114.3 CMR 40.06 - Fees

(1) Acupuncture.

Code

Fee

40.06(1) Acupuncture Description

97039

9.53

Unlisted modality (specify type and time if constant attendance)

97124

18.73

Therapeutic procedure, one or more areas, each 15 minutes; massage, including effleurage, petrissage and/or tapotement (stroking, compression, percussion)

97139

13.17

Unlisted therapeutic procedure (specify)

97810

27.01

Acupuncture, one or more needles; without electrical stimulation, initial 15 minutes of personal one-on-one contact with the patient

97811

20.33

Acupuncture, one or more needles; without electrical stimulation, each additional 15 minutes of personal one-on-one contact with the patient, with re-insertion of needle(s) (List separately in addition to code for primary procedure)

97813

28.63

Acupuncture, one or more needles; with electrical stimulation, initial 15 minutes of personal one-on-one contact with the patient

97814

22.98

Acupuncture, one or more needles; with electrical stimulation, each additional 15 minutes of personal one-on-one contact with the patient, with re-insertion of needle(s) (List separately in addition to code for primary procedure)

99080

26.09

Special reports such as insurance forms, more than the information conveyed in the usual medical communications or standard reporting form

99201

30.72

Office or other outpatient visit for the evaluation and management of a new patient, which requires these three key components: a problem focused history; a problem focused

examination; straightforward medical decision making. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually the presenting problems are self limited or minor. Physicians typically spend ten minutes face-to-face with the patient and/or family

99202

53.39

Office or other outpatient visit for the evaluation and management of a new patient, which requires these three key components: an expanded problem focused history; an expanded problem focused examination; straightforward medical decision making. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually the presenting problems are of low to moderate severity. Physicians typically spend 20 minutes face-to-face with the patient and/or family

99203

79.92

Office or other outpatient visit for the evaluation and management of a new patient, which requires these three key components: a detailed history; a detailed examination; medical decision making of low complexity. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually the presenting problems are of moderate severity. Physicians typically spend 30 minutes face-to-face with the patient and/or family

99204

112.90

Office or other outpatient visit for the evaluation and management of a new patient, which requires these three key components: a comprehensive history; a comprehensive examination; medical decision making of moderate complexity. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually the presenting problems are of moderate to high severity. Physicians typically spend 45 minutes face-to-face with the patient and/or family

99211

17.60

Office or other outpatient visit for the evaluation and management of an established patient that may not require the presence of a physician. Usually, the presenting problem(s) are minimal. Typically, five minutes are spent performing or supervising these services

99212

31.79

Office or other outpatient visit for the evaluation and management of an established patient, which requires at least two of these three key components: a problem focused history; a problem focused examination; straightforward medical decision making. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually the presenting problem(s) are self limited or minor. Physicians typically spend ten minutes face-to-face with the patient and/or family.

99213

49.73

Office or other outpatient visit for the evaluation and management of an established patient, which requires at least two of these three key components: an expanded problem focused history; an expanded problem focused examination; medical decision making of low complexity. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually the presenting problem(s) are of low to moderate complexity. Physicians typically spend 15 minutes face-to-face with the patient and/or family.

99214

74.00

Office or other outpatient visit for the evaluation and management of an established patient, which requires at least two of these three key components: a detailed history; a detailed examination; medical decision making of moderate complexity. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually the presenting problem(s) are of moderate to high severity. Physicians typically spend 25 minutes face-to-face with the patient and/or family.

(2) Anesthesia.

PAYMENT EQUALS : (TIME UNITS + BASE UNITS + MODIFYING UNITS) TIMES $39.00 (Rate per UNIT)

Code

2008 Base Unit

40.06(2) - Anesthesia Description

00100

5

Anesthesia for procedures on salivary glands, including biopsy

00102

6

Anesthesia for procedures involving plastic repair of cleft lip

00103

5

Anesthesia for reconstructive procedures of eyelid (eg, blepharoplasty, ptosis surgery)

00104

4

Anesthesia for electroconvulsive therapy

00120

5

Anesthesia for procedures on external, middle, and inner ear including biopsy; not otherwise specified

00124

4

Anesthesia for procedures on external, middle, and inner ear including biopsy; otoscopy

00126

4

Anesthesia for procedures on external, middle, and inner ear including biopsy; tympanotomy

00140

5

Anesthesia for procedures on eye; not otherwise specified

00142

4

Anesthesia for procedures on eye; lens surgery

00144

6

Anesthesia for procedures on eye; corneal transplant

00145

6

Anesthesia for procedures on eye; vitreoretinal surgery

00147

4

Anesthesia for procedures on eye; iridectomy

00148

4

Anesthesia for procedures on eye; ophthalmoscopy

00160

5

Anesthesia for procedures on nose and accessory sinuses; not otherwise specified

00162

7

Anesthesia for procedures on nose and accessory sinuses; radical surgery

00164

4

Anesthesia for procedures on nose and accessory sinuses; biopsy, soft tissue

00170

5

Anesthesia for intraoral procedures, including biopsy; not otherwise specified

00172

6

Anesthesia for intraoral procedures, including biopsy; repair of cleft palate

00174

6

Anesthesia for intraoral procedures, including biopsy; excision of retropharyngeal tumor

00176

7

Anesthesia for intraoral procedures, including biopsy; radical surgery

00190

5

Anesthesia for procedures on facial bones or skull; not otherwise specified

00192

7

Anesthesia for procedures on facial bones or skull; radical surgery (including prognathism)

00210

11

Anesthesia for intracranial procedures; not otherwise specified

00212

5

Anesthesia for intracranial procedures; subdural taps

00214

9

Anesthesia for intracranial procedures; burr holes, including ventriculography

00215

9

Anesthesia for intracranial procedures; cranioplasty or elevation of depressed skull fracture, extradural (simple or compound)

00216

15

Anesthesia for intracranial procedures; vascular procedures

00218

13

Anesthesia for intracranial procedures; procedures in sitting position

00220

10

Anesthesia for intracranial procedures; cerebrospinal fluid shunting procedures

00222

6

Anesthesia for intracranial procedures; electrocoagulation of intracranial nerve

00300

5

Anesthesia for all procedures on the integumentary system, muscles and nerves of head, neck, and posterior trunk, not otherwise specified

00320

6

Anesthesia for all procedures on esophagus, thyroid, larynx, trachea and lymphatic system of neck; not otherwise specified, age 1 year or older

00322

3

Anesthesia for all procedures on esophagus, thyroid, larynx, trachea and lymphatic system of neck; needle biopsy of thyroid

00350

10

Anesthesia for procedures on major vessels of neck; not otherwise specified

00352

5

Anesthesia for procedures on major vessels of neck; simple ligation

00400

3

Anesthesia for procedures on the integumentary system on the extremities, anterior trunk and perineum; not otherwise specified

00402

5

Anesthesia for procedures on the integumentary system on the extremities, anterior trunk and perineum; reconstructive procedures on breast (eg, reduction or augmentation mammoplasty, muscle flaps)

00404

5

Anesthesia for procedures on the integumentary system on the extremities, anterior trunk and perineum; radical or modified radical procedures on breast

00406

13

Anesthesia for procedures on the integumentary system on the extremities, anterior trunk and perineum; radical or modified radical procedures on breast with internal mammary node dissection

00410

4

Anesthesia for procedures on the integumentary system on the extremities, anterior trunk and perineum; electrical conversion of arrhythmias

00450

5

Anesthesia for procedures on clavicle and scapula; not otherwise specified

00452

6

Anesthesia for procedures on clavicle and scapula; radical surgery

00454

3

Anesthesia for procedures on clavicle and scapula; biopsy of clavicle

00470

6

Anesthesia for partial rib resection; not otherwise specified

00472

10

Anesthesia for partial rib resection; thoracoplasty (any type)

00474

13

Anesthesia for partial rib resection; radical procedures (eg, pectus excavatum)

00500

15

Anesthesia for all procedures on esophagus

00520

6

Anesthesia for closed chest procedures; (including bronchoscopy) not otherwise specified

00522

4

Anesthesia for closed chest procedures; needle biopsy of pleura

00524

4

Anesthesia for closed chest procedures; pneumocentesis

00528

8

Anesthesia for closed chest procedures; mediastinoscopy and diagnostic thoracoscopy not utilizing one lung ventilation

00529

11

Anesthesia for closed chest procedures; mediastinoscopy and diagnostic thoracoscopy utilizing one lung ventilation

00530

4

Anesthesia for permanent transvenous pacemaker insertion

00532

4

Anesthesia for access to central venous circulation

00534

7

Anesthesia for transvenous insertion or replacement of pacing cardioverter-defibrillator

00537

7

Anesthesia for cardiac electrophysiologic procedures including radiofrequency ablation

00539

18

Anesthesia for tracheobronchial reconstruction

00540

12

Anesthesia for thoracotomy procedures involving lungs, pleura, diaphragm, and mediastinum (including surgical thoracoscopy); not otherwise specified

00542

15

Anesthesia for thoracotomy procedures involving lungs, pleura, diaphragm, and mediastinum (including surgical thoracoscopy); decortication

00541

15

Anesthesia for thoracotomy procedures involving lungs, pleura, diaphragm, and mediastinum (including surgical thoracoscopy); utilizing one lung ventilation

00546

15

Anesthesia for thoracotomy procedures involving lungs, pleura, diaphragm, and mediastinum (including surgical thoracoscopy); pulmonary resection with thoracoplasty

00548

17

Anesthesia for thoracotomy procedures involving lungs, pleura, diaphragm, and mediastinum (including surgical thoracoscopy); intrathoracic procedures on the trachea and bronchi

00550

10

Anesthesia for sternal debridement

00560

15

Anesthesia for procedures on heart, pericardial sac, and great vessels of chest; without pump oxygenator

00562

20

Anesthesia for procedures on heart, pericardial sac, and great vessels of chest; with pump oxygenator

00563

25

Anesthesia for procedures on heart, pericardial sac, and great vessels of chest; with pump oxygenator with hypothermic circulatory arrest

00566

25

Anesthesia for direct coronary artery bypass grafting without pump oxygenator

00580

20

Anesthesia for heart transplant or heart/lung transplant

00600

10

Anesthesia for procedures on cervical spine and cord; not otherwise specified

00604

13

Anesthesia for procedures on cervical spine and cord; procedures with patient in the sitting position

00620

10

Anesthesia for procedures on thoracic spine and cord; not otherwise specified

00622

13

Anesthesia for procedures on thoracic spine and cord; thoracolumbar sympathectomy

00625

13

Anesthesia for procedures on the thoracic spine and cord, via an anterior transthoracic approach; not utilizing one lung ventilation

00626

15

Anesthesia for procedures on the thoracic spine and cord, via an anterior transthoracic approach; utilizing one lung ventilation

00630

8

Anesthesia for procedures in lumbar region; not otherwise specified

00632

7

Anesthesia for procedures in lumbar region; lumbar sympathectomy

00634

10

Anesthesia for procedures in lumbar region; chemonucleolysis

00635

4

Anesthesia for procedures in lumbar region; diagnostic or therapeutic lumbar puncture

00640

3

Anesthesia for manipulation of the spine or for closed procedures on the cervical, thoracic or lumbar spine

00670

13

Anesthesia for extensive spine and spinal cord procedures (eg, spinal instrumentation or vascular procedures)

00700

4

Anesthesia for procedures on upper anterior abdominal wall; not otherwise specified

00702

4

Anesthesia for procedures on upper anterior abdominal wall; percutaneous liver biopsy

00730

5

Anesthesia for procedures on upper posterior abdominal wall

00740

5

Anesthesia for upper gastrointestinal endoscopic procedures, endoscope introduced proximal to duodenum

00750

4

Anesthesia for hernia repairs in upper abdomen; not otherwise specified

00752

6

Anesthesia for hernia repairs in upper abdomen; lumbar and ventral (incisional) hernias and/or wound dehiscence

00754

7

Anesthesia for hernia repairs in upper abdomen; omphalocele

00756

7

Anesthesia for hernia repairs in upper abdomen; transabdominal repair of diaphragmatic hernia

00770

15

Anesthesia for all procedures on major abdominal blood vessels

00790

7

Anesthesia for intraperitoneal procedures in upper abdomen including laparoscopy; not otherwise specified

00792

13

Anesthesia for intraperitoneal procedures in upper abdomen including laparoscopy; partial hepatectomy or management of liver hemorrhage (excluding liver biopsy)

00794

8

Anesthesia for intraperitoneal procedures in upper abdomen including laparoscopy; pancreatectomy, partial or total (eg, Whipple procedure)

00796

30

Anesthesia for intraperitoneal procedures in upper abdomen including laparoscopy; liver transplant (recipient)

00797

11

Anesthesia for intraperitoneal procedures in upper abdomen including laparoscopy; gastric restrictive procedure for morbid obesity

00800

4

Anesthesia for procedures on lower anterior abdominal wall; not otherwise specified

00802

5

Anesthesia for procedures on lower anterior abdominal wall; panniculectomy

00810

5

Anesthesia for lower intestinal endoscopic procedures, endoscope introduced distal to duodenum

00820

5

Anesthesia for procedures on lower posterior abdominal wall

00830

4

Anesthesia for hernia repairs in lower abdomen; not otherwise specified

00832

6

Anesthesia for hernia repairs in lower abdomen; ventral and incisional hernias

00840

6

Anesthesia for intraperitoneal procedures in lower abdomen including laparoscopy; not otherwise specified

00842

4

Anesthesia for intraperitoneal procedures in lower abdomen including laparoscopy; amniocentesis

00844

7

Anesthesia for intraperitoneal procedures in lower abdomen including laparoscopy; abdominoperineal resection

00846

8

Anesthesia for intraperitoneal procedures in lower abdomen including laparoscopy; radical hysterectomy

00848

8

Anesthesia for intraperitoneal procedures in lower abdomen including laparoscopy; pelvic exenteration

00851

6

Anesthesia for intraperitoneal procedures in lower abdomen including laparoscopy; tubal ligation/transection

00860

6

Anesthesia for extraperitoneal procedures in lower abdomen, including urinary tract; not otherwise specified

00862

7

Anesthesia for extraperitoneal procedures in lower abdomen, including urinary tract; renal procedures, including upper one-third of ureter, or donor nephrectomy

00864

8

Anesthesia for extraperitoneal procedures in lower abdomen, including urinary tract; total cystectomy

00865

7

Anesthesia for extraperitoneal procedures in lower abdomen, including urinary tract; radical prostatectomy (suprapubic, retropubic)

00866

10

Anesthesia for extraperitoneal procedures in lower abdomen, including urinary tract; adrenalectomy

00868

10

Anesthesia for extraperitoneal procedures in lower abdomen, including urinary tract; renal transplant (recipient)

00870

5

Anesthesia for extraperitoneal procedures in lower abdomen, including urinary tract; cystolithotomy

00872

7

Anesthesia for lithotripsy, extracorporeal shock wave; with water bath

00873

5

Anesthesia for lithotripsy, extracorporeal shock wave; without water bath

00880

15

Anesthesia for procedures on major lower abdominal vessels; not otherwise specified

00882

10

Anesthesia for procedures on major lower abdominal vessels; inferior vena cava ligation

00902

5

Anesthesia for; anorectal procedure

00904

7

Anesthesia for; radical perineal procedure

00906

4

Anesthesia for; vulvectomy

00908

6

Anesthesia for; perineal prostatectomy

00910

3

Anesthesia for transurethral procedures (including urethrocystoscopy); not otherwise specified

00912

5

Anesthesia for transurethral procedures (including urethrocystoscopy); transurethral resection of bladder tumor(s)

00914

5

Anesthesia for transurethral procedures (including urethrocystoscopy); transurethral resection of prostate

00916

5

Anesthesia for transurethral procedures (including urethrocystoscopy); post-transurethral resection bleeding

00918

5

Anesthesia for transurethral procedures (including urethrocystoscopy); with fragmentation, manipulation and/or removal of ureteral calculus

00920

3

Anesthesia for procedures on male genitalia (including open urethral procedures); not otherwise specified

00921

3

Anesthesia for procedures on male genitalia (including open urethral procedures); vasectomy, unilateral or bilateral

00922

6

Anesthesia for procedures on male genitalia (including open urethral procedures); seminal vesicles

00924

4

Anesthesia for procedures on male genitalia (including open urethral procedures); undescended testis, unilateral or bilateral

00926

4

Anesthesia for procedures on male genitalia (including open urethral procedures); radical orchiectomy, inguinal

00928

6

Anesthesia for procedures on male genitalia (including open urethral procedures); radical orchiectomy, abdominal

00930

4

Anesthesia for procedures on male genitalia (including open urethral procedures); orchiopexy, unilateral or bilateral

00932

4

Anesthesia for procedures on male genitalia (including open urethral procedures); complete amputation of penis

00934

6

Anesthesia for procedures on male genitalia (including open urethral procedures); radical amputation of penis with bilateral inguinal lymphadenectomy

00936

8

Anesthesia for procedures on male genitalia (including open urethral procedures); radical amputation of penis with bilateral inguinal and iliac lymphadenectomy

00938

4

Anesthesia for procedures on male genitalia (including open urethral procedures); insertion of penile prosthesis (perineal approach)

00940

3

Anesthesia for vaginal procedures (including biopsy of labia, vagina, cervix or endometrium); not otherwise specified

00942

4

Anesthesia for vaginal procedures (including biopsy of labia, vagina, cervix or endometrium); colpotomy, vaginectomy, colporrhaphy, and open urethral procedures

00944

6

Anesthesia for vaginal procedures (including biopsy of labia, vagina, cervix or endometrium); vaginal hysterectomy

00948

4

Anesthesia for vaginal procedures (including biopsy of labia, vagina, cervix or endometrium); cervical cerclage

00950

5

Anesthesia for vaginal procedures (including biopsy of labia, vagina, cervix or endometrium); culdoscopy

00952

4

Anesthesia for vaginal procedures (including biopsy of labia, vagina, cervix or endometrium); hysteroscopy and/or hysterosalpingography

01112

5

Anesthesia for bone marrow aspiration and/or biopsy, anterior or posterior iliac crest

01120

6

Anesthesia for procedures on bony pelvis

01130

3

Anesthesia for body cast application or revision

01140

15

Anesthesia for interpelviabdominal (hindquarter) amputation

01150

10

Anesthesia for radical procedures for tumor of pelvis, except hindquarter amputation

01160

4

Anesthesia for closed procedures involving symphysis pubis or sacroiliac joint

01170

8

Anesthesia for open procedures involving symphysis pubis or sacroiliac joint

01173

12

Anesthesia for open repair of fracture disruption of pelvis or column fracture involving acetabulum

01180

3

Anesthesia for obturator neurectomy; extrapelvic

01190

4

Anesthesia for obturator neurectomy; intrapelvic

01200

4

Anesthesia for all closed procedures involving hip joint

01202

4

Anesthesia for arthroscopic procedures of hip joint

01210

6

Anesthesia for open procedures involving hip joint; not otherwise specified

01212

10

Anesthesia for open procedures involving hip joint; hip disarticulation

01214

8

Anesthesia for open procedures involving hip joint; total hip arthroplasty

01215

10

Anesthesia for open procedures involving hip joint; revision of total hip arthroplasty

01220

4

Anesthesia for all closed procedures involving upper two-thirds of femur

01230

6

Anesthesia for open procedures involving upper two-thirds of femur; not otherwise specified

01232

5

Anesthesia for open procedures involving upper two-thirds of femur; amputation

01234

8

Anesthesia for open procedures involving upper two-thirds of femur; radical resection

01250

4

Anesthesia for all procedures on nerves, muscles, tendons, fascia, and bursae of upper leg

01260

3

Anesthesia for all procedures involving veins of upper leg, including exploration

01270

8

Anesthesia for procedures involving arteries of upper leg, including bypass graft; not otherwise specified

01272

4

Anesthesia for procedures involving arteries of upper leg, including bypass graft; femoral artery ligation

01274

6

Anesthesia for procedures involving arteries of upper leg, including bypass graft; femoral artery embolectomy

01320

4

Anesthesia for all procedures on nerves, muscles, tendons, fascia, and bursae of knee and/or popliteal area

01340

4

Anesthesia for all closed procedures on lower one-third of femur

01360

5

Anesthesia for all open procedures on lower one-third of femur

01380

3

Anesthesia for all closed procedures on knee joint

01382

3

Anesthesia for diagnostic arthroscopic procedures of knee joint

01390

3

Anesthesia for all closed procedures on upper ends of tibia, fibula, and/or patella

01392

4

Anesthesia for all open procedures on upper ends of tibia, fibula, and/or patella

01400

4

Anesthesia for open or surgical arthroscopic procedures on knee joint; not otherwise specified

01402

7

Anesthesia for open or surgical arthroscopic procedures on knee joint; total knee arthroplasty

01404

5

Anesthesia for open or surgical arthroscopic procedures on knee joint; disarticulation at knee

01420

3

Anesthesia for all cast applications, removal, or repair involving knee joint

01430

3

Anesthesia for procedures on veins of knee and popliteal area; not otherwise specified

01432

6

Anesthesia for procedures on veins of knee and popliteal area; arteriovenous fistula

01440

8

Anesthesia for procedures on arteries of knee and popliteal area; not otherwise specified

01442

8

Anesthesia for procedures on arteries of knee and popliteal area; popliteal thromboendarterectomy, with or without patch graft

01444

8

Anesthesia for procedures on arteries of knee and popliteal area; popliteal excision and graft or repair for occlusion or aneurysm

01462

3

Anesthesia for all closed procedures on lower leg, ankle, and foot

01464

3

Anesthesia for arthroscopic procedures of ankle and/or foot

01470

3

Anesthesia for procedures on nerves, muscles, tendons, and fascia of lower leg, ankle, and foot; not otherwise specified

01472

5

Anesthesia for procedures on nerves, muscles, tendons, and fascia of lower leg, ankle, and foot; repair of ruptured Achilles tendon, with or without graft

01474

5

Anesthesia for procedures on nerves, muscles, tendons, and fascia of lower leg, ankle, and foot; gastrocnemius recession (eg, Strayer procedure)

01480

3

Anesthesia for open procedures on bones of lower leg, ankle, and foot; not otherwise specified

01482

4

Anesthesia for open procedures on bones of lower leg, ankle, and foot; radical resection (including below knee amputation)

01484

4

Anesthesia for open procedures on bones of lower leg, ankle, and foot; osteotomy or osteoplasty of tibia and/or fibula

01486

7

Anesthesia for open procedures on bones of lower leg, ankle, and foot; total ankle replacement

01490

3

Anesthesia for lower leg cast application, removal, or repair

01500

8

Anesthesia for procedures on arteries of lower leg, including bypass graft; not otherwise specified

01502

6

Anesthesia for procedures on arteries of lower leg, including bypass graft; embolectomy, direct or with catheter

01520

3

Anesthesia for procedures on veins of lower leg; not otherwise specified

01522

5

Anesthesia for procedures on veins of lower leg; venous thrombectomy, direct or with catheter

01610

5

Anesthesia for all procedures on nerves, muscles, tendons, fascia, and bursae of shoulder and axilla

01620

4

Anesthesia for all closed procedures on humeral head and neck, sternoclavicular joint, acromioclavicular joint, and shoulder joint

01622

4

Anesthesia for diagnostic arthroscopic procedures of shoulder joint

01630

5

Anesthesia for open or surgical arthroscopic procedures on humeral head and neck, sternoclavicular joint, acromioclavicular joint, and shoulder joint; not otherwise specified

01632

6

Anesthesia for open or surgical arthroscopic procedures on humeral head and neck, sternoclavicular joint, acromioclavicular joint, and shoulder joint; radical resection

01634

9

Anesthesia for open or surgical arthroscopic procedures on humeral head and neck, sternoclavicular joint, acromioclavicular joint, and shoulder joint; shoulder disarticulation

01636

15

Anesthesia for open or surgical arthroscopic procedures on humeral head and neck, sternoclavicular joint, acromioclavicular joint, and shoulder joint; interthoracoscapular (forequarter) amputation

01638

10

Anesthesia for open or surgical arthroscopic procedures on humeral head and neck, sternoclavicular joint, acromioclavicular joint, and shoulder joint; total shoulder replacement

01650

6

Anesthesia for procedures on arteries of shoulder and axilla; not otherwise specified

01652

10

Anesthesia for procedures on arteries of shoulder and axilla; axillary-brachial aneurysm

01654

8

Anesthesia for procedures on arteries of shoulder and axilla; bypass graft

01656

10

Anesthesia for procedures on arteries of shoulder and axilla; axillary-femoral bypass graft

01670

4

Anesthesia for all procedures on veins of shoulder and axilla

01680

3

Anesthesia for shoulder cast application, removal or repair; not otherwise specified

01682

4

Anesthesia for shoulder cast application, removal or repair; shoulder spica

01710

3

Anesthesia for procedures on nerves, muscles, tendons, fascia, and bursae of upper arm and elbow; not otherwise specified

01712

5

Anesthesia for procedures on nerves, muscles, tendons, fascia, and bursae of upper arm and elbow; tenotomy, elbow to shoulder, open

01714

5

Anesthesia for procedures on nerves, muscles, tendons, fascia, and bursae of upper arm and elbow; tenoplasty, elbow to shoulder

01716

5

Anesthesia for procedures on nerves, muscles, tendons, fascia, and bursae of upper arm and elbow; tenodesis, rupture of long tendon of biceps

01730

3

Anesthesia for all closed procedures on humerus and elbow

01732

3

Anesthesia for diagnostic arthroscopic procedures of elbow joint

01740

4

Anesthesia for open or surgical arthroscopic procedures of the elbow; not otherwise specified

01742

5

Anesthesia for open or surgical arthroscopic procedures of the elbow; osteotomy of humerus

01744

5

Anesthesia for open or surgical arthroscopic procedures of the elbow; repair of nonunion or malunion of humerus

01756

6

Anesthesia for open or surgical arthroscopic procedures of the elbow; radical procedures

01758

5

Anesthesia for open or surgical arthroscopic procedures of the elbow; excision of cyst or tumor of humerus

01760

7

Anesthesia for open or surgical arthroscopic procedures of the elbow; total elbow replacement

01770

6

Anesthesia for procedures on arteries of upper arm and elbow; not otherwise specified

01772

6

Anesthesia for procedures on arteries of upper arm and elbow; embolectomy

01780

3

Anesthesia for procedures on veins of upper arm and elbow; not otherwise specified

01782

4

Anesthesia for procedures on veins of upper arm and elbow; phleborrhaphy

01810

3

Anesthesia for all procedures on nerves, muscles, tendons, fascia, and bursae of forearm, wrist, and hand

01820

3

Anesthesia for all closed procedures on radius, ulna, wrist, or hand bones

01829

3

Anesthesia for diagnostic arthroscopic procedures on the wrist

01830

3

Anesthesia for open or surgical arthroscopic/endoscopic procedures on distal radius, distal ulna, wrist, or hand joints; not otherwise specified

01832

6

Anesthesia for open or surgical arthroscopic/endoscopic procedures on distal radius, distal ulna, wrist, or hand joints; total wrist replacement

01840

6

Anesthesia for procedures on arteries of forearm, wrist, and hand; not otherwise specified

01842

6

Anesthesia for procedures on arteries of forearm, wrist, and hand; embolectomy

01844

6

Anesthesia for vascular shunt, or shunt revision, any type (eg, dialysis)

01850

3

Anesthesia for procedures on veins of forearm, wrist, and hand; not otherwise specified

01852

4

Anesthesia for procedures on veins of forearm, wrist, and hand; phleborrhaphy

01860

3

Anesthesia for forearm, wrist, or hand cast application, removal, or repair

01916

5

Anesthesia for diagnostic arteriography/venography

01920

7

Anesthesia for cardiac catheterization including coronary angiography and ventriculography (not to include Swan-Ganz catheter)

01922

7

Anesthesia for non-invasive imaging or radiation therapy

01924

5

Anesthesia for therapeutic interventional radiological procedures involving the arterial system; not otherwise specified

01925

7

Anesthesia for therapeutic interventional radiological procedures involving the arterial system; carotid or coronary

01926

8

Anesthesia for therapeutic interventional radiological procedures involving the arterial system; intracranial, intracardiac, or aortic

01930

5

Anesthesia for therapeutic interventional radiological procedures involving the venous/lymphatic system (not to include access to the central circulation); not otherwise specified

01931

7

Anesthesia for therapeutic interventional radiological procedures involving the venous/lymphatic system (not to include access to the central circulation); intrahepatic or portal circulation (eg, transvenous intrahepatic portosystemic shunt[s] [TIPS])

01932

6

Anesthesia for therapeutic interventional radiological procedures involving the venous/lymphatic system (not to include access to the central circulation); intrathoracic or jugular

01933

7

Anesthesia for therapeutic interventional radiological procedures involving the venous/lymphatic system (not to include access to the central circulation); intracranial

01935

5

Anesthesia for percutaneous image guided procedures on the spine and spinal cord; diagnostic

01936

5

Anesthesia for percutaneous image guided procedures on the spine and spinal cord; therapeutic

01951

3

Anesthesia for second- and third-degree burn excision or debridement with or without skin grafting, any site, for total body surface area (TBSA) treated during anesthesia and surgery; less than 4% total body surface area

01952

5

Anesthesia for second- and third-degree burn excision or debridement with or without skin grafting, any site, for total body surface area (TBSA) treated during anesthesia and surgery; between 4% and 9% of total body surface area

01953

1

Anesthesia for second- and third-degree burn excision or debridement with or without skin grafting, any site, for total body surface area (TBSA) treated during anesthesia and surgery; each additional 9% total body surface area or part thereof (List separately in addition to code for primary procedure performed)

01958

5

Anesthesia for external cephalic version procedure

01960

5

Anesthesia for vaginal delivery only

01961

7

Anesthesia for cesarean delivery only

01962

8

Anesthesia for urgent hysterectomy following delivery

01963

8

Anesthesia for cesarean hysterectomy without any labor analgesia/anesthesia care

01965

4

Anesthesia for incomplete or missed abortion procedures

01966

4

Anesthesia for induced abortion procedures

01967

5

Neuraxial labor analgesia/anesthesia for planned vaginal delivery (this includes any repeat subarachnoid needle placement and drug injection and/or any necessary replacement of an epidural catheter during labor)

01968

2

Anesthesia for cesarean delivery following neuraxial labor analgesia/anesthesia (List separately in addition to code for primary procedure performed)

01969

5

Anesthesia for cesarean hysterectomy following neuraxial labor analgesia/anesthesia (List separately in addition to code for primary procedure performed)

01990

7

Physiological support for harvesting of organ(s) from brain-dead patient

01991

3

Anesthesia for diagnostic or therapeutic nerve blocks and injections (when block or injection is performed by a different provider); other than the prone position

01992

5

Anesthesia for diagnostic or therapeutic nerve blocks and injections (when block or injection is performed by a different provider); prone position

01996

3

Daily hospital management of epidural or subarachnoid continuous drug administration

01999

0

Unlisted anesthesia procedure(s)

(3) Chiropractors.

Code

Fee

40.06(3) - Chiropractic Description

98940

29.79

Chiropractic manipulative treatment (CMT); spinal, one to two regions

98941

38.54

Chiropractic manipulative treatment (CMT); spinal, three to four regions

98942

47.66

Chiropractic manipulative treatment (CMT); spinal, five regions

98943

28.60

Chiropractic manipulative treatment (CMT); extraspinal, one or more regions

99201

30.10

Office or other outpatient visit for the evaluation and management of a new patient, which requires these three key components: A problem focused history; A problem focused examination; Straightforward medical decision making. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are self limited or minor. Physicians typically spend ten minutes face-to-face with the patient and/or family.

99202

51.54

Office or other outpatient visit for the evaluation and management of a new patient, which requires these three key components: An expanded problem focused history; An expanded problem focused examination; Straightforward medical decision making. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of low to moderate severity. Physicians typically spend 20 minutes face-to-face with the patient and/or family.

99203

76.11

Office or other outpatient visit for the evaluation and management of a new patient, which requires these three key components: A detailed history; A detailed examination; Medical decision making of low complexity. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of moderate severity. Physicians typically spend 30 minutes face-to-face with the patient and/or family.

99204

112.85

Office or other outpatient visit for the evaluation and management of a new patient, which requires these three key components: A comprehensive history; A comprehensive examination; Medical decision making of moderate complexity. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of moderate to high severity. Physicians typically spend 45 minutes face-to-face with the patient and/or family.

9921 1

17.97

Office or other outpatient visit for the evaluation and management of an established patien that may not require the presence of a physician. Usually, the presenting problem(s) are minimal. Typically, five minutes are spent performing or supervising these services.

99212

31.13

Office or other outpatient visit for the evaluation and management of an established patient, which requires at least two of these three key components: A problem focused history; A problem focused examination; Straightforward medical decision making. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are self limited or minor. Physicians typically spend ten minutes face-to-face with the patient and/or family.

99213

49.35

Office or other outpatient visit for the evaluation and management of an established patient, which requires at least two of these three key components: An expanded problem focused history; An expanded problem focused examination; Medical decision making of low complexity. Counseling and coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of low to moderate severity. Physicians typically spend 15 minutes face-to-face with the patient and/or family.

99214

73.96

Office or other outpatient visit for the evaluation and management of an established patient, which requires at least two of these three key components: A detailed history; A detailed examination; Medical decision making of moderate complexity. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of moderate to high severity. Physicians typically spend 25 minutes face-to-face with the patient and/or family.

99358

73.29

Prolonged evaluation and management service before and/or after direct (face-to-face) patient care (eg, review of extensive records and tests, communication with other professionals and/or the patient/family); first hour (List separately in addition to code for other physician service(s) and/or inpatient or outpatient Evaluation and Management service)

99359

35.43

Prolonged evaluation and management service before and/or after direct (face-to-face) patient care (eg, review of extensive records and tests, communication with other professionals and/or the patient/family); each additional 30 minutes (List separately in addition to code for prolonged physician service)

99368

24.60

Medical team conference with interdisciplinary team of health care professionals, patient and/or family not present, 30 minutes or more; participation by nonphysician qualified health care professional

80047

30.51

Basic metabolic panel (Calcium, ionized) This panel must include the following: Calcium, ionized (82330) Carbon dioxide (82374) Chloride (82435) Creatinine (82565) Glucose (82947) Potassium (84132) Sodium (84295) Urea Nitrogen (BUN) (84520)

80048

11.83

Basic metabolic panel (Calcium, total) This panel must include the following: Calcium (82310) Carbon dioxide (82374) Chloride (82435) Creatinine (82565) Glucose (82947) Potassium (84132) Sodium (84295) Urea nitrogen (BUN) (84520)

80051

9.80

Electrolyte panel This panel must include the following: Carbon dioxide (82374) Chloride (82435) Potassium (84132) Sodium (84295)

80053

14.77

Comprehensive metabolic panel This panel must include the following: Albumin (82040) Bilirubin, total (82247) Calcium (82310) Carbon dioxide (bicarbonate) (82374) Chloride (82435) Creatinine (82565) Glucose (82947) Phosphatase, alkaline (84075) Potassium (84132) Protein, total (84155) Sodium (84295) Transferase, alanine amino (ALT) (SGPT) (84460) Transferase, aspartate amino (AST) (SGOT) (84450)

80061

18.72

Lipid panel This panel must include the following: Cholesterol, serum, total (82465)

Lipoprotein, direct measurement, high density cholesterol (HDL cholesterol) (83718)

Triglycerides (84478)

80069

12.13

Renal function panel This panel must include the following: Albumin (82040) Calcium (82310) Carbon dioxide (bicarbonate) (82374) Chloride (82435) Creatinine (82565) Glucose (82947) Phosphorus inorganic (phosphate) (84100) Potassium (84132) Sodium (84295)

80074

62.84

Acute hepatitis panel This panel must include the following: Hepatitis A antibody (HAAb), IgM antibody (86709) Hepatitis B core antibody (HBcAb), IgM antibody (86705) Hepatitis B surface antigen (HBsAg) (87340) Hepatitis C antibody (86803)

80076

11.42

Hepatic function panel This panel must include the following: Albumin (82040) Bilirubin, total (82247) Bilirubin, direct (82248) Phosphatase, alkaline (84075) Protein, total (84155) Transferase, alanine amino (ALT) (SGPT) (84460) Transferase, aspartate amino (AST) (SGOT) (84450)

80100

16.32

Drug screen, qualitative; multiple drug classes chromatographic method, each procedure

80101

19.24

Drug screen, qualitative; single drug class method (eg, immunoassay, enzyme assay), each drug class

80102

18.51

Drug confirmation, each procedure

80150

21.06

Amikacin

80152

25.01

Amitriptyline

80154

25.84

Benzodiazepines

80156

20.34

Carbamazepine; total

80157

18.52

Carbamazepine; free

80158

25.23

Cyclosporine

80160

24.05

Desipramine

80162

18.55

Digoxin

80164

18.93

Dipropylacetic acid (valproic acid)

80166

21.66

Doxepin

80168

22.83

Ethosuximide

80170

22.90

Gentamicin

80172

22.76

Gold

80173

20.34

Haloperidol

80174

24.05

Imipramine

80176

20.52

Lidocaine

80178

9.24

Lithium

80182

18.93

Nortriptyline

80184

16.01

Phenobarbital

80185

18.52

Phenytoin; total

80186

19.23

Phenytoin; free

80188

23.18

Primidone

80190

23.41

Procainamide;

80192

23.41

Procainamide; with metabolites (eg, n-acetyl procainamide)

80194

20.39

Quinidine

80195

10.18

Sirolimus

80196

9.92

Salicylate

80197

10.18

Tacrolimus

80198

19.77

Theophylline

80200

22.52

Tobramycin

80201

16.66

Topiramate

80202

18.93

Vancomycin

80299

19.13

Quantitation of drug, not elsewhere specified

80400

45.56

ACTH stimulation panel; for adrenal insufficiency This panel must include the following: Cortisol (82533 x 2)

80402

121.46

ACTH stimulation panel; for 21 hydroxylase deficiency This panel must include the following: Cortisol (82533 x 2) 17 hydroxyprogesterone (83498 x 2)

80406

106.06

ACTH stimulation panel; for 3 beta-hydroxydehydrogenase deficiency This panel must include the following: Cortisol (82533 x 2) 17 hydroxypregnenolone (84143 x 2)

80408

175.34

Aldosterone suppression evaluation panel (eg, saline infusion) This panel must include the following: Aldosterone (82088 x 2) Renin (84244 x 2)

80410

112.23

Calcitonin stimulation panel (eg, calcium, pentagastrin) This panel must include the following: Calcitonin (82308 x 3)

80412

460.50

Corticotropic releasing hormone (CRH) stimulation panel This panel must include the following: Cortisol (82533 x 6) Adrenocorticotropic hormone (ACTH) (82024 x 6)

80414

72.16

Chorionic gonadotropin stimulation panel; testosterone response This panel must include the following: Testosterone (84403 x 2 on three pooled blood samples)

80415

78.08

Chorionic gonadotropin stimulation panel; estradiol response This panel must include the following: Estradiol (82670 x 2 on three pooled blood samples)

80416

184.38

Renal vein renin stimulation panel (eg, captopril) This panel must include the following: Renin (84244 x 6)

80417

61.46

Peripheral vein renin stimulation panel (eg, captopril) This panel must include the following: Renin (84244 x 2)

80418

809.76

Combined rapid anterior pituitary evaluation panel This panel must include the following: Adrenocorticotropic hormone (ACTH) (82024 x 4) Luteinizing hormone (LH) (83002 x 4) Follicle stimulating hormone (FSH) (83001 x 4) Prolactin (84146 x 4) Human growth hormone (HGH) (93003x4) Cortisol (82533 x 4) Thyroid stimulating hormone (TSH) (84443 x 4)

80420

100.64

Dexamethasone suppression panel, 48 hour This panel must include the following: Free cortisol, urine (82530 x 2) Cortisol (82533 x 2) Volume measurement for timed collection (81050 x 2)

80422

64.38

Glucagon tolerance panel; for insulinoma This panel must include the following: Glucose (82947 x 3) Insulin (83525 x 3)

80424

70.56

Glucagon tolerance panel; for pheochromocytoma This panel must include the following: Catecholamines, fractionated (82384 x 2)

80426

207.40

Gonadotropin releasing hormone stimulation panel This panel must include the following: Follicle stimulating hormone (FSH) (83001 x 4) Luteinizing hormone (LH) (83002 x 4)

80428

93.16

Growth hormone stimulation panel (eg, arginine infusion, l-dopa administration) This panel must include the following: Human growth hormone (HGH) (83003 x 4)

80430

109.60

Growth hormone suppression panel (glucose administration) This panel must include the following: Glucose (82947 x 3) Human growth hormone (HGH) (83003 x 4)

80432

188.73

Insulin-induced C-peptide suppression panel This panel must include the following: Insulin (83525) C-peptide (84681 x 5) Glucose (82947 x 5)

80434

141.30

Insulin tolerance panel; for ACTH insufficiency This panel must include the following: Cortisol (82533 x 5) Glucose (82947 x 5)

80435

143.85

Insulin tolerance panel; for growth hormone deficiency This panel must include the following: Glucose (82947 x 5) Human growth hormone (HGH) (83003 x 5)

80436

127.36

Metyrapone panel This panel must include the following: Cortisol (82533 x 2) 11 deoxycortisol (82634 x 2)

80438

70.41

Thyrotropin releasing hormone (TRH) stimulation panel; one hour This panel must include the following: Thyroid stimulating hormone (TSH) (84443 x 3)

80439

93.88

Thyrotropin releasing hormone (TRH) stimulation panel; two hour This panel must include the following: Thyroid stimulating hormone (TSH) (84443 x 4)

80440

81.24

Thyrotropin releasing hormone (TRH) stimulation panel; for hyperprolactinemia This panel must include the following: Prolactin (84146 x 3)

81000

4.43

Urinalysis, by dip stick or tablet reagent for bilirubin, glucose, hemoglobin, ketones, leukocytes, nitrite, pH, protein, specific gravity, urobilinogen, any number of these constituents; non-automated, with microscopy

81001

4.43

Urinalysis, by dip stick or tablet reagent for bilirubin, glucose, hemoglobin, ketones, leukocytes, nitrite, pH, protein, specific gravity, urobilinogen, any number of these constituents; automated, with microscopy

81002

3.57

Urinalysis, by dip stick or tablet reagent for bilirubin, glucose, hemoglobin, ketones, leukocytes, nitrite, pH, protein, specific gravity, urobilinogen, any number of these constituents; non-automated, without microscopy

81003

3.14

Urinalysis, by dip stick or tablet reagent for bilirubin, glucose, hemoglobin, ketones, leukocytes, nitrite, pH, protein, specific gravity, urobilinogen, any number of these constituents; automated, without microscopy

81005

3.03

Urinalysis; qualitative or semiquantitative, except immunoassays

81007

3.59

Urinalysis; bacteriuria screen, except by culture or dipstick

81015

4.24

Urinalysis; microscopic only

81020

5.15

Urinalysis; two or three glass test

81025

8.84

Urine pregnancy test, by visual color comparison methods

81050

4.19

Volume measurement for timed collection, each

82000

17.31

Acetaldehyde, blood

82003

28.28

Acetaminophen

82009

6.31

Acetone or other ketone bodies, serum; qualitative

82010

11.42

Acetone or other ketone bodies, serum; quantitative

82013

15.61

Acetylcholinesterase

82016

19.37

Acylcarnitines; qualitative, each specimen

82017

14.94

Acylcarnitines; quantitative, each specimen

82024

53.97

Adrenocorticotropic hormone (ACTH)

82030

36.05

Adenosine, 5-monophosphate, cyclic (cyclic AMP)

82040

6.92

Albumin; serum

82042

7.23

Albumin; urine or other source, quantitative, each specimen

82043

7.56

Albumin; urine, microalbumin, quantitative

82044

6.39

Albumin; urine, microalbumin, semiquantitative (eg, reagent strip assay)

82045

47.43

Albumin; ischemia modified

82055

15.10

Alcohol (ethanol); any specimen except breath

82075

16.84

Alcohol (ethanol); breath

82085

13.56

Aldolase

82088

56.94

Aldosterone

82101

38.96

Alkaloids, urine, quantitative

82103

18.77

Alpha-1-antitrypsin; total

82104

20.20

Alpha-1-antitrypsin; phenotype

82105

23.44

Alpha-fetoprotein (AFP); serum

82106

23.44

Alpha-fetoprotein (AFP); amniotic fluid

82107

89.99

Alpha-fetoprotein (AFP); AFP-L3 fraction isoform and total AFP (including ratio)

82108

35.60

Aluminum

82120

5.25

Amines, vaginal fluid, qualitative

82127

19.37

Amino acids; single, qualitative, each specimen

82128

19.37

Amino acids; multiple, qualitative, each specimen

82131

23.57

Amino acids; single, quantitative, each specimen

82135

23.00

Aminolevulinic acid, delta (ALA)

82136

14.94

Amino acids, two to five amino acids, quantitative, each specimen

82139

14.94

Amino acids, six or more amino acids, quantitative, each specimen

82140

20.36

Ammonia

82143

9.61

Amniotic fluid scan (spectrophotometric)

82145

21.72

Amphetamine or methamphetamine

82150

9.06

Amylase

82154

40.29

Androstanediol glucuronide

82157

40.90

Androstenedione

82160

34.94

Androsterone

82163

25.16

Angiotensin II

82164

20.39

Angiotensin I - converting enzyme (ACE)

82172

21.65

Apolipoprotein, each

82175

26.51

Arsenic

82180

13.81

Ascorbic acid (Vitamin C), blood

82190

7.61

Atomic absorption spectroscopy, each analyte

82205

16.01

Barbiturates, not elsewhere specified

82232

22.61

Beta-2 microglobulin

82239

23.94

Bile acids; total

82240

37.13

Bile acids; cholylglycine

82247

7.02

Bilirubin; total

82248

7.02

Bilirubin; direct

82252

6.35

Bilirubin; feces, qualitative

82261

14.94

Biotinidase, each specimen

82270

4.54

Blood, occult, by peroxidase activity (eg, guaiac), qualitative; feces, consecutive collected specimens with single determination, for colorectal neoplasm screening (ie, patient was provided three cards or single triple card for consecutive collection)

82271

4.54

Blood, occult, by peroxidase activity (eg, guaiac), qualitative; other sources

82272

4.54

Blood, occult, by peroxidase activity (eg, guaiac), qualitative, feces, one-three simultaneous determinations, performed for other than colorectal neoplasm screening

82274

20.70

Blood, occult, by fecal hemoglobin determination by immunoassay, qualitative, feces, one-three simultaneous determinations

82286

9.62

Bradykinin

82300

32.33

Cadmium

82306

41.36

Calcifediol (25-OH Vitamin D-3)

82307

45.02

Calciferol (Vitamin D)

82308

37.41

Calcitonin

82310

7.20

Calcium; total

82330

19.09

Calcium; ionized

82331

7.23

Calcium; after calcium infusion test

82340

8.43

Calcium; urine quantitative, timed specimen

82355

16.17

Calculus; qualitative analysis

82360

17.99

Calculus; quantitative analysis, chemical

82365

18.01

Calculus; infrared spectroscopy

82370

17.51

Calculus; X-ray diffraction

82373

25.23

Carbohydrate deficient transferrin

82374

6.83

Carbon dioxide (bicarbonate)

82375

17.22

Carbon monoxide (carboxyhemoglobin); quantitative

82376

8.37

Carbon monoxide (carboxyhemoglobin); qualitative

82378

26.51

Carcinoembryonic antigen (CEA)

82379

14.94

Carnitine (total and free), quantitative, each specimen

82380

12.89

Carotene

82382

24.02

Catecholamines; total urine

82383

35.01

Catecholamines; blood

82384

35.28

Catecholamines; fractionated

82387

29.07

Cathepsin-D

82390

15.01

Ceruloplasmin

82397

14.94

Chemiluminescent assay

82415

17.70

Chloramphenicol

82435

6.42

Chloride; blood

82436

7.02

Chloride; urine

82438

6.83

Chloride; other source

82441

8.38

Chlorinated hydrocarbons, screen

82465

6.08

Cholesterol, serum or whole blood, total

82480

11.01

Cholinesterase; serum

82482

10.74

Cholinesterase; RBC

82485

28.85

Chondroitin B sulfate, quantitative

82486

25.23

Chromatography, qualitative; column (eg, gas liquid or HPLC), analyte not elsewhere specified

82487

22.30

Chromatography, qualitative; paper, 1-dimensional, analyte not elsewhere specified

82488

29.85

Chromatography, qualitative; paper, 2-dimensional, analyte not elsewhere specified

82489

25.84

Chromatography, qualitative; thin layer, analyte not elsewhere specified

82491

25.23

Chromatography, quantitative, column (eg, gas liquid or HPLC); single analyte not elsewhere specified, single stationary and mobile phase

82492

25.23

Chromatography, quantitative, column (eg, gas liquid or HPLC); multiple analytes, single stationary and mobile phase

82495

28.34

Chromium

82507

38.85

Citrate

82520

21.17

Cocaine or metabolite

82523

17.81

Collagen cross links, any method

82525

17.34

Copper

82528

31.45

Corticosterone

82530

23.35

Cortisol; free

82533

22.78

Cortisol; total

82540

6.48

Creatine

82541

25.23

Column chromatography/mass spectrometry (eg, GC/MS, or HPLC/MS), analyte not elsewhere specified; qualitative, single stationary and mobile phase

82542

25.23

Column chromatography/mass spectrometry (eg, GC/MS, or HPLC/MS), analyte not elsewhere specified; quantitative, single stationary and mobile phase

82543

25.23

Column chromatography/mass spectrometry (eg, GC/MS, or HPLC/MS), analyte not elsewhere specified; stable isotope dilution, single analyte, quantitative, single stationary and mobile phase

82544

25.23

Column chromatography/mass spectrometry (eg, GC/MS, or HPLC/MS), analyte not elsewhere specified; stable isotope dilution, multiple analytes, quantitative, single stationary and mobile phase

82550

9.10

Creatine kinase (CK), (CPK); total

82552

18.71

Creatine kinase (CK), (CPK); isoenzymes

82553

10.83

Creatine kinase (CK), (CPK); MB fraction only

82554

10.68

Creatine kinase (CK), (CPK); isoforms

82565

7.16

Creatinine; blood

82570

7.23

Creatinine; other source

82575

13.20

Creatinine; clearance

82585

8.11

Cryofibrinogen

82595

9.04

Cryoglobulin, qualitative or semi-quantitative (eg, cryocrit)

82600

27.11

Cyanide

82607

20.91

Cyanocobalamin (Vitamin B-12);

82608

20.01

Cyanocobalamin (Vitamin B-12); unsaturated binding capacity

82610

15.86

Cystatin C

82615

11.41

Cystine and homocystine, urine, qualitative

82626

35.31

Dehydroepiandrosterone (DHEA)

82627

31.07

Dehydroepiandrosterone-sulfate (DHEA-S)

82633

43.28

Desoxycorticosterone, 11-

82634

40.90

Deoxycortisol, 11-

82638

17.11

Dibucaine number

82646

28.85

Dihydrocodeinone

82649

35.91

Dihydromorphinone

82651

36.07

Dihydrotestosterone (DHT)

82652

53.78

Dihydroxyvitamin D, 1,25-

82654

19.34

Dimethadione

82656

16.01

Elastase, pancreatic (EL-1), fecal, qualitative or semi-quantitative

82657

25.23

Enzyme activity in blood cells, cultured cells, or tissue, not elsewhere specified; nonradioactive substrate, each specimen

82658

25.23

Enzyme activity in blood cells, cultured cells, or tissue, not elsewhere specified; radioactive substrate, each specimen

82664

48.00

Electrophoretic technique, not elsewhere specified

82666

29.50

Epiandrosterone

82668

26.26

Erythropoietin

82670

39.04

Estradiol

82671

45.13

Estrogens; fractionated

82672

30.30

Estrogens; total

82677

25.91

Estriol

82679

34.88

Estrone

82690

24.15

Ethchlorvynol

82693

20.82

Ethylene glycol

82696

32.95

Etiocholanolone

82705

7.11

Fat or lipids, feces; qualitative

82710

23.47

Fat or lipids, feces; quantitative

82715

24.05

Fat differential, feces, quantitative

82725

18.60

Fatty acids, nonesterified

82726

25.23

Very long chain fatty acids

82728

19.03

Ferritin

82731

89.99

Fetal fibronectin, cervicovaginal secretions, semi-quantitative

82735

25.91

Fluoride

82742

27.66

Flurazepam

82746

20.54

Folic acid; serum

82747

21.91

Folic acid; RBC

82757

24.24

Fructose, semen

82759

30.01

Galactokinase, RBC

82760

15.64

Galactose

82775

29.43

Galactose-1-phosphate uridyl transferase; quantitative

82776

11.71

Galactose-1-phosphate uridyl transferase; screen

82784

10.39

Gammaglobulin; IgA, IgD, IgG, IgM, each

82785

23.01

Gammaglobulin; IgE

82787

5.15

Gammaglobulin; immunoglobulin subclasses (IgG1, 2, 3, or 4), each

82800

11.83

Gases, blood, pH only

82803

27.04

Gases, blood, any combination of pH, pCO2, pO2, CO2, HCO3 (including calculated O2 saturation);

82805

39.65

Gases, blood, any combination of pH, pCO2, pO2, CO2, HCO3 (including calculated O2 saturation); with O2 saturation, by direct measurement, except pulse oximetry

82810

12.20

Gases, blood, O2 saturation only, by direct measurement, except pulse oximetry

82820

10.76

Hemoglobin-oxygen affinity (pO2 for 50% hemoglobin saturation with oxygen)

82926

7.61

Gastric acid, free and total, each specimen

82928

9.15

Gastric acid, free or total, each specimen

82938

24.72

Gastrin after secretin stimulation

82941

24.64

Gastrin

82943

19.97

Glucagon

82945

5.48

Glucose, body fluid, other than blood

82946

21.06

Glucagon tolerance test

82947

5.48

Glucose; quantitative, blood (except reagent strip)

82948

3.57

Glucose; blood, reagent strip

82950

6.64

Glucose; post glucose dose (includes glucose)

82951

17.99

Glucose; tolerance test (GTT), three specimens (includes glucose)

82952

4.02

Glucose; tolerance test, each additional beyond three specimens

82953

21.16

Glucose; tolbutamide tolerance test

82955

12.47

Glucose-6-phosphate dehydrogenase (G6PD); quantitative

82960

8.11

Glucose-6-phosphate dehydrogenase (G6PD); screen

82962

3.27

Glucose, blood by glucose monitoring device(s) cleared by the FDA specifically for home use

82963

30.01

Glucosidase, beta

82965

10.80

Glutamate dehydrogenase

82975

22.13

Glutamine (glutamic acid amide)

82977

10.06

Glutamyltransferase, gamma (GGT)

82978

19.91

Glutathione

82979

9.62

Glutathione reductase, RBC

82980

25.60

Glutethimide

82985

21.06

Glycated protein

83001

25.97

Gonadotropin; follicle stimulating hormone (FSH)

83002

25.88

Gonadotropin; luteinizing hormone (LH)

83003

23.29

Growth hormone, human (HGH) (somatotropin)

83008

23.45

Guanosine monophosphate (GMP), cyclic

83009

94.11

Helicobacter pylori, blood test analysis for urease activity, non-radioactive isotope (eg, C-13)

83010

17.58

Haptoglobin; quantitative

83012

24.02

Haptoglobin; phenotypes

83013

94.11

Helicobacter pylori; breath test analysis for urease activity, non-radioactive isotope (eg, C-13)

83014

10.98

Helicobacter pylori; drug administration

83015

26.31

Heavy metal (eg, arsenic, barium, beryllium, bismuth, antimony, mercury); screen

83018

30.68

Heavy metal (eg, arsenic, barium, beryllium, bismuth, antimony, mercury); quantitative, each

83020

17.99

Hemoglobin fractionation and quantitation; electrophoresis (eg, A2, S, C, and/or F)

83021

25.23

Hemoglobin fractionation and quantitation; chromatography (eg, A2, S, C, and/or F)

83026

3.30

Hemoglobin; by copper sulfate method, non-automated

83030

11.56

Hemoglobin; F (fetal), chemical

83033

8.33

Hemoglobin; F (fetal), qualitative

83036

13.56

Hemoglobin; glycosylated (A1C)

83037

21.06

Hemoglobin; glycosylated (A1C) by device cleared by FDA for home use

83045

6.93

Hemoglobin; methemoglobin, qualitative

83050

10.23

Hemoglobin; methemoglobin, quantitative

83051

10.21

Hemoglobin; plasma

83055

6.87

Hemoglobin; sulfhemoglobin, qualitative

83060

11.56

Hemoglobin; sulfhemoglobin, quantitative

83065

9.62

Hemoglobin; thermolabile

83068

11.83

Hemoglobin; unstable, screen

83069

5.51

Hemoglobin; urine

83070

6.64

Hemosiderin; qualitative

83071

9.61

Hemosiderin; quantitative

83080

14.94

b-Hexosaminidase, each assay

83088

41.26

Histamine

83090

23.57

Homocysteine

83150

27.04

Homovanillic acid (HVA)

83491

24.47

Hydroxycorticosteroids, 17- (17-OHCS)

83497

18.01

Hydroxyindolacetic acid, 5-(HIAA)

83498

37.95

Hydroxyprogesterone, 17-d

83499

35.22

Hydroxyprogesterone, 20-

83500

31.65

Hydroxyproline; free

83505

33.96

Hydroxyproline; total

83516

16.01

Immunoassay for analyte other than infectious agent antibody or infectious agent antigen, qualitative or semiquantitative; multiple step method

83518

10.68

Immunoassay for analyte other than infectious agent antibody or infectious agent antigen, qualitative or semiquantitative; single step method (eg, reagent strip)

83519

18.88

Immunoassay, analyte, quantitative; by radiopharmaceutical technique (eg, RIA)

83520

18.09

Immunoassay, analyte, quantitative; not otherwise specified

83525

15.98

Insulin; total

83527

17.68

Insulin; free

83528

22.22

Intrinsic factor

83540

9.05

Iron

83550

12.21

Iron binding capacity

83570

9.61

Isocitric dehydrogenase (IDH)

83582

19.8

Ketogenic steroids, fractionation

83586

17.89

Ketosteroids, 17- (17-KS); total

83593

36.75

Ketosteroids, 17- (17-KS); fractionation

83605

14.92

Lactate (lactic acid)

83615

8.44

Lactate dehydrogenase (LD), (LDH);

83625

17.88

Lactate dehydrogenase (LD), (LDH); isoenzymes, separation and quantitation

83630

27.42

Lactoferrin, fecal; qualitative

83631

27.42

Lactoferrin, fecal; quantitative

83632

28.24

Lactogen, human placental (HPL) human chorionic somatomammotropin

83633

7.69

Lactose, urine; qualitative

83634

16.10

Lactose, urine; quantitative

83655

16.91

Lead

83661

30.71

Fetal lung maturity assessment; lecithin sphingomyelin (L/S) ratio

83662

26.43

Fetal lung maturity assessment; foam stability test

83663

26.43

Fetal lung maturity assessment; fluorescence polarization

83664

26.43

Fetal lung maturity assessment; lamellar body density

83670

11.77

Leucine aminopeptidase (LAP)

83690

9.62

Lipase

83695

18.09

Lipoprotein (a)

83698

47.43

Lipoprotein-associated phospholipase A2 (Lp-PLA2)

83700

15.73

Lipoprotein, blood; electrophoretic separation and quantitation

83701

34.68

Lipoprotein, blood; high resolution fractionation and quantitation of lipoproteins including lipoprotein subclasses when performed (eg, electrophoresis, ultracentrifugation)

83704

44.08

Lipoprotein, blood; quantitation of lipoprotein particle numbers and lipoprotein particle subclasses (eg, by nuclear magnetic resonance spectroscopy)

83718

11.44

Lipoprotein, direct measurement; high density cholesterol (HDL cholesterol)

83719

16.26

Lipoprotein, direct measurement; VLDL cholesterol

83721

12.81

Lipoprotein, direct measurement; LDL cholesterol

83727

24.02

Luteinizing releasing factor (LRH)

83735

9.36

Magnesium

83775

9.75

Malate dehydrogenase

83785

34.36

Manganese

83788

25.23

Mass spectrometry and tandem mass spectrometry (MS, MS/MS), analyte not elsewhere specified; qualitative, each specimen

83789

25.23

Mass spectrometry and tandem mass spectrometry (MS, MS/MS), analyte not elsewhere specified; quantitative, each specimen

83805

24.63

Meprobamate

83825

22.72

Mercury, quantitative

83835

23.67

Metanephrines

83840

22.81

Methadone

83857

10.97

Methemalbumin

83858

20.71

Methsuximide

83864

27.82

Mucopolysaccharides, acid; quantitative

83866

13.76

Mucopolysaccharides, acid; screen

83872

8.19

Mucin, synovial fluid (Ropes test)

83873

24.04

Myelin basic protein, cerebrospinal fluid

83874

18.04

Myoglobin

83880

47.43

Natriuretic peptide

83883

15.86

Nephelometry, each analyte not elsewhere specified

83885

34.23

Nickel

83887

33.09

Nicotine

83890

5.60

Molecular diagnostics; molecular isolation or extraction

83891

5.60

Molecular diagnostics; isolation or extraction of highly purified nucleic acid

83892

5.60

Molecular diagnostics; enzymatic digestion

83893

5.60

Molecular diagnostics; dot/slot blot production

83894

5.60

Molecular diagnostics; separation by gel electrophoresis (eg, agarose, polyacrylamide)

83896

5.60

Molecular diagnostics; nucleic acid probe, each

83897

5.60

Molecular diagnostics; nucleic acid transfer (eg, Southern, Northern)

83898

6.10

Molecular diagnostics; amplification, target, each nucleic acid sequence

83900

12.20

Molecular diagnostics; amplification, target, multiplex, first two nucleic acid sequences

83901

6.10

Molecular diagnostics; amplification, target, multiplex, each additional nucleic acid sequence beyond two (List separately in addition to code for primary procedure)

83902

5.75

Molecular diagnostics; reverse transcription

83903

6.10

Molecular diagnostics; mutation scanning, by physical properties (eg, single strand conformational polymorphisms (SSCP), heteroduplex, denaturing gradient gel electrophoresis (DGGE), RNA'ase A), single segment, each

83904

6.10

Molecular diagnostics; mutation identification by sequencing, single segment, each segment

83905

6.10

Molecular diagnostics; mutation identification by allele specific transcription, single segment, each segment

83906

6.10

Molecular diagnostics; mutation identification by allele specific translation, single segment, each segment

83907

18.66

Molecular diagnostics; lysis of cells prior to nucleic acid extraction (eg, stool specimens, paraffin embedded tissue)

83908

6.10

Molecular diagnostics; amplification, signal, each nucleic acid sequence

83909

6.10

Molecular diagnostics; separation and identification by high resolution technique (eg, capillary electrophoresis)

83912

5.60

Molecular diagnostics; interpretation and report

83913

18.66

Molecular diagnostics; RNA stabilization

83914

6.10

Mutation identification by enzymatic ligation or primer extension, single segment, each segment (eg, oligonucleotide ligation assay (OLA), single base chain extension (SBCE), or allele-specific primer extension (ASPE))

83915

15.58

Nucleotidase 5'-

83916

28.09

Oligoclonal immune (oligoclonal bands)

83918

23.00

Organic acids; total, quantitative, each specimen

83919

23.00

Organic acids; qualitative, each specimen

83921

23.00

Organic acid, single, quantitative

83925

27.19

Opiates (eg, morphine, meperidine)

83930

9.24

Osmolality; blood

83935

9.52

Osmolality; urine

83937

41.71

Osteocalcin (bone g1a protein)

83945

17.99

Oxalate

83950

89.99

Oncoprotein, HER-2/neu

83970

57.67

Parathormone (parathyroid hormone)

83986

5.00

pH, body fluid, except blood

83992

20.54

Phencyclidine (PCP)

83993

27.42

Calprotectin, fecal

84022

21.76

Phenothiazine

84030

7.69

Phenylalanine (PKU), blood

84035

5.11

Phenylketones, qualitative

84060

10.32

Phosphatase, acid; total

84061

10.39

Phosphatase, acid; forensic examination

84066

13.50

Phosphatase, acid; prostatic

84075

7.23

Phosphatase, alkaline;

84078

10.20

Phosphatase, alkaline; heat stable (total not included)

84080

20.66

Phosphatase, alkaline; isoenzymes

84081

23.09

Phosphatidylglycerol

84085

9.42

Phosphogluconate, 6-, dehydrogenase, RBC

84087

14.42

Phosphohexose isomerase

84100

6.63

Phosphorus inorganic (phosphate);

84105

7.23

Phosphorus inorganic (phosphate); urine

84106

5.99

Porphobilinogen, urine; qualitative

84110

11.80

Porphobilinogen, urine; quantitative

84119

10.60

Porphyrins, urine; qualitative

84120

20.55

Porphyrins, urine; quantitation and fractionation

84126

35.59

Porphyrins, feces; quantitative

84127

10.60

Porphyrins, feces; qualitative

84132

6.42

Potassium; serum

84133

6.01

Potassium; urine

84134

20.38

Prealbumin

84135

26.73

Pregnanediol

84138

26.46

Pregnanetriol

84140

28.89

Pregnenolone

84143

30.25

17-hydroxypregnenolone

84144

29.15

Progesterone

84146

27.08

Prolactin

84150

34.88

Prostaglandin, each

84152

25.70

Prostate specific antigen (PSA); complexed (direct measurement)

84153

25.70

Prostate specific antigen (PSA); total

84154

25.70

Prostate specific antigen (PSA); free

84155

5.12

Protein, total, except by refractometry; serum

84156

5.12

Protein, total, except by refractometry; urine

84157

5.12

Protein, total, except by refractometry; other source (eg, synovial fluid, cerebrospinal fluid)

84160

7.23

Protein, total, by refractometry, any source

84163

21.03

Pregnancy-associated plasma protein-A (PAPP-A)

84165

15.01

Protein; electrophoretic fractionation and quantitation, serum

84166

24.92

Protein; electrophoretic fractionation and quantitation, other fluids with concentration (eg, urine, CSF)

84181

23.80

Protein; Western Blot, with interpretation and report, blood or other body fluid

84182

25.15

Protein; Western Blot, with interpretation and report, blood or other body fluid, immunological probe for band identification, each

84202

20.05

Protoporphyrin, RBC; quantitative

84203

12.03

Protoporphyrin, RBC; screen

84206

24.89

Proinsulin

84207

37.96

Pyridoxal phosphate (Vitamin B-6)

84210

15.17

Pyruvate

84220

13.18

Pyruvate kinase

84228

16.26

Quinine

84233

89.99

Receptor assay; estrogen

84234

90.64

Receptor assay; progesterone

84235

73.12

Receptor assay; endocrine, other than estrogen or progesterone (specify hormone)

84238

51.09

Receptor assay; non-endocrine (specify receptor)

84244

30.73

Renin

84252

28.28

Riboflavin (Vitamin B-2)

84255

35.67

Selenium

84260

43.28

Serotonin

84270

30.36

Sex hormone binding globulin (SHBG)

84275

18.77

Sialic acid

84285

32.90

Silica

84295

6.72

Sodium; serum

84300

6.79

Sodium; urine

84302

6.79

Sodium; other source

84305

23.62

Somatomedin

84307

23.62

Somatostatin

84311

9.03

Spectrophotometry, analyte not elsewhere specified

84315

3.50

Specific gravity (except urine)

84375

27.39

Sugars, chromatographic, TLC or paper chromatography

84376

7.69

Sugars (mono-, di-, and oligosaccharides); single qualitative, each specimen

84377

7.69

Sugars (mono-, di-, and oligosaccharides); multiple qualitative, each specimen

84378

16.10

Sugars (mono-, di-, and oligosaccharides); single quantitative, each specimen

84379

16.10

Sugars (mono-, di-, and oligosaccharides); multiple quantitative, each specimen

84392

6.64

Sulfate, urine

84402

35.57

Testosterone; free

84403

36.08

Testosterone; total

84425

29.67

Thiamine (Vitamin B-1)

84430

16.26

Thiocyanate

84432

22.44

Thyroglobulin

84436

9.61

Thyroxine; total

84437

9.04

Thyroxine; requiring elution (eg, neonatal)

84439

12.60

Thyroxine; free

84442

20.66

Thyroxine binding globulin (TBG)

84443

23.47

Thyroid stimulating hormone (TSH)

84445

71.05

Thyroid stimulating immune globulins (TSI)

84446

19.81

Tocopherol alpha (Vitamin E)

84449

24.57

Transcortin (cortisol binding globulin)

84450

7.22

Transferase; aspartate amino (AST) (SGOT)

84460

7.40

Transferase; alanine amino (ALT) (SGPT)

84466

17.84

Transferrin

84478

8.04

Triglycerides

84479

9.04

Thyroid hormone (T3 or T4) uptake or thyroid hormone binding ratio (THBR)

84480

19.81

Triiodothyronine T3; total (TT-3)

84481

23.67

Triiodothyronine T3; free

84482

21.27

Triiodothyronine T3; reverse

84484

13.75

Troponin, quantitative

84485

10.49

Trypsin; duodenal fluid

84488

9.61

Trypsin; feces, qualitative

84490

10.63

Trypsin; feces, quantitative, 24-hour collection

84510

14.53

Tyrosine

84512

10.31

Troponin, qualitative

84520

5.51

Urea nitrogen; quantitative

84525

5.25

Urea nitrogen; semiquantitative (eg, reagent strip test)

84540

6.64

Urea nitrogen, urine

84545

9.23

Urea nitrogen, clearance

84550

6.31

Uric acid; blood

84560

6.64

Uric acid; other source

84577

17.43

Urobilinogen, feces, quantitative

84578

4.54

Urobilinogen, urine; qualitative

84580

8.92

Urobilinogen, urine; quantitative, timed specimen

84583

7.02

Urobilinogen, urine; semiquantitative

84585

21.66

Vanillylmandelic acid (VMA), urine

84586

26.68

Vasoactive intestinal peptide (VIP)

84588

47.43

Vasopressin (antidiuretic hormone, ADH)

84590

16.20

Vitamin A

84591

16.20

Vitamin, not otherwise specified

84597

19.15

Vitamin K

84600

22.45

Volatiles (eg, acetic anhydride, carbon tetrachloride, dichloroethane, dichloromethane, diethylether, isopropyl alcohol, methanol)

