2009 Fee Schedule

Fee Schedule 2009
Procedure Code Pricing Action Code Description Maximum Allowable
0001F 9 HEART FAILURE COMPOSITE $0.00
0001T O ENDOVAS REPR ABDO AO ANEURYS $0.00
0002F O TOBACCO USE, SMOKING, ASSESS $0.00
0002T 9 ENDOVAS REPR ABDO AO ANEURYS $0.00
0003F O TOBACCO USE, NON-SMOKING $0.00
0003T O CERVICOGRAPHY $0.00
0004F O TOBACCO USE TXMNT COUNSELING $0.00
0005F 9 OSTEOARTHRITIS COMPOSITE $0.00
0005T O PERC CATH STENT/BRAIN CV ART $0.00
0006F O STATIN THERAPY, PRESCRIBED $0.00

0007F O BETA-BLOCKER THX PRESCRIBED $0.00
0008F O ACE INHIBITOR THX PRESCRIBED $0.00
0008T O UPPER GI ENDOSCOPY W/SUTURE $0.00
0009F O ASSESS ANGINAL SYMPTOM/LEVEL $0.00
0009T O ENDOMETRIAL CRYOABLATION $0.00
00100 A ANESTH, SALIVARY GLAND $0.00
00102 A ANESTH, REPAIR OF CLEFT LIP $0.00
00103 A ANESTH, BLEPHAROPLASTY $0.00

00104 A ANESTH, ELECTROSHOCK $0.00
0010F O ASSESS ANGINAL SYMPTOM/LEVEL $0.00
0010T O TB TEST, GAMMA INTERFERON $0.00
0011F O ORAL ANTIPLAT THX PRESCRIBED $0.00
00120 A ANESTH, EAR SURGERY $0.00
00124 A ANESTH, EAR EXAM $0.00
00126 A ANESTH, TYMPANOTOMY $0.00
0012F 9 CAP BACTERIAL ASSESS $0.00
0012T O OSTEOCHONDRAL KNEE AUTOGRAFT $0.00
0013T O OSTEOCHONDRAL KNEE ALLOGRAFT $0.00
00140 A ANESTH, PROCEDURES ON EYE $0.00
00142 A ANESTH, LENS SURGERY $0.00
00144 A ANESTH, CORNEAL TRANSPLANT $0.00

00145 A ANESTH, VITREORETINAL SURG $0.00
00147 A ANESTH, IRIDECTOMY $0.00
00148 A ANESTH, EYE EXAM $0.00
0014F 9 COMP PREOP ASSESS CAT SURG $0.00
0014T O MENISCAL TRANSPLANTATION, MEDIAL OR $0.00
0015F 9 MELAN FOLLOW-UP COMPLETE $0.00
00160 A ANESTH, NOSE/SINUS SURGERY $0.00
00162 A ANESTH, NOSE/SINUS SURGERY $0.00
00164 A ANESTH, BIOPSY OF NOSE $0.00
0016T 9 THERMOTX CHOROID VASC LESION $0.00
00170 A ANESTH, PROCEDURE ON MOUTH $0.00
00172 A ANESTH, CLEFT PALATE REPAIR $0.00

00174 A ANESTH, PHARYNGEAL SURGERY $0.00
00176 A ANESTH, PHARYNGEAL SURGERY $0.00
0017T 9 PHOTOCOAGULAT MACULAR DRUSEN $0.00
0018T O TRANSCRANIAL MAGNETIC STIMUL $0.00
00190 A ANESTH, FACE/SKULL BONE SURG $0.00
00192 A ANESTH, FACIAL BONE SURGERY $0.00
0019T 9 EXTRACORP SHOCK WAVE, MS, NOS $0.00
0020T O EXTRACORP SHOCK WAVE TX, FT $0.00
00210 A ANESTH, CRANIAL SURG NOS $0.00
00211 A ANESTH, CRAN SURG, HEMOTOMA $0.00

00212 A ANESTH, SKULL DRAINAGE $0.00
00214 A ANESTH, SKULL DRAINAGE $0.00
00215 A ANESTH, SKULL REPAIR/FRACT $0.00
00216 A ANESTH, HEAD VESSEL SURGERY $0.00
00218 A ANESTH, SPECIAL HEAD SURGERY $0.00
0021T O FETAL OXIMETRY, TRNSVAG/CERV $0.00
00220 A ANESTH, INTRCRN NERVE $0.00
00222 A ANESTH, HEAD NERVE SURGERY $0.00
0023T O PHENOTYPE DRUG TEST, HIV 1 $0.00
0024T O TRANSCATH CARDIAC REDUCTION $0.00
0025T O ULTRASONIC PACHYMETRY $0.00
0026T O MEASURE REMNANT LIPOPROTEINS $0.00
0027T O ENDOSCOPIC EPIDURAL LYSIS $0.00

0028T O DEXA BODY COMPOSITION STUDY $0.00
0029T O MAGNETIC TX FOR INCONTINENCE $0.00
00300 A ANESTH, HEAD/NECK/PTRUNK $0.00
0030T 9 ANTIPROTHROMBIN ANTIBODY $0.00
0031T O SPECULOSCOPY $0.00
00320 A ANESTH, NECK ORGAN, 1 & OVER $0.00
00322 A ANESTH, BIOPSY OF THYROID $0.00
00326 A ANESTH, LARYNX/TRACH, < 1 YR $0.00
0032T O SPECULOSCOPY W/DIRECT SAMPLE $0.00
0033T O ENDOVASC TAA REPR INCL SUBCL $0.00
0034T O ENDOVASC TAA REPR W/O SUBCL $0.00
00350 A ANESTH, NECK VESSEL SURGERY $0.00

00352 A ANESTH, NECK VESSEL SURGERY $0.00
0035T O INSERT ENDOVASC PROSTH, TAA $0.00
0036T O ENDOVASC PROSTH, TAA, ADD-ON $0.00
0037T O ARTERY TRANSPOSE/ENDOVAS TAA $0.00
0038T O RAD ENDOVASC TAA RPR W/COVER $0.00
0039T O RAD S/I, ENDOVASC TAA REPAIR $0.00
00400 A ANESTH, SKIN, EXT/PER/ATRUNK $0.00
00402 A ANESTH, SURGERY OF BREAST $0.00

0040T O RAD S/I, ENDOVASC TAA PROSTH $0.00
00410 A ANESTH, CORRECT HEART RHYTHM $0.00
0041T O DETECT UR INFECT AGNT W/CPAS $0.00
00420 9 ANESTH, SKIN SURGERY, BACK $0.00
0042T 9 CT PERFUSION W/CONTRAST, CBF $0.00
0043T O CO EXPIRED GAS ANALYSIS $0.00
0044T O WHOLE BODY PHOTOGRAPHY $0.00
00450 A ANESTH, SURGERY OF SHOULDER $0.00
00454 A ANESTH, COLLAR BONE BIOPSY $0.00
0045T O WHOLE BODY PHOTOGRAPHY $0.00
0046T O CATH LAVAGE, MAMMARY DUCT(S) $0.00
00470 A ANESTH, REMOVAL OF RIB $0.00

00472 A ANESTH, CHEST WALL REPAIR $0.00
00474 A ANESTH, SURGERY OF RIB(S) $0.00
0047T O CATH LAVAGE, MAMMARY DUCT(S) $0.00
0048T 9 IMPLANT VENTRICULAR DEVICE $0.00
0049T O EXTERNAL CIRCULATION ASSIST $0.00
00500 A ANESTH, ESOPHAGEAL SURGERY $0.00
0050T 9 REMOVAL CIRCULATION ASSIST $0.00
0051T 9 IMPLANT TOTAL HEART SYSTEM $0.00
00520 A ANESTH, CHEST PROCEDURE $0.00
00522 A ANESTH, CHEST LINING BIOPSY $0.00
00524 A ANESTH, CHEST DRAINAGE $0.00
00528 A ANESTH, CHEST PARTITION VIEW $0.00

00529 9 ANESTH, CHEST PARTITION VIEW $0.00
0052T 9 REPLACE COMPONENT HEART SYST $0.00
00530 A ANESTH, PACEMAKER INSERTION $0.00
00532 A ANESTH, VASCULAR ACCESS $0.00
00534 A ANESTH, CARDIOVERTER/DEFIB $0.00
00537 A ANESTH, CARDIAC ELECTROPHYS $0.00
00539 A ANESTH,TRACHEOBRONCHIAL RECONSTRUC $0.00
0053T 9 REPLACE COMPONENT HEART SYST $0.00
00540 A ANESTH, CHEST SURGERY $0.00
00541 A ANESTH, ONE LUNG VENTILATION $0.00

00542 A ANESTH, RELEASE OF LUNG $0.00
00544 O ANESTH, CHEST LINING REMOVAL $0.00
00546 A ANESTH, LUNG,CHEST WALL SURG $0.00
00548 A ANESTH, TRACHEA,BRONCHI SURG $0.00
0054T O BONE SURGERY USING COMPUTER $0.00
00550 A ANESTH, STERNAL DEBRIDEMENT $0.00
00560 A ANESTH, HEART SURG W/O PUMP $0.00
00561 A ANESTH, HEART SURG < AGE 1 $0.00
00562 A ANESTH HRT SURG W/PMP AGE 1+ $0.00
00563 A ANESTH, HEART SURG W/ARREST $0.00
00566 A ANESTH, CABG W/O PUMP $0.00
00567 A ANESTH, CABG W/PUMP $0.00

0057T O UPPR GI SCOPE W/ THRML TXMNT $0.00
00580 A ANESTH, HEART/LUNG TRANSPLNT $0.00
0058T O CRYOPRESERVATION, OVARY TISS $0.00
0059T O CRYOPRESERVATION, OOCYTE $0.00
00600 A ANESTH, SPINE, CORD SURGERY $0.00
00604 A ANESTH, SITTING PROCEDURE $0.00
0060T O ELECTRICAL IMPEDANCE SCAN $0.00
0061T O DESTRUCTION OF TUMOR, BREAST $0.00
00622 A ANESTH, REMOVAL OF NERVES $0.00
00625 A ANES SPINE TRANTHOR W/O VENT $0.00

00626 A ANES, SPINE TRANSTHOR W/VENT $0.00
0062T 9 REP INTRADISC ANNULUS;1 LEV $0.00
00632 A ANESTH, REMOVAL OF NERVES $0.00
00634 5 ANESTH FOR CHEMONUCLEOLYSIS $0.00
00635 A ANESTH, LUMBAR PUNCTURE $0.00
0063T 9 REP INTRADISC ANNULUS;>1LEV $0.00
00640 A ANESTH, SPINE MANIPULATION $0.00
0064T 9 SPECTROSCOP EVAL EXPIRED GAS $0.00
0065T O OCULAR PHOTOSCREEN BILAT $0.00

0066T 9 CT COLONOGRAPHY;SCREEN $0.00
0067T 9 CT COLONOGRAPHY;DX $0.00
0068T 9 INTERP/REPT HEART SOUND $0.00
0069T 9 ANALYSIS ONLY HEART SOUND $0.00
00700 A ANESTH, ABDOMINAL WALL SURG $0.00
00702 A ANESTH, FOR LIVER BIOPSY $0.00
0070T 9 INTERP ONLY HEART SOUND $0.00
0071T 9 U/S LEIOMYOMATA ABLATE <200 $0.00
0072T 9 U/S LEIOMYOMATA ABLATE >200 $0.00
0073T 9 DELIVERY, COMP IMRT $0.00
00740 A ANESTH, UPPER GI VISUALIZE $0.00

0074T O ONLINE PHYSICIAN E/M $0.00
00750 A ANESTH, REPAIR OF HERNIA $0.00
0075T 9 PERQ STENT/CHEST VERT ART $0.00
0076T 9 S&I STENT/CHEST VERT ART $0.00
00770 A ANESTH, BLOOD VESSEL REPAIR $0.00
0077T 9 CEREB THERM PERFUSION PROBE $0.00
0078T 9 ENDOVASC AORT REPR W/DEVICE $0.00
00790 A ANESTH, SURG UPPER ABDOMEN $0.00
00792 A ANESTH, HEMORR/EXCISE LIVER $0.00

00794 A ANESTH, PANCREAS REMOVAL $0.00
00796 A ANESTH, FOR LIVER TRANSPLANT $0.00
00797 A ANESTH, SURGERY FOR OBESITY $0.00
0079T 9 ENDOVASC VISC EXTNSN REPR $0.00
00802 A ANESTH, FAT LAYER REMOVAL $0.00
00806 O ANESTHESIA FOR LAPAROSCOPIC PROCEDU $0.00
0080T 9 ENDOVASC AORT REPR RAD S&I $0.00
00810 A ANESTH, LOW INTESTINE SCOPE $0.00
0081T 9 ENDOVASC VISC EXTNSN S&I $0.00

0082T O STEREOTACTIC RAD DELIVERY $0.00
00834 A ANESTH, HERNIA REPAIR< 1 YR $0.00
00836 A ANESTH HERNIA REPAIR PREEMIE $0.00
0083T O STEREOTACTIC RAD TX MNGMT $0.00
00840 A ANESTH, SURG LOWER ABDOMEN $0.00
00842 A ANESTH, AMNIOCENTESIS $0.00
00844 A ANESTH, PELVIS SURGERY $0.00
00846 A ANESTH, HYSTERECTOMY $0.00
00848 A ANESTH, PELVIC ORGAN SURG $0.00
0084T 9 TEMP PROSTATE URETHRAL STENT $0.00

00850 9 ANESTH, CESAREAN SECTION $0.00
00851 A ANESTH, TUBAL LIGATION $0.00
00855 9 ANESTH, HYSTERECTOMY $0.00
00857 9 ANALGESIA, LABOR & C-SECTION $0.00
0085T 9 BREATH TEST HEART REJECT $0.00
00860 A ANESTH, SURGERY OF ABDOMEN $0.00
00862 A ANESTH, KIDNEY/URETER SURG $0.00
00864 A ANESTH, REMOVAL OF BLADDER $0.00
00865 A ANESTH, REMOVAL OF PROSTATE $0.00
00866 A ANESTH, REMOVAL OF ADRENAL $0.00
00868 A ANESTH, KIDNEY TRANSPLANT $0.00
00869 O ANESTH, VASECTOMY $0.00

0086T 9 L VENTRICLE FILL PRESSURE $0.00
00870 A ANESTH, BLADDER STONE SURG $0.00
00872 A ANESTH KIDNEY STONE DESTRUCT $0.00
00873 A ANESTH KIDNEY STONE DESTRUCT $0.00
0087T 9 SPERM EVAL HYALURONAN $0.00
00880 A ANESTH, ABDOMEN VESSEL SURG $0.00
00882 A ANESTH, MAJOR VEIN LIGATION $0.00
00884 9 ANESTH, MAJOR VEIN REVISION $0.00
0088T O RF TONGUE BASE VOL REDUXN $0.00
0089T O ACTIGRAPHY TESTING, 3-DAY $0.00

00900 9 ANESTH, PERINEAL PROCEDURE $0.00
00902 A ANESTH, ANORECTAL SURGERY $0.00
00904 A ANESTH, PERINEAL SURGERY $0.00
00906 A ANESTH, REMOVAL OF VULVA $0.00
0090T O CERVICAL ARTIFIC DISC $0.00
00910 A ANESTH, BLADDER SURGERY $0.00
00912 A ANESTH, BLADDER TUMOR SURG $0.00
00916 A ANESTH, BLEEDING CONTROL $0.00
00918 A ANESTH, STONE REMOVAL $0.00
0091T O LUMBAR ARTIFIC DISC $0.00
00920 A ANESTH, GENITALIA SURGERY $0.00

00921 A ANESTH, VASECTOMY $0.00
00922 A ANESTH, SPERM DUCT SURGERY $0.00
00924 A ANESTH, TESTIS EXPLORATION $0.00
00926 A ANESTH, REMOVAL OF TESTIS $0.00
00928 A ANESTH, REMOVAL OF TESTIS $0.00
0092T 9 ARTIFIC DISC ADDL $0.00
00930 A ANESTH, TESTIS SUSPENSION $0.00
00932 A ANESTH, AMPUTATION OF PENIS $0.00
00934 A ANESTH, PENIS, NODES REMOVAL $0.00
00936 A ANESTH, PENIS, NODES REMOVAL $0.00
00938 9 ANESTH, INSERT PENIS DEVICE $0.00
0093T O CERVICAL ARTIFIC DISKECTOMY $0.00

00940 A ANESTH, VAGINAL PROCEDURES $0.00
00942 A ANESTH, SURG ON VAG/URETHRAL $0.00
00944 A ANESTH, VAGINAL HYSTERECTOMY $0.00
00946 9 ANESTH, VAGINAL DELIVERY $0.00
00948 A ANESTH, REPAIR OF CERVIX $0.00
0094T O LUMBAR ARTIFIC DISKECTOMY $0.00
00950 A ANESTH, VAGINAL ENDOSCOPY $0.00
00952 A ANESTH, HYSTEROSCOPE/GRAPH $0.00
00955 9 ANALGESIA, VAGINAL DELIVERY $0.00
0095T 9 ARTIFIC DISKECTOMY ADDL $0.00

0096T O REV CERVICAL ARTIFIC DISC $0.00
0097T O REV LUMBAR ARTIFIC DISC $0.00
0098T 9 REV ARTIFIC DISC ADDL $0.00
0099T 9 IMPLANT CORNEAL RING $0.00
01000 9 ANESTH, SKIN SURGERY, PELVIS $0.00
0100T 9 PROSTH RETINA RECEIVE&GEN $0.00
0101T 9 EXTRACORP SHOCKWV TX,HI ENRG $0.00
0102T 9 EXTRACORP SHOCKWV TX,ANESTH $0.00
0103T 9 HOLOTRANSCOBALAMIN $0.00
0104T 9 AT REST CARDIO GAS REBREATHE $0.00
0105T 9 EXERC CARDIO GAS REBREATHE $0.00
0106T 9 TOUCH QUANT SENSORY TEST $0.00
0107T 9 VIBRATE QUANT SENSORY TEST $0.00

0108T 9 COOL QUANT SENSORY TEST $0.00
0109T 9 HEAT QUANT SENSORY TEST $0.00
0110T 9 NOS QUANT SENSORY TEST $0.00
01110 9 ANESTH, SKIN SURGERY, PELVIS $0.00
01112 A ANESTH, BONE ASPIRATE/BX $0.00
0111T 9 RBC MEMBRANES FATTY ACIDS $0.00
01130 A ANESTH, BODY CAST PROCEDURE $0.00
01140 A ANESTH, AMPUTATION AT PELVIS $0.00
01150 A ANESTH, PELVIC TUMOR SURGERY $0.00
0115T O MED TX MNGMT 15 MIN $0.00
01160 A ANESTH, PELVIS PROCEDURE $0.00

0116T O MED TX MNGMT SUBSQT $0.00
01173 A ANESTH, FX REPAIR, PELVIS $0.00
0117T O MED TX MNGMT ADDL 15 MIN $0.00
01180 A ANESTH, PELVIS NERVE REMOVAL $0.00
01190 A ANESTH, PELVIS NERVE REMOVAL $0.00
01200 A ANESTH, HIP JOINT PROCEDURE $0.00
01202 A ANESTH, ARTHROSCOPY OF HIP $0.00
0120T O FIBROADENOMA CRYOABLATE, EA $0.00
01210 A ANESTH, HIP JOINT SURGERY $0.00

01212 A ANESTH, HIP DISARTICULATION $0.00
01214 A ANESTH, HIP ARTHROPLASTY $0.00
01215 A ANESTH, REVISE HIP REPAIR $0.00
01220 A ANESTH, PROCEDURE ON FEMUR $0.00
01230 A ANESTH, SURGERY OF FEMUR $0.00
01232 A ANESTH, AMPUTATION OF FEMUR $0.00
01234 A ANESTH, RADICAL FEMUR SURG $0.00
0123T 9 SCLERAL FISTULIZATION $0.00
01240 9 ANESTH, UPPER LEG SKIN SURG $0.00
0124T 9 CONJUNCTIVAL DRUG PLACEMENT $0.00
01250 A ANESTH, UPPER LEG SURGERY $0.00
01260 A ANESTH, UPPER LEG VEINS SURG $0.00
0126T 9 CHD RISK IMT STUDY $0.00

01270 A ANESTH, THIGH ARTERIES SURG $0.00
01272 A ANESTH, FEMORAL ARTERY SURG $0.00
01274 A ANESTH, FEMORAL EMBOLECTOMY $0.00
01300 9 ANESTH, SKIN SURGERY, KNEE $0.00
0130T 9 CHRON CARE DRUG INVESTIGATN $0.00
01320 A ANESTH, KNEE AREA SURGERY $0.00
0133T O ESOPHAGEAL IMPLANT INJEXN $0.00
01340 A ANESTH, KNEE AREA PROCEDURE $0.00
0135T O PERQ CRYOABLATE RENAL TUMOR $0.00
0137T O PROSTATE SATURATION SAMPLING $0.00
01380 A ANESTH, KNEE JOINT PROCEDURE $0.00

01382 A ANESTH, DX KNEE ARTHROSCOPY $0.00
01390 A ANESTH, KNEE AREA PROCEDURE $0.00
01400 A ANESTH, KNEE JOINT SURGERY $0.00
01402 A ANESTH, KNEE ARTHROPLASTY $0.00
01404 A ANESTH, AMPUTATION AT KNEE $0.00
0140T 9 EXHALED BREATH CONDENSATE PH $0.00
0141T 9 PERQ ISLET TRANSPLANT $0.00
01420 A ANESTH, KNEE JOINT CASTING $0.00
0142T 9 OPEN ISLET TRANSPLANT $0.00

01430 A ANESTH, KNEE VEINS SURGERY $0.00
01432 A ANESTH, KNEE VESSEL SURG $0.00
0143T 9 LAPAROSCOPIC ISLET TRANSPLNT $0.00
01440 A ANESTH, KNEE ARTERIES SURG $0.00
01442 A ANESTH, KNEE ARTERY SURG $0.00
01444 A ANESTH, KNEE ARTERY REPAIR $0.00
0144T 9 CT HEART WO DYE; QUAL CALC $0.00
0145T 9 CT HEART W/WO DYE FUNCT $0.00
01460 9 ANESTH, LOWER LEG SKIN SURG $0.00
01462 A ANESTH, LOWER LEG PROCEDURE $0.00
01464 A ANESTH, ANKLE/FT ARTHROSCOPY $0.00
0146T 9 CCTA W/WO DYE $0.00
01470 A ANESTH, LOWER LEG SURGERY $0.00

01472 A ANESTH, ACHILLES TENDON SURG $0.00
01474 A ANESTH, LOWER LEG SURGERY $0.00
0147T 9 CCTA W/WO, QUAN CALCIUM $0.00
01480 A ANESTH, LOWER LEG BONE SURG $0.00
01482 A ANESTH, RADICAL LEG SURGERY $0.00
01484 A ANESTH, LOWER LEG REVISION $0.00
01486 A ANESTH, ANKLE REPLACEMENT $0.00
0148T 9 CCTA W/WO, STRXR $0.00
01490 A ANESTH, LOWER LEG CASTING $0.00
0149T 9 CCTA W/WO, STRXR QUAN CALC $0.00
01500 A ANESTH, LEG ARTERIES SURG $0.00
01502 A ANESTH, LWR LEG EMBOLECTOMY $0.00

0150T 9 CCTA W/WO, DISEASE STRXR $0.00
0151T 9 CT HEART FUNCT ADD-ON $0.00
01520 A ANESTH, LOWER LEG VEIN SURG $0.00
01522 A ANESTH, LOWER LEG VEIN SURG $0.00
0152T 9 COMPUTER CHEST ADD-ON $0.00
0153T O TCATH SENSOR ANEURYSM SAC $0.00
0154T O STUDY SENSOR ANEURYSM SAC $0.00
0155T 9 LAP IMPL GAST CURVE ELECTRD $0.00
0156T 9 LAP REMV GAST CURVE ELECTRD $0.00
0157T 9 OPEN IMPL GAST CURVE ELECTRD $0.00

0158T 9 OPEN REMV GAST CURVE ELECTRD $0.00
0159T 9 CAD BREAST MRI $0.00
01600 9 ANESTH, SHOULDER SKIN SURG $0.00
0160T 9 TCRANIAL MAGN STIM TX PLAN $0.00
0161T 9 TCRANIAL MAGN STIM TX DELIV $0.00
01620 A ANESTH, SHOULDER PROCEDURE $0.00
01622 A ANES DX SHOULDER ARTHROSCOPY $0.00
0162T O ANAL PROGRAM GAST NEUROSTIM $0.00
01634 A ANESTH, SHOULDER JOINT AMPUT $0.00
01636 A ANESTH, FOREQUARTER AMPUT $0.00

01638 A ANESTH, SHOULDER REPLACEMENT $0.00
0163T 9 LUMB ARTIF DISKECTOMY ADDL $0.00
0164T 9 REMOVE LUMB ARTIF DISC ADDL $0.00
01650 A ANESTH, SHOULDER ARTERY SURG $0.00
01652 A ANESTH, SHOULDER VESSEL SURG $0.00
01654 A ANESTH, SHOULDER VESSEL SURG $0.00
01656 A ANESTH, ARM-LEG VESSEL SURG $0.00
0165T 9 REVISE LUMB ARTIF DISC ADDL $0.00
0166T 9 TCATH VSD CLOSE W/O BYPASS $0.00
01670 A ANESTH, SHOULDER VEIN SURG $0.00
0167T 9 TCATH VSD CLOSE W BYPASS $0.00
01680 A ANESTH, SHOULDER CASTING $0.00

01682 A ANESTH, AIRPLANE CAST $0.00
0168T 9 RHINOPHOTOTX LIGHT APP BILAT $0.00
0169T 9 PLACE STEREO CATH BRAIN $0.00
01700 9 ANESTH, ELBOW AREA SKIN SURG $0.00
0170T 9 ANORECTAL FISTULA PLUG RPR $0.00
01710 A ANESTH, ELBOW AREA SURGERY $0.00
01712 A ANESTH, UPPR ARM TENDON SURG $0.00
01714 A ANESTH, UPPR ARM TENDON SURG $0.00
01716 A ANESTH, BICEPS TENDON REPAIR $0.00
0171T 9 LUMBAR SPINE PROCES DISTRACT $0.00

0172T 9 LUMBAR SPINE PROCES ADDL $0.00
01730 A ANESTH, UPPR ARM PROCEDURE $0.00
01732 A ANESTH, DX ELBOW ARTHROSCOPY $0.00
0173T 9 IOP MONIT IO PRESSURE $0.00
01740 A ANESTH, UPPER ARM SURGERY $0.00
01742 A ANESTH, HUMERUS SURGERY $0.00
01744 A ANESTH, HUMERUS REPAIR $0.00
0174T 9 CAD CXR WITH INTERP $0.00
01756 A ANESTH, RADICAL HUMERUS SURG $0.00
01758 A ANESTH, HUMERAL LESION SURG $0.00
0175T 9 CAD CXR REMOTE $0.00
01760 A ANESTH, ELBOW REPLACEMENT $0.00
0176T 9 AQU CANAL DILAT W/O RETENT $0.00

01770 A ANESTH, UPPR ARM ARTERY SURG $0.00
01772 A ANESTH, UPPR ARM EMBOLECTOMY $0.00
0177T 9 AQU CANAL DILAT W RETENT $0.00
01780 A ANESTH, UPPER ARM VEIN SURG $0.00
01782 A ANESTH, UPPR ARM VEIN REPAIR $0.00
0178T 9 64 LEAD ECG W I&R $0.00
0179T 9 64 LEAD ECG W TRACING $0.00
01800 9 ANESTH, LOWER ARM SKIN SURG $0.00
0180T 9 64 LEAD ECG W I&R ONLY $0.00
01810 A ANESTH, LOWER ARM SURGERY $0.00
0181T 9 CORNEAL HYSTERESIS $0.00
01820 A ANESTH, LOWER ARM PROCEDURE $0.00

01829 A ANESTH, DX WRIST ARTHROSCOPY $0.00
0182T 9 HDR ELECT BRACHYTHERAPY $0.00
01830 A ANESTH, LOWER ARM SURGERY $0.00
01832 A ANESTH, WRIST REPLACEMENT $0.00
0183T 9 WOUND ULTRASOUND $0.00
01840 A ANESTH, LWR ARM ARTERY SURG $0.00
01842 A ANESTH, LWR ARM EMBOLECTOMY $0.00
01844 A ANESTH, VASCULAR SHUNT SURG $0.00
0184T 9 EXC RECTAL TUMOR ENDOSCOPIC $0.00
01850 A ANESTH, LOWER ARM VEIN SURG $0.00

01852 A ANESTH, LWR ARM VEIN REPAIR $0.00
0185T 9 COMPTR PROBABILITY ANALYSIS $0.00
01860 A ANESTH, LOWER ARM CASTING $0.00
0186T 9 SUPRACHOROIDAL DRUG DELIVERY $0.00
0187T 9 OPHTHALMIC DX IMAGE ANTERIOR $0.00
0188T 9 VIDEOCONF CRIT CARE 74 MIN $0.00
0189T 9 VIDEOCONF CRIT CARE ADDL 30 $0.00
01900 9 ANESTH, UTERUS/TUBE INJECT $0.00
01902 9 ANESTH, BURR HOLES, SKULL $0.00
01904 9 ANESTH, SKULL X-RAY INJECT $0.00
01905 O ANES, SPINE INJECT, X-RAY/RE $0.00
01906 9 ANESTH, LUMBAR MYELOGRAPHY $0.00
01908 9 ANESTH, CERVICAL MYELOGRAPHY $0.00

0190T 9 PLACE INTRAOC RADIATION SRC $0.00
01910 9 ANESTH, SKULL MYELOGRAPHY $0.00
01912 9 ANESTH, LUMBAR DISKOGRAPHY $0.00
01914 9 ANESTH, CERVICAL DISKOGRAPHY $0.00
01916 A ANESTH, DX ARTERIOGRAPHY $0.00
01918 9 ANESTH, LIMB ARTERIOGRAM $0.00
0191T 9 INSERT ANT SEGMENT DRAIN INT $0.00
01920 A ANESTH, CATHETERIZE HEART $0.00
01921 9 ANESTH, VESSEL SURGERY $0.00
01922 A ANESTH, CAT OR MRI SCAN $0.00
01924 A ANES, THER INTERVEN RAD, ART $0.00
01925 A ANES, THER INTERVEN RAD, CAR $0.00

01926 A ANES, TX INTERV RAD HRT/CRAN $0.00
0192T 9 INSERT ANT SEGMENT DRAIN EXT $0.00
01930 A ANES, THER INTERVEN RAD, VEI $0.00
01931 A ANES, THER INTERVEN RAD, TIP $0.00
01932 A ANES, TX INTERV RAD, TH VEIN $0.00
01933 A ANES, TX INTERV RAD, CRAN V $0.00
01935 A ANESTH, PERC IMG DX SP PROC $0.00
01936 A ANESTH, PERC IMG TX SP PROC $0.00
0193T 9 RF BLADDER NECK MICROREMODEL $0.00
0194T 9 PROCALCITONIN (PCT) $0.00

01951 A ANESTH, BURN, LESS 4 PERCENT $0.00
01952 A ANESTH, BURN, 4-9 PERCENT $0.00
01953 5 ANESTH, BURN, EACH 9 PERCENT $0.00
01958 A ANESTH, ANTEPARTUM MANIPUL $0.00
0195T 9 ARTHROD PRESAC INTERBODY $0.00
01960 A ANESTH, VAGINAL DELIVERY $0.00
01961 A ANESTH, CS DELIVERY $0.00
01962 A ANESTH, EMER HYSTERECTOMY $0.00
01963 A ANESTH, CS HYSTERECTOMY $0.00
01964 O ANESTH, ABORTION PROCEDURES $0.00
01965 A ANESTH, INC/MISSED AB PROC $0.00
01966 A ANESTH, INDUCED AB PROCEDURE $0.00
01967 A ANESTH/ANALG, VAG DELIVERY $0.00

01968 A ANES/ANALG CS DELIVER ADD-ON $0.00
01969 A ANESTH/ANALG CS HYST ADD-ON $0.00
0196T 9 ARTHROD PRESAC INTERBODY EAC $0.00
0197T 9 INTRAFRACTION TRACK MOTION $0.00
0198T 9 OCULAR BLOOD FLOW MEASURE $0.00
01990 A SUPPORT FOR ORGAN DONOR $0.00
01991 A ANESTH, NERVE BLOCK/INJ $0.00
01992 A ANESTH, N BLOCK/INJ, PRONE $0.00
01995 O REGIONAL ANESTHESIA LIMB $0.00
01996 3 HOSP MANAGE CONT DRUG ADMIN $48.15
01999 5 UNLISTED ANESTH PROCEDURE $0.00
0500F 9 INITIAL PRENATAL CARE VISIT $0.00

0501F 9 PRENATAL FLOW SHEET $0.00
0502F 9 SUBSEQUENT PRENATAL CARE $0.00
0503F 9 POSTPARTUM CARE VISIT $0.00
0505F 9 HEMODIALYSIS PLAN DOCÏD $0.00
0507F 9 PERITON DIALYSIS PLAN DOCÏD $0.00
0509F 9 URINE INCON PLAN DOCÏD $0.00
0513F 9 ELEV BP PLAN OF CARE DOCÏD $0.00
0514F 9 CARE PLAN HGB DOCÏD ESA PT $0.00
0516F 9 ANEMIA PLAN OF CARE DOCÏD $0.00
0517F 9 GLAUCOMA PLAN OF CARE DOCÏD $0.00

0518F 9 FALL PLAN OF CARE DOCÏD $0.00
0519F 9 PLANÏD CHEMO DOCÏD B/4 TXMNT $0.00
0520F 9 RAD DOS LIMTS B/4 3D RAD $0.00
0521F 9 PLAN OF CARE 4 PAIN DOCÏD $0.00
0525F 9 INITIAL VISIT FOR EPISODE $0.00
0526F 9 SUBS VISIT FOR EPISODE $0.00
0528F 9 RCMND FLW-UP 10 YRS DOCD $0.00
0529F 9 INTRVL 3+YRS PTS CLNSCP DOCD $0.00
0535F 9 DYSPNEA MNGMNT PLAN DOCD $0.00
0540F 9 GLUCO MNGMNT PLAN DOCD $0.00
0575F 9 HIV RNA PLAN CARE DOCD $0.00
10000 O INCISION AND DRAINAGE OF INFECTED O $0.00

1000F 9 TOBACCO USE ASSESSED $0.00
1000H O PART H-ONLY DME, SUPPLIES AND HEARI $0.00
1001F O TOBACCO USE, NON-SMOKING $0.00
10020 O INCISION AND DRAINAGE OF FURUNCLE $0.00
10021 3 FNA W/O IMAGE $127.26
10022 3 FNA W/IMAGE $130.85
1002F 9 ASSESS ANGINAL SYMPTOM/LEVEL $0.00
1003F 9 LEVEL OF ACTIVITY ASSESS $0.00
10040 3 ACNE SURGERY $90.31
1004F 9 CLIN SYMP VOL OVRLD ASSESS $0.00

1005F 9 ASTHMA SYMPTOMS EVALUATE $0.00
10060 3 DRAINAGE OF SKIN ABSCESS $97.53
10061 3 DRAINAGE OF SKIN ABSCESS $166.28
1006F 9 OSTEOARTHRITIS ASSESS $0.00
1007F 9 ANTI-INFLM/ANLGSC OTC ASSESS $0.00
10080 3 DRAINAGE OF PILONIDAL CYST $146.46
10081 3 DRAINAGE OF PILONIDAL CYST $228.59
1008F 9 GI/RENAL RISK ASSESS $0.00
10100 O INCISION AND DRAINAGE OF ONYCHIA OR $0.00
10101 O INCISION AND DRAINAGE OF ONYCHIA OR $0.00

1010H O TRANSPORTATION IN VEHICLE OTHER THA $0.00
10120 3 REMOVE FOREIGN BODY $120.03
10121 3 REMOVE FOREIGN BODY $232.67
10140 3 DRAINAGE OF HEMATOMA/FLUID $137.58
10141 O INCISION AND DRAINAGE OF HEMATOMA C $0.00
1015F 9 COPD SYMPTOMS ASSESS $0.00
1015H O SOCIAL WORK $0.00
10160 3 PUNCTURE DRAINAGE OF LESION $86.51
1016H O PARENT TRAINING $0.00
10180 3 COMPLEX DRAINAGE, WOUND $206.70

1018F 9 ASSESS DYSPNEA NOT PRESENT $0.00
1019F 9 ASSESS DYSPNEA PRESENT $0.00
1020H O INDIVIDUAL DEVELOPMENTAL SERVICES $0.00
1021H O GROUP DEVELOPMENTAL SERVICES $0.00
1022F 9 PNEUMO IMM STATUS ASSESS $0.00
1022H O CO-TREAT/SIMULTANEOUS DEVELOPMENTAL $0.00
1023H O DEVELOPMENTAL EVALUATION $0.00
1026F 9 CO-MORBID CONDITION ASSESS $0.00
1030F 9 INFLUENZA IMM STATUS ASSESS $0.00
1034F 9 CURRENT TOBACCO SMOKER $0.00
1035F 9 SMOKELESS TOBACCO USER $0.00
1036F 9 TOBACCO NON-USER $0.00

1038F 9 PERSISTENT ASTHMA $0.00
1039F 9 INTERMITTENT ASTHMA $0.00
1040F 9 SM-IV INFO MDD DOCD $0.00
1050F 9 HISTORY OF MOLE CHANGES $0.00
1055F 9 VISUAL FUNCT STATUS ASSESS $0.00
1060F 9 DOC PERM/CONT/PAROX ATR. FIB $0.00
1061F 9 DOC LACK PERM+CONT+PAROX FIB $0.00
1065F 9 ISCHM STROKE SYMP LT3 HRSB/4 $0.00
1066F 9 ISCHM STROKE SYMP GE3 HRSB/4 $0.00
1070F 9 ALARM SYMP ASSESSED-ABSENT $0.00

1071F 9 ALARM SYMP ASSESSED-1+ PRSNT $0.00
1090F 9 PRES/ABSN URINE INCON ASSESS $0.00
1091F 9 URINE INCON CHARACTERIZED $0.00
11000 3 DEBRIDE INFECTED SKIN $48.26
11001 3 DEBRIDE INFECTED SKIN ADD-ON $20.18
11004 3 DEBRIDE GENITALIA & PERINEUM $533.60
11005 3 DEBRIDE ABDOM WALL $695.64
11006 3 DEBRIDE GENIT/PER/ABDOM WALL $659.25
11008 3 REMOVE MESH FROM ABD WALL $250.97
1100F 9 PTFALLS ASSESS-DOCÏD GE2+/YR $0.00
11010 3 DEBRIDE SKIN, FX $418.79
11011 3 DEBRIDE SKIN/MUSCLE, FX $466.00
11012 3 DEBRIDE SKIN/MUSCLE/BONE, FX $635.98

1101F 9 PT FALLS ASSESS-DOCÏD LE1/YR $0.00
11040 3 DEBRIDE SKIN, PARTIAL $42.23
11041 3 DEBRIDE SKIN, FULL $49.34
11042 3 DEBRIDE SKIN/TISSUE $66.83
11043 3 DEBRIDE TISSUE/MUSCLE $243.48
11044 3 DEBRIDE TISSUE/MUSCLE/BONE $332.79
11050 O PARING OR CURETTEMENT OF BENIGN HYP $0.00
11055 3 TRIM SKIN LESION $43.55
11056 3 TRIM SKIN LESIONS, 2 TO 4 $53.05
11057 3 TRIM SKIN LESIONS, OVER 4 $63.90

11060 O SHAVING OF EPIDERMAL OR SUPERFICIAL $0.00
11061 O SHAVING OF EPIDERMAL OR SUPERFICIAL $0.00
11062 O SHAVING OF EPIDERMAL OR SPUERFICIAL $0.00
11100 3 BIOPSY, SKIN LESION $92.88
11101 3 BIOPSY, SKIN ADD-ON $29.92
1110F 9 PT LFT INPT FAC W/IN 60 DAYS $0.00
1111F 9 DSCHRG MED/CURRENT MED MERGE $0.00
1116F 9 AURIC/PERI PAIN ASSESSED $0.00
1118F 9 GERD SYMPS ASSESSED 12 MONTH $0.00
1119F 9 INIT. EVAL FOR CONDITION $0.00

11200 3 REMOVAL OF SKIN TAGS $72.81
11201 3 REMOVE SKIN TAGS ADD-ON $16.76
1121F 9 SUBS. EVAL FOR CONDITION $0.00
1123F 9 ACP DISCUSS/DSCN MKR DOCÏD $0.00
1124F 9 ACP DISCUSS-NO DSCNMKR DOCÏD $0.00
1125F 9 AMNT PAIN NOTED; PAIN PRSNT $0.00
1126F 9 AMNT PAIN NOTED; NONE PRSNT $0.00
1127F 9 NEW EPISODE FOR CONDITION $0.00
1128F 9 SUBS. EPISODE FOR CONDITION $0.00
11300 3 SHAVE SKIN LESION $60.72

1130F 9 BK PAIN + FXN ASSESSED $0.00
1134F 9 EPSD BK PAIN FOR =< 6 WKS $0.00
1135F 9 EPSD BK PAIN FOR > 6 WKS $0.00
1136F 9 EPSD BK PAIN FOR <= 12 WKS $0.00

1137F 9 EPSD BK PAIN FOR > 12 WKS $0.00
11400 3 EXC TR-EXT B9+MARG 0.5 < CM $103.15
11401 3 EXC TR-EXT B9+MARG 0.6-1 CM $126.55
11406 3 EXC TR-EXT B9+MARG > 4.0 CM $258.85
11420 3 EXC H-F-NK-SP B9+MARG 0.5 < $104.07
11421 3 EXC H-F-NK-SP B9+MARG 0.6-1 $134.80
11422 3 EXC H-F-NK-SP B9+MARG 1.1-2 $150.42

11423 3 EXC H-F-NK-SP B9+MARG 2.1-3 $174.94
11424 3 EXC H-F-NK-SP B9+MARG 3.1-4 $201.50
11426 3 EXC H-F-NK-SP B9+MARG > 4 CM $287.64
11440 3 EXC FACE-MM B9+MARG 0.5 < CM $114.16
11441 3 EXC FACE-MM B9+MARG 0.6-1 CM $144.33
11446 3 EXC FACE-MM B9+MARG > 4 CM $332.73
11450 3 REMOVAL, SWEAT GLAND LESION $308.53

1150F 9 DOC PT RSK DEATH W/IN 1YR $0.00
1151F 9 DOC NO PT RSK DEATH W/IN 1YR $0.00
1152F 9 DOC ADVNCD DIS COMFORT 1ST $0.00
1153F 9 DOC ADVNCD DIS CMFRT NOT 1ST $0.00
1157F 9 ADVNC CARE PLAN IN RCRD $0.00
1158F 9 ADVNC CARE PLAN TLK DOCD $0.00
1159F 9 MED LIST DOCD IN RCRD $0.00
11600 3 EXC TR-EXT MLG+MARG 0.5 < CM $158.31
11601 3 EXC TR-EXT MLG+MARG 0.6-1 CM $195.59

11606 3 EXC TR-EXT MLG+MARG > 4 CM $377.37
1160F 9 RVW MEDS BY RX/DR IN RCRD $0.00
11620 3 EXC H-F-NK-SP MLG+MARG 0.5 < $161.75
11621 3 EXC H-F-NK-SP MLG+MARG 0.6-1 $197.42
11626 3 EXC H-F-NK-SP MLG+MAR > 4 CM $355.26

11640 3 EXC FACE-MM MALIG+MARG 0.5 < $169.22
11641 3 EXC FACE-MM MALIG+MARG 0.6-1 $207.88
11646 3 EXC FACE-MM MLG+MARG > 4 CM $455.02
11700 O DEBRIDEMENT OF NAILS, MANUAL; FIVE $0.00
11701 O DEBRIDEMENT OF NAILS, MANUAL; EACH $0.00
1170F 9 FXNL STATUS ASSESSED $0.00
11710 O DEBRIDEMENT OF NAILS, ELECTRIC GRIN $0.00
11711 O DEBRIDEMENT OF NAILS, ELECTRIC GRIN $0.00
11719 3 TRIM NAIL(S) $19.12
11720 3 DEBRIDE NAIL, 1-5 $27.92

11721 3 DEBRIDE NAIL, 6 OR MORE $39.83
11730 3 REMOVAL OF NAIL PLATE $88.14
11731 O REMOVAL OF SECOND NAIL PLATE $0.00
11732 3 REMOVE NAIL PLATE, ADD-ON $40.91
11740 3 DRAIN BLOOD FROM UNDER NAIL $40.43
11750 3 REMOVAL OF NAIL BED $190.86
11752 3 REMOVE NAIL BED/FINGER TIP $271.38
11755 3 BIOPSY, NAIL UNIT $119.31
11760 3 REPAIR OF NAIL BED $179.77
11762 3 RECONSTRUCTION OF NAIL BED $239.80
11765 3 EXCISION OF NAIL FOLD, TOE $115.28
11770 3 REMOVAL OF PILONIDAL LESION $229.44

1180F 9 THROMBOEMB RISK ASSESSED $0.00
11900 3 INJECTION INTO SKIN LESIONS $50.49
11901 3 ADDED SKIN LESIONS INJECTION $63.69
11920 3 CORRECT SKIN COLOR DEFECTS $162.74
11950 3 THERAPY FOR CONTOUR DEFECTS $67.69

11960 3 INSERT TISSUE EXPANDER(S) $818.94
11970 3 REPLACE TISSUE EXPANDER $535.99
11971 3 REMOVE TISSUE EXPANDER(S) $406.68
11975 5 INSERT CONTRACEPTIVE CAP $0.00
11976 3 REMOVAL OF CONTRACEPTIVE CAP $134.82
11977 5 REMOVAL/REINSERT CONTRA CAP $0.00
11980 5 IMPLANT HORMONE PELLET(S) $0.00
11981 5 INSERT DRUG IMPLANT DEVICE $0.00
11982 3 REMOVE DRUG IMPLANT DEVICE $142.73
11983 5 REMOVE/INSERT DRUG IMPLANT $0.00
12001 3 REPAIR SUPERFICIAL WOUND(S) $130.50


12020 3 CLOSURE OF SPLIT WOUND $237.58
12021 3 CLOSURE OF SPLIT WOUND $140.25
12031 3 INTMD WND REPAIR S/TR/EXT $210.65
12041 3 INTMD WND REPAIR N-HF/GENIT $220.47
12042 3 INTMD WND REPAIR N-HG/GENIT $257.24

12051 3 INTMD WND REPAIR FACE/MM $237.22
12054 3 INTMD WND REPAIR, FACE/MM $312.35
1220F 9 PT SCREENED FOR DEPRESSION $0.00
13100 3 REPAIR OF WOUND OR LESION $281.11

13102 3 REPAIR WOUND/LESION ADD-ON $95.85

13160 3 LATE CLOSURE OF WOUND $725.82
13300 O REPAIR OF WOUND OR LESION $0.00
14000 3 SKIN TISSUE REARRANGEMENT $547.00

15000 O WOUND PREP, 1ST 100 SQ CM $0.00
15001 O WOUND PREP, ADDL 100 SQ CM $0.00
15002 3 WOUND PREP, TRK/ARM/LEG $296.71
15003 3 WOUND PREP, ADDL 100 CM $64.49
15004 3 WOUND PREP, F/N/HF/G $359.68
15005 3 WND PREP, F/N/HF/G, ADDL CM $107.92
15040 3 HARVEST CULTURED SKIN GRAFT $226.95
15050 3 SKIN PINCH GRAFT $479.14
15100 3 SKIN SPLT GRFT, TRNK/ARM/LEG $767.29
15101 3 SKIN SPLT GRFT T/A/L, ADD-ON $169.63
15110 3 EPIDRM AUTOGRFT TRNK/ARM/LEG $755.14

15111 3 EPIDRM AUTOGRFT T/A/L ADD-ON $109.68
15115 3 EPIDRM A-GRFT FACE/NCK/HF/G $764.23
15116 3 EPIDRM A-GRFT F/N/HF/G ADDL $149.00
15120 3 SKN SPLT A-GRFT FAC/NCK/HF/G $833.15
15121 3 SKN SPLT A-GRFT F/N/HF/G ADD $238.98
15130 3 DERM AUTOGRAFT, TRNK/ARM/LEG $597.11
15131 3 DERM AUTOGRAFT T/A/L ADD-ON $89.32
15135 3 DERM AUTOGRAFT FACE/NCK/HF/G $767.23
15136 3 DERM AUTOGRAFT, F/N/HF/G ADD $82.06
15150 3 CULT EPIDERM GRFT T/ARM/LEG $621.77
15151 3 CULT EPIDERM GRFT T/A/L ADDL $115.52
15152 3 CULT EPIDERM GRAFT T/A/L +% $150.59

15155 3 CULT EPIDERM GRAFT, F/N/HF/G $654.18
15156 3 CULT EPIDRM GRFT F/N/HFG ADD $160.50
15157 3 CULT EPIDERM GRFT F/N/HFG +% $177.18
15170 3 ACELL GRAFT TRUNK/ARMS/LEGS $379.18
15171 3 ACELL GRAFT T/ARM/LEG ADD-ON $84.71
15175 3 ACELLULAR GRAFT, F/N/HF/G $481.52
15176 3 ACELL GRAFT, F/N/HF/G ADD-ON $135.53
15200 3 SKIN FULL GRAFT, TRUNK $712.99
15201 3 SKIN FULL GRAFT TRUNK ADD-ON $132.32
15220 3 SKIN FULL GRAFT SCLP/ARM/LEG $679.85

15221 3 SKIN FULL GRAFT ADD-ON $123.25
15240 3 SKIN FULL GRFT FACE/GENIT/HF $815.10
15260 3 SKIN FULL GRAFT EEN & LIPS $883.47
15300 3 APPLY SKINALLOGRFT, T/ARM/LG $304.72
15301 3 APPLY SKNALLOGRFT T/A/L ADDL $57.20
15320 3 APPLY SKIN ALLOGRFT F/N/HF/G $343.33
15321 3 APLY SKNALLOGRFT F/N/HFG ADD $85.25
15330 3 APLY ACELL ALOGRFT T/ARM/LEG $282.24
15331 3 APLY ACELL GRFT T/A/L ADD-ON $57.20
15335 3 APPLY ACELL GRAFT, F/N/HF/G $296.72
15336 3 APLY ACELL GRFT F/N/HF/G ADD $79.56

15340 3 APPLY CULT SKIN SUBSTITUTE $282.83
15341 3 APPLY CULT SKIN SUB ADD-ON $42.23
15342 O CULTURED SKIN GRAFT, 25 CM $0.00
15343 O CULTURE SKN GRAFT ADDL 25 CM $0.00
15350 O SKIN HOMOGRAFT $0.00
15351 O SKIN HOMOGRAFT ADD-ON $0.00
15360 3 APPLY CULT DERM SUB, T/A/L $321.18
15361 3 APLY CULT DERM SUB T/A/L ADD $64.04
15365 3 APPLY CULT DERM SUB F/N/HF/G $315.27
15366 3 APPLY CULT DERM F/HF/G ADD $78.81
15400 3 APPLY SKIN XENOGRAFT, T/A/L $351.15
15401 3 APPLY SKN XENOGRFT T/A/L ADD $84.19

15410 O FREE TRANSPLANTATION OF SKIN FLAP B $0.00
15420 3 APPLY SKIN XGRAFT, F/N/HF/G $396.09
15421 3 APPLY SKN XGRFT F/N/HF/G ADD $103.00
15430 3 APPLY ACELLULAR XENOGRAFT $466.19
15431 6 APPLY ACELLULAR XGRAFT ADD $0.00
15500 O FORMATION OF TUBE PEDICLE WITHOUT T $0.00

15540 O PRIMARY ATTACHMENT OF OPEN OR TUBED $0.00
15570 3 FORM SKIN PEDICLE FLAP $783.20
15580 O ATTACH SKIN PEDICLE GRAFT $0.00
15600 3 SKIN GRAFT $291.70
15610 3 SKIN GRAFT $292.24

15620 3 SKIN GRAFT $387.30
15625 O SKIN GRAFT $0.00
15630 3 SKIN GRAFT $409.21
15650 3 TRANSFER SKIN PEDICLE FLAP $456.11
15700 O EXCISION OF LESION AND/OR EXCISIONA $0.00
15731 3 FOREHEAD FLAP W/VASC PEDICLE $1,008.10
15732 3 MUSCLE-SKIN GRAFT, HEAD/NECK $1,332.34
15734 3 MUSCLE-SKIN GRAFT, TRUNK $1,213.83
15736 3 MUSCLE-SKIN GRAFT, ARM $1,214.45

15738 3 MUSCLE-SKIN GRAFT, LEG $1,294.40
15740 3 ISLAND PEDICLE FLAP GRAFT $903.99
15750 3 NEUROVASCULAR PEDICLE GRAFT $819.07
15755 O FREE FLAP (MICROVASCULAR TRANSFER) $0.00
15756 3 FREE MYO/SKIN FLAP MICROVASC $2,150.81
15757 3 FREE SKIN FLAP, MICROVASC $2,128.85
15758 3 FREE FASCIAL FLAP, MICROVASC $2,130.66
15760 3 COMPOSITE SKIN GRAFT $750.03
15770 3 DERMA-FAT-FASCIA GRAFT $587.41
15775 3 HAIR TRANSPLANT PUNCH GRAFTS $289.67

15776 3 HAIR TRANSPLANT PUNCH GRAFTS $401.20
15780 3 ABRASION TREATMENT OF SKIN $740.53
15786 3 ABRASION, LESION, SINGLE $212.68
15787 3 ABRASION, LESIONS, ADD-ON $43.81
15788 9 CHEMICAL PEEL, FACE, EPIDERM $0.00
15789 9 CHEMICAL PEEL, FACE, DERMAL $0.00
15790 O CHEMICAL PEEL (CHEMEXFOLIATION) TOT $0.00
15791 O CHEMICAL PEEL (CHEMEXFOLIATION) REG $0.00
15792 9 CHEMICAL PEEL, NONFACIAL $0.00
15793 9 CHEMICAL PEEL, NONFACIAL $0.00

15810 O SALABRASION $0.00
15811 O SALABRASION $0.00
15819 3 PLASTIC SURGERY, NECK $659.53
15820 3 REVISION OF LOWER EYELID $473.80
15821 3 REVISION OF LOWER EYELID $503.50
15822 3 REVISION OF UPPER EYELID $371.52
15823 3 REVISION OF UPPER EYELID $585.34
15824 9 REMOVAL OF FOREHEAD WRINKLES $0.00
15825 5 REMOVAL OF NECK WRINKLES $0.00
15826 5 REMOVAL OF BROW WRINKLES $0.00
15828 5 REMOVAL OF FACE WRINKLES $0.00
15829 5 REMOVAL OF SKIN WRINKLES $0.00

15830 3 EXC SKIN ABD $1,048.64
15831 O EXCISE EXCESSIVE SKIN TISSUE $0.00
15832 3 EXCISE EXCESSIVE SKIN TISSUE $797.56

15840 3 GRAFT FOR FACE NERVE PALSY $907.71
15841 3 GRAFT FOR FACE NERVE PALSY $1,516.31
15842 3 FLAP FOR FACE NERVE PALSY $2,393.91
15845 3 SKIN AND MUSCLE REPAIR, FACE $851.27
15847 6 EXC SKIN ABD ADD-ON $0.00
15850 9 REMOVAL OF SUTURES $0.00
15851 3 REMOVAL OF SUTURES $83.55
15852 3 DRESSING CHANGE NOT FOR BURN $43.61
15860 3 TEST FOR BLOOD FLOW IN GRAFT $102.77
15876 5 SUCTION ASSISTED LIPECTOMY $0.00

15920 3 REMOVAL OF TAIL BONE ULCER $523.57
15922 3 REMOVAL OF TAIL BONE ULCER $665.41
15931 3 REMOVE SACRUM PRESSURE SORE $594.75
15940 3 REMOVE HIP PRESSURE SORE $611.90

15946 3 REMOVE HIP PRESSURE SORE $1,455.12
15950 3 REMOVE THIGH PRESSURE SORE $507.96
15954 O EXCISION, TROCHANTERIC PRESSURE ULC $0.00
15955 O EXCISION, TROCHANTERIC PRESSURE ULC $0.00
15956 3 REMOVE THIGH PRESSURE SORE $1,019.44
15958 3 REMOVE THIGH PRESSURE SORE $1,041.15
15960 O EXCISION, HEEL PRESSURE ULCER, WITH $0.00

15970 O EXCISION, LEG PRESSURE ULCER, WITH $0.00
15980 O EXCISION, KNEE PRESSURE ULCER, WITH $0.00

15999 5 REMOVAL OF PRESSURE SORE $0.00
16000 3 INITIAL TREATMENT OF BURN(S) $61.45
16010 O TREATMENT OF BURN(S) $0.00
16015 O TREATMENT OF BURN(S) $0.00
16020 3 DRESS/DEBRID P-THICK BURN, S $72.65
16025 3 DRESS/DEBRID P-THICK BURN, M $130.93
16030 3 DRESS/DEBRID P-THICK BURN, L $156.98
16035 3 INCISION OF BURN SCAB, INITI $194.95
16036 3 ESCHAROTOMY; ADDÏL INCISION $77.62
16040 O BURN WOUND EXCISION $0.00

17000 3 DESTRUCT PREMALG LESION $70.57
17001 O DESTRUCTION BY ANY METHOD, INCLUDIN $0.00
17003 3 DESTRUCT PREMALG LES, 2-14 $6.81
17004 3 DESTROY PREMLG LESIONS 15+ $157.14

17106 3 DESTRUCTION OF SKIN LESIONS $308.56
17110 3 DESTRUCT B9 LESION, 1-14 $98.34
17111 3 DESTRUCT LESION, 15 OR MORE $116.49
17200 O ELECTROSURGICAL DESTRUCTION OF MULT $0.00
17201 O ELECTROSURGICAL DESTRUCTION OF MULT $0.00
17250 3 CHEMICAL CAUTERY, TISSUE $66.63


17303 O CHEMOSURGERY (MOHS' TECHNIQUE), FIR $0.00
17304 O 1 STAGE MOHS, UP TO 5 SPEC $0.00
17307 O MOHS ADDL STAGE UP TO 5 SPEC $0.00
17310 O MOHS ANY STAGE > 5 SPEC EACH $0.00

17311 3 MOHS, 1 STAGE, H/N/HF/G $621.05
17312 3 MOHS ADDL STAGE $372.81
17313 3 MOHS, 1 STAGE, T/A/L $567.01
17314 3 MOHS, ADDL STAGE, T/A/L $345.51
17315 3 MOHS SURG, ADDL BLOCK $73.95
17340 3 CRYOTHERAPY OF SKIN $43.51
17360 3 SKIN PEEL THERAPY $117.96
17380 9 HAIR REMOVAL BY ELECTROLYSIS $0.00
17999 5 SKIN TISSUE PROCEDURE $0.00
19000 3 DRAINAGE OF BREAST LESION $103.29
19001 3 DRAIN BREAST LESION ADD-ON $25.58
19020 3 INCISION OF BREAST LESION $385.11
19030 3 INJECTION FOR BREAST X-RAY $158.13

19100 3 BX BREAST PERCUT W/O IMAGE $125.74
19101 3 BIOPSY OF BREAST, OPEN $286.00
19102 3 BX BREAST PERCUT W/IMAGE $207.18
19103 3 BX BREAST PERCUT W/DEVICE $186.74
19105 3 CRYOSURG ABLATE FA, EACH $2,032.71
19110 3 NIPPLE EXPLORATION $398.32
19112 3 EXCISE BREAST DUCT FISTULA $373.28
19120 3 REMOVAL OF BREAST LESION $409.92
19125 3 EXCISION, BREAST LESION $388.13
19126 3 EXCISION, ADDL BREAST LESION $145.24
19140 O REMOVAL OF BREAST TISSUE $0.00
19160 O PARTIAL MASTECTOMY $0.00

19162 O P-MASTECTOMY W/LN REMOVAL $0.00
19180 O REMOVAL OF BREAST $0.00
19260 3 REMOVAL OF CHEST WALL LESION $1,071.36
19271 3 REVISION OF CHEST WALL $1,459.38
19272 3 EXTENSIVE CHEST WALL SURGERY $1,615.78
19290 3 PLACE NEEDLE WIRE, BREAST $64.44

19291 3 PLACE NEEDLE WIRE, BREAST $66.36
19295 3 PLACE BREAST CLIP, PERCUT $87.12
19296 3 PLACE PO BREAST CATH FOR RAD $3,631.74
19297 3 PLACE BREAST CATH FOR RAD $84.39
19298 3 PLACE BREAST RAD TUBE/CATHS $1,226.63
19300 9 REMOVAL OF BREAST TISSUE $0.00
19301 3 PARTICAL MASTECTOMY $540.06
19302 3 P-MASTECTOMY W/LN REMOVAL $773.89
19303 3 MAST, SIMPLE, COMPLETE $834.83
19304 3 MAST, SUBQ $486.28
19305 3 MAST, RADICAL $965.49
19306 3 MAST, RAD, URBAN TYPE $1,012.30
19307 3 MAST, MOD RAD $1,018.19

19316 3 SUSPENSION OF BREAST $695.26
19318 3 REDUCTION OF LARGE BREAST $1,023.98
19324 9 ENLARGE BREAST $0.00
19325 9 ENLARGE BREAST WITH IMPLANT $0.00
19328 3 REMOVAL OF BREAST IMPLANT $435.80
19330 3 REMOVAL OF IMPLANT MATERIAL $559.96
19340 3 IMMEDIATE BREAST PROSTHESIS $361.79
19342 3 DELAYED BREAST PROSTHESIS $823.27
19350 3 BREAST RECONSTRUCTION $756.55
19355 9 CORRECT INVERTED NIPPLE(S) $0.00
19357 3 BREAST RECONSTRUCTION $1,383.73
19360 O BREAST RECONSTRUCTION WITH MUSCLE O $0.00

19361 3 BREAST RECONSTR W/LAT FLAP $1,484.53
19362 O BREAST RECONSTRUCTION WITH TRANSVER $0.00
19370 3 SURGERY OF BREAST CAPSULE $607.27
19371 3 REMOVAL OF BREAST CAPSULE $700.29
19380 3 REVISE BREAST RECONSTRUCTION $685.14

19396 3 DESIGN CUSTOM BREAST IMPLANT $196.38
19499 5 BREAST SURGERY PROCEDURE $0.00
20000 3 INCISION OF ABSCESS $183.40
20005 3 INCISION OF DEEP ABSCESS $271.71
2000F 9 BLOOD PRESSURE MEASURE $0.00
2001F 9 WEIGHT RECORD $0.00
2002F 9 CLIN SIGN VOL OVRLD ASSESS $0.00
2003F O AUSCULTATION HEART PERFORM $0.00
2004F 9 INITIAL EXAM INVOLVED JOINTS $0.00
20100 3 EXPLORE WOUND, NECK $534.18
20101 3 EXPLORE WOUND, CHEST $352.98
20102 3 EXPLORE WOUND, ABDOMEN $412.80
20103 3 EXPLORE WOUND, EXTREMITY $502.01

2010F 9 VITAL SIGNS RECORDED $0.00
2014F 9 MENTAL STATUS ASSESS $0.00
20150 3 EXCISE EPIPHYSEAL BAR $870.81
2018F 9 HYDRATION STATUS ASSESS $0.00
2019F 9 DILATED MACUL EXAM DONE $0.00
20200 3 MUSCLE BIOPSY $171.56
20205 3 DEEP MUSCLE BIOPSY $233.49
20206 3 NEEDLE BIOPSY, MUSCLE $241.14
2020F 9 DILATED FUNDUS EVAL DONE $0.00
2021F 9 DILAT MACUL+ EXAM DONE $0.00
20220 3 BONE BIOPSY, TROCAR/NEEDLE $164.87
20225 3 BONE BIOPSY, TROCAR/NEEDLE $112.76

2022F 9 DIL RETINA EXAM INTERP REV $0.00
20240 3 BONE BIOPSY, EXCISIONAL $207.64
20245 3 BONE BIOPSY, EXCISIONAL $566.98
2024F 9 7 FIELD PHOTO INTERP DOC REV $0.00
20250 3 OPEN BONE BIOPSY $341.19
20251 3 OPEN BONE BIOPSY $378.40
2026F 9 EYE IMAGE VALID TO DX REV $0.00
2027F 9 OPTIC NERVE HEAD EVAL DONE $0.00
2028F 9 FOOT EXAM PERFORMED $0.00
2029F 9 COMPLETE PHYS SKIN EXAM DONE $0.00

2030F 9 H2O STAT DOCÏD, NORMAL $0.00
2031F 9 H2O STAT DOCÏD, DEHYDRATED $0.00
2035F 9 TYMP MEMB MOTION EXAMÏD $0.00
2040F 9 BK PN XM ON INIT VISIT DATE $0.00
2044F 9 DOC MNTL TST B/4 BK TRXMNT $0.00
20500 3 INJECTION OF SINUS TRACT $105.96
20501 3 INJECT SINUS TRACT FOR X-RAY $38.84
2050F 9 WOUND CHAR SIZE ETC DOCD $0.00
20520 3 REMOVAL OF FOREIGN BODY $170.20
20526 3 THER INJECTION, CARP TUNNEL $68.50
20550 3 INJ TENDON SHEATH/LIGAMENT $52.99
20551 3 INJ TENDON ORIGIN/INSERTION $52.38

20552 3 INJ TRIGGER POINT, 1/2 MUSCL $47.71
20553 3 INJECT TRIGGER POINTS, =/> 3 $53.27
20555 3 PLACE NDL MUSC/TIS FOR RT $310.86
20600 3 DRAIN/INJECT, JOINT/BURSA $49.90
20612 3 ASPIRATE/INJ GANGLION CYST $53.29
20615 3 TREATMENT OF BONE CYST $195.30
20650 3 INSERT AND REMOVE BONE PIN $177.30
20660 3 APPLY, REM FIXATION DEVICE $229.54
20661 3 APPLICATION OF HEAD BRACE $419.88
20662 3 APPLICATION OF PELVIS BRACE $433.43

20663 3 APPLICATION OF THIGH BRACE $401.18
20664 3 HALO BRACE APPLICATION $685.24
20665 3 REMOVAL OF FIXATION DEVICE $110.12
20670 3 REMOVAL OF SUPPORT IMPLANT $135.41
20680 3 REMOVAL OF SUPPORT IMPLANT $373.62
20690 3 APPLY BONE FIXATION DEVICE $489.61
20692 3 APPLY BONE FIXATION DEVICE $916.34
20693 3 ADJUST BONE FIXATION DEVICE $415.39
20694 3 REMOVE BONE FIXATION DEVICE $380.79
20696 3 COMP MULTIPLANE EXT FIXATION $981.74

20697 3 COMP EXT FIXATE STRUT CHANGE $1,223.25
20802 3 REPLANTATION, ARM, COMPLETE $2,238.62
20804 O REPLANTATION, ARM (INCLUDES SURGICA $0.00
20805 3 REPLANT FOREARM, COMPLETE $2,744.46
20806 O REPLANTATION, FOREARM (INCLUDES RAD $0.00
20808 3 REPLANTATION HAND, COMPLETE $3,732.20
20812 O REPLANTATION, HAND (INCLUDES HAND T $0.00
20816 3 REPLANTATION DIGIT, COMPLETE $2,070.54
20820 O REPLANTATION, DIGIT, EXCLUDING THUM $0.00
20822 3 REPLANTATION DIGIT, COMPLETE $1,756.93
20823 O REPLANTATION, DIGIT, EXCLUDING THUM $0.00
20824 3 REPLANTATION THUMB, COMPLETE $2,061.98
20826 O REPLANTATION, THUMB (INCLUDES CARPO $0.00

20827 3 REPLANTATION THUMB, COMPLETE $1,827.39
20828 O REPLANTATION, THUMB (INCLUDES DISTA $0.00
20832 O REPLANTATION, LEG; COMPLETE AMPUTAT $0.00
20834 O REPLANTATION, LEG; INCOMPLETE AMPUT $0.00
20838 3 REPLANTATION FOOT, COMPLETE $2,264.18
20840 O REPLANTATION, FOOT; INCOMPLETE AMPU $0.00
20900 3 REMOVAL OF BONE FOR GRAFT $381.50
20902 3 REMOVAL OF BONE FOR GRAFT $333.45
20910 3 REMOVE CARTILAGE FOR GRAFT $391.13
20912 3 REMOVE CARTILAGE FOR GRAFT $438.20
20920 3 REMOVAL OF FASCIA FOR GRAFT $369.22
20922 3 REMOVAL OF FASCIA FOR GRAFT $548.83

20924 3 REMOVAL OF TENDON FOR GRAFT $457.10
20926 3 REMOVAL OF TISSUE FOR GRAFT $394.60
20930 9 SP BONE ALGRFT MORSEL ADD-ON $0.00
20931 3 SP BONE ALGRFT STRUCT ADD-ON $103.82
20936 9 SP BONE AGRFT LOCAL ADD-ON $0.00
20937 3 SP BONE AGRFT MORSEL ADD-ON $158.11
20938 3 SP BONE AGRFT STRUCT ADD-ON $171.69
20950 3 FLUID PRESSURE, MUSCLE $222.84
20955 3 FIBULA BONE GRAFT, MICROVASC $2,333.14
20956 3 ILIAC BONE GRAFT, MICROVASC $2,435.55

20957 3 MT BONE GRAFT, MICROVASC $2,316.85
20960 O BONE GRAFT WITH MICROVASCULAR ANAST $0.00
20962 3 OTHER BONE GRAFT, MICROVASC $2,388.58
20969 3 BONE/SKIN GRAFT, MICROVASC $2,582.88
20970 3 BONE/SKIN GRAFT, ILIAC CREST $2,596.85
20971 O FREE OSTEOCUTANEOUS FLAP WITH MICRO $0.00
20972 3 BONE/SKIN GRAFT, METATARSAL $2,362.07
20973 3 BONE/SKIN GRAFT, GREAT TOE $2,477.55
20974 3 ELECTRICAL BONE STIMULATION $59.17
20975 3 ELECTRICAL BONE STIMULATION $163.18
20976 O ELECTRICAL STIMULATION TO AID BONE $0.00
20979 3 US BONE STIMULATION $48.34
20982 3 ABLATE, BONE TUMOR(S) PERQ $3,475.81

20985 3 CPTR-ASST DIR MS PX $140.03
20986 O CPTR-ASST DIR MS PX IO IMG $0.00
20987 O CPTR-ASST DIR MS PX PRE IMG $0.00
20999 5 MUSCULOSKELETAL SURGERY $0.00
21010 3 INCISION OF JAW JOINT $657.52
21015 3 RESECTION OF FACIAL TUMOR $385.12
21025 3 EXCISION OF BONE, LOWER JAW $795.07
21026 3 EXCISION OF FACIAL BONE(S) $528.08
21029 3 CONTOUR OF FACE BONE LESION $670.40
21030 3 EXCISE MAX/ZYGOMA B9 TUMOR $441.41
21031 3 REMOVE EXOSTOSIS, MANDIBLE $340.58
21032 3 REMOVE EXOSTOSIS, MAXILLA $345.13

21034 3 EXCISE MAX/ZYGOMA MLG TUMOR $1,194.92
21040 3 EXCISE MANDIBLE LESION $445.11
21041 O REMOVAL OF JAW BONE LESION $0.00
21044 3 REMOVAL OF JAW BONE LESION $794.66
21045 3 EXTENSIVE JAW SURGERY $1,106.86
21046 3 REMOVE MANDIBLE CYST COMPLEX $983.00
21047 3 EXCISE LWR JAW CYST W/REPAIR $1,181.86
21048 3 REMOVE MAXILLA CYST COMPLEX $995.38
21049 3 EXCIS UPPR JAW CYST W/REPAIR $1,143.60
21050 3 REMOVAL OF JAW JOINT $781.81

21060 3 REMOVE JAW JOINT CARTILAGE $713.16
21070 3 REMOVE CORONOID PROCESS $580.41
21073 3 MNPJ OF TMJ W/ANESTH $328.95
21076 3 PREPARE FACE/ORAL PROSTHESIS $873.18
21077 3 PREPARE FACE/ORAL PROSTHESIS $2,150.91

21100 3 MAXILLOFACIAL FIXATION $639.52
21110 3 INTERDENTAL FIXATION $670.75
21116 3 INJECTION, JAW JOINT X-RAY $136.12
21120 3 RECONSTRUCTION OF CHIN $556.86
21125 3 AUGMENTATION, LOWER JAW BONE $2,753.42
21127 3 AUGMENTATION, LOWER JAW BONE $3,278.07

21137 3 REDUCTION OF FOREHEAD $650.58
21141 3 RECONSTRUCT MIDFACE, LEFORT $1,222.45
21144 O RECONSTRUCTION MIDFACE, LEFORT I; I $0.00

21172 3 RECONSTRUCT ORBIT/FOREHEAD $1,617.79
21175 3 RECONSTRUCT ORBIT/FOREHEAD $1,954.61
21179 3 RECONSTRUCT ENTIRE FOREHEAD $1,340.86
21180 3 RECONSTRUCT ENTIRE FOREHEAD $1,529.13
21181 3 CONTOUR CRANIAL BONE LESION $640.53
21182 3 RECONSTRUCT CRANIAL BONE $1,856.89

21188 3 RECONSTRUCTION OF MIDFACE $1,480.45
21193 3 RECONST LWR JAW W/O GRAFT $1,126.43
21194 3 RECONST LWR JAW W/GRAFT $1,286.04
21195 3 RECONST LWR JAW W/O FIXATION $1,212.70
21196 3 RECONST LWR JAW W/FIXATION $1,321.37
21198 3 RECONSTR LWR JAW SEGMENT $1,041.31
21199 3 RECONSTR LWR JAW W/ADVANCE $935.18
21200 O OSTEOTOMY (EG, FOR PROGNATHISM, MIC $0.00

21206 3 RECONSTRUCT UPPER JAW BONE $1,025.51
21208 3 AUGMENTATION OF FACIAL BONES $1,553.28
21209 3 REDUCTION OF FACIAL BONES $731.65
21210 3 FACE BONE GRAFT $1,863.02
21215 3 LOWER JAW BONE GRAFT $776.10
21230 3 RIB CARTILAGE GRAFT $693.44
21235 3 EAR CARTILAGE GRAFT $648.51
21240 3 RECONSTRUCTION OF JAW JOINT $1,003.06
21242 3 RECONSTRUCTION OF JAW JOINT $919.51
21243 3 RECONSTRUCTION OF JAW JOINT $1,508.01

21244 3 RECONSTRUCTION OF LOWER JAW $944.00
21245 3 RECONSTRUCTION OF JAW $1,021.52
21246 3 RECONSTRUCTION OF JAW $771.86
21247 3 RECONSTRUCT LOWER JAW BONE $1,465.39
21248 3 RECONSTRUCTION OF JAW $959.96
21249 3 RECONSTRUCTION OF JAW $1,328.84
21250 O OSTEOPLASTY OF MAXILLA AND/OR OTHER $0.00
21254 O OSTEOPLASTY OF MAXILLA AND/OR OTHER $0.00
21255 3 RECONSTRUCT LOWER JAW BONE $1,305.54
21256 3 RECONSTRUCTION OF ORBIT $1,058.83
21260 3 REVISE EYE SOCKETS $1,199.53

21270 3 AUGMENTATION, CHEEK BONE $815.75
21275 3 REVISION, ORBITOFACIAL BONES $728.93
21280 3 REVISION OF EYELID $472.14
21295 3 REVISION OF JAW MUSCLE/BONE $157.23
21296 3 REVISION OF JAW MUSCLE/BONE $381.69
21299 5 CRANIO/MAXILLOFACIAL SURGERY $0.00
21300 O TREATMENT OF SKULL FRACTURE $0.00
21310 3 TREATMENT OF NOSE FRACTURE $95.86

21336 3 TREAT NASAL SEPTAL FRACTURE $576.27
21337 3 TREAT NASAL SEPTAL FRACTURE $348.72
21338 3 TREAT NASOETHMOID FRACTURE $661.61
21339 3 TREAT NASOETHMOID FRACTURE $735.41
21343 3 TREATMENT OF SINUS FRACTURE $1,037.07

21344 3 TREATMENT OF SINUS FRACTURE $1,355.99
21345 3 TREAT NOSE/JAW FRACTURE $718.70
21348 3 TREAT NOSE/JAW FRACTURE $1,048.98
21355 3 TREAT CHEEK BONE FRACTURE $390.63
21366 3 TREAT CHEEK BONE FRACTURE $1,104.46
21385 3 TREAT EYE SOCKET FRACTURE $643.01

21421 3 TREAT MOUTH ROOF FRACTURE $650.29
21431 3 TREAT CRANIOFACIAL FRACTURE $662.70
21432 3 TREAT CRANIOFACIAL FRACTURE $601.22

21433 3 TREAT CRANIOFACIAL FRACTURE $1,536.31
21440 3 TREAT DENTAL RIDGE FRACTURE $474.58
21445 3 TREAT DENTAL RIDGE FRACTURE $671.15
21450 3 TREAT LOWER JAW FRACTURE $494.13

21455 O CLOSED MANIPULATIVE TREATMENT BY IN $0.00
21462 3 TREAT LOWER JAW FRACTURE $1,853.84
21470 3 TREAT LOWER JAW FRACTURE $1,070.69
21480 3 RESET DISLOCATED JAW $81.28
21485 3 RESET DISLOCATED JAW $582.57
21490 3 REPAIR DISLOCATED JAW $832.65
21493 O TREAT HYOID BONE FRACTURE $0.00
21494 O TREAT HYOID BONE FRACTURE $0.00
21495 3 TREAT HYOID BONE FRACTURE $612.21
21497 3 INTERDENTAL WIRING $588.77
21499 5 HEAD SURGERY PROCEDURE $0.00

21501 3 DRAIN NECK/CHEST LESION $388.90
21502 3 DRAIN CHEST LESION $469.91
21510 3 DRAINAGE OF BONE LESION $416.51
21550 3 BIOPSY OF NECK/CHEST $229.01
21555 3 REMOVE LESION, NECK/CHEST $382.49
21556 3 REMOVE LESION, NECK/CHEST $371.30
21557 3 REMOVE TUMOR, NECK/CHEST $523.58
21600 3 PARTIAL REMOVAL OF RIB $497.73
21610 3 PARTIAL REMOVAL OF RIB $963.44
21615 3 REMOVAL OF RIB $608.35
21616 3 REMOVAL OF RIB AND NERVES $777.96
21620 3 PARTIAL REMOVAL OF STERNUM $472.33

21627 3 STERNAL DEBRIDEMENT $496.93
21630 3 EXTENSIVE STERNUM SURGERY $1,152.12
21632 3 EXTENSIVE STERNUM SURGERY $1,138.03
21633 O RADICAL RESECTION OF STERNUM; FOR O $0.00
21685 3 HYOID MYOTOMY & SUSPENSION $899.84
21700 3 REVISION OF NECK MUSCLE $382.61
21705 3 REVISION OF NECK MUSCLE/RIB $586.66
21740 3 RECONSTRUCTION OF STERNUM $989.78

21742 5 REPAIR STERN/NUSS W/O SCOPE $0.00
21743 5 REPAIR STERNUM/NUSS W/SCOPE $0.00
21750 3 REPAIR OF STERNUM SEPARATION $656.85
21800 3 TREATMENT OF RIB FRACTURE $86.72
21805 3 TREATMENT OF RIB FRACTURE $231.91
21810 3 TREATMENT OF RIB FRACTURE(S) $450.97
21820 3 TREAT STERNUM FRACTURE $115.72
21825 3 TREAT STERNUM FRACTURE $512.55
21899 5 NECK/CHEST SURGERY PROCEDURE $0.00
21920 3 BIOPSY SOFT TISSUE OF BACK $228.53
21925 3 BIOPSY SOFT TISSUE OF BACK $373.66
21930 3 REMOVE LESION, BACK OR FLANK $416.98
21935 3 REMOVE TUMOR, BACK $1,049.71

22010 3 I&D, P-SPINE, C/T/CERV-THOR $812.16
22015 3 I&D, P-SPINE, L/S/LS $807.75
22100 3 REMOVE PART OF NECK VERTEBRA $734.09
22101 3 REMOVE PART, THORAX VERTEBRA $732.18
22102 3 REMOVE PART, LUMBAR VERTEBRA $729.24
22103 3 REMOVE EXTRA SPINE SEGMENT $132.24
22105 O PARTIAL RESECTION OF VERTEBRAL COMP $0.00
22110 3 REMOVE PART OF NECK VERTEBRA $911.11
22112 3 REMOVE PART, THORAX VERTEBRA $881.24
22114 3 REMOVE PART, LUMBAR VERTEBRA $904.94

22116 3 REMOVE EXTRA SPINE SEGMENT $131.49
22140 O RECONSTRUCTION OF SPINE WITH BONE G $0.00
22145 O RECONSTRUCTION OF SPINE FOLLOWING V $0.00
22148 O HARVESTING OF BONE AUTOGRAFT FOR VE $0.00
22150 O RECONSTRUCTION OF SPINE WITH PREFAB $0.00
22206 3 CUT SPINE 3 COL, THOR $2,160.60

22207 3 CUT SPINE 3 COL, LUMB $2,132.62
22208 3 CUT SPINE 3 COL, ADDL SEG $542.31
22210 3 REVISION OF NECK SPINE $1,590.80
22212 3 REVISION OF THORAX SPINE $1,316.56
22214 3 REVISION OF LUMBAR SPINE $1,324.89
22216 3 REVISE, EXTRA SPINE SEGMENT $344.73
22220 3 REVISION OF NECK SPINE $1,432.03
22222 3 REVISION OF THORAX SPINE $1,302.22
22224 3 REVISION OF LUMBAR SPINE $1,417.53
22226 3 REVISE, EXTRA SPINE SEGMENT $343.25
22230 O OSTEOTOMY OF SPINE, ANY APPROACH, E $0.00
22305 3 TREAT SPINE PROCESS FRACTURE $165.01
22310 3 TREAT SPINE FRACTURE $254.39

22315 3 TREAT SPINE FRACTURE $760.65
22318 3 TREAT ODONTOID FX W/O GRAFT $1,430.46
22319 3 TREAT ODONTOID FX W/GRAFT $1,570.90
22325 3 TREAT SPINE FRACTURE $1,254.01
22326 3 TREAT NECK SPINE FRACTURE $1,306.22
22327 3 TREAT THORAX SPINE FRACTURE $1,296.57
22328 3 TREAT EACH ADD SPINE FX $259.74
22505 3 MANIPULATION OF SPINE $110.95
22520 3 PERCUT VERTEBROPLASTY THOR $2,110.61
22521 3 PERCUT VERTEBROPLASTY LUMB $2,056.31
22522 3 PERCUT VERTEBROPLASTY ADDÏL $235.05
22523 3 PERCUT KYPHOPLASTY, THOR $560.36

22524 3 PERCUT KYPHOPLASTY, LUMBAR $536.90
22525 3 PERCUT KYPHOPLASTY, ADD-ON $250.37
22526 9 IDET, SINGLE LEVEL $0.00
22527 9 IDET, 1 OR MORE LEVELS $0.00
22532 3 LAT THORAX SPINE FUSION $1,559.30
22533 3 LAT LUMBAR SPINE FUSION $1,469.78
22534 3 LAT THOR/LUMB, ADDÏL SEG $340.13
22548 3 NECK SPINE FUSION $1,660.29
22556 3 THORAX SPINE FUSION $1,487.35

22558 3 LUMBAR SPINE FUSION $1,366.37
22585 3 ADDITIONAL SPINAL FUSION $314.09
22590 3 SPINE & SKULL SPINAL FUSION $1,380.62
22595 3 NECK SPINAL FUSION $1,311.16
22610 3 THORAX SPINE FUSION $1,110.11
22614 3 SPINE FUSION, EXTRA SEGMENT $366.73
22625 O ARTHRODESIS, LATERAL TRANSVERSE PRO $0.00
22632 3 SPINE FUSION, EXTRA SEGMENT $297.88
22650 O ARTHRODESIS, POSTERIOR, POSTEROLATE $0.00
22800 3 FUSION OF SPINE $1,220.47

22802 3 FUSION OF SPINE $1,938.09
22804 3 FUSION OF SPINE $2,238.20
22808 3 FUSION OF SPINE $1,648.98
22810 3 FUSION OF SPINE $1,837.86
22812 3 FUSION OF SPINE $2,012.25
22818 3 KYPHECTOMY, 1-2 SEGMENTS $2,027.13
22819 3 KYPHECTOMY, 3 OR MORE $2,335.49
22820 O HARVESTING OF BONE AUTOGRAFT THROUG $0.00
22830 3 EXPLORATION OF SPINAL FUSION $728.28
22840 3 INSERT SPINE FIXATION DEVICE $715.74

22848 3 INSERT PELV FIXATION DEVICE $341.06
22849 3 REINSERT SPINAL FIXATION $1,178.99
22850 3 REMOVE SPINE FIXATION DEVICE $644.52
22851 3 APPLY SPINE PROSTH DEVICE $381.60

22856 3 CERV ARTIFIC DISKECTOMY $1,492.64
22857 3 LUMBAR ARTIF DISKECTOMY $1,556.36
22861 3 REVISE CERV ARTIFIC DISC $1,818.88
22862 3 REVISE LUMBAR ARTIF DISC $1,794.55
22864 3 REMOVE CERV ARTIF DISC $1,665.72
22865 3 REMOVE LUMB ARTIF DISC $1,925.16
22899 5 SPINE SURGERY PROCEDURE $0.00
22900 3 REMOVE ABDOMINAL WALL LESION $367.75
22999 5 ABDOMEN SURGERY PROCEDURE $0.00
23000 3 REMOVAL OF CALCIUM DEPOSITS $472.62
23020 3 RELEASE SHOULDER JOINT $622.19
23030 3 DRAIN SHOULDER LESION $377.27

23031 3 DRAIN SHOULDER BURSA $345.16
23035 3 DRAIN SHOULDER BONE LESION $617.43
23040 3 EXPLORATORY SHOULDER SURGERY $647.92
23044 3 EXPLORATORY SHOULDER SURGERY $514.03
23065 3 BIOPSY SHOULDER TISSUES $190.52
23066 3 BIOPSY SHOULDER TISSUES $449.48
23075 3 REMOVAL OF SHOULDER LESION $229.95
23076 3 REMOVAL OF SHOULDER LESION $505.48
23077 3 REMOVE TUMOR OF SHOULDER $1,070.75
23100 3 BIOPSY OF SHOULDER JOINT $437.75
23101 3 SHOULDER JOINT SURGERY $402.39
23105 3 REMOVE SHOULDER JOINT LINING $573.07

23106 3 INCISION OF COLLARBONE JOINT $427.03
23107 3 EXPLORE TREAT SHOULDER JOINT $595.35
23120 3 PARTIAL REMOVAL, COLLAR BONE $515.58
23125 3 REMOVAL OF COLLAR BONE $633.00
23130 3 REMOVE SHOULDER BONE, PART $542.26
23140 3 REMOVAL OF BONE LESION $460.86
23150 3 REMOVAL OF HUMERUS LESION $588.26

23170 3 REMOVE COLLAR BONE LESION $475.76
23172 3 REMOVE SHOULDER BLADE LESION $488.16
23174 3 REMOVE HUMERUS LESION $677.62
23180 3 REMOVE COLLAR BONE LESION $616.93
23182 3 REMOVE SHOULDER BLADE LESION $595.41
23190 3 PARTIAL REMOVAL OF SCAPULA $499.93
23195 3 REMOVAL OF HEAD OF HUMERUS $677.90
23200 3 REMOVAL OF COLLAR BONE $799.05
23210 3 REMOVAL OF SHOULDER BLADE $836.12
23220 3 PARTIAL REMOVAL OF HUMERUS $968.28
23221 3 PARTIAL REMOVAL OF HUMERUS $1,129.37

23222 3 PARTIAL REMOVAL OF HUMERUS $1,537.23
23330 3 REMOVE SHOULDER FOREIGN BODY $199.02
23350 3 INJECTION FOR SHOULDER X-RAY $144.76
23395 3 MUSCLE TRANSFER,SHOULDER/ARM $1,165.84
23397 3 MUSCLE TRANSFERS $1,043.69
23400 3 FIXATION OF SHOULDER BLADE $885.15
23405 3 INCISION OF TENDON & MUSCLE $569.64
23406 3 INCISE TENDON(S) & MUSCLE(S) $711.47
23410 3 REPAIR ROTATOR CUFF, ACUTE $755.35
23412 3 REPAIR ROTATOR CUFF, CHRONIC $789.33

23415 3 RELEASE OF SHOULDER LIGAMENT $629.41
23420 3 REPAIR OF SHOULDER $884.62
23430 3 REPAIR BICEPS TENDON $669.60
23440 3 REMOVE/TRANSPLANT TENDON $690.39
23450 3 REPAIR SHOULDER CAPSULE $865.71
23465 3 REPAIR SHOULDER CAPSULE $1,022.80
23466 3 REPAIR SHOULDER CAPSULE $1,008.97

23470 3 RECONSTRUCT SHOULDER JOINT $1,112.61
23472 3 RECONSTRUCT SHOULDER JOINT $1,377.07
23480 3 REVISION OF COLLAR BONE $744.30
23485 3 REVISION OF COLLAR BONE $879.00
23490 3 REINFORCE CLAVICLE $759.38
23491 3 REINFORCE SHOULDER BONES $925.73
23500 3 TREAT CLAVICLE FRACTURE $182.75
23510 O TREATMENT OF OPEN CLAVICULAR FRACTU $0.00
23520 3 TREAT CLAVICLE DISLOCATION $189.53

23570 3 TREAT SHOULDER BLADE FX $195.47
23575 3 TREAT SHOULDER BLADE FX $333.65
23580 O TREATMENT OF OPEN SCAPULAR FRACTURE $0.00
23585 3 TREAT SCAPULA FRACTURE $856.16
23600 3 TREAT HUMERUS FRACTURE $273.62
23610 O TREATMENT OF OPEN HUMERAL (SURGICAL $0.00

23616 3 TREAT HUMERUS FRACTURE $1,171.97
23650 3 TREAT SHOULDER DISLOCATION $253.97
23658 O TREATMENT OF OPEN SHOULDER DISLOCAT $0.00
23665 3 TREAT DISLOCATION/FRACTURE $364.10

23700 3 FIXATION OF SHOULDER $175.25
23800 3 FUSION OF SHOULDER JOINT $931.36
23802 3 FUSION OF SHOULDER JOINT $1,130.53
23900 3 AMPUTATION OF ARM & GIRDLE $1,204.87
23920 3 AMPUTATION AT SHOULDER JOINT $976.95
23921 3 AMPUTATION FOLLOW-UP SURGERY $354.10
23929 5 SHOULDER SURGERY PROCEDURE $0.00
23930 3 DRAINAGE OF ARM LESION $313.13
23931 3 DRAINAGE OF ARM BURSA $245.16
23935 3 DRAIN ARM/ELBOW BONE LESION $444.79

24000 3 EXPLORATORY ELBOW SURGERY $422.89
24006 3 RELEASE ELBOW JOINT $639.62
24065 3 BIOPSY ARM/ELBOW SOFT TISSUE $223.68
24066 3 BIOPSY ARM/ELBOW SOFT TISSUE $518.43
24075 3 REMOVE ARM/ELBOW LESION $420.75
24076 3 REMOVE ARM/ELBOW LESION $424.54
24077 3 REMOVE TUMOR OF ARM/ELBOW $733.56
24100 3 BIOPSY ELBOW JOINT LINING $361.00
24101 3 EXPLORE/TREAT ELBOW JOINT $444.78
24102 3 REMOVE ELBOW JOINT LINING $551.58
24105 3 REMOVAL OF ELBOW BURSA $299.19

24115 3 REMOVE/GRAFT BONE LESION $658.62
24120 3 REMOVE ELBOW LESION $467.26
24130 3 REMOVAL OF HEAD OF RADIUS $451.53
24134 3 REMOVAL OF ARM BONE LESION $678.24
24136 3 REMOVE RADIUS BONE LESION $535.61
24138 3 REMOVE ELBOW BONE LESION $593.38
24140 3 PARTIAL REMOVAL OF ARM BONE $646.38

24145 3 PARTIAL REMOVAL OF RADIUS $542.10
24147 3 PARTIAL REMOVAL OF ELBOW $563.64
24149 3 RADICAL RESECTION OF ELBOW $1,041.12
24150 3 EXTENSIVE HUMERUS SURGERY $881.83
24151 3 EXTENSIVE HUMERUS SURGERY $1,013.28
24152 3 EXTENSIVE RADIUS SURGERY $663.14
24153 3 EXTENSIVE RADIUS SURGERY $709.37
24155 3 REMOVAL OF ELBOW JOINT $767.54
24160 3 REMOVE ELBOW JOINT IMPLANT $543.06
24164 3 REMOVE RADIUS HEAD IMPLANT $443.85
24200 3 REMOVAL OF ARM FOREIGN BODY $174.14
24201 3 REMOVAL OF ARM FOREIGN BODY $487.00
24220 3 INJECTION FOR ELBOW X-RAY $158.53

24300 3 MANIPULATE ELBOW W/ANESTH $348.71
24301 3 MUSCLE/TENDON TRANSFER $679.26
24305 3 ARM TENDON LENGTHENING $518.86
24310 3 REVISION OF ARM TENDON $424.82
24320 3 REPAIR OF ARM TENDON $699.44
24330 3 REVISION OF ARM MUSCLES $645.64
24331 3 REVISION OF ARM MUSCLES $713.96
24332 3 TENOLYSIS, TRICEPS $541.53
24340 3 REPAIR OF BICEPS TENDON $550.69
24341 3 REPAIR ARM TENDON/MUSCLE $648.56
24342 3 REPAIR OF RUPTURED TENDON $709.71
24343 3 REPR ELBOW LAT LIGMNT W/TISS $630.22

24344 3 RECONSTRUCT ELBOW LAT LIGMNT $982.15
24345 3 REPR ELBW MED LIGMNT W/TISSU $626.01
24346 3 RECONSTRUCT ELBOW MED LIGMNT $984.39
24350 O REPAIR OF TENNIS ELBOW $0.00
24356 O REVISION OF TENNIS ELBOW $0.00
24357 3 REPAIR ELBOW, PERC $395.07
24358 3 REPAIR ELBOW W/DEB, OPEN $466.01

24359 3 REPAIR ELBOW DEB/ATTCH OPEN $585.90
24360 3 RECONSTRUCT ELBOW JOINT $815.80
24363 3 REPLACE ELBOW JOINT $1,355.58
24365 3 RECONSTRUCT HEAD OF RADIUS $575.99
24366 3 RECONSTRUCT HEAD OF RADIUS $616.89
24400 3 REVISION OF HUMERUS $744.84
24430 3 REPAIR OF HUMERUS $948.48
24435 3 REPAIR HUMERUS WITH GRAFT $963.27
24470 3 REVISION OF ELBOW JOINT $566.94

24495 3 DECOMPRESSION OF FOREARM $591.80
24498 3 REINFORCE HUMERUS $791.00
24506 O TREATMENT OF CLOSED HUMERAL SHAFT F $0.00
24510 O TREATMENT OF OPEN HUMERAL SHAFT FRA $0.00
24531 O TREATMENT OF CLOSED HUMERAL SUPRACO $0.00
24536 O TREATMENT OF CLOSED HUMERAL SUPRACO $0.00

24540 O TREATMENT OF OPEN HUMERAL SUPRACOND $0.00
24542 O TREATMENT OF OPEN HUMERAL SUPRACOND $0.00
24570 O TREATMENT OF OPEN HUMERAL EPICONDYL $0.00

24578 O TREATMENT OF OPEN HUMERAL CONDYLAR $0.00
24580 O TREATMENT OF CLOSED COMMINUTED ELBO $0.00
24581 O TREATMENT OF CLOSED COMMINUTED ELBO $0.00
24583 O TREATMENT OF OPEN COMMINUTED ELBOW $0.00
24585 O OPEN TREATMENT OF CLOSED OR OPEN CO $0.00
24586 3 TREAT ELBOW FRACTURE $996.53
24588 O OPEN TREATMENT OF CLOSED OR OPEN CO $0.00
24600 3 TREAT ELBOW DISLOCATION $313.18

24610 O TREATMENT OF OPEN ELBOW DISLOCATION $0.00
24625 O TREATMENT OF OPEN MONTEGGIA TYPE OF $0.00
24650 3 TREAT RADIUS FRACTURE $217.48
24660 O TREATMENT OF OPEN RADIAL HEAD OR NE $0.00

24670 3 TREAT ULNAR FRACTURE $244.33
24680 O TREATMENT OF OPEN ULNAR FRACTURE, P $0.00
24800 3 FUSION OF ELBOW JOINT $716.11
24802 3 FUSION/GRAFT OF ELBOW JOINT $907.58
24900 3 AMPUTATION OF UPPER ARM $647.21
24920 3 AMPUTATION OF UPPER ARM $642.87

24931 3 AMPUTATE UPPER ARM & IMPLANT $759.97
24935 3 REVISION OF AMPUTATION $922.12
24940 5 REVISION OF UPPER ARM $0.00
24999 5 UPPER ARM/ELBOW SURGERY $0.00
25000 3 INCISION OF TENDON SHEATH $311.35
25001 3 INCISE FLEXOR CARPI RADIALIS $294.05
25005 O TENDON SHEATH INCISION; AT WRIST FO $0.00
25020 3 DECOMPRESS FOREARM 1 SPACE $515.49
25023 3 DECOMPRESS FOREARM 1 SPACE $988.76
25024 3 DECOMPRESS FOREARM 2 SPACES $689.74
25025 3 DECOMPRESS FOREARM 2 SPACES $1,061.87
25028 3 DRAINAGE OF FOREARM LESION $459.10
25031 3 DRAINAGE OF FOREARM BURSA $337.12

25035 3 TREAT FOREARM BONE LESION $582.72
25040 3 EXPLORE/TREAT WRIST JOINT $514.18
25065 3 BIOPSY FOREARM SOFT TISSUES $222.20
25066 3 BIOPSY FOREARM SOFT TISSUES $337.73
25075 3 REMOVAL FOREARM LESION SUBCU $295.40
25076 3 REMOVAL FOREARM LESION DEEP $399.41
25077 3 REMOVE TUMOR, FOREARM/WRIST $674.69
25085 3 INCISION OF WRIST CAPSULE $415.01
25100 3 BIOPSY OF WRIST JOINT $308.36
25101 3 EXPLORE/TREAT WRIST JOINT $363.34
25105 3 REMOVE WRIST JOINT LINING $441.38
25107 3 REMOVE WRIST JOINT CARTILAGE $548.68

25109 3 EXCISE TENDON FOREARM/WRIST $467.85
25110 3 REMOVE WRIST TENDON LESION $323.48
25111 3 REMOVE WRIST TENDON LESION $280.55
25112 3 REREMOVE WRIST TENDON LESION $342.37
25115 3 REMOVE WRIST/FOREARM LESION $723.46
25116 3 REMOVE WRIST/FOREARM LESION $586.09
25118 3 EXCISE WRIST TENDON SHEATH $343.57
25119 3 PARTIAL REMOVAL OF ULNA $454.68
25120 3 REMOVAL OF FOREARM LESION $500.30
25125 3 REMOVE/GRAFT FOREARM LESION $581.72

25126 3 REMOVE/GRAFT FOREARM LESION $587.40
25130 3 REMOVAL OF WRIST LESION $403.01
25135 3 REMOVE & GRAFT WRIST LESION $502.74
25136 3 REMOVE & GRAFT WRIST LESION $444.61
25145 3 REMOVE FOREARM BONE LESION $513.51
25170 3 EXTENSIVE FOREARM SURGERY $802.43
25210 3 REMOVAL OF WRIST BONE $441.41
25215 3 REMOVAL OF WRIST BONES $568.36
25246 3 INJECTION FOR WRIST X-RAY $160.82

25248 3 REMOVE FOREARM FOREIGN BODY $394.95
25250 3 REMOVAL OF WRIST PROSTHESIS $468.86
25251 3 REMOVAL OF WRIST PROSTHESIS $639.68
25259 3 MANIPULATE WRIST W/ANESTHES $349.85
25260 3 REPAIR FOREARM TENDON/MUSCLE $612.88
25275 3 REPAIR FOREARM TENDON SHEATH $602.78
25280 3 REVISE WRIST/FOREARM TENDON $561.09

25290 3 INCISE WRIST/FOREARM TENDON $477.03
25295 3 RELEASE WRIST/FOREARM TENDON $522.66
25300 3 FUSION OF TENDONS AT WRIST $614.44
25301 3 FUSION OF TENDONS AT WRIST $584.98
25310 3 TRANSPLANT FOREARM TENDON $607.38
25312 3 TRANSPLANT FOREARM TENDON $702.42
25315 3 REVISE PALSY HAND TENDON(S) $752.76
25316 3 REVISE PALSY HAND TENDON(S) $869.84
25317 O FLEXOR ORIGIN SLIDE FOR VOLKMANN CO $0.00
25318 O FLEXOR ORIGIN SLIDE FOR VOLKMANN CO $0.00

25320 3 REPAIR/REVISE WRIST JOINT $865.47
25330 O ARTHROPLASTY, WRIST; $0.00
25331 O ARTHROPLASTY, WRIST; WITH IMPLANT $0.00
25332 3 REVISE WRIST JOINT $762.88
25335 3 REALIGNMENT OF HAND $866.14
25337 3 RECONSTRUCT ULNA/RADIOULNAR $796.39
25350 3 REVISION OF RADIUS $668.30
25355 3 REVISION OF RADIUS $750.87
25360 3 REVISION OF ULNA $648.68
25365 3 REVISE RADIUS & ULNA $881.13
25370 3 REVISE RADIUS OR ULNA $960.45
25375 3 REVISE RADIUS & ULNA $926.96
25390 3 SHORTEN RADIUS OR ULNA $755.16

25391 3 LENGTHEN RADIUS OR ULNA $958.51
25392 3 SHORTEN RADIUS & ULNA $972.88
25393 3 LENGTHEN RADIUS & ULNA $1,092.72
25394 3 REPAIR CARPAL BONE, SHORTEN $700.69
25400 3 REPAIR RADIUS OR ULNA $792.03
25405 3 REPAIR/GRAFT RADIUS OR ULNA $1,005.72
25415 3 REPAIR RADIUS & ULNA $945.57
25420 3 REPAIR/GRAFT RADIUS & ULNA $1,124.40
25425 3 REPAIR/GRAFT RADIUS OR ULNA $974.20
25426 3 REPAIR/GRAFT RADIUS & ULNA $1,015.86
25430 3 VASC GRAFT INTO CARPAL BONE $639.34
25431 3 REPAIR NONUNION CARPAL BONE $707.57

25440 3 REPAIR/GRAFT WRIST BONE $703.68
25441 3 RECONSTRUCT WRIST JOINT $852.12
25446 3 WRIST REPLACEMENT $1,070.43
25447 3 REPAIR WRIST JOINT(S) $734.88
25449 3 REMOVE WRIST JOINT IMPLANT $938.10
25450 3 REVISION OF WRIST JOINT $545.91

25455 3 REVISION OF WRIST JOINT $621.57
25490 3 REINFORCE RADIUS $687.12
25491 3 REINFORCE ULNA $725.43
25492 3 REINFORCE RADIUS AND ULNA $873.43
25500 3 TREAT FRACTURE OF RADIUS $222.68
25510 O TREATMENT OF OPEN RADIAL SHAFT FRAC $0.00
25530 3 TREAT FRACTURE OF ULNA $216.23

25540 O TREATMENT OF OPEN ULNAR SHAFT FRACT $0.00
25560 3 TREAT FRACTURE RADIUS & ULNA $225.65
25570 O TREATMENT OF OPEN RADIAL AND ULNAR $0.00
25575 3 TREAT FRACTURE RADIUS/ULNA $803.56
25606 3 TREAT FX DISTAL RADIAL $592.49
25607 3 TREAT FX RAD EXTRA-ARTICUL $639.19
25608 3 TREAT FX RAD INTRA-ARTICUL $728.68

25609 3 TREAT FX RADIAL 3+ FRAG $929.83
25610 O TREATMENT OF CLOSED, COMPLEX, DISTA $0.00
25611 O TREAT FRACTURE RADIUS/ULNA $0.00
25615 O TREATMENT OF OPEN DISTAL RADIAL FRA $0.00
25620 O TREAT FRACTURE RADIUS/ULNA $0.00
25622 3 TREAT WRIST BONE FRACTURE $252.37
25626 O TREATMENT OF OPEN CARPAL SCAPHOID ( $0.00

25640 O TREATMENT OF OPEN CARPAL BONE FRACT $0.00
25651 3 PIN ULNAR STYLOID FRACTURE $419.89
25652 3 TREAT FRACTURE ULNAR STYLOID $552.32
25660 3 TREAT WRIST DISLOCATION $350.63
25665 O TREATMENT OF OPEN RADIOCARPAL OR IN $0.00
25671 3 PIN RADIOULNAR DISLOCATION $462.02
25680 3 TREAT WRIST FRACTURE $404.17

25685 3 TREAT WRIST FRACTURE $657.84
25800 3 FUSION OF WRIST JOINT $671.57
25805 3 FUSION/GRAFT OF WRIST JOINT $774.00
25810 3 FUSION/GRAFT OF WRIST JOINT $781.41
25820 3 FUSION OF HAND BONES $550.10
25825 3 FUSE HAND BONES WITH GRAFT $677.48
25830 3 FUSION, RADIOULNAR JNT/ULNA $849.11
25900 3 AMPUTATION OF FOREARM $675.32
25905 3 AMPUTATION OF FOREARM $667.34

25915 3 AMPUTATION OF FOREARM $1,146.26
25920 3 AMPUTATE HAND AT WRIST $616.55
25922 3 AMPUTATE HAND AT WRIST $521.06
25927 3 AMPUTATION OF HAND $702.18
25999 5 FOREARM OR WRIST SURGERY $0.00
26010 3 DRAINAGE OF FINGER ABSCESS $222.73

26011 3 DRAINAGE OF FINGER ABSCESS $340.13
26020 3 DRAIN HAND TENDON SHEATH $378.10
26025 3 DRAINAGE OF PALM BURSA $369.19
26030 3 DRAINAGE OF PALM BURSA(S) $435.89
26034 3 TREAT HAND BONE LESION $472.77
26035 3 DECOMPRESS FINGERS/HAND $734.99
26037 3 DECOMPRESS FINGERS/HAND $508.43
26040 3 RELEASE PALM CONTRACTURE $271.38
26055 3 INCISE FINGER TENDON SHEATH $497.57
26060 3 INCISION OF FINGER TENDON $232.42
26070 3 EXPLORE/TREAT HAND JOINT $263.84
26075 3 EXPLORE/TREAT FINGER JOINT $279.70

26080 3 EXPLORE/TREAT FINGER JOINT $337.98
26100 3 BIOPSY HAND JOINT LINING $283.79
26105 3 BIOPSY FINGER JOINT LINING $290.48
26110 3 BIOPSY FINGER JOINT LINING $278.92
26115 3 REMOVAL HAND LESION SUBCUT $545.00
26116 3 REMOVAL HAND LESION, DEEP $425.42
26117 3 REMOVE TUMOR, HAND/FINGER $579.28
26130 3 REMOVE WRIST JOINT LINING $403.95
26135 3 REVISE FINGER JOINT, EACH $491.29

26140 3 REVISE FINGER JOINT, EACH $446.90
26145 3 TENDON EXCISION, PALM/FINGER $454.20
26160 3 REMOVE TENDON SHEATH LESION $497.33
26170 3 REMOVAL OF PALM TENDON, EACH $357.36
26180 3 REMOVAL OF FINGER TENDON $390.79
26185 3 REMOVE FINGER BONE $467.08
26200 3 REMOVE HAND BONE LESION $400.93
26210 3 REMOVAL OF FINGER LESION $388.85
26215 3 REMOVE/GRAFT FINGER LESION $493.40

26230 3 PARTIAL REMOVAL OF HAND BONE $448.51
26235 3 PARTIAL REMOVAL, FINGER BONE $440.59
26236 3 PARTIAL REMOVAL, FINGER BONE $390.61
26250 3 EXTENSIVE HAND SURGERY $520.14
26255 3 EXTENSIVE HAND SURGERY $789.60
26260 3 EXTENSIVE FINGER SURGERY $487.19
26261 3 EXTENSIVE FINGER SURGERY $602.95
26262 3 PARTIAL REMOVAL OF FINGER $407.01
26320 3 REMOVAL OF IMPLANT FROM HAND $304.19
26340 3 MANIPULATE FINGER W/ANESTH $274.88
26350 3 REPAIR FINGER/HAND TENDON $637.00
26352 3 REPAIR/GRAFT HAND TENDON $722.90

26390 3 REVISE HAND/FINGER TENDON $742.23
26410 3 REPAIR HAND TENDON $506.75
26415 3 EXCISION, HAND/FINGER TENDON $643.45
26416 3 GRAFT HAND OR FINGER TENDON $688.64
26418 3 REPAIR FINGER TENDON $509.44

26420 3 REPAIR/GRAFT FINGER TENDON $637.94
26437 3 REALIGNMENT OF TENDONS $554.94
26440 3 RELEASE PALM/FINGER TENDON $558.87
26442 3 RELEASE PALM & FINGER TENDON $843.68
26445 3 RELEASE HAND/FINGER TENDON $519.27

26449 3 RELEASE FOREARM/HAND TENDON $676.13
26450 3 INCISION OF PALM TENDON $358.19
26455 3 INCISION OF FINGER TENDON $355.77
26460 3 INCISE HAND/FINGER TENDON $346.03
26471 3 FUSION OF FINGER TENDONS $546.68
26474 3 FUSION OF FINGER TENDONS $524.72
26476 3 TENDON LENGTHENING $510.83
26477 3 TENDON SHORTENING $515.40
26478 3 LENGTHENING OF HAND TENDON $559.28
26479 3 SHORTENING OF HAND TENDON $553.17
26480 3 TRANSPLANT HAND TENDON $673.43
26483 3 TRANSPLANT/GRAFT HAND TENDON $759.27
26485 3 TRANSPLANT PALM TENDON $727.80

26489 3 TRANSPLANT/GRAFT PALM TENDON $784.93
26490 3 REVISE THUMB TENDON $701.73
26492 3 TENDON TRANSFER WITH GRAFT $781.68
26494 3 HAND TENDON/MUSCLE TRANSFER $710.36
26496 3 REVISE THUMB TENDON $769.99
26497 3 FINGER TENDON TRANSFER $770.53
26498 3 FINGER TENDON TRANSFER $1,027.69
26499 3 REVISION OF FINGER $736.55
26500 3 HAND TENDON RECONSTRUCTION $557.96
26502 3 HAND TENDON RECONSTRUCTION $629.31
26504 O HAND TENDON RECONSTRUCTION $0.00
26508 3 RELEASE THUMB CONTRACTURE $560.93

26510 3 THUMB TENDON TRANSFER $532.33
26516 3 FUSION OF KNUCKLE JOINT $627.46
26517 3 FUSION OF KNUCKLE JOINTS $738.10
26518 3 FUSION OF KNUCKLE JOINTS $744.93
26520 3 RELEASE KNUCKLE CONTRACTURE $584.12
26525 3 RELEASE FINGER CONTRACTURE $586.54
26527 O ARTHROPLASTY, CARPOMETACARPAL JOINT $0.00
26530 3 REVISE KNUCKLE JOINT $476.49
26531 3 REVISE KNUCKLE WITH IMPLANT $554.60
26535 3 REVISE FINGER JOINT $356.88

26536 3 REVISE/IMPLANT FINGER JOINT $598.81
26540 3 REPAIR HAND JOINT $589.49
26541 3 REPAIR HAND JOINT WITH GRAFT $719.42
26542 3 REPAIR HAND JOINT WITH GRAFT $609.36
26545 3 RECONSTRUCT FINGER JOINT $620.25
26546 3 REPAIR NONUNION HAND $869.97
26548 3 RECONSTRUCT FINGER JOINT $682.36
26550 3 CONSTRUCT THUMB REPLACEMENT $1,335.53
26551 3 GREAT TOE-HAND TRANSFER $2,905.51
26552 O RECONSTRUCTION THUMB WITH TOE $0.00
26553 3 SINGLE TRANSFER, TOE-HAND $2,535.67
26554 3 DOUBLE TRANSFER, TOE-HAND $3,321.88
26555 3 POSITIONAL CHANGE OF FINGER $1,231.40

26556 3 TOE JOINT TRANSFER $2,619.72
26557 O TOE TO FINGER TRANSFER; FIRST STAGE $0.00
26558 O TOE TO FINGER TRANSFER; EACH DELAY $0.00
26559 O TOE TO FINGER TRANSFER; SECOND STAG $0.00
26560 3 REPAIR OF WEB FINGER $507.95
26561 3 REPAIR OF WEB FINGER $811.23
26562 3 REPAIR OF WEB FINGER $1,180.23
26565 3 CORRECT METACARPAL FLAW $603.76
26567 3 CORRECT FINGER DEFORMITY $609.80
26568 3 LENGTHEN METACARPAL/FINGER $802.63
26580 3 REPAIR HAND DEFORMITY $1,250.80
26585 O REPAIR FINGER DEFORMITY $0.00

26587 3 RECONSTRUCT EXTRA FINGER $854.81
26590 3 REPAIR FINGER DEFORMITY $1,136.96
26591 3 REPAIR MUSCLES OF HAND $390.07
26593 3 RELEASE MUSCLES OF HAND $531.11
26596 3 EXCISION CONSTRICTING TISSUE $654.94
26597 O RELEASE OF SCAR CONTRACTURE $0.00
26600 3 TREAT METACARPAL FRACTURE $235.19

26610 O TREATMENT OF OPEN METACARPAL FRACTU $0.00
26641 3 TREAT THUMB DISLOCATION $310.88
26645 3 TREAT THUMB FRACTURE $355.09
26655 O TREATMENT OF OPEN CARPOMETACARPAL F $0.00
26660 O TREATMENT OF OPEN CARPOMETACARPAL F $0.00
26670 3 TREAT HAND DISLOCATION $280.53
26676 3 PIN HAND DISLOCATION $440.78
26680 O TREATMENT OF OPEN CARPOMETACARPAL D $0.00

26700 3 TREAT KNUCKLE DISLOCATION $267.36
26706 3 PIN KNUCKLE DISLOCATION $381.59
26710 O TREATMENT OF OPEN METACARPOPHALANGE $0.00
26720 3 TREAT FINGER FRACTURE, EACH $162.99
26730 O TREATMENT OF OPEN PHALANGEAL SHAFT $0.00

26744 O TREATMENT OF OPEN ARTICULAR FRACTUR $0.00
26756 3 PIN FINGER FRACTURE, EACH $364.57
26760 O TREATMENT OF OPEN DISTAL PHALANGEAL $0.00
26770 3 TREAT FINGER DISLOCATION $227.09

26776 3 PIN FINGER DISLOCATION $387.69
26780 O TREATMENT OF OPEN INTERPHALANGEAL J $0.00
26820 3 THUMB FUSION WITH GRAFT $703.34
26841 3 FUSION OF THUMB $651.94
26842 3 THUMB FUSION WITH GRAFT $707.46
26843 3 FUSION OF HAND JOINT $655.08
26844 3 FUSION/GRAFT OF HAND JOINT $730.38
26850 3 FUSION OF KNUCKLE $621.18
26852 3 FUSION OF KNUCKLE WITH GRAFT $711.45
26860 3 FUSION OF FINGER JOINT $499.62
26861 3 FUSION OF FINGER JNT, ADD-ON $97.85
26862 3 FUSION/GRAFT OF FINGER JOINT $647.52

26863 3 FUSE/GRAFT ADDED JOINT $218.24
26910 3 AMPUTATE METACARPAL BONE $636.83
26951 3 AMPUTATION OF FINGER/THUMB $551.78
26952 3 AMPUTATION OF FINGER/THUMB $577.96
26989 5 HAND/FINGER SURGERY $0.00
26990 3 DRAINAGE OF PELVIS LESION $552.66
26991 3 DRAINAGE OF PELVIS BURSA $620.60
27000 3 INCISION OF HIP TENDON $401.35

27006 3 INCISION OF HIP TENDONS $666.14
27010 O GLUTEAL-ILIOTIBIAL FASCIOTOMY (OBER $0.00
27015 O ILIAC CREST FASCIOTOMY (SOUTTER OR $0.00
27025 3 INCISION OF HIP/THIGH FASCIA $806.18
27027 3 BUTTOCK FASCIOTOMY $786.14
27030 3 DRAINAGE OF HIP JOINT $859.89
27033 3 EXPLORATION OF HIP JOINT $890.35
27035 3 DENERVATION OF HIP JOINT $994.29
27036 3 EXCISION OF HIP JOINT/MUSCLE $910.49
27040 3 BIOPSY OF SOFT TISSUES $303.84

27041 3 BIOPSY OF SOFT TISSUES $621.78
27047 3 REMOVE HIP/PELVIS LESION $553.69
27048 3 REMOVE HIP/PELVIS LESION $427.04
27049 3 REMOVE TUMOR, HIP/PELVIS $903.32
27050 3 BIOPSY OF SACROILIAC JOINT $312.53
27052 3 BIOPSY OF HIP JOINT $498.99
27054 3 REMOVAL OF HIP JOINT LINING $612.56
27057 3 BUTTOCK FASCIOTOMY W/DBRDMT $871.82
27060 3 REMOVAL OF ISCHIAL BURSA $385.43
27062 3 REMOVE FEMUR LESION/BURSA $403.11
27065 3 REMOVAL OF HIP BONE LESION $449.54
27066 3 REMOVAL OF HIP BONE LESION $730.06
27067 3 REMOVE/GRAFT HIP BONE LESION $925.82

27070 3 PARTIAL REMOVAL OF HIP BONE $764.99
27071 3 PARTIAL REMOVAL OF HIP BONE $821.17
27075 3 EXTENSIVE HIP SURGERY $2,108.04
27078 3 EXTENSIVE HIP SURGERY $921.28
27079 3 EXTENSIVE HIP SURGERY $880.47
27080 3 REMOVAL OF TAIL BONE $442.74
27086 3 REMOVE HIP FOREIGN BODY $218.09
27087 3 REMOVE HIP FOREIGN BODY $569.85
27090 3 REMOVAL OF HIP PROSTHESIS $754.46
27091 3 REMOVAL OF HIP PROSTHESIS $1,459.52

27093 3 INJECTION FOR HIP X-RAY $177.86
27095 3 INJECTION FOR HIP X-RAY $214.83
27096 3 INJECT SACROILIAC JOINT $162.86
27097 3 REVISION OF HIP TENDON $601.56
27098 3 TRANSFER TENDON TO PELVIS $560.78
27100 3 TRANSFER OF ABDOMINAL MUSCLE $742.03
27105 3 TRANSFER OF SPINAL MUSCLE $776.89
27110 3 TRANSFER OF ILIOPSOAS MUSCLE $867.10
27111 3 TRANSFER OF ILIOPSOAS MUSCLE $772.96
27120 3 RECONSTRUCTION OF HIP SOCKET $1,175.08

27122 3 RECONSTRUCTION OF HIP SOCKET $1,006.89
27125 3 PARTIAL HIP REPLACEMENT $1,024.91
27126 O PARTIAL HIP REPLACEMENT (HEMIARTHRO $0.00
27127 O PARTIAL HIP REPLACEMENT (HEMIARTHRO $0.00
27130 3 TOTAL HIP ARTHROPLASTY $1,321.42
27132 3 TOTAL HIP ARTHROPLASTY $1,544.00
27134 3 REVISE HIP JOINT REPLACEMENT $1,790.53
27140 3 TRANSPLANT FEMUR RIDGE $817.45
27146 3 INCISION OF HIP BONE $1,151.97
27147 3 REVISION OF HIP BONE $1,342.37
27151 3 INCISION OF HIP BONES $1,396.78

27156 3 REVISION OF HIP BONES $1,565.52
27157 O ACETABULAR AUGMENTATION (WILSON PRO $0.00
27158 3 REVISION OF PELVIS $1,258.34
27161 3 INCISION OF NECK OF FEMUR $1,114.62
27165 3 INCISION/FIXATION OF FEMUR $1,244.99
27170 3 REPAIR/GRAFT FEMUR HEAD/NECK $1,078.22
27175 3 TREAT SLIPPED EPIPHYSIS $599.88
27177 3 TREAT SLIPPED EPIPHYSIS $1,011.34
27179 3 REVISE HEAD/NECK OF FEMUR $883.69

27185 3 REVISION OF FEMUR EPIPHYSIS $624.15
27187 3 REINFORCE HIP BONES $906.21
27190 O TREATMENT OF CLOSED SACRAL FRACTURE $0.00
27192 O OPEN TREATMENT OF CLOSED OR OPEN SA $0.00
27193 3 TREAT PELVIC RING FRACTURE $415.27
27195 O TREATMENT OF SACROILIAC AND/OR SYMP $0.00
27196 O TREATMENT OF SACROILIAC AND/OR SYMP $0.00
27200 3 TREAT TAIL BONE FRACTURE $151.17
27201 O TREATMENT OF OPEN COCCYGEAL FRACTUR $0.00

27202 3 TREAT TAIL BONE FRACTURE $577.65
27210 O TREATMENT OF CLOSED ILIAC, PUBIC OR $0.00
27212 O TREATMENT OF OPEN ILIAC, PUBIC OR I $0.00
27214 O OPEN TREATMENT OF CLOSED OR OPEN IL $0.00
27215 3 TREAT PELVIC FRACTURE(S) $668.95
27218 3 TREAT PELVIC RING FRACTURE $1,263.37
27220 3 TREAT HIP SOCKET FRACTURE $468.01
27222 3 TREAT HIP SOCKET FRACTURE $888.00
27224 O OPEN TREATMENT OF CLOSED OR OPEN AC $0.00
27225 O OPEN TREATMENT OF CLOSED OR OPEN AC $0.00
27226 3 TREAT HIP WALL FRACTURE $944.13

27227 3 TREAT HIP FRACTURE(S) $1,529.43
27228 3 TREAT HIP FRACTURE(S) $1,751.41
27230 3 TREAT THIGH FRACTURE $416.86
27234 O TREATMENT OF OPEN FEMORAL FRACTURE, $0.00
27236 3 TREAT THIGH FRACTURE $1,083.62
27242 O TREATMENT OF OPEN INTERTROCHANTERIC $0.00

27250 3 TREAT HIP DISLOCATION $214.95
27254 3 TREAT HIP DISLOCATION $1,163.19
27255 O OPEN TREATMENT OF CLOSED OR OPEN HI $0.00

27267 3 CLTX THIGH FX $371.81
27268 3 CLTX THIGH FX W/MNPJ $460.21
27269 3 OPTX THIGH FX $1,105.87
27275 3 MANIPULATION OF HIP JOINT $161.79
27280 3 FUSION OF SACROILIAC JOINT $934.32
27282 3 FUSION OF PUBIC BONES $731.67
27284 3 FUSION OF HIP JOINT $1,417.98
27286 3 FUSION OF HIP JOINT $1,500.78
27290 3 AMPUTATION OF LEG AT HIP $1,432.03
27295 3 AMPUTATION OF LEG AT HIP $1,156.64

27299 5 PELVIS/HIP JOINT SURGERY $0.00
27301 3 DRAIN THIGH/KNEE LESION $585.66
27305 3 INCISE THIGH TENDON & FASCIA $419.28
27306 3 INCISION OF THIGH TENDON $339.58
27307 3 INCISION OF THIGH TENDONS $417.93
27310 3 EXPLORATION OF KNEE JOINT $655.61
27315 O PARTIAL REMOVAL, THIGH NERVE $0.00
27320 O PARTIAL REMOVAL, THIGH NERVE $0.00
27323 3 BIOPSY, THIGH SOFT TISSUES $236.19
27324 3 BIOPSY, THIGH SOFT TISSUES $341.63
27325 3 NEURECTOMY, HAMSTRING $473.20

27326 3 NEURECTOMY, POPLITEAL $436.79
27327 3 REMOVAL OF THIGH LESION $399.42
27328 3 REMOVAL OF THIGH LESION $376.60
27329 3 REMOVE TUMOR, THIGH/KNEE $938.65
27330 3 BIOPSY, KNEE JOINT LINING $358.23
27331 3 EXPLORE/TREAT KNEE JOINT $423.42
27332 3 REMOVAL OF KNEE CARTILAGE $574.46
27333 3 REMOVAL OF KNEE CARTILAGE $520.49
27334 3 REMOVE KNEE JOINT LINING $611.32
27335 3 REMOVE KNEE JOINT LINING $691.56

27340 3 REMOVAL OF KNEECAP BURSA $324.43
27345 3 REMOVAL OF KNEE CYST $428.80
27347 3 REMOVE KNEE CYST $459.74
27350 3 REMOVAL OF KNEECAP $584.44
27355 3 REMOVE FEMUR LESION $541.69
27356 3 REMOVE FEMUR LESION/GRAFT $664.22
27357 3 REMOVE FEMUR LESION/GRAFT $736.53
27358 3 REMOVE FEMUR LESION/FIXATION $267.79
27360 3 PARTIAL REMOVAL, LEG BONE(S) $766.90
27365 3 EXTENSIVE LEG SURGERY $1,116.34
27370 3 INJECTION FOR KNEE X-RAY $152.31
27380 3 REPAIR OF KNEECAP TENDON $530.84

27381 3 REPAIR/GRAFT KNEECAP TENDON $723.55
27385 3 REPAIR OF THIGH MUSCLE $568.39
27386 3 REPAIR/GRAFT OF THIGH MUSCLE $750.44
27390 3 INCISION OF THIGH TENDON $393.53
27393 3 LENGTHENING OF THIGH TENDON $454.58
27394 3 LENGTHENING OF THIGH TENDONS $587.56
27395 3 LENGTHENING OF THIGH TENDONS $795.76
27396 3 TRANSPLANT OF THIGH TENDON $552.33
27397 3 TRANSPLANTS OF THIGH TENDONS $813.34
27400 3 REVISE THIGH MUSCLES/TENDONS $615.23

27403 3 REPAIR OF KNEE CARTILAGE $578.18
27405 3 REPAIR OF KNEE LIGAMENT $609.25
27407 3 REPAIR OF KNEE LIGAMENT $695.50
27409 3 REPAIR OF KNEE LIGAMENTS $874.90
27412 3 AUTOCHONDROCYTE IMPLANT KNEE $1,514.53
27415 3 OSTEOCHONDRAL KNEE ALLOGRAFT $1,268.26
27416 3 OSTEOCHONDRAL KNEE AUTOGRAFT $876.41
27418 3 REPAIR DEGENERATED KNEECAP $755.01
27420 3 REVISION OF UNSTABLE KNEECAP $676.04
27422 3 REVISION OF UNSTABLE KNEECAP $673.27

27424 3 REVISION/REMOVAL OF KNEECAP $675.08
27425 3 LAT RETINACULAR RELEASE OPEN $393.99
27427 3 RECONSTRUCTION, KNEE $648.21
27428 3 RECONSTRUCTION, KNEE $998.30
27429 3 RECONSTRUCTION, KNEE $1,117.99
27430 3 REVISION OF THIGH MUSCLES $669.03
27435 3 INCISION OF KNEE JOINT $717.78
27437 3 REVISE KNEECAP $594.89
27438 3 REVISE KNEECAP WITH IMPLANT $762.22
27440 3 REVISION OF KNEE JOINT $695.90

27445 3 REVISION OF KNEE JOINT $1,151.76
27446 3 REVISION OF KNEE JOINT $1,021.41
27447 3 TOTAL KNEE ARTHROPLASTY $1,414.96
27448 3 INCISION OF THIGH $744.59
27450 3 INCISION OF THIGH $928.01
27454 3 REALIGNMENT OF THIGH BONE $1,170.29
27455 3 REALIGNMENT OF KNEE $857.56
27457 3 REALIGNMENT OF KNEE $883.15
27465 3 SHORTENING OF THIGH BONE $1,111.74
27466 3 LENGTHENING OF THIGH BONE $1,079.15
27468 3 SHORTEN/LENGTHEN THIGHS $1,221.98
27470 3 REPAIR OF THIGH $1,076.12

27472 3 REPAIR/GRAFT OF THIGH $1,163.30
27475 3 SURGERY TO STOP LEG GROWTH $591.77
27486 3 REVISE/REPLACE KNEE JOINT $1,290.83
27487 3 REVISE/REPLACE KNEE JOINT $1,628.27
27488 3 REMOVAL OF KNEE PROSTHESIS $1,092.14
27495 3 REINFORCE THIGH $1,034.62
27496 3 DECOMPRESSION OF THIGH/KNEE $451.38

27500 3 TREATMENT OF THIGH FRACTURE $455.24
27504 O TREATMENT OF OPEN FEMORAL SHAFT FRA $0.00
27506 3 TREATMENT OF THIGH FRACTURE $1,213.79

27512 O TREATMENT OF OPEN FEMORAL FRACTURE, $0.00
27513 3 TREATMENT OF THIGH FRACTURE $1,171.23
27516 3 TREAT THIGH FX GROWTH PLATE $430.07
27518 O TREATMENT OF OPEN DISTAL FEMORAL EP $0.00
27520 3 TREAT KNEECAP FRACTURE $271.62
27522 O TREATMENT OF OPEN PATELLAR FRACTURE $0.00
27524 3 TREAT KNEECAP FRACTURE $682.90
27530 3 TREAT KNEE FRACTURE $340.81

27534 O TREATMENT OF OPEN TIBIAL FRACTURE, $0.00
27536 3 TREAT KNEE FRACTURE $1,081.80
27537 O OPEN TREATMENT OF CLOSED OR OPEN TI $0.00
27538 3 TREAT KNEE FRACTURE(S) $407.75
27550 3 TREAT KNEE DISLOCATION $430.61
27554 O TREATMENT OF OPEN KNEE DISLOCATION, $0.00

27557 3 TREAT KNEE DISLOCATION $1,002.08
27558 3 TREAT KNEE DISLOCATION $1,124.00
27560 3 TREAT KNEECAP DISLOCATION $315.72
27564 O TREATMENT OF OPEN PATELLAR DISLOCAT $0.00
27570 3 FIXATION OF KNEE JOINT $132.19
27580 3 FUSION OF KNEE $1,317.71
27590 3 AMPUTATE LEG AT THIGH $752.64

27598 3 AMPUTATE LOWER LEG AT KNEE $680.96
27599 5 LEG SURGERY PROCEDURE $0.00
27600 3 DECOMPRESSION OF LOWER LEG $384.45
27603 3 DRAIN LOWER LEG LESION $464.29
27604 3 DRAIN LOWER LEG BURSA $407.29
27605 3 INCISION OF ACHILLES TENDON $325.68
27606 3 INCISION OF ACHILLES TENDON $270.20
27607 3 TREAT LOWER LEG BONE LESION $556.58
27610 3 EXPLORE/TREAT ANKLE JOINT $594.35

27612 3 EXPLORATION OF ANKLE JOINT $518.50
27613 3 BIOPSY LOWER LEG SOFT TISSUE $221.70
27614 3 BIOPSY LOWER LEG SOFT TISSUE $498.54
27615 3 REMOVE TUMOR, LOWER LEG $799.32
27618 3 REMOVE LOWER LEG LESION $434.95
27619 3 REMOVE LOWER LEG LESION $693.46
27620 3 EXPLORE/TREAT ANKLE JOINT $418.39
27625 3 REMOVE ANKLE JOINT LINING $540.87
27626 3 REMOVE ANKLE JOINT LINING $584.10
27630 3 REMOVAL OF TENDON LESION $477.20

27635 3 REMOVE LOWER LEG BONE LESION $538.10
27637 3 REMOVE/GRAFT LEG BONE LESION $682.33
27638 3 REMOVE/GRAFT LEG BONE LESION $710.78
27640 3 PARTIAL REMOVAL OF TIBIA $787.49
27641 3 PARTIAL REMOVAL OF FIBULA $631.13
27645 3 EXTENSIVE LOWER LEG SURGERY $955.12
27646 3 EXTENSIVE LOWER LEG SURGERY $844.54
27647 3 EXTENSIVE ANKLE/HEEL SURGERY $745.74
27648 3 INJECTION FOR ANKLE X-RAY $146.76
27650 3 REPAIR ACHILLES TENDON $614.81
27652 3 REPAIR/GRAFT ACHILLES TENDON $676.16
27654 3 REPAIR OF ACHILLES TENDON $660.27
27656 3 REPAIR LEG FASCIA DEFECT $480.36

27658 3 REPAIR OF LEG TENDON, EACH $348.77
27675 3 REPAIR LOWER LEG TENDONS $466.47
27676 3 REPAIR LOWER LEG TENDONS $566.39
27680 3 RELEASE OF LOWER LEG TENDON $395.19
27681 3 RELEASE OF LOWER LEG TENDONS $470.76
27685 3 REVISION OF LOWER LEG TENDON $565.24
27686 3 REVISE LOWER LEG TENDONS $513.83
27687 3 REVISION OF CALF TENDON $422.85
27690 3 REVISE LOWER LEG TENDON $582.01

27691 3 REVISE LOWER LEG TENDON $683.19
27692 3 REVISE ADDITIONAL LEG TENDON $103.69
27695 3 REPAIR OF ANKLE LIGAMENT $450.32
27696 3 REPAIR OF ANKLE LIGAMENTS $537.07
27698 3 REPAIR OF ANKLE LIGAMENT $603.20
27700 3 REVISION OF ANKLE JOINT $569.85
27702 3 RECONSTRUCT ANKLE JOINT $911.52
27703 3 RECONSTRUCTION, ANKLE JOINT $1,054.55
27704 3 REMOVAL OF ANKLE IMPLANT $516.71
27705 3 INCISION OF TIBIA $699.63

27707 3 INCISION OF FIBULA $356.27
27709 3 INCISION OF TIBIA & FIBULA $1,019.97
27712 3 REALIGNMENT OF LOWER LEG $997.23
27715 3 REVISION OF LOWER LEG $973.69
27720 3 REPAIR OF TIBIA $800.79
27722 3 REPAIR/GRAFT OF TIBIA $798.70
27724 3 REPAIR/GRAFT OF TIBIA $1,175.05
27725 3 REPAIR OF LOWER LEG $1,093.94
27726 3 REPAIR FIBULA NONUNION $832.66
27727 3 REPAIR OF LOWER LEG $886.94
27730 3 REPAIR OF TIBIA EPIPHYSIS $533.39
27732 3 REPAIR OF FIBULA EPIPHYSIS $362.30
27734 3 REPAIR LOWER LEG EPIPHYSES $542.49

27740 3 REPAIR OF LEG EPIPHYSES $602.36
27742 3 REPAIR OF LEG EPIPHYSES $633.53
27745 3 REINFORCE TIBIA $687.07
27750 3 TREATMENT OF TIBIA FRACTURE $293.45
27754 O TREATMENT OF OPEN TIBIAL SHAFT FRAC $0.00
27760 3 CLTX MEDIAL ANKLE FX $282.75
27762 3 CLTX MED ANKLE FX W/MNPJ $422.67
27764 O TREATMENT OF OPEN DISTAL TIBIAL FRA $0.00

27766 3 OPTX MEDIAL ANKLE FX $550.67
27767 3 CLTX POST ANKLE FX $224.45
27768 3 CLTX POST ANKLE FX W/MNPJ $360.64
27769 3 OPTX POST ANKLE FX $626.48
27780 3 TREATMENT OF FIBULA FRACTURE $253.06
27782 O TREATMENT OF OPEN PROXIMAL FIBULA O $0.00
27786 3 TREATMENT OF ANKLE FRACTURE $268.07

27790 O TREATMENT OF OPEN DISTAL FIBULAR FR $0.00
27800 O TREATMENT OF CLOSED TIBIA AND FIBUL $0.00
27802 O TREATMENT OF CLOSED TIBIA AND FIBUL $0.00
27804 O TREATMENT OF OPEN TIBIA AND FIBULA $0.00
27806 O OPEN TREATMENT OF CLOSED OR OPEN TI $0.00
27812 O TREATMENT OF OPEN BIMALLEOLAR ANKLE $0.00
27820 O TREATMENT OF OPEN TRIMALLEOLAR ANKL $0.00

27824 3 TREAT LOWER LEG FRACTURE $266.36
27828 3 TREAT LOWER LEG FRACTURE $1,179.70
27829 3 TREAT LOWER LEG JOINT $591.78
27830 3 TREAT LOWER LEG DISLOCATION $309.49
27840 3 TREAT ANKLE DISLOCATION $310.65

27844 O TREATMENT OF OPEN ANKLE DISLOCATION $0.00
27860 3 FIXATION OF ANKLE JOINT $162.44
27870 3 FUSION OF ANKLE JOINT, OPEN $958.56
27871 3 FUSION OF TIBIOFIBULAR JOINT $630.19
27880 3 AMPUTATION OF LOWER LEG $844.82

27888 3 AMPUTATION OF FOOT AT ANKLE $645.75
27889 3 AMPUTATION OF FOOT AT ANKLE $629.53
27892 3 DECOMPRESSION OF LEG $495.46
27899 5 LEG/ANKLE SURGERY PROCEDURE $0.00
28001 3 DRAINAGE OF BURSA OF FOOT $241.49
28002 3 TREATMENT OF FOOT INFECTION $449.27
28003 3 TREATMENT OF FOOT INFECTION $617.65
28005 3 TREAT FOOT BONE LESION $569.75
28008 3 INCISION OF FOOT FASCIA $381.13

28010 3 INCISION OF TOE TENDON $211.35
28011 3 INCISION OF TOE TENDONS $299.17
28020 3 EXPLORATION OF FOOT JOINT $452.80
28022 3 EXPLORATION OF FOOT JOINT $417.92
28024 3 EXPLORATION OF TOE JOINT $397.35
28030 O REMOVAL OF FOOT NERVE $0.00
28035 3 DECOMPRESSION OF TIBIA NERVE $455.55
28043 3 EXCISION OF FOOT LESION $303.48
28045 3 EXCISION OF FOOT LESION $425.86
28046 3 RESECTION OF TUMOR, FOOT $772.64
28050 3 BIOPSY OF FOOT JOINT LINING $400.58
28052 3 BIOPSY OF FOOT JOINT LINING $369.35

28054 3 BIOPSY OF TOE JOINT LINING $347.21
28055 3 NEURECTOMY, FOOT $369.79
28060 3 PARTIAL REMOVAL, FOOT FASCIA $448.71
28062 3 REMOVAL OF FOOT FASCIA $527.49
28070 3 REMOVAL OF FOOT JOINT LINING $445.17
28072 3 REMOVAL OF FOOT JOINT LINING $439.43
28080 3 REMOVAL OF FOOT LESION $431.05
28086 3 EXCISE FOOT TENDON SHEATH $471.79
28088 3 EXCISE FOOT TENDON SHEATH $400.58

28092 3 REMOVAL OF TOE LESIONS $365.06
28100 3 REMOVAL OF ANKLE/HEEL LESION $520.93
28102 3 REMOVE/GRAFT FOOT LESION $518.63
28108 3 REMOVAL OF TOE LESIONS $376.09
28110 3 PART REMOVAL OF METATARSAL $395.29
28114 3 REMOVAL OF METATARSAL HEADS $922.88

28116 3 REVISION OF FOOT $658.77
28118 3 REMOVAL OF HEEL BONE $511.80
28119 3 REMOVAL OF HEEL SPUR $455.91
28120 3 PART REMOVAL OF ANKLE/HEEL $506.52
28122 3 PARTIAL REMOVAL OF FOOT BONE $587.56
28124 3 PARTIAL REMOVAL OF TOE $417.61
28130 3 REMOVAL OF ANKLE BONE $589.89
28140 3 REMOVAL OF METATARSAL $553.13
28150 3 REMOVAL OF TOE $376.56

28171 3 EXTENSIVE FOOT SURGERY $576.84
28190 3 REMOVAL OF FOOT FOREIGN BODY $215.78
28200 3 REPAIR OF FOOT TENDON $413.33
28202 3 REPAIR/GRAFT OF FOOT TENDON $548.54
28208 3 REPAIR OF FOOT TENDON $398.11
28210 3 REPAIR/GRAFT OF FOOT TENDON $511.33

28220 3 RELEASE OF FOOT TENDON $392.86
28222 3 RELEASE OF FOOT TENDONS $453.54
28225 3 RELEASE OF FOOT TENDON $341.78
28226 3 RELEASE OF FOOT TENDONS $410.48
28230 3 INCISION OF FOOT TENDON(S) $377.59
28232 3 INCISION OF TOE TENDON $335.35
28234 3 INCISION OF FOOT TENDON $347.91
28236 O TRANSFER OF TENDON, ANTERIOR TIBIAL $0.00
28238 3 REVISION OF FOOT TENDON $601.32
28240 3 RELEASE OF BIG TOE $388.52
28250 3 REVISION OF FOOT FASCIA $493.63
28260 3 RELEASE OF MIDFOOT JOINT $602.21
28261 3 REVISION OF FOOT TENDON $871.62

28262 3 REVISION OF FOOT AND ANKLE $1,219.90
28264 3 RELEASE OF MIDFOOT JOINT $781.05
28270 3 RELEASE OF FOOT CONTRACTURE $420.02
28272 3 RELEASE OF TOE JOINT, EACH $343.45
28280 3 FUSION OF TOES $460.95
28285 3 REPAIR OF HAMMERTOE $406.94
28286 3 REPAIR OF HAMMERTOE $397.64
28288 3 PARTIAL REMOVAL OF FOOT BONE $509.72
28289 3 REPAIR HALLUX RIGIDUS $643.29
28290 3 CORRECTION OF BUNION $502.45

28300 3 INCISION OF HEEL BONE $616.18
28302 3 INCISION OF ANKLE BONE $610.34
28304 3 INCISION OF MIDFOOT BONES $701.43
28305 3 INCISE/GRAFT MIDFOOT BONES $644.31
28306 3 INCISION OF METATARSAL $527.08

28309 3 INCISION OF METATARSALS $830.06
28310 3 REVISION OF BIG TOE $469.92
28312 3 REVISION OF TOE $430.88
28313 3 REPAIR DEFORMITY OF TOE $452.30
28315 3 REMOVAL OF SESAMOID BONE $414.97
28320 3 REPAIR OF FOOT BONES $582.57
28322 3 REPAIR OF METATARSALS $682.55
28340 3 RESECT ENLARGED TOE TISSUE $543.44
28341 3 RESECT ENLARGED TOE $625.44
28344 3 REPAIR EXTRA TOE(S) $418.74
28345 3 REPAIR WEBBED TOE(S) $504.23

28360 3 RECONSTRUCT CLEFT FOOT $895.94
28400 3 TREATMENT OF HEEL FRACTURE $213.05
28410 O TREATMENT OF OPEN CALCANEAL FRACTUR $0.00
28415 3 TREAT HEEL FRACTURE $1,044.31
28420 3 TREAT/GRAFT HEEL FRACTURE $1,098.88
28440 O TREATMENT OF OPEN TALUS FRACTURE, W $0.00
28445 3 TREAT ANKLE FRACTURE $984.15

28446 3 OSTEOCHONDRAL TALUS AUTOGRFT $1,077.80
28450 3 TREAT MIDFOOT FRACTURE, EACH $184.35
28456 3 TREAT MIDFOOT FRACTURE $245.61
28460 O TREATMENT OF OPEN TARSAL BONE FRACT $0.00
28470 3 TREAT METATARSAL FRACTURE $184.03
28480 O TREATMENT OF OPEN METATARSAL FRACTU $0.00

28490 3 TREAT BIG TOE FRACTURE $118.80
28500 O TREATMENT OF OPEN FRACTURE GREAT TO $0.00
28510 3 TREATMENT OF TOE FRACTURE $102.90
28515 3 TREATMENT OF TOE FRACTURE $135.55
28520 O TREATMENT OF OPEN FRACTURE, PHALANX $0.00
28525 3 TREAT TOE FRACTURE $488.94
28530 3 TREAT SESAMOID BONE FRACTURE $99.25
28531 3 TREAT SESAMOID BONE FRACTURE $323.00
28540 3 TREAT FOOT DISLOCATION $175.92

28550 O TREATMENT OF OPEN TARSAL BONE DISLO $0.00
28555 3 REPAIR FOOT DISLOCATION $758.15
28580 O TREATMENT OF OPEN TALOTARSAL JOINT $0.00

28610 O TREATMENT OF OPEN TARSOMETATARSAL J $0.00
28630 3 TREAT TOE DISLOCATION $130.59
28640 O TREATMENT OF OPEN METATARSOPHALANGE $0.00
28645 3 REPAIR TOE DISLOCATION $548.13

28670 O TREATMENT OF OPEN INTERPHALANGEAL J $0.00
28675 3 REPAIR OF TOE DISLOCATION $500.55
28705 3 FUSION OF FOOT BONES $1,212.27
28715 3 FUSION OF FOOT BONES $898.20
28737 3 REVISION OF FOOT BONES $655.51
28750 3 FUSION OF BIG TOE JOINT $732.12
28800 3 AMPUTATION OF MIDFOOT $529.65

28805 3 AMPUTATION THRU METATARSAL $695.61
28810 3 AMPUTATION TOE & METATARSAL $408.13
28820 3 AMPUTATION OF TOE $467.01
28825 3 PARTIAL AMPUTATION OF TOE $505.34
28890 3 HIGH ENERGY ESWT, PLANTAR F $306.99
28899 5 FOOT/TOES SURGERY PROCEDURE $0.00
29000 3 APPLICATION OF BODY CAST $237.38

29049 3 APPLICATION OF FIGURE EIGHT $75.59
29055 3 APPLICATION OF SHOULDER CAST $181.34
29058 3 APPLICATION OF SHOULDER CAST $97.47
29065 3 APPLICATION OF LONG ARM CAST $82.38
29075 3 APPLICATION OF FOREARM CAST $76.48
29085 3 APPLY HAND/WRIST CAST $81.40
29086 3 APPLY FINGER CAST $62.28

29105 3 APPLY LONG ARM SPLINT $75.37
29125 3 APPLY FOREARM SPLINT $58.62
29126 3 APPLY FOREARM SPLINT $67.28
29130 3 APPLICATION OF FINGER SPLINT $35.57
29131 3 APPLICATION OF FINGER SPLINT $44.03
29200 3 STRAPPING OF CHEST $47.11
29220 3 STRAPPING OF LOW BACK $48.60
29240 3 STRAPPING OF SHOULDER $52.68
29260 3 STRAPPING OF ELBOW OR WRIST $45.62
29280 3 STRAPPING OF HAND OR FINGER $44.08
29305 3 APPLICATION OF HIP CAST $204.78
29325 3 APPLICATION OF HIP CASTS $227.80
29345 3 APPLICATION OF LONG LEG CAST $118.26

29358 3 APPLY LONG LEG CAST BRACE $133.25
29405 3 APPLY SHORT LEG CAST $78.09
29440 3 ADDITION OF WALKER TO CAST $46.31
29445 3 APPLY RIGID LEG CAST $129.61
29450 3 APPLICATION OF LEG CAST $136.62
29505 3 APPLICATION, LONG LEG SPLINT $66.50
29515 3 APPLICATION LOWER LEG SPLINT $62.26
29520 3 STRAPPING OF HIP $44.41

29530 3 STRAPPING OF KNEE $46.33
29540 3 STRAPPING OF ANKLE AND/OR FT $38.15
29550 3 STRAPPING OF TOES $37.09
29580 3 APPLICATION OF PASTE BOOT $46.84
29590 3 APPLICATION OF FOOT SPLINT $50.02
29700 3 REMOVAL/REVISION OF CAST $56.67
29720 3 REPAIR OF BODY CAST $70.06

29730 3 WINDOWING OF CAST $57.77
29740 3 WEDGING OF CAST $82.79
29750 3 WEDGING OF CLUBFOOT CAST $90.36
29799 5 CASTING/STRAPPING PROCEDURE $0.00
29800 3 JAW ARTHROSCOPY/SURGERY $467.19
29804 3 JAW ARTHROSCOPY/SURGERY $579.45
29805 3 SHOULDER ARTHROSCOPY, DX $423.04
29806 3 SHOULDER ARTHROSCOPY/SURGERY $967.17
29815 O SHOULDER ARTHROSCOPY $0.00

29827 3 ARTHROSCOP ROTATOR CUFF REPR $991.35
29828 3 ARTHROSCOPY BICEPS TENODESIS $829.33
29830 3 ELBOW ARTHROSCOPY $408.07
29834 3 ELBOW ARTHROSCOPY/SURGERY $444.69

29840 3 WRIST ARTHROSCOPY $400.30
29843 3 WRIST ARTHROSCOPY/SURGERY $430.10
29848 3 WRIST ENDOSCOPY/SURGERY $444.71
29850 3 KNEE ARTHROSCOPY/SURGERY $515.99

29855 3 TIBIAL ARTHROSCOPY/SURGERY $712.97
29856 3 TIBIAL ARTHROSCOPY/SURGERY $911.82
29860 3 HIP ARTHROSCOPY, DX $586.93
29861 3 HIP ARTHROSCOPY/SURGERY $650.97
29866 3 AUTGRFT IMPLNT, KNEE W/SCOPE $948.36
29867 3 ALLGRFT IMPLNT, KNEE W/SCOPE $1,148.70
29868 3 MENISCAL TRNSPL, KNEE W/SCPE $1,535.53
29870 3 KNEE ARTHROSCOPY, DX $367.12
29871 3 KNEE ARTHROSCOPY/DRAINAGE $461.33


29889 3 KNEE ARTHROSCOPY/SURGERY $1,105.23
29891 3 ANKLE ARTHROSCOPY/SURGERY $629.03
29893 3 SCOPE, PLANTAR FASCIOTOMY $527.39

29900 3 MCP JOINT ARTHROSCOPY, DX $411.38
29901 3 MCP JOINT ARTHROSCOPY, SURG $450.72
29902 3 MCP JOINT ARTHROSCOPY, SURG $481.78
29904 3 SUBTALAR ARTHRO W/FB RMVL $558.48
29905 3 SUBTALAR ARTHRO W/EXC $601.32
29906 3 SUBTALAR ARTHRO W/DEB $633.47
29907 3 SUBTALAR ARTHRO W/FUSION $775.66
29909 O ARTHROSCOPY OF JOINT $0.00
29999 5 ARTHROSCOPY OF JOINT $0.00
30000 3 DRAINAGE OF NOSE LESION $204.06
3000F O BLOOD PRESS </= 140/90 MMHG $0.00
30020 3 DRAINAGE OF NOSE LESION $197.40
3002F O BLOOD PRESSURE > 140/90 MMHG $0.00

3006F 9 CXR DOC REV $0.00
30100 3 INTRANASAL BIOPSY $124.00
30110 3 REMOVAL OF NOSE POLYP(S) $199.48
30115 3 REMOVAL OF NOSE POLYP(S) $385.58
30117 3 REMOVAL OF INTRANASAL LESION $736.52
30118 3 REMOVAL OF INTRANASAL LESION $693.85
3011F 9 LIPID PANEL DOC REV $0.00
30120 3 REVISION OF NOSE $463.60
30124 3 REMOVAL OF NOSE LESION $243.53
30125 3 REMOVAL OF NOSE LESION $554.09
30130 3 EXCISE INFERIOR TURBINATE $337.06
30140 3 RESECT INFERIOR TURBINATE $385.62

3014F 9 SCREEN MAMMO DOC REV $0.00
30150 3 PARTIAL REMOVAL OF NOSE $711.22
30160 3 REMOVAL OF NOSE $714.27
3016F 9 PT SCRND UNHLTHY OH USE $0.00
3017F 9 COLORECTAL CA SCREEN DOC REV $0.00
3018F 9 PRE-PRXD RSK ET AL DOCD $0.00
30200 3 INJECTION TREATMENT OF NOSE $99.19
3020F 9 LVF ASSESS $0.00
30210 3 NASAL SINUS THERAPY $130.19
3021F 9 LVEF MOD/SEVER DEPRS SYST $0.00

30220 9 INSERT NASAL SEPTAL BUTTON $0.00
3022F 9 LVEF =40% SYSTOLIC $0.00
3023F 9 SPIROM DOC REV $0.00
3025F 9 SPIROM FEV/FVC<70% W COPD $0.00
3027F 9 SPIROM FEV/FVC=70%/ W/O COPD $0.00
3028F 9 O2 SATURATION DOC REV $0.00
30300 3 REMOVE NASAL FOREIGN BODY $199.88
3035F 9 O2 SATURATION =88% /PA0 =55 $0.00
3037F 9 O2 SATURATION> 88% /PAO>55 $0.00
30400 3 RECONSTRUCTION OF NOSE $932.41
3040F 9 FEV<40% PREDICTED VALUE $0.00

30410 3 RECONSTRUCTION OF NOSE $1,103.64
30420 3 RECONSTRUCTION OF NOSE $1,238.92
3042F 9 FEV= 40% PREDICTED VALUE $0.00
3044F 9 HG A1C LEVEL LT 7.0% $0.00
30450 3 REVISION OF NOSE $1,425.18
3045F 9 HG A1C LEVEL 7.09.0% $0.00
30462 3 REVISION OF NOSE $1,385.43
30465 3 REPAIR NASAL STENOSIS $883.20
3046F 9 HEMOGLOBIN A1C LEVEL > 9.0% $0.00

3047F O HEMOGLOBIN A1C LEVEL = 9.0% $0.00
3048F 9 LDL-C <100 MG/DL $0.00
3049F 9 LDL-C 100-129 MG/DL $0.00
3050F 9 LDL-C = 130 MG/DL $0.00
30520 3 REPAIR OF NASAL SEPTUM $541.21
30540 3 REPAIR NASAL DEFECT $603.85
30545 3 REPAIR NASAL DEFECT $872.65
30560 3 RELEASE OF NASAL ADHESIONS $236.69
30580 3 REPAIR UPPER JAW FISTULA $563.83
30600 3 REPAIR MOUTH/NOSE FISTULA $519.10

3060F 9 POS MICROALBUMINURIA REV $0.00
3061F 9 NEG MICROALBUMINURIA REV $0.00
30620 3 INTRANASAL RECONSTRUCTION $553.36
3062F 9 POS MACROALBUMINURIA REV $0.00
30630 3 REPAIR NASAL SEPTUM DEFECT $560.68
3066F 9 NEPHROPATHY DOC TX $0.00
3072F 9 LOW RISK FOR RETINOPATHY $0.00
3073F 9 PRE-SURG EYE MEASURES DOCD $0.00
3074F 9 SYST BP LT 130 MM HG $0.00
3075F 9 SYST BP GE 130 - 139MM HG $0.00
3076F O SYST BP < 140 MM HG $0.00
3077F 9 SYST BP = 140 MM HG6 IT $0.00
3078F 9 DIAST BP < 80 MM HG $0.00

3079F 9 DIAST BP 80-89 MM HG $0.00
30800 O CAUTERIZATION TURBINATES, UNILATERA $0.00
30801 3 ABLATE INF TURBINATE, SUPERF $198.95
30802 3 CAUTERIZATION, INNER NOSE $256.40
30805 O CAUTERIZATION TURBINATES, UNILATERA $0.00
3080F 9 DIAST BP = 90 MM HG $0.00
30820 O CRYOSURGERY OF TURBINATES, UNILATER $0.00
3082F 9 KT/V LT1.2 $0.00
3083F 9 KT/V GE 1.2 AND <1.7 $0.00
3084F 9 KT/V GE 1.7 $0.00
3085F 9 SUICIDE RISK ASSESSED $0.00
3088F 9 MDD, MILD $0.00

3089F 9 MDD, MODERATE $0.00
30901 3 CONTROL OF NOSEBLEED $93.57
30906 3 REPEAT CONTROL OF NOSEBLEED $246.51
3090F 9 MDD, SEVERE; W/O PSYCH $0.00
30915 3 LIGATION, NASAL SINUS ARTERY $519.80
3091F 9 MDD, SEVERE; W/ PSYCH $0.00
30920 3 LIGATION, UPPER JAW ARTERY $747.91
3092F 9 MDD, IN REMISSION $0.00

30930 3 THER FX, NASAL INF TURBINATE $109.25
3093F 9 DOC NEW DIAG 1ST/ADDL. MDD $0.00
3095F 9 CENTRAL DEXA RESULTS DOCÏD $0.00
3096F 9 CENTRAL DEXA ORDERED $0.00
30999 5 NASAL SURGERY PROCEDURE $0.00
31000 3 IRRIGATION, MAXILLARY SINUS $158.21
31002 3 IRRIGATION, SPHENOID SINUS $180.52
3100F 9 IMAGE TEST REF CAROT DIAM $0.00
31020 3 EXPLORATION, MAXILLARY SINUS $428.79
31030 3 EXPLORATION, MAXILLARY SINUS $622.58
31032 3 EXPLORE SINUS, REMOVE POLYPS $513.21
31040 3 EXPLORATION BEHIND UPPER JAW $674.75
31050 3 EXPLORATION, SPHENOID SINUS $443.66

31051 3 SPHENOID SINUS SURGERY $579.43
31070 3 EXPLORATION OF FRONTAL SINUS $390.11
31071 O SINUSOTOMY FRONTAL; INTRANASAL $0.00
31075 3 EXPLORATION OF FRONTAL SINUS $706.58
31080 3 REMOVAL OF FRONTAL SINUS $911.99
31081 3 REMOVAL OF FRONTAL SINUS $1,115.52
31087 3 REMOVAL OF FRONTAL SINUS $997.92
31090 3 EXPLORATION OF SINUSES $899.70
3110F 9 PRES/ABSN HMRHG/LESION DOCÏD $0.00

3111F 9 CT/MRI BRAIN DONE W/IN 24HRS $0.00
3112F 9 CT/MRI BRAIN DONE GT24 HRS $0.00
31200 3 REMOVAL OF ETHMOID SINUS $480.24
3120F 9 12-LEAD ECG PERFORMED $0.00
31225 3 REMOVAL OF UPPER JAW $1,658.38
31230 3 REMOVAL OF UPPER JAW $1,857.84
31231 3 NASAL ENDOSCOPY, DX $170.86
31233 3 NASAL/SINUS ENDOSCOPY, DX $239.82

31235 3 NASAL/SINUS ENDOSCOPY, DX $275.44
31237 3 NASAL/SINUS ENDOSCOPY, SURG $296.58
31245 O NASAL/SINUS ENDOSCOPY, SURGICAL, WI $0.00
31250 O NASAL ENDOSCOPY, DIAGNOSTIC (INCLUD $0.00
31252 O NASAL ENDOSCOPY, SURGICAL WITH NASA $0.00

31254 3 REVISION OF ETHMOID SINUS $259.78
31256 3 EXPLORATION MAXILLARY SINUS $188.33
31258 O NASAL ENDOSCOPY, SURGICAL WITH REMO $0.00
31260 O MAXILLARY SINUS ENDOSCOPY, DIAGNOST $0.00
31263 O MAXILLARY SINUS ENDOSCOPY, SURGICAL $0.00
31267 3 ENDOSCOPY, MAXILLARY SINUS $302.95

31270 O SPHENOID ENDOSCOPY, DIAGNOSTIC $0.00
31275 O SPHENOID ENDOSCOPY, SURGICAL; $0.00
31276 3 SINUS ENDOSCOPY, SURGICAL $483.23
31277 O SPHENOID ENDOSCOPY, SURGICAL WITH R $0.00

31285 O SINUS ENDOSCOPY, TWO OR MORE SINUSE $0.00
31290 3 NASAL/SINUS ENDOSCOPY, SURG $1,068.78
31299 5 SINUS SURGERY PROCEDURE $0.00
31300 3 REMOVAL OF LARYNX LESION $1,139.92

3130F 9 UPPER GI ENDOSCOPY PERFORMED $0.00
31320 3 DIAGNOSTIC INCISION, LARYNX $583.78
3132F 9 DOC REF. UPPER GI ENDOSCOPY $0.00
31360 3 REMOVAL OF LARYNX $1,814.36
31365 3 REMOVAL OF LARYNX $2,268.78
31367 3 PARTIAL REMOVAL OF LARYNX $1,963.12
31390 3 REMOVAL OF LARYNX & PHARYNX $2,528.86

31395 3 RECONSTRUCT LARYNX & PHARYNX $2,684.84
31400 3 REVISION OF LARYNX $907.78
3140F 9 UPPER GI ENDO SHOWS BARRTTÏS $0.00
3141F 9 UPPER GI ENDO NOT BARRTTÏS $0.00
31420 3 REMOVAL OF EPIGLOTTIS $758.99
3142F 9 BARIUM SWALLOW TEST ORDERED $0.00
31500 3 INSERT EMERGENCY AIRWAY $104.34
31502 3 CHANGE OF WINDPIPE AIRWAY $33.30
31505 3 DIAGNOSTIC LARYNGOSCOPY $75.50
3150F 9 FORCEPS ESOPH BIOPSY DONE $0.00

31510 3 LARYNGOSCOPY WITH BIOPSY $192.23
31511 3 REMOVE FOREIGN BODY, LARYNX $192.29
31512 3 REMOVAL OF LARYNX LESION $189.93
31513 9 INJECTION INTO VOCAL CORD $0.00
31515 3 LARYNGOSCOPY FOR ASPIRATION $190.05
31520 3 DX LARYNGOSCOPY, NEWBORN $144.33
31525 3 DX LARYNGOSCOPY EXCL NB $228.05
31526 3 DX LARYNGOSCOPY W/OPER SCOPE $149.00
31527 9 LARYNGOSCOPY FOR TREATMENT $0.00
31528 3 LARYNGOSCOPY AND DILATION $135.83
31529 9 LARYNGOSCOPY AND DILATION $0.00
31530 3 LARYNGOSCOPY W/FB REMOVAL $187.26
31531 3 LARYNGOSCOPY W/FB & OP SCOPE $201.79

31535 3 LARYNGOSCOPY W/BIOPSY $179.41
31536 3 LARYNGOSCOPY W/BX & OP SCOPE $200.35
31540 3 LARYNGOSCOPY W/EXC OF TUMOR $230.18
31541 3 LARYNSCOP W/TUMR EXC + SCOPE $251.72
31545 3 REMOVE VC LESION W/SCOPE $340.47
31546 3 REMOVE VC LESION SCOPE/GRAFT $518.33
3155F 9 CYTOGEN TEST MARROW B/4 TX $0.00
31560 3 LARYNGOSCOP W/ARYTENOIDECTOM $297.85
31561 3 LARYNSCOP, REMVE CART + SCOP $326.35
31570 3 LARYNGOSCOPE W/VC INJ $317.28
31571 3 LARYNGOSCOP W/VC INJ + SCOPE $237.51

31576 3 LARYNGOSCOPY WITH BIOPSY $205.74
31577 9 REMOVE FOREIGN BODY, LARYNX $0.00
31578 3 REMOVAL OF LARYNX LESION $257.47
31580 3 REVISION OF LARYNX $1,088.96
31584 3 TREAT LARYNX FRACTURE $1,382.50
31585 O TREAT LARYNX FRACTURE $0.00
31586 O TREAT LARYNX FRACTURE $0.00
31587 3 REVISION OF LARYNX $900.72

31590 9 REINNERVATE LARYNX $0.00
31595 9 LARYNX NERVE SURGERY $0.00
31599 5 LARYNX SURGERY PROCEDURE $0.00
31600 3 INCISION OF WINDPIPE $372.25
3160F 9 DOC FE+ STORES B/4 EPO THX $0.00
31611 3 SURGERY/SPEECH PROSTHESIS $484.70
31612 3 PUNCTURE/CLEAR WINDPIPE $73.99
31613 3 REPAIR WINDPIPE OPENING $401.41

31614 9 REPAIR WINDPIPE OPENING $0.00
31615 3 VISUALIZATION OF WINDPIPE $168.35
31620 3 ENDOBRONCHIAL US ADD-ON $266.73
31622 3 DX BRONCHOSCOPE/WASH $139.15
31623 3 DX BRONCHOSCOPE/BRUSH $326.38
31624 3 DX BRONCHOSCOPE/LAVAGE $141.15
31625 3 BRONCHOSCOPY W/BIOPSY(S) $326.24
31628 3 BRONCHOSCOPY/LUNG BX, EACH $183.36
31629 3 BRONCHOSCOPY/NEEDLE BX, EACH $196.20
31630 3 BRONCHOSCOPY DILATE/FX REPR $196.31
31631 3 BRONCHOSCOPY, DILATE W/STENT $221.25
31632 3 BRONCHOSCOPY/LUNG BX, ADDÏL $71.80

31633 3 BRONCHOSCOPY/NEEDLE BX ADDÏL $86.49
31635 3 BRONCHOSCOPY W/FB REMOVAL $334.69
31636 3 BRONCHOSCOPY, BRONCH STENTS $216.17
31637 3 BRONCHOSCOPY, STENT ADD-ON $76.58
31638 3 BRONCHOSCOPY, REVISE STENT $242.50
31640 3 BRONCHOSCOPY W/TUMOR EXCISE $251.15
31641 3 BRONCHOSCOPY, TREAT BLOCKAGE $248.04
31643 3 DIAG BRONCHOSCOPE/CATHETER $170.18
31645 3 BRONCHOSCOPY, CLEAR AIRWAYS $154.47
31646 3 BRONCHOSCOPY, RECLEAR AIRWAY $133.83

31656 3 BRONCHOSCOPY, INJ FOR X-RAY $304.81
31659 O BRONCHOSCOPY; WITH OTHER BRONCHOSCO $0.00
31700 O INSERTION OF AIRWAY CATHETER $0.00
31708 O INSTILL AIRWAY CONTRAST DYE $0.00
3170F 9 FLOW CYTO DONE B/4 TX $0.00
31710 O INSERTION OF AIRWAY CATHETER $0.00
31715 3 INJECTION FOR BRONCHUS X-RAY $53.55
31717 3 BRONCHIAL BRUSH BIOPSY $286.15
31719 O TRANSTRACHEAL (PERCUTANEOUS) INTROD $0.00
31720 3 CLEARANCE OF AIRWAYS $50.27
31725 3 CLEARANCE OF AIRWAYS $90.41
31730 3 INTRO, WINDPIPE WIRE/TUBE $818.94
31750 3 REPAIR OF WINDPIPE $1,217.18

31766 3 RECONSTRUCTION OF WINDPIPE $1,699.18
31770 3 REPAIR/GRAFT OF BRONCHUS $1,259.06
31775 3 RECONSTRUCT BRONCHUS $1,301.28
31780 3 RECONSTRUCT WINDPIPE $1,102.49
31781 3 RECONSTRUCT WINDPIPE $1,335.01
31785 3 REMOVE WINDPIPE LESION $1,008.89
31786 3 REMOVE WINDPIPE LESION $1,403.10
31800 3 REPAIR OF WINDPIPE INJURY $637.05
31805 3 REPAIR OF WINDPIPE INJURY $774.17
31820 3 CLOSURE OF WINDPIPE LESION $387.94

31825 3 REPAIR OF WINDPIPE DEFECT $542.00
31830 3 REVISE WINDPIPE SCAR $390.90
31899 5 AIRWAYS SURGICAL PROCEDURE $0.00
32000 O DRAINAGE OF CHEST $0.00
32001 O TOTAL LUNG LAVAGE $0.00
32002 O TREATMENT OF COLLAPSED LUNG $0.00
32005 O TREAT LUNG LINING CHEMICALLY $0.00
3200F 9 BARIUM SWALLOW TEST NOT REQ $0.00
32019 O INSERT PLEURAL CATHETER $0.00
32020 O INSERTION OF CHEST TUBE $0.00

32035 3 EXPLORATION OF CHEST $659.64
32095 3 BIOPSY THROUGH CHEST WALL $586.88
32100 3 EXPLORATION/BIOPSY OF CHEST $905.94
3210F 9 GRP A STREP TEST PERFORMED $0.00
32110 3 EXPLORE/REPAIR CHEST $1,363.70
32120 3 RE-EXPLORATION OF CHEST $812.59
32124 3 EXPLORE CHEST FREE ADHESIONS $863.60
32140 3 REMOVAL OF LUNG LESION(S) $923.67
32141 3 REMOVE/TREAT LUNG LESIONS $1,392.19
32150 3 REMOVAL OF LUNG LESION(S) $930.72
32151 3 REMOVE LUNG FOREIGN BODY $952.35
3215F 9 PT IMMUNITY TO HEP A DOCÏD $0.00

32160 3 OPEN CHEST HEART MASSAGE $714.41
3216F 9 PT IMMUNITY TO HEP B DOCÏD $0.00
3218F 9 RNA TSTNG HEP C DOCÏD-DONE $0.00
32200 3 DRAIN, OPEN, LUNG LESION $1,045.13
32201 3 DRAIN, PERCUT, LUNG LESION $889.23
3220F 9 HEP C QUANT RNA TSTNG DOCÏD $0.00
32215 3 TREAT CHEST LINING $750.25
32220 3 RELEASE OF LUNG $1,498.45
32225 3 PARTIAL RELEASE OF LUNG $931.87
3230F 9 NOTE HRING TST W/IN 6 MON $0.00
32310 3 REMOVAL OF CHEST LINING $859.92
32315 O PLEURECTOMY; PARTIAL $0.00

32320 3 FREE/REMOVE CHEST LINING $1,500.54
32400 3 NEEDLE BIOPSY CHEST LINING $145.52
32402 3 OPEN BIOPSY CHEST LINING $528.92
32405 3 BIOPSY, LUNG OR MEDIASTINUM $98.96
32420 3 PUNCTURE/CLEAR LUNG $108.88
32421 3 THORACENTESIS FOR ASPIRATION $151.96
32422 3 THORACENTESIS W/TUBE INSERT $191.31
32440 3 REMOVAL OF LUNG $1,500.02
32442 3 SLEEVE PNEUMONECTOMY $2,779.09
32445 3 REMOVAL OF LUNG $3,159.30

32450 O PNEUMONECTOMY, EXTRAPLEURAL WITH EM $0.00
32480 3 PARTIAL REMOVAL OF LUNG $1,415.56
32482 3 BILOBECTOMY $1,510.12
32484 3 SEGMENTECTOMY $1,364.75
32485 O REMOVAL OF LUNG, OTHER THAN TOTAL P $0.00
32486 3 SLEEVE LOBECTOMY $2,173.89
32488 3 COMPLETION PNEUMONECTOMY $2,203.35
32490 O LOBECTOMY, TOTAL OR SEGMENTAL WITH $0.00
32491 3 LUNG VOLUME REDUCTION $1,406.70
32500 3 PARTIAL REMOVAL OF LUNG $1,369.19
32501 3 REPAIR BRONCHUS ADD-ON $238.27
32503 3 RESECT APICAL LUNG TUMOR $1,727.34
32504 3 RESECT APICAL LUNG TUM/CHEST $1,983.90

3250F 9 NONPRIM LOC ANAT BX SITE TUM $0.00
32520 O REMOVE LUNG & REVISE CHEST $0.00
32540 3 REMOVAL OF LUNG LESION $1,568.58
32545 O EXTRAPLEURAL ENUCLEATION OF EMPYEMA $0.00
32550 3 INSERT PLEURAL CATH $755.79
32551 3 INSERTION OF CHEST TUBE $169.65
32560 3 TREAT LUNG LINING CHEMICALLY $281.94
32601 3 THORACOSCOPY, DIAGNOSTIC $297.11

3260F 9 PT CAT/PN CAT/HIST GRD DOCÏD $0.00
32650 3 THORACOSCOPY, SURGICAL $637.52
32651 3 THORACOSCOPY, SURGICAL $1,004.00

3265F 9 RNA TSTNG HEPC VIR ORD/DOCÏD $0.00
3266F 9 HEPC GN TSTNG DOCÏD B/4TXMNT $0.00
3268F 9 PSA/T/G1SC DOCÏD B/4 TXMNT $0.00

3269F 9 BONE SCN B/4 TXMNT/AFTR DX $0.00
32700 O THORACOSCOPY, EXPLORATORY (SEPARATE $0.00
32705 O THORACOSCOPY, EXPLORATORY (SEPARATE $0.00
3270F 9 NO BONE SCN B/4 TXMNT/AFTRDX $0.00
3271F 9 LOW RISK, PROSTATE CANCER $0.00
3272F 9 MED. RISK, PROSTATE CANCER $0.00
3273F 9 HIGH RISK, PROSTATE CANCER $0.00
3274F 9 PROST CNCR RSK NOT LW/MD/HGH $0.00
3278F 9 SERUM LVLS CA/IPTH/LPD ORD $0.00
3279F 9 HGB LVL >/=13 G/DL $0.00
32800 3 REPAIR LUNG HERNIA $877.63
3280F 9 HGB LVL 11-12.9 G/DL $0.00

32810 3 CLOSE CHEST AFTER DRAINAGE $849.64
32815 3 CLOSE BRONCHIAL FISTULA $2,505.54
3281F 9 HGB LVL <11 G/DL $0.00
32820 3 RECONSTRUCT INJURED CHEST $1,265.62
3284F 9 IOP DOWN >15% OF PRE-SVC LVL $0.00
32850 9 DONOR PNEUMONECTOMY $0.00
32851 3 LUNG TRANSPLANT, SINGLE $2,451.44
32852 3 LUNG TRANSPLANT WITH BYPASS $2,715.09
32853 3 LUNG TRANSPLANT, DOUBLE $2,926.86
32854 3 LUNG TRANSPLANT WITH BYPASS $3,189.02

32855 9 PREPARE DONOR LUNG, SINGLE $0.00
32856 9 PREPARE DONOR LUNG, DOUBLE $0.00
3285F 9 IOP DOWN <15% OF PRE-SVC LVL $0.00
3288F 9 FALL RISK ASSESSMENT DOCÏD $0.00
32900 3 REMOVAL OF RIB(S) $1,289.30
32905 3 REVISE & REPAIR CHEST WALL $1,271.91
32906 3 REVISE & REPAIR CHEST WALL $1,578.79
3290F 9 PT=D(RH)- AND UNSENSITIZED $0.00
3291F 9 PT=D(RH)+OR SENSITIZED $0.00
3292F 9 HIV TSTNG ASKED/DOCÏD/REVWÏD $0.00
32940 3 REVISION OF LUNG $1,165.45
32960 3 THERAPEUTIC PNEUMOTHORAX $132.44
32997 3 TOTAL LUNG LAVAGE $343.17

32998 3 PERQ RF ABLATE TX, PUL TUMOR $2,733.40
32999 5 CHEST SURGERY PROCEDURE $0.00
3300F 9 AJCC STAGE DOCD B/4 THXPY $0.00
33010 3 DRAINAGE OF HEART SAC $120.37
33011 3 REPEAT DRAINAGE OF HEART SAC $117.65
33015 3 INCISION OF HEART SAC $512.75
3301F 9 CANCER STAGE DOCD METAST $0.00
3302F O AJCC STAGE 0 DOCÏD $0.00
33030 3 PARTIAL REMOVAL OF HEART SAC $1,219.15
33031 3 PARTIAL REMOVAL OF HEART SAC $1,360.49

3303F O AJCC STAGE IA DOCÏD $0.00
3304F O AJCC STAGE IB DOCÏD $0.00
33050 3 REMOVAL OF HEART SAC LESION $943.12
3305F O AJCC STAGE IC DOCÏD $0.00
3306F O AJCC STAGE IIA DOCÏD $0.00
3307F O AJCC STAGE IIB DOCÏD $0.00
3308F O AJCC STAGE IIC DOCÏD $0.00
3309F O AJCC STAGE IIIA DOCÏD $0.00
33100 O PERICARDIECTOMY (SEPARATE PROCEDURE $0.00
3310F O AJCC STAGE IIIB DOCÏD $0.00

3311F O AJCC STAGE IIIC DOCÏD $0.00
33120 3 REMOVAL OF HEART LESION $1,488.23
3312F O AJCC STAGE IVA DOCÏD $0.00
3313F O AJCC STAGE IVB DOCÏD $0.00
33140 3 HEART REVASCULARIZE (TMR) $1,494.68
33141 3 HEART TMR W/OTHER PROCEDURE $145.38
3314F O AJCC STAGE IVC DOCÏD $0.00
3315F 9 ER +OR PR +BREAST CANCER $0.00
3316F 9 ER- OR PR- BREAST CANCER $0.00
3317F 9 PATH RPT MALIG CANCER DOCÏD $0.00
3318F 9 PATH RPT MALIG CANCER DOCÏD $0.00
3319F 9 X-RAY/CT/ULTRSND ET AL ORDÏD $0.00

33200 O INSERTION OF HEART PACEMAKER $0.00
33201 O INSERTION OF HEART PACEMAKER $0.00
33202 3 INSERT EPICARD ELTRD, OPEN $744.17
33203 3 INSERT EPICARD ELTRD, ENDO $784.72
33206 3 INSERTION OF HEART PACEMAKER $457.42
3320F 9 NO XRAY/CT/ ET AL ORDÏD $0.00
33210 3 INSERTION OF HEART ELECTRODE $180.65
33211 3 INSERTION OF HEART ELECTRODE $181.26
33212 3 INSERTION OF PULSE GENERATOR $341.78
33213 3 INSERTION OF PULSE GENERATOR $390.00

33214 3 UPGRADE OF PACEMAKER SYSTEM $483.79
33215 3 REPOSITION PACING-DEFIB LEAD $309.31
33216 3 INSERT LEAD PACE-DEFIB, ONE $381.50
33217 3 INSERT LEAD PACE-DEFIB, DUAL $378.19
33218 3 REPAIR LEAD PACE-DEFIB, ONE $394.49
33219 O REPAIR OF PACEMAKER WITH REPLACEMEN $0.00
3321F 9 AJCC CNCR 0/IA MELAN DOCD $0.00
33220 3 REPAIR LEAD PACE-DEFIB, DUAL $398.09
33222 3 REVISE POCKET, PACEMAKER $347.69
33223 3 REVISE POCKET, PACING-DEFIB $420.16

33224 3 INSERT PACING LEAD & CONNECT $510.85
33225 3 L VENTRIC PACING LEAD ADD-ON $460.40
33226 3 REPOSITION L VENTRIC LEAD $493.64
3322F 9 MELAN >AJCC STAGE 0 OR IA $0.00
33232 O REMOVAL OF PERMANENT PACEMAKER $0.00
33233 3 REMOVAL OF PACEMAKER SYSTEM $243.69
33234 3 REMOVAL OF PACEMAKER SYSTEM $491.36
33235 3 REMOVAL PACEMAKER ELECTRODE $635.57
33236 3 REMOVE ELECTRODE/THORACOTOMY $747.65
33240 3 INSERT PULSE GENERATOR $469.58
33241 3 REMOVE PULSE GENERATOR $230.24

33242 O REPAIR PULSE GENERATOR/LEADS $0.00
33243 3 REMOVE ELTRD/THORACOTOMY $1,309.43
33244 3 REMOVE ELTRD, TRANSVEN $863.22
33245 O INSERT EPIC ELTRD PACE-DEFIB $0.00
33246 O INSERT EPIC ELTRD/GENERATOR $0.00
33247 O INSERT/REPLACE LEADS $0.00
33248 O REVISION OR REMOVAL OF AUTOMATIC IM $0.00
33249 3 ELTRD/INSERT PACE-DEFIB $913.06
33250 3 ABLATE HEART DYSRHYTHM FOCUS $1,400.28
33253 O RECONSTRUCT ATRIA $0.00
33254 3 ABLATE ATRIA, LMTD $1,306.65

33255 3 ABLATE ATRIA W/O BYPASS, EXT $1,598.51
33256 3 ABLATE ATRIA W/BYPASS, EXTEN $1,905.68
33257 3 ABLATE ATRIA, LMTD, ADD-ON $552.15
33258 3 ABLATE ATRIA, X10SV, ADD-ON $623.28
33259 3 ABLATE ATRIA W/BYPASS ADD-ON $813.39
3325F 9 PREOP ASSES 4 CATARACT SURG $0.00
33260 O OPERATIVE ABLATION OF ARRHYTHMOGENI $0.00
33265 3 ABLATE ATRIA, LMTD, ENDO $1,303.69
33266 3 ABLATE ATRIA, X10SV, ENDO $1,787.93

33282 3 IMPLANT PAT-ACTIVE HT RECORD $326.89
33284 3 REMOVE PAT-ACTIVE HT RECORD $236.21
33300 3 REPAIR OF HEART WOUND $2,207.25
33305 3 REPAIR OF HEART WOUND $3,680.75
3330F 9 IMAGING STUDY ORDERED (BKP) $0.00
33310 3 EXPLORATORY HEART SURGERY $1,117.35
33315 3 EXPLORATORY HEART SURGERY $1,420.23
3331F 9 BK IMAGING TST NOT ORDERED $0.00
33320 3 REPAIR MAJOR BLOOD VESSEL(S) $1,013.03
33321 3 REPAIR MAJOR VESSEL $1,142.16
33322 3 REPAIR MAJOR BLOOD VESSEL(S) $1,326.19
33330 3 INSERT MAJOR VESSEL GRAFT $1,337.46

33350 O GREAT VESSEL REPAIR WITH OTHER MAJO $0.00
33400 3 REPAIR OF AORTIC VALVE $2,173.52
33401 3 VALVULOPLASTY, OPEN $1,441.40
33403 3 VALVULOPLASTY, W/CP BYPASS $1,447.11
33404 3 PREPARE HEART-AORTA CONDUIT $1,712.54
33405 3 REPLACEMENT OF AORTIC VALVE $2,218.88
33407 O VALVOTOMY, AORTIC VALVE (COMMISSURO $0.00
33408 O VALVOTOMY, AORTIC VALVE (COMMISSURO $0.00
3340F 9 MAMMO ASSESS INC XRAY DOCD $0.00

33415 3 REVISION, SUBVALVULAR TISSUE $1,924.68
33416 3 REVISE VENTRICLE MUSCLE $1,934.82
3341F 9 MAMMO ASSESS NEGATIVE DOCD $0.00
33420 3 REVISION OF MITRAL VALVE $1,308.44

33425 3 REPAIR OF MITRAL VALVE $2,522.20
3342F 9 MAMMO ASSESS BENGN DOCD $0.00
33430 3 REPLACEMENT OF MITRAL VALVE $2,649.64
3343F 9 MAMMO PROBABLY BENGN DOCD $0.00
3344F 9 MAMMO ASSESS SUSP, DOCD $0.00
33452 O VALVOTOMY, TRICUSPID VALVE, WITH CA $0.00
3345F 9 MAMMO ASSESS HGHLYMALIG DOC $0.00
33460 3 REVISION OF TRICUSPID VALVE $2,243.90
33463 3 VALVULOPLASTY, TRICUSPID $2,834.69
33464 3 VALVULOPLASTY, TRICUSPID $2,285.23
33465 3 REPLACE TRICUSPID VALVE $2,556.65

33468 3 REVISION OF TRICUSPID VALVE $1,807.15
33470 3 REVISION OF PULMONARY VALVE $1,141.46
33471 3 VALVOTOMY, PULMONARY VALVE $1,273.04
33475 3 REPLACEMENT, PULMONARY VALVE $2,218.68
33476 3 REVISION OF HEART CHAMBER $1,405.46
33480 O REPLACEMENT AND/OR REPAIR, DOUBLE V $0.00
33481 O SINGLE VALVE REPLACEMENT WITH COMMI $0.00
33482 O SINGLE VALVE REPLACEMENT WITH COMMI $0.00
33483 O DOUBLE VALVE REPLACEMENT $0.00

33485 O DOUBLE VALVE REPLACEMENT WITH COMMI $0.00
33490 O REPLACEMENT AND/OR REPAIR, TRIPLE V $0.00
33492 O TRIPLE VALVE REPLACEMENT $0.00
33496 3 REPAIR, PROSTH VALVE CLOT $1,616.85
33500 3 REPAIR HEART VESSEL FISTULA $1,517.21
33501 3 REPAIR HEART VESSEL FISTULA $1,053.23
33502 3 CORONARY ARTERY CORRECTION $1,217.79
33503 3 CORONARY ARTERY GRAFT $1,307.97
33504 3 CORONARY ARTERY GRAFT $1,389.42
33505 3 REPAIR ARTERY W/TUNNEL $1,906.10

33506 3 REPAIR ARTERY, TRANSLOCATION $1,977.80
33507 3 REPAIR ART, INTRAMURAL $1,674.15
33508 3 ENDOSCOPIC VEIN HARVEST $15.73
3350F 9 MAMMO BX PROVEN MALIG DOCD $0.00
33510 3 CABG, VEIN, SINGLE $1,887.44
33511 3 CABG, VEIN, TWO $2,059.76
33512 3 CABG, VEIN, THREE $2,318.80
33513 3 CABG, VEIN, FOUR $2,367.58
33514 3 CABG, VEIN, FIVE $2,509.48
33516 3 CABG, VEIN, SIX OR MORE $2,609.56
33517 3 CABG, ARTERY-VEIN, SINGLE $179.02
33518 3 CABG, ARTERY-VEIN, TWO $387.37
33519 3 CABG, ARTERY-VEIN, THREE $516.97

3351F 9 NEG SCRN DEP SYMP BY DEPTOOL $0.00
33520 O CORONARY ARTERY BYPASS, NONAUTOGENO $0.00
33521 3 CABG, ARTERY-VEIN, FOUR $625.80
33522 3 CABG, ARTERY-VEIN, FIVE $712.09
33523 3 CABG, ART-VEIN, SIX OR MORE $812.72
3352F 9 NO SIG DEP SYMP BY DEP TOOL $0.00
33530 3 CORONARY ARTERY, BYPASS/REOP $492.51
33533 3 CABG, ARTERIAL, SINGLE $1,838.58
33534 3 CABG, ARTERIAL, TWO $2,136.77
33535 3 CABG, ARTERIAL, THREE $2,371.58

33536 3 CABG, ARTERIAL, FOUR OR MORE $2,539.90
3353F 9 MILD-MOD DEP SYMP BY DEPTOOL $0.00
33545 3 REPAIR OF HEART DAMAGE $2,884.20
33548 3 RESTORE/REMODEL, VENTRICLE $2,833.80
3354F 9 CLIN SIG DEP SYM BY DEP TOOL $0.00
33570 O CORONARY ANGIOPLASTY (ENDARTERECTOM $0.00
33572 3 OPEN CORONARY ENDARTERECTOMY $227.48
33575 O CORONARY ANGIOPLASTY (ENDARTERECTOM $0.00
33600 3 CLOSURE OF VALVE $1,645.44

33602 3 CLOSURE OF VALVE $1,566.82
33606 3 ANASTOMOSIS/ARTERY-AORTA $1,707.65
33608 3 REPAIR ANOMALY W/CONDUIT $1,754.32
33610 3 REPAIR BY ENLARGEMENT $1,711.04
33611 3 REPAIR DOUBLE VENTRICLE $1,878.69
33612 3 REPAIR DOUBLE VENTRICLE $1,939.67
33615 3 REPAIR, MODIFIED FONTAN $1,935.57
33617 3 REPAIR SINGLE VENTRICLE $2,074.27
33619 3 REPAIR SINGLE VENTRICLE $2,539.95
33641 3 REPAIR HEART SEPTUM DEFECT $1,543.78
33645 3 REVISION OF HEART VEINS $1,522.49
33647 3 REPAIR HEART SEPTUM DEFECTS $1,621.16
33649 O REPAIR OF TRICUSPID ATRESIA (EG, FO $0.00

33660 3 REPAIR OF HEART DEFECTS $1,695.05
33670 3 REPAIR OF HEART CHAMBERS $1,905.86
33675 3 CLOSE MULT VSD $1,903.21
33676 3 CLOSE MULT VSD W/RESECTION $1,981.75
33677 3 CL MULT VSD W/REM PUL BAND $2,059.58
33690 3 REINFORCE PULMONARY ARTERY $1,111.39

33696 O COMPLETE REPAIR TETRALOGY OF FALLOT $0.00
33698 O COMPLETE REPAIR TETRALOGY OF FALLOT $0.00
3370F 9 AJCC BRST CNCR STAGE 0 DOCD $0.00
33720 3 REPAIR OF HEART DEFECT $1,495.53
33722 3 REPAIR OF HEART DEFECT $1,485.90
33724 3 REPAIR VENOUS ANOMALY $1,517.70
33726 3 REPAIR PUL VENOUS STENOSIS $1,980.21

3372F 9 AJCC BRST CNCR STAGE 1 +DOCD $0.00
33730 3 REPAIR HEART-VEIN DEFECT(S) $1,884.99
33732 3 REPAIR HEART-VEIN DEFECT $1,577.25
33738 O ATRIAL SEPTECTOMY OR SEPTOSTOMY TRA $0.00
33739 O ATRIAL SEPTECTOMY OR SEPTOSTOMY BLA $0.00
3374F 9 AJCC BRST CNCR STAGE 1 +DOCD $0.00
33750 3 MAJOR VESSEL SHUNT $1,262.34
33764 3 MAJOR VESSEL SHUNT & GRAFT $1,221.17

33768 3 CAVOPULMONARY SHUNTING $413.47
3376F 9 AJCC BRSTCNCR STAGE 2 DOCD $0.00
33770 3 REPAIR GREAT VESSELS DEFECT $2,064.65

33786 3 REPAIR ARTERIAL TRUNK $2,211.41
33788 3 REVISION OF PULMONARY ARTERY $1,495.12
33800 3 AORTIC SUSPENSION $937.52
33802 3 REPAIR VESSEL DEFECT $1,009.35
33803 3 REPAIR VESSEL DEFECT $1,096.52
33813 3 REPAIR SEPTAL DEFECT $1,248.46

33820 3 REVISE MAJOR VESSEL $940.45
33822 3 REVISE MAJOR VESSEL $998.49
33824 3 REVISE MAJOR VESSEL $1,128.75
3382F 9 AJCC CLN CNCR STAGE 0 DOCD $0.00
33830 O PATENT DUCTUS ARTERIOSUS LIGATION O $0.00
33840 3 REMOVE AORTA CONSTRICTION $1,139.47
33855 O EXCISION OF COARCTATION OF AORTA, W $0.00

33860 3 ASCENDING AORTIC GRAFT $3,017.52
33865 O ASCENDING AORTA GRAFT, WITH CARDIOP $0.00
33870 3 TRANSVERSE AORTIC ARCH GRAFT $2,457.25
33875 3 THORACIC AORTIC GRAFT $1,907.19
33877 3 THORACOABDOMINAL GRAFT $3,381.99
33880 3 ENDOVASC TAA REPR INCL SUBCL $1,753.49
33881 3 ENDOVASC TAA REPR W/O SUBCL $1,505.60
33883 3 INSERT ENDOVASC PROSTH, TAA $1,100.46

33884 3 ENDOVASC PROSTH, TAA, ADD-ON $401.25
33886 3 ENDOVASC PROSTH, DELAYED $945.53
33889 3 ARTERY TRANSPOSE/ENDOVAS TAA $787.87
33891 3 CAR-CAR BP GRFT/ENDOVAS TAA $985.29
33910 3 REMOVE LUNG ARTERY EMBOLI $1,597.09
33915 3 REMOVE LUNG ARTERY EMBOLI $1,275.60
33916 3 SURGERY OF GREAT VESSEL $1,602.40
33917 3 REPAIR PULMONARY ARTERY $1,451.01

33918 O REPAIR PULMONARY ATRESIA $0.00
33919 O REPAIR PULMONARY ATRESIA $0.00
33920 3 REPAIR PULMONARY ATRESIA $1,747.21
33922 3 TRANSECT PULMONARY ARTERY $1,322.95
33924 3 REMOVE PULMONARY SHUNT $278.68
33925 3 RPR PUL ART UNIFOCAL W/O CPB $1,701.13
33926 3 REPR PUL ART, UNIFOCAL W/CPB $2,256.60
33930 9 REMOVAL OF DONOR HEART/LUNG $0.00
33933 9 PREPARE DONOR HEART/LUNG $0.00
33935 3 TRANSPLANTATION, HEART/LUNG $3,346.95
33940 9 REMOVAL OF DONOR HEART $0.00
33944 9 PREPARE DONOR HEART $0.00
33945 3 TRANSPLANTATION OF HEART $4,441.23

33960 3 EXTERNAL CIRCULATION ASSIST $968.04
33961 3 EXTERNAL CIRCULATION ASSIST $539.61
33967 3 INSERT IA PERCUT DEVICE $266.75
33968 3 REMOVE AORTIC ASSIST DEVICE $34.16
33970 3 AORTIC CIRCULATION ASSIST $357.37
33971 3 AORTIC CIRCULATION ASSIST $688.83
33972 O INTRA-AORTIC BALLOON COUNTERPULSATI $0.00
33973 3 INSERT BALLOON DEVICE $520.94
33974 3 REMOVE INTRA-AORTIC BALLOON $878.00
33975 3 IMPLANT VENTRICULAR DEVICE $1,075.80
33976 3 IMPLANT VENTRICULAR DEVICE $1,196.18
33977 3 REMOVE VENTRICULAR DEVICE $1,162.00

33978 3 REMOVE VENTRICULAR DEVICE $1,278.55
33979 3 INSERT INTRACORPOREAL DEVICE $2,359.16
33980 3 REMOVE INTRACORPOREAL DEVICE $3,473.72
33999 5 CARDIAC SURGERY PROCEDURE $0.00
34001 3 REMOVAL OF ARTERY CLOT $932.57
34111 3 REMOVAL OF ARM ARTERY CLOT $594.29
34151 3 REMOVAL OF ARTERY CLOT $1,373.62

34203 3 REMOVAL OF LEG ARTERY CLOT $950.03
34401 3 REMOVAL OF VEIN CLOT $1,418.42
34421 3 REMOVAL OF VEIN CLOT $720.20
34490 3 REMOVAL OF VEIN CLOT $597.88
34501 3 REPAIR VALVE, FEMORAL VEIN $926.98
34502 3 RECONSTRUCT VENA CAVA $1,499.20
3450F 9 DYSPNEA SCRND, NO-MILD DYSP $0.00
34510 3 TRANSPOSITION OF VEIN VALVE $1,051.37
3451F 9 DYSPNEA SCRND MOD-HIGH DYSP $0.00
34520 3 CROSS-OVER VEIN GRAFT $1,009.57
3452F 9 DYSPNEA NOT SCREENED $0.00

34530 3 LEG VEIN FUSION $949.54
3455F 9 TB SCRNG DONE-INTERPD 6MON $0.00
3470F 9 RA DISEASE ACTIVITY, LOW $0.00
3471F 9 RA DISEASE ACTIVITY, MOD $0.00
3472F 9 RA DISEASE ACTIVITY, HIGH $0.00
3475F 9 DISEASE PROGN RA POOR DOCD $0.00
3476F 9 DISEASE PROGN RA GOOD DOCD $0.00
34800 3 ENDOVAS AAA REPR W/SM TUBE $1,129.34
34802 3 ENDOVAS AAA REPR W/2-P PART $1,232.87
34805 3 ENDOVAS AAA REPR W/LONG TUBE $1,156.71

34806 3 ANEURYSM PRESS SENSOR ADD-ON $104.46
34808 3 ENDOVAS ILIAC A DEVICE ADDON $205.36
34812 3 XPOSE FOR ENDOPROSTH, FEMORL $339.74
34813 3 FEMORAL ENDOVAS GRAFT ADD-ON $236.02
34820 3 XPOSE FOR ENDOPROSTH, ILIAC $487.88
34825 3 ENDOVASC EXTEND PROSTH, INIT $691.51
34826 3 ENDOVASC EXTEN PROSTH, ADDÏL $203.99
34830 3 OPEN AORTIC TUBE PROSTH REPR $1,802.15
34831 3 OPEN AORTOILIAC PROSTH REPR $1,908.20
34832 3 OPEN AORTOFEMOR PROSTH REPR $1,936.08

34833 3 XPOSE FOR ENDOPROSTH, ILIAC $607.47
34834 3 XPOSE, ENDOPROSTH, BRACHIAL $275.58
34900 3 ENDOVASC ILIAC REPR W/GRAFT $897.11
3490F 9 HISTORY - AIDS-DEFINING COND $0.00
3491F 9 HIV UNSURE BABY OF HIV+MOMS $0.00
3492F 9 HISTORY CD4+CELL COUNT <350 $0.00
3493F 9 NO HIST CD4+CELL CNT <350 $0.00
3494F 9 CD4+CELL COUNT <200CELLS/MM3 $0.00
3495F 9 CD4+CELL CNT 200-499 CELLS $0.00
3496F 9 CD4+ CELL COUNT >=500 CELLS $0.00
3497F 9 CD4+ CELL PERCENTAGE <15% $0.00
3498F 9 CD4+ CELL PERCENTAGE >=15% $0.00
35001 3 REPAIR DEFECT OF ARTERY $1,119.07

35002 3 REPAIR ARTERY RUPTURE, NECK $1,181.02
3500F 9 CD4 +CELL CNT/% DOCD AS DONE $0.00
35011 3 REPAIR DEFECT OF ARTERY $981.35
35013 3 REPAIR ARTERY RUPTURE, ARM $1,217.33
35022 3 REPAIR ARTERY RUPTURE, CHEST $1,350.10
3502F 9 HIV RNA VRL LD <LMTS QUANTIF $0.00
3503F 9 HIV RNA VRL LDNOT<LMTS QUNTF $0.00
35045 3 REPAIR DEFECT OF ARM ARTERY $954.51
35082 3 REPAIR ARTERY RUPTURE, AORTA $2,145.55

