79
1.00
92582
CONDITIONING PLAY AUDIOMETRY
1.12
1.00
92583
SELECT PICTURE AUDIOMETRY
0.91
1.00
92583
SELECT PICTURE AUDIOMETRY
0.96
1.00
92583
SELECT PICTURE AUDIOMETRY
0.97
1.00
92584
ELECTROCOCHLEOGRAPHY
1.86
1.00
92584
ELECTROCOCHLEOGRAPHY
2.64
1.00
92584
ELECTROCOCHLEOGRAPHY
2.70
1.00
92585
AUDITOR EVOKE POTENT, COMPRE
2.70
1.00
92585
AUDITOR EVOKE POTENT, COMPRE
2.74
1.00
92585
AUDITOR EVOKE POTENT, COMPRE
2.76
1.00
92585
AUDITOR EVOKE POTENT, COMPRE
4.00
1.00
92586
AUDITOR EVOKE POTENT, LIMIT
1.71
1.00
92586
AUDITOR EVOKE POTENT, LIMIT
1.96
1.00
92586
AUDITOR EVOKE POTENT, LIMIT
2.00
1.00
92587
EVOKED AUDITORY TEST
1.07
1.00
92587
EVOKED AUDITORY TEST
1.60
1.00
92587
EVOKED AUDITORY TEST
1.63
1.00
92588
EVOKED AUDITORY TEST
1.74
1.00
92588
EVOKED AUDITORY TEST
2.11
1.00
92588
EVOKED AUDITORY TEST
2.14
1.00
92589
AUDITORY FUNCTION TEST(S)
0.58
1.00
92589
AUDITORY FUNCTION TEST(S)
0.59
1.00
92950
HEART/LUNG RESUSCITATION CPR
4.91
1.00
92950
HEART/LUNG RESUSCITATION CPR
5.02
1.00
92950
HEART/LUNG RESUSCITATION CPR
10.00
1.00
92960
CARDIOVERSION ELECTRIC, EXT
3.19
1.00
Procedure Code Description
RVU
RVU Coeff Value
92960
CARDIOVERSION ELECTRIC, EXT
3.52
1.00
92960
CARDIOVERSION ELECTRIC, EXT
3.70
1.00
92960
CARDIOVERSION ELECTRIC, EXT
4.00
1.00
92970
CARDIOASSIST, INTERNAL
4.77
1.00
92970
CARDIOASSIST, INTERNAL
4.79
1.00
92970
CARDIOASSIST, INTERNAL
5.04
1.00
92971
CARDIOASSIST, EXTERNAL
2.69
1.00
92971
CARDIOASSIST, EXTERNAL
2.71
1.00
92971
CARDIOASSIST, EXTERNAL
2.87
1.00
92973
PERCUT CORONARY THROMBECTOMY
4.71
1.00
92973
PERCUT CORONARY THROMBECTOMY
4.72
1.00
92973
PERCUT CORONARY THROMBECTOMY
5.16
1.00
92974
CATH PLACE, CARDIO BRACHYTX
4.34
1.00
92974
CATH PLACE, CARDIO BRACHYTX
4.35
1.00
92974
CATH PLACE, CARDIO BRACHYTX
4.73
1.00
92975
DISSOLVE CLOT, HEART VESSEL
10.32
1.00
92975
DISSOLVE CLOT, HEART VESSEL
10.35
1.00
92975
DISSOLVE CLOT, HEART VESSEL
11.33
1.00
92977
DISSOLVE CLOT, HEART VESSEL
3.72
1.00
92977
DISSOLVE CLOT, HEART VESSEL
8.40
1.00
92977
DISSOLVE CLOT, HEART VESSEL
8.54
1.00
92978
INTRAVASC US, HEART ADD-ON
7.34
1.00
92978
INTRAVASC US, HEART ADD-ON
7.40
1.00
92979
INTRAVASC US, HEART ADD-ON
4.45
1.00
92979
INTRAVASC US, HEART ADD-ON
4.48
1.00
92980
INSERT INTRACORONARY STENT
21.75
1.00
92980
INSERT INTRACORONARY STENT
21.76
1.00
92980
INSERT INTRACORONARY STENT
23.51
1.00
92981
INSERT INTRACORONARY STENT
6.04
1.00
92981
INSERT INTRACORONARY STENT
6.05
1.00
92981
INSERT INTRACORONARY STENT
6.54
1.00
92982
CORONARY ARTERY DILATION
7.00
1.00
92982
CORONARY ARTERY DILATION
16.14
1.00
92982
CORONARY ARTERY DILATION
16.16
1.00
92982
CORONARY ARTERY DILATION
17.43
1.00
Procedure Code Description
RVU
RVU Coeff Value
92984
CORONARY ARTERY DILATION
4.30
1.00
92984
CORONARY ARTERY DILATION
4.67
1.00
92986
REVISION OF AORTIC VALVE
33.21
1.00
92986
REVISION OF AORTIC VALVE
34.76
1.00
92986
REVISION OF AORTIC VALVE
38.57
1.00
92987
REVISION OF MITRAL VALVE
34.54
1.00
92987
REVISION OF MITRAL VALVE
36.10
1.00
92987
REVISION OF MITRAL VALVE
39.93
1.00
92990
REVISION OF PULMONARY VALVE
26.48
1.00
92990
REVISION OF PULMONARY VALVE
28.03
1.00
92990
REVISION OF PULMONARY VALVE
30.72
1.00
92995
CORONARY ATHERECTOMY
17.75
1.00
92995
CORONARY ATHERECTOMY
17.77
1.00
92995
CORONARY ATHERECTOMY
19.21
1.00
92996
CORONARY ATHERECTOMY ADD-ON
4.72
1.00
92996
CORONARY ATHERECTOMY ADD-ON
4.73
1.00
92996
CORONARY ATHERECTOMY ADD-ON
5.00
1.00
92997
PUL ART BALLOON REPR, PERCUT
7.00
1.00
92997
PUL ART BALLOON REPR, PERCUT
17.59
1.00
92997
PUL ART BALLOON REPR, PERCUT
17.63
1.00
92998
PUL ART BALLOON REPR, PERCUT
8.57
1.00
92998
PUL ART BALLOON REPR, PERCUT
9.06
1.00
93000
ELECTROCARDIOGRAM, COMPLETE
0.58
1.00
93000
ELECTROCARDIOGRAM, COMPLETE
0.71
1.00
93005
ELECTROCARDIOGRAM, TRACING
0.33
1.00
93005
ELECTROCARDIOGRAM, TRACING
0.47
1.00
93010
ELECTROCARDIOGRAM REPORT
0.24
1.00
93010
ELECTROCARDIOGRAM REPORT
0.25
1.00
93015
CARDIOVASCULAR STRESS TEST
2.78
1.00
93015
CARDIOVASCULAR STRESS TEST
2.83
1.00
93015
CARDIOVASCULAR STRESS TEST
2.86
1.00
93017
CARDIOVASCULAR STRESS TEST
1.65
1.00
93017
CARDIOVASCULAR STRESS TEST
1.76
1.00
93017
CARDIOVASCULAR STRESS TEST
1.80
1.00
93018
CARDIOVASCULAR STRESS TEST
0.43
1.00
Procedure Code Description
RVU
RVU Coeff Value
93018
CARDIOVASCULAR STRESS TEST
0.45
1.00
93024
CARDIAC DRUG STRESS TEST
2.85
1.00
93024
CARDIAC DRUG STRESS TEST
2.87
1.00
93024
CARDIAC DRUG STRESS TEST
3.38
1.00
93025
MICROVOLT T-WAVE ASSESS
5.91
1.00
93025
MICROVOLT T-WAVE ASSESS
9.06
1.00
93025
MICROVOLT T-WAVE ASSESS
11.59
1.00
93040
RHYTHM ECG WITH REPORT
0.37
1.00
93040
RHYTHM ECG WITH REPORT
0.38
1.00
93041
RHYTHM ECG, TRACING
0.15
1.00
93041
RHYTHM ECG, TRACING
0.16
1.00
93042
RHYTHM ECG, REPORT
0.22
1.00
93224
ECG MONITOR/REPORT, 24 HRS
3.31
1.00
93224
ECG MONITOR/REPORT, 24 HRS
4.34
1.00
93224
ECG MONITOR/REPORT, 24 HRS
4.39
1.00
93225
ECG MONITOR/RECORD, 24 HRS
0.99
1.00
93225
ECG MONITOR/RECORD, 24 HRS
1.30
1.00
93225
ECG MONITOR/RECORD, 24 HRS
1.32
1.00
93226
ECG MONITOR/REPORT, 24 HRS
1.53
1.00
93226
ECG MONITOR/REPORT, 24 HRS
2.30
1.00
93226
ECG MONITOR/REPORT, 24 HRS
2.33
1.00
93227
ECG MONITOR/REVIEW, 24 HRS
0.74
1.00
93227
ECG MONITOR/REVIEW, 24 HRS
0.79
1.00
93228
REMOTE 30 DAY ECG REV/REPORT
0.71
1.00
93230
ECG MONITOR/REPORT, 24 HRS
3.39
1.00
93230
ECG MONITOR/REPORT, 24 HRS
4.62
1.00
93230
ECG MONITOR/REPORT, 24 HRS
4.68
1.00
93231
ECG MONITOR/RECORD, 24 HRS
1.00
1.00
93231
ECG MONITOR/RECORD, 24 HRS
1.60
1.00
93231
ECG MONITOR/RECORD, 24 HRS
1.63
1.00
93232
ECG MONITOR/REPORT, 24 HRS
1.63
1.00
93232
ECG MONITOR/REPORT, 24 HRS
2.28
1.00
93232
ECG MONITOR/REPORT, 24 HRS
2.31
1.00
93233
ECG MONITOR/REVIEW, 24 HRS
0.74
1.00
93233
ECG MONITOR/REVIEW, 24 HRS
0.76
1.00
Procedure Code Description
RVU
RVU Coeff Value
93235
ECG MONITOR/REPORT, 24 HRS
3.36
1.00
93235
ECG MONITOR/REPORT, 24 HRS
3.39
1.00
93235
ECG MONITOR/REPORT, 24 HRS
3.40
1.00
93236
ECG MONITOR/REPORT, 24 HRS
2.73
1.00
93236
ECG MONITOR/REPORT, 24 HRS
2.76
1.00
93236
ECG MONITOR/REPORT, 24 HRS
