Health Services Authority Charge Master

Gazette No. 60 dated 15 August, 2014.

CAYMAN ISLANDS HEALTH SERVICES AUTHORITY CHARGE MASTER

Row # CPT-4 HCPCS Price 00100 Anesthesia for procedures on salivary glands, including biopsy 00102 Anesthesia for procedures involving plastic repair of cleft lip 00103 Anesthesia for reconstructive procedures of eyelid (eg, blepharoplasty, ptosis surgery) 00104 Anesthesia for electroconvulsive therapy 00120 including biopsy; not otherwise specified 00124 including biopsy; otoscopy 00126 including biopsy; tympanotomy 00140 Anesthesia for procedures on eye; not otherwise specified 00142 Anesthesia for procedures on eye; lens surgery 00144 Anesthesia for procedures on eye; corneal transplant 00145 Anesthesia for procedures on eye; vitreoretinal surgery 00147 Anesthesia for procedures on eye; iridectomy 00148 Anesthesia for procedures on eye; ophthalmoscopy 00160 Anesthesia for procedures on nose and accessory sinuses; not 00162 Anesthesia for procedures on nose and accessory sinuses; radical 00164 Anesthesia for procedures on nose and accessory sinuses; biopsy, soft tissue 00170 Anesthesia for intraoral procedures, including biopsy; not otherwise 00172 Anesthesia for intraoral procedures, including biopsy; repair of cleft palate 00174 Anesthesia for intraoral procedures, including biopsy; excision of retropharyngeal tumor 00176 Anesthesia for intraoral procedures, including biopsy; radical 00190 Anesthesia for procedures on facial bones or skull; not otherwise 00192 Anesthesia for procedures on facial bones or skull; radical surgery (including prognathism) 00210 Anesthesia for intracranial procedures; not otherwise specified 00211 Anesthesia for intracranial procedures; craniotomy or craniectomy for evacuation of hematoma 00214 Anesthesia for intracranial procedures; burr holes, including ventriculography 00215 Anesthesia for intracranial procedures; cranioplasty or elevation of depressed skull fracture, extradural (simple or compound) 00218 Anesthesia for intracranial procedures; procedures in sitting position 00300 Anesthesia for all procedures on the integumentary system, muscles and nerves of head, neck, and posterior trunk, not otherwise 00320 Anesthesia for all procedures on esophagus, thyroid, larynx, trachea and lymphatic system of neck; not otherwise specified, age 1 year or older 00322 Anesthesia for all procedures on esophagus, thyroid, larynx, trachea and lymphatic system of neck; needle biopsy of thyroid 00326 Anesthesia for all procedures on the larynx and trachea in children younger than 1 year of age 00350 Anesthesia for procedures on major vessels of neck; not otherwise 00352 Anesthesia for procedures on major vessels of neck; simple ligation 00400 extremities, anterior trunk and perineum; not otherwise specified 00402 extremities, anterior trunk and perineum; reconstructive procedures on breast (eg, reduction or augmentation mammoplasty, muscle flaps)

Row # CPT-4 HCPCS Price 00404 extremities, anterior trunk and perineum; radical or modified radical procedures on breast 00406 extremities, anterior trunk and perineum; radical or modified radical procedures on breast with internal mammary node 00410 extremities, anterior trunk and perineum; electrical conversion of arrhythmias 0042T Cerebral perfusion analysis using computed tomography with contrast administration, including post-processing of parametric maps with determination of cerebral blood flow, cerebral blood volume, and mean transit time 00450 Anesthesia for procedures on clavicle and scapula; not otherwise 00452 Anesthesia for procedures on clavicle and scapula; radical surgery 00454 Anesthesia for procedures on clavicle and scapula; biopsy of clavicle 00500 Anesthesia for all procedures on esophagus 00520 Anesthesia for closed chest procedures; (including bronchoscopy) 00524 Anesthesia for closed chest procedures; pneumocentesis 00530 Anesthesia for permanent transvenous pacemaker insertion 00532 Anesthesia for access to central venous circulation 00534 Anesthesia for transvenous insertion or replacement of pacing cardioverter-defibrillator 00540 diaphragm, and mediastinum (including surgical thoracoscopy); not 00541 utilizing 1 lung ventilation 00542 decortication 00546 pulmonary resection with thoracoplasty 00548 intrathoracic procedures on the trachea and bronchi 00550 Anesthesia for sternal debridement 00560 vessels of chest; without pump oxygenator 00561 vessels of chest; with pump oxygenator, younger than 1 year of age 00562 vessels of chest; with pump oxygenator, age 1 year or older, for all non-coronary bypass procedures (eg, valve procedures) or for re- operation for coronary bypass more than 1 month after origi 00563 vessels of chest; with pump oxygenator with hypothermic circulatory arrest 00566 Anesthesia for direct coronary artery bypass grafting; without pump oxygenator 00567 Anesthesia for direct coronary artery bypass grafting; with pump oxygenator 00580 Anesthesia for heart transplant or heart/lung transplant 00600 Anesthesia for procedures on cervical spine and cord; not otherwise $ 88.00 00604 Anesthesia for procedures on cervical spine and cord; procedures with patient in the sitting position 00620 Anesthesia for procedures on thoracic spine and cord; not

Row # CPT-4 HCPCS Price 00622 Anesthesia for procedures on thoracic spine and cord; thoracolumbar sympathectomy 00625 Anesthesia for procedures on the thoracic spine and cord, via an anterior transthoracic approach; not utilizing 1 lung ventilation 00626 Anesthesia for procedures on the thoracic spine and cord, via an anterior transthoracic approach; utilizing 1 lung ventilation 00630 Anesthesia for procedures in lumbar region; not otherwise specified $ 385.00 00632 Anesthesia for procedures in lumbar region; lumbar sympathectomy 00634 Anesthesia for procedures in lumbar region; chemonucleolysis 00635 Anesthesia for procedures in lumbar region; diagnostic or therapeutic lumbar puncture 00640 Anesthesia for manipulation of the spine or for closed procedures on the cervical, thoracic or lumbar spine 00670 Anesthesia for extensive spine and spinal cord procedures (eg, spinal instrumentation or vascular procedures) 00700 Anesthesia for procedures on upper anterior abdominal wall; not 00702 Anesthesia for procedures on upper anterior abdominal wall; percutaneous liver biopsy 00730 Anesthesia for procedures on upper posterior abdominal wall 00740 Anesthesia for upper gastrointestinal endoscopic procedures, endoscope introduced proximal to duodenum 00750 Anesthesia for hernia repairs in upper abdomen; not otherwise 00752 Anesthesia for hernia repairs in upper abdomen; lumbar and ventral (incisional) hernias and/or wound dehiscence 00754 Anesthesia for hernia repairs in upper abdomen; omphalocele 00756 Anesthesia for hernia repairs in upper abdomen; transabdominal repair of diaphragmatic hernia 00770 Anesthesia for all procedures on major abdominal blood vessels 00790 including laparoscopy; not otherwise specified 00792 including laparoscopy; partial hepatectomy or management of liver hemorrhage (excluding liver biopsy) 00794 including laparoscopy; pancreatectomy, partial or total (eg, Whipple 00796 including laparoscopy; liver transplant (recipient) 00797 including laparoscopy; gastric restrictive procedure for morbid obesity 00800 Anesthesia for procedures on lower anterior abdominal wall; not 00802 Anesthesia for procedures on lower anterior abdominal wall; panniculectomy 00810 Anesthesia for lower intestinal endoscopic procedures, endoscope introduced distal to duodenum 00820 Anesthesia for procedures on lower posterior abdominal wall 00830 Anesthesia for hernia repairs in lower abdomen; not otherwise 00832 Anesthesia for hernia repairs in lower abdomen; ventral and incisional hernias 00834 Anesthesia for hernia repairs in the lower abdomen not otherwise specified, younger than 1 year of age 00836 Anesthesia for hernia repairs in the lower abdomen not otherwise specified, infants younger than 37 weeks gestational age at birth and younger than 50 weeks gestational age at time of surgery

Row # CPT-4 HCPCS Price 00840 including laparoscopy; not otherwise specified 00842 including laparoscopy; amniocentesis 00844 including laparoscopy; abdominoperineal resection 00846 including laparoscopy; radical hysterectomy 00848 including laparoscopy; pelvic exenteration 00851 including laparoscopy; tubal ligation/transection 00860 including urinary tract; not otherwise specified 00862 including urinary tract; renal procedures, including upper one-third of ureter, or donor nephrectomy 00864 including urinary tract; total cystectomy 00865 including urinary tract; radical prostatectomy (suprapubic, retropubic) 00866 including urinary tract; adrenalectomy 00868 including urinary tract; renal transplant (recipient) 00869 urethral procedures); vasectomy, unilateral or bilateral 00870 including urinary tract; cystolithotomy 00872 Anesthesia for lithotripsy, extracorporeal shock wave; with water bath 00873 Anesthesia for lithotripsy, extracorporeal shock wave; without water bath 00880 Anesthesia for procedures on major lower abdominal vessels; not 00882 Anesthesia for procedures on major lower abdominal vessels; inferior vena cava ligation 00902 Anesthesia for; anorectal procedure 00904 Anesthesia for; radical perineal procedure 00906 Anesthesia for; vulvectomy 00908 Anesthesia for; perineal prostatectomy 00910 urethrocystoscopy); not otherwise specified 00912 urethrocystoscopy); transurethral resection of bladder tumor(s) 00914 urethrocystoscopy); transurethral resection of prostate 00916 urethrocystoscopy); post-transurethral resection bleeding 00918 urethrocystoscopy); with fragmentation, manipulation and/or removal of ureteral calculus 00920 urethral procedures); not otherwise specified 00921 urethral procedures); vasectomy, unilateral or bilateral 00922 urethral procedures); seminal vesicles 00924 urethral procedures); undescended testis, unilateral or bilateral 00926 urethral procedures); radical orchiectomy, inguinal

Row # CPT-4 HCPCS Price 00928 urethral procedures); radical orchiectomy, abdominal 00930 urethral procedures); orchiopexy, unilateral or bilateral 00932 urethral procedures); complete amputation of penis 00934 urethral procedures); radical amputation of penis with bilateral inguinal lymphadenectomy 00936 urethral procedures); radical amputation of penis with bilateral inguinal and iliac lymphadenectomy 00938 urethral procedures); insertion of penile prosthesis (perineal 00940 cervix or endometrium); not otherwise specified 00942 cervix or endometrium); colpotomy, vaginectomy, colporrhaphy, and open urethral procedures 00944 cervix or endometrium); vaginal hysterectomy 00948 cervix or endometrium); cervical cerclage 00950 cervix or endometrium); culdoscopy 00952 cervix or endometrium); hysteroscopy and/or hysterosalpingography 01112 Anesthesia for bone marrow aspiration and/or biopsy, anterior or posterior iliac crest 01120 Anesthesia for procedures on bony pelvis 01130 Anesthesia for body cast application or revision 01140 Anesthesia for interpelviabdominal (hindquarter) amputation 01150 Anesthesia for radical procedures for tumor of pelvis, except hindquarter amputation 01160 Anesthesia for closed procedures involving symphysis pubis or sacroiliac joint 01170 Anesthesia for open procedures involving symphysis pubis or sacroiliac joint 01173 Anesthesia for open repair of fracture disruption of pelvis or column fracture involving acetabulum 01180 Anesthesia for obturator neurectomy; extrapelvic 01190 Anesthesia for obturator neurectomy; intrapelvic 01200 Anesthesia for all closed procedures involving hip joint 01202 Anesthesia for arthroscopic procedures of hip joint 01210 Anesthesia for open procedures involving hip joint; not otherwise 01212 Anesthesia for open procedures involving hip joint; hip disarticulation 01214 Anesthesia for open procedures involving hip joint; total hip 01215 Anesthesia for open procedures involving hip joint; revision of total hip arthroplasty 01220 Anesthesia for all closed procedures involving upper two-thirds of femur 01230 femur; not otherwise specified 01232 femur; amputation 01234 femur; radical resection 01250 and bursae of upper leg 01260 Anesthesia for all procedures involving veins of upper leg, including exploration

Row # CPT-4 HCPCS Price 01270 bypass graft; not otherwise specified 01272 bypass graft; femoral artery ligation 01274 bypass graft; femoral artery embolectomy 01320 and bursae of knee and/or popliteal area 01340 Anesthesia for all closed procedures on lower one-third of femur 01360 Anesthesia for all open procedures on lower one-third of femur 01380 Anesthesia for all closed procedures on knee joint 01382 Anesthesia for diagnostic arthroscopic procedures of knee joint 01390 Anesthesia for all closed procedures on upper ends of tibia, fibula, and/or patella 01392 Anesthesia for all open procedures on upper ends of tibia, fibula, and/or patella 01400 joint; not otherwise specified 01402 joint; total knee arthroplasty 01404 joint; disarticulation at knee 01420 Anesthesia for all cast applications, removal, or repair involving knee joint 01430 Anesthesia for procedures on veins of knee and popliteal area; not 01432 Anesthesia for procedures on veins of knee and popliteal area; arteriovenous fistula 01440 01442 popliteal thromboendarterectomy, with or without patch graft 01444 popliteal excision and graft or repair for occlusion or aneurysm 01462 Anesthesia for all closed procedures on lower leg, ankle, and foot 01464 Anesthesia for arthroscopic procedures of ankle and/or foot 01470 of lower leg, ankle, and foot; not otherwise specified 01472 of lower leg, ankle, and foot; repair of ruptured Achilles tendon, with or without graft 01474 of lower leg, ankle, and foot; gastrocnemius recession (eg, Strayer 01480 foot; not otherwise specified 01482 foot; radical resection (including below knee amputation) 01484 foot; osteotomy or osteoplasty of tibia and/or fibula 01486 foot; total ankle replacement 01490 Anesthesia for lower leg cast application, removal, or repair 01500 Anesthesia for procedures on arteries of lower leg, including bypass graft; not otherwise specified 01502 Anesthesia for procedures on arteries of lower leg, including bypass graft; embolectomy, direct or with catheter 01520 Anesthesia for procedures on veins of lower leg; not otherwise

Row # CPT-4 HCPCS Price 01522 Anesthesia for procedures on veins of lower leg; venous thrombectomy, direct or with catheter 01610 and bursae of shoulder and axilla 01620 Anesthesia for all closed procedures on humeral head and neck, sternoclavicular joint, acromioclavicular joint, and shoulder joint 01622 Anesthesia for diagnostic arthroscopic procedures of shoulder joint 01630 shoulder joint; not otherwise specified 01634 shoulder joint; shoulder disarticulation 01636 shoulder joint; interthoracoscapular (forequarter) amputation 01638 shoulder joint; total shoulder replacement 01650 Anesthesia for procedures on arteries of shoulder and axilla; not 01652 Anesthesia for procedures on arteries of shoulder and axilla; axillary- brachial aneurysm 01654 Anesthesia for procedures on arteries of shoulder and axilla; bypass graft 01656 Anesthesia for procedures on arteries of shoulder and axilla; axillary- femoral bypass graft 01670 Anesthesia for all procedures on veins of shoulder and axilla 01680 Anesthesia for shoulder cast application, removal or repair; not 01682 Anesthesia for shoulder cast application, removal or repair; shoulder spica 01710 bursae of upper arm and elbow; not otherwise specified 01712 bursae of upper arm and elbow; tenotomy, elbow to shoulder, open $ 273.00 01714 bursae of upper arm and elbow; tenoplasty, elbow to shoulder 01716 bursae of upper arm and elbow; tenodesis, rupture of long tendon of biceps 01730 Anesthesia for all closed procedures on humerus and elbow 01732 Anesthesia for diagnostic arthroscopic procedures of elbow joint 01740 elbow; not otherwise specified 01742 elbow; osteotomy of humerus 01744 elbow; repair of nonunion or malunion of humerus 01756 elbow; radical procedures 01758 elbow; excision of cyst or tumor of humerus 01760 elbow; total elbow replacement 01770 Anesthesia for procedures on arteries of upper arm and elbow; not 01772 Anesthesia for procedures on arteries of upper arm and elbow; embolectomy

Row # CPT-4 HCPCS Price 01780 Anesthesia for procedures on veins of upper arm and elbow; not 01782 Anesthesia for procedures on veins of upper arm and elbow; phleborrhaphy 01810 and bursae of forearm, wrist, and hand 01820 Anesthesia for all closed procedures on radius, ulna, wrist, or hand bones 01829 Anesthesia for diagnostic arthroscopic procedures on the wrist 01830 Anesthesia for open or surgical arthroscopic/endoscopic procedures on distal radius, distal ulna, wrist, or hand joints; not otherwise 01832 Anesthesia for open or surgical arthroscopic/endoscopic procedures on distal radius, distal ulna, wrist, or hand joints; total wrist 01840 Anesthesia for procedures on arteries of forearm, wrist, and hand; 01842 Anesthesia for procedures on arteries of forearm, wrist, and hand; embolectomy 01844 Anesthesia for vascular shunt, or shunt revision, any type (eg, dialysis) 01850 Anesthesia for procedures on veins of forearm, wrist, and hand; not 01852 Anesthesia for procedures on veins of forearm, wrist, and hand; phleborrhaphy 01860 Anesthesia for forearm, wrist, or hand cast application, removal, or 01916 Anesthesia for diagnostic arteriography/venography 01920 Anesthesia for cardiac catheterization including coronary angiography and ventriculography (not to include Swan-Ganz 01922 Anesthesia for non-invasive imaging or radiation therapy 01924 involving the arterial system; not otherwise specified 01925 involving the arterial system; carotid or coronary 01926 involving the arterial system; intracranial, intracardiac, or aortic 01930 central circulation); not otherwise specified 01931 central circulation); intrahepatic or portal circulation (eg, transvenous intrahepatic portosystemic shunt[s] [TIPS]) 01932 central circulation); intrathoracic or jugular 01933 central circulation); intracranial 01935 Anesthesia for percutaneous image guided procedures on the spine and spinal cord; diagnostic 01936 Anesthesia for percutaneous image guided procedures on the spine and spinal cord; therapeutic 01951 surface area (TBSA) treated during anesthesia and surgery; less than 4% total body surface area 01952 surface area (TBSA) treated during anesthesia and surgery; between 4% and 9% of total body surface area

Row # CPT-4 HCPCS Price 01953 surface area (TBSA) treated during anesthesia and surgery; each additional 9% total body surface area or part thereof (List separa 01958 Anesthesia for external cephalic version procedure 01960 Anesthesia for vaginal delivery only 01961 Anesthesia for cesarean delivery only $ 214.50 01962 Anesthesia for urgent hysterectomy following delivery 01963 Anesthesia for cesarean hysterectomy without any labor analgesia/anesthesia care 01965 Anesthesia for incomplete or missed abortion procedures 01966 Anesthesia for induced abortion procedures 01967 Neuraxial labor analgesia/anesthesia for planned vaginal delivery (this includes any repeat subarachnoid needle placement and drug injection and/or any necessary replacement of an epidural catheter during labor) 01968 Anesthesia for cesarean delivery following neuraxial labor analgesia/anesthesia (List separately in addition to code for primary procedure performed) 01969 Anesthesia for cesarean hysterectomy following neuraxial labor analgesia/anesthesia (List separately in addition to code for primary procedure performed) 01990 Physiological support for harvesting of organ(s) from brain-dead patient 01991 Anesthesia for diagnostic or therapeutic nerve blocks and injections (when block or injection is performed by a different physician or other qualified health care professional); other than the prone position 01992 Anesthesia for diagnostic or therapeutic nerve blocks and injections (when block or injection is performed by a different physician or other qualified health care professional); prone position 01996 Daily hospital management of epidural or subarachnoid continuous drug administration $ 88.00 01999 Unlisted anesthesia procedure(s) 0234T including radiological supervision and interpretation; renal artery 0235T including radiological supervision and interpretation; visceral artery (except renal), each vessel $ 2,580.30 0237T including radiological supervision and interpretation; brachiocephalic trunk and branches, each vessel 0238T including radiological supervision and interpretation; iliac artery, each vessel 10021 Fine needle aspiration; without imaging guidance $ 196.46 10022 Fine needle aspiration; with imaging guidance $ 215.09 10040 Acne surgery (eg, marsupialization, opening or removal of multiple milia, comedones, cysts, pustules) 10060 Incision and drainage of abscess (eg, carbuncle, suppurative hidradenitis, cutaneous or subcutaneous abscess, cyst, furuncle, or paronychia); simple or single $ 134.44 10061 Incision and drainage of abscess (eg, carbuncle, suppurative hidradenitis, cutaneous or subcutaneous abscess, cyst, furuncle, or paronychia); complicated or multiple $ 358.05 10080 Incision and drainage of pilonidal cyst; simple 10081 Incision and drainage of pilonidal cyst; complicated $ 450.90 10120 Incision and removal of foreign body, subcutaneous tissues; simple $ 149.67 10121 Incision and removal of foreign body, subcutaneous tissues; $ 413.45 10140 Incision and drainage of hematoma, seroma or fluid collection $ 183.32 10160 Puncture aspiration of abscess, hematoma, bulla, or cyst $ 125.34 10180 Incision and drainage, complex, postoperative wound infection $ 560.32

Row # CPT-4 HCPCS Price 11004 necrotizing soft tissue infection; external genitalia and perineum $ 756.94 11005 necrotizing soft tissue infection; abdominal wall, with or without fascial closure $ 1,068.79 11006 necrotizing soft tissue infection; external genitalia, perineum and abdominal wall, with or without fascial closure $ 973.26 11008 Removal of prosthetic material or mesh, abdominal wall for infection (eg, for chronic or recurrent mesh infection or necrotizing soft tissue infection) (List separately in addition to code for primary $ 437.12 11044 Debridement, bone (includes epidermis, dermis, subcutaneous tissue, muscle and/or fascia, if performed); first 20 sq cm or less $ 846.90 11100 Biopsy of skin, subcutaneous tissue and/or mucous membrane (including simple closure), unless otherwise listed; single lesion $ 134.31 11101 Biopsy of skin, subcutaneous tissue and/or mucous membrane (including simple closure), unless otherwise listed; each separate/additional lesion (List separately in addition to code for $ 77.57 11200 Removal of skin tags, multiple fibrocutaneous tags, any area; up to and including 15 lesions $ 130.55 11201 Removal of skin tags, multiple fibrocutaneous tags, any area; each additional 10 lesions, or part thereof (List separately in addition to $ 94.70 11300 legs; lesion diameter 0.5 cm or less $ 113.80 11301 legs; lesion diameter 0.6 to 1.0 cm $ 142.45 11302 legs; lesion diameter 1.1 to 2.0 cm $ 178.74 11303 legs; lesion diameter over 2.0 cm $ 289.80 11305 hands, feet, genitalia; lesion diameter 0.5 cm or less $ 125.15 11306 hands, feet, genitalia; lesion diameter 0.6 to 1.0 cm $ 166.40 11307 hands, feet, genitalia; lesion diameter 1.1 to 2.0 cm 11308 hands, feet, genitalia; lesion diameter over 2.0 cm $ 261.50 11310 eyelids, nose, lips, mucous membrane; lesion diameter 0.5 cm or less $ 141.10 11311 eyelids, nose, lips, mucous membrane; lesion diameter 0.6 to 1.0 cm $ 216.00 11312 eyelids, nose, lips, mucous membrane; lesion diameter 1.1 to 2.0 cm $ 252.00 11313 eyelids, nose, lips, mucous membrane; lesion diameter over 2.0 cm $ 283.29 11400 listed elsewhere), trunk, arms or legs; excised diameter 0.5 cm or less $ 151.78 11402 listed elsewhere), trunk, arms or legs; excised diameter 1.1 to 2.0 cm $ 304.20 11403 listed elsewhere), trunk, arms or legs; excised diameter 2.1 to 3.0 cm $ 323.56 11404 listed elsewhere), trunk, arms or legs; excised diameter 3.1 to 4.0 cm $ 435.46

Row # CPT-4 HCPCS Price 11441 Excision, other benign lesion including margins, except skin tag (unless listed elsewhere), face, ears, eyelids, nose, lips, mucous membrane; excised diameter 0.6 to 1.0 cm $ 262.16 11442 Excision, other benign lesion including margins, except skin tag (unless listed elsewhere), face, ears, eyelids, nose, lips, mucous membrane; excised diameter 1.1 to 2.0 cm $ 345.79 11604 Excision, malignant lesion including margins, trunk, arms, or legs; excised diameter 3.1 to 4.0 cm $ 582.43 11606 Excision, malignant lesion including margins, trunk, arms, or legs; excised diameter over 4.0 cm $ 780.74 11623 feet, genitalia; excised diameter 2.1 to 3.0 cm $ 568.31 11624 feet, genitalia; excised diameter 3.1 to 4.0 cm 11626 feet, genitalia; excised diameter over 4.0 cm $ 990.00 11719 Trimming of nondystrophic nails, any number $ 39.46 11720 Debridement of nail(s) by any method(s); 1 to 5 $ 87.30 11721 Debridement of nail(s) by any method(s); 6 or more 11740 Evacuation of subungual hematoma $ 117.00 11750 Excision of nail and nail matrix, partial or complete (eg, ingrown or deformed nail), for permanent removal; $ 341.38 11765 Wedge excision of skin of nail fold (eg, for ingrown toenail) $ 226.39 11900 Injection, intralesional; up to and including 7 lesions $ 68.38 11901 Injection, intralesional; more than 7 lesions $ 103.02 11950 Subcutaneous injection of filling material (eg, collagen); 1 cc or less $ 348.30 11951 Subcutaneous injection of filling material (eg, collagen); 1.1 to 5.0 cc $ 549.90 11952 Subcutaneous injection of filling material (eg, collagen); 5.1 to 10.0 cc $ 899.10 11954 Subcutaneous injection of filling material (eg, collagen); over 10.0 cc 11976 Removal, implantable contraceptive capsules 11980 Subcutaneous hormone pellet implantation (implantation of estradiol and/or testosterone pellets beneath the skin) $ 430.20 11981 Insertion, non-biodegradable drug delivery implant 11982 Removal, non-biodegradable drug delivery implant $ 165.40 11983 Removal with reinsertion, non-biodegradable drug delivery implant $ 193.58 12001 genitalia, trunk and/or extremities (including hands and feet); 2.5 cm or less $ 179.15 12002 genitalia, trunk and/or extremities (including hands and feet); 2.6 cm to 7.5 cm $ 230.42 12004 genitalia, trunk and/or extremities (including hands and feet); 7.6 cm to 12.5 cm $ 327.60 12005 genitalia, trunk and/or extremities (including hands and feet); 12.6 cm to 20.0 cm $ 421.20 12006 genitalia, trunk and/or extremities (including hands and feet); 20.1 cm to 30.0 cm $ 487.80 12007 genitalia, trunk and/or extremities (including hands and feet); over 30.0 cm $ 675.90 12011 and/or mucous membranes; 2.5 cm or less $ 222.77 12013 and/or mucous membranes; 2.6 cm to 5.0 cm $ 288.43 12014 and/or mucous membranes; 5.1 cm to 7.5 cm $ 363.06 12015 and/or mucous membranes; 7.6 cm to 12.5 cm $ 477.90 12016 and/or mucous membranes; 12.6 cm to 20.0 cm $ 629.10 12017 and/or mucous membranes; 20.1 cm to 30.0 cm

Row # CPT-4 HCPCS Price 12018 and/or mucous membranes; over 30.0 cm $ 1,124.10 12020 Treatment of superficial wound dehiscence; simple closure $ 388.79 12031 extremities (excluding hands and feet); 2.5 cm or less $ 255.60 12032 extremities (excluding hands and feet); 2.6 cm to 7.5 cm 12034 extremities (excluding hands and feet); 7.6 cm to 12.5 cm $ 423.00 12035 extremities (excluding hands and feet); 12.6 cm to 20.0 cm $ 555.30 12036 extremities (excluding hands and feet); 20.1 cm to 30.0 cm $ 719.10 12037 extremities (excluding hands and feet); over 30.0 cm 12041 genitalia; 2.5 cm or less $ 291.60 12042 genitalia; 2.6 cm to 7.5 cm $ 352.09 12044 genitalia; 7.6 cm to 12.5 cm 12045 genitalia; 12.6 cm to 20.0 cm 12046 genitalia; 20.1 cm to 30.0 cm $ 812.70 12047 genitalia; over 30.0 cm $ 963.00 12051 and/or mucous membranes; 2.5 cm or less $ 350.10 12052 and/or mucous membranes; 2.6 cm to 5.0 cm $ 470.70 12053 and/or mucous membranes; 5.1 cm to 7.5 cm $ 549.00 12054 and/or mucous membranes; 7.6 cm to 12.5 cm $ 704.70 12055 and/or mucous membranes; 12.6 cm to 20.0 cm $ 942.30 12056 and/or mucous membranes; 20.1 cm to 30.0 cm 12057 and/or mucous membranes; over 30.0 cm $ 1,338.30 13160 Secondary closure of surgical wound or dehiscence, extensive or $ 1,059.69 14000 Adjacent tissue transfer or rearrangement, trunk; defect 10 sq cm $ 1,088.10 14301 Adjacent tissue transfer or rearrangement, any area; defect 30.1 sq cm to 60.0 sq cm $ 2,113.30 14302 Adjacent tissue transfer or rearrangement, any area; each additional 30.0 sq cm, or part thereof (list separately in addition to $ 480.88 15005 Surgical preparation or creation of recipient site by excision of open wounds, burn eschar, or scar (including subcutaneous tissues), or incisional release of scar contracture, face, scalp, eyelids, mouth, neck, ears, orbits, genitalia, hands, feet and/or $ 265.38 15040 Harvest of skin for tissue cultured skin autograft, 100 sq cm or less $ 563.25 15110 Epidermal autograft, trunk, arms, legs; first 100 sq cm or less, or 1% of body area of infants and children $ 1,887.78 15111 Epidermal autograft, trunk, arms, legs; each additional 100 sq cm, or each additional 1% of body area of infants and children, or part thereof (List separately in addition to code for primary procedure) $ 294.39 15116 Epidermal autograft, face, scalp, eyelids, mouth, neck, ears, orbits, genitalia, hands, feet, and/or multiple digits; each additional 100 sq cm, or each additional 1% of body area of infants and children, or part thereof (List separately in addition to co $ 402.77 15130 Dermal autograft, trunk, arms, legs; first 100 sq cm or less, or 1% of body area of infants and children $ 1,469.33

Row # CPT-4 HCPCS Price 15131 Dermal autograft, trunk, arms, legs; each additional 100 sq cm, or each additional 1% of body area of infants and children, or part thereof (List separately in addition to code for primary procedure) $ 246.06 15135 Dermal autograft, face, scalp, eyelids, mouth, neck, ears, orbits, genitalia, hands, feet, and/or multiple digits; first 100 sq cm or less, or 1% of body area of infants and children $ 1,861.86 15136 Dermal autograft, face, scalp, eyelids, mouth, neck, ears, orbits, genitalia, hands, feet, and/or multiple digits; each additional 100 sq cm, or each additional 1% of body area of infants and children, or part thereof (List separately in addition to code $ 227.31 15150 Tissue cultured skin autograft, trunk, arms, legs; first 25 sq cm or less $ 1,481.15 15151 Tissue cultured skin autograft, trunk, arms, legs; additional 1 sq cm to 75 sq cm (List separately in addition to code for primary $ 297.75 15155 ears, orbits, genitalia, hands, feet, and/or multiple digits; first 25 sq cm or less $ 1,472.04 15156 ears, orbits, genitalia, hands, feet, and/or multiple digits; additional 1 sq cm to 75 sq cm (List separately in addition to code for primary $ 424.98 15157 ears, orbits, genitalia, hands, feet, and/or multiple digits; each additional 100 sq cm, or each additional 1% of body area of infants and children, or part thereof (List separately in add $ 481.51 15200 Full thickness graft, free, including direct closure of donor site, trunk; 20 sq cm or less $ 1,299.60 15738 Muscle, myocutaneous, or fasciocutaneous flap; lower extremity $ 5,279.40 15780 Dermabrasion; total face (eg, for acne scarring, fine wrinkling, rhytids, general keratosis) $ 2,763.90 15781 Dermabrasion; segmental, face 15782 Dermabrasion; regional, other than face 15783 Dermabrasion; superficial, any site (eg, tattoo removal) 15786 Abrasion; single lesion (eg, keratosis, scar) 15787 Abrasion; each additional 4 lesions or less (List separately in $ 207.90 15788 Chemical peel, facial; epidermal 15789 Chemical peel, facial; dermal $ 1,901.70 15792 Chemical peel, nonfacial; epidermal $ 544.50 15793 Chemical peel, nonfacial; dermal 15820 Blepharoplasty, lower eyelid; $ 2,253.60 15822 Blepharoplasty, upper eyelid; $ 2,542.50 15830 Excision, excessive skin and subcutaneous tissue (includes lipectomy); abdomen, infraumbilical panniculectomy $ 1,777.49 15847 Excision, excessive skin and subcutaneous tissue (includes lipectomy), abdomen (eg, abdominoplasty) (includes umbilical transposition and fascial plication) (List separately in addition to $ 715.00 15851 Removal of sutures under anesthesia (other than local), other surgeon $ 259.49 15852 Dressing change (for other than burns) under anesthesia (other than local) 15877 Suction assisted lipectomy; trunk 15878 Suction assisted lipectomy; upper extremity 15879 Suction assisted lipectomy; lower extremity $ 2,292.30 15999 Unlisted procedure, excision pressure ulcer Cost 16000 Initial treatment, first degree burn, when no more than local treatment is required 16020 subsequent; small (less than 5% total body surface area) $ 115.89 16025 subsequent; medium (eg, whole face or whole extremity, or 5% to 10% total body surface area) $ 217.86

Row # CPT-4 HCPCS Price 16030 subsequent; large (eg, more than 1 extremity, or greater than 10% total body surface area) $ 363.34 17000 actinic keratoses); first lesion $ 97.34 17003 actinic keratoses); second through 14 lesions, each (List separately in addition to code for first lesion) $ 37.26 17004 actinic keratoses), 15 or more lesions $ 540.00 17110 chemosurgery, surgical curettement), of benign lesions other than skin tags or cutaneous vascular proliferative lesions; up to 14 lesions $ 110.03 17111 chemosurgery, surgical curettement), of benign lesions other than skin tags or cutaneous vascular proliferative lesions; 15 or more lesions 17250 Chemical cauterization of granulation tissue (proud flesh, sinus or fistula) $ 152.10 17340 Cryotherapy (CO2 slush, liquid N2) for acne $ 74.83 17380 Electrolysis epilation, each 30 minutes 19100 Biopsy of breast; percutaneous, needle core, not using imaging guidance (separate procedure) 19105 Ablation, cryosurgical, of fibroadenoma, including ultrasound guidance, each fibroadenoma $ 3,171.04 19110 Nipple exploration, with or without excision of a solitary lactiferous duct or a papilloma lactiferous duct 19120 Excision of cyst, fibroadenoma, or other benign or malignant tumor, aberrant breast tissue, duct lesion, nipple or areolar lesion (except 19300), open, male or female, 1 or more lesions $ 1,105.37 19125 Excision of breast lesion identified by preoperative placement of radiological marker, open; single lesion $ 1,289.70 19281 Placement of breast localization device(s) (eg, clip, metallic pellet, wire/needle, radioactive seeds), percutaneous; first lesion, including mammographic guidance $98.25 19296 Placement of radiotherapy afterloading expandable catheter (single or multichannel) into the breast for interstitial radioelement application following partial mastectomy, includes imaging guidance; on date separate from partial mastectomy $ 9,940.72 19297 Placement of radiotherapy afterloading expandable catheter (single or multichannel) into the breast for interstitial radioelement application following partial mastectomy, includes imaging guidance; concurrent with partial mastectomy (List separately in a $ 218.27 19298 Placement of radiotherapy afterloading brachytherapy catheters (multiple tube and button type) into the breast for interstitial radioelement application following (at the time of or subsequent to) partial mastectomy, includes imaging guidance $ 3,605.44 19301 Mastectomy, partial (eg, lumpectomy, tylectomy, quadrantectomy, $ 933.84 19303 Mastectomy, simple, complete $ 1,597.79 19304 Mastectomy, subcutaneous $ 1,169.33 19305 Mastectomy, radical, including pectoral muscles, axillary lymph nodes $ 2,032.87 19306 Mastectomy, radical, including pectoral muscles, axillary and internal mammary lymph nodes (Urban type operation) $ 2,299.98 19318 Reduction mammaplasty $ 4,137.80 19325 Mammaplasty, augmentation; with prosthetic implant $ 2,711.70 19328 Removal of intact mammary implant $ 1,848.60 19342 Delayed insertion of breast prosthesis following mastopexy, mastectomy or in reconstruction $ 2,786.40 19361 Breast reconstruction with latissimus dorsi flap, without prosthetic $ 5,408.10