84620

16.55

Xylose absorption test, blood and/or urine

84630

15.91

Zinc

84681

29.07

C-peptide

84702

21.03

Gonadotropin, chorionic (hCG); quantitative

84703

10.49

Gonadotropin, chorionic (hCG); qualitative

84704

21.03

Gonadotropin, chorionic (hCG); free beta chain

84830

14.02

Ovulation tests, by visual color comparison methods for human luteinizing hormone

85002

6.29

Bleeding time

85004

9.04

Blood count; automated differential WBC count

85007

4.81

Blood count; blood smear, microscopic examination with manual differential WBC count

85008

4.81

Blood count; blood smear, microscopic examination without manual differential WBC count

85009

5.19

Blood count; manual differential WBC count, buffy coat

85013

3.31

Blood count; spun microhematocrit

85014

3.31

Blood count; hematocrit (Hct)

85018

3.31

Blood count; hemoglobin (Hgb)

85025

10.86

Blood count; complete (CBC), automated (Hgb, Hct, RBC, WBC and platelet count) and automated differential WBC count

85027

9.04

Blood count; complete (CBC), automated (Hgb, Hct, RBC, WBC and platelet count)

85032

6.01

Blood count; manual cell count (erythrocyte, leukocyte, or platelet) each

85041

4.05

Blood count; red blood cell (RBC), automated

85044

6.01

Blood count; reticulocyte, manual

85045

5.59

Blood count; reticulocyte, automated

85046

7.80

Blood count; reticulocytes, automated, including one or more cellular parameters (eg, reticulocyte hemoglobin content (CHr), immature reticulocyte fraction (IRF), reticulocyte volume (MRV), RNA content), direct measurement

85048

3.55

Blood count; leukocyte (WBC), automated

85049

6.25

Blood count; platelet, automated

85055

15.37

Reticulated platelet assay

85130

10.68

Chromogenic substrate assay

85170

5.05

Clot retraction

85175

5.41

Clot lysis time, whole blood dilution

85210

18.14

Clotting; factor II, prothrombin, specific

85220

24.66

Clotting; factor V (AcG or proaccelerin), labile factor

85230

25.02

Clotting; factor VII (proconvertin, stable factor)

85240

25.02

Clotting; factor VIII (AHG), one stage

85244

28.53

Clotting; factor VIII related antigen

85245

32.06

Clotting; factor VIII, VW factor, ristocetin cofactor

85246

32.06

Clotting; factor VIII, VW factor antigen

85247

32.06

Clotting; factor VIII, von Willebrand factor, multimetric analysis

85250

26.60

Clotting; factor IX (PTC or Christmas)

85260

25.02

Clotting; factor X (Stuart-Prower)

85270

25.02

Clotting; factor XI (PTA)

85280

27.04

Clotting; factor XII (Hageman)

85290

22.83

Clotting; factor XIII (fibrin stabilizing)

85291

12.42

Clotting; factor XIII (fibrin stabilizing), screen solubility

85292

26.46

Clotting; prekallikrein assay (Fletcher factor assay)

85293

26.46

Clotting; high molecular weight kininogen assay (Fitzgerald factor assay)

85300

16.55

Clotting inhibitors or anticoagulants; antithrombin III, activity

85301

15.11

Clotting inhibitors or anticoagulants; antithrombin III, antigen assay

85302

16.80

Clotting inhibitors or anticoagulants; protein C, antigen

85303

17.81

Clotting inhibitors or anticoagulants; protein C, activity

85305

16.20

Clotting inhibitors or anticoagulants; protein S, total

85306

19.97

Clotting inhibitors or anticoagulants; protein S, free

85307

19.97

Activated Protein C (APC) resistance assay

85335

17.99

Factor inhibitor test

85337

14.56

Thrombomodulin

85345

6.01

Coagulation time; Lee and White

85347

5.95

Coagulation time; activated

85348

5.20

Coagulation time; other methods

85360

11.74

Euglobulin lysis

85362

9.62

Fibrin(ogen) degradation (split) products (FDP) (FSP); agglutination slide, semiquantitative

85366

10.54

Fibrin(ogen) degradation (split) products (FDP) (FSP); paracoagulation

85370

9.60

Fibrin(ogen) degradation (split) products (FDP) (FSP); quantitative

85378

9.97

Fibrin degradation products, D-dimer; qualitative or semiquantitative

85379

14.22

Fibrin degradation products, D-dimer; quantitative

85380

14.22

Fibrin degradation products, D-dimer; ultrasensitive (eg, for evaluation for venous thromboembolism), qualitative or semiquantitative

85384

11.87

Fibrinogen; activity

85385

11.87

Fibrinogen; antigen

85390

7.22

Fibrinolysins or coagulopathy screen, interpretation and report

85400

12.36

Fibrinolytic factors and inhibitors; plasmin

85410

10.77

Fibrinolytic factors and inhibitors; alpha-2 antiplasmin

85415

24.02

Fibrinolytic factors and inhibitors; plasminogen activator

85420

9.13

Fibrinolytic factors and inhibitors; plasminogen, except antigenic assay

85421

14.23

Fibrinolytic factors and inhibitors; plasminogen, antigenic assay

85441

5.88

Heinz bodies; direct

85445

9.52

Heinz bodies; induced, acetyl phenylhydrazine

85460

8.11

Hemoglobin or RBCs, fetal, for fetomaternal hemorrhage; differential lysis (Kleihauer-Betke)

85461

9.26

Hemoglobin or RBCs, fetal, for fetomaternal hemorrhage; rosette

85475

12.40

Hemolysin, acid

85520

18.29

Heparin assay

85525

16.55

Heparin neutralization

85530

19.81

Heparin-protamine tolerance test

85536

9.04

Iron stain, peripheral blood

85540

12.02

Leukocyte alkaline phosphatase with count

85547

8.92

Mechanical fragility, RBC

85549

26.21

Muramidase

85555

9.34

Osmotic fragility, RBC; unincubated

85557

11.36

Osmotic fragility, RBC; incubated

85576

30.01

Platelet, aggregation (in vitro), each agent

85576

30.01

Platelet, aggregation (in vitro), each agent

85597

6.53

Platelet neutralization

85610

5.49

Prothrombin time;

85611

5.51

Prothrombin time; substitution, plasma fractions, each

85612

8.38

Russell viper venom time (includes venom); undiluted

85613

8.38

Russell viper venom time (includes venom); diluted

85635

13.76

Reptilase test

85651

4.96

Sedimentation rate, erythrocyte; non-automated

85652

3.77

Sedimentation rate, erythrocyte; automated

85660

7.71

Sickling of RBC, reduction

85670

8.07

Thrombin time; plasma

85675

9.58

Thrombin time; titer

85705

9.77

Thromboplastin inhibition, tissue

85730

8.38

Thromboplastin time, partial (PTT); plasma or whole blood

85732

9.04

Thromboplastin time, partial (PTT); substitution, plasma fractions, each

85810

16.32

Viscosity

86000

9.75

Agglutinins, febrile (eg, Brucella, Francisella, Murine typhus, Q fever, Rocky Mountain spotted fever, scrub typhus), each antigen

86001

7.30

Allergen specific IgG quantitative or semiquantitative, each allergen

86003

7.30

Allergen specific IgE; quantitative or semiquantitative, each allergen

86005

11.14

Allergen specific IgE; qualitative, multiallergen screen (dipstick, paddle, or disk)

86021

21.03

Antibody identification; leukocyte antibodies

86022

25.66

Antibody identification; platelet antibodies

86023

17.40

Antibody identification; platelet associated immunoglobulin assay

86038

16.89

Antinuclear antibodies (ANA);

86039

15.60

Antinuclear antibodies (ANA); titer

86060

10.20

Antistreptolysin 0; titer

86063

8.07

Antistreptolysin 0; screen

86140

7.23

C-reactive protein;

86141

18.09

C-reactive protein; high sensitivity (hsCRP)

86146

19.21

Beta 2 Glycoprotein I antibody, each

86147

19.21

Cardiolipin (phospholipid) antibody, each Ig class

86148

19.21

Anti-phosphatidylserine (phospholipid) antibody

86155

22.33

Chemotaxis assay, specify method

86156

8.91

Cold agglutinin; screen

86157

11.27

Cold agglutinin; titer

86160

16.78

Complement; antigen, each component

86161

16.78

Complement; functional activity, each component

86162

28.39

Complement; total hemolytic (CH50)

86171

12.16

Complement fixation tests, each antigen

86185

12.50

Counterimmunoelectrophoresis, each antigen

86200

18.09

Cyclic citrullinated peptide (CCP), antibody

86215

18.51

Deoxyribonuclease, antibody

86225

19.20

Deoxyribonucleic acid (DNA) antibody; native or double stranded

86226

16.92

Deoxyribonucleic acid (DNA) antibody; single stranded

86235

25.06

Extractable nuclear antigen, antibody to, any method (eg, nRNP, SS-A, SS-B, Sm, RNP, Sc170, J01), each antibody

86243

28.68

Fc receptor

86255

12.16

Fluorescent noninfectious agent antibody; screen, each antibody

86256

16.84

Fluorescent noninfectious agent antibody; titer, each antibody

86277

21.99

Growth hormone, human (HGH), antibody

86280

11.44

Hemagglutination inhibition test (HAI)

86294

27.41

Immunoassay for tumor antigen, qualitative or semiquantitative (eg, bladder tumor antigen)

86300

29.07

Immunoassay for tumor antigen, quantitative; CA 15-3 (27.29)

86301

29.07

Immunoassay for tumor antigen, quantitative; CA 19-9

86304

29.07

Immunoassay for tumor antigen, quantitative; CA 125

86308

7.23

Heterophile antibodies; screening

86309

9.04

Heterophile antibodies; titer

86310

10.30

Heterophile antibodies; titers after absorption with beef cells and guinea pig kidney

86316

29.07

Immunoassay for tumor antigen, other antigen, quantitative (eg, CA 50, 72-4, 549), each

86317

20.95

Immunoassay for infectious agent antibody, quantitative, not otherwise specified

86318

18.09

Immunoassay for infectious agent antibody, qualitative or semiquantitative, single step method (eg, reagent strip)

86320

31.32

Immunoelectrophoresis; serum

86325

31.24

Immunoelectrophoresis; other fluids (eg, urine, cerebrospinal fluid) with concentration

86327

31.70

Immunoelectrophoresis; crossed (2-dimensional assay)

86329

19.62

Immunodiffusion; not elsewhere specified

86331

16.75

Immunodiffusion; gel diffusion, qualitative (Ouchterlony), each antigen or antibody

86332

34.05

Immune complex assay

86334

31.21

Immunofixation electrophoresis; serum

86335

41.00

Immunofixation electrophoresis; other fluids with concentration (eg, urine, CSF)

86336

21.77

Inhibin A

86337

29.92

Insulin antibodies

86340

21.06

Intrinsic factor antibodies

86341

27.65

Islet cell antibody

86343

17.41

Leukocyte histamine release test (LHR)

86344

11.16

Leukocyte phagocytosis

86353

68.49

Lymphocyte transformation, mitogen (phytomitogen) or antigen induced blastogenesis

86355

16.01

B cells, total count

86356

15.37

Mononuclear cell antigen, quantitative (eg, flow cytometry), not otherwise specified, each antigen

86357

16.01

Natural killer (NK) cells, total count

86359

16.01

T cells; total count

86360

19.21

T cells; absolute CD4 and CD8 count, including ratio

86361

15.37

T cells; absolute CD4 count

86367

16.01

Stem cells (ie, CD34), total count

86376

20.33

Microsomal antibodies (eg, thyroid or liver-kidney), each

86378

27.51

Migration inhibitory factor test (MIF)

86382

23.62

Neutralization test, viral

86384

15.91

Nitroblue tetrazolium dye test (NTD)

86403

14.24

Particle agglutination; screen, each antibody

86406

14.87

Particle agglutination; titer, each antibody

86430

7.93

Rheumatoid factor; qualitative

86431

7.93

Rheumatoid factor; quantitative

86480

86.59

Tuberculosis test, cell mediated immunity measurement of gamma interferon antigen response

86590

15.41

Streptokinase, antibody

86592

5.96

Syphilis test; qualitative (eg, VDRL, RPR, ART)

86593

6.16

Syphilis test; quantitative

86602

13.64

Antibody; actinomyces

86603

14.58

Antibody; adenovirus

86606

20.59

Antibody; Aspergillus

86609

13.64

Antibody; bacterium, not elsewhere specified

86611

13.64

Antibody; Bartonella

86612

18.03

Antibody; Blastomyces

86615

18.43

Antibody; Bordetella

86617

21.64

Antibody; Borrelia burgdorferi (Lyme disease) confirmatory test (eg, Western Blot or immunoblot)

86618

19.97

Antibody; Borrelia burgdorferi (Lyme disease)

86619

18.69

Antibody; Borrelia (relapsing fever)

86622

12.14

Antibody; Brucella

86625

13.64

Antibody; Campylobacter

86628

16.78

Antibody; Candida

86631

16.52

Antibody; Chlamydia

86632

17.74

Antibody; Chlamydia, IgM

86635

16.03

Antibody; Coccidioides

86638

16.94

Antibody; Coxiella burnetii (Q fever)

86641

12.14

Antibody; Cryptococcus

86644

20.11

Antibody; cytomegalovirus (CMV)

86645

19.97

Antibody; cytomegalovirus (CMV), IgM

86648

13.64

Antibody; Diphtheria

86651

18.43

Antibody; encephalitis, California (La Crosse)

86652

18.43

Antibody; encephalitis, Eastern equine

86653

18.43

Antibody; encephalitis, St. Louis

86654

18.43

Antibody; encephalitis, Western equine

86658

14.58

Antibody; enterovirus (eg, coxsackie, echo, polio)

86663

18.33

Antibody; Epstein-Barr (EB) virus, early antigen (EA)

86664

19.97

Antibody; Epstein-Barr (EB) virus, nuclear antigen (EBNA)

86665

19.97

Antibody; Epstein-Barr (EB) virus, viral capsid (VCA)

86666

13.64

Antibody; Ehrlichia

86668

12.14

Antibody; Francisella tularensis

86671

13.64

Antibody; fungus, not elsewhere specified

86674

19.97

Antibody; Giardia lamblia

86677

20.28

Antibody; Helicobacter pylori

86682

13.64

Antibody; helminth, not elsewhere specified

86684

13.64

Antibody; Haemophilus influenza

86687

11.72

Antibody; HTLV-I

86688

13.94

Antibody; HTLV-II

86689

27.05

Antibody; HTLV or HIV antibody, confirmatory test (eg, Western Blot)

86692

23.62

Antibody; hepatitis, delta agent

86694

20.11

Antibody; herpes simplex, non-specific type test

86695

18.43

Antibody; herpes simplex, type 1

86696

27.05

Antibody; herpes simplex, type 2

86698

17.46

Antibody; histoplasma

86701

12.41

Antibody; HIV-1

86702

14.75

Antibody; HIV-2

86703

14.75

Antibody; HIV-1 and HIV-2, single assay

86704

16.84

Hepatitis B core antibody (HBcAb); total

86705

16.44

Hepatitis B core antibody (HBcAb); IgM antibody

86706

14.61

Hepatitis B surface antibody (HBsAb)

86707

16.16

Hepatitis Be antibody (HBeAb)

86708

16.24

Hepatitis A antibody (HAAb); total

86709

15.73

Hepatitis A antibody (HAAb); IgM antibody

86710

14.58

Antibody; influenza virus

86713

21.39

Antibody; Legionella

86717

13.00

Antibody; Leishmania

86720

12.14

Antibody; Leptospira

86723

13.00

Antibody; Listeria monocytogenes

86727

14.58

Antibody; lymphocytic choriomeningitis

86729

16.69

Antibody; lymphogranuloma venereum

86732

13.00

Antibody; mucormycosis

86735

18.23

Antibody; mumps

86738

14.58

Antibody; mycoplasma

86741

13.00

Antibody; Neisseria meningitides

86744

13.00

Antibody; Nocardia

86747

13.00

Antibody; parvovirus

86750

13.00

Antibody; Plasmodium (malaria)

86753

13.00

Antibody; protozoa, not elsewhere specified

86756

18.01

Antibody; respiratory syncytial virus

86757

27.05

Antibody; Rickettsia

86759

18.43

Antibody; rotavirus

86762

20.11

Antibody; rubella

86765

18.00

Antibody; rubeola

86768

13.00

Antibody; Salmonella

86771

13.00

Antibody; Shigella

86774

13.00

Antibody; tetanus

86777

20.11

Antibody; Toxoplasma

86778

20.12

Antibody; Toxoplasma, IgM

86781

18.50

Antibody; Treponema pallidum, confirmatory test (eg, FTA-abs)

86784

17.55

Antibody; Trichinella

86787

18.00

Antibody; varicella-zoster

86788

19.97

Antibody; West Nile virus, IgM

86789

20.11

Antibody; West Nile virus

86790

13.00

Antibody; virus, not elsewhere specified

86793

13.00

Antibody; Yersinia

86800

20.70

Thyroglobulin antibody

86803

16.24

Hepatitis C antibody;

86804

21.64

Hepatitis C antibody; confirmatory test (eg, immunoblot)

86805

73.05

Lymphocytotoxicity assay, visual crossmatch; with titration

86806

66.49

Lymphocytotoxicity assay, visual crossmatch; without titration

86807

55.29

Serum screening for cytotoxic percent reactive antibody (PRA); standard method

86808

41.47

Serum screening for cytotoxic percent reactive antibody (PRA); quick method

86812

36.06

HLA typing; A, B, or C (eg, A10, B7, B27), single antigen

86813

81.02

HLA typing; A, B, or C, multiple antigens

86816

38.92

HLA typing; DR/DQ, single antigen

86817

89.95

HLA typing; DR/DQ, multiple antigens

86821

78.88

HLA typing; lymphocyte culture, mixed (MLC)

86822

51.07

HLA typing; lymphocyte culture, primed (PLC)

86880

7.50

Antihuman globulin test (Coombs test); direct, each antiserum

86885

7.99

Antihuman globulin test (Coombs test); indirect, qualitative, each reagent red cell

86886

7.23

Antihuman globulin test (Coombs test); indirect, each antibody titer

86900

4.17

Blood typing; ABO

86901

4.17

Blood typing; Rh (D)

86903

13.19

Blood typing; antigen screening for compatible blood unit using reagent serum, per unit screened

86904

13.28

Blood typing; antigen screening for compatible unit using patient serum, per unit screened

86905

5.34

Blood typing; RBC antigens, other than ABO or Rh (D), each

86906

10.83

Blood typing; Rh phenotyping, complete

86940

11.46

Hemolysins and agglutinins; auto, screen, each

86941

16.92

Hemolysins and agglutinins; incubated

87001

6.88

Animal inoculation, small animal; with observation

87003

23.52

Animal inoculation, small animal; with observation and dissection

87015

9.33

Concentration (any type), for infectious agents

87040

14.42

Culture, bacterial; blood, aerobic, with isolation and presumptive identification of isolates (includes anaerobic culture, if appropriate)

87045

13.18

Culture, bacterial; stool, aerobic, with isolation and preliminary examination (eg, KIA, LIA), Salmonella and Shigella species

87046

13.18

Culture, bacterial; stool, aerobic, additional pathogens, isolation and presumptive identification of isolates, each plate

87070

12.03

Culture, bacterial; any other source except urine, blood or stool, aerobic, with isolation and presumptive identification of isolates

87071

13.18

Culture, bacterial; quantitative, aerobic with isolation and presumptive identification of isolates, any source except urine, blood or stool

87073

13.18

Culture, bacterial; quantitative, anaerobic with isolation and presumptive identification of isolates, any source except urine, blood or stool

87075

13.22

Culture, bacterial; any source, except blood, anaerobic with isolation and presumptive identification of isolates

87076

7.30

Culture, bacterial; anaerobic isolate, additional methods required for definitive identification, each isolate

87077

7.30

Culture, bacterial; aerobic isolate, additional methods required for definitive identification, each isolate

87081

9.26

Culture, presumptive, pathogenic organisms, screening only;

87084

9.75

Culture, presumptive, pathogenic organisms, screening only; with colony estimation from density chart

87086

11.28

Culture, bacterial; quantitative colony count, urine

87088

11.31

Culture, bacterial; with isolation and presumptive identification of each isolate, urine

87101

10.77

Culture, fungi (mold or yeast) isolation, with presumptive identification of isolates; skin, hair, or nail

87102

11.74

Culture, fungi (mold or yeast) isolation, with presumptive identification of isolates; other source (except blood)

87103

12.60

Culture, fungi (mold or yeast) isolation, with presumptive identification of isolates; blood

87106

14.42

Culture, fungi, definitive identification, each organism; yeast

87107

14.42

Culture, fungi, definitive identification, each organism; mold

87109

21.50

Culture, mycoplasma, any source

87110

27.37

Culture, chlamydia, any source

87116

15.10

Culture, tubercle or other acid-fast bacilli (eg, TB, AFB, mycobacteria) any source, with isolation and presumptive identification of isolates

87118

15.29

Culture, mycobacterial, definitive identification, each isolate

87140

7.79

Culture, typing; immunofluorescent method, each antiserum

87143

17.51

Culture, typing; gas liquid chromatography (GLC) or high pressure liquid chromatography (HPLC) method

87147

7.23

Culture, typing; immunologic method, other than immunofluoresence (eg, agglutination grouping), per antiserum

87149

28.02

Culture, typing; identification by nucleic acid probe

87152

7.31

Culture, typing; identification by pulse field gel typing

87158

7.31

Culture, typing; other methods

87164

8.11

Dark field examination, any source (eg, penile, vaginal, oral, skin); includes specimen collection

87166

8.11

Dark field examination, any source (eg, penile, vaginal, oral, skin); without collection

87168

5.96

Macroscopic examination; arthropod

87169

5.96

Macroscopic examination; parasite

87172

5.96

Pinworm exam (eg, cellophane tape prep)

87176

8.22

Homogenization, tissue, for culture

87177

12.43

Ova and parasites, direct smears, concentration and identification

87181

6.64

Susceptibility studies, antimicrobial agent; agar dilution method, per agent (eg, antibiotic gradient strip)

87184

9.63

Susceptibility studies, antimicrobial agent; disk method, per plate (12 or fewer agents)

87185

6.64

Susceptibility studies, antimicrobial agent; enzyme detection (eg, beta lactamase), per enzyme

87186

12.08

Susceptibility studies, antimicrobial agent; microdilution or agar dilution (minimum inhibitory concentration (MIC) or breakpoint), each multi-antimicrobial, per plate

87187

14.48

Susceptibility studies, antimicrobial agent; microdilution or agar dilution, minimum lethal concentration (MLC), each plate (List separately in addition to code for primary procedure)

87188

9.27

Susceptibility studies, antimicrobial agent; macrobroth dilution method, each agent

87190

6.88

Susceptibility studies, antimicrobial agent; mycobacteria, proportion method, each agent

87197

20.99

Serum bactericidal titer (Schlicter test)

87205

5.96

Smear, primary source with interpretation; Gram or Giemsa stain for bacteria, fungi, or cell types

87206

7.50

Smear, primary source with interpretation; fluorescent and/or acid fast stain for bacteria, fungi, parasites, viruses or cell types

87207

8.37

Smear, primary source with interpretation; special stain for inclusion bodies or parasites (eg, malaria, coccidia, microsporidia, trypanosomes, herpes viruses)

87209

25.11

Smear, primary source with interpretation; complex special stain (eg, trichrome, iron hemotoxylin) for ova and parasites

87210

5.96

Smear, primary source with interpretation; wet mount for infectious agents (eg, saline, India ink, KOH preps)

87220

5.96

Tissue examination by KOH slide of samples from skin, hair, or nails for fungi or ectoparasite ova or mites (eg, scabies)

87230

27.30

Toxin or antitoxin assay, tissue culture (eg, Clostridium difficile toxin)

87250

27.32

Virus isolation; inoculation of embryonated eggs, or small animal, includes observation and dissection

87252

36.42

Virus isolation; tissue culture inoculation, observation, and presumptive identification by cytopathic effect

87253

28.22

Virus isolation; tissue culture, additional studies or definitive identification (eg, hemabsorption, neutralization, immunofluoresence stain), each isolate

87254

27.32

Virus isolation; centrifuge enhanced (shell vial) technique, includes identification with immunofluorescence stain, each virus

87255

47.31

Virus isolation; including identification by non-immunologic method, other than by cytopathic effect (eg, virus specific enzymatic activity)

87260

16.01

Infectious agent antigen detection by immunofluorescent technique; adenovirus

87265

16.01

Infectious agent antigen detection by immunofluorescent technique; Bordetella pertussis/parapertussis

87267

16.01

Infectious agent antigen detection by immunofluorescent technique; Enterovirus, direct fluorescent antibody (DFA)

87269

16.01

Infectious agent antigen detection by immunofluorescent technique; giardia

87270

16.01

Infectious agent antigen detection by immunofluorescent technique; Chlamydia trachomatis

87271

16.01

Infectious agent antigen detection by immunofluorescent technique; Cytomegalovirus, direct fluorescent antibody (DFA)

87272

16.01

Infectious agent antigen detection by immunofluorescent technique; cryptosporidium

87273

16.01

Infectious agent antigen detection by immunofluorescent technique; Herpes simplex virus type 2

87274

16.01

Infectious agent antigen detection by immunofluorescent technique; Herpes simplex virus type 1

87275

16.01

Infectious agent antigen detection by immunofluorescent technique; influenza B virus

87276

16.01

Infectious agent antigen detection by immunofluorescent technique; influenza A virus

87277

16.01

Infectious agent antigen detection by immunofluorescent technique; Legionella micdadei

87278

16.01

Infectious agent antigen detection by immunofluorescent technique; Legionella pneumophila

87279

16.01

Infectious agent antigen detection by immunofluorescent technique; Parainfluenza virus, each type

87280

16.01

Infectious agent antigen detection by immunofluorescent technique; respiratory syncytial virus

87281

16.01

Infectious agent antigen detection by immunofluorescent technique; Pneumocystis carinii

87283

16.01

Infectious agent antigen detection by immunofluorescent technique; Rubeola

87285

16.01

Infectious agent antigen detection by immunofluorescent technique; Treponema pallidum

87290

16.01

Infectious agent antigen detection by immunofluorescent technique; Varicella zoster virus

87299

16.01

Infectious agent antigen detection by immunofluorescent technique; not otherwise specified, each organism

87300

16.01

Infectious agent antigen detection by immunofluorescent technique, polyvalent for multiple organisms, each polyvalent antiserum

87301

16.01

Infectious agent antigen detection by enzyme immunoassay technique, qualitative or semiquantitative, multiple-step method; adenovirus enteric types 40/41

87305

16.01

Infectious agent antigen detection by enzyme immunoassay technique, qualitative or semiquantitative, multiple-step method; Aspergillus

87320

16.01

Infectious agent antigen detection by enzyme immunoassay technique, qualitative or semiquantitative, multiple-step method; Chlamydia trachomatis

87324

16.01

Infectious agent antigen detection by enzyme immunoassay technique, qualitative or semiquantitative, multiple-step method; Clostridium difficile toxin(s)

87327

16.01

Infectious agent antigen detection by enzyme immunoassay technique, qualitative or semiquantitative, multiple-step method; Cryptococcus neoformans

87328

16.01

Infectious agent antigen detection by enzyme immunoassay technique, qualitative or semiquantitative, multiple-step method; cryptosporidium

87329

16.01

Infectious agent antigen detection by enzyme immunoassay technique, qualitative or semiquantitative, multiple-step method; giardia

87332

16.01

Infectious agent antigen detection by enzyme immunoassay technique, qualitative or semiquantitative, multiple-step method; cytomegalovirus

87335

16.01

Infectious agent antigen detection by enzyme immunoassay technique, qualitative or semiquantitative, multiple-step method; Escherichia coli 0157

87336

16.01

Infectious agent antigen detection by enzyme immunoassay technique, qualitative or semiquantitative, multiple-step method; Entamoeba histolytica dispar group

87337

16.01

Infectious agent antigen detection by enzyme immunoassay technique, qualitative or semiquantitative, multiple-step method; Entamoeba histolytica group

87338

16.04

Infectious agent antigen detection by enzyme immunoassay technique, qualitative or semiquantitative, multiple-step method; Helicobacter pylori, stool

87339

16.01

Infectious agent antigen detection by enzyme immunoassay technique, qualitative or semiquantitative, multiple-step method; Helicobacter pylori

87340

14.43

Infectious agent antigen detection by enzyme immunoassay technique, qualitative or semiquantitative, multiple-step method; hepatitis B surface antigen (HBsAg)

87341

14.43

Infectious agent antigen detection by enzyme immunoassay technique, qualitative or semiquantitative, multiple-step method; hepatitis B surface antigen (HBsAg) neutralization

87350

16.10

Infectious agent antigen detection by enzyme immunoassay technique, qualitative or semiquantitative, multiple-step method; hepatitis Be antigen (HBeAg)

87380

15.54

Infectious agent antigen detection by enzyme immunoassay technique, qualitative or semiquantitative, multiple-step method; hepatitis, delta agent

87385

16.01

Infectious agent antigen detection by enzyme immunoassay technique, qualitative or semiquantitative, multiple-step method; Histoplasma capsulatum

87390

24.65

Infectious agent antigen detection by enzyme immunoassay technique, qualitative or semiquantitative, multiple-step method; HIV-1

87391

24.65

Infectious agent antigen detection by enzyme immunoassay technique, qualitative or semiquantitative, multiple-step method; HIV-2

87400

16.01

Infectious agent antigen detection by enzyme immunoassay technique, qualitative or semiquantitative, multiple-step method; Influenza, A or B, each

87420

16.01

Infectious agent antigen detection by enzyme immunoassay technique, qualitative or semiquantitative, multiple-step method; respiratory syncytial virus

87425

16.01

Infectious agent antigen detection by enzyme immunoassay technique, qualitative or semiquantitative, multiple-step method; rotavirus

87427

16.01

Infectious agent antigen detection by enzyme immunoassay technique, qualitative or semiquantitative, multiple-step method; Shiga-like toxin

87430

16.01

Infectious agent antigen detection by enzyme immunoassay technique, qualitative or semiquantitative, multiple-step method; Streptococcus, group A

87449

16.01

Infectious agent antigen detection by enzyme immunoassay technique qualitative or semiquantitative; multiple step method, not otherwise specified, each organism

87450

10.68

Infectious agent antigen detection by enzyme immunoassay technique qualitative or semiquantitative; single step method, not otherwise specified, each organism

87451

10.68

Infectious agent antigen detection by enzyme immunoassay technique qualitative or semiquantitative; multiple step method, polyvalent for multiple organisms, each polyvalent antiserum

87470

28.02

Infectious agent detection by nucleic acid (DNA or RNA); Bartonella henselae and Bartonella quintana, direct probe technique

87471

36.39

Infectious agent detection by nucleic acid (DNA or RNA); Bartonella henselae and Bartonella quintana, amplified probe technique

87472

59.85

Infectious agent detection by nucleic acid (DNA or RNA); Bartonella henselae and Bartonella quintana, quantification

87475

28.02

Infectious agent detection by nucleic acid (DNA or RNA); Borrelia burgdorferi, direct probe technique

87476

36.39

Infectious agent detection by nucleic acid (DNA or RNA); Borrelia burgdorferi, amplified probe technique

87477

59.85

Infectious agent detection by nucleic acid (DNA or RNA); Borrelia burgdorferi, quantification

87480

28.02

Infectious agent detection by nucleic acid (DNA or RNA); Candida species, direct probe technique

87481

36.39

Infectious agent detection by nucleic acid (DNA or RNA); Candida species, amplified probe technique

87482

58.33

Infectious agent detection by nucleic acid (DNA or RNA); Candida species, quantification

87485

28.02

Infectious agent detection by nucleic acid (DNA or RNA); Chlamydia pneumoniae, direct probe technique

87486

36.39

Infectious agent detection by nucleic acid (DNA or RNA); Chlamydia pneumoniae, amplified probe technique

87487

59.85

Infectious agent detection by nucleic acid (DNA or RNA); Chlamydia pneumoniae, quantification

87490

28.02

Infectious agent detection by nucleic acid (DNA or RNA); Chlamydia trachomatis, direct probe technique

87491

36.39

Infectious agent detection by nucleic acid (DNA or RNA); Chlamydia trachomatis, amplified probe technique

87492

22.93

Infectious agent detection by nucleic acid (DNA or RNA); Chlamydia trachomatis, quantification

87495

28.02

Infectious agent detection by nucleic acid (DNA or RNA); cytomegalovirus, direct probe technique

87496

36.39

Infectious agent detection by nucleic acid (DNA or RNA); cytomegalovirus, amplified probe technique

87497

59.85

Infectious agent detection by nucleic acid (DNA or RNA); cytomegalovirus, quantification

87498

36.39

Infectious agent detection by nucleic acid (DNA or RNA); enterovirus, amplified probe technique

87500

36.39

Infectious agent detection by nucleic acid (DNA or RNA); vancomycin resistance (eg, enterococcus species van A, van B), amplified probe technique

87510

28.02

Infectious agent detection by nucleic acid (DNA or RNA); Gardnerella vaginalis, direct probe technique

87511

36.39

Infectious agent detection by nucleic acid (DNA or RNA); Gardnerella vaginalis, amplified probe technique

87512

58.33

Infectious agent detection by nucleic acid (DNA or RNA); Gardnerella vaginalis, quantification

87515

28.02

Infectious agent detection by nucleic acid (DNA or RNA); hepatitis B virus, direct probe technique

87516

36.39

Infectious agent detection by nucleic acid (DNA or RNA); hepatitis B virus, amplified probe technique

87517

59.85

Infectious agent detection by nucleic acid (DNA or RNA); hepatitis B virus, quantification

87520

28.02

Infectious agent detection by nucleic acid (DNA or RNA); hepatitis C, direct probe technique

87521

36.39

Infectious agent detection by nucleic acid (DNA or RNA); hepatitis C, amplified probe technique

87522

59.85

Infectious agent detection by nucleic acid (DNA or RNA); hepatitis C, quantification

87525

28.02

Infectious agent detection by nucleic acid (DNA or RNA); hepatitis G, direct probe technique

87526

36.39

Infectious agent detection by nucleic acid (DNA or RNA); hepatitis G, amplified probe technique

87527

58.33

Infectious agent detection by nucleic acid (DNA or RNA); hepatitis G, quantification

87528

28.02

Infectious agent detection by nucleic acid (DNA or RNA); Herpes simplex virus, direct probe technique

87529

36.39

Infectious agent detection by nucleic acid (DNA or RNA); Herpes simplex virus, amplified probe technique

87530

59.85

Infectious agent detection by nucleic acid (DNA or RNA); Herpes simplex virus, quantification

87531

28.02

Infectious agent detection by nucleic acid (DNA or RNA); Herpes virus-6, direct probe technique

87532

36.39

Infectious agent detection by nucleic acid (DNA or RNA); Herpes virus-6, amplified probe technique

87533

58.33

Infectious agent detection by nucleic acid (DNA or RNA); Herpes virus-6, quantification

87534

28.02

Infectious agent detection by nucleic acid (DNA or RNA); HIV-1, direct probe technique

87535

36.39

Infectious agent detection by nucleic acid (DNA or RNA); HIV-1, amplified probe technique

87536

78.52

Infectious agent detection by nucleic acid (DNA or RNA); HIV-1, quantification

87537

28.02

Infectious agent detection by nucleic acid (DNA or RNA); HIV-2, direct probe technique

87538

36.39

Infectious agent detection by nucleic acid (DNA or RNA); HIV-2, amplified probe technique

87539

59.85

Infectious agent detection by nucleic acid (DNA or RNA); HIV-2, quantification

87540

28.02

Infectious agent detection by nucleic acid (DNA or RNA); Legionella pneumophila, direct probe technique

87541

36.39

Infectious agent detection by nucleic acid (DNA or RNA); Legionella pneumophila, amplified probe technique

87542

58.33

Infectious agent detection by nucleic acid (DNA or RNA); Legionella pneumophila, quantification

87550

28.02

Infectious agent detection by nucleic acid (DNA or RNA); Mycobacteria species, direct probe technique

87551

36.39

Infectious agent detection by nucleic acid (DNA or RNA); Mycobacteria species, amplified probe technique

87552

59.85

Infectious agent detection by nucleic acid (DNA or RNA); Mycobacteria species, quantification

87555

28.02

Infectious agent detection by nucleic acid (DNA or RNA); Mycobacteria tuberculosis, direct probe technique

87556

36.39

Infectious agent detection by nucleic acid (DNA or RNA); Mycobacteria tuberculosis, amplified probe technique

87557

59.85

Infectious agent detection by nucleic acid (DNA or RNA); Mycobacteria tuberculosis, quantification

87560

28.02

Infectious agent detection by nucleic acid (DNA or RNA); Mycobacteria avium-intracellulare, direct probe technique

87561

36.39

Infectious agent detection by nucleic acid (DNA or RNA); Mycobacteria avium-intracellulare, amplified probe technique

87562

59.85

Infectious agent detection by nucleic acid (DNA or RNA); Mycobacteria avium-intracellulare, quantification

87580

28.02

Infectious agent detection by nucleic acid (DNA or RNA); Mycoplasma pneumoniae, direct probe technique

87581

36.39

Infectious agent detection by nucleic acid (DNA or RNA); Mycoplasma pneumoniae, amplified probe technique

87582

58.33

Infectious agent detection by nucleic acid (DNA or RNA); Mycoplasma pneumoniae, quantification

87590

28.02

Infectious agent detection by nucleic acid (DNA or RNA); Neisseria gonorrhoeae, direct probe technique

87591

36.39

Infectious agent detection by nucleic acid (DNA or RNA); Neisseria gonorrhoeae, amplified probe technique

87592

59.85

Infectious agent detection by nucleic acid (DNA or RNA); Neisseria gonorrhoeae, quantification

87620

28.02

Infectious agent detection by nucleic acid (DNA or RNA); papillomavirus, human, direct probe technique

87621

36.39

Infectious agent detection by nucleic acid (DNA or RNA); papillomavirus, human, amplified probe technique

87622

58.33

Infectious agent detection by nucleic acid (DNA or RNA); papillomavirus, human, quantification

87640

36.39

Infectious agent detection by nucleic acid (DNA or RNA); Staphylococcus aureus, amplified probe technique

87641

36.39

Infectious agent detection by nucleic acid (DNA or RNA); Staphylococcus aureus, methicillin resistant, amplified probe technique

87650

28.02

Infectious agent detection by nucleic acid (DNA or RNA); Streptococcus, group A, direct probe technique

87651

36.39

Infectious agent detection by nucleic acid (DNA or RNA); Streptococcus, group A, amplified probe technique

87652

58.33

Infectious agent detection by nucleic acid (DNA or RNA); Streptococcus, group A, quantification

87653

36.39

Infectious agent detection by nucleic acid (DNA or RNA); Streptococcus, group B, amplified probe technique

87660

28.02

Infectious agent detection by nucleic acid (DNA or RNA); Trichomonas vaginalis, direct probe technique

87797

28.02

Infectious agent detection by nucleic acid (DNA or RNA), not otherwise specified; direct probe technique, each organism

87798

36.39

Infectious agent detection by nucleic acid (DNA or RNA), not otherwise specified; amplified probe technique, each organism

87799

59.85

Infectious agent detection by nucleic acid (DNA or RNA), not otherwise specified; quantification, each organism

87800

56.03

Infectious agent detection by nucleic acid (DNA or RNA), multiple organisms; direct probe(s) technique

87801

72.78

Infectious agent detection by nucleic acid (DNA or RNA), multiple organisms; amplified probe(s) technique

87802

16.01

Infectious agent antigen detection by immunoassay with direct optical observation; Streptococcus, group B

87803

16.01

Infectious agent antigen detection by immunoassay with direct optical observation; Clostridium difficile toxin A

87804

16.01

Infectious agent antigen detection by immunoassay with direct optical observation; Influenza

87804

16.01

Infectious agent antigen detection by immunoassay with direct optical observation; Influenza

87807

16.01

Infectious agent antigen detection by immunoassay with direct optical observation; respiratory syncytial virus

87808

16.01

Infectious agent antigen detection by immunoassay with direct optical observation; Trichomonas vaginalis

87809

16.01

Infectious agent antigen detection by immunoassay with direct optical observation; adenovirus

87810

16.01

Infectious agent detection by immunoassay with direct optical observation; Chlamydia trachomatis

87850

16.01

Infectious agent detection by immunoassay with direct optical observation; Neisseria gonorrhoeae

87880

16.01

Infectious agent detection by immunoassay with direct optical observation; Streptococcus, group A

87899

16.01

Infectious agent detection by immunoassay with direct optical observation; not otherwise specified

87900

182.11

Infectious agent drug susceptibility phenotype prediction using regularly updated genotypic bioinformatics

87901

114.95

Infectious agent genotype analysis by nucleic acid (DNA or RNA); HIV 1, reverse transcriptase and protease

87902

114.95

Infectious agent genotype analysis by nucleic acid (DNA or RNA); Hepatitis C virus

87903

682.72

Infectious agent phenotype analysis by nucleic acid (DNA or RNA) with drug resistance tissue culture analysis, HIV 1; first through ten drugs tested

87904

36.42

Infectious agent phenotype analysis by nucleic acid (DNA or RNA) with drug resistance tissue culture analysis, HIV 1; each additional drug tested (List separately in addition to code for primary procedure)

88130

21.02

Sex chromatin identification; Barr bodies

88140

11.17

Sex chromatin identification; peripheral blood smear, polymorphonuclear drumsticks

88142

28.31

Cytopathology, cervical or vaginal (any reporting system), collected in preservative fluid, automated thin layer preparation; manual screening under physician supervision

88143

28.31

Cytopathology, cervical or vaginal (any reporting system), collected in preservative fluid, automated thin layer preparation; with manual screening and rescreening under physician supervision

88147

15.90

Cytopathology smears, cervical or vaginal; screening by automated system under physician supervision

88148

21.23

Cytopathology smears, cervical or vaginal; screening by automated system with manual rescreening under physician supervision

88150

14.76

Cytopathology, slides, cervical or vaginal; manual screening under physician supervision

88152

14.76

Cytopathology, slides, cervical or vaginal; with manual screening and computer-assisted rescreening under physician supervision

88153

14.76

Cytopathology, slides, cervical or vaginal; with manual screening and rescreening under physician supervision

88154

14.76

Cytopathology, slides, cervical or vaginal; with manual screening and computer-assisted rescreening using cell selection and review under physician supervision

88155

8.37

Cytopathology, slides, cervical or vaginal, definitive hormonal evaluation (eg, maturation index, karyopyknotic index, estrogenic index) (List separately in addition to code(s) for other technical and interpretation services)

88164

14.76

Cytopathology, slides, cervical or vaginal (the Bethesda System); manual screening under physician supervision

88165

14.76

Cytopathology, slides, cervical or vaginal (the Bethesda System); with manual screening and rescreening under physician supervision

88166

14.76

Cytopathology, slides, cervical or vaginal (the Bethesda System); with manual screening and computer-assisted rescreening under physician supervision

88167

14.76

Cytopathology, slides, cervical or vaginal (the Bethesda System); with manual screening and computer-assisted rescreening using cell selection and review under physician supervision

88174

29.85

Cytopathology, cervical or vaginal (any reporting system), collected in preservative fluid, automated thin layer preparation; screening by automated system, under physician supervision

88175

37.01

Cytopathology, cervical or vaginal (any reporting system), collected in preservative fluid, automated thin layer preparation; with screening by automated system and manual rescreening or review, under physician supervision

88230

48.38

Tissue culture for non-neoplastic disorders; lymphocyte

88233

122.81

Tissue culture for non-neoplastic disorders; skin or other solid tissue biopsy

88235

122.81

Tissue culture for non-neoplastic disorders; amniotic fluid or chorionic villus cells

88237

55.83

Tissue culture for neoplastic disorders; bone marrow, blood cells

88239

206.12

Tissue culture for neoplastic disorders; solid tumor

88240

14.11

Cryopreservation, freezing and storage of cells, each cell line

88241

14.11

Thawing and expansion of frozen cells, each aliquot

88245

207.98

Chromosome analysis for breakage syndromes; baseline Sister Chromatid Exchange (SCE), 20-25 cells

88248

241.96

Chromosome analysis for breakage syndromes; baseline breakage, score 50-100 cells, count 20 cells, two karyotypes (eg, for ataxia telangiectasia, Fanconi anemia, fragile X)

88249

241.96

Chromosome analysis for breakage syndromes; score 100 cells, clastogen stress (eg, diepoxybutane, mitomycin C, ionizing radiation, UV radiation)

88261

246.93

Chromosome analysis; count five cells, one karyotype, with banding

88262

174.14

Chromosome analysis; count 15-20 cells, two karyotypes, with banding

88263

204.68

Chromosome analysis; count 45 cells for mosaicism, two karyotypes, with banding

88264

174.14

Chromosome analysis; analyze 20-25 cells

88267

251.17

Chromosome analysis, amniotic fluid or chorionic villus, count 15 cells, one karyotype, with banding

88269

232.38

Chromosome analysis, in situ for amniotic fluid cells, count cells from six-12 colonies, one karyotype, with banding

88271

29.93

Molecular cytogenetics; DNA probe, each (eg, FISH)

88272

37.41

Molecular cytogenetics; chromosomal in situ hybridization, analyze three-five cells (eg, for derivatives and markers)

88273

44.89

Molecular cytogenetics; chromosomal in situ hybridization, analyze ten-30 cells (eg, for microdeletions)

88274

48.63

Molecular cytogenetics; interphase in situ hybridization, analyze 25-99 cells

88275

56.11

Molecular cytogenetics; interphase in situ hybridization, analyze 100-300 cells

88280

35.07

Chromosome analysis; additional karyotypes, each study

88283

95.84

Chromosome analysis; additional specialized banding technique (eg, NOR, C-banding)

88285

26.54

Chromosome analysis; additional cells counted, each study

88289

48.11

Chromosome analysis; additional high resolution study

88371

31.05

Protein analysis of tissue by Western Blot, with interpretation and report;

88372

31.79

Protein analysis of tissue by Western Blot, with interpretation and report; immunological probe for band identification, each

88400

7.02

Bilirubin, total, transcutaneous

89050

6.61

Cell count, miscellaneous body fluids (eg, cerebrospinal fluid, joint fluid), except blood;

89051

7.70

Cell count, miscellaneous body fluids (eg, cerebrospinal fluid, joint fluid), except blood; with differential count

89055

5.96

Leukocyte assessment, fecal, qualitative or semiquantitative

89060

9.99

Crystal identification by light microscopy with or without polarizing lens analysis, tissue or any body fluid (except urine)

89125

6.03

Fat stain, feces, urine, or respiratory secretions

89160

5.15

Meat fibers, feces

89190

6.64

Nasal smear for eosinophils

89225

4.67

Starch granules, feces

89235

7.69

Water load test

89300

9.77

Semen analysis; presence and/or motility of sperm including Huhner test (post coital)

89310

12.03

Semen analysis; motility and count (not including Huhner test)

89320

16.84

Semen analysis; volume, count, motility, and differential

89321

16.84

Semen analysis; sperm presence and motility of sperm, if performed

89322

21.65

Semen analysis; volume, count, motility, and differential using strict morphologic criteria (eg, Kruger)

89325

14.91

Sperm antibodies

89329

29.30

Sperm evaluation; hamster penetration test

89330

13.83

Sperm evaluation; cervical mucus penetration test, with or without spinnbarkeit test

89331

27.37

Sperm evaluation, for retrograde ejaculation, urine (sperm concentration, motility, and morphology, as indicated)

(5) Dental Services.

Code

Fee

40.06(5) - Dental Service Description

D0120

30.40

Periodic oral evaluation - established patient

D0140

60.00

Limited oral evaluation - problem focused

D0150

60.00

Comprehensive oral evaluation - new or established patient

D0160

80.00

Detailed and extensive oral evaluation - problem focused, by report

D0170

53.60

Re-evaluation - limited, problem focused (established patient; not postoperative visit)

D0180

79.20

Comprehensive periodontal evaluation - new or established patient

D0210

100.00

Intraoral - complete series (including bitewings)

D0220

20.00

Intraoral - periapical, first film

D0230

16.00

Intraoral - periapical, each additional film

D0240

30.40

Intraoral - occlusal film

D0250

32.00

Extraoral - first film

D0260

28.00

Extraoral - each additional film

D0270

20.00

Bitewing - single film

D0272

32.00

Bitewings - two films

D0273

40.00

Bitewings - three films

D0274

48.00

Bitewings - four films

D0277

72.80

Vertical bitewings - seven to eight films

D0290

66.40

Posterior-anterior or lateral skull and facial bone survey film

D0310

132.00

Sialography

D0321

104.00

Other temporomandibular joint films, by report

D0322

220.00

Tomographic survey

D0330

88.00

Panoramic film

D0340

92.00

Cephalometric film

D0350

36.00

Oral/facial photographic images

D0460

40.00

Pulp vitality tests

D0470

76.80

Diagnostic casts

D0472

112.00

Accession of tissue, gross examination, preparation, and transmission of written report

D0473

264.00

Accession of tissue, gross and microscopic examination, preparation and transmission of written report

D0474

12.00

Accession of tissue, gross and microscopic examination, including assessment of surgical margins for presence of disease, preparation and transmission of written report

D0480

12.00

Accession of exfoliative cytologic smears, microscopic examination, preparation and transmission of written report

D1110

69.60

Prophylaxis - adult

D1204

26.40

Topical application of fluoride (prophylaxis not included) - adult

D1206

28.80

Topical fluoride varnish; therapeutic application for moderate to high caries risk patients

D1351

41.60

Sealant - per tooth

D1510

280.00

Space maintainer - fixed-unilateral

D1515

424.00

Space maintainer - fixed-bilateral

D1520

128.00

Space maintainer - removable-unilateral

D1525

180.00

Space maintainer - removable-bilateral

D1550

80.00

Recementation of space maintainer

D1555

44.00

Removal of fixed space maintainer

D2140

88.00

Amalgam-one surface, primary or permanent

D2150

110.40

Amalgam-two surfaces, primary or permanent

D2160

132.00

Amalgam-three surfaces, primary or permanent

D2161

156.00

Amalgam-four or more surfaces, primary or permanent

D2330

104.00

Resin - one surface, anterior

D2331

129.60

Resin - two surfaces, anterior

D2332

157.60

Resin - three surfaces, anterior

D2335

200.00

Resin - four or more surfaces or involving incisal angle (anterior)

D2390

176.80

Resin-based composite crown, anterior

D2391

116.00

Resin-based composite - one surface, posterior

D2392

151.20

Resin-based composite - two surfaces, posterior

D2393

184.00

Resin-based composite - three surfaces, posterior

D2394

216.00

Resin-based composite - four or more surfaces, posterior

D2510

240.00

Inlay - metallic -one surface

D2520

680.00

Inlay - metallic - two surfaces

D2530

756.00

Inlay - metallic - three or more surfaces

D2542

720.00

Onlay - metallic - two surfaces

D2543

772.00

Onlay - metallic - three surfaces

D2544

880.00

Onlay - metallic - four or more surfaces

D2610

288.00

Inlay - porcelain/ceramic - one surface

D2620

389.60

Inlay - porcelain/ceramic - two surfaces

D2630

632.00

Inlay - porcelain/ceramic - three or more surfaces

D2642

748.00

Onlay - porcelain/ceramic - two surfaces

D2643

796.00

Onlay - porcelain/ceramic - three surfaces

D2644

912.00

Onlay - porcelain/ceramic - four or more surfaces

D2662

1,016.00

Onlay - resin-based composite - two surfaces

D2663

960.00

Onlay - resin-based composite - three surfaces

D2664

1,016.00

Onlay - resin-based composite - four or more surfaces

D2710

240.00

Crown - resin-based composite (indirect)

D2712

300.00

Crown - ¾ resin-based composite (indirect)

D2720

1,120.00

Crown - resin with high noble metal

D2721

640.00

Crown - resin with predominantly base metal

D2740

960.00

Crown - porcelain/ceramic substrate

D2750

880.00

Crown - porcelain fused to high noble metal

D2751

796.00

Crown - porcelain fused to predominantly base metal

D2752

800.00

Crown - porcelain fused to noble metal

D2780

920.00

Crown - ¾ cast high noble metal

D2782

1,100.00

Crown - ¾ cast noble metal

D2783

1,005.60

Crown - 3/4 porcelain/ceramic

D2790

918.40

Crown - full cast high noble metal

D2791

744.00

Crown - full cast predominantly base metal

D2792

856.00

Crown - full cast noble metal

D2794

1,120.00

Crown - titanium

D2799

200.00

Provisional crown

D2910

75.20

Recement inlay, onlay or partial coverage restoration

D2915

72.00

Recement cast or prefabricated post and core

D2920

76.00

Recement crown

D2930

208.00

Prefabricated stainless steel crown - primary tooth

D2931

240.00

Prefabricated stainless steel crown - permanent tooth

D2932

200.00

Prefabricated resin crown

D2934

232.00

Stainless steel crown - primary

D2940

80.00

Sedative filling

D2950

227.20

Core buildup, including any pins

D2951

36.00

Pin retention - per tooth, in addition to restoration

D2952

316.00

Post and core in addition to crown, indirectly fabricated

D2954

256.00

Prefabricated post and core in addition to crown

D2970

224.80

Temporary crown (fractured tooth)

D2971

224.80

Additional procedures to construct new crown under existing partial denture framework

D2980

150.40

Crown repair, by report

D3110

48.00

Pulp cap - direct (excluding final restoration)

D3120

56.00

Pulp cap - indirect (excluding final restoration)

D3220

132.00

Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction and application of medicament

D3221

145.60

Pulpal debridement, primary and permanent teeth

D3310

560.00

Anterior (excluding final restoration)

D3320

660.00 Bicuspid (excluding final restoration)

D3330

840.00

Molar (excluding final restoration)

D3332

260.00

Incomplete endodontic therapy; inoperable, unrestorable or fractured tooth

D3333

312.00

Internal root repair of perforation defects

D3346

640.00

Retreatment of previous root canal therapy - anterior

D3347

760.00

Retreatment of previous root canal therapy - bicuspid

D3348

921.60

Retreatment of previous root canal therapy - molar

D3351

156.00

Apexification/recalcification - initial visit (apical closure/calcific repair of perforations, root resorption, etc.)

D3352

169.60

Apexification/recalcification - interim medication replacement (apical closure/calcific repair of perforations, root resorption, etc.)

D3410

639.20

Apicoectomy/periradicular surgery - anterior

D3421

560.00

Apicoectomy/periradicular surgery - bicuspid (first root)

D3425

656.00

Apicoectomy/periradicular surgery - molar (first root)

D3430

120.00

Retrograde filling - per root

D3450

420.00

Root amputation - per root

D3920

313.60

Hemisection (including any root removal), not including root canal therapy

D4210

304.00

Gingivectomy or gingivoplasty - Four or more contiguous teeth or bounded teeth spaces per quadrant

D4211

140.00

Gingivectomy or gingivoplasty - one to three contiguous teeth or bounded teeth spaces per quadrant

D4240

560.00

Gingival flap procedure, including root planing - four or more contiguous teeth or bounded teeth spaces per quadrant

D4241

240.00

Gingival flap procedure, including root planing - one to three contiguous teeth or bounded teeth spaces per quadrant

D4249

625.60

Clinical crown lengthening - hard tissue

D4260

880.00

Osseous surgery (including flap entry and closure) - four or more contiguous teeth or bounded teeth spaces per quadrant

D4261

760.00

Osseous surgery (including flap entry and closure) - one to three contiguous teeth or bounded teeth spaces per quadrant

D4263

269.60

Bone replacement graft - first site in quadrant

D4264

180.00

Bone replacement graft - each additional site in quadrant

D4265

236.00

Biologic materials to aid in soft and osseous tissue regeneration

D4266

360.00

Guided tissue regeneration - resorbable barrier, per site

D4270

743.20

Pedicle soft tissue graft procedure

D4271

718.40

Free soft tissue graft procedure (including donor site surgery)

D4273

928.00

Subepithelial connective tissue graft procedures, per tooth

D4274

460.00

Distal or proximal wedge procedure (when not performed in conjunction with surgical procedures in the same anatomical area)

D4275

780.00

Soft tissue allograft

D4341

180.00

Periodontal scaling and root planing - four or more teeth per quadrant

D4342

124.00

Periodontal scaling and root planing - one to three teeth, per quadrant

D4355

116.00

Full mouth debridement to enable comprehensive evaluation and diagnosis

D4381

29.60

Localized delivery of antimicrobial agents via a controlled release vehicle into diseased crevicular tissue, per tooth, by report

D4910

96.00

Periodontal maintenance

D4920

88.00

Unscheduled dressing change (by someone other than treating dentist)

D5110

960.00

Complete denture - maxillary

D5120

960.00

Complete denture - mandibular

D5130

1,040.00

Immediate denture - maxillary

D5140

1,040.00

Immediate denture - mandibular

D5211

760.00

Maxillary partial denture - resin base (including any conventional clasps, rests and teeth)

D5212

780.00

Mandibular partial denture - resin base (including any conventional clasps, rests and teeth)

D5213

1,040.00

Maxillary partial denture - cast metal framework with resin denture bases (including any conventional clasps, rests and teeth)

D5214

1,040.00

Mandibular partial denture - cast metal framework with resin denture bases (including any conventional clasps, rests and teeth)

D5225

1,000.00

Maxillary partial denture - flexible base (including any clasps, rests and teeth)

D5226

960.00

Mandibular partial denture - flexible base (including any clasps, rests and teeth)

D5281

520.00

Removable unilateral partial denture - one piece cast metal (including clasps and teeth)

D5410

60.00

Adjust complete denture - maxillary

D5411

36.00

Adjust complete denture - mandibular

D5421

68.00

Adjust partial denture - maxillary

D5422

60.00

Adjust partial denture - mandibular

D5510

132.00

Repair broken complete denture base

D5520

116.00

Replace missing or broken teeth - complete denture (each tooth)

D5610

124.00

Repair resin denture base

D5620

168.00

Repair cast framework

D5630

140.00

Repair or replace broken clasp

D5640

112.00

Replace broken teeth - per tooth

D5650

128.00

Add tooth to existing partial denture

D5660

132.80

Add clasp to existing partial denture

D5670

340.00

Replace all teeth and acrylic on cast metal framework (maxillary)

D5671

480.00

Replace all teeth and acrylic on cast metal framework (mandibular)

D5710

280.00

Rebase complete maxillary denture

D5711

378.40

Rebase complete mandibular denture

D5720

320.00

Rebase maxillary partial denture

D5721

316.00

Rebase mandibular partial denture

D5730

240.00

Reline complete maxillary denture (chairside)

D5731

211.20

Reline lower complete mandibular denture (chairside)

D5740

180.00

Reline maxillary partial denture (chairside)

D5741

200.00

Reline mandibular partial denture (chairside)

D5750

285.60

Reline complete maxillary denture (laboratory)

D5751

300.00

Reline complete mandibular denture (laboratory)

D5760

285.60

Reline maxillary partial denture (laboratory)

D5761

267.20

Reline mandibular partial denture (laboratory)

D5820

380.00

Interim partial denture (maxillary)

D5821

428.00

Interim partial denture (mandibular)

D5850

110.40

Tissue conditioning, maxillary

D5851

134.40

Tissue conditioning, mandibular

D5862

360.00

Precision attachment, by report

D6010

1,560.00

Surgical placement of implant body: endosteal implant

D6040

1,200.00

Surgical placement: eposteal implant

D6050

360.00

Surgical placement: transosteal implant

D6055

1,040.00

Dental implant supported connecting bar

D6056

420.00

Prefabricated abutment - includes placement

D6057

560.00

Custom abutment - includes placement

D6058

1,000.00

Abutment supported porcelain/ceramic crown

D6059

1,036.00

Abutment supported porcelain fused to metal crown (high noble metal)

D6060

960.00

Abutment supported porcelain fused to metal crown (predominantly base metal)

D6061

920.00

Abutment supported porcelain fused to metal crown (noble metal)

D6062

1,050.40

Abutment supported cast metal crown (high noble metal)

D6063

360.00

Abutment supported cast metal crown (predominantly base metal)

D6064

820.00

Abutment supported cast metal crown (noble metal)

D6065

1,040.00

Implant supported porcelain/ceramic crown

D6066

1,120.00

Implant supported porcelain fused to metal crown (titanium, titanium alloy, high noble metal)

D6067

1,480.00

Implant supported metal crown (titanium, titanium alloy, high noble metal)

D6068

480.00

Abutment supported retainer for porcelain/ceramic FPD

D6069

960.00

Abutment supported retainer for porcelain fused to metal FPD (high noble metal)

D6071

528.80

Abutment supported retainer for porcelain fused to metal FPD (noble metal)

D6072

1,360.00

Abutment supported retainer for cast metal FPD (high noble metal)

D6077

1,120.00

Implant supported retainer for cast metal FPD (titanium, titanium alloy, or high noble metal)

D6092

88.00

Recement implant/abutment supported crown

D6093

60.00

Recement implant/abutment supported fixed partial denture

D6205

240.00

Pontic - indirect resin based composite

D6210

880.00

Pontic - cast high noble metal

D6211

520.00

Pontic - cast predominantly base metal

D6212

704.00

Pontic - cast noble metal

D6240

872.00

Pontic - porcelain fused to high noble metal

D6241

760.00

Pontic - porcelain fused to predominantly base metal

D6242

798.40

Pontic - porcelain fused to noble metal

D6250

904.00

Pontic - resin with high noble metal

D6251

616.00

Pontic - resin with predominantly base metal

D6252

480.00

Pontic - resin with noble metal

D6253

240.00

Provisional pontic

D6545

320.00

Retainer - cast metal for resin bonded fixed prosthesis

D6602

676.00

Inlay - cast high noble metal, two surfaces

D6606

600.00

Inlay - cast noble metal, two surfaces

D6610

720.00

Onlay - cast high noble metal, two surfaces

D6611

860.00

Onlay - cast high noble metal, three or more surfaces

D6615

920.00

Onlay - cast noble metal, three or more surfaces

D6710

276.00

Crown - indirect resin based composite

D6720

764.00

Crown - resin with high noble metal

D6721

604.00

Crown - resin with predominantly base metal

D6722

640.00

Crown - resin with noble metal

D6750

877.60

Crown - porcelain fused to high noble metal

D6751

756.80

Crown - porcelain fused to predominantly base metal

D6752

800.00

Crown - porcelain fused to noble metal

D6780

800.00

Crown - ¾ cast high noble metal

D6782

840.00

Crown - ¾ noble metal

D6790

864.00

Crown - full cast high noble metal

D6791

560.00

Crown - full cast predominantly base metal

D6792

680.00

Crown - full cast noble metal

D6793

240.00

Provisional retainer crown

D6930

100.00

Recement bridge

D6950

360.00

Precision attachment

D6970

200.00

Post and core in addition to fixed partial denture retainer, indirectly fabricated

D6972

280.00

Prefabricated post and core in addition to bridge retainer

D6973

216.00

Core build up for retainer, including any pins

D6980

168.80

Bridge repair, by report

D7111

80.00

Extraction, coronal remnants - deciduous tooth

D7140

112.00

Extraction, erupted tooth or exposed root (elevation and/or forceps removal)

D7210

200.00

Surgical removal of erupted tooth requiring elevation of mucoperiosteal flap and removal of bone and/or section of tooth

D7220

247.20

Removal of impacted tooth - soft tissue

D7230

320.00

Removal of impacted tooth - partially bony

D7240

400.00

Removal of impacted tooth - completely bony

D7241

476.00

Removal of impacted tooth - completely bony, with unusual surgical complications

D7250

214.40

Surgical removal of residual tooth roots (cutting procedure)

D7261

460.00

Primary closure of a sinus perforation

D7280

320.00

Surgical access of an unerupted tooth

D7283

120.00

Placement of device to facilitate eruption of impacted tooth

D7285

312.00

Biopsy of oral tissue - hard (bone, tooth)

D7286

277.60

Biopsy of oral tissue - soft

D7287

72.00

Exfoliative cytological sample collection

D7288

104.00

Brush biopsy - transepithelial sample collection

D7291

171.20

Transseptal fiberotomy/supra crestal fiberotomy, by report

D7310

200.00

Alveoloplasty in conjunction with extractions-four or more teeth or tooth spaces, per quadrant

D7311

224.00

Alveoloplasty in conjunction with extractions - one to three teeth or tooth spaces, per quadrant

D7320

200.00

Alveoloplasty not in conjunction with extractions-four or more teeth or tooth spaces, per quadrant

D7321

160.80

Alveoloplasty not in conjunction with extractions - one to three teeth or tooth spaces, per quadrant

D7340

357.60

Vestibuloplasty - ridge extension (second epithelialization)

D7350

1,760.00

Vestibuloplasty - ridge extension (including soft tissue grafts, muscle reattachments, revision of soft tissue attachment and management of hytrophied and hyperplastic tissue

D7410

200.00

Excision of benign lesion up to 1.25 cm

D7411

400.80

Excision of benign lesion greater than 1.25 cm

D7465

56.00

Destruction of lesion(s) by physical or chemical method, by report

D7471

236.00

Removal of lateral exostosis (maxilla or mandible)

D7473

400.00

Removal of torus mandibularis

D7510

148.00

Incision and drainage of abscess - intraoral soft tissue

D7511

236.00

Incision and drainage of abscess - intraoral soft tissue - complicated (includes drainage of multiple fascial spaces)

D7520

80.00

Incision and drainage of abscess - extraoral soft tissue

D7530

60.00

Removal of foreign body from mucosa, skin, or subcutaneous alveolar tissue

D7550

244.00

Partial ostectomy/sequestrectomy for removal of nonvital bone

D7670

80.00

Alveolus-closed reduction, may include stabilization of teeth

D7740

796.00

Mandible-closed reduction

D7820

192.00

Closed reduction of dislocation

D7830

960.00

Manipulation under anesthesia

D7880

356.00

Occlusal orthotic appliance

D7881

380.00

TMD therapy

D7911

12.00

Complicated suture - up to 5 cm

D7960

380.00

Frenulectomy (frenectomy or frenotomy) - separate procedure

D7963

557.60

Frenuloplasty

D8010

243.20

Limited orthodontic treatment of the primary dentition

D8020

353.60

Limited orthodontic treatment of the transitional dentition

D8030

200.00

Limited orthodontic treatment of the adolescent dentition

D8040

333.60

Limited orthodontic treatment of the adult dentition

D8050

333.60

Interceptive orthodontic treatment of the primary dentition

D8060

373.60

Interceptive orthodontic treatment of the transitional dentition

D8070

316.80

Comprehensive orthodontic treatment of the transitional dentition

D8080

323.20

Comprehensive orthodontic treatment of the adolescent dentition

D8090

323.20

Comprehensive orthodontic treatment of the adult dentition

D8210

280.00

Removable appliance therapy

D8220

360.00

Fixed appliance therapy

D8660

244.00

Preorthodontic treatment visit

D8670

300.00

Periodic orthodontic treatment visit (as part of contract)

D8680

308.00

Orthodontic retention (removal of appliances, construction and placement of retainer(s))

D8690

200.00

Orthodontic treatment (alternative billing to a contract fee)

D8691

76.00

Repair of orthodontic appliance

D8692

200.00

Replacement of lost or broken retainer

D9110

75.20

Palliative (emergency) treatment of dental pain - minor procedure

D9120

120.00

Fixed partial denture sectioning

D9220

248.00

Deep sedation/general anesthesia - first 30 minutes

D9221

132.00

Deep sedation/general anesthesia - each additional 15 minutes

D9230

52.00

Analgesia, anxiolysis, inhalation of nitrous oxide

D9241

240.00

Intravenous conscious sedation/analgesia - first 30 minutes

D9242

116.00

Intravenous conscious sedation/analgesia - each additional 15 minutes

D9310

64.00

Consultation-diagnostic service provided by dentist or physician other than requesting dentist or physician

D9910

27.20

Application of desensitizing medicament

D9940

333.60

Occlusal guards, by report

D9942

100.00

Repair and/or reline of occlusal guard

D9952

220.00

Occlusal adjustment - complete

(6) Durable Medical Equipment, Prosthetics/Orthotics, and Supplies.

Code

Fee Nu

Fee Ue

Fee RR

114.3 CMR 40.06(6) - DMEPOS Description

A4216

0.45

Sterile water, saline and/or dextrose, diluent/flush, 10 ml

A4217

2.66

Sterile water/saline, 500 ml

A4221

22.64

Supplies for maintenance of drug infusion catheter, per week (list drug separately)

A4222

46.73

Infusion supplies for external drug infusion pump, per cassette or bag (list drugs separately)

A4233

0.80

Replacement battery, alkaline (other than J cell), for use with medically necessary home blood glucose monitor owned by patient, each

A4234

3.63

Replacement battery, alkaline, J cell, for use with medically necessary home blood glucose monitor owned by patient, each

A4235

2.34

Replacement battery, lithium, for use with medically necessary home blood glucose monitor owned by patient, each

A4236

1.68

Replacement battery, silver oxide, for use with medically necessary home blood glucose monitor owned by patient, each

A4253

36.94

Blood glucose test or reagent strips for home blood glucose monitor, per 50 strips

A4255

3.91

Platforms for home blood glucose monitor, 50 per box

A4256

11.44

Normal, low, and high calibrator solution/chips

A4257

12.75

Replacement lens shield cartridge for use with laser skin piercing device, each

A4258

18.05

Spring-powered device for lancet, each

A4259

10.83

Lancets, per box of 100

A4265

3.39

Paraffin, per pound

A4280

5.45

Adhesive skin support attachment for use with external breast prosthesis, each

A4310

7.72

Insertion tray without drainage bag and without catheter (accessories only)

A4311

13.97

Insertion tray without drainage bag with indwelling catheter, Foley type, two-way latex with coating (Teflon, silicone, silicone elastomer or hydrophilic, etc.)

A4312

15.33

Insertion tray without drainage bag with indwelling catheter, Foley type, two-way, all silicone

A4313

15.74

Insertion tray without drainage bag with indwelling catheter, Foley type, three-way, for continuous irrigation

A4314

21.50

Insertion tray with drainage bag with indwelling catheter, Foley type, two-way latex with coating (Teflon, silicone, silicone elastomer or hydrophilic, etc.)