35092 3 REPAIR ARTERY RUPTURE, AORTA $2,561.30
35103 3 REPAIR ARTERY RUPTURE, GROIN $2,216.73
3510F 9 DOC TB SCRNG-RSLTS INTERPD $0.00
35112 3 REPAIR ARTERY RUPTURE,SPLEEN $1,674.39
3511F 9 CHLMYD/GONRH TSTS DOCD DONE $0.00
35122 3 REPAIR ARTERY RUPTURE, BELLY $1,941.93

3512F 9 SYPH SCRNG DOCD AS DONE $0.00
35132 3 REPAIR ARTERY RUPTURE, GROIN $1,671.90
3513F 9 HEP B SCRNG DOCD AS DONE $0.00
35142 3 REPAIR ARTERY RUPTURE, THIGH $1,313.60
3514F 9 HEP C SCRNG DOCD AS DONE $0.00
35152 3 REPAIR ARTERY RUPTURE, KNEE $1,437.76
3515F 9 PT HAS DOCD IMMUN TO HEP C $0.00
35161 O REPAIR DEFECT OF ARTERY $0.00
35162 O REPAIR ARTERY RUPTURE $0.00
35180 3 REPAIR BLOOD VESSEL LESION $825.41

35182 3 REPAIR BLOOD VESSEL LESION $1,691.77


35301 3 RECHANNELING OF ARTERY $1,035.69
35306 3 RECHANNELING OF ARTERY $451.75

35381 O RECHANNELING OF ARTERY $0.00
35390 3 REOPERATION, CAROTID ADD-ON $159.40
35400 3 ANGIOSCOPY $150.78
35450 3 REPAIR ARTERIAL BLOCKAGE $510.72

35460 3 REPAIR VENOUS BLOCKAGE $308.20

35480 3 ATHERECTOMY, OPEN $553.82
35490 3 ATHERECTOMY, PERCUTANEOUS $607.81
35500 3 HARVEST VEIN FOR BYPASS $318.96

35501 3 ARTERY BYPASS GRAFT $1,543.09
35507 O ARTERY BYPASS GRAFT $0.00
3550F 9 LOW RSK THROMBOEMBOLISM $0.00

3551F 9 INTRMED RSK THROMBOEMBOLISM $0.00
3552F 9 HGH RISK FOR THROMBOEMBOLISM $0.00

3555F 9 PT INR MEASUREMENT PERFORMED $0.00

35572 3 HARVEST FEMOROPOPLITEAL VEIN $345.82
35582 O VEIN BYPASS GRAFT $0.00
35583 3 VEIN BYPASS GRAFT $1,411.21
35600 3 HARVEST ART FOR CABG ADD-ON $254.65

35612 3 ARTERY BYPASS GRAFT $909.69
35623 3 BYPASS GRAFT, NOT VEIN $1,345.37

35637 3 BYPASS GRAFT, WITH OTHER THAN VEIN $1,689.45
35638 3 BYPASS GRAFT, WITH OTHER THAN VEIN $1,726.54
35645 3 ARTERY BYPASS GRAFT $970.74

35681 3 COMPOSITE BYPASS GRAFT $79.69
35685 3 BYPASS GRAFT PATENCY/PATCH $199.68
35686 3 BYPASS GRAFT/AV FIST PATENCY $167.22
35691 3 ARTERIAL TRANSPOSITION $978.84
35693 3 ARTERIAL TRANSPOSITION $869.40

35694 3 ARTERIAL TRANSPOSITION $1,011.46
35695 3 ARTERIAL TRANSPOSITION $1,053.60
35697 3 REIMPLANT ARTERY EACH $148.82
35700 3 REOPERATION, BYPASS GRAFT $153.14
35701 3 EXPLORATION, CAROTID ARTERY $526.14
3570F 9 RPRT BONE SCINT X-REFW/X-RAY $0.00
35721 3 EXPLORATION, FEMORAL ARTERY $447.03
3572F 9 PT CONSID POSS RISK FX $0.00
3573F 9 PT NOT CONSID POSS RISK FX $0.00
35741 3 EXPLORATION POPLITEAL ARTERY $489.05

35761 3 EXPLORATION OF ARTERY/VEIN $362.35
35800 3 EXPLORE NECK VESSELS $465.04
35820 3 EXPLORE CHEST VESSELS $1,813.15
35840 3 EXPLORE ABDOMINAL VESSELS $606.87
35860 3 EXPLORE LIMB VESSELS $393.03
35870 3 REPAIR VESSEL GRAFT DEFECT $1,266.44
35875 3 REMOVAL OF CLOT IN GRAFT $584.81
35876 3 REMOVAL OF CLOT IN GRAFT $935.08
35879 3 REVISE GRAFT W/VEIN $915.39
35881 3 REVISE GRAFT W/VEIN $1,017.68
35883 3 REVISE GRAFT W/NONAUTO GRAFT $1,185.13
35884 3 REVISE GRAFT W/VEIN $1,249.56
35900 O EXCISION OF INFECTED GRAFT $0.00

35901 3 EXCISION, GRAFT, NECK $492.05
35903 3 EXCISION, GRAFT, EXTREMITY $556.30
35905 3 EXCISION, GRAFT, THORAX $1,722.14
35907 3 EXCISION, GRAFT, ABDOMEN $1,896.49
35910 O EXCISION OF INFECTED GRAFT WITH REV $0.00
36000 3 PLACE NEEDLE IN VEIN $24.42
36002 3 PSEUDOANEURYSM INJECTION TRT $163.95
36005 3 INJECTION EXT VENOGRAPHY $48.82
36010 3 PLACE CATHETER IN VEIN $122.69
36013 3 PLACE CATHETER IN ARTERY $790.73

36100 3 ESTABLISH ACCESS TO ARTERY $522.68
36145 3 ARTERY TO VEIN SHUNT $99.97
36160 3 ESTABLISH ACCESS TO AORTA $526.25
36200 3 PLACE CATHETER IN AORTA $155.51

36230 O SELECTIVE CATHETER PLACEMENT, CORON $0.00
36260 3 INSERTION OF INFUSION PUMP $558.54
36261 3 REVISION OF INFUSION PUMP $341.17
36262 3 REMOVAL OF INFUSION PUMP $260.07
36299 5 VESSEL INJECTION PROCEDURE $0.00
36400 3 BL DRAW < 3 YRS FEM/JUGULAR $24.65
36405 3 BL DRAW < 3 YRS SCALP VEIN $22.52

36406 3 BL DRAW < 3 YRS OTHER VEIN $16.29
36410 3 NON-ROUTINE BL DRAW > 3 YRS $18.13
36415 3 ROUTINE VENIPUNCTURE $15.00
36416 9 CAPILLARY BLOOD DRAW $0.00
36420 3 VEIN ACCESS CUTDOWN < 1 YR $47.01
36425 3 VEIN ACCESS CUTDOWN > 1 YR $37.10
36430 3 BLOOD TRANSFUSION SERVICE $36.19
36440 3 BL PUSH TRANSFUSE, 2 YR OR < $49.56
36450 3 BL EXCHANGE/TRANSFUSE, NB $114.30
36455 3 BL EXCHANGE/TRANSFUSE NON-NB $124.81
36460 3 TRANSFUSION SERVICE, FETAL $325.05
36468 5 INJECTION(S), SPIDER VEINS $0.00

36469 9 INJECTION(S), SPIDER VEINS $0.00
36470 3 INJECTION THERAPY OF VEIN $131.66
36471 3 INJECTION THERAPY OF VEINS $161.92
36475 3 ENDOVENOUS RF, 1ST VEIN $330.34
36476 3 ENDOVENOUS RF, VEIN ADD-ON $161.33
36478 3 ENDOVENOUS LASER, 1ST VEIN $333.66
36479 3 ENDOVENOUS LASER VEIN ADDON $162.44
36481 3 INSERTION OF CATHETER, VEIN $404.20
36488 O INSERTION OF CATHETER, VEIN $0.00

36493 O REPOSITIONING OF CVC $0.00
36495 O INSERTION OF IMPLANTABLE INTRAVENOU $0.00
36496 O REVISION OF IMPLANTABLE INTRAVENOUS $0.00
36497 O REMOVAL OF IMPLANTABLE INTRAVENOUS $0.00
36511 3 APHERESIS WBC $87.01
36512 3 APHERESIS RBC $88.49
36513 3 APHERESIS PLATELETS $91.39
36514 3 APHERESIS PLASMA $504.43
36515 3 APHERESIS, ADSORP/REINFUSE $1,888.62

36516 3 APHERESIS, SELECTIVE $2,139.19
36520 O PLASMA AND/OR CELL EXCHANGE $0.00
36521 O APHERESIS W/ ADSORP/REINFUSE $0.00
36522 3 PHOTOPHERESIS $98.66
36530 O INSERTION OF INFUSION PUMP $0.00
36531 O REVISION OF INFUSION PUMP $0.00
36532 O REMOVAL OF INFUSION PUMP $0.00
36533 O INSERTION OF ACCESS DEVICE $0.00
36534 O REVISION OF ACCESS DEVICE $0.00
36535 O REMOVAL OF ACCESS DEVICE $0.00
36536 O REMOVE CVA DEVICE OBSTRUCT $0.00
36537 O REMOVE CVA LUMEN OBSTRUCT $0.00

36540 O COLLECT BLOOD VENOUS DEVICE $0.00
36550 O DECLOT VASCULAR DEVICE $0.00
36555 3 INSERT NON-TUNNEL CV CATH $264.40
36556 3 INSERT NON-TUNNEL CV CATH $116.81
36557 3 INSERT TUNNELED CV CATH $290.90

36566 3 INSERT TUNNELED CV CATH $3,524.15
36568 3 INSERT PICC CATH $94.90
36569 3 INSERT PICC CATH $95.10
36570 3 INSERT PICVAD CATH $1,142.45
36571 3 INSERT PICVAD CATH $298.79
36575 3 REPAIR TUNNELED CV CATH $156.65
36576 3 REPAIR TUNNELED CV CATH $346.64
36578 3 REPLACE TUNNELED CV CATH $486.38
36580 3 REPLACE CVAD CATH $68.37
36581 3 REPLACE TUNNELED CV CATH $196.60
36582 3 REPLACE TUNNELED CV CATH $1,027.76
36583 3 REPLACE TUNNELED CV CATH $1,028.06
36584 3 REPLACE PICC CATH $222.30

36585 3 REPLACE PICVAD CATH $1,056.35
36589 3 REMOVAL TUNNELED CV CATH $160.44
36590 3 REMOVAL TUNNELED CV CATH $261.54
36591 3 DRAW BLOOD OFF VENOUS DEVICE $22.42
36592 3 COLLECT BLOOD FROM PICC $24.64
36593 3 DECLOT VASCULAR DEVICE $35.11
36595 3 MECH REMOV TUNNELED CV CATH $593.61
36596 3 MECH REMOV TUNNELED CV CATH $133.37
36597 3 REPOSITION VENOUS CATHETER $124.40
36598 3 INJ W/FLUOR, EVAL CV DEVICE $112.31
36600 3 WITHDRAWAL OF ARTERIAL BLOOD $29.66
36620 3 INSERTION CATHETER, ARTERY $49.06

36680 3 INSERT NEEDLE, BONE CAVITY $57.35
36800 3 INSERTION OF CANNULA $152.71
36818 3 AV FUSE, UPPR ARM, CEPHALIC $653.89
36819 3 AV FUSE, UPPR ARM, BASILIC $769.33
36820 3 AV FUSION/FOREARM VEIN $772.04

36821 3 AV FUSION DIRECT ANY SITE $641.66
36822 3 INSERTION OF CANNULA(S) $363.34
36823 3 INSERTION OF CANNULA(S) $1,228.91
36825 3 ARTERY-VEIN AUTOGRAFT $558.28
36830 3 ARTERY-VEIN NONAUTOGRAFT $637.18
36831 3 OPEN THROMBECT AV FISTULA $440.64
36832 3 AV FISTULA REVISION, OPEN $562.04
36833 3 AV FISTULA REVISION $634.79
36834 3 REPAIR A-V ANEURYSM $596.20
36835 3 ARTERY TO VEIN SHUNT $442.42
36838 3 DIST REVAS LIGATION, HEMO $1,133.72
36840 O INSERTION MANDRIL $0.00
36845 O ANASTOMOSIS MANDRIL $0.00

36860 3 EXTERNAL CANNULA DECLOTTING $184.27
36861 3 CANNULA DECLOTTING $145.70
36870 3 PERCUT THROMBECT AV FISTULA $300.39
37140 3 REVISION OF CIRCULATION $1,296.53
37181 3 SPLICE SPLEEN/KIDNEY VEINS $1,473.11
37182 3 INSERT HEPATIC SHUNT (TIPS) $882.15
37183 3 REMOVE HEPATIC SHUNT (TIPS) $419.52
37184 3 PRIM ART MECH THROMBECTOMY $2,370.47
37185 3 PRIM ART M-THROMBECT ADD-ON $782.91

37186 3 SEC ART M-THROMBECT ADD-ON $1,599.48
37187 3 VENOUS MECH THROMBECTOMY $419.32
37188 3 VENOUS M-THROMBECTOMY ADD-ON $1,932.81
37190 O PLASTIC REPAIR OF ARTERIOVENOUS ANE $0.00
37195 3 THROMBOLYTIC THERAPY, STROKE $326.02
37200 3 TRANSCATHETER BIOPSY $234.13
37201 3 TRANSCATHETER THERAPY INFUSE $277.91
37202 3 TRANSCATHETER THERAPY INFUSE $334.92
37203 3 TRANSCATHETER RETRIEVAL $266.56
37204 3 TRANSCATHETER OCCLUSION $929.58

37205 3 TRANSCATH IV STENT, PERCUT $437.82
37206 3 TRANSCATH IV STENT/PERC ADDL $213.07
37207 3 TRANSCATH IV STENT, OPEN $423.38
37208 3 TRANSCATH IV STENT/OPEN ADDL $204.62
37209 3 CHANGE IV CATH AT THROMB TX $114.66
37210 3 EMBOLIZATION UTERINE FIBROID $554.72
37215 3 TRANSCATH STENT, CCA W/EPS $1,090.70
37216 3 TRANSCATH STENT, CCA W/O EPS $998.72
37250 3 IV US FIRST VESSEL ADD-ON $108.91
37251 3 IV US EACH ADD VESSEL ADD-ON $80.95
37500 3 ENDOSCOPY LIGATE PERF VEINS $665.93
37501 5 VASCULAR ENDOSCOPY PROCEDURE $0.00
37565 3 LIGATION OF NECK VEIN $660.74

37600 3 LIGATION OF NECK ARTERY $675.50
37607 3 LIGATION OF A-V FISTULA $360.61
37609 3 TEMPORAL ARTERY PROCEDURE $274.41
37616 3 LIGATION OF CHEST ARTERY $1,037.34
37617 3 LIGATION OF ABDOMEN ARTERY $1,232.18
37618 3 LIGATION OF EXTREMITY ARTERY $357.70
37620 3 REVISION OF MAJOR VEIN $646.08
37650 3 REVISION OF MAJOR VEIN $487.77
37660 3 REVISION OF MAJOR VEIN $1,153.91

37700 3 REVISE LEG VEIN $240.23
37718 3 LIGATE/STRIP SHORT LEG VEIN $394.29
37720 O REMOVAL OF LEG VEIN $0.00
37722 3 LIGATE/STRIP LONG LEG VEIN $455.75
37730 O REMOVAL OF LEG VEINS $0.00
37735 3 REMOVAL OF LEG VEINS/LESION $605.87
37760 3 LIGATION, LEG VEINS, OPEN $596.56
37765 3 PHLEB VEINS - EXTREM - TO 20 $429.45
37766 3 PHLEB VEINS - EXTREM 20+ $521.68
37780 3 REVISION OF LEG VEIN $247.85

37785 3 LIGATE/DIVIDE/EXCISE VEIN $334.61
37788 3 REVASCULARIZATION, PENIS $1,323.87
37790 3 PENILE VENOUS OCCLUSION $480.35
37799 5 VASCULAR SURGERY PROCEDURE $0.00
38100 3 REMOVAL OF SPLEEN, TOTAL $997.96
38101 3 REMOVAL OF SPLEEN, PARTIAL $1,003.29
38102 3 REMOVAL OF SPLEEN, TOTAL $238.39
38115 3 REPAIR OF RUPTURED SPLEEN $1,109.70
38120 3 LAPAROSCOPY, SPLENECTOMY $926.88
38129 5 LAPAROSCOPE PROC, SPLEEN $0.00
38200 3 INJECTION FOR SPLEEN X-RAY $133.93
38204 9 BL DONOR SEARCH MANAGEMENT $0.00
38205 9 HARVEST ALLOGENIC STEM CELLS $0.00

38206 3 HARVEST AUTO STEM CELLS $77.46
38207 9 CRYOPRESERVE STEM CELLS $0.00
38208 9 THAW PRESERVED STEM CELLS $0.00
38209 9 WASH HARVEST STEM CELLS $0.00
38210 9 T-CELL DEPLETION OF HARVEST $0.00
38211 9 TUMOR CELL DEPLETE OF HARVST $0.00
38212 9 RBC DEPLETION OF HARVEST $0.00
38213 9 PLATELET DEPLETE OF HARVEST $0.00
38214 9 VOLUME DEPLETE OF HARVEST $0.00
38215 9 HARVEST STEM CELL CONCENTRTE $0.00
38220 3 BONE MARROW ASPIRATION $148.85
38221 3 BONE MARROW BIOPSY $164.88

38230 3 BONE MARROW COLLECTION $299.49
38231 O STEM CELL COLLECTION $0.00
38240 3 BONE MARROW/STEM TRANSPLANT $120.02
38241 3 BONE MARROW/STEM TRANSPLANT $120.77
38242 3 LYMPHOCYTE INFUSE TRANSPLANT $91.49
38300 3 DRAINAGE, LYMPH NODE LESION $244.59
38305 3 DRAINAGE, LYMPH NODE LESION $413.38
38308 3 INCISION OF LYMPH CHANNELS $395.80
38380 3 THORACIC DUCT PROCEDURE $510.96

38500 3 BIOPSY/REMOVAL, LYMPH NODES $284.38
38505 3 NEEDLE BIOPSY, LYMPH NODES $120.53
38542 9 EXPLORE DEEP NODE(S), NECK $0.00
38550 3 REMOVAL, NECK/ARMPIT LESION $427.26
38555 3 REMOVAL, NECK/ARMPIT LESION $887.12
38562 3 REMOVAL, PELVIC LYMPH NODES $637.84
38564 3 REMOVAL, ABDOMEN LYMPH NODES $631.76
38570 3 LAPAROSCOPY, LYMPH NODE BIOP $515.08

38571 3 LAPAROSCOPY, LYMPHADENECTOMY $810.54
38572 3 LAPAROSCOPY, LYMPHADENECTOMY $888.19
38589 5 LAPAROSCOPE PROC, LYMPHATIC $0.00
38700 3 REMOVAL OF LYMPH NODES, NECK $715.48
38720 3 REMOVAL OF LYMPH NODES, NECK $1,186.81
38724 3 REMOVAL OF LYMPH NODES, NECK $1,286.82
38740 3 REMOVE ARMPIT LYMPH NODES $598.63
38745 3 REMOVE ARMPIT LYMPH NODES $761.21
38746 3 REMOVE THORACIC LYMPH NODES $249.68
38747 3 REMOVE ABDOMINAL LYMPH NODES $242.96
38760 3 REMOVE GROIN LYMPH NODES $751.01
38765 3 REMOVE GROIN LYMPH NODES $1,166.02

38770 3 REMOVE PELVIS LYMPH NODES $783.77
38780 3 REMOVE ABDOMEN LYMPH NODES $987.04
38790 3 INJECT FOR LYMPHATIC X-RAY $77.31
38792 3 IDENTIFY SENTINEL NODE $37.77
38794 3 ACCESS THORACIC LYMPH DUCT $294.53
38999 5 BLOOD/LYMPH SYSTEM PROCEDURE $0.00
39020 O MEDIASTINOTOMY WITH EXPLORATION, DR $0.00
39200 3 REMOVAL CHEST LESION $836.75

39220 3 REMOVAL CHEST LESION $1,077.45
39400 3 VISUALIZATION OF CHEST $470.41
39499 5 CHEST PROCEDURE $0.00
39501 3 REPAIR DIAPHRAGM LACERATION $766.74
39502 3 REPAIR PARAESOPHAGEAL HERNIA $918.91
39503 3 REPAIR OF DIAPHRAGM HERNIA $5,337.56
39520 3 REPAIR OF DIAPHRAGM HERNIA $918.94
39545 3 REVISION OF DIAPHRAGM $833.87
39547 O IMBRICATION OF DIAPHRAGM FOR EVENTR $0.00

39560 3 RESECT DIAPHRAGM, SIMPLE $719.33
39561 3 RESECT DIAPHRAGM, COMPLEX $1,119.75
39599 5 DIAPHRAGM SURGERY PROCEDURE $0.00
4000F 9 TOBACCO USE TXMNT COUNSELING $0.00
4001F 9 TOBACCO USE TXMNT, PHARMACOL $0.00
4002F 9 STATIN THERAPY, RX $0.00
4003F 9 PT ED WRITE/ORAL, PTS W/ HF $0.00
4005F 9 PHARM THX FOR OP RXÏD $0.00
4006F 9 BETA-BLOCKER THERAPY RX $0.00
4007F O ANTIOX VIT/MIN SUPP RXÏD $0.00
4009F 9 ACE/ARB INHIBITOR THERAPY RX $0.00
4011F 9 ORAL ANTIPLATELET THERAPY RX $0.00

4012F 9 WARFARIN THERAPY RX $0.00
4014F 9 WRITTEN DISCHARGE INSTR PRVD $0.00
4015F 9 PERSIST ASTHMA MEDICINE CTRL $0.00
4016F 9 ANTI-INFLM/ANLGSC AGENT RX $0.00
4017F 9 GI PROPHYLAXIS FOR NSAID RX $0.00
4018F 9 THERAPY EXERCISE JOINT RX $0.00
4019F 9 DOC RECPT COUNSL VIT D/CALC+ $0.00
4025F 9 INHALED BRONCHODILATOR RX $0.00
4030F 9 OXYGEN THERAPY RX $0.00
4033F 9 PULMONARY REHAB REC $0.00

4035F 9 INFLUENZA IMM REC $0.00
4037F 9 INFLUENZA IMM ORDER/ADMIN $0.00
4040F 9 PNEUMOC VAC/ADMIN/RCVD $0.00
4041F 9 DOC ORDER CEFAZOLIN/CEFUROX $0.00
4042F 9 DOC ANTIBIO NOT GIVEN $0.00
4043F 9 DOC ORDER GIVEN STOP ANTIBIO $0.00
4044F 9 DOC ORDER GIVEN VTE PROPHYLX $0.00
4045F 9 EMPIRIC ANTIBIOTIC RX $0.00
4046F 9 DOC ANTIBIO GIVEN B/4 SURG $0.00
40490 3 BIOPSY OF LIP $117.63
4049F 9 DOC ORDER GIVEN STOP ANTIBIO $0.00

40500 3 PARTIAL EXCISION OF LIP $444.79
4050F 9 HT CARE PLAN DOC $0.00
4051F 9 REFERRED FOR AN AV FISTULA $0.00
40525 3 RECONSTRUCT LIP WITH FLAP $504.89
40527 3 RECONSTRUCT LIP WITH FLAP $596.01
4052F 9 HEMODIALYSIS VIA AV FISTULA $0.00
40530 3 PARTIAL REMOVAL OF LIP $487.43
4053F 9 HEMODIALYSIS VIA AV GRAFT $0.00
4054F 9 HEMODIALYSIS VIA CATHETER $0.00
4055F 9 PT. RCVNG PERITON DIALYSIS $0.00

4056F 9 APPROP. ORAL REHYD. RECOMMD $0.00
4058F 9 PED GASTRO ED GIVEN, CAREGVR $0.00
4060F 9 PSYCH SVCS PROVIDED $0.00
4062F 9 PT REFERRAL PSYCH DOCÏD $0.00
4064F 9 ANTIDEPRESSANT RX $0.00
40650 3 REPAIR LIP $367.60
40652 3 REPAIR LIP $432.65
40654 3 REPAIR LIP $509.81
4065F 9 ANTIPSYCHOTIC RX $0.00
4066F 9 ECT PROVIDED $0.00

4067F 9 PT REFERRAL FOR ECT DOCÏD $0.00
40700 3 REPAIR CLEFT LIP/NASAL $843.25
40701 3 REPAIR CLEFT LIP/NASAL $1,047.01
4070F 9 DVT PROPHYLX RECVÏD DAY 2 $0.00
4073F 9 ORAL ANTIPLAT THX RX DISCHRG $0.00
4075F 9 ANTICOAG THX RX AT DISCHRG $0.00
4077F 9 DOC T-PA ADMIN CONSIDERED $0.00
40799 5 LIP SURGERY PROCEDURE $0.00
4079F 9 DOC REHAB SVCS CONSIDERED $0.00
40800 3 DRAINAGE OF MOUTH LESION $178.73

40804 3 REMOVAL, FOREIGN BODY, MOUTH $182.24
40805 3 REMOVAL, FOREIGN BODY, MOUTH $286.01
40806 3 INCISION OF LIP FOLD $95.22
40808 3 BIOPSY OF MOUTH LESION $160.90
40810 3 EXCISION OF MOUTH LESION $178.57
40812 3 EXCISE/REPAIR MOUTH LESION $250.43
40814 3 EXCISE/REPAIR MOUTH LESION $336.45
40818 3 EXCISE ORAL MUCOSA FOR GRAFT $312.59
40819 3 EXCISE LIP OR CHEEK FOLD $268.27
40820 3 TREATMENT OF MOUTH LESION $233.57

40830 3 REPAIR MOUTH LACERATION $214.20
40831 3 REPAIR MOUTH LACERATION $283.96
40840 3 RECONSTRUCTION OF MOUTH $723.07
40844 3 RECONSTRUCTION OF MOUTH $1,230.11
40845 3 RECONSTRUCTION OF MOUTH $1,336.61
4084F 9 ASPIRIN RECVÏD W/IN 24 HRS $0.00
40899 5 MOUTH SURGERY PROCEDURE $0.00
4090F 9 PT RCVNG EPO THXPY $0.00

4095F 9 PT NOT RCVNG EPO THXPY $0.00
4100F 9 BIPHOS THXPY VEIN ORD/RECÏVD $0.00
41010 3 INCISION OF TONGUE FOLD $179.65

41019 3 PLACE NEEDLES H&N FOR RT $460.53
41100 3 BIOPSY OF TONGUE $149.76
41105 3 BIOPSY OF TONGUE $149.96
41108 3 BIOPSY OF FLOOR OF MOUTH $129.00
4110F 9 INT. MAM ART USED FOR CABG $0.00
41110 3 EXCISION OF TONGUE LESION $185.71
41115 3 EXCISION OF TONGUE FOLD $216.20
41120 3 PARTIAL REMOVAL OF TONGUE $950.79

41130 3 PARTIAL REMOVAL OF TONGUE $1,170.28
41135 3 TONGUE AND NECK SURGERY $1,944.94
41140 3 REMOVAL OF TONGUE $2,003.00
41145 3 TONGUE REMOVAL, NECK SURGERY $2,506.10
41150 3 TONGUE, MOUTH, JAW SURGERY $1,982.26
41153 3 TONGUE, MOUTH, NECK SURGERY $2,147.63
41155 3 TONGUE, JAW, & NECK SURGERY $2,666.21
4115F 9 BETA BLCKR ADMIN W/IN 24 HRS $0.00
4120F 9 ANTIBIOT RXÏD/GIVEN $0.00
4124F 9 ANTIBIOT NOT RXÏD/GIVEN $0.00

41250 3 REPAIR TONGUE LACERATION $201.57
4130F 9 TOPICAL PREP RX, AOE $0.00
4131F 9 SYST ANTIMICROBIAL THX RX $0.00
4132F 9 NO SYST ANTIMICROBIAL THX RX $0.00
4133F 9 ANTIHIST/DECONG RX/RECOM $0.00
4134F 9 NO ANTIHIST/DECONG RX/RECOM $0.00
4135F 9 SYSTEMIC CORTICOSTEROIDS RX $0.00
4136F 9 SYST CORTICOSTEROIDS NOT RX $0.00
4148F 9 HEP A VAC INJXN ADMIN/RECVD $0.00
4149F 9 HEP B VAC INJXN ADMIN/RECVD $0.00
41500 3 FIXATION OF TONGUE $404.07

4150F 9 PT RECVNG ANTIVIR TXMNT HEPC $0.00
41510 3 TONGUE TO LIP SURGERY $370.98
41512 3 TONGUE SUSPENSION $564.76
4151F 9 PT NOT RECVNG ANTIV HEP C $0.00
41520 3 RECONSTRUCTION, TONGUE FOLD $306.21
4152F O DOCÏD PEGINTF/RIB THXY CONSD $0.00
41530 3 TONGUE BASE VOL REDUCTION $2,867.27
4153F 9 COMBO PEGINTF/RIB RX $0.00
4154F O HEP A VAC SERIES RECOMMENDED $0.00
4155F 9 HEP A VAC SERIES PREV RECVD $0.00
4156F O HEP B VAC SERIES RECOMMENDED $0.00
4157F 9 HEP B VAC SERIES PREV RECVD $0.00

4158F 9 PT EDU RE: ALCOH DRNKNG DONE $0.00
41599 5 TONGUE AND MOUTH SURGERY $0.00
4159F 9 CONTRCP TALK B/4 ANTIV TXMNT $0.00
4163F 9 PT COUNS 4 TXMNT OPT PROST $0.00
4164F 9 ADJV HRMNL THXPY RXÏD $0.00
4165F 9 3D-CRT/IMRT RECEIVED $0.00
4167F 9 HD BED TILTED, 1ST DAY VENT $0.00
4168F 9 PT CARE, ICU&VENT W/IN 24HRS $0.00
4169F 9 NO PT CARE ICU/VENT IN 24HRS $0.00
4171F 9 PT. RCVNG ESA THXPY $0.00

4172F 9 PT. NOT RCVNG ESA THXPY $0.00
4174F 9 COUNS., POTENT. GLAUC IMPCT $0.00
4175F 9 VIS OF >=20/40 W/IN 90 DAYS $0.00
4176F 9 TALK RE UV LIGHT, PT/CRGVR $0.00
4177F 9 TALK PT/CRGVR RE: AREDS,PREV $0.00
4178F 9 ANTID GLBLN RCVÏD W/IN 26WKS $0.00
4179F 9 TAMOXIFEN/AI PRESCRIBED $0.00
41800 3 DRAINAGE OF GUM LESION $201.39
41805 3 REMOVAL FOREIGN BODY, GUM $207.83
41806 3 REMOVAL FOREIGN BODY,JAWBONE $302.37
4180F 9 ADJV THXPYRXÏD/RCVÏD STG3A-C $0.00
4181F 9 CONFORMAL RADN THXPY RCVD 00 $0.00
41820 5 EXCISION, GUM, EACH QUADRANT $0.00

41821 5 EXCISION OF GUM FLAP $0.00
41822 3 EXCISION OF GUM LESION $253.70
4182F 9 NO CONFORMAL RADN THXPY $0.00
41830 3 REMOVAL OF GUM TISSUE $341.32
41850 5 TREATMENT OF GUM LESION $0.00
4185F 9 CONTINUOUS PPI OR H2RA RCVÏD $0.00
4186F 9 NO CONT. PPI OR H2RA RCVÏD $0.00

41870 5 GUM GRAFT $0.00
41872 3 REPAIR GUM $320.81
41874 3 REPAIR TOOTH SOCKET $325.23
4187F 9 ANTI RHEUM DRUGTHXPYRXÏD/GVN $0.00
4188F 9 APPROP ACE/ARB TSTNG DONE $0.00
41899 5 DENTAL SURGERY PROCEDURE $0.00
4189F 9 APPROP DIGOXIN TSTNG DONE $0.00
4190F 9 APPROP DIURETIC TSTNG DONE $0.00
4191F 9 APPROP ANTICONVULS TSTNG $0.00
4192F 9 PT NOT RCVNG GLUCOCO THXPY $0.00

4193F 9 PT RCVNG<10MG DAILY PREDNISO $0.00
4194F 9 PT RCVNG>10MG DAILY PREDNISO $0.00
4195F 9 PT RCVNG ANTI-RHEUM THXPY RA $0.00
4196F 9 PTNOT RCVNG ANTI-RHM THXPYRA $0.00
42000 3 DRAINAGE MOUTH ROOF LESION $139.97
4200F 9 EXTERNAL BEAM TO PROST ONLY $0.00
4201F 9 EXTRNL BEAM OTHER THAN PROST $0.00
42100 3 BIOPSY ROOF OF MOUTH $132.72
42104 3 EXCISION LESION, MOUTH ROOF $185.16
4210F 9 ACE/ARB THXPY FOR >= 6 MONS $0.00
42120 3 REMOVE PALATE/LESION $881.60

42140 3 EXCISION OF UVULA $221.79
42145 3 REPAIR PALATE, PHARYNX/UVULA $638.83
42160 3 TREATMENT MOUTH ROOF LESION $214.03
42180 3 REPAIR PALATE $216.34
42200 3 RECONSTRUCT CLEFT PALATE $809.23
4220F 9 DIGOXIN THXPY FOR >= 6 MONS $0.00
4221F 9 DIURETIC THXPY FOR >= 6 MONS $0.00

42226 3 LENGTHENING OF PALATE $852.26
42227 3 LENGTHENING OF PALATE $828.79
42260 3 REPAIR NOSE TO LIP FISTULA $752.32
42280 9 PREPARATION, PALATE MOLD $0.00
42281 3 INSERTION, PALATE PROSTHESIS $181.34
42299 5 PALATE/UVULA SURGERY $0.00
42300 3 DRAINAGE OF SALIVARY GLAND $185.53

4230F 9 ANTICONV THXPY FOR >= 6 MONS $0.00
42325 O CREATE SALIVARY CYST DRAIN $0.00
42326 O CREATE SALIVARY CYST DRAIN $0.00
42330 3 REMOVAL OF SALIVARY STONE $207.72
42400 3 BIOPSY OF SALIVARY GLAND $98.81
42405 3 BIOPSY OF SALIVARY GLAND $272.87
42408 3 EXCISION OF SALIVARY CYST $406.99
42409 3 DRAINAGE OF SALIVARY CYST $295.38
4240F 9 INSTR XRCZ 4BK PN >12 WEEKS $0.00

42410 3 EXCISE PAROTID GLAND/LESION $570.59
42415 3 EXCISE PAROTID GLAND/LESION $1,028.35
42425 3 EXCISE PAROTID GLAND/LESION $776.59
4242F 9 SPRVSD XRCZ BK PN >12 WEEKS $0.00
42440 3 EXCISE SUBMAXILLARY GLAND $429.48
42450 3 EXCISE SUBLINGUAL GLAND $406.54
4245F 9 PT INSTR NRML LIFEST $0.00
4248F 9 PT INSTR-NO BD REST>= 4 DAYS $0.00
42500 3 REPAIR SALIVARY DUCT $387.84
42505 3 REPAIR SALIVARY DUCT $502.37

42507 3 PAROTID DUCT DIVERSION $470.69
4250F 9 WRMNG 4 SURG - NORMOTHERMIA $0.00
42550 3 INJECTION FOR SALIVARY X-RAY $139.51
42600 3 CLOSURE OF SALIVARY FISTULA $436.12
4260F 9 WOUND SRFC CULTURETECH USED $0.00
4261F 9 TECH OTHER THAN SURFC CULTR $0.00
42650 3 DILATION OF SALIVARY DUCT $74.67

4265F 9 WET-DRY DRESSINGS RX-RECMD $0.00
42660 3 DILATION OF SALIVARY DUCT $95.78
42665 3 LIGATION OF SALIVARY DUCT $276.65
4266F 9 NO WET-DRY DRSSINGS RX-RECMD $0.00
4267F 9 COMPRSSION THXPY PRESCRIBED $0.00
4268F 9 PT ED RE COMP THXPY RCVD $0.00
42699 5 SALIVARY SURGERY PROCEDURE $0.00
4269F 9 APPROPOS MTHD OFFLOADING RXD $0.00
42700 3 DRAINAGE OF TONSIL ABSCESS $168.20
4270F 9 PT RCVNG ANTI R-VIRAL THXPY $0.00
4271F 9 PT RCVNG ANTI R-VIRAL THXPY $0.00
42720 3 DRAINAGE OF THROAT ABSCESS $415.33
42725 3 DRAINAGE OF THROAT ABSCESS $744.19

4274F 9 FLU IMMUNO ADMIND RCVD $0.00
4275F 9 POTENT ANTIVIR THXPY RXD $0.00
4279F 9 PCP PROPHYLAXIS RXD $0.00
42800 3 BIOPSY OF THROAT $141.01
42802 3 BIOPSY OF THROAT $216.12
42804 3 BIOPSY OF UPPER NOSE/THROAT $180.52
42806 3 BIOPSY OF UPPER NOSE/THROAT $203.37
42808 3 EXCISE PHARYNX LESION $205.40
42809 3 REMOVE PHARYNX FOREIGN BODY $152.78
4280F 9 PCP PROPHYLAX RXD 3MON LOW % $0.00
42810 3 EXCISION OF NECK CYST $346.69
42815 3 EXCISION OF NECK CYST $508.11

42820 3 REMOVE TONSILS AND ADENOIDS $267.73
42821 3 REMOVE TONSILS AND ADENOIDS $279.60
42825 3 REMOVAL OF TONSILS $240.19
42826 3 REMOVAL OF TONSILS $231.86
42830 3 REMOVAL OF ADENOIDS $189.39
42842 3 EXTENSIVE SURGERY OF THROAT $885.02
42844 3 EXTENSIVE SURGERY OF THROAT $1,242.75

42845 3 EXTENSIVE SURGERY OF THROAT $2,026.30
42860 3 EXCISION OF TONSIL TAGS $171.60
42870 3 EXCISION OF LINGUAL TONSIL $525.48
42880 O EXCISION NASOPHARYNGEAL LESION (EG, $0.00
42890 3 PARTIAL REMOVAL OF PHARYNX $1,262.48
42892 3 REVISION OF PHARYNGEAL WALLS $1,654.36
42894 3 REVISION OF PHARYNGEAL WALLS $2,118.36
42900 3 REPAIR THROAT WOUND $318.26
4290F 9 PT SCRNED FOR INJ DRUG USE $0.00
4293F 9 PT SCRND - HGH-RSK SEX BEHAV $0.00
42950 3 RECONSTRUCTION OF THROAT $725.88
42953 3 REPAIR THROAT, ESOPHAGUS $894.27
42955 3 SURGICAL OPENING OF THROAT $682.99

42960 3 CONTROL THROAT BLEEDING $155.45
42970 3 CONTROL NOSE/THROAT BLEEDING $356.77
42999 5 THROAT SURGERY PROCEDURE $0.00
43000 O ESOPHAGOTOMY, CERVICAL APPROACH; WI $0.00
4300F 9 PT RCVNG WARF THXPY $0.00
4301F 9 PT NOT RCVNG WARF THXPY $0.00
43020 3 INCISION OF ESOPHAGUS $484.75
43030 3 THROAT MUSCLE SURGERY $480.59

43040 O ESOPHAGOTOMY, THORACIC APPROACH; WI $0.00
43045 3 INCISION OF ESOPHAGUS $1,216.08
4305F 9 PT ED RE FT CARE INSPCT RCVD $0.00
4306F 9 PT TLK PSYCH & RX OPD ADDIC $0.00
43100 3 EXCISION OF ESOPHAGUS LESION $574.28
43101 3 EXCISION OF ESOPHAGUS LESION $949.61
43105 O WIDE EXCISION OF MALIGNANT LESION O $0.00
43106 O WIDE EXCISION OF MALIGNANT LESION O $0.00
43107 3 REMOVAL OF ESOPHAGUS $2,345.28

43110 O ESOPHAGECTOMY (AT UPPER TWO-THIRDS $0.00
43116 3 PARTIAL REMOVAL OF ESOPHAGUS $4,478.28
43119 O TOTAL ESOPHAGECTOMY WITH GASTROPHAR $0.00
43120 O ESOPHAGOGASTRECTOMY (LOWER THIRD) A $0.00

43130 3 REMOVAL OF ESOPHAGUS POUCH $726.73
43135 3 REMOVAL OF ESOPHAGUS POUCH $1,353.28
43136 O DIVERTICULOPEXY OF HYPOPHARYNX, WIT $0.00
43200 3 ESOPHAGUS ENDOSCOPY $199.31
43201 3 ESOPH SCOPE W/SUBMUCOUS INJ $274.22
43202 3 ESOPHAGUS ENDOSCOPY, BIOPSY $262.28
43204 3 ESOPH SCOPE W/SCLEROSIS INJ $212.91
43205 3 ESOPHAGUS ENDOSCOPY/LIGATION $213.51
4320F 9 PT TALK PSYCHSOC+RX OH DPND $0.00
43216 3 ESOPHAGUS ENDOSCOPY/LESION $184.09

43220 3 ESOPH ENDOSCOPY, DILATION $120.16
43227 3 ESOPH ENDOSCOPY, REPAIR $199.32
43228 3 ESOPH ENDOSCOPY, ABLATION $212.75
43231 3 ESOPH ENDOSCOPY W/US EXAM $181.24
43232 3 ESOPH ENDOSCOPY W/US FN BX $249.59
43234 3 UPPER GI ENDOSCOPY, EXAM $260.01
43235 3 UPPR GI ENDOSCOPY, DIAGNOSIS $280.73

43236 3 UPPR GI SCOPE W/SUBMUC INJ $349.68
43237 3 ENDOSCOPIC US EXAM, ESOPH $228.32
43238 3 UPPR GI ENDOSCOPY W/US FN BX $282.86
43239 3 UPPER GI ENDOSCOPY, BIOPSY $324.85
43240 3 ESOPH ENDOSCOPE W/DRAIN CYST $379.47
43241 3 UPPER GI ENDOSCOPY WITH TUBE $148.23
43242 3 UPPR GI ENDOSCOPY W/US FN BX $404.81
43243 3 UPPER GI ENDOSCOPY & INJECT $255.15
43244 3 UPPER GI ENDOSCOPY/LIGATION $282.88
43245 3 UPPR GI SCOPE DILATE STRICTR $178.28
43246 3 PLACE GASTROSTOMY TUBE $238.68
43247 3 OPERATIVE UPPER GI ENDOSCOPY $190.85
43248 3 UPPR GI ENDOSCOPY/GUIDE WIRE $180.56

43250 3 UPPER GI ENDOSCOPY/TUMOR $178.25
43256 3 UPPR GI ENDOSCOPY W/STENT $242.61
43257 3 UPPR GI SCOPE W/THRML TXMNT $297.60
43259 3 ENDOSCOPIC ULTRASOUND EXAM $289.97
43260 3 ENDO CHOLANGIOPANCREATOGRAPH $331.98

43273 3 ENDOSCOPIC PANCREATOSCOPY $123.80
43279 3 LAP MYOTOMY, HELLER $1,147.30
43280 3 LAPAROSCOPY, FUNDOPLASTY $958.13

43289 5 LAPAROSCOPE PROC, ESOPH $0.00
43300 3 REPAIR OF ESOPHAGUS $570.75
43305 3 REPAIR ESOPHAGUS AND FISTULA $1,019.53
43310 3 REPAIR OF ESOPHAGUS $1,418.73
43312 3 REPAIR ESOPHAGUS AND FISTULA $1,565.78
43313 3 ESOPHAGOPLASTY CONGENITAL $2,489.03
43314 3 TRACHEO-ESOPHAGOPLASTY CONG $2,857.94
43320 3 FUSE ESOPHAGUS & STOMACH $1,246.32
43321 O ESOPHAGOGASTROSTOMY (CARDIOPLASTY), $0.00
43324 3 REVISE ESOPHAGUS & STOMACH $1,207.62

43340 3 FUSE ESOPHAGUS & INTESTINE $1,210.79
43341 3 FUSE ESOPHAGUS & INTESTINE $1,335.63
43350 3 SURGICAL OPENING, ESOPHAGUS $1,034.24
43351 3 SURGICAL OPENING, ESOPHAGUS $1,215.58
43352 3 SURGICAL OPENING, ESOPHAGUS $994.66
43360 3 GASTROINTESTINAL REPAIR $2,124.60
43361 3 GASTROINTESTINAL REPAIR $2,371.86
43400 3 LIGATE ESOPHAGUS VEINS $1,467.69
43401 3 ESOPHAGUS SURGERY FOR VEINS $1,381.79
43405 3 LIGATE/STAPLE ESOPHAGUS $1,341.29
43410 3 REPAIR ESOPHAGUS WOUND $919.48

43415 3 REPAIR ESOPHAGUS WOUND $1,563.06
43420 3 REPAIR ESOPHAGUS OPENING $919.47
43425 3 REPAIR ESOPHAGUS OPENING $1,374.23
43450 3 DILATE ESOPHAGUS $148.81
43451 O DILATION OF ESOPHAGUS, BY UNGUIDED $0.00
43455 O DILATION OF ESOPHAGUS, BY BALLOON O $0.00
43460 3 PRESSURE TREATMENT ESOPHAGUS $209.04

43496 5 FREE JEJUNUM FLAP, MICROVASC $0.00
43499 5 ESOPHAGUS SURGERY PROCEDURE $0.00
43500 3 SURGICAL OPENING OF STOMACH $685.62
43501 3 SURGICAL REPAIR OF STOMACH $1,177.74
43502 3 SURGICAL REPAIR OF STOMACH $1,333.33
43510 3 SURGICAL OPENING OF STOMACH $849.49
43520 3 INCISION OF PYLORIC MUSCLE $620.99
43600 3 BIOPSY OF STOMACH $101.19
43605 3 BIOPSY OF STOMACH $727.51
43610 3 EXCISION OF STOMACH LESION $858.97
43611 3 EXCISION OF STOMACH LESION $1,068.92
43620 3 REMOVAL OF STOMACH $1,739.94

43625 O GASTRECTOMY, TOTAL WITH REPAIR BY I $0.00
43630 O HEMIGASTRECTOMY OR DISTAL SUBTOTAL $0.00
43631 3 REMOVAL OF STOMACH, PARTIAL $1,277.07
43635 3 REMOVAL OF STOMACH, PARTIAL $101.89
43638 O REMOVAL OF STOMACH, PARTIAL $0.00
43639 O REMOVAL OF STOMACH, PARTIAL $0.00
43640 3 VAGOTOMY & PYLORUS REPAIR $1,027.24
43641 3 VAGOTOMY & PYLORUS REPAIR $1,035.93

43644 3 LAP GASTRIC BYPASS/ROUX-EN-Y $1,519.51
43645 3 LAP GASTR BYPASS INCL SMLL I $1,625.44
43647 6 LAP IMPL ELECTRODE, ANTRUM $0.00
43648 6 LAP REVISE/REMV ELTRD ANTRUM $0.00
43651 3 LAPAROSCOPY, VAGUS NERVE $572.06
43652 3 LAPAROSCOPY, VAGUS NERVE $669.13
43653 3 LAPAROSCOPY, GASTROSTOMY $488.91
43659 5 LAPAROSCOPE PROC, STOM $0.00
43750 O PLACE GASTROSTOMY TUBE $0.00
43752 3 NASAL/OROGASTRIC W/STENT $39.78

43760 3 CHANGE GASTROSTOMY TUBE $48.00
43761 3 REPOSITION GASTROSTOMY TUBE $116.72
43770 3 LAP PLACE GASTR ADJ DEVICE $975.76
43771 3 LAP REVISE GASTR ADJ DEVICE $1,112.17
43772 3 LAP RMVL GASTR ADJ DEVICE $841.04
43773 3 LAP REPLACE GASTR ADJ DEVICE $1,113.15
43774 3 LAP RMVL GASTR ADJ ALL PARTS $842.03
43800 3 RECONSTRUCTION OF PYLORUS $815.44
43810 3 FUSION OF STOMACH AND BOWEL $883.44
43820 3 FUSION OF STOMACH AND BOWEL $1,143.25
43825 3 FUSION OF STOMACH AND BOWEL $1,136.59

43840 3 REPAIR OF STOMACH LESION $1,159.62
43842 3 V-BAND GASTROPLASTY $1,131.27
43843 3 GASTROPLASTY W/O V-BAND $1,108.00
43844 O GASTRIC BYPASS, OTHER THAN WITH ROU $0.00
43845 3 GASTRIC RESTRICTIVE PROCEDURE $1,714.11
43846 3 GASTRIC BYPASS FOR OBESITY $1,428.81
43847 3 GASTRIC BYPASS INCL SMALL I $1,560.20
43848 3 REVISION GASTROPLASTY $1,693.47
43850 3 REVISE STOMACH-BOWEL FUSION $1,417.76

43870 3 REPAIR STOMACH OPENING $618.27
43880 3 REPAIR STOMACH-BOWEL FISTULA $1,406.92
43881 6 IMPL/REDO ELECTRD, ANTRUM $0.00
43882 6 REVISE/REMOVE ELECTRD ANTRUM $0.00
43885 O ANTERIOR GASTROPEXY FOR HIATAL HERN $0.00
43886 3 REVISE GASTRIC PORT, OPEN $293.92
43887 3 REMOVE GASTRIC PORT, OPEN $275.75
43888 3 CHANGE GASTRIC PORT, OPEN $388.63
43999 5 STOMACH SURGERY PROCEDURE $0.00

44005 3 FREEING OF BOWEL ADHESION $961.57
44010 3 INCISION OF SMALL BOWEL $756.75
44015 3 INSERT NEEDLE CATH BOWEL $130.85
44020 3 EXPLORE SMALL INTESTINE $850.17
44021 3 DECOMPRESS SMALL BOWEL $860.28
44025 3 INCISION OF LARGE BOWEL $865.57
44040 O EXTERIORIZATION OF INTESTINE (MIKUL $0.00
44050 3 REDUCE BOWEL OBSTRUCTION $819.61
44055 3 CORRECT MALROTATION OF BOWEL $1,311.07
44100 3 BIOPSY OF BOWEL $109.17
44110 3 EXCISE INTESTINE LESION(S) $741.92
44111 3 EXCISION OF BOWEL LESION(S) $863.35
44120 3 REMOVAL OF SMALL INTESTINE $1,068.63

44121 3 REMOVAL OF SMALL INTESTINE $219.88
44125 3 REMOVAL OF SMALL INTESTINE $1,037.95
44126 3 ENTERECTOMY W/O TAPER, CONG $2,141.52
44127 3 ENTERECTOMY W/TAPER, CONG $2,492.87
44128 3 ENTERECTOMY CONG, ADD-ON $220.97
44130 3 BOWEL TO BOWEL FUSION $1,118.87
44131 O ENTEROENTEROSTOMY, ANASTOMOSIS OF I $0.00
44132 9 ENTERECTOMY, CADAVER DONOR $0.00
44133 5 ENTERECTOMY, LIVE DONOR $0.00
44135 5 INTESTINE TRANSPLNT, CADAVER $0.00
44136 5 INTESTINE TRANSPLANT, LIVE $0.00
44137 6 REMOVE INTESTINAL ALLOGRAFT $0.00

44139 3 MOBILIZATION OF COLON $110.05
44140 3 PARTIAL REMOVAL OF COLON $1,181.78
44150 3 REMOVAL OF COLON $1,617.01
44151 3 REMOVAL OF COLON/ILEOSTOMY $1,847.82

44152 O REMOVAL OF COLON/ILEOSTOMY $0.00
44153 O REMOVAL OF COLON/ILEOSTOMY $0.00
44157 3 COLECTOMY W/ILEOANAL ANAST $1,889.59
44158 3 COLECTOMY W/NEO-RECTUM POUCH $1,936.57
44160 3 REMOVAL OF COLON $1,088.83
44180 3 LAP, ENTEROLYSIS $812.53
44186 3 LAP, JEJUNOSTOMY $574.10
44187 3 LAP, ILEO/JEJUNO-STOMY $968.00
44188 3 LAP, COLOSTOMY $1,070.67
44200 O LAPAROSCOPY, ENTEROLYSIS $0.00
44201 O LAPAROSCOPY, JEJUNOSTOMY $0.00

44202 3 LAP, ENTERECTOMY $1,222.97
44203 3 LAP RESECT S/INTESTINE, ADDL $218.90
44204 3 LAPARO PARTIAL COLECTOMY $1,364.84
44205 3 LAP COLECTOMY PART W/ILEUM $1,191.86
44206 3 LAP PART COLECTOMY W/STOMA $1,549.14
44207 3 L COLECTOMY/COLOPROCTOSTOMY $1,625.81
44208 3 L COLECTOMY/COLOPROCTOSTOMY $1,769.51
44209 O LAPAROSCOPE PROC, INTESTINE $0.00
44210 3 LAPARO TOTAL PROCTOCOLECTOMY $1,582.62
44211 3 LAP COLECTOMY W/PROCTECTOMY $1,942.44
44212 3 LAPARO TOTAL PROCTOCOLECTOMY $1,822.68
44213 3 LAP, MOBIL SPLENIC FL ADD-ON $172.59

44227 3 LAP, CLOSE ENTEROSTOMY $1,477.64
44238 5 LAPAROSCOPE PROC, INTESTINE $0.00
44239 O LAPAROSCOPE PROC, RECTUM $0.00
44300 3 OPEN BOWEL TO SKIN $736.85
44305 O ENTEROSTOMY OR CECOSTOMY, TUBE (EG, $0.00
44310 3 ILEOSTOMY/JEJUNOSTOMY $920.39
44312 3 REVISION OF ILEOSTOMY $525.14
44314 3 REVISION OF ILEOSTOMY $892.06
44316 3 DEVISE BOWEL POUCH $1,219.59
44320 3 COLOSTOMY $1,050.13

44322 3 COLOSTOMY WITH BIOPSIES $840.65
44340 3 REVISION OF COLOSTOMY $528.93
44345 3 REVISION OF COLOSTOMY $919.70
44346 3 REVISION OF COLOSTOMY $1,031.83
44360 3 SMALL BOWEL ENDOSCOPY $150.34
44361 3 SMALL BOWEL ENDOSCOPY/BIOPSY $165.63
44370 3 SMALL BOWEL ENDOSCOPY/STENT $273.94

44377 3 SMALL BOWEL ENDOSCOPY/BIOPSY $307.03
44379 3 S BOWEL ENDOSCOPE W/STENT $417.49
44383 3 ILEOSCOPY W/STENT $168.87
44385 3 ENDOSCOPY OF BOWEL POUCH $231.30
44386 3 ENDOSCOPY, BOWEL POUCH/BIOP $322.34
44388 3 COLONOSCOPY $319.95
44389 3 COLONOSCOPY WITH BIOPSY $371.94

44390 3 COLONOSCOPY FOR FOREIGN BODY $429.22
44391 3 COLONOSCOPY FOR BLEEDING $480.86
44392 3 COLONOSCOPY & POLYPECTOMY $402.35
44393 3 COLONOSCOPY, LESION REMOVAL $466.97
44394 3 COLONOSCOPY W/SNARE $470.96
44397 3 COLONOSCOPY W/STENT $262.70
44500 9 INTRO, GASTROINTESTINAL TUBE $0.00
44600 O SUTURE OF INTESTINE (ENTERORRHAPHY) $0.00
44602 3 SUTURE, SMALL INTESTINE $1,210.79
44603 3 SUTURE, SMALL INTESTINE $1,388.29

44604 3 SUTURE, LARGE INTESTINE $932.41
44605 3 REPAIR OF BOWEL LESION $1,150.44
44610 O SUTURE OF INTESTINE (ENTERORRHAPHY) $0.00
44615 3 INTESTINAL STRICTUROPLASTY $947.82
44620 3 REPAIR BOWEL OPENING $757.12
44625 3 REPAIR BOWEL OPENING $896.18
44626 3 REPAIR BOWEL OPENING $1,423.71
44640 3 REPAIR BOWEL-SKIN FISTULA $1,242.41
44650 3 REPAIR BOWEL FISTULA $1,292.19
44660 3 REPAIR BOWEL-BLADDER FISTULA $1,254.79
44661 3 REPAIR BOWEL-BLADDER FISTULA $1,404.86
44680 3 SURGICAL REVISION, INTESTINE $936.04
44700 3 SUSPEND BOWEL W/PROSTHESIS $906.18

44701 3 INTRAOP COLON LAVAGE ADD-ON $152.17
44715 9 PREPARE DONOR INTESTINE $0.00
44720 9 PREP DONOR INTESTINE/VENOUS $0.00
44721 9 PREP DONOR INTESTINE/ARTERY $0.00
44799 5 UNLISTED PROCEDURE INTESTINE $0.00
44800 3 EXCISION OF BOWEL POUCH $668.19
44820 3 EXCISION OF MESENTERY LESION $737.00
44850 3 REPAIR OF MESENTERY $650.27
44899 5 BOWEL SURGERY PROCEDURE $0.00
44900 3 DRAIN APP ABSCESS, OPEN $666.07
44901 3 DRAIN APP ABSCESS, PERCUT $933.52
44950 3 APPENDECTOMY $564.07

44955 3 APPENDECTOMY ADD-ON $76.47
44960 3 APPENDECTOMY $759.21
44970 3 LAPAROSCOPY, APPENDECTOMY $519.30
44979 5 LAPAROSCOPE PROC, APP $0.00
45000 3 DRAINAGE OF PELVIC ABSCESS $363.79
45005 3 DRAINAGE OF RECTAL ABSCESS $223.13
45020 3 DRAINAGE OF RECTAL ABSCESS $474.13
45100 3 BIOPSY OF RECTUM $253.35
45108 3 REMOVAL OF ANORECTAL LESION $307.74
45110 3 REMOVAL OF RECTUM $1,629.13

45111 3 PARTIAL REMOVAL OF RECTUM $956.93
45113 3 PARTIAL PROCTECTOMY $1,720.45
45114 3 PARTIAL REMOVAL OF RECTUM $1,570.27
45116 3 PARTIAL REMOVAL OF RECTUM $1,410.98
45119 3 REMOVE RECTUM W/RESERVOIR $1,722.56
45121 3 REMOVAL OF RECTUM AND COLON $1,506.52
45123 3 PARTIAL PROCTECTOMY $976.78
45126 3 PELVIC EXENTERATION $2,546.97
45130 3 EXCISION OF RECTAL PROLAPSE $955.04
45135 3 EXCISION OF RECTAL PROLAPSE $1,170.08
45136 3 EXCISE ILEOANAL RESERVIOR $1,620.56

45150 3 EXCISION OF RECTAL STRICTURE $350.20
45160 3 EXCISION OF RECTAL LESION $870.22
45170 3 EXCISION OF RECTAL LESION $680.54
45180 O EXCISION AND/OR ELECTRODESICCATION $0.00
45190 3 DESTRUCTION, RECTAL TUMOR $593.32
45300 3 PROCTOSIGMOIDOSCOPY DX $97.57
45302 O PROCTOSIGMOIDOSCOPY; WITH COLLECTIO $0.00
45303 3 PROCTOSIGMOIDOSCOPY DILATE $765.38
45305 3 PROCTOSIGMOIDOSCOPY W/BX $158.96
45307 3 PROCTOSIGMOIDOSCOPY FB $176.52
45308 3 PROCTOSIGMOIDOSCOPY REMOVAL $161.98

45310 O PROCTOSIGMOIDOSCOPY; WITH REMOVAL O $0.00
45317 3 PROCTOSIGMOIDOSCOPY BLEED $189.31
45320 3 PROCTOSIGMOIDOSCOPY ABLATE $190.92
45321 3 PROCTOSIGMOIDOSCOPY VOLVUL $94.85
45327 3 PROCTOSIGMOIDOSCOPY W/STENT $110.80
45330 3 DIAGNOSTIC SIGMOIDOSCOPY $126.06
45331 3 SIGMOIDOSCOPY AND BIOPSY $160.45
45332 3 SIGMOIDOSCOPY W/FB REMOVAL $263.75
45333 3 SIGMOIDOSCOPY & POLYPECTOMY $265.35

45334 3 SIGMOIDOSCOPY FOR BLEEDING $156.32
45335 3 SIGMOIDOSCOPY W/SUBMUC INJ $227.10
45336 O SIGMOIDOSCOPY, FLEXIBLE FIBEROPTIC; $0.00
45337 3 SIGMOIDOSCOPY & DECOMPRESS $133.73
45338 3 SIGMOIDOSCOPY W/TUMR REMOVE $295.58
45339 3 SIGMOIDOSCOPY W/ABLATE TUMR $305.51
45340 3 SIG W/BALLOON DILATION $406.09
45341 3 SIGMOIDOSCOPY W/ULTRASOUND $149.22
45342 3 SIGMOIDOSCOPY W/US GUIDE BX $228.08
45345 3 SIGMOIDOSCOPY W/STENT $165.68
45355 3 SURGICAL COLONOSCOPY $190.25
45378 3 DIAGNOSTIC COLONOSCOPY $369.74
45379 3 COLONOSCOPY W/FB REMOVAL $469.39

45380 3 COLONOSCOPY AND BIOPSY $443.97
45381 3 COLONOSCOPY, SUBMUCOUS INJ $432.35
45382 3 COLONOSCOPY/CONTROL BLEEDING $585.46
45383 3 LESION REMOVAL COLONOSCOPY $527.40
45384 3 LESION REMOVE COLONOSCOPY $435.49
45385 3 LESION REMOVAL COLONOSCOPY $500.04
45386 3 COLONOSCOPY DILATE STRICTURE $620.37
45387 3 COLONOSCOPY W/STENT $328.44
45391 3 COLONOSCOPY W/ENDOSCOPE US $283.64
45392 3 COLONOSCOPY W/ENDOSCOPIC FNB $358.75
45395 3 LAP, REMOVAL OF RECTUM $1,761.52
45397 3 LAP, REMOVE RECTUM W/POUCH $1,906.77

45400 3 LAPAROSCOPIC PROC $1,015.96
45402 3 LAP PROCTOPEXY W/SIG RESECT $1,357.77
45499 6 LAPAROSCOPE PROC, RECTUM $0.00
45500 3 REPAIR OF RECTUM $448.85
45505 3 REPAIR OF RECTUM $492.57
45520 3 TREATMENT OF RECTAL PROLAPSE $114.02
45540 3 CORRECT RECTAL PROLAPSE $937.08
45541 3 CORRECT RECTAL PROLAPSE $806.79
45550 3 REPAIR RECTUM/REMOVE SIGMOID $1,288.92
45560 3 REPAIR OF RECTOCELE $639.24

45562 3 EXPLORATION/REPAIR OF RECTUM $979.24
45563 3 EXPLORATION/REPAIR OF RECTUM $1,417.05
45800 3 REPAIR RECT/BLADDER FISTULA $1,099.54
45805 3 REPAIR FISTULA W/COLOSTOMY $1,241.48
45820 3 REPAIR RECTOURETHRAL FISTULA $1,091.64
45825 3 REPAIR FISTULA W/COLOSTOMY $1,314.34
45900 3 REDUCTION OF RECTAL PROLAPSE $173.60
45905 3 DILATION OF ANAL SPHINCTER $147.78
45910 3 DILATION OF RECTAL NARROWING $174.88
45915 3 REMOVE RECTAL OBSTRUCTION $275.39
45990 3 SURG DX EXAM, ANORECTAL $96.86
45999 5 RECTUM SURGERY PROCEDURE $0.00
46000 O FISTULOTOMY, SUBCUTANEOUS $0.00

46020 3 PLACEMENT OF SETON $221.92
46030 3 REMOVAL OF RECTAL MARKER $111.99
46040 3 INCISION OF RECTAL ABSCESS $433.89
46050 3 INCISION OF ANAL ABSCESS $156.77
46070 3 INCISION OF ANAL SEPTUM $201.56
46080 3 INCISION OF ANAL SPHINCTER $203.00
46083 3 INCISE EXTERNAL HEMORRHOID $154.53
46200 3 REMOVAL OF ANAL FISSURE $341.84
46210 3 REMOVAL OF ANAL CRYPT $314.61
46211 3 REMOVAL OF ANAL CRYPTS $424.68

46220 3 REMOVAL OF ANAL TAG $164.80
46221 3 LIGATION OF HEMORRHOID(S) $215.24
46230 3 REMOVAL OF ANAL TAGS $225.08
46250 3 HEMORRHOIDECTOMY $374.95
46257 3 REMOVE HEMORRHOIDS & FISSURE $352.14
46258 3 REMOVE HEMORRHOIDS & FISTULA $384.90
46261 3 REMOVE HEMORRHOIDS & FISSURE $446.49
46262 3 REMOVE HEMORRHOIDS & FISTULA $466.46

46270 3 REMOVAL OF ANAL FISTULA $404.73
46281 O CLOSURE OF ANAL FISTULA WITH RECTAL $0.00
46288 3 REPAIR ANAL FISTULA $460.48
46320 3 REMOVAL OF HEMORRHOID CLOT $148.34
46500 3 INJECTION INTO HEMORRHOID(S) $181.11
46505 3 CHEMODENERVATION ANAL MUSC $234.62
46600 3 DIAGNOSTIC ANOSCOPY $72.98
46602 O ANOSCOPY FOR COLLECTION OF SPECIMEN $0.00
46604 3 ANOSCOPY AND DILATION $458.56
46606 3 ANOSCOPY AND BIOPSY $187.00

46608 3 ANOSCOPY, REMOVE FOR BODY $193.00
46610 3 ANOSCOPY, REMOVE LESION $190.93
46611 3 ANOSCOPY $150.09
46612 3 ANOSCOPY, REMOVE LESIONS $228.90
46614 3 ANOSCOPY, CONTROL BLEEDING $115.21
46615 3 ANOSCOPY $132.12
46700 3 REPAIR OF ANAL STRICTURE $553.66
46705 3 REPAIR OF ANAL STRICTURE $457.89
46706 3 REPR OF ANAL FISTULA W/GLUE $146.80
46710 3 REPR PER/VAG POUCH SNGL PROC $941.85
46712 3 REPR PER/VAG POUCH DBL PROC $1,918.19
46715 3 REP PERF ANOPER FISTU $451.94

46716 3 REP PERF ANOPER/VESTIB FISTU $1,108.79
46730 3 CONSTRUCTION OF ABSENT ANUS $1,670.41
46742 3 REPAIR OF IMPERFORATED ANUS $2,115.75
46744 3 REPAIR OF CLOACAL ANOMALY $3,013.24
46750 3 REPAIR OF ANAL SPHINCTER $668.84

46753 3 RECONSTRUCTION OF ANUS $505.56
46754 3 REMOVAL OF SUTURE FROM ANUS $243.89
46762 3 IMPLANT ARTIFICIAL SPHINCTER $806.46
46900 3 DESTRUCTION, ANAL LESION(S) $198.03
46916 3 CRYOSURGERY, ANAL LESION(S) $204.76
46917 3 LASER SURGERY, ANAL LESIONS $397.18
46922 3 EXCISION OF ANAL LESION(S) $215.53
46930 3 DESTROY INTERNAL HEMORRHOIDS $190.45
46934 O DESTRUCTION OF HEMORRHOIDS $0.00

46937 3 CRYOTHERAPY OF RECTAL LESION $220.74
46938 3 CRYOTHERAPY OF RECTAL LESION $385.19
46940 3 TREATMENT OF ANAL FISSURE $185.64
46942 3 TREATMENT OF ANAL FISSURE $172.09
46945 3 LIGATION OF HEMORRHOIDS $241.12
46946 3 LIGATION OF HEMORRHOIDS $260.57
46947 3 HEMORRHOIDOPEXY BY STAPLING $327.28
46999 5 ANUS SURGERY PROCEDURE $0.00
47000 3 NEEDLE BIOPSY OF LIVER $310.35
47001 3 NEEDLE BIOPSY, LIVER ADD-ON $94.22

47010 3 OPEN DRAINAGE, LIVER LESION $1,047.71
47011 3 PERCUT DRAIN, LIVER LESION $189.26
47015 3 INJECT/ASPIRATE LIVER CYST $993.71
47100 3 WEDGE BIOPSY OF LIVER $729.22
47120 3 PARTIAL REMOVAL OF LIVER $2,046.78
47122 3 EXTENSIVE REMOVAL OF LIVER $3,042.64
47133 9 REMOVAL OF DONOR LIVER $0.00
47134 O PARTIAL REMOVAL, DONOR LIVER $0.00

47135 3 TRANSPLANTATION OF LIVER $4,314.50
47136 3 TRANSPLANTATION OF LIVER $3,681.05
47140 9 PARTIAL REMOVAL, DONOR LIVER $0.00
47143 9 PREP DONOR LIVER, WHOLE $0.00
47144 9 PREP DONOR LIVER, 3-SEGMENT $0.00
47145 9 PREP DONOR LIVER, LOBE SPLIT $0.00
47146 9 PREP DONOR LIVER/VENOUS $0.00
47147 9 PREP DONOR LIVER/ARTERIAL $0.00
47300 3 SURGERY FOR LIVER LESION $977.79
47350 3 REPAIR LIVER WOUND $1,199.36
47355 O HEPATORRHAPHY, SUTURE OF LIVER WOUN $0.00

47370 3 LAPARO ABLATE LIVER TUMOR RF $1,096.11
47371 3 LAPARO ABLATE LIVER CRYOSURG $1,117.27
47379 5 LAPAROSCOPE PROCEDURE, LIVER $0.00
47380 3 OPEN ABLATE LIVER TUMOR RF $1,281.15
47381 3 OPEN ABLATE LIVER TUMOR CRYO $1,306.57
47382 3 PERCUT ABLATE LIVER RF $811.29
47399 5 LIVER SURGERY PROCEDURE $0.00
47400 3 INCISION OF LIVER DUCT $1,859.80
47420 3 INCISION OF BILE DUCT $1,174.25

47425 3 INCISION OF BILE DUCT $1,185.87
47440 O DUODENOCHOLEDOCHOTOMY, TRANSDUODENA $0.00
47460 3 INCISE BILE DUCT SPHINCTER $1,120.95
47480 3 INCISION OF GALLBLADDER $747.24
47490 3 INCISION OF GALLBLADDER $504.63
47500 3 INJECTION FOR LIVER X-RAYS $100.65
47505 3 INJECTION FOR LIVER X-RAYS $38.84
47510 3 INSERT CATHETER, BILE DUCT $477.39
47511 3 INSERT BILE DUCT DRAIN $598.29
47525 3 CHANGE BILE DUCT CATHETER $505.86

47530 3 REVISE/REINSERT BILE TUBE $1,384.58
47550 3 BILE DUCT ENDOSCOPY ADD-ON $150.77
47552 3 BILIARY ENDOSCOPY THRU SKIN $324.25
47560 3 LAPAROSCOPY W/CHOLANGIO $243.57
47561 3 LAPARO W/CHOLANGIO/BIOPSY $264.52
47562 3 LAPAROSCOPIC CHOLECYSTECTOMY $647.26
47563 3 LAPARO CHOLECYSTECTOMY/GRAPH $662.22
47564 3 LAPARO CHOLECYSTECTOMY/EXPLR $764.55
47570 3 LAPARO CHOLECYSTOENTEROSTOMY $682.82

47579 5 LAPAROSCOPE PROC, BILIARY $0.00
47600 3 REMOVAL OF GALLBLADDER $927.10
47605 3 REMOVAL OF GALLBLADDER $858.18
47610 3 REMOVAL OF GALLBLADDER $1,099.40
47630 3 REMOVE BILE DUCT STONE $543.15
47700 3 EXPLORATION OF BILE DUCTS $917.01
47701 3 BILE DUCT REVISION $1,576.73
47710 O EXCISION OF BILE DUCT TUMOR, WITH R $0.00
47711 3 EXCISION OF BILE DUCT TUMOR $1,365.15
47712 3 EXCISION OF BILE DUCT TUMOR $1,747.02

47715 3 EXCISION OF BILE DUCT CYST $1,147.85
47716 O FUSION OF BILE DUCT CYST $0.00
47719 O FUSION OF BILE DUCT CYST $0.00
47720 3 FUSE GALLBLADDER & BOWEL $992.24
47721 3 FUSE UPPER GI STRUCTURES $1,170.08
47740 3 FUSE GALLBLADDER & BOWEL $1,130.68
47741 3 FUSE GALLBLADDER & BOWEL $1,280.63
47760 3 FUSE BILE DUCTS AND BOWEL $1,925.11
47765 3 FUSE LIVER DUCTS & BOWEL $2,538.40

47800 3 RECONSTRUCTION OF BILE DUCTS $1,378.47
47801 3 PLACEMENT, BILE DUCT SUPPORT $977.42
47802 3 FUSE LIVER DUCT & INTESTINE $1,323.72
47900 3 SUTURE BILE DUCT INJURY $1,193.10
47999 5 BILE TRACT SURGERY PROCEDURE $0.00
48000 3 DRAINAGE OF ABDOMEN $1,652.28
48001 3 PLACEMENT OF DRAIN, PANCREAS $2,029.95
48005 O RESECT/DEBRIDE PANCREAS $0.00
48020 3 REMOVAL OF PANCREATIC STONE $1,020.27
48100 3 BIOPSY OF PANCREAS, OPEN $774.50
48102 3 NEEDLE BIOPSY, PANCREAS $517.04
48105 3 RESECT/DEBRIDE PANCREAS $2,501.57

48120 3 REMOVAL OF PANCREAS LESION $966.71
48140 3 PARTIAL REMOVAL OF PANCREAS $1,368.22
48146 3 PANCREATECTOMY $1,622.69
48148 3 REMOVAL OF PANCREATIC DUCT $1,077.45
48151 O PANCREATECTOMY, NEAR-TOTAL, WITH PR $0.00
48155 3 REMOVAL OF PANCREAS $1,574.61
48160 5 PANCREAS REMOVAL/TRANSPLANT $0.00

48180 O FUSE PANCREAS AND BOWEL $0.00
48400 9 INJECTION, INTRAOP ADD-ON $0.00
48500 3 SURGERY OF PANCREATIC CYST $987.22
48510 3 DRAIN PANCREATIC PSEUDOCYST $937.78
48511 3 DRAIN PANCREATIC PSEUDOCYST $903.65
48520 3 FUSE PANCREAS CYST AND BOWEL $955.73
48540 3 FUSE PANCREAS CYST AND BOWEL $1,141.68
48545 3 PANCREATORRHAPHY $1,156.20
48547 3 DUODENAL EXCLUSION $1,558.50
48548 3 FUSE PANCREAS AND BOWEL $1,460.38

48550 9 DONOR PANCREATECTOMY $0.00
48551 9 PREP DONOR PANCREAS $0.00
48552 9 PREP DONOR PANCREAS/VENOUS $0.00
48554 3 TRANSPL ALLOGRAFT PANCREAS $2,177.48
48556 3 REMOVAL, ALLOGRAFT PANCREAS $1,083.79
48999 5 PANCREAS SURGERY PROCEDURE $0.00
49000 3 EXPLORATION OF ABDOMEN $680.97
49002 3 REOPENING OF ABDOMEN $891.40
49010 3 EXPLORATION BEHIND ABDOMEN $843.09
49020 3 DRAIN ABDOMINAL ABSCESS $1,394.63
49021 3 DRAIN ABDOMINAL ABSCESS $864.27
49040 3 DRAIN, OPEN, ABDOM ABSCESS $874.47
49041 3 DRAIN, PERCUT, ABDOM ABSCESS $881.47

49060 3 DRAIN, OPEN, RETROP ABSCESS $978.92
49061 3 DRAIN, PERCUT, RETROPER ABSC $189.26
49062 3 DRAIN TO PERITONEAL CAVITY $666.05
49080 3 PUNCTURE, PERITONEAL CAVITY $69.01
49081 3 REMOVAL OF ABDOMINAL FLUID $152.18
49085 O REMOVE ABDOMEN FOREIGN BODY $0.00
49180 3 BIOPSY, ABDOMINAL MASS $162.93
49200 O REMOVAL OF ABDOMINAL LESION $0.00
49201 O REMOVE ABDOM LESION, COMPLEX $0.00
49203 3 EXC ABD TUM 5 CM OR LESS $1,065.96
49204 3 EXC ABD TUM OVER 5 CM $1,360.38
49205 3 EXC ABD TUM OVER 10 CM $1,557.22

49215 3 EXCISE SACRAL SPINE TUMOR $1,952.41
49220 3 MULTIPLE SURGERY, ABDOMEN $850.70
49250 3 EXCISION OF UMBILICUS $509.14
49255 3 REMOVAL OF OMENTUM $690.68
49300 O PERITONEOSCOPY WITHOUT BIOPSY $0.00
49301 O PERITONEOSCOPY WITH BIOPSY $0.00
49302 O PERITONEOSCOPY WITH GUIDED TRANSHEP $0.00
49303 O PERITONEOSCOPY WITH GUIDED TRANSHEP $0.00
49310 O LAPAROSCOPY, SURGICAL; CHOLECYSTECT $0.00
49311 O LAPAROSCOPY, SURGICAL; CHOLECYSTECT $0.00

49315 O LAPAROSCOPY, SURGICAL;APPENDECTOMY $0.00
49320 3 DIAG LAPARO SEPARATE PROC $291.74
49321 3 LAPAROSCOPY, BIOPSY $306.99
49322 3 LAPAROSCOPY, ASPIRATION $333.51
49323 3 LAPARO DRAIN LYMPHOCELE $566.35
49324 3 LAP INSERTION PERM IP CATH $346.91
49325 3 LAP REVISION PERM IP CATH $372.33
49326 3 LAP W/OMENTOPEXY ADD-ON $170.74
49329 5 LAPARO PROC, ABDM/PER/OMENT $0.00
49400 3 AIR INJECTION INTO ABDOMEN $169.49
49401 O PNEUMOPERITONEUM (SEPARATE PROCEDUR $0.00
49402 3 REMOVE FOREIGN BODY, ADBOMEN $750.93
49419 3 INSRT ABDOM CATH FOR CHEMOTX $402.98

49420 3 INSERT ABDOM DRAIN, TEMP $127.99
49421 3 INSERT ABDOM DRAIN, PERM $345.80
49422 3 REMOVE PERM CANNULA/CATHETER $346.00
49423 3 EXCHANGE DRAINAGE CATHETER $76.51
49424 3 ASSESS CYST, CONTRAST INJECT $39.94
49425 3 INSERT ABDOMEN-VENOUS DRAIN $675.92
49426 3 REVISE ABDOMEN-VENOUS SHUNT $575.79
49427 3 INJECTION, ABDOMINAL SHUNT $46.05
49428 3 LIGATION OF SHUNT $387.87
49429 3 REMOVAL OF SHUNT $409.02
49435 3 INSERT SUBQ EXTEN TO IP CATH $109.29
49436 3 EMBEDDED IP CATH EXIT-SITE $162.36

49440 3 PLACE GASTROSTOMY TUBE PERC $1,063.95
49441 3 PLACE DUOD/JEJ TUBE PERC $1,154.92
49442 3 PLACE CECOSTOMY TUBE PERC $1,035.62
49446 3 CHANGE G-TUBE TO G-J PERC $968.12
49450 3 REPLACE G/C TUBE PERC $67.89
49451 3 REPLACE DUOD/JEJ TUBE PERC $94.64
49452 3 REPLACE G-J TUBE PERC $147.55
49460 3 FIX G/COLON TUBE W/DEVICE $796.74
49465 3 FLUORO EXAM OF G/COLON TUBE $165.95
49491 3 RPR HERN PREEMIE REDUC $679.23

49492 3 RPR ING HERN PREMIE, BLOCKED $829.29
49495 3 RPR ING HERNIA BABY, REDUC $345.82
49496 3 RPR ING HERNIA BABY, BLOCKED $524.68
49500 3 RPR ING HERNIA, INIT, REDUCE $344.85
49501 3 RPR ING HERNIA, INIT BLOCKED $520.75
49505 3 PRP I/HERN INIT REDUC >5 YR $451.56
49507 3 PRP I/HERN INIT BLOCK >5 YR $555.29
49510 O REPAIR INGUINAL HERNIA, AGE 5 OR OV $0.00
49515 O REPAIR INGUINAL HERNIA, AGE 5 OR OV $0.00
49520 3 REREPAIR ING HERNIA, REDUCE $551.17
49521 3 REREPAIR ING HERNIA, BLOCKED $671.65
49525 3 REPAIR ING HERNIA, SLIDING $498.60
49530 O REPAIR INGUINAL HERNIA, ANY AGE INC $0.00

49535 O REPAIR INGUINAL HERNIA, ANY AGE STR $0.00
49540 3 REPAIR LUMBAR HERNIA $589.37
49550 3 RPR REM HERNIA, INIT, REDUCE $500.99
49552 O REPAIR FEMORAL HERNIA, HENRY APPROA $0.00
49553 3 RPR FEM HERNIA, INIT BLOCKED $548.07
49555 3 REREPAIR FEM HERNIA, REDUCE $521.53
49557 3 REREPAIR FEM HERNIA, BLOCKED $632.83
49560 3 RPR VENTRAL HERN INIT, REDUC $646.96
49561 3 RPR VENTRAL HERN INIT, BLOCK $815.33
49565 3 REREPAIR VENTRL HERN, REDUCE $670.80
49566 3 REREPAIR VENTRL HERN, BLOCK $823.76
49568 3 HERNIA REPAIR W/MESH $242.22

49570 3 RPR EPIGASTRIC HERN, REDUCE $355.90
49572 3 RPR EPIGASTRIC HERN, BLOCKED $440.31
49575 O REPAIR EPIGASTRIC HERNIA, PROPERITO $0.00
49580 3 RPR UMBIL HERN, REDUC < 5 YR $277.77
49581 O REPAIR UMBILICAL HERNIA AGE 5 OR OV $0.00
49582 3 RPR UMBIL HERN, BLOCK < 5 YR $411.29
49585 3 RPR UMBIL HERN, REDUC > 5 YR $382.42
49587 3 RPR UMBIL HERN, BLOCK > 5 YR $452.72
49590 3 REPAIR SPIGELIAN HERNIA $496.79
49600 3 REPAIR UMBILICAL LESION $641.15

49605 3 REPAIR UMBILICAL LESION $4,412.89
49606 3 REPAIR UMBILICAL LESION $1,000.49
49650 3 LAP ING HERNIA REPAIR INIT $372.01
49651 3 LAP ING HERNIA REPAIR RECUR $480.68
49652 3 LAP VENT/ABD HERNIA REPAIR $697.45
49653 3 LAP VENT/ABD HERN PROC COMP $871.08
49654 3 LAP INC HERNIA REPAIR $800.64
49655 3 LAP INC HERN REPAIR COMP $963.71
49656 3 LAP INC HERNIA REPAIR RECUR $803.52
49657 3 LAP INC HERN RECUR COMP $1,159.17
49659 5 LAPARO PROC, HERNIA REPAIR $0.00

49900 3 REPAIR OF ABDOMINAL WALL $713.91
49904 3 OMENTAL FLAP, EXTRA-ABDOM $1,332.39
49905 3 OMENTAL FLAP, INTRA-ABDOM $323.40
49906 5 FREE OMENTAL FLAP, MICROVASC $0.00
49999 5 ABDOMEN SURGERY PROCEDURE $0.00
50010 3 EXPLORATION OF KIDNEY $699.38
50020 3 RENAL ABSCESS, OPEN DRAIN $996.39
50021 3 RENAL ABSCESS, PERCUT DRAIN $172.54
50040 3 DRAINAGE OF KIDNEY $940.04
5005F 9 PT COUNSLD ON EXAM FOR MOLES $0.00
50060 3 REMOVAL OF KIDNEY STONE $1,168.12

50065 3 INCISION OF KIDNEY $1,227.03
50070 3 INCISION OF KIDNEY $1,220.69
50080 3 REMOVAL OF KIDNEY STONE $892.92
50100 3 REVISE KIDNEY BLOOD VESSELS $953.23
5010F 9 MACUL+FNDNGS TO DR MNG DM $0.00
50125 3 EXPLORE AND DRAIN KIDNEY $999.91

50135 3 EXPLORATION OF KIDNEY $1,146.04
5015F 9 DOC FX & TEST/TXMNT FOR OP $0.00
50200 3 BIOPSY OF KIDNEY $144.77
50205 3 BIOPSY OF KIDNEY $671.57
5020F 9 TXMNTS 2 MAIN DR BY 1 MON $0.00
50220 3 REMOVE KIDNEY, OPEN $1,041.66
50225 3 REMOVAL KIDNEY OPEN, COMPLEX $1,206.19
50230 3 REMOVAL KIDNEY OPEN, RADICAL $1,307.75
50234 3 REMOVAL OF KIDNEY & URETER $1,328.04
50236 3 REMOVAL OF KIDNEY & URETER $1,503.71
50240 3 PARTIAL REMOVAL OF KIDNEY $1,350.61
50250 3 CRYOABLATE RENAL MASS OPEN $1,253.79
50280 3 REMOVAL OF KIDNEY LESION $963.26

50290 3 REMOVAL OF KIDNEY LESION $887.63
50300 9 REMOVE CADAVER DONOR KIDNEY $0.00
50320 3 REMOVE KIDNEY, LIVING DONOR $1,313.00
50323 9 PREP CADAVER RENAL ALLOGRAFT $0.00
50325 9 PREP DONOR RENAL GRAFT $0.00
50327 9 PREP RENAL GRAFT/VENOUS $0.00
50328 9 PREP RENAL GRAFT/ARTERIAL $0.00
50329 9 PREP RENAL GRAFT/URETERAL $0.00
50340 3 REMOVAL OF KIDNEY $809.14
50360 3 TRANSPLANTATION OF KIDNEY $2,215.04
50365 3 TRANSPLANTATION OF KIDNEY $2,494.92
50370 3 REMOVE TRANSPLANTED KIDNEY $1,036.08

50380 3 REIMPLANTATION OF KIDNEY $1,756.67
50382 3 CHANGE URETER STENT, PERCUT $1,279.44
50384 3 REMOVE URETER STENT, PERCUT $1,100.03
50385 3 CHANGE STENT VIA TRANSURETH $1,253.56
50386 3 REMOVE STENT VIA TRANSURETH $811.86
50387 3 CHANGE EXT/INT URETER STENT $593.05
50389 3 REMOVE RENAL TUBE W/FLUORO $344.15
50390 3 DRAINAGE OF KIDNEY LESION $100.65
50391 3 INSTLL RX AGNT INTO RNAL TUB $130.33
50392 3 INSERT KIDNEY DRAIN $185.11

50393 3 INSERT URETERAL TUBE $225.65
50394 3 INJECTION FOR KIDNEY X-RAY $105.62
50395 3 CREATE PASSAGE TO KIDNEY $186.45
50396 3 MEASURE KIDNEY PRESSURE $120.69
50398 3 CHANGE KIDNEY TUBE $75.51
50400 3 REVISION OF KIDNEY/URETER $1,179.30
50405 3 REVISION OF KIDNEY/URETER $1,430.45
50500 3 REPAIR OF KIDNEY WOUND $1,139.98
5050F 9 PLAN 2 MAIN DR. BY 1 MONTH $0.00
50520 3 CLOSE KIDNEY-SKIN FISTULA $1,057.71
50525 3 REPAIR RENAL-ABDOMEN FISTULA $1,320.33
50526 3 REPAIR RENAL-ABDOMEN FISTULA $1,380.59
50540 3 REVISION OF HORSESHOE KIDNEY $1,154.63

50541 3 LAPARO ABLATE RENAL CYST $941.71
50542 3 LAPARO ABLATE RENAL MASS $1,194.99
50543 3 LAPARO PARTIAL NEPHRECTOMY $1,524.46
50544 3 LAPAROSCOPY, PYELOPLASTY $1,284.21
50545 3 LAPARO RADICAL NEPHRECTOMY $1,378.44
50546 3 LAPAROSCOPIC NEPHRECTOMY $1,223.08
50547 3 LAPARO REMOVAL DONOR KIDNEY $1,467.30
50548 3 LAPARO REMOVE W/URETER $1,389.60
50549 5 LAPAROSCOPE PROC, RENAL $0.00
50551 3 KIDNEY ENDOSCOPY $379.03
50555 3 KIDNEY ENDOSCOPY & BIOPSY $431.21

50557 3 KIDNEY ENDOSCOPY & TREATMENT $440.09
50559 O RENAL ENDOSCOPY/RADIOTRACER $0.00
50562 3 RENAL SCOPE W/TUMOR RESECT $605.16
50574 3 KIDNEY ENDOSCOPY & BIOPSY $588.99
50578 O RENAL ENDOSCOPY/RADIOTRACER $0.00

50590 3 FRAGMENTING OF KIDNEY STONE $950.85
50592 3 PERC RF ABLATE RENAL TUMOR $3,646.91
50593 3 PERC CRYO ABLATE RENAL TUM $4,706.51
50600 3 EXPLORATION OF URETER $955.78
50605 3 INSERT URETERAL SUPPORT $919.94
5060F 9 FNDNGS MAMMO 2PT W/IN 3 DAYS $0.00
50610 3 REMOVAL OF URETER STONE $975.82
5062F 9 DOC F2FMAMMO FNDNG IN 5 DAYS $0.00
50650 3 REMOVAL OF URETER $1,055.25
50660 3 REMOVAL OF URETER $1,166.30

50684 3 INJECTION FOR URETER X-RAY $50.91
50686 3 MEASURE URETER PRESSURE $92.83
50688 3 CHANGE OF URETER TUBE/STENT $81.18
50690 3 INJECTION FOR URETER X-RAY $101.55
50700 3 REVISION OF URETER $945.35
50715 3 RELEASE OF URETER $1,114.00
50722 3 RELEASE OF URETER $969.10
50725 3 RELEASE/REVISE URETER $1,110.04
50727 3 REVISE URETER $511.76
50728 3 REVISE URETER $703.07
50740 3 FUSION OF URETER & KIDNEY $1,091.41
50750 3 FUSION OF URETER & KIDNEY $1,187.12

50760 3 FUSION OF URETERS $1,106.48
50770 3 SPLICING OF URETERS $1,147.77
50780 3 REIMPLANT URETER IN BLADDER $1,110.10
50800 3 IMPLANT URETER IN BOWEL $936.78
50810 3 FUSION OF URETER & BOWEL $1,229.11
50815 3 URINE SHUNT TO INTESTINE $1,248.52
50820 3 CONSTRUCT BOWEL BLADDER $1,328.45

50825 3 CONSTRUCT BOWEL BLADDER $1,685.83
50830 3 REVISE URINE FLOW $1,828.94
50840 3 REPLACE URETER BY BOWEL $1,256.66
50845 3 APPENDICO-VESICOSTOMY $1,275.30
50860 3 TRANSPLANT URETER TO SKIN $965.67
50900 3 REPAIR OF URETER $849.62
50920 3 CLOSURE URETER/SKIN FISTULA $898.80
50930 3 CLOSURE URETER/BOWEL FISTULA $1,085.44
50940 3 RELEASE OF URETER $903.89
50945 3 LAPAROSCOPY URETEROLITHOTOMY $1,002.42
50947 3 LAPARO NEW URETER/BLADDER $1,420.39
50948 3 LAPARO NEW URETER/BLADDER $1,318.97
50949 5 LAPAROSCOPE PROC, URETER $0.00

50951 3 ENDOSCOPY OF URETER $395.99
50953 3 ENDOSCOPY OF URETER $417.78
50955 3 URETER ENDOSCOPY & BIOPSY $462.34
50957 3 URETER ENDOSCOPY & TREATMENT $449.36
50959 O URETER ENDOSCOPY & TRACER $0.00
50970 3 URETER ENDOSCOPY $386.66
50972 3 URETER ENDOSCOPY & CATHETER $372.20
50974 3 URETER ENDOSCOPY & BIOPSY $492.76
50978 O URETER ENDOSCOPY & TRACER $0.00

51000 O DRAINAGE OF BLADDER $0.00
5100F 9 RSK FX REF W/N 24 HRS X-RAY $0.00
51020 3 INCISE & TREAT BLADDER $474.40
51030 3 INCISE & TREAT BLADDER $469.50
51040 3 INCISE & DRAIN BLADDER $296.98
51045 3 INCISE BLADDER/DRAIN URETER $472.50
51050 3 REMOVAL OF BLADDER STONE $481.15

51065 3 REMOVE URETER CALCULUS $588.21
51080 3 DRAINAGE OF BLADDER ABSCESS $412.51
51100 3 DRAIN BLADDER BY NEEDLE $61.98
51101 3 DRAIN BLADDER BY TROCAR/CATH $127.95
51102 3 DRAIN BL W/CATH INSERTION $240.73
51500 3 REMOVAL OF BLADDER CYST $632.29
51520 3 REMOVAL OF BLADDER LESION $596.34
51535 3 REPAIR OF URETER LESION $792.90
51550 3 PARTIAL REMOVAL OF BLADDER $962.61
51555 3 PARTIAL REMOVAL OF BLADDER $1,279.62
51565 3 REVISE BLADDER & URETER(S) $1,308.42

51570 3 REMOVAL OF BLADDER $1,493.30
51575 3 REMOVAL OF BLADDER & NODES $1,867.37
51580 3 REMOVE BLADDER/REVISE TRACT $1,946.62
51585 3 REMOVAL OF BLADDER & NODES $2,167.82
51596 3 REMOVE BLADDER/CREATE POUCH $2,412.34
51597 3 REMOVAL OF PELVIC STRUCTURES $2,325.93
51600 3 INJECTION FOR BLADDER X-RAY $45.45
51605 3 PREPARATION FOR BLADDER XRAY $39.36
51610 3 INJECTION FOR BLADDER X-RAY $113.51
51700 3 IRRIGATION OF BLADDER $89.08

51701 3 INSERT BLADDER CATHETER $62.08
51702 3 INSERT TEMP BLADDER CATH $80.19
51703 3 INSERT BLADDER CATH, COMPLEX $143.66
51705 3 CHANGE OF BLADDER TUBE $115.76
51710 3 CHANGE OF BLADDER TUBE $163.08
51715 3 ENDOSCOPIC INJECTION/IMPLANT $300.32
51720 3 TREATMENT OF BLADDER LESION $119.07
51725 3 SIMPLE CYSTOMETROGRAM $225.65
51726 3 COMPLEX CYSTOMETROGRAM $329.03
51736 3 URINE FLOW MEASUREMENT $54.66

51739 O SOUND RECORDING OF EXTERNAL STREAM $0.00
51741 3 ELECTRO-UROFLOWMETRY, FIRST $86.26
51772 3 URETHRA PRESSURE PROFILE $252.72
51784 3 ANAL/URINARY MUSCLE STUDY $206.76
51785 3 ANAL/URINARY MUSCLE STUDY $224.64
51792 3 URINARY REFLEX STUDY $236.35
51795 3 URINE VOIDING PRESSURE STUDY $310.24
51797 3 INTRAABDOMINAL PRESSURE TEST $153.18
51798 3 US URINE CAPACITY MEASURE $21.14
51800 3 REVISION OF BLADDER/URETHRA $1,064.35
51820 3 REVISION OF URINARY TRACT $1,083.43
51840 3 ATTACH BLADDER/URETHRA $647.72
51841 3 ATTACH BLADDER/URETHRA $768.21

51845 3 REPAIR BLADDER NECK $590.99
51860 3 REPAIR OF BLADDER WOUND $721.82
51865 3 REPAIR OF BLADDER WOUND $894.04
51880 3 REPAIR OF BLADDER OPENING $468.99
51900 3 REPAIR BLADDER/VAGINA LESION $829.26
51920 3 CLOSE BLADDER-UTERUS FISTULA $766.82
51925 3 HYSTERECTOMY/BLADDER REPAIR $999.02
51940 3 CORRECTION OF BLADDER DEFECT $1,635.00
51960 3 REVISION OF BLADDER & BOWEL $1,414.27
51980 3 CONSTRUCT BLADDER OPENING $725.42
51990 3 LAPARO URETHRAL SUSPENSION $744.13
51992 3 LAPARO SLING OPERATION $811.14

51999 6 LAPAROSCOPE PROC, BLA $0.00
52000 3 CYSTOSCOPY $128.52
52001 3 CYSTOSCOPY, REMOVAL OF CLOTS $394.88
52005 3 CYSTOSCOPY & URETER CATHETER $298.76
52007 3 CYSTOSCOPY AND BIOPSY $561.28
52010 3 CYSTOSCOPY & DUCT CATHETER $416.85
52204 3 CYSTOSCOPY W/BIOPSY(S) $145.42
52214 3 CYSTOSCOPY AND TREATMENT $603.54

52250 3 CYSTOSCOPY AND RADIOTRACER $251.30
52270 3 CYSTOSCOPY & REVISE URETHRA $422.69
52275 3 CYSTOSCOPY & REVISE URETHRA $578.12
52282 3 CYSTOSCOPY, IMPLANT STENT $347.45

52317 3 REMOVE BLADDER STONE $345.49
52318 3 REMOVE BLADDER STONE $492.98
52325 3 CYSTOSCOPY, STONE REMOVAL $333.09
52327 3 CYSTOSCOPY, INJECT MATERIAL $550.37

52334 3 CREATE PASSAGE TO KIDNEY $266.40
52335 O ENDOSCOPY OF URINARY TRACT $0.00
52336 O CYSTOSCOPY, STONE REMOVAL $0.00
52337 O CYSTOSCOPY, STONE REMOVAL $0.00
52338 O CYSTOSCOPY AND TREATMENT $0.00
52341 3 CYSTO W/URETER STRICTURE TX $303.15
52342 3 CYSTO W/UP STRICTURE TX $329.51

52343 3 CYSTO W/RENAL STRICTURE TX $366.43
52344 3 CYSTO/URETERO, STRICTURE TX $397.46
52345 3 CYSTO/URETERO W/UP STRICTURE $423.81
52346 3 CYSTOURETERO W/RENAL STRICT $478.19
52347 O CYSTOSCOPY, RESECT DUCTS $0.00
52351 3 CYSTOURETERO & OR PYELOSCOPE $326.09
52352 3 CYSTOURETERO W/STONE REMOVE $382.94
52353 3 CYSTOURETERO W/LITHOTRIPSY $440.44
52354 3 CYSTOURETERO W/BIOPSY $407.12
52355 3 CYSTOURETERO W/EXCISE TUMOR $485.20
52400 3 CYSTOURETERO W/CONGEN REPR $499.14
52402 3 CYSTOURETHRO CUT EJACUL DUCT $278.87
52450 3 INCISION OF PROSTATE $477.48

52500 3 REVISION OF BLADDER NECK $498.80
52510 O DILATION PROSTATIC URETHRA $0.00
52601 3 PROSTATECTOMY (TURP) $843.59
52606 O CONTROL POSTOP BLEEDING $0.00
52612 O PROSTATECTOMY, FIRST STAGE $0.00
52614 O PROSTATECTOMY, SECOND STAGE $0.00
52620 O REMOVE RESIDUAL PROSTATE $0.00
52630 3 REMOVE PROSTATE REGROWTH $452.70
52640 3 RELIEVE BLADDER CONTRACTURE $310.05
52647 3 LASER SURGERY OF PROSTATE $658.82
52648 3 LASER SURGERY OF PROSTATE $2,301.11
52649 3 PROSTATE LASER ENUCLEATION $1,004.71

52650 O TRANSURETHRAL CRYOSURGICAL REMOVAL $0.00
52700 3 DRAINAGE OF PROSTATE ABSCESS $442.31
53000 3 INCISION OF URETHRA $151.83
53040 3 DRAINAGE OF URETHRA ABSCESS $400.19
53060 3 DRAINAGE OF URETHRA ABSCESS $176.46
53080 3 DRAINAGE OF URINARY LEAKAGE $444.35
53085 3 DRAINAGE OF URINARY LEAKAGE $626.53

53200 3 BIOPSY OF URETHRA $158.72
53210 3 REMOVAL OF URETHRA $785.34
53215 3 REMOVAL OF URETHRA $953.62
53220 3 TREATMENT OF URETHRA LESION $459.39
53230 3 REMOVAL OF URETHRA LESION $611.80
53235 3 REMOVAL OF URETHRA LESION $651.18
53240 3 SURGERY FOR URETHRA POUCH $437.86
53250 3 REMOVAL OF URETHRA GLAND $406.42
53270 3 REMOVAL OF URETHRA GLAND $206.31
53275 3 REPAIR OF URETHRA DEFECT $271.21
53400 3 REVISE URETHRA, STAGE 1 $816.97

53405 3 REVISE URETHRA, STAGE 2 $899.66
53410 3 RECONSTRUCTION OF URETHRA $1,003.60
53420 3 RECONSTRUCT URETHRA, STAGE 1 $821.09
53425 3 RECONSTRUCT URETHRA, STAGE 2 $966.63
53430 3 RECONSTRUCTION OF URETHRA $963.34
53431 3 RECONSTRUCT URETHRA/BLADDER $1,182.35
53440 3 MALE SLING PROCEDURE $896.14
53442 3 REMOVE/REVISE MALE SLING $789.59
53443 O RECONSTRUCTION OF URETHRA $0.00
53444 3 INSERT TANDEM CUFF $814.80
53445 3 INSERT URO/VES NCK SPHINCTER $900.35

53446 3 REMOVE URO SPHINCTER $658.54
53447 3 REMOVE/REPLACE UR SPHINCTER $832.30
53448 3 REMOV/REPLC UR SPHINCTR COMP $1,313.73
53449 3 REPAIR URO SPHINCTER $625.98
53450 3 REVISION OF URETHRA $416.87
53500 3 URETHRLYS, TRANSVAG W/ SCOPE $751.36
53502 3 REPAIR OF URETHRA INJURY $494.64

53520 3 REPAIR OF URETHRA DEFECT $567.60
53600 3 DILATE URETHRA STRICTURE $88.65
53640 O PASSAGE OF FILIFORM AND FOLLOWER FO $0.00
53660 3 DILATION OF URETHRA $75.37
53670 O INSERT URINARY CATHETER $0.00
53675 O INSERT URINARY CATHETER $0.00

53800 O TWO OR THREE GLASS TEST INCLUDING E $0.00
53850 3 PROSTATIC MICROWAVE THERMOTX $2,593.54
53852 3 PROSTATIC RF THERMOTX $2,493.94
53853 O PROSTATIC WATER THERMOTHER $0.00
53899 5 UROLOGY SURGERY PROCEDURE $0.00
54000 3 SLITTING OF PREPUCE $161.16
54001 3 SLITTING OF PREPUCE $197.55
54015 3 DRAIN PENIS LESION $316.77
54050 3 DESTRUCTION, PENIS LESION(S) $121.26
54056 3 CRYOSURGERY, PENIS LESION(S) $126.69
54057 3 LASER SURG, PENIS LESION(S) $139.61

54060 3 EXCISION OF PENIS LESION(S) $188.15
54100 3 BIOPSY OF PENIS $189.34
54105 3 BIOPSY OF PENIS $283.74
54110 3 TREATMENT OF PENIS LESION $636.85
54111 3 TREAT PENIS LESION, GRAFT $822.39
54112 3 TREAT PENIS LESION, GRAFT $965.18
54120 3 PARTIAL REMOVAL OF PENIS $644.28
54125 3 REMOVAL OF PENIS $829.74

54130 3 REMOVE PENIS & NODES $1,227.46
54135 3 REMOVE PENIS & NODES $1,557.30
54150 3 CIRCUMCISION W/REGIONL BLOCK $99.46
54152 O CIRCUMCISION $0.00
54160 3 CIRCUMCISION, NEONATE $148.23
54161 3 CIRCUM 28 DAYS OR OLDER $201.46
54162 3 LYSIS PENIL CIRCUMIC LESION $277.16
54163 3 REPAIR OF CIRCUMCISION $222.44
54164 9 FRENULOTOMY OF PENIS $0.00
54230 3 PREPARE PENIS STUDY $100.32

54231 O DYNAMIC CAVERNOSOMETRY $0.00
54235 O PENILE INJECTION $0.00
54240 O PENIS STUDY $0.00
54250 O PENIS STUDY $0.00
54300 3 REVISION OF PENIS $664.09

54328 3 REVISE PENIS/URETHRA $958.11
54332 3 REVISE PENIS/URETHRA $1,047.56
54336 3 REVISE PENIS/URETHRA $1,186.22
54340 3 SECONDARY URETHRAL SURGERY $576.67
54344 3 SECONDARY URETHRAL SURGERY $992.76
54348 3 SECONDARY URETHRAL SURGERY $1,053.65
54352 3 RECONSTRUCT URETHRA/PENIS $1,484.40
54360 3 PENIS PLASTIC SURGERY $746.12
54380 3 REPAIR PENIS $826.80

54385 3 REPAIR PENIS $1,000.79
54390 3 REPAIR PENIS AND BLADDER $1,209.05
54400 O INSERT SEMI-RIGID PROSTHESIS $0.00
54401 O INSERT SELF-CONTD PROSTHESIS $0.00
54402 O REMOVE PENIS PROSTHESIS $0.00
54405 O INSERT MULTI-COMP PENIS PROS $0.00
54406 9 REMOVE MUTI-COMP PENIS PROS $0.00
54407 O REMOVE MULTI-COMP PROSTHESIS $0.00
54408 9 REPAIR MULTI-COMP PENIS PROS $0.00
54409 O REVISE PENIS PROSTHESIS $0.00
54410 9 REMOVE/REPLACE PENIS PROSTH $0.00
54411 9 REMOV/REPLC PENIS PROS, COMP $0.00
54415 9 REMOVE SELF-CONTD PENIS PROS $0.00

54416 9 REMV/REPL PENIS CONTAIN PROS $0.00
54417 9 REMV/REPLC PENIS PROS, COMPL $0.00
54440 5 REPAIR OF PENIS $0.00
54450 3 PREPUTIAL STRETCHING $75.22
54500 3 BIOPSY OF TESTIS $77.67
54505 3 BIOPSY OF TESTIS $218.46
54510 O REMOVAL OF TESTIS LESION $0.00
54512 3 EXCISE LESION TESTIS $547.38
54520 3 REMOVAL OF TESTIS $332.31

54522 3 ORCHIECTOMY, PARTIAL $593.65
54530 3 REMOVAL OF TESTIS $518.27
54535 3 EXTENSIVE TESTIS SURGERY $750.46
54550 3 EXPLORATION FOR TESTIS $499.27
54560 3 EXPLORATION FOR TESTIS $679.27
54600 3 REDUCE TESTIS TORSION $462.08
54620 3 SUSPENSION OF TESTIS $310.08
54640 3 SUSPENSION OF TESTIS $475.03
54645 O ORCHIOPEXY, ANY TYPE, WITH OR WITHO $0.00
54650 3 ORCHIOPEXY (FOWLER-STEPHENS) $725.83

54660 9 REVISION OF TESTIS $0.00
54670 3 REPAIR TESTIS INJURY $413.15
54680 3 RELOCATION OF TESTIS(ES) $800.66
54690 3 LAPAROSCOPY, ORCHIECTOMY $645.62
54692 3 LAPAROSCOPY, ORCHIOPEXY $791.05
54699 5 LAPAROSCOPE PROC, TESTIS $0.00
54700 3 DRAINAGE OF SCROTUM $215.40
54800 3 BIOPSY OF EPIDIDYMIS $135.73
54820 O EXPLORATION OF EPIDIDYMIS $0.00
54830 3 REMOVE EPIDIDYMIS LESION $376.29
54840 3 REMOVE EPIDIDYMIS LESION $330.34
54860 3 REMOVAL OF EPIDIDYMIS $426.37
54861 3 REMOVAL OF EPIDIDYMIS $575.95

54865 3 EXPLORE EPIDIDYMIS $363.41
54900 3 FUSION OF SPERMATIC DUCTS $769.84
54901 3 FUSION OF SPERMATIC DUCTS $1,098.53
55000 3 DRAINAGE OF HYDROCELE $124.72
55040 3 REMOVAL OF HYDROCELE $343.40
55041 3 REMOVAL OF HYDROCELES $516.03
55060 3 REPAIR OF HYDROCELE $383.97
55100 3 DRAINAGE OF SCROTUM ABSCESS $220.72
55110 3 EXPLORE SCROTUM $390.42
55120 3 REMOVAL OF SCROTUM LESION $358.43
55150 3 REMOVAL OF SCROTUM $494.49
55175 3 REVISION OF SCROTUM $367.75

55180 3 REVISION OF SCROTUM $697.80
55200 9 INCISION OF SPERM DUCT $0.00
55250 3 REMOVAL OF SPERM DUCT(S) $231.48
55300 9 PREPARE, SPERM DUCT X-RAY $0.00
55400 9 REPAIR OF SPERM DUCT $0.00
55450 3 LIGATION OF SPERM DUCT $391.95
55500 3 REMOVAL OF HYDROCELE $380.49
55520 3 REMOVAL OF SPERM CORD LESION $390.66
55530 3 REVISE SPERMATIC CORD VEINS $360.15
55535 3 REVISE SPERMATIC CORD VEINS $435.05

55540 3 REVISE HERNIA & SPERM VEINS $473.05
55550 3 LAPARO LIGATE SPERMATIC VEIN $430.42
55559 5 LAPARO PROC, SPERMATIC CORD $0.00
55600 3 INCISE SPERM DUCT POUCH $434.43
55605 3 INCISE SPERM DUCT POUCH $512.28
55650 3 REMOVE SPERM DUCT POUCH $728.60
55680 3 REMOVE SPERM POUCH LESION $345.59
55700 3 BIOPSY OF PROSTATE $237.54
55705 3 BIOPSY OF PROSTATE $275.96
55706 3 PROSTATE SATURATION SAMPLING $391.41
55740 O PROSTATOLITHOTOMY, REMOVAL OF PROST $0.00

55801 3 REMOVAL OF PROSTATE $1,112.17
55810 3 EXTENSIVE PROSTATE SURGERY $1,344.62
55821 3 REMOVAL OF PROSTATE $895.13
55831 3 REMOVAL OF PROSTATE $969.84
55859 O PERCUT/NEEDLE INSERT, PROS $0.00
55860 3 SURGICAL EXPOSURE, PROSTATE $897.87

55866 3 LAPARO RADICAL PROSTATECTOMY $1,787.09
55870 O VAG HYST W/ENTEROCELE REPAIR $0.00
55873 3 CRYOABLATE PROSTATE $1,170.77
55875 3 TRANSPERI NEEDLE PLACE, PROS $779.78
55876 3 PLACE RT DEVICE/MARKER, PROS $145.80
55899 5 GENITAL SURGERY PROCEDURE $0.00
55920 3 PLACE NEEDLES PELVIC FOR RT $437.29
55970 9 SEX TRANSFORMATION, M TO F $0.00
55980 9 SEX TRANSFORMATION, F TO M $0.00

56000 O INCISION AND DRAINAGE OF PERINEAL A $0.00
56100 O BIOPSY OF PERINEUM (SEPARATE PROCED $0.00
56200 O PERINEOPLASTY, REPAIR OF PERINEUM, $0.00
56300 O LAPAROSCOPY; DIAGNOSTIC $0.00
56301 O LAPAROSCOPY; TUBAL CAUTERY $0.00
56302 O LAPAROSCOPY; TUBAL BLOCK $0.00
56303 O LAPAROSCOPY; EXCISE LESIONS $0.00
56304 O LAPAROSCOPY; LYSIS $0.00
56305 O LAPAROSCOPY; BIOPSY $0.00
56306 O LAPAROSCOPY; ASPIRATION $0.00
56307 O LAPAROSCOPY; REMOVE ADNEXA $0.00
56308 O LAPAROSCOPY; HYSTERECTOMY $0.00
56309 O LAPAROSCOPY; REMOVE MYOMA $0.00

56310 O LAPAROSCOPIC ENTEROLYSIS $0.00
56311 O LAPAROSCOPIC LYMPH NODE BIOP $0.00
56312 O LAPAROSCOPIC LYMPHADENECTOMY $0.00
56313 O LAPAROSCOPIC LYMPHADENECTOMY $0.00
56314 O LAPAR; DRAIN LYMPHOCELE $0.00
56315 O LAPAROSCOPIC APPENDECTOMY $0.00
56316 O LAPAROSCOPIC HERNIA REPAIR $0.00
56317 O LAPAROSCOPIC HERNIA REPAIR $0.00
56318 O LAPAROSCOPIC ORCHIECTOMY $0.00
56320 O LAPAROSCOPY, SPERMATIC VEINS $0.00
56321 O LAPAROSCOPY; ADRENALECTOMY $0.00
56322 O LAPAROSCOPY, VAGUS NERVES $0.00

56323 O LAPAROSCOPY, VAGUS NERVES $0.00
56324 O LAPAROSCOPY, CHOLECYSTOENTER $0.00
56340 O LAPAROSCOPIC CHOLECYSTECTOMY $0.00
56343 O LAPAROSCOPIC SALPINGOSTOMY $0.00
56344 O LAPAROSCOPIC FIMBRIOPLASTY $0.00
56345 O LAPAROSCOPIC SPLENECTOMY $0.00
56346 O LAPAROSCOPIC GASTROSTOMY $0.00
56347 O LAPAROSCOPIC JEJUNOSTOMY $0.00

56348 O LAPARO; RESECT INTESTINE $0.00
56349 O LAPAROSCOPY; FUNDOPLASTY $0.00
56350 O HYSTEROSCOPY; DIAGNOSTIC $0.00
56351 O HYSTEROSCOPY; BIOPSY $0.00
56352 O HYSTEROSCOPY; LYSIS $0.00
56353 O HYSTEROSCOPY; RESECT SEPTUM $0.00
56354 O HYSTEROSCOPY; REMOVE MYOMA $0.00
56355 O HYSTEROSCOPY; REMOVE IMPACT $0.00
56356 O HYSTEROSCOPY; ABLATION $0.00
56360 O PERITONEOSCOPY; WITHOUT BIOPSY $0.00
56361 O PERITONEOSCOPY; WITH BIOPSY $0.00
56362 O LAPAROSCOPY W/CHOLANGIO $0.00
56363 O LAPAROSCOPY W/BIOPSY $0.00

56399 O LAPAROSCOPY PROCEDURE $0.00
56400 O INCISION AND DRAINAGE, ABSCESS OF V $0.00
56405 3 I & D OF VULVA/PERINEUM $101.35
56420 3 DRAINAGE OF GLAND ABSCESS $117.44
56440 3 SURGERY FOR VULVA LESION $170.61
56441 3 LYSIS OF LABIAL LESION(S) $140.60
56442 3 HYMENOTOMY $45.82
56501 3 DESTROY, VULVA LESIONS, SIM $121.81
56515 3 DESTROY VULVA LESION/S COMPL $207.13
56600 O BIOPSY OF VULVA (SEPARATE PROCEDURE $0.00
56605 3 BIOPSY OF VULVA/PERINEUM $78.28
56606 3 BIOPSY OF VULVA/PERINEUM $36.12

56620 3 PARTIAL REMOVAL OF VULVA $459.45
56625 3 COMPLETE REMOVAL OF VULVA $551.67
56630 3 EXTENSIVE VULVA SURGERY $805.41
56631 3 EXTENSIVE VULVA SURGERY $1,024.51
56635 O VULVECTOMY, RADICAL WITH INGUINOFEM $0.00

56680 O CLITORIDECTOMY SIMPLE $0.00
56685 O CLITORIDECTOMY EXTENSIVE $0.00
56700 3 PARTIAL REMOVAL OF HYMEN $173.07
56710 O PLASTIC REVISION OF HYMEN $0.00
56720 O INCISION OF HYMEN $0.00
56740 3 REMOVE VAGINA GLAND LESION $275.86
56800 3 REPAIR OF VAGINA $227.17
56805 3 REPAIR CLITORIS $1,067.46
56810 3 REPAIR OF PERINEUM $243.82
56820 3 EXAM OF VULVA W/SCOPE $103.76
56821 3 EXAM/BIOPSY OF VULVA W/SCOPE $138.77
57000 3 EXPLORATION OF VAGINA $177.86
57010 3 DRAINAGE OF PELVIC ABSCESS $399.83

57020 3 DRAINAGE OF PELVIC FLUID $88.23
57022 3 I & D VAGINAL HEMATOMA, PP $154.84
57023 3 I & D VAG HEMATOMA, NON-OB $290.01
57061 3 DESTROY VAG LESIONS, SIMPLE $106.28
57065 3 DESTROY VAG LESIONS, COMPLEX $179.42
57100 3 BIOPSY OF VAGINA $82.84
57105 3 BIOPSY OF VAGINA $126.90
57106 3 REMOVE VAGINA WALL, PARTIAL $440.96
57107 3 REMOVE VAGINA TISSUE, PART $1,300.48
57108 O PARTIAL REMOVAL OF VAGINA $0.00
57109 3 VAGINECTOMY PARTIAL W/NODES $1,485.94
57110 3 REMOVE VAGINA WALL, COMPLETE $837.88

57111 3 REMOVE VAGINA TISSUE, COMPL $1,502.36
57112 3 VAGINECTOMY W/NODES, COMPL $1,594.58
57120 3 CLOSURE OF VAGINA $476.31
57126 9 COMPLEX CYSTOMETROGRAM (EG, CALIBRA $0.00
57130 3 REMOVE VAGINA LESION $169.20
57135 3 REMOVE VAGINA LESION $181.20
57150 3 TREAT VAGINA INFECTION $47.95
57155 3 INSERT UTERI TANDEMS/OVOIDS $394.91
57160 3 INSERT PESSARY/OTHER DEVICE $72.65
57170 3 FITTING OF DIAPHRAGM/CAP $65.10

57180 3 TREAT VAGINAL BLEEDING $133.46
57210 3 REPAIR VAGINA/PERINEUM $342.11
57230 3 REPAIR OF URETHRAL LESION $372.00
57240 3 REPAIR BLADDER & VAGINA $617.04
57250 3 REPAIR RECTUM & VAGINA $602.97
57265 3 EXTENSIVE REPAIR OF VAGINA $839.43
57267 3 INSERT MESH/PELVIC FLR ADDON $252.94
57268 3 REPAIR OF BOWEL BULGE $448.16
57270 3 REPAIR OF BOWEL POUCH $742.24
57280 3 SUSPENSION OF VAGINA $902.57

57282 3 COLPOPEXY, EXTRAPERITONEAL $475.41
57283 3 COLPOPEXY, INTRAPERITONEAL $640.48
57284 3 REPAIR PARAVAG DEFECT, OPEN $782.57
57285 3 REPAIR PARAVAG DEFECT, VAG $624.92
57287 3 REVISE/REMOVE SLING REPAIR $659.79
57288 3 REPAIR BLADDER DEFECT $692.63
57289 3 REPAIR BLADDER & VAGINA $727.58
57291 3 CONSTRUCTION OF VAGINA $505.66
57292 3 CONSTRUCT VAGINA WITH GRAFT $772.65
57295 3 REVISE VAG GRAFT VIA VAGINA $460.33
57296 3 REVISE VAG GRAFT, OPEN ABD $882.80
57300 3 REPAIR RECTUM-VAGINA FISTULA $494.18

57305 3 REPAIR RECTUM-VAGINA FISTULA $823.77
57307 3 FISTULA REPAIR & COLOSTOMY $921.68
57308 3 FISTULA REPAIR, TRANSPERINE $589.25
57310 3 REPAIR URETHROVAGINAL LESION $462.41
57311 3 REPAIR URETHROVAGINAL LESION $527.45
57320 3 REPAIR BLADDER-VAGINA LESION $525.49
57330 3 REPAIR BLADDER-VAGINA LESION $744.91
57335 3 REPAIR VAGINA $1,084.35
57400 3 DILATION OF VAGINA $126.91
57410 3 PELVIC EXAMINATION $99.75

57415 3 REMOVE VAGINAL FOREIGN BODY $149.14
57420 3 EXAM OF VAGINA W/SCOPE $109.05
57421 3 EXAM/BIOPSY OF VAG W/SCOPE $146.82
57423 3 REPAIR PARAVAG DEFECT, LAP $863.06
57425 3 LAPAROSCOPY, SURG, COLPOPEXY $910.02
57450 O CULDOSCOPY, DIAGNOSTIC $0.00
57451 O CULDOSCOPY, DIAGNOSTIC WITH BIOPSY $0.00
57452 3 EXAM OF CERVIX W/SCOPE $102.65
57454 3 BX/CURETT OF CERVIX W/SCOPE $144.69
57455 3 BIOPSY OF CERVIX W/SCOPE $134.91
57456 3 ENDOCERV CURETTAGE W/SCOPE $127.58
57460 3 BX OF CERVIX W/SCOPE, LEEP $281.93
57461 3 CONZ OF CERVIX W/SCOPE, LEEP $315.77

57500 3 BIOPSY OF CERVIX $124.87
57505 3 ENDOCERVICAL CURETTAGE $95.09
57510 3 CAUTERIZATION OF CERVIX $124.43
57511 3 CRYOCAUTERY OF CERVIX $135.87
57513 3 LASER SURGERY OF CERVIX $134.02
57520 3 CONIZATION OF CERVIX $287.70
57522 3 CONIZATION OF CERVIX $246.03
57530 3 REMOVAL OF CERVIX $319.88
57531 3 REMOVAL OF CERVIX, RADICAL $1,578.50
57540 3 REMOVAL OF RESIDUAL CERVIX $723.69
57545 3 REMOVE CERVIX/REPAIR PELVIS $763.33
57550 3 REMOVAL OF RESIDUAL CERVIX $378.04

57555 3 REMOVE CERVIX/REPAIR VAGINA $557.05
57556 3 REMOVE CERVIX, REPAIR BOWEL $532.26
57558 3 D&C OF CERVICAL STUMP $116.94
57700 3 REVISION OF CERVIX $285.22
57800 3 DILATION OF CERVICAL CANAL $56.66
57820 O D & C OF RESIDUAL CERVIX $0.00
58100 3 BIOPSY OF UTERUS LINING $103.35
58101 O ENDOMETRIAL WASHINGS (EG, FOR CYTOL $0.00
58102 O OFFICE ENDOMETRIAL CURETTAGE $0.00

58110 3 BX DONE W/COLPOSCOPY ADD-ON $45.94
58120 3 DILATION AND CURETTAGE $233.08
58140 3 MYOMECTOMY ABDOM METHOD $847.93
58145 3 MYOMECTOMY VAG METHOD $503.69
58146 3 MYOMECTOMY ABDOM COMPLEX $1,079.67
58150 3 TOTAL HYSTERECTOMY $918.49
58152 3 TOTAL HYSTERECTOMY $1,159.43
58180 3 PARTIAL HYSTERECTOMY $882.17
58200 3 EXTENSIVE HYSTERECTOMY $1,213.89
58240 3 REMOVAL OF PELVIS CONTENTS $2,541.08
58260 3 VAGINAL HYSTERECTOMY $767.84
58262 3 VAG HYST INCLUDING T/O $857.65

58263 3 VAG HYST W/T/O & VAG REPAIR $923.97
58265 O VAGINAL HYSTERECTOMY WITH PLASTIC R $0.00
58267 3 VAG HYST W/URINARY REPAIR $981.65
58270 3 VAG HYST W/ENTEROCELE REPAIR $822.21
58275 3 HYSTERECTOMY/REVISE VAGINA $915.00
58280 3 HYSTERECTOMY/REVISE VAGINA $978.73
58290 3 VAG HYST COMPLEX $1,074.60
58291 3 VAG HYST INCL T/O, COMPLEX $1,167.74
58292 3 VAG HYST T/O & REPAIR, COMPL $1,230.37
58293 3 VAG HYST W/URO REPAIR, COMPL $1,277.26
58294 3 VAG HYST W/ENTEROCELE, COMPL $1,134.94

58300 5 INSERT INTRAUTERINE DEVICE $0.00
58301 3 REMOVE INTRAUTERINE DEVICE $90.39
58310 9 ARTIFICIAL INSEMINATION $0.00
58311 9 ARTIFICIAL INSEMINATION WITH SPERM $0.00
58320 O INSUFFLATION OF UTERUS AND TUBES WI $0.00
58323 9 SPERM WASHING $0.00
58340 3 CATHETER FOR HYSTEROGRAPHY $121.96
58345 9 REOPEN FALLOPIAN TUBE $0.00

58346 3 INSERT HEYMAN UTERI CAPSULE $424.16
58350 9 REOPEN FALLOPIAN TUBE $0.00
58353 3 ENDOMETR ABLATE, THERMAL $205.90
58356 3 ENDOMETRIAL CRYOABLATION $1,997.50
58400 3 SUSPENSION OF UTERUS $417.03
58410 3 SUSPENSION OF UTERUS $744.65
58520 3 REPAIR OF RUPTURED UTERUS $727.04
58540 3 REVISION OF UTERUS $843.98
58541 3 LSH, UTERUS 250 G OR LESS $796.41
58542 3 LSH W/T/O UT 250 G OR LESS $884.19
58543 3 LSH UTERUS ABOVE 250 G $898.82
58544 3 LSH W/T/O UTERUS ABOVE 250 G $971.03
58545 3 LAPAROSCOPIC MYOMECTOMY $830.99

58546 3 LAPARO-MYOMECTOMY, COMPLEX $1,052.70
58548 3 LAP RADICAL HYST $1,640.76
58550 3 LAPARO-ASST VAG HYSTERECTOMY $821.14
58551 O LAPAROSCOPY, REMOVE MYOMA $0.00
58552 3 LAPARO-VAG HYST INCL T/O $905.78
58553 3 LAPARO-VAG HYST, COMPLEX $1,058.10
58554 3 LAPARO-VAG HYST W/T/O, COMPL $1,212.61
58555 3 HYSTEROSCOPY, DX, SEP PROC $225.81
58558 3 HYSTEROSCOPY, BIOPSY $304.67
58559 3 HYSTEROSCOPY, LYSIS $323.26
58560 3 HYSTEROSCOPY, RESECT SEPTUM $365.30
58561 3 HYSTEROSCOPY, REMOVE MYOMA $516.86

58562 3 HYSTEROSCOPY, REMOVE FB $321.81
58563 3 HYSTEROSCOPY, ABLATION $323.26
58565 3 HYSTEROSCOPY, STERILIZATION $413.53
58570 3 TLH, UTERUS 250 G OR LESS $854.87
58571 3 TLH W/T/O 250 G OR LESS $938.91
58572 3 TLH, UTERUS OVER 250 G $1,062.16
58573 3 TLH W/T/O UTERUS OVER 250 G $1,201.89
58578 5 LAPARO PROC, UTERUS $0.00
58579 5 HYSTEROSCOPE PROCEDURE $0.00
58600 3 DIVISION OF FALLOPIAN TUBE $337.61

58605 3 DIVISION OF FALLOPIAN TUBE $307.11
58611 3 LIGATE OVIDUCT(S) ADD-ON $73.14
58615 3 OCCLUDE FALLOPIAN TUBE(S) $232.32
58660 3 LAPAROSCOPY, LYSIS $624.86
58661 3 LAPAROSCOPY, REMOVE ADNEXA $600.05
58662 3 LAPAROSCOPY, EXCISE LESIONS $657.08
58670 3 LAPAROSCOPY, TUBAL CAUTERY $340.07
58671 3 LAPAROSCOPY, TUBAL BLOCK $339.94
58672 3 LAPAROSCOPY, FIMBRIOPLASTY $691.21
58673 3 LAPAROSCOPY, SALPINGOSTOMY $751.77
58679 5 LAPARO PROC, OVIDUCT-OVARY $0.00
58700 3 REMOVAL OF FALLOPIAN TUBE $707.96
58720 3 REMOVAL OF OVARY/TUBE(S) $665.36

58740 3 ADHESIOLYSIS TUBE, OVARY $811.15
58750 9 REPAIR OVIDUCT $0.00
58752 9 REVISE OVARIAN TUBE(S) $0.00
58760 9 FIMBRIOPLASTY $0.00
58770 3 CREATE NEW TUBAL OPENING $782.91
58800 3 DRAINAGE OF OVARIAN CYST(S) $298.24
58805 3 DRAINAGE OF OVARIAN CYST(S) $376.18
58820 3 DRAIN OVARY ABSCESS, OPEN $291.05
58822 3 DRAIN OVARY ABSCESS, PERCUT $654.76
58823 3 DRAIN PELVIC ABSCESS, PERCUT $874.47
58825 3 TRANSPOSITION, OVARY(S) $646.78
58900 3 BIOPSY OF OVARY(S) $383.74

58920 3 PARTIAL REMOVAL OF OVARY(S) $651.05
58925 3 REMOVAL OF OVARIAN CYST(S) $678.84
58940 3 REMOVAL OF OVARY(S) $465.40
58943 3 REMOVAL OF OVARY(S) $1,036.51
58950 3 RESECT OVARIAN MALIGNANCY $988.92
58951 3 RESECT OVARIAN MALIGNANCY $1,274.51
58952 3 RESECT OVARIAN MALIGNANCY $1,437.64
58953 3 TAH, RAD DISSECT FOR DEBULK $1,782.84
58954 3 TAH RAD DEBULK/LYMPH REMOVE $1,935.16
58956 3 BSO, OMENTECTOMY W/TAH $1,250.78

58957 3 RESECT RECURRENT GYN MAL $1,372.37
58958 3 RESECT RECUR GYN MAL W/LYM $1,525.07
58960 3 EXPLORATION OF ABDOMEN $854.85
58970 9 RETRIEVAL OF OOCYTE $0.00
58972 O CULTURE AND FERTILIZATION OF OOCYTE $0.00
58974 9 TRANSFER OF EMBRYO $0.00
58976 9 TRANSFER OF EMBRYO $0.00
58980 O LAPAROSCOPY, SURGICAL $0.00
58982 O LAPAROSCOPY, SURGICAL WITH FULGURAT $0.00
58983 O LAPAROSCOPY, SURGICAL WITH OCCLUSIO $0.00
58984 O LAPAROSCOPY, SURGICAL WITH FULGURAT $0.00
58985 O LAPAROSCOPY, SURGICAL WITH LYSIS OF $0.00
58986 O LAPAROSCOPY, SURGICAL WITH BIOPSY ( $0.00

58987 O LAPAROSCOPY, SURGICAL WITH ASPIRATI $0.00
58988 O LAPAROSCOPY, SURGICAL WITH REMOVAL $0.00
58990 O HYSTEROSCOPY DIAGNOSTIC $0.00
58992 O HYSTEROSCOPY WITH LYSIS OF INTRAUTE $0.00
58994 O HYSTEROSCOPY WITH REMOVAL OF SUBMUC $0.00
58996 O HYSTEROSCOPY; WITH ENDOMETRIAL ABLA $0.00
58999 5 GENITAL SURGERY PROCEDURE $0.00
59000 3 AMNIOCENTESIS, DIAGNOSTIC $121.54
59001 3 AMNIOCENTESIS, THERAPEUTIC $173.02
59012 3 FETAL CORD PUNCTURE,PRENATAL $190.27
59015 3 CHORION BIOPSY $145.79
59020 3 FETAL CONTRACT STRESS TEST $66.41

59025 3 FETAL NON-STRESS TEST $43.97
59030 3 FETAL SCALP BLOOD SAMPLE $105.66
59050 3 FETAL MONITOR W/REPORT $47.19
59051 3 FETAL MONITOR/INTERPRET ONLY $39.02
59070 3 TRANSABDOM AMNIOINFUS W/US $371.42
59072 3 UMBILICAL CORD OCCLUD W/US $447.46
59074 3 FETAL FLUID DRAINAGE W/US $351.46
59076 3 FETAL SHUNT PLACEMENT, W/US $437.11
59100 3 REMOVE UTERUS LESION $761.92
59120 3 TREAT ECTOPIC PREGNANCY $728.31

59160 3 D & C AFTER DELIVERY $199.40
59200 3 INSERT CERVICAL DILATOR $69.76
59300 3 EPISIOTOMY OR VAGINAL REPAIR $179.63
59350 3 REPAIR OF UTERUS $258.54

59400 7 OBSTETRICAL CARE $0.00
59412 9 ANTEPARTUM MANIPULATION $0.00
59414 3 DELIVER PLACENTA $85.50
59420 O ANTEPARTUM CARE ONLY (SEPARATE PROC $0.00
59425 9 ANTEPARTUM CARE ONLY $0.00
59426 9 ANTEPARTUM CARE ONLY $0.00
59430 3 CARE AFTER DELIVERY $130.24
59510 7 CESAREAN DELIVERY $0.00
59514 3 CESAREAN DELIVERY ONLY $717.47
59515 3 CESAREAN DELIVERY $833.70

59525 3 REMOVE UTERUS AFTER CESAREAN $452.10
59610 9 VBAC DELIVERY $0.00
59612 3 VBAC DELIVERY ONLY $717.47
59614 3 VBAC CARE AFTER DELIVERY $833.70
59618 9 ATTEMPTED VBAC DELIVERY $0.00
59620 3 ATTEMPTED VBAC DELIVERY ONLY $717.47
59622 3 ATTEMPTED VBAC AFTER CARE $833.70
59812 3 TREATMENT OF MISCARRIAGE $290.55
59820 3 CARE OF MISCARRIAGE $344.91
59821 3 TREATMENT OF MISCARRIAGE $350.52

59830 3 TREAT UTERUS INFECTION $402.08
59840 3 ABORTION $201.48
59841 3 ABORTION $349.65
59850 3 ABORTION $359.82
59851 3 ABORTION $369.77
59852 3 ABORTION $519.36
59855 3 ABORTION $383.63
59856 3 ABORTION $452.57
59857 3 ABORTION $541.56
59866 9 ABORTION (MPR) $0.00
59870 3 EVACUATE MOLE OF UTERUS $433.90
59871 3 REMOVE CERCLAGE SUTURE $125.07
59897 6 FETAL INVAS PX W/US $0.00

59898 5 LAPARO PROC, OB CARE/DELIVER $0.00
59899 5 MATERNITY CARE PROCEDURE $0.00
60000 3 DRAIN THYROID/TONGUE CYST $145.95
60001 O ASPIRATE/INJECT THYRIOD CYST $0.00
6005F 9 CARE LEVEL RATIONALE DOC $0.00
60100 3 BIOPSY OF THYROID $108.79
6010F 9 DYSPHAG TEST DONE B/4 EATING $0.00
6015F 9 DYSPHAG TEST DONE B/4 EATING $0.00
60200 3 REMOVE THYROID LESION $590.91
6020F 9 NPO (NOTHING-MOUTH) ORDERED $0.00
60210 3 PARTIAL THYROID EXCISION $630.88
60212 3 PARTIAL THYROID EXCISION $905.34

60220 3 PARTIAL REMOVAL OF THYROID $691.52
60225 3 PARTIAL REMOVAL OF THYROID $831.19
60240 3 REMOVAL OF THYROID $878.96
60245 O THYROIDECTOMY, SUBTOTAL OR PARTIAL; $0.00
60246 O THYROIDECTOMY, SUBTOTAL OR PARTIAL; $0.00
60252 3 REMOVAL OF THYROID $1,187.09
60254 3 EXTENSIVE THYROID SURGERY $1,530.05
60260 3 REPEAT THYROID SURGERY $991.53
60270 3 REMOVAL OF THYROID $1,249.20
60271 3 REMOVAL OF THYROID $958.20

60280 3 REMOVE THYROID DUCT LESION $398.83
60281 3 REMOVE THYROID DUCT LESION $531.34
60300 3 ASPIR/INJ THYROID CYST $102.89
6030F 9 MAX STERILE BARRIERS FOLLWD $0.00
6040F 9 APPRO RAD DS DVCS TECHS DOCD $0.00
6045F 9 RADXPS IN END RPRT4FLURO PXD $0.00
60500 3 EXPLORE PARATHYROID GLANDS $911.50
60502 3 RE-EXPLORE PARATHYROIDS $1,144.01
60505 3 EXPLORE PARATHYROID GLANDS $1,257.06
60512 3 AUTOTRANSPLANT PARATHYROID $222.38
60520 3 REMOVAL OF THYMUS GLAND $939.24
60521 3 REMOVAL OF THYMUS GLAND $1,079.13
60522 3 REMOVAL OF THYMUS GLAND $1,300.92

60540 3 EXPLORE ADRENAL GLAND $991.39
60545 3 EXPLORE ADRENAL GLAND $1,126.94
60600 3 REMOVE CAROTID BODY LESION $1,308.04
60605 3 REMOVE CAROTID BODY LESION $1,644.64
60650 3 LAPAROSCOPY ADRENALECTOMY $1,102.63
60659 5 LAPARO PROC, ENDOCRINE $0.00
60699 5 ENDOCRINE SURGERY PROCEDURE $0.00
61000 3 REMOVE CRANIAL CAVITY FLUID $101.35
61001 3 REMOVE CRANIAL CAVITY FLUID $99.23
61020 3 REMOVE BRAIN CAVITY FLUID $118.67
61026 3 INJECTION INTO BRAIN CANAL $118.21
61050 3 REMOVE BRAIN CANAL FLUID $100.96

61055 3 INJECTION INTO BRAIN CANAL $129.76
61070 3 BRAIN CANAL SHUNT PROCEDURE $75.80
61105 3 TWIST DRILL HOLE $389.12
61106 O DRILL SKULL FOR EXAM/SURGERY $0.00
61107 3 DRILL SKULL FOR IMPLANTATION $286.49
61108 3 DRILL SKULL FOR DRAINAGE $771.45
61120 3 BURR HOLE FOR PUNCTURE $632.31
61130 O PIERCE SKULL, EXAM/SURGERY $0.00
61140 3 PIERCE SKULL FOR BIOPSY $1,095.40
61150 3 PIERCE SKULL FOR DRAINAGE $1,171.29

61151 3 PIERCE SKULL FOR DRAINAGE $848.57
61154 3 PIERCE SKULL & REMOVE CLOT $1,097.78
61156 3 PIERCE SKULL FOR DRAINAGE $1,093.26
61210 3 PIERCE SKULL, IMPLANT DEVICE $334.48
61215 3 INSERT BRAIN-FLUID DEVICE $423.46
61250 3 PIERCE SKULL & EXPLORE $739.18
61253 3 PIERCE SKULL & EXPLORE $812.98
61304 3 OPEN SKULL FOR EXPLORATION $1,442.22
61305 3 OPEN SKULL FOR EXPLORATION $1,738.88
61312 3 OPEN SKULL FOR DRAINAGE $1,802.95

61316 3 IMPLT CRAN BONE FLAP TO ABDO $78.76
61322 3 DECOMPRESSIVE CRANIOTOMY $2,042.85
61323 3 DECOMPRESSIVE LOBECTOMY $2,077.64
61330 3 DECOMPRESS EYE SOCKET $1,425.29
61332 3 EXPLORE/BIOPSY EYE SOCKET $1,650.65
61333 3 EXPLORE ORBIT/REMOVE LESION $1,667.95
61334 3 EXPLORE ORBIT/REMOVE OBJECT $1,082.21
61340 3 SUBTEMPORAL DECOMPRESSION $1,251.75
61343 3 INCISE SKULL (PRESS RELIEF) $1,932.50
61345 3 RELIEVE CRANIAL PRESSURE $1,789.02

61440 3 INCISE SKULL FOR SURGERY $1,751.24
61458 3 INCISE SKULL FOR BRAIN WOUND $1,768.92
61500 3 REMOVAL OF SKULL LESION $1,184.43
61501 3 REMOVE INFECTED SKULL BONE $1,015.76
61510 3 REMOVAL OF BRAIN LESION $1,908.80

61512 3 REMOVE BRAIN LINING LESION $2,251.46
61514 3 REMOVAL OF BRAIN ABSCESS $1,671.92
61517 3 IMPLT BRAIN CHEMOTX ADD-ON $78.77
61519 3 REMOVE BRAIN LINING LESION $2,608.02
61522 3 REMOVAL OF BRAIN ABSCESS $1,923.54
61531 3 IMPLANT BRAIN ELECTRODES $1,054.49

61535 3 REMOVE BRAIN ELECTRODES $858.87
61537 3 REMOVAL OF BRAIN TISSUE $2,099.67
61541 3 INCISION OF BRAIN TISSUE $1,860.65
61544 3 REMOVE & TREAT BRAIN LESION $1,553.06

61545 3 EXCISION OF BRAIN TUMOR $2,777.03
61546 3 REMOVAL OF PITUITARY GLAND $2,012.97
61548 3 REMOVAL OF PITUITARY GLAND $1,366.26
61550 3 RELEASE OF SKULL SEAMS $896.49
61552 3 RELEASE OF SKULL SEAMS $1,177.86
61553 O CRANIECTOMY FOR CRANIOSTENOSIS EACH $0.00
61555 O RECONSTRUCTION OF SKULL BY MULTIPLE $0.00
61556 3 INCISE SKULL/SUTURES $1,435.99
61557 3 INCISE SKULL/SUTURES $1,479.38
61558 3 EXCISION OF SKULL/SUTURES $1,523.58

61559 3 EXCISION OF SKULL/SUTURES $2,115.28
61561 O RECONSTRUCTION OF SKULL BY ORBITAL $0.00
61563 3 EXCISION OF SKULL TUMOR $1,700.03
61564 3 EXCISION OF SKULL TUMOR $2,128.20
61567 3 INCISION OF BRAIN TISSUE $2,210.37
61570 3 REMOVE FOREIGN BODY, BRAIN $1,607.08
61571 3 INCISE SKULL FOR BRAIN WOUND $1,745.95
61575 3 SKULL BASE/BRAINSTEM SURGERY $2,078.24
61576 3 SKULL BASE/BRAINSTEM SURGERY $3,330.83
61580 3 CRANIOFACIAL APPROACH, SKULL $2,192.58

61584 3 ORBITOCRANIAL APPROACH/SKULL $2,484.97
61586 3 RESECT NASOPHARYNX, SKULL $1,901.42
61590 3 INFRATEMPORAL APPROACH/SKULL $2,785.17
61591 3 INFRATEMPORAL APPROACH/SKULL $2,805.01
61595 3 TRANSTEMPORAL APPROACH/SKULL $2,110.19
61596 3 TRANSCOCHLEAR APPROACH/SKULL $2,316.93
61597 3 TRANSCONDYLAR APPROACH/SKULL $2,532.05
61598 3 TRANSPETROSAL APPROACH/SKULL $2,247.71
61600 3 RESECT/EXCISE CRANIAL LESION $1,900.62

61609 3 TRANSECT ARTERY, SINUS $551.19
61610 3 TRANSECT ARTERY, SINUS $1,690.57
61611 3 TRANSECT ARTERY, SINUS $426.91
61612 3 TRANSECT ARTERY, SINUS $1,502.59
61613 3 REMOVE ANEURYSM, SINUS $2,787.38

61615 3 RESECT/EXCISE LESION, SKULL $2,206.58
61616 3 RESECT/EXCISE LESION, SKULL $2,895.02
61618 3 REPAIR DURA $1,143.13
61619 3 REPAIR DURA $1,317.42
61623 3 ENDOVASC TEMPORY VESSEL OCCL $528.60
61624 3 TRANSCATH OCCLUSION, CNS $1,051.73
61626 3 TRANSCATH OCCLUSION, NON-CNS $856.93
61630 3 INTRACRANIAL ANGIOPLASTY $1,199.75
61635 3 INTRACRAN ANGIOPLSTY W/STENT $1,313.58
61640 3 DILATE IC VASOSPASM, INIT $609.95
61641 3 DILATE IC VASOSPASM ADD-ON $214.33
61642 3 DILATE IC VASOSPASM ADD-ON $428.65
61680 3 INTRACRANIAL VESSEL SURGERY $1,992.70

61697 3 BRAIN ANEURYSM REPR, COMPLX $3,657.69
61698 3 BRAIN ANEURYSM REPR, COMPLX $3,935.37
61700 3 BRAIN ANEURYSM REPR, SIMPLE $3,059.05
61702 3 INNER SKULL VESSEL SURGERY $3,425.79
61703 3 CLAMP NECK ARTERY $1,176.27
61705 3 REVISE CIRCULATION TO HEAD $2,251.87

61711 3 FUSION OF SKULL ARTERIES $2,295.21
61712 O SKULL OR SPINE MICROSURGERY $0.00
61720 3 INCISE SKULL/BRAIN SURGERY $1,025.30
61735 3 INCISE SKULL/BRAIN SURGERY $1,258.72
61750 3 INCISE SKULL/BRAIN BIOPSY $1,229.26
61751 3 BRAIN BIOPSY W/CT/MR GUIDE $1,199.05
61770 3 INCISE SKULL FOR TREATMENT $1,334.23
61780 O STEREOTACTIC LOCALIZATION, ANY METH $0.00

61790 3 TREAT TRIGEMINAL NERVE $745.08
61791 3 TREAT TRIGEMINAL TRACT $964.26
61793 O FOCUS RADIATION BEAM $0.00
61795 3 BRAIN SURGERY USING COMPUTER $223.94
61796 3 SRS, CRANIAL LESION SIMPLE $702.09
61797 3 SRS, CRAN LES SIMPLE, ADDL $191.15
61798 3 SRS, CRANIAL LESION COMPLEX $702.09
61799 3 SRS, CRAN LES COMPLEX, ADDL $264.24
61800 3 APPLY SRS HEADFRAME ADD-ON $135.10
61850 3 IMPLANT NEUROELECTRODES $856.38
61855 O IMPLANT NEUROELECTRODES $0.00
61860 3 IMPLANT NEUROELECTRODES $1,363.01
61862 O IMPLANT NEUROSTIMUL, SUBCORT $0.00

61863 3 IMPLANT NEUROELECTRODE $1,323.63
61864 3 IMPLANT NEUROELECTRDE, ADDL $360.82
61865 O IMPLANT NEUROELECTRODES $0.00
61867 3 IMPLANT NEUROELECTRODE $1,949.47
61868 3 IMPLANT NEUROELECTRDE, ADDÏL $536.27
61880 3 REVISE/REMOVE NEUROELECTRODE $479.00
61885 3 INSRT/REDO NEUROSTIM 1 ARRAY $555.45
61886 3 IMPLANT NEUROSTIM ARRAYS $699.92
61888 3 REVISE/REMOVE NEURORECEIVER $349.67
62000 3 TREAT SKULL FRACTURE $769.53

62005 3 TREAT SKULL FRACTURE $1,085.55
62010 3 TREATMENT OF HEAD INJURY $1,325.74
62100 3 REPAIR BRAIN FLUID LEAKAGE $1,410.97
62115 3 REDUCTION OF SKULL DEFECT $1,250.42
62120 3 REPAIR SKULL CAVITY LESION $1,601.90
62121 3 INCISE SKULL REPAIR $1,459.83
62140 3 REPAIR OF SKULL DEFECT $918.20
62141 3 REPAIR OF SKULL DEFECT $1,008.30

62142 3 REMOVE SKULL PLATE/FLAP $769.26
62143 3 REPLACE SKULL PLATE/FLAP $900.40
62145 3 REPAIR OF SKULL & BRAIN $1,232.91
62146 3 REPAIR OF SKULL WITH GRAFT $1,058.17
62147 3 REPAIR OF SKULL WITH GRAFT $1,256.35
62148 3 RETR BONE FLAP TO FIX SKULL $112.54
62160 3 NEUROENDOSCOPY ADD-ON $172.61
62161 3 DISSECT BRAIN W/SCOPE $1,326.45
62162 3 REMOVE COLLOID CYST W/SCOPE $1,649.22
62163 3 NEUROENDOSCOPY W/FB REMOVAL $1,069.22
62164 3 REMOVE BRAIN TUMOR W/SCOPE $1,757.89
62165 3 REMOVE PITUIT TUMOR W/SCOPE $1,364.53
62180 3 ESTABLISH BRAIN CAVITY SHUNT $1,389.63

62190 3 ESTABLISH BRAIN CAVITY SHUNT $791.96
62194 3 REPLACE/IRRIGATE CATHETER $344.07
62200 3 ESTABLISH BRAIN CAVITY SHUNT $1,202.00
62201 3 BRAIN CAVITY SHUNT W/SCOPE $1,033.11
62225 3 REPLACE/IRRIGATE CATHETER $435.39
62230 3 REPLACE/REVISE BRAIN SHUNT $732.65
62252 3 CSF SHUNT REPROGRAM $92.48
62256 3 REMOVE BRAIN CAVITY SHUNT $509.85
62258 3 REPLACE BRAIN CAVITY SHUNT $984.69

62263 3 EPIDURAL LYSIS MULT SESSIONS $598.98
62264 3 EPIDURAL LYSIS ON SINGLE DAY $365.91
62267 3 INTERDISCAL PERQ ASPIR, DX $237.68
62268 3 DRAIN SPINAL CORD CYST $434.42
62269 3 NEEDLE BIOPSY, SPINAL CORD $471.46
62270 3 SPINAL FLUID TAP, DIAGNOSTIC $144.41
62272 3 DRAIN CEREBRO SPINAL FLUID $170.49
62273 3 INJECT EPIDURAL PATCH $152.41
62274 O INJECT SPINAL ANESTHETIC $0.00

62280 3 TREAT SPINAL CORD LESION $283.81
62281 3 TREAT SPINAL CORD LESION $262.65
62282 3 TREAT SPINAL CANAL LESION $272.93
62284 3 INJECTION FOR MYELOGRAM $208.62
62287 3 PERCUTANEOUS DISKECTOMY $504.98
62288 O INJECTION INTO SPINAL CANAL $0.00
62290 3 INJECT FOR SPINE DISK X-RAY $303.11
62291 3 INJECT FOR SPINE DISK X-RAY $283.61

62292 3 INJECTION INTO DISK LESION $452.37
62294 3 INJECTION INTO SPINAL ARTERY $729.68
62310 3 INJECT SPINE C/T $200.16
62311 3 INJECT SPINE L/S (CD) $176.98
62318 3 INJECT SPINE W/CATH, C/T $214.04
62319 3 INJECT SPINE W/CATH L/S (CD) $193.68
62350 3 IMPLANT SPINAL CANAL CATH $353.08
62351 3 IMPLANT SPINAL CANAL CATH $745.79
62355 3 REMOVE SPINAL CANAL CATHETER $265.32
62360 3 INSERT SPINE INFUSION DEVICE $255.37
62361 3 IMPLANT SPINE INFUSION PUMP $352.38

62362 3 IMPLANT SPINE INFUSION PUMP $371.28
62365 3 REMOVE SPINE INFUSION DEVICE $293.68
62367 3 ANALYZE SPINE INFUSION PUMP $35.61
62368 3 ANALYZE SPINE INFUSION PUMP $50.79
63001 3 REMOVAL OF SPINAL LAMINA $1,082.80
63010 O LAMINECTOMY FOR EXPLORATION/DECOMPR $0.00
63011 3 REMOVAL OF SPINAL LAMINA $977.62

63020 3 NECK SPINE DISK SURGERY $1,033.13
63030 3 LOW BACK DISK SURGERY $859.03
63035 3 SPINAL DISK SURGERY ADD-ON $181.77
63040 3 LAMINOTOMY, SINGLE CERVICAL $1,253.63
63042 3 LAMINOTOMY, SINGLE LUMBAR $1,174.52
63043 5 LAMINOTOMY, ADDÏL CERVICAL $0.00
63044 5 LAMINOTOMY, ADDÏL LUMBAR $0.00
63047 3 REMOVAL OF SPINAL LAMINA $979.39

63048 3 REMOVE SPINAL LAMINA ADD-ON $195.60
63050 3 CERVICAL LAMINOPLASTY $1,347.41
63051 3 C-LAMINOPLASTY W/GRAFT/PLATE $1,521.28
63055 3 DECOMPRESS SPINAL CORD $1,442.44
63057 3 DECOMPRESS SPINE CORD ADD-ON $299.65
63066 3 DECOMPRESS SPINE CORD ADD-ON $184.79
63075 3 NECK SPINE DISK SURGERY $1,232.23
63076 3 NECK SPINE DISK SURGERY $231.33
63077 3 SPINE DISK SURGERY, THORAX $1,350.00
63078 3 SPINE DISK SURGERY, THORAX $184.04

63081 3 REMOVAL OF VERTEBRAL BODY $1,581.44
63082 3 REMOVE VERTEBRAL BODY ADD-ON $249.75

63170 3 INCISE SPINAL CORD TRACT(S) $1,355.65
63172 3 DRAINAGE OF SPINAL CYST $1,220.88
63173 3 DRAINAGE OF SPINAL CYST $1,504.93
63180 3 REVISE SPINAL CORD LIGAMENTS $1,226.12
63182 3 REVISE SPINAL CORD LIGAMENTS $1,310.59
63185 3 INCISE SPINAL COLUMN/NERVES $998.87
63190 3 INCISE SPINAL COLUMN/NERVES $1,148.29
63191 3 INCISE SPINAL COLUMN/NERVES $1,090.04
63194 3 INCISE SPINAL COLUMN & CORD $1,304.51

63200 3 RELEASE OF SPINAL CORD $1,324.62
63250 3 REVISE SPINAL CORD VESSELS $2,565.66
63265 3 EXCISE INTRASPINAL LESION $1,466.64

63275 3 BIOPSY/EXCISE SPINAL TUMOR $1,574.65

63295 3 REPAIR OF LAMINECTOMY DEFECT $288.44

63600 3 REMOVE SPINAL CORD LESION $749.50
63610 3 STIMULATION OF SPINAL CORD $1,244.66
63615 3 REMOVE LESION OF SPINAL CORD $1,013.06
63620 3 SRS, SPINAL LESION $702.09
63621 3 SRS, SPINAL LESION, ADDL $219.77
63652 O PERCUTANEOUS IMPLANTATION OF NEUROS $0.00
63656 O LAMINECTOMY FOR IMPLANTATION OF NEU $0.00

63685 3 INSRT/REDO SPINE N GENERATOR $358.61
63688 3 REVISE/REMOVE NEURORECEIVER $321.69
63690 O ANALYSIS OF NEURORECEIVER $0.00
63691 O ANALYSIS OF NEURORECEIVER $0.00
63700 3 REPAIR OF SPINAL HERNIATION $1,083.94
63707 3 REPAIR SPINAL FLUID LEAKAGE $801.33

63709 3 REPAIR SPINAL FLUID LEAKAGE $973.08
63710 3 GRAFT REPAIR OF SPINE DEFECT $972.32
63740 3 INSTALL SPINAL SHUNT $825.84
63741 3 INSTALL SPINAL SHUNT $535.13
63744 3 REVISION OF SPINAL SHUNT $562.89
63746 3 REMOVAL OF SPINAL SHUNT $492.42
63750 O INSERTION, SUBARACHNOID CATHETER WI $0.00
63780 O INSERTION OR REPLACEMENT, SUBARACHN $0.00
64400 3 N BLOCK INJ, TRIGEMINAL $98.27
64402 3 N BLOCK INJ, FACIAL $100.43
64405 3 N BLOCK INJ, OCCIPITAL $94.56
64408 3 N BLOCK INJ, VAGUS $109.35
64410 3 N BLOCK INJ, PHRENIC $127.57

64412 3 N BLOCK INJ, SPINAL ACCESSOR $127.27
64413 3 N BLOCK INJ, CERVICAL PLEXUS $105.18
64415 3 N BLOCK INJ, BRACHIAL PLEXUS $119.75
64416 3 N BLOCK CONT INFUSE, B PLEX $85.42
64417 3 N BLOCK INJ, AXILLARY $121.01
64418 3 N BLOCK INJ, SUPRASCAPULAR $123.53
64420 3 N BLOCK INJ, INTERCOST, SNG $147.60
64421 3 N BLOCK INJ, INTERCOST, MLT $217.95
64425 3 N BLOCK INJ, ILIO-ING/HYPOGI $117.41
64430 3 N BLOCK INJ, PUDENDAL $144.41
64435 3 N BLOCK INJ, PARACERVICAL $133.66
64440 O INJECTION FOR NERVE BLOCK $0.00

64443 O INJECT, NERVE BLOCK ADD-ON $0.00
64445 3 N BLOCK INJ, SCIATIC, SNG $124.42
64446 3 N BLK INJ, SCIATIC, CONT INF $85.37
64447 3 N BLOCK INJ FEM, SINGLE $64.63
64448 3 N BLOCK INJ FEM, CONT INF $75.50
64449 3 N BLOCK INJ, LUMBAR PLEXUS $84.54
64450 3 N BLOCK, OTHER PERIPHERAL $94.71
64455 3 N BLOCK INJ, PLANTAR DIGIT $48.19

64470 3 INJ PARAVERTEBRAL C/T $241.77
64472 3 INJ PARAVERTEBRAL C/T ADD-ON $103.84
64475 3 INJ PARAVERTEBRAL L/S $216.93
64476 3 INJ PARAVERTEBRAL L/S ADD-ON $87.35
64479 3 INJ FORAMEN EPIDURAL C/T $255.62
64480 3 INJ FORAMEN EPIDURAL ADD-ON $127.67
64483 3 INJ FORAMEN EPIDURAL L/S $249.11
64484 3 INJ FORAMEN EPIDURAL ADD-ON $125.61
64505 3 N BLOCK, SPENOPALATINE GANGL $93.14
64508 3 N BLOCK, CAROTID SINUS S/P $131.17
64510 3 N BLOCK, STELLATE GANGLION $130.31
64517 3 N BLOCK INJ, HYPOGAS PLXS $155.57
64520 3 N BLOCK, LUMBAR/THORACIC $171.05

64530 3 N BLOCK INJ, CELIAC PELUS $176.42
64550 3 APPLY NEUROSTIMULATOR $14.44

64590 3 INSRT/REDO PN/GASTR STIMUL $292.15
64595 3 REVISE/RMV PN/GASTR STIMUL $302.97
64600 3 INJECTION TREATMENT OF NERVE $369.88
64612 3 DESTROY NERVE, FACE MUSCLE $141.05
64613 3 DESTROY NERVE, NECK MUSCLE $138.83
64614 3 DESTROY NERVE, EXTREM MUSC $155.69

64622 3 DESTR PARAVERTEBRL NERVE L/S $297.82
64623 3 DESTR PARAVERTEBRAL N ADD-ON $110.76
64626 3 DESTR PARAVERTEBRL NERVE C/T $346.12
64627 3 DESTR PARAVERTEBRAL N ADD-ON $151.46
64632 3 N BLOCK INJ, COMMON DIGIT $79.20
64650 3 CHEMODENERV ECCRINE GLANDS $61.57
64653 3 CHEMODENERV ECCRINE GLANDS $71.44
64702 3 REVISE FINGER/TOE NERVE $414.13
64704 3 REVISE HAND/FOOT NERVE $304.32

64708 3 REVISE ARM/LEG NERVE $430.13
64712 3 REVISION OF SCIATIC NERVE $493.15
64713 3 REVISION OF ARM NERVE(S) $689.09
64714 3 REVISE LOW BACK NERVE(S) $587.55
64716 3 REVISION OF CRANIAL NERVE $470.60
64718 3 REVISE ULNAR NERVE AT ELBOW $507.78
64719 3 REVISE ULNAR NERVE AT WRIST $352.16
64721 3 CARPAL TUNNEL SURGERY $372.34
64722 3 RELIEVE PRESSURE ON NERVE(S) $300.66
64726 3 RELEASE FOOT/TOE NERVE $264.68
64727 3 INTERNAL NERVE REVISION $171.82
64732 3 INCISION OF BROW NERVE $344.36

64734 3 INCISION OF CHEEK NERVE $371.72
64736 3 INCISION OF CHIN NERVE $351.43
64738 3 INCISION OF JAW NERVE $414.47
64740 3 INCISION OF TONGUE NERVE $414.17
64742 3 INCISION OF FACIAL NERVE $422.85
64744 3 INCISE NERVE, BACK OF HEAD $371.31
64746 3 INCISE DIAPHRAGM NERVE $400.22
64752 3 INCISION OF VAGUS NERVE $452.49
64755 9 INCISION OF STOMACH NERVES $0.00
64760 3 INCISION OF VAGUS NERVE $426.81

64761 3 INCISION OF PELVIS NERVE $404.51
64763 3 INCISE HIP/THIGH NERVE $491.33
64766 3 INCISE HIP/THIGH NERVE $564.72
64771 3 SEVER CRANIAL NERVE $531.24
64772 3 INCISION OF SPINAL NERVE $510.51
64774 3 REMOVE SKIN NERVE LESION $368.56
64776 3 REMOVE DIGIT NERVE LESION $354.10
64778 3 DIGIT NERVE SURGERY ADD-ON $170.59
64782 3 REMOVE LIMB NERVE LESION $416.72
64783 3 LIMB NERVE SURGERY ADD-ON $203.95
64784 3 REMOVE NERVE LESION $648.60
64786 3 REMOVE SCIATIC NERVE LESION $972.42
64787 3 IMPLANT NERVE END $234.11

64788 3 REMOVE SKIN NERVE LESION $346.46
64790 3 REMOVAL OF NERVE LESION $741.54
64792 3 REMOVAL OF NERVE LESION $961.56
64795 3 BIOPSY OF NERVE $175.48
64802 3 REMOVE SYMPATHETIC NERVES $543.23

64830 O MICROREPAIR OF NERVE $0.00
64831 3 REPAIR OF DIGIT NERVE $609.02
64832 3 REPAIR NERVE ADD-ON $317.28
64834 3 REPAIR OF HAND OR FOOT NERVE $672.13
64837 3 REPAIR NERVE ADD-ON $352.32
64840 3 REPAIR OF LEG NERVE $827.93
64856 3 REPAIR/TRANSPOSE NERVE $915.80
64857 3 REPAIR ARM/LEG NERVE $957.33

64858 3 REPAIR SCIATIC NERVE $1,104.07
64859 3 NERVE SURGERY $238.91
64861 3 REPAIR OF ARM NERVES $1,243.60
64862 3 REPAIR OF LOW BACK NERVES $1,216.70
64864 3 REPAIR OF FACIAL NERVE $793.45
64865 3 REPAIR OF FACIAL NERVE $1,052.87
64866 3 FUSION OF FACIAL/OTHER NERVE $1,093.97
64868 3 FUSION OF FACIAL/OTHER NERVE $956.87
64870 3 FUSION OF FACIAL/OTHER NERVE $929.66
64872 3 SUBSEQUENT REPAIR OF NERVE $112.07
64874 3 REPAIR & REVISE NERVE ADD-ON $164.61
64876 3 REPAIR NERVE/SHORTEN BONE $179.38
64885 3 NERVE GRAFT, HEAD OR NECK $1,033.01

64886 3 NERVE GRAFT, HEAD OR NECK $1,225.65
64890 3 NERVE GRAFT, HAND OR FOOT $986.46
64891 3 NERVE GRAFT, HAND OR FOOT $1,017.46
64892 3 NERVE GRAFT, ARM OR LEG $959.60
64893 3 NERVE GRAFT, ARM OR LEG $1,009.62
64901 3 NERVE GRAFT ADD-ON $559.99
64902 3 NERVE GRAFT ADD-ON $643.28
64905 3 NERVE PEDICLE TRANSFER $917.68

64907 3 NERVE PEDICLE TRANSFER $1,205.21
64910 3 NERVE REPAIR W/ALLOGRAFT $739.53
64911 3 NEURORRAPHY W/VEIN AUTOGRAFT $891.09
64999 5 NERVOUS SYSTEM SURGERY $0.00
65091 3 REVISE EYE $530.87
65093 3 REVISE EYE WITH IMPLANT $530.11
65101 3 REMOVAL OF EYE $612.09
65103 3 REMOVE EYE/INSERT IMPLANT $638.89
65105 3 REMOVE EYE/ATTACH IMPLANT $704.58
65110 3 REMOVAL OF EYE $1,024.81

65112 3 REMOVE EYE/REVISE SOCKET $1,206.53
65114 3 REMOVE EYE/REVISE SOCKET $1,253.86
65125 3 REVISE OCULAR IMPLANT $384.38
65130 3 INSERT OCULAR IMPLANT $605.29
65135 3 INSERT OCULAR IMPLANT $616.39
65140 3 ATTACH OCULAR IMPLANT $671.41
65150 3 REVISE OCULAR IMPLANT $487.26
65155 3 REINSERT OCULAR IMPLANT $708.14
65175 3 REMOVAL OF OCULAR IMPLANT $545.67
65205 3 REMOVE FOREIGN BODY FROM EYE $47.90

65230 O REMOVAL OF FOREIGN BODY, INTRAOCULA $0.00
65270 3 REPAIR OF EYE WOUND $225.30

65290 3 REPAIR OF EYE SOCKET WOUND $406.62
65300 O DELIMITING KERATOTOMY $0.00
65400 3 REMOVAL OF EYE LESION $555.72
65410 3 BIOPSY OF CORNEA $121.13
65430 3 CORNEAL SMEAR $97.46
65435 3 CURETTE/TREAT CORNEA $67.47
65436 3 CURETTE/TREAT CORNEA $319.73

65450 3 TREATMENT OF CORNEAL LESION $265.51
65600 3 REVISION OF CORNEA $321.79
65710 3 CORNEAL TRANSPLANT $915.18
65730 3 CORNEAL TRANSPLANT $1,017.40
65756 3 CORNEAL TRNSPL, ENDOTHELIAL $985.80
65757 6 PREP CORNEAL ENDO ALLOGRAFT $0.00
65767 5 CORNEAL TISSUE TRANSPLANT $0.00
65770 3 REVISE CORNEA WITH IMPLANT $1,177.70
65771 5 RADIAL KERATOTOMY $0.00

65772 3 CORRECTION OF ASTIGMATISM $371.57
65775 3 CORRECTION OF ASTIGMATISM $455.35
65780 3 OCULAR RECONST, TRANSPLANT $734.11
65781 3 OCULAR RECONST, TRANSPLANT $1,111.66
65782 3 OCULAR RECONST, TRANSPLANT $959.32
65800 3 DRAINAGE OF EYE $127.34
65820 3 RELIEVE INNER EYE PRESSURE $622.51
65825 O GONIOTOMY WITH GONIOPUNCTURE $0.00
65830 O GONIOPUNCTURE, WITHOUT GONIOTOMY $0.00

65850 3 INCISION OF EYE $705.44
65855 3 LASER SURGERY OF EYE $283.67
65860 3 INCISE INNER EYE ADHESIONS $262.03
65900 3 REMOVE EYE LESION $801.52
65920 3 REMOVE IMPLANT OF EYE $648.84
65930 3 REMOVE BLOOD CLOT FROM EYE $533.65

66020 3 INJECTION TREATMENT OF EYE $156.31
66030 3 INJECTION TREATMENT OF EYE $138.51
66130 3 REMOVE EYE LESION $589.23
66150 3 GLAUCOMA SURGERY $714.56
66172 3 INCISION OF EYE $1,232.20
66180 3 IMPLANT EYE SHUNT $972.49
66185 3 REVISE EYE SHUNT $615.44
66220 3 REPAIR EYE LESION $601.48
66225 3 REPAIR/GRAFT EYE LESION $772.41

66250 3 FOLLOW-UP SURGERY OF EYE $623.44
66500 3 INCISION OF IRIS $293.23
66505 3 INCISION OF IRIS $320.96
66600 3 REMOVE IRIS AND LESION $677.60
66605 3 REMOVAL OF IRIS $878.47
66680 3 REPAIR IRIS & CILIARY BODY $423.55
66682 9 REPAIR IRIS & CILIARY BODY $0.00
66700 3 DESTRUCTION, CILIARY BODY $372.16
66701 O CYCLODIATHERMY SUBSEQUENT $0.00

66702 O CILIARY BODY DESTRUCTION, ANY METHO $0.00
66710 3 CILIARY TRANSSLERAL THERAPY $365.64
66711 3 CILIARY ENDOSCOPIC ABLATION $523.39
66721 O CYCLOCRYOTHERAPY SUBSEQUENT $0.00
66741 O CYCLODIALYSIS SUBSEQUENT $0.00
66761 3 REVISION OF IRIS $373.28
66762 3 REVISION OF IRIS $390.91
66770 3 REMOVAL OF INNER EYE LESION $433.98

66800 O DISCISSION OF LENS CAPSULE INCISION $0.00
66801 O DISCISSION OF LENS CAPSULE INCISION $0.00
66802 O DISCISSION OF LENS CAPSULE LASER SU $0.00
66820 3 INCISION, SECONDARY CATARACT $329.85
66821 3 AFTER CATARACT LASER SURGERY $267.68
66825 3 REPOSITION INTRAOCULAR LENS $631.25
66830 3 REMOVAL OF LENS LESION $589.07
66840 3 REMOVAL OF LENS MATERIAL $574.25
66915 O EXPRESSION OF LENS, LINEAR, ONE OR $0.00
66920 3 EXTRACTION OF LENS $625.66

66982 3 CATARACT SURGERY, COMPLEX $887.39
66983 3 CATARACT SURG W/IOL, 1 STAGE $612.23
66984 3 CATARACT SURG W/IOL, 1 STAGE $636.87
66985 3 INSERT LENS PROSTHESIS $631.01
66986 3 EXCHANGE LENS PROSTHESIS $771.53
66990 3 OPHTHALMIC ENDOSCOPE ADD-ON $78.56
66999 5 EYE SURGERY PROCEDURE $0.00
67005 3 PARTIAL REMOVAL OF EYE FLUID $389.62
67010 3 PARTIAL REMOVAL OF EYE FLUID $450.61
67015 3 RELEASE OF EYE FLUID $481.59
67025 3 REPLACE EYE FLUID $600.25

67027 3 IMPLANT EYE DRUG SYSTEM $709.76
67028 3 INJECTION EYE DRUG $179.81
67030 3 INCISE INNER EYE STRANDS $431.00
67031 3 LASER SURGERY, EYE STRANDS $318.75
67036 3 REMOVAL OF INNER EYE FLUID $801.45
67038 O STRIP RETINAL MEMBRANE $0.00
67039 3 LASER TREATMENT OF RETINA $1,027.13
67040 3 LASER TREATMENT OF RETINA $1,184.47
67041 3 VIT FOR MACULAR PUCKER $1,105.87
67042 3 VIT FOR MACULAR HOLE $1,266.18

67043 3 VIT FOR MEMBRANE DISSECT $1,328.99
67101 3 REPAIR DETACHED RETINA $642.64
67107 3 REPAIR DETACHED RETINA $1,008.06
67108 3 REPAIR DETACHED RETINA $1,340.89
67109 O REPAIR OF RETINAL DETACHMENT, ONE O $0.00
67112 3 REREPAIR DETACHED RETINA $1,106.57
67113 3 REPAIR RETINAL DETACH, CPLX $1,455.41
67115 3 RELEASE ENCIRCLING MATERIAL $406.82
67120 3 REMOVE EYE IMPLANT MATERIAL $542.61
67121 3 REMOVE EYE IMPLANT MATERIAL $751.70
67141 3 TREATMENT OF RETINA $429.52

67145 3 TREATMENT OF RETINA $432.88
67208 3 TREATMENT OF RETINAL LESION $495.52
67218 3 TREATMENT OF RETINAL LESION $1,170.50
67220 3 TREATMENT OF CHOROID LESION $887.55
67221 3 OCULAR PHOTODYNAMIC THER $251.93
67225 3 EYE PHOTODYNAMIC THER ADD-ON $25.77
67229 3 TR RETINAL LES PRETERM INF $958.47
67250 3 REINFORCE EYE WALL $654.69
67255 3 REINFORCE/GRAFT EYE WALL $700.29

67299 5 EYE SURGERY PROCEDURE $0.00
67311 3 REVISE EYE MUSCLE $495.26
67312 3 REVISE TWO EYE MUSCLES $591.60
67313 O STRABISMUS SURGERY ON PATIENT NOT P $0.00
67314 3 REVISE EYE MUSCLE $555.13
67316 3 REVISE TWO EYE MUSCLES $663.95
67318 3 REVISE EYE MUSCLE(S) $581.09
67320 3 REVISE EYE MUSCLE(S) ADD-ON $275.14
67331 3 EYE SURGERY FOLLOW-UP ADD-ON $260.44
67332 3 REREVISE EYE MUSCLES ADD-ON $283.31

67334 3 REVISE EYE MUSCLE W/SUTURE $256.98
67335 3 EYE SUTURE DURING SURGERY $129.44
67340 3 REVISE EYE MUSCLE ADD-ON $306.17
67343 3 RELEASE EYE TISSUE $539.50
67345 3 DESTROY NERVE OF EYE MUSCLE $196.71
67346 3 BIOPSY, EYE MUSCLE $171.22
67350 O BIOPSY EYE MUSCLE $0.00
67399 5 EYE MUSCLE SURGERY PROCEDURE $0.00
67400 3 EXPLORE/BIOPSY EYE SOCKET $779.20
67405 3 EXPLORE/DRAIN EYE SOCKET $663.78
67412 3 EXPLORE/TREAT EYE SOCKET $721.34
67413 3 EXPLORE/TREAT EYE SOCKET $721.92
67414 3 EXPLR/DECOMPRESS EYE SOCKET $1,101.61

67415 3 ASPIRATION, ORBITAL CONTENTS $90.56
67420 3 EXPLORE/TREAT EYE SOCKET $1,373.92
67430 3 EXPLORE/TREAT EYE SOCKET $1,046.87
67440 3 EXPLORE/DRAIN EYE SOCKET $1,009.18
67445 3 EXPLR/DECOMPRESS EYE SOCKET $1,182.30
67450 3 EXPLORE/BIOPSY EYE SOCKET $1,047.22
67500 3 INJECT/TREAT EYE SOCKET $75.95
67550 3 INSERT EYE SOCKET IMPLANT $811.93
67560 3 REVISE EYE SOCKET IMPLANT $826.30
67570 3 DECOMPRESS OPTIC NERVE $970.69

67599 5 ORBIT SURGERY PROCEDURE $0.00
67700 3 DRAINAGE OF EYELID ABSCESS $225.88
67710 3 INCISION OF EYELID $190.68
67715 3 INCISION OF EYELID FOLD $200.66
67800 3 REMOVE EYELID LESION $106.07
67801 3 REMOVE EYELID LESIONS $135.88
67805 3 REMOVE EYELID LESIONS $168.45
67808 3 REMOVE EYELID LESION(S) $302.18
67810 3 BIOPSY OF EYELID $193.71
67820 3 REVISE EYELASHES $44.44

67840 3 REMOVE EYELID LESION $235.72
67850 3 TREAT EYELID LESION $189.59
67875 3 CLOSURE OF EYELID BY SUTURE $147.16
67900 3 REPAIR BROW DEFECT $540.23
67901 3 REPAIR EYELID DEFECT $583.04

67907 O REPAIR OF BLEPHAROPTOSIS SUPERIOR R $0.00
67909 3 REVISE EYELID DEFECT $452.09
67911 3 REVISE EYELID DEFECT $461.55
67912 3 CORRECTION EYELID W/IMPLANT $769.11

67930 3 REPAIR EYELID WOUND $310.63
67935 3 REPAIR EYELID WOUND $503.66
67938 3 REMOVE EYELID FOREIGN BODY $206.06
67971 3 RECONSTRUCTION OF EYELID $612.74

68020 3 INCISE/DRAIN EYELID LINING $99.54
68040 3 TREATMENT OF EYELID LESIONS $55.36
68100 3 BIOPSY OF EYELID LINING $146.04
68110 3 REMOVE EYELID LINING LESION $189.97
68200 3 TREAT EYELID BY INJECTION $35.73
68320 3 REVISE/GRAFT EYELID LINING $599.28

68330 3 REVISE EYELID LINING $503.07
68340 3 SEPARATE EYELID ADHESIONS $453.42
68371 3 HARVEST EYE TISSUE, ALOGRAFT $348.60
68399 5 EYELID LINING SURGERY $0.00
68400 3 INCISE/DRAIN TEAR GLAND $238.27
68420 3 INCISE/DRAIN TEAR SAC $271.14
68440 3 INCISE TEAR DUCT OPENING $89.85

68500 3 REMOVAL OF TEAR GLAND $806.66
68505 3 PARTIAL REMOVAL, TEAR GLAND $811.93
68510 3 BIOPSY OF TEAR GLAND $385.06
68520 3 REMOVAL OF TEAR SAC $571.67
68525 3 BIOPSY OF TEAR SAC $229.40
68530 3 CLEARANCE OF TEAR DUCT $368.37
68540 3 REMOVE TEAR GLAND LESION $771.51
68550 3 REMOVE TEAR GLAND LESION $947.99
68700 3 REPAIR TEAR DUCTS $498.03
68705 3 REVISE TEAR DUCT OPENING $200.58

68720 3 CREATE TEAR SAC DRAIN $632.13
68745 3 CREATE TEAR DUCT DRAIN $634.88
68750 3 CREATE TEAR DUCT DRAIN $652.86
68760 3 CLOSE TEAR DUCT OPENING $170.06
68761 3 CLOSE TEAR DUCT OPENING $123.59
68770 3 CLOSE TEAR SYSTEM FISTULA $491.58
68800 O DILATION OF LACRIMAL PUNCTUM, WITH $0.00
68801 3 DILATE TEAR DUCT OPENING $102.79
68810 3 PROBE NASOLACRIMAL DUCT $198.71
68816 3 PROBE NL DUCT W/BALLOON $579.09
68820 O PROBING OF NASOLACRIMAL DUCT, WITH $0.00

68840 3 EXPLORE/IRRIGATE TEAR DUCTS $104.13
68850 3 INJECTION FOR TEAR SAC X-RAY $58.38
68899 5 TEAR DUCT SYSTEM SURGERY $0.00
69000 3 DRAIN EXTERNAL EAR LESION $161.51
69005 3 DRAIN EXTERNAL EAR LESION $190.73
69020 3 DRAIN OUTER EAR CANAL LESION $206.58
69090 9 PIERCE EARLOBES $0.00
69100 3 BIOPSY OF EXTERNAL EAR $96.22
69105 3 BIOPSY OF EXTERNAL EAR CANAL $126.33
69110 3 REMOVE EXTERNAL EAR, PARTIAL $410.32

69120 3 REMOVAL OF EXTERNAL EAR $361.57
69140 3 REMOVE EAR CANAL LESION(S) $791.65
69145 3 REMOVE EAR CANAL LESION(S) $345.59
69150 3 EXTENSIVE EAR CANAL SURGERY $960.49
69155 3 EXTENSIVE EAR/NECK SURGERY $1,539.45
69200 3 CLEAR OUTER EAR CANAL $109.92
69205 3 CLEAR OUTER EAR CANAL $92.23
69210 O REMOVE IMPACTED EAR WAX $0.00
69220 3 CLEAN OUT MASTOID CAVITY $123.39
69222 3 CLEAN OUT MASTOID CAVITY $197.80

69300 3 REVISE EXTERNAL EAR $586.47
69310 3 REBUILD OUTER EAR CANAL $987.06
69320 3 REBUILD OUTER EAR CANAL $1,404.47
69399 5 OUTER EAR SURGERY PROCEDURE $0.00
69400 3 INFLATE MIDDLE EAR CANAL $128.20
69401 3 INFLATE MIDDLE EAR CANAL $74.73
69405 3 CATHETERIZE MIDDLE EAR CANAL $233.56
69410 O INSET MIDDLE EAR (BAFFLE) $0.00
69420 3 INCISION OF EARDRUM $171.03
69421 3 INCISION OF EARDRUM $137.86
69424 3 REMOVE VENTILATING TUBE $116.35
69433 3 CREATE EARDRUM OPENING $177.93
69436 3 CREATE EARDRUM OPENING $149.62

69440 3 EXPLORATION OF MIDDLE EAR $621.13
69450 9 EARDRUM REVISION $0.00
69501 3 MASTOIDECTOMY $665.41
69502 3 MASTOIDECTOMY $884.79
69505 3 REMOVE MASTOID STRUCTURES $1,097.45
69511 3 EXTENSIVE MASTOID SURGERY $1,128.07
69530 3 EXTENSIVE MASTOID SURGERY $1,516.23
69535 3 REMOVE PART OF TEMPORAL BONE $2,457.55
69540 3 REMOVE EAR LESION $186.86
69550 3 REMOVE EAR LESION $948.95
69552 3 REMOVE EAR LESION $1,443.05
69554 3 REMOVE EAR LESION $2,282.15

69601 3 MASTOID SURGERY REVISION $954.16
69602 3 MASTOID SURGERY REVISION $992.92
69603 3 MASTOID SURGERY REVISION $1,160.08
69610 3 REPAIR OF EARDRUM $355.84
69620 3 REPAIR OF EARDRUM $627.12
69631 3 REPAIR EARDRUM STRUCTURES $798.81
69632 3 REBUILD EARDRUM STRUCTURES $980.06
69633 3 REBUILD EARDRUM STRUCTURES $944.54

69635 3 REPAIR EARDRUM STRUCTURES $1,112.91
69636 3 REBUILD EARDRUM STRUCTURES $1,260.93
69637 3 REBUILD EARDRUM STRUCTURES $1,255.27
69641 3 REVISE MIDDLE EAR & MASTOID $948.69
69642 3 REVISE MIDDLE EAR & MASTOID $1,222.84
69650 3 RELEASE MIDDLE EAR BONE $722.45
69660 3 REVISE MIDDLE EAR BONE $848.95
69661 9 REVISE MIDDLE EAR BONE $0.00
69662 3 REVISE MIDDLE EAR BONE $1,063.36

69666 3 REPAIR MIDDLE EAR STRUCTURES $733.29
69667 3 REPAIR MIDDLE EAR STRUCTURES $735.86
69670 3 REMOVE MASTOID AIR CELLS $857.88
69676 3 REMOVE MIDDLE EAR NERVE $757.33
69700 3 CLOSE MASTOID FISTULA $630.99
69710 5 IMPLANT/REPLACE HEARING AID $0.00
69711 3 REMOVE/REPAIR HEARING AID $789.21
69714 3 IMPLANT TEMPLE BONE W/STIMUL $985.42
69715 3 TEMPLE BNE IMPLNT W/STIMULAT $1,224.49
69717 3 TEMPLE BONE IMPLANT REVISION $1,041.54
69718 3 REVISE TEMPLE BONE IMPLANT $1,280.30
69720 3 RELEASE FACIAL NERVE $1,070.85

69740 3 REPAIR FACIAL NERVE $1,075.92
69745 3 REPAIR FACIAL NERVE $1,143.26
69799 5 MIDDLE EAR SURGERY PROCEDURE $0.00
69801 3 INCISE INNER EAR $679.87
69802 3 INCISE INNER EAR $951.60
69805 3 EXPLORE INNER EAR $963.44
69806 3 EXPLORE INNER EAR $866.20
69820 3 ESTABLISH INNER EAR WINDOW $787.31
69840 3 REVISE INNER EAR WINDOW $828.40

69905 3 REMOVE INNER EAR $838.89
69910 3 REMOVE INNER EAR & MASTOID $936.17
69915 3 INCISE INNER EAR NERVE $1,415.40
69930 3 IMPLANT COCHLEAR DEVICE $1,138.44
69949 5 INNER EAR SURGERY PROCEDURE $0.00
69950 3 INCISE INNER EAR NERVE $1,675.03
69960 3 RELEASE INNER EAR CANAL $1,775.92
69970 3 REMOVE INNER EAR LESION $1,983.90
69979 5 TEMPORAL BONE SURGERY $0.00
69990 3 MICROSURGERY ADD-ON $198.95
70010 3 CONTRAST X-RAY OF BRAIN $170.26
70011 O MYELOGRAPHY, POSTERIOR FOSSA COMPLE $0.00

70015 3 CONTRAST X-RAY OF BRAIN $142.11
70016 O CISTERNOGRAPHY, POSITIVE CONTRAST C $0.00
70030 3 X-RAY EYE FOR FOREIGN BODY $27.87
70100 3 X-RAY EXAM OF JAW $30.08
7010F 9 PT INFO INTO RECALL SYSTEM $0.00
70110 3 X-RAY EXAM OF JAW $38.96
70120 3 X-RAY EXAM OF MASTOIDS $32.77
70130 3 X-RAY EXAM OF MASTOIDS $54.13
70134 3 X-RAY EXAM OF MIDDLE EAR $46.36
70140 3 X-RAY EXAM OF FACIAL BONES $29.43
70150 3 X-RAY EXAM OF FACIAL BONES $42.15
70160 3 X-RAY EXAM OF NASAL BONES $31.57

70170 3 X-RAY EXAM OF TEAR DUCT $0.00
70171 O DACRYOCYSTOGRAPHY, NASOLACRIMAL DUC $0.00
70190 3 X-RAY EXAM OF EYE SOCKETS $34.96
70200 3 X-RAY EXAM OF EYE SOCKETS $43.61
7020F 9 MAMMO ASSESS CAT IN DBASE $0.00
70210 3 X-RAY EXAM OF SINUSES $29.46
70220 3 X-RAY EXAM OF SINUSES $38.47
70240 3 X-RAY EXAM, PITUITARY SADDLE $28.95
70250 3 X-RAY EXAM OF SKULL $35.65
7025F 9 PT INFOSYS ALARM 4 NXT MAMMO $0.00

70260 3 X-RAY EXAM OF SKULL $47.34
70300 3 X-RAY EXAM OF TEETH $13.91
70310 3 X-RAY EXAM OF TEETH $33.43
70320 3 FULL MOUTH X-RAY OF TEETH $43.07
70328 3 X-RAY EXAM OF JAW JOINT $29.33
70330 3 X-RAY EXAM OF JAW JOINTS $46.62
70332 3 X-RAY EXAM OF JAW JOINT $83.65
70333 O TEMPOROMANDIBULAR JOINT ARTHROGRAPH $0.00
70336 3 MAGNETIC IMAGE, JAW JOINT $425.18
70350 3 X-RAY HEAD FOR ORTHODONTIA $20.10
70355 3 PANORAMIC X-RAY OF JAWS $22.39
70360 3 X-RAY EXAM OF NECK $26.75
70370 3 THROAT X-RAY & FLUOROSCOPY $73.62

70371 3 SPEECH EVALUATION, COMPLEX $96.33
70373 3 CONTRAST X-RAY OF LARYNX $79.47
70374 O LARYNGOGRAPHY, CONTRAST COMPLETE PR $0.00
70380 3 X-RAY EXAM OF SALIVARY GLAND $36.48
70390 3 X-RAY EXAM OF SALIVARY DUCT $98.77
70391 O SIALOGRAPHY COMPLETE PROCEDURE $0.00
70450 3 CT HEAD/BRAIN W/O DYE $219.23
70460 3 CT HEAD/BRAIN W/DYE $283.53
70470 3 CT HEAD/BRAIN W/O & W/DYE $343.32
70480 3 CT ORBIT/EAR/FOSSA W/O DYE $261.48
70481 3 CT ORBIT/EAR/FOSSA W/DYE $381.20
70482 3 CT ORBIT/EAR/FOSSA W/O&W/DYE $417.80

70486 3 CT MAXILLOFACIAL W/O DYE $253.88
70487 3 CT MAXILLOFACIAL W/DYE $341.61
70488 3 CT MAXILLOFACIAL W/O & W/DYE $415.97
70490 3 CT SOFT TISSUE NECK W/O DYE $261.21
70491 3 CT SOFT TISSUE NECK W/DYE $335.59
70492 3 CT SFT TSUE NCK W/O & W/DYE $407.80
70496 3 CT ANGIOGRAPHY, HEAD $444.88
70498 3 CT ANGIOGRAPHY, NECK $445.24
70540 3 MRI ORBIT/FACE/NECK W/O DYE $420.92
70541 O MAGNETIC IMAGE, HEAD (MRA) $0.00

70542 3 MRI ORBIT/FACE/NECK W/DYE $514.55
70543 3 MRI ORBT/FAC/NCK W/O & W/DYE $652.35
70544 3 MR ANGIOGRAPHY HEAD W/O DYE $412.18
70545 3 MR ANGIOGRAPHY HEAD W/DYE $492.34
70546 3 MR ANGIOGRAPH HEAD W/O&W/DYE $637.80
70547 3 MR ANGIOGRAPHY NECK W/O DYE $412.04
70548 3 MR ANGIOGRAPHY NECK W/DYE $492.60
70549 3 MR ANGIOGRAPH NECK W/O&W/DYE $637.80
70551 3 MRI BRAIN W/O DYE $426.20
70552 3 MRI BRAIN W/DYE $520.88
70553 3 MRI BRAIN W/O & W/DYE $658.38
70554 3 FMRI BRAIN BY TECH $620.22
70555 3 FMRI BRAIN BY PHYS/PSYCH $0.00

70557 3 MRI BRAIN W/O DYE $0.00
70558 3 MRI BRAIN W/DYE $0.00
70559 3 MRI BRAIN W/O & W/DYE $0.00
71010 3 CHEST X-RAY $23.78
71015 3 CHEST X-RAY $29.29
71020 3 CHEST X-RAY $31.61
71021 3 CHEST X-RAY $38.07
71022 3 CHEST X-RAY $45.79
71023 3 CHEST X-RAY AND FLUOROSCOPY $66.40
71030 3 CHEST X-RAY $46.16
71034 3 CHEST X-RAY AND FLUOROSCOPY $91.30
71035 3 CHEST X-RAY $34.14

71036 O X-RAY GUIDANCE FOR BIOPSY $0.00
71037 O NEEDLE BIOPSY OF INTRATHORACIC LESI $0.00
71038 O X-RAY GUIDANCE FOR BIOPSY $0.00
71040 3 CONTRAST X-RAY OF BRONCHI $95.09
71041 O BRONCHOGRAPHY, UNILATERAL COMPLETE $0.00
71060 3 CONTRAST X-RAY OF BRONCHI $138.60
71061 O BRONCHOGRAPHY, BILATERAL COMPLETE P $0.00
71090 3 X-RAY & PACEMAKER INSERTION $0.00
71100 3 X-RAY EXAM OF RIBS $32.35
71101 3 X-RAY EXAM OF RIBS/CHEST $38.95

71110 3 X-RAY EXAM OF RIBS $40.30
71111 3 X-RAY EXAM OF RIBS/CHEST $51.56
71120 3 X-RAY EXAM OF BREASTBONE $32.38
71130 3 X-RAY EXAM OF BREASTBONE $37.16
71250 3 CT THORAX W/O DYE $254.31
71260 3 CT THORAX W/DYE $343.49
71270 3 CT THORAX W/O & W/DYE $413.50
71275 3 CT ANGIOGRAPHY, CHEST $453.94
71550 3 MRI CHEST W/O DYE $426.20
71551 3 MRI CHEST W/DYE $519.96
71552 3 MRI CHEST W/O & W/DYE $660.83
71555 3 MRI ANGIO CHEST W OR W/O DYE $523.84
72010 3 X-RAY EXAM OF SPINE $68.28

72020 3 X-RAY EXAM OF SPINE $23.45
72040 3 X-RAY EXAM OF NECK SPINE $36.42
72069 3 X-RAY EXAM OF TRUNK SPINE $34.46
72070 3 X-RAY EXAM OF THORACIC SPINE $33.46
72100 3 X-RAY EXAM OF LOWER SPINE $38.27

72125 3 CT NECK SPINE W/O DYE $254.31
72126 3 CT NECK SPINE W/DYE $342.77
72127 3 CT NECK SPINE W/O & W/DYE $407.72
72128 3 CT CHEST SPINE W/O DYE $254.31
72129 3 CT CHEST SPINE W/DYE $343.15
72130 3 CT CHEST SPINE W/O & W/DYE $408.09
72131 3 CT LUMBAR SPINE W/O DYE $254.31
72132 3 CT LUMBAR SPINE W/DYE $342.77

72133 3 CT LUMBAR SPINE W/O & W/DYE $408.09
72141 3 MRI NECK SPINE W/O DYE $430.96
72142 3 MRI NECK SPINE W/DYE $527.60
72146 3 MRI CHEST SPINE W/O DYE $431.06
72147 3 MRI CHEST SPINE W/DYE $527.19
72148 3 MRI LUMBAR SPINE W/O DYE $424.93
72149 3 MRI LUMBAR SPINE W/DYE $520.88
72156 3 MRI NECK SPINE W/O & W/DYE $668.83
72157 3 MRI CHEST SPINE W/O & W/DYE $668.42
72158 3 MRI LUMBAR SPINE W/O & W/DYE $658.13
72159 3 MR ANGIO SPINE W/O&W/DYE $653.63
72170 3 X-RAY EXAM OF PELVIS $25.65
72190 3 X-RAY EXAM OF PELVIS $39.02

72191 3 CT ANGIOGRAPH PELV W/O&W/DYE $448.15
72192 3 CT PELVIS W/O DYE $250.94
72193 3 CT PELVIS W/DYE $325.97
72194 3 CT PELVIS W/O & W/DYE $405.71
72195 3 MRI PELVIS W/O DYE $425.81
72196 3 MRI PELVIS W/DYE $520.17
72197 3 MRI PELVIS W/O & W/DYE $657.47
72198 3 MR ANGIO PELVIS W/O & W/DYE $522.74
72200 3 X-RAY EXAM SACROILIAC JOINTS $28.61
72202 3 X-RAY EXAM SACROILIAC JOINTS $34.60
72220 3 X-RAY EXAM OF TAILBONE $29.09
72240 3 CONTRAST X-RAY OF NECK SPINE $157.41

72241 O MYELOGRAPHY, CERVICAL COMPLETE PROC $0.00
72255 3 CONTRAST X-RAY, THORAX SPINE $143.75
72256 O MYELOGRAPHY, THORACIC COMPLETE PROC $0.00
72265 3 CONTRAST X-RAY, LOWER SPINE $146.43
72266 O MYELOGRAPHY, LUMBOSACRAL COMPLETE P $0.00
72270 3 CONTRAST X-RAY, SPINE $228.42
72271 O MYELOGRAPHY, ENTIRE SPINAL CANAL CO $0.00
72275 3 EPIDUROGRAPHY $102.89
72285 3 X-RAY C/T SPINE DISK $175.44
72286 O DISKOGRAPHY, CERVICAL COMPLETE PROC $0.00

72291 3 PERQ VERTEBROPLASTY, FLUOR $0.00
72292 3 PERQ VERTEBROPLASTY, CT $0.00
72295 3 X-RAY OF LOWER SPINE DISK $156.40
72296 O DISKOGRAPHY, LUMBAR COMPLETE PROCED $0.00
73000 3 X-RAY EXAM OF COLLAR BONE $27.14
73010 3 X-RAY EXAM OF SHOULDER BLADE $27.87
73020 3 X-RAY EXAM OF SHOULDER $23.09
73030 3 X-RAY EXAM OF SHOULDER $29.44
73040 3 CONTRAST X-RAY OF SHOULDER $105.84
73041 O RADIOLOGIC EXAMINATION, SHOULDER, A $0.00
73050 3 X-RAY EXAM OF SHOULDERS $35.34
73060 3 X-RAY EXAM OF HUMERUS $28.71
73070 3 X-RAY EXAM OF ELBOW $26.41

73080 3 X-RAY EXAM OF ELBOW $33.89
73085 3 CONTRAST X-RAY OF ELBOW $95.48
73086 O RADIOLOGIC EXAMINATION, ELBOW, ARTH $0.00
73090 3 X-RAY EXAM OF FOREARM $26.77
73092 3 X-RAY EXAM OF ARM, INFANT $27.51
73100 3 X-RAY EXAM OF WRIST $27.88
73110 3 X-RAY EXAM OF WRIST $33.41
73115 3 CONTRAST X-RAY OF WRIST $101.29
73116 O RADIOLOGIC EXAMINATION, WRIST, ARTH $0.00
73120 3 X-RAY EXAM OF HAND $26.40
73130 3 X-RAY EXAM OF HAND $30.46
73140 3 X-RAY EXAM OF FINGER(S) $28.28

73200 3 CT UPPER EXTREMITY W/O DYE $251.22
73201 3 CT UPPER EXTREMITY W/DYE $325.88
73202 3 CT UPPR EXTREMITY W/O&W/DYE $406.24
73206 3 CT ANGIO UPR EXTRM W/O&W/DYE $448.63
73218 3 MRI UPPER EXTREMITY W/O DYE $420.68
73219 3 MRI UPPER EXTREMITY W/DYE $514.91
73220 3 MRI UPPR EXTREMITY W/O&W/DYE $652.85
73221 3 MRI JOINT UPR EXTREM W/O DYE $420.79
73222 3 MRI JOINT UPR EXTREM W/DYE $514.28
73223 3 MRI JOINT UPR EXTR W/O&W/DYE $652.08

73225 3 MR ANGIO UPR EXTR W/O&W/DYE $637.36
73500 3 X-RAY EXAM OF HIP $24.91
73520 3 X-RAY EXAM OF HIPS $38.96
73525 3 CONTRAST X-RAY OF HIP $95.35
73526 O RADIOLOGIC EXAMINATION, HIP, ARTHRO $0.00
73540 3 X-RAY EXAM OF PELVIS & HIPS $36.07
73542 3 X-RAY EXAM, SACROILIAC JOINT $77.92
73550 3 X-RAY EXAM OF THIGH $27.98
73560 3 X-RAY EXAM OF KNEE, 1 OR 2 $27.87
73562 3 X-RAY EXAM OF KNEE, 3 $33.51
73564 3 X-RAY EXAM, KNEE, 4 OR MORE $39.00

73565 3 X-RAY EXAM OF KNEES $29.71
73580 3 CONTRAST X-RAY OF KNEE JOINT $119.13
73581 O RADIOLOGIC EXAMINATION, KNEE, ARTHR $0.00
73590 3 X-RAY EXAM OF LOWER LEG $26.75
73592 3 X-RAY EXAM OF LEG, INFANT $27.51
73600 3 X-RAY EXAM OF ANKLE $26.40
73610 3 X-RAY EXAM OF ANKLE $30.46
73615 3 CONTRAST X-RAY OF ANKLE $97.94
73616 O RADIOLOGIC EXAMINATION, ANKLE, ARTH $0.00
73620 3 X-RAY EXAM OF FOOT $25.67
73630 3 X-RAY EXAM OF FOOT $30.09
73650 3 X-RAY EXAM OF HEEL $26.03