Row # CPT-4 HCPCS Price 19368 Breast reconstruction with transverse rectus abdominis myocutaneous flap (TRAM), single pedicle, including closure of donor site; with microvascular anastomosis (supercharging) $ 6,352.72 19369 Breast reconstruction with transverse rectus abdominis myocutaneous flap (TRAM), double pedicle, including closure of donor site $ 5,552.58 19499 Unlisted procedure, breast Cost 20005 Incision and drainage of soft tissue abscess, subfascial (ie, involves the soft tissue below the deep fascia) $ 664.63 20100 Exploration of penetrating wound (separate procedure); neck $ 1,610.10 20101 Exploration of penetrating wound (separate procedure); chest 20102 Exploration of penetrating wound (separate procedure); abdomen/flank/back $ 798.30 20103 Exploration of penetrating wound (separate procedure); extremity $ 1,134.00 20150 Excision of epiphyseal bar, with or without autogenous soft tissue graft obtained through same fascial incision $ 2,912.40 20200 Biopsy, muscle; superficial 20205 Biopsy, muscle; deep $ 617.40 20206 Biopsy, muscle, percutaneous needle $ 272.70 20220 Biopsy, bone, trocar, or needle; superficial (eg, ilium, sternum, spinous process, ribs) 20225 Biopsy, bone, trocar, or needle; deep (eg, vertebral body, femur) $ 814.50 20240 Biopsy, bone, open; superficial (eg, ilium, sternum, spinous process, ribs, trochanter of femur) 20245 Biopsy, bone, open; deep (eg, humerus, ischium, femur) $ 1,028.70 20250 Biopsy, vertebral body, open; thoracic $ 3,141.00 20251 Biopsy, vertebral body, open; lumbar or cervical $ 2,589.30 20500 Injection of sinus tract; therapeutic (separate procedure) 20501 Injection of sinus tract; diagnostic (sinogram) $ 147.60 20520 Removal of foreign body in muscle or tendon sheath; simple $ 307.46 20525 Removal of foreign body in muscle or tendon sheath; deep or 20526 Injection, therapeutic (eg, local anesthetic, corticosteroid), carpal tunnel $ 135.84 20550 Injection(s); single tendon sheath, or ligament, aponeurosis (eg, plantar 'fascia') $ 108.18 20551 Injection(s); single tendon origin/insertion $ 104.87 20552 Injection(s); single or multiple trigger point(s), 1 or 2 muscle(s) $ 103.78 20553 Injection(s); single or multiple trigger point(s), 3 or more muscle(s) $ 121.48 20555 Placement of needles or catheters into muscle and/or soft tissue for subsequent interstitial radioelement application (at the time of or subsequent to the procedure) $ 582.66 20600 Arthrocentesis, aspiration and/or injection; small joint or bursa (eg, fingers, toes) $ 94.96 20605 Arthrocentesis, aspiration and/or injection; intermediate joint or bursa (eg, temporomandibular, acromioclavicular, wrist, elbow or ankle, olecranon bursa) $ 107.28 20610 Arthrocentesis, aspiration and/or injection; major joint or bursa (eg, shoulder, hip, knee joint, subacromial bursa) $ 135.03 20612 Aspiration and/or injection of ganglion cyst(s) any location $ 105.01 20615 Aspiration and injection for treatment of bone cyst $ 527.40 20650 Insertion of wire or pin with application of skeletal traction, including removal (separate procedure) 20660 Application of cranial tongs, caliper, or stereotactic frame, including removal (separate procedure) $ 853.20 20661 Application of halo, including removal; cranial $ 1,326.60 20662 Application of halo, including removal; pelvic $ 902.70 20663 Application of halo, including removal; femoral 20664 Application of halo, including removal, cranial, 6 or more pins placed, for thin skull osteology (eg, pediatric patients, hydrocephalus, osteogenesis imperfecta) $ 1,032.30 20665 Removal of tongs or halo applied by another individual

Row # CPT-4 HCPCS Price 20670 Removal of implant; superficial (eg, buried wire, pin or rod) 20680 Removal of implant; deep (eg, buried wire, pin, screw, metal band, nail, rod or plate) $ 857.90 20690 Application of a uniplane (pins or wires in 1 plane), unilateral, external fixation system $ 1,138.50 20692 Application of a multiplane (pins or wires in more than 1 plane), unilateral, external fixation system (eg, Ilizarov, Monticelli type) $ 1,752.30 20693 Adjustment or revision of external fixation system requiring anesthesia (eg, new pin[s] or wire[s] and/or new ring[s] or bar[s]) $ 908.10 20694 Removal, under anesthesia, of external fixation system 20696 Application of multiplane (pins or wires in more than 1 plane), unilateral, external fixation with stereotactic computer-assisted adjustment (eg, spatial frame), including imaging; initial and subsequent alignment(s), assessment(s), and computation(s) of $ 1,752.70 20697 Application of multiplane (pins or wires in more than 1 plane), unilateral, external fixation with stereotactic computer-assisted adjustment (eg, spatial frame), including imaging; exchange (ie, removal and replacement) of strut, each $ 2,193.99 20802 Replantation, arm (includes surgical neck of humerus through elbow joint), complete amputation $ 9,720.90 20805 Replantation, forearm (includes radius and ulna to radial carpal joint), complete amputation $ 10,085.40 20808 Replantation, hand (includes hand through metacarpophalangeal joints), complete amputation $ 11,040.30 20816 Replantation, digit, excluding thumb (includes metacarpophalangeal joint to insertion of flexor sublimis tendon), complete amputation $ 5,793.30 20822 Replantation, digit, excluding thumb (includes distal tip to sublimis tendon insertion), complete amputation $ 5,794.20 20824 Replantation, thumb (includes carpometacarpal joint to MP joint), complete amputation $ 6,571.80 20827 Replantation, thumb (includes distal tip to MP joint), complete amputation 20838 Replantation, foot, complete amputation $ 9,888.30 20900 Bone graft, any donor area; minor or small (eg, dowel or button) 20902 Bone graft, any donor area; major or large $ 1,587.60 20910 Cartilage graft; costochondral $ 1,491.30 20912 Cartilage graft; nasal septum 20920 Fascia lata graft; by stripper 20922 Fascia lata graft; by incision and area exposure, complex or sheet $ 1,241.10 20924 Tendon graft, from a distance (eg, palmaris, toe extensor, plantaris) $ 1,360.80 20926 Tissue grafts, other (eg, paratenon, fat, dermis) $ 1,014.30 20930 Allograft, morselized, or placement of osteopromotive material, for spine surgery only (List separately in addition to code for primary 20931 Allograft, structural, for spine surgery only (List separately in 20936 Autograft for spine surgery only (includes harvesting the graft); local (eg, ribs, spinous process, or laminar fragments) obtained from same incision (List separately in addition to code for primary 20937 Autograft for spine surgery only (includes harvesting the graft); morselized (through separate skin or fascial incision) (List separately 20938 Autograft for spine surgery only (includes harvesting the graft); structural, bicortical or tricortical (through separate skin or fascial incision) (List separately in addition to code for primary procedure) $ 1,506.60 20950 Monitoring of interstitial fluid pressure (includes insertion of device, eg, wick catheter technique, needle manometer technique) in detection of muscle compartment syndrome 20955 Bone graft with microvascular anastomosis; fibula $ 10,791.90

Row # CPT-4 HCPCS Price 20956 Bone graft with microvascular anastomosis; iliac crest $ 8,655.30 20957 Bone graft with microvascular anastomosis; metatarsal $ 8,967.60 20962 Bone graft with microvascular anastomosis; other than fibula, iliac crest, or metatarsal $ 8,168.40 20969 Free osteocutaneous flap with microvascular anastomosis; other than iliac crest, metatarsal, or great toe $ 7,750.80 20970 Free osteocutaneous flap with microvascular anastomosis; iliac crest $ 9,907.20 20972 Free osteocutaneous flap with microvascular anastomosis; metatarsal $ 8,745.30 20973 Free osteocutaneous flap with microvascular anastomosis; great toe with web space $ 8,745.30 20974 Electrical stimulation to aid bone healing; noninvasive (nonoperative) $ 915.30 20975 Electrical stimulation to aid bone healing; invasive (operative) $ 1,344.60 20979 Low intensity ultrasound stimulation to aid bone healing, noninvasive (nonoperative) 20982 Ablation, bone tumor(s) (eg, osteoid osteoma, metastasis) radiofrequency, percutaneous, including computed tomographic guidance $ 8,951.44 20985 Computer-assisted surgical navigational procedure for musculoskeletal procedures, image-less (List separately in addition $ 207.47 20999 Unlisted procedure, musculoskeletal system, general Cost 21010 Arthrotomy, temporomandibular joint $ 2,836.80 21011 Excision, tumor, soft tissue of face or scalp, subcutaneous; less than 2 cm $ 441.95 21012 Excision, tumor, soft tissue of face or scalp, subcutaneous; 2 cm or $ 465.84 21013 Excision, tumor, soft tissue of face and scalp, subfascial (eg, subgaleal, intramuscular); less than 2 cm $ 767.09 21014 Excision, tumor, soft tissue of face and scalp, subfascial (eg, subgaleal, intramuscular); 2 cm or greater $ 813.32 21015 Radical resection of tumor (eg, sarcoma), soft tissue of face or scalp; less than 2 cm $ 1,773.90 21016 Radical resection of tumor (eg, sarcoma), soft tissue of face or scalp; 2 cm or greater $ 1,706.33 21025 Excision of bone (eg, for osteomyelitis or bone abscess); mandible $ 1,602.00 21026 Excision of bone (eg, for osteomyelitis or bone abscess); facial bone(s) $ 1,498.50 21029 Removal by contouring of benign tumor of facial bone (eg, fibrous dysplasia) 21030 Excision of benign tumor or cyst of maxilla or zygoma by enucleation and curettage $ 2,193.30 21031 Excision of torus mandibularis $ 696.60 21032 Excision of maxillary torus palatinus $ 1,056.60 21034 Excision of malignant tumor of maxilla or zygoma $ 3,169.80 21040 Excision of benign tumor or cyst of mandible, by enucleation and/or curettage $ 1,246.50 21044 Excision of malignant tumor of mandible; $ 2,851.20 21045 Excision of malignant tumor of mandible; radical resection $ 5,918.40 21046 Excision of benign tumor or cyst of mandible; requiring intra-oral osteotomy (eg, locally aggressive or destructive lesion(s)) $ 1,872.04 21047 Excision of benign tumor or cyst of mandible; requiring extra-oral osteotomy and partial mandibulectomy (eg, locally aggressive or destructive lesion(s)) $ 2,304.17 21048 Excision of benign tumor or cyst of maxilla; requiring intra-oral osteotomy (eg, locally aggressive or destructive lesion(s)) $ 1,918.12 21049 Excision of benign tumor or cyst of maxilla; requiring extra-oral osteotomy and partial maxillectomy (eg, locally aggressive or destructive lesion(s)) $ 2,210.72 21050 Condylectomy, temporomandibular joint (separate procedure) $ 3,355.20 21060 Meniscectomy, partial or complete, temporomandibular joint $ 3,330.00 21070 Coronoidectomy (separate procedure) $ 2,724.30

Row # CPT-4 HCPCS Price 21073 Manipulation of temporomandibular joint(s) (TMJ), therapeutic, requiring an anesthesia service (ie, general or monitored anesthesia care) $ 524.35 21076 Impression and custom preparation; surgical obturator prosthesis $ 1,781.92 21077 Impression and custom preparation; orbital prosthesis $ 4,473.18 21079 Impression and custom preparation; interim obturator prosthesis $ 2,974.29 21080 Impression and custom preparation; definitive obturator prosthesis $ 3,342.10 21081 Impression and custom preparation; mandibular resection $ 3,048.99 21083 Impression and custom preparation; palatal lift prosthesis $ 2,579.92 21084 Impression and custom preparation; speech aid prosthesis $ 3,019.99 21085 Impression and custom preparation; oral surgical splint 21086 Impression and custom preparation; auricular prosthesis $ 3,303.10 21087 Impression and custom preparation; nasal prosthesis $ 3,302.27 21088 Impression and custom preparation; facial prosthesis 21089 Unlisted maxillofacial prosthetic procedure Cost 21100 Application of halo type appliance for maxillofacial fixation, includes removal (separate procedure) 21110 Application of interdental fixation device for conditions other than fracture or dislocation, includes removal 21116 Injection procedure for temporomandibular joint arthrography 21120 Genioplasty; augmentation (autograft, allograft, prosthetic material) $ 2,880.90 21121 Genioplasty; sliding osteotomy, single piece 21122 Genioplasty; sliding osteotomies, 2 or more osteotomies (eg, wedge excision or bone wedge reversal for asymmetrical chin) $ 2,385.00 21123 Genioplasty; sliding, augmentation with interpositional bone grafts (includes obtaining autografts) $ 2,490.30 21125 Augmentation, mandibular body or angle; prosthetic material 21127 Augmentation, mandibular body or angle; with bone graft, onlay or interpositional (includes obtaining autograft) 21137 Reduction forehead; contouring only 21138 Reduction forehead; contouring and application of prosthetic material or bone graft (includes obtaining autograft) 21139 Reduction forehead; contouring and setback of anterior frontal sinus wall $ 3,278.60 21141 Reconstruction midface, LeFort I; single piece, segment movement in any direction (eg, for Long Face Syndrome), without bone graft $ 4,120.20 21142 Reconstruction midface, LeFort I; 2 pieces, segment movement in any direction, without bone graft $ 4,326.30 21143 Reconstruction midface, LeFort I; 3 or more pieces, segment movement in any direction, without bone graft 21145 Reconstruction midface, LeFort I; single piece, segment movement in any direction, requiring bone grafts (includes obtaining autografts) $ 4,496.20 21146 Reconstruction midface, LeFort I; 2 pieces, segment movement in any direction, requiring bone grafts (includes obtaining autografts) (eg, ungrafted unilateral alveolar cleft) $ 5,983.20 21147 Reconstruction midface, LeFort I; 3 or more pieces, segment movement in any direction, requiring bone grafts (includes obtaining autografts) (eg, ungrafted bilateral alveolar cleft or multiple osteotomies) $ 6,391.80 21150 Reconstruction midface, LeFort II; anterior intrusion (eg, Treacher- Collins Syndrome) $ 5,568.30 21151 Reconstruction midface, LeFort II; any direction, requiring bone grafts (includes obtaining autografts) 21154 Reconstruction midface, LeFort III (extracranial), any type, requiring bone grafts (includes obtaining autografts); without LeFort I $ 6,677.10

Row # CPT-4 HCPCS Price 21155 Reconstruction midface, LeFort III (extracranial), any type, requiring bone grafts (includes obtaining autografts); with LeFort I $ 6,431.40 21159 Reconstruction midface, LeFort III (extra and intracranial) with forehead advancement (eg, mono bloc), requiring bone grafts (includes obtaining autografts); without LeFort I $ 9,682.20 21160 Reconstruction midface, LeFort III (extra and intracranial) with forehead advancement (eg, mono bloc), requiring bone grafts (includes obtaining autografts); with LeFort I $ 10,815.30 21172 Reconstruction superior-lateral orbital rim and lower forehead, advancement or alteration, with or without grafts (includes obtaining autografts) $ 8,767.80 21175 Reconstruction, bifrontal, superior-lateral orbital rims and lower forehead, advancement or alteration (eg, plagiocephaly, trigonocephaly, brachycephaly), with or without grafts (includes obtaining autografts) $ 9,409.50 21179 Reconstruction, entire or majority of forehead and/or supraorbital rims; with grafts (allograft or prosthetic material) $ 7,056.00 21180 Reconstruction, entire or majority of forehead and/or supraorbital rims; with autograft (includes obtaining grafts) $ 6,390.00 21181 Reconstruction by contouring of benign tumor of cranial bones (eg, fibrous dysplasia), extracranial $ 1,539.90 21182 (includes obtaining grafts); total area of bone grafting less $ 6,723.90 21183 (includes obtaining grafts); total area of bone grafting grea $ 7,144.20 21184 (includes obtaining grafts); total area of bone grafting grea $ 7,754.40 21188 Reconstruction midface, osteotomies (other than LeFort type) and bone grafts (includes obtaining autografts) $ 4,563.00 21193 Reconstruction of mandibular rami, horizontal, vertical, C, or L osteotomy; without bone graft $ 4,586.40 21194 Reconstruction of mandibular rami, horizontal, vertical, C, or L osteotomy; with bone graft (includes obtaining graft) $ 5,648.40 21195 Reconstruction of mandibular rami and/or body, sagittal split; without internal rigid fixation $ 4,891.50 21196 Reconstruction of mandibular rami and/or body, sagittal split; with internal rigid fixation $ 5,547.60 21198 Osteotomy, mandible, segmental; 21199 Osteotomy, mandible, segmental; with genioglossus advancement $ 3,879.00 21206 Osteotomy, maxilla, segmental (eg, Wassmund or Schuchard) $ 4,425.30 21208 Osteoplasty, facial bones; augmentation (autograft, allograft, or prosthetic implant) $ 2,608.20 21209 Osteoplasty, facial bones; reduction $ 2,713.50 21210 Graft, bone; nasal, maxillary or malar areas (includes obtaining graft) $ 3,510.00 21215 Graft, bone; mandible (includes obtaining graft) $ 3,878.10 21230 Graft; rib cartilage, autogenous, to face, chin, nose or ear (includes $ 4,305.60 21235 Graft; ear cartilage, autogenous, to nose or ear (includes obtaining graft) 21240 Arthroplasty, temporomandibular joint, with or without autograft $ 4,120.20 21242 Arthroplasty, temporomandibular joint, with allograft $ 3,933.00 21243 Arthroplasty, temporomandibular joint, with prosthetic joint $ 5,049.90 21244 Reconstruction of mandible, extraoral, with transosteal bone plate (eg, mandibular staple bone plate) $ 4,204.80

Row # CPT-4 HCPCS Price 21245 Reconstruction of mandible or maxilla, subperiosteal implant; partial 21246 Reconstruction of mandible or maxilla, subperiosteal implant; $ 5,781.60 21247 Reconstruction of mandibular condyle with bone and cartilage autografts (includes obtaining grafts) (eg, for hemifacial microsomia) 21248 Reconstruction of mandible or maxilla, endosteal implant (eg, blade, cylinder); partial $ 3,985.20 21249 Reconstruction of mandible or maxilla, endosteal implant (eg, blade, cylinder); complete 21255 Reconstruction of zygomatic arch and glenoid fossa with bone and cartilage (includes obtaining autografts) 21256 Reconstruction of orbit with osteotomies (extracranial) and with bone grafts (includes obtaining autografts) (eg, micro-ophthalmia) $ 5,800.50 21260 Periorbital osteotomies for orbital hypertelorism, with bone grafts; extracranial approach $ 6,687.00 21261 Periorbital osteotomies for orbital hypertelorism, with bone grafts; combined intra- and extracranial approach $ 8,191.80 21267 Orbital repositioning, periorbital osteotomies, unilateral, with bone grafts; extracranial approach $ 6,246.90 21268 Orbital repositioning, periorbital osteotomies, unilateral, with bone grafts; combined intra- and extracranial approach $ 9,558.90 21270 Malar augmentation, prosthetic material $ 4,648.50 21275 Secondary revision of orbitocraniofacial reconstruction $ 6,386.40 21280 Medial canthopexy (separate procedure) 21282 Lateral canthopexy $ 1,957.50 21295 Reduction of masseter muscle and bone (eg, for treatment of benign masseteric hypertrophy); extraoral approach $ 2,487.73 21296 Reduction of masseter muscle and bone (eg, for treatment of benign masseteric hypertrophy); intraoral approach $ 2,095.08 21299 Unlisted craniofacial and maxillofacial procedure Cost 21310 Closed treatment of nasal bone fracture without manipulation $ 396.90 21315 Closed treatment of nasal bone fracture; without stabilization $ 489.60 21320 Closed treatment of nasal bone fracture; with stabilization 21325 Open treatment of nasal fracture; uncomplicated $ 1,708.20 21330 Open treatment of nasal fracture; complicated, with internal and/or external skeletal fixation $ 2,563.20 21335 Open treatment of nasal fracture; with concomitant open treatment of fractured septum $ 2,959.20 21336 Open treatment of nasal septal fracture, with or without stabilization $ 1,738.80 21337 Closed treatment of nasal septal fracture, with or without stabilization 21338 Open treatment of nasoethmoid fracture; without external fixation $ 2,750.40 21339 Open treatment of nasoethmoid fracture; with external fixation $ 3,019.50 21340 Percutaneous treatment of nasoethmoid complex fracture, with splint, wire or headcap fixation, including repair of canthal ligaments and/or the nasolacrimal apparatus $ 3,490.20 21343 Open treatment of depressed frontal sinus fracture $ 3,550.50 21344 posterior wall) frontal sinus fracture, via coronal or multiple approaches 21345 Closed treatment of nasomaxillary complex fracture (LeFort II type), with interdental wire fixation or fixation of denture or splint $ 3,108.60 21346 with wiring and/or local fixation $ 3,837.60 21347 requiring multiple open approaches 21348 with bone grafting (includes obtaining graft) $ 3,829.50 21355 Percutaneous treatment of fracture of malar area, including zygomatic arch and malar tripod, with manipulation $ 2,138.40

Row # CPT-4 HCPCS Price 21356 Open treatment of depressed zygomatic arch fracture (eg, Gillies $ 1,796.40 21360 Open treatment of depressed malar fracture, including zygomatic arch and malar tripod $ 2,407.50 21365 cranial nerve foramina) fracture(s) of malar area, including zygomatic arch and malar tripod; with internal fixation and multiple $ 3,566.70 21366 cranial nerve foramina) fracture(s) of malar area, including zygomatic arch and malar tripod; with bone grafting (includes 21385 Open treatment of orbital floor blowout fracture; transantral approach (Caldwell-Luc type operation) 21386 $ 2,984.40 21387 Open treatment of orbital floor blowout fracture; combined $ 3,267.00 21390 approach, with alloplastic or other implant $ 3,502.80 21395 approach with bone graft (includes obtaining graft) $ 3,692.70 21400 Closed treatment of fracture of orbit, except blowout; without $ 879.30 21401 Closed treatment of fracture of orbit, except blowout; with $ 2,475.90 21406 Open treatment of fracture of orbit, except blowout; without $ 2,877.30 21407 Open treatment of fracture of orbit, except blowout; with implant $ 3,400.20 21408 Open treatment of fracture of orbit, except blowout; with bone grafting (includes obtaining graft) 21421 Closed treatment of palatal or maxillary fracture (LeFort I type), with interdental wire fixation or fixation of denture or splint 21422 Open treatment of palatal or maxillary fracture (LeFort I type); $ 3,348.90 21423 Open treatment of palatal or maxillary fracture (LeFort I type); complicated (comminuted or involving cranial nerve foramina), multiple approaches $ 2,865.60 21431 Closed treatment of craniofacial separation (LeFort III type) using interdental wire fixation of denture or splint 21432 Open treatment of craniofacial separation (LeFort III type); with wiring and/or internal fixation 21433 complicated (eg, comminuted or involving cranial nerve foramina), multiple surgical approaches $ 5,049.90 21435 complicated, utilizing internal and/or external fixation techniques (eg, head cap, halo device, and/or intermaxillary fixation) $ 4,278.60 21436 complicated, multiple surgical approaches, internal fixation, with bone grafting (includes obtaining graft) $ 5,112.00 21440 Closed treatment of mandibular or maxillary alveolar ridge fracture $ 1,808.10 21445 Open treatment of mandibular or maxillary alveolar ridge fracture $ 2,088.00 21450 Closed treatment of mandibular fracture; without manipulation $ 812.70 21451 Closed treatment of mandibular fracture; with manipulation $ 2,193.30 21452 Percutaneous treatment of mandibular fracture, with external $ 1,540.80 21453 Closed treatment of mandibular fracture with interdental fixation $ 2,735.10 21454 Open treatment of mandibular fracture with external fixation $ 2,820.60

Row # CPT-4 HCPCS Price 21461 Open treatment of mandibular fracture; without interdental $ 2,774.70 21462 Open treatment of mandibular fracture; with interdental fixation $ 3,288.60 21465 Open treatment of mandibular condylar fracture $ 2,871.00 21470 Open treatment of complicated mandibular fracture by multiple surgical approaches including internal fixation, interdental fixation, and/or wiring of dentures or splints 21480 Closed treatment of temporomandibular dislocation; initial or 21485 Closed treatment of temporomandibular dislocation; complicated (eg, recurrent requiring intermaxillary fixation or splinting), initial or 21490 Open treatment of temporomandibular dislocation 21495 Open treatment of hyoid fracture $ 2,726.10 21497 Interdental wiring, for condition other than fracture $ 2,046.60 21499 Unlisted musculoskeletal procedure, head Cost 21501 Incision and drainage, deep abscess or hematoma, soft tissues of neck or thorax; 21502 Incision and drainage, deep abscess or hematoma, soft tissues of neck or thorax; with partial rib ostectomy $ 946.80 21510 Incision, deep, with opening of bone cortex (eg, for osteomyelitis or bone abscess), thorax $ 1,161.90 21550 Biopsy, soft tissue of neck or thorax $ 405.00 21552 Excision, tumor, soft tissue of neck or anterior thorax, subcutaneous; 3 cm or greater $ 791.93 21554 Excision, tumor, soft tissue of neck or anterior thorax, subfascial (eg, intramuscular); 5 cm or greater $ 1,366.14 21555 Excision, tumor, soft tissue of neck or anterior thorax, $ 632.14 21556 Excision, tumor, soft tissue of neck or anterior thorax, subfascial (eg, intramuscular); less than 5 cm $ 1,127.30 21557 Radical resection of tumor (eg, sarcoma), soft tissue of neck or anterior thorax; less than 5 cm 21558 Radical resection of tumor (eg, sarcoma), soft tissue of neck or anterior thorax; 5 cm or greater $ 2,439.66 21600 Excision of rib, partial 21610 Costotransversectomy (separate procedure) $ 3,476.70 21615 Excision first and/or cervical rib; $ 3,032.10 21616 Excision first and/or cervical rib; with sympathectomy $ 2,896.20 21620 Ostectomy of sternum, partial $ 3,269.70 21627 Sternal debridement $ 1,960.20 21630 Radical resection of sternum; $ 3,826.80 21632 Radical resection of sternum; with mediastinal lymphadenectomy 21685 Hyoid myotomy and suspension $ 2,168.29 21700 Division of scalenus anticus; without resection of cervical rib 21705 Division of scalenus anticus; with resection of cervical rib 21720 Division of sternocleidomastoid for torticollis, open operation; without cast application $ 1,333.80 21725 Division of sternocleidomastoid for torticollis, open operation; with cast application $ 1,486.80 21740 Reconstructive repair of pectus excavatum or carinatum; open 21742 Reconstructive repair of pectus excavatum or carinatum; minimally invasive approach (Nuss procedure), without thoracoscopy 21743 Reconstructive repair of pectus excavatum or carinatum; minimally invasive approach (Nuss procedure), with thoracoscopy 21750 Closure of median sternotomy separation with or without debridement (separate procedure) 21800 Closed treatment of rib fracture, uncomplicated, each $ 219.60 21805 Open treatment of rib fracture without fixation, each $ 1,426.50 21810 Treatment of rib fracture requiring external fixation (flail chest) $ 3,409.20 21820 Closed treatment of sternum fracture 21825 Open treatment of sternum fracture with or without skeletal $ 1,791.90

Row # CPT-4 HCPCS Price 21899 Unlisted procedure, neck or thorax Cost 21920 Biopsy, soft tissue of back or flank; superficial $ 466.20 21925 Biopsy, soft tissue of back or flank; deep 21930 Excision, tumor, soft tissue of back or flank, subcutaneous; less than 3 cm $ 1,846.80 21931 Excision, tumor, soft tissue of back or flank, subcutaneous; 3 cm or $ 1,124.11 21932 Excision, tumor, soft tissue of back or flank, subfascial (eg, $ 1,469.92 21933 Excision, tumor, soft tissue of back or flank, subfascial (eg, $ 1,605.17 21935 Radical resection of tumor (eg, sarcoma), soft tissue of back or flank; less than 5 cm $ 3,547.80 21936 Radical resection of tumor (eg, sarcoma), soft tissue of back or flank; 5 cm or greater $ 3,109.09 22010 Incision and drainage, open, of deep abscess (subfascial), posterior spine; cervical, thoracic, or cervicothoracic $ 1,829.44 22015 Incision and drainage, open, of deep abscess (subfascial), posterior spine; lumbar, sacral, or lumbosacral $ 1,795.54 22100 22101 $ 1,560.60 22102 $ 1,827.00 22103 segment; each additional segment (List separately in addition to $ 421.75 22110 $ 2,437.20 22112 $ 2,290.50 22114 $ 1,809.90 22116 segment; each additional vertebral segment (List separately in $ 510.03 22206 subtraction); thoracic $ 8,139.79 22207 subtraction); lumbar $ 7,918.14 22208 subtraction); each additional vertebral segment (List separately in $ 2,343.90 22210 vertebral segment; cervical $ 5,474.70 22212 vertebral segment; thoracic $ 5,826.60 22214 vertebral segment; lumbar $ 5,076.00 22216 vertebral segment; each additional vertebral segment (List separately in addition to primary procedure) $ 1,650.31 22220 vertebral segment; cervical $ 5,062.50 22222 vertebral segment; thoracic

Row # CPT-4 HCPCS Price 22224 vertebral segment; lumbar 22226 vertebral segment; each additional vertebral segment (List $ 1,576.45 22305 Closed treatment of vertebral process fracture(s) $ 646.20 22310 Closed treatment of vertebral body fracture(s), without manipulation, requiring and including casting or bracing $ 1,089.00 22315 Closed treatment of vertebral fracture(s) and/or dislocation(s) requiring casting or bracing, with and including casting and/or bracing by manipulation or traction $ 1,676.70 22318 Open treatment and/or reduction of odontoid fracture(s) and or dislocation(s) (including os odontoideum), anterior approach, including placement of internal fixation; without grafting $ 4,835.70 22319 Open treatment and/or reduction of odontoid fracture(s) and or dislocation(s) (including os odontoideum), anterior approach, including placement of internal fixation; with grafting $ 5,462.10 22325 dislocated segment; lumbar $ 3,702.60 22326 dislocated segment; cervical $ 4,303.80 22327 dislocated segment; thoracic $ 3,861.00 22328 dislocated segment; each additional fractured vertebra or dislocated segment (List separately in addition to code for primary proce 22505 Manipulation of spine requiring anesthesia, any region $ 594.00 22520 performed), 1 vertebral body, unilateral or bilateral injection; $ 10,247.30 22521 performed), 1 vertebral body, unilateral or bilateral injection; $ 4,183.34 22522 performed), 1 vertebral body, unilateral or bilateral injection; each additional thoracic or lumbar vertebral body (List separately in $ 499.51 22523 cannulation (eg, kyphoplasty); thoracic $ 1,477.34 22524 cannulation (eg, kyphoplasty); lumbar $ 1,382.74 22525 cannulation (eg, kyphoplasty); each additional thoracic or lumba $ 716.85 22526 Percutaneous intradiscal electrothermal annuloplasty, unilateral or bilateral including fluoroscopic guidance; single level $ 3,625.48 22527 Percutaneous intradiscal electrothermal annuloplasty, unilateral or bilateral including fluoroscopic guidance; 1 or more additional levels $ 2,933.60 22532 $ 7,248.19

Row # CPT-4 HCPCS Price 22533 $ 6,841.56 22534 thoracic or lumbar, each additional vertebral segment (List $ 1,793.42 22548 Arthrodesis, anterior transoral or extraoral technique, clivus-C1-C2 (atlas-axis), with or without excision of odontoid process $ 4,671.90 22554 cervical below C2 22556 $ 5,232.60 22558 $ 4,895.10 22585 each additional interspace (List separately in addition to code for $ 2,109.60 22590 Arthrodesis, posterior technique, craniocervical (occiput-C2) 22595 Arthrodesis, posterior technique, atlas-axis (C1-C2) $ 5,839.20 22600 cervical below C2 segment 22610 thoracic (with lateral transverse technique, when performed) $ 4,143.60 22612 lumbar (with lateral transverse technique, when performed) $ 4,961.70 22614 Arthrodesis, posterior or posterolateral technique, single level; each additional vertebral segment (List separately in addition to code for $ 1,858.50 22630 Arthrodesis, posterior interbody technique, including laminectomy and/or discectomy to prepare interspace (other than for decompression), single interspace; lumbar $ 4,412.70 22632 Arthrodesis, posterior interbody technique, including laminectomy and/or discectomy to prepare interspace (other than for decompression), single interspace; each additional interspace (List 22800 Arthrodesis, posterior, for spinal deformity, with or without cast; up to 6 vertebral segments $ 4,953.60 22802 Arthrodesis, posterior, for spinal deformity, with or without cast; 7 to 12 vertebral segments $ 6,030.00 22804 Arthrodesis, posterior, for spinal deformity, with or without cast; 13 or more vertebral segments $ 6,646.50 22808 Arthrodesis, anterior, for spinal deformity, with or without cast; 2 to 3 vertebral segments $ 4,555.80 22810 Arthrodesis, anterior, for spinal deformity, with or without cast; 4 to 7 vertebral segments 22812 Arthrodesis, anterior, for spinal deformity, with or without cast; 8 or more vertebral segments $ 5,985.90 22818 Kyphectomy, circumferential exposure of spine and resection of vertebral segment(s) (including body and posterior elements); single or 2 segments $ 6,687.90 22819 Kyphectomy, circumferential exposure of spine and resection of vertebral segment(s) (including body and posterior elements); 3 or more segments $ 7,163.10 22830 Exploration of spinal fusion $ 4,411.80 22840 Posterior non-segmental instrumentation (eg, Harrington rod technique, pedicle fixation across 1 interspace, atlantoaxial transarticular screw fixation, sublaminar wiring at C1, facet screw fixation) (List separately in addition to code for primary proced $ 5,926.50

Row # CPT-4 HCPCS Price 22841 Internal spinal fixation by wiring of spinous processes (List 22842 with multiple hooks and sublaminar wires); 3 to 6 vertebral segments (List separately in addition to code for primary procedure) $ 6,488.10 22843 with multiple hooks and sublaminar wires); 7 to 12 vertebral segments (List separately in addition to code for primary procedure) $ 2,050.20 22844 with multiple hooks and sublaminar wires); 13 or more vertebral segments (List separately in addition to code for primary procedure) $ 2,503.80 22845 Anterior instrumentation; 2 to 3 vertebral segments (List separately $ 6,088.50 22846 Anterior instrumentation; 4 to 7 vertebral segments (List separately $ 6,129.00 22847 Anterior instrumentation; 8 or more vertebral segments (List $ 4,006.54 22848 Pelvic fixation (attachment of caudal end of instrumentation to pelvic bony structures) other than sacrum (List separately in $ 1,716.14 22849 Reinsertion of spinal fixation device $ 3,637.80 22850 Removal of posterior nonsegmental instrumentation (eg, Harrington rod) $ 2,196.90 22851 Application of intervertebral biomechanical device(s) (eg, synthetic cage(s), methylmethacrylate) to vertebral defect or interspace (List $ 2,188.80 22852 Removal of posterior segmental instrumentation 22855 Removal of anterior instrumentation $ 3,174.30 22856 Total disc arthroplasty (artificial disc), anterior approach, including discectomy with end plate preparation (includes osteophytectomy for nerve root or spinal cord decompression and microdissection), single interspace, cervical $ 7,409.11 22857 Total disc arthroplasty (artificial disc), anterior approach, including single interspace, lumbar $ 7,481.77 22861 Revision including replacement of total disc arthroplasty (artificial disc), anterior approach, single interspace; cervical $ 9,122.80 22862 Revision including replacement of total disc arthroplasty (artificial disc), anterior approach, single interspace; lumbar $ 8,973.95 22864 Removal of total disc arthroplasty (artificial disc), anterior approach, single interspace; cervical $ 8,487.18 22865 Removal of total disc arthroplasty (artificial disc), anterior approach, single interspace; lumbar $ 9,570.92 22899 Unlisted procedure, spine $ 1,613.81 22900 Excision, tumor, soft tissue of abdominal wall, subfascial (eg, $ 1,592.10 22901 Excision, tumor, soft tissue of abdominal wall, subfascial (eg, $ 1,370.05 22902 Excision, tumor, soft tissue of abdominal wall, subcutaneous; less $ 861.30 22903 Excision, tumor, soft tissue of abdominal wall, subcutaneous; 3 cm or greater $ 901.22 22904 Radical resection of tumor (eg, sarcoma), soft tissue of abdominal wall; less than 5 cm $ 2,178.75 22905 Radical resection of tumor (eg, sarcoma), soft tissue of abdominal wall; 5 cm or greater $ 2,821.24 22999 Unlisted procedure, abdomen, musculoskeletal system Cost 23000 Removal of subdeltoid calcareous deposits, open $ 1,048.50 23020 Capsular contracture release (eg, Sever type procedure) $ 1,676.70 23030 Incision and drainage, shoulder area; deep abscess or hematoma 23031 Incision and drainage, shoulder area; infected bursa

Row # CPT-4 HCPCS Price 23035 Incision, bone cortex (eg, osteomyelitis or bone abscess), shoulder area $ 1,620.00 23040 Arthrotomy, glenohumeral joint, including exploration, drainage, or removal of foreign body $ 1,976.40 23044 Arthrotomy, acromioclavicular, sternoclavicular joint, including exploration, drainage, or removal of foreign body $ 1,288.80 23065 Biopsy, soft tissue of shoulder area; superficial 23066 Biopsy, soft tissue of shoulder area; deep 23073 Excision, tumor, soft tissue of shoulder area, subfascial (eg, $ 1,601.52 23075 Excision, tumor, soft tissue of shoulder area, subcutaneous; less 23076 Excision, tumor, soft tissue of shoulder area, subfascial (eg, 23077 Radical resection of tumor (eg, sarcoma), soft tissue of shoulder area; less than 5 cm $ 3,457.80 23100 Arthrotomy, glenohumeral joint, including biopsy 23101 Arthrotomy, acromioclavicular joint or sternoclavicular joint, including biopsy and/or excision of torn cartilage $ 1,510.20 23105 Arthrotomy; glenohumeral joint, with synovectomy, with or without 23106 Arthrotomy; sternoclavicular joint, with synovectomy, with or 23107 Arthrotomy, glenohumeral joint, with joint exploration, with or without removal of loose or foreign body $ 2,521.80 23120 Claviculectomy; partial 23125 Claviculectomy; total $ 2,212.20 23130 Acromioplasty or acromionectomy, partial, with or without coracoacromial ligament release $ 1,876.50 23140 scapula; $ 1,152.90 23145 scapula; with autograft (includes obtaining graft) $ 1,894.50 23146 scapula; with allograft $ 1,276.20 23150 humerus; $ 1,902.60 23155 humerus; with autograft (includes obtaining graft) $ 2,513.70 23156 humerus; with allograft $ 2,136.60 23170 Sequestrectomy (eg, for osteomyelitis or bone abscess), clavicle 23172 Sequestrectomy (eg, for osteomyelitis or bone abscess), scapula 23174 Sequestrectomy (eg, for osteomyelitis or bone abscess), humeral head to surgical neck $ 2,029.50 23180 bone (eg, osteomyelitis), clavicle $ 1,142.10 23182 bone (eg, osteomyelitis), scapula $ 1,146.60 23184 bone (eg, osteomyelitis), proximal humerus 23190 Ostectomy of scapula, partial (eg, superior medial angle) 23195 Resection, humeral head $ 2,023.20 23200 Radical resection of tumor; clavicle $ 1,987.20 23210 Radical resection of tumor; scapula $ 2,709.00 23220 Radical resection of tumor, proximal humerus $ 2,718.90 23330 Removal of foreign body, shoulder; subcutaneous 23333 Removal of foreign body, shoulder; deep (subfascial or $640.91 23350 Injection procedure for shoulder arthrography or enhanced CT/MRI shoulder arthrography 23395 Muscle transfer, any type, shoulder or upper arm; single 23397 Muscle transfer, any type, shoulder or upper arm; multiple 23400 Scapulopexy (eg, Sprengels deformity or for paralysis) $ 2,549.70 23405 Tenotomy, shoulder area; single tendon $ 1,497.60 23406 Tenotomy, shoulder area; multiple tendons through same incision $ 2,154.60