A4315

22.43

Insertion tray with drainage bag with indwelling catheter, Foley type, two-way, all silicone

A4316

28.40

Insertion tray with drainage bag with indwelling catheter, Foley type, three-way, for continuous irrigation

A4320

5.33

Irrigation tray with bulb or piston syringe, any purpose

A4321

I.C

Therapeutic agent for urinary catheter irrigation

A4322

3.04

Irrigation syringe, bulb or piston, each

A4326

10.37

Male external catheter with integral collection chamber, any type, each

A4327

42.27

Female external urinary collection device; meatal cup, each

A4328

8.88

Female external urinary collection device; pouch, each

A4330

7.15

Perianal fecal collection pouch with adhesive, each

A4331

3.18

Extension drainage tubing, any type, any length, with connector/adaptor, for use with urinary leg bag or urostomy pouch, each

A4332

0.12

Lubricant, individual sterile packet, each

A4333

2.20

Urinary catheter anchoring device, adhesive skin attachment, each

A4334

4.93

Urinary catheter anchoring device, leg strap, each

A4338

12.26

Indwelling catheter; Foley type, two-way latex with coating (Teflon, silicone, silicone elastomer, or hydrophilic, etc.), each

A4340

31.75

Indwelling catheter; specialty type, (eg, Coude, mushroom, wing, etc.), each

A4344

15.20

Indwelling catheter, Foley type, two-way, all silicone, each

A4346

19.59

Indwelling catheter; Foley type, three-way for continuous irrigation, each

A4349

2.02

Male external catheter, with or without adhesive, disposable, each

A4351

1.81

Intermittent urinary catheter; straight tip, with or without coating (Teflon, silicone, silicone elastomer, or hydrophilic, etc.), each

A4352

6.42

Intermittent urinary catheter; Coude (curved) tip, with or without coating (Teflon, silicone, silicone elastomeric, or hydrophilic, etc.), each

A4353

6.99

Intermittent urinary catheter, with insertion supplies

A4354

11.80

Insertion tray with drainage bag but without catheter

A4355

7.57

Irrigation tubing set for continuous bladder irrigation through a three-way indwelling Foley catheter, each

A4356

38.79

External urethral clamp or compression device (not to be used for catheter clamp), each

A4357

8.25

Bedside drainage bag, day or night, with or without anti-reflux device, with or without tube, each

A4358

6.63

Urinary drainage bag, leg or abdomen, vinyl, with or without tube, with straps, each

A4361

17.83

Ostomy faceplate, each

A4362

2.94

Skin barrier; solid, 4 x 4 or equivalent; each

A4363

2.36

Ostomy clamp, any type, replacement only, each

A4364

2.89

Adhesive, liquid, or equal, any type, per oz.

A4365

11.32

Adhesive remover wipes, any type, per 50

A4366

1.30

Ostomy vent, any type, each

A4367

6.62

Ostomy belt, each

A4368

0.26

Ostomy filter, any type, each

A4369

2.42

Ostomy skin barrier, liquid (spray, brush, etc.), per oz.

A4371

3.65

Ostomy skin barrier, powder, per oz.

A4372

4.18

Ostomy skin barrier, solid 4 x 4 or equivalent, standard wear, with built-in convexity, each

A4373

6.28

Ostomy skin barrier, with flange (solid, flexible or accordion), with built-in convexity, any size, each

A4375

17.18

Ostomy pouch, drainable, with faceplate attached, plastic, each

A4376

47.58

Ostomy pouch, drainable, with faceplate attached, rubber, each

A4377

4.29

Ostomy pouch, drainable, for use on faceplate, plastic, each

A4378

30.75

Ostomy pouch, drainable, for use on faceplate, rubber, each

A4379

15.02

Ostomy pouch, urinary, with faceplate attached, plastic, each

A4380

37.33

Ostomy pouch, urinary, with faceplate attached, rubber, each

A4381

4.61

Ostomy pouch, urinary, for use on faceplate, plastic, each

A4382

24.62

Ostomy pouch, urinary, for use on faceplate, heavy plastic, each

A4383

28.19

Ostomy pouch, urinary, for use on faceplate, rubber, each

A4384

9.62

Ostomy faceplate equivalent, silicone ring, each

A4385

5.10

Ostomy skin barrier, solid 4 x 4 or equivalent, extended wear, without built-in convexity, each

A4387

I.C

Ostomy pouch, closed, with barrier attached, with built-in convexity (one piece), each

A4388

4.36

Ostomy pouch, drainable, with extended wear barrier attached, (one piece), each

A4389

6.22

Ostomy pouch, drainable, with barrier attached, with built-in convexity (one piece), each

A4390

9.61

Ostomy pouch, drainable, with extended wear barrier attached, with built-in convexity (one piece), each

A4391

7.07

Ostomy pouch, urinary, with extended wear barrier attached (one piece), each

A4392

8.18

Ostomy pouch, urinary, with standard wear barrier attached, with built-in convexity (one piece), each

A4393

9.04

Ostomy pouch, urinary, with extended wear barrier attached, with built-in convexity (one piece), each

A4394

2.58

Ostomy deodorant, with or without lubricant, for use in ostomy pouch, per fluid ounce

A4395

0.05

Ostomy deodorant for use in ostomy pouch, solid, per tablet

A4396

40.48

Ostomy belt with peristomal hernia support

A4397

4.07

Irrigation supply; sleeve, each

A4398

13.56

Ostomy irrigation supply; bag, each

A4399

12.26

Ostomy irrigation supply; cone/catheter, including brush

A4400

48.87

Ostomy irrigation set

A4402

1.36

Lubricant, per oz.

A4404

1.69

Ostomy ring, each

A4405

3.40

Ostomy skin barrier, nonpectin-based, paste, per oz.

A4406

5.74

Ostomy skin barrier, pectin-based, paste, per oz.

A4407

8.76

Ostomy skin barrier, with flange (solid, flexible, or accordion), extended wear, with built-in convexity, 4 x 4 in. or smaller, each

A4408

9.87

Ostomy skin barrier, with flange (solid, flexible or accordion), extended wear, with built-in convexity, larger than 4 x 4 in., each

A4409

6.22

Ostomy skin barrier, with flange (solid, flexible or accordion), extended wear, without built-in convexity, 4 x 4 in. or smaller, each

A4410

9.04

Ostomy skin barrier, with flange (solid, flexible or accordion), extended wear, without built-in convexity, larger than 4 x 4 in., each

A4411

5.10

Ostomy skin barrier, solid 4 x 4 or equivalent, extended wear, with built-in convexity, each

A4412

2.70

Ostomy pouch, drainable, high output, for use on a barrier with flange (two piece system), without filter, each

A4413

5.50

Ostomy pouch, drainable, high output, for use on a barrier with flange (two piece system), with filter, each

A4414

4.93

Ostomy skin barrier, with flange (solid, flexible or accordion), without built-in convexity, 4 x 4 in. or smaller, each

A4415

6.00

Ostomy skin barrier, with flange (solid, flexible or accordion), without built-in convexity, larger than 4 x 4 in., each

A4416

A4417

2.75

3.72

Ostomy pouch, closed, with barrier attached, with filter (one piece), each Ostomy pouch, closed, with barrier attached, with built-in convexity, with filter (one piece), each

A4418

1.81

Ostomy pouch, closed; without barrier attached, with filter (one piece), each

A4419

1.74

Ostomy pouch, closed; for use on barrier with

nonlocking flange, with filter (two piece), each

A4420

I.C

Ostomy pouch, closed; for use on barrier with locking

flange (two piece), each

A4422

0.12

Ostomy absorbent material (sheet/pad/crystal packet)

for use in ostomy pouch to thicken liquid stomal

output, each

A4423

1.86

Ostomy pouch, closed; for use on barrier with locking

A4424

4.75

flange, with filter (two piece), each Ostomy pouch, drainable, with barrier attached, with

A4425

3.58

filter (one piece), each Ostomy pouch, drainable; for use on barrier with

A4426

2.73

nonlocking flange, with filter (two piece system), each Ostomy pouch, drainable; for use on barrier with

A4427

2.78

locking flange (two piece system), each Ostomy pouch, drainable; for use on barrier with

A4428

6.51

locking flange, with filter (two piece system), each Ostomy pouch, urinary, with extended wear barrier

attached, with faucet-type tap with valve (one piece), each

A4429

8.25

Ostomy pouch, urinary, with barrier attached, with built-in convexity, with faucet-type tap with valve

A4430

8.52

(one piece), each Ostomy pouch, urinary, with extended wear barrier

attached, with built-in convexity, with faucet-type tap with valve (one piece), each

A4431

6.22

Ostomy pouch, urinary; with barrier attached, with faucet-type tap with valve (one piece), each

A4432

3.59

Ostomy pouch, urinary; for use on barrier with nonlocking flange, with faucet-type tap with valve

A4433

3.34

(two piece), each Ostomy pouch, urinary; for use on barrier with

A4434

3.76

locking flange (two piece), each Ostomy pouch, urinary; for use on barrier with

locking flange, with faucet-type tap with valve (two piece), each

A4455

1.43

Adhesive remover or solvent (for tape, cement or other adhesive), per oz.

A4461

A4463

3.29

13.31

Surgical dressing holder, nonreusable, each Surgical dressing holder, reusable, each

A4481

A4483

0.37 I.C

Tracheostoma filter, any type, any size, each Moisture exchanger, disposable, for use with invasive

A4556

10.32

mechanical ventilation Electrodes (eg, apnea monitor), per pair

A4557

A4558

21.10

4.63

Lead wires (eg, apnea monitor), per pair Conductive gel or paste, for use with electrical device

A4559

0.10

(eg, TENS, NMES), per oz.

Coupling gel or paste, for use with ultrasound device,

A4561

19.95

per oz.

Pessary, rubber, any type

A4562

49.68

Pessary, nonrubber, any type

A4595

28.81

Electrical stimulator supplies, two lead, per month, (eg, TENS, NMES)

A4604

66.81

Tubing with integrated heating element for use with positive airway pressure device

A4605

16.40

Tracheal suction catheter, closed system, each

A4608

58.15

Transtracheal oxygen catheter, each

A4611

196.45

147.34

20.37

Battery, heavy duty; replacement for patient-owned ventilator

A4612

79.93

60.95

8.14

Battery cables; replacement for patient-owned ventilator

A4613

122.58

88.65

12.27

Battery charger; replacement for patient-owned ventilator

A4614

23.78

Peak expiratory flow rate meter, hand held

A4615

0.83

Cannula, nasal

A4616

0.08

Tubing (oxygen), per foot

A4617

3.59

Mouthpiece

A4618

8.89

6.67

1.02

Breathing circuits

A4619

1.21

Face tent

A4620

0.69

Variable concentration mask

A4623

6.55

Tracheostomy, inner cannula

A4624

2.24

Tracheal suction catheter, any type other than closed system, each

A4625

5.89

Tracheostomy care kit for new tracheostomy

A4626

3.19

Tracheostomy cleaning brush, each

A4628

3.74

Oropharyngeal suction catheter, each

A4629

4.63

Tracheostomy care kit for established tracheostomy

A4630

6.25

Replacement batteries, medically necessary,

transcutaneous electrical stimulator, owned by patient

A4633

41.04

Replacement bulb/lamp for ultraviolet light therapy system, each

A4635

5.12

3.39

0.69

Underarm pad, crutch, replacement, each

A4636

4.21

3.07

0.43

Replacement, handgrip, cane, crutch, or walker, each

A4637

2.13

1.61

0.30

Replacement, tip, cane, crutch, walker, each

A4638

I.C

I.C

I.C

Replacement battery for patient-owned ear pulse generator, each

A4639

287.21

Replacement pad for infrared heating pad system, each

A4640

63.32

44.86

6.45

Replacement pad for use with medically necessary alternating pressure pad owned by patient

A5051

2.07

Ostomy pouch, closed; with barrier attached (one piece), each

A5052

1.49

Ostomy pouch, closed; without barrier attached (one piece), each

A5053

1.49

Ostomy pouch, closed; for use on faceplate, each

A5054

1.79

Ostomy pouch, closed; for use on barrier with flange (two piece), each

A5055

1.44

Stoma cap

A5061

3.52

Ostomy pouch, drainable; with barrier attached, (one piece), each

A5062

2.22

Ostomy pouch, drainable; without barrier attached (one piece), each

A5063

2.70

Ostomy pouch, drainable; for use on barrier with flange (two piece system), each

A5071

6.01

Ostomy pouch, urinary; with barrier attached (one piece), each

A5072

3.52

Ostomy pouch, urinary; without barrier attached (one piece), each

A5073

3.18

Ostomy pouch, urinary; for use on barrier with flange (two piece), each

A5081

3.30

Continent device; plug for continent stoma

A5082

11.89

Continent device; catheter for continent stoma

A5083

I.C.

Continent device, stoma absorptive cover for continent stoma

A5093

1.95

Ostomy accessory; convex insert

A5102

22.42

Bedside drainage bottle, with or without tubing, rigid or expandable, each

A5105

34.65

Urinary suspensory with leg bag, with or without tube, each

A5112

29.93

Urinary leg bag; latex

A5113

4.47

Leg strap; latex, replacement only, per set

A5114

A5121

7.60

7.39

Leg strap; foam or fabric, replacement only, per set Skin barrier; solid, 6 x 6 or equivalent, each

A5122

10.92

Skin barrier; solid, 8 x 8 or equivalent, each

A5126

1.32

Adhesive or nonadhesive; disk or foam pad

A5131

15.86

Appliance cleaner, incontinence and ostomy appliances, per 16 oz.

A5200

11.30

Percutaneous catheter/tube anchoring device, adhesive skin attachment

A5500

63.58

For diabetics only, fitting (including follow-up), custom preparation and supply of off-the-shelf depth-inlay shoe manufactured to accommodate multi-density insert(s), per shoe

A5501

190.71

For diabetics only, fitting (including follow-up), custom preparation and supply of shoe molded from cast(s) of patient's foot (custom molded shoe), per shoe

A5503

28.28

For diabetics only, modification (including fitting) of off-the-shelf depth-inlay shoe or custom molded shoe with roller or rigid rocker bottom, per shoe

A5504

28.28

For diabetics only, modification (including fitting) of off-the-shelf depth-inlay shoe or custom molded shoe with wedge(s), per shoe

A5505

28.28

For diabetics only, modification (including fitting) of off-the-shelf depth-inlay shoe or custom molded shoe with metatarsal bar, per shoe

A5506

28.28

For diabetics only, modification (including fitting) of off-the-shelf depth-inlay shoe or custom molded shoe with off-set heel(s), per shoe

A5507

28.28

For diabetics only, not otherwise specified modification (including fitting) of off-the-shelf depth-inlay shoe or custom molded shoe, per shoe

A5512

25.94

For diabetics only, multiple density insert, direct formed, molded to foot after external heat source of 230 degrees Fahrenheit or higher, total contact with patient's foot, including arch, base layer minimum of ¼ inch material of shore a 35 durometer or 3/16 inch material

A5513

38.71

For diabetics only, multiple density insert, custom molded from model of patient's foot, total contact with patient's foot, including arch, base layer minimum of 3/16 inch material of shore a 35 durometer or higher, includes arch filler and other shaping

A6010

30.96

Collagen based wound filler, dry form, per gram of collagen

A6011

2.28

Collagen based wound filler, gel/paste, per gram of collagen

A6021

21.02

Collagen dressing, pad size 16 sq. in. or less, each

A6022

21.02

Collagen dressing, pad size more than 16 sq. in. but less than or equal to 48 sq. in., each

A6023

190.30

Collagen dressing, pad size more than 48 square inches, each

A6024

6.19

Collagen dressing wound filler, per 6 in.

A6154

14.38

Wound pouch, each

A6196

7.35

Alginate or other fiber gelling dressing, wound cover, pad size 16 sq. in. or less, each dressing

A6197

16.44

Alginate or other fiber gelling dressing, wound cover, pad size more than 16 sq. in. but less than or equal to 48 sq. in., each dressing

A6199

5.29

Alginate or other fiber gelling dressing, wound filler, per 6 in.

A6203

3.35

Composite dressing, pad size 16 sq. in. or less, with any size adhesive border, each dressing

A6204

6.23

Composite dressing, pad size more than 16 sq. in. but less than or equal to 48 sq. in., with any size adhesive border, each dressing

A6207

7.34

Contact layer, more than 16 sq. in. but less than or equal to 48 sq. in., each dressing

A6209

7.48

Foam dressing, wound cover, pad size 16 sq. in. or less, without adhesive border, each dressing

A6210

19.92

Foam dressing, wound cover, pad size more than 16 sq. in. but less than or equal to 48 sq. in., without adhesive border, each dressing

A6211

29.37

Foam dressing, wound cover, pad size more then 48 sq. in., without adhesive border, each dressing

A6212

9.70

Foam dressing, wound cover, pad size 16 sq. in. or less, with any size adhesive border, each dressing

A6214

10.29

Foam dressing, wound cover, pad size more than 48 sq. in., with any size adhesive border, each dressing

A6216

0.05

Gauze, nonimpregnated, nonsterile, pad size 16 sq. in. or less, without adhesive border, each dressing

A6217

I.C.

Gauze, nonimpregnated, nonsterile, pad size more than 16 sq. in. but less than or equal to 48 sq. in., without adhesive border, each dressing

A6219

0.95

Gauze, nonimpregnated, pad size 16 sq. in. or less, with any size adhesive border, each dressing

A6220

2.58

Gauze, nonimpregnated, pad size more than 16 sq. in. but less than or equal to 48 sq. in., with any size adhesive border, each dressing

A6222

2.13

Gauze, impregnated with other than water, normal saline, or hydrogel, pad size 16 sq. in. or less, without adhesive border, each dressing

A6223

2.42

Gauze, impregnated with other than water, normal saline, or hydrogel, pad size more than 16 sq. in. but less than or equal to 48 sq. in., without adhesive border, each dressing

A6224

3.61

Gauze, impregnated with other than water, normal saline, or hydrogel, pad size more than 48 sq. in., without adhesive border, each dressing

A6229

3.61

Gauze, impregnated, water or normal saline, pad size more than 16 sq. in. but less than or equal to 48 sq. in., without adhesive border, each dressing

A6231

4.66

Gauze, impregnated, hydrogel, for direct wound contact, pad size 16 sq. in. or less, each dressing

A6232

6.88

Gauze, impregnated, hydrogel, for direct wound contact, pad size greater than 16 sq. in., but less than or equal to 48 sq. in., each dressing

A6233

19.19

Gauze, impregnated, hydrogel for direct wound contact, pad size more than 48 sq. in., each dressing

A6234

6.54

Hydrocolloid dressing, wound cover, pad size 16 sq. in. or less, without adhesive border, each dressing

A6235

16.82

Hydrocolloid dressing, wound cover, pad size more than 16 sq. in. but less than or equal to 48 sq. in., without adhesive border, each dressing

A6236

27.25

Hydrocolloid dressing, wound cover, pad size more than 48 sq. in., without adhesive border, each dressing

A6237

7.91

Hydrocolloid dressing, wound cover, pad size 16 sq. in. or less, with any size adhesive border, each dressing

A6238

22.79

Hydrocolloid dressing, wound cover, pad size more than 16 sq. in. but less than or equal to 48 sq. in., with any size adhesive border, each dressing

A6240

12.24

Hydrocolloid dressing, wound filler, paste, per fl. oz.

A6241

2.57

Hydrocolloid dressing, wound filler, dry form, per gm

A6242

6.07

Hydrogel dressing, wound cover, pad size 16 sq. in. or less, without adhesive border, each dressing

A6243

12.31

Hydrogel dressing, wound cover, pad size more than 16 sq. in. but less than or equal to 48 sq. in., without adhesive border, each dressing

A6244

39.28

Hydrogel dressing, wound cover, pad size more than 48 sq. in., without adhesive border, each dressing

A6245

7.27

Hydrogel dressing, wound cover, pad size 16 sq. in. or less, with any size adhesive border, each dressing

A6246

9.92

Hydrogel dressing, wound cover, pad size more than 16 sq. in. but less than or equal to 48 sq. in., with any size adhesive border, each dressing

A6247

23.78

Hydrogel dressing, wound cover, pad size more than 48 sq. in., with any size adhesive border, each dressing

A6248

16.24

Hydrogel dressing, wound filler, gel, per fl. oz.

A6251

1.99

Specialty absorptive dressing, wound cover, pad size 16 sq. in. or less, without adhesive border, each dressing

A6252

3.25

Specialty absorptive dressing, wound cover, pad size more than 16 sq. in. but less than or equal to 48 sq. in., without adhesive border, each dressing

A6253

6.34

Specialty absorptive dressing, wound cover, pad size more than 48 sq. in., without adhesive border, each dressing

A6254

1.21

Specialty absorptive dressing, wound cover, pad size 16 sq. in. or less, with any size adhesive border, each dressing

A6255

3.03

Specialty absorptive dressing, wound cover, pad size more than 16 sq. in. but less than or equal to 48 sq. in., with any size adhesive border, each dressing

A6257

1.53

Transparent film, 16 sq. in. or less, each dressing

A6258

4.30

Transparent film, more than 16 sq. in. but less than or equal to 48 sq. in., each dressing

A6259

10.94

Transparent film, more than 48 sq. in., each dressing

A6266

1.92

Gauze, impregnated, other than water, normal saline, or zinc paste, any width, per linear yd.

A6402

0.12

Gauze, nonimpregnated, sterile, pad size 16 sq. in. or less, without adhesive border, each dressing

A6403

0.43

Gauze, nonimpregnated, sterile, pad size more than 16 sq. in. but less than or equal to 48 sq. in., without adhesive border, each dressing

A6407

1.88

Packing strips, nonimpregnated, up to two in. in width, per linear yd.

A6410

0.39

Eye pad, sterile, each

A6411

I.C.

Eye pad, non-sterile, each

A6441

0.67

Padding bandage, nonelastic, nonwoven/nonknitted, width greater than or equal to three in. and less than five in., per yd.

A6442

0.17

Conforming bandage, nonelastic, knitted/woven, nonsterile, width less than three in., per yd.

A6443

0.29

Conforming bandage, nonelastic, knitted/woven, nonsterile, width greater than or equal to three in. and less than five in., per yd.

A6444

0.56

Conforming bandage, nonelastic, knitted/woven, nonsterile, width greater than or equal to five in., per yd.

A6445

0.32

Conforming bandage, nonelastic, knitted/woven, sterile, width less than three in., per yd.

A6446

0.41

Conforming bandage, nonelastic, knitted/woven, sterile, width greater than or equal to three in. and less than five in., per yd.

A6447

0.67

Conforming bandage, nonelastic, knitted/woven, sterile, width greater than or equal to five in., per yd.

A6448

1.16

Light compression bandage, elastic, knitted/woven, width less than three in., per yd.

A6449

1.75

Light compression bandage, elastic, knitted/woven, width greater than or equal to three in. and less than five in., per yd.

A6450

I.C.

Light compression bandage, elastic, knitted/woven, width greater than or equal to five inches, per yard

A6451

I.C.

Moderate compression bandage, elastic,

knitted/woven, load resistance of 1.25 to 1.34 foot pounds at 50% maximum stretch, width greater than or equal to three in. and less than five in., per yd.

A6452

5.91

High compression bandage, elastic, knitted/woven, load resistance greater than or equal to 1.35 foot pounds at 50% maximum stretch, width greater than or equal to three in. and less than five in., per yd.

A6453

0.61

Self-adherent bandage, elastic, nonknitted/nonwoven, width less than three in., per yd.

A6454

0.77

Self-adherent bandage, elastic, nonknitted/nonwoven, width greater than or equal to three in. and less than five in., per yard

A6455

1.39

Self-adherent bandage, elastic, nonknitted/nonwoven, width greater than or equal to five in., per yd.

A6456

1.28

Zinc paste impregnated bandage, nonelastic, knitted/woven, width greater than or equal to 3 in. and less than 5 in., per yd.

A6457

1.14

Tubular dressing with or without elastic, any width, per linear yard

A6501

AI +20%

Compression burn garment, bodysuit (head to foot), custom fabricated

A6502

AI +20%

Compression burn garment, chin strap, custom fabricated

A6503

AI +20%

Compression burn garment, facial hood, custom fabricated

A6504

AI +20%

Compression burn garment, glove to wrist, custom fabricated

A6505

AI +20%

Compression burn garment, glove to elbow, custom fabricated

A6506

AI +20%

Compression burn garment, glove to axilla, custom fabricated

A6507

AI +20%

Compression burn garment, foot to knee length, custom fabricated

A6508

AI +20%

Compression burn garment, foot to thigh length, custom fabricated

A6509

AI +20%

Compression burn garment, upper trunk to waist including arm openings (vest), custom fabricated

A6510

AI +20%

Compression burn garment, trunk, including arms down to leg openings (leotard), custom fabricated

A6511

AI +20%

Compression burn garment, lower trunk including leg openings (panty), custom fabricated

A6513

AI +20%

Compression burn mask, face and/or neck, plastic or equal, custom fabricated

A6531

43.27

Gradient compression stocking, below knee, 30-40 mm Hg, each

A6532

60.96

Gradient compression stocking, below knee, 40-50 mm Hg, each

A6550

27.42

Wound care set, for negative pressure wound therapy electrical pump, includes all supplies and accessories

A7000

8.75

Canister, disposable, used with suction pump, each

A7001

31.30

Canister, nondisposable, used with suction pump, each

A7002

3.63

Tubing, used with suction pump, each

A7003

2.74

Administration set, with small volume nonfiltered pneumatic nebulizer, disposable

A7004

1.55

Small volume nonfiltered pneumatic nebulizer, disposable

A7005

29.20

Administration set, with small volume nonfiltered pneumatic nebulizer, nondisposable

A7006

8.54

Administration set, with small volume filtered pneumatic nebulizer

A7007

4.18

Large volume nebulizer, disposable, unfilled, used with aerosol compressor

A7008

11.00

Large volume nebulizer, disposable, prefilled, used with aerosol compressor

A7009

39.79

Reservoir bottle, nondisposable, used with large volume ultrasonic nebulizer

A7010

23.59

Corrugated tubing, disposable, used with large volume nebulizer, 100 ft.

A7012

3.76

Water collection device, used with large volume nebulizer

A7013

0.78

Filter, disposable, used with aerosol compressor

A7014

4.24

Filter, nondisposable, used with aerosol compressor or

ultrasonic generator

A7015

1.72

Aerosol mask, used with DME nebulizer

A7016

6.85

Dome and mouthpiece, used with small volume

ultrasonic nebulizer

A7017

134.04

100.52

13.40

Nebulizer, durable, glass or autoclavable plastic,

bottle type, not used with oxygen

A7018

0.38

Water, distilled, used with large volume nebulizer,

1000 ml

A7025

434.94

High frequency chest wall oscillation system vest,

replacement for use with patient owned equipment,

each

A7026

28.75

High frequency chest wall oscillation system hose,

replacement for use with patient owned equipment,

each

A7027

179.35

Combination oral/nasal mask, used with continuous

positive airway pressure device, each

A7028

49.54

Oral cushion for combination oral/nasal mask,

replacement only, each

A7029

20.24

Nasal pillows for combination oral/nasal mask,

replacement only, pair

A7030

188.64

Full face mask used with positive airway pressure

device, each

A7031

69.77

Face mask interface, replacement for full face mask,

each

A7032

40.53

Cushion for use on nasal mask interface, replacement

only, each

A7033

28.41

Pillow for use on nasal cannula type interface,

replacement only, pair

A7034

117.64

Nasal interface (mask or cannula type) used with

positive airway pressure device, with or without head

strap

A7035

37.16

Headgear used with positive airway pressure device

A7036

18.20

Chinstrap used with positive airway pressure device

A7037

41.02

Tubing used with positive airway pressure device

A7038

4.58

Filter, disposable, used with positive airway pressure

device

A7039

15.33

Filter, nondisposable, used with positive airway

pressure device

A7040

39.48

One way chest drain valve

A7041

74.19

Water seal drainage container and tubing for use with

implanted chest tube

A7042

177.41

Implanted pleural catheter, each

A7043

28.11

Vacuum drainage bottle and tubing for use with

implanted catheter

A7044

120.91

Oral interface used with positive airway pressure

device, each

A7045

19.47

14.60

1.95

Exhalation port with or without swivel used with

accessories for positive airway devices, replacement

only

A7046

19.51

Water chamber for humidifier, used with positive

airway pressure device, replacement, each

A7501

105.03

Tracheostoma valve, including diaphragm, each

A7502

49.91

Replacement diaphragm/faceplate for tracheostoma

valve, each

A7503

11.33

Filter holder or filter cap, reusable, for use in a tracheostoma heat and moisture exchange system, each

A7504

0.67

Filter for use in a tracheostoma heat and moisture exchange system, each

A7505

4.68

Housing, reusable without adhesive, for use in a heat and moisture exchange system and/or with a tracheostoma valve, each

A7506

0.33

Adhesive disc for use in a heat and moisture exchange system and/or with tracheostoma valve, any type each

A7507

2.49

Filter holder and integrated filter without adhesive, for use in a tracheostoma heat and moisture exchange system, each

A7508

2.87

Housing and integrated adhesive, for use in a tracheostoma heat and moisture exchange system and/or with a tracheostoma valve, each

A7509

1.41

Filter holder and integrated filter housing, and adhesive, for use as a tracheostoma heat and moisture exchange system, each

A7520

47.48

Tracheostomy/laryngectomy tube, noncuffed, polyvinylchloride (PVC), silicone or equal, each

A7521

47.05

Tracheostomy/laryngectomy tube, cuffed, polyvinylchloride (PVC), silicone or equal, each

A7522

45.16

Tracheostomy/laryngectomy tube, stainless steel or equal (sterilizable and reusable), each

A7524

77.40

Tracheostoma stent/stud/button, each

A7525

2.07

Tracheostomy mask, each

A7526

3.37

Tracheostomy tube collar/holder, each

A7527

3.58

Tracheostomy/laryngectomy tube plug/stop, each

A8000

153.35

115.03

15.33

Helmet, protective, soft, prefabricated, includes all components and accessories

A8001

153.35

115.03

15.33

Helmet, protective, hard, prefabricated, includes all components and accessories

A8002

AI +70%

Helmet, protective, soft, custom fabricated, includes all components and accessories

A8003

AI +70%

Helmet, protective, hard, custom fabricated, includes all components and accessories

A8004

I.C.

I.C.

I.C.

Soft interface for helmet, replacement only

E0100

20.29

15.20

5.31

Cane, includes canes of all materials, adjustable or fixed, with tip

E0105

48.46

36.35

7.53

Cane, quad or three-prong, includes canes of all materials, adjustable or fixed, with tips

E0110

77.59

58.18

15.99

Crutches, forearm, includes crutches of various materials, adjustable or fixed, pair, complete with tips and handgrips

E0111

53.26

41.10

8.43

Crutch, forearm, includes crutches of various materials, adjustable or fixed, each, with tip and handgrip

E0112

31.45

24.00

8.44

Crutches, underarm, wood, adjustable or fixed, pair, with pads, tips and handgrips

E0113

21.13

15.86

5.15

Crutch, underarm, wood, adjustable or fixed, each, with pad, tip and handgrip

E0114

40.11

30.32

7.28

Crutches, underarm, other than wood, adjustable or fixed, pair, with pads, tips and handgrips

E0116

27.74

20.88

4.59

Crutch, underarm, other than wood, adjustable or fixed, with pad, tip, handgrip, with or without shock absorber, each

E0117

192.71

144.55

19.26

Crutch, underarm, articulating, spring assisted, each

E0130

64.70

48.52

14.30

Walker, rigid (pickup), adjustable or fixed height

E0135

83.84

64.32

14.67

Walker, folding (pickup), adjustable or fixed height

E0140

360.71

270.54

36.08

Walker, with trunk support, adjustable or fixed height, any type

E0141

114.09

85.57

19.01

Walker, rigid, wheeled, adjustable or fixed height

E0143

120.23

89.98

18.35

Walker, folding, wheeled, adjustable or fixed height

E0144

318.45

203.01

27.08

Walker, enclosed, four sided framed, rigid or folding, wheeled with posterior seat

E0147

574.81

431.13

57.48

Walker, heavy duty, multiple braking system, variable wheel resistance

E0148

127.05

95.28

12.72

Walker, heavy duty, without wheels, rigid or folding, any type, each

E0149

223.20

167.39

22.32

Walker, heavy duty, wheeled, rigid or folding, any type

E0153

58.97

44.23

6.66

Platform attachment, forearm crutch, each

E0154

65.40

49.06

7.28

Platform attachment, walker, each

E0155

31.56

24.05

3.85

Wheel attachment, rigid pick-up walker, per pair

E0156

26.43

19.85

3.38

Seat attachment, walker

E0157

81.92

61.45

8.99

Crutch attachment, walker, each

E0158

32.18

24.12

3.55

Leg extensions for walker, per set of four

E0159

17.81

13.38

1.80

Brake attachment for wheeled walker, replacement, each

E0160

33.06

24.77

3.96

Sitz type bath or equipment, portable, used with or without commode

E0161

22.30

16.69

3.57

Sitz type bath or equipment, portable, used with or without commode, with faucet attachment(s)

E0162

145.70

113.00

15.29

Sitz bath chair

E0163

102.25

76.67

20.77

Commode chair, mobile or stationary, with fixed arms

E0165

15.79

Commode chair, mobile or stationary, with detachable

arms

E0167

12.00

9.04

1.07

Pail or pan for use with commode chair, replacement only

E0168

150.92

113.18

15.17

Commode chair, extra wide and/or heavy duty, stationary or mobile, with or without arms, any type, each

E0170

160.72

Commode chair with integrated seat lift mechanism, electric, any type

E0171

28.92

Commode chair with integrated seat lift mechanism, non-electric, any type

E0175

64.98

48.74

6.51

Foot rest, for use with commode chair, each

E0181

26.06

Powered pressure reducing mattress overlay/pad, alternating, with pump, includes heavy duty

E0182

22.25

Pump for alternating pressure pad, for replacement only

E0184

194.70

149.32

23.78

Dry pressure mattress

E0185

319.86

245.48

44.94

Gel or gel-like pressure pad for mattress, standard mattress length and width

E0186

17.26

Air pressure mattress

E0187

19.73

Water pressure mattress

E0188

22.47

16.87

2.64

Synthetic sheepskin pad

E0189

51.96

38.98

5.31

Lambswool sheepskin pad, any size

E0191

9.99

7.46

1.02

Heel or elbow protector, each

E0193

903.46

Powered air flotation bed (low air loss therapy)

E0194

3,254.34

Air fluidized bed

E0196

27.62

Gel pressure mattress

E0197

188.34

165.44

25.98

Air pressure pad for mattress, standard mattress length and width

E0198

188.34

142.92

19.51

Water pressure pad for mattress, standard mattress length and width

E0199

28.30

21.21

2.82

Dry pressure pad for mattress, standard mattress length and width

E0200

67.39

50.57

9.15

Heat lamp, without stand (table model), includes bulb, or infrared element

E0202

60.28

Phototherapy (bilirubin) light with photometer

E0205

164.95

123.71

18.14

Heat lamp, with stand, includes bulb, or infrared element

E0210

32.64

24.48

2.66

Electric heat pad, standard

E0215

60.21

45.17

6.30

Electric heat pad, moist

E0217

496.47

372.32

55.28

Water circulating heat pad with pump

E0220

7.20

5.38

0.76

Hot water bottle

E0225

330.35

247.76

32.56

Hydrocollator unit, includes pads

E0230

7.21

5.39

0.81

Ice cap or collar

E0235

15.76

Paraffin bath unit, portable (see medical supply code A4265 for paraffin)

E0236

44.25

Pump for water circulating pad

E0238

22.98

16.90

2.61

Nonelectric heat pad, moist

E0239

449.83

337.39

44.99

Hydrocollator unit, portable

E0249

99.60

74.70

10.95

Pad for water circulating heat unit

E0250

97.76

Hospital bed, fixed height, with any type side rails, with mattress

E0251

74.08

Hospital bed, fixed height, with any type side rails, without mattress

E0255

117.48

Hospital bed, variable height, hi-lo, with any type side rails, with mattress

E0256

83.35

Hospital bed, variable height, hi-lo, with any type side rails, without mattress

E0260

140.46

Hospital bed, semi-electric (head and foot adjustment), with any type side rails, with mattress

E0261

136.94

Hospital bed, semi-electric (head and foot adjustment), with any type side rails, without mattress

E0265

199.88

Hospital bed, total electric (head, foot, and height adjustments), with any type side rails, with mattress

E0266

177.59

Hospital bed, total electric (head, foot, and height adjustments), with any type side rails, without

mattress

E0271

222.04

173.46

23.06

Mattress, innerspring

E0272

202.37

151.05

21.13

Mattress, foam rubber

E0275

14.57

10.94

1.46

Bed pan, standard, metal or plastic

E0276

11.31

8.94

1.51

Bed pan, fracture, metal or plastic

E0277

703.47

Powered pressure-reducing air mattress

E0280

36.58

27.42

3.65

Bed cradle, any type

E0290

74.74

Hospital bed, fixed height, without side rails, with mattress

E0291

54.30

Hospital bed, fixed height, without side rails, without mattress

E0292

84.04

Hospital bed, variable height, hi-lo, without side rails, with mattress

E0293

71.51

Hospital bed, variable height, hi-lo, without side rails, without mattress

E0294

130.65

Hospital bed, semi-electric (head and foot adjustment), without side rails, with mattress

E0295

127.35

Hospital bed, semi-electric (head and foot adjustment), without side rails, without mattress

E0296

164.20

Hospital bed, total electric (head, foot, and height adjustments), without side rails, with mattress

E0297

140.67

Hospital bed, total electric (head, foot, and height adjustments), without side rails, without mattress

E0300

2,838.62

2,128.96

283.86

Pediatric crib, hospital grade, fully enclosed

E0301

270.72

Hospital bed, heavy duty, extra wide, with weight capacity greater than 350 pounds, but less than or equal to 600 pounds, with any type side rails, without

mattress

E0302

715.44

Hospital bed, extra heavy duty, extra wide, with weight capacity greater than 600 pounds, with any type side rails, without mattress

E0303

303.98

Hospital bed, heavy duty, extra wide, with weight capacity greater than 350 pounds, but less than or equal to 600 pounds, with any type side rails, with

mattress

E0304

770.67

Hospital bed, extra heavy duty, extra wide, with weight capacity greater than 600 pounds, with any type side rails, with mattress

E0305

17.79

Bedside rails, half-length

E0310

185.02

138.77

22.76

Bedside rails, full-length

E0316

211.28

Safety enclosure frame/canopy for use with hospital bed, any type

E0325

10.11

6.69

1.51

Urinal; male, jug-type, any material

E0326

10.50

7.87

1.19

Urinal; female, jug-type, any material

E0371

444.48

Nonpowered advanced pressure reducing overlay for mattress, standard mattress length and width

E0372

539.34

Powered air overlay for mattress, standard mattress length and width

E0373

614.47

Nonpowered advanced pressure reducing mattress

E0424

199.28

Stationary compressed gaseous oxygen system, rental; includes container, contents, regulator, flowmeter, humidifier, nebulizer, cannula or mask, and tubing

E0431

31.79

Portable gaseous oxygen system, rental; includes portable container, regulator, flowmeter, humidifier, cannula or mask, and tubing

E0434

31.79

Portable liquid oxygen system, rental; includes portable container, supply reservoir, humidifier, flowmeter, refill adaptor, contents gauge, cannula or mask, and tubing

E0439

199.28

Stationary liquid oxygen system, rental; includes container, contents, regulator, flowmeter, humidifier, nebulizer, cannula or mask, & tubing

E0441

77.45

Oxygen contents, gaseous (for use with owned gaseous stationary systems or when both a stationary and portable gaseous system are owned), one month's supply = 1 unit

E0442

77.45

Oxygen contents, liquid (for use with owned liquid stationary systems or when both a stationary and portable liquid system are owned), one month's supply = 1 unit

E0443

77.45

Portable oxygen contents, gaseous (for use only with portable gaseous systems when no stationary gas or liquid system is used), one month's supply = 1 unit

E0444

77.45

Portable oxygen contents, liquid (for use only with portable liquid systems when no stationary gas or liquid system is used), one month's supply = 1 unit

E0450

954.52

Volume control ventilator, without pressure support mode, may include pressure control mode, used with invasive interface (eg, tracheostomy tube)

E0457

614.51

460.85

61.45

Chest shell (cuirass)

E0459

50.89

Chest wrap

E0460

623.53

Negative pressure ventilator; portable or stationary

E0462

247.69

Rocking bed, with or without side rails

E0463

1,406.38

Pressure support ventilator with volume control mode, may include pressure control mode, used with invasive interface (eg, tracheostomy tube)

E0464

1,406.38

Pressure support ventilator with volume control mode, may include pressure control mode, used with noninvasive interface (eg, mask)

E0470

231.77

Respiratory assist device, bi-level pressure capability, without backup rate feature, used with noninvasive interface, eg, nasal or facial mask (intermittent assist device with continuous positive airway pressure device)

E0471

642.17

Respiratory assist device, bi-level pressure capability, with back-up rate feature, used with noninvasive interface, eg, nasal or facial mask (intermittent assist device with continuous positive airway pressure device)

E0472

642.17

Respiratory assist device, bi-level pressure capability, with backup rate feature, used with invasive interface, eg, tracheostomy tube (intermittent assist device with continuous positive airway pressure device)

E0480

43.94

Percussor, electric or pneumatic, home model

E0482

430.02

Cough stimulating device, alternating positive and negative airway pressure

E0483

1,063.13

High frequency chest wall oscillation air-pulse generator system, (includes hoses and vest), each

E0484

36.92

27.70

3.69

Oscillatory positive expiratory pressure device,

nonelectric, any type, each

E0485

AI + 50%

Oral device/appliance used to reduce upper airway collapsibility, adjustable or non-adjustable, prefabricated, includes fitting and adjustment

E0486

AI + 70%

Oral device/appliance used to reduce upper airway collapsibility, adjustable or non-adjustable, custom fabricated, includes fitting and adjustment

E0486

AI + 70%

Oral device/appliance used to reduce upper airway collapsibility, adjustable or non-adjustable, custom fabricated, includes fitting and adjustment

E0486

AI + 70%

Oral device/appliance used to reduce upper airway collapsibility, adjustable or non-adjustable, custom fabricated, includes fitting and adjustment

E0500

109.77

IPPB machine, all types, with built-in nebulization; manual or automatic valves; internal or external power source

E0550

42.61

Humidifier, durable for extensive supplemental humidification during IPPB treatments or oxygen delivery

E0560

171.52

128.64

20.10

Humidifier, durable for supplemental humidification during IPPB treatment or oxygen delivery

E0561

107.00

80.24

10.69

Humidifier, nonheated, used with positive airway pressure device

E0562

301.22

225.91

30.11

Humidifier, heated, used with positive airway pressure device

E0565

61.01

Compressor, air power source for equipment which is not self-contained or cylinder driven

E0570

16.11

Nebulizer, with compressor

E0571

29.97

Aerosol compressor, battery powered, for use with small volume nebulizer

E0572

38.09

Aerosol compressor, adjustable pressure, light duty for intermittent use

E0574

40.26

Ultrasonic/electronic aerosol generator with small volume nebulizer

E0575

102.78

Nebulizer, ultrasonic, large volume

E0580

134.04

100.52

13.40

Nebulizer, durable, glass or autoclavable plastic, bottle type, for use with regulator or flowmeter

E0585

29.81

Nebulizer, with compressor and heater

E0600

45.79

Respiratory suction pump, home model, portable or stationary, electric

E0601

96.99

Continuous airway pressure (CPAP) device

E0602

29.52

22.14

2.96

Breast pump, manual, any type

E0605

26.43

19.85

2.66

Vaporizer, room type

E0606

22.94

Postural drainage board

E0607

66.82

50.10

6.68

Home blood glucose monitor

E0610

202.18

151.66

21.33

Pacemaker monitor, self-contained, (checks battery depletion, includes audible and visible check systems)

E0615

478.82

359.12

58.50

Pacemaker monitor, self-contained, checks battery depletion and other pacemaker components, includes digital/visible check systems

E0617

304.05

External defibrillator with integrated electrocardiogram analysis

E0617

337.57

External defibrillator with integrated electrocardiogram analysis

E0618

280.35

Apnea monitor, without recording feature

E0619

I.C.

Apnea monitor, with recording feature

E0620

874.39

655.79

87.43

Skin piercing device for collection of capillary blood, laser, each

E0621

95.99

72.36

9.25

Sling or seat, patient lift, canvas or nylon

E0627

337.32

253.00

33.74

Seat lift mechanism incorporated into a combination lift-chair mechanism

E0628

337.32

253.00

33.74

Separate seat lift mechanism for use with patient owned furniture - electric

E0629

330.71

248.01

33.08

Separate seat lift mechanism for use with patient owned furniture - nonelectric

E0630

101.89

Patient lift, hydraulic or mechanical, includes any seat, sling, strap(s), or pad(s)

E0635

122.36

Patient lift, electric, with seat or sling

E0636

1,054.56

Multipositional patient support system, with integrated lift, patient accessible controls

E0650

720.22

540.16

88.87

Pneumatic compressor, nonsegmental home model

E0651

780.66

585.50

92.49

Pneumatic compressor, segmental home model without calibrated gradient pressure

E0652

5,301.45

3,972.53

445.36

Pneumatic compressor, segmental home model with calibrated gradient pressure

E0655

101.75

76.30

10.78

Nonsegmental pneumatic appliance for use with pneumatic compressor, half arm

E0660

158.24

118.68

14.14

Nonsegmental pneumatic appliance for use with pneumatic compressor, full leg

E0665

136.99

102.88

13.22

Nonsegmental pneumatic appliance for use with pneumatic compressor, full arm

E0666

138.08

103.59

14.23

Nonsegmental pneumatic appliance for use with pneumatic compressor, half leg

E0667

275.20

206.41

36.56

Segmental pneumatic appliance for use with pneumatic compressor, full leg

E0668

441.88

331.42

43.61

Segmental pneumatic appliance for use with pneumatic compressor, full arm

E0669

174.06

130.56

17.41

Segmental pneumatic appliance for use with pneumatic compressor, half leg

E0671

415.35

311.50

41.54

Segmental gradient pressure pneumatic appliance, full leg

E0672

322.73

242.06

32.28

Segmental gradient pressure pneumatic appliance, full arm

E0673

268.17

201.15

26.82

Segmental gradient pressure pneumatic appliance, half leg

E0675

384.55

Pneumatic compression device, high pressure, rapid inflation/deflation cycle, for arterial insufficiency (unilateral or bilateral system)

E0691

898.59

673.94

89.86

Ultraviolet light therapy system panel, includes bulbs/lamps, timer, and eye protection; treatment area 2 sq. ft. or less

E0692

1,128.37

846.29

112.83

Ultraviolet light therapy system panel, includes bulbs/lamps, timer, and eye protection, 4 ft. panel

E0693

1,390.98

1,043.24

139.10

Ultraviolet light therapy system panel, includes bulbs/lamps, timer, and eye protection, 6 ft. panel

E0694

4,427.34

3,320.53

442.73

Ultraviolet multidirectional light therapy system in 6 ft. cabinet, includes bulbs/lamps, timer, and eye protection

E0705

54.89

40.36

5.61

Transfer device, any type, each

E0720

367.58

Transcutaneous electrical nerve stimulation (TENS) device, two lead, localized stimulation

E0730

370.56

Transcutaneous electrical nerve stimulation (TENS) device, four or more leads, for multiple nerve stimulation

E0731

303.19

Form-fitting conductive garment for delivery of TENS or NMES (with conductive fibers separated from the patient's skin by layers of fabric)

E0740

522.87

392.18

52.29

Incontinence treatment system, pelvic floor stimulator, monitor, sensor, and/or trainer

E0744

91.57

Neuromuscular stimulator for scoliosis

E0745

89.51

Neuromuscular stimulator, electronic shock unit

E0747

3,328.66

2,473.13

330.78

Osteogenesis stimulator, electrical, noninvasive, other than spinal applications

E0748

3,890.70

2,918.04

389.07

Osteogenesis stimulator, electrical, noninvasive, spinal applications

E0749

284.37

Osteogenesis stimulator, electrical, surgically implanted

E0760

3,233.10

2,424.83

323.32

Osteogenesis stimulator, low intensity ultrasound,

noninvasive

E0762

934.63

700.95

93.47

Transcutaneous electrical joint stimulation device system, includes all accessories

E0764

11,066.82

8,300.12

1,106.67

Functional neuromuscular stimulator, transcutaneous stimulation of muscles of ambulation with computer control, used for walking by spinal cord injured, entire system, after completion of training program

E0765

84.13

63.12

8.43

FDA approved nerve stimulator, with replaceable batteries, for treatment of nausea and vomiting

E0776

143.16

105.33

18.65

IV pole

E0779

16.73

Ambulatory infusion pump, mechanical, reusable, for infusion eight hours or greater

E0780

10.37

Ambulatory infusion pump, mechanical, reusable, for infusion less than eight hours

E0781

225.14

Ambulatory infusion pump, single or multiple channels, electric or battery operated, with administrative equipment, worn by patient

E0782

3,649.40

2,737.06

364.96

Infusion pump, implantable, non-programmable (includes all components, eg, pump, catheter, connectors, etc.)

E0783

8,186.91

6,140.19

818.70

Infusion pump system, implantable, programmable (includes all components, eg, pump, catheter, connectors, etc.)

E0784

417.57

External ambulatory infusion pump, insulin

E0785

472.50

Implantable intraspinal (epidural/intrathecal) catheter used with implantable infusion pump, replacement

E0786

7,697.60

5,773.22

769.76

Implantable programmable infusion pump,

replacement (excludes implantable intraspinal catheter)

E0791

316.20

Parenteral infusion pump, stationary, single, or multi-channel

E0840

73.28

54.93

14.53

Traction frame, attached to headboard, cervical traction

E0849

515.31

386.46

51.53

Traction equipment, cervical, free-standing stand/frame, pneumatic, applying traction force to other than mandible

E0850

105.06

78.80

12.27

Traction stand, freestanding, cervical traction

E0855

502.63

376.96

50.26

Cervical traction equipment not requiring additional stand or frame

E0856

I.C.

I.C.

I.C.

Cervical traction device, cervical collar with inflatable air bladder

E0860

38.53

29.51

6.51

Traction equipment, overdoor, cervical

E0870

116.31

87.62

13.40

Traction frame, attached to footboard, extremity traction (eg, Buck's)

E0880

125.54

95.02

19.71

Traction stand, freestanding, extremity traction (eg, Buck's)

E0890

120.41

96.99

32.83

Traction frame, attached to footboard, pelvic traction

E0900

128.12

96.12

27.62

Traction stand, freestanding, pelvic traction (eg, Buck's)

E0910

20.00

Trapeze bars, also known as Patient Helper, attached to bed, with grab bar

E0911

49.85

Trapeze bar, heavy duty, for patient weight capacity greater than 250 pounds, attached to bed, with grab bar

E0912

114.47

Trapeze bar, heavy duty, for patient weight capacity greater than 250 pounds, free standing, complete with grab bar

E0920

46.14

Fracture frame, attached to bed, includes weights

E0930

45.69

Fracture frame, freestanding, includes weights

E0935

22.73

Continuous passive motion exercise device for use on knee only

E0940

34.77

Trapeze bar, freestanding, complete with grab bar

E0941

36.90

Gravity assisted traction device, any type

E0942

19.85

14.88

1.99

Cervical head harness/halter

E0944

45.88

34.40

3.97

Pelvic belt/harness/boot

E0945

44.32

34.31

3.77

Extremity belt/harness

E0946

59.16

Fracture frame, dual with cross bars, attached to bed (eg, Balken, Four Poster)

E0947

606.46

454.84

62.89

Fracture frame, attachments for complex pelvic traction

E0948

586.59

413.70

58.64

Fracture frame, attachments for complex cervical traction

E0950

88.36

66.27

8.85

Wheelchair accessory, tray, each

E0951

17.08

12.80

1.96

Heel loop/holder, any type, with or without ankle strap, each

E0952

16.89

12.66

1.96

Toe loop/holder, any type, each

E0955

202.18

151.63

20.23

Wheelchair accessory, headrest, cushioned, any type, including fixed mounting hardware, each

E0956

98.58

73.93

9.87

Wheelchair accessory, lateral trunk or hip support, any type, including fixed mounting hardware, each

E0957

137.93

103.45

13.79

Wheelchair accessory, medial thigh support, any type, including fixed mounting hardware, each

E0958

37.09

Manual wheelchair accessory, one-arm drive attachment, each

E0959

44.21

33.46

3.91

Manual wheelchair accessory, adapter for amputee, each

E0960

90.98

68.24

9.10

Wheelchair accessory, shoulder harness/straps or chest strap, including any type mounting hardware

E0961

29.74

12.63

2.64

Manual wheelchair accessory, wheel lock brake extension (handle), each

E0966

71.37

53.52

6.62

Manual wheelchair accessory, headrest extension, each

E0967

65.69

49.25

6.57

Manual wheelchair accessory, hand rim with projections, any type, each

E0968

16.94

Commode seat, wheelchair

E0969

156.63

117.48

13.22

Narrowing device, wheelchair

E0971

43.39

32.56

4.34

Manual wheelchair accessory, anti-tipping device, each

E0973

114.97

86.23

9.31

Wheelchair accessory, adjustable height, detachable armrest, complete assembly, each

E0974

74.07

55.54

7.06

Manual wheelchair accessory, anti-rollback device, each

E0978

42.70

31.66

4.28

Wheelchair accessory, positioning belt/safety belt/pelvic strap, each

E0980

33.06

24.66

3.30

Safety vest, wheelchair

E0981

47.15

35.70

4.08

Wheelchair accessory, seat upholstery, replacement only, each

E0982

51.53

38.64

4.38

Wheelchair accessory, back upholstery, replacement only, each

E0983

249.93

Manual wheelchair accessory, power add-on to convert manual wheelchair to motorized wheelchair, joystick control

E0984

1,760.94

1,320.70

176.09

Manual wheelchair accessory, power add-on to convert manual wheelchair to motorized wheelchair, tiller control

E0985

202.85

152.12

20.30

Wheelchair accessory, seat lift mechanism

E0986

4,864.24

3,648.20

486.43

Manual wheelchair accessory, push activated power assist, each

E0990

117.43

91.75

13.22

Wheelchair accessory, elevating leg rest, complete assembly, each

E0992

95.15

71.37

7.92

Manual wheelchair accessory, solid seat insert

E0994

17.63

13.23

1.78

Armrest, each

E0995

25.84

19.36

2.66

Wheelchair accessory, calf rest/pad, each

E1002

4,053.21

3,039.90

405.32

Wheelchair accessory, power seating system, tilt only

E1003

4,391.30

3,293.48

439.14

Wheelchair accessory, power seating system, recline only, without shear reduction

E1004

4,869.05

3,651.77

486.90

Wheelchair accessory, power seating system, recline only, with mechanical shear reduction

E1005

5,270.36

3,952.78

527.03

Wheelchair accessory, power seatng System, recline only, with power shear reduction

E1006

6,455.70

4,841.78

645.55

Wheelchair accessory, power seating system, combination tilt and recline, without shear reduction

E1007

8,741.27

6,555.94

874.13

Wheelchair accessory, power seating system, combination tilt and recline, with mechanical shear reduction

E1008

8,742.05

6,556.55

874.20

Wheelchair accessory, power seating system, combination tilt and recline, with power shear reduction

E1009

AI + 35%

I.C.

I.C.

Wheelchair accessory, addition to power seating system, mechanically linked leg elevation system, including pushrod and leg rest, each

E1010

1,143.79

857.86

114.38

Wheelchair accessory, addition to power seating system, power leg elevation system, including leg rest, pair

E1011

I.C.

I.C.

I.C.

Modification to pediatric size wheelchair, width adjustment package (not to be dispensed with initial chair)

E1014

365.14

273.85

36.52

Reclining back, addition to pediatric size wheelchair

E1015

114.70

86.02

11.46

Shock absorber for manual wheelchair, each

E1016

131.31

98.48

13.14

Shock absorber for power wheelchair, each

E1017

AI + 35%

I.C.

I.C.

Heavy duty shock absorber for heavy duty or extra heavy duty manual wheelchair, each

E1018

AI + 35%

I.C.

I.C.

Heavy duty shock absorber for heavy duty or extra heavy duty power wheelchair, each

E1020

243.41

182.55

24.32

Residual limb support system for wheelchair

E1028

206.54

154.89

20.65

Wheelchair accessory, manual swingaway, retractable or removable mounting hardware for joystick, other control interface or positioning accessory

E1029

369.54

277.15

36.95

Wheelchair accessory, ventilator tray, fixed

E1030

1,165.27

873.96

116.53

Wheelchair accessory, ventilator tray, gimbaled

E1031

49.09

Rollabout chair, any and all types with castors five in. or greater

E1035

613.20

Multi-positional patient transfer system, with integrated seat, operated by care giver

E1037

108.49

Transport chair, pediatric size

E1038

18.03

Transport chair, adult size, patient weight capacity up to and including 300 pounds

E1039

34.20

Transport chair, adult size, heavy duty, patient weight capacity greater than 300 pounds

E1050

86.56

Fully reclining wheelchair; fixed full-length arms, swing-away, detachable, elevating legrests

E1060

126.07

Fully reclining wheelchair; detachable arms, desk, or full-length, swing-away, detachable, elevating leg rests

E1070

109.53

Fully reclining wheelchair; detachable arms, desk or full-length, swing-away, detachable footrests

E1083

72.72

Hemi-wheelchair; fixed full-length arms, swing-away, detachable, elevating legrests

E1084

96.57

Hemi-wheelchair; detachable arms, desk, or full-length, swing-away, detachable, elevating leg rests

E1087

126.51

High-strength lightweight wheelchair; fixed full-length arms, swing-away, detachable, elevating legrests

E1088

150.77

High strength lightweight wheelchair, detachable arms desk or full length, swing away detachable elevating leg rests

E1092

109.23

Wide heavy duty wheel chair, detachable arms (desk or full length), swing away detachable elevating leg rests

E1093

93.94

Wide, heavy-duty wheelchair; detachable arms, desk or full-length arms, swing-away, detachable footrests

E1100

103.81

Semi-reclining wheelchair, fixed full-length arms, swing away detachable elevating leg rests

E1110

101.66

Semi-reclining wheelchair; detachable arms, desk or full-length, elevating legrest

E1150

81.58

Wheelchair, detachable arms, desk or full-length swing away detachable elevating leg rests

E1160

62.50

Wheelchair, fixed full-length arms, swing away detachable elevating leg rests

E1161

2,366.09

1,774.57

236.61

Manual adult size wheelchair, includes tilt in space

E1170

89.31

Amputee wheelchair, fixed full-length arms, swing away detachable elevating leg rests

E1171

80.15

Amputee wheelchair, fixed full-length arms, without footrests or leg rest

E1172

97.95

Amputee wheelchair, detachable arms (desk or full-length) without footrests or leg rest

E1180

101.34

Amputee wheelchair, detachable arms (desk or full-length) swing away detachable foot rests

E1190

107.92

Amputee wheelchair, detachable arms (desk or full-length) swing away detachable elevating leg rests

E1195

125.63

Heavy duty wheelchair, fixed full-length arms, swing away detachable elevating leg rests

E1200

87.01

Amputee wheelchair, fixed full-length arms, swing away detachable footrest

E1221

47.51

Wheelchair with fixed arm, footrests

E1222

67.79

Wheelchair with fixed arm, elevating leg rests

E1223

74.02

Wheelchair with detachable arms, footrests

E1224

81.15

Wheelchair with detachable arms, elevating leg rests

E1225

38.42

Wheelchair accessory, manual semi-reclining back, (recline greater than 15 degrees, but less than 80 degrees), each

E1226

463.80

347.82

47.74

Wheelchair accessory, manual fully reclining back, (recline greater than 80 degrees), each

E1227

E1228

235.88

176.93

23.59

28.02

Special height arms for wheelchair Special back height for wheelchair

E1230

2,261.79

1,788.81

222.45

Power operated vehicle (three- or four-wheel nonhighway), specify brand name and model number

E1240

103.02

Lightweight wheelchair, detachable arms, (desk or full length) swing away detachable, elevating leg rest

E1270

78.94

Lightweight wheelchair, fixed full length arms, swing away detachable elevating leg rests

E1280

131.26

Heavy duty wheelchair, detachable arms (desk or full length) elevating leg rests

E1295

121.47

Heavy duty wheelchair, fixed full length arms, elevating leg rest

E1296

491.67

368.75

49.94

Special wheelchair seat height from floor

E1297

88.92

66.68

9.88

Special wheelchair seat depth, by upholstery

E1298

360.10

270.07

36.85

Special wheelchair seat depth and/or width, by construction

E1310

1,825.29

1,368.97

156.12

Whirlpool, nonportable (built-in type)

E1353

32.87

Regulator

E1355

24.75

Stand/rack

E1372

163.03

120.68

23.69

Immersion external heater for nebulizer

E1390

199.28

Oxygen concentrator, single delivery port, capable of delivering 85% or greater oxygen concentration at the prescribed flow rate

E1391

199.28

Oxygen concentrator, dual delivery port, capable of delivering 85% or greater oxygen concentration at the prescribed flow rate, each

E1392

51.63

Portable oxygen concentrator, rental

E1405

229.09

Oxygen and water vapor enriching system with heated delivery

E1406

215.39

Oxygen and water vapor enriching system without heated delivery

E1700

312.39

234.31

31.23

Jaw motion rehabilitation system

E1701

10.37

Replacement cushions for jaw motion rehabilitation system, package of six

E1702

22.57

Replacement measuring scales for jaw motion rehabilitation system, package of 200

E1800

104.13

Dynamic adjustable elbow extension/flexion device, includes soft interface material

E1801

129.00

Static progressive stretch elbow device, extension and/or flexion, with or without range of motion adjustment, includes all components and accessories

E1802

326.80

Dynamic adjustable forearm pronation/supination device, includes soft interface material

E1805

126.34

Dynamic adjustable wrist extension/flexion device, includes soft interface material

E1806

105.91

Static progressive stretch wrist device, flexion and/or extension, with or without range of motion adjustment, includes all components and accessories

E1810

105.89

Dynamic adjustable knee extension/flexion device, includes soft interface material

E1811

134.12

Static progressive stretch knee device, extension and/or flexion, with or without range of motion adjustment, includes all components and accessories

E1812

85.99

Dynamic knee, extension/flexion device with active resistance control

E1815

126.34

Dynamic adjustable ankle extension/flexion device, includes soft interface material

E1816

136.24

Static progressive stretch ankle device, flexion and/or extension, with or without range of motion adjustment, includes all components and accessories

E1818

139.09

Static progressive stretch forearm pronation/supination device, with or without range of motion adjustment, includes all components and accessories

E1820

81.74

61.31

8.17

Replacement soft interface material, dynamic adjustable extension/flexion device

E1821

105.25

78.95

10.51

Replacement soft interface material/cuffs for bi-directional static progressive stretch device

E1825

126.34

Dynamic adjustable finger extension/flexion device, includes soft interface material

E1830

126.34

Dynamic adjustable toe extension/flexion device, includes soft interface material

E1840

382.71

Dynamic adjustable shoulder flexion/abduction/ rotation device, includes soft interface material

E1841

453.00

Static progressive stretch shoulder device, with or without range of motion adjustment, includes all components and accessories

E2000

51.83

Gastric suction pump, home model, portable or stationary, electric

E2100

643.19

482.40

64.32

Blood glucose monitor with integrated voice synthesizer

E2101

188.56

141.42

18.86

Blood glucose monitor with integrated lancing/blood sample

E2120

283.52

Pulse generator system for tympanic treatment of inner ear endolymphatic fluid

E2201

373.10

279.83

37.31

Manual wheelchair accessory, nonstandard seat frame, width greater than or equal to 20 inches and less than 24 inches

E2202

473.98

355.50

47.40

Manual wheelchair accessory, nonstandard seat frame width, 24-27 in.

E2203

479.05

359.28

47.89

Manual wheelchair accessory, nonstandard seat frame depth, 20 to less than 22 inches

E2204

813.40

610.05

81.35

Manual wheelchair accessory, nonstandard seat frame depth, 22 to 25 inches

E2205

32.67

24.52

3.25

Manual wheelchair accessory, handrim without projections (includes ergonomic or contoured), any type, replacement only, each

E2206

40.68

30.50

4.06

Manual wheelchair accessory, wheel Lock assembly, complete, each

E2207

43.35

32.51

4.34

Wheelchair accessory, crutch and cane holder, each

E2208

118.78

89.09

11.87

Wheelchair accessory, cylinder tank carrier, each

E2209

107.16

80.38

10.74

Accessory, arm trough, with or without hand support, each

E2210

6.55

4.92

0.56

Wheelchair accessory, bearings, any type, replacement only, each

E2211

40.91

29.30

3.96

Manual wheelchair accessory, pneumatic propulsion tire, any size, each

E2212

5.88

4.42

0.61

Manual wheelchair accessory, tube for pneumatic propulsion tire, any size, each

E2213

30.41

22.79

3.05

Manual wheelchair accessory, insert for pneumatic propulsion tire (removable), any type, any size, each

E2214

36.00

26.99

3.96

Manual wheelchair accessory, pneumatic caster tire, any size, each

E2215

9.60

7.18

0.95

Manual wheelchair accessory, tube for pneumatic caster tire, any size, each

E2216

AI + 30%

I.C.

I.C.

Manual wheelchair accessory, foam filled propulsion tire, any size, each

E2217

AI + 30%

I.C.

I.C.

Manual wheelchair accessory, foam filled caster tire, any size, each

E2218

AI + 30%

I.C.

I.C.

Manual wheelchair accessory, foam propulsion tire, any size, each

E2219

40.31

30.24

4.01

Manual wheelchair accessory, foam caster tire, any size, each

E2220

28.52

21.81

2.75

Manual wheelchair accessory, solid (rubber/plastic) propulsion tire, any size, each

E2221

25.55

19.18

2.58

Manual wheelchair accessory, solid (rubber/plastic) caster tire (removable), any size, each

E2222

21.06

15.81

2.09

Manual wheelchair accessory, solid (rubber/plastic) caster tire with integrated wheel, any size, each

E2223

5.61

4.21

0.56

Manual wheelchair accessory, valve, any type, replacement only, each

E2224

98.06

73.55

10.29

Manual wheelchair accessory, propulsion wheel excludes tire, any size, each

E2225

17.40

13.04

1.74

Manual wheelchair accessory, caster wheel excludes tire, any size, replacement only, each

E2226

37.94

28.46

3.79

Manual wheelchair accessory, caster fork, any size, replacement only, each

E2227

AI + 35%

I.C.

I.C.

Manual wheelchair accessory, gear reduction drive wheel, each

E2228

AI + 35%

I.C.

I.C.

Manual wheelchair accessory, wheel braking system and lock, complete, each

E2310

1,170.24

877.68

117.02

Power wheelchair accessory, electronic connection between wheelchair controller and one power seating system motor, including all related electronics, indicator feature, mechanical function selection switch, and fixed mounting hardware

E2311

2,369.20

1,776.90

236.93

Power wheelchair accessory, electronic connection between wheelchair controller and two or more power seating system motors, including all related electronics, indicator feature, mechanical function selection switch, and fixed mounting hardware

E2312

2,473.18

1,454.36

193.92

Power wheelchair accessory, hand or chin control interface, mini-proportional remote joystick, proportional, including fixed mounting hardware

E2312

1,939.18

1,854.88

193.92

Power wheelchair accessory, hand or chin control interface, mini-proportional remote joystick, proportional, including fixed mounting hardware

E2313

307.93

230.95

30.81

Power wheelchair accessory, harness for upgrade to expandable controller, including all fasteners, connectors and mounting hardware, each

E2321

2,231.00

1,673.25

223.10

Power wheelchair accessory, hand control interface, remote joystick, nonproportional, including all related electronics, mechanical stop switch, and fixed mounting hardware

E2322

1,410.36

1,771.94

236.26

Power wheelchair accessory, hand control interface, multiple mechanical switches, nonproportional, including all related electronics, mechanical stop switch, and fixed mounting hardware

E2323

69.16

51.87

6.92

Power wheelchair accessory, specialty joystick handle for hand control interface, prefabricated

E2323

69.16

51.87

6.92

Power wheelchair accessory, specialty joystick handle for hand control interface, prefabricated

E2323

69.16

51.87

6.92

Power wheelchair accessory, specialty joystick handle for hand control interface, prefabricated

E2324

43.82

32.87

4.37

Power wheelchair accessory, chin cup for chin control interface

E2324

43.82

32.87

4.37

Power wheelchair accessory, chin cup for chin control interface

E2324

43.82

32.87

4.37

Power wheelchair accessory, chin cup for chin control interface

E2325

1,346.83

1,010.13

134.70

Power wheelchair accessory, sip and puff interface, nonproportional, including all related electronics, mechanical stop switch, and manual swingaway mounting hardware

E2325

1,346.83

1,010.13

134.70

Power wheelchair accessory, sip and puff interface, nonproportional, including all related electronics, mechanical stop switch, and manual swingaway mounting hardware

E2325

1,346.83

1,010.13

134.70

Power wheelchair accessory, sip and puff interface, nonproportional, including all related electronics, mechanical stop switch, and manual swingaway mounting hardware

E2326

347.14

260.34

34.73

Power wheelchair accessory, breath tube kit for sip and puff interface

E2326

347.14

260.34

34.73

Power wheelchair accessory, breath tube kit for sip and puff interface

E2326

347.14

260.34

34.73

Power wheelchair accessory, breath tube kit for sip and puff interface

E2327

3,420.77

2,565.57

342.08

Power wheelchair accessory, head control interface, mechanical, proportional, including all related electronics, mechanical direction change switch, and fixed mounting hardware

E2328

4,955.32

3,716.50

495.52

Power wheelchair accessory, head control or extremity control interface, electronic, proportional, including all related electronics and fixed mounting hardware

E2329

1,766.13

1,324.60

176.61

Power wheelchair accessory, head control interface, contact switch mechanism, nonproportional, including all related electronics, mechanical stop switch, mechanical direction change switch, head array, and fixed mounting hardware

E2330

3,422.09

2,566.58

342.20

Power wheelchair accessory, head control interface, proximity switch mechanism, nonproportional, including all related electronics, mechanical stop switch, mechanical direction change switch, head array, and fixed mounting hardware

E2340

358.36

268.79

35.85

Power wheelchair accessory, nonstandard seat frame width, 20-23 in.