73660 3 X-RAY EXAM OF TOE(S) $26.80
73700 3 CT LOWER EXTREMITY W/O DYE $251.22
73701 3 CT LOWER EXTREMITY W/DYE $328.10
73702 3 CT LWR EXTREMITY W/O&W/DYE $406.60
73706 3 CT ANGIO LWR EXTR W/O&W/DYE $453.48
73718 3 MRI LOWER EXTREMITY W/O DYE $420.92
73719 3 MRI LOWER EXTREMITY W/DYE $514.55
73720 3 MRI LWR EXTREMITY W/O&W/DYE $652.85
73721 3 MRI JNT OF LWR EXTRE W/O DYE $420.79
73722 3 MRI JOINT OF LWR EXTR W/DYE $514.78

73723 3 MRI JOINT LWR EXTR W/O&W/DYE $652.08
73725 3 MR ANG LWR EXT W OR W/O DYE $524.06
74000 3 X-RAY EXAM OF ABDOMEN $25.26
74022 3 X-RAY EXAM SERIES, ABDOMEN $47.99
74150 3 CT ABDOMEN W/O DYE $255.75
74160 3 CT ABDOMEN W/DYE $365.64
74170 3 CT ABDOMEN W/O & W/DYE $415.38
74175 3 CT ANGIO ABDOM W/O & W/DYE $453.10
74181 3 MRI ABDOMEN W/O DYE $425.66
74182 3 MRI ABDOMEN W/DYE $520.57
74183 3 MRI ABDOMEN W/O & W/DYE $657.47

74185 3 MRI ANGIO, ABDOM W ORW/O DYE $522.61
74190 3 X-RAY EXAM OF PERITONEUM $0.00
74210 3 CONTRST X-RAY EXAM OF THROAT $76.16
74220 3 CONTRAST X-RAY, ESOPHAGUS $86.38
74230 3 CINE/VID X-RAY, THROAT/ESOPH $88.75
74235 3 REMOVE ESOPHAGUS OBSTRUCTION $0.00
74240 3 X-RAY EXAM, UPPER GI TRACT $106.78
74246 3 CONTRST X-RAY UPPR GI TRACT $122.42

74250 3 X-RAY EXAM OF SMALL BOWEL $100.66
74270 3 CONTRAST X-RAY EXAM OF COLON $124.03
74290 3 CONTRAST X-RAY, GALLBLADDER $64.26
74291 3 CONTRAST X-RAYS, GALLBLADDER $55.56
74300 O X-RAY BILE DUCTS/PANCREAS $0.00
74301 3 X-RAYS AT SURGERY ADD-ON $0.00

74305 3 X-RAY BILE DUCTS/PANCREAS $0.00
74320 3 CONTRAST X-RAY OF BILE DUCTS $114.06
74321 O CHOLANGIOGRAPHY, PERCUTANEOUS, TRAN $0.00
74327 3 X-RAY BILE STONE REMOVAL $129.67
74328 3 X-RAY BILE DUCT ENDOSCOPY $0.00
74329 3 X-RAY FOR PANCREAS ENDOSCOPY $0.00
74330 3 X-RAY BILE/PANC ENDOSCOPY $0.00
74340 3 X-RAY GUIDE FOR GI TUBE $0.00
74350 O X-RAY GUIDE, STOMACH TUBE $0.00
74351 O PERCUTANEOUS PLACEMENT OF GASTROSTO $0.00
74355 3 X-RAY GUIDE, INTESTINAL TUBE $0.00
74356 O PERCUTANEOUS PLACEMENT OF ENTEROCLY $0.00
74360 3 X-RAY GUIDE, GI DILATION $0.00

74361 O INTRALUMINAL DILATION OF STRICTURES $0.00
74363 3 X-RAY, BILE DUCT DILATION $0.00
74400 3 CONTRST X-RAY, URINARY TRACT $108.99
74405 O CONTRAST X-RAY URINARY TRACT $0.00
74426 O UROGRAPHY, ANTEGRADE, (PYELOSTOGRAM $0.00
74430 3 CONTRAST X-RAY, BLADDER $78.05
74431 O CYSTOGRAPHY, MINIMUM OF THREE VIEWS $0.00
74440 3 X-RAY, MALE GENITAL TRACT $83.89

74441 O VASOGRAPHY, VESICULOGRAPHY, OR EPID $0.00
74445 3 X-RAY EXAM OF PENIS $0.00
74446 O CORPORA CAVERNOSOGRAPHY COMPLETE PR $0.00
74450 3 X-RAY, URETHRA/BLADDER $0.00
74451 O URETHROCYSTOGRAPHY, RETROGRADE COMP $0.00
74455 3 X-RAY, URETHRA/BLADDER $90.45
74456 O URETHROCYSTOGRAPHY, VOIDING COMPLET $0.00
74470 3 X-RAY EXAM OF KIDNEY LESION $0.00
74471 O RADIOLOGIC EXAMINATION, RENAL CYST $0.00
74475 3 X-RAY CONTROL, CATH INSERT $123.39

74476 O INTRODUCTION OF INTRACATHETER OR CA $0.00
74480 3 X-RAY CONTROL, CATH INSERT $123.76
74481 O INTRODUCTION OF URETERAL CATHETER O $0.00
74485 3 X-RAY GUIDE, GU DILATION $117.99
74486 O DILATION OF NEPHROSTOMY OR URETERS $0.00
74710 3 X-RAY MEASUREMENT OF PELVIS $43.28
74740 3 X-RAY, FEMALE GENITAL TRACT $77.48
74741 O HYSTEROSALPINGOGRAPHY COMPLETE PROC $0.00
74742 9 X-RAY, FALLOPIAN TUBE $0.00
74775 3 X-RAY EXAM OF PERINEUM $0.00
75120 O RADIOLOGIC EXAMINATION, HAND; TWO V $0.00
75500 O ANGIOCARDIOGRAPHY BY CINERADIOGRAPH $0.00
75501 O ANGIOCARDIOGRAPHY BY CINERADIOGRAPH $0.00

75505 O ANGIOCARDIOGRAPHY BY SERIALOGRAPHY, $0.00
75519 O CARDIAC RADIOGRAPHY, SELECTIVE CARD $0.00
75552 O HEART MRI FOR MORPH W/O DYE $0.00
75553 O HEART MRI FOR MORPH W/DYE $0.00

75554 O CARDIAC MRI/FUNCTION $0.00
75555 O CARDIAC MRI/LIMITED STUDY $0.00
75556 O CARDIAC MRI/FLOW MAPPING $0.00
75557 3 CARDIAC MRI FOR MORPH $470.10
75558 3 CARDIAC MRI FLOW/VELOCITY $628.75
75559 3 CARDIAC MRI W/STRESS IMG $507.87
75560 3 CARDIAC MRI FLOW/VEL/STRESS $822.90
75561 3 CARDIAC MRI FOR MORPH W/DYE $676.46
75562 3 CARD MRI FLOW/VEL W/DYE $815.28
75563 3 CARD MRI W/STRESS IMG & DYE $705.54

75564 3 HT MRI W/FLO/VEL/STRS & DYE $958.74
75600 3 CONTRAST X-RAY EXAM OF AORTA $321.57
75601 O AORTOGRAPHY, THORACIC, WITHOUT SERI $0.00
75606 O AORTOGRAPHY, THORACIC, BY SERIALOGR $0.00
75626 O AORTOGRAPHY, ABDOMINAL, TRANSLUMBAR $0.00
75627 O AORTOGRAPHY, ABDOMINAL, CATHETER, B $0.00
75628 O AORTOGRAPHY, ABDOMINAL, CATHETER, B $0.00
75630 3 X-RAY AORTA, LEG ARTERIES $312.36
75631 O AORTOGRAPHY, ABDOMINAL PLUS BILATER $0.00
75635 3 CT ANGIO ABDOMINAL ARTERIES $480.58
75650 3 ARTERY X-RAYS, HEAD & NECK $289.00

75651 O ANGIOGRAPHY, CERVICOCEREBRAL, CATHE $0.00
75652 O ANGIOGRAPHY, CERVICOCEREBRAL, SELEC $0.00
75658 3 ARTERY X-RAYS, ARM $285.90
75659 O ANGIOGRAPHY, BRACHIAL, RETROGRADE C $0.00
75661 O ANGIOGRAPHY, EXTERNAL CAROTID, CERE $0.00

75663 O ANGIOGRAPHY, EXTERNAL CAROTID, CERE $0.00
75667 O ANGIOGRAPHY, CAROTID, CEREBRAL, UNI $0.00
75669 O ANGIOGRAPHY, CAROTID, CEREBRAL, UNI $0.00
75672 O ANGIOGRAPHY, CAROTID, CEREBRAL, BIL $0.00
75673 O ANGIOGRAPHY, CAROTID, CEREBRAL, BIL $0.00
75676 3 ARTERY X-RAYS, NECK $291.44
75677 O ANGIOGRAPHY, CAROTID, CERVICAL, UNI $0.00
75678 O ANGIOGRAPHY, CAROTID, CERVICAL, UNI $0.00

75680 3 ARTERY X-RAYS, NECK $325.02
75681 O ANGIOGRAPHY, CAROTID, CERVICAL, BIL $0.00
75682 O ANGIOGRAPHY, CAROTID, CERVICAL, BIL $0.00
75685 3 ARTERY X-RAYS, SPINE $291.94
75686 O ANGIOGRAPHY, VERTEBRAL DIRECT PUNCT $0.00
75687 O ANGIOGRAPHY, VERTEBRAL CATHETER, CO $0.00
75690 O ANGIOGRAPHY, VERTEBRAL, CERVICAL, U $0.00
75692 O ANGIOGRAPHY, VERTEBRAL, CERVICAL, U $0.00
75695 O ANGIOGRAPHY, VERTEBRAL, CERVICAL, B $0.00
75697 O ANGIOGRAPHY, VERTEBRAL, CERVICAL, B $0.00
75705 3 ARTERY X-RAYS, SPINE $335.42
75706 O ANGIOGRAPHY, SPINAL, SELECTIVE COMP $0.00
75710 3 ARTERY X-RAYS, ARM/LEG $285.37

75711 O ANGIOGRAPHY, EXTREMITY, UNILATERAL $0.00
75712 O ANGIOGRAPHY, EXTREMITY, UNILATERAL $0.00
75716 3 ARTERY X-RAYS, ARMS/LEGS $318.43
75717 O ANGIOGRAPHY, EXTREMITY, BILATERAL W $0.00
75718 O ANGIOGRAPHY, EXTREMITY, BILATERAL B $0.00
75722 3 ARTERY X-RAYS, KIDNEY $281.93
75723 O ANGIOGRAPHY, RENAL, UNILATERAL, SEL $0.00
75724 3 ARTERY X-RAYS, KIDNEYS $328.45
75725 O ANGIOGRAPHY, RENAL, BILATERAL, SELE $0.00
75726 3 ARTERY X-RAYS, ABDOMEN $282.30
75727 O ANGIOGRAPHY, VISCERAL SELECTIVE (WI $0.00
75728 O ANGIOGRAPHY, VISCERAL SUPRASELECTIV $0.00

75731 3 ARTERY X-RAYS, ADRENAL GLAND $292.15
75732 O ANGIOGRAPHY, ADRENAL, UNILATERAL, S $0.00
75733 3 ARTERY X-RAYS, ADRENALS $331.13
75734 O ANGIOGRAPHY, ADRENAL, BILATERAL, SE $0.00
75736 3 ARTERY X-RAYS, PELVIS $284.76
75737 O ANGIOGRAPHY, PELVIC SELECTIVE, COMP $0.00
75738 O ANGIOGRAPHY, PELVIC SUPRASELECTIVE, $0.00
75741 3 ARTERY X-RAYS, LUNG $273.09
75742 O ANGIOGRAPHY, PULMONARY, UNILATERAL, $0.00
75743 3 ARTERY X-RAYS, LUNGS $298.77

75744 O ANGIOGRAPHY, PULMONARY, BILATERAL, $0.00
75746 3 ARTERY X-RAYS, LUNG $276.01
75747 O ANGIOGRAPHY, PULMONARY CATHETER, NO $0.00
75748 O ANGIOGRAPHY, PULMONARY VENOUS INJEC $0.00
75750 O ANGIOGRAPHY, CORONARY, ROOT INJECTI $0.00
75751 O ANGIOGRAPHY, CORONARY, ROOT INJECTI $0.00
75752 O ANGIOGRAPHY, CORONARY, UNILATERAL S $0.00
75753 O ANGIOGRAPHY, CORONARY, UNILATERAL S $0.00
75754 O ANGIOGRAPHY, CORONARY, BILATERAL SE $0.00
75755 O ANGIOGRAPHY, CORONARY, BILATERAL SE $0.00
75756 3 ARTERY X-RAYS, CHEST $293.15
75757 O ANGIOGRAPHY, INTERNAL MAMMARY COMPL $0.00
75762 O ANGIOGRAPHY, CORONARY BYPASS, UNILA $0.00

75764 O ANGIOGRAPHY, CORONARY BYPASS, UNILA $0.00
75766 O ANGIOGRAPHY, CORONARY BYPASS, MULTI $0.00
75767 O ANGIOGRAPHY, CORONARY BYPASS, MULTI $0.00
75774 3 ARTERY X-RAY, EACH VESSEL $214.88
75775 O ANGIOGRAPHY, SELECTIVE, EACH ADDITI $0.00
75790 3 VISUALIZE A-V SHUNT $174.45
75801 3 LYMPH VESSEL X-RAY, ARM/LEG $0.00
75802 O LYMPHANGIOGRAPHY, EXTREMITY ONLY, U $0.00
75803 3 LYMPH VESSEL X-RAY,ARMS/LEGS $0.00
75804 O LYMPHANGIOGRAPHY, EXTREMITY ONLY, B $0.00
75805 3 LYMPH VESSEL X-RAY, TRUNK $0.00
75806 O LYMPHANGIOGRAPHY, PELVIC/ABDOMINAL, $0.00

75807 3 LYMPH VESSEL X-RAY, TRUNK $0.00
75808 O LYMPHANGIOGRAPHY, PELVIC/ABDOMINAL, $0.00
75809 3 NONVASCULAR SHUNT, X-RAY $86.87
75810 3 VEIN X-RAY, SPLEEN/LIVER $0.00
75811 O SPLENOPORTOGRAPHY COMPLETE PROCEDUR $0.00
75820 3 VEIN X-RAY, ARM/LEG $119.23
75821 O VENOGRAPHY, EXTREMITY, UNILATERAL C $0.00
75822 3 VEIN X-RAY, ARMS/LEGS $145.62
75823 O VENOGRAPHY, EXTREMITY, BILATERAL CO $0.00
75825 3 VEIN X-RAY, TRUNK $259.86

75826 O VENOGRAPHY, CAVAL, INFERIOR, WITH S $0.00
75827 3 VEIN X-RAY, CHEST $259.38
75828 O VENOGRAPHY, CAVAL, SUPERIOR, WITH S $0.00
75831 3 VEIN X-RAY, KIDNEY $262.94
75832 O VENOGRAPHY, RENAL, UNILATERAL, SELE $0.00
75833 3 VEIN X-RAY, KIDNEYS $293.18
75834 O VENOGRAPHY, RENAL, BILATERAL, SELEC $0.00
75840 3 VEIN X-RAY, ADRENAL GLAND $260.59
75841 O VENOGRAPHY, ADRENAL, UNILATERAL, SE $0.00
75842 3 VEIN X-RAY, ADRENAL GLANDS $294.91
75843 O VENOGRAPHY, ADRENAL, BILATERAL, SEL $0.00
75860 3 VEIN X-RAY, NECK $268.37
75861 O VENOGRAPHY, SINUS OR JUGULAR, CATHE $0.00

75870 3 VEIN X-RAY, SKULL $266.03
75871 O VENOGRAPHY, SUPERIOR SAGITTAL SINUS $0.00
75872 3 VEIN X-RAY, SKULL $290.36
75873 O VENOGRAPHY, EPIDURAL COMPLETE PROCE $0.00
75880 3 VEIN X-RAY, EYE SOCKET $120.33
75881 O VENOGRAPHY, ORBITAL COMPLETE PROCED $0.00
75885 3 VEIN X-RAY, LIVER $279.57
75886 O PERCUTANEOUS TRANSHEPATIC PORTOGRAP $0.00
75887 3 VEIN X-RAY, LIVER $281.80
75888 O PERCUTANEOUS TRANSHEPATIC PORTOGRAP $0.00
75889 3 VEIN X-RAY, LIVER $263.81
75890 O HEPATIC VENOGRAPHY WEDGED OR FREE, $0.00

75891 3 VEIN X-RAY, LIVER $263.81
75892 O HEPATIC VENOGRAPHY, WEDGED OR FREE, $0.00
75893 3 VENOUS SAMPLING BY CATHETER $232.41
75894 3 X-RAYS, TRANSCATH THERAPY $0.00
75895 O TRANSCATHETER THERAPY, EMBOLIZATION $0.00
75896 3 X-RAYS, TRANSCATH THERAPY $0.00
75897 O TRANSCATHETER THERAPY, INFUSION (EG $0.00
75898 3 FOLLOW-UP ANGIOGRAPHY $0.00
75900 3 INTRAVASCULAR CATH EXCHANGE $0.00
75901 3 REMOVE CVA DEVICE OBSTRUCT $166.54

75902 3 REMOVE CVA LUMEN OBSTRUCT $92.72
75940 3 X-RAY PLACEMENT, VEIN FILTER $0.00
75941 O PERCUTANEOUS PLACEMENT OF IVC FILTE $0.00
75945 3 INTRAVASCULAR US $0.00
75946 3 INTRAVASCULAR US ADD-ON $0.00
75950 O TRANSCATHETER INTRAVASCULAR OCCLUSI $0.00
75952 3 ENDOVASC REPAIR ABDOM AORTA $0.00
75953 3 ABDOM ANEURYSM ENDOVAS RPR $0.00
75954 3 ILIAC ANEURYSM ENDOVAS RPR $0.00
75956 3 ENDOVASCULAR REPAIR OF DESCENDING $0.00
75957 3 XRAY, ENDOVASC THOR AO REPR $0.00

75958 3 XRAY, PLACE PROX EXT THOR AO $0.00
75959 3 XRAY, PLACE DIST EXT THOR AO $0.00
75960 3 TRANSCATH IV STENT RS&I $263.01
75961 3 RETRIEVAL, BROKEN CATHETER $411.90
75963 O PERCUTANEOUS TRANSLUMINAL ANGIOPLAS $0.00
75964 3 REPAIR ARTERY BLOCKAGE, EACH $166.23
75968 3 REPAIR ARTERY BLOCKAGE, EACH $166.73

75970 3 VASCULAR BIOPSY $0.00
75971 O TRANSCATHETER BIOPSY COMPLETE PROCE $0.00
75980 3 CONTRAST XRAY EXAM BILE DUCT $0.00
75981 O PERCUTANEOUS TRANSHEPATIC BILIARY D $0.00
75982 9 CONTRAST XRAY EXAM BILE DUCT $0.00
75983 O PERCUTANEOUS PLACEMENT OF DRAINAGE $0.00
75984 3 XRAY CONTROL CATHETER CHANGE $114.12
75985 O CHANGE OF PERCUTANEOUS DRAINAGE CAT $0.00

75989 3 ABSCESS DRAINAGE UNDER X-RAY $143.55
75990 O RADIOLOGICAL GUIDANCE FOR PERCUTANE $0.00
75992 3 ATHERECTOMY, X-RAY EXAM $0.00
75998 O FLUOROGUIDE FOR VEIN DEVICE $0.00
76000 3 FLUOROSCOPE EXAMINATION $93.02
76001 3 FLUOROSCOPE EXAM, EXTENSIVE $0.00
76003 O NEEDLE LOCALIZATION BY X-RAY $0.00
76005 O FLUOROGUIDE FOR SPINE INJECT $0.00
76006 O X-RAY STRESS VIEW $0.00

76010 3 X-RAY, NOSE TO RECTUM $27.85
76012 O PERCUT VERTEBROPLASTY FLUOR $0.00
76013 O PERCUT VERTEBROPLASTY, CT $0.00
76020 O X-RAYS FOR BONE AGE $0.00
76040 O X-RAYS, BONE EVALUATION $0.00
76061 O X-RAYS, BONE SURVEY $0.00
76062 O X-RAYS, BONE SURVEY $0.00
76065 O X-RAYS, BONE EVALUATION $0.00
76066 O JOINT SURVEY, SINGLE VIEW $0.00
76070 O CT BONE DENSITY, AXIAL $0.00
76071 O CT BONE DENSITY, PERIPHERAL $0.00
76075 O DXA BONE DENSITY, AXIAL $0.00

76076 O DXA BONE DENSITY/PERIPHERAL $0.00
76077 O DXA BONE DENSITY/V-FRACTURE $0.00
76078 O RADIOGRAPHIC ABSORPTIOMETRY $0.00
76080 3 X-RAY EXAM OF FISTULA $63.36
76081 O RADIOLOGIC EXAMINATION, FISTULA OR $0.00
76082 O COMPUTER MAMMOGRAM ADD-ON $0.00
76086 O X-RAY OF MAMMARY DUCT $0.00
76087 O MAMMARY DUCTOGRAM OR GALACTOGRAM, S $0.00

76088 O X-RAY OF MAMMARY DUCTS $0.00
76089 O MAMMARY DUCTOGRAM OR GALACTOGRAM, M $0.00
76090 O MAMMOGRAM, ONE BREAST $0.00
76091 O MAMMOGRAM, BOTH BREASTS $0.00
76092 O MAMM0GRAM, SCREENING $0.00
76093 O MAGNETIC IMAGE, BREAST $0.00
76094 O MAGNETIC IMAGE, BOTH BREASTS $0.00
76095 O STEREOTACTIC BREAST BIOPSY $0.00
76096 O X-RAY OF NEEDLE WIRE, BREAST $0.00
76097 O LOCALIZATION OF BREAST NODULE OR CA $0.00
76098 3 X-RAY EXAM, BREAST SPECIMEN $19.75
76100 3 X-RAY EXAM OF BODY SECTION $104.72
76101 3 COMPLEX BODY SECTION X-RAY $186.41

76102 3 COMPLEX BODY SECTION X-RAYS $231.62
76120 3 CINE/VIDEO X-RAYS $75.39
76125 3 CINE/VIDEO X-RAYS ADD-ON $0.00
76140 3 X-RAY CONSULTATION $38.59
76150 3 X-RAY EXAM, DRY PROCESS $18.59
76350 5 SPECIAL X-RAY CONTRAST STUDY $0.00
76355 O CT SCAN FOR LOCALIZATION $0.00
76360 O CT SCAN FOR NEEDLE BIOPSY $0.00
76361 O COMPUTERIZED TOMOGRAPHY GUIDANCE FO $0.00
76362 O CT GUIDE FOR TISSUE ABLATION $0.00
76365 O CAT SCAN FOR CYST ASPIRATION $0.00
76366 O COMPUTERIZED TOMOGRAPHY GUIDANCE FO $0.00

76370 O CT SCAN FOR THERAPY GUIDE $0.00
76375 O 3D/HOLOGRAPH RECONSTR ADD-ON $0.00
76376 3 3D RENDER W/O POSTPROCESS $80.53
76377 3 3D RENDERING W/POSTPROCESS $110.78
76380 3 CAT SCAN FOLLOW-UP STUDY $155.31
76390 3 MR SPECTROSCOPY $462.91
76393 O MR GUIDANCE FOR NEEDLE PLACE $0.00
76394 O MRI FOR TISSUE ABLATION $0.00
76400 O MAGNETIC IMAGE, BONE MARROW $0.00
76490 O US FOR TISSUE ABLATION $0.00

76496 5 FLUOROSCOPIC PROCEDURE $0.00
76497 5 CT PROCEDURE $0.00
76498 5 MRI PROCEDURE $0.00
76499 5 RADIOGRAPHIC PROCEDURE $0.00
76506 3 ECHO EXAM OF HEAD $95.64
76510 3 OPHTH US, B & QUANT A $147.63
76511 3 OPHTH US, QUANT A ONLY $96.25
76512 3 OPHTH US, B W/NON-QUANT A $90.07
76513 3 ECHO EXAM OF EYE, WATER BATH $83.40
76514 3 ECHO EXAM OF EYE, THICKNESS $12.47
76516 3 ECHO EXAM OF EYE $66.69

76536 3 US EXAM OF HEAD AND NECK $110.40
76604 3 US EXAM, CHEST $86.14
76645 3 US EXAM, BREAST(S) $90.35
76700 3 US EXAM, ABDOM, COMPLETE $136.43
76705 3 ECHO EXAM OF ABDOMEN $103.58
76770 3 US EXAM ABDO BACK WALL, COMP $130.73
76775 3 US EXAM ABDO BACK WALL, LIM $111.72
76776 3 US EXAM K TRANSPL W/DOPPLER $145.49
76778 O US EXAM KIDNEY TRANSPLANT $0.00
76800 3 US EXAM, SPINAL CANAL $122.25
76801 3 OB US < 14 WKS, SINGLE FETUS $130.53
76802 3 OB US < 14 WKS, ADDÏL FETUS $73.05

76805 3 OB US >/= 14 WKS, SNGL FETUS $145.69
76810 3 OB US >/= 14 WKS, ADDL FETUS $99.67
76811 3 OB US, DETAILED, SNGL FETUS $203.47
76812 3 OB US, DETAILED, ADDL FETUS $147.70
76813 3 OB US NUCHAL MEAS, 1 GEST $126.95
76814 3 OB US NUCHAL MEAS, ADD-ON $82.08
76815 3 OB US, LIMITED, FETUS(S) $90.56
76816 3 OB US, FOLLOW-UP, PER FETUS $105.00
76817 3 TRANSVAGINAL US, OBSTETRIC $99.94
76818 3 FETAL BIOPHYS PROFILE W/NST $120.24

76819 3 FETAL BIOPHYS PROFIL W/O NST $93.11
76820 3 UMBILICAL ARTERY ECHO $53.63
76821 3 MIDDLE CEREBRAL ARTERY ECHO $97.00
76825 3 ECHO EXAM OF FETAL HEART $207.81
76830 3 TRANSVAGINAL US, NON-OB $119.83
76831 3 ECHO EXAM, UTERUS $119.80
76855 O ECHOGRAPHY, PELVIC AREA (DOPPLER) $0.00
76856 3 US EXAM, PELVIC, COMPLETE $120.57
76857 3 US EXAM, PELVIC, LIMITED $83.28
76870 3 US EXAM, SCROTUM $119.52

76872 3 US, TRANSRECTAL $134.99
76873 3 ECHOGRAP TRANS R, PROS STUDY $176.36
76880 3 US EXAM, EXTREMITY $125.39
76885 3 US EXAM INFANT HIPS, DYNAMIC $100.32
76886 3 US EXAM INFANT HIPS, STATIC $93.69
76925 O ECHOGRAPHY, PERIPHERAL VASCULAR SYS $0.00
76926 O ECHOGRAPHY, HEAD AND TRUNK, VASCULA $0.00
76930 3 ECHO GUIDE, CARDIOCENTESIS $98.18
76931 O ULTRASONIC GUIDANCE FOR PERICARDIOC $0.00
76932 3 ECHO GUIDE FOR HEART BIOPSY $0.00
76933 O ULTRASONIC GUIDANCE FOR ENDOMYOCARD $0.00
76934 O ECHO GUIDE FOR CHEST TAP $0.00

76935 O ULTRASONIC GUIDANCE FOR THORACENTES $0.00
76936 3 ECHO GUIDE FOR ARTERY REPAIR $196.13
76937 3 US GUIDE, VASCULAR ACCESS $35.65
76938 O ECHO EXAM FOR DRAINAGE $0.00
76939 O ULTRASONIC GUIDANCE FOR CYST (ANY L $0.00
76940 3 US GUIDE, TISSUE ABLATION $0.00
76941 3 ECHO GUIDE FOR TRANSFUSION $0.00
76942 3 ECHO GUIDE FOR BIOPSY $186.03
76943 O ULTRASONIC GUIDANCE FOR NEEDLE BIOP $0.00
76945 3 ECHO GUIDE, VILLUS SAMPLING $0.00

76946 3 ECHO GUIDE FOR AMNIOCENTESIS $44.18
76947 O ULTRASONIC GUIDANCE FOR AMNIOCENTES $0.00
76948 9 ECHO GUIDE, OVA ASPIRATION $0.00
76949 O ULTRASONIC GUIDANCE FOR ASPIRATION $0.00
76950 3 ECHO GUIDANCE RADIOTHERAPY $70.44
76960 O ECHO GUIDANCE RADIOTHERAPY $0.00
76965 3 ECHO GUIDANCE RADIOTHERAPY $146.22
76970 3 ULTRASOUND EXAM FOLLOW-UP $82.39
76975 3 GI ENDOSCOPIC ULTRASOUND $0.00
76977 3 US BONE DENSITY MEASURE $13.95
76986 O ULTRASOUND GUIDE INTRAOPER $0.00
76998 3 US GUIDE, INTRAOP $0.00
76999 5 ECHO EXAMINATION PROCEDURE $0.00

77001 3 FLUOROGUIDE FOR VEIN DEVICE $104.58
77002 3 NEEDLE LOCALIZATION BY XRAY $70.63
77003 3 FLUOROGUIDE FOR SPINE INJECT $58.59
77011 3 CT SCAN FOR LOCALIZATION $684.12
77012 3 CT SCAN FOR NEEDLE BIOPSY $198.01
77013 3 CT GUIDE FOR TISSUE ABLATION $0.00
77014 3 CT SCAN FOR THERAPY GUIDE $186.01
77021 3 MR GUIDANCE FOR NEEDLE PLACE $449.00
77022 3 MRI FOR TISSUE ABLATION $0.00
77031 3 STEREOTACT GUIDE FOR BRST BX $191.70
77032 3 GUIDANCE FOR NEEDLE, BREAST $59.51
77051 3 COMPUTER DX MAMMOGRAM ADD-ON $12.24

77052 3 COMP SCREEN MAMMOGRAM ADD-ON $12.24
77053 3 X-RAY OF MAMMARY DUCT $76.22
77054 3 X-RAY OF MAMMARY DUCTS $102.82
77055 3 MAMMOGRAM, ONE BREAST $84.85
77056 3 MAMMOGRAM, BOTH BREASTS $107.66
77057 3 MAMMOGRAM, SCREENING $81.39
77058 3 MRI, ONE BREAST $846.16
77059 3 MRI, BOTH BREASTS $908.55
77071 3 X-RAY STRESS VIEW $39.01
77072 3 X-RAYS FOR BONE AGE $23.40

77073 3 X-RAYS, BONE LENGTH STUDIES $37.34
77074 3 X-RAYS, BONE SURVEY, LIMITED $68.65
77075 3 X-RAYS, BONE SURVEY COMPLETE $99.71
77076 3 X-RAYS, BONE SURVEY, INFANT $92.74
77077 3 JOINT SURVEY, SINGLE VIEW $42.20
77078 3 CT BONE DENSITY, AXIAL $85.16
77079 3 CT BONE DENSITY, PERIPHERAL $57.73
77080 3 DXA BONE DENSITY, AXIAL $70.98
77081 3 DXA BONE DENSITY/PERIPHERAL $30.01
77082 3 DXA BONE DENSITY, VERT FX $28.96
77083 3 RADIOGRAPHIC ABSORPTIOMETRY $26.33
77084 3 MAGNETIC IMAGE, BONE MARROW $432.47
77261 3 RADIATION THERAPY PLANNING $70.21

77280 3 SET RADIATION THERAPY FIELD $185.19
77300 3 RADIATION THERAPY DOSE PLAN $71.14
77301 3 RADIOTHERAPY DOSE PLAN, IMRT $2,176.54
77305 3 TELETX ISODOSE PLAN SIMPLE $72.97
77310 3 TELETX ISODOSE PLAN INTERMED $101.36
77315 3 TELETX ISODOSE PLAN COMPLEX $147.90

77321 3 SPECIAL TELETX PORT PLAN $121.88
77326 3 BRACHYTX ISODOSE CALC SIMP $142.91
77327 3 BRACHYTX ISODOSE CALC INTERM $203.55
77328 3 BRACHYTX ISODOSE PLAN COMPL $278.52
77331 3 SPECIAL RADIATION DOSIMETRY $62.10
77332 3 RADIATION TREATMENT AID(S) $77.89
77336 3 RADIATION PHYSICS CONSULT $62.25
77370 3 RADIATION PHYSICS CONSULT $118.55

77371 3 SRS, MULTISOURCE $1,188.49
77372 3 SRS, LINEAR BASED $827.57
77373 3 SBRT DELIVERY $1,532.98
77380 O PROTON BEAM DELIVERY $0.00
77381 O PROTON BEAM TREATMENT $0.00
77399 5 EXTERNAL RADIATION DOSIMETRY $0.00
77400 O DAILY MEGAVOLTAGE TREATMENT MANAGEM $0.00
77401 3 RADIATION TREATMENT DELIVERY $31.84

77415 O THERAPEUTIC RADIOLOGY TREATMENT POR $0.00
77417 3 RADIOLOGY PORT FILM(S) $16.12
77418 3 RADIATION TX DELIVERY, IMRT $528.10

77419 O WEEKLY RADIATION THERAPY $0.00
77421 3 STEREOSCOPIC X-RAY GUIDANCE $114.04
77422 3 NEUTRON BEAM TX, SIMPLE $196.84
77423 3 NEUTRON BEAM TX, COMPLEX $226.05
77427 3 RADIATION TX MANAGEMENT, X5 $186.20
77431 3 RADIATION THERAPY MANAGEMENT $95.31
77432 3 STEREOTACTIC RADIATION TRMT $395.62

77435 3 SBRT MANAGEMENT $656.58
77465 O DAILY KILOVOLTAGE TREATMENT MANAGEM $0.00
77470 3 SPECIAL RADIATION TREATMENT $254.51
77499 5 RADIATION THERAPY MANAGEMENT $0.00
77520 5 PROTON TRMT, SIMPLE W/O COMP $0.00
77522 5 PROTON TRMT, SIMPLE W/COMP $0.00
77523 5 PROTON TRMT, INTERMEDIATE $0.00
77525 5 PROTON TREATMENT, COMPLEX $0.00
77600 9 HYPERTHERMIA TREATMENT $0.00

77750 3 INFUSE RADIOACTIVE MATERIALS $337.26
77761 3 APPLY INTRCAV RADIAT SIMPLE $351.09
77762 3 APPLY INTRCAV RADIAT INTERM $478.01
77763 3 APPLY INTRCAV RADIAT COMPL $675.84
77776 3 APPLY INTERSTIT RADIAT SIMPL $411.61
77777 3 APPLY INTERSTIT RADIAT INTER $571.38
77778 3 APPLY INTERSTIT RADIAT COMPL $817.02
77781 O REMOTE AFTERLOADING HIGH INTENSITY $0.00
77785 3 HDR BRACHYTX, 1 CHANNEL $186.42

77786 3 HDR BRACHYTX, 2-12 CHANNEL $561.94
77787 3 HDR BRACHYTX OVER 12 CHAN $834.94
77789 3 APPLY SURFACE RADIATION $104.40
77790 3 RADIATION HANDLING $87.26
77799 5 RADIUM/RADIOISOTOPE THERAPY $0.00
78000 3 THYROID, SINGLE UPTAKE $69.10
78001 3 THYROID, MULTIPLE UPTAKES $87.74
78003 3 THYROID SUPPRESS/STIMUL $76.32
78006 3 THYROID IMAGING WITH UPTAKE $216.32
78007 3 THYROID IMAGE, MULT UPTAKES $131.51

78010 3 THYROID IMAGING $150.52
78011 3 THYROID IMAGING WITH FLOW $161.03
78015 3 THYROID MET IMAGING $203.26
78016 3 THYROID MET IMAGING/STUDIES $309.03
78017 O THYROID MET IMAGING, MULT $0.00
78018 3 THYROID MET IMAGING, BODY $311.48
78020 3 THYROID MET UPTAKE $90.35
78070 3 PARATHYROID NUCLEAR IMAGING $171.91
78075 3 ADRENAL NUCLEAR IMAGING $405.67
78099 5 ENDOCRINE NUCLEAR PROCEDURE $0.00
78102 3 BONE MARROW IMAGING, LTD $159.80
78103 3 BONE MARROW IMAGING, MULT $214.60
78104 3 BONE MARROW IMAGING, BODY $246.05

78110 3 PLASMA VOLUME, SINGLE $76.49
78111 3 PLASMA VOLUME, MULTIPLE $97.60
78120 3 RED CELL MASS, SINGLE $86.89
78121 3 RED CELL MASS, MULTIPLE $105.24
78122 9 BLOOD VOLUME $0.00
78130 3 RED CELL SURVIVAL STUDY $152.31
78135 3 RED CELL SURVIVAL KINETICS $318.70
78140 3 RED CELL SEQUESTRATION $147.33
78160 O PLASMA IRON TURNOVER $0.00
78162 O RADIOIRON ABSORPTION EXAM $0.00
78170 O RED CELL IRON UTILIZATION $0.00
78172 O TOTAL BODY IRON ESTIMATION $0.00

78185 3 SPLEEN IMAGING $185.74
78186 O SPLEEN IMAGING ONLY WITH VASCULAR F $0.00
78190 3 KINETICS, STUDY OF PLATELET SURVIV $221.42
78191 3 PLATELET SURVIVAL $197.75
78192 O WHITE BLOOD CELL LOCALIZATION LIMIT $0.00
78193 O WHITE BLOOD CELL LOCALIZATION WHOLE $0.00
78195 3 LYMPH SYSTEM IMAGING $327.24
78199 5 BLOOD/LYMPH NUCLEAR EXAM $0.00
78201 3 LIVER IMAGING $171.26
78202 3 LIVER IMAGING WITH FLOW $197.68

78205 3 LIVER IMAGING (3D) $236.12
78206 3 LIVER IMAGE (3D) WITH FLOW $329.23
78215 3 LIVER AND SPLEEN IMAGING $182.91
78216 3 LIVER & SPLEEN IMAGE/FLOW $137.93
78220 3 LIVER FUNCTION STUDY $143.81
78223 3 HEPATOBILIARY IMAGING $306.16
78225 O LIVER-LUNG IMAGING (EG, SUBPHRENIC $0.00
78230 3 SALIVARY GLAND IMAGING $155.73
78231 3 SERIAL SALIVARY IMAGING $132.56
78232 3 SALIVARY GLAND FUNCTION EXAM $135.09
78258 3 ESOPHAGEAL MOTILITY STUDY $216.85
78261 3 GASTRIC MUCOSA IMAGING $239.53
78262 3 GASTROESOPHAGEAL REFLUX EXAM $236.22

78264 3 GASTRIC EMPTYING STUDY $271.96
78267 5 BREATH TST ATTAIN/ANAL C-14 $0.00
78268 5 BREATH TEST ANALYSIS, C-14 $0.00
78270 3 VIT B-12 ABSORPTION EXAM $78.92
78271 3 VIT B-12 ABSRP EXAM, INT FAC $79.65
78272 3 VIT B-12 ABSORP, COMBINED $90.28
78276 O GASTROINTESTINAL ASPIRATE BLOOD LOS $0.00
78278 3 ACUTE GI BLOOD LOSS IMAGING $296.34
78280 O GASTROINTESTINAL BLOOD LOSS STUDY ( $0.00
78282 3 GI PROTEIN LOSS EXAM $0.00
78290 3 MECKELÏS DIVERT EXAM $281.87
78291 3 LEVEEN/SHUNT PATENCY EXAM $238.47

78299 5 GI NUCLEAR PROCEDURE $0.00
78300 3 BONE IMAGING, LIMITED AREA $167.46
78305 3 BONE IMAGING, MULTIPLE AREAS $222.62
78306 3 BONE IMAGING, WHOLE BODY $246.59
78310 O BONE IMAGING VASCULAR FLOW ONLY $0.00
78315 3 BONE IMAGING, 3 PHASE $300.61
78320 3 BONE IMAGING (3D) $252.59
78350 3 BONE MINERAL, SINGLE PHOTON $33.33
78351 3 BONE MINERAL, DUAL PHOTON $15.02
78380 O JOINT IMAGING LIMITED AREA $0.00

78381 O JOINT IMAGING MULTIPLE AREAS $0.00
78399 5 MUSCULOSKELETAL NUCLEAR EXAM $0.00
78414 3 NON-IMAGING HEART FUNCTION $0.00
78415 O CARDIAC BLOOD POOL IMAGING, FUNCTIO $0.00
78425 O CARDIAC REGURGITANT INDEX $0.00
78428 3 CARDIAC SHUNT IMAGING $194.38
78435 O CARDIAC FLOW IMAGING (IE, ANGIOCARD $0.00
78445 3 VASCULAR FLOW IMAGING $163.34
78455 O VENOUS THROMBOSIS STUDY $0.00
78456 3 ACUTE VENOUS THROMBUS IMAGE $242.74
78457 3 VENOUS THROMBOSIS IMAGING $187.24
78458 3 VEN THROMBOSIS IMAGES, BILAT $206.37
78459 3 HEART MUSCLE IMAGING (PET) $274.66

78460 3 HEART MUSCLE BLOOD, SINGLE $187.49
78461 3 HEART MUSCLE BLOOD, MULTIPLE $210.48
78464 3 HEART IMAGE (3D), SINGLE $274.66
78465 3 HEART IMAGE (3D), MULTIPLE $486.74
78466 3 HEART INFARCT IMAGE $178.83
78467 O MYOCARDIAL IMAGING, INFARCT AVID, A $0.00
78468 3 HEART INFARCT IMAGE (EF) $225.74
78469 3 HEART INFARCT IMAGE (3D) $256.58
78470 O CARDIAC OUTPUT $0.00
78471 O CARDIAC BLOOD POOL IMAGING, GATED E $0.00
78472 3 GATED HEART, PLANAR, SINGLE $260.93
78473 3 GATED HEART, MULTIPLE $356.48

78478 3 HEART WALL MOTION ADD-ON $58.82
78480 3 HEART FUNCTION ADD-ON $49.09
78481 3 HEART FIRST PASS, SINGLE $228.78
78483 3 HEART FIRST PASS, MULTIPLE $323.09
78484 O CARDIAC BLOOD POOL IMAGING, FIRST P $0.00

78491 3 HEART IMAGE (PET), SINGLE $323.62
78492 3 HEART IMAGE (PET), MULTIPLE $323.62
78494 3 HEART IMAGE, SPECT $284.57
78496 3 HEART FIRST PASS ADD-ON $116.86
78499 5 CARDIOVASCULAR NUCLEAR EXAM $0.00
78580 3 LUNG PERFUSION IMAGING $206.72
78581 O PULMONARY PERFUSION IMAGING GASEOUS $0.00
78582 O PULMONARY PERFUSION IMAGING GASEOUS $0.00
78584 3 LUNG V/Q IMAGE SINGLE BREATH $156.50

78585 3 LUNG V/Q IMAGING $341.26
78586 3 AEROSOL LUNG IMAGE, SINGLE $157.88
78587 3 AEROSOL LUNG IMAGE, MULTIPLE $198.80
78588 3 PERFUSION LUNG IMAGE $316.57
78591 3 VENT IMAGE, 1 BREATH, 1 PROJ $160.09
78593 3 VENT IMAGE, 1 PROJ, GAS $188.67
78594 3 VENT IMAGE, MULT PROJ, GAS $220.62
78596 3 LUNG DIFFERENTIAL FUNCTION $366.37
78599 5 RESPIRATORY NUCLEAR EXAM $0.00
78600 3 BRAIN IMAGE < 4 VIEWS $171.88
78601 3 BRAIN IMAGE W/FLOW < 4 VIEWS $204.55
78605 3 BRAIN IMAGE 4+ VIEWS $191.21

78606 3 BRAIN IMAGE W/FLOW 4 + VIEWS $299.99
78607 3 BRAIN IMAGING (3D) $358.93
78608 3 BRAIN IMAGING (PET) $323.62
78609 3 BRAIN IMAGING (PET) $323.62
78610 3 BRAIN FLOW IMAGING ONLY $173.81
78615 O CEREBRAL VASCULAR FLOW IMAGE $0.00
78630 3 CEREBROSPINAL FLUID SCAN $318.38
78635 3 CSF VENTRICULOGRAPHY $289.97
78645 3 CSF SHUNT EVALUATION $218.43
78647 3 CEREBROSPINAL FLUID SCAN $335.58

78650 3 CSF LEAKAGE IMAGING $310.73
78652 O CSF LEAKAGE DETECTION AND LOCALIZAT $0.00
78655 O RADIOPHARMACEUTICAL IDENTIFICATION $0.00
78660 3 NUCLEAR EXAM OF TEAR FLOW $161.67
78699 5 NERVOUS SYSTEM NUCLEAR EXAM $0.00
78700 3 KIDNEY IMAGING, MORPHOL $170.50
78701 3 KIDNEY IMAGING WITH FLOW $204.20
78704 O IMAGING RENOGRAM $0.00
78707 3 K FLOW/FUNCT IMAGE W/O DRUG $237.09
78708 3 K FLOW/FUNCT IMAGE W/DRUG $192.29
78709 3 K FLOW/FUNCT IMAGE, MULTIPLE $349.41
78710 3 KIDNEY IMAGING (3D) $234.34
78715 O RENAL VASCULAR FLOW EXAM $0.00

78725 3 KIDNEY FUNCTION STUDY $98.77
78726 O KIDNEY FUNCTION STUDY INCLUDING PHA $0.00
78727 O KIDNEY TRANSPLANT EVALUATION $0.00
78730 3 URINARY BLADDER RETENTION $76.16
78740 3 URETERAL REFLUX STUDY $202.90
78760 O TESTICULAR IMAGING $0.00
78761 3 TESTICULAR IMAGING W/FLOW $203.19
78799 5 GENITOURINARY NUCLEAR EXAM $0.00
78800 3 TUMOR IMAGING, LIMITED AREA $181.55
78801 3 TUMOR IMAGING, MULT AREAS $243.22
78802 3 TUMOR IMAGING, WHOLE BODY $318.75
78803 3 TUMOR IMAGING (3D) $350.96

78804 3 TUMOR IMAGING, WHOLE BODY $562.87
78805 3 ABSCESS IMAGING, LTD AREA $181.96
78806 3 ABSCESS IMAGING, WHOLE BODY $333.63
78807 3 NUCLEAR LOCALIZATION/ABSCESS $351.46
78808 3 IV INJ RA DRUG DX STUDY $44.73
78810 O TUMOR IMAGING (PET) $0.00
78811 3 PET IMAGE, LTD AREA $0.00
78812 3 PET IMAGE, SKULL-THIGH $0.00
78813 3 PET IMAGE, FULL BODY $0.00
78814 3 PET IMAGE W/CT, LMTD $0.00

78815 3 PET IMAGE W/CT, SKULL-THIGH $0.00
78816 3 PET IMAGE W/CT, FULL BODY $0.00
78890 O NUCLEAR MEDICINE DATA PROC $0.00
78891 O NUCLEAR MED DATA PROC $0.00
78990 O PROVIDE DIAG RADIONUCLIDE(S) $0.00
78999 5 NUCLEAR DIAGNOSTIC EXAM $0.00
79000 O INIT HYPERTHYROID THERAPY $0.00
79001 O REPEAT HYPERTHYROID THERAPY $0.00
79005 3 NUCLEAR RX, ORAL ADMIN $152.41
79020 O THYROID ABLATION $0.00
79030 O THYROID ABLATION, CARCINOMA $0.00
79035 O THYROID METASTATIC THERAPY $0.00
79100 O HEMATOPOETIC NUCLEAR THERAPY $0.00

79101 3 NUCLEAR RX, IV ADMIN $171.80
79200 3 NUCLEAR RX, INTRACAV ADMIN $174.22
79300 3 NUCLR RX, INTERSTIT COLLOID $0.00
79400 O NONHEMATO NUCLEAR THERAPY $0.00
79403 3 HEMATOPOIETIC NUCLEAR TX $218.51
79420 O INTRAVASCULAR NUCLEAR THER $0.00
79440 3 NUCLEAR RX, INTRA-ARTICULAR $160.68
79445 3 NUCLEAR RX, INTRA-ARTERIAL $0.00
79900 O PROVIDE THER RADIOPHARM(S) $0.00
79999 5 NUCLEAR MEDICINE THERAPY $0.00
80002 O AUTOMATED MULTICHANNEL TEST 1 OR 2 $0.00
80003 O AUTOMATED MULTICHANNEL TEST 3 CLINI $0.00

80010 O AUTOMATED MULTICHANNEL TEST 10 CLIN $0.00
80016 O AUTOMATED MULTICHANNEL TEST 13-16 C $0.00

80018 O AUTOMATED MULTICHANNEL TEST 17-18 C $0.00
80019 O AUTOMATED MULTICHANNEL TEST; 19 CLI $0.00
80031 O THERAPEUTIC QUANTITATIVE DRUG MONIT $0.00
80040 O SERUM RADIOIMMUNOASSAY FOR CIRCULAT $0.00
80042 O SERUM ANTIMICROBIAL LEVEL, BIOASSAY $0.00
80047 3 METABOLIC PANEL IONIZED CA $12.11
80048 3 METABOLIC PANEL TOTAL CA $12.11
80049 9 METABOLIC PANEL, BASIC $0.00
80050 3 GENERAL HEALTH PANEL $16.32
80051 3 ELECTROLYTE PANEL $10.04

80052 9 PRE-MARITAL PROFILE $0.00
80053 3 COMPREHEN METABOLIC PANEL $15.13
80054 9 COMPREHEN METABOLIC PANEL $0.00
80055 3 OBSTETRIC PANEL $23.08
80056 9 AMENORRHEA PROFILE $0.00
80057 9 MALE INFERTILITY AND/OR GYNECOMASTI $0.00
80058 O HEPATIC FUNCTION PANEL $0.00
80059 O HEPATITIS PANEL $0.00
80060 O HYPERTENSION PANEL $0.00
80061 3 LIPID PANEL $19.18
80062 O CARDIAC EVALUATION (INCLUDING CORON $0.00
80063 O CARDIAC INJURY PANEL $0.00

80064 O CARDIAC INJURY PANEL WITH CREATINE $0.00
80065 O METABOLIC PANEL $0.00
80066 O MALABSORPTION PANEL $0.00
80067 O PULMONARY (LUNG FUNCTION) PANEL $0.00
80068 O LUNG MATURITY PROFILE $0.00
80069 3 RENAL FUNCTION PANEL $12.43
80070 O THYROID PANEL $0.00
80071 O THYROID PANEL WITH THYROTROPIN RELE $0.00
80072 O ARTHRITIS PANEL $0.00
80073 O RENAL PANEL $0.00

80074 3 ACUTE HEPATITIS PANEL $67.88
80075 O PARATHYROID PANEL $0.00
80076 3 HEPATIC FUNCTION PANEL $11.69
80080 O PROSTATIC PANEL $0.00
80082 O PANCREATIC PANEL $0.00
80084 O PITUITARY PANEL $0.00
80085 O MICROCYTIC ANEMIA PANEL $0.00
80086 O MACROCYTIC ANEMIA PANEL $0.00
80088 O TRANSITION PANEL (FOR MANAGEMENT OF $0.00
80089 O MUSCLE PANEL $0.00
80090 O TORCH ANTIBODY PANEL $0.00
80091 O THYROID PANEL $0.00
80092 O THYROID PANEL W/TSH $0.00

80099 O UNLISTED PANEL $0.00
80100 3 DRUG SCREEN, QUALITATE/MULTI $20.81
80101 3 DRUG SCREEN, SINGLE $19.71
80102 3 DRUG CONFIRMATION $18.95
80103 5 DRUG ANALYSIS, TISSUE PREP $0.00
80150 3 ASSAY OF AMIKACIN $21.57
80152 3 ASSAY OF AMITRIPTYLINE $25.62
80154 3 ASSAY OF BENZODIAZEPINES $22.97
80156 3 ASSAY, CARBAMAZEPINE, TOTAL $20.83
80157 3 ASSAY, CARBAMAZEPINE, FREE $18.97
80158 3 ASSAY OF CYCLOSPORINE $25.83
80160 3 ASSAY OF DESIPRAMINE $24.63

80162 3 ASSAY OF DIGOXIN $19.00
80164 3 ASSAY, DIPROPYLACETIC ACID $19.38
80166 3 ASSAY OF DOXEPIN $22.19
80168 3 ASSAY OF ETHOSUXIMIDE $21.56
80170 3 ASSAY OF GENTAMICIN $23.45
80172 3 ASSAY OF GOLD $23.30
80173 3 ASSAY OF HALOPERIDOL $20.83
80174 3 ASSAY OF IMIPRAMINE $24.63
80176 3 ASSAY OF LIDOCAINE $21.02
80178 3 ASSAY OF LITHIUM $9.46

80182 3 ASSAY OF NORTRIPTYLINE $19.38
80184 3 ASSAY OF PHENOBARBITAL $16.39
80185 3 ASSAY OF PHENYTOIN, TOTAL $18.97
80186 3 ASSAY OF PHENYTOIN, FREE $19.70
80188 3 ASSAY OF PRIMIDONE $23.75
80190 3 ASSAY OF PROCAINAMIDE $23.97
80192 3 ASSAY OF PROCAINAMIDE $23.97
80194 3 ASSAY OF QUINIDINE $20.88
80195 3 ASSAY OF SIROLIMUS $19.64
80196 3 ASSAY OF SALICYLATE $10.15
80197 3 ASSAY OF TACROLIMUS $19.64
80198 3 ASSAY OF THEOPHYLLINE $20.25
80200 3 ASSAY OF TOBRAMYCIN $23.06

80201 3 ASSAY OF TOPIRAMATE $17.05
80202 3 ASSAY OF VANCOMYCIN $19.38
80299 3 QUANTITATIVE ASSAY, DRUG $19.59
80400 3 ACTH STIMULATION PANEL $46.67
80408 3 ALDOSTERONE SUPPRESSION EVAL $179.58
80410 3 CALCITONIN STIMUL PANEL $64.30
80412 3 CRH STIMULATION PANEL $471.63
80414 3 TESTOSTERONE RESPONSE $73.89
80415 3 ESTRADIOL RESPONSE PANEL $79.97
80416 3 RENIN STIMULATION PANEL $188.87

80417 3 RENIN STIMULATION PANEL $62.96
80418 3 PITUITARY EVALUATION PANEL $829.32
80420 3 DEXAMETHASONE PANEL $102.74
80422 3 GLUCAGON TOLERANCE PANEL $65.91
80424 3 GLUCAGON TOLERANCE PANEL $72.27
80426 3 GONADOTROPIN HORMONE PANEL $212.39
80428 3 GROWTH HORMONE PANEL $95.41
80430 3 GROWTH HORMONE PANEL $112.26
80432 3 INSULIN SUPPRESSION PANEL $193.30
80434 3 INSULIN TOLERANCE PANEL $144.75

80435 3 INSULIN TOLERANCE PANEL $147.34
80436 3 METYRAPONE PANEL $130.44
80438 3 TRH STIMULATION PANEL $72.12
80500 3 LAB PATHOLOGY CONSULTATION $22.88
80502 3 LAB PATHOLOGY CONSULTATION $76.36
81000 3 URINALYSIS, NONAUTO W/SCOPE $4.52
81001 3 URINALYSIS, AUTO W/SCOPE $4.52
81002 3 URINALYSIS NONAUTO W/O SCOPE $3.67
81003 3 URINALYSIS, AUTO, W/O SCOPE $3.21
81004 O URINALYSIS COMPONENTS, SINGLE, NOT $0.00
81005 3 URINALYSIS $3.10

81007 3 URINE SCREEN FOR BACTERIA $3.68
81010 O URINALYSIS CONCENTRATION AND DILUTI $0.00
81011 O URINALYSIS WATER DEPRIVATION TEST $0.00
81012 O URINALYSIS WATER DEPRIVATION TEST W $0.00
81015 3 MICROSCOPIC EXAM OF URINE $4.34
81020 3 URINALYSIS, GLASS TEST $4.40
81025 3 URINE PREGNANCY TEST $9.06
81030 O QUANTITATIVE SEDIMENT ANALYSIS AND $0.00
81050 3 URINALYSIS, VOLUME MEASURE $4.12
81099 5 URINALYSIS TEST PROCEDURE $0.00
82000 3 ASSAY OF BLOOD ACETALDEHYDE $17.73
82003 3 ASSAY OF ACETAMINOPHEN $28.96

82005 O ACETOACETIC ACID $0.00
82009 3 TEST FOR ACETONE/KETONES $6.46
82010 3 ACETONE ASSAY $11.69
82011 O ACETYLSALICYLIC ACID QUANTITATIVE $0.00
82012 O ACETYLSALICYLIC ACID QUALITATIVE $0.00
82013 3 ACETYLCHOLINESTERASE ASSAY $12.37
82015 O ACIDITY, TITRATABLE, URINE $0.00
82016 3 ACYLCARNITINES, QUAL $19.84
82017 3 ACYLCARNITINES, QUANT $24.14
82024 3 ASSAY OF ACTH $55.27

82030 3 ASSAY OF ADP & AMP $36.92
82035 O ADENOSINE 5'-TRIPHOSPHATE, BLOOD $0.00
82040 3 ASSAY OF SERUM ALBUMIN $7.09
82042 3 ASSAY OF URINE ALBUMIN $2.52
82043 3 MICROALBUMIN, QUANTITATIVE $8.28
82044 3 MICROALBUMIN, SEMIQUANT $3.64
82045 3 ALBUMIN, ISCHEMIA MODIFIED $48.57
82055 3 ASSAY OF ETHANOL $15.46
82060 O ALCOHOL (ETHANOL), BLOOD BY GAS-LIQ $0.00
82065 O ALCOHOL (ETHANOL), URINE CHEMICAL $0.00
82070 O ALCOHOL (ETHANOL), URINE BY GAS-LIQ $0.00
82072 O ALCOHOL (ETHANOL) GELATION $0.00
82075 3 ASSAY OF BREATH ETHANOL $17.25

82076 O ALCOHOL ISOPROPYL $0.00
82078 O ALCOHOL METHYL $0.00
82085 3 ASSAY OF ALDOLASE $13.89
82086 O ALDOLASE, BLOOD COLORIMETRIC $0.00
82087 O ALDOSTERONE DOUBLE ISOTOPE TECHNIQU $0.00
82088 3 ASSAY OF ALDOSTERONE $58.31
82089 O ALDOSTERONE RIA, URINE $0.00
82091 O ALDOSTERONE SALINE INFUSION TEST $0.00
82095 O ALKALOIDS, TISSUE SCREENING $0.00
82096 O ALKALOIDS, TISSUE QUANTITATIVE $0.00
82100 O ALKALOIDS, URINE SCREENING $0.00
82101 3 ASSAY OF URINE ALKALOIDS $42.95

82103 3 ALPHA-1-ANTITRYPSIN, TOTAL $19.22
82104 3 ALPHA-1-ANTITRYPSIN, PHENO $20.69
82105 3 ALPHA-FETOPROTEIN, SERUM $24.00
82106 3 ALPHA-FETOPROTEIN, AMNIOTIC $24.00
82107 3 ALPHA-FETOPROTEIN L3 $90.65
82108 3 ASSAY OF ALUMINUM $36.46
82112 O AMIKACIN $0.00
82120 3 AMINES, VAGINAL FLUID QUAL $5.38
82126 O AMINO ACID NITROGEN, ALPHA $0.00
82127 3 AMINO ACID, SINGLE QUAL $19.84

82128 3 AMINO ACIDS, MULT QUAL $19.84
82130 O AMINO ACIDS ANALYSIS $0.00
82131 3 AMINO ACIDS, SINGLE QUANT $24.14
82134 O AMINOHIPPURATE, PARA (PAH) $0.00
82135 3 ASSAY, AMINOLEVULINIC ACID $23.56
82136 3 AMINO ACIDS, QUANT, 2-5 $24.14
82137 O AMINOPHYLLINE $0.00
82138 O AMITRIPTYLINE $0.00
82139 3 AMINO ACIDS, QUAN, 6 OR MORE $24.14
82140 3 ASSAY OF AMMONIA $20.85
82141 O AMMONIA URINE $0.00
82142 O AMMONIUM CHLORIDE LOADING TEST $0.00
82143 3 AMNIOTIC FLUID SCAN $9.83

82145 3 ASSAY OF AMPHETAMINES $22.25
82150 3 ASSAY OF AMYLASE $9.27
82154 3 ANDROSTANEDIOL GLUCURONIDE $41.26
82156 O AMYLASE, URINE (DIASTASE) $0.00
82157 3 ASSAY OF ANDROSTENEDIONE $41.89
82159 O ANDROSTERONE $0.00
82160 3 ASSAY OF ANDROSTERONE $35.78
82163 3 ASSAY OF ANGIOTENSIN II $29.37
82164 3 ANGIOTENSIN I ENZYME TEST $20.88
82165 O ANILINE $0.00
82168 O ANTIHISTAMINES $0.00
82170 O ANTIMONY, URINE $0.00

82172 3 ASSAY OF APOLIPOPROTEIN $22.17
82173 O ARGININE TOLERANCE TEST $0.00
82175 3 ASSAY OF ARSENIC $27.15
82180 3 ASSAY OF ASCORBIC ACID $14.14
82190 3 ATOMIC ABSORPTION $21.33
82205 3 ASSAY OF BARBITURATES $16.39
82210 O BARBITURATES QUANTITATIVE AND IDENT $0.00
82225 O BARIUM $0.00
82230 O BERYLLIUM, URINE $0.00
82231 O BETA-2 MICROGLOBULIN, RIA URINE $0.00

82232 3 ASSAY OF BETA-2 PROTEIN $23.15
82235 O BICARBONATE EXCRETION, URINE $0.00
82236 O BICARBONATE LOADING TEST $0.00
82239 3 BILE ACIDS, TOTAL $24.51
82240 3 BILE ACIDS, CHOLYLGLYCINE $38.03
82245 O BILE PIGMENTS, URINE $0.00
82247 3 BILIRUBIN, TOTAL $7.18
82248 3 BILIRUBIN, DIRECT $7.18
82250 O ASSAY BILIRUBIN $0.00
82251 O ASSAY OF BILIRUBIN $0.00
82252 3 FECAL BILIRUBIN TEST $6.51
82260 O BILIRUBIN URINE, QUANTITATIVE $0.00
82261 3 ASSAY OF BIOTINIDASE $24.14

82265 O BILIRUBIN AMNIOTIC FLUID, QUANTITAT $0.00
82268 O BISMUTH $0.00
82270 3 OCCULT BLOOD, FECES $4.66
82271 3 OCCULT BLOOD, OTHER SOURCES $4.66
82272 3 OCCULT BLD FECES, 1-3 TESTS $4.66
82273 O TEST FOR BLOOD, OTHER SOURCE $0.00
82274 3 ASSAY TEST FOR BLOOD, FECAL $22.76
82280 O BORIC ACID BLOOD $0.00
82285 O BORIC ACID URINE $0.00
82286 3 ASSAY OF BRADYKININ $9.86
82290 O BROMIDES BLOOD $0.00
82291 O BROMIDES URINE $0.00

82300 3 ASSAY OF CADMIUM $33.11
82305 O CAFFEINE $0.00
82306 3 ASSAY OF VITAMIN D $42.36
82307 3 ASSAY OF VITAMIN D $46.11
82308 3 ASSAY OF CALCITONIN $21.43
82310 3 ASSAY OF CALCIUM $7.38
82315 O CALCIUM, BLOOD FLUOROMETRIC $0.00
82320 O CALCIUM, BLOOD EMISSION FLAME PHOTO $0.00
82325 O CALCIUM, BLOOD ATOMIC ABSORPTION FL $0.00
82330 3 ASSAY OF CALCIUM $9.07

82331 3 CALCIUM INFUSION TEST $7.41
82335 O CALCIUM, URINE QUALITATIVE (SULKOWI $0.00
82340 3 ASSAY OF CALCIUM IN URINE $8.63
82355 3 CALCULUS ANALYSIS, QUAL $16.55
82360 3 CALCULUS ASSAY, QUANT $18.42
82365 3 CALCULUS SPECTROSCOPY $18.45
82370 3 X-RAY ASSAY, CALCULUS $17.92
82372 O CARBAMAZEPINE, SERUM $0.00
82373 3 ASSAY, C-D TRANSFER MEASURE $25.84
82374 3 ASSAY, BLOOD CARBON DIOXIDE $7.00
82375 3 CARBOXYHEMOGLOBIN; QUANTITATIVE $17.64
82376 3 ASSAY, CARBOXYHB, QUAL $7.86
82378 3 CARCINOEMBRYONIC ANTIGEN $27.15

82379 3 ASSAY OF CARNITINE $24.14
82380 3 ASSAY OF CAROTENE $13.20
82382 3 ASSAY, URINE CATECHOLAMINES $24.60
82383 3 ASSAY, BLOOD CATECHOLAMINES $35.86
82384 3 ASSAY, THREE CATECHOLAMINES $36.13
82387 3 ASSAY OF CATHEPSIN-D $29.77
82390 3 ASSAY OF CERULOPLASMIN $15.37
82397 3 CHEMILUMINESCENT ASSAY $20.22
82400 O CHLORAL HYDRATE BLOOD $0.00
82405 O CHLORAL HYDRATE URINE $0.00
82415 3 ASSAY OF CHLORAMPHENICOL $18.13
82418 O CHLORAZEPATE DIPOTASSIUM $0.00

82420 O CHLORDIAZEPOXIDE BLOOD $0.00
82425 O CHLORDIAZEPOXIDE URINE $0.00
82435 3 ASSAY OF BLOOD CHLORIDE $6.57
82436 3 ASSAY OF URINE CHLORIDE $7.19
82437 O CHLORIDES SWEAT (WITHOUT IONTOPHORE $0.00
82438 3 ASSAY, OTHER FLUID CHLORIDES $7.00
82441 3 TEST FOR CHLOROHYDROCARBONS $8.58
82443 O CHLOROTHIAZIDE-HYDROCHLOROTHIAZIDE $0.00
82465 3 ASSAY, BLD/SERUM CHOLESTEROL $6.23
82470 O CHOLESTEROL, SERUM TOTAL AND ESTERS $0.00

82480 3 ASSAY, SERUM CHOLINESTERASE $11.28
82482 3 ASSAY, RBC CHOLINESTERASE $11.00
82484 O CHOLINESTERASE SERUM AND RBC $0.00
82485 3 ASSAY, CHONDROITIN SULFATE $29.55
82486 3 GAS/LIQUID CHROMATOGRAPHY $25.84
82487 3 PAPER CHROMATOGRAPHY $22.84
82488 3 PAPER CHROMATOGRAPHY $30.58
82489 3 THIN LAYER CHROMATOGRAPHY $26.46
82491 3 CHROMOTOGRAPHY, QUANT, SING $25.84
82492 3 CHROMOTOGRAPHY, QUANT, MULT $25.84
82495 3 ASSAY OF CHROMIUM $29.02
82507 3 ASSAY OF CITRATE $39.79
82512 O CLONAZEPAM $0.00

82520 3 ASSAY OF COCAINE $19.96
82523 3 COLLAGEN CROSSLINKS $15.53
82525 3 ASSAY OF COPPER $17.76
82526 O COPPER URINE $0.00
82528 3 ASSAY OF CORTICOSTERONE $32.20
82529 O CORTISOL FLUOROMETRIC, PLASMA $0.00
82530 3 CORTISOL, FREE $23.92
82531 O CORTISOL CPB, PLASMA $0.00
82532 O CORTISOL CPB, URINE $0.00
82533 3 TOTAL CORTISOL $23.33
82534 O CORTISOL RIA, URINE $0.00
82536 O CORTISOL AFTER ADRENOCORTICOTROPIC $0.00

82537 O CORTISOL 48 HOURS AFTER CONTINUOUS $0.00
82538 O CORTISOL AFTER METYRAPONE TARTRATE $0.00
82539 O CORTISOL DEXAMETHASONE SUPPRESSION $0.00
82540 3 ASSAY OF CREATINE $6.62
82541 3 COLUMN CHROMOTOGRAPHY, QUAL $25.84
82542 3 COLUMN CHROMOTOGRAPHY, QUANT $25.84
82543 3 COLUMN CHROMOTOGRAPH/ISOTOPE $25.84
82544 3 COLUMN CHROMOTOGRAPH/ISOTOPE $25.84
82545 O CREATINE URINE $0.00
82546 O CREATINE AND CREATININE $0.00

82550 3 ASSAY OF CK (CPK) $9.32
82552 3 ASSAY OF CPK IN BLOOD $19.17
82553 3 CREATINE, MB FRACTION $10.86
82554 3 CREATINE, ISOFORMS $16.98
82555 O CREATINE PHOSPHOKINASE (CPK), BLOOD $0.00
82565 3 ASSAY OF CREATININE $6.57
82570 3 ASSAY OF URINE CREATININE $7.41
82575 3 CREATININE CLEARANCE TEST $13.51
82585 3 ASSAY OF CRYOFIBRINOGEN $12.27
82595 3 ASSAY OF CRYOGLOBULIN $9.26
82600 3 ASSAY OF CYANIDE $27.76
82601 O CYANIDE TISSUE $0.00
82606 O CYANOCOBALAMIN (VITAMIN B-12) BIOAS $0.00

82607 3 VITAMIN B-12 $21.57
82608 3 B-12 BINDING CAPACITY $20.49
82610 3 CYSTATIN C $19.45
82614 O CYSTINE, BLOOD, QUALITATIVE $0.00
82615 3 TEST FOR URINE CYSTINES $11.68
82620 O CYSTINE AND HOMOCYSTINE, URINE QUAN $0.00
82624 O CYSTINE AMINOPEPTIDASE $0.00
82626 3 DEHYDROEPIANDROSTERONE $36.16
82627 3 DEHYDROEPIANDROSTERONE $31.81
82628 O DESIPRAMINE $0.00
82633 3 DESOXYCORTICOSTERONE $44.33
82634 3 DEOXYCORTISOL $41.89

82635 O DIACETIC ACID $0.00
82636 O DIAZEPAM $0.00
82638 3 ASSAY OF DIBUCAINE NUMBER $16.65
82639 O DICUMAROL $0.00
82640 O DIGITOXIN (DIGITALIS) BLOOD, RIA $0.00
82641 O DIGITOXIN (DIGITALIS) URINE $0.00
82643 O DIGOXIN, RIA $0.00
82646 3 ASSAY OF DIHYDROCODEINONE $29.55
82649 3 ASSAY OF DIHYDROMORPHINONE $36.78
82651 3 ASSAY OF DIHYDROTESTOSTERONE $36.94

82652 3 ASSAY OF DIHYDROXYVITAMIN D $55.08
82654 3 ASSAY OF DIMETHADIONE $19.82
82656 3 ELASTASE, PANCREATIC (EL-1), FECAL $15.76
82657 3 ENZYME CELL ACTIVITY $25.84
82658 3 ENZYME CELL ACTIVITY, RA $25.84
82660 O DRUG SCREEN (AMPHETAMINES, BARBITUR $0.00
82664 3 ELECTROPHORETIC TEST $49.16
82666 3 ASSAY OF EPIANDROSTERONE $30.74
82668 3 ASSAY OF ERYTHROPOIETIN $24.89
82670 3 ASSAY OF ESTRADIOL $39.98
82671 3 ASSAY OF ESTROGENS $46.21
82672 3 ASSAY OF ESTROGEN $14.26
82673 O ESTRIOL FLUOROMETRIC $0.00

82674 O ESTRIOL GLC $0.00
82676 O ESTRIOL CHEMICAL $0.00
82677 3 ASSAY OF ESTRIOL $34.60
82678 O ESTRONE CHEMICAL $0.00
82679 3 ASSAY OF ESTRONE $33.58
82690 3 ASSAY OF ETHCHLORVYNOL $24.74
82691 O ETHCHLORVYNOL URINE $0.00
82692 O ETHOSUXIMIDE $0.00
82693 3 ASSAY OF ETHYLENE GLYCOL $18.44
82694 O ETIOCHOLANOLONE $0.00
82696 3 ASSAY OF ETIOCHOLANOLONE $33.74
82705 3 FATS/LIPIDS, FECES, QUAL $7.28

82710 3 FATS/LIPIDS, FECES, QUANT $4.12
82715 3 ASSAY OF FECAL FAT $12.51
82720 O FATTY ACIDS, BLOOD ESTERIFIED $0.00
82725 3 ASSAY OF BLOOD FATTY ACIDS $19.05
82726 3 LONG CHAIN FATTY ACIDS $25.84
82727 O FERRIC CHLORIDE, URINE $0.00
82728 3 ASSAY OF FERRITIN $19.49
82730 O FIBRINOGEN, QUANTITATIVE $0.00
82731 3 ASSAY OF FETAL FIBRONECTIN $90.65
82735 3 ASSAY OF FLUORIDE $26.54

82740 O FLUORIDE URINE $0.00
82741 O FLUCYTOSINE (5-FLUOROCYTOSINE) $0.00
82742 3 ASSAY OF FLURAZEPAM $22.50
82745 O FOLIC ACID (FOLATE), BLOOD BIOASSAY $0.00
82746 3 BLOOD FOLIC ACID SERUM $21.04
82747 3 ASSAY OF FOLIC ACID, RBC $24.65
82750 O FORMIMINOGLUTAMIC ACID (FIGLU), URI $0.00
82755 O FREE RADICAL ASSAY TECHNIQUE FOR DR $0.00
82756 O FREE THYROXINE INDEX (T-7) $0.00
82757 3 ASSAY OF SEMEN FRUCTOSE $24.81
82759 3 ASSAY OF RBC GALACTOKINASE $30.74
82760 3 ASSAY OF GALACTOSE $16.02
82763 O GALACTOSE TOLERANCE TEST $0.00

82765 O GALACTOSE URINE $0.00
82775 3 ASSAY GALACTOSE TRANSFERASE $30.14
82776 3 GALACTOSE TRANSFERASE TEST $12.00
82780 O GALLIUM $0.00
82784 3 ASSAY OF GAMMAGLOBULIN IGM $13.31
82785 3 ASSAY OF GAMMAGLOBULIN IGE $23.57
82786 O GAMMAGLOBULIN, SALT PRECIPITATION M $0.00
82787 3 IGG 1, 2, 3 OR 4, EACH $11.48
82790 O GASES, BLOOD, OXYGEN SATURATION BY $0.00
82792 O GASES, BLOOD, OXYGEN SATURATION QUA $0.00

82800 3 BLOOD PH $12.12
82801 O GASES, BLOOD PCO2 $0.00
82802 O GASES, BLOOD PH, PCO2 BY ELECTRODE $0.00
82803 3 BLOOD GASES: PH, PO2 & PCO2 $27.69
82804 O GASES, BLOOD PO2 BY ELECTRODE $0.00
82805 3 BLOOD GASES W/02 SATURATION $40.60
82810 3 BLOOD GASES, O2 SAT ONLY $12.49
82812 O GASES, BLOOD PO2 BY MANOMETRY $0.00
82817 O GASES, BLOOD PH, PCO2 BY TONOMETRY $0.00

82820 3 HEMOGLOBIN-OXYGEN AFFINITY $14.30
82926 3 ASSAY OF GASTRIC ACID $7.80
82927 O GASTRIC ACID, FREE AND TOTAL EACH A $0.00
82928 3 ASSAY OF GASTRIC ACID $9.37
82929 O GASTRIC ACID, FREE OR TOTAL EACH AD $0.00
82931 O GASTRIC ACID, PH TITRATION SINGLE S $0.00
82932 O GASTRIC ACID, PH TITRATION EACH ADD $0.00
82938 3 GASTRIN TEST $25.31
82941 3 ASSAY OF GASTRIN $25.24
82942 O GLOBULIN, SERUM $0.00
82943 3 ASSAY OF GLUCAGON $20.44
82944 O GLUCOSAMINE $0.00
82945 3 GLUCOSE OTHER FLUID $5.62

82946 3 GLUCAGON TOLERANCE TEST $21.57
82947 3 ASSAY, GLUCOSE, BLOOD QUANT $5.62
82948 3 REAGENT STRIP/BLOOD GLUCOSE $4.54
82949 O GLUCOSE FERMENTATION $0.00
82950 3 GLUCOSE TEST $6.79
82951 3 GLUCOSE TOLERANCE TEST (GTT) $18.42
82952 3 GTT-ADDED SAMPLES $4.12
82953 3 GLUCOSE-TOLBUTAMIDE TEST $21.68
82954 O GLUCOSE, URINE $0.00
82955 3 ASSAY OF G6PD ENZYME $13.88
82960 3 TEST FOR G6PD ENZYME $8.66
82961 O GLUCOSE TOLERANCE TEST, INTRAVENOUS $0.00

82962 3 GLUCOSE BLOOD TEST $3.35
82963 3 ASSAY OF GLUCOSIDASE $30.74
82965 3 ASSAY OF GDH ENZYME $11.06
82975 3 ASSAY OF GLUTAMINE $22.67
82977 3 ASSAY OF GGT $9.58
82978 3 ASSAY OF GLUTATHIONE $8.53
82979 3 ASSAY, RBC GLUTATHIONE $9.86
82980 3 ASSAY OF GLUTETHIMIDE $26.22
82985 3 GLYCATED PROTEIN $21.57
82995 O GOLD, BLOOD $0.00

83000 O GONADOTROPIN, PITUITARY, FOLLICLE S $0.00
83001 3 GONADOTROPIN (FSH) $26.60
83002 3 GONADOTROPIN (LH) $26.50
83003 3 ASSAY, GROWTH HORMONE (HGH) $23.85
83004 O GROWTH HORMONE, HUMAN (HGH) (SOMATO $0.00
83008 3 ASSAY OF GUANOSINE $24.02
83009 3 H PYLORI (C-13), BLOOD $96.38
83010 3 ASSAY OF HAPTOGLOBIN, QUANT $18.00
83011 O HAPTOGLOBIN QUANTITATIVE, ELECTROPH $0.00
83012 3 ASSAY OF HAPTOGLOBINS $24.60
83013 3 H PYLORI (C-13), BREATH $96.38
83014 3 H PYLORI DRUG ADMIN $11.25
83015 3 HEAVY METAL SCREEN $26.95

83018 3 QUANTITATIVE SCREEN, METALS $31.42
83019 O BREATH ISOTOPE TEST $0.00
83020 3 HEMOGLOBIN ELECTROPHORESIS $18.42
83021 3 HEMOGLOBIN CHROMOTOGRAPHY $25.84
83026 3 HEMOGLOBIN, COPPER SULFATE $3.38
83030 3 FETAL HEMOGLOBIN, CHEMICAL $11.84
83033 3 FETAL HEMOGLOBIN ASSAY, QUAL $8.25
83036 3 GLYCOSYLATED HEMOGLOBIN TEST $13.89
83037 3 GLYCOSYLATED HB, HOME DEVICE $13.89
83040 O HEMOGLOBIN METHEMOGLOBIN, ELECTROPH $0.00
83045 3 BLOOD METHEMOGLOBIN TEST $7.10
83050 3 BLOOD METHEMOGLOBIN ASSAY $10.48

83051 3 ASSAY OF PLASMA HEMOGLOBIN $4.12
83052 O HEMOGLOBIN SICKLE, TURBIDIMETRIC $0.00
83053 O HEMOGLOBIN SOLUBILITY, S-D, ETC $0.00
83055 3 BLOOD SULFHEMOGLOBIN TEST $4.12
83060 3 BLOOD SULFHEMOGLOBIN ASSAY $11.84
83065 3 ASSAY OF HEMOGLOBIN HEAT $9.86
83068 3 HEMOGLOBIN STABILITY SCREEN $3.36
83069 3 ASSAY OF URINE HEMOGLOBIN $5.64
83070 3 ASSAY OF HEMOSIDERIN, QUAL $6.79
83071 3 ASSAY OF HEMOSIDERIN, QUANT $9.18

83080 3 ASSAY OF B HEXOSAMINIDASE $24.14
83086 O HISTIDINE BLOOD, QUALITATIVE $0.00
83087 O HISTIDINE URINE, QUALITATIVE $0.00
83088 3 ASSAY OF HISTAMINE $42.26
83090 3 ASSAY OF HOMOCYSTINE $24.14
83093 O HOMOGENTISIC ACID BLOOD, QUALITATIV $0.00
83094 O HOMOGENTISIC ACID URINE, QUALITATIV $0.00
83095 O HOMOGENTISIC ACID URINE, QUANTITATI $0.00
83150 3 ASSAY OF FOR HVA $27.69
83485 O HYDROXYBUTYRIC DEHYDROGENASE, ALPHA $0.00
83486 O HYDROXYBUTYRIC DEHYDROGENASE, ALPHA $0.00
83491 3 ASSAY OF CORTICOSTEROIDS $25.06
83492 O HYDROXYCORTICOSTEROIDS, 17- (17-OHC $0.00

83497 3 ASSAY OF 5-HIAA $18.45
83498 3 ASSAY OF PROGESTERONE $38.87
83500 3 ASSAY, FREE HYDROXYPROLINE $32.41
83505 3 ASSAY, TOTAL HYDROXYPROLINE $34.78
83510 O HYDROXYPROLINE, URINE FREE AND TOTA $0.00
83516 3 IMMUNOASSAY, NONANTIBODY $15.76
83518 3 IMMUNOASSAY, DIPSTICK $12.13

83519 3 IMMUNOASSAY, NONANTIBODY $19.34
83520 3 IMMUNOASSAY, RIA $18.53
83523 O IMIPRAMINE $0.00
83524 O INDICAN, URINE $0.00
83525 3 ASSAY OF INSULIN $16.36
83526 O INSULIN TOLERANCE TEST $0.00
83527 3 ASSAY OF INSULIN $18.53
83528 3 ASSAY OF INTRINSIC FACTOR $22.76
83530 O INULIN CLEARANCE $0.00
83540 3 ASSAY OF IRON $9.27

83545 O IRON, SERUM AUTOMATED $0.00
83546 O IRON, SERUM RADIOACTIVE UPTAKE METH $0.00
83550 3 IRON BINDING TEST $12.51
83555 O IRON BINDING CAPACITY, SERUM AUTOMA $0.00
83565 O IRON BINDING CAPACITY, SERUM RADIOA $0.00
83570 3 ASSAY OF IDH ENZYME $10.76
83571 O ISOCITRIC DEHYDROGENASE (IDH), BLOO $0.00
83576 O ISONICOTINIC ACID HYDRAZIDE (INH) $0.00
83578 O KANAMYCIN $0.00
83582 3 ASSAY OF KETOGENIC STEROIDS $20.28
83583 O KETOGENIC STEROIDS, URINE 11-DESOXY $0.00
83584 O KETOGLUTARATE, ALPHA $0.00
83586 3 ASSAY 17- KETOSTEROIDS $18.32

83587 O KETOSTEROIDS, 17- (17-KS), BLOOD FR $0.00
83588 O KETOSTEROIDS, 17- (17-KS), BLOOD RI $0.00
83589 O KETOSTEROIDS, 17- (17-KS), URINE TO $0.00
83590 O KETOSTEROIDS, 17- (17-KS), URINE FR $0.00
83593 3 FRACTIONATION, KETOSTEROIDS $37.63
83597 O KETOSTEROIDS, 17- (17-KS), URINE 11 $0.00
83599 O KETOSTEROIDS, 17-OH, RIA $0.00
83600 O KYNURENIC ACID $0.00
83605 3 ASSAY OF LACTIC ACID $15.28
83610 O LACTIC DEHYDROGENASE (LDH), RIA $0.00
83615 3 LACTATE (LD) (LDH) ENZYME $8.02
83620 O LACTIC DEHYDROGENASE (LDH), BLOOD C $0.00

83624 O LACTIC DEHYDROGENASE (LDH), BLOOD H $0.00
83625 3 ASSAY OF LDH ENZYMES $18.32
83626 O LACTIC DEHYDROGENASE (LDH), BLOOD I $0.00
83628 O LACTIC DEHYDROGENASE, LIVER (LLDH) $0.00
83629 O LACTIC DEHYDROGENASE (LDH), URINE $0.00
83630 3 LACTOFERRIN, FECAL (QUAL) $28.09
83631 3 LACTOFERRIN, FECAL; QUANTITATIVE $28.09
83632 3 PLACENTAL LACTOGEN $28.92
83633 3 TEST URINE FOR LACTOSE $7.88
83634 3 ASSAY OF URINE FOR LACTOSE $16.49

83645 O LEAD, SCREENING BLOOD $0.00
83650 O LEAD, SCREENING URINE $0.00
83655 3 ASSAY OF LEAD $17.32
83660 O LEAD, QUANTITATIVE URINE $0.00
83661 3 L/S RATIO, FETAL LUNG $31.45
83662 3 FOAM STABILITY, FETAL LUNG $27.07
83663 3 FLUORO POLARIZE, FETAL LUNG $27.07
83664 3 LAMELLAR BDY, FETAL LUNG $27.07
83670 3 ASSAY OF LAP ENZYME $13.11
83675 O LEUCINE AMINOPEPTIDASE (LAP), BLOOD $0.00
83680 O LEUCINE AMINOPEPTIDASE (LAP), URINE $0.00
83681 O LEUCINE TOLERANCE TEST $0.00
83685 O LIDOCAINE $0.00

83690 3 ASSAY OF LIPASE $9.86
83695 3 ASSAY OF LIPOPROTEIN(A) $18.53
83698 3 ASSAY LIPOPROTEIN PLA2 $48.57
83700 3 LIPOPROTEIN, BLOOD; ELECTROPHORETI $16.11
83701 3 LIPOPROTEIN BLD, HR FRACTION $35.52
83704 3 LIPOPROTEIN, BLD, BY NMR $45.15
83705 O LIPIDS, BLOOD FRACTIONATED (CHOLEST $0.00
83715 O ASSAY OF BLOOD LIPOPROTEINS $0.00
83716 O ASSAY OF BLOOD LIPOPROTEINS $0.00
83717 O ASSAY BLOOD LIPOPROTEINS $0.00
83718 3 ASSAY OF LIPOPROTEIN $11.72
83719 3 ASSAY OF BLOOD LIPOPROTEIN $16.65

83720 O LIPOPROTEIN CHOLESTEROL FRACTIONATI $0.00
83721 3 ASSAY OF BLOOD LIPOPROTEIN $13.65
83725 O LITHIUM, BLOOD, QUANTITATIVE $0.00
83727 3 ASSAY OF LRH HORMONE $24.60
83728 O LYSERGIC ACID DIETHYLAMIDE (LSD), R $0.00
83730 O MACROGLOBULINS (SIA TEST) $0.00
83735 3 ASSAY OF MAGNESIUM $9.58
83740 O MAGNESIUM, BLOOD FLUOROMETRIC $0.00
83750 O MAGNESIUM, BLOOD ATOMIC ABSORPTION $0.00
83755 O MAGNESIUM, URINE CHEMICAL $0.00

83760 O MAGNESIUM, URINE FLUOROMETRIC $0.00
83765 O MAGNESIUM, URINE ATOMIC ABSORPTION $0.00
83775 3 ASSAY OF MD ENZYME $10.55
83785 3 ASSAY OF MANGANESE $15.57
83788 3 MASS SPECTROMETRY QUAL $25.84
83789 3 MASS SPECTROMETRY QUANT $25.84
83790 O MANNITOL CLEARANCE $0.00
83795 O MELANIN, URINE, QUALITATIVE $0.00
83799 O MEPERIDINE, QUANTITATIVE $0.00
83805 3 ASSAY OF MEPROBAMATE $25.23
83825 3 ASSAY OF MERCURY $23.27
83830 O MERCURY, QUANTITATIVE URINE $0.00
83835 3 ASSAY OF METANEPHRINES $24.25

83840 3 ASSAY OF METHADONE $23.30
83842 O METHAPYRILENE $0.00
83845 O METHAQUALONE $0.00
83857 3 ASSAY OF METHEMALBUMIN $15.37
83858 3 ASSAY OF METHSUXIMIDE $21.21
83859 O METHYPRYLON $0.00
83860 O MORPHINE SCREENING $0.00
83861 O MORPHINE QUANTITATIVE $0.00
83862 O MORPHINE RIA $0.00
83864 3 MUCOPOLYSACCHARIDES $28.49
83865 O MUCOPOLYSACCHARIDES, ACID, URINE QU $0.00
83866 3 MUCOPOLYSACCHARIDES SCREEN $14.10

83872 3 ASSAY SYNOVIAL FLUID MUCIN $8.39
83873 3 ASSAY OF CSF PROTEIN $24.62
83874 3 ASSAY OF MYOGLOBIN $18.48
83875 O MYOGLOBIN, URINE $0.00
83876 3 ASSAY, MYELOPEROXIDASE $18.53
83880 3 NATRIURETIC PEPTIDE $48.57
83883 3 ASSAY, NEPHELOMETRY NOT SPEC $19.45
83885 3 ASSAY OF NICKEL $35.05
83887 3 ASSAY OF NICOTINE $33.89
83890 3 MOLECULE ISOLATE $5.73

83891 3 MOLECULE ISOLATE NUCLEIC $5.73
83892 3 MOLECULAR DIAGNOSTICS $5.73
83893 3 MOLECULE DOT/SLOT/BLOT $5.73
83894 3 MOLECULE GEL ELECTROPHOR $5.73
83895 O NITROGEN, TOTAL URINE, 24-HOUR SPEC $0.00
83897 3 MOLECULE NUCLEIC TRANSFER $5.73
83898 3 MOLECULE NUCLEIC AMPLI, EACH $23.98
83900 3 MOLECULE NUCLEIC AMPLI 2 SEQ $47.97
83901 3 MOLECULE NUCLEIC AMPLI ADDON $23.98
83903 3 MOLECULE MUTATION SCAN $23.98
83904 3 MOLECULE MUTATION IDENTIFY $23.98

83907 3 LYSE CELLS FOR NUCLEIC EXT $19.11
83908 3 NUCLEIC ACID, SIGNAL AMPLI $23.98
83909 3 NUCLEIC ACID, HIGH RESOLUTE $23.98
83910 O NONPROTEIN NITROGEN (NPN), BLOOD $0.00
83912 3 GENETIC EXAMINATION $5.73
83913 3 NUCLEIC ACID PROBE, WITH ELECTROPHO $19.11
83914 3 MUTATION IDENT OLA/SBCE/ASPE $23.98
83915 3 ASSAY OF NUCLEOTIDASE $15.96
83916 3 OLIGOCLONAL BANDS $28.77
83917 O ORGANIC ACIDS SCREEN, QUALITATIVE $0.00

83918 3 ORGANIC ACIDS, TOTAL, QUANT $23.56
83919 3 ORGANIC ACIDS, QUAL, EACH $23.56
83920 O ORNITHINE CARBAMYL TRANSFERASE (OCT $0.00
83921 3 ORGANIC ACID, SINGLE, QUANT $23.56
83925 3 ASSAY OF OPIATES $27.84
83930 3 ASSAY OF BLOOD OSMOLALITY $9.46
83935 3 ASSAY OF URINE OSMOLALITY $9.75
83937 3 ASSAY OF OSTEOCALCIN $42.72
83938 O OUABAIN $0.00
83945 3 ASSAY OF OXALATE $18.42

83946 O OXAZEPAM $0.00
83947 O OXYBUTYRIC ACID, BETA $0.00
83948 O OXYCODINONE $0.00
83949 O OXYTOCINASE, RIA $0.00
83950 3 ONCOPROTEIN, HER-2/NEU $90.65
83951 3 ONCOPROTEIN, DCP $90.65
83965 O PARALDEHYDE, BLOOD, QUANTITATIVE $0.00
83970 3 ASSAY OF PARATHORMONE $59.06
83971 O PENICILLIN, URINE $0.00
83972 O PENTAZOCINE $0.00
83973 O PENTOSE, URINE, QUALITATIVE $0.00
83975 O PEPSINOGEN, BLOOD $0.00
83985 O PESTICIDE OTHER THAN CHLORINATED HY $0.00

83986 3 ASSAY OF BODY FLUID ACIDITY $3.36
83992 3 ASSAY FOR PHENCYCLIDINE $21.03
83993 3 ASSAY FOR CALPROTECTIN FECAL $28.09
83995 O PHENOL, BLOOD OR URINE $0.00
84005 O PHENOLSULFONPHTHALEIN (PSP) TEST, U $0.00
84021 O PHENOTHIAZINE, URINE QUALITATIVE, C $0.00
84022 3 ASSAY OF PHENOTHIAZINE $22.29
84030 3 ASSAY OF BLOOD PKU $7.88
84031 O PHENYLALANINE (PKU), BLOOD FLUOROME $0.00
84033 O PHENYLBUTAZONE $0.00
84035 3 ASSAY OF PHENYLKETONES $5.23
84037 O PHENYLKETONES URINE, QUALITATIVE $0.00

84038 O PHENYLPROPANOLAMINE $0.00
84039 O PHENYLPYRUVIC ACID BLOOD $0.00
84040 O PHENYLPYRUVIC ACID URINE $0.00
84045 O PHENYTOIN $0.00
84060 3 ASSAY ACID PHOSPHATASE $8.25
84061 3 PHOSPHATASE, FORENSIC EXAM $8.25
84065 O PHOSPHATASE, ACID PROSTATIC FRACTIO $0.00
84066 3 ASSAY PROSTATE PHOSPHATASE $13.42
84075 3 ASSAY ALKALINE PHOSPHATASE $6.53
84078 3 ASSAY ALKALINE PHOSPHATASE $10.45

84080 3 ASSAY ALKALINE PHOSPHATASES $21.16
84081 3 AMNIOTIC FLUID ENZYME TEST $23.64
84082 O PHOSPHATES, TUBULAR REABSORPTION OF $0.00
84083 O PHOSPHOGLUCOMUTASE, ISOENZYMES $0.00
84085 3 ASSAY OF RBC PG6D ENZYME $9.64
84087 3 ASSAY PHOSPHOHEXOSE ENZYMES $14.77
84090 O PHOSPHOLIPIDS, BLOOD $0.00
84100 3 ASSAY OF PHOSPHORUS $6.79
84105 3 ASSAY OF URINE PHOSPHORUS $7.41
84106 3 TEST FOR PORPHOBILINOGEN $6.13
84110 3 ASSAY OF PORPHOBILINOGEN $11.05
84118 O PORPHYRINS, COPRO-, URINE QUANTITAT $0.00
84119 3 TEST URINE FOR PORPHYRINS $12.32

84120 3 ASSAY OF URINE PORPHYRINS $20.89
84121 O PORPHYRINS URO-, COPRO- AND PORPHOB $0.00
84126 3 ASSAY OF FECES PORPHYRINS $36.45
84127 3 ASSAY OF FECES PORPHYRINS $16.67
84128 O PORPHYRINS, PLASMA $0.00
84132 3 ASSAY OF SERUM POTASSIUM $6.57
84133 3 ASSAY OF URINE POTASSIUM $6.15
84134 3 ASSAY OF PREALBUMIN $20.87
84135 3 ASSAY OF PREGNANEDIOL $27.38
84136 O PREGNANEDIOL OTHER METHOD (SPECIFY) $0.00
84138 3 ASSAY OF PREGNANETRIOL $27.10
84139 O PREGNANETRIOL OTHER METHOD (SPECIFY $0.00

84140 3 ASSAY OF PREGNENOLONE $29.59
84141 O PRIMIDONE $0.00
84142 O PROCAINAMIDE $0.00
84143 3 ASSAY OF 17-HYDROXYPREGNENO $32.65
84146 3 ASSAY OF PROLACTIN $27.73
84147 O PROPOXYPHENE $0.00
84149 O PROPRANOLOL $0.00
84150 3 ASSAY OF PROSTAGLANDIN $35.72
84152 3 ASSAY OF PSA, COMPLEXED $26.31

84153 3 ASSAY OF PSA, TOTAL $26.31
84154 3 ASSAY OF PSA, FREE $26.31
84155 3 ASSAY OF PROTEIN, SERUM $4.78
84156 3 ASSAY OF PROTEIN, URINE $4.78
84157 3 ASSAY OF PROTEIN, OTHER $4.78
84160 3 ASSAY OF PROTEIN, ANY SOURCE $7.41
84163 3 PAPPA, SERUM $20.76
84165 3 PROTEIN E-PHORESIS, SERUM $15.37
84166 3 PROTEIN E-PHORESIS/URINE/CSF $25.52
84170 O PROTEIN, TOTAL, AND ALBUMIN/GLOBULI $0.00
84175 O PROTEIN;ELECTROPHORESIS,OTHER SOURC $0.00
84176 O PROTEIN, SPECIAL STUDIES (EG, MONOC $0.00
84180 O PROTEIN, URINE QUANTITATIVE, 24-HOU $0.00

84181 3 WESTERN BLOT TEST $24.37
84182 3 PROTEIN, WESTERN BLOT TEST $25.75
84185 O PROTEIN, URINE BENCE-JONES $0.00
84190 O PROTEIN, URINE ELECTROPHORETIC FRAC $0.00
84195 O PROTEIN, SPINAL FLUID SEMI-QUANTITA $0.00
84200 O PROTEIN, SPINAL FLUID ELECTROPHORET $0.00
84201 O PROTIRELIN, THYROTROPIN RELEASING H $0.00
84202 3 ASSAY RBC PROTOPORPHYRIN $20.53
84203 3 TEST RBC PROTOPORPHYRIN $12.32
84205 O PROTRIPTYLENE $0.00
84206 3 ASSAY OF PROINSULIN $11.17
84207 3 ASSAY OF VITAMIN B-6 $40.20

84208 O PYROPHOSPHATE VS URATE, CRYSTALS (P $0.00
84210 3 ASSAY OF PYRUVATE $15.53
84220 3 ASSAY OF PYRUVATE KINASE $13.49
84228 3 ASSAY OF QUININE $16.65
84230 O QUINIDINE, BLOOD $0.00
84231 O RADIOIMMUNOASSAY (RIA) NOT ELSEWHER $0.00
84232 O RELEASING FACTOR $0.00
84233 3 ASSAY OF ESTROGEN $90.65
84235 3 ASSAY OF ENDOCRINE HORMONE $74.88

84236 O RECEPTOR ASSAY PROGESTERONE AND EST $0.00
84238 3 ASSAY, NONENDOCRINE RECEPTOR $52.32
84244 3 ASSAY OF RENIN $31.48
84246 O RENIN (ANGIOTENSIN I) FUROSEMIDE TE $0.00
84255 3 ASSAY OF SELENIUM $36.52
84260 3 ASSAY OF SEROTONIN $44.33
84270 3 ASSAY OF SEX HORMONE GLOBUL $28.22
84275 3 ASSAY OF SIALIC ACID $19.22
84285 3 ASSAY OF SILICA $33.69
84295 3 ASSAY OF SERUM SODIUM $6.65
84300 3 ASSAY OF URINE SODIUM $6.96
84302 3 ASSAY OF SWEAT SODIUM $6.96

84305 3 ASSAY OF SOMATOMEDIN $28.10
84307 3 ASSAY OF SOMATOSTATIN $26.17
84310 O SORBITOL DEHYDROGENASE, SERUM $0.00
84311 3 SPECTROPHOTOMETRY $10.00
84315 3 BODY FLUID SPECIFIC GRAVITY $3.59
84318 O STERCOBILIN, QUALITATIVE, FECES $0.00
84324 O STRYCHNINE $0.00
84375 3 CHROMATOGRAM ASSAY, SUGARS $28.05
84376 3 SUGARS, SINGLE, QUAL $7.88
84377 3 SUGARS, MULTIPLE, QUAL $7.88
84378 3 SUGARS, SINGLE, QUANT $16.49
84379 3 SUGARS MULTIPLE QUANT $16.49

84392 3 ASSAY OF URINE SULFATE $6.79
84395 O SULFONAMIDE, BLOOD, CHEMICAL $0.00
84402 3 ASSAY OF TESTOSTERONE $36.44
84403 3 ASSAY OF TOTAL TESTOSTERONE $36.95
84405 O TESTOSTERONE, URINE, RIA $0.00
84406 O TESTOSTERONE, BINDING PROTEIN $0.00
84407 O TETRACAINE $0.00
84408 O TETRAHYDROCANNABINOL THC (MARIJUANA $0.00
84409 O TETRAHYDROCORTISONE OR TETRAHYDROCO $0.00
84410 O THALLIUM, BLOOD OR URINE $0.00

84420 O THEOPHYLLINE, BLOOD OR SALIVA $0.00
84430 3 ASSAY OF THIOCYANATE $6.53
84432 3 ASSAY OF THYROGLOBULIN $22.98
84434 O THIORIDAZINE $0.00
84435 O THYROXINE, (T-4), CPB OR RESIN UPTA $0.00
84436 3 ASSAY OF TOTAL THYROXINE $9.83
84437 3 ASSAY OF NEONATAL THYROXINE $9.26
84439 3 ASSAY OF FREE THYROXINE $12.91
84442 3 ASSAY OF THYROID ACTIVITY $21.16
84443 3 ASSAY THYROID STIM HORMONE $24.04
84444 O THYROTROPIN RELEASING FACTOR (TRF) $0.00
84445 3 ASSAY OF TSI $72.76

84446 3 ASSAY OF VITAMIN E $20.29
84447 O TOXICOLOGY, SCREEN GENERAL $0.00
84448 O TOXICOLOGY, SCREEN SEDATIVE (ACID A $0.00
84449 3 ASSAY OF TRANSCORTIN $25.75
84450 3 TRANSFERASE (AST) (SGOT) $7.40
84455 O TRANSAMINASE, GLUTAMIC OXALOACETIC $0.00
84460 3 ALANINE AMINO (ALT) (SGPT) $7.58
84465 O TRANSAMINASE, GLUTAMIC PYRUVIC (SGP $0.00
84466 3 ASSAY OF TRANSFERRIN $18.27
84472 O TRICHLOROETHANOL $0.00
84474 O TRICHLOROACETIC ACID $0.00
84476 O TRIFLUOPERAZINE $0.00

84478 3 ASSAY OF TRIGLYCERIDES $8.23
84479 3 ASSAY OF THYROID (T3 OR T4) $9.26
84480 3 ASSAY, TRIIODOTHYRONINE (T3) $20.29
84481 3 FREE ASSAY (FT-3) $24.25
84482 3 T3 REVERSE $22.55
84483 O TRIMETHADIONE $0.00
84484 3 ASSAY OF TROPONIN, QUANT $12.47
84485 3 ASSAY DUODENAL FLUID TRYPSIN $10.74
84488 3 TEST FECES FOR TRYPSIN $10.45
84490 3 ASSAY OF FECES FOR TRYPSIN $10.89

84510 3 ASSAY OF TYROSINE $14.88
84512 3 ASSAY OF TROPONIN, QUAL $10.55
84520 3 ASSAY OF UREA NITROGEN $5.64
84525 3 UREA NITROGEN SEMI-QUANT $5.38
84540 3 ASSAY OF URINE/UREA-N $6.79
84545 3 UREA-N CLEARANCE TEST $9.45
84550 3 ASSAY OF BLOOD/URIC ACID $6.46
84555 O URIC ACID URICASE, ULTRAVIOLET METH $0.00
84560 3 ASSAY OF URINE/URIC ACID $4.95
84565 O UROBILIN, URINE QUALITATIVE $0.00
84570 O UROBILIN, URINE QUANTITATIVE, TIMED $0.00
84575 O UROBILIN, FECES, QUANTITATIVE $0.00
84577 3 ASSAY OF FECES/UROBILINOGEN $17.86

84578 3 TEST URINE UROBILINOGEN $4.12
84580 3 ASSAY OF URINE UROBILINOGEN $10.15
84583 3 ASSAY OF URINE UROBILINOGEN $7.19
84584 O UROPEPSIN, URINE $0.00
84585 3 ASSAY OF URINE VMA $22.19
84586 3 ASSAY OF VIP $50.56
84588 3 ASSAY OF VASOPRESSIN $48.57
84589 O VISCOSITY $0.00
84590 3 ASSAY OF VITAMIN A $16.59
84591 3 ASSAY OF NOS VITAMIN $16.59
84595 O VITAMIN A, BLOOD INCLUDING CAROTENE $0.00
84597 3 ASSAY OF VITAMIN K $19.61

84600 3 ASSAY OF VOLATILES $23.00
84605 O VOLUME, BLOOD, DYE METHOD (EVANS BL $0.00
84610 O VOLUME, BLOOD, DYE METHOD (EVANS BL $0.00
84613 O WARFARIN $0.00
84615 O XANTHURENIC ACID $0.00
84620 3 XYLOSE TOLERANCE TEST $6.65
84630 3 ASSAY OF ZINC $16.30
84635 O ZINC, QUANTITATIVE URINE $0.00
84681 3 ASSAY OF C-PEPTIDE $29.77
84695 O GENTAMICIN $0.00

84702 3 CHORIONIC GONADOTROPIN TEST $20.76
84703 3 CHORIONIC GONADOTROPIN ASSAY $10.75
84704 3 HCG, FREE BETACHAIN TEST $20.76
84800 O THYROID STIMULATING HORMONE (TSH), $0.00
84810 O TOBRAMYCIN $0.00
84830 9 OVULATION TESTS $0.00
84999 5 CLINICAL CHEMISTRY TEST $0.00
85000 O BLEEDING TIME DUKE $0.00
85002 3 BLEEDING TIME TEST $6.44
85004 3 AUTOMATED DIFF WBC COUNT $9.26
85005 O BLOOD COUNT BASOPHIL COUNT, DIRECT $0.00
85007 3 BL SMEAR W/DIFF WBC COUNT $4.92
85008 3 BL SMEAR W/O DIFF WBC COUNT $4.92

85009 3 MANUAL DIFF WBC COUNT B-COAT $5.32
85012 O BLOOD COUNT EOSINOPHIL COUNT, DIREC $0.00
85013 3 SPUN MICROHEMATOCRIT $3.39
85014 3 HEMATOCRIT $3.39
85018 3 HEMOGLOBIN $3.39
85021 O AUTOMATED HEMOGRAM $0.00
85025 3 COMPLETE CBC W/AUTO DIFF WBC $11.12
85027 3 COMPLETE CBC, AUTOMATED $9.26

85031 O MANUAL HEMOGRAM, CBC $0.00
85032 3 MANUAL CELL COUNT, EACH $6.15
85041 3 AUTOMATED RBC COUNT $4.12
85044 3 MANUAL RETICULOCYTE COUNT $6.15
85045 3 AUTOMATED RETICULOCYTE COUNT $5.73
85046 3 RETICYTE/HGB CONCENTRATE $7.99
85048 3 AUTOMATED LEUKOCYTE COUNT $3.64
85049 3 AUTOMATED PLATELET COUNT $6.40
85055 3 RETICULATED PLATELET ASSAY $38.31

85060 3 BLOOD SMEAR INTERPRETATION $25.45
85095 O BONE MARROW ASPIRATION $0.00
85097 3 BONE MARROW INTERPRETATION $104.59
85100 O BONE MARROW SMEAR AND/OR CELL BLOCK $0.00
85101 O BONE MARROW SMEAR AND/OR CELL BLOCK $0.00
85102 O BONE MARROW BIOPSY $0.00
85103 O BONE MARROW BIOPSY, NEEDLE OR TROCA $0.00
85130 3 CHROMOGENIC SUBSTRATE ASSAY $17.02
85170 3 BLOOD CLOT RETRACTION $5.17
85171 O CLOT RETRACTION QUANTITATIVE $0.00
85172 O CLOT RETRACTION INHIBITION BY DRUGS $0.00

85175 3 BLOOD CLOT LYSIS TIME $6.51
85210 3 BLOOD CLOT FACTOR II TEST $8.25
85220 3 BLOOD CLOT FACTOR V TEST $25.25
85230 3 BLOOD CLOT FACTOR VII TEST $25.62
85240 3 BLOOD CLOT FACTOR VIII TEST $25.62
85242 O CLOTTING FACTOR VIII (AHG), TWO STA $0.00
85250 3 BLOOD CLOT FACTOR IX TEST $27.23
85260 3 BLOOD CLOT FACTOR X TEST $25.62

85270 3 BLOOD CLOT FACTOR XI TEST $25.62
85280 3 BLOOD CLOT FACTOR XII TEST $27.69
85290 3 BLOOD CLOT FACTOR XIII TEST $11.58
85291 3 BLOOD CLOT FACTOR XIII TEST $11.58
85292 3 BLOOD CLOT FACTOR ASSAY $27.10
85293 3 BLOOD CLOT FACTOR ASSAY $27.10
85300 3 ANTITHROMBIN III TEST $13.85
85301 3 ANTITHROMBIN III TEST $15.47
85302 3 BLOOD CLOT INHIBITOR ANTIGEN $17.20
85303 3 BLOOD CLOT INHIBITOR TEST $19.79

85305 3 BLOOD CLOT INHIBITOR ASSAY $16.59
85306 3 BLOOD CLOT INHIBITOR TEST $21.92
85307 3 ASSAY ACTIVATED PROTEIN C $21.92
85310 O CLOTTING INHIBITORS OR ANTICOAGULAN $0.00
85335 3 FACTOR INHIBITOR TEST $18.42
85337 3 THROMBOMODULIN $14.92
85345 3 COAGULATION TIME $4.78

85360 3 EUGLOBULIN LYSIS $12.00
85362 3 FIBRIN DEGRADATION PRODUCTS $9.86
85363 O FIBRIN DEGRADATION (SPLIT) PRODUCTS $0.00
85366 3 FIBRINOGEN TEST $12.32
85370 3 FIBRINOGEN TEST $11.58
85371 O FIBRINOGEN, SEMIQUANTITATIVE LATEX $0.00

85372 O FIBRINOGEN, SEMIQUANTITATIVE TURBID $0.00
85376 O FIBRINOGEN THROMBIN WITH PLASMA DIL $0.00
85377 O FIBRINOGEN THROMBIN TIME DILUTION $0.00
85378 3 FIBRIN DEGRADE, SEMIQUANT $10.20
85379 3 FIBRIN DEGRADATION, QUANT $11.58
85380 3 FIBRIN DEGRADATION, VTE $11.58
85384 3 FIBRINOGEN $12.15
85385 3 FIBRINOGEN $12.15
85390 3 FIBRINOLYSINS SCREEN $7.39
85392 O FIBRINOLYSINS WITH EACA CONTROL $0.00

85395 O FIBRINOLYSINS SEMIQUANTITATIVE $0.00
85396 3 CLOTTING ASSAY, WHOLE BLOOD $21.84
85397 3 CLOTTING FUNCT ACTIVITY $32.84
85398 O FIBRINOLYSIS, QUANTITATIVE $0.00
85400 3 FIBRINOLYTIC PLASMIN $12.65
85410 3 FIBRINOLYTIC ANTIPLASMIN $11.03
85415 3 FIBRINOLYTIC PLASMINOGEN $20.79
85426 O FIBRINOLYTIC MECHANISMS VON WILLEBR $0.00
85441 3 HEINZ BODIES, DIRECT $6.02
85445 3 HEINZ BODIES, INDUCED $8.25
85460 3 HEMOGLOBIN, FETAL $11.07

85461 3 HEMOGLOBIN, FETAL $9.50
85475 3 HEMOLYSIN $11.17
85520 3 HEPARIN ASSAY $18.73
85525 3 HEPARIN NEUTRALIZATION $16.95
85530 3 HEPARIN-PROTAMINE TOLERANCE $20.29
85535 O IRON STAIN, BLOOD CELLS $0.00
85536 3 IRON STAIN PERIPHERAL BLOOD $9.26
85538 O LEDER STAIN (ESTERASE) BLOOD OR BON $0.00
85540 3 WBC ALKALINE PHOSPHATASE $12.31
85544 O LUPUS ERYTHEMATOSUS (LE) CELL PREP $0.00
85547 3 RBC MECHANICAL FRAGILITY $12.31
85548 O MORPHOLOGY OF RED BLOOD CELLS, ONLY $0.00

85549 3 MURAMIDASE $20.77
85555 3 RBC OSMOTIC FRAGILITY $9.56
85556 O OSMOTIC FRAGILITY, RBC INCUBATED, Q $0.00
85557 3 RBC OSMOTIC FRAGILITY $19.11
85560 O PEROXIDASE STAIN, WBC $0.00
85575 O PLATELET; IN VITRO AGGREGATION,EACH $0.00
85576 3 BLOOD PLATELET AGGREGATION $30.74
85577 O PLATELET RETENTION (IN VITRO), GLAS $0.00
85580 O PLATELET COUNT (REES-ECKER) $0.00
85585 O BLOOD PLATELET ESTIMATION $0.00

85590 O PLATELET COUNT, MANUAL $0.00
85595 O PLATELET COUNT, AUTOMATED $0.00
85597 3 PLATELET NEUTRALIZATION $25.72
85610 3 PROTHROMBIN TIME $5.63
85611 3 PROTHROMBIN TEST $5.64
85612 3 VIPER VENOM PROTHROMBIN TIME $13.69
85613 3 RUSSELL VIPER VENOM, DILUTED $13.69
85615 O PROTHROMBIN UTILIZATION (CONSUMPTIO $0.00
85618 O PROTHROMBIN-PROCONVERTIN, P&P (OWRE $0.00
85630 O RED BLOOD CELL SIZE (PRICE-JONES) $0.00
85632 O RED BLOOD CELL PEROXIDE HEMOLYSIS $0.00
85635 3 REPTILASE TEST $10.01
85650 O SEDIMENTATION RATE (ESR) WINTROBE T $0.00

85651 3 RBC SED RATE, NONAUTOMATED $5.08
85652 3 RBC SED RATE, AUTOMATED $3.86
85660 3 RBC SICKLE CELL TEST $6.46
85665 O STREPTOKINASE TITER (PLASMINOGEN AC $0.00
85667 O T-CELL DEPLETION (ANY METHOD) OF BO $0.00
85670 3 THROMBIN TIME, PLASMA $8.27
85675 3 THROMBIN TIME, TITER $9.80
85700 O THROMBOPLASTIN GENERATION TEST SCRE $0.00
85705 3 THROMBOPLASTIN INHIBITION $12.18
85710 O THROMBOPLASTIN GENERATION TEST DEFI $0.00
85711 O THROMBOPLASTIN GENERATION TEST WITH $0.00
85720 O THROMBOPLASTIN GENERATION TEST ALL $0.00

85730 3 THROMBOPLASTIN TIME, PARTIAL $8.58
85732 3 THROMBOPLASTIN TIME, PARTIAL $9.26
85810 3 BLOOD VISCOSITY EXAMINATION $16.71
85820 O VISCOSITY SERUM OR PLASMA $0.00
85999 5 HEMATOLOGY PROCEDURE $0.00
86000 3 AGGLUTININS, FEBRILE $9.99
86001 3 ALLERGEN SPECIFIC IGG $7.47
86002 O AGGLUTININS FEBRILE PANEL (TYPHOID $0.00
86003 3 ALLERGEN SPECIFIC IGE $7.47
86004 O AGGLUTININS WARM $0.00

86005 3 ALLERGEN SPECIFIC IGE $4.15
86006 O ANTIBODY, NON-RBC QUALITATIVE FIRST $0.00
86007 O ANTIBODY, NON-RBC QUALITATIVE EACH $0.00
86008 O ANTIBODY, NON-RBC, QUANTITATIVE FIR $0.00
86009 O ANTIBODY, NON-RBC, QUANTITATIVE EAC $0.00
86011 O ANTIBODY, DETECTION, LEUKOCYTE ANTI $0.00
86012 O ANTIBODY ABSORPTION, COLD AUTO ABSO $0.00
86013 O ANTIBODY ABSORPTION, COLD AUTO ABSO $0.00
86014 O ANTIBODY, PLATELET ANTIBODIES (AGGL $0.00
86016 O ANTIBODY SCREEN, RBC, EACH SERUM $0.00
86019 O ANTIBODY (RBC) ELUTION, ANY METHOD, $0.00
86021 3 WBC ANTIBODY IDENTIFICATION $19.03
86022 3 PLATELET ANTIBODIES $19.03

86023 3 IMMUNOGLOBULIN ASSAY $17.83
86024 O ANTIBODY IDENTIFICATION RBC ANTIBOD $0.00
86031 O ANTIHUMAN GLOBULIN TEST DIRECT (COO $0.00
86032 O ANTIHUMAN GLOBULIN TEST INDIRECT, Q $0.00
86033 O ANTIHUMAN GLOBULIN TEST INDIRECT, T $0.00
86034 O ANTIHUMAN GLOBULIN TEST ENZYME TECH $0.00
86038 3 ANTINUCLEAR ANTIBODIES $17.30
86039 3 ANTINUCLEAR ANTIBODIES (ANA) $15.97
86060 3 ANTISTREPTOLYSIN O, TITER $10.45
86063 3 ANTISTREPTOLYSIN O, SCREEN $8.27
86064 O B CELLS, TOTAL COUNT $0.00
86066 O ANTITRYPSIN, ALPHA-1 PI (PROTEASE I $0.00

86067 O ANTITRYPSIN, ALPHA-1 OTHER METHOD ( $0.00
86068 O BLOOD COMPATIBILITY TEST CROSSMATCH $0.00
86070 O BLOOD COMPATIBILITY TEST CROSSMATCH $0.00
86077 9 PHYSICIAN BLOOD BANK SERVICE $0.00
86080 O BLOOD TYPING ABO ONLY $0.00
86082 O BLOOD TYPING ABO AND RHO(D) $0.00
86083 O BLOOD TYPING ABO, RH(D) AND RBC ANT $0.00
86084 O BLOOD TYPING ANTIGEN SCREENING FOR $0.00

86085 O BLOOD TYPING ANTIGEN SCREENING FOR $0.00
86095 O BLOOD TYPING RBC ANTIGENS, OTHER TH $0.00
86100 O BLOOD TYPING RHO(D) ONLY $0.00
86105 O BLOOD TYPING RH GENOTYPING, COMPLET $0.00
86115 O BLOOD TYPING ANTI-RH IMMUNOGLOBULIN $0.00
86128 O COLLECTION, PROCESSING AND STORAGE $0.00
86130 O COLLECTION AND PROCESSING FOR TRANS $0.00
86140 3 C-REACTIVE PROTEIN $7.41
86141 3 C-REACTIVE PROTEIN, HS $18.53
86146 3 GLYCOPROTEIN ANTIBODY $36.40
86147 3 CARDIOLIPIN ANTIBODY $36.40
86148 3 PHOSPHOLIPID ANTIBODY $14.20
86149 O CARCINOEMBRYONIC ANTIGEN (CEA) GEL $0.00

86151 O CARCINOEMBRYONIC ANTIGEN (CEA) RIA $0.00
86155 3 CHEMOTAXIS ASSAY $22.86
86156 3 COLD AGGLUTININ, SCREEN $9.13
86157 3 COLD AGGLUTININ, TITER $11.53
86158 O COMPLEMENT C'1 ESTERASE $0.00
86160 3 COMPLEMENT, ANTIGEN $17.18
86161 3 COMPLEMENT/FUNCTION ACTIVITY $17.18
86162 3 COMPLEMENT, TOTAL (CH50) $29.08
86171 3 COMPLEMENT FIXATION, EACH $10.11

86185 3 COUNTERIMMUNOELECTROPHORESIS $12.80
86200 3 CCP ANTIBODY $18.53
86215 3 DEOXYRIBONUCLEASE, ANTIBODY $18.96
86225 3 DNA ANTIBODY $19.66
86226 3 DNA ANTIBODY, SINGLE STRAND $17.33
86235 3 NUCLEAR ANTIGEN ANTIBODY $25.66
86243 3 FC RECEPTOR $29.36
86244 O FETO-PROTEIN, ALPHA-1, RIA OR EIA $0.00
86255 3 FLUORESCENT ANTIBODY, SCREEN $17.25
86256 3 FLUORESCENT ANTIBODY, TITER $12.51

86265 O FROZEN BLOOD, PREPARATION FOR FREEZ $0.00
86277 3 GROWTH HORMONE ANTIBODY $22.52
86280 3 HEMAGGLUTINATION INHIBITION $11.72
86281 O HEMOLYSINS, ACID (FOR PAROXYSMAL HE $0.00
86282 O HEMOLYSINS AND AGGLUTININS, AUTO, S $0.00
86283 O HEMOLYSINS AND AGGLUTININS, AUTO, S $0.00
86287 O HEPATITIS B SURFACE ANTIGEN (HBSAG) $0.00
86288 O HEPATITIS B CORE ANTIGEN (HBCAG), R $0.00
86289 O HEPATITIS B CORE ANTIBODY (HBCAB); $0.00
86290 O HEPATITIS B CORE ANTIBODY (HBCAB); $0.00
86291 O HEPATITIS B SURFACE ANTIBODY (HBSAB $0.00

86293 O HEPATITIS BE ANTIGEN (HBEAG) $0.00
86294 3 IMMUNOASSAY, TUMOR, QUAL $25.04
86295 O HEPATITIS BE ANTIBODY (HBEAB) $0.00
86296 O HEPATITIS A ANTIBODY (HAAB); IGG AN $0.00
86298 O HEPATITIS A ANTIBODY (HAAB) (EG, RI $0.00
86299 O HEPATITIS A ANTIBODY (HAAB); IGM AN $0.00
86300 3 IMMUNOASSAY, TUMOR, CA 15-3 $29.77
86301 3 IMMUNOASSAY, TUMOR, CA 19-9 $29.77
86302 O HEPATITIS C ANTIBODY; $0.00
86303 O HEPATITIS C ANTIBODY; CONFIRMATORY $0.00
86304 3 IMMUNOASSAY, TUMOR, CA 125 $29.77
86305 O HETEROPHILE ANTIBODIES QUANTITATIVE $0.00

86306 O HEPATITIS, DELTA AGENT $0.00
86308 3 HETEROPHILE ANTIBODIES $7.41
86311 O HIV, ANTIGEN $0.00
86312 O HIV (HTLV-III) ANTIBODY DETECTION I $0.00
86313 O IMMUNOASSAY FOR INFECTIOUS AGENT AN $0.00
86314 O HIV (HTLV-III) ANTIBODY DETECTION C $0.00
86315 O IMMUNOASSAY FOR INFECTIOUS AGENT AN $0.00
86316 3 IMMUNOASSAY, TUMOR OTHER $29.77

86317 3 IMMUNOASSAY,INFECTIOUS AGENT $21.45
86318 3 IMMUNOASSAY,INFECTIOUS AGENT $18.53
86319 O IMMUNOASSAY TECHNIQUE FOR DRUGS $0.00
86320 3 SERUM IMMUNOELECTROPHORESIS $32.07
86325 3 OTHER IMMUNOELECTROPHORESIS $30.50
86327 3 IMMUNOELECTROPHORESIS ASSAY $32.47
86329 3 IMMUNODIFFUSION $20.10
86331 3 IMMUNODIFFUSION OUCHTERLONY $17.15
86332 3 IMMUNE COMPLEX ASSAY $34.88
86333 O IMMUNE COMPLEX ASSAY RAJI CELL $0.00
86334 3 IMMUNOFIX E-PHORESIS, SERUM $31.97
86335 3 IMMUNOFIXATION ELECTROPHORESIS; OT $41.99
86336 3 INHIBIN A $22.29

86337 3 INSULIN ANTIBODIES $20.91
86338 O INSULIN FACTOR ANTIBODIES, RIA $0.00
86340 3 INTRINSIC FACTOR ANTIBODY $21.57
86341 3 ISLET CELL ANTIBODY $28.31
86342 O IRRADIATION OF BLOOD PRODUCTS, EACH $0.00
86343 3 LEUKOCYTE HISTAMINE RELEASE $17.84
86344 3 LEUKOCYTE PHAGOCYTOSIS $11.43
86349 O LEUKOCYTE TRANSFUSION (LEUKAPHERESI $0.00
86353 3 LYMPHOCYTE TRANSFORMATION $70.15
86355 3 B CELLS, TOTAL COUNT $53.98
86356 3 MONONUCLEAR CELL ANTIGEN $38.31
86357 3 NATURAL KILLER (NK) CELLS, TOTAL C $53.98

86358 O LYMPHOCYTES B-CELL EVALUATION $0.00
86359 3 T CELLS, TOTAL COUNT $53.98
86360 3 T CELL, ABSOLUTE COUNT/RATIO $67.23
86361 3 T CELL, ABSOLUTE COUNT $38.31
86367 3 STEM CELLS, TOTAL COUNT $53.98
86376 3 MICROSOMAL ANTIBODY $20.83
86377 O MICROSOMAL ANTIBODY (THYROID) OTHER $0.00
86378 3 MIGRATION INHIBITORY FACTOR $28.18
86379 O NK CELLS, TOTAL COUNT $0.00
86382 3 NEUTRALIZATION TEST, VIRAL $24.20

86384 3 NITROBLUE TETRAZOLIUM DYE $16.30
86385 O PATERNITY TESTING, ABO+RH FACTORS+M $0.00
86386 O PATERNITY TESTING, ABO+RH FACTORS+M $0.00
86403 3 PARTICLE AGGLUTINATION TEST $14.58
86404 O POOLING OF PLATELETS OR OTHER BLOOD $0.00
86405 O PRECIPITIN TEST FOR BLOOD (SPECIES $0.00
86406 3 PARTICLE AGGLUTINATION TEST $15.22
86410 O PRETREATMENT OF RBC'S FOR USE IN RB $0.00
86417 O PRETREATMENT OF SERUM FOR USE IN RB $0.00

86421 O RADIOALLERGOSORBENT TEST, IN VITRO $0.00
86422 9 RADIOALLERGOSORBENT TEST, IN VITRO $0.00
86423 O RADIOIMMUNOSORBENT TEST (RIST) IGE, $0.00
86430 3 RHEUMATOID FACTOR TEST $8.12
86431 3 RHEUMATOID FACTOR, QUANT $8.12
86455 O SKIN TEST ANERGY TESTING, ONE OR MO $0.00
86480 3 TB TEST, CELL IMMUN MEASURE $88.68
86485 5 SKIN TEST, CANDIDA $0.00
86486 6 SKIN TEST, NOS ANTIGEN $0.00
86490 3 COCCIDIOIDOMYCOSIS SKIN TEST $11.81
86510 3 HISTOPLASMOSIS SKIN TEST $12.97

86540 O SKIN TEST MUMPS $0.00
86580 3 TB INTRADERMAL TEST $5.00
86585 O TB TINE TEST $0.00
86586 O SKIN TEST, UNLISTED $0.00
86587 O STEM CELLS (IE, CD34), TOTAL COUNT $0.00
86588 O STREPTOCOLLUS, DIRECT SCREEN $0.00
86590 3 STREPTOKINASE, ANTIBODY $15.79
86592 3 BLOOD SEROLOGY, QUALITATIVE $5.87
86593 3 BLOOD SEROLOGY, QUANTITATIVE $6.25
86594 O THYROID AUTOANTIBODIES $0.00

86595 O TISSUE CULTURE $0.00
86600 O TOXOPLASMOSIS, DYE TEST $0.00
86602 3 ANTINOMYCES ANTIBODY $14.55
86603 3 ADENOVIRUS ANTIBODY $18.41
86606 3 ASPERGILLUS ANTIBODY $21.54
86609 3 BACTERIUM ANTIBODY $18.43
86611 3 BARTONELLA ANTIBODY $14.55
86612 3 BLASTOMYCES ANTIBODY $18.46
86615 3 BORDETELLA ANTIBODY $18.87
86617 3 LYME DISEASE ANTIBODY $22.16
86618 3 LYME DISEASE ANTIBODY $24.37
86619 3 BORRELIA ANTIBODY $19.15
86622 3 BRUCELLA ANTIBODY $11.70

86625 3 CAMPYLOBACTER ANTIBODY $18.78
86628 3 CANDIDA ANTIBODY $17.18
86630 O TRANSFER FACTOR TEST (TFT) $0.00
86631 3 CHLAMYDIA ANTIBODY $10.11
86632 3 CHLAMYDIA IGM ANTIBODY $18.16
86635 3 COCCIDIOIDES ANTIBODY $16.42
86638 3 Q FEVER ANTIBODY $17.35
86641 3 CRYPTOCOCCUS ANTIBODY $20.63
86644 3 CMV ANTIBODY $20.60
86645 3 CMV ANTIBODY, IGM $24.11
86648 3 DIPHTHERIA ANTIBODY $21.77
86650 O TREPONEMA ANTIBODIES, FLUORESCENT, $0.00

86651 3 ENCEPHALITIS ANTIBODY $18.87
86658 3 ENTEROVIRUS ANTIBODY $18.65
86662 O TREPONEMA PALLIDUM TEST, OTHER, SPE $0.00
86663 3 EPSTEIN-BARR ANTIBODY $18.78
86666 3 EHRLICHIA ANTIBODY $14.55

86668 3 FRANCISELLA TULARENSIS $14.88
86671 3 FUNGUS ANTIBODY $17.54
86674 3 GIARDIA LAMBLIA ANTIBODY $21.07
86677 3 HELICOBACTER PYLORI $20.77
86681 O ADRENAL CORTEX ANTIBODIES, RIA $0.00
86682 3 HELMINTH ANTIBODY $18.61
86683 O HEMOGLOBIN, FECAL ANTIBODY $0.00
86684 3 HEMOPHILUS INFLUENZA $22.67
86685 O ANTI-ACHR (ACETYLCHOLINE RECEPTOR) $0.00
86687 3 HTLV-I ANTIBODY $12.00
86688 3 HTLV-II ANTIBODY $15.11
86689 3 HTLV/HIV CONFIRMATORY TEST $27.69
86692 3 HEPATITIS, DELTA AGENT $24.56

86694 3 HERPES SIMPLEX TEST $20.60
86695 3 HERPES SIMPLEX TEST $18.87
86696 3 HERPES SIMPLEX TYPE 2 $27.69
86698 3 HISTOPLASMA $17.88
86701 3 HIV-1 $12.70
86702 3 HIV-2 $15.11
86703 3 HIV-1/HIV-2, SINGLE ASSAY $19.62
86704 3 HEP B CORE ANTIBODY, TOTAL $17.25
86705 3 HEP B CORE ANTIBODY, IGM $16.84
86706 3 HEP B SURFACE ANTIBODY $15.37
86707 3 HEP BE ANTIBODY $16.55
86708 3 HEP A ANTIBODY, TOTAL $17.73

86709 3 HEP A ANTIBODY, IGM $16.11
86710 3 INFLUENZA VIRUS ANTIBODY $19.40
86713 3 LEGIONELLA ANTIBODY $21.90
86717 3 LEISHMANIA ANTIBODY $17.53
86720 3 LEPTOSPIRA ANTIBODY $18.87
86723 3 LISTERIA MONOCYTOGENES AB $18.87
86727 3 LYMPH CHORIOMENINGITIS AB $18.41
86729 3 LYMPHO VENEREUM ANTIBODY $10.11
86732 3 MUCORMYCOSIS ANTIBODY $18.87
86735 3 MUMPS ANTIBODY $18.68

86738 3 MYCOPLASMA ANTIBODY $18.95
86741 3 NEISSERIA MENINGITIDIS $18.87
86744 3 NOCARDIA ANTIBODY $18.87
86747 3 PARVOVIRUS ANTIBODY $21.51
86750 3 MALARIA ANTIBODY $18.87
86753 3 PROTOZOA ANTIBODY NOS $17.73
86756 3 RESPIRATORY VIRUS ANTIBODY $18.44
86757 3 RICKETTSIA ANTIBODY $27.69
86759 3 ROTAVIRUS ANTIBODY $18.87
86762 3 RUBELLA ANTIBODY $20.60
86765 3 RUBEOLA ANTIBODY $14.01
86768 3 SALMONELLA ANTIBODY $18.87
86771 3 SHIGELLA ANTIBODY $18.87

86774 3 TETANUS ANTIBODY $21.18
86777 3 TOXOPLASMA ANTIBODY $20.60
86778 3 TOXOPLASMA ANTIBODY, IGM $20.61
86781 3 TREPONEMA PALLIDUM, CONFIRM $18.95
86784 3 TRICHINELLA ANTIBODY $17.97
86787 3 VARICELLA-ZOSTER ANTIBODY $18.43
86788 3 WEST NILE VIRUS AB, IGM $24.11
86789 3 WEST NILE VIRUS ANTIBODY $20.60
86790 3 VIRUS ANTIBODY NOS $18.43
86793 3 YERSINIA ANTIBODY $12.42
86800 3 THYROGLOBULIN ANTIBODY $22.76
86803 3 HEPATITIS C AB TEST $20.42

86804 3 HEP C AB TEST, CONFIRM $22.16
86805 3 LYMPHOCYTOTOXICITY ASSAY $48.17
86806 3 LYMPHOCYTOTOXICITY ASSAY $48.17
86807 3 CYTOTOXIC ANTIBODY SCREENING $56.61
86808 3 CYTOTOXIC ANTIBODY SCREENING $42.46
86812 3 HLA TYPING, A, B, OR C $36.93
86813 3 HLA TYPING, A, B, OR C $82.97
86816 3 HLA TYPING, DR/DQ $39.86
86817 3 HLA TYPING, DR/DQ $92.12
86821 3 LYMPHOCYTE CULTURE, MIXED $80.79

86822 3 LYMPHOCYTE CULTURE, PRIMED $52.31
86849 5 IMMUNOLOGY PROCEDURE $0.00
86850 3 RBC ANTIBODY SCREEN $15.00
86860 5 RBC ANTIBODY ELUTION $0.00
86870 3 RBC ANTIBODY IDENTIFICATION $15.00
86880 3 COOMBS TEST, DIRECT $7.68
86885 3 COOMBS TEST, INDIRECT, QUAL $8.18
86886 3 COOMBS TEST, INDIRECT, TITER $7.41
86890 5 AUTOLOGOUS BLOOD PROCESS $0.00
86891 5 AUTOLOGOUS BLOOD, OP SALVAGE $0.00
86900 3 BLOOD TYPING, ABO $4.26
86901 3 BLOOD TYPING, RH (D) $4.26
86903 3 BLOOD TYPING, ANTIGEN SCREEN $13.50

86904 3 BLOOD TYPING, PATIENT SERUM $13.60
86905 3 BLOOD TYPING, RBC ANTIGENS $5.47
86906 3 BLOOD TYPING, RH PHENOTYPE $11.08
86910 9 BLOOD TYPING, PATERNITY TEST $0.00
86911 9 BLOOD TYPING, ANTIGEN SYSTEM $0.00
86915 O BONE MARROW/STEM CELL PREP $0.00
86920 3 COMPATIBILITY TEST, SPIN $36.00
86921 3 COMPATIBILITY TEST, INCUBATE $36.00
86922 3 COMPATIBILITY TEST, ANTIGLOB $36.00
86923 6 COMPATIBILITY TEST, ELECTRIC $0.00
86927 5 PLASMA, FRESH FROZEN $0.00
86930 5 FROZEN BLOOD PREP $0.00

86931 5 FROZEN BLOOD THAW $0.00
86932 5 FROZEN BLOOD FREEZE/THAW $0.00
86940 3 HEMOLYSINS/AGGLUTININS, AUTO $8.73
86941 3 HEMOLYSINS/AGGLUTININS $17.02
86945 3 BLOOD PRODUCT/IRRADIATION $42.00
86950 5 LEUKACYTE TRANSFUSION $0.00
86960 6 VOL REDUCTION OF BLOOD/PROD $0.00
86965 5 POOLING BLOOD PLATELETS $0.00
86970 5 RBC PRETREATMENT $0.00

86975 5 RBC PRETREATMENT, SERUM $0.00
86985 5 SPLIT BLOOD OR PRODUCTS $0.00
86999 5 TRANSFUSION PROCEDURE $0.00
87001 3 SMALL ANIMAL INOCULATION $18.91
87003 3 SMALL ANIMAL INOCULATION $24.09
87015 3 SPECIMEN CONCENTRATION $9.56
87040 3 BLOOD CULTURE FOR BACTERIA $14.77
87045 3 FECES CULTURE, BACTERIA $13.49
87046 3 STOOL CULTR, BACTERIA, EACH $13.49

87060 O NOSE/THROAT CULTURE, BACT $0.00
87070 3 CULTURE, BACTERIA, OTHER $12.32
87071 3 CULTURE BACTERI AEROBIC OTHR $13.49
87072 O CULTURE OF SPECIMEN BY KIT $0.00
87073 3 CULTURE BACTERIA ANAEROBIC $13.49
87075 3 CULTR BACTERIA, EXCEPT BLOOD $13.53
87076 3 CULTURE ANAEROBE IDENT, EACH $11.56
87077 3 CULTURE AEROBIC IDENTIFY $11.56
87081 3 CULTURE SCREEN ONLY $9.50
87084 3 CULTURE OF SPECIMEN BY KIT $12.32

87086 3 URINE CULTURE/COLONY COUNT $11.55
87087 O URINE BACTERIA CULTURE $0.00
87088 3 URINE BACTERIA CULTURE $11.58
87101 3 SKIN FUNGI CULTURE $11.03
87102 3 FUNGUS ISOLATION CULTURE $12.01
87103 3 BLOOD FUNGUS CULTURE $12.91
87106 3 FUNGI IDENTIFICATION, YEAST $14.77
87107 3 FUNGI IDENTIFICATION, MOLD $14.77
87109 3 MYCOPLASMA $22.02

87110 3 CHLAMYDIA CULTURE $28.03
87116 3 MYCOBACTERIA CULTURE $15.46
87117 O MYCOBACTERIA CULTURE $0.00
87118 3 MYCOBACTERIC IDENTIFICATION $15.66
87140 3 CULTURE TYPE IMMUNOFLUORESC $6.92
87143 3 CULTURE TYPING, GLC/HPLC $17.92
87145 O CULTURE TYPING, PHAGE METHOD $0.00
87147 3 CULTURE TYPE, IMMUNOLOGIC $7.41
87149 3 CULTURE TYPE, NUCLEIC ACID $28.68
87151 O CULTURE TYPING, SEROLOGIC $0.00
87152 3 CULTURE TYPE PULSE FIELD GEL $7.49
87155 O CULTURE TYPING, PRECIPITIN $0.00
87158 3 CULTURE TYPING, ADDED METHOD $7.49

87163 O SPECIAL MICROBIOLOGY CULTURE $0.00
87164 3 DARK FIELD EXAMINATION $15.37
87166 3 DARK FIELD EXAMINATION $16.16
87168 3 MACROSCOPIC EXAM ARTHROPOD $6.11
87169 3 MACROSCOPIC EXAM PARASITE $6.11
87172 3 PINWORM EXAM $6.11
87174 O ENDOTOXIN, BACTERIAL $0.00
87175 O ASSAY, ENDOTOXIN, BACTERIAL $0.00
87176 3 TISSUE HOMOGENIZATION, CULTR $8.42
87177 3 OVA AND PARASITES SMEARS $12.73
87178 O MICROBIAL IDENTIFICATION, NUCLEIC A $0.00
87179 O MICROBIAL IDENTIFICATION, NUCLEIC A $0.00

87181 3 MICROBE SUSCEPTIBLE, DIFFUSE $6.79
87184 3 MICROBE SUSCEPTIBLE, DISK $9.87
87185 3 MICROBE SUSCEPTIBLE, ENZYME $6.79
87186 3 MICROBE SUSCEPTIBLE, MIC $12.37
87187 3 MICROBE SUSCEPTIBLE, MLC $14.83
87188 3 MICROBE SUSCEPT, MACROBROTH $9.18
87190 3 MICROBE SUSCEPT, MYCOBACTERI $8.08
87192 O ANTIBIOTIC SENSITIVITY, EACH $0.00
87197 3 BACTERICIDAL LEVEL, SERUM $16.63
87198 O CYTOMEGALOVIRUS ANTIBODY DFA $0.00

87199 O ENTEROVIRUS ANTIBODY, DFA $0.00
87205 3 SMEAR, GRAM STAIN $6.11
87206 3 SMEAR, FLUORESCENT/ACID STAI $6.92
87207 3 SMEAR, SPECIAL STAIN $8.25
87208 O SMEAR, STAIN & INTERPRET $0.00
87209 3 SMEAR, COMPLEX STAIN $24.76
87210 3 SMEAR, WET MOUNT, SALINE/INK $6.11
87211 O SMEAR, STAIN & INTERPRET $0.00
87220 3 TISSUE EXAM FOR FUNGI $4.95
87230 3 ASSAY, TOXIN OR ANTITOXIN $24.96
87250 3 VIRUS INOCULATE, EGGS/ANIMAL $27.98
87252 3 VIRUS INOCULATION, TISSUE $37.30
87253 3 VIRUS INOCULATE TISSUE, ADDL $28.90

87254 3 VIRUS INOCULATION, SHELL VIA $27.98
87255 3 GENET VIRUS ISOLATE, HSV $48.45
87260 3 ADENOVIRUS AG, IF $15.76
87265 3 PERTUSSIS AG, IF $15.76
87267 3 ENTEROVIRUS ANTIBODY, DFA $15.76
87269 3 GIARDIA AG, IF $15.76
87270 3 CHLAMYDIA TRACHOMATIS AG, IF $15.76
87271 3 CYTOMEGALOVIRUS DFA $15.76
87272 3 CRYPTOSPORIDIUM AG, IF $15.76
87273 3 HERPES SIMPLEX 2, AG, IF $15.76
87274 3 HERPES SIMPLEX 1, AG, IF $15.76
87275 3 INFLUENZA B, AG, IF $15.76

87276 3 INFLUENZA A, AG, IF $15.76
87277 3 LEGIONELLA MICDADEI, AG, IF $15.76
87278 3 LEGION PNEUMOPHILIA AG, IF $15.76
87279 3 PARAINFLUENZA, AG, IF $15.76
87280 3 RESPIRATORY SYNCYTIAL AG, IF $15.76
87281 3 PNEUMOCYSTIS CARINII, AG, IF $15.76
87283 3 RUBEOLA, AG, IF $15.76
87285 3 TREPONEMA PALLIDUM, AG, IF $15.76
87290 3 VARICELLA ZOSTER, AG, IF $15.76
87299 3 ANTIBODY DETECTION, NOS, IF $15.76

87300 3 AG DETECTION, POLYVAL, IF $15.76
87301 3 ADENOVIRUS AG, EIA $15.76
87305 3 ASPERGILLUS AG, EIA $15.76
87320 3 CHYLMD TRACH AG, EIA $15.76
87324 3 CLOSTRIDIUM AG, EIA $15.76
87327 3 CRYPTOCOCCUS NEOFORM AG, EIA $15.76
87328 3 CRYPTOSPORIDIUM AG, EIA $15.76
87329 3 GIARDIA AG, EIA $15.76
87332 3 CYTOMEGALOVIRUS AG, EIA $15.76
87335 3 E COLI 0157 AG, EIA $15.76
87336 3 ENTAMOEB HIST DISPR, AG, EIA $15.76
87337 3 ENTAMOEB HIST GROUP, AG, EIA $15.76
87338 3 HPYLORI, STOOL, EIA $15.76

87339 3 H PYLORI AG, EIA $15.76
87340 3 HEPATITIS B SURFACE AG, EIA $14.51
87341 3 HEPATITIS B SURFACE, AG, EIA $14.51
87350 3 HEPATITIS BE AG, EIA $16.49
87380 3 HEPATITIS DELTA AG, EIA $23.50
87385 3 HISTOPLASMA CAPSUL AG, EIA $15.76
87390 3 HIV-1 AG, EIA $25.24
87391 3 HIV-2 AG, EIA $25.24
87400 3 INFLUENZA A/B, AG, EIA $15.76
87420 3 RESP SYNCYTIAL AG, EIA $15.76
87425 3 ROTAVIRUS AG, EIA $15.76
87427 3 SHIGA-LIKE TOXIN AG, EIA $15.76

87430 3 STREP A AG, EIA $15.76
87449 3 AG DETECT NOS, EIA, MULT $15.76
87450 3 AG DETECT NOS, EIA, SINGLE $13.71
87451 3 AG DETECT POLYVAL, EIA, MULT $13.71
87470 3 BARTONELLA, DNA, DIR PROBE $28.68
87471 3 BARTONELLA, DNA, AMP PROBE $50.23
87472 3 BARTONELLA, DNA, QUANT $40.60
87475 3 LYME DIS, DNA, DIR PROBE $28.68
87476 3 LYME DIS, DNA, AMP PROBE $50.23
87477 3 LYME DIS, DNA, QUANT $40.60

87480 3 CANDIDA, DNA, DIR PROBE $28.68
87481 3 CANDIDA, DNA, AMP PROBE $50.23
87482 3 CANDIDA, DNA, QUANT $40.60
87485 3 CHYLMD PNEUM, DNA, DIR PROBE $28.68
87486 3 CHYLMD PNEUM, DNA, AMP PROBE $50.23
87487 3 CHYLMD PNEUM, DNA, QUANT $40.60
87490 3 CHYLMD TRACH, DNA, DIR PROBE $28.68
87491 3 CHYLMD TRACH, DNA, AMP PROBE $50.23
87492 3 CHYLMD TRACH, DNA, QUANT $40.60
87495 3 CYTOMEG, DNA, DIR PROBE $28.68
87496 3 CYTOMEG, DNA, AMP PROBE $50.23
87497 3 CYTOMEG, DNA, QUANT $40.60
87498 3 ENTEROVIRUS, DNA, AMP PROBE $50.23

87500 3 VANOMYCIN, DNA, AMP PROBE $50.23
87510 3 GARDNER VAG, DNA, DIR PROBE $28.68
87511 3 GARDNER VAG, DNA, AMP PROBE $50.23
87512 3 GARDNER VAG, DNA, QUANT $40.60
87515 3 HEPATITIS B, DNA, DIR PROBE $28.68
87516 3 HEPATITIS B, DNA, AMP PROBE $50.23
87517 3 HEPATITIS B, DNA, QUANT $40.60
87520 3 HEPATITIS C, RNA, DIR PROBE $28.68
87521 3 HEPATITIS C, RNA, AMP PROBE $50.23
87522 3 HEPATITIS C, RNA, QUANT $40.60
87525 3 HEPATITIS G, DNA, DIR PROBE $28.68
87526 3 HEPATITIS G, DNA, AMP PROBE $50.23

87527 3 HEPATITIS G, DNA, QUANT $40.60
87528 3 HSV, DNA, DIR PROBE $28.68
87529 3 HSV, DNA, AMP PROBE $50.23
87530 3 HSV, DNA, QUANT $40.60
87531 3 HHV-6, DNA, DIR PROBE $28.68
87532 3 HHV-6, DNA, AMP PROBE $50.23
87533 3 HHV-6, DNA, QUANT $40.60
87534 3 HIV-1, DNA, DIR PROBE $28.68
87535 3 HIV-1, DNA, AMP PROBE $50.23
87536 3 HIV-1, DNA, QUANT $121.76

87537 3 HIV-2, DNA, DIR PROBE $28.68
87538 3 HIV-2, DNA, AMP PROBE $50.23
87539 3 HIV-2, DNA, QUANT $40.60
87540 3 LEGION PNEUMO, DNA, DIR PROB $28.68
87541 3 LEGION PNEUMO, DNA, AMP PROB $50.23
87542 3 LEGION PNEUMO, DNA, QUANT $40.60
87550 3 MYCOBACTERIA, DNA, DIR PROBE $28.68
87551 3 MYCOBACTERIA, DNA, AMP PROBE $50.23
87552 3 MYCOBACTERIA, DNA, QUANT $40.60
87555 3 M.TUBERCULO, DNA, DIR PROBE $28.68
87556 3 M.TUBERCULO, DNA, AMP PROBE $50.23
87557 3 M.TUBERCULO, DNA, QUANT $40.60
87560 3 M.AVIUM-INTRA, DNA, DIR PROB $28.68

87561 3 M.AVIUM-INTRA, DNA, AMP PROB $50.23
87562 3 M.AVIUM-INTRA, DNA, QUANT $40.60
87580 3 M.PNEUMON, DNA, DIR PROBE $28.68
87581 3 M.PNEUMON, DNA, AMP PROBE $50.23
87582 3 M.PNEUMON, DNA, QUANT $40.60
87590 3 N.GONORRHOEAE, DNA, DIR PROB $28.68
87591 3 N.GONORRHOEAE, DNA, AMP PROB $50.23
87592 3 N.GONORRHOEAE, DNA, QUANT $40.60
87620 3 HPV, DNA, DIR PROBE $28.68
87621 3 HPV, DNA, AMP PROBE $50.23
87622 3 HPV, DNA, QUANT $40.60
87640 3 STAPH A, DNA, AMP PROBE $50.23

87641 3 MR-STAPH, DNA, AMP PROBE $50.23
87650 3 STREP A, DNA, DIR PROBE $28.68
87651 3 STREP A, DNA, AMP PROBE $50.23
87652 3 STREP A, DNA, QUANT $40.60
87653 3 STREP B, DNA, AMP PROBE $50.23
87660 3 TRICHOMONAS VAGIN, DIR PROBE $28.68
87797 3 DETECT AGENT NOS, DNA, DIR $28.68
87798 3 DETECT AGENT NOS, DNA, AMP $50.23
87799 3 DETECT AGENT NOS, DNA, QUANT $61.29
87800 3 DETECT AGNT MULT, DNA, DIREC $57.39

87801 3 DETECT AGNT MULT, DNA, AMPLI $100.44
87802 3 STREP B ASSAY W/OPTIC $15.76
87803 3 CLOSTRIDIUM TOXIN A W/OPTIC $15.76
87804 3 INFLUENZA ASSAY W/OPTIC $15.76
87807 3 INFECTIOUS AGENT ANTIGEN DETECTION $15.76
87808 3 TRICHOMONAS ASSAY W/OPTIC $15.76
87809 3 ADENOVIRUS ASSAY W/OPTIC $15.76
87810 3 CHYLMD TRACH ASSAY W/OPTIC $15.76
87850 3 N. GONORRHOEAE ASSAY W/OPTIC $15.76
87880 3 STREP A ASSAY W/OPTIC $15.76
87899 3 AGENT NOS ASSAY W/OPTIC $15.76
87900 3 PHENOTYPE, INFECT AGENT DRUG $186.50
87901 3 GENOTYPE, DNA, HIV REVERSE T $368.36

87902 3 GENOTYPE, DNA, HEPATITIS C $368.36
87903 3 PHENOTYPE, DNA HIV W/CULTURE $699.16
87904 3 PHENOTYPE, DNA HIV W/CLT ADD $37.30
87905 3 SIALIDASE ENZYME ASSAY $8.99
87999 5 MICROBIOLOGY PROCEDURE $0.00
88000 9 AUTOPSY (NECROPSY), GROSS $0.00
88020 9 AUTOPSY (NECROPSY), COMPLETE $0.00

88036 9 LIMITED AUTOPSY $0.00
88037 9 LIMITED AUTOPSY $0.00
88040 9 FORENSIC AUTOPSY (NECROPSY) $0.00
88045 9 CORONERÏS AUTOPSY (NECROPSY) $0.00
88099 9 NECROPSY (AUTOPSY) PROCEDURE $0.00
88104 3 CYTOPATH FL NONGYN, SMEARS $51.49

88106 3 CYTOPATH FL NONGYN, FILTER $46.46
88107 3 CYTOPATH FL NONGYN, SM/FLTR $68.58
88108 3 CYTOPATH, CONCENTRATE TECH $53.81
88112 3 CYTOPATH, CELL ENHANCE TECH $123.81
88125 3 FORENSIC CYTOPATHOLOGY $20.54
88130 3 SEX CHROMATIN IDENTIFICATION $21.53
88140 3 SEX CHROMATIN IDENTIFICATION $11.44
88141 3 CYTOPATH, C/V, INTERPRET $23.24
88142 3 CYTOPATH, C/V, THIN LAYER $28.99
88143 3 CYTOPATH C/V THIN LAYER REDO $28.99
88144 O CYTOPATH, C/V, THIN LYR REDO $0.00
88145 O CYTOPATH, C/V, THIN LYR SEL $0.00
88147 3 CYTOPATH, C/V, AUTOMATED $16.29

88148 3 CYTOPATH, C/V, AUTO RESCREEN $21.75
88150 3 CYTOPATH, C/V, MANUAL $15.11
88151 O CYTOPATHOLOGY, SMEARS, CERVICAL OR $0.00
88152 3 CYTOPATH, C/V, AUTO REDO $15.11
88153 3 CYTOPATH, C/V, REDO $15.11
88154 3 CYTOPATH, C/V, SELECT $15.11
88155 3 CYTOPATH, C/V, INDEX ADD-ON $8.58
88156 O CYTOPATH CERV/VAG TBS $0.00
88157 O CYTOPATHOLOGY, SMEARS, CERVICAL OR $0.00
88158 O CYTOPATH CERV/VAG TBS AUTO $0.00
88160 3 CYTOPATH SMEAR, OTHER SOURCE $55.77

88164 3 CYTOPATH TBS, C/V, MANUAL $15.11
88165 3 CYTOPATH TBS, C/V, REDO $15.11
88166 3 CYTOPATH TBS, C/V, AUTO REDO $15.11
88167 3 CYTOPATH TBS, C/V, SELECT $15.11
88170 O FINE NEEDLE ASPIRATION $0.00
88171 O FINE NEEDLE ASPIRATION $0.00
88172 3 CYTOPATHOLOGY EVAL OF FNA $49.53
88173 3 CYTOPATH EVAL, FNA, REPORT $122.91
88174 3 CYTOPATH, C/V AUTO, IN FLUID $30.57

88175 3 CYTOPATH C/V AUTO FLUID REDO $37.91
88180 O CELL MARKER STUDY $0.00
88182 3 CELL MARKER STUDY $93.14
88184 3 FLOWCYTOMETRY/ TC, 1 MARKER $49.26
88185 3 FLOWCYTOMETRY/TC, ADD-ON $24.22
88187 3 FLOWCYTOMETRY/READ, 2-8 $63.03
88188 3 FLOWCYTOMETRY/READ, 9-15 $83.19
88189 3 FLOWCYTOMETRY/READ, 16 & > $109.59
88199 5 CYTOPATHOLOGY PROCEDURE $0.00
88230 3 TISSUE CULTURE, LYMPHOCYTE $166.70
88233 3 TISSUE CULTURE, SKIN/BIOPSY $201.37
88235 3 TISSUE CULTURE, PLACENTA $210.70
88237 3 TISSUE CULTURE, BONE MARROW $180.72

88239 3 TISSUE CULTURE, TUMOR $211.08
88240 3 CELL CRYOPRESERVE/STORAGE $14.46
88241 3 FROZEN CELL PREPARATION $14.46
88245 3 CHROMOSOME ANALYSIS, 20-25 $213.00
88249 3 CHROMOSOME ANALYSIS, 100 $247.78
88250 O CHROMOSOME ANALYSIS $0.00
88260 O CHROMOSOME ANALYSIS: 5 CELLS $0.00

88267 3 CHROMOSOME ANALYS, PLACENTA $257.22
88269 3 CHROMOSOME ANALYS, AMNIOTIC $237.98
88271 3 CYTOGENETICS, DNA PROBE $30.64
88272 3 CYTOGENETICS, 3-5 $38.31
88273 3 CYTOGENETICS, 10-30 $45.97
88274 3 CYTOGENETICS, 25-99 $49.80
88275 3 CYTOGENETICS, 100-300 $57.47
88280 3 CHROMOSOME KARYOTYPE STUDY $35.91
88283 3 CHROMOSOME BANDING STUDY $98.15
88285 3 CHROMOSOME COUNT, ADDITIONAL $27.19

88289 3 CHROMOSOME STUDY, ADDITIONAL $49.27
88291 3 CYTO/MOLECULAR REPORT $31.20
88299 5 CYTOGENETIC STUDY $0.00
88300 3 SURGICAL PATH, GROSS $14.46
88302 3 TISSUE EXAM BY PATHOLOGIST $32.51
88311 3 DECALCIFY TISSUE $17.46
88312 3 SPECIAL STAINS $73.61
88313 3 SPECIAL STAINS $51.85
88314 3 HISTOCHEMICAL STAIN $52.71

88317 O INTERPRETATION AND REPORT BY TREATI $0.00
88318 3 CHEMICAL HISTOCHEMISTRY $47.79
88319 3 ENZYME HISTOCHEMISTRY $94.40
88321 3 MICROSLIDE CONSULTATION $82.65
88323 9 MICROSLIDE CONSULTATION $0.00
88325 3 COMPREHENSIVE REVIEW OF DATA $199.53
88329 3 PATH CONSULT INTROP $50.44
88331 3 PATH CONSULT INTRAOP, 1 BLOC $85.84
88332 3 PATH CONSULT INTRAOP, ADDÏL $42.97
88333 3 INTRAOP CYTO PATH CONSULT, 1 $90.40
88334 3 INTRAOP CYTO PATH CONSULT, 2 $52.97
88342 3 IMMUNOHISTOCHEMISTRY $86.31

88346 3 IMMUNOFLUORESCENT STUDY $90.16
88347 3 IMMUNOFLUORESCENT STUDY $102.53
88348 3 ELECTRON MICROSCOPY $388.66
88349 3 SCANNING ELECTRON MICROSCOPY $417.97
88355 3 ANALYSIS, SKELETAL MUSCLE $175.05
88356 3 ANALYSIS, NERVE $231.50
88358 3 ANALYSIS, TUMOR $63.47
88360 3 TUMOR IMMUNOHISTOCHEM/MANUAL $106.57
88361 3 TUMOR IMMUNOHISTOCHEM/COMPUT $141.54
88362 3 NERVE TEASING PREPARATIONS $256.79

88365 3 INSITU HYBRIDIZATION (FISH) $122.58
88367 3 INSITU HYBRIDIZATION, AUTO $200.25
88368 3 INSITU HYBRIDIZATION, MANUAL $143.52
88371 3 PROTEIN, WESTERN BLOT TISSUE $31.79
88372 3 PROTEIN ANALYSIS W/PROBE $32.56
88380 5 MICRODISSECTION, LASER $0.00
88381 6 MICRODISSECTION, MANUAL $0.00
88384 3 EVAL MOLECULAR PROBES, 11-50 $326.65
88385 3 EVAL MOLECUL PROBES, 51-250 $335.50
88386 3 EVAL MOLECUL PROBES, 251-500 $349.50
88399 5 SURGICAL PATHOLOGY PROCEDURE $0.00
88400 O BILIRUBIN TOTAL TRANSCUT $0.00
88720 3 BILIRUBIN TOTAL TRANSCUT $7.18

88740 3 TRANSCUTANEOUS CARBOXYHB $7.18
88741 3 TRANSCUTANEOUS METHB $7.18
89049 6 CHCT FOR MAL HYPERTHERMIA $0.00
89050 3 BODY FLUID CELL COUNT $6.76
89051 3 BODY FLUID CELL COUNT $7.88
89055 3 LEUKOCYTE ASSESSMENT, FECAL $6.11
89060 3 EXAM,SYNOVIAL FLUID CRYSTALS $10.23
89100 3 SAMPLE INTESTINAL CONTENTS $85.26
89105 3 SAMPLE INTESTINAL CONTENTS $106.19
89125 3 SPECIMEN FAT STAIN $6.17
89130 3 SAMPLE STOMACH CONTENTS $84.96

89160 3 EXAM FECES FOR MEAT FIBERS $5.27
89190 3 NASAL SMEAR FOR EOSINOPHILS $6.79
89205 O OCCULT BLOOD, ANY SOURCE EXCEPT FEC $0.00
89220 3 SPUTUM SPECIMEN COLLECTION $16.06
89225 3 STARCH GRANULES, FECES $4.78
89230 3 COLLECT SWEAT FOR TEST $17.60

89235 3 WATER LOAD TEST $7.88
89240 6 PATHOLOGY LAB PROCEDURE $0.00
89250 9 CULTR OOCYTE/EMBRYO <4 DAYS $0.00
89251 9 CULTR OOCYTE/EMBRYO <4 DAYS $0.00
89252 O ASSIST OOCYTE FERTILIZATION $0.00
89253 9 EMBRYO HATCHING $0.00
89254 9 OOCYTE IDENTIFICATION $0.00
89255 9 PREPARE EMBRYO FOR TRANSFER $0.00
89256 O PREPARE CRYOPRESERVED EMBRYO $0.00
89257 9 SPERM IDENTIFICATION $0.00
89258 9 CRYOPRESERVATION; EMBRYO(S) $0.00
89259 9 CRYOPRESERVATION, SPERM $0.00
89260 9 SPERM ISOLATION, SIMPLE $0.00

89261 9 SPERM ISOLATION, COMPLEX $0.00
89264 9 IDENTIFY SPERM TISSUE $0.00
89268 9 INSEMINATION OF OOCYTES $0.00
89272 9 EXTENDED CULTURE OF OOCYTES $0.00
89280 9 ASSIST OOCYTE FERTILIZATION $0.00
89281 9 ASSIST OOCYTE FERTILIZATION $0.00
89290 9 BIOPSY, OOCYTE POLAR BODY $0.00
89291 9 BIOPSY, OOCYTE POLAR BODY $0.00
89300 9 SEMEN ANALYSIS W/HUHNER $0.00
89310 3 SEMEN ANALYSIS W/COUNT $12.32
89320 3 SEMEN ANAL VOL/COUNT/MOT $17.25
89321 3 SEMEN ANAL, SPERM DETECTION $17.25

89322 3 SEMEN ANAL, STRICT CRITERIA $22.18
89325 3 SPERM ANTIBODY TEST $15.27
89329 9 SPERM EVALUATION TEST $0.00
89330 9 EVALUATION, CERVICAL MUCUS $0.00
89331 3 RETROGRADE EJACULATION ANAL $28.03
89335 9 CRYOPRESERVE TESTICULAR TISS $0.00
89342 9 STORAGE/YEAR; EMBRYO(S) $0.00
89343 9 STORAGE/YEAR; SPERM/SEMEN $0.00
89344 9 STORAGE/YEAR; REPROD TISSUE $0.00
89346 9 STORAGE/YEAR; OOCYTE(S) $0.00

89350 O SPUTUM SPECIMEN COLLECTION $0.00
89352 9 THAWING CRYOPRESRVED; EMBRYO $0.00
89353 9 THAWING CRYOPRESRVED; SPERM $0.00
89354 9 THAW CRYOPRSVRD; REPROD TISS $0.00
89355 O EXAM FECES FOR STARCH $0.00
89356 9 THAWING CRYOPRESRVED; OOCYTE $0.00
89360 O COLLECT SWEAT FOR TEST $0.00
89365 O WATER LOAD TEST $0.00
89399 O PATHOLOGY LAB PROCEDURE $0.00
90000 O OFFICE AND OTHER OUTPATIENT MEDICAL $0.00

90100 O HOME MEDICAL SERVICE, NEW PATIENT B $0.00
90110 O HOME MEDICAL SERVICE, NEW PATIENT L $0.00
90115 O HOME MEDICAL SERVICE, NEW PATIENT I $0.00
90117 O HOME MEDICAL SERVICE, NEW PATIENT E $0.00
90130 O HOME MEDICAL SERVICE, ESTABLISHED P $0.00

90200 O INITIAL HOSPITAL CARE BRIEF HISTORY $0.00
90215 O INITIAL HOSPITAL CARE INTERMEDIATE $0.00
90220 O INITIAL HOSPITAL CARE COMPREHENSIVE $0.00
90225 O HISTORY AND EXAMINATION OF THE NORM $0.00
90240 O SUBSEQUENT HOSPITAL CARE, EACH DAY $0.00

90281 5 HUMAN IG, IM $0.00
90283 5 HUMAN IG, IV $0.00
90284 6 HUMAN IG, SC $0.00
90287 5 BOTULINUM ANTITOXIN $0.00
90288 5 BOTULISM IG, IV $0.00
90291 5 CMV IG, IV $0.00
90292 O HOSPITAL DISCHARGE DAY MANAGEMENT $0.00
90296 5 DIPHTHERIA ANTITOXIN $0.00
90300 O INITIAL CARE, SKILLED NURSING FACIL $0.00

90340 O SUBSEQUENT CARE, SKILLED NURSING FA $0.00
90371 5 HEP B IG, IM $0.00
90375 5 RABIES IG, IM/SC $0.00
90376 5 RABIES IG, HEAT TREATED $0.00
90378 5 RSV IG, IM, 50MG $0.00
90379 5 RSV IG, IV $0.00
90384 5 RH IG, FULL-DOSE, IM $0.00

90385 5 RH IG, MINIDOSE, IM $0.00
90386 5 RH IG, IV $0.00
90389 5 TETANUS IG, IM $0.00
90393 5 VACCINA IG, IM $0.00
90396 5 VARICELLA-ZOSTER IG, IM $0.00
90399 5 IMMUNE GLOBULIN $0.00
90400 O REST HOME (EG, BOARDING HOME), DOMI $0.00

90465 9 IMMUNE ADMIN 1 INJ, < 8 YRS $0.00
90466 9 IMMUNE ADMIN ADDL INJ, < 8 Y $0.00
90467 9 IMMUNE ADMIN O OR N, < 8 YRS $0.00
90468 9 IMMUNE ADMIN O/N, ADDL < 8 Y $0.00
90471 9 IMMUNIZATION ADMIN $0.00
90472 9 IMMUNIZATION ADMIN, EACH ADD $0.00
90473 9 IMMUNE ADMIN ORAL/NASAL $0.00
90474 9 IMMUNE ADMIN ORAL/NASAL ADDL $0.00

90476 5 ADENOVIRUS VACCINE, TYPE 4 $0.00
90477 5 ADENOVIRUS VACCINE, TYPE 7 $0.00
90500 O EMERGENCY DEPARTMENT SERVICE, NEW P $0.00
90530 O EMERGENCY DEPARTMENT SERVICE, ESTAB $0.00

90581 5 ANTHRAX VACCINE, SC $0.00
90585 5 BCG VACCINE, PERCUT $0.00
90586 5 BCG VACCINE, INTRAVESICAL $0.00
90590 9 PHYSICIAN DIRECTION OF EMERGENCY ME $0.00
90592 9 CHOLERA VACCINE, ORAL $0.00
90600 O INITIAL CONSULTATION LIMITED $0.00
90605 O INITIAL CONSULTATION INTERMEDIATE $0.00
90610 O INITIAL CONSULTATION EXTENDED $0.00

90620 O INITIAL CONSULTATION COMPREHENSIVE $0.00
90630 O INITIAL CONSULTATION COMPLEX $0.00
90632 3 HEP A VACCINE, ADULT IM $48.22
90633 5 HEP A VACC, PED/ADOL, 2 DOSE $0.00
90634 5 HEP A VACC, PED/ADOL, 3 DOSE $0.00
90636 6 HEP A/HEP B VACC, ADULT IM $0.00
90640 9 FOLLOW-UP CONSULTATION BRIEF $0.00
90641 9 FOLLOW-UP CONSULTATION LIMITED $0.00
90642 9 FOLLOW-UP CONSULTATION INTERMEDIATE $0.00
90643 9 FOLLOW-UP CONSULTATION COMPLEX $0.00
90645 5 HIB VACCINE, HBOC, IM $0.00
90646 5 HIB VACCINE, PRP-D, IM $0.00
90647 5 HIB VACCINE, PRP-OMP, IM $0.00

90648 5 HIB VACCINE, PRP-T, IM $0.00
90650 9 HPV VACCINE TYPES 16, 18, BIVALENT $0.00
90651 9 CONFIRMATORY CONSULTATION INTERMEDI $0.00
90652 9 CONFIRMATORY CONSULTATION EXTENDED $0.00
90653 9 CONFIRMATORY CONSULTATION COMPREHEN $0.00
90654 9 CONFIRMATORY CONSULTATION COMPLEX $0.00
90655 5 FLU VACCINE NO PRESERV 6-35M $0.00
90656 5 FLU VACCINE NO PRESERV 3 & > $0.00
90657 5 FLU VACCINE, 3 YRS, IM $0.00
90658 3 FLU VACCINE, 3 YRS & >, IM $13.22
90659 O FLU VACCINE, WHOLE, IM $0.00
90660 5 FLU VACCINE, NASAL $0.00

90661 9 FLU VACC CELL CULT PRSV FREE $0.00
90662 9 FLU VACC PRSV FREE INC ANTIG $0.00
90663 9 FLU VACC PANDEMIC $0.00
90665 3 LYME DISEASE VACCINE, IM $53.35
90669 5 PNEUMOCOCCAL VACC, PED <5 $0.00
90675 5 RABIES VACCINE, IM $0.00
90676 5 RABIES VACCINE, ID $0.00
90680 5 ROTOVIRUS VACC 3 DOSE, ORAL $0.00
90681 6 ROTAVIRUS VACCINE, HUMAN, ATTENUAT $0.00
90690 9 TYPHOID VACCINE, ORAL $0.00

90691 9 TYPHOID VACCINE, IM $0.00
90692 9 TYPHOID VACCINE, H-P, SC/ID $0.00
90693 9 TYPHOID VACCINE, AKD, SC $0.00
90696 6 DIPTHERIA,TETANUS TOXOIDS,ACELLULA $0.00
90698 6 DTAP-HIB-IP VACCINE, IM $0.00
90699 O UNLISTED MEDICAL SERVICE, GENERAL $0.00
90700 5 DTAP VACCINE, < 7 YRS, IM $0.00
90701 5 DTP VACCINE, IM $0.00
90702 5 DT VACCINE < 7, IM $0.00
90703 3 TETANUS VACCINE, IM $22.47
90704 5 MUMPS VACCINE, SC $0.00
90705 5 MEASLES VACCINE, SC $0.00
90706 5 RUBELLA VACCINE, SC $0.00

90707 3 MMR VACCINE, SC $44.73
90708 5 MEASLES-RUBELLA VACCINE, SC $0.00
90709 O RUBELLA & MUMPS VACCINE, SC $0.00
90710 5 MMRV VACCINE, SC $0.00
90711 O COMBINED VACCINE $0.00
90712 5 ORAL POLIOVIRUS VACCINE $0.00
90713 6 POLIOVIRUS, IPV, SC/IM $0.00
90714 3 TD VACCINE NO PRSRV >/= 7 IM $19.98
90715 3 TDAP VACCINE >7 IM $35.05
90716 6 CHICKEN POX VACCINE, SC $0.00
90717 9 YELLOW FEVER VACCINE, SC $0.00
90718 3 TD VACCINE > 7, IM $13.85

90719 5 DIPHTHERIA VACCINE, IM $0.00
90720 5 DTP/HIB VACCINE, IM $0.00
90721 6 DTAP/HIB VACCINE, IM $0.00
90723 5 DTAP-HEP B-IPV VACCINE, IM $0.00
90724 O INFLUENZA IMMUNIZATION $0.00
90725 9 CHOLERA VACCINE, INJECTABLE $0.00
90726 O RABIES IMMUNIZATION $0.00
90727 9 PLAGUE VACCINE, IM $0.00
90728 O BCG IMMUNIZATION $0.00
90730 O HEPATITIS A VACCINE $0.00

90731 O IMMUNIZATION, ACTIVE; HEPATITIS B V $0.00
90732 3 PNEUMOCOCCAL VACCINE $12.85
90733 3 MENINGOCOCCAL VACCINE, SC $12.85
90734 3 MENINGOCOCCAL VACCINE, IM $41.00
90735 9 ENCEPHALITIS VACCINE, SC $0.00
90736 6 ZOSTER VACC, SC $0.00
90737 O INFLUENZA B IMMUNIZATION $0.00
90738 9 JAPANESE ENCEPHALITIS VIRUS VACCIN $0.00
90740 5 HEPB VACC, ILL PAT 3 DOSE IM $0.00
90741 O PASSIVE IMMUNIZATION, ISG $0.00
90742 O SPECIAL PASSIVE IMMUNIZATION $0.00
90743 5 HEP B VACC, ADOL, 2 DOSE, IM $0.00
90744 5 HEPB VACC PED/ADOL 3 DOSE IM $0.00

90745 O HEPB VACCINE, ADOL/RISK, IM $0.00
90746 3 HEP B VACCINE, ADULT, IM $59.71
90747 5 HEPB VACC, ILL PAT 4 DOSE IM $0.00
90748 6 HEP B/HIB VACCINE, IM $0.00
90749 5 VACCINE TOXOID $0.00
90750 9 INITIAL HISTORY AND EXAMINATION REL $0.00
90751 9 INITIAL HISTORY AND EXAMINATION REL $0.00
90752 O INITIAL HISTORY AND EXAMINATION REL $0.00
90755 9 INFANT CARE TO ONE YEAR OF AGE, WIT $0.00
90757 O NEWBORN CARE, IN OTHER THAN HOSPITA $0.00

90760 O HYDRATION IV INFUSION, INIT $0.00
90761 O HYDRATE IV INFUSION, ADD-ON $0.00
90762 O INTERVAL HISTORY AND EXAMINATION RE $0.00
90765 O THER/PROPH/DIAG IV INF, INIT $0.00
90766 O THER/PROPH/DG IV INF, ADD-ON $0.00
90767 O TX/PROPH/DG ADDL SEQ IV INF $0.00
90768 O THER/DIAG CONCURRENT INF $0.00
90769 O SC THER INFUSION, UP TO 1 HR $0.00

90770 O SC THER INFUSION, ADDL HR $0.00
90771 O SC THER INFUSION, RESET PUMP $0.00
90772 O THER/PROPH/DIAG INJ, SC/IM $0.00
90773 O THER/PROPH/DIAG INJ, IA $0.00
90774 O THERAPEUTIC, PROPHYLACTIC OR DIAG $0.00
90775 O TX/PRO/DX INJ NEW DRUG ADDON $0.00
90776 O TX/PRO/DX INJ SAME DRUG ADON $0.00
90778 O CIRCADIAN RESPIRATORY PATTERN RECOR $0.00
90779 O THER/PROP/DIAG INJ/INF PROC $0.00
90780 O IV INFUSION THERAPY, 1 HOUR $0.00
90781 O IV INFUSION, ADDITIONAL HOUR $0.00
90782 O INJECTION, SC/IM $0.00
90783 O INJECTION, IA $0.00

90784 O INJECTION, IV $0.00
90788 O INJECTION OF ANTIBIOTIC $0.00
90798 O INTRAVENOUS THERAPY FOR SEVERE OR I $0.00
90799 O THER/PROPHYLACTIC/DX INJECT $0.00
90801 3 PSY DX INTERVIEW $152.51
90802 3 INTAC PSY DX INTERVIEW $162.48
90804 3 PSYTX, OFFICE, 20-30 MIN $66.73
90805 3 PSYTX, OFF, 20-30 MIN W/E&M $74.29
90806 3 PSYTX, OFF, 45-50 MIN $92.92
90807 3 PSYTX, OFF, 45-50 MIN W/E&M $104.22
90808 3 PSYTX, OFFICE, 75-80 MIN $136.47
90809 3 PSYTX, OFF, 75-80, W/E&M $147.38

90810 3 INTAC PSYTX, OFF, 20-30 MIN $70.72
90811 3 INTAC PSYTX, 20-30, W/E&M $82.55
90813 3 INTAC PSYTX, 45-50 MIN W/E&M $112.62
90815 3 INTAC PSYTX, 75-80 W/E&M $155.78
90816 3 PSYTX, HOSP, 20-30 MIN $61.63
90817 3 PSYTX, HOSP, 20-30 MIN W/E&M $68.41
90818 3 PSYTX, HOSP, 45-50 MIN $91.72

90820 9 INTERACTIVE MEDICAL PSYCHIATRIC DIA $0.00
90821 3 PSYTX, HOSP, 75-80 MIN $135.26
90823 3 INTAC PSYTX, HOSP, 20-30 MIN $66.53
90824 3 INTAC PSYTX, HSP 20-30 W/E&M $73.95
90825 9 PSYCHIATRIC EVALUATION OF HOSPITAL $0.00
90830 O PSYCHOLOGICAL TESTING (INCLUDES PSY $0.00
90835 9 NARCOSYNTHESIS FOR PSYCHIATRIC DIAG $0.00
90841 9 INDIVIDUAL MEDICAL PSYCHOTHERAPY BY $0.00

90845 3 PSYCHOANALYSIS $81.19
90846 3 FAMILY PSYTX W/O PATIENT $86.69
90847 3 FAMILY PSYTX W/PATIENT $107.90
90849 3 MULTIPLE FAMILY GROUP PSYTX $32.65
90853 3 GROUP PSYCHOTHERAPY $30.94
90855 9 INTERACTIVE INDIVIDUAL MEDICAL PSYC $0.00
90857 3 INTAC GROUP PSYTX $34.95
90862 3 MEDICATION MANAGEMENT $55.13
90865 9 NARCOSYNTHESIS $0.00

90870 3 ELECTROCONVULSIVE THERAPY $137.28
90871 O ELECTROCONVULSIVE THERAPY $0.00
90875 9 PSYCHOPHYSIOLOGICAL THERAPY $0.00
90876 9 PSYCHOPHYSIOLOGICAL THERAPY $0.00
90880 9 HYPNOTHERAPY $0.00
90882 9 ENVIRONMENTAL MANIPULATION $0.00
90885 3 PSY EVALUATION OF RECORDS $47.71
90887 9 CONSULTATION WITH FAMILY $0.00
90889 9 PREPARATION OF REPORT $0.00
90899 O PSYCHIATRIC SERVICE/THERAPY $0.00

90900 O BIOFEEDBACK TRAINING; BY ELECTROMYO $0.00
90901 9 BIOFEEDBACK TRAIN, ANY METH $0.00
90902 O BIOFEEDBACK TRAINING; IN CONDUCTION $0.00
90904 O BIOFEEDBACK TRAINING; REGULATION OF $0.00
90906 9 BIOFEEDBACK TRAINING REGULATION OF $0.00
90908 O BIOFEEDBACK TRAINING; BY ELECTROENC $0.00
90910 O BIOFEEDBACK TRAINING; BY ELECTRO-OC $0.00
90911 3 BIOFEEDBACK PERI/URO/RECTAL $86.11
90915 O BIOFEEDBACK TRAINING; OTHER $0.00
90918 O ESRD RELATED SERVICES, MONTH $0.00

90922 O ESRD RELATED SERVICES, DAY $0.00
90935 3 HEMODIALYSIS, ONE EVALUATION $65.99
90937 3 HEMODIALYSIS, REPEATED EVAL $108.13
90939 O HEMODIALYSIS STUDY, TRANSCUT $0.00
90940 5 HEMODIALYSIS ACCESS STUDY $0.00
90945 3 DIALYSIS, ONE EVALUATION $68.51
90947 3 DIALYSIS, REPEATED EVAL $110.66
90951 3 ESRD SERV, 4 VISITS P MO, <2 $955.25
90952 6 ESRD SERV, 2-3 VSTS P MO, <2 $0.00

90953 6 ESRD SERV, 1 VISIT P MO, <2 $0.00
90954 3 ESRD SERV, 4 VSTS P MO, 2-11 $780.77
90955 3 ESRD SRV 2-3 VSTS P MO, 2-11 $443.17
90956 3 ESRD SRV, 1 VISIT P MO, 2-11 $300.22
90957 3 ESRD SRV, 4 VSTS P MO, 12-19 $628.02
90958 3 ESRD SRV 2-3 VSTS P MO 12-19 $424.14
90959 3 ESRD SERV, 1 VST P MO, 12-19 $278.25
90960 3 ESRD SRV, 4 VISITS P MO, 20+ $280.12
90961 3 ESRD SRV, 2-3 VSTS P MO, 20+ $225.83
90962 3 ESRD SERV, 1 VISIT P MO, 20+ $163.02

90963 3 ESRD HOME PT, SERV P MO, <2 $539.04
90964 3 ESRD HOME PT SERV P MO, 2-11 $448.39
90965 3 ESRD HOME PT SERV P MO 12-19 $426.55
90966 3 ESRD HOME PT, SERV P MO, 20+ $223.24
90967 3 ESRD HOME PT SERV P DAY, <2 $19.40
90968 3 ESRD HOME PT SRV P DAY, 2-11 $15.02
90969 3 ESRD HOME PT SRV P DAY 12-19 $14.67
90970 3 ESRD HOME PT SERV P DAY, 20+ $7.83
90988 O SUPERVISION OF HEMODIALYSIS IN HOSP $0.00
90989 9 DIALYSIS TRAINING, COMPLETE $0.00
90990 O HEMODIALYSIS TRAINING AND/OR COUNSE $0.00
90991 O HOME HEMODIALYSIS CARE, OUTPATIENT, $0.00
90992 9 PERITONEAL DIALYSIS TRAINING AND/OR $0.00

90993 9 DIALYSIS TRAINING, INCOMPL $0.00
90994 O SUPERVISION OF CHRONIC AMBULATORY P $0.00
90995 O END STAGE RENAL DISEASE (ESRD) RELA $0.00
90997 3 HEMOPERFUSION $87.90
90998 O END STAGE RENAL DISEASE (ESRD) RELA $0.00
90999 5 DIALYSIS PROCEDURE $0.00
91000 3 ESOPHAGEAL INTUBATION $88.04
91010 3 ESOPHAGUS MOTILITY STUDY $186.55
91020 3 GASTRIC MOTILITY STUDIES $226.86
91022 3 DUODENAL MOTILITY STUDY $186.19

91030 3 ACID PERFUSION OF ESOPHAGUS $135.99
91032 O ESOPHAGUS, ACID REFLUX TEST $0.00
91033 O PROLONGED ACID REFLUX TEST $0.00
91034 3 GASTROESOPHAGEAL REFLUX TEST $196.15
91035 3 G-ESOPH REFLX TST W/ELECTROD $463.42
91037 3 ESOPH IMPED FUNCTION TEST $156.96
91038 3 ESOPH IMPED FUNCT TEST > 1H $137.94
91040 3 ESOPH BALLOON DISTENSION TST $375.46
91052 3 GASTRIC ANALYSIS TEST $121.12
91055 3 GASTRIC INTUBATION FOR SMEAR $130.65

91060 O GASTRIC SALINE LOAD TEST $0.00
91065 3 BREATH HYDROGEN TEST $64.80
91100 O PASS INTESTINE BLEEDING TUBE $0.00
91105 3 GASTRIC INTUBATION TREATMENT $78.27
91110 3 GI TRACT CAPSULE ENDOSCOPY $891.82
91111 3 ESOPHAGEAL CAPSULE ENDOSCOPY $699.46
91120 3 RECTAL SENSATION TEST $384.83
91122 3 ANAL PRESSURE RECORD $227.62
91123 3 IRRIGATE FECAL IMPACTION $92.29
91132 3 ELECTROGASTROGRAPHY $0.00
91133 3 ELECTROGASTROGRAPHY W/TEST $0.00
91299 5 GASTROENTEROLOGY PROCEDURE $0.00
92002 3 EYE EXAM, NEW PATIENT $67.41

92004 3 EYE EXAM, NEW PATIENT $126.63
92012 3 EYE EXAM ESTABLISHED PAT $71.07
92014 3 EYE EXAM & TREATMENT $103.59
92015 3 REFRACTION $31.57
92018 3 NEW EYE EXAM & TREATMENT $126.87
92019 3 EYE EXAM & TREATMENT $63.06
92020 3 SPECIAL EYE EVALUATION $23.81
92025 3 CORNEAL TOPOGRAPHY $31.11
92060 3 SPECIAL EYE EVALUATION $53.84
92065 3 ORTHOPTIC/PLEOPTIC TRAINING $42.54
92070 9 FITTING OF CONTACT LENS $0.00
92081 3 VISUAL FIELD EXAMINATION(S) $48.47

92100 3 SERIAL TONOMETRY EXAM(S) $81.05
92120 3 TONOGRAPHY & EYE EVALUATION $66.77
92130 3 WATER PROVOCATION TONOGRAPHY $73.79
92135 3 OPHTH DX IMAGING POST SEG $42.56
92136 3 OPHTHALMIC BIOMETRY $75.93
92140 3 GLAUCOMA PROVOCATIVE TESTS $52.49
92225 3 SPECIAL EYE EXAM, INITIAL $22.69
92226 3 SPECIAL EYE EXAM, SUBSEQUENT $20.53

92230 3 EYE EXAM WITH PHOTOS $55.19
92240 3 ICG ANGIOGRAPHY $201.68
92260 3 OPHTHALMOSCOPY/DYNAMOMETRY $16.26
92265 3 EYE MUSCLE EVALUATION $71.05
92270 3 ELECTRO-OCULOGRAPHY $81.90
92275 3 ELECTRORETINOGRAPHY $122.70
92280 O VISUALLY EVOKED POTENTIAL (RESPONSE $0.00
92283 3 COLOR VISION EXAMINATION $42.04
92284 3 DARK ADAPTATION EYE EXAM $56.38
92285 3 EYE PHOTOGRAPHY $38.68
92286 3 INTERNAL EYE PHOTOGRAPHY $110.32

92287 3 INTERNAL EYE PHOTOGRAPHY $104.48
92310 9 CONTACT LENS FITTING $0.00
92311 O CONTACT LENS FITTING $0.00
92312 O CONTACT LENS FITTING $0.00
92313 9 CONTACT LENS FITTING $0.00
92314 9 PRESCRIPTION OF CONTACT LENS $0.00
92315 O PRESCRIPTION OF CONTACT LENS $0.00
92316 O PRESCRIPTION OF CONTACT LENS $0.00
92317 9 PRESCRIPTION OF CONTACT LENS $0.00
92325 9 MODIFICATION OF CONTACT LENS $0.00
92326 9 REPLACEMENT OF CONTACT LENS $0.00
92330 O FITTING OF ARTIFICIAL EYE $0.00

92335 O FITTING OF ARTIFICIAL EYE $0.00
92340 9 FITTING OF SPECTACLES $0.00
92352 9 SPECIAL SPECTACLES FITTING $0.00
92358 9 EYE PROSTHESIS SERVICE $0.00
92370 9 REPAIR & ADJUST SPECTACLES $0.00

92371 9 REPAIR & ADJUST SPECTACLES $0.00
92390 O SUPPLY OF SPECTACLES $0.00
92391 O SUPPLY OF CONTACT LENSES $0.00
92392 O SUPPLY OF LOW VISION AIDS $0.00
92393 O SUPPLY OF ARTIFICIAL EYE $0.00
92395 O SUPPLY OF SPECTACLES $0.00
92396 O SUPPLY OF CONTACT LENSES $0.00
92499 5 EYE SERVICE OR PROCEDURE $0.00
92502 3 EAR AND THROAT EXAMINATION $91.02
92504 3 EAR MICROSCOPY EXAMINATION $27.74
92506 3 SPEECH/HEARING EVALUATION $149.39
92507 3 SPEECH/HEARING THERAPY $61.95
92508 3 SPEECH/HEARING THERAPY $29.50

92510 O REHAB FOR EAR IMPLANT $0.00
92511 3 NASOPHARYNGOSCOPY $146.82
92512 3 NASAL FUNCTION STUDIES $57.84
92516 3 FACIAL NERVE FUNCTION TEST $59.97
92520 3 LARYNGEAL FUNCTION STUDIES $58.57
92525 O ORAL FUNCTION EVALUATION $0.00
92526 3 ORAL FUNCTION THERAPY $79.28
92531 5 SPONTANEOUS NYSTAGMUS STUDY $0.00
92532 5 POSITIONAL NYSTAGMUS TEST $0.00
92533 5 CALORIC VESTIBULAR TEST $0.00
92534 5 OPTOKINETIC NYSTAGMUS TEST $0.00
92541 3 SPONTANEOUS NYSTAGMUS TEST $57.40

92542 3 POSITIONAL NYSTAGMUS TEST $59.84
92543 3 CALORIC VESTIBULAR TEST $27.71
92544 3 OPTOKINETIC NYSTAGMUS TEST $48.09
92545 3 OSCILLATING TRACKING TEST $45.17
92546 3 SINUSOIDAL ROTATIONAL TEST $81.33
92547 3 SUPPLEMENTAL ELECTRICAL TEST $5.14
92548 3 POSTUROGRAPHY $91.71
92551 3 PURE TONE HEARING TEST, AIR $10.59
92552 3 PURE TONE AUDIOMETRY, AIR $21.30
92553 3 AUDIOMETRY, AIR & BONE $28.43

92555 3 SPEECH THRESHOLD AUDIOMETRY $15.75
92556 3 SPEECH AUDIOMETRY, COMPLETE $24.36
92557 3 COMPREHENSIVE HEARING TEST $43.91
92559 9 GROUP AUDIOMETRIC TESTING $0.00
92560 5 BEKESY AUDIOMETRY, SCREEN $0.00
92561 3 BEKESY AUDIOMETRY, DIAGNOSIS $27.69
92562 3 LOUDNESS BALANCE TEST $22.40
92563 3 TONE DECAY HEARING TEST $20.19
92564 3 SISI HEARING TEST $19.32
92565 3 STENGER TEST, PURE TONE $12.42
92566 O IMPEDANCE TESTING $0.00
92567 3 TYMPANOMETRY $17.09
92568 3 ACOUSTIC REFL THRESHOLD TST $17.61

92569 3 ACOUSTIC REFLEX DECAY TEST $14.02
92571 3 FILTERED SPEECH HEARING TEST $16.12
92572 3 STAGGERED SPONDAIC WORD TEST $17.25
92573 O LOMBARD TEST $0.00
92574 O SWINGING STORY TEST $0.00
92575 3 SENSORINEURAL ACUITY TEST $34.86
92576 3 SYNTHETIC SENTENCE TEST $20.80
92577 3 STENGER TEST, SPEECH $16.84
92578 O DELAYED AUDITORY FEEDBACK TEST $0.00
92579 3 VISUAL AUDIOMETRY (VRA) $43.09
92580 O ELECTRODERMAL AUDIOMETRY $0.00
92581 O EVOKED RESPONSE (EEG) AUDIOMETRY $0.00

92582 3 CONDITIONING PLAY AUDIOMETRY $40.63
92583 3 SELECT PICTURE AUDIOMETRY $32.60
92584 3 ELECTROCOCHLEOGRAPHY $66.03
92585 3 AUDITOR EVOKE POTENT, COMPRE $99.22
92586 3 AUDITOR EVOKE POTENT, LIMIT $61.40
92587 3 EVOKED AUDITORY TEST $37.84
92588 3 EVOKED AUDITORY TEST $62.06
92589 O AUDITORY FUNCTION TEST(S) $0.00
92590 9 HEARING AID EXAM, ONE EAR $0.00
92591 9 HEARING AID EXAM, BOTH EARS $0.00

92592 9 HEARING AID CHECK, ONE EAR $0.00
92593 9 HEARING AID CHECK, BOTH EARS $0.00
92594 9 ELECTRO HEARNG AID TEST, ONE $0.00
92595 9 ELECTRO HEARNG AID TST, BOTH $0.00
92596 9 EAR PROTECTOR EVALUATION $0.00
92597 9 ORAL SPEECH DEVICE EVAL $0.00
92598 9 MODIFY ORAL SPEECH DEVICE $0.00
92599 O ENT PROCEDURE/SERVICE $0.00
92601 3 COCHLEAR IMPLT F/UP EXAM < 7 $151.89
92602 3 REPROGRAM COCHLEAR IMPLT < 7 $95.09
92603 3 COCHLEAR IMPLT F/UP EXAM 7 > $136.43
92604 3 REPROGRAM COCHLEAR IMPLT 7 > $81.10
92605 5 EVAL FOR NONSPEECH DEVICE RX $0.00

92606 5 NON-SPEECH DEVICE SERVICE $0.00
92607 3 EX FOR SPEECH DEVICE RX, 1HR $153.52
92608 3 EX FOR SPEECH DEVICE RX ADDL $29.29
92609 3 USE OF SPEECH DEVICE SERVICE $81.56
92610 3 EVALUATE SWALLOWING FUNCTION $78.82
92611 3 MOTION FLUOROSCOPY/SWALLOW $85.84
92612 3 ENDOSCOPY SWALLOW TST (FEES) $153.18
92613 3 ENDOSCOPY SWALLOW TST (FEES) $37.29
92614 3 LARYNGOSCOPIC SENSORY TEST $136.18
92615 3 EVAL LARYNGOSCOPY SENSE TST $33.32
92616 3 FEES W/LARYNGEAL SENSE TEST $186.93
92617 3 INTERPRT FEES/LARYNGEAL TEST $40.89

92620 9 AUDITORY FUNCTION, 60 MIN $0.00
92621 9 AUDITORY FUNCTION, + 15 MIN $0.00
92625 9 TINNITUS ASSESSMENT $0.00
92626 9 EVAL AUD REHAB STATUS $0.00
92627 9 EVAL AUD STATUS REHAB ADD-ON $0.00
92630 9 AUD REHAB PRE-LING HEAR LOSS $0.00
92633 9 AUD REHAB POSTLING HEAR LOSS $0.00
92640 3 AUD BRAINSTEM IMPLT PROGRAMG $73.71
92700 5 ENT PROCEDURE/SERVICE $0.00
92950 3 HEART/LUNG RESUSCITATION CPR $268.58

92953 9 TEMPORARY EXTERNAL PACING $0.00
92960 3 CARDIOVERSION ELECTRIC, EXT $257.69
92961 9 CARDIOVERSION, ELECTRIC, INT $0.00
92970 3 CARDIOASSIST, INTERNAL $179.91
92971 3 CARDIOASSIST, EXTERNAL $103.14
92973 3 PERCUT CORONARY THROMBECTOMY $183.72
92974 3 CATH PLACE, CARDIO BRACHYTX $168.43
92975 3 DISSOLVE CLOT, HEART VESSEL $403.43
92977 3 DISSOLVE CLOT, HEART VESSEL $131.55
92978 3 INTRAVASC US, HEART ADD-ON $0.00
92979 3 INTRAVASC US, HEART ADD-ON $0.00
92980 3 INSERT INTRACORONARY STENT $837.46
92981 3 INSERT INTRACORONARY STENT $232.88

92982 3 CORONARY ARTERY DILATION $620.97
92984 3 CORONARY ARTERY DILATION $166.25
92986 3 REVISION OF AORTIC VALVE $1,378.25
92992 5 REVISION OF HEART CHAMBER $0.00
92993 5 REVISION OF HEART CHAMBER $0.00
92995 3 CORONARY ATHERECTOMY $684.35
92996 3 CORONARY ATHERECTOMY ADD-ON $179.53
92997 3 PUL ART BALLOON REPR, PERCUT $631.78
92998 3 PUL ART BALLOON REPR, PERCUT $323.91
93000 3 ELECTROCARDIOGRAM, COMPLETE $20.84

93005 3 ELECTROCARDIOGRAM, TRACING $11.94
93010 3 ELECTROCARDIOGRAM REPORT $8.90
93012 9 TRANSMISSION OF ECG $0.00
93014 9 REPORT ON TRANSMITTED ECG $0.00
93015 3 CARDIOVASCULAR STRESS TEST $100.03
93024 3 CARDIAC DRUG STRESS TEST $121.95
93025 3 MICROVOLT T-WAVE ASSESS $215.75

93040 3 RHYTHM ECG WITH REPORT $13.22
93041 3 RHYTHM ECG, TRACING $5.42
93042 3 RHYTHM ECG, REPORT $7.80
93201 O PHONOCARDIOGRAM WITH OR WITHOUT ECG $0.00
93205 O PHONOCARDIOGRAM WITH ECG LEAD, WITH $0.00
93210 O PHONOCARDIOGRAM, INTRACARDIAC $0.00
93220 O VECTORCARDIOGRAM (VCG), WITH OR WIT $0.00

93224 3 ECG MONITOR/REPORT, 24 HRS $118.61
93225 3 ECG MONITOR/RECORD, 24 HRS $35.56
93227 3 ECG MONITOR/REVIEW, 24 HRS $28.30
93228 3 REMOTE 30 DAY ECG REV/REPORT $25.34
93229 6 REMOTE 30 DAY ECG TECH SUPP $0.00
93231 3 ECG MONITOR/RECORD, 24 HRS $35.54

93255 O APEXCARDIOGRAPHY $0.00
93268 3 ECG RECORD/REVIEW $267.82
93270 3 ECG RECORDING $21.14
93271 3 ECG/MONITORING AND ANALYSIS $219.48
93272 3 ECG/REVIEW, INTERPRET ONLY $27.20
93278 3 ECG/SIGNAL-AVERAGED $39.91
93279 3 PM DEVICE PROGR EVAL, SNGL $55.72
93280 O CARDIAC FLUOROSCOPY $0.00
93281 3 PM DEVICE PROGR EVAL, MULTI $77.22

93282 3 ICD DEVICE PROG EVAL, 1 SNGL $71.24
93283 3 ICD DEVICE PROGR EVAL, DUAL $86.76
93284 3 ICD DEVICE PROGR EVAL, MULT $101.68
93285 3 ILR DEVICE EVAL PROGR $48.12
93286 3 PRE-OP PM DEVICE EVAL $27.20
93287 3 PRE-OP ICD DEVICE EVAL $35.76
93288 3 PM DEVICE EVAL IN PERSON $43.18
93289 3 ICD DEVICE INTERROGATE $66.41
93290 3 ICM DEVICE EVAL $31.60
93291 3 ILR DEVICE INTERROGATE $41.34
93292 3 WCD DEVICE INTERROGATE $37.27
93293 3 PM PHONE R-STRIP DEVICE EVAL $59.29
93294 3 PM DEVICE INTERROGATE REMOTE $36.51