2.77
1.00
93237
ECG MONITOR/REVIEW, 24 HRS
0.63
1.00
93237
ECG MONITOR/REVIEW, 24 HRS
0.68
1.00
93268
ECG RECORD/REVIEW
7.36
1.00
93268
ECG RECORD/REVIEW
8.17
1.00
93268
ECG RECORD/REVIEW
8.27
1.00
93270
ECG RECORDING
0.60
1.00
93270
ECG RECORDING
1.30
1.00
93270
ECG RECORDING
1.32
1.00
93271
ECG/MONITORING AND ANALYSIS
6.00
1.00
93271
ECG/MONITORING AND ANALYSIS
6.14
1.00
93271
ECG/MONITORING AND ANALYSIS
6.22
1.00
93272
ECG/REVIEW, INTERPRET ONLY
0.73
1.00
93272
ECG/REVIEW, INTERPRET ONLY
0.76
1.00
93278
ECG/SIGNAL-AVERAGED
1.13
1.00
93278
ECG/SIGNAL-AVERAGED
1.59
1.00
93278
ECG/SIGNAL-AVERAGED
1.62
1.00
93279
PM DEVICE PROGR EVAL, SNGL
1.55
1.00
93281
PM DEVICE PROGR EVAL, MULTI
2.14
1.00
93282
ICD DEVICE PROG EVAL, 1 SNGL
1.98
1.00
93283
ICD DEVICE PROGR EVAL, DUAL
2.41
1.00
93284
ICD DEVICE PROGR EVAL, MULT
2.82
1.00
93285
ILR DEVICE EVAL PROGR
1.34
1.00
93286
PRE-OP PM DEVICE EVAL
0.76
1.00
93287
PRE-OP ICD DEVICE EVAL
1.00
1.00
93288
PM DEVICE EVAL IN PERSON
1.20
1.00
93289
ICD DEVICE INTERROGATE
1.84
1.00
93290
ICM DEVICE EVAL
0.89
1.00
93291
ILR DEVICE INTERROGATE
1.15
1.00
93292
WCD DEVICE INTERROGATE
1.04
1.00
Procedure Code Description
RVU
RVU Coeff Value
93293
PM PHONE R-STRIP DEVICE EVAL
1.66
1.00
93294
PM DEVICE INTERROGATE REMOTE
1.02
1.00
93295
ICD DEVICE INTERROGAT REMOTE
1.84
1.00
93296
PM/ICD REMOTE TECH SERV
1.01
1.00
93297
ICM DEVICE INTERROGAT REMOTE
0.71
1.00
93298
ILR DEVICE INTERROGAT REMOTE
0.82
1.00
93303
ECHO TRANSTHORACIC
5.86
1.00
93303
ECHO TRANSTHORACIC
5.93
1.00
93303
ECHO TRANSTHORACIC
6.05
1.00
93304
ECHO TRANSTHORACIC
3.10
1.00
93304
ECHO TRANSTHORACIC
3.13
1.00
93304
ECHO TRANSTHORACIC
3.74
1.00
93306
TTE W/DOPPLER, COMPLETE
7.42
1.00
93307
TTE W/O DOPPLER, COMPLETE
4.91
1.00
93307
TTE W/O DOPPLER, COMPLETE
5.34
1.00
93307
TTE W/O DOPPLER, COMPLETE
5.42
1.00
93308
TTE, F-UP OR LMTD
2.80
1.00
93308
TTE, F-UP OR LMTD
2.84
1.00
93308
TTE, F-UP OR LMTD
3.10
1.00
93312
ECHO TRANSESOPHAGEAL
3.00
1.00
93312
ECHO TRANSESOPHAGEAL
7.09
1.00
93312
ECHO TRANSESOPHAGEAL
7.17
1.00
93312
ECHO TRANSESOPHAGEAL
9.03
1.00
93313
ECHO TRANSESOPHAGEAL
1.15
1.00
93313
ECHO TRANSESOPHAGEAL
1.21
1.00
93313
ECHO TRANSESOPHAGEAL
1.22
1.00
93314
ECHO TRANSESOPHAGEAL
5.77
1.00
93314
ECHO TRANSESOPHAGEAL
5.85
1.00
93314
ECHO TRANSESOPHAGEAL
7.77
1.00
93315
ECHO TRANSESOPHAGEAL
3.88
1.00
93315
ECHO TRANSESOPHAGEAL
3.90
1.00
93315
ECHO TRANSESOPHAGEAL
3.91
1.00
93315
ECHO TRANSESOPHAGEAL
3.92
1.00
93315
ECHO TRANSESOPHAGEAL
3.97
1.00
93315
ECHO TRANSESOPHAGEAL
4.12
1.00
Procedure Code Description
RVU
RVU Coeff Value
93316
ECHO TRANSESOPHAGEAL
1.24
1.00
93316
ECHO TRANSESOPHAGEAL
1.25
1.00
93316
ECHO TRANSESOPHAGEAL
1.26
1.00
93317
ECHO TRANSESOPHAGEAL
2.56
1.00
93317
ECHO TRANSESOPHAGEAL
2.57
1.00
93317
ECHO TRANSESOPHAGEAL
2.58
1.00
93318
ECHO TRANSESOPHAGEAL INTRAOP
2.74
1.00
93318
ECHO TRANSESOPHAGEAL INTRAOP
2.75
1.00
93318
ECHO TRANSESOPHAGEAL INTRAOP
2.82
1.00
93318
ECHO TRANSESOPHAGEAL INTRAOP
2.93
1.00
93318
ECHO TRANSESOPHAGEAL INTRAOP
3.13
1.00
93320
DOPPLER ECHO EXAM, HEART
2.17
1.00
93320
DOPPLER ECHO EXAM, HEART
2.34
1.00
93320
DOPPLER ECHO EXAM, HEART
2.38
1.00
93321
DOPPLER ECHO EXAM, HEART
0.97
1.00
93321
DOPPLER ECHO EXAM, HEART
1.39
1.00
93321
DOPPLER ECHO EXAM, HEART
1.42
1.00
93325
DOPPLER COLOR FLOW ADD-ON
1.50
1.00
93325
DOPPLER COLOR FLOW ADD-ON
3.17
1.00
93325
DOPPLER COLOR FLOW ADD-ON
3.23
1.00
93350
STRESS TTE ONLY
3.94
1.00
93350
STRESS TTE ONLY
3.97
1.00
93350
STRESS TTE ONLY
5.87
1.00
93351
STRESS TTE COMPLETE
7.04
1.00
93352
ADMIN ECG CONTRAST AGENT
1.07
1.00
93501
RIGHT HEART CATHETERIZATION
22.06
1.00
93501
RIGHT HEART CATHETERIZATION
22.29
1.00
93501
RIGHT HEART CATHETERIZATION
22.37
1.00
93501
RIGHT HEART CATHETERIZATION
22.68
1.00
93503
INSERT/PLACE HEART CATHETER
3.11
1.00
93503
INSERT/PLACE HEART CATHETER
3.76
1.00
93503
INSERT/PLACE HEART CATHETER
3.78
1.00
93505
BIOPSY OF HEART LINING
8.43
1.00
93505
BIOPSY OF HEART LINING
8.49
1.00
93505
BIOPSY OF HEART LINING
20.70
1.00
Procedure Code Description
RVU
RVU Coeff Value
93508
CATH PLACEMENT, ANGIOGRAPHY
19.04
1.00
93508
CATH PLACEMENT, ANGIOGRAPHY
19.72
1.00
93508
CATH PLACEMENT, ANGIOGRAPHY
29.41
1.00
93510
LEFT HEART CATHETERIZATION
5.00
1.00
93510
LEFT HEART CATHETERIZATION
36.98
1.00
93510
LEFT HEART CATHETERIZATION
44.99
1.00
93510
LEFT HEART CATHETERIZATION
46.15
1.00
93510
LEFT HEART CATHETERIZATION
46.17
1.00
93511
LEFT HEART CATHETERIZATION
44.98
1.00
93511
LEFT HEART CATHETERIZATION
46.11
1.00
93514
LEFT HEART CATHETERIZATION
47.85
1.00
93514
LEFT HEART CATHETERIZATION
48.96
1.00
93524
LEFT HEART CATHETERIZATION
59.31
1.00
93524
LEFT HEART CATHETERIZATION
60.66
1.00
93526
RT & LT HEART CATHETERS
7.00
1.00
93526
RT & LT HEART CATHETERS
47.46
1.00
93526
RT & LT HEART CATHETERS
59.28
1.00
93526
RT & LT HEART CATHETERS
60.65
1.00
93526
RT & LT HEART CATHETERS
60.69
1.00
93527
RT & LT HEART CATHETERS
59.81
1.00
93527
RT & LT HEART CATHETERS
61.16
1.00
93528
RT & LT HEART CATHETERS
62.34
1.00
93528
RT & LT HEART CATHETERS
63.71
1.00
93529
RT, LT HEART CATHETERIZATION
56.15
1.00
93529
RT, LT HEART CATHETERIZATION
57.48
1.00
93530
RT HEART CATH, CONGENITAL
7.00
1.00
93530
RT HEART CATH, CONGENITAL
23.71
1.00
93530
RT HEART CATH, CONGENITAL
24.46
1.00
93531
R & L HEART CATH, CONGENITAL
7.00
1.00
93531
R & L HEART CATH, CONGENITAL
62.61
1.00
93531
R & L HEART CATH, CONGENITAL
63.96
1.00
93531
R & L HEART CATH, CONGENITAL
63.98
1.00
93532
R & L HEART CATH, CONGENITAL
7.00
1.00
93532
R & L HEART CATH, CONGENITAL
63.65
1.00
93532
R & L HEART CATH, CONGENITAL
64.99
1.00
Procedure Code Description
RVU
RVU Coeff Value
93533
R & L HEART CATH, CONGENITAL
7.00
1.00
93533
R & L HEART CATH, CONGENITAL
58.80
1.00
93533
R & L HEART CATH, CONGENITAL
60.12
1.00
93539
INJECTION, CARDIAC CATH
0.57
1.00
93539
INJECTION, CARDIAC CATH
0.61
1.00
93540
INJECTION, CARDIAC CATH
0.61
1.00
93540
INJECTION, CARDIAC CATH
0.66
1.00
93541
INJECTION FOR LUNG ANGIOGRAM
0.41
1.00
93541