Row # CPT-4 HCPCS Price 23410 Repair of ruptured musculotendinous cuff (eg, rotator cuff) open; acute $ 2,492.10 23412 Repair of ruptured musculotendinous cuff (eg, rotator cuff) open; chronic $ 3,027.60 23415 Coracoacromial ligament release, with or without acromioplasty $ 1,882.80 23420 Reconstruction of complete shoulder (rotator) cuff avulsion, chronic (includes acromioplasty) $ 3,345.30 23430 Tenodesis of long tendon of biceps 23440 Resection or transplantation of long tendon of biceps $ 1,823.40 23450 Capsulorrhaphy, anterior; Putti-Platt procedure or Magnuson type 23455 Capsulorrhaphy, anterior; with labral repair (eg, Bankart procedure) $ 3,392.10 23460 Capsulorrhaphy, anterior, any type; with bone block $ 3,116.70 23462 Capsulorrhaphy, anterior, any type; with coracoid process transfer $ 3,337.20 23465 Capsulorrhaphy, glenohumeral joint, posterior, with or without bone block $ 2,945.70 23466 Capsulorrhaphy, glenohumeral joint, any type multi-directional instability $ 3,508.20 23470 Arthroplasty, glenohumeral joint; hemiarthroplasty $ 3,598.20 23472 Arthroplasty, glenohumeral joint; total shoulder (glenoid and proximal humeral replacement (eg, total shoulder)) $ 5,374.80 23480 Osteotomy, clavicle, with or without internal fixation; $ 1,863.00 23485 Osteotomy, clavicle, with or without internal fixation; with bone graft for nonunion or malunion (includes obtaining graft and/or necessary fixation) $ 2,413.80 23490 without methylmethacrylate; clavicle $ 2,123.10 23491 without methylmethacrylate; proximal humerus $ 2,097.00 23500 Closed treatment of clavicular fracture; without manipulation $ 342.90 23505 Closed treatment of clavicular fracture; with manipulation $ 586.80 23515 Open treatment of clavicular fracture, includes internal fixation, $ 1,595.70 23520 Closed treatment of sternoclavicular dislocation; without 23525 Closed treatment of sternoclavicular dislocation; with manipulation $ 556.20 23530 Open treatment of sternoclavicular dislocation, acute or chronic; $ 1,455.30 23532 Open treatment of sternoclavicular dislocation, acute or chronic; with fascial graft (includes obtaining graft) 23540 Closed treatment of acromioclavicular dislocation; without $ 418.50 23545 Closed treatment of acromioclavicular dislocation; with $ 565.20 23550 Open treatment of acromioclavicular dislocation, acute or chronic; $ 1,890.00 23552 Open treatment of acromioclavicular dislocation, acute or chronic; with fascial graft (includes obtaining graft) $ 2,283.30 23570 Closed treatment of scapular fracture; without manipulation $ 372.60 23575 Closed treatment of scapular fracture; with manipulation, with or without skeletal traction (with or without shoulder joint involvement) $ 533.70 23585 Open treatment of scapular fracture (body, glenoid or acromion) $ 2,152.80 23600 Closed treatment of proximal humeral (surgical or anatomical neck) fracture; without manipulation 23605 Closed treatment of proximal humeral (surgical or anatomical neck) fracture; with manipulation, with or without skeletal traction 23615 Open treatment of proximal humeral (surgical or anatomical neck) fracture, includes internal fixation, when performed, includes repair of tuberosity(s), when performed; $ 2,034.00

Row # CPT-4 HCPCS Price 23616 Open treatment of proximal humeral (surgical or anatomical neck) fracture, includes internal fixation, when performed, includes repair of tuberosity(s), when performed; with proximal humeral prosthetic 23620 Closed treatment of greater humeral tuberosity fracture; without $ 471.60 23625 Closed treatment of greater humeral tuberosity fracture; with $ 744.30 23630 Open treatment of greater humeral tuberosity fracture, includes $ 1,616.40 23650 Closed treatment of shoulder dislocation, with manipulation; without anesthesia $ 457.20 23655 Closed treatment of shoulder dislocation, with manipulation; 23660 Open treatment of acute shoulder dislocation 23665 Closed treatment of shoulder dislocation, with fracture of greater humeral tuberosity, with manipulation $ 749.70 23670 Open treatment of shoulder dislocation, with fracture of greater humeral tuberosity, includes internal fixation, when performed 23675 Closed treatment of shoulder dislocation, with surgical or anatomical neck fracture, with manipulation $ 888.30 23680 Open treatment of shoulder dislocation, with surgical or anatomical neck fracture, includes internal fixation, when performed $ 2,415.60 23700 Manipulation under anesthesia, shoulder joint, including application of fixation apparatus (dislocation excluded) $ 625.50 23800 Arthrodesis, glenohumeral joint; $ 3,604.50 23802 Arthrodesis, glenohumeral joint; with autogenous graft (includes 23900 Interthoracoscapular amputation (forequarter) $ 4,063.50 23920 Disarticulation of shoulder; $ 3,162.60 23921 Disarticulation of shoulder; secondary closure or scar revision $ 909.90 23929 Unlisted procedure, shoulder Cost 23930 Incision and drainage, upper arm or elbow area; deep abscess or $ 819.90 23931 Incision and drainage, upper arm or elbow area; bursa $ 675.90 23935 Incision, deep, with opening of bone cortex (eg, for osteomyelitis or bone abscess), humerus or elbow $ 1,374.30 24000 Arthrotomy, elbow, including exploration, drainage, or removal of 24006 Arthrotomy of the elbow, with capsular excision for capsular release 24065 Biopsy, soft tissue of upper arm or elbow area; superficial 24066 Biopsy, soft tissue of upper arm or elbow area; deep (subfascial or $ 707.89 24071 Excision, tumor, soft tissue of upper arm or elbow area, subcutaneous; 3 cm or greater $ 972.78 24073 Excision, tumor, soft tissue of upper arm or elbow area, subfascial (eg, intramuscular); 5 cm or greater $ 1,396.93 24075 Excision, tumor, soft tissue of upper arm or elbow area, $ 686.70 24076 Excision, tumor, soft tissue of upper arm or elbow area, subfascial (eg, intramuscular); less than 5 cm $ 1,179.00 24077 Radical resection of tumor (eg, sarcoma), soft tissue of upper arm or elbow area; less than 5 cm $ 2,430.90 24079 Radical resection of tumor (eg, sarcoma), soft tissue of upper arm or elbow area; 5 cm or greater $ 2,604.12 24100 Arthrotomy, elbow; with synovial biopsy only $ 1,082.70 24101 Arthrotomy, elbow; with joint exploration, with or without biopsy, with or without removal of loose or foreign body $ 1,861.20 24102 Arthrotomy, elbow; with synovectomy 24105 Excision, olecranon bursa $ 898.20 24110 Excision or curettage of bone cyst or benign tumor, humerus; 24115 Excision or curettage of bone cyst or benign tumor, humerus; with $ 1,887.30 24116 Excision or curettage of bone cyst or benign tumor, humerus; with

Row # CPT-4 HCPCS Price 24120 of radius or olecranon process; 24125 of radius or olecranon process; with autograft (includes obtaining graft) $ 1,740.60 24126 of radius or olecranon process; with allograft $ 1,524.60 24130 Excision, radial head $ 1,459.80 24134 Sequestrectomy (eg, for osteomyelitis or bone abscess), shaft or distal humerus 24136 Sequestrectomy (eg, for osteomyelitis or bone abscess), radial head or neck 24138 Sequestrectomy (eg, for osteomyelitis or bone abscess), olecranon process 24140 bone (eg, osteomyelitis), humerus $ 2,168.10 24145 bone (eg, osteomyelitis), radial head or neck $ 1,442.70 24147 bone (eg, osteomyelitis), olecranon process $ 1,296.00 24149 Radical resection of capsule, soft tissue, and heterotopic bone, elbow, with contracture release (separate procedure) 24150 Radical resection of tumor, shaft or distal humerus $ 2,443.50 24152 Radical resection of tumor, radial head or neck $ 2,158.20 24155 Resection of elbow joint (arthrectomy) 24160 Removal of prosthesis, includes debridement and synovectomy when performed; humeral and ulnar components $ 1,489.50 24164 Removal of prosthesis, includes debridement and synovectomy when performed; radial head 24200 Removal of foreign body, upper arm or elbow area; subcutaneous $ 368.10 24201 Removal of foreign body, upper arm or elbow area; deep (subfascial or intramuscular) $ 962.10 24220 Injection procedure for elbow arthrography 24300 Manipulation, elbow, under anesthesia $ 777.16 24301 Muscle or tendon transfer, any type, upper arm or elbow, single (excluding 24320-24331) $ 1,998.00 24305 Tendon lengthening, upper arm or elbow, each tendon $ 900.90 24310 Tenotomy, open, elbow to shoulder, each tendon $ 955.80 24320 Tenoplasty, with muscle transfer, with or without free graft, elbow to shoulder, single (Seddon-Brookes type procedure) $ 2,311.20 24330 Flexor-plasty, elbow (eg, Steindler type advancement); $ 2,269.80 24331 Flexor-plasty, elbow (eg, Steindler type advancement); with extensor advancement 24332 Tenolysis, triceps $ 1,181.38 24340 Tenodesis of biceps tendon at elbow (separate procedure) $ 1,922.40 24341 Repair, tendon or muscle, upper arm or elbow, each tendon or muscle, primary or secondary (excludes rotator cuff) $ 1,816.20 24342 Reinsertion of ruptured biceps or triceps tendon, distal, with or without tendon graft $ 2,416.50 24343 Repair lateral collateral ligament, elbow, with local tissue $ 1,858.95 24344 Reconstruction lateral collateral ligament, elbow, with tendon graft (includes harvesting of graft) $ 2,485.31 24345 Repair medial collateral ligament, elbow, with local tissue $ 1,857.96 24357 golfer's elbow); percutaneous $ 1,115.21 24358 golfer's elbow); debridement, soft tissue and/or bone, open $ 1,270.13 24359 golfer's elbow); debridement, soft tissue and/or bone, open with tendon repair or reattachment $ 1,520.03 24360 Arthroplasty, elbow; with membrane (eg, fascial) $ 3,267.00 24361 Arthroplasty, elbow; with distal humeral prosthetic replacement

Row # CPT-4 HCPCS Price 24362 Arthroplasty, elbow; with implant and fascia lata ligament $ 3,446.10 24363 Arthroplasty, elbow; with distal humerus and proximal ulnar prosthetic replacement (eg, total elbow) $ 4,614.30 24365 Arthroplasty, radial head; 24366 Arthroplasty, radial head; with implant 24400 Osteotomy, humerus, with or without internal fixation $ 2,451.60 24410 humeral shaft (Sofield type procedure) 24420 Osteoplasty, humerus (eg, shortening or lengthening) (excluding 64876) $ 2,397.60 24430 Repair of nonunion or malunion, humerus; without graft (eg, $ 2,629.80 24435 Repair of nonunion or malunion, humerus; with iliac or other $ 3,298.50 24470 Hemiepiphyseal arrest (eg, cubitus varus or valgus, distal humerus) 24495 Decompression fasciotomy, forearm, with brachial artery exploration $ 2,070.00 24498 without methylmethacrylate, humeral shaft 24500 Closed treatment of humeral shaft fracture; without manipulation 24505 Closed treatment of humeral shaft fracture; with manipulation, with or without skeletal traction $ 1,046.70 24515 Open treatment of humeral shaft fracture with plate/screws, with or without cerclage $ 2,314.80 24516 Treatment of humeral shaft fracture, with insertion of intramedullary implant, with or without cerclage and/or locking screws 24530 Closed treatment of supracondylar or transcondylar humeral fracture, with or without intercondylar extension; without $ 612.20 24535 Closed treatment of supracondylar or transcondylar humeral fracture, with or without intercondylar extension; with 24538 Percutaneous skeletal fixation of supracondylar or transcondylar humeral fracture, with or without intercondylar extension 24545 Open treatment of humeral supracondylar or transcondylar fracture, includes internal fixation, when performed; without intercondylar extension $ 2,343.60 24546 Open treatment of humeral supracondylar or transcondylar fracture, includes internal fixation, when performed; with intercondylar extension $ 2,875.50 24560 Closed treatment of humeral epicondylar fracture, medial or lateral; $ 535.50 24565 Closed treatment of humeral epicondylar fracture, medial or lateral; $ 788.40 24566 Percutaneous skeletal fixation of humeral epicondylar fracture, medial or lateral, with manipulation $ 1,277.10 24575 Open treatment of humeral epicondylar fracture, medial or lateral, $ 1,759.50 24576 Closed treatment of humeral condylar fracture, medial or lateral; $ 549.90 24577 Closed treatment of humeral condylar fracture, medial or lateral; 24579 Open treatment of humeral condylar fracture, medial or lateral, 24582 Percutaneous skeletal fixation of humeral condylar fracture, medial or lateral, with manipulation 24586 Open treatment of periarticular fracture and/or dislocation of the elbow (fracture distal humerus and proximal ulna and/or proximal radius); 24587 Open treatment of periarticular fracture and/or dislocation of the elbow (fracture distal humerus and proximal ulna and/or proximal radius); with implant arthroplasty 24600 Treatment of closed elbow dislocation; without anesthesia 24605 Treatment of closed elbow dislocation; requiring anesthesia $ 753.30

Row # CPT-4 HCPCS Price 24615 Open treatment of acute or chronic elbow dislocation $ 1,831.50 24620 Closed treatment of Monteggia type of fracture dislocation at elbow (fracture proximal end of ulna with dislocation of radial head), with manipulation $ 952.20 24635 Open treatment of Monteggia type of fracture dislocation at elbow (fracture proximal end of ulna with dislocation of radial head), $ 2,043.00 24640 Closed treatment of radial head subluxation in child, nursemaid elbow, with manipulation 24650 Closed treatment of radial head or neck fracture; without $ 413.10 24655 Closed treatment of radial head or neck fracture; with manipulation $ 778.50 24665 Open treatment of radial head or neck fracture, includes internal fixation or radial head excision, when performed; $ 1,544.40 24666 Open treatment of radial head or neck fracture, includes internal fixation or radial head excision, when performed; with radial head prosthetic replacement 24670 Closed treatment of ulnar fracture, proximal end (eg, olecranon or coronoid process[es]); without manipulation $ 478.80 24675 Closed treatment of ulnar fracture, proximal end (eg, olecranon or coronoid process[es]); with manipulation 24685 Open treatment of ulnar fracture, proximal end (eg, olecranon or coronoid process[es]), includes internal fixation, when performed 24800 Arthrodesis, elbow joint; local 24802 Arthrodesis, elbow joint; with autogenous graft (includes obtaining graft) 24900 Amputation, arm through humerus; with primary closure $ 1,834.20 24920 Amputation, arm through humerus; open, circular (guillotine) 24925 Amputation, arm through humerus; secondary closure or scar revision $ 774.90 24930 Amputation, arm through humerus; re-amputation $ 1,470.60 24931 Amputation, arm through humerus; with implant 24935 Stump elongation, upper extremity $ 2,499.30 24940 Cineplasty, upper extremity, complete procedure 24999 Unlisted procedure, humerus or elbow Cost 25000 Incision, extensor tendon sheath, wrist (eg, deQuervains disease) $ 1,080.90 25001 Incision, flexor tendon sheath, wrist (eg, flexor carpi radialis) $ 963.51 25020 Decompression fasciotomy, forearm and/or wrist, flexor OR extensor compartment; without debridement of nonviable muscle 25023 Decompression fasciotomy, forearm and/or wrist, flexor OR extensor compartment; with debridement of nonviable muscle 25024 Decompression fasciotomy, forearm and/or wrist, flexor AND extensor compartment; without debridement of nonviable muscle $ 1,555.24 25025 Decompression fasciotomy, forearm and/or wrist, flexor AND extensor compartment; with debridement of nonviable muscle $ 2,070.11 25028 Incision and drainage, forearm and/or wrist; deep abscess or 25031 Incision and drainage, forearm and/or wrist; bursa $ 586.80 25035 Incision, deep, bone cortex, forearm and/or wrist (eg, osteomyelitis or bone abscess) 25040 Arthrotomy, radiocarpal or midcarpal joint, with exploration, drainage, or removal of foreign body $ 1,479.60 25065 Biopsy, soft tissue of forearm and/or wrist; superficial $ 434.70 25066 Biopsy, soft tissue of forearm and/or wrist; deep (subfascial or 25073 Excision, tumor, soft tissue of forearm and/or wrist area, subfascial (eg, intramuscular); 3 cm or greater $ 1,806.54 25075 Excision, tumor, soft tissue of forearm and/or wrist area, $ 650.70 25076 Excision, tumor, soft tissue of forearm and/or wrist area, subfascial (eg, intramuscular); less than 3 cm

Row # CPT-4 HCPCS Price 25077 Radical resection of tumor (eg, sarcoma), soft tissue of forearm and/or wrist area; less than 3 cm $ 2,590.20 25085 Capsulotomy, wrist (eg, contracture) 25100 Arthrotomy, wrist joint; with biopsy $ 1,330.20 25101 Arthrotomy, wrist joint; with joint exploration, with or without biopsy, with or without removal of loose or foreign body $ 1,323.00 25105 Arthrotomy, wrist joint; with synovectomy $ 1,722.60 25107 Arthrotomy, distal radioulnar joint including repair of triangular cartilage, complex $ 1,453.50 25109 Excision of tendon, forearm and/or wrist, flexor or extensor, each $ 1,481.65 25110 Excision, lesion of tendon sheath, forearm and/or wrist 25111 Excision of ganglion, wrist (dorsal or volar); primary $ 943.10 25112 Excision of ganglion, wrist (dorsal or volar); recurrent $ 1,357.20 25115 Radical excision of bursa, synovia of wrist, or forearm tendon sheaths (eg, tenosynovitis, fungus, Tbc, or other granulomas, rheumatoid arthritis); flexors $ 2,098.80 25116 Radical excision of bursa, synovia of wrist, or forearm tendon sheaths (eg, tenosynovitis, fungus, Tbc, or other granulomas, rheumatoid arthritis); extensors, with or without transposition of dorsal retinaculum $ 2,058.30 25118 Synovectomy, extensor tendon sheath, wrist, single compartment; $ 1,926.00 25119 Synovectomy, extensor tendon sheath, wrist, single compartment; with resection of distal ulna $ 1,556.10 25120 (excluding head or neck of radius and olecranon process); $ 1,530.90 25125 (excluding head or neck of radius and olecranon process); with $ 1,812.60 25126 (excluding head or neck of radius and olecranon process); with 25130 $ 1,552.50 25135 25136 with allograft $ 1,669.50 25145 Sequestrectomy (eg, for osteomyelitis or bone abscess), forearm and/or wrist 25150 Partial excision (craterization, saucerization, or diaphysectomy) of bone (eg, for osteomyelitis); ulna 25151 Partial excision (craterization, saucerization, or diaphysectomy) of bone (eg, for osteomyelitis); radius $ 1,522.80 25170 Radical resection of tumor, radius or ulna 25210 Carpectomy; 1 bone $ 1,483.20 25215 Carpectomy; all bones of proximal row $ 2,278.80 25230 Radial styloidectomy (separate procedure) $ 1,163.70 25240 Excision distal ulna partial or complete (eg, Darrach type or matched resection) $ 1,516.50 25246 Injection procedure for wrist arthrography $ 223.20 25248 Exploration with removal of deep foreign body, forearm or wrist $ 1,003.50 25250 Removal of wrist prosthesis; (separate procedure) 25251 Removal of wrist prosthesis; complicated, including total wrist $ 2,194.20 25259 Manipulation, wrist, under anesthesia $ 1,033.88 25260 Repair, tendon or muscle, flexor, forearm and/or wrist; primary, $ 1,475.10 25263 Repair, tendon or muscle, flexor, forearm and/or wrist; secondary, 25265 Repair, tendon or muscle, flexor, forearm and/or wrist; secondary, with free graft (includes obtaining graft), each tendon or muscle $ 1,890.00 25270 Repair, tendon or muscle, extensor, forearm and/or wrist; primary, $ 1,206.90

Row # CPT-4 HCPCS Price 25272 Repair, tendon or muscle, extensor, forearm and/or wrist; secondary, single, each tendon or muscle 25274 Repair, tendon or muscle, extensor, forearm and/or wrist; secondary, with free graft (includes obtaining graft), each tendon or muscle 25275 Repair, tendon sheath, extensor, forearm and/or wrist, with free graft (includes obtaining graft) (eg, for extensor carpi ulnaris subluxation) $ 1,683.67 25280 Lengthening or shortening of flexor or extensor tendon, forearm and/or wrist, single, each tendon 25290 Tenotomy, open, flexor or extensor tendon, forearm and/or wrist, single, each tendon $ 943.20 25295 Tenolysis, flexor or extensor tendon, forearm and/or wrist, single, 25300 Tenodesis at wrist; flexors of fingers $ 1,893.60 25301 Tenodesis at wrist; extensors of fingers 25310 Tendon transplantation or transfer, flexor or extensor, forearm and/or wrist, single; each tendon 25312 Tendon transplantation or transfer, flexor or extensor, forearm and/or wrist, single; with tendon graft(s) (includes obtaining graft), $ 2,202.30 25315 Flexor origin slide (eg, for cerebral palsy, Volkmann contracture), forearm and/or wrist; $ 2,035.80 25316 Flexor origin slide (eg, for cerebral palsy, Volkmann contracture), forearm and/or wrist; with tendon(s) transfer $ 2,677.50 25320 Capsulorrhaphy or reconstruction, wrist, open (eg, capsulodesis, ligament repair, tendon transfer or graft) (includes synovectomy, capsulotomy and open reduction) for carpal instability 25332 Arthroplasty, wrist, with or without interposition, with or without external or internal fixation $ 2,537.10 25335 Centralization of wrist on ulna (eg, radial club hand) $ 3,493.80 25337 Reconstruction for stabilization of unstable distal ulna or distal radioulnar joint, secondary by soft tissue stabilization (eg, tendon transfer, tendon graft or weave, or tenodesis) with or without open reduction of distal radioulnar joint $ 1,961.10 25350 Osteotomy, radius; distal third 25355 Osteotomy, radius; middle or proximal third $ 1,962.90 25360 Osteotomy; ulna $ 1,773.00 25365 Osteotomy; radius AND ulna $ 2,209.50 25370 (Sofield type procedure); radius OR ulna $ 2,259.00 25375 (Sofield type procedure); radius AND ulna $ 3,060.90 25390 Osteoplasty, radius OR ulna; shortening $ 2,204.10 25391 Osteoplasty, radius OR ulna; lengthening with autograft $ 2,938.50 25392 Osteoplasty, radius AND ulna; shortening (excluding 64876) $ 2,710.80 25393 Osteoplasty, radius AND ulna; lengthening with autograft $ 3,029.40 25394 Osteoplasty, carpal bone, shortening $ 1,709.09 25400 Repair of nonunion or malunion, radius OR ulna; without graft (eg, $ 1,773.90 25405 Repair of nonunion or malunion, radius OR ulna; with autograft $ 2,500.20 25415 Repair of nonunion or malunion, radius AND ulna; without graft (eg, $ 2,615.40 25420 Repair of nonunion or malunion, radius AND ulna; with autograft $ 2,688.30 25425 Repair of defect with autograft; radius OR ulna $ 2,207.70 25426 Repair of defect with autograft; radius AND ulna $ 3,141.00 25430 Insertion of vascular pedicle into carpal bone (eg, Hori procedure) $ 1,713.16 25431 Repair of nonunion of carpal bone (excluding carpal scaphoid (navicular)) (includes obtaining graft and necessary fixation), each bone $ 2,472.29 25440 Repair of nonunion, scaphoid carpal (navicular) bone, with or without radial styloidectomy (includes obtaining graft and necessary $ 2,318.40 25441 Arthroplasty with prosthetic replacement; distal radius 25442 Arthroplasty with prosthetic replacement; distal ulna $ 1,840.50

Row # CPT-4 HCPCS Price 25443 Arthroplasty with prosthetic replacement; scaphoid carpal (navicular) $ 2,010.60 25444 Arthroplasty with prosthetic replacement; lunate $ 2,404.80 25445 Arthroplasty with prosthetic replacement; trapezium $ 2,321.10 25446 Arthroplasty with prosthetic replacement; distal radius and partial or entire carpus (total wrist) $ 3,823.20 25447 Arthroplasty, interposition, intercarpal or carpometacarpal joints $ 2,806.20 25449 Revision of arthroplasty, including removal of implant, wrist joint $ 1,763.10 25450 Epiphyseal arrest by epiphysiodesis or stapling; distal radius OR ulna $ 1,053.00 25455 Epiphyseal arrest by epiphysiodesis or stapling; distal radius AND ulna $ 1,548.00 25490 without methylmethacrylate; radius 25491 without methylmethacrylate; ulna $ 1,681.20 25492 without methylmethacrylate; radius AND ulna 25500 Closed treatment of radial shaft fracture; without manipulation 25505 Closed treatment of radial shaft fracture; with manipulation $ 775.80 25515 $ 1,587.60 25520 Closed treatment of radial shaft fracture and closed treatment of dislocation of distal radioulnar joint (Galeazzi fracture/dislocation) 25525 when performed, and closed treatment of distal radioulnar joint dislocation (Galeazzi fracture/dislocation), includes percutaneous skeletal fixation, when performed $ 2,566.80 25526 when performed, and open treatment of distal radioulnar joint dislocation (Galeazzi fracture/dislocation), includes internal fixation, when performed, includes repair of triangular fibro 25530 Closed treatment of ulnar shaft fracture; without manipulation 25535 Closed treatment of ulnar shaft fracture; with manipulation $ 811.80 25545 Open treatment of ulnar shaft fracture, includes internal fixation, $ 1,704.60 25560 Closed treatment of radial and ulnar shaft fractures; without $ 612.90 25565 Closed treatment of radial and ulnar shaft fractures; with 25574 Open treatment of radial AND ulnar shaft fractures, with internal fixation, when performed; of radius OR ulna $ 2,353.50 25575 Open treatment of radial AND ulnar shaft fractures, with internal fixation, when performed; of radius AND ulna $ 2,425.50 25600 Closed treatment of distal radial fracture (eg, Colles or Smith type) or epiphyseal separation, includes closed treatment of fracture of ulnar styloid, when performed; without manipulation 25605 Closed treatment of distal radial fracture (eg, Colles or Smith type) or epiphyseal separation, includes closed treatment of fracture of ulnar styloid, when performed; with manipulation 25606 Percutaneous skeletal fixation of distal radial fracture or epiphyseal separation $ 1,524.64 25607 Open treatment of distal radial extra-articular fracture or epiphyseal separation, with internal fixation $ 1,539.22 25622 Closed treatment of carpal scaphoid (navicular) fracture; without $ 612.90 25624 Closed treatment of carpal scaphoid (navicular) fracture; with $ 808.20 25628 Open treatment of carpal scaphoid (navicular) fracture, includes 25630 Closed treatment of carpal bone fracture (excluding carpal scaphoid [navicular]); without manipulation, each bone $ 506.70

Row # CPT-4 HCPCS Price 25635 Closed treatment of carpal bone fracture (excluding carpal scaphoid [navicular]); with manipulation, each bone 25645 Open treatment of carpal bone fracture (other than carpal scaphoid [navicular]), each bone 25650 Closed treatment of ulnar styloid fracture $ 758.70 25651 Percutaneous skeletal fixation of ulnar styloid fracture $ 1,006.20 25652 Open treatment of ulnar styloid fracture $ 1,318.22 25660 Closed treatment of radiocarpal or intercarpal dislocation, 1 or more bones, with manipulation $ 781.20 25670 Open treatment of radiocarpal or intercarpal dislocation, 1 or more bones $ 1,624.50 25671 Percutaneous skeletal fixation of distal radioulnar dislocation $ 1,128.99 25675 Closed treatment of distal radioulnar dislocation with manipulation $ 776.70 25676 Open treatment of distal radioulnar dislocation, acute or chronic 25680 Closed treatment of trans-scaphoperilunar type of fracture dislocation, with manipulation $ 1,107.90 25685 Open treatment of trans-scaphoperilunar type of fracture dislocation $ 2,005.20 25690 Closed treatment of lunate dislocation, with manipulation 25695 Open treatment of lunate dislocation 25800 Arthrodesis, wrist; complete, without bone graft (includes radiocarpal and/or intercarpal and/or carpometacarpal joints) $ 2,785.50 25805 Arthrodesis, wrist; with sliding graft $ 2,888.10 25810 Arthrodesis, wrist; with iliac or other autograft (includes obtaining graft) $ 3,366.00 25820 Arthrodesis, wrist; limited, without bone graft (eg, intercarpal or radiocarpal) $ 2,223.00 25825 Arthrodesis, wrist; with autograft (includes obtaining graft) 25830 Arthrodesis, distal radioulnar joint with segmental resection of ulna, with or without bone graft (eg, Sauve-Kapandji procedure) $ 2,169.90 25900 Amputation, forearm, through radius and ulna; $ 1,926.00 25905 Amputation, forearm, through radius and ulna; open, circular (guillotine) $ 1,746.00 25907 Amputation, forearm, through radius and ulna; secondary closure or scar revision $ 837.00 25909 Amputation, forearm, through radius and ulna; re-amputation $ 1,625.40 25915 Krukenberg procedure $ 2,570.40 25920 Disarticulation through wrist; $ 1,611.90 25922 Disarticulation through wrist; secondary closure or scar revision $ 945.90 25924 Disarticulation through wrist; re-amputation $ 1,646.10 25927 Transmetacarpal amputation; $ 1,952.10 25929 Transmetacarpal amputation; secondary closure or scar revision 25931 Transmetacarpal amputation; re-amputation $ 1,794.60 25999 Unlisted procedure, forearm or wrist Cost 26010 Drainage of finger abscess; simple 26011 Drainage of finger abscess; complicated (eg, felon) 26020 Drainage of tendon sheath, digit and/or palm, each 26025 Drainage of palmar bursa; single, bursa $ 1,323.90 26030 Drainage of palmar bursa; multiple bursa 26034 Incision, bone cortex, hand or finger (eg, osteomyelitis or bone $ 1,782.00 26035 Decompression fingers and/or hand, injection injury (eg, grease gun) $ 2,395.80 26037 Decompressive fasciotomy, hand (excludes 26035) $ 2,175.30 26040 Fasciotomy, palmar (eg, Dupuytren's contracture); percutaneous 26045 Fasciotomy, palmar (eg, Dupuytren's contracture); open, partial $ 1,457.10 26055 Tendon sheath incision (eg, for trigger finger) $ 931.88 26060 Tenotomy, percutaneous, single, each digit $ 499.50 26070 foreign body; carpometacarpal joint

Row # CPT-4 HCPCS Price 26075 foreign body; metacarpophalangeal joint, each $ 1,145.70 26080 foreign body; interphalangeal joint, each $ 895.50 26100 Arthrotomy with biopsy; carpometacarpal joint, each $ 920.70 26105 Arthrotomy with biopsy; metacarpophalangeal joint, each $ 1,050.30 26110 Arthrotomy with biopsy; interphalangeal joint, each 26111 Excision, tumor or vascular malformation, soft tissue of hand or finger, subcutaneous; 1.5 cm or greater $ 1,075.54 26113 Excision, tumor, soft tissue, or vascular malformation, of hand or finger, subfascial (eg, intramuscular); 1.5 cm or greater $ 1,621.65 26115 Excision, tumor or vascular malformation, soft tissue of hand or finger, subcutaneous; less than 1.5 cm 26116 Excision, tumor, soft tissue, or vascular malformation, of hand or finger, subfascial (eg, intramuscular); less than 1.5 cm $ 1,284.30 26117 Radical resection of tumor (eg, sarcoma), soft tissue of hand or finger; less than 3 cm $ 2,445.30 26118 Radical resection of tumor (eg, sarcoma), soft tissue of hand or finger; 3 cm or greater $ 3,201.59 26121 Fasciectomy, palm only, with or without Z-plasty, other local tissue rearrangement, or skin grafting (includes obtaining graft) $ 2,585.70 26123 Fasciectomy, partial palmar with release of single digit including proximal interphalangeal joint, with or without Z-plasty, other local tissue rearrangement, or skin grafting (includes obtaining graft); $ 2,606.40 26125 Fasciectomy, partial palmar with release of single digit including proximal interphalangeal joint, with or without Z-plasty, other local tissue rearrangement, or skin grafting (includes obtaining graft); each additional digit (List separately in addition 26130 Synovectomy, carpometacarpal joint $ 1,566.00 26135 Synovectomy, metacarpophalangeal joint including intrinsic release and extensor hood reconstruction, each digit $ 1,762.20 26140 Synovectomy, proximal interphalangeal joint, including extensor reconstruction, each interphalangeal joint $ 1,708.20 26145 Synovectomy, tendon sheath, radical (tenosynovectomy), flexor tendon, palm and/or finger, each tendon $ 1,744.20 26160 Excision of lesion of tendon sheath or joint capsule (eg, cyst, mucous cyst, or ganglion), hand or finger $ 913.50 26170 Excision of tendon, palm, flexor or extensor, single, each tendon $ 945.90 26180 Excision of tendon, finger, flexor or extensor, each tendon $ 834.30 26185 Sesamoidectomy, thumb or finger (separate procedure) $ 929.70 26200 Excision or curettage of bone cyst or benign tumor of metacarpal; $ 1,137.60 26205 Excision or curettage of bone cyst or benign tumor of metacarpal; $ 1,695.60 26210 middle, or distal phalanx of finger; $ 1,234.80 26215 middle, or distal phalanx of finger; with autograft (includes $ 1,538.10 26230 bone (eg, osteomyelitis); metacarpal $ 1,121.40 26235 bone (eg, osteomyelitis); proximal or middle phalanx of finger 26236 bone (eg, osteomyelitis); distal phalanx of finger $ 931.50 26250 Radical resection of tumor, metacarpal $ 1,561.50 26260 Radical resection of tumor, proximal or middle phalanx of finger $ 1,692.00 26262 Radical resection of tumor, distal phalanx of finger $ 1,568.70 26320 Removal of implant from finger or hand 26340 Manipulation, finger joint, under anesthesia, each joint $ 841.74

Row # CPT-4 HCPCS Price 26350 Repair or advancement, flexor tendon, not in zone 2 digital flexor tendon sheath (eg, no man's land); primary or secondary without free graft, each tendon $ 2,094.30 26352 Repair or advancement, flexor tendon, not in zone 2 digital flexor tendon sheath (eg, no man's land); secondary with free graft $ 2,346.30 26356 tendon sheath (eg, no man's land); primary, without free graft, each 26357 tendon sheath (eg, no man's land); secondary, without free graft, 26358 tendon sheath (eg, no man's land); secondary, with free graft 26370 superficialis tendon; primary, each tendon 26372 superficialis tendon; secondary with free graft (includes obtaining 26373 superficialis tendon; secondary without free graft, each tendon 26390 Excision flexor tendon, with implantation of synthetic rod for delayed tendon graft, hand or finger, each rod $ 1,753.20 26392 Removal of synthetic rod and insertion of flexor tendon graft, hand or finger (includes obtaining graft), each rod $ 2,260.80 26410 Repair, extensor tendon, hand, primary or secondary; without free 26412 Repair, extensor tendon, hand, primary or secondary; with free graft (includes obtaining graft), each tendon $ 1,515.60 26415 Excision of extensor tendon, with implantation of synthetic rod for delayed tendon graft, hand or finger, each rod $ 1,444.50 26416 Removal of synthetic rod and insertion of extensor tendon graft (includes obtaining graft), hand or finger, each rod $ 1,515.60 26418 Repair, extensor tendon, finger, primary or secondary; without free $ 1,251.90 26420 Repair, extensor tendon, finger, primary or secondary; with free graft (includes obtaining graft) each tendon 26426 Repair of extensor tendon, central slip, secondary (eg, boutonniere deformity); using local tissue(s), including lateral band(s), each finger 26428 Repair of extensor tendon, central slip, secondary (eg, boutonniere deformity); with free graft (includes obtaining graft), each finger $ 1,773.00 26432 Closed treatment of distal extensor tendon insertion, with or without percutaneous pinning (eg, mallet finger) $ 1,139.40 26433 Repair of extensor tendon, distal insertion, primary or secondary; without graft (eg, mallet finger) 26434 Repair of extensor tendon, distal insertion, primary or secondary; with free graft (includes obtaining graft) $ 1,368.00 26437 Realignment of extensor tendon, hand, each tendon 26440 Tenolysis, flexor tendon; palm OR finger, each tendon $ 1,247.40 26442 Tenolysis, flexor tendon; palm AND finger, each tendon $ 1,440.90 26445 Tenolysis, extensor tendon, hand OR finger, each tendon $ 1,212.30 26449 Tenolysis, complex, extensor tendon, finger, including forearm, each 26450 Tenotomy, flexor, palm, open, each tendon $ 733.50 26455 Tenotomy, flexor, finger, open, each tendon $ 847.80 26460 Tenotomy, extensor, hand or finger, open, each tendon 26471 Tenodesis; of proximal interphalangeal joint, each joint $ 1,384.20 26474 Tenodesis; of distal joint, each joint 26476 Lengthening of tendon, extensor, hand or finger, each tendon $ 1,012.50 26477 Shortening of tendon, extensor, hand or finger, each tendon $ 1,078.20 26478 Lengthening of tendon, flexor, hand or finger, each tendon 26479 Shortening of tendon, flexor, hand or finger, each tendon $ 1,348.20 26480 Transfer or transplant of tendon, carpometacarpal area or dorsum of hand; without free graft, each tendon $ 1,838.70