93295 3 ICD DEVICE INTERROGAT REMOTE $66.06
93296 3 PM/ICD REMOTE TECH SERV $37.21
93297 3 ICM DEVICE INTERROGAT REMOTE $25.34
93298 3 ILR DEVICE INTERROGAT REMOTE $29.41
93299 6 ICM/ILR REMOTE TECH SERV $0.00
93303 3 ECHO TRANSTHORACIC $218.56
93304 3 ECHO TRANSTHORACIC $135.40
93306 3 TTE W/DOPPLER, COMPLETE $267.90
93307 3 TTE W/O DOPPLER, COMPLETE $177.01
93308 3 TTE, F-UP OR LMTD $112.00
93312 3 ECHO TRANSESOPHAGEAL $326.31

93318 3 ECHO TRANSESOPHAGEAL INTRAOP $0.00
93320 3 DOPPLER ECHO EXAM, HEART $78.07
93321 3 DOPPLER ECHO EXAM, HEART $34.51
93325 3 DOPPLER COLOR FLOW ADD-ON $52.51
93350 3 STRESS TTE ONLY $212.88
93351 3 STRESS TTE COMPLETE $255.25

93352 3 ADMIN ECG CONTRAST AGENT $38.81
93501 3 RIGHT HEART CATHETERIZATION $803.84
93503 3 INSERT/PLACE HEART CATHETER $108.78
93505 3 BIOPSY OF HEART LINING $753.91
93508 3 CATH PLACEMENT, ANGIOGRAPHY $1,070.17
93510 3 LEFT HEART CATHETERIZATION $1,327.90
93511 3 LEFT HEART CATHETERIZATION $0.00
93526 3 RT & LT HEART CATHETERS $1,702.25
93527 3 RT & LT HEART CATHETERS $0.00
93528 3 RT & LT HEART CATHETERS $0.00
93529 3 RT, LT HEART CATHETERIZATION $0.00

93530 3 RT HEART CATH, CONGENITAL $0.00
93531 3 R & L HEART CATH, CONGENITAL $0.00
93536 O INSERT CIRCULATION ASSI $0.00
93539 3 INJECTION, CARDIAC CATH $81.45
93540 3 INJECTION, CARDIAC CATH $244.09
93541 3 INJECTION FOR LUNG ANGIOGRAM $15.78
93542 3 INJECTION FOR HEART X-RAYS $148.14
93543 3 INJECTION FOR HEART X-RAYS $80.85
93544 3 INJECTION FOR AORTOGRAPHY $58.71
93545 3 INJECT FOR CORONARY X-RAYS $21.92

93546 O COMBINED LEFT HEART CATHETERIZATION $0.00
93549 O COMBINED RIGHT AND LEFT HEART CATHE $0.00
93550 O COMBINED RIGHT AND LEFT HEART CATHE $0.00
93551 O SELECTIVE OPACIFICATION OF AORTOCOR $0.00
93555 3 IMAGING, CARDIAC CATH $115.08
93556 3 IMAGING, CARDIAC CATH $160.91

93561 3 CARDIAC OUTPUT MEASUREMENT $0.00
93562 3 CARDIAC OUTPUT MEASUREMENT $0.00
93571 3 HEART FLOW RESERVE MEASURE $0.00
93572 3 HEART FLOW RESERVE MEASURE $0.00
93580 3 TRANSCATH CLOSURE OF ASD $1,005.95
93581 3 TRANSCATH CLOSURE OF VSD $1,315.39
93600 3 BUNDLE OF HIS RECORDING $0.00
93602 3 INTRA-ATRIAL RECORDING $0.00
93603 3 RIGHT VENTRICULAR RECORDING $0.00
93607 O LEFT VENTRICULAR RECORDING $0.00
93609 3 MAP TACHYCARDIA, ADD-ON $0.00
93610 3 INTRA-ATRIAL PACING $0.00
93612 3 INTRAVENTRICULAR PACING $0.00

93613 3 ELECTROPHYS MAP 3D, ADD-ON $390.19
93615 3 ESOPHAGEAL RECORDING $0.00
93616 3 ESOPHAGEAL RECORDING $0.00
93618 3 HEART RHYTHM PACING $0.00
93619 3 ELECTROPHYSIOLOGY EVALUATION $0.00
93623 3 STIMULATION, PACING HEART $0.00
93624 3 ELECTROPHYSIOLOGIC STUDY $0.00
93631 3 HEART PACING, MAPPING $0.00
93640 3 EVALUATION HEART DEVICE $0.00

93650 3 ABLATE HEART DYSRHYTHM FOCUS $594.58
93660 3 TILT TABLE EVALUATION $172.24
93662 3 INTRACARDIAC ECG (ICE) $0.00
93668 9 PERIPHERAL VASCULAR REHAB $0.00
93701 3 BIOIMPEDANCE, THORACIC $34.28
93720 3 TOTAL BODY PLETHYSMOGRAPHY $46.21

93721 3 PLETHYSMOGRAPHY TRACING $38.04
93722 3 PLETHYSMOGRAPHY REPORT $8.16
93724 3 ANALYZE PACEMAKER SYSTEM $331.98
93727 O ANALYZE ILR SYSTEM $0.00
93731 O ANALYZE PACEMAKER SYSTEM $0.00
93733 O TELEPHONE ANALY, PACEMAKER $0.00
93736 O TELEPHONIC ANALY, PACEMAKER $0.00
93737 O ANALYZE CARDIO/DEFIBRILLATOR $0.00
93738 O ANALYZE CARDIO/DEFIBRILLATOR $0.00
93740 O TEMPERATURE GRADIENT STUDIES $0.00

93741 O ANALYZE HT PACE DEVICE SNGL $0.00
93742 O ANALYZE HT PACE DEVICE SNGL $0.00
93743 O ANALYZE HT PACE DEVICE DUAL $0.00
93744 O ANALYZE HT PACE DEVICE DUAL $0.00
93745 3 SET-UP CARDIOVERT-DEFIBRILL $215.95
93760 O CEPHALIC THERMOGRAM $0.00
93762 O PERIPHERAL THERMOGRAM $0.00
93770 3 MEASURE VENOUS PRESSURE $8.42
93784 3 AMBULATORY BP MONITORING $66.06
93786 3 AMBULATORY BP RECORDING $30.18
93788 3 AMBULATORY BP ANALYSIS $16.88
93790 3 REVIEW/REPORT BP RECORDING $18.99

93797 3 CARDIAC REHAB $18.13
93798 3 CARDIAC REHAB/MONITOR $26.15
93799 5 CARDIOVASCULAR PROCEDURE $0.00
93850 O NON-INVASIVE STUDIES OF CEREBRAL AR $0.00
93860 O NON-INVASIVE STUDIES OF CAROTID ART $0.00
93870 O NON-INVASIVE STUDIES OF CAROTID ART $0.00
93875 3 EXTRACRANIAL STUDY $102.06
93886 3 INTRACRANIAL STUDY $200.50

93888 3 INTRACRANIAL STUDY $94.15
93890 3 TRANSCRANIAL DOPPLER STUDY OF THE $147.23
93892 3 TCD, EMBOLI DETECT W/O INJ $154.19
93893 3 TCD, EMBOLI DETECT W/INJ $154.57
93910 O NON-INVASIVE STUDIES OF LOWER EXTRE $0.00
93920 O NON-INVASIVE PHYSIOLOGIC STUDIES OF $0.00
93921 O NON-INVASIVE PHYSIOLOGIC STUDIES OF $0.00
93922 3 EXTREMITY STUDY $121.23
93925 3 LOWER EXTREMITY STUDY $183.37
93926 3 LOWER EXTREMITY STUDY $118.20
93930 3 UPPER EXTREMITY STUDY $177.06

93931 3 UPPER EXTREMITY STUDY $113.60
93950 O NON-INVASIVE STUDIES OF EXTREMITY V $0.00
93960 O QUANTITATIVE VENOUS FLOW STUDIES (E $0.00
93975 3 VASCULAR STUDY $245.61
93980 3 PENILE VASCULAR STUDY $182.65
93981 3 PENILE VASCULAR STUDY $128.63

93982 3 ANEURYSM PRESSURE SENS STUDY $40.17
93990 3 DOPPLER FLOW TESTING $110.87
94002 9 VENT MGMT INPAT, INIT DAY $0.00
94003 9 VENT MGMT INPAT, SUBQ DAY $0.00
94004 9 VENT MGMT NF PER DAY $0.00
94005 9 HOME VENT MGMT SUPERVISION $0.00
94010 3 BREATHING CAPACITY TEST $33.05
94014 3 PATIENT RECORDED SPIROMETRY $48.51
94015 3 PATIENT RECORDED SPIROMETRY $23.90
94016 3 REVIEW PATIENT SPIROMETRY $24.61

94060 3 EVALUATION OF WHEEZING $57.86
94070 3 EVALUATION OF WHEEZING $59.31
94150 3 VITAL CAPACITY TEST $22.58
94160 O VITAL CAPACITY SCREENING TESTS: TOT $0.00
94200 3 LUNG FUNCTION TEST (MBC/MVV) $22.39
94240 3 RESIDUAL LUNG CAPACITY $38.83
94250 3 EXPIRED GAS COLLECTION $24.37
94260 3 THORACIC GAS VOLUME $31.35
94350 3 LUNG NITROGEN WASHOUT CURVE $34.52
94360 3 MEASURE AIRFLOW RESISTANCE $43.13
94370 3 BREATH AIRWAY CLOSING VOLUME $33.30
94375 3 RESPIRATORY FLOW VOLUME LOOP $36.94
94400 3 CO2 BREATHING RESPONSE CURVE $52.31

94450 3 HYPOXIA RESPONSE CURVE $50.37
94452 3 HAST W/REPORT $55.66
94453 3 HAST W/OXYGEN TITRATE $74.40
94610 3 SURFACTANT ADMIN THRU TUBE $61.36
94620 3 PULMONARY STRESS TEST/SIMPLE $71.09
94621 3 PULM STRESS TEST/COMPLEX $161.05
94640 3 AIRWAY INHALATION TREATMENT $13.42
94642 3 AEROSOL INHALATION TREATMENT $34.88
94644 3 CBT, 1ST HOUR $34.50
94645 3 CBT, EACH ADDL HOUR $13.42
94650 O PRESSURE BREATHING (IPPB) $0.00

94656 O INITIAL VENTILATOR MGMT $0.00
94657 O CONTINUED VENTILATOR MGMT $0.00
94660 9 POS AIRWAY PRESSURE, CPAP $0.00
94662 9 NEG PRESS VENTILATION, CNP $0.00
94664 3 EVALUATE PT USE OF INHALER $14.64
94665 O AEROSOL OR VAPOR INHALATIONS $0.00
94667 9 CHEST WALL MANIPULATION $0.00
94668 9 CHEST WALL MANIPULATION $0.00
94680 3 EXHALED AIR ANALYSIS, O2 $57.56

94681 3 EXHALED AIR ANALYSIS, O2/CO2 $62.39
94690 3 EXHALED AIR ANALYSIS $50.66
94700 O ANALYSIS OF ARTERIAL BLOOD GAS (OXY $0.00
94715 O HEMOGLOBIN-OXYGEN AFFINITY (PO2 FOR $0.00
94720 3 MONOXIDE DIFFUSING CAPACITY $51.26
94725 3 MEMBRANE DIFFUSION CAPACITY $66.39
94750 3 PULMONARY COMPLIANCE STUDY $71.16
94760 3 MEASURE BLOOD OXYGEN LEVEL $2.70
94770 3 EXHALED CARBON DIOXIDE TEST $36.11

94772 3 BREATH RECORDING, INFANT $167.00
94774 9 PED HOME APNEA REC, COMPL $0.00
94775 9 PED HOME APNEA REC, HK-UP $0.00
94776 9 PED HOME APNEA REC, DOWNLD $0.00
94777 9 PED HOME APNEA REC, REPORT $0.00
94799 O PULMONARY SERVICE/PROCEDURE $0.00
95000 O PERCUTANEOUS TESTS (SCRATCH, PUNCTU $0.00
95004 3 PERCUT ALLERGY SKIN TESTS $5.77

95010 3 PERCUT ALLERGY TITRATE TEST $17.06
95012 3 EXHALED NITRIC OXIDE MEAS $19.84
95014 O INTRACUTANEOUS (INTRADERMAL) TESTS, $0.00
95015 3 ID ALLERGY TITRATE-DRUG/BUG $12.62

95020 O INTRACUTANEOUS (INTRADERMAL) TESTS $0.00
95024 3 ID ALLERGY TEST, DRUG/BUG $6.88
95027 3 ID ALLERGY TITRATE-AIRBORNE $4.66
95028 3 ID ALLERGY TEST-DELAYED TYPE $10.96
95040 O PATCH OR APPLICATION TESTS UP TO 10 $0.00

95041 O PATCH OR APPLICATION TESTS 11-20 TE $0.00
95042 O PATCH OR APPLICATION TESTS 21-30 TE $0.00
95043 O PATCH OR APPLICATION TESTS MORE THA $0.00
95044 3 ALLERGY PATCH TESTS $6.15
95050 9 PHOTO PATCH TESTS UP TO 10 TESTS $0.00
95051 9 PHOTO PATCH TESTS MORE THAN 10 TEST $0.00
95052 3 PHOTO PATCH TEST $6.90
95056 3 PHOTOSENSITIVITY TESTS $35.00
95060 3 EYE ALLERGY TESTS $23.40
95065 3 NOSE ALLERGY TEST $21.32
95070 3 BRONCHIAL ALLERGY TESTS $43.37
95071 3 BRONCHIAL ALLERGY TESTS $53.71

95075 3 INGESTION CHALLENGE TEST $62.02
95078 O PROVOCATIVE TESTING $0.00
95080 9 PASSIVE TRANSFER TESTS UP TO 10 TES $0.00
95081 9 PASSIVE TRANSFER TESTS 11-20 TESTS $0.00
95082 9 PASSIVE TRANSFER TESTS MORE THAN 20 $0.00
95105 O MEDICAL CONFERENCE SERVICES (EG, US $0.00
95115 3 IMMUNOTHERAPY, ONE INJECTION $10.46
95117 3 IMMUNOTHERAPY INJECTIONS $12.68
95120 9 IMMUNOTHERAPY, ONE INJECTION $0.00
95125 9 IMMUNOTHERAPY, MANY ANTIGENS $0.00

95130 9 IMMUNOTHERAPY, INSECT VENOM $0.00
95131 9 IMMUNOTHERAPY, INSECT VENOMS $0.00
95135 9 PROFESSIONAL SERVICES FOR THE SUPER $0.00
95140 9 PROFESSIONAL SERVICES FOR THE SUPER $0.00
95144 3 ANTIGEN THERAPY SERVICES $11.62

95150 9 PROFESSIONAL SERVICE FOR THE SUPERV $0.00
95155 O PROFESSIONAL SERVICE FOR THE SUPERV $0.00
95180 3 RAPID DESENSITIZATION $139.34
95199 5 ALLERGY IMMUNOLOGY SERVICES $0.00
95250 3 GLUCOSE MONITORING, CONT $131.49
95251 3 GLUC MONITOR, CONT, PHYS I&R $39.36
95803 9 ACTIGRAPHY TESTING $0.00
95805 3 MULTIPLE SLEEP LATENCY TEST $424.27
95806 9 SLEEP STUDY, UNATTENDED $0.00
95807 3 SLEEP STUDY, ATTENDED $497.21

95808 3 POLYSOMNOGRAPHY, 1-3 $650.98
95810 3 POLYSOMNOGRAPHY, 4 OR MORE $774.72
95811 3 POLYSOMNOGRAPHY W/CPAP $853.98
95812 3 EEG, 41-60 MINUTES $237.50
95813 3 EEG, OVER 1 HOUR $290.66
95816 3 EEG, AWAKE AND DROWSY $217.67
95817 O ELECTROENCEPHALOGRAM (EEG) INCLUDIN $0.00
95819 3 EEG, AWAKE AND ASLEEP $233.94
95821 O ELECTROENCEPHALOGRAM (EEG) INCLUDIN $0.00
95822 3 EEG, COMA OR SLEEP ONLY $232.81

95823 O ELECTROENCEPHALOGRAM (EEG); PHYSICA $0.00
95824 3 EEG, CEREBRAL DEATH ONLY $0.00
95826 O ELECTROENCEPHALOGRAM (EEG); INTRACE $0.00
95827 3 EEG, ALL NIGHT RECORDING $378.10
95828 O POLYSOMNOGRAPHY (RECORDING, ANALYSI $0.00
95829 3 SURGERY ELECTROCORTICOGRAM $1,213.27
95830 9 INSERT ELECTRODES FOR EEG $0.00
95831 3 LIMB MUSCLE TESTING, MANUAL $25.40
95832 3 HAND MUSCLE TESTING, MANUAL $23.78
95833 3 BODY MUSCLE TESTING, MANUAL $35.03
95834 3 BODY MUSCLE TESTING, MANUAL $41.39
95842 O MUSCLE TESTING, ELECTRICAL: REACTIO $0.00
95851 9 RANGE OF MOTION MEASUREMENTS $0.00

95852 3 RANGE OF MOTION MEASUREMENTS $12.67
95857 3 TENSILON TEST $40.87
95858 O TENSILON TEST & MYOGRAM $0.00
95860 3 MUSCLE TEST, ONE LIMB $80.35
95861 3 MUSCLE TEST, 2 LIMBS $116.19
95865 3 MUSCLE TEST, LARYNX $111.24
95866 3 MUSCLE TEST, HEMIDIAPHRAGM $91.06
95867 3 MUSCLE TEST CRAN NERV UNILAT $69.83
95868 3 MUSCLE TEST CRAN NERVE BILAT $95.58
95869 3 MUSCLE TEST, THOR PARASPINAL $44.86

95870 3 MUSCLE TEST, NONPARASPINAL $43.76
95872 9 MUSCLE TEST, ONE FIBER $0.00
95873 3 GUIDE NERV DESTR, ELEC STIM $45.61
95874 3 GUIDE NERV DESTR, NEEDLE EMG $43.02
95875 3 LIMB EXERCISE TEST $91.48
95880 O ASSESSMENT OF APHASIA (INCLUDES ASS $0.00
95881 O DEVELOPMENTAL TESTING (INCLUDES ASS $0.00
95882 O NEUROBEHAVIORAL STATUS EXAM (CLINIC $0.00
95883 O NEUROPSYCHOLOGICAL TESTING BATTERY $0.00
95900 3 MOTOR NERVE CONDUCTION TEST $52.57

95903 3 MOTOR NERVE CONDUCTION TEST $61.46
95904 3 SENSE NERVE CONDUCTION TEST $46.38
95920 3 INTRAOP NERVE TEST ADD-ON $148.20
95921 3 AUTONOMIC NERV FUNCTION TEST $72.42
95925 3 SOMATOSENSORY TESTING $117.08
95928 3 C MOTOR EVOKED, UPPR LIMBS $186.63
95929 3 C MOTOR EVOKED, LWR LIMBS $196.99
95930 3 VISUAL EVOKED POTENTIAL TEST $104.17
95933 3 BLINK REFLEX TEST $63.04

95934 3 H-REFLEX TEST $47.29
95935 O ''H'' OR ''F'' REFLEX STUDY, BY ELE $0.00
95936 3 H-REFLEX TEST $41.55
95937 3 NEUROMUSCULAR JUNCTION TEST $55.94
95950 3 AMBULATORY EEG MONITORING $234.77
95951 3 EEG MONITORING/VIDEORECORD $0.00
95952 9 MONITORING FOR LOCALIZATION OF CERE $0.00
95953 3 EEG MONITORING/COMPUTER $397.02
95954 9 EEG MONITORING/GIVING DRUGS $0.00
95955 9 EEG DURING SURGERY $0.00
95956 3 EEG MONITORING, CABLE/RADIO $706.49
95957 3 EEG DIGITAL ANALYSIS $257.43

95958 9 EEG MONITORING/FUNCTION TEST $0.00
95961 3 ELECTRODE STIMULATION, BRAIN $226.53
95962 3 ELECTRODE STIM, BRAIN ADD-ON $208.72
95965 3 MEG, SPONTANEOUS $0.00
95966 3 MEG, EVOKED, SINGLE $0.00
95967 3 MEG, EVOKED, EACH ADDÏL $0.00
95970 3 ANALYZE NEUROSTIM, NO PROG $49.33
95971 3 ANALYZE NEUROSTIM, SIMPLE $56.17
95972 3 ANALYZE NEUROSTIM, COMPLEX $99.84
95973 3 ANALYZE NEUROSTIM, COMPLEX $54.52

95974 3 CRANIAL NEUROSTIM, COMPLEX $167.24
95975 3 CRANIAL NEUROSTIM, COMPLEX $92.46
95978 3 ANALYZE NEUROSTIM BRAIN/1H $198.89
95979 3 ANALYZ NEUROSTIM BRAIN ADDON $88.98
95980 3 IO ANAL GAST N-STIM INIT $39.50
95981 3 IO ANAL GAST N-STIM SUBSQ $27.47
95982 3 IO GA N-STIM SUBSQ W/REPROG $42.54
95990 3 SPIN/BRAIN PUMP REFIL & MAIN $59.11
95991 3 SPIN/BRAIN PUMP REFIL & MAIN $86.99
95992 3 CANALITH REPOSITIONING PROC $40.59
95999 5 NEUROLOGICAL PROCEDURE $0.00
96000 9 MOTION ANALYSIS, VIDEO/3D $0.00
96001 9 MOTION TEST W/FT PRESS MEAS $0.00

96002 9 DYNAMIC SURFACE EMG $0.00
96003 9 DYNAMIC FINE WIRE EMG $0.00
96004 9 PHYS REVIEW OF MOTION TESTS $0.00
96020 3 FUNCTIONAL BRAIN MAPPING $0.00
96040 9 GENETIC COUNSELING, 30 MIN $0.00
96100 O PSYCHOLOGICAL TESTING $0.00
96101 3 PSYCHO TESTING BY PSYCH/PHYS $83.56
96102 9 PSYCHO TESTING BY TECHNICIAN $0.00
96103 9 PSYCHO TESTING ADMIN BY COMP $0.00
96105 9 ASSESSMENT OF APHASIA $0.00
96110 3 DEVELOPMENTAL TEST, LIM $10.97
96111 7 DEVELOPMENTAL TEST, EXTEND $0.00

96115 O NEUROBEHAVIOR STATUS EXAM $0.00
96116 9 NEUROBEHAVIORAL STATUS EXAM $0.00
96117 O NEUROPSYCH TEST BATTERY $0.00
96118 3 NEUROPSYCH TST BY PSYCH/PHYS $106.27
96119 9 NEUROPSYCH TESTING BY TEC $0.00
96120 9 NEUROPSYCH TST ADMIN W/COMP $0.00
96125 9 COGNITIVE TEST BY HC PRO $0.00
96150 9 ASSESS HLTH/BEHAVE, INIT $0.00
96151 9 ASSESS HLTH/BEHAVE, SUBSEQ $0.00
96152 9 INTERVENE HLTH/BEHAVE, INDIV $0.00

96153 9 INTERVENE HLTH/BEHAVE, GROUP $0.00
96154 7 INTERV HLTH/BEHAV, FAM W/PT $0.00
96155 7 INTERV HLTH/BEHAV FAM NO PT $0.00
96360 3 HYDRATION IV INFUSION, INIT $56.93
96361 3 HYDRATE IV INFUSION, ADD-ON $16.38
96365 3 THER/PROPH/DIAG IV INF, INIT $69.44
96366 3 THER/PROPH/DIAG IV INF ADDON $21.81
96367 3 TX/PROPH/DG ADDL SEQ IV INF $34.74
96368 3 THER/DIAG CONCURRENT INF $20.34
96369 3 SC THER INFUSION, UP TO 1 HR $152.39
96370 3 SC THER INFUSION, ADDL HR $15.52
96371 3 SC THER INFUSION, RESET PUMP $74.19
96372 9 THER/PROPH/DIAG INJ, SC/IM $0.00

96373 9 THER/PROPH/DIAG INJ, IA $0.00
96374 9 THER/PROPH/DIAG INJ, IV PUSH $0.00
96375 9 TX/PRO/DX INJ NEW DRUG ADDON $0.00
96376 6 TX/PRO/DX INJ NEW DRUG ADON $0.00
96379 9 THER/PROP/DIAG INJ/INF PROC $0.00
96400 O CHEMOTHERAPY, SC/IM $0.00
96401 3 CHEMO, ANTI-NEOPL, SQ/IM $68.75
96402 3 CHEMO HORMON ANTINEOPL SQ/IM $37.35
96405 3 CHEMO INTRALESIONAL, UP TO 7 $85.48
96406 3 CHEMO INTRALESIONAL OVER 7 $118.04
96408 O CHEMOTHERAPY, PUSH TECHNIQUE $0.00
96409 3 CHEMO, IV PUSH, SNGL DRUG $113.53

96410 O CHEMOTHERAPY,INFUSION METHOD $0.00
96411 3 CHEMO, IV PUSH, ADDL DRUG $64.42
96412 O CHEMO, INFUSE METHOD ADD-ON $0.00
96413 3 CHEMO, IV INFUSION, 1 HR $149.82
96414 O CHEMO, INFUSE METHOD ADD-ON $0.00
96415 3 CHEMO, IV INFUSION, ADDL HR $33.24
96416 3 CHEMO PROLONG INFUSE W/PUMP $163.59
96417 3 CHEMO IV INFUS EACH ADDL SEQ $74.25
96420 3 CHEMO, IA, PUSH TECNIQUE $109.29
96422 3 CHEMO IA INFUSION UP TO 1 HR $176.95

96423 3 CHEMO IA INFUSE EACH ADDL HR $79.02
96425 3 CHEMOTHERAPY,INFUSION METHOD $174.36
96440 3 CHEMOTHERAPY, INTRACAVITARY $607.84
96445 3 CHEMOTHERAPY, INTRACAVITARY $287.89
96450 3 CHEMOTHERAPY, INTO CNS $210.26
96520 O PORT PUMP REFILL & MAIN $0.00
96521 3 REFILL/MAINT, PORTABLE PUMP $129.10
96522 3 REFILL/MAINT PUMP/RESVR SYST $109.51
96523 3 IRRIG DRUG DELIVERY DEVICE $25.70
96530 O SYST PUMP REFILL & MAIN $0.00
96542 3 CHEMOTHERAPY INJECTION $135.69
96545 O PROVIDE CHEMOTHERAPY AGENT $0.00
96549 5 CHEMOTHERAPY, UNSPECIFIED $0.00

96567 3 PHOTODYNAMIC TX, SKIN $119.27
96570 3 PHOTODYNAMIC TX, 30 MIN $56.73
96571 3 PHOTODYNAMIC TX, ADDL 15 MIN $27.40
96900 3 ULTRAVIOLET LIGHT THERAPY $19.71
96902 3 TRICHOGRAM $20.81
96904 9 WHOLE BODY PHOTOGRAPHY $0.00
96910 3 PHOTOCHEMOTHERAPY WITH UV-B $63.81
96912 3 PHOTOCHEMOTHERAPY WITH UV-A $81.79
96913 3 PHOTOCHEMOTHERAPY, UV-A OR B $113.31
96920 3 LASER TX, SKIN < 250 SQ CM $162.46
96921 3 LASER TX, SKIN 250-500 SQ CM $158.99
96922 3 LASER TX, SKIN > 500 SQ CM $234.97

96999 5 DERMATOLOGICAL PROCEDURE $0.00
97001 3 PT EVALUATION $69.59
97002 3 PT RE-EVALUATION $37.45
97003 3 OT EVALUATION $73.89
97004 3 OT RE-EVALUATION $42.99
97005 9 ATHLETIC TRAIN EVAL $0.00
97006 9 ATHLETIC TRAIN REEVAL $0.00
97010 3 HOT OR COLD PACKS THERAPY $4.61
97012 3 MECHANICAL TRACTION THERAPY $14.35
97014 3 ELECTRIC STIMULATION THERAPY $13.33

97016 3 VASOPNEUMATIC DEVICE THERAPY $15.17
97018 3 PARAFFIN BATH THERAPY $7.93
97020 O MICROWAVE THERAPY $0.00
97022 3 WHIRLPOOL THERAPY $17.40
97024 3 DIATHERMY EG, MICROWAVE $5.34
97026 3 INFRARED THERAPY $4.97
97028 3 ULTRAVIOLET THERAPY $6.06
97032 3 ELECTRICAL STIMULATION $16.20
97033 3 ELECTRIC CURRENT THERAPY $24.32
97034 3 CONTRAST BATH THERAPY $14.77
97035 3 ULTRASOUND THERAPY $11.44
97036 3 HYDROTHERAPY $25.40
97039 3 PHYSICAL THERAPY TREATMENT $11.27

97110 3 THERAPEUTIC EXERCISES $28.02
97112 3 NEUROMUSCULAR REEDUCATION $28.89
97113 3 AQUATIC THERAPY/EXERCISES $34.45
97114 O PHYSICAL MEDICINE TREATMENT TO ONE $0.00
97116 3 GAIT TRAINING THERAPY $24.52
97122 O MANUAL TRACTION THERAPY $0.00
97124 3 MASSAGE THERAPY $22.36
97139 3 PHYSICAL MEDICINE PROCEDURE $15.30

97140 3 MANUAL THERAPY $25.96
97150 3 GROUP THERAPEUTIC PROCEDURES $17.65
97220 O HUBBARD TANK; INITIAL 30 MINUTES, E $0.00
97221 O HUBBARD TANK; EACH ADDITIONAL 15 MI $0.00
97240 O POOL THERAPY OR HUBBARD TANK WITH T $0.00
97241 O POOL THERAPY OR HUBBARD TANK WITH T $0.00
97250 O MYOFASCIAL RELEASE $0.00
97260 O REGIONAL MANIPULATION $0.00
97261 O SUPPLEMENTAL MANIPULATIONS $0.00

97265 O JOINT MOBILIZATION $0.00
97500 O ORTHOTICS TRAINING (DYNAMIC BRACING $0.00
97501 O ORTHOTICS TRAINING (DYNAMIC BRACING $0.00
97504 O ORTHOTIC TRAINING $0.00
97520 O PROSTHETIC TRAINING $0.00
97521 O PROSTHETIC TRAINING; EACH ADDITIONA $0.00
97530 3 THERAPEUTIC ACTIVITIES $29.65
97531 O KINETIC ACTIVITIES TO INCREASE COOR $0.00
97532 3 COGNITIVE SKILLS DEVELOPMENT $24.10
97533 3 SENSORY INTEGRATION $25.94
97535 3 SELF CARE MNGMENT TRAINING $29.63
97537 3 COMMUNITY/WORK REINTEGRATION $26.68
97540 O TRAINING IN ACTIVITIES OF DAILY LIV $0.00

97541 O TRAINING IN ACTIVITIES OF DAILY LIV $0.00
97542 3 WHEELCHAIR MNGMENT TRAINING $27.04
97545 O WORK HARDENING $0.00
97546 O WORK HARDENING ADD-ON $0.00
97597 3 ACTIVE WOUND CARE/20 CM OR < $58.53
97598 3 ACTIVE WOUND CARE > 20 CM $72.30
97601 O WOUND(S) CARE, SELECTIVE $0.00
97602 9 WOUND(S) CARE NON-SELECTIVE $0.00
97605 3 NEG PRESS WOUND TX, < 50 CM $34.55
97606 3 NEG PRESS WOUND TX, > 50 CM $36.95
97700 O OFFICE VISIT, INCLUDING ONE OF THE $0.00
97701 O OFFICE VISIT, INCLUDING ONE OF THE $0.00

97703 O PROSTHETIC CHECKOUT $0.00
97720 O EXTREMITY TESTING FOR STRENGTH, DEX $0.00
97721 O EXTREMITY TESTING FOR STRENGTH, DEX $0.00
97750 3 PHYSICAL PERFORMANCE TEST $28.76
97752 O MUSCLE TESTING WITH TORQUE CURVES D $0.00
97755 3 ASSISTIVE TECHNOLOGY ASSESS $32.99
97760 3 ORTHOTIC MGMT AND TRAINING $31.96
97761 3 PROSTHETIC TRAINING $28.39
97762 3 C/O FOR ORTHOTIC/PROSTH USE $33.45
97770 O COGNITIVE SKILLS DEVELOPMENT $0.00

97780 O ACUPUNCTURE W/O STIMUL $0.00
97781 O ACUPUNCTURE W/STIMUL $0.00
97799 5 PHYSICAL MEDICINE PROCEDURE $0.00
97802 7 MEDICAL NUTRITION, INDIV, IN $0.00
97803 7 MED NUTRITION, INDIV, SUBSEQ $0.00
97804 9 MEDICAL NUTRITION, GROUP $0.00
97810 9 ACUPUNCT W/O STIMUL 15 MIN $0.00
97811 9 ACUPUNCT W/O STIMUL ADDL 15M $0.00
97813 9 ACUPUNCT W/STIMUL 15 MIN $0.00
97814 9 ACUPUNCT W/STIMUL ADDL 15M $0.00
98900 O MEDICAL CONFERENCE BY PHYSICIAN REG $0.00
98902 O MEDICAL CONFERENCE BY PHYSICIAN REG $0.00
98910 O MEDICAL CONFERENCE BY PHYSICIAN WIT $0.00

98912 O MEDICAL CONFERENCE BY PHYSICIAN WIT $0.00
98920 9 TELEPHONE CALL BY A PHYSICIAN TO PA $0.00
98925 3 OSTEOPATHIC MANIPULATION $27.66
98940 9 CHIROPRACTIC MANIPULATION $0.00

98960 9 SELF-MGMT EDUC & TRAIN, 1 PT $0.00
98961 9 SELF-MGMT EDUC/TRAIN, 2-4 PT $0.00
98962 9 SELF-MGMT EDUC/TRAIN, 5-8 PT $0.00
98966 9 HC PRO PHONE CALL 5-10 MIN $0.00
98969 9 ONLINE SERVICE BY HC PRO $0.00
99000 9 SPECIMEN HANDLING $0.00
99001 3 SPECIMEN HANDLING $3.10

99002 9 DEVICE HANDLING $0.00
99024 9 POSTOP FOLLOW-UP VISIT $0.00
99025 O INITIAL SURGICAL EVALUATION $0.00
99026 9 IN-HOSPITAL ON CALL SERVICE $0.00
99027 9 OUT-OF-HOSP ON CALL SERVICE $0.00
99050 3 MEDICAL SERVICES AFTER HRS $20.00
99051 9 MED SERV, EVE/WKEND/HOLIDAY $0.00
99052 O MEDICAL SERVICES AT NIGHT $0.00
99053 9 MED SERV 10PM-8AM, 24 HR FAC $0.00
99054 O MEDICAL SERVCS, UNUSUAL HRS $0.00
99056 O MED SERVICE OUT OF OFFICE $0.00
99058 9 OFFICE EMERGENCY CARE $0.00
99060 9 OUT OF OFFICE EMERG MED SERV $0.00

99062 O EMERGENCY CARE FACILITY SERVICES: W $0.00
99070 O SPECIAL SUPPLIES $0.00
99071 9 PATIENT EDUCATION MATERIALS $0.00
99075 9 MEDICAL TESTIMONY $0.00
99078 9 GROUP HEALTH EDUCATION $0.00
99080 9 SPECIAL REPORTS OR FORMS $0.00
99082 9 UNUSUAL PHYSICIAN TRAVEL $0.00
99090 9 COMPUTER DATA ANALYSIS $0.00
99091 9 COLLECT/REVIEW DATA FROM PT $0.00
99100 9 SPECIAL ANESTHESIA SERVICE $0.00

99116 9 ANESTHESIA WITH HYPOTHERMIA $0.00
99135 9 SPECIAL ANESTHESIA PROCEDURE $0.00
99140 9 EMERGENCY ANESTHESIA $0.00
99141 O SEDATION, IV/IM OR INHALANT $0.00
99142 O SEDATION, ORAL/RECTAL/NASAL $0.00
99143 9 MOD CS BY SAME PHYS, < 5 YRS $0.00
99144 9 MOD CS BY SAME PHYS, 5 YRS + $0.00
99145 9 MOD CS BY SAME PHYS ADD-ON $0.00
99148 3 MOD CS DIFF PHYS < 5 YRS $112.36
99149 3 MOD CS DIFF PHYS 5 YRS + $112.36

99150 3 MODERATE SEDATION SERVICES (OTHER $56.18
99151 O PROLONGED PHYSICIAN ATTENDANCE REQU $0.00
99152 O NEWBORN RESUSCITATION: CARE OF THE $0.00
99160 O CRITICAL CARE, INITIAL, INCLUDING T $0.00
99162 O CRITICAL CARE, INITIAL, INCLUDING T $0.00
99170 3 ANOGENITAL EXAM, CHILD $142.46
99171 O CRITICAL CARE, SUBSEQUENT FOLLOW-UP $0.00
99172 O OCULAR FUNCTION SCREEN $0.00
99173 3 VISUAL ACUITY SCREEN $2.46
99174 3 OCULAR PHOTOSCREENING WITH INTERPR $25.75
99175 3 INDUCTION OF VOMITING $25.32
99178 O ADMINISTRATION AND MEDICAL INTERPRE $0.00
99180 O HYPERBARIC OXYGEN PRESSURIZATION IN $0.00

99182 O HYPERBARIC OXYGEN PRESSURIZATION SU $0.00
99183 3 HYPERBARIC OXYGEN THERAPY $189.12
99185 3 REGIONAL HYPOTHERMIA $57.15
99186 3 TOTAL BODY HYPOTHERMIA $72.53
99190 9 SPECIAL PUMP SERVICES $0.00
99195 3 PHLEBOTOMY $71.83
99199 5 SPECIAL SERVICE/PROC/REPORT $0.00
99201 3 OFFICE/OUTPATIENT VISIT, NEW $36.76

99211 3 OFFICE/OUTPATIENT VISIT, EST $18.88
99217 3 OBSERVATION CARE DISCHARGE $66.03
99218 3 OBSERVATION CARE $61.97

99221 3 INITIAL HOSPITAL CARE $88.82
99231 3 SUBSEQUENT HOSPITAL CARE $36.75
99234 3 OBSERV/HOSP SAME DATE $125.65
99238 3 HOSPITAL DISCHARGE DAY $65.80
99239 3 HOSPITAL DISCHARGE DAY $95.45
99241 3 OFFICE CONSULTATION $48.47

99251 3 INPATIENT CONSULTATION $48.02
99261 O FOLLOW-UP INPATIENT CONSULT $0.00

99271 O CONFIRMATORY CONSULTATION $0.00
99281 3 EMERGENCY DEPT VISIT $19.88

99288 9 DIRECT ADVANCED LIFE SUPPORT $0.00
99289 O PED CRIT CARE TRANSPORT $0.00
99290 O PED CRIT CARE TRANSPORT ADDL $0.00
99291 3 CRITICAL CARE, FIRST HOUR $251.98
99292 3 CRITICAL CARE, ADDÏL 30 MIN $113.36
99293 O PED CRITICAL CARE, INITIAL $0.00
99294 O PED CRITICAL CARE, SUBSEQ $0.00
99295 O NEONATE CRIT CARE, INITIAL $0.00
99296 O NEONATE CRITICAL CARE SUBSEQ $0.00
99297 O NEONATAL CRITICAL CARE $0.00
99298 O IC FOR LBW INFANT < 1500 GM $0.00
99299 O IC, LBW INFANT 1500-2500 GM $0.00
99300 O IC, INFANT PBW 2501-5000 GM $0.00

99301 O NURSING FACILITY CARE $0.00
99304 3 NURSING FACILITY CARE, INIT $79.43
99307 3 NURSING FAC CARE, SUBSEQ $39.34
99311 O NURSING FAC CARE, SUBSEQ $0.00

99315 9 NURSING FAC DISCHARGE DAY $0.00
99316 9 NURSING FAC DISCHARGE DAY $0.00
99318 3 ANNUAL NURSING FAC ASSESSMNT $83.01
99321 O REST HOME VISIT, NEW PATIENT $0.00
99324 9 DOMICIL/R-HOME VISIT NEW PAT $0.00

99331 O REST HOME VISIT, EST PAT $0.00
99334 9 DOMICIL/R-HOME VISIT EST PAT $0.00
99339 9 DOMICIL/R-HOME CARE SUPERVIS $0.00
99340 9 DOMICIL/R-HOME CARE SUPERVIS $0.00
99341 3 HOME VISIT, NEW PATIENT $53.56

99347 3 HOME VISIT, EST PATIENT $52.22
99351 O HOME VISIT FOR THE EVALUATION AND M $0.00
99354 3 PROLONGED SERVICE, OFFICE $91.04
99355 3 PROLONGED SERVICE, OFFICE $90.07

99356 3 PROLONGED SERVICE, INPATIENT $82.75
99357 3 PROLONGED SERVICE, INPATIENT $83.36
99358 9 PROLONGED SERV, W/O CONTACT $0.00
99359 9 PROLONGED SERV, W/O CONTACT $0.00
99360 3 PHYSICIAN STANDBY SERVICES $58.87
99361 O PHYSICIAN/TEAM CONFERENCE $0.00
99362 O PHYSICIAN/TEAM CONFERENCE $0.00
99363 9 ANTICOAG MGMT, INIT $0.00
99364 9 ANTICOAG MGMT, SUBSEQ $0.00
99366 9 TEAM CONF W/PAT BY HC PRO $0.00

99367 9 TEAM CONF W/O PAT BY PHYS $0.00
99368 9 TEAM CONF W/O PAT BY HC PRO $0.00
99371 O PHYSICIAN PHONE CONSULTATION $0.00
99374 9 HOME HEALTH CARE SUPERVISION $0.00
99375 9 HOME HEALTH CARE SUPERVISION $0.00
99376 9 PHYSICIAN SUPERVISION OF PATIENTS U $0.00
99377 9 HOSPICE CARE SUPERVISION $0.00
99378 9 HOSPICE CARE SUPERVISION $0.00
99379 9 NURSING FAC CARE SUPERVISION $0.00
99380 9 NURSING FAC CARE SUPERVISION $0.00
99381 3 INIT PM E/M, NEW PAT, INF $90.68

99382 3 INIT PM E/M, NEW PAT 1-4 YRS $98.60
99383 3 PREV VISIT, NEW, AGE 5-11 $97.86
99387 3 INIT PM E/M, NEW PAT 65+ YRS $136.29
99391 3 PER PM REEVAL, EST PAT, INF $75.49
99392 3 PREV VISIT, EST, AGE 1-4 $84.02

99397 3 PER PM REEVAL EST PAT 65+ YR $113.19
99401 7 PREVENTIVE COUNSELING, INDIV $0.00
99406 9 BEHAV CHNG SMOKING 3-10 MIN $0.00
99407 9 BEHAV CHNG SMOKING > 10 MIN $0.00
99408 9 AUDIT/DAST, 15-30 MIN $0.00
99409 9 AUDIT/DAST, OVER 30 MIN $0.00
99411 9 PREVENTIVE COUNSELING, GROUP $0.00

99412 9 PREVENTIVE COUNSELING, GROUP $0.00
99420 9 HEALTH RISK ASSESSMENT TEST $0.00
99429 9 UNLISTED PREVENTIVE SERVICE $0.00
99431 O INITIAL CARE, NORMAL NEWBORN $0.00
99432 O NEWBORN CARE, NOT IN HOSP $0.00
99433 O NORMAL NEWBORN CARE/HOSPITAL $0.00
99435 O NEWBORN DISCHARGE DAY HOSP $0.00
99436 O ATTENDANCE, BIRTH $0.00
99438 9 INFANT CARE TO ONE YEAR OF AGE, WIT $0.00
99440 O NEWBORN RESUSCITATION $0.00
99441 9 PHONE E/M BY PHYS 5-10 MIN $0.00

99444 9 ONLINE E/M BY PHYS $0.00
99450 9 BASIC LIFE DISABILITY EXAM $0.00
99455 9 WORK RELATED DISABILITY EXAM $0.00
99456 9 DISABILITY EXAMINATION $0.00
99460 3 INIT NB EM PER DAY, HOSP $55.58
99461 3 INIT NB EM PER DAY, NON-FAC $84.04
99462 3 SBSQ NB EM PER DAY, HOSP $29.65
99463 3 SAME DAY NB DISCHARGE $74.64
99464 3 ATTENDANCE AT DELIVERY $69.83
99465 3 NB RESUSCITATION $143.44
99466 3 PED CRIT CARE TRANSPORT $228.67
99467 3 PED CRIT CARE TRANSPORT ADDL $114.15

99468 3 NEONATE CRIT CARE, INITIAL $854.56
99469 3 NEONATE CRIT CARE, SUBSQ $374.89
99471 3 PED CRITICAL CARE, INITIAL $763.14
99472 3 PED CRITICAL CARE, SUBSQ $378.01
99475 3 PED CRIT CARE AGE 2-5, INIT $525.56
99476 3 PED CRIT CARE AGE 2-5, SUBSQ $313.16
99477 3 INIT DAY HOSP NEONATE CARE $333.60
99478 3 IC, LBW INF < 1500 GM SUBSQ $135.98
99479 3 IC LBW INF 1500-2500 G SUBSQ $119.42
99480 3 IC INF PBW 2501-5000 G SUBSQ $114.87

99499 5 UNLISTED E&M SERVICE $0.00
99500 9 HOME VISIT, PRENATAL $0.00
99501 9 HOME VISIT, POSTNATAL $0.00
99502 9 HOME VISIT, NB CARE $0.00
99503 9 HOME VISIT, RESP THERAPY $0.00
99504 9 HOME VISIT MECH VENTILATOR $0.00
99505 9 HOME VISIT, STOMA CARE $0.00
99506 9 HOME VISIT, IM INJECTION $0.00
99507 9 HOME VISIT, CATH MAINTAIN $0.00
99508 9 HOME VISIT, SLEEP STUDIES $0.00
99509 9 HOME VISIT DAY LIFE ACTIVITY $0.00
99510 7 HOME VISIT, SING/M/FAM COUNS $0.00
99511 9 HOME VISIT, FECAL/ENEMA MGMT $0.00

99512 9 HOME VISIT FOR HEMODIALYSIS $0.00
99539 9 HOME VISIT, NOS $0.00
99551 O HOME INFUS, PAIN MGMT, IV/SC $0.00
99552 O HM INFUS PAIN MGMT, EPID/ITH $0.00
99553 O HOME INFUSE, TOCOLYTIC TX $0.00
99554 O HOME INFUS, HORMONE/PLATELET $0.00
99555 O HOME INFUSE, CHEMOTHERAPHY $0.00
99556 O HOME INFUS, ANTIBIO/FUNG/VIR $0.00
99557 O HOME INFUSE, ANTICOAGULANT $0.00
99558 O HOME INFUSE, IMMUNOTHERAPY $0.00
99559 O HOME INFUS, PERITON DIALYSIS $0.00
99560 O HOME INFUS, ENTERO NUTRITION $0.00

99561 O HOME INFUSE, HYDRATION TX $0.00
99562 O HOME INFUS, PARENT NUTRITION $0.00
99563 O HOME ADMIN, PENTAMIDINE $0.00
99564 O HME INFUS, ANTIHEMOPHIL AGNT $0.00
99565 O HOME INFUS, PROTEINASE INHIB $0.00
99566 O HOME INFUSE, IV THERAPY $0.00
99567 O HOME INFUSE, SYMPATH AGENT $0.00
99568 O HOME INFUS, MISC DRUG, DAILY $0.00
99569 O HOME INFUSE, EACH ADDL TX $0.00
99600 9 HOME VISIT NOS $0.00

99601 9 HOME INFUSION/VISIT, 2 HRS $0.00
99602 9 HOME INFUSION, EACH ADDTL HR $0.00
99605 9 MTMS BY PHARM, NP, 15 MIN $0.00
99606 9 MTMS BY PHARM, EST, 15 MIN $0.00
99607 9 MTMS BY PHARM, ADDL 15 MIN $0.00
A0010 9 AMBULANCE SERVICE, BASIC LIFE SUPPO $0.00
A0020 9 AMBULANCE SERVICE, (BLS) PER MILE, $0.00
A0021 9 OUTSIDE STATE AMBULANCE SERV $0.00
A0030 9 AIR AMBULANCE SERVICE $0.00
A0040 O HELICOPTER AMBULANCE SERVICE $0.00
A0050 9 WATER AMB SERVICE EMERGENCY $0.00
A0060 9 AMBULANCE SERVICE, WAITING TIME, ON $0.00
A0070 O AMBULANCE SERVICE, OXYGEN, ADMINIST $0.00

A0080 9 NONINTEREST ESCORT IN NON ER $0.00
A0090 3 INTEREST ESCORT IN NON ER $0.20
A0100 7 NONEMERGENCY TRANSPORT TAXI $0.00
A0110 7 NONEMERGENCY TRANSPORT BUS $0.00
A0120 7 NONER TRANSPORT MINI-BUS $0.00
A0130 3 NONER TRANSPORT WHEELCH VAN $11.01
A0140 5 NONEMERGENCY TRANSPORT AIR $0.00
A0150 O NON-EMERGENCY TRANSPORTATION, AMBUL $0.00
A0160 9 NONER TRANSPORT CASE WORKER $0.00
A0170 5 TRANSPORT PARKING FEES/TOLLS $0.00
A0180 5 NONER TRANSPORT LODGNG RECIP $0.00
A0190 5 NONER TRANSPORT MEALS RECIP $0.00

A0200 5 NONER TRANSPORT LODGNG ESCRT $0.00
A0210 5 NONER TRANSPORT MEALS ESCORT $0.00
A0215 9 AMBULANCE SERVICE, MISCELLANEOUS DI $0.00
A0220 9 AMBULANCE SERVICE, ADVANCED LIFE SU $0.00
A0221 9 AMBULANCE SERVICE, (ALS) PER MILE, $0.00
A0222 9 AMBULANCE SERVICE, RETURN TRIP, TRA $0.00
A0223 9 AMBULANCE SERVICE, ADVANCED LIFE SU $0.00
A0225 3 NEONATAL EMERGENCY TRANSPORT $95.00
A0300 9 AMBULANCE BASIC NON-EMER ALL $0.00
A0302 9 AMBULANCE BASIC EMERGENY ALL $0.00

A0304 9 AMB ADV NON-ER NO SERV ALL $0.00
A0306 9 AMB ADV NON-ER SPEC SERV ALL $0.00
A0308 9 AMB ADV ER NO SPEC SERV ALL $0.00
A0310 9 AMB ADV ER SPEC SERV ALL $0.00
A0320 9 AMB BASIC NON-ER + SUPPLIES $0.00
A0322 9 AMB BASIC EMERG + SUPPLIES $0.00
A0324 9 ADV NON-ER SERV SEP MILEAGE $0.00
A0326 9 ADV NON-ER NO SERV SEP MILE $0.00
A0328 9 ADV ER NO SERV SEP MILEAGE $0.00
A0330 9 ADV ER SPEC SERV SEP MILE $0.00
A0340 9 AMB BASIC NON-ER + MILEAGE $0.00
A0342 9 AMBUL BASIC EMER + MILEAGE $0.00
A0344 9 AMB ADV NON-ER NO SERV +MILE $0.00

A0346 9 AMB ADV NON-ER SERV + MILE $0.00
A0348 9 ADV EMER NO SPEC SERV + MILE $0.00
A0350 9 ADV EMER SPEC SERV + MILEAGE $0.00
A0360 9 BASIC NON-ER SEP MILE & SUPP $0.00
A0362 9 BASIC EMER SEP MILE & SUPPLY $0.00
A0364 9 ADV NON-ER NO SERV SEP MI&SU $0.00
A0366 9 ADV NON-ER SERV SEP MIL&SUPP $0.00
A0368 9 ADV ER NO SERV SEP MILE&SUPP $0.00
A0370 9 ADV ER SPEC SERV SEP MI&SUPP $0.00
A0380 3 BASIC LIFE SUPPORT MILEAGE $1.50
A0382 9 BASIC SUPPORT ROUTINE SUPPLS $0.00
A0384 9 BLS DEFIBRILLATION SUPPLIES $0.00

A0390 3 ADVANCED LIFE SUPPORT MILEAG $1.50
A0392 9 ALS DEFIBRILLATION SUPPLIES $0.00
A0394 9 ALS IV DRUG THERAPY SUPPLIES $0.00
A0396 9 ALS ESOPHAGEAL INTUB SUPPLS $0.00
A0398 9 ALS ROUTINE DISPOSBLE SUPPLS $0.00
A0420 9 AMBULANCE WAITING 1/2 HR $0.00
A0422 3 AMBULANCE 02 LIFE SUSTAINING $12.00
A0424 5 EXTRA AMBULANCE ATTENDANT $0.00
A0425 9 GROUND MILEAGE $0.00
A0426 3 ALS 1 $35.00

A0427 3 ALS1-EMERGENCY $55.00
A0428 3 BLS $35.00
A0429 3 BLS-EMERGENCY $55.00
A0430 9 FIXED WING AIR TRANSPORT $0.00
A0431 3 ROTARY WING AIR TRANSPORT $2,124.00
A0432 9 PI VOLUNTEER AMBULANCE CO $0.00
A0433 9 ALS 2 $0.00
A0434 9 SPECIALTY CARE TRANSPORT $0.00
A0435 9 FIXED WING AIR MILEAGE $0.00
A0436 3 ROTARY WING AIR MILEAGE $12.80
A0800 O AMB TRANS 7PM-7AM $0.00
A0888 9 NONCOVERED AMBULANCE MILEAGE $0.00
A0998 9 AMBULANCE RESPONSE/TREATMENT $0.00

A0999 9 UNLISTED AMBULANCE SERVICE $0.00
A2000 9 MANIPULATION OF SPINE BY CHIROPRACT $0.00
A4190 O TRANSPARENT FILM, EACH $0.00
A4200 O GAUZE PADS, MEDICATED OR NON-MEDICA $0.00
A4202 O GAUZE, ELASTIC, ALL TYPES, PER ROLL $0.00
A4203 O GAUZE, NON-ELASTIC, PER ROLL $0.00
A4204 O ABSORPTIVE DRESSING (E.G. HYDROCOLL $0.00
A4205 O NON-ABSORPTIVE DRESSING (E.G. HYDRO $0.00
A4206 3 1 CC STERILE SYRINGE&NEEDLE $0.22
A4209 3 5+ CC STERILE SYRINGE&NEEDLE $0.36

A4210 3 NONNEEDLE INJECTION DEVICE $1.50
A4211 O SUPP FOR SELF-ADM INJECTIONS $0.00
A4212 5 NON CORING NEEDLE OR STYLET $0.00
A4213 3 20+ CC SYRINGE ONLY $0.68
A4214 O 30 CC STERILE WATER/SALINE $0.00
A4215 5 STERILE NEEDLE $0.00
A4216 3 STERILE WATER/SALINE, 10 ML $0.54
A4217 3 STERILE WATER/SALINE, 500 ML $3.13
A4218 6 STERILE SALINE OR WATER $0.00
A4220 9 INFUSION PUMP REFILL KIT $0.00

A4221 3 MAINT DRUG INFUS CATH PER WK $22.52
A4222 3 INFUSION SUPPLIES WITH PUMP $46.50
A4223 6 INFUSION SUPPLIES W/O PUMP $0.00
A4230 3 INFUS INSULIN PUMP NON NEEDL $10.07
A4231 5 INFUSION INSULIN PUMP NEEDLE $0.00
A4232 3 SYRINGE W/NEEDLE INSULIN 3CC $2.54
A4233 6 ALKALIN BATT FOR GLUCOSE MON $0.00
A4234 6 J-CELL BATT FOR GLUCOSE MON $0.00
A4235 3 LITHIUM BATT FOR GLUCOSE MON $2.34
A4236 6 SILVR OXIDE BATT GLUCOSE MON $0.00
A4244 3 ALCOHOL OR PEROXIDE PER PINT $1.00
A4245 3 ALCOHOL WIPES PER BOX $10.00
A4246 3 BETADINE/PHISOHEX SOLUTION $10.00

A4247 3 BETADINE/IODINE SWABS/WIPES $8.00
A4248 6 CHLORHEXIDINE ANTISEPT $0.00
A4250 3 URINE REAGENT STRIPS/TABLETS $17.25
A4252 6 BLOOD KETONE TEST OR STRIP $0.00
A4253 9 BLOOD GLUCOSE/REAGENT STRIPS $0.00
A4254 O BATTERY FOR GLUCOSE MONITOR $0.00
A4255 9 GLUCOSE MONITOR PLATFORMS $0.00
A4256 9 CALIBRATOR SOLUTION/CHIPS $0.00
A4257 9 REPLACE LENSSHIELD CARTRIDGE $0.00
A4258 9 LANCET DEVICE EACH $0.00
A4259 9 LANCETS PER BOX $0.00
A4260 O LEVONORGESTREL (CONTRACEPTIVE) IMP $0.00

A4261 9 CERVICAL CAP CONTRACEPTIVE $0.00
A4262 9 TEMPORARY TEAR DUCT PLUG $0.00
A4263 9 PERMANENT TEAR DUCT PLUG $0.00
A4265 9 PARAFFIN $0.00
A4266 9 DIAPHRAGM $0.00
A4267 9 MALE CONDOM $0.00
A4268 9 FEMALE CONDOM $0.00
A4269 9 SPERMICIDE $0.00
A4270 9 DISPOSABLE ENDOSCOPE SHEATH $0.00
A4280 3 BRST PRSTHS ADHSV ATTCHMNT $4.62

A4281 5 REPLACEMENT BREASTPUMP TUBE $0.00
A4282 5 REPLACEMENT BREASTPUMP ADPT $0.00
A4283 5 REPLACEMENT BREASTPUMP CAP $0.00
A4284 5 REPLCMNT BREAST PUMP SHIELD $0.00
A4285 5 REPLCMNT BREAST PUMP BOTTLE $0.00
A4286 5 REPLCMNT BREASTPUMP LOK RING $0.00
A4290 5 SACRAL NERVE STIM TEST LEAD $0.00
A4300 9 CATH IMPL VASC ACCESS PORTAL $0.00
A4301 9 IMPLANTABLE ACCESS SYST PERC $0.00
A4305 3 DRUG DELIVERY SYSTEM >=50 ML $17.04
A4306 3 DRUG DELIVERY SYSTEM <=50 ML $29.64
A4310 3 INSERT TRAY W/O BAG/CATH $6.81
A4311 3 CATHETER W/O BAG 2-WAY LATEX $12.04

A4312 3 CATH W/O BAG 2-WAY SILICONE $14.62
A4313 3 CATHETER W/BAG 3-WAY $17.31
A4314 3 CATH W/DRAINAGE 2-WAY LATEX $22.90
A4315 3 CATH W/DRAINAGE 2-WAY SILCNE $24.61
A4316 3 CATH W/DRAINAGE 3-WAY $25.71
A4319 O STERILE H2O IRRIGATION SOLUT $0.00
A4320 3 IRRIGATION TRAY $4.81
A4321 9 CATH THERAPEUTIC IRRIG AGENT $0.00
A4322 3 IRRIGATION SYRINGE $2.81
A4323 O SALINE IRRIGATION SOLUTION $0.00
A4324 O MALE EXT CATH W/ADH COATING $0.00
A4325 O MALE EXT CATH W/ADH STRIP $0.00

A4326 3 MALE EXTERNAL CATHETER $10.29
A4327 3 FEM URINARY COLLECT DEV CUP $40.32
A4328 3 FEM URINARY COLLECT POUCH $9.97
A4329 O EXTERNAL CATHETER START SET $0.00
A4330 3 STOOL COLLECTION POUCH $6.82
A4331 3 EXTENSION DRAINAGE TUBING $3.04
A4332 3 LUBE STERILE PACKET $0.12
A4333 3 URINARY CATH ANCHOR DEVICE $2.10
A4334 3 URINARY CATH LEG STRAP $4.71
A4335 5 INCONTINENCE SUPPLY $0.00

A4338 3 INDWELLING CATHETER LATEX $10.08
A4340 3 INDWELLING CATHETER SPECIAL $30.28
A4344 3 CATH INDW FOLEY 2 WAY SILICN $12.99
A4346 3 CATH INDW FOLEY 3 WAY $16.26
A4347 O MALE EXTERNAL CATHETER $0.00
A4348 O MALE EXT CATH EXTENDED WEAR $0.00
A4349 3 DISPOSABLE MALE EXTERNAL CAT $2.02
A4350 9 CATHETER CARE KIT $0.00
A4351 3 STRAIGHT TIP URINE CATHETER $1.66
A4352 3 COUDE TIP URINARY CATHETER $6.12
A4353 3 INTERMITTENT URINARY CATH $6.66
A4354 3 CATH INSERTION TRAY W/BAG $11.16
A4355 3 BLADDER IRRIGATION TUBING $8.50

A4356 3 EXT URETH CLMP OR COMPR DVC $43.52
A4357 3 BEDSIDE DRAINAGE BAG $8.77
A4358 3 URINARY LEG OR ABDOMEN BAG $6.33
A4359 O URINARY SUSPENSORY W/O LEG B $0.00
A4360 9 ADULT INCONTINENCE GARMENT $0.00
A4361 3 OSTOMY FACE PLATE $17.42
A4362 3 SOLID SKIN BARRIER $3.30
A4363 6 OSTOMY CLAMP $0.00
A4364 3 ADHESIVE, LIQUID OR EQUAL $2.80
A4365 3 ADHESIVE REMOVER WIPES $10.80
A4366 6 OSTOMY VENT $0.00
A4367 3 OSTOMY BELT $7.01

A4368 9 OSTOMY FILTER $0.00
A4369 3 SKIN BARRIER LIQUID PER OZ $2.30
A4370 O SKIN BARRIER PASTE PER OZ $0.00
A4371 3 SKIN BARRIER POWDER PER OZ $3.48
A4372 3 SKIN BARRIER SOLID 4X4 EQUIV $3.98
A4373 3 SKIN BARRIER WITH FLANGE $5.99
A4374 O SKIN BARRIER EXTENDED WEAR $0.00
A4375 3 DRAINABLE PLASTIC PCH W FCPL $16.38
A4376 3 DRAINABLE RUBBER PCH W FCPLT $45.38
A4377 3 DRAINABLE PLSTIC PCH W/O FP $4.09

A4378 3 DRAINABLE RUBBER PCH W/O FP $29.33
A4379 3 URINARY PLASTIC POUCH W FCPL $14.33
A4380 3 URINARY RUBBER POUCH W FCPLT $35.60
A4381 3 URINARY PLASTIC POUCH W/O FP $4.40
A4382 3 URINARY HVY PLSTC PCH W/O FP $23.48
A4383 3 URINARY RUBBER POUCH W/O FP $26.89
A4384 3 OSTOMY FACEPLT/SILICONE RING $9.18
A4385 3 OST SKN BARRIER SLD EXT WEAR $4.86
A4386 O OST SKN BARRIER W FLNG EX WR $0.00
A4387 3 OST CLSD POUCH W ATT ST BARR $3.83
A4388 3 DRAINABLE PCH W EX WEAR BARR $4.16
A4389 3 DRAINABLE PCH W ST WEAR BARR $5.93
A4390 3 DRAINABLE PCH EX WEAR CONVEX $9.17

A4391 3 URINARY POUCH W EX WEAR BARR $6.74
A4392 3 URINARY POUCH W ST WEAR BARR $6.34
A4393 3 URINE PCH W EX WEAR BAR CONV $8.75
A4394 3 OSTOMY POUCH LIQ DEODORANT $2.46
A4395 3 OSTOMY POUCH SOLID DEODORANT $0.05
A4396 3 PERISTOMAL HERNIA SUPPRT BLT $38.61
A4397 3 IRRIGATION SUPPLY SLEEVE $4.57
A4398 3 OSTOMY IRRIGATION BAG $13.17
A4399 3 OSTOMY IRRIG CONE/CATH W BRS $11.70
A4400 3 OSTOMY IRRIGATION SET $46.62
A4402 3 LUBRICANT PER OUNCE $1.32
A4404 3 OSTOMY RING EACH $1.52

A4405 3 NONPECTIN BASED OSTOMY PASTE $3.40
A4406 3 PECTIN BASED OSTOMY PASTE $5.74
A4407 3 EXT WEAR OST SKN BARR <=4SQÊ $8.76
A4408 3 EXT WEAR OST SKN BARR >4SQÊ $9.87
A4409 3 OST SKN BARR CONVEX <=4 SQ I $6.22
A4410 3 OST SKN BARR EXTND >4 SQ $9.04
A4411 6 OST SKN BARR EXTND =4SQ $0.00
A4412 6 OST POUCH DRAIN HIGH OUTPUT $0.00
A4413 3 2 PC DRAINABLE OST POUCH $5.50
A4414 3 OST SKNBAR W/O CONV<=4 SQ IN $4.93

A4415 3 OST SKN BARR W/O CONV >4 SQI $6.00
A4416 3 OST PCH CLSD W BARRIER/FILTR $2.75
A4417 6 OST PCH W BAR/BLTINCONV/FLTR $0.00
A4418 6 OST PCH CLSD W/O BAR W FILTR $0.00
A4419 3 OST PCH FOR BAR W FLANGE/FLT $1.74
A4420 6 OST PCH CLSD FOR BAR W LK FL $0.00
A4421 3 OSTOMY SUPPLY MISC $200.00
A4422 3 OST POUCH ABSORBENT MATERIAL $0.12
A4423 3 OST PCH FOR BAR W LK FL/FLTR $1.86
A4424 3 OST PCH DRAIN W BAR & FILTER $4.75
A4425 3 OST PCH DRAIN FOR BARRIER FL $3.58
A4426 3 OST PCH DRAIN 2 PIECE SYSTEM $2.73
A4427 3 OST PCH DRAIN/BARR LK FLNG/F $2.78

A4428 3 URINE OST POUCH W FAUCET/TAP $6.51
A4429 3 URINE OST POUCH W BLTINCONV $8.25
A4430 3 OST URINE PCH W B/BLTIN CONV $8.52
A4431 3 OST PCH URINE W BARRIER/TAPV $6.22
A4432 3 OS PCH URINE W BAR/FANGE/TAP $3.59
A4433 3 URINE OST PCH BAR W LOCK FLN $3.34
A4434 3 OST PCH URINE W LOCK FLNG/FT $3.76
A4450 3 NON-WATERPROOF TAPE $0.09
A4452 3 WATERPROOF TAPE $0.36
A4454 O TAPE ALL TYPES ALL SIZES $0.00
A4455 3 ADHESIVE REMOVER PER OUNCE $1.33
A4458 5 REUSABLE ENEMA BAG $0.00

A4460 O ELASTIC COMPRESSION BANDAGE $0.00
A4461 6 SURGICL DRESS HOLD NON-REUSE $0.00
A4462 O ABDMNL DRSSNG HOLDER/BINDER $0.00
A4463 6 SURGICAL DRESS HOLDER REUSE $0.00
A4464 O JOINT SUPPORT DEVICE/GARMENT $0.00
A4465 9 NON-ELASTIC EXTREMITY BINDER $0.00
A4470 5 GRAVLEE JET WASHER $0.00
A4480 3 VABRA ASPIRATOR $20.00
A4481 9 TRACHEOSTOMA FILTER $0.00
A4483 3 MOISTURE EXCHANGER $2.86

A4490 3 ABOVE KNEE SURGICAL STOCKING $60.00
A4495 3 THIGH LENGTH SURG STOCKING $60.00
A4500 3 BELOW KNEE SURGICAL STOCKING $30.00
A4510 3 FULL LENGTH SURG STOCKING $60.00
A4520 9 INCONTINENCE GARMENT ANYTYPE $0.00
A4521 O ADULT SIZE DIAPER SM EACH $0.00
A4522 O ADULT SIZE DIAPER MED EACH $0.00
A4523 O ADULT SIZE DIAPER LG EACH $0.00
A4524 O ADULT SIZE DIAPER XL EACH $0.00
A4525 O ADULT SIZE BRIEF SM EACH $0.00
A4526 O ADULT SIZE BRIEF MED EACH $0.00
A4527 O ADULT SIZE BRIEF LG EACH $0.00
A4528 O ADULT SIZE BRIEF XL EACH $0.00

A4529 O CHILD SIZE DIAPER SM/MED EA $0.00
A4530 O CHILD SIZE DIAPER LG EACH $0.00
A4531 O CHILD SIZE BRIEF SM/MED EACH $0.00
A4532 O CHILD SIZE BRIEF LG EACH $0.00
A4533 O YOUTH SIZE DIAPER EACH $0.00
A4534 9 YOUTH SIZE BRIEF EACH $0.00
A4535 O DISP INCONT LINER/SHIELD EA $0.00
A4536 O PROT UNDERWR WSHBL ANY SZ EA $0.00
A4537 O UNDER PAD REUSABLE ANY SZ EA $0.00
A4538 O REUSABLE DIAPER FROM DPR SVC $0.00
A4550 9 SURGICAL TRAYS $0.00
A4554 3 DISPOSABLE UNDERPADS $0.20

A4555 9 PRIMARY SURGICAL DRESSING KIT, (E.G $0.00
A4556 5 ELECTRODES, PAIR $0.00
A4557 3 LEAD WIRES, PAIR $17.16
A4558 3 CONDUCTIVE GEL OR PASTE $4.44
A4559 9 COUPLING GEL OR PASTE $0.00
A4560 O PESSARY $0.00
A4561 3 PESSARY RUBBER, ANY TYPE $17.78
A4562 3 PESSARY, NON RUBBER,ANY TYPE $44.25
A4565 3 SLINGS $60.00
A4570 3 SPLINT $50.00

A4572 O RIB BELT $0.00
A4575 9 HYPERBARIC O2 CHAMBER DISPS $0.00
A4580 O CAST SUPPLIES (PLASTER) $0.00
A4581 9 SUPPLIES RISSER JACKET $0.00
A4590 O SPECIAL CASTING MATERIAL $0.00
A4595 3 TENS SUPPL 2 LEAD PER MONTH $27.56
A4600 6 SLEEVE, INTER LIMB COMP DEV $0.00
A4601 6 LITH ION BATT, NON-PROS USE $0.00
A4604 3 TUBING WITH HEATING ELEMENT $66.81
A4605 6 TRACH SUCTION CATH CLOSE SYS $0.00
A4606 5 OXYGEN PROBE USED W OXIMETER $0.00
A4608 3 TRANSTRACHEAL OXYGEN CATH $58.32
A4609 O TRACH SUCTION CATH CLSED SYS $0.00

A4610 O TRACH SUCTION CATH CLSED SYS $0.00
A4611 3 HEAVY DUTY BATTERY $187.94
A4612 3 BATTERY CABLES $65.00
A4613 3 BATTERY CHARGER $137.96
A4614 3 HAND-HELD PEFR METER $22.75
A4615 3 CANNULA NASAL $20.00
A4616 3 TUBING (OXYGEN) PER FOOT $1.00
A4617 3 MOUTH PIECE $5.00
A4618 3 BREATHING CIRCUITS $8.51
A4619 3 FACE TENT $1.21
A4620 3 VARIABLE CONCENTRATION MASK $20.00
A4621 O TRACHEOTOMY MASK OR COLLAR $0.00

A4622 O TRACHEOSTOMY OR LARNGECTOMY $0.00
A4623 3 TRACHEOSTOMY INNER CANNULA $6.25
A4624 3 TRACHEAL SUCTION TUBE $2.25
A4625 3 TRACH CARE KIT FOR NEW TRACH $6.61
A4626 3 TRACHEOSTOMY CLEANING BRUSH $3.05
A4627 9 SPACER BAG/RESERVOIR $0.00
A4628 3 OROPHARYNGEAL SUCTION CATH $3.51
A4629 3 TRACHEOSTOMY CARE KIT $4.42
A4630 3 REPL BAT T.E.N.S. OWN BY PT $5.45
A4631 O WHEELCHAIR BATTERY $0.00

A4632 O INFUS PUMP RPLCEMNT BATTERY $0.00
A4633 3 UVL REPLACEMENT BULB $41.04
A4634 5 REPLACEMENT BULB TH LIGHTBOX $0.00
A4635 3 UNDERARM CRUTCH PAD $4.16
A4636 3 HANDGRIP FOR CANE ETC $3.42
A4637 3 REPL TIP CANE/CRUTCH/WALKER $1.90
A4638 6 REPL BATT PULSE GEN SYS $0.00
A4639 3 INFRARED HT SYS REPLCMNT PAD $287.21
A4640 3 ALTERNATING PRESSURE PAD $51.49
A4641 9 RADIOPHARM DX AGENT NOC $0.00
A4642 9 IN111 SATUMOMAB $0.00
A4643 O HIGH DOSE CONTRAST MRI $0.00
A4644 O CONTRAST 100-199 MGS IODINE $0.00

A4647 O SUPP- PARAMAGNETIC CONTR MAT $0.00
A4648 9 TISSUE MARKER, IMPLANTABLE, ANY TY $0.00
A4649 9 SURGICAL SUPPLIES $0.00
A4650 9 IMPLANTABLE RADIATION DOSIMETER, E $0.00
A4651 9 CALIBRATED MICROCAP TUBE $0.00
A4652 9 MICROCAPILLARY TUBE SEALANT $0.00
A4653 5 PD CATHETER ANCHOR BELT $0.00
A4655 9 ESRD SYRINGE/NEEDLE $0.00
A4656 O NEEDLE ANY SIZE $0.00
A4657 9 SYRINGE W/WO NEEDLE $0.00

A4660 3 SPHYG/BP APP W CUFF AND STET $20.00
A4663 3 DIALYSIS BLOOD PRESSURE CUFF $6.27
A4670 5 AUTOMATIC BP MONITOR, DIAL $0.00
A4671 6 DISPOSABLE CYCLER SET $0.00
A4672 6 DRAINAGE EXT LINE, DIALYSIS $0.00
A4673 6 EXT LINE W EASY LOCK CONNECT $0.00
A4674 6 CHEM/ANTISEPT SOLUTION, 8OZ $0.00
A4680 9 ACTIFICIAL CARBON FILTER, EA $0.00
A4690 9 DIALYZER, EACH $0.00
A4700 9 STANDARD DIALYSATE SOLUTION $0.00

A4705 9 BICARB DIALYSATE SOLUTION $0.00
A4706 9 BICARBONATE CONC SOL PER GAL $0.00
A4707 9 BICARBONATE CONC POW PER PAC $0.00
A4708 9 ACETATE CONC SOL PER GALLON $0.00
A4709 9 ACID CONC SOL PER GALLON $0.00
A4712 O STERILE WATER INJ PER 10 ML $0.00
A4714 9 TREATED WATER PER GALLON $0.00
A4719 9 ¾Y SET¾ TUBING $0.00
A4720 9 DIALYSAT SOL FLD VOL > 249CC $0.00
A4721 9 DIALYSAT SOL FLD VOL > 999CC $0.00
A4722 9 DIALYS SOL FLD VOL > 1999CC $0.00

A4728 6 DIALYSATE SOLUTION, NON-DEX $0.00
A4730 9 FISTULA CANNULATION SET, EA $0.00
A4735 9 LOCAL/TOPICAL ANESTHETICS $0.00
A4736 9 TOPICAL ANESTHETIC, PER GRAM $0.00
A4737 9 INJ ANESTHETIC PER 10 ML $0.00
A4740 9 SHUNT ACCESSORY $0.00
A4750 9 ART OR VENOUS BLOOD TUBING $0.00
A4755 9 COMB ART/VENOUS BLOOD TUBING $0.00
A4760 9 DIALYSATE SOL TEST KIT, EACH $0.00
A4765 9 DIALYSATE CONC POW PER PACK $0.00

A4766 9 DIALYSATE CONC SOL ADD 10 ML $0.00
A4770 9 BLOOD COLLECTION TUBE/VACUUM $0.00
A4771 9 SERUM CLOTTING TIME TUBE $0.00
A4772 9 BLOOD GLUCOSE TEST STRIPS $0.00
A4773 9 OCCULT BLOOD TEST STRIPS $0.00
A4774 9 AMMONIA TEST STRIPS $0.00
A4780 9 ESRD STERILIZING AGENT $0.00
A4790 9 ESRD CLEANSING AGENTS $0.00
A4800 9 HEPARIN/ANTIDOTE DIALYSIS $0.00
A4801 9 HEPARIN PER 1000 UNITS $0.00

A4802 9 PROTAMINE SULFATE PER 50 MG $0.00
A4820 9 SUPPLIES HEMODIALYSIS KIT $0.00
A4850 9 RUBBER TIPPED HEMOSTATS $0.00
A4860 9 DISPOSABLE CATHETER TIPS $0.00
A4870 9 PLUMB/ELEC WK HM HEMO EQUIP $0.00
A4880 9 WATER STORAGE TANKS $0.00
A4890 9 REPAIR/MAINT CONT HEMO EQUIP $0.00
A4900 9 CAPD SUPPLY KIT $0.00
A4901 9 CCPD SUPPLY KIT $0.00
A4905 9 IPD SUPPLY KIT $0.00
A4910 9 ESRD NONMEDICAL SUPPLIES $0.00
A4911 9 DRAIN BAG/BOTTLE $0.00
A4912 9 GOMCO DRAIN BOTTLE $0.00

A4913 9 MISC DIALYSIS SUPPLIES NOC $0.00
A4914 9 PREPARATION KIT $0.00
A4918 9 VENOUS PRESSURE CLAMP $0.00
A4919 9 SUPP DIALYSIS DIALYZER HOLDE $0.00
A4920 9 HARVARD PRESSURE CLAMP $0.00
A4921 9 MEASURING CYLINDER $0.00
A4927 3 NON-STERILE GLOVES $6.19
A4928 9 SURGICAL MASK $0.00
A4929 9 TOURNIQUET FOR DIALYSIS, EA $0.00
A4930 3 STERILE, GLOVES PER PAIR $0.44
A4931 9 REUSABLE ORAL THERMOMETER $0.00
A4932 9 REUSABLE RECTAL THERMOMETER $0.00

A5051 3 POUCH CLSD W BARR ATTACHED $2.21
A5052 3 CLSD OSTOMY POUCH W/O BARR $1.59
A5053 3 CLSD OSTOMY POUCH FACEPLATE $1.66
A5054 3 CLSD OSTOMY POUCH W/FLANGE $1.37
A5055 3 STOMA CAP $1.35
A5061 3 POUCH DRAINABLE W BARRIER AT $2.58
A5062 3 DRNBLE OSTOMY POUCH W/O BARR $2.12
A5063 3 DRAIN OSTOMY POUCH W/FLANGE $2.09
A5064 O DRAIN OSTOMY POUCH W/FCEPLTE $0.00
A5065 O DRAIN OSTOMY POUCH ON FCPLTE $0.00

A5071 3 URINARY POUCH W/BARRIER $4.15
A5072 3 URINARY POUCH W/O BARRIER $3.36
A5073 3 URINARY POUCH ON BARR W/FLNG $3.04
A5074 O URINARY POUCH W/FACEPLATE $0.00
A5075 O URINARY POUCH ON FACEPLATE $0.00
A5081 3 CONTINENT STOMA PLUG $3.14
A5082 3 CONTINENT STOMA CATHETER $11.34
A5083 6 STOMA ABSORPTIVE COVER $0.00
A5093 3 OSTOMY ACCESSORY CONVEX INSE $1.85
A5102 3 BEDSIDE DRAIN BTL W/WO TUBE $21.39
A5105 3 URINARY SUSPENSORY $38.88
A5112 3 URINARY LEG BAG $28.07
A5113 3 LATEX LEG STRAP $4.48

A5114 3 FOAM/FABRIC LEG STRAP $8.52
A5119 O SKIN BARRIER WIPES BOX PR 50 $0.00
A5120 3 SKIN BARRIER, WIPE OR SWAB $0.23
A5121 3 SOLID SKIN BARRIER 6X6 $6.24
A5122 3 SOLID SKIN BARRIER 8X8 $10.42
A5123 O SKIN BARRIER WITH FLANGE $0.00
A5126 3 DISK/FOAM PAD +OR- ADHESIVE $1.26
A5131 3 APPLIANCE CLEANER $15.13
A5149 O INCONTINENCE/OSTOMY SUPPLY $0.00
A5200 3 PERCUTANEOUS CATHETER ANCHOR $10.78
A5500 5 DIAB SHOE FOR DENSITY INSERT $0.00
A5501 5 DIABETIC CUSTOM MOLDED SHOE $0.00

A5502 9 DIABETIC SHOE DENSITY INSERT $0.00
A5503 5 DIABETIC SHOE W/ROLLER/ROCKR $0.00
A5504 5 DIABETIC SHOE WITH WEDGE $0.00
A5505 5 DIAB SHOE W/METATARSAL BAR $0.00
A5506 5 DIABETIC SHOE W/OFF SET HEEL $0.00
A5507 5 MODIFICATION DIABETIC SHOE $0.00
A5508 5 DIABETIC DELUXE SHOE $0.00
A5509 O DIRECT HEAT FORM SHOE INSERT $0.00
A5510 5 COMPRESSION FORM SHOE INSERT $0.00
A5511 O CUSTOM FAB MOLDED SHOE INSER $0.00

A5512 6 MULTI DEN INSERT DIRECT FORM $0.00
A5513 6 MULTI DEN INSERT CUSTOM MOLD $0.00
A6000 5 WOUND WARMING WOUND COVER $0.00
A6010 3 COLLAGEN BASED WOUND FILLER $30.62
A6011 3 COLLAGEN GEL/PASTE WOUND FIL $2.28
A6020 O COLLAGEN WOUND DRESSING $0.00
A6021 3 COLLAGEN DRESSING <=16 SQ IN $20.05
A6022 3 COLLAGEN DRSG>6<=48 SQ IN $20.05
A6023 3 COLLAGEN DRESSING >48 SQ IN $181.51
A6024 3 COLLAGEN DSG WOUND FILLER $5.90
A6025 9 SILICONE GEL SHEET, EACH $0.00
A6154 9 WOUND POUCH EACH $0.00
A6196 3 ALGINATE DRESSING <=16 SQ IN $7.01

A6197 3 ALGINATE DRSG >16 <=48 SQ IN $15.68
A6198 3 ALGINATE DRESSING > 48 SQ IN $15.68
A6199 3 ALGINATE DRSG WOUND FILLER $5.04
A6200 3 COMPOS DRSG <=16 NO BORDER $9.06
A6201 3 COMPOS DRSG >16<=48 NO BDR $19.84
A6202 3 COMPOS DRSG >48 NO BORDER $33.27
A6203 3 COMPOSITE DRSG <= 16 SQ IN $3.19
A6204 3 COMPOSITE DRSG >16<=48 SQ IN $5.94
A6205 3 COMPOSITE DRSG > 48 SQ IN $5.94
A6206 3 CONTACT LAYER <= 16 SQ IN $2.07
A6207 3 CONTACT LAYER >16<= 48 SQ IN $7.00
A6208 3 CONTACT LAYER > 48 SQ IN $7.00

A6209 3 FOAM DRSG <=16 SQ IN W/O BDR $7.14
A6210 3 FOAM DRG >16<=48 SQ IN W/O B $19.00
A6211 3 FOAM DRG > 48 SQ IN W/O BRDR $28.01
A6212 3 FOAM DRG <=16 SQ IN W/BORDER $9.25
A6213 3 FOAM DRG >16<=48 SQ IN W/BDR $9.82
A6214 3 FOAM DRG > 48 SQ IN W/BORDER $9.82
A6215 5 FOAM DRESSING WOUND FILLER $0.00
A6216 3 NON-STERILE GAUZE<=16 SQ IN $0.05
A6217 3 NON-STERILE GAUZE>16<=48 SQ $0.41
A6218 3 NON-STERILE GAUZE > 48 SQ IN $0.41

A6219 3 GAUZE <= 16 SQ IN W/BORDER $0.91
A6220 3 GAUZE >16 <=48 SQ IN W/BORDR $2.46
A6221 3 GAUZE > 48 SQ IN W/BORDER $2.46
A6222 3 GAUZE <=16 IN NO W/SAL W/O B $2.03
A6223 3 GAUZE >16<=48 NO W/SAL W/O B $2.30
A6224 3 GAUZE > 48 IN NO W/SAL W/O B $3.44
A6228 3 GAUZE <= 16 SQ IN WATER/SAL $2.30
A6229 3 GAUZE >16<=48 SQ IN WATR/SAL $3.44
A6230 3 GAUZE > 48 SQ IN WATER/SALNE $3.44
A6231 3 HYDROGEL DSG<=16 SQ IN $4.45
A6232 3 HYDROGEL DSG>16<=48 SQ IN $6.57
A6233 3 HYDROGEL DRESSING >48 SQ IN $18.30
A6234 3 HYDROCOLLD DRG <=16 W/O BDR $6.24

A6235 3 HYDROCOLLD DRG >16<=48 W/O B $16.05
A6236 3 HYDROCOLLD DRG > 48 IN W/O B $25.99
A6237 3 HYDROCOLLD DRG <=16 IN W/BDR $7.54
A6238 3 HYDROCOLLD DRG >16<=48 W/BDR $21.74
A6239 3 HYDROCOLLD DRG > 48 IN W/BDR $21.74
A6240 3 HYDROCOLLD DRG FILLER PASTE $11.68
A6241 3 HYDROCOLLOID DRG FILLER DRY $2.45
A6242 3 HYDROGEL DRG <=16 IN W/O BDR $5.79
A6243 3 HYDROGEL DRG >16<=48 W/O BDR $11.75
A6244 3 HYDROGEL DRG >48 IN W/O BDR $37.46
A6245 3 HYDROGEL DRG <= 16 IN W/BDR $6.93
A6246 3 HYDROGEL DRG >16<=48 IN W/B $9.46

A6247 3 HYDROGEL DRG > 48 SQ IN W/B $22.68
A6248 3 HYDROGEL DRSG GEL FILLER $15.49
A6250 9 SKIN SEAL PROTECT MOISTURIZR $0.00
A6251 3 ABSORPT DRG <=16 SQ IN W/O B $1.90
A6252 3 ABSORPT DRG >16 <=48 W/O BDR $3.10
A6253 3 ABSORPT DRG > 48 SQ IN W/O B $6.05
A6254 3 ABSORPT DRG <=16 SQ IN W/BDR $1.16
A6255 3 ABSORPT DRG >16<=48 IN W/BDR $2.89
A6256 3 ABSORPT DRG > 48 SQ IN W/BDR $2.89
A6257 3 TRANSPARENT FILM <= 16 SQ IN $1.46

A6258 3 TRANSPARENT FILM >16<=48 IN $4.10
A6259 3 TRANSPARENT FILM > 48 SQ IN $10.43
A6260 9 WOUND CLEANSER ANY TYPE/SIZE $0.00
A6261 5 WOUND FILLER GEL/PASTE /OZ $0.00
A6262 5 WOUND FILLER DRY FORM / GRAM $0.00
A6263 O NON-STERILE ELASTIC GAUZE/YD $0.00
A6264 O NON-STERILE NO ELASTIC GAUZE $0.00
A6265 O TAPE PER 18 SQ INCHES $0.00
A6266 3 IMPREG GAUZE NO H20/SAL/YARD $1.83
A6402 3 STERILE GAUZE <= 16 SQ IN $0.12
A6403 3 STERILE GAUZE>16 <= 48 SQ IN $0.41
A6404 3 STERILE GAUZE > 48 SQ IN $0.41
A6405 O STERILE ELASTIC GAUZE /YD $0.00

A6406 O STERILE NON-ELASTIC GAUZE/YD $0.00
A6407 3 PACKING STRIPS, NON-IMPREG $1.88
A6410 5 STERILE EYE PAD $0.00
A6411 5 NON-STERILE EYE PAD $0.00
A6412 5 OCCLUSIVE EYE PATCH $0.00
A6413 9 ADHESIVE BANDAGE, FIRST-AID $0.00
A6421 O PAD BANDAGE >=3 <5IN W /ROLL $0.00
A6422 O CONF BANDAGE NS >=3<5ÊW/ROLL $0.00
A6424 O CONF BANDAGE NS >=5ÊW /ROLL $0.00
A6426 O CONF BANDAGE S >=3<5Ê W/ROLL $0.00
A6428 O CONF BANDAGE S >=5Ê W /ROLL $0.00
A6430 O LT COMPRES BDG >=3<5ÊW /ROLL $0.00

A6432 O LT COMPRES BDG >=5ÊW /ROLL $0.00
A6434 O MO COMPRES BDG >=3<5ÊW /ROLL $0.00
A6436 O HI COMPRES BDG >=3<5ÊW /ROLL $0.00
A6438 O SELF-ADHER BDG >=3<5ÊW /ROLL $0.00
A6440 O ZINC PASTE BDG >=3<5ÊW /ROLL $0.00
A6441 3 PAD BAND W>=3" <5"/YD $0.67
A6442 3 CONFORM BAND N/S W<3"/YD $0.17
A6443 3 CONFORM BAND N/S W>=3"<5"/YD $0.29
A6444 6 CONFORM BAND N/S W>=5"/YD $0.00
A6445 3 CONFORM BAND S W <3"/YD $0.32

A6446 3 CONFORM BAND S W>=3" <5"/YD $0.41
A6447 3 CONFORM BAND S W >=5"/YD $0.67
A6448 3 LT COMPRES BAND <3"/YD $1.16
A6449 3 LT COMPRES BAND >=3" <5"/YD $1.75
A6450 6 LT COMPRES BAND >=5"/YD $0.00
A6451 6 MOD COMPRES BAND W>=3"<5"/YD $0.00
A6452 3 HIGH COMPRES BAND W>=3"<5"YD $5.91
A6453 3 SELF-ADHER BAND W <3"/YD $0.61
A6454 3 SELF-ADHER BAND W>=3" <5"/YD $0.77
A6455 3 SELF-ADHER BAND >=5"/YD $1.39
A6456 3 ZINC PASTE BAND W >=3"<5"/YD $1.28
A6457 3 TUBULAR DRESSING $1.14
A6501 5 COMPRES BURNGARMENT BODYSUIT $0.00

A6502 5 COMPRES BURNGARMENT CHINSTRP $0.00
A6503 5 COMPRES BURNGARMENT FACEHOOD $0.00
A6504 5 CMPRSBURNGARMENT GLOVE-WRIST $0.00
A6505 5 CMPRSBURNGARMENT GLOVE-ELBOW $0.00
A6506 5 CMPRSBURNGRMNT GLOVE-AXILLA $0.00
A6507 5 CMPRS BURNGARMENT FOOT-KNEE $0.00
A6508 5 CMPRS BURNGARMENT FOOT-THIGH $0.00
A6509 5 COMPRES BURN GARMENT JACKET $0.00
A6510 5 COMPRES BURN GARMENT LEOTARD $0.00
A6511 5 COMPRES BURN GARMENT PANTY $0.00
A6512 5 COMPRES BURN GARMENT, NOC $0.00
A6513 6 COMPRESS BURN MASK FACE/NECK $0.00

A6530 6 COMPRESSION STOCKING BK18-30 $0.00
A6533 6 GC STOCKING THIGHLNGTH 18-30 $0.00
A6536 6 GC STOCKING FULL LNGTH 18-30 $0.00
A6539 6 GC STOCKING WAISTLNGTH 18-30 $0.00

A6542 6 GC STOCKING CUSTOM MADE $0.00
A6543 6 GC STOCKING LYMPHEDEMA $0.00
A6544 6 GC STOCKING GARTER BELT $0.00
A6545 6 GRAD COMP NON-ELASTIC BK $0.00
A6549 6 G COMPRESSION STOCKING $0.00
A6550 6 NEG PRES WOUND THER DRSG SET $0.00
A6551 O NEG PRESS WOUND THER CANISTR $0.00
A7000 3 DISPOSABLE CANISTER FOR PUMP $7.97
A7001 3 NONDISPOSABLE PUMP CANISTER $28.55
A7002 3 TUBING USED W SUCTION PUMP $3.31
A7003 3 NEBULIZER ADMINISTRATION SET $2.61

A7004 3 DISPOSABLE NEBULIZER SML VOL $1.47
A7005 3 NONDISPOSABLE NEBULIZER SET $26.59
A7006 3 FILTERED NEBULIZER ADMIN SET $7.78
A7007 3 LG VOL NEBULIZER DISPOSABLE $3.80
A7008 3 DISPOSABLE NEBULIZER PREFILL $10.52
A7009 3 NEBULIZER RESERVOIR BOTTLE $36.26
A7010 3 DISPOSABLE CORRUGATED TUBING $22.31
A7011 5 NONDISPOS CORRUGATED TUBING $0.00
A7012 3 NEBULIZER WATER COLLEC DEVIC $3.42
A7013 3 DISPOSABLE COMPRESSOR FILTER $0.71
A7014 3 COMPRESSOR NONDISPOS FILTER $3.87
A7015 3 AEROSOL MASK USED W NEBULIZE $1.57

A7016 3 NEBULIZER DOME & MOUTHPIECE $6.24
A7017 3 NEBULIZER NOT USED W OXYGEN $128.23
A7018 3 WATER DISTILLED W/NEBULIZER $0.37
A7019 O SALINE SOLUTION DISPENSER $0.00
A7020 O STERILE H2O OR NSS W LGV NEB $0.00
A7025 3 REPLACE CHEST COMPRESS VEST $434.94
A7026 3 REPLACE CHST CMPRSS SYS HOSE $28.75
A7027 6 COMBINATION ORAL/NASAL MASK $0.00
A7028 6 REPL ORAL CUSHION COMBO MASK $0.00
A7029 6 REPL NASAL PILLOW COMB MASK $0.00

A7030 3 CPAP FULL FACE MASK $188.64
A7031 3 REPLACEMENT FACEMASK INTERFA $69.77
A7032 3 REPLACEMENT NASAL CUSHION $40.53
A7033 3 REPLACEMENT NASAL PILLOWS $28.41
A7034 3 NASAL APPLICATION DEVICE $117.64
A7035 3 POS AIRWAY PRESS HEADGEAR $35.42
A7036 3 POS AIRWAY PRESS CHINSTRAP $18.20
A7037 3 POS AIRWAY PRESSURE TUBING $39.21
A7038 3 POS AIRWAY PRESSURE FILTER $4.58
A7039 3 FILTER, NON DISPOSABLE W PAP $15.33
A7040 6 ONE WAY CHEST DRAIN VALVE $0.00
A7041 6 WATER SEAL DRAIN CONTAINER $0.00
A7042 9 IMPLANTED PLEURAL CATHETER $0.00

A7043 5 VACUUM DRAINAGEBOTTLE/TUBING $0.00
A7044 3 PAP ORAL INTERFACE $120.91
A7045 3 REPL EXHALATION PORT FOR PAP $19.47
A7046 6 REPL WATER CHAMBER, PAP DEV $0.00
A7501 3 TRACHEOSTOMA VALVE W DIAPHRA $100.18
A7502 3 REPLACEMENT DIAPHRAGM/FPLATE $47.61
A7503 3 HMES FILTER HOLDER OR CAP $10.81
A7504 3 TRACHEOSTOMA HMES FILTER $0.64
A7505 3 HMES OR TRACH VALVE HOUSING $4.46
A7506 3 HMES/TRACHVALVE ADHESIVEDISK $0.32
A7507 3 INTEGRATED FILTER & HOLDER $2.37
A7508 3 HOUSING & INTEGRATED ADHESIV $2.74

A7509 3 HEAT & MOISTURE EXCHANGE SYS $1.34
A7520 6 TRACH/LARYN TUBE NON-CUFFED $0.00
A7521 6 TRACH/LARYN TUBE CUFFED $0.00
A7522 6 TRACH/LARYN TUBE STAINLESS $0.00
A7523 6 TRACHEOSTOMY SHOWER PROTECT $0.00
A7524 6 TRACHEOSTOMA STENT/STUD/BTTN $0.00
A7525 3 TRACHEOSTOMY MASK $2.07
A7526 3 TRACHEOSTOMY TUBE COLLAR $3.37
A7527 6 TRACH/LARYN TUBE PLUG/STOP $0.00
A8000 6 SOFT PROTECT HELMET PREFAB $0.00

A8001 6 HARD PROTECT HELMET PREFAB $0.00
A8002 6 SOFT PROTECT HELMET CUSTOM $0.00
A8003 6 HARD PROTECT HELMET CUSTOM $0.00
A8004 6 REPL SOFT INTERFACE, HELMET $0.00
A9150 9 MISC/EXPER NON-PRESCRIPT DRU $0.00
A9152 9 SINGLE VITAMIN NOS $0.00
A9153 9 MULTI-VITAMIN NOS $0.00
A9155 6 ARTIFICIAL SALIVA $0.00
A9160 9 PODIATRIST NON-COVERED SERVI $0.00
A9170 9 CHIROPRACTOR NON-COVERED SER $0.00
A9180 9 PEDICULOSIS (LICE INFESTATION) TRE $0.00
A9190 9 MISC/EXPE PERSONAL COMFORT I $0.00
A9250 9 NURSING HOME RENTALS $0.00

A9260 9 NON-CERTIFIED PHYSICAL THERAPISTS $0.00
A9270 9 NON-COVERED ITEM OR SERVICE $0.00
A9274 6 EXT AMB INSULIN DELIVERY SYS $0.00
A9275 9 DISP HOME GLUCOSE MONITOR $0.00
A9276 9 DISPOSABLE SENSOR, CGM SYS $0.00
A9277 9 EXTERNAL TRANSMITTER, CGM $0.00
A9278 9 EXTERNAL RECEIVER, CGM SYS $0.00
A9279 9 MONITORING FEATURE/DEVICENOC $0.00
A9280 6 ALERT OR ALARM DEVICE, NOC $0.00
A9281 9 REACHING/GRABBING DEVICE $0.00
A9282 9 WIG ANY TYPE $0.00
A9283 6 FOOT PRESS OFF LOAD SUPP DEV $0.00

A9284 9 NON-ELECTRONIC SPIROMETER $0.00
A9290 9 DESCRIPTION OF SERVICE DOES NOT IND $0.00
A9300 O EXERCISE EQUIPMENT $0.00
A9500 9 TC99M SESTAMIBI $0.00
A9501 9 TECHNETIUM TC-99M TEBOROXIME $0.00
A9502 9 TC99M TETROFOSMIN $0.00
A9503 9 TC99M MEDRONATE $0.00
A9504 9 TC99M APCITIDE $0.00
A9505 9 TL201 THALLIUM $0.00
A9507 9 IN111 CAPROMAB $0.00

A9508 9 I131 IODOBENGUATE, DX $0.00
A9509 9 IODINE I-123 SOD IODIDE MIL $0.00
A9510 9 TC99M DISOFENIN $0.00
A9511 O TECHNETIUM TC 99M DEPREOTIDE $0.00
A9512 9 TC99M PERTECHNETATE $0.00
A9513 O TECHNETIUM TC-99M MEBROFENIN $0.00
A9514 O TECHNETIUMTC99MPYROPHOSPHATE $0.00
A9515 O TECHNETIUM TC-99M PENTETATE $0.00
A9516 9 IODINE I-123 SOD IODIDE MIC $0.00
A9517 9 I131 IODIDE CAP, RX $0.00
A9518 O I-131 SODIUM IODIDE SOLUTION $0.00
A9519 O TECHNETIUMTC-99MMACROAG ALBU $0.00
A9520 O TECHNETIUMTC-99M SULFUR CLLD $0.00

A9521 9 TC99M EXAMETAZIME $0.00
A9522 O INDIUM111IBRITUMOMABTIUXETAN $0.00
A9523 O YTTRIUM90IBRITUMOMABTIUXETAN $0.00
A9524 9 I131 SERUM ALBUMIN, DX $0.00
A9525 O LOW/ISO-OSMOLAR CONTRAST MAT $0.00
A9526 9 NITROGEN N-13 AMMONIA $0.00
A9527 9 IODINE I-125 SODIUM IODIDE $0.00
A9528 9 IODINE I-131 IODIDE CAP, DX $0.00
A9529 9 I131 IODIDE SOL, DX $0.00
A9530 9 I131 IODIDE SOL, RX $0.00
A9531 9 I131 MAX 100UCI $0.00
A9532 9 I125 SERUM ALBUMIN, DX $0.00

A9533 O I-131 TOSITUMOMAB DIAGNOSTIC $0.00
A9534 O I-131 TOSITUMOMAB THERAPEUT $0.00
A9535 9 INJECTION, METHYLENE BLUE $0.00
A9536 9 TC99M DEPREOTIDE $0.00
A9537 9 TC99M MEBROFENIN $0.00
A9538 9 TC99M PYROPHOSPHATE $0.00
A9539 9 TC99M PENTETATE $0.00
A9540 9 TC99M MAA $0.00
A9541 9 TC99M SULFUR COLLOID $0.00
A9542 9 IN111 IBRITUMOMAB, DX $0.00

A9543 9 Y90 IBRITUMOMAB, RX $0.00
A9544 9 I131 TOSITUMOMAB, DX $0.00
A9545 9 I131 TOSITUMOMAB, RX $0.00
A9546 9 CO57/58 $0.00
A9547 9 IN111 OXYQUINOLINE $0.00
A9548 9 IN111 PENTETATE $0.00
A9549 O TC99M ARCITUMOMAB $0.00
A9550 9 TC99M GLUCEPTATE $0.00
A9551 9 TC99M SUCCIMER $0.00
A9552 9 F18 FDG $0.00
A9553 9 CR51 CHROMATE $0.00
A9554 9 I125 IOTHALAMATE, DX $0.00
A9555 9 RB82 RUBIDIUM $0.00

A9556 9 GA67 GALLIUM $0.00
A9557 9 TC99M BICISATE $0.00
A9558 9 XE133 XENON 10MCI $0.00
A9559 9 CO57 CYANO $0.00
A9560 9 TC99M LABELED RBC $0.00
A9561 9 TC99M OXIDRONATE $0.00
A9562 9 TC99M MERTIATIDE $0.00
A9563 9 P32 NA PHOSPHATE $0.00
A9564 9 P32 CHROMIC PHOSPHATE $0.00
A9565 O IN111 PENTETREOTIDE $0.00
A9566 9 TC99M FANOLESOMAB $0.00
A9567 9 TECHNETIUM TC-99M AEROSOL $0.00

A9568 9 TECHNETIUM TC99M ARCITUMOMAB $0.00
A9569 9 TECHNETIUM TC-99M AUTO WBC $0.00
A9570 9 INDIUM IN-111 AUTO WBC $0.00
A9571 9 INDIUM IN-111 AUTO PLATELET $0.00
A9572 9 INDIUM IN-111 PENTETREOTIDE $0.00
A9576 9 INJ PROHANCE MULTIPACK $0.00
A9577 9 INJ MULTIHANCE $0.00
A9578 9 INJ MULTIHANCE MULTIPACK $0.00
A9579 9 GAD-BASE MR CONTRAST NOS,1ML $0.00
A9580 9 SODIUM FLUORIDE F-18 $0.00

A9600 9 SR89 STRONTIUM $0.00
A9603 9 I-131SODIUMIODIDECAP PER MCI $0.00
A9605 9 SM 153 LEXIDRONM $0.00
A9698 9 NON-RAD CONTRAST MATERIALNOC $0.00
A9699 9 RADIOPHARM RX AGENT NOC $0.00
A9700 9 ECHOCARDIOGRAPHY CONTRAST $0.00
A9900 5 SUPPLY/ACCESSORY/SERVICE $0.00
A9901 9 DELIVERY/SET UP/DISPENSING $0.00
A9999 5 MISC DME SUPPLY OR ACCESS, NOS $0.00
ASC0001 7 AMBULATORY SURGICAL CENTER $0.00

B4034 3 ENTER FEED SUPKIT SYR BY DAY $5.60
B4035 3 ENTERAL FEED SUPP PUMP PER D $10.67
B4036 3 ENTERAL FEED SUP KIT GRAV BY $7.31
B4081 3 ENTERAL NG TUBING W/ STYLET $19.78
B4082 3 ENTERAL NG TUBING W/O STYLET $14.73
B4083 3 ENTERAL STOMACH TUBE LEVINE $2.25
B4084 O GASTROSTOMY/JEJUNOSTOMY TUBI $0.00

B4085 9 GASTROSTOMY TUBE W/RING EACH $0.00
B4086 O GASTROSTOMY/JEJUNOSTOMY TUBE $0.00
B4087 6 GASTRO/JEJUNO TUBE, STD $0.00
B4088 6 GASTRO/JEJUNO TUBE, LOW-PRO $0.00
B4100 5 FOOD THICKENER ORAL $0.00
B4102 6 EF ADULT FLUIDS AND ELECTRO $0.00
B4103 6 EF PED FLUID AND ELECTROLYTE $0.00
B4104 6 ADDITIVE FOR ENTERAL FORMULA $0.00
B4149 6 EF BLENDERIZED FOODS $0.00
B4150 3 EF COMPLET W/INTACT NUTRIENT $0.61

B4151 O ENTERAL FORMULAE CAT1NATURAL $0.00
B4152 3 EF CALORIE DENSE>/=1.5KCAL $0.51
B4153 3 EF HYDROLYZED/AMINO ACIDS $1.74
B4154 3 EF SPEC METABOLIC NONINHERIT $1.12
B4155 3 EF INCOMPLETE/MODULAR $0.89
B4156 O ENTERAL FORMULAE CATEGORY VI $0.00
B4157 6 EF SPECIAL METABOLIC INHERIT $0.00
B4158 3 EF PED COMPLETE INTACT NUT $0.65
B4159 6 EF PED COMPLETE SOY BASED $0.00
B4160 6 EF PED CALORIC DENSE>/=0.7KC $0.00
B4161 3 EF PED HYDROLYZED/AMINO ACID $1.80
B4162 6 EF PED SPECMETABOLIC INHERIT $0.00
B4164 9 PARENTERAL 50% DEXTROSE SOLU $0.00

B4168 9 PARENTERAL SOL AMINO ACID 3. $0.00
B4172 9 PARENTERAL SOL AMINO ACID 5. $0.00
B4176 9 PARENTERAL SOL AMINO ACID 7- $0.00
B4178 9 PARENTERAL SOL AMINO ACID > $0.00
B4180 9 PARENTERAL SOL CARB > 50% $0.00
B4184 O PARENTERAL SOL LIPIDS 10% $0.00
B4185 6 PARENTERAL SOL 10 GM LIPIDS $0.00
B4186 O PARENTERAL SOL LIPIDS 20% $0.00
B4189 9 PARENTERAL SOL AMINO ACID & $0.00
B4193 9 PARENTERAL SOL 52-73 GM PROT $0.00
B4197 9 PARENTERAL SOL 74-100 GM PRO $0.00
B4199 9 PARENTERAL SOL > 100GM PROTE $0.00

B4216 9 PARENTERAL NUTRITION ADDITIV $0.00
B4220 3 PARENTERAL SUPPLY KIT PREMIX $8.09
B4222 O PARENTERAL SUPPLY KIT HOMEMI $0.00
B4224 3 PARENTERAL ADMINISTRATION KI $25.29
B5000 9 PARENTERAL SOL RENAL-AMIROSY $0.00
B5100 9 PARENTERAL SOL HEPATIC-FREAM $0.00
B5200 9 PARENTERAL SOL STRES-BRNCH C $0.00
B9000 3 ENTER INFUSION PUMP W/O ALRM $988.00
B9002 3 ENTERAL INFUSION PUMP W/ ALA $988.00
B9004 3 PARENTERAL INFUS PUMP PORTAB $2,551.22

B9006 3 PARENTERAL INFUS PUMP STATIO $1,970.80
B9998 5 ENTERAL SUPP NOT OTHERWISE C $0.00
B9999 5 PARENTERAL SUPP NOT OTHRWS C $0.00
BONUS O MCO SPECIFIC CODE: SMART START OUT $0.00
C1000 9 PERCLOSCLOSR PROSTARARTVAS $0.00
C1001 9 ACUNAV-DIAGNSTIC ULTRSND CA $0.00
C1003 9 CATH, ABLATION, LIVEWIRE TC $0.00
C1004 9 FAST-CATH,SWARTZ,SAFL,CSTA $0.00
C1006 9 ARRAY POST CHAMB IOL $0.00
C1007 9 AMS 700/AMBICOR PROSTHESIS $0.00
C1008 9 UROLUME-IMPLT URETHRAL STNT $0.00
C1009 9 PLASMA,CRYOPRECIPITATE-REDUC $0.00
C1010 O BLOOD, L/R, CMV-NEG $0.00

C1011 O PLATELETS, HLA-M, L/R, UNIT $0.00
C1012 9 PLATELET CONC, L/R, IRRAD $0.00
C1013 9 PLATELET CONC, L/R, UNIT $0.00
C1014 9 PLATELET,APH/PHER, L/R, UNIT $0.00
C1015 O PLT, PHER,L/R,CMV, IRRAD $0.00
C1016 O BLOOD,L/R,FROZ/DEGLY/WASHED $0.00
C1017 O PLT, APH/PHER,L/R,CMV-NEG $0.00
C1018 O BLOOD, L/R, IRRADIATED $0.00
C1019 9 PLT, APH/PHER, L/R, IRRAD $0.00
C1020 O RBC, FRZ/DEG/WSH, L/R, IRRAD $0.00
C1021 O RBC, L/R, CMV NEG, IRRAD $0.00
C1022 O PLASMA, FRZ WITHIN 24 HOUR $0.00

C1024 9 QUINOPRISTIN 10ML/DALFOPRIS $0.00
C1025 9 MARINR CS CATH $0.00
C1026 9 RF PERFRMR CATH 5F RF MARINR $0.00
C1027 9 MAGIC X/SHORT RADIUS 14MM $0.00
C1028 9 PRCIS TWST TRSNSVG ANCH SYS $0.00
C1029 9 CRE GUIDED BALLOON DIL CATH $0.00
C1030 9 CTHTR:MRSHAL,BLU MAX UTR DMD $0.00
C1031 9 MR COMP/MOD LEVEEN NED ELECT $0.00
C1033 9 SONICATH MDL 37-410 $0.00
C1034 9 SURPASS, LONG30 SURPASS-CATH $0.00

C1035 9 CATH, ULTRA ICE $0.00
C1036 9 R PORT/RESERVOIR IMPL DEV $0.00
C1037 9 VAXCELCHRONIC DIALYSIS CATH $0.00
C1038 9 ULTRACROSS IMAGING CATH $0.00
C1039 9 WALLSTENT, RP/TRACH $0.00
C1040 9 WALLSTENT, TIPS $0.00
C1042 9 WALLSTENT, BILIARY $0.00
C1043 9 ATHERECTOMY SYS, CORONARY $0.00
C1045 9 I-131 MIBG(IOBEN-SULFATE)0.5 $0.00
C1047 9 NOGA/NAVI-STAR CATH $0.00
C1048 9 NEUROCYBERNETICPROS:GEN $0.00
C1050 9 PROSORBA COLUMN $0.00
C1051 9 OASIS THROMBECTOMY CATH $0.00

C1053 9 ENSITE 3000 CATHETER $0.00
C1054 9 HYDROLYSER THROMB CATH 6/7F $0.00
C1055 9 TRANSESOPH 210, 210-S CATH $0.00
C1056 9 THERMACHOICE II CATH $0.00
C1057 9 MICROMARK TISSUE MARKER $0.00
C1058 9 TC 99M OXIDRONATE, PER VIAL $0.00
C1059 9 CARTICEL,AUTO CULT-CHNDR CYT $0.00
C1060 9 ACS MULTI-LINK TRISTAR STENT $0.00
C1061 9 ACS VIKING GUIDING CATH $0.00
C1063 9 ENDOTAK ENDURANCE EZ,RX LEAD $0.00
C1064 9 I-131 CAP, EACH ADD MCI $0.00
C1065 9 I-131 SOL, EACH ADD MCI $0.00

C1066 9 IN 111 SATUMOMAB PENDETIDE $0.00
C1067 9 MEGALINK BILIARY STENT $0.00
C1068 9 PULSAR DDD PMKR $0.00
C1069 9 DISCOVERY DR, PMKR $0.00
C1071 9 PULSAR MAX, PULSAR SR PMKR $0.00
C1072 9 GUIDANT:BLLN DIL CATH $0.00
C1073 9 MORCELLATOR $0.00
C1074 9 RX/OTW VIATRAC-PERI DIL CATH $0.00
C1075 9 GUIDANT:LEAD,PMKR $0.00
C1076 9 VENTAK MINI SC DEFIB $0.00

C1077 9 VENTAK VR,PRIZM VR, SC DEFIB $0.00
C1078 9 VENTAK:PRIZM,AV III DR DEFIB $0.00
C1079 O CO 57/58 PER 0.5 UCI $0.00
C1080 O I-131 TOSITUMOMAB, DX $0.00
C1081 O I-131 TOSITUMOMAB, TX $0.00
C1082 O IN-111 IBRITUMOMAB TIUXETAN $0.00
C1083 O YTTRIUM 90 IBRITUMOMAB TIUXE $0.00
C1084 9 DENILEUKIN DIFTITOX, 300 MCG $0.00
C1086 9 TEMOZOLOMIDE, 5 MG $0.00
C1087 9 I-123 PER 100 UCI $0.00
C1088 9 LASER OPTIC TR SYS $0.00
C1089 9 CO 57, 0.5 MCI $0.00
C1090 9 IN 111 CHLORIDE, PER MCI $0.00

C1091 O IN111 OXYQUINOLINE,PER0.5MCI $0.00
C1092 O IN 111 PENTETATE PER 0.5 MCI $0.00
C1093 O TC99M FANOLESOMAB $0.00
C1094 9 TC99MALBUMIN AGGR,PER 1.0MCI $0.00
C1095 9 TC 99M DEPREOTIDE, PER VIAL $0.00
C1096 9 TC 99M EXAMETAZIME, PER DOSE $0.00
C1097 9 TC 99M MEBROFENIN, PER VIAL $0.00
C1098 9 TC 99M PENTETATE, PER VIAL $0.00
C1099 9 TC 99M PYROPHOSPHATE,PER VIA $0.00
C1100 9 MEDTRONIC AVE GT1 GUIDEWIRE $0.00
C1101 9 MEDTRONIC AVE ZUMA GUIDECATH $0.00
C1102 9 SYNERGY NEUROSTIM GENRTR $0.00

C1103 9 MICRO JEWEL DEFIBRILLATOR $0.00
C1104 9 RF CONDUCTR ABLATION CATH $0.00
C1105 9 SIGMA 300VDD PMKR $0.00
C1106 9 SYNERGYEX PT PROGRMR $0.00
C1107 9 TORQR,SOLOIST CATH $0.00
C1109 9 IMPLANTABLE ANCHOR:ETHICON $0.00
C1110 9 STABLE MAPPER,CATH ELECTR $0.00
C1111 9 ANEURXAORT-UNI-ILIAC STNT $0.00
C1112 9 ANEURX STENT GRAFT/DEL CATH $0.00
C1113 9 TLNT ENDO SPRNG STNT GRFT SY $0.00

C1114 9 TALNTSPRGSTNT+GRAF ENDO PROS $0.00
C1115 9 5038S, 5038 5038L PACE LEAD $0.00
C1116 9 CAPSURESP PACING LEAD $0.00
C1117 9 ANCURE ENDOGRAFT DEL SYS $0.00
C1118 9 SIGMA300DR LEGIIDR, PMKR $0.00
C1119 9 SPRINT6932,6943 DEFIB LEAD $0.00
C1120 9 SPRINT6942,6945 DEFIB LEAD $0.00
C1121 9 GEM DEFIBRILLATOR $0.00
C1122 O TC 99M ARCITUMOMAB PER VIAL $0.00
C1123 9 GEM II VR DEFIBRILLATOR $0.00
C1124 9 INTERSTIM TEST STIM KIT $0.00
C1125 9 KAPPA 400SR,TOPAZ II SR PMKR $0.00
C1126 9 KAPPA 700 DR, PMKR $0.00

C1127 9 KAPPA 700SR, SC PMKR $0.00
C1128 9 KAPPA 700D, RUBY IID PMKR $0.00
C1129 9 KAPPA 700VDD, PMKR $0.00
C1130 9 SIGMA200D, LGCY IID DC PMKR $0.00
C1131 9 SIGMA 200DR, PMKR $0.00
C1132 9 SIGMA 200 SR LEG II:SC PA $0.00
C1133 9 SIGMA SR, VITA SR, PMKR $0.00
C1134 9 SIGMA 300D PMKR $0.00
C1135 9 ENTITY DR 5326L/R, DC, PMKR $0.00
C1136 9 AFFINITY DR 5330L/R, DC, PMK $0.00
C1137 9 CARDIOSEAL IMPLANT SYS $0.00
C1143 9 ADDVENT MOD 2060BL, VDD $0.00

C1144 9 AFNTY SP 5130,INTEGRITY SR $0.00
C1145 9 ANGIO-SEAL 6FR,8FR $0.00
C1146 9 VETT TUBE $0.00
C1147 9 AV PLUS DX 1368:LEAD $0.00
C1148 9 CONTOUR MD SC DEFIB $0.00
C1149 9 ENTITY DC 5226R,PMKR $0.00
C1151 9 PASSIVEPLUS DX LEAD, 10MDLS $0.00
C1152 9 LIFESITE ACCESS SYSTEM $0.00
C1153 9 REGENCY SC+2402L PMKR $0.00
C1154 9 SPL:SPO1,02,04-DEFIB LEAD $0.00

C1155 9 REPLIFORM 8 SQ CM $0.00
C1156 9 TR1102TRSR+2260L,2264L,5131 $0.00
C1157 9 TRILOGY DCT 23/8L PMKR $0.00
C1158 9 TVL LEAD SV01,SV02,SV04 $0.00
C1159 9 TVL RV02, RV06,RV07:LEAD $0.00
C1160 9 TVL-ADX 1559:LEAD $0.00
C1161 9 TENDRIL DX, 1388 PACING LEAD $0.00
C1162 9 TEMPODR TRILOGYDR+DC PMKR $0.00
C1163 9 TENDRIL SDX, 1488T LEAD $0.00
C1164 9 IODINE-125 BRACHYTX SEED $0.00
C1166 O CYTARABINE LIPOSOMAL, 10 MG $0.00
C1167 O EPIRUBICIN HCL, 2 MG $0.00
C1170 9 ABBI DISP BIOPSY DEVICE $0.00

C1171 9 AUTOSUTURE SITE MARKER STPLE $0.00
C1172 9 SPACEMAKER DISSECT BALLOON $0.00
C1173 9 COR STNTS540,S670,O-WIRE STN $0.00
C1174 9 BARD BRACHYTX NEEDLE $0.00
C1175 9 MIBB DISP BIOPSY DEVICE $0.00
C1176 9 MAMMOTOME HH PROBE W/VAC SYS $0.00
C1177 9 11-G MAMMOTOME PROBE $0.00
C1178 O BUSULFAN IV, 6 MG $0.00
C1179 9 14-G MAMMOTOME PROBE $0.00
C1180 9 VIGOR SR, SC, PMKR $0.00
C1181 9 MERIDIAN SSI, SC, PMKR $0.00
C1182 9 PULSAR SSI, SC, PMKR $0.00

C1183 9 JADE IIS, SIGMA 300S, SC, PM $0.00
C1184 9 SIGMA 200S, SC, PMKR $0.00
C1188 9 I-131 CAP, PER 1-5 MCI $0.00
C1200 O TC 99M SODIUM GLUCOHEPTONAT $0.00
C1201 O TC 99M SUCCIMER, PER VIAL $0.00
C1202 9 TC 99M SULFUR COLLOID, VIAL $0.00
C1203 9 VERTEPORFIN FOR INJ $0.00
C1205 9 TC 99M DISOFENIN, PER VIAL $0.00
C1207 O OCTREOTIDE ACETATE DEPOT 1MG $0.00
C1300 9 HYPERBARIC OXYGEN $0.00

C1302 9 SQ01: LEAD $0.00
C1303 9 CAPSURE FIX 6940/4068-110 $0.00
C1304 9 SONCATH MDL 37-416,-418 $0.00
C1305 O APLIGRAF $0.00
C1306 9 NEUROCYBERNETICPROS:LEAD $0.00
C1311 9 TRILOGY DR+/DAO PMKR $0.00
C1312 9 MAGIC WALLSTENT--MINI $0.00
C1313 9 MAGIC MEDIUM,RADIUS 31MM $0.00
C1314 9 MAGIC WALLSTENT--LONG $0.00
C1315 9 VIGOR DR, MERIDIAN DR PMKR $0.00
C1316 9 MERIDIAN DDD PMKR $0.00
C1317 9 DISCOVERY SR, PMKR $0.00
C1318 9 MERIDIAN SR PMKR $0.00

C1319 9 WALLSTENT: ENTERAL--60MM $0.00
C1320 9 WALLSTENT: ILIAC $0.00
C1321 9 PALATE/BASE OF TONGUE ELECTR $0.00
C1322 9 TURBINATE SOMNOPLASTY ELECTR $0.00
C1323 9 VAPR/T DISP ELECTRODE $0.00
C1324 9 LIGASURE DISPOSABLE ELECTROD $0.00
C1325 9 PALLADIUM-103 SEED $0.00
C1326 9 ANGIO-JET RHEOLYTIC THROMB $0.00
C1328 9 ANS RENEW NS TRNSMTR $0.00
C1329 9 VERSAPOINT DISP ELECTRODE $0.00
C1333 9 PALMAZ CORINTHIAN BIL STENT $0.00
C1334 9 CROWN,MINI-CROWN,CROSSLC $0.00

C1335 9 MESH, PROLENE $0.00
C1336 9 CONSTANT FLOW IMP PUMP $0.00
C1337 9 ISOMED 8472-20/35/60 $0.00
C1348 9 I-131 SOL, PER 1-6 MCI $0.00
C1350 9 PROSTASEED I-125, PER SOURCE $0.00
C1351 9 CAPSURE FIX LEAD $0.00
C1352 9 GEM II DR $0.00
C1353 9 ITREL INTERSTM NEUROSTIM+EXT $0.00
C1354 9 KAPPA 400DR,DIAMOND II 820DR $0.00
C1355 9 KAPPA 600DR, VITA DR $0.00

C1356 9 PROFILE MD V-186HV3 SC DEFIB $0.00
C1357 9 ANGSTROM MD V-190HV3 SC DEF $0.00
C1358 9 AFFINITY DC 5230R, PMKR $0.00
C1359 9 PULSAR,PULSAR MAX DR, PMKR $0.00
C1360 9 OCULAR PHOTODYNAMIC TX $0.00
C1361 9 REVEAL CARDIAC RECORDER $0.00
C1362 9 HERCULINK,OTW,SDS BIL STNT $0.00
C1363 9 GEM DR, DC, DEFIB $0.00
C1364 9 PHOTON DR V-230HV3 DC DEFIB $0.00
C1365 9 GUIDEWIRE, HI-TORQUE14/18/35 $0.00
C1366 9 GUIDEWIRE,PTCA,HI-TORQUE $0.00
C1367 9 GUIDE WIRE, HI-TORQUECROSSIT $0.00
C1368 9 ON-Q PAIN MGT SYS $0.00

C1369 9 ANS RENEW STIM SYS RECVR $0.00
C1370 9 TENSION-FREE VAGINAL TAPE $0.00
C1371 9 SYMP NITINOL TRANSHEP BIL SY $0.00
C1372 9 CORDIS NITINOL BIL STENT $0.00
C1375 9 STENT, CORONARY, NIR $0.00
C1376 9 ANS RENEW STIM SYS LEAD $0.00
C1377 9 SPECIFY 3988 NEURO LEAD $0.00
C1378 9 INTERSTIM TX 3080/3886 LEAD $0.00
C1379 9 PISCES-QUAD 3887 LEAD $0.00
C1420 9 STAPLETAC2 BONEW/DERMIS $0.00
C1421 9 STAPLETAC2 BONE WO DERMIS $0.00
C1450 9 ORTHOSPHERE ARTHROPLASTY $0.00

C1451 9 ORTHOSPHERE ARTHROPLASTY KIT $0.00
C1500 9 ATHERECTOMY SYS, PERIPHERAL $0.00
C1700 9 AUTHEN MICK TP BRACHY NEEDLE $0.00
C1701 9 MEDTEC MT-BT-5201-25 NEEDLE $0.00
C1702 9 WWMT BRACHY NEEDLE $0.00
C1703 9 MENTOR PROSTATE BRACHY $0.00
C1704 9 MT-BT-5001-25/5051-25 $0.00
C1705 9 BEST FLEXI BRACHY NEEDLE $0.00
C1706 9 INDIGO PROSTATE SEEDING NDL $0.00
C1707 9 VARISOURCE IMPLT NDL $0.00

C1708 9 UROMED PROSTATE SEED NDL $0.00
C1709 9 REMINGTON BRACHYTX NEEDLE $0.00
C1710 9 US BIOPSY PROSTATE NEEDLE $0.00
C1711 9 MD TECH BRACHYTX NEEDLE $0.00
C1712 9 IMAGYN BRACHYTX NEEDLE $0.00
C1713 9 ANCHOR/SCREW BN/BN,TIS/BN $0.00
C1714 9 CATH, TRANS ATHERECTOMY, DIR $0.00
C1715 9 BRACHYTHERAPY NEEDLE $0.00
C1716 9 BRACHYTX, NON-STR, GOLD-198 $0.00
C1717 O BRACHYTX, NON-STR,HDR IR-192 $0.00
C1718 O BRACHYTX SOURCE, IODINE 125 $0.00
C1719 9 BRACHYTX, NS, NON-HDRIR-192 $0.00
C1720 O BRACHYTX SOUR, PALLADIUM 103 $0.00

C1721 9 AICD, DUAL CHAMBER $0.00
C1722 9 AICD, SINGLE CHAMBER $0.00
C1724 9 CATH, TRANS ATHEREC,ROTATION $0.00
C1725 9 CATH, TRANSLUMIN NON-LASER $0.00
C1726 9 CATH, BAL DIL, NON-VASCULAR $0.00
C1727 9 CATH, BAL TIS DIS, NON-VAS $0.00
C1728 9 CATH, BRACHYTX SEED ADM $0.00
C1729 9 CATH, DRAINAGE $0.00
C1730 9 CATH, EP, 19 OR FEW ELECT $0.00
C1731 9 CATH, EP, 20 OR MORE ELEC $0.00
C1732 9 CATH, EP, DIAG/ABL, 3D/VECT $0.00
C1733 9 CATH, EP, OTHR THAN COOL-TIP $0.00

C1750 9 CATH, HEMODIALYSIS,LONG-TERM $0.00
C1751 9 CATH, INF, PER/CENT/MIDLINE $0.00
C1752 9 CATH,HEMODIALYSIS,SHORT-TERM $0.00
C1753 9 CATH, INTRAVAS ULTRASOUND $0.00
C1754 9 CATHETER, INTRADISCAL $0.00
C1755 9 CATHETER, INTRASPINAL $0.00
C1756 9 CATH, PACING, TRANSESOPH $0.00
C1757 9 CATH, THROMBECTOMY/EMBOLECT $0.00
C1758 9 CATHETER, URETERAL $0.00
C1759 9 CATH, INTRA ECHOCARDIOGRAPHY $0.00

C1760 9 CLOSURE DEV, VASC $0.00
C1762 9 CONN TISS, HUMAN(INC FASCIA) $0.00
C1763 9 CONN TISS, NON-HUMAN $0.00
C1764 9 EVENT RECORDER, CARDIAC $0.00
C1765 9 ADHESION BARRIER $0.00
C1766 9 INTRO/SHEATH,STRBLE,NON-PEEL $0.00
C1767 9 GENERATOR, NEURO NON-RECHARG $0.00
C1768 9 GRAFT, VASCULAR $0.00
C1769 9 GUIDE WIRE $0.00
C1770 9 IMAGING COIL, MR, INSERTABLE $0.00
C1771 9 REP DEV, URINARY, W/SLING $0.00
C1772 9 INFUSION PUMP, PROGRAMMABLE $0.00
C1773 9 RET DEV, INSERTABLE $0.00

C1775 O FDG, PER DOSE (4-40 MCI/ML) $0.00
C1776 9 JOINT DEVICE (IMPLANTABLE) $0.00
C1777 9 LEAD, AICD, ENDO SINGLE COIL $0.00
C1778 9 LEAD, NEUROSTIMULATOR $0.00
C1779 9 LEAD, PMKR, TRANSVENOUS VDD $0.00
C1780 9 LENS, INTRAOCULAR (NEW TECH) $0.00
C1781 9 MESH (IMPLANTABLE) $0.00
C1782 9 MORCELLATOR $0.00
C1783 9 OCULAR IMP, AQUEOUS DRAIN DE $0.00
C1784 9 OCULAR DEV, INTRAOP, DET RET $0.00
C1785 9 PMKR, DUAL, RATE-RESP $0.00
C1786 9 PMKR, SINGLE, RATE-RESP $0.00

C1787 9 PATIENT PROGR, NEUROSTIM $0.00
C1788 9 PORT, INDWELLING, IMP $0.00
C1789 9 PROSTHESIS, BREAST, IMP $0.00
C1790 9 IRIDIUM 192 HDR $0.00
C1791 9 ONCOSEED, RAPID STRAND I-125 $0.00
C1792 9 UROMED I-125 BRACHY SEED $0.00
C1793 9 BARD INTERSOURCE P-103 SEED $0.00
C1794 9 BARD ISOSEED P-103 SEED $0.00
C1795 9 BARD BRACHYSOURCE I-125 $0.00
C1796 9 SOURCETECH MED I-125 $0.00

C1797 9 DRAXIMAGE I-125 SEED $0.00
C1798 9 SYNCOR I-125 PHARMASEED $0.00
C1799 9 I-PLANT I-125 BRACHYTX SEED $0.00
C1800 9 PD-103 BRACHYTX SEED $0.00
C1801 9 IOGOLD I-125 BRACHYTX SEED $0.00
C1802 9 IRIDIUM 192 BRACHYTX SEEDS $0.00
C1803 9 BEST IODINE 125 BRACHYTX SDS $0.00
C1804 9 BEST PALLADIUM 103 SEEDS $0.00
C1805 9 ISOSTAR IODINE-125 SEEDS $0.00
C1806 9 BEST GOLD 198 BRACHYTX SEED $0.00
C1810 9 D114S DILATATION CATH $0.00
C1811 9 SUGICAL DYNAMICS ANCHORS $0.00
C1812 9 OBL ANCHORS $0.00

C1813 9 PROSTHESIS, PENILE, INFLATAB $0.00
C1814 9 RETINAL TAMP, SILICONE OIL $0.00
C1815 9 PROS, URINARY SPH, IMP $0.00
C1816 9 RECEIVER/TRANSMITTER, NEURO $0.00
C1817 9 SEPTAL DEFECT IMP SYS $0.00
C1818 9 INTEGRATED KERATOPROSTHESIS $0.00
C1819 9 TISSUE LOCALIZATION-EXCISION $0.00
C1820 9 GENERATOR NEURO RECHG BAT SY $0.00
C1821 9 INTERSPINOUS IMPLANT $0.00
C1850 9 REPLIFORM 14/21 SQ CM $0.00
C1851 9 REPLIFORM 24/28 SQ CM $0.00
C1852 9 TRANSCYTE, PER 247 SQ CM $0.00

C1853 9 SUSPEND, PER 8/14 SQ CM $0.00
C1854 9 SUSPEND, PER 24/28 SQ CM $0.00
C1855 9 SUSPEND, PER 36 SQ CM $0.00
C1858 9 DURADERM, PER 8/14 SQ CM $0.00
C1859 9 DURADERM, PER 21/24/28 SQ CM $0.00
C1860 9 DURADERM, PER 48 SQ CM $0.00

C1864 9 SPERMATEX, PER 13.44 SQ CM $0.00
C1865 9 FASLATA, PER 8/14 SQ CM $0.00
C1868 9 FASLATA, PER 96 SQ CM $0.00
C1869 9 GORE THYROPLASTY DEVICE $0.00
C1870 9 DERMMATRIX, PER 16 SQ CM $0.00
C1871 9 DERMMATRIX, 32 OR 64 SQ CM $0.00
C1872 9 DERMAGRAFT, PER 37.5 SQ CM $0.00
C1873 9 BARD 3DMAX MESH $0.00
C1874 9 STENT, COATED/COV W/DEL SYS $0.00
C1875 9 STENT, COATED/COV W/O DEL SY $0.00

C1876 9 STENT, NON-COA/NON-COV W/DEL $0.00
C1877 9 STENT, NON-COAT/COV W/O DEL $0.00
C1878 9 MATRL FOR VOCAL CORD $0.00
C1879 O TISSUE MARKER, IMPLANTABLE $0.00
C1880 9 VENA CAVA FILTER $0.00
C1881 9 DIALYSIS ACCESS SYSTEM $0.00
C1882 9 AICD, OTHER THAN SING/DUAL $0.00
C1883 9 ADAPT/EXT, PACING/NEURO LEAD $0.00
C1884 9 EMBOLIZATION PROTECT SYST $0.00
C1885 9 CATH, TRANSLUMIN ANGIO LASER $0.00
C1887 9 CATHETER, GUIDING $0.00
C1888 9 ENDOVAS NON-CARDIAC ABL CATH $0.00

C1891 9 INFUSION PUMP,NON-PROG, PERM $0.00
C1892 9 INTRO/SHEATH,FIXED,PEEL-AWAY $0.00
C1893 9 INTRO/SHEATH, FIXED,NON-PEEL $0.00
C1894 9 INTRO/SHEATH, NON-LASER $0.00
C1895 9 LEAD, AICD, ENDO DUAL COIL $0.00
C1896 9 LEAD, AICD, NON SING/DUAL $0.00
C1897 9 LEAD, NEUROSTIM TEST KIT $0.00
C1898 9 LEAD, PMKR, OTHER THAN TRANS $0.00
C1899 9 LEAD, PMKR/AICD COMBINATION $0.00
C1900 9 LEAD, CORONARY VENOUS $0.00

C1925 9 INJECTION, RISPERIDONE $0.00
C1929 9 MAVERICK PTCA CATH $0.00
C1930 9 COYOTE DIL CATH, 20/30/40MM $0.00
C1931 9 TALON DIL CATH $0.00
C1932 9 SCIMED REMEDY DIL CATH $0.00
C1933 9 OPTI-PLAST XL/CENTURION CATH $0.00
C1934 9 ULTRAVERSE 3.5F BAL DIL CATH $0.00
C1935 9 WORKHORSE PTA BAL CATH $0.00
C1936 9 UROMAX ULTRA BAL DIL CATH $0.00
C1937 9 SYNERGY/EXPLORER CATH $0.00
C1938 9 UROFORCE BAL DIL CATH $0.00
C1939 9 RAPTUR, NINJA PTCA DIL CATH $0.00
C1940 9 POWERFLEX,OPTA 5/LP BAL CATH $0.00

C1941 9 JUPITER PTA DIL CATH $0.00
C1942 9 CORDIS MAXI LD PTA BAL CATH $0.00
C1943 9 RXCROSSSAIL OTW OPENSAIL $0.00
C1944 9 RAPID EXCHANGE BIL DIL CATH $0.00
C1945 9 SAVVY PTA DIL CATH $0.00
C1946 9 R1S RAPID DIL CATH $0.00
C1947 9 GAZELLE BAL DIL CATH $0.00
C1948 9 ORACLE MEGASONICS CATH $0.00
C1949 9 ORACLE MEGASONICS CATH $0.00
C1979 9 VISIONS PV/AVANAR US CATH $0.00
C1980 9 ATLANTIS SR CORONARY CATH $0.00
C1981 9 PTCA CATHETERS $0.00

C2000 9 ORBITER ST STEERABLE CATH $0.00
C2001 9 CONSTELLATION DIAG CATH $0.00
C2002 9 IRVINE 5F INQUIRY EP CATH $0.00
C2003 9 IRVINE 6F INQUIRY EP CATH $0.00
C2004 9 EP CATH--OCTAPOLAR $0.00
C2005 9 EP TIP CATH--HEXAPOLAR $0.00
C2006 9 EP CATH--DECAPOLAR $0.00
C2007 9 IRVINE 6F LUMA-CATH EP CATH $0.00
C2008 9 LUMA-CATH EP CATH 81910-15 $0.00
C2009 9 IRVINE 7F LUMA-CATH EP CATH $0.00

C2010 9 FIXED CURVE EP CATH $0.00
C2011 9 DEFLECTABLE TIP CATH--QUAD $0.00
C2012 9 CELSIUS ABLN CATH $0.00
C2013 9 CELSIUS LARGE ABLN CATH $0.00
C2014 9 CELSIUS II ASYM ABLN CATH $0.00
C2015 9 CELSIUS II SYM ABLN CATH $0.00
C2016 9 NAVI-STAR DS, NAVI-STAR THER $0.00
C2017 9 NAVI-STAR ABLN CATH $0.00
C2018 9 POLARIS T ABLATION CATH $0.00
C2019 9 EP DEFLECTABLE CATH $0.00
C2020 9 BLAZER II XP ABLN CATH $0.00
C2021 9 SILVERFLEX EP CATH $0.00
C2022 9 CP CHILLI COOLED ABLN CATH $0.00

C2023 9 CHILLI CLD ABLNCATH-STD,LG $0.00
C2100 9 CP CS REFERENCE CATH $0.00
C2101 9 CP RV REFERENCE CATH $0.00
C2102 9 CP RADII 7F EP CATH $0.00
C2103 9 CP RADII 7F EP CATH W/TRACK $0.00
C2104 9 LASSO DEFLECTABLE CATH $0.00
C2151 9 VERIPATH GUIDING CATH $0.00
C2152 9 CORDIS VISTA BRITE TIP CATH $0.00
C2153 9 BARD VIKING CATH $0.00
C2200 9 ARROW-TREROTOLA PTD CATH $0.00
C2300 9 VARISOURCE STND CATH $0.00
C2597 9 CLINICATH 16/18 SGL/DBL $0.00

C2598 9 CLINICATH 18/20/24G--SINGLE $0.00
C2599 9 CLINICATH 16/18 DOUBLE $0.00
C2600 9 GOLD PROBE CATHETER $0.00
C2601 9 BARD DL URETERAL CATH $0.00
C2602 9 VITESSE LASER CATH 1.4/1.7MM $0.00
C2603 9 VITESSE LASER CATH 2.0MM $0.00
C2604 9 VITESSE E LASER CATH 2.0MM $0.00
C2605 9 EXTREME LASER CATH $0.00
C2606 9 SPINECATH XL CATHETER $0.00
C2607 9 SPINECATH INTRADISCAL CATH $0.00

C2608 9 SCIMED 6F WISEGUIDE CATHETER $0.00
C2609 9 FLEXIMA BIL DRAINAGE CATH $0.00
C2610 9 FLEXTIPPLUS INTRASPINAL CATH $0.00
C2611 9 ALGOLINE INTRASPINAL CATH $0.00
C2612 9 INDURA CATHETER $0.00
C2614 9 PROBE, PERC LUMB DISC $0.00
C2615 9 SEALANT, PULMONARY, LIQUID $0.00
C2616 9 BRACHYTX, NON-STR,YTTRIUM-90 $0.00
C2617 9 STENT, NON-COR, TEM W/O DEL $0.00
C2618 9 PROBE, CRYOABLATION $0.00
C2619 9 PMKR, DUAL, NON RATE-RESP $0.00
C2620 9 PMKR, SINGLE, NON RATE-RESP $0.00
C2621 9 PMKR, OTHER THAN SING/DUAL $0.00

C2622 9 PROSTHESIS, PENILE, NON-INF $0.00
C2625 9 STENT, NON-COR, TEM W/DEL SY $0.00
C2626 9 INFUSION PUMP, NON-PROG,TEMP $0.00
C2627 9 CATH, SUPRAPUBIC/CYSTOSCOPIC $0.00
C2628 9 CATHETER, OCCLUSION $0.00
C2629 9 INTRO/SHEATH, LASER $0.00
C2630 9 CATH, EP, COOL-TIP $0.00
C2631 9 REP DEV, URINARY, W/O SLING $0.00
C2632 O BRACHYTX SOL, I-125, PER MCI $0.00
C2633 O BRACHYTX SOURCE, CESIUM-131 $0.00
C2634 9 BRACHYTX, NON-STR, HA, I-125 $0.00
C2635 9 BRACHYTX, NON-STR, HA, P-103 $0.00

C2636 9 BRACHY LINEAR, NON-STR,P-103 $0.00
C2637 9 BRACHY,NON-STR,YTTERBIUM-169 $0.00
C2638 9 BRACHYTX, STRANDED, I-125 $0.00
C2639 9 BRACHYTX, NON-STRANDED,I-125 $0.00
C2640 9 BRACHYTX, STRANDED, P-103 $0.00
C2641 9 BRACHYTX, NON-STRANDED,P-103 $0.00
C2642 9 BRACHYTX, STRANDED, C-131 $0.00
C2643 9 BRACHYTX, NON-STRANDED,C-131 $0.00
C2676 9 RSPONSE CV CATHETER $0.00
C2698 9 BRACHYTX, STRANDED, NOS $0.00

C2699 9 BRACHYTX, NON-STRANDED, NOS $0.00
C2700 9 MYCROPHYLAX PLUS SC DEFIB $0.00
C2701 9 PHYLAX XM SC DEFIB $0.00
C2702 9 VENTAK PRIZM 2 VR DEFIB $0.00
C2703 9 VENTAK PRIZM VR HE DEFIB $0.00
C2704 9 VENTAK MINI IV+ DEFIB $0.00
C2801 9 DEFENDER IV DR 612 DC DEFIB $0.00
C2802 9 PHYLAX AV $0.00
C2803 9 VENTAK PRIZM DR HE DEFIB $0.00
C2804 9 VENTAK PRIZM 2 DR DEFIB $0.00
C2805 9 JEWEL AF 7250 DEFIB $0.00
C2806 9 GEM VR 7227 DEFIB $0.00
C2807 9 CONTAK CD 1823 $0.00

C2808 9 CONTAK TR 1241 $0.00
C3001 9 KAINOX SL/RV DEFIB LEAD $0.00
C3002 9 EASYTRAK DEFIB LEAD $0.00
C3003 9 ENDOTAK SQ ARAY XP LEAD $0.00
C3004 9 INTERVENE DEFIB LEAD $0.00
C3400 9 SILTEX SPECTRUM,CONTOUR PROF $0.00
C3401 9 SALINE-FILLED SPECTRUM $0.00
C3500 9 ALPHA I INF PRO $0.00
C3510 9 AMS 800 URINARY PROS $0.00
C3551 9 CHOICE/PT GRAPHIX/LUGE/TROOP $0.00
C3552 9 HI-TORQUE WHISPER $0.00
C3553 9 CORDIS GUIDEWIRES $0.00

C3554 9 JINDO GUIDEWIRE $0.00
C3555 9 WHOLEY HI-TORQUE PLUS GW $0.00
C3556 9 WAVE/FLOWWIRE GUIDEWIRE $0.00
C3557 9 HYTEK GUIDEWIRE $0.00
C3800 9 SYNCHROMED EL INFUSION PUMP $0.00
C3801 9 ARROW/MICROJECT PCA SYS $0.00
C3851 9 ELASTIC UV IOLAA-4203T/TF/TL $0.00
C4000 9 OPUS G 4621, 4624 SC PMKR $0.00
C4001 9 OPUS S 4121/4124 SC PMKR $0.00
C4002 9 TALENT 113 SC PMKR $0.00

C4003 9 KAIROS SR SC PMKR $0.00
C4004 9 ACTROS SR, ACTROSSR-B SC PMK $0.00
C4005 9 PHILOS SR/SR-B SC PMKR $0.00
C4006 9 PULSAR MAX II SR PMKR $0.00
C4007 9 MARATHON SR PMKR $0.00
C4008 9 DISCOVERY II SSI PMKR $0.00
C4009 9 DISCOVERY II SR PMKR $0.00
C4300 9 INTEGRITY AFX DR 5342 PMKR $0.00
C4301 9 INTEGRITY AFX DR 5346 PMKR $0.00
C4302 9 AFFINITY VDR 5430 PMKR $0.00
C4303 9 BRIO 112 DC PMKR $0.00
C4304 9 BRIO212,TALENT213/223DCPMKR $0.00
C4305 9 BRIO 222 DC PMKR $0.00

C4306 9 BRIO 220 DC PMKR $0.00
C4307 9 KAIROS DR DC PMKR $0.00
C4308 9 INOS2, INOS2+ DC PMKR $0.00
C4309 9 ACTROS DR,D,DR-A,SLR DC PMKR $0.00
C4310 9 ACTROS DR-B DC PMKR $0.00
C4311 9 PHILOS DR/DR-B/SLR DC PMKR $0.00
C4312 9 PULSAR MAX II DR PMKR $0.00
C4313 9 MARATHON DR PMKR $0.00
C4314 9 MOMENTUM DR PMKR $0.00
C4315 9 SELECTION AFM PMKR $0.00
C4316 9 DISCOVERY II DR $0.00
C4317 9 DISCOVERY II DDD $0.00

C4600 9 SYNOX,POLYROX,ELOX,RETROX $0.00
C4601 9 AESCULA LV PMKR LEAD $0.00
C4602 9 TENDRIL SDX, 1488K PMKR LEAD $0.00
C4603 9 OSCOR PR/FLEXION PMKR LEAD $0.00
C4604 9 CRYSTALLINEACTFIX,CAPSUREFIX $0.00
C4605 9 CAPSURE EPI PMKR LEAD $0.00
C4606 9 FLEXTEND PMKR LEAD $0.00
C4607 9 FINELINEII/EZ, THINLINEII/EZ $0.00
C5000 9 BX VELOCITY W/HEPACOAT $0.00
C5001 9 MEMOTHERM BIL STENT, SM, MED $0.00

C5002 9 MEMOTHERM BIL STENT, LARGE $0.00
C5003 9 MEMOTHERM BIL STENT, X-LARGE $0.00
C5004 9 PALMAZCORINTHIAN IQ BIL STNT $0.00
C5005 9 PALMAZCORINTHIAN IQ TRANS/BI $0.00
C5006 9 PALMAZTRANS BIL STENTSYS-MED $0.00
C5007 9 PALMAZTRANS XL BIL ST-40MM $0.00
C5008 9 PALMAZTRANS XL BIL ST-50MM $0.00
C5009 9 VISTAFLEX BILIARY STENT $0.00
C5010 9 RAPID EXCHANGE BIL STENT SYS $0.00
C5011 9 INTRASTENT, INTRASTENT LP $0.00
C5012 9 INTRASTENT DOUBLESTRUT LD $0.00
C5013 9 INTRASTENT DOUBLESTRUT, XS $0.00
C5014 9 AVE BRIDGE STENTSYS10/17/28 $0.00

C5015 9 AVE/X3 BRIDGE SYS, 40-100 $0.00
C5016 9 BILIARY STENT SINGLE USE COV $0.00
C5017 9 WALLSTENTRP-BIL-20/40/60/68 $0.00
C5018 9 WALLSTENTRP BIL--80/94MM $0.00
C5019 9 FLEXIMA BIL STENT SYS $0.00
C5020 9 SMART NITINOL STENT--20MM $0.00
C5021 9 SMART NITINOL STENT--40/60MM $0.00
C5022 9 SMART NITINOL STENT--80MM $0.00
C5023 9 BX VELOCITY STENT--8/13MM $0.00
C5024 9 BX VELOCITY STENT $0.00
C5025 9 BX VELOCITY STENT--23MM $0.00
C5026 9 BX VELOCITY STENT--28/33MM $0.00

C5027 9 BX VELOCITY W/HEP--8/13MM $0.00
C5028 9 BX VELOCITY W/HEP--18MM $0.00
C5029 9 BX VELOCITY W/HEP--23MM $0.00
C5030 9 STENT, CORONARY, S660 9/12MM $0.00
C5031 9 STENT, CORONARY, S660 15/18 $0.00
C5032 9 STENT,CORONARY, S660 24/30 $0.00
C5033 9 NIROYAL STNT SYS, 9MM $0.00
C5034 9 NIROYAL STENT SYS, 12/15MM $0.00
C5035 9 NIROYAL STENT SYS, 18MM $0.00

C5038 9 BX VELOCITY STNT W/RAPTOR $0.00
C5039 9 INTRACOIL PERIP STENT--40MM $0.00
C5040 9 INTRACOIL PERIPH STENT--60MM $0.00
C5041 9 BESTENT OVER-THE-WIRE24/30MM $0.00
C5042 9 BESTENT OVER-THE-WIRE 18MM $0.00
C5043 9 BESTENT OVER-THE-WIRE 15MM $0.00
C5044 9 BESTENT OVER-THE-WIRE 9/12MM $0.00
C5045 9 MULTILINK TETRA COR STENT SY $0.00
C5046 9 RADIUS 20MM COR STENT $0.00
C5047 9 NIROYAL ELITE COR STENT SYS $0.00
C5048 9 GR II CORONARY STENT $0.00
C5130 9 WILSON-COOK Z-STENT $0.00

C5131 9 BARD COLORECTAL STENT--60MM $0.00
C5132 9 BARD COLORECTAL STENT--80MM $0.00
C5133 9 BARD COLORECTAL STENT-100MM $0.00
C5134 9 ENTERAL WALLSTENT--90MM $0.00
C5279 9 CONTOUR/PERCUFLEX STENT $0.00
C5280 9 INLAY DBL URETERAL STENT $0.00
C5281 9 WALLGRAFT TRACH SYS 70MM $0.00
C5282 9 WALLGRAFT TRACH SYS 20/30/50 $0.00
C5283 9 WALLSTENT/RP TIPS--80MM $0.00
C5284 9 WALLSTENT TRACHULTRAFLEX $0.00
C5600 9 CLOSURE DEV, VASOSEAL ES $0.00
C5601 9 VASOSEAL 1000 $0.00

C6001 9 COMPOSIX MESH 8/18 IN $0.00
C6002 9 COMPOSIX MESH 32 IN $0.00
C6012 9 PELVICOL COLLAGEN 8/14 SQ CM $0.00
C6013 9 PELVICOL COLLAGEN 21/24/28 $0.00
C6014 9 PELVICOL COLLAGEN 40 SQ CM $0.00

C6017 9 GORE-TEX DUALMESH 75/96 SQCM $0.00
C6018 9 GORE-TEX DUALMESH 150SQCM $0.00
C6019 9 GORE-TEX DUALMESH 285 SQCM $0.00
C6020 9 GORE-TEX DUALMESH 432SQCM $0.00
C6023 9 GORE-TEXPLUS 1MM,75/96 SQCM $0.00
C6024 9 GORE-TEXPLUS 1MM, 150 SQ CM $0.00
C6026 9 GORE-TEXPLUS 1MM, 432 SQCM $0.00
C6027 9 GORE-TEXPLUS 1MM, 600 SQCM $0.00
C6028 9 GORE-TEXPLUS 1MM,884 SQ CM $0.00

C6033 9 GORE-TEXPLUS 2MM,884 SQ CM $0.00
C6034 9 BARD EPTFE: 150 SQ CM-2MM $0.00
C6035 9 BARD EPTFE150SQCM-1MM,75-2MM $0.00
C6036 9 BARD EPTFE: 50/75SQCM-1,2MM $0.00
C6037 9 BARD EPFTE: 300SQ CM-1MM $0.00
C6038 9 BARD EPTFE: 600SQ CM-1MM $0.00
C6039 9 BARD EPTFE: 884 CM--1MM $0.00

C6050 9 FEMALE SLING SYS W/WO MATRL $0.00
C6051 9 STRATASIS SLING, 20/40CM $0.00
C6052 9 STRATASIS SLING, 60CM $0.00
C6053 9 SURGISIS SOFT GRAFT $0.00
C6054 9 SURGISIS ENCHANCED GRAFT $0.00
C6055 9 SURGISIS ENHANCED TISSUE $0.00
C6056 9 SURGISIS SOFT TISSUE GRAFT $0.00
C6057 9 SURGISIS HERNIA GRAFT $0.00
C6058 9 SURGIPRO HERNIA PLUG,MED/LG $0.00

C6080 9 MALE SLING SYS W/WO MATRL $0.00
C6200 9 EXXCEL SFT EPTFE VAS GRAFT $0.00
C6201 9 IMPRA VENAFLO-10/20CM $0.00
C6202 9 IMPRA VENAFLO-30/40CM $0.00
C6203 9 IMPRA VENAFLO-50CM/VT45 $0.00
C6204 9 IMPRA VENAFLO-STEPPED $0.00
C6205 9 IMPRA CARBOFLO-10CM $0.00
C6206 9 IMPRA CARBOFLO-20CM $0.00
C6207 9 IMPRA CARBOFLO-30/34/40CM $0.00
C6208 9 IMPRA CARBOFLO-40/50CM $0.00
C6209 9 IMPRA CARBOFLO-CTRFLEX $0.00
C6210 9 EXXCEL EPTFE VAS GRAFT $0.00
C6300 9 VANGUARD III ENDOVAS GRAFT $0.00

C6500 9 PREFACE GUIDING SHEATH $0.00
C6501 9 SOFT TIP SHEATHS $0.00
C6525 9 SPECTRANETICS LASER SHEATH $0.00
C6600 9 MICRO LITHO FLEX PROBES $0.00
C6650 9 FAST-CATH GUIDING INTRODUCER $0.00
C6651 9 SEAL-AWAYGUIDING INTRODUCER $0.00
C6652 9 BARD EXCALIBUR INTRODUCER $0.00
C6700 9 FOCAL SEAL-L $0.00
C8099 9 SPECTRANETICS LEAD LOCK DEV $0.00
C8100 9 ADHESION BARRIER, ADCON-L $0.00
C8102 9 SURGIVISION ESOPH COIL $0.00
C8103 9 CAPIO CAPTURING DEV $0.00

C8500 9 ATHEROCATH-GTO $0.00
C8501 9 VIGOR SSI, SC, PMKR $0.00
C8502 9 LIVEWIRE STEERABLE EP CATH $0.00
C8503 9 SYNCHROMED VAS CATH $0.00
C8504 9 VASOSEAL HEMOSTASIS DEV $0.00
C8505 9 SYNCHROMED INFUSION PUMP $0.00
C8506 9 PMKR LEADS 4057M,4058M $0.00
C8507 9 6721L/M/S,6939 LEAD $0.00
C8508 9 CAPSURE 4965 DEFIB LEAD $0.00
C8509 9 TRANSVENE 6933/6937 LEAD $0.00

C8510 9 DP-3238 DEFIB LEAD $0.00
C8511 9 ENDOTAK DSP DEFIB LEAD $0.00
C8512 9 ON-POINT,PISCES-QUAD LEAD $0.00
C8513 9 PISCES,RESUME II LEAD $0.00
C8514 9 DURA II PENILE PROSTHESIS $0.00
C8516 9 MENTOR ACU-FORM/MAL PROS $0.00
C8518 9 VIGOR DDD DC PMKR $0.00
C8519 9 VISTA DDD C PMKR $0.00
C8520 9 LEGACY II S, SC, PMKR $0.00
C8521 9 MEDTRONIC MATTRIX RCVR/TRMR $0.00
C8522 9 PALMAZ BAL STENT $0.00
C8523 9 WALLSTENT TRANS BIL $0.00
C8524 9 WALLSTENT ESOP $0.00

C8525 9 WALLSTENT ESOPH--DOUBLE $0.00
C8526 9 OPTIPLAST XT PTA CATH $0.00
C8528 9 MS CLASSIQUE BL DIL CATH $0.00
C8529 9 CRISTA CATH II DEF 20-POLE $0.00
C8530 9 GEL-FILLED/SMOOTH MAMMARY PR $0.00
C8531 9 WILSON-COOK ESOPH Z-STENT $0.00
C8532 9 ULTRAFLEX ESOPHAGEAL PROS $0.00
C8533 9 SYNCHROMED VAS CATH 8700A/V $0.00
C8534 9 AMS 650 PENILE PROSTHESIS $0.00
C8535 9 ZA/SPIRAL Z BIL STENT $0.00
C8536 9 ESOPH Z METAL STENT $0.00
C8539 9 QUANTUM DIL BALLOON $0.00

C8540 9 FLEX-EZ BAL DILATOR $0.00
C8541 9 CARSON/PASSPRT DIL CATH $0.00
C8542 9 URETHRAMAX DIL CATH $0.00
C8543 9 AMPLATZ RENAL DIL $0.00
C8550 9 LIVEWIRE 5F, 7F EP CATH $0.00
C8551 9 LIVEWIRE 7F DUO-DECAPOLAR $0.00
C8552 9 SANTURO FIXED CURVE CATH $0.00
C8597 9 WISDOM ST GUIDEWIRE $0.00
C8598 9 SV GUIDEWIRE-5/8/14CM $0.00
C8599 9 STABILIZER XS GUIDEWIRE $0.00

C8600 9 SHINOBI PLUS GUIDEWIRE $0.00
C8650 9 XL CHECK-FLO INTRODUCER $0.00
C8724 9 OCTAD NEURO LEAD $0.00
C8725 9 SYMMIX NEURO LEAD $0.00
C8748 9 ENDOTAK SQ PATCH DEFIB LEAD $0.00
C8749 9 ENDOTAK SQ ARRAY DEFIB LEAD $0.00
C8750 9 UNITY VDDR DC PMKR $0.00
C8775 9 2188 COR PMKR LEAD $0.00
C8776 9 INNOMEDICA PMKR LEAD $0.00
C8777 9 UNIPASS PMKR LEAD $0.00
C8800 9 LG PALMAZ BIL STENT $0.00
C8801 9 GIANTURCO BIL Z STENT $0.00
C8802 9 OASIS STENT INTRO SYS $0.00

C8830 9 GIANTURCO-ROUBIN COR SNT $0.00
C8890 9 PERFLUORON, 2ML $0.00
C8891 9 PERFLUORON, 5/7ML $0.00
C8900 9 MRA W/CONT, ABD $0.00
C8901 9 MRA W/O CONT, ABD $0.00
C8902 9 MRA W/O FOL W/CONT, ABD $0.00
C8903 9 MRI W/CONT, BREAST, UNI $0.00
C8904 9 MRI W/O CONT, BREAST, UNI $0.00
C8905 9 MRI W/O FOL W/CONT, BRST, UN $0.00
C8906 9 MRI W/CONT, BREAST, BI $0.00
C8907 9 MRI W/O CONT, BREAST, BI $0.00
C8908 9 MRI W/O FOL W/CONT, BREAST, $0.00

C8909 9 MRA W/CONT, CHEST $0.00
C8910 9 MRA W/O CONT, CHEST $0.00
C8911 9 MRA W/O FOL W/CONT, CHEST $0.00
C8912 9 MRA W/CONT, LWR EXT $0.00
C8913 9 MRA W/O CONT, LWR EXT $0.00
C8914 9 MRA W/O FOL W/CONT, LWR EXT $0.00
C8918 9 MRA W/CONT, PELVIS $0.00
C8919 9 MRA W/O CONT, PELVIS $0.00
C8920 9 MRA W/O FOL W/CONT, PELVIS $0.00
C8921 9 TTE W OR W/O FOL W/CONT, COM $0.00

C8922 9 TTE W OR W/O FOL W/CONT, F/U $0.00
C8923 9 2D TTE W OR W/O FOL W/CON,CO $0.00
C8924 9 2D TTE W OR W/O FOL W/CON,FU $0.00
C8925 9 2D TEE W OR W/O FOL W/CON,IN $0.00
C8926 9 TEE W OR W/O FOL W/CONT,CONG $0.00
C8927 9 TEE W OR W/O FOL W/CONT, MON $0.00
C8928 9 TTE W OR W/O FOL W/CON,STRES $0.00
C8929 9 TTE W OR WO FOL WCON,DOPPLER $0.00
C8930 9 TTE W OR W/O CONTR, CONT ECG $0.00
C8950 O INTRAVENOUS INFUSION FOR THERAPY/ $0.00
C8951 O INTRAVENOUS INFUSION FOR THERAPY/ $0.00
C8952 O THERAPEUTIC, PROPHYLACTIC OR DIAGN $0.00
C8953 O CHEMOTHERAPY ADMINISTRATION, INTRA $0.00

C8956 9 REFILLING AND MAINTENANCE OF PORTA $0.00
C8957 9 INTRAVENOUS INFUSION FOR THERAPY/ $0.00
C9000 O NA CHROMATECR51, PER 0.25MCI $0.00
C9001 9 LINEZOLID INJ, 200MG $0.00
C9002 9 TENECTEPLASE, 50MG/VIAL $0.00
C9003 O PALIVIZUMAB, PER 50 MG $0.00
C9004 9 GEMTUZUMAB OZOGAMICIN INJ,5M $0.00
C9005 9 RETEPLASE INJ, HALF-KIT,18.8 $0.00
C9006 9 TACROLIMUS INJ, PER 5 MG $0.00
C9007 O BACLOFEN INTRATHECAL KIT-1AM $0.00

C9008 O BACLOFEN REFILL KIT-500MCG $0.00
C9009 O BACLOFEN REFILL KIT-2000MCG $0.00
C9010 O BACLOFEN REFILL KIT--4000MCG $0.00
C9011 9 CAFFEINE CITRATE, INJ, 1ML $0.00
C9013 O CO 57 COBALTOUS CHLORIDE $0.00
C9019 9 CASPOFUNGIN ACETATE, 5 MG $0.00
C9020 9 SIROLIMUS TABLET, 1 MG $0.00
C9100 9 IODINATED I-131 ALBUMIN $0.00
C9102 O 51 NA CHROMATE, 50MCI $0.00
C9103 O NA IOTHALAMATE I-125, 10 UCI $0.00

C9104 9 ANTI-THYMOCYTE GLOBULIN,25MG $0.00
C9105 O HEP B IMM GLOB, PER 1 ML $0.00
C9106 9 SIROLIMUS 1MG/ML $0.00
C9107 9 TINZAPARIN SODIUM, 2ML VIAL $0.00
C9108 9 THYROTROPIN ALFA, 1.1 MG $0.00
C9109 O TIROFIBAN HCL, 6.25 MG $0.00
C9110 9 ALEMTUZUMAB, PER 10MG/ML $0.00
C9111 O INJ, BIVALIRUDIN, 250MG VIAL $0.00
C9112 O PERFLUTREN LIPID MICRO, 2ML $0.00
C9113 9 INJ PANTOPRAZOLE SODIUM, VIA $0.00
C9114 9 NESIRITIDE, PER 1.5 MG VIAL $0.00
C9115 9 INJ, ZOLEDRONIC ACID, 2 MG $0.00
C9116 O ERTAPENEM SODIUM, PER 1 GM $0.00

C9119 O INJECTION, PEGFILGRASTIM $0.00
C9120 O INJECTION, FULVESTRANT $0.00
C9121 9 INJECTION, ARGATROBAN $0.00
C9123 O TRANSCYTE, PER 247 SQ CM $0.00
C9124 O INJECTION, DAPTOMYCIN $0.00
C9125 O INJECTION, RISPERIDONE $0.00
C9126 O INJECTION, NATALIZUMAB $0.00
C9200 O ORCEL, PER 36 CM2 $0.00
C9201 O DERMAGRAFT, PER 37.5 SQ CM $0.00
C9202 O OCTAFLUOROPROPANE $0.00
C9203 O PERFLEXANE LIPID MICRO $0.00
C9205 O OXALIPLATIN $0.00

C9206 O INTEGRA, PER CM2 $0.00
C9207 O INJECTION, BORTEZOMIB $0.00
C9208 O INJECTION, AGALSIDASE BETA $0.00
C9209 O INJECTION, LARONIDASE $0.00
C9210 O INJECTION, PALONOSETRON HCL $0.00
C9211 O INJ, ALEFACEPT, IV $0.00
C9212 O INJ, ALEFACEPT, IM $0.00
C9213 O INJECTION, PEMETREXED $0.00
C9214 O INJECTION, BEVACIZUMAB $0.00
C9215 O INJECTION, CETUXIMAB $0.00

C9216 O ABARELIX, INJECT SUSPENSION $0.00
C9217 O INJECTION, OMALIZUMAB $0.00
C9218 O INJECTION, AZACITIDINE $0.00
C9220 O SODIUM HYALURONATE $0.00
C9221 O GRAFTJACKET REG MATRIX $0.00
C9222 O GRAFTJACKET SFTTIS $0.00
C9224 O INJECTION, GALSULFASE $0.00
C9225 O FLUOCINOLONE ACETONIDE $0.00
C9227 O INJECTION, MICAFUNGIN SODIUM, PER $0.00
C9228 O INJECTION, TIGECYCLINE, PER 1 MG $0.00
C9229 O INJECTION, IBANDRONATE SODIUM, PER $0.00
C9230 O INJECTION, ABATACEPT, PER 10 MG $0.00
C9231 O INJECTION, DECITABINE, PER 1 MG $0.00

C9232 O INJECTION, IDURSULFASE $0.00
C9233 O INJECTION, RANIBIZUMAB $0.00
C9234 O INJ, ALGLUCOSIDASE ALFA $0.00
C9235 O INJECTION, PANITUMUMAB $0.00
C9238 O INJ, LEVETIRACETAM $0.00
C9239 O INJ, TEMSIROLIMUS $0.00
C9241 O INJ DORIPENEM 10 MG $0.00
C9245 9 INJECTION, ROMIPLOSTIM $0.00
C9246 9 INJ, GADOXETATE DISODIUM $0.00
C9247 9 INJ, IOBENGUANE, I-123, DX $0.00
C9248 9 INJ, CLEVIDIPINE BUTYRATE $0.00
C9350 O POROUS COLLAGEN TUBE PER CM $0.00

C9351 O ACELLULAR DERM TISSUE PERCM2 $0.00
C9352 9 NEURAGEN NERVE GUIDE, PER CM $0.00
C9353 9 NEURAWRAP NERVE PROTECTOR,CM $0.00
C9356 9 TENOGLIDE TENDON PROT, CM2 $0.00
C9358 9 SURGIMEND, 0.5CM2 $0.00
C9359 9 IMPLANT, BONE VOID FILLER $0.00
C9399 9 UNCLASSIFIED DRUGS OR BIOLOGICALS $0.00
C9400 O THALLOUS CHLORIDE, BRAND $0.00
C9401 O STRONTIUM-89 CHLORIDE,BRAND $0.00
C9402 O TH I131 SO IODIDE CAP, BRAND $0.00

C9403 O DX I131 SO IODIDE CAP, BRAND $0.00
C9404 O DX I131 SO IODIDE SOL, BRAND $0.00
C9405 O TH I131 SO IODIDE SOL, BRAND $0.00
C9408 9 FDG, BRAND, PER DOSE $0.00
C9410 O DEXRAZOXANE HCL INJ, BRAND $0.00
C9411 O PAMIDRONATE DISODIUM, BRAND $0.00
C9412 O GANCICLOVIR IMPLANT, BRAND $0.00
C9413 O SODIUM HYALURONATE INJ, BRAND $0.00
C9414 O ETOPOSIDE ORAL, BRAND $0.00
C9415 O DOXORUBIC HCL CHEMO, BRAND $0.00
C9416 9 BCG LIVE INTRAVESICAL, BRAND $0.00
C9417 O BLEOMYCIN SULFATE INJ, BRAND $0.00
C9418 O CISPLATIN INJ, BRAND $0.00

C9419 O INJ CLADRIBINE, BRAND $0.00
C9420 O CYCLOPHOSPHAMIDE INJ, BRAND $0.00
C9421 O CYCLOPHOSPHAMIDE LYO, BRAND $0.00
C9422 O CYTARABINE HCL INJ, BRAND $0.00
C9423 O DACARBAZINE INJ, BRAND $0.00
C9424 O DAUNORUBICIN, BRAND $0.00
C9425 O ETOPOSIDE INJ, BRAND $0.00
C9426 O FLOXURIDINE INJ, BRAND $0.00
C9427 O IFOSFOMIDE INJ, BRAND $0.00
C9428 O MESNA INJECTION, BRAND $0.00
C9429 O IDARUBICIN HCL INJ, BRAND $0.00
C9430 O LEUPROLIDE ACETATE INJ, BRAN $0.00

C9431 O PACLITAXEL INJ, BRAND $0.00
C9432 O MITOMYCIN INJ, BRAND $0.00
C9433 O THIOTEPA INJ, BRAND $0.00
C9434 9 GALLIUM GA 67, BRAND $0.00
C9435 O GONADORELIN HYDROCH, BRAND $0.00
C9436 O AZATHIOPRINE PARENTERAL,BRND $0.00
C9437 O CARMUS BISCHL NITRO INJ $0.00
C9438 O CYCLOSPORINE ORAL, BRAND $0.00
C9439 O DIETHYLSTILBESTROL INJECTION $0.00
C9500 9 PLATELETS, IRRAD, EA UNIT $0.00

C9501 9 PLATELETS, PHERESIS, EA UNIT $0.00
C9502 9 PLATELETS, PHER/IRRAD, EA UN $0.00
C9503 O FRESH FROZEN PLASMA, EA UNIT $0.00
C9504 9 RBC, DEGLYCEROLIZED, EA UNIT $0.00
C9505 9 RBC, IRRADIATED, EACH UNIT $0.00
C9700 9 WATER INDUCED THERMO $0.00
C9701 O STRETTA SYSTEM $0.00
C9702 9 CHKMATE/NOVOST/GALILEO BRACH $0.00
C9703 O BARD ENDOSCOPIC SUTURING SYS $0.00
C9704 O INJ INERT SUBS UPPER GI $0.00
C9708 9 PREVIEW TX PLANNING SOFTWARE $0.00
C9711 O H.E.L.P. APHERESIS SYSTEM $0.00
C9712 O INSERT PH CAPSULE, GERD $0.00

C9713 O NON-CONTACT LASER VAP PROSTA $0.00
C9714 O BREAST INTERS RAD TX, IMMED $0.00
C9715 O BREAST INTERS RAD TX, DELAY $0.00
C9716 9 RADIOFREQUENCY ENERGY TO ANUS $0.00
C9718 O KYPHOPLASTY, FIRST VERTEBRA $0.00
C9719 O KYPHOPLASTY, EACH ADDL $0.00
C9720 O HE ESW TX, TENNIS ELBOW $0.00
C9721 O HE ESW TX, PLANTAR FASCIITIS $0.00
C9722 O KV IMAGING W/IR TRACKING $0.00
C9723 O DYN IR PERF IMG $0.00
C9724 9 EPS GAST CARDIA PLIC $0.00
C9725 9 PLACE ENDORECTAL APP $0.00

C9726 9 RXT BREAST APPL PLACE/REMOV $0.00
C9727 9 INSERT PALATE IMPLANTS $0.00
C9728 9 PLACE DEVICE/MARKER, NON PRO $0.00
C9898 9 INPNT STAY RADIOLABELED ITEM $0.00
C9899 9 INPT IMPLANT PROS DEV,NO COV $0.00
CEDCL O MCO SPECIFIC CODE: SMART START COM $0.00
CEDRV O MCO SPECIFIC CODE: SMART START CHI $0.00
D0110 O INITIAL ORAL EXAMINATION $0.00
D0120 1 PERIODIC ORAL EVALUATION $0.00
D0130 O EMERGENCY ORAL EXAMINATION $0.00

D0140 1 LIMIT ORAL EVAL PROBLM FOCUS $0.00
D0145 1 ORAL EVALUATION, PT < 3YRS $0.00
D0150 1 COMPREHENSVE ORAL EVALUATION $0.00
D0160 1 EXTENSV ORAL EVAL PROB FOCUS $0.00
D0170 1 RE-EVAL,EST PT,PROBLEM FOCUS $0.00
D0180 9 COMP PERIODONTAL EVALUATION $0.00
D0210 1 INTRAOR COMPLETE FILM SERIES $0.00
D0220 1 INTRAORAL PERIAPICAL FIRST F $0.00
D0230 1 INTRAORAL PERIAPICAL EA ADD $0.00
D0240 1 INTRAORAL OCCLUSAL FILM $0.00
D0250 1 EXTRAORAL FIRST FILM $0.00
D0260 1 EXTRAORAL EA ADDITIONAL FILM $0.00
D0270 1 DENTAL BITEWING SINGLE FILM $0.00

D0272 1 DENTAL BITEWINGS TWO FILMS $0.00
D0273 1 BITEWINGS - THREE FILMS $0.00
D0274 1 DENTAL BITEWINGS FOUR FILMS $0.00
D0275 9 BITEWINGS-EACH ADDITIONAL FILM $0.00
D0277 1 VERT BITEWINGS-SEV TO EIGHT $0.00
D0290 1 DENTAL FILM SKULL/FACIAL BON $0.00
D0310 1 DENTAL SALIOGRAPHY $0.00
D0320 1 DENTAL TMJ ARTHROGRAM INCL I $0.00
D0321 1 DENTAL OTHER TMJ FILMS $0.00
D0322 1 DENTAL TOMOGRAPHIC SURVEY $0.00
D0330 1 DENTAL PANORAMIC FILM $0.00
D0340 1 DENTAL CEPHALOMETRIC FILM $0.00

D0350 9 ORAL/FACIAL PHOTO IMAGES $0.00
D0360 1 CONE BEAM CT $0.00
D0362 1 CONE BEAM, TWO DIMENSIONAL $0.00
D0363 1 CONE BEAM, THREE DIMENSIONAL $0.00
D0410 9 BACTERIOLOGIC STUDIES FOR DETERMINA $0.00
D0415 9 COLLECTION OF MICROORGANISMS $0.00
D0416 9 VIRAL CULTURE $0.00
D0417 9 COLLECT & PREP SALIVA SAMPLE $0.00
D0418 9 ANALYSIS OF SALIVA SAMPLE $0.00
D0420 9 CARIES SUSCEPTIBILITY TESTS $0.00

D0421 9 GEN TST SUSCEPT ORAL DISEASE $0.00
D0425 9 CARRIES SUSCEPTIBILITY TESTS $0.00
D0431 9 DIAG TST DETECT MUCOS ABNORM $0.00
D0460 1 PULP VITALITY TEST $0.00
D0470 1 DIAGNOSTIC CASTS $0.00
D0471 9 DIAGNOSTIC PHOTOGRAPHS $0.00
D0472 1 GROSS EXAM, PREP & REPORT $0.00
D0473 1 MICRO EXAM, PREP & REPORT $0.00
D0474 1 MICRO W EXAM OF SURG MARGINS $0.00
D0475 9 DECALCIFICATION PROCEDURE $0.00
D0476 9 SPEC STAINS FOR MICROORGANIS $0.00
D0477 9 SPEC STAINS NOT FOR MICROORG $0.00
D0478 9 IMMUNOHISTOCHEMICAL STAINS $0.00

D0479 9 TISSUE IN-SITU HYBRIDIZATION $0.00
D0480 1 CYTOPATH SMEAR PREP & REPORT $0.00
D0481 9 ELECTRON MICROSCOPY DIAGNOST $0.00
D0482 9 DIRECT IMMUNOFLUORESCENCE $0.00
D0483 9 INDIRECT IMMUNOFLUORESCENCE $0.00
D0484 9 CONSULT SLIDES PREP ELSEWHER $0.00
D0485 9 CONSULT INC PREP OF SLIDES $0.00
D0486 9 ACCESSION OF BRUSH BIOPSY $0.00
D0501 O HISTOPATHOLOGIC EXAMINATIONS $0.00
D0502 1 OTHER ORAL PATHOLOGY PROCEDU $0.00
D0999 1 UNSPECIFIED DIAGNOSTIC PROCE $0.00
D1110 1 DENTAL PROPHYLAXIS ADULT $0.00

D1120 1 DENTAL PROPHYLAXIS CHILD $0.00
D1201 O TOPICAL FLUOR W PROPHY CHILD $0.00
D1202 9 TOPICAL APPLICATION OF FLUORIDE (IN $0.00
D1203 1 TOPICAL APP FLUORIDE CHILD $0.00
D1204 1 TOPICAL APP FLUORIDE ADULT $0.00
D1205 O TOPICAL FLUORIDE W/ PROPHY A $0.00
D1206 1 TOPICAL FLUORIDE VARNISH $0.00
D1310 9 NUTRI COUNSEL-CONTROL CARIES $0.00
D1320 1 TOBACCO COUNSELING $0.00
D1330 9 ORAL HYGIENE INSTRUCTION $0.00

D1351 1 DENTAL SEALANT PER TOOTH $0.00
D1510 1 SPACE MAINTAINER FXD UNILAT $0.00
D1515 1 FIXED BILAT SPACE MAINTAINER $0.00
D1520 1 REMOVE UNILAT SPACE MAINTAIN $0.00
D1525 1 REMOVE BILAT SPACE MAINTAIN $0.00
D1550 1 RECEMENT SPACE MAINTAINER $0.00
D1555 1 REMOVE FIX SPACE MAINTAINER $0.00
D2110 O AMALGAM ONE SURFACE PRIMARY $0.00
D2120 O AMALGAM TWO SURFACES PRIMARY $0.00
D2130 O AMALGAM THREE SURFACES PRIMA $0.00
D2131 O AMALGAM FOUR/MORE SURF PRIMA $0.00
D2140 1 AMALGAM ONE SURFACE PERMANEN $0.00
D2150 1 AMALGAM TWO SURFACES PERMANE $0.00

D2160 1 AMALGAM THREE SURFACES PERMA $0.00
D2161 1 AMALGAM 4 OR > SURFACES PERM $0.00
D2210 9 SILCATE CEMENT PER RESTORAT $0.00
D2330 1 RESIN ONE SURFACE-ANTERIOR $0.00
D2331 1 RESIN TWO SURFACES-ANTERIOR $0.00
D2332 1 RESIN THREE SURFACES-ANTERIO $0.00
D2335 1 RESIN 4/> SURF OR W INCIS AN $0.00
D2336 O COMPOSITE RESIN CROWN $0.00
D2337 O COMPO RESIN CROWN ANT-PERM $0.00
D2380 O RESIN ONE SURF POSTER PRIMAR $0.00
D2381 O RESIN TWO SURF POSTER PRIMAR $0.00
D2382 O RESIN THREE/MORE SURF POST P $0.00

D2385 O RESIN ONE SURF POSTER PERMAN $0.00
D2386 O RESIN TWO SURF POSTER PERMAN $0.00
D2387 O RESIN THREE/MORE SURF POST P $0.00
D2388 O RESIN FOUR/MORE, POST PERM $0.00
D2390 1 ANT RESIN-BASED CMPST CROWN $0.00
D2391 1 POST 1 SRFC RESINBASED CMPST $0.00
D2394 1 POST >=4SRFC RESINBASE CMPST $0.00
D2410 9 DENTAL GOLD FOIL ONE SURFACE $0.00

D2420 9 DENTAL GOLD FOIL TWO SURFACE $0.00
D2430 9 DENTAL GOLD FOIL THREE SURFA $0.00
D2510 9 DENTAL INLAY METALIC 1 SURF $0.00
D2520 9 DENTAL INLAY METALLIC 2 SURF $0.00
D2530 9 DENTAL INLAY METL 3/MORE SUR $0.00
D2540 O ONLAY-METALLIC-PER TOOTH (IN ADDITI $0.00
D2542 9 DENTAL ONLAY METALLIC 2 SURF $0.00
D2543 9 DENTAL ONLAY METALLIC 3 SURF $0.00
D2544 9 DENTAL ONLAY METL 4/MORE SUR $0.00
D2610 9 INLAY PORCELAIN/CERAMIC 1 SU $0.00
D2620 9 INLAY PORCELAIN/CERAMIC 2 SU $0.00
D2630 9 DENTAL ONLAY PORC 3/MORE SUR $0.00
D2642 9 DENTAL ONLAY PORCELIN 2 SURF $0.00

D2643 9 DENTAL ONLAY PORCELIN 3 SURF $0.00
D2644 9 DENTAL ONLAY PORC 4/MORE SUR $0.00
D2650 9 DENTAL INLAY RESIN ONE SURFACE $0.00
D2651 9 DENTAL INLAY RESIN 2 SURFACES $0.00
D2652 9 DENTAL INLAY RESIN 3 OR MORE SURFA $0.00
D2662 9 DENTAL ONLAY RESIN 2 SURFACE $0.00
D2663 9 DENTAL ONLAY RESIN 3 SURFACE $0.00
D2664 9 DENTAL ONLAY RESIN 4/MRE SUR $0.00
D2710 1 CROWN RESIN-BASED INDIRECT $0.00
D2712 1 CROWN 3/4 RESIN-BASED COMPOS $0.00
D2720 9 CROWN RESIN W/ HIGH NOBLE ME $0.00
D2721 1 CROWN RESIN W/ BASE METAL $0.00

D2722 1 CROWN RESIN W/ NOBLE METAL $0.00
D2740 9 CROWN PORCELAIN/CERAMIC SUBS $0.00
D2750 9 CROWN PORCELAIN W/ H NOBLE M $0.00
D2751 1 CROWN PORCELAIN FUSED BASE M $0.00
D2752 1 CROWN PORCELAIN W/ NOBLE MET $0.00
D2780 9 CROWN 3/4 CAST HI NOBLE MET $0.00
D2781 1 CROWN 3/4 CAST BASE METAL $0.00
D2782 1 CROWN 3/4 CAST NOBLE METAL $0.00
D2783 9 CROWN 3/4 PORCELAIN/CERAMIC $0.00
D2790 9 CROWN FULL CAST HIGH NOBLE M $0.00

D2791 1 CROWN FULL CAST BASE METAL $0.00
D2792 1 CROWN FULL CAST NOBLE METAL $0.00
D2794 9 CROWN-TITANIUM $0.00
D2799 1 PROVISIONAL CROWN $0.00
D2810 9 CROWN 3/4 CAST METALLIC $0.00
D2910 1 RECEMENT INLAY ONLAY OR PART $0.00
D2915 1 RECEMENT CAST OR PREFAB POST $0.00
D2920 1 DENTAL RECEMENT CROWN $0.00
D2930 1 PREFAB STNLSS STEEL CRWN PRI $0.00
D2931 1 PREFAB STNLSS STEEL CROWN PE $0.00
D2932 1 PREFABRICATED RESIN CROWN $0.00
D2933 1 PREFAB STAINLESS STEEL CROWN $0.00
D2934 1 PREFAB STEEL CROWN PRIMARY $0.00

D2940 1 DENTAL SEDATIVE FILLING $0.00
D2950 1 CORE BUILD-UP INCL ANY PINS $0.00
D2951 1 TOOTH PIN RETENTION $0.00
D2952 1 POST AND CORE CAST + CROWN $0.00
D2953 1 EACH ADDTNL CAST POST $0.00
D2954 1 PREFAB POST/CORE + CROWN $0.00
D2955 1 POST REMOVAL $0.00
D2957 1 EACH ADDTNL PREFAB POST $0.00
D2960 9 LAMINATE LABIAL VENEER $0.00
D2970 1 TEMPORARY- FRACTURED TOOTH $0.00

D2971 9 ADD PROC CONSTRUCT NEW CROWN $0.00
D2975 9 COPING $0.00
D2980 1 CROWN REPAIR $0.00
D2999 1 DENTAL UNSPEC RESTORATIVE PR $0.00
D3110 1 PULP CAP DIRECT $0.00
D3120 1 PULP CAP INDIRECT $0.00
D3220 1 THERAPEUTIC PULPOTOMY $0.00
D3221 1 GROSS PULPAL DEBRIDEMENT $0.00
D3222 1 PART PULP FOR APEXOGENESIS $0.00
D3230 1 PULPAL THERAPY ANTERIOR PRIM $0.00

D3240 1 PULPAL THERAPY POSTERIOR PRI $0.00
D3310 1 END THXPY, ANTERIOR TOOTH $0.00
D3320 1 END THXPY, BICUSPID TOOTH $0.00
D3330 1 END THXPY, MOLAR $0.00
D3331 9 NON-SURG TX ROOT CANAL OBS $0.00
D3332 1 INCOMPLETE ENDODONTIC TX $0.00
D3333 1 INTERNAL ROOT REPAIR $0.00
D3340 9 FOUR OR MORE CANALS (EXCLUDING FINA $0.00
D3346 1 RETREAT ROOT CANAL ANTERIOR $0.00
D3347 1 RETREAT ROOT CANAL BICUSPID $0.00
D3348 1 RETREAT ROOT CANAL MOLAR $0.00
D3350 9 APEXIFICATION (PER TREATMENT VISIT) $0.00
D3351 1 APEXIFICATION/RECALC INITIAL $0.00

D3352 1 APEXIFICATION/RECALC INTERIM $0.00
D3353 1 APEXIFICATION/RECALC FINAL $0.00
D3410 1 APICOECT/PERIRAD SURG ANTER $0.00
D3411 9 APICOECTOMY (PER TOOTH) - EACH ADDI $0.00
D3421 1 ROOT SURGERY BICUSPID $0.00
D3425 1 ROOT SURGERY MOLAR $0.00
D3426 1 ROOT SURGERY EA ADD ROOT $0.00
D3430 1 RETROGRADE FILLING $0.00
D3440 9 APICAL CURETTAGE $0.00
D3450 1 ROOT AMPUTATION $0.00
D3460 9 ENDODONTIC ENDOSSEOUS IMPLAN $0.00
D3470 1 INTENTIONAL REPLANTATION $0.00

D3910 1 ISOLATION- TOOTH W RUBB DAM $0.00
D3920 9 TOOTH SPLITTING $0.00
D3940 9 RECALCIFICATION OR REPAIR (PERFORAT $0.00
D3950 9 CANAL PREP/FITTING OF DOWEL $0.00
D3960 9 BLEACHING OF DISCOLORED TOOT $0.00
D3999 1 ENDODONTIC PROCEDURE $0.00
D4210 1 GINGIVECTOMY/PLASTY PER QUAD $0.00
D4211 1 GINGIVECTOMY/PLASTY PER TOOT $0.00
D4220 O GINGIVAL CURETTAGE PER QUADR $0.00
D4230 1 ANA CROWN EXP 4 OR> PER QUAD $0.00

D4231 1 ANA CROWN EXP 1-3 PER QUAD $0.00
D4240 1 GINGIVAL FLAP PROC W/ PLANIN $0.00
D4241 1 GNGVL FLAP W ROOTPLAN 1-3 TH $0.00
D4245 1 APICALLY POSITIONED FLAP $0.00
D4249 1 CROWN LENGTHEN HARD TISSUE $0.00
D4260 1 OSSEOUS SURGERY PER QUADRANT $0.00
D4261 1 OSSEOUS SURGL-3TEETHPERQUAD $0.00
D4262 O BONE REPLACEMENT GRAFT-MULTIPLE SIT $0.00
D4263 1 BONE REPLCE GRAFT FIRST SITE $0.00
D4264 1 BONE REPLCE GRAFT EACH ADD $0.00
D4265 1 BIO MTRLS TO AID SOFT/OS REG $0.00
D4266 1 GUIDED TISS REGEN RESORBLE $0.00
D4267 1 GUIDED TISS REGEN NONRESORB $0.00

D4268 1 SURGICAL REVISION PROCEDURE $0.00
D4270 1 PEDICLE SOFT TISSUE GRAFT PR $0.00
D4271 1 FREE SOFT TISSUE GRAFT PROC $0.00
D4272 9 APICALLY REPOSITIONING FLAP PROCEDU $0.00
D4273 1 SUBEPITHELIAL TISSUE GRAFT $0.00
D4274 1 DISTAL/PROXIMAL WEDGE PROC $0.00
D4275 1 SOFT TISSUE ALLOGRAFT $0.00
D4276 1 CON TISSUE W DBLE PED GRAFT $0.00
D4320 1 PROVISION SPLNT INTRACORONAL $0.00
D4321 1 PROVISIONAL SPLINT EXTRACORO $0.00
D4340 9 PERIODONTAL SCALING AND ROOT PLANIN $0.00
D4341 1 PERIODONTAL SCALING & ROOT $0.00

D4342 1 PERIODONTAL SCALING 1-3TEETH $0.00
D4355 1 FULL MOUTH DEBRIDEMENT $0.00
D4381 1 LOCALIZED DELIVERY ANTIMICRO $0.00
D4910 1 PERIODONTAL MAINT PROCEDURES $0.00
D4920 1 UNSCHEDULED DRESSING CHANGE $0.00
D4999 1 UNSPECIFIED PERIODONTAL PROC $0.00
D5110 1 DENTURES COMPLETE MAXILLARY $0.00
D5120 1 DENTURES COMPLETE MANDIBLE $0.00
D5130 1 DENTURES IMMEDIAT MAXILLARY $0.00
D5140 1 DENTURES IMMEDIAT MANDIBLE $0.00

D5211 1 DENTURES MAXILL PART RESIN $0.00
D5212 1 DENTURES MAND PART RESIN $0.00
D5213 1 DENTURES MAXILL PART METAL $0.00
D5214 1 DENTURES MANDIBL PART METAL $0.00
D5215 9 UPPER PARTIAL - HIGH NOBLE CAST BAS $0.00
D5216 9 LOWER PARTIAL - HIGH NOBLE CAST BAS $0.00
D5225 1 MAXILLARY PART DENTURE FLEX $0.00
D5226 1 MANDIBULAR PART DENTURE FLEX $0.00
D5280 9 REMOVABLE UNILATERAL PARTIAL DENTUR $0.00
D5281 9 REMOVABLE PARTIAL DENTURE $0.00
D5410 1 DENTURES ADJUST CMPLT MAXIL $0.00
D5411 1 DENTURES ADJUST CMPLT MAND $0.00
D5421 1 DENTURES ADJUST PART MAXILL $0.00

D5422 1 DENTURES ADJUST PART MANDBL $0.00
D5510 1 DENTUR REPR BROKEN COMPL BAS $0.00
D5520 1 REPLACE DENTURE TEETH COMPLT $0.00
D5610 1 DENTURES REPAIR RESIN BASE $0.00
D5620 1 REP PART DENTURE CAST FRAME $0.00
D5630 1 REP PARTIAL DENTURE CLASP $0.00
D5640 1 REPLACE PART DENTURE TEETH $0.00
D5650 1 ADD TOOTH TO PARTIAL DENTURE $0.00
D5660 1 ADD CLASP TO PARTIAL DENTURE $0.00
D5670 1 REPLC TTH&ACRLC ON MTL FRMWK $0.00
D5671 1 REPLC TTH&ACRLC MANDIBULAR $0.00
D5710 9 DENTURES REBASE CMPLT MAXIL $0.00

D5711 9 DENTURES REBASE CMPLT MAND $0.00
D5720 9 DENTURES REBASE PART MAXILL $0.00
D5721 9 DENTURES REBASE PART MANDBL $0.00
D5730 1 DENTURE RELN CMPLT MAXIL CH $0.00
D5731 1 DENTURE RELN CMPLT MAND CHR $0.00
D5740 1 DENTURE RELN PART MAXIL CHR $0.00
D5741 1 DENTURE RELN PART MAND CHR $0.00
D5750 1 DENTURE RELN CMPLT MAX LAB $0.00
D5751 1 DENTURE RELN CMPLT MAND LAB $0.00
D5760 1 DENTURE RELN PART MAXIL LAB $0.00

D5761 1 DENTURE RELN PART MAND LAB $0.00
D5810 1 DENTURE INTERM CMPLT MAXILL $0.00
D5811 1 DENTURE INTERM CMPLT MANDBL $0.00
D5820 1 DENTURE INTERM PART MAXILL $0.00
D5821 1 DENTURE INTERM PART MANDBL $0.00
D5850 1 DENTURE TISS CONDITN MAXILL $0.00
D5851 1 DENTURE TISS CONDTIN MANDBL $0.00
D5860 9 OVERDENTURE COMPLETE $0.00
D5861 9 OVERDENTURE PARTIAL $0.00
D5862 9 PRECISION ATTACHMENT $0.00
D5867 9 REPLACEMENT OF PRECISION ATT $0.00
D5875 9 PROSTHESIS MODIFICATION $0.00
D5899 1 REMOVABLE PROSTHODONTIC PROC $0.00

D5911 1 FACIAL MOULAGE SECTIONAL $0.00
D5912 1 FACIAL MOULAGE COMPLETE $0.00
D5913 1 NASAL PROSTHESIS $0.00
D5914 1 AURICULAR PROSTHESIS $0.00
D5915 1 ORBITAL PROSTHESIS $0.00
D5916 1 OCULAR PROSTHESIS $0.00
D5917 9 COMPOSITE FACIAL PROSTHESIS $0.00
D5918 9 REPLACEMENT PROSTHESIS $0.00
D5919 1 FACIAL PROSTHESIS $0.00
D5920 9 OCULAR IMPLANT $0.00
D5921 9 ORBITAL IMPLANT $0.00
D5922 1 NASAL SEPTAL PROSTHESIS $0.00

D5923 1 OCULAR PROSTHESIS INTERIM $0.00
D5924 1 CRANIAL PROSTHESIS $0.00
D5925 1 FACIAL AUGMENTATION IMPLANT $0.00
D5926 1 REPLACEMENT NASAL PROSTHESIS $0.00
D5927 1 AURICULAR REPLACEMENT $0.00
D5928 1 ORBITAL REPLACEMENT $0.00
D5929 1 FACIAL REPLACEMENT $0.00
D5931 1 SURGICAL OBTURATOR $0.00
D5932 1 POSTSURGICAL OBTURATOR $0.00
D5933 1 REFITTING OF OBTURATOR $0.00

D5934 1 MANDIBULAR FLANGE PROSTHESIS $0.00
D5935 1 MANDIBULAR DENTURE PROSTH $0.00
D5936 1 TEMP OBTURATOR PROSTHESIS $0.00
D5937 1 TRISMUS APPLIANCE $0.00
D5951 1 FEEDING AID $0.00
D5952 1 PEDIATRIC SPEECH AID $0.00
D5953 1 ADULT SPEECH AID $0.00
D5954 1 SUPERIMPOSED PROSTHESIS $0.00
D5955 1 PALATAL LIFT PROSTHESIS $0.00
D5956 9 OBTURATOR $0.00
D5957 9 SPEECH BULB $0.00
D5958 1 INTRAORAL CON DEF INTER PLT $0.00
D5959 1 INTRAORAL CON DEF MOD PALAT $0.00

D5960 1 MODIFY SPEECH AID PROSTHESIS $0.00
D5971 9 SIMPLE IMPLANT $0.00
D5972 9 COMPLEX IMPLANT $0.00
D5973 9 SUBPERIOSTEAL IMPLANT $0.00
D5974 9 ENDOSSEOUS IMPLANT (IN THE BONE) $0.00
D5976 9 MANDIBULAR STAPLE IMPLANT $0.00
D5982 9 SURGICAL STENT $0.00
D5983 9 RADIATION APPLICATOR $0.00
D5984 9 RADIATION SHIELD $0.00
D5985 9 RADIATION CONE LOCATOR $0.00
D5986 1 FLUORIDE APPLICATOR $0.00
D5987 1 COMMISSURE SPLINT $0.00

D5988 1 SURGICAL SPLINT $0.00
D5991 1 TOPICAL MEDICAMENT CARRIER $0.00
D5999 1 MAXILLOFACIAL PROSTHESIS $0.00
D6010 9 ODONTICS ENDOSTEAL IMPLANT $0.00
D6012 9 ENDOSTEAL IMPLANT $0.00
D6020 O ODONTICS ABUTMENT PLACEMENT $0.00
D6040 9 SURGICAL PLACEMENT:EPOSTEAL IMPLAN $0.00
D6050 9 SURGICAL PLACEMENT TRANSOSTEAL $0.00
D6053 9 IMPLNT/ABTMNT SPPRT REMV DNT $0.00
D6054 9 IMPLNT/ABTMNT SPPRT REMVPRTL $0.00

D6055 9 DENTAL IMPLANT SUPPORTED BAR $0.00
D6056 9 PREFABRICATED ABUTMENT $0.00
D6057 9 CUSTOM ABUTMENT $0.00
D6058 9 ABUTMENT SUPPORTED CROWN $0.00
D6059 9 ABUTMENT SUPPORTED MTL CROWN $0.00
D6065 9 IMPLANT SUPPORTED CROWN $0.00
D6066 9 IMPLANT SUPPORTED MTL CROWN $0.00
D6067 9 IMPLANT SUPPORTED MTL CROWN $0.00

D6068 9 ABUTMENT SUPPORTED RETAINER $0.00
D6075 9 IMPLANT SUPPORTED RETAINER $0.00
D6078 9 IMPLNT/ABUT SUPRTD FIXD DENT $0.00
D6079 9 IMPLNT/ABUT SUPRTD FIXD DENT $0.00

D6080 9 IMPLANT MAINTENANCE PROCEDURES INC $0.00
D6090 9 REPAIR IMPLANT SUPPORTED PROSTHESI $0.00
D6091 9 REPL SEMI/PRECISION ATTACH $0.00
D6092 9 RECEMENT SUPP CROWN $0.00
D6093 9 RECEMENT SUPP PART DENTURE $0.00
D6094 9 ABUT SUPPORT CROWN TITANIUM $0.00
D6095 9 ODONTICS REPR ABUTMENT $0.00
D6100 9 IMPLANT REMOVAL, BY REPORT. $0.00
D6190 9 RADIO/SURGICAL IMPLANT INDEX $0.00
D6194 9 ABUT SUPPORT RETAINER TITANI $0.00

D6199 9 UNSPECIFIED IMPLANT PROCEDURE, BY $0.00
D6205 9 PONTIC-INDIRECT RESIN BASED $0.00
D6210 9 PROSTHODONT HIGH NOBLE METAL $0.00
D6211 1 BRIDGE BASE METAL CAST $0.00
D6212 1 BRIDGE NOBLE METAL CAST $0.00
D6214 9 PONTIC TITANIUM $0.00
D6240 9 BRIDGE PORCELAIN HIGH NOBLE $0.00
D6241 1 BRIDGE PORCELAIN BASE METAL $0.00
D6242 1 BRIDGE PORCELAIN NOBEL METAL $0.00
D6245 9 BRIDGE PORCELAIN/CERAMIC $0.00
D6250 9 BRIDGE RESIN W/HIGH NOBLE $0.00
D6251 1 BRIDGE RESIN BASE METAL $0.00
D6252 1 BRIDGE RESIN W/NOBLE METAL $0.00