INJECTION FOR LUNG ANGIOGRAM
0.42
1.00
93541
INJECTION FOR LUNG ANGIOGRAM
0.44
1.00
93541
INJECTION FOR LUNG ANGIOGRAM
999.99
1.00
93542
INJECTION FOR HEART X-RAYS
0.41
1.00
93542
INJECTION FOR HEART X-RAYS
0.42
1.00
93542
INJECTION FOR HEART X-RAYS
0.44
1.00
93543
INJECTION FOR HEART X-RAYS
0.42
1.00
93543
INJECTION FOR HEART X-RAYS
0.44
1.00
93544
INJECTION FOR AORTOGRAPHY
0.36
1.00
93544
INJECTION FOR AORTOGRAPHY
0.39
1.00
93545
INJECT FOR CORONARY X-RAYS
0.57
1.00
93545
INJECT FOR CORONARY X-RAYS
0.60
1.00
93545
INJECT FOR CORONARY X-RAYS
0.61
1.00
93555
IMAGING, CARDIAC CATH
3.27
1.00
93556
IMAGING, CARDIAC CATH
4.57
1.00
93556
IMAGING, CARDIAC CATH
11.46
1.00
93556
IMAGING, CARDIAC CATH
11.64
1.00
93561
CARDIAC OUTPUT MEASUREMENT
1.25
1.00
93561
CARDIAC OUTPUT MEASUREMENT
1.26
1.00
93562
CARDIAC OUTPUT MEASUREMENT
0.57
1.00
93562
CARDIAC OUTPUT MEASUREMENT
0.58
1.00
93571
HEART FLOW RESERVE MEASURE
7.36
1.00
93571
HEART FLOW RESERVE MEASURE
7.43
1.00
93572
HEART FLOW RESERVE MEASURE
4.50
1.00
93572
HEART FLOW RESERVE MEASURE
4.58
1.00
93580
TRANSCATH CLOSURE OF ASD
26.48
1.00
93580
TRANSCATH CLOSURE OF ASD
26.55
1.00
Procedure Code Description
RVU
RVU Coeff Value
93580
TRANSCATH CLOSURE OF ASD
28.25
1.00
93581
TRANSCATH CLOSURE OF VSD
35.41
1.00
93581
TRANSCATH CLOSURE OF VSD
35.42
1.00
93581
TRANSCATH CLOSURE OF VSD
37.00
1.00
93600
BUNDLE OF HIS RECORDING
5.13
1.00
93600
BUNDLE OF HIS RECORDING
5.17
1.00
93602
INTRA-ATRIAL RECORDING
4.24
1.00
93602
INTRA-ATRIAL RECORDING
4.28
1.00
93603
RIGHT VENTRICULAR RECORDING
4.83
1.00
93603
RIGHT VENTRICULAR RECORDING
4.87
1.00
93609
MAP TACHYCARDIA, ADD-ON
10.37
1.00
93609
MAP TACHYCARDIA, ADD-ON
10.46
1.00
93610
INTRA-ATRIAL PACING
5.79
1.00
93610
INTRA-ATRIAL PACING
5.85
1.00
93612
INTRAVENTRICULAR PACING
6.07
1.00
93612
INTRAVENTRICULAR PACING
6.12
1.00
93613
ELECTROPHYS MAP 3D, ADD-ON
10.24
1.00
93613
ELECTROPHYS MAP 3D, ADD-ON
10.38
1.00
93613
ELECTROPHYS MAP 3D, ADD-ON
10.96
1.00
93615
ESOPHAGEAL RECORDING
1.63
1.00
93615
ESOPHAGEAL RECORDING
1.64
1.00
93616
ESOPHAGEAL RECORDING
2.32
1.00
93616
ESOPHAGEAL RECORDING
2.33
1.00
93618
HEART RHYTHM PACING
10.34
1.00
93618
HEART RHYTHM PACING
10.42
1.00
93619
ELECTROPHYSIOLOGY EVALUATION
4.00
1.00
93619
ELECTROPHYSIOLOGY EVALUATION
18.68
1.00
93619
ELECTROPHYSIOLOGY EVALUATION
19.18
1.00
93620
ELECTROPHYSIOLOGY EVALUATION
16.79
1.00
93620
ELECTROPHYSIOLOGY EVALUATION
16.81
1.00
93620
ELECTROPHYSIOLOGY EVALUATION
17.15
1.00
93620
ELECTROPHYSIOLOGY EVALUATION
17.22
1.00
93620
ELECTROPHYSIOLOGY EVALUATION
17.59
1.00
93620
ELECTROPHYSIOLOGY EVALUATION
18.18
1.00
93621
ELECTROPHYSIOLOGY EVALUATION
2.99
1.00
Procedure Code Description
RVU
RVU Coeff Value
93621
ELECTROPHYSIOLOGY EVALUATION
3.07
1.00
93621
ELECTROPHYSIOLOGY EVALUATION
3.09
1.00
93621
ELECTROPHYSIOLOGY EVALUATION
3.10
1.00
93621
ELECTROPHYSIOLOGY EVALUATION
3.15
1.00
93621
ELECTROPHYSIOLOGY EVALUATION
3.29
1.00
93622
ELECTROPHYSIOLOGY EVALUATION
4.41
1.00
93622
ELECTROPHYSIOLOGY EVALUATION
4.53
1.00
93622
ELECTROPHYSIOLOGY EVALUATION
4.81
1.00
93622
ELECTROPHYSIOLOGY EVALUATION
5.00
1.00
93622
ELECTROPHYSIOLOGY EVALUATION
5.12
1.00
93623
STIMULATION, PACING HEART
4.05
1.00
93623
STIMULATION, PACING HEART
4.13
1.00
93623
STIMULATION, PACING HEART
4.15
1.00
93623
STIMULATION, PACING HEART
4.16
1.00
93623
STIMULATION, PACING HEART
4.27
1.00
93623
STIMULATION, PACING HEART
4.46
1.00
93624
ELECTROPHYSIOLOGIC STUDY
9.05
1.00
93624
ELECTROPHYSIOLOGIC STUDY
9.42
1.00
93631
HEART PACING, MAPPING
17.70
1.00
93631
HEART PACING, MAPPING
17.96
1.00
93640
EVALUATION HEART DEVICE
12.58
1.00
93640
EVALUATION HEART DEVICE
12.71
1.00
93641
ELECTROPHYSIOLOGY EVALUATION
16.10
1.00
93641
ELECTROPHYSIOLOGY EVALUATION
16.23
1.00
93642
ELECTROPHYSIOLOGY EVALUATION
13.11
1.00
93642
ELECTROPHYSIOLOGY EVALUATION
14.47
1.00
93642
ELECTROPHYSIOLOGY EVALUATION
14.91
1.00
93650
ABLATE HEART DYSRHYTHM FOCUS
15.25
1.00
93650
ABLATE HEART DYSRHYTHM FOCUS
15.60
1.00
93650
ABLATE HEART DYSRHYTHM FOCUS
16.69
1.00
93651
ABLATE HEART DYSRHYTHM FOCUS
23.59
1.00
93651
ABLATE HEART DYSRHYTHM FOCUS
23.61
1.00
93651
ABLATE HEART DYSRHYTHM FOCUS
25.39
1.00
93652
ABLATE HEART DYSRHYTHM FOCUS
25.67
1.00
93652
ABLATE HEART DYSRHYTHM FOCUS
27.63
1.00
Procedure Code Description
RVU
RVU Coeff Value
93660
TILT TABLE EVALUATION
4.40
1.00
93660
TILT TABLE EVALUATION
4.41
1.00
93660
TILT TABLE EVALUATION
4.75
1.00
93662
INTRACARDIAC ECG (ICE)
4.00
1.00
93662
INTRACARDIAC ECG (ICE)
4.27
1.00
93662
INTRACARDIAC ECG (ICE)
4.29
1.00
93662
INTRACARDIAC ECG (ICE)
4.40
1.00
93701
BIOIMPEDANCE, THORACIC
0.94
1.00
93701
BIOIMPEDANCE, THORACIC
1.21
1.00
93701
BIOIMPEDANCE, THORACIC
1.33
1.00
93720
TOTAL BODY PLETHYSMOGRAPHY
0.99
1.00
93720
TOTAL BODY PLETHYSMOGRAPHY
1.00
1.00
93720
TOTAL BODY PLETHYSMOGRAPHY
1.28
1.00
93721
PLETHYSMOGRAPHY TRACING
0.76
1.00
93721
PLETHYSMOGRAPHY TRACING
0.77
1.00
93721
PLETHYSMOGRAPHY TRACING
1.05
1.00
93722
PLETHYSMOGRAPHY REPORT
0.23
1.00
93724
ANALYZE PACEMAKER SYSTEM
9.28
1.00
93724
ANALYZE PACEMAKER SYSTEM
11.18
1.00
93724
ANALYZE PACEMAKER SYSTEM
11.24
1.00
93727
ANALYZE ILR SYSTEM
0.77
1.00
93727
ANALYZE ILR SYSTEM
0.78
1.00
93727
ANALYZE ILR SYSTEM
0.96
1.00
93731
ANALYZE PACEMAKER SYSTEM
1.17
1.00
93731
ANALYZE PACEMAKER SYSTEM
1.18
1.00
93731
ANALYZE PACEMAKER SYSTEM
1.22
1.00
93732
ANALYZE PACEMAKER SYSTEM
1.85
1.00
93732
ANALYZE PACEMAKER SYSTEM
1.87
1.00
93732
ANALYZE PACEMAKER SYSTEM
2.00
1.00
93733
TELEPHONE ANALY, PACEMAKER
1.03
1.00
93733
TELEPHONE ANALY, PACEMAKER
1.04
1.00
93733
TELEPHONE ANALY, PACEMAKER
1.10
1.00
93734
ANALYZE PACEMAKER SYSTEM
0.91
1.00
93734
ANALYZE PACEMAKER SYSTEM
1.01
1.00
93735
ANALYZE PACEMAKER SYSTEM
1.54
1.00
Procedure Code Description
RVU
RVU Coeff Value
93735
ANALYZE PACEMAKER SYSTEM
1.55
1.00
93735
ANALYZE PACEMAKER SYSTEM
1.64
1.00
93736
TELEPHONIC ANALY, PACEMAKER
0.90
1.00
93736
TELEPHONIC ANALY, PACEMAKER
0.91
1.00
93736
TELEPHONIC ANALY, PACEMAKER
1.01
1.00
93741
ANALYZE HT PACE DEVICE SNGL