E2341

537.58

403.19

53.76

Power wheelchair accessory, nonstandard seat frame width, 24-27 in.

E2342

447.98

335.99

44.80

Power wheelchair accessory, nonstandard seat frame depth, 20 or 21 in.

E2343

716.78

537.58

71.67

Power wheelchair accessory, nonstandard seat frame depth, 22-25 in.

E2351

698.63

523.96

69.88

Power wheelchair accessory, electronic interface to operate speech generating device using power wheelchair control interface

E2360

112.34

84.26

11.29

Power wheelchair accessory, 22 NF nonsealed lead acid battery, each

E2361

139.47

104.62

13.95

Power wheelchair accessory, 22 NF sealed lead acid battery, each, (e.g., gel cell, absorbed glassmat)

E2362

91.98

68.98

9.20

Power wheelchair accessory, group 24 nonsealed lead acid battery, each

E2363

186.00

139.50

18.61

Power wheelchair accessory, group 24 sealed lead acid battery, each (e.g., gel cell, absorbed glassmat)

E2364

112.34

84.26

11.29

Power wheelchair accessory, U-1 nonsealed lead acid battery, each

E2365

112.17

84.15

11.22

Power wheelchair accessory, U-1 sealed lead acid battery, each (e.g., gel cell, absorbed glassmat)

E2366

263.62

197.72

26.43

Power wheelchair accessory, battery charger, single mode, for use with only one battery type, sealed or non-sealed, each

E2367

419.08

314.31

41.91

Power wheelchair accessory, battery charger, dual mode, for use with either battery type, sealed or nonsealed, each

E2368

516.57

387.44

51.67

Power wheelchair component, motor, replacement only

E2369

449.94

337.45

45.00

Power wheelchair component, gear box, replacement only

E2370

802.84

602.12

80.29

Power wheelchair component, motor and gear box combination, replacement only

E2371

150.74

113.06

15.08

Power wheelchair accessory, group 27 sealed lead acid battery, (e.g., gel cell, absorbed glassmat), each

E2372

AI + 35%

I.C.

I.C.

Power wheelchair accessory, group 27 nonsealed lead acid battery, each

E2373

1,209.93

907.47

121.00

Power wheelchair accessory, hand or chin control interface, compact remote joystick, proportional, including fixed mounting hardware

E2374

534.02

400.53

53.40

Power wheelchair accessory, hand or chin control interface, standard remote joystick (not including controller), proportional, including all related electronics and fixed mounting hardware, replacement only

E2375

856.56

642.40

85.65

Power wheelchair accessory, nonexpandable controller, including all related electronics and mounting hardware, replacement only

E2376

1,342.27

1,006.72

134.23

Power wheelchair accessory, expandable controller, including all related electronics and mounting hardware, replacement only

E2377

485.71

364.30

48.56

Power wheelchair accessory, expandable controller, including all related electronics and mounting hardware, upgrade provided at initial issue

E2381

76.18

57.14

7.63

Power wheelchair accessory, pneumatic drive wheel tire, any size, replacement only, each

E2382

20.77

15.57

2.07

Power wheelchair accessory, tube for pneumatic drive wheel tire, any size, replacement only, each

E2383

151.88

113.91

15.19

Power wheelchair accessory, insert for pneumatic drive wheel tire (removable), any type, any size, replacement only, each

E2384

80.91

60.68

8.11

Power wheelchair accessory, pneumatic caster tire, any size, replacement only, each

E2385

49.50

37.11

4.96

Power wheelchair accessory, tube for pneumatic caster tire, any size, replacement only, each

E2386

150.51

112.87

15.05

Power wheelchair accessory, foam filled drive wheel tire, any size, replacement only, each

E2387

67.49

50.65

6.75

Power wheelchair accessory, foam filled caster tire, any size, replacement only, each

E2388

50.39

37.80

5.04

Power wheelchair accessory, foam drive wheel tire, any size, replacement only, each

E2389

27.36

20.51

2.74

Power wheelchair accessory, foam caster tire, any size, replacement only, each

E2390

42.79

32.07

4.28

Power wheelchair accessory, solid (rubber/plastic) drive wheel tire, any size, replacement only, each

E2391

20.50

15.38

2.05

Power wheelchair accessory, solid (rubber/plastic) caster tire (removable), any size, replacement only, each

E2392

53.88

40.41

5.40

Power wheelchair accessory, solid (rubber/plastic) caster tire with integrated wheel, any size, replacement only, each

E2393

AI + 35%

I.C

I.C

Power wheelchair accessory, valve for pneumatic tire tube, any type, replacement only, each

E2394

76.75

57.57

7.69

Power wheelchair accessory, drive wheel excludes tire, any size, replacement only, each

E2395

54.55

40.93

5.46

Power wheelchair accessory, caster wheel excludes tire, any size, replacement only, each

E2396

64.07

48.07

7.13

Power wheelchair accessory, caster fork, any size, replacement only, each

E2397

E2402

AI + 35%

I.C

I.C

1,716.46

Power wheelchair accessory, lithium-based battery, each Negative pressure wound therapy electrical pump, stationary or portable

E2500

391.06

293.29

39.11

Speech generating device, digitized speech, using pre-recorded messages, less than or equal to eight minutes recording time

E2502

1,195.80

896.86

119.59

Speech generating device, digitized speech, using prerecorded messages, greater than eight minutes but less than or equal to 20 minutes recording time

E2504

1,577.42

1,183.05

157.76

Speech generating device, digitized speech, using prerecorded messages, greater than 20 minutes but less than or equal to 40 minutes recording time

E2506

2,312.96

1,734.69

231.29

Speech generating device, digitized speech, using prerecorded messages, greater than 40 minutes recording time

E2508

3,576.61

2,682.47

357.67

Speech generating device, synthesized speech, requiring message formulation by spelling and access by physical contact with the device

E2510

6,768.25

5,076.18

676.82

Speech generating device, synthesized speech, permitting multiple methods of message formulation and multiple methods of device access

E2511

AI + 30%

I.C

I.C

Speech generating software program, for personal computer or personal digital assistant

E2512

AI + 30%

I.C

I.C

Accessory for speech generating device, mounting system

E2601

61.16

45.87

6.13

General use wheelchair seat cushion, width less than 22 in., any depth

E2602

119.40

89.55

11.94

General use wheelchair seat cushion, width 22 in. or greater, any depth

E2603

151.59

113.69

15.17

Skin protection wheelchair seat cushion, width less than 22 in., any depth

E2604

188.41

141.33

18.83

Skin protection wheelchair seat cushion, width 22 in. or greater, any depth

E2605

269.17

201.91

26.93

Positioning wheelchair seat cushion, width less than 22 in., any depth

E2606

419.93

314.94

42.01

Positioning wheelchair seat cushion, width 22 in. or greater, any depth

E2607

289.85

217.39

28.99

Skin protection and positioning wheelchair seat cushion, width less than 22 in., any depth

E2608

348.09

261.07

34.80

Skin protection and positioning wheelchair seat cushion, width 22 in. or greater, any depth

E2611

312.35

234.29

31.23

General use wheelchair back cushion, width less than 22 in., any height, including any type mounting hardware

E2612

422.54

316.89

42.25

General use wheelchair back cushion, width 22 in. or greater, any height, including any type mounting hardware

E2613

393.04

294.78

39.31

Positioning wheelchair back cushion, posterior, width less than 22 in., any height, including any type mounting hardware

E2614

543.93

407.97

54.40

Positioning wheelchair back cushion, posterior, width 22 in. or greater, any height, including any type mounting hardware

E2615

452.32

339.23

45.24

Positioning wheelchair back cushion, posterior-lateral, width less than 22 in., any height, including any type mounting hardware

E2616

608.58

456.45

60.86

Positioning wheelchair back cushion, posterior-lateral, width 22 in. or greater, any height, including any type mounting hardware

E2619

51.32

38.51

5.13

Replacement cover for wheelchair seat cushion or back cushion, each

E2620

547.70

410.79

54.77

Positioning wheelchair back cushion, planar back with lateral supports, width less than 22 in., any height, including any type mounting hardware

E2621

574.76

431.08

57.47

Positioning wheelchair back cushion, planar back with lateral supports, width 22 in. or greater, any height, including any type mounting hardware

L0112

1,178.03

Cranial cervical orthosis, congenital torticollis type, with or without soft interface material, adjustable range of motion joint, custom fabricated

L0120

21.39

Cervical, flexible, nonadjustable (foam collar)

L0130

137.29

Cervical, flexible, thermoplastic collar, molded to patient

L0140

66.73

Cervical, semi-rigid, adjustable (plastic collar)

L0150

99.40

Cervical, semi-rigid, adjustable molded chin cup (plastic collar with mandibular/occipital piece)

L0160

168.38

Cervical, semi-rigid, wire frame occipital/mandibular support

L0170

663.10

Cervical, collar, molded to patient model

L0172

102.37

Cervical, collar, semi-rigid thermoplastic foam, two piece

L0174

295.33

Cervical, collar, semi-rigid, thermoplastic foam, two piece with thoracic extension

L0180

398.35

Cervical, multiple post collar, occipital/mandibular supports, adjustable

L0190

482.75

Cervical, multiple post collar, occipital/mandibular supports, adjustable cervical bars (SOMI, Guilford, Taylor types)

L0200

452.73

Cervical, multiple post collar, occipital/mandibular supports, adjustable cervical bars, and thoracic extension

L0210

39.84

Thoracic, rib belt

L0220

107.26

Thoracic, rib belt, custom fabricated

L0430

1,135.00

Spinal orthosis, anterior-posterior-lateral control, with interface material, custom fitted (DeWall Posture Protector only)

L0450

186.85

TLSO, flexible, provides trunk support, upper thoracic region, produces intracavitary pressure to reduce load on the intervertebral disks with rigid stays or panel(s), includes shoulder straps and closures, prefabricated, includes fitting and adjustment

L0452

AI + 70%.

TLSO, flexible, provides trunk support, upper thoracic region, produces intracavitary pressure to reduce load on the intervertebral disks with rigid stays or panel(s), includes shoulder straps and closures, custom fabricated

L0454

291.91

TLSO flexible, provides trunk support, extends from sacrococcygeal junction to above T-9 vertebra, restricts gross trunk motion in the sagittal plane, produces intracavitary pressure to reduce load on the intervertebral disks with rigid stays or panel(s), includes shoulder

L0456

837.12

TLSO, flexible, provides trunk support, thoracic region, rigid posterior panel and soft anterior apron, extends from the sacrococcygeal junction and terminates just inferior to the scapular spine, restricts gross trunk motion in the sagittal plane, produces intracavitary

L0458

750.63

TLSO, triplanar control, modular segmented spinal system, two rigid plastic shells, posterior extends from the sacrococcygeal junction and terminates just inferior to the scapular spine, anterior extends from the symphysis pubis to the xiphoid, soft liner restricts gross trunk motion in the sagittal, coronal, and transverse planes, lateral strength is provided by overlapping plastic and stabilizing closures, includes straps and closures, prefabricated, includes fitting and adjustment

L0460

844.88

TLSO, triplanar control, modular segmented spinal system, two rigid plastic shells, posterior extends from the sacrococcygeal junction and terminates just inferior to the scapular spine, anterior extends from the symphysis pubis to the sternal notch, soft liner, restricts gross trunk motion in the sagittal, coronal, and transverse planes, lateral strength is provided by overlapping plastic and stabilizing closures, includes straps and closures, prefabricated, includes fitting and adjustment

L0462

1,050.90

TLSO, triplanar control, modular segmented spinal system, three rigid plastic shells, posterior extends from the sacrococcygeal junction and terminates just inferior to the scapular spine, anterior extends from the symphysis pubis to the sternal notch, soft liner, restricts gross trunk motion in the sagittal, coronal, and transverse planes, lateral strength is provided by overlapping plastic and stabilizing closures, includes straps and closures, prefabricated, includes fitting and adjustment

L0464

1,251.08

TLSO, triplanar control, modular segmented spinal system, four rigid plastic shells, posterior extends from sacrococcygeal junction and terminates just inferior to scapular spine, anterior extends from symphysis pubis to the sternal notch, soft liner, restricts gross trunk motion in the sagittal, coronal, and transverse planes, lateral strength is provided by overlapping plastic and stabilizing closures, includes straps and closures, prefabricated, includes fitting and adjustment

L0466

347.54

TLSO, sagittal control, rigid posterior frame and flexible soft anterior apron with straps, closures and padding, restricts gross trunk motion in sagittal plane, produces intracavitary pressure to reduce load on intervertebral disks, includes fitting and shaping the frame, prefabricated, includes fitting and adjustment

L0468

449.08

TLSO, sagittal-coronal control, rigid posterior frame and flexible soft anterior apron with straps, closures and padding, extends from sacrococcygeal junction over scapulae, lateral strength provided by pelvic, thoracic, and lateral frame pieces, restricts gross trunk motion in sagittal, and coronal planes, produces intracavitary pressure to reduce load on intravertebral disks, includes fitting and shaping the frame, prefabricated, includes fitting and adjustment

L0470

637.80

TLSO, triplanar control, rigid posterior frame and flexible soft anterior apron with straps, closures and padding, extends from sacrococcygeal junction to scapula, lateral strength provided by pelvic, thoracic, and lateral frame pieces, rotational strength provided by subclavicular extensions, restricts gross trunk motion in the sagittal, coronal, and transverse planes, produces intracavitary pressure to reduce load on intravertebral disks, includes fitting and shaping the frame, prefabricated, includes fitting and adjustment

L0472

388.61

TLSO, triplanar control, hyperextension, rigid anterior and lateral frame extends from symphysis pubis to sternal notch with two anterior components (one pubic and one sternal), posterior and lateral pads with straps and closures, limits spinal flexion, restricts gross trunk motion in the sagittal, coronal, and transverse planes, includes fitting and shaping the frame, prefabricated, includes fitting and adjustment

L0480

1,342.86

TLSO, triplanar control, one piece rigid plastic shell without interface liner, with multiple straps and closures, posterior extends from sacrococcygeal junction and terminates just inferior to scapular spine, anterior extends from symphysis pubis to sternal notch, anterior or posterior opening, restricts gross trunk motion in the sagittal, coronal, and transverse planes, includes a carved plaster or CAD-CAM model, custom fabricated

L0482

1,401.23

TLSO, triplanar control, one piece rigid plastic shell with interface liner, multiple straps and closures, posterior extends from sacrococcygeal junction and terminates just inferior to scapular spine, anterior extends from symphysis pubis to sternal notch, anterior or posterior opening, restricts gross trunk motion in the sagittal, coronal, and transverse planes, includes a carved plaster or CAD-CAM model, custom fabricated

L0484

1,910.59

TLSO, triplanar control, two piece rigid plastic shell without interface liner, with multiple straps and closures, posterior extends from sacrococcygeal junction and terminates just inferior to scapular spine, anterior extends from symphysis pubis to sternal notch, lateral strength is enhanced by overlapping plastic, restricts gross trunk motion in the sagittal, coronal, and transverse planes, includes a carved plaster or CAD-CAM model, custom fabricated

L0486

2,027.03

TLSO, triplanar control, two piece rigid plastic shell with interface liner, multiple straps and closures, posterior extends from sacrococcygeal junction and terminates just inferior to scapular spine, anterior extends from symphysis pubis to sternal notch, lateral strength is enhanced by overlapping plastic, restricts gross trunk motion in the sagittal, coronal, and transverse planes, includes a carved plaster or CAD-CAM model, custom fabricated

L0488

844.88

TLSO, triplanar control, one piece rigid plastic shell with interface liner, multiple straps and closures, posterior extends from sacrococcygeal junction and terminates just inferior to scapular spine, anterior extends from symphysis pubis to sternal notch, anterior or posterior opening, restricts gross trunk motion in sagittal, coronal, and transverse planes, prefabricated, includes fitting and adjustment

L0490

238.10

TLSO, sagittal-coronal control, one piece rigid plastic shell, with overlapping reinforced anterior, with multiple straps and closures, posterior extends from sacrococcygeal junction and terminates at or before the T-9 vertebra, anterior extends from symphysis pubis to xiphoid, anterior opening, restricts gross trunk motion in sagittal and coronal planes, prefabricated, includes fitting and adjustment

L0491

646.42

TLSO, sagittal-coronal control, modular segmented spinal System, two rigid plastic shells, posterior extends from the sacrococcygeal junction and terminates just inferior to the scapular spine, anterior extends from the symphysis pubis to the xiphoid, soft liner, restricts gross trunk motion in the sagittal and coronal planes, lateral strength is provided by overlapping plastic and stabilizing closures, includes straps and closures, prefabricated, includes fitting and adjustment

L0492

425.36

TLSO, sagittal-coronal control, modular segmented spinal system, three rigid plastic shells, posterior extends from the sacrococcygeal junction and terminates just inferior to the scapular spine, anterior extends from the symphysis pubis to the xiphoid, soft liner, restricts gross trunk motion in the sagittal and coronal planes, lateral strength is provided by overlapping plastic and stabilizing closures, includes straps and closures, prefabricated, includes fitting and adjustment

L0621

87.11

Sacroiliac orthosis, flexible, provides pelvic-sacral support, reduces motion about the sacroiliac joint, includes straps, closures, may include pendulous abdomen design, prefabricated, includes fitting and adjustment

L0622

277.74

Sacroiliac orthosis, flexible, provides pelvic-sacral support, reduces motion about the sacroiliac joint, includes straps, closures, may include pendulous abdomen design, custom fabricated

L0623

AI + 50%.

Sacroiliac orthosis, provides pelvic-sacral support, with rigid or semi-rigid panels over the sacrum and abdomen, reduces motion about the sacroiliac joint, includes straps, closures, may include pendulous abdomen design, prefabricated, includes fitting and adjustment

L0624

AI + 70%

Sacroiliac orthosis, provides pelvic-sacral support, with rigid or semi-rigid panels placed over the sacrum and abdomen, reduces motion about the sacroiliac joint, includes straps, closures, may include pendulous abdomen design, custom fabricated

L0625

46.35

Lumbar orthosis, flexible, provides lumbar support, posterior extends from L-1 to below L-5 vertebra, produces intracavitary pressure to reduce load on the intervertebral discs, includes straps, closures, may include pendulous abdomen design, shoulder straps, stays, prefabricated, includes fitting and adjustment

L0626

65.60

Lumbar orthosis, sagittal control, with rigid posterior panel(s), posterior extends from L-1 to below L-5 vertebra, produces intracavitary pressure to reduce load on the intervertebral discs, includes straps, closures, may include padding, stays, shoulder

L0627

345.97

Lumbar orthosis, sagittal control, with rigid anterior and posterior panels, posterior extends from L-1 to below L-5 vertebra, produces intracavitarypressure to reduce load on the intervertebral discs, includes straps, closures, may include padding, shoulder straps, pendulous abdomen design, prefabricated, includes fitting and adjustment

L0628

70.61

Lumbar-sacral orthosis, flexible, provides lumbosacral support, posterior extends from sacrococcygeal junction to T-9 vertebra, produces intracavitary pressure to reduce load on the intervertebral discs, includes straps, closures, may include stays, shoulder straps, pendulous abdomen design, prefabricated, includes fitting and adjustment

L0629

AI + 70%

Lumbar-sacral orthosis, flexible, provides lumbosacral support, posterior extends from sacrococcygeal junction to T-9 vertebra, produces intracavitary pressure to reduce load on the intervertebral discs, includes straps, closures, may include stays, shoulder straps, pendulous abdomen design, custom fabricated

L0630

136.31

Lumbar-sacral orthosis, sagittal control, with rigid posterior panel(s), posterior extends from sacrococcygeal junction to T-9 vertebra, produces intracavitary pressure to reduce load on the intervertebral discs, includes straps, closures, may include padding, stays, shoulder straps, pendulous abdomen design, prefabricated, includes fitting and adjustment

L0631

864.05

Lumbar-sacral orthosis, sagittal control, with rigid anterior and posterior panels, posterior extends from sacrococcygeal junction to T-9 vertebra, produces intracavitary pressure to reduce load on the intervertebral discs, includes straps, closures, may include padding, shoulder straps, pendulous abdomen design, prefabricated, includes fitting and adjustment

L0632

AI + 70%.

LSO, sagittal control, with rigid anterior and posterio panels, posterior extends from sacrococcygeal junction to T-9 vertebra, produces intracavitary pressure to reduce load on the intervertebral discs, includes straps, closures, may include padding, shoulder straps, pendulous abdomen design, custom fabricated

L0633

241.35

LSO, sagittal-coronal control, with rigid posterior frame/panel(s), posterior extends from sacrococcygeal junction to T-9 vertebra, lateral strength provided by rigid lateral frame/panels, produces intracavitary pressure to reduce load on intervertebral discs, includes straps, closures, may include padding, stays, shoulder straps, pendulous abdomen design, prefabricated, includes fitting and adjustment

L0634

AI + 70%.

LSO, sagittal-coronal control, with rigid posterior frame/panel(s), posterior extends from sacrococcygeal junction to T-9 vertebra, lateral strength provided by rigid lateral frame/panel(s), produces intracavitary pressure to reduce load on intervertebral discs, includes straps, closures, may include padding, stays, shoulder straps, pendulous abdomen design, custom

L0635

788.67

LSO, sagittal-coronal control, lumbar flexion, rigid posterior frame/panel(s), lateral articulating design to flex the lumbar spine, posterior extends from sacrococcygeal junction to T-9 vertebra, lateral strength provided by rigid lateral frame/panel(s), produces intracavitary pressure to reduce load on intervertebral discs, includes straps, closures, may include padding, anterior panel, pendulous abdomen design, prefabricated, includes fitting and adjustment

L0636

1,270.32

LSO, sagittal-coronal control, lumbar flexion, rigid posterior frame/panels, lateral articulating design to flex the lumbar spine, posterior extends from sacrococcygeal junction to T-9 vertebra, lateral strength provided by rigid lateral frame/panels, produces intracavitary pressure to reduce load on intervertebral discs, includes straps, closures, may include padding, anterior panel, pendulous abdomen design, custom fabricated

L0637

985.53

LSO, sagittal-coronal control, with rigid anterior and posterior frame/panels, posterior extends from sacrococcygeal junction to T-9 vertebra, lateral strength provided by rigid lateral frame/panels, produces intracavitary pressure to reduce load on intervertebral discs, includes straps, closures, may include padding, shoulder straps, pendulous abdomen design, prefabricated, includes fitting and adjustment

L0638

1,110.09

LSO, sagittal-coronal control, with rigid anterior and posterior frame/panels, posterior extends from sacrococcygeal junction to T-9 vertebra, lateral strength provided by rigid lateral frame/panels, produces intracavitary pressure to reduce load on intervertebral discs, includes straps, closures, may include padding, shoulder straps, pendulous abdomen design, custom fabricated

L0639

985.53

LSO, sagittal-coronal control, rigid shell(s)/panel(s), posterior extends from sacrococcygeal junction to T-9 vertebra, anterior extends from symphysis pubis to xyphoid, produces intracavitary pressure to reduce load on the intervertebral discs, overall strength is provided by overlapping rigid material and stabilizing closures, includes straps, closures, may include soft interface, pendulous abdomen design, prefabricated, includes fitting and adjustment

L0640

880.72

LSO, sagittal-coronal control, rigid shell(s)/panel(s), posterior extends from sacrococcygeal junction to T-9 vertebra, anterior extends from symphysis pubis to xyphoid, produces intracavitary pressure to reduce load on the intervertebral discs, overall strength is provided by overlapping rigid material and stabilizing closures, includes straps, closures, may include soft interface, pendulous abdomen design, custom fabricated

L0700

1,811.11

CTLSO, anterior-posterior-lateral control, molded to patient model (Minerva type)

L0710

1,954.07

CTLSO, anterior-posterior-lateral control, molded to patient model, with interface material (Minerva type)

L0810

2,726.96

Halo procedure, cervical halo incorporated into jacket

L0820

2,322.30

Halo procedure, cervical halo incorporated into plaster body jacket

L0830

3,020.24

Halo procedure, cervical halo incorporated into Milwaukee type orthosis

L0859

1,043.56

Addition to halo procedure, magnetic resonance image compatible systems, rings and pins, any material

L0861

181.41

Addition to halo procedure, replacement liner/interface material

L0970

92.15

TLSO, corset front

L0972

82.98

LSO, corset front

L0974

181.90

TLSO, full corset

L0976

137.81

LSO, full corset

L0978

166.92

Axillary crutch extension

L0980

18.77

Peroneal straps, pair

L0982

17.50

Stocking supporter grips, set of four

L0984

55.14

Protective body sock, each

L1000

2,065.61

CTLSO (Milwaukee), inclusive of furnishing initial orthosis, including model

L1005

2,693.89

Tension based scoliosis orthosis and accessory pads, includes fitting and adjustment

L1010

59.72

Addition to CTLSO or scoliosis orthosis, axilla sling

L1020

69.69

Addition to CTLSO or scoliosis orthosis, kyphosis pad

L1025

107.97

Addition to CTLSO or scoliosis orthosis, kyphosis pad, floating

L1030

51.29

Addition to CTLSO or scoliosis orthosis, lumbar bolster pad

L1040

62.90

Addition to CTLSO or scoliosis orthosis, lumbar or lumbar rib pad

L1050

67.13

Addition to CTLSO or scoliosis orthosis, sternal pad

L1060

80.17

Addition to CTLSO or scoliosis orthosis, thoracic pad

L1070

72.55

Addition to CTLSO or scoliosis orthosis, trapezius sling

L1080

47.50

Addition to CTLSO or scoliosis orthosis, outrigger

L1085

124.11

Addition to CTLSO or scoliosis orthosis, outrigger, bilateral with vertical extensions

L1090

73.91

Addition to CTLSO or scoliosis orthosis, lumbar sling

L1100

155.95

Addition to CTLSO or scoliosis orthosis, ring flange, plastic or leather

L1110

243.03

Addition to CTLSO or scoliosis orthosis, ring flange, plastic or leather, molded to patient model

L1120

32.02

Addition to CTLSO, scoliosis orthosis, cover for upright, each

L1200

1,499.67

TLSO, inclusive of furnishing initial orthosis only

L1210

210.98

Addition to TLSO, (low profile), lateral thoracic extension

L1220

178.63

Addition to TLSO, (low profile), anterior thoracic extension

L1230

515.39

Addition to TLSO, (low profile), Milwaukee type superstructure

L1240

68.06

Addition to TLSO, (low profile), lumbar derotation pad

L1250

68.02

Addition to TLSO, (low profile), anterior ASIS pad

L1260

68.06

Addition to TLSO, (low profile), anterior thoracic derotation pad

L1270

68.06

Addition to TLSO, (low profile), abdominal pad

L1280

92.74

Addition to TLSO, (low profile), rib gusset (elastic), each

L1290

68.06

Addition to TLSO, (low profile), lateral trochanteric pad

L1300

1,432.76

Other scoliosis procedure, body jacket molded to patient model

L1310

1,542.02

Other scoliosis procedure, postoperative body jacket

L1500

2,015.56

THKAO, mobility frame (Newington, Parapodium types)

L1510

1,191.06

THKAO, standing frame, with or without tray and accessories

L1520

1,998.13

THKAO, swivel walker

L1600

124.86

HO, abduction control of hip joints, flexible, Frejka type with cover, prefabricated, includes fitting and adjustment

L1610

38.26

HO, abduction control of hip joints, flexible, (Frejka cover only), prefabricated, includes fitting and adjustment

L1620

127.09

HO, abduction control of hip joints, flexible, (Pavlik harness), prefabricated, includes fitting and adjustment

L1630

182.18

HO, abduction control of hip joints, semi-flexible (Von Rosen type), custom fabricated

L1640

496.08

HO, abduction control of hip joints, static, pelvic band or spreader bar, thigh cuffs, custom fabricated

L1650

246.94

HO, abduction control of hip joints, static, adjustable (Ilfled type), prefabricated, includes fitting and adjustment

L1652

300.03

Hip orthosis, bilateral thigh cuffs with adjustable abductor spreader bar, adult size, prefabricated, includes fitting and adjustment, any type

L1660

169.65

HO, abduction control of hip joints, static, plastic, prefabricated, includes fitting and adjustment

L1680

982.44

HO, abduction control of hip joints, dynamic, pelvic control, adjustable hip motion control, thigh cuffs (Rancho hip action type), custom fabricated

L1685

1,278.81

HO, abduction control of hip joint, postoperative hip abduction type, custom fabricated

L1686

810.92

HO, abduction control of hip joint, postoperative hip abduction type, prefabricated, includes fitting and adjustments

L1690

1,627.58

Combination, bilateral, lumbo-sacral, hip, femur orthosis providing adduction and internal rotation control, prefabricated, includes fitting and adjustment

L1700

1,564.68

Legg Perthes orthosis, (Toronto type), custom fabricated

L1710

1,921.90

Legg Perthes orthosis, (Newington type), custom fabricated

L1720

1,086.86

Legg Perthes orthosis, trilateral, (Tachdijan type), custom fabricated

L1730

1,142.67

Legg Perthes orthosis, (Scottish Rite type), custom fabricated

L1755

1,702.14

Legg Perthes orthosis, (Patten bottom type), custom fabricated

L1800

53.64

KO, elastic with stays, prefabricated, includes fitting and adjustment

L1810

83.35

KO, elastic with joints, prefabricated, includes fitting and adjustment

L1815

104.15

KO, elastic or other elastic type material with condylar pad(s), prefabricated, includes fitting and adjustment

L1820

122.74

Knee orthosis, elastic with condylar pads and joints, with or without patellar control, prefabricated, includes fitting and adjustment

L1825

57.52

KO, elastic knee cap, prefabricated, includes fitting and adjustment

L1830

70.54

KO, immobilizer, canvas longitudinal, prefabricated, includes fitting and adjustment

L1831

247.71

Knee orthosis, locking knee joint(s), positional orthosis, prefabricated, includes fitting and adjustment

L1832

640.07

Knee orthosis, adjustable knee joints (unicentric or polycentric), positional orthosis, rigid support, prefabricated, includes fitting and adjustment

L1834

834.56

KO, without knee joint, rigid, custom fabricated

L1836

112.30

Knee orthosis, rigid, without joint(s), includes soft interface material, prefabricated, includes fitting and adjustment

L1840

786.51

KO, derotation, medial-lateral, anterior cruciate ligament, custom fabricated

L1843

755.20

Knee orthosis, single upright, thigh and calf, with adjustable flexion and extension joint (unicentric or polycentric), medial-lateral and rotation control, with or without varus/valgus adjustment, prefabricated, includes fitting and adjustment

L1844

1,377.12

Knee orthosis, single upright, thigh and calf, with adjustable flexion and extension joint (unicentric or polycentric), medial-lateral and rotation control, with or without varus/valgus adjustment, custom fabricated

L1845

702.24

Knee orthosis, double upright, thigh and calf, with adjustable flexion and extension joint (unicentric or polycentric), medial-lateral and rotation control, with or without varus/valgus adjustment, prefabricated, includes fitting and adjustment

L1846

1,045.16

Knee orthosis, double upright, thigh and calf, with adjustable flexion and extension joint (unicentric or polycentric), medial-lateral and rotation control, with or without varus/valgus adjustment, custom fabricated

L1847

484.10

KO, double upright with adjustable joint, with inflatable air support chamber(s), prefabricated, includes fitting and adjustment

L1850

285.45

KO, Swedish type, prefabricated, includes fitting and adjustment

L1860

914.78

KO, modification of supracondylar prosthetic socket, custom fabricated (SK)

L1900

256.10

AFO, spring wire, dorsiflexion assist calf band, custom fabricated

L1901

14.90

Ankle orthosis, elastic, prefabricated, includes fitting and adjustment (e.g., neoprene, Lycra)

L1902

74.14

AFO, ankle gauntlet, prefabricated, includes fitting and adjustment

L1904

505.56

AFO, molded ankle gauntlet, custom fabricated

L1906

108.58

AFO, multiligamentus ankle support, prefabricated, includes fitting and adjustment

L1907

473.60

AFO, supramalleolar with straps, with or without interface/pads, custom fabricated

L1910

255.64

AFO, posterior, single bar, clasp attachment to shoe counter, prefabricated, includes fitting and adjustment

L1920

374.64

AFO, single upright with static or adjustable stop (Phelps or Perlstein type), custom fabricated

L1930

220.14

AFO, plastic or other material, prefabricated, includes fitting and adjustment

L1932

751.08

AFO, rigid anterior tibial section, total carbon fiber or equal material, prefabricated, includes fitting and adjustment

L1940

531.69

AFO, plastic or other material, custom-fabricated

L1945

995.21

AFO, molded to patient model, plastic, rigid anterior tibial section (floor reaction), custom fabricated

L1950

768.97

AFO, spiral, (Institute of Rehabilitative Medicine type), plastic, custom fabricated

L1951

706.87

AFO, spiral, (Institute of Rehabilitative Medicine type), plastic or other material, prefabricated, includes fitting and adjustment

L1960

595.91

AFO, posterior solid ankle, plastic, custom fabricated

L1970

765.00

AFO, plastic, with ankle joint, custom fabricated

L1971

394.51

AFO, plastic or other material with ankle joint, prefabricated, includes fitting and adjustment

L1980

382.79

AFO, single upright free plantar dorsiflexion, solid stirrup, calf band/cuff (single bar BK orthosis), custom fabricated

L1990

455.40

AFO, double upright free plantar dorsiflexion, solid stirrup, calf band/cuff (double bar BK orthosis), custom fabricated

L2000

928.46

KAFO, single upright, free knee, free ankle, solid stirrup, thigh and calf bands/cuffs (single bar AK orthosis), custom fabricated

L2005

3,448.94

Knee ankle foot orthosis, any material, single or double upright, stance control, automatic lock and swing phase release, mechanical activation, includes ankle joint, any type, custom fabricated

L2010

843.90

KAFO, single upright, free ankle, solid stirrup, thigh and calf bands/cuffs (single bar AK orthosis), without knee joint, custom fabricated

L2020

1,197.45

KAFO, double upright, free knee, free ankle, solid stirrup, thigh and calf bands/cuffs (double bar AK orthosis), custom fabricated

L2030

971.19

KAFO, double upright, free ankle, solid stirrup, thigh and calf bands/cuffs, (double bar AK orthosis), without knee joint, custom fabricated

L2034

1,684.16

Knee ankle foot orthosis, full plastic, single upright, with or without free motion knee, medial lateral rotation control, with or without free motion ankle, custom fabricated

L2035

148.30

Knee ankle foot orthosis, full plastic, static (pediatric size), without free motion ankle, prefabricated, includes fitting and adjustment

L2036

1,994.65

Knee ankle foot orthosis, full plastic, double upright, with or without free motion knee, with or without free motion ankle, custom fabricated

L2037

1,790.67

Knee ankle foot orthosis, full plastic, single upright, with or without free motion knee, with or without free motion ankle, custom fabricated

L2038

1,537.10

Knee ankle foot orthosis, full plastic, with or without free motion knee, multi-axis ankle, custom fabricated

L2040

183.03

HKAFO, torsion control, bilateral rotation straps, pelvic band/belt, custom fabricated

L2050

512.14

HKAFO, torsion control, bilateral torsion cables, hip joint, pelvic band/belt, custom fabricated

L2060

521.33

HKAFO, torsion control, bilateral torsion cables, ball bearing hip joint, pelvic band/ belt, custom fabricated

L2070

125.86

HKAFO, torsion control, unilateral rotation straps, pelvic band/belt, custom fabricated

L2080

386.69

HKAFO, torsion control, unilateral torsion cable, hip joint, pelvic band/belt, custom fabricated

L2090

371.63

HKAFO, torsion control, unilateral torsion cable, ball bearing hip joint, pelvic band/belt, custom fabricated

L2106

730.97

AFO, fracture orthosis, tibial fracture cast orthosis, thermoplastic type casting material, custom fabricated

L2108

1,110.45

AFO, fracture orthosis, tibial fracture cast orthosis, custom fabricated

L2112

455.80

AFO, fracture orthosis, tibial fracture orthosis, soft, prefabricated, includes fitting and adjustment

L2114

550.54

AFO, fracture orthosis, tibial fracture orthosis, semi-rigid, prefabricated, includes fitting and adjustment

L2116

707.02

AFO, fracture orthosis, tibial fracture orthosis, rigid, prefabricated, includes fitting and adjustment

L2126

1,157.86

KAFO, fracture orthosis, femoral fracture cast orthosis, thermoplastic type casting material, custom fabricated

L2128

1,843.50

KAFO, fracture orthosis, femoral fracture cast orthosis, custom fabricated

L2132

681.12

Knee ankle foot orthosis (KAFO), fracture orthosis, femoral fracture cast orthosis, soft, prefabricated, includes fitting and adjustment

L2134

958.80

Knee ankle foot orthosis (KAFO), fracture orthosis, femoral fracture cast orthosis, semi-rigid, prefabricated, includes fitting and adjustment

L2136

1,071.71

KAFO, fracture orthosis, femoral fracture cast orthosis, rigid, prefabricated, includes fitting and adjustment

L2180

111.39

Addition to lower extremity fracture orthosis, plastic shoe insert with ankle joints

L2182

98.49

Addition to lower extremity fracture orthosis, drop lock knee joint

L2184

103.39

Addition to lower extremity fracture orthosis, limited motion knee joint

L2186

124.80

Addition to lower extremity fracture orthosis, adjustable motion knee joint, Lerman type

L2188

302.99

Addition to lower extremity fracture orthosis, quadrilateral brim

L2190

93.89

Addition to lower extremity fracture orthosis, waist belt

L2192

347.28

Addition to lower extremity fracture orthosis, hip joint, pelvic band, thigh flange, and pelvic belt

L2200

38.34

Addition to lower extremity, limited ankle motion, each joint

L2210

54.20

Addition to lower extremity, dorsiflexion assist (plantar flexion resist), each joint

L2220

66.03

Addition to lower extremity, dorsiflexion and plantar flexion assist/resist, each joint

L2230

61.87

Addition to lower extremity, split flat caliper stirrups and plate attachment

L2232

83.76

Addition to lower extremity orthosis, rocker bottom for total contact ankle foot orthosis, for custom fabricated orthosis only

L2240

82.97

Addition to lower extremity, round caliper and plate attachment

L2250

286.51

Addition to lower extremity, foot plate, molded to patient model, stirrup attachment

L2260

161.64

Addition to lower extremity, reinforced solid stirrup (Scott-Craig type)

L2265

126.61

Addition to lower extremity, long tongue stirrup

L2270

50.63

Addition to lower extremity, varus/valgus correction (T) strap, padded/lined or malleolus pad

L2275

106.16

Addition to lower extremity, varus/valgus correction, plastic modification, padded/lined

L2280

402.85

Addition to lower extremity, molded inner boot

L2300

217.09

Addition to lower extremity, abduction bar (bilateral hip involvement), jointed, adjustable

L2310

99.19

Addition to lower extremity, abduction bar, straight

L2320

203.36

Addition to lower extremity, non-molded lacer, for custom fabricated orthosis only

L2330

354.30

Addition to lower extremity, lacer molded to patient model, for custom fabricated orthosis only

L2335

242.04

Addition to lower extremity, anterior swing band

L2340

360.37

Addition to lower extremity, pretibial shell, molded to patient model

L2350

718.47

Addition to lower extremity, prosthetic type, (BK) socket, molded to patient model, (used for PTB, AFO orthoses)

L2360

41.72

Addition to lower extremity, extended steel shank

L2370

206.99

Addition to lower extremity, Patten bottom

L2375

97.58

Addition to lower extremity, torsion control, ankle joint and half solid stirrup

L2380

99.27

Addition to lower extremity, torsion control, straight knee joint, each joint

L2385

137.66

Addition to lower extremity, straight knee joint, heavy duty, each joint

L2387

177.92

Addition to lower extremity, polycentric knee joint, for custom fabricated knee ankle foot orthosis, each joint

L2390

117.68

Addition to lower extremity, offset knee joint, each joint

L2395

168.21

Addition to lower extremity, offset knee joint, heavy duty, each joint

L2397

99.42

Addition to lower extremity orthosis, suspension sleeve

L2405

73.38

Addition to knee joint, drop lock, each

L2415

102.22

Addition to knee lock with integrated release mechanism (bail, cable, or equal), any material, each joint

L2425

120.65

Addition to knee joint, disc or dial lock for adjustable knee flexion, each joint

L2430

120.65

Addition to knee joint, ratchet lock for active and progressive knee extension, each joint

L2492

95.65

Addition to knee joint, lift loop for drop lock ring

L2500

339.17

Addition to lower extremity, thigh/weight bearing, gluteal/ischial weight bearing, ring

L2510

652.26

Addition to lower extremity, thigh/weight bearing, quadri-lateral brim, molded to patient model

L2520

480.46

Addition to lower extremity, thigh/weight bearing, quadri-lateral brim, custom fitted

L2525

1,310.53

Addition to lower extremity, thigh/weight bearing, ischial containment/narrow M-L brim molded to patient model

L2526

712.20

Addition to lower extremity, thigh/weight bearing, ischial containment/narrow M-L brim, custom fitted

L2530

214.87

Addition to lower extremity, thigh/weight bearing, lacer, nonmolded

L2540

454.53

Addition to lower extremity, thigh/weight bearing, lacer, molded to patient model

L2550

231.58

Addition to lower extremity, thigh/weight bearing, high roll cuff

L2570

384.06

Addition to lower extremity, pelvic control, hip joint, Clevis type, two position joint, each

L2580

417.55

Addition to lower extremity, pelvic control, pelvic sling

L2600

165.60

Addition to lower extremity, pelvic control, hip joint, Clevis type, or thrust bearing, free, each

L2610

195.82

Addition to lower extremity, pelvic control, hip joint, Clevis or thrust bearing, lock, each

L2620

287.46

Addition to lower extremity, pelvic control, hip joint, heavy-duty, each

L2622

329.52

Addition to lower extremity, pelvic control, hip joint, adjustable flexion, each

L2624

267.01

Addition to lower extremity, pelvic control, hip joint, adjustable flexion, extension, abduction control, each

L2627

1,843.03

Addition to lower extremity, pelvic control, plastic, molded to patient model, reciprocating hip joint and cables

L2628

1,575.36

Addition to lower extremity, pelvic control, metal frame, reciprocating hip joint and cables

L2630

247.55

Addition to lower extremity, pelvic control, band and belt, unilateral

L2640

354.83

Addition to lower extremity, pelvic control, band and belt, bilateral

L2650

97.02

Addition to lower extremity, pelvic and thoracic control, gluteal pad, each

L2660

200.12

Addition to lower extremity, thoracic control, thoracic band

L2670

137.54

Addition to lower extremity, thoracic control, paraspinal uprights

L2680

126.18

Addition to lower extremity, thoracic control, lateral support uprights

L2750

89.86

Addition to lower extremity orthosis, plating chrome or nickel, per bar

L2755

109.94

Addition to lower extremity orthosis, high strength, lightweight material, all hybrid lamination/prepreg composite, per segment, for custom fabricated orthosis only

L2760

48.99

Addition to lower extremity orthosis, extension, per extension, per bar (for lineal adjustment for growth)

L2768

109.66

Orthotic side bar disconnect device, per bar

L2770

49.79

Addition to lower extremity orthosis, any material, per bar or joint

L2780

72.76

Addition to lower extremity orthosis, noncorrosive finish, per bar

L2785

27.64

Addition to lower extremity orthosis, drop lock retainer, each

L2795

91.35

Addition to lower extremity orthosis, knee control, full kneecap

L2800

114.67

Addition to lower extremity orthosis, knee control, knee cap, medial or lateral pull, for use with custom fabricated orthosis only

L2810

83.97

Addition to lower extremity orthosis, knee control, condylar pad

L2820

92.97

Addition to lower extremity orthosis, soft interface for molded plastic, below knee section

L2830

101.01

Addition to lower extremity orthosis, soft interface for molded plastic, above knee section

L2840

35.36

Addition to lower extremity orthosis, tibial length sock, fracture or equal, each

L2850

63.93

Addition to lower extremity orthosis, femoral length sock, fracture or equal, each

L2999

A.I. + 50%

Unlisted procedure for lower extremity orthosis

L3000

264.39

Foot insert, removable, molded to patient model, UCB type, Berkeley shell, each

L3001

111.32

Foot insert, removable, molded to patient model, Spenco, each

L3002

135.93

Foot insert, removable, molded to patient model, Plastazote or equal, each

L3003

146.67

Foot insert, removable, molded to patient model, silicone gel, each

L3010

146.67

Foot insert, removable, molded to patient model, longitudinal arch support, each

L3020

167.00

Foot insert, removable, molded to patient model, longitudinal/metatarsal support, each

L3030

64.24

Foot insert, removable, formed to patient foot, each

L3031

130.00

Foot, insert/plate, removable, addition to lower extremity orthosis, high strength, lightweight material, all hybrid lamination/prepreg composite, each

L3040

39.60

Foot, arch support, removable, premolded,

longitudinal, each

L3050

39.60

Foot, arch support, removable, premolded, metatarsal, each

L3060

62.09

Foot, arch support, removable, premolded,

longitudinal/metatarsal, each

L3070

26.73

Foot, arch support, nonremovable, attached to shoe, longitudinal, each

L3080

26.73

Foot, arch support, nonremovable, attached to shoe, metatarsal, each

L3090

34.27

Foot, arch support, nonremovable, attached to shoe, longitudinal/metatarsal, each

L3100

36.39

Hallus-valgus night dynamic splint

L3140

74.94

Foot, abduction rotation bar, including shoes

L3150

68.51

Foot, abduction rotation bar, without shoes

L3160

AI + 50%

Foot, adjustable shoe style positioning device

L3170

42.84

Foot, plastic, silicone, or equal, heel stabilizer, each

L3203

58.03

Orthopedic shoe, oxford wit supinator or pronator, junior

L3207

AI + 50%

Orthopedic shoe, hightop with supinator or pronator, junior

L3211

70.56

Surgical boot, each, junior

L3214

AI + 50%

Benesch boot, pair, junior

L3215

89.99

Orthopedic footwear, ladies shoes, oxford, "each"

L3216

115.06

Orthopedic footwear, ladies shoes, depth inlay "each"

L3217

AI + 50%

Orthopedic footwear, ladies shoes, hightop, depth inlay "each"

L3219

137.00

Orthopedic footwear, mens shoes, oxford, "each"

L3221

139.94

Orthopedic footwear, mens shoes, depth inlay "each"

L3222

175.00

Orthopedic footwear, mens shoes, hightop, depth inlay "each"

L3224

60.09

Orthopedic footwear, woman's shoe, oxford, used as an integral part of a brace (orthosis)

L3225

72.73

Orthopedic footwear, man's shoe, oxford, used as an integral part of a brace (orthosis)

L3230

303.97

Orthopedic footwear, custom shoes, depth inlay "each"

L3250

399.89

Orthopedic footwear, custom molded shoe, removable inner mold, prosthetic shoe, each

L3251

Foot, shoe molded to patient model, silicone shoe, each

L3252

300.08

Foot, shoe molded to patient model, plastazote (or similar), custom fabricated, each

L3253

80.02

Foot, molded shoe, plastazote (or similar) custom fitted, each

L3254

28.00

Non-standard size or width

L3255

AI + 70%

Non-standard size or length

L3257

54.99

Orthopedic footware, additional charge for split size

L3260

30.00

Ambulatory surgical boot, each

L3265

24.99

Plastazote sandal, each

L3300

43.88

Lift, elevation, heel, tapered to metatarsals, per inch

L3310

68.51

Lift, elevation, heel and sole, neoprene, per inch

L3330

476.34

Lift, elevation, metal extension (skate)

L3332

62.09

Lift, elevation, inside shoe, tapered, up to one-half in.

L3334

32.11

Lift, elevation, heel, per in.

L3340

71.73

Heel wedge, SACH

L3350

19.28

Heel wedge

L3360

29.97

Sole wedge, outside sole

L3370

41.72

Sole wedge, between sole

L3380

41.72

Clubfoot wedge

L3390

41.72

Outflare wedge

L3400

34.27

Metatarsal bar wedge, rocker

L3410

78.13

Metatarsal bar wedge, between sole

L3420

46.03

Full sole and heel wedge, between sole

L3430

134.88

Heel, counter, plastic reinforced

L3440

64.24

Heel, counter, leather reinforced

L3450

88.85

Heel, SACH cushion type

L3455

34.27

Heel, new leather, standard

L3460

28.89

Heel, new rubber, standard

L3465

49.25

Heel, Thomas with wedge

L3470

52.45

Heel, Thomas extended to ball

L3480

52.45

Heel, pad and depression for spur

L3485

28.50

Heel, pad-removeable for spur

L3500

24.62

Orthopedic shoe addition, insole, leather

L3510

24.62

Orthopedic shoe addition, insole, rubber

L3520

26.73

Orthopedic shoe addition, insole, felt covered with leather

L3530

26.73

Orthopedic shoe addition, sole, half

L3540

42.84

Orthopedic shoe addition, sole, full

L3550

7.48

Orthopedic shoe addition, toe tap, standard

L3560

19.28

Orthopedic shoe addition, toe tap, horseshoe

L3570

71.73

Orthopedic shoe addition, special extension to instep (leather with eyelets)

L3580

54.59

Orthopedic shoe addition, convert instep to Velcro closure

L3590

44.95

Orthopedic shoe addition, convert firm shoe counter to soft counter

L3595

35.32

Orthopedic shoe addition, March bar

L3600

64.24

Transfer of an orthosis from one shoe to another, caliper plate, existing

L3610

84.55

Transfer of an orthosis from one shoe to another, caliper plate, new

L3620

64.24

Transfer of an orthosis from one shoe to another, solid stirrup, existing

L3630

84.55

Transfer of an orthosis from one shoe to another, solid stirrup, new

L3640

36.39

Transfer of an orthosis from one shoe to another, Dennis Browne splint (Riveton), both shoes

L3649

AI + 70%

Orthopedic shoe modification, addition or transfer not otherwise specified

L3650

58.00

SO, figure of eight design abduction restrainer, prefabricated, includes fitting and adjustment

L3651

50.44

SO, single shoulder, elastic, prefabricated, includes fitting and adjustment (e.g., neoprene, Lycra)

L3652

152.00

SO, double shoulder, elastic, prefabricated, includes fitting and adjustment (e.g., neoprene, Lycra)

L3660

108.13

SO, figure of eight design abduction restrainer, canvas and webbing, prefabricated, includes fitting and adjustment

L3670

89.22

SO, acromio/clavicular (canvas and webbing type), prefabricated, includes fitting and adjustment

L3671

690.23

Shoulder orthosis (SO), shoulder cap design, without joints, may include soft interface, straps, custom fabricated, includes fitting and adjustment

L3672

858.34

SO, abduction positioning (airplane design), thoracic component and support bar, without joints, may inlcude soft interface, straps, custom fabricated, includes fitting and adjustment

L3673

935.49

Shoulder orthosis (SO), abduction positioning (airplane design), thoracic component and support bar, includes nontorsion joint/turnbuckle, may include soft interface, straps, custom fabricated, includes fitting and adjustment

L3675

134.42

SO, vest type abduction restrainer, canvas webbing type, or equal, prefabricated, includes fitting and adjustment

L3700

55.08

EO, elastic with stays, prefabricated, includes fitting and adjustment

L3701

15.60

Elbow orthosis (EO), elastic, prefabricated, includes fitting and adjustment (e.g., neoprene, Lycra)

L3702

221.18

Elbow orthosis (EO), without joints, may include soft interface, straps, custom fabricated, includes fitting and adjustment

L3710

122.49

EO, elastic with metal joints, prefabricated, includes fitting and adjustment

L3720

516.08

Elbow orthosis (EO), double upright with forearm/arm cuffs, free motion, custom fabricated

L3730

948.36

EO, double upright with forearm/arm cuffs, extension/flexion assist, custom fabricated

L3740

1,124.36

Elbow orthosis (EO), double upright with forearm/arm cuffs, adjustable position Lock with active control, custom fabricated

L3760

383.07

Elbow orthosis (EO), with adjustable position locking joint(s), prefabricated, includes fitting and adjustments, any type

L3762

82.37

Elbow orthosis (EO), rigid, without joints, includes soft interface material, prefabricated, includes fitting and adjustment

L3763

557.35

Elbow wrist hand orthosis (EWHO), rigid, without joints, may include soft interface, straps, custom fabricated, includes fitting and adjustment

L3764

728.30

Elbow wrist hand orthosis (EWHO), includes one or more nontorsion joints, elastic bands, turnbuckles, may include soft interface, straps, custom fabricated, includes fitting and adjustment

L3765

982.19

Elbow wrist hand finger orthosis (EWHFO), rigid, without joints, may include soft interface, straps, custom fabricated, includes fitting and adjustment

L3766

1,040.07

Elbow wrist hand finger orthosis (EWHFO), includes one or more nontorsion joints, elastic bands, turnbuckles, may include soft interface, straps, custom fabricated, includes fitting and adjustment

L3806

347.95

WHFO, includes one or more nontorsion joint(s), turnbuckles, elastic bands/springs, may include soft interface material, straps, custom fabricated, includes fitting and adjustment

L3807

191.54

Wrist hand finger orthosis (WHFO), without joint(s), prefabricated, includes fitting and adjustments, any type

L3808

323.61

Wrist hand finger orthosis (WHFO), rigid without joints, may include soft interface material; straps, custom fabricated, includes fitting and adjustment

L3900

1,026.53

WHFO, dynamic flexor hinge, reciprocal wrist extension/flexion, finger flexion/extension, wrist or finger driven, custom fabricated

L3901

1,267.98

WHFO, dynamic flexor hinge, reciprocal wrist extension/flexion, finger flexion/extension, cable driven, custom fabricated

L3904

2,431.38

WHFO, external powered, electric, custom fabricated

L3905

759.66

Wrist hand finger orthosis (WHFO), includes one or more nontorsion joints, elastic bands, turnbuckles, may include soft interface, straps, custom fabricated, includes fitting and adjustment

L3906

370.14

Wrist hand orthosis (WHO), without joints, may include soft interface, straps, custom fabricated, includes fitting and adjustment

L3908

63.03

WHO, wrist extension control cock-up, nonmolded, prefabricated, includes fitting and adjustment

L3909

10.80

WO, elastic, prefabricated, includes fitting and adjustment (e.g., neoprene, Lycra)

L3911

18.97

Wrist hand finger orthosis (WHFO), elastic, prefabricated, includes fitting and adjustment (e.g., neoprene, Lycra)

L3912

74.83

HFO, flexion glove with elastic finger control, prefabricated, includes fitting and adjustment

L3913

207.47

Hand finger orthosis (HFO), without joints, may include soft interface, straps, custom fabricated, includes fitting and adjustment

L3915

407.17

Wrist hand orthosis (WHO), includes one or more nontorsion joint(s), elastic bands, turnbuckles, may include soft interface, straps, prefabricated, includes fitting and adjustment

L3917

80.92

Hand orthosis (HO), metacarpal fracture orthosis, prefabricated, includes fitting and adjustment

L3919

207.47

Hand orthosis (HO), without joints, may include soft interface, straps, custom fabricated, includes fitting and adjustment

L3921

246.06

Hand finger orthosis (HFO), includes one or more nontorsion joints, elastic bands, turnbuckles, may include soft interface, straps, custom fabricated, includes fitting and adjustment

L3923

91.52

Hand finger orthosis (HFO), without joints, may include soft interface, straps, prefabricated, includes fitting and adjustment

L3925

41.16

FO, proximal interphalangeal (PIP)/distal interphalangeal (DIP), nontorsion joint/spring, extension/flexion, may include soft interface material, prefabricated, includes fitting and adjustment

L3927

AI + 50%

FO, proximal interphalangeal (PIP)/distal interphalangeal (DIP), without joint/spring, extension/flexion (e.g., static or ring type), may include soft interface material, prefabricated, includes fitting and adjustment

L3929

61.68

HFO, includes one or more nontorsion joint(s), turnbuckles, elastic bands/springs, may include soft interface material, straps, prefabricated, includes fitting and adjustment

L3931

162.84

WHFO, includes one or more nontorsion joint(s), turnbuckles, elastic bands/springs, may include soft interface material, straps, prefabricated, includes fitting and adjustment

L3933

163.44

Finger orthosis (FO), without joints, may include soft interface, custom fabricated, includes fitting and adjustment

L3935

169.22

Finger orthosis, nontorsion joint, may include soft interface, custom fabricated, includes fitting and adjustment

L3956

I.C.

Addition of joint to upper extremity orthosis, any material; per joint

L3960

688.97

SEWHO, abduction positioning, airplane design, prefabricated, includes fitting and adjustment

L3961

1,286.96

Shoulder elbow wrist hand orthosis (SEWHO), shoulder cap design, without joints, may include soft interface, straps, custom fabricated, includes fitting and adjustment

L3962

754.83

SEWHO, abduction positioning, Erb's palsy design, prefabricated, includes fitting and adjustment

L3964

621.11

465.80

62.10

SEO, mobile arm support attached to wheelchair, balanced, adjustable, prefabricated, includes fitting and adjustment

L3964

621.11

465.80

62.10

SEO, mobile arm support attached to wheelchair, balanced, adjustable, prefabricated, includes fitting and adjustment

L3964

621.11

465.80

62.10

SEO, mobile arm support attached to wheelchair, balanced, adjustable, prefabricated, includes fitting and adjustment

L3965

991.11

743.33

99.13

SEO, mobile arm support attached to wheelchair, balanced, adjustable Rancho type, prefabricated, includes fitting and adjustment

L3965

991.11

743.33

99.13

SEO, mobile arm support attached to wheelchair, balanced, adjustable Rancho type, prefabricated, includes fitting and adjustment

L3965

991.11

743.33

99.13

SEO, mobile arm support attached to wheelchair, balanced, adjustable Rancho type, prefabricated, includes fitting and adjustment

L3966

746.64

559.98

74.67

SEO, mobile arm support attached to wheelchair, balanced, reclining, prefabricated, includes fitting and adjustment

L3966

746.64

559.98

74.67

SEO, mobile arm support attached to wheelchair, balanced, reclining, prefabricated, includes fitting and adjustment

L3966

746.64

559.98

74.67

SEO, mobile arm support attached to wheelchair, balanced, reclining, prefabricated, includes fitting and adjustment

L3967

1,519.48

Shoulder elbow wrist hand orthosis (SEWHO), abduction positioning (airplane design), thoracic component and support bar, without joints, may include soft interface, straps, custom fabricated, includes fitting and adjustment

L3968

858.96

644.22

85.89

SEO, mobile arm support attached to wheelchair, balanced, friction arm support (friction dampening to proximal and distal joints), prefabricated, includes fitting and adjustment

L3968

858.96

644.22

85.89

SEO, mobile arm support attached to wheelchair, balanced, friction arm support (friction dampening to proximal and distal joints), prefabricated, includes fitting and adjustment

L3968

858.96

644.22

85.89

SEO, mobile arm support attached to wheelchair, balanced, friction arm support (friction dampening to proximal and distal joints), prefabricated, includes fitting and adjustment

L3969

660.74

495.54

66.08

SEO, mobile arm support, monosuspension arm and hand support, overhead elbow forearm hand sling support, yoke type arm suspension support, prefabricated, includes fitting and adjustment

L3969

660.74

495.54

66.08

SEO, mobile arm support, monosuspension arm and hand support, overhead elbow forearm hand sling support, yoke type arm suspension support, prefabricated, includes fitting and adjustment

L3969

660.74

495.54

66.08

SEO, mobile arm support, monosuspension arm and hand support, overhead elbow forearm hand sling support, yoke type arm suspension support, prefabricated, includes fitting and adjustment

L3970

224.66

168.50

22.47

Shoulder elbow orthosis (SEO), addition to mobile arm support, elevating proximal arm

L3970

224.66

168.50

22.47

Shoulder elbow orthosis (SEO), addition to mobile arm support, elevating proximal arm

L3970

224.66

168.50

22.47

Shoulder elbow orthosis (SEO), addition to mobile arm support, elevating proximal arm

L3971

1,442.33

Shoulder elbow wrist hand orthosis (SEWHO), shoulder cap design, includes one or more nontorsion joints, elastic bands, turnbuckles, may include soft interface, straps, custom fabricated, includes fitting and adjustment

L3972

168.07

126.05

16.81

Shoulder elbow orthosis (SEO), addition to mobile arm support, offset or lateral rocker arm with elastic balance control

L3972

168.07

126.05

16.81

Shoulder elbow orthosis (SEO), addition to mobile arm support, offset or lateral rocker arm with elastic balance control

L3972

168.07

126.05

16.81

Shoulder elbow orthosis (SEO), addition to mobile arm support, offset or lateral rocker arm with elastic balance control

L3973

1,519.48

Shoulder elbow wrist hand orthosis (SEWHO), abduction positioning (airplane design), thoracic component and support bar, includes one or more nontorsion joints, elastic bands, turnbuckles, may include soft interface, straps, custom fabricated, includes fitting and adjustment

L3974

142.55

106.91

14.27

Shoulder elbow orthosis (SEO), addition to mobile arm support, supinator

L3974

142.55

106.91

14.27

Shoulder elbow orthosis (SEO), addition to mobile arm support, supinator

L3974

142.55

106.91

14.27

Shoulder elbow orthosis (SEO), addition to mobile arm support, supinator

L3975

1,286.96

Shoulder elbow wrist hand finger orthosis (SEWHO), shoulder cap design, without joints, may include soft interface, straps, custom fabricated, includes fitting and adjustment

L3976

1,286.96

Shoulder elbow wrist hand finger orthosis (SEWHO), abduction positioning (airplane design), thoracic component and support bar, without joints, may include soft interface, straps, custom fabricated, includes fitting and adjustment

L3977

1,442.33

Shoulder elbow wrist hand finger orthosis (SEWHO), shoulder cap design, includes one or more nontorsion joints, elastic bands, turnbuckles, may include soft interface, straps, custom fabricated, includes fitting and adjustment

L3978

1,519.48

Shoulder elbow wrist hand finger orthosis (SEWHO), abduction positioning (airplane design), thoracic component and support bar, includes one or more nontorsion joints, elastic bands, turnbuckles, may include soft interface, straps, custom fabricated, incl

L3980

325.24

Upper extremity fracture orthosis, humeral,

prefabricated, includes fitting and adjustment

L3982

342.79

Upper extremity fracture orthosis, radius/ulnar, prefabricated, includes fitting and adjustment

L3984

341.01

Upper extremity fracture orthosis, wrist, prefabricated, includes fitting and adjustment

L3995

34.40

Addition to upper extremity orthosis, sock, fracture or equal, each

L4000

1,232.35

Replace girdle for spinal orthosis (CTLSO or SO)

L4002

AI + 70%

Replacement strap, any orthosis, includes all components, any length, any type

L4010

541.14

Replace trilateral socket brim

L4020

701.52

Replace quadrilateral socket brim, molded to patient model

L4030

407.10

Replace quadrilateral socket brim, custom fitted

L4040

360.36

Replace molded thigh lacer, for custom fabricated orthosis only

L4045

352.66

Replace non-molded thigh lacer, for custom fabricated orthosis only

L4050

405.45

Replace molded calf lacer, for custom fabricated orthosis only

L4055

287.40

Replace non-molded calf lacer, for custom fabricated orthosis only

L4060

268.36

Replace high roll cuff

L4070

254.04

Replace proximal and distal upright for KAFO

L4080

108.74

Replace metal bands KAFO, proximal thigh

L4090

84.70

Replace metal bands KAFO-AFO, calf or distal thigh

L4100

95.17

Replace leather cuff KAFO, proximal thigh

L4110

81.81

Replace leather cuff KAFO-AFO, calf or distal thigh

L4130

400.04

Replace pretibial shell

L4350

83.72

Ankle control orthosis, stirrup style, rigid, includes any type interface (e.g., pneumatic, gel), prefabricated, includes fitting and adjustment

L4360

297.68

Walking boot, pneumatic, with or without joints, with or without interface material, prefabricated, includes fitting and adjustment

L4370

202.97

Pneumatic full leg splint, prefabricated, includes fitting and adjustment

L4380

115.48

Pneumatic knee splint, prefabricated, includes fitting and adjustment

L4386

133.45

Walking boot, non-pneumatic, with or without joints, with or without interface material, prefabricated, includes fitting and adjustment

L4392

20.68

Replacement, soft interface material, static AFO

L4394

15.10

Replace soft interface material, foot drop splint

L4396

147.55

Static ankle foot orthosis, including soft interface material, adjustable for fit, for positioning, pressure reduction, may be used for minimal ambulation, prefabricated, includes fitting and adjustment

L4398

67.93

Foot drop splint, recumbent positioning device, prefabricated, includes fitting and adjustment

L5000

434.04

Partial foot, shoe insert with longitudinal arch, toe filler

L5010

1,052.05

Partial foot, molded socket, ankle height, with toe filler

L5020

1,789.88

Partial foot, molded socket, tibial tubercle height, with toe filler

L5050

2,340.34

Ankle, Symes, molded socket, SACH foot

L5060

2,372.67

Ankle, Symes, metal frame, molded leather socket, articulated ankle/foot

L5100

2,399.82

Below knee, molded socket, shin, SACH foot

L5105

3,655.13

Below knee, plastic socket, joints and thigh lacer, SACH foot

L5150

3,085.81

Knee disarticulation (or through knee), molded socket, external knee joints, shin, SACH foot

L5160

3,618.72

Knee disarticulation (or through knee), molded socket, bent knee configuration, external knee joints, shin, SACH foot

L5200

3,598.61

Above knee, molded socket, single axis constant friction knee, shin, SACH foot

L5210

2,265.99

Above knee, short prosthesis, no knee joint (stubbies), with foot blocks, no ankle joints, each

L5220

2,432.04

Above knee, short prosthesis, no knee joint (stubbies), with articulated ankle/foot, dynamically aligned, each

L5230

3,428.72

Above knee, for proximal femoral focal deficiency, constant friction knee, shin, SACH foot

L5250

4,786.21

Hip disarticulation, Canadian type; molded socket, hip joint, single axis constant friction knee, shin, SACH foot

L5270

5,138.59

Hip disarticulation, tilt table type; molded socket, locking hip joint, single axis constant friction knee, shin, SACH foot

L5280

5,147.34

Hemipelvectomy, Canadian type; molded socket, hip joint, single axis constant friction knee, shin, SACH foot

L5301

2,107.24

Below knee, molded socket, shin, SACH foot, endoskeletal system

L5311

2,833.53

Knee disarticulation (or through knee), molded socket, external knee joints, shin, SACH foot, endoskeletal system

L5321

2,972.75

Above knee, molded socket, open end, SACH foot, endoskeletal system, single axis knee

L5331

4,429.79

Hip disarticulation, Canadian type, molded socket, endoskeletal system, hip joint, single axis knee, SACH foot

L5341

4,341.54

Hemipelvectomy, Canadian type, molded socket, endoskeletal system, hip joint, single axis knee, SACH foot

L5400

1,033.89

Immediate postsurgical or early fitting, application of initial rigid dressing, including fitting, alignment, suspension, and one cast change, below knee

L5410

394.79

Immediate postsurgical or early fitting, application of initial rigid dressing, including fitting, alignment and suspension, below knee, each additional cast change and realignment

L5420

1,305.75

Immediate postsurgical or early fitting, application of initial rigid dressing, including fitting, alignment and suspension and one cast change AK or knee disarticulation

L5430

452.26

Immediate postsurgical or early fitting, application of initial rigid dressing, including fitting, alignment and suspension, AK or knee disarticulation, each additional cast change and realignment

L5450

349.98

Immediate postsurgical or early fitting, application of nonweight bearing rigid dressing, below knee

L5460

514.57

Immediate postsurgical or early fitting, application of nonweight bearing rigid dressing, above knee

L5500

1,256.53

Initial, below knee PTB type socket, nonalignable system, pylon, no cover, SACH foot, plaster socket, direct formed

L5505

1,758.90

Initial, above knee - knee disarticulation, ischial level socket, nonalignable system, pylon, no cover, SACH foot plaster socket, direct formed

L5510

1,566.55

Preparatory, below knee PTB type socket,

nonalignable system, pylon, no cover, SACH foot, plaster socket, molded to model

L5520

1,640.70

Preparatory, below knee PTB type socket,

nonalignable system, pylon, no cover, SACH foot, thermoplastic or equal, direct formed

L5530

1,787.90

Preparatory, below knee PTB type socket,

nonalignable system, pylon, no cover, SACH foot, thermoplastic or equal, molded to model

L5535

1,865.14

Preparatory, below knee PTB type socket,

nonalignable system, pylon, no cover, SACH foot, prefabricated, adjustable open end socket

L5540

1,773.42

Preparatory, below knee PTB type socket,

nonalignable system, pylon, no cover, SACH foot, laminated socket, molded to model

L5560

1,689.04

Preparatory, above knee - knee disarticulation, ischial level socket, nonalignable system, pylon, no cover, SACH foot, plaster socket, molded to model

L5570

2,037.01

Preparatory, above knee - knee disarticulation, ischial level socket, nonalignable system, pylon, no cover, SACH foot, thermoplastic or equal, direct formed

L5580

2,112.61

Preparatory, above knee - knee disarticulation, ischial level socket, nonalignable system, pylon, no cover, SACH foot, thermoplastic or equal, molded to model

L5585

2,364.77

Preparatory, above knee - knee disarticulation, ischial level socket, nonalignable system, pylon, no cover, SACH foot, prefabricated adjustable open end socket

L5590

2,382.30

Preparatory, above knee - knee disarticulation, ischial level socket, nonalignable system, pylon, no cover, SACH foot, laminated socket, molded to model

L5595

4,248.26

Preparatory, hip disarticulation - hemipelvectomy, pylon, no cover, SACH foot, thermoplastic or equal, molded to patient model

L5600

5,023.42

Preparatory, hip disarticulation - hemipelvectomy, pylon, no cover, SACH foot, laminated socket, molded to patient model

L5610

2,125.16

Addition to lower extremity, endoskeletal system, above knee, hydracadence system

L5611

1,845.41

Addition to lower extremity, endoskeletal system, above knee - knee disarticulation, 4-bar linkage, with friction swing phase control

L5613

2,806.98

Addition to lower extremity, endoskeletal system, above knee - knee disarticulation, 4-bar linkage, with hydraulic swing phase control

L5614

1,423.05

Addition to lower extremity, endoskeletal system, above knee - knee disarticulation, 4-bar linkage, with pneumatic swing phase control

L5616

1,317.12

Addition to lower extremity, endoskeletal system, above knee, universal multiplex system, friction swing phase control