D6253 9 PROVISIONAL PONTIC $0.00
D6519 9 INLAY/ONLAY PORCE/CERAMIC $0.00
D6520 9 DENTAL RETAINER TWO SURFACES $0.00
D6530 9 RETAINER METALLIC 3+ SURFACE $0.00
D6540 O ONLAY-METALLIC-PER TOOTH (IN ADDITI $0.00
D6543 9 DENTAL RETAINR ONLAY 3 SURF $0.00
D6544 9 DENTAL RETAINR ONLAY 4/MORE $0.00
D6545 1 DENTAL RETAINR CAST METL $0.00
D6548 9 PORCELAIN/CERAMIC RETAINER $0.00
D6600 9 PORCELAIN/CERAMIC INLAY 2SRF $0.00
D6601 9 PORC/CERAM INLAY >= 3 SURFAC $0.00
D6602 9 CST HGH NBLE MTL INLAY 2 SRF $0.00

D6603 9 CST HGH NBLE MTL INLAY >=3SR $0.00
D6604 9 CST BSE MTL INLAY 2 SURFACES $0.00
D6605 9 CST BSE MTL INLAY >= 3 SURFA $0.00
D6606 9 CAST NOBLE METAL INLAY 2 SUR $0.00
D6607 9 CST NOBLE MTL INLAY >=3 SURF $0.00
D6608 9 ONLAY PORC/CRMC 2 SURFACES $0.00
D6609 9 ONLAY PORC/CRMC >=3 SURFACES $0.00
D6610 9 ONLAY CST HGH NBL MTL 2 SRFC $0.00
D6611 9 ONLAY CST HGH NBL MTL >=3SRF $0.00
D6612 9 ONLAY CST BASE MTL 2 SURFACE $0.00

D6613 9 ONLAY CST BASE MTL >=3 SURFA $0.00
D6614 9 ONLAY CST NBL MTL 2 SURFACES $0.00
D6615 9 ONLAY CST NBL MTL >=3 SURFAC $0.00
D6624 9 INLAY TITANIUM $0.00
D6634 9 ONLAY TITANIUM $0.00
D6710 9 CROWN-INDIRECT RESIN BASED $0.00
D6720 9 RETAIN CROWN RESIN W HI NBLE $0.00
D6721 1 CROWN RESIN W/BASE METAL $0.00
D6722 1 CROWN RESIN W/NOBLE METAL $0.00
D6740 9 CROWN PORCELAIN/CERAMIC $0.00
D6750 9 CROWN PORCELAIN HIGH NOBLE $0.00
D6751 1 CROWN PORCELAIN BASE METAL $0.00
D6752 1 CROWN PORCELAIN NOBLE METAL $0.00

D6780 9 CROWN 3/4 HIGH NOBLE METAL $0.00
D6781 9 CROWN 3/4 CAST BASED METAL $0.00
D6782 9 CROWN 3/4 CAST NOBLE METAL $0.00
D6783 9 CROWN 3/4 PORCELAIN/CERAMIC $0.00
D6790 9 CROWN FULL HIGH NOBLE METAL $0.00
D6791 1 CROWN FULL BASE METAL CAST $0.00
D6792 1 CROWN FULL NOBLE METAL CAST $0.00
D6793 9 PROVISIONAL RETAINER CROWN $0.00
D6794 9 CROWN TITANIUM $0.00
D6920 9 DENTAL CONNECTOR BAR $0.00
D6930 1 DENTAL RECEMENT BRIDGE $0.00
D6940 9 STRESS BREAKER $0.00

D6950 9 PRECISION ATTACHMENT $0.00
D6970 9 POST & CORE PLUS RETAINER $0.00
D6971 O CAST POST BRIDGE RETAINER $0.00
D6972 1 PREFAB POST & CORE PLUS RETA $0.00
D6973 9 CORE BUILD UP FOR RETAINER, INCLUD $0.00
D6975 9 COPING METAL $0.00
D6976 9 EACH ADDTNL CAST POST $0.00
D6977 9 EACH ADDTL PREFAB POST $0.00
D6980 1 BRIDGE REPAIR $0.00
D6985 1 PEDIATRIC PARTIAL DENTURE FX $0.00

D6999 1 FIXED PROSTHODONTIC PROC $0.00
D7110 O ORAL SURGERY SINGLE TOOTH $0.00
D7111 1 EXTRACTION CORONAL REMNANTS $0.00
D7120 O EACH ADD TOOTH EXTRACTION $0.00
D7130 O TOOTH ROOT REMOVAL $0.00
D7140 1 EXTRACTION ERUPTED TOOTH/EXR $0.00
D7210 1 REM IMP TOOTH W MUCOPER FLP $0.00
D7220 1 IMPACT TOOTH REMOV SOFT TISS $0.00
D7230 1 IMPACT TOOTH REMOV PART BONY $0.00
D7240 1 IMPACT TOOTH REMOV COMP BONY $0.00
D7241 1 IMPACT TOOTH REM BONY W/COMP $0.00
D7250 1 TOOTH ROOT REMOVAL $0.00
D7260 1 ORAL ANTRAL FISTULA CLOSURE $0.00

D7261 1 PRIMARY CLOSURE SINUS PERF $0.00
D7270 1 TOOTH REIMPLANTATION $0.00
D7271 O TOOTH IMPLANTATION $0.00
D7272 1 TOOTH TRANSPLANTATION $0.00
D7280 1 EXPOSURE IMPACT TOOTH ORTHOD $0.00
D7281 O EXPOSURE TOOTH AID ERUPTION $0.00
D7282 1 MOBILIZE ERUPTED/MALPOS TOOT $0.00
D7283 1 PLACE DEVICE IMPACTED TOOTH $0.00
D7285 9 BIOPSY OF ORAL TISSUE HARD $0.00
D7286 9 BIOPSY OF ORAL TISSUE SOFT $0.00
D7287 9 EXFOLIATIVE CYTOLOG COLLECT $0.00
D7288 9 BRUSH BIOPSY $0.00

D7290 1 REPOSITIONING OF TEETH $0.00
D7291 1 TRANSSEPTAL FIBEROTOMY $0.00
D7292 9 SCREW RETAINED PLATE $0.00
D7293 9 TEMP ANCHORAGE DEV W FLAP $0.00
D7294 9 TEMP ANCHORAGE DEV W/O FLAP $0.00
D7310 1 ALVEOPLASTY W/ EXTRACTION $0.00
D7311 1 ALVEOLOPLASTY W/EXTRACT 1-3 $0.00
D7320 1 ALVEOPLASTY W/O EXTRACTION $0.00
D7321 1 ALVEOLOPLASTY NOT W/EXTRACTS $0.00
D7340 1 VESTIBULOPLASTY RIDGE EXTENS $0.00

D7350 1 VESTIBULOPLASTY EXTEN GRAFT $0.00
D7410 9 RAD EXC LESION UP TO 1.25 CM $0.00
D7411 9 EXCISION BENIGN LESION>1.25C $0.00
D7412 9 EXCISION BENIGN LESION COMPL $0.00
D7413 9 EXCISION MALIG LESION<=1.25C $0.00
D7414 9 EXCISION MALIG LESION>1.25CM $0.00
D7415 9 EXCISION MALIG LES COMPLICAT $0.00
D7420 9 LESION > 1.25 CM $0.00
D7430 9 EXC BENIGN TUMOR TO 1.25 CM $0.00
D7431 9 BENIGN TUMOR EXC > 1.25 CM $0.00
D7440 9 MALIG TUMOR EXC TO 1.25 CM $0.00
D7441 9 MALIG TUMOR > 1.25 CM $0.00
D7450 9 REM ODONTOGEN CYST TO 1.25CM $0.00

D7451 9 REM ODONTOGEN CYST > 1.25 CM $0.00
D7460 9 REM NONODONTO CYST TO 1.25CM $0.00
D7461 9 REM NONODONTO CYST > 1.25 CM $0.00
D7465 9 LESION DESTRUCTION $0.00
D7470 9 REM EXOSTOSIS MAXILLA/MANDIB $0.00
D7471 9 REM EXOSTOSIS ANY SITE $0.00
D7472 9 REMOVAL OF TORUS PALATINUS $0.00
D7473 9 REMOVE TORUS MANDIBULARIS $0.00
D7480 9 PARTIAL OSTECTOMY $0.00
D7485 9 SURG REDUCT OSSEOUSTUBEROSIT $0.00
D7490 9 MAXILLA OR MANDIBLE RESECTIO $0.00
D7510 1 I&D ABSC INTRAORAL SOFT TISS $0.00

D7511 1 INCISION/DRAIN ABSCESS INTRA $0.00
D7520 1 I&D ABSCESS EXTRAORAL $0.00
D7521 1 INCISION/DRAIN ABSCESS EXTRA $0.00
D7530 1 REMOVAL FB SKIN/AREOLAR TISS $0.00
D7540 1 REMOVAL OF FB REACTION $0.00
D7550 1 REMOVAL OF SLOUGHED OFF BONE $0.00
D7560 1 MAXILLARY SINUSOTOMY $0.00
D7610 9 MAXILLA OPEN REDUCT SIMPLE $0.00
D7620 9 CLSD REDUCT SIMPL MAXILLA FX $0.00
D7630 9 OPEN RED SIMPL MANDIBLE FX $0.00

D7640 9 CLSD RED SIMPL MANDIBLE FX $0.00
D7650 9 OPEN RED SIMP MALAR/ZYGOM FX $0.00
D7660 9 CLSD RED SIMP MALAR/ZYGOM FX $0.00
D7670 9 CLOSD RDUCTN SPLINT ALVEOLUS $0.00
D7671 9 ALVEOLUS OPEN REDUCTION $0.00
D7680 9 REDUCT SIMPLE FACIAL BONE FX $0.00
D7710 9 MAXILLA OPEN REDUCT COMPOUND $0.00
D7720 9 CLSD REDUCT COMPD MAXILLA FX $0.00
D7730 9 OPEN REDUCT COMPD MANDBLE FX $0.00
D7740 9 CLSD REDUCT COMPD MANDBLE FX $0.00
D7750 9 OPEN RED COMP MALAR/ZYGMA FX $0.00
D7760 9 CLSD RED COMP MALAR/ZYGMA FX $0.00
D7770 9 OPEN REDUC COMPD ALVEOLUS FX $0.00

D7771 9 ALVEOLUS CLSD REDUC STBLZ TE $0.00
D7780 9 REDUCT COMPND FACIAL BONE FX $0.00
D7810 9 TMJ OPEN REDUCT-DISLOCATION $0.00
D7820 9 CLOSED TMP MANIPULATION $0.00
D7830 9 TMJ MANIPULATION UNDER ANEST $0.00
D7840 9 REMOVAL OF TMJ CONDYLE $0.00
D7850 9 TMJ MENISCECTOMY $0.00
D7852 9 DISC REPAIR $0.00
D7854 9 SYNOVECTOMY $0.00
D7856 9 MYOTOMY $0.00
D7858 9 JOINT RECONSTRUCTION $0.00
D7860 9 TMJ CUTTING INTO JOINT $0.00

D7865 9 ARTHROPLASTY $0.00
D7870 9 TMJ ASPIRATION JOINT FLUID $0.00
D7871 9 LYSIS + LAVAGE W CATHETERS $0.00
D7872 9 ARTHROSCOPY- DIAGNOSIS WITH $0.00
D7873 9 ARTHOSCOPY- SURGICAL: LAVAGE AND $0.00
D7874 9 ARTHROSCOPY- SURGICAL: DISC REPOSI $0.00
D7875 9 ARTHROSCOPY- SURGICAL: SYNOVECTOMY $0.00
D7876 9 ARTHROSCOPY- SURGICAL: DISCECTOMY $0.00
D7877 9 ARTHROSCOPY- SURGICAL DEBRIDEMENT $0.00
D7880 1 OCCLUSAL ORTHOTIC APPLIANCE $0.00

D7899 1 TMJ UNSPECIFIED THERAPY $0.00
D7910 1 DENT SUTUR RECENT WND TO 5CM $0.00
D7911 1 DENTAL SUTURE WOUND TO 5 CM $0.00
D7912 1 SUTURE COMPLICATE WND > 5 CM $0.00
D7920 9 DENTAL SKIN GRAFT $0.00
D7940 9 RESHAPING BONE ORTHOGNATHIC $0.00
D7941 9 BONE CUTTING RAMUS CLOSED $0.00
D7942 9 BONE CUTTING RAMUS OPEN $0.00
D7943 9 CUTTING RAMUS OPEN W/GRAFT $0.00
D7944 9 BONE CUTTING SEGMENTED $0.00
D7945 9 BONE CUTTING BODY MANDIBLE $0.00
D7946 9 RECONSTRUCTION MAXILLA TOTAL $0.00
D7947 9 RECONSTRUCT MAXILLA SEGMENT $0.00

D7948 9 RECONSTRUCT MIDFACE NO GRAFT $0.00
D7949 9 RECONSTRUCT MIDFACE W/GRAFT $0.00
D7950 9 MANDIBLE GRAFT $0.00
D7951 9 SINUS AUG W BONE/BONE SUP $0.00
D7953 9 BONE REPLACEMENT GRAFT $0.00
D7955 9 REPAIR MAXILLOFACIAL DEFECTS $0.00
D7960 1 FRENULECTOMY/FRENULOTOMY $0.00
D7963 1 FRENULOPLASTY $0.00
D7970 1 EXCISION HYPERPLASTIC TISSUE $0.00
D7971 1 EXCISION PERICORONAL GINGIVA $0.00
D7972 9 SURG REDCT FIBROUS TUBEROSIT $0.00
D7980 9 SIALOLITHOTOMY $0.00

D7981 9 EXCISION OF SALIVARY GLAND $0.00
D7982 9 SIALODOCHOPLASTY $0.00
D7983 9 CLOSURE OF SALIVARY FISTULA $0.00
D7990 9 EMERGENCY TRACHEOTOMY $0.00
D7991 9 DENTAL CORONOIDECTOMY $0.00
D7992 9 EMINENECTOMY $0.00
D7993 O IMPLANT-FACIAL BONES (HOMOLOGOUS, H $0.00
D7994 O IMPLANT-OTHER THAN FACIAL BONES $0.00
D7995 9 SYNTHETIC GRAFT FACIAL BONES $0.00
D7996 9 IMPLANT MANDIBLE FOR AUGMENT $0.00

D7997 1 APPLIANCE REMOVAL $0.00
D7998 9 INTRAORAL PLACE OF FIX DEV $0.00
D7999 1 ORAL SURGERY PROCEDURE $0.00
D8010 1 LIMITED DENTAL TX PRIMARY $0.00
D8020 1 LIMITED DENTAL TX TRANSITION $0.00
D8030 1 LIMITED DENTAL TX ADOLESCENT $0.00
D8040 1 LIMITED DENTAL TX ADULT $0.00
D8050 1 INTERCEP DENTAL TX PRIMARY $0.00
D8060 1 INTERCEP DENTAL TX TRANSITN $0.00
D8070 1 COMPRE DENTAL TX TRANSITION $0.00
D8080 3 COMPRE DENTAL TX ADOLESCENT $1,585.00
D8090 1 COMPRE DENTAL TX ADULT $0.00
D8110 O REMOVABLE APPLIANCE THERAPY $0.00

D8120 O FIXED APPLIANCE THERAPY $0.00
D8210 1 ORTHODONTIC REM APPLIANCE TX $0.00
D8220 1 FIXED APPLIANCE THERAPY HABT $0.00
D8360 O REMOVABLE APPLIANCE THERAPY $0.00
D8370 O FIXED APPLIANCE THERAPY $0.00
D8460 O CLASS I MALOCCLUSION $0.00
D8470 O CLASS II MALOCCLUSION $0.00
D8480 O CLASS III MALOCCLUSION $0.00
D8560 O CLASS I MALOCCLUSION $0.00
D8570 O CLASS II MALOCCLUSION $0.00
D8580 O CLASS III MALOCCLUSION $0.00
D8650 O TREATMENT OF THE ATYPICAL OR EXTEND $0.00

D8660 3 PREORTHODONTIC TX VISIT $225.00
D8670 3 PERIODIC ORTHODONTC TX VISIT $465.00
D8680 1 ORTHODONTIC RETENTION $0.00
D8690 1 ORTHODONTIC TREATMENT $0.00
D8691 1 REPAIR ORTHO APPLIANCE $0.00
D8692 1 REPLACEMENT RETAINER $0.00
D8693 9 REBOND/CEMENT/REPAIR RETAIN $0.00
D8750 O POST-TREATMENT STABILIZATION $0.00
D8999 1 ORTHODONTIC PROCEDURE $0.00
D9110 1 TX DENTAL PAIN MINOR PROC $0.00

D9120 1 FIX PARTIAL DENTURE SECTION $0.00
D9210 1 DENT ANESTHESIA W/O SURGERY $0.00
D9211 9 REGIONAL BLOCK ANESTHESIA $0.00
D9212 9 TRIGEMINAL BLOCK ANESTHESIA $0.00
D9215 9 LOCAL ANESTHESIA $0.00
D9220 1 GENERAL ANESTHESIA $0.00
D9221 1 GENERAL ANESTHESIA EA AD 15M $0.00
D9230 1 ANALGESIA $0.00
D9240 9 INTRAVENOUS SEDATION $0.00
D9241 1 INTRAVENOUS SEDATION $0.00
D9242 1 IV SEDATION EA AD 30 M $0.00
D9248 1 SEDATION (NON-IV) $0.00
D9310 1 DENTAL CONSULTATION $0.00

D9410 9 DENTAL HOUSE CALL $0.00
D9420 9 HOSPITAL CALL $0.00
D9430 9 OFFICE VISIT DURING HOURS $0.00
D9440 1 OFFICE VISIT AFTER HOURS $0.00
D9450 9 CASE PRESENTATION TX PLAN $0.00
D9610 1 DENT THERAPEUTIC DRUG INJECT $0.00
D9612 1 THERA PAR DRUGS 2 OR > ADMIN $0.00
D9630 9 OTHER DRUGS/MEDICAMENTS $0.00
D9910 1 DENT APPL DESENSITIZING MED $0.00
D9911 1 APPL DESENSITIZING RESIN $0.00
D9920 1 BEHAVIOR MANAGEMENT $0.00
D9930 1 TREATMENT OF COMPLICATIONS $0.00

D9940 1 DENTAL OCCLUSAL GUARD $0.00
D9941 9 FABRICATION ATHLETIC GUARD $0.00
D9942 9 REPAIR/RELINE OCCLUSAL GUARD $0.00
D9950 9 OCCLUSION ANALYSIS $0.00
D9951 9 LIMITED OCCLUSAL ADJUSTMENT $0.00
D9952 9 COMPLETE OCCLUSAL ADJUSTMENT $0.00
D9960 9 COMPLETION OF CLAIM FORM $0.00
D9970 9 ENAMEL MICROABRASION $0.00
D9971 9 ODONTOPLASTY 1-2 TEETH $0.00
D9972 9 EXTRNL BLEACHING PER ARCH $0.00

D9973 9 EXTRNL BLEACHING PER TOOTH $0.00
D9974 9 INTRNL BLEACHING PER TOOTH $0.00
D9999 1 ADJUNCTIVE PROCEDURE $0.00
DCD03 O MCO SPECIFIC CODE: DEVELOPMENTAL CE $0.00
DCP01 O MCO SPECIFIC CODE: PARENT INFANT PR $0.00
DCT02 O MCO SPECIFIC CODE: TODDLER PROGRAM $0.00
E0100 3 CANE ADJUST/FIXED WITH TIP $20.16
E0105 3 CANE ADJUST/FIXED QUAD/3 PRO $46.99
E0110 3 CRUTCH FOREARM PAIR $69.54
E0111 3 CRUTCH FOREARM EACH $50.95
E0112 3 CRUTCH UNDERARM PAIR WOOD $35.40
E0113 3 CRUTCH UNDERARM EACH WOOD $20.21
E0114 3 CRUTCH UNDERARM PAIR NO WOOD $45.15

E0116 3 CRUTCH UNDERARM EACH NO WOOD $22.76
E0117 5 UNDERARM SPRINGASSIST CRUTCH $0.00
E0118 6 CRUTCH SUBSTITUTE $0.00
E0130 3 WALKER RIGID ADJUST/FIXED HT $57.13
E0135 3 WALKER FOLDING ADJUST/FIXED $77.57
E0140 6 WALKER W TRUNK SUPPORT $0.00
E0141 3 RIGID WHEELED WALKER ADJ/FIX $110.30
E0142 O WALKER RIGID WHEELED WITH SE $0.00
E0143 3 WALKER FOLDING WHEELED W/O S $115.02
E0144 3 ENCLOSED WALKER W REAR SEAT $304.66
E0145 O WALKER WHLED SEAT/CRUTCH ATT $0.00
E0146 O FOLDING WALKER WHEELS W SEAT $0.00

E0147 3 WALKER VARIABLE WHEEL RESIST $549.91
E0148 3 HEAVYDUTY WALKER NO WHEELS $121.55
E0149 3 HEAVY DUTY WHEELED WALKER $213.53
E0150 9 UNDERARM PAD, CRUTCH, REPLACEMENT, $0.00
E0151 9 HANDGRIP, CANE, CRUTCH, OR WALKER R $0.00
E0152 9 TIP, CANE OR CRUTCH WALKER REPLACEM $0.00
E0153 3 FOREARM CRUTCH PLATFORM ATTA $66.38
E0154 3 WALKER PLATFORM ATTACHMENT $66.38
E0155 3 WALKER WHEEL ATTACHMENT,PAIR $30.20
E0156 3 WALKER SEAT ATTACHMENT $25.29

E0157 3 WALKER CRUTCH ATTACHMENT $66.61
E0158 3 WALKER LEG EXTENDERS SET OF4 $30.78
E0159 9 BRAKE FOR WHEELED WALKER $0.00
E0160 3 SITZ TYPE BATH OR EQUIPMENT $31.62
E0161 3 SITZ BATH/EQUIPMENT W/FAUCET $25.09
E0162 3 SITZ BATH CHAIR $139.39
E0163 3 COMMODE CHAIR WITH FIXED ARM $98.08
E0164 O COMMODE CHAIR MOBILE FIXED A $0.00
E0165 3 COMMODE CHAIR WITH DETACHARM $144.20
E0166 O COMMODE CHAIR MOBILE DETACH $0.00
E0167 3 COMMODE CHAIR PAIL OR PAN $10.11
E0168 3 HEAVYDUTY/WIDE COMMODE CHAIR $144.38
E0169 O SEATLIFT INCORP COMMODECHAIR $0.00

E0170 6 COMMODE CHAIR ELECTRIC $0.00
E0171 6 COMMODE CHAIR NON-ELECTRIC $0.00
E0172 6 SEAT LIFT MECHANISM TOILET $0.00
E0175 3 COMMODE CHAIR FOOT REST $53.86
E0176 O AIR PRESSRE PAD/CUSHION NONP $0.00
E0177 O WATER PRESS PAD/CUSHION NONP $0.00
E0178 O GEL PRESSRE PAD/CUSHION NONP $0.00
E0179 O DRY PRESSRE PAD/CUSHION NONP $0.00
E0180 O PRESS PAD ALTERNATING W PUMP $0.00
E0181 3 PRESS PAD ALTERNATING W/ PUM $304.20
E0182 3 REPLACE PUMP, ALT PRESS PAD $235.90
E0183 9 FLOTATION PAD FOR WHEELCHAIR $0.00

E0184 3 DRY PRESSURE MATTRESS $186.27
E0185 3 GEL PRESSURE MATTRESS PAD $306.01
E0186 3 AIR PRESSURE MATTRESS $182.80
E0187 3 WATER PRESSURE MATTRESS $209.20
E0188 3 SYNTHETIC SHEEPSKIN PAD $23.85
E0189 3 LAMBSWOOL SHEEPSKIN PAD $36.30
E0190 6 POSITIONING CUSHION $0.00
E0191 3 PROTECTOR HEEL OR ELBOW $9.56
E0192 O PAD WHEELCHR LOW PRESS/POSIT $0.00
E0193 3 POWERED AIR FLOTATION BED $6,956.30

E0194 3 AIR FLUIDIZED BED $0.00
E0195 9 REPLACEMENT PAD FOR USE WITH MEDICA $0.00
E0196 3 GEL PRESSURE MATTRESS $287.60
E0197 3 AIR PRESSURE PAD FOR MATTRES $211.98
E0198 3 WATER PRESSURE PAD FOR MATTR $211.98
E0199 3 DRY PRESSURE PAD FOR MATTRES $30.66
E0200 3 HEAT LAMP WITHOUT STAND $75.85
E0202 3 PHOTOTHERAPY LIGHT W/ PHOTOM $564.10
E0203 5 THERAPEUTIC LIGHTBOX TABLETP $0.00
E0205 3 HEAT LAMP WITH STAND $157.81
E0210 3 ELECTRIC HEAT PAD STANDARD $31.22
E0215 3 ELECTRIC HEAT PAD MOIST $67.77
E0217 3 WATER CIRC HEAT PAD W PUMP $403.72

E0218 9 WATER CIRC COLD PAD W PUMP $0.00
E0220 3 HOT WATER BOTTLE $6.89
E0221 5 INFRARED HEATING PAD SYSTEM $0.00
E0225 3 HYDROCOLLATOR UNIT $316.04
E0230 3 ICE CAP OR COLLAR $6.89
E0231 5 WOUND WARMING DEVICE $0.00
E0232 5 WARMING CARD FOR NWT $0.00
E0235 3 PARAFFIN BATH UNIT PORTABLE $155.40
E0236 3 PUMP FOR WATER CIRCULATING P $358.90
E0237 O WATER CIRCULATING HEAT/COLD PAD WIT $0.00
E0238 3 HEAT PAD NON-ELECTRIC MOIST $25.87
E0239 3 HYDROCOLLATOR UNIT PORTABLE $430.35

E0240 6 BATH/SHOWER CHAIR $0.00
E0241 5 BATH TUB WALL RAIL $0.00
E0242 5 BATH TUB RAIL FLOOR $0.00
E0243 5 TOILET RAIL $0.00
E0244 5 TOILET SEAT RAISED $0.00
E0245 5 TUB STOOL OR BENCH $0.00
E0246 5 TRANSFER TUB RAIL ATTACHMENT $0.00
E0247 6 TRANS BENCH W/WO COMM OPEN $0.00
E0248 6 HDTRANS BENCH W/WO COMM OPEN $0.00
E0249 3 PAD WATER CIRCULATING HEAT U $95.29

E0250 3 HOSP BED FIXED HT W/ MATTRES $880.70
E0251 3 HOSP BED FIXD HT W/O MATTRES $667.40
E0252 9 HOSPITAL BED, FIXED HEIGHT, WITH MA $0.00
E0255 3 HOSPITAL BED VAR HT W/ MATTR $1,058.30
E0256 3 HOSPITAL BED VAR HT W/O MATT $706.90
E0260 3 HOSP BED SEMI-ELECTR W/ MATT $1,512.70
E0261 3 HOSP BED SEMI-ELECTR W/O MAT $1,233.60
E0265 3 HOSP BED TOTAL ELECTR W/ MAT $1,800.70
E0266 3 HOSP BED TOTAL ELEC W/O MATT $1,359.80
E0270 9 HOSPITAL BED INSTITUTIONAL T $0.00
E0271 3 MATTRESS INNERSPRING $212.42
E0272 3 MATTRESS FOAM RUBBER $186.47
E0273 5 BED BOARD $0.00

E0274 5 OVER-BED TABLE $0.00
E0275 3 BED PAN STANDARD $14.64
E0276 3 BED PAN FRACTURE $12.73
E0277 3 POWERED PRES-REDU AIR MATTRS $1.00
E0280 3 BED CRADLE $35.40
E0290 3 HOSP BED FX HT W/O RAILS W/M $673.30
E0291 3 HOSP BED FX HT W/O RAIL W/O $489.00
E0292 3 HOSP BED VAR HT W/O RAIL W/O $701.60
E0293 3 HOSP BED VAR HT W/O RAIL W/ $644.30
E0294 3 HOSP BED SEMI-ELECT W/ MATTR $1,177.20
E0295 3 HOSP BED SEMI-ELECT W/O MATT $1,147.10
E0296 3 HOSP BED TOTAL ELECT W/ MATT $1,479.10

E0297 3 HOSP BED TOTAL ELECT W/O MAT $1,077.10
E0298 O HEAVYDUTY/XTRA WIDE HOSP BED $0.00
E0300 6 ENCLOSED PED CRIB HOSP GRADE $0.00
E0301 6 HD HOSP BED, 350-600 LBS $0.00
E0302 6 EX HD HOSP BED > 600 LBS $0.00
E0303 6 HOSP BED HVY DTY XTRA WIDE $0.00
E0304 6 HOSP BED XTRA HVY DTY X WIDE $0.00
E0305 3 RAILS BED SIDE HALF LENGTH $160.00
E0310 3 RAILS BED SIDE FULL LENGTH $185.74
E0315 9 BED ACCESSORY BRD/TBL/SUPPRT $0.00

E0316 5 BED SAFETY ENCLOSURE $0.00
E0325 3 URINAL MALE JUG-TYPE $9.67
E0326 3 URINAL FEMALE JUG-TYPE $9.48
E0328 6 PED HOSPITAL BED, MANUAL $0.00
E0329 6 PED HOSPITAL BED SEMI/ELECT $0.00
E0350 9 CONTROL UNIT BOWEL SYSTEM $0.00
E0352 9 DISPOSABLE PACK W/BOWEL SYST $0.00
E0370 9 AIR ELEVATOR FOR HEEL $0.00
E0371 5 NONPOWER MATTRESS OVERLAY $0.00
E0372 3 POWERED AIR MATTRESS OVERLAY $0.00
E0373 5 NONPOWERED PRESSURE MATTRESS $0.00
E0400 O OXYGEN CONTENTS, GASEOUS, PER CUBIC $0.00
E0405 O OXYGEN CONTENTS, GASEOUS, PER 100 C $0.00

E0410 O OXYGEN CONTENTS, LIQUID, PER POUND $0.00
E0415 O OXYGEN CONTENTS, LIQUID, PER 100 PO $0.00
E0416 O OXYGEN REFILL FOR PORTABLE GASEOUS $0.00
E0424 3 STATIONARY COMPRESSED GAS 02 $1.00
E0425 5 GAS SYSTEM STATIONARY COMPRE $0.00
E0430 5 OXYGEN SYSTEM GAS PORTABLE $0.00
E0431 3 PORTABLE GASEOUS 02 $0.00
E0434 3 PORTABLE LIQUID 02 $1.00
E0435 5 OXYGEN SYSTEM LIQUID PORTABL $0.00
E0439 3 STATIONARY LIQUID 02 $1.00
E0440 5 OXYGEN SYSTEM LIQUID STATION $0.00
E0441 3 OXYGEN CONTENTS, GASEOUS $148.00

E0442 3 OXYGEN CONTENTS, LIQUID $148.00
E0443 3 PORTABLE 02 CONTENTS, GAS $18.31
E0444 3 PORTABLE 02 CONTENTS, LIQUID $18.31
E0445 3 OXIMETER NON-INVASIVE $1.00
E0450 3 VOL CONTROL VENT INVASIV INT $1.00
E0451 O VOLUME VENTILATOR; PORTABLE (INCLUD $0.00
E0452 O INTERMIT ASSIS DEVICE W CPAP $0.00
E0453 9 VENTILATOR 12 HRS/LESS PER D $0.00
E0454 O PRESSURE VENTILATOR $0.00
E0455 O OXYGEN TENT EXCL CROUP/PED T $0.00

E0457 3 CHEST SHELL $0.00
E0458 9 NEGATIVE PRESSURE PUMP $0.00
E0459 3 CHEST WRAP $458.40
E0460 O NEG PRESS VENT PORTABL/STATN $0.00
E0461 5 VOL CONTROL VENT NONINV INT $0.00
E0462 3 ROCKING BED W/ OR W/O SIDE R $2,625.00
E0463 6 PRESS SUPP VENT INVASIVE INT $0.00
E0464 6 PRESS SUPP VENT NONINV INT $0.00
E0470 3 RAD W/O BACKUP NON-INV INTFC $0.00
E0471 3 RAD W/BACKUP NON INV INTRFC $0.00
E0472 6 RAD W BACKUP INVASIVE INTRFC $0.00
E0480 3 PERCUSSOR ELECT/PNEUM HOME M $395.80
E0481 5 INTRPULMNRY PERCUSS VENT SYS $0.00

E0482 5 COUGH STIMULATING DEVICE $0.00
E0483 5 CHEST COMPRESSION GEN SYSTEM $0.00
E0484 3 NON-ELEC OSCILLATORY PEP DVC $36.92
E0485 6 ORAL DEVICE/APPLIANCE PREFAB $0.00
E0486 6 ORAL DEVICE/APPLIANCE CUSFAB $0.00
E0487 6 ELECTRONIC SPIROMETER $0.00
E0500 3 IPPB ALL TYPES $0.00
E0505 9 IPPB MACHINES WITH MANUAL VALVES EL $0.00
E0510 9 IPPB MACHINES WITH AUTOMATIC VALVES $0.00
E0515 9 IPPB MACHINES WITH AUTOMATIC VALVES $0.00
E0550 3 HUMIDIF EXTENS SUPPLE W IPPB $451.60
E0555 9 HUMIDIFIER FOR USE W/ REGULA $0.00

E0560 3 HUMIDIFIER SUPPLEMENTAL W/ I $164.09
E0561 3 HUMIDIFIER NONHEATED W PAP $107.00
E0562 3 HUMIDIFIER HEATED USED W PAP $301.22
E0565 3 COMPRESSOR AIR POWER SOURCE $467.20
E0570 3 NEBULIZER WITH COMPRESSION $177.80
E0571 5 AEROSOL COMPRESSOR FOR SVNEB $0.00
E0572 5 AEROSOL COMPRESSOR ADJUST PR $0.00
E0574 5 ULTRASONIC GENERATOR W SVNEB $0.00
E0575 3 NEBULIZER ULTRASONIC $530.00
E0580 9 NEBULIZER FOR USE W/ REGULAT $0.00

E0585 3 NEBULIZER W/ COMPRESSOR & HE $315.90
E0590 O DISPENSING FEE DME NEB DRUG $0.00
E0600 3 SUCTION PUMP PORTAB HOM MODL $1.00
E0601 3 CONT AIRWAY PRESSURE DEVICE $0.00
E0602 9 MANUAL BREAST PUMP $0.00
E0603 3 ELECTRIC BREAST PUMP $742.80
E0604 5 HOSP GRADE ELEC BREAST PUMP $0.00
E0605 3 VAPORIZER ROOM TYPE $25.29
E0606 3 DRAINAGE BOARD POSTURAL $175.60
E0607 9 BLOOD GLUCOSE MONITOR HOME $0.00
E0608 O APNEA MONITOR $0.00
E0609 O BLOOD GLUC MON W/SPECIAL FEA $0.00
E0610 3 PACEMAKER MONITR AUDIBLE/VIS $227.56

E0615 3 PACEMAKER MONITR DIGITAL/VIS $403.28
E0616 9 CARDIAC EVENT RECORDER $0.00
E0617 5 AUTOMATIC EXT DEFIBRILLATOR $0.00
E0618 3 APNEA MONITOR $3,000.00
E0619 3 APNEA MONITOR W RECORDER $1.00
E0620 9 CAP BLD SKIN PIERCING LASER $0.00
E0621 3 PATIENT LIFT SLING OR SEAT $91.83
E0625 5 PATIENT LIFT BATHROOM OR TOI $0.00
E0627 3 SEAT LIFT INCORP LIFT-CHAIR $316.39
E0628 3 SEAT LIFT FOR PT FURN-ELECTR $316.39
E0629 3 SEAT LIFT FOR PT FURN-NON-EL $316.39
E0630 3 PATIENT LIFT HYDRAULIC $917.70

E0635 3 PATIENT LIFT ELECTRIC $936.90
E0636 5 PT SUPPORT & POSITIONING SYS $0.00
E0637 6 COMBINATION SIT TO STAND SYS $0.00
E0638 6 STANDING FRAME SYS $0.00
E0639 6 MOVEABLE PATIENT LIFT SYSTEM $0.00
E0640 6 FIXED PATIENT LIFT SYSTEM $0.00
E0641 6 MULTI-POSITION STND FRAM SYS $0.00
E0642 6 DYNAMIC STANDING FRAME $0.00
E0650 3 PNEUMA COMPRESOR NON-SEGMENT $689.02
E0651 3 PNEUM COMPRESSOR SEGMENTAL $878.65

E0652 3 PNEUM COMPRES W/CAL PRESSURE $5,012.71
E0655 3 PNEUMATIC APPLIANCE HALF ARM $87.76
E0656 6 SEGMENTAL PNEUMATIC TRUNK $0.00
E0657 6 SEGMENTAL PNEUMATIC CHEST $0.00
E0660 3 PNEUMATIC APPLIANCE FULL LEG $139.07
E0665 3 PNEUMATIC APPLIANCE FULL ARM $111.40
E0666 3 PNEUMATIC APPLIANCE HALF LEG $112.29
E0667 3 SEG PNEUMATIC APPL FULL LEG $309.75
E0668 3 SEG PNEUMATIC APPL FULL ARM $359.33
E0669 3 SEG PNEUMATIC APPLI HALF LEG $166.53
E0670 O SEGMENTAL PNEUMATIC APPLIANCE FOR U $0.00
E0671 9 PRESSURE PNEUM APPL FULL LEG $0.00
E0672 9 PRESSURE PNEUM APPL FULL ARM $0.00

E0673 9 PRESSURE PNEUM APPL HALF LEG $0.00
E0675 6 PNEUMATIC COMPRESSION DEVICE $0.00
E0676 6 INTER LIMB COMPRESS DEV NOS $0.00
E0690 O ULTRAVIOLET CABINET $0.00
E0691 5 UVL PNL 2 SQ FT OR LESS $0.00
E0692 5 UVL SYS PANEL 4 FT $0.00
E0693 5 UVL SYS PANEL 6 FT $0.00
E0694 5 UVL MD CABINET SYS 6 FT $0.00
E0700 5 SAFETY EQUIPMENT $0.00
E0701 O HELMET W FACE GUARD PREFAB $0.00
E0705 6 TRANSFER DEVICE $0.00
E0710 5 RESTRAINTS ANY TYPE $0.00

E0720 3 TENS TWO LEAD $314.34
E0730 3 TENS FOUR LEAD $354.51
E0731 3 CONDUCTIVE GARMENT FOR TENS/ $341.24
E0740 9 INCONTINENCE TREATMENT SYSTM $0.00
E0744 3 NEUROMUSCULAR STIM FOR SCOLI $824.90
E0745 3 NEUROMUSCULAR STIM FOR SHOCK $806.30
E0746 O ELECTROMYOGRAPH BIOFEEDBACK $0.00
E0747 3 ELEC OSTEOGEN STIM NOT SPINE $3,774.74
E0748 3 ELEC OSTEOGEN STIM SPINAL $3,890.70
E0749 O ELEC OSTEOGEN STIM IMPLANTED $0.00

E0750 O IMPLANTABLE ELECTRICAL NERVE STIMUL $0.00
E0751 9 PULSE GENERATOR OR RECEIVER $0.00
E0752 O NEUROSTIMULATOR ELECTRODE $0.00
E0753 9 NEUROSTIMULATOR ELECTRODES $0.00
E0754 O PULSEGENERATOR PT PROGRAMMER $0.00
E0755 5 ELECTRONIC SALIVARY REFLEX S $0.00
E0756 O IMPLANTABLE PULSE GENERATOR $0.00
E0757 O IMPLANTABLE RF RECEIVER $0.00
E0758 O EXTERNAL RF TRANSMITTER $0.00
E0759 O REPLACE RDFRQUNCY TRANSMITTR $0.00
E0760 9 OSTEOGEN ULTRASOUND STIMLTOR $0.00
E0761 5 NONTHERM ELECTROMGNTC DEVICE $0.00
E0762 6 TRANS ELEC JT STIM DEV SYS $0.00

E0764 6 FUNCTIONAL NEUROMUSCULARSTIM $0.00
E0765 5 NERVE STIMULATOR FOR TX N&V $0.00
E0769 6 ELECTRIC WOUND TREATMENT DEV $0.00
E0770 6 FUNCTIONAL ELECTRIC STIM NOS $0.00
E0776 3 IV POLE $136.96
E0779 3 AMB INFUSION PUMP MECHANICAL $15.67
E0780 3 MECH AMB INFUSION PUMP <8HRS $9.92
E0781 3 EXTERNAL AMBULATORY INFUS PU $2,484.00
E0782 O NON-PROGRAMBLE INFUSION PUMP $0.00
E0783 9 PROGRAMMABLE INFUSION PUMP $0.00
E0784 5 EXT AMB INFUSN PUMP INSULIN $0.00
E0785 9 REPLACEMENT IMPL PUMP CATHET $0.00

E0786 9 IMPLANTABLE PUMP REPLACEMENT $0.00
E0791 3 PARENTERAL INFUSION PUMP STA $2,421.20
E0830 5 AMBULATORY TRACTION DEVICE $0.00
E0840 3 TRACT FRAME ATTACH HEADBOARD $59.59
E0849 6 CERVICAL PNEUM TRAC EQUIP $0.00
E0850 3 TRACTION STAND FREE STANDING $85.43
E0855 3 CERVICAL TRACTION EQUIPMENT $480.86
E0856 6 CERVIC COLLAR W AIR BLADDER $0.00
E0860 3 TRACT EQUIP CERVICAL TRACT $36.86
E0870 3 TRACT FRAME ATTACH FOOTBOARD $100.51

E0880 3 TRAC STAND FREE STAND EXTREM $102.09
E0890 3 TRACTION FRAME ATTACH PELVIC $97.91
E0900 3 TRAC STAND FREE STAND PELVIC $104.19
E0910 3 TRAPEZE BAR ATTACHED TO BED $180.20
E0911 6 HD TRAPEZE BAR ATTACH TO BED $0.00
E0912 6 HD TRAPEZE BAR FREE STANDING $0.00
E0920 3 FRACTURE FRAME ATTACHED TO B $415.70
E0930 3 FRACTURE FRAME FREE STANDING $372.00
E0935 5 CONT PAS MOTION EXERCISE DEV $0.00
E0936 6 CPM DEVICE, OTHER THAN KNEE $0.00
E0940 3 TRAPEZE BAR FREE STANDING $313.20
E0941 3 GRAVITY ASSISTED TRACTION DE $363.00
E0942 3 CERVICAL HEAD HARNESS/HALTER $18.99

E0943 O CERVICAL PILLOW $0.00
E0944 3 PELVIC BELT/HARNESS/BOOT $43.89
E0945 3 BELT/HARNESS EXTREMITY $42.41
E0946 3 FRACTURE FRAME DUAL W CROSS $532.90
E0947 3 FRACTURE FRAME ATTACHMNTS PE $580.20
E0948 3 FRACTURE FRAME ATTACHMNTS CE $561.19
E0950 3 TRAY $99.45
E0951 3 LOOP HEEL $18.02
E0952 3 TOE LOOP/HOLDER, EACH $18.02
E0953 O PNEUMATIC TIRE $0.00
E0954 O WHEELCHAIR SEMI-PNEUMATIC CA $0.00
E0955 6 CUSHIONED HEADREST $0.00

E0956 6 W/C LATERAL TRUNK/HIP SUPPOR $0.00
E0957 6 W/C MEDIAL THIGH SUPPORT $0.00
E0958 3 WHLCHR ATT- CONV 1 ARM DRIVE $393.10
E0959 3 AMPUTEE ADAPTER $84.59
E0960 6 W/C SHOULDER HARNESS/STRAPS $0.00
E0961 3 WHEELCHAIR BRAKE EXTENSION $27.82
E0962 O WHEELCHAIR 1 INCH CUSHION $0.00

E0966 3 WHEELCHAIR HEAD REST EXTENSI $61.94
E0967 3 MANUAL WC HAND RIM W PROJECT $126.41
E0968 3 WHEELCHAIR COMMODE SEAT $161.60
E0969 3 WHEELCHAIR NARROWING DEVICE $139.86
E0970 3 WHEELCHAIR NO. 2 FOOTPLATES $46.08
E0971 3 WHEELCHAIR ANTI-TIPPING DEVI $62.90
E0972 O TRANSFER BOARD OR DEVICE $0.00
E0973 3 W/CH ACCESS DET ADJ ARMREST $109.99
E0974 3 W/CH ACCESS ANTI-ROLLBACK $75.59
E0975 O WHEELCHAIR REINFORCED SEAT U $0.00
E0976 O WHEELCHAIR REINFORCED BACK U $0.00
E0977 O WHEELCHAIR WEDGE CUSHION $0.00
E0978 3 W/C ACC,SAF BELT PELV STRAP $42.81

E0979 O WHEELCHAIR BELT WITH VELCRO $0.00
E0980 3 WHEELCHAIR SAFETY VEST $31.62
E0981 6 SEAT UPHOLSTERY, REPLACEMENT $0.00
E0982 6 BACK UPHOLSTERY, REPLACEMENT $0.00
E0983 6 ADD PWR JOYSTICK $0.00
E0984 6 ADD PWR TILLER $0.00
E0985 6 W/C SEAT LIFT MECHANISM $0.00
E0986 6 MAN W/C PUSH-RIM POW ASSIST $0.00
E0990 3 WHELLCHAIR ELEVATING LEG RES $112.35
E0991 O WHEELCHAIR UPHOLSTRY SEAT $0.00
E0992 3 WHEELCHAIR SOLID SEAT INSERT $88.48
E0993 O WHEELCHAIR BACK UPHOLSTERY $0.00

E0994 3 WHEELCHAIR ARM REST $15.18
E0995 3 WHEELCHAIR CALF REST $25.29
E0996 O WHEELCHAIR TIRE SOLID $0.00
E0997 O WHEELCHAIR CASTER W/ A FORK $0.00
E0998 O WHEELCHAIR CASTER W/O A FORK $0.00
E0999 O WHEELCHR PNEUMATIC TIRE W/WH $0.00
E1000 O WHEELCHAIR TIRE PNEUMATIC CA $0.00
E1001 O WHEELCHAIR WHEEL $0.00
E1002 6 PWR SEAT TILT $0.00
E1003 6 PWR SEAT RECLINE $0.00

E1004 6 PWR SEAT RECLINE MECH $0.00
E1005 6 WHEELCHAIR ACCESSORY, POWER SEAT $0.00
E1006 6 PWR SEAT COMBO W/O SHEAR $0.00
E1007 3 PWR SEAT COMBO W/SHEAR $8,741.27
E1008 3 PWR SEAT COMBO PWR SHEAR $8,742.05
E1009 6 ADD MECH LEG ELEVATION $0.00
E1010 6 ADD PWR LEG ELEVATION $0.00
E1011 5 PED WC MODIFY WIDTH ADJUSTM $0.00
E1012 O INT SEAT SYS PLANAR PED W/C $0.00
E1013 O INT SEAT SYS CONTOUR PED W/C $0.00
E1014 5 RECLINING BACK ADD PED W/C $0.00
E1015 5 SHOCK ABSORBER FOR MAN W/C $0.00
E1016 5 SHOCK ABSORBER FOR POWER W/C $0.00

E1017 5 HD SHCK ABSRBR FOR HD MAN WC $0.00
E1018 5 HD SHCK ABSRBER FOR HD POWWC $0.00
E1020 5 RESIDUAL LIMB SUPPORT SYSTEM $0.00
E1025 O PEDWC LAT/THOR SUP NOCONTOUR $0.00
E1026 O PEDWC CONTOURED LAT/THOR SUP $0.00
E1027 O PED WC LAT/ANT SUPPORT $0.00
E1028 3 W/C MANUAL SWINGAWAY $206.54
E1029 6 W/C VENT TRAY FIXED $0.00
E1030 6 W/C VENT TRAY GIMBALED $0.00
E1031 3 ROLLABOUT CHAIR WITH CASTERS $455.00
E1035 5 PATIENT TRANSFER SYSTEM $0.00
E1037 5 TRANSPORT CHAIR, PED SIZE $0.00

E1038 5 TRANSPORT CHAIR PT WT<=300LB $0.00
E1039 6 TRANSPORT CHAIR PT WT >300LB $0.00
E1050 3 WHELCHR FXD FULL LENGTH ARMS $917.40
E1060 3 WHEELCHAIR DETACHABLE ARMS $1,135.60
E1065 O WHEELCHAIR POWER ATTACHMENT $0.00
E1066 O WHEELCHAIR BATTERY CHARGER $0.00
E1069 O WHEELCHAIR DEEP CYCLE BATTER $0.00
E1070 3 WHEELCHAIR DETACHABLE FOOT R $838.60
E1083 3 HEMI-WHEELCHAIR FIXED ARMS $709.40
E1084 3 HEMI-WHEELCHAIR DETACHABLE A $883.70

E1085 3 HEMI-WHEELCHAIR FIXED ARMS $623.40
E1086 3 HEMI-WHEELCHAIR DETACHABLE A $757.10
E1087 3 WHEELCHAIR LIGHTWT FIXED ARM $1,139.60
E1088 3 WHEELCHAIR LIGHTWEIGHT DET A $1,358.29
E1089 3 WHEELCHAIR LIGHTWT FIXED ARM $1,082.80
E1090 3 WHEELCHAIR LIGHTWEIGHT DET A $1,042.60
E1091 3 WHEELCHAIR YOUTH $751.00
E1092 3 WHEELCHAIR WIDE W/ LEG RESTS $1,157.70
E1093 3 WHEELCHAIR WIDE W/ FOOT REST $995.60
E1100 3 WHCHR S-RECL FXD ARM LEG RES $935.10
E1110 3 WHEELCHAIR SEMI-RECL DETACH $778.30
E1130 3 WHLCHR STAND FXD ARM FT REST $420.70
E1140 3 WHEELCHAIR STANDARD DETACH A $647.00

E1150 3 WHEELCHAIR STANDARD W/ LEG R $735.00
E1160 3 WHEELCHAIR FIXED ARMS $563.00
E1161 5 MANUAL ADULT WC W TILTINSPAC $0.00
E1170 3 WHLCHR AMPU FXD ARM LEG REST $804.60
E1171 3 WHEELCHAIR AMPUTEE W/O LEG R $643.40
E1172 3 WHEELCHAIR AMPUTEE DETACH AR $827.40
E1180 3 WHEELCHAIR AMPUTEE W/ FOOT R $776.00
E1190 3 WHEELCHAIR AMPUTEE W/ LEG RE $1,054.70
E1195 3 WHEELCHAIR AMPUTEE HEAVY DUT $961.90
E1200 3 WHEELCHAIR AMPUTEE FIXED ARM $689.20
E1210 O WHLCHR MOTO FUL ARM LEG REST $0.00
E1211 O WHEELCHAIR MOTORIZED W/ DET $0.00

E1212 O WHEELCHAIR MOTORIZED W FULL $0.00
E1213 O WHEELCHAIR MOTORIZED W/ DET $0.00
E1220 5 WHLCHR SPECIAL SIZE/CONSTRC $0.00
E1221 3 WHEELCHAIR SPEC SIZE W FOOT $428.10
E1222 3 WHEELCHAIR SPEC SIZE W/ LEG $610.70
E1223 3 WHEELCHAIR SPEC SIZE W FOOT $666.80
E1224 3 WHEELCHAIR SPEC SIZE W/ LEG $731.10
E1225 3 MANUAL SEMI-RECLINING BACK $407.20
E1226 3 MANUAL FULLY RECLINING BACK $522.01
E1227 3 WHEELCHAIR SPEC SZ SPEC HT A $265.23

E1228 3 WHEELCHAIR SPEC SZ SPEC HT B $214.50
E1229 6 PEDIATRIC WHEELCHAIR NOS $0.00
E1230 3 POWER OPERATED VEHICLE $1,946.92
E1231 5 RIGID PED W/C TILT-IN-SPACE $0.00
E1232 5 FOLDING PED WC TILT-IN-SPACE $0.00
E1233 5 RIG PED WC TLTNSPC W/O SEAT $0.00
E1234 5 FLD PED WC TLTNSPC W/O SEAT $0.00
E1235 5 RIGID PED WC ADJUSTABLE $0.00
E1236 5 FOLDING PED WC ADJUSTABLE $0.00
E1237 5 RGD PED WC ADJSTABL W/O SEAT $0.00
E1238 5 FLD PED WC ADJSTABL W/O SEAT $0.00
E1239 6 PED POWER WHEELCHAIR NOS $0.00
E1240 3 WHCHR LITWT DET ARM LEG REST $928.10

E1250 3 WHEELCHAIR LIGHTWT FIXED ARM $684.70
E1260 3 WHEELCHAIR LIGHTWT FOOT REST $713.70
E1270 3 WHEELCHAIR LIGHTWEIGHT LEG R $604.40
E1280 3 WHCHR H-DUTY DET ARM LEG RES $1,005.00
E1285 3 WHEELCHAIR HEAVY DUTY FIXED $923.50
E1290 3 WHEELCHAIR HVY DUTY DETACH A $958.20
E1295 3 WHEELCHAIR HEAVY DUTY FIXED $1,046.20
E1296 3 WHEELCHAIR SPECIAL SEAT HEIG $399.82
E1297 3 WHEELCHAIR SPECIAL SEAT DEPT $85.07
E1298 3 WHEELCHAIR SPEC SEAT DEPTH/W $365.36
E1300 5 WHIRLPOOL PORTABLE $0.00
E1310 3 WHIRLPOOL NON-PORTABLE $2,054.39

E1340 3 REPAIR FOR DME, PER 15 MIN $25.00
E1350 O REPAIR OR NON-ROUTINE SERVICE (E.G. $0.00
E1353 5 OXYGEN SUPPLIES REGULATOR $0.00
E1354 6 WHEELED CART, PORT CYL/CONC $0.00
E1355 3 OXYGEN SUPPLIES STAND/RACK $46.67
E1356 O BREATHING CIRCUITS $0.00
E1357 6 BATTERY CHARGER, PORT CONC $0.00
E1358 6 DC POWER ADAPTER, PORT CONC $0.00
E1372 3 OXY SUPPL HEATER FOR NEBULIZ $155.98
E1375 O OXYGEN SUPPL NEBULIZER PORTA $0.00

E1377 O OXYGEN CONCENTRATOR TO 244 C $0.00
E1381 O OXYGEN CONCENTRAT TO 1220 CU $0.00
E1385 O OXYGEN CONCENTRATOR > 1952 C $0.00
E1388 O OXYGEN CONCENTRATOR, EQUIVALENT TO $0.00
E1390 3 OXYGEN CONCENTRATOR $0.00
E1391 6 OXYGEN CONCENTRATOR $0.00

E1392 6 PORTABLE OXYGEN CONCENTRATOR $0.00
E1399 3 DURABLE MEDICAL EQUIPMENT MI $325.00
E1400 9 OXYGEN CONCENTRATOR < 2 LITE $0.00
E1401 O OXYGEN CONCENTRATOR 2-3 LITE $0.00
E1404 9 OXYGEN CONCENTRATOR > 5 LITE $0.00
E1405 5 O2/WATER VAPOR ENRICH W/HEAT $0.00

E1406 5 O2/WATER VAPOR ENRICH W/O HE $0.00
E1500 9 CENTRIFUGE $0.00
E1510 5 KIDNEY DIALYSATE DELIVRY SYS $0.00
E1520 5 HEPARIN INFUSION PUMP $0.00
E1530 5 REPLACEMENT AIR BUBBLE DETEC $0.00
E1540 5 REPLACEMENT PRESSURE ALARM $0.00
E1550 5 BATH CONDUCTIVITY METER $0.00
E1560 5 REPLACE BLOOD LEAK DETECTOR $0.00
E1570 5 ADJUSTABLE CHAIR FOR ESRD PT $0.00
E1575 5 TRANSDUCER PROTECT/FLD BAR $0.00

E1580 5 UNIPUNCTURE CONTROL SYSTEM $0.00
E1590 5 HEMODIALYSIS MACHINE $0.00
E1592 5 AUTO INTERM PERITONEAL DIALY $0.00
E1594 5 CYCLER DIALYSIS MACHINE $0.00
E1600 5 DELI/INSTALL CHRG HEMO EQUIP $0.00
E1610 5 REVERSE OSMOSIS H2O PURI SYS $0.00
E1615 5 DEIONIZER H2O PURI SYSTEM $0.00
E1620 5 REPLACEMENT BLOOD PUMP $0.00
E1625 5 WATER SOFTENING SYSTEM $0.00
E1630 5 RECIPROCATING PERITONEAL DIA $0.00
E1632 5 WEARABLE ARTIFICIAL KIDNEY $0.00
E1634 6 PERITONEAL DIALYSIS CLAMP $0.00
E1635 5 COMPACT TRAVEL HEMODIALYZER $0.00

E1636 5 SORBENT CARTRIDGES PER 10 $0.00
E1637 9 HEMOSTATS FOR DIALYSIS, EACH $0.00
E1638 9 PERI DIALYSIS HEATING PAD $0.00
E1639 9 DIALYSIS SCALE $0.00
E1640 O REPLACEMENT COMPONENTS FOR D $0.00
E1699 5 DIALYSIS EQUIPMENT NOC $0.00
E1700 O JAW MOTION REHAB SYSTEM $0.00
E1701 O REPL CUSHIONS FOR JAW MOTION $0.00
E1702 O REPL MEASR SCALES JAW MOTION $0.00
E1800 9 ADJUST ELBOW EXT/FLEX DEVICE $0.00
E1801 9 SPS ELBOW DEVICE $0.00
E1802 5 ADJST FOREARM PRO/SUP DEVICE $0.00

E1805 9 ADJUST WRIST EXT/FLEX DEVICE $0.00
E1806 9 SPS WRIST DEVICE $0.00
E1810 9 ADJUST KNEE EXT/FLEX DEVICE $0.00
E1811 9 SPS KNEE DEVICE $0.00
E1812 6 KNEE EXT/FLEX W ACT RES CTRL $0.00
E1815 9 ADJUST ANKLE EXT/FLEX DEVICE $0.00
E1816 9 SPS ANKLE DEVICE $0.00
E1818 9 SPS FOREARM DEVICE $0.00
E1820 9 SOFT INTERFACE MATERIAL $0.00
E1821 9 REPLACEMENT INTERFACE SPSD $0.00

E1825 9 ADJUST FINGER EXT/FLEX DEVC $0.00
E1830 9 ADJUST TOE EXT/FLEX DEVICE $0.00
E1840 9 ADJ SHOULDER EXT/FLEX DEVICE $0.00
E1841 6 STATIC STR SHLDR DEV ROM ADJ $0.00
E1900 O SPEECH COMMUNICATION DEVICE $0.00
E1902 5 AAC NON-ELECTRONIC BOARD $0.00
E2000 3 GASTRIC SUCTION PUMP HME MDL $1.00
E2100 5 BLD GLUCOSE MONITOR W VOICE $0.00
E2101 5 BLD GLUCOSE MONITOR W LANCE $0.00
E2120 6 PULSE GEN SYS TX ENDOLYMP FL $0.00
E2201 6 MAN W/CH ACC SEAT W>=20"<24" $0.00
E2202 6 SEAT WIDTH 24-27 IN $0.00
E2203 6 FRAME DEPTH LESS THAN 22 IN $0.00

E2204 6 FRAME DEPTH 22 TO 25 IN $0.00
E2205 6 MANUAL WC ACCESSORY, HANDRIM $0.00
E2206 3 COMPLETE WHEEL LOCK ASSEMBLY $40.68
E2207 6 CRUTCH AND CANE HOLDER $0.00
E2208 6 CYLINDER TANK CARRIER $0.00
E2209 6 ARM TROUGH EACH $0.00
E2210 6 WHEELCHAIR BEARINGS $0.00
E2211 6 PNEUMATIC PROPULSION TIRE $0.00
E2212 6 PNEUMATIC PROP TIRE TUBE $0.00
E2213 6 PNEUMATIC PROP TIRE INSERT $0.00
E2214 6 PNEUMATIC CASTER TIRE EACH $0.00
E2215 6 PNEUMATIC CASTER TIRE TUBE $0.00

E2216 6 FOAM FILLED PROPULSION TIRE $0.00
E2217 6 FOAM FILLED CASTER TIRE EACH $0.00
E2218 6 FOAM PROPULSION TIRE EACH $0.00
E2219 6 FOAM CASTER TIRE ANY SIZE EA $0.00
E2220 6 SOLID PROPULSION TIRE EACH $0.00
E2221 6 SOLID CASTER TIRE EACH $0.00
E2222 6 SOLID CASTER INTEGRATED WHL $0.00
E2223 6 VALVE REPLACEMENT ONLY EACH $0.00
E2224 6 PROPULSION WHL EXCLUDES TIRE $0.00
E2225 6 CASTER WHEEL EXCLUDES TIRE $0.00

E2226 6 CASTER FORK REPLACEMENT ONLY $0.00
E2227 6 GEAR REDUCTION DRIVE WHEEL $0.00
E2228 6 MWC ACC, WHEELCHAIR BRAKE $0.00
E2230 6 MANUAL STANDING SYSTEM $0.00
E2231 6 SOLID SEAT SUPPORT BASE $0.00
E2291 6 PLANAR BACK FOR PED SIZE WC $0.00
E2292 6 PLANAR SEAT FOR PED SIZE WC $0.00
E2293 6 CONTOUR BACK FOR PED SIZE WC $0.00
E2294 6 CONTOUR SEAT FOR PED SIZE WC $0.00
E2295 6 PED DYNAMIC SEATING FRAME $0.00
E2300 6 PWR SEAT ELEVATION SYS $0.00
E2301 6 PWR STANDING $0.00
E2310 6 ELECTRO CONNECT BTW CONTROL $0.00

E2311 3 ELECTRO CONNECT BTW 2 SYS $2,369.20
E2312 6 MINI-PROP REMOTE JOYSTICK $0.00
E2313 6 PWC HARNESS, EXPAND CONTROL $0.00
E2320 O HAND CHIN CONTROL $0.00
E2321 6 HAND INTERFACE JOYSTICK $0.00
E2322 6 MULT MECH SWITCHES $0.00
E2323 6 SPECIAL JOYSTICK HANDLE $0.00
E2324 6 CHIN CUP INTERFACE $0.00
E2325 6 SIP AND PUFF INTERFACE $0.00
E2326 6 BREATH TUBE KIT $0.00
E2327 6 HEAD CONTROL INTERFACE MECH $0.00
E2328 6 HEAD/EXTREMITY CONTROL INTER $0.00

E2329 6 HEAD CONTROL NONPROPORTIONAL $0.00
E2330 6 HEAD CONTROL PROXIMITY SWITC $0.00
E2331 6 ATTENDANT CONTROL $0.00
E2340 6 W/C WDTH 20-23 IN SEAT FRAME $0.00
E2341 6 W/C WDTH 24-27 IN SEAT FRAME $0.00
E2342 6 W/C DPTH 20-21 IN SEAT FRAME $0.00
E2343 6 W/C DPTH 22-25 IN SEAT FRAME $0.00
E2351 6 ELECTRONIC SGD INTERFACE $0.00
E2360 3 22NF NONSEALED LEADACID $112.34
E2361 3 22NF SEALED LEADACID BATTERY $139.47

E2362 3 GR24 NONSEALED LEADACID $91.98
E2363 3 GR24 SEALED LEADACID BATTERY $186.00
E2364 3 U1NONSEALED LEADACID BATTERY $112.34
E2365 3 U1 SEALED LEADACID BATTERY $112.17
E2366 3 BATTERY CHARGER, SINGLE MODE $263.62
E2367 3 BATTERY CHARGER, DUAL MODE $419.07
E2368 6 POWER WC MOTOR REPLACEMENT $0.00
E2369 6 PWR WC GEAR BOX REPLACEMENT $0.00
E2370 6 PWR WC MOTOR/GEAR BOX COMBO $0.00
E2371 6 GR27 SEALED LEADACID BATTERY $0.00
E2372 6 GR27 NON-SEALED LEADACID $0.00
E2373 6 HAND/CHIN CTRL SPEC JOYSTICK $0.00
E2374 6 HAND/CHIN CTRL STD JOYSTICK $0.00

E2375 6 NON-EXPANDABLE CONTROLLER $0.00
E2376 6 EXPANDABLE CONTROLLER, REPL $0.00
E2377 6 EXPANDABLE CONTROLLER, INITL $0.00
E2381 6 PNEUM DRIVE WHEEL TIRE $0.00
E2382 6 TUBE, PNEUM WHEEL DRIVE TIRE $0.00
E2383 6 INSERT, PNEUM WHEEL DRIVE $0.00
E2384 6 PNEUMATIC CASTER TIRE $0.00
E2385 6 TUBE, PNEUMATIC CASTER TIRE $0.00
E2386 6 FOAM FILLED DRIVE WHEEL TIRE $0.00
E2387 6 FOAM FILLED CASTER TIRE $0.00
E2388 6 FOAM DRIVE WHEEL TIRE $0.00
E2389 6 FOAM CASTER TIRE $0.00

E2390 6 SOLID DRIVE WHEEL TIRE $0.00
E2391 6 SOLID CASTER TIRE $0.00
E2392 6 SOLID CASTER TIRE, INTEGRATE $0.00
E2393 6 VALVE, PNEUMATIC TIRE TUBE $0.00
E2394 6 DRIVE WHEEL EXCLUDES TIRE $0.00
E2395 6 CASTER WHEEL EXCLUDES TIRE $0.00
E2396 6 CASTER FORK $0.00
E2397 6 PWC ACC, LITH-BASED BATTERY $0.00
E2399 6 NOC INTERFACE $0.00
E2402 6 NEG PRESS WOUND THERAPY PUMP $0.00

E2500 6 SGD DIGITIZED PRE-REC <=8MIN $0.00
E2502 6 SGD PREREC MSG >8MIN <=20MIN $0.00
E2504 6 SGD PREREC MSG>20MIN <=40MIN $0.00
E2506 6 SGD PREREC MSG > 40 MIN $0.00
E2508 6 SGD SPELLING PHYS CONTACT $0.00
E2510 6 SGD W MULTI METHODS MSG/ACCS $0.00
E2511 6 SGD SFTWRE PRGRM FOR PC/PDA $0.00
E2512 6 SGD ACCESSORY, MOUNTING SYS $0.00
E2599 6 SGD ACCESSORY NOC $0.00
E2601 6 GEN W/C CUSHION WDTH < 22 IN $0.00
E2602 6 GEN W/C CUSHION WDTH >=22 IN $0.00
E2603 6 SKIN PROTECT WC CUS WD <22IN $0.00
E2604 6 SKIN PROTECT WC CUS WD>=22IN $0.00

E2605 6 POSITION WC CUSH WDTH <22 IN $0.00
E2606 6 POSITION WC CUSH WDTH>=22 IN $0.00
E2607 6 SKIN PRO/POS WC CUS WD <22IN $0.00
E2608 6 SKIN PRO/POS WC CUS WD>=22IN $0.00
E2609 6 CUSTOM FABRICATE W/C CUSHION $0.00
E2610 6 POWERED W/C CUSHION $0.00
E2611 6 GEN USE BACK CUSH WDTH <22IN $0.00
E2612 6 GEN USE BACK CUSH WDTH>=22IN $0.00
E2613 6 POSITION BACK CUSH WD <22IN $0.00
E2614 6 POSITION BACK CUSH WD>=22IN $0.00
E2615 6 POS BACK POST/LAT WDTH <22IN $0.00
E2616 6 POS BACK POST/LAT WDTH>=22IN $0.00

E2617 6 CUSTOM FAB W/C BACK CUSHION $0.00
E2618 O WC ACC SOLID SEAT SUPP BASE $0.00
E2619 6 REPLACE COVER W/C SEAT CUSH $0.00
E2620 6 WC PLANAR BACK CUSH WD <22IN $0.00
E2621 6 WC PLANAR BACK CUSH WD>=22IN $0.00
E4610 9 LANCET DEVICE $0.00
E8000 6 POSTERIOR GAIT TRAINER $0.00
E8001 6 UPRIGHT GAIT TRAINER $0.00
E8002 6 ANTERIOR GAIT TRAINER $0.00
EDUCW O MCO SPECIFIC CODE: SMART START INDI $0.00

EDURN O MCO SPECIFIC CODE: SMART START INDI $0.00
EDUSW O MCO SPECIFIC CODE: SMART START INDI $0.00
EXRCL O MCO SPECIFIC CODE: SMART START PRE $0.00
FS001 O MCO SPECIFIC CODE: FULL BABY FIRST $0.00
FS002 O MCO SPECIFIC CODE: LATE REFERRAL BA $0.00
FS003 O MCO SPECIFIC CODE: PARTIAL BABY FIR $0.00
FS100 O MCO SPECIFIC CODE: PREGNANT MOTHER $0.00
FS104 O MCO SPECIFIC CODE: SMART START, PRE $0.00

FS110 O MCO SPECIFIC CODE: RESOURCE MOTHER' $0.00
FS111 O MCO SPECIFIC CODE: RESOURCE MOTHER' $0.00
FS112 O MCO SPECIFIC CODE: RSEOURCE MOTHER' $0.00
FS912 O MCO SPECIFIC CODE: NEOCATE 1+, 100 $0.00
FS913 O MCO SPECIFIC CODE: NEOCATE 1+, 8 OU $0.00
G0001 O DRAWING BLOOD FOR SPECIMEN $0.00
G0002 9 TEMPORARY URINARY CATHETER $0.00
G0004 9 ECG TRANSM PHYS REVIEW & INT $0.00
G0005 9 ECG 24 HOUR RECORDING $0.00
G0006 9 ECG TRANSMISSION & ANALYSIS $0.00
G0007 9 ECG PHY REVIEW & INTERPRET $0.00
G0008 9 ADMIN INFLUENZA VIRUS VAC $0.00

G0009 9 ADMIN PNEUMOCOCCAL VACCINE $0.00
G0010 9 ADMIN HEPATITIS B VACCINE $0.00
G0015 9 POST SYMPTOM ECG TRACING $0.00
G0016 9 POST SYMPTOM ECG MD REVIEW $0.00
G0020 O IMPRESSION AND CUSTOM PREPARATION; $0.00
G0021 O IMPRESSION AND CUSTOM PREPARATION; $0.00
G0025 O COLLAGEN SKIN TEST KIT $0.00
G0026 O FECAL LEUKOCYTE EXAMINATION $0.00
G0027 9 SEMEN ANALYSIS $0.00
G0030 O PET IMAGING PREV PET SINGLE $0.00

G0031 O PET IMAGING PREV PET MULTPLE $0.00
G0032 O PET FOLLOW SPECT 78464 SINGL $0.00
G0033 O PET FOLLOW SPECT 78464 MULT $0.00
G0034 O PET FOLLOW SPECT 76865 SINGL $0.00
G0035 O PET FOLLOW SPECT 78465 MULT $0.00
G0036 O PET FOLLOW CORNRY ANGIO SING $0.00
G0037 O PET FOLLOW CORNRY ANGIO MULT $0.00
G0038 O PET FOLLOW MYOCARD PERF SING $0.00
G0039 O PET FOLLOW MYOCARD PERF MULT $0.00
G0040 O PET FOLLOW STRESS ECHO SINGL $0.00
G0041 O PET FOLLOW STRESS ECHO MULT $0.00
G0042 O PET FOLLOW VENTRICULOGM SING $0.00
G0043 O PET FOLLOW VENTRICULOGM MULT $0.00

G0044 O PET FOLLOWING REST ECG SINGL $0.00
G0045 O PET FOLLOWING REST ECG MULT $0.00
G0046 O PET FOLLOW STRESS ECG SINGL $0.00
G0047 O PET FOLLOW STRESS ECG MULT $0.00
G0050 9 RESIDUAL URINE BY ULTRASOUND $0.00
G0051 9 DESTRUCTION BY ANY METHOD, INCLUDIN $0.00
G0054 O BLOOD CHOLESTEROL TEST, BY CHOLESTE $0.00
G0055 O GLUCOSE POST DOSE (INCLUDES GLUCOSE $0.00
G0056 O GLUCOSE TOLERANCE TEST (GTT), BY DI $0.00
G0057 O GLUCOSE TOLERANCE TEST (GTT), BY DI $0.00

G0058 O AUTOMATED MULTICHANNEL TEST; 20 CLI $0.00
G0059 O AUTOMATED MULTICHANNEL TEST; 21 CLI $0.00
G0060 O AUTOMATED MULTICHANNEL TEST, 22 CLI $0.00
G0061 O LUNG VOLUME REDUCTION SURGERY (REDU $0.00
G0062 9 PERIPHERAL SKELETAL BONE MINERAL DE $0.00
G0063 9 CENTRAL SKELETAL BONE MINERAL DENSI $0.00
G0064 9 PHYSICIAN SUPERVISION OF A PATIENT $0.00
G0065 9 PHYSICIAN SUPERVISION OF A HOSPICE $0.00
G0066 9 PHYSICIAN SUPERVISION OF A NURSING $0.00
G0071 9 INDIVIDUAL PSYCHOTHERAPY, INSIGHT O $0.00

G0077 9 INDIVIDUAL PSYCHOTHERAPY, INTERACTI $0.00

G0101 9 CA SCREEN;PELVIC/BREAST EXAM $0.00
G0102 9 PROSTATE CA SCREENING; DRE $0.00

G0103 9 PSA, TOTAL SCREENING $0.00
G0104 9 CA SCREEN;FLEXI SIGMOIDSCOPE $0.00
G0105 9 COLORECTAL SCRN; HI RISK IND $0.00
G0106 9 COLON CA SCREEN;BARIUM ENEMA $0.00
G0107 O CA SCREEN; FECAL BLOOD TEST $0.00
G0108 9 DIAB MANAGE TRN PER INDIV $0.00
G0109 9 DIAB MANAGE TRN IND/GROUP $0.00
G0110 O NETT PULM-REHAB EDUC; IND $0.00
G0111 O NETT PULM-REHAB EDUC; GROUP $0.00
G0112 O NETT;NUTRITION GUID, INITIAL $0.00

G0113 O NETT;NUTRITION GUID,SUBSEQNT $0.00
G0114 O NETT; PSYCHOSOCIAL CONSULT $0.00
G0115 O NETT; PSYCHOLOGICAL TESTING $0.00
G0116 O NETT; PSYCHOSOCIAL COUNSEL $0.00
G0117 9 GLAUCOMA SCRN HGH RISK DIREC $0.00
G0118 9 GLAUCOMA SCRN HGH RISK DIREC $0.00
G0120 9 COLON CA SCRN; BARIUM ENEMA $0.00
G0121 9 COLON CA SCRN NOT HI RSK IND $0.00
G0122 9 COLON CA SCRN; BARIUM ENEMA $0.00
G0123 3 SCREEN CERV/VAG THIN LAYER $28.00
G0124 9 SCREEN C/V THIN LAYER BY MD $0.00
G0125 O PET IMAGE PULMONARY NODULE $0.00
G0126 9 LUNG IMAGE (PET) STAGING $0.00

G0127 9 TRIM NAIL(S) $0.00
G0128 9 CORF SKILLED NURSING SERVICE $0.00
G0129 9 PARTIAL HOSP PROG SERVICE $0.00
G0130 9 SINGLE ENERGY X-RAY STUDY $0.00
G0131 9 CT SCAN, BONE DENSITY STUDY $0.00
G0132 9 CT SCAN, BONE DENSITY STUDY $0.00
G0141 9 SCR C/V CYTO,AUTOSYS AND MD $0.00
G0143 9 SCR C/V CYTO,THINLAYER,RESCR $0.00
G0147 9 SCR C/V CYTO, AUTOMATED SYS $0.00
G0148 9 SCR C/V CYTO, AUTOSYS, RESCR $0.00

G0151 7 HHCP-SERV OF PT,EA 15 MIN $0.00
G0152 7 HHCP-SERV OF OT,EA 15 MIN $0.00
G0153 7 HHCP-SVS OF S/L PATH,EA 15MN $0.00
G0154 7 HHCP-SVS OF RN,EA 15 MIN $0.00
G0155 9 HHCP-SVS OF CSW,EA 15 MIN $0.00
G0156 7 HHCP-SVS OF AIDE,EA 15 MIN $0.00
G0159 9 PERC DECLOT DIALYSIS GRAFT $0.00
G0160 9 CRYO. ABLATION, PROSTATE $0.00
G0161 9 ECHO GUIDE FOR CRYO PROBES $0.00
G0163 9 PET FOR REC OF COLORECTAL CA $0.00

G0164 9 PET FOR LYMPHOMA STAGING $0.00
G0165 9 PET,REC OF MELANOMA/MET CA $0.00
G0166 9 EXTRNL COUNTERPULSE, PER TX $0.00
G0167 O HYPERBARIC OZ TX;NO MD REQRD $0.00
G0168 9 WOUND CLOSURE BY ADHESIVE $0.00
G0169 9 REMOVAL TISSUE; NO ANESTHSIA $0.00
G0170 9 SKIN BIOGRAFT $0.00
G0171 9 SKIN BIOGRAFT ADD-ON $0.00
G0172 9 PHP;TRAIN & ED, PER DAY $0.00
G0173 9 LINEAR ACC STEREO RADSUR COM $0.00
G0174 9 INTENSITYMODULATEDRADIATION $0.00
G0175 7 OPPS SERVICE,SCHED TEAM CONF $0.00
G0176 3 OPPS/PHP;ACTIVITY THERAPY $10,128.26

G0177 O OPPS/PHP; TRAIN & EDUC SERV $0.00
G0178 9 INTENSITYMODULATEDRADIATION $0.00
G0179 9 MD RECERTIFICATION HHA PT $0.00
G0180 9 MD CERTIFICATION HHA PATIENT $0.00
G0181 9 HOME HEALTH CARE SUPERVISION $0.00
G0182 9 HOSPICE CARE SUPERVISION $0.00
G0183 9 DESTRUCTION OF LOCALIZED LESION OF $0.00
G0184 9 OCULAR PHOTDYNAMICTX 2ND EYE $0.00
G0185 9 TRANSPUPPILLARY THERMOTX $0.00
G0186 9 DSTRY EYE LESN,FDR VSSL TECH $0.00
G0187 9 DSTRY MCLR DRUSEN,PHOTOCOAG $0.00
G0188 9 XRAY LWR EXTRMTY-FULL LNGTH $0.00

G0190 9 IMMUNIZATION ADMINISTRATION $0.00
G0191 9 IMMUNIZATION ADMIN,EACH ADD $0.00
G0192 9 IMMUNIZATION ORAL/INTRANASAL $0.00
G0193 9 ENDOSCOPICSTUDYSWALLOWFUNCTN $0.00
G0194 9 SENSORYTESTINGENDOSCOPICSTUD $0.00
G0195 9 CLINICALEVALSWALLOWINGFUNCT $0.00
G0196 9 EVALOFSWALLOWINGWITHRADIOOPA $0.00
G0197 9 EVALOFPTFORPRESCIPSPEECHDEVI $0.00
G0198 9 PATIENTADAPATION&TRAINFORSPE $0.00
G0199 9 REEVALUATIONOFPATIENTUSESPEC $0.00

G0200 9 EVALOFPATIENTPRESCIPOFVOICEP $0.00
G0201 9 MODIFORTRAININGINUSEVOICEPRO $0.00
G0202 3 SCREENINGMAMMOGRAPHYDIGITAL $136.60
G0204 3 DIAGNOSTICMAMMOGRAPHYDIGITAL $154.48
G0206 3 DIAGNOSTICMAMMOGRAPHYDIGITAL $123.32
G0210 O PET IMG WHOLEBODY DXLUNG $0.00
G0211 O PET IMG WHOLBODY INIT LUNG $0.00
G0212 O PET IMG WHOLEBOD RESTAG LUNG $0.00
G0213 O PET IMG WHOLBODY DX $0.00
G0214 O PET IMG WHOLEBOD INIT $0.00
G0215 O PETIMG WHOLEBOD RESTAG $0.00
G0216 O PET IMG WHOLEBOD DX MELANOMA $0.00
G0217 O PET IMG WHOLEBOD INIT MELAN $0.00

G0218 O PET IMG WHOLEBOD RESTAG MELA $0.00
G0219 9 PET IMG WHOLBOD MELANO NONCO $0.00
G0220 O PET IMG WHOLEBOD DX LYMPHOMA $0.00
G0221 O PET IMAG WHOLBOD INIT LYMPHO $0.00
G0222 O PET IMAG WHOLBOD RESTA LYMPH $0.00
G0223 O PET IMAG WHOLBOD REG DX HEAD $0.00
G0224 O PET IMAG WHOLBOD REG INI HEA $0.00
G0225 O PET WHOL RESTAG HEADNECKONLY $0.00
G0226 O PET IMG WHOLBODY DX ESOPHAGL $0.00
G0227 O PET IMG WHOLBOD INI ESOPHAGE $0.00
G0228 O PET IMG WHOLBOD RESTG ESOPHA $0.00
G0229 O PET IMG METABOLOC BRAIN PRES $0.00

G0230 O PET MYOCARD VIABILITY POST $0.00
G0231 O PET WHBD COLOREC; GAMMA CAM $0.00
G0232 O PET WHBD LYMPHOMA; GAMMA CAM $0.00
G0233 O PET WHBD MELANOMA; GAMMA CAM $0.00
G0234 O PET WHBD PULM NOD; GAMMA CAM $0.00
G0235 6 PET NOT OTHERWISE SPECIFIED $0.00
G0236 O DIGITAL FILM CONVERT DIAG MA $0.00
G0237 9 THERAPEUTIC PROCD STRG ENDUR $0.00
G0238 9 OTH RESP PROC, INDIV $0.00
G0239 9 OTH RESP PROC, GROUP $0.00

G0240 9 CRITIC CARE BY MD TRANSPORT $0.00
G0241 9 EACH ADDITIONAL 30 MINUTES $0.00
G0242 O MULTISOURCE PHOTON STER PLAN $0.00
G0243 O MULTISOUR PHOTON STERO TREAT $0.00
G0244 O OBSERV CARE BY FACILITY TOPT $0.00
G0245 9 INITIAL FOOT EXAM PT LOPS $0.00
G0246 9 FOLLOWUP EVAL OF FOOT PT LOP $0.00
G0247 9 ROUTINE FOOTCARE PT W LOPS $0.00
G0248 9 DEMONSTRATE USE HOME INR MON $0.00
G0249 9 PROVIDE INR TEST MATER/EQUIP $0.00
G0250 9 MD INR TEST REVIE INTER MGMT $0.00
G0251 9 LINEAR ACC BASED STERO RADIO $0.00
G0252 3 PET IMAGING INITIAL DX $521.95

G0253 O PET IMAGE BRST DECTION RECUR $0.00
G0254 O PET IMAGE BRST EVAL TO TX $0.00
G0255 5 CURRENT PERCEP THRESHOLD TST $0.00
G0256 O PROSTATE BRACHY W PALLADIUM $0.00
G0257 5 UNSCHED DIALYSIS ESRD PT HOS $0.00
G0258 O IV INFUSION DURING OBS STAY $0.00
G0259 5 INJECT FOR SACROILIAC JOINT $0.00
G0260 5 INJ FOR SACROILIAC JT ANESTH $0.00
G0261 O PROSTATE BRACHY W IODINE SEE $0.00
G0262 O SM INTESTINAL IMAGE CAPSULE $0.00
G0263 O ADM WITH CHF, CP, ASTHMA $0.00
G0264 O ASSMT OTR CHF, CP, ASTHMA $0.00

G0265 O CRYOPRESEVATION FREEZE+STORA $0.00
G0266 O THAWING + EXPANSION FROZ CEL $0.00
G0267 O BONE MARROW OR PSC HARVEST $0.00
G0268 9 REMOVAL OF IMPACTED WAX MD $0.00
G0269 5 OCCLUSIVE DEVICE IN VEIN ART $0.00
G0270 5 MNT SUBS TX FOR CHANGE DX $0.00
G0271 5 GROUP MNT 2 OR MORE 30 MINS $0.00
G0272 O NASO/ORO GASTRIC TUBE PL MD $0.00
G0273 O PRETX PLANNING, NON-HODGKINS $0.00
G0274 O RADIOPHARM TX, NON-HODGKINS $0.00

G0275 3 RENAL ANGIO, CARDIAC CATH $13.49
G0278 3 ILIAC ART ANGIO,CARDIAC CATH $13.85
G0279 O EXCORP SHOCK TX, ELBOW EPI $0.00
G0280 O EXCORP SHOCK TX OTHER THAN $0.00
G0281 5 ELEC STIM UNATTEND FOR PRESS $0.00
G0282 5 ELECT STIM WOUND CARE NOT PD $0.00
G0283 9 ELEC STIM OTHER THAN WOUND $0.00
G0288 3 RECON, CTA FOR SURG PLAN $234.70
G0289 3 ARTHRO, LOOSE BODY + CHONDRO $84.90
G0290 5 DRUG-ELUTING STENTS, SINGLE $0.00
G0291 5 DRUG-ELUTING STENTS,EACH ADD $0.00
G0292 O ADM EXP DRUGS,CLINICAL TRIAL $0.00
G0293 9 NON-COV SURG PROC,CLIN TRIAL $0.00

G0294 9 NON-COV PROC, CLINICAL TRIAL $0.00
G0295 9 ELECTROMAGNETIC THERAPY ONC $0.00
G0296 O PET IMGE RESTAG THYROD CANCE $0.00
G0297 O INSERT SINGLE CHAMBER/CD $0.00
G0298 O INSERT DUAL CHAMBER/CD $0.00
G0299 O INSER/REPOS SINGLE ICD+LEADS $0.00
G0300 O INSERT REPOSIT LEAD DUAL+GEN $0.00
G0302 9 PRE-OP SERVICE LVRS COMPLETE $0.00
G0303 9 PRE-OP SERVICE LVRS 10-15DOS $0.00
G0304 9 PRE-OP SERVICE LVRS 1-9 DOS $0.00
G0305 9 POST OP SERVICE LVRS MIN 6 $0.00
G0306 9 CBC/DIFFWBC W/O PLATELET $0.00

G0307 9 CBC WITHOUT PLATELET $0.00
G0308 O ESRD RELATED SVC 4+MO < 2YRS $0.00
G0309 O ESRD RELATED SVC 2-3MO <2YRS $0.00
G0310 O ESRD RELATED SVC 1 VST <2YRS $0.00
G0311 O ESRD RELATED SVS 4+MO 2-11YR $0.00
G0312 O ESRD RELATE SVS 2-3 MO 2-11Y $0.00
G0313 O ESRD RELATED SVS 1 MON 2-11Y $0.00
G0314 O ESRD RELATED SVS 4+ MO 12-19 $0.00
G0315 O ESRD RELATED SVS 2-3MO/12-19 $0.00
G0316 O ESRD RELATED SVS 1VIS/12-19Y $0.00

G0317 O ESRD RELATED SVS 4+MO 20+YRS $0.00
G0318 O ESRD RELATED SVS 2-3 MO 20+Y $0.00
G0319 O ESRD RELATED SVS 1VISIT 20+Y $0.00
G0320 O ESD RELATED SVS HOME UNDR 2 $0.00
G0321 O ESRDRELATEDSVS HOME MO 2-11Y $0.00
G0322 O ESRD RELATED SVS HOM MO12-19 $0.00
G0323 O ESRD RELATED SVS HOME MO 20+ $0.00
G0324 O ESRD RELATE SVS HOME/DY<2Y $0.00
G0325 O ESRD RELATE HOME/DAY/ 2-11YR $0.00
G0326 O ESRD RELATE HOME/DY 12-19YR $0.00
G0327 O ESRD RELATE HOME/DY 20+YRS $0.00
G0328 5 FECAL BLOOD SCRN IMMUNOASSAY $0.00
G0329 9 ELECTROMAGNTIC TX FOR ULCERS $0.00

G0332 O PREADMIN IV IMMUNOGLOBULIN $0.00
G0333 9 DISPENSE FEE INITIAL 30 DAY $0.00
G0336 O PET IMAGING BRAIN ALZHEIMERS $0.00
G0337 9 HOSPICE EVALUATION PREELECTI $0.00
G0338 O LINEAR ACCELERATOR STERO PLN $0.00
G0339 9 ROBOT LIN-RADSURG COM, FIRST $0.00
G0340 9 ROBOT LINEAR STERORADIO MAX5 $0.00
G0341 9 PERCUTANEOUS ISLET CELLTRANS $0.00
G0342 9 LAPAROSCOPY ISLET CELL TRANS $0.00
G0343 9 LAPAROTOMY ISLET CELL TRANSP $0.00
G0344 O INITIAL PREVENTIVE EXAM $0.00
G0345 O IV INFUSE HYDRATION, INITIAL $0.00

G0346 O EACH ADDITIONAL INFUSE HOUR $0.00
G0347 O IV INFUSION THERAPY/DIAGNOST $0.00
G0348 O EACH ADDITIONAL HR UP TO 8HR $0.00
G0349 O ADDITIONAL SEQUENTIAL INFUSE $0.00
G0350 O CONCURRENT INFUSION $0.00
G0351 O THERAPEUTIC/DIAGNOSTIC INJEC $0.00
G0353 O IV PUSH,SINGLE ORINITIAL DRU $0.00
G0354 O EACH ADDITION SEQUENTIAL IV $0.00
G0355 O CHEMO ADMINISRATE SUBCUT/IM $0.00
G0356 O HORMONAL ANTI-NEOPLASTIC $0.00

G0357 O IV PUSH SINGLE/INITIAL SUBST $0.00
G0358 O IV PUSH EACH ADDITIONAL DRUG $0.00
G0359 O CHEMOTHERAPY IV ONE HR INITI $0.00
G0360 O EACH ADDITIONAL HR 1-8 HRS $0.00
G0361 O PROLONG CHEMO INFUSE>8HRS PU $0.00
G0362 O EACH ADD SEQUENTIAL INFUSION $0.00
G0363 O IRRIGATE IMPLANTED VENOUS DE $0.00
G0364 3 BONE MARROW ASPIRATE &BIOPSY $12.24
G0365 9 VESSEL MAPPING HEMO ACCESS $0.00
G0366 O EKG FOR INITIAL PREVENT EXAM $0.00
G0367 O EKG TRACING FOR INITIAL PREV $0.00
G0368 O EKG INTERPRET & REPORT PREVE $0.00
G0369 O SUPPLYING FEE FOR THE INITIAL SUPP $0.00

G0370 O SUPPLYING FEE FOR EACH SUPPLIED PR $0.00
G0371 O DISPENSING FEE FOR A 30 DAY PERIOD $0.00
G0372 9 MD SERVICE REQUIRED FOR PMD $0.00
G0374 O DISPENSING FEE FOR EACH DISPENSED $0.00
G0375 O SMOKE/TOBACCO COUNSELNG 3-10 $0.00
G0376 O SMOKE/TOBACCO COUNSELING >10 $0.00
G0378 9 HOSPITAL OBSERVATION PER HR $0.00
G0379 9 DIRECT ADMIT HOSPITAL OBSERV $0.00
G0380 9 LEV 1 HOSP TYPE B ED VISIT $0.00

G0389 6 ULTRASOUND EXAM AAA SCREEN $0.00
G0390 9 TRAUMA RESPONS W/HOSP CRITI $0.00
G0392 3 AV FISTULA OR GRAFT ARTERIAL $476.40
G0393 3 AV FISTULA OR GRAFT VENOUS $304.63
G0394 O BLOOD OCCULT TEST,COLORECTAL $0.00
G0396 9 ALCOHOL/SUBS INTERV 15-30MN $0.00
G0397 9 ALCOHOL/SUBS INTERV >30 MIN $0.00
G0398 9 HOME SLEEP TEST/TYPE 2 PORTA $0.00

G0402 9 INITIAL PREVENTIVE EXAM $0.00
G0403 9 EKG FOR INITIAL PREVENT EXAM $0.00
G0404 9 EKG TRACING FOR INITIAL PREV $0.00
G0405 9 EKG INTERPRET & REPORT PREVE $0.00
G0406 9 TELHEALTH INPT CONSULT 15MIN $0.00
G0407 9 TELHEATH INPT CONSULT 25MIN $0.00
G0408 9 TELHEALTH INPT CONSULT 35MIN $0.00
G0409 9 CORF RELATED SERV 15 MINS EA $0.00
G0410 9 GRP PSYCH PARTIAL HOSP 45-50 $0.00
G0411 9 INTER ACTIVE GRP PSYCH PARTI $0.00
G0412 9 OPEN TX ILIAC SPINE UNI/BIL $0.00
G0413 9 PELVIC RING FRACTURE UNI/BIL $0.00

G0414 9 PELVIC RING FX TREAT INT FIX $0.00
G0415 9 OPEN TX POST PELVIC FXCTURE $0.00
G0416 6 SAT BIOPSY PROSTATE 1-20 SPC $0.00
G0417 6 SAT BIOPSY PROSTATE 21-40 $0.00
G0418 6 SAT BIOPSY PROSTATE 41-60 $0.00
G0419 6 SAT BIOPSY PROSTATE: >60 $0.00
G3001 6 ADMIN + SUPPLY, TOSITUMOMAB $0.00
G8006 9 AMI PT RECD ASPIRIN AT ARRIV $0.00
G8007 9 AMI PT DID NOT RECEIV ASPIRI $0.00
G8008 9 AMI PT INELIGIBLE FOR ASPIRI $0.00
G8009 9 AMI PT RECD BBLOCK AT ARR $0.00
G8010 9 AMI PT DID NOT REC BBLOCK $0.00

G8011 9 AMI PT INELIG BBLOC AT ARRIV $0.00
G8012 9 PNEUM PT RECV ANTIBIOTIC 4 H $0.00
G8013 9 PNEUM PT W/O ANTIBIOTIC 4 HR $0.00
G8014 9 PNEUM PT NOT ELIG ANTIBIOTIC $0.00
G8015 9 DIABETIC PT W/ HBA1C>9% $0.00
G8016 9 DIABETIC PT W/ HBA1C<OR=9% $0.00
G8017 9 DM PT INELIG FOR HBA1C MEASU $0.00
G8018 9 CARE NOT PROVIDED FOR HBA1C $0.00
G8019 9 DIABETIC PT W/LDL>= 100MG/DL $0.00
G8020 9 DIAB PT W/LDL< 100MG/DL $0.00

G8021 9 DIAB PT INELIG FOR LDL MEAS $0.00
G8022 9 CARE NOT PROVIDED FOR LDL $0.00
G8023 9 DM PT W BP>=140/80 $0.00
G8024 9 DIABETIC PT WBP<140/80 $0.00
G8025 9 DIABETIC PT INELIG FOR BP ME $0.00
G8026 9 DIABET PT W NO CARE RE BP ME $0.00
G8027 9 HF P W/LVSD ON ACE-I/ARB $0.00
G8028 9 HF PT W/LVSD NOT ON ACE-I/AR $0.00
G8029 9 HF PT NOT ELIG FOR ACE-I/ARB $0.00
G8030 9 HF PT W/LVSD ON BBLOCKER $0.00
G8031 9 HF PT W/LVSD NOT ON BBLOCKER $0.00
G8032 9 HF PT NOT ELIG FOR BBLOCKER $0.00
G8033 9 PMI-CAD PT ON BBLOCKER $0.00

G8034 9 PMI-CAD PT NOT ON BBLOCKER $0.00
G8035 9 PMI-CAD PT INELIG BBLOCKER $0.00
G8036 9 AMI-CAD PT DOC ON ANTIPLATEL $0.00
G8037 9 AMI-CAD PT NOT DOCU ON ANTIP $0.00
G8038 9 AMI-CAD INELIG ANTIPLATE MEA $0.00
G8039 9 CAD PT W/LDL>100MG/DL $0.00
G8040 9 CAD PT W/LDL<OR=100MG/DL $0.00
G8041 9 CAD PT NOT ELIGIBLE FOR LDL $0.00
G8051 9 OSTEOPOROSIS ASSESS $0.00
G8052 9 OSTEOPOR PT NOT ASSESS $0.00
G8053 9 PT INELIG FOR OSTEOPOR MEAS $0.00
G8054 9 FALLS ASSESS NOT DOCUM 12 MO $0.00

G8055 9 FALLS ASSESS W/ 12 MON $0.00
G8056 9 NOT ELIG FOR FALLS ASSESSMEN $0.00
G8057 9 HEARING ASSESS RECEIVE $0.00
G8058 9 PT W/O HEARING ASSESS $0.00
G8059 9 PT INELIG FOR HEARING ASSESS $0.00
G8060 9 URINARY INCONT PT ASSESS $0.00
G8061 9 PT NOT ASSESS FOR URINARY IN $0.00
G8062 9 PT NOT ELIG FOR URINARY INCO $0.00
G8075 9 ESRD PT W/ DIALY OF URR>=65% $0.00
G8076 9 ESRD PT W/ DIALY OF URR<65% $0.00

G8077 9 ESRD PT NOT ELIG FOR URR/KTV $0.00
G8078 9 ESRD PT W/HCT>OR=33 $0.00
G8079 9 ESRD PT W/HCT<33 $0.00
G8080 9 ESRD PT INELIG FOR HCT/HGB $0.00
G8081 9 ESRD PT W/ AUTO AV FISTULA $0.00
G8082 9 ESRD PT W OTHER FISTULA $0.00
G8085 9 ESRD PT INELIG AUTO AV FISTU $0.00
G8093 9 COPD PT REC SMOKING CESSAT $0.00
G8094 9 COPD PT W/O SMOKE CESSAT INT $0.00
G8099 9 OSTEOPO PT GIVEN CA+VITD SUP $0.00
G8100 9 OSTEOP PT INELIG FOR CA+VITD $0.00
G8103 9 NEW DX OSTEO PT W/ANTIRESORP $0.00
G8104 9 OSTEO PT INELIG FOR ANTIRESO $0.00

G8106 9 BONE DENS MEAS TEST PERF $0.00
G8107 9 BONE DENS MEAS TEST INELIG $0.00
G8108 9 PT RECEIV INFLUENZA VACC $0.00
G8109 9 PT W/O INFLUENZA VACC $0.00
G8110 9 PT INELIG FOR INFLUENZA VACC $0.00
G8111 9 PT RECEIV MAMMOGRAM $0.00
G8112 9 PT NOT DOC MAMMOGRAM $0.00
G8113 9 PT INELIGIBLE MAMMOGRAPHY $0.00
G8114 9 CARE NOT PROVIDED FOR MAMOGR $0.00
G8115 9 PT RECEIV PNEUMO VACC $0.00
G8116 9 PT DID NOT REC PNEUMO VACC $0.00
G8117 9 PT WAS INELIG FOR PNEUMO VAC $0.00

G8126 9 PT TREAT W/ANTIDEPRESS12WKS $0.00
G8127 9 PT NOT TREAT W/ANTIDEPRES12W $0.00
G8128 9 PT INELIG FOR ANTIDEPRES MED $0.00
G8129 9 PT TREAT W/ANTIDEPRES FOR 6M $0.00
G8130 9 PT NOT TREAT W/ANTIDEPRES 6M $0.00
G8131 9 PT INELIG FOR ANTIDEPRES MED $0.00
G8152 9 PT W/AB 1 HR PRIOR TO INCISI $0.00
G8153 9 PT NOT DOC FOR AB 1 HR PRIOR $0.00
G8154 9 PT INELIGI FOR AB THERAPY $0.00
G8155 9 PT RECD THROMBOEMB PROPHYLAX $0.00

G8156 9 PT DID NOT REC THROMBOEMBO $0.00
G8157 9 PT INELIGI FOR THROMBOLISM $0.00
G8158 O PT RECD CABG W/ IMA $0.00
G8159 9 PT W/CABG W/O IMA $0.00
G8160 O PT INELIG FOR CABG W/IMA $0.00
G8161 O ISO CABG PT REC PREOP BBLOCK $0.00
G8162 9 ISO CABG PT W/O PREOP BBLOCK $0.00
G8163 O ISO CABG PT INELIG FOR PREO $0.00
G8164 9 ISO CABG PT W/PROLNG INTUB $0.00
G8165 9 ISO CABG PT W/O PROLNG INTUB $0.00
G8166 9 ISO CABG REQ SURG REXPO $0.00
G8167 9 ISO CABG W/O SURG EXPLO $0.00
G8170 9 CEA/EXT BYPASS PT ON ASPIRIN $0.00

G8171 9 PT W/CAROT ENDARCT/EXT BYPAS $0.00
G8172 9 CEA/EXT BYPASS PT NOT ON ASP $0.00
G8182 9 CAD PT CARE NOT PROV LDL $0.00
G8183 9 HF/ATRIAL FIB PT ON WARFARIN $0.00
G8184 9 HF/ATRIAL FIB PT INELIG WARF $0.00
G8185 9 OSTEOARTH PT W/ ASSESS PAIN $0.00
G8186 9 OSTEOARTH PT INELIG ASSESS $0.00
G8191 O ANTIBIOTIC GIVEN PRIOR SURG $0.00
G8192 O ANTIB GIVEN PRIOR SURG INCIS $0.00
G8193 9 ANTIBIO NOT DOC PRIOR SURG $0.00
G8194 O PT NOT ELIG FOR ANTIBIOTIC $0.00
G8195 O ANTIBIOTIC GIVEN PRIOR SURG $0.00

G8196 9 ANTIBIO NOT DOCUM PRIOR SURG $0.00
G8197 O ANTIB ORDER PRIOR TO SURG $0.00
G8198 O CEFAZOLIN DOCUMENTED ORDERED $0.00
G8199 O CEFAZOLIN GIVEN PROPHYLAXIS $0.00
G8200 9 CEFAZOLIN NOT DOCUM PROPHY $0.00
G8201 O PT NOT ELIGI FOR CEFAZOLIN $0.00
G8202 O ORDER GIVEN TO D/C ANTIBIO $0.00
G8203 O ANTIB WAS D/C 24HRS SURG TIM $0.00
G8204 9 MD NOT DOC ORDER TO D/C ANTI $0.00
G8205 O PT NOT ELIGI FOR PROPH ANTIB $0.00

G8206 O MD DOC PROPHYLACTIC AB GIVEN $0.00
G8207 O CLINI DOC ORDER TO D/C ANTIB $0.00
G8208 O CLINI DOC AB WAS D/C 48 H $0.00
G8209 9 CLINICIAN DID NOT DOC $0.00
G8210 O CLINI DOC PT INELIGIB ANTI $0.00
G8211 O CLINI DOC PROPH AB GIV $0.00
G8212 O CLINI ORDER GIVEN FOR VTE $0.00
G8213 O CLINI GIVEN VTE PROP $0.00
G8214 9 CLINI NOT DOC ORDER VTE $0.00
G8215 O CLINI DOC PT INELIG VTE $0.00
G8216 O PT RECEIVED DVT PROPHYLAXIS $0.00
G8217 9 PT NOT RECEIVED DVT PROPH $0.00
G8218 O PT INELIG DVT PROPHYLAXIS $0.00

G8219 9 RECEIVED DVT PROPH DAY 2 $0.00
G8220 9 PT NOT REC DVT PROPH DAY 2 $0.00
G8221 9 PT INELIG FOR DVT PROPH $0.00
G8222 O PT PRESCRIBE PLATELET AT D/C $0.00
G8223 9 PT NOT DOC FOR PRESC ANTIPLA $0.00
G8224 O PT INELIG FOR ANTIPLAT PROPH $0.00
G8225 O PT PRESCRIB ANTICOAG AT D/C $0.00
G8226 9 PT NO PRESCR ANTICOA AT D/C $0.00
G8227 O PT NOT DOC TO HAVE PERM/AF $0.00
G8228 O CLIN PT INELIG ANTICOAG D/C $0.00
G8229 O PT DOC TO HAVE ADMIN T-PA $0.00
G8230 O PT INELIG T-PA ISCH STROK>3H $0.00

G8231 9 PT NOT DOC FOR ADMIN T-PA $0.00
G8232 O PT RECEIVED DYSPHAGIA SCREEN $0.00
G8234 9 PT NOT DOC DYSPHAGIA SCREEN $0.00
G8235 O PT RECEIVED NPO $0.00
G8236 O PT INELIG DYSPHAGIA SCREEN $0.00
G8237 O PT DOC REC REHAB SERV $0.00
G8238 9 PT NOT DOC TO REC REHAB SERV $0.00
G8239 O INTER CAROTID STENOSIS <30% $0.00
G8240 9 INTER CAROTID STENOSIS30-99% $0.00
G8241 O PT INELIG CANDIDATE ITO MEAS $0.00

G8242 O PT DOC TO HAVE CT/MRI W/LES $0.00
G8243 9 PT NOT DOC MRI/CT W/O LESION $0.00
G8245 O CLINI DOC PRESE/ABS ALARM $0.00
G8246 9 PT INELIG HX W NEW/CHG MOLE $0.00
G8247 O PT W/ALARM SYMP UPPER ENDO $0.00
G8248 9 PT W/ONE ALARM SYMP NOT DOC $0.00
G8249 O PT INELIG FOR UPPER ENDO $0.00
G8250 O PT W/BARRETTS ESOPH ENDO RE $0.00
G8251 9 PT NOT DOC W/BARRETTS, ENDO $0.00
G8252 O PT INELIG FOR ESOPHAG BIOP $0.00
G8253 O PT REC ORDER FOR BARIUM $0.00
G8254 9 PT W/NO DOC ORDER FOR BARIUM $0.00
G8255 O CLINI DOC PT INELIG BAR SWAL $0.00

G8256 O CLINI DOC REV D/C MEDS W/MED $0.00
G8257 9 PT NOT DOC REV MEDS D/C $0.00
G8258 O PT INELIG FOR D/C MEDS REV $0.00
G8259 O PT DOC TO HAV DECISION MAKER $0.00
G8260 9 PT NOT DOC TO HAVE DEC MAKER $0.00
G8261 O CLIN DOC PT INELIG DEC MAKER $0.00
G8262 O PT DOC ASSESS URINY INCON $0.00
G8263 9 PT NOT DOC ASSESS URINARY IN $0.00
G8264 O PT INELIG ASSESS URINARY INC $0.00
G8265 O PT DOC REC CHARC URIN INCON $0.00
G8266 9 PT NOT DOC CHARC URIN INCON $0.00
G8267 O PT DOC REC PLAN URINARY INCO $0.00

G8268 9 PT NOT DOC REC CARE URIN INC $0.00
G8269 O CLIN NOT PROV CARE URIN INCO $0.00
G8270 O PT RECEIV SCREEN FOR FALL $0.00
G8271 9 PT NO DOC SCREEN FALL $0.00
G8272 O CLIN DOC PT INELIG FALL RISK $0.00
G8273 O CLIN NOT PROV CARE SCRE FALL $0.00
G8274 9 CLINI NOT DOC PRES/ABS ALARM $0.00
G8275 O PT HX W/ NEW MOLES $0.00
G8276 9 PT NOT DOC MOLE CHANGE $0.00
G8277 O PT INELIG FOR ASSESS MOLE $0.00

G8278 O PT DOC REC PE SKIN $0.00
G8279 9 PT NOT DOC REC PE $0.00
G8280 O PT INELIG PE SKIN $0.00
G8281 O PT REC COUNSEL FOR SELF-EXAM $0.00
G8282 9 PT NOT DOC TO REC COUNS $0.00
G8283 O PT INELIG FOR COUNSEL $0.00
G8284 O PT DOC TO REC PRES OSTEO $0.00
G8285 9 PT DID NOT REC PRES OSTEO $0.00
G8286 O PT INELIG TO REC PRES OSTEO $0.00
G8287 O CLIN NOT PROV CARE FOR PHARM $0.00
G8288 O PT DOC REC CA/VIT D $0.00
G8289 9 PT NOT DOC REC CA/VIT D $0.00
G8290 O CLIN DOC PT INELIG CA/VIT D $0.00

G8291 O CLIN NO PRO CARE PT CA/VIT D $0.00
G8292 O COPD PT W/SPIR RESULTS $0.00
G8293 9 COPD PT W/O SPIR RESULTS $0.00
G8294 O COPD PT INELIG SPIR RESULTS $0.00
G8295 O COPD PT DOC BRONCH THER $0.00
G8296 9 COPD PT NOT DOC BRONCH THER $0.00
G8297 O COPD PT INELIG BRONCH THERAP $0.00
G8298 9 PT DOC OPTIC NERVE EVAL $0.00
G8299 9 PT NOT DOC OPTIC NERV EVAL $0.00
G8300 O PT INELIG FOR OPTIC NERV EVA $0.00
G8301 O CLIN NOT PROV CARE POAG $0.00
G8302 9 PT DOC W/ TARGET IOP $0.00

G8303 9 PT NOT DOC W/ IOP $0.00
G8304 9 CLIN DOC PT INELIG IOP $0.00
G8305 9 CLIN NOT PROV CARE POAG $0.00
G8306 9 POAG W/ IOP REC CARE PLAN $0.00
G8307 9 POAG W/ IOP NO CARE PLAN $0.00
G8308 9 POAG W/ IOP NOT DOC PLAN $0.00
G8309 O PT DOC REC ANTIOXIDANT $0.00
G8310 9 PT NOT DOC REC ANTIOX $0.00
G8311 O PT INELIG FOR ANTIOXIDANT $0.00
G8312 O CLIN NO PROV CARE FOR ANTIOX $0.00

G8313 O PT DOC REC MACULAR EXAM $0.00
G8314 9 PT NOT DOC TO REC MAC EXAM $0.00
G8315 O CLIN DOC PT INELIG MAC EXAM $0.00
G8316 O CLIN NO PRO CARE FOR MAC DEG $0.00
G8317 O PT DOC TO HAVE VISUAL FUNC $0.00
G8318 9 PT DOC NOT HAVE VISUAL FUNC $0.00
G8319 O PT INELIG FOR VIS FUNC STAT $0.00
G8320 O CLIN NOT PROV CARE CATARAC $0.00
G8321 O PT DOC TO PRE AXIAL LENG $0.00
G8322 9 PT NOT DOC PRE AXIAL LENG $0.00
G8323 O PT INELIG FOR PRE SURG AXIAL $0.00
G8324 O CLIN NOT PROV CARE FOR IOL $0.00
G8325 O PT REC FUND EXAM PRIOR SURG $0.00

G8326 9 PT NOT DOC REC FUNDUS EXAM $0.00
G8327 O PT INELIG FOR PRE SURG FUNDU $0.00
G8328 O CLIN NOT PROV CARE FUND EVAL $0.00
G8329 O PT DOC REC DILATED MACULAR $0.00
G8330 9 PT NOT DOC REC DILATED MAC $0.00
G8331 O PT INELIG DILATE FUNDUS $0.00
G8332 O CLIN PROV NO CARE DIABETIC R $0.00
G8333 O PT DOC TO HAVE MACULAR EXAM $0.00
G8334 9 DOC OF MACULAR NOT GIV MD $0.00
G8335 O CLIN DOC PT INELIG MACULAR $0.00
G8336 O CLIN DID NOT PRO CARE DIABET $0.00
G8337 O CLIN DOC PT WAS TEST OSTEO $0.00

G8338 9 CLIN NOT DOC PT TEST OSTEO $0.00
G8339 O PT INELIG FOR TEST OSTEO $0.00
G8340 O PT DOC HAVE DEXA $0.00
G8341 9 PT NOT DOC FOR DEXA $0.00
G8342 O CLIN DOC PT INELIG DEXA $0.00
G8343 O CLIN NOT PROV CARE DEXA $0.00
G8344 O PT DOC HAVE DEXA PERFORM $0.00
G8345 9 PT NOT DOC HAVE DEXA $0.00
G8346 O CLIN DOC PT INELIG DEXA $0.00
G8347 O CLIN NOT PROV CARE DEXA $0.00

G8351 9 PT NOT DOC ECG $0.00
G8354 9 PT NOT REC ASPIRIN PRIOR ER $0.00
G8357 9 PT NOT DOC TO HAVE ECG $0.00
G8360 9 PT NOT DOC VITAL SIGNS RECOR $0.00
G8362 9 PT NOT DOC 02 SAT ASSESS $0.00
G8365 9 PT NOT DOC MENTAL STATUS $0.00
G8367 9 PT NOT DOC HAVE EMPIRIC AB $0.00
G8370 9 ASTHMA PT W SURVEY NOT DOCUM $0.00
G8371 9 CHEMOTHER NOT REC STG3 COLON $0.00
G8372 9 CHEMOTHER REC STG3 COLON CA $0.00
G8373 9 CHEMO PLAN DOCUMEN PRIOR CHE $0.00
G8374 9 CHEMO PLAN NOT DOC PRIOR CHE $0.00
G8375 9 CLL PT W/O DOC FLOW CYTOMETR $0.00

G8376 9 BRST CA PT INELIG TAMOXIFEN $0.00
G8377 9 MD DOC COLON CA PT INELIG CH $0.00
G8378 9 MD DOC PT INELIG RADIATION $0.00
G8379 9 DOC RADIAT TX RECOM 12MO OV $0.00
G8380 9 PT W STGIC-3BRST CA NOT REC $0.00
G8381 9 PT W STGIC-3BRST CA REC TAM $0.00
G8382 9 MM PT W/O DOC IV BISPHOPHON $0.00
G8383 9 NO DOC RADIATION REC 12MO OV $0.00
G8384 9 BASE CYTOGEN TEST MDS NOTPER $0.00
G8385 9 DIABET PT NO DO HGB A1C 12M $0.00
G8386 9 DIABET PT NODOC LDLIPROTEI $0.00
G8387 9 ESRD PT W HCT/HGB NOT DOCUME $0.00

G8388 9 ESRD PT W URR/KTV NOTDOC ELI $0.00
G8389 9 MDS PT NO DOC FE ST PRIO EPO $0.00
G8390 9 DIABETIC W/O DOCUMENT BP 12M $0.00
G8391 9 PT W ASTHMA NO DOC MED OR TX $0.00
G8395 9 LVEF>=40% DOC NORMAL OR MILD $0.00
G8396 9 LVEF NOT PERFORMED $0.00
G8397 9 DIL MACULA/FUNDUS EXAM/W DOC $0.00
G8398 9 DIL MACULAR/FUNDUS NOT PERFO $0.00
G8399 9 PT W/DXA DOCUMENT OR ORDER $0.00
G8400 9 PT W/DXA NO DOCUMENT OR ORDE $0.00

G8401 9 PT INELIG OSTEO SCREEN MEASU $0.00
G8402 9 SMOKE PREVEN INTERVEN COUNSE $0.00
G8403 9 SMOKE PREVEN NOCOUNSEL $0.00
G8404 9 LOW EXTEMITY NEUR EXAM DOCUM $0.00
G8405 9 LOW EXTEMITY NEUR NOT PERFOR $0.00
G8406 9 PT INELIG LOWER EXTREM NEURO $0.00
G8407 9 ABI DOCUMENTED $0.00
G8408 9 ABI NOT DOCUMENTED $0.00
G8409 9 PT INELIG FOR ABI MEASURE $0.00
G8410 9 EVAL ON FOOT DOCUMENTED $0.00
G8415 9 EVAL ON FOOT NOT PERFORMED $0.00
G8416 9 PT INELIG FOOTWEAR EVALUATIO $0.00
G8417 9 CALC BMI ABV UP PARAM F/U $0.00

G8418 9 CALC BMI BLW LOW PARAM F/U $0.00
G8419 9 CALC BMI OUT NRM PARAM NOF/U $0.00
G8420 9 CALC BMI NORM PARAMETERS $0.00
G8421 9 BMI NOT CALCULATED $0.00
G8422 9 PT INELIG BMI CALCULATION $0.00
G8423 9 PT SCREEN FLU VAC & COUNSEL $0.00
G8424 9 FLU VACCINE NOT SCREEN $0.00
G8425 9 FLU VACCINE SCREEN NOT CURRE $0.00
G8426 9 PT NOT APPROP SCREEN & COUNC $0.00
G8427 9 DOC MEDS VERIFIED W/PT OR RE $0.00
G8428 9 MEDS DOCUMENT W/O VERIFICA $0.00
G8429 9 INCOMPLETE DOC PT ON MEDS $0.00

G8430 9 PT INELIG MED CHECK $0.00
G8431 9 POS CLIN DEPRES SCRN F/U DOC $0.00
G8432 9 CLIN DEPRESSION SCREEN NOT D $0.00
G8433 9 PT INELIG; SCRN CLIN DEP $0.00
G8434 9 COGNITIVE IMPAIRMENT SCREEN $0.00
G8435 9 COGNITIVE SCREEN NOT DOCUMEN $0.00
G8436 9 PT INELIG FOR COGNITIVE IMPA $0.00
G8437 9 CARE PLAN DEVELOP & DOCUMENT $0.00
G8438 9 PT INELIG FOR DEVLP CARE PLN $0.00
G8439 9 CARE PLAN DEVELP & NOT DOCUM $0.00

G8440 9 PAIN ASSESS F/U PLN DOCUMENT $0.00
G8441 9 NO DOCUMENT OF PAIN ASSESS $0.00
G8442 9 PT INELIG PAIN ASSESSMENT $0.00
G8443 9 PRESCRIPTION BY E-PRESCRIB S $0.00
G8445 9 PRESCRIP NOT GEN AT ENCOUNTE $0.00
G8446 9 SOME PRESCRIB PRINT OR CALL $0.00
G8447 9 PT VIS DOC USE CCHIT CER EHR $0.00
G8448 9 PT VIS DOC W/NON-CCHIT EHR $0.00
G8449 9 PT NOT DOC W/EMR DUE TO SYST $0.00
G8450 9 BETA-BLOC RX PT W/ABN LVEF $0.00
G8451 9 PT W/ABN LVEF INELIG B-BLOC $0.00
G8452 9 PT W/ABN LVEF B-BLOC NO RX $0.00
G8453 9 TOB USE CESS INT COUNSEL $0.00

G8454 9 TOB USE CESS INT NO COUNSEL $0.00
G8455 9 CURRENT TOBACCO SMOKER $0.00
G8456 9 SMOKELESS TOBACCO USER $0.00
G8457 9 CUR TOBACCO NON-USER $0.00
G8458 9 PT INELIG GENO NO ANTVIR TX $0.00
G8459 9 DOC PT REC ANTIVIR TREAT $0.00
G8460 9 PT INELIG RNA NO ANTVIR TX $0.00
G8461 9 PT REC ANTIVIR TREAT HEP C $0.00
G8462 9 PT INELIG COUNS NO ANTVIR TX $0.00
G8463 9 PT REC ANTIVIRAL TREAT DOC $0.00
G8464 9 PT INELIG; LO TO NO DTER RSK $0.00
G8465 9 HIGH RISK RECURRENCE PRO CA $0.00

G8466 9 PT INELIG SUIC; MDD REMIS $0.00
G8467 9 NEW DX INIT/REC EPISODE MDD $0.00
G8468 9 ACE/ARB RX PT W/ABN LVEF $0.00
G8469 9 PT W/ABN LVEF INELIG ACE/ARB $0.00
G8470 9 PT W/ NORMAL LVEF $0.00
G8471 9 LVEF NOT PERFORMED/DOC $0.00
G8472 9 ACE/ARB NO RX PT W/ABN LVEF $0.00
G8473 9 ACE/ARB THXPY RX'D $0.00
G8474 9 ACE/ARB NOT RX'D; DOC REAS $0.00
G8475 9 ACE/ARB THXPY NOT RX'D $0.00

G8476 9 BP SYS <130 AND DIAS <80 $0.00
G8477 9 BP SYS>=130 AND/OR DIAS >=80 $0.00
G8478 9 BP NOT PERFORMED/DOC $0.00
G8479 9 MD RX'D ACE/ARB THXPY $0.00
G8480 9 PT INELIG ACE/ARB THXPY $0.00
G8481 9 MD NOT RX'D ACE/ARB THXPY $0.00
G8482 9 FLU IMMUNIZE ORDER/ADMIN $0.00
G8483 9 FLU IMM NO ORD/ADMIN DOC REA $0.00
G8484 9 FLU IMMUNIZE NO ORDER/ADMIN $0.00
G8485 9 REPORT, DIABETES MEASURES $0.00
G8486 9 REPORT, PREV CARE MEASURES $0.00
G8487 9 REPORT CKD MEASURES $0.00
G8488 9 REPORT ESRD MEASURES $0.00

G8489 9 CAD MEASURES GRP $0.00
G8490 9 RA MEASURES GRP $0.00
G8491 9 HIV/AIDS MEASURES GRP $0.00
G8492 9 PREV CARE MEASURES GRP $0.00
G8493 9 BACK PAIN MEASURES GRP $0.00
G8494 9 DM MEAS QUAL ACT PERFORM $0.00
G8495 9 CKD MEAS QUAL ACT PERFORM $0.00
G8496 9 PC MEAS QUAL ACT PERFORM $0.00
G8497 9 CABG MEAS QUAL ACT PERFORM $0.00
G8498 9 CAD MEAS QUAL ACT PERFORM $0.00
G8499 9 RA MEAS QUAL ACT PERFORM $0.00
G8500 9 HIV MEAS QUAL ACT PERFORM $0.00

G8501 9 PERIO MEAS QUAL ACT PERFORM $0.00
G8502 9 BP MEAS QUAL ACT PERFORM $0.00
G8503 9 DOC PROPH ANTIBX W/IN 1 HR $0.00
G8504 9 DOC ORD PRO ANTBX W/IN 1 HR $0.00
G8505 9 NO DOC PROPH ANTIBX W/IN 1HR $0.00
G8506 9 PT REC ACE/ARB $0.00
G8507 9 PT INELIG PT VERIF MEDS $0.00
G8508 9 PT INELIG; PAIN ASSES NO F/U $0.00
G8509 9 PAIN ASSESS NO F/U PLN DOC $0.00
G8510 9 PT INELIG NEG SCRN DEPRES $0.00

G8511 9 CLIN DEPRES SCRN NO F/U DOC $0.00
G8512 9 PAIN SEV QUANT PRESENT $0.00
G8513 9 ABI MEAS & DOC $0.00
G8514 9 PT INELIG; ABI MEASURE $0.00
G8515 9 NO ABI MEASUREMENT $0.00
G8516 9 SCRN FAL RSK >2 FAL OR W/INJ $0.00
G8517 9 SCRN FALL RSK; <2 FALLS $0.00
G8518 9 CLIN STG B/F LUN/ESO CA SURG $0.00
G8519 9 PT IN; CLIN CA STG B/F SURG $0.00
G8520 9 CLIN STG B/F SURG NOT DOC $0.00
G8521 9 ANTPLT RECD 48 HRS & DISCH $0.00
G8522 9 PT INELIG; ANTIPLT THERAPY $0.00
G8523 9 ANTPLT NOT RECD REAS NO SPEC $0.00

G8524 9 PATCH CLOSURE CONV CEA $0.00
G8525 9 NO PATCH CLOSURE CEA $0.00
G8526 9 NO PATCH CLOSURE CONV CEA $0.00
G8527 9 DOC ORD ANTIMIC PROPHY $0.00
G8528 9 PT INELIG; PROPH ANTIBIOT $0.00
G8529 9 NO DOC ORD ANTIMIC PROPHY $0.00
G8530 9 AUTO AV FISTULA RECD $0.00
G8531 9 PT INELIG; AUTO AV FISTULA $0.00
G8532 9 NO AUTO AV FISTULA; NO REAS $0.00
G8533 9 PARTIC IN CLIN DATA BASE REG $0.00
G8534 9 DOC ELDER MAL SCRN F/U PLAN $0.00
G8535 9 PT INELIG NO ELD MAL SCRN $0.00

G8536 9 NO DOC ELDER MAL SCRN $0.00
G8537 9 PT INELIG ELDMAL SCRN NO F/U $0.00
G8538 9 ELD MAL SCRN NO F/U PLN $0.00
G8539 9 CUR FUNCT ASSESS & CARE PLN $0.00
G8540 9 PT INELIG FUNCT ASSESS $0.00
G8541 9 NO DOC CUR FUNCT ASSESS $0.00
G8542 9 PT INELIG FUNC ASSES NO PLN $0.00
G8543 9 CUR FUNCT ASSES; NO CARE PLN $0.00
G8544 9 CABG MEASURES GRP $0.00
G9001 7 MCCD, INITIAL RATE $0.00

G9002 7 MCCD,MAINTENANCE RATE $0.00
G9003 9 MCCD, RISK ADJ HI, INITIAL $0.00
G9004 9 MCCD, RISK ADJ LO, INITIAL $0.00
G9005 7 MCCD, RISK ADJ, MAINTENANCE $0.00
G9006 7 MCCD, HOME MONITORING $0.00
G9007 7 MCCD, SCH TEAM CONF $0.00
G9008 7 MCCD,PHYS COOR-CARE OVRSGHT $0.00
G9009 7 MCCD, RISK ADJ, LEVEL 3 $0.00
G9012 7 OTHER SPECIFIED CASE MGMT $0.00
G9013 9 ESRD DEMO BUNDLE LEVEL I $0.00
G9014 9 ESRD DEMO BUNDLE-LEVEL II $0.00

G9016 9 DEMO-SMOKING CESSATION COUN $0.00
G9017 9 AMANTADINE HCL 100MG ORAL $0.00
G9018 9 ZANAMIVIR,INHALATION PWD 10M $0.00
G9019 9 OSELTAMIVIR PHOSPHATE 75MG $0.00
G9020 9 RIMANTADINE HCL 100MG ORAL $0.00
G9021 O CHEMOTHERAPY ASSESSMENT FOR NAUSEA $0.00
G9025 O CHEMOTHERAPY ASSESSMENT FOR PAIN $0.00

G9029 O CHEMOTHERAPY ASSESSMENT FOR LACK O $0.00
G9033 9 AMANTADINE HCL ORAL BRAND $0.00
G9034 9 SERVICES PROVIDED BY OCCUPATIONAL $0.00
G9035 9 SERVICES PROVIDED BY ORIENTATION $0.00
G9036 9 SERVICES PROVIDED BY LOW VISION TH $0.00
G9037 9 SERVICES PROVIDED BY REHABILITATIO $0.00

G9041 9 LOW VISION REHAB OCCUPATIONA $0.00
G9042 9 LOW VISION REHAB ORIENT/MOBI $0.00
G9043 9 LOW VISION LOWVISION THERAPI $0.00
G9044 9 LOW VISION REHABILATE TEACHE $0.00
G9050 9 ONCOLOGY WORK-UP EVALUATION $0.00
G9051 9 ONCOLOGY TX DECISION-MGMT $0.00
G9052 9 ONC SURVEILLANCE FOR DISEASE $0.00
G9053 9 ONC EXPECTANT MANAGEMENT PT $0.00
G9054 9 ONC SUPERVISION PALLIATIVE $0.00
G9055 9 ONC VISIT UNSPECIFIED NOS $0.00
G9056 9 ONC PRAC MGMT ADHERES GUIDE $0.00
G9057 9 ONC PRACT MGMT DIFFERS TRIAL $0.00
G9058 9 ONC PRAC MGMT DISAGREE W/GUI $0.00

G9059 9 ONC PRAC MGMT PT OPT ALTERNA $0.00
G9060 9 ONC PRAC MGMT DIF PT COMORB $0.00
G9061 9 ONC PRAC COND NOADD BY GUIDE $0.00
G9062 9 ONC PRAC GUIDE DIFFERS NOS $0.00
G9063 9 ONC DX NSCLC STGI NO DX PROG $0.00
G9064 9 ONC DX NSCLC STG2 NO DX PROG $0.00
G9065 9 ONC DX NSCLC STG3A NODX PROG $0.00
G9066 9 ONC DX NSCLC STG3B-4 METASTA $0.00
G9067 9 ONC DX NSCLC DX UNKNOWN NOS $0.00
G9068 9 ONC DX NSCLC/SCLC LIMITED $0.00
G9069 9 ONC DX SCLC/NSCLC EXT AT DX $0.00
G9070 9 ONC DX SCLC/NSCLC EXT UNKNWN $0.00

G9071 9 ONC DX BRST STG1 2B NO DX PR $0.00
G9072 9 ONC DX BRST STG1-2 NOPROGRES $0.00
G9073 9 ONC DX BRST STG3-W/PROGRES $0.00
G9074 9 ONC DX BRST STG3-NOPROGRESS $0.00
G9075 9 ONC DX BRST METASTIC/ RECUR $0.00
G9076 O ONC DX BRST UNKNOWN NOS $0.00
G9077 9 ONC DX PROSTATE T1NO PROGRES $0.00
G9078 9 ONC DX PROSTATE T2NO PROGRES $0.00
G9079 9 ONC DX PROSTATE T3B-T4NOPROG $0.00
G9080 9 ONC DX PROSTATE W/RISE PSA $0.00

G9081 O ONC DX PROSTATE METS NO CAST $0.00
G9082 O ONC DX PROSTATE CASTRATE MET $0.00
G9083 9 ONC DX PROSTATE UNKNWN NOS $0.00
G9084 9 ONC DX COLON T1-3,N1-2,NO PR $0.00
G9085 9 ONC DX COLON T4, N0 W/O PROG $0.00
G9086 9 ONC DX COLON T1-4 NO DX PROG $0.00
G9087 9 ONC DX COLON RADIOLG EVID DX $0.00
G9088 9 ONC DX COLON M1/METS W/O RAD $0.00
G9089 9 ONC DX COLON EXTENT UNKNOWN $0.00
G9090 9 ONC DX RECTAL T1-2 NO PROGR $0.00
G9091 9 ONC DX RECTAL T3 N0 NO PROG $0.00
G9092 9 ONC DX RECTAL T1-3,N1-2NOPRG $0.00
G9093 9 ONC DX RECTAL T4,N,M0 NO PRG $0.00

G9094 9 ONC DX RECTAL M1 W/METS PROG $0.00
G9095 9 ONC DX RECTAL EXTENT UNKNWN $0.00
G9096 9 ONC DX ESOPHAG T1-T3 NOPROG $0.00
G9097 9 ONC DX ESOPHAGEAL T4 NO PROG $0.00
G9098 9 ONC DX ESOPHAGEAL METS RECUR $0.00
G9099 9 ONC DX ESOPHAGEAL UNKNOWN $0.00
G9100 9 ONC DX GASTRIC NO RECURRENCE $0.00
G9101 9 ONC DX GASTRIC P R1-R2NOPROG $0.00
G9102 9 ONC DX GASTRIC UNRESECTABLE $0.00
G9103 9 ONC DX GASTRIC RECURRENT $0.00
G9104 9 ONC DX GASTRIC UNKNOWN NOS $0.00
G9105 9 ONC DX PANCREATC P R0 RES NO $0.00

G9106 9 ONC DX PANCREATC P R1/R2 NO $0.00
G9107 9 ONC DX PANCREATIC UNRESECTAB $0.00
G9108 9 ONC DX PANCREATIC UNKNWN NOS $0.00
G9109 9 ONC DX HEAD/NECK T1-T2NO PRG $0.00
G9110 9 ONC DX HEAD/NECK T3-4 NOPROG $0.00
G9111 9 ONC DX HEAD/NECK M1 METS REC $0.00
G9112 9 ONC DX HEAD/NECK EXT UNKNOWN $0.00
G9113 9 ONC DX OVARIAN STG1A-B NO PR $0.00
G9114 9 ONC DX OVARIAN STG1A-B OR 2 $0.00
G9115 9 ONC DX OVARIAN STG3/4 NOPROG $0.00

G9116 9 ONC DX OVARIAN RECURRENCE $0.00
G9117 9 ONC DX OVARIAN UNKNOWN NOS $0.00
G9118 O ONC DX NHL STG 1-2 NOT RELAP $0.00
G9119 O ONC DX NHL STG 3-4 NOT RELAP $0.00
G9120 O ONC DX NHL TRANS TO LG BCELL $0.00
G9121 O ONC NHLSTG 1-2 NO RELAP NO $0.00
G9122 O ONC DX NHL STG 3/4NO RELAP $0.00
G9123 9 ONC DX NHL LGE BCELL RELAP $0.00
G9124 9 ONC DX NHL RELAPSE/REFRACTOR $0.00
G9125 9 ONC DX NHL STG UNKNOWN $0.00
G9126 9 ONC DX OVARIAN STG IA/B $0.00
G9127 O ONC DX MULTI MYELOMA STAGE I $0.00
G9128 9 ONC DX MULT MYELOMA STG2 HIG $0.00

G9129 9 ONC DX MULT MYELOMA UNKWN OP $0.00
G9130 9 ONC DX MULTI MYELOMA UNKNOWN $0.00
G9131 9 ONC DX BRST UNKNOWN NOS $0.00
G9132 9 ONC DX PROSTATE METS NO CAST $0.00
G9133 9 ONC DX PROSTATE CLINICAL MET $0.00
G9134 9 ONC NHLSTG 1-2 NO RELAP NO $0.00
G9135 9 ONC DX NHL STG 3-4 NOT RELAP $0.00
G9136 9 ONC DX NHL TRANS TO LG BCELL $0.00
G9137 9 ONC DX NHL RELAPSE/REFRACTOR $0.00
G9138 9 ONC DX NHL STG UNKNOWN $0.00
G9139 9 ONC DX CML DX STATUS UNKNOWN $0.00
G9140 9 FRONTIER EXTENDED STAY DEMO $0.00

H0001 7 ALCOHOL AND/OR DRUG ASSESS $0.00
H0002 7 ALCOHOL AND/OR DRUG SCREENIN $0.00
H0003 9 ALCOHOL AND/OR DRUG SCREENIN $0.00
H0004 9 ALCOHOL AND/OR DRUG SERVICES $0.00

H0021 9 ALCOHOL AND/OR DRUG TRAINING $0.00
H0022 9 ALCOHOL AND/OR DRUG INTERVEN $0.00
H0023 9 ALCOHOL AND/OR DRUG OUTREACH $0.00

H0024 9 ALCOHOL AND/OR DRUG PREVENTI $0.00
H0030 9 ALCOHOL AND/OR DRUG HOTLINE $0.00
H0031 7 MH HEALTH ASSESS BY NON-MD $0.00
H0032 7 MH SVC PLAN DEV BY NON-MD $0.00
H0033 9 ORAL MED ADM DIRECT OBSERVE $0.00
H0034 9 MED TRNG & SUPPORT PER 15MIN $0.00
H0035 9 MH PARTIAL HOSP TX UNDER 24H $0.00

H0036 9 COMM PSY FACE-FACE PER 15MIN $0.00
H0037 7 COMM PSY SUP TX PGM PER DIEM $0.00
H0038 9 SELF-HELP/PEER SVC PER 15MIN $0.00
H0039 7 ASSER COM TX FACE-FACE/15MIN $0.00
H0040 9 ASSERT COMM TX PGM PER DIEM $0.00
H0041 9 FOS C CHLD NON-THER PER DIEM $0.00
H0042 9 FOS C CHLD NON-THER PER MON $0.00
H0043 7 SUPPORTED HOUSING, PER DIEM $0.00
H0044 9 SUPPORTED HOUSING, PER MONTH $0.00
H0045 9 RESPITE NOT-IN-HOME PER DIEM $0.00

H0046 7 MENTAL HEALTH SERVICE, NOS $0.00
H0047 9 ALCOHOL/DRUG ABUSE SVC NOS $0.00
H0048 9 SPEC COLL NON-BLOOD:A/D TEST $0.00
H0049 9 ALCOHOL/DRUG SCREENING $0.00
H0050 9 ALCOHOL/DRUG SERVICE 15 MIN $0.00
H1000 9 PRENATAL CARE ATRISK ASSESSM $0.00
H1001 9 ANTEPARTUM MANAGEMENT $0.00
H1002 9 CARECOORDINATION PRENATAL $0.00
H1003 9 PRENATAL AT RISK EDUCATION $0.00
H1004 9 FOLLOW UP HOME VISIT/PRENTAL $0.00
H1005 9 PRENATALCARE ENHANCED SRV PK $0.00
H1010 9 NONMED FAMILY PLANNING ED $0.00
H1011 9 FAMILY ASSESSMENT $0.00

H2000 9 COMP MULTIDISIPLN EVALUATION $0.00
H2001 9 REHABILITATION PROGRAM 1/2 D $0.00
H2010 9 COMPREHENSIVE MED SVC 15 MIN $0.00
H2011 7 CRISIS INTERVEN SVC, 15 MIN $0.00
H2012 7 BEHAV HLTH DAY TREAT, PER HR $0.00
H2013 9 PSYCH HLTH FAC SVC, PER DIEM $0.00
H2014 9 SKILLS TRAIN AND DEV, 15 MIN $0.00
H2015 9 COMP COMM SUPP SVC, 15 MIN $0.00
H2016 7 COMP COMM SUPP SVC, PER DIEM $0.00
H2017 9 PSYSOC REHAB SVC, PER 15 MIN $0.00
H2018 7 PSYSOC REHAB SVC, PER DIEM $0.00
H2019 9 THER BEHAV SVC, PER 15 MIN $0.00

H2020 7 THER BEHAV SVC, PER DIEM $0.00
H2021 9 COM WRAP-AROUND SV, 15 MIN $0.00
H2022 9 COM WRAP-AROUND SV, PER DIEM $0.00
H2023 9 SUPPPORTED EMPLOY, PER 15 MIN $0.00
H2024 7 SUPPORTED EMPLOY, PER DIEM $0.00
H2025 9 SUPP MAINT EMPLOY, 15 MIN $0.00
H2026 9 SUPP MAINT EMPLOY, PER DIEM $0.00
H2027 7 PSYCHOED SVC, PER 15 MIN $0.00
H2028 9 SEX OFFEND TX SVC, 15 MIN $0.00
H2029 9 SEX OFFEND TX SVC, PER DIEM $0.00

H2030 9 MH CLUBHOUSE SVC, PER 15 MIN $0.00
H2031 9 MH CLUBHOUSE SVC, PER DIEM $0.00
H2032 9 ACTIVITY THERAPY, PER 15 MIN $0.00
H2033 9 MULTISYS THER/JUVENILE 15MIN $0.00
H2034 9 A/D HALFWAY HOUSE, PER DIEM $0.00
H2035 7 A/D TX PROGRAM, PER HOUR $0.00
H2036 7 A/D TX PROGRAM, PER DIEM $0.00
H2037 9 DEV DELAY PREV DP CH, 15 MIN $0.00
H5010 9 THERAPY, INDIVIDUAL, BY SOCIAL WORK $0.00
H5020 9 PSYCHOTHERAPY, GROUP (MAXIMUM 8 PER $0.00
H5025 9 PSYCHOTHERAPY, GROUP (MAXIMUM 8 PER $0.00
H5030 9 OTHER SERVICES BY SOCIAL WORKER, PS $0.00
H5040 9 RESIDENTIAL CARE IN PUBLIC INSTITUT $0.00

H5050 9 RESIDENTIAL CARE IN PRIVATE INSTITU $0.00
H5060 9 PUBLIC SPECIAL SCHOOLS OR DAY CARE $0.00
H5090 9 SPECIAL CLASS PRIVATE $0.00
H5100 9 SPECIAL CLASS PRIVATE PROPRIETARY $0.00
H5110 9 SUMMER TREATMENT CAMP $0.00
H5120 9 SPECIALIZED CARE NURSING HOME, CONV $0.00
H5130 9 VISITING TEACHER SERVICES $0.00
H5160 9 READING THERAPY $0.00
H5170 9 OTHER SPECIAL EDUCATION OR VOCATION $0.00
H5180 9 TRANSPORTATION FOR HANDICAPPED $0.00
H5190 9 NURSING CARE, HOME $0.00
H5200 9 NURSING CARE, OTHER $0.00

H5220 9 REHABILITATIVE EVALUATION, 0-20 MIN $0.00
H5230 9 REHABILITATIVE EVALUATION, 21-40 MI $0.00
H5240 9 REHABILITATIVE EVALUATION, 41-60 MI $0.00
H5299 9 REHABILITATIVE EVALUATION, NOT OTHE $0.00
H5300 9 OCCUPATIONAL THERAPY, EXCLUDING INI $0.00
HI010 O MCO SPECIFIC CODE: HOME INFUSION PA $0.00

HI021 O MCO SPECIFIC: HOME INFUSION PACKAGE $0.00
HI031 O MCO SCPECIFIC CODE: HOME INFUSION P $0.00

HI080 O MCO SPECIFIC CODE: HOME INFUSION, S $0.00

HI120 O MCO SPECIFIC CODE: HOME INFUSION, E $0.00

HM1CW O MCO SPECIFIC CODE: SMART START INIT $0.00
HM1RN O MCO SPECIFIC CODE: SMART START INIT $0.00
HM1SW O MCO SPECIFIC CODE: SMART START INIT $0.00
HM2CW O MCO SPECIFIC CODE: SMART START POST $0.00
HM2RN O MCO SPECIFIC CODE: SMART START POST $0.00
HM2SW O MCO SPECIFIC CODE: SMART START POST $0.00
J0110 O ADMINISTRATION OF INJECTION, INCLUD $0.00
J0120 5 TETRACYCLIN INJECTION $0.00
J0128 6 ABARELIX INJECTION $0.00
J0129 3 ABATACEPT INJECTION $19.04
J0130 3 ABCIXIMAB INJECTION $444.32

J0132 5 ACETYLCYSTEINE INJECTION $0.00
J0133 5 ACYCLOVIR INJECTION $0.00
J0135 6 ADALIMUMAB INJECTION $0.00
J0150 3 INJECTION ADENOSINE 6 MG $9.62
J0151 5 ADENOSINE INJECTION $0.00
J0152 3 ADENOSINE INJECTION $37.63
J0170 3 ADRENALIN EPINEPHRIN INJECT $0.67
J0180 6 AGALSIDASE BETA INJECTION $0.00
J0190 5 INJ BIPERIDEN LACTATE/5 MG $0.00
J0200 9 ALATROFLOXACIN MESYLATE $0.00
J0205 5 ALGLUCERASE INJECTION $0.00
J0207 3 AMIFOSTINE $188.30

J0210 5 METHYLDOPATE HCL INJECTION $0.00
J0215 6 ALEFACEPT $0.00
J0220 3 INJECTION, ALGLUCOSIDASE ALFA, $123.84
J0230 O INJECTION, ALLERGY DESENSITIZATION, $0.00
J0240 O INJECTION, ALLERGY DESENSITIZATION, $0.00
J0256 5 ALPHA 1 PROTEINASE INHIBITOR $0.00
J0270 9 ALPROSTADIL FOR INJECTION $0.00
J0275 9 ALPROSTADIL URETHRAL SUPPOS $0.00
J0278 5 AMIKACIN SULFATE INJECTION $0.00
J0280 3 AMINOPHYLLIN 250 MG INJ $0.42

J0282 5 AMIODARONE HCL $0.00
J0285 5 AMPHOTERICIN B $0.00
J0286 O AMPHOTERICIN B LIPID COMPLEX $0.00
J0287 3 AMPHOTERICIN B LIPID COMPLEX $10.58
J0288 5 AMPHO B CHOLESTERYL SULFATE $0.00
J0289 3 AMPHOTERICIN B LIPOSOME INJ $15.59
J0290 3 AMPICILLIN 500 MG INJ $1.34
J0295 3 AMPICILLIN SODIUM PER 1.5 GM $3.12
J0300 5 AMOBARBITAL 125 MG INJ $0.00
J0330 3 SUCCINYCHOLINE CHLORIDE INJ $0.14
J0340 O NANDROLON PHENPROPIONATE INJ $0.00
J0348 3 ANIDULAFUNGIN INJECTION $1.28
J0350 5 INJECTION ANISTREPLASE 30 U $0.00

J0360 5 HYDRALAZINE HCL INJECTION $0.00
J0364 3 APOMORPHINE HYDROCHLORIDE $3.71
J0365 5 APROTONIN, 10,000 KIU $0.00
J0380 5 INJ METARAMINOL BITARTRATE $0.00
J0390 5 CHLOROQUINE INJECTION $0.00
J0395 5 ARBUTAMINE HCL INJECTION $0.00
J0400 3 INJECTION, ARIPIPRAZOLE, INTRAMUSC $0.29
J0456 3 AZITHROMYCIN $9.17
J0460 3 ATROPINE SULFATE INJECTION $0.28
J0470 5 DIMECAPROL INJECTION $0.00
J0475 6 BACLOFEN 10 MG INJECTION $0.00
J0476 3 BACLOFEN INTRATHECAL TRIAL $69.97

J0480 5 BASILIXIMAB $0.00
J0500 5 DICYCLOMINE INJECTION $0.00
J0510 O BENZQUINAMIDE INJECTION $0.00
J0515 5 INJ BENZTROPINE MESYLATE $0.00
J0520 5 BETHANECHOL CHLORIDE INJECT $0.00
J0530 5 PENICILLIN G BENZATHINE INJ $0.00

J0583 6 BIVALIRUDIN $0.00
J0585 3 BOTULINUM TOXIN A PER UNIT $5.41
J0587 3 BOTULINUM TOXIN TYPE B $8.87
J0590 O ETHYLNOREPINEPHRINE HCL INJ $0.00
J0592 5 BUPRENORPHINE HYDROCHLORIDE $0.00
J0594 3 BUSULFAN INJECTION $9.53
J0595 6 BUTORPHANOL TARTRATE 1 MG $0.00
J0600 5 EDETATE CALCIUM DISODIUM INJ $0.00
J0610 3 CALCIUM GLUCONATE INJECTION $0.29
J0620 5 CALCIUM GLYCER & LACT/10 ML $0.00
J0630 5 CALCITONIN SALMON INJECTION $0.00
J0635 O CALCITRIOL INJECTION $0.00

J0636 5 INJ CALCITRIOL PER 0.1 MCG $0.00
J0637 5 CASPOFUNGIN ACETATE $0.00
J0640 3 LEUCOVORIN CALCIUM INJECTION $1.95
J0641 3 LEVOLEUCOVORIN INJECTION $1.05
J0670 3 INJ MEPIVACAINE HCL/10 ML $1.82
J0680 O INJECTION, DESLANOSIDE, UP TO 0.4 M $0.00
J0690 3 CEFAZOLIN SODIUM INJECTION $0.59
J0692 3 CEFEPIME HCL FOR INJECTION $5.25
J0694 3 CEFOXITIN SODIUM INJECTION $6.45
J0695 O CEFONOCID SODIUM INJECTION $0.00
J0696 3 CEFTRIAXONE SODIUM INJECTION $13.78
J0697 5 STERILE CEFUROXIME INJECTION $0.00

J0698 5 CEFOTAXIME SODIUM INJECTION $0.00
J0700 O INJECTION, BETAMETHASONE, UP TO 6 M $0.00
J0702 3 BETAMETHASONE ACET&SOD PHOSP $6.08
J0704 5 BETAMETHASONE SOD PHOSP/4 MG $0.00
J0706 5 CAFFEINE CITRATE INJECTION $0.00
J0710 5 CEPHAPIRIN SODIUM INJECTION $0.00
J0713 5 INJ CEFTAZIDIME PER 500 MG $0.00
J0715 5 CEFTIZOXIME SODIUM / 500 MG $0.00
J0720 5 CHLORAMPHENICOL SODIUM INJEC $0.00
J0725 5 CHORIONIC GONADOTROPIN/1000U $0.00

J0730 O CHLORPHENIRAMIN MALEATE INJ $0.00
J0735 5 CLONIDINE HYDROCHLORIDE $0.00
J0740 3 CIDOFOVIR INJECTION $761.41
J0743 3 CILASTATIN SODIUM INJECTION $13.68
J0744 3 CIPROFLOXACIN IV $1.66
J0745 5 INJ CODEINE PHOSPHATE /30 MG $0.00
J0760 6 COLCHICINE INJECTION $0.00
J0770 5 COLISTIMETHATE SODIUM INJ $0.00
J0780 5 PROCHLORPERAZINE INJECTION $0.00
J0790 O INJECTION, NIKETHAMIDE, UP TO 1.5 M $0.00
J0795 5 CORTICORELIN OVINE TRIFLUTAL $0.00
J0800 3 CORTICOTROPIN INJECTION $2,425.07
J0810 O CORTISONE INJECTION $0.00

J0820 O INJECTION, CORTIGEL 40, UP TO 40 UN $0.00
J0830 O INJECTION, CORTROPHIN ZINC HYDROXID $0.00
J0835 3 INJ COSYNTROPIN PER 0.25 MG $98.20
J0840 O INJECTION, WARFARIN SODIUM, UP TO 5 $0.00
J0850 3 CYTOMEGALOVIRUS IMM IV /VIAL $878.83
J0878 3 DAPTOMYCIN INJECTION $0.38
J0880 O DARBEPOETIN ALFA INJECTION $0.00
J0881 3 DARBEPOETIN ALFA, NON-ESRD $3.06
J0882 5 DARBEPOETIN ALFA, ESRD USE $0.00
J0885 3 EPOETIN ALFA, NON-ESRD $9.20
J0886 5 EPOETIN ALFA 1000 UNITS ESRD $0.00
J0894 3 DECITABINE INJECTION $27.68

J0895 5 DEFEROXAMINE MESYLATE INJ $0.00
J0900 5 TESTOSTERONE ENANTHATE INJ $0.00
J0945 5 BROMPHENIRAMINE MALEATE INJ $0.00
J0970 5 ESTRADIOL VALERATE INJECTION $0.00
J1000 5 DEPO-ESTRADIOL CYPIONATE INJ $0.00
J1020 3 METHYLPREDNISOLONE 20 MG INJ $1.88
J1050 5 MEDROXYPROGESTERONE INJ $0.00
J1051 3 MEDROXYPROGESTERONE INJ $7.28

J1055 3 MEDRXYPROGESTER ACETATE INJ $28.91
J1056 3 MA/EC CONTRACEPTIVEINJECTION $22.50
J1060 5 TESTOSTERONE CYPIONATE 1 ML $0.00
J1070 5 TESTOSTERONE CYPIONAT 100 MG $0.00
J1080 5 TESTOSTERONE CYPIONAT 200 MG $0.00
J1090 O TESTOSTERONE CYPIONATE 50 MG $0.00
J1094 6 INJ DEXAMETHASONE ACETATE $0.00
J1095 5 INJ DEXAMETHASONE ACETATE $0.00
J1100 3 DEXAMETHASONE SODIUM PHOS $0.09
J1110 3 INJ DIHYDROERGOTAMINE MESYLT $22.69
J1120 5 ACETAZOLAMID SODIUM INJECTIO $0.00
J1155 O INJECTION, DIGITOXIN $0.00
J1160 5 DIGOXIN INJECTION $0.00

J1162 5 DIGOXIN IMMUNE FAB (OVINE) $0.00
J1165 5 PHENYTOIN SODIUM INJECTION $0.00
J1170 6 HYDROMORPHONE INJECTION $0.00
J1180 5 DYPHYLLINE INJECTION $0.00
J1190 5 DEXRAZOXANE HCL INJECTION $0.00
J1200 3 DIPHENHYDRAMINE HCL INJECTIO $0.73
J1205 5 CHLOROTHIAZIDE SODIUM INJ $0.00
J1212 5 DIMETHYL SULFOXIDE 50% 50 ML $0.00
J1230 5 METHADONE INJECTION $0.00
J1240 5 DIMENHYDRINATE INJECTION $0.00
J1245 3 DIPYRIDAMOLE INJECTION $7.52
J1250 3 INJ DOBUTAMINE HCL/250 MG $3.25

J1260 3 DOLASETRON MESYLATE $4.63
J1265 5 DOPAMINE INJECTION $0.00
J1267 3 DORIPENEM INJECTION $0.65
J1270 5 INJECTION, DOXERCALCIFEROL $0.00
J1300 3 ECULIZUMAB INJECTION $176.19
J1320 5 AMITRIPTYLINE INJECTION $0.00
J1324 3 ENFUVIRTIDE INJECTION $26.04
J1325 3 EPOPROSTENOL INJECTION $11.93
J1327 5 EPTIFIBATIDE INJECTION $0.00
J1330 5 ERGONOVINE MALEATE INJECTION $0.00

J1335 3 ERTAPENEM INJECTION $26.07
J1340 O INJECTION, AQUEOUS OR SALINE PLACEB $0.00
J1350 O INJECTION, ERYTHROMYCIN-IM, UP TO 1 $0.00
J1360 O INJECTION, ERTHROMYCIN-IV, UP TO 50 $0.00
J1362 O ERYTHROMYCIN GLUCEP / 250 MG $0.00
J1364 5 ERYTHRO LACTOBIONATE /500 MG $0.00
J1380 5 ESTRADIOL VALERATE 10 MG INJ $0.00
J1390 5 ESTRADIOL VALERATE 20 MG INJ $0.00
J1410 3 INJ ESTROGEN CONJUGATE 25 MG $78.49
J1430 3 ETHANOLAMINE OLEATE 100 MG $79.46
J1435 5 INJECTION ESTRONE PER 1 MG $0.00
J1436 5 ETIDRONATE DISODIUM INJ $0.00
J1438 5 ETANERCEPT INJECTION $0.00

J1440 3 FILGRASTIM 300 MCG INJECITON $202.11
J1441 3 FILGRASTIM 480 MCG INJECTION $274.45
J1450 5 FLUCONAZOLE $0.00
J1451 5 FOMEPIZOLE, 15 MG $0.00
J1452 5 INTRAOCULAR FOMIVIRSEN NA $0.00
J1453 3 FOSAPREPITANT INJECTION $1.57
J1455 3 FOSCARNET SODIUM INJECTION $10.61
J1457 6 GALLIUM NITRATE INJECTION $0.00
J1458 3 GALSULFASE INJECTION $326.65
J1459 3 INJ IVIG PRIVIGEN 500 MG $34.15
J1460 5 GAMMA GLOBULIN 1 CC INJ $0.00

J1560 5 GAMMA GLOBULIN > 10 CC INJ $0.00
J1561 3 IMMUNE GLOBULIN 500 MG $35.53

J1562 3 VIVAGLOBIN, INJ $7.02
J1563 O IV IMMUNE GLOBULIN $0.00
J1564 O IMMUNE GLOBULIN 10 MG $0.00
J1565 5 RSV-IVIG $0.00
J1566 5 IMMUNE GLOBULIN, POWDER $0.00
J1567 O IMMUNE GLOBULIN, LIQUID $0.00
J1568 3 OCTAGAM INJECTION $36.87
J1569 3 GAMMAGARD LIQUID INJECTION $35.38
J1570 6 GANCICLOVIR SODIUM INJECTION $0.00
J1571 3 HEPAGAM B IM INJECTION $44.09
J1572 3 FLEBOGAMMA INJECTION $35.60
J1573 3 HEPAGAM B INTRAVENOUS, INJ $44.09
J1580 3 GARAMYCIN GENTAMICIN INJ $0.69

J1590 5 GATIFLOXACIN INJECTION $0.00
J1595 3 INJECTION GLATIRAMER ACETATE $67.64
J1600 5 GOLD SODIUM THIOMALEATE INJ $0.00
J1610 5 GLUCAGON HYDROCHLORIDE/1 MG $0.00
J1620 5 GONADORELIN HYDROCH/ 100 MCG $0.00
J1625 O INJECTION, GRANISETRON HYDROCHLORID $0.00
J1626 3 GRANISETRON HCL INJECTION $3.45
J1630 5 HALOPERIDOL INJECTION $0.00
J1631 5 HALOPERIDOL DECANOATE INJ $0.00
J1640 5 INJECTION, HEMIN, 1 MG $0.00
J1642 3 INJ HEPARIN SODIUM PER 10 U $0.02
J1644 3 INJ HEPARIN SODIUM PER 1000U $0.11

J1645 5 DALTEPARIN SODIUM $0.00
J1650 3 INJ ENOXAPARIN SODIUM $6.20
J1652 5 FONDAPARINUX SODIUM $0.00
J1655 3 TINZAPARIN SODIUM INJECTION $2.12
J1660 O INJECTION, HISTAMINE, UP TO 2.75 MG $0.00
J1670 5 TETANUS IMMUNE GLOBULIN INJ $0.00
J1675 5 HISTRELIN ACETATE $0.00
J1690 O PREDNISOLONE TEBUTATE INJ $0.00
J1700 5 HYDROCORTISONE ACETATE INJ $0.00
J1710 5 HYDROCORTISONE SODIUM PH INJ $0.00

J1720 3 HYDROCORTISONE SODIUM SUCC I $2.10
J1730 5 DIAZOXIDE INJECTION $0.00
J1739 O HYDROXYPROGESTERONE CAP 125 $0.00
J1740 3 IBANDRONATE SODIUM INJECTION $138.96
J1741 O HYDROXYPROGESTERONE CAP 250 $0.00
J1742 5 IBUTILIDE FUMARATE INJECTION $0.00
J1743 3 IDURSULFASE INJECTION $452.09
J1745 3 INFLIXIMAB INJECTION $57.08
J1750 6 IRON DEXTRAN $0.00
J1751 O IRON DEXTRAN 165 INJECTION $0.00
J1752 O IRON DEXTRAN 267 INJECTION $0.00
J1755 O IRON SUCROSE INJECTION $0.00
J1756 3 IRON SUCROSE INJECTION $0.37

J1760 O IRON DEXTRAN 2 CC INJ $0.00
J1785 5 INJECTION IMIGLUCERASE /UNIT $0.00
J1790 5 DROPERIDOL INJECTION $0.00
J1800 5 PROPRANOLOL INJECTION $0.00
J1810 5 DROPERIDOL/FENTANYL INJ $0.00
J1815 3 INSULIN INJECTION $0.19
J1817 5 INSULIN FOR INSULIN PUMP USE $0.00
J1820 O INSULIN INJECTION $0.00
J1825 3 INTERFERON BETA-1A $542.32
J1830 5 INTERFERON BETA-1B / .25 MG $0.00

J1835 5 INTRACONAZOLE INJECTION $0.00
J1840 5 KANAMYCIN SULFATE 500 MG INJ $0.00
J1850 5 KANAMYCIN SULFATE 75 MG INJ $0.00
J1885 3 KETOROLAC TROMETHAMINE INJ $0.30
J1890 5 CEPHALOTHIN SODIUM INJECTION $0.00
J1910 O KUTAPRESSIN INJECTION $0.00
J1930 6 INJECTION, LANREOTIDE, 1 MG $0.00
J1931 3 LARONIDASE INJECTION $24.96
J1940 3 FUROSEMIDE INJECTION $0.21
J1945 5 LEPIRUDIN $0.00

J1950 5 LEUPROLIDE ACETATE /3.75 MG $0.00
J1953 3 LEVETIRACETAM INJECTION $0.43
J1955 5 INJ LEVOCARNITINE PER 1 GM $0.00
J1956 3 LEVOFLOXACIN INJECTION $5.97
J1960 5 LEVORPHANOL TARTRATE INJ $0.00
J1970 O METHOTRIMEPRAZINE INJECTION $0.00
J1980 5 HYOSCYAMINE SULFATE INJ $0.00
J1990 5 CHLORDIAZEPOXIDE INJECTION $0.00
J2000 O LIDOCAINE INJECTION $0.00
J2001 3 LIDOCAINE INJECTION $0.02
J2010 5 LINCOMYCIN INJECTION $0.00
J2020 5 LINEZOLID INJECTION $0.00
J2050 O INJECTION, LIVER, UP TO 20 MCG $0.00

J2060 3 LORAZEPAM INJECTION $0.75
J2100 O INJECTION, LUMINAL SODIUM, UP TO 12 $0.00
J2150 3 MANNITOL INJECTION $0.91
J2160 O INJECTION, CYCLIZINE LACTATE, UP TO $0.00
J2170 3 MECASERMIN INJECTION $17.65
J2175 3 MEPERIDINE HYDROCHL /100 MG $0.54
J2180 5 MEPERIDINE/PROMETHAZINE INJ $0.00
J2185 6 MEROPENEM $0.00
J2190 O INJECTION, MERSALYL WITH THEOPHYLLI $0.00
J2210 5 METHYLERGONOVIN MALEATE INJ $0.00
J2220 5 INJECTION, METHYLANDROSTENEDIOL, AL $0.00
J2240 O METOCURINE IODIDE INJECTION $0.00

J2248 3 MICAFUNGIN SODIUM INJECTION $1.96
J2250 3 INJ MIDAZOLAM HYDROCHLORIDE $0.16
J2260 5 INJECTION, MILRINONE LACTATE 5MG $0.00
J2270 3 MORPHINE SULFATE INJECTION $0.26
J2271 5 MORPHINE SO4 INJECTION 100MG $0.00
J2275 5 MORPHINE SULFATE INJECTION $0.00
J2278 5 ZICONOTIDE INJECTION $0.00
J2280 6 INJ, MOXIFLOXACIN 100 MG $0.00
J2300 3 INJ NALBUPHINE HYDROCHLORIDE $1.55
J2310 3 INJ NALOXONE HYDROCHLORIDE $3.72

J2315 3 NALTREXONE, DEPOT FORM $1.88
J2320 5 NANDROLONE DECANOATE 50 MG $0.00
J2323 3 NATALIZUMAB INJECTION $7.91
J2324 O NESIRITIDE $0.00
J2325 5 NESIRITIDE INJECTION $0.00
J2330 O THIOTHIXENE INJECTION $0.00
J2350 O NIACINAMIDE/NIACIN INJECTION $0.00
J2352 O OCTREOTIDE ACETATE INJECTION $0.00
J2353 6 OCTREOTIDE INJECTION, DEPOT $0.00
J2354 6 OCTREOTIDE INJ, NON-DEPOT $0.00
J2355 5 OPRELVEKIN INJECTION $0.00

J2357 3 OMALIZUMAB INJECTION $18.23
J2360 5 ORPHENADRINE INJECTION $0.00
J2370 5 PHENYLEPHRINE HCL INJECTION $0.00
J2400 5 CHLOROPROCAINE HCL INJECTION $0.00
J2405 3 ONDANSETRON HCL INJECTION $0.21
J2410 5 OXYMORPHONE HCL INJECTION $0.00
J2425 5 PALIFERMIN INJECTION $0.00
J2430 5 PAMIDRONATE DISODIUM /30 MG $0.00
J2440 5 PAPAVERIN HCL INJECTION $0.00
J2460 5 OXYTETRACYCLINE INJECTION $0.00
J2469 3 PALONOSETRON HCL $16.64
J2480 O HYDROCHLORIDES OF OPIUM INJ $0.00

J2490 O INJECTION, PARALDEHYDE, UP TO 5 ML $0.00
J2495 O INJECTION, TRIDIHEXETHYL CHLORIDE P $0.00
J2500 O PARICALCITOL $0.00
J2501 5 PARICALCITOL $0.00
J2503 5 PEGAPTANIB SODIUM INJECTION $0.00
J2504 5 PEGADEMASE BOVINE, 25 IU $0.00
J2505 3 INJECTION, PEGFILGRASTIM 6MG $2,176.15
J2510 5 PENICILLIN G PROCAINE INJ $0.00
J2512 O INJ PENTAGASTRIN PER 2 ML $0.00
J2513 5 PENTASTARCH 10% SOLUTION $0.00

J2515 3 PENTOBARBITAL SODIUM INJ $9.17
J2520 5 INJECTION, THIOPENTAL SODIUM $0.00
J2540 3 PENICILLIN G POTASSIUM INJ $0.79
J2543 5 PIPERACILLIN/TAZOBACTAM $0.00
J2545 9 PENTAMIDINE NON-COMP UNIT $0.00
J2550 3 PROMETHAZINE HCL INJECTION $1.36
J2560 5 PHENOBARBITAL SODIUM INJ $0.00
J2590 5 OXYTOCIN INJECTION $0.00
J2595 O INJECTION, VASOPRESSIN TANNATE $0.00
J2597 5 INJ DESMOPRESSIN ACETATE $0.00
J2600 O INJECTION, POSTERIOR PITUITARY, UP $0.00
J2640 O PREDNISOLONE SODIUM PH INJ $0.00
J2650 5 PREDNISOLONE ACETATE INJ $0.00

J2670 5 TOTAZOLINE HCL INJECTION $0.00
J2672 O INJECTION, PROPANTHELINE BROMIDE $0.00
J2675 O INJ PROGESTERONE PER 50 MG $0.00
J2680 5 FLUPHENAZINE DECANOATE 25 MG $0.00
J2690 5 PROCAINAMIDE HCL INJECTION $0.00
J2700 3 OXACILLIN SODIUM INJECITON $1.82
J2710 5 NEOSTIGMINE METHYLSLFTE INJ $0.00
J2720 5 INJ PROTAMINE SULFATE/10 MG $0.00
J2724 6 PROTEIN C CONCENTRATE $0.00
J2725 5 INJ PROTIRELIN PER 250 MCG $0.00
J2730 5 PRALIDOXIME CHLORIDE INJ $0.00
J2760 9 PHENTOLAINE MESYLATE INJ $0.00

J2765 3 METOCLOPRAMIDE HCL INJECTION $1.30
J2770 5 QUINUPRISTIN/DALFOPRISTIN $0.00
J2778 3 RANIBIZUMAB INJECTION $406.60
J2780 3 RANITIDINE HYDROCHLORIDE INJ $0.99
J2783 6 RASBURICASE $0.00
J2785 3 REGADENOSON INJECTION $47.40
J2788 3 RHO D IMMUNE GLOBULIN 50 MCG $23.50
J2790 3 RHO D IMMUNE GLOBULIN INJ $86.26
J2791 6 RHOPHYLAC INJECTION $0.00
J2792 3 RHO(D) IMMUNE GLOBULIN H, SD $16.39

J2794 6 RISPERIDONE, LONG ACTING $0.00
J2795 5 ROPIVACAINE HCL INJECTION $0.00
J2800 5 METHOCARBAMOL INJECTION $0.00
J2805 5 SINCALIDE INJECTION $0.00
J2810 5 INJ THEOPHYLLINE PER 40 MG $0.00
J2820 3 SARGRAMOSTIM INJECTION $24.07
J2825 O INJECTION, SARRACENIA PURPUREA PLAN $0.00
J2850 5 INJ SECRETIN SYNTHETIC HUMAN $0.00
J2860 O SECOBARBITAL SODIUM INJ $0.00
J2910 5 AUROTHIOGLUCOSE INJECITON $0.00
J2914 O INJECTION, SODIUM SALICYLATE $0.00
J2915 O NA FERRIC GLUCONATE COMPLEX $0.00
J2916 5 NA FERRIC GLUCONATE COMPLEX $0.00

J2920 3 METHYLPREDNISOLONE INJECTION $1.70
J2930 3 METHYLPREDNISOLONE INJECTION $2.95
J2940 5 SOMATREM INJECTION $0.00
J2941 5 SOMATROPIN INJECTION $0.00
J2950 5 PROMAZINE HCL INJECITON $0.00
J2970 O METHICILLIN SODIUM INJECTION $0.00
J2993 5 RETEPLASE INJECTION $0.00
J2994 9 RETEPLASE DOUBLE BOLUS $0.00
J2995 5 INJ STREPTOKINASE /250000 IU $0.00
J2996 O ALTEPLASE RECOMBINANT INJ $0.00
J2997 3 ALTEPLASE RECOMBINANT $34.10
J3000 3 STREPTOMYCIN INJECTION $4.61

J3005 O INJECTION, STRONTIUM-89 CHLORIDE, P $0.00
J3010 3 FENTANYL CITRATE INJECITON $0.18
J3030 5 SUMATRIPTAN SUCCINATE / 6 MG $0.00
J3050 O INJECTION, DECAMETHONIUM BROMIDE, U $0.00
J3070 5 PENTAZOCINE INJECTION $0.00
J3080 O CHLORPROTHIXENE INJECTION $0.00
J3100 O TENECTEPLASE INJECTION $0.00
J3101 9 TENECTEPLASE INJECTION $0.00
J3105 5 TERBUTALINE SULFATE INJ $0.00
J3110 6 TERIPARATIDE INJECTION $0.00

J3140 5 TESTOSTERONE SUSPENSION INJ $0.00
J3150 5 TESTOSTERON PROPIONATE INJ $0.00
J3180 O INJECTION, TETANUS TOXOID, UP TO 1 $0.00
J3230 5 CHLORPROMAZINE HCL INJECTION $0.00
J3240 5 THYROTROPIN INJECTION $0.00
J3243 6 TIGECYCLINE INJECTION $0.00
J3245 O TIROFIBAN HYDROCHLORIDE $0.00
J3246 6 TIROFIBAN HCL $0.00
J3250 5 TRIMETHOBENZAMIDE HCL INJ $0.00
J3260 5 TOBRAMYCIN SULFATE INJECTION $0.00
J3265 5 INJECTION TORSEMIDE 10 MG/ML $0.00

J3270 O IMIPRAMINE HCL INJECTION $0.00
J3280 5 THIETHYLPERAZINE MALEATE INJ $0.00
J3285 5 TREPROSTINIL INJECTION $0.00
J3300 6 INJECTION, TRIAMCINOLONE ACETONIDE, $0.00
J3301 3 TRIAMCINOLONE ACET INJ NOS $1.40
J3302 5 TRIAMCINOLONE DIACETATE INJ $0.00
J3303 3 TRIAMCINOLONE HEXACETONL INJ $1.33
J3305 5 INJ TRIMETREXATE GLUCORONATE $0.00
J3310 5 PERPHENAZINE INJECITON $0.00
J3315 5 TRIPTORELIN PAMOATE $0.00
J3320 5 SPECTINOMYCN DI-HCL INJ $0.00
J3340 O INJECTION, CRYPTENAMINE ACETATE, UP $0.00

J3350 5 UREA INJECTION $0.00
J3355 9 UROFOLLITROPIN, 75 IU $0.00
J3360 5 DIAZEPAM INJECTION $0.00
J3364 5 UROKINASE 5000 IU INJECTION $0.00
J3365 5 UROKINASE 250,000 IU INJ $0.00
J3370 3 VANCOMYCIN HCL INJECITON $3.08
J3380 O INJECTION, ISOXSUPRINE HCL, UP TO 1 $0.00
J3390 O METHOXAMINE INJECTION $0.00
J3395 O VERTEPORFIN INJECTION $0.00
J3396 6 VERTEPORFIN INJECTION $0.00

J3400 5 TRIFLUPROMAZINE HCL INJ $0.00
J3410 3 HYDROXYZINE HCL INJECITON $0.25
J3411 3 THIAMINE HCL 100 MG $2.63
J3415 6 PYRIDOXINE HCL 100 MG $0.00
J3420 3 VITAMIN B12 INJECTION $0.13
J3430 5 VITAMIN K PHYTONADIONE INJ $0.00
J3450 O MEPHENTERMINE SULFATE INJ $0.00
J3465 6 INJECTION, VORICONAZOLE $0.00
J3470 5 HYALURONIDASE INJECTION $0.00
J3471 5 OVINE, UP TO 999 USP UNITS $0.00
J3472 5 OVINE, 1000 USP UNITS $0.00
J3473 3 HYALURONIDASE RECOMBINANT $0.48
J3475 3 INJ MAGNESIUM SULFATE $0.05

J3480 3 INJ POTASSIUM CHLORIDE $0.02
J3485 5 ZIDOVUDINE $0.00
J3486 3 ZIPRASIDONE MESYLATE $5.38
J3487 3 ZOLEDRONIC ACID $5.36
J3488 3 RECLAST INJECTION $215.21
J3490 5 DRUGS UNCLASSIFIED INJECTION $0.00
J3500 O VITAMIN THERAPY $0.00
J3520 5 EDETATE DISODIUM PER 150 MG $0.00
J3530 9 NASAL VACCINE INHALATION $0.00
J3535 9 METERED DOSE INHALER DRUG $0.00
J3540 O AUTOGENOUS BLOOD EXTRACT, INTRAVENO $0.00
J3550 O INTRA-ARTERIAL OXYGEN INJECTION $0.00

J3560 O ADRENAL CORTEX EXTRACT $0.00
J3570 9 LAETRILE AMYGDALIN VIT B17 $0.00
J3590 5 UNCLASSIFIED BIOLOGICS $0.00
J6015 O TYPHUS $0.00
J7010 O VIAL OF ALLERGY VACCINE, SINGLE DOS $0.00
J7020 O VIAL OF ALLERGY VACCINE, MULTIPLE D $0.00
J7030 3 NORMAL SALINE SOLUTION INFUS $218.51
J7042 3 5% DEXTROSE/NORMAL SALINE $0.54

J7051 O STERILE SALINE/WATER $0.00
J7060 3 5% DEXTROSE/WATER $1.09
J7070 5 D5W INFUSION $0.00
J7080 O INFUSION, ALBUMISOL 5%, 500 ML VIAL $0.00
J7090 O INFUSION, ALBUMISOL 25%, 50 ML VIAL $0.00
J7100 5 DEXTRAN 40 INFUSION $0.00
J7110 5 DEXTRAN 75 INFUSION $0.00
J7120 5 RINGERS LACTATE INFUSION $0.00
J7130 5 HYPERTONIC SALINE SOLUTION $0.00
J7140 9 PRESCRIPTION DRUG, ORAL, DISPENSED $0.00
J7150 9 PRESCRIPTION DRUG, ORAL CHEMOTHERAP $0.00
J7186 6 ANTIHEMOPHILIC VIII/VWF COMP $0.00
J7187 3 HUMATE-P, INJ $0.86

J7188 O INJ VONWILLEBRAND FACTOR IU $0.00
J7189 5 FACTOR VIIA $0.00
J7190 5 FACTOR VIII $0.00
J7191 5 FACTOR VIII (PORCINE) $0.00
J7192 5 FACTOR VIII RECOMBINANT $0.00
J7193 5 FACTOR IX NON-RECOMBINANT $0.00
J7194 5 FACTOR IX COMPLEX $0.00
J7195 5 FACTOR IX RECOMBINANT $0.00
J7196 O OTHR HEMOPHILIA CLOT FACTORS $0.00
J7198 5 ANTI-INHIBITOR $0.00
J7199 5 HEMOPHILIA CLOT FACTOR NOC $0.00
J7300 9 INTRAUT COPPER CONTRACEPTIVE $0.00

J7302 3 LEVONORGESTREL IU CONTRACEPT $468.71
J7303 6 CONTRACEPTIVE VAGINAL RING $0.00
J7304 9 CONTRACEPTIVE HORMONE PATCH $0.00
J7306 9 LEVONORGESTREL IMPLANT SYS $0.00
J7307 3 ETONOGESTREL IMPLANT SYSTEM $483.70
J7308 9 AMINOLEVULINIC ACID HCL TOP $0.00
J7310 9 GANCICLOVIR LONG ACT IMPLANT $0.00
J7311 9 FLUOCINOLONE ACETONIDE IMPLT $0.00
J7315 O SODIUM HYALURONATE INJECTION $0.00

J7321 3 HYALGAN/SUPARTZ INJ PER DOSE $97.39
J7322 3 SYNVISC INJ PER DOSE $182.84
J7323 3 EUFLEXXA INJ PER DOSE $111.01
J7324 3 ORTHOVISC INJ PER DOSE $178.09
J7330 9 CULTURED CHONDROCYTES IMPLNT $0.00
J7340 O METABOLIC ACTIVE D/E TISSUE $0.00
J7341 O NON-HUMAN, METABOLIC TISSUE $0.00
J7342 O METABOLICALLY ACTIVE TISSUE $0.00
J7343 O NONMETABOLIC ACT D/E TISSUE $0.00
J7344 O NONMETABOLIC ACTIVE TISSUE $0.00
J7345 O NON-HUMAN, NON-METAB TISSUE $0.00

J7346 O INJECTABLE HUMAN TISSUE $0.00
J7347 O INTEGRA MATRIX TISSUE $0.00
J7348 O TISSUEMEND TISSUE $0.00
J7349 O PRIMATRIX TISSUE $0.00
J7350 O INJECTABLE HUMAN TISSUE $0.00
J7500 9 AZATHIOPRINE ORAL 50MG $0.00
J7501 5 AZATHIOPRINE PARENTERAL $0.00
J7502 9 CYCLOSPORINE ORAL 100 MG $0.00
J7503 O CYCLOSPORINE PARENTERAL $0.00
J7504 5 LYMPHOCYTE IMMUNE GLOBULIN $0.00
J7505 5 MONOCLONAL ANTIBODIES $0.00
J7506 9 PREDNISONE ORAL $0.00

J7507 9 TACROLIMUS ORAL PER 1 MG $0.00
J7508 O TACROLIMUS ORAL PER 5 MG $0.00
J7509 9 METHYLPREDNISOLONE ORAL $0.00
J7510 9 PREDNISOLONE ORAL PER 5 MG $0.00
J7511 5 ANTITHYMOCYTE GLOBULN RABBIT $0.00
J7513 5 DACLIZUMAB, PARENTERAL $0.00
J7515 9 CYCLOSPORINE ORAL 25 MG $0.00
J7516 5 CYCLOSPORIN PARENTERAL 250MG $0.00
J7517 9 MYCOPHENOLATE MOFETIL ORAL $0.00
J7518 9 MYCOPHENOLIC ACID $0.00

J7520 9 SIROLIMUS, ORAL $0.00
J7525 5 TACROLIMUS INJECTION $0.00
J7599 5 IMMUNOSUPPRESSIVE DRUG NOC $0.00
J7602 O ALBUTEROL INH NON-COMP CON $0.00
J7603 O ALBUTEROL INH NON-COMP U D $0.00
J7604 9 ACETYLCYSTEINE COMP UNIT $0.00
J7605 9 ARFORMOTEROL NON-COMP UNIT $0.00
J7606 9 FORMOTEROL FUMARATE, INH $0.00
J7607 9 LEVALBUTEROL COMP CON $0.00
J7608 9 ACETYLCYSTEINE NON-COMP UNIT $0.00
J7609 9 ALBUTEROL COMP UNIT $0.00
J7610 9 ALBUTEROL COMP CON $0.00
J7611 9 ALBUTEROL NON-COMP CON $0.00

J7612 9 LEVALBUTEROL NON-COMP CON $0.00
J7613 9 ALBUTEROL NON-COMP UNIT $0.00
J7614 9 LEVALBUTEROL NON-COMP UNIT $0.00
J7615 9 LEVALBUTEROL COMP UNIT $0.00
J7616 O ALBUTEROL COMPOUND SOLUTION $0.00
J7617 O LEVALBUTEROL COMPOUNDED SOL $0.00
J7618 O ALBUTEROL INH SOL CON $0.00
J7619 O ALBUTEROL INH SOL U D $0.00
J7620 9 ALBUTEROL IPRATROP NON-COMP $0.00
J7621 O (LEVO)ALBUTEROL/IPRA-BROMIDE $0.00
J7622 9 BECLOMETHASONE COMP UNIT $0.00
J7624 9 BETAMETHASONE COMP UNIT $0.00

J7625 O ALBUTEROL SULFATE .5% INJ $0.00
J7626 9 BUDESONIDE NON-COMP UNIT $0.00
J7627 9 BUDESONIDE COMP UNIT $0.00
J7628 9 BITOLTEROL MESYLATE COMP CON $0.00
J7629 9 BITOLTEROL MESYLATE COMP UNT $0.00
J7630 O CROMOLYN SODIUM INJECITON $0.00
J7631 9 CROMOLYN SODIUM NONCOMP UNIT $0.00
J7632 9 CROMOLYN SODIUM COMP UNIT $0.00
J7633 9 BUDESONIDE NON-COMP CON $0.00
J7634 9 BUDESONIDE COMP CON $0.00

J7635 9 ATROPINE COMP CON $0.00
J7636 9 ATROPINE COMP UNIT $0.00
J7637 9 DEXAMETHASONE COMP CON $0.00
J7638 9 DEXAMETHASONE COMP UNIT $0.00
J7639 9 DORNASE ALFA NON-COMP UNIT $0.00
J7640 9 FORMOTEROL COMP UNIT $0.00
J7641 9 FLUNISOLIDE COMP UNIT $0.00
J7642 9 GLYCOPYRROLATE COMP CON $0.00
J7643 9 GLYCOPYRROLATE COMP UNIT $0.00
J7644 9 IPRATROPIUM BROMIDE NON-COMP $0.00
J7645 9 IPRATROPIUM BROMIDE $0.00
J7647 9 ISOETHARINE COMP CON $0.00
J7648 9 ISOETHARINE NON-COMP CON $0.00

J7649 9 ISOETHARINE NON-COMP UNIT $0.00
J7650 9 ISOETHARINE COMP UNIT $0.00
J7651 O ISOETHARINE HCL .125% INJ $0.00
J7653 O ISOETHARINE HCL .2%/ INJ $0.00
J7655 O ISOETHARINE HCL 1% INJ $0.00
J7657 9 ISOPROTERENOL COMP CON $0.00
J7658 9 ISOPROTERENOL NON-COMP CON $0.00
J7659 9 ISOPROTERENOL NON-COMP UNIT $0.00
J7660 9 ISOPROTERENOL COMP UNIT $0.00
J7665 O ISOPROTERENOL HCL 1% INJ $0.00

J7667 9 METAPROTERENOL COMP CON $0.00
J7668 9 METAPROTERENOL NON-COMP CON $0.00
J7669 9 METAPROTERENOL NON-COMP UNIT $0.00
J7670 9 METAPROTERENOL COMP UNIT $0.00
J7672 O METAPROTERENOL SULFATE .6% $0.00
J7674 9 METHACHOLINE CHLORIDE, NEB $0.00
J7675 O METAPROTERENOL SULFATE 5% $0.00
J7676 9 PENTAMIDINE COMP UNIT DOSE $0.00
J7680 9 TERBUTALINE SULF COMP CON $0.00
J7681 9 TERBUTALINE SULF COMP UNIT $0.00

J7682 9 TOBRAMYCIN NON-COMP UNIT $0.00
J7683 9 TRIAMCINOLONE COMP CON $0.00
J7684 9 TRIAMCINOLONE COMP UNIT $0.00
J7685 9 TOBRAMYCIN COMP UNIT $0.00
J7699 O INHALATION SOLUTION FOR DME $0.00
J7799 O NON-INHALATION DRUG FOR DME $0.00
J8498 9 ANTIEMETIC RECTAL/SUPP NOS $0.00
J8499 9 ORAL PRESCRIP DRUG NON CHEMO $0.00
J8501 9 ORAL APREPITANT $0.00
J8510 9 ORAL BUSULFAN $0.00
J8515 9 CABERGOLINE, ORAL 0.25MG $0.00
J8520 9 CAPECITABINE, ORAL, 150 MG $0.00
J8521 9 CAPECITABINE, ORAL, 500 MG $0.00

J8530 9 CYCLOPHOSPHAMIDE ORAL 25 MG $0.00
J8540 9 ORAL DEXAMETHASONE $0.00
J8560 9 ETOPOSIDE ORAL 50 MG $0.00
J8565 9 GEFITINIB ORAL $0.00
J8597 9 ANTIEMETIC DRUG ORAL NOS $0.00
J8600 9 MELPHALAN ORAL 2 MG $0.00
J8610 9 METHOTREXATE ORAL 2.5 MG $0.00
J8650 9 NABILONE ORAL $0.00
J8700 9 TEMOZOLMIDE $0.00
J8705 9 TOPOTECAN ORAL $0.00
J8999 9 ORAL PRESCRIPTION DRUG CHEMO $0.00
J9000 3 DOXORUBICIN HCL INJECTION $3.79

J9001 3 DOXORUBICIN HCL LIPOSOME INJ $441.25
J9010 O ALEMTUZUMAB INJECTION $0.00
J9015 5 ALDESLEUKIN INJECTION $0.00
J9017 5 ARSENIC TRIOXIDE INJECTION $0.00
J9020 3 ASPARAGINASE INJECTION $57.68
J9025 3 AZACITIDINE INJECTION $4.64
J9027 5 CLOFARABINE INJECTION $0.00
J9031 3 BCG LIVE INTRAVESICAL VAC $125.35
J9033 3 BENDAMUSTINE INJECTION $18.58
J9035 3 BEVACIZUMAB INJECTION $57.39

J9040 3 BLEOMYCIN SULFATE INJECTION $24.24
J9041 3 BORTEZOMIB INJECTION $36.11
J9045 3 CARBOPLATIN INJECTION $5.75
J9050 5 CARMUSTINE INJECTION $0.00
J9055 3 CETUXIMAB INJECTION $49.54
J9060 3 CISPLATIN 10 MG INJECITON $2.23
J9062 3 CISPLATIN 50 MG INJECITON $11.14
J9065 5 INJ CLADRIBINE PER 1 MG $0.00
J9070 5 CYCLOPHOSPHAMIDE 100 MG INJ $0.00
J9091 3 CYCLOPHOSPHAMIDE 1.0 GRM INJ $29.00
J9092 5 CYCLOPHOSPHAMIDE 2.0 GRM INJ $0.00

J9093 3 CYCLOPHOSPHAMIDE LYOPHILIZED $5.16
J9098 6 CYTARABINE LIPOSOME INJ $0.00
J9100 3 CYTARABINE HCL 100 MG INJ $0.88
J9110 3 CYTARABINE HCL 500 MG INJ $6.83
J9120 5 DACTINOMYCIN INJECTION $0.00
J9130 3 DACARBAZINE 100 MG INJ $4.39
J9140 3 DACARBAZINE 200 MG INJ $8.54
J9150 3 DAUNORUBICIN INJECTION $16.26

J9151 5 DAUNORUBICIN CITRATE INJ $0.00
J9160 5 DENILEUKIN DIFTITOX INJ $0.00
J9165 5 DIETHYLSTILBESTROL INJECTION $0.00
J9170 3 DOCETAXEL INJECTION $336.94
J9175 5 ELLIOTTS B SOLUTION PER ML $0.00
J9178 6 INJ, EPIRUBICIN HCL, 2 MG $0.00
J9180 O EPIRUBICIN HCL INJECTION $0.00
J9181 3 ETOPOSIDE INJECTION $0.48
J9182 O ETOPOSIDE 100 MG INJ $0.00
J9185 5 FLUDARABINE PHOSPHATE INJ $0.00

J9190 3 FLUOROURACIL INJECTION $1.55
J9200 5 FLOXURIDINE INJECTION $0.00
J9201 3 GEMCITABINE HCL INJECTION $138.19
J9202 3 GOSERELIN ACETATE IMPLANT $182.99
J9206 3 IRINOTECAN INJECTION $21.72
J9207 3 IXABEPILONE INJECTION $63.46
J9208 5 IFOSFOMIDE INJECTION $0.00
J9209 5 MESNA INJECTION $0.00
J9211 5 IDARUBICIN HCL INJECTION $0.00
J9212 5 INTERFERON ALFACON-1 INJ $0.00
J9213 5 INTERFERON ALFA-2A INJ $0.00
J9214 3 INTERFERON ALFA-2B INJ $14.71
J9215 5 INTERFERON ALFA-N3 INJ $0.00

J9216 5 INTERFERON GAMMA 1-B INJ $0.00
J9217 3 LEUPROLIDE ACETATE SUSPNSION $515.00
J9218 5 LEUPROLIDE ACETATE INJECITON $0.00
J9219 5 LEUPROLIDE ACETATE IMPLANT $0.00
J9225 5 VANTAS IMPLANT $0.00
J9226 6 SUPPRELIN LA IMPLANT $0.00
J9230 5 MECHLORETHAMINE HCL INJ $0.00
J9240 O MEDROXYPROGESTERONE ACETATE, 100 MG $0.00
J9245 5 INJ MELPHALAN HYDROCHL 50 MG $0.00
J9250 5 METHOTREXATE SODIUM INJ $0.00
J9260 3 METHOTREXATE SODIUM INJ $1.69
J9261 3 NELARABINE INJECTION $96.96

J9263 3 OXALIPLATIN $9.57
J9264 3 PACLITAXEL PROTEIN BOUND $9.07
J9265 3 PACLITAXEL INJECTION $5.28
J9266 5 PEGASPARGASE INJECTION $0.00
J9268 5 PENTOSTATIN INJECTION $0.00
J9270 5 PLICAMYCIN (MITHRAMYCIN) INJ $0.00
J9280 3 MITOMYCIN 5 MG INJ $15.64
J9293 5 MITOXANTRONE HYDROCHL / 5 MG $0.00

J9295 O POLYESTRADIOL PHOSPHATE 40 MG $0.00
J9300 5 GEMTUZUMAB OZOGAMICIN INJ $0.00
J9303 3 PANITUMUMAB INJECTION $83.56
J9305 6 PEMETREXED INJECTION $0.00
J9310 3 RITUXIMAB INJECTION $535.32
J9320 5 STREPTOZOCIN INJECTION $0.00
J9330 3 TEMSIROLIMUS INJECTION $48.53
J9340 5 THIOTEPA INJECTION $0.00
J9350 3 TOPOTECAN INJECTION $939.34
J9355 3 TRASTUZUMAB INJECTION $61.64
J9357 5 VALRUBICIN INJECTION $0.00
J9360 3 VINBLASTINE SULFATE INJ $0.79
J9370 3 VINCRISTINE SULFATE 1 MG INJ $5.68

J9390 3 VINORELBINE TARTRATE INJ $19.64
J9395 3 INJECTION, FULVESTRANT $81.38
J9600 5 PORFIMER SODIUM INJECTION $0.00
J9999 5 CHEMOTHERAPY DRUG $0.00
K0001 3 STANDARD WHEELCHAIR $532.70
K0002 5 STND HEMI (LOW SEAT) WHLCHR $0.00
K0003 3 LIGHTWEIGHT WHEELCHAIR $0.00
K0004 3 HIGH STRENGTH LTWT WHLCHR $1.00
K0005 3 ULTRALIGHTWEIGHT WHEELCHAIR $1,839.61
K0006 5 HEAVY DUTY WHEELCHAIR $0.00

K0007 5 EXTRA HEAVY DUTY WHEELCHAIR $0.00
K0008 9 CSTM MANUAL WHEELCHAIR/BASE $0.00
K0009 5 OTHER MANUAL WHEELCHAIR/BASE $0.00
K0010 5 STND WT FRAME POWER WHLCHR $0.00
K0011 5 STND WT PWR WHLCHR W CONTROL $0.00
K0012 5 LTWT PORTBL POWER WHLCHR $0.00
K0013 9 CUSTOM POWER WHLCHR BASE $0.00
K0014 5 OTHER POWER WHLCHR BASE $0.00
K0015 3 DETACH NON-ADJUS HGHT ARMRST $180.80
K0016 O DETACH ADJUST ARMRST CMPLETE $0.00

K0017 3 DETACH ADJUST ARMREST BASE $50.85
K0018 3 DETACH ADJUST ARMRST UPPER $28.41
K0019 3 ARM PAD EACH $14.58
K0020 3 FIXED ADJUST ARMREST PAIR $46.23
K0021 O ANTI-TIPPING DEVICE EACH $0.00
K0022 O REINFORCED BACK UPHOLSTERY $0.00
K0023 O PLANR BACK INSRT FOAM W/STRP $0.00
K0024 O PLNR BACK INSRT FOAM W/HRDWR $0.00
K0025 O HOOK-ON HEADREST EXTENSION $0.00
K0026 O BACK UPHOLST LGTWT WHLCHR $0.00
K0027 O BACK UPHOLST OTHER WHLCHR $0.00
K0028 O MANUAL FULLY RECLINING BACK $0.00
K0029 O REINFORCED SEAT UPHOLSTERY $0.00

K0030 O SOLID PLNR SEAT SNGL DNSFOAM $0.00
K0031 O SAFETY BELT/PELVIC STRAP $0.00
K0032 O SEAT UPHOLS LGTWT WHLCHR $0.00
K0033 O SEAT UPHOLSTERY OTHER WHLCHR $0.00
K0034 O HEEL LOOP EACH $0.00
K0035 O HEEL LOOP WITH ANKLE STRAP $0.00
K0036 O TOE LOOP EACH $0.00
K0037 3 HIGH MOUNT FLIP-UP FOOTREST $47.93
K0038 3 LEG STRAP EACH $24.14
K0039 3 LEG STRAP H STYLE EACH $53.61
K0040 3 ADJUSTABLE ANGLE FOOTPLATE $74.30
K0041 3 LARGE SIZE FOOTPLATE EACH $52.65

K0042 3 STANDARD SIZE FOOTPLATE EACH $36.25
K0043 3 FTRST LOWER EXTENSION TUBE $19.44
K0044 3 FTRST UPPER HANGER BRACKET $16.56
K0045 3 FOOTREST COMPLETE ASSEMBLY $56.34
K0046 3 ELEVAT LEGRST LOW EXTENSION $19.44
K0047 3 ELEVAT LEGRST UP HANGR BRACK $76.10
K0048 O ELEVATE LEGREST COMPLETE $0.00
K0049 O CALF PAD EACH $0.00
K0050 3 RATCHET ASSEMBLY $32.34
K0051 3 CAM RELESE ASSEM FTRST/LGRST $52.35

K0052 3 SWINGAWAY DETACH FOOTREST $91.98
K0053 3 ELEVATE FOOTREST ARTICULATE $101.51
K0054 O SEAT WDTH 10-12/15/17/20 WC $0.00
K0055 O SEAT DPTH 15/17/18 LTWT WC $0.00
K0056 3 SEAT HT <17 OR >=21 LTWT WC $94.63
K0057 O SEAT WDTH 19/20 HVY DTY WC $0.00
K0058 O SEAT DPTH 17/18 POWER WC $0.00
K0059 O PLASTIC COATED HANDRIM EACH $0.00
K0060 O STEEL HANDRIM EACH $0.00
K0061 O ALUMINUM HANDRIM EACH $0.00
K0062 O HANDRIM 8-10 VERT/OBLIQ PROJ $0.00
K0063 O HNDRM 12-16 VERT/OBLIQ PROJ $0.00
K0064 O ZERO PRESSURE TUBE FLAT FREE $0.00

K0065 3 SPOKE PROTECTORS $44.24
K0066 O SOLID TIRE ANY SIZE EACH $0.00
K0067 O PNEUMATIC TIRE ANY SIZE EACH $0.00
K0068 O PNEUMATIC TIRE TUBE EACH $0.00
K0069 3 REAR WHL COMPLETE SOLID TIRE $99.42
K0070 3 REAR WHL COMPL PNEUM TIRE $182.26
K0071 3 FRONT CASTR COMPL PNEUM TIRE $108.71
K0072 3 FRNT CSTR CMPL SEM-PNEUM TIR $65.43
K0073 3 CASTER PIN LOCK EACH $34.63
K0074 O PNEUMATIC CASTER TIRE EACH $0.00
K0075 O SEMI-PNEUMATIC CASTER TIRE $0.00
K0076 O SOLID CASTER TIRE EACH $0.00

K0077 3 FRONT CASTER ASSEM COMPLETE $58.56
K0078 O PNEUMATIC CASTER TIRE TUBE $0.00
K0079 O WHEEL LOCK EXTENSION PAIR $0.00
K0080 O ANTI-ROLLBACK DEVICE PAIR $0.00
K0081 O WHEEL LOCK ASSEMBLY COMPLETE $0.00
K0082 O 22 NF NONSEALED LEADACID $0.00
K0083 O 22NF SEALED LEADACID BATTERY $0.00
K0084 O GR24 NONSEALED LEADACID $0.00
K0085 O GR 24 SEALED LEAD ACID BATTERY $0.00
K0086 O U1NONSEALED LEADACID BATTERY $0.00

K0087 O U1 SEALED LEADACID BATTERY $0.00
K0088 O BATTERY CHARGER, SINGLE MODE $0.00
K0089 O BATTERY CHARGER, DUAL MODE $0.00
K0090 O REAR TIRE POWER WHEELCHAIR $0.00
K0091 O REAR TIRE TUBE POWER WHLCHR $0.00
K0092 O REAR ASSEM CMPLT POWR WHLCHR $0.00
K0093 O REAR ZERO PRESSURE TIRE TUBE $0.00
K0094 O WHEEL TIRE FOR POWER BASE $0.00
K0095 O WHEEL TIRE TUBE EACH BASE $0.00
K0096 O WHEEL ASSEM POWR BASE COMPLT $0.00
K0097 O WHEEL ZERO PRESURE TIRE TUBE $0.00
K0098 3 DRIVE BELT POWER WHEELCHAIR $27.07
K0099 O PWR WHEELCHAIR FRONT CASTER $0.00

K0100 O AMPUTEE ADAPTER PAIR $0.00
K0101 O ONE-ARM DRIVE ATTACHMENT $0.00
K0102 O CRUTCH AND CANE HOLDER $0.00
K0103 O TRANSFER BOARD < 25" $0.00
K0104 O CYLINDER TANK CARRIER $0.00
K0105 3 IV HANGER $98.94
K0106 O ARM TROUGH EACH $0.00
K0107 O WHEELCHAIR TRAY $0.00
K0108 5 W/C COMPONENT-ACCESSORY NOS $0.00
K0109 9 CUSTOMIZE WHLCHR BASE FRAME $0.00
K0110 9 SUPPLIES FOR MAINTENANCE OF DRUG IN $0.00
K0111 9 SUPPLIES FOR EXTERNAL DRUG INFUSION $0.00

K0112 O TRUNK VEST SUPPRT INNR FRAME $0.00
K0113 O TRUNK VEST SUPRT W/O INR FRM $0.00
K0114 O WHLCHR BACK SUPRT INR FRAME $0.00
K0115 O BACK MODULE ORTHOTIC SYSTEM $0.00
K0116 O BACK & SEAT MODUL ORTHOT SYS $0.00
K0117 O UNLISTED ITEM, ORTHOTIC SEATING, BA $0.00
K0118 O TENS SUPPLIES - ONE MONTH SUPPLY FO $0.00
K0119 9 AZATHIOPRINE ORAL TAB 50 MG $0.00
K0120 9 AZATHIOPRINE PRENTRL 100 MG $0.00
K0121 9 CYCLOSPORINE ORAL 25 MG $0.00