1.84
1.00
93741
ANALYZE HT PACE DEVICE SNGL
1.85
1.00
93741
ANALYZE HT PACE DEVICE SNGL
1.86
1.00
93742
ANALYZE HT PACE DEVICE SNGL
2.00
1.00
93742
ANALYZE HT PACE DEVICE SNGL
2.07
1.00
93743
ANALYZE HT PACE DEVICE DUAL
2.24
1.00
93743
ANALYZE HT PACE DEVICE DUAL
2.25
1.00
93743
ANALYZE HT PACE DEVICE DUAL
2.26
1.00
93744
ANALYZE HT PACE DEVICE DUAL
2.38
1.00
93744
ANALYZE HT PACE DEVICE DUAL
2.39
1.00
93744
ANALYZE HT PACE DEVICE DUAL
2.49
1.00
93770
MEASURE VENOUS PRESSURE
0.24
1.00
93770
MEASURE VENOUS PRESSURE
0.26
1.00
93784
AMBULATORY BP MONITORING
1.17
1.00
93784
AMBULATORY BP MONITORING
1.81
1.00
93784
AMBULATORY BP MONITORING
1.96
1.00
93786
AMBULATORY BP RECORDING
0.82
1.00
93786
AMBULATORY BP RECORDING
0.92
1.00
93788
AMBULATORY BP ANALYSIS
0.46
1.00
93788
AMBULATORY BP ANALYSIS
0.52
1.00
93790
REVIEW/REPORT BP RECORDING
0.25
1.00
93790
REVIEW/REPORT BP RECORDING
0.52
1.00
93790
REVIEW/REPORT BP RECORDING
0.53
1.00
93797
CARDIAC REHAB
0.26
1.00
93797
CARDIAC REHAB
0.27
1.00
93798
CARDIAC REHAB/MONITOR
0.40
1.00
93798
CARDIAC REHAB/MONITOR
0.42
1.00
93875
EXTRACRANIAL STUDY
1.97
1.00
93875
EXTRACRANIAL STUDY
2.00
1.00
93875
EXTRACRANIAL STUDY
2.81
1.00
Procedure Code Description
RVU
RVU Coeff Value
93880
EXTRACRANIAL STUDY
5.18
1.00
93880
EXTRACRANIAL STUDY
5.23
1.00
93880
EXTRACRANIAL STUDY
6.89
1.00
93882
EXTRACRANIAL STUDY
3.57
1.00
93882
EXTRACRANIAL STUDY
3.68
1.00
93882
EXTRACRANIAL STUDY
4.54
1.00
93886
INTRACRANIAL STUDY
5.86
1.00
93886
INTRACRANIAL STUDY
6.04
1.00
93886
INTRACRANIAL STUDY
8.26
1.00
93888
INTRACRANIAL STUDY
3.96
1.00
93888
INTRACRANIAL STUDY
4.02
1.00
93888
INTRACRANIAL STUDY
5.63
1.00
93890
TRANSCRANIAL DOPPLER STUDY OF THE
6.35
1.00
93890
TRANSCRANIAL DOPPLER STUDY OF THE
6.36
1.00
93890
TRANSCRANIAL DOPPLER STUDY OF THE
7.26
1.00
93892
TCD, EMBOLI DETECT W/O INJ
7.95
1.00
93893
TCD, EMBOLI DETECT W/INJ
7.93
1.00
93922
EXTREMITY STUDY
2.26
1.00
93922
EXTREMITY STUDY
2.33
1.00
93922
EXTREMITY STUDY
3.34
1.00
93923
EXTREMITY STUDY
3.62
1.00
93923
EXTREMITY STUDY
3.72
1.00
93923
EXTREMITY STUDY
5.16
1.00
93924
EXTREMITY STUDY
4.43
1.00
93924
EXTREMITY STUDY
4.57
1.00
93924
EXTREMITY STUDY
6.35
1.00
93925
LOWER EXTREMITY STUDY
5.85
1.00
93925
LOWER EXTREMITY STUDY
5.86
1.00
93925
LOWER EXTREMITY STUDY
8.55
1.00
93926
LOWER EXTREMITY STUDY
4.00
1.00
93926
LOWER EXTREMITY STUDY
4.15
1.00
93926
LOWER EXTREMITY STUDY
5.46
1.00
93930
UPPER EXTREMITY STUDY
4.72
1.00
93930
UPPER EXTREMITY STUDY
4.74
1.00
93930
UPPER EXTREMITY STUDY
6.77
1.00
Procedure Code Description
RVU
RVU Coeff Value
93931
UPPER EXTREMITY STUDY
3.36
1.00
93931
UPPER EXTREMITY STUDY
3.39
1.00
93931
UPPER EXTREMITY STUDY
4.53
1.00
93965
EXTREMITY STUDY
2.32
1.00
93965
EXTREMITY STUDY
2.35
1.00
93965
EXTREMITY STUDY
3.41
1.00
93970
EXTREMITY STUDY
5.11
1.00
93970
EXTREMITY STUDY
7.04
1.00
93971
EXTREMITY STUDY
3.57
1.00
93971
EXTREMITY STUDY
3.62
1.00
93971
EXTREMITY STUDY
4.66
1.00
93975
VASCULAR STUDY
8.18
1.00
93975
VASCULAR STUDY
8.19
1.00
93975
VASCULAR STUDY
10.49
1.00
93976
VASCULAR STUDY
5.01
1.00
93976
VASCULAR STUDY
5.04
1.00
93976
VASCULAR STUDY
6.05
1.00
93978
VASCULAR STUDY
4.64
1.00
93978
VASCULAR STUDY
4.66
1.00
93978
VASCULAR STUDY
6.62
1.00
93979
VASCULAR STUDY
3.31
1.00
93979
VASCULAR STUDY
3.38
1.00
93979
VASCULAR STUDY
4.57
1.00
93980
PENILE VASCULAR STUDY
5.13
1.00
93980
PENILE VASCULAR STUDY
6.10
1.00
93980
PENILE VASCULAR STUDY
6.45
1.00
93981
PENILE VASCULAR STUDY
3.61
1.00
93981
PENILE VASCULAR STUDY
5.38
1.00
93981
PENILE VASCULAR STUDY
5.54
1.00
93982
ANEURYSM PRESSURE SENS STUDY
1.10
1.00
93990
DOPPLER FLOW TESTING
3.81
1.00
93990
DOPPLER FLOW TESTING
3.92
1.00
93990
DOPPLER FLOW TESTING
5.35
1.00
94010
BREATHING CAPACITY TEST
0.87
1.00
94010
BREATHING CAPACITY TEST
0.91
1.00
Procedure Code Description
RVU
RVU Coeff Value
94010
BREATHING CAPACITY TEST
1.08
1.00
94014
PATIENT RECORDED SPIROMETRY
1.01
1.00
94014
PATIENT RECORDED SPIROMETRY
1.32
1.00
94014
PATIENT RECORDED SPIROMETRY
1.34
1.00
94015
PATIENT RECORDED SPIROMETRY
0.30
1.00
94015
PATIENT RECORDED SPIROMETRY
0.61
1.00
94015
PATIENT RECORDED SPIROMETRY
0.65
1.00
94016
REVIEW PATIENT SPIROMETRY
0.69
1.00
94016
REVIEW PATIENT SPIROMETRY
0.71
1.00
94060
EVALUATION OF WHEEZING
1.50
1.00
94060
EVALUATION OF WHEEZING
1.60
1.00
94060
EVALUATION OF WHEEZING
1.89
1.00
94070
EVALUATION OF WHEEZING
1.67
1.00
94070
EVALUATION OF WHEEZING
3.71
1.00
94070
EVALUATION OF WHEEZING
5.04
1.00
94150
VITAL CAPACITY TEST
0.57
1.00
94150
VITAL CAPACITY TEST
0.62
1.00
94150
VITAL CAPACITY TEST
0.75
1.00
94200
LUNG FUNCTION TEST (MBC/MVV)
0.58
1.00
94200
LUNG FUNCTION TEST (MBC/MVV)
0.62
1.00
94200
LUNG FUNCTION TEST (MBC/MVV)
0.77
1.00
94240
RESIDUAL LUNG CAPACITY
0.97
1.00
94240
RESIDUAL LUNG CAPACITY
1.08
1.00
94240
RESIDUAL LUNG CAPACITY
2.20
1.00
94250
EXPIRED GAS COLLECTION
0.67
1.00
94250
EXPIRED GAS COLLECTION
0.78
1.00
94250
EXPIRED GAS COLLECTION
0.83
1.00
94260
THORACIC GAS VOLUME
0.72
1.00
94260
THORACIC GAS VOLUME
0.75
1.00
94260
THORACIC GAS VOLUME
0.87
1.00
94350
LUNG NITROGEN WASHOUT CURVE
0.96
1.00
94350
LUNG NITROGEN WASHOUT CURVE
1.06
1.00
94350
LUNG NITROGEN WASHOUT CURVE
2.26
1.00
94360
MEASURE AIRFLOW RESISTANCE
0.89
1.00
94360
MEASURE AIRFLOW RESISTANCE
1.02
1.00
Procedure Code Description
RVU
RVU Coeff Value
94360
MEASURE AIRFLOW RESISTANCE
1.20
1.00
94370
BREATH AIRWAY CLOSING VOLUME
0.92
1.00
94370
BREATH AIRWAY CLOSING VOLUME
1.01
1.00
94370
BREATH AIRWAY CLOSING VOLUME
2.25
1.00
94375
RESPIRATORY FLOW VOLUME LOOP
0.95
1.00
94375
RESPIRATORY FLOW VOLUME LOOP
1.01
1.00
94375
RESPIRATORY FLOW VOLUME LOOP
1.02
1.00
94400
CO2 BREATHING RESPONSE CURVE
1.31
1.00
94400
CO2 BREATHING RESPONSE CURVE
1.35
1.00
94400
CO2 BREATHING RESPONSE CURVE
1.46
1.00
94450
HYPOXIA RESPONSE CURVE
1.12
1.00
94450
HYPOXIA RESPONSE CURVE
1.39
1.00
94452
HAST W/REPORT
1.53
1.00
94453
HAST W/OXYGEN TITRATE
2.04
1.00
94610
SURFACTANT ADMIN THRU TUBE
1.79
1.00
94620
PULMONARY STRESS TEST/SIMPLE
1.99
1.00
94620