L5617

495.65

Addition to lower extremity, quick change self-aligning unit, above or below knee, each

L5618

322.12

Addition to lower extremity, test socket, Symes

L5620

318.43

Addition to lower extremity, test socket, below knee

L5622

388.19

Addition to lower extremity, test socket, knee disarticulation

L5624

416.41

Addition to lower extremity, test socket, above knee

L5626

495.90

Addition to lower extremity, test socket, hip disarticulation

L5628

469.85

Addition to lower extremity, test socket,

hemipelvectomy

L5629

364.00

Addition to lower extremity, below knee, acrylic socket

L5630

439.02

Addition to lower extremity, Symes type, expandable wall socket

L5631

503.26

Addition to lower extremity, above knee or knee disarticulation, acrylic socket

L5632

217.40

Addition to lower extremity, Symes type, PTB brim design socket

L5634

339.98

Addition to lower extremity, Symes type, posterior opening (Canadian) socket

L5636

291.85

Addition to lower extremity, Symes type, medial opening socket

L5637

285.72

Addition to lower extremity, below knee, total contact

L5638

418.06

Addition to lower extremity, below knee, leather socket

L5639

1,284.18

Addition to lower extremity, below knee, wood socket

L5640

549.30

Addition to lower extremity, knee disarticulation, leather socket

L5642

532.23

Addition to lower extremity, above knee, leather socket

L5643

1,782.72

Addition to lower extremity, hip disarticulation, flexible inner socket, external frame

L5644

665.79

Addition to lower extremity, above knee, wood socket

L5645

763.36

Addition to lower extremity, below knee, flexible inner socket, external frame

L5646

627.57

Addition to lower extremity, below knee, air, fluid, gel or equal, cushion socket

L5647

911.10

Addition to lower extremity, below knee, suction socket

L5648

565.57

Addition to lower extremity, above knee, air, fluid, gel or equal, cushion socket

L5649

1,635.55

Addition to lower extremity, ischial containment/narrow M-L socket

L5650

419.37

Addition to lower extremity, total contact, above knee or knee disarticulation socket

L5651

1,375.51

Addition to lower extremity, above knee, flexible inner socket, external frame

L5652

462.76

Addition to lower extremity, suction suspension, above knee or knee disarticulation socket

L5653

523.53

Addition to lower extremity, knee disarticulation, expandable wall socket

L5654

379.85

Addition to lower extremity, socket insert, Symes (Kemblo, Pelite, Aliplast, Plastazote or equal)

L5655

271.16

Addition to lower extremity, socket insert, below knee (Kemblo, Pelite, Aliplast, Plastazote or equal)

L5656

321.75

Addition to lower extremity, socket insert, knee disarticulation (Kemblo, Pelite, Aliplast, Plastazote or equal)

L5658

363.21

Addition to lower extremity, socket insert, above knee (Kemblo, Pelite, Aliplast, Plastazote or equal)

L5661

697.01

Addition to lower extremity, socket insert, multidurometer, Symes

L5665

586.46

Addition to lower extremity, socket insert,

multidurometer, below knee

L5666

73.41

Addition to lower extremity, below knee, cuff suspension

L5668

106.43

Addition to lower extremity, below knee, molded distal cushion

L5670

247.58

Addition to lower extremity, below knee, molded supracondylar suspension (PTS or similar)

L5671

427.29

Addition to lower extremity, below knee/above knee suspension locking mechanism (shuttle, lanyard or equal), excludes socket insert

L5672

301.18

Addition to lower extremity, below knee, removable medial brim suspension

L5673

677.72

Addition to lower extremity, below knee/above knee, custom fabricated from existing mold or prefabricated, socket insert, silicone gel, elastomeric or equal, for use with locking mechanism

L5676

407.76

Addition to lower extremity, below knee, knee joints, single axis, pair

L5677

564.74

Addition to lower extremity, below knee, knee joints, polycentric, pair

L5678

34.11

Addition to lower extremity, below knee joint covers, pair

L5679

564.73

Addition to lower extremity, below knee/above knee, custom fabricated from existing mold or prefabricated, socket insert, silicone gel, elastomeric or equal, not for use with locking mechanism

L5680

296.84

Addition to lower extremity, below knee, thigh lacer, nonmolded

L5681

1,109.28

Addition to lower extremity, below knee/above knee, custom fabricated socket insert for congenital or atypical traumatic amputee, silicone gel, elastomeric or equal, for use with or without locking mechanism, initial only (for other than initial, use code L5673 or L5679)

L5682

716.31

Addition to lower extremity, below knee, thigh lacer, gluteal/ischial, molded

L5683

1,109.28

Addition to lower extremity, below knee/above knee, custom fabricated socket insert for other than congenital or atypical traumatic amputee, silicone gel, elastomeric or equal, for use with or without locking mechanism, initial only (for other than initial, use code L5673 or L5679)

L5684

51.79

Addition to lower extremity, below knee, fork strap

L5685

108.01

Addition to lower extremity prosthesis, below knee, suspension/sealing sleeve, with or without valve, any material, each

L5686

51.73

Addition to lower extremity, below knee, back check (extension control)

L5688

61.00

Addition to lower extremity, below knee, waist belt, webbing

L5690

112.08

Addition to lower extremity, below knee, waist belt, padded and lined

L5692

135.02

Addition to lower extremity, above knee, pelvic control belt, light

L5694

207.79

Addition to lower extremity, above knee, pelvic control belt, padded and lined

L5695

157.73

Addition to lower extremity, above knee, pelvic control, sleeve suspension, neoprene or equal, each

L5696

203.68

Addition to lower extremity, above knee or knee disarticulation, pelvic joint

L5697

91.95

Addition to lower extremity, above knee or knee disarticulation, pelvic band

L5698

103.21

Addition to lower extremity, above knee or knee disarticulation, Silesian bandage

L5699

207.21

All lower extremity prostheses, shoulder harness

L5700

2,503.15

Replacement, socket, below knee, molded to patient model

L5701

3,105.38

Replacement, socket, above knee/knee disarticulation, including attachment plate, molded to patient model

L5702

3,913.86

Replacement, socket, hip disarticulation, including hip joint, molded to patient model

L5703

2,030.95

Ankle, Symes, molded to patient model, socket without solid ankle cushion heel (SACH) foot, replacement only

L5704

510.40

Custom shaped protective cover, below knee

L5705

935.70

Custom shaped protective cover, above knee

L5706

912.68

Custom shaped protective cover, knee disarticulation

L5707

1,226.17

Custom shaped protective cover, hip disarticulation

L5710

348.86

Addition, exoskeletal knee-shin system, single axis, manual lock

L5711

585.21

Addition, exoskeletal knee-shin system, single axis, manual lock, ultra-light material

L5712

464.98

Addition, exoskeletal knee-shin system, single axis, friction swing and stance phase control (safety knee)

L5714

418.64

Addition, exoskeletal knee-shin system, single axis, variable friction swing phase control

L5716

752.15

Addition, exoskeletal knee-shin system, polycentric, mechanical stance phase lock

L5718

903.46

Addition, exoskeletal knee-shin system, polycentric, friction swing and stance phase control

L5722

847.65

Addition, exoskeletal knee-shin system, single axis, pneumatic swing, friction stance phase control

L5724

1,559.20

Addition, exoskeletal knee-shin system, single axis, fluid swing phase control

L5726

1,936.91

Addition, exoskeletal knee-shin system, single axis, external joints, fluid swing phase control

L5728

2,725.43

Addition, exoskeletal knee-shin system, single axis, fluid swing and stance phase control

L5780

1,048.19

Addition, exoskeletal knee-shin system, single axis, pneumatic/hydra pneumatic swing phase control

L5781

3,374.24

Addition to lower limb prosthesis, vacuum pump, residual limb volume management and moisture evacuation system

L5782

3,557.22

Addition to lower limb prosthesis, vacuum pump, residual limb volume management and moisture evacuation system, heavy duty

L5785

595.08

Addition, exoskeletal system, below knee, ultra-light material (titanium, carbon fiber or equal)

L5790

823.56

Addition, exoskeletal system, above knee, ultra-light material (titanium, carbon fiber or equal)

L5795

1,229.79

Addition, exoskeletal system, hip disarticulation, ultra-light material (titanium, carbon fiber or equal)

L5810

557.65

Addition, endoskeletal knee-shin system, single axis, manual lock

L5811

835.34

Addition, endoskeletal knee-shin system, single axis, manual lock, ultra-light material

L5812

631.92

Addition, endoskeletal knee-shin system, single axis, friction swing and stance phase control (safety knee)

L5814

3,131.94

Addition, endoskeletal knee-shin system, polycentric, hydraulic swing phase control, mechanical stance phase lock

L5816

787.77

Addition, endoskeletal knee-shin system, polycentric, mechanical stance phase lock

L5818

1,099.94

Addition, endoskeletal knee-shin system, polycentric, friction swing and stance phase control

L5822

1,950.47

Addition, endoskeletal knee-shin system, single axis, pneumatic swing, friction stance phase control

L5824

1,530.65

Addition, endoskeletal knee-shin system, single axis, fluid swing phase control

L5826

2,678.39

Addition, endoskeletal knee-shin system, single axis, hydraulic swing phase control, with miniature high activity frame

L5828

3,234.48

Addition, endoskeletal knee-shin system, single axis, fluid swing and stance phase control

L5830

2,173.40

Addition, endoskeletal knee-shin system, single axis, pneumatic/swing phase control

L5840

3,182.45

Addition, endoskeletal knee-shin system, 4-bar linkage or multiaxial, pneumatic swing phase control

L5845

1,511.53

Addition, endoskeletal knee-shin system, stance flexion feature, adjustable

L5848

906.84

Addition to endoskeletal knee-shin system, fluid stance extension, dampening feature, with or without adjustability

L5850

109.89

Addition, endoskeletal system, above knee or hip disarticulation, knee extension assist

L5855

265.30

Addition, endoskeletal system, hip disarticulation, mechanical hip extension assist

L5856

20,475.22

Addition to lower extremity prosthesis, endoskeletal knee-shin system, microprocessor control feature, swing and stance phase, includes electronic sensor(s), any type

L5857

7,414.22

Addition to lower extremity prosthesis, endoskeletal knee-shin system, microprocessor control feature, swing phase only, includes electronic sensor(s), any type

L5858

15,673.19

Addition to lower extremity prosthesis, endoskeletal knee shin system, microprocessor control feature, stance phase only, includes electronic sensor(s), any type

L5910

414.83

Addition, endoskeletal system, below knee, alignable system

L5920

607.73

Addition, endoskeletal system, above knee or hip disarticulation, alignable system

L5925

288.64

Addition, endoskeletal system, above knee, knee disarticulation or hip disarticulation, manual lock

L5930

2,981.78

Addition, endoskeletal system, high activity knee control frame

L5940

430.90

Addition, endoskeletal system, below knee, ultra-light material (titanium, carbon fiber or equal)

L5950

839.16

Addition, endoskeletal system, above knee, ultra-light material (titanium, carbon fiber or equal)

L5960

923.06

Addition, endoskeletal system, hip disarticulation, ultra-light material (titanium, carbon fiber or equal)

L5962

504.94

Addition, endoskeletal system, below knee, flexible protective outer surface covering system

L5964

914.80

Addition, endoskeletal system, above knee, flexible protective outer surface covering system

L5966

1,178.41

Addition, endoskeletal system, hip disarticulation, flexible protective outer surface covering system

L5968

3,064.55

Addition to lower limb prosthesis, multiaxial ankle with swing phase active dorsiflexion feature

L5970

232.62

All lower extremity prostheses, foot, external keel, SACH foot

L5971

232.62

All lower extremity prosthesis, solid ankle cushion heel (SACH) foot, replacement only

L5972

352.92

All lower extremity prostheses, flexible keel foot (SAFE, STEN, Bock Dynamic or equal)

L5974

260.97

All lower extremity prostheses, foot, single axis ankle/foot

L5975

390.95

All lower extremity prosthesis, combination single axis ankle and flexible keel foot

L5976

590.25

All lower extremity prostheses, energy storing foot (Seattle Carbon Copy II or equal)

L5978

319.08

All lower extremity prostheses, foot, multiaxial ankle/foot

L5979

2,034.66

All lower extremity prostheses, multiaxial ankle, dynamic response foot, one piece system

L5980

3,739.01

All lower extremity prostheses, flex-foot system

L5981

2,784.58

All lower extremity prostheses, flex-walk system or equal

L5982

659.38

All exoskeletal lower extremity prostheses, axial rotation unit

L5984

594.67

All endoskeletal lower extremity prosthesis, axial rotation unit, with or without adjustability

L5985

250.14

All endoskeletal lower extremity prostheses, dynamic prosthetic pylon

L5986

557.24

All lower extremity prostheses, multiaxial rotation unit (MCP or equal)

L5987

6,066.57

All lower extremity prosthesis, shank foot system with vertical loading pylon

L5988

1,684.70

Addition to lower limb prosthesis, vertical shock reducing pylon feature

L5990

1,529.95

Addition to lower extremity prosthesis, user adjustable heel height

L5993

AI + 70%

Addition to lower extremity prosthesis, heavy duty feature, foot only, (for patient weight greater than 300 lbs)

L5994

AI + 70%

Addition to lower extremity prosthesis, heavy duty feature, knee only, (for patient weight greater than 300 lbs)

L5995

AI + 70%

Addition to lower extremity prosthesis, heavy duty feature, other than foot or knee, (for patient weight greater than 300 lbs)

L6000

1,141.39

Partial hand, Robin-Aids, thumb remaining (or equal)

L6010

1,270.18

Partial hand, Robin-Aids, little and/or ring finger remaining (or equal)

L6020

1,184.25

Partial hand, Robin-Aids, no finger remaining (or equal)

L6025

6,748.54

Transcarpal/metacarpal or partial hand disarticulation prosthesis, external power, self-suspended, inner socket with removable forearm section, electrodes and cables, two batteries, charger, myoelectric control of terminal device

L6050

1,807.84

Wrist disarticulation, molded socket, flexible elbow hinges, triceps pad

L6055

2,854.00

Wrist disarticulation, molded socket with expandable interface, flexible elbow hinges, triceps pad

L6100

1,819.17

Below elbow, molded socket, flexible elbow hinge, triceps pad

L6110

1,816.09

Below elbow, molded socket (Muenster or Northwestern suspension types)

L6120

2,295.01

Below elbow, molded double wall split socket, step-up hinges, half cuff

L6130

2,494.19

Below elbow, molded double wall split socket, stump activated locking hinge, half cuff

L6200

2,855.32

Elbow disarticulation, molded socket, outside locking hinge, forearm

L6205

3,958.13

Elbow disarticulation, molded socket with expandable interface, outside locking hinges, forearm

L6250

2,366.60

Above elbow, molded double wall socket, internal locking elbow, forearm

L6300

4,264.68

Shoulder disarticulation, molded socket, shoulder bulkhead, humeral section, internal locking elbow, forearm

L6310

2,606.83

Shoulder disarticulation, passive restoration (complete prosthesis)

L6320

1,474.80

Shoulder disarticulation, passive restoration (shoulder cap only)

L6350

3,364.78

Interscapular thoracic, molded socket, shoulder bulkhead, humeral section, internal locking elbow, forearm

L6360

2,736.19

Interscapular thoracic, passive restoration (complete prosthesis)

L6370

1,799.79

Interscapular thoracic, passive restoration (shoulder cap only)

L6380

1,007.86

Immediate postsurgical or early fitting, application of initial rigid dressing, including fitting alignment and suspension of components, and one cast change, wrist disarticulation or below elbow

L6382

1,313.50

Immediate postsurgical or early fitting, application of initial rigid dressing including fitting alignment and suspension of components, and one cast change, elbow disarticulation or above elbow

L6384

1,637.85

Immediate postsurgical or early fitting, application of initial rigid dressing including fitting alignment and suspension of components, and one cast change, shoulder disarticulation or interscapular thoracic

L6386

388.51

Immediate postsurgical or early fitting, each additional cast change and realignment

L6388

503.54

Immediate postsurgical or early fitting, application of rigid dressing only

L6400

1,993.31

Below elbow, molded socket, endoskeletal system, including soft prosthetic tissue shaping

L6450

3,468.52

Elbow disarticulation, molded socket, endoskeletal system, including soft prosthetic tissue shaping

L6500

2,989.76

Above elbow, molded socket, endoskeletal system, including soft prosthetic tissue shaping

L6550

3,515.90

Shoulder disarticulation, molded socket, endoskeletal system, including soft prosthetic tissue shaping

L6570

4,775.34

Interscapular thoracic, molded socket, endoskeletal system, including soft prosthetic tissue shaping

L6580

1,393.42

Preparatory, wrist disarticulation or below elbow, single wall plastic socket, friction wrist, flexible elbow hinges, figure of eight harness, humeral cuff, Bowden cable control, USMC or equal pylon, no cover, molded to patient model

L6582

1,233.06

Preparatory, wrist disarticulation or below elbow, single wall socket, friction wrist, flexible elbow hinges, figure of eight harness, humeral cuff, Bowden cable control, USMC or equal pylon, no cover, direct formed

L6584

2,039.35

Preparatory, elbow disarticulation or above elbow, single wall plastic socket, friction wrist, locking elbow, figure of eight harness, fair lead cable control, USMC or equal pylon, no cover, molded to patient model

L6586

1,782.69

Preparatory, elbow disarticulation or above elbow, single wall socket, friction wrist, locking elbow, figure of eight harness, fair lead cable control, USMC or equal pylon, no cover, direct formed

L6588

2,998.33

Preparatory, shoulder disarticulation or interscapular thoracic, single wall plastic socket, shoulder joint, locking elbow, friction wrist, chest strap, fair lead cable control, USMC or equal pylon, no cover, molded to patient model

L6590

2,647.08

Preparatory, shoulder disarticulation or interscapular thoracic, single wall socket, shoulder joint, locking elbow, friction wrist, chest strap, fair lead cable control, USMC or equal pylon, no cover, direct formed

L6600

161.14

Upper extremity additions, polycentric hinge, pair

L6605

159.10

Upper extremity additions, single pivot hinge, pair

L6610

143.02

Upper extremity additions, flexible metal hinge, pair

L6611

347.22

Addition to upper extremity prosthesis, external powered, additional switch, any type

L6615

149.23

Upper extremity addition, disconnect locking wrist unit

L6616

61.66

Upper extremity addition, additional disconnect insert for locking wrist unit, each

L6620

276.73

Upper extremity addition, flexion/extension wrist unit, with or without friction

L6621

1,928.92

Upper extremity prosthesis addition, flexion/extension wrist with or without friction, for use with external powered terminal device

L6623

605.94

Upper extremity addition, spring assisted rotational wrist unit with latch release

L6624

3,176.01

Upper extremity addition, flexion/extension and rotation wrist unit

L6625

609.18

Upper extremity addition, rotation wrist unit with cable lock

L6628

488.66

Upper extremity addition, quick disconnect hook adapter, Otto Bock or equal

L6629

129.79

Upper extremity addition, quick disconnect lamination collar with coupling piece, Otto Bock or equal

L6630

246.85

Upper extremity addition, stainless steel, any wrist

L6632

60.00

Upper extremity addition, latex suspension sleeve, each

L6635

154.79

Upper extremity addition, lift assist for elbow

L6637

420.57

Upper extremity addition, nudge control elbow lock

L6638

2,108.91

Upper extremity addition to prosthesis, electric locking feature, only for use with manually powered elbow

L6639

1,286.19

Upper extremity addition, heavy duty feature, any elbow

L6640

240.63

Upper extremity additions, shoulder abduction joint, pair

L6641

163.33

Upper extremity addition, excursion amplifier, pulley type

L6642

228.47

Upper extremity addition, excursion amplifier, lever type

L6645

274.23

Upper extremity addition, shoulder flexion-abduction joint, each

L6646

2,659.81

Upper extremity addition, shoulder joint,

multipositional locking, flexion, adjustable abduction friction control, for use with body powered or external powered system

L6647

437.88

Upper extremity addition, shoulder lock mechanism, body powered actuator

L6648

2,743.22

Upper extremity addition, shoulder lock mechanism, external powered actuator

L6650

317.09

Upper extremity addition, shoulder universal joint, each

L6655

70.61

Upper extremity addition, standard control cable, extra

L6660

100.03

Upper extremity addition, heavy duty control cable

L6665

48.10

Upper extremity addition, Teflon, or equal, cable lining

L6670

43.99

Upper extremity addition, hook to hand, cable adapter

L6672

144.85

Upper extremity addition, harness, chest or shoulder, saddle type

L6675

137.55

Upper extremity addition, harness, (e.g. figure of eight type), single cable design

L6676

108.97

Upper extremity addition, harness, (e.g. figure of eight type), dual cable design

L6677

250.16

Upper extremity addition, harness, triple control, simultaneous operation of terminal device and elbow

L6680

202.80

Upper extremity addition, test socket, wrist disarticulation or below elbow

L6682

246.79

Upper extremity addition, test socket, elbow disarticulation or above elbow

L6684

369.09

Upper extremity addition, test socket, shoulder disarticulation or interscapular thoracic

L6686

676.20

Upper extremity addition, suction socket

L6687

495.50

Upper extremity addition, frame type socket, below elbow or wrist disarticulation

L6688

480.92

Upper extremity addition, frame type socket, above elbow or elbow disarticulation

L6689

591.48

Upper extremity addition, frame type socket, shoulder disarticulation

L6690

620.28

Upper extremity addition, frame type socket, interscapular-thoracic

L6691

395.37

Upper extremity addition, removable insert, each

L6692

534.94

Upper extremity addition, silicone gel insert or equal, each

L6693

2,394.18

Upper extremity addition, locking elbow, forearm counterbalance

L6694

677.72

Addition to upper extremity prosthesis, below elbow/above elbow, custom fabricated from existing mold or prefabricated, socket insert, silicone gel, elastomeric or equal, for use with locking mechanism

L6695

564.73

Addition to upper extremity prosthesis, below elbow/above elbow, custom fabricated from existing mold or prefabricated, socket insert, silicone gel, elastomeric or equal, not for use with locking mechanism

L6696

1,109.28

Addition to upper extremity prosthesis, below elbow/above elbow, custom fabricated socket insert for congenital or atypical traumatic amputee, silicone gel, elastomeric or equal, for use with or without locking mechanism, initial only (for other than initial, use code L6694 or L6695)

L6697

1,109.28

Addition to upper extremity prosthesis, below elbow/above elbow, custom fabricated socket insert for other than congenital or atypical traumatic amputee, silicone gel, elastomeric or equal, for use with or without locking mechanism, initial only (for other than initial, use code L6694 or L6695)

L6698

427.29

Addition to upper extremity prosthesis, below elbow/above elbow, lock mechanism, excludes socket insert

L6703

332.40

Terminal device, passive hand/mitt, any material, any size

L6704

503.08

Terminal device, sport/recreational/work attachment, any material, any size

L6706

343.57

Terminal device, hook, mechanical, voluntary opening, any material, any size, lined or unlined

L6707

1,237.49

Terminal device, hook, mechanical, voluntary closing, any material, any size, lined or unlined

L6708

744.38

Terminal device, hand, mechanical, voluntary opening, any material, any size

L6709

1,040.75

Terminal device, hand, mechanical, voluntary closing, any material, any size

L6805

310.65

Addition to terminal device, modifier wrist unit

L6810

160.41

Addition to terminal device, precision pinch device

L6881

3,447.69

Automatic grasp feature, addition to upper limb electric prosthetic terminal device

L6882

2,615.22

Microprocessor control feature, addition to upper limb prosthetic terminal device

L6883

1,363.19

Replacement socket, below elbow/wrist disarticulation, molded to patient model, for use with or without external power

L6884

1,934.38

Replacement socket, above elbow/elbow disarticulation, molded to patient model, for use with or without external power

L6885

2,736.19

Replacement socket, shoulder disarticulation/

interscapular thoracic, molded to patient model, for use with or without external power

L6890

161.57

Addition to upper extremity prosthesis, glove for terminal device, any material, prefabricated, includes fitting and adjustment

L6895

639.57

Addition to upper extremity prosthesis, glove for terminal device, any material, custom fabricated

L6900

1,297.54

Hand restoration (casts, shading and measurements included), partial hand, with glove, thumb or one finger remaining

L6905

1,261.25

Hand restoration (casts, shading and measurements included), partial hand, with glove, multiple fingers remaining

L6910

1,228.71

Hand restoration (casts, shading and measurements included), partial hand, with glove, no fingers remaining

L6915

577.34

Hand restoration (shading and measurements included), replacement glove for above

L6920

6,551.88

Wrist disarticulation, external power, self-suspended inner socket, removable forearm shell, Otto Bock or equal switch, cables, two batteries and one charger, switch control of terminal device

L6925

7,617.30

Wrist disarticulation, external power, self-suspended inner socket, removable forearm shell, Otto Bock or equal electrodes, cables, two batteries and one charger, myoelectronic control of terminal device

L6930

6,388.01

Below elbow, external power, self-suspended inner socket, removable forearm shell, Otto Bock or equal switch, cables, two batteries and one charger, switch control of terminal device

L6935

7,437.03

Below elbow, external power, self-suspended inner socket, removable forearm shell, Otto Bock or equal electrodes, cables, two batteries and one charger, myoelectronic control of terminal device

L6940

8,153.41

Elbow disarticulation, external power, molded inner socket, removable humeral shell, outside locking hinges, forearm, Otto Bock or equal switch, cables, two batteries and one charger, switch control of terminal device

L6945

9,280.46

Elbow disarticulation, external power, molded inner socket, removable humeral shell, outside locking hinges, forearm, Otto Bock or equal electrodes, cables, two batteries and one charger, myoelectronic control of terminal device

L6950

8,572.50

Above elbow, external power, molded inner socket, removable humeral shell, internal locking elbow, forearm, Otto Bock or equal switch, cables, two batteries and one charger, switch control of terminal device

L6955

10,378.59

Above elbow, external power, molded inner socket, removable humeral shell, internal locking elbow, forearm, Otto Bock or equal electrodes, cables, two batteries and one charger, myoelectronic control of terminal device

L6960

11,439.98

Shoulder disarticulation, external power, molded inner socket, removable shoulder shell, shoulder bulkhead, humeral section, mechanical elbow, forearm, Otto Bock or equal switch, cables, two batteries and one charger, switch control of terminal device

L6965

13,422.59

Shoulder disarticulation, external power, molded inner socket, removable shoulder shell, shoulder bulkhead, humeral section, mechanical elbow, forearm, Otto Bock or equal electrodes, cables, two batteries and one charger, myoelectronic control of terminal device

L6970

14,367.62

Interscapular-thoracic, external power, molded inner socket, removable shoulder shell, shoulder bulkhead, humeral section, mechanical elbow, forearm, Otto Bock or equal switch, cables, two batteries and one charger, switch control of terminal device

L6975

16,193.97

Interscapular-thoracic, external power, molded inner socket, removable shoulder shell, shoulder bulkhead, humeral section, mechanical elbow, forearm, Otto Bock or equal electrodes, cables, two batteries and one charger, myoelectronic control of terminal device

L7007

3,114.32

Electric hand, switch or myoelectric controlled, adult

L7008

5,262.22

Electric hand, switch or myoelectric, controlled, pediatric

L7009

3,264.81

Electric hook, switch or myoelectric controlled, adult

L7040

2,495.91

Prehensile actuator, switch controlled

L7045

1,388.49

Electric hook, switch or myoelectric controlled, pediatric

L7170

5,085.91

Electronic elbow, Hosmer or equal, switch controlled

L7180

32,334.77

Electronic elbow, microprocessor sequential control of elbow and terminal device

L7181

33,790.06

Electronic elbow, microprocessor simultaneous control of elbow and terminal device

L7185

5,297.57

Electronic elbow, adolescent, Variety Village or equal, switch controlled

L7186

8,360.17

Electronic elbow, child, Variety Village or equal, switch controlled

L7190

7,099.57

Electronic elbow, adolescent, Variety Village or equal, myoelectronically controlled

L7191

8,801.11

Electronic elbow, child, Variety Village or equal, myoelectronically controlled

L7260

2,245.57

Electronic wrist rotator, Otto Bock or equal

L7261

4,056.39

Electronic wrist rotator, for Utah arm

L7266

850.51

Servo control, Steeper or equal

L7272

1,891.14

Analogue control, UNB or equal

L7274

6,108.88

Proportional control, six-12 volt, Liberty, Utah or equal

L7360

231.27

Six volt battery, each

L7362

239.02

Battery charger, six volt, each

L7364

432.51

Twelve volt battery, each

L7366

588.81

Battery charger, twelve volt, each

L7367

328.32

Lithium ion battery, replacement

L7368

425.62

Lithium ion battery charger

L7400

258.47

Addition to upper extremity prosthesis, below elbow/wrist disarticulation, ultralight material (titanium, carbon fiber or equal)

L7401

289.35

Addition to upper extremity prosthesis, above elbow disarticulation, ultralight material (titanium, carbon fiber or equal)

L7402

312.48

Addition to upper extremity prosthesis, shoulder disarticulation/interscapular thoracic, ultralight material (titanium, carbon fiber or equal)

L7403

310.56

Addition to upper extremity prosthesis, below elbow/wrist disarticulation, acrylic material

L7404

468.72

Addition to upper extremity prosthesis, above elbow disarticulation, acrylic material

L7405

613.03

Addition to upper extremity prosthesis, shoulder disarticulation/interscapular thoracic, acrylic material

L7621

I.C.

Terminal device, hook or hand, heavy duty, mechanical, voluntary opening, any material, any size, lined or unlined

L7622

I.C.

Terminal device, hook or hand, heavy duty, mechanical, voluntary closing, any material, any size, lined or unlined

L7900

462.85

Male vacuum erection system

L8000

31.94

Breast prosthesis, mastectomy bra

L8001

105.77

Breast prosthesis, mastectomy bra, with integrated breast prosthesis form, unilateral

L8002

139.12

Breast prosthesis, mastectomy bra, with integrated breast prosthesis form, bilateral

L8015

50.55

External breast prosthesis garment, with mastectomy form, post-mastectomy

L8020

172.33

Breast prosthesis, mastectomy form

L8030

361.35

Breast prosthesis, silicone or equal

L8035

3,089.60

Custom breast prosthesis, post mastectomy, molded to patient model

L8040

2,256.97

Nasal prosthesis, provided by a nonphysician

L8040

2,256.97

Nasal prosthesis, provided by a nonphysician

L8040

2,256.97

Nasal prosthesis, provided by a nonphysician

L8041

2,720.52

Midfacial prosthesis, provided by a nonphysician

L8041

2,720.52

Midfacial prosthesis, provided by a nonphysician

L8041

2,720.52

Midfacial prosthesis, provided by a nonphysician

L8042

3,056.77

Orbital prosthesis, provided by a nonphysician

L8042

3,056.77

Orbital prosthesis, provided by a nonphysician

L8042

3,056.77

Orbital prosthesis, provided by a nonphysician

L8043

3,423.59

Upper facial prosthesis, provided by a nonphysician

L8043

3,423.59

Upper facial prosthesis, provided by a nonphysician

L8043

3,423.59

Upper facial prosthesis, provided by a nonphysician

L8044

3,790.39

Hemi-facial prosthesis, provided by a nonphysician

L8044

3,790.39

Hemi-facial prosthesis, provided by a nonphysician

L8044

3,790.39

Hemi-facial prosthesis, provided by a nonphysician

L8045

2,382.92

Auricular prosthesis, provided by a nonphysician

L8045

2,382.92

Auricular prosthesis, provided by a nonphysician

L8045

2,382.92

Auricular prosthesis, provided by a nonphysician

L8046

2,445.42

Partial facial prosthesis, provided by a nonphysician

L8046

2,445.42

Partial facial prosthesis, provided by a nonphysician

L8046

2,445.42

Partial facial prosthesis, provided by a nonphysician

L8047

1,253.28

Nasal septal prosthesis, provided by a nonphysician

L8047

1,253.28

Nasal septal prosthesis, provided by a nonphysician

L8047

1,253.28

Nasal septal prosthesis, provided by a nonphysician

L8300

72.46

Truss, single with standard pad

L8310

114.41

Truss, double with standard pads

L8320

60.83

Truss, addition to standard pad, water pad

L8330

56.55

Truss, addition to standard pad, scrotal pad

L8400

15.39

Prosthetic sheath, below knee, each

L8410

23.73

Prosthetic sheath, above knee, each

L8415

24.55

Prosthetic sheath, upper limb, each

L8417

63.32

Prosthetic sheath/sock, including a gel cushion layer, below knee or above knee, each

L8420

17.87

Prosthetic sock, multiple ply, below knee, each

L8430

20.90

Prosthetic sock, multiple ply, above knee, each

L8435

23.31

Prosthetic sock, multiple ply, upper limb, each

L8440

40.40

Prosthetic shrinker, below knee, each

L8460

65.87

Prosthetic shrinker, above knee, each

L8465

44.03

Prosthetic shrinker, upper limb, each

L8470

5.74

Prosthetic sock, single ply, fitting, below knee, each

L8480

10.02

Prosthetic sock, single ply, fitting, above knee, each

L8485

10.04

Prosthetic sock, single ply, fitting, upper limb, each

L8500

638.30

Artificial larynx, any type

L8501

138.36

Tracheostomy speaking valve

L8507

35.33

Tracheo-esophageal voice prosthesis, patient inserted, any type, each

L8509

92.10

Tracheo-esophageal voice prosthesis, inserted by a licensed health care provider, any type

L8510

213.09

Voice amplifier

L8511

61.33

Insert for indwelling tracheoesophageal prosthesis, with or without valve, replacement only, each

L8512

1.82

Gelatin capsules or equivalent, for use with tracheoesophageal voice prosthesis, replacement only, per ten

L8513

4.38

Cleaning device used with tracheoesophageal voice prosthesis, pipet, brush, or equal, replacement only, each

L8514

79.52

Tracheoesophageal puncture dilator, replacement only, each

L8515

53.23

Gelatin capsule, application device for use with tracheoesophageal voice prosthesis, each

L8600

541.09

Implantable breast prosthesis, silicone or equal

L8603

376.16

Injectable bulking agent, collagen implant, urinary tract, 2.5 ml syringe, includes shipping and necessary supplies

L8606

184.87

Injectable bulking agent, synthetic implant, urinary tract, 1 ml syringe, includes shipping and necessary supplies

L8609

5,494.58

Artificial cornea

L8610

502.81

Ocular implant

L8612

616.35

Aqueous shunt

L8613

268.38

Ossicula implant

L8614

16,447.22

Cochlear device, includes all internal and external components

L8615

380.34

Headset/headpiece for use with cochlear implant device, replacement

L8616

88.59

Microphone for use with cochlear implant device, replacement

L8617

77.37

Transmitting coil for use with cochlear implant device, replacement

L8618

22.11

Transmitter cable for use with cochlear implant device, replacement

L8619

7,060.69

Cochlear implant external speech processor, replacement

L8621

0.52

Zinc air battery for use with cochlear implant device, replacement, each

L8622

0.28

Alkaline battery for use with cochlear implant device, any size, replacement, each

L8623

54.55

Lithium ion battery for use with cochlear implant device speech processor, other than ear level, replacement, each

L8624

136.00

Lithium ion battery for use with cochlear implant device speech processor, ear level, replacement, each

L8630

385.88

Metacarpophalangeal joint implant

L8631

1,881.80

Metacarpal phalangeal joint replacement, two or more pieces, metal (e.g., stainless steel or cobalt chrome), ceramic-like material (e.g., pyrocarbon), for surgical implantation (all sizes, includes entire system)

L8641

400.93

Metatarsal joint implant

L8642

243.90

Hallux implant

L8658

349.58

Interphalangeal joint spacer, silicone or equal, each

L8659

1,627.34

Interphalangeal finger joint replacement, two or more pieces, metal (e.g., stainless steel or cobalt chrome), ceramic-like material (e.g., pyrocarbon) for surgical implantation, any size

L8670

478.18

Vascular graft material, synthetic, implant

L8680

387.36

Implantable neurostimulator electrode, each

L8681

926.72

Patient programmer (external) for use with implantable programmable neurostimulator pulse generator

L8682

5,027.57

Implantable neurostimulator radiofrequency receiver

L8683

4,425.41

Radiofrequency transmitter (external) for use with implantable neurostimulator radiofrequency receiver

L8684

584.96

Radiofrequency transmitter (external) for use with implantable sacral root neurostimulator receiver for bowel and bladder management, replacement

L8685

11,027.88

Implantable neurostimulator pulse generator, single array, rechargeable, includes extension

L8686

7,036.64

Implantable neurostimulator pulse generator, single array, non-rechargeable, includes extension

L8687

14,351.67

Implantable neurostimulator pulse generator, dual array, rechargeable, includes extension

L8688

9,157.52

Implantable neurostimulator pulse generator, dual array, non-rechargeable, includes extension

L8689

1,454.68

External recharging system for battery (internal) for use with implantable neurostimulator

L8690

4,011.80

Auditory osseointegrated device, includes all internal and external components

L8691

2,248.74

Auditory osseointegrated device, external sound processor, replacement

L8695

14.04

External recharging system for battery (external) for use with implantable neurostimulator

L7614

I.C.

Terminal device, hand, mechanical, voluntary closing, any material, any size, pediatric

L7621

I.C.

Terminal device, hook or hand, heavy duty, mechanical, voluntary opening, any material, any size, lined or unlined

L7622

I.C.

Terminal device, hook or hand, heavy duty, mechanical, voluntary closing, any material, any size, lined or unlined

L7900

462.85

Male vacuum erection system

L8000

31.94

Breast prosthesis, mastectomy bra

L8001

105.77

Breast prosthesis, mastectomy bra, with integrated breast prosthesis form, unilateral

L8002

139.12

Breast prosthesis, mastectomy bra, with integrated breast prosthesis form, bilateral

L8015

50.55

External breast prosthesis garment, with mastectomy form, post-mastectomy

L8020

172.33

Breast prosthesis, mastectomy form

L8030

361.35

Breast prosthesis, silicone or equal

L8035

3,089.60

Custom breast prosthesis, post mastectomy, molded to patient model

L8040

2,256.97

Nasal prosthesis, provided by a nonphysician

L8041

2,720.52

Midfacial prosthesis, provided by a nonphysician

L8042

3,056.77

Orbital prosthesis, provided by a nonphysician

L8043

3,423.59

Upper facial prosthesis, provided by a nonphysician

L8044

3,790.39

Hemi-facial prosthesis, provided by a nonphysician

L8045

2,382.92

Auricular prosthesis, provided by a nonphysician

L8046

2,445.42

Partial facial prosthesis, provided by a nonphysician

L8047

1,253.28

Nasal septal prosthesis, provided by a nonphysician

L8300

72.46

Truss, single with standard pad

L8310

114.41

Truss, double with standard pads

L8320

60.83

Truss, addition to standard pad, water pad

L8330

56.55

Truss, addition to standard pad, scrotal pad

L8400

15.39

Prosthetic sheath, below knee, each

L8410

23.73

Prosthetic sheath, above knee, each

L8415

24.55

Prosthetic sheath, upper limb, each

L8417

63.32

Prosthetic sheath/sock, including a gel cushion layer, below knee or above knee, each

L8420

17.87

Prosthetic sock, multiple ply, below knee, each

L8430

20.90

Prosthetic sock, multiple ply, above knee, each

L8435

23.31

Prosthetic sock, multiple ply, upper limb, each

L8440

40.40

Prosthetic shrinker, below knee, each

L8460

65.87

Prosthetic shrinker, above knee, each

L8465

44.03

Prosthetic shrinker, upper limb, each

L8470

5.74

Prosthetic sock, single ply, fitting, below knee, each

L8480

10.02

Prosthetic sock, single ply, fitting, above knee, each

L8485

10.04

Prosthetic sock, single ply, fitting, upper limb, each

L8500

638.30

Artificial larynx, any type

L8501

138.36

Tracheostomy speaking valve

L8507

35.33

Tracheo-esophageal voice prosthesis, patient inserted, any type, each

L8509

92.10

Tracheo-esophageal voice prosthesis, inserted by a licensed health care provider, any type

L8510

213.09

Voice amplifier

L8511

61.33

Insert for indwelling tracheoesophageal prosthesis, with or without valve, replacement only, each

L8512

1.82

Gelatin capsules or equivalent, for use with tracheoesophageal voice prosthesis, replacement only, per ten

L8513

4.38

Cleaning device used with tracheoesophageal voice prosthesis, pipet, brush, or equal, replacement only, each

L8514

79.52

Tracheoesophageal puncture dilator, replacement only, each

L8515

53.23

Gelatin capsule, application device for use with tracheoesophageal voice prosthesis, each

L8600

541.09

Implantable breast prosthesis, silicone or equal

L8603

376.16

Injectable bulking agent, collagen implant, urinary tract, 2.5 ml syringe, includes shipping and necessary supplies

L8606

184.87

Injectable bulking agent, synthetic implant, urinary tract, 1 ml syringe, includes shipping and necessary supplies

L8609

5,494.58

Artificial cornea

L8610

502.81

Ocular implant

L8612

616.35

Aqueous shunt

L8613

268.38

Ossicula implant

L8614

16,447.22

Cochlear device, includes all internal and external components

L8615

380.34

Headset/headpiece for use with cochlear implant device, replacement

L8616

88.59

Microphone for use with cochlear implant device, replacement

L8617

77.37

Transmitting coil for use with cochlear implant device, replacement

L8618

22.11

Transmitter cable for use with cochlear implant device, replacement

L8619

7,060.69

Cochlear implant external speech processor, replacement

L8621

0.52

Zinc air battery for use with cochlear implant device, replacement, each

L8622

0.28

Alkaline battery for use with cochlear implant device, any size, replacement, each

L8623

54.55

Lithium ion battery for use with cochlear implant device speech processor, other than ear level, replacement, each

L8624

136.00

Lithium ion battery for use with cochlear implant device speech processor, ear level, replacement, each

L8630

385.88

Metacarpophalangeal joint implant

L8631

1,881.80

Metacarpal phalangeal joint replacement, two or more pieces, metal (e.g., stainless steel or cobalt chrome), ceramic-like material (e.g., pyrocarbon), for surgical implantation (all sizes, includes entire system)

L8641

400.93

Metatarsal joint implant

L8642

243.90

Hallux implant

L8658

349.58

Interphalangeal joint spacer, silicone or equal, each

L8659

1,627.34

Interphalangeal finger joint replacement, two or more pieces, metal (e.g., stainless steel or cobalt chrome), ceramic-like material (e.g., pyrocarbon) for surgical implantation, any size

L8670

478.18

Vascular graft material, synthetic, implant

L8680

387.36

Implantable neurostimulator electrode, each

L8681

926.72

Patient programmer (external) for use with implantable programmable neurostimulator pulse generator

L8682

5,027.57

Implantable neurostimulator radiofrequency receiver

L8683

4,425.41

Radiofrequency transmitter (external) for use with implantable neurostimulator radiofrequency receiver

L8684

584.96

Radiofrequency transmitter (external) for use with implantable sacral root neurostimulator receiver for bowel and bladder management, replacement

L8685

11,027.88

Implantable neurostimulator pulse generator, single array, rechargeable, includes extension

L8686

7,036.64

Implantable neurostimulator pulse generator, single array, non-rechargeable, includes extension

L8687

14,351.67

Implantable neurostimulator pulse generator, dual array, rechargeable, includes extension

L8688

9,157.52

Implantable neurostimulator pulse generator, dual array, non-rechargeable, includes extension

L8689

1,454.68

External recharging system for battery (internal) for use with implantable neurostimulator

L8690

4,011.80

Auditory osseointegrated device, includes all internal and external components

L8691

2,248.74

Auditory osseointegrated device, external sound processor, replacement

L8695

14.04

External recharging system for battery (external) for use with implantable neurostimulator

(7) Freestanding Diagnostic Facilities/Radiology.

Code

Global

PC

TC

40.06(7) - Radiologic Service Description

70010

222.25

60.54

161.71

Myelography, posterior fossa, radiological supervision and interpretation

70015

152.67

61.90

90.77

Cisternography, positive contrast, radiological supervision and interpretation

70030

31.56

8.87

22.69

Radiologic examination, eye, for detection of foreign body

70100

35.12

9.21

25.91

Radiologic examination, mandible; partial, less than four views

70110

44.56

12.52

32.04

Radiologic examination, mandible; complete, minimum of four views

70120

39.40

9.21

30.20

Radiologic examination, mastoids; less than three views per side

70130

60.66

17.27

43.38

Radiologic examination, mastoids; complete, minimum of three views per side

70134

53.75

17.27

36.48

Radiologic examination, internal auditory meati, complete

70140

36.52

9.55

26.97

Radiologic examination, facial bones; less than three views

70150

49.80

12.86

36.94

Radiologic examination, facial bones; complete, minimum of three views

70160

36.16

8.87

27.30

Radiologic examination, nasal bones, complete, minimum of three views

70170

I.C.

15.15

I.C.

Dacryocystography, nasolacrimal duct, radiological supervision and interpretation

70190

41.35

10.69

30.66

Radiologic examination; optic foramina

70200

51.40

14.00

37.40

Radiologic examination; orbits, complete, minimum of four views

70210

35.84

8.41

27.44

Radiologic examination, sinuses, paranasal, less than three views

70220

47.16

12.52

34.64

Radiologic examination, sinuses, paranasal, complete, minimum of three views

70240

32.24

9.55

22.69

Radiologic examination, sella turcica

70250

41.45

11.72

29.74

Radiologic examination, skull; less than four views

70260

57.27

17.27

40.00

Radiologic examination, skull; complete, minimum of four views

70300

16.74

5.56

11.19

Radiologic examination, teeth; single view

70310

36.28

8.52

27.76

Radiologic examination, teeth; partial examination, less than full mouth

70320

53.96

11.49

42.46

Radiologic examination, teeth; complete, full mouth

70328

34.20

9.21

24.99

Radiologic examination, temporomandibular joint, open and closed mouth; unilateral

70330

54.18

12.18

42.00

Radiologic examination, temporomandibular joint, open and closed mouth; bilateral

70332

109.17

27.32

81.84

Temporomandibular joint arthrography, radiological supervision and interpretation

70336

619.89

75.64

544.25

Magnetic resonance (eg, proton) imaging, temporomandibular joint(s)

70350

24.65

8.87

15.79

Cephalogram, orthodontic

70355

29.96

10.35

19.61

Orthopantogram

70360

30.64

8.87

21.77

Radiologic examination; neck, soft tissue

70370

83.75

15.83

67.92

Radiologic examination; pharynx or larynx, including fluoroscopy and/or magnification technique

70371

122.31

42.31

80.00

Complex dynamic pharyngeal and speech evaluation by cine or video recording

70373

99.93

21.61

78.32

Laryngography, contrast, radiological supervision and interpretation

70380

43.21

8.87

34.34

Radiologic examination, salivary gland for calculus

70390

114.91

19.56

95.35

Sialography, radiological supervision and interpretation

70450

266.01

43.57

222.45

Computed tomography, head or brain; without contrast material

70460

338.13

58.03

280.10

Computed tomography, head or brain; with contrast material(s)

70470

411.13

64.95

346.18

Computed tomography, head or brain; without contrast material, followed by contrast material(s) and further sections

70480

366.45

65.29

301.15

Computed tomography, orbit, sella, or posterior fossa or outer, middle, or inner ear; without contrast material

70481

428.43

70.55

357.89

Computed tomography, orbit, sella, or posterior fossa or outer, middle, or inner ear; with contrast material(s)

70482

498.74

73.86

424.88

Computed tomography, orbit, sella, or posterior fossa or outer, middle, or inner ear; without contrast material, followed by contrast material(s) and further sections

70486

321.32

57.91

263.41

Computed tomography, maxillofacial area; without contrast material

70487

387.96

66.90

321.06

Computed tomography, maxillofacial area; with contrast material(s)

70488

474.24

72.38

401.87

Computed tomography, maxillofacial area; without contrast material, followed by contrast material(s) and further sections

70490

320.88

65.75

255.13

Computed tomography, soft tissue neck; without contrast material

70491

383.79

70.55

313.24

Computed tomography, soft tissue neck; with contrast material(s)

70492

466.98

73.86

393.12

Computed tomography, soft tissue neck; without contrast material followed by contrast material(s) and further sections

70496

730.37

89.77

640.61

Computed tomographic angiography, head, with contrast material(s), including noncontrast images, if performed, and image postprocessing

70498

733.59

90.23

643.37

Computed tomographic angiography, neck, with contrast material(s), including noncontrast images, if performed, and image postprocessing

70540

653.81

68.60

585.20

Magnetic resonance (eg, proton) imaging, orbit, face, and/or neck; without contrast material(s)

70542

745.35

82.73

662.62

Magnetic resonance (eg, proton) imaging, orbit, face, and/or neck; with contrast material(s)

70543

1,122.49

109.55

1,012.94

Magnetic resonance (eg, proton) imaging, orbit, face, and/or neck; without contrast material(s), followed by contrast material(s) and further sequences

70544

692.12

61.34

630.78

Magnetic resonance angiography, head; without contrast material(s)

70545

689.36

61.34

628.02

Magnetic resonance angiography, head; with contrast material(s)

70546

1,164.58

91.93

1,072.65

Magnetic resonance angiography, head; without contrast material(s), followed by contrast material(s) and further sequences

70547

690.28

60.88

629.40

Magnetic resonance angiography, neck; without contrast material(s)

70548

710.53

61.34

649.19

Magnetic resonance angiography, neck; with contrast material(s)

70549

1,164.58

91.93

1,072.65

Magnetic resonance angiography, neck; without contrast material(s), followed by contrast material(s) and further sequences

70551

671.90

75.64

596.26

Magnetic resonance (eg, proton) imaging, brain (including brain stem); without contrast material

70552

766.29

91.25

675.04

Magnetic resonance (eg, proton) imaging, brain (including brain stem); with contrast material(s)

70553

1,129.94

120.40

1,009.54

Magnetic resonance (eg, proton) imaging, brain (including brain stem); without contrast material, followed by contrast material(s) and further sequences

70554

809.37

106.80

702.57

Magnetic resonance imaging, brain, functional MRI; including test selection and administration of repetitive body part movement and/or visual stimulation, not requiring physician or psychologist administration

70555

I.C.

131.45

I.C.

Magnetic resonance imaging, brain, functional MRI; requiring physician or psychologist administration of entire neurofunctional testing

70557

I.C.

151.12

I.C.

Magnetic resonance (eg, proton) imaging, brain (including brain stem and skull base), during open intracranial procedure (eg, to assess for residual tumor or residual vascular malformation); without contrast material

70558

I.C.

166.11

I.C.

Magnetic resonance (eg, proton) imaging, brain (including brain stem and skull base), during open intracranial procedure (eg, to assess for residual tumor or residual vascular malformation); with contrast material(s)

70559

I.C.

167.63

I.C.

Magnetic resonance (eg, proton) imaging, brain (including brain stem and skull base), during open intracranial procedure (eg, to assess for residual tumor or residual vascular malformation); without contrast material(s), followed by contrast material(s) and further sequences

71010

29.14

9.21

19.93

Radiologic examination, chest; single view, frontal

71015

34.77

10.69

24.07

Radiologic examination, chest; stereo, frontal

71020

38.01

11.03

26.97

Radiologic examination, chest, two views, frontal and lateral;

71021

46.46

13.66

32.80

Radiologic examination, chest, two views, frontal and lateral; with apical lordotic procedure

71022

51.97

15.49

36.48

Radiologic examination, chest, two views, frontal and lateral; with oblique projections

71023

71.39

19.72

51.67

Radiologic examination, chest, two views, frontal and lateral; with fluoroscopy

71030

53.81

15.49

38.32

Radiologic examination, chest, complete, minimum of four views;

71034

103.86

24.59

79.26

Radiologic examination, chest, complete, minimum of four views; with fluoroscopy

71035

38.34

9.21

29.14

Radiologic examination, chest, special views (eg, lateral decubitus, Bucky studies)

71040

108.25

28.99

79.26

Bronchography, unilateral, radiological supervision and interpretation

71060

158.02

37.67

120.35

Bronchography, bilateral, radiological supervision and interpretation

71090

I.C.

30.08

I.C.

Insertion pacemaker, fluoroscopy and radiography, radiological supervision and interpretation

71100

38.01

11.03

26.97

Radiologic examination, ribs, unilateral; two views

71101

45.70

13.66

32.04

Radiologic examination, ribs, unilateral; including posteroanterior chest, minimum of three views

71110

48.76

13.66

35.10

Radiologic examination, ribs, bilateral; three views

71111

60.43

15.83

44.60

Radiologic examination, ribs, bilateral; including posteroanterior chest, minimum of four views

71120

39.63

10.35

29.28

Radiologic examination; sternum, minimum of two

views

71130

43.99

11.03

32.96

Radiologic examination; sternoclavicular joint or joints, minimum of three views

71250

343.60

59.06

284.54

Computed tomography, thorax; without contrast material

71260

411.18

63.17

348.02

Computed tomography, thorax; with contrast material(s)

71270

508.26

70.55

437.71

Computed tomography, thorax; without contrast material, followed by contrast material(s) and further sections

71275

650.23

98.63

551.60

Computed tomographic angiography, chest (noncoronary), with contrast material(s), including noncontrast images, if performed, and image postprocessing

71550

710.91

74.20

636.71

Magnetic resonance (eg, proton) imaging, chest (eg, for evaluation of hilar and mediastinal lymphadenopathy); without contrast material(s)

71551

812.12

88.16

723.96

Magnetic resonance (eg, proton) imaging, chest (eg, for evaluation of hilar and mediastinal lymphadenopathy); with contrast material(s)

71552

1,209.82

115.60

1,094.22

Magnetic resonance (eg, proton) imaging, chest (eg, for evaluation of hilar and mediastinal lymphadenopathy); without contrast material(s), followed by contrast material(s) and further sequences

71555

706.02

93.19

612.83

Magnetic resonance angiography, chest (excluding myocardium), with or without contrast material(s)

72010

77.60

22.41

55.19

Radiologic examination, spine, entire, survey study, anteroposterior and lateral

72020

27.65

7.72

19.93

Radiologic examination, spine, single view, specify level

72040

42.15

11.03

31.12

Radiologic examination, spine, cervical; two or three views

72050

60.09

15.49

44.60

Radiologic examination, spine, cervical; minimum of four views

72052

75.45

18.41

57.03

Radiologic examination, spine, cervical; complete, including oblique and flexion and/or extension studies

72069

38.79

11.49

27.30

Radiologic examination, spine, thoracolumbar, standing (scoliosis)

72070

40.31

11.03

29.28

Radiologic examination, spine; thoracic, two views

72072

45.21

11.03

34.18

Radiologic examination, spine; thoracic, three views

72074

53.80

11.03

42.76

Radiologic examination, spine; thoracic, minimum of four views

72080

41.69

11.03

30.66

Radiologic examination, spine; thoracolumbar, two views

72090

52.02

14.46

37.56

Radiologic examination, spine; scoliosis study, including supine and erect studies

72100

44.45

11.03

33.42

Radiologic examination, spine, lumbosacral; two or three views

72110

61.93

15.49

46.45

Radiologic examination, spine, lumbosacral; minimum of four views

72114

80.51

18.41

62.10

Radiologic examination, spine, lumbosacral; complete, including bending views

72120

56.10

11.03

45.06

Radiologic examination, spine, lumbosacral, bending views only, minimum of four views

72125

344.06

59.06

285.00

Computed tomography, cervical spine; without contrast material

72126

410.04

62.02

348.02

Computed tomography, cervical spine; with contrast material

72127

503.58

64.95

438.63

Computed tomography, cervical spine; without contrast material, followed by contrast material(s) and further sections

72128

343.60

59.06

284.54

Computed tomography, thoracic spine; without contrast material

72129

410.50

62.49

348.02

Computed tomography, thoracic spine; with contrast material

72130

502.20

64.95

437.25

Computed tomography, thoracic spine; without contrast material, followed by contrast material(s) and further sections

72131

343.14

59.06

284.08

Computed tomography, lumbar spine; without contrast material

72132

409.58

62.02

347.56

Computed tomography, lumbar spine; with contrast material

72133

503.12

64.95

438.17

Computed tomography, lumbar spine; without contrast material, followed by contrast material(s) and further sections

72141

631.35

81.58

549.77

Magnetic resonance (eg, proton) imaging, spinal canal and contents, cervical; without contrast material

72142

772.75

98.17

674.58

Magnetic resonance (eg, proton) imaging, spinal canal and contents, cervical; with contrast material(s)

72146

661.85

81.58

580.27

Magnetic resonance (eg, proton) imaging, spinal canal and contents, thoracic; without contrast material

72147

725.80

98.17

627.63

Magnetic resonance (eg, proton) imaging, spinal canal and contents, thoracic; with contrast material(s)

72148

655.45

75.64

579.81

Magnetic resonance (eg, proton) imaging, spinal canal and contents, lumbar; without contrast material

72149

764.91

91.25

673.66

Magnetic resonance (eg, proton) imaging, spinal canal and contents, lumbar; with contrast material(s)

72156

1,132.34

131.09

1,001.25

Magnetic resonance (eg, proton) imaging, spinal canal and contents, without contrast material, followed by contrast material(s) and further sequences; cervical

72157

1,095.98

131.09

964.89

Magnetic resonance (eg, proton) imaging, spinal canal and contents, without contrast material, followed by contrast material(s) and further sequences; thoracic

72158

1,121.19

120.40

1,000.79

Magnetic resonance (eg, proton) imaging, spinal canal and contents, without contrast material, followed by contrast material(s) and further sequences; lumbar

72159

718.83

89.77

629.06

Magnetic resonance angiography, spinal canal and contents, with or without contrast material(s)

72170

31.56

8.87

22.69

Radiologic examination, pelvis; one or two views

72190

45.03

10.69

34.34

Radiologic examination, pelvis; complete, minimum of three views

72191

627.76

93.19

534.57

Computed tomographic angiography, pelvis, with contrast material(s), including noncontrast images, if performed, and image postprocessing

72192

331.08

55.75

275.33

Computed tomography, pelvis; without contrast material

72193

392.04

59.52

332.53

Computed tomography, pelvis; with contrast material(s)

72194

493.77

62.02

431.75

Computed tomography, pelvis; without contrast material, followed by contrast material(s) and further sections

72195

666.26

74.20

592.06

Magnetic resonance (eg, proton) imaging, pelvis; without contrast material(s)

72196

757.35

88.62

668.73

Magnetic resonance (eg, proton) imaging, pelvis; with contrast material(s)

72197

1,134.16

115.14

1,019.02

Magnetic resonance (eg, proton) imaging, pelvis; without contrast material(s), followed by contrast material(s) and further sequences

72198

700.16

91.93

608.23

Magnetic resonance angiography, pelvis, with or without contrast material(s)

72200

33.86

8.87

24.99

Radiologic examination, sacroiliac joints; less than three views

72202

40.67

9.55

31.12

Radiologic examination, sacroiliac joints; three or

more views

72220

35.38

8.87

26.51

Radiologic examination, sacrum and coccyx, minimum of two views

72240

214.67

46.08

168.59

Myelography, cervical, radiological supervision and interpretation

72255

196.74

45.16

151.58

Myelography, thoracic, radiological supervision and interpretation

72265

194.01

41.97

152.04

Myelography, lumbosacral, radiological supervision and interpretation

72270

299.67

67.92

231.75

Myelography, two or more regions (eg, lumbar/thoracic, cervical/thoracic, lumbar/cervical, lumbar/thoracic/cervical), radiological supervision and interpretation

72275

126.72

36.35

90.37

Epidurography, radiological supervision and interpretation

72285

288.88

56.89

231.98

Discography, cervical or thoracic, radiological supervision and interpretation

72291

I.C.

69.36

I.C.

Radiological supervision and interpretation, percutaneous vertebroplasty or vertebral augmentation including cavity creation, per vertebral body; under fluoroscopic guidance

72292

I.C.

71.77

I.C.

Radiological supervision and interpretation, percutaneous vertebroplasty or vertebral augmentation including cavity creation, per vertebral body; under CT guidance

72295

263.06

42.10

220.96

Discography, lumbar, radiological supervision and interpretation

73000

32.14

8.06

24.07

Radiologic examination; clavicle, complete

73010

33.40

8.87

24.53

Radiologic examination; scapula, complete

73020

28.11

7.72

20.39

Radiologic examination, shoulder; one view

73030

35.26

9.21

26.05

Radiologic examination, shoulder; complete, minimum of two views

73040

127.12

27.78

99.34

Radiologic examination, shoulder, arthrography, radiological supervision and interpretation

73050

41.93

10.35

31.58

Radiologic examination; acromioclavicular joints, bilateral, with or without weighted distraction

73060

34.92

8.87

26.05

Radiologic examination; humerus, minimum of two views

73070

31.80

7.72

24.07

Radiologic examination, elbow; two views

73080

39.06

8.87

30.20

Radiologic examination, elbow; complete, minimum of three views

73085

117.91

27.78

90.13

Radiologic examination, elbow, arthrography, radiological supervision and interpretation

73090

32.14

8.06

24.07

Radiologic examination; forearm, two views

73092

32.14

8.06

24.07

Radiologic examination; upper extremity, infant, minimum of two views

73100

32.60

8.06

24.53

Radiologic examination, wrist; two views

73110

38.00

8.87

29.14

Radiologic examination, wrist; complete, minimum of three views

73115

115.93

27.32

88.61

Radiologic examination, wrist, arthrography, radiological supervision and interpretation

73120

31.68

8.06

23.61

Radiologic examination, hand; two views

73130

35.70

8.87

26.84

Radiologic examination, hand; minimum of three views

73140

31.57

6.58

24.99

Radiologic examination, finger(s), minimum of two

views

73200

315.93

55.75

260.19

Computed tomography, upper extremity; without contrast material

73201

377.20

59.06

318.14

Computed tomography, upper extremity; with contrast material(s)

73202

477.84

62.02

415.82

Computed tomography, upper extremity; without contrast material, followed by contrast material(s) and further sections

73206

593.24

93.19

500.05

Computed tomographic angiography, upper extremity, with contrast material(s), including noncontrast images, if performed, and image postprocessing

73218

664.85

68.60

596.25

Magnetic resonance (eg, proton) imaging, upper extremity, other than joint; without contrast material(s)

73219

748.11

82.73

665.39

Magnetic resonance (eg, proton) imaging, upper extremity, other than joint; with contrast material(s)

73220

1,129.39

110.01

1,019.39

Magnetic resonance (eg, proton) imaging, upper extremity, other than joint; without contrast material(s), followed by contrast material(s) and further sequences

73221

639.54

68.60

570.93

Magnetic resonance (eg, proton) imaging, any joint of upper extremity; without contrast material(s)

73222

722.80

82.73

640.07

Magnetic resonance (eg, proton) imaging, any joint of upper extremity; with contrast material(s)

73223

1,095.33

109.55

985.79

Magnetic resonance (eg, proton) imaging, any joint of upper extremity; without contrast material(s), followed by contrast material(s) and further sequences

73225

685.48

86.46

599.02

Magnetic resonance angiography, upper extremity, with or without contrast material(s)

73500

30.18

8.87

21.31

Radiologic examination, hip, unilateral; one view

73510

41.35

10.69

30.66

Radiologic examination, hip, unilateral; complete, minimum of two views

73520

45.82

13.32

32.50

Radiologic examination, hips, bilateral, minimum of two views of each hip, including anteroposterior view of pelvis

73525

117.75

27.62

90.13

Radiologic examination, hip, arthrography, radiological supervision and interpretation

73530

I.C.

14.80

I.C.

Radiologic examination, hip, during operative procedure

73540

41.47

10.35

31.12

Radiologic examination, pelvis and hips, infant or child, minimum of two views

73542

102.89

27.95

74.94

Radiological examination, sacroiliac joint arthrography, radiological supervision and interpretation

73550

34.46

8.87

25.59

Radiologic examination, femur, two views

73560

33.40

8.87

24.53

Radiologic examination, knee; one or two views

73562

38.94

9.21

29.74

Radiologic examination, knee; three views

73564

44.45

11.03

33.42

Radiologic examination, knee; complete, four or more

views

73565

34.32

8.87

25.45

Radiologic examination, knee; both knees, standing, anteroposterior

73580

146.89

27.62

119.27

Radiologic examination, knee, arthrography, radiological supervision and interpretation

73590

32.48

8.87

23.61

Radiologic examination; tibia and fibula, two views

73592

32.14

8.06

24.07

Radiologic examination; lower extremity, infant, minimum of two views

73600

31.68

8.06

23.61

Radiologic examination, ankle; two views

73610

35.70

8.87

26.84

Radiologic examination, ankle; complete, minimum of three views

73615

121.43

27.62

93.81

Radiologic examination, ankle, arthrography, radiological supervision and interpretation

73620

31.22

8.06

23.15

Radiologic examination, foot; two views

73630

35.70

8.87

26.84

Radiologic examination, foot; complete, minimum of three views

73650

30.76

8.06

22.69

Radiologic examination; calcaneus, minimum of two

views

73660

30.65

6.58

24.07

Radiologic examination; toe(s), minimum of two views

73700

315.93

55.75

260.19

Computed tomography, lower extremity; without contrast material

73701

379.04

59.52

319.52

Computed tomography, lower extremity; with contrast material(s)

73702

481.98

62.49

419.50

Computed tomography, lower extremity; without contrast material, followed by contrast material(s) and further sections

73706

629.92

98.11

531.81

Computed tomographic angiography, lower extremity, with contrast material(s), including noncontrast images, if performed, and image postprocessing

73718

656.11

68.60

587.50

Magnetic resonance (eg, proton) imaging, lower extremity other than joint; without contrast material(s)

73719

748.11

82.73

665.39

Magnetic resonance (eg, proton) imaging, lower extremity other than joint; with contrast material(s)

73720

1,127.55

109.55

1,018.01

Magnetic resonance (eg, proton) imaging, lower extremity other than joint; without contrast material(s), followed by contrast material(s) and further sequences

73721

646.90

68.60

578.30

Magnetic resonance (eg, proton) imaging, any joint of lower extremity; without contrast material

73722

726.94

82.73

644.21

Magnetic resonance (eg, proton) imaging, any joint of lower extremity; with contrast material(s)

73723

1,095.33

110.01

985.33

Magnetic resonance (eg, proton) imaging, any joint of lower extremity; without contrast material(s), followed by contrast material(s) and further sequences

73725

702.22

93.08

609.15

Magnetic resonance angiography, lower extremity, with or without contrast material(s)

74000

30.98

9.21

21.77

Radiologic examination, abdomen; single anteroposterior view

74010

42.49

11.83

30.66

Radiologic examination, abdomen; anteroposterior and additional oblique and cone views

74020

45.70

13.66

32.04

Radiologic examination, abdomen; complete, including decubitus and/or erect views

74022

54.61

16.29

38.32

Radiologic examination, abdomen; complete acute abdomen series, including supine, erect, and/or decubitus views, single view chest

74150

330.51

61.00

269.51

Computed tomography, abdomen; without contrast material

74160

426.48

65.41

361.06

Computed tomography, abdomen; with contrast material(s)

74170

549.01

71.69

477.31

Computed tomography, abdomen; without contrast material, followed by contrast material(s) and further sections

74175

652.47

97.19

555.28

Computed tomographic angiography, abdomen, with contrast material(s), including noncontrast images, if performed, and image postprocessing

74181

620.70

74.66

546.03

Magnetic resonance (eg, proton) imaging, abdomen; without contrast material(s)

74182

801.54

88.62

712.91

Magnetic resonance (eg, proton) imaging, abdomen; with contrast material(s)

74183

1,134.63

115.14

1,019.48

Magnetic resonance (eg, proton) imaging, abdomen; without contrast material(s), followed by with contrast material(s) and further sequences

74185

700.16

91.93

608.23

Magnetic resonance angiography, abdomen, with or without contrast material(s)

74190

I.C.

24.35

I.C.

Peritoneogram (eg, after injection of air or contrast), radiological supervision and interpretation

74210

85.57

18.41

67.16

Radiologic examination; pharynx and/or cervical esophagus

74220

95.43

23.67

71.76

Radiologic examination; esophagus

74230

99.96

26.98

72.98

Swallowing function, with cineradiography/ videoradiography

74235

I.C.

61.92

I.C.

Removal of foreign body(s), esophageal, with use of balloon catheter, radiological supervision and interpretation

74240

118.91

35.50

83.41

Radiologic examination, gastrointestinal tract, upper; with or without delayed films, without KUB

74241

125.36

35.04

90.31

Radiologic examination, gastrointestinal tract, upper; with or without delayed films, with KUB

74245

188.98

46.54

142.44

Radiologic examination, gastrointestinal tract, upper; with small intestine, includes multiple serial films

74246

135.16

35.50

99.66

Radiological examination, gastrointestinal tract, upper, air contrast, with specific high density barium, effervescent agent, with or without glucagon; with or without delayed films, without KUB

74247

146.05

35.50

110.54

Radiological examination, gastrointestinal tract, upper, air contrast, with specific high density barium, effervescent agent, with or without glucagon; with or without delayed films, with KUB

74249

202.63

46.54

156.09

Radiological examination, gastrointestinal tract, upper, air contrast, with specific high density barium, effervescent agent, with or without glucagon; with small intestine follow-through

74250

109.42

24.01

85.41

Radiologic examination, small intestine, includes multiple serial films;

74251

292.60

35.50

257.09

Radiologic examination, small intestine, includes multiple serial films; via enteroclysis tube

74260

249.29

25.50

223.79

Duodenography, hypotonic

74270

154.79

35.50

119.29

Radiologic examination, colon; barium enema, with or without KUB

74280

211.50

50.19

161.31

Radiologic examination, colon; air contrast with specific high density barium, with or without glucagon

74283

230.06

102.51

127.55

Therapeutic enema, contrast or air, for reduction of intussusception or other intraluminal obstruction (eg, meconium ileus)

74290

68.42

16.29

52.13

Cholecystography, oral contrast;

74291

54.68

10.35

44.33

Cholecystography, oral contrast; additional or repeat examination or multiple day examination

74300

I.C.

18.41

I.C.

Cholangiography and/or pancreatography; intraoperative, radiological supervision and interpretation

74301

I.C.

10.69

I.C.

Cholangiography and/or pancreatography; additional set intraoperative, radiological supervision and interpretation (List separately in addition to code for primary procedure)

74305

I.C.

21.84

I.C.