Row # CPT-4 HCPCS Price 26483 Transfer or transplant of tendon, carpometacarpal area or dorsum of hand; with free tendon graft (includes obtaining graft), each 26485 Transfer or transplant of tendon, palmar; without free tendon graft, 26489 Transfer or transplant of tendon, palmar; with free tendon graft $ 2,232.90 26490 Opponensplasty; superficialis tendon transfer type, each tendon $ 2,045.70 26492 Opponensplasty; tendon transfer with graft (includes obtaining $ 2,237.40 26494 Opponensplasty; hypothenar muscle transfer 26496 Opponensplasty; other methods 26497 Transfer of tendon to restore intrinsic function; ring and small finger $ 2,201.40 26498 Transfer of tendon to restore intrinsic function; all 4 fingers $ 2,544.30 26499 Correction claw finger, other methods $ 2,403.90 26500 Reconstruction of tendon pulley, each tendon; with local tissues $ 1,257.30 26502 Reconstruction of tendon pulley, each tendon; with tendon or fascial graft (includes obtaining graft) (separate procedure) 26508 Release of thenar muscle(s) (eg, thumb contracture) $ 1,460.70 26510 Cross intrinsic transfer, each tendon 26516 Capsulodesis, metacarpophalangeal joint; single digit $ 1,593.90 26517 Capsulodesis, metacarpophalangeal joint; 2 digits 26518 Capsulodesis, metacarpophalangeal joint; 3 or 4 digits $ 2,031.30 26520 Capsulectomy or capsulotomy; metacarpophalangeal joint, each joint $ 1,548.00 26525 Capsulectomy or capsulotomy; interphalangeal joint, each joint $ 1,649.70 26530 Arthroplasty, metacarpophalangeal joint; each joint $ 1,611.90 26531 Arthroplasty, metacarpophalangeal joint; with prosthetic implant, each joint $ 1,847.70 26535 Arthroplasty, interphalangeal joint; each joint $ 1,657.80 26536 Arthroplasty, interphalangeal joint; with prosthetic implant, each joint 26540 Repair of collateral ligament, metacarpophalangeal or interphalangeal joint $ 1,791.00 26541 Reconstruction, collateral ligament, metacarpophalangeal joint, single; with tendon or fascial graft (includes obtaining graft) $ 2,261.70 26542 Reconstruction, collateral ligament, metacarpophalangeal joint, single; with local tissue (eg, adductor advancement) $ 2,025.00 26545 Reconstruction, collateral ligament, interphalangeal joint, single, including graft, each joint $ 1,589.40 26546 Repair non-union, metacarpal or phalanx (includes obtaining bone graft with or without external or internal fixation) 26548 Repair and reconstruction, finger, volar plate, interphalangeal joint 26550 Pollicization of a digit $ 3,405.60 26551 Transfer, toe-to-hand with microvascular anastomosis; great toe wrap-around with bone graft $ 9,160.20 26553 Transfer, toe-to-hand with microvascular anastomosis; other than great toe, single $ 9,096.30 26554 Transfer, toe-to-hand with microvascular anastomosis; other than great toe, double $ 10,847.70 26555 Transfer, finger to another position without microvascular anastomosis $ 2,587.50 26556 Transfer, free toe joint, with microvascular anastomosis $ 9,251.10 26560 Repair of syndactyly (web finger) each web space; with skin flaps 26561 Repair of syndactyly (web finger) each web space; with skin flaps and grafts 26562 Repair of syndactyly (web finger) each web space; complex (eg, involving bone, nails) $ 2,721.60 26565 Osteotomy; metacarpal, each $ 1,844.10 26567 Osteotomy; phalanx of finger, each $ 1,483.20 26568 Osteoplasty, lengthening, metacarpal or phalanx $ 2,240.10

Row # CPT-4 HCPCS Price 26580 Repair cleft hand $ 3,350.70 26587 Reconstruction of polydactylous digit, soft tissue and bone 26590 Repair macrodactylia, each digit $ 2,241.00 26591 Repair, intrinsic muscles of hand, each muscle $ 1,861.20 26593 Release, intrinsic muscles of hand, each muscle $ 1,684.80 26596 Excision of constricting ring of finger, with multiple Z-plasties $ 1,884.60 26600 Closed treatment of metacarpal fracture, single; without manipulation, each bone $ 341.10 26605 Closed treatment of metacarpal fracture, single; with manipulation, each bone $ 504.00 26607 Closed treatment of metacarpal fracture, with manipulation, with external fixation, each bone $ 983.70 26608 Percutaneous skeletal fixation of metacarpal fracture, each bone $ 1,079.10 26615 Open treatment of metacarpal fracture, single, includes internal fixation, when performed, each bone $ 1,511.10 26641 Closed treatment of carpometacarpal dislocation, thumb, with 26645 Closed treatment of carpometacarpal fracture dislocation, thumb (Bennett fracture), with manipulation 26650 Percutaneous skeletal fixation of carpometacarpal fracture dislocation, thumb (Bennett fracture), with manipulation $ 1,207.80 26665 Open treatment of carpometacarpal fracture dislocation, thumb (Bennett fracture), includes internal fixation, when performed $ 1,818.90 26670 Closed treatment of carpometacarpal dislocation, other than thumb, with manipulation, each joint; without anesthesia 26675 Closed treatment of carpometacarpal dislocation, other than thumb, with manipulation, each joint; requiring anesthesia $ 617.66 26676 Percutaneous skeletal fixation of carpometacarpal dislocation, other than thumb, with manipulation, each joint 26685 Open treatment of carpometacarpal dislocation, other than thumb; includes internal fixation, when performed, each joint $ 1,269.00 26686 Open treatment of carpometacarpal dislocation, other than thumb; complex, multiple, or delayed reduction $ 1,341.00 26700 Closed treatment of metacarpophalangeal dislocation, single, with manipulation; without anesthesia $ 340.20 26705 Closed treatment of metacarpophalangeal dislocation, single, with manipulation; requiring anesthesia $ 525.60 26706 Percutaneous skeletal fixation of metacarpophalangeal dislocation, single, with manipulation $ 847.80 26715 Open treatment of metacarpophalangeal dislocation, single, $ 1,225.80 26720 Closed treatment of phalangeal shaft fracture, proximal or middle phalanx, finger or thumb; without manipulation, each $ 278.10 26725 Closed treatment of phalangeal shaft fracture, proximal or middle phalanx, finger or thumb; with manipulation, with or without skin or skeletal traction, each 26727 Percutaneous skeletal fixation of unstable phalangeal shaft fracture, proximal or middle phalanx, finger or thumb, with manipulation, each $ 967.50 26735 Open treatment of phalangeal shaft fracture, proximal or middle phalanx, finger or thumb, includes internal fixation, when performed, each 26740 Closed treatment of articular fracture, involving metacarpophalangeal or interphalangeal joint; without $ 492.30 26742 Closed treatment of articular fracture, involving metacarpophalangeal or interphalangeal joint; with manipulation, each 26746 Open treatment of articular fracture, involving metacarpophalangeal or interphalangeal joint, includes internal fixation, when performed, each

Row # CPT-4 HCPCS Price 26750 Closed treatment of distal phalangeal fracture, finger or thumb; without manipulation, each $ 227.70 26755 Closed treatment of distal phalangeal fracture, finger or thumb; with manipulation, each $ 368.40 26756 Percutaneous skeletal fixation of distal phalangeal fracture, finger or thumb, each 26765 Open treatment of distal phalangeal fracture, finger or thumb, includes internal fixation, when performed, each $ 889.20 26770 Closed treatment of interphalangeal joint dislocation, single, with manipulation; without anesthesia $ 244.56 26775 Closed treatment of interphalangeal joint dislocation, single, with manipulation; requiring anesthesia 26776 Percutaneous skeletal fixation of interphalangeal joint dislocation, single, with manipulation $ 712.80 26785 Open treatment of interphalangeal joint dislocation, includes internal fixation, when performed, single $ 990.90 26820 Fusion in opposition, thumb, with autogenous graft (includes $ 1,808.10 26841 Arthrodesis, carpometacarpal joint, thumb, with or without internal 26842 Arthrodesis, carpometacarpal joint, thumb, with or without internal fixation; with autograft (includes obtaining graft) 26843 Arthrodesis, carpometacarpal joint, digit, other than thumb, each; 26844 Arthrodesis, carpometacarpal joint, digit, other than thumb, each; 26850 Arthrodesis, metacarpophalangeal joint, with or without internal $ 1,919.70 26852 Arthrodesis, metacarpophalangeal joint, with or without internal fixation; with autograft (includes obtaining graft) 26860 $ 1,250.10 26861 each additional interphalangeal joint (List separately in addition to 26862 26863 with autograft (includes obtaining graft), each additional joint (List $ 646.20 26910 Amputation, metacarpal, with finger or thumb (ray amputation), single, with or without interosseous transfer 26951 Amputation, finger or thumb, primary or secondary, any joint or phalanx, single, including neurectomies; with direct closure $ 910.80 26952 Amputation, finger or thumb, primary or secondary, any joint or phalanx, single, including neurectomies; with local advancement flaps (V-Y, hood) 26989 Unlisted procedure, hands or fingers $ 658.80 26990 Incision and drainage, pelvis or hip joint area; deep abscess or $ 900.90 26991 Incision and drainage, pelvis or hip joint area; infected bursa 26992 Incision, bone cortex, pelvis and/or hip joint (eg, osteomyelitis or bone abscess) $ 1,793.70 27000 Tenotomy, adductor of hip, percutaneous (separate procedure) $ 498.60 27001 Tenotomy, adductor of hip, open $ 912.60 27003 Tenotomy, adductor, subcutaneous, open, with obturator neurectomy 27005 Tenotomy, hip flexor(s), open (separate procedure) $ 1,452.60 27006 Tenotomy, abductors and/or extensor(s) of hip, open (separate $ 1,012.50 27025 Fasciotomy, hip or thigh, any type $ 1,698.30 27027 Decompression fasciotomy(ies), pelvic (buttock) compartment(s) (eg, gluteus medius-minimus, gluteus maximus, iliopsoas, and/or tensor fascia lata muscle), unilateral $ 1,637.28 27030 Arthrotomy, hip, with drainage (eg, infection) $ 2,173.50

Row # CPT-4 HCPCS Price 27033 Arthrotomy, hip, including exploration or removal of loose or $ 2,332.80 27035 Denervation, hip joint, intrapelvic or extrapelvic intra-articular branches of sciatic, femoral, or obturator nerves 27036 Capsulectomy or capsulotomy, hip, with or without excision of heterotopic bone, with release of hip flexor muscles (ie, gluteus medius, gluteus minimus, tensor fascia latae, rectus femoris, sartorius, iliopsoas) 27040 Biopsy, soft tissue of pelvis and hip area; superficial 27041 Biopsy, soft tissue of pelvis and hip area; deep, subfascial or 27043 Excision, tumor, soft tissue of pelvis and hip area, subcutaneous; 3 $ 877.66 27045 Excision, tumor, soft tissue of pelvis and hip area, subfascial (eg, $ 1,380.69 27047 Excision, tumor, soft tissue of pelvis and hip area, subcutaneous; less than 3 cm $ 697.50 27048 Excision, tumor, soft tissue of pelvis and hip area, subfascial (eg, $ 1,323.00 27049 Radical resection of tumor (eg, sarcoma), soft tissue of pelvis and hip area; less than 5 cm $ 3,126.60 27050 Arthrotomy, with biopsy; sacroiliac joint 27052 Arthrotomy, with biopsy; hip joint $ 2,218.50 27054 Arthrotomy with synovectomy, hip joint $ 2,638.80 27057 Decompression fasciotomy(ies), pelvic (buttock) compartment(s) (eg, gluteus medius-minimus, gluteus maximus, iliopsoas, and/or tensor fascia lata muscle) with debridement of nonviable muscle, $ 1,660.89 27059 Radical resection of tumor (eg, sarcoma), soft tissue of pelvis and hip area; 5 cm or greater $ 3,359.14 27060 Excision; ischial bursa $ 999.90 27062 Excision; trochanteric bursa or calcification $ 904.50 27065 pubis, or greater trochanter of femur; superficial, includes autograft, when performed $ 1,318.50 27066 pubis, or greater trochanter of femur; deep (subfascial), includes autograft, when performed $ 1,965.60 27067 pubis, or greater trochanter of femur; with autograft requiring separate incision 27070 Partial excision, wing of ilium, symphysis pubis, or greater trochanter of femur, (craterization, saucerization) (eg, osteomyelitis or bone abscess); superficial $ 1,739.70 27071 Partial excision, wing of ilium, symphysis pubis, or greater trochanter of femur, (craterization, saucerization) (eg, osteomyelitis or bone abscess); deep (subfascial or intramuscular) $ 1,902.60 27075 Radical resection of tumor; wing of ilium, 1 pubic or ischial ramus or symphysis pubis $ 3,087.90 27076 Radical resection of tumor; ilium, including acetabulum, both pubic rami, or ischium and acetabulum $ 4,360.50 27077 Radical resection of tumor; innominate bone, total $ 5,816.70 27078 Radical resection of tumor; ischial tuberosity and greater trochanter of femur $ 1,979.10 27080 Coccygectomy, primary $ 1,275.30 27086 Removal of foreign body, pelvis or hip; subcutaneous tissue $ 332.10 27087 Removal of foreign body, pelvis or hip; deep (subfascial or $ 1,123.53 27090 Removal of hip prosthesis; (separate procedure) 27091 Removal of hip prosthesis; complicated, including total hip prosthesis, methylmethacrylate with or without insertion of spacer $ 5,319.90 27093 Injection procedure for hip arthrography; without anesthesia $ 275.40 27095 Injection procedure for hip arthrography; with anesthesia $ 504.00 27096 Injection procedure for sacroiliac joint, anesthetic/steroid, with image guidance (fluoroscopy or ct) including arthrography when 27097 Release or recession, hamstring, proximal $ 1,754.10

Row # CPT-4 HCPCS Price 27098 Transfer, adductor to ischium $ 2,065.50 27100 Transfer external oblique muscle to greater trochanter including fascial or tendon extension (graft) 27105 Transfer paraspinal muscle to hip (includes fascial or tendon extension graft) $ 2,504.70 27110 Transfer iliopsoas; to greater trochanter of femur $ 2,935.80 27111 Transfer iliopsoas; to femoral neck $ 2,898.90 27120 Acetabuloplasty; (eg, Whitman, Colonna, Haygroves, or cup type) $ 3,783.60 27122 Acetabuloplasty; resection, femoral head (eg, Girdlestone 27125 Hemiarthroplasty, hip, partial (eg, femoral stem prosthesis, bipolar $ 4,079.70 27130 Arthroplasty, acetabular and proximal femoral prosthetic replacement (total hip arthroplasty), with or without autograft or $ 5,616.90 27132 Conversion of previous hip surgery to total hip arthroplasty, with or without autograft or allograft $ 6,371.10 27134 Revision of total hip arthroplasty; both components, with or without autograft or allograft $ 8,532.18 27137 Revision of total hip arthroplasty; acetabular component only, with or without autograft or allograft $ 5,851.80 27138 Revision of total hip arthroplasty; femoral component only, with or without allograft $ 5,899.50 27140 Osteotomy and transfer of greater trochanter of femur (separate $ 2,176.20 27146 Osteotomy, iliac, acetabular or innominate bone; $ 3,255.30 27147 Osteotomy, iliac, acetabular or innominate bone; with open reduction of hip $ 3,914.10 27151 Osteotomy, iliac, acetabular or innominate bone; with femoral osteotomy $ 3,619.80 27156 Osteotomy, iliac, acetabular or innominate bone; with femoral osteotomy and with open reduction of hip $ 4,401.00 27158 Osteotomy, pelvis, bilateral (eg, congenital malformation) 27161 Osteotomy, femoral neck (separate procedure) $ 3,132.00 27165 Osteotomy, intertrochanteric or subtrochanteric including internal or external fixation and/or cast $ 3,549.60 27170 Bone graft, femoral head, neck, intertrochanteric or subtrochanteric area (includes obtaining bone graft) $ 3,708.00 27175 Treatment of slipped femoral epiphysis; by traction, without reduction $ 1,855.80 27176 Treatment of slipped femoral epiphysis; by single or multiple pinning, in situ $ 2,770.20 27177 Open treatment of slipped femoral epiphysis; single or multiple pinning or bone graft (includes obtaining graft) $ 3,270.60 27178 Open treatment of slipped femoral epiphysis; closed manipulation with single or multiple pinning $ 3,458.70 27179 Open treatment of slipped femoral epiphysis; osteoplasty of femoral neck (Heyman type procedure) $ 2,672.10 27181 Open treatment of slipped femoral epiphysis; osteotomy and internal fixation $ 3,789.90 27185 Epiphyseal arrest by epiphysiodesis or stapling, greater trochanter of femur $ 1,233.00 27187 without methylmethacrylate, femoral neck and proximal femur $ 4,241.70 27193 Closed treatment of pelvic ring fracture, dislocation, diastasis or subluxation; without manipulation 27194 Closed treatment of pelvic ring fracture, dislocation, diastasis or subluxation; with manipulation, requiring more than local $ 1,568.70 27200 Closed treatment of coccygeal fracture $ 441.90 27202 Open treatment of coccygeal fracture $ 897.30 27215 Open treatment of iliac spine(s), tuberosity avulsion, or iliac wing fracture(s), unilateral, for pelvic bone fracture patterns that do not disrupt the pelvic ring, includes internal fixation, when performed

Row # CPT-4 HCPCS Price 27216 Percutaneous skeletal fixation of posterior pelvic bone fracture and/or dislocation, for fracture patterns that disrupt the pelvic ring, unilateral (includes ipsilateral ilium, sacroiliac joint and/or sacrum) $ 2,767.50 27217 Open treatment of anterior pelvic bone fracture and/or dislocation for fracture patterns that disrupt the pelvic ring, unilateral, includes internal fixation, when performed (includes pubic symphysis and/or ipsilateral superior/inferior rami) $ 3,654.90 27218 Open treatment of posterior pelvic bone fracture and/or dislocation, for fracture patterns that disrupt the pelvic ring, unilateral, includes internal fixation, when performed (includes ipsilateral ilium, sacroiliac joint and/or sacrum) $ 4,345.20 27220 Closed treatment of acetabulum (hip socket) fracture(s); without 27222 Closed treatment of acetabulum (hip socket) fracture(s); with manipulation, with or without skeletal traction 27226 Open treatment of posterior or anterior acetabular wall fracture, with internal fixation $ 3,602.70 27227 Open treatment of acetabular fracture(s) involving anterior or posterior (one) column, or a fracture running transversely across the acetabulum, with internal fixation $ 6,057.90 27228 Open treatment of acetabular fracture(s) involving anterior and posterior (two) columns, includes T-fracture and both column fracture with complete articular detachment, or single column or transverse fracture with associated acetabular wall fracture, wit $ 6,196.50 27230 Closed treatment of femoral fracture, proximal end, neck; without $ 1,077.30 27232 Closed treatment of femoral fracture, proximal end, neck; with manipulation, with or without skeletal traction $ 1,769.40 27235 Percutaneous skeletal fixation of femoral fracture, proximal end, neck $ 3,135.60 27236 Open treatment of femoral fracture, proximal end, neck, internal fixation or prosthetic replacement $ 3,712.50 27238 Closed treatment of intertrochanteric, peritrochanteric, or subtrochanteric femoral fracture; without manipulation $ 1,142.10 27240 Closed treatment of intertrochanteric, peritrochanteric, or subtrochanteric femoral fracture; with manipulation, with or without skin or skeletal traction $ 2,139.30 27244 Treatment of intertrochanteric, peritrochanteric, or subtrochanteric femoral fracture; with plate/screw type implant, with or without cerclage $ 3,339.00 27245 Treatment of intertrochanteric, peritrochanteric, or subtrochanteric femoral fracture; with intramedullary implant, with or without interlocking screws and/or cerclage $ 3,947.40 27246 Closed treatment of greater trochanteric fracture, without 27248 Open treatment of greater trochanteric fracture, includes internal $ 2,221.20 27250 Closed treatment of hip dislocation, traumatic; without anesthesia $ 764.10 27252 Closed treatment of hip dislocation, traumatic; requiring anesthesia $ 1,134.90 27253 Open treatment of hip dislocation, traumatic, without internal $ 2,451.60 27254 Open treatment of hip dislocation, traumatic, with acetabular wall and femoral head fracture, with or without internal or external 27256 Treatment of spontaneous hip dislocation (developmental, including congenital or pathological), by abduction, splint or traction; without anesthesia, without manipulation $ 1,652.40 27257 Treatment of spontaneous hip dislocation (developmental, including congenital or pathological), by abduction, splint or traction; with manipulation, requiring anesthesia $ 1,835.10 27258 Open treatment of spontaneous hip dislocation (developmental, including congenital or pathological), replacement of femoral head in acetabulum (including tenotomy, etc); $ 2,468.70

Row # CPT-4 HCPCS Price 27259 Open treatment of spontaneous hip dislocation (developmental, including congenital or pathological), replacement of femoral head in acetabulum (including tenotomy, etc); with femoral shaft shortening 27265 Closed treatment of post hip arthroplasty dislocation; without 27266 Closed treatment of post hip arthroplasty dislocation; requiring regional or general anesthesia $ 1,535.40 27267 Closed treatment of femoral fracture, proximal end, head; without $ 864.17 27268 Closed treatment of femoral fracture, proximal end, head; with $ 1,109.74 27269 Open treatment of femoral fracture, proximal end, head, includes $ 2,878.69 27275 Manipulation, hip joint, requiring general anesthesia $ 505.80 27280 Arthrodesis, sacroiliac joint (including obtaining graft) $ 2,464.20 27282 Arthrodesis, symphysis pubis (including obtaining graft) $ 2,461.50 27284 Arthrodesis, hip joint (including obtaining graft); $ 4,975.20 27286 Arthrodesis, hip joint (including obtaining graft); with subtrochanteric osteotomy $ 4,097.70 27290 Interpelviabdominal amputation (hindquarter amputation) $ 5,978.70 27295 Disarticulation of hip $ 4,355.10 27299 Unlisted procedure, pelvis or hip joint Cost 27301 Incision and drainage, deep abscess, bursa, or hematoma, thigh or knee region $ 832.94 27303 Incision, deep, with opening of bone cortex, femur or knee (eg, osteomyelitis or bone abscess) $ 1,818.00 27305 Fasciotomy, iliotibial (tenotomy), open $ 1,055.70 27306 Tenotomy, percutaneous, adductor or hamstring; single tendon 27307 Tenotomy, percutaneous, adductor or hamstring; multiple tendons $ 1,024.20 27310 Arthrotomy, knee, with exploration, drainage, or removal of foreign body (eg, infection) 27323 Biopsy, soft tissue of thigh or knee area; superficial 27324 Biopsy, soft tissue of thigh or knee area; deep (subfascial or $ 807.30 27325 Neurectomy, hamstring muscle $ 1,757.66 27326 Neurectomy, popliteal (gastrocnemius) $ 1,605.75 27327 Excision, tumor, soft tissue of thigh or knee area, subcutaneous; less $ 720.00 27328 Excision, tumor, soft tissue of thigh or knee area, subfascial (eg, 27329 Radical resection of tumor (eg, sarcoma), soft tissue of thigh or knee area; less than 5 cm $ 2,625.30 27330 Arthrotomy, knee; with synovial biopsy only $ 2,022.30 27331 Arthrotomy, knee; including joint exploration, biopsy, or removal of loose or foreign bodies $ 1,806.30 27332 Arthrotomy, with excision of semilunar cartilage (meniscectomy) knee; medial OR lateral $ 2,399.40 27333 Arthrotomy, with excision of semilunar cartilage (meniscectomy) knee; medial AND lateral $ 3,174.14 27334 Arthrotomy, with synovectomy, knee; anterior OR posterior 27335 Arthrotomy, with synovectomy, knee; anterior AND posterior including popliteal area $ 2,895.30 27337 Excision, tumor, soft tissue of thigh or knee area, subcutaneous; 3 $ 1,376.91 27339 Excision, tumor, soft tissue of thigh or knee area, subfascial (eg, $ 2,414.25 27340 Excision, prepatellar bursa $ 1,103.40 27345 Excision of synovial cyst of popliteal space (eg, Baker's cyst) $ 1,524.60 27347 Excision of lesion of meniscus or capsule (eg, cyst, ganglion), knee $ 784.80 27350 Patellectomy or hemipatellectomy $ 2,124.00 27355 Excision or curettage of bone cyst or benign tumor of femur; 27356 27357 $ 2,436.30

Row # CPT-4 HCPCS Price 27358 internal fixation (List in addition to code for primary procedure) $ 2,508.30 27360 bone, femur, proximal tibia and/or fibula (eg, osteomyelitis or bone 27364 Radical resection of tumor (eg, sarcoma), soft tissue of thigh or knee area; 5 cm or greater $ 4,912.84 27365 Radical resection of tumor, femur or knee $ 3,127.50 27370 Injection procedure for knee arthrography $ 197.10 27372 Removal of foreign body, deep, thigh region or knee area $ 955.80 27380 Suture of infrapatellar tendon; primary $ 1,602.00 27381 Suture of infrapatellar tendon; secondary reconstruction, including fascial or tendon graft 27385 Suture of quadriceps or hamstring muscle rupture; primary $ 1,827.90 27386 Suture of quadriceps or hamstring muscle rupture; secondary reconstruction, including fascial or tendon graft $ 2,734.20 27390 Tenotomy, open, hamstring, knee to hip; single tendon 27391 Tenotomy, open, hamstring, knee to hip; multiple tendons, 1 leg 27392 Tenotomy, open, hamstring, knee to hip; multiple tendons, bilateral 27393 Lengthening of hamstring tendon; single tendon $ 1,071.00 27394 Lengthening of hamstring tendon; multiple tendons, 1 leg $ 1,632.60 27395 Lengthening of hamstring tendon; multiple tendons, bilateral $ 2,038.50 27396 Transplant or transfer (with muscle redirection or rerouting), thigh (eg, extensor to flexor); single tendon $ 2,131.20 27397 Transplant or transfer (with muscle redirection or rerouting), thigh (eg, extensor to flexor); multiple tendons $ 2,707.20 27400 Transfer, tendon or muscle, hamstrings to femur (eg, Egger's type $ 1,980.00 27403 Arthrotomy with meniscus repair, knee $ 2,745.00 27405 Repair, primary, torn ligament and/or capsule, knee; collateral $ 2,272.50 27407 Repair, primary, torn ligament and/or capsule, knee; cruciate $ 3,190.50 27409 Repair, primary, torn ligament and/or capsule, knee; collateral and cruciate ligaments $ 3,634.20 27412 Autologous chondrocyte implantation, knee $ 5,606.85 27415 Osteochondral allograft, knee, open $ 4,366.31 27416 Osteochondral autograft(s), knee, open (eg, mosaicplasty) (includes harvesting of autograft[s]) $ 2,968.11 27418 Anterior tibial tubercleplasty (eg, Maquet type procedure) 27420 Reconstruction of dislocating patella; (eg, Hauser type procedure) $ 2,293.20 27422 Reconstruction of dislocating patella; with extensor realignment and/or muscle advancement or release (eg, Campbell, Goldwaite type procedure) $ 2,475.00 27424 Reconstruction of dislocating patella; with patellectomy $ 2,765.70 27425 Lateral retinacular release, open $ 2,367.00 27427 Ligamentous reconstruction (augmentation), knee; extra-articular $ 3,698.10 27428 Ligamentous reconstruction (augmentation), knee; intra-articular (open) $ 3,715.20 27429 Ligamentous reconstruction (augmentation), knee; intra-articular (open) and extra-articular $ 4,960.80 27430 Quadricepsplasty (eg, Bennett or Thompson type) $ 2,210.40 27435 Capsulotomy, posterior capsular release, knee $ 2,236.50 27437 Arthroplasty, patella; without prosthesis $ 2,274.30 27438 Arthroplasty, patella; with prosthesis $ 2,720.70 27440 Arthroplasty, knee, tibial plateau; $ 3,292.20 27441 Arthroplasty, knee, tibial plateau; with debridement and partial synovectomy 27442 Arthroplasty, femoral condyles or tibial plateau(s), knee; $ 3,510.00 27443 Arthroplasty, femoral condyles or tibial plateau(s), knee; with debridement and partial synovectomy 27445 Arthroplasty, knee, hinge prosthesis (eg, Walldius type) $ 4,499.10 27446 Arthroplasty, knee, condyle and plateau; medial OR lateral compartment $ 4,126.63

Row # CPT-4 HCPCS Price 27447 Arthroplasty, knee, condyle and plateau; medial AND lateral compartments with or without patella resurfacing (total knee $ 5,226.12 27448 Osteotomy, femur, shaft or supracondylar; without fixation $ 2,877.30 27450 Osteotomy, femur, shaft or supracondylar; with fixation $ 2,826.90 27454 Osteotomy, multiple, with realignment on intramedullary rod, femoral shaft (eg, Sofield type procedure) 27455 Osteotomy, proximal tibia, including fibular excision or osteotomy (includes correction of genu varus [bowleg] or genu valgus [knock- knee]); before epiphyseal closure 27457 Osteotomy, proximal tibia, including fibular excision or osteotomy (includes correction of genu varus [bowleg] or genu valgus [knock- knee]); after epiphyseal closure $ 2,886.30 27465 Osteoplasty, femur; shortening (excluding 64876) $ 3,267.90 27466 Osteoplasty, femur; lengthening $ 3,707.10 27468 Osteoplasty, femur; combined, lengthening and shortening with femoral segment transfer $ 4,853.70 27470 Repair, nonunion or malunion, femur, distal to head and neck; without graft (eg, compression technique) $ 3,579.30 27472 Repair, nonunion or malunion, femur, distal to head and neck; with iliac or other autogenous bone graft (includes obtaining graft) $ 4,050.00 27475 Arrest, epiphyseal, any method (eg, epiphysiodesis); distal femur $ 2,453.40 27477 Arrest, epiphyseal, any method (eg, epiphysiodesis); tibia and fibula, proximal $ 2,636.10 27479 Arrest, epiphyseal, any method (eg, epiphysiodesis); combined distal femur, proximal tibia and fibula $ 3,160.80 27485 Arrest, hemiepiphyseal, distal femur or proximal tibia or fibula (eg, genu varus or valgus) 27486 Revision of total knee arthroplasty, with or without allograft; 1 component $ 5,175.90 27487 Revision of total knee arthroplasty, with or without allograft; femoral and entire tibial component $ 6,452.10 27488 Removal of prosthesis, including total knee prosthesis, methylmethacrylate with or without insertion of spacer, knee $ 3,144.60 27495 without methylmethacrylate, femur 27496 Decompression fasciotomy, thigh and/or knee, 1 compartment (flexor or extensor or adductor); 27497 Decompression fasciotomy, thigh and/or knee, 1 compartment (flexor or extensor or adductor); with debridement of nonviable muscle and/or nerve 27498 Decompression fasciotomy, thigh and/or knee, multiple compartments; 27499 Decompression fasciotomy, thigh and/or knee, multiple compartments; with debridement of nonviable muscle and/or nerve $ 2,421.00 27500 Closed treatment of femoral shaft fracture, without manipulation $ 1,207.80 27501 Closed treatment of supracondylar or transcondylar femoral fracture with or without intercondylar extension, without $ 1,495.80 27502 Closed treatment of femoral shaft fracture, with manipulation, with or without skin or skeletal traction $ 1,648.80 27503 Closed treatment of supracondylar or transcondylar femoral fracture with or without intercondylar extension, with $ 2,035.80 27506 Open treatment of femoral shaft fracture, with or without external fixation, with insertion of intramedullary implant, with or without cerclage and/or locking screws 27507 Open treatment of femoral shaft fracture with plate/screws, with or without cerclage $ 3,386.70 27508 Closed treatment of femoral fracture, distal end, medial or lateral condyle, without manipulation $ 1,017.00 27509 Percutaneous skeletal fixation of femoral fracture, distal end, medial or lateral condyle, or supracondylar or transcondylar, with or without intercondylar extension, or distal femoral epiphyseal separation

Row # CPT-4 HCPCS Price 27510 Closed treatment of femoral fracture, distal end, medial or lateral condyle, with manipulation 27511 Open treatment of femoral supracondylar or transcondylar fracture without intercondylar extension, includes internal fixation, when 27513 Open treatment of femoral supracondylar or transcondylar fracture with intercondylar extension, includes internal fixation, when $ 3,411.90 27514 Open treatment of femoral fracture, distal end, medial or lateral condyle, includes internal fixation, when performed $ 3,283.20 27516 Closed treatment of distal femoral epiphyseal separation; without $ 1,274.40 27517 Closed treatment of distal femoral epiphyseal separation; with 27519 Open treatment of distal femoral epiphyseal separation, includes $ 3,119.40 27520 Closed treatment of patellar fracture, without manipulation 27524 Open treatment of patellar fracture, with internal fixation and/or partial or complete patellectomy and soft tissue repair 27530 Closed treatment of tibial fracture, proximal (plateau); without $ 852.30 27532 Closed treatment of tibial fracture, proximal (plateau); with or without manipulation, with skeletal traction $ 1,169.10 27535 Open treatment of tibial fracture, proximal (plateau); unicondylar, $ 2,665.80 27536 Open treatment of tibial fracture, proximal (plateau); bicondylar, with or without internal fixation $ 2,615.40 27538 Closed treatment of intercondylar spine(s) and/or tuberosity fracture(s) of knee, with or without manipulation $ 950.40 27540 Open treatment of intercondylar spine(s) and/or tuberosity fracture(s) of the knee, includes internal fixation, when performed $ 2,468.70 27550 Closed treatment of knee dislocation; without anesthesia 27552 Closed treatment of knee dislocation; requiring anesthesia $ 1,050.30 27556 performed; without primary ligamentous repair or augmentation/reconstruction $ 2,856.60 27557 performed; with primary ligamentous repair $ 3,537.90 27558 performed; with primary ligamentous repair, with augmentation/reconstruction 27560 Closed treatment of patellar dislocation; without anesthesia $ 461.70 27562 Closed treatment of patellar dislocation; requiring anesthesia 27566 Open treatment of patellar dislocation, with or without partial or total patellectomy 27570 Manipulation of knee joint under general anesthesia (includes application of traction or other fixation devices) $ 529.96 27580 Arthrodesis, knee, any technique $ 3,822.30 27590 Amputation, thigh, through femur, any level; 27591 Amputation, thigh, through femur, any level; immediate fitting technique including first cast $ 2,583.00 27592 Amputation, thigh, through femur, any level; open, circular (guillotine) $ 2,543.40 27594 Amputation, thigh, through femur, any level; secondary closure or scar revision 27596 Amputation, thigh, through femur, any level; re-amputation $ 2,379.60 27598 Disarticulation at knee $ 2,443.50 27599 Unlisted procedure, femur or knee Cost 27600 Decompression fasciotomy, leg; anterior and/or lateral compartments only 27601 Decompression fasciotomy, leg; posterior compartment(s) only 27602 Decompression fasciotomy, leg; anterior and/or lateral, and posterior compartment(s) $ 1,403.10

Row # CPT-4 HCPCS Price 27603 Incision and drainage, leg or ankle; deep abscess or hematoma $ 799.29 27604 Incision and drainage, leg or ankle; infected bursa $ 529.20 27605 Tenotomy, percutaneous, Achilles tendon (separate procedure); local anesthesia $ 489.60 27606 Tenotomy, percutaneous, Achilles tendon (separate procedure); general anesthesia 27607 Incision (eg, osteomyelitis or bone abscess), leg or ankle 27610 Arthrotomy, ankle, including exploration, drainage, or removal of $ 1,504.80 27612 Arthrotomy, posterior capsular release, ankle, with or without Achilles tendon lengthening 27613 Biopsy, soft tissue of leg or ankle area; superficial $ 421.20 27614 Biopsy, soft tissue of leg or ankle area; deep (subfascial or 27615 Radical resection of tumor (eg, sarcoma), soft tissue of leg or ankle area; less than 5 cm $ 2,870.10 27616 Radical resection of tumor (eg, sarcoma), soft tissue of leg or ankle area; 5 cm or greater $ 3,296.27 27618 Excision, tumor, soft tissue of leg or ankle area, subcutaneous; less $ 846.00 27619 Excision, tumor, soft tissue of leg or ankle area, subfascial (eg, $ 1,333.80 27620 Arthrotomy, ankle, with joint exploration, with or without biopsy, with or without removal of loose or foreign body $ 1,577.70 27625 Arthrotomy, with synovectomy, ankle; $ 2,103.30 27626 Arthrotomy, with synovectomy, ankle; including tenosynovectomy $ 2,202.30 27630 Excision of lesion of tendon sheath or capsule (eg, cyst or ganglion), leg and/or ankle $ 867.60 27632 Excision, tumor, soft tissue of leg or ankle area, subcutaneous; 3 cm or greater $ 802.95 27634 Excision, tumor, soft tissue of leg or ankle area, subfascial (eg, $ 1,801.95 27635 $ 1,979.10 27637 $ 2,095.20 27638 with allograft $ 2,301.30 27640 bone (eg, osteomyelitis); tibia 27641 bone (eg, osteomyelitis); fibula $ 1,883.70 27645 Radical resection of tumor; tibia 27646 Radical resection of tumor; fibula $ 2,287.80 27647 Radical resection of tumor; talus or calcaneus $ 2,766.60 27648 Injection procedure for ankle arthrography 27650 Repair, primary, open or percutaneous, ruptured Achilles tendon; $ 1,908.66 27652 Repair, primary, open or percutaneous, ruptured Achilles tendon; with graft (includes obtaining graft) $ 2,335.50 27654 Repair, secondary, Achilles tendon, with or without graft $ 2,672.10 27656 Repair, fascial defect of leg $ 1,035.90 27658 Repair, flexor tendon, leg; primary, without graft, each tendon $ 1,115.10 27659 Repair, flexor tendon, leg; secondary, with or without graft, each 27664 Repair, extensor tendon, leg; primary, without graft, each tendon $ 1,085.40 27665 Repair, extensor tendon, leg; secondary, with or without graft, each $ 1,157.40 27675 Repair, dislocating peroneal tendons; without fibular osteotomy $ 1,295.10 27676 Repair, dislocating peroneal tendons; with fibular osteotomy 27680 Tenolysis, flexor or extensor tendon, leg and/or ankle; single, each $ 1,331.10 27681 Tenolysis, flexor or extensor tendon, leg and/or ankle; multiple tendons (through separate incision(s)) $ 1,042.20