K0122 9 CYCLOSPORINE PRENTRL 250 MG $0.00
K0123 9 IMUN/ANTITYMOCYT GLOB 250 MG $0.00
K0124 9 MONOCLONAL ANTIBODIES - PARENTERAL, $0.00
K0125 9 PREDNISONE - ORAL, 5 MG $0.00
K0126 9 REPLACE SOFT INTERFACE MATERIAL, MU $0.00
K0127 9 REPLACE SOFT INTERFACE MATERIAL, AN $0.00
K0128 9 REPLACE SOFT INTERFACE MATERIAL, FO $0.00
K0129 9 ANKLE CONTRACTURE SPLINT $0.00
K0130 9 FOOT DROP SPLINT, RECUMBENT POSITIO $0.00
K0131 O SPRING-POWERED DEVICE FOR LANCET $0.00
K0132 O MALE EXTERNAL CATHETER WITH OR WITH $0.00
K0133 O INTERMITTENT URINARY CATHETER, DISP $0.00
K0134 O INTERMITTENT URINARY CATHETER, DISP $0.00

K0135 O INTERMITTENT URINARY CATHETER, REUS $0.00
K0136 O INTERMITTENT URINARY CATHETER, REUS $0.00
K0137 9 SKIN BARRIER LIQUID PER OZ $0.00
K0138 9 SKIN BARRIER PASTE PER OZ $0.00
K0139 9 SKIN BARRIER POWDER PER OZ $0.00
K0140 9 ACETYLCYSTEINE, COMPOUNDED, PER MG, $0.00
K0141 9 ALBUTEROL SULFATE, COMPOUNDED, PER $0.00
K0142 9 CROMOLYN SODIUM, COMPOUNDED, PER MG $0.00
K0143 9 ISOETHARINE HYDROCHLORIDE, COMPOUND $0.00
K0144 9 ISOPROTHERENOL HYDROCHLORIDE, COMPO $0.00
K0145 9 METAPROTERENOL, COMPOUNDED, PER MG, $0.00
K0146 9 TERBUTALINE, COMPOUNDED, PER MG, IN $0.00

K0147 O GASTROSTOMY TUBE, SILICONE WITH SLI $0.00
K0148 O HYDROGEL DRESSING, EACH $0.00
K0149 O HYDROCOLLOID DRESSING, EACH $0.00
K0150 O ALGINATE DRESSING, EACH $0.00
K0151 O FOAM DRESSING, EACH $0.00
K0152 9 PASTES, POWDERS, GRANULES, BEADS, C $0.00
K0153 O COMPOSITE DRESSING, EACH $0.00
K0154 9 WOUND POUCH, EACH $0.00
K0162 O PROGRESSIVE LENS, EACH LENS $0.00
K0163 9 VACUUM ERECTION SYSTEM $0.00

K0164 O OROPHARYNGEAL SUCTION CATHETER, EAC $0.00
K0165 O TRACHEOSTOMY CARE KIT FOR ESTABLISH $0.00
K0166 O METHYLPREDNISOLONE - ORAL, 4 MG $0.00
K0167 O PREDNISOLONE - ORAL, 5 MG $0.00
K0168 9 DISPOSABLE NEBULIZER SET $0.00
K0169 9 DISPOSABLE NEBULIZER SMALL $0.00
K0170 9 NON DISPOSABLE NEBULIZER SET $0.00
K0171 9 FILTERED NEBULIZER SET $0.00
K0172 9 DISPOSABLE NEBULIZER UNFILL $0.00
K0173 9 DISPOSABLE NEBULIZER PREFILL $0.00
K0174 9 RESERVOIR BOTTLE W NEBULIZER $0.00
K0175 9 DISPOSABLE CORRUGATED TUBING $0.00
K0176 9 NON DISPOS CORRUGATED TUBING $0.00

K0177 9 WATER COLLEC DEV W NEBULIZER $0.00
K0178 9 DISPOSBL FILTER W COMPRESSOR $0.00
K0179 9 NON-DISPOS FILTER W/COMPRESS $0.00
K0180 9 AEROSOL MASK WITH NEBULIZER $0.00
K0181 9 DOME & MOUTHPIECE W/ NEBULIZ $0.00
K0182 9 WATER DISTILLED W/ NEBULIZER $0.00
K0183 O NASAL APPLICATION DEVICE $0.00
K0184 O NASAL PILLOW OR FACE SEAL $0.00
K0185 O POS AIRWAY PRESSURE HEADGEAR $0.00
K0186 O POS AIRWAY PRSSURE CHINSTRAP $0.00
K0187 O POS AIRWAY PRESSURE TUBING $0.00
K0188 O POS AIRWAY PRESSURE FILTER $0.00

K0189 O FILTER NONDISPOSABLE W PAP $0.00
K0190 9 DISPOSABLE CANISTER W/PUMP $0.00
K0191 9 NON-DISPOSBL CANISTER W/PUMP $0.00
K0192 9 TUBING USED W/ SUCTION PUMP $0.00
K0193 9 AIRWAY PRESSURE DEV/W HMDFER $0.00
K0194 9 ASSIST DEVICE W/HUMIDIFIER $0.00
K0195 3 ELEVATING WHLCHAIR LEG RESTS $0.00
K0196 9 ALGINATE DRESSING, WOUND COVER, PAD $0.00

K0199 9 ALGINATE DRESSING, WOUND FILLER, PE $0.00
K0203 9 COMPOSITE DRESSING, PAD SIZE 16 SQ. $0.00
K0204 9 COMPOSITE DRESSING, PAD SIZE MORE T $0.00
K0205 9 COMPOSITE DRESSING, PAD SIZE MORE T $0.00
K0206 9 CONTACT LAYER, 16 SQ. IN. OR LESS, $0.00
K0207 9 CONTACT LAYER, MORE THAN 16 BUT LES $0.00
K0208 9 CONTACT LAYER, MORE THAN 48 SQ. IN. $0.00
K0209 9 FOAM DRESSING, WOUND COVER, PAD SIZ $0.00

K0215 9 FOAM DRESSING, WOUND FILLER, PER GR $0.00
K0216 9 GAUZE, NON-IMPREGNATED, NON-STERILE $0.00
K0219 9 GAUZE, NON-IMPREGNATED, PAD SIZE 16 $0.00
K0220 9 GAUZE, NON-IMPREGNATED, PAD SIZE MO $0.00
K0221 9 GAUZE, NON-IMPREGNATED, PAD SIZE MO $0.00
K0222 9 GAUZE, IMPREGNATED, OTHER THAN WATE $0.00
K0228 9 GAUZE, IMPREGNATED, WATER OR NORMAL $0.00

K0234 9 HYDROCOLLOID DRESSING, WOUND COVER, $0.00
K0240 9 HYDROCOLLOID DRESSING, WOUND FILLER $0.00
K0241 9 HYDROCOLLOID DRESSING, WOUND FILLER $0.00
K0242 9 HYDROGEL DRESSING, WOUND COVER, PAD $0.00

K0248 9 HYDROGEL DRESSING, WOUND FILLER, GE $0.00
K0249 9 HYDROGEL DRESSING, WOUND FILLER, DR $0.00
K0250 9 SKIN SEALANTS, PROTECTANTS, MOISTUR $0.00
K0251 9 SPECIALTY ABSORPTIVE DRESSING, WOUN $0.00

K0257 9 TRANSPARENT FILM, 16 SQ. IN. OR LES $0.00
K0258 9 TRANSPARENT FILM, MORE THAN 16 BUT $0.00
K0259 9 TRANSPARENT FILM, MORE THAN 48 SQ. $0.00
K0260 9 WOUND CLEANSERS, ANY TYPE, ANY SIZE $0.00
K0261 9 WOUND FILLER, NOT ELSEWHERE CLASSIF $0.00
K0262 9 WOUND FILLER, NOT ELSEWHERE CLASSIF $0.00
K0263 9 GAUZE, ELASTIC, NON-STERILE, ALL T $0.00
K0264 9 GAUZE, NON-ELASTIC, NON-STERILE, PE $0.00
K0265 9 TAPE, ALL TYPES, PER 18 SQUARE INCH $0.00
K0267 O REPLACEMENT BATTERY, ANY TYPE, FOR $0.00

K0268 O HUMIDIFIER NONHEATED W PAP $0.00
K0269 9 AEROSOL COMPRESSOR CPAP DEV $0.00
K0270 9 ULTRASONIC GENERATOR W NEBUL $0.00
K0271 9 POUCH, DRAINABLE; WITH FACEPLATE AT $0.00
K0272 9 POUCH, DRAINABLE; WITHOUT FACEPLATE $0.00
K0273 9 POUCH, URINARY; WITH FACEPLATE ATTA $0.00
K0274 9 POUCH, URINARY; WITHOUT FACEPLATE A $0.00
K0275 9 OSTOMY FACEPLATE; CONVEX; REUSABLE; $0.00
K0276 9 OSTOMY FACEPLATE; CONVEX; CUSTOM FI $0.00
K0277 9 SKIN BARRIER SOLID 4X4 EQUIV $0.00

K0278 9 SKIN BARRIER WITH FLANGE $0.00
K0279 9 SKIN BARRIER EXTENDED WEAR $0.00
K0280 9 EXTENSION DRAINAGE TUBING $0.00
K0281 9 LUBRICANT CATHETER INSERTION $0.00
K0283 9 SALINE SOLUTION DISPENSER $0.00
K0284 9 EXTERNAL INFUSION PUMP REUSE $0.00
K0285 9 REPAIR OF PROSTHETIC DEVICE, LABOR $0.00
K0400 9 SKIN SUPPORT ATTACHMENT EACH $0.00
K0401 9 DIABETIC DELUXE SHOE $0.00
K0402 9 GAUZE, NON-IMPREGNATED, STERILE, PA $0.00
K0405 9 GAUZE, ELASTIC, STERILE, ALL TYPES, $0.00

K0406 9 GAUZE, NON-ELASTIC, STERILE, PER LI $0.00
K0407 9 URINARY CATH SKIN ATTACHMENT $0.00
K0408 9 URINARY CATH LEG STRAP $0.00
K0409 9 STERILE H2O IRRIGATION SOLUT $0.00
K0410 9 MALE EXT CATH W/ADH COATING $0.00
K0411 9 MALE EXT CATH W/ADH STRIP $0.00
K0412 9 MYCOPHENOLATE MOFETIL 25O MG $0.00
K0413 O NON-POWERED, ADVANCED PRESSURE-REDU $0.00
K0414 O POWERED AIR OVERLAY FOR MATTRESS, S $0.00
K0415 O RX ANTIEMETIC DRG, ORAL NOS $0.00
K0416 O RX ANTIEMETIC DRG,RECTAL NOS $0.00
K0417 9 MECH INFUS PUMP SHT TRM DRUG $0.00

K0418 9 ORAL CYCLOSPORIN $0.00
K0419 9 DRAINABLE PLSTIC PCH W FCPLT $0.00
K0420 9 DRAINABLE RUBBER PCH W FCPLT $0.00
K0421 9 DRAINABLE PLSTIC PCH W/O FP $0.00
K0422 9 DRAINABLE RUBBER PCH W/O FP $0.00
K0423 9 URINARY PLSTIC POUCH W FCPLT $0.00
K0424 9 URINARY RUBBER POUCH W FCPLT $0.00
K0425 9 URINARY PLSTIC POUCH W/O FP $0.00
K0426 9 URINARY HVY PLSTC PCH W/O FP $0.00
K0427 9 URINARY RUBBER POUCH W/O FP $0.00

K0428 9 OSTOMY FACEPLT/SILICONE RING $0.00
K0429 9 SKIN BARRIER SOLID EXT WEAR $0.00
K0430 9 SKIN BARRIER W FLANG EX WEAR $0.00
K0431 9 CLOSED POUCH W ST WEAR BAR $0.00
K0432 9 DRAINABLE PCH W EX WEAR BAR $0.00
K0433 9 DRAINABLE PCH W ST WEAR BAR $0.00
K0434 9 DRAINABLE PCH EX WEAR CONVEX $0.00
K0435 9 URINARY POUCH W EX WEAR BAR $0.00
K0436 9 URINARY POUCH W ST WEAR BAR $0.00
K0437 9 URINE PCH W EX WEAR BAR CONV $0.00
K0438 9 OSTOMY POUCH LIQ DEODORANT $0.00
K0439 9 OSTOMY POUCH SOLID DEODORANT $0.00
K0440 9 NASAL PROSTHESIS $0.00

K0441 9 MIDFACIAL PROSTHESIS $0.00
K0442 9 ORBITAL PROSTHESIS $0.00
K0443 9 UPPER FACIAL PROSTHESIS $0.00
K0444 9 HEMI-FACIAL PROSTHESIS $0.00
K0445 9 AURICULAR PROSTHESIS $0.00
K0446 9 PARTIAL FACIAL PROSTHESIS $0.00
K0447 9 NASAL SEPTAL PROSTHESIS $0.00
K0448 9 UNSPEC MAXILLOFACIAL PROSTH $0.00
K0449 9 REPAIR MAXILLOFACIAL PROSTH $0.00
K0450 9 LIQ ADHES FOR FACIAL PROSTH $0.00
K0451 9 ADHESIVE REMOVER WIPES $0.00
K0452 O WHEELCHAIR BEARINGS $0.00

K0453 9 AMPHOTERICIN B $0.00
K0455 9 PUMP UNINTERRUPTED INFUSION $0.00
K0456 O HEAVYDUTY/XTRA WIDE HOSP BED $0.00
K0457 O HEAVYDUTY/WIDE COMMODE CHAIR $0.00
K0458 O HEAVYDUTY WALKER NO WHEELS $0.00
K0459 O HEAVY DUTY WHEELED WALKER $0.00
K0460 O WC POWER ADD-ON JOYSTICK $0.00
K0461 O WC POWER ADD-ON TILLER CNTRL $0.00
K0462 9 TEMPORARY REPLACEMENT EQPMNT $0.00
K0501 9 AEROSOL COMPRESSOR FOR SVNEB $0.00

K0503 9 ACETYLCYSTEINE INH SOL U D $0.00
K0504 9 ALBUTEROL INH SOL CON $0.00
K0505 9 ALBUTEROL INH SOL U D $0.00
K0506 9 ATROPINE INH SOL CON $0.00
K0507 9 ATROPINE INH SOL U D $0.00
K0508 9 BITOLTEROL MES INH SOL CON $0.00
K0509 9 BITOLTEROL MES INH SOL U D $0.00
K0511 9 CROMOLYN SODIUM INH SOL U D $0.00
K0512 9 DEXAMETHASONE INH SOL CON $0.00
K0513 9 DEXAMETHASONE INH SOL U D $0.00
K0514 9 DORNASE ALPHA INH SOL U D $0.00
K0515 9 GLYCOPYRROLATE INH SOL CON $0.00
K0516 9 GLYCOPYRROLATE INH SOL U D $0.00

K0518 9 IPRATROPIUM BROM INH SOL U D $0.00
K0519 9 ISOETHARINE HCL INH SOL CON $0.00
K0520 9 ISOETHARINE HCL INH SOL U D $0.00
K0521 9 ISOPROTERENOLHCL INH SOL CON $0.00
K0522 9 ISOPROTERENOLHCL INH SOL U D $0.00
K0523 9 METAPROTERENOL INH SOL CON $0.00
K0524 9 METAPROTERENOL INH SOL U D $0.00
K0525 9 TERBUTALINE SO4 INH SOL CON $0.00
K0526 9 TERBUTALINE SO4 INH SOL U D $0.00
K0527 9 TRIAMCINOLONE INH SOL CON $0.00
K0528 9 TRIAMCINOLONE INH SOL U D $0.00
K0529 9 STERILE H20 OR NSS W LV NEB $0.00

K0530 9 NEBULIZER NOT USED W OXYGEN $0.00
K0531 O HEATED HUMIDIFIER USED W PAP $0.00
K0532 O NONINVASIVE ASSIST WO BACKUP $0.00
K0533 O NONINVASIVE ASSIST W BACKUP $0.00
K0534 O INVASIVE ASSIST W BACKUP $0.00
K0538 O NEG PRESSURE WND THRPY PUMP $0.00
K0539 O NEG PRES WND THRPY DSG SET $0.00
K0540 O NEG PRES WND THRP CANISTER $0.00
K0541 O SGD PRERECORDED MSG <= 8 MIN $0.00
K0542 O SGD PRERECORDED MSG > 8 MIN $0.00

K0543 O SGD MSG FORMED BY SPELLING $0.00
K0544 O SGD W MULTI METHODS MSG/ACCS $0.00
K0545 O SGD SFTWRE PRGRM FOR PC/PDA $0.00
K0546 O SGD ACCESSORY,MOUNTING SYSTM $0.00
K0547 O SGD ACCESSORY NOC $0.00
K0549 O HOSPITAL BED, HEAVY DUTY, EXTRA WI $0.00
K0550 O HOSPITAL BED, EXTRA HEAVY DUTY, EX $0.00
K0551 9 RESIDUAL LIMB SUPPORT SYSTEM $0.00
K0552 6 SUPPLY/EXT INF PUMP SYR TYPE $0.00
K0556 O SOCKET INSERT W LOCK MECH $0.00
K0557 O SOCKET INSERT W/O LOCK MECH $0.00
K0558 O INTL CUSTM CONG/ATYP INSERT $0.00
K0559 O INITIAL CUSTOM SOCKET INSERT $0.00

K0561 9 NONPECTIN BASED OSTOMY PASTE $0.00
K0562 9 PECTIN BASED OSTOMY PASTE $0.00
K0563 O OSTOMY SKIN BARRIER WITH FLANGE (S $0.00
K0565 O OSTOMY SKIN BARRIER WITH FLANGE (S $0.00
K0570 O BUILT IN CONVEXITY, 4X INCHES OR S $0.00
K0572 O TAPE, NON WATERPROOF, PER 18 SQUAR $0.00
K0573 O TAPE, WATERPROOF, PER 18 SQUARE IN $0.00
K0581 O OST PCH CLSD W BARRIER/FILTR $0.00
K0582 O OST PCH W BAR/BLTINCONV/FLTR $0.00
K0583 O OST PCH CLSD W/O BAR W FILTR $0.00
K0584 O OST PCH FOR BAR W FLANGE/FLT $0.00
K0585 O OST PCH CLSD FOR BAR W LK FL $0.00

K0586 O OST PCH FOR BAR W LK FL/FLTR $0.00
K0587 O OST PCH DRAIN W BAR & FILTER $0.00
K0588 O OST PCH DRAIN FOR BARRIER FL $0.00
K0589 O OST PCH DRAIN 2 PIECE SYSTEM $0.00
K0590 O OST PCH DRAIN/BARR LK FLNG/F $0.00
K0591 O URINE OST POUCH W FAUCET/TAP $0.00
K0592 O URINE OST POUCH W BLTINCONV $0.00
K0593 O OST URINE PCH W B/BLTIN CONV $0.00
K0594 O OST PCH URINE W BARRIER/TAPV $0.00
K0595 O OS PCH URINE W BAR/FANGE/TAP $0.00

K0596 O URINE OST PCH BAR W LOCK FLN $0.00
K0597 O OST PCH URINE W LOCK FLNG/FT $0.00
K0600 O FUNCTIONAL NEUROMUSCULARSTIM $0.00
K0601 6 REPL BATT SILVER OXIDE 1.5 V $0.00
K0602 6 REPL BATT SILVER OXIDE 3 V $0.00
K0603 6 REPL BATT ALKALINE 1.5 V $0.00
K0604 6 REPL BATT LITHIUM 3.6 V $0.00
K0605 6 REPL BATT LITHIUM 4.5 V $0.00
K0606 6 AED GARMENT W ELEC ANALYSIS $0.00
K0607 6 REPL BATT FOR AED $0.00
K0608 6 REPL GARMENT FOR AED $0.00
K0609 6 REPL ELECTRODE FOR AED $0.00
K0618 O TLSO 2 PIECE RIGID SHELL $0.00

K0619 O TLSO 3 PIECE RIGID SHELL $0.00
K0620 O TUBULAR ELASTIC DRESSING $0.00
K0627 O CERVICAL PNEUM TRAC EQUIP $0.00
K0628 O MULT DENS INSERT DIRECT FORM $0.00
K0629 O MULT DENS INSERT CUSTOM MOLD $0.00
K0630 O SIO FLEX PELVISACRAL PREFAB $0.00
K0631 O SIO FLEX PELVISACRAL CUSTOM $0.00
K0632 O SIO PANEL PREFAB $0.00
K0633 O SIO PANEL CUSTOM $0.00
K0634 O LO FLEXIBLE L1 BELOW L5 PRE $0.00
K0635 O LO SAG STAYS/PANELS PRE-FAB $0.00
K0636 O LO SAGITT RIGID PANEL PREFAB $0.00

K0637 O LO FLEX W/O RIGID STAYS PRE $0.00
K0638 O LSO FLEX W/RIGID STAYS CUST $0.00
K0639 O LSO POST RIGID PANEL PRE $0.00
K0640 O LSO SAG-CORO RIGID FRAME PRE $0.00
K0641 O LSO SAG-COR RIGID FRAME CUST $0.00
K0642 O LSO FLEXION CONTROL PREFAB $0.00
K0643 O LSO FLEXION CONTROL CUSTOM $0.00
K0644 O LSO SAGIT RIGID PANEL PREFAB $0.00
K0645 O LSO SAGITTAL RIGID PANEL CUS $0.00
K0646 O LSO SAG-CORONAL PANEL PREFAB $0.00

K0647 O LSO SAG-CORONAL PANEL CUSTOM $0.00
K0648 O LSO S/C SHELL/PANEL PREFAB $0.00
K0649 O LSO S/C SHELL/PANEL CUSTOM $0.00
K0650 O GEN W/C CUSHION WIDTH LESS THAN 22 $0.00
K0651 O GEN W/C CUSHION WIDTH GREATER THAN $0.00
K0652 O SKIN PROTECT W/C CUS WD LESS THAN2 $0.00
K0653 O SKIN PROTECT W/C CUS WD GREATER TH $0.00
K0654 O POSITION W/C CUSH WIDTH LESS THAN2 $0.00
K0655 O POSITION W/C CUSH WIDTH GREATER TH $0.00
K0656 O SKIN PRO/POS W/C CUS WD LESS THAN2 $0.00
K0657 O SKIN PRO/POS W/C CUS WD GREATER TH $0.00
K0658 O CUSTOM FABRICATE W/C CUSHION $0.00
K0659 O POWERED W/C CUSHION $0.00

K0660 O GEN USE BACK CUSH WIDTH LESS THAN2 $0.00
K0661 O GEN USE BACK CUSH WIDTH GREATER TH $0.00
K0662 O POSITION BACK CUSH WDTH LESS THAN2 $0.00
K0663 O POSITION BACK CUSH WDTH GREATER TH $0.00
K0664 O POS BACK POST/LAT WIDTH LESS THAN2 $0.00
K0665 O POS BACK POST/LAT WIDTH GREATER TH $0.00
K0666 O CUSTOM FAB W/C BACK CUSHION $0.00
K0667 O MT HARDWRE MAN/LIGHT PWR W/C $0.00
K0668 O REP ACE COVER W/C SEAT CUSH $0.00
K0669 6 SEAT/BACK CUS NO SADMERC VER $0.00
K0670 O STANCE PHASE ONLY $0.00
K0672 6 REMOVABLE SOFT INTERFACE LE $0.00

K0730 6 CTRL DOSE INH DRUG DELIV SYS $0.00
K0733 6 12-24HR SEALED LEAD ACID $0.00
K0734 6 ADJ SKIN PRO W/C CUS WD<22IN $0.00
K0735 6 ADJ SKIN PRO WC CUS WD>=22IN $0.00
K0736 6 ADJ SKIN PRO/POS WC CUS<22IN $0.00
K0737 6 ADJ SKIN PRO/POS WC CUS>=22Ê $0.00
K0738 6 PORTABLE GAS OXYGEN SYSTEM $0.00
K0800 6 POV GROUP 1 STD UP TO 300LBS $0.00
K0801 6 POV GROUP 1 HD 301-450 LBS $0.00
K0802 6 POV GROUP 1 VHD 451-600 LBS $0.00

K0806 6 POV GROUP 2 STD UP TO 300LBS $0.00
K0807 6 POV GROUP 2 HD 301-450 LBS $0.00
K0808 6 POV GROUP 2 VHD 451-600 LBS $0.00
K0812 6 POWER OPERATED VEHICLE NOC $0.00
K0813 6 PWC GP 1 STD PORT SEAT/BACK $0.00
K0814 6 PWC GP 1 STD PORT CAP CHAIR $0.00
K0815 6 PWC GP 1 STD SEAT/BACK $0.00
K0816 6 PWC GP 1 STD CAP CHAIR $0.00
K0820 6 PWC GP 2 STD PORT SEAT/BACK $0.00
K0821 6 PWC GP 2 STD PORT CAP CHAIR $0.00
K0824 6 PWC GP 2 HD SEAT/BACK $0.00

K0825 6 PWC GP 2 HD CAP CHAIR $0.00
K0826 6 PWC GP 2 VHD SEAT/BACK $0.00
K0827 6 PWC GP VHD CAP CHAIR $0.00
K0828 6 PWC GP 2 XTRA HD SEAT/BACK $0.00
K0829 6 PWC GP 2 XTRA HD CAP CHAIR $0.00
K0830 6 PWC GP2 STD SEAT ELEVATE S/B $0.00
K0831 6 PWC GP2 STD SEAT ELEVATE CAP $0.00
K0835 6 PWC GP2 STD SING POW OPT S/B $0.00
K0836 6 PWC GP2 STD SING POW OPT CAP $0.00
K0837 6 PWC GP 2 HD SING POW OPT S/B $0.00
K0838 6 PWC GP 2 HD SING POW OPT CAP $0.00
K0839 6 PWC GP2 VHD SING POW OPT S/B $0.00

K0840 6 PWC GP2 XHD SING POW OPT S/B $0.00
K0841 6 PWC GP2 STD MULT POW OPT S/B $0.00
K0842 6 PWC GP2 STD MULT POW OPT CAP $0.00
K0843 6 PWC GP2 HD MULT POW OPT S/B $0.00
K0851 6 PWC GP 3 HD CAP CHAIR $0.00
K0853 6 PWC GP 3 VHD CAP CHAIR $0.00

K0854 6 PWC GP 3 XHD SEAT/BACK $0.00
K0855 6 PWC GP 3 XHD CAP CHAIR $0.00
K0858 6 PWC GP3 HD SING POW OPT S/B $0.00
K0859 6 PWC GP3 HD SING POW OPT CAP $0.00
K0862 6 PWC GP3 HD MULT POW OPT S/B $0.00
K0863 6 PWC GP3 VHD MULT POW OPT S/B $0.00
K0864 6 PWC GP3 XHD MULT POW OPT S/B $0.00

K0879 6 PWC GP4 HD SING POW OPT S/B $0.00
K0885 6 PWC GP4 STD MULT POW OPT CAP $0.00
K0886 6 PWC GP4 HD MULT POW S/B $0.00
K0890 6 PWC GP5 PED SING POW OPT S/B $0.00
K0891 6 PWC GP5 PED MULT POW OPT S/B $0.00
K0898 6 POWER WHEELCHAIR NOC $0.00

K0899 9 POW MOBIL DEV NO SADMERC $0.00
KKEVL O MCO SPECIFIC CODE: DPH KIDS KARE IN $0.00
KKTX1 O MCO SPECIFIC CODE: DPH KIDS KARE TE $0.00
KKTX2 O MCO SPECIFIC CODE: DPH KIDS KARE TE $0.00
L0100 O CRANIAL ORTHOSIS/HELMET MOLD $0.00
L0101 O ONE-ARM DRIVE ATTACHMENT, EACH $0.00
L0110 O CRANIAL ORTHOSIS/HELMET NONM $0.00
L0112 6 CRANIAL CERVICAL ORTHOSIS $0.00
L0113 6 CRANIAL CERVICAL TORTICOLLIS $0.00
L0120 3 CERV FLEXIBLE NON-ADJUSTABLE $20.07

L0130 3 FLEX THERMOPLASTIC COLLAR MO $141.92
L0140 3 CERVICAL SEMI-RIGID ADJUSTAB $46.91
L0150 3 CERV SEMI-RIG ADJ MOLDED CHN $86.11
L0160 3 CERV SEMI-RIG WIRE OCC/MAND $112.45
L0170 3 CERVICAL COLLAR MOLDED TO PT $463.04
L0172 3 CERV COL THERMPLAS FOAM 2 PI $100.39
L0174 3 CERV COL FOAM 2 PIECE W THOR $197.24
L0180 3 CER POST COL OCC/MAN SUP ADJ $273.50
L0190 3 CERV COLLAR SUPP ADJ CERV BA $355.67
L0200 3 CERV COL SUPP ADJ BAR & THOR $370.78
L0210 3 THORACIC RIB BELT $34.05
L0220 3 THOR RIB BELT CUSTOM FABRICA $101.25
L0300 O TLSO FLEX SURGICAL SUPPORT $0.00

L0310 O TLSO FLEXIBLE CUSTOM FABRICA $0.00
L0315 O TLSO FLEX ELAS RIGID POST PA $0.00
L0317 O TLSO FLEX HYPEXT ELAS POST P $0.00
L0320 O TLSO A-P CONTRL W APRON FRNT $0.00
L0321 O TLSO ANTI-POST-CNTRL PREFAB $0.00
L0330 O TLSO ANT-POS-LATERAL CONTROL $0.00
L0331 O TLSO ANT-POST-LAT CNTRL PRFB $0.00
L0340 O TLSO A-P-L-ROTARY WITH APRON $0.00
L0350 O TLSO FLEX COMPRESS JACKET CU $0.00
L0360 O TLSO FLEX COMPRESS JACKET MO $0.00
L0370 O TLSO A-P-L-ROTARY HYPEREXTEN $0.00
L0380 O TLSO A-P-L-ROT W/ POS EXTENS $0.00

L0390 O TLSO A-P-L CONTROL MOLDED $0.00
L0391 O TLSO ANT-POST-LAT-ROT CNTRL $0.00
L0400 O TLSO A-P-L W INTERFACE MATER $0.00
L0410 O TLSO A-P-L TWO PIECE CONSTR $0.00
L0420 O TLSO A-P-L 2 PIECE W INTERFA $0.00
L0430 6 TLSO A-P-L W INTERFACE CUSTM $0.00
L0440 O TLSO A-P-L OVERLAP FRNT CUST $0.00
L0450 5 TLSO FLEX PREFAB THORACIC $0.00
L0452 5 TLSO FLEX CUSTOM FAB THORACI $0.00
L0454 5 TLSO FLEX PREFAB SACROCOC-T9 $0.00

L0456 5 TLSO FLEX PREFAB $0.00
L0458 5 TLSO 2MOD SYMPHIS-XIPHO PRE $0.00
L0460 5 TLSO2MOD SYMPHYSIS-STERN PRE $0.00
L0462 3 TLSO 3MOD SACRO-SCAP PRE $1,050.90
L0464 5 TLSO 4MOD SACRO-SCAP PRE $0.00
L0466 5 TLSO RIGID FRAME PRE SOFT AP $0.00
L0468 5 TLSO RIGID FRAME PREFAB PELV $0.00
L0470 5 TLSO RIGID FRAME PRE SUBCLAV $0.00
L0472 5 TLSO RIGID FRAME HYPEREX PRE $0.00
L0474 5 TLSO RIGID FRAME PRE PELVIC $0.00
L0476 O TLSO FLEXION COMPRES JAC PRE $0.00
L0478 O TLSO FLEXION COMPRES JAC CUS $0.00
L0480 5 TLSO RIGID PLASTIC CUSTOM FA $0.00

L0482 5 TLSO RIGID LINED CUSTOM FAB $0.00
L0484 5 TLSO RIGID PLASTIC CUST FAB $0.00
L0486 5 TLSO RIGIDLINED CUST FAB TWO $0.00
L0488 5 TLSO RIGID LINED PRE ONE PIE $0.00
L0490 5 TLSO RIGID PLASTIC PRE ONE $0.00
L0491 6 TLSO 2 PIECE RIGID SHELL $0.00
L0492 6 TLSO 3 PIECE RIGID SHELL $0.00
L0500 O LSO FLEX SURGICAL SUPPORT $0.00
L0510 O LSO FLEXIBLE CUSTOM FABRICAT $0.00
L0515 O LSO FLEX ELAS W/ RIG POST PA $0.00
L0520 O LSO A-P-L CONTROL WITH APRON $0.00
L0530 O LSO ANT-POS CONTROL W APRON $0.00

L0540 O LSO LUMBAR FLEXION A-P-L $0.00
L0550 O LSO A-P-L CONTROL MOLDED $0.00
L0560 O LSO A-P-L W INTERFACE $0.00
L0561 O PREFAB LSO $0.00
L0565 O LSO A-P-L CONTROL CUSTOM $0.00
L0600 O SACROILIAC FLEX SURG SUPPORT $0.00
L0610 O SACROILIAC FLEXIBLE CUSTM FA $0.00
L0620 O SACROILIAC SEMI-RIG W APRON $0.00
L0621 6 SIO FLEX PELVISACRAL PREFAB $0.00
L0622 6 SIO FLEX PELVISACRAL CUSTOM $0.00

L0623 6 SIO PANEL PREFAB $0.00
L0624 6 SIO PANEL CUSTOM $0.00
L0625 6 LO FLEXIBL L1-BELOW L5 PRE $0.00
L0626 6 LO SAG STAYS/PANELS PRE-FAB $0.00
L0627 6 LO SAGITT RIGID PANEL PREFAB $0.00
L0628 6 LO FLEX W/O RIGID STAYS PRE $0.00
L0629 6 LSO FLEX W/RIGID STAYS CUST $0.00
L0630 3 LSO POST RIGID PANEL PRE $127.26
L0631 6 LSO SAG-CORO RIGID FRAME PRE $0.00
L0632 6 LSO SAG RIGID FRAME CUST $0.00
L0633 6 LSO FLEXION CONTROL PREFAB $0.00
L0634 6 LSO FLEXION CONTROL CUSTOM $0.00
L0635 6 LSO SAGIT RIGID PANEL PREFAB $0.00

L0636 6 LSO SAGITTAL RIGID PANEL CUS $0.00
L0637 6 LSO SAG-CORONAL PANEL PREFAB $0.00
L0638 6 LSO SAG-CORONAL PANEL CUSTOM $0.00
L0639 6 LSO S/C SHELL/PANEL PREFAB $0.00
L0640 6 LSO S/C SHELL/PANEL CUSTOM $0.00
L0700 3 CTLSO A-P-L CONTROL MOLDED $1,467.79
L0710 3 CTLSO A-P-L CONTROL W/ INTER $1,499.54
L0810 3 HALO CERVICAL INTO JCKT VEST $1,875.37
L0820 3 HALO CERVICAL INTO BODY JACK $1,683.27
L0830 3 HALO CERV INTO MILWAUKEE TYP $2,372.22
L0859 6 MRI COMPATIBLE SYSTEM $0.00
L0860 O MAGNETIC RESONANC IMAGE COMP $0.00

L0861 6 HALO REPL LINER/INTERFACE $0.00
L0900 O TORSO/PTOSIS SUPPORT $0.00
L0910 O TORSO & PTOSIS SUPP CUSTM FA $0.00
L0920 O TORSO/PENDULOUS ABD SUPPORT $0.00
L0930 O PENDULOUS ABDOMEN SUPP CUSTM $0.00
L0940 O TORSO/POSTSURGICAL SUPPORT $0.00
L0950 O POST SURG SUPPORT CUSTOM FAB $0.00
L0960 O POST SURGICAL SUPPORT PADS $0.00
L0970 3 TLSO CORSET FRONT $96.55
L0972 3 LSO CORSET FRONT $86.71

L0974 3 TLSO FULL CORSET $128.76
L0976 3 LSO FULL CORSET $114.81
L0978 3 AXILLARY CRUTCH EXTENSION $151.56
L0980 3 PERONEAL STRAPS PAIR $16.53
L0982 3 STOCKING SUPP GRIPS SET OF F $11.69
L0984 3 PROTECTIVE BODY SOCK EACH $48.54
L0986 O SPINAL ORTH ABDM PNL PREFAB $0.00
L0999 5 ADD TO SPINAL ORTHOSIS NOS $0.00
L1000 3 CTLSO MILWAUKE INITIAL MODEL $1,472.64
L1001 6 CTLSO INFANT IMMOBILIZER $0.00
L1005 5 TENSION BASED SCOLIOSIS ORTH $0.00
L1010 3 CTLSO AXILLA SLING $48.19
L1020 3 KYPHOSIS PAD $62.06

L1025 3 KYPHOSIS PAD FLOATING $118.46
L1030 3 LUMBAR BOLSTER PAD $45.67
L1040 3 LUMBAR OR LUMBAR RIB PAD $59.77
L1050 3 STERNAL PAD $72.03
L1060 3 THORACIC PAD $86.42
L1070 3 TRAPEZIUS SLING $84.40
L1080 3 OUTRIGGER $47.48
L1085 3 OUTRIGGER BIL W/ VERT EXTENS $128.42
L1090 3 LUMBAR SLING $84.96
L1100 3 RING FLANGE PLASTIC/LEATHER $135.65
L1110 3 RING FLANGE PLAS/LEATHER MOL $183.38
L1120 3 COVERS FOR UPRIGHT EACH $31.00

L1200 3 FURNSH INITIAL ORTHOSIS ONLY $1,124.98
L1210 3 LATERAL THORACIC EXTENSION $187.88
L1220 3 ANTERIOR THORACIC EXTENSION $179.47
L1230 3 MILWAUKEE TYPE SUPERSTRUCTUR $460.04
L1240 3 LUMBAR DEROTATION PAD $62.18
L1250 3 ANTERIOR ASIS PAD $62.18
L1260 3 ANTERIOR THORACIC DEROTATION $63.50
L1270 3 ABDOMINAL PAD $64.52
L1280 3 RIB GUSSET (ELASTIC) EACH $74.19
L1290 3 LATERAL TROCHANTERIC PAD $58.74

L1300 3 BODY JACKET MOLD TO PATIENT $1,322.50
L1310 3 POST-OPERATIVE BODY JACKET $1,358.90
L1499 5 SPINAL ORTHOSIS NOS $0.00
L1500 3 THKAO MOBILITY FRAME $1,363.82
L1510 3 THKAO STANDING FRAME $862.81
L1520 3 THKAO SWIVEL WALKER $1,638.02
L1600 3 ABDUCT HIP FLEX FREJKA W CVR $92.52
L1610 3 ABDUCT HIP FLEX FREJKA COVR $40.82
L1620 3 ABDUCT HIP FLEX PAVLIK HARNE $115.65
L1630 3 ABDUCT CONTROL HIP SEMI-FLEX $121.67
L1640 3 PELV BAND/SPREAD BAR THIGH C $370.37
L1650 3 HO ABDUCTION HIP ADJUSTABLE $187.41
L1652 5 HO BI THIGHCUFFS W SPRDR BAR $0.00

L1660 3 HO ABDUCTION STATIC PLASTIC $122.87
L1680 3 PELVIC & HIP CONTROL THIGH C $874.83
L1685 3 POST-OP HIP ABDUCT CUSTOM FA $892.79
L1686 3 HO POST-OP HIP ABDUCTION $824.39
L1690 3 COMBINATION BILATERAL HO $1,449.30
L1700 3 LEG PERTHES ORTH TORONTO TYP $1,096.46
L1710 3 LEGG PERTHES ORTH NEWINGTON $1,283.53
L1720 3 LEGG PERTHES ORTHOSIS TRILAT $946.12
L1730 3 LEGG PERTHES ORTH SCOTTISH R $812.63
L1750 O LEGG PERTHES SLING $0.00
L1755 3 LEGG PERTHES PATTEN BOTTOM T $1,289.59
L1800 3 KNEE ORTHOSES ELAS W STAYS $52.19

L1810 3 KO ELASTIC WITH JOINTS $70.71
L1815 3 ELASTIC WITH CONDYLAR PADS $74.89
L1820 3 KO ELAS W/ CONDYLE PADS & JO $109.56
L1825 3 KO ELASTIC KNEE CAP $48.39
L1830 3 KO IMMOBILIZER CANVAS LONGIT $66.62
L1831 6 KNEE ORTH POS LOCKING JOINT $0.00
L1832 3 KO ADJ JNT POS RIGID SUPPORT $507.82
L1834 3 KO W/0 JOINT RIGID MOLDED TO $557.35
L1836 5 RIGID KO WO JOINTS $0.00
L1840 3 KO DEROT ANT CRUCIATE CUSTOM $742.41

L1843 3 KO SINGLE UPRIGHT CUSTOM FIT $672.48
L1844 3 KO W/ADJ JT ROT CNTRL MOLDED $1,165.61
L1845 3 KO W/ ADJ FLEX/EXT ROTAT CUS $697.85
L1846 3 KO W ADJ FLEX/EXT ROTAT MOLD $791.83
L1847 3 KO ADJUSTABLE W AIR CHAMBERS $431.07
L1850 3 KO SWEDISH TYPE $218.25
L1855 O KO PLAS DOUB UPRIGHT JNT MOL $0.00
L1858 O KO POLYCENTRIC PNEUMATIC PAD $0.00
L1860 3 KO SUPRACONDYLAR SOCKET MOLD $770.45
L1870 O KO DOUB UPRIGHT LACERS MOLDE $0.00
L1880 O KO DOUB UPRIGHT CUFFS/LACERS $0.00
L1885 O KNEE UPRIGHT W/RESISTANCE $0.00
L1900 3 AFO SPRNG WIR DRSFLX CALF BD $193.70

L1901 5 PREFAB ANKLE ORTHOSIS $0.00
L1902 3 AFO ANKLE GAUNTLET $66.93
L1904 3 AFO MOLDED ANKLE GAUNTLET $402.52
L1906 3 AFO MULTILIGAMENTUS ANKLE SU $86.35
L1907 6 AFO SUPRAMALLEOLAR CUSTOM $0.00
L1910 3 AFO SING BAR CLASP ATTACH SH $196.12
L1920 3 AFO SING UPRIGHT W/ ADJUST S $251.01
L1930 3 AFO PLASTIC $169.85
L1932 6 AFO RIG ANT TIB PREFAB TCF/= $0.00
L1940 3 AFO MOLDED TO PATIENT PLASTI $355.08
L1945 3 AFO MOLDED PLAS RIG ANT TIB $848.95
L1950 3 AFO SPIRAL MOLDED TO PT PLAS $562.89

L1951 6 AFO SPIRAL PREFABRICATED $0.00
L1960 3 AFO POS SOLID ANK PLASTIC MO $424.55
L1970 3 AFO PLASTIC MOLDED W/ANKLE J $510.90
L1971 6 AFO W/ANKLE JOINT, PREFAB $0.00
L1980 3 AFO SING SOLID STIRRUP CALF $263.51
L1990 3 AFO DOUB SOLID STIRRUP CALF $320.05
L2000 3 KAFO SING FRE STIRR THI/CALF $758.23
L2005 6 KAFO SNG/DBL MECHANICAL ACT $0.00
L2010 3 KAFO SNG SOLID STIRRUP W/O J $707.32
L2020 3 KAFO DBL SOLID STIRRUP BAND/ $890.63

L2030 3 KAFO DBL SOLID STIRRUP W/O J $808.48
L2034 6 KAFO PLA SIN UP W/WO K/A CUS $0.00
L2035 3 KAFO PLASTIC PEDIATRIC SIZE $131.14
L2036 3 KAFO PLAS DOUB FREE KNEE MOL $1,380.47
L2037 3 KAFO PLAS SING FREE KNEE MOL $1,287.91
L2038 3 KAFO W/O JOINT MULTI-AXIS AN $1,308.30
L2039 O KAFO,PLSTIC,MEDLAT ROTAT CON $0.00
L2040 3 HKAFO TORSION BIL ROT STRAPS $158.68
L2050 3 HKAFO TORSION CABLE HIP PELV $342.03
L2060 3 HKAFO TORSION BALL BEARING J $416.86
L2070 3 HKAFO TORSION UNILAT ROT STR $107.04
L2080 3 HKAFO UNILAT TORSION CABLE $258.25
L2090 3 HKAFO UNILAT TORSION BALL BR $314.84

L2102 O AFO TIBIAL FX CAST PLSTR MOL $0.00
L2104 O AFO TIB FX CAST SYNTHETIC MO $0.00
L2106 3 AFO TIB FX CAST PLASTER MOLD $488.18
L2108 3 AFO TIB FX CAST MOLDED TO PT $850.00
L2112 3 AFO TIBIAL FRACTURE SOFT $390.97
L2114 3 AFO TIB FX SEMI-RIGID $490.39
L2116 3 AFO TIBIAL FRACTURE RIGID $564.23
L2122 O KAFO FEM FX CAST PLASTER MOL $0.00
L2124 O KAFO FEM FX CAST SYNTHET MOL $0.00
L2126 3 KAFO FEM FX CAST THERMOPLAS $943.82
L2128 3 KAFO FEM FX CAST MOLDED TO P $1,336.53
L2132 3 KAFO FEMORAL FX CAST SOFT $724.60

L2134 3 KAFO FEM FX CAST SEMI-RIGID $773.23
L2136 3 KAFO FEMORAL FX CAST RIGID $922.89
L2180 3 PLAS SHOE INSERT W ANK JOINT $86.13
L2182 3 DROP LOCK KNEE $71.37
L2184 3 LIMITED MOTION KNEE JOINT $97.56
L2186 3 ADJ MOTION KNEE JNT LERMAN T $135.31
L2188 3 QUADRILATERAL BRIM $259.14
L2190 3 WAIST BELT $66.96
L2192 3 PELVIC BAND & BELT THIGH FLA $294.02
L2200 3 LIMITED ANKLE MOTION EA JNT $34.14

L2210 3 DORSIFLEXION ASSIST EACH JOI $49.41
L2220 3 DORSI & PLANTAR FLEX ASS/RES $58.80
L2230 3 SPLIT FLAT CALIPER STIRR & P $55.09
L2232 6 ROCKER BOTTOM, CONTACT AFO $0.00
L2240 3 ROUND CALIPER AND PLATE ATTA $68.19
L2250 3 FOOT PLATE MOLDED STIRRUP AT $276.47
L2260 3 REINFORCED SOLID STIRRUP $143.93
L2265 3 LONG TONGUE STIRRUP $84.55
L2270 3 VARUS/VALGUS STRAP PADDED/LI $39.65
L2275 3 PLASTIC MOD LOW EXT PAD/LINE $93.48
L2280 3 MOLDED INNER BOOT $326.87
L2300 3 ABDUCTION BAR JOINTED ADJUST $204.94
L2310 3 ABDUCTION BAR-STRAIGHT $102.64

L2320 3 NON-MOLDED LACER $147.73
L2330 3 LACER MOLDED TO PATIENT MODE $309.23
L2335 3 ANTERIOR SWING BAND $190.92
L2340 3 PRE-TIBIAL SHELL MOLDED TO P $413.33
L2350 3 PROSTHETIC TYPE SOCKET MOLDE $713.86
L2360 3 EXTENDED STEEL SHANK $37.15
L2370 3 PATTEN BOTTOM $240.71
L2375 3 TORSION ANK & HALF SOLID STI $101.69
L2380 3 TORSION STRAIGHT KNEE JOINT $88.39
L2385 3 STRAIGHT KNEE JOINT HEAVY DU $96.17
L2387 6 ADD LE POLY KNEE CUSTOM KAFO $0.00
L2390 3 OFFSET KNEE JOINT EACH $80.51

L2395 3 OFFSET KNEE JOINT HEAVY DUTY $112.34
L2397 3 SUSPENSION SLEEVE LOWER EXT $87.53
L2405 3 KNEE JOINT DROP LOCK EA JNT $65.34
L2415 3 KNEE JOINT CAM LOCK EACH JOI $91.03
L2425 3 KNEE DISC/DIAL LOCK/ADJ FLEX $107.43
L2430 3 KNEE JNT RATCHET LOCK EA JNT $107.43
L2435 O KNEE JOINT POLYCENTRIC JOINT $0.00
L2492 3 KNEE LIFT LOOP DROP LOCK RIN $97.54
L2500 3 THI/GLUT/ISCHIA WGT BEARING $233.34
L2510 3 TH/WGHT BEAR QUAD-LAT BRIM M $523.55

L2520 3 TH/WGHT BEAR QUAD-LAT BRIM C $345.37
L2525 3 TH/WGHT BEAR NAR M-L BRIM MO $931.80
L2526 3 TH/WGHT BEAR NAR M-L BRIM CU $531.72
L2530 3 THIGH/WGHT BEAR LACER NON-MO $168.70
L2540 3 THIGH/WGHT BEAR LACER MOLDED $303.55
L2550 3 THIGH/WGHT BEAR HIGH ROLL CU $206.21
L2570 3 HIP CLEVIS TYPE 2 POSIT JNT $341.99
L2580 3 PELVIC CONTROL PELVIC SLING $333.23
L2600 3 HIP CLEVIS/THRUST BEARING FR $182.48
L2610 3 HIP CLEVIS/THRUST BEARING LO $193.28
L2620 3 PELVIC CONTROL HIP HEAVY DUT $217.32
L2622 3 HIP JOINT ADJUSTABLE FLEXION $246.37
L2624 3 HIP ADJ FLEX EXT ABDUCT CONT $237.76

L2627 3 PLASTIC MOLD RECIPRO HIP & C $1,297.39
L2628 3 METAL FRAME RECIPRO HIP & CA $1,276.17
L2630 3 PELVIC CONTROL BAND & BELT U $177.79
L2640 3 PELVIC CONTROL BAND & BELT B $241.29
L2650 3 PELV & THOR CONTROL GLUTEAL $102.75
L2660 3 THORACIC CONTROL THORACIC BA $133.82
L2670 3 THORAC CONT PARASPINAL UPRIG $129.79
L2680 3 THORAC CONT LAT SUPPORT UPRI $120.23
L2750 3 PLATING CHROME/NICKEL PR BAR $60.02
L2755 3 CARBON GRAPHITE LAMINATION $97.91
L2760 3 EXTENSION PER EXTENSION PER $43.62
L2768 5 ORTHO SIDEBAR DISCONNECT $0.00

L2770 3 LOW EXT ORTHOSIS PER BAR/JNT $44.33
L2780 3 NON-CORROSIVE FINISH $48.59
L2785 3 DROP LOCK RETAINER EACH $22.86
L2795 3 KNEE CONTROL FULL KNEECAP $61.97
L2800 3 KNEE CAP MEDIAL OR LATERAL P $95.24
L2810 3 KNEE CONTROL CONDYLAR PAD $74.77
L2820 3 SOFT INTERFACE BELOW KNEE SE $62.35
L2830 3 SOFT INTERFACE ABOVE KNEE SE $67.46
L2840 3 TIBIAL LENGTH SOCK FX OR EQU $39.88
L2850 3 FEMORAL LGTH SOCK FX OR EQUA $44.46

L2860 O TORSION MECHANISM KNEE/ANKLE $0.00
L2999 5 LOWER EXTREMITY ORTHOSIS NOS $0.00
L3000 3 FT INSERT UCB BERKELEY SHELL $80.00
L3001 5 FOOT INSERT REMOV MOLDED SPE $0.00
L3002 5 FOOT INSERT PLASTAZOTE OR EQ $0.00
L3003 5 FOOT INSERT SILICONE GEL EAC $0.00
L3010 5 FOOT LONGITUDINAL ARCH SUPPO $0.00
L3020 3 FOOT LONGITUD/METATARSAL SUP $155.91
L3030 5 FOOT ARCH SUPPORT REMOV PREM $0.00
L3031 6 FOOT LAMIN/PREPREG COMPOSITE $0.00
L3040 5 FT ARCH SUPRT PREMOLD LONGIT $0.00
L3050 5 FOOT ARCH SUPP PREMOLD METAT $0.00
L3060 5 FOOT ARCH SUPP LONGITUD/META $0.00

L3070 5 ARCH SUPRT ATT TO SHO LONGIT $0.00
L3080 5 ARCH SUPP ATT TO SHOE METATA $0.00
L3090 5 ARCH SUPP ATT TO SHOE LONG/M $0.00
L3100 5 HALLUS-VALGUS NGHT DYNAMIC S $0.00
L3140 5 ABDUCTION ROTATION BAR SHOE $0.00
L3150 5 ABDUCT ROTATION BAR W/O SHOE $0.00
L3160 5 SHOE STYLED POSITIONING DEV $0.00
L3170 5 FOOT PLASTIC HEEL STABILIZER $0.00
L3201 5 OXFORD W SUPINAT/PRONAT INF $0.00
L3202 5 OXFORD W/ SUPINAT/PRONATOR C $0.00
L3203 5 OXFORD W/ SUPINATOR/PRONATOR $0.00
L3204 5 HIGHTOP W/ SUPP/PRONATOR INF $0.00

L3206 5 HIGHTOP W/ SUPP/PRONATOR CHI $0.00
L3207 5 HIGHTOP W/ SUPP/PRONATOR JUN $0.00
L3208 5 SURGICAL BOOT EACH INFANT $0.00
L3209 5 SURGICAL BOOT EACH CHILD $0.00
L3211 5 SURGICAL BOOT EACH JUNIOR $0.00
L3212 5 BENESCH BOOT PAIR INFANT $0.00
L3213 5 BENESCH BOOT PAIR CHILD $0.00
L3214 5 BENESCH BOOT PAIR JUNIOR $0.00
L3215 3 ORTHOPEDIC FTWEAR LADIES OXF $86.72
L3216 5 ORTHOPED LADIES SHOES DPTH I $0.00

L3217 5 LADIES SHOES HIGHTOP DEPTH I $0.00
L3218 O LADIES SURGICAL BOOT EACH $0.00
L3219 3 ORTHOPEDIC MENS SHOES OXFORD $89.02
L3221 5 ORTHOPEDIC MENS SHOES DPTH I $0.00
L3222 5 MENS SHOES HIGHTOP DEPTH INL $0.00
L3223 O MENS SURGICAL BOOT EACH $0.00
L3224 3 WOMAN'S SHOE OXFORD BRACE $47.77
L3225 3 MAN'S SHOE OXFORD BRACE $49.05
L3230 5 CUSTOM SHOES DEPTH INLAY $0.00
L3250 5 CUSTOM MOLD SHOE REMOV PROST $0.00
L3251 5 SHOE MOLDED TO PT SILICONE S $0.00
L3252 5 SHOE MOLDED PLASTAZOTE CUST $0.00
L3253 5 SHOE MOLDED PLASTAZOTE CUST $0.00

L3254 5 ORTH FOOT NON-STNDARD SIZE/W $0.00
L3255 5 ORTH FOOT NON-STANDARD SIZE/ $0.00
L3257 5 ORTH FOOT ADD CHARGE SPLIT S $0.00
L3260 5 AMBULATORY SURGICAL BOOT EAC $0.00
L3265 5 PLASTAZOTE SANDAL EACH $0.00
L3300 5 SHO LIFT TAPER TO METATARSAL $0.00
L3310 5 SHOE LIFT ELEV HEEL/SOLE NEO $0.00
L3320 5 SHOE LIFT ELEV HEEL/SOLE COR $0.00
L3330 5 LIFTS ELEVATION METAL EXTENS $0.00
L3332 5 SHOE LIFTS TAPERED TO ONE-HA $0.00
L3334 5 SHOE LIFTS ELEVATION HEEL /I $0.00
L3340 5 SHOE WEDGE SACH $0.00

L3350 5 SHOE HEEL WEDGE $0.00
L3360 5 SHOE SOLE WEDGE OUTSIDE SOLE $0.00
L3370 5 SHOE SOLE WEDGE BETWEEN SOLE $0.00
L3380 5 SHOE CLUBFOOT WEDGE $0.00
L3390 5 SHOE OUTFLARE WEDGE $0.00
L3400 5 SHOE METATARSAL BAR WEDGE RO $0.00
L3410 5 SHOE METATARSAL BAR BETWEEN $0.00
L3420 5 FULL SOLE/HEEL WEDGE BTWEEN $0.00
L3430 5 SHO HEEL COUNT PLAST REINFOR $0.00
L3440 5 HEEL LEATHER REINFORCED $0.00

L3450 5 SHOE HEEL SACH CUSHION TYPE $0.00
L3455 5 SHOE HEEL NEW LEATHER STANDA $0.00
L3460 5 SHOE HEEL NEW RUBBER STANDAR $0.00
L3465 5 SHOE HEEL THOMAS WITH WEDGE $0.00
L3470 5 SHOE HEEL THOMAS EXTEND TO B $0.00
L3480 5 SHOE HEEL PAD & DEPRESS FOR $0.00
L3485 5 SHOE HEEL PAD REMOVABLE FOR $0.00
L3500 5 ORTHO SHOE ADD LEATHER INSOL $0.00
L3510 5 ORTHOPEDIC SHOE ADD RUB INSL $0.00
L3520 5 O SHOE ADD FELT W LEATH INSL $0.00
L3530 5 ORTHO SHOE ADD HALF SOLE $0.00
L3540 5 ORTHO SHOE ADD FULL SOLE $0.00
L3550 5 O SHOE ADD STANDARD TOE TAP $0.00

L3560 5 O SHOE ADD HORSESHOE TOE TAP $0.00
L3570 5 O SHOE ADD INSTEP EXTENSION $0.00
L3580 5 O SHOE ADD INSTEP VELCRO CLO $0.00
L3590 5 O SHOE CONVERT TO SOF COUNTE $0.00
L3595 5 ORTHO SHOE ADD MARCH BAR $0.00
L3600 5 TRANS SHOE CALIP PLATE EXIST $0.00
L3610 3 TRANS SHOE CALIPER PLATE NEW $30.00
L3620 5 TRANS SHOE SOLID STIRRUP EXI $0.00
L3630 5 TRANS SHOE SOLID STIRRUP NEW $0.00
L3640 5 SHOE DENNIS BROWNE SPLINT BO $0.00
L3649 5 ORTHOPEDIC SHOE MODIFICA NOS $0.00
L3650 3 SHLDER FIG 8 ABDUCT RESTRAIN $47.75

L3651 5 PREFAB SHOULDER ORTHOSIS $0.00
L3652 5 PREFAB DBL SHOULDER ORTHOSIS $0.00
L3660 3 ABDUCT RESTRAINER CANVAS&WEB $72.21
L3670 3 ACROMIO/CLAVICULAR CANVAS&WE $95.42
L3671 6 SO CAP DESIGN W/O JNTS CF $0.00
L3672 6 SO AIRPLANE W/O JNTS CF $0.00
L3673 6 SO AIRPLANE W/JOINT CF $0.00
L3675 3 CANVAS VEST SO $119.70
L3677 5 SO HARD PLASTIC STABILIZER $0.00
L3700 3 ELBOW ORTHOSES ELAS W STAYS $49.04

L3701 3 PREFAB ELBOW ORTHOSIS $14.56
L3702 6 EO W/O JOINTS CF $0.00
L3710 3 ELBOW ELASTIC WITH METAL JOI $109.80
L3720 3 FOREARM/ARM CUFFS FREE MOTIO $489.89
L3730 3 FOREARM/ARM CUFFS EXT/FLEX A $633.36
L3740 3 CUFFS ADJ LOCK W/ ACTIVE CON $750.90
L3760 3 EO WITHJOINT, PREFABRICATED $341.11
L3762 5 RIGID EO WO JOINTS $0.00
L3763 6 EWHO RIGID W/O JNTS CF $0.00
L3764 6 EWHO W/JOINT(S) CF $0.00
L3765 6 EWHFO RIGID W/O JNTS CF $0.00
L3766 6 EWHFO W/JOINT(S) CF $0.00
L3800 O WHFO SHORT OPPONEN NO ATTACH $0.00

L3805 O WHFO LONG OPPONENS NO ATTACH $0.00
L3806 6 WHFO W/JOINT(S) CUSTOM FAB $0.00
L3807 3 WHFO,NO JOINT, PREFABRICATED $170.55
L3808 6 WHFO, RIGID W/O JOINTS $0.00
L3810 O WHFO THUMB ABDUCTION BAR $0.00
L3815 O WHFO SECOND M.P. ABDUCTION A $0.00
L3820 O WHFO IP EXT ASST W/ MP EXT S $0.00
L3825 O WHFO M.P. EXTENSION STOP $0.00
L3830 O WHFO M.P. EXTENSION ASSIST $0.00
L3835 O WHFO M.P. SPRING EXTENSION A $0.00
L3840 O WHFO SPRING SWIVEL THUMB $0.00
L3845 O WHFO THUMB IP EXT ASS W/ MP $0.00

L3850 O ACTION WRIST W/ DORSIFLEX AS $0.00
L3855 O WHFO ADJ M.P. FLEXION CONTRO $0.00
L3860 O WHFO ADJ M.P. FLEX CTRL & I. $0.00
L3890 O TORSION MECHANISM WRIST/ELBO $0.00
L3900 3 HINGE EXTENSION/FLEX WRIST/F $994.57
L3901 3 HINGE EXT/FLEX WRIST FINGER $1,129.43
L3902 O WHFO EXT POWER COMPRESS GAS $0.00
L3904 3 WHFO ELECTRIC CUSTOM FITTED $2,057.53
L3905 6 WHO W/NONTORSION JNT(S) CF $0.00
L3906 3 WHO W/O JOINTS CF $300.34

L3907 O WHFO WRST GAUNTLT THMB SPICA $0.00
L3908 3 WRIST COCK-UP NON-MOLDED $47.27
L3909 5 PREFAB WRIST ORTHOSIS $0.00
L3910 O WHFO SWANSON DESIGN $0.00
L3911 5 PREFAB HAND FINGER ORTHOSIS $0.00
L3912 3 FLEX GLOVE W/ELASTIC FINGER $81.88
L3913 6 HFO W/O JOINTS CF $0.00
L3914 O WHO WRIST EXTENSION COCK-UP $0.00
L3915 6 WHO W NONTOR JNT(S) PREFAB $0.00
L3916 O WHFO WRIST EXTENS W/ OUTRIGG $0.00
L3917 6 PREFAB METACARPL FX ORTHOSIS $0.00
L3918 O HFO KNUCKLE BENDER $0.00
L3919 6 HO W/O JOINTS CF $0.00

L3920 O KNUCKLE BENDER WITH OUTRIGGE $0.00
L3921 6 HFO W/JOINT(S) CF $0.00
L3922 O KNUCKLE BEND 2 SEG TO FLEX J $0.00
L3923 3 HFO W/O JOINTS PF $25.99
L3924 O OPPENHEIMER $0.00
L3925 6 FO PIP/DIP WITH JOINT/SPRING $0.00
L3926 O THOMAS SUSPENSION $0.00
L3927 6 FO PIP/DIP W/O JOINT/SPRING $0.00
L3928 O FINGER EXTENSION W/ CLOCK SP $0.00
L3929 6 HFO NONTORSION JOINT, PREFAB $0.00
L3930 O FINGER EXTENSION WITH WRIST $0.00
L3931 6 WHFO NONTORSION JOINT PREFAB $0.00

L3932 O SAFETY PIN SPRING WIRE $0.00
L3933 6 FO W/O JOINTS CF $0.00
L3934 O SAFETY PIN MODIFIED $0.00
L3935 6 FO NONTORSION JOINT CF $0.00
L3936 O PALMER $0.00
L3938 O DORSAL WRIST $0.00
L3940 O DORSAL WRIST W/ OUTRIGGER AT $0.00
L3942 O REVERSE KNUCKLE BENDER $0.00
L3944 O REVERSE KNUCKLE BEND W/ OUTR $0.00
L3946 O HFO COMPOSITE ELASTIC $0.00

L3948 O FINGER KNUCKLE BENDER $0.00
L3950 O OPPENHEIMER W/ KNUCKLE BEND $0.00
L3952 O OPPENHEIMER W/ REV KNUCKLE 2 $0.00
L3954 O SPREADING HAND $0.00
L3956 5 ADD JOINT UPPER EXT ORTHOSIS $0.00
L3960 3 SEWHO AIRPLAN DESIG ABDU POS $516.83
L3961 6 SEWHO CAP DESIGN W/O JNTS CF $0.00
L3962 3 SEWHO ERBS PALSEY DESIGN ABD $504.11
L3963 O MOLDED W/ ARTICULATING ELBOW $0.00
L3964 3 SEO MOBILE ARM SUP ATT TO WC $594.21
L3965 3 ARM SUPP ATT TO WC RANCHO TY $948.19
L3966 3 MOBILE ARM SUPPORTS RECLININ $714.31
L3967 6 SEWHO AIRPLANE W/O JNTS CF $0.00

L3968 3 FRICTION DAMPENING ARM SUPP $903.93
L3969 3 MONOSUSPENSION ARM/HAND SUPP $615.05
L3970 3 ELEVAT PROXIMAL ARM SUPPORT $252.86
L3971 6 SEWHO CAP DESIGN W/JNT(S) CF $0.00
L3972 3 OFFSET/LAT ROCKER ARM W/ ELA $160.79
L3973 6 SEWHO AIRPLANE W/JNT(S) CF $0.00
L3974 3 MOBILE ARM SUPPORT SUPINATOR $136.38
L3975 6 SEWHFO CAP DESIGN W/O JNT CF $0.00
L3976 6 SEWHFO AIRPLANE W/O JNTS CF $0.00
L3977 6 SEWHFO CAP DESGN W/JNT(S) CF $0.00
L3978 6 SEWHFO AIRPLANE W/JNT(S) CF $0.00
L3980 3 UPP EXT FX ORTHOSIS HUMERAL $224.99

L3982 3 UPPER EXT FX ORTHOSIS RAD/UL $262.29
L3984 3 UPPER EXT FX ORTHOSIS WRIST $241.83
L3985 O FOREARM HAND FX ORTH W/ WR H $0.00
L3986 O HUMERAL RAD/ULNA WRIST FX OR $0.00
L3995 3 SOCK FRACTURE OR EQUAL EACH $25.05
L3999 5 UPPER LIMB ORTHOSIS NOS $0.00
L4000 3 REPL GIRDLE MILWAUKEE ORTH $988.41
L4002 6 REPLACE STRAP, ANY ORTHOSIS $0.00
L4010 3 REPLACE TRILATERAL SOCKET BR $481.87
L4020 3 REPLACE QUADLAT SOCKET BRIM $673.89

L4030 3 REPLACE SOCKET BRIM CUST FIT $362.50
L4040 3 REPLACE MOLDED THIGH LACER $295.81
L4045 3 REPLACE NON-MOLDED THIGH LAC $235.52
L4050 3 REPLACE MOLDED CALF LACER $296.42
L4055 3 REPLACE NON-MOLDED CALF LACE $191.94
L4060 3 REPLACE HIGH ROLL CUFF $228.18
L4070 3 REPLACE PROX & DIST UPRIGHT $202.07
L4080 3 REPL MET BAND KAFO-AFO PROX $82.87
L4090 3 REPL MET BAND KAFO-AFO CALF/ $65.40
L4100 3 REPL LEATH CUFF KAFO PROX TH $85.87
L4110 3 REPL LEATH CUFF KAFO-AFO CAL $64.70
L4130 3 REPLACE PRETIBIAL SHELL $362.78
L4200 O REPAIR OF ORTHOTIC DEVICE, HOURLY R $0.00

L4205 3 ORTHO DVC REPAIR PER 15 MIN $6.25
L4210 5 ORTH DEV REPAIR/REPL MINOR P $0.00
L4310 O MULT-PODUS/EQ ORTH PREP MGMT $0.00
L4320 O LOW EXT MGMT SYS FT POS AFO $0.00
L4350 3 ANKLE CONTROL ORTHOSI PREFAB $71.87
L4360 3 PNEUMATI WALKING BOOT PREFAB $220.93
L4370 3 PNEUMATIC FULL LEG SPLINT $146.11
L4380 3 PNEUMATIC KNEE SPLINT $82.45
L4386 3 NON-PNEUM WALK BOOT PREFAB $124.58
L4390 O REPLACE MULTI-PODUS SPLINT $0.00
L4392 3 REPLACE AFO SOFT INTERFACE $17.63
L4394 3 REPLACE FOOT DROP SPINT $12.87

L4396 3 STATIC AFO $125.77
L4398 3 FOOT DROP SPLINT RECUMBENT $57.91
L5000 3 SHO INSERT W ARCH TOE FILLER $426.36
L5010 3 MOLD SOCKET ANK HGT W/ TOE F $931.27
L5020 3 TIBIAL TUBERCLE HGT W/ TOE F $1,515.92
L5050 3 ANK SYMES MOLD SCKT SACH FT $1,755.51
L5060 3 SYMES MET FR LEATH SOCKET AR $2,112.77
L5100 3 MOLDED SOCKET SHIN SACH FOOT $1,828.78
L5105 3 PLAST SOCKET JTS/THGH LACER $2,902.64
L5150 3 MOLD SCKT EXT KNEE SHIN SACH $2,686.23

L5160 3 MOLD SOCKET BENT KNEE SHIN S $2,921.76
L5200 3 KNE SING AXIS FRIC SHIN SACH $2,545.10
L5210 3 NO KNEE/ANKLE JOINTS W/ FT B $1,856.19
L5220 3 NO KNEE JOINT WITH ARTIC ALI $2,109.89
L5230 3 FEM FOCAL DEFIC CONSTANT FRI $2,909.97
L5250 3 HIP CANAD SING AXI CONS FRIC $3,968.93
L5270 3 TILT TABLE LOCKING HIP SING $3,934.16
L5280 3 HEMIPELVECT CANAD SING AXIS $3,894.82
L5300 O BK SACH SOFT COVER & FINISH $0.00
L5301 5 BK MOLD SOCKET SACH FT ENDO $0.00
L5310 O KNEE DISART SACH SOFT CV/FIN $0.00
L5311 5 KNEE DISART, SACH FT, ENDO $0.00
L5320 O AK OPEN END SACH SOFT CV/FIN $0.00

L5321 5 AK OPEN END SACH $0.00
L5330 O HIP CANADIAN SACH SFT CV/FIN $0.00
L5331 5 HIP DISART CANADIAN SACH FT $0.00
L5340 O HEMIPELVECTOMY CANAD CV/FIN $0.00
L5341 5 HEMIPELVECTOMY CANADIAN SACH $0.00
L5400 3 POSTOP DRESS & 1 CAST CHG BK $920.64
L5410 3 POSTOP DSG BK EA ADD CAST CH $403.36
L5420 3 POSTOP DSG & 1 CAST CHG AK/D $1,162.72
L5430 3 POSTOP DSG AK EA ADD CAST CH $513.24
L5450 3 POSTOP APP NON-WGT BEAR DSG $328.33
L5460 3 POSTOP APP NON-WGT BEAR DSG $483.92
L5500 3 INIT BK PTB PLASTER DIRECT $982.44

L5505 3 INIT AK ISCHAL PLSTR DIRECT $1,330.47
L5510 3 PREP BK PTB PLASTER MOLDED $1,113.65
L5520 3 PERP BK PTB THERMOPLS DIRECT $1,100.03
L5530 3 PREP BK PTB THERMOPLS MOLDED $1,392.40
L5535 3 PREP BK PTB OPEN END SOCKET $1,372.22
L5540 3 PREP BK PTB LAMINATED SOCKET $1,448.99
L5560 3 PREP AK ISCHIAL PLAST MOLDED $1,486.72
L5570 3 PREP AK ISCHIAL DIRECT FORM $1,545.67
L5580 3 PREP AK ISCHIAL THERMO MOLD $1,804.46
L5585 3 PREP AK ISCHIAL OPEN END $1,957.15

L5590 3 PREP AK ISCHIAL LAMINATED $1,838.87
L5595 3 HIP DISARTIC SACH THERMOPLS $3,232.24
L5600 3 HIP DISART SACH LAMINAT MOLD $3,525.47
L5610 3 ABOVE KNEE HYDRACADENCE $1,583.72
L5611 3 AK 4 BAR LINK W/FRIC SWING $1,232.45
L5613 3 AK 4 BAR LING W/HYDRAUL SWIG $1,874.64
L5614 3 4-BAR LINK ABOVE KNEE W/SWNG $1,267.18
L5616 3 AK UNIV MULTIPLEX SYS FRICT $1,038.91
L5617 3 AK/BK SELF-ALIGNING UNIT EA $420.17
L5618 3 TEST SOCKET SYMES $242.04
L5620 3 TEST SOCKET BELOW KNEE $212.67
L5622 3 TEST SOCKET KNEE DISARTICULA $324.80
L5624 3 TEST SOCKET ABOVE KNEE $309.88

L5626 3 TEST SOCKET HIP DISARTICULAT $435.56
L5628 3 TEST SOCKET HEMIPELVECTOMY $412.54
L5629 3 BELOW KNEE ACRYLIC SOCKET $315.05
L5630 3 SYME TYP EXPANDABL WALL SCKT $343.30
L5631 3 AK/KNEE DISARTIC ACRYLIC SOC $410.52
L5632 3 SYMES TYPE PTB BRIM DESIGN S $169.85
L5634 3 SYMES TYPE POSTER OPENING SO $232.68
L5636 3 SYMES TYPE MEDIAL OPENING SO $194.91
L5637 3 BELOW KNEE TOTAL CONTACT $260.35
L5638 3 BELOW KNEE LEATHER SOCKET $372.27
L5639 3 BELOW KNEE WOOD SOCKET $873.31
L5640 3 KNEE DISARTICULAT LEATHER SO $531.69

L5642 3 ABOVE KNEE LEATHER SOCKET $476.00
L5643 3 HIP FLEX INNER SOCKET EXT FR $1,190.58
L5644 3 ABOVE KNEE WOOD SOCKET $451.81
L5645 3 BK FLEX INNER SOCKET EXT FRA $610.34
L5646 3 BELOW KNEE CUSHION SOCKET $419.12
L5647 3 BELOW KNEE SUCTION SOCKET $608.48
L5648 3 ABOVE KNEE CUSHION SOCKET $503.62
L5649 3 ISCH CONTAINMT/NARROW M-L SO $1,528.91
L5650 3 TOT CONTACT AK/KNEE DISART S $373.43
L5651 3 AK FLEX INNER SOCKET EXT FRA $918.63

L5652 3 SUCTION SUSP AK/KNEE DISART $333.50
L5653 3 KNEE DISART EXPAND WALL SOCK $445.19
L5654 3 SOCKET INSERT SYMES $253.68
L5655 3 SOCKET INSERT BELOW KNEE $214.80
L5656 3 SOCKET INSERT KNEE ARTICULAT $302.59
L5658 3 SOCKET INSERT ABOVE KNEE $294.67
L5660 O SOCK INSRT SYME SILICONE GEL $0.00
L5661 3 MULTI-DUROMETER SYMES $512.05
L5662 O SOCKET INSERT BK SILICONE GE $0.00
L5663 O SOCK KNEE DISARTIC SILICONE $0.00
L5664 O SOCKET INSERT AK SILICONE GE $0.00
L5665 3 MULTI-DUROMETER BELOW KNEE $391.67
L5666 3 BELOW KNEE CUFF SUSPENSION $58.20

L5667 O SOCKET INSERT W LOCK LOWER $0.00
L5668 3 SOCKET INSERT W/O LOCK LOWER $77.71
L5669 O BELOW KNEE SOCKET W/O LOCK $0.00
L5670 3 BK MOLDED SUPRACONDYLAR SUSP $236.56
L5671 5 BK/AK LOCKING MECHANISM $0.00
L5672 3 BK REMOVABLE MEDIAL BRIM SUS $289.06
L5673 6 SOCKET INSERT W LOCK MECH $0.00
L5674 O BK SUSPENSION SLEEVE $0.00
L5675 O BK HEAVY DUTY SUSP SLEEVE $0.00
L5676 3 BK KNEE JOINTS SINGLE AXIS P $277.19
L5677 3 BK KNEE JOINTS POLYCENTRIC P $377.16
L5678 3 BK JOINT COVERS PAIR $30.37

L5679 6 SOCKET INSERT W/O LOCK MECH $0.00
L5680 3 BK THIGH LACER NON-MOLDED $264.93
L5681 6 INTL CUSTM CONG/LATYP INSERT $0.00
L5682 3 BK THIGH LACER GLUT/ISCHIA M $478.39
L5683 6 INITIAL CUSTOM SOCKET INSERT $0.00
L5684 3 BK FORK STRAP $36.81
L5685 6 BELOW KNEE SUS/SEAL SLEEVE $0.00
L5686 3 BK BACK CHECK $49.66
L5688 3 BK WAIST BELT WEBBING $46.72
L5690 3 BK WAIST BELT PADDED AND LIN $90.49

L5692 3 AK PELVIC CONTROL BELT LIGHT $105.02
L5694 3 AK PELVIC CONTROL BELT PAD/L $138.77
L5695 3 AK SLEEVE SUSP NEOPRENE/EQUA $145.59
L5696 3 AK/KNEE DISARTIC PELVIC JOIN $159.10
L5697 3 AK/KNEE DISARTIC PELVIC BAND $64.62
L5698 3 AK/KNEE DISARTIC SILESIAN BA $80.36
L5699 3 SHOULDER HARNESS $142.63
L5700 3 REPLACE SOCKET BELOW KNEE $2,203.73
L5701 3 REPLACE SOCKET ABOVE KNEE $2,733.93
L5702 3 REPLACE SOCKET HIP $3,445.70
L5703 6 SYMES ANKLE W/O (SACH) FOOT $0.00
L5704 3 CUSTOM SHAPE COVER BK $449.33
L5705 3 CUSTOM SHAPE COVER AK $823.79

L5706 3 CUSTOM SHAPE CVR KNEE DISART $803.52
L5707 3 CUSTOM SHAPE CVR HIP DISART $1,079.50
L5710 3 KNE-SHIN EXO SNG AXI MNL LOC $275.12
L5711 3 KNEE-SHIN EXO MNL LOCK ULTRA $417.34
L5712 3 KNEE-SHIN EXO FRICT SWG & ST $329.61
L5714 3 KNEE-SHIN EXO VARIABLE FRICT $339.91
L5716 3 KNEE-SHIN EXO MECH STANCE PH $557.52
L5718 3 KNEE-SHIN EXO FRCT SWG & STA $696.84
L5722 3 KNEE-SHIN PNEUM SWG FRCT EXO $727.18
L5724 3 KNEE-SHIN EXO FLUID SWING PH $1,154.61
L5726 3 KNEE-SHIN EXT JNTS FLD SWG E $1,516.14
L5728 3 KNEE-SHIN FLUID SWG & STANCE $1,888.89

L5780 3 KNEE-SHIN PNEUM/HYDRA PNEUM $910.73
L5781 5 LOWER LIMB PROS VACUUM PUMP $0.00
L5782 5 HD LOW LIMB PROS VACUUM PUMP $0.00
L5785 3 EXOSKELETAL BK ULTRALT MATER $397.43
L5790 3 EXOSKELETAL AK ULTRA-LIGHT M $550.01
L5795 3 EXOSKEL HIP ULTRA-LIGHT MATE $821.31
L5810 3 ENDOSKEL KNEE-SHIN MNL LOCK $382.08
L5811 3 ENDO KNEE-SHIN MNL LCK ULTRA $557.88
L5812 3 ENDO KNEE-SHIN FRCT SWG & ST $432.41
L5814 3 ENDO KNEE-SHIN HYDRAL SWG PH $2,788.88

L5816 3 ENDO KNEE-SHIN POLYC MCH STA $650.54
L5818 3 ENDO KNEE-SHIN FRCT SWG & ST $734.59
L5822 3 ENDO KNEE-SHIN PNEUM SWG FRC $1,425.17
L5824 3 ENDO KNEE-SHIN FLUID SWING P $1,173.08
L5826 3 MINIATURE KNEE JOINT $2,368.56
L5828 3 ENDO KNEE-SHIN FLUID SWG/STA $2,236.15
L5830 3 ENDO KNEE-SHIN PNEUM/SWG PHA $1,588.87
L5840 3 MULTI-AXIAL KNEE/SHIN SYSTEM $2,801.79
L5845 3 KNEE-SHIN SYS STANCE FLEXION $1,345.96
L5846 O KNEE-SHIN SYS MICROPROCESSOR $0.00
L5847 O MICROPROCESSOR CNTRL FEATURE $0.00
L5848 5 KNEE-SHIN SYS HYDRAUL STANCE $0.00
L5850 3 ENDO AK/HIP KNEE EXTENS ASSI $101.61

L5855 3 MECH HIP EXTENSION ASSIST $236.23
L5856 6 ELEC KNEE-SHIN SWING/STANCE $0.00
L5857 6 ELEC KNEE-SHIN SWING ONLY $0.00
L5858 6 STANCE PHASE ONLY $0.00
L5910 3 ENDO BELOW KNEE ALIGNABLE SY $279.01
L5920 3 ENDO AK/HIP ALIGNABLE SYSTEM $405.87
L5925 3 ABOVE KNEE MANUAL LOCK $257.02
L5930 3 HIGH ACTIVITY KNEE FRAME $2,527.60
L5940 3 ENDO BK ULTRA-LIGHT MATERIAL $383.70
L5950 3 ENDO AK ULTRA-LIGHT MATERIAL $648.20
L5960 3 ENDO HIP ULTRA-LIGHT MATERIA $776.46
L5962 3 BELOW KNEE FLEX COVER SYSTEM $449.63

L5964 3 ABOVE KNEE FLEX COVER SYSTEM $805.38
L5966 3 HIP FLEXIBLE COVER SYSTEM $1,037.45
L5968 3 MULTIAXIAL ANKLE W DORSIFLEX $2,728.85
L5970 3 FOOT EXTERNAL KEEL SACH FOOT $167.93
L5971 6 SACH FOOT, REPLACEMENT $0.00
L5972 3 FLEXIBLE KEEL FOOT $269.59
L5974 3 FOOT SINGLE AXIS ANKLE/FOOT $227.45
L5975 3 COMBO ANKLE/FOOT PROSTHESIS $348.14
L5976 3 ENERGY STORING FOOT $428.39
L5978 3 FT PROSTH MULTIAXIAL ANKL/FT $223.23

L5979 3 MULTI-AXIAL ANKLE/FT PROSTH $1,791.29
L5980 3 FLEX FOOT SYSTEM $2,836.17
L5981 3 FLEX-WALK SYS LOW EXT PROSTH $2,451.49
L5982 3 EXOSKELETAL AXIAL ROTATION U $442.22
L5984 3 ENDOSKELETAL AXIAL ROTATION $438.30
L5985 3 LWR EXT DYNAMIC PROSTH PYLON $212.05
L5986 3 MULTI-AXIAL ROTATION UNIT $487.29
L5987 3 SHANK FT W VERT LOAD PYLON $5,402.07
L5988 3 VERTICAL SHOCK REDUCING PYLO $1,500.16
L5989 O PYLON W ELCTRNC FORCE SENSOR $0.00
L5990 5 USER ADJUSTABLE HEEL HEIGHT $0.00
L5993 O HEAVY DUTY FEATURE, FOOT $0.00
L5994 O HEAVY DUTY FEATURE, KNEE $0.00

L5995 O LOWER EXT PROS HEAVYDUTY FEA $0.00
L5999 5 LOWR EXTREMITY PROSTHES NOS $0.00
L6000 3 PAR HAND ROBIN-AIDS THUM REM $1,016.37
L6010 3 HAND ROBIN-AIDS LITTLE/RING $1,131.05
L6020 3 PART HAND ROBIN-AIDS NO FING $1,054.53
L6025 5 PART HAND DISART MYOELECTRIC $0.00
L6050 3 WRST MLD SCK FLX HNG TRI PAD $1,453.10
L6055 3 WRST MOLD SOCK W/EXP INTERFA $2,309.76
L6100 3 ELB MOLD SOCK FLEX HINGE PAD $1,472.21
L6110 3 ELBOW MOLD SOCK SUSPENSION T $1,561.53
L6120 3 ELBOW MOLD DOUB SPLT SOC STE $1,819.73
L6130 3 ELBOW STUMP ACTIVATED LOCK H $1,980.21

L6200 3 ELBOW MOLD OUTSID LOCK HINGE $2,086.82
L6205 3 ELBOW MOLDED W/ EXPAND INTER $3,477.47
L6250 3 ELBOW INTER LOC ELBOW FORARM $2,054.13
L6300 3 SHLDER DISART INT LOCK ELBOW $2,849.88
L6310 3 SHOULDER PASSIVE RESTOR COMP $2,343.65
L6320 3 SHOULDER PASSIVE RESTOR CAP $1,307.24
L6350 3 THORACIC INTERN LOCK ELBOW $2,996.21
L6360 3 THORACIC PASSIVE RESTOR COMP $2,459.71
L6370 3 THORACIC PASSIVE RESTOR CAP $1,851.78
L6380 3 POSTOP DSG CAST CHG WRST/ELB $1,000.12

L6382 3 POSTOP DSG CAST CHG ELB DIS/ $1,196.80
L6384 3 POSTOP DSG CAST CHG SHLDER/T $1,460.42
L6386 3 POSTOP EA CAST CHG & REALIGN $350.22
L6388 3 POSTOP APPLICAT RIGID DSG ON $336.28
L6400 3 BELOW ELBOW PROSTH TISS SHAP $1,778.70
L6450 3 ELB DISART PROSTH TISS SHAP $2,358.38
L6500 3 ABOVE ELBOW PROSTH TISS SHAP $2,360.31
L6550 3 SHLDR DISAR PROSTH TISS SHAP $2,916.91
L6570 3 SCAP THORAC PROSTH TISS SHAP $3,539.21
L6580 3 WRIST/ELBOW BOWDEN CABLE MOL $1,235.42
L6582 3 WRIST/ELBOW BOWDEN CBL DIR F $1,052.79
L6584 3 ELBOW FAIR LEAD CABLE MOLDED $1,705.33
L6586 3 ELBOW FAIR LEAD CABLE DIR FO $1,491.81

L6588 3 SHDR FAIR LEAD CABLE MOLDED $2,462.65
L6590 3 SHDR FAIR LEAD CABLE DIRECT $2,252.61
L6600 3 POLYCENTRIC HINGE PAIR $151.99
L6605 3 SINGLE PIVOT HINGE PAIR $141.87
L6610 3 FLEXIBLE METAL HINGE PAIR $127.35
L6611 6 ADDITIONAL SWITCH, EXT POWER $0.00
L6615 3 DISCONNECT LOCKING WRIST UNI $157.03
L6616 3 DISCONNECT INSERT LOCKING WR $66.15
L6620 3 FLEXION/EXTENSION WRIST UNIT $246.46
L6621 6 FLEX/EXT WRIST W/WO FRICTION $0.00
L6623 3 SPRING-ASS ROT WRST W/ LATCH $564.15
L6624 6 FLEX/EXT/ROTATION WRIST UNIT $0.00

L6625 3 ROTATION WRST W/ CABLE LOCK $410.51
L6628 3 QUICK DISCONN HOOK ADAPTER O $419.48
L6629 3 LAMINATION COLLAR W/ COUPLIN $111.91
L6630 3 STAINLESS STEEL ANY WRIST $164.86
L6632 3 LATEX SUSPENSION SLEEVE EACH $54.98
L6635 3 LIFT ASSIST FOR ELBOW $152.70
L6637 3 NUDGE CONTROL ELBOW LOCK $316.97
L6638 5 ELEC LOCK ON MANUAL PW ELBOW $0.00
L6639 6 HEAVY DUTY ELBOW FEATURE $0.00
L6640 3 SHOULDER ABDUCTION JOINT PAI $216.31

L6641 3 EXCURSION AMPLIFIER PULLEY T $143.76
L6642 3 EXCURSION AMPLIFIER LEVER TY $204.69
L6645 3 SHOULDER FLEXION-ABDUCTION J $248.55
L6646 5 MULTIPO LOCKING SHOULDER JNT $0.00
L6647 5 SHOULDER LOCK ACTUATOR $0.00
L6648 5 EXT PWRD SHLDER LOCK/UNLOCK $0.00
L6650 3 SHOULDER UNIVERSAL JOINT $258.92
L6655 3 STANDARD CONTROL CABLE EXTRA $57.46
L6660 3 HEAVY DUTY CONTROL CABLE $70.21
L6665 3 TEFLON OR EQUAL CABLE LINING $40.14
L6670 3 HOOK TO HAND CABLE ADAPTER $38.06
L6672 3 HARNESS CHEST/SHLDER SADDLE $128.98
L6675 3 HARNESS FIGURE OF 8 SING CON $91.86

L6676 3 HARNESS FIGURE OF 8 DUAL CON $92.77
L6677 6 UE TRIPLE CONTROL HARNESS $0.00
L6680 3 TEST SOCK WRIST DISART/BEL E $177.47
L6682 3 TEST SOCK ELBW DISART/ABOVE $198.90
L6684 3 TEST SOCKET SHLDR DISART/THO $266.63
L6686 3 SUCTION SOCKET $495.85
L6687 3 FRAME TYP SOCKET BEL ELBOW/W $441.23
L6688 3 FRAME TYP SOCK ABOVE ELB/DIS $426.80
L6689 3 FRAME TYP SOCKET SHOULDER DI $515.42
L6690 3 FRAME TYP SOCK INTERSCAP-THO $558.16
L6691 3 REMOVABLE INSERT EACH $333.79
L6692 3 SILICONE GEL INSERT OR EQUAL $427.78

L6693 3 LOCKINGELBOW FOREARM CNTRBAL $2,131.93
L6694 6 ELBOW SOCKET INS USE W/LOCK $0.00
L6695 6 ELBOW SOCKET INS USE W/O LCK $0.00
L6696 6 CUS ELBO SKT IN FOR CON/ATYP $0.00
L6697 6 CUS ELBO SKT IN NOT CON/ATYP $0.00
L6698 6 BELOW/ABOVE ELBOW LOCK MECH $0.00
L6700 O TERMINAL DEVICE MODEL #3 $0.00
L6703 6 TERM DEV, PASSIVE HAND MITT $0.00
L6704 6 TERM DEV, SPORT/REC/WORK ATT $0.00

L6706 6 TERM DEV MECH HOOK VOL OPEN $0.00
L6707 6 TERM DEV MECH HOOK VOL CLOSE $0.00
L6708 6 TERM DEV MECH HAND VOL OPEN $0.00
L6709 6 TERM DEV MECH HAND VOL CLOSE $0.00
L6710 O TERMINAL DEVICE MODEL #5X $0.00
L6711 6 PED TERM DEV, HOOK, VOL OPEN $0.00
L6712 6 PED TERM DEV, HOOK, VOL CLOS $0.00
L6713 6 PED TERM DEV, HAND, VOL OPEN $0.00
L6714 6 PED TERM DEV, HAND, VOL CLOS $0.00
L6715 O TERMINAL DEVICE MODEL #5XA $0.00
L6721 6 HOOK/HAND, HVY DTY, VOL OPEN $0.00
L6722 6 HOOK/HAND, HVY DTY, VOL CLOS $0.00

L6730 O TERMINAL DEVICE MODEL #7LO $0.00
L6750 O TERMINAL DEVICE MODEL #10P $0.00
L6765 O TERMINAL DEVICE MODEL #12P $0.00
L6775 O TERMINAL DEVICE MODEL#555 $0.00
L6780 O TERMINAL DEVICE MODEL #SS555 $0.00
L6790 O HOOKS-ACCU HOOK OR EQUAL $0.00

L6795 O HOOKS-2 LOAD OR EQUAL $0.00
L6800 O HOOKS-APRL VC OR EQUAL $0.00
L6805 3 TERM DEV MODIFIER WRIST UNIT $275.35
L6806 O TRS GRIP VC OR EQUAL $0.00
L6807 O TERM DEVICE GRIP1/2 OR EQUAL $0.00
L6808 O TERM DEVICE INFANT OR CHILD $0.00
L6809 O TRS SUPER SPORT PASSIVE $0.00
L6810 3 TERM DEV PRECISION PINCH DEV $150.10
L6825 O HANDS DORRANCE VO $0.00
L6830 O HAND APRL VC $0.00

L6835 O HAND SIERRA VO $0.00
L6840 O HAND BECKER IMPERIAL $0.00
L6845 O HAND BECKER LOCK GRIP $0.00
L6850 O TERM DVC-HAND BECKER PLYLITE $0.00
L6855 O HAND ROBIN-AIDS VO $0.00
L6860 O HAND ROBIN-AIDS VO SOFT $0.00
L6865 O HAND PASSIVE HAND $0.00
L6867 O HAND DETROIT INFANT HAND $0.00
L6868 O PASSIVE INF HAND STEEPER/HOS $0.00
L6870 O HAND CHILD MITT $0.00
L6872 O HAND NYU CHILD HAND $0.00
L6873 O HAND MECH INF STEEPER OR EQU $0.00
L6875 O HAND BOCK VC $0.00

L6880 O HAND BOCK VO $0.00
L6881 5 TERM DEV AUTO GRASP FEATURE $0.00
L6882 9 MICROPROCESSOR CONTROL UPLMB $0.00
L6883 6 REPLC SOCKT BELOW E/W DISA $0.00
L6884 6 REPLC SOCKT ABOVE ELBOW DISA $0.00
L6885 6 REPLC SOCKT SHLDR DIS/INTERC $0.00
L6890 3 PREFAB GLOVE FOR TERM DEVICE $130.10
L6895 3 CUSTOM GLOVE FOR TERM DEVICE $473.54
L6900 3 HAND RESTORAT THUMB/1 FINGER $1,228.99
L6905 3 HAND RESTORATION MULTIPLE FI $1,206.52
L6910 3 HAND RESTORATION NO FINGERS $1,238.56
L6915 3 HAND RESTORATION REPLACMNT G $478.87

L6920 3 WRIST DISARTICUL SWITCH CTRL $5,896.34
L6925 3 WRIST DISART MYOELECTRONIC C $6,464.09
L6930 3 BELOW ELBOW SWITCH CONTROL $5,578.08
L6935 3 BELOW ELBOW MYOELECTRONIC CT $6,600.69
L6940 3 ELBOW DISARTICULATION SWITCH $7,272.04
L6945 3 ELBOW DISART MYOELECTRONIC C $8,133.63
L6950 3 ABOVE ELBOW SWITCH CONTROL $7,706.82
L6955 3 ABOVE ELBOW MYOELECTRONIC CT $9,372.94
L6960 3 SHLDR DISARTIC SWITCH CONTRO $9,950.82
L6965 3 SHLDR DISARTIC MYOELECTRONIC $11,398.65

L6970 3 INTERSCAPULAR-THOR SWITCH CT $12,251.26
L6975 3 INTERSCAP-THOR MYOELECTRONIC $13,525.58
L7007 6 ADULT ELECTRIC HAND $0.00
L7008 6 PEDIATRIC ELECTRIC HAND $0.00
L7009 6 ADULT ELECTRIC HOOK $0.00
L7010 O HAND OTTO BACK STEEPER/EQ SW $0.00
L7015 O HAND SYS TEKNIK VILLAGE SWIT $0.00
L7020 O ELECTRONIC GREIFER SWITCH CT $0.00
L7025 O ELECTRON HAND MYOELECTRONIC $0.00
L7030 O HAND SYS TEKNIK VILL MYOELEC $0.00
L7035 O ELECTRON GREIFER MYOELECTRO $0.00
L7040 3 PREHENSILE ACTUATOR $2,225.23
L7045 3 PEDIATRIC ELECTRIC HOOK $1,236.40

L7160 O ELECTRONIC ELBOW, BOSTON OR EQUAL, $0.00
L7165 O ELECTRONIC ELBOW, BOSTON OR EQUAL, $0.00
L7170 3 ELECTRONIC ELBOW HOSMER SWIT $4,485.23
L7180 3 ELECTRONIC ELBOW SEQUENTIAL $26,708.37
L7181 6 ELECTRONIC ELBO SIMULTANEOUS $0.00
L7185 3 ELECTRON ELBOW ADOLESCENT SW $4,592.13
L7186 3 ELECTRON ELBOW CHILD SWITCH $7,012.55
L7190 3 ELBOW ADOLESCENT MYOELECTRON $5,978.78
L7191 3 ELBOW CHILD MYOELECTRONIC CT $7,553.10
L7260 3 ELECTRON WRIST ROTATOR OTTO $1,945.02
L7261 3 ELECTRON WRIST ROTATOR UTAH $3,581.46
L7266 3 SERVO CONTROL STEEPER OR EQU $757.35

L7272 3 ANALOGUE CONTROL UNB OR EQUA $1,688.10
L7274 3 PROPORTIONAL CTL 12 VOLT UTA $5,406.56
L7360 3 SIX VOLT BAT OTTO BOCK/EQ EA $228.56
L7362 3 BATTERY CHRGR SIX VOLT OTTO $205.92
L7364 3 TWELVE VOLT BATTERY UTAH/EQU $380.62
L7366 3 BATTERY CHRGR 12 VOLT UTAH/E $512.77
L7367 5 REPLACEMNT LITHIUM IONBATTER $0.00
L7368 5 LITHIUM ION BATTERY CHARGER $0.00
L7400 6 ADD UE PROST BE/WD, ULTLITE $0.00
L7401 6 ADD UE PROST A/E ULTLITE MAT $0.00

L7402 6 ADD UE PROST S/D ULTLITE MAT $0.00
L7403 6 ADD UE PROST B/E ACRYLIC $0.00
L7404 6 ADD UE PROST A/E ACRYLIC $0.00
L7405 6 ADD UE PROST S/D ACRYLIC $0.00
L7499 5 UPPER EXTREMITY PROSTHES NOS $0.00
L7500 5 PROSTHETIC DVC REPAIR HOURLY $0.00
L7510 5 PROSTHETIC DEVICE REPAIR REP $0.00
L7520 3 REPAIR PROSTHESIS PER 15 MIN $6.25
L7600 6 PROSTHETIC DONNING SLEEVE $0.00
L7611 O PED TERM DEV, HOOK, VOL OPEN $0.00
L7612 O PED TERM DEV, HOOK, VOL CLOS $0.00
L7613 O PED TERM DEV, HAND, VOL OPEN $0.00
L7614 O PED TERM DEV, HAND, VOL CLOS $0.00

L7621 O HOOK/HAND, HVY DTY, VOL OPEN $0.00
L7622 O HOOK/HAND, HVY DTY, VOL CLOS $0.00
L7900 9 VACUUM ERECTION SYSTEM $0.00
L8000 3 MASTECTOMY BRA $27.93
L8001 5 BREAST PROSTHESIS BRA & FORM $0.00
L8002 5 BRST PRSTH BRA & BILAT FORM $0.00
L8010 3 MASTECTOMY SLEEVE $46.39
L8015 3 EXT BREASTPROSTHESIS GARMENT $45.02
L8020 3 MASTECTOMY FORM $191.37
L8030 3 BREAST PROSTHESIS SILICONE/E $247.69
L8035 3 CUSTOM BREAST PROSTHESIS $2,751.16
L8039 5 BREAST PROSTHESIS NOS $0.00

L8040 3 NASAL PROSTHESIS $1,294.46
L8041 3 MIDFACIAL PROSTHESIS $1,560.25
L8042 3 ORBITAL PROSTHESIS $1,753.08
L8043 3 UPPER FACIAL PROSTHESIS $1,963.45
L8044 3 HEMI-FACIAL PROSTHESIS $2,173.82
L8045 3 AURICULAR PROSTHESIS $1,517.49
L8046 3 PARTIAL FACIAL PROSTHESIS $1,402.47
L8047 3 NASAL SEPTAL PROSTHESIS $718.77
L8048 5 UNSPEC MAXILLOFACIAL PROSTH $0.00
L8049 3 REPAIR MAXILLOFACIAL PROSTH $15.69

L8100 O COMPRESSION STOCKING BK18-30 $0.00
L8130 O GC STOCKING THIGHLNGTH 18-30 $0.00
L8160 O GC STOCKING FULL LNGTH 18-30 $0.00
L8190 O GC STOCKING WAISTLNGTH 18-30 $0.00
L8210 O GC STOCKING CUSTOM MADE $0.00

L8220 O GC STOCKING LYMPHEDEMA $0.00
L8230 O GC STOCKING GARTER BELT $0.00
L8239 O G COMPRESSION STOCKING NOS $0.00
L8300 3 TRUSS SINGLE W/ STANDARD PAD $64.52
L8310 3 TRUSS DOUBLE W/ STANDARD PAD $101.87
L8320 3 TRUSS ADDITION TO STD PAD WA $45.67
L8330 3 TRUSS ADD TO STD PAD SCROTAL $37.77
L8400 3 SHEATH BELOW KNEE $13.28
L8410 3 SHEATH ABOVE KNEE $17.75
L8415 3 SHEATH UPPER LIMB $17.44
L8417 3 PROS SHEATH/SOCK W GEL CUSHN $56.42
L8420 3 PROSTHETIC SOCK MULTI PLY BK $15.68

L8430 3 PROSTHETIC SOCK MULTI PLY AK $16.93
L8435 3 PROS SOCK MULTI PLY UPPER LM $16.09
L8440 3 SHRINKER BELOW KNEE $31.99
L8460 3 SHRINKER ABOVE KNEE $50.98
L8465 3 SHRINKER UPPER LIMB $45.15
L8470 3 PROS SOCK SINGLE PLY BK $5.11
L8480 3 PROS SOCK SINGLE PLY AK $7.04
L8485 3 PROS SOCK SINGLE PLY UPPER L $8.84
L8490 O AIR SEAL SUCTION RETEN SYSTM $0.00
L8499 5 UNLISTED MISC PROSTHETIC SER $0.00

L8500 3 ARTIFICIAL LARYNX $673.10
L8501 3 TRACHEOSTOMY SPEAKING VALVE $92.40
L8505 5 ARTIFICIAL LARYNX, ACCESSORY $0.00
L8507 5 TRACH-ESOPH VOICE PROS PT IN $0.00
L8509 5 TRACH-ESOPH VOICE PROS MD IN $0.00
L8510 5 VOICE AMPLIFIER $0.00
L8511 6 INDWELLING TRACH INSERT $0.00
L8512 6 GEL CAP FOR TRACH VOICE PROS $0.00
L8513 6 TRACH PROS CLEANING DEVICE $0.00
L8514 6 REPL TRACH PUNCTURE DILATOR $0.00
L8515 6 GEL CAP APP DEVICE FOR TRACH $0.00
L8603 9 COLLAGEN IMP URINARY 2.5 ML $0.00
L8604 9 DEXTRANOMER/HYALURONIC ACID $0.00

L8606 3 SYNTHETIC IMPLNT URINARY 1ML $166.75
L8609 6 ARTIFICIAL CORNEA $0.00
L8614 9 COCHLEAR DEVICE, $0.00
L8615 6 COCH IMPLANT HEADSET REPLACE $0.00
L8616 6 COCH IMPLANT MICROPHONE REPL $0.00
L8617 6 COCH IMPLANT TRANS COIL REPL $0.00
L8618 6 COCH IMPLANT TRAN CABLE REPL $0.00
L8619 3 REPLACE COCHLEAR PROCESSOR $6,403.44
L8620 O REPL LITHIUM ION BATTERY $0.00
L8621 6 REPL ZINC AIR BATTERY $0.00
L8622 6 REPL ALKALINE BATTERY $0.00
L8623 6 LITH ION BATT CID,NON-EARLVL $0.00

L8624 6 LITH ION BATT CID, EAR LEVEL $0.00
L8630 9 METACARPOPHALANGEAL JOINT IMPLANT $0.00
L8631 9 MCP JOINT REPL 2 PC OR MORE $0.00
L8641 9 METATARSAL JOINT IMPLANT $0.00
L8642 9 HALLUX IMPLANT $0.00
L8658 9 INTERPHALANGEAL JOINT SPACER, SILI $0.00
L8659 9 INTERPHALANGEAL JOINT REPL $0.00
L8670 9 VASCULAR GRAFT MATERIAL, SYNTHETIC $0.00
L8680 9 IMPLANTABLE NEUROSTIMULATOR ELECTR $0.00
L8681 6 PT PRGRM FOR IMPLT NEUROSTIM $0.00

L8682 6 IMPLT NEUROSTIM RADIOFQ REC $0.00
L8683 6 RADIOFQ TRSMTR FOR IMPLT NEU $0.00
L8684 6 RADIOF TRSMTR IMPLT SCRL NEU $0.00
L8685 9 IMPLT NROSTM PLS GEN SNG REC $0.00
L8686 9 IMPLT NROSTM PLS GEN SNG NON $0.00
L8687 9 IMPLT NROSTM PLS GEN DUA REC $0.00
L8688 9 IMPLT NROSTM PLS GEN DUA NON $0.00
L8689 6 EXTERNAL RECHARG SYS INTERN $0.00
L8690 9 AUD OSSEO DEV, INT/EXT COMP $0.00
L8691 6 AUD OSSEO DEV EXT SND PROCES $0.00
L8695 6 EXTERNAL RECHARG SYS EXTERN $0.00
L8699 9 PROSTHETIC IMPLANT NOS $0.00
L9900 5 O&P SUPPLY/ACCESSORY/SERVICE $0.00

L9999 O SALES TAX, ORTHOTIC/PROSTHETIC/OTHE $0.00
M0005 9 OFFICE VISITS WITH TWO OR MORE MODA $0.00
M0006 9 OFFICE VISITS WITH ONE OF THE ABOVE $0.00
M0007 9 OFFICE VISITS INCLUDING COMBINATION $0.00
M0008 9 OFFICE VISIT INCLUDING COMBINATION $0.00
M0009 9 NOT OTHERWISE CLASSIFIED, OFFICE VI $0.00
M0019 9 NOT OTHERWISE CLASSIFIED, HOME VISI $0.00
M0021 9 PER DIEM INPATIENT HOSPITAL CARE WH $0.00
M0022 9 I.C.U. CARE FOLLOW-UP WHEN ONE OR $0.00
M0023 9 ROUTINE NEWBORN CARE, INHOSPITAL, I $0.00
M0024 9 CHEMOTHERAPY(FOR MALIGNANCIES, FOLL $0.00
M0029 9 NOT OTHERWISE CLASSIFIED, HOSPITAL $0.00

M0039 9 NOT OTHERWISE CLASSIFIED, SNF, ECF, $0.00
M0049 9 NOT OTHERWISE CLASSIFIED, NH, BOARD $0.00
M0059 9 NOT OTHERWISE CLASSIFIED, EMERGENCY $0.00
M0064 9 BRIEF OFFICE VISIT FOR THE SOLE PU $0.00
M0070 9 INSULIN SHOCK THERAPY, HYPOGLYCEMIA $0.00
M0071 9 ORTHOMOLECULAR THERAPY $0.00
M0072 9 IMMUNOTHERAPY FOR MALIGNANT DISEASE $0.00
M0075 9 CELLULAR THERAPY $0.00
M0076 9 PROLOTHERAPY $0.00
M0080 9 HYPERTHERMIA THERAPY (TO INCLUDE SY $0.00

M0100 9 INTRAGASTRIC HYPOTHERMIA $0.00
M0101 9 FOOT CARE HYGIENIC/PM $0.00
M0260 9 TONSILLECTOMY, WITH OR WITHOUT ADEN $0.00
M0261 9 TONSILLECTOMY, WITH OR WITHOUT ADEN $0.00
M0300 9 IV CHELATIONTHERAPY $0.00
M0301 9 FABRIC WRAPPING OF ANEURYSM $0.00
M0520 9 ELECTRONIC PACEMAKER ANALYSIS, PULS $0.00
M0525 9 SINGLE LEAD EKG WITH ANALYSIS OF PA $0.00
M0526 9 COMPUTER TRACING AND INTERPRETATION $0.00
M0530 9 CARDIAC EVENTS RECORDER, ELECTROCAR $0.00
M0535 9 CARDIAC EVENTS RECORDER, ELECTROCAR $0.00
M0540 9 SIGNAL-AVERAGING EKG $0.00
M0560 9 PNEUMOPLETHYSMOGRAPHY VENOUS OCCLUS $0.00

M0575 9 ELECTROENCEPHALOGRAM (EEG), INTERPR $0.00
M0580 9 TRANSTELEPHONIC ELECTROENCEPHALOGRA $0.00
M0585 9 ACHILLES REFLEX RESPONSE, ELECTRICA $0.00
M0590 9 MONITORING ECG, EEG OR PRESSURE IN $0.00
M0601 9 PSYCHOLOGICAL TESTING, WITH WRITTEN $0.00
M0702 9 BRIEF, OSTEOPATHIC MANIPULATIVE THE $0.00
M0704 9 LIMITED, OSTEOPATHIC MANIPULATIVE T $0.00
M0706 9 INTERMEDIATE OSTEOPATHIC MANIPULATI $0.00
M0708 9 EXTENDED OSTEOPATHIC MANIPULATIVE T $0.00
M0710 9 COMPREHENSIVE OSTEOPATHIC MANIPULAT $0.00
M0722 9 BRIEF INPATIENT HOSPITAL OMT (UP TO $0.00
M0724 9 LIMITED INPATIENT HOSPITAL OMT (UP $0.00

M0726 9 INTERMEDIATE INPATIENT HOSPITAL OMT $0.00
M0728 9 EXTENDED INPATIENT HOSPITAL OMT (UP $0.00
M0730 9 COMPREHENSIVE INPATIENT HOSPITAL OM $0.00
M0799 9 PHYSICAL MEDICINE, NOT OTHERWISE CL $0.00
M0900 9 EXCISION, REVISION OR REMOVAL OF A- $0.00
M0910 9 INSERTION CATHETERS FEMORAL VEIN, U $0.00
M0945 9 OUTPATIENT DIALYSIS RELATED PHYSICI $0.00
M0974 9 SELF DIALYSIS TRAINING, ANY MODE, C $0.00
M0978 9 SELF DIALYSIS TRAINING, ANY MODE, C $0.00
ORVCW O MCO SPECIFIC CODE: SMART START OUR $0.00

ORVRN O MCO SPECIFIC CODE: SMART START OUTR $0.00
ORVSW O MCO SPECIFIC CODE: SMART START OUTR $0.00
P2028 9 CEPHALIN FLOCULATION TEST $0.00
P2029 9 CONGO RED BLOOD TEST $0.00
P2031 9 HAIR ANALYSIS $0.00
P2032 9 ICTERUS INDEX, BLOOD $0.00
P2033 9 BLOOD THYMOL TURBIDITY $0.00
P2038 9 BLOOD MUCOPROTEIN $0.00
P3000 9 SCREEN PAP BY TECH W MD SUPV $0.00
P3001 9 SCREENING PAP SMEAR BY PHYS $0.00
P7001 9 CULTURE BACTERIAL URINE $0.00
P7020 9 VACCINE, AUTOGENOUS (MEDICAL NECESS $0.00
P9005 9 ADMINISTRATION FEE CHARGE BY A PROV $0.00

P9006 9 MULTIPLE PATHOLOGY SERVICES $0.00
P9007 9 HANDLING CHARGE FOR PURCHASED LAB S $0.00
P9010 9 WHOLE BLOOD FOR TRANSFUSION $0.00
P9011 9 BLOOD SPLIT UNIT $0.00
P9012 9 CRYOPRECIPITATE EACH UNIT $0.00
P9013 9 UNIT/S BLOOD FIBRINOGEN $0.00
P9014 9 GAMMA GLOBULIN 1 ML $0.00
P9015 9 RH IMMUNE GLOBULIN 1 ML $0.00
P9016 9 RBC LEUKOCYTES REDUCED $0.00
P9017 9 PLASMA 1 DONOR FRZ W/IN 8 HR $0.00
P9018 9 PLASMA PROTEIN FRACT, UNIT $0.00
P9019 9 PLATELETS, EACH UNIT $0.00

P9020 9 PLAELET RICH PLASMA UNIT $0.00
P9021 9 RED BLOOD CELLS UNIT $0.00
P9022 9 WASHED RED BLOOD CELLS UNIT $0.00
P9023 9 FROZEN PLASMA, POOLED, SD $0.00
P9024 9 FACTOR VIII DILUTION, EACH BOTTLE. $0.00
P9031 9 PLATELETS LEUKOCYTES REDUCED $0.00
P9032 9 PLATELETS, IRRADIATED $0.00
P9033 9 PLATELETS LEUKOREDUCED IRRAD $0.00
P9034 9 PLATELETS, PHERESIS $0.00
P9035 9 PLATELET PHERES LEUKOREDUCED $0.00

P9036 9 PLATELET PHERESIS IRRADIATED $0.00
P9037 9 PLATE PHERES LEUKOREDU IRRAD $0.00
P9038 9 RBC IRRADIATED $0.00
P9039 9 RBC DEGLYCEROLIZED $0.00
P9040 9 RBC LEUKOREDUCED IRRADIATED $0.00
P9041 9 ALBUMIN (HUMAN),5%, 50ML $0.00
P9042 9 ALBUMIN (HUMAN), 25% $0.00
P9043 9 PLASMA PROTEIN FRACT,5%,50ML $0.00
P9044 9 CRYOPRECIPITATEREDUCEDPLASMA $0.00
P9045 9 ALBUMIN (HUMAN), 5%, 250 ML $0.00
P9046 9 ALBUMIN (HUMAN), 25%, 20 ML $0.00
P9047 9 ALBUMIN (HUMAN), 25%, 50ML $0.00
P9048 9 PLASMAPROTEIN FRACT,5%,250ML $0.00

P9050 9 GRANULOCYTES, PHERESIS UNIT $0.00
P9051 9 BLOOD, L/R, CMV-NEG $0.00
P9052 9 PLATELETS, HLA-M, L/R, UNIT $0.00
P9053 9 PLT, PHER, L/R CMV-NEG, IRR $0.00
P9054 9 BLOOD, L/R, FROZ/DEGLY/WASH $0.00
P9055 9 PLT, APH/PHER, L/R, CMV-NEG $0.00
P9056 9 BLOOD, L/R, IRRADIATED $0.00
P9057 9 RBC, FRZ/DEG/WSH, L/R, IRRAD $0.00
P9058 9 RBC, L/R, CMV-NEG, IRRAD $0.00
P9059 9 PLASMA, FRZ BETWEEN 8-24HOUR $0.00
P9060 9 FR FRZ PLASMA DONOR RETESTED $0.00
P9603 9 ONE-WAY ALLOW PRORATED MILES $0.00

P9604 9 ONE-WAY ALLOW PRORATED TRIP $0.00
P9605 O ROUTINE VENIPUNCTURE FOR COLLECTION $0.00
P9610 9 URINE SPECIMEN COLLECT SINGL $0.00
P9612 9 CATHETERIZE FOR URINE SPEC $0.00
P9615 9 URINE SPECIMEN COLLECT MULT $0.00
PEDCL O MCO SPECIFIC CODE: SMART START PREN $0.00
Q0033 9 LINOZ V. BOWEN AMBULANCE REIMBURSE $0.00
Q0034 9 ADMIN OF INFLUENZA VACCINE $0.00
Q0035 9 CARDIOKYMOGRAPHY $0.00
Q0036 O OXYGEN CONCENTRATOR, HIGH HUMIDITY $0.00

Q0037 5 OXYGEN AND WATER VAPOR ENRICHING SY $0.00
Q0038 O OXYGEN CONTENTS, GASEOUS, PER UNIT $0.00
Q0039 9 OXYGEN CONTENTS, LIQUID, PER UNIT, $0.00
Q0040 O PORTABLE OXYGEN CONTENTS, GASEOUS P $0.00
Q0041 O PORTABLE OXYGEN CONTENTS, LIQUID, P $0.00
Q0042 O STATIONARY COMPRESSED GAS SYSTEM RE $0.00
Q0043 O STATIONARY LIQUID OXYGEN SYSTEM REN $0.00
Q0045 9 ANESTHESIA FOR IRIDECTOMY $0.00
Q0046 9 PORTABLE LIQUID OXYGEN SYSTEM RENTA $0.00
Q0047 9 ANESTHESIA FOR BLEPHAROPLASTY $0.00
Q0066 9 ASSESSMENT OF CARDIAC OUTPUT BY ELE $0.00
Q0068 9 EXTRACORPEAL PLASMAPHERESIS $0.00
Q0081 9 INFUSION THER OTHER THAN CHE $0.00

Q0082 9 ACTIVITY THERAPY W/PARTIAL H $0.00
Q0083 9 CHEMO BY OTHER THAN INFUSION $0.00
Q0084 9 CHEMOTHERAPY BY INFUSION $0.00
Q0085 9 CHEMO BY BOTH INFUSION AND O $0.00
Q0086 O PHYSICAL THERAPY EVALUATION/ $0.00
Q0091 9 OBTAINING SCREEN PAP SMEAR $0.00
Q0092 O SET UP PORT XRAY EQUIPMENT $0.00
Q0093 O FILGRASTIM (G-CSF), PER 100 MCG $0.00
Q0094 O SARGRAMOSTIM (GM-CSF), PER 250 MCG $0.00
Q0095 O URINE PREGNANCY TESTS, VISUAL COLOR $0.00
Q0096 O OVULATION TEST KITS, VISUAL COLOR C $0.00
Q0097 O HEMOGLOBIN; BY COPPER SULFATE METHO $0.00

Q0098 O GLUCOSE, BLOOD; BY GLUCOSE MONITORI $0.00
Q0100 O URINALYSIS BY DIP STICK OR TABLET F $0.00
Q0101 O MICROHEMATOCRIT, SPUN $0.00
Q0102 O SEDIMENTATION RATE, ERYTHROCYTE; NO $0.00
Q0103 9 PHYSICAL THERAPY EVALUATION, INITIA $0.00
Q0104 9 PHYSICAL THERAPY RE-EVALUATION, PER $0.00
Q0109 9 OCCUPATIONAL THERAPY EVALUATION, IN $0.00
Q0110 9 OCCUPATIONAL THERAPY RE-EVALUATION, $0.00
Q0111 O WET MOUNTS/ W PREPARATIONS $0.00
Q0112 O POTASSIUM HYDROXIDE PREPS $0.00

Q0113 O PINWORM EXAMINATIONS $0.00
Q0114 9 FERN TEST $0.00
Q0115 9 POST-COITAL MUCOUS EXAM $0.00
Q0116 O HEMOGLOBIN BY SINGLE ANALYTE INSTRU $0.00
Q0117 9 FOR DIABETICS ONLY, FITTING (INCLUD $0.00
Q0118 9 FOR DIABETICS ONLY, FITTING (INCLUD $0.00
Q0119 9 FOR DIABETICS ONLY, MULTIPLE DENSIT $0.00
Q0120 9 FOR DIABETICS ONLY, MODIFICATION (I $0.00
Q0132 9 DISPENSING FEE DME NEB DRUG $0.00
Q0136 O NON ESRD EPOETIN ALPHA INJ $0.00

Q0137 O INJECTION, DARBEPOETIN ALFA $0.00
Q0138 O INJECTION, DEXAMETHASONE ACETATE, 1 $0.00
Q0144 9 AZITHROMYCIN DIHYDRATE, ORAL $0.00
Q0156 9 HUMAN ALBUMIN 5% $0.00
Q0157 O HUMAN ALBUMIN 25% $0.00
Q0160 9 FACTOR IX NON-RECOMBINANT $0.00
Q0161 9 FACTOR IX RECOMBINANT $0.00
Q0163 9 DIPHENHYDRAMINE HCL 50MG $0.00
Q0164 9 PROCHLORPERAZINE MALEATE 5MG $0.00
Q0165 9 PROCHLORPERAZINE MALEATE10MG $0.00
Q0166 9 GRANISETRON HCL 1 MG ORAL $0.00
Q0167 9 DRONABINOL 2.5MG ORAL $0.00

Q0168 9 DRONABINOL 5MG ORAL $0.00
Q0169 9 PROMETHAZINE HCL 12.5MG ORAL $0.00
Q0170 9 PROMETHAZINE HCL 25 MG ORAL $0.00
Q0171 9 CHLORPROMAZINE HCL 10MG ORAL $0.00
Q0172 9 CHLORPROMAZINE HCL 25MG ORAL $0.00
Q0173 9 TRIMETHOBENZAMIDE HCL 250MG $0.00
Q0174 9 THIETHYLPERAZINE MALEATE10MG $0.00
Q0175 9 PERPHENAZINE 4MG ORAL $0.00
Q0176 9 PERPHENAZINE 8MG ORAL $0.00
Q0177 9 HYDROXYZINE PAMOATE 25MG $0.00

Q0178 9 HYDROXYZINE PAMOATE 50MG $0.00
Q0179 9 ONDANSETRON HCL 8 MG ORAL $0.00
Q0180 9 DOLASETRON MESYLATE ORAL $0.00
Q0181 9 UNSPECIFIED ORAL ANTI-EMETIC $0.00
Q0182 O NONMETABOLIC ACT D/E TISSUE $0.00
Q0183 O NONMETABOLIC ACTIVE TISSUE $0.00
Q0184 9 METABOLICALLY ACTIVE TISSUE $0.00
Q0185 9 METABOLIC ACTIVE D/E TISSUE $0.00
Q0186 9 PARAMEDIC INTERCEPT, RURAL $0.00
Q0187 O FACTOR VIIA RECOMBINANT $0.00
Q0480 9 DRIVER PNEUMATIC VAD, REP $0.00
Q0481 9 MICROPRCSR CU ELEC VAD, REP $0.00
Q0482 9 MICROPRCSR CU COMBO VAD, REP $0.00

Q0483 9 MONITOR ELEC VAD, REP $0.00
Q0484 9 MONITOR ELEC OR COMB VAD REP $0.00
Q0485 9 MONITOR CABLE ELEC VAD, REP $0.00
Q0486 9 MON CABLE ELEC/PNEUM VAD REP $0.00
Q0487 9 LEADS ANY TYPE VAD, REP ONLY $0.00
Q0488 9 PWR PACK BASE ELEC VAD, REP $0.00
Q0489 9 PWR PCK BASE COMBO VAD, REP $0.00
Q0490 9 EMR PWR SOURCE ELEC VAD, REP $0.00
Q0491 9 EMR PWR SOURCE COMBO VAD REP $0.00
Q0492 9 EMR PWR CBL ELEC VAD, REP $0.00
Q0493 9 EMR PWR CBL COMBO VAD, REP $0.00
Q0494 9 EMR HD PMP ELEC/COMBO, REP $0.00

Q0495 9 CHARGER ELEC/COMBO VAD, REP $0.00
Q0496 9 BATTERY ELEC/COMBO VAD, REP $0.00
Q0497 9 BAT CLPS ELEC/COMB VAD, REP $0.00
Q0498 9 HOLSTER ELEC/COMBO VAD, REP $0.00
Q0499 9 BELT/VEST ELEC/COMBO VAD REP $0.00
Q0500 9 FILTERS ELEC/COMBO VAD, REP $0.00
Q0501 9 SHWR COV ELEC/COMBO VAD, REP $0.00
Q0502 9 MOBILITY CART PNEUM VAD, REP $0.00
Q0503 9 BATTERY PNEUM VAD REPLACEMNT $0.00
Q0504 9 PWR ADPT PNEUM VAD, REP VEH $0.00

Q0505 9 MISCL SUPPLY/ACCESSORY VAD $0.00
Q0510 9 DISPENS FEE IMMUNOSUPRESSIVE $0.00
Q0511 9 SUP FEE ANTIEM,ANTICA,IMMUNO $0.00
Q0512 9 PX SUP FEE ANTI-CAN SUB PRES $0.00
Q0513 9 DISP FEE INHAL DRUGS/30 DAYS $0.00
Q0514 9 DISP FEE INHAL DRUGS/90 DAYS $0.00
Q0515 5 SERMORELIN ACETATE INJECTION $0.00
Q1001 O NTIOL CATEGORY 1 $0.00
Q1002 O NTIOL CATEGORY 2 $0.00
Q1003 9 NTIOL CATEGORY 3 $0.00
Q2001 O ORAL CABERGOLINE 0.5 MG $0.00

Q2002 O ELLIOTTS B SOLUTION PER ML $0.00
Q2003 O APROTININ, 10,000 KIU $0.00
Q2004 5 BLADDER CALCULI IRRIG SOL $0.00
Q2005 O CORTICORELIN OVINE TRIFLUTAT $0.00
Q2006 O DIGOXIN IMMUNE FAB (OVINE) $0.00
Q2007 O ETHANOLAMINE OLEATE 100 MG $0.00
Q2008 O FOMEPIZOLE, 15 MG $0.00
Q2009 5 FOSPHENYTOIN, 50 MG $0.00
Q2010 O GLATIRAMER ACETATE, PER DOSE $0.00
Q2011 O HEMIN, PER 1 MG $0.00
Q2012 O PEGADEMASE BOVINE, 25 IU $0.00
Q2013 O PENTASTARCH 10% SOLUTION $0.00

Q2014 O SERMORELIN ACETATE, 0.5 MG $0.00
Q2015 O SOMATREM, 5 MG $0.00
Q2016 O SOMATROPIN, 1 MG $0.00
Q2017 5 TENIPOSIDE, 50 MG $0.00
Q2018 O UROFOLLITROPIN, 75 IU $0.00
Q2019 O BASILIXIMAB $0.00
Q2020 O HISTRELIN ACETATE $0.00
Q2021 O LEPIRUDIN $0.00
Q2022 O VONWILLEBRANDFACTRCMPLXPERIU $0.00
Q3000 O RUBIDIUM RB 82 $0.00

Q3001 5 BRACHYTHERAPY RADIOELEMENTS $0.00
Q3002 O GALLIUM GA 67 $0.00
Q3003 O TECHNETIUM TC99M BICISATE $0.00
Q3004 O XENON XE 133 $0.00
Q3005 O TECHNETIUM TC99M MERTIATIDE $0.00
Q3006 O TECHNETIUM TC99M GLUCEPATATE $0.00
Q3007 O SODIUM PHOSPHATE P32 $0.00
Q3008 O INDIUM 111-IN PENTETREOTIDE $0.00
Q3009 O TECHNETIUM TC99M OXIDRONATE $0.00
Q3010 O TECHNETIUM TC99MLABELEDRBCS $0.00
Q3011 O CHROMIC PHOSPHATE P32 $0.00
Q3012 O CYANOCOBALAMIN COBALT CO57 $0.00
Q3014 9 TELEHEALTH FACILITY FEE $0.00

Q3017 9 ALS ASSESSMENT $0.00
Q3019 O ALS EMER TRANS NO ALS SERV $0.00
Q3020 O ALS NONEMER TRANS NO ALS SER $0.00
Q3021 5 PED HEPATITIS B VACCINE INJ $0.00
Q3022 5 HEPATITIS B VACCINE ADULT DS $0.00
Q3023 5 INJECTION HEPATITIS BVACCINE $0.00
Q3025 5 IM INJ INTERFERON BETA 1-A $0.00
Q3026 5 SUBC INJ INTERFERON BETA-1A $0.00
Q3031 9 COLLAGEN SKIN TEST $0.00
Q4001 9 CAST SUP BODY CAST PLASTER $0.00
Q4002 9 CAST SUP BODY CAST FIBERGLAS $0.00
Q4003 9 CAST SUP SHOULDER CAST PLSTR $0.00

Q4004 9 CAST SUP SHOULDER CAST FBRGL $0.00
Q4005 9 CAST SUP LONG ARM ADULT PLST $0.00
Q4006 9 CAST SUP LONG ARM ADULT FBRG $0.00
Q4007 9 CAST SUP LONG ARM PED PLSTER $0.00
Q4008 9 CAST SUP LONG ARM PED FBRGLS $0.00
Q4009 9 CAST SUP SHT ARM ADULT PLSTR $0.00
Q4010 9 CAST SUP SHT ARM ADULT FBRGL $0.00
Q4011 9 CAST SUP SHT ARM PED PLASTER $0.00
Q4012 9 CAST SUP SHT ARM PED FBRGLAS $0.00
Q4013 9 CAST SUP GAUNTLET PLASTER $0.00

Q4014 9 CAST SUP GAUNTLET FIBERGLASS $0.00
Q4015 9 CAST SUP GAUNTLET PED PLSTER $0.00
Q4016 9 CAST SUP GAUNTLET PED FBRGLS $0.00
Q4017 9 CAST SUP LNG ARM SPLINT PLST $0.00
Q4018 9 CAST SUP LNG ARM SPLINT FBRG $0.00
Q4019 9 CAST SUP LNG ARM SPLNT PED P $0.00
Q4020 9 CAST SUP LNG ARM SPLNT PED F $0.00
Q4021 9 CAST SUP SHT ARM SPLINT PLST $0.00
Q4022 9 CAST SUP SHT ARM SPLINT FBRG $0.00
Q4023 9 CAST SUP SHT ARM SPLNT PED P $0.00
Q4024 9 CAST SUP SHT ARM SPLNT PED F $0.00
Q4025 9 CAST SUP HIP SPICA PLASTER $0.00
Q4026 9 CAST SUP HIP SPICA FIBERGLAS $0.00

Q4027 9 CAST SUP HIP SPICA PED PLSTR $0.00
Q4028 9 CAST SUP HIP SPICA PED FBRGL $0.00
Q4029 9 CAST SUP LONG LEG PLASTER $0.00
Q4030 9 CAST SUP LONG LEG FIBERGLASS $0.00
Q4031 9 CAST SUP LNG LEG PED PLASTER $0.00
Q4032 9 CAST SUP LNG LEG PED FBRGLS $0.00
Q4033 9 CAST SUP LNG LEG CYLINDER PL $0.00
Q4034 9 CAST SUP LNG LEG CYLINDER FB $0.00
Q4035 9 CAST SUP LNGLEG CYLNDR PED P $0.00
Q4036 9 CAST SUP LNGLEG CYLNDR PED F $0.00
Q4037 9 CAST SUP SHRT LEG PLASTER $0.00
Q4038 9 CAST SUP SHRT LEG FIBERGLASS $0.00

Q4039 9 CAST SUP SHRT LEG PED PLSTER $0.00
Q4040 9 CAST SUP SHRT LEG PED FBRGLS $0.00
Q4041 9 CAST SUP LNG LEG SPLNT PLSTR $0.00
Q4042 9 CAST SUP LNG LEG SPLNT FBRGL $0.00
Q4043 9 CAST SUP LNG LEG SPLNT PED P $0.00
Q4044 9 CAST SUP LNG LEG SPLNT PED F $0.00
Q4045 9 CAST SUP SHT LEG SPLNT PLSTR $0.00
Q4046 9 CAST SUP SHT LEG SPLNT FBRGL $0.00
Q4047 9 CAST SUP SHT LEG SPLNT PED P $0.00
Q4048 9 CAST SUP SHT LEG SPLNT PED F $0.00

Q4049 9 FINGER SPLINT, STATIC $0.00
Q4050 9 CAST SUPPLIES UNLISTED $0.00
Q4051 9 SPLINT SUPPLIES MISC $0.00
Q4054 O DARBEPOETIN ALFA, ESRD USE $0.00
Q4055 O EPOETIN ALFA, ESRD USE $0.00
Q4075 O ACYCLOVIR, 5 MG $0.00
Q4076 O DOPAMINE HCL, 40 MG $0.00
Q4077 O TREPROSTINIL, 1 MG $0.00
Q4079 O NATALIZUMAB INJECTION $0.00
Q4080 9 ILOPROST NON-COMP UNIT DOSE $0.00
Q4081 6 EPOETIN ALFA, 100 UNITS ESRD $0.00
Q4082 9 DRUG/BIO NOC PART B DRUG CAP $0.00
Q4083 O HYALURONAN OR DERIVATIVE, HYALGAN $0.00

Q4084 O HYALURONAN OR DERIVATIVE, SYNVISC, $0.00
Q4085 O HYALURONAN OR DERIVATIVE, EUFLEXXA $0.00
Q4086 O HYALURONAN OR DERIVATIVE, ORTHVISC $0.00
Q4096 O INJECTION, VON WILLEBRAND FACTOR C $0.00
Q4097 O INJECTION, IMMUNE GLOBULIN (PRIVIG $0.00
Q4098 O INJECTION, IRON DEXTRAN, 50 MG $0.00
Q4099 O FORMOTEROL FUMARATE INHALATION UD $0.00
Q4100 9 SKIN SUBSTITUTE, NOS $0.00
Q4101 9 APLIGRAF SKIN SUB $0.00
Q4102 9 OASIS WOUND MATRIX SKIN SUB $0.00
Q4103 9 OASIS BURN MATRIX SKIN SUB $0.00
Q4104 9 INTEGRA BMWD SKIN SUB $0.00

Q4105 9 INTEGRA DRT SKIN SUB $0.00
Q4106 9 DERMAGRAFT SKIN SUB $0.00
Q4107 9 GRAFTJACKET SKIN SUB $0.00
Q4108 9 INTEGRA MATRIX SKIN SUB $0.00
Q4109 9 TISSUEMEND SKIN SUB $0.00
Q4110 9 PRIMATRIX SKIN SUB $0.00
Q4111 9 GAMMAGRAFT SKIN SUB $0.00
Q4112 9 CYMETRA ALLOGRAFT $0.00
Q4113 9 GRAFTJACKET EXPRESS ALLOGRAF $0.00
Q4114 9 INTEGRA FLOWABLE WOUND MATRI $0.00

Q5001 9 HOSPICE IN PATIENT HOME $0.00
Q5002 9 HOSPICE IN ASSISTED LIVING $0.00
Q5003 9 HOSPICE IN LT/NON-SKILLED NF $0.00
Q5004 9 HOSPICE IN SNF $0.00
Q5005 9 HOSPICE, INPATIENT HOSPITAL $0.00
Q5006 9 HOSPICE IN HOSPICE FACILITY $0.00
Q5007 9 HOSPICE IN LTCH $0.00
Q5008 9 HOSPICE IN INPATIENT PSYCH $0.00
Q5009 9 HOSPICE CARE, NOS $0.00
Q9920 O EPOETIN WITH HCT <= 20 $0.00
Q9921 O EPOETIN WITH HCT = 21 $0.00


Q9940 O EPOETIN WITH HCT >= 40 $0.00
Q9945 O LOCM <=149 MG/ML IODINE, 1ML $0.00
Q9946 O LOCM 150-199MG/ML IODINE,1ML $0.00

Q9951 9 LOCM >= 400 MG/ML IODINE,1ML $0.00
Q9952 O INJ GAD-BASE MR CONTRAST,1ML $0.00
Q9953 9 INJ FE-BASED MR CONTRAST,1ML $0.00
Q9954 9 ORAL MR CONTRAST, 100 ML $0.00
Q9955 5 INJ PERFLEXANE LIP MICROS,ML $0.00
Q9956 5 INJ OCTAFLUOROPROPANE MIC,ML $0.00
Q9957 5 INJ PERFLUTREN LIP MICROS,ML $0.00
Q9958 9 HOCM <=149 MG/ML IODINE, 1ML $0.00
Q9959 9 HOCM 150-199MG/ML IODINE,1ML $0.00

Q9964 9 HOCM>= 400MG/ML IODINE, 1ML $0.00
Q9965 9 LOCM 100-199MG/ML IODINE,1ML $0.00
R0059 9 NOT OTHERWISE CLASSIFIED, CHEST $0.00
R0065 9 CIRCULATION TIME, RADIONUCLIDE STUD $0.00
R0070 9 TRANSPORT PORTABLE X-RAY $0.00
R0075 9 TRANSPORT PORT X-RAY MULTIPL $0.00
R0076 9 TRANSPORT PORTABLE EKG $0.00
R0085 9 MULTIPLE RADIOLOGY SERVICES $0.00
S0009 O INJECTION, BUTORPHANOL TARTR $0.00

S0010 O INJECTION, SOMATREM, 5 MG $0.00
S0011 O INJECTION, SOMATROPIN, 5 MG $0.00
S0012 9 BUTORPHANOL TARTRATE, NASAL $0.00
S0014 9 TACRINE HYDROCHLORIDE, 10 MG $0.00
S0016 O INJECTION, AMIKACIN SULFATE $0.00
S0017 5 INJECTION, AMINOCAPROIC ACID $0.00
S0020 3 INJECTION, BUPIVICAINE HYDRO $1.69
S0021 5 INJECTION, CEFOPERAZONE SOD $0.00
S0023 5 INJECTION, CIMETIDINE HYDROC $0.00
S0024 O INJECTION, CIPROFLOXACIN $0.00

S0028 5 INJECTION, FAMOTIDINE, 20 MG $0.00
S0029 O INJECTION, FLUCONAZOLE $0.00
S0030 5 INJECTION, METRONIDAZOLE $0.00
S0032 5 INJECTION, NAFCILLIN SODIUM $0.00
S0034 5 INJECTION, OFLOXACIN, 400 MG $0.00
S0039 5 INJECTION, SULFAMETHOXAZOLE $0.00
S0040 5 INJECTION, TICARCILLIN DISOD $0.00
S0071 O INJECTION, ACYCLOVIR SODIUM $0.00
S0072 O INJECTION, AMIKACIN SULFATE $0.00
S0073 5 INJECTION, AZTREONAM, 500 MG $0.00
S0074 5 INJECTION, CEFOTETAN DISODIU $0.00
S0077 5 INJECTION, CLINDAMYCIN PHOSP $0.00
S0078 5 INJECTION, FOSPHENYTOIN SODI $0.00

S0079 O OCTREOTIDE 100 MCG $0.00
S0080 5 INJECTION, PENTAMIDINE ISETH $0.00
S0081 5 INJECTION, PIPERACILLIN SODI $0.00
S0085 O INJECTION, GATIFLOXACIN $0.00
S0086 O INJECTION, VERTEPORFIN, 15MG $0.00
S0087 O ALEMTUZUMAB 30 MG $0.00
S0088 9 IMATINIB 100 MG $0.00
S0090 9 SILDENAFIL CITRATE, 25 MG $0.00
S0091 5 GRANISETRON 1MG $0.00
S0092 9 HYDROMORPHONE 250 MG $0.00
S0093 9 MORPHINE 500 MG $0.00
S0096 O INJECTION, ITRACONAZOLE, 200 $0.00

S0097 O INJECTION, IBUTILIDE FUMARAT $0.00
S0098 O INJECTION, SODIUM FERRIC GLU $0.00
S0104 9 ZIDOVUDINE ORAL 100 MG $0.00
S0106 9 BUPROPION HCL SR 60 TABLETS $0.00
S0107 O INJ, OMALIZUMAB 25 MG $0.00
S0108 9 MERCAPTOPURINE 50 MG $0.00
S0109 9 METHADONE ORAL 5 MG $0.00
S0114 O TREPROSTINIL SODIUM INJECT $0.00
S0115 O BORTEZOMIB 3.5 MG $0.00
S0116 O BEVACIZUMAB, 100MG $0.00

S0117 9 TRETINOIN TOPICAL 5G $0.00
S0118 O ZICONOTIDE INJ $0.00
S0122 9 INJ MENOTROPINS 75 IU $0.00
S0124 O INJ UROFOLLITROPIN 75 IU $0.00
S0126 9 INJ FOLLITROPIN ALFA 75 IU $0.00
S0128 9 INJ FOLLITROPIN BETA 75 IU $0.00
S0130 O INJ C GONADOTROPIN 5000 IU $0.00
S0132 9 INJ GANIRELIX ACETAT 250 MCG $0.00
S0133 O HISTRELIN IMPLANT $0.00
S0135 5 PEGFILGRASTIM INJECTION 6MG $0.00
S0136 9 CLOZAPINE, 25 MG $0.00
S0137 9 DIDANOSINE, 25 MG $0.00
S0138 9 FINASTERIDE, 5 MG $0.00

S0139 9 MINOXIDIL, 10 MG $0.00
S0140 9 SAQUINAVIR, 200 MG $0.00
S0141 O ZALCITABINE, 0.375 MG $0.00
S0142 9 COLISTIMETHATE INH SOL MG $0.00
S0143 O AZTREONAM, INH SOL GRAM $0.00
S0145 5 PEG INTERFERON ALFA-2A/180 $0.00
S0146 5 PEG INTERFERON ALFA-2B/10 $0.00
S0147 O ALGLUCOSIDASE ALFA 20 MG $0.00
S0155 5 EPOPROSTENOL DILUTANT $0.00
S0156 5 EXEMESTANE, 25 MG $0.00
S0157 9 BECAPLERMIN GEL 1%, 0.5 GM $0.00
S0158 O INJECTION LARONIDASE $0.00

S0159 O INJECTION AGALSIDASE $0.00
S0160 9 DEXTROAMPHETAMINE $0.00
S0161 5 CALCITROL $0.00
S0162 5 INJECTION EFALIZUMAB $0.00
S0163 O INJECTION RISPERIDONELA $0.00
S0164 5 INJECTION PANTOPRAZOLE $0.00
S0165 O INJECTION ABARELIX $0.00
S0166 9 INJ OLANZAPINE 2.5MG $0.00
S0167 O INJ APOMORPHINE HCL 1MG $0.00
S0168 O INJ AZACITIDINE 100 MG $0.00

S0170 9 ANASTROZOLE 1 MG $0.00
S0171 5 BUMETANIDE 0.5 MG $0.00
S0172 9 CHLORAMBUCIL 2 MG $0.00
S0173 O DEXAMETHASONE 4 MG $0.00
S0174 9 DOLASETRON 50 MG $0.00
S0175 9 FLUTAMIDE 125 MG $0.00
S0176 9 HYDROXYUREA 500 MG $0.00
S0177 9 LEVAMISOLE 50 MG $0.00
S0178 9 LOMUSTINE 10 MG $0.00
S0179 9 MEGESTROL 20 MG $0.00
S0180 O ETONOGESTREL IMPLANT SYSTEM $0.00
S0181 9 ONDANSETRON 4 MG $0.00
S0182 9 PROCARBAZINE 5 MG $0.00

S0183 9 PROCHLORPERAZINE 5 MG $0.00
S0187 9 TAMOXIFEN 10 MG $0.00
S0189 9 TESTOSTERONE PELLET 75 MG $0.00
S0190 5 MIFEPRISTONE, ORAL, 200 MG $0.00
S0191 5 MISOPROSTOL, ORAL, 200 MCG $0.00
S0194 9 VITAMIN SUPPL 100 CAPS $0.00
S0195 5 PNEUMOCOCCAL CONJUGATE VAC $0.00
S0196 9 POLY-L-LACTIC ACID 1ML FACE $0.00
S0197 9 PRENATAL VITAMINS 30 DAY $0.00
S0198 O INJ PEGAPTANIB 0.3 MG $0.00
S0199 9 MEDICALLY INDUCED ABORTION BY ORAL $0.00
S0201 9 PARTIAL HOSPITALIZATION SERV $0.00

S0206 9 SURGERY IN OFFICE $0.00
S0207 9 PARAMEDICINTERCEP NONHOSPALS $0.00
S0208 9 PARAMED INTRCEPT NONVOL $0.00
S0209 3 WC VAN MILEAGE PER MI $0.42
S0215 3 NONEMERG TRANSP MILEAGE $0.42
S0220 6 MEDICAL CONFERENCE BY PHYSIC $0.00
S0221 6 MEDICAL CONFERENCE, 60 MIN $0.00
S0250 9 COMP GERIATR ASSMT TEAM $0.00
S0255 9 HOSPICE REFER VISIT NONMD $0.00
S0257 9 END OF LIFE COUNSELING $0.00

S0260 9 H&P FOR SURGERY $0.00
S0265 9 GENETIC COUNSEL 15 MINS $0.00
S0270 9 HOME STD CASE RATE 30 DAYS $0.00
S0271 9 HOME HOSPICE CASE 30 DAYS $0.00
S0272 9 HOME EPISODIC CASE 30 DAYS $0.00
S0273 9 MD HOME VISIT OUTSIDE CAP $0.00
S0274 9 NURSE PRACTR VISIT OUTS CAP $0.00
S0302 9 COMPLETED EPSDT $0.00
S0310 9 HOSPITALIST VISIT $0.00
S0315 9 DISEASE MANAGEMENT PROGRAM $0.00
S0316 9 FOLLOW-UP/REASSESSMENT $0.00
S0317 9 DISEASE MGMT PER DIEM $0.00
S0320 9 RN TELEPHONE CALLS TO DMP $0.00

S0340 9 LIFESTYLE MOD 1ST STAGE $0.00
S0341 9 LIFESTYLE MOD 2 OR 3 STAGE $0.00
S0342 9 LIFESTYLE MOD 4TH STAGE $0.00
S0345 9 HOME ECG MONITRNG GLOBAL 24H $0.00
S0346 9 HOME ECG MONITRNG TECH 24HR $0.00
S0347 9 HOME ECG MONITRNG PROF 24HR $0.00
S0390 5 ROUT FOOT CARE PER VISIT $0.00
S0395 9 IMPRESSION CASTING FT $0.00
S0400 9 GLOBAL ESWL KIDNEY $0.00
S0500 6 DISPOS CONT LENS $0.00
S0504 9 SINGL PRSCRP LENS $0.00
S0506 9 BIFOC PRSCP LENS $0.00

S0508 9 TRIFOC PRSCRP LENS $0.00
S0510 9 NON-PRSCRP LENS $0.00
S0512 6 DAILY CONT LENS $0.00
S0514 9 COLOR CONT LENS $0.00
S0515 9 SCLERAL LENS LIQUID BANDAGE $0.00
S0516 6 SAFETY FRAMES $0.00
S0518 9 SUNGLASS FRAMES $0.00
S0580 3 POLYCARB LENS $18.96
S0581 6 NONSTND LENS $0.00
S0590 9 MISC INTEGRAL LENS SERV $0.00

S0592 6 COMP CONT LENS EVAL $0.00
S0595 9 NEW LENSES IN PTS OLD FRAME $0.00
S0601 9 SCREENING PROCTOSCOPY $0.00
S0605 9 DIGITAL RECTAL EXAMINATION, $0.00
S0610 3 ANNUAL GYNECOLOGICAL EXAMINA $63.33
S0612 3 ANNUAL GYNECOLOGICAL EXAMINA $61.32
S0613 9 ANN BREAST EXAM $0.00
S0618 9 AUDIOMETRY FOR HEARING AID $0.00
S0620 6 ROUTINE OPHTHALMOLOGICAL EXA $0.00
S0621 6 ROUTINE OPHTHALMOLOGICAL EXA $0.00
S0622 9 PHYS EXAM FOR COLLEGE $0.00
S0625 9 DIGITAL SCREENING RETINA $0.00
S0630 9 REMOVAL OF SUTURES $0.00

S0800 9 LASER IN SITU KERATOMILEUSIS $0.00
S0810 9 PHOTOREFRACTIVE KERATECTOMY $0.00
S0812 9 PHOTOTHERAP KERATECT $0.00
S0820 O COMPUTERIZED CORNEAL TOPOGRA $0.00
S0830 O ULTRASOUND PACHYMETRY $0.00
S1001 9 DELUXE ITEM $0.00
S1002 9 CUSTOM ITEM $0.00
S1015 9 IV TUBING EXTENSION SET $0.00
S1016 9 NON-PVC INTRAVENOUS ADMINIST $0.00
S1025 O INHAL NITRIC OXIDE NEONATE $0.00
S1030 9 GLUC MONITOR PURCHASE $0.00
S1031 9 GLUC MONITOR RENTAL $0.00

S1040 6 CRANIAL REMOLDING ORTHOSIS $0.00
S2050 9 DONOR ENTERECTOMY, WITH PREP $0.00
S2052 9 TRANSPLANTATION OF SMALL INT $0.00
S2053 9 TRANSPLANTATION OF SMALL INT $0.00
S2054 9 TRANSPLANTATION OF MULTIVISC $0.00
S2055 9 HARVESTING OF DONOR MULTIVIS $0.00
S2060 9 LOBAR LUNG TRANSPLANTATION $0.00
S2061 9 DONOR LOBECTOMY (LUNG) $0.00
S2065 9 SIMULT PANC KIDN TRANS $0.00
S2066 9 BREAST GAP FLAP RECONST $0.00

S2067 9 BREAST "STACKED" DIEP/GAP $0.00
S2068 9 BREAST DIEP OR SIEA FLAP $0.00
S2070 9 CYSTO LASER TX URETERAL CALC $0.00
S2075 O LAP INC/VENT HERNIA REPAIR $0.00
S2076 O LAP UMBILICAL HERNIA REPAIR $0.00
S2077 O LAP MESH IMPLANT HERN REP $0.00
S2078 O LAP SUPRACERV HYSTERECTOMY $0.00
S2079 9 LAP ESOPHAGOMYOTOMY $0.00
S2080 9 LAUP $0.00
S2082 O LAP ADJUSTABLE GASTRIC BAND $0.00
S2083 9 ADJUSTMENT GASTRIC BAND $0.00
S2085 O LAPAROSCOP GASTRIC BYPASS $0.00
S2090 O OPEN CRYOSURG RENAL $0.00

S2091 O PERC CRYOSURG RENAL $0.00
S2095 9 TRANSCATH EMBOLIZ MICROSPHER $0.00
S2102 9 ISLET CELL TISSUE TRANSPLANT $0.00
S2103 9 ADRENAL TISSUE TRANSPLANT $0.00
S2107 5 ADOPTIVE IMMUNOTHERAPY $0.00
S2109 9 AUTOLOGOUS CHONDROCYTE TRANS $0.00
S2112 9 KNEE ARTHROSCP HARV $0.00
S2113 O ARTHRO CHONDROCYTE IMPLANT $0.00
S2114 O ARTHROSC SH TENODESIS BICEPS $0.00
S2115 9 PERIACETABULAR OSTEOTOMY $0.00
S2117 9 ARTHROEREISIS, SUBTALAR $0.00
S2118 9 TOTAL HIP RESURFACING $0.00

S2120 9 LOW DENSITY LIPOPROTEIN(LDL) $0.00
S2130 O ERA OF REFLUX SAPHENOUS VEIN $0.00
S2131 O LASER ABLAT SAPHENOUS VEIN $0.00
S2135 O NEUROLYSIS INTERSPACE FOOT $0.00
S2140 9 CORD BLOOD HARVESTING $0.00
S2142 9 CORD BLOOD-DERIVED STEM-CELL $0.00
S2150 9 BMT HARV/TRANSPL 28D PKG $0.00
S2152 9 SOLID ORGAN TRANSPL PKG $0.00
S2180 9 DONOR LEUKOCYTE INFUSION $0.00
S2190 9 SUBCUTANEOUS IMPLANTATION OF $0.00

S2202 9 ECHOSCLEROTHERAPY $0.00
S2204 9 TRANSMYOCARDIAL LASER REVASC $0.00
S2205 9 MINIMALLY INVASIVE DIRECT CO $0.00
S2210 9 CRYOSURGICAL ABLATION (IN SI $0.00
S2211 O TRANSV CAROTID STENT PLACEMT $0.00
S2213 O IMPLANT GASTRIC STIM $0.00
S2215 O UGI ENDOSCOPY INJ IMPLANT $0.00
S2220 9 THROMBECTOMY, CORONARY $0.00
S2225 9 MYRINGOTOMY LASER-ASSIST $0.00

S2230 9 IMPLANT SEMI-IMP HEAR $0.00
S2235 9 IMPLANT AUDITORY BRAIN IMP $0.00
S2250 O UTERINE ARTERY EMBOLIZ $0.00
S2260 9 INDUCED ABORTION 17-24 WEEKS $0.00
S2262 O ABORTION MATERNAL INDIC 25W $0.00
S2265 9 INDUCED ABORTION 25-28 WKS $0.00
S2266 9 INDUCED ABORTION 29-31 WKS $0.00
S2267 9 INDUCED ABORTION 32 OR MORE $0.00
S2270 9 INSERTION VAGINAL CYLINDER $0.00
S2300 9 ARTHROSCOPY, SHOULDER, SURGI $0.00
S2325 6 HIP CORE DECOMPRESSION $0.00
S2340 9 CHEMODENERVATION OF ABDUCTOR $0.00

S2341 9 CHEMODENERV ADDUCT VOCAL $0.00
S2342 9 NASAL ENDOSCOP PO DEBRID $0.00
S2344 9 ENDOSC BALLOON SINUPLASTY $0.00
S2348 9 DECOMPRESS DISC RF LUMBAR $0.00
S2350 9 DISKECTOMY, ANTERIOR, WITH D $0.00
S2351 9 DISKECTOMY, ANTERIOR, WITH D $0.00
S2360 9 VERTEBROPLAST CERV 1ST $0.00
S2361 9 VERTEBROPLAST CERV ADDL $0.00
S2362 O KYPHOPLASTY, FIRST VERTEBRA $0.00
S2363 O KYPHOPLASTY, EACH ADDL $0.00

S2370 O INTRADISCAL ELECTROTHERMAL $0.00
S2371 O EACH ADDITIONAL INTERSPACE $0.00
S2400 5 FETAL SURG CONGEN HERNIA $0.00
S2401 9 FETAL SURG URIN TRAC OBSTR $0.00
S2402 9 FETAL SURG CONG CYST MALF $0.00
S2403 9 FETAL SURG PULMON SEQUEST $0.00
S2404 9 FETAL SURG MYELOMENINGO $0.00
S2405 5 FETAL SURG SACROCOC TERATOMA $0.00
S2409 9 FETAL SURG NOC $0.00
S2411 9 FETOSCOP LASER THER TTTS $0.00
S2900 9 ROBOTIC SURGICAL SYSTEM $0.00
S3000 9 BILAT DIL RETINAL EXAM $0.00
S3005 9 EVAL SELF-ASSESS DEPRESSION $0.00

S3600 9 STAT LAB $0.00
S3601 9 STAT LAB HOME/NF $0.00
S3620 9 NEWBORN METABOLIC SCREENING $0.00
S3625 9 MATERNAL TRIPLE SCREEN TEST $0.00
S3626 9 MATERNAL SERUM QUAD SCREEN $0.00
S3628 6 PLACENTAL ALPHA MICROGLOBULIN-1RAP $0.00
S3630 9 EOSINOPHIL BLOOD COUNT $0.00
S3645 9 HIV-1 ANTIBODY TESTING OF OR $0.00
S3650 9 SALIVA TEST, HORMONE LEVEL; $0.00
S3652 9 SALIVA TEST, HORMONE LEVEL; $0.00
S3655 9 ANTISPERM ANTIBODIES TEST $0.00
S3700 9 BLADDER TUMOR-ASSOCIATED $0.00

S3701 O NMP-22 ASSAY $0.00
S3708 9 GASTROINTESTINAL FAT ABSORPT $0.00
S3711 9 CIRCULATING TUMOR CELL TEST $0.00
S3800 9 GENETIC TESTING ALS $0.00
S3818 9 BRCA1 GENE ANAL $0.00
S3819 9 BRCA2 GENE ANAL $0.00
S3820 9 COMP BRCA1/BRCA2 $0.00
S3822 9 SING MUTATION BRST/OVAR $0.00
S3823 9 3 MUTATION BRST/OVAR $0.00
S3828 9 COMP MLH1 GENE $0.00

S3829 9 COMP MLH2 GENE $0.00
S3830 9 GENE TEST HNPCC COMP $0.00
S3831 9 GENE TEST HNPCC SINGLE $0.00
S3833 9 COMP APC SEQUENCE $0.00
S3834 9 SING MUTATION APC $0.00
S3835 9 GENE TEST CYSTIC FIBROSIS $0.00
S3837 9 GENE TEST HEMOCHROMATO $0.00
S3840 9 DNA ANALYSIS RET-ONCOGENE $0.00
S3841 9 GENE TEST RETINOBLASTOMA $0.00
S3842 9 GENE TEST HIPPEL-LINDAU $0.00
S3843 9 DNA ANALYSIS FACTOR V $0.00
S3844 9 DNA ANALYSIS DEAFNESS $0.00
S3845 9 GENE TEST ALPHA-THALASSEMIA $0.00

S3846 9 GENE TEST BETA-THALASSEMIA $0.00
S3847 9 GENE TEST TAY-SACHS $0.00
S3848 9 GENE TEST GAUCHER $0.00
S3849 9 GENE TEST NIEMANN-PICK $0.00
S3850 9 GENE TEST SICKLE CELL $0.00
S3851 9 GENE TEST CANAVAN $0.00
S3852 9 DNA ANALYSIS APOE ALZHEIMER $0.00
S3853 9 GENE TEST MYO MUSCLR DYST $0.00
S3854 9 GENE PROFILE PANEL BREAST $0.00
S3855 9 GENE TEST PRESENILIN-1 GENE $0.00
S3860 9 GENET TEST CARDIAC ION-COMP $0.00
S3861 9 GENETIC TEST BRUGADA $0.00

S3862 9 GENET TEST CARDIAC ION-SPEC $0.00
S3890 9 FECAL DNA ANALYSIS $0.00
S3900 9 SURFACE EMG $0.00
S3902 9 BALLISTOCARDIOGRAM $0.00
S3904 9 MASTERS TWO STEP $0.00
S3905 9 AUTO HANDHELD DIAG NERV TEST $0.00
S3906 9 TRANSFUSION, DIRECT, BLOOD $0.00
S4005 9 INTERIM LABOR FACILITY GLOBA $0.00
S4011 9 IVF PACKAGE $0.00
S4013 9 COMPL GIFT CASE RATE $0.00

S4014 9 COMPL ZIFT CASE RATE $0.00
S4015 9 COMPLETE IVF NOS CASE RATE $0.00
S4016 9 FROZEN IVF CASE RATE $0.00
S4017 9 IVF CANC A STIM CASE RATE $0.00
S4018 9 F EMB TRNS CANC CASE RATE $0.00
S4020 9 IVF CANC A ASPIR CASE RATE $0.00
S4021 9 IVF CANC P ASPIR CASE RATE $0.00
S4022 9 ASST OOCYTE FERT CASE RATE $0.00
S4023 9 INCOMPL DONOR EGG CASE RATE $0.00
S4025 9 DONOR SERV IVF CASE RATE $0.00
S4026 9 PROCURE DONOR SPERM $0.00
S4027 9 STORE PREV FROZ EMBRYOS $0.00
S4028 9 MICROSURG EPI SPERM ASP $0.00

S4030 9 SPERM PROCURE INIT VISIT $0.00
S4031 9 SPERM PROCURE SUBS VISIT $0.00
S4035 9 STIMULATED IUI CASE RATE $0.00
S4036 O INTRAVAG CULT CASE RATE $0.00
S4037 9 CRYO EMBRYO TRANSF CASE RATE $0.00
S4040 9 MONIT STORE CRYO EMBRYO 30 D $0.00
S4042 9 OVULATION MGMT PER CYCLE $0.00
S4386 O EARLY INTERVENTION $0.00
S4516 O MULTI-DISCIPLINARY ASSESSMENT/EVALU $0.00
S4518 5 ENVIROMENTAL LEAD TESTING $0.00
S4981 9 INSERT LEVONORGESTREL IUS $0.00
S4989 9 CONTRACEPT IUD $0.00

S4990 9 NICOTINE PATCH LEGEND $0.00
S4991 9 NICOTINE PATCH NONLEGEND $0.00
S4993 9 CONTRACEPTIVE PILLS FOR BC $0.00
S4995 9 SMOKING CESSATION GUM $0.00
S5000 9 PRESCRIPTION DRUG, GENERIC $0.00
S5001 9 PRESCRIPTION DRUG,BRAND NAME $0.00
S5002 9 FAT EMULSION 10% IN 250 ML $0.00
S5003 9 FAT EMULSION 20% IN 250 ML $0.00
S5010 9 5% DEXTROSE AND 0.45% SALINE $0.00
S5011 9 5% DEXTROSE IN LACTATED RING $0.00

S5012 9 5% DEXTROSE WITH POTASSIUM $0.00
S5013 9 5%DEXTROSE/0.45%SALINE1000ML $0.00
S5014 9 D5W/0.45NS W KCL AND MGS04 $0.00
S5016 9 ANTIBIOTIC ADMIN SUPPLIES W/ $0.00
S5017 9 ANTIBIOTIC ADMINSUPPLIES W/O $0.00
S5018 9 PAIN THERAPY ADMIN SUPPLIES $0.00
S5019 9 CHEMOTHERAPY ADMIN SUPPLIES $0.00
S5020 9 CHEMOTHERAPY ADMIN SUPPLIES $0.00
S5021 9 HYDRATION THERAPY ADMIN SUPP $0.00
S5022 9 GROWTH HORMONE THERAPY $0.00
S5025 9 INFUSION PUMP RENTAL,PERDIEM $0.00
S5035 9 HIT ROUTINE DEVICE MAINT $0.00
S5036 9 HIT DEVICE REPAIR $0.00

S5100 9 ADULT DAYCARE SERVICES 15 MIN $0.00
S5101 7 ADULT DAY CARE PER HALF DAY $0.00
S5102 7 ADULY DAY CARE PER DIEM $0.00
S5105 7 CENTERBASED DAYCARE PERDIEM $0.00
S5108 9 HOMECARE TRAIN PT 15 MIN $0.00
S5109 9 HOMECARE TRAIN PT SESSION $0.00
S5110 9 FAMILY HOMECARE TRAINING 15M $0.00
S5111 9 FAMILY HOMECARE TRAIN SESSION $0.00
S5115 9 NONFAMILY HOMECARE TRAIN 15M $0.00
S5116 9 NON FAMILY HC TRAIN SESSION $0.00
S5120 9 CHORE SERVICES PER 15 MIN $0.00
S5121 9 CHORE SERVICES PER DIEM $0.00

S5125 9 ATTENDANT CARE SERVICES 15 M $0.00
S5126 9 ATTENDANT CARE SERVICE 15M $0.00
S5130 7 HOMAKER SERVICE NOS PER 15M $0.00
S5131 9 HOMEMAKER SERVICE NOS PER 15 M $0.00
S5135 9 ADULT COMPANION CARE PER 15M $0.00
S5136 9 ADULT COMPANION CARE PER DIEM $0.00
S5140 7 ADULT FOSTER CARE PER DIEM $0.00
S5141 9 ADULT FOSTER CARE PER MONTH $0.00
S5145 7 CHILD FOSTERCARE TH PER DIEM $0.00
S5146 9 THER FOSTERCARE CHILD MONTH $0.00

S5150 9 UNSKILLED RESPITE CARE 15M $0.00
S5151 9 UNSKILLED RESPIT CARE DIEM $0.00
S5160 7 EMERGENCY RESPONSE SYSTEM ERS INST $0.00
S5161 7 EMERGENCY RESPONSE SYSTEM ERS PER $0.00
S5162 7 EMERGENCY RESPONSE SYSTEM PURCHASE $0.00
S5165 5 HOME MODIFICATIONS PER SERV $0.00
S5170 9 HOMEDELIVERED PREPARED MEAL $0.00
S5175 9 LAUNDRY SERV EXT PROF ORDER $0.00
S5180 9 HH RESPIRATORY THRPY IN EVAL $0.00
S5181 9 HH RESIRATORY THRPY NOS DAY $0.00
S5185 9 MED REMINDER SER PER MONTH $0.00
S5190 6 WELLNESS ASSESSMENT BY NONPH $0.00
S5199 9 PERSONAL CARE ITEM NOS EACH $0.00

S5497 9 HIT CATH CARE NOC $0.00
S5498 9 HIT SIMPLE CATH CARE $0.00
S5501 9 HIT COMPLEX CATH CARE $0.00
S5502 9 HIT INTERIM CATH CARE $0.00
S5503 9 MAINTENANCE OF IMPLANTED VAS $0.00
S5517 9 HIT DECLOTTING KIT $0.00
S5518 9 HIT CATH REPAIR KIT $0.00
S5520 9 HIT PICC INSERT KIT $0.00
S5521 9 HIT MIDLINE CATH INSERT KIT $0.00
S5522 9 HIT PICC INSERT NO SUPP $0.00
S5523 9 HIP MIDLINE CATH INSERT KIT $0.00
S5550 6 INSULIN RAPID 5 U $0.00

S5551 6 INSULIN MOST RAPID 5 U $0.00
S5552 6 INSULIN INTERMED 5 U $0.00
S5553 6 INSULIN LONG ACTING 5 U $0.00
S5560 6 INSULIN REUSE PEN 1.5 ML $0.00
S5561 6 INSULIN REUSE PEN 3 ML $0.00
S5565 9 INSULIN CARTRIDGE 150 U $0.00
S5566 9 INSULIN CARTRIDGE 300 U $0.00
S5570 9 INSULIN DISPOS PEN 1.5 ML $0.00
S5571 9 INSULIN DISPOS PEN 3 ML $0.00
S8001 9 RADIOFREQUENCY STIMULATION $0.00

S8004 O WHOLEBODY RADIOPHARM TRGCELL $0.00
S8030 9 TANTALUM RING APPLICATION $0.00
S8035 9 MAGNETIC SOURCE IMAGING $0.00
S8037 9 MRCP $0.00
S8040 9 TOPOGRAPHIC BRAIN MAPPING $0.00
S8042 5 MRI LOW FIELD $0.00
S8048 9 ISOLATED LIMB PERFUSION $0.00
S8049 9 INTRAOPERATIVE RADIATION THE $0.00
S8055 9 US GUIDANCE FETAL REDUCT $0.00
S8060 9 SUPPLY OF CONTRAST MATERIAL $0.00
S8075 O CAD OF DIGITAL MAMMOGR $0.00
S8080 9 SCINTIMAMMOGRAPHY $0.00
S8085 9 FLUORINE-18 FLUORODEOXYGLUCO $0.00

S8092 9 ELECTRON BEAM COMPUTED TOMOG $0.00
S8093 O CT ANGIOGRAPHY CORONARY $0.00
S8095 O WIG (FOR MEDICALLY-INDUCED H $0.00
S8096 9 PORTABLE PEAK FLOW METER $0.00
S8097 9 ASTHMA KIT $0.00
S8100 9 SPACER WITHOUT MASK $0.00
S8101 9 SPACER WITH MASK $0.00
S8105 O OXIMETER FOR MEASURING BLOOD $0.00
S8110 9 PEAK EXPIRATORY FLOW RATE (P $0.00
S8120 9 O2 CONTENTS GAS CUBIC FT $0.00
S8121 9 O2 CONTENTS LIQUID LB $0.00
S8180 O TRACH SHOWER PROTECTOR $0.00

S8181 O TRACH TUBE HOLDER $0.00
S8182 O HUMIDIFIER NON-SERVO $0.00
S8183 O HUMIDIFIER DUAL SERVO $0.00
S8185 9 FLUTTER DEVICE $0.00
S8186 9 SWIVEL ADAPTOR $0.00
S8189 9 TRACH SUPPLY NOC $0.00
S8190 9 ELECTRONIC SPIROMETER $0.00
S8200 9 CHEST COMPRESSION VEST $0.00
S8205 9 CHEST COMPRESSION SYSTEM GEN $0.00
S8210 9 MUCUS TRAP $0.00

S8260 O ORAL ORTHOTIC FOR TREATMENT $0.00
S8262 5 MANDIB ORTHO REPOS DEVICE $0.00
S8265 5 HABERMAN FEEDER $0.00
S8270 9 ENURESIS ALARM $0.00
S8300 9 SACRAL NERVE STIMULATION TES $0.00
S8301 9 INFECT CONTROL SUPPLIES NOS $0.00
S8400 9 INCONTINENCE PANTS, EACH $0.00
S8401 O CHILD-SIZE DIAPER $0.00
S8402 9 DIAPERS, EACH $0.00
S8403 O ADULT-SIZE PULL-UP BRIEF $0.00
S8404 9 CHILD-SIZE PULL-UP BRIEF $0.00
S8405 O INCONTINENCE LINERS, EACH $0.00
S8415 9 SUPPLIES FOR HOME DELIVERY $0.00

S8420 9 CUSTOM GRADIENT SLEEV/GLOV $0.00
S8421 9 READY GRADIENT SLEEV/GLOV $0.00
S8422 9 CUSTOM GRAD SLEEVE MED $0.00
S8423 9 CUSTOM GRAD SLEEVE HEAVY $0.00
S8424 9 READY GRADIENT SLEEVE $0.00
S8425 9 CUSTOM GRAD GLOVE MED $0.00
S8426 9 CUSTOM GRAD GLOVE HEAVY $0.00
S8427 9 READY GRADIENT GLOVE $0.00
S8428 9 READY GRADIENT GAUNTLET $0.00
S8429 9 GRADIENT PRESSURE WRAP $0.00
S8430 9 PADDING FOR COMPRSSN BDG $0.00
S8431 9 COMPRESSION BANDAGE $0.00

S8433 O SKIN SUPPORT/BREAST PROSTH $0.00
S8450 9 SPLINT DIGIT $0.00
S8451 9 SPLINT WRIST OR ANKLE $0.00
S8452 9 SPLINT ELBOW $0.00
S8460 9 CAMISOLE POST-MAST $0.00
S8490 9 100 INSULIN SYRINGES $0.00
S8940 9 HIPPOTHERAPY PER SESSION $0.00
S8945 O PT PHONOPHORESIS 30 MINS $0.00
S8948 6 LOW-LEVEL LASER TRMT 15 MIN $0.00
S8950 9 COMPLEX LYMPHEDEMA THERAPY, $0.00

S8990 9 PT OR MANIP FOR MAINT $0.00
S8999 9 RESUSCITATION BAG $0.00
S9001 9 HOME UTERINE MONITOR WITH OR $0.00
S9007 9 ULTRAFILTRATION MONITOR $0.00
S9015 9 AUTOMATED EEG MONITORING $0.00
S9022 O DIGITAL SUBTRACTION ANGIOGRA $0.00
S9023 9 XENON REGIONAL CEREBRAL BLOO $0.00
S9024 9 PARANASAL SINUS ULTRASOUND $0.00
S9025 9 OMNICARDIOGRAM/CARDIOINTEGRA $0.00
S9033 9 GAIT ANALYSIS $0.00
S9034 5 ESWL FOR GALLSTONES $0.00
S9035 9 MEDICAL EQUIPMENT OR SUPPLIE $0.00
S9055 9 PROCUREN OR OTHER GROWTH FAC $0.00

S9056 9 COMA STIMULATION PER DIEM $0.00
S9061 9 MEDICAL SUPPLIES AND EQUIPME $0.00
S9075 9 SMOKING CESSATION TREATMENT $0.00
S9083 7 URGENT CARE CENTER GLOBAL $0.00
S9085 9 MENISCAL ALLOGRAFT TRANSPLAN $0.00
S9088 9 SERVICES PROVIDED IN URGENT $0.00
S9090 9 VERTEBRAL AXIAL DECOMPRESSIO $0.00
S9092 O CANOLITH REPOSITIONING $0.00
S9097 9 HOME VISIT WOUND CARE $0.00
S9098 9 HOME PHOTOTHERAPY VISIT $0.00
S9105 5 EVALUATION BY OCULARIST $0.00
S9109 9 CHF TELEMONITORING MONTH $0.00

S9117 9 BACK SCHOOL VISIT $0.00
S9122 7 HOME HEALTH AIDE OR CERTIFIE $0.00
S9123 3 NURSING CARE IN HOME RN $51.50
S9124 3 NURSING CARE, IN THE HOME; B $46.14
S9125 7 RESPITE CARE, IN THE HOME, P $0.00
S9126 9 HOSPICE CARE, IN THE HOME, P $0.00
S9127 7 SOCIAL WORK VISIT, IN THE HO $0.00
S9128 3 SPEECH THERAPY, IN THE HOME, $43.50
S9129 3 OCCUPATIONAL THERAPY, IN THE $43.50
S9131 3 PT IN THE HOME PER DIEM $43.50

S9140 9 DIABETIC MANAGEMENT PROGRAM, $0.00
S9145 5 INSULIN PUMP INITIATION $0.00
S9152 9 SPEECH THERAPY, RE-EVAL $0.00
S9200 9 NURSING SERVICES AND ALL NEC $0.00
S9208 9 HOME MGMT PRETERM LABOR $0.00
S9209 9 HOME MGMT PPROM $0.00
S9211 5 HOME MGMT GEST HYPERTENSION $0.00
S9212 9 HM POSTPAR HYPER PER DIEM $0.00
S9213 9 HM PREECLAMP PER DIEM $0.00
S9214 9 HM GEST DM PER DIEM $0.00
S9216 9 GEST HYPER W NURS DIEM $0.00

S9217 9 POSTPAR HYPER W NURS DIEM $0.00
S9218 9 PREECLAMP W NURS DIEM $0.00
S9325 9 HIT PAIN MGMT PER DIEM $0.00
S9326 9 HIT CONT PAIN PER DIEM $0.00
S9327 9 HIT INT PAIN PER DIEM $0.00
S9328 9 HIT PAIN IMP PUMP DIEM $0.00

S9329 9 HIT CHEMO PER DIEM $0.00
S9330 9 HIT CONT CHEM DIEM $0.00
S9331 9 HIT INTERMIT CHEMO DIEM $0.00
S9335 9 HT HEMODIALYSIS DIEM $0.00
S9336 9 HIT CONT ANTICOAG DIEM $0.00
S9338 9 HIT IMMUNOTHERAPY DIEM $0.00
S9339 9 HIT PERITON DIALYSIS DIEM $0.00
S9340 9 HIT ENTERAL PER DIEM $0.00
S9341 9 HIT ENTERAL GRAV DIEM $0.00
S9342 9 HIT ENTERAL PUMP DIEM $0.00

S9343 9 HIT ENTERAL BOLUS NURS $0.00
S9345 9 HIT ANTI-HEMOPHIL DIEM $0.00
S9346 9 HIT ALPHA-1-PROTEINAS DIEM $0.00
S9347 9 HIT LONGTERM INFUSION DIEM $0.00
S9348 9 HIT SYMPATHOMIM DIEM $0.00
S9349 9 HIT TOCOLYSIS DIEM $0.00
S9351 9 HIT CONT ANTIEMETIC DIEM $0.00
S9353 9 HIT CONT INSULIN DIEM $0.00
S9355 9 HIT CHELATION DIEM $0.00
S9357 9 HIT ENZYME REPLACE DIEM $0.00
S9359 9 HIT ANTI-TNF PER DIEM $0.00
S9361 9 HIT DIURETIC INFUS DIEM $0.00
S9363 9 HIT ANTI-SPASMOTIC DIEM $0.00

S9364 9 HIT TPN TOTAL DIEM $0.00
S9365 9 HIT TPN 1 LITER DIEM $0.00
S9368 9 HIT TPN OVER 3L DIEM $0.00
S9370 9 HT INJ ANTIEMETIC DIEM $0.00
S9372 9 HT INJ ANTICOAG DIEM $0.00
S9373 9 HIT HYDRA TOTAL DIEM $0.00
S9374 9 HIT HYDRA 1 LITER DIEM $0.00
S9377 9 HIT HYDRA OVER 3L DIEM $0.00

S9379 9 HIT NOC PER DIEM $0.00
S9381 9 HIT HIGH RISK/ESCORT $0.00
S9401 9 ANTICOAG CLINIC PER SESSION $0.00
S9423 9 NURSING SERVICES, PATIENT AS $0.00
S9430 9 PHARMACY COMP/DISP SERV $0.00
S9433 9 MEDICAL FOOD ORAL 100% NUTR $0.00
S9434 6 MOD SOLID FOOD SUPPL $0.00

S9435 9 MEDICAL FOODS FOR INBORN ERR $0.00
S9436 9 LAMAZE CLASS $0.00
S9437 9 CHILDBIRTH REFRESHER CLASS $0.00
S9438 9 CESAREAN BIRTH CLASS $0.00
S9439 9 VBAC CLASS $0.00
S9441 9 ASTHMA EDUCATION $0.00
S9442 9 BIRTHING CLASS $0.00
S9443 9 LACTATION CLASS $0.00
S9444 9 PARENTING CLASS $0.00
S9445 7 PT EDUCATION NOC INDIVID $0.00
S9446 9 PT EDUCATION NOC GROUP $0.00
S9447 9 INFANT SAFETY CLASS $0.00
S9449 9 WEIGHT MGMT CLASS $0.00

S9451 9 EXERCISE CLASS $0.00
S9452 9 NUTRITION CLASS $0.00
S9453 9 SMOKING CESSATION CLASS $0.00
S9454 9 STRESS MGMT CLASS $0.00
S9470 3 NUTRITIONAL COUNSELING, DIET $44.00
S9472 9 CARDIAC REHABILITATION PROGR $0.00
S9473 9 PULMONARY REHABILITATION PRO $0.00
S9474 9 ENTEROSTOMAL THERAPY BY A RE $0.00
S9475 9 AMBULATORY SETTING SUBSTANCE $0.00

S9476 9 VESTIBULAR REHAB PER DIEM $0.00
S9480 9 INTENSIVE OUTPATIENT PSYCHIA $0.00
S9482 9 FAMILY STABILIZATION 15 MIN $0.00
S9484 7 CRISIS INTERVENTION PER HOUR $0.00
S9485 9 CRISIS INTERVENTION MENTAL H $0.00
S9490 9 HIT CORTICOSEROID DIEM $0.00
S9494 9 HIT ANTIBIOTIC TOTAL DIEM $0.00
S9497 9 HIT ANTIBIOTIC Q3H DIEM $0.00

S9524 O NURSING SERVICES RELATED TO $0.00
S9526 9 SKILLED NURSING VISITS FOR $0.00
S9527 9 INSERTION OF A PERIPHERALLY $0.00
S9528 9 INSERTION OF MIDLINE CENTRAL $0.00
S9529 9 VENIPUNCTURE HOME/SNF $0.00
S9533 9 PAIN MANAGEMENT, INTRAVENOUS $0.00
S9535 9 ADMINISTRATION OF HEMATOPOIE $0.00
S9537 9 HT HEM HORM INJ DIEM $0.00
S9538 9 HIT BLOOD PRODUCTS DIEM $0.00
S9539 9 ADMINISTRATION OF ANTIBIOTIC $0.00

S9542 9 HT INJ NOC PER DIEM $0.00
S9543 O ADMINISTRATION OF MEDICATION $0.00
S9545 9 ADMINISTRATION OF IMMUNE GLO $0.00
S9546 O HOME INF BLOOD PROD NURS SER $0.00
S9550 9 HOME IV THERAPY, HYDRATION $0.00
S9555 9 ADDITIONAL HOME INFUSION $0.00
S9558 9 HT INJ GROWTH HORM DIEM $0.00
S9559 9 HIT INJ INTERFERON DIEM $0.00
S9560 9 HT INJ HORMONE DIEM $0.00
S9562 9 PALIVIZUMAB HOME INJ PERDIEM $0.00
S9590 9 IN HOME IRRIGATION THERAPY $0.00
S9800 9 HT RN PER HOUR $0.00

S9802 O SPECIALTY DRUG ADMIN/NSG SRV $0.00
S9803 O EACH ADDITIONAL HOUR $0.00
S9806 O RN INFUSION SUITE VISIT $0.00
S9810 9 HT PHARM PER HOUR $0.00
S9900 9 CHRISTIAN SCI PRACT VISIT $0.00
S9970 9 HEALTH CLUB MEMBERSHIP YR $0.00
S9975 9 TRANSPLANT RELATED PER DIEM $0.00
S9976 9 LODGING PER DIEM $0.00
S9977 9 MEALS PER DIEM $0.00
S9981 9 MED RECORD COPY ADMIN $0.00

S9982 9 MED RECORD COPY PER PAGE $0.00
S9986 9 NOT MEDICALLY NECESSARY SVC $0.00
S9988 9 SERV PART OF PHASE I TRIAL $0.00
S9989 9 SERVICES OUTSIDE US $0.00
S9990 9 SERVICES PROVIDED AS PART OF $0.00
S9991 9 SERVICES PROVIDED AS PART OF $0.00
S9992 9 TRANSPORTATION COSTS TO AND $0.00
S9994 9 LODGING COSTS (E.G. HOTEL CH $0.00
S9996 9 MEALS FOR CLINICAL TRIAL PAR $0.00
S9999 9 SALES TAX $0.00
SARCW O MCO SPECIFIC CODE: SMART START SUBS $0.00
SARRN O MCO SPECIFIC CODE: SMART START SUBS $0.00
SARSW O MCO SPECIFIC CODE: SMART START SUBS $0.00

T1000 7 PRIVATE DUTY/INDEPENDENT NSG $0.00
T1001 7 NURSING ASSESSMENT/EVALUATN $0.00
T1002 3 RN SERVICES UP TO 15 MINUTES $19.00
T1003 9 LPN/LVN SERVICES UP TO 15MIN $0.00
T1004 9 NSG AIDE SERVICE UP TO 15MIN $0.00
T1005 7 RESPITE CARE SERVICE 15 MIN $0.00
T1006 9 FAMILY/COUPLE COUNSELING $0.00
T1007 9 TREATMENT PLAN DEVELOPMENT $0.00
T1008 O DAY TREATMENT FOR INDIVIDUAL $0.00
T1009 9 CHILD SITTING SERVICES $0.00
T1010 9 MEALS WHEN RECEIVE SERVICES $0.00
T1011 O ALCOHOL/SUBSTANCE ABUSE NOC $0.00

T1012 9 ALCOHOL/SUBSTANCE ABUSE SKIL $0.00
T1013 9 SIGN LANG/ORAL INTERPRETER $0.00
T1014 9 TELEHEALTH TRANSMIT, PER MIN $0.00
T1015 9 CLINIC SERVICE $0.00
T1016 9 CASE MANAGEMENT $0.00
T1017 9 TARGETED CASE MANAGEMENT $0.00
T1018 9 SCHOOL-BASED IEP SER BUNDLED $0.00
T1019 9 PERSONAL CARE SER PER 15 MIN $0.00
T1020 9 PERSONAL CARE SER PER DIEM $0.00
T1021 9 HH AIDE OR CN AIDE PER VISIT $0.00

T1022 9 CONTRACTED SERVICES PER DAY $0.00
T1023 7 PROGRAM INTAKE ASSESSMENT $0.00
T1024 3 TEAM EVALUATION & MANAGEMENT $1,429.81
T1025 9 PED COMPR CARE PKG, PER DIEM $0.00
T1026 9 PED COMPR CARE PKG, PER HOUR $0.00
T1027 9 FAMILY TRAINING & COUNSELING $0.00
T1028 9 HOME ENVIRONMENT ASSESSMENT $0.00
T1029 5 DWELLING LEAD INVESTIGATION $0.00
T1030 9 RN HOME CARE PER DIEM $0.00
T1031 9 LPN HOME CARE PER DIEM $0.00
T1500 O REUSABLE DIAPER/PANT $0.00
T1502 9 MEDICATION ADMIN VISIT $0.00
T1503 9 MED ADMIN, NOT ORAL/INJECT $0.00

T1999 9 NOC RETAIL ITEMS ANDSUPPLIES $0.00
T2001 3 NONEMERGENCY TRANSPORTATION ATTEND $10.10
T2002 7 N-ET; PER DIEM $0.00
T2003 3 NON-EMERGENCY TRANSPORTATION; ENCOU $10.10
T2004 9 N-ET; COMMERC CARRIER PASS $0.00
T2005 9 N-ET; STRETCHER VAN $0.00
T2006 O AMB RESPONSE & TRT, NO TRANS $0.00
T2007 9 NON-EMER TRANSPORT WAIT TIME $0.00
T2010 9 PASRR LEVEL I $0.00
T2011 9 PASRR LEVEL II $0.00
T2012 9 HABIL. ED. WAIVER; PER DIEM $0.00
T2013 9 HABIL. ED. WAIVER, PER HOUR $0.00

T2014 7 HABIL. PREVOC WAIVER, PER D $0.00
T2015 7 HABIL. PREVOC WAIVER PER HR $0.00
T2016 7 HABIL., RES. WAIVER PER DIEM $0.00
T2017 9 HABIL., RES. WAIVER 15 MIN $0.00
T2018 7 HABIL. SUP EMPL WAIVER/DAY $0.00
T2019 9 HABIL. SUP EMPL WAIVER 15 MIN $0.00
T2020 7 DAY HABIL WAIVER PER DIEM $0.00
T2021 7 DAY HABIL WAIVER PER 15 MIN $0.00
T2022 7 CASE MANAGEMENT, PER MONTH $0.00
T2023 9 TARGETED CASE MGMT PER MONTH $0.00

T2024 9 SERV ASMNT/CARE PLAN WAIVER $0.00
T2025 7 WAIVER SERVICE, NOS $0.00
T2026 9 SPECIAL CHILDCARE WAIVER/D $0.00
T2027 9 SPEC CHILDCARE WAIVER 15 MIN $0.00
T2028 9 SPECIAL SUPPLY, NOS WAIVER $0.00
T2029 9 SPECIAL MED EQUIP, NOS WAIVER $0.00
T2030 9 ASSIST LIVING WAIVER/MONTH $0.00
T2031 9 ASSIST LIVING WAIVER/D $0.00
T2032 9 RES CARE, NOS WAIVER/MONTH $0.00
T2033 7 RES, NOS WAIVER PER DIEM $0.00
T2034 9 CRISIS INTERVEN WAIVER/D $0.00
T2035 9 UTILITY SERVICES WAIVER $0.00
T2036 9 CAMP OVERNITE WAIVER/SESSION $0.00

T2037 9 CAMP DAY WAIVER/SESSION $0.00
T2038 9 COMM TRANS WAIVER/SERVICE $0.00
T2039 9 VEHICLE MOD WAIVER/SERVICE $0.00
T2040 9 FINANCIAL MGT WAIVER/15 MIN $0.00
T2041 9 SUPPORT BROKER WAIVER/15 MIN $0.00
T2042 9 HOSPICE ROUTINE HOME CARE $0.00
T2043 9 HOSPICE CONTINUOUS HOME CARE $0.00
T2044 9 HOSPICE RESPITE CARE $0.00
T2045 9 HOSPICE GENERAL CARE $0.00
T2046 9 HOSPICE LONG TERM CARE, R&B $0.00
T2048 9 BH LTC RES R&B, PER DIEM $0.00
T2049 9 N-ET; STRETCHER VAN, MILEAGE $0.00

T2101 9 BREAST MILK PROC/STORE/DIST $0.00
T4521 3 ADULT SIZE BRIEF/DIAPER SM $0.50
T4522 3 ADULT SIZE BRIEF/DIAPER MED $0.50
T4523 3 ADULT SIZE BRIEF/DIAPER LG $0.74
T4524 3 ADULT SIZE BRIEF/DIAPER XL $0.88
T4525 3 ADULT SIZE PULL-ON SM $0.50
T4526 3 ADULT SIZE PULL-ON MED $0.50
T4527 3 ADULT SIZE PULL-ON LG $0.74
T4528 3 ADULT SIZE PULL-ON XL $0.88
T4529 3 PED SIZE BRIEF/DIAPER SM/MED $0.25

T4530 3 PED SIZE BRIEF/DIAPER LG $0.37
T4531 3 PED SIZE PULL-ON SM/MED $0.25
T4532 3 PED SIZE PULL-ON LG $0.37
T4533 3 YOUTH SIZE BRIEF/DIAPER $0.47
T4534 3 YOUTH SIZE PULL-ON $0.47
T4535 3 DISPOSABLE LINER/SHIELD/PAD $0.33
T4536 9 REUSABLE PULL-ON ANY SIZE $0.00
T4537 9 REUSABLE UNDERPAD BED SIZE $0.00
T4538 9 DIAPER SERV REUSABLE DIAPER $0.00
T4539 9 REUSE DIAPER/BRIEF ANY SIZE $0.00
T4540 9 REUSABLE UNDERPAD CHAIR SIZE $0.00
T4541 3 LARGE DISPOSABLE UNDERPAD $0.54
T4542 3 SMALL DISPOSABLE UNDERPAD $0.20

T4543 6 DISP BARIATRIC BRIEF/DIAPER $0.00
T5001 6 POSITION SEAT SPEC ORTH NEED $0.00
T5999 9 SUPPLY, NOS $0.00
TBEVL O MCO SPECIFIC CODE: DPH INITIAL EVAL $0.00
TBTXA O MCO SPECIFIC CODE: DPH TB TREATMENT $0.00
TBTXS O MCO SPECIFIC CODE: DPH TB TREATMENT $0.00
TI10H O PART C SPECIFIC CODE: INTERPERIODIC $0.00
TI13H 7 PART C SPECIFIC CODE: INTERPERIODIC $0.00
TI420 O MCO SPECIFIC CODE: INTERPERIODIC CO $0.00
TI42H O INTERPERIODIC CONSULTATION BY A PHY $0.00

TI43H O INTERPERIODIC CONSULTATION BY A OCC $0.00
TI44H O INTERPERIODIC CONSULTATION BY A SPE $0.00
TV10H O PART C SPECIFIC CODE: TREATMENT VIS $0.00
TV420 O MCO SPECIFIC CODE: TRANSDISCIPLINAR $0.00
TV42H O TRANSDISCIPLINARY VISIT BY A PHYSIC $0.00

TV43H O TRANSDISCIPLINARY VISIT BY A OCCUPA $0.00
TV44H O TRANSDISCIPLINARY VISIT BY A SPEECH $0.00
V2020 3 VISION SVCS FRAMES PURCHASES $49.74
V2025 6 EYEGLASSES DELUX FRAMES $0.00
V2100 3 LENS SPHER SINGLE PLANO 4.00 $38.15
V2101 3 SINGLE VISN SPHERE 4.12-7.00 $40.00
V2102 3 SINGL VISN SPHERE 7.12-20.00 $58.93
V2103 3 SPHEROCYLINDR 4.00D/12-2.00D $35.97
V2104 3 SPHEROCYLINDR 4.00D/2.12-4D $38.98
V2105 3 SPHEROCYLINDER 4.00D/4.25-6D $43.37
V2106 3 SPHEROCYLINDER 4.00D/>6.00D $48.13
V2107 3 SPHEROCYLINDER 4.25D/12-2D $44.62

V2110 3 SPHEROCYLINDER 4.25D/OVER 6D $51.74
V2111 3 SPHEROCYLINDR 7.25D/.25-2.25 $53.06
V2114 3 SPHEROCYLINDER OVER 12.00D $71.89
V2115 3 LENS LENTICULAR BIFOCAL $63.63
V2116 O NONASPHERIC LENS BIFOCAL $0.00
V2117 O ASPHERIC LENS BIFOCAL $0.00
V2118 3 LENS ANISEIKONIC SINGLE $77.56
V2121 6 LENTICULAR LENS, SINGLE $0.00

V2199 6 LENS SINGLE VISION NOT OTH C $0.00
V2200 3 LENS SPHER BIFOC PLANO 4.00D $52.57
V2201 3 LENS SPHERE BIFOCAL 4.12-7.0 $57.57
V2202 3 LENS SPHERE BIFOCAL 7.12-20. $69.55
V2203 3 LENS SPHCYL BIFOCAL 4.00D/.1 $54.25
V2204 3 LENS SPHCY BIFOCAL 4.00D/2.1 $57.19
V2205 3 LENS SPHCY BIFOCAL 4.00D/4.2 $61.83
V2206 3 LENS SPHCY BIFOCAL 4.00D/OVE $66.43
V2207 3 LENS SPHCY BIFOCAL 4.25-7D/. $58.71
V2208 3 LENS SPHCY BIFOCAL 4.25-7/2. $62.97

V2209 3 LENS SPHCY BIFOCAL 4.25-7/4. $67.36
V2210 3 LENS SPHCY BIFOCAL 4.25-7/OV $75.32
V2211 3 LENS SPHCY BIFO 7.25-12/.25- $72.60
V2212 3 LENS SPHCYL BIFO 7.25-12/2.2 $72.60
V2213 3 LENS SPHCYL BIFO 7.25-12/4.2 $68.64
V2214 3 LENS SPHCYL BIFOCAL OVER 12. $88.57
V2215 3 LENS LENTICULAR BIFOCAL $75.38
V2216 O LENS LENTICULAR NONASPHERIC $0.00
V2217 O LENS LENTICULAR ASPHERIC BIF $0.00
V2218 3 LENS ANISEIKONIC BIFOCAL $106.98
V2219 3 LENS BIFOCAL SEG WIDTH OVER $47.09
V2220 3 LENS BIFOCAL ADD OVER 3.25D $38.19
V2221 6 LENTICULAR LENS, BIFOCAL $0.00

V2299 6 LENS BIFOCAL SPECIALITY $0.00
V2300 3 LENS SPHERE TRIFOCAL 4.00D $62.84
V2301 3 LENS SPHERE TRIFOCAL 4.12-7. $73.64
V2302 3 LENS SPHERE TRIFOCAL 7.12-20 $86.73
V2303 3 LENS SPHCY TRIFOCAL 4.0/.12- $57.57
V2304 3 LENS SPHCY TRIFOCAL 4.0/2.25 $67.29
V2305 3 LENS SPHCY TRIFOCAL 4.0/4.25 $77.94
V2306 3 LENS SPHCYL TRIFOCAL 4.00/>6 $82.73
V2307 3 LENS SPHCY TRIFOCAL 4.25-7/. $76.36
V2308 3 LENS SPHC TRIFOCAL 4.25-7/2. $79.36
V2309 3 LENS SPHC TRIFOCAL 4.25-7/4. $82.96
V2310 3 LENS SPHC TRIFOCAL 4.25-7/>6 $88.00

V2311 3 LENS SPHC TRIFO 7.25-12/.25- $79.49
V2312 3 LENS SPHC TRIFO 7.25-12/2.25 $79.95
V2313 3 LENS SPHC TRIFO 7.25-12/4.25 $82.94
V2314 3 LENS SPHCYL TRIFOCAL OVER 12 $106.56
V2315 3 LENS LENTICULAR TRIFOCAL $94.65
V2316 O LENS LENTICULAR NONASPHERIC $0.00
V2317 O LENS LENTICULAR ASPHERIC TRI $0.00
V2318 3 LENS ANISEIKONIC TRIFOCAL $148.07
V2319 3 LENS TRIFOCAL SEG WIDTH > 28 $52.52
V2320 3 LENS TRIFOCAL ADD OVER 3.25D $55.41

V2321 6 LENTICULAR LENS, TRIFOCAL $0.00
V2399 6 LENS TRIFOCAL SPECIALITY $0.00
V2410 3 LENS VARIAB ASPHERICITY SING $82.58
V2430 3 LENS VARIABLE ASPHERICITY BI $92.26
V2499 6 VARIABLE ASPHERICITY LENS $0.00
V2500 3 CONTACT LENS PMMA SPHERICAL $85.97
V2501 3 CNTCT LENS PMMA-TORIC/PRISM $116.84
V2502 3 CONTACT LENS PMMA BIFOCAL $153.78
V2503 3 CNTCT LENS PMMA COLOR VISION $148.27
V2510 3 CNTCT GAS PERMEABLE SPHERICL $116.23
V2511 3 CNTCT TORIC PRISM BALLAST $150.69
V2512 3 CNTCT LENS GAS PERMBL BIFOCL $185.42
V2513 3 CONTACT LENS EXTENDED WEAR $151.11

V2520 3 CONTACT LENS HYDROPHILIC $107.68
V2521 3 CNTCT LENS HYDROPHILIC TORIC $169.90
V2522 3 CNTCT LENS HYDROPHIL BIFOCL $151.60
V2523 3 CNTCT LENS HYDROPHIL EXTEND $149.83
V2530 3 CONTACT LENS GAS IMPERMEABLE $202.40
V2531 3 CONTACT LENS GAS PERMEABLE $421.66
V2599 6 CONTACT LENS/ES OTHER TYPE $0.00
V2600 6 HAND HELD LOW VISION AIDS $0.00
V2610 6 SINGLE LENS SPECTACLE MOUNT $0.00
V2615 6 TELESCOP/OTHR COMPOUND LENS $0.00
V2620 9 PROSTHETIC, EYE, GLASS, STOCK $0.00
V2621 9 PROSTHETIC, EYE PLASTIC, STOCK $0.00

V2622 9 PROSTHETIC, EYE, GLASS, CUSTOM $0.00
V2623 3 PLASTIC EYE PROSTH CUSTOM $712.05
V2624 3 POLISHING ARTIFICAL EYE $64.39
V2625 3 ENLARGEMNT OF EYE PROSTHESIS $293.59
V2626 3 REDUCTION OF EYE PROSTHESIS $158.26
V2627 3 SCLERAL COVER SHELL $1,022.12
V2628 3 FABRICATION & FITTING $241.34
V2629 6 PROSTHETIC EYE OTHER TYPE $0.00
V2630 6 ANTER CHAMBER INTRAOCUL LENS $0.00
V2631 6 IRIS SUPPORT INTRAOCLR LENS $0.00

V2632 6 POST CHMBR INTRAOCULAR LENS $0.00
V2700 3 BALANCE LENS $42.70
V2702 9 DELUXE LENS FEATURE $0.00
V2710 3 GLASS/PLASTIC SLAB OFF PRISM $59.65
V2715 3 PRISM LENS/ES $9.76
V2718 3 FRESNELL PRISM PRESS-ON LENS $23.48
V2730 3 SPECIAL BASE CURVE $16.73
V2740 O ROSE TINT PLASTIC $0.00
V2741 O NON-ROSE TINT PLASTIC $0.00
V2742 O ROSE TINT GLASS $0.00
V2743 O NON-ROSE TINT GLASS $0.00
V2744 5 TINT PHOTOCHROMATIC LENS/ES $0.00
V2745 9 TINT, ANY COLOR/SOLID/GRAD $0.00

V2750 5 ANTI-REFLECTIVE COATING $0.00
V2755 9 UV LENS/ES $0.00
V2756 9 EYE GLASS CASE $0.00
V2760 3 SCRATCH RESISTANT COATING $16.31
V2761 9 MIRROR COATING $0.00
V2762 9 POLARIZATION, ANY LENS $0.00
V2770 9 OCCLUDER LENS/ES $0.00
V2780 9 OVERSIZE LENS/ES $0.00
V2781 9 PROGRESSIVE LENS PER LENS $0.00
V2782 6 LENS, 1.54-1.65 P/1.60-1.79G $0.00
V2783 6 LENS, >= 1.66 P/>=1.80 G $0.00
V2784 3 LENS POLYCARB OR EQUAL $37.16