PULMONARY STRESS TEST/SIMPLE
3.18
1.00
94620
PULMONARY STRESS TEST/SIMPLE
3.21
1.00
94621
PULM STRESS TEST/COMPLEX
3.64
1.00
94621
PULM STRESS TEST/COMPLEX
3.67
1.00
94621
PULM STRESS TEST/COMPLEX
4.46
1.00
94640
AIRWAY INHALATION TREATMENT
0.34
1.00
94640
AIRWAY INHALATION TREATMENT
0.37
1.00
94640
AIRWAY INHALATION TREATMENT
0.72
1.00
94644
CBT, 1ST HOUR
0.94
1.00
94645
CBT, EACH ADDL HOUR
0.37
1.00
94662
NEG PRESS VENTILATION, CNP
1.02
1.00
94664
EVALUATE PT USE OF INHALER
0.36
1.00
94664
EVALUATE PT USE OF INHALER
0.41
1.00
94664
EVALUATE PT USE OF INHALER
0.55
1.00
94680
EXHALED AIR ANALYSIS, O2
1.59
1.00
94680
EXHALED AIR ANALYSIS, O2
2.22
1.00
94680
EXHALED AIR ANALYSIS, O2
2.23
1.00
94681
EXHALED AIR ANALYSIS, O2/CO2
1.74
1.00
94681
EXHALED AIR ANALYSIS, O2/CO2
2.95
1.00
Procedure Code Description
RVU
RVU Coeff Value
94681
EXHALED AIR ANALYSIS, O2/CO2
3.11
1.00
94690
EXHALED AIR ANALYSIS
1.39
1.00
94690
EXHALED AIR ANALYSIS
2.09
1.00
94690
EXHALED AIR ANALYSIS
2.24
1.00
94720
MONOXIDE DIFFUSING CAPACITY
1.33
1.00
94720
MONOXIDE DIFFUSING CAPACITY
1.42
1.00
94720
MONOXIDE DIFFUSING CAPACITY
1.87
1.00
94725
MEMBRANE DIFFUSION CAPACITY
1.85
1.00
94725
MEMBRANE DIFFUSION CAPACITY
2.93
1.00
94725
MEMBRANE DIFFUSION CAPACITY
3.31
1.00
94750
PULMONARY COMPLIANCE STUDY
1.63
1.00
94750
PULMONARY COMPLIANCE STUDY
1.95
1.00
94750
PULMONARY COMPLIANCE STUDY
2.34
1.00
94760
MEASURE BLOOD OXYGEN LEVEL
0.06
1.00
94760
MEASURE BLOOD OXYGEN LEVEL
0.08
1.00
94760
MEASURE BLOOD OXYGEN LEVEL
0.11
1.00
94761
MEASURE BLOOD OXYGEN LEVEL
0.13
1.00
94761
MEASURE BLOOD OXYGEN LEVEL
0.16
1.00
94761
MEASURE BLOOD OXYGEN LEVEL
0.22
1.00
94762
MEASURE BLOOD OXYGEN LEVEL
0.50
1.00
94762
MEASURE BLOOD OXYGEN LEVEL
0.82
1.00
94770
EXHALED CARBON DIOXIDE TEST
1.01
1.00
94770
EXHALED CARBON DIOXIDE TEST
1.90
1.00
95805
MULTIPLE SLEEP LATENCY TEST
11.69
1.00
95805
MULTIPLE SLEEP LATENCY TEST
18.55
1.00
95805
MULTIPLE SLEEP LATENCY TEST
19.33
1.00
95806
SLEEP STUDY, UNATTENDED
5.39
1.00
95806
SLEEP STUDY, UNATTENDED
5.85
1.00
95806
SLEEP STUDY, UNATTENDED
6.08
1.00
95807
SLEEP STUDY, ATTENDED
13.68
1.00
95807
SLEEP STUDY, ATTENDED
13.81
1.00
95807
SLEEP STUDY, ATTENDED
14.06
1.00
95808
POLYSOMNOGRAPHY, 1-3
16.09
1.00
95808
POLYSOMNOGRAPHY, 1-3
16.19
1.00
95808
POLYSOMNOGRAPHY, 1-3
17.89
1.00
Procedure Code Description
RVU
RVU Coeff Value
95810
POLYSOMNOGRAPHY, 4 OR MORE
21.10
1.00
95810
POLYSOMNOGRAPHY, 4 OR MORE
21.28
1.00
95810
POLYSOMNOGRAPHY, 4 OR MORE
21.29
1.00
95811
POLYSOMNOGRAPHY W/CPAP
21.96
1.00
95811
POLYSOMNOGRAPHY W/CPAP
22.83
1.00
95811
POLYSOMNOGRAPHY W/CPAP
23.44
1.00
95812
EEG, 41-60 MINUTES
5.15
1.00
95812
EEG, 41-60 MINUTES
5.93
1.00
95812
EEG, 41-60 MINUTES
6.52
1.00
95813
EEG, OVER 1 HOUR
6.84
1.00
95813
EEG, OVER 1 HOUR
7.68
1.00
95813
EEG, OVER 1 HOUR
7.99
1.00
95816
EEG, AWAKE AND DROWSY
4.37
1.00
95816
EEG, AWAKE AND DROWSY
4.87
1.00
95816
EEG, AWAKE AND DROWSY
5.98
1.00
95819
EEG, AWAKE AND ASLEEP
4.92
1.00
95819
EEG, AWAKE AND ASLEEP
5.51
1.00
95819
EEG, AWAKE AND ASLEEP
6.42
1.00
95822
EEG, COMA OR SLEEP ONLY
5.61
1.00
95822
EEG, COMA OR SLEEP ONLY
6.34
1.00
95822
EEG, COMA OR SLEEP ONLY
6.40
1.00
95824
EEG, CEREBRAL DEATH ONLY
1.02
1.00
95824
EEG, CEREBRAL DEATH ONLY
1.09
1.00
95824
EEG, CEREBRAL DEATH ONLY
1.11
1.00
95824
EEG, CEREBRAL DEATH ONLY
1.12
1.00
95827
EEG, ALL NIGHT RECORDING
3.93
1.00
95827
EEG, ALL NIGHT RECORDING
3.96
1.00
95827
EEG, ALL NIGHT RECORDING
10.33
1.00
95829
SURGERY ELECTROCORTICOGRAM
33.20
1.00
95829
SURGERY ELECTROCORTICOGRAM
37.89
1.00
95829
SURGERY ELECTROCORTICOGRAM
46.66
1.00
95831
LIMB MUSCLE TESTING, MANUAL
0.39
1.00
95831
LIMB MUSCLE TESTING, MANUAL
0.42
1.00
95832
HAND MUSCLE TESTING, MANUAL
0.41
1.00
95832
HAND MUSCLE TESTING, MANUAL
0.42
1.00
Procedure Code Description
RVU
RVU Coeff Value
95833
BODY MUSCLE TESTING, MANUAL
0.65
1.00
95833
BODY MUSCLE TESTING, MANUAL
0.71
1.00
95834
BODY MUSCLE TESTING, MANUAL
0.82
1.00
95834
BODY MUSCLE TESTING, MANUAL
0.90
1.00
95852
RANGE OF MOTION MEASUREMENTS
0.16
1.00
95852
RANGE OF MOTION MEASUREMENTS
0.17
1.00
95857
TENSILON TEST
0.74
1.00
95857
TENSILON TEST
0.78
1.00
95858
TENSILON TEST & MYOGRAM
2.71
1.00
95858
TENSILON TEST & MYOGRAM
2.72
1.00
95858
TENSILON TEST & MYOGRAM
2.75
1.00
95860
MUSCLE TEST, ONE LIMB
2.23
1.00
95860
MUSCLE TEST, ONE LIMB
2.47
1.00
95860
MUSCLE TEST, ONE LIMB
2.63
1.00
95861
MUSCLE TEST, 2 LIMBS
3.08
1.00
95861
MUSCLE TEST, 2 LIMBS
3.24
1.00
95863
MUSCLE TEST, 3 LIMBS
3.75
1.00
95863
MUSCLE TEST, 3 LIMBS
3.86
1.00
95864
MUSCLE TEST, 4 LIMBS
4.44
1.00
95864
MUSCLE TEST, 4 LIMBS
4.81
1.00
95864
MUSCLE TEST, 4 LIMBS
4.84
1.00
95865
MUSCLE TEST, LARYNX
3.10
1.00
95866
MUSCLE TEST, HEMIDIAPHRAGM
2.54
1.00
95867
MUSCLE TEST CRAN NERV UNILAT
1.79
1.00
95867
MUSCLE TEST CRAN NERV UNILAT
1.80
1.00
95867
MUSCLE TEST CRAN NERV UNILAT
1.94
1.00
95868
MUSCLE TEST CRAN NERVE BILAT
2.49
1.00
95868
MUSCLE TEST CRAN NERVE BILAT
2.66
1.00
95869
MUSCLE TEST, THOR PARASPINAL
0.78
1.00
95869
MUSCLE TEST, THOR PARASPINAL
1.24
1.00
95870
MUSCLE TEST, NONPARASPINAL
0.77
1.00
95870
MUSCLE TEST, NONPARASPINAL
0.78
1.00
95870
MUSCLE TEST, NONPARASPINAL
1.21
1.00
95873
GUIDE NERV DESTR, ELEC STIM
1.26
1.00
95874
GUIDE NERV DESTR, NEEDLE EMG
1.19
1.00
Procedure Code Description
RVU
RVU Coeff Value
95875
LIMB EXERCISE TEST
2.55
1.00
95875
LIMB EXERCISE TEST
2.67
1.00
95875
LIMB EXERCISE TEST
2.91
1.00
95900
MOTOR NERVE CONDUCTION TEST
1.45
1.00
95900
MOTOR NERVE CONDUCTION TEST
1.57
1.00
95900
MOTOR NERVE CONDUCTION TEST
1.74
1.00
95903
MOTOR NERVE CONDUCTION TEST
1.70
1.00
95903
MOTOR NERVE CONDUCTION TEST
1.71
1.00
95903
MOTOR NERVE CONDUCTION TEST
1.85
1.00
95904
SENSE NERVE CONDUCTION TEST
1.28
1.00
95904
SENSE NERVE CONDUCTION TEST
1.32
1.00
95904
SENSE NERVE CONDUCTION TEST
1.48
1.00
95920
INTRAOP NERVE TEST ADD-ON
4.16
1.00
95920
INTRAOP NERVE TEST ADD-ON
4.57
1.00
95920
INTRAOP NERVE TEST ADD-ON
4.60
1.00
95921
AUTONOMIC NERV FUNCTION TEST
1.66
1.00
95921
AUTONOMIC NERV FUNCTION TEST