Row # CPT-4 HCPCS Price 27685 Lengthening or shortening of tendon, leg or ankle; single tendon $ 1,200.60 27686 Lengthening or shortening of tendon, leg or ankle; multiple tendons (through same incision), each $ 1,363.50 27687 Gastrocnemius recession (eg, Strayer procedure) 27690 rerouting); superficial (eg, anterior tibial extensors into midfoot) 27691 rerouting); deep (eg, anterior tibial or posterior tibial through interosseous space, flexor digitorum longus, flexor hallucis longus, or peroneal tendon to midfoot or hindfoot) 27692 rerouting); each additional tendon (List separately in addition to $ 544.50 27695 Repair, primary, disrupted ligament, ankle; collateral $ 1,703.70 27696 Repair, primary, disrupted ligament, ankle; both collateral ligaments $ 2,338.20 27698 Repair, secondary, disrupted ligament, ankle, collateral (eg, Watson- Jones procedure) $ 2,367.00 27700 Arthroplasty, ankle; 27702 Arthroplasty, ankle; with implant (total ankle) $ 4,042.80 27703 Arthroplasty, ankle; revision, total ankle $ 3,919.50 27704 Removal of ankle implant $ 2,137.50 27705 Osteotomy; tibia $ 2,241.00 27707 Osteotomy; fibula $ 1,283.40 27709 Osteotomy; tibia and fibula $ 2,755.80 27712 Osteotomy; multiple, with realignment on intramedullary rod (eg, Sofield type procedure) 27715 Osteoplasty, tibia and fibula, lengthening or shortening 27720 Repair of nonunion or malunion, tibia; without graft, (eg, $ 2,987.10 27722 Repair of nonunion or malunion, tibia; with sliding graft $ 3,027.60 27724 Repair of nonunion or malunion, tibia; with iliac or other autograft $ 3,375.90 27725 Repair of nonunion or malunion, tibia; by synostosis, with fibula, any method $ 3,711.60 27726 Repair of fibula nonunion and/or malunion with internal fixation $ 2,950.61 27727 Repair of congenital pseudarthrosis, tibia 27730 Arrest, epiphyseal (epiphysiodesis), open; distal tibia $ 1,624.50 27732 Arrest, epiphyseal (epiphysiodesis), open; distal fibula 27734 Arrest, epiphyseal (epiphysiodesis), open; distal tibia and fibula $ 1,830.60 27740 Arrest, epiphyseal (epiphysiodesis), any method, combined, proximal and distal tibia and fibula; $ 2,415.60 27742 Arrest, epiphyseal (epiphysiodesis), any method, combined, proximal and distal tibia and fibula; and distal femur $ 3,129.30 27745 without methylmethacrylate, tibia $ 2,493.00 27750 Closed treatment of tibial shaft fracture (with or without fibular fracture); without manipulation $ 702.97 27752 Closed treatment of tibial shaft fracture (with or without fibular fracture); with manipulation, with or without skeletal traction 27756 Percutaneous skeletal fixation of tibial shaft fracture (with or without fibular fracture) (eg, pins or screws) 27758 Open treatment of tibial shaft fracture (with or without fibular fracture), with plate/screws, with or without cerclage $ 2,968.20 27759 Treatment of tibial shaft fracture (with or without fibular fracture) by intramedullary implant, with or without interlocking screws and/or cerclage $ 3,328.20 27760 Closed treatment of medial malleolus fracture; without 27762 Closed treatment of medial malleolus fracture; with manipulation, with or without skin or skeletal traction

Row # CPT-4 HCPCS Price 27766 Open treatment of medial malleolus fracture, includes internal $ 1,553.40 27767 Closed treatment of posterior malleolus fracture; without $ 548.09 27768 Closed treatment of posterior malleolus fracture; with manipulation $ 868.53 27769 Open treatment of posterior malleolus fracture, includes internal $ 1,707.43 27780 Closed treatment of proximal fibula or shaft fracture; without $ 562.50 27781 Closed treatment of proximal fibula or shaft fracture; with $ 893.70 27784 Open treatment of proximal fibula or shaft fracture, includes $ 1,605.60 27786 Closed treatment of distal fibular fracture (lateral malleolus); 27788 Closed treatment of distal fibular fracture (lateral malleolus); with $ 818.10 27792 Open treatment of distal fibular fracture (lateral malleolus), $ 1,539.90 27808 Closed treatment of bimalleolar ankle fracture (eg, lateral and medial malleoli, or lateral and posterior malleoli, or medial and posterior malleoli); without manipulation 27810 Closed treatment of bimalleolar ankle fracture (eg, lateral and medial malleoli, or lateral and posterior malleoli, or medial and posterior malleoli); with manipulation $ 1,189.80 27814 Open treatment of bimalleolar ankle fracture (eg, lateral and medial malleoli, or lateral and posterior malleoli, or medial and posterior malleoli), includes internal fixation, when performed $ 2,196.90 27816 Closed treatment of trimalleolar ankle fracture; without 27818 Closed treatment of trimalleolar ankle fracture; with manipulation $ 1,312.20 27822 Open treatment of trimalleolar ankle fracture, includes internal fixation, when performed, medial and/or lateral malleolus; without fixation of posterior lip 27823 Open treatment of trimalleolar ankle fracture, includes internal fixation, when performed, medial and/or lateral malleolus; with fixation of posterior lip $ 2,880.90 27824 Closed treatment of fracture of weight bearing articular portion of distal tibia (eg, pilon or tibial plafond), with or without anesthesia; 27825 Closed treatment of fracture of weight bearing articular portion of distal tibia (eg, pilon or tibial plafond), with or without anesthesia; with skeletal traction and/or requiring manipulation $ 1,673.10 27826 internal fixation, when performed; of fibula only 27827 internal fixation, when performed; of tibia only $ 2,786.40 27828 internal fixation, when performed; of both tibia and fibula 27829 Open treatment of distal tibiofibular joint (syndesmosis) disruption, 27830 Closed treatment of proximal tibiofibular joint dislocation; without 27831 Closed treatment of proximal tibiofibular joint dislocation; requiring $ 695.70 27832 Open treatment of proximal tibiofibular joint dislocation, includes internal fixation, when performed, or with excision of proximal fibula $ 1,254.60 27840 Closed treatment of ankle dislocation; without anesthesia 27842 Closed treatment of ankle dislocation; requiring anesthesia, with or without percutaneous skeletal fixation $ 761.40

Row # CPT-4 HCPCS Price 27846 Open treatment of ankle dislocation, with or without percutaneous skeletal fixation; without repair or internal fixation 27848 Open treatment of ankle dislocation, with or without percutaneous skeletal fixation; with repair or internal or external fixation $ 2,139.30 27860 Manipulation of ankle under general anesthesia (includes application of traction or other fixation apparatus) 27870 Arthrodesis, ankle, open $ 2,708.10 27871 Arthrodesis, tibiofibular joint, proximal or distal $ 2,174.40 27880 Amputation, leg, through tibia and fibula; $ 2,462.40 27881 Amputation, leg, through tibia and fibula; with immediate fitting technique including application of first cast 27882 Amputation, leg, through tibia and fibula; open, circular (guillotine) $ 2,366.10 27884 Amputation, leg, through tibia and fibula; secondary closure or scar revision $ 1,488.60 27886 Amputation, leg, through tibia and fibula; re-amputation $ 2,375.10 27888 Amputation, ankle, through malleoli of tibia and fibula (eg, Syme, Pirogoff type procedures), with plastic closure and resection of nerves $ 2,007.90 27889 Ankle disarticulation $ 1,886.40 27892 Decompression fasciotomy, leg; anterior and/or lateral compartments only, with debridement of nonviable muscle and/or nerve 27893 Decompression fasciotomy, leg; posterior compartment(s) only, with debridement of nonviable muscle and/or nerve 27894 Decompression fasciotomy, leg; anterior and/or lateral, and posterior compartment(s), with debridement of nonviable muscle 27899 Unlisted procedure, leg or ankle Cost 28001 Incision and drainage, bursa, foot 28002 Incision and drainage below fascia, with or without tendon sheath involvement, foot; single bursal space 28003 Incision and drainage below fascia, with or without tendon sheath involvement, foot; multiple areas 28005 Incision, bone cortex (eg, osteomyelitis or bone abscess), foot 28008 Fasciotomy, foot and/or toe $ 700.20 28010 Tenotomy, percutaneous, toe; single tendon 28011 Tenotomy, percutaneous, toe; multiple tendons 28020 foreign body; intertarsal or tarsometatarsal joint $ 1,106.10 28022 foreign body; metatarsophalangeal joint $ 725.40 28024 foreign body; interphalangeal joint 28035 Release, tarsal tunnel (posterior tibial nerve decompression) 28039 Excision, tumor, soft tissue of foot or toe, subcutaneous; 1.5 cm or $ 805.26 28041 Excision, tumor, soft tissue of foot or toe, subfascial (eg, intramuscular); 1.5 cm or greater $ 941.09 28043 Excision, tumor, soft tissue of foot or toe, subcutaneous; less than 1.5 cm $ 525.60 28045 Excision, tumor, soft tissue of foot or toe, subfascial (eg, intramuscular); less than 1.5 cm $ 1,077.30 28046 Radical resection of tumor (eg, sarcoma), soft tissue of foot or toe; less than 3 cm $ 1,923.30 28047 Radical resection of tumor (eg, sarcoma), soft tissue of foot or toe; 3 $ 1,845.03 28050 Arthrotomy with biopsy; intertarsal or tarsometatarsal joint $ 1,000.80 28052 Arthrotomy with biopsy; metatarsophalangeal joint 28054 Arthrotomy with biopsy; interphalangeal joint $ 588.60 28055 Neurectomy, intrinsic musculature of foot $ 757.64 28060 Fasciectomy, plantar fascia; partial (separate procedure) $ 1,038.60 28062 Fasciectomy, plantar fascia; radical (separate procedure) $ 1,872.90 28070 Synovectomy; intertarsal or tarsometatarsal joint, each 28072 Synovectomy; metatarsophalangeal joint, each $ 727.20 28080 Excision, interdigital (Morton) neuroma, single, each $ 817.76

Row # CPT-4 HCPCS Price 28086 Synovectomy, tendon sheath, foot; flexor 28088 Synovectomy, tendon sheath, foot; extensor $ 873.90 28090 Excision of lesion, tendon, tendon sheath, or capsule (including synovectomy) (eg, cyst or ganglion); foot $ 762.08 28092 Excision of lesion, tendon, tendon sheath, or capsule (including synovectomy) (eg, cyst or ganglion); toe(s), each 28100 calcaneus; $ 1,274.40 28102 calcaneus; with iliac or other autograft (includes obtaining graft) 28103 calcaneus; with allograft $ 1,577.70 28104 metatarsal, except talus or calcaneus; $ 1,057.50 28106 metatarsal, except talus or calcaneus; with iliac or other autograft $ 1,435.50 28107 metatarsal, except talus or calcaneus; with allograft 28108 Excision or curettage of bone cyst or benign tumor, phalanges of foot $ 862.20 28110 Ostectomy, partial excision, fifth metatarsal head (bunionette) 28111 Ostectomy, complete excision; first metatarsal head $ 1,013.40 28112 Ostectomy, complete excision; other metatarsal head (second, third or fourth) 28113 Ostectomy, complete excision; fifth metatarsal head 28114 Ostectomy, complete excision; all metatarsal heads, with partial proximal phalangectomy, excluding first metatarsal (eg, Clayton type procedure) 28116 Ostectomy, excision of tarsal coalition $ 1,553.40 28118 Ostectomy, calcaneus; $ 1,267.20 28119 Ostectomy, calcaneus; for spur, with or without plantar fascial release 28120 diaphysectomy) bone (eg, osteomyelitis or bossing); talus or calcaneus 28122 diaphysectomy) bone (eg, osteomyelitis or bossing); tarsal or metatarsal bone, except talus or calcaneus $ 1,105.20 28124 diaphysectomy) bone (eg, osteomyelitis or bossing); phalanx of toe $ 754.20 28126 Resection, partial or complete, phalangeal base, each toe $ 708.30 28130 Talectomy (astragalectomy) $ 1,640.70 28140 Metatarsectomy 28150 Phalangectomy, toe, each toe 28153 Resection, condyle(s), distal end of phalanx, each toe 28160 Hemiphalangectomy or interphalangeal joint excision, toe, proximal end of phalanx, each $ 651.60 28171 Radical resection of tumor; tarsal (except talus or calcaneus) 28173 Radical resection of tumor; metatarsal $ 1,408.50 28175 Radical resection of tumor; phalanx of toe $ 999.00 28190 Removal of foreign body, foot; subcutaneous $ 346.50 28192 Removal of foreign body, foot; deep $ 671.40 28193 Removal of foreign body, foot; complicated $ 1,028.70 28200 Repair, tendon, flexor, foot; primary or secondary, without free $ 1,134.00 28202 Repair, tendon, flexor, foot; secondary with free graft, each tendon $ 1,766.70 28208 Repair, tendon, extensor, foot; primary or secondary, each tendon $ 967.50 28210 Repair, tendon, extensor, foot; secondary with free graft, each tendon (includes obtaining graft) $ 1,038.60 28222 Tenolysis, flexor, foot; multiple tendons $ 1,048.50 28225 Tenolysis, extensor, foot; single tendon $ 580.50 28226 Tenolysis, extensor, foot; multiple tendons

Row # CPT-4 HCPCS Price 28230 Tenotomy, open, tendon flexor; foot, single or multiple tendon(s) 28232 Tenotomy, open, tendon flexor; toe, single tendon (separate $ 399.60 28234 Tenotomy, open, extensor, foot or toe, each tendon $ 517.50 28238 Reconstruction (advancement), posterior tibial tendon with excision of accessory tarsal navicular bone (eg, Kidner type procedure) 28240 Tenotomy, lengthening, or release, abductor hallucis muscle $ 711.90 28250 Division of plantar fascia and muscle (eg, Steindler stripping) 28260 Capsulotomy, midfoot; medial release only (separate procedure) $ 1,608.30 28261 Capsulotomy, midfoot; with tendon lengthening 28262 Capsulotomy, midfoot; extensive, including posterior talotibial capsulotomy and tendon(s) lengthening (eg, resistant clubfoot deformity) $ 2,923.20 28264 Capsulotomy, midtarsal (eg, Heyman type procedure) $ 2,145.60 28270 Capsulotomy; metatarsophalangeal joint, with or without tenorrhaphy, each joint (separate procedure) $ 712.80 28272 Capsulotomy; interphalangeal joint, each joint (separate procedure) $ 654.30 28280 Syndactylization, toes (eg, webbing or Kelikian type procedure) 28285 Correction, hammertoe (eg, interphalangeal fusion, partial or total phalangectomy) 28286 Correction, cock-up fifth toe, with plastic skin closure (eg, Ruiz- Mora type procedure) 28288 Ostectomy, partial, exostectomy or condylectomy, metatarsal head, each metatarsal head 28289 Hallux rigidus correction with cheilectomy, debridement and capsular release of the first metatarsophalangeal joint 28290 sesamoidectomy; simple exostectomy (eg, Silver type procedure) 28292 sesamoidectomy; Keller, McBride, or Mayo type procedure 28293 sesamoidectomy; resection of joint with implant $ 1,776.60 28294 sesamoidectomy; with tendon transplants (eg, Joplin type $ 1,939.50 28296 sesamoidectomy; with metatarsal osteotomy (eg, Mitchell, Chevron, or concentric type procedures) $ 1,827.42 28297 sesamoidectomy; Lapidus-type procedure $ 1,831.50 28298 sesamoidectomy; by phalanx osteotomy $ 1,392.30 28299 sesamoidectomy; by double osteotomy 28300 Osteotomy; calcaneus (eg, Dwyer or Chambers type procedure), with or without internal fixation $ 1,506.60 28302 Osteotomy; talus 28304 Osteotomy, tarsal bones, other than calcaneus or talus; $ 1,385.10 28305 Osteotomy, tarsal bones, other than calcaneus or talus; with autograft (includes obtaining graft) (eg, Fowler type) 28306 correction, metatarsal; first metatarsal 28307 correction, metatarsal; first metatarsal with autograft (other than first toe) 28308 correction, metatarsal; other than first metatarsal, each $ 1,104.30 28309 correction, metatarsal; multiple (eg, Swanson type cavus foot $ 1,880.10

Row # CPT-4 HCPCS Price 28310 Osteotomy, shortening, angular or rotational correction; proximal phalanx, first toe (separate procedure) $ 986.40 28312 Osteotomy, shortening, angular or rotational correction; other phalanges, any toe 28313 Reconstruction, angular deformity of toe, soft tissue procedures only (eg, overlapping second toe, fifth toe, curly toes) $ 919.80 28315 Sesamoidectomy, first toe (separate procedure) 28320 Repair, nonunion or malunion; tarsal bones $ 1,640.70 28322 Repair, nonunion or malunion; metatarsal, with or without bone graft (includes obtaining graft) 28340 Reconstruction, toe, macrodactyly; soft tissue resection $ 1,427.40 28341 Reconstruction, toe, macrodactyly; requiring bone resection $ 1,542.60 28344 Reconstruction, toe(s); polydactyly $ 1,073.70 28345 Reconstruction, toe(s); syndactyly, with or without skin graft(s), each web $ 1,471.50 28360 Reconstruction, cleft foot $ 2,493.00 28400 Closed treatment of calcaneal fracture; without manipulation $ 621.90 28405 Closed treatment of calcaneal fracture; with manipulation $ 1,003.50 28406 Percutaneous skeletal fixation of calcaneal fracture, with $ 1,278.00 28415 Open treatment of calcaneal fracture, includes internal fixation, 28420 Open treatment of calcaneal fracture, includes internal fixation, when performed; with primary iliac or other autogenous bone graft $ 2,753.10 28430 Closed treatment of talus fracture; without manipulation 28435 Closed treatment of talus fracture; with manipulation $ 768.60 28436 Percutaneous skeletal fixation of talus fracture, with manipulation $ 918.00 28445 Open treatment of talus fracture, includes internal fixation, when $ 1,998.00 28446 Open osteochondral autograft, talus (includes obtaining graft[s]) $ 2,581.39 28450 Treatment of tarsal bone fracture (except talus and calcaneus); without manipulation, each $ 496.80 28455 Treatment of tarsal bone fracture (except talus and calcaneus); with 28456 Percutaneous skeletal fixation of tarsal bone fracture (except talus and calcaneus), with manipulation, each 28465 Open treatment of tarsal bone fracture (except talus and calcaneus), includes internal fixation, when performed, each 28470 Closed treatment of metatarsal fracture; without manipulation, each $ 459.00 28475 Closed treatment of metatarsal fracture; with manipulation, each 28476 Percutaneous skeletal fixation of metatarsal fracture, with 28485 Open treatment of metatarsal fracture, includes internal fixation, when performed, each $ 1,177.20 28490 Closed treatment of fracture great toe, phalanx or phalanges; $ 266.40 28495 Closed treatment of fracture great toe, phalanx or phalanges; with 28496 Percutaneous skeletal fixation of fracture great toe, phalanx or phalanges, with manipulation $ 576.90 28505 Open treatment of fracture, great toe, phalanx or phalanges, $ 783.90 28510 Closed treatment of fracture, phalanx or phalanges, other than great toe; without manipulation, each $ 208.80 28515 Closed treatment of fracture, phalanx or phalanges, other than great toe; with manipulation, each 28525 Open treatment of fracture, phalanx or phalanges, other than great toe, includes internal fixation, when performed, each $ 744.30 28530 Closed treatment of sesamoid fracture $ 348.30

Row # CPT-4 HCPCS Price 28531 Open treatment of sesamoid fracture, with or without internal $ 880.47 28540 Closed treatment of tarsal bone dislocation, other than talotarsal; without anesthesia $ 410.40 28545 Closed treatment of tarsal bone dislocation, other than talotarsal; 28546 Percutaneous skeletal fixation of tarsal bone dislocation, other than talotarsal, with manipulation 28555 Open treatment of tarsal bone dislocation, includes internal 28570 Closed treatment of talotarsal joint dislocation; without anesthesia 28575 Closed treatment of talotarsal joint dislocation; requiring anesthesia $ 577.80 28576 Percutaneous skeletal fixation of talotarsal joint dislocation, with 28585 Open treatment of talotarsal joint dislocation, includes internal 28600 Closed treatment of tarsometatarsal joint dislocation; without 28605 Closed treatment of tarsometatarsal joint dislocation; requiring 28606 Percutaneous skeletal fixation of tarsometatarsal joint dislocation, 28615 Open treatment of tarsometatarsal joint dislocation, includes 28630 Closed treatment of metatarsophalangeal joint dislocation; without $ 335.70 28635 Closed treatment of metatarsophalangeal joint dislocation; $ 369.90 28636 Percutaneous skeletal fixation of metatarsophalangeal joint dislocation, with manipulation 28645 Open treatment of metatarsophalangeal joint dislocation, includes $ 782.10 28660 Closed treatment of interphalangeal joint dislocation; without 28665 Closed treatment of interphalangeal joint dislocation; requiring $ 320.40 28666 Percutaneous skeletal fixation of interphalangeal joint dislocation, 28675 Open treatment of interphalangeal joint dislocation, includes $ 684.90 28705 Arthrodesis; pantalar $ 2,897.10 28715 Arthrodesis; triple $ 3,185.10 28725 Arthrodesis; subtalar $ 2,137.50 28730 Arthrodesis, midtarsal or tarsometatarsal, multiple or transverse; 28735 Arthrodesis, midtarsal or tarsometatarsal, multiple or transverse; with osteotomy (eg, flatfoot correction) $ 2,173.50 28737 Arthrodesis, with tendon lengthening and advancement, midtarsal, tarsal navicular-cuneiform (eg, Miller type procedure) $ 1,982.70 28740 Arthrodesis, midtarsal or tarsometatarsal, single joint 28750 Arthrodesis, great toe; metatarsophalangeal joint $ 1,392.70 28755 Arthrodesis, great toe; interphalangeal joint $ 1,186.20 28760 Arthrodesis, with extensor hallucis longus transfer to first metatarsal neck, great toe, interphalangeal joint (eg, Jones type $ 1,071.90 28800 Amputation, foot; midtarsal (eg, Chopart type procedure) $ 1,847.70 28805 Amputation, foot; transmetatarsal $ 2,238.30 28810 Amputation, metatarsal, with toe, single $ 1,152.90 28820 Amputation, toe; metatarsophalangeal joint 28825 Amputation, toe; interphalangeal joint $ 782.10 28890 Extracorporeal shock wave, high energy, performed by a physician or other qualified health care professional, requiring anesthesia other than local, including ultrasound guidance, involving the plantar fascia $ 905.09 28899 Unlisted procedure, foot or toes Cost 29000 Application of halo type body cast (see 20661-20663 for insertion) $ 608.40

Row # CPT-4 HCPCS Price 29010 Application of Risser jacket, localizer, body; only $ 492.30 29015 Application of Risser jacket, localizer, body; including head $ 670.50 29020 Application of turnbuckle jacket, body; only $ 534.60 29025 Application of turnbuckle jacket, body; including head 29035 Application of body cast, shoulder to hips; 29040 Application of body cast, shoulder to hips; including head, Minerva type $ 495.90 29044 Application of body cast, shoulder to hips; including 1 thigh 29046 Application of body cast, shoulder to hips; including both thighs $ 469.80 29049 Application, cast; figure-of-eight $ 194.40 29055 Application, cast; shoulder spica $ 389.70 29058 Application, cast; plaster Velpeau $ 198.90 29065 Application, cast; shoulder to hand (long arm) 29075 Application, cast; elbow to finger (short arm) 29085 Application, cast; hand and lower forearm (gauntlet) $ 156.05 29086 Application, cast; finger (eg, contracture) $ 110.50 29105 Application of long arm splint (shoulder to hand) 29125 Application of short arm splint (forearm to hand); static $ 99.00 29126 Application of short arm splint (forearm to hand); dynamic 29130 Application of finger splint; static $ 82.80 29131 Application of finger splint; dynamic 29200 Strapping; thorax $ 81.00 29240 Strapping; shoulder (eg, Velpeau) $ 90.00 29260 Strapping; elbow or wrist $ 65.68 29280 Strapping; hand or finger $ 86.40 29305 Application of hip spica cast; 1 leg 29325 Application of hip spica cast; 1 and one-half spica or both legs $ 494.10 29345 Application of long leg cast (thigh to toes); 29355 Application of long leg cast (thigh to toes); walker or ambulatory type 29358 Application of long leg cast brace $ 451.80 29365 Application of cylinder cast (thigh to ankle) 29405 Application of short leg cast (below knee to toes); $ 215.17 29425 Application of short leg cast (below knee to toes); walking or ambulatory type $ 237.60 29435 Application of patellar tendon bearing (PTB) cast $ 282.60 29440 Adding walker to previously applied cast $ 83.70 29445 Application of rigid total contact leg cast $ 339.30 29450 Application of clubfoot cast with molding or manipulation, long or short leg 29505 Application of long leg splint (thigh to ankle or toes) 29515 Application of short leg splint (calf to foot) 29520 Strapping; hip $ 98.10 29530 Strapping; knee $ 95.40 29540 Strapping; ankle and/or foot $ 73.52 29550 Strapping; toes $ 66.60 29580 Strapping; Unna boot $ 96.09 29581 Application of multi-layer compression system; leg (below knee), including ankle and foot $ 132.61 29700 Removal or bivalving; gauntlet, boot or body cast $ 92.42 29705 Removal or bivalving; full arm or full leg cast $ 90.31 29710 Removal or bivalving; shoulder or hip spica, Minerva, or Risser jacket, etc. $ 186.30 29715 Removal or bivalving; turnbuckle jacket 29720 Repair of spica, body cast or jacket $ 87.30 29730 Windowing of cast $ 85.50 29740 Wedging of cast (except clubfoot casts) 29750 Wedging of clubfoot cast $ 97.20 29799 Unlisted procedure, casting or strapping $ 100.21 29800 Arthroscopy, temporomandibular joint, diagnostic, with or without synovial biopsy (separate procedure) 29804 Arthroscopy, temporomandibular joint, surgical 29805 Arthroscopy, shoulder, diagnostic, with or without synovial biopsy $ 1,129.02 29806 Arthroscopy, shoulder, surgical; capsulorrhaphy $ 2,796.86 29807 Arthroscopy, shoulder, surgical; repair of SLAP lesion $ 2,663.48 29819 Arthroscopy, shoulder, surgical; with removal of loose body or $ 2,304.90

Row # CPT-4 HCPCS Price 29820 Arthroscopy, shoulder, surgical; synovectomy, partial $ 2,215.80 29821 Arthroscopy, shoulder, surgical; synovectomy, complete 29822 Arthroscopy, shoulder, surgical; debridement, limited $ 2,419.20 29823 Arthroscopy, shoulder, surgical; debridement, extensive 29824 Arthroscopy, shoulder, surgical; distal claviculectomy including distal articular surface (Mumford procedure) $ 1,813.74 29825 Arthroscopy, shoulder, surgical; with lysis and resection of adhesions, with or without manipulation $ 2,412.00 29826 Arthroscopy, shoulder, surgical; decompression of subacromial space with partial acromioplasty, with coracoacromial ligament (ie, arch)release, when performed (List separately in addition to code $ 2,722.75 29827 Arthroscopy, shoulder, surgical; with rotator cuff repair $ 2,928.75 29828 Arthroscopy, shoulder, surgical; biceps tenodesis $ 2,558.94 29830 Arthroscopy, elbow, diagnostic, with or without synovial biopsy $ 1,206.00 29834 Arthroscopy, elbow, surgical; with removal of loose body or foreign body $ 2,052.00 29835 Arthroscopy, elbow, surgical; synovectomy, partial $ 2,308.50 29836 Arthroscopy, elbow, surgical; synovectomy, complete $ 2,322.90 29837 Arthroscopy, elbow, surgical; debridement, limited $ 1,981.80 29838 Arthroscopy, elbow, surgical; debridement, extensive $ 2,250.90 29840 Arthroscopy, wrist, diagnostic, with or without synovial biopsy $ 1,214.10 29843 Arthroscopy, wrist, surgical; for infection, lavage and drainage 29844 Arthroscopy, wrist, surgical; synovectomy, partial $ 1,881.00 29845 Arthroscopy, wrist, surgical; synovectomy, complete $ 1,916.10 29846 Arthroscopy, wrist, surgical; excision and/or repair of triangular fibrocartilage and/or joint debridement 29847 Arthroscopy, wrist, surgical; internal fixation for fracture or instability $ 2,093.40 29848 Endoscopy, wrist, surgical, with release of transverse carpal ligament 29850 Arthroscopically aided treatment of intercondylar spine(s) and/or tuberosity fracture(s) of the knee, with or without manipulation; without internal or external fixation (includes arthroscopy) $ 2,285.10 29851 Arthroscopically aided treatment of intercondylar spine(s) and/or tuberosity fracture(s) of the knee, with or without manipulation; with internal or external fixation (includes arthroscopy) $ 2,887.20 29855 Arthroscopically aided treatment of tibial fracture, proximal (plateau); unicondylar, includes internal fixation, when performed (includes arthroscopy) 29856 Arthroscopically aided treatment of tibial fracture, proximal (plateau); bicondylar, includes internal fixation, when performed (includes arthroscopy) $ 2,907.90 29860 Arthroscopy, hip, diagnostic with or without synovial biopsy $ 1,547.10 29861 Arthroscopy, hip, surgical; with removal of loose body or foreign body $ 2,295.90 29862 Arthroscopy, hip, surgical; with debridement/shaving of articular cartilage (chondroplasty), abrasion arthroplasty, and/or resection of labrum $ 2,525.40 29863 Arthroscopy, hip, surgical; with synovectomy $ 2,306.70 29866 Arthroscopy, knee, surgical; osteochondral autograft(s) (eg, mosaicplasty) (includes harvesting of the autograft[s]) $ 2,666.26 29867 Arthroscopy, knee, surgical; osteochondral allograft (eg, mosaicplasty) $ 4,120.16 29868 Arthroscopy, knee, surgical; meniscal transplantation (includes arthrotomy for meniscal insertion), medial or lateral $ 5,488.61 29870 Arthroscopy, knee, diagnostic, with or without synovial biopsy 29871 Arthroscopy, knee, surgical; for infection, lavage and drainage 29873 Arthroscopy, knee, surgical; with lateral release $ 1,675.37

Row # CPT-4 HCPCS Price 29874 Arthroscopy, knee, surgical; for removal of loose body or foreign body (eg, osteochondritis dissecans fragmentation, chondral fragmentation) 29875 Arthroscopy, knee, surgical; synovectomy, limited (eg, plica or shelf resection) (separate procedure) $ 2,459.70 29876 Arthroscopy, knee, surgical; synovectomy, major, 2 or more compartments (eg, medial or lateral) $ 2,733.79 29877 Arthroscopy, knee, surgical; debridement/shaving of articular cartilage (chondroplasty) $ 2,552.87 29879 Arthroscopy, knee, surgical; abrasion arthroplasty (includes chondroplasty where necessary) or multiple drilling or microfracture 29880 Arthroscopy, knee, surgical; with meniscectomy (medial AND lateral, including any meniscal shaving) including debridement/shaving of articular cartilage (chondroplasty), same or separate compartment(s), when performed $ 3,254.71 29882 Arthroscopy, knee, surgical; with meniscus repair (medial OR lateral) $ 2,919.72 29883 Arthroscopy, knee, surgical; with meniscus repair (medial AND lateral) $ 3,747.60 29884 Arthroscopy, knee, surgical; with lysis of adhesions, with or without manipulation (separate procedure) $ 2,337.30 29885 Arthroscopy, knee, surgical; drilling for osteochondritis dissecans with bone grafting, with or without internal fixation (including debridement of base of lesion) $ 2,697.30 29886 Arthroscopy, knee, surgical; drilling for intact osteochondritis dissecans lesion 29887 Arthroscopy, knee, surgical; drilling for intact osteochondritis dissecans lesion with internal fixation $ 3,380.40 29888 Arthroscopically aided anterior cruciate ligament repair/augmentation or reconstruction $ 4,793.75 29889 Arthroscopically aided posterior cruciate ligament repair/augmentation or reconstruction $ 4,867.20 29891 Arthroscopy, ankle, surgical, excision of osteochondral defect of talus and/or tibia, including drilling of the defect 29892 Arthroscopically aided repair of large osteochondritis dissecans lesion, talar dome fracture, or tibial plafond fracture, with or without internal fixation (includes arthroscopy) $ 2,223.90 29893 Endoscopic plantar fasciotomy $ 1,233.00 29894 Arthroscopy, ankle (tibiotalar and fibulotalar joints), surgical; with removal of loose body or foreign body $ 2,206.80 29895 synovectomy, partial $ 2,299.50 29897 debridement, limited $ 2,115.00 29898 debridement, extensive $ 2,721.60 29899 Arthroscopy, ankle (tibiotalar and fibulotalar joints), surgical; with ankle arthrodesis $ 2,665.75 29900 Arthroscopy, metacarpophalangeal joint, diagnostic, includes synovial biopsy $ 1,121.89 29901 Arthroscopy, metacarpophalangeal joint, surgical; with debridement $ 1,598.44 29902 Arthroscopy, metacarpophalangeal joint, surgical; with reduction of displaced ulnar collateral ligament (eg, Stenar lesion) $ 1,839.03 29904 Arthroscopy, subtalar joint, surgical; with removal of loose body or $ 2,032.59 29905 Arthroscopy, subtalar joint, surgical; with synovectomy $ 2,146.58 29906 Arthroscopy, subtalar joint, surgical; with debridement $ 2,078.55 29907 Arthroscopy, subtalar joint, surgical; with subtalar arthrodesis $ 2,547.20 29999 Unlisted procedure, arthroscopy Cost 30000 Drainage abscess or hematoma, nasal, internal approach $ 329.40 30020 Drainage abscess or hematoma, nasal septum 30100 Biopsy, intranasal 30110 Excision, nasal polyp(s), simple 30115 Excision, nasal polyp(s), extensive

Row # CPT-4 HCPCS Price 30117 Excision or destruction (eg, laser), intranasal lesion; internal 30118 Excision or destruction (eg, laser), intranasal lesion; external approach (lateral rhinotomy) $ 2,187.00 30120 Excision or surgical planing of skin of nose for rhinophyma 30124 Excision dermoid cyst, nose; simple, skin, subcutaneous $ 774.00 30125 Excision dermoid cyst, nose; complex, under bone or cartilage $ 1,936.80 30130 Excision inferior turbinate, partial or complete, any method 30140 Submucous resection inferior turbinate, partial or complete, any $ 1,149.30 30150 Rhinectomy; partial $ 2,242.80 30160 Rhinectomy; total $ 2,889.00 30200 Injection into turbinate(s), therapeutic 30210 Displacement therapy (Proetz type) 30220 Insertion, nasal septal prosthesis (button) $ 401.40 30300 Removal foreign body, intranasal; office type procedure $ 134.21 30310 Removal foreign body, intranasal; requiring general anesthesia $ 567.90 30320 Removal foreign body, intranasal; by lateral rhinotomy $ 1,482.30 30400 Rhinoplasty, primary; lateral and alar cartilages and/or elevation of nasal tip 30410 Rhinoplasty, primary; complete, external parts including bony pyramid, lateral and alar cartilages, and/or elevation of nasal tip $ 3,969.90 30420 Rhinoplasty, primary; including major septal repair $ 4,673.70 30430 Rhinoplasty, secondary; minor revision (small amount of nasal tip work) $ 1,877.40 30435 Rhinoplasty, secondary; intermediate revision (bony work with $ 2,531.70 30450 Rhinoplasty, secondary; major revision (nasal tip work and $ 4,104.90 30460 Rhinoplasty for nasal deformity secondary to congenital cleft lip and/or palate, including columellar lengthening; tip only $ 2,551.50 30462 Rhinoplasty for nasal deformity secondary to congenital cleft lip and/or palate, including columellar lengthening; tip, septum, $ 4,778.10 30465 Repair of nasal vestibular stenosis (eg, spreader grafting, lateral nasal wall reconstruction) $ 2,367.57 30520 Septoplasty or submucous resection, with or without cartilage scoring, contouring or replacement with graft $ 2,891.27 30540 Repair choanal atresia; intranasal 30545 Repair choanal atresia; transpalatine $ 3,063.60 30560 Lysis intranasal synechia $ 240.30 30580 Repair fistula; oromaxillary (combine with 31030 if antrotomy is included) $ 1,683.00 30600 Repair fistula; oronasal $ 1,819.80 30620 Septal or other intranasal dermatoplasty (does not include 30630 Repair nasal septal perforations 30801 Ablation, soft tissue of inferior turbinates, unilateral or bilateral, any method (eg, electrocautery, radiofrequency ablation, or tissue volume reduction); superficial $ 264.60 30802 Ablation, soft tissue of inferior turbinates, unilateral or bilateral, any method (eg, electrocautery, radiofrequency ablation, or tissue volume reduction); intramural (ie, submucosal) 30901 Control nasal hemorrhage, anterior, simple (limited cautery and/or packing) any method $ 189.81 30903 Control nasal hemorrhage, anterior, complex (extensive cautery and/or packing) any method $ 280.57 30905 Control nasal hemorrhage, posterior, with posterior nasal packs and/or cautery, any method; initial $ 495.90 30906 Control nasal hemorrhage, posterior, with posterior nasal packs and/or cautery, any method; subsequent $ 449.10 30915 Ligation arteries; ethmoidal 30920 Ligation arteries; internal maxillary artery, transantral $ 2,600.10 30930 Fracture nasal inferior turbinate(s), therapeutic 30999 Unlisted procedure, nose Cost