Cholangiography and/or pancreatography; through existing catheter, radiological supervision and interpretation

74320

149.79

27.78

122.01

Cholangiography, percutaneous, transhepatic, radiological supervision and interpretation

74327

142.25

35.85

106.40

Postoperative biliary duct calculus removal, percutaneous via T-tube tract, basket, or snare (eg, Burhenne technique), radiological supervision and interpretation

74328

I.C.

36.31

I.C.

Endoscopic catheterization of the biliary ductal system, radiological supervision and interpretation

74329

I.C.

36.31

I.C.

Endoscopic catheterization of the pancreatic ductal system, radiological supervision and interpretation

74330

I.C.

46.20

I.C.

Combined endoscopic catheterization of the biliary and pancreatic ductal systems, radiological supervision and interpretation

74340

I.C.

27.78

I.C.

Introduction of long gastrointestinal tube (eg, Miller-Abbott), including multiple fluoroscopies and films, radiological supervision and interpretation

74355

I.C.

38.82

I.C.

Percutaneous placement of enteroclysis tube, radiological supervision and interpretation

74360

I.C.

28.70

I.C.

Intraluminal dilation of strictures and/or obstructions (eg, esophagus), radiological supervision and interpretation

74363

I.C.

45.05

I.C.

Percutaneous transhepatic dilation of biliary duct stricture with or without placement of stent, radiological supervision and interpretation

74400

122.81

25.15

97.65

Urography (pyelography), intravenous, with or without KUB, with or without tomography

74410

131.09

25.15

105.94

Urography, infusion, drip technique and/or bolus technique;

74415

148.88

25.15

123.73

Urography, infusion, drip technique and/or bolus technique; with nephrotomography

74420

I.C.

18.87

I.C.

Urography, retrograde, with or without KUB

74425

I.C.

18.87

I.C.

Urography, antegrade (pyelostogram, nephrostogram,

loopogram), radiological supervision and interpretation

74430

85.13

16.59

68.54

Cystography, minimum of thee views, radiological supervision and interpretation

74440

92.70

19.56

73.14

Vasography, vesiculography, or epididymography, radiological supervision and interpretation

74445

I.C.

59.89

I.C.

Corpora cavernosography, radiological supervision and interpretation

74450

I.C.

17.39

I.C.

Urethrocystography, retrograde, radiological supervision and interpretation

74455

104.16

17.39

86.77

Urethrocystography, voiding, radiological supervision and interpretation

74470

I.C.

27.32

I.C.

Radiologic examination, renal cyst study, translumbar, contrast visualization, radiological supervision and interpretation

74475

172.46

27.78

144.68

Introduction of intracatheter or catheter into renal pelvis for drainage and/or injection, percutaneous, radiological supervision and interpretation

74480

172.46

27.78

144.68

Introduction of ureteral catheter or stent into ureter through renal pelvis for drainage and/or injection, percutaneous, radiological supervision and interpretation

74485

153.31

28.08

125.23

Dilation of nephrostomy, ureters, or urethra, radiological supervision and interpretation

74710

55.43

17.27

38.16

Pelvimetry, with or without placental localization

74740

89.32

19.56

69.76

Hysterosalpingography, radiological supervision and interpretation

74742

I.C.

30.93

I.C.

Transcervical catheterization of fallopian tube, radiological supervision and interpretation

74775

I.C.

31.73

I.C.

Perineogram (eg, vaginogram, for sex determination or extent of anomalies)

75557

628.05

126.50

501.55

Cardiac magnetic resonance imaging for morphology and function without contrast material;

75558

691.13

119.69

571.45

Cardiac magnetic resonance imaging for morphology and function without contrast material; with flow/velocity quantification

75559

924.24

162.18

762.07

Cardiac magnetic resonance imaging for morphology and function without contrast material; with stress imaging

75560

907.52

137.49

770.03

Cardiac magnetic resonance imaging for morphology and function without contrast material; with flow/velocity quantification and stress

75561

856.37

139.94

716.44

Cardiac magnetic resonance imaging for morphology and function without contrast material(s), followed by contrast material(s) and further sequences;

75562

900.41

131.33

769.09

Cardiac magnetic resonance imaging for morphology and function without contrast material(s), followed by contrast material(s) and further sequences; with flow/velocity quantification

75563

1,065.49

169.25

896.25

Cardiac magnetic resonance imaging for morphology and function without contrast material(s), followed by contrast material(s) and further sequences; with stress imaging

75564

1,058.78

153.72

905.07

Cardiac magnetic resonance imaging for morphology and function without contrast material(s), followed by contrast material(s) and further sequences; with flow/velocity quantification and stress

75600

479.60

27.46

452.15

Aortography, thoracic, without serialography, radiological supervision and interpretation

75605

441.02

60.67

380.34

Aortography, thoracic, by serialography, radiological supervision and interpretation

75625

436.25

59.13

377.12

Aortography, abdominal, by serialography, radiological supervision and interpretation

75630

488.30

94.79

393.51

Aortography, abdominal plus bilateral iliofemoral lower extremity, catheter, by serialography, radiological supervision and interpretation

75635

779.07

124.36

654.70

Computed tomographic angiography, abdominal aorta and bilateral iliofemoral lower extremity runoff, with contrast material(s), including noncontrast images, if performed, and image postprocessing

75650

454.95

77.37

377.58

Angiography, cervicocerebral, catheter, including vessel origin, radiological supervision and interpretation

75658

453.41

68.00

385.41

Angiography, brachial, retrograde, radiological supervision and interpretation

75660

455.87

68.16

387.71

Angiography, external carotid, unilateral, selective, radiological supervision and interpretation

75662

497.28

88.39

408.88

Angiography, external carotid, bilateral, selective, radiological supervision and interpretation

75665

461.83

68.60

393.23

Angiography, carotid, cerebral, unilateral, radiological supervision and interpretation

75671

498.50

85.93

412.56

Angiography, carotid, cerebral, bilateral, radiological supervision and interpretation

75676

455.71

68.00

387.71

Angiography, carotid, cervical, unilateral, radiological supervision and interpretation

75680

486.99

86.39

400.60

Angiography, carotid, cervical, bilateral, radiological supervision and interpretation

75685

455.87

68.16

387.71

Angiography, vertebral, cervical, and/or intracranial, radiological supervision and interpretation

75705

500.56

113.31

387.25

Angiography, spinal, selective, radiological supervision and interpretation

75710

450.82

59.89

390.93

Angiography, extremity, unilateral, radiological supervision and interpretation

75716

479.64

68.00

411.64

Angiography, extremity, bilateral, radiological supervision and interpretation

75722

447.92

60.67

387.25

Angiography, renal, unilateral, selective (including flush aortogram), radiological supervision and interpretation

75724

493.01

82.29

410.72

Angiography, renal, bilateral, selective (including flush aortogram), radiological supervision and interpretation

75726

445.16

58.37

386.79

Angiography, visceral, selective or supraselective (with or without flush aortogram), radiological supervision and interpretation

75731

453.29

60.97

392.31

Angiography, adrenal, unilateral, selective, radiological supervision and interpretation

75733

492.23

71.84

420.39

Angiography, adrenal, bilateral, selective, radiological supervision and interpretation

75736

448.68

59.59

389.09

Angiography, pelvic, selective or supraselective, radiological supervision and interpretation

75741

439.30

67.70

371.60

Angiography, pulmonary, unilateral, selective, radiological supervision and interpretation

75743

463.05

85.47

377.58

Angiography, pulmonary, bilateral, selective, radiological supervision and interpretation

75746

440.10

58.37

381.72

Angiography, pulmonary, by nonselective catheter or venous injection, radiological supervision and interpretation

75756

460.05

63.60

396.45

Angiography, internal mammary, radiological supervision and interpretation

75774

383.11

18.87

364.23

Angiography, selective, each additional vessel studied after basic examination, radiological supervision and interpretation (List separately in addition to code for primary procedure)

75790

184.83

93.14

91.69

Angiography, arteriovenous shunt (eg, dialysis patient), radiological supervision and interpretation

75801

I.C.

41.56

I.C.

Lymphangiography, extremity only, unilateral, radiological supervision and interpretation

75803

I.C.

59.40

I.C.

Lymphangiography, extremity only, bilateral, radiological supervision and interpretation

75805

I.C.

41.58

I.C.

Lymphangiography, pelvic/abdominal, unilateral, radiological supervision and interpretation

75807

I.C.

59.40

I.C.

Lymphangiography, pelvic/abdominal, bilateral, radiological supervision and interpretation

75809

89.03

23.55

65.48

Shuntogram for investigation of previously placed indwelling nonvascular shunt (eg, LeVeen shunt, ventriculoperitoneal shunt, indwelling infusion pump), radiological supervision and interpretation

75810

I.C.

57.91

I.C.

Splenoportography, radiological supervision and interpretation

75820

122.80

36.77

86.03

Venography, extremity, unilateral, radiological supervision and interpretation

75822

155.16

54.26

100.90

Venography, extremity, bilateral, radiological supervision and interpretation

75825

426.89

58.51

368.38

Venography, caval, inferior, with serialography, radiological supervision and interpretation

75827

426.75

57.45

369.30

Venography, caval, superior, with serialography, radiological supervision and interpretation

75831

428.89

57.75

371.14

Venography, renal, unilateral, selective, radiological supervision and interpretation

75833

459.23

76.59

382.65

Venography, renal, bilateral, selective, radiological supervision and interpretation

75840

427.81

58.05

369.76

Venography, adrenal, unilateral, selective, radiological supervision and interpretation

75842

460.01

76.45

383.57

Venography, adrenal, bilateral, selective, radiological supervision and interpretation

75860

437.04

60.37

376.66

Venography, venous sinus (eg, petrosal and inferior sagittal) or jugular, catheter, radiological supervision and interpretation

75870

435.03

58.83

376.20

Venography, superior sagittal sinus, radiological supervision and interpretation

75872

454.76

61.99

392.77

Venography, epidural, radiological supervision and interpretation

75880

127.86

36.31

91.55

Venography, orbital, radiological supervision and interpretation

75885

444.66

73.52

371.14

Percutaneous transhepatic portography with hemodynamic evaluation, radiological supervision and interpretation

75887

450.18

74.90

375.28

Percutaneous transhepatic portography without hemodynamic evaluation, radiological supervision and interpretation

75889

429.51

58.37

371.14

Hepatic venography, wedged or free, with hemodynamic evaluation, radiological supervision and interpretation

75891

429.05

58.37

370.68

Hepatic venography, wedged or free, without hemodynamic evaluation, radiological supervision and interpretation

75893

398.92

27.78

371.14

Venous sampling through catheter, with or without angiography (eg, for parathyroid hormone, renin), radiological supervision and interpretation

75894

I.C.

67.38

I.C.

Transcatheter therapy, embolization, any method, radiological supervision and interpretation

75896

I.C.

68.32

I.C.

Transcatheter therapy, infusion, any method (eg, thrombolysis other than coronary), radiological supervision and interpretation

75898

I.C.

85.59

I.C.

Angiography through existing catheter for follow-up study for transcatheter therapy, embolization or infusion

75900

I.C.

24.99

I.C.

Exchange of a previously placed intravascular catheter during thrombolytic therapy with contrast monitoring, radiological supervision and interpretation

75901

171.55

25.15

146.39

Mechanical removal of pericatheter obstructive material (eg, fibrin sheath) from central venous device via separate venous access, radiologic supervision and interpretation

75902

109.22

19.90

89.32

Mechanical removal of intraluminal (intracatheter) obstructive material from central venous device through device lumen, radiologic supervision and interpretation

75940

I.C.

27.92

I.C.

Percutaneous placement of IVC filter, radiological supervision and interpretation

75945

I.C.

21.30

I.C.

Intravascular ultrasound (non-coronary vessel), radiological supervision and interpretation; initial vessel

75946

I.C.

21.14

I.C.

Intravascular ultrasound (non-coronary vessel), radiological supervision and interpretation; each additional non-coronary vessel (List separately in addition to code for primary procedure)

75952

I.C.

230.17

I.C.

Endovascular repair of infrarenal abdominal aortic aneurysm or dissection, radiological supervision and interpretation

75953

I.C.

69.66

I.C.

Placement of proximal or distal extension prosthesis for endovascular repair of infrarenal aortic or iliac artery aneurysm, pseudoaneurysm, or dissection, radiological supervision and interpretation

75954

I.C.

113.54

I.C.

Endovascular repair of iliac artery aneurysm, pseudoaneurysm, arteriovenous malformation, or trauma, radiological supervision and interpretation

75956

I.C.

365.09

I.C.

Endovascular repair of descending thoracic aorta (eg, aneurysm, pseudoaneurysm, dissection, penetrating ulcer, intramural hematoma, or traumatic disruption); involving coverage of left subclavian artery origin, initial endoprosthesis plus descending thoracic aortic extension(s), if required, to level of celiac artery origin, radiological supervision and interpretation

75957

I.C.

313.22

I.C.

Endovascular repair of descending thoracic aorta (eg, aneurysm, pseudoaneurysm, dissection, penetrating ulcer, intramural hematoma, or traumatic disruption); not involving coverage of left subclavian artery origin, initial endoprosthesis plus descending thoracic aortic extension(s), if required, to level of celiac artery origin, radiological supervision and interpretation

75958

I.C.

208.10

I.C.

Placement of proximal extension prosthesis for endovascular repair of descending thoracic aorta (eg, aneurysm, pseudoaneurysm, dissection, penetrating ulcer, intramural hematoma, or traumatic disruption), radiological supervision and interpretation

75959

I.C.

182.16

I.C.

Placement of distal extension prosthesis(s) (delayed) after endovascular repair of descending thoracic aorta, as needed, to level of celiac origin, radiological supervision and interpretation

75960

464.53

43.30

421.22

Transcatheter introduction of intravascular stent(s) (except coronary, carotid, and vertebral vessel), percutaneous and/or open, radiological supervision and interpretation, each vessel

75961

548.22

216.44

331.78

Transcatheter retrieval, percutaneous, of intravascular foreign body (eg, fractured venous or arterial catheter), radiological supervision and interpretation

75962

491.61

28.08

463.53

Transluminal balloon angioplasty, peripheral artery, radiological supervision and interpretation

75964

276.01

18.71

257.30

Transluminal balloon angioplasty, each additional peripheral artery, radiological supervision and interpretation (List separately in addition to code for primary procedure)

75966

540.43

70.00

470.43

Transluminal balloon angioplasty, renal or other visceral artery, radiological supervision and interpretation

75968

277.09

19.33

257.76

Transluminal balloon angioplasty, each additional visceral artery, radiological supervision and interpretation (List separately in addition to code for primary procedure)

75970

I.C.

42.89

I.C.

Transcatheter biopsy, radiological supervision and interpretation

75978

485.79

27.32

458.46

Transluminal balloon angioplasty, venous (eg, subclavian stenosis), radiological supervision and interpretation

75980

I.C.

73.98

I.C.

Percutaneous transhepatic biliary drainage with contrast monitoring, radiological supervision and interpretation

75982

I.C.

73.98

I.C.

Percutaneous placement of drainage catheter for combined internal and external biliary drainage or of a drainage stent for internal biliary drainage in patients with an inoperable mechanical biliary obstruction, radiological supervision and interpretation

75984

131.88

36.53

95.35

Change of percutaneous tube or drainage catheter with contrast monitoring (eg, genitourinary system, abscess), radiological supervision and interpretation

75989

180.71

61.00

119.71

Radiological guidance (ie, fluoroscopy, ultrasound, or computed tomography), for percutaneous drainage (eg, abscess, specimen collection), with placement of catheter, radiological supervision and interpretation

75992

I.C.

29.00

I.C.

Transluminal atherectomy, peripheral artery, radiological supervision and interpretation

75993

I.C.

18.87

I.C.

Transluminal atherectomy, each additional peripheral artery, radiological supervision and interpretation (List separately in addition to code for primary procedure)

75994

I.C.

69.84

I.C.

Transluminal atherectomy, renal, radiological supervision and interpretation

75995

I.C.

67.86

I.C.

Transluminal atherectomy, visceral, radiological supervision and interpretation

75996

I.C.

18.41

I.C.

Transluminal atherectomy, each additional visceral artery, radiological supervision and interpretation (List separately in addition to code for primary procedure)

76000

103.02

8.41

94.61

Fluoroscopy (separate procedure), up to one hour physician time, other than 71023 or 71034 (eg, cardiac fluoroscopy)

76001

I.C.

34.96

I.C.

Fluoroscopy, physician time more than one hour, assisting a nonradiologic physician (eg, nephrostolithotomy, ERCP, bronchoscopy, transbronchial biopsy)

76010

32.82

9.21

23.61

Radiologic examination from nose to rectum for foreign body, single view, child

76080

74.23

27.78

46.45

Radiologic examination, abscess, fistula or sinus tract study, radiological supervision and interpretation

76098

24.31

8.06

16.25

Radiological examination, surgical specimen

76100

137.87

29.91

107.96

Radiologic examination, single plane body section (eg, tomography), other than with urography

76101

186.04

29.45

156.59

Radiologic examination, complex motion (ie, hypercycloidal) body section (eg, mastoid polytomography), other than with urography; unilateral

76102

244.01

28.99

215.03

Radiologic examination, complex motion (ie, hypercycloidal) body section (eg, mastoid polytomography), other than with urography; bilateral

76120

85.80

19.56

66.24

Cineradiography/videoradiography, except where specifically included

76125

I.C.

14.58

I.C.

Cineradiography/videoradiography to complement routine examination (List separately in addition to code for primary procedure)

76140

I.C.

I.C.

I.C.

Consultation on X-ray examination made elsewhere, written report

76150

25.91

I.C.

I.C.

Xeroradiography

76350

I.C.

I.C.

I.C.

Subtraction in conjunction with contrast studies

76376

122.60

10.65

111.94

3D rendering with interpretation and reporting of computed tomography, magnetic resonance imaging, ultrasound, or other tomographic modality; not requiring image postprocessing on an independent workstation

76377

155.57

41.80

113.78

3D rendering with interpretation and reporting of computed tomography, magnetic resonance imaging, ultrasound, or other tomographic modality; requiring image postprocessing on an independent workstation

76380

236.59

49.85

186.75

Computed tomography, limited or localized follow-up study

76390

549.04

68.31

480.73

Magnetic resonance spectroscopy

76496

I.C.

I.C.

I.C.

Unlisted fluoroscopic procedure (eg, diagnostic, interventional)

76497

I.C.

I.C.

I.C.

Unlisted computed tomography procedure (eg, diagnostic, interventional)

76498

I.C.

I.C.

I.C.

Unlisted magnetic resonance procedure (eg, diagnostic, interventional)

76499

I.C.

I.C.

I.C.

Unlisted diagnostic radiographic procedure

76506

127.43

33.43

93.99

Echoencephalography, real time with image documentation (gray scale) (for determination of ventricular size, delineation of cerebral contents, and detection of fluid masses or other intracranial abnormalities), including A-mode encephalography as secondary component where indicated

76510

173.29

81.90

91.39

Ophthalmic ultrasound, diagnostic; B-scan and quantitative A-scan performed during the same patient encounter

76511

122.09

49.56

72.52

Ophthalmic ultrasound, diagnostic; quantitative A-scan only

76512

113.48

49.72

63.75

Ophthalmic ultrasound, diagnostic; B-scan (with or without superimposed non-quantitative A-scan)

76513

103.00

35.10

67.90

Ophthalmic ultrasound, diagnostic; anterior segment ultrasound, immersion (water bath) B-scan or high resolution biomicroscopy

76514

13.31

9.33

3.98

Ophthalmic ultrasound, diagnostic; corneal pachymetry, unilateral or bilateral (determination of corneal thickness)

76516

81.13

28.40

52.73

Ophthalmic biometry by ultrasound echography, A-scan;

76519

86.20

28.86

57.33

Ophthalmic biometry by ultrasound echography, A-scan; with intraocular lens power calculation

76529

80.45

30.19

50.27

Ophthalmic ultrasonic foreign body localization

76536

120.62

28.00

92.61

Ultrasound, soft tissues of head and neck (eg, thyroid, parathyroid, parotid), real time with image documentation

76604

97.88

28.12

69.76

Ultrasound, chest (includes mediastinum), real time with image documentation

76645

97.70

27.32

70.38

Ultrasound, breast(s) (unilateral or bilateral), real time with image documentation

76700

153.21

41.28

111.92

Ultrasound, abdominal, real time with image documentation; complete

76705

114.58

30.25

84.33

Ultrasound, abdominal, real time with image documentation; limited (eg, single organ, quadrant, follow-up)

76770

147.75

37.67

110.08

Ultrasound, retroperitoneal (eg, renal, aorta, nodes), real time with image documentation; complete

76775

115.62

29.91

85.71

Ultrasound, retroperitoneal (eg, renal, aorta, nodes), real time with image documentation; limited

76776

160.40

38.82

121.59

Ultrasound, transplanted kidney, real time and duplex Doppler with image documentation

76800

135.92

54.35

81.57

Ultrasound, spinal canal and contents

76801

151.37

49.73

101.64

Ultrasound, pregnant uterus, real time with image documentation, fetal and maternal evaluation, first trimester (< 14 weeks 0 days), transabdominal approach; single or first gestation

76802

86.53

42.43

44.10

Ultrasound, pregnant uterus, real time with image documentation, fetal and maternal evaluation, first trimester (< 14 weeks 0 days), transabdominal approach; each additional gestation (List separately in addition to code for primary procedure)

76805

164.71

49.73

114.99

Ultrasound, pregnant uterus, real time with image documentation, fetal and maternal evaluation, after first trimester (> or = 14 weeks 0 days),

transabdominal approach; single or first gestation

76810

111.22

49.39

61.83

Ultrasound, pregnant uterus, real time with image documentation, fetal and maternal evaluation, after first trimester (> or = 14 weeks 0 days), transabdominal approach; each additional gestation (List separately in addition to code for primary procedure)

76811

248.00

96.11

151.89

Ultrasound, pregnant uterus, real time with image documentation, fetal and maternal evaluation plus detailed fetal anatomic examination, transabdominal approach; single or first gestation

76812

206.18

89.87

116.31

Ultrasound, pregnant uterus, real time with image documentation, fetal and maternal evaluation plus detailed fetal anatomic examination, transabdominal approach; each additional gestation (List separately in addition to code for primary procedure)

76813

147.71

60.20

87.51

Ultrasound, pregnant uterus, real time with image documentation, first trimester fetal nuchal translucency measurement, transabdominal or transvaginal approach; single or first gestation

76814

92.43

48.65

43.78

Ultrasound, pregnant uterus, real time with image documentation, first trimester fetal nuchal translucency measurement, transabdominal or transvaginal approach; each additional gestation (List separately in addition to code for primary procedure)

76815

104.66

32.76

71.90

Ultrasound, pregnant uterus, real time with image documentation, limited (eg, fetal heart beat, placental location, fetal position and/or qualitative amniotic fluid volume), one or more fetuses

76816

119.47

43.11

76.36

Ultrasound, pregnant uterus, real time with image documentation, follow-up (eg, re-evaluation of fetal size by measuring standard growth parameters and amniotic fluid volume, re-evaluation of organ system(s) suspected or confirmed to be abnormal on a previous scan), transabdominal approach, per fetus

76817

115.30

37.55

77.74

Ultrasound, pregnant uterus, real time with image documentation, transvaginal

76818

137.47

53.46

84.01

Fetal biophysical profile; with non-stress testing

76819

111.20

39.16

72.04

Fetal biophysical profile; without non-stress testing

76820

75.88

25.80

50.09

Doppler velocimetry, fetal; umbilical artery

76821

114.93

35.85

79.08

Doppler velocimetry, fetal; middle cerebral artery

76825

222.13

84.43

137.70

Echocardiography, fetal, cardiovascular system, real time with image documentation (2D), with or without M-mode recording;

76826

117.27

41.67

75.60

Echocardiography, fetal, cardiovascular system, real time with image documentation (2D), with or without M-mode recording; follow-up or repeat study

76827

93.04

29.15

63.89

Doppler echocardiography, fetal, pulsed wave and/or continuous wave with spectral display; complete

76828

67.52

28.76

38.76

Doppler echocardiography, fetal, pulsed wave and/or continuous wave with spectral display; follow-up or repeat study

76830

131.48

35.04

96.43

Ultrasound, transvaginal

76831

132.04

36.07

95.97

Saline infusion sonohysterography (SIS), including color flow Doppler, when performed

76856

131.94

35.04

96.89

Ultrasound, pelvic (nonobstetric), real time with image documentation; complete

76857

114.79

19.56

95.24

Ultrasound, pelvic (nonobstetric), real time with image documentation; limited or follow-up (eg, for follicles)

76870

130.69

32.88

97.82

Ultrasound, scrotum and contents

76872

157.55

35.80

121.75

Ultrasound, transrectal;

76873

198.50

79.55

118.95

Ultrasound, transrectal; prostate volume study for brachytherapy treatment planning (separate procedure)

76880

133.91

29.79

104.12

Ultrasound, extremity, nonvascular, real time with image documentation

76885

144.23

37.21

107.02

Ultrasound, infant hips, real time with imaging documentation; dynamic (requiring physician manipulation)

76886

114.22

31.73

82.49

Ultrasound, infant hips, real time with imaging documentation; limited, static (not requiring physician manipulation)

76930

114.85

36.82

78.02

Ultrasonic guidance for pericardiocentesis, imaging supervision and interpretation

76932

I.C.

37.28

I.C.

Ultrasonic guidance for endomyocardial biopsy, imaging supervision and interpretation

76936

383.52

103.60

279.92

Ultrasound guided compression repair of arterial pseudoaneurysm or arteriovenous fistulae (includes diagnostic ultrasound evaluation, compression of lesion and imaging)

76937

39.46

15.74

23.71

Ultrasound guidance for vascular access requiring ultrasound evaluation of potential access sites, documentation of selected vessel patency, concurrent realtime ultrasound visualization of vascular needle entry, with permanent recording and reporting (List separately in addition to code for primary procedure)

76940

I.C.

107.50

I.C.

Ultrasound guidance for, and monitoring of, parenchymal tissue ablation

76941

I.C.

67.64

I.C.

Ultrasonic guidance for intrauterine fetal transfusion or cordocentesis, imaging supervision and interpretation

76942

206.74

34.36

172.38

Ultrasonic guidance for needle placement (eg, biopsy aspiration, injection, localization device), imaging supervision and interpretation

76945

I.C.

33.44

I.C.

Ultrasonic guidance for chorionic villus sampling, imaging supervision and interpretation

76946

64.90

19.10

45.80

Ultrasonic guidance for amniocentesis, imaging supervision and interpretation

76948

64.44

18.64

45.80

Ultrasonic guidance for aspiration of ova, imaging supervision and interpretation

76950

84.94

29.45

55.49

Ultrasonic guidance for placement of radiation therapy fields

76965

222.54

69.32

153.22

Ultrasonic guidance for interstitial radioelement application

76970

88.78

19.78

69.00

Ultrasound study follow-up (specify)

76975

I.C.

42.20

I.C.

Gastrointestinal endoscopic ultrasound, supervision and interpretation

76977

25.60

2.93

22.67

Ultrasound bone density measurement and interpretation, peripheral site(s), any method

76998

I.C.

62.36

I.C.

Ultrasonic guidance, intraoperative

76999

I.C.

I.C.

I.C.

Unlisted ultrasound procedure (eg, diagnostic, interventional)

77001

112.01

19.26

92.75

Fluoroscopic guidance for central venous access device placement, replacement (catheter only or complete), or removal (includes fluoroscopic guidance for vascular access and catheter manipulation, any necessary contrast injections through access site or catheter with related venographyradiologic supervision and interpretation, and radiographic documentation of final catheter position) (List separately in addition to code for primary procedure)

77002

83.27

26.40

56.87

Fluoroscopic guidance for needle placement (eg, biopsy, aspiration, injection, localization device)

77003

74.57

28.29

46.29

Fluoroscopic guidance and localization of needle or catheter tip for spine or paraspinous diagnostic or therapeutic injection procedures (epidural, transforaminal epidural, subarachnoid, paravertebral facet joint, paravertebral facet joint nerve, or sacroiliac joint), including neurolytic agent destruction

77011

721.43

61.22

660.21

Computed tomography guidance for stereotactic localization

77012

306.39

59.52

246.87

Computed tomography guidance for needle placement (eg, biopsy, aspiration, injection, localization device), radiological supervision and interpretation

77013

I.C.

204.22

I.C.

Computed tomography guidance for, and monitoring of, parenchymal tissue ablation

77014

212.69

43.11

169.58

Computed tomography guidance for placement of radiation therapy fields

77021

563.36

77.39

485.97

Magnetic resonance guidance for needle placement (eg, for biopsy, needle aspiration, injection, or placement of localization device) radiological supervision and interpretation

77022

I.C.

218.70

I.C.

Magnetic resonance guidance for, and monitoring of, parenchymal tissue ablation

77031

288.09

81.38

206.71

Stereotactic localization guidance for breast biopsy or needle placement (eg, for wire localization or for injection), each lesion, radiological supervision and interpretation

77032

75.67

28.46

47.21

Mammographic guidance for needle placement, breast (eg, for wire localization or for injection), each lesion, radiological supervision and interpretation

77051

17.38

3.27

14.11

Computer-aided detection (computer algorithm analysis of digital image data for lesion detection) with further physician review for interpretation, with or without digitization of film radiographic images; diagnostic mammography (List separately in addition to code for primary procedure)

77052

17.38

3.27

14.11

Computer-aided detection (computer algorithm analysis of digital image data for lesion detection) with further physician review for interpretation, with or without digitization of film radiographic images; screening mammography (List separately in addition to code for primary procedure)

77053

108.68

18.41

90.27

Mammary ductogram or galactogram, single duct, radiological supervision and interpretation

77054

147.78

22.87

124.91

Mammary ductogram or galactogram, multiple ducts, radiological supervision and interpretation

77055

93.80

35.85

57.95

Mammography; unilateral

77056

118.61

44.25

74.36

Mammography; bilateral

77057

94.10

35.85

58.25

Screening mammography, bilateral (2-view film study of each breast)

77058

1,001.75

83.07

918.68

Magnetic resonance imaging, breast, without and/or with contrast material(s); unilateral

77059

1,154.49

83.07

1,071.42

Magnetic resonance imaging, breast, without and/or with contrast material(s); bilateral

77071

37.89

I.C.

I.C.

Manual application of stress performed by physician for joint radiography, including contralateral joint if indicated

77072

26.72

9.55

17.17

Bone age studies

77073

46.92

14.12

32.80

Bone length studies (orthoroentgenogram, scanogram)

77074

77.60

23.33

54.27

Radiologic examination, osseous survey; limited (eg, for metastases)

77075

111.65

27.78

83.87

Radiologic examination, osseous survey; complete (axial and appendicular skeleton)

77076

97.64

35.39

62.26

Radiologic examination, osseous survey, infant

77077

55.79

15.79

40.00

Joint survey, single view, two or more joints (specify)

77078

192.22

12.52

179.70

Computed tomography, bone mineral density study, one or more sites; axial skeleton (eg, hips, pelvis, spine)

77079

97.68

11.03

86.65

Computed tomography, bone mineral density study, one or more sites; appendicular skeleton (peripheral) (eg, radius, wrist, heel)

77080

111.18

10.81

100.37

Dual-energy X-ray absorptiometry (DXA), bone density study, one or more sites; axial skeleton (eg, hips, pelvis, spine)

77081

39.23

11.03

28.20

Dual-energy X-ray absorptiometry (DXA), bone density study, one or more sites; appendicular skeleton (peripheral) (eg, radius, wrist, heel)

77082

37.98

8.41

29.58

Dual-energy X-ray absorptiometry (DXA), bone density study, one or more sites; vertebral fracture assessment

77083

35.78

9.89

25.89

Radiographic absorptiometry (eg, photodensitometry, radiogrammetry), one or more sites

77084

656.67

80.66

576.01

Magnetic resonance (eg, proton) imaging, bone marrow blood supply

77261

72.11

I.C.

I.C.

Therapeutic radiology treatment planning; simple

77262

108.48

I.C.

I.C.

Therapeutic radiology treatment planning; intermediate

77263

161.26

I.C.

I.C.

Therapeutic radiology treatment planning; complex

77280

217.83

35.69

182.14

Therapeutic radiology simulation-aided field setting; simple

77285

367.16

53.00

314.16

Therapeutic radiology simulation-aided field setting; intermediate

77290

536.56

78.68

457.88

Therapeutic radiology simulation-aided field setting; complex

77295

1,055.25

230.71

824.54

Therapeutic radiology simulation-aided field setting; 3-dimensional

77299

I.C.

I.C.

I.C.

Unlisted procedure, therapeutic radiology clinical treatment planning

77300

86.76

31.27

55.49

Basic radiation dosimetry calculation, central axis depth dose calculation, TDF, NSD, gap calculation, off axis factor, tissue inhomogeneity factors, calculation of non-ionizing radiation surface and depth dose, as required during course of treatment, only when prescribed by the treating physician

77301

2,353.93

404.01

1,949.93

Intensity modulated radiotherapy plan, including dose-volume histograms for target and critical structure partial tolerance specifications

77305

97.44

35.69

61.75

Teletherapy, isodose plan (whether hand or computer calculated); simple (one or two parallel opposed unmodified ports directed to a single area of interest)

77310

131.46

53.00

78.46

Teletherapy, isodose plan (whether hand or computer calculated); intermediate (three or more treatment ports directed to a single area of interest)

77315

180.45

78.68

101.78

Teletherapy, isodose plan (whether hand or computer calculated); complex (mantle or inverted Y, tangential ports, the use of wedges, compensators, complex blocking, rotational beam, or special beam considerations)

77321

175.09

48.20

126.89

Special teletherapy port plan, particles, hemibody, total body

77326

166.95

47.06

119.89

Brachytherapy isodose plan; simple (calculation made from single plane, one to four sources/ribbon application, remote afterloading brachytherapy, one to eight sources)

77327

239.53

70.27

169.26

Brachytherapy isodose plan; intermediate (multiplane dosage calculations, application involving five to ten sources/ribbons, remote afterloading brachytherapy, nine to 12 sources)

77328

332.54

105.96

226.59

Brachytherapy isodose plan; complex (multiplane isodose plan, volume implant calculations, over ten sources/ribbons used, special spatial reconstruction, remote afterloading brachytherapy, over 12 sources)

77331

67.87

43.79

24.07

Special dosimetry (eg, TLD, microdosimetry) (specify), only when prescribed by the treating physician

77332

91.86

27.16

64.70

Treatment devices, design and construction; simple (simple block, simple bolus)

77333

94.85

42.31

52.55

Treatment devices, design and construction;

intermediate (multiple blocks, stents, bite blocks, special bolus)

77373

1,967.92

Stereotactic body radiation therapy, treatment delivery, per fraction to one or more lesions, including image guidance, entire course not to exceed five fractions

77399

I.C.

Unlisted procedure, medical radiation physics, dosimetry and treatment devices, and special services

77401

54.85

Radiation treatment delivery, superficial and/or ortho voltage

77402

144.14

Radiation treatment delivery, single treatment area, single port or parallel opposed ports, simple blocks or no blocks; up to 5 MeV

77403

130.80

Radiation treatment delivery, single treatment area, single port or parallel opposed ports, simple blocks or no blocks; 6-10 MeV

77404

140.92

Radiation treatment delivery, single treatment area, single port or parallel opposed ports, simple blocks or no blocks; 11-19 MeV

77406

141.84

Radiation treatment delivery, single treatment area, single port or parallel opposed ports, simple blocks or no blocks; 20 MeV or greater

77407

184.95

Radiation treatment delivery, two separate treatment areas, three or more ports on a single treatment area, use of multiple blocks; up to 5 MeV

77408

171.14

Radiation treatment delivery, two separate treatment areas, three or more ports on a single treatment area, use of multiple blocks; 6-10 MeV

77409

184.49

Radiation treatment delivery, two separate treatment areas, three or more ports on a single treatment area, use of multiple blocks; 11-19 MeV

77411

184.03

Radiation treatment delivery, two separate treatment areas, three or more ports on a single treatment area, use of multiple blocks; 20 MeV or greater

77412

213.78

Radiation treatment delivery, three or more separate treatment areas, custom blocking, tangential ports, wedges, rotational beam, compensators, electron beam; up to 5 MeV

77413

215.63

Radiation treatment delivery, three or more separate treatment areas, custom blocking, tangential ports, wedges, rotational beam, compensators, electron beam; 6-10 MeV

77414

235.42

Radiation treatment delivery, three or more separate treatment areas, custom blocking, tangential ports, wedges, rotational beam, compensators, electron beam; 11-19 MeV

77416

235.42

Radiation treatment delivery, three or more separate treatment areas, custom blocking, tangential ports, wedges, rotational beam, compensators, electron beam; 20 MeV or greater

77417

23.29

Therapeutic radiology port film(s)

77418

721.94

Intensity modulated treatment delivery, single or multiple fields/arcs, via narrow spatially and temporally modulated beams, binary, dynamic MLC, per treatment session

77421

151.78

19.90

131.88

Stereoscopic X-ray guidance for localization of target volume for the delivery of radiation therapy

77422

166.38

High energy neutron radiation treatment delivery; single treatment area using a single port or parallel-opposed ports with no blocks or simple blocking

77423

227.59

High energy neutron radiation treatment delivery; one or more isocenter(s) with coplanar or non-coplanar geometry with blocking and/or wedge, and/or compensator(s)

77427

187.58

Radiation treatment management, five treatments

77431

98.10

Radiation therapy management with complete course of therapy consisting of one or two fractions only

77432

409.28

Stereotactic radiation treatment management of cranial lesion(s) (complete course of treatment consisting of one session)

77435

683.04

Stereotactic body radiation therapy, treatment management, per treatment course, to one or more lesions, including image guidance, entire course not to exceed five fractions

77470

409.01

105.96

303.06

Special treatment procedure (eg, total body irradiation, hemibody radiation, per oral, endocavitary or intraoperative cone irradiation)

77499

I.C.

I.C.

I.C.

Unlisted procedure, therapeutic radiology treatment management

77520

I.C.

Proton treatment delivery; simple, without compensation

77522

I.C.

Proton treatment delivery; simple, with compensation

77523

I.C.

Proton treatment delivery; intermediate

77525

I.C.

Proton treatment delivery; complex

77600

378.05

78.68

299.38

Hyperthermia, externally generated; superficial (ie, heating to a depth of 4 cm or less)

77605

616.68

103.77

512.90

Hyperthermia, externally generated; deep (ie, heating to depths greater than 4 cm)

77610

555.26

75.45

479.81

Hyperthermia generated by interstitial probe(s); five or fewer interstitial applicators

77615

786.40

104.57

681.83

Hyperthermia generated by interstitial probe(s); more than five interstitial applicators

77620

388.09

80.43

307.66

Hyperthermia generated by intracavitary probe(s)

77750

349.94

249.81

100.14

Infusion or instillation of radioelement solution (includes three months follow-up care)

77761

369.08

189.97

179.10

Intracavitary radiation source application; simple

77762

511.05

289.95

221.11

Intracavitary radiation source application; intermediate

77763

718.00

434.48

283.52

Intracavitary radiation source application; complex

77776

420.48

232.93

187.55

Interstitial radiation source application; simple

77777

608.18

378.35

229.83

Interstitial radiation source application; intermediate

77778

869.35

567.59

301.75

Interstitial radiation source application; complex

77781

656.36

64.88

591.48

Remote afterloading high intensity brachytherapy; one - four source positions or catheters

77782

876.75

107.15

769.60

Remote afterloading high intensity brachytherapy; five - eight source positions or catheters

77783

1,201.32

169.35

1,031.96

Remote afterloading high intensity brachytherapy; nine-12 source positions or catheters

77784

1,777.12

264.62

1,512.50

Remote afterloading high intensity brachytherapy; over 12 source positions or catheters

77789

106.68

58.21

48.47

Surface application of radiation source

77790

90.88

53.00

37.88

Supervision, handling, loading of radiation source

77799

I.C.

I.C.

I.C.

Unlisted procedure, clinical brachytherapy

78000

74.87

9.55

65.32

Thyroid uptake; single determination

78001

96.43

13.32

83.11

Thyroid uptake; multiple determinations

78003

82.41

16.63

65.78

Thyroid uptake; stimulation, suppression or discharge (not including initial uptake studies)

78006

222.83

24.69

198.14

Thyroid imaging, with uptake; single determination

78007

155.35

25.50

129.85

Thyroid imaging, with uptake; multiple determinations

78010

158.52

19.90

138.62

Thyroid imaging; only

78011

183.26

22.87

160.39

Thyroid imaging; with vascular flow

78015

215.77

34.36

181.40

Thyroid carcinoma metastases imaging; limited area (eg, neck and chest only)

78016

317.37

41.78

275.58

Thyroid carcinoma metastases imaging; with additional studies (eg, urinary recovery)

78018

353.63

44.37

309.26

Thyroid carcinoma metastases imaging; whole body

78020

101.69

30.75

70.94

Thyroid carcinoma metastases uptake (List separately in addition to code for primary procedure)

78070

217.53

42.08

175.44

Parathyroid imaging

78075

433.00

37.67

395.33

Adrenal imaging, cortex and/or medulla

78099

I.C.

I.C.

I.C.

Unlisted endocrine procedure, diagnostic nuclear medicine

78102

170.73

28.12

142.60

Bone marrow imaging; limited area

78103

235.97

38.47

197.49

Bone marrow imaging; multiple areas

78104

278.30

41.10

237.20

Bone marrow imaging; whole body

78110

81.31

10.01

71.30

Plasma volume, radiopharmaceutical volume-dilution technique (separate procedure); single sampling

78111

122.48

11.49

110.98

Plasma volume, radiopharmaceutical volume-dilution technique (separate procedure); multiple samplings

78120

101.67

11.83

89.83

Red cell volume determination (separate procedure); single sampling

78121

136.02

16.29

119.73

Red cell volume determination (separate procedure); multiple samplings

78122

184.72

23.33

161.39

Whole blood volume determination, including separate measurement of plasma volume and red cell volume (radiopharmaceutical volume-dilution technique)

78130

176.90

31.39

145.50

Red cell survival study;

78135

347.38

32.88

314.50

Red cell survival study; differential organ/tissue kinetics (eg, splenic and/or hepatic sequestration)

78140

190.96

31.39

159.57

Labeled red cell sequestration, differential organ/tissue (eg, splenic and/or hepatic)

78185

195.36

20.70

174.66

Spleen imaging only, with or without vascular flow

78190

381.85

54.34

327.51

Kinetics, study of platelet survival, with or without differential organ/tissue localization

78191

287.35

31.39

255.96

Platelet survival study

78195

352.23

61.64

290.59

Lymphatics and lymph nodes imaging

78199

I.C.

I.C.

I.C.

Unlisted hematopoietic, reticuloendothelial and lymphatic procedure, diagnostic nuclear medicine

78201

183.38

22.07

161.31

Liver imaging; static only

78202

215.53

25.84

189.69

Liver imaging; with vascular flow

78205

297.25

36.19

261.07

Liver imaging (SPECT);

78206

378.80

49.17

329.64

Liver imaging (SPECT); with vascular flow

78215

204.26

25.15

179.10

Liver and spleen imaging; static only

78216

175.51

28.81

146.70

Liver and spleen imaging; with vascular flow

78220

183.20

24.69

158.51

Liver function study with hepatobiliary agents, with serial images

78223

322.33

43.23

279.10

Hepatobiliary ductal system imaging, including gallbladder, with or without pharmacologic intervention, with or without quantitative measurement of gallbladder function

78230

169.45

22.87

146.58

Salivary gland imaging;

78231

164.76

26.18

138.58

Salivary gland imaging; with serial images

78232

171.17

24.01

147.16

Salivary gland function study

78258

229.66

38.13

191.53

Esophageal motility

78261

269.02

35.50

233.51

Gastric mucosa imaging

78262

270.98

34.24

236.74

Gastroesophageal reflux study

78264

300.17

39.96

260.21

Gastric emptying study

78267

I.C.

Urea breath test, C-14 (isotopic); acquisition for analysis

78268

I.C.

Urea breath test, C-14 (isotopic); analysis

78270

92.06

10.35

81.71

Vitamin B-12 absorption study (eg, Schilling test); without intrinsic factor

78271

92.98

9.89

83.09

Vitamin B-12 absorption study (eg, Schilling test); with intrinsic factor

78272

116.52

13.20

103.32

Vitamin B-12 absorption studies combined, with and without intrinsic factor

78278

360.55

50.65

309.90

Acute gastrointestinal blood loss imaging

78282

I.C.

19.56

I.C.

Gastrointestinal protein loss

78290

300.94

35.16

265.78

Intestine imaging (eg, ectopic gastric mucosa, Meckel's localization, volvulus)

78291

255.13

45.05

210.08

Peritoneal-venous shunt patency test (eg, for LeVeen, Denver shunt)

78299

I.C.

I.C.

I.C.

Unlisted gastrointestinal procedure, diagnostic nuclea medicine

78300

185.52

31.73

153.79

Bone and/or joint imaging; limited area

78305

252.03

42.43

209.60

Bone and/or joint imaging; multiple areas

78306

282.03

44.37

237.66

Bone and/or joint imaging; whole body

78315

359.27

52.13

307.14

Bone and/or joint imaging; three phase study

78320

313.88

53.28

260.61

Bone and/or joint imaging; tomographic (SPECT)

78350

40.15

10.57

29.58

Bone density (bone mineral content) study, one or more sites; single photon absorptiometry

78351

14.69

Bone density (bone mineral content) study, one or more sites; dual photon absorptiometry, one or more sites

78399

I.C.

I.C.

I.C.

Unlisted musculoskeletal procedure, diagnostic nuclear medicine

78414

I.C.

23.79

I.C.

Determination of central c-v hemodynamics (non-imaging) (eg, ejection fraction with probe technique) with or without pharmacologic intervention or exercise, single or multiple determinations

78428

210.94

42.26

168.68

Cardiac shunt detection

78445

170.68

25.15

145.52

Non-cardiac vascular flow imaging (ie, angiography, venography)

78456

346.44

51.91

294.53

Acute venous thrombosis imaging, peptide

78457

205.83

38.70

167.14

Venous thrombosis imaging, venogram; unilateral

78458

242.13

46.20

195.93

Venous thrombosis imaging, venogram; bilateral

78459

I.C.

79.87

I.C.

Myocardial imaging, positron emission tomography (PET), metabolic evaluation

78460

202.46

44.37

158.09

Myocardial perfusion imaging; (planar) single study, at rest or stress (exercise and/or pharmacologic), with or without quantification

78461

263.18

63.75

199.43

Myocardial perfusion imaging; multiple studies (planar), at rest and/or stress (exercise and/or pharmacologic), and redistribution and/or rest injection, with or without quantification

78464

356.05

58.67

297.39

Myocardial perfusion imaging; tomographic (SPECT), single study (including attenuation correction when performed), at rest or stress (exercise and/or pharmacologic), with or without quantification

78465

616.75

79.42

537.32

Myocardial perfusion imaging; tomographic (SPECT), multiple studies (including attenuation correction when performed), at rest and/or stress (exercise and/or pharmacologic) and redistribution and/or rest injection, with or without quantification

78466

199.88

36.43

163.45

Myocardial imaging, infarct avid, planar; qualitative or quantitative

78468

259.45

43.40

216.04

Myocardial imaging, infarct avid, planar; with ejection fraction by first pass technique

78469

313.19

49.80

263.39

Myocardial imaging, infarct avid, planar; tomographic SPECT with or without quantification

78472

317.06

51.69

265.37

Cardiac blood pool imaging, gated equilibrium; planar, single study at rest or stress (exercise and/or pharmacologic), wall motion study plus ejection fraction, with or without additional quantitative processing

78473

445.23

78.69

366.55

Cardiac blood pool imaging, gated equilibrium; multiple studies, wall motion study plus ejection fraction, at rest and stress (exercise and/or pharmacologic), with or without additional quantification

78478

80.51

28.72

51.79

Myocardial perfusion study with wall motion, qualitative or quantitative study (List separately in addition to code for primary procedure)

78480

70.91

19.13

51.79

Myocardial perfusion study with ejection fraction (List separately in addition to code for primary procedure)

78481

288.08

54.15

233.93

Cardiac blood pool imaging (planar), first pass technique; single study, at rest or with stress (exercise and/or pharmacologic), wall motion study plus ejection fraction, with or without quantification

78483

415.63

82.07

333.57

Cardiac blood pool imaging (planar), first pass technique; multiple studies, at rest and with stress (exercise and/ or pharmacologic), wall motion study plus ejection fraction, with or without quantification

78491

I.C.

81.09

I.C.

Myocardial imaging, positron emission tomography (PET), perfusion; single study at rest or stress

78492

I.C.

103.69

I.C.

Myocardial imaging, positron emission tomography (PET), perfusion; multiple studies at rest and/or stress

78494

366.87

64.22

302.65

Cardiac blood pool imaging, gated equilibrium, SPECT, at rest, wall motion study plus ejection fraction, with or without quantitative processing

78496

213.54

26.88

186.66

Cardiac blood pool imaging, gated equilibrium, single study, at rest, with right ventricular ejection fraction by first pass technique (List separately in addition to code for primary procedure)

78499

I.C.

I.C.

I.C.

Unlisted cardiovascular procedure, diagnostic nuclea medicine

78580

234.54

38.13

196.41

Pulmonary perfusion imaging, particulate

78584

191.07

50.65

140.42

Pulmonary perfusion imaging, particulate, with ventilation; single breath

78585

384.63

55.75

328.89

Pulmonary perfusion imaging, particulate, with ventilation; rebreathing and washout, with or without single breath

78586

176.79

20.24

156.55

Pulmonary ventilation imaging, aerosol; single projection

78587

215.30

25.15

190.15

Pulmonary ventilation imaging, aerosol; multiple projections (eg, anterior, posterior, lateral views)

78588

325.34

55.75

269.60

Pulmonary perfusion imaging, particulate, with ventilation imaging, aerosol, one or multiple projections

78591

183.23

20.70

162.53

Pulmonary ventilation imaging, gaseous, single breath, single projection

78593

216.50

24.69

191.81

Pulmonary ventilation imaging, gaseous, with rebreathing and washout with or without single breath; single projection

78594

266.92

26.98

239.94

Pulmonary ventilation imaging, gaseous, with rebreathing and washout with or without single breath; multiple projections (eg, anterior, posterior, lateral views)

78596

428.32

63.73

364.59

Pulmonary quantitative differential function (ventilation/perfusion) study

78599

I.C.

I.C.

I.C.

Unlisted respiratory procedure, diagnostic nuclear medicine

78600

190.58

22.53

168.06

Brain imaging, less than four static views;

78601

229.15

25.84

203.32

Brain imaging, less than four static views; with vascular flow

78605

218.33

27.44

190.89

Brain imaging, minimum four static views;

78606

319.48

32.42

287.07

Brain imaging, minimum four static views; with vascular flow

78607

413.47

62.83

350.64

Brain imaging, tomographic (SPECT)

78608

I.C.

76.03

I.C.

Brain imaging, positron emission tomography (PET) metabolic evaluation

78609

75.57

75.57

I.C.

Brain imaging, positron emission tomography (PET); perfusion evaluation

78610

208.70

16.53

192.17

Brain imaging, vascular flow only

78630

352.57

34.70

317.86

Cerebrospinal fluid flow, imaging (not including introduction of material); cisternography

78635

292.13

31.55

260.57

Cerebrospinal fluid flow, imaging (not including introduction of material); ventriculography

78645

303.93

28.81

275.12

Cerebrospinal fluid flow, imaging (not including introduction of material); shunt evaluation

78647

380.91

45.74

335.17

Cerebrospinal fluid flow, imaging (not including introduction of material); tomographic (SPECT)

78650

337.77

31.39

306.38

Cerebrospinal fluid leakage detection and localization

78660

173.26

26.98

146.28

Radiopharmaceutical dacryocystography

78699

I.C.

I.C.

I.C.

Unlisted nervous system procedure, diagnostic nuclea medicine

78700

195.67

23.33

172.34

Kidney imaging morphology;

78701

232.61

25.15

207.46

Kidney imaging morphology; with vascular flow

78707

277.46

49.17

228.29

Kidney imaging morphology; with vascular flow and function, single study without pharmacological intervention

78708

242.10

62.14

179.96

Kidney imaging morphology; with vascular flow and function, single study, with pharmacological intervention (eg, angiotensin converting enzyme inhibitor and/or diuretic)

78709

374.89

72.03

302.86

Kidney imaging morphology; with vascular flow and function, multiple studies, with and without pharmacological intervention (eg, angiotensin converting enzyme inhibitor and/or diuretic)

78710

295.55

33.56

261.99

Kidney imaging morphology; tomographic (SPECT)

78725

115.37

19.56

95.81

Kidneyfunction study, non-imaging radioisotopic study

78730

90.05

9.86

80.19

Urinary bladder residual study (List separately in addition to code for primary procedure)

78740

207.15

29.11

178.04

Ureteral reflux study (radiopharmaceutical voiding cystogram)

78761

225.40

36.19

189.21

Testicular imaging with vascular flow

78799

I.C.

I.C.

I.C.

Unlisted genitourinary procedure, diagnostic nuclear medicine

78800

212.78

33.86

178.92

Radiopharmaceutical localization of tumor or distribution of radiopharmaceutical agent(s); limited

area

78801

277.63

40.90

236.74

Radiopharmaceutical localization of tumor or distribution of radiopharmaceutical agent(s); multiple

areas

78802

360.83

43.91

316.92

Radiopharmaceutical localization of tumor or distribution of radiopharmaceutical agent(s); whole body, single day imaging

78803

405.46

56.21

349.26

Radiopharmaceutical localization of tumor or distribution of radiopharmaceutical agent(s); tomographic (SPECT)

78804

651.53

54.76

596.77

Radiopharmaceutical localization of tumor or distribution of radiopharmaceutical agent(s); whole body, requiring two or more days imaging

78805

212.57

37.33

175.24

Radiopharmaceutical localization of inflammatory process; limited area

78806

388.11

43.91

344.20

Radiopharmaceutical localization of inflammatory process; whole body

78807

404.70

55.91

348.80

Radiopharmaceutical localization of inflammatory process; tomographic (SPECT)

78811

I.C.

80.27

I.C.

Positron emission tomography (PET) imaging; limited area (eg, chest, head/neck)

78812

I.C.

99.57

I.C.

Positron emission tomography (PET) imaging; skull base to mid-thigh

78813

I.C.

103.34

I.C.

Positron emission tomography (PET) imaging; whole body

78814

I.C.

112.93

I.C.

Positron emission tomography (PET) with concurrently acquired computed tomography (CT) for attenuation correction and anatomical localization imaging; limited area (eg, chest, head/neck)

78815

I.C.

125.27

I.C.

Positron emission tomography (PET) with concurrently acquired computed tomography (CT) for attenuation correction and anatomical localization imaging; skull base to mid-thigh

78816

I.C.

128.24

I.C.

Positron emission tomography (PET) with concurrently acquired computed tomography (CT) for attenuation correction and anatomical localization imaging; whole body

78890

43.39

2.93

40.46

Generation of automated data: interactive process involving nuclear physician and/or allied health professional personnel; simple manipulations and interpretation, not to exceed 30 minutes

78891

89.08

5.09

83.99

Generation of automated data: interactive process involving nuclear physician and/or allied health professional personnel; complex manipulations and interpretation, exceeding 30 minutes

78999

I.C.

I.C.

I.C.

Unlisted miscellaneous procedure, diagnostic nuclear medicine

79005

184.96

91.01

93.95

Radiopharmaceutical therapy, by oral administration

79101

199.17

101.54

97.63

Radiopharmaceutical therapy, by intravenous administration

79200

202.34

101.48

100.86

Radiopharmaceutical therapy, by intracavitary administration

79300

I.C.

83.84

I.C.

Radiopharmaceutical therapy, by interstitial radioactive colloid administration

79403

269.97

117.56

152.41

Radiopharmaceutical therapy, radiolabeled monoclonal antibody by intravenous infusion

79440

193.75

102.56

91.19

Radiopharmaceutical therapy, by intra-articular administration

79445

I.C.

123.74

I.C.

Radiopharmaceutical therapy, by intra-arterial particulate administration

79999

I.C.

I.C.

I.C.

Radiopharmaceutical therapy, unlisted procedure

(8) Freestanding Ambulatory Surgical Services / Surgery.

Code

ASC

Rate

Incl

GL Fee

PC

Fee

TC

Fee

40.06(8) - Surgical Services Description

10021

49.59

146.24

Fine needle aspiration; without imaging guidance

10022

193.36

153.93

Fine needle aspiration; with imaging guidance

10040

35.44

95.98

Acne surgery (eg, marsupialization, opening or removal of multiple milia, comedones, cysts, pustules)

10060

49.64

106.83

Incision and drainage of abscess (eg, carbuncle, suppurative hidradenitis, cutaneous or subcutaneous abscess, cyst, furuncle, or paronychia); simple or single

10061

62.85

180.17

Incision and drainage of abscess (eg, carbuncle, suppurative hidradenitis, cutaneous or subcutaneous abscess, cyst, furuncle, or paronychia); complicated or multiple

10080

62.85

176.95

Incision and drainage of pilonidal cyst; simple

10081

138.64

265.51

Incision and drainage of pilonidal cyst; complicated

10120

62.85

140.41

Incision and removal of foreign body, subcutaneous tissues; simple

10121

719.48

263.98

Incision and removal of foreign body, subcutaneous tissues; complicated

10140

73.92

151.59

Incision and drainage of hematoma, seroma or fluid collection

10160

63.25

125.02

Puncture aspiration of abscess, hematoma, bulla, or cyst

10180

818.67

231.60

Incision and drainage, complex, postoperative wound infection

11000

23.90

52.50

Debridement of extensive eczematous or infected skin; up to 10% of body surface

11001

8.46

22.03

Debridement of extensive eczematous or infected skin; each additional 10% of the body surface (List separately in addition to code for primary procedure)

11004

552.23

Debridement of skin, subcutaneous tissue, muscle and fascia for necrotizing soft tissue infection; external genitalia and perineum

11005

729.92

Debridement of skin, subcutaneous tissue, muscle and fascia for necrotizing soft tissue infection; abdominal wall, with or without fascial closure

11006

688.17

Debridement of skin, subcutaneous tissue, muscle and fascia for necrotizing soft tissue infection; external genitalia, perineum and abdominal wall, with or without fascial closure

11008

265.41

Removal of prosthetic material or mesh, abdominal wall for infection (eg, for chronic or recurrent mesh infection or necrotizing soft tissue infection) (List separately in addition to code for primary procedure)

11010

192.34

477.68

Debridement including removal of foreign material associated with open fracture(s) and/or dislocation(s); skin and subcutaneous tissues

11011

192.34

540.66

Debridement including removal of foreign material associated with open fracture(s) and/or dislocation(s); skin, subcutaneous tissue, muscle fascia, and muscle

11012

192.34

755.39

Debridement including removal of foreign material associated with open fracture(s) and/or dislocation(s); skin, subcutaneous tissue, muscle fascia, muscle, and bone

11040

22.06

46.49

Debridement; skin, partial thickness

11041

25.38

55.24

Debridement; skin, full thickness

11042

118.89

75.40

Debridement; skin, and subcutaneous tissue

11043

118.89

271.72

Debridement; skin, subcutaneous tissue, and muscle

11044

307.53

367.25

Debridement; skin, subcutaneous tissue, muscle, and bone

11055

25.01

47.48

Paring or cutting of benign hyperkeratotic lesion (eg, corn or callus); single lesion

11056

27.95

57.91

Paring or cutting of benign hyperkeratotic lesion (eg, corn or callus); two to four lesions

11057

31.63

69.55

Paring or cutting of benign hyperkeratotic lesion (eg, corn or callus); more than four lesions

11100

35.44

100.36

Biopsy of skin, subcutaneous tissue and/or mucous membrane (including simple closure), unless otherwise listed; single lesion

11101

13.61

31.63

Biopsy of skin, subcutaneous tissue and/or mucous membrane (including simple closure), unless otherwise listed; each separate/additional lesion (List separately in addition to code for primary procedure)

11200

35.44

80.18

Removal of skin tags, multiple fibrocutaneous tags, any area; up to and including 15 lesions

11201

5.88

17.87

Removal of skin tags, multiple fibrocutaneous tags, any area; each additional ten lesions (List separately in addition to code for primary procedure)

11300

35.44

68.48

Shaving of epidermal or dermal lesion, single lesion, trunk, arms or legs; lesion diameter 0.5 cm or less

11301

35.44

90.52

Shaving of epidermal or dermal lesion, single lesion, trunk, arms or legs; lesion diameter 0.6 to 1.0 cm

11302

35.44

107.77

Shaving of epidermal or dermal lesion, single lesion, trunk, arms or legs; lesion diameter 1.1 to 2.0 cm

11303

66.19

127.75

Shaving of epidermal or dermal lesion, single lesion, trunk, arms or legs; lesion diameter over 2.0 cm

11305

35.31

69.16

Shaving of epidermal or dermal lesion, single lesion, scalp, neck, hands, feet, genitalia; lesion diameter 0.5 cm or less

11306

35.44

93.90

Shaving of epidermal or dermal lesion, single lesion, scalp, neck, hands, feet, genitalia; lesion diameter 0.6 to 1.0 cm

11307

35.44

109.60

Shaving of epidermal or dermal lesion, single lesion, scalp, neck, hands, feet, genitalia; lesion diameter 1.1 to 2.0 cm

11308

35.44

124.76

Shaving of epidermal or dermal lesion, single lesion, scalp, neck, hands, feet, genitalia; lesion diameter over 2.0 cm

11310

35.44

83.66

Shaving of epidermal or dermal lesion, single lesion, face, ears, eyelids, nose, lips, mucous membrane; lesion diameter 0.5 cm or less

11311

35.44

103.17

Shaving of epidermal or dermal lesion, single lesion, face, ears, eyelids, nose, lips, mucous membrane; lesion diameter 0.6 to 1.0 cm

11312

35.44

119.64

Shaving of epidermal or dermal lesion, single lesion, face, ears, eyelids, nose, lips, mucous membrane; lesion diameter 1.1 to 2.0 cm

11313

35.44

150.37

Shaving of epidermal or dermal lesion, single lesion, face, ears, eyelids, nose, lips, mucous membrane; lesion diameter over 2.0 cm

11400

71.34

120.80

Excision, benign lesion including margins, except skin tag (unless listed elsewhere), trunk, arms or legs; excised diameter 0.5 cm or less

11401

77.95

143.26

Excision, benign lesion including margins, except skin tag (unless listed elsewhere), trunk, arms or legs; excised diameter 0.6 to 1.0 cm

11402

84.95

158.70

Excision, benign lesion including margins, except skin tag (unless listed elsewhere), trunk, arms or legs; excised diameter 1.1 to 2.0 cm

11403

90.83

181.04

Excision, benign lesion including margins, except skin tag (unless listed elsewhere), trunk, arms or legs; excised diameter 2.1 to 3.0 cm

11404

719.48

205.27

Excision, benign lesion including margins, except skin tag (unless listed elsewhere), trunk, arms or legs; excised diameter 3.1 to 4.0 cm

11406

719.48

279.96

Excision, benign lesion including margins, except skin tag (unless listed elsewhere), trunk, arms or legs; excised diameter over 4.0 cm

11420

65.82

119.69

Excision, benign lesion including margins, except skin tag (unless listed elsewhere), scalp, neck, hands, feet, genitalia; excised diameter 0.5 cm or less

11421

78.70

151.56

Excision, benign lesion including margins, except skin tag (unless listed elsewhere), scalp, neck, hands, feet, genitalia; excised diameter 0.6 to 1.0 cm

11422

86.05

169.30

Excision, benign lesion including margins, except skin tag (unless listed elsewhere), scalp, neck, hands, feet, genitalia; excised diameter 1.1 to 2.0 cm

11423

96.35

196.36

Excision, benign lesion including margins, except skin tag (unless listed elsewhere), scalp, neck, hands, feet, genitalia; excised diameter 2.1 to 3.0 cm

11424

719.48

224.17

Excision, benign lesion including margins, except skin tag (unless listed elsewhere), scalp, neck, hands, feet, genitalia; excised diameter 3.1 to 4.0 cm

11426

943.36

314.07

Excision, benign lesion including margins, except skin tag (unless listed elsewhere), scalp, neck, hands, feet, genitalia; excised diameter over 4.0 cm

11440

77.22

133.88

Excision, other benign lesion including margins, except skin tag (unless listed elsewhere), face, ears, eyelids, nose, lips, mucous membrane; excised diameter 0.5 cm or less

11441

86.42

163.74

Excision, other benign lesion including margins, except skin tag (unless listed elsewhere), face, ears, eyelids, nose, lips, mucous membrane; excised diameter 0.6 to 1.0 cm

11442

95.25

183.42

Excision, other benign lesion including margins, except skin tag (unless listed elsewhere), face, ears, eyelids, nose, lips, mucous membrane; excised diameter 1.1 to 2.0 cm

11443

106.64

218.95

Excision, other benign lesion including margins, except skin tag (unless listed elsewhere), face, ears, eyelids, nose, lips, mucous membrane; excised diameter 2.1 to 3.0 cm

11444

388.12

273.38

Excision, other benign lesion including margins, except skin tag (unless listed elsewhere), face, ears, eyelids, nose, lips, mucous membrane; excised diameter 3.1 to 4.0 cm

11446

943.36

362.40

Excision, other benign lesion including margins, except skin tag (unless listed elsewhere), face, ears, eyelids, nose, lips, mucous membrane; excised diameter over 4.0 cm

11450

943.36

351.22

Excision of skin and subcutaneous tissue for hidradenitis, axillary; with simple or intermediate repair

11451

943.36

463.13

Excision of skin and subcutaneous tissue for hidradenitis, axillary; with complex repair

11462

943.36

349.56

Excision of skin and subcutaneous tissue for hidradenitis, inguinal; with simple or intermediate repair

11463

943.36

472.18

Excision of skin and subcutaneous tissue for hidradenitis, inguinal; with complex repair

11470

943.36

379.52

Excision of skin and subcutaneous tissue for hidradenitis, perianal, perineal, or umbilical; with simple or intermediate repair

11471

943.36

485.86

Excision of skin and subcutaneous tissue for hidradenitis, perianal, perineal, or umbilical; with complex repair

11600

98.92

180.76

Excision, malignant lesion including margins, trunk, arms, or legs; excised diameter 0.5 cm or less

11601

112.89

213.87

Excision, malignant lesion including margins, trunk, arms, or legs; excised diameter 0.6 to 1.0 cm

11602

122.46

233.13

Excision, malignant lesion including margins, trunk, arms, or legs; excised diameter 1.1 to 2.0 cm

11603

130.91

263.23

Excision, malignant lesion including margins, trunk, arms, or legs; excised diameter 2.1 to 3.0 cm

11604

388.12

290.19

Excision, malignant lesion including margins, trunk, arms, or legs; excised diameter 3.1 to 4.0 cm

11606

719.48

400.50

Excision, malignant lesion including margins, trunk, arms, or legs; excised diameter over 4.0 cm

11620

100.03

182.18

Excision, malignant lesion including margins, scalp, neck, hands, feet, genitalia; excised diameter 0.5 cm or less

11621

114.00

215.59

Excision, malignant lesion including margins, scalp, neck, hands, feet, genitalia; excised diameter 0.6 to 1.0 cm

11622

126.13

242.65

Excision, malignant lesion including margins, scalp, neck, hands, feet, genitalia; excised diameter 1.1 to 2.0 cm

11623

136.79

282.16

Excision, malignant lesion including margins, scalp, neck, hands, feet, genitalia; excised diameter 2.1 to 3.0 cm

11624

719.48

318.24

Excision, malignant lesion including margins, scalp, neck, hands, feet, genitalia; excised diameter 3.1 to 4.0 cm

11626

943.36

390.12

Excision, malignant lesion including margins, scalp, neck, hands, feet, genitalia; excised diameter over 4.0 cm

11640

104.80

190.25

Excision, malignant lesion including margins, face, ears, eyelids, nose, lips; excised diameter 0.5 cm or less

11641

122.46

230.45

Excision, malignant lesion including margins, face, ears, eyelids, nose, lips; excised diameter 0.6 to 1.0 cm

11642

136.79

264.67

Excision, malignant lesion including margins, face, ears, eyelids, nose, lips; excised diameter 1.1 to 2.0 cm

11643

148.57

308.81

Excision, malignant lesion including margins, face, ears, eyelids, nose, lips; excised diameter 2.1 to 3.0 cm

11644

719.48

382.18

Excision, malignant lesion including margins, face, ears, eyelids, nose, lips; excised diameter 3.1 to 4.0 cm

11646

943.36

498.66

Excision, malignant lesion including margins, face, ears, eyelids, nose, lips; excised diameter over 4.0 cm

11719

11.40

20.67

Trimming of nondystrophic nails, any number

11720

14.71

30.54

Debridement of nail(s) by any method(s); one to five

11721

18.02

43.09

Debridement of nail(s) by any method(s); six or more

11730

35.44

96.07

Avulsion of nail plate, partial or complete, simple; single

11732

18.02

44.11

Avulsion of nail plate, partial or complete, simple; each additional nail plate (List separately in addition to code for primary procedure)

11740

13.24

44.67

Evacuation of subungual hematoma

11750

94.13

206.37

Excision of nail and nail matrix, partial or complete (eg, ingrown or deformed nail), for permanent removal;

11752

129.44

291.79

Excision of nail and nail matrix, partial or complete

(eg, ingrown or deformed nail), for permanent removal; with amputation of tuft of distal phalanx

11755

65.82

131.77

Biopsy of nail unit (eg, plate, bed, matrix, hyponychium, proximal and lateral nail folds) (separate procedure)

11760

94.07

199.47

Repair of nail bed

11762

120.98

261.58

Reconstruction of nail bed with graft

11765

65.22

129.28

Wedge excision of skin of nail fold (eg, for ingrown toenail)

11770

943.36

259.41

Excision of pilonidal cyst or sinus; simple

11771

943.36

508.97

Excision of pilonidal cyst or sinus; extensive

11772

943.36

631.17

Excision of pilonidal cyst or sinus; complicated

11900

28.68

54.26

Injection, intralesional; up to and including seven lesions

11901

30.53

66.42

Injection, intralesional; more than seven lesions

11920

94.07

201.17

Tattooing, intradermal introduction of insoluble opaque pigments to correct color defects of skin, including micropigmentation; 6.0 sq cm or less

11921

94.07

226.94

Tattooing, intradermal introduction of insoluble opaque pigments to correct color defects of skin, including micropigmentation; 6.1 to 20.0 sq cm