1.67
1.00
95921
AUTONOMIC NERV FUNCTION TEST
2.01
1.00
95922
AUTONOMIC NERV FUNCTION TEST
1.79
1.00
95922
AUTONOMIC NERV FUNCTION TEST
1.80
1.00
95922
AUTONOMIC NERV FUNCTION TEST
2.41
1.00
95923
AUTONOMIC NERV FUNCTION TEST
3.04
1.00
95923
AUTONOMIC NERV FUNCTION TEST
3.16
1.00
95923
AUTONOMIC NERV FUNCTION TEST
3.87
1.00
95925
SOMATOSENSORY TESTING
1.75
1.00
95925
SOMATOSENSORY TESTING
1.76
1.00
95925
SOMATOSENSORY TESTING
3.22
1.00
95926
SOMATOSENSORY TESTING
1.76
1.00
95926
SOMATOSENSORY TESTING
1.77
1.00
95926
SOMATOSENSORY TESTING
3.16
1.00
95927
SOMATOSENSORY TESTING
1.79
1.00
95927
SOMATOSENSORY TESTING
1.80
1.00
95927
SOMATOSENSORY TESTING
3.24
1.00
95928
C MOTOR EVOKED, UPPR LIMBS
5.13
1.00
95929
C MOTOR EVOKED, LWR LIMBS
5.41
1.00
Procedure Code Description
RVU
RVU Coeff Value
95930
VISUAL EVOKED POTENTIAL TEST
1.55
1.00
95930
VISUAL EVOKED POTENTIAL TEST
1.80
1.00
95930
VISUAL EVOKED POTENTIAL TEST
2.84
1.00
95933
BLINK REFLEX TEST
1.69
1.00
95933
BLINK REFLEX TEST
1.70
1.00
95933
BLINK REFLEX TEST
1.76
1.00
95934
H-REFLEX TEST
0.98
1.00
95934
H-REFLEX TEST
0.99
1.00
95934
H-REFLEX TEST
1.31
1.00
95936
H-REFLEX TEST
1.05
1.00
95936
H-REFLEX TEST
1.16
1.00
95937
NEUROMUSCULAR JUNCTION TEST
1.30
1.00
95937
NEUROMUSCULAR JUNCTION TEST
1.57
1.00
95950
AMBULATORY EEG MONITORING
6.51
1.00
95950
AMBULATORY EEG MONITORING
6.58
1.00
95950
AMBULATORY EEG MONITORING
8.74
1.00
95951
EEG MONITORING/VIDEORECORD
8.27
1.00
95951
EEG MONITORING/VIDEORECORD
8.43
1.00
95951
EEG MONITORING/VIDEORECORD
8.65
1.00
95951
EEG MONITORING/VIDEORECORD
8.80
1.00
95951
EEG MONITORING/VIDEORECORD
8.82
1.00
95951
EEG MONITORING/VIDEORECORD
8.87
1.00
95953
EEG MONITORING/COMPUTER
11.06
1.00
95953
EEG MONITORING/COMPUTER
11.17
1.00
95953
EEG MONITORING/COMPUTER
11.27
1.00
95956
EEG MONITORING, CABLE/RADIO
17.78
1.00
95956
EEG MONITORING, CABLE/RADIO
19.24
1.00
95956
EEG MONITORING, CABLE/RADIO
19.42
1.00
95957
EEG DIGITAL ANALYSIS
4.71
1.00
95957
EEG DIGITAL ANALYSIS
4.74
1.00
95957
EEG DIGITAL ANALYSIS
7.11
1.00
95961
ELECTRODE STIMULATION, BRAIN
5.86
1.00
95961
ELECTRODE STIMULATION, BRAIN
5.89
1.00
95961
ELECTRODE STIMULATION, BRAIN
6.42
1.00
95962
ELECTRODE STIM, BRAIN ADD-ON
5.89
1.00
Procedure Code Description
RVU
RVU Coeff Value
95962
ELECTRODE STIM, BRAIN ADD-ON
6.16
1.00
95962
ELECTRODE STIM, BRAIN ADD-ON
6.19
1.00
95965
MEG, SPONTANEOUS
11.31
1.00
95965
MEG, SPONTANEOUS
11.42
1.00
95965
MEG, SPONTANEOUS
11.78
1.00
95965
MEG, SPONTANEOUS
11.86
1.00
95965
MEG, SPONTANEOUS
11.88
1.00
95966
MEG, EVOKED, SINGLE
5.62
1.00
95966
MEG, EVOKED, SINGLE
5.70
1.00
95966
MEG, EVOKED, SINGLE
5.89
1.00
95966
MEG, EVOKED, SINGLE
5.90
1.00
95967
MEG, EVOKED, EACH ADDÏL
4.81
1.00
95967
MEG, EVOKED, EACH ADDÏL
4.82
1.00
95967
MEG, EVOKED, EACH ADDÏL
4.83
1.00
95967
MEG, EVOKED, EACH ADDÏL
4.98
1.00
95967
MEG, EVOKED, EACH ADDÏL
4.99
1.00
95970
ANALYZE NEUROSTIM, NO PROG
0.61
1.00
95970
ANALYZE NEUROSTIM, NO PROG
0.63
1.00
95970
ANALYZE NEUROSTIM, NO PROG
0.64
1.00
95971
ANALYZE NEUROSTIM, SIMPLE
1.07
1.00
95971
ANALYZE NEUROSTIM, SIMPLE
1.08
1.00
95971
ANALYZE NEUROSTIM, SIMPLE
1.11
1.00
95972
ANALYZE NEUROSTIM, COMPLEX
2.11
1.00
95972
ANALYZE NEUROSTIM, COMPLEX
2.18
1.00
95972
ANALYZE NEUROSTIM, COMPLEX
2.20
1.00
95973
ANALYZE NEUROSTIM, COMPLEX
1.25
1.00
95973
ANALYZE NEUROSTIM, COMPLEX
1.34
1.00
95973
ANALYZE NEUROSTIM, COMPLEX
1.35
1.00
95974
CRANIAL NEUROSTIM, COMPLEX
4.10
1.00
95974
CRANIAL NEUROSTIM, COMPLEX
4.47
1.00
95975
CRANIAL NEUROSTIM, COMPLEX
2.37
1.00
95975
CRANIAL NEUROSTIM, COMPLEX
2.51
1.00
95975
CRANIAL NEUROSTIM, COMPLEX
2.52
1.00
95978
ANALYZE NEUROSTIM BRAIN/1H
4.81
1.00
95979
ANALYZ NEUROSTIM BRAIN ADDON
2.26
1.00
Procedure Code Description
RVU
RVU Coeff Value
95980
IO ANAL GAST N-STIM INIT
1.12
1.00
95981
IO ANAL GAST N-STIM SUBSQ
0.44
1.00
95982
IO GA N-STIM SUBSQ W/REPROG
0.90
1.00
95990
SPIN/BRAIN PUMP REFIL & MAIN
1.54
1.00
95990
SPIN/BRAIN PUMP REFIL & MAIN
1.56
1.00
95990
SPIN/BRAIN PUMP REFIL & MAIN
1.62
1.00
95991
SPIN/BRAIN PUMP REFIL & MAIN
1.01
1.00
95991
SPIN/BRAIN PUMP REFIL & MAIN
1.02
1.00
95992
CANALITH REPOSITIONING PROC
1.02
1.00
97001
PT EVALUATION
1.71
1.00
97001
PT EVALUATION
1.94
1.00
97002
PT RE-EVALUATION
0.86
1.00
97002
PT RE-EVALUATION
1.04
1.00
97003
OT EVALUATION
1.66
1.00
97003
OT EVALUATION
2.06
1.00
97004
OT RE-EVALUATION
0.82
1.00
97004
OT RE-EVALUATION
1.19
1.00
97010
HOT OR COLD PACKS THERAPY
0.12
1.00
97010
HOT OR COLD PACKS THERAPY
0.13
1.00
97012
MECHANICAL TRACTION THERAPY
0.40
1.00
97014
ELECTRIC STIMULATION THERAPY
0.37
1.00
97014
ELECTRIC STIMULATION THERAPY
0.38
1.00
97016
VASOPNEUMATIC DEVICE THERAPY
0.38
1.00
97016
VASOPNEUMATIC DEVICE THERAPY
0.42
1.00
97018
PARAFFIN BATH THERAPY
0.18
1.00
97018
PARAFFIN BATH THERAPY
0.22
1.00
97020
MICROWAVE THERAPY
0.13
1.00
97022
WHIRLPOOL THERAPY
0.40
1.00
97022
WHIRLPOOL THERAPY
0.48
1.00
97024
DIATHERMY EG, MICROWAVE
0.13
1.00
97024
DIATHERMY EG, MICROWAVE
0.15
1.00
97024
DIATHERMY EG, MICROWAVE
0.16
1.00
97026
INFRARED THERAPY
0.13
1.00
97026
INFRARED THERAPY
0.14
1.00
97028
ULTRAVIOLET THERAPY
0.16
1.00
Procedure Code Description
RVU
RVU Coeff Value
97028
ULTRAVIOLET THERAPY
0.17
1.00
97032
ELECTRICAL STIMULATION
0.42
1.00
97032
ELECTRICAL STIMULATION
0.44
1.00
97032
ELECTRICAL STIMULATION
0.45
1.00
97033
ELECTRIC CURRENT THERAPY
0.55
1.00
97033
ELECTRIC CURRENT THERAPY
0.56
1.00
97033
ELECTRIC CURRENT THERAPY
0.67
1.00
97034
CONTRAST BATH THERAPY
0.38
1.00
97034
CONTRAST BATH THERAPY
0.41
1.00
97035
ULTRASOUND THERAPY
0.32
1.00
97035
ULTRASOUND THERAPY
0.33
1.00
97036
HYDROTHERAPY
0.62
1.00
97036
HYDROTHERAPY
0.70
1.00
97039
PHYSICAL THERAPY TREATMENT
0.31
1.00
97039
PHYSICAL THERAPY TREATMENT
0.32
1.00
97110
THERAPEUTIC EXERCISES
0.76
1.00
97110
THERAPEUTIC EXERCISES
0.77
1.00
97110
THERAPEUTIC EXERCISES
0.78
1.00
97112
NEUROMUSCULAR REEDUCATION
0.77
1.00
97112
NEUROMUSCULAR REEDUCATION
0.78
1.00
97112
NEUROMUSCULAR REEDUCATION
0.80
1.00
97113
AQUATIC THERAPY/EXERCISES
0.81