Row # CPT-4 HCPCS Price 31000 Lavage by cannulation; maxillary sinus (antrum puncture or natural ostium) $ 134.23 31002 Lavage by cannulation; sphenoid sinus $ 291.60 31020 Sinusotomy, maxillary (antrotomy); intranasal 31030 Sinusotomy, maxillary (antrotomy); radical (Caldwell-Luc) without removal of antrochoanal polyps $ 1,966.50 31032 Sinusotomy, maxillary (antrotomy); radical (Caldwell-Luc) with removal of antrochoanal polyps 31040 Pterygomaxillary fossa surgery, any approach $ 3,172.50 31050 Sinusotomy, sphenoid, with or without biopsy; 31051 Sinusotomy, sphenoid, with or without biopsy; with mucosal stripping or removal of polyp(s) $ 2,057.40 31070 Sinusotomy frontal; external, simple (trephine operation) $ 1,499.40 31075 Sinusotomy frontal; transorbital, unilateral (for mucocele or osteoma, Lynch type) $ 2,574.00 31080 Sinusotomy frontal; obliterative without osteoplastic flap, brow incision (includes ablation) $ 3,005.10 31081 Sinusotomy frontal; obliterative, without osteoplastic flap, coronal incision (includes ablation) $ 2,971.80 31084 Sinusotomy frontal; obliterative, with osteoplastic flap, brow 31085 Sinusotomy frontal; obliterative, with osteoplastic flap, coronal $ 3,885.30 31086 Sinusotomy frontal; nonobliterative, with osteoplastic flap, brow $ 3,278.70 31087 Sinusotomy frontal; nonobliterative, with osteoplastic flap, coronal $ 3,210.30 31090 Sinusotomy, unilateral, 3 or more paranasal sinuses (frontal, maxillary, ethmoid, sphenoid) $ 4,236.30 31200 Ethmoidectomy; intranasal, anterior $ 1,301.40 31201 Ethmoidectomy; intranasal, total 31205 Ethmoidectomy; extranasal, total 31225 Maxillectomy; without orbital exenteration $ 4,426.20 31230 Maxillectomy; with orbital exenteration (en bloc) $ 5,388.30 31231 Nasal endoscopy, diagnostic, unilateral or bilateral (separate $ 244.28 31233 Nasal/sinus endoscopy, diagnostic with maxillary sinusoscopy (via inferior meatus or canine fossa puncture) $ 683.10 31235 Nasal/sinus endoscopy, diagnostic with sphenoid sinusoscopy (via puncture of sphenoidal face or cannulation of ostium) 31237 Nasal/sinus endoscopy, surgical; with biopsy, polypectomy or debridement (separate procedure) 31238 Nasal/sinus endoscopy, surgical; with control of nasal hemorrhage $ 909.90 31239 Nasal/sinus endoscopy, surgical; with dacryocystorhinostomy $ 2,768.40 31240 Nasal/sinus endoscopy, surgical; with concha bullosa resection 31254 Nasal/sinus endoscopy, surgical; with ethmoidectomy, partial (anterior) $ 1,690.20 31255 Nasal/sinus endoscopy, surgical; with ethmoidectomy, total (anterior and posterior) $ 1,789.35 31256 Nasal/sinus endoscopy, surgical, with maxillary antrostomy; $ 1,530.00 31267 Nasal/sinus endoscopy, surgical, with maxillary antrostomy; with removal of tissue from maxillary sinus $ 1,867.50 31276 Nasal/sinus endoscopy, surgical with frontal sinus exploration, with or without removal of tissue from frontal sinus 31287 Nasal/sinus endoscopy, surgical, with sphenoidotomy; $ 1,337.40 31288 Nasal/sinus endoscopy, surgical, with sphenoidotomy; with removal of tissue from the sphenoid sinus 31290 Nasal/sinus endoscopy, surgical, with repair of cerebrospinal fluid leak; ethmoid region $ 3,514.50 31291 Nasal/sinus endoscopy, surgical, with repair of cerebrospinal fluid leak; sphenoid region $ 3,903.30 31292 Nasal/sinus endoscopy, surgical; with medial or inferior orbital wall decompression $ 3,122.10 31293 Nasal/sinus endoscopy, surgical; with medial orbital wall and inferior orbital wall decompression $ 3,414.60

Row # CPT-4 HCPCS Price 31294 Nasal/sinus endoscopy, surgical; with optic nerve decompression $ 3,854.70 31299 Unlisted procedure, accessory sinuses Cost 31300 Laryngotomy (thyrotomy, laryngofissure); with removal of tumor or laryngocele, cordectomy $ 2,842.20 31320 Laryngotomy (thyrotomy, laryngofissure); diagnostic 31360 Laryngectomy; total, without radical neck dissection $ 3,825.90 31365 Laryngectomy; total, with radical neck dissection $ 5,740.20 31367 Laryngectomy; subtotal supraglottic, without radical neck dissection $ 4,111.20 31368 Laryngectomy; subtotal supraglottic, with radical neck dissection $ 6,336.00 31370 Partial laryngectomy (hemilaryngectomy); horizontal $ 4,670.10 31375 Partial laryngectomy (hemilaryngectomy); laterovertical $ 3,898.80 31380 Partial laryngectomy (hemilaryngectomy); anterovertical $ 3,970.80 31382 Partial laryngectomy (hemilaryngectomy); antero-latero-vertical $ 4,020.30 31390 Pharyngolaryngectomy, with radical neck dissection; without $ 5,854.50 31395 Pharyngolaryngectomy, with radical neck dissection; with $ 6,849.90 31400 Arytenoidectomy or arytenoidopexy, external approach $ 2,953.80 31420 Epiglottidectomy $ 2,694.60 31500 Intubation, endotracheal, emergency procedure $ 307.80 31502 Tracheotomy tube change prior to establishment of fistula tract 31505 Laryngoscopy, indirect; diagnostic (separate procedure) $ 217.68 31510 Laryngoscopy, indirect; with biopsy $ 306.90 31511 Laryngoscopy, indirect; with removal of foreign body 31512 Laryngoscopy, indirect; with removal of lesion 31513 Laryngoscopy, indirect; with vocal cord injection $ 585.90 31515 Laryngoscopy direct, with or without tracheoscopy; for aspiration $ 377.10 31520 Laryngoscopy direct, with or without tracheoscopy; diagnostic, newborn $ 460.04 31525 Laryngoscopy direct, with or without tracheoscopy; diagnostic, except newborn 31526 Laryngoscopy direct, with or without tracheoscopy; diagnostic, with 31527 Laryngoscopy direct, with or without tracheoscopy; with insertion of obturator $ 1,164.60 31528 Laryngoscopy direct, with or without tracheoscopy; with dilation, 31529 Laryngoscopy direct, with or without tracheoscopy; with dilation, 31530 Laryngoscopy, direct, operative, with foreign body removal; 31531 Laryngoscopy, direct, operative, with foreign body removal; with $ 1,302.30 31535 Laryngoscopy, direct, operative, with biopsy; 31536 Laryngoscopy, direct, operative, with biopsy; with operating microscope or telescope 31540 Laryngoscopy, direct, operative, with excision of tumor and/or stripping of vocal cords or epiglottis; $ 1,155.60 31541 Laryngoscopy, direct, operative, with excision of tumor and/or stripping of vocal cords or epiglottis; with operating microscope or telescope $ 1,328.82 31545 Laryngoscopy, direct, operative, with operating microscope or telescope, with submucosal removal of non-neoplastic lesion(s) of vocal cord; reconstruction with local tissue flap(s) $ 1,137.51 31546 Laryngoscopy, direct, operative, with operating microscope or telescope, with submucosal removal of non-neoplastic lesion(s) of vocal cord; reconstruction with graft(s) (includes obtaining autograft) $ 1,746.43 31560 Laryngoscopy, direct, operative, with arytenoidectomy; 31561 Laryngoscopy, direct, operative, with arytenoidectomy; with $ 2,378.70 31570 Laryngoscopy, direct, with injection into vocal cord(s), therapeutic; $ 1,323.90

Row # CPT-4 HCPCS Price 31571 Laryngoscopy, direct, with injection into vocal cord(s), therapeutic; with operating microscope or telescope $ 1,458.90 31575 Laryngoscopy, flexible fiberoptic; diagnostic $ 323.11 31576 Laryngoscopy, flexible fiberoptic; with biopsy 31577 Laryngoscopy, flexible fiberoptic; with removal of foreign body $ 982.80 31578 Laryngoscopy, flexible fiberoptic; with removal of lesion 31579 Laryngoscopy, flexible or rigid fiberoptic, with stroboscopy $ 626.40 31580 Laryngoplasty; for laryngeal web, 2- stage, with keel insertion and removal 31582 Laryngoplasty; for laryngeal stenosis, with graft or core mold, including tracheotomy $ 4,155.30 31584 Laryngoplasty; with open reduction of fracture $ 3,971.70 31587 Laryngoplasty, cricoid split $ 2,544.30 31588 Laryngoplasty, not otherwise specified (eg, for burns, reconstruction after partial laryngectomy) $ 3,209.40 31590 Laryngeal reinnervation by neuromuscular pedicle $ 2,811.60 31595 Section recurrent laryngeal nerve, therapeutic (separate procedure), unilateral 31599 Unlisted procedure, larynx Cost 31600 Tracheostomy, planned (separate procedure); 31601 Tracheostomy, planned (separate procedure); younger than 2 years $ 1,423.80 31605 Tracheostomy, emergency procedure; cricothyroid membrane $ 957.60 31610 Tracheostomy, fenestration procedure with skin flaps $ 1,731.60 31611 Construction of tracheoesophageal fistula and subsequent insertion of an alaryngeal speech prosthesis (eg, voice button, Blom-Singer $ 1,748.70 31612 Tracheal puncture, percutaneous with transtracheal aspiration and/or injection 31613 Tracheostoma revision; simple, without flap rotation 31614 Tracheostoma revision; complex, with flap rotation 31615 Tracheobronchoscopy through established tracheostomy incision $ 555.30 31620 Endobronchial ultrasound (EBUS) during bronchoscopic diagnostic or therapeutic intervention(s) (List separately in addition to code for primary procedure[s]) $ 798.23 31622 when performed; diagnostic, with cell washing, when performed 31623 when performed; with brushing or protected brushings $ 686.70 31624 when performed; with bronchial alveolar lavage $ 693.00 31625 when performed; with bronchial or endobronchial biopsy(s), single or multiple sites 31626 when performed; with placement of fiducial markers, single or multiple $ 823.11 31627 when performed; with computer-assisted, image-guided navigation (List separately in addition to code for primary procedure[s]) $ 948.86 31628 when performed; with transbronchial lung biopsy(s), single lobe $ 915.30 31629 when performed; with transbronchial needle aspiration biopsy(s), trachea, main stem and/or lobar bronchus(i) 31630 when performed; with tracheal/bronchial dilation or closed reduction of fracture $ 874.80 31632 when performed; with transbronchial lung biopsy(s), each additional lobe (List separately in addition to code for primary $ 221.90

Row # CPT-4 HCPCS Price 31633 when performed; with transbronchial needle aspiration biopsy(s), each additional lobe (List separately in addition to code for primary $ 302.61 31635 when performed; with removal of foreign body 31636 when performed; with placement of bronchial stent(s) (includes tracheal/bronchial dilation as required), initial bronchus $ 822.83 31637 when performed; each additional major bronchus stented (List $ 274.30 31638 when performed; with revision of tracheal or bronchial stent inserted at previous session (includes tracheal/bronchial dilation as required) $ 907.48 31640 when performed; with excision of tumor $ 1,161.00 31641 when performed; with destruction of tumor or relief of stenosis by any method other than excision (eg, laser therapy, cryotherapy) 31643 when performed; with placement of catheter(s) for intracavitary radioelement application $ 606.60 31645 when performed; with therapeutic aspiration of tracheobronchial tree, initial (eg, drainage of lung abscess) 31646 when performed; with therapeutic aspiration of tracheobronchial tree, subsequent $ 706.50 31717 Catheterization with bronchial brush biopsy $ 230.40 31720 Catheter aspiration (separate procedure); nasotracheal $ 169.20 31725 Catheter aspiration (separate procedure); tracheobronchial with fiberscope, bedside $ 406.80 31730 Transtracheal (percutaneous) introduction of needle wire dilator/stent or indwelling tube for oxygen therapy $ 668.70 31750 Tracheoplasty; cervical $ 3,236.40 31755 Tracheoplasty; tracheopharyngeal fistulization, each stage $ 3,572.10 31760 Tracheoplasty; intrathoracic 31766 Carinal reconstruction 31770 Bronchoplasty; graft repair $ 3,687.30 31775 Bronchoplasty; excision stenosis and anastomosis $ 4,083.30 31780 Excision tracheal stenosis and anastomosis; cervical 31781 Excision tracheal stenosis and anastomosis; cervicothoracic $ 4,003.20 31785 Excision of tracheal tumor or carcinoma; cervical $ 3,078.00 31786 Excision of tracheal tumor or carcinoma; thoracic $ 4,113.90 31800 Suture of tracheal wound or injury; cervical $ 2,929.50 31805 Suture of tracheal wound or injury; intrathoracic $ 2,932.20 31820 Surgical closure tracheostomy or fistula; without plastic repair $ 899.10 31825 Surgical closure tracheostomy or fistula; with plastic repair $ 1,259.10 31830 Revision of tracheostomy scar 31899 Unlisted procedure, trachea, bronchi $ 951.62 32035 Thoracostomy; with rib resection for empyema 32036 Thoracostomy; with open flap drainage for empyema $ 1,944.00 32096 Thoracotomy, with diagnostic biopsy(ies) of lung infiltrate(s) (eg, wedge, incisional), unilateral $ 2,016.26 32097 Thoracotomy, with diagnostic biopsy(ies) of lung nodule(s) or mass(es) (eg, wedge, incisional), unilateral $ 2,016.26 32098 Thoracotomy, with biopsy(ies) of pleura $ 1,955.37 32100 Thoracotomy; with exploration $ 2,701.80 32110 Thoracotomy; with control of traumatic hemorrhage and/or repair of lung tear $ 3,024.90 32120 Thoracotomy; for postoperative complications $ 2,522.70 32124 Thoracotomy; with open intrapleural pneumonolysis $ 2,365.20 32140 Thoracotomy; with cyst(s) removal, includes pleural procedure

Row # CPT-4 HCPCS Price 32141 Thoracotomy; with resection-plication of bullae, includes any pleural procedure when performed $ 2,962.80 32150 Thoracotomy; with removal of intrapleural foreign body or fibrin deposit 32151 Thoracotomy; with removal of intrapulmonary foreign body $ 2,255.40 32160 Thoracotomy; with cardiac massage $ 2,646.00 32200 Pneumonostomy, with open drainage of abscess or cyst $ 2,478.60 32215 Pleural scarification for repeat pneumothorax $ 2,565.90 32220 Decortication, pulmonary (separate procedure); total $ 3,480.30 32225 Decortication, pulmonary (separate procedure); partial 32310 Pleurectomy, parietal (separate procedure) $ 3,073.50 32320 Decortication and parietal pleurectomy $ 4,303.80 32400 Biopsy, pleura; percutaneous needle 32405 Biopsy, lung or mediastinum, percutaneous needle; $ 518.40 32440 Removal of lung, pneumonectomy; $ 4,605.30 32442 Removal of lung, pneumonectomy; with resection of segment of trachea followed by broncho-tracheal anastomosis (sleeve pneumonectomy) $ 4,649.40 32445 Removal of lung, pneumonectomy; extrapleural $ 4,839.30 32480 Removal of lung, other than pneumonectomy; single lobe $ 4,327.20 32482 Removal of lung, other than pneumonectomy; 2 lobes (bilobectomy) $ 4,661.10 32484 Removal of lung, other than pneumonectomy; single segment $ 4,255.20 32486 Removal of lung, other than pneumonectomy; with circumferential resection of segment of bronchus followed by broncho-bronchial anastomosis (sleeve lobectomy) $ 4,365.00 32488 Removal of lung, other than pneumonectomy; with all remaining lung following previous removal of a portion of lung (completion pneumonectomy) $ 5,346.00 32491 Removal of lung, other than pneumonectomy; with resection- plication of emphysematous lung(s) (bullous or non-bullous) for lung volume reduction, sternal split or transthoracic approach, includes any pleural procedure, when performed $ 3,131.92 32501 Resection and repair of portion of bronchus (bronchoplasty) when performed at time of lobectomy or segmentectomy (List separately $ 529.40 32503 Resection of apical lung tumor (eg, Pancoast tumor), including chest wall resection, rib(s) resection(s), neurovascular dissection, when performed; without chest wall reconstruction(s) $ 4,016.73 32504 Resection of apical lung tumor (eg, Pancoast tumor), including chest wall resection, rib(s) resection(s), neurovascular dissection, when performed; with chest wall reconstruction $ 4,300.61 32505 Thoracotomy; with therapeutic wedge resection (eg, mass, nodule), $ 2,383.63 32506 Thoracotomy; with therapeutic wedge resection (eg, mass or nodule), each additional resection, ipsilateral (List separately in 32507 Thoracotomy; with diagnostic wedge resection followed by anatomic lung resection (List separately in addition to code for 32540 Extrapleural enucleation of empyema (empyemectomy) 32550 Insertion of indwelling tunneled pleural catheter with cuff $ 739.02 32551 Tube thoracostomy, includes connection to drainage system (eg, water seal), when performed, open (separate procedure) $ 397.73 32552 Removal of indwelling tunneled pleural catheter with cuff $ 393.46 32553 (eg, fiducial markers, dosimeter), percutaneous, intra-thoracic, $ 603.94 32554 Thoracentesis, needle or catheter, aspiration of the pleural space; without imaging guidance $ 1,393.37 32555 Thoracentesis, needle or catheter, aspiration of the pleural space; with imaging guidance $ 1,606.11 32560 Instillation, via chest tube/catheter, agent for pleurodesis (eg, talc for recurrent or persistent pneumothorax) $ 300.45

Row # CPT-4 HCPCS Price 32561 Instillation(s), via chest tube/catheter, agent for fibrinolysis (eg, fibrinolytic agent for break up of multiloculated effusion); initial day $ 184.63 32562 Instillation(s), via chest tube/catheter, agent for fibrinolysis (eg, fibrinolytic agent for break up of multiloculated effusion); subsequent day $ 170.85 32601 Thoracoscopy, diagnostic (separate procedure); lungs, pericardial sac, mediastinal or pleural space, without biopsy 32604 Thoracoscopy, diagnostic (separate procedure); pericardial sac, with $ 1,803.60 32606 Thoracoscopy, diagnostic (separate procedure); mediastinal space, with biopsy $ 1,832.40 32607 Thoracoscopy; with diagnostic biopsy(ies) of lung infiltrate(s) (eg, wedge, incisional), unilateral $ 795.40 32608 Thoracoscopy; with diagnostic biopsy(ies) of lung nodule(s) or mass(es) (eg, wedge, incisional), unilateral $ 979.00 32609 Thoracoscopy; with biopsy(ies) of pleura $ 675.96 32650 Thoracoscopy, surgical; with pleurodesis (eg, mechanical or chemical) 32651 Thoracoscopy, surgical; with partial pulmonary decortication $ 2,722.50 32652 Thoracoscopy, surgical; with total pulmonary decortication, including intrapleural pneumonolysis $ 3,548.70 32653 Thoracoscopy, surgical; with removal of intrapleural foreign body or fibrin deposit $ 2,567.70 32654 Thoracoscopy, surgical; with control of traumatic hemorrhage 32655 Thoracoscopy, surgical; with resection-plication of bullae, includes any pleural procedure when performed $ 2,972.70 32656 Thoracoscopy, surgical; with parietal pleurectomy $ 2,995.20 32658 Thoracoscopy, surgical; with removal of clot or foreign body from pericardial sac $ 2,766.60 32659 Thoracoscopy, surgical; with creation of pericardial window or partial resection of pericardial sac for drainage $ 2,986.20 32661 Thoracoscopy, surgical; with excision of pericardial cyst, tumor, or mass 32662 Thoracoscopy, surgical; with excision of mediastinal cyst, tumor, or mass $ 3,102.30 32663 Thoracoscopy, surgical; with lobectomy (single lobe) $ 3,747.60 32664 Thoracoscopy, surgical; with thoracic sympathectomy 32665 Thoracoscopy, surgical; with esophagomyotomy (Heller type) $ 3,350.70 32666 Thoracoscopy, surgical; with therapeutic wedge resection (eg, mass, nodule), initial unilateral $ 2,222.05 32667 Thoracoscopy, surgical; with therapeutic wedge resection (eg, mass or nodule), each additional resection, ipsilateral (List separately in 32668 Thoracoscopy, surgical; with diagnostic wedge resection followed by anatomic lung resection (List separately in addition to code for $ 411.71 32669 Thoracoscopy, surgical; with removal of a single lung segment $ 3,335.83 32670 Thoracoscopy, surgical; with removal of two lobes (bilobectomy) $ 3,974.02 32671 Thoracoscopy, surgical; with removal of lung (pneumonectomy) $ 4,409.85 32672 Thoracoscopy, surgical; with resection-plication for emphysematous lung (bullous or non-bullous) for lung volume reduction (LVRS), unilateral includes any pleural procedure, when performed $ 3,774.81 32673 Thoracoscopy, surgical; with resection of thymus, unilateral or bilateral $ 2,957.25 32674 Thoracoscopy, surgical; with mediastinal and regional lymphadenectomy (List separately in addition to code for primary $ 531.96 32800 Repair lung hernia through chest wall $ 2,565.00 32810 Closure of chest wall following open flap drainage for empyema (Clagett type procedure) $ 2,710.80 32815 Open closure of major bronchial fistula $ 4,140.90 32820 Major reconstruction, chest wall (posttraumatic) $ 3,856.50

Row # CPT-4 HCPCS Price 32850 Donor pneumonectomy(s) (including cold preservation), from cadaver donor $ - 32851 Lung transplant, single; without cardiopulmonary bypass $ 8,134.00 32852 Lung transplant, single; with cardiopulmonary bypass $ 8,881.42 32853 Lung transplant, double (bilateral sequential or en bloc); without $ 11,365.84 32854 Lung transplant, double (bilateral sequential or en bloc); with $ 12,075.71 32855 Backbench standard preparation of cadaver donor lung allograft surrounding soft tissues to prepare pulmonary venous/atrial cuff, pulmonary artery, and bronchus; unilateral $ - 32856 Backbench standard preparation of cadaver donor lung allograft surrounding soft tissues to prepare pulmonary venous/atrial cuff, pulmonary artery, and bronchus; bilateral $ - 32900 Resection of ribs, extrapleural, all stages $ 2,188.80 32905 Thoracoplasty, Schede type or extrapleural (all stages); 32906 Thoracoplasty, Schede type or extrapleural (all stages); with closure of bronchopleural fistula 32940 Pneumonolysis, extraperiosteal, including filling or packing 32960 Pneumothorax, therapeutic, intrapleural injection of air 32997 Total lung lavage (unilateral) $ 993.60 32998 Ablation therapy for reduction or eradication of 1 or more pulmonary tumor(s) including pleura or chest wall when involved by tumor extension, percutaneous, radiofrequency, unilateral $ 2,369.98 32999 Unlisted procedure, lungs and pleura Cost 33010 Pericardiocentesis; initial 33011 Pericardiocentesis; subsequent 33015 Tube pericardiostomy 33020 Pericardiotomy for removal of clot or foreign body (primary $ 2,667.60 33025 Creation of pericardial window or partial resection for drainage 33030 Pericardiectomy, subtotal or complete; without cardiopulmonary $ 4,041.00 33031 Pericardiectomy, subtotal or complete; with cardiopulmonary $ 5,037.30 33050 Resection of pericardial cyst or tumor $ 3,219.30 33120 Excision of intracardiac tumor, resection with cardiopulmonary $ 6,552.90 33130 Resection of external cardiac tumor $ 4,139.10 33140 Transmyocardial laser revascularization, by thoracotomy; (separate $ 3,384.56 33141 Transmyocardial laser revascularization, by thoracotomy; performed at the time of other open cardiac procedure(s) (List $ 1,649.90 33202 Insertion of epicardial electrode(s); open incision (eg, thoracotomy, median sternotomy, subxiphoid approach) $ 2,051.82 33203 Insertion of epicardial electrode(s); endoscopic approach (eg, thoracoscopy, pericardioscopy) $ 2,105.33 33206 transvenous electrode(s); atrial $ 2,232.90 33207 transvenous electrode(s); ventricular $ 2,424.60 33208 transvenous electrode(s); atrial and ventricular $ 3,028.50 33210 Insertion or replacement of temporary transvenous single chamber cardiac electrode or pacemaker catheter (separate procedure) $ 874.80 33211 Insertion or replacement of temporary transvenous dual chamber pacing electrodes (separate procedure) 33212 Insertion of pacemaker pulse generator only; with existing single lead $ 1,445.40 33213 Insertion of pacemaker pulse generator only; with existing dual leads

Row # CPT-4 HCPCS Price 33214 Upgrade of implanted pacemaker system, conversion of single chamber system to dual chamber system (includes removal of previously placed pulse generator, testing of existing lead, insertion of new lead, insertion of new pulse generator) $ 1,986.30 33215 Repositioning of previously implanted transvenous pacemaker or pacing cardioverter-defibrillator (right atrial or right ventricular) electrode $ 829.37 33216 Insertion of a single transvenous electrode, permanent pacemaker or cardioverter-defibrillator $ 1,427.40 33217 Insertion of 2 transvenous electrodes, permanent pacemaker or cardioverter-defibrillator $ 1,512.90 33218 Repair of single transvenous electrode, permanent pacemaker or pacing cardioverter-defibrillator $ 1,392.30 33220 Repair of 2 transvenous electrodes for permanent pacemaker or pacing cardioverter-defibrillator $ 1,192.50 33222 Relocation of skin pocket for pacemaker $ 1,442.70 33223 Relocation of skin pocket for cardioverter-defibrillator $ 1,238.40 33224 Insertion of pacing electrode, cardiac venous system, for left ventricular pacing, with attachment to previously placed pacemaker or pacing cardioverter-defibrillator pulse generator (including revision of pocket, removal, insertion, and/or replacement of $ 1,345.09 33225 Insertion of pacing electrode, cardiac venous system, for left ventricular pacing, at time of insertion of pacing cardioverter- defibrillator or pacemaker pulse generator (eg, for upgrade to dual chamber system) (List separately in addition to code for pri $ 1,199.61 33226 Repositioning of previously implanted cardiac venous system (left ventricular) electrode (including removal, insertion and/or replacement of existing generator) $ 1,296.07 33233 Removal of permanent pacemaker pulse generator only $ 995.40 33234 Removal of transvenous pacemaker electrode(s); single lead system, atrial or ventricular $ 1,511.10 33235 Removal of transvenous pacemaker electrode(s); dual lead system $ 1,649.70 33236 Removal of permanent epicardial pacemaker and electrodes by thoracotomy; single lead system, atrial or ventricular $ 1,722.60 33237 Removal of permanent epicardial pacemaker and electrodes by thoracotomy; dual lead system $ 2,735.10 33238 Removal of permanent transvenous electrode(s) by thoracotomy 33240 Insertion of pacing cardioverter-defibrillator pulse generator only; with existing single lead $ 1,513.80 33241 Removal of pacing cardioverter-defibrillator pulse generator only 33243 Removal of single or dual chamber pacing cardioverter-defibrillator electrode(s); by thoracotomy $ 3,192.30 33244 Removal of single or dual chamber pacing cardioverter-defibrillator electrode(s); by transvenous extraction $ 2,707.20 33249 Insertion or replacement of permanent pacing cardioverter- defibrillator system with transvenous lead(s), single or dual chamber 33250 Operative ablation of supraventricular arrhythmogenic focus or pathway (eg, Wolff-Parkinson-White, atrioventricular node re- entry), tract(s) and/or focus (foci); without cardiopulmonary bypass 33251 Operative ablation of supraventricular arrhythmogenic focus or pathway (eg, Wolff-Parkinson-White, atrioventricular node re- entry), tract(s) and/or focus (foci); with cardiopulmonary bypass $ 5,150.70 33254 Operative tissue ablation and reconstruction of atria, limited (eg, modified maze procedure) $ 2,975.87 33255 Operative tissue ablation and reconstruction of atria, extensive (eg, maze procedure); without cardiopulmonary bypass $ 3,580.01 33256 Operative tissue ablation and reconstruction of atria, extensive (eg, maze procedure); with cardiopulmonary bypass $ 4,278.05

Row # CPT-4 HCPCS Price 33257 the time of other cardiac procedure(s), limited (eg, modified maze $ 1,362.89 33258 the time of other cardiac procedure(s), extensive (eg, maze procedure), without cardiopulmonary bypass (List separately in $ 1,535.93 33259 the time of other cardiac procedure(s), extensive (eg, maze procedure), with cardiopulmonary bypass (List separately in $ 2,004.34 33261 Operative ablation of ventricular arrhythmogenic focus with $ 5,135.40 33265 Endoscopy, surgical; operative tissue ablation and reconstruction of atria, limited (eg, modified maze procedure), without $ 2,970.81 33266 Endoscopy, surgical; operative tissue ablation and reconstruction of atria, extensive (eg, maze procedure), without cardiopulmonary $ 4,068.64 33282 Implantation of patient-activated cardiac event recorder $ 786.37 33284 Removal of an implantable, patient-activated cardiac event recorder $ 567.29 33300 Repair of cardiac wound; without bypass 33305 Repair of cardiac wound; with cardiopulmonary bypass $ 5,122.80 33310 Cardiotomy, exploratory (includes removal of foreign body, atrial or ventricular thrombus); without bypass $ 3,654.90 33315 Cardiotomy, exploratory (includes removal of foreign body, atrial or ventricular thrombus); with cardiopulmonary bypass $ 5,318.10 33320 Suture repair of aorta or great vessels; without shunt or $ 4,713.30 33321 Suture repair of aorta or great vessels; with shunt bypass $ 3,833.13 33322 Suture repair of aorta or great vessels; with cardiopulmonary $ 5,744.70 33330 Insertion of graft, aorta or great vessels; without shunt, or $ 6,261.30 33332 Insertion of graft, aorta or great vessels; with shunt bypass $ 5,066.72 33335 Insertion of graft, aorta or great vessels; with cardiopulmonary $ 6,984.00 33400 Valvuloplasty, aortic valve; open, with cardiopulmonary bypass 33401 Valvuloplasty, aortic valve; open, with inflow occlusion $ 5,706.90 33403 Valvuloplasty, aortic valve; using transventricular dilation, with $ 6,159.60 33404 Construction of apical-aortic conduit 33405 prosthetic valve other than homograft or stentless valve $ 7,717.50 33406 allograft valve (freehand) $ 7,029.90 33410 stentless tissue valve $ 6,661.86 33411 Replacement, aortic valve; with aortic annulus enlargement, noncoronary sinus $ 7,921.80 33412 Replacement, aortic valve; with transventricular aortic annulus enlargement (Konno procedure) $ 8,019.00 33413 Replacement, aortic valve; by translocation of autologous pulmonary valve with allograft replacement of pulmonary valve (Ross procedure) $ 7,622.10 33414 Repair of left ventricular outflow tract obstruction by patch enlargement of the outflow tract $ 6,825.57 33415 Resection or incision of subvalvular tissue for discrete subvalvular aortic stenosis $ 6,087.60 33416 Ventriculomyotomy (-myectomy) for idiopathic hypertrophic subaortic stenosis (eg, asymmetric septal hypertrophy) $ 6,592.50 33417 Aortoplasty (gusset) for supravalvular stenosis $ 6,952.50

Row # CPT-4 HCPCS Price 33420 Valvotomy, mitral valve; closed heart $ 5,495.40 33422 Valvotomy, mitral valve; open heart, with cardiopulmonary bypass $ 6,451.20 33425 Valvuloplasty, mitral valve, with cardiopulmonary bypass; $ 6,628.50 33426 Valvuloplasty, mitral valve, with cardiopulmonary bypass; with prosthetic ring $ 7,905.60 33427 Valvuloplasty, mitral valve, with cardiopulmonary bypass; radical reconstruction, with or without ring $ 6,978.60 33430 Replacement, mitral valve, with cardiopulmonary bypass $ 7,627.50 33460 Valvectomy, tricuspid valve, with cardiopulmonary bypass $ 6,223.50 33463 Valvuloplasty, tricuspid valve; without ring insertion $ 7,105.50 33464 Valvuloplasty, tricuspid valve; with ring insertion $ 6,801.30 33465 Replacement, tricuspid valve, with cardiopulmonary bypass $ 6,721.20 33468 Tricuspid valve repositioning and plication for Ebstein anomaly $ 6,988.50 33470 Valvotomy, pulmonary valve, closed heart; transventricular $ 5,030.10 33471 Valvotomy, pulmonary valve, closed heart; via pulmonary artery $ 4,708.80 33472 Valvotomy, pulmonary valve, open heart; with inflow occlusion $ 4,979.70 33474 Valvotomy, pulmonary valve, open heart; with cardiopulmonary $ 5,535.90 33475 Replacement, pulmonary valve $ 7,105.50 33476 Right ventricular resection for infundibular stenosis, with or without commissurotomy 33478 Outflow tract augmentation (gusset), with or without commissurotomy or infundibular resection 33496 Repair of non-structural prosthetic valve dysfunction with cardiopulmonary bypass (separate procedure) $ 5,799.60 33500 Repair of coronary arteriovenous or arteriocardiac chamber fistula; with cardiopulmonary bypass $ 5,355.90 33501 Repair of coronary arteriovenous or arteriocardiac chamber fistula; without cardiopulmonary bypass $ 4,027.50 33502 by ligation $ 3,878.10 33503 by graft, without cardiopulmonary bypass 33504 by graft, with cardiopulmonary bypass $ 6,170.40 33505 with construction of intrapulmonary artery tunnel (Takeuchi $ 5,183.04 33506 by translocation from pulmonary artery to aorta $ 5,719.19 33507 Repair of anomalous (eg, intramural) aortic origin of coronary artery by unroofing or translocation $ 5,300.00 33508 Endoscopy, surgical, including video-assisted harvest of vein(s) for coronary artery bypass procedure (List separately in addition to $ 260.39 33510 Coronary artery bypass, vein only; single coronary venous graft $ 7,254.00 33511 Coronary artery bypass, vein only; 2 coronary venous grafts $ 7,448.40 33512 Coronary artery bypass, vein only; 3 coronary venous grafts $ 8,284.50 33513 Coronary artery bypass, vein only; 4 coronary venous grafts $ 9,268.20 33514 Coronary artery bypass, vein only; 5 coronary venous grafts $ 10,083.60 33516 Coronary artery bypass, vein only; 6 or more coronary venous grafts $ 10,809.00 33517 Coronary artery bypass, using venous graft(s) and arterial graft(s); single vein graft (List separately in addition to code for primary $ 1,161.90 33518 Coronary artery bypass, using venous graft(s) and arterial graft(s); 2 $ 1,747.80 33519 Coronary artery bypass, using venous graft(s) and arterial graft(s); 3 33521 Coronary artery bypass, using venous graft(s) and arterial graft(s); 4

Row # CPT-4 HCPCS Price 33522 Coronary artery bypass, using venous graft(s) and arterial graft(s); 5 $ 3,634.20 33523 Coronary artery bypass, using venous graft(s) and arterial graft(s); 6 or more venous grafts (List separately in addition to code for $ 4,606.20 33530 Reoperation, coronary artery bypass procedure or valve procedure, more than 1 month after original operation (List separately in 33533 Coronary artery bypass, using arterial graft(s); single arterial graft $ 6,878.70 33534 Coronary artery bypass, using arterial graft(s); 2 coronary arterial $ 7,822.80 33535 Coronary artery bypass, using arterial graft(s); 3 coronary arterial $ 8,479.80 33536 Coronary artery bypass, using arterial graft(s); 4 or more coronary arterial grafts $ 8,454.60 33542 Myocardial resection (eg, ventricular aneurysmectomy) $ 6,769.80 33545 Repair of postinfarction ventricular septal defect, with or without myocardial resection $ 7,679.70 33548 Surgical ventricular restoration procedure, includes prosthetic patch, when performed (eg, ventricular remodeling, SVR, SAVER, Dor procedures) $ 7,924.63 33572 Coronary endarterectomy, open, any method, of left anterior descending, circumflex, or right coronary artery performed in conjunction with coronary artery bypass graft procedure, each vessel (List separately in addition to primary procedure) 33600 Closure of atrioventricular valve (mitral or tricuspid) by suture or patch 33602 Closure of semilunar valve (aortic or pulmonary) by suture or patch $ 6,479.10 33606 Anastomosis of pulmonary artery to aorta (Damus-Kaye-Stansel $ 6,581.70 33608 Repair of complex cardiac anomaly other than pulmonary atresia with ventricular septal defect by construction or replacement of conduit from right or left ventricle to pulmonary artery $ 6,643.80 33610 Repair of complex cardiac anomalies (eg, single ventricle with subaortic obstruction) by surgical enlargement of ventricular septal defect $ 6,591.66 33611 Repair of double outlet right ventricle with intraventricular tunnel $ 6,644.56 33612 Repair of double outlet right ventricle with intraventricular tunnel repair; with repair of right ventricular outflow tract obstruction 33615 Repair of complex cardiac anomalies (eg, tricuspid atresia) by closure of atrial septal defect and anastomosis of atria or vena cava to pulmonary artery (simple Fontan procedure) 33617 Repair of complex cardiac anomalies (eg, single ventricle) by modified Fontan procedure $ 7,584.08 33619 Repair of single ventricle with aortic outflow obstruction and aortic arch hypoplasia (hypoplastic left heart syndrome) (eg, Norwood $ 8,214.30 33641 Repair atrial septal defect, secundum, with cardiopulmonary bypass, with or without patch $ 5,459.40 33645 Direct or patch closure, sinus venosus, with or without anomalous pulmonary venous drainage $ 6,368.40 33647 Repair of atrial septal defect and ventricular septal defect, with direct or patch closure $ 7,210.80 33660 Repair of incomplete or partial atrioventricular canal (ostium primum atrial septal defect), with or without atrioventricular valve $ 6,916.50 33665 Repair of intermediate or transitional atrioventricular canal, with or without atrioventricular valve repair $ 7,938.00 33670 Repair of complete atrioventricular canal, with or without prosthetic valve $ 7,625.70 33675 Closure of multiple ventricular septal defects; $ 6,647.90 33676 Closure of multiple ventricular septal defects; with pulmonary valvotomy or infundibular resection (acyanotic) $ 6,341.84