11922

37.88

66.24

Tattooing, intradermal introduction of insoluble opaque pigments to correct color defects of skin, including micropigmentation; each additional 20.0 sq cm (List separately in addition to code for primary procedure)

11950

37.14

76.97

Subcutaneous injection of filling material (eg, collagen); 1 cc or less

11951

43.76

99.16

Subcutaneous injection of filling material (eg, collagen); 1.1 to 5.0 cc

11952

57.17

142.59

Subcutaneous injection of filling material (eg, collagen); 5.1 to 10.0 cc

11954

57.17

168.24

Subcutaneous injection of filling material (eg, collagen); over 10.0 cc

11960

903.02

898.02

Insertion of tissue expander(s) for other than breast, including subsequent expansion

119701,920.92

582.91

Replacement of tissue expander with permanent prosthesis

11971

943.36

499.38

Removal of tissue expander(s) without insertion of prosthesis

11980

28.19

104.14

Subcutaneous hormone pellet implantation (implantation of estradiol and/or testosterone pellets beneath the skin)

11981

28.19

136.98

Insertion, non-biodegradable drug delivery implant

11982

28.19

157.01

Removal, non-biodegradable drug delivery implant

11983

28.19

232.80

Removal with reinsertion, non-biodegradable drug delivery implant

12001

57.17

148.83

Simple repair of superficial wounds of scalp, neck, axillae, external genitalia, trunk and/or extremities (including hands and feet); 2.5 cm or less

12002

57.17

157.66

Simple repair of superficial wounds of scalp, neck, axillae, external genitalia, trunk and/or extremities

(including hands and feet); 2.6 cm to 7.5 cm

12004

57.17

184.72

Simple repair of superficial wounds of scalp, neck,

axillae, external genitalia, trunk and/or extremities (including hands and feet); 7.6 cm to 12.5 cm

12005

57.17

229.32

Simple repair of superficial wounds of scalp, neck, axillae, external genitalia, trunk and/or extremities (including hands and feet); 12.6 cm to 20.0 cm

12006

57.17

284.81

Simple repair of superficial wounds of scalp, neck, axillae, external genitalia, trunk and/or extremities (including hands and feet); 20.1 cm to 30.0 cm

12007

57.17

319.74

Simple repair of superficial wounds of scalp, neck, axillae, external genitalia, trunk and/or extremities (including hands and feet); over 30.0 cm

12011

57.17

158.55

Simple repair of superficial wounds of face, ears, eyelids, nose, lips and/or mucous membranes; 2.5 cm or less

12013

57.17

173.90

Simple repair of superficial wounds of face, ears, eyelids, nose, lips and/or mucous membranes; 2.6 cm to 5.0 cm

12014

57.17

203.42

Simple repair of superficial wounds of face, ears, eyelids, nose, lips and/or mucous membranes; 5.1 cm to 7.5 cm

12015

57.17

254.54

Simple repair of superficial wounds of face, ears, eyelids, nose, lips and/or mucous membranes; 7.6 cm to 12.5 cm

12016

57.17

300.27

Simple repair of superficial wounds of face, ears, eyelids, nose, lips and/or mucous membranes; 12.6 cm to 20.0 cm

12017

57.17

253.95

Simple repair of superficial wounds of face, ears, eyelids, nose, lips and/or mucous membranes; 20.1 cm to 30.0 cm

12018

57.17

304.54

Simple repair of superficial wounds of face, ears, eyelids, nose, lips and/or mucous membranes; over 30.0 cm

12020

202.27

272.20

Treatment of superficial wound dehiscence; simple closure

12021

202.27

155.39

Treatment of superficial wound dehiscence; with packing

12031

94.07

221.41

Layer closure of wounds of scalp, axillae, trunk and/o extremities (excluding hands and feet); 2.5 cm or less

12032

94.07

298.32

Layer closure of wounds of scalp, axillae, trunk and/o extremities (excluding hands and feet); 2.6 cm to 7.5 cm

12034

94.07

287.38

Layer closure of wounds of scalp, axillae, trunk and/o extremities (excluding hands and feet); 7.6 cm to 12.5 cm

12035

94.07

370.79

Layer closure of wounds of scalp, axillae, trunk and/o extremities (excluding hands and feet); 12.6 cm to 20.0 cm

12036

94.07

407.34

Layer closure of wounds of scalp, axillae, trunk and/o extremities (excluding hands and feet); 20.1 cm to 30.0 cm

12037

94.07

457.58

Layer closure of wounds of scalp, axillae, trunk and/o extremities (excluding hands and feet); over 30.0 cm

12041

94.07

235.05

Layer closure of wounds of neck, hands, feet and/or external genitalia; 2.5 cm or less

12042

94.07

277.92

Layer closure of wounds of neck, hands, feet and/or external genitalia; 2.6 cm to 7.5 cm

12044

94.07

314.37

Layer closure of wounds of neck, hands, feet and/or external genitalia; 7.6 cm to 12.5 cm

12045

94.07

373.96

Layer closure of wounds of neck, hands, feet and/or external genitalia; 12.6 cm to 20.0 cm

12046

94.07

441.49

Layer closure of wounds of neck, hands, feet and/or external genitalia; 20.1 cm to 30.0 cm

12047

94.07

471.99

Layer closure of wounds of neck, hands, feet and/or external genitalia; over 30.0 cm

12051

94.07

260.86

Layer closure of wounds of face, ears, eyelids, nose, lips and/or mucous membranes; 2.5 cm or less

12052

94.07

286.99

Layer closure of wounds of face, ears, eyelids, nose, lips and/or mucous membranes; 2.6 cm to 5.0 cm

12053

94.07

312.95

Layer closure of wounds of face, ears, eyelids, nose, lips and/or mucous membranes; 5.1 cm to 7.5 cm

12054

94.07

334.60

Layer closure of wounds of face, ears, eyelids, nose, lips and/or mucous membranes; 7.6 cm to 12.5 cm

12055

94.07

406.73

Layer closure of wounds of face, ears, eyelids, nose, lips and/or mucous membranes; 12.6 cm to 20.0 cm

12056

94.07

503.48

Layer closure of wounds of face, ears, eyelids, nose, lips and/or mucous membranes; 20.1 cm to 30.0 cm

12057

94.07

540.52

Layer closure of wounds of face, ears, eyelids, nose, lips and/or mucous membranes; over 30.0 cm

13100

202.27

310.16

Repair, complex, trunk; 1.1 cm to 2.5 cm

13101

202.27

385.92

Repair, complex, trunk; 2.6 cm to 7.5 cm

13102

202.27

104.23

Repair, complex, trunk; each additional 5 cm or less (List separately in addition to code for primary procedure)

13120

94.07

321.83

Repair, complex, scalp, arms, and/or legs; 1.1 cm to 2.5 cm

13121

202.27

422.40

Repair, complex, scalp, arms, and/or legs; 2.6 cm to 7.5 cm

13122

94.07

119.94

Repair, complex, scalp, arms, and/or legs; each additional 5 cm or less (List separately in addition to code for primary procedure)

13131

202.27

353.41

Repair, complex, forehead, cheeks, chin, mouth, neck axillae, genitalia, hands and/or feet; 1.1 cm to 2.5 cm

13132

202.27

548.43

Repair, complex, forehead, cheeks, chin, mouth, neck axillae, genitalia, hands and/or feet; 2.6 cm to 7.5 cm

13133

202.27

161.64

Repair, complex, forehead, cheeks, chin, mouth, neck axillae, genitalia, hands and/or feet; each additional 5 cm or less (List separately in addition to code for primary procedure)

13150

202.27

361.55

Repair, complex, eyelids, nose, ears and/or lips; 1.0 cm or less

13151

202.27

399.08

Repair, complex, eyelids, nose, ears and/or lips; 1.1 cm to 2.5 cm

13152

202.27

540.99

Repair, complex, eyelids, nose, ears and/or lips; 2.6 cm to 7.5 cm

13153

94.07

180.05

Repair, complex, eyelids, nose, ears and/or lips; each additional 5 cm or less (List separately in addition to code for primary procedure)

13160

903.02

776.75

Secondary closure of surgical wound or dehiscence, extensive or complicated

14000

672.37

637.52

Adjacent tissue transfer or rearrangement, trunk; defect 10 sq cm or less

14001

672.37

822.76

Adjacent tissue transfer or rearrangement, trunk; defect 10.1 sq cm to 30.0 sq cm

14020

672.37

709.70

Adjacent tissue transfer or rearrangement, scalp, arm and/or legs; defect 10 sq cm or less

14021

672.37

922.90

Adjacent tissue transfer or rearrangement, scalp, arm and/or legs; defect 10.1 sq cm to 30.0 sq cm

14040

672.37

744.02

Adjacent tissue transfer or rearrangement, forehead, cheeks, chin, mouth, neck, axillae, genitalia, hands and/or feet; defect 10 sq cm or less

14041

672.37

1,010.95

Adjacent tissue transfer or rearrangement, forehead, cheeks, chin, mouth, neck, axillae, genitalia, hands and/or feet; defect 10.1 sq cm to 30.0 sq cm

14060

672.37

755.36

Adjacent tissue transfer or rearrangement, eyelids, nose, ears and/or lips; defect 10 sq cm or less

14061

672.37

1,098.01

Adjacent tissue transfer or rearrangement, eyelids, nose, ears and/or lips; defect 10.1 sq cm to 30.0 sq cm

14300

903.02

1,055.04

Adjacent tissue transfer or rearrangement, more than 30 sq cm, unusual or complicated, any area

14350

903.02

732.71

Filleted finger or toe flap, including preparation of recipient site

15040

94.07

271.10

Harvest of skin for tissue cultured skin autograft, 100 sq cm or less

15050

202.27

535.06

Pinch graft, single or multiple, to cover small ulcer, tip of digit, or other minimal open area (except on face), up to defect size 2 cm diameter

15150

202.27

708.42

Tissue cultured epidermal autograft, trunk, arms, legs first 25 sq cm or less

15151

202.27

126.85

Tissue cultured epidermal autograft, trunk, arms, legs additional 1 sq cm to 75 sq cm (List separately in addition to code for primary procedure)

15155

202.27

730.87

Tissue cultured epidermal autograft, face, scalp, eyelids, mouth, neck, ears, orbits, genitalia, hands, feet, and/or multiple digits; first 25 sq cm or less

15156

202.27

166.82

Tissue cultured epidermal autograft, face, scalp, eyelids, mouth, neck, ears, orbits, genitalia, hands, feet, and/or multiple digits; additional 1 sq cm to 75 sq cm (List separately in addition to code for primary procedure)

15200

672.37

780.27

Full thickness graft, free, including direct closure of donor site, trunk; 20 sq cm or less

15201

672.37

156.17

Full thickness graft, free, including direct closure of donor site, trunk; each additional 20 sq cm (List separately in addition to code for primary procedure)

15220

672.37

749.07

Full thickness graft, free, including direct closure of donor site, scalp, arms, and/or legs; 20 sq cm or less

15221

202.27

144.85

Full thickness graft, free, including direct closure of donor site, scalp, arms, and/or legs; each additional 20 sq cm (List separately in addition to code for primary procedure)

15240

672.37

885.96

Full thickness graft, free, including direct closure of donor site, forehead, cheeks, chin, mouth, neck, axillae, genitalia, hands, and/or feet; 20 sq cm or less

15241

202.27

185.01

Full thickness graft, free, including direct closure of donor site, forehead, cheeks, chin, mouth, neck, axillae, genitalia, hands, and/or feet; each additional 20 sq cm (List separately in addition to code for primary procedure)

15260

672.37

944.42

Full thickness graft, free, including direct closure of donor site, nose, ears, eyelids, and/or lips; 20 sq cm or less

15261

672.37

213.15

Full thickness graft, free, including direct closure of donor site, nose, ears, eyelids, and/or lips; each additional 20 sq cm (List separately in addition to code for primary procedure)

15340

94.07

317.42

Tissue cultured allogeneic skin substitute; first 25 sq cm or less

15341

94.07

47.41

Tissue cultured allogeneic skin substitute; each additional 25 sq cm

15570

903.02

874.10

Formation of direct or tubed pedicle, with or without transfer; trunk

15572

903.02

819.06

Formation of direct or tubed pedicle, with or without transfer; scalp, arms, or legs

15574

903.02

883.97

Formation of direct or tubed pedicle, with or without transfer; forehead, cheeks, chin, mouth, neck, axillae, genitalia, hands or feet

15576

903.02

788.95

Formation of direct or tubed pedicle, with or without transfer; eyelids, nose, ears, lips, or intraoral

15600

903.02

372.01

Delay of flap or sectioning of flap (division and inset) at trunk

15610

903.02

330.61

Delay of flap or sectioning of flap (division and inset) at scalp, arms, or legs

15620

903.02

462.27

Delay of flap or sectioning of flap (division and inset) at forehead, cheeks, chin, neck, axillae, genitalia, hands, or feet

15630

903.02

470.02

Delay of flap or sectioning of flap (division and inset) at eyelids, nose, ears, or lips

15650

903.02

502.88

Transfer, intermediate, of any pedicle flap (eg, abdomen to wrist, Walking tube), any location

15731

903.02

1,068.20

Forehead flap with preservation of vascular pedicle (eg, axial pattern flap, paramedian forehead flap)

15732

903.02

1,485.59

Muscle, myocutaneous, or fasciocutaneous flap; head and neck (eg, temporalis, masseter muscle, sternocleidomastoid, levator scapulae)

15734

903.02

1,526.76

Muscle, myocutaneous, or fasciocutaneous flap; trun

15736

903.02

1,379.60

Muscle, myocutaneous, or fasciocutaneous flap; uppe extremity

15738

903.02

1,456.65

Muscle, myocutaneous, or fasciocutaneous flap; lowe extremity

15740

672.37

959.81

Flap; island pedicle

15750

903.02

889.16

Flap; neurovascular pedicle

15756

2,293.67

Free muscle or myocutaneous flap with microvascula anastomosis

15757

2,287.08

Free skin flap with microvascular anastomosis

15758

2,281.38

Free fascial flap with microvascular anastomosis

15760

903.02

826.85

Graft; composite (eg, full thickness of external ear or nasal ala), including primary closure, donor area

15770

903.02

636.09

Graft; derma-fat-fascia

15775

903.02

314.31

Punch graft for hair transplant; one to 15 punch grafts

15776

903.02

445.60

Punch graft for hair transplant; more than 15 punch grafts

15780

903.02

834.10

Dermabrasion; total face (eg, for acne scarring, fine wrinkling, rhytids, general keratosis)

15781

903.02

536.85

Dermabrasion; segmental, face

15782

903.02

586.66

Dermabrasion; regional, other than face

15783

903.02

496.84

Dermabrasion; superficial, any site (eg, tattoo removal

15786

903.02

240.37

Abrasion; single lesion (eg, keratosis, scar)

15787

903.02

56.65

Abrasion; each additional four lesions or less (List separately in addition to code for primary procedure)

15788

903.02

447.02

Chemical peel, facial; epidermal

15789

903.02

576.84

Chemical peel, facial; dermal

15792

903.02

437.47

Chemical peel, nonfacial; epidermal

15793

903.02

467.52

Chemical peel, nonfacial; dermal

15819

903.02

704.85

Cervicoplasty

15820

903.02

527.39

Blepharoplasty, lower eyelid;

15821

903.02

561.24

Blepharoplasty, lower eyelid; with extensive herniate fat pad

15822

903.02

419.61

Blepharoplasty, upper eyelid;

15823

903.02

642.96

Blepharoplasty, upper eyelid; with excessive skin weighting down lid

15824

903.02

I.C.

Rhytidectomy; forehead

15825

903.02

I.C.

Rhytidectomy; neck with platysmal tightening (platysmal flap, P-flap)

15826

903.02

I.C.

Rhytidectomy; glabellar frown lines

15828

903.02

I.C.

Rhytidectomy; cheek, chin, and neck

15829

903.02

I.C.

Rhytidectomy; superficial musculoaponeurotic system (SMAS) flap

15830

903.02

1,116.84

Excision, excessive skin and subcutaneous tissue (includes lipectomy); abdomen, infraumbilical panniculectomy

15832

903.02

864.16

Excision, excessive skin and subcutaneous tissue (includes lipectomy); thigh

15833

903.02

805.92

Excision, excessive skin and subcutaneous tissue (includes lipectomy); leg

15834

57.17

821.96

Excision, excessive skin and subcutaneous tissue (includes lipectomy); hip

15835

57.17

839.07

Excision, excessive skin and subcutaneous tissue (includes lipectomy); buttock

15836

418.12

709.05

Excision, excessive skin and subcutaneous tissue (includes lipectomy); arm

15837

192.34

752.05

Excision, excessive skin and subcutaneous tissue (includes lipectomy); forearm or hand

15838

192.34

558.04

Excision, excessive skin and subcutaneous tissue (includes lipectomy); submental fat pad

15839

118.89

816.99

Excision, excessive skin and subcutaneous tissue (includes lipectomy); other area

15840

35.44

978.48

Graft for facial nerve paralysis; free fascia graft (including obtaining fascia)

15841

35.31

1,610.39

Graft for facial nerve paralysis; free muscle graft (including obtaining graft)

15842

35.44

2,545.49

Graft for facial nerve paralysis; free muscle flap by microsurgical technique

15845

65.22

910.54

Graft for facial nerve paralysis; regional muscle transfer

15847

65.22

I.C.

Excision, excessive skin and subcutaneous tissue (includes lipectomy), abdomen (eg, abdominoplasty)

15850

35.44

91.65

(includes umbilical transposition and fascial plication) (List separately in addition to code for primary procedure)

Removal of sutures under anesthesia (other than

15851

94.07

100.66

local), same surgeon Removal of sutures under anesthesia (other than

15852

903.02

45.41

local), other surgeon Dressing change (for other than burns) under

15860

903.02

107.35

anesthesia (other than local)

Intravenous injection of agent (eg, fluorescein) to test

15876

903.02

I.C.

vascular flow in flap or graft Suction assisted lipectomy; head and neck

15877

903.02

I.C.

Suction assisted lipectomy; trunk

15878

903.02

I.C.

Suction assisted lipectomy; upper extremity

15879

903.02

I.C.

Suction assisted lipectomy; lower extremity

15920

903.02

560.29

Excision, coccygeal pressure ulcer, with

15922

903.02

722.79

coccygectomy; with primary suture Excision, coccygeal pressure ulcer, with

15931

903.02

636.67

coccygectomy; with flap closure Excision, sacral pressure ulcer, with primary suture;

15933

943.36

790.51

Excision, sacral pressure ulcer, with primary suture;

15934

943.36

878.65

with ostectomy Excision, sacral pressure ulcer, with skin flap closure

15935

943.36

1,043.67

Excision, sacral pressure ulcer, with skin flap closure

15936

943.36

858.22

with ostectomy Excision, sacral pressure ulcer, in preparation for

15937

943.36

1,005.94

muscle or myocutaneous flap or skin graft closure;

Excision, sacral pressure ulcer, in preparation for

15940

719.48

660.16

muscle or myocutaneous flap or skin graft closure; with ostectomy Excision, ischial pressure ulcer, with primary suture;

15941

719.48

879.16

Excision, ischial pressure ulcer, with primary suture;

15944

719.48

853.65

with ostectomy (ischiectomy)

Excision, ischial pressure ulcer, with skin flap closure

15945

719.48

943.61

Excision, ischial pressure ulcer, with skin flap

15946

903.02

1,553.86

closure; with ostectomy Excision, ischial pressure ulcer, with ostectomy, in

15950

903.02

550.26

preparation for muscle or myocutaneous flap or skin graft closure Excision, trochanteric pressure ulcer, with primary

15951

903.02

784.05

suture;

Excision, trochanteric pressure ulcer, with primary

15952

903.02

812.73

suture; with ostectomy Excision, trochanteric pressure ulcer, with skin flap

15953

943.36

907.89

closure;

Excision, trochanteric pressure ulcer, with skin flap

15956

118.89

1,100.62

closure; with ostectomy Excision, trochanteric pressure ulcer, in preparation

15958

55.16

1,127.15

for muscle or myocutaneous flap or skin graft closure; Excision, trochanteric pressure ulcer, in preparation

15999

I.C.

for muscle or myocutaneous flap or skin graft closure;

with ostectomy Unlisted procedure, excision pressure ulcer

16000

28.19

69.15

Initial treatment, first degree burn, when no more tha local treatment is required

16020

903.02

84.95

Dressings and/or debridement of partial-thickness burns, initial or subsequent; small (less than 5% total body surface area)

16025

903.02

145.73

Dressings and/or debridement of partial-thickness burns, initial or subsequent; medium (eg, whole face or whole extremity, or 5% to 10% total body surface area)

16030

903.02

176.25

Dressings and/or debridement of partial-thickness burns, initial or subsequent; large (eg, more than one extremity, or greater than 10% total body surface area)

16035

903.02

205.92

Escharotomy; initial incision

16036

81.60

Escharotomy; each additional incision (List separatel in addition to code for primary procedure)

17000

35.44

76.84

Destruction (eg, laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical curettement), premalignant lesions (eg, actinic keratoses); first lesion

17003

4.05

7.75

Destruction (eg, laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical curettement), premalignant lesions (eg, actinic keratoses); second through 14 lesions, each (List separately in addition to code for first lesion)

17004

87.15

174.52

Destruction (eg, laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical curettement), premalignant lesions (eg, actinic keratoses), 15 or more lesions

17106

118.89

382.26

Destruction of cutaneous vascular proliferative lesion (eg, laser technique); less than 10 sq cm

17107

118.89

659.00

Destruction of cutaneous vascular proliferative lesion (eg, laser technique); 10.0 to 50.0 sq cm

17108

118.89

885.03

Destruction of cutaneous vascular proliferative lesion (eg, laser technique); over 50.0 sq cm

17110

35.44

102.62

Destruction (eg, laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical curettement), of benign lesions other than skin tags or cutaneous vascular proliferative lesions; up to 14 lesions

17111

65.22

123.81

Destruction (eg, laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical curettement), of benign lesions other than skin tags or cutaneous vascular proliferative lesions; 15 or more lesions

17250

46.71

77.33

Chemical cauterization of granulation tissue (proud flesh, sinus or fistula)

17260

49.27

94.63

Destruction, malignant lesion (eg, laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical curettement), trunk, arms or legs; lesion diameter 0.5 cm or less

17261

65.22

136.49

Destruction, malignant lesion (eg, laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical curettement), trunk, arms or legs; lesion diameter 0.6 to 1.0 cm

17262

65.22

165.05

Destruction, malignant lesion (eg, laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical curettement), trunk, arms or legs; lesion diameter 1.1 to 2.0 cm

17263

65.22

181.73

Destruction, malignant lesion (eg, laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical curettement), trunk, arms or legs; lesion diameter 2.1 to 3.0 cm

17264

65.22

195.90

Destruction, malignant lesion (eg, laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical curettement), trunk, arms or legs; lesion diameter 3.1 to 4.0 cm

17266

110.31

221.36

Destruction, malignant lesion (eg, laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical curettement), trunk, arms or legs; lesion diameter over 4.0 cm

17270

65.22

142.53

Destruction, malignant lesion (eg, laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical curettement), scalp, neck, hands, feet, genitalia; lesion diameter 0.5 cm or less

17271

65.22

155.54

Destruction, malignant lesion (eg, laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical curettement), scalp, neck, hands, feet, genitalia; lesion diameter 0.6 to 1.0 cm

17272

65.22

177.82

Destruction, malignant lesion (eg, laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical curettement), scalp, neck, hands, feet, genitalia; lesion diameter 1.1 to 2.0 cm

17273

99.65

197.81

Destruction, malignant lesion (eg, laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical curettement), scalp, neck, hands, feet, genitalia; lesion diameter 2.1 to 3.0 cm

17274

113.26

234.34

Destruction, malignant lesion (eg, laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical curettement), scalp, neck, hands, feet, genitalia; lesion diameter 3.1 to 4.0 cm

17276

118.89

272.15

Destruction, malignant lesion (eg, laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical curettement), scalp, neck, hands, feet, genitalia; lesion diameter over 4.0 cm

17280

65.22

133.73

Destruction, malignant lesion (eg, laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical curettement), face, ears, eyelids, nose, lips, mucous membrane; lesion diameter 0.5 cm or less

17281

85.32

168.29

Destruction, malignant lesion (eg, laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical curettement), face, ears, eyelids, nose, lips, mucous membrane; lesion diameter 0.6 to 1.0 cm

17282

97.08

194.71

Destruction, malignant lesion (eg, laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical curettement), face, ears, eyelids, nose, lips, mucous membrane; lesion diameter 1.1 to 2.0 cm

17283

112.16

234.50

Destruction, malignant lesion (eg, laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical curettement), face, ears, eyelids, nose, lips, mucous membrane; lesion diameter 2.1 to 3.0 cm

17284

118.89

272.98

Destruction, malignant lesion (eg, laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical curettement), face, ears, eyelids, nose, lips, mucous membrane; lesion diameter 3.1 to 4.0 cm

17286

118.89

345.71

Destruction, malignant lesion (eg, laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical curettement), face, ears, eyelids, nose, lips, mucous membrane; lesion diameter over 4.0 cm

17311

162.31

711.84

Mohs micrographic technique, including removal of all gross tumor, surgical excision of tissue specimens, mapping, color coding of specimens, microscopic examination of specimens by the surgeon, and histopathologic preparation including routine stain(s) (eg, hematoxylin and eosin, toluidine blue), head, neck, hands, feet, genitalia, or any location with surgery directly involving muscle, cartilage, bone, tendon, major nerves, or vessels; first stage, up to five tissue blocks

17312

162.31

433.70

Mohs micrographic technique, including removal of all gross tumor, surgical excision of tissue specimens, mapping, color coding of specimens, microscopic examination of specimens by the surgeon, and histopathologic preparation including routine stain(s) (eg, hematoxylin and eosin, toluidine blue), head, neck, hands, feet, genitalia, or any location with surgery directly involving muscle, cartilage, bone, tendon, major nerves, or vessels; each additional stage after the first stage, up to five tissue blocks (List separately in addition to code for primary procedure)

17313

162.31

651.19

Mohs micrographic technique, including removal of all gross tumor, surgical excision of tissue specimens, mapping, color coding of specimens, microscopic examination of specimens by the surgeon, and histopathologic preparation including routine stain(s) (eg, hematoxylin and eosin, toluidine blue), of the trunk, arms, or legs; first stage, up to five tissue blocks

17314

162.31

401.27

Mohs micrographic technique, including removal of all gross tumor, surgical excision of tissue specimens, mapping, color coding of specimens, microscopic examination of specimens by the surgeon, and histopathologic preparation including routine stain(s) (eg, hematoxylin and eosin, toluidine blue), of the trunk, arms, or legs; each additional stage after the first stage, up to five tissue blocks (List separately in addition to code for primary procedure)

17315

41.92

83.08

Mohs micrographic technique, including removal of

all gross tumor, surgical excision of tissue specimens, mapping, color coding of specimens, microscopic examination of specimens by the surgeon, and histopathologic preparation including routine stain(s) (eg, hematoxylin and eosin, toluidine blue), each additional block after the first five tissue blocks, any stage (List separately in addition to code for primary procedure)

17340

13.23

44.02

Cryotherapy (CO2 slush, liquid N2) for acne

17360

35.44

126.91

Chemical exfoliation for acne (eg, acne paste, acid)

17380

35.44

I.C.

Electrolysis epilation, each 30 minutes

17999

I.C.

Unlisted procedure, skin, mucous membrane and subcutaneous tissue

19000

71.70

120.83

Puncture aspiration of cyst of breast;

19001

71.70

27.05

Puncture aspiration of cyst of breast; each additional cyst (List separately in addition to code for primary procedure)

19020

71.70

439.45

Mastotomy with exploration or drainage of abscess, deep

19030

182.43

Injection procedure only for mammary ductogram or galactogram

19100

193.36

143.90

Biopsy of breast; percutaneous, needle core, not using imaging guidance (separate procedure)

19101

922.44

325.31

Biopsy of breast; open, incisional

19102

317.95

240.49

Biopsy of breast; percutaneous, needle core, using imaging guidance

19103

606.71

632.08

Biopsy of breast; percutaneous, automated vacuum assisted or rotating biopsy device, using imaging guidance

19105

1,417.2

2

2,27

5.75

Ablation, cryosurgical, of fibroadenoma, including ultrasound guidance, each fibroadenoma

19110

922.44

438.55

Nipple exploration, with or without excision of a solitary lactiferous duct or a papilloma lactiferous duct

19112

922.44

424.47

Excision of lactiferous duct fistula

19120

922.44

442.67

Excision of cyst, fibroadenoma, or other benign or malignant tumor, aberrant breast tissue, duct lesion, nipple or areolar lesion (except 19300), open, male or female, one or more lesions

19125

922.44

486.95

Excision of breast lesion identified by preoperative placement of radiological marker, open; single lesion

19126

922.44

151.47

Excision of breast lesion identified by preoperative placement of radiological marker, open; each additional lesion separately identified by a preoperative radiological marker (List separately in addition to code for primary procedure)

19260

1,155.26

Excision of chest wall tumor including ribs

19271

1,603.08

Excision of chest wall tumor involving ribs, with plastic reconstruction; without mediastinal lymphadenectomy

19272

1,763.56

Excision of chest wall tumor involving ribs, with plastic reconstruction; with mediastinal lymphadenectomy

19290

177.56

Preoperative placement of needle localization wire, breast;

19291

76.56

Preoperative placement of needle localization wire, breast; each additional lesion (List separately in addition to code for primary procedure)

19295

114.91

Image guided placement, metallic localization clip, percutaneous, during breast biopsy (List separately in addition to code for primary procedure)

19296

2,528.34

5,002.21

Placement of radiotherapy afterloading balloon catheter into the breast for interstitial radioelement application following partial mastectomy, includes imaging guidance; on date separate from partial mastectomy

19297

2,528.34

88.68

Placement of radiotherapy afterloading balloon catheter into the breast for interstitial radioelement application following partial mastectomy, includes imaging guidance; concurrent with partial mastectomy (List separately in addition to code for primary procedure)

19298

2,528.34

1,695.25

Placement of radiotherapy afterloading brachytherapy catheters (multiple tube and button type) into the breast for interstitial radioelement application following (at the time of or subsequent to) partial mastectomy, includes imaging guidance

19300

2,528.34

548.04

Mastectomy for gynecomastia

19301

2,528.34

550.14

Mastectomy, partial (eg, lumpectomy, tylectomy, quadrantectomy, segmentectomy);

19302

2,528.34

815.08

Mastectomy, partial (eg, lumpectomy, tylectomy, quadrantectomy, segmentectomy); with axillary lymphadenectomy

19303

2,528.34

847.02

Mastectomy, simple, complete

19304

2,528.34

521.07

Mastectomy, subcutaneous

19305

1,016.20

Mastectomy, radical, including pectoral muscles, axillary lymph nodes

19306

1,062.12

Mastectomy, radical, including pectoral muscles, axillary and internal mammary lymph nodes (Urban type operation)

19307

1,067.49

Mastectomy, modified radical, including axillary lymph nodes, with or without pectoralis minor muscle, but excluding pectoralis major muscle

19316

1,417.22

756.83

Mastopexy

19318

1,779.44

1,116.18

Reduction mammaplasty

19324

1,779.44

467.64

Mammaplasty, augmentation; without prosthetic implant

19325

2,528.34

628.57

Mammaplasty, augmentation; with prosthetic implan

19328

1,417.22

474.69

Removal of intact mammary implant

19330

1,417.22

600.40

Removal of mammary implant material

19340

1,779.44

383.80

Immediate insertion of breast prosthesis following mastopexy, mastectomy or in reconstruction

19342

2,528.34

889.56

Delayed insertion of breast prosthesis following mastopexy, mastectomy or in reconstruction

19350

922.44

895.56

Nipple/areola reconstruction

19357

2,528.34

1,504.35

Breast reconstruction, immediate or delayed, with tissue expander, including subsequent expansion

19361

1,551.85

Breast reconstruction with latissimus dorsi flap, without prosthetic implant

19364

2,687.37

Breast reconstruction with free flap

19366

1,417.22

1,333.13

Breast reconstruction with other technique

19367

1,763.11

Breast reconstruction with transverse rectus abdominis myocutaneous flap (TRAM), single pedicle, including closure of donor site;

19368

2,164.21

Breast reconstruction with transverse rectus abdominis myocutaneous flap (TRAM), single pedicle, including closure of donor site; with microvascular anastomosis (supercharging)

19369

1,993.81

Breast reconstruction with transverse rectus abdominis myocutaneous flap (TRAM), double pedicle, including closure of donor site

19370

1,417.22

660.91

Open periprosthetic capsulotomy, breast

19371

1,417.22

761.51

Periprosthetic capsulectomy, breast

19380

1,779.44

744.34

Revision of reconstructed breast

19396

1,417.22

212.42

Preparation of moulage for custom breast implant

19499

I.C.

Unlisted procedure, breast

20000

62.85

206.68

Incision of soft tissue abscess (eg, secondary to osteomyelitis); superficial

20005

950.47

299.78

Incision of soft tissue abscess (eg, secondary to osteomyelitis); deep or complicated

20100

574.00

Exploration of penetrating wound (separate procedure); neck

20101

411.27

Exploration of penetrating wound (separate procedure); chest

20102

481.42

Exploration of penetrating wound (separate procedure); abdomen/flank/back

20103

430.53

581.21

Exploration of penetrating wound (separate procedure); extremity

20150

1,920.92

897.48

Excision of epiphyseal bar, with or without autogenous soft tissue graft obtained through same fascial incision

20200

719.48

197.59

Biopsy, muscle; superficial

20205

719.48

267.80

Biopsy, muscle; deep

20206

317.95

305.62

Biopsy, muscle, percutaneous needle

20220

388.12

212.84

Biopsy, bone, trocar, or needle; superficial (eg, ilium sternum, spinous process, ribs)

20225

388.12

909.54

Biopsy, bone, trocar, or needle; deep (eg, vertebral body, femur)

20240

943.36

229.56

Biopsy, bone, open; superficial (eg, ilium, sternum, spinous process, ribs, trochanter of femur)

20245

943.36

622.24

Biopsy, bone, open; deep (eg, humerus, ischium, femur

20250

950.47

371.07

Biopsy, vertebral body, open; thoracic

20251

950.47

412.86

Biopsy, vertebral body, open; lumbar or cervical

20500

66.19

129.13

Injection of sinus tract; therapeutic (separate procedure

20501

148.66

Injection of sinus tract; diagnostic (sinogram)

20520

101.50

197.18

Removal of foreign body in muscle or tendon sheath; simple

20525

943.36

509.34

Removal of foreign body in muscle or tendon sheath; deep or complicated

20526

32.73

76.96

Injection, therapeutic (eg, local anesthetic, corticosteroid), carpal tunnel

20550

24.64

59.14

Injection(s); single tendon sheath, or ligament, aponeurosis (eg, plantar "fascia")

20551

24.28

58.38

Injection(s); single tendon origin/insertion

20552

23.90

53.95

Injection(s); single or multiple trigger point(s), one o two muscle(s)

20553

26.84

60.41

Injection(s); single or multiple trigger point(s), three or more muscle(s)

20555

1,304.45

318.09

Placement of needles or catheters into muscle and/or soft tissue for subsequent interstitial radioelement application (at the time of or subsequent to the procedure)

20600

24.28

55.31

Arthrocentesis, aspiration and/or injection; small join or bursa (eg, fingers, toes)

20605

27.58

60.14

Arthrocentesis, aspiration and/or injection; intermediate joint or bursa (eg, temporomandibular, acromioclavicular, wrist, elbow or ankle, olecranon bursa)

20610

37.14

76.76

Arthrocentesis, aspiration and/or injection; major join or bursa (eg, shoulder, hip, knee joint, subacromial bursa)

20612

25.74

59.12

Aspiration and/or injection of ganglion cyst(s) any location

20615

114.36

227.67

Aspiration and injection for treatment of bone cyst

20650

950.47

197.04

Insertion of wire or pin with application of skeletal traction, including removal (separate procedure)

20660

259.20

Application of cranial tongs, caliper, or stereotactic frame, including removal (separate procedure)

20661

461.90

Application of halo, including removal; cranial

20662

950.47

468.49

Application of halo, including removal; pelvic

20663

950.47

442.84

Application of halo, including removal; femoral

20664

731.10

Application of halo, including removal, cranial, 6 or more pins placed, for thin skull osteology (eg, pediatric patients, hydrocephalus, osteogenesis imperfecta), requiring general anesthesia

20665

28.19

132.12

Removal of tongs or halo applied by another physicia

20670

719.48

486.42

Removal of implant; superficial (eg, buried wire, pin or rod) (separate procedure)

20680

943.36

608.09

Removal of implant; deep (eg, buried wire, pin, screw, metal band, nail, rod or plate)

20690

1,304.45

483.79

Application of a uniplane (pins or wires in one plane), unilateral, external fixation system

20692

1,304.45

890.29

Application of a multiplane (pins or wires in more than one plane), unilateral, external fixation system (eg, Ilizarov, Monticelli type)

20693

950.47

461.97

Adjustment or revision of external fixation system requiring anesthesia (eg, new pin(s) or wire(s) and/or new ring(s) or bar(s))

20694

950.47

451.44

Removal, under anesthesia, of external fixation system

20802

2,345.84

Replantation, arm (includes surgical neck of humerus through elbow joint), complete amputation

20805

3,095.55

Replantation, forearm (includes radius and ulna to radial carpal joint), complete amputation

20808

4,019.75

Replantation, hand (includes hand through metacarpophalangeal joints), complete amputation

20816

2,466.39

Replantation, digit, excluding thumb (includes metacarpophalangeal joint to insertion of flexor sublimis tendon), complete amputation

20822

1,175.77

2,170.99

Replantation, digit, excluding thumb (includes distal tip to sublimis tendon insertion), complete amputation

20824

2,436.87

Replantation, thumb (includes carpometacarpal joint to MP joint), complete amputation

20827

2,219.31

Replantation, thumb (includes distal tip to MP joint), complete amputation

20838

2,322.57

Replantation, foot, complete amputation

20900

1,304.45

631.61

Bone graft, any donor area; minor or small (eg, dowel or button)

20902

1,304.45

607.39

Bone graft, any donor area; major or large

20910

903.02

430.61

Cartilage graft; costochondral

20912

903.02

487.05

Cartilage graft; nasal septum

20920

672.37

401.84

Fascia lata graft; by stripper

20922

672.37

602.03

Fascia lata graft; by incision and area exposure, complex or sheet

20924

1,304.45

506.11

Tendon graft, from a distance (eg, palmaris, toe extensor, plantaris)

20926

202.27

433.34

Tissue grafts, other (eg, paratenon, fat, dermis)

20930

I.C.

Allograft for spine surgery only; morselized (List separately in addition to code for primary procedure)

20931

111.51

Allograft for spine surgery only; structural (List separately in addition to code for primary procedure)

20936

I.C.

Autograft for spine surgery only (includes harvesting the graft); local (eg, ribs, spinous process, or laminar fragments) obtained from same incision (List separately in addition to code for primary procedure)

20937

169.44

Autograft for spine surgery only (includes harvesting the graft); morselized (through separate skin or fascial incision) (List separately in addition to code for primary procedure)

20938

184.43

Autograft for spine surgery only (includes harvesting the graft); structural, bicortical or tricortical (through separate skin or fascial incision) (List separately in addition to code for primary procedure)

20950

62.85

304.01

Monitoring of interstitial fluid pressure (includes insertion of device, eg, wick catheter technique, needle manometer technique) in detection of muscle compartment syndrome

20955

2,499.21

Bone graft with microvascular anastomosis; fibula

20956

2,646.13

Bone graft with microvascular anastomosis; iliac cres

20957

2,459.01

Bone graft with microvascular anastomosis; metatarsa

20962

2,637.14

Bone graft with microvascular anastomosis; other than fibula, iliac crest, or metatarsal

20969

2,783.23

Free osteocutaneous flap with microvascular anastomosis; other than iliac crest, metatarsal, or great

toe

20970

2,775.62

Free osteocutaneous flap with microvascular anastomosis; iliac crest

20972

1,978.29

2,485.71

Free osteocutaneous flap with microvascular anastomosis; metatarsal

20973

1,978.29

2,675.05

Free osteocutaneous flap with microvascular anastomosis; great toe with web space

20974

62.67

Electrical stimulation to aid bone healing; noninvasiv (nonoperative)

20975

176.78

Electrical stimulation to aid bone healing; invasive (operative)

20979

26.11

56.55

Low intensity ultrasound stimulation to aid bone healing, noninvasive (nonoperative)

20982

1,920.92

4,634.67

Ablation, bone tumor(s) (eg, osteoid osteoma, metastasis) radiofrequency, percutaneous, including computed tomographic guidance

20985

145.31

Computer-assisted surgical navigational procedure fo musculoskeletal procedures; image-less (List separately in addition to code for primary procedure)

20986

I.C.

Computer-assisted surgical navigational procedure for musculoskeletal procedures; with image guidance based on intraoperatively obtained images (eg, fluoroscopy, ultrasound) (List separately in addition to code for primary procedure)

20987

I.C.

Computer-assisted surgical navigational procedure for musculoskeletal procedures; with image guidance based on preoperative images (List separately in addition to code for primary procedure)

20999

I.C.

Unlisted procedure, musculoskeletal system, general

21010

1,071.47

713.36

Arthrotomy, temporomandibular joint

21015

729.71

426.33

Radical resection of tumor (eg, malignant neoplasm), soft tissue of face or scalp

21025

1,782.06

988.28

Excision of bone (eg, for osteomyelitis or bone abscess); mandible

21026

1,782.06

591.47

Excision of bone (eg, for osteomyelitis or bone abscess); facial bone(s)

21029

1,782.06

746.08

Removal by contouring of benign tumor of facial bone (eg, fibrous dysplasia)

21030

248.59

491.22

Excision of benign tumor or cyst of maxilla or zygoma by enucleation and curettage

21031

203.73

380.69

Excision of torus mandibularis

21032

209.24

388.44

Excision of maxillary torus palatinus

21034

1,782.06

1,325.45

Excision of malignant tumor of maxilla or zygoma

21040

1,071.47

493.06

Excision of benign tumor or cyst of mandible, by enucleation and/or curettage

21044

1,782.06

866.40

Excision of malignant tumor of mandible;

21045

1,197.58

Excision of malignant tumor of mandible; radical resection

21046

1,782.06

1,071.26

Excision of benign tumor or cyst of mandible; requiring intra-oral osteotomy (eg, locally aggressive or destructive lesion(s))

21047

1,782.06

1,285.42

Excision of benign tumor or cyst of mandible; requiring extra-oral osteotomy and partial mandibulectomy (eg, locally aggressive or destructive lesion(s))

21048

1,782.06

1,088.86

Excision of benign tumor or cyst of maxilla; requiring intra-oral osteotomy (eg, locally aggressive or destructive lesion(s))

21049

1,235.80

Excision of benign tumor or cyst of maxilla; requiring extra-oral osteotomy and partial maxillectomy (eg, locally aggressive or destructive lesion(s))

21050

1,782.06

844.50

Condylectomy, temporomandibular joint (separate procedure)

21060

1,782.06

777.49

Meniscectomy, partial or complete, temporomandibular joint (separate procedure)

21070

1,782.06

636.21

Coronoidectomy (separate procedure)

21073

202.26

379.74

Manipulation of temporomandibular joint(s) (TMJ), therapeutic, requiring an anesthesia service (ie, general or monitored anesthesia care)

21076

374.35

986.49

Impression and custom preparation; surgical obturato prosthesis

21077

914.19

2,432.95

Impression and custom preparation; orbital prosthesis

21079

651.62

1,672.99

Impression and custom preparation; interim obturator prosthesis

21080

746.87

1,903.78

Impression and custom preparation; definitive obturator prosthesis

21081

685.82

1,735.73

Impression and custom preparation; mandibular resection prosthesis

21082

629.19

1,593.53

Impression and custom preparation; palatal augmentation prosthesis

21083

618.90

1,520.60

Impression and custom preparation; palatal lift prosthesis

21084

721.86

1,737.63

Impression and custom preparation; speech aid prosthesis

21085

279.48

695.29

Impression and custom preparation; oral surgical splint

21086

673.32

1,805.14

Impression and custom preparation; auricular prosthesis

21087

667.44

1,789.22

Impression and custom preparation; nasal prosthesis

21088

1,782.06

I.C.

Impression and custom preparation; facial prosthesis

21089

I.C.

Unlisted maxillofacial prosthetic procedure

21100

1,782.06

773.46

Application of halo type appliance for maxillofacial fixation, includes removal (separate procedure)

21110

332.81

740.19

Application of interdental fixation device for conditions other than fracture or dislocation, includes removal

21116

186.87

Injection procedure for temporomandibular joint arthrography

21120

1,071.47

654.16

Genioplasty; augmentation (autograft, allograft, prosthetic material)

21121

1,071.47

758.91

Genioplasty; sliding osteotomy, single piece

21122

1,071.47

718.44

Genioplasty; sliding osteotomies, two or more osteotomies (eg, wedge excision or bone wedge reversal for asymmetrical chin)

21123

1,071.47

835.62

Genioplasty; sliding, augmentation with interpositional bone grafts (includes obtaining autografts)

21125

1,071.47

3,132.9

9

Augmentation, mandibular body or angle; prosthetic material

21127

1,782.06

3,406.0

5

Augmentation, mandibular body or angle; with bone graft, onlay or interpositional (includes obtaining autograft)

21137

1,071.47

734.45

Reduction forehead; contouring only

21138

1,782.06

885.70

Reduction forehead; contouring and application of prosthetic material or bone graft (includes obtaining autograft)

21139

1,782.06

959.74

Reduction forehead; contouring and setback of anterior frontal sinus wall

21141

1,316.00

Reconstruction midface, LeFort I; single piece, segment movement in any direction (eg, for Long Face Syndrome), without bone graft

21142

1,281.30

Reconstruction midface, LeFort I; two pieces, segment movement in any direction, without bone graft

21143

1,359.35

Reconstruction midface, LeFort I; three or more pieces, segment movement in any direction, without bone graft

21145

1,511.19

Reconstruction midface, LeFort I; single piece, segment movement in any direction, requiring bone grafts (includes obtaining autografts)

21146

1,495.10

Reconstruction midface, LeFort I; two pieces, segment movement in any direction, requiring bone grafts (includes obtaining autografts) (eg, ungrafted unilateral alveolar cleft)

21147

1,623.65

Reconstruction midface, LeFort I; three or more pieces, segment movement in any direction, requiring bone grafts (includes obtaining autografts) (eg, ungrafted bilateral alveolar cleft or multiple osteotomies)

21150

1,782.06

1,732.52

Reconstruction midface, LeFort II; anterior intrusion (eg, Treacher-Collins Syndrome)

21151

1,849.76

Reconstruction midface, LeFort II; any direction, requiring bone grafts (includes obtaining autografts)

21154

2,079.28

Reconstruction midface, LeFort III (extracranial), an type, requiring bone grafts (includes obtaining autografts); without LeFort I

21155

2,362.39

Reconstruction midface, LeFort III (extracranial), an type, requiring bone grafts (includes obtaining autografts); with LeFort I

21159

2,728.67

Reconstruction midface, LeFort III (extra and intracranial) with forehead advancement (eg, mono bloc), requiring bone grafts (includes obtaining autografts); without LeFort I

21160

2,894.85

Reconstruction midface, LeFort III (extra and intracranial) with forehead advancement (eg, mono bloc), requiring bone grafts (includes obtaining autografts); with LeFort I

21172

1,697.99

Reconstruction superior-lateral orbital rim and lower forehead, advancement or alteration, with or without grafts (includes obtaining autografts)

21175

2,007.74

Reconstruction, bifrontal, superior-lateral orbital rim and lower forehead, advancement or alteration (eg, plagiocephaly, trigonocephaly, brachycephaly), with or without grafts (includes obtaining autografts)

21179

1,437.11

Reconstruction, entire or majority of forehead and/or supraorbital rims; with grafts (allograft or prosthetic material)

21180

1,627.03

Reconstruction, entire or majority of forehead and/or supraorbital rims; with autograft (includes obtaining grafts)

21181

1,071.47

716.24

Reconstruction by contouring of benign tumor of cranial bones (eg, fibrous dysplasia), extracranial

21182

1,983.86

Reconstruction of orbital walls, rims, forehead, nasoethmoid complex following intra-and extracranial excision of benign tumor of cranial bone (eg, fibrous dysplasia), with multiple autografts (includes obtaining grafts); total area of bone grafting less than 40 sq cm

21183

2,270.70

Reconstruction of orbital walls, rims, forehead, nasoethmoid complex following intra- and extracranial excision of benign tumor of cranial bone (eg, fibrous dysplasia), with multiple autografts (includes obtaining grafts); total area of bone grafting greater than 40 sq cm but less than 80 sq cm

21184

2,350.49

Reconstruction of orbital walls, rims, forehead, nasoethmoid complex following intra- and extracranial excision of benign tumor of cranial bone (eg, fibrous dysplasia), with multiple autografts (includes obtaining grafts); total area of bone grafting greater than 80 sq cm

21188

21193

1,630.13

1,221.27

Reconstruction midface, osteotomies (other than LeFort type) and bone grafts (includes obtaining autografts)

Reconstruction of mandibular rami, horizontal, vertical, C, or L osteotomy; without bone graft

21194

1,392.36

Reconstruction of mandibular rami, horizontal, vertical, C, or L osteotomy; with bone graft (includes obtaining graft)

21195

21196

1,335.87

1,446.59

Reconstruction of mandibular rami and/or body, sagittal split; without internal rigid fixation Reconstruction of mandibular rami and/or body, sagittal split; with internal rigid fixation

21198

1,782.06

1,137.84

Osteotomy, mandible, segmental;

21199

1,782.06

993.46

Osteotomy, mandible, segmental; with genioglossus advancement

21206

1,782.06

1,106.06

Osteotomy, maxilla, segmental (eg, Wassmund or Schuchard)

21208

1,782.06

1,691.11

Osteoplasty, facial bones; augmentation (autograft, allograft, or prosthetic implant)

21209

1,782.06

815.11

Osteoplasty, facial bones; reduction

21210

1,782.06

2,001.90

Graft, bone; nasal, maxillary or malar areas (includes obtaining graft)

21215

1,782.06

3,400.25

Graft, bone; mandible (includes obtaining graft)

21230

1,782.06

762.88

Graft; rib cartilage, autogenous, to face, chin, nose or ear (includes obtaining graft)

21235

1,071.47

727.23

Graft; ear cartilage, autogenous, to nose or ear (includes obtaining graft)

21240

1,782.06

1,100.68

Arthroplasty, temporomandibular joint, with or without autograft (includes obtaining graft)

21242

1,782.06

1,015.29

Arthroplasty, temporomandibular joint, with allograf

21243

1,782.06

1,645.42

Arthroplasty, temporomandibular joint, with prosthetic joint replacement

21244

1,782.06

1,036.87

Reconstruction of mandible, extraoral, with transosteal bone plate (eg, mandibular staple bone plate)

21245

1,782.06

1,134.10

Reconstruction of mandible or maxilla, subperiosteal implant; partial

21246

1,782.06

856.09

Reconstruction of mandible or maxilla, subperiosteal implant; complete

21247

1,598.07

Reconstruction of mandibular condyle with bone and cartilage autografts (includes obtaining grafts) (eg, for hemifacial microsomia)

21248

1,782.06

1,044.44

Reconstruction of mandible or maxilla, endosteal implant (eg, blade, cylinder); partial

21249

1,782.06

1,456.17

Reconstruction of mandible or maxilla, endosteal

implant (eg, blade, cylinder); complete

21255

1,386.02

Reconstruction of zygomatic arch and glenoid fossa with bone and cartilage (includes obtaining autografts)

21256

1,132.24

Reconstruction of orbit with osteotomies (extracranial) and with bone grafts (includes obtaining autografts) (eg, micro-ophthalmia)

21260

1,782.06

1,227.16

Periorbital osteotomies for orbital hypertelorism, with bone grafts; extracranial approach

21261

2,153.72

Periorbital osteotomies for orbital hypertelorism, wit bone grafts; combined intra- and extracranial approach

21263

1,890.40

Periorbital osteotomies for orbital hypertelorism, wit bone grafts; with forehead advancement

21267

21268

1,782.06

1,791.81

1,574.31

Orbital repositioning, periorbital osteotomies, unilateral, with bone grafts; extracranial approach Orbital repositioning, periorbital osteotomies, unilateral, with bone grafts; combined intra- and extracranial approach

21270

1,782.06

905.95

Malar augmentation, prosthetic material

21275

1,782.06

789.01

Secondary revision of orbitocraniofacial reconstruction

21280

1,782.06

515.36

Medial canthopexy (separate procedure)

21282

729.71

346.96

Lateral canthopexy

21295

332.81

176.48

Reduction of masseter muscle and bone (eg, for treatment of benign masseteric hypertrophy); extraoral approach

21296

21299

1,071.47

I.C.

407.61

Reduction of masseter muscle and bone (eg, for treatment of benign masseteric hypertrophy); intraoral approach Unlisted craniofacial and maxillofacial procedure

21310

111.73

119.80

Closed treatment of nasal bone fracture without manipulation

21315

111.73

271.18

Closed treatment of nasal bone fracture; without stabilization

21320

729.71

258.08

Closed treatment of nasal bone fracture; with stabilization

21325

1,071.47

507.27

Open treatment of nasal fracture; uncomplicated

21330

1,071.47

609.78

Open treatment of nasal fracture; complicated, with internal and/or external skeletal fixation

21335

1,071.47

742.95

Open treatment of nasal fracture; with concomitant open treatment of fractured septum

21336

1,169.01

661.16

Open treatment of nasal septal fracture, with or without stabilization

21337

729.71

402.31

Closed treatment of nasal septal fracture, with or without stabilization

21338

1,071.47

806.80

Open treatment of nasoethmoid fracture; without external fixation

21339

1,071.47

861.59

Open treatment of nasoethmoid fracture; with externa fixation

21340

1,782.06

781.71

Percutaneous treatment of nasoethmoid complex fracture, with splint, wire or headcap fixation, including repair of canthal ligaments and/or the nasolacrimal apparatus

21343

1,176.66

Open treatment of depressed frontal sinus fracture

21344

1,483.19

Open treatment of complicated (eg, comminuted or involving posterior wall) frontal sinus fracture, via coronal or multiple approaches

21345

1,071.47

798.53

Closed treatment of nasomaxillary complex fracture (LeFort II type), with interdental wire fixation or fixation of denture or splint

21346

951.99

Open treatment of nasomaxillary complex fracture (LeFort II type); with wiring and/or local fixation

21347

1,143.57

Open treatment of nasomaxillary complex fracture (LeFort II type); requiring multiple open approaches

21348

1,176.43

Open treatment of nasomaxillary complex fracture (LeFort II type); with bone grafting (includes obtaining graft)

21355

1,782.06

437.08

Percutaneous treatment of fracture of malar area, including zygomatic arch and malar tripod, with manipulation

21356

1,071.47

498.76

Open treatment of depressed zygomatic arch fracture (eg, Gillies approach)

21360

1,071.47

523.19

Open treatment of depressed malar fracture, including zygomatic arch and malar tripod

21365

1,073.90

Open treatment of complicated (eg, comminuted or involving cranial nerve foramina) fracture(s) of malar area, including zygomatic arch and malar tripod; with internal fixation and multiple surgical approaches

21366

1,207.16

Open treatment of complicated (eg, comminuted or involving cranial nerve foramina) fracture(s) of malar area, including zygomatic arch and malar tripod; with bone grafting (includes obtaining graft)

21385

21386

706.95

653.09

Open treatment of orbital floor blowout fracture; transantral approach (Caldwell-Luc type operation) Open treatment of orbital floor blowout fracture; periorbital approach

21387

751.69

Open treatment of orbital floor blowout fracture; combined approach

21390

21395

1,782.06

942.32

746.01

Open treatment of orbital floor blowout fracture; periorbital approach, with alloplastic or other implant Open treatment of orbital floor blowout fracture; periorbital approach with bone graft (includes obtaining graft)

21400

332.81

176.10

Closed treatment of fracture of orbit, except blowout; without manipulation

21401

729.71

479.41

Closed treatment of fracture of orbit, except blowout; with manipulation

21406

1,782.06

533.37

Open treatment of fracture of orbit, except blowout; without implant

21407

1,782.06

626.51

Open treatment of fracture of orbit, except blowout; with implant

21408

851.81

Open treatment of fracture of orbit, except blowout; with bone grafting (includes obtaining graft)

21421

1,071.47

721.62

Closed treatment of palatal or maxillary fracture (LeFort I type), with interdental wire fixation or fixation of denture or splint

21422

671.96

Open treatment of palatal or maxillary fracture (LeFort I type);

21423

789.00

Open treatment of palatal or maxillary fracture (LeFort I type); complicated (comminuted or involving cranial nerve foramina), multiple approaches

21431

754.28

Closed treatment of craniofacial separation (LeFort II type) using interdental wire fixation of denture or splint

21432

665.82

Open treatment of craniofacial separation (LeFort III type); with wiring and/or internal fixation

21433

1,633.07

Open treatment of craniofacial separation (LeFort III type); complicated (eg, comminuted or involving cranial nerve foramina), multiple surgical approaches

21435

1,290.93

Open treatment of craniofacial separation (LeFort III type); complicated, utilizing internal and/or external fixation techniques (eg, head cap, halo device, and/or intermaxillary fixation)

21436

1,839.74

Open treatment of craniofacial separation (LeFort III type); complicated, multiple surgical approaches, internal fixation, with bone grafting (includes obtaining graft)

21440

315.52

518.76

Closed treatment of mandibular or maxillary alveolar ridge fracture (separate procedure)

21445

1,071.47

736.83

Open treatment of mandibular or maxillary alveolar ridge fracture (separate procedure)

21450

111.73

543.05

Closed treatment of mandibular fracture; without manipulation

21451

332.81

719.44

Closed treatment of mandibular fracture; with manipulation

21452

729.71

663.47

Percutaneous treatment of mandibular fracture, with external fixation

21453

1,782.06

828.94

Closed treatment of mandibular fracture with interdental fixation

21454

1,071.47

545.55

Open treatment of mandibular fracture with external fixation

21461

1,782.06

1,862.58

Open treatment of mandibular fracture; without interdental fixation

21462

1,782.06

2,031.50

Open treatment of mandibular fracture; with interdental fixation

21465

1,782.06

897.60

Open treatment of mandibular condylar fracture

21470

1,158.59

Open treatment of complicated mandibular fracture b multiple surgical approaches including internal fixation, interdental fixation, and/or wiring of dentures or splints

21480

111.73

98.57

Closed treatment of temporomandibular dislocation; initial or subsequent

21485

729.71

639.31

Closed treatment of temporomandibular dislocation; complicated (eg, recurrent requiring intermaxillary fixation or splinting), initial or subsequent

21490

1,782.06

903.12

Open treatment of temporomandibular dislocation

21495

729.71

672.39

Open treatment of hyoid fracture

21497

729.71

642.86

Interdental wiring, for condition other than fracture

21499

I.C.

Unlisted musculoskeletal procedure, head

21501

818.67

443.75

Incision and drainage, deep abscess or hematoma, sof tissues of neck or thorax;

21502

950.47

517.50

Incision and drainage, deep abscess or hematoma, sof tissues of neck or thorax; with partial rib ostectomy

21510

472.07

Incision, deep, with opening of bone cortex (eg, for osteomyelitis or bone abscess), thorax

21550

388.12

258.55

Biopsy, soft tissue of neck or thorax

21555

943.36

427.07

Excision tumor, soft tissue of neck or thorax; subcutaneous

21556

943.36

401.35

Excision tumor, soft tissue of neck or thorax; deep, subfascial, intramuscular

21557

943.36

563.97

Radical resection of tumor (eg, malignant neoplasm), soft tissue of neck or thorax

21600

1,304.45

542.72

Excision of rib, partial

21610

1,304.45

1,039.61

Costotransversectomy (separate procedure)

21615

668.43

Excision first and/or cervical rib;

21616

818.83

Excision first and/or cervical rib; with sympathectom

21620

521.01

Ostectomy of sternum, partial

21627

548.67

Sternal debridement

21630

1,237.61

Radical resection of sternum;

21632

1,218.57

Radical resection of sternum; with mediastinal lymphadenectomy

21685

332.81

971.45

Hyoid myotomy and suspension

21700

950.47

425.75

Division of scalenus anticus; without resection of cervical rib

21705

607.25

Division of scalenus anticus; with resection of cervical rib

21720

950.47

374.01

Division of sternocleidomastoid for torticollis, open operation; without cast application

21725

62.85

522.63

Division of sternocleidomastoid for torticollis, open operation; with cast application

21740

1,052.32

Reconstructive repair of pectus excavatum or carinatum; open

21742

I.C.

Reconstructive repair of pectus excavatum or carinatum; minimally invasive approach (Nuss procedure), without thoracoscopy

21743

I.C.

Reconstructive repair of pectus excavatum or carinatum; minimally invasive approach (Nuss procedure), with thoracoscopy

21750

699.66

Closure of median sternotomy separation with or without debridement (separate procedure)

21800

79.02

98.30

Closed treatment of rib fracture, uncomplicated, each

21805

1,169.01

256.12

Open treatment of rib fracture without fixation, each

21810

502.41

Treatment of rib fracture requiring external fixation (flail chest)

21820

79.02

133.75

Closed treatment of sternum fracture

21825

565.57

Open treatment of sternum fracture with or without skeletal fixation

21899

I.C.

Unlisted procedure, neck or thorax

21920

141.94

252.88

Biopsy, soft tissue of back or flank; superficial

21925

943.36

415.10

Biopsy, soft tissue of back or flank; deep

21930

943.36

463.19

Excision, tumor, soft tissue of back or flank

21935

943.36

1,117.98

Radical resection of tumor (eg, malignant neoplasm), soft tissue of back or flank

22010

878.10

Incision and drainage, open, of deep abscess (subfascial), posterior spine; cervical, thoracic, or cervicothoracic

22015

872.36

Incision and drainage, open, of deep abscess (subfascial), posterior spine; lumbar, sacral, or lumbosacral

22100

795.13

Partial excision of posterior vertebral component (eg, spinous process, lamina or facet) for intrinsic bony lesion, single vertebral segment; cervical

22101

794.19

Partial excision of posterior vertebral component (eg, spinous process, lamina or facet) for intrinsic bony lesion, single vertebral segment; thoracic

22102

2,090.17

796.97

Partial excision of posterior vertebral component (eg, spinous process, lamina or facet) for intrinsic bony lesion, single vertebral segment; lumbar

22103

2,090.17

141.41

Partial excision of posterior vertebral component (eg, spinous process, lamina or facet) for intrinsic bony lesion, single vertebral segment; each additional segment (List separately in addition to code for primary procedure)

22110

975.36

Partial excision of vertebral body, for intrinsic bony lesion, without decompression of spinal cord or nerve root(s), single vertebral segment; cervical

22112

971.02

Partial excision of vertebral body, for intrinsic bony lesion, without decompression of spinal cord or nerve root(s), single vertebral segment; thoracic

22114

973.39

Partial excision of vertebral body, for intrinsic bony lesion, without decompression of spinal cord or nerve root(s), single vertebral segment; lumbar

22116

141.61

Partial excision of vertebral body, for intrinsic bony lesion, without decompression of spinal cord or nerve root(s), single vertebral segment; each additional vertebral segment (List separately in addition to code for primary procedure)

22206

2,266.12

Osteotomy of spine, posterior or posterolateral approach, three columns, one vertebral segment (eg, pedicle/vertebral body subtraction); thoracic

22207

2,238.72

Osteotomy of spine, posterior or posterolateral approach, three columns, one vertebral segment (eg, pedicle/vertebral body subtraction); lumbar

22208

563.55

Osteotomy of spine, posterior or posterolateral approach, three columns, one vertebral segment (eg, pedicle/vertebral body subtraction); each additional vertebral segment (List separately in addition to code for primary procedure)

22210

1,711.64

Osteotomy of spine, posterior or posterolateral approach, one vertebral segment; cervical

22212

1,417.71

Osteotomy of spine, posterior or posterolateral approach, one vertebral segment; thoracic

22214

1,433.30

Osteotomy of spine, posterior or posterolateral approach, one vertebral segment; lumbar

22216

370.21

Osteotomy of spine, posterior or posterolateral approach, one vertebral segment; each additional vertebral segment (List separately in addition to primary procedure)

22220

1,548.36

Osteotomy of spine, including discectomy, anterior approach, single vertebral segment; cervical

22222

1,400.73

Osteotomy of spine, including discectomy, anterior approach, single vertebral segment; thoracic

22224

1,530.02

Osteotomy of spine, including discectomy, anterior approach, single vertebral segment; lumbar

22226

368.37

Osteotomy of spine, including discectomy, anterior approach, single vertebral segment; each additional vertebral segment (List separately in addition to code for primary procedure)

22305

79.02

185.35

Closed treatment of vertebral process fracture(s)

22310

79.02

274.46

Closed treatment of vertebral body fracture(s), without manipulation, requiring and including casting or bracing

22315

79.02

844.73

Closed treatment of vertebral fracture(s) and/or dislocation(s) requiring casting or bracing, with and including casting and/or bracing, with or without anesthesia, by manipulation or traction

22318

1,542.01

Open treatment and/or reduction of odontoid fracture(s) and or dislocation(s) (including os odontoideum), anterior approach, including placement of internal fixation; without grafting

22319

1,688.58

Open treatment and/or reduction of odontoid fracture(s) and or dislocation(s) (including os odontoideum), anterior approach, including placement of internal fixation; with grafting

22325

1,344.05

Open treatment and/or reduction of vertebral fracture(s) and/or dislocation(s), posterior approach, one fractured vertebra or dislocated segment; lumbar

22326

1,406.87

Open treatment and/or reduction of vertebral fracture(s) and/or dislocation(s), posterior approach, one fractured vertebra or dislocated segment; cervical

22327

1,389.12

Open treatment and/or reduction of vertebral fracture(s) and/or dislocation(s), posterior approach, one fractured vertebra or dislocated segment; thoracic

22328

277.75

Open treatment and/or reduction of vertebral fracture(s) and/or dislocation(s), posterior approach, one fractured vertebra or dislocated segment; each additional fractured vertebra or dislocated segment (List separately in addition to code for primary procedure)

22505

659.86

121.59

Manipulation of spine requiring anesthesia, any region

22520

1,304.45

2,793.55

Percutaneous vertebroplasty, one vertebral body, unilateral or bilateral injection; thoracic

22521

1,304.45

2,666.47

Percutaneous vertebroplasty, one vertebral body, unilateral or bilateral injection; lumbar

22522

1,304.45

244.58

Percutaneous vertebroplasty, one vertebral body, unilateral or bilateral injection; each additional thoracic or lumbar vertebral body (List separately in addition to code for primary procedure)

22523

3,549.34

609.50

Percutaneous vertebral augmentation, including cavity creation (fracture reduction and bone biopsy included

22524

3,549.34

583.96

when performed) using mechanical device, one vertebral body, unilateral or bilateral cannulation (eg, kyphoplasty); thoracic Percutaneous vertebral augmentation, including cavity

22525

3,549.34

268.33

creation (fracture reduction and bone biopsy included when performed) using mechanical device, one vertebral body, unilateral or bilateral cannulation (eg, kyphoplasty); lumbar Percutaneous vertebral augmentation, including cavity

22526

1,304.45

2,392.91

creation (fracture reduction and bone biopsy included when performed) using mechanical device, one vertebral body, unilateral or bilateral cannulation (eg, kyphoplasty); each additional thoracic or lumbar vertebral body (List separately in addition to code for primary procedure)

Percutaneous intradiscal electrothermal annuloplasty,

22527

1,304.45

1,980.38

unilateral or bilateral including fluoroscopic guidance;

single level Percutaneous intradiscal electrothermal annuloplasty,

unilateral or bilateral including fluoroscopic guidance; one or more additional levels (List separately in addition to code for primary procedure)

22532

1,670.29

Arthrodesis, lateral extracavitary technique, including minimal discectomy to prepare interspace (other than for decompression); thoracic

22533

1,560.50

Arthrodesis, lateral extracavitary technique, including minimal discectomy to prepare interspace (other than for decompression); lumbar

22534

364.42

Arthrodesis, lateral extracavitary technique, including minimal discectomy to prepare interspace (other than for decompression); thoracic or lumbar, each additional vertebral segment (List separately in addition to code for primary procedure)

22548

1,793.15

Arthrodesis, anterior transoral or extraoral technique, clivus-C1-C2 (atlas-axis), with or without excision of odontoid process

22554

1,261.88

Arthrodesis, anterior interbody technique, including minimal discectomy to prepare interspace (other than for decompression); cervical below C2

22556

1,604.39

Arthrodesis, anterior interbody technique, including minimal discectomy to prepare interspace (other than for decompression); thoracic

22558

1,460.65

Arthrodesis, anterior interbody technique, including minimal discectomy to prepare interspace (other than for decompression); lumbar

22585

I

1,259.20

Arthrodesis, anterior interbody technique, including minimal discectomy to prepare interspace (other than for decompression); each additional interspace (List separately in addition to code for primary procedure)

22590

1,487.74

Arthrodesis, posterior technique, craniocervical (occiput-C2)

22595

1,416.93

Arthrodesis, posterior technique, atlas-axis (C1-C2)

22600

1,214.58

Arthrodesis, posterior or posterolateral technique, single level; cervical below C2 segment

22610

1,200.81

Arthrodesis, posterior or posterolateral technique, single level; thoracic (with or without lateral transverse technique)

22612

I

3,883.08

Arthrodesis, posterior or posterolateral technique, single level; lumbar (with or without lateral transverse technique)

22614

394.39

Arthrodesis, posterior or posterolateral technique, single level; each additional vertebral segment (List separately in addition to code for primary procedure)

22630

1,491.22

Arthrodesis, posterior interbody technique, including laminectomy and/or discectomy to prepare interspace (other than for decompression), single interspace; lumbar

22632

320.24

Arthrodesis, posterior interbody technique, including laminectomy and/or discectomy to prepare interspace (other than for decompression), single interspace; each additional interspace (List separately in addition to code for primary procedure)

22800

1,322.62

Arthrodesis, posterior, for spinal deformity, with or without cast; up to six vertebral segments

22802

2,093.75

Arthrodesis, posterior, for spinal deformity, with or without cast; seven to 12 vertebral segments

22804

2,423.25

Arthrodesis, posterior, for spinal deformity, with or without cast; 13 or more vertebral segments

22808

1,779.39

Arthrodesis, anterior, for spinal deformity, with or without cast; two to three vertebral segments

22810

1,988.96

Arthrodesis, anterior, for spinal deformity, with or without cast; four to seven vertebral segments

22812

2,181.84

Arthrodesis, anterior, for spinal deformity, with or without cast; eight or more vertebral segments

22818

2,177.95

Kyphectomy, circumferential exposure of spine and resection of vertebral segment(s) (including body and posterior elements); single or two segments

22819

2,463.80

Kyphectomy, circumferential exposure of spine and resection of vertebral segment(s) (including body and posterior elements); three or more segments

22830

794.63

Exploration of spinal fusion

22840

I

2,245.41

Posterior non-segmental instrumentation (eg, Harrington rod technique, pedicle fixation across one interspace, atlantoaxial transarticular screw fixation, sublaminar wiring at C1, facet screw fixation) (List separately in addition to code for primary procedure)

22841

I.C.