1.00
97113
AQUATIC THERAPY/EXERCISES
0.88
1.00
97113
AQUATIC THERAPY/EXERCISES
0.95
1.00
97116
GAIT TRAINING THERAPY
0.66
1.00
97116
GAIT TRAINING THERAPY
0.67
1.00
97116
GAIT TRAINING THERAPY
0.68
1.00
97124
MASSAGE THERAPY
0.59
1.00
97124
MASSAGE THERAPY
0.60
1.00
97124
MASSAGE THERAPY
0.62
1.00
97139
PHYSICAL MEDICINE PROCEDURE
0.42
1.00
97139
PHYSICAL MEDICINE PROCEDURE
0.43
1.00
97140
MANUAL THERAPY
0.71
1.00
97140
MANUAL THERAPY
0.72
1.00
97150
GROUP THERAPEUTIC PROCEDURES
0.47
1.00
Procedure Code Description
RVU
RVU Coeff Value
97150
GROUP THERAPEUTIC PROCEDURES
0.49
1.00
97150
GROUP THERAPEUTIC PROCEDURES
0.50
1.00
97150
GROUP THERAPEUTIC PROCEDURES
100.00
1.00
97504
ORTHOTIC TRAINING
0.77
1.00
97504
ORTHOTIC TRAINING
0.81
1.00
97504
ORTHOTIC TRAINING
0.82
1.00
97520
PROSTHETIC TRAINING
0.74
1.00
97520
PROSTHETIC TRAINING
0.75
1.00
97530
THERAPEUTIC ACTIVITIES
0.77
1.00
97530
THERAPEUTIC ACTIVITIES
0.78
1.00
97530
THERAPEUTIC ACTIVITIES
0.82
1.00
97532
COGNITIVE SKILLS DEVELOPMENT
0.65
1.00
97532
COGNITIVE SKILLS DEVELOPMENT
0.66
1.00
97532
COGNITIVE SKILLS DEVELOPMENT
0.67
1.00
97532
COGNITIVE SKILLS DEVELOPMENT
100.00
1.00
97533
SENSORY INTEGRATION
0.69
1.00
97533
SENSORY INTEGRATION
0.72
1.00
97535
SELF CARE MNGMENT TRAINING
0.80
1.00
97535
SELF CARE MNGMENT TRAINING
0.82
1.00
97537
COMMUNITY/WORK REINTEGRATION
0.73
1.00
97537
COMMUNITY/WORK REINTEGRATION
0.74
1.00
97542
WHEELCHAIR MNGMENT TRAINING
0.74
1.00
97542
WHEELCHAIR MNGMENT TRAINING
0.75
1.00
97597
ACTIVE WOUND CARE/20 CM OR <
0.89
1.00
97598
ACTIVE WOUND CARE > 20 CM
1.18
1.00
97601
WOUND(S) CARE, SELECTIVE
1.04
1.00
97601
WOUND(S) CARE, SELECTIVE
1.07
1.00
97605
NEG PRESS WOUND TX, < 50 CM
0.72
1.00
97606
NEG PRESS WOUND TX, > 50 CM
0.79
1.00
97703
PROSTHETIC CHECKOUT
0.60
1.00
97703
PROSTHETIC CHECKOUT
0.68
1.00
97750
PHYSICAL PERFORMANCE TEST
0.77
1.00
97750
PHYSICAL PERFORMANCE TEST
0.78
1.00
97750
PHYSICAL PERFORMANCE TEST
0.80
1.00
97755
ASSISTIVE TECHNOLOGY ASSESS
0.92
1.00
Procedure Code Description
RVU
RVU Coeff Value
97755
ASSISTIVE TECHNOLOGY ASSESS
0.93
1.00
97760
ORTHOTIC MGMT AND TRAINING
0.89
1.00
97761
PROSTHETIC TRAINING
0.79
1.00
97762
C/O FOR ORTHOTIC/PROSTH USE
0.92
1.00
99288
DIRECT ADVANCED LIFE SUPPORT
999.99
1.00
99291
CRITICAL CARE, FIRST HOUR
5.44
1.00
99292
CRITICAL CARE, ADDÏL 30 MIN
2.72
1.00
99293
PED CRITICAL CARE, INITIAL
21.37
1.00
99293
PED CRITICAL CARE, INITIAL
21.78
1.00
99294
PED CRITICAL CARE, SUBSEQ
10.47
1.00
99294
PED CRITICAL CARE, SUBSEQ
10.76
1.00
99295
NEONATE CRIT CARE, INITIAL
24.59
1.00
99295
NEONATE CRIT CARE, INITIAL
24.67
1.00
99295
NEONATE CRIT CARE, INITIAL
24.69
1.00
99296
NEONATE CRITICAL CARE SUBSEQ
10.61
1.00
99296
NEONATE CRITICAL CARE SUBSEQ
10.82
1.00
99296
NEONATE CRITICAL CARE SUBSEQ
10.84
1.00
99298
IC FOR LBW INFANT < 1500 GM
3.72
1.00
99298
IC FOR LBW INFANT < 1500 GM
3.80
1.00
99298
IC FOR LBW INFANT < 1500 GM
3.81
1.00
99299
IC, LBW INFANT 1500-2500 GM
3.38
1.00
99299
IC, LBW INFANT 1500-2500 GM
3.57
1.00
99300
IC, INFANT PBW 2501-5000 GM
3.32
1.00
99301
NURSING FACILITY CARE
1.65
1.00
99301
NURSING FACILITY CARE
1.66
1.00
99301
NURSING FACILITY CARE
1.75
1.00
99302
NURSING FACILITY CARE
2.21
1.00
99302
NURSING FACILITY CARE
2.32
1.00
99303
NURSING FACILITY CARE
2.75
1.00
99303
NURSING FACILITY CARE
2.86
1.00
99311
NURSING FAC CARE, SUBSEQ
0.82
1.00
99311
NURSING FAC CARE, SUBSEQ
0.83
1.00
99311
NURSING FAC CARE, SUBSEQ
0.90
1.00
99312
NURSING FAC CARE, SUBSEQ
1.37
1.00
99312
NURSING FAC CARE, SUBSEQ
1.38
1.00
Procedure Code Description
RVU
RVU Coeff Value
99312
NURSING FAC CARE, SUBSEQ
1.49
1.00
99313
NURSING FAC CARE, SUBSEQ
1.94
1.00
99313
NURSING FAC CARE, SUBSEQ
1.95
1.00
99313
NURSING FAC CARE, SUBSEQ
2.10
1.00
99341
HOME VISIT, NEW PATIENT
1.55
1.00
99341
HOME VISIT, NEW PATIENT
1.61
1.00
99342
HOME VISIT, NEW PATIENT
2.26
1.00
99342
HOME VISIT, NEW PATIENT
2.42
1.00
99343
HOME VISIT, NEW PATIENT
3.30
1.00
99343
HOME VISIT, NEW PATIENT
3.60
1.00
99344
HOME VISIT, NEW PATIENT
4.33
1.00
99344
HOME VISIT, NEW PATIENT
4.68
1.00
99345
HOME VISIT, NEW PATIENT
5.36
1.00
99345
HOME VISIT, NEW PATIENT
5.72
1.00
99347
HOME VISIT, EST PATIENT
1.19
1.00
99347
HOME VISIT, EST PATIENT
1.27
1.00
99348
HOME VISIT, EST PATIENT
2.02
1.00
99349
HOME VISIT, EST PATIENT
3.13
1.00
99350
HOME VISIT, EST PATIENT
4.55
1.00
99350
HOME VISIT, EST PATIENT
4.56
1.00
99354
PROLONGED SERVICE, OFFICE
2.44
1.00
99354
PROLONGED SERVICE, OFFICE
2.50
1.00
99355
PROLONGED SERVICE, OFFICE
2.42
1.00
99355
PROLONGED SERVICE, OFFICE
2.46
1.00
99356
PROLONGED SERVICE, INPATIENT
2.37
1.00
99356
PROLONGED SERVICE, INPATIENT
2.40
1.00
99357
PROLONGED SERVICE, INPATIENT
2.38
1.00
99357
PROLONGED SERVICE, INPATIENT
2.41
1.00
99360
PHYSICIAN STANDBY SERVICES
2.44
1.00
99360
PHYSICIAN STANDBY SERVICES
2.50
1.00
99381
INIT PM E/M, NEW PAT, INF
1.69
1.00
99382
INIT PM E/M, NEW PAT 1-4 YRS
1.93
1.00
99383
PREV VISIT, NEW, AGE 5-11
1.93
1.00
99384
PREV VISIT, NEW, AGE 12-17
2.18
1.00
99385
PREV VISIT, NEW, AGE 18-39
2.18
1.00
Procedure Code Description
RVU
RVU Coeff Value
99386
PREV VISIT, NEW, AGE 40-64
2.67
1.00
99387
INIT PM E/M, NEW PAT 65+ YRS
2.92
1.00
99391
PER PM REEVAL, EST PAT, INF
1.45
1.00
99392
PREV VISIT, EST, AGE 1-4
1.69
1.00
99393
PREV VISIT, EST, AGE 5-11
1.69
1.00
99394
PREV VISIT, EST, AGE 12-17
1.93
1.00
99395
PREV VISIT, EST, AGE 18-39
1.93
1.00
99396
PREV VISIT, EST, AGE 40-64
2.18
1.00
99397
PER PM REEVAL EST PAT 65+ YR
2.43
1.00
99431
INITIAL CARE, NORMAL NEWBORN
1.54
1.00
99431
INITIAL CARE, NORMAL NEWBORN
1.60
1.00
99432
NEWBORN CARE, NOT IN HOSP
1.67
1.00
99432
NEWBORN CARE, NOT IN HOSP
1.73
1.00
99433
NORMAL NEWBORN CARE/HOSPITAL
0.83
1.00
99433
NORMAL NEWBORN CARE/HOSPITAL
0.84
1.00
99435
NEWBORN DISCHARGE DAY HOSP
2.10
1.00
99436
ATTENDANCE, BIRTH
1.96
1.00
99440
NEWBORN RESUSCITATION
3.85
1.00
99440
NEWBORN RESUSCITATION
3.99
1.00
99440
NEWBORN RESUSCITATION
4.00
1.00
G0030
PET IMAGING PREV PET SINGLE
8.87
1.00
G0030
PET IMAGING PREV PET SINGLE