Row # CPT-4 HCPCS Price 33677 Closure of multiple ventricular septal defects; with removal of pulmonary artery band, with or without gusset $ 6,334.62 33681 $ 6,144.30 33684 with pulmonary valvotomy or infundibular resection (acyanotic) $ 6,494.40 33688 with removal of pulmonary artery band, with or without gusset $ 6,613.20 33690 Banding of pulmonary artery 33692 Complete repair tetralogy of Fallot without pulmonary atresia; 33694 Complete repair tetralogy of Fallot without pulmonary atresia; with transannular patch $ 7,090.20 33697 Complete repair tetralogy of Fallot with pulmonary atresia including construction of conduit from right ventricle to pulmonary artery and closure of ventricular septal defect $ 7,173.90 33702 Repair sinus of Valsalva fistula, with cardiopulmonary bypass; $ 5,951.70 33710 Repair sinus of Valsalva fistula, with cardiopulmonary bypass; with repair of ventricular septal defect $ 7,786.80 33720 Repair sinus of Valsalva aneurysm, with cardiopulmonary bypass 33722 Closure of aortico-left ventricular tunnel 33724 Repair of isolated partial anomalous pulmonary venous return (eg, Scimitar Syndrome) $ 5,384.20 33726 Repair of pulmonary venous stenosis $ 6,373.14 33730 Complete repair of anomalous pulmonary venous return (supracardiac, intracardiac, or infracardiac types) $ 6,602.40 33732 Repair of cor triatriatum or supravalvular mitral ring by resection of left atrial membrane $ 5,942.70 33735 Atrial septectomy or septostomy; closed heart (Blalock-Hanlon type $ 4,538.70 33736 Atrial septectomy or septostomy; open heart with cardiopulmonary $ 5,480.10 33737 Atrial septectomy or septostomy; open heart, with inflow occlusion 33750 Shunt; subclavian to pulmonary artery (Blalock-Taussig type $ 4,233.60 33755 Shunt; ascending aorta to pulmonary artery (Waterston type $ 4,748.40 33762 Shunt; descending aorta to pulmonary artery (Potts-Smith type $ 4,645.80 33764 Shunt; central, with prosthetic graft 33766 Shunt; superior vena cava to pulmonary artery for flow to 1 lung (classical Glenn procedure) $ 4,068.90 33767 Shunt; superior vena cava to pulmonary artery for flow to both lungs (bidirectional Glenn procedure) 33768 Anastomosis, cavopulmonary, second superior vena cava (List separately in addition to primary procedure) $ 1,373.84 33770 Repair of transposition of the great arteries with ventricular septal defect and subpulmonary stenosis; without surgical enlargement of ventricular septal defect $ 7,014.60 33771 Repair of transposition of the great arteries with ventricular septal defect and subpulmonary stenosis; with surgical enlargement of ventricular septal defect $ 7,655.60 33774 (eg, Mustard or Senning type) with cardiopulmonary bypass; 33775 removal of pulmonary band $ 6,685.20 33776 closure of ventricular septal defect $ 8,601.30

Row # CPT-4 HCPCS Price 33777 repair of subpulmonic obstruction $ 8,343.00 33778 artery reconstruction (eg, Jatene type); $ 9,038.70 33779 artery reconstruction (eg, Jatene type); with removal of pulmonary band 33780 artery reconstruction (eg, Jatene type); with closure of ventricular septal defect 33781 artery reconstruction (eg, Jatene type); with repair of subpulmonic obstruction 33782 Aortic root translocation with ventricular septal defect and pulmonary stenosis repair (ie, Nikaidoh procedure); without coronary ostium reimplantation $ 12,843.24 33783 Aortic root translocation with ventricular septal defect and pulmonary stenosis repair (ie, Nikaidoh procedure); with reimplantation of 1 or both coronary ostia $ 13,932.80 33786 Total repair, truncus arteriosus (Rastelli type operation) 33788 Reimplantation of an anomalous pulmonary artery $ 5,548.50 33800 Aortic suspension (aortopexy) for tracheal decompression (eg, for tracheomalacia) (separate procedure) 33802 Division of aberrant vessel (vascular ring); 33803 Division of aberrant vessel (vascular ring); with reanastomosis $ 3,893.40 33813 Obliteration of aortopulmonary septal defect; without $ 4,243.50 33814 Obliteration of aortopulmonary septal defect; with $ 5,994.90 33820 Repair of patent ductus arteriosus; by ligation $ 3,869.10 33822 Repair of patent ductus arteriosus; by division, younger than 18 years $ 3,641.40 33824 Repair of patent ductus arteriosus; by division, 18 years and older $ 4,058.10 33840 ductus arteriosus; with direct anastomosis $ 4,342.50 33845 ductus arteriosus; with graft $ 6,087.60 33851 ductus arteriosus; repair using either left subclavian artery or prosthetic material as gusset for enlargement $ 5,986.48 33852 Repair of hypoplastic or interrupted aortic arch using autogenous or prosthetic material; without cardiopulmonary bypass $ 5,514.30 33853 Repair of hypoplastic or interrupted aortic arch using autogenous or prosthetic material; with cardiopulmonary bypass $ 6,901.20 33860 Ascending aorta graft, with cardiopulmonary bypass, includes valve suspension, when performed $ 7,323.30 33863 Ascending aorta graft, with cardiopulmonary bypass, with aortic root replacement using valved conduit and coronary reconstruction (eg, Bentall) $ 7,577.10 33864 Ascending aorta graft, with cardiopulmonary bypass with valve suspension, with coronary reconstruction and valve-sparing aortic root remodeling (eg, David Procedure, Yacoub Procedure) $ 7,601.41 33870 Transverse arch graft, with cardiopulmonary bypass $ 9,652.50 33875 Descending thoracic aorta graft, with or without bypass $ 7,810.20 33877 Repair of thoracoabdominal aortic aneurysm with graft, with or without cardiopulmonary bypass $ 9,241.20 33880 Endovascular repair of descending thoracic aorta (eg, aneurysm, pseudoaneurysm, dissection, penetrating ulcer, intramural hematoma, or traumatic disruption); involving coverage of left subclavian artery origin, initial endoprosthesis plus descending thora $ 5,712.22

Row # CPT-4 HCPCS Price 33881 Endovascular repair of descending thoracic aorta (eg, aneurysm, pseudoaneurysm, dissection, penetrating ulcer, intramural hematoma, or traumatic disruption); not involving coverage of left subclavian artery origin, initial endoprosthesis plus descending t $ 4,930.62 33883 Placement of proximal extension prosthesis for endovascular repair of descending thoracic aorta (eg, aneurysm, pseudoaneurysm, dissection, penetrating ulcer, intramural hematoma, or traumatic disruption); initial extension $ 3,643.31 33884 Placement of proximal extension prosthesis for endovascular repair of descending thoracic aorta (eg, aneurysm, pseudoaneurysm, dissection, penetrating ulcer, intramural hematoma, or traumatic disruption); each additional proximal extension (List separatel $ 1,385.57 33886 Placement of distal extension prosthesis(s) delayed after endovascular repair of descending thoracic aorta $ 3,119.61 33889 Open subclavian to carotid artery transposition performed in conjunction with endovascular repair of descending thoracic aorta, by neck incision, unilateral $ 2,690.56 33891 Bypass graft, with other than vein, transcervical retropharyngeal carotid-carotid, performed in conjunction with endovascular repair of descending thoracic aorta, by neck incision $ 3,430.57 33910 Pulmonary artery embolectomy; with cardiopulmonary bypass $ 6,566.40 33915 Pulmonary artery embolectomy; without cardiopulmonary bypass 33916 Pulmonary endarterectomy, with or without embolectomy, with $ 4,653.00 33917 Repair of pulmonary artery stenosis by reconstruction with patch or graft $ 6,633.90 33920 Repair of pulmonary atresia with ventricular septal defect, by construction or replacement of conduit from right or left ventricle to pulmonary artery $ 6,891.30 33922 Transection of pulmonary artery with cardiopulmonary bypass 33924 Ligation and takedown of a systemic-to-pulmonary artery shunt, performed in conjunction with a congenital heart procedure (List $ 1,096.26 33925 Repair of pulmonary artery arborization anomalies by unifocalization; without cardiopulmonary bypass $ 6,455.33 33926 Repair of pulmonary artery arborization anomalies by unifocalization; with cardiopulmonary bypass $ 8,708.02 33930 Donor cardiectomy-pneumonectomy (including cold preservation) $ - 33933 Backbench standard preparation of cadaver donor heart/lung allograft prior to transplantation, including dissection of allograft from surrounding soft tissues to prepare aorta, superior vena cava, inferior vena cava, and trachea for implantation $ - 33935 Heart-lung transplant with recipient cardiectomy-pneumonectomy $ 12,504.94 33940 Donor cardiectomy (including cold preservation) $ 4,149.00 33944 Backbench standard preparation of cadaver donor heart allograft surrounding soft tissues to prepare aorta, superior vena cava, inferior vena cava, pulmonary artery, and left atrium for impla $ - 33945 Heart transplant, with or without recipient cardiectomy $ 11,331.00 33960 Prolonged extracorporeal circulation for cardiopulmonary insufficiency; initial day $ 2,981.70 33961 Prolonged extracorporeal circulation for cardiopulmonary insufficiency; each subsequent day $ 1,626.30 33967 Insertion of intra-aortic balloon assist device, percutaneous $ 681.97 33968 Removal of intra-aortic balloon assist device, percutaneous $ 98.27 33970 Insertion of intra-aortic balloon assist device through the femoral artery, open approach

Row # CPT-4 HCPCS Price 33971 Removal of intra-aortic balloon assist device including repair of femoral artery, with or without graft 33973 Insertion of intra-aortic balloon assist device through the ascending aorta $ 2,047.50 33974 Removal of intra-aortic balloon assist device from the ascending aorta, including repair of the ascending aorta, with or without graft 33975 Insertion of ventricular assist device; extracorporeal, single ventricle $ 4,377.60 33976 Insertion of ventricular assist device; extracorporeal, biventricular $ 4,364.10 33977 Removal of ventricular assist device; extracorporeal, single ventricle $ 3,388.50 33978 Removal of ventricular assist device; extracorporeal, biventricular $ 3,780.00 33979 Insertion of ventricular assist device, implantable intracorporeal, single ventricle $ 6,113.20 33980 Removal of ventricular assist device, implantable intracorporeal, single ventricle $ 9,056.83 33981 Replacement of extracorporeal ventricular assist device, single or biventricular, pump(s), single or each pump $ 2,099.36 33982 Replacement of ventricular assist device pump(s); implantable intracorporeal, single ventricle, without cardiopulmonary bypass $ 5,143.44 33983 Replacement of ventricular assist device pump(s); implantable intracorporeal, single ventricle, with cardiopulmonary bypass $ 5,744.73 33999 Unlisted procedure, cardiac surgery $ - 34001 Embolectomy or thrombectomy, with or without catheter; carotid, subclavian or innominate artery, by neck incision 34051 Embolectomy or thrombectomy, with or without catheter; innominate, subclavian artery, by thoracic incision $ 2,909.70 34101 Embolectomy or thrombectomy, with or without catheter; axillary, brachial, innominate, subclavian artery, by arm incision $ 2,623.50 34111 Embolectomy or thrombectomy, with or without catheter; radial or ulnar artery, by arm incision $ 2,964.60 34151 Embolectomy or thrombectomy, with or without catheter; renal, celiac, mesentery, aortoiliac artery, by abdominal incision $ 3,651.30 34201 Embolectomy or thrombectomy, with or without catheter; femoropopliteal, aortoiliac artery, by leg incision $ 2,886.30 34203 Embolectomy or thrombectomy, with or without catheter; popliteal- tibio-peroneal artery, by leg incision $ 2,952.90 34401 Thrombectomy, direct or with catheter; vena cava, iliac vein, by abdominal incision 34421 Thrombectomy, direct or with catheter; vena cava, iliac, femoropopliteal vein, by leg incision $ 2,549.70 34451 Thrombectomy, direct or with catheter; vena cava, iliac, femoropopliteal vein, by abdominal and leg incision $ 2,923.20 34471 Thrombectomy, direct or with catheter; subclavian vein, by neck 34490 Thrombectomy, direct or with catheter; axillary and subclavian vein, by arm incision $ 2,148.30 34501 Valvuloplasty, femoral vein 34502 Reconstruction of vena cava, any method $ 5,296.50 34510 Venous valve transposition, any vein donor 34520 Cross-over vein graft to venous system $ 3,444.30 34530 Saphenopopliteal vein anastomosis $ 2,738.70 34800 dissection; using aorto-aortic tube prosthesis $ 3,621.60 34802 dissection; using modular bifurcated prosthesis (1 docking limb) $ 3,996.90 34803 dissection; using modular bifurcated prosthesis (2 docking limbs) $ 4,301.78 34804 dissection; using unibody bifurcated prosthesis $ 3,996.90

Row # CPT-4 HCPCS Price 34805 dissection; using aorto-uniiliac or aorto-unifemoral prosthesis $ 3,987.05 34806 Transcatheter placement of wireless physiologic sensor in aneurysmal sac during endovascular repair, including radiological supervision and interpretation, instrument calibration, and collection of pressure data (List separately in addition to code for pr $ 420.95 34808 Endovascular placement of iliac artery occlusion device (List 34812 Open femoral artery exposure for delivery of endovascular prosthesis, by groin incision, unilateral $ 1,125.90 34813 Placement of femoral-femoral prosthetic graft during endovascular aortic aneurysm repair (List separately in addition to code for $ 800.10 34820 Open iliac artery exposure for delivery of endovascular prosthesis or iliac occlusion during endovascular therapy, by abdominal or retroperitoneal incision, unilateral $ 1,626.30 34825 Placement of proximal or distal extension prosthesis for endovascular repair of infrarenal abdominal aortic or iliac aneurysm, false aneurysm, or dissection; initial vessel 34826 Placement of proximal or distal extension prosthesis for endovascular repair of infrarenal abdominal aortic or iliac aneurysm, false aneurysm, or dissection; each additional vessel (List 34830 repair; tube prosthesis $ 5,635.80 34831 repair; aorto-bi-iliac prosthesis $ 6,093.00 34832 repair; aorto-bifemoral prosthesis $ 6,093.00 34833 Open iliac artery exposure with creation of conduit for delivery of aortic or iliac endovascular prosthesis, by abdominal or retroperitoneal incision, unilateral $ 1,682.17 34834 Open brachial artery exposure to assist in the deployment of aortic or iliac endovascular prosthesis by arm incision, unilateral $ 965.20 34900 Endovascular repair of iliac artery (eg, aneurysm, pseudoaneurysm, arteriovenous malformation, trauma) using ilio-iliac tube endoprosthesis $ 2,239.64 35001 and associated occlusive disease, carotid, subclavian artery, by neck $ 3,978.00 35002 aneurysm, carotid, subclavian artery, by neck incision $ 4,092.30 35005 pseudoaneurysm, and associated occlusive disease, vertebral artery $ 3,744.00 35011 and associated occlusive disease, axillary-brachial artery, by arm $ 3,550.50 35013 aneurysm, axillary-brachial artery, by arm incision $ 3,780.90 35021 pseudoaneurysm, and associated occlusive disease, innominate, subclavian artery, by thoracic incision $ 4,011.30

Row # CPT-4 HCPCS Price 35022 aneurysm, innominate, subclavian artery, by thoracic incision $ 4,035.60 35045 pseudoaneurysm, and associated occlusive disease, radial or ulnar $ 3,766.50 35081 aorta $ 5,967.00 35082 aneurysm, abdominal aorta $ 7,056.00 35091 aorta involving visceral vessels (mesenteric, celiac, ren $ 6,876.00 35092 aneurysm, abdominal aorta involving visceral vessels (mesenteric, celiac, renal) $ 7,870.50 35102 aorta involving iliac vessels (common, hypogastric, exter $ 6,484.50 35103 aneurysm, abdominal aorta involving iliac vessels (common, hypogastric, external) $ 6,972.30 35111 pseudoaneurysm, and associated occlusive disease, splenic artery $ 4,826.70 35112 aneurysm, splenic artery $ 3,327.30 35121 pseudoaneurysm, and associated occlusive disease, hepatic, celiac, renal, or mesenteric artery $ 4,541.40 35122 aneurysm, hepatic, celiac, renal, or mesenteric artery 35131 pseudoaneurysm, and associated occlusive disease, iliac artery (common, hypogastric, external) $ 4,762.80 35132 aneurysm, iliac artery (common, hypogastric, external) $ 4,635.00 35141 pseudoaneurysm, and associated occlusive disease, common femoral artery (profunda femoris, superficial femoral) $ 4,068.90 35142 aneurysm, common femoral artery (profunda femoris, superficial femoral) $ 4,619.70

Row # CPT-4 HCPCS Price 35151 pseudoaneurysm, and associated occlusive disease, popliteal artery $ 4,226.40 35152 aneurysm, popliteal artery $ 3,790.80 35180 Repair, congenital arteriovenous fistula; head and neck 35182 Repair, congenital arteriovenous fistula; thorax and abdomen 35184 Repair, congenital arteriovenous fistula; extremities $ 3,888.00 35188 Repair, acquired or traumatic arteriovenous fistula; head and neck $ 3,234.60 35189 Repair, acquired or traumatic arteriovenous fistula; thorax and abdomen $ 4,228.20 35190 Repair, acquired or traumatic arteriovenous fistula; extremities 35201 Repair blood vessel, direct; neck 35206 Repair blood vessel, direct; upper extremity $ 3,393.00 35207 Repair blood vessel, direct; hand, finger 35211 Repair blood vessel, direct; intrathoracic, with bypass $ 4,775.40 35216 Repair blood vessel, direct; intrathoracic, without bypass $ 4,719.60 35221 Repair blood vessel, direct; intra-abdominal $ 4,332.60 35226 Repair blood vessel, direct; lower extremity $ 4,322.70 35231 Repair blood vessel with vein graft; neck $ 3,770.10 35236 Repair blood vessel with vein graft; upper extremity $ 5,035.50 35241 Repair blood vessel with vein graft; intrathoracic, with bypass $ 4,771.80 35246 Repair blood vessel with vein graft; intrathoracic, without bypass $ 4,289.40 35251 Repair blood vessel with vein graft; intra-abdominal $ 5,365.80 35256 Repair blood vessel with vein graft; lower extremity 35261 Repair blood vessel with graft other than vein; neck 35266 Repair blood vessel with graft other than vein; upper extremity $ 3,907.80 35271 Repair blood vessel with graft other than vein; intrathoracic, with $ 5,134.50 35276 Repair blood vessel with graft other than vein; intrathoracic, without bypass 35281 Repair blood vessel with graft other than vein; intra-abdominal 35286 Repair blood vessel with graft other than vein; lower extremity $ 4,189.50 35301 carotid, vertebral, subclavian, by neck incision $ 4,066.20 35302 superficial femoral artery $ 3,050.03 35303 popliteal artery $ 3,211.06 35304 tibioperoneal trunk artery $ 3,248.55 35305 Thromboendarterectomy, including patch graft, if performed; tibial or peroneal artery, initial vessel $ 3,210.32 35306 Thromboendarterectomy, including patch graft, if performed; each additional tibial or peroneal artery (List separately in addition to $ 1,331.62 35311 subclavian, innominate, by thoracic incision 35321 axillary-brachial 35331 abdominal aorta $ 5,119.20 35341 mesenteric, celiac, or renal $ 4,953.60 35351 Thromboendarterectomy, including patch graft, if performed; iliac $ 4,340.70 35355 iliofemoral $ 4,176.00 35361 combined aortoiliac $ 5,794.20

Row # CPT-4 HCPCS Price 35363 combined aortoiliofemoral 35371 common femoral 35372 Thromboendarterectomy, including patch graft, if performed; deep (profunda) femoral $ 4,039.20 35390 Reoperation, carotid, thromboendarterectomy, more than 1 month after original operation (List separately in addition to code for $ 855.00 35400 Angioscopy (non-coronary vessels or grafts) during therapeutic intervention (List separately in addition to code for primary 35450 Transluminal balloon angioplasty, open; renal or other visceral $ 2,514.60 35452 Transluminal balloon angioplasty, open; aortic 35458 Transluminal balloon angioplasty, open; brachiocephalic trunk or branches, each vessel 35460 Transluminal balloon angioplasty, open; venous 35471 Transluminal balloon angioplasty, percutaneous; renal or visceral 35472 Transluminal balloon angioplasty, percutaneous; aortic 35475 Transluminal balloon angioplasty, percutaneous; brachiocephalic trunk or branches, each vessel $ 2,426.40 35476 Transluminal balloon angioplasty, percutaneous; venous 35500 Harvest of upper extremity vein, 1 segment, for lower extremity or coronary artery bypass procedure (List separately in addition to $ 871.62 35501 Bypass graft, with vein; common carotid-ipsilateral internal carotid $ 3,636.00 35506 Bypass graft, with vein; carotid-subclavian or subclavian-carotid $ 4,938.30 35508 Bypass graft, with vein; carotid-vertebral 35509 Bypass graft, with vein; carotid-contralateral carotid 35510 Bypass graft, with vein; carotid-brachial $ 3,271.58 35511 Bypass graft, with vein; subclavian-subclavian $ 3,365.10 35512 Bypass graft, with vein; subclavian-brachial $ 3,264.42 35515 Bypass graft, with vein; subclavian-vertebral $ 3,420.00 35516 Bypass graft, with vein; subclavian-axillary $ 3,505.50 35518 Bypass graft, with vein; axillary-axillary $ 4,264.20 35521 Bypass graft, with vein; axillary-femoral $ 4,596.30 35522 Bypass graft, with vein; axillary-brachial $ 3,209.65 35523 Bypass graft, with vein; brachial-ulnar or -radial $ 3,277.08 35525 Bypass graft, with vein; brachial-brachial $ 3,187.18 35526 Bypass graft, with vein; aortosubclavian, aortoinnominate, or aortocarotid 35531 Bypass graft, with vein; aortoceliac or aortomesenteric $ 4,910.40 35533 Bypass graft, with vein; axillary-femoral-femoral $ 4,089.60 35535 Bypass graft, with vein; hepatorenal $ 4,060.85 35536 Bypass graft, with vein; splenorenal $ 4,485.60 35537 Bypass graft, with vein; aortoiliac $ 4,523.50 35538 Bypass graft, with vein; aortobi-iliac $ 5,514.25 35539 Bypass graft, with vein; aortofemoral $ 5,177.02 35540 Bypass graft, with vein; aortobifemoral $ 5,915.40 35556 Bypass graft, with vein; femoral-popliteal $ 4,336.20 35558 Bypass graft, with vein; femoral-femoral $ 4,312.80 35560 Bypass graft, with vein; aortorenal $ 4,439.70 35563 Bypass graft, with vein; ilioiliac $ 3,582.90 35565 Bypass graft, with vein; iliofemoral $ 4,176.90 35566 Bypass graft, with vein; femoral-anterior tibial, posterior tibial, peroneal artery or other distal vessels $ 5,097.60 35570 Bypass graft, with vein; tibial-tibial, peroneal-tibial, or tibial/peroneal trunk-tibial $ 3,570.22 35571 Bypass graft, with vein; popliteal-tibial, -peroneal artery or other distal vessels $ 4,784.40 35572 Harvest of femoropopliteal vein, 1 segment, for vascular reconstruction procedure (eg, aortic, vena caval, coronary, peripheral artery) (List separately in addition to code for primary $ 878.05 35583 In-situ vein bypass; femoral-popliteal $ 4,646.70

Row # CPT-4 HCPCS Price 35585 In-situ vein bypass; femoral-anterior tibial, posterior tibial, or peroneal artery $ 5,580.90 35587 In-situ vein bypass; popliteal-tibial, peroneal $ 5,259.60 35600 Harvest of upper extremity artery, 1 segment, for coronary artery bypass procedure (List separately in addition to code for primary 35601 Bypass graft, with other than vein; common carotid-ipsilateral internal carotid 35606 Bypass graft, with other than vein; carotid-subclavian $ 4,417.20 35612 Bypass graft, with other than vein; subclavian-subclavian 35616 Bypass graft, with other than vein; subclavian-axillary $ 3,502.80 35621 Bypass graft, with other than vein; axillary-femoral $ 4,295.70 35623 Bypass graft, with other than vein; axillary-popliteal or -tibial $ 4,099.50 35626 Bypass graft, with other than vein; aortosubclavian, aortoinnominate, or aortocarotid $ 5,134.50 35631 Bypass graft, with other than vein; aortoceliac, aortomesenteric, aortorenal $ 4,752.00 35632 Bypass graft, with other than vein; ilio-celiac $ 3,986.67 35633 Bypass graft, with other than vein; ilio-mesenteric $ 4,261.60 35634 Bypass graft, with other than vein; iliorenal $ 3,929.70 35636 Bypass graft, with other than vein; splenorenal (splenic to renal arterial anastomosis) 35637 Bypass graft, with other than vein; aortoiliac $ 3,861.68 35638 Bypass graft, with other than vein; aortobi-iliac $ 3,898.02 35642 Bypass graft, with other than vein; carotid-vertebral $ 3,672.00 35645 Bypass graft, with other than vein; subclavian-vertebral $ 3,720.60 35646 Bypass graft, with other than vein; aortobifemoral $ 5,142.60 35647 Bypass graft, with other than vein; aortofemoral $ 3,664.37 35650 Bypass graft, with other than vein; axillary-axillary $ 4,328.10 35654 Bypass graft, with other than vein; axillary-femoral-femoral $ 5,381.10 35656 Bypass graft, with other than vein; femoral-popliteal $ 4,311.00 35661 Bypass graft, with other than vein; femoral-femoral $ 4,134.60 35663 Bypass graft, with other than vein; ilioiliac $ 3,662.10 35665 Bypass graft, with other than vein; iliofemoral $ 4,484.70 35666 Bypass graft, with other than vein; femoral-anterior tibial, posterior tibial, or peroneal artery 35671 Bypass graft, with other than vein; popliteal-tibial or -peroneal $ 4,197.60 35681 Bypass graft; composite, prosthetic and vein (List separately in $ 3,032.10 35682 Bypass graft; autogenous composite, 2 segments of veins from 2 locations (List separately in addition to code for primary procedure) $ 1,248.30 35683 Bypass graft; autogenous composite, 3 or more segments of vein from 2 or more locations (List separately in addition to code for $ 1,425.60 35685 Placement of vein patch or cuff at distal anastomosis of bypass graft, synthetic conduit (List separately in addition to code for $ 840.77 35686 Creation of distal arteriovenous fistula during lower extremity bypass surgery (non-hemodialysis) (List separately in addition to $ 858.30 35691 Transposition and/or reimplantation; vertebral to carotid artery $ 3,834.00 35693 Transposition and/or reimplantation; vertebral to subclavian artery $ 3,316.50 35694 Transposition and/or reimplantation; subclavian to carotid artery 35695 Transposition and/or reimplantation; carotid to subclavian artery $ 3,321.00 35697 Reimplantation, visceral artery to infrarenal aortic prosthesis, each artery (List separately in addition to code for primary procedure) $ 1,617.23 35700 Reoperation, femoral-popliteal or femoral (popliteal)-anterior tibial, posterior tibial, peroneal artery, or other distal vessels, more than 1 month after original operation (List separately in addition to code 35701 artery; carotid artery $ 1,827.90

Row # CPT-4 HCPCS Price 35721 artery; femoral artery $ 1,711.80 35741 artery; popliteal artery $ 1,733.40 35761 artery; other vessels $ 1,645.20 35800 neck $ 1,757.70 35820 chest $ 2,691.90 35840 abdomen 35860 extremity $ 1,816.20 35870 Repair of graft-enteric fistula $ 5,026.50 35875 Thrombectomy of arterial or venous graft (other than hemodialysis graft or fistula); $ 2,820.60 35876 Thrombectomy of arterial or venous graft (other than hemodialysis graft or fistula); with revision of arterial or venous graft $ 3,186.90 35879 Revision, lower extremity arterial bypass, without thrombectomy, open; with vein patch angioplasty $ 3,326.40 35881 Revision, lower extremity arterial bypass, without thrombectomy, open; with segmental vein interposition $ 3,647.70 35883 Revision, femoral anastomosis of synthetic arterial bypass graft in groin, open; with nonautogenous patch graft (eg, Dacron, ePTFE, bovine pericardium) $ 3,256.61 35884 Revision, femoral anastomosis of synthetic arterial bypass graft in groin, open; with autogenous vein patch graft $ 3,453.76 35901 Excision of infected graft; neck $ 2,307.60 35903 Excision of infected graft; extremity 35905 Excision of infected graft; thorax $ 2,797.20 35907 Excision of infected graft; abdomen 36000 Introduction of needle or intracatheter, vein $ 128.91 36002 Injection procedures (eg, thrombin) for percutaneous treatment of extremity pseudoaneurysm $ 282.31 36005 Injection procedure for extremity venography (including introduction of needle or intracatheter) $ 186.30 36010 Introduction of catheter, superior or inferior vena cava 36011 Selective catheter placement, venous system; first order branch (eg, renal vein, jugular vein) $ 510.30 36012 Selective catheter placement, venous system; second order, or more selective, branch (eg, left adrenal vein, petrosal sinus) $ 679.50 36013 Introduction of catheter, right heart or main pulmonary artery 36014 Selective catheter placement, left or right pulmonary artery $ 591.30 36015 Selective catheter placement, segmental or subsegmental pulmonary artery 36100 Introduction of needle or intracatheter, carotid or vertebral artery 36120 Introduction of needle or intracatheter; retrograde brachial artery $ 741.60 36140 Introduction of needle or intracatheter; extremity artery 36147 Introduction of needle and/or catheter, arteriovenous shunt created for dialysis (graft/fistula); initial access with complete radiological evaluation of dialysis access, including fluoroscopy, image documentation and report (includes access of shunt, inj $ 1,052.96 36148 Introduction of needle and/or catheter, arteriovenous shunt created for dialysis (graft/fistula); additional access for therapeutic intervention (List separately in addition to code for primary $ 325.12 36160 Introduction of needle or intracatheter, aortic, translumbar $ 650.70 36200 Introduction of catheter, aorta $ 624.60 36215 Selective catheter placement, arterial system; each first order thoracic or brachiocephalic branch, within a vascular family 36216 Selective catheter placement, arterial system; initial second order thoracic or brachiocephalic branch, within a vascular family $ 729.00

Row # CPT-4 HCPCS Price 36217 Selective catheter placement, arterial system; initial third order or more selective thoracic or brachiocephalic branch, within a vascular family 36218 Selective catheter placement, arterial system; additional second order, third order, and beyond, thoracic or brachiocephalic branch, within a vascular family (List in addition to code for initial second or third order vessel as appropriate) 36221 Non-selective catheter placement, thoracic aorta, with angiography of the extracranial carotid, vertebral, and/or intracranial vessels, unilateral or bilateral, and all associated radiological supervision and interpretation, includes angiography of the ce $ 2,880.37 36222 Selective catheter placement, common carotid or innominate artery, unilateral, any approach, with angiography of the ipsilateral extracranial carotid circulation and all associated radiological supervision and interpretation, includes angiography of the c $ 3,561.38 36223 Selective catheter placement, common carotid or innominate artery, unilateral, any approach, with angiography of the ipsilateral intracranial carotid circulation and all associated radiological supervision and interpretation, includes angiography of the e $ 3,896.31 36224 Selective catheter placement, internal carotid artery, unilateral, with angiography of the ipsilateral intracranial carotid circulation and all associated radiological supervision and interpretation, includes angiography of the extracranial carotid and ce $ 4,230.34 36225 Selective catheter placement, subclavian or innominate artery, unilateral, with angiography of the ipsilateral vertebral circulation and all associated radiological supervision and interpretation, includes angiography of the cervicocerebral arch, when per $ 3,867.22 36226 Selective catheter placement, vertebral artery, unilateral, with angiography of the ipsilateral vertebral circulation and all associated radiological supervision and interpretation, includes angiography of the cervicocerebral arch, when performed $ 4,313.16 36227 Selective catheter placement, external carotid artery, unilateral, with angiography of the ipsilateral external carotid circulation and all associated radiological supervision and interpretation (List $ 614.41 36245 Selective catheter placement, arterial system; each first order abdominal, pelvic, or lower extremity artery branch, within a vascular family $ 768.60 36246 Selective catheter placement, arterial system; initial second order abdominal, pelvic, or lower extremity artery branch, within a vascular family 36247 Selective catheter placement, arterial system; initial third order or more selective abdominal, pelvic, or lower extremity artery branch, within a vascular family $ 1,114.20 36248 Selective catheter placement, arterial system; additional second order, third order, and beyond, abdominal, pelvic, or lower extremity artery branch, within a vascular family (List in addition to code for initial second or third order vessel as appropriat 36252 Selective catheter placement (first-order), main renal artery and any accessory renal artery(s) for renal angiography, including arterial puncture and catheter placement(s), fluoroscopy, contrast injection(s), image postprocessing, permanent recording of $ 4,101.15 36254 Superselective catheter placement (one or more second order or higher renal artery branches) renal artery and any accessory renal artery(s) for renal angiography, including arterial puncture, catheterization, fluoroscopy, contrast injection(s), image post $ 5,947.12 36260 Insertion of implantable intra-arterial infusion pump (eg, for chemotherapy of liver) $ 2,344.50 36261 Revision of implanted intra-arterial infusion pump $ 919.80

Row # CPT-4 HCPCS Price 36262 Removal of implanted intra-arterial infusion pump 36299 Unlisted procedure, vascular injection Cost 36400 for routine venipuncture; femoral or jugular vein $ 57.60 36405 for routine venipuncture; scalp vein $ 87.30 36406 for routine venipuncture; other vein $ 93.20 36410 Venipuncture, age 3 years or older, necessitating the skill of a physician or other qualified health care professional (separate procedure), for diagnostic or therapeutic purposes (not to be used for routine venipuncture) $ 75.26 36415 Collection of venous blood by venipuncture $ 17.04 36416 Collection of capillary blood specimen (eg, finger, heel, ear stick) $ - 36420 Venipuncture, cutdown; younger than age 1 year $ 212.40 36425 Venipuncture, cutdown; age 1 or over 36430 Transfusion, blood or blood components 36440 Push transfusion, blood, 2 years or younger $ 212.40 36450 Exchange transfusion, blood; newborn 36455 Exchange transfusion, blood; other than newborn 36460 Transfusion, intrauterine, fetal 36468 Single or multiple injections of sclerosing solutions, spider veins (telangiectasia); limb or trunk $ 327.60 36469 Single or multiple injections of sclerosing solutions, spider veins (telangiectasia); face 36470 Injection of sclerosing solution; single vein $ 152.52 36471 Injection of sclerosing solution; multiple veins, same leg $ 246.87 36475 radiofrequency; first vein treated $ 3,072.75 36476 radiofrequency; second and subsequent veins treated in a single extremity, each through separate access sites (List separately in a $ 1,042.37 36478 laser; first vein treated $ 2,978.33 36479 laser; second and subsequent veins treated in a single extremity, each through separate access sites (List separately in addition t $ 1,045.01 36481 Percutaneous portal vein catheterization by any method $ 1,143.00 36500 Venous catheterization for selective organ blood sampling 36510 Catheterization of umbilical vein for diagnosis or therapy, newborn 36511 Therapeutic apheresis; for white blood cells $ 274.52 36512 Therapeutic apheresis; for red blood cells $ 273.39 36513 Therapeutic apheresis; for platelets $ 276.08 36515 Therapeutic apheresis; with extracorporeal immunoadsorption and plasma reinfusion $ 2,040.30 36516 Therapeutic apheresis; with extracorporeal selective adsorption or selective filtration and plasma reinfusion $ 2,129.80 36522 Photopheresis, extracorporeal 36555 Insertion of non-tunneled centrally inserted central venous catheter; younger than 5 years of age $ 500.71 36556 Insertion of non-tunneled centrally inserted central venous catheter; age 5 years or older $ 373.52 36557 Insertion of tunneled centrally inserted central venous catheter, without subcutaneous port or pump; younger than 5 years of age $ 1,519.07

Row # CPT-4 HCPCS Price 36558 Insertion of tunneled centrally inserted central venous catheter, without subcutaneous port or pump; age 5 years or older $ 1,287.53 36560 device, with subcutaneous port; younger than 5 years of age $ 1,595.76 36561 device, with subcutaneous port; age 5 years or older $ 1,280.08 36563 Insertion of tunneled centrally inserted central venous access device with subcutaneous pump $ 1,557.18 36565 device, requiring 2 catheters via 2 separate venous access sites; without subcutaneous port or pump (eg, Tesio type catheter) $ 1,535.22 36566 device, requiring 2 catheters via 2 separate venous access sites; with subcutaneous port(s) $ 2,580.53 36568 Insertion of peripherally inserted central venous catheter (PICC), without subcutaneous port or pump; younger than 5 years of age $ 548.20 36569 Insertion of peripherally inserted central venous catheter (PICC), without subcutaneous port or pump; age 5 years or older $ 459.11 36570 Insertion of peripherally inserted central venous access device, with subcutaneous port; younger than 5 years of age $ 1,264.84 36571 Insertion of peripherally inserted central venous access device, with subcutaneous port; age 5 years or older $ 1,302.40 36575 Repair of tunneled or non-tunneled central venous access catheter, without subcutaneous port or pump, central or peripheral insertion site $ 294.90 36576 Repair of central venous access device, with subcutaneous port or pump, central or peripheral insertion site $ 671.12 36578 Replacement, catheter only, of central venous access device, with subcutaneous port or pump, central or peripheral insertion site $ 1,052.89 36580 Replacement, complete, of a non-tunneled centrally inserted central venous catheter, without subcutaneous port or pump, through same venous access $ 402.39 36581 venous catheter, without subcutaneous port or pump, through same venous access $ 1,347.18 36582 venous access device, with subcutaneous port, through same $ 1,777.44 36583 venous access device, with subcutaneous pump, through same $ 1,809.20 36584 Replacement, complete, of a peripherally inserted central venous catheter (PICC), without subcutaneous port or pump, through same $ 423.34 36585 Replacement, complete, of a peripherally inserted central venous access device, with subcutaneous port, through same venous access $ 1,778.45 36589 Removal of tunneled central venous catheter, without subcutaneous port or pump $ 388.65 36590 Removal of tunneled central venous access device, with subcutaneous port or pump, central or peripheral insertion $ 579.93 36591 Collection of blood specimen from a completely implantable venous access device $ 40.50 36592 Collection of blood specimen using established central or peripheral catheter, venous, not otherwise specified $ 52.78 36593 Declotting by thrombolytic agent of implanted vascular access device or catheter $ 146.47 36595 Mechanical removal of pericatheter obstructive material (eg, fibrin sheath) from central venous device via separate venous access $ 1,257.21 36596 Mechanical removal of intraluminal (intracatheter) obstructive material from central venous device through device lumen $ 265.15