V2785 6 CORNEAL TISSUE PROCESSING $0.00
V2786 9 OCCUPATIONAL MULTIFOCAL LENS $0.00
V2787 9 ASTIGMATISM-CORRECT FUNCTION $0.00
V2788 9 PRESBYOPIA-CORRECT FUNCTION $0.00
V2790 6 AMNIOTIC MEMBRANE $0.00
V2797 9 VIS ITEM/SVC IN OTHER CODE $0.00
V2799 6 MISCELLANEOUS VISION SERVICE $0.00
V5000 9 BASIC AUDIOLOGIC ASSESSMENT - HEARI $0.00
V5001 9 COMPREHENSIVE AUDIOLOGIC ASSESSMENT $0.00
V5002 9 ASSESSMENT OF VESTIBULAR AND/OR AUD $0.00

V5003 9 ASSESSMENT OF VESTIBULAR AND/OR AUD $0.00
V5008 3 HEARING SCREENING $16.00
V5010 9 ASSESSMENT FOR HEARING AID $0.00
V5011 9 HEARING AID FITTING/CHECKING $0.00
V5012 9 COMPLETE COCHLEAR IMPLANT REHABILIT $0.00
V5014 5 HEARING AID REPAIR/MODIFYING $0.00
V5016 9 UNLISTED AUDIOLOGIC PROCEDURE (SPEC $0.00
V5020 9 CONFORMITY EVALUATION $0.00
V5030 5 BODY-WORN HEARING AID AIR $0.00
V5040 5 BODY-WORN HEARING AID BONE $0.00
V5050 5 HEARING AID MONAURAL IN EAR $0.00
V5060 5 BEHIND EAR HEARING AID $0.00
V5070 5 GLASSES AIR CONDUCTION $0.00

V5080 5 GLASSES BONE CONDUCTION $0.00
V5090 3 HEARING AID DISPENSING FEE $400.00
V5095 5 IMPLANT MID EAR HEARING PROS $0.00
V5100 5 BODY-WORN BILAT HEARING AID $0.00
V5110 9 HEARING AID DISPENSING FEE $0.00
V5120 5 BODY-WORN BINAUR HEARING AID $0.00
V5130 5 IN EAR BINAURAL HEARING AID $0.00
V5140 5 BEHIND EAR BINAUR HEARING AI $0.00
V5150 5 GLASSES BINAURAL HEARING AID $0.00
V5160 9 DISPENSING FEE BINAURAL $0.00
V5170 5 WITHIN EAR CROS HEARING AID $0.00
V5180 5 BEHIND EAR CROS HEARING AID $0.00

V5190 5 GLASSES CROS HEARING AID $0.00
V5200 9 CROS HEARING AID DISPENS FEE $0.00
V5210 5 IN EAR BICROS HEARING AID $0.00
V5220 5 BEHIND EAR BICROS HEARING AI $0.00
V5230 5 GLASSES BICROS HEARING AID $0.00
V5240 9 DISPENSING FEE BICROS $0.00
V5241 9 DISPENSING FEE, MONAURAL $0.00
V5242 5 HEARING AID, MONAURAL, CIC $0.00
V5243 5 HEARING AID, MONAURAL, ITC $0.00
V5244 5 HEARING AID, PROG, MON, CIC $0.00

V5245 5 HEARING AID, PROG, MON, ITC $0.00
V5246 5 HEARING AID, PROG, MON, ITE $0.00
V5247 5 HEARING AID, PROG, MON, BTE $0.00
V5248 5 HEARING AID, BINAURAL, CIC $0.00
V5249 5 HEARING AID, BINAURAL, ITC $0.00
V5250 5 HEARING AID, PROG, BIN, CIC $0.00
V5251 5 HEARING AID, PROG, BIN, ITC $0.00
V5252 5 HEARING AID, PROG, BIN, ITE $0.00
V5253 5 HEARING AID, PROG, BIN, BTE $0.00
V5254 5 HEARING ID, DIGIT, MON, CIC $0.00
V5255 5 HEARING AID, DIGIT, MON, ITC $0.00
V5256 5 HEARING AID, DIGIT, MON, ITE $0.00
V5257 5 HEARING AID, DIGIT, MON, BTE $0.00

V5258 5 HEARING AID, DIGIT, BIN, CIC $0.00
V5259 5 HEARING AID, DIGIT, BIN, ITC $0.00
V5260 5 HEARING AID, DIGIT, BIN, ITE $0.00
V5261 5 HEARING AID, DIGIT, BIN, BTE $0.00
V5262 5 HEARING AID, DISP, MONAURAL $0.00
V5263 5 HEARING AID, DISP, BINAURAL $0.00
V5264 9 EAR MOLD/INSERT $0.00
V5265 9 EAR MOLD/INSERT, DISP $0.00
V5266 5 BATTERY FOR HEARING DEVICE $0.00
V5267 5 HEARING AID SUPPLY/ACCESSORY $0.00
V5268 9 ALD TELEPHONE AMPLIFIER $0.00
V5269 9 ALERTING DEVICE, ANY TYPE $0.00

V5270 9 ALD, TV AMPLIFIER, ANY TYPE $0.00
V5271 9 ALD, TV CAPTION DECODER $0.00
V5272 9 TDD $0.00
V5273 9 ALD FOR COCHLEAR IMPLANT $0.00
V5274 9 ALD UNSPECIFIED $0.00
V5275 9 EAR IMPRESSION $0.00
V5298 5 HEARING AID NOC $0.00
V5299 9 HEARING SERVICE $0.00
V5301 9 BASIC ASSESSMENT OF SPECIFIC SINGLE $0.00
V5310 9 COMPREHENSIVE ASSESSMENT OF SPEECH, $0.00

V5321 9 ASSESSMENT FOR ORAL OR LARYNGEAL PR $0.00
V5322 9 ASSESSMENT FOR AUGMENTATIVE COMMUNI $0.00
V5330 9 TREATMENT FOR SPEECH, LANGUAGE, ORA $0.00
V5335 9 REPAIR/MODIFICATION OF ORAL OR LARY $0.00
V5336 5 REPAIR COMMUNICATION DEVICE $0.00
V5360 9 UNLISTED SPEECH-LANGUAGE SERVICE (S $0.00
V5362 3 SPEECH SCREENING $16.00
V5363 3 LANGUAGE SCREENING $16.00
V5364 3 DYSPHAGIA SCREENING $16.00
W5950 O MCO SPECIFIC CODE: INTAKE/RISK ASSE $0.00
W9026 O HOSPITAL VISIT,INITIAL,OUTPATIENT;E $0.00
W9045 O ER SUPPORT SERVICES,SPECIAL NON-EME $0.00
W9047 O ER SUPPORT SERVICES, SPECIAL EMERGE $0.00

W9049 O HOSPITAL OUTPATIENT CLINIC VISIT $0.00
W9057 O RURAL HEALTH CLINIC VISIT $0.00
WW101 O OFFICE VISIT COPAY $0.00
WW102 O EMERGENCY ROOM COPAY $0.00
WW103 O VISION CARE COPAY $0.00
WW104 O TRANSPORTATION COPAY $0.00
WW105 O INPATIENT HOSPITAL VISIT OR PROCEDU $0.00
WW106 O OUTPATIENT HOSPITAL CO-PAY, EXCLUDI $0.00
WW201 O INJECTION, AMPICILLIN SODIUM AND SU $0.00
WW202 O INJECTION, AMPICILLIN SODIUM AND SU $0.00
WW203 O INJECTION, LEUCOVORIN CALCIUM, UP T $0.00
WW204 O INJECTION, CYTOVENE, UP TO 500 MG $0.00

WW205 O INJECTION, HEPARIN SODIUM, UP TO 50 $0.00
WW208 O INJECTION, PROMETHAZINE HCL, UP TO $0.00
WW209 O INJECTION, NALBUPHINE, UP TO 20 MG. $0.00
WW210 O INJECTION, LORAZEPAN, UP TO 2 MG. $0.00
WW211 O INJECTION, CEFTAZADIME, UP TO 500 M $0.00
WW212 O INJECTION, CEFTAZADIME, UP TO 1,000 $0.00
WW213 O INFECTION, STINGING INSECT VENOM, S $0.00
WW214 O INJECTION, STINGING INSECT VENOM, M $0.00

WW215 O INJECTION, POISON IVY/ OAK, PROPHYL $0.00
WW216 O INJECTION, LONG ACTING ADRENALIN, U $0.00
WW217 O INJECTION, LEUPROLIDE ACETATE DEPOT $0.00
WW218 O INJECTION, LEUPROLIDE ACETATE DEPOT $0.00
WW219 O INJECTION, HEPARIN SODIUM FLUSH, UP $0.00
WW220 O INJECTION, KETOROLAC TROMETHAMINE, $0.00
WW221 O INJECTION, KETOROLAC TROMETHAMINE, $0.00
WW222 O INJECTION, MARCAINE HCL, UP TO 10CC $0.00
WW223 O INJECTION, ONDANSETRON HCL, UP TO 1 $0.00
WW224 O IMMUNIZATION, ACTIVE; DIPHTHEIA AND $0.00
WW225 O INJECTION, DEPO-PROVERA, 150 MG/ML $0.00
WW226 O IMMUNIZATION, ACTIVE; DPT AND HIB $0.00
WW227 O INJECTION, MIDAZOLAM, UP TO 10 MG. $0.00

WW228 O INJECTION, FLUMAZENIL, UP TO 0.5 MG $0.00
WW229 O INJECTION, NALOXONE HCL, UP TO O.4 $0.00
WW230 O INJECTION, KYTRIL, 1MG/ML $0.00
WW231 O INJECTION, HEPARIN SODIUM, PER 100 $0.00
WW232 O INJECTION, DEXAMETHASONE ACETATE, 1 $0.00
WW301 O ROUTINE GYNECOLOGICAL EVALUATION IN $0.00
WW302 O ROUTINE GYNECOLOGICAL EVALUATION IN $0.00
WW303 O INITIAL ANTEPARTUM CARE $0.00
WW304 O USE OF A BIRTHING CENTER FACILITY F $0.00
WW305 O USE OF A BIRTHING CENTER FACILITY W $0.00
WW310 O INSERTION OF HORMONAL CONTRACEPTIVE $0.00
WW311 O REMOVAL OF HORMONAL CONTRACEPTIVE I $0.00

WW312 O PROVISION AND INSERTION OF VAGINAL $0.00
WW313 O INSERTION OF VAGINAL RING CONTAININ $0.00
WW351 O HOSPITAL BASED EMERGENCY ROOM PHYSI $0.00
WW401 O METHADONE CLINIC SERVICES $0.00
WW402 O OPIOID MEDICATION DISPENSING FOR IN $0.00
WW403 O OPIOID THERAPY PHYSICAL EVALUATION $0.00
WW404 O OPIOID DOSAGE MONITORING FOR INDIVI $0.00
WW430 O CHRONIC RENAL DISEASE PROGRAM-NEPRO $0.00
WW451 O INSERTION OF AN EPIDURAL OR SUBARAC $0.00
WW452 O RE-INJECTION OF A NARCOTIC INTO AN $0.00

WW453 O MAINTENANCE OF INTRAVENOUS ACCESS C $0.00
WW501 O VISION PROGRAM UNDER EPSDT - ROUTIN $0.00
WW502 O VISION PROGRAM UNDER EPSDT - PROVIS $0.00
WW503 O VISION PROGRAM UNDER EPSDT - PROVIS $0.00
WW504 O EPSDT/VISION-CONTACT LENS TO CORREC $0.00
WW505 O VISION PROGRAM UNDER EPSDT-PROVISIO $0.00
WW506 O VISION PROGRAM UNDER EPSDT-STOCK SI $0.00
WW508 O VISION PROGRAM UNDER EPSDT-STOCK SI $0.00
WW510 O VISION PROGRAM UNDER EPSDT-NON-STOC $0.00
WW512 O VISION PROGRAM UNDER EPSDT-NON-STOC $0.00

WW514 O VISION PROGRAM UNDER EPSDT-BIFOCAL $0.00
WW515 O VISION PROGARM UNDER EPSDT-PROVISIO $0.00
WW519 O VISION PROGRAM UNDER EPSDT-REPLACEM $0.00
WW520 O VISION PROGRAM UNDER EPSDT-POLYCARB $0.00
WW521 O VISION PROGRAM UNDER EPSDT-PHOTO GR $0.00
WW524 O VISION PROGRAM UNDER EPSDT-UNLISTED $0.00

WW531 O EPSDT SCREENING WITHOUT TREATMENT R $0.00
WW536 O EPSDT SCREENING WITH TREATMENT REFE $0.00

WW571 O DPH SPECIAL DENTAL CLINIC REFERRALS $0.00
WW572 O EPSDT - TOTAL YEARLY DENTAL CARE FO $0.00
WW573 O DENTAL CARE FOR INDIVIDUALS, EPSDT, $0.00
WW574 O DENTAL SERVICES FOR SPECIAL NEEDS P $0.00
WW575 O ENVIRONMENTAL INSPECTION FOR SOURCE $0.00
WW601 O POTENTIAL ACUITY METER (PAM) $0.00
WW651 O COMMUNITY SUPPORT SERVICES - MENTAL $0.00
WW652 O PSYCHOSOCIAL REHABILITATION CENTER $0.00
WW653 O RESIDENTIAL REHABILITATION MENTAL H $0.00
WW654 O PERSONAL CARE-DADAMH APPROVED C.S.S $0.00
WW655 O COMMUNITY SUPPORT SERVICES-ALCOHOL $0.00
WW660 O PHYS SERVICE DADAMH COMM MENTAL HEA $0.00
WW661 O PHYS SUPERVISED DADAMH COMM MENTAL $0.00

WW663 O PHYS SUPERVISED DADAMH CMHC SERVICE $0.00
WW664 O PHYSICIAN SERVICE - DADAMH COMMUNIT $0.00
WW665 O PHYS. SUPERVISED DADAMH COMMUNITY M $0.00
WW668 O EPSDT BEHAVIORAL HEALTH SERVICES, A $0.00
WW701 O PRIVATE DUTY NURSE, EMPLOYED BY AGE $0.00
WW702 O EPSDT EXTENDED PRIVATE DUTY NURSE,E $0.00
WW703 O PRIVATE DUTY NURSE,SELF-EMPLOYED,PE $0.00
WW704 O PRIVATE DUTY NURSE,SELF-EMPLOYED, P $0.00
WW705 O PRIVATE DUTY NURSE, SELF-EMPLOYED, $0.00
WW706 O PRIVATE DUTY NURSE, SELF-EMPLOYED, $0.00

WW713 O EPSDT EXTENDED PRIVATE DUTY NURSE,S $0.00

WW751 O 'PULMONARY EVALUATION AND DIAGNOSTI $0.00
WW752 O MULTICHANNEL RECORDING OF 3 TO 5 PH $0.00
WW753 O MULTICHANNEL RECORDING OF 6 TO 12 P $0.00
WW754 O 4 HR OVERNIGHT GROWTH HORMONE TEST; $0.00
WW755 O 12 HR OVERNIGHT GROWTH HORMONE TEST $0.00
WW797 O ENTERAL FORMULAE NOC $0.00
WW798 O DISPOSABLE INCONTINENCE PRODUCTS ME $0.00
WW799 O DIAPERS THAT ARE MEDICALLY NECESSAR $0.00
WW800 O EPSDT NON-STATE PLAN SUPPLIES FOR U $0.00

WW801 O MISCELLANEOUS SUPPLIES $0.00
WW802 O EPSDT $0.00
WW803 O NEEDLE WASTE UNIT (ALL SIZES) - IV $0.00
WW804 O INJECTION CAPS $0.00
WW805 O HUBER NEEDLE (ALL SIZES) $0.00
WW806 O SYRINGES (ALL TYPES) $0.00
WW808 O ADMINISTRATION SET-INCLUDES TUBING $0.00
WW809 O IV TUBING - ALL SIZES & TYPES $0.00
WW810 O CLAMP SCISSORS $0.00
WW811 O INTRAVENOUS CATHETER -ANGIO CATH, B $0.00
WW812 O IV START KIT $0.00
WW813 O IV CATHETER DRESSING KIT $0.00

WW814 O PEAK EXPIRATORY FLOW METER, EPSDT, $0.00
WW815 O MOUTHPIECE FOR PEAK FLOW METER, BOX $0.00
WW816 O LANCET DEVICE $0.00
WW821 O FEDERALLY QUALIFIED HEALTH CENTER E $0.00
WW822 O LINE MAINTENANCE-WEEKLY-SINGLE LUME $0.00
WW823 O LINE MAINTENANCE-WEEKLY-DOUBLE LUME $0.00
WW824 O LINE MAINTENANCE-WEEKLY-TRIPLE LUME $0.00
WW825 O PROTECTED NEEDLE HOUSING $0.00
WW826 O THERMOMETER-MERCURY $0.00
WW827 O HIBICLENS- 4 OZ $0.00

WW828 O TUBEX HOLDER $0.00
WW829 O CHEMO SPILL KIT-INCLUDES SAFETY GLA $0.00
WW830 O VIAL ADAPTER $0.00
WW831 O PICC INSERTION TRAY $0.00
WW838 O ENURESIS ALARM FOR AGES 4-20 $0.00
WW839 O PHOTOTHERAPY BLANKET $0.00
WW840 9 CARBON ELECTRODES FOR APNEA MONITOR $0.00
WW841 O STICKY ELECTRODES FOR APNEA MONITOR $0.00
WW842 O FOAM/VELCRO BELT FOR USE WITH CARBO $0.00
WW843 9 LEAD WIRES FOR APNEA MONITOR-1 SET $0.00
WW844 O PULSE OXIMETER $0.00
WW845 O OXIBANDS - FOR USE WITH PULSE OXIME $0.00
WW846 O OXISENSOR / PROBE - FOR USE WITH PU $0.00

WW847 O MEMORY MONITOR - RENTAL - INCLUDES $0.00
WW848 O SKIN LEVEL GASTROSTOMY KIT $0.00
WW849 O ADAPTER FOR SKIN LEVEL GASTROSTOMY $0.00
WW850 O OXYGEN CONTENT, LIQUID, PER POUND $0.00
WW851 O OXYGEN CONTENT, GASEOUS, PER EACH D $0.00
WW852 O OXYGEN CONTENT, GASEOUS, PER EACH E $0.00
WW853 O OXYGEN CONTENT, GASEOUS, PER EACH H $0.00
WW854 O OXYGEN CONTENT, GASEOUS, PER EACH M $0.00
WW855 O OXYGEN CONTENT, GASEOUS, PER EACH C $0.00
WW856 O STATIONARY COMPRESSED GAS SYSTEM; I $0.00
WW858 O STATIONARY LIQUID OXYGEN SYSTEM, IN $0.00
WW860 O OXYGEN CONCENTRATOR $0.00

WW870 O REPAIR OF PATIENT OWNED DURABLE MED $0.00
WW871 O EPSDT NON-STATE PLAN ORTHOTIC/PROST $0.00
WW880 O ARGININGE POWDER $0.00
WW881 O SPECIAL NEEDS EQUIPMENT - MISCELLAN $0.00
WW900 O HEARING ASSESSMENT-EPSDT SCHOOL BAS $0.00
WW901 O VISION ASSESSMENT-EPSDT SCHOOL BASE $0.00
WW902 O IMMUNIZATION ASSESSMENT-EPSDT SCHOO $0.00
WW903 O DEVELOPMENTAL/ORTHOPEDIC ASSESSMENT $0.00
WW904 O DENTAL ASSESSMENT-EPSDT SCHOOL BASE $0.00
WW905 O HEALTH EDUCATION ASSESSMENT-EPSDT S $0.00

WW906 O DENTAL HEALTH EDUCATION-EPSDT SCHOO $0.00
WW910 O INDIVIDUAL NURSING TREATMENT-EPSDT $0.00
WW920 O OCCUPATIONAL THERAPY EVALUATION-EPS $0.00
WW921 O INDIVIDUAL OCCUPATIONAL THERAPY TRE $0.00
WW922 O GROUP OCCUPATIONAL THERAPY TREATMEN $0.00
WW930 O PHYSICAL THERAPY ASSESSMENT-EPSDT S $0.00
WW931 O INDIVIDUAL PHYSICAL THERAPY TREATME $0.00
WW932 O GROUP PHYSICAL THERAPY TREATMENT-EP $0.00
WW936 O ICT PLACEMENT FOR 0-0-S RTC-BASED B $0.00
WW938 O ICT PLACEMENT FOR O-O-S RTC-BASED B $0.00
WW940 O MENTAL HEALTH TREATMENT ASSESSMENT- $0.00

WW941 O INDIVIDUAL MENTAL HEALTH TREATMENT $0.00
WW942 O GROUP MENTAL HEALTH TREATMENT THERA $0.00
WW943 O FAMILY MENTAL HEALTH TREATMENT THER $0.00
WW944 O INDIVIDUAL MENTAL HEALTH CO-TREATME $0.00
WW945 O GROUP MENTAL HEALTH CO-TREATMENT TH $0.00
WW946 O FAMILY MENTAL HEALTH CO-TREATMENT T $0.00
WW947 O MENTAL HEALTH CASE CONSULTATION-EPS $0.00
WW948 O AU CLAIR BEHAVIORAL THERAPY, EPSDT $0.00
WW950 O SPEECH, LANGUAGE AND HEARING ASSESS $0.00
WW951 O INDIVIDUAL SPEECH/LANGUAGE THERAPY- $0.00
WW952 O INDIVIDUAL HEARING THERAPY-EPSDT SC $0.00
WW953 O GROUP SPEECH/LANGUAGE THERAPY-EPSDT $0.00

WW954 O INDIVUDUAL SPEECH/LANGUAGE CO-TREAT $0.00
WW955 O INDIVIDUAL HEARING CO-TREATMENT THE $0.00
WW956 O GROUP SPEECH/LANGAUAGE CO-TREATMENT $0.00
WW960 O TRANSPORTATION,ROUND TRIP-EPSDT SCH $0.00
WW967 O ASSESSMENT OF HIGHER CEREBRAL FUNCT $0.00
WW968 O PDDN EARLY INTERVENTION THERAPIES, $0.00
WW969 O EARLY INTERVENTION MULTI-DISCIPLINA $0.00
WW970 O CHILD DEVELOPMENT ORIENTED FAMILY T $0.00
WW975 O MENTAL HEALTH TREATMENT EVALUATION, $0.00
WW976 O INDIVIDUAL MENTAL HEALTH TREATMENT $0.00

WW980 O SPEECH/LANGUAGE/HEARING SCREEN, EPS $0.00
WW981 O SPEECH/LANGUAGE/HEARING COMPREHENSI $0.00
WW982 O SPEECH/LANGUAGE/HEARING INDIVIDUAL $0.00
WW983 O GROUP SPEECH/LANGUAGE/HEARING THERA $0.00
WW985 O OCCUPATIONAL THERAPY SCREEN, EPSDT, $0.00
WW986 O OCCUPATIONAL THERAPY EVALUATION, CO $0.00
WW987 O OCCUPATIONAL THERAPY TREATMENT, IND $0.00
WW990 O PHYSICAL THERAPY SCREEN, EPSDT, AGE $0.00
WW991 O PHYSICAL THERAPY EVALUATION, COMPRE $0.00
WW992 O INDIVIDUAL PHYSICAL THERAPY TREATME $0.00
WW995 O INITIAL NUTRITION CONSULTATION $0.00
WW996 O NUTRITION COUNSELING $0.00
WW997 O ASTHMA REHABILITATION CASE MANAGEME $0.00

WW998 O NURSING SERVICES, INTERMITTENT, EPS $0.00
WW999 O EPSDT CASE MANAGEMENT SERVICE FOR C $0.00
X0019 O MCO SPECIFIC CODE: PRIVATE DUTY NUR $0.00
YY001 O NURSING HOME ANCILLARIES - OXYGEN H $0.00
YY002 O NURSING HOME ANCILLARIES - OXYGEN P $0.00
YY003 O NURSING HOME ANCILLARIES - OXYGEN C $0.00
YY004 O NURSING HOME ANCILLARIES - PHYSICAL $0.00
YY005 O NURSING HOME ANCILLARIES - PHYSICAL $0.00
YY006 O NURSING HOME ANCILLARIES - SPEECH T $0.00
YY007 O NURSING HOME ANCILLARIES - SPEECH T $0.00
YY008 O NURSING HOME ANCILLARIES - OCCUPATI $0.00
YY009 O NURSING HOME ANCILLARIES - OCCUPATI $0.00

YY101 O EXTENDED PREGNANCY-PER FIFTEEN MINU $0.00
YY102 O EXTENDED PREGNANCY-NUTRITION PER FI $0.00
YY103 O EXTENDED PREGNANCY-SOCIAL WORK PER $0.00
YY201 O HOSPICE - ROUTINE HOME CARE PER DAY $0.00
YY202 O HOSPICE - CONTINUOUS HOME CARE PER $0.00
YY203 O HOSPICE - INPATIENT RESPIT CARE PER $0.00
YY204 O HOSPICE - GENERAL INPATIENT CARE PE $0.00
YY205 O HOSPICE - NURSING HOME ROOM AND BOA $0.00
YY301 O FAMILY AND CHILDREN'S SERVICES CLIN $0.00
YY302 O FAMILY AND CHILDREN'S SERVICES NURS $0.00

YY303 O FAMILY AND CHILDREN'S SERVICES NURS $0.00
YY304 O FAMILY AND CHILDREN'S SERVICES EPSD $0.00
YY401 O DPH SPECIALTY AUDIOLOGY CLINIC VISI $0.00
YY402 O DPH SPECIALTY CARDIAC CLINIC VISIT $0.00
YY403 O DPH SPECIALTY ORTHOPEDIC CLINIC VIS $0.00
YY404 O DPH SPECIALTY NEUROLOGY CLINIC VISI $0.00
YY405 O DPH SPECIALTY SPEECH CLINIC VISIT $0.00
YY406 O DPH GENERAL MEDICAL CLINIC VISIT $0.00
YY407 O DPH URINALYSIS $0.00
YY408 O DPH PRENATAL CLINIC VISIT $0.00
YY409 O DPH TUBERCULOSIS CLINIC VISIT $0.00
YY410 O DPH STD CLINIC VISIT $0.00
YY411 O DPH ENHANCED CARE FOR AT-RISK CHILD $0.00

YY431 O DPH - SPECIALTY FAMILY PLANNING CLI $0.00
YY434 O DPH FAMILY PLANNING CLINIC VISIT - $0.00
YY441 O DPH - SUPPLIED DIAPHRAGM $0.00
YY442 O DPH - SUPPLIED FOAM $0.00
YY443 O DPH - SUPPLIED BIRTH CONTROL PILLS $0.00
YY444 O DPH - SUPPLIED IUD $0.00
YY445 O DPH - SUPPLIED PREGNANCY TEST $0.00
YY471 O DPH - HEALTH SCREENING - AGE 35 TO $0.00
YY472 O DPH - HEALTH SCREENING - AGE 50 TO $0.00
YY473 O DPH - HEALTH SCREENING - AGE 60 AND $0.00

YY501 O TRANSPORTATION IN VEHICLE OTHER THA $0.00
YY506 O AMBULANCE - EMERGENCY TRANSPORT (ON $0.00
YY507 O AMBULANCE - EMERGENCY TRANSPORT (ON $0.00
YY508 O AMBULANCE - NON-EMERGENCY TRANSPORT $0.00
YY509 O AMBULANCE, NON-EMERGENCY TRANSPORT, $0.00
YY510 O AMBULANCE, NON-EMERGENCY TRANSPORT, $0.00

YY511 O ADDITIONAL AMBULANCE CREW(S) NECESS $0.00
YY512 O CHRONIC RENAL DISEASE PROGRAM MILEA $0.00
YY513 O AMBULANCE, NEONATAL EMERGENCY TRANS $0.00
YY514 O AMBULANCE, NEONATAL EMERGENCY TRANS $0.00
YY518 O TRANSPORTATION-TAXI SERVICE-METERED $0.00

YY560 O HCBS WAIVER FOR THE MENTALLY RETARD $0.00

YY599 O HOME AND COMMUNITY-BASED SERVICES W $0.00

YY606 O HOME AND COMMUNITY - BASED SERVICES $0.00
YY607 O HCBS WAIVER FOR MENTALLY RETARDED R $0.00
YY608 O HCBS WAIVER FOR THE MENTALLY-RETARD $0.00

YY614 O HOME AND COMMUNITY-BASED SERVICES F $0.00
YY617 O HOME AND COMMUNITY-BASED WAIVER FOR $0.00


YY644 O HOME & COMMUNITY-BASED SERVICES WAI $0.00
YY645 O HOME & COMMUNITY-BASED WAIVER FOR A $0.00
YY646 O HOME & COMMUNITY BASED WAIVER FOR A $0.00
YY648 O HOME&COMMUNITY-BASED WAIVER FOR AID $0.00
YY652 O AGED AND DISABLED WAIVER - EMERGENC $0.00

YY661 O HCBS-A/D-WAIVER-DURABLE MEDICAL EQU $0.00
YY664 O HOME & COMMUNITY BASED SERVICES FOR $0.00
YY701 O HOME HEALTH-SKILLED NURSE VISIT-PLA $0.00
YY702 O HOME HEALTH - NURSE AIDE - PER 15 M $0.00

YY703 O HOME HEALTH - PHYSICAL THERAPY EVAL $0.00
YY704 O HOME HEALTH - PHYSICAL THERAPY TREA $0.00
YY705 O HOME HEALTH - OCCUPATIONAL THERAPY $0.00
YY706 O HOME HEALTH - OCCUPATIONAL THERAPY $0.00
YY707 O HOME HEALTH - SPEECH THERAPY EVALUA $0.00
YY708 O HOME HEALTH - SPEECH THERAPY TREATM $0.00
YY709 O HOME HEALTH- MEDICALLY NECESSARY SU $0.00
YY710 O HOME HEALTH-SKILLED NURSE VISIT-ADU $0.00
YY711 O HOME HEALTH-NURSE AIDE-ADULT FOSTER $0.00
YY712 O HOME HEALTH-PHYSICAL THERAPY EVALUA $0.00

YY713 O HOME HEALTH-PHYSICAL THERAPY TREATM $0.00
YY714 O HOME HEALTH-OCCUPATIONAL THERAPY EV $0.00
YY715 O HOME HEALTH-OCCUPATIONAL THERAPY TR $0.00
YY716 O HOME HEALTH-SPEECH THERAPY EVALUATI $0.00
YY717 O HOME HEALTH-SPEECH THERAPY TREATMEN $0.00
YY718 O HOME HEALTH-NURSE AIDE-HCBS/WAIVER $0.00
YY719 O HOME HEALTH-SKILLED NURSE VISIT-HCB $0.00
YY720 O HOME HEALTH-PHYSICAL THERAPY EVALUA $0.00
YY721 O HOME HEALTH-PHYSICAL THERAPY TREATM $0.00
YY722 O HOME HEALTH-OCCUPATIONAL THERAPY EV $0.00
YY723 O HOME HEALTH-OCCUPATIONAL THERAPY TR $0.00
YY724 O HOME HEALTH-SPEECH THERAPY EVALUATI $0.00
YY725 O HOME HEALTH-SPEECH THERAPY TREATMEN $0.00

YY726 O HOME HEALTH-SKILLED NURSE VISIT-IN $0.00
YY727 O HOME HEALTH-SKILLED NURSE VISIT-ASS $0.00
YY728 O HOME HEALTH-NURSE AIDE-ASSISTED LIV $0.00
YY740 O MH/SA ASSESSMENT, EPSDT-DSCYF, AGE $0.00
YY741 O CLINICAL COORDINATION, EPSDT-DSCYF, $0.00
YY742 O CLINICAL BEHAVIORAL GUIDANCE,PERIOD $0.00
YY750 O MENTAL HEALTH CRISIS SERVICES, EPSD $0.00
YY751 O CENTER-BASED INDIVIDUAL OUTPATIENT $0.00
YY752 O MEDICATION MONITORING OR PSYCHIATRI $0.00
YY753 O CENTER-BASED OUTPATIENT GROUP MENTA $0.00
YY754 O RTC-BASED INDIVIDUAL OUT-PT MENTAL $0.00
YY755 O MENTAL HEALTH DAY TREATMENT, EPSDT- $0.00

YY756 O RTC-BASED INDIVIDUAL MENTAL HEALTH $0.00
YY760 O DRUG/ALCOHOL INTENSIVE INDIVIDUAL D $0.00
YY761 O DRUG/ALCOHOL INDIVIDUAL OUTPATIENT $0.00
YY762 O DRUG/ALCOHOL GROUP OUTPATIENT SERVI $0.00
YY763 O DRUG/ALCOHOL TREATMENT PROGRAM IN A $0.00
YY764 7 DRUG\ALCOHOL PARTIAL DAY TREATMENT $0.00
YY765 O MENTAL HEALTH/SUBSTANCE ABUSE SERVI $0.00
YY801 O PRESCRIBED PEDIATRIC EXTENDED CARE $0.00

YY803 O PRESCRIBED PEDIATRIC EXTENDED CARE( $0.00
YY822 O VFC IMMUNIZATION CODE CREATED FOR L $0.00
YY850 O DAY HEALTH & REHAB FOR MR & DD CLIE $0.00
YY851 O DAY HEALTH & REHAB FOR MR & DD CLIE $0.00
YY852 O DAY HEALTH AND REHABILITATION FOR N $0.00
YY853 O DAY HEALTH AND REHABILITATION FOR N $0.00
YY921 O MONTHLY CAPITATED RATE, PEDIATRIC M $0.00

Z0402 O PORTABLE OXYGEN REFILL (13 TO 28 CU $0.00
Z0406 O H TANK REFILL (151-282 CU. FT.) $0.00
Z0445 O OXYGEN CONCENTRATOR $0.00
Z0526 O WARM-N-FORM ORTHOSIS $0.00
Z3255 O ORTHOPEDIC SHOES ATTACHED TO BRACE $0.00
Z4442 O TRACHEOSTOMY SUCTION KIT $0.00
Z4443 O TRACHEOSTOMY SUCTION CATHETER $0.00
ZE001 O MCO SPECIFIC CODE: HOME INFUSION SE $0.00
ZE002 O MCO SPECIFIC CODE: HOME INFUSION SE $0.00
ZH003 O MCO SPECIFIC CODE: HOME INFUSION SE $0.00

ZM001 O MCO SPECIFIC CODE: HOME INFUSION SE $0.00
ZR001 O MCO SPECIFIC CODE: HOME INFUSION SE $0.00
ZR002 O MCO SPECIFIC CODE: HOME INFUSION SE $0.00

Pricing Action Codes
Pricing Action Code Pricing Action Description
1 PAY PERCENTAGE OF BILLED AMOUNT.
3 LOWER OF BILLED OR ALLOWED AMOUNT.
5 MANUAL PRICE - INDIVIDUAL CONSIDERATION. SET EDIT TO SUSPEND.
6 MANUAL PRICE - NO REASONABLE CHARGE ESTABLISHED. SET EDIT TO SUSPEND.
7 ONLY LEVEL I PRICING SHOULD BE USED. SET EDIT TO SUSPEND.
9 NON-COVERED. SET EDIT TO AUTODENY.
A LOWER OF BILLED AMOUNT OR ((RVU + BILLED UNITS) X CONVERSION FACTOR DOLLAR AMOUNT)
O OBSOLETE. SET EDIT TO AUTODENY.

SUSPEND.
FACTOR DOLLAR AMOUNT) .

Procedure Modifier Pricing
Procedure Code Procedure Code Modifier Pricing Action Code Modifier Price
11975 26 5 $120.18
11977 26 5 $215.89
11980 26 5 $95.19
11981 26 5 $124.16
11983 26 5 $219.93
51725 26 3 $77.91
51725 TC 3 $147.74
51726 26 3 $88.62
51726 TC 3 $240.40
51736 26 3 $31.87
51736 TC 3 $22.79
51741 26 3 $59.54
51741 TC 3 $26.72
51772 26 3 $82.57
51772 TC 3 $170.16
51784 26 3 $78.63
51784 TC 3 $128.14
51785 26 3 $78.75
51785 TC 3 $145.88
51792 26 3 $56.52
51792 TC 3 $179.84
51795 26 3 $78.99
51795 TC 3 $231.25
51797 26 3 $45.14
51797 TC 3 $108.05
58300 26 5 $73.72
59020 26 3 $35.18
59020 TC 3 $31.23
59025 26 3 $28.34
59025 TC 3 $15.64
62252 26 3 $42.45
62252 TC 3 $50.02
70010 26 3 $59.62
70010 TC 3 $110.64
70015 26 3 $61.07
70015 TC 3 $81.04
70030 26 3 $8.54
70030 TC 3 $19.34
70100 26 3 $8.89
70100 TC 3 $21.19
70110 26 3 $12.50
70110 TC 3 $26.47
70120 26 3 $8.89
70120 TC 3 $23.88
70130 26 3 $17.06
70130 TC 3 $37.06
70134 26 3 $17.06
70134 TC 3 $29.29
70140 26 3 $9.25
70140 TC 3 $20.19
70150 26 3 $12.86
70150 TC 3 $29.29
70160 26 3 $8.54
70160 TC 3 $23.03
70170 26 3 $15.02
70190 26 3 $10.33
70190 TC 3 $24.62
70200 26 3 $13.95
70200 TC 3 $29.66
70210 26 3 $8.54
70210 TC 3 $20.92
70220 26 3 $12.13
70220 TC 3 $26.34
70240 26 3 $9.61
70240 TC 3 $19.34
70250 26 3 $11.77
70250 TC 3 $23.88
70260 26 3 $16.70
70260 TC 3 $30.64
70300 26 3 $5.29
70300 TC 3 $8.61
70310 26 3 $8.17
70310 TC 3 $25.25
70320 26 3 $11.05
70320 TC 3 $32.02
70328 26 3 $8.89
70328 TC 3 $20.44
70330 26 3 $12.14
70330 TC 3 $34.48
70332 26 3 $26.43
70332 TC 3 $57.22
70336 26 3 $74.53
70336 TC 3 $350.65
70350 26 3 $8.54
70350 TC 3 $11.57
70355 26 3 $9.98
70355 TC 3 $12.42
70360 26 3 $8.54
70360 TC 3 $18.23
70370 26 3 $15.74
70370 TC 3 $57.87
70371 26 3 $40.95
70371 TC 3 $55.37
70373 26 3 $20.64
70373 TC 3 $58.83
70380 26 3 $8.54
70380 TC 3 $27.95
70390 26 3 $19.24
70390 TC 3 $79.54
70450 26 3 $43.16
70450 TC 3 $176.06
70460 26 3 $57.10
70460 TC 3 $226.43
70470 26 3 $64.20
70470 TC 3 $279.12
70480 26 3 $64.55
70480 TC 3 $196.93
70481 26 3 $69.61
70481 TC 3 $311.59
70482 26 3 $72.84
70482 TC 3 $344.95
70486 26 3 $57.47
70486 TC 3 $196.41
70487 26 3 $66.01
70487 TC 3 $275.60
70488 26 3 $71.40
70488 TC 3 $344.57
70490 26 3 $64.93
70490 TC 3 $196.28
70491 26 3 $69.61
70491 TC 3 $265.99
70492 26 3 $72.84
70492 TC 3 $334.95
70496 26 3 $88.86
70496 TC 3 $356.02
70498 26 3 $89.22
70498 TC 3 $356.02
70540 26 3 $67.80
70540 TC 3 $353.13
70542 26 3 $81.38
70542 TC 3 $433.17
70543 26 3 $108.06
70543 TC 3 $544.28
70544 26 3 $60.35
70544 TC 3 $351.83
70545 26 3 $60.35
70545 TC 3 $431.99
70546 26 3 $90.64
70546 TC 3 $547.16
70547 26 3 $60.35
70547 TC 3 $351.70
70548 26 3 $60.35
70548 TC 3 $432.26
70549 26 3 $90.64
70549 TC 3 $547.16
70551 26 3 $74.53
70551 TC 3 $351.68
70552 26 3 $89.92
70552 TC 3 $430.96
70553 26 3 $118.89
70553 TC 3 $539.49
70554 26 3 $107.37
70554 TC 3 $512.84
70555 26 3 $129.63
70557 26 3 $147.32
70558 26 3 $160.74
70559 26 3 $163.43
71010 26 3 $8.89
71010 TC 3 $14.90
71015 26 3 $10.33
71015 TC 3 $18.96
71020 26 3 $11.05
71020 TC 3 $20.55
71021 26 3 $13.21
71021 TC 3 $24.86
71022 26 3 $15.39
71022 TC 3 $30.41
71023 26 3 $19.36
71023 TC 3 $47.04
71030 26 3 $15.39
71030 TC 3 $30.77
71034 26 3 $24.68
71034 TC 3 $66.62
71035 26 3 $9.26
71035 TC 3 $24.88
71040 26 3 $29.20
71040 TC 3 $65.88
71060 26 3 $37.14
71060 TC 3 $101.46
71090 26 3 $29.39
71100 26 3 $11.05
71100 TC 3 $21.30
71101 26 3 $13.21
71101 TC 3 $25.73
71110 26 3 $13.21
71110 TC 3 $27.08
71111 26 3 $15.74
71111 TC 3 $35.82
71120 26 3 $9.98
71120 TC 3 $22.40
71130 26 3 $11.05
71130 TC 3 $26.10
71250 26 3 $58.55
71250 TC 3 $195.76
71260 26 3 $62.51
71260 TC 3 $280.98
71270 26 3 $69.61
71270 TC 3 $343.89
71275 26 3 $97.38
71275 TC 3 $356.54
71550 26 3 $73.21
71550 TC 3 $353.00
71551 26 3 $86.66
71551 TC 3 $433.30
71552 26 3 $114.58
71552 TC 3 $546.25
71555 26 3 $92.11
71555 TC 3 $431.74
72010 26 3 $21.74
72010 TC 3 $46.54
72020 26 3 $7.82
72020 TC 3 $15.64
72040 26 3 $11.05
72040 TC 3 $25.36
72050 26 3 $15.39
72050 TC 3 $36.19
72052 26 3 $18.15
72052 TC 3 $46.54
72069 26 3 $11.05
72069 TC 3 $23.40
72070 26 3 $11.05
72070 TC 3 $22.40
72072 26 3 $11.05
72072 TC 3 $27.08
72074 26 3 $11.05
72074 TC 3 $33.60
72080 26 3 $11.05
72080 TC 3 $23.88
72090 26 3 $14.31
72090 TC 3 $31.64
72100 26 3 $11.05
72100 TC 3 $27.20
72110 26 3 $15.39
72110 TC 3 $38.04
72114 26 3 $18.15
72114 TC 3 $51.71
72120 26 3 $11.05
72120 TC 3 $36.93
72125 26 3 $58.55
72125 TC 3 $195.76
72126 26 3 $61.43
72126 TC 3 $281.35
72127 26 3 $63.83
72127 TC 3 $343.89
72128 26 3 $58.55
72128 TC 3 $195.76
72129 26 3 $61.80
72129 TC 3 $281.35
72130 26 3 $64.20
72130 TC 3 $343.89
72131 26 3 $58.55
72131 TC 3 $195.76
72132 26 3 $61.80
72132 TC 3 $280.98
72133 26 3 $64.20
72133 TC 3 $343.89
72141 26 3 $80.29
72141 TC 3 $350.65
72142 26 3 $96.65
72142 TC 3 $430.96
72146 26 3 $80.66
72146 TC 3 $350.40
72147 26 3 $97.02
72147 TC 3 $430.17
72148 26 3 $74.53
72148 TC 3 $350.40
72149 26 3 $89.92
72149 TC 3 $430.96
72156 26 3 $129.22
72156 TC 3 $539.60
72157 26 3 $129.60
72157 TC 3 $538.82
72158 26 3 $118.52
72158 TC 3 $539.60
72159 26 3 $90.01
72159 TC 3 $563.62
72170 26 3 $8.54
72170 TC 3 $17.12
72190 26 3 $10.70
72190 TC 3 $28.32
72191 26 3 $91.74
72191 TC 3 $356.42
72192 26 3 $55.31
72192 TC 3 $195.64
72193 26 3 $58.55
72193 TC 3 $267.42
72194 26 3 $61.43
72194 TC 3 $344.28
72195 26 3 $73.21
72195 TC 3 $352.61
72196 26 3 $87.40
72196 TC 3 $432.78
72197 26 3 $113.84
72197 TC 3 $543.64
72198 26 3 $91.01
72198 TC 3 $431.74
72200 26 3 $8.54
72200 TC 3 $20.07
72202 26 3 $9.61
72202 TC 3 $24.99
72220 26 3 $8.54
72220 TC 3 $20.55
72240 26 3 $45.68
72240 TC 3 $111.73
72255 26 3 $44.57
72255 TC 3 $99.18
72265 26 3 $41.71
72265 TC 3 $104.72
72270 26 3 $67.08
72270 TC 3 $161.34
72275 26 3 $35.88
72275 TC 3 $67.01
72285 26 3 $55.70
72285 TC 3 $119.74
72291 26 3 $68.06
72292 26 3 $70.95
72295 26 3 $40.71
72295 TC 3 $115.69
73000 26 3 $8.17
73000 TC 3 $18.96
73010 26 3 $8.54
73010 TC 3 $19.34
73020 26 3 $7.45
73020 TC 3 $15.64
73030 26 3 $9.26
73030 TC 3 $20.19
73040 26 3 $27.17
73040 TC 3 $78.66
73050 26 3 $10.35
73050 TC 3 $24.99
73060 26 3 $8.54
73060 TC 3 $20.19
73070 26 3 $7.45
73070 TC 3 $18.96
73080 26 3 $8.54
73080 TC 3 $25.36
73085 26 3 $26.80
73085 TC 3 $68.69
73090 26 3 $7.80
73090 TC 3 $18.96
73092 26 3 $7.80
73092 TC 3 $19.71
73100 26 3 $8.17
73100 TC 3 $19.71
73110 26 3 $8.54
73110 TC 3 $24.88
73115 26 3 $27.17
73115 TC 3 $74.12
73120 26 3 $7.80
73120 TC 3 $18.59
73130 26 3 $8.54
73130 TC 3 $21.92
73140 26 3 $6.73
73140 TC 3 $21.55
73200 26 3 $54.94
73200 TC 3 $196.28
73201 26 3 $58.55
73201 TC 3 $267.33
73202 26 3 $61.43
73202 TC 3 $344.80
73206 26 3 $92.47
73206 TC 3 $356.15
73218 26 3 $67.42
73218 TC 3 $353.26
73219 26 3 $81.38
73219 TC 3 $433.53
73220 26 3 $108.43
73220 TC 3 $544.42
73221 26 3 $67.80
73221 TC 3 $353.00
73222 26 3 $81.38
73222 TC 3 $432.91
73223 26 3 $108.06
73223 TC 3 $544.03
73225 26 3 $86.40
73225 TC 3 $550.96
73500 26 3 $8.54
73500 TC 3 $16.38
73510 26 3 $10.70
73510 TC 3 $25.36
73520 26 3 $12.86
73520 TC 3 $26.10
73525 26 3 $27.41
73525 TC 3 $67.94
73530 26 3 $14.67
73540 26 3 $9.98
73540 TC 3 $26.10
73542 26 3 $27.71
73542 TC 3 $50.20
73550 26 3 $8.54
73550 TC 3 $19.44
73560 26 3 $8.54
73560 TC 3 $19.34
73562 26 3 $9.26
73562 TC 3 $24.26
73564 26 3 $11.05
73564 TC 3 $27.95
73565 26 3 $8.90
73565 TC 3 $20.82
73580 26 3 $27.41
73580 TC 3 $91.72
73590 26 3 $8.54
73590 TC 3 $18.23
73592 26 3 $7.80
73592 TC 3 $19.71
73600 26 3 $7.80
73600 TC 3 $18.59
73610 26 3 $8.54
73610 TC 3 $21.92
73615 26 3 $27.04
73615 TC 3 $70.90
73620 26 3 $7.80
73620 TC 3 $17.86
73630 26 3 $8.54
73630 TC 3 $21.55
73650 26 3 $7.80
73650 TC 3 $18.23
73660 26 3 $6.36
73660 TC 3 $20.44
73700 26 3 $54.94
73700 TC 3 $196.28
73701 26 3 $58.92
73701 TC 3 $269.19
73702 26 3 $61.80
73702 TC 3 $344.80
73706 26 3 $97.17
73706 TC 3 $356.31
73718 26 3 $67.80
73718 TC 3 $353.13
73719 26 3 $81.38
73719 TC 3 $433.17
73720 26 3 $108.43
73720 TC 3 $544.42
73721 26 3 $67.80
73721 TC 3 $353.00
73722 26 3 $81.75
73722 TC 3 $433.03
73723 26 3 $108.43
73723 TC 3 $543.66
73725 26 3 $92.09
73725 TC 3 $431.97
74000 26 3 $8.89
74000 TC 3 $16.38
74010 26 3 $11.42
74010 TC 3 $25.73
74020 26 3 $13.58
74020 TC 3 $26.10
74022 26 3 $16.11
74022 TC 3 $31.88
74150 26 3 $59.99
74150 TC 3 $195.76
74160 26 3 $64.56
74160 TC 3 $301.07
74170 26 3 $70.69
74170 TC 3 $344.70
74175 26 3 $96.43
74175 TC 3 $356.68
74181 26 3 $73.58
74181 TC 3 $352.08
74182 26 3 $87.40
74182 TC 3 $433.17
74183 26 3 $113.84
74183 TC 3 $543.64
74185 26 3 $91.01
74185 TC 3 $431.60
74190 26 3 $24.28
74210 26 3 $18.52
74210 TC 3 $57.63
74220 26 3 $23.21
74220 TC 3 $63.18
74230 26 3 $26.81
74230 TC 3 $61.94
74235 26 3 $61.47
74240 26 3 $34.99
74240 TC 3 $71.79
74241 26 3 $34.61
74241 TC 3 $79.18
74245 26 3 $46.05
74245 TC 3 $124.75
74246 26 3 $34.99
74246 TC 3 $87.43
74247 26 3 $34.99
74247 TC 3 $88.91
74249 26 3 $46.05
74249 TC 3 $137.19
74250 26 3 $23.56
74250 TC 3 $77.10
74251 26 3 $34.99
74251 TC 3 $145.88
74260 26 3 $25.00
74260 TC 3 $89.82
74270 26 3 $34.99
74270 TC 3 $89.04
74280 26 3 $50.02
74280 TC 3 $144.72
74283 26 3 $101.69
74283 TC 3 $88.65
74290 26 3 $16.11
74290 TC 3 $48.15
74291 26 3 $9.98
74291 TC 3 $45.58
74300 26 O $18.66
74301 26 3 $10.70
74305 26 3 $21.40
74320 26 3 $27.54
74320 TC 3 $86.52
74327 26 3 $35.71
74327 TC 3 $93.95
74328 26 3 $35.71
74329 26 3 $35.71
74330 26 3 $45.69
74340 26 3 $27.17
74355 26 3 $38.60
74360 26 3 $28.28
74363 26 3 $44.97
74400 26 3 $24.65
74400 TC 3 $84.34
74410 26 3 $25.01
74410 TC 3 $89.89
74415 26 3 $24.65
74415 TC 3 $107.13
74420 26 3 $18.52
74425 26 3 $18.52
74430 26 3 $16.35
74430 TC 3 $61.70
74440 26 3 $19.24
74440 TC 3 $64.66
74445 26 3 $59.05
74450 26 3 $17.08
74455 26 3 $17.08
74455 TC 3 $73.38
74470 26 3 $27.54
74475 26 3 $27.54
74475 TC 3 $95.85
74480 26 3 $27.54
74480 TC 3 $96.22
74485 26 3 $27.78
74485 TC 3 $90.22
74710 26 3 $17.43
74710 TC 3 $25.84
74740 26 3 $19.24
74740 TC 3 $58.24
74775 26 3 $31.38
75600 26 3 $26.49
75600 TC 3 $295.08
75605 26 3 $59.68
75605 TC 3 $213.74
75625 26 3 $58.07
75625 TC 3 $211.52
75630 26 3 $92.85
75630 TC 3 $219.51
75635 26 3 $123.52
75635 TC 3 $357.06
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75680 TC 3 $239.62
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75685 TC 3 $224.83
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75705 TC 3 $223.35
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75746 TC 3 $218.18
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75891 26 3 $58.20
75891 TC 3 $205.60
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78120 TC 3 $75.10
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78121 TC 3 $89.13
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92285 26 3 $10.35
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92286 TC 3 $77.01
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92541 TC 3 $37.45
92542 26 3 $16.46
92542 TC 3 $43.37
92543 26 3 $5.29
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92544 TC 3 $35.23
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92545 TC 3 $33.75
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92546 TC 3 $67.03
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93024 TC 3 $59.22
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93025 TC 3 $174.92
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93508 TC 3 $837.08
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93510 TC 3 $1,082.05
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93514 26 3 $391.97
93524 26 3 $392.96
93526 26 3 $338.74
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93529 26 3 $271.87
93530 26 3 $231.32
93531 26 3 $452.78
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93980 TC 3 $117.95
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94010 TC 3 $24.88
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94060 TC 3 $43.58
94070 26 3 $28.08
94070 TC 3 $31.23
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94250 TC 3 $19.09
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94260 TC 3 $25.36
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94350 TC 3 $22.40
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94680 TC 3 $45.43
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94690 TC 3 $47.18
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95805 TC 3 $334.23
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95807 TC 3 $418.22
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95808 TC 3 $524.33
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95810 TC 3 $607.88
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95811 TC 3 $674.68
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95812 TC 3 $184.53
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95816 TC 3 $164.70
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95819 TC 3 $180.97
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95822 TC 3 $179.84
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95829 TC 3 $905.90
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95860 TC 3 $31.91
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95861 TC 3 $38.78
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95867 TC 3 $30.54
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95868 TC 3 $37.06
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95875 TC 3 $37.30
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95903 TC 3 $31.91
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95904 TC 3 $29.32
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95920 TC 3 $42.72
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95921 TC 3 $28.58
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95922 TC 3 $40.04
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95923 TC 3 $70.35
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95925 TC 3 $90.17
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95926 TC 3 $88.32
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95928 TC 3 $113.48
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95929 TC 3 $123.46
95930 26 3 $17.42
95930 TC 3 $86.75
95933 26 3 $29.44
95933 TC 3 $33.60
95934 26 3 $25.36
95934 TC 3 $21.92
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95950 TC 3 $160.78
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95953 26 3 $160.82
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95956 TC 3 $555.26
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95957 TC 3 $160.00
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95961 TC 3 $71.19
95962 26 3 $161.19
95962 TC 3 $47.52
95965 26 3 $402.28
95966 26 3 $200.37
95967 26 3 $171.43
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A7017 UE 3 $96.17
B9000 RR 3 $125.00
B9000 UE 3 $741.00
B9002 RR 3 $125.00
B9002 UE 3 $741.00
B9004 RR 3 $403.88
B9004 UE 3 $1,913.41
B9006 RR 3 $400.00
B9006 UE 3 $1,478.10
E0100 RR 3 $4.84
E0100 UE 3 $16.08
E0105 RR 3 $7.46
E0105 UE 3 $32.84
E0110 RR 3 $15.31
E0110 UE 3 $52.16
E0111 RR 3 $8.06
E0111 UE 3 $39.32
E0112 RR 3 $9.50
E0112 UE 3 $27.00
E0113 RR 3 $4.92
E0113 UE 3 $15.18
E0114 RR 3 $8.20
E0114 UE 3 $34.12
E0116 RR 3 $5.17
E0116 UE 3 $17.07
E0130 RR 3 $16.10
E0130 UE 3 $51.20
E0135 RR 3 $16.51
E0135 UE 3 $56.91
E0141 RR 3 $21.39
E0141 UE 3 $82.73
E0143 RR 3 $20.66
E0143 UE 3 $86.08
E0144 RR 3 $25.91
E0144 UE 3 $194.21
E0147 RR 3 $54.98
E0147 UE 3 $412.45
E0148 RR 3 $12.17
E0148 UE 3 $91.15
E0149 RR 3 $21.35
E0149 UE 3 $160.14
E0153 RR 3 $7.49
E0153 UE 3 $49.77
E0154 RR 3 $8.19
E0154 UE 3 $49.77
E0155 RR 3 $3.68
E0155 UE 3 $23.01
E0156 RR 3 $3.23
E0156 UE 3 $18.99
E0157 RR 3 $8.60
E0157 UE 3 $49.97
E0158 RR 3 $3.39
E0158 UE 3 $23.24
E0160 RR 3 $4.14
E0160 UE 3 $23.70
E0161 RR 3 $3.41
E0161 UE 3 $18.80
E0162 RR 3 $14.62
E0162 UE 3 $108.10
E0163 RR 3 $23.37
E0163 UE 3 $81.36
E0165 RR 3 $15.32
E0165 UE 3 $96.45
E0167 RR 3 $1.21
E0167 UE 3 $7.58
E0168 RR 3 $14.50
E0168 UE 3 $108.28
E0175 RR 3 $5.39
E0175 UE 3 $39.64
E0181 RR 3 $22.47
E0181 UE 3 $201.60
E0182 RR 3 $25.05
E0182 UE 3 $216.38
E0183 UE 9 $233.34
E0184 RR 3 $23.50
E0184 UE 3 $142.86
E0185 RR 3 $42.99
E0185 UE 3 $234.85
E0186 RR 3 $19.42
E0187 RR 3 $22.21
E0188 UE 3 $14.04
E0189 RR 3 $3.63
E0189 UE 3 $23.31
E0191 RR 3 $0.97
E0191 UE 3 $7.14
E0193 RR 3 $806.39
E0193 UE 3 $5,217.23
E0194 RR 3 $3,113.39
E0196 RR 3 $30.54
E0197 RR 3 $29.25
E0197 UE 3 $186.21
E0198 RR 3 $21.96
E0198 UE 3 $160.86
E0199 RR 3 $3.06
E0199 UE 3 $23.00
E0200 RR 3 $10.29
E0200 UE 3 $56.90
E0202 RR 3 $59.90
E0202 UE 3 $673.58
E0205 RR 3 $20.42
E0205 UE 3 $118.35
E0210 RR 3 $2.94
E0210 UE 3 $23.42
E0215 RR 3 $7.09
E0215 UE 3 $50.83
E0217 RR 3 $44.96
E0217 UE 3 $302.77
E0225 RR 3 $31.15
E0225 UE 3 $237.02
E0235 RR 3 $16.51
E0235 UE 3 $148.28
E0236 RR 3 $38.12
E0238 RR 3 $2.60
E0238 UE 3 $19.02
E0239 RR 3 $43.04
E0239 UE 3 $322.78
E0249 RR 3 $10.47
E0249 UE 3 $71.46
E0250 RR 3 $93.53
E0250 UE 3 $712.05
E0251 RR 3 $70.87
E0251 UE 3 $601.88
E0255 RR 3 $112.39
E0255 UE 3 $688.88
E0256 RR 3 $75.06
E0260 RR 3 $160.65
E0260 UE 3 $1,083.60
E0261 RR 3 $131.01
E0265 RR 3 $191.23
E0265 UE 3 $1,412.85
E0266 RR 3 $144.42
E0266 UE 3 $938.40
E0271 RR 3 $22.07
E0271 UE 3 $165.95
E0272 RR 3 $20.21
E0272 UE 3 $139.85
E0275 RR 3 $1.52
E0275 UE 3 $10.98
E0276 RR 3 $1.49
E0276 UE 3 $10.07
E0277 RR 3 $642.27
E0280 RR 3 $3.93
E0280 UE 3 $26.55
E0290 RR 3 $71.50
E0291 RR 3 $51.95
E0292 RR 3 $74.50
E0293 RR 3 $68.41
E0294 RR 3 $124.99
E0295 RR 3 $121.83
E0296 RR 3 $157.09
E0297 RR 3 $114.39
E0305 RR 3 $17.02
E0305 UE 3 $104.02
E0310 RR 3 $21.78
E0310 UE 3 $140.55
E0325 UE 3 $6.40
E0326 RR 3 $1.14
E0326 UE 3 $7.07
E0371 RR 5 $415.05
E0372 RR 3 $503.67
E0373 RR 5 $576.95
E0424 RR 3 $230.17
E0431 RR 3 $36.19
E0434 RR 3 $36.19
E0439 RR 3 $230.17
E0445 RR 3 $195.00
E0450 RR 3 $850.00
E0451 UE O $4,296.56
E0453 RR 9 $520.64
E0457 RR 3 $58.79
E0459 RR 3 $48.69
E0462 RR 3 $278.78
E0462 UE 3 $1,831.27
E0480 RR 3 $42.04
E0480 UE 3 $289.20
E0484 RR 3 $3.69
E0484 UE 3 $27.70
E0500 RR 3 $98.86
E0550 RR 3 $47.95
E0550 UE 3 $373.50
E0560 RR 3 $19.23
E0560 UE 3 $123.07
E0565 RR 3 $49.61
E0565 UE 3 $318.83
E0570 RR 3 $18.88
E0571 RR 5 $28.12
E0572 RR 5 $35.76
E0574 RR 5 $37.81
E0575 RR 3 $94.83
E0585 RR 3 $33.55
E0600 RR 3 $43.80
E0601 RR 3 $99.59
E0603 RR 3 $74.28
E0605 RR 3 $2.94
E0605 UE 3 $20.82
E0606 RR 3 $18.66
E0610 RR 3 $24.00
E0610 UE 3 $170.69
E0615 RR 3 $55.97
E0615 UE 3 $302.46
E0618 RR 3 $300.00
E0619 RR 3 $330.00
E0621 RR 3 $8.85
E0621 UE 3 $69.23
E0627 RR 3 $31.64
E0627 UE 3 $237.27
E0628 RR 3 $31.64
E0628 UE 3 $237.27
E0629 RR 3 $31.64
E0629 UE 3 $237.27
E0630 RR 3 $97.47
E0630 UE 3 $662.78
E0635 RR 3 $99.50
E0635 UE 3 $637.65
E0650 RR 3 $85.01
E0650 UE 3 $516.77
E0651 RR 3 $87.87
E0651 UE 3 $658.99
E0652 RR 3 $501.26
E0652 UE 3 $3,759.53
E0655 RR 3 $12.13
E0655 UE 3 $65.91
E0660 RR 3 $15.91
E0660 UE 3 $104.30
E0665 RR 3 $13.46
E0665 UE 3 $83.66
E0666 RR 3 $13.62
E0666 UE 3 $84.24
E0667 RR 3 $30.98
E0667 UE 3 $232.30
E0668 RR 3 $35.46
E0668 UE 3 $269.50
E0669 RR 3 $16.66
E0669 UE 3 $124.90
E0720 RR 3 $29.59
E0730 RR 3 $33.38
E0730 UE 3 $265.88
E0744 RR 3 $87.60
E0744 UE 3 $632.40
E0745 RR 3 $85.64
E0745 UE 3 $603.75
E0746 UE O $521.09
E0776 RR 3 $17.84
E0776 UE 3 $100.76
E0781 RR 3 $215.39
E0781 UE 3 $1,335.90
E0782 UE O $2,774.69
E0791 RR 3 $257.13
E0791 UE 3 $1,391.93
E0840 RR 3 $15.61
E0840 UE 3 $44.67
E0850 RR 3 $12.65
E0850 UE 3 $64.08
E0855 RR 3 $48.08
E0855 UE 3 $360.64
E0860 RR 3 $6.23
E0860 UE 3 $28.23
E0870 RR 3 $12.65
E0870 UE 3 $75.39
E0880 RR 3 $18.86
E0880 UE 3 $77.27
E0890 RR 3 $30.34
E0890 UE 3 $78.87
E0900 RR 3 $26.43
E0900 UE 3 $78.17
E0910 RR 3 $19.13
E0910 UE 3 $131.93
E0920 RR 3 $44.14
E0920 UE 3 $292.05
E0930 RR 3 $39.52
E0930 UE 3 $254.40
E0935 RR 5 $21.75
E0940 RR 3 $33.26
E0940 UE 3 $217.20
E0941 RR 3 $38.56
E0941 UE 3 $278.40
E0942 RR 3 $2.24
E0942 UE 3 $14.22
E0944 RR 3 $4.40
E0944 UE 3 $32.92
E0945 RR 3 $4.24
E0945 UE 3 $32.83
E0946 RR 3 $56.60
E0946 UE 3 $408.08
E0947 RR 3 $60.17
E0947 UE 3 $435.14
E0948 RR 3 $56.10
E0948 UE 3 $395.78
E0950 RR 3 $9.96
E0950 UE 3 $74.59
E0951 RR 3 $1.81
E0951 UE 3 $13.52
E0952 RR 3 $1.81
E0952 UE 3 $13.52
E0958 RR 3 $41.74
E0958 UE 3 $278.25
E0959 RR 3 $8.50
E0959 UE 3 $64.02
E0961 RR 3 $2.78
E0961 UE 3 $20.86
E0966 RR 3 $6.19
E0966 UE 3 $46.45
E0967 RR 3 $12.65
E0967 UE 3 $94.83
E0968 RR 3 $17.15
E0968 UE 3 $111.15
E0969 RR 3 $13.99
E0969 UE 3 $104.89
E0970 RR 3 $4.11
E0970 UE 3 $34.56
E0971 RR 3 $7.14
E0971 UE 3 $47.17
E0973 RR 3 $10.47
E0973 UE 3 $82.50
E0974 RR 3 $7.95
E0974 UE 3 $56.69
E0978 RR 3 $4.26
E0978 UE 3 $32.12
E0980 RR 3 $3.15
E0980 UE 3 $23.59
E0990 RR 3 $12.65
E0990 UE 3 $87.77
E0992 RR 3 $8.85
E0992 UE 3 $66.38
E0994 RR 3 $1.52
E0994 UE 3 $11.37
E0995 RR 3 $2.54
E0995 UE 3 $18.99
E1031 RR 3 $48.32
E1031 UE 3 $352.50
E1050 RR 3 $97.43
E1050 UE 3 $651.53
E1060 RR 3 $120.61
E1060 UE 3 $769.57
E1070 RR 3 $89.06
E1070 UE 3 $544.05
E1083 RR 3 $75.33
E1083 UE 3 $462.83
E1084 RR 3 $93.85
E1084 UE 3 $590.70
E1085 RR 3 $66.21
E1085 UE 3 $443.55
E1086 RR 3 $80.40
E1086 UE 3 $540.83
E1087 RR 3 $121.03
E1087 UE 3 $855.90
E1088 RR 3 $144.24
E1088 UE 3 $890.63
E1089 RR 3 $114.99
E1089 UE 3 $798.38
E1090 RR 3 $110.73
E1090 UE 3 $633.38
E1091 RR 3 $79.76
E1091 UE 3 $640.80
E1092 RR 3 $122.94
E1092 UE 3 $896.93
E1093 RR 3 $105.74
E1093 UE 3 $763.13
E1100 RR 3 $99.32
E1100 UE 3 $627.53
E1110 RR 3 $82.66
E1110 UE 3 $541.05
E1130 RR 3 $44.67
E1130 UE 3 $316.05
E1140 RR 3 $68.73
E1140 UE 3 $498.08
E1150 RR 3 $78.04
E1150 UE 3 $581.48
E1160 RR 3 $59.79
E1160 UE 3 $420.00
E1170 RR 3 $85.45
E1170 UE 3 $522.98
E1171 RR 3 $68.33
E1171 UE 3 $480.08
E1172 RR 3 $87.87
E1172 UE 3 $537.75
E1180 RR 3 $82.41
E1180 UE 3 $497.33
E1190 RR 3 $112.01
E1190 UE 3 $693.08
E1195 RR 3 $102.16
E1195 UE 3 $562.95
E1200 RR 3 $73.20
E1200 UE 3 $447.97
E1221 RR 3 $45.45
E1222 RR 3 $64.85
E1223 RR 3 $70.81
E1223 UE 3 $477.15
E1224 RR 3 $77.64
E1225 RR 3 $43.24
E1228 RR 3 $22.79
E1230 RR 3 $194.69
E1230 UE 3 $1,454.64
E1240 RR 3 $98.55
E1240 UE 3 $641.18
E1250 RR 3 $72.71
E1250 UE 3 $441.68
E1260 RR 3 $75.79
E1260 UE 3 $467.33
E1270 RR 3 $64.19
E1270 UE 3 $407.63
E1280 RR 3 $106.74
E1280 UE 3 $681.23
E1285 RR 3 $98.07
E1285 UE 3 $592.05
E1290 RR 3 $101.77
E1290 UE 3 $566.33
E1295 RR 3 $111.11
E1295 UE 3 $679.95
E1296 RR 3 $40.61
E1296 UE 3 $299.87
E1297 RR 3 $9.44
E1297 UE 3 $63.79
E1298 RR 3 $36.55
E1298 UE 3 $274.02
E1310 RR 3 $175.72
E1310 UE 3 $1,540.80
E1353 RR 5 $308.71
E1355 RR 3 $4.67
E1355 UE 3 $35.00
E1372 RR 3 $22.66
E1372 UE 3 $115.46
E1390 RR 3 $230.17
E1405 RR 5 $263.04
E1406 RR 5 $248.37
E2000 RR 3 $50.57
G0202 26 3 $33.81
G0202 TC 3 $102.79
G0204 26 3 $42.24
G0204 TC 3 $112.23
G0206 26 3 $33.81
G0206 TC 3 $89.51
G0252 26 3 $74.46
G0252 TC 3 $447.50
K0001 RR 3 $53.27
K0001 UE 3 $399.52
K0002 RR 5 $81.43
K0003 RR 3 $76.15
K0004 RR 3 $113.03
K0005 RR 3 $183.95
K0005 UE 3 $1,379.69
K0006 RR 5 $106.07
K0015 RR 3 $18.09
K0015 UE 3 $135.60
K0017 RR 3 $5.08
K0017 UE 3 $38.14
K0018 RR 3 $2.83
K0018 UE 3 $21.33
K0019 RR 3 $1.63
K0019 UE 3 $12.19
K0020 RR 3 $4.63
K0020 UE 3 $34.66
K0037 RR 3 $4.28
K0037 UE 3 $35.95
K0038 RR 3 $2.41
K0038 UE 3 $18.11
K0039 RR 3 $5.37
K0039 UE 3 $40.21
K0040 RR 3 $7.41
K0040 UE 3 $55.71
K0041 RR 3 $5.28
K0042 RR 3 $3.61
K0042 UE 3 $27.18
K0043 RR 3 $1.94
K0043 UE 3 $14.59
K0044 RR 3 $1.66
K0044 UE 3 $12.41
K0045 RR 3 $5.64
K0045 UE 3 $42.26
K0046 RR 3 $1.94
K0046 UE 3 $14.59
K0047 RR 3 $7.64
K0047 UE 3 $57.06
K0050 RR 3 $3.22
K0050 UE 3 $24.26
K0051 RR 3 $5.26
K0051 UE 3 $39.24
K0052 RR 3 $9.19
K0052 UE 3 $68.98
K0053 RR 3 $10.14
K0053 UE 3 $76.13
K0056 RR 3 $9.47
K0056 UE 3 $70.98
K0065 RR 3 $4.43
K0065 UE 3 $33.18
K0069 RR 3 $9.94
K0069 UE 3 $74.56
K0070 RR 3 $15.50
K0070 UE 3 $136.70
K0071 RR 3 $10.87
K0071 UE 3 $81.52
K0072 RR 3 $6.54
K0072 UE 3 $49.07
K0073 RR 3 $3.46
K0073 UE 3 $25.97
K0077 RR 3 $5.85
K0077 UE 3 $43.91
K0098 RR 3 $2.71
K0098 UE 3 $20.29
K0105 RR 3 $9.88
K0105 UE 3 $74.20
K0193 RR 9 $107.84
K0195 RR 3 $21.07
Q0037 RR 5 $275.35
Procedure Percentage Pricing
Procedure Code Description Pricing Percent
D0120 PERIODIC ORAL EVALUATION 80%
D0140 LIMIT ORAL EVAL PROBLM FOCUS 80%
D0145 ORAL EVALUATION, PT < 3YRS 80%
D0150 COMPREHENSVE ORAL EVALUATION 80%
D0160 EXTENSV ORAL EVAL PROB FOCUS 80%
D0170 RE-EVAL,EST PT,PROBLEM FOCUS 80%
D0210 INTRAOR COMPLETE FILM SERIES 80%
D0220 INTRAORAL PERIAPICAL FIRST F 80%
D0230 INTRAORAL PERIAPICAL EA ADD 80%
D0240 INTRAORAL OCCLUSAL FILM 80%

D0250 EXTRAORAL FIRST FILM 80%
D0260 EXTRAORAL EA ADDITIONAL FILM 80%
D0270 DENTAL BITEWING SINGLE FILM 80%
D0272 DENTAL BITEWINGS TWO FILMS 80%
D0273 BITEWINGS - THREE FILMS 80%
D0274 DENTAL BITEWINGS FOUR FILMS 80%
D0277 VERT BITEWINGS-SEV TO EIGHT 80%
D0290 DENTAL FILM SKULL/FACIAL BON 80%
D0310 DENTAL SALIOGRAPHY 80%
D0320 DENTAL TMJ ARTHROGRAM INCL I 80%

D0321 DENTAL OTHER TMJ FILMS 80%
D0322 DENTAL TOMOGRAPHIC SURVEY 80%
D0330 DENTAL PANORAMIC FILM 80%
D0340 DENTAL CEPHALOMETRIC FILM 80%
D0360 CONE BEAM CT 80%
D0362 CONE BEAM, TWO DIMENSIONAL 80%
D0363 CONE BEAM, THREE DIMENSIONAL 80%
D0460 PULP VITALITY TEST 80%
D0470 DIAGNOSTIC CASTS 80%
D0472 GROSS EXAM, PREP & REPORT 80%
D0473 MICRO EXAM, PREP & REPORT 80%
D0474 MICRO W EXAM OF SURG MARGINS 80%
D0480 CYTOPATH SMEAR PREP & REPORT 80%

D0502 OTHER ORAL PATHOLOGY PROCEDU 80%
D0999 UNSPECIFIED DIAGNOSTIC PROCE 80%
D1110 DENTAL PROPHYLAXIS ADULT 80%
D1120 DENTAL PROPHYLAXIS CHILD 80%
D1203 TOPICAL APP FLUORIDE CHILD 80%
D1204 TOPICAL APP FLUORIDE ADULT 80%
D1206 TOPICAL FLUORIDE VARNISH 80%
D1320 TOBACCO COUNSELING 80%
D1351 DENTAL SEALANT PER TOOTH 80%
D1510 SPACE MAINTAINER FXD UNILAT 80%
D1515 FIXED BILAT SPACE MAINTAINER 80%
D1520 REMOVE UNILAT SPACE MAINTAIN 80%

D1525 REMOVE BILAT SPACE MAINTAIN 80%
D1550 RECEMENT SPACE MAINTAINER 80%
D1555 REMOVE FIX SPACE MAINTAINER 80%
D2140 AMALGAM ONE SURFACE PERMANEN 80%
D2150 AMALGAM TWO SURFACES PERMANE 80%
D2160 AMALGAM THREE SURFACES PERMA 80%
D2161 AMALGAM 4 OR > SURFACES PERM 80%
D2330 RESIN ONE SURFACE-ANTERIOR 80%
D2331 RESIN TWO SURFACES-ANTERIOR 80%
D2332 RESIN THREE SURFACES-ANTERIO 80%

D2335 RESIN 4/> SURF OR W INCIS AN 80%
D2390 ANT RESIN-BASED CMPST CROWN 80%
D2391 POST 1 SRFC RESINBASED CMPST 80%
D2394 POST >=4SRFC RESINBASE CMPST 80%
D2710 CROWN RESIN-BASED INDIRECT 80%
D2712 CROWN 3/4 RESIN-BASED COMPOS 80%
D2721 CROWN RESIN W/ BASE METAL 80%
D2722 CROWN RESIN W/ NOBLE METAL 80%
D2751 CROWN PORCELAIN FUSED BASE M 80%
D2752 CROWN PORCELAIN W/ NOBLE MET 80%
D2781 CROWN 3/4 CAST BASE METAL 80%

D2782 CROWN 3/4 CAST NOBLE METAL 80%
D2791 CROWN FULL CAST BASE METAL 80%
D2792 CROWN FULL CAST NOBLE METAL 80%
D2799 PROVISIONAL CROWN 80%
D2910 RECEMENT INLAY ONLAY OR PART 80%
D2915 RECEMENT CAST OR PREFAB POST 80%
D2920 DENTAL RECEMENT CROWN 80%
D2930 PREFAB STNLSS STEEL CRWN PRI 80%
D2931 PREFAB STNLSS STEEL CROWN PE 80%
D2932 PREFABRICATED RESIN CROWN 80%
D2933 PREFAB STAINLESS STEEL CROWN 80%
D2934 PREFAB STEEL CROWN PRIMARY 80%

D2940 DENTAL SEDATIVE FILLING 80%
D2950 CORE BUILD-UP INCL ANY PINS 80%
D2951 TOOTH PIN RETENTION 80%
D2952 POST AND CORE CAST + CROWN 80%
D2953 EACH ADDTNL CAST POST 80%
D2954 PREFAB POST/CORE + CROWN 80%
D2955 POST REMOVAL 80%
D2957 EACH ADDTNL PREFAB POST 80%
D2970 TEMPORARY- FRACTURED TOOTH 80%
D2980 CROWN REPAIR 80%

D2999 DENTAL UNSPEC RESTORATIVE PR 80%
D3110 PULP CAP DIRECT 80%
D3120 PULP CAP INDIRECT 80%
D3220 THERAPEUTIC PULPOTOMY 80%
D3221 GROSS PULPAL DEBRIDEMENT 80%
D3222 PART PULP FOR APEXOGENESIS 80%
D3230 PULPAL THERAPY ANTERIOR PRIM 80%
D3240 PULPAL THERAPY POSTERIOR PRI 80%
D3310 END THXPY, ANTERIOR TOOTH 80%
D3320 END THXPY, BICUSPID TOOTH 80%
D3330 END THXPY, MOLAR 80%
D3332 INCOMPLETE ENDODONTIC TX 80%
D3333 INTERNAL ROOT REPAIR 80%

D3346 RETREAT ROOT CANAL ANTERIOR 80%
D3347 RETREAT ROOT CANAL BICUSPID 80%
D3348 RETREAT ROOT CANAL MOLAR 80%
D3351 APEXIFICATION/RECALC INITIAL 80%
D3352 APEXIFICATION/RECALC INTERIM 80%
D3353 APEXIFICATION/RECALC FINAL 80%
D3410 APICOECT/PERIRAD SURG ANTER 80%
D3421 ROOT SURGERY BICUSPID 80%
D3425 ROOT SURGERY MOLAR 80%
D3426 ROOT SURGERY EA ADD ROOT 80%
D3430 RETROGRADE FILLING 80%
D3450 ROOT AMPUTATION 80%

D3470 INTENTIONAL REPLANTATION 80%
D3910 ISOLATION- TOOTH W RUBB DAM 80%
D3999 ENDODONTIC PROCEDURE 80%
D4210 GINGIVECTOMY/PLASTY PER QUAD 80%
D4211 GINGIVECTOMY/PLASTY PER TOOT 80%
D4230 ANA CROWN EXP 4 OR> PER QUAD 80%
D4231 ANA CROWN EXP 1-3 PER QUAD 80%
D4240 GINGIVAL FLAP PROC W/ PLANIN 80%
D4241 GNGVL FLAP W ROOTPLAN 1-3 TH 80%
D4245 APICALLY POSITIONED FLAP 80%

D4249 CROWN LENGTHEN HARD TISSUE 80%
D4260 OSSEOUS SURGERY PER QUADRANT 80%
D4261 OSSEOUS SURGL-3TEETHPERQUAD 80%
D4263 BONE REPLCE GRAFT FIRST SITE 80%
D4264 BONE REPLCE GRAFT EACH ADD 80%
D4265 BIO MTRLS TO AID SOFT/OS REG 80%
D4266 GUIDED TISS REGEN RESORBLE 80%
D4267 GUIDED TISS REGEN NONRESORB 80%
D4268 SURGICAL REVISION PROCEDURE 80%
D4270 PEDICLE SOFT TISSUE GRAFT PR 80%
D4271 FREE SOFT TISSUE GRAFT PROC 80%
D4273 SUBEPITHELIAL TISSUE GRAFT 80%
D4274 DISTAL/PROXIMAL WEDGE PROC 80%

D4275 SOFT TISSUE ALLOGRAFT 80%
D4276 CON TISSUE W DBLE PED GRAFT 80%
D4320 PROVISION SPLNT INTRACORONAL 80%
D4321 PROVISIONAL SPLINT EXTRACORO 80%
D4341 PERIODONTAL SCALING & ROOT 80%
D4342 PERIODONTAL SCALING 1-3TEETH 80%
D4355 FULL MOUTH DEBRIDEMENT 80%
D4381 LOCALIZED DELIVERY ANTIMICRO 80%
D4910 PERIODONTAL MAINT PROCEDURES 80%
D4920 UNSCHEDULED DRESSING CHANGE 80%
D4999 UNSPECIFIED PERIODONTAL PROC 80%
D5110 DENTURES COMPLETE MAXILLARY 80%

D5120 DENTURES COMPLETE MANDIBLE 80%
D5130 DENTURES IMMEDIAT MAXILLARY 80%
D5140 DENTURES IMMEDIAT MANDIBLE 80%
D5211 DENTURES MAXILL PART RESIN 80%
D5212 DENTURES MAND PART RESIN 80%
D5213 DENTURES MAXILL PART METAL 80%
D5214 DENTURES MANDIBL PART METAL 80%
D5225 MAXILLARY PART DENTURE FLEX 80%
D5226 MANDIBULAR PART DENTURE FLEX 80%
D5410 DENTURES ADJUST CMPLT MAXIL 80%

D5411 DENTURES ADJUST CMPLT MAND 80%
D5421 DENTURES ADJUST PART MAXILL 80%
D5422 DENTURES ADJUST PART MANDBL 80%
D5510 DENTUR REPR BROKEN COMPL BAS 80%
D5520 REPLACE DENTURE TEETH COMPLT 80%
D5610 DENTURES REPAIR RESIN BASE 80%
D5620 REP PART DENTURE CAST FRAME 80%
D5630 REP PARTIAL DENTURE CLASP 80%
D5640 REPLACE PART DENTURE TEETH 80%
D5650 ADD TOOTH TO PARTIAL DENTURE 80%
D5660 ADD CLASP TO PARTIAL DENTURE 80%
D5670 REPLC TTH&ACRLC ON MTL FRMWK 80%
D5671 REPLC TTH&ACRLC MANDIBULAR 80%

D5730 DENTURE RELN CMPLT MAXIL CH 80%
D5731 DENTURE RELN CMPLT MAND CHR 80%
D5740 DENTURE RELN PART MAXIL CHR 80%
D5741 DENTURE RELN PART MAND CHR 80%
D5750 DENTURE RELN CMPLT MAX LAB 80%
D5751 DENTURE RELN CMPLT MAND LAB 80%
D5760 DENTURE RELN PART MAXIL LAB 80%
D5761 DENTURE RELN PART MAND LAB 80%
D5810 DENTURE INTERM CMPLT MAXILL 80%
D5811 DENTURE INTERM CMPLT MANDBL 80%
D5820 DENTURE INTERM PART MAXILL 80%
D5821 DENTURE INTERM PART MANDBL 80%

D5850 DENTURE TISS CONDITN MAXILL 80%
D5851 DENTURE TISS CONDTIN MANDBL 80%
D5899 REMOVABLE PROSTHODONTIC PROC 80%
D5911 FACIAL MOULAGE SECTIONAL 80%
D5912 FACIAL MOULAGE COMPLETE 80%
D5913 NASAL PROSTHESIS 80%
D5914 AURICULAR PROSTHESIS 80%
D5915 ORBITAL PROSTHESIS 80%
D5916 OCULAR PROSTHESIS 80%
D5919 FACIAL PROSTHESIS 80%

D5922 NASAL SEPTAL PROSTHESIS 80%
D5923 OCULAR PROSTHESIS INTERIM 80%
D5924 CRANIAL PROSTHESIS 80%
D5925 FACIAL AUGMENTATION IMPLANT 80%
D5926 REPLACEMENT NASAL PROSTHESIS 80%
D5927 AURICULAR REPLACEMENT 80%
D5928 ORBITAL REPLACEMENT 80%
D5929 FACIAL REPLACEMENT 80%
D5931 SURGICAL OBTURATOR 80%
D5932 POSTSURGICAL OBTURATOR 80%
D5933 REFITTING OF OBTURATOR 80%
D5934 MANDIBULAR FLANGE PROSTHESIS 80%
D5935 MANDIBULAR DENTURE PROSTH 80%

D5936 TEMP OBTURATOR PROSTHESIS 80%
D5937 TRISMUS APPLIANCE 80%
D5951 FEEDING AID 80%
D5952 PEDIATRIC SPEECH AID 80%
D5953 ADULT SPEECH AID 80%
D5954 SUPERIMPOSED PROSTHESIS 80%
D5955 PALATAL LIFT PROSTHESIS 80%
D5958 INTRAORAL CON DEF INTER PLT 80%
D5959 INTRAORAL CON DEF MOD PALAT 80%
D5960 MODIFY SPEECH AID PROSTHESIS 80%
D5986 FLUORIDE APPLICATOR 80%
D5987 COMMISSURE SPLINT 80%

D5988 SURGICAL SPLINT 80%
D5991 TOPICAL MEDICAMENT CARRIER 80%
D5999 MAXILLOFACIAL PROSTHESIS 80%
D6211 BRIDGE BASE METAL CAST 80%
D6212 BRIDGE NOBLE METAL CAST 80%
D6241 BRIDGE PORCELAIN BASE METAL 80%
D6242 BRIDGE PORCELAIN NOBEL METAL 80%
D6251 BRIDGE RESIN BASE METAL 80%
D6252 BRIDGE RESIN W/NOBLE METAL 80%
D6545 DENTAL RETAINR CAST METL 80%

D6721 CROWN RESIN W/BASE METAL 80%
D6722 CROWN RESIN W/NOBLE METAL 80%
D6751 CROWN PORCELAIN BASE METAL 80%
D6752 CROWN PORCELAIN NOBLE METAL 80%
D6791 CROWN FULL BASE METAL CAST 80%
D6792 CROWN FULL NOBLE METAL CAST 80%
D6930 DENTAL RECEMENT BRIDGE 80%
D6972 PREFAB POST & CORE PLUS RETA 80%
D6980 BRIDGE REPAIR 80%
D6985 PEDIATRIC PARTIAL DENTURE FX 80%
D6999 FIXED PROSTHODONTIC PROC 80%
D7111 EXTRACTION CORONAL REMNANTS 80%
D7140 EXTRACTION ERUPTED TOOTH/EXR 80%

D7210 REM IMP TOOTH W MUCOPER FLP 80%
D7220 IMPACT TOOTH REMOV SOFT TISS 80%
D7230 IMPACT TOOTH REMOV PART BONY 80%
D7240 IMPACT TOOTH REMOV COMP BONY 80%
D7241 IMPACT TOOTH REM BONY W/COMP 80%
D7250 TOOTH ROOT REMOVAL 80%
D7260 ORAL ANTRAL FISTULA CLOSURE 80%
D7261 PRIMARY CLOSURE SINUS PERF 80%
D7270 TOOTH REIMPLANTATION 80%
D7272 TOOTH TRANSPLANTATION 80%
D7280 EXPOSURE IMPACT TOOTH ORTHOD 80%
D7282 MOBILIZE ERUPTED/MALPOS TOOT 80%

D7283 PLACE DEVICE IMPACTED TOOTH 80%
D7290 REPOSITIONING OF TEETH 80%
D7291 TRANSSEPTAL FIBEROTOMY 80%
D7310 ALVEOPLASTY W/ EXTRACTION 80%
D7311 ALVEOLOPLASTY W/EXTRACT 1-3 80%
D7320 ALVEOPLASTY W/O EXTRACTION 80%
D7321 ALVEOLOPLASTY NOT W/EXTRACTS 80%
D7340 VESTIBULOPLASTY RIDGE EXTENS 80%
D7350 VESTIBULOPLASTY EXTEN GRAFT 80%
D7510 I&D ABSC INTRAORAL SOFT TISS 80%

D7511 INCISION/DRAIN ABSCESS INTRA 80%
D7520 I&D ABSCESS EXTRAORAL 80%
D7521 INCISION/DRAIN ABSCESS EXTRA 80%
D7530 REMOVAL FB SKIN/AREOLAR TISS 80%
D7540 REMOVAL OF FB REACTION 80%
D7550 REMOVAL OF SLOUGHED OFF BONE 80%
D7560 MAXILLARY SINUSOTOMY 80%
D7880 OCCLUSAL ORTHOTIC APPLIANCE 80%
D7899 TMJ UNSPECIFIED THERAPY 80%
D7910 DENT SUTUR RECENT WND TO 5CM 80%
D7911 DENTAL SUTURE WOUND TO 5 CM 80%
D7912 SUTURE COMPLICATE WND > 5 CM 80%
D7960 FRENULECTOMY/FRENULOTOMY 80%

D7963 FRENULOPLASTY 80%
D7970 EXCISION HYPERPLASTIC TISSUE 80%
D7971 EXCISION PERICORONAL GINGIVA 80%
D7997 APPLIANCE REMOVAL 80%
D7999 ORAL SURGERY PROCEDURE 80%
D8010 LIMITED DENTAL TX PRIMARY 80%
D8020 LIMITED DENTAL TX TRANSITION 80%
D8030 LIMITED DENTAL TX ADOLESCENT 80%
D8040 LIMITED DENTAL TX ADULT 80%
D8050 INTERCEP DENTAL TX PRIMARY 80%
D8060 INTERCEP DENTAL TX TRANSITN 80%
D8070 COMPRE DENTAL TX TRANSITION 80%

D8090 COMPRE DENTAL TX ADULT 80%
D8210 ORTHODONTIC REM APPLIANCE TX 80%
D8220 FIXED APPLIANCE THERAPY HABT 80%
D8680 ORTHODONTIC RETENTION 80%
D8690 ORTHODONTIC TREATMENT 80%
D8691 REPAIR ORTHO APPLIANCE 80%
D8692 REPLACEMENT RETAINER 80%
D8999 ORTHODONTIC PROCEDURE 80%
D9110 TX DENTAL PAIN MINOR PROC 80%
D9120 FIX PARTIAL DENTURE SECTION 80%

D9210 DENT ANESTHESIA W/O SURGERY 80%
D9220 GENERAL ANESTHESIA 80%
D9221 GENERAL ANESTHESIA EA AD 15M 80%
D9230 ANALGESIA 80%
D9241 INTRAVENOUS SEDATION 80%
D9242 IV SEDATION EA AD 30 M 80%
D9248 SEDATION (NON-IV) 80%
D9310 DENTAL CONSULTATION 80%
D9440 OFFICE VISIT AFTER HOURS 80%
D9610 DENT THERAPEUTIC DRUG INJECT 80%
D9612 THERA PAR DRUGS 2 OR > ADMIN 80%
D9910 DENT APPL DESENSITIZING MED 80%
D9911 APPL DESENSITIZING RESIN 80%

D9920 BEHAVIOR MANAGEMENT 80%
D9930 TREATMENT OF COMPLICATIONS 80%
D9940 DENTAL OCCLUSAL GUARD 80%
D9999 ADJUNCTIVE PROCEDURE 80%

Procedure RVU Pricing
Procedure Code Description RVU RVU Coeff Value
00100 ANESTH, SALIVARY GLAND 5.00 16.05
00102 ANESTH, REPAIR OF CLEFT LIP 6.00 16.05
00103 ANESTH, BLEPHAROPLASTY 5.00 16.05
00104 ANESTH, ELECTROSHOCK 4.00 16.05
00120 ANESTH, EAR SURGERY 4.00 16.05
00124 ANESTH, EAR EXAM 4.00 16.05
00126 ANESTH, TYMPANOTOMY 4.00 16.05
00140 ANESTH, PROCEDURES ON EYE 5.00 16.05
00142 ANESTH, LENS SURGERY 6.00 16.05
00144 ANESTH, CORNEAL TRANSPLANT 6.00 16.05

00145 ANESTH, VITREORETINAL SURG 6.00 16.05
00147 ANESTH, IRIDECTOMY 4.00 16.05
00148 ANESTH, EYE EXAM 4.00 16.05
00160 ANESTH, NOSE/SINUS SURGERY 5.00 16.05
00162 ANESTH, NOSE/SINUS SURGERY 7.00 16.05
00164 ANESTH, BIOPSY OF NOSE 4.00 16.05
00170 ANESTH, PROCEDURE ON MOUTH 5.00 16.05
00172 ANESTH, CLEFT PALATE REPAIR 6.00 16.05
00174 ANESTH, PHARYNGEAL SURGERY 6.00 16.05
00176 ANESTH, PHARYNGEAL SURGERY 7.00 16.05

00190 ANESTH, FACE/SKULL BONE SURG 5.00 16.05
00192 ANESTH, FACIAL BONE SURGERY 7.00 16.05
00210 ANESTH, CRANIAL SURG NOS 11.00 16.05
00211 ANESTH, CRAN SURG, HEMOTOMA 10.00 16.05
00212 ANESTH, SKULL DRAINAGE 5.00 16.05
00214 ANESTH, SKULL DRAINAGE 9.00 16.05
00215 ANESTH, SKULL REPAIR/FRACT 9.00 16.05
00216 ANESTH, HEAD VESSEL SURGERY 15.00 16.05
00218 ANESTH, SPECIAL HEAD SURGERY 13.00 16.05
00220 ANESTH, INTRCRN NERVE 10.00 16.05
00222 ANESTH, HEAD NERVE SURGERY 6.00 16.05
00300 ANESTH, HEAD/NECK/PTRUNK 5.00 16.05
00320 ANESTH, NECK ORGAN, 1 & OVER 6.00 16.05

00322 ANESTH, BIOPSY OF THYROID 3.00 16.05
00326 ANESTH, LARYNX/TRACH, < 1 YR 7.00 16.05
00350 ANESTH, NECK VESSEL SURGERY 10.00 16.05
00352 ANESTH, NECK VESSEL SURGERY 5.00 16.05
00400 ANESTH, SKIN, EXT/PER/ATRUNK 3.00 16.05
00402 ANESTH, SURGERY OF BREAST 5.00 16.05
00410 ANESTH, CORRECT HEART RHYTHM 4.00 16.05
00450 ANESTH, SURGERY OF SHOULDER 5.00 16.05
00454 ANESTH, COLLAR BONE BIOPSY 3.00 16.05

00470 ANESTH, REMOVAL OF RIB 6.00 16.05
00472 ANESTH, CHEST WALL REPAIR 10.00 16.05
00474 ANESTH, SURGERY OF RIB(S) 13.00 16.05
00500 ANESTH, ESOPHAGEAL SURGERY 15.00 16.05
00520 ANESTH, CHEST PROCEDURE 6.00 16.05
00522 ANESTH, CHEST LINING BIOPSY 4.00 16.05
00524 ANESTH, CHEST DRAINAGE 4.00 16.05
00528 ANESTH, CHEST PARTITION VIEW 8.00 16.05
00530 ANESTH, PACEMAKER INSERTION 4.00 16.05
00532 ANESTH, VASCULAR ACCESS 4.00 16.05

00534 ANESTH, CARDIOVERTER/DEFIB 7.00 16.05
00537 ANESTH, CARDIAC ELECTROPHYS 10.00 16.05
00539 ANESTH,TRACHEOBRONCHIAL RECONSTRUC 18.00 16.05
00540 ANESTH, CHEST SURGERY 13.00 16.05
00541 ANESTH, ONE LUNG VENTILATION 15.00 16.05
00542 ANESTH, RELEASE OF LUNG 15.00 16.05
00544 ANESTH, CHEST LINING REMOVAL 15.00 16.05
00546 ANESTH, LUNG,CHEST WALL SURG 15.00 16.05
00548 ANESTH, TRACHEA,BRONCHI SURG 17.00 16.05
00550 ANESTH, STERNAL DEBRIDEMENT 10.00 16.05
00560 ANESTH, HEART SURG W/O PUMP 15.00 16.05
00561 ANESTH, HEART SURG < AGE 1 25.00 16.05
00562 ANESTH HRT SURG W/PMP AGE 1+ 20.00 16.05

00563 ANESTH, HEART SURG W/ARREST 25.00 16.05
00566 ANESTH, CABG W/O PUMP 25.00 16.05
00567 ANESTH, CABG W/PUMP 18.00 16.05
00580 ANESTH, HEART/LUNG TRANSPLNT 20.00 16.05
00600 ANESTH, SPINE, CORD SURGERY 10.00 16.05
00604 ANESTH, SITTING PROCEDURE 13.00 16.05
00622 ANESTH, REMOVAL OF NERVES 13.00 16.05
00625 ANES SPINE TRANTHOR W/O VENT 13.00 16.05
00626 ANES, SPINE TRANSTHOR W/VENT 15.00 16.05
00632 ANESTH, REMOVAL OF NERVES 7.00 16.05

00635 ANESTH, LUMBAR PUNCTURE 4.00 16.05
00640 ANESTH, SPINE MANIPULATION 3.00 16.05
00700 ANESTH, ABDOMINAL WALL SURG 4.00 16.05
00702 ANESTH, FOR LIVER BIOPSY 4.00 16.05
00740 ANESTH, UPPER GI VISUALIZE 5.00 16.05
00750 ANESTH, REPAIR OF HERNIA 4.00 16.05

00770 ANESTH, BLOOD VESSEL REPAIR 15.00 16.05
00790 ANESTH, SURG UPPER ABDOMEN 7.00 16.05
00792 ANESTH, HEMORR/EXCISE LIVER 7.00 16.05
00794 ANESTH, PANCREAS REMOVAL 13.00 16.05
00796 ANESTH, FOR LIVER TRANSPLANT 30.00 16.05
00797 ANESTH, SURGERY FOR OBESITY 10.00 16.05
00802 ANESTH, FAT LAYER REMOVAL 5.00 16.05
00810 ANESTH, LOW INTESTINE SCOPE 5.00 16.05

00834 ANESTH, HERNIA REPAIR< 1 YR 5.00 16.05
00836 ANESTH HERNIA REPAIR PREEMIE 6.00 16.05
00840 ANESTH, SURG LOWER ABDOMEN 6.00 16.05
00842 ANESTH, AMNIOCENTESIS 4.00 16.05
00844 ANESTH, PELVIS SURGERY 7.00 16.05
00846 ANESTH, HYSTERECTOMY 8.00 16.05
00848 ANESTH, PELVIC ORGAN SURG 8.00 16.05
00851 ANESTH, TUBAL LIGATION 6.00 16.05
00860 ANESTH, SURGERY OF ABDOMEN 6.00 16.05
00862 ANESTH, KIDNEY/URETER SURG 7.00 16.05
00864 ANESTH, REMOVAL OF BLADDER 8.00 16.05
00865 ANESTH, REMOVAL OF PROSTATE 7.00 16.05

00866 ANESTH, REMOVAL OF ADRENAL 10.00 16.05
00868 ANESTH, KIDNEY TRANSPLANT 10.00 16.05
00869 ANESTH, VASECTOMY 3.00 16.05
00870 ANESTH, BLADDER STONE SURG 5.00 16.05
00872 ANESTH KIDNEY STONE DESTRUCT 7.00 16.05
00873 ANESTH KIDNEY STONE DESTRUCT 5.00 16.05
00880 ANESTH, ABDOMEN VESSEL SURG 15.00 16.05
00882 ANESTH, MAJOR VEIN LIGATION 10.00 16.05
00902 ANESTH, ANORECTAL SURGERY 5.00 16.05
00904 ANESTH, PERINEAL SURGERY 7.00 16.05

00906 ANESTH, REMOVAL OF VULVA 4.00 16.05
00910 ANESTH, BLADDER SURGERY 3.00 16.05
00910 ANESTH, BLADDER SURGERY 4.00 16.05
00912 ANESTH, BLADDER TUMOR SURG 5.00 16.05
00916 ANESTH, BLEEDING CONTROL 5.00 16.05
00918 ANESTH, STONE REMOVAL 5.00 16.05
00920 ANESTH, GENITALIA SURGERY 3.00 16.05
00921 ANESTH, VASECTOMY 3.00 16.05
00922 ANESTH, SPERM DUCT SURGERY 6.00 16.05
00924 ANESTH, TESTIS EXPLORATION 4.00 16.05
00926 ANESTH, REMOVAL OF TESTIS 4.00 16.05

00928 ANESTH, REMOVAL OF TESTIS 6.00 16.05
00930 ANESTH, TESTIS SUSPENSION 4.00 16.05
00932 ANESTH, AMPUTATION OF PENIS 4.00 16.05
00934 ANESTH, PENIS, NODES REMOVAL 6.00 16.05
00936 ANESTH, PENIS, NODES REMOVAL 8.00 16.05
00940 ANESTH, VAGINAL PROCEDURES 3.00 16.05
00942 ANESTH, SURG ON VAG/URETHRAL 4.00 16.05
00944 ANESTH, VAGINAL HYSTERECTOMY 6.00 16.05
00948 ANESTH, REPAIR OF CERVIX 4.00 16.05
00950 ANESTH, VAGINAL ENDOSCOPY 5.00 16.05
00952 ANESTH, HYSTEROSCOPE/GRAPH 4.00 16.05
01112 ANESTH, BONE ASPIRATE/BX 5.00 16.05

01130 ANESTH, BODY CAST PROCEDURE 3.00 16.05
01140 ANESTH, AMPUTATION AT PELVIS 15.00 16.05
01150 ANESTH, PELVIC TUMOR SURGERY 10.00 16.05
01160 ANESTH, PELVIS PROCEDURE 4.00 16.05
01173 ANESTH, FX REPAIR, PELVIS 12.00 16.05
01180 ANESTH, PELVIS NERVE REMOVAL 3.00 16.05
01190 ANESTH, PELVIS NERVE REMOVAL 4.00 16.05
01200 ANESTH, HIP JOINT PROCEDURE 4.00 16.05

01202 ANESTH, ARTHROSCOPY OF HIP 4.00 16.05
01210 ANESTH, HIP JOINT SURGERY 6.00 16.05
01212 ANESTH, HIP DISARTICULATION 10.00 16.05
01214 ANESTH, HIP ARTHROPLASTY 8.00 16.05
01215 ANESTH, REVISE HIP REPAIR 10.00 16.05
01220 ANESTH, PROCEDURE ON FEMUR 4.00 16.05
01230 ANESTH, SURGERY OF FEMUR 6.00 16.05
01232 ANESTH, AMPUTATION OF FEMUR 5.00 16.05
01234 ANESTH, RADICAL FEMUR SURG 8.00 16.05
01250 ANESTH, UPPER LEG SURGERY 4.00 16.05
01250 ANESTH, UPPER LEG SURGERY 8.00 16.05
01260 ANESTH, UPPER LEG VEINS SURG 3.00 16.05
01270 ANESTH, THIGH ARTERIES SURG 8.00 16.05

01272 ANESTH, FEMORAL ARTERY SURG 4.00 16.05
01274 ANESTH, FEMORAL EMBOLECTOMY 6.00 16.05
01320 ANESTH, KNEE AREA SURGERY 4.00 16.05
01340 ANESTH, KNEE AREA PROCEDURE 4.00 16.05
01380 ANESTH, KNEE JOINT PROCEDURE 3.00 16.05
01382 ANESTH, DX KNEE ARTHROSCOPY 3.00 16.05
01390 ANESTH, KNEE AREA PROCEDURE 3.00 16.05
01400 ANESTH, KNEE JOINT SURGERY 4.00 16.05
01402 ANESTH, KNEE ARTHROPLASTY 7.00 16.05
01404 ANESTH, AMPUTATION AT KNEE 5.00 16.05

01420 ANESTH, KNEE JOINT CASTING 3.00 16.05
01430 ANESTH, KNEE VEINS SURGERY 3.00 16.05
01432 ANESTH, KNEE VESSEL SURG 6.00 16.05
01440 ANESTH, KNEE ARTERIES SURG 8.00 16.05
01442 ANESTH, KNEE ARTERY SURG 8.00 16.05
01444 ANESTH, KNEE ARTERY REPAIR 8.00 16.05
01462 ANESTH, LOWER LEG PROCEDURE 3.00 16.05
01464 ANESTH, ANKLE/FT ARTHROSCOPY 3.00 16.05
01470 ANESTH, LOWER LEG SURGERY 3.00 16.05
01472 ANESTH, ACHILLES TENDON SURG 5.00 16.05

01474 ANESTH, LOWER LEG SURGERY 5.00 16.05
01480 ANESTH, LOWER LEG BONE SURG 3.00 16.05
01482 ANESTH, RADICAL LEG SURGERY 4.00 16.05
01484 ANESTH, LOWER LEG REVISION 4.00 16.05
01486 ANESTH, ANKLE REPLACEMENT 7.00 16.05
01490 ANESTH, LOWER LEG CASTING 3.00 16.05
01500 ANESTH, LEG ARTERIES SURG 8.00 16.05
01502 ANESTH, LWR LEG EMBOLECTOMY 6.00 16.05
01520 ANESTH, LOWER LEG VEIN SURG 3.00 16.05
01522 ANESTH, LOWER LEG VEIN SURG 5.00 16.05
01620 ANESTH, SHOULDER PROCEDURE 4.00 16.05
01622 ANES DX SHOULDER ARTHROSCOPY 4.00 16.05

01634 ANESTH, SHOULDER JOINT AMPUT 9.00 16.05
01636 ANESTH, FOREQUARTER AMPUT 15.00 16.05
01638 ANESTH, SHOULDER REPLACEMENT 10.00 16.05
01650 ANESTH, SHOULDER ARTERY SURG 6.00 16.05
01652 ANESTH, SHOULDER VESSEL SURG 10.00 16.05
01654 ANESTH, SHOULDER VESSEL SURG 8.00 16.05
01656 ANESTH, ARM-LEG VESSEL SURG 10.00 16.05
01670 ANESTH, SHOULDER VEIN SURG 4.00 16.05
01680 ANESTH, SHOULDER CASTING 3.00 16.05
01682 ANESTH, AIRPLANE CAST 4.00 16.05

01710 ANESTH, ELBOW AREA SURGERY 3.00 16.05
01712 ANESTH, UPPR ARM TENDON SURG 5.00 16.05
01714 ANESTH, UPPR ARM TENDON SURG 5.00 16.05
01716 ANESTH, BICEPS TENDON REPAIR 5.00 16.05
01730 ANESTH, UPPR ARM PROCEDURE 3.00 16.05
01732 ANESTH, DX ELBOW ARTHROSCOPY 3.00 16.05
01740 ANESTH, UPPER ARM SURGERY 4.00 16.05
01742 ANESTH, HUMERUS SURGERY 5.00 16.05
01744 ANESTH, HUMERUS REPAIR 5.00 16.05
01756 ANESTH, RADICAL HUMERUS SURG 6.00 16.05

01758 ANESTH, HUMERAL LESION SURG 5.00 16.05
01760 ANESTH, ELBOW REPLACEMENT 7.00 16.05
01770 ANESTH, UPPR ARM ARTERY SURG 6.00 16.05
01772 ANESTH, UPPR ARM EMBOLECTOMY 6.00 16.05
01780 ANESTH, UPPER ARM VEIN SURG 3.00 16.05
01782 ANESTH, UPPR ARM VEIN REPAIR 4.00 16.05
01810 ANESTH, LOWER ARM SURGERY 3.00 16.05
01820 ANESTH, LOWER ARM PROCEDURE 3.00 16.05
01829 ANESTH, DX WRIST ARTHROSCOPY 3.00 16.05
01830 ANESTH, LOWER ARM SURGERY 3.00 16.05
01832 ANESTH, WRIST REPLACEMENT 6.00 16.05
01840 ANESTH, LWR ARM ARTERY SURG 6.00 16.05
01842 ANESTH, LWR ARM EMBOLECTOMY 6.00 16.05

01844 ANESTH, VASCULAR SHUNT SURG 6.00 16.05
01850 ANESTH, LOWER ARM VEIN SURG 3.00 16.05
01852 ANESTH, LWR ARM VEIN REPAIR 4.00 16.05
01860 ANESTH, LOWER ARM CASTING 3.00 16.05
01905 ANES, SPINE INJECT, X-RAY/RE 5.00 16.05
01916 ANESTH, DX ARTERIOGRAPHY 6.00 16.05
01920 ANESTH, CATHETERIZE HEART 7.00 16.05
01922 ANESTH, CAT OR MRI SCAN 7.00 16.05
01924 ANES, THER INTERVEN RAD, ART 6.00 16.05
01925 ANES, THER INTERVEN RAD, CAR 8.00 16.05
01926 ANES, TX INTERV RAD HRT/CRAN 10.00 16.05
01930 ANES, THER INTERVEN RAD, VEI 5.00 16.05

01931 ANES, THER INTERVEN RAD, TIP 6.00 16.05
01932 ANES, TX INTERV RAD, TH VEIN 8.00 16.05
01933 ANES, TX INTERV RAD, CRAN V 10.00 16.05
01935 ANESTH, PERC IMG DX SP PROC 5.00 16.05
01936 ANESTH, PERC IMG TX SP PROC 5.00 16.05
01951 ANESTH, BURN, LESS 4 PERCENT 3.00 16.05
01952 ANESTH, BURN, 4-9 PERCENT 5.00 16.05
01958 ANESTH, ANTEPARTUM MANIPUL 5.00 16.05
01960 ANESTH, VAGINAL DELIVERY 5.00 16.05
01961 ANESTH, CS DELIVERY 3.00 16.05

01961 ANESTH, CS DELIVERY 7.00 16.05
01962 ANESTH, EMER HYSTERECTOMY 5.00 16.05
01963 ANESTH, CS HYSTERECTOMY 8.00 16.05
01964 ANESTH, ABORTION PROCEDURES 4.00 16.05
01965 ANESTH, INC/MISSED AB PROC 4.00 16.05
01966 ANESTH, INDUCED AB PROCEDURE 4.00 16.05
01967 ANESTH/ANALG, VAG DELIVERY 5.00 16.05
01968 ANES/ANALG CS DELIVER ADD-ON 3.00 16.05
01969 ANESTH/ANALG CS HYST ADD-ON 5.00 16.05
01990 SUPPORT FOR ORGAN DONOR 7.00 16.05
01991 ANESTH, NERVE BLOCK/INJ 3.00 16.05
01992 ANESTH, N BLOCK/INJ, PRONE 5.00 16.05
01995 REGIONAL ANESTHESIA LIMB 5.00 16.05

10040 ACNE SURGERY 1.92 1.00
10040 ACNE SURGERY 1.94 1.00
10040 ACNE SURGERY 2.19 1.00
10040 ACNE SURGERY 4.00 1.00
10060 DRAINAGE OF SKIN ABSCESS 1.92 1.00

10080 DRAINAGE OF PILONIDAL CYST 1.99 1.00
10120 REMOVE FOREIGN BODY 1.68 1.00

10140 DRAINAGE OF HEMATOMA/FLUID 2.55 1.00
10160 PUNCTURE DRAINAGE OF LESION 1.73 1.00

10180 COMPLEX DRAINAGE, WOUND 3.00 1.00
11000 DEBRIDE INFECTED SKIN 0.85 1.00
11001 DEBRIDE INFECTED SKIN ADD-ON 0.43 1.00
11004 DEBRIDE GENITALIA & PERINEUM 15.03 1.00
11005 DEBRIDE ABDOM WALL 19.63 1.00
11006 DEBRIDE GENIT/PER/ABDOM WALL 18.72 1.00

11008 REMOVE MESH FROM ABD WALL 7.17 1.00
11010 DEBRIDE SKIN, FX 3.00 1.00
11011 DEBRIDE SKIN/MUSCLE, FX 3.00 1.00
11012 DEBRIDE SKIN/MUSCLE/BONE, FX 5.00 1.00

11040 DEBRIDE SKIN, PARTIAL 0.73 1.00
11041 DEBRIDE SKIN, FULL 0.92 1.00
11042 DEBRIDE SKIN/TISSUE 1.23 1.00

11043 DEBRIDE TISSUE/MUSCLE 3.00 1.00
11044 DEBRIDE TISSUE/MUSCLE/BONE 3.00 1.00
11055 TRIM SKIN LESION 0.61 1.00

11056 TRIM SKIN LESIONS, 2 TO 4 0.86 1.00
11057 TRIM SKIN LESIONS, OVER 4 1.12 1.00
11100 BIOPSY, SKIN LESION 1.23 1.00
11101 BIOPSY, SKIN ADD-ON 0.62 1.00

11200 REMOVAL OF SKIN TAGS 1.12 1.00
11201 REMOVE SKIN TAGS ADD-ON 0.43 1.00
11300 SHAVE SKIN LESION 0.76 1.00



11400 EXC TR-EXT B9+MARG 0.5 < CM 1.81 1.00
11401 EXC TR-EXT B9+MARG 0.6-1 CM 2.37 1.00


11406 EXC TR-EXT B9+MARG > 4.0 CM 3.00 1.00
11420 EXC H-F-NK-SP B9+MARG 0.5 < 2.02 1.00
11420 EXC H-F-NK-SP B9+MARG 0.5 < 2.06 1.00
11420 EXC H-F-NK-SP B9+MARG 0.5 < 3.00 1.00
11421 EXC H-F-NK-SP B9+MARG 0.6-1 2.67 1.00
11421 EXC H-F-NK-SP B9+MARG 0.6-1 2.71 1.00
11421 EXC H-F-NK-SP B9+MARG 0.6-1 2.73 1.00

11421 EXC H-F-NK-SP B9+MARG 0.6-1 3.00 1.00
11422 EXC H-F-NK-SP B9+MARG 1.1-2 3.00 1.00
11422 EXC H-F-NK-SP B9+MARG 1.1-2 3.14 1.00
11422 EXC H-F-NK-SP B9+MARG 1.1-2 3.15 1.00
11422 EXC H-F-NK-SP B9+MARG 1.1-2 3.30 1.00
11423 EXC H-F-NK-SP B9+MARG 2.1-3 3.00 1.00
11423 EXC H-F-NK-SP B9+MARG 2.1-3 3.67 1.00
11423 EXC H-F-NK-SP B9+MARG 2.1-3 3.68 1.00
11423 EXC H-F-NK-SP B9+MARG 2.1-3 3.85 1.00
11424 EXC H-F-NK-SP B9+MARG 3.1-4 3.00 1.00
11424 EXC H-F-NK-SP B9+MARG 3.1-4 4.28 1.00
11424 EXC H-F-NK-SP B9+MARG 3.1-4 4.29 1.00
11424 EXC H-F-NK-SP B9+MARG 3.1-4 4.44 1.00

11426 EXC H-F-NK-SP B9+MARG > 4 CM 3.00 1.00
11440 EXC FACE-MM B9+MARG 0.5 < CM 2.42 1.00
11441 EXC FACE-MM B9+MARG 0.6-1 CM 3.00 1.00


11446 EXC FACE-MM B9+MARG > 4 CM 3.00 1.00
11450 REMOVAL, SWEAT GLAND LESION 3.97 1.00


11600 EXC TR-EXT MLG+MARG 0.5 < CM 2.39 1.00
11601 EXC TR-EXT MLG+MARG 0.6-1 CM 3.00 1.00


11606 EXC TR-EXT MLG+MARG > 4 CM 3.00 1.00
11620 EXC H-F-NK-SP MLG+MARG 0.5 < 2.25 1.00
11621 EXC H-F-NK-SP MLG+MARG 0.6-1 3.00 1.00


11626 EXC H-F-NK-SP MLG+MAR > 4 CM 3.00 1.00
11640 EXC FACE-MM MALIG+MARG 0.5 < 2.59 1.00
11641 EXC FACE-MM MALIG+MARG 0.6-1 3.88 1.00

11646 EXC FACE-MM MLG+MARG > 4 CM 3.00 1.00
11719 TRIM NAIL(S) 0.24 1.00

11719 TRIM NAIL(S) 0.25 1.00
11720 DEBRIDE NAIL, 1-5 0.45 1.00
11720 DEBRIDE NAIL, 1-5 0.47 1.00
11720 DEBRIDE NAIL, 1-5 3.00 1.00
11721 DEBRIDE NAIL, 6 OR MORE 0.78 1.00
11730 REMOVAL OF NAIL PLATE 1.56 1.00

11732 REMOVE NAIL PLATE, ADD-ON 0.81 1.00
11732 REMOVE NAIL PLATE, ADD-ON 0.85 1.00
11740 DRAIN BLOOD FROM UNDER NAIL 0.54 1.00
11750 REMOVAL OF NAIL BED 2.79 1.00
11752 REMOVE NAIL BED/FINGER TIP 3.00 1.00

11755 BIOPSY, NAIL UNIT 1.92 1.00
11760 REPAIR OF NAIL BED 3.00 1.00
11760 REPAIR OF NAIL BED 3.33 1.00
11762 RECONSTRUCTION OF NAIL BED 3.00 1.00

11765 EXCISION OF NAIL FOLD, TOE 1.23 1.00
11770 REMOVAL OF PILONIDAL LESION 4.00 1.00

11900 INJECTION INTO SKIN LESIONS 0.76 1.00
11901 ADDED SKIN LESIONS INJECTION 1.19 1.00

11920 CORRECT SKIN COLOR DEFECTS 2.58 1.00
11950 THERAPY FOR CONTOUR DEFECTS 1.30 1.00

11960 INSERT TISSUE EXPANDER(S) 5.00 1.00

11970 REPLACE TISSUE EXPANDER 12.81 1.00
11971 REMOVE TISSUE EXPANDER(S) 3.00 1.00
11975 INSERT CONTRACEPTIVE CAP 2.17 1.00

11976 REMOVAL OF CONTRACEPTIVE CAP 2.54 1.00
11977 REMOVAL/REINSERT CONTRA CAP 4.82 1.00
11980 IMPLANT HORMONE PELLET(S) 2.12 1.00
11980 IMPLANT HORMONE PELLET(S) 2.14 1.00
11981 INSERT DRUG IMPLANT DEVICE 2.20 1.00

11982 REMOVE DRUG IMPLANT DEVICE 2.65 1.00
11983 REMOVE/INSERT DRUG IMPLANT 4.89 1.00
12001 REPAIR SUPERFICIAL WOUND(S) 2.27 1.00





12020 CLOSURE OF SPLIT WOUND 4.28 1.00
12031 INTMD WND REPAIR S/TR/EXT 3.07 1.00


12041 INTMD WND REPAIR N-HF/GENIT 3.37 1.00

12042 INTMD WND REPAIR N-HG/GENIT 4.00 1.00

12051 INTMD WND REPAIR FACE/MM 4.00 1.00

12054 INTMD WND REPAIR, FACE/MM 4.00 1.00

13100 REPAIR OF WOUND OR LESION 4.00 1.00

13102 REPAIR WOUND/LESION ADD-ON 1.92 1.00




13160 LATE CLOSURE OF WOUND 3.00 1.00
14000 SKIN TISSUE REARRANGEMENT 4.00 1.00



15000 WOUND PREP, 1ST 100 SQ CM 3.00 1.00

15001 WOUND PREP, ADDL 100 SQ CM 1.53 1.00
15002 WOUND PREP, TRK/ARM/LEG 5.87 1.00
15003 WOUND PREP, ADDL 100 CM 1.19 1.00
15004 WOUND PREP, F/N/HF/G 7.34 1.00
15005 WND PREP, F/N/HF/G, ADDL CM 2.36 1.00
15040 HARVEST CULTURED SKIN GRAFT 3.29 1.00
15050 SKIN PINCH GRAFT 3.00 1.00

15100 SKIN SPLT GRFT, TRNK/ARM/LEG 4.00 1.00
15101 SKIN SPLT GRFT T/A/L, ADD-ON 2.91 1.00
15110 EPIDRM AUTOGRFT TRNK/ARM/LEG 18.60 1.00
15111 EPIDRM AUTOGRFT T/A/L ADD-ON 2.81 1.00
15115 EPIDRM A-GRFT FACE/NCK/HF/G 19.20 1.00

15116 EPIDRM A-GRFT F/N/HF/G ADDL 3.87 1.00
15120 SKN SPLT A-GRFT FAC/NCK/HF/G 4.00 1.00
15121 SKN SPLT A-GRFT F/N/HF/G ADD 4.45 1.00
15130 DERM AUTOGRAFT, TRNK/ARM/LEG 14.14 1.00
15131 DERM AUTOGRAFT T/A/L ADD-ON 2.30 1.00
15135 DERM AUTOGRAFT FACE/NCK/HF/G 19.38 1.00
15136 DERM AUTOGRAFT, F/N/HF/G ADD 2.18 1.00
15150 CULT EPIDERM GRFT T/ARM/LEG 16.15 1.00

15151 CULT EPIDERM GRFT T/A/L ADDL 3.04 1.00
15152 CULT EPIDERM GRAFT T/A/L +% 4.00 1.00
15155 CULT EPIDERM GRAFT, F/N/HF/G 17.25 1.00
15156 CULT EPIDRM GRFT F/N/HFG ADD 4.33 1.00
15157 CULT EPIDERM GRFT F/N/HFG +% 4.70 1.00
15170 ACELL GRAFT TRUNK/ARMS/LEGS 9.25 1.00
15171 ACELL GRAFT T/ARM/LEG ADD-ON 2.30 1.00
15175 ACELLULAR GRAFT, F/N/HF/G 12.26 1.00
15176 ACELL GRAFT, F/N/HF/G ADD-ON 3.64 1.00
15200 SKIN FULL GRAFT, TRUNK 3.00 1.00

15201 SKIN FULL GRAFT TRUNK ADD-ON 2.08 1.00
15220 SKIN FULL GRAFT SCLP/ARM/LEG 3.00 1.00

15221 SKIN FULL GRAFT ADD-ON 1.89 1.00
15240 SKIN FULL GRFT FACE/GENIT/HF 3.00 1.00
15260 SKIN FULL GRAFT EEN & LIPS 4.00 1.00

15300 APPLY SKINALLOGRFT, T/ARM/LG 7.38 1.00
15301 APPLY SKNALLOGRFT T/A/L ADDL 1.51 1.00
15320 APPLY SKIN ALLOGRFT F/N/HF/G 8.36 1.00
15321 APLY SKNALLOGRFT F/N/HFG ADD 2.27 1.00
15330 APLY ACELL ALOGRFT T/ARM/LEG 6.72 1.00
15331 APLY ACELL GRFT T/A/L ADD-ON 1.52 1.00
15335 APPLY ACELL GRAFT, F/N/HF/G 7.18 1.00
15336 APLY ACELL GRFT F/N/HF/G ADD 2.09 1.00
15340 APPLY CULT SKIN SUBSTITUTE 6.84 1.00

15341 APPLY CULT SKIN SUB ADD-ON 0.72 1.00
15342 CULTURED SKIN GRAFT, 25 CM 1.66 1.00
15343 CULTURE SKN GRAFT ADDL 25 CM 0.37 1.00
15350 SKIN HOMOGRAFT 3.00 1.00
15351 SKIN HOMOGRAFT ADD-ON 1.50 1.00

15351 SKIN HOMOGRAFT ADD-ON 1.52 1.00
15360 APPLY CULT DERM SUB, T/A/L 7.70 1.00
15361 APLY CULT DERM SUB T/A/L ADD 1.66 1.00
15365 APPLY CULT DERM SUB F/N/HF/G 7.69 1.00
15366 APPLY CULT DERM F/HF/G ADD 2.07 1.00
15400 APPLY SKIN XENOGRAFT, T/A/L 3.00 1.00
15401 APPLY SKN XENOGRFT T/A/L ADD 1.50 1.00
15401 APPLY SKN XENOGRFT T/A/L ADD 1.57 1.00
15420 APPLY SKIN XGRAFT, F/N/HF/G 9.84 1.00
15421 APPLY SKN XGRFT F/N/HF/G ADD 2.24 1.00

15430 APPLY ACELLULAR XENOGRAFT 12.58 1.00
15570 FORM SKIN PEDICLE FLAP 4.00 1.00

15600 SKIN GRAFT 4.00 1.00
15600 SKIN GRAFT 4.44 1.00
15600 SKIN GRAFT 4.84 1.00
15600 SKIN GRAFT 5.04 1.00
15610 SKIN GRAFT 4.00 1.00

15610 SKIN GRAFT 5.29 1.00
15610 SKIN GRAFT 5.75 1.00
15610 SKIN GRAFT 5.97 1.00
15620 SKIN GRAFT 4.00 1.00
15620 SKIN GRAFT 6.61 1.00
15620 SKIN GRAFT 6.95 1.00
15620 SKIN GRAFT 7.87 1.00
15630 SKIN GRAFT 4.00 1.00
15630 SKIN GRAFT 7.21 1.00
15630 SKIN GRAFT 7.54 1.00
15630 SKIN GRAFT 8.59 1.00
15650 TRANSFER SKIN PEDICLE FLAP 4.00 1.00

15731 FOREHEAD FLAP W/VASC PEDICLE 25.57 1.00
15732 MUSCLE-SKIN GRAFT, HEAD/NECK 4.00 1.00
15734 MUSCLE-SKIN GRAFT, TRUNK 4.00 1.00

15736 MUSCLE-SKIN GRAFT, ARM 3.00 1.00
15738 MUSCLE-SKIN GRAFT, LEG 3.00 1.00
15740 ISLAND PEDICLE FLAP GRAFT 4.00 1.00

15750 NEUROVASCULAR PEDICLE GRAFT 4.00 1.00
15756 FREE MYO/SKIN FLAP MICROVASC 4.00 1.00
15757 FREE SKIN FLAP, MICROVASC 4.00 1.00

15758 FREE FASCIAL FLAP, MICROVASC 4.00 1.00
15760 COMPOSITE SKIN GRAFT 4.00 1.00
15770 DERMA-FAT-FASCIA GRAFT 4.00 1.00

15775 HAIR TRANSPLANT PUNCH GRAFTS 4.00 1.00

15780 ABRASION TREATMENT OF SKIN 4.00 1.00

15786 ABRASION, LESION, SINGLE 3.43 1.00
15787 ABRASION, LESIONS, ADD-ON 0.49 1.00
15787 ABRASION, LESIONS, ADD-ON 0.51 1.00
15810 SALABRASION 4.00 1.00
15811 SALABRASION 10.64 1.00
15811 SALABRASION 10.95 1.00

15811 SALABRASION 11.53 1.00
15819 PLASTIC SURGERY, NECK 16.82 1.00
15820 REVISION OF LOWER EYELID 4.00 1.00

15822 REVISION OF UPPER EYELID 4.00 1.00
15830 EXC SKIN ABD 29.96 1.00
15831 EXCISE EXCESSIVE SKIN TISSUE 4.00 1.00



15840 GRAFT FOR FACE NERVE PALSY 4.00 1.00

15842 FLAP FOR FACE NERVE PALSY 4.00 1.00
15845 SKIN AND MUSCLE REPAIR, FACE 4.00 1.00

15850 REMOVAL OF SUTURES 5.00 1.00
15852 DRESSING CHANGE NOT FOR BURN 1.24 1.00

15860 TEST FOR BLOOD FLOW IN GRAFT 2.89 1.00
15920 REMOVAL OF TAIL BONE ULCER 4.00 1.00
15931 REMOVE SACRUM PRESSURE SORE 4.00 1.00



15940 REMOVE HIP PRESSURE SORE 4.00 1.00

15950 REMOVE THIGH PRESSURE SORE 4.00 1.00


16000 INITIAL TREATMENT OF BURN(S) 1.21 1.00

16010 TREATMENT OF BURN(S) 1.30 1.00
16020 DRESS/DEBRID P-THICK BURN, S 1.12 1.00
16025 DRESS/DEBRID P-THICK BURN, M 2.68 1.00

16030 DRESS/DEBRID P-THICK BURN, L 3.17 1.00
16035 INCISION OF BURN SCAB, INITI 5.00 1.00
16036 ESCHAROTOMY; ADDÏL INCISION 2.22 1.00

16036 ESCHAROTOMY; ADDÏL INCISION 2.23 1.00
17000 DESTRUCT PREMALG LESION 0.90 1.00
17003 DESTRUCT PREMALG LES, 2-14 0.12 1.00
17003 DESTRUCT PREMALG LES, 2-14 0.23 1.00
17004 DESTROY PREMLG LESIONS 15+ 3.40 1.00
17106 DESTRUCTION OF SKIN LESIONS 7.07 1.00

17110 DESTRUCT B9 LESION, 1-14 1.14 1.00
17111 DESTRUCT LESION, 15 OR MORE 1.52 1.00

17250 CHEMICAL CAUTERY, TISSUE 0.88 1.00






17304 1 STAGE MOHS, UP TO 5 SPEC 3.00 1.00

17307 MOHS ADDL STAGE UP TO 5 SPEC 3.00 1.00
17310 MOHS ANY STAGE > 5 SPEC EACH 0.98 1.00
17311 MOHS, 1 STAGE, H/N/HF/G 9.70 1.00
17312 MOHS ADDL STAGE 5.16 1.00
17313 MOHS, 1 STAGE, T/A/L 8.71 1.00

17314 MOHS, ADDL STAGE, T/A/L 4.79 1.00
17315 MOHS SURG, ADDL BLOCK 1.36 1.00
17340 CRYOTHERAPY OF SKIN 1.06 1.00
17360 SKIN PEEL THERAPY 2.21 1.00
19000 DRAINAGE OF BREAST LESION 1.20 1.00

19001 DRAIN BREAST LESION ADD-ON 0.59 1.00
19020 INCISION OF BREAST LESION 3.00 1.00
19030 INJECTION FOR BREAST X-RAY 2.11 1.00

19100 BX BREAST PERCUT W/O IMAGE 1.80 1.00
19101 BIOPSY OF BREAST, OPEN 3.00 1.00
19102 BX BREAST PERCUT W/IMAGE 2.81 1.00

19103 BX BREAST PERCUT W/DEVICE 3.00 1.00
19105 CRYOSURG ABLATE FA, EACH 5.29 1.00
19110 NIPPLE EXPLORATION 3.00 1.00

19112 EXCISE BREAST DUCT FISTULA 3.00 1.00
19120 REMOVAL OF BREAST LESION 3.00 1.00
19125 EXCISION, BREAST LESION 3.00 1.00

19126 EXCISION, ADDL BREAST LESION 4.16 1.00
19140 REMOVAL OF BREAST TISSUE 3.00 1.00

19160 PARTIAL MASTECTOMY 3.00 1.00
19162 P-MASTECTOMY W/LN REMOVAL 3.00 1.00
19180 REMOVAL OF BREAST 3.00 1.00


19260 REMOVAL OF CHEST WALL LESION 13.00 1.00
19271 REVISION OF CHEST WALL 13.00 1.00

19272 EXTENSIVE CHEST WALL SURGERY 13.00 1.00
19290 PLACE NEEDLE WIRE, BREAST 1.75 1.00

19295 PLACE BREAST CLIP, PERCUT 2.36 1.00
19296 PLACE PO BREAST CATH FOR RAD 5.31 1.00
19297 PLACE BREAST CATH FOR RAD 2.40 1.00
19298 PLACE BREAST RAD TUBE/CATHS 8.70 1.00
19301 PARTICAL MASTECTOMY 15.22 1.00
19303 MAST, SIMPLE, COMPLETE 23.52 1.00
19304 MAST, SUBQ 13.78 1.00

19305 MAST, RADICAL 27.37 1.00
19306 MAST, RAD, URBAN TYPE 28.71 1.00
19307 MAST, MOD RAD 28.89 1.00
19316 SUSPENSION OF BREAST 5.00 1.00
19318 REDUCTION OF LARGE BREAST 6.00 1.00
19328 REMOVAL OF BREAST IMPLANT 6.00 1.00

19330 REMOVAL OF IMPLANT MATERIAL 6.00 1.00
19340 IMMEDIATE BREAST PROSTHESIS 10.20 1.00
19342 DELAYED BREAST PROSTHESIS 5.00 1.00

19350 BREAST RECONSTRUCTION 6.00 1.00

19361 BREAST RECONSTR W/LAT FLAP 6.00 1.00

19370 SURGERY OF BREAST CAPSULE 6.00 1.00

19371 REMOVAL OF BREAST CAPSULE 5.00 1.00
19380 REVISE BREAST RECONSTRUCTION 5.00 1.00

19396 DESIGN CUSTOM BREAST IMPLANT 3.42 1.00
22900 REMOVE ABDOMINAL WALL LESION 6.00 1.00
23000 REMOVAL OF CALCIUM DEPOSITS 4.00 1.00
23020 RELEASE SHOULDER JOINT 5.00 1.00

23030 DRAIN SHOULDER LESION 5.00 1.00
23031 DRAIN SHOULDER BURSA 3.00 1.00
23035 DRAIN SHOULDER BONE LESION 5.00 1.00

23040 EXPLORATORY SHOULDER SURGERY 5.00 1.00

23065 BIOPSY SHOULDER TISSUES 3.00 1.00
23075 REMOVAL OF SHOULDER LESION 3.00 1.00

23077 REMOVE TUMOR OF SHOULDER 3.00 1.00
23100 BIOPSY OF SHOULDER JOINT 5.00 1.00
23101 SHOULDER JOINT SURGERY 4.00 1.00

23105 REMOVE SHOULDER JOINT LINING 5.00 1.00
23106 INCISION OF COLLARBONE JOINT 4.00 1.00

23107 EXPLORE TREAT SHOULDER JOINT 5.00 1.00
23120 PARTIAL REMOVAL, COLLAR BONE 5.00 1.00
23125 REMOVAL OF COLLAR BONE 5.00 1.00

23130 REMOVE SHOULDER BONE, PART 5.00 1.00
23140 REMOVAL OF BONE LESION 4.00 1.00

23150 REMOVAL OF HUMERUS LESION 4.00 1.00

23170 REMOVE COLLAR BONE LESION 5.00 1.00
23172 REMOVE SHOULDER BLADE LESION 5.00 1.00

23174 REMOVE HUMERUS LESION 5.00 1.00

23190 PARTIAL REMOVAL OF SCAPULA 5.00 1.00
23195 REMOVAL OF HEAD OF HUMERUS 4.00 1.00

23210 REMOVAL OF SHOULDER BLADE 6.00 1.00
23220 PARTIAL REMOVAL OF HUMERUS 5.00 1.00

23330 REMOVE SHOULDER FOREIGN BODY 3.00 1.00


23350 INJECTION FOR SHOULDER X-RAY 1.39 1.00
23395 MUSCLE TRANSFER,SHOULDER/ARM 5.00 1.00
23397 MUSCLE TRANSFERS 29.75 1.00
23400 FIXATION OF SHOULDER BLADE 6.00 1.00

23405 INCISION OF TENDON & MUSCLE 5.00 1.00
23406 INCISE TENDON(S) & MUSCLE(S) 5.00 1.00
23410 REPAIR ROTATOR CUFF, ACUTE 4.00 1.00

23412 REPAIR ROTATOR CUFF, CHRONIC 5.00 1.00
23415 RELEASE OF SHOULDER LIGAMENT 4.00 1.00
23420 REPAIR OF SHOULDER 4.00 1.00

23430 REPAIR BICEPS TENDON 3.00 1.00
23440 REMOVE/TRANSPLANT TENDON 5.00 1.00
23450 REPAIR SHOULDER CAPSULE 5.00 1.00



23470 RECONSTRUCT SHOULDER JOINT 4.00 1.00
23480 REVISION OF COLLAR BONE 5.00 1.00

23490 REINFORCE CLAVICLE 5.00 1.00
23491 REINFORCE SHOULDER BONES 5.00 1.00
23500 TREAT CLAVICLE FRACTURE 3.00 1.00


23520 TREAT CLAVICLE DISLOCATION 3.00 1.00


23570 TREAT SHOULDER BLADE FX 4.00 1.00

23585 TREAT SCAPULA FRACTURE 5.00 1.00
23600 TREAT HUMERUS FRACTURE 4.00 1.00



23650 TREAT SHOULDER DISLOCATION 6.50 1.00

23665 TREAT DISLOCATION/FRACTURE 4.00 1.00

23700 FIXATION OF SHOULDER 4.00 1.00
23800 FUSION OF SHOULDER JOINT 4.00 1.00

23900 AMPUTATION OF ARM & GIRDLE 15.00 1.00
23920 AMPUTATION AT SHOULDER JOINT 9.00 1.00

23921 AMPUTATION FOLLOW-UP SURGERY 3.00 1.00
23930 DRAINAGE OF ARM LESION 3.00 1.00
23931 DRAINAGE OF ARM BURSA 3.00 1.00

23935 DRAIN ARM/ELBOW BONE LESION 3.00 1.00
24000 EXPLORATORY ELBOW SURGERY 3.00 1.00

24006 RELEASE ELBOW JOINT 5.00 1.00
24065 BIOPSY ARM/ELBOW SOFT TISSUE 3.00 1.00
24075 REMOVE ARM/ELBOW LESION 3.00 1.00

24077 REMOVE TUMOR OF ARM/ELBOW 6.00 1.00
24100 BIOPSY ELBOW JOINT LINING 3.00 1.00

24101 EXPLORE/TREAT ELBOW JOINT 3.00 1.00
24102 REMOVE ELBOW JOINT LINING 3.00 1.00

24105 REMOVAL OF ELBOW BURSA 3.00 1.00
24115 REMOVE/GRAFT BONE LESION 5.00 1.00

24120 REMOVE ELBOW LESION 3.00 1.00

24130 REMOVAL OF HEAD OF RADIUS 3.00 1.00
24134 REMOVAL OF ARM BONE LESION 4.00 1.00

24136 REMOVE RADIUS BONE LESION 3.00 1.00
24138 REMOVE ELBOW BONE LESION 3.00 1.00
24140 PARTIAL REMOVAL OF ARM BONE 4.00 1.00

24145 PARTIAL REMOVAL OF RADIUS 3.00 1.00
24147 PARTIAL REMOVAL OF ELBOW 4.00 1.00
24149 RADICAL RESECTION OF ELBOW 4.00 1.00

24150 EXTENSIVE HUMERUS SURGERY 6.00 1.00
24152 EXTENSIVE RADIUS SURGERY 6.00 1.00

24155 REMOVAL OF ELBOW JOINT 4.00 1.00
24160 REMOVE ELBOW JOINT IMPLANT 3.00 1.00

24164 REMOVE RADIUS HEAD IMPLANT 4.00 1.00
24200 REMOVAL OF ARM FOREIGN BODY 3.00 1.00

24220 INJECTION FOR ELBOW X-RAY 1.83 1.00
24300 MANIPULATE ELBOW W/ANESTH 3.00 1.00

24301 MUSCLE/TENDON TRANSFER 3.00 1.00
24305 ARM TENDON LENGTHENING 3.00 1.00
24310 REVISION OF ARM TENDON 3.00 1.00
24320 REPAIR OF ARM TENDON 3.00 1.00

24330 REVISION OF ARM MUSCLES 3.00 1.00
24332 TENOLYSIS, TRICEPS 3.00 1.00

24340 REPAIR OF BICEPS TENDON 3.00 1.00
24341 REPAIR ARM TENDON/MUSCLE 3.00 1.00

24342 REPAIR OF RUPTURED TENDON 4.00 1.00
24343 REPR ELBOW LAT LIGMNT W/TISS 3.00 1.00
24344 RECONSTRUCT ELBOW LAT LIGMNT 3.00 1.00

24345 REPR ELBW MED LIGMNT W/TISSU 3.00 1.00
24346 RECONSTRUCT ELBOW MED LIGMNT 3.00 1.00
24350 REPAIR OF TENNIS ELBOW 3.00 1.00


24356 REVISION OF TENNIS ELBOW 3.00 1.00
24357 REPAIR ELBOW, PERC 11.17 1.00
24358 REPAIR ELBOW W/DEB, OPEN 13.20 1.00
24359 REPAIR ELBOW DEB/ATTCH OPEN 16.64 1.00
24360 RECONSTRUCT ELBOW JOINT 3.00 1.00

24363 REPLACE ELBOW JOINT 7.00 1.00

24365 RECONSTRUCT HEAD OF RADIUS 3.00 1.00
24400 REVISION OF HUMERUS 5.00 1.00

24430 REPAIR OF HUMERUS 5.00 1.00

24435 REPAIR HUMERUS WITH GRAFT 5.00 1.00
24470 REVISION OF ELBOW JOINT 4.00 1.00
24495 DECOMPRESSION OF FOREARM 4.00 1.00

24498 REINFORCE HUMERUS 5.00 1.00






24586 TREAT ELBOW FRACTURE 4.00 1.00

24600 TREAT ELBOW DISLOCATION 3.00 1.00

24650 TREAT RADIUS FRACTURE 3.00 1.00


24670 TREAT ULNAR FRACTURE 3.00 1.00

24800 FUSION OF ELBOW JOINT 3.00 1.00
24802 FUSION/GRAFT OF ELBOW JOINT 3.00 1.00
24900 AMPUTATION OF UPPER ARM 4.00 1.00


24931 AMPUTATE UPPER ARM & IMPLANT 4.00 1.00
24935 REVISION OF AMPUTATION 25.87 1.00
25000 INCISION OF TENDON SHEATH 3.00 1.00

25001 INCISE FLEXOR CARPI RADIALIS 3.00 1.00
25020 DECOMPRESS FOREARM 1 SPACE 3.00 1.00

25024 DECOMPRESS FOREARM 2 SPACES 3.00 1.00

25028 DRAINAGE OF FOREARM LESION 4.00 1.00
25031 DRAINAGE OF FOREARM BURSA 3.00 1.00
25035 TREAT FOREARM BONE LESION 3.00 1.00

25040 EXPLORE/TREAT WRIST JOINT 3.00 1.00
25065 BIOPSY FOREARM SOFT TISSUES 3.00 1.00

25075 REMOVAL FOREARM LESION SUBCU 3.00 1.00
25076 REMOVAL FOREARM LESION DEEP 3.00 1.00
25077 REMOVE TUMOR, FOREARM/WRIST 3.00 1.00

25085 INCISION OF WRIST CAPSULE 5.00 1.00
25100 BIOPSY OF WRIST JOINT 3.00 1.00

25105 REMOVE WRIST JOINT LINING 3.00 1.00
25107 REMOVE WRIST JOINT CARTILAGE 3.00 1.00
25109 EXCISE TENDON FOREARM/WRIST 13.22 1.00
25110 REMOVE WRIST TENDON LESION 3.00 1.00

25112 REREMOVE WRIST TENDON LESION 3.00 1.00

25115 REMOVE WRIST/FOREARM LESION 3.00 1.00
25118 EXCISE WRIST TENDON SHEATH 3.00 1.00
25119 PARTIAL REMOVAL OF ULNA 3.00 1.00

25120 REMOVAL OF FOREARM LESION 3.00 1.00
25125 REMOVE/GRAFT FOREARM LESION 3.00 1.00

25130 REMOVAL OF WRIST LESION 3.00 1.00
25135 REMOVE & GRAFT WRIST LESION 3.00 1.00

25145 REMOVE FOREARM BONE LESION 3.00 1.00

25170 EXTENSIVE FOREARM SURGERY 4.00 1.00
25210 REMOVAL OF WRIST BONE 3.00 1.00

25215 REMOVAL OF WRIST BONES 3.00 1.00

25246 INJECTION FOR WRIST X-RAY 2.01 1.00
25248 REMOVE FOREARM FOREIGN BODY 3.00 1.00
25250 REMOVAL OF WRIST PROSTHESIS 5.00 1.00

25259 MANIPULATE WRIST W/ANESTHES 3.00 1.00
25260 REPAIR FOREARM TENDON/MUSCLE 3.00 1.00


25275 REPAIR FOREARM TENDON SHEATH 3.00 1.00

25280 REVISE WRIST/FOREARM TENDON 3.00 1.00
25290 INCISE WRIST/FOREARM TENDON 3.00 1.00
25295 RELEASE WRIST/FOREARM TENDON 3.00 1.00

25300 FUSION OF TENDONS AT WRIST 3.00 1.00

25310 TRANSPLANT FOREARM TENDON 3.00 1.00
25315 REVISE PALSY HAND TENDON(S) 3.00 1.00

25320 REPAIR/REVISE WRIST JOINT 3.00 1.00
25332 REVISE WRIST JOINT 3.00 1.00
25335 REALIGNMENT OF HAND 3.00 1.00

25337 RECONSTRUCT ULNA/RADIOULNAR 3.00 1.00
25350 REVISION OF RADIUS 3.00 1.00

25360 REVISION OF ULNA 3.00 1.00
25365 REVISE RADIUS & ULNA 3.00 1.00
25370 REVISE RADIUS OR ULNA 3.00 1.00

25390 SHORTEN RADIUS OR ULNA 3.00 1.00
25391 LENGTHEN RADIUS OR ULNA 3.00 1.00

25392 SHORTEN RADIUS & ULNA 3.00 1.00
25393 LENGTHEN RADIUS & ULNA 3.00 1.00

25394 REPAIR CARPAL BONE, SHORTEN 3.00 1.00
25400 REPAIR RADIUS OR ULNA 4.00 1.00
25405 REPAIR/GRAFT RADIUS OR ULNA 4.00 1.00

25415 REPAIR RADIUS & ULNA 4.00 1.00
25420 REPAIR/GRAFT RADIUS & ULNA 4.00 1.00

25430 VASC GRAFT INTO CARPAL BONE 3.00 1.00
25431 REPAIR NONUNION CARPAL BONE 3.00 1.00

25440 REPAIR/GRAFT WRIST BONE 3.00 1.00
25441 RECONSTRUCT WRIST JOINT 3.00 1.00


25446 WRIST REPLACEMENT 3.00 1.00
25447 REPAIR WRIST JOINT(S) 3.00 1.00
25449 REMOVE WRIST JOINT IMPLANT 3.00 1.00

25450 REVISION OF WRIST JOINT 3.00 1.00
25490 REINFORCE RADIUS 3.00 1.00

25491 REINFORCE ULNA 3.00 1.00
25492 REINFORCE RADIUS AND ULNA 3.00 1.00
25500 TREAT FRACTURE OF RADIUS 3.00 1.00


25530 TREAT FRACTURE OF ULNA 3.00 1.00

25560 TREAT FRACTURE RADIUS & ULNA 3.00 1.00


25575 TREAT FRACTURE RADIUS/ULNA 3.00 1.00

25606 TREAT FX DISTAL RADIAL 16.74 1.00
25607 TREAT FX RAD EXTRA-ARTICUL 18.08 1.00
25608 TREAT FX RAD INTRA-ARTICUL 20.72 1.00
25609 TREAT FX RADIAL 3+ FRAG 26.46 1.00

25622 TREAT WRIST BONE FRACTURE 3.00 1.00


25651 PIN ULNAR STYLOID FRACTURE 3.00 1.00
25652 TREAT FRACTURE ULNAR STYLOID 3.00 1.00

25660 TREAT WRIST DISLOCATION 3.00 1.00
25671 PIN RADIOULNAR DISLOCATION 3.00 1.00

25680 TREAT WRIST FRACTURE 3.00 1.00


25800 FUSION OF WRIST JOINT 3.00 1.00
25805 FUSION/GRAFT OF WRIST JOINT 3.00 1.00

25820 FUSION OF HAND BONES 3.00 1.00
25825 FUSE HAND BONES WITH GRAFT 3.00 1.00
25830 FUSION, RADIOULNAR JNT/ULNA 3.00 1.00

25900 AMPUTATION OF FOREARM 4.00 1.00


25920 AMPUTATE HAND AT WRIST 3.00 1.00

25927 AMPUTATION OF HAND 5.00 1.00

26010 DRAINAGE OF FINGER ABSCESS 3.00 1.00
26020 DRAIN HAND TENDON SHEATH 3.00 1.00

26025 DRAINAGE OF PALM BURSA 3.00 1.00
26030 DRAINAGE OF PALM BURSA(S) 4.00 1.00
26034 TREAT HAND BONE LESION 3.00 1.00

26035 DECOMPRESS FINGERS/HAND 3.00 1.00
26040 RELEASE PALM CONTRACTURE 3.00 1.00

26055 INCISE FINGER TENDON SHEATH 3.00 1.00
26060 INCISION OF FINGER TENDON 3.00 1.00

26070 EXPLORE/TREAT HAND JOINT 3.00 1.00
26075 EXPLORE/TREAT FINGER JOINT 3.00 1.00

26100 BIOPSY HAND JOINT LINING 3.00 1.00
26105 BIOPSY FINGER JOINT LINING 3.00 1.00

26115 REMOVAL HAND LESION SUBCUT 3.00 1.00
26116 REMOVAL HAND LESION, DEEP 3.00 1.00

26117 REMOVE TUMOR, HAND/FINGER 3.00 1.00

26135 REVISE FINGER JOINT, EACH 3.00 1.00

26145 TENDON EXCISION, PALM/FINGER 3.00 1.00
26160 REMOVE TENDON SHEATH LESION 3.00 1.00

26170 REMOVAL OF PALM TENDON, EACH 3.00 1.00
26180 REMOVAL OF FINGER TENDON 3.00 1.00
26185 REMOVE FINGER BONE 3.00 1.00
26200 REMOVE HAND BONE LESION 3.00 1.00

26210 REMOVAL OF FINGER LESION 3.00 1.00
26215 REMOVE/GRAFT FINGER LESION 3.00 1.00

26230 PARTIAL REMOVAL OF HAND BONE 3.00 1.00
26235 PARTIAL REMOVAL, FINGER BONE 3.00 1.00

26250 EXTENSIVE HAND SURGERY 3.00 1.00
26260 EXTENSIVE FINGER SURGERY 3.00 1.00

26262 PARTIAL REMOVAL OF FINGER 3.00 1.00
26320 REMOVAL OF IMPLANT FROM HAND 3.00 1.00

26340 MANIPULATE FINGER W/ANESTH 3.00 1.00
26350 REPAIR FINGER/HAND TENDON 3.00 1.00

26352 REPAIR/GRAFT HAND TENDON 3.00 1.00


26390 REVISE HAND/FINGER TENDON 3.00 1.00

26410 REPAIR HAND TENDON 3.00 1.00
26415 EXCISION, HAND/FINGER TENDON 3.00 1.00

26416 GRAFT HAND OR FINGER TENDON 3.00 1.00
26418 REPAIR FINGER TENDON 3.00 1.00
26420 REPAIR/GRAFT FINGER TENDON 3.00 1.00


26437 REALIGNMENT OF TENDONS 3.00 1.00

26440 RELEASE PALM/FINGER TENDON 3.00 1.00
26442 RELEASE PALM & FINGER TENDON 3.00 1.00
26445 RELEASE HAND/FINGER TENDON 3.00 1.00

26449 RELEASE FOREARM/HAND TENDON 3.00 1.00
26450 INCISION OF PALM TENDON 3.00 1.00

26460 INCISE HAND/FINGER TENDON 3.00 1.00
26471 FUSION OF FINGER TENDONS 3.00 1.00

26476 TENDON LENGTHENING 3.00 1.00
26477 TENDON SHORTENING 3.00 1.00
26478 LENGTHENING OF HAND TENDON 3.00 1.00

26479 SHORTENING OF HAND TENDON 3.00 1.00
26480 TRANSPLANT HAND TENDON 3.00 1.00

26483 TRANSPLANT/GRAFT HAND TENDON 3.00 1.00
26485 TRANSPLANT PALM TENDON 3.00 1.00
26489 TRANSPLANT/GRAFT PALM TENDON 3.00 1.00

26490 REVISE THUMB TENDON 3.00 1.00
26492 TENDON TRANSFER WITH GRAFT 3.00 1.00
26494 HAND TENDON/MUSCLE TRANSFER 3.00 1.00

26497 FINGER TENDON TRANSFER 3.00 1.00

26499 REVISION OF FINGER 3.00 1.00
26500 HAND TENDON RECONSTRUCTION 5.00 1.00

26508 RELEASE THUMB CONTRACTURE 3.00 1.00
26510 THUMB TENDON TRANSFER 3.00 1.00

26516 FUSION OF KNUCKLE JOINT 3.00 1.00
26517 FUSION OF KNUCKLE JOINTS 3.00 1.00

26520 RELEASE KNUCKLE CONTRACTURE 3.00 1.00
26525 RELEASE FINGER CONTRACTURE 3.00 1.00
26530 REVISE KNUCKLE JOINT 3.00 1.00

26531 REVISE KNUCKLE WITH IMPLANT 3.00 1.00
26535 REVISE FINGER JOINT 3.00 1.00
26536 REVISE/IMPLANT FINGER JOINT 3.00 1.00

26540 REPAIR HAND JOINT 3.00 1.00
26541 REPAIR HAND JOINT WITH GRAFT 3.00 1.00

26545 RECONSTRUCT FINGER JOINT 3.00 1.00
26546 REPAIR NONUNION HAND 3.00 1.00

26550 CONSTRUCT THUMB REPLACEMENT 3.00 1.00
26551 GREAT TOE-HAND TRANSFER 3.00 1.00
26553 SINGLE TRANSFER, TOE-HAND 3.00 1.00

26554 DOUBLE TRANSFER, TOE-HAND 3.00 1.00
26555 POSITIONAL CHANGE OF FINGER 3.00 1.00

26556 TOE JOINT TRANSFER 3.00 1.00
26560 REPAIR OF WEB FINGER 3.00 1.00

26565 CORRECT METACARPAL FLAW 3.00 1.00
26567 CORRECT FINGER DEFORMITY 3.00 1.00

26568 LENGTHEN METACARPAL/FINGER 3.00 1.00
26580 REPAIR HAND DEFORMITY 3.00 1.00
26587 RECONSTRUCT EXTRA FINGER 3.00 1.00

26590 REPAIR FINGER DEFORMITY 3.00 1.00
26591 REPAIR MUSCLES OF HAND 3.00 1.00
26593 RELEASE MUSCLES OF HAND 3.00 1.00

26596 EXCISION CONSTRICTING TISSUE 3.00 1.00
26600 TREAT METACARPAL FRACTURE 3.00 1.00


26641 TREAT THUMB DISLOCATION 3.00 1.00
26645 TREAT THUMB FRACTURE 3.00 1.00

26670 TREAT HAND DISLOCATION 7.10 1.00

26676 PIN HAND DISLOCATION 3.00 1.00

26700 TREAT KNUCKLE DISLOCATION 3.00 1.00
26706 PIN KNUCKLE DISLOCATION 3.00 1.00

26720 TREAT FINGER FRACTURE, EACH 3.00 1.00



26756 PIN FINGER FRACTURE, EACH 3.00 1.00

26770 TREAT FINGER DISLOCATION 5.81 1.00
26776 PIN FINGER DISLOCATION 3.00 1.00

26820 THUMB FUSION WITH GRAFT 3.00 1.00
26841 FUSION OF THUMB 3.00 1.00

26843 FUSION OF HAND JOINT 3.00 1.00
26844 FUSION/GRAFT OF HAND JOINT 3.00 1.00

26850 FUSION OF KNUCKLE 3.00 1.00
26852 FUSION OF KNUCKLE WITH GRAFT 3.00 1.00

26860 FUSION OF FINGER JOINT 3.00 1.00
26861 FUSION OF FINGER JNT, ADD-ON 2.80 1.00
26862 FUSION/GRAFT OF FINGER JOINT 3.00 1.00
26863 FUSE/GRAFT ADDED JOINT 6.23 1.00

26910 AMPUTATE METACARPAL BONE 3.00 1.00
26951 AMPUTATION OF FINGER/THUMB 3.00 1.00

33010 DRAINAGE OF HEART SAC 3.35 1.00
33011 REPEAT DRAINAGE OF HEART SAC 3.31 1.00
33015 INCISION OF HEART SAC 10.00 1.00

33030 PARTIAL REMOVAL OF HEART SAC 15.00 1.00

33050 REMOVAL OF HEART SAC LESION 20.00 1.00
33120 REMOVAL OF HEART LESION 24.00 1.00

33140 HEART REVASCULARIZE (TMR) 20.00 1.00

33141 HEART TMR W/OTHER PROCEDURE 4.26 1.00
33200 INSERTION OF HEART PACEMAKER 15.00 1.00
33202 INSERT EPICARD ELTRD, OPEN 21.17 1.00
33203 INSERT EPICARD ELTRD, ENDO 22.18 1.00

33210 INSERTION OF HEART ELECTRODE 4.75 1.00

33212 INSERTION OF PULSE GENERATOR 6.00 1.00

33214 UPGRADE OF PACEMAKER SYSTEM 6.00 1.00
33215 REPOSITION PACING-DEFIB LEAD 8.27 1.00
33216 INSERT LEAD PACE-DEFIB, ONE 6.00 1.00

33217 INSERT LEAD PACE-DEFIB, DUAL 6.00 1.00
33218 REPAIR LEAD PACE-DEFIB, ONE 6.00 1.00
33220 REPAIR LEAD PACE-DEFIB, DUAL 6.00 1.00

33222 REVISE POCKET, PACEMAKER 3.00 1.00
33223 REVISE POCKET, PACING-DEFIB 6.00 1.00

33224 INSERT PACING LEAD & CONNECT 13.33 1.00
33225 L VENTRIC PACING LEAD ADD-ON 11.81 1.00
33226 REPOSITION L VENTRIC LEAD 12.84 1.00
33233 REMOVAL OF PACEMAKER SYSTEM 6.00 1.00

33235 REMOVAL PACEMAKER ELECTRODE 6.00 1.00
33236 REMOVE ELECTRODE/THORACOTOMY 6.00 1.00

33240 INSERT PULSE GENERATOR 6.00 1.00

33241 REMOVE PULSE GENERATOR 6.00 1.00
33243 REMOVE ELTRD/THORACOTOMY 6.00 1.00
33244 REMOVE ELTRD, TRANSVEN 6.00 1.00

33245 INSERT EPIC ELTRD PACE-DEFIB 13.00 1.00
33246 INSERT EPIC ELTRD/GENERATOR 13.00 1.00
33249 ELTRD/INSERT PACE-DEFIB 6.00 1.00

33250 ABLATE HEART DYSRHYTHM FOCUS 34.17 1.00
33253 RECONSTRUCT ATRIA 15.00 1.00

33254 ABLATE ATRIA, LMTD 37.31 1.00
33255 ABLATE ATRIA W/O BYPASS, EXT 45.59 1.00
33256 ABLATE ATRIA W/BYPASS, EXTEN 54.45 1.00
33257 ABLATE ATRIA, LMTD, ADD-ON 15.57 1.00
33258 ABLATE ATRIA, X10SV, ADD-ON 17.61 1.00
33259 ABLATE ATRIA W/BYPASS ADD-ON 23.10 1.00
33265 ABLATE ATRIA, LMTD, ENDO 37.23 1.00
33266 ABLATE ATRIA, X10SV, ENDO 51.15 1.00

33282 IMPLANT PAT-ACTIVE HT RECORD 6.00 1.00
33284 REMOVE PAT-ACTIVE HT RECORD 6.00 1.00
33300 REPAIR OF HEART WOUND 15.00 1.00

33310 EXPLORATORY HEART SURGERY 15.00 1.00

33320 REPAIR MAJOR BLOOD VESSEL(S) 15.00 1.00
33321 REPAIR MAJOR VESSEL 15.00 1.00

33330 INSERT MAJOR VESSEL GRAFT 15.00 1.00

33400 REPAIR OF AORTIC VALVE 15.00 1.00
33401 VALVULOPLASTY, OPEN 15.00 1.00
33403 VALVULOPLASTY, W/CP BYPASS 15.00 1.00

33404 PREPARE HEART-AORTA CONDUIT 20.00 1.00
33405 REPLACEMENT OF AORTIC VALVE 15.00 1.00



33415 REVISION, SUBVALVULAR TISSUE 20.00 1.00
33416 REVISE VENTRICLE MUSCLE 48.53 1.00
33420 REVISION OF MITRAL VALVE 15.00 1.00

33425 REPAIR OF MITRAL VALVE 15.00 1.00

33430 REPLACEMENT OF MITRAL VALVE 20.00 1.00
33460 REVISION OF TRICUSPID VALVE 15.00 1.00

33463 VALVULOPLASTY, TRICUSPID 15.00 1.00
33465 REPLACE TRICUSPID VALVE 15.00 1.00

33470 REVISION OF PULMONARY VALVE 15.00 1.00
33471 VALVOTOMY, PULMONARY VALVE 15.00 1.00

33475 REPLACEMENT, PULMONARY VALVE 15.00 1.00

33476 REVISION OF HEART CHAMBER 15.00 1.00
33496 REPAIR, PROSTH VALVE CLOT 15.00 1.00

33500 REPAIR HEART VESSEL FISTULA 40.43 1.00
33502 CORONARY ARTERY CORRECTION 15.00 1.00

33503 CORONARY ARTERY GRAFT 10.00 1.00
33505 REPAIR ARTERY W/TUNNEL 15.00 1.00

33506 REPAIR ARTERY, TRANSLOCATION 15.00 1.00
33507 REPAIR ART, INTRAMURAL 47.76 1.00
33508 ENDOSCOPIC VEIN HARVEST 0.45 1.00
33510 CABG, VEIN, SINGLE 20.00 1.00

33511 CABG, VEIN, TWO 20.00 1.00
33511 CABG, VEIN, TWO 49.55 1.00
33511 CABG, VEIN, TWO 51.14 1.00
33511 CABG, VEIN, TWO 58.60 1.00
33512 CABG, VEIN, THREE 20.00 1.00
33512 CABG, VEIN, THREE 52.25 1.00
33512 CABG, VEIN, THREE 53.89 1.00
33512 CABG, VEIN, THREE 65.83 1.00
33513 CABG, VEIN, FOUR 20.00 1.00
33513 CABG, VEIN, FOUR 52.90 1.00
33513 CABG, VEIN, FOUR 54.62 1.00
33513 CABG, VEIN, FOUR 67.27 1.00

33514 CABG, VEIN, FIVE 20.00 1.00
33514 CABG, VEIN, FIVE 54.28 1.00
33514 CABG, VEIN, FIVE 56.11 1.00
33514 CABG, VEIN, FIVE 71.16 1.00
33516 CABG, VEIN, SIX OR MORE 20.00 1.00
33517 CABG, ARTERY-VEIN, SINGLE 3.73 1.00

33518 CABG, ARTERY-VEIN, TWO 7.04 1.00
33519 CABG, ARTERY-VEIN, THREE 10.32 1.00
33521 CABG, ARTERY-VEIN, FOUR 13.63 1.00

33522 CABG, ARTERY-VEIN, FIVE 16.94 1.00
33523 CABG, ART-VEIN, SIX OR MORE 20.00 1.00
33530 CORONARY ARTERY, BYPASS/REOP 8.49 1.00

33533 CABG, ARTERIAL, SINGLE 20.00 1.00
33534 CABG, ARTERIAL, TWO 20.00 1.00
33535 CABG, ARTERIAL, THREE 20.00 1.00

33536 CABG, ARTERIAL, FOUR OR MORE 20.00 1.00
33545 REPAIR OF HEART DAMAGE 15.00 1.00

33548 RESTORE/REMODEL, VENTRICLE 80.40 1.00
33572 OPEN CORONARY ENDARTERECTOMY 6.44 1.00
33600 CLOSURE OF VALVE 15.00 1.00

33606 ANASTOMOSIS/ARTERY-AORTA 15.00 1.00
33608 REPAIR ANOMALY W/CONDUIT 15.00 1.00

33610 REPAIR BY ENLARGEMENT 15.00 1.00
33611 REPAIR DOUBLE VENTRICLE 15.00 1.00
33615 REPAIR, MODIFIED FONTAN 15.00 1.00

33617 REPAIR SINGLE VENTRICLE 15.00 1.00
33641 REPAIR HEART SEPTUM DEFECT 20.00 1.00

33645 REVISION OF HEART VEINS 20.00 1.00
33647 REPAIR HEART SEPTUM DEFECTS 20.00 1.00

33660 REPAIR OF HEART DEFECTS 15.00 1.00
33670 REPAIR OF HEART CHAMBERS 15.00 1.00

33675 CLOSE MULT VSD 54.42 1.00
33676 CLOSE MULT VSD W/RESECTION 56.75 1.00
33677 CL MULT VSD W/REM PUL BAND 58.99 1.00

33690 REINFORCE PULMONARY ARTERY 15.00 1.00


33720 REPAIR OF HEART DEFECT 15.00 1.00

33724 REPAIR VENOUS ANOMALY 43.38 1.00
33726 REPAIR PUL VENOUS STENOSIS 56.57 1.00
33730 REPAIR HEART-VEIN DEFECT(S) 20.00 1.00
33732 REPAIR HEART-VEIN DEFECT 15.00 1.00

33750 MAJOR VESSEL SHUNT 15.00 1.00

33764 MAJOR VESSEL SHUNT & GRAFT 15.00 1.00


33768 CAVOPULMONARY SHUNTING 11.87 1.00
33770 REPAIR GREAT VESSELS DEFECT 20.00 1.00



33786 REPAIR ARTERIAL TRUNK 15.00 1.00
33788 REVISION OF PULMONARY ARTERY 15.00 1.00
33800 AORTIC SUSPENSION 10.00 1.00

33802 REPAIR VESSEL DEFECT 15.00 1.00
33813 REPAIR SEPTAL DEFECT 34.96 1.00

33820 REVISE MAJOR VESSEL 15.00 1.00

33840 REMOVE AORTA CONSTRICTION 15.00 1.00

33860 ASCENDING AORTIC GRAFT 20.00 1.00


33870 TRANSVERSE AORTIC ARCH GRAFT 20.00 1.00
33875 THORACIC AORTIC GRAFT 20.00 1.00
33877 THORACOABDOMINAL GRAFT 15.00 1.00

33880 ENDOVASC TAA REPR INCL SUBCL 49.55 1.00
33881 ENDOVASC TAA REPR W/O SUBCL 42.53 1.00
33883 INSERT ENDOVASC PROSTH, TAA 31.21 1.00
33884 ENDOVASC PROSTH, TAA, ADD-ON 11.43 1.00
33886 ENDOVASC PROSTH, DELAYED 26.81 1.00
33889 ARTERY TRANSPOSE/ENDOVAS TAA 22.61 1.00
33891 CAR-CAR BP GRFT/ENDOVAS TAA 28.28 1.00
33910 REMOVE LUNG ARTERY EMBOLI 20.00 1.00

33916 SURGERY OF GREAT VESSEL 40.89 1.00
33917 REPAIR PULMONARY ARTERY 15.00 1.00

33918 REPAIR PULMONARY ATRESIA 15.00 1.00
33922 TRANSECT PULMONARY ARTERY 20.00 1.00

33924 REMOVE PULMONARY SHUNT 8.01 1.00
33925 RPR PUL ART UNIFOCAL W/O CPB 48.68 1.00
33926 REPR PUL ART, UNIFOCAL W/CPB 64.72 1.00
33935 TRANSPLANTATION, HEART/LUNG 20.00 1.00

33945 TRANSPLANTATION OF HEART 20.00 1.00
33960 EXTERNAL CIRCULATION ASSIST 26.46 1.00

33967 INSERT IA PERCUT DEVICE 4.00 1.00
33968 REMOVE AORTIC ASSIST DEVICE 0.94 1.00
33970 AORTIC CIRCULATION ASSIST 9.74 1.00

33973 INSERT BALLOON DEVICE 14.08 1.00
33974 REMOVE INTRA-AORTIC BALLOON 15.00 1.00
33975 IMPLANT VENTRICULAR DEVICE 15.00 1.00

33977 REMOVE VENTRICULAR DEVICE 15.00 1.00

33979 INSERT INTRACORPOREAL DEVICE 15.00 1.00
33980 REMOVE INTRACORPOREAL DEVICE 15.00 1.00
34001 REMOVAL OF ARTERY CLOT 10.00 1.00

34111 REMOVAL OF ARM ARTERY CLOT 10.00 1.00


34203 REMOVAL OF LEG ARTERY CLOT 8.00 1.00
34401 REMOVAL OF VEIN CLOT 10.00 1.00

34501 REPAIR VALVE, FEMORAL VEIN 8.00 1.00

34502 RECONSTRUCT VENA CAVA 20.00 1.00
34510 TRANSPOSITION OF VEIN VALVE 3.00 1.00

34520 CROSS-OVER VEIN GRAFT 3.00 1.00
34530 LEG VEIN FUSION 3.00 1.00
34800 ENDOVAS AAA REPR W/SM TUBE 7.00 1.00

34802 ENDOVAS AAA REPR W/2-P PART 7.00 1.00
34805 ENDOVAS AAA REPR W/LONG TUBE 32.75 1.00
34805 ENDOVAS AAA REPR W/LONG TUBE 33.30 1.00
34806 ANEURYSM PRESS SENSOR ADD-ON 3.00 1.00

34808 ENDOVAS ILIAC A DEVICE ADDON 5.82 1.00
34812 XPOSE FOR ENDOPROSTH, FEMORL 9.53 1.00
34813 FEMORAL ENDOVAS GRAFT ADD-ON 6.74 1.00
34813 FEMORAL ENDOVAS GRAFT ADD-ON 6.78 1.00
34820 XPOSE FOR ENDOPROSTH, ILIAC 13.75 1.00

34825 ENDOVASC EXTEND PROSTH, INIT 7.00 1.00
34826 ENDOVASC EXTEN PROSTH, ADDÏL 5.81 1.00
34830 OPEN AORTIC TUBE PROSTH REPR 15.00 1.00

34831 OPEN AORTOILIAC PROSTH REPR 15.00 1.00
34832 OPEN AORTOFEMOR PROSTH REPR 15.00 1.00

34834 XPOSE, ENDOPROSTH, BRACHIAL 7.90 1.00
34900 ENDOVASC ILIAC REPR W/GRAFT 25.53 1.00
35001 REPAIR DEFECT OF ARTERY 6.00 1.00

35002 REPAIR ARTERY RUPTURE, NECK 6.00 1.00
35013 REPAIR ARTERY RUPTURE, ARM 6.00 1.00

35022 REPAIR ARTERY RUPTURE, CHEST 6.00 1.00
35045 REPAIR DEFECT OF ARM ARTERY 6.00 1.00

35082 REPAIR ARTERY RUPTURE, AORTA 6.00 1.00


35103 REPAIR ARTERY RUPTURE, GROIN 6.00 1.00
35112 REPAIR ARTERY RUPTURE,SPLEEN 6.00 1.00

35122 REPAIR ARTERY RUPTURE, BELLY 6.00 1.00

35142 REPAIR ARTERY RUPTURE, THIGH 6.00 1.00

35152 REPAIR ARTERY RUPTURE, KNEE 6.00 1.00

35162 REPAIR ARTERY RUPTURE 6.00 1.00
35180 REPAIR BLOOD VESSEL LESION 10.00 1.00








35301 RECHANNELING OF ARTERY 6.00 1.00





35390 REOPERATION, CAROTID ADD-ON 4.58 1.00
35400 ANGIOSCOPY 4.33 1.00
35400 ANGIOSCOPY 4.39 1.00
35400 ANGIOSCOPY 4.53 1.00
35450 REPAIR ARTERIAL BLOCKAGE 14.59 1.00


35460 REPAIR VENOUS BLOCKAGE 8.83 1.00




35480 ATHERECTOMY, OPEN 15.00 1.00


35490 ATHERECTOMY, PERCUTANEOUS 6.00 1.00


35500 HARVEST VEIN FOR BYPASS 9.15 1.00
35501 ARTERY BYPASS GRAFT 6.00 1.00










35572 HARVEST FEMOROPOPLITEAL VEIN 9.91 1.00
35582 VEIN BYPASS GRAFT 3.00 1.00


35600 HARVEST ART FOR CABG ADD-ON 7.17 1.00


35623 BYPASS GRAFT, NOT VEIN 5.00 1.00

35637 BYPASS GRAFT, WITH OTHER THAN VEIN 48.36 1.00
35638 BYPASS GRAFT, WITH OTHER THAN VEIN 49.41 1.00





35681 COMPOSITE BYPASS GRAFT 2.29 1.00

35685 BYPASS GRAFT PATENCY/PATCH 5.69 1.00
35686 BYPASS GRAFT/AV FIST PATENCY 4.72 1.00
35691 ARTERIAL TRANSPOSITION 10.00 1.00


35697 REIMPLANT ARTERY EACH 4.27 1.00
35697 REIMPLANT ARTERY EACH 4.44 1.00
35700 REOPERATION, BYPASS GRAFT 4.40 1.00
35701 EXPLORATION, CAROTID ARTERY 6.00 1.00

35721 EXPLORATION, FEMORAL ARTERY 5.00 1.00
35741 EXPLORATION POPLITEAL ARTERY 4.00 1.00
35761 EXPLORATION OF ARTERY/VEIN 10.15 1.00

35800 EXPLORE NECK VESSELS 4.00 1.00
35820 EXPLORE CHEST VESSELS 18.68 1.00
35840 EXPLORE ABDOMINAL VESSELS 6.00 1.00

35860 EXPLORE LIMB VESSELS 4.00 1.00
35870 REPAIR VESSEL GRAFT DEFECT 6.00 1.00
35875 REMOVAL OF CLOT IN GRAFT 6.00 1.00

35879 REVISE GRAFT W/VEIN 8.00 1.00

35883 REVISE GRAFT W/NONAUTO GRAFT 33.95 1.00
35901 EXCISION, GRAFT, NECK 10.00 1.00
35903 EXCISION, GRAFT, EXTREMITY 8.00 1.00

35905 EXCISION, GRAFT, THORAX 15.00 1.00
35907 EXCISION, GRAFT, ABDOMEN 15.00 1.00
36000 PLACE NEEDLE IN VEIN 0.24 1.00
36000 PLACE NEEDLE IN VEIN 0.26 1.00
36002 PSEUDOANEURYSM INJECTION TRT 3.06 1.00

36002 PSEUDOANEURYSM INJECTION TRT 3.07 1.00
36005 INJECTION EXT VENOGRAPHY 1.31 1.00
36010 PLACE CATHETER IN VEIN 3.40 1.00

36013 PLACE CATHETER IN ARTERY 3.36 1.00

36100 ESTABLISH ACCESS TO ARTERY 4.00 1.00

36145 ARTERY TO VEIN SHUNT 2.76 1.00

36160 ESTABLISH ACCESS TO AORTA 3.58 1.00
36200 PLACE CATHETER IN AORTA 4.21 1.00





36260 INSERTION OF INFUSION PUMP 3.00 1.00
36261 REVISION OF INFUSION PUMP 9.28 1.00
36262 REMOVAL OF INFUSION PUMP 6.93 1.00
36400 BL DRAW < 3 YRS FEM/JUGULAR 0.48 1.00

36400 BL DRAW < 3 YRS FEM/JUGULAR 0.49 1.00
36405 BL DRAW < 3 YRS SCALP VEIN 0.40 1.00
36405 BL DRAW < 3 YRS SCALP VEIN 0.43 1.00
36406 BL DRAW < 3 YRS OTHER VEIN 0.24 1.00
36406 BL DRAW < 3 YRS OTHER VEIN 0.25 1.00
36410 NON-ROUTINE BL DRAW > 3 YRS 0.24 1.00
36420 VEIN ACCESS CUTDOWN < 1 YR 1.33 1.00
36425 VEIN ACCESS CUTDOWN > 1 YR 1.03 1.00

36430 BLOOD TRANSFUSION SERVICE 1.00 1.00
36440 BL PUSH TRANSFUSE, 2 YR OR < 1.40 1.00
36450 BL EXCHANGE/TRANSFUSE, NB 3.11 1.00
36455 BL EXCHANGE/TRANSFUSE NON-NB 3.38 1.00

36460 TRANSFUSION SERVICE, FETAL 3.00 1.00
36470 INJECTION THERAPY OF VEIN 1.58 1.00
36471 INJECTION THERAPY OF VEINS 2.27 1.00
36475 ENDOVENOUS RF, 1ST VEIN 9.29 1.00

36476 ENDOVENOUS RF, VEIN ADD-ON 4.54 1.00
36478 ENDOVENOUS LASER, 1ST VEIN 9.38 1.00

36479 ENDOVENOUS LASER VEIN ADDON 4.57 1.00
36481 INSERTION OF CATHETER, VEIN 10.19 1.00

36493 REPOSITIONING OF CVC 2.13 1.00
36493 REPOSITIONING OF CVC 999.99 1.00
36511 APHERESIS WBC 2.44 1.00

36512 APHERESIS RBC 2.48 1.00
36513 APHERESIS PLATELETS 2.50 1.00
36514 APHERESIS PLASMA 2.42 1.00

36515 APHERESIS, ADSORP/REINFUSE 2.37 1.00
36516 APHERESIS, SELECTIVE 1.71 1.00
36522 PHOTOPHERESIS 2.77 1.00

36533 INSERTION OF ACCESS DEVICE 3.00 1.00
36533 INSERTION OF ACCESS DEVICE 9.19 1.00
36534 REVISION OF ACCESS DEVICE 3.00 1.00
36534 REVISION OF ACCESS DEVICE 4.45 1.00
36535 REMOVAL OF ACCESS DEVICE 3.00 1.00
36535 REMOVAL OF ACCESS DEVICE 4.30 1.00
36536 REMOVE CVA DEVICE OBSTRUCT 5.30 1.00
36537 REMOVE CVA LUMEN OBSTRUCT 1.28 1.00
36540 COLLECT BLOOD VENOUS DEVICE 0.24 1.00
36550 DECLOT VASCULAR DEVICE 0.68 1.00

36555 INSERT NON-TUNNEL CV CATH 3.46 1.00
36557 INSERT TUNNELED CV CATH 8.15 1.00


36568 INSERT PICC CATH 2.60 1.00

36570 INSERT PICVAD CATH 8.54 1.00

36575 REPAIR TUNNELED CV CATH 1.12 1.00
36578 REPLACE TUNNELED CV CATH 5.81 1.00
36580 REPLACE CVAD CATH 1.88 1.00

36584 REPLACE PICC CATH 1.90 1.00
36584 REPLACE PICC CATH 2.02 1.00
36585 REPLACE PICVAD CATH 7.56 1.00
36585 REPLACE PICVAD CATH 8.00 1.00
36589 REMOVAL TUNNELED CV CATH 3.82 1.00

36591 DRAW BLOOD OFF VENOUS DEVICE 0.61 1.00
36592 COLLECT BLOOD FROM PICC 0.67 1.00
36595 MECH REMOV TUNNELED CV CATH 5.31 1.00

36597 REPOSITION VENOUS CATHETER 1.71 1.00
36597 REPOSITION VENOUS CATHETER 1.77 1.00
36598 INJ W/FLUOR, EVAL CV DEVICE 1.67 1.00
36600 WITHDRAWAL OF ARTERIAL BLOOD 0.42 1.00
36620 INSERTION CATHETER, ARTERY 1.39 1.00

36680 INSERT NEEDLE, BONE CAVITY 1.63 1.00
36800 INSERTION OF CANNULA 4.00 1.00

36818 AV FUSE, UPPR ARM, CEPHALIC 18.75 1.00
36819 AV FUSE, UPPR ARM, BASILIC 5.00 1.00

36820 AV FUSION/FOREARM VEIN 6.00 1.00
36821 AV FUSION DIRECT ANY SITE 5.00 1.00
36822 INSERTION OF CANNULA(S) 10.29 1.00

36825 ARTERY-VEIN AUTOGRAFT 12.00 1.00
36830 ARTERY-VEIN NONAUTOGRAFT 6.00 1.00

36831 OPEN THROMBECT AV FISTULA 5.00 1.00
36832 AV FISTULA REVISION, OPEN 5.00 1.00
36833 AV FISTULA REVISION 5.00 1.00

36834 REPAIR A-V ANEURYSM 14.78 1.00
36838 DIST REVAS LIGATION, HEMO 32.45 1.00
36838 DIST REVAS LIGATION, HEMO 32.95 1.00
36860 EXTERNAL CANNULA DECLOTTING 2.80 1.00

36861 CANNULA DECLOTTING 4.12 1.00
36870 PERCUT THROMBECT AV FISTULA 3.00 1.00

37140 REVISION OF CIRCULATION 11.00 1.00

37181 SPLICE SPLEEN/KIDNEY VEINS 11.00 1.00
37182 INSERT HEPATIC SHUNT (TIPS) 24.78 1.00

37183 REMOVE HEPATIC SHUNT (TIPS) 11.55 1.00
37184 PRIM ART MECH THROMBECTOMY 12.69 1.00
37185 PRIM ART M-THROMBECT ADD-ON 4.67 1.00
37186 SEC ART M-THROMBECT ADD-ON 7.18 1.00
37187 VENOUS MECH THROMBECTOMY 11.54 1.00
37188 VENOUS M-THROMBECTOMY ADD-ON 8.54 1.00

37195 THROMBOLYTIC THERAPY, STROKE 8.40 1.00
37200 TRANSCATHETER BIOPSY 6.28 1.00
37201 TRANSCATHETER THERAPY INFUSE 7.77 1.00

37203 TRANSCATHETER RETRIEVAL 7.29 1.00
37204 TRANSCATHETER OCCLUSION 25.14 1.00

37205 TRANSCATH IV STENT, PERCUT 12.33 1.00
37206 TRANSCATH IV STENT/PERC ADDL 5.83 1.00
37207 TRANSCATH IV STENT, OPEN 12.14 1.00
37208 TRANSCATH IV STENT/OPEN ADDL 5.88 1.00

37209 CHANGE IV CATH AT THROMB TX 3.15 1.00
37209 CHANGE IV CATH AT THROMB TX 3.23 1.00
37210 EMBOLIZATION UTERINE FIBROID 14.33 1.00
37215 TRANSCATH STENT, CCA W/EPS 30.54 1.00
37216 TRANSCATH STENT, CCA W/O EPS 28.01 1.00
37250 IV US FIRST VESSEL ADD-ON 3.04 1.00

37251 IV US EACH ADD VESSEL ADD-ON 2.31 1.00
37251 IV US EACH ADD VESSEL ADD-ON 2.32 1.00
37500 ENDOSCOPY LIGATE PERF VEINS 18.58 1.00
37565 LIGATION OF NECK VEIN 6.00 1.00
37600 LIGATION OF NECK ARTERY 5.00 1.00

37607 LIGATION OF A-V FISTULA 10.00 1.00

37609 TEMPORAL ARTERY PROCEDURE 5.00 1.00

37616 LIGATION OF CHEST ARTERY 6.00 1.00
37617 LIGATION OF ABDOMEN ARTERY 6.00 1.00
37618 LIGATION OF EXTREMITY ARTERY 4.00 1.00
37620 REVISION OF MAJOR VEIN 7.00 1.00

37700 REVISE LEG VEIN 3.00 1.00

37718 LIGATE/STRIP SHORT LEG VEIN 10.95 1.00
37720 REMOVAL OF LEG VEIN 3.00 1.00
37722 LIGATE/STRIP LONG LEG VEIN 12.90 1.00
37730 REMOVAL OF LEG VEINS 3.00 1.00

37735 REMOVAL OF LEG VEINS/LESION 4.00 1.00
37760 LIGATION, LEG VEINS, OPEN 4.00 1.00
37765 PHLEB VEINS - EXTREM - TO 20 12.04 1.00
37765 PHLEB VEINS - EXTREM - TO 20 12.37 1.00

37766 PHLEB VEINS - EXTREM 20+ 14.60 1.00
37766 PHLEB VEINS - EXTREM 20+ 15.03 1.00
37780 REVISION OF LEG VEIN 3.00 1.00
37785 LIGATE/DIVIDE/EXCISE VEIN 3.00 1.00
37788 REVASCULARIZATION, PENIS 32.90 1.00

37790 PENILE VENOUS OCCLUSION 3.00 1.00
40490 BIOPSY OF LIP 1.89 1.00
40490 BIOPSY OF LIP 1.90 1.00
40490 BIOPSY OF LIP 4.00 1.00
40500 PARTIAL EXCISION OF LIP 4.00 1.00

40525 RECONSTRUCT LIP WITH FLAP 4.00 1.00

40530 PARTIAL REMOVAL OF LIP 4.00 1.00
40650 REPAIR LIP 4.00 1.00
40650 REPAIR LIP 7.27 1.00

40650 REPAIR LIP 7.80 1.00
40650 REPAIR LIP 8.76 1.00
40652 REPAIR LIP 4.00 1.00
40652 REPAIR LIP 8.89 1.00
40652 REPAIR LIP 9.95 1.00
40652 REPAIR LIP 11.45 1.00
40654 REPAIR LIP 5.00 1.00
40654 REPAIR LIP 10.78 1.00
40654 REPAIR LIP 11.84 1.00
40654 REPAIR LIP 13.29 1.00

40700 REPAIR CLEFT LIP/NASAL 6.00 1.00

40799 LIP SURGERY PROCEDURE 999.99 1.00
40800 DRAINAGE OF MOUTH LESION 2.13 1.00

40804 REMOVAL, FOREIGN BODY, MOUTH 2.36 1.00

40806 INCISION OF LIP FOLD 0.86 1.00
40808 BIOPSY OF MOUTH LESION 2.05 1.00
40810 EXCISION OF MOUTH LESION 2.56 1.00

40812 EXCISE/REPAIR MOUTH LESION 4.00 1.00

40818 EXCISE ORAL MUCOSA FOR GRAFT 4.00 1.00
40819 EXCISE LIP OR CHEEK FOLD 4.00 1.00
40820 TREATMENT OF MOUTH LESION 3.66 1.00

40830 REPAIR MOUTH LACERATION 3.99 1.00
40840 RECONSTRUCTION OF MOUTH 3.00 1.00




41010 INCISION OF TONGUE FOLD 2.73 1.00


41019 PLACE NEEDLES H&N FOR RT 12.96 1.00
41100 BIOPSY OF TONGUE 2.79 1.00

41108 BIOPSY OF FLOOR OF MOUTH 2.23 1.00
41110 EXCISION OF TONGUE LESION 2.93 1.00

41115 EXCISION OF TONGUE FOLD 3.75 1.00

41120 PARTIAL REMOVAL OF TONGUE 6.00 1.00

41135 TONGUE AND NECK SURGERY 6.00 1.00
41140 REMOVAL OF TONGUE 6.00 1.00
41145 TONGUE REMOVAL, NECK SURGERY 6.00 1.00

41150 TONGUE, MOUTH, JAW SURGERY 6.00 1.00
41153 TONGUE, MOUTH, NECK SURGERY 41.75 1.00
41155 TONGUE, JAW, & NECK SURGERY 8.00 1.00

41250 REPAIR TONGUE LACERATION 3.58 1.00

41500 FIXATION OF TONGUE 5.00 1.00
41510 TONGUE TO LIP SURGERY 6.00 1.00
41512 TONGUE SUSPENSION 15.66 1.00
41520 RECONSTRUCTION, TONGUE FOLD 4.00 1.00

41530 TONGUE BASE VOL REDUCTION 10.26 1.00
41800 DRAINAGE OF GUM LESION 2.63 1.00
41805 REMOVAL FOREIGN BODY, GUM 3.28 1.00

41806 REMOVAL FOREIGN BODY,JAWBONE 4.00 1.00
41820 EXCISION, GUM, EACH QUADRANT 4.00 1.00
41822 EXCISION OF GUM LESION 3.51 1.00


41830 REMOVAL OF GUM TISSUE 4.00 1.00
41872 REPAIR GUM 4.00 1.00

41872 REPAIR GUM 5.65 1.00
41872 REPAIR GUM 6.34 1.00
41872 REPAIR GUM 6.54 1.00
41874 REPAIR TOOTH SOCKET 4.00 1.00
42000 DRAINAGE MOUTH ROOF LESION 2.60 1.00
42100 BIOPSY ROOF OF MOUTH 2.76 1.00

42104 EXCISION LESION, MOUTH ROOF 3.33 1.00

42120 REMOVE PALATE/LESION 4.00 1.00
42140 EXCISION OF UVULA 3.00 1.00
42145 REPAIR PALATE, PHARYNX/UVULA 5.00 1.00

42160 TREATMENT MOUTH ROOF LESION 3.87 1.00
42180 REPAIR PALATE 4.69 1.00

42200 RECONSTRUCT CLEFT PALATE 6.00 1.00


42226 LENGTHENING OF PALATE 6.00 1.00

42260 REPAIR NOSE TO LIP FISTULA 6.00 1.00
42281 INSERTION, PALATE PROSTHESIS 3.87 1.00
42300 DRAINAGE OF SALIVARY GLAND 3.87 1.00


42325 CREATE SALIVARY CYST DRAIN 4.00 1.00
42330 REMOVAL OF SALIVARY STONE 3.42 1.00

42400 BIOPSY OF SALIVARY GLAND 1.23 1.00

42408 EXCISION OF SALIVARY CYST 4.00 1.00
42409 DRAINAGE OF SALIVARY CYST 4.00 1.00

42410 EXCISE PAROTID GLAND/LESION 4.00 1.00

42440 EXCISE SUBMAXILLARY GLAND 3.00 1.00

42450 EXCISE SUBLINGUAL GLAND 3.00 1.00
42500 REPAIR SALIVARY DUCT 4.00 1.00

42507 PAROTID DUCT DIVERSION 5.00 1.00

42550 INJECTION FOR SALIVARY X-RAY 1.73 1.00
42600 CLOSURE OF SALIVARY FISTULA 4.00 1.00

42650 DILATION OF SALIVARY DUCT 1.23 1.00

42665 LIGATION OF SALIVARY DUCT 5.00 1.00
42700 DRAINAGE OF TONSIL ABSCESS 3.45 1.00
42720 DRAINAGE OF THROAT ABSCESS 4.00 1.00

42800 BIOPSY OF THROAT 2.85 1.00
42804 BIOPSY OF UPPER NOSE/THROAT 2.93 1.00

42808 EXCISE PHARYNX LESION 4.23 1.00

42809 REMOVE PHARYNX FOREIGN BODY 3.32 1.00
42810 EXCISION OF NECK CYST 4.00 1.00
42820 REMOVE TONSILS AND ADENOIDS 5.00 1.00

42825 REMOVAL OF TONSILS 5.00 1.00

42830 REMOVAL OF ADENOIDS 5.00 1.00

42842 EXTENSIVE SURGERY OF THROAT 7.00 1.00

42860 EXCISION OF TONSIL TAGS 4.78 1.00

42870 EXCISION OF LINGUAL TONSIL 4.00 1.00
42890 PARTIAL REMOVAL OF PHARYNX 7.00 1.00
42892 REVISION OF PHARYNGEAL WALLS 7.00 1.00

42900 REPAIR THROAT WOUND 5.00 1.00
42950 RECONSTRUCTION OF THROAT 8.00 1.00

42953 REPAIR THROAT, ESOPHAGUS 5.00 1.00
42955 SURGICAL OPENING OF THROAT 5.00 1.00
42960 CONTROL THROAT BLEEDING 4.00 1.00

42970 CONTROL NOSE/THROAT BLEEDING 4.00 1.00

43020 INCISION OF ESOPHAGUS 6.00 1.00

43030 THROAT MUSCLE SURGERY 6.00 1.00
43100 EXCISION OF ESOPHAGUS LESION 6.00 1.00

43107 REMOVAL OF ESOPHAGUS 15.00 1.00

43116 PARTIAL REMOVAL OF ESOPHAGUS 15.00 1.00



43130 REMOVAL OF ESOPHAGUS POUCH 13.00 1.00
43200 ESOPHAGUS ENDOSCOPY 2.74 1.00

43201 ESOPH SCOPE W/SUBMUCOUS INJ 3.44 1.00
43202 ESOPHAGUS ENDOSCOPY, BIOPSY 2.99 1.00
43204 ESOPH SCOPE W/SCLEROSIS INJ 4.00 1.00

43205 ESOPHAGUS ENDOSCOPY/LIGATION 5.00 1.00
43216 ESOPHAGUS ENDOSCOPY/LESION 3.73 1.00

43220 ESOPH ENDOSCOPY, DILATION 3.23 1.00

43227 ESOPH ENDOSCOPY, REPAIR 5.28 1.00
43228 ESOPH ENDOSCOPY, ABLATION 5.64 1.00
43231 ESOPH ENDOSCOPY W/US EXAM 4.76 1.00

43232 ESOPH ENDOSCOPY W/US FN BX 5.00 1.00
43234 UPPER GI ENDOSCOPY, EXAM 3.07 1.00

43235 UPPR GI ENDOSCOPY, DIAGNOSIS 3.58 1.00
43236 UPPR GI SCOPE W/SUBMUC INJ 4.32 1.00
43237 ENDOSCOPIC US EXAM, ESOPH 5.86 1.00
43237 ENDOSCOPIC US EXAM, ESOPH 6.46 1.00
43238 UPPR GI ENDOSCOPY W/US FN BX 7.26 1.00
43239 UPPER GI ENDOSCOPY, BIOPSY 4.00 1.00

43240 ESOPH ENDOSCOPE W/DRAIN CYST 5.00 1.00
43241 UPPER GI ENDOSCOPY WITH TUBE 3.87 1.00

43243 UPPER GI ENDOSCOPY & INJECT 5.00 1.00
43244 UPPER GI ENDOSCOPY/LIGATION 5.00 1.00
43245 UPPR GI SCOPE DILATE STRICTR 4.70 1.00

43246 PLACE GASTROSTOMY TUBE 5.00 1.00
43247 OPERATIVE UPPER GI ENDOSCOPY 4.98 1.00
43248 UPPR GI ENDOSCOPY/GUIDE WIRE 4.65 1.00

43250 UPPER GI ENDOSCOPY/TUMOR 4.72 1.00

43256 UPPR GI ENDOSCOPY W/STENT 5.00 1.00
43257 UPPR GI SCOPE W/THRML TXMNT 8.36 1.00

43259 ENDOSCOPIC ULTRASOUND EXAM 5.00 1.00
43260 ENDO CHOLANGIOPANCREATOGRAPH 4.00 1.00




43273 ENDOSCOPIC PANCREATOSCOPY 3.48 1.00
43279 LAP MYOTOMY, HELLER 32.69 1.00
43280 LAPAROSCOPY, FUNDOPLASTY 6.00 1.00
43300 REPAIR OF ESOPHAGUS 13.00 1.00

43305 REPAIR ESOPHAGUS AND FISTULA 19.00 1.00

43313 ESOPHAGOPLASTY CONGENITAL 15.00 1.00
43314 TRACHEO-ESOPHAGOPLASTY CONG 15.00 1.00
43320 FUSE ESOPHAGUS & STOMACH 13.00 1.00

43324 REVISE ESOPHAGUS & STOMACH 7.00 1.00

43340 FUSE ESOPHAGUS & INTESTINE 13.00 1.00

43350 SURGICAL OPENING, ESOPHAGUS 13.00 1.00

43360 GASTROINTESTINAL REPAIR 15.00 1.00

43400 LIGATE ESOPHAGUS VEINS 12.00 1.00
43401 ESOPHAGUS SURGERY FOR VEINS 15.00 1.00

43405 LIGATE/STAPLE ESOPHAGUS 15.00 1.00
43410 REPAIR ESOPHAGUS WOUND 7.00 1.00
43420 REPAIR ESOPHAGUS OPENING 7.00 1.00

43450 DILATE ESOPHAGUS 2.07 1.00


43460 PRESSURE TREATMENT ESOPHAGUS 4.00 1.00
43496 FREE JEJUNUM FLAP, MICROVASC 5.00 1.00
43500 SURGICAL OPENING OF STOMACH 7.00 1.00
43501 SURGICAL REPAIR OF STOMACH 7.00 1.00

43520 INCISION OF PYLORIC MUSCLE 7.00 1.00

43600 BIOPSY OF STOMACH 2.85 1.00

43610 EXCISION OF STOMACH LESION 6.00 1.00
43620 REMOVAL OF STOMACH 7.00 1.00

43631 REMOVAL OF STOMACH, PARTIAL 7.00 1.00



43640 VAGOTOMY & PYLORUS REPAIR 7.00 1.00
43644 LAP GASTRIC BYPASS/ROUX-EN-Y 43.19 1.00
43645 LAP GASTR BYPASS INCL SMLL I 46.26 1.00
43651 LAPAROSCOPY, VAGUS NERVE 6.00 1.00

43653 LAPAROSCOPY, GASTROSTOMY 6.00 1.00

43752 NASAL/OROGASTRIC W/STENT 0.96 1.00
43760 CHANGE GASTROSTOMY TUBE 1.36 1.00
43761 REPOSITION GASTROSTOMY TUBE 2.89 1.00

43770 LAP PLACE GASTR ADJ DEVICE 27.76 1.00
43771 LAP REVISE GASTR ADJ DEVICE 31.67 1.00
43772 LAP RMVL GASTR ADJ DEVICE 23.95 1.00
43773 LAP REPLACE GASTR ADJ DEVICE 31.70 1.00
43774 LAP RMVL GASTR ADJ ALL PARTS 23.95 1.00
43800 RECONSTRUCTION OF PYLORUS 7.00 1.00
43810 FUSION OF STOMACH AND BOWEL 7.00 1.00



43840 REPAIR OF STOMACH LESION 7.00 1.00
43842 V-BAND GASTROPLASTY 7.00 1.00
43843 GASTROPLASTY W/O V-BAND 7.00 1.00

43845 GASTRIC RESTRICTIVE PROCEDURE 48.90 1.00
43846 GASTRIC BYPASS FOR OBESITY 7.00 1.00
43847 GASTRIC BYPASS INCL SMALL I 7.00 1.00
43848 REVISION GASTROPLASTY 7.00 1.00