8.95
1.00
G0030
PET IMAGING PREV PET SINGLE
8.99
1.00
G0031
PET IMAGING PREV PET MULTPLE
14.30
1.00
G0031
PET IMAGING PREV PET MULTPLE
14.45
1.00
G0031
PET IMAGING PREV PET MULTPLE
14.49
1.00
G0032
PET FOLLOW SPECT 78464 SINGL
8.87
1.00
G0032
PET FOLLOW SPECT 78464 SINGL
8.95
1.00
G0032
PET FOLLOW SPECT 78464 SINGL
8.99
1.00
G0033
PET FOLLOW SPECT 78464 MULT
14.30
1.00
G0033
PET FOLLOW SPECT 78464 MULT
14.45
1.00
G0033
PET FOLLOW SPECT 78464 MULT
14.49
1.00
G0034
PET FOLLOW SPECT 76865 SINGL
8.87
1.00
G0034
PET FOLLOW SPECT 76865 SINGL
8.95
1.00
G0034
PET FOLLOW SPECT 76865 SINGL
8.99
1.00
Procedure Code Description
RVU
RVU Coeff Value
G0035
PET FOLLOW SPECT 78465 MULT
14.30
1.00
G0035
PET FOLLOW SPECT 78465 MULT
14.45
1.00
G0035
PET FOLLOW SPECT 78465 MULT
14.49
1.00
G0036
PET FOLLOW CORNRY ANGIO SING
8.87
1.00
G0036
PET FOLLOW CORNRY ANGIO SING
8.95
1.00
G0036
PET FOLLOW CORNRY ANGIO SING
8.99
1.00
G0037
PET FOLLOW CORNRY ANGIO MULT
14.30
1.00
G0037
PET FOLLOW CORNRY ANGIO MULT
14.45
1.00
G0037
PET FOLLOW CORNRY ANGIO MULT
14.49
1.00
G0038
PET FOLLOW MYOCARD PERF SING
8.87
1.00
G0038
PET FOLLOW MYOCARD PERF SING
8.95
1.00
G0038
PET FOLLOW MYOCARD PERF SING
8.99
1.00
G0039
PET FOLLOW MYOCARD PERF MULT
14.30
1.00
G0039
PET FOLLOW MYOCARD PERF MULT
14.45
1.00
G0039
PET FOLLOW MYOCARD PERF MULT
14.49
1.00
G0040
PET FOLLOW STRESS ECHO SINGL
8.87
1.00
G0040
PET FOLLOW STRESS ECHO SINGL
8.95
1.00
G0040
PET FOLLOW STRESS ECHO SINGL
8.99
1.00
G0041
PET FOLLOW STRESS ECHO MULT
14.30
1.00
G0041
PET FOLLOW STRESS ECHO MULT
14.45
1.00
G0041
PET FOLLOW STRESS ECHO MULT
14.49
1.00
G0042
PET FOLLOW VENTRICULOGM SING
8.87
1.00
G0042
PET FOLLOW VENTRICULOGM SING
8.95
1.00
G0042
PET FOLLOW VENTRICULOGM SING
8.99
1.00
G0043
PET FOLLOW VENTRICULOGM MULT
14.30
1.00
G0043
PET FOLLOW VENTRICULOGM MULT
14.45
1.00
G0043
PET FOLLOW VENTRICULOGM MULT
14.49
1.00
G0044
PET FOLLOWING REST ECG SINGL
8.87
1.00
G0044
PET FOLLOWING REST ECG SINGL
8.95
1.00
G0044
PET FOLLOWING REST ECG SINGL
8.99
1.00
G0045
PET FOLLOWING REST ECG MULT
14.30
1.00
G0045
PET FOLLOWING REST ECG MULT
14.45
1.00
G0045
PET FOLLOWING REST ECG MULT
14.49
1.00
G0046
PET FOLLOW STRESS ECG SINGL
8.87
1.00
G0046
PET FOLLOW STRESS ECG SINGL
8.95
1.00
Procedure Code Description
RVU
RVU Coeff Value
G0046
PET FOLLOW STRESS ECG SINGL
8.99
1.00
G0047
PET FOLLOW STRESS ECG MULT
14.30
1.00
G0047
PET FOLLOW STRESS ECG MULT
14.45
1.00
G0047
PET FOLLOW STRESS ECG MULT
14.49
1.00
G0210
PET IMG WHOLEBODY DXLUNG
5.64
1.00
G0210
PET IMG WHOLEBODY DXLUNG
14.45
1.00
G0210
PET IMG WHOLEBODY DXLUNG
14.49
1.00
G0211
PET IMG WHOLBODY INIT LUNG
5.64
1.00
G0211
PET IMG WHOLBODY INIT LUNG
14.45
1.00
G0211
PET IMG WHOLBODY INIT LUNG
14.49
1.00
G0212
PET IMG WHOLEBOD RESTAG LUNG
5.64
1.00
G0212
PET IMG WHOLEBOD RESTAG LUNG
14.45
1.00
G0212
PET IMG WHOLEBOD RESTAG LUNG
14.49
1.00
G0213
PET IMG WHOLBODY DX
5.64
1.00
G0213
PET IMG WHOLBODY DX
14.45
1.00
G0213
PET IMG WHOLBODY DX
14.49
1.00
G0214
PET IMG WHOLEBOD INIT
5.64
1.00
G0214
PET IMG WHOLEBOD INIT
14.45
1.00
G0214
PET IMG WHOLEBOD INIT
14.49
1.00
G0215
PETIMG WHOLEBOD RESTAG
5.64
1.00
G0215
PETIMG WHOLEBOD RESTAG
14.45
1.00
G0215
PETIMG WHOLEBOD RESTAG
14.49
1.00
G0216
PET IMG WHOLEBOD DX MELANOMA
5.64
1.00
G0216
PET IMG WHOLEBOD DX MELANOMA
14.45
1.00
G0216
PET IMG WHOLEBOD DX MELANOMA
14.49
1.00
G0217
PET IMG WHOLEBOD INIT MELAN
5.64
1.00
G0217
PET IMG WHOLEBOD INIT MELAN
14.45
1.00
G0217
PET IMG WHOLEBOD INIT MELAN
14.49
1.00
G0218
PET IMG WHOLEBOD RESTAG MELA
5.64
1.00
G0218
PET IMG WHOLEBOD RESTAG MELA
14.45
1.00
G0218
PET IMG WHOLEBOD RESTAG MELA
14.49
1.00
G0220
PET IMG WHOLEBOD DX LYMPHOMA
5.64
1.00
G0220
PET IMG WHOLEBOD DX LYMPHOMA
14.45
1.00
G0220
PET IMG WHOLEBOD DX LYMPHOMA
14.49
1.00
G0221
PET IMAG WHOLBOD INIT LYMPHO
5.64
1.00
Procedure Code Description
RVU
RVU Coeff Value
G0221
PET IMAG WHOLBOD INIT LYMPHO
14.45
1.00
G0221
PET IMAG WHOLBOD INIT LYMPHO
14.49
1.00
G0222
PET IMAG WHOLBOD RESTA LYMPH
5.64
1.00
G0222
PET IMAG WHOLBOD RESTA LYMPH
14.45
1.00
G0222
PET IMAG WHOLBOD RESTA LYMPH
14.49
1.00
G0223
PET IMAG WHOLBOD REG DX HEAD
5.64
1.00
G0223
PET IMAG WHOLBOD REG DX HEAD
14.45
1.00
G0223
PET IMAG WHOLBOD REG DX HEAD
14.49
1.00
G0224
PET IMAG WHOLBOD REG INI HEA
5.64
1.00
G0224
PET IMAG WHOLBOD REG INI HEA
14.45
1.00
G0224
PET IMAG WHOLBOD REG INI HEA
14.49
1.00
G0225
PET WHOL RESTAG HEADNECKONLY
5.64
1.00
G0225
PET WHOL RESTAG HEADNECKONLY
14.45
1.00
G0225
PET WHOL RESTAG HEADNECKONLY
14.49
1.00
G0226
PET IMG WHOLBODY DX ESOPHAGL
5.64
1.00
G0226
PET IMG WHOLBODY DX ESOPHAGL
14.45
1.00
G0226
PET IMG WHOLBODY DX ESOPHAGL
14.49
1.00
G0227
PET IMG WHOLBOD INI ESOPHAGE
5.64
1.00
G0227
PET IMG WHOLBOD INI ESOPHAGE
14.45
1.00
G0227
PET IMG WHOLBOD INI ESOPHAGE
14.49
1.00
G0228
PET IMG WHOLBOD RESTG ESOPHA
5.64
1.00
G0228
PET IMG WHOLBOD RESTG ESOPHA
14.45
1.00
G0228
PET IMG WHOLBOD RESTG ESOPHA
14.49
1.00
G0229
PET IMG METABOLOC BRAIN PRES
5.64
1.00
G0229
PET IMG METABOLOC BRAIN PRES
14.45
1.00
G0229
PET IMG METABOLOC BRAIN PRES
14.49
1.00
G0230
PET MYOCARD VIABILITY POST
5.64
1.00
G0230
PET MYOCARD VIABILITY POST
14.45
1.00
G0230
PET MYOCARD VIABILITY POST
14.49
1.00
G0231
PET WHBD COLOREC; GAMMA CAM
5.64
1.00
G0231
PET WHBD COLOREC; GAMMA CAM
14.45
1.00
G0231
PET WHBD COLOREC; GAMMA CAM
14.49
1.00
G0232
PET WHBD LYMPHOMA; GAMMA CAM
5.64
1.00
G0232
PET WHBD LYMPHOMA; GAMMA CAM
14.45
1.00
G0232
PET WHBD LYMPHOMA; GAMMA CAM
14.49
1.00
Procedure Code Description
RVU
RVU Coeff Value
G0233
PET WHBD MELANOMA; GAMMA CAM
5.64
1.00
G0233
PET WHBD MELANOMA; GAMMA CAM
14.45
1.00
G0233
PET WHBD MELANOMA; GAMMA CAM
14.49
1.00
G0234
PET WHBD PULM NOD; GAMMA CAM
5.64
1.00
G0234
PET WHBD PULM NOD; GAMMA CAM
14.45
1.00
G0234
PET WHBD PULM NOD; GAMMA CAM
14.49
1.00
G0253
PET IMAGE BRST DECTION RECUR
14.45
1.00
G0253
PET IMAGE BRST DECTION RECUR
14.49
1.00
G0254
PET IMAGE BRST EVAL TO TX
14.45
1.00
G0254
PET IMAGE BRST EVAL TO TX
14.49
1.00
G0296
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