Row # CPT-4 HCPCS Price 36597 Repositioning of previously placed central venous catheter under fluoroscopic guidance $ 238.99 36598 Contrast injection(s) for radiologic evaluation of existing central venous access device, including fluoroscopy, image documentation $ 282.77 36600 Arterial puncture, withdrawal of blood for diagnosis $ 91.80 36620 Arterial catheterization or cannulation for sampling, monitoring or transfusion (separate procedure); percutaneous 36625 Arterial catheterization or cannulation for sampling, monitoring or transfusion (separate procedure); cutdown 36640 Arterial catheterization for prolonged infusion therapy (chemotherapy), cutdown 36660 Catheterization, umbilical artery, newborn, for diagnosis or therapy 36680 Placement of needle for intraosseous infusion 36800 procedure); vein to vein 36810 procedure); arteriovenous, external (Scribner type) $ 1,357.20 36815 procedure); arteriovenous, external revision, or closure $ 1,125.90 36818 Arteriovenous anastomosis, open; by upper arm cephalic vein $ 1,990.48 36819 Arteriovenous anastomosis, open; by upper arm basilic vein $ 4,174.20 36820 Arteriovenous anastomosis, open; by forearm vein transposition $ 2,132.80 36821 Arteriovenous anastomosis, open; direct, any site (eg, Cimino type) $ 2,295.00 36823 Insertion of arterial and venous cannula(s) for isolated extracorporeal circulation including regional chemotherapy perfusion to an extremity, with or without hyperthermia, with removal of cannula(s) and repair of arteriotomy and venotomy sites $ 3,310.72 36825 Creation of arteriovenous fistula by other than direct arteriovenous anastomosis (separate procedure); autogenous graft 36831 Thrombectomy, open, arteriovenous fistula without revision, $ 1,346.40 36832 Revision, open, arteriovenous fistula; without thrombectomy, $ 2,439.90 36833 Revision, open, arteriovenous fistula; with thrombectomy, $ 1,944.90 36835 Insertion of Thomas shunt (separate procedure) $ 1,480.23 36838 Distal revascularization and interval ligation (DRIL), upper extremity hemodialysis access (steal syndrome) $ 3,556.18 36860 External cannula declotting (separate procedure); without balloon 36861 External cannula declotting (separate procedure); with balloon $ 891.00 36870 Thrombectomy, percutaneous, arteriovenous fistula, autogenous or nonautogenous graft (includes mechanical thrombus extraction and intra-graft thrombolysis) $ 3,973.50 37140 Venous anastomosis, open; portocaval $ 5,608.80 37145 Venous anastomosis, open; renoportal $ 3,990.60 37160 Venous anastomosis, open; caval-mesenteric $ 5,255.10 37180 Venous anastomosis, open; splenorenal, proximal $ 4,969.80 37181 Venous anastomosis, open; splenorenal, distal (selective decompression of esophagogastric varices, any technique) $ 5,961.60 37182 Insertion of transvenous intrahepatic portosystemic shunt(s) (TIPS) (includes venous access, hepatic and portal vein catheterization, portography with hemodynamic evaluation, intrahepatic tract formation/dilatation, stent placement and all associated imag $ 1,959.09

Row # CPT-4 HCPCS Price 37183 Revision of transvenous intrahepatic portosystemic shunt(s) (TIPS) (includes venous access, hepatic and portal vein catheterization, portography with hemodynamic evaluation, intrahepatic tract recanulization/dilatation, stent placement and all associated $ 15,255.65 37184 Primary percutaneous transluminal mechanical thrombectomy, injection(s); initial vessel $ 2,214.84 37185 Primary percutaneous transluminal mechanical thrombectomy, injection(s); second and all subsequent vessel(s) within the same v $ 872.39 37186 Secondary percutaneous transluminal thrombectomy (eg, nonprimary mechanical, snare basket, suction technique), injections, pro $ 1,250.30 37187 Percutaneous transluminal mechanical thrombectomy, vein(s), including intraprocedural pharmacological thrombolytic injections and fluoroscopic guidance $ 1,941.11 37188 Percutaneous transluminal mechanical thrombectomy, vein(s), including intraprocedural pharmacological thrombolytic injections and fluoroscopic guidance, repeat treatment on subsequent day during course of thrombolytic therapy $ 1,473.77 37191 Insertion of intravascular vena cava filter, endovascular approach including vascular access, vessel selection, and radiological imaging guidance (ultrasound and fluoroscopy), when performed $ 6,918.36 37192 Repositioning of intravascular vena cava filter, endovascular approach including vascular access, vessel selection, and radiological supervision and interpretation, intraprocedural roadmapping, and imaging guidance (ultrasound and fluoroscopy), $ 4,487.46 37193 Retrieval (removal) of intravascular vena cava filter, endovascular approach including vascular access, vessel selection, and radiological supervision and interpretation, intraprocedural roadmapping, and imaging guidance (ultrasound and fluoroscopy), $ 4,282.95 37195 Thrombolysis, cerebral, by intravenous infusion $ 846.90 37197 Transcatheter retrieval, percutaneous, of intravascular foreign body (eg, fractured venous or arterial catheter), includes radiological supervision and interpretation, and imaging guidance (ultrasound or fluoroscopy), when performed $ 3,887.58 37200 Transcatheter biopsy $ 814.79 37202 Transcatheter therapy, infusion other than for thrombolysis, any type (eg, spasmolytic, vasoconstrictive) 37211 Transcatheter therapy, arterial infusion for thrombolysis other than coronary, any method, including radiological supervision and interpretation, initial treatment day $ 972.47 37212 Transcatheter therapy, venous infusion for thrombolysis, any method, including radiological supervision and interpretation, initial treatment day $ 858.67 37213 Transcatheter therapy, arterial or venous infusion for thrombolysis other than coronary, any method, including radiological supervision and interpretation, continued treatment on subsequent day during course of thrombolytic therapy, including follow-up ca $ 599.49 37214 Transcatheter therapy, arterial or venous infusion for thrombolysis other than coronary, any method, including radiological supervision and interpretation, continued treatment on subsequent day during course of thrombolytic therapy, including follow-up ca $ 353.25 37215 Transcatheter placement of intravascular stent(s), cervical carotid artery, percutaneous; with distal embolic protection $ 3,812.78

Row # CPT-4 HCPCS Price 37216 Transcatheter placement of intravascular stent(s), cervical carotid artery, percutaneous; without distal embolic protection $ 3,498.17 37220 unilateral, initial vessel; with transluminal angioplasty $ 2,257.95 37221 unilateral, initial vessel; with transluminal stent placement(s), includes angioplasty within the same vessel, when performed $ 3,035.71 37222 each additional ipsilateral iliac vessel; with transluminal angioplasty $ 861.42 37223 each additional ipsilateral iliac vessel; with transluminal stent placement(s), includes angioplasty within the same vessel, when performed (List separately in addition to code for prima $ 1,606.46 37224 popliteal artery(s), unilateral; with transluminal angioplasty $ 2,605.53 37225 popliteal artery(s), unilateral; with atherectomy, includes angioplasty within the same vessel, when performed $ 5,405.06 37226 popliteal artery(s), unilateral; with transluminal stent placement(s), includes angioplasty within the same vessel, when performed $ 4,490.45 37227 popliteal artery(s), unilateral; with transluminal stent placement(s) and atherectomy, includes angioplasty within the same vessel, $ 7,098.85 37228 peroneal artery, unilateral, initial vessel; with transluminal angioplasty $ 3,436.34 37229 peroneal artery, unilateral, initial vessel; with atherectomy, includes angioplasty within the same vessel, when performed $ 5,676.63 37230 peroneal artery, unilateral, initial vessel; with transluminal stent placement(s), includes angioplasty within the same vessel, when $ 4,780.81 37231 peroneal artery, unilateral, initial vessel; with transluminal stent placement(s) and atherectomy, includes angioplasty within the same vessel, when performed $ 6,604.22 37232 transluminal angioplasty (List separately in addition to code for $ 1,046.39 37233 atherectomy, includes angioplasty within the same vessel, when performed (List separately in addition to code for primary $ 1,367.77 37234 transluminal stent placement(s), includes angioplasty within the same vessel, when performed (List separately in addition to code for p $ 2,092.73 37235 transluminal stent placement(s) and atherectomy, includes angioplasty within the same vessel, when performed (List separately in additi $ 2,470.73

Row # CPT-4 HCPCS Price 37236 Transcatheter placement of an intravascular stent(s) (except lower extremity, cervical carotid, extracranial vertebral or intrathoracic carotid, intracranial, or coronary), open or percutaneous, including radiological supervision and interpretation and in $ 9,119.70 37237 Transcatheter placement of an intravascular stent(s) (except lower extremity, cervical carotid, extracranial vertebral or intrathoracic carotid, intracranial, or coronary), open or percutaneous, including radiological supervision and interpretation and in 37238 Transcatheter placement of an intravascular stent(s), open or percutaneous, including radiological supervision and interpretation and including angioplasty within the same vessel, when performed; initial vein $ 9,119.70 37239 Transcatheter placement of an intravascular stent(s), open or percutaneous, including radiological supervision and interpretation and including angioplasty within the same vessel, when performed; each additional vein (List separately in addition to code f 37241 imaging guidance necessary to complete the intervention; venous, other than hemorrhage (eg, congenital or acquired venous ma 37242 imaging guidance necessary to complete the intervention; arterial, other than hemorrhage or tumor (eg, congenital or acquire 37243 imaging guidance necessary to complete the intervention; for tumors, organ ischemia, or infarction 37244 imaging guidance necessary to complete the intervention; for arterial or venous hemorrhage or lymphatic extravasation 37250 Intravascular ultrasound (non-coronary vessel) during diagnostic evaluation and/or therapeutic intervention; initial vessel (List $ 408.08 37251 Intravascular ultrasound (non-coronary vessel) during diagnostic evaluation and/or therapeutic intervention; each additional vessel $ 319.58 37500 Vascular endoscopy, surgical, with ligation of perforator veins, subfascial (SEPS) $ 2,240.80 37501 Unlisted vascular endoscopy procedure Cost 37565 Ligation, internal jugular vein $ 1,462.50 37600 Ligation; external carotid artery 37605 Ligation; internal or common carotid artery $ 1,402.20 37606 Ligation; internal or common carotid artery, with gradual occlusion, as with Selverstone or Crutchfield clamp $ 1,670.40 37607 Ligation or banding of angioaccess arteriovenous fistula $ 1,293.30 37609 Ligation or biopsy, temporal artery $ 689.40 37615 Ligation, major artery (eg, post-traumatic, rupture); neck $ 1,608.30 37616 Ligation, major artery (eg, post-traumatic, rupture); chest $ 2,796.30 37617 Ligation, major artery (eg, post-traumatic, rupture); abdomen $ 2,619.00 37618 Ligation, major artery (eg, post-traumatic, rupture); extremity 37619 Ligation of inferior vena cava $ 4,215.75 37650 Ligation of femoral vein $ 1,337.40 37660 Ligation of common iliac vein 37700 Ligation and division of long saphenous vein at saphenofemoral junction, or distal interruptions $ 998.10 37718 Ligation, division, and stripping, short saphenous vein $ 1,006.21 37722 Ligation, division, and stripping, long (greater) saphenous veins from saphenofemoral junction to knee or below $ 1,208.89

Row # CPT-4 HCPCS Price 37735 Ligation and division and complete stripping of long or short saphenous veins with radical excision of ulcer and skin graft and/or interruption of communicating veins of lower leg, with excision of deep fascia $ 2,844.00 37760 Ligation of perforator veins, subfascial, radical (Linton type), including skin graft, when performed, open, 1 leg $ 2,987.10 37761 Ligation of perforator vein(s), subfascial, open, including ultrasound guidance, when performed, 1 leg $ 1,390.71 37765 Stab phlebectomy of varicose veins, 1 extremity; 10-20 stab incisions $ 1,167.91 37766 Stab phlebectomy of varicose veins, 1 extremity; more than 20 incisions $ 1,416.38 37780 Ligation and division of short saphenous vein at saphenopopliteal junction (separate procedure) $ 641.70 37785 Ligation, division, and/or excision of varicose vein cluster(s), 1 leg $ 739.80 37788 Penile revascularization, artery, with or without vein graft $ 4,092.33 37790 Penile venous occlusive procedure $ 1,527.94 37799 Unlisted procedure, vascular surgery Cost 38100 Splenectomy; total (separate procedure) $ 2,660.40 38101 Splenectomy; partial (separate procedure) $ 2,975.40 38102 Splenectomy; total, en bloc for extensive disease, in conjunction with other procedure (List in addition to code for primary $ 1,835.10 38115 Repair of ruptured spleen (splenorrhaphy) with or without partial splenectomy 38120 Laparoscopy, surgical, splenectomy $ 3,954.23 38129 Unlisted laparoscopy procedure, spleen Cost 38200 Injection procedure for splenoportography $ 351.00 38204 Management of recipient hematopoietic progenitor cell donor search and cell acquisition $ 232.57 38205 Blood-derived hematopoietic progenitor cell harvesting for transplantation, per collection; allogeneic $ 718.59 38206 Blood-derived hematopoietic progenitor cell harvesting for transplantation, per collection; autologous $ 718.94 38207 Transplant preparation of hematopoietic progenitor cells; cryopreservation and storage $ 78.09 38208 Transplant preparation of hematopoietic progenitor cells; thawing of previously frozen harvest, without washing, per donor $ 50.46 38209 Transplant preparation of hematopoietic progenitor cells; thawing of previously frozen harvest, with washing, per donor $ 20.85 38210 Transplant preparation of hematopoietic progenitor cells; specific cell depletion within harvest, T-cell depletion $ 140.03 38211 Transplant preparation of hematopoietic progenitor cells; tumor cell depletion $ 128.01 38212 Transplant preparation of hematopoietic progenitor cells; red blood cell removal $ 82.28 38213 Transplant preparation of hematopoietic progenitor cells; platelet depletion $ 20.85 38214 Transplant preparation of hematopoietic progenitor cells; plasma (volume) depletion $ 71.84 38215 Transplant preparation of hematopoietic progenitor cells; cell concentration in plasma, mononuclear, or buffy coat layer $ 82.28 38220 Bone marrow; aspiration only $ 293.47 38221 Bone marrow; biopsy, needle or trocar $ 316.63 38230 Bone marrow harvesting for transplantation; allogeneic 38240 Hematopoietic progenitor cell (HPC); allogeneic transplantation per donor $ 1,089.69 38241 Hematopoietic progenitor cell (HPC); autologous transplantation $ 986.52 38242 Allogeneic lymphocyte infusions $ 1,082.79 38300 Drainage of lymph node abscess or lymphadenitis; simple 38305 Drainage of lymph node abscess or lymphadenitis; extensive $ 729.00 38308 Lymphangiotomy or other operations on lymphatic channels $ 884.70 38380 Suture and/or ligation of thoracic duct; cervical approach $ 1,355.40

Row # CPT-4 HCPCS Price 38381 Suture and/or ligation of thoracic duct; thoracic approach 38382 Suture and/or ligation of thoracic duct; abdominal approach $ 2,037.60 38500 Biopsy or excision of lymph node(s); open, superficial $ 587.77 38505 Biopsy or excision of lymph node(s); by needle, superficial (eg, cervical, inguinal, axillary) $ 399.60 38510 Biopsy or excision of lymph node(s); open, deep cervical node(s) $ 850.50 38520 Biopsy or excision of lymph node(s); open, deep cervical node(s) with excision scalene fat pad 38525 Biopsy or excision of lymph node(s); open, deep axillary node(s) $ 1,233.90 38542 Dissection, deep jugular node(s) 38550 Excision of cystic hygroma, axillary or cervical; without deep neurovascular dissection $ 1,267.20 38555 Excision of cystic hygroma, axillary or cervical; with deep neurovascular dissection 38562 Limited lymphadenectomy for staging (separate procedure); pelvic and para-aortic $ 2,771.10 38564 Limited lymphadenectomy for staging (separate procedure); retroperitoneal (aortic and/or splenic) $ 2,665.80 38570 Laparoscopy, surgical; with retroperitoneal lymph node sampling $ 2,667.60 38571 Laparoscopy, surgical; with bilateral total pelvic lymphadenectomy 38572 Laparoscopy, surgical; with bilateral total pelvic lymphadenectomy and peri-aortic lymph node sampling (biopsy), single or multiple 38589 Unlisted laparoscopy procedure, lymphatic system Cost 38700 Suprahyoid lymphadenectomy $ 2,449.80 38720 Cervical lymphadenectomy (complete) 38724 Cervical lymphadenectomy (modified radical neck dissection) $ 3,672.00 38740 Axillary lymphadenectomy; superficial $ 1,797.30 38745 Axillary lymphadenectomy; complete $ 2,779.20 38746 Thoracic lymphadenectomy by thoracotomy, mediastinal and regional lymphadenectomy (List separately in addition to code for $ 846.00 38747 Abdominal lymphadenectomy, regional, including celiac, gastric, portal, peripancreatic, with or without para-aortic and vena caval nodes (List separately in addition to code for primary procedure) $ 1,178.10 38760 Inguinofemoral lymphadenectomy, superficial, including Cloquets node (separate procedure) $ 2,240.10 38765 Inguinofemoral lymphadenectomy, superficial, in continuity with pelvic lymphadenectomy, including external iliac, hypogastric, and obturator nodes (separate procedure) $ 3,024.90 38770 Pelvic lymphadenectomy, including external iliac, hypogastric, and obturator nodes (separate procedure) $ 3,276.00 38780 Retroperitoneal transabdominal lymphadenectomy, extensive, including pelvic, aortic, and renal nodes (separate procedure) $ 4,169.70 38790 Injection procedure; lymphangiography $ 396.90 38792 Injection procedure; radioactive tracer for identification of sentinel node $ 174.37 38794 Cannulation, thoracic duct $ 1,099.47 38999 Unlisted procedure, hemic or lymphatic system Cost 39000 Mediastinotomy with exploration, drainage, removal of foreign body, or biopsy; cervical approach $ 1,619.10 39200 Resection of mediastinal cyst 39220 Resection of mediastinal tumor $ 3,410.10 39400 Mediastinoscopy, includes biopsy(ies), when performed $ 1,290.60 39499 Unlisted procedure, mediastinum Cost 39501 Repair, laceration of diaphragm, any approach 39503 Repair, neonatal diaphragmatic hernia, with or without chest tube insertion and with or without creation of ventral hernia $ 3,626.10 39540 Repair, diaphragmatic hernia (other than neonatal), traumatic; acute

Row # CPT-4 HCPCS Price 39541 Repair, diaphragmatic hernia (other than neonatal), traumatic; chronic $ 3,515.40 39545 Imbrication of diaphragm for eventration, transthoracic or transabdominal, paralytic or nonparalytic $ 3,464.10 39560 Resection, diaphragm; with simple repair (eg, primary suture) $ 3,485.19 39561 Resection, diaphragm; with complex repair (eg, prosthetic material, local muscle flap) $ 5,241.89 39599 Unlisted procedure, diaphragm Cost 40490 Biopsy of lip 40500 Vermilionectomy (lip shave), with mucosal advancement 40510 Excision of lip; transverse wedge excision with primary closure $ 1,710.90 40520 Excision of lip; V-excision with primary direct linear closure 40525 Excision of lip; full thickness, reconstruction with local flap (eg, Estlander or fan) $ 3,300.30 40527 Excision of lip; full thickness, reconstruction with cross lip flap (Abbe- Estlander) $ 3,558.60 40530 Resection of lip, more than one-fourth, without reconstruction 40650 Repair lip, full thickness; vermilion only $ 1,409.40 40652 Repair lip, full thickness; up to half vertical height $ 1,440.00 40654 Repair lip, full thickness; over one-half vertical height, or complex $ 1,681.20 40700 Plastic repair of cleft lip/nasal deformity; primary, partial or complete, unilateral 40701 Plastic repair of cleft lip/nasal deformity; primary bilateral, 1-stage $ 4,107.60 40702 Plastic repair of cleft lip/nasal deformity; primary bilateral, 1 of 2 stages $ 2,590.20 40720 Plastic repair of cleft lip/nasal deformity; secondary, by recreation of defect and reclosure 40761 Plastic repair of cleft lip/nasal deformity; with cross lip pedicle flap (Abbe-Estlander type), including sectioning and inserting of pedicle 40799 Unlisted procedure, lips Cost 40800 Drainage of abscess, cyst, hematoma, vestibule of mouth; simple $ 201.60 40801 Drainage of abscess, cyst, hematoma, vestibule of mouth; 40804 Removal of embedded foreign body, vestibule of mouth; simple 40805 Removal of embedded foreign body, vestibule of mouth; $ 657.90 40806 Incision of labial frenum (frenotomy) $ 315.90 40808 Biopsy, vestibule of mouth 40810 without repair 40812 with simple repair 40814 with complex repair 40816 complex, with excision of underlying muscle 40818 Excision of mucosa of vestibule of mouth as donor graft $ 627.30 40819 Excision of frenum, labial or buccal (frenumectomy, frenulectomy, frenectomy) $ 414.00 40820 Destruction of lesion or scar of vestibule of mouth by physical methods (eg, laser, thermal, cryo, chemical) $ 349.20 40830 Closure of laceration, vestibule of mouth; 2.5 cm or less $ 232.24 40831 Closure of laceration, vestibule of mouth; over 2.5 cm or complex $ 528.30 40840 Vestibuloplasty; anterior $ 1,712.70 40842 Vestibuloplasty; posterior, unilateral $ 1,566.90 40843 Vestibuloplasty; posterior, bilateral $ 2,436.30 40844 Vestibuloplasty; entire arch $ 3,133.80 40845 Vestibuloplasty; complex (including ridge extension, muscle repositioning) $ 3,672.90 40899 Unlisted procedure, vestibule of mouth Cost 41000 tongue or floor of mouth; lingual

Row # CPT-4 HCPCS Price 41005 tongue or floor of mouth; sublingual, superficial $ 286.20 41006 tongue or floor of mouth; sublingual, deep, supramylohyoid $ 610.20 41007 tongue or floor of mouth; submental space 41008 tongue or floor of mouth; submandibular space 41009 tongue or floor of mouth; masticator space $ 810.00 41010 Incision of lingual frenum (frenotomy) 41015 floor of mouth; sublingual 41016 floor of mouth; submental $ 839.70 41017 floor of mouth; submandibular $ 829.80 41018 floor of mouth; masticator space 41019 Placement of needles, catheters, or other device(s) into the head and/or neck region (percutaneous, transoral, or transnasal) for subsequent interstitial radioelement application $ 1,028.05 41100 Biopsy of tongue; anterior two-thirds 41105 Biopsy of tongue; posterior one-third 41108 Biopsy of floor of mouth 41110 Excision of lesion of tongue without closure $ 393.30 41112 Excision of lesion of tongue with closure; anterior two-thirds $ 642.60 41113 Excision of lesion of tongue with closure; posterior one-third $ 954.00 41114 Excision of lesion of tongue with closure; with local tongue flap $ 2,168.10 41115 Excision of lingual frenum (frenectomy) $ 426.60 41116 Excision, lesion of floor of mouth 41120 Glossectomy; less than one-half tongue $ 1,905.30 41130 Glossectomy; hemiglossectomy $ 2,204.10 41135 Glossectomy; partial, with unilateral radical neck dissection $ 4,789.80 41140 Glossectomy; complete or total, with or without tracheostomy, without radical neck dissection $ 4,610.70 41145 Glossectomy; complete or total, with or without tracheostomy, with unilateral radical neck dissection $ 5,366.70 41150 and mandibular resection, without radical neck dissection $ 4,663.80 41153 with suprahyoid neck dissection $ 4,880.70 41155 mandibular resection, and radical neck dissection (Commando type) $ 6,470.10 41250 Repair of laceration 2.5 cm or less; floor of mouth and/or anterior two-thirds of tongue $ 361.80 41251 Repair of laceration 2.5 cm or less; posterior one-third of tongue 41252 Repair of laceration of tongue, floor of mouth, over 2.6 cm or $ 838.80 41500 Fixation of tongue, mechanical, other than suture (eg, K-wire) $ 766.80 41510 Suture of tongue to lip for micrognathia (Douglas type procedure) $ 1,354.50 41512 Tongue base suspension, permanent suture technique $ 1,094.85 41520 Frenoplasty (surgical revision of frenum, eg, with Z-plasty) 41530 Submucosal ablation of the tongue base, radiofrequency, 1 or more sites, per session $ 6,950.37 41599 Unlisted procedure, tongue, floor of mouth Cost 41800 Drainage of abscess, cyst, hematoma from dentoalveolar structures $ 229.50

Row # CPT-4 HCPCS Price 41805 Removal of embedded foreign body from dentoalveolar structures; soft tissues 41806 Removal of embedded foreign body from dentoalveolar structures; bone $ 493.20 41821 Operculectomy, excision pericoronal tissues $ - 41822 Excision of fibrous tuberosities, dentoalveolar structures 41823 Excision of osseous tuberosities, dentoalveolar structures $ 705.60 41825 structures; without repair 41826 structures; with simple repair $ 546.30 41827 structures; with complex repair 41828 Excision of hyperplastic alveolar mucosa, each quadrant (specify) 41830 Alveolectomy, including curettage of osteitis or sequestrectomy 41850 Destruction of lesion (except excision), dentoalveolar structures 41870 Periodontal mucosal grafting 41872 Gingivoplasty, each quadrant (specify) 41874 Alveoloplasty, each quadrant (specify) $ 756.90 41899 Unlisted procedure, dentoalveolar structures Cost 42000 Drainage of abscess of palate, uvula 42100 Biopsy of palate, uvula $ 273.60 42104 Excision, lesion of palate, uvula; without closure $ 478.80 42106 Excision, lesion of palate, uvula; with simple primary closure 42107 Excision, lesion of palate, uvula; with local flap closure 42120 Resection of palate or extensive resection of lesion $ 2,958.30 42140 Uvulectomy, excision of uvula $ 470.70 42145 Palatopharyngoplasty (eg, uvulopalatopharyngoplasty, uvulopharyngoplasty) $ 2,509.20 42160 Destruction of lesion, palate or uvula (thermal, cryo or chemical) 42180 Repair, laceration of palate; up to 2 cm $ 416.96 42182 Repair, laceration of palate; over 2 cm or complex $ 825.30 42200 Palatoplasty for cleft palate, soft and/or hard palate only 42205 Palatoplasty for cleft palate, with closure of alveolar ridge; soft tissue only $ 3,186.00 42210 Palatoplasty for cleft palate, with closure of alveolar ridge; with bone graft to alveolar ridge (includes obtaining graft) 42215 Palatoplasty for cleft palate; major revision $ 2,664.90 42220 Palatoplasty for cleft palate; secondary lengthening procedure 42225 Palatoplasty for cleft palate; attachment pharyngeal flap $ 2,811.60 42226 Lengthening of palate, and pharyngeal flap $ 3,475.80 42227 Lengthening of palate, with island flap $ 2,935.80 42235 Repair of anterior palate, including vomer flap $ 2,310.30 42260 Repair of nasolabial fistula 42280 Maxillary impression for palatal prosthesis 42281 Insertion of pin-retained palatal prosthesis $ 355.50 42299 Unlisted procedure, palate, uvula Cost 42300 Drainage of abscess; parotid, simple $ 324.90 42305 Drainage of abscess; parotid, complicated $ 806.40 42310 Drainage of abscess; submaxillary or sublingual, intraoral 42320 Drainage of abscess; submaxillary, external $ 597.60 42330 Sialolithotomy; submandibular (submaxillary), sublingual or parotid, uncomplicated, intraoral $ 415.95 42335 Sialolithotomy; submandibular (submaxillary), complicated, intraoral 42340 Sialolithotomy; parotid, extraoral or complicated intraoral $ 1,092.60 42400 Biopsy of salivary gland; needle 42405 Biopsy of salivary gland; incisional 42408 Excision of sublingual salivary cyst (ranula) 42409 Marsupialization of sublingual salivary cyst (ranula) 42410 Excision of parotid tumor or parotid gland; lateral lobe, without nerve dissection $ 2,012.40 42415 Excision of parotid tumor or parotid gland; lateral lobe, with dissection and preservation of facial nerve $ 3,630.60

Row # CPT-4 HCPCS Price 42420 Excision of parotid tumor or parotid gland; total, with dissection and preservation of facial nerve $ 4,627.80 42425 Excision of parotid tumor or parotid gland; total, en bloc removal with sacrifice of facial nerve $ 3,363.30 42426 Excision of parotid tumor or parotid gland; total, with unilateral radical neck dissection $ 6,180.30 42440 Excision of submandibular (submaxillary) gland $ 2,312.10 42450 Excision of sublingual gland 42500 Plastic repair of salivary duct, sialodochoplasty; primary or simple $ 1,374.30 42505 Plastic repair of salivary duct, sialodochoplasty; secondary or $ 1,757.70 42507 Parotid duct diversion, bilateral (Wilke type procedure); $ 2,302.20 42508 excision of 1 submandibular gland 42509 excision of both submandibular glands $ 3,194.10 42510 ligation of both submandibular (Wharton's) ducts $ 2,726.10 42550 Injection procedure for sialography $ 193.50 42600 Closure salivary fistula 42650 Dilation salivary duct $ 143.10 42660 Dilation and catheterization of salivary duct, with or without injection 42665 Ligation salivary duct, intraoral 42699 Unlisted procedure, salivary glands or ducts Cost 42700 Incision and drainage abscess; peritonsillar 42720 Incision and drainage abscess; retropharyngeal or parapharyngeal, intraoral approach 42725 Incision and drainage abscess; retropharyngeal or parapharyngeal, external approach $ 1,467.00 42800 Biopsy; oropharynx 42804 Biopsy; nasopharynx, visible lesion, simple $ 308.70 42806 Biopsy; nasopharynx, survey for unknown primary lesion 42808 Excision or destruction of lesion of pharynx, any method 42809 Removal of foreign body from pharynx $ 312.30 42810 Excision branchial cleft cyst or vestige, confined to skin and subcutaneous tissues $ 878.40 42815 Excision branchial cleft cyst, vestige, or fistula, extending beneath subcutaneous tissues and/or into pharynx $ 1,880.10 42820 Tonsillectomy and adenoidectomy; younger than age 12 $ 816.61 42821 Tonsillectomy and adenoidectomy; age 12 or over $ 1,031.40 42825 Tonsillectomy, primary or secondary; younger than age 12 42826 Tonsillectomy, primary or secondary; age 12 or over 42830 Adenoidectomy, primary; younger than age 12 $ 581.64 42831 Adenoidectomy, primary; age 12 or over 42835 Adenoidectomy, secondary; younger than age 12 $ 536.40 42836 Adenoidectomy, secondary; age 12 or over 42842 trigone; without closure 42844 trigone; closure with local flap (eg, tongue, buccal) 42845 trigone; closure with other flap $ 4,507.20 42860 Excision of tonsil tags 42870 Excision or destruction lingual tonsil, any method (separate 42890 Limited pharyngectomy $ 2,689.20 42892 Resection of lateral pharyngeal wall or pyriform sinus, direct closure by advancement of lateral and posterior pharyngeal walls 42894 Resection of pharyngeal wall requiring closure with myocutaneous or fasciocutaneous flap or free muscle, skin, or fascial flap with microvascular anastomosis $ 4,776.30 42900 Suture pharynx for wound or injury $ 977.40 42950 Pharyngoplasty (plastic or reconstructive operation on pharynx) $ 1,989.90 42953 Pharyngoesophageal repair

Row # CPT-4 HCPCS Price 42955 Pharyngostomy (fistulization of pharynx, external for feeding) 42960 tonsillectomy); simple $ 366.30 42961 tonsillectomy); complicated, requiring hospitalization $ 600.30 42962 tonsillectomy); with secondary surgical intervention 42970 postadenoidectomy); simple, with posterior nasal packs, with or without anterior packs and/or cautery $ 629.10 42971 postadenoidectomy); complicated, requiring hospitalization $ 945.00 42972 postadenoidectomy); with secondary surgical intervention $ 1,179.00 42999 Unlisted procedure, pharynx, adenoids, or tonsils Cost 43020 Esophagotomy, cervical approach, with removal of foreign body 43030 Cricopharyngeal myotomy $ 2,510.10 43045 Esophagotomy, thoracic approach, with removal of foreign body 43100 Excision of lesion, esophagus, with primary repair; cervical approach $ 2,568.60 43101 Excision of lesion, esophagus, with primary repair; thoracic or $ 3,299.40 43107 Total or near total esophagectomy, without thoracotomy; with pharyngogastrostomy or cervical esophagogastrostomy, with or without pyloroplasty (transhiatal) $ 5,637.60 43108 Total or near total esophagectomy, without thoracotomy; with colon interposition or small intestine reconstruction, including intestine mobilization, preparation and anastomosis(es) 43112 Total or near total esophagectomy, with thoracotomy; with pharyngogastrostomy or cervical esophagogastrostomy, with or without pyloroplasty 43113 Total or near total esophagectomy, with thoracotomy; with colon interposition or small intestine reconstruction, including intestine mobilization, preparation, and anastomosis(es) $ 5,426.85 43116 Partial esophagectomy, cervical, with free intestinal graft, including microvascular anastomosis, obtaining the graft and intestinal $ 6,171.24 43117 Partial esophagectomy, distal two-thirds, with thoracotomy and separate abdominal incision, with or without proximal gastrectomy; with thoracic esophagogastrostomy, with or without pyloroplasty (Ivor Lewis) $ 6,574.50 43118 Partial esophagectomy, distal two-thirds, with thoracotomy and separate abdominal incision, with or without proximal gastrectomy; with colon interposition or small intestine reconstruction, including intestine mobilization, preparation, and anastomosis(es $ 5,531.39 43121 Partial esophagectomy, distal two-thirds, with thoracotomy only, with or without proximal gastrectomy, with thoracic esophagogastrostomy, with or without pyloroplasty $ 6,251.40 43122 Partial esophagectomy, thoracoabdominal or abdominal approach, with or without proximal gastrectomy; with esophagogastrostomy, with or without pyloroplasty $ 5,902.20 43123 Partial esophagectomy, thoracoabdominal or abdominal approach, with or without proximal gastrectomy; with colon interposition or small intestine reconstruction, including intestine mobilization, preparation, and anastomosis(es) 43124 Total or partial esophagectomy, without reconstruction (any approach), with cervical esophagostomy $ 4,452.63 43130 Diverticulectomy of hypopharynx or esophagus, with or without myotomy; cervical approach $ 2,642.40

Row # CPT-4 HCPCS Price 43135 Diverticulectomy of hypopharynx or esophagus, with or without myotomy; thoracic approach 43200 Esophagoscopy, flexible, transoral; diagnostic, including collection of specimen(s) by brushing or washing, when performed (separate $ 567.90 43201 Esophagoscopy, flexible, transoral; with directed submucosal injection(s), any substance $ 754.53 43202 Esophagoscopy, flexible, transoral; with biopsy, single or multiple 43204 Esophagoscopy, flexible, transoral; with injection sclerosis of esophageal varices 43205 Esophagoscopy, flexible, transoral; with band ligation of esophageal varices 43212 Esophagoscopy, flexible, transoral; with placement of endoscopic stent (includes pre- and post-dilation and guide wire passage, when $2,371.40 43215 Esophagoscopy, flexible, transoral; with removal of foreign body $ 832.50 43216 Esophagoscopy, flexible, transoral; with removal of tumor(s), polyp(s), or other lesion(s) by hot biopsy forceps or bipolar cautery $ 839.70 43217 Esophagoscopy, flexible, transoral; with removal of tumor(s), polyp(s), or other lesion(s) by snare technique $ 929.70 43220 Esophagoscopy, flexible, transoral; with transendoscopic balloon dilation (less than 30 mm diameter) 43226 Esophagoscopy, flexible, transoral; with insertion of guide wire followed by passage of dilator(s) over guide wire 43227 Esophagoscopy, flexible, transoral; with control of bleeding, any $ 1,059.30 43229 Esophagoscopy, flexible, transoral; with ablation of tumor(s), polyp(s), or other lesion(s) (includes pre- and post-dilation and guide wire passage, when performed) $1,968.75 43231 Esophagoscopy, flexible, transoral; with endoscopic ultrasound examination $ 762.30 43232 Esophagoscopy, flexible, transoral; with transendoscopic ultrasound- guided intramural or transmural fine needle aspiration/biopsy(s) $ 782.57 43235 Esophagogastroduodenoscopy, flexible, transoral; diagnostic, including collection of specimen(s) by brushing or washing, when performed (separate procedure) $ 575.48 43236 Esophagogastroduodenoscopy, flexible, transoral; with directed submucosal injection(s), any substance $ 833.87 43237 Esophagogastroduodenoscopy, flexible, transoral; with endoscopic ultrasound examination limited to the esophagus, stomach or duodenum, and adjacent structures $ 605.29 43238 needle aspiration/biopsy(s), (includes endoscopic ultrasound examination limited to the esophagus, stomach or duodenum, and adjacent stru $ 712.37 43239 Esophagogastroduodenoscopy, flexible, transoral; with biopsy, $ 645.72 43240 Esophagogastroduodenoscopy, flexible, transoral; with transmural drainage of pseudocyst (includes placement of transmural drainage catheter[s]/stent[s], when performed, and endoscopic ultrasound, $ 1,233.90 43241 Esophagogastroduodenoscopy, flexible, transoral; with insertion of intraluminal tube or catheter 43242 needle aspiration/biopsy(s) (includes endoscopic ultrasound examination of the esophagus, stomach, and either the duodenum or a surgicall $ 968.40 43243 Esophagogastroduodenoscopy, flexible, transoral; with injection sclerosis of esophageal/gastric varices 43244 Esophagogastroduodenoscopy, flexible, transoral; with band ligation of esophageal/gastric varices 43245 Esophagogastroduodenoscopy, flexible, transoral; with dilation of gastric/duodenal stricture(s) (eg, balloon, bougie)

Row # CPT-4 HCPCS Price 43246 Esophagogastroduodenoscopy, flexible, transoral; with directed placement of percutaneous gastrostomy tube 43247 43248 Esophagogastroduodenoscopy, flexible, transoral; with insertion of guide wire followed by passage of dilator(s) through esophagus over guide wire $ 733.50 43249 transendoscopic balloon dilation of esophagus (less than 30 mm diameter) 43250 tumor(s), polyp(s), or other lesion(s) by hot biopsy forceps or bipolar cautery 43251 tumor(s), polyp(s), or other lesion(s) by snare technique 43255 Esophagogastroduodenoscopy, flexible, transoral; with control of bleeding, any method 43257 Esophagogastroduodenoscopy, flexible, transoral; with delivery of thermal energy to the muscle of lower esophageal sphincter and/or gastric cardia, for