Internal spinal fixation by wiring of spinous processe (List separately in addition to code for primary procedure)

22842

I

2,856.09

Posterior segmental instrumentation (eg, pedicle fixation, dual rods with multiple hooks and sublaminar wires); three to six vertebral segments (List separately in addition to code for primary procedure)

22843

815.26

Posterior segmental instrumentation (eg, pedicle fixation, dual rods with multiple hooks and sublaminar wires); seven to 12 vertebral segments (List separately in addition to code for primary procedure)

22844

1,005.14

Posterior segmental instrumentation (eg, pedicle fixation, dual rods with multiple hooks and sublaminar wires); 13 or more vertebral segments (List separately in addition to code for primary procedure)

22845

I

1,844.78

Anterior instrumentation; two to three vertebral segments (List separately in addition to code for

primary procedure)

22846

765.25

Anterior instrumentation; four to seven vertebral segments (List separately in addition to code for

primary procedure)

22847

841.65

Anterior instrumentation; eight or more vertebral segments (List separately in addition to code for primary procedure)

22848

366.03

Pelvic fixation (attachment of caudal end of instrumentation to pelvic bony structures) other than sacrum (List separately in addition to code for primary procedure)

22849

1,272.36

Reinsertion of spinal fixation device

22850

702.39

Removal of posterior nonsegmental instrumentation (eg, Harrington rod)

22851

I

1,827.17

Application of intervertebral biomechanical device(s) (eg, synthetic cage(s), threaded bone dowel(s), methylmethacrylate) to vertebral defect or interspace (List separately in addition to code for primary procedure)

22852

672.86

Removal of posterior segmental instrumentation

22855

1,077.99

Removal of anterior instrumentation

22857

1,708.32

Total disc arthroplasty (artificial disc), anterior approach, including discectomy to prepare interspace (other than for decompression), lumbar, single interspace

22862

2,008.52

Revision including replacement of total disc arthroplasty (artificial disc) anterior approach, lumbar, single interspace

22865

1,956.97

Removal of total disc arthroplasty (artificial disc), anterior approach, lumbar, single interspace

22899

I.C.

Unlisted procedure, spine

22900

943.36

387.99

Excision, abdominal wall tumor, subfascial (eg, desmoid)

22999

I.C.

Unlisted procedure, abdomen, musculoskeletal system

23000

23020

719.48

1,920.92

548.50

684.76

Removal of subdeltoid calcareous deposits, open Capsular contracture release (eg, Sever type procedure)

23030

818.67

449.37

Incision and drainage, shoulder area; deep abscess or hematoma

23031

818.67

438.97

Incision and drainage, shoulder area; infected bursa

23035

950.47

691.48

Incision, bone cortex (eg, osteomyelitis or bone abscess), shoulder area

23040

1,304.45

713.22

Arthrotomy, glenohumeral joint, including exploration, drainage, or removal of foreign body

23044

1,304.45

567.81

Arthrotomy, acromioclavicular, sternoclavicular joint, including exploration, drainage, or removal of foreign body

23065

100.03

209.04

Biopsy, soft tissue of shoulder area; superficial

23066

943.36

517.96

Biopsy, soft tissue of shoulder area; deep

23075

719.48

261.86

Excision, soft tissue tumor, shoulder area; subcutaneous

23076

943.36

549.56

Excision, soft tissue tumor, shoulder area; deep, subfascial, or intramuscular

23077

943.36

1,144.05

Radical resection of tumor (eg, malignant neoplasm), soft tissue of shoulder area

23100

950.47

484.44

Arthrotomy, glenohumeral joint, including biopsy

23101

1,304.45

448.38

Arthrotomy, acromioclavicular joint or sternoclavicular joint, including biopsy and/or excision of torn cartilage

23105

1,304.45

632.25

Arthrotomy; glenohumeral joint, with synovectomy, with or without biopsy

23106

1,304.45

476.86

Arthrotomy; sternoclavicular joint, with synovectomy, with or without biopsy

23107

1,304.45

657.79

Arthrotomy, glenohumeral joint, with joint exploration, with or without removal of loose or foreign body

23120

1,304.45

558.51

Claviculectomy; partial

23125

1,304.45

694.88

Claviculectomy; total

23130

1,920.92

603.72

Acromioplasty or acromionectomy, partial, with or without coracoacromial ligament release

23140

950.47

505.08

Excision or curettage of bone cyst or benign tumor of clavicle or scapula;

23145

1,304.45

682.33

Excision or curettage of bone cyst or benign tumor of clavicle or scapula; with autograft (includes obtaining graft)

23146

1,304.45

612.35

Excision or curettage of bone cyst or benign tumor of clavicle or scapula; with allograft

23150

1,304.45

643.01

Excision or curettage of bone cyst or benign tumor of proximal humerus;

23155

1,304.45

778.83

Excision or curettage of bone cyst or benign tumor of proximal humerus; with autograft (includes obtaining graft)

23156

1,304.45

666.74

Excision or curettage of bone cyst or benign tumor of proximal humerus; with allograft

23170

1,304.45

529.60

Sequestrectomy (eg, for osteomyelitis or bone abscess), clavicle

23172

1,304.45

547.67

Sequestrectomy (eg, for osteomyelitis or bone abscess), scapula

23174

1,304.45

745.11

Sequestrectomy (eg, for osteomyelitis or bone abscess), humeral head to surgical neck

23180

1,304.45

701.11

Partial excision (craterization, saucerization, or diaphysectomy) bone (eg, osteomyelitis), clavicle

23182

1,304.45

675.01

Partial excision (craterization, saucerization, or diaphysectomy) bone (eg, osteomyelitis), scapula

23184

1,304.45

755.84

Partial excision (craterization, saucerization, or diaphysectomy) bone (eg, osteomyelitis), proximal humerus

23190

1,304.45

550.57

Ostectomy of scapula, partial (eg, superior medial angle)

23195

1,304.45

738.27

Resection, humeral head

23200

855.97

Radical resection for tumor; clavicle

23210

897.27

Radical resection for tumor; scapula

23220

1,058.90

Radical resection of bone tumor, proximal humerus;

23221

1,234.43

Radical resection of bone tumor, proximal humerus; with autograft (includes obtaining graft)

23222

1,657.63

Radical resection of bone tumor, proximal humerus; with prosthetic replacement

23330

388.12

233.06

Removal of foreign body, shoulder; subcutaneous

23331

943.36

585.38

Removal of foreign body, shoulder; deep (eg, Neer hemiarthroplasty removal)

23332

876.56

Removal of foreign body, shoulder; complicated (eg, total shoulder)

23350

178.63

Injection procedure for shoulder arthrography or enhanced CT/MRI shoulder arthrography

23395

1,920.92

1,266.78

Muscle transfer, any type, shoulder or upper arm; single

23397

3,549.34

1,131.50

Muscle transfer, any type, shoulder or upper arm; multiple

23400

1,304.45

966.25

Scapulopexy (eg, Sprengels deformity or for paralysis)

23405

1,304.45

626.79

Tenotomy, shoulder area; single tendon

23406

1,304.45

779.71

Tenotomy, shoulder area; multiple tendons through

same incision

23410

1,920.92

892.11

Repair of ruptured musculotendinous cuff (eg, rotator cuff) open; acute

23412

1,920.92

I

2,271.64

Repair of ruptured musculotendinous cuff (eg, rotato cuff) open; chronic

23415

1,920.92

732.20

Coracoacromial ligament release, with or without acromioplasty

23420

1,920.92

I

2,118.74

Reconstruction of complete shoulder (rotator) cuff avulsion, chronic (includes acromioplasty)

23430

1,920.92

737.74

Tenodesis of long tendon of biceps

23440

1,920.92

760.51

Resection or transplantation of long tendon of biceps

23450

3,549.34

948.68

Capsulorrhaphy, anterior; Putti-Platt procedure or Magnuson type operation

23455

3,549.34

1,008.99

Capsulorrhaphy, anterior; with labral repair (eg, Bankart procedure)

23460

3,549.34

1,092.71

Capsulorrhaphy, anterior, any type; with bone block

23462

1,920.92

1,067.17

Capsulorrhaphy, anterior, any type; with coracoid process transfer

23465

3,549.34

1,110.71

Capsulorrhaphy, glenohumeral joint, posterior, with or without bone block

23466

1,920.92

1,097.00

Capsulorrhaphy, glenohumeral joint, any type multi-directional instability

23470

1,210.72

Arthroplasty, glenohumeral joint; hemiarthroplasty

23472

1,488.46

Arthroplasty, glenohumeral joint; total shoulder (glenoid and proximal humeral replacement (eg, total shoulder))

23480

1,920.92

818.43

Osteotomy, clavicle, with or without internal fixation

23485

3,549.34

957.53

Osteotomy, clavicle, with or without internal fixation with bone graft for nonunion or malunion (includes obtaining graft and/or necessary fixation)

23490

1,920.92

810.94

Prophylactic treatment (nailing, pinning, plating or wiring) with or without methylmethacrylate; clavicle

23491

3,549.34

1,013.09

Prophylactic treatment (nailing, pinning, plating or wiring) with or without methylmethacrylate; proximal humerus

23500

79.02

208.75

Closed treatment of clavicular fracture; without manipulation

23505

79.02

339.76

Closed treatment of clavicular fracture; with manipulation

23515

2,646.58

675.82

Open treatment of clavicular fracture, includes internal fixation, when performed

23520

79.02

214.99

Closed treatment of sternoclavicular dislocation; without manipulation

23525

79.02

339.32

Closed treatment of sternoclavicular dislocation; with manipulation

23530

1,837.10

546.28

Open treatment of sternoclavicular dislocation, acute or chronic;

23532

1,169.01

616.42

Open treatment of sternoclavicular dislocation, acute or chronic; with fascial graft (includes obtaining graft)

23540

79.02

214.04

Closed treatment of acromioclavicular dislocation; without manipulation

23545

79.02

306.58

Closed treatment of acromioclavicular dislocation; with manipulation

23550

1,837.10

567.19

Open treatment of acromioclavicular dislocation, acute or chronic;

23552

1,837.10

653.34

Open treatment of acromioclavicular dislocation, acute or chronic; with fascial graft (includes obtaining graft)

23570

79.02

222.12

Closed treatment of scapular fracture; without manipulation

23575

79.02

376.53

Closed treatment of scapular fracture; with manipulation, with or without skeletal traction (with or without shoulder joint involvement)

23585

2,646.58

898.46

Open treatment of scapular fracture (body, glenoid or acromion) with or without internal fixation

23600

79.02

315.20

Closed treatment of proximal humeral (surgical or anatomical neck) fracture; without manipulation

23605

79.02

459.43

Closed treatment of proximal humeral (surgical or anatomical neck) fracture; with manipulation, with or without skeletal traction

23615

2,646.58

851.31

Open treatment of proximal humeral (surgical or anatomical neck) fracture, includes internal fixation, when performed, includes repair of tuberosity(s), when performed;

23616

2,646.58

1,298.12

Open treatment of proximal humeral (surgical or anatomical neck) fracture, includes internal fixation, when performed, includes repair of tuberosity(s), when performed; with proximal humeral prosthetic replacement

23620

79.02

257.54

Closed treatment of greater humeral tuberosity fracture; without manipulation

23625

79.02

372.19

Closed treatment of greater humeral tuberosity fracture; with manipulation

23630

2,646.58

715.01

Open treatment of greater humeral tuberosity fracture, includes internal fixation, when performed

23650

79.02

288.92

Closed treatment of shoulder dislocation, with manipulation; without anesthesia

23655

659.86

370.58

Closed treatment of shoulder dislocation, with manipulation; requiring anesthesia

23660

1,837.10

574.46

Open treatment of acute shoulder dislocation

23665

79.02

410.57

Closed treatment of shoulder dislocation, with fracture of greater humeral tuberosity, with manipulation

23670

2,646.58

794.27

Open treatment of shoulder dislocation, with fracture of greater humeral tuberosity, includes internal fixation, when performed

23675

79.02

537.83

Closed treatment of shoulder dislocation, with surgical or anatomical neck fracture, with manipulation

23680

1,837.10

872.32

Open treatment of shoulder dislocation, with surgical or anatomical neck fracture, includes internal fixation, when performed

23700

659.86

193.81

Manipulation under anesthesia, shoulder joint, including application of fixation apparatus (dislocation excluded)

23800

3,549.34

1,012.60

Arthrodesis, glenohumeral joint;

23802

1,920.92

1,194.11

Arthrodesis, glenohumeral joint; with autogenous graft (includes obtaining graft)

23900

1,307.47

Interthoracoscapular amputation (forequarter)

23920

1,062.30

Disarticulation of shoulder;

23921

672.37

443.68

Disarticulation of shoulder; secondary closure or scar

revision

23929

I.C.

Unlisted procedure, shoulder

23930

818.67

374.01

Incision and drainage, upper arm or elbow area; deep abscess or hematoma

23931

818.67

306.78

Incision and drainage, upper arm or elbow area; bursa

23935

950.47

499.17

Incision, deep, with opening of bone cortex (eg, for osteomyelitis or bone abscess), humerus or elbow

24000

1,304.45

467.42

Arthrotomy, elbow, including exploration, drainage, or removal of foreign body

24006

1,304.45

703.90

Arthrotomy of the elbow, with capsular excision for capsular release (separate procedure)

24065

135.32

246.18

Biopsy, soft tissue of upper arm or elbow area; superficial

24066

719.48

599.87

Biopsy, soft tissue of upper arm or elbow area; deep (subfascial or intramuscular)

24075

719.48

486.62

Excision, tumor, soft tissue of upper arm or elbow area; subcutaneous

24076

943.36

462.88

Excision, tumor, soft tissue of upper arm or elbow area; deep (subfascial or intramuscular)

24077

943.36

795.87

Radical resection of tumor (eg, malignant neoplasm), soft tissue of upper arm or elbow area

24100

950.47

393.89

Arthrotomy, elbow; with synovial biopsy only

24101

1,304.45

494.91

Arthrotomy, elbow; with joint exploration, with or without biopsy, with or without removal of loose or foreign body

24102

1,304.45

609.95

Arthrotomy, elbow; with synovectomy

24105

950.47

337.37

Excision, olecranon bursa

24110

950.47

576.61

Excision or curettage of bone cyst or benign tumor, humerus;

24115

1,304.45

657.37

Excision or curettage of bone cyst or benign tumor, humerus; with autograft (includes obtaining graft)

24116

1,304.45

860.94

Excision or curettage of bone cyst or benign tumor, humerus; with allograft

24120

950.47

517.53

Excision or curettage of bone cyst or benign tumor of head or neck of radius or olecranon process;

24125

1,304.45

585.45

Excision or curettage of bone cyst or benign tumor of head or neck of radius or olecranon process; with autograft (includes obtaining graft)

24126

1,304.45

625.09

Excision or curettage of bone cyst or benign tumor of head or neck of radius or olecranon process; with allograft

24130

1,304.45

503.45

Excision, radial head

24134

1,304.45

756.71

Sequestrectomy (eg, for osteomyelitis or bone abscess), shaft or distal humerus

24136

1,304.45

623.59

Sequestrectomy (eg, for osteomyelitis or bone abscess), radial head or neck

24138

1,304.45

653.22

Sequestrectomy (eg, for osteomyelitis or bone abscess), olecranon process

24140

1,304.45

728.09

Partial excision (craterization, saucerization, or diaphysectomy) bone (eg, osteomyelitis), humerus

24145

1,304.45

615.66

Partial excision (craterization, saucerization, or diaphysectomy) bone (eg, osteomyelitis), radial head or neck

24147

1,304.45

643.98

Partial excision (craterization, saucerization, or diaphysectomy) bone (eg, osteomyelitis), olecranon

process

24149

1,304.45

1,129.51

Radical resection of capsule, soft tissue, and heterotopic bone, elbow, with contracture release (separate procedure)

24150

963.36

Radical resection for tumor, shaft or distal humerus;

24151

1,115.31

Radical resection for tumor, shaft or distal humerus; with autograft (includes obtaining graft)

24152

1,920.92

713.88

Radical resection for tumor, radial head or neck;

24153

3,549.34

662.95

Radical resection for tumor, radial head or neck; with autograft (includes obtaining graft)

24155

1,920.92

830.63

Resection of elbow joint (arthrectomy)

24160

1,304.45

601.10

Implant removal; elbow joint

24164

1,304.45

493.13

Implant removal; radial head

24200

112.89

208.54

Removal of foreign body, upper arm or elbow area; subcutaneous

24201

719.48

584.49

Removal of foreign body, upper arm or elbow area; deep (subfascial or intramuscular)

24220

192.11

Injection procedure for elbow arthrography

24300

659.86

401.67

Manipulation, elbow, under anesthesia

24301

1,304.45

745.74

Muscle or tendon transfer, any type, upper arm or elbow, single (excluding 24320-24331)

24305

1,304.45

575.80

Tendon lengthening, upper arm or elbow, each tendon

24310

950.47

472.16

Tenotomy, open, elbow to shoulder, each tendon

24320

1,920.92

753.94

Tenoplasty, with muscle transfer, with or without free graft, elbow to shoulder, single (Seddon-Brookes type procedure)

24330

3,549.34

712.29

Flexor-plasty, elbow (eg, Steindler type advancement);

24331

1,920.92

783.06

Flexor-plasty, elbow (eg, Steindler type advancement); with extensor advancement

24332

950.47

594.44

Tenolysis, triceps

24340

1,920.92

610.35

Tenodesis of biceps tendon at elbow (separate procedure)

24341

1,920.92

711.58

Repair, tendon or muscle, upper arm or elbow, each tendon or muscle, primary or secondary (excludes rotator cuff)

24342

1,920.92

781.01

Reinsertion of ruptured biceps or triceps tendon, distal, with or without tendon graft

24343

1,304.45

698.24

Repair lateral collateral ligament, elbow, with local tissue

24344

3,549.34

1,076.50

Reconstruction lateral collateral ligament, elbow, with tendon graft (includes harvesting of graft)

24345

1,304.45

694.40

Repair medial collateral ligament, elbow, with local tissue

24346

1,920.92

1,073.30

Reconstruction medial collateral ligament, elbow, with tendon graft (includes harvesting of graft)

24357

1,304.45

444.76

Tenotomy, elbow, lateral or medial (eg, epicondylitis, tennis elbow, golfer's elbow); percutaneous

24358

1,304.45

519.11

Tenotomy, elbow, lateral or medial (eg, epicondylitis, tennis elbow, golfer's elbow); debridement, soft tissue and/or bone, open

24359

1,304.45

630.15

Tenotomy, elbow, lateral or medial (eg, epicondylitis, tennis elbow, golfer's elbow); debridement, soft tissue and/or bone, open with tendon repair or reattachment

24360

1,604.48

888.16

Arthroplasty, elbow; with membrane (eg, fascial)

24361

5,461.16

997.96

Arthroplasty, elbow; with distal humeral prosthetic replacement

24362

2,274.08

959.69

Arthroplasty, elbow; with implant and fascia lata ligament reconstruction

24363

5,461.16

1,453.78

Arthroplasty, elbow; with distal humerus and proximal ulnar prosthetic replacement (eg, total elbow)

24365

1,604.48

636.15

Arthroplasty, radial head;

24366

5,461.16

680.36

Arthroplasty, radial head; with implant

24400

1,304.45

816.42

Osteotomy, humerus, with or without internal fixation

24410

1,304.45

1,038.27

Multiple osteotomies with realignment on intramedullary rod, humeral shaft (Sofield type procedure)

24420

1,920.92

967.66

Osteoplasty, humerus (eg, shortening or lengthening) (excluding 64876)

24430

3,549.34

1,017.89

Repair of nonunion or malunion, humerus; without graft (eg, compression technique)

24435

3,549.34

1,048.00

Repair of nonunion or malunion, humerus; with iliac or other autograft (includes obtaining graft)

24470

1,920.92

653.09

Hemiepiphyseal arrest (eg, cubitus varus or valgus, distal humerus)

24495

1,304.45

667.65

Decompression fasciotomy, forearm, with brachial artery exploration

24498

3,549.34

867.09

Prophylactic treatment (nailing, pinning, plating or wiring), with or without methylmethacrylate, humeral shaft

24500

79.02

341.35

Closed treatment of humeral shaft fracture; without manipulation

24505

79.02

492.22

Closed treatment of humeral shaft fracture; with manipulation, with or without skeletal traction

24515

2,646.58

870.91

Open treatment of humeral shaft fracture with plate/screws, with or without cerclage

24516

2,646.58

858.67

Treatment of humeral shaft fracture, with insertion of intramedullary implant, with or without cerclage and/or locking screws

24530

79.02

367.74

Closed treatment of supracondylar or transcondylar humeral fracture, with or without intercondylar extension; without manipulation

24535

79.02

610.39

Closed treatment of supracondylar or transcondylar humeral fracture, with or without intercondylar extension; with manipulation, with or without skin or skeletal traction

24538

1,169.01

743.88

Percutaneous skeletal fixation of supracondylar or transcondylar humeral fracture, with or without intercondylar extension

24545

2,646.58

883.63

Open treatment of humeral supracondylar or transcondylar fracture, includes internal fixation, when performed; without intercondylar extension

24546

2,646.58

1,055.47

Open treatment of humeral supracondylar or transcondylar fracture, includes internal fixation, when performed; with intercondylar extension

24560

79.02

309.10

Closed treatment of humeral epicondylar fracture, medial or lateral; without manipulation

24565

79.02

509.50

Closed treatment of humeral epicondylar fracture, medial or lateral; with manipulation

24566

1,169.01

685.77

Percutaneous skeletal fixation of humeral epicondylar fracture, medial or lateral, with manipulation

24575

2,646.58

735.39

Open treatment of humeral epicondylar fracture, medial or lateral, includes internal fixation, when performed

24576

79.02

325.44

Closed treatment of humeral condylar fracture, medial or lateral; without manipulation

24577

79.02

527.62

Closed treatment of humeral condylar fracture, medial or lateral; with manipulation

24579

2,646.58

826.87

Open treatment of humeral condylar fracture, medial or lateral, includes internal fixation, when performed

24582

1,169.01

780.18

Percutaneous skeletal fixation of humeral condylar fracture, medial or lateral, with manipulation

24586

2,646.58

1,086.60

Open treatment of periarticular fracture and/or dislocation of the elbow (fracture distal humerus and proximal ulna and/or proximal radius);

24587

2,646.58

1,078.28

Open treatment of periarticular fracture and/or dislocation of the elbow (fracture distal humerus and proximal ulna and/or proximal radius); with implant arthroplasty

24600

79.02

361.80

Treatment of closed elbow dislocation; without anesthesia

24605

659.86

451.05

Treatment of closed elbow dislocation; requiring anesthesia

24615

2,646.58

710.77

Open treatment of acute or chronic elbow dislocation

24620

79.02

543.65

Closed treatment of Monteggia type of fracture dislocation at elbow (fracture proximal end of ulna with dislocation of radial head), with manipulation

24635

2,646.58

838.19

Open treatment of Monteggia type of fracture dislocation at elbow (fracture proximal end of ulna with dislocation of radial head), includes internal fixation, when performed

24640

61.77

123.04

Closed treatment of radial head subluxation in child, nursemaid elbow, with manipulation

24650

79.02

251.99

Closed treatment of radial head or neck fracture; without manipulation

24655

79.02

430.32

Closed treatment of radial head or neck fracture; with manipulation

24665

1,837.10

645.58

Open treatment of radial head or neck fracture, includes internal fixation or radial head excision, when performed;

24666

2,646.58

726.78

Open treatment of radial head or neck fracture, includes internal fixation or radial head excision, when performed; with radial head prosthetic replacement

24670

79.02

281.49

Closed treatment of ulnar fracture, proximal end (eg, olecranon or coronoid process[es]); without manipulation

24675

79.02

449.72

Closed treatment of ulnar fracture, proximal end (eg, olecranon or coronoid process[es]); with manipulation

24685

1,837.10

648.99

Open treatment of ulnar fracture, proximal end (eg, olecranon or coronoid process[es]), includes internal fixation, when performed

24800

1,920.92

793.59

Arthrodesis, elbow joint; local

24802

1,920.92

979.41

Arthrodesis, elbow joint; with autogenous graft (includes obtaining graft)

24900

698.89

Amputation, arm through humerus; with primary closure

24920

689.10

Amputation, arm through humerus; open, circular (guillotine)

24925

950.47

533.74

Amputation, arm through humerus; secondary closure or scar revision

24930

725.68

Amputation, arm through humerus; re-amputation

24931

760.29

Amputation, arm through humerus; with implant

24935

1,046.44

Stump elongation, upper extremity

24940

I.C.

Cineplasty, upper extremity, complete procedure

24999

I.C.

Unlisted procedure, humerus or elbow

25000

950.47

383.87

Incision, extensor tendon sheath, wrist (eg, deQuervains disease)

25001

950.47

330.39

Incision, flexor tendon sheath, wrist (eg, flexor carpi radialis)

25020

950.47

611.90

Decompression fasciotomy, forearm and/or wrist, flexor OR extensor compartment; without debridement of nonviable muscle and/or nerve

25023

1,304.45

1,133.38

Decompression fasciotomy, forearm and/or wrist, flexor OR extensor compartment; with debridement of nonviable muscle and/or nerve

25024

1,304.45

738.45

Decompression fasciotomy, forearm and/or wrist, flexor AND extensor compartment; without debridement of nonviable muscle and/or nerve

25025

1,304.45

1,114.49

Decompression fasciotomy, forearm and/or wrist, flexor AND extensor compartment; with debridement of nonviable muscle and/or nerve

25028

950.47

535.72

Incision and drainage, forearm and/or wrist; deep abscess or hematoma

25031

950.47

424.42

Incision and drainage, forearm and/or wrist; bursa

25035

950.47

736.94

Incision, deep, bone cortex, forearm and/or wrist (eg, osteomyelitis or bone abscess)

25040

1,304.45

579.75

Arthrotomy, radiocarpal or midcarpal joint, with exploration, drainage, or removal of foreign body

25065

138.64

247.11

Biopsy, soft tissue of forearm and/or wrist; superficial

25066

943.36

412.76

Biopsy, soft tissue of forearm and/or wrist; deep (subfascial or intramuscular)

25075

719.48

357.28

Excision, tumor, soft tissue of forearm and/or wrist area; subcutaneous

25076

943.36

506.24

Excision, tumor, soft tissue of forearm and/or wrist area; deep (subfascial or intramuscular)

25077

943.36

801.28

Radical resection of tumor (eg, malignant neoplasm), soft tissue of forearm and/or wrist area

25085

950.47

485.16

Capsulotomy, wrist (eg, contracture)

25100

950.47

360.72

Arthrotomy, wrist joint; with biopsy

25101

1,304.45

419.98

Arthrotomy, wrist joint; with joint exploration, with or without biopsy, with or without removal of loose or foreign body

25105

1,304.45

511.98

Arthrotomy, wrist joint; with synovectomy

25107

1,304.45

621.29

Arthrotomy, distal radioulnar joint including repair of triangular cartilage, complex

25109

950.47

502.48

Excision of tendon, forearm and/or wrist, flexor or extensor, each

25110

950.47

399.58

Excision, lesion of tendon sheath, forearm and/or wrist

25111

735.73

324.82

Excision of ganglion, wrist (dorsal or volar); primary

25112

735.73

392.31

Excision of ganglion, wrist (dorsal or volar); recurrent

25115

950.47

868.98

Radical excision of bursa, synovia of wrist, or forearm tendon sheaths (eg, tenosynovitis, fungus, Tbc, or other granulomas, rheumatoid arthritis); flexors

25116

950.47

730.34

Radical excision of bursa, synovia of wrist, or forearm tendon sheaths (eg, tenosynovitis, fungus, Tbc, or other granulomas, rheumatoid arthritis); extensors, with or without transposition of dorsal retinaculum

25118

1,304.45

399.13

Synovectomy, extensor tendon sheath, wrist, single compartment;

25119

1,304.45

528.41

Synovectomy, extensor tendon sheath, wrist, single compartment; with resection of distal ulna

25120

1,304.45

636.14

Excision or curettage of bone cyst or benign tumor of radius or ulna (excluding head or neck of radius and olecranon process);

25125

1,304.45

716.23

Excision or curettage of bone cyst or benign tumor of radius or ulna (excluding head or neck of radius and olecranon process); with autograft (includes obtaining graft)

25126

1,304.45

732.74

Excision or curettage of bone cyst or benign tumor of radius or ulna (excluding head or neck of radius and olecranon process); with allograft

25130

1,304.45

462.46

Excision or curettage of bone cyst or benign tumor of carpal bones;

25135

1,304.45

570.61

Excision or curettage of bone cyst or benign tumor of carpal bones; with autograft (includes obtaining graft)

25136

1,304.45

506.02

Excision or curettage of bone cyst or benign tumor of carpal bones; with allograft

25145

1,304.45

647.50

Sequestrectomy (eg, for osteomyelitis or bone abscess), forearm and/or wrist

25150

1,304.45

598.60

Partial excision (craterization, saucerization, or diaphysectomy) of bone (eg, for osteomyelitis); ulna

25151

1,304.45

716.83

Partial excision (craterization, saucerization, or diaphysectomy) of bone (eg, for osteomyelitis); radius

25170

958.81

Radical resection for tumor, radius or ulna

25210

1,175.77

504.06

Carpectomy; one bone

25215

1,175.77

650.11

Carpectomy; all bones of proximal row

25230

1,304.45

448.83

Radial styloidectomy (separate procedure)

25240

1,304.45

465.33

Excision distal ulna partial or complete (eg, Darrach type or matched resection)

25246

194.43

Injection procedure for wrist arthrography

25248

950.47

488.64

Exploration with removal of deep foreign body, forearm or wrist

25250

1,304.45

519.57

Removal of wrist prosthesis; (separate procedure)

25251

1,304.45

706.34

Removal of wrist prosthesis; complicated, including total wrist

25259

79.02

400.77

Manipulation, wrist, under anesthesia

25260

1,304.45

758.44

Repair, tendon or muscle, flexor, forearm and/or wrist; primary, single, each tendon or muscle

25263

1,304.45

750.65

Repair, tendon or muscle, flexor, forearm and/or wrist; secondary, single, each tendon or muscle

25265

1,304.45

877.09

Repair, tendon or muscle, flexor, forearm and/or wrist; secondary, with free graft (includes obtaining graft), each tendon or muscle

25270

1,304.45

626.62

Repair, tendon or muscle, extensor, forearm and/or wrist; primary, single, each tendon or muscle

25272

1,304.45

696.39

Repair, tendon or muscle, extensor, forearm and/or wrist; secondary, single, each tendon or muscle

25274

1,304.45

802.19

Repair, tendon or muscle, extensor, forearm and/or wrist; secondary, with free graft (includes obtaining graft), each tendon or muscle

25275

1,304.45

663.99

Repair, tendon sheath, extensor, forearm and/or wrist, with free graft (includes obtaining graft) (eg, for extensor carpi ulnaris subluxation)

25280

1,304.45

699.79

Lengthening or shortening of flexor or extensor tendon, forearm and/or wrist, single, each tendon

25290

1,304.45

655.68

Tenotomy, open, flexor or extensor tendon, forearm and/or wrist, single, each tendon

25295

950.47

657.49

Tenolysis, flexor or extensor tendon, forearm and/or wrist, single, each tendon

25300

1,304.45

688.93

Tenodesis at wrist; flexors of fingers

25301

1,304.45

656.04

Tenodesis at wrist; extensors of fingers

25310

1,920.92

755.10

Tendon transplantation or transfer, flexor or extensor, forearm and/or wrist, single; each tendon

25312

1,920.92

848.92

Tendon transplantation or transfer, flexor or extensor, forearm and/or wrist, single; with tendon graft(s) (includes obtaining graft), each tendon

25315

1,920.92

903.17

Flexor origin slide (eg, for cerebral palsy, Volkmann contracture), forearm and/or wrist;

25316

3,549.34

1,041.84

Flexor origin slide (eg, for cerebral palsy, Volkmann contracture), forearm and/or wrist; with tendon(s) transfer

25320

1,920.92

960.23

Capsulorrhaphy or reconstruction, wrist, open (eg, capsulodesis, ligament repair, tendon transfer or graft) (includes synovectomy, capsulotomy and open reduction) for carpal instability

25332

1,604.48

837.85

Arthroplasty, wrist, with or without interposition, with or without external or internal fixation

25335

1,920.92

968.23

Centralization of wrist on ulna (eg, radial club hand)

25337

1,920.92

892.69

Reconstruction for stabilization of unstable distal ulna or distal radioulnar joint, secondary by soft tissue stabilization (eg, tendon transfer, tendon graft or weave, or tenodesis) with or without open reduction of distal radioulnar joint

25350

3,549.34

818.13

Osteotomy, radius; distal third

25355

1,920.92

899.17

Osteotomy, radius; middle or proximal third

25360

1,304.45

799.62

Osteotomy; ulna

25365

1,304.45

1,049.41

Osteotomy; radius AND ulna

25370

1,920.92

1,121.91

Multiple osteotomies, with realignment on intramedullary rod (Sofield type procedure); radius OR ulna

25375

1,920.92

1,096.65

Multiple osteotomies, with realignment on intramedullary rod (Sofield type procedure); radius AND ulna

25390

1,304.45

909.18

Osteoplasty, radius OR ulna; shortening

25391

1,920.92

1,130.20

Osteoplasty, radius OR ulna; lengthening with autograft

25392

1,304.45

1,128.86

Osteoplasty, radius AND ulna; shortening (excluding 64876)

25393

1,920.92

1,268.72

Osteoplasty, radius AND ulna; lengthening with autograft

25394

735.73

759.00

Osteoplasty, carpal bone, shortening

25400

3,549.34

952.79

Repair of nonunion or malunion, radius OR ulna; without graft (eg, compression technique)

25405

3,549.34

1,180.98

Repair of nonunion or malunion, radius OR ulna; with autograft (includes obtaining graft)

25415

3,549.34

1,114.46

Repair of nonunion or malunion, radius AND ulna; without graft (eg, compression technique)

25420

3,549.34

1,304.67

Repair of nonunion or malunion, radius AND ulna; with autograft (includes obtaining graft)

25425

1,920.92

1,213.97

Repair of defect with autograft; radius OR ulna

25426

1,920.92

1,226.15

Repair of defect with autograft; radius AND ulna

25430

1,175.77

695.76

Insertion of vascular pedicle into carpal bone (eg, Hori procedure)

25431

1,175.77

782.39

Repair of nonunion of carpal bone (excluding carpal scaphoid (navicular)) (includes obtaining graft and necessary fixation), each bone

25440

3,549.34

784.54

Repair of nonunion, scaphoid carpal (navicular) bone with or without radial styloidectomy (includes obtaining graft and necessary fixation)

25441

5,461.16

928.34

Arthroplastywith prosthetic replacement; distal radius

25442

5,461.16

798.18

Arthroplasty with prosthetic replacement; distal ulna

25443

2,274.08

768.48

Arthroplasty with prosthetic replacement; scaphoid carpal (navicular)

25444

2,274.08

815.96

Arthroplasty with prosthetic replacement; lunate

25445

2,274.08

718.00

Arthroplasty with prosthetic replacement; trapezium

25446

5,461.16

1,164.70

Arthroplastywith prosthetic replacement; distal radius and partial or entire carpus (total wrist)

25447

1,604.48

802.78

Arthroplasty, interposition, intercarpal or carpometacarpal joints

25449

1,604.48

1,023.86

Revision of arthroplasty, including removal of implant, wrist joint

25450

1,920.92

634.98

Epiphyseal arrest by epiphysiodesis or stapling; distal radius OR ulna

25455

1,920.92

763.33

Epiphyseal arrest by epiphysiodesis or stapling; distal radius AND ulna

25490

1,920.92

838.62

Prophylactic treatment (nailing, pinning, plating or wiring) with or without methylmethacrylate; radius

25491

1,920.92

879.69

Prophylactic treatment (nailing, pinning, plating or wiring) with or without methylmethacrylate; ulna

25492

1,920.92

1,035.97

Prophylactic treatment (nailing, pinning, plating or wiring) with or without methylmethacrylate; radius AND ulna

25500

79.02

254.53

Closed treatment of radial shaft fracture; without manipulation

25505

79.02

492.85

Closed treatment of radial shaft fracture; with manipulation

25515

1,837.10

663.47

Open treatment of radial shaft fracture, includes internal fixation, when performed

25520

79.02

538.24

Closed treatment of radial shaft fracture and closed treatment of dislocation of distal radioulnar joint (Galeazzi fracture/dislocation)

25525

1,837.10

818.81

Open treatment of radial shaft fracture, includes internal fixation, when performed, and closed treatment of distal radioulnar joint dislocation (Galeazzi fracture/ dislocation), includes percutaneous skeletal fixation, when performed

25526

1,837.10

1,019.35

Open treatment of radial shaft fracture, includes internal fixation, when performed, and open treatment of distal radioulnar joint dislocation (Galeazzi fracture/ dislocation), includes internal fixation, when performed, includes repair of triangular fibrocartilage complex

25530

79.02

250.22

Closed treatment of ulnar shaft fracture; without manipulation

25535

79.02

471.41

Closed treatment of ulnar shaft fracture; with manipulation

25545

1,837.10

631.39

Open treatment of ulnar shaft fracture, includes internal fixation, when performed

25560

79.02

258.33

Closed treatment of radial and ulnar shaft fractures; without manipulation

25565

79.02

513.27

Closed treatment of radial and ulnar shaft fractures; with manipulation

25574

2,646.58

647.94

Open treatment of radial AND ulnar shaft fractures, with internal fixation, when performed; of radius OR ulna

25575

2,646.58

879.18

Open treatment of radial AND ulnar shaft fractures, with internal fixation, when performed; of radius AND ulna

25600

79.02

283.48

Closed treatment of distal radial fracture (eg, Colles o Smith type) or epiphyseal separation, includes closed treatment of fracture of ulnar styloid, when performed; without manipulation

25605

79.02

594.16

Closed treatment of distal radial fracture (eg, Colles o Smith type) or epiphyseal separation, includes closed treatment of fracture of ulnar styloid, when performed; with manipulation

25606

1,169.01

674.73

Percutaneous skeletal fixation of distal radial fracture or epiphyseal separation

25607

2,646.58

691.41

Open treatment of distal radial extra-articular fracture or epiphyseal separation, with internal fixation

25608

2,646.58

784.97

Open treatment of distal radial intra-articular fracture or epiphyseal separation; with internal fixation of 2 fragments

25609

2,646.58

998.07

Open treatment of distal radial intra-articular fracture or epiphyseal separation; with internal fixation of 3 or more fragments

25622

79.02

292.05

Closed treatment of carpal scaphoid (navicular) fracture; without manipulation

25624

79.02

455.31

Closed treatment of carpal scaphoid (navicular) fracture; with manipulation

25628

1,837.10

703.61

Open treatment of carpal scaphoid (navicular) fracture, includes internal fixation, when performed

25630

79.02

296.60

Closed treatment of carpal bone fracture (excluding carpal scaphoid (navicular)); without manipulation, each bone

25635

79.02

429.34

Closed treatment of carpal bone fracture (excluding carpal scaphoid (navicular)); with manipulation, each bone

25645

1,837.10

566.33

Open treatment of carpal bone fracture (other than carpal scaphoid (navicular)), each bone

25650

79.02

307.81

Closed treatment of ulnar styloid fracture

25651

1,169.01

464.58

Percutaneous skeletal fixation of ulnar styloid fracture

25652

1,837.10

609.55

Open treatment of ulnar styloid fracture

25660

79.02

390.69

Closed treatment of radiocarpal or intercarpal dislocation, one or more bones, with manipulation

25670

1,169.01

605.87

Open treatment of radiocarpal or intercarpal dislocation, one or more bones

25671

1,169.01

515.02

Percutaneous skeletal fixation of distal radioulnar dislocation

25675

79.02

419.65

Closed treatment of distal radioulnar dislocation with manipulation

25676

1,169.01

628.42

Open treatment of distal radioulnar dislocation, acute or chronic

25680

79.02

440.86

Closed treatment of trans-scaphoperilunar type of fracture dislocation, with manipulation

25685

1,169.01

720.23

Open treatment of trans-scaphoperilunar type of fracture dislocation

25690

79.02

455.32

Closed treatment of lunate dislocation, with manipulation

25695

1,169.01

627.85

Open treatment of lunate dislocation

25800

3,549.34

752.71

Arthrodesis, wrist; complete, without bone graft (includes radiocarpal and/or intercarpal and/or carpometacarpal joints)

25805

1,920.92

862.84

Arthrodesis, wrist; with sliding graft

25810

3,549.34

864.87

Arthrodesis, wrist; with iliac or other autograft (includes obtaining graft)

25820

735.73

621.51

Arthrodesis, wrist; limited, without bone graft (eg, intercarpal or radiocarpal)

25825

3,549.34

756.93

Arthrodesis, wrist; with autograft (includes obtaining graft)

25830

3,549.34

986.80

Arthrodesis, distal radioulnar joint with segmental resection of ulna, with or without bone graft (eg, Sauve-Kapandji procedure)

25900

806.59

Amputation, forearm, through radius and ulna;

25905

788.64

Amputation, forearm, through radius and ulna; open, circular (guillotine)

25907

950.47

709.10

Amputation, forearm, through radius and ulna; secondary closure or scar revision

25909

785.80

Amputation, forearm, through radius and ulna; re-amputation

25915

1,253.6

Krukenberg procedure

25920

677.35

Disarticulation through wrist;

25922

950.47

598.02

Disarticulation through wrist; secondary closure or scar revision

25924

663.87

Disarticulation through wrist; re-amputation

25927

812.78

Transmetacarpal amputation;

25929

672.37

563.00

Transmetacarpal amputation; secondary closure or scar revision

25931

25999

950.47

760.90 I.C.

Transmetacarpal amputation; re-amputation Unlisted procedure, forearm or wrist

26010

62.85

280.05

Drainage of finger abscess; simple

26011

516.57

432.40

Drainage of finger abscess; complicated (eg, felon)

26020

735.73

424.01

Drainage of tendon sheath, digit and/or palm, each

26025

735.73

413.63

Drainage of palmar bursa; single, bursa

26030

735.73

484.61

Drainage of palmar bursa; multiple bursa

26034

735.73

526.65

Incision, bone cortex, hand or finger (eg,

osteomyelitis or bone abscess)

26035

735.73

792.64

Decompression fingers and/or hand, injection injury (eg, grease gun)

26037

561.29

Decompressive fasciotomy, hand (excludes 26035)

26040

1,175.77

307.58

Fasciotomy, palmar (eg, Dupuytren's contracture); percutaneous

26045

1,175.77

462.33

Fasciotomy, palmar (eg, Dupuytren's contracture); open, partial

26055

735.73

653.85

Tendon sheath incision (eg, for trigger finger)

26060

735.73

261.77

Tenotomy, percutaneous, single, each digit

26070

735.73

289.49

Arthrotomy, with exploration, drainage, or removal of loose or foreign body; carpometacarpal joint

26075

735.73

311.44

Arthrotomy, with exploration, drainage, or removal of loose or foreign body; metacarpophalangeal joint, each

26080

735.73

379.92

Arthrotomy, with exploration, drainage, or removal of loose or foreign body; interphalangeal joint, each

26100

735.73

322.37

Arthrotomy with biopsy; carpometacarpal joint, each

26105

735.73

327.99

Arthrotomy with biopsy; metacarpophalangeal joint, each

26110

735.73

314.07

Arthrotomy with biopsy; interphalangeal joint, each

26115

943.36

679.47

Excision, tumor or vascular malformation, soft tissue of hand or finger; subcutaneous

26116

943.36

477.24

Excision, tumor or vascular malformation, soft tissue of hand or finger; deep (subfascial or intramuscular)

26117

943.36

637.25

Radical resection of tumor (eg, malignant neoplasm), soft tissue of hand or finger

26121

1,175.77

591.78

Fasciectomy, palm only, with or without Z-plasty, other local tissue rearrangement, or skin grafting (includes obtaining graft)

26123

1,175.77

798.89

Fasciectomy, partial palmar with release of single digit including proximal interphalangeal joint, with or without Z-plasty, other local tissue rearrangement, or skin grafting (includes obtaining graft);

26125

735.73

277.46

Fasciectomy, partial palmar with release of single digit including proximal interphalangeal joint, with or without Z-plasty, other local tissue rearrangement, or skin grafting (includes obtaining graft); each additional digit (List separately in addition to code for primary procedure)

26130

735.73

450.94

Synovectomy, carpometacarpal joint

26135

1,175.77

546.55

Synovectomy, metacarpophalangeal joint including intrinsic release and extensor hood reconstruction, each digit

26140

735.73

498.51

Synovectomy, proximal interphalangeal joint, including extensor reconstruction, each interphalangeal joint

26145

735.73

505.59

Synovectomy, tendon sheath, radical (tenosynovectomy), flexor tendon, palm and/or finger, each tendon

26160

735.73

625.78

Excision of lesion of tendon sheath or joint capsule (eg, cyst, mucous cyst, or ganglion), hand or finger

26170

735.73

399.74

Excision of tendon, palm, flexor or extensor, single, each tendon

26180

735.73

435.19

Excision of tendon, finger, flexor or extensor, each tendon

26185

735.73

511.17

Sesamoidectomy, thumb or finger (separate procedure)

26200

735.73

444.51

Excision or curettage of bone cyst or benign tumor of metacarpal;

26205

1,175.77

596.17

Excision or curettage of bone cyst or benign tumor of metacarpal; with autograft (includes obtaining graft)

26210

735.73

435.39

Excision or curettage of bone cyst or benign tumor of proximal, middle, or distal phalanx of finger;

26215

735.73

546.79

Excision or curettage of bone cyst or benign tumor of proximal, middle, or distal phalanx of finger; with autograft (includes obtaining graft)

26230

735.73

498.04

Partial excision (craterization, saucerization, or diaphysectomy) bone (eg, osteomyelitis); metacarpal

26235

735.73

489.16

Partial excision (craterization, saucerization, or diaphysectomy) bone (eg, osteomyelitis); proximal or middle phalanx of finger

26236

735.73

435.47

Partial excision (craterization, saucerization, or diaphysectomy) bone (eg, osteomyelitis); distal phalanx of finger

26250

735.73

571.75

Radical resection, metacarpal (eg, tumor);

26255

1,175.77

894.12

Radical resection, metacarpal (eg, tumor); with autograft (includes obtaining graft)

26260

735.73

540.69

Radical resection, proximal or middle phalanx of finger (eg, tumor);

26261

735.73

647.90

Radical resection, proximal or middle phalanx of finger (eg, tumor); with autograft (includes obtaining graft)

26262

735.73

453.66

Radical resection, distal phalanx of finger (eg, tumor)

26320

719.48

341.35

Removal of implant from finger or hand

26340

79.02

319.32

Manipulation, finger joint, under anesthesia, each joint

26350

1,175.77

791.14

Repair or advancement, flexor tendon, not in zone 2 digital flexor tendon sheath (eg, no man's land); primary or secondary without free graft, each tendon

26352

1,175.77

883.96

Repair or advancement, flexor tendon, not in zone 2 digital flexor tendon sheath (eg, no man's land); secondary with free graft (includes obtaining graft), each tendon

26356

1,175.77

1,123.96

Repair or advancement, flexor tendon, in zone 2 digital flexor tendon sheath (eg, no man's land); primary, without free graft, each tendon

26357

1,175.77

933.57

Repair or advancement, flexor tendon, in zone 2 digital flexor tendon sheath (eg, no man's land); secondary, without free graft, each tendon

26358

1,175.77

991.81

Repair or advancement, flexor tendon, in zone 2 digital flexor tendon sheath (eg, no man's land); secondary, with free graft (includes obtaining graft), each tendon

26370

1,175.77

844.98

Repair or advancement of profundus tendon, with intact superficialis tendon; primary, each tendon

26372

1,175.77

968.72

Repair or advancement of profundus tendon, with intact superficialis tendon; secondary with free graft (includes obtaining graft), each tendon

26373

1,175.77

923.34

Repair or advancement of profundus tendon, with intact superficialis tendon; secondary without free graft, each tendon

26390

1,175.77

877.65

Excision flexor tendon, with implantation of synthetic rod for delayed tendon graft, hand or finger, each rod

26392

1,175.77

1,043.56

Removal of synthetic rod and insertion of flexor tendon graft, hand or finger (includes obtaining graft), each rod

26410

735.73

632.29

Repair, extensor tendon, hand, primary or secondary; without free graft, each tendon

26412

1,175.77

750.58

Repair, extensor tendon, hand, primary or secondary; with free graft (includes obtaining graft), each tendon

26415

1,175.77

759.43

Excision of extensor tendon, with implantation of synthetic rod for delayed tendon graft, hand or finger, each rod

26416

1,175.77

890.50

Removal of synthetic rod and insertion of extensor tendon graft (includes obtaining graft), hand or finger, each rod

26418

735.73

639.25

Repair, extensor tendon, finger, primary or secondary; without free graft, each tendon

26420

1,175.77

781.71

Repair, extensor tendon, finger, primary or secondary; with free graft (includes obtaining graft) each tendon

26426

1,175.77

661.20

Repair of extensor tendon, central slip, secondary (eg,

boutonniere deformity); using local tissue(s), including lateral band(s), each finger

26428

1,175.77

813.78

Repair of extensor tendon, central slip, secondary (eg, boutonniere deformity); with free graft (includes obtaining graft), each finger

26432

735.73

550.77

Closed treatment of distal extensor tendon insertion, with or without percutaneous pinning (eg, mallet finger)

26433

735.73

589.09

Repair of extensor tendon, distal insertion, primary or secondary; without graft (eg, mallet finger)

26434

1,175.77

686.17

Repair of extensor tendon, distal insertion, primary or secondary; with free graft (includes obtaining graft)

26437

735.73

673.45

Realignment of extensor tendon, hand, each tendon

26440

735.73

700.52

Tenolysis, flexor tendon; palm OR finger, each tendon

26442

1,175.77

999.66

Tenolysis, flexor tendon; palm AND finger, each tendon

26445

735.73

660.39

Tenolysis, extensor tendon, hand OR finger, each tendon

26449

1,175.77

847.23

Tenolysis, complex, extensor tendon, finger, including forearm, each tendon

26450

735.73

432.49

Tenotomy, flexor, palm, open, each tendon

26455

735.73

429.33

Tenotomy, flexor, finger, open, each tendon

26460

735.73

418.14

Tenotomy, extensor, hand or finger, open, each tendon

26471

735.73

662.25

Tenodesis; of proximal interphalangeal joint, each joint

26474

735.73

643.74

Tenodesis; of distal joint, each joint

26476

735.73

623.75

Lengthening of tendon, extensor, hand or finger, each tendon

26477

735.73

631.15

Shortening of tendon, extensor, hand or finger, each tendon

26478

735.73

678.59

Lengthening of tendon, flexor, hand or finger, each tendon

26479

735.73

669.78

Shortening of tendon, flexor, hand or finger, each tendon

26480

1,175.77

830.29

Transfer or transplant of tendon, carpometacarpal area or dorsum of hand; without free graft, each tendon

26483

1,175.77

915.59

Transfer or transplant of tendon, carpometacarpal area or dorsum of hand; with free tendon graft (includes obtaining graft), each tendon

26485

1,175.77

885.70

Transfer or transplant of tendon, palmar; without free tendon graft, each tendon

26489

1,175.77

897.34

Transfer or transplant of tendon, palmar; with free tendon graft (includes obtaining graft), each tendon

26490

1,175.77

825.67

Opponensplasty; superficialis tendon transfer type, each tendon

26492

1,175.77

912.60

Opponensplasty; tendon transfer with graft (includes obtaining graft), each tendon

26494

1,175.77

841.32

Opponensplasty; hypothenar muscle transfer

26496

1,175.77

898.47

Opponensplasty; other methods

26497

1,175.77

903.49

Transfer of tendon to restore intrinsic function; ring and small finger

26498

1,175.77

1,184.35

Transfer of tendon to restore intrinsic function; all four fingers

26499

1,175.77

853.47

Correction claw finger, other methods

26500

735.73

674.39

Reconstruction of tendon pulley, each tendon; with local tissues (separate procedure)

26502

1,175.77

748.27

Reconstruction of tendon pulley, each tendon; with tendon or fascial graft (includes obtaining graft) (separate procedure)

26508

735.73

684.94

Release of thenar muscle(s) (eg, thumb contracture)

26510

1,175.77

647.93

Cross intrinsic transfer, each tendon

26516

1,175.77

752.31

Capsulodesis, metacarpophalangeal joint; single digit

26517

1,175.77

866.46

Capsulodesis, metacarpophalangeal joint; two digits

26518

1,175.77

867.47

Capsulodesis, metacarpophalangeal joint; three or four digits

26520

735.73

731.25

Capsulectomy or capsulotomy; metacarpophalangeal joint, each joint

26525

735.73

734.87

Capsulectomy or capsulotomy; interphalangeal joint, each joint

26530

1,604.48

528.02

Arthroplasty, metacarpophalangeal joint; each joint

26531

2,274.08

613.96

Arthroplasty, metacarpophalangeal joint; with prosthetic implant, each joint

26535

1,604.48

382.67

Arthroplasty, interphalangeal joint; each joint

26536

2,274.08

683.62

Arthroplasty, interphalangeal joint; with prosthetic implant, each joint

26540

735.73

710.16

Repair of collateral ligament, metacarpophalangeal or interphalangeal joint

26541

1,175.77

853.35

Reconstruction , collateralli ga ment, metacarpophalangeal joint, single; with tendon or fascial graft (includes obtaining graft)

26542

735.73

729.92

Reconstruction , collateral ligament, metacarpophalangeal joint, single; with local tissue (eg, adductor advancement)

26545

1,175.77

744.22

Reconstruction, collateral ligament, interphalangeal joint, single, including graft, each joint

26546

1,175.77

1,012.10

Repair non-union, metacarpal or phalanx (includes obtaining bone graft with or without external or internal fixation)

26548

1,175.77

811.01

Repair and reconstruction, finger, volar plate, interphalangeal joint

26550

1,175.77

1,548.85

Pollicization of a digit

26551

3,028.34

Transfer, toe-to-hand with microvascular anastomosis; great toe wrap-around with bone graft

26553

2,861.22

Transfer, toe-to-hand with microvascular anastomosis; other than great toe, single

26554

3,908.67

Transfer, toe-to-hand with microvascular anastomosis; other than great toe, double

26555

1,175.77

1,394.07

Transfer, finger to another position without microvascular anastomosis

26556

2,947.95

Transfer, free toe joint, with microvascular anastomosis

26560

735.73

589.69

Repair of syndactyly (web finger) each web space; with skin flaps

26561

1,175.77

921.44

Repair of syndactyly (web finger) each web space; with skin flaps and grafts

26562

1,175.77

1,223.61

Repair of syndactyly (web finger) each web space; complex (eg, involving bone, nails)

26565

1,175.77

726.11

Osteotomy; metacarpal, each

26567

1,175.77

728.20

Osteotomy; phalanx of finger, each

26568

1,175.77

958.66

Osteoplasty, lengthening, metacarpal or phalanx

26580

735.73

1,272.96

Repair cleft hand

26587

735.73

932.92

Reconstruction of polydactylous digit, soft tissue and bone

26590

735.73

1,322.43

Repair macrodactylia, each digit

26591

1,175.77

491.60

Repair, intrinsic muscles of hand, each muscle

26593

735.73

642.96

Release, intrinsic muscles of hand, each muscle

26596

735.73

726.42

Excision of constricting ring of finger, with multiple Z-plasties

26600

79.02

265.35

Closed treatment of metacarpal fracture, single; without manipulation, each bone

26605

79.02

313.23

Closed treatment of metacarpal fracture, single; with manipulation, each bone

26607

79.02

467.29

Closed treatment of metacarpal fracture, with manipulation, with external fixation, each bone

26608

1,169.01

475.98

Percutaneous skeletal fixation of metacarpal fracture, each bone

26615

1,837.10

522.23

Open treatment of metacarpal fracture, single, includes internal fixation, when performed, each bone

26641

79.02

346.52

Closed treatment of carpometacarpal dislocation, thumb, with manipulation

26645

79.02

397.78

Closed treatment of carpometacarpal fracture dislocation, thumb (Bennett fracture), with manipulation

26650

1,169.01

471.88

Percutaneous skeletal fixation of carpometacarpal fracture dislocation, thumb (Bennett fracture), with manipulation

26665

1,837.10

590.41

Open treatment of carpometacarpal fracture dislocation, thumb (Bennett fracture), includes internal fixation, when performed

26670

79.02

320.74

Closed treatment of carpometacarpal dislocation, other than thumb, with manipulation, each joint; without anesthesia

26675

79.02

431.07

Closed treatment of carpometacarpal dislocation, other than thumb, with manipulation, each joint; requiring anesthesia

26676

1,169.01

500.63

Percutaneous skeletal fixation of carpometacarpal dislocation, other than thumb, with manipulation, each joint

26685

1,169.01

547.53

Open treatment of carpometacarpal dislocation, other than thumb; includes internal fixation, when performed, each joint

26686

2,646.58

611.08

Open treatment of carpometacarpal dislocation, other than thumb; complex, multiple, or delayed reduction

26700

79.02

300.67

Closed treatment of metacarpophalangeal dislocation, single, with manipulation; without anesthesia

26705

79.02

397.21

Closed treatment of metacarpophalangeal dislocation, single, with manipulation; requiring anesthesia

26706

79.02

427.02

Percutaneous skeletal fixation of metacarpophalangeal dislocation, single, with manipulation

26715

1,169.01

526.96

Open treatment of metacarpophalangeal dislocation, single, includes internal fixation, when performed

26720

79.02

188.59

Closed treatment of phalangeal shaft fracture, proximal or middle phalanx, finger or thumb; without manipulation, each

26725

79.02

335.54

Closed treatment of phalangeal shaft fracture,

proximal or middle phalanx, finger or thumb; with manipulation, with or without skin or skeletal traction, each

26727

1,169.01

468.96

Percutaneous skeletal fixation of unstable phalangeal shaft fracture, proximal or middle phalanx, finger or thumb, with manipulation, each

26735

1,169.01

545.16

Open treatment of phalangeal shaft fracture, proximal or middle phalanx, finger or thumb, includes internal fixation, when performed, each

26740

79.02

218.54

Closed treatment of articular fracture, involving metacarpophalangeal or interphalangeal joint; without manipulation, each

26742

79.02

363.65

Closed treatment of articular fracture, involving metacarpophalangeal or interphalangeal joint; with manipulation, each

26746

1,169.01

648.37

Open treatment of articular fracture, involving metacarpophalangeal or interphalangeal joint, includes internal fixation, when performed, each

26750

79.02

175.09

Closed treatment of distal phalangeal fracture, finger or thumb; without manipulation, each

26755

79.02

307.93

Closed treatment of distal phalangeal fracture, finger or thumb; with manipulation, each

26756

1,169.01

417.05

Percutaneous skeletal fixation of distal phalangeal fracture, finger or thumb, each

26765

1,169.01

441.32

Open treatment of distal phalangeal fracture, finger or thumb, includes internal fixation, when performed, each

26770

79.02

259.28

Closed treatment of interphalangeal joint dislocation, single, with manipulation; without anesthesia

26775

180.18

371.25

Closed treatment of interphalangeal joint dislocation, single, with manipulation; requiring anesthesia

26776

1,169.01

442.51

Percutaneous skeletal fixation of interphalangeal joint dislocation, single, with manipulation

26785

1,169.01

477.31

Open treatment of interphalangeal joint dislocation, includes internal fixation, when performed, single

26820

1,175.77

834.75

Fusion in opposition, thumb, with autogenous graft (includes obtaining graft)

26841

1,175.77

787.85

Arthrodesis, carpometacarpal joint, thumb, with or without internal fixation;

26842

1,175.77

840.86

Arthrodesis, carpometacarpal joint, thumb, with or without internal fixation; with autograft (includes obtaining graft)

26843

1,175.77

777.80

Arthrodesis, carpometacarpal joint, digit, other than thumb, each;

26844

1,175.77

861.11

Arthrodesis, carpometacarpal joint, digit, other than thumb, each; with autograft (includes obtaining graft)

26850

1,175.77

743.13

Arthrodesis, metacarpophalangeal joint, with or without internal fixation;

26852

1,175.77

837.09

Arthrodesis, metacarpophalangeal joint, with or without internal fixation; with autograft (includes obtaining graft)

26860

1,175.77

615.69

Arthrodesis, interphalangeal joint, with or without internal fixation;

26861

1,175.77

105.25

Arthrodesis, interphalangeal joint, with or without internal fixation; each additional interphalangeal joint (List separately in addition to code for primary procedure)

26862

1,175.77

770.75

Arthrodesis, interphalangeal joint, with or without internal fixation; with autograft (includes obtaining graft)

26863

1,175.77

234.75

Arthrodesis, interphalangeal joint, with or without internal fixation; with autograft (includes obtaining graft), each additional joint (List separately in addition to code for primary procedure)

26910

1,175.77

745.42

Amputation, metacarpal, with finger or thumb (ray amputation), single, with or without interosseous transfer

26951

735.73

648.16

Amputation, finger or thumb, primary or secondary, any joint or phalanx, single, including neurectomies; with direct closure

26952

735.73

696.58

Amputation, finger or thumb, primary or secondary, any joint or phalanx, single, including neurectomies; with local advancement flaps (V-Y, hood)

26989

I.C.

Unlisted procedure, hands or fingers

26990

950.47

613.10

Incision and drainage, pelvis or hip joint area; deep abscess or hematoma

26991

950.47

726.47

Incision and drainage, pelvis or hip joint area; infected bursa

26992

954.20

Incision, bone cortex, pelvis and/or hip joint (eg, osteomyelitis or bone abscess)

27000

950.47

448.16

Tenotomy, adductor of hip, percutaneous (separate procedure)

27001

1,304.45

538.40

Tenotomy, adductor of hip, open

27003

1,304.45

577.71

Tenotomy, adductor, subcutaneous, open, with obturator neurectomy

27005

721.02

Tenotomy, hip flexor(s), open (separate procedure)

27006

731.27

Tenotomy, abductors and/or extensor(s) of hip, open (separate procedure)

27025

873.42

Fasciotomy, hip or thigh, any type

27030

937.23

Arthrotomy, hip, with drainage (eg, infection)

27033

1,920.92

969.12

Arthrotomy, hip, including exploration or removal of loose or foreign body

27035

1,920.92

1,107.79

Denervation, hip joint, intrapelvic or extrapelvic intra-articular branches of sciatic, femoral, or obturator nerves

27036

988.08

Capsulectomy or capsulotomy, hip, with or without excision of heterotopic bone, with release of hip flexor muscles (ie, gluteus medius, gluteus minimus, tensor fascia latae, rectus femoris, sartorius, iliopsoas)

27040

388.12

347.03

Biopsy, soft tissue of pelvis and hip area; superficial

27041

388.12

669.20

Biopsy, soft tissue of pelvis and hip area; deep, subfascial or intramuscular

27047

943.36

612.71

Excision, tumor, pelvis and hip area; subcutaneous tissue

27048

943.36

463.79

Excision, tumor, pelvis and hip area; deep, subfascial, intramuscular

27049

943.36

962.60

Radical resection of tumor, soft tissue of pelvis and hip area (eg, malignant neoplasm)

27050

950.47

347.97

Arthrotomy, with biopsy; sacroiliac joint

27052

950.47

546.18

Arthrotomy, with biopsy; hip joint

27054

672.94

Arthrotomy with synovectomy, hip joint

27060

950.47

422.47

Excision; ischial bursa

27062

950.47

446.66

Excision; trochanteric bursa or calcification

27065

950.47

490.42

Excision of bone cyst or benign tumor; superficial (wing of ilium, symphysis pubis, or greater trochanter of femur) with or without autograft

27066

1,304.45

797.04

Excision of bone cyst or benign tumor; deep, with or without autograft

27067

1,304.45

1,002.15

Excision of bone cyst or benign tumor; with autograft requiring separate incision

27070

838.43

Partial excision (craterization, saucerization) (eg, osteomyelitis or bone abscess); superficial (eg, wing of ilium, symphysis pubis, or greater trochanter of femur)

27071

904.63

Partial excision (craterization, saucerization) (eg, osteomyelitis or bone abscess); deep (subfascial or intramuscular)

27075

2,238.88

Radical resection of tumor or infection; wing of ilium, one pubic or is chial ramus or symphysis pubis

27076

1,568.84

Radical resection of tumor or infection; ilium, including acetabulum, both pubic rami, or is chium and acetabulum

27077

2,617.35

Radical resection of tumor or infection; innominate bone, total

27078

995.03

Radical resection of tumor or infection; ischial tuberosity and greater trochanter of femur

27079

971.65

Radical resection of tumor or infection; is chial tuberosity and greater trochanter of femur, with skin flaps

27080

1,304.45

476.84

Coccygectomy, primary

27086

388.12

261.20

Removal of foreign body, pelvis or hip; subcutaneous tissue

27087

950.47

621.73

Removal of foreign body, pelvis or hip; deep (subfascial or intramuscular)

27090

826.31

Removal of hip prosthesis; (separate procedure)

27091

1,559.50

Removal of hip prosthesis; complicated, including total hip prosthesis, methylmethacrylate with or without insertion of spacer

27093

223.65

Injection procedure for hip arthrography; without anesthesia

27095

272.66

Injection procedure for hip arthrography; with anesthesia

27096

208.54

Injection procedure for sacroiliac joint, arthrography and/or anesthetic/steroid

27097

1,304.45

653.47

Release or recession, hamstring, proximal

27098

1,304.45

617.38

Transfer, adductor to ischium

27100

1,920.92

808.56

Transfer external oblique muscle to greater trochanter including fascial or tendon extension (graft)

27105

1,920.92

838.35

Transfer paraspinal muscle to hip (includes fascial or tendon extension graft)

27110

1,920.92

931.46

Transfer iliopsoas; to greater trochanter of femur

27111

1,920.92

880.18

Transfer iliopsoas; to femoral neck

27120

1,266.25

Acetabuloplasty; (eg, Whitman, Colonna, Haygroves, or cup type)

27122

1,094.44

Acetabuloplasty; resection, femoral head (eg, Girdlestone procedure)

27125

1,103.78

Hemiarthroplasty, hip, partial (eg, femoral stem prosthesis, bipolar arthroplasty)

27130

1,420.24

Arthroplasty, acetabular and proximal femoral prosthetic replacement (total hip arthroplasty), with or without autograft or allograft

27132

1,660.95

Conversion of previous hip surgery to total hip arthroplasty, with or without autograft or allograft

27134

1,925.06

Revision of total hip arthroplasty; both components, with or without autograft or allograft

27137

1,471.23

Revision of total hip arthroplasty; acetabular component only, with or without autograft or allograft

27138

1,529.81

Revision of total hip arthroplasty; femoral component only, with or without allograft

27140

893.94

Osteotomy and transfer of greater trochanter of femur (separate procedure)

27146

1,253.82

Osteotomy, iliac, acetabular or innominate bone;

27147

1,435.81

Osteotomy, iliac, acetabular or innominate bone; with open reduction of hip

27151

1,413.82

Osteotomy, iliac, acetabular or innominate bone; with femoral osteotomy

27156

1,701.06

Osteotomy, iliac, acetabular or innominate bone; with femoral osteotomy and with open reduction of hip

27158

1,326.09

Osteotomy, pelvis, bilateral (eg, congenital malformation)

27161

1,211.48

Osteotomy, femoral neck (separate procedure)

27165

1,341.98

Osteotomy, intertrochanteric or subtrochanteric including internal or external fixation and/or cast

27170

1,165.34

Bone graft, femoral head, neck, intertrochanteric or subtrochanteric area (includes obtaining bone graft)

27175

633.44

Treatment of slipped femoral epiphysis; by traction, without reduction

27176

899.03

Treatment of slipped femoral epiphysis; by single or multiple pinning, in situ

27177

1,095.48

Open treatment of slipped femoral epiphysis; single or multiple pinning or bone graft (includes obtaining graft)

27178

876.43

Open treatment of slipped femoral epiphysis; closed manipulation with single or multiple pinning

27179

967.54

Open treatment of slipped femoral epiphysis; osteoplasty of femoral neck (Heyman type procedure)

27181

1,052.03

Open treatment of slipped femoral epiphysis; osteotomy and internal fixation

27185

727.98

Epiphyseal arrest by epiphysiodesis or stapling, greater trochanter of femur

27187

990.14

Prophylactic treatment (nailing, pinning, plating or wiring) with or without methylmethacrylate, femoral neck and proximal femur

27193

79.02

456.65

Closed treatment of pelvic ring fracture, dislocation, diastasis or subluxation; without manipulation

27194

659.86

721.80

Closed treatment of pelvic ring fracture, dislocation, diastasis or subluxation; with manipulation, requiring more than local anesthesia

27200

79.07

171.20

Closed treatment of coccygeal fracture

27202

1,837.10

780.56

Open treatment of coccygeal fracture

27215

730.06

Open treatment of iliac spine(s), tuberosity avulsion, or iliac wing fracture(s) (eg, pelvic fracture(s) which do not disrupt the pelvic ring), with internal fixation

27216

1,047.49

Percutaneous skeletal fixation of posterior pelvic ring fracture and/or dislocation (includes ilium, sacroiliac joint and/or