43850 REVISE STOMACH-BOWEL FUSION 6.00 1.00

43870 REPAIR STOMACH OPENING 6.00 1.00
43880 REPAIR STOMACH-BOWEL FISTULA 7.00 1.00

43886 REVISE GASTRIC PORT, OPEN 8.19 1.00
43887 REMOVE GASTRIC PORT, OPEN 7.78 1.00
43888 CHANGE GASTRIC PORT, OPEN 10.93 1.00
44005 FREEING OF BOWEL ADHESION 6.00 1.00
44010 INCISION OF SMALL BOWEL 7.00 1.00

44015 INSERT NEEDLE CATH BOWEL 3.00 1.00
44020 EXPLORE SMALL INTESTINE 6.00 1.00
44021 DECOMPRESS SMALL BOWEL 6.00 1.00

44025 INCISION OF LARGE BOWEL 5.00 1.00
44050 REDUCE BOWEL OBSTRUCTION 5.00 1.00
44055 CORRECT MALROTATION OF BOWEL 6.00 1.00

44100 BIOPSY OF BOWEL 3.08 1.00
44110 EXCISE INTESTINE LESION(S) 6.00 1.00

44111 EXCISION OF BOWEL LESION(S) 6.00 1.00
44120 REMOVAL OF SMALL INTESTINE 6.00 1.00

44126 ENTERECTOMY W/O TAPER, CONG 6.00 1.00
44127 ENTERECTOMY W/TAPER, CONG 6.00 1.00
44128 ENTERECTOMY CONG, ADD-ON 6.34 1.00

44130 BOWEL TO BOWEL FUSION 6.00 1.00
44133 ENTERECTOMY, LIVE DONOR 6.00 1.00
44136 INTESTINE TRANSPLANT, LIVE 6.00 1.00
44139 MOBILIZATION OF COLON 3.15 1.00

44140 PARTIAL REMOVAL OF COLON 6.00 1.00


44150 REMOVAL OF COLON 6.00 1.00
44151 REMOVAL OF COLON/ILEOSTOMY 7.00 1.00


44157 COLECTOMY W/ILEOANAL ANAST 53.68 1.00
44158 COLECTOMY W/NEO-RECTUM POUCH 55.03 1.00
44180 LAP, ENTEROLYSIS 23.14 1.00
44186 LAP, JEJUNOSTOMY 16.32 1.00

44187 LAP, ILEO/JEJUNO-STOMY 27.45 1.00
44188 LAP, COLOSTOMY 30.39 1.00
44200 LAPAROSCOPY, ENTEROLYSIS 6.00 1.00
44201 LAPAROSCOPY, JEJUNOSTOMY 6.00 1.00

44202 LAP, ENTERECTOMY 6.00 1.00
44203 LAP RESECT S/INTESTINE, ADDL 6.27 1.00
44204 LAPARO PARTIAL COLECTOMY 6.00 1.00
44205 LAP COLECTOMY PART W/ILEUM 6.00 1.00

44206 LAP PART COLECTOMY W/STOMA 40.24 1.00
44207 L COLECTOMY/COLOPROCTOSTOMY 44.04 1.00
44210 LAPARO TOTAL PROCTOCOLECTOMY 42.16 1.00

44211 LAP COLECTOMY W/PROCTECTOMY 52.35 1.00
44213 LAP, MOBIL SPLENIC FL ADD-ON 4.94 1.00
44227 LAP, CLOSE ENTEROSTOMY 42.11 1.00

44300 OPEN BOWEL TO SKIN 6.00 1.00
44310 ILEOSTOMY/JEJUNOSTOMY 6.00 1.00
44312 REVISION OF ILEOSTOMY 5.00 1.00

44316 DEVISE BOWEL POUCH 6.00 1.00
44320 COLOSTOMY 5.00 1.00
44320 COLOSTOMY 26.75 1.00
44320 COLOSTOMY 26.86 1.00
44320 COLOSTOMY 29.86 1.00
44322 COLOSTOMY WITH BIOPSIES 6.00 1.00

44340 REVISION OF COLOSTOMY 5.00 1.00

44360 SMALL BOWEL ENDOSCOPY 3.88 1.00
44361 SMALL BOWEL ENDOSCOPY/BIOPSY 4.26 1.00


44370 SMALL BOWEL ENDOSCOPY/STENT 5.00 1.00


44379 S BOWEL ENDOSCOPE W/STENT 5.00 1.00

44383 ILEOSCOPY W/STENT 4.38 1.00

44385 ENDOSCOPY OF BOWEL POUCH 2.83 1.00
44386 ENDOSCOPY, BOWEL POUCH/BIOP 3.33 1.00
44388 COLONOSCOPY 4.20 1.00

44389 COLONOSCOPY WITH BIOPSY 4.63 1.00
44390 COLONOSCOPY FOR FOREIGN BODY 5.60 1.00
44391 COLONOSCOPY FOR BLEEDING 6.00 1.00

44392 COLONOSCOPY & POLYPECTOMY 5.61 1.00
44393 COLONOSCOPY, LESION REMOVAL 6.00 1.00
44394 COLONOSCOPY W/SNARE 5.00 1.00

44397 COLONOSCOPY W/STENT 6.00 1.00
44602 SUTURE, SMALL INTESTINE 6.00 1.00

44604 SUTURE, LARGE INTESTINE 6.00 1.00
44605 REPAIR OF BOWEL LESION 6.00 1.00
44615 INTESTINAL STRICTUROPLASTY 6.00 1.00

44620 REPAIR BOWEL OPENING 5.00 1.00

44640 REPAIR BOWEL-SKIN FISTULA 5.00 1.00
44650 REPAIR BOWEL FISTULA 6.00 1.00
44660 REPAIR BOWEL-BLADDER FISTULA 6.00 1.00

44680 SURGICAL REVISION, INTESTINE 5.00 1.00
44700 SUSPEND BOWEL W/PROSTHESIS 6.00 1.00

44701 INTRAOP COLON LAVAGE ADD-ON 4.35 1.00
44800 EXCISION OF BOWEL POUCH 5.00 1.00
44820 EXCISION OF MESENTERY LESION 6.00 1.00

44850 REPAIR OF MESENTERY 6.00 1.00
44900 DRAIN APP ABSCESS, OPEN 5.00 1.00
44901 DRAIN APP ABSCESS, PERCUT 4.00 1.00

44950 APPENDECTOMY 6.00 1.00
44955 APPENDECTOMY ADD-ON 2.19 1.00

44970 LAPAROSCOPY, APPENDECTOMY 6.00 1.00
45000 DRAINAGE OF PELVIC ABSCESS 4.00 1.00
45005 DRAINAGE OF RECTAL ABSCESS 3.74 1.00

45100 BIOPSY OF RECTUM 4.00 1.00
45108 REMOVAL OF ANORECTAL LESION 4.00 1.00

45110 REMOVAL OF RECTUM 6.00 1.00
45111 PARTIAL REMOVAL OF RECTUM 6.00 1.00

45113 PARTIAL PROCTECTOMY 7.00 1.00

45119 REMOVE RECTUM W/RESERVOIR 7.00 1.00
45121 REMOVAL OF RECTUM AND COLON 7.00 1.00

45126 PELVIC EXENTERATION 8.00 1.00
45130 EXCISION OF RECTAL PROLAPSE 4.00 1.00

45136 EXCISE ILEOANAL RESERVIOR 4.00 1.00

45150 EXCISION OF RECTAL STRICTURE 4.00 1.00
45160 EXCISION OF RECTAL LESION 6.00 1.00
45190 DESTRUCTION, RECTAL TUMOR 4.00 1.00

45300 PROCTOSIGMOIDOSCOPY DX 0.66 1.00
45303 PROCTOSIGMOIDOSCOPY DILATE 0.76 1.00
45305 PROCTOSIGMOIDOSCOPY W/BX 1.55 1.00

45307 PROCTOSIGMOIDOSCOPY FB 1.51 1.00
45308 PROCTOSIGMOIDOSCOPY REMOVAL 1.35 1.00

45317 PROCTOSIGMOIDOSCOPY BLEED 2.32 1.00

45320 PROCTOSIGMOIDOSCOPY ABLATE 2.44 1.00
45321 PROCTOSIGMOIDOSCOPY VOLVUL 1.85 1.00
45327 PROCTOSIGMOIDOSCOPY W/STENT 2.47 1.00

45330 DIAGNOSTIC SIGMOIDOSCOPY 1.53 1.00
45331 SIGMOIDOSCOPY AND BIOPSY 1.75 1.00
45332 SIGMOIDOSCOPY W/FB REMOVAL 2.65 1.00

45333 SIGMOIDOSCOPY & POLYPECTOMY 2.66 1.00
45334 SIGMOIDOSCOPY FOR BLEEDING 3.97 1.00
45335 SIGMOIDOSCOPY W/SUBMUC INJ 2.08 1.00

45337 SIGMOIDOSCOPY & DECOMPRESS 3.46 1.00
45338 SIGMOIDOSCOPY W/TUMR REMOVE 3.44 1.00
45339 SIGMOIDOSCOPY W/ABLATE TUMR 4.00 1.00

45340 SIG W/BALLOON DILATION 2.49 1.00
45341 SIGMOIDOSCOPY W/ULTRASOUND 3.96 1.00
45342 SIGMOIDOSCOPY W/US GUIDE BX 5.00 1.00

45345 SIGMOIDOSCOPY W/STENT 4.30 1.00
45355 SURGICAL COLONOSCOPY 4.00 1.00
45378 DIAGNOSTIC COLONOSCOPY 4.00 1.00

45379 COLONOSCOPY W/FB REMOVAL 4.00 1.00
45380 COLONOSCOPY AND BIOPSY 4.00 1.00
45381 COLONOSCOPY, SUBMUCOUS INJ 6.11 1.00
45382 COLONOSCOPY/CONTROL BLEEDING 4.00 1.00

45383 LESION REMOVAL COLONOSCOPY 4.00 1.00
45384 LESION REMOVE COLONOSCOPY 4.00 1.00

45386 COLONOSCOPY DILATE STRICTURE 6.63 1.00
45391 COLONOSCOPY W/ENDOSCOPE US 7.99 1.00

45392 COLONOSCOPY W/ENDOSCOPIC FNB 10.07 1.00
45395 LAP, REMOVAL OF RECTUM 50.02 1.00
45397 LAP, REMOVE RECTUM W/POUCH 54.08 1.00
45400 LAPAROSCOPIC PROC 28.84 1.00
45402 LAP PROCTOPEXY W/SIG RESECT 38.60 1.00
45500 REPAIR OF RECTUM 4.00 1.00

45520 TREATMENT OF RECTAL PROLAPSE 0.78 1.00
45540 CORRECT RECTAL PROLAPSE 5.00 1.00

45550 REPAIR RECTUM/REMOVE SIGMOID 5.00 1.00
45560 REPAIR OF RECTOCELE 4.00 1.00
45562 EXPLORATION/REPAIR OF RECTUM 4.00 1.00

45800 REPAIR RECT/BLADDER FISTULA 4.00 1.00
45805 REPAIR FISTULA W/COLOSTOMY 6.00 1.00

45820 REPAIR RECTOURETHRAL FISTULA 4.00 1.00

45900 REDUCTION OF RECTAL PROLAPSE 3.00 1.00
45905 DILATION OF ANAL SPHINCTER 3.00 1.00
45910 DILATION OF RECTAL NARROWING 3.00 1.00
45915 REMOVE RECTAL OBSTRUCTION 4.00 1.00

45990 SURG DX EXAM, ANORECTAL 2.74 1.00
46020 PLACEMENT OF SETON 3.00 1.00
46030 REMOVAL OF RECTAL MARKER 2.07 1.00

46040 INCISION OF RECTAL ABSCESS 3.00 1.00
46050 INCISION OF ANAL ABSCESS 2.18 1.00

46070 INCISION OF ANAL SEPTUM 4.00 1.00
46080 INCISION OF ANAL SPHINCTER 3.00 1.00

46083 INCISE EXTERNAL HEMORRHOID 2.49 1.00
46200 REMOVAL OF ANAL FISSURE 3.00 1.00
46210 REMOVAL OF ANAL CRYPT 3.00 1.00

46211 REMOVAL OF ANAL CRYPTS 3.00 1.00
46220 REMOVAL OF ANAL TAG 2.25 1.00
46221 LIGATION OF HEMORRHOID(S) 3.23 1.00

46230 REMOVAL OF ANAL TAGS 3.00 1.00
46250 HEMORRHOIDECTOMY 3.00 1.00

46257 REMOVE HEMORRHOIDS & FISSURE 4.00 1.00
46258 REMOVE HEMORRHOIDS & FISTULA 4.00 1.00

46270 REMOVAL OF ANAL FISTULA 3.00 1.00


46288 REPAIR ANAL FISTULA 4.00 1.00
46320 REMOVAL OF HEMORRHOID CLOT 2.63 1.00
46500 INJECTION INTO HEMORRHOID(S) 2.30 1.00

46505 CHEMODENERVATION ANAL MUSC 5.50 1.00
46600 DIAGNOSTIC ANOSCOPY 0.69 1.00
46604 ANOSCOPY AND DILATION 1.69 1.00

46606 ANOSCOPY AND BIOPSY 1.16 1.00
46608 ANOSCOPY, REMOVE FOR BODY 2.06 1.00
46610 ANOSCOPY, REMOVE LESION 1.91 1.00
46611 ANOSCOPY 2.12 1.00

46611 ANOSCOPY 2.60 1.00
46611 ANOSCOPY 2.79 1.00
46611 ANOSCOPY 3.00 1.00
46612 ANOSCOPY, REMOVE LESIONS 2.53 1.00
46614 ANOSCOPY, CONTROL BLEEDING 1.81 1.00
46615 ANOSCOPY 2.59 1.00

46615 ANOSCOPY 3.00 1.00
46615 ANOSCOPY 3.85 1.00
46615 ANOSCOPY 4.06 1.00
46700 REPAIR OF ANAL STRICTURE 5.00 1.00

46706 REPR OF ANAL FISTULA W/GLUE 3.80 1.00
46710 REPR PER/VAG POUCH SNGL PROC 26.53 1.00
46712 REPR PER/VAG POUCH DBL PROC 54.39 1.00
46715 REP PERF ANOPER FISTU 4.00 1.00
46716 REP PERF ANOPER/VESTIB FISTU 4.00 1.00

46730 CONSTRUCTION OF ABSENT ANUS 5.00 1.00

46742 REPAIR OF IMPERFORATED ANUS 4.00 1.00
46744 REPAIR OF CLOACAL ANOMALY 4.00 1.00

46750 REPAIR OF ANAL SPHINCTER 4.00 1.00

46753 RECONSTRUCTION OF ANUS 3.00 1.00
46754 REMOVAL OF SUTURE FROM ANUS 3.68 1.00

46762 IMPLANT ARTIFICIAL SPHINCTER 4.00 1.00

46900 DESTRUCTION, ANAL LESION(S) 2.79 1.00
46916 CRYOSURGERY, ANAL LESION(S) 3.37 1.00
46917 LASER SURGERY, ANAL LESIONS 3.17 1.00

46922 EXCISION OF ANAL LESION(S) 3.00 1.00
46930 DESTROY INTERNAL HEMORRHOIDS 3.81 1.00

46934 DESTRUCTION OF HEMORRHOIDS 4.00 1.00

46937 CRYOTHERAPY OF RECTAL LESION 4.00 1.00
46940 TREATMENT OF ANAL FISSURE 3.00 1.00

46945 LIGATION OF HEMORRHOIDS 3.93 1.00

46947 HEMORRHOIDOPEXY BY STAPLING 9.30 1.00
47000 NEEDLE BIOPSY OF LIVER 2.64 1.00
47001 NEEDLE BIOPSY, LIVER ADD-ON 2.70 1.00
47010 OPEN DRAINAGE, LIVER LESION 12.00 1.00

47011 PERCUT DRAIN, LIVER LESION 5.11 1.00
47015 INJECT/ASPIRATE LIVER CYST 7.00 1.00
47100 WEDGE BIOPSY OF LIVER 6.00 1.00

47120 PARTIAL REMOVAL OF LIVER 12.00 1.00
47122 EXTENSIVE REMOVAL OF LIVER 13.00 1.00

47134 PARTIAL REMOVAL, DONOR LIVER 13.00 1.00
47134 PARTIAL REMOVAL, DONOR LIVER 56.69 1.00
47135 TRANSPLANTATION OF LIVER 13.00 1.00

47300 SURGERY FOR LIVER LESION 7.00 1.00
47350 REPAIR LIVER WOUND 13.00 1.00

47370 LAPARO ABLATE LIVER TUMOR RF 7.00 1.00

47371 LAPARO ABLATE LIVER CRYOSURG 7.00 1.00
47380 OPEN ABLATE LIVER TUMOR RF 7.00 1.00

47381 OPEN ABLATE LIVER TUMOR CRYO 7.00 1.00
47382 PERCUT ABLATE LIVER RF 4.00 1.00
47400 INCISION OF LIVER DUCT 7.00 1.00

47420 INCISION OF BILE DUCT 7.00 1.00
47460 INCISE BILE DUCT SPHINCTER 4.00 1.00

47480 INCISION OF GALLBLADDER 7.00 1.00
47500 INJECTION FOR LIVER X-RAYS 2.71 1.00

47510 INSERT CATHETER, BILE DUCT 4.00 1.00
47511 INSERT BILE DUCT DRAIN 16.14 1.00
47525 CHANGE BILE DUCT CATHETER 3.22 1.00

47530 REVISE/REINSERT BILE TUBE 3.00 1.00
47550 BILE DUCT ENDOSCOPY ADD-ON 4.32 1.00
47552 BILIARY ENDOSCOPY THRU SKIN 5.00 1.00


47560 LAPAROSCOPY W/CHOLANGIO 6.00 1.00
47561 LAPARO W/CHOLANGIO/BIOPSY 6.00 1.00

47562 LAPAROSCOPIC CHOLECYSTECTOMY 6.00 1.00
47563 LAPARO CHOLECYSTECTOMY/GRAPH 6.00 1.00
47564 LAPARO CHOLECYSTECTOMY/EXPLR 6.00 1.00

47570 LAPARO CHOLECYSTOENTEROSTOMY 6.00 1.00
47600 REMOVAL OF GALLBLADDER 7.00 1.00


47630 REMOVE BILE DUCT STONE 7.00 1.00
47700 EXPLORATION OF BILE DUCTS 7.00 1.00
47701 BILE DUCT REVISION 7.00 1.00

47711 EXCISION OF BILE DUCT TUMOR 7.00 1.00

47715 EXCISION OF BILE DUCT CYST 7.00 1.00
47716 FUSION OF BILE DUCT CYST 7.00 1.00
47720 FUSE GALLBLADDER & BOWEL 7.00 1.00

47721 FUSE UPPER GI STRUCTURES 7.00 1.00

47760 FUSE BILE DUCTS AND BOWEL 7.00 1.00
47765 FUSE LIVER DUCTS & BOWEL 7.00 1.00

47800 RECONSTRUCTION OF BILE DUCTS 7.00 1.00
47801 PLACEMENT, BILE DUCT SUPPORT 7.00 1.00

47802 FUSE LIVER DUCT & INTESTINE 7.00 1.00
47900 SUTURE BILE DUCT INJURY 7.00 1.00
48000 DRAINAGE OF ABDOMEN 7.00 1.00

48001 PLACEMENT OF DRAIN, PANCREAS 4.00 1.00
48005 RESECT/DEBRIDE PANCREAS 7.00 1.00
48020 REMOVAL OF PANCREATIC STONE 7.00 1.00

48100 BIOPSY OF PANCREAS, OPEN 7.00 1.00
48102 NEEDLE BIOPSY, PANCREAS 7.00 1.00
48120 REMOVAL OF PANCREAS LESION 7.00 1.00

48140 PARTIAL REMOVAL OF PANCREAS 7.00 1.00
48146 PANCREATECTOMY 8.00 1.00

48148 REMOVAL OF PANCREATIC DUCT 7.00 1.00


48155 REMOVAL OF PANCREAS 7.00 1.00
48180 FUSE PANCREAS AND BOWEL 7.00 1.00
48500 SURGERY OF PANCREATIC CYST 7.00 1.00

48510 DRAIN PANCREATIC PSEUDOCYST 7.00 1.00
48520 FUSE PANCREAS CYST AND BOWEL 7.00 1.00

48545 PANCREATORRHAPHY 7.00 1.00
48547 DUODENAL EXCLUSION 7.00 1.00

48554 TRANSPL ALLOGRAFT PANCREAS 7.00 1.00
48556 REMOVAL, ALLOGRAFT PANCREAS 7.00 1.00
49000 EXPLORATION OF ABDOMEN 5.00 1.00

49002 REOPENING OF ABDOMEN 5.00 1.00
49010 EXPLORATION BEHIND ABDOMEN 6.00 1.00

49020 DRAIN ABDOMINAL ABSCESS 6.00 1.00
49040 DRAIN, OPEN, ABDOM ABSCESS 7.00 1.00
49041 DRAIN, PERCUT, ABDOM ABSCESS 4.00 1.00

49060 DRAIN, OPEN, RETROP ABSCESS 7.00 1.00
49061 DRAIN, PERCUT, RETROPER ABSC 4.00 1.00

49062 DRAIN TO PERITONEAL CAVITY 4.00 1.00
49080 PUNCTURE, PERITONEAL CAVITY 1.88 1.00

49081 REMOVAL OF ABDOMINAL FLUID 1.83 1.00
49085 REMOVE ABDOMEN FOREIGN BODY 7.00 1.00
49180 BIOPSY, ABDOMINAL MASS 2.39 1.00
49200 REMOVAL OF ABDOMINAL LESION 5.00 1.00

49201 REMOVE ABDOM LESION, COMPLEX 6.00 1.00
49203 EXC ABD TUM 5 CM OR LESS 30.30 1.00
49204 EXC ABD TUM OVER 5 CM 38.70 1.00
49205 EXC ABD TUM OVER 10 CM 44.32 1.00
49215 EXCISE SACRAL SPINE TUMOR 6.00 1.00

49220 MULTIPLE SURGERY, ABDOMEN 6.00 1.00
49250 EXCISION OF UMBILICUS 6.00 1.00

49255 REMOVAL OF OMENTUM 5.00 1.00
49320 DIAG LAPARO SEPARATE PROC 6.00 1.00
49321 LAPAROSCOPY, BIOPSY 6.00 1.00
49322 LAPAROSCOPY, ASPIRATION 6.00 1.00

49323 LAPARO DRAIN LYMPHOCELE 6.00 1.00
49324 LAP INSERTION PERM IP CATH 9.85 1.00
49325 LAP REVISION PERM IP CATH 10.60 1.00
49326 LAP W/OMENTOPEXY ADD-ON 4.89 1.00
49400 AIR INJECTION INTO ABDOMEN 2.71 1.00

49402 REMOVE FOREIGN BODY, ADBOMEN 21.35 1.00
49419 INSRT ABDOM CATH FOR CHEMOTX 10.86 1.00
49420 INSERT ABDOM DRAIN, TEMP 3.32 1.00

49421 INSERT ABDOM DRAIN, PERM 4.00 1.00
49422 REMOVE PERM CANNULA/CATHETER 4.00 1.00
49423 EXCHANGE DRAINAGE CATHETER 2.06 1.00

49424 ASSESS CYST, CONTRAST INJECT 1.08 1.00
49425 INSERT ABDOMEN-VENOUS DRAIN 4.00 1.00
49426 REVISE ABDOMEN-VENOUS SHUNT 7.00 1.00

49427 INJECTION, ABDOMINAL SHUNT 1.30 1.00
49428 LIGATION OF SHUNT 4.00 1.00
49429 REMOVAL OF SHUNT 4.00 1.00

49435 INSERT SUBQ EXTEN TO IP CATH 3.13 1.00
49436 EMBEDDED IP CATH EXIT-SITE 4.58 1.00
49440 PLACE GASTROSTOMY TUBE PERC 6.58 1.00
49441 PLACE DUOD/JEJ TUBE PERC 7.18 1.00
49442 PLACE CECOSTOMY TUBE PERC 5.93 1.00
49446 CHANGE G-TUBE TO G-J PERC 4.77 1.00
49450 REPLACE G/C TUBE PERC 1.88 1.00
49450 REPLACE G/C TUBE PERC 1.91 1.00
49451 REPLACE DUOD/JEJ TUBE PERC 2.59 1.00
49451 REPLACE DUOD/JEJ TUBE PERC 2.66 1.00
49452 REPLACE G-J TUBE PERC 4.04 1.00

49452 REPLACE G-J TUBE PERC 4.15 1.00
49460 FIX G/COLON TUBE W/DEVICE 1.36 1.00
49465 FLUORO EXAM OF G/COLON TUBE 0.89 1.00
49491 RPR HERN PREEMIE REDUC 4.00 1.00
49492 RPR ING HERN PREMIE, BLOCKED 4.00 1.00
49495 RPR ING HERNIA BABY, REDUC 4.00 1.00

49496 RPR ING HERNIA BABY, BLOCKED 4.00 1.00
49500 RPR ING HERNIA, INIT, REDUCE 4.00 1.00

49501 RPR ING HERNIA, INIT BLOCKED 4.00 1.00
49505 PRP I/HERN INIT REDUC >5 YR 4.00 1.00
49507 PRP I/HERN INIT BLOCK >5 YR 4.00 1.00

49520 REREPAIR ING HERNIA, REDUCE 4.00 1.00
49521 REREPAIR ING HERNIA, BLOCKED 4.00 1.00
49525 REPAIR ING HERNIA, SLIDING 4.00 1.00

49540 REPAIR LUMBAR HERNIA 4.00 1.00
49550 RPR REM HERNIA, INIT, REDUCE 4.00 1.00
49553 RPR FEM HERNIA, INIT BLOCKED 4.00 1.00

49555 REREPAIR FEM HERNIA, REDUCE 4.00 1.00
49557 REREPAIR FEM HERNIA, BLOCKED 4.00 1.00
49560 RPR VENTRAL HERN INIT, REDUC 4.00 1.00

49561 RPR VENTRAL HERN INIT, BLOCK 6.00 1.00
49565 REREPAIR VENTRL HERN, REDUCE 4.00 1.00
49566 REREPAIR VENTRL HERN, BLOCK 6.00 1.00

49568 HERNIA REPAIR W/MESH 6.00 1.00
49570 RPR EPIGASTRIC HERN, REDUCE 4.00 1.00
49572 RPR EPIGASTRIC HERN, BLOCKED 6.00 1.00

49580 RPR UMBIL HERN, REDUC < 5 YR 5.00 1.00
49582 RPR UMBIL HERN, BLOCK < 5 YR 4.00 1.00
49585 RPR UMBIL HERN, REDUC > 5 YR 4.00 1.00

49587 RPR UMBIL HERN, BLOCK > 5 YR 4.00 1.00
49590 REPAIR SPIGELIAN HERNIA 4.00 1.00
49600 REPAIR UMBILICAL LESION 5.00 1.00


49650 LAP ING HERNIA REPAIR INIT 6.00 1.00
49651 LAP ING HERNIA REPAIR RECUR 6.00 1.00

49652 LAP VENT/ABD HERNIA REPAIR 19.87 1.00
49653 LAP VENT/ABD HERN PROC COMP 24.80 1.00
49654 LAP INC HERNIA REPAIR 22.80 1.00
49655 LAP INC HERN REPAIR COMP 27.45 1.00
49656 LAP INC HERNIA REPAIR RECUR 22.89 1.00
49657 LAP INC HERN RECUR COMP 33.05 1.00
49900 REPAIR OF ABDOMINAL WALL 5.00 1.00

49904 OMENTAL FLAP, EXTRA-ABDOM 37.73 1.00
49905 OMENTAL FLAP, INTRA-ABDOM 9.23 1.00
49906 FREE OMENTAL FLAP, MICROVASC 4.00 1.00
50010 EXPLORATION OF KIDNEY 6.00 1.00

50020 RENAL ABSCESS, OPEN DRAIN 6.00 1.00
50021 RENAL ABSCESS, PERCUT DRAIN 4.64 1.00
50040 DRAINAGE OF KIDNEY 6.00 1.00

50060 REMOVAL OF KIDNEY STONE 6.00 1.00
50065 INCISION OF KIDNEY 6.00 1.00


50100 REVISE KIDNEY BLOOD VESSELS 6.00 1.00

50125 EXPLORE AND DRAIN KIDNEY 6.00 1.00

50200 BIOPSY OF KIDNEY 3.00 1.00

50220 REMOVE KIDNEY, OPEN 6.00 1.00
50225 REMOVAL KIDNEY OPEN, COMPLEX 6.00 1.00
50230 REMOVAL KIDNEY OPEN, RADICAL 6.00 1.00

50234 REMOVAL OF KIDNEY & URETER 7.00 1.00
50240 PARTIAL REMOVAL OF KIDNEY 7.00 1.00

50250 CRYOABLATE RENAL MASS OPEN 35.14 1.00
50280 REMOVAL OF KIDNEY LESION 6.00 1.00
50320 REMOVE KIDNEY, LIVING DONOR 6.00 1.00

50340 REMOVAL OF KIDNEY 6.00 1.00
50360 TRANSPLANTATION OF KIDNEY 6.00 1.00

50370 REMOVE TRANSPLANTED KIDNEY 6.00 1.00
50380 REIMPLANTATION OF KIDNEY 6.00 1.00
50382 CHANGE URETER STENT, PERCUT 8.03 1.00
50384 REMOVE URETER STENT, PERCUT 7.31 1.00

50385 CHANGE STENT VIA TRANSURETH 6.86 1.00
50386 REMOVE STENT VIA TRANSURETH 5.18 1.00
50387 CHANGE EXT/INT URETER STENT 2.91 1.00
50389 REMOVE RENAL TUBE W/FLUORO 1.60 1.00
50390 DRAINAGE OF KIDNEY LESION 2.71 1.00
50391 INSTLL RX AGNT INTO RNAL TUB 2.89 1.00
50392 INSERT KIDNEY DRAIN 4.66 1.00

50393 INSERT URETERAL TUBE 5.00 1.00
50394 INJECTION FOR KIDNEY X-RAY 1.06 1.00
50395 CREATE PASSAGE TO KIDNEY 4.66 1.00
50396 MEASURE KIDNEY PRESSURE 3.06 1.00

50398 CHANGE KIDNEY TUBE 2.01 1.00
50400 REVISION OF KIDNEY/URETER 7.00 1.00

50500 REPAIR OF KIDNEY WOUND 10.00 1.00
50520 CLOSE KIDNEY-SKIN FISTULA 6.00 1.00

50525 REPAIR RENAL-ABDOMEN FISTULA 6.00 1.00
50540 REVISION OF HORSESHOE KIDNEY 6.00 1.00

50541 LAPARO ABLATE RENAL CYST 6.00 1.00
50542 LAPARO ABLATE RENAL MASS 29.70 1.00
50543 LAPARO PARTIAL NEPHRECTOMY 37.34 1.00
50544 LAPAROSCOPY, PYELOPLASTY 6.00 1.00

50545 LAPARO RADICAL NEPHRECTOMY 7.00 1.00
50546 LAPAROSCOPIC NEPHRECTOMY 6.00 1.00

50547 LAPARO REMOVAL DONOR KIDNEY 6.00 1.00
50548 LAPARO REMOVE W/URETER 6.00 1.00
50551 KIDNEY ENDOSCOPY 6.00 1.00

50555 KIDNEY ENDOSCOPY & BIOPSY 6.00 1.00
50557 KIDNEY ENDOSCOPY & TREATMENT 6.00 1.00
50559 RENAL ENDOSCOPY/RADIOTRACER 9.29 1.00

50562 RENAL SCOPE W/TUMOR RESECT 15.75 1.00


50590 FRAGMENTING OF KIDNEY STONE 7.00 1.00

50592 PERC RF ABLATE RENAL TUMOR 10.44 1.00
50593 PERC CRYO ABLATE RENAL TUM 13.25 1.00
50600 EXPLORATION OF URETER 5.00 1.00
50605 INSERT URETERAL SUPPORT 7.00 1.00

50610 REMOVAL OF URETER STONE 5.00 1.00

50650 REMOVAL OF URETER 5.00 1.00
50684 INJECTION FOR URETER X-RAY 1.05 1.00

50686 MEASURE URETER PRESSURE 2.27 1.00
50688 CHANGE OF URETER TUBE/STENT 2.26 1.00

50700 REVISION OF URETER 5.00 1.00
50715 RELEASE OF URETER 5.00 1.00

50725 RELEASE/REVISE URETER 5.00 1.00
50727 REVISE URETER 6.00 1.00

50740 FUSION OF URETER & KIDNEY 5.00 1.00
50760 FUSION OF URETERS 5.00 1.00

50770 SPLICING OF URETERS 5.00 1.00
50780 REIMPLANT URETER IN BLADDER 5.00 1.00

50800 IMPLANT URETER IN BOWEL 6.00 1.00

50810 FUSION OF URETER & BOWEL 7.00 1.00
50815 URINE SHUNT TO INTESTINE 7.00 1.00

50820 CONSTRUCT BOWEL BLADDER 7.00 1.00
50830 REVISE URINE FLOW 7.00 1.00
50840 REPLACE URETER BY BOWEL 7.00 1.00

50845 APPENDICO-VESICOSTOMY 6.00 1.00
50860 TRANSPLANT URETER TO SKIN 5.00 1.00
50900 REPAIR OF URETER 6.00 1.00

50920 CLOSURE URETER/SKIN FISTULA 6.00 1.00
50930 CLOSURE URETER/BOWEL FISTULA 6.00 1.00

50945 LAPAROSCOPY URETEROLITHOTOMY 6.00 1.00
50947 LAPARO NEW URETER/BLADDER 6.00 1.00

50951 ENDOSCOPY OF URETER 6.00 1.00

50955 URETER ENDOSCOPY & BIOPSY 6.00 1.00
50957 URETER ENDOSCOPY & TREATMENT 6.00 1.00
50959 URETER ENDOSCOPY & TRACER 5.98 1.00

50970 URETER ENDOSCOPY 3.00 1.00
50972 URETER ENDOSCOPY & CATHETER 3.00 1.00


51000 DRAINAGE OF BLADDER 1.08 1.00

51020 INCISE & TREAT BLADDER 5.00 1.00
51040 INCISE & DRAIN BLADDER 5.00 1.00

51045 INCISE BLADDER/DRAIN URETER 5.00 1.00
51050 REMOVAL OF BLADDER STONE 5.00 1.00

51065 REMOVE URETER CALCULUS 5.00 1.00
51080 DRAINAGE OF BLADDER ABSCESS 5.00 1.00
51100 DRAIN BLADDER BY NEEDLE 1.11 1.00
51101 DRAIN BLADDER BY TROCAR/CATH 1.50 1.00

51102 DRAIN BL W/CATH INSERTION 4.36 1.00
51500 REMOVAL OF BLADDER CYST 6.00 1.00
51520 REMOVAL OF BLADDER LESION 5.00 1.00

51535 REPAIR OF URETER LESION 5.00 1.00
51550 PARTIAL REMOVAL OF BLADDER 6.00 1.00

51565 REVISE BLADDER & URETER(S) 6.00 1.00
51570 REMOVAL OF BLADDER 6.00 1.00

51575 REMOVAL OF BLADDER & NODES 7.00 1.00
51580 REMOVE BLADDER/REVISE TRACT 8.00 1.00

51596 REMOVE BLADDER/CREATE POUCH 8.00 1.00

51597 REMOVAL OF PELVIC STRUCTURES 7.00 1.00
51600 INJECTION FOR BLADDER X-RAY 1.22 1.00
51605 PREPARATION FOR BLADDER XRAY 0.90 1.00

51700 IRRIGATION OF BLADDER 1.22 1.00
51701 INSERT BLADDER CATHETER 0.73 1.00
51701 INSERT BLADDER CATHETER 0.78 1.00
51702 INSERT TEMP BLADDER CATH 0.80 1.00
51702 INSERT TEMP BLADDER CATH 0.86 1.00

51703 INSERT BLADDER CATH, COMPLEX 2.15 1.00
51703 INSERT BLADDER CATH, COMPLEX 2.35 1.00
51705 CHANGE OF BLADDER TUBE 1.62 1.00
51715 ENDOSCOPIC INJECTION/IMPLANT 5.22 1.00

51720 TREATMENT OF BLADDER LESION 2.41 1.00
51725 SIMPLE CYSTOMETROGRAM 6.21 1.00
51726 COMPLEX CYSTOMETROGRAM 3.00 1.00

51736 URINE FLOW MEASUREMENT 1.21 1.00
51741 ELECTRO-UROFLOWMETRY, FIRST 2.02 1.00
51772 URETHRA PRESSURE PROFILE 3.00 1.00

51784 ANAL/URINARY MUSCLE STUDY 5.70 1.00
51792 URINARY REFLEX STUDY 6.50 1.00
51795 URINE VOIDING PRESSURE STUDY 3.00 1.00

51797 INTRAABDOMINAL PRESSURE TEST 3.00 1.00
51798 US URINE CAPACITY MEASURE 0.44 1.00
51800 REVISION OF BLADDER/URETHRA 5.00 1.00

51820 REVISION OF URINARY TRACT 6.00 1.00
51840 ATTACH BLADDER/URETHRA 6.00 1.00

51845 REPAIR BLADDER NECK 6.00 1.00
51860 REPAIR OF BLADDER WOUND 4.00 1.00

51880 REPAIR OF BLADDER OPENING 3.00 1.00
51900 REPAIR BLADDER/VAGINA LESION 5.00 1.00
51920 CLOSE BLADDER-UTERUS FISTULA 5.00 1.00

51925 HYSTERECTOMY/BLADDER REPAIR 6.00 1.00
51940 CORRECTION OF BLADDER DEFECT 7.00 1.00
51960 REVISION OF BLADDER & BOWEL 6.00 1.00

51980 CONSTRUCT BLADDER OPENING 5.00 1.00
51990 LAPARO URETHRAL SUSPENSION 6.00 1.00
51992 LAPARO SLING OPERATION 6.00 1.00

52000 CYSTOSCOPY 2.91 1.00
52000 CYSTOSCOPY 3.00 1.00
52000 CYSTOSCOPY 3.28 1.00
52000 CYSTOSCOPY 3.40 1.00
52000 CYSTOSCOPY 3.60 1.00
52001 CYSTOSCOPY, REMOVAL OF CLOTS 3.00 1.00

52005 CYSTOSCOPY & URETER CATHETER 3.00 1.00
52007 CYSTOSCOPY AND BIOPSY 3.00 1.00
52010 CYSTOSCOPY & DUCT CATHETER 3.00 1.00

52204 CYSTOSCOPY W/BIOPSY(S) 3.00 1.00
52214 CYSTOSCOPY AND TREATMENT 3.00 1.00


52250 CYSTOSCOPY AND RADIOTRACER 3.00 1.00

52270 CYSTOSCOPY & REVISE URETHRA 3.00 1.00

52282 CYSTOSCOPY, IMPLANT STENT 3.00 1.00




52317 REMOVE BLADDER STONE 3.00 1.00
52325 CYSTOSCOPY, STONE REMOVAL 3.00 1.00

52327 CYSTOSCOPY, INJECT MATERIAL 3.00 1.00

52341 CYSTO W/URETER STRICTURE TX 3.00 1.00

52342 CYSTO W/UP STRICTURE TX 3.00 1.00
52343 CYSTO W/RENAL STRICTURE TX 3.00 1.00
52344 CYSTO/URETERO, STRICTURE TX 3.00 1.00

52345 CYSTO/URETERO W/UP STRICTURE 3.00 1.00
52346 CYSTOURETERO W/RENAL STRICT 3.00 1.00
52347 CYSTOSCOPY, RESECT DUCTS 3.00 1.00
52351 CYSTOURETERO & OR PYELOSCOPE 3.00 1.00

52352 CYSTOURETERO W/STONE REMOVE 3.00 1.00
52353 CYSTOURETERO W/LITHOTRIPSY 3.00 1.00
52354 CYSTOURETERO W/BIOPSY 3.00 1.00

52355 CYSTOURETERO W/EXCISE TUMOR 3.00 1.00
52400 CYSTOURETERO W/CONGEN REPR 3.00 1.00
52402 CYSTOURETHRO CUT EJACUL DUCT 7.86 1.00
52450 INCISION OF PROSTATE 11.75 1.00

52500 REVISION OF BLADDER NECK 4.00 1.00
52510 DILATION PROSTATIC URETHRA 10.33 1.00
52601 PROSTATECTOMY (TURP) 5.00 1.00

52606 CONTROL POSTOP BLEEDING 5.00 1.00
52612 PROSTATECTOMY, FIRST STAGE 5.00 1.00

52614 PROSTATECTOMY, SECOND STAGE 5.00 1.00
52620 REMOVE RESIDUAL PROSTATE 5.00 1.00
52630 REMOVE PROSTATE REGROWTH 5.00 1.00
52640 RELIEVE BLADDER CONTRACTURE 5.00 1.00

52647 LASER SURGERY OF PROSTATE 5.00 1.00

52649 PROSTATE LASER ENUCLEATION 28.14 1.00
52700 DRAINAGE OF PROSTATE ABSCESS 5.00 1.00
53000 INCISION OF URETHRA 3.00 1.00


53040 DRAINAGE OF URETHRA ABSCESS 3.00 1.00
53080 DRAINAGE OF URINARY LEAKAGE 3.00 1.00

53200 BIOPSY OF URETHRA 3.00 1.00
53210 REMOVAL OF URETHRA 5.00 1.00

53220 TREATMENT OF URETHRA LESION 3.00 1.00
53230 REMOVAL OF URETHRA LESION 3.00 1.00

53240 SURGERY FOR URETHRA POUCH 3.00 1.00
53250 REMOVAL OF URETHRA GLAND 3.00 1.00


53275 REPAIR OF URETHRA DEFECT 3.00 1.00
53400 REVISE URETHRA, STAGE 1 3.00 1.00

53410 RECONSTRUCTION OF URETHRA 4.00 1.00
53420 RECONSTRUCT URETHRA, STAGE 1 3.00 1.00


53431 RECONSTRUCT URETHRA/BLADDER 3.00 1.00
53440 MALE SLING PROCEDURE 3.00 1.00
53442 REMOVE/REVISE MALE SLING 3.00 1.00
53444 INSERT TANDEM CUFF 3.00 1.00

53445 INSERT URO/VES NCK SPHINCTER 3.00 1.00
53446 REMOVE URO SPHINCTER 3.00 1.00
53447 REMOVE/REPLACE UR SPHINCTER 3.00 1.00

53448 REMOV/REPLC UR SPHINCTR COMP 3.00 1.00
53449 REPAIR URO SPHINCTER 3.00 1.00

53450 REVISION OF URETHRA 3.00 1.00
53500 URETHRLYS, TRANSVAG W/ SCOPE 19.27 1.00
53500 URETHRLYS, TRANSVAG W/ SCOPE 21.07 1.00
53502 REPAIR OF URETHRA INJURY 4.00 1.00


53600 DILATE URETHRA STRICTURE 1.72 1.00


53660 DILATION OF URETHRA 1.08 1.00

53850 PROSTATIC MICROWAVE THERMOTX 3.00 1.00
53852 PROSTATIC RF THERMOTX 3.00 1.00
53853 PROSTATIC WATER THERMOTHER 3.00 1.00

54000 SLITTING OF PREPUCE 3.00 1.00
54015 DRAIN PENIS LESION 3.00 1.00
54015 DRAIN PENIS LESION 8.70 1.00
54050 DESTRUCTION, PENIS LESION(S) 1.81 1.00
54056 CRYOSURGERY, PENIS LESION(S) 1.84 1.00

54056 CRYOSURGERY, PENIS LESION(S) 3.00 1.00
54057 LASER SURG, PENIS LESION(S) 2.56 1.00
54057 LASER SURG, PENIS LESION(S) 3.00 1.00
54060 EXCISION OF PENIS LESION(S) 3.00 1.00
54060 EXCISION OF PENIS LESION(S) 3.61 1.00
54100 BIOPSY OF PENIS 2.76 1.00
54110 TREATMENT OF PENIS LESION 3.00 1.00

54111 TREAT PENIS LESION, GRAFT 3.00 1.00
54120 PARTIAL REMOVAL OF PENIS 4.00 1.00
54120 PARTIAL REMOVAL OF PENIS 17.80 1.00
54125 REMOVAL OF PENIS 4.00 1.00

54125 REMOVAL OF PENIS 22.77 1.00
54130 REMOVE PENIS & NODES 6.00 1.00
54150 CIRCUMCISION W/REGIONL BLOCK 3.86 1.00
54152 CIRCUMCISION 3.00 1.00
54152 CIRCUMCISION 4.12 1.00
54160 CIRCUMCISION, NEONATE 3.00 1.00
54160 CIRCUMCISION, NEONATE 4.39 1.00
54161 CIRCUM 28 DAYS OR OLDER 3.00 1.00
54161 CIRCUM 28 DAYS OR OLDER 5.39 1.00
54162 LYSIS PENIL CIRCUMIC LESION 3.00 1.00

54162 LYSIS PENIL CIRCUMIC LESION 5.50 1.00
54163 REPAIR OF CIRCUMCISION 3.00 1.00
54163 REPAIR OF CIRCUMCISION 5.27 1.00
54230 PREPARE PENIS STUDY 1.86 1.00
54300 REVISION OF PENIS 3.00 1.00


54328 REVISE PENIS/URETHRA 3.00 1.00
54340 SECONDARY URETHRAL SURGERY 3.00 1.00

54352 RECONSTRUCT URETHRA/PENIS 3.00 1.00
54352 RECONSTRUCT URETHRA/PENIS 40.89 1.00
54360 PENIS PLASTIC SURGERY 3.00 1.00
54360 PENIS PLASTIC SURGERY 20.50 1.00
54380 REPAIR PENIS 3.00 1.00
54380 REPAIR PENIS 23.84 1.00
54385 REPAIR PENIS 3.00 1.00
54385 REPAIR PENIS 28.29 1.00
54390 REPAIR PENIS AND BLADDER 6.00 1.00

54390 REPAIR PENIS AND BLADDER 35.91 1.00
54440 REPAIR OF PENIS 3.00 1.00
54450 PREPUTIAL STRETCHING 1.67 1.00
54450 PREPUTIAL STRETCHING 3.00 1.00

54500 BIOPSY OF TESTIS 1.83 1.00
54512 EXCISE LESION TESTIS 3.00 1.00
54512 EXCISE LESION TESTIS 13.64 1.00
54520 REMOVAL OF TESTIS 3.00 1.00
54522 ORCHIECTOMY, PARTIAL 4.00 1.00
54522 ORCHIECTOMY, PARTIAL 15.24 1.00
54535 EXTENSIVE TESTIS SURGERY 6.00 1.00

54535 EXTENSIVE TESTIS SURGERY 19.71 1.00
54550 EXPLORATION FOR TESTIS 3.00 1.00
54600 REDUCE TESTIS TORSION 3.00 1.00
54600 REDUCE TESTIS TORSION 11.34 1.00
54620 SUSPENSION OF TESTIS 3.00 1.00
54650 ORCHIOPEXY (FOWLER-STEPHENS) 4.00 1.00

54650 ORCHIOPEXY (FOWLER-STEPHENS) 18.85 1.00
54660 REVISION OF TESTIS 999.99 1.00
54670 REPAIR TESTIS INJURY 3.00 1.00
54670 REPAIR TESTIS INJURY 10.65 1.00
54680 RELOCATION OF TESTIS(ES) 3.00 1.00
54680 RELOCATION OF TESTIS(ES) 20.65 1.00
54690 LAPAROSCOPY, ORCHIECTOMY 6.00 1.00
54690 LAPAROSCOPY, ORCHIECTOMY 18.27 1.00
54692 LAPAROSCOPY, ORCHIOPEXY 6.00 1.00
54692 LAPAROSCOPY, ORCHIOPEXY 19.22 1.00

54700 DRAINAGE OF SCROTUM 3.00 1.00
54700 DRAINAGE OF SCROTUM 6.72 1.00
54800 BIOPSY OF EPIDIDYMIS 3.00 1.00
54800 BIOPSY OF EPIDIDYMIS 3.26 1.00
54820 EXPLORATION OF EPIDIDYMIS 3.00 1.00
54820 EXPLORATION OF EPIDIDYMIS 8.73 1.00
54830 REMOVE EPIDIDYMIS LESION 3.00 1.00
54860 REMOVAL OF EPIDIDYMIS 3.00 1.00

54900 FUSION OF SPERMATIC DUCTS 3.00 1.00
55000 DRAINAGE OF HYDROCELE 2.01 1.00
55000 DRAINAGE OF HYDROCELE 3.00 1.00
55040 REMOVAL OF HYDROCELE 3.00 1.00
55041 REMOVAL OF HYDROCELES 3.00 1.00
55041 REMOVAL OF HYDROCELES 12.35 1.00
55060 REPAIR OF HYDROCELE 4.00 1.00

55060 REPAIR OF HYDROCELE 9.08 1.00
55100 DRAINAGE OF SCROTUM ABSCESS 3.00 1.00
55100 DRAINAGE OF SCROTUM ABSCESS 5.50 1.00
55110 EXPLORE SCROTUM 3.00 1.00
55110 EXPLORE SCROTUM 9.28 1.00
55120 REMOVAL OF SCROTUM LESION 3.00 1.00
55120 REMOVAL OF SCROTUM LESION 8.47 1.00
55150 REMOVAL OF SCROTUM 3.00 1.00
55150 REMOVAL OF SCROTUM 11.91 1.00
55175 REVISION OF SCROTUM 3.00 1.00

55250 REMOVAL OF SPERM DUCT(S) 3.00 1.00
55250 REMOVAL OF SPERM DUCT(S) 6.42 1.00
55450 LIGATION OF SPERM DUCT 3.00 1.00
55450 LIGATION OF SPERM DUCT 6.79 1.00
55520 REMOVAL OF SPERM CORD LESION 3.00 1.00
55520 REMOVAL OF SPERM CORD LESION 10.23 1.00
55530 REVISE SPERMATIC CORD VEINS 3.00 1.00

55540 REVISE HERNIA & SPERM VEINS 3.00 1.00
55540 REVISE HERNIA & SPERM VEINS 12.61 1.00
55550 LAPARO LIGATE SPERMATIC VEIN 6.00 1.00
55550 LAPARO LIGATE SPERMATIC VEIN 10.54 1.00
55600 INCISE SPERM DUCT POUCH 3.00 1.00
55650 REMOVE SPERM DUCT POUCH 4.00 1.00
55650 REMOVE SPERM DUCT POUCH 18.33 1.00

55680 REMOVE SPERM POUCH LESION 6.00 1.00
55680 REMOVE SPERM POUCH LESION 8.98 1.00
55700 BIOPSY OF PROSTATE 2.40 1.00

55801 REMOVAL OF PROSTATE 4.00 1.00
55810 EXTENSIVE PROSTATE SURGERY 4.00 1.00

55859 PERCUT/NEEDLE INSERT, PROS 6.00 1.00
55859 PERCUT/NEEDLE INSERT, PROS 20.12 1.00
55860 SURGICAL EXPOSURE, PROSTATE 6.00 1.00
55860 SURGICAL EXPOSURE, PROSTATE 22.85 1.00

55866 LAPARO RADICAL PROSTATECTOMY 43.90 1.00
55873 CRYOABLATE PROSTATE 4.00 1.00
55873 CRYOABLATE PROSTATE 29.95 1.00
56405 I & D OF VULVA/PERINEUM 2.81 1.00
56405 I & D OF VULVA/PERINEUM 3.00 1.00
56420 DRAINAGE OF GLAND ABSCESS 2.76 1.00
56420 DRAINAGE OF GLAND ABSCESS 3.00 1.00
56440 SURGERY FOR VULVA LESION 3.00 1.00
56440 SURGERY FOR VULVA LESION 5.34 1.00

56441 LYSIS OF LABIAL LESION(S) 3.00 1.00
56441 LYSIS OF LABIAL LESION(S) 3.95 1.00
56501 DESTROY, VULVA LESIONS, SIM 2.97 1.00
56501 DESTROY, VULVA LESIONS, SIM 3.00 1.00
56515 DESTROY VULVA LESION/S COMPL 3.00 1.00
56515 DESTROY VULVA LESION/S COMPL 5.18 1.00
56605 BIOPSY OF VULVA/PERINEUM 1.68 1.00
56620 PARTIAL REMOVAL OF VULVA 3.00 1.00
56620 PARTIAL REMOVAL OF VULVA 13.08 1.00
56625 COMPLETE REMOVAL OF VULVA 3.00 1.00

56625 COMPLETE REMOVAL OF VULVA 15.02 1.00
56630 EXTENSIVE VULVA SURGERY 3.00 1.00

56700 PARTIAL REMOVAL OF HYMEN 3.00 1.00
56700 PARTIAL REMOVAL OF HYMEN 4.46 1.00
56720 INCISION OF HYMEN 1.16 1.00
56720 INCISION OF HYMEN 3.00 1.00
56740 REMOVE VAGINA GLAND LESION 3.00 1.00
56740 REMOVE VAGINA GLAND LESION 7.52 1.00
56800 REPAIR OF VAGINA 3.00 1.00

56805 REPAIR CLITORIS 29.80 1.00
56805 REPAIR CLITORIS 999.99 1.00
56810 REPAIR OF PERINEUM 3.00 1.00
56810 REPAIR OF PERINEUM 7.26 1.00
56820 EXAM OF VULVA W/SCOPE 2.25 1.00
56821 EXAM/BIOPSY OF VULVA W/SCOPE 3.10 1.00
57000 EXPLORATION OF VAGINA 3.00 1.00
57000 EXPLORATION OF VAGINA 5.44 1.00
57020 DRAINAGE OF PELVIC FLUID 2.28 1.00
57020 DRAINAGE OF PELVIC FLUID 3.00 1.00

57022 I & D VAGINAL HEMATOMA, PP 3.00 1.00
57022 I & D VAGINAL HEMATOMA, PP 4.83 1.00
57023 I & D VAG HEMATOMA, NON-OB 3.00 1.00
57023 I & D VAG HEMATOMA, NON-OB 7.88 1.00
57061 DESTROY VAG LESIONS, SIMPLE 2.54 1.00
57061 DESTROY VAG LESIONS, SIMPLE 3.00 1.00
57065 DESTROY VAG LESIONS, COMPLEX 3.00 1.00
57065 DESTROY VAG LESIONS, COMPLEX 5.10 1.00
57100 BIOPSY OF VAGINA 1.80 1.00

57106 REMOVE VAGINA WALL, PARTIAL 5.00 1.00
57106 REMOVE VAGINA WALL, PARTIAL 10.81 1.00
57107 REMOVE VAGINA TISSUE, PART 5.00 1.00
57107 REMOVE VAGINA TISSUE, PART 35.45 1.00
57109 VAGINECTOMY PARTIAL W/NODES 5.00 1.00
57109 VAGINECTOMY PARTIAL W/NODES 40.50 1.00
57110 REMOVE VAGINA WALL, COMPLETE 5.00 1.00
57110 REMOVE VAGINA WALL, COMPLETE 22.93 1.00
57111 REMOVE VAGINA TISSUE, COMPL 5.00 1.00
57111 REMOVE VAGINA TISSUE, COMPL 42.01 1.00

57112 VAGINECTOMY W/NODES, COMPL 5.00 1.00
57112 VAGINECTOMY W/NODES, COMPL 43.58 1.00
57120 CLOSURE OF VAGINA 4.00 1.00
57120 CLOSURE OF VAGINA 12.75 1.00
57130 REMOVE VAGINA LESION 3.00 1.00
57150 TREAT VAGINA INFECTION 0.83 1.00
57155 INSERT UTERI TANDEMS/OVOIDS 10.54 1.00
57160 INSERT PESSARY/OTHER DEVICE 1.38 1.00
57170 FITTING OF DIAPHRAGM/CAP 1.34 1.00
57180 TREAT VAGINAL BLEEDING 3.15 1.00

57210 REPAIR VAGINA/PERINEUM 4.00 1.00
57210 REPAIR VAGINA/PERINEUM 9.34 1.00
57230 REPAIR OF URETHRAL LESION 3.00 1.00
57230 REPAIR OF URETHRAL LESION 9.68 1.00
57240 REPAIR BLADDER & VAGINA 4.00 1.00
57250 REPAIR RECTUM & VAGINA 4.00 1.00
57250 REPAIR RECTUM & VAGINA 9.88 1.00

57265 EXTENSIVE REPAIR OF VAGINA 4.00 1.00
57265 EXTENSIVE REPAIR OF VAGINA 18.86 1.00
57268 REPAIR OF BOWEL BULGE 4.00 1.00
57268 REPAIR OF BOWEL BULGE 11.90 1.00
57270 REPAIR OF BOWEL POUCH 5.00 1.00
57270 REPAIR OF BOWEL POUCH 19.88 1.00
57280 SUSPENSION OF VAGINA 5.00 1.00
57280 SUSPENSION OF VAGINA 24.21 1.00

57282 COLPOPEXY, EXTRAPERITONEAL 6.00 1.00
57282 COLPOPEXY, EXTRAPERITONEAL 15.30 1.00
57284 REPAIR PARAVAG DEFECT, OPEN 6.00 1.00
57284 REPAIR PARAVAG DEFECT, OPEN 20.99 1.00
57287 REVISE/REMOVE SLING REPAIR 6.00 1.00
57287 REVISE/REMOVE SLING REPAIR 17.05 1.00
57288 REPAIR BLADDER DEFECT 5.00 1.00
57288 REPAIR BLADDER DEFECT 19.93 1.00
57291 CONSTRUCTION OF VAGINA 6.00 1.00
57291 CONSTRUCTION OF VAGINA 14.02 1.00
57292 CONSTRUCT VAGINA WITH GRAFT 6.00 1.00

57292 CONSTRUCT VAGINA WITH GRAFT 21.76 1.00
57300 REPAIR RECTUM-VAGINA FISTULA 4.00 1.00
57307 FISTULA REPAIR & COLOSTOMY 6.00 1.00
57307 FISTULA REPAIR & COLOSTOMY 25.07 1.00
57308 FISTULA REPAIR, TRANSPERINE 4.00 1.00
57308 FISTULA REPAIR, TRANSPERINE 16.74 1.00
57310 REPAIR URETHROVAGINAL LESION 4.00 1.00

57320 REPAIR BLADDER-VAGINA LESION 4.00 1.00
57335 REPAIR VAGINA 29.36 1.00
57335 REPAIR VAGINA 999.99 1.00
57400 DILATION OF VAGINA 3.00 1.00
57400 DILATION OF VAGINA 3.63 1.00
57410 PELVIC EXAMINATION 2.92 1.00

57410 PELVIC EXAMINATION 3.00 1.00
57415 REMOVE VAGINAL FOREIGN BODY 3.00 1.00
57415 REMOVE VAGINAL FOREIGN BODY 4.23 1.00
57420 EXAM OF VAGINA W/SCOPE 2.39 1.00
57421 EXAM/BIOPSY OF VAG W/SCOPE 3.31 1.00
57452 EXAM OF CERVIX W/SCOPE 2.25 1.00
57452 EXAM OF CERVIX W/SCOPE 3.00 1.00
57454 BX/CURETT OF CERVIX W/SCOPE 3.00 1.00
57454 BX/CURETT OF CERVIX W/SCOPE 3.48 1.00
57455 BIOPSY OF CERVIX W/SCOPE 3.01 1.00
57456 ENDOCERV CURETTAGE W/SCOPE 2.82 1.00
57460 BX OF CERVIX W/SCOPE, LEEP 3.00 1.00
57460 BX OF CERVIX W/SCOPE, LEEP 4.36 1.00

57461 CONZ OF CERVIX W/SCOPE, LEEP 5.22 1.00
57500 BIOPSY OF CERVIX 1.56 1.00
57500 BIOPSY OF CERVIX 3.00 1.00
57505 ENDOCERVICAL CURETTAGE 2.47 1.00
57505 ENDOCERVICAL CURETTAGE 3.00 1.00
57510 CAUTERIZATION OF CERVIX 3.59 1.00
57510 CAUTERIZATION OF CERVIX 4.00 1.00
57511 CRYOCAUTERY OF CERVIX 2.83 1.00
57511 CRYOCAUTERY OF CERVIX 4.00 1.00
57513 LASER SURGERY OF CERVIX 3.00 1.00
57513 LASER SURGERY OF CERVIX 3.59 1.00
57520 CONIZATION OF CERVIX 3.00 1.00

57530 REMOVAL OF CERVIX 3.00 1.00
57530 REMOVAL OF CERVIX 8.80 1.00
57531 REMOVAL OF CERVIX, RADICAL 3.00 1.00
57531 REMOVAL OF CERVIX, RADICAL 43.99 1.00
57540 REMOVAL OF RESIDUAL CERVIX 5.00 1.00
57545 REMOVE CERVIX/REPAIR PELVIS 6.00 1.00

57545 REMOVE CERVIX/REPAIR PELVIS 20.92 1.00
57555 REMOVE CERVIX/REPAIR VAGINA 4.00 1.00
57555 REMOVE CERVIX/REPAIR VAGINA 15.44 1.00
57556 REMOVE CERVIX, REPAIR BOWEL 4.00 1.00
57556 REMOVE CERVIX, REPAIR BOWEL 14.00 1.00
57700 REVISION OF CERVIX 4.00 1.00
57800 DILATION OF CERVICAL CANAL 1.33 1.00
57800 DILATION OF CERVICAL CANAL 3.00 1.00

57820 D & C OF RESIDUAL CERVIX 2.95 1.00
57820 D & C OF RESIDUAL CERVIX 3.00 1.00
58100 BIOPSY OF UTERUS LINING 2.35 1.00
58100 BIOPSY OF UTERUS LINING 3.00 1.00
58120 DILATION AND CURETTAGE 5.57 1.00
58120 DILATION AND CURETTAGE 6.00 1.00
58140 MYOMECTOMY ABDOM METHOD 6.00 1.00
58140 MYOMECTOMY ABDOM METHOD 23.07 1.00
58145 MYOMECTOMY VAG METHOD 5.00 1.00
58145 MYOMECTOMY VAG METHOD 13.68 1.00
58146 MYOMECTOMY ABDOM COMPLEX 29.61 1.00
58150 TOTAL HYSTERECTOMY 6.00 1.00

58180 PARTIAL HYSTERECTOMY 6.00 1.00
58180 PARTIAL HYSTERECTOMY 24.68 1.00
58200 EXTENSIVE HYSTERECTOMY 6.00 1.00
58240 REMOVAL OF PELVIS CONTENTS 7.00 1.00

58240 REMOVAL OF PELVIS CONTENTS 60.63 1.00
58260 VAGINAL HYSTERECTOMY 6.00 1.00
58260 VAGINAL HYSTERECTOMY 20.89 1.00
58262 VAG HYST INCLUDING T/O 6.00 1.00
58262 VAG HYST INCLUDING T/O 23.62 1.00
58263 VAG HYST W/T/O & VAG REPAIR 6.00 1.00
58263 VAG HYST W/T/O & VAG REPAIR 25.56 1.00
58267 VAG HYST W/URINARY REPAIR 7.00 1.00
58267 VAG HYST W/URINARY REPAIR 27.07 1.00
58270 VAG HYST W/ENTEROCELE REPAIR 5.00 1.00
58270 VAG HYST W/ENTEROCELE REPAIR 22.82 1.00
58275 HYSTERECTOMY/REVISE VAGINA 6.00 1.00

58290 VAG HYST COMPLEX 29.60 1.00
58291 VAG HYST INCL T/O, COMPLEX 32.55 1.00
58292 VAG HYST T/O & REPAIR, COMPL 34.48 1.00
58293 VAG HYST W/URO REPAIR, COMPL 35.82 1.00
58294 VAG HYST W/ENTEROCELE, COMPL 31.75 1.00
58300 INSERT INTRAUTERINE DEVICE 1.50 1.00
58301 REMOVE INTRAUTERINE DEVICE 1.90 1.00
58301 REMOVE INTRAUTERINE DEVICE 3.00 1.00

58340 CATHETER FOR HYSTEROGRAPHY 1.28 1.00
58340 CATHETER FOR HYSTEROGRAPHY 3.00 1.00
58346 INSERT HEYMAN UTERI CAPSULE 11.26 1.00
58353 ENDOMETR ABLATE, THERMAL 4.00 1.00
58353 ENDOMETR ABLATE, THERMAL 6.16 1.00
58400 SUSPENSION OF UTERUS 5.00 1.00
58520 REPAIR OF RUPTURED UTERUS 5.00 1.00

58520 REPAIR OF RUPTURED UTERUS 19.02 1.00
58540 REVISION OF UTERUS 6.00 1.00
58540 REVISION OF UTERUS 22.82 1.00
58545 LAPAROSCOPIC MYOMECTOMY 23.81 1.00
58546 LAPARO-MYOMECTOMY, COMPLEX 30.00 1.00
58550 LAPARO-ASST VAG HYSTERECTOMY 6.00 1.00
58550 LAPARO-ASST VAG HYSTERECTOMY 22.84 1.00
58551 LAPAROSCOPY, REMOVE MYOMA 6.00 1.00
58552 LAPARO-VAG HYST INCL T/O 23.19 1.00
58553 LAPARO-VAG HYST, COMPLEX 29.80 1.00
58554 LAPARO-VAG HYST W/T/O, COMPL 29.49 1.00
58555 HYSTEROSCOPY, DX, SEP PROC 5.16 1.00
58555 HYSTEROSCOPY, DX, SEP PROC 6.00 1.00

58558 HYSTEROSCOPY, BIOPSY 6.00 1.00
58558 HYSTEROSCOPY, BIOPSY 7.36 1.00
58559 HYSTEROSCOPY, LYSIS 6.00 1.00
58559 HYSTEROSCOPY, LYSIS 9.48 1.00
58560 HYSTEROSCOPY, RESECT SEPTUM 6.00 1.00
58560 HYSTEROSCOPY, RESECT SEPTUM 10.76 1.00
58561 HYSTEROSCOPY, REMOVE MYOMA 6.00 1.00
58561 HYSTEROSCOPY, REMOVE MYOMA 15.30 1.00
58562 HYSTEROSCOPY, REMOVE FB 6.00 1.00
58562 HYSTEROSCOPY, REMOVE FB 8.00 1.00
58563 HYSTEROSCOPY, ABLATION 6.00 1.00
58563 HYSTEROSCOPY, ABLATION 9.50 1.00

58600 DIVISION OF FALLOPIAN TUBE 5.00 1.00
58611 LIGATE OVIDUCT(S) ADD-ON 2.11 1.00
58615 OCCLUDE FALLOPIAN TUBE(S) 6.00 1.00
58615 OCCLUDE FALLOPIAN TUBE(S) 7.41 1.00
58660 LAPAROSCOPY, LYSIS 6.00 1.00
58660 LAPAROSCOPY, LYSIS 18.03 1.00
58661 LAPAROSCOPY, REMOVE ADNEXA 6.00 1.00

58661 LAPAROSCOPY, REMOVE ADNEXA 17.44 1.00
58662 LAPAROSCOPY, EXCISE LESIONS 6.00 1.00
58662 LAPAROSCOPY, EXCISE LESIONS 18.51 1.00
58670 LAPAROSCOPY, TUBAL CAUTERY 6.00 1.00
58670 LAPAROSCOPY, TUBAL CAUTERY 9.77 1.00
58671 LAPAROSCOPY, TUBAL BLOCK 6.00 1.00
58671 LAPAROSCOPY, TUBAL BLOCK 9.79 1.00
58672 LAPAROSCOPY, FIMBRIOPLASTY 6.00 1.00
58672 LAPAROSCOPY, FIMBRIOPLASTY 20.62 1.00
58673 LAPAROSCOPY, SALPINGOSTOMY 6.00 1.00
58673 LAPAROSCOPY, SALPINGOSTOMY 22.00 1.00
58700 REMOVAL OF FALLOPIAN TUBE 6.00 1.00
58700 REMOVAL OF FALLOPIAN TUBE 18.49 1.00

58720 REMOVAL OF OVARY/TUBE(S) 6.00 1.00
58720 REMOVAL OF OVARY/TUBE(S) 18.25 1.00
58740 ADHESIOLYSIS TUBE, OVARY 6.00 1.00
58740 ADHESIOLYSIS TUBE, OVARY 21.58 1.00
58770 CREATE NEW TUBAL OPENING 6.00 1.00
58770 CREATE NEW TUBAL OPENING 22.36 1.00
58800 DRAINAGE OF OVARIAN CYST(S) 6.00 1.00
58820 DRAIN OVARY ABSCESS, OPEN 5.00 1.00
58820 DRAIN OVARY ABSCESS, OPEN 7.85 1.00

58822 DRAIN OVARY ABSCESS, PERCUT 5.00 1.00
58822 DRAIN OVARY ABSCESS, PERCUT 16.09 1.00
58823 DRAIN PELVIC ABSCESS, PERCUT 5.88 1.00
58823 DRAIN PELVIC ABSCESS, PERCUT 6.00 1.00
58825 TRANSPOSITION, OVARY(S) 6.00 1.00
58825 TRANSPOSITION, OVARY(S) 17.34 1.00
58900 BIOPSY OF OVARY(S) 6.00 1.00
58900 BIOPSY OF OVARY(S) 10.08 1.00
58920 PARTIAL REMOVAL OF OVARY(S) 5.00 1.00
58920 PARTIAL REMOVAL OF OVARY(S) 17.62 1.00

58925 REMOVAL OF OVARIAN CYST(S) 6.00 1.00
58925 REMOVAL OF OVARIAN CYST(S) 18.04 1.00
58940 REMOVAL OF OVARY(S) 6.00 1.00
58950 RESECT OVARIAN MALIGNANCY 6.00 1.00
58953 TAH, RAD DISSECT FOR DEBULK 8.00 1.00
58953 TAH, RAD DISSECT FOR DEBULK 50.38 1.00

58954 TAH RAD DEBULK/LYMPH REMOVE 8.00 1.00
58954 TAH RAD DEBULK/LYMPH REMOVE 54.71 1.00
58999 GENITAL SURGERY PROCEDURE 999.99 1.00
61000 REMOVE CRANIAL CAVITY FLUID 2.69 1.00

61020 REMOVE BRAIN CAVITY FLUID 3.15 1.00
61026 INJECTION INTO BRAIN CANAL 3.35 1.00
61050 REMOVE BRAIN CANAL FLUID 2.82 1.00

61070 BRAIN CANAL SHUNT PROCEDURE 2.02 1.00
61105 TWIST DRILL HOLE 9.00 1.00

61107 DRILL SKULL FOR IMPLANTATION 4.00 1.00
61108 DRILL SKULL FOR DRAINAGE 9.00 1.00
61120 BURR HOLE FOR PUNCTURE 4.00 1.00

61140 PIERCE SKULL FOR BIOPSY 9.00 1.00
61150 PIERCE SKULL FOR DRAINAGE 9.00 1.00

61154 PIERCE SKULL & REMOVE CLOT 11.00 1.00
61210 PIERCE SKULL, IMPLANT DEVICE 7.00 1.00

61215 INSERT BRAIN-FLUID DEVICE 3.00 1.00
61250 PIERCE SKULL & EXPLORE 7.00 1.00

61304 OPEN SKULL FOR EXPLORATION 11.00 1.00
61312 OPEN SKULL FOR DRAINAGE 11.00 1.00


61316 IMPLT CRAN BONE FLAP TO ABDO 2.30 1.00

61322 DECOMPRESSIVE CRANIOTOMY 48.37 1.00
61323 DECOMPRESSIVE LOBECTOMY 50.07 1.00
61330 DECOMPRESS EYE SOCKET 11.00 1.00

61332 EXPLORE/BIOPSY EYE SOCKET 11.00 1.00
61333 EXPLORE ORBIT/REMOVE LESION 11.00 1.00
61334 EXPLORE ORBIT/REMOVE OBJECT 11.00 1.00

61340 SUBTEMPORAL DECOMPRESSION 11.00 1.00
61343 INCISE SKULL (PRESS RELIEF) 11.00 1.00
61345 RELIEVE CRANIAL PRESSURE 11.00 1.00
61440 INCISE SKULL FOR SURGERY 11.00 1.00

61458 INCISE SKULL FOR BRAIN WOUND 11.00 1.00


61500 REMOVAL OF SKULL LESION 9.00 1.00
61501 REMOVE INFECTED SKULL BONE 11.00 1.00

61510 REMOVAL OF BRAIN LESION 11.00 1.00
61512 REMOVE BRAIN LINING LESION 11.00 1.00
61514 REMOVAL OF BRAIN ABSCESS 11.00 1.00

61517 IMPLT BRAIN CHEMOTX ADD-ON 2.02 1.00



61531 IMPLANT BRAIN ELECTRODES 9.00 1.00

61535 REMOVE BRAIN ELECTRODES 11.00 1.00

61537 REMOVAL OF BRAIN TISSUE 45.90 1.00

61541 INCISION OF BRAIN TISSUE 11.00 1.00

61544 REMOVE & TREAT BRAIN LESION 11.00 1.00
61545 EXCISION OF BRAIN TUMOR 11.00 1.00
61546 REMOVAL OF PITUITARY GLAND 12.00 1.00

61550 RELEASE OF SKULL SEAMS 9.00 1.00

61556 INCISE SKULL/SUTURES 37.84 1.00
61558 EXCISION OF SKULL/SUTURES 42.57 1.00

61563 EXCISION OF SKULL TUMOR 47.36 1.00

61570 REMOVE FOREIGN BODY, BRAIN 11.00 1.00

61575 SKULL BASE/BRAINSTEM SURGERY 11.00 1.00

61580 CRANIOFACIAL APPROACH, SKULL 7.00 1.00

61584 ORBITOCRANIAL APPROACH/SKULL 11.00 1.00

61586 RESECT NASOPHARYNX, SKULL 11.00 1.00
61590 INFRATEMPORAL APPROACH/SKULL 11.00 1.00

61595 TRANSTEMPORAL APPROACH/SKULL 11.00 1.00
61596 TRANSCOCHLEAR APPROACH/SKULL 11.00 1.00

61597 TRANSCONDYLAR APPROACH/SKULL 11.00 1.00
61598 TRANSPETROSAL APPROACH/SKULL 11.00 1.00
61600 RESECT/EXCISE CRANIAL LESION 11.00 1.00


61609 TRANSECT ARTERY, SINUS 16.14 1.00


61613 REMOVE ANEURYSM, SINUS 11.00 1.00
61615 RESECT/EXCISE LESION, SKULL 11.00 1.00
61618 REPAIR DURA 11.00 1.00

61618 REPAIR DURA 30.99 1.00
61618 REPAIR DURA 31.36 1.00
61618 REPAIR DURA 32.85 1.00
61619 REPAIR DURA 11.00 1.00
61619 REPAIR DURA 37.11 1.00
61619 REPAIR DURA 37.51 1.00
61619 REPAIR DURA 37.76 1.00
61623 ENDOVASC TEMPORY VESSEL OCCL 14.69 1.00
61624 TRANSCATH OCCLUSION, CNS 15.00 1.00

61626 TRANSCATH OCCLUSION, NON-CNS 15.00 1.00
61630 INTRACRANIAL ANGIOPLASTY 33.90 1.00
61635 INTRACRAN ANGIOPLSTY W/STENT 37.12 1.00
61640 DILATE IC VASOSPASM, INIT 17.16 1.00
61641 DILATE IC VASOSPASM ADD-ON 6.03 1.00

61642 DILATE IC VASOSPASM ADD-ON 12.06 1.00
61680 INTRACRANIAL VESSEL SURGERY 15.00 1.00


61697 BRAIN ANEURYSM REPR, COMPLX 15.00 1.00
61700 BRAIN ANEURYSM REPR, SIMPLE 15.00 1.00

61702 INNER SKULL VESSEL SURGERY 15.00 1.00
61703 CLAMP NECK ARTERY 15.00 1.00
61705 REVISE CIRCULATION TO HEAD 15.00 1.00

61711 FUSION OF SKULL ARTERIES 15.00 1.00

61720 INCISE SKULL/BRAIN SURGERY 11.00 1.00
61750 INCISE SKULL/BRAIN BIOPSY 11.00 1.00

61751 BRAIN BIOPSY W/CT/MR GUIDE 7.00 1.00
61770 INCISE SKULL FOR TREATMENT 11.00 1.00

61790 TREAT TRIGEMINAL NERVE 7.00 1.00
61791 TREAT TRIGEMINAL TRACT 7.00 1.00
61793 FOCUS RADIATION BEAM 11.00 1.00

61795 BRAIN SURGERY USING COMPUTER 6.47 1.00
61796 SRS, CRANIAL LESION SIMPLE 20.28 1.00
61797 SRS, CRAN LES SIMPLE, ADDL 5.54 1.00
61798 SRS, CRANIAL LESION COMPLEX 20.28 1.00
61799 SRS, CRAN LES COMPLEX, ADDL 7.66 1.00
61800 APPLY SRS HEADFRAME ADD-ON 3.93 1.00
61850 IMPLANT NEUROELECTRODES 9.00 1.00

61862 IMPLANT NEUROSTIMUL, SUBCORT 11.00 1.00
61862 IMPLANT NEUROSTIMUL, SUBCORT 35.39 1.00
61863 IMPLANT NEUROELECTRODE 32.97 1.00
61864 IMPLANT NEUROELECTRDE, ADDL 7.91 1.00
61864 IMPLANT NEUROELECTRDE, ADDL 11.82 1.00

61868 IMPLANT NEUROELECTRDE, ADDÏL 13.15 1.00
61868 IMPLANT NEUROELECTRDE, ADDÏL 16.68 1.00

61880 REVISE/REMOVE NEUROELECTRODE 5.00 1.00
61885 INSRT/REDO NEUROSTIM 1 ARRAY 5.00 1.00
61886 IMPLANT NEUROSTIM ARRAYS 6.00 1.00

61888 REVISE/REMOVE NEURORECEIVER 5.00 1.00
62000 TREAT SKULL FRACTURE 9.00 1.00

62010 TREATMENT OF HEAD INJURY 11.00 1.00
62100 REPAIR BRAIN FLUID LEAKAGE 9.00 1.00
62115 REDUCTION OF SKULL DEFECT 36.52 1.00

62120 REPAIR SKULL CAVITY LESION 11.00 1.00

62121 INCISE SKULL REPAIR 37.28 1.00
62140 REPAIR OF SKULL DEFECT 11.00 1.00

62142 REMOVE SKULL PLATE/FLAP 11.00 1.00
62143 REPLACE SKULL PLATE/FLAP 11.00 1.00
62145 REPAIR OF SKULL & BRAIN 11.00 1.00

62146 REPAIR OF SKULL WITH GRAFT 29.33 1.00

62148 RETR BONE FLAP TO FIX SKULL 3.25 1.00
62160 NEUROENDOSCOPY ADD-ON 4.68 1.00
62161 DISSECT BRAIN W/SCOPE 33.41 1.00
62162 REMOVE COLLOID CYST W/SCOPE 42.91 1.00
62163 NEUROENDOSCOPY W/FB REMOVAL 27.17 1.00

62164 REMOVE BRAIN TUMOR W/SCOPE 46.39 1.00
62165 REMOVE PITUIT TUMOR W/SCOPE 36.31 1.00
62180 ESTABLISH BRAIN CAVITY SHUNT 11.00 1.00

62194 REPLACE/IRRIGATE CATHETER 6.00 1.00

62201 BRAIN CAVITY SHUNT W/SCOPE 27.15 1.00

62230 REPLACE/REVISE BRAIN SHUNT 8.00 1.00

62252 CSF SHUNT REPROGRAM 2.39 1.00
62256 REMOVE BRAIN CAVITY SHUNT 5.00 1.00
62258 REPLACE BRAIN CAVITY SHUNT 9.00 1.00

62263 EPIDURAL LYSIS MULT SESSIONS 8.00 1.00
62264 EPIDURAL LYSIS ON SINGLE DAY 5.98 1.00
62267 INTERDISCAL PERQ ASPIR, DX 4.38 1.00
62268 DRAIN SPINAL CORD CYST 7.10 1.00
62269 NEEDLE BIOPSY, SPINAL CORD 5.00 1.00

62270 SPINAL FLUID TAP, DIAGNOSTIC 1.69 1.00
62272 DRAIN CEREBRO SPINAL FLUID 2.13 1.00
62273 INJECT EPIDURAL PATCH 2.87 1.00

62280 TREAT SPINAL CORD LESION 3.62 1.00
62282 TREAT SPINAL CANAL LESION 3.20 1.00

62284 INJECTION FOR MYELOGRAM 2.25 1.00
62287 PERCUTANEOUS DISKECTOMY 8.00 1.00
62290 INJECT FOR SPINE DISK X-RAY 3.00 1.00

62292 INJECTION INTO DISK LESION 5.00 1.00
62294 INJECTION INTO SPINAL ARTERY 18.46 1.00

62310 INJECT SPINE C/T 2.53 1.00
62311 INJECT SPINE L/S (CD) 2.08 1.00
62318 INJECT SPINE W/CATH, C/T 2.65 1.00
62319 INJECT SPINE W/CATH L/S (CD) 2.46 1.00

62350 IMPLANT SPINAL CANAL CATH 8.00 1.00
62355 REMOVE SPINAL CANAL CATHETER 7.57 1.00

62360 INSERT SPINE INFUSION DEVICE 5.11 1.00
62361 IMPLANT SPINE INFUSION PUMP 8.00 1.00

62365 REMOVE SPINE INFUSION DEVICE 8.00 1.00
62367 ANALYZE SPINE INFUSION PUMP 0.63 1.00

63001 REMOVAL OF SPINAL LAMINA 10.00 1.00


63020 NECK SPINE DISK SURGERY 10.00 1.00

63030 LOW BACK DISK SURGERY 8.00 1.00
63035 SPINAL DISK SURGERY ADD-ON 5.30 1.00
63040 LAMINOTOMY, SINGLE CERVICAL 10.00 1.00
63042 LAMINOTOMY, SINGLE LUMBAR 8.00 1.00


63048 REMOVE SPINAL LAMINA ADD-ON 5.55 1.00
63050 CERVICAL LAMINOPLASTY 38.82 1.00
63051 C-LAMINOPLASTY W/GRAFT/PLATE 43.64 1.00
63055 DECOMPRESS SPINAL CORD 10.00 1.00

63057 DECOMPRESS SPINE CORD ADD-ON 8.71 1.00

63077 SPINE DISK SURGERY, THORAX 10.00 1.00

63081 REMOVAL OF VERTEBRAL BODY 42.99 1.00
63082 REMOVE VERTEBRAL BODY ADD-ON 7.26 1.00



63170 INCISE SPINAL CORD TRACT(S) 10.00 1.00
63172 DRAINAGE OF SPINAL CYST 32.65 1.00

63180 REVISE SPINAL CORD LIGAMENTS 9.00 1.00
63185 INCISE SPINAL COLUMN/NERVES 11.00 1.00

63194 INCISE SPINAL COLUMN & CORD 10.00 1.00


63200 RELEASE OF SPINAL CORD 8.00 1.00

63250 REVISE SPINAL CORD VESSELS 15.00 1.00

63265 EXCISE INTRASPINAL LESION 10.00 1.00


63275 BIOPSY/EXCISE SPINAL TUMOR 10.00 1.00





63295 REPAIR OF LAMINECTOMY DEFECT 8.34 1.00



63600 REMOVE SPINAL CORD LESION 20.91 1.00
63610 STIMULATION OF SPINAL CORD 11.41 1.00
63615 REMOVE LESION OF SPINAL CORD 28.98 1.00
63620 SRS, SPINAL LESION 20.28 1.00
63621 SRS, SPINAL LESION, ADDL 6.37 1.00

63685 INSRT/REDO SPINE N GENERATOR 5.00 1.00

63700 REPAIR OF SPINAL HERNIATION 11.00 1.00


63707 REPAIR SPINAL FLUID LEAKAGE 8.00 1.00
63710 GRAFT REPAIR OF SPINE DEFECT 8.00 1.00

63740 INSTALL SPINAL SHUNT 7.00 1.00
63744 REVISION OF SPINAL SHUNT 5.00 1.00

63746 REMOVAL OF SPINAL SHUNT 5.00 1.00
64400 N BLOCK INJ, TRIGEMINAL 1.53 1.00
64402 N BLOCK INJ, FACIAL 1.86 1.00
64402 N BLOCK INJ, FACIAL 5.00 1.00
64405 N BLOCK INJ, OCCIPITAL 1.80 1.00

64408 N BLOCK INJ, VAGUS 2.17 1.00
64410 N BLOCK INJ, PHRENIC 1.91 1.00
64412 N BLOCK INJ, SPINAL ACCESSOR 1.63 1.00

64413 N BLOCK INJ, CERVICAL PLEXUS 1.93 1.00
64415 N BLOCK INJ, BRACHIAL PLEXUS 1.92 1.00

64416 N BLOCK CONT INFUSE, B PLEX 2.48 1.00
64417 N BLOCK INJ, AXILLARY 1.91 1.00
64418 N BLOCK INJ, SUPRASCAPULAR 1.76 1.00
64420 N BLOCK INJ, INTERCOST, SNG 1.60 1.00

64421 N BLOCK INJ, INTERCOST, MLT 2.24 1.00
64425 N BLOCK INJ, ILIO-ING/HYPOGI 2.34 1.00
64430 N BLOCK INJ, PUDENDAL 2.07 1.00

64435 N BLOCK INJ, PARACERVICAL 2.22 1.00
64445 N BLOCK INJ, SCIATIC, SNG 1.94 1.00

64446 N BLK INJ, SCIATIC, CONT INF 2.44 1.00
64447 N BLOCK INJ FEM, SINGLE 1.83 1.00
64448 N BLOCK INJ FEM, CONT INF 2.16 1.00
64449 N BLOCK INJ, LUMBAR PLEXUS 2.40 1.00
64449 N BLOCK INJ, LUMBAR PLEXUS 4.07 1.00
64450 N BLOCK, OTHER PERIPHERAL 1.77 1.00

64455 N BLOCK INJ, PLANTAR DIGIT 1.08 1.00
64470 INJ PARAVERTEBRAL C/T 2.54 1.00
64472 INJ PARAVERTEBRAL C/T ADD-ON 1.70 1.00
64475 INJ PARAVERTEBRAL L/S 1.98 1.00

64476 INJ PARAVERTEBRAL L/S ADD-ON 1.29 1.00
64479 INJ FORAMEN EPIDURAL C/T 3.07 1.00

64480 INJ FORAMEN EPIDURAL ADD-ON 2.08 1.00
64483 INJ FORAMEN EPIDURAL L/S 2.69 1.00
64505 N BLOCK, SPENOPALATINE GANGL 1.93 1.00

64508 N BLOCK, CAROTID SINUS S/P 1.70 1.00
64510 N BLOCK, STELLATE GANGLION 1.67 1.00
64517 N BLOCK INJ, HYPOGAS PLXS 3.07 1.00
64517 N BLOCK INJ, HYPOGAS PLXS 3.20 1.00
64520 N BLOCK, LUMBAR/THORACIC 1.85 1.00

64530 N BLOCK INJ, CELIAC PELUS 2.15 1.00
64550 APPLY NEUROSTIMULATOR 0.24 1.00



64590 INSRT/REDO PN/GASTR STIMUL 4.64 1.00

64595 REVISE/RMV PN/GASTR STIMUL 3.49 1.00
64600 INJECTION TREATMENT OF NERVE 4.00 1.00

64612 DESTROY NERVE, FACE MUSCLE 3.08 1.00
64613 DESTROY NERVE, NECK MUSCLE 3.02 1.00
64614 DESTROY NERVE, EXTREM MUSC 3.33 1.00

64622 DESTR PARAVERTEBRL NERVE L/S 4.34 1.00

64623 DESTR PARAVERTEBRAL N ADD-ON 1.28 1.00
64626 DESTR PARAVERTEBRL NERVE C/T 5.34 1.00

64632 N BLOCK INJ, COMMON DIGIT 1.88 1.00
64650 CHEMODENERV ECCRINE GLANDS 1.03 1.00
64653 CHEMODENERV ECCRINE GLANDS 1.29 1.00
64702 REVISE FINGER/TOE NERVE 3.00 1.00

64704 REVISE HAND/FOOT NERVE 3.00 1.00
64708 REVISE ARM/LEG NERVE 3.00 1.00

64712 REVISION OF SCIATIC NERVE 3.00 1.00
64713 REVISION OF ARM NERVE(S) 4.00 1.00
64714 REVISE LOW BACK NERVE(S) 8.00 1.00

64716 REVISION OF CRANIAL NERVE 6.00 1.00
64718 REVISE ULNAR NERVE AT ELBOW 3.00 1.00
64719 REVISE ULNAR NERVE AT WRIST 3.00 1.00

64721 CARPAL TUNNEL SURGERY 3.00 1.00
64722 RELIEVE PRESSURE ON NERVE(S) 3.00 1.00
64726 RELEASE FOOT/TOE NERVE 3.00 1.00

64727 INTERNAL NERVE REVISION 4.92 1.00
64732 INCISION OF BROW NERVE 3.00 1.00
64734 INCISION OF CHEEK NERVE 4.00 1.00

64736 INCISION OF CHIN NERVE 4.00 1.00
64738 INCISION OF JAW NERVE 4.00 1.00
64740 INCISION OF TONGUE NERVE 5.00 1.00

64742 INCISION OF FACIAL NERVE 4.00 1.00
64744 INCISE NERVE, BACK OF HEAD 4.00 1.00
64746 INCISE DIAPHRAGM NERVE 4.00 1.00

64752 INCISION OF VAGUS NERVE 4.00 1.00
64761 INCISION OF PELVIS NERVE 5.00 1.00

64763 INCISE HIP/THIGH NERVE 3.00 1.00
64771 SEVER CRANIAL NERVE 4.00 1.00

64772 INCISION OF SPINAL NERVE 4.00 1.00
64774 REMOVE SKIN NERVE LESION 3.00 1.00
64776 REMOVE DIGIT NERVE LESION 3.00 1.00

64778 DIGIT NERVE SURGERY ADD-ON 4.88 1.00
64782 REMOVE LIMB NERVE LESION 3.00 1.00
64783 LIMB NERVE SURGERY ADD-ON 5.82 1.00

64784 REMOVE NERVE LESION 4.00 1.00
64786 REMOVE SCIATIC NERVE LESION 4.00 1.00
64787 IMPLANT NERVE END 3.00 1.00

64790 REMOVAL OF NERVE LESION 3.00 1.00

64795 BIOPSY OF NERVE 5.03 1.00
64802 REMOVE SYMPATHETIC NERVES 6.00 1.00



64831 REPAIR OF DIGIT NERVE 3.00 1.00
64832 REPAIR NERVE ADD-ON 9.07 1.00
64834 REPAIR OF HAND OR FOOT NERVE 3.00 1.00

64840 REPAIR OF LEG NERVE 3.00 1.00

64856 REPAIR/TRANSPOSE NERVE 3.00 1.00
64857 REPAIR ARM/LEG NERVE 3.00 1.00

64858 REPAIR SCIATIC NERVE 4.00 1.00
64859 NERVE SURGERY 6.84 1.00
64861 REPAIR OF ARM NERVES 5.00 1.00
64862 REPAIR OF LOW BACK NERVES 6.00 1.00

64864 REPAIR OF FACIAL NERVE 5.00 1.00
64866 FUSION OF FACIAL/OTHER NERVE 11.00 1.00


64872 SUBSEQUENT REPAIR OF NERVE 3.00 1.00
64874 REPAIR & REVISE NERVE ADD-ON 4.00 1.00
64876 REPAIR NERVE/SHORTEN BONE 5.08 1.00
64885 NERVE GRAFT, HEAD OR NECK 29.10 1.00

64890 NERVE GRAFT, HAND OR FOOT 3.00 1.00

64892 NERVE GRAFT, ARM OR LEG 3.00 1.00


64901 NERVE GRAFT ADD-ON 15.97 1.00
64905 NERVE PEDICLE TRANSFER 24.39 1.00

64910 NERVE REPAIR W/ALLOGRAFT 20.99 1.00
64911 NEURORRAPHY W/VEIN AUTOGRAFT 25.25 1.00
65091 REVISE EYE 4.00 1.00
65091 REVISE EYE 14.71 1.00
65091 REVISE EYE 16.49 1.00
65091 REVISE EYE 18.00 1.00

65093 REVISE EYE WITH IMPLANT 4.00 1.00
65101 REMOVAL OF EYE 4.00 1.00
65101 REMOVAL OF EYE 16.95 1.00
65101 REMOVAL OF EYE 18.04 1.00
65101 REMOVAL OF EYE 18.90 1.00
65103 REMOVE EYE/INSERT IMPLANT 4.00 1.00
65105 REMOVE EYE/ATTACH IMPLANT 4.00 1.00

65110 REMOVAL OF EYE 4.00 1.00
65110 REMOVAL OF EYE 28.52 1.00
65110 REMOVAL OF EYE 29.36 1.00
65110 REMOVAL OF EYE 29.92 1.00
65112 REMOVE EYE/REVISE SOCKET 6.00 1.00

65125 REVISE OCULAR IMPLANT 4.72 1.00
65130 INSERT OCULAR IMPLANT 6.00 1.00

65140 ATTACH OCULAR IMPLANT 6.00 1.00

65155 REINSERT OCULAR IMPLANT 6.00 1.00
65175 REMOVAL OF OCULAR IMPLANT 5.00 1.00
65205 REMOVE FOREIGN BODY FROM EYE 0.93 1.00


65270 REPAIR OF EYE WOUND 3.29 1.00



65290 REPAIR OF EYE SOCKET WOUND 5.00 1.00
65400 REMOVAL OF EYE LESION 4.00 1.00

65410 BIOPSY OF CORNEA 2.19 1.00

65430 CORNEAL SMEAR 2.20 1.00
65435 CURETTE/TREAT CORNEA 1.36 1.00

65450 TREATMENT OF CORNEAL LESION 5.00 1.00
65600 REVISION OF CORNEA 4.00 1.00
65710 CORNEAL TRANSPLANT 8.00 1.00


65756 CORNEAL TRNSPL, ENDOTHELIAL 27.48 1.00
65767 CORNEAL TISSUE TRANSPLANT 5.00 1.00
65770 REVISE CORNEA WITH IMPLANT 8.00 1.00
65771 RADIAL KERATOTOMY 999.99 1.00
65772 CORRECTION OF ASTIGMATISM 5.00 1.00

65780 OCULAR RECONST, TRANSPLANT 20.36 1.00
65800 DRAINAGE OF EYE 3.11 1.00


65820 RELIEVE INNER EYE PRESSURE 4.00 1.00
65850 INCISION OF EYE 6.00 1.00

65855 LASER SURGERY OF EYE 5.00 1.00
65860 INCISE INNER EYE ADHESIONS 5.00 1.00


65900 REMOVE EYE LESION 6.00 1.00
65920 REMOVE IMPLANT OF EYE 6.00 1.00
65930 REMOVE BLOOD CLOT FROM EYE 5.00 1.00

66020 INJECTION TREATMENT OF EYE 3.04 1.00

66150 GLAUCOMA SURGERY 6.00 1.00


66180 IMPLANT EYE SHUNT 26.78 1.00
66185 REVISE EYE SHUNT 16.69 1.00
66220 REPAIR EYE LESION 5.00 1.00

66225 REPAIR/GRAFT EYE LESION 5.00 1.00
66250 FOLLOW-UP SURGERY OF EYE 7.00 1.00
66500 INCISION OF IRIS 6.00 1.00

66600 REMOVE IRIS AND LESION 4.00 1.00

66605 REMOVAL OF IRIS 4.00 1.00

66680 REPAIR IRIS & CILIARY BODY 4.00 1.00
66700 DESTRUCTION, CILIARY BODY 9.05 1.00
66710 CILIARY TRANSSLERAL THERAPY 8.77 1.00

66711 CILIARY ENDOSCOPIC ABLATION 14.52 1.00

66761 REVISION OF IRIS 6.00 1.00
66770 REMOVAL OF INNER EYE LESION 6.00 1.00

66820 INCISION, SECONDARY CATARACT 4.00 1.00
66821 AFTER CATARACT LASER SURGERY 5.00 1.00
66825 REPOSITION INTRAOCULAR LENS 6.00 1.00

66830 REMOVAL OF LENS LESION 8.00 1.00
66840 REMOVAL OF LENS MATERIAL 14.96 1.00

66920 EXTRACTION OF LENS 8.00 1.00

66982 CATARACT SURGERY, COMPLEX 6.00 1.00
66983 CATARACT SURG W/IOL, 1 STAGE 8.00 1.00

66985 INSERT LENS PROSTHESIS 8.00 1.00

66986 EXCHANGE LENS PROSTHESIS 21.34 1.00
66990 OPHTHALMIC ENDOSCOPE ADD-ON 2.20 1.00
66990 OPHTHALMIC ENDOSCOPE ADD-ON 2.27 1.00
67005 PARTIAL REMOVAL OF EYE FLUID 4.00 1.00

67015 RELEASE OF EYE FLUID 6.00 1.00
67025 REPLACE EYE FLUID 4.00 1.00
67027 IMPLANT EYE DRUG SYSTEM 6.00 1.00

67028 INJECTION EYE DRUG 3.78 1.00
67030 INCISE INNER EYE STRANDS 4.00 1.00
67031 LASER SURGERY, EYE STRANDS 5.00 1.00

67036 REMOVAL OF INNER EYE FLUID 6.00 1.00
67038 STRIP RETINAL MEMBRANE 6.00 1.00
67039 LASER TREATMENT OF RETINA 6.00 1.00

67041 VIT FOR MACULAR PUCKER 30.85 1.00
67042 VIT FOR MACULAR HOLE 35.34 1.00
67043 VIT FOR MEMBRANE DISSECT 37.08 1.00
67101 REPAIR DETACHED RETINA 5.00 1.00


67112 REREPAIR DETACHED RETINA 6.00 1.00
67113 REPAIR RETINAL DETACH, CPLX 40.60 1.00
67115 RELEASE ENCIRCLING MATERIAL 5.00 1.00

67120 REMOVE EYE IMPLANT MATERIAL 6.00 1.00
67141 TREATMENT OF RETINA 5.00 1.00

67208 TREATMENT OF RETINAL LESION 5.00 1.00

67220 TREATMENT OF CHOROID LESION 5.00 1.00

67221 OCULAR PHOTODYNAMIC THER 5.00 1.00
67225 EYE PHOTODYNAMIC THER ADD-ON 0.68 1.00

67229 TR RETINAL LES PRETERM INF 26.71 1.00
67250 REINFORCE EYE WALL 5.00 1.00
67255 REINFORCE/GRAFT EYE WALL 5.00 1.00

67311 REVISE EYE MUSCLE 4.00 1.00
67312 REVISE TWO EYE MUSCLES 4.00 1.00

67318 REVISE EYE MUSCLE(S) 15.27 1.00
67320 REVISE EYE MUSCLE(S) ADD-ON 6.49 1.00

67331 EYE SURGERY FOLLOW-UP ADD-ON 6.17 1.00
67331 EYE SURGERY FOLLOW-UP ADD-ON 7.29 1.00
67332 REREVISE EYE MUSCLES ADD-ON 6.73 1.00
67334 REVISE EYE MUSCLE W/SUTURE 5.97 1.00
67335 EYE SUTURE DURING SURGERY 3.63 1.00

67340 REVISE EYE MUSCLE ADD-ON 7.38 1.00
67343 RELEASE EYE TISSUE 14.65 1.00
67345 DESTROY NERVE OF EYE MUSCLE 4.43 1.00
67346 BIOPSY, EYE MUSCLE 4.78 1.00
67350 BIOPSY EYE MUSCLE 4.90 1.00

67405 EXPLORE/DRAIN EYE SOCKET 6.00 1.00
67412 EXPLORE/TREAT EYE SOCKET 6.00 1.00

67414 EXPLR/DECOMPRESS EYE SOCKET 25.70 1.00

67415 ASPIRATION, ORBITAL CONTENTS 2.54 1.00

67500 INJECT/TREAT EYE SOCKET 1.02 1.00

67550 INSERT EYE SOCKET IMPLANT 22.60 1.00

67560 REVISE EYE SOCKET IMPLANT 5.00 1.00
67570 DECOMPRESS OPTIC NERVE 26.97 1.00
67700 DRAINAGE OF EYELID ABSCESS 1.99 1.00
67710 INCISION OF EYELID 1.54 1.00

67715 INCISION OF EYELID FOLD 1.84 1.00
67800 REMOVE EYELID LESION 2.08 1.00
67801 REMOVE EYELID LESIONS 2.84 1.00

67808 REMOVE EYELID LESION(S) 4.00 1.00

67810 BIOPSY OF EYELID 2.23 1.00
67820 REVISE EYELASHES 1.28 1.00

67850 TREAT EYELID LESION 3.32 1.00

67875 CLOSURE OF EYELID BY SUTURE 2.04 1.00
67880 REVISION OF EYELID 4.00 1.00

67900 REPAIR BROW DEFECT 11.98 1.00
67901 REPAIR EYELID DEFECT 4.00 1.00


67909 REVISE EYELID DEFECT 5.00 1.00

67912 CORRECTION EYELID W/IMPLANT 11.22 1.00
67912 CORRECTION EYELID W/IMPLANT 11.56 1.00



67930 REPAIR EYELID WOUND 4.00 1.00
67938 REMOVE EYELID FOREIGN BODY 1.90 1.00


67971 RECONSTRUCTION OF EYELID 5.00 1.00

68020 INCISE/DRAIN EYELID LINING 2.06 1.00

68040 TREATMENT OF EYELID LESIONS 1.26 1.00
68100 BIOPSY OF EYELID LINING 2.03 1.00
68110 REMOVE EYELID LINING LESION 3.19 1.00


68200 TREAT EYELID BY INJECTION 0.74 1.00
68320 REVISE/GRAFT EYELID LINING 4.00 1.00

68330 REVISE EYELID LINING 4.00 1.00

68340 SEPARATE EYELID ADHESIONS 4.00 1.00

68371 HARVEST EYE TISSUE, ALOGRAFT 9.72 1.00
68371 HARVEST EYE TISSUE, ALOGRAFT 9.75 1.00
68400 INCISE/DRAIN TEAR GLAND 3.18 1.00
68420 INCISE/DRAIN TEAR SAC 4.00 1.00

68440 INCISE TEAR DUCT OPENING 1.42 1.00
68500 REMOVAL OF TEAR GLAND 4.00 1.00
68505 PARTIAL REMOVAL, TEAR GLAND 4.00 1.00

68510 BIOPSY OF TEAR GLAND 4.00 1.00
68520 REMOVAL OF TEAR SAC 4.00 1.00

68525 BIOPSY OF TEAR SAC 4.00 1.00
68530 CLEARANCE OF TEAR DUCT 5.00 1.00
68540 REMOVE TEAR GLAND LESION 4.00 1.00

68700 REPAIR TEAR DUCTS 4.00 1.00
68705 REVISE TEAR DUCT OPENING 3.11 1.00
68720 CREATE TEAR SAC DRAIN 5.00 1.00

68745 CREATE TEAR DUCT DRAIN 4.00 1.00

68760 CLOSE TEAR DUCT OPENING 2.99 1.00
68770 CLOSE TEAR SYSTEM FISTULA 4.00 1.00

68801 DILATE TEAR DUCT OPENING 1.54 1.00
68810 PROBE NASOLACRIMAL DUCT 2.86 1.00

68816 PROBE NL DUCT W/BALLOON 5.76 1.00
68840 EXPLORE/IRRIGATE TEAR DUCTS 2.23 1.00
68850 INJECTION FOR TEAR SAC X-RAY 1.14 1.00

70010 CONTRAST X-RAY OF BRAIN 4.74 1.00
70030 X-RAY EYE FOR FOREIGN BODY 0.67 1.00
70100 X-RAY EXAM OF JAW 0.79 1.00
70100 X-RAY EXAM OF JAW 0.83 1.00
70110 X-RAY EXAM OF JAW 0.99 1.00

70110 X-RAY EXAM OF JAW 1.00 1.00
70110 X-RAY EXAM OF JAW 1.08 1.00
70120 X-RAY EXAM OF MASTOIDS 0.90 1.00
70134 X-RAY EXAM OF MIDDLE EAR 1.25 1.00
70134 X-RAY EXAM OF MIDDLE EAR 1.29 1.00
70140 X-RAY EXAM OF FACIAL BONES 0.82 1.00

70160 X-RAY EXAM OF NASAL BONES 0.78 1.00
70160 X-RAY EXAM OF NASAL BONES 0.87 1.00
70170 X-RAY EXAM OF TEAR DUCT 1.41 1.00
70170 X-RAY EXAM OF TEAR DUCT 1.42 1.00
70190 X-RAY EXAM OF EYE SOCKETS 0.94 1.00

70210 X-RAY EXAM OF SINUSES 0.82 1.00
70240 X-RAY EXAM, PITUITARY SADDLE 0.69 1.00
70250 X-RAY EXAM OF SKULL 0.98 1.00

70300 X-RAY EXAM OF TEETH 0.39 1.00
70320 FULL MOUTH X-RAY OF TEETH 1.13 1.00
70328 X-RAY EXAM OF JAW JOINT 0.76 1.00

70330 X-RAY EXAM OF JAW JOINTS 1.21 1.00
70336 MAGNETIC IMAGE, JAW JOINT 7.00 1.00

70350 X-RAY HEAD FOR ORTHODONTIA 0.56 1.00
70350 X-RAY HEAD FOR ORTHODONTIA 0.64 1.00
70355 PANORAMIC X-RAY OF JAWS 0.63 1.00
70360 X-RAY EXAM OF NECK 0.67 1.00
70370 THROAT X-RAY & FLUOROSCOPY 1.80 1.00
70371 SPEECH EVALUATION, COMPLEX 2.69 1.00

70373 CONTRAST X-RAY OF LARYNX 2.21 1.00
70380 X-RAY EXAM OF SALIVARY GLAND 0.94 1.00
70390 X-RAY EXAM OF SALIVARY DUCT 2.39 1.00
70450 CT HEAD/BRAIN W/O DYE 6.06 1.00

70460 CT HEAD/BRAIN W/DYE 7.45 1.00
70470 CT HEAD/BRAIN W/O & W/DYE 7.00 1.00

70480 CT ORBIT/EAR/FOSSA W/O DYE 6.69 1.00
70481 CT ORBIT/EAR/FOSSA W/DYE 7.79 1.00
70482 CT ORBIT/EAR/FOSSA W/O&W/DYE 9.35 1.00
70486 CT MAXILLOFACIAL W/O DYE 6.49 1.00
70487 CT MAXILLOFACIAL W/DYE 7.68 1.00

70488 CT MAXILLOFACIAL W/O & W/DYE 9.31 1.00
70490 CT SOFT TISSUE NECK W/O DYE 6.68 1.00
70491 CT SOFT TISSUE NECK W/DYE 7.79 1.00
70492 CT SFT TSUE NCK W/O & W/DYE 9.35 1.00

70496 CT ANGIOGRAPHY, HEAD 7.00 1.00
70498 CT ANGIOGRAPHY, NECK 13.47 1.00
70540 MRI ORBIT/FACE/NECK W/O DYE 7.00 1.00

70542 MRI ORBIT/FACE/NECK W/DYE 16.00 1.00
70543 MRI ORBT/FAC/NCK W/O & W/DYE 23.41 1.00
70544 MR ANGIOGRAPHY HEAD W/O DYE 7.00 1.00

70545 MR ANGIOGRAPHY HEAD W/DYE 7.00 1.00
70546 MR ANGIOGRAPH HEAD W/O&W/DYE 7.00 1.00
70547 MR ANGIOGRAPHY NECK W/O DYE 13.31 1.00
70548 MR ANGIOGRAPHY NECK W/DYE 13.31 1.00

70549 MR ANGIOGRAPH NECK W/O&W/DYE 25.30 1.00
70551 MRI BRAIN W/O DYE 7.00 1.00
70551 MRI BRAIN W/O DYE 13.71 1.00
70551 MRI BRAIN W/O DYE 13.88 1.00
70551 MRI BRAIN W/O DYE 15.80 1.00
70552 MRI BRAIN W/DYE 16.44 1.00

70552 MRI BRAIN W/DYE 16.66 1.00
70552 MRI BRAIN W/DYE 17.67 1.00
70553 MRI BRAIN W/O & W/DYE 23.64 1.00
70553 MRI BRAIN W/O & W/DYE 29.14 1.00
70553 MRI BRAIN W/O & W/DYE 29.55 1.00
70554 FMRI BRAIN BY TECH 17.17 1.00
71010 CHEST X-RAY 0.66 1.00
71010 CHEST X-RAY 0.74 1.00
71015 CHEST X-RAY 0.81 1.00
71015 CHEST X-RAY 0.83 1.00
71020 CHEST X-RAY 0.88 1.00
71020 CHEST X-RAY 0.95 1.00
71020 CHEST X-RAY 0.96 1.00

71021 CHEST X-RAY 1.06 1.00
71021 CHEST X-RAY 1.15 1.00
71021 CHEST X-RAY 1.16 1.00
71022 CHEST X-RAY 1.22 1.00
71022 CHEST X-RAY 1.27 1.00
71023 CHEST X-RAY AND FLUOROSCOPY 1.36 1.00
71030 CHEST X-RAY 1.24 1.00
71030 CHEST X-RAY 1.26 1.00
71030 CHEST X-RAY 1.28 1.00

71035 CHEST X-RAY 0.79 1.00
71035 CHEST X-RAY 0.94 1.00
71040 CONTRAST X-RAY OF BRONCHI 2.33 1.00

71090 X-RAY & PACEMAKER INSERTION 2.53 1.00
71090 X-RAY & PACEMAKER INSERTION 2.57 1.00
71100 X-RAY EXAM OF RIBS 0.90 1.00
71101 X-RAY EXAM OF RIBS/CHEST 1.07 1.00
71120 X-RAY EXAM OF BREASTBONE 0.90 1.00

71250 CT THORAX W/O DYE 3.00 1.00
71250 CT THORAX W/O DYE 7.74 1.00
71250 CT THORAX W/O DYE 7.84 1.00
71250 CT THORAX W/O DYE 7.90 1.00
71260 CT THORAX W/DYE 9.06 1.00
71260 CT THORAX W/DYE 9.17 1.00
71260 CT THORAX W/DYE 9.48 1.00

71270 CT THORAX W/O & W/DYE 11.10 1.00
71270 CT THORAX W/O & W/DYE 11.24 1.00
71270 CT THORAX W/O & W/DYE 11.71 1.00
71275 CT ANGIOGRAPHY, CHEST 14.39 1.00
71550 MRI CHEST W/O DYE 7.00 1.00
71550 MRI CHEST W/O DYE 13.53 1.00
71550 MRI CHEST W/O DYE 13.68 1.00
71550 MRI CHEST W/O DYE 17.02 1.00

71551 MRI CHEST W/DYE 16.19 1.00
71551 MRI CHEST W/DYE 16.38 1.00
71551 MRI CHEST W/DYE 19.10 1.00
71552 MRI CHEST W/O & W/DYE 26.19 1.00
71552 MRI CHEST W/O & W/DYE 28.45 1.00
71552 MRI CHEST W/O & W/DYE 28.76 1.00
71555 MRI ANGIO CHEST W OR W/O DYE 14.16 1.00
72010 X-RAY EXAM OF SPINE 1.70 1.00

72040 X-RAY EXAM OF NECK SPINE 0.93 1.00
72069 X-RAY EXAM OF TRUNK SPINE 0.83 1.00
72070 X-RAY EXAM OF THORACIC SPINE 0.93 1.00


72100 X-RAY EXAM OF LOWER SPINE 1.02 1.00
72125 CT NECK SPINE W/O DYE 7.74 1.00

72126 CT NECK SPINE W/DYE 9.03 1.00
72127 CT NECK SPINE W/O & W/DYE 10.95 1.00
72128 CT CHEST SPINE W/O DYE 7.74 1.00
72129 CT CHEST SPINE W/DYE 9.03 1.00

72130 CT CHEST SPINE W/O & W/DYE 10.95 1.00
72131 CT LUMBAR SPINE W/O DYE 7.75 1.00
72132 CT LUMBAR SPINE W/DYE 9.04 1.00

72133 CT LUMBAR SPINE W/O & W/DYE 10.96 1.00
72141 MRI NECK SPINE W/O DYE 7.00 1.00
72142 MRI NECK SPINE W/DYE 16.64 1.00
72146 MRI CHEST SPINE W/O DYE 3.00 1.00

72147 MRI CHEST SPINE W/DYE 16.33 1.00
72148 MRI LUMBAR SPINE W/O DYE 14.66 1.00
72149 MRI LUMBAR SPINE W/DYE 16.45 1.00
72156 MRI NECK SPINE W/O & W/DYE 23.65 1.00

72157 MRI CHEST SPINE W/O & W/DYE 22.49 1.00
72158 MRI LUMBAR SPINE W/O & W/DYE 23.34 1.00
72159 MR ANGIO SPINE W/O&W/DYE 15.46 1.00

72170 X-RAY EXAM OF PELVIS 0.71 1.00
72191 CT ANGIOGRAPH PELV W/O&W/DYE 13.87 1.00
72192 CT PELVIS W/O DYE 7.52 1.00
72192 CT PELVIS W/O DYE 7.65 1.00
72192 CT PELVIS W/O DYE 7.75 1.00
72193 CT PELVIS W/DYE 8.72 1.00
72193 CT PELVIS W/DYE 8.83 1.00

72193 CT PELVIS W/DYE 9.00 1.00
72194 CT PELVIS W/O & W/DYE 10.49 1.00
72194 CT PELVIS W/O & W/DYE 10.63 1.00
72194 CT PELVIS W/O & W/DYE 11.47 1.00
72195 MRI PELVIS W/O DYE 13.54 1.00
72196 MRI PELVIS W/DYE 7.00 1.00
72196 MRI PELVIS W/DYE 16.18 1.00
72196 MRI PELVIS W/DYE 16.37 1.00
72196 MRI PELVIS W/DYE 17.30 1.00
72197 MRI PELVIS W/O & W/DYE 23.77 1.00

72198 MR ANGIO PELVIS W/O & W/DYE 14.23 1.00
72200 X-RAY EXAM SACROILIAC JOINTS 0.78 1.00

72220 X-RAY EXAM OF TAILBONE 0.81 1.00
72240 CONTRAST X-RAY OF NECK SPINE 4.39 1.00
72255 CONTRAST X-RAY, THORAX SPINE 4.01 1.00
72265 CONTRAST X-RAY, LOWER SPINE 4.08 1.00
72270 CONTRAST X-RAY, SPINE 6.36 1.00

72275 EPIDUROGRAPHY 2.90 1.00
72285 X-RAY C/T SPINE DISK 4.96 1.00
72295 X-RAY OF LOWER SPINE DISK 4.42 1.00
73000 X-RAY EXAM OF COLLAR BONE 0.75 1.00

73000 X-RAY EXAM OF COLLAR BONE 0.76 1.00
73010 X-RAY EXAM OF SHOULDER BLADE 0.77 1.00
73010 X-RAY EXAM OF SHOULDER BLADE 0.78 1.00
73020 X-RAY EXAM OF SHOULDER 0.64 1.00
73040 CONTRAST X-RAY OF SHOULDER 2.93 1.00

73050 X-RAY EXAM OF SHOULDERS 0.98 1.00
73060 X-RAY EXAM OF HUMERUS 0.80 1.00
73070 X-RAY EXAM OF ELBOW 0.73 1.00
73085 CONTRAST X-RAY OF ELBOW 2.65 1.00

73090 X-RAY EXAM OF FOREARM 0.74 1.00
73090 X-RAY EXAM OF FOREARM 0.76 1.00
73092 X-RAY EXAM OF ARM, INFANT 0.73 1.00
73092 X-RAY EXAM OF ARM, INFANT 0.76 1.00
73100 X-RAY EXAM OF WRIST 0.75 1.00
73115 CONTRAST X-RAY OF WRIST 2.41 1.00

73120 X-RAY EXAM OF HAND 0.73 1.00
73140 X-RAY EXAM OF FINGER(S) 0.61 1.00
73200 CT UPPER EXTREMITY W/O DYE 6.66 1.00

73201 CT UPPER EXTREMITY W/DYE 7.75 1.00
73202 CT UPPR EXTREMITY W/O&W/DYE 9.41 1.00
73206 CT ANGIO UPR EXTRM W/O&W/DYE 13.29 1.00
73218 MRI UPPER EXTREMITY W/O DYE 13.33 1.00

73219 MRI UPPER EXTREMITY W/DYE 16.00 1.00
73220 MRI UPPR EXTREMITY W/O&W/DYE 7.00 1.00
73221 MRI JOINT UPR EXTREM W/O DYE 7.00 1.00
73222 MRI JOINT UPR EXTREM W/DYE 15.99 1.00

73223 MRI JOINT UPR EXTR W/O&W/DYE 22.60 1.00
73225 MR ANGIO UPR EXTR W/O&W/DYE 14.10 1.00
73500 X-RAY EXAM OF HIP 0.69 1.00
73500 X-RAY EXAM OF HIP 0.73 1.00

73510 X-RAY EXAM OF HIP 0.90 1.00
73510 X-RAY EXAM OF HIP 0.91 1.00
73510 X-RAY EXAM OF HIP 1.00 1.00
73520 X-RAY EXAM OF HIPS 1.07 1.00
73520 X-RAY EXAM OF HIPS 1.08 1.00
73525 CONTRAST X-RAY OF HIP 2.65 1.00
73530 X-RAY EXAM OF HIP 0.94 1.00
73540 X-RAY EXAM OF PELVIS & HIPS 0.89 1.00
73542 X-RAY EXAM, SACROILIAC JOINT 2.18 1.00

73550 X-RAY EXAM OF THIGH 0.78 1.00
73560 X-RAY EXAM OF KNEE, 1 OR 2 0.77 1.00
73560 X-RAY EXAM OF KNEE, 1 OR 2 0.79 1.00
73562 X-RAY EXAM OF KNEE, 3 0.86 1.00
73562 X-RAY EXAM OF KNEE, 3 0.87 1.00
73562 X-RAY EXAM OF KNEE, 3 0.93 1.00
73564 X-RAY EXAM, KNEE, 4 OR MORE 0.97 1.00

73565 X-RAY EXAM OF KNEES 0.76 1.00
73565 X-RAY EXAM OF KNEES 0.82 1.00
73580 CONTRAST X-RAY OF KNEE JOINT 3.30 1.00
73590 X-RAY EXAM OF LOWER LEG 0.74 1.00
73590 X-RAY EXAM OF LOWER LEG 0.78 1.00
73592 X-RAY EXAM OF LEG, INFANT 0.74 1.00
73592 X-RAY EXAM OF LEG, INFANT 0.76 1.00

73600 X-RAY EXAM OF ANKLE 0.73 1.00
73615 CONTRAST X-RAY OF ANKLE 2.72 1.00
73620 X-RAY EXAM OF FOOT 0.71 1.00
73650 X-RAY EXAM OF HEEL 0.71 1.00

73650 X-RAY EXAM OF HEEL 0.72 1.00
73660 X-RAY EXAM OF TOE(S) 0.61 1.00
73660 X-RAY EXAM OF TOE(S) 0.62 1.00
73660 X-RAY EXAM OF TOE(S) 0.74 1.00
73700 CT LOWER EXTREMITY W/O DYE 6.66 1.00
73701 CT LOWER EXTREMITY W/DYE 7.74 1.00
73702 CT LWR EXTREMITY W/O&W/DYE 9.39 1.00

73706 CT ANGIO LWR EXTR W/O&W/DYE 13.85 1.00
73718 MRI LOWER EXTREMITY W/O DYE 13.33 1.00
73719 MRI LOWER EXTREMITY W/DYE 15.99 1.00

73720 MRI LWR EXTREMITY W/O&W/DYE 7.00 1.00
73721 MRI JNT OF LWR EXTRE W/O DYE 7.00 1.00
73722 MRI JOINT OF LWR EXTR W/DYE 16.01 1.00
73723 MRI JOINT LWR EXTR W/O&W/DYE 22.55 1.00

73725 MR ANG LWR EXT W OR W/O DYE 14.17 1.00
74000 X-RAY EXAM OF ABDOMEN 0.70 1.00

74022 X-RAY EXAM SERIES, ABDOMEN 1.22 1.00
74150 CT ABDOMEN W/O DYE 3.00 1.00
74160 CT ABDOMEN W/DYE 3.00 1.00

74160 CT ABDOMEN W/DYE 10.08 1.00
74170 CT ABDOMEN W/O & W/DYE 3.00 1.00
74175 CT ANGIO ABDOM W/O & W/DYE 14.67 1.00
74181 MRI ABDOMEN W/O DYE 3.00 1.00
74182 MRI ABDOMEN W/DYE 16.19 1.00

74183 MRI ABDOMEN W/O & W/DYE 23.79 1.00
74185 MRI ANGIO, ABDOM W ORW/O DYE 14.14 1.00
74190 X-RAY EXAM OF PERITONEUM 2.02 1.00
74190 X-RAY EXAM OF PERITONEUM 2.04 1.00
74210 CONTRST X-RAY EXAM OF THROAT 1.73 1.00

74220 CONTRAST X-RAY, ESOPHAGUS 1.87 1.00
74230 CINE/VID X-RAY, THROAT/ESOPH 2.09 1.00
74235 REMOVE ESOPHAGUS OBSTRUCTION 4.38 1.00
74235 REMOVE ESOPHAGUS OBSTRUCTION 4.40 1.00
74240 X-RAY EXAM, UPPER GI TRACT 2.47 1.00

74246 CONTRST X-RAY UPPR GI TRACT 2.66 1.00

74250 X-RAY EXAM OF SMALL BOWEL 2.01 1.00

74270 CONTRAST X-RAY EXAM OF COLON 2.73 1.00

74290 CONTRAST X-RAY, GALLBLADDER 1.22 1.00
74291 CONTRAST X-RAYS, GALLBLADDER 0.71 1.00
74301 X-RAYS AT SURGERY ADD-ON 0.29 1.00
74301 X-RAYS AT SURGERY ADD-ON 0.30 1.00
74305 X-RAY BILE DUCTS/PANCREAS 1.40 1.00
74305 X-RAY BILE DUCTS/PANCREAS 1.42 1.00
74320 CONTRAST X-RAY OF BILE DUCTS 3.17 1.00

74327 X-RAY BILE STONE REMOVAL 2.81 1.00
74328 X-RAY BILE DUCT ENDOSCOPY 4.24 1.00
74328 X-RAY BILE DUCT ENDOSCOPY 4.31 1.00
74329 X-RAY FOR PANCREAS ENDOSCOPY 4.24 1.00
74329 X-RAY FOR PANCREAS ENDOSCOPY 4.31 1.00
74330 X-RAY BILE/PANC ENDOSCOPY 4.52 1.00
74330 X-RAY BILE/PANC ENDOSCOPY 4.59 1.00
74340 X-RAY GUIDE FOR GI TUBE 3.47 1.00
74340 X-RAY GUIDE FOR GI TUBE 3.50 1.00
74350 X-RAY GUIDE, STOMACH TUBE 4.03 1.00

74355 X-RAY GUIDE, INTESTINAL TUBE 3.78 1.00
74355 X-RAY GUIDE, INTESTINAL TUBE 3.81 1.00
74360 X-RAY GUIDE, GI DILATION 4.02 1.00
74360 X-RAY GUIDE, GI DILATION 4.09 1.00
74363 X-RAY, BILE DUCT DILATION 7.56 1.00
74363 X-RAY, BILE DUCT DILATION 7.67 1.00
74400 CONTRST X-RAY, URINARY TRACT 2.44 1.00

74430 CONTRAST X-RAY, BLADDER 1.54 1.00

74440 X-RAY, MALE GENITAL TRACT 1.70 1.00
74445 X-RAY EXAM OF PENIS 2.74 1.00
74445 X-RAY EXAM OF PENIS 2.76 1.00
74450 X-RAY, URETHRA/BLADDER 1.98 1.00
74470 X-RAY EXAM OF KIDNEY LESION 2.04 1.00

74470 X-RAY EXAM OF KIDNEY LESION 2.06 1.00
74475 X-RAY CONTROL, CATH INSERT 3.44 1.00
74485 X-RAY GUIDE, GU DILATION 3.28 1.00

74710 X-RAY MEASUREMENT OF PELVIS 1.21 1.00
74740 X-RAY, FEMALE GENITAL TRACT 1.89 1.00
74775 X-RAY EXAM OF PERINEUM 2.39 1.00
75552 HEART MRI FOR MORPH W/O DYE 13.87 1.00
75553 HEART MRI FOR MORPH W/DYE 14.42 1.00

75554 CARDIAC MRI/FUNCTION 14.22 1.00
75555 CARDIAC MRI/LIMITED STUDY 14.12 1.00
75557 CARDIAC MRI FOR MORPH 14.36 1.00
75558 CARDIAC MRI FLOW/VELOCITY 17.47 1.00
75559 CARDIAC MRI W/STRESS IMG 20.74 1.00
75560 CARDIAC MRI FLOW/VEL/STRESS 22.71 1.00

75561 CARDIAC MRI FOR MORPH W/DYE 19.30 1.00
75562 CARD MRI FLOW/VEL W/DYE 22.51 1.00
75563 CARD MRI W/STRESS IMG & DYE 23.67 1.00
75564 HT MRI W/FLO/VEL/STRS & DYE 26.47 1.00
75600 CONTRAST X-RAY EXAM OF AORTA 8.95 1.00

75630 X-RAY AORTA, LEG ARTERIES 8.79 1.00
75635 CT ANGIO ABDOMINAL ARTERIES 16.68 1.00
75650 ARTERY X-RAYS, HEAD & NECK 8.12 1.00
75658 ARTERY X-RAYS, ARM 8.03 1.00


75676 ARTERY X-RAYS, NECK 8.18 1.00
75685 ARTERY X-RAYS, SPINE 8.19 1.00

75710 ARTERY X-RAYS, ARM/LEG 8.01 1.00
75716 ARTERY X-RAYS, ARMS/LEGS 8.91 1.00
75722 ARTERY X-RAYS, KIDNEY 7.91 1.00

75724 ARTERY X-RAYS, KIDNEYS 9.18 1.00
75726 ARTERY X-RAYS, ABDOMEN 7.92 1.00
75731 ARTERY X-RAYS, ADRENAL GLAND 8.19 1.00
75733 ARTERY X-RAYS, ADRENALS 9.25 1.00

75736 ARTERY X-RAYS, PELVIS 7.99 1.00
75741 ARTERY X-RAYS, LUNG 7.68 1.00
75743 ARTERY X-RAYS, LUNGS 4.00 1.00

75756 ARTERY X-RAYS, CHEST 8.21 1.00
75774 ARTERY X-RAY, EACH VESSEL 6.06 1.00
75790 VISUALIZE A-V SHUNT 3.96 1.00
75801 LYMPH VESSEL X-RAY, ARM/LEG 6.77 1.00

75801 LYMPH VESSEL X-RAY, ARM/LEG 6.87 1.00
75803 LYMPH VESSEL X-RAY,ARMS/LEGS 7.25 1.00
75803 LYMPH VESSEL X-RAY,ARMS/LEGS 7.34 1.00
75805 LYMPH VESSEL X-RAY, TRUNK 7.47 1.00
75809 NONVASCULAR SHUNT, X-RAY 1.47 1.00
75810 VEIN X-RAY, SPLEEN/LIVER 14.68 1.00
75810 VEIN X-RAY, SPLEEN/LIVER 14.87 1.00

75820 VEIN X-RAY, ARM/LEG 1.97 1.00
75822 VEIN X-RAY, ARMS/LEGS 3.01 1.00
75825 VEIN X-RAY, TRUNK 7.32 1.00
75825 VEIN X-RAY, TRUNK 14.68 1.00
75825 VEIN X-RAY, TRUNK 14.87 1.00
75827 VEIN X-RAY, CHEST 7.30 1.00

75827 VEIN X-RAY, CHEST 14.66 1.00
75827 VEIN X-RAY, CHEST 14.86 1.00
75831 VEIN X-RAY, KIDNEY 7.40 1.00
75833 VEIN X-RAY, KIDNEYS 8.24 1.00
75840 VEIN X-RAY, ADRENAL GLAND 7.34 1.00
75842 VEIN X-RAY, ADRENAL GLANDS 8.28 1.00

75860 VEIN X-RAY, NECK 7.54 1.00
75860 VEIN X-RAY, NECK 14.69 1.00
75860 VEIN X-RAY, NECK 14.89 1.00
75870 VEIN X-RAY, SKULL 7.48 1.00
75870 VEIN X-RAY, SKULL 14.69 1.00
75870 VEIN X-RAY, SKULL 14.89 1.00
75872 VEIN X-RAY, SKULL 8.17 1.00
75872 VEIN X-RAY, SKULL 14.67 1.00
75872 VEIN X-RAY, SKULL 14.86 1.00
75880 VEIN X-RAY, EYE SOCKET 1.97 1.00

75885 VEIN X-RAY, LIVER 7.86 1.00
75885 VEIN X-RAY, LIVER 15.08 1.00
75885 VEIN X-RAY, LIVER 15.27 1.00
75887 VEIN X-RAY, LIVER 7.92 1.00
75887 VEIN X-RAY, LIVER 15.08 1.00
75887 VEIN X-RAY, LIVER 15.27 1.00
75889 VEIN X-RAY, LIVER 7.42 1.00
75889 VEIN X-RAY, LIVER 14.66 1.00
75889 VEIN X-RAY, LIVER 14.86 1.00

75891 VEIN X-RAY, LIVER 7.42 1.00
75891 VEIN X-RAY, LIVER 14.66 1.00
75891 VEIN X-RAY, LIVER 14.86 1.00
75893 VENOUS SAMPLING BY CATHETER 6.54 1.00
75894 X-RAYS, TRANSCATH THERAPY 26.91 1.00
75898 FOLLOW-UP ANGIOGRAPHY 3.38 1.00
75898 FOLLOW-UP ANGIOGRAPHY 3.40 1.00

75900 INTRAVASCULAR CATH EXCHANGE 22.48 1.00
75900 INTRAVASCULAR CATH EXCHANGE 22.82 1.00
75940 X-RAY PLACEMENT, VEIN FILTER 13.84 1.00
75940 X-RAY PLACEMENT, VEIN FILTER 14.05 1.00
75945 INTRAVASCULAR US 5.33 1.00
75945 INTRAVASCULAR US 5.40 1.00

75946 INTRAVASCULAR US ADD-ON 2.96 1.00
75946 INTRAVASCULAR US ADD-ON 3.01 1.00
75952 ENDOVASC REPAIR ABDOM AORTA 6.31 1.00
75953 ABDOM ANEURYSM ENDOVAS RPR 1.91 1.00

75954 ILIAC ANEURYSM ENDOVAS RPR 3.10 1.00
75960 TRANSCATH IV STENT RS&I 7.43 1.00
75961 RETRIEVAL, BROKEN CATHETER 11.54 1.00

75964 REPAIR ARTERY BLOCKAGE, EACH 4.67 1.00
75970 VASCULAR BIOPSY 13.15 1.00

75970 VASCULAR BIOPSY 13.36 1.00
75980 CONTRAST XRAY EXAM BILE DUCT 7.62 1.00
75980 CONTRAST XRAY EXAM BILE DUCT 7.71 1.00
75984 XRAY CONTROL CATHETER CHANGE 3.02 1.00
75989 ABSCESS DRAINAGE UNDER X-RAY 4.00 1.00

75992 ATHERECTOMY, X-RAY EXAM 17.12 1.00
75998 FLUOROGUIDE FOR VEIN DEVICE 1.93 1.00

75998 FLUOROGUIDE FOR VEIN DEVICE 1.97 1.00
76000 FLUOROSCOPE EXAMINATION 1.59 1.00
76001 FLUOROSCOPE EXAM, EXTENSIVE 3.66 1.00
76001 FLUOROSCOPE EXAM, EXTENSIVE 3.69 1.00
76003 NEEDLE LOCALIZATION BY X-RAY 2.11 1.00
76003 NEEDLE LOCALIZATION BY X-RAY 2.13 1.00
76005 FLUOROGUIDE FOR SPINE INJECT 2.15 1.00
76006 X-RAY STRESS VIEW 0.64 1.00

76006 X-RAY STRESS VIEW 0.65 1.00
76010 X-RAY, NOSE TO RECTUM 0.77 1.00
76010 X-RAY, NOSE TO RECTUM 0.79 1.00
76012 PERCUT VERTEBROPLASTY FLUOR 1.88 1.00
76012 PERCUT VERTEBROPLASTY FLUOR 2.05 1.00
76013 PERCUT VERTEBROPLASTY, CT 1.93 1.00
76020 X-RAYS FOR BONE AGE 0.80 1.00

76040 X-RAYS, BONE EVALUATION 1.20 1.00
76061 X-RAYS, BONE SURVEY 1.67 1.00
76066 JOINT SURVEY, SINGLE VIEW 1.59 1.00
76070 CT BONE DENSITY, AXIAL 3.41 1.00

76070 CT BONE DENSITY, AXIAL 3.46 1.00
76071 CT BONE DENSITY, PERIPHERAL 3.28 1.00
76071 CT BONE DENSITY, PERIPHERAL 3.31 1.00
76075 DXA BONE DENSITY, AXIAL 3.64 1.00
76076 DXA BONE DENSITY/PERIPHERAL 1.10 1.00
76077 DXA BONE DENSITY/V-FRACTURE 1.04 1.00
76078 RADIOGRAPHIC ABSORPTIOMETRY 1.07 1.00

76080 X-RAY EXAM OF FISTULA 1.76 1.00
76082 COMPUTER MAMMOGRAM ADD-ON 0.51 1.00
76086 X-RAY OF MAMMARY DUCT 3.23 1.00

76088 X-RAY OF MAMMARY DUCTS 4.43 1.00
76090 MAMMOGRAM, ONE BREAST 2.06 1.00
76091 MAMMOGRAM, BOTH BREASTS 2.56 1.00
76092 MAMM0GRAM, SCREENING 2.25 1.00

76093 MAGNETIC IMAGE, BREAST 20.57 1.00
76094 MAGNETIC IMAGE, BOTH BREASTS 27.08 1.00
76095 STEREOTACTIC BREAST BIOPSY 9.66 1.00
76096 X-RAY OF NEEDLE WIRE, BREAST 2.14 1.00
76096 X-RAY OF NEEDLE WIRE, BREAST 2.17 1.00

76098 X-RAY EXAM, BREAST SPECIMEN 0.55 1.00
76100 X-RAY EXAM OF BODY SECTION 2.11 1.00
76101 COMPLEX BODY SECTION X-RAY 2.29 1.00
76102 COMPLEX BODY SECTION X-RAYS 2.62 1.00

76120 CINE/VIDEO X-RAYS 1.62 1.00
76125 CINE/VIDEO X-RAYS ADD-ON 1.20 1.00
76125 CINE/VIDEO X-RAYS ADD-ON 1.21 1.00
76150 X-RAY EXAM, DRY PROCESS 0.43 1.00
76355 CT SCAN FOR LOCALIZATION 10.26 1.00

76360 CT SCAN FOR NEEDLE BIOPSY 10.17 1.00
76362 CT GUIDE FOR TISSUE ABLATION 14.96 1.00
76375 3D/HOLOGRAPH RECONSTR ADD-ON 3.89 1.00
76376 3D RENDER W/O POSTPROCESS 2.22 1.00
76377 3D RENDERING W/POSTPROCESS 3.16 1.00
76380 CAT SCAN FOLLOW-UP STUDY 4.98 1.00

76390 MR SPECTROSCOPY 12.80 1.00
76393 MR GUIDANCE FOR NEEDLE PLACE 13.71 1.00
76393 MR GUIDANCE FOR NEEDLE PLACE 13.87 1.00
76394 MRI FOR TISSUE ABLATION 18.33 1.00
76394 MRI FOR TISSUE ABLATION 18.66 1.00
76400 MAGNETIC IMAGE, BONE MARROW 7.00 1.00

76490 US FOR TISSUE ABLATION 7.20 1.00
77261 RADIATION THERAPY PLANNING 1.97 1.00
77280 SET RADIATION THERAPY FIELD 4.57 1.00

77300 RADIATION THERAPY DOSE PLAN 1.98 1.00

77301 RADIOTHERAPY DOSE PLAN, IMRT 40.26 1.00
77305 TELETX ISODOSE PLAN SIMPLE 2.05 1.00
77310 TELETX ISODOSE PLAN INTERMED 2.84 1.00

77315 TELETX ISODOSE PLAN COMPLEX 4.13 1.00
77315 TELETX ISODOSE PLAN COMPLEX 4.92 1.00
77321 SPECIAL TELETX PORT PLAN 3.42 1.00
77326 BRACHYTX ISODOSE CALC SIMP 3.74 1.00
77327 BRACHYTX ISODOSE CALC INTERM 5.52 1.00
77328 BRACHYTX ISODOSE PLAN COMPL 7.73 1.00

77331 SPECIAL RADIATION DOSIMETRY 1.72 1.00
77331 SPECIAL RADIATION DOSIMETRY 1.73 1.00
77332 RADIATION TREATMENT AID(S) 2.13 1.00

77336 RADIATION PHYSICS CONSULT 1.74 1.00

77371 SRS, MULTISOURCE 30.24 1.00
77372 SRS, LINEAR BASED 22.43 1.00
77373 SBRT DELIVERY 41.51 1.00
77401 RADIATION TREATMENT DELIVERY 0.90 1.00



77417 RADIOLOGY PORT FILM(S) 0.45 1.00
77418 RADIATION TX DELIVERY, IMRT 14.33 1.00

77421 STEREOSCOPIC X-RAY GUIDANCE 3.14 1.00
77422 NEUTRON BEAM TX, SIMPLE 5.37 1.00
77423 NEUTRON BEAM TX, COMPLEX 6.16 1.00
77427 RADIATION TX MANAGEMENT, X5 4.53 1.00
77431 RADIATION THERAPY MANAGEMENT 2.57 1.00
77432 STEREOTACTIC RADIATION TRMT 11.11 1.00

77435 SBRT MANAGEMENT 18.43 1.00
77470 SPECIAL RADIATION TREATMENT 7.20 1.00
77620 HYPERTHERMIA TREATMENT 5.33 1.00
77750 INFUSE RADIOACTIVE MATERIALS 8.09 1.00

77761 APPLY INTRCAV RADIAT SIMPLE 3.00 1.00
77762 APPLY INTRCAV RADIAT INTERM 3.00 1.00
77763 APPLY INTRCAV RADIAT COMPL 3.00 1.00
77776 APPLY INTERSTIT RADIAT SIMPL 8.16 1.00

77777 APPLY INTERSTIT RADIAT INTER 14.68 1.00
77778 APPLY INTERSTIT RADIAT COMPL 20.70 1.00
77781 REMOTE AFTERLOADING HIGH INTENSITY 14.97 1.00

77785 HDR BRACHYTX, 1 CHANNEL 5.16 1.00
77786 HDR BRACHYTX, 2-12 CHANNEL 15.47 1.00

77787 HDR BRACHYTX OVER 12 CHAN 22.99 1.00
77789 APPLY SURFACE RADIATION 2.00 1.00
77790 RADIATION HANDLING 1.96 1.00
78000 THYROID, SINGLE UPTAKE 1.29 1.00
78001 THYROID, MULTIPLE UPTAKES 1.72 1.00

78003 THYROID SUPPRESS/STIMUL 1.47 1.00
78006 THYROID IMAGING WITH UPTAKE 3.16 1.00
78007 THYROID IMAGE, MULT UPTAKES 3.37 1.00
78010 THYROID IMAGING 2.45 1.00

78011 THYROID IMAGING WITH FLOW 3.14 1.00
78015 THYROID MET IMAGING 3.61 1.00
78016 THYROID MET IMAGING/STUDIES 4.76 1.00
78018 THYROID MET IMAGING, BODY 6.84 1.00

78020 THYROID MET UPTAKE 2.26 1.00
78070 PARATHYROID NUCLEAR IMAGING 3.04 1.00
78075 ADRENAL NUCLEAR IMAGING 6.68 1.00
78102 BONE MARROW IMAGING, LTD 2.90 1.00

78103 BONE MARROW IMAGING, MULT 4.34 1.00
78104 BONE MARROW IMAGING, BODY 5.34 1.00
78110 PLASMA VOLUME, SINGLE 1.27 1.00
78111 PLASMA VOLUME, MULTIPLE 2.70 1.00

78120 RED CELL MASS, SINGLE 2.13 1.00
78121 RED CELL MASS, MULTIPLE 2.91 1.00
78130 RED CELL SURVIVAL STUDY 3.82 1.00

78135 RED CELL SURVIVAL KINETICS 5.97 1.00
78140 RED CELL SEQUESTRATION 4.09 1.00
78160 PLASMA IRON TURNOVER 4.29 1.00
78162 RADIOIRON ABSORPTION EXAM 3.97 1.00
78162 RADIOIRON ABSORPTION EXAM 4.03 1.00
78170 RED CELL IRON UTILIZATION 6.10 1.00

78185 SPLEEN IMAGING 3.02 1.00
78190 KINETICS, STUDY OF PLATELET SURVIV 7.57 1.00
78191 PLATELET SURVIVAL 5.51 1.00
78195 LYMPH SYSTEM IMAGING 5.91 1.00

78201 LIVER IMAGING 3.07 1.00
78202 LIVER IMAGING WITH FLOW 3.70 1.00
78205 LIVER IMAGING (3D) 6.53 1.00
78205 LIVER IMAGING (3D) 7.13 1.00
78205 LIVER IMAGING (3D) 7.24 1.00

78206 LIVER IMAGE (3D) WITH FLOW 7.31 1.00
78215 LIVER AND SPLEEN IMAGING 3.73 1.00
78216 LIVER & SPLEEN IMAGE/FLOW 3.82 1.00
78220 LIVER FUNCTION STUDY 3.98 1.00
78223 HEPATOBILIARY IMAGING 4.98 1.00

78230 SALIVARY GLAND IMAGING 2.90 1.00
78231 SERIAL SALIVARY IMAGING 3.67 1.00
78232 SALIVARY GLAND FUNCTION EXAM 3.74 1.00
78258 ESOPHAGEAL MOTILITY STUDY 4.02 1.00

78261 GASTRIC MUCOSA IMAGING 5.23 1.00
78262 GASTROESOPHAGEAL REFLUX EXAM 5.37 1.00
78264 GASTRIC EMPTYING STUDY 5.37 1.00

78270 VIT B-12 ABSORPTION EXAM 1.90 1.00
78271 VIT B-12 ABSRP EXAM, INT FAC 1.99 1.00
78272 VIT B-12 ABSORP, COMBINED 2.50 1.00
78278 ACUTE GI BLOOD LOSS IMAGING 6.44 1.00

78282 GI PROTEIN LOSS EXAM 0.52 1.00
78290 MECKELÏS DIVERT EXAM 4.12 1.00
78291 LEVEEN/SHUNT PATENCY EXAM 4.41 1.00
78300 BONE IMAGING, LIMITED AREA 3.46 1.00

78305 BONE IMAGING, MULTIPLE AREAS 4.96 1.00
78306 BONE IMAGING, WHOLE BODY 5.64 1.00
78315 BONE IMAGING, 3 PHASE 6.39 1.00
78320 BONE IMAGING (3D) 6.99 1.00

78320 BONE IMAGING (3D) 7.59 1.00
78320 BONE IMAGING (3D) 7.70 1.00
78350 BONE MINERAL, SINGLE PHOTON 0.93 1.00
78351 BONE MINERAL, DUAL PHOTON 0.42 1.00
78351 BONE MINERAL, DUAL PHOTON 0.43 1.00
78414 NON-IMAGING HEART FUNCTION 0.60 1.00
78414 NON-IMAGING HEART FUNCTION 0.63 1.00
78428 CARDIAC SHUNT IMAGING 3.46 1.00
78445 VASCULAR FLOW IMAGING 2.63 1.00

78455 VENOUS THROMBOSIS STUDY 5.16 1.00
78456 ACUTE VENOUS THROMBUS IMAGE 5.61 1.00
78457 VENOUS THROMBOSIS IMAGING 3.84 1.00
78458 VEN THROMBOSIS IMAGES, BILAT 5.43 1.00

78459 HEART MUSCLE IMAGING (PET) 2.13 1.00
78460 HEART MUSCLE BLOOD, SINGLE 3.65 1.00
78461 HEART MUSCLE BLOOD, MULTIPLE 5.84 1.00

78464 HEART IMAGE (3D), SINGLE 7.61 1.00
78465 HEART IMAGE (3D), MULTIPLE 13.45 1.00
78466 HEART INFARCT IMAGE 3.70 1.00
78468 HEART INFARCT IMAGE (EF) 4.92 1.00

78469 HEART INFARCT IMAGE (3D) 6.69 1.00
78472 GATED HEART, PLANAR, SINGLE 7.10 1.00
78472 GATED HEART, PLANAR, SINGLE 7.21 1.00
78473 GATED HEART, MULTIPLE 9.86 1.00
78478 HEART WALL MOTION ADD-ON 1.65 1.00
78480 HEART FUNCTION ADD-ON 1.38 1.00

78481 HEART FIRST PASS, SINGLE 6.33 1.00
78483 HEART FIRST PASS, MULTIPLE 8.95 1.00
78491 HEART IMAGE (PET), SINGLE 2.15 1.00
78492 HEART IMAGE (PET), MULTIPLE 2.68 1.00

78494 HEART IMAGE, SPECT 7.86 1.00
78496 HEART FIRST PASS ADD-ON 3.29 1.00
78580 LUNG PERFUSION IMAGING 4.59 1.00
78584 LUNG V/Q IMAGE SINGLE BREATH 4.34 1.00
78585 LUNG V/Q IMAGING 7.38 1.00

78586 AEROSOL LUNG IMAGE, SINGLE 3.26 1.00
78587 AEROSOL LUNG IMAGE, MULTIPLE 3.60 1.00
78588 PERFUSION LUNG IMAGE 4.85 1.00
78591 VENT IMAGE, 1 BREATH, 1 PROJ 3.52 1.00

78593 VENT IMAGE, 1 PROJ, GAS 4.26 1.00
78594 VENT IMAGE, MULT PROJ, GAS 5.91 1.00
78596 LUNG DIFFERENTIAL FUNCTION 9.11 1.00

78600 BRAIN IMAGE < 4 VIEWS 3.61 1.00
78601 BRAIN IMAGE W/FLOW < 4 VIEWS 4.25 1.00
78605 BRAIN IMAGE 4+ VIEWS 4.28 1.00
78606 BRAIN IMAGE W/FLOW 4 + VIEWS 4.91 1.00

78607 BRAIN IMAGING (3D) 8.55 1.00
78607 BRAIN IMAGING (3D) 8.65 1.00
78607 BRAIN IMAGING (3D) 9.89 1.00
78610 BRAIN FLOW IMAGING ONLY 2.07 1.00
78615 CEREBRAL VASCULAR FLOW IMAGE 4.60 1.00
78630 CEREBROSPINAL FLUID SCAN 6.19 1.00

78635 CSF VENTRICULOGRAPHY 3.52 1.00
78645 CSF SHUNT EVALUATION 4.35 1.00
78650 CSF LEAKAGE IMAGING 5.67 1.00

78660 NUCLEAR EXAM OF TEAR FLOW 2.95 1.00
78700 KIDNEY IMAGING, MORPHOL 3.80 1.00
78701 KIDNEY IMAGING WITH FLOW 4.37 1.00
78704 IMAGING RENOGRAM 5.14 1.00

78707 K FLOW/FUNCT IMAGE W/O DRUG 5.98 1.00
78708 K FLOW/FUNCT IMAGE W/DRUG 5.34 1.00
78709 K FLOW/FUNCT IMAGE, MULTIPLE 6.60 1.00
78710 KIDNEY IMAGING (3D) 6.48 1.00

78715 RENAL VASCULAR FLOW EXAM 2.07 1.00
78715 RENAL VASCULAR FLOW EXAM 2.10 1.00
78725 KIDNEY FUNCTION STUDY 2.38 1.00
78730 URINARY BLADDER RETENTION 2.03 1.00
78740 URETERAL REFLUX STUDY 2.99 1.00

78760 TESTICULAR IMAGING 3.71 1.00
78760 TESTICULAR IMAGING 3.74 1.00
78761 TESTICULAR IMAGING W/FLOW 4.31 1.00
78800 TUMOR IMAGING, LIMITED AREA 4.46 1.00
78801 TUMOR IMAGING, MULT AREAS 5.49 1.00

78802 TUMOR IMAGING, WHOLE BODY 6.95 1.00
78803 TUMOR IMAGING (3D) 8.35 1.00
78803 TUMOR IMAGING (3D) 8.45 1.00
78803 TUMOR IMAGING (3D) 9.67 1.00
78805 ABSCESS IMAGING, LTD AREA 4.56 1.00
78806 ABSCESS IMAGING, WHOLE BODY 7.89 1.00

78807 NUCLEAR LOCALIZATION/ABSCESS 8.36 1.00
78808 IV INJ RA DRUG DX STUDY 1.23 1.00
78810 TUMOR IMAGING (PET) 2.77 1.00
79000 INIT HYPERTHYROID THERAPY 5.23 1.00
79000 INIT HYPERTHYROID THERAPY 5.24 1.00
79001 REPEAT HYPERTHYROID THERAPY 2.82 1.00

79001 REPEAT HYPERTHYROID THERAPY 2.84 1.00
79005 NUCLEAR RX, ORAL ADMIN 4.26 1.00
79005 NUCLEAR RX, ORAL ADMIN 5.24 1.00
79020 THYROID ABLATION 5.23 1.00
79020 THYROID ABLATION 5.25 1.00
79030 THYROID ABLATION, CARCINOMA 5.65 1.00
79030 THYROID ABLATION, CARCINOMA 5.67 1.00
79035 THYROID METASTATIC THERAPY 6.25 1.00
79035 THYROID METASTATIC THERAPY 6.27 1.00
79100 HEMATOPOETIC NUCLEAR THERAPY 4.58 1.00
79100 HEMATOPOETIC NUCLEAR THERAPY 4.60 1.00
79101 NUCLEAR RX, IV ADMIN 4.79 1.00
79200 NUCLEAR RX, INTRACAV ADMIN 4.86 1.00

79300 NUCLR RX, INTERSTIT COLLOID 2.24 1.00
79400 NONHEMATO NUCLEAR THERAPY 5.47 1.00
79400 NONHEMATO NUCLEAR THERAPY 5.49 1.00
79403 HEMATOPOIETIC NUCLEAR TX 6.07 1.00
79420 INTRAVASCULAR NUCLEAR THER 2.07 1.00

79420 INTRAVASCULAR NUCLEAR THER 2.09 1.00
79440 NUCLEAR RX, INTRA-ARTICULAR 4.49 1.00
80048 METABOLIC PANEL TOTAL CA 1.00 1.00
80051 ELECTROLYTE PANEL 1.00 1.00
80053 COMPREHEN METABOLIC PANEL 1.00 1.00
80061 LIPID PANEL 1.00 1.00
80069 RENAL FUNCTION PANEL 1.00 1.00
80076 HEPATIC FUNCTION PANEL 1.00 1.00

90801 PSY DX INTERVIEW 3.62 1.00
90802 INTAC PSY DX INTERVIEW 3.91 1.00
90804 PSYTX, OFFICE, 20-30 MIN 1.54 1.00
90804 PSYTX, OFFICE, 20-30 MIN 1.63 1.00
90805 PSYTX, OFF, 20-30 MIN W/E&M 1.73 1.00
90805 PSYTX, OFF, 20-30 MIN W/E&M 1.83 1.00
90805 PSYTX, OFF, 20-30 MIN W/E&M 1.84 1.00
90806 PSYTX, OFF, 45-50 MIN 2.36 1.00
90806 PSYTX, OFF, 45-50 MIN 2.51 1.00

90807 PSYTX, OFF, 45-50 MIN W/E&M 2.56 1.00
90807 PSYTX, OFF, 45-50 MIN W/E&M 2.71 1.00
90808 PSYTX, OFFICE, 75-80 MIN 3.55 1.00
90808 PSYTX, OFFICE, 75-80 MIN 3.78 1.00
90809 PSYTX, OFF, 75-80, W/E&M 3.66 1.00
90809 PSYTX, OFF, 75-80, W/E&M 3.95 1.00
90810 INTAC PSYTX, OFF, 20-30 MIN 1.64 1.00
90811 INTAC PSYTX, 20-30, W/E&M 1.84 1.00
90811 INTAC PSYTX, 20-30, W/E&M 1.98 1.00
90811 INTAC PSYTX, 20-30, W/E&M 1.99 1.00

90813 INTAC PSYTX, 45-50 MIN W/E&M 2.64 1.00
90813 INTAC PSYTX, 45-50 MIN W/E&M 2.86 1.00
90815 INTAC PSYTX, 75-80 W/E&M 3.79 1.00
90815 INTAC PSYTX, 75-80 W/E&M 4.09 1.00
90816 PSYTX, HOSP, 20-30 MIN 1.64 1.00
90816 PSYTX, HOSP, 20-30 MIN 1.75 1.00
90816 PSYTX, HOSP, 20-30 MIN 1.76 1.00

90817 PSYTX, HOSP, 20-30 MIN W/E&M 1.82 1.00
90818 PSYTX, HOSP, 45-50 MIN 2.44 1.00
90821 PSYTX, HOSP, 75-80 MIN 3.60 1.00
90823 INTAC PSYTX, HOSP, 20-30 MIN 1.77 1.00
90824 INTAC PSYTX, HSP 20-30 W/E&M 1.97 1.00

90845 PSYCHOANALYSIS 2.26 1.00
90846 FAMILY PSYTX W/O PATIENT 2.41 1.00
90846 FAMILY PSYTX W/O PATIENT 2.53 1.00
90847 FAMILY PSYTX W/PATIENT 2.89 1.00
90847 FAMILY PSYTX W/PATIENT 3.03 1.00
90849 MULTIPLE FAMILY GROUP PSYTX 0.83 1.00
90849 MULTIPLE FAMILY GROUP PSYTX 0.84 1.00

90853 GROUP PSYCHOTHERAPY 0.81 1.00
90853 GROUP PSYCHOTHERAPY 0.83 1.00
90857 INTAC GROUP PSYTX 0.87 1.00
90857 INTAC GROUP PSYTX 0.91 1.00
90862 MEDICATION MANAGEMENT 1.26 1.00
90870 ELECTROCONVULSIVE THERAPY 2.36 1.00

90875 PSYCHOPHYSIOLOGICAL THERAPY 1.70 1.00
90885 PSY EVALUATION OF RECORDS 1.29 1.00
90885 PSY EVALUATION OF RECORDS 1.36 1.00
90911 BIOFEEDBACK PERI/URO/RECTAL 1.25 1.00
90918 ESRD RELATED SERVICES, MONTH 16.45 1.00

90922 ESRD RELATED SERVICES, DAY 0.55 1.00

90935 HEMODIALYSIS, ONE EVALUATION 1.86 1.00
90937 HEMODIALYSIS, REPEATED EVAL 3.02 1.00

90945 DIALYSIS, ONE EVALUATION 1.91 1.00
90947 DIALYSIS, REPEATED EVAL 3.09 1.00
90947 DIALYSIS, REPEATED EVAL 3.24 1.00
90951 ESRD SERV, 4 VISITS P MO, <2 26.67 1.00
90954 ESRD SERV, 4 VSTS P MO, 2-11 21.85 1.00
90955 ESRD SRV 2-3 VSTS P MO, 2-11 12.39 1.00
90956 ESRD SRV, 1 VISIT P MO, 2-11 8.39 1.00
90957 ESRD SRV, 4 VSTS P MO, 12-19 17.55 1.00
90958 ESRD SRV 2-3 VSTS P MO 12-19 11.85 1.00
90959 ESRD SERV, 1 VST P MO, 12-19 7.77 1.00
90960 ESRD SRV, 4 VISITS P MO, 20+ 7.81 1.00

90961 ESRD SRV, 2-3 VSTS P MO, 20+ 6.30 1.00
90962 ESRD SERV, 1 VISIT P MO, 20+ 4.55 1.00
90963 ESRD HOME PT, SERV P MO, <2 15.06 1.00
90964 ESRD HOME PT SERV P MO, 2-11 12.55 1.00
90965 ESRD HOME PT SERV P MO 12-19 11.93 1.00
90966 ESRD HOME PT, SERV P MO, 20+ 6.23 1.00
90967 ESRD HOME PT SERV P DAY, <2 0.54 1.00
90968 ESRD HOME PT SRV P DAY, 2-11 0.42 1.00
90969 ESRD HOME PT SRV P DAY 12-19 0.41 1.00
90970 ESRD HOME PT SERV P DAY, 20+ 0.22 1.00
90997 HEMOPERFUSION 2.46 1.00

91000 ESOPHAGEAL INTUBATION 1.10 1.00
91010 ESOPHAGUS MOTILITY STUDY 4.08 1.00

91020 GASTRIC MOTILITY STUDIES 4.50 1.00
91022 DUODENAL MOTILITY STUDY 5.13 1.00
91030 ACID PERFUSION OF ESOPHAGUS 3.37 1.00
91032 ESOPHAGUS, ACID REFLUX TEST 3.74 1.00
91032 ESOPHAGUS, ACID REFLUX TEST 5.43 1.00
91033 PROLONGED ACID REFLUX TEST 4.08 1.00

91033 PROLONGED ACID REFLUX TEST 5.63 1.00
91034 GASTROESOPHAGEAL REFLUX TEST 5.38 1.00
91035 G-ESOPH REFLX TST W/ELECTROD 12.51 1.00
91037 ESOPH IMPED FUNCTION TEST 4.02 1.00
91038 ESOPH IMPED FUNCT TEST > 1H 3.44 1.00

91040 ESOPH BALLOON DISTENSION TST 10.23 1.00
91052 GASTRIC ANALYSIS TEST 3.04 1.00
91055 GASTRIC INTUBATION FOR SMEAR 3.17 1.00

91060 GASTRIC SALINE LOAD TEST 0.79 1.00
91060 GASTRIC SALINE LOAD TEST 2.47 1.00
91065 BREATH HYDROGEN TEST 1.77 1.00
91100 PASS INTESTINE BLEEDING TUBE 1.43 1.00
91105 GASTRIC INTUBATION TREATMENT 0.47 1.00
91110 GI TRACT CAPSULE ENDOSCOPY 24.30 1.00
91110 GI TRACT CAPSULE ENDOSCOPY 24.86 1.00

91111 ESOPHAGEAL CAPSULE ENDOSCOPY 18.97 1.00
91120 RECTAL SENSATION TEST 10.48 1.00
91122 ANAL PRESSURE RECORD 6.29 1.00
91132 ELECTROGASTROGRAPHY 0.72 1.00
91133 ELECTROGASTROGRAPHY W/TEST 0.92 1.00

92502 EAR AND THROAT EXAMINATION 2.53 1.00
92504 EAR MICROSCOPY EXAMINATION 0.26 1.00
92504 EAR MICROSCOPY EXAMINATION 0.28 1.00
92506 SPEECH/HEARING EVALUATION 1.21 1.00
92506 SPEECH/HEARING EVALUATION 1.31 1.00

92507 SPEECH/HEARING THERAPY 0.72 1.00
92511 NASOPHARYNGOSCOPY 1.29 1.00
92512 NASAL FUNCTION STUDIES 0.75 1.00
92512 NASAL FUNCTION STUDIES 0.76 1.00
92516 FACIAL NERVE FUNCTION TEST 0.61 1.00
92516 FACIAL NERVE FUNCTION TEST 0.67 1.00
92520 LARYNGEAL FUNCTION STUDIES 1.07 1.00

92526 ORAL FUNCTION THERAPY 0.75 1.00
92541 SPONTANEOUS NYSTAGMUS TEST 1.41 1.00
92542 POSITIONAL NYSTAGMUS TEST 1.42 1.00
92543 CALORIC VESTIBULAR TEST 0.65 1.00

92544 OPTOKINETIC NYSTAGMUS TEST 1.13 1.00
92545 OSCILLATING TRACKING TEST 1.05 1.00
92546 SINUSOIDAL ROTATIONAL TEST 2.12 1.00

92547 SUPPLEMENTAL ELECTRICAL TEST 0.16 1.00
92548 POSTUROGRAPHY 2.55 1.00
92551 PURE TONE HEARING TEST, AIR 0.29 1.00
92551 PURE TONE HEARING TEST, AIR 0.48 1.00
92552 PURE TONE AUDIOMETRY, AIR 0.48 1.00
92552 PURE TONE AUDIOMETRY, AIR 0.59 1.00
92553 AUDIOMETRY, AIR & BONE 0.71 1.00

92555 SPEECH THRESHOLD AUDIOMETRY 0.41 1.00
92555 SPEECH THRESHOLD AUDIOMETRY 0.44 1.00
92556 SPEECH AUDIOMETRY, COMPLETE 0.62 1.00
92557 COMPREHENSIVE HEARING TEST 1.18 1.00
92561 BEKESY AUDIOMETRY, DIAGNOSIS 0.77 1.00
92561 BEKESY AUDIOMETRY, DIAGNOSIS 0.78 1.00
92562 LOUDNESS BALANCE TEST 0.44 1.00
92562 LOUDNESS BALANCE TEST 0.62 1.00

92563 TONE DECAY HEARING TEST 0.41 1.00
92563 TONE DECAY HEARING TEST 0.56 1.00
92564 SISI HEARING TEST 0.51 1.00
92565 STENGER TEST, PURE TONE 0.35 1.00
92565 STENGER TEST, PURE TONE 0.43 1.00
92567 TYMPANOMETRY 0.44 1.00

92568 ACOUSTIC REFL THRESHOLD TST 0.41 1.00
92568 ACOUSTIC REFL THRESHOLD TST 0.50 1.00
92569 ACOUSTIC REFLEX DECAY TEST 0.40 1.00
92569 ACOUSTIC REFLEX DECAY TEST 0.44 1.00
92571 FILTERED SPEECH HEARING TEST 0.42 1.00
92571 FILTERED SPEECH HEARING TEST 0.45 1.00
92572 STAGGERED SPONDAIC WORD TEST 0.10 1.00
92572 STAGGERED SPONDAIC WORD TEST 0.47 1.00
92573 LOMBARD TEST 0.38 1.00
92573 LOMBARD TEST 0.39 1.00
92575 SENSORINEURAL ACUITY TEST 0.32 1.00
92575 SENSORINEURAL ACUITY TEST 0.95 1.00
92576 SYNTHETIC SENTENCE TEST 0.49 1.00

92576 SYNTHETIC SENTENCE TEST 0.58 1.00
92577 STENGER TEST, SPEECH 0.48 1.00
92579 VISUAL AUDIOMETRY (VRA) 0.78 1.00
92582 CONDITIONING PLAY AUDIOMETRY 0.78 1.00
92583 SELECT PICTURE AUDIOMETRY 0.91 1.00

92584 ELECTROCOCHLEOGRAPHY 1.86 1.00
92585 AUDITOR EVOKE POTENT, COMPRE 2.70 1.00
92586 AUDITOR EVOKE POTENT, LIMIT 1.71 1.00

92587 EVOKED AUDITORY TEST 1.07 1.00
92589 AUDITORY FUNCTION TEST(S) 0.58 1.00
92589 AUDITORY FUNCTION TEST(S) 0.59 1.00
92950 HEART/LUNG RESUSCITATION CPR 4.91 1.00
92960 CARDIOVERSION ELECTRIC, EXT 3.19 1.00

92970 CARDIOASSIST, INTERNAL 4.77 1.00
92971 CARDIOASSIST, EXTERNAL 2.69 1.00
92973 PERCUT CORONARY THROMBECTOMY 4.71 1.00

92974 CATH PLACE, CARDIO BRACHYTX 4.34 1.00
92975 DISSOLVE CLOT, HEART VESSEL 10.32 1.00
92978 INTRAVASC US, HEART ADD-ON 7.34 1.00

92980 INSERT INTRACORONARY STENT 21.75 1.00
92982 CORONARY ARTERY DILATION 7.00 1.00

92986 REVISION OF AORTIC VALVE 33.21 1.00
92995 CORONARY ATHERECTOMY 17.75 1.00

92996 CORONARY ATHERECTOMY ADD-ON 4.72 1.00
92997 PUL ART BALLOON REPR, PERCUT 7.00 1.00

93000 ELECTROCARDIOGRAM, COMPLETE 0.58 1.00
93000 ELECTROCARDIOGRAM, COMPLETE 0.71 1.00
93005 ELECTROCARDIOGRAM, TRACING 0.33 1.00
93005 ELECTROCARDIOGRAM, TRACING 0.47 1.00
93010 ELECTROCARDIOGRAM REPORT 0.24 1.00
93010 ELECTROCARDIOGRAM REPORT 0.25 1.00
93015 CARDIOVASCULAR STRESS TEST 2.78 1.00

93024 CARDIAC DRUG STRESS TEST 2.85 1.00
93025 MICROVOLT T-WAVE ASSESS 5.91 1.00
93040 RHYTHM ECG WITH REPORT 0.37 1.00
93040 RHYTHM ECG WITH REPORT 0.38 1.00
93041 RHYTHM ECG, TRACING 0.15 1.00
93041 RHYTHM ECG, TRACING 0.16 1.00
93042 RHYTHM ECG, REPORT 0.22 1.00

93224 ECG MONITOR/REPORT, 24 HRS 3.31 1.00
93225 ECG MONITOR/RECORD, 24 HRS 0.99 1.00
93227 ECG MONITOR/REVIEW, 24 HRS 0.74 1.00

93228 REMOTE 30 DAY ECG REV/REPORT 0.71 1.00

93268 ECG RECORD/REVIEW 7.36 1.00
93270 ECG RECORDING 0.60 1.00

93271 ECG/MONITORING AND ANALYSIS 6.00 1.00
93272 ECG/REVIEW, INTERPRET ONLY 0.73 1.00
93272 ECG/REVIEW, INTERPRET ONLY 0.76 1.00
93278 ECG/SIGNAL-AVERAGED 1.13 1.00

93279 PM DEVICE PROGR EVAL, SNGL 1.55 1.00
93281 PM DEVICE PROGR EVAL, MULTI 2.14 1.00
93282 ICD DEVICE PROG EVAL, 1 SNGL 1.98 1.00
93283 ICD DEVICE PROGR EVAL, DUAL 2.41 1.00
93284 ICD DEVICE PROGR EVAL, MULT 2.82 1.00
93285 ILR DEVICE EVAL PROGR 1.34 1.00
93286 PRE-OP PM DEVICE EVAL 0.76 1.00
93287 PRE-OP ICD DEVICE EVAL 1.00 1.00
93288 PM DEVICE EVAL IN PERSON 1.20 1.00
93289 ICD DEVICE INTERROGATE 1.84 1.00
93290 ICM DEVICE EVAL 0.89 1.00
93291 ILR DEVICE INTERROGATE 1.15 1.00
93292 WCD DEVICE INTERROGATE 1.04 1.00

93293 PM PHONE R-STRIP DEVICE EVAL 1.66 1.00
93294 PM DEVICE INTERROGATE REMOTE 1.02 1.00
93295 ICD DEVICE INTERROGAT REMOTE 1.84 1.00
93296 PM/ICD REMOTE TECH SERV 1.01 1.00
93297 ICM DEVICE INTERROGAT REMOTE 0.71 1.00
93298 ILR DEVICE INTERROGAT REMOTE 0.82 1.00
93303 ECHO TRANSTHORACIC 5.86 1.00

93306 TTE W/DOPPLER, COMPLETE 7.42 1.00
93307 TTE W/O DOPPLER, COMPLETE 4.91 1.00
93308 TTE, F-UP OR LMTD 2.80 1.00
93308 TTE, F-UP OR LMTD 2.84 1.00
93308 TTE, F-UP OR LMTD 3.10 1.00
93312 ECHO TRANSESOPHAGEAL 3.00 1.00


93318 ECHO TRANSESOPHAGEAL INTRAOP 2.74 1.00
93320 DOPPLER ECHO EXAM, HEART 2.17 1.00

93325 DOPPLER COLOR FLOW ADD-ON 1.50 1.00
93350 STRESS TTE ONLY 3.94 1.00

93351 STRESS TTE COMPLETE 7.04 1.00
93352 ADMIN ECG CONTRAST AGENT 1.07 1.00
93501 RIGHT HEART CATHETERIZATION 22.06 1.00
93503 INSERT/PLACE HEART CATHETER 3.11 1.00
93505 BIOPSY OF HEART LINING 8.43 1.00

93508 CATH PLACEMENT, ANGIOGRAPHY 19.04 1.00
93510 LEFT HEART CATHETERIZATION 5.00 1.00

93526 RT & LT HEART CATHETERS 7.00 1.00

93529 RT, LT HEART CATHETERIZATION 56.15 1.00
93529 RT, LT HEART CATHETERIZATION 57.48 1.00
93530 RT HEART CATH, CONGENITAL 7.00 1.00
93531 R & L HEART CATH, CONGENITAL 7.00 1.00

93539 INJECTION, CARDIAC CATH 0.57 1.00
93541 INJECTION FOR LUNG ANGIOGRAM 0.41 1.00
93542 INJECTION FOR HEART X-RAYS 0.41 1.00

93544 INJECTION FOR AORTOGRAPHY 0.36 1.00
93544 INJECTION FOR AORTOGRAPHY 0.39 1.00
93545 INJECT FOR CORONARY X-RAYS 0.57 1.00
93555 IMAGING, CARDIAC CATH 3.27 1.00

93561 CARDIAC OUTPUT MEASUREMENT 1.25 1.00
93571 HEART FLOW RESERVE MEASURE 7.36 1.00
93580 TRANSCATH CLOSURE OF ASD 26.48 1.00

93581 TRANSCATH CLOSURE OF VSD 35.41 1.00
93600 BUNDLE OF HIS RECORDING 5.13 1.00
93600 BUNDLE OF HIS RECORDING 5.17 1.00
93602 INTRA-ATRIAL RECORDING 4.24 1.00
93602 INTRA-ATRIAL RECORDING 4.28 1.00
93603 RIGHT VENTRICULAR RECORDING 4.83 1.00
93603 RIGHT VENTRICULAR RECORDING 4.87 1.00
93609 MAP TACHYCARDIA, ADD-ON 10.37 1.00
93609 MAP TACHYCARDIA, ADD-ON 10.46 1.00

93610 INTRA-ATRIAL PACING 5.79 1.00
93610 INTRA-ATRIAL PACING 5.85 1.00
93612 INTRAVENTRICULAR PACING 6.07 1.00
93612 INTRAVENTRICULAR PACING 6.12 1.00
93613 ELECTROPHYS MAP 3D, ADD-ON 10.24 1.00
93615 ESOPHAGEAL RECORDING 1.63 1.00

93618 HEART RHYTHM PACING 10.34 1.00
93618 HEART RHYTHM PACING 10.42 1.00
93619 ELECTROPHYSIOLOGY EVALUATION 4.00 1.00

93623 STIMULATION, PACING HEART 4.05 1.00

93624 ELECTROPHYSIOLOGIC STUDY 9.05 1.00
93624 ELECTROPHYSIOLOGIC STUDY 9.42 1.00
93631 HEART PACING, MAPPING 17.70 1.00
93631 HEART PACING, MAPPING 17.96 1.00
93640 EVALUATION HEART DEVICE 12.58 1.00
93640 EVALUATION HEART DEVICE 12.71 1.00


93660 TILT TABLE EVALUATION 4.40 1.00
93662 INTRACARDIAC ECG (ICE) 4.00 1.00
93701 BIOIMPEDANCE, THORACIC 0.94 1.00
93720 TOTAL BODY PLETHYSMOGRAPHY 0.99 1.00

93721 PLETHYSMOGRAPHY TRACING 0.76 1.00
93722 PLETHYSMOGRAPHY REPORT 0.23 1.00
93724 ANALYZE PACEMAKER SYSTEM 9.28 1.00
93727 ANALYZE ILR SYSTEM 0.77 1.00

93733 TELEPHONE ANALY, PACEMAKER 1.03 1.00

93736 TELEPHONIC ANALY, PACEMAKER 0.90 1.00
93741 ANALYZE HT PACE DEVICE SNGL 1.84 1.00
93743 ANALYZE HT PACE DEVICE DUAL 2.24 1.00

93770 MEASURE VENOUS PRESSURE 0.24 1.00
93770 MEASURE VENOUS PRESSURE 0.26 1.00
93784 AMBULATORY BP MONITORING 1.17 1.00
93786 AMBULATORY BP RECORDING 0.82 1.00

93786 AMBULATORY BP RECORDING 0.92 1.00
93788 AMBULATORY BP ANALYSIS 0.46 1.00
93788 AMBULATORY BP ANALYSIS 0.52 1.00
93790 REVIEW/REPORT BP RECORDING 0.25 1.00
93797 CARDIAC REHAB 0.26 1.00
93797 CARDIAC REHAB 0.27 1.00
93798 CARDIAC REHAB/MONITOR 0.40 1.00
93798 CARDIAC REHAB/MONITOR 0.42 1.00
93875 EXTRACRANIAL STUDY 1.97 1.00

93886 INTRACRANIAL STUDY 5.86 1.00

93890 TRANSCRANIAL DOPPLER STUDY OF THE 6.35 1.00
93892 TCD, EMBOLI DETECT W/O INJ 7.95 1.00
93893 TCD, EMBOLI DETECT W/INJ 7.93 1.00
93922 EXTREMITY STUDY 2.26 1.00

93925 LOWER EXTREMITY STUDY 5.85 1.00
93930 UPPER EXTREMITY STUDY 4.72 1.00

93975 VASCULAR STUDY 8.18 1.00


93980 PENILE VASCULAR STUDY 5.13 1.00
93982 ANEURYSM PRESSURE SENS STUDY 1.10 1.00
93990 DOPPLER FLOW TESTING 3.81 1.00
94010 BREATHING CAPACITY TEST 0.87 1.00

94014 PATIENT RECORDED SPIROMETRY 1.01 1.00
94016 REVIEW PATIENT SPIROMETRY 0.69 1.00
94016 REVIEW PATIENT SPIROMETRY 0.71 1.00
94060 EVALUATION OF WHEEZING 1.50 1.00

94150 VITAL CAPACITY TEST 0.57 1.00
94200 LUNG FUNCTION TEST (MBC/MVV) 0.58 1.00
94240 RESIDUAL LUNG CAPACITY 0.97 1.00

94250 EXPIRED GAS COLLECTION 0.67 1.00
94260 THORACIC GAS VOLUME 0.72 1.00
94350 LUNG NITROGEN WASHOUT CURVE 0.96 1.00
94360 MEASURE AIRFLOW RESISTANCE 0.89 1.00

94370 BREATH AIRWAY CLOSING VOLUME 0.92 1.00
94375 RESPIRATORY FLOW VOLUME LOOP 0.95 1.00
94400 CO2 BREATHING RESPONSE CURVE 1.31 1.00
94450 HYPOXIA RESPONSE CURVE 1.12 1.00
94450 HYPOXIA RESPONSE CURVE 1.39 1.00

94452 HAST W/REPORT 1.53 1.00
94453 HAST W/OXYGEN TITRATE 2.04 1.00
94610 SURFACTANT ADMIN THRU TUBE 1.79 1.00
94620 PULMONARY STRESS TEST/SIMPLE 1.99 1.00
94621 PULM STRESS TEST/COMPLEX 3.64 1.00
94640 AIRWAY INHALATION TREATMENT 0.34 1.00

94644 CBT, 1ST HOUR 0.94 1.00
94645 CBT, EACH ADDL HOUR 0.37 1.00
94662 NEG PRESS VENTILATION, CNP 1.02 1.00
94664 EVALUATE PT USE OF INHALER 0.36 1.00
94680 EXHALED AIR ANALYSIS, O2 1.59 1.00
94681 EXHALED AIR ANALYSIS, O2/CO2 1.74 1.00

94690 EXHALED AIR ANALYSIS 1.39 1.00
94720 MONOXIDE DIFFUSING CAPACITY 1.33 1.00
94725 MEMBRANE DIFFUSION CAPACITY 1.85 1.00
94750 PULMONARY COMPLIANCE STUDY 1.63 1.00

94760 MEASURE BLOOD OXYGEN LEVEL 0.06 1.00
94770 EXHALED CARBON DIOXIDE TEST 1.01 1.00

94770 EXHALED CARBON DIOXIDE TEST 1.90 1.00
95805 MULTIPLE SLEEP LATENCY TEST 11.69 1.00
95806 SLEEP STUDY, UNATTENDED 5.39 1.00
95807 SLEEP STUDY, ATTENDED 13.68 1.00
95808 POLYSOMNOGRAPHY, 1-3 16.09 1.00

95810 POLYSOMNOGRAPHY, 4 OR MORE 21.10 1.00
95811 POLYSOMNOGRAPHY W/CPAP 21.96 1.00
95812 EEG, 41-60 MINUTES 5.15 1.00
95812 EEG, 41-60 MINUTES 5.93 1.00
95812 EEG, 41-60 MINUTES 6.52 1.00
95813 EEG, OVER 1 HOUR 6.84 1.00
95813 EEG, OVER 1 HOUR 7.68 1.00
95813 EEG, OVER 1 HOUR 7.99 1.00

95816 EEG, AWAKE AND DROWSY 4.37 1.00
95819 EEG, AWAKE AND ASLEEP 4.92 1.00
95822 EEG, COMA OR SLEEP ONLY 5.61 1.00
95824 EEG, CEREBRAL DEATH ONLY 1.02 1.00

95827 EEG, ALL NIGHT RECORDING 3.93 1.00
95829 SURGERY ELECTROCORTICOGRAM 33.20 1.00
95831 LIMB MUSCLE TESTING, MANUAL 0.39 1.00
95831 LIMB MUSCLE TESTING, MANUAL 0.42 1.00
95832 HAND MUSCLE TESTING, MANUAL 0.41 1.00
95832 HAND MUSCLE TESTING, MANUAL 0.42 1.00

95833 BODY MUSCLE TESTING, MANUAL 0.65 1.00
95852 RANGE OF MOTION MEASUREMENTS 0.16 1.00
95852 RANGE OF MOTION MEASUREMENTS 0.17 1.00
95857 TENSILON TEST 0.74 1.00
95857 TENSILON TEST 0.78 1.00
95858 TENSILON TEST & MYOGRAM 2.71 1.00
95860 MUSCLE TEST, ONE LIMB 2.23 1.00

95861 MUSCLE TEST, 2 LIMBS 3.08 1.00
95865 MUSCLE TEST, LARYNX 3.10 1.00

95866 MUSCLE TEST, HEMIDIAPHRAGM 2.54 1.00
95867 MUSCLE TEST CRAN NERV UNILAT 1.79 1.00
95868 MUSCLE TEST CRAN NERVE BILAT 2.49 1.00
95868 MUSCLE TEST CRAN NERVE BILAT 2.66 1.00
95869 MUSCLE TEST, THOR PARASPINAL 0.78 1.00
95869 MUSCLE TEST, THOR PARASPINAL 1.24 1.00
95870 MUSCLE TEST, NONPARASPINAL 0.77 1.00
95873 GUIDE NERV DESTR, ELEC STIM 1.26 1.00
95874 GUIDE NERV DESTR, NEEDLE EMG 1.19 1.00

95875 LIMB EXERCISE TEST 2.55 1.00
95900 MOTOR NERVE CONDUCTION TEST 1.45 1.00
95904 SENSE NERVE CONDUCTION TEST 1.28 1.00

95920 INTRAOP NERVE TEST ADD-ON 4.16 1.00
95921 AUTONOMIC NERV FUNCTION TEST 1.66 1.00

95925 SOMATOSENSORY TESTING 1.75 1.00
95928 C MOTOR EVOKED, UPPR LIMBS 5.13 1.00
95929 C MOTOR EVOKED, LWR LIMBS 5.41 1.00

95930 VISUAL EVOKED POTENTIAL TEST 1.55 1.00
95933 BLINK REFLEX TEST 1.69 1.00
95934 H-REFLEX TEST 0.98 1.00
95934 H-REFLEX TEST 0.99 1.00
95934 H-REFLEX TEST 1.31 1.00
95936 H-REFLEX TEST 1.05 1.00
95936 H-REFLEX TEST 1.16 1.00
95937 NEUROMUSCULAR JUNCTION TEST 1.30 1.00

95937 NEUROMUSCULAR JUNCTION TEST 1.57 1.00
95950 AMBULATORY EEG MONITORING 6.51 1.00
95951 EEG MONITORING/VIDEORECORD 8.27 1.00

95953 EEG MONITORING/COMPUTER 11.06 1.00
95956 EEG MONITORING, CABLE/RADIO 17.78 1.00
95957 EEG DIGITAL ANALYSIS 4.71 1.00
95961 ELECTRODE STIMULATION, BRAIN 5.86 1.00
95962 ELECTRODE STIM, BRAIN ADD-ON 5.89 1.00

95965 MEG, SPONTANEOUS 11.31 1.00
95966 MEG, EVOKED, SINGLE 5.62 1.00
95967 MEG, EVOKED, EACH ADDÏL 4.81 1.00

95970 ANALYZE NEUROSTIM, NO PROG 0.61 1.00
95971 ANALYZE NEUROSTIM, SIMPLE 1.07 1.00

95972 ANALYZE NEUROSTIM, COMPLEX 2.11 1.00
95974 CRANIAL NEUROSTIM, COMPLEX 4.10 1.00
95978 ANALYZE NEUROSTIM BRAIN/1H 4.81 1.00
95979 ANALYZ NEUROSTIM BRAIN ADDON 2.26 1.00

95980 IO ANAL GAST N-STIM INIT 1.12 1.00
95981 IO ANAL GAST N-STIM SUBSQ 0.44 1.00
95982 IO GA N-STIM SUBSQ W/REPROG 0.90 1.00
95990 SPIN/BRAIN PUMP REFIL & MAIN 1.54 1.00
95992 CANALITH REPOSITIONING PROC 1.02 1.00
97001 PT EVALUATION 1.71 1.00
97001 PT EVALUATION 1.94 1.00
97002 PT RE-EVALUATION 0.86 1.00

97002 PT RE-EVALUATION 1.04 1.00
97003 OT EVALUATION 1.66 1.00
97003 OT EVALUATION 2.06 1.00
97004 OT RE-EVALUATION 0.82 1.00
97004 OT RE-EVALUATION 1.19 1.00
97010 HOT OR COLD PACKS THERAPY 0.12 1.00
97010 HOT OR COLD PACKS THERAPY 0.13 1.00
97012 MECHANICAL TRACTION THERAPY 0.40 1.00
97014 ELECTRIC STIMULATION THERAPY 0.37 1.00
97014 ELECTRIC STIMULATION THERAPY 0.38 1.00

97016 VASOPNEUMATIC DEVICE THERAPY 0.38 1.00
97016 VASOPNEUMATIC DEVICE THERAPY 0.42 1.00
97018 PARAFFIN BATH THERAPY 0.18 1.00
97018 PARAFFIN BATH THERAPY 0.22 1.00
97020 MICROWAVE THERAPY 0.13 1.00
97022 WHIRLPOOL THERAPY 0.40 1.00
97022 WHIRLPOOL THERAPY 0.48 1.00
97024 DIATHERMY EG, MICROWAVE 0.13 1.00
97026 INFRARED THERAPY 0.13 1.00
97026 INFRARED THERAPY 0.14 1.00
97028 ULTRAVIOLET THERAPY 0.16 1.00

97028 ULTRAVIOLET THERAPY 0.17 1.00
97032 ELECTRICAL STIMULATION 0.42 1.00
97033 ELECTRIC CURRENT THERAPY 0.55 1.00
97034 CONTRAST BATH THERAPY 0.38 1.00
97034 CONTRAST BATH THERAPY 0.41 1.00
97035 ULTRASOUND THERAPY 0.32 1.00
97035 ULTRASOUND THERAPY 0.33 1.00
97036 HYDROTHERAPY 0.62 1.00

97036 HYDROTHERAPY 0.70 1.00
97039 PHYSICAL THERAPY TREATMENT 0.31 1.00
97039 PHYSICAL THERAPY TREATMENT 0.32 1.00
97110 THERAPEUTIC EXERCISES 0.76 1.00
97112 NEUROMUSCULAR REEDUCATION 0.77 1.00
97113 AQUATIC THERAPY/EXERCISES 0.81 1.00

97116 GAIT TRAINING THERAPY 0.66 1.00
97124 MASSAGE THERAPY 0.59 1.00
97139 PHYSICAL MEDICINE PROCEDURE 0.42 1.00
97139 PHYSICAL MEDICINE PROCEDURE 0.43 1.00
97140 MANUAL THERAPY 0.71 1.00
97140 MANUAL THERAPY 0.72 1.00
97150 GROUP THERAPEUTIC PROCEDURES 0.47 1.00

97504 ORTHOTIC TRAINING 0.77 1.00
97520 PROSTHETIC TRAINING 0.74 1.00
97530 THERAPEUTIC ACTIVITIES 0.77 1.00
97532 COGNITIVE SKILLS DEVELOPMENT 0.65 1.00

97533 SENSORY INTEGRATION 0.69 1.00
97533 SENSORY INTEGRATION 0.72 1.00
97535 SELF CARE MNGMENT TRAINING 0.80 1.00
97535 SELF CARE MNGMENT TRAINING 0.82 1.00
97537 COMMUNITY/WORK REINTEGRATION 0.73 1.00
97537 COMMUNITY/WORK REINTEGRATION 0.74 1.00
97542 WHEELCHAIR MNGMENT TRAINING 0.74 1.00

97542 WHEELCHAIR MNGMENT TRAINING 0.75 1.00
97597 ACTIVE WOUND CARE/20 CM OR < 0.89 1.00
97598 ACTIVE WOUND CARE > 20 CM 1.18 1.00
97601 WOUND(S) CARE, SELECTIVE 1.04 1.00
97601 WOUND(S) CARE, SELECTIVE 1.07 1.00
97605 NEG PRESS WOUND TX, < 50 CM 0.72 1.00
97606 NEG PRESS WOUND TX, > 50 CM 0.79 1.00
97703 PROSTHETIC CHECKOUT 0.60 1.00
97703 PROSTHETIC CHECKOUT 0.68 1.00
97750 PHYSICAL PERFORMANCE TEST 0.77 1.00
97755 ASSISTIVE TECHNOLOGY ASSESS 0.92 1.00

97755 ASSISTIVE TECHNOLOGY ASSESS 0.93 1.00
97760 ORTHOTIC MGMT AND TRAINING 0.89 1.00
97762 C/O FOR ORTHOTIC/PROSTH USE 0.92 1.00
99288 DIRECT ADVANCED LIFE SUPPORT 999.99 1.00
99291 CRITICAL CARE, FIRST HOUR 5.44 1.00
99292 CRITICAL CARE, ADDÏL 30 MIN 2.72 1.00
99293 PED CRITICAL CARE, INITIAL 21.37 1.00
99293 PED CRITICAL CARE, INITIAL 21.78 1.00
99294 PED CRITICAL CARE, SUBSEQ 10.47 1.00
99294 PED CRITICAL CARE, SUBSEQ 10.76 1.00
99295 NEONATE CRIT CARE, INITIAL 24.59 1.00

99296 NEONATE CRITICAL CARE SUBSEQ 10.61 1.00
99298 IC FOR LBW INFANT < 1500 GM 3.72 1.00
99299 IC, LBW INFANT 1500-2500 GM 3.38 1.00
99299 IC, LBW INFANT 1500-2500 GM 3.57 1.00

99300 IC, INFANT PBW 2501-5000 GM 3.32 1.00
99301 NURSING FACILITY CARE 1.65 1.00
99311 NURSING FAC CARE, SUBSEQ 0.82 1.00

99341 HOME VISIT, NEW PATIENT 1.55 1.00

99347 HOME VISIT, EST PATIENT 1.19 1.00
99354 PROLONGED SERVICE, OFFICE 2.44 1.00

99356 PROLONGED SERVICE, INPATIENT 2.37 1.00
99360 PHYSICIAN STANDBY SERVICES 2.44 1.00
99360 PHYSICIAN STANDBY SERVICES 2.50 1.00
99381 INIT PM E/M, NEW PAT, INF 1.69 1.00
99382 INIT PM E/M, NEW PAT 1-4 YRS 1.93 1.00
99383 PREV VISIT, NEW, AGE 5-11 1.93 1.00

99387 INIT PM E/M, NEW PAT 65+ YRS 2.92 1.00
99391 PER PM REEVAL, EST PAT, INF 1.45 1.00
99392 PREV VISIT, EST, AGE 1-4 1.69 1.00
99397 PER PM REEVAL EST PAT 65+ YR 2.43 1.00
99431 INITIAL CARE, NORMAL NEWBORN 1.54 1.00
99431 INITIAL CARE, NORMAL NEWBORN 1.60 1.00
99432 NEWBORN CARE, NOT IN HOSP 1.67 1.00

99432 NEWBORN CARE, NOT IN HOSP 1.73 1.00
99433 NORMAL NEWBORN CARE/HOSPITAL 0.83 1.00
99433 NORMAL NEWBORN CARE/HOSPITAL 0.84 1.00
99435 NEWBORN DISCHARGE DAY HOSP 2.10 1.00
99436 ATTENDANCE, BIRTH 1.96 1.00
99440 NEWBORN RESUSCITATION 3.85 1.00
G0030 PET IMAGING PREV PET SINGLE 8.87 1.00

G0031 PET IMAGING PREV PET MULTPLE 14.30 1.00
G0032 PET FOLLOW SPECT 78464 SINGL 8.87 1.00
G0033 PET FOLLOW SPECT 78464 MULT 14.30 1.00

G0036 PET FOLLOW CORNRY ANGIO SING 8.87 1.00
G0037 PET FOLLOW CORNRY ANGIO MULT 14.30 1.00
G0038 PET FOLLOW MYOCARD PERF SING 8.87 1.00

G0039 PET FOLLOW MYOCARD PERF MULT 14.30 1.00
G0040 PET FOLLOW STRESS ECHO SINGL 8.87 1.00
G0041 PET FOLLOW STRESS ECHO MULT 14.30 1.00
G0042 PET FOLLOW VENTRICULOGM SING 8.87 1.00

G0043 PET FOLLOW VENTRICULOGM MULT 14.30 1.00
G0044 PET FOLLOWING REST ECG SINGL 8.87 1.00
G0045 PET FOLLOWING REST ECG MULT 14.30 1.00
G0046 PET FOLLOW STRESS ECG SINGL 8.87 1.00

G0047 PET FOLLOW STRESS ECG MULT 14.30 1.00
G0210 PET IMG WHOLEBODY DXLUNG 5.64 1.00
G0211 PET IMG WHOLBODY INIT LUNG 5.64 1.00
G0212 PET IMG WHOLEBOD RESTAG LUNG 5.64 1.00

G0213 PET IMG WHOLBODY DX 5.64 1.00
G0214 PET IMG WHOLEBOD INIT 5.64 1.00
G0215 PETIMG WHOLEBOD RESTAG 5.64 1.00

G0216 PET IMG WHOLEBOD DX MELANOMA 5.64 1.00
G0217 PET IMG WHOLEBOD INIT MELAN 5.64 1.00
G0218 PET IMG WHOLEBOD RESTAG MELA 5.64 1.00
G0220 PET IMG WHOLEBOD DX LYMPHOMA 5.64 1.00
G0221 PET IMAG WHOLBOD INIT LYMPHO 5.64 1.00

G0222 PET IMAG WHOLBOD RESTA LYMPH 5.64 1.00
G0223 PET IMAG WHOLBOD REG DX HEAD 5.64 1.00
G0224 PET IMAG WHOLBOD REG INI HEA 5.64 1.00
G0225 PET WHOL RESTAG HEADNECKONLY 5.64 1.00

G0226 PET IMG WHOLBODY DX ESOPHAGL 5.64 1.00
G0227 PET IMG WHOLBOD INI ESOPHAGE 5.64 1.00
G0228 PET IMG WHOLBOD RESTG ESOPHA 5.64 1.00

G0229 PET IMG METABOLOC BRAIN PRES 5.64 1.00
G0230 PET MYOCARD VIABILITY POST 5.64 1.00
G0231 PET WHBD COLOREC; GAMMA CAM 5.64 1.00
G0232 PET WHBD LYMPHOMA; GAMMA CAM 5.64 1.00

G0233 PET WHBD MELANOMA; GAMMA CAM 5.64 1.00
G0234 PET WHBD PULM NOD; GAMMA CAM 5.64 1.00
G0253 PET IMAGE BRST DECTION RECUR 14.45 1.00
G0253 PET IMAGE BRST DECTION RECUR 14.49 1.00
G0254 PET IMAGE BRST EVAL TO TX 14.45 1.00
G0254 PET IMAGE BRST EVAL TO TX 14.49 1.00
G0296 PET IMGE RESTAG THYROD CANCE 14.45 1.00
G0296 PET IMGE RESTAG THYROD CANCE 14.49 1.00

V2101 SINGLE VISN SPHERE 4.12-7.00 1.00 16.05

2009 Fee Schedule

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Fee Schedule 2009

Procedure Code Pricing Action Code Description Maximum Allowable

0001F 9 HEART FAILURE COMPOSITE $0.00

0001T O ENDOVAS REPR ABDO AO ANEURYS $0.00

0002F O TOBACCO USE, SMOKING, ASSESS $0.00

0002T 9 ENDOVAS REPR ABDO AO ANEURYS $0.00

0003F O TOBACCO USE, NON-SMOKING $0.00

0003T O CERVICOGRAPHY $0.00

0004F O TOBACCO USE TXMNT COUNSELING $0.00

0005F 9 OSTEOARTHRITIS COMPOSITE $0.00

0005T O PERC CATH STENT/BRAIN CV ART $0.00

0006F O STATIN THERAPY, PRESCRIBED $0.00

0007F O BETA-BLOCKER THX PRESCRIBED $0.00

0007T O PERC CATH STENT/BRAIN CV ART $0.00

0008F O ACE INHIBITOR THX PRESCRIBED $0.00

0008T O UPPER GI ENDOSCOPY W/SUTURE $0.00

0009F O ASSESS ANGINAL SYMPTOM/LEVEL $0.00

0009T O ENDOMETRIAL CRYOABLATION $0.00

00100 A ANESTH, SALIVARY GLAND $0.00

00102 A ANESTH, REPAIR OF CLEFT LIP $0.00

00103 A ANESTH, BLEPHAROPLASTY $0.00

0010F O ASSESS ANGINAL SYMPTOM/LEVEL $0.00

0010T O TB TEST, GAMMA INTERFERON $0.00

0011F O ORAL ANTIPLAT THX PRESCRIBED $0.00

00120 A ANESTH, EAR SURGERY $0.00

00124 A ANESTH, EAR EXAM $0.00

00126 A ANESTH, TYMPANOTOMY $0.00

0012F 9 CAP BACTERIAL ASSESS $0.00

0012T O OSTEOCHONDRAL KNEE AUTOGRAFT $0.00

0013T O OSTEOCHONDRAL KNEE ALLOGRAFT $0.00

00140 A ANESTH, PROCEDURES ON EYE $0.00

00142 A ANESTH, LENS SURGERY $0.00

00144 A ANESTH, CORNEAL TRANSPLANT $0.00

00145 A ANESTH, VITREORETINAL SURG $0.00

00147 A ANESTH, IRIDECTOMY $0.00

00148 A ANESTH, EYE EXAM $0.00

0014F 9 COMP PREOP ASSESS CAT SURG $0.00

0014T O MENISCAL TRANSPLANTATION, MEDIAL OR $0.00

0015F 9 MELAN FOLLOW-UP COMPLETE $0.00

00160 A ANESTH, NOSE/SINUS SURGERY $0.00

00162 A ANESTH, NOSE/SINUS SURGERY $0.00

00164 A ANESTH, BIOPSY OF NOSE $0.00

0016T 9 THERMOTX CHOROID VASC LESION $0.00

00170 A ANESTH, PROCEDURE ON MOUTH $0.00

00172 A ANESTH, CLEFT PALATE REPAIR $0.00

00176 A ANESTH, PHARYNGEAL SURGERY $0.00

0017T 9 PHOTOCOAGULAT MACULAR DRUSEN $0.00

0018T O TRANSCRANIAL MAGNETIC STIMUL $0.00

00190 A ANESTH, FACE/SKULL BONE SURG $0.00

00192 A ANESTH, FACIAL BONE SURGERY $0.00

0019T 9 EXTRACORP SHOCK WAVE, MS, NOS $0.00

0020T O EXTRACORP SHOCK WAVE TX, FT $0.00

00210 A ANESTH, CRANIAL SURG NOS $0.00

00211 A ANESTH, CRAN SURG, HEMOTOMA $0.00

00214 A ANESTH, SKULL DRAINAGE $0.00

00215 A ANESTH, SKULL REPAIR/FRACT $0.00

00216 A ANESTH, HEAD VESSEL SURGERY $0.00

00218 A ANESTH, SPECIAL HEAD SURGERY $0.00

0021T O FETAL OXIMETRY, TRNSVAG/CERV $0.00

00220 A ANESTH, INTRCRN NERVE $0.00

00222 A ANESTH, HEAD NERVE SURGERY $0.00

0023T O PHENOTYPE DRUG TEST, HIV 1 $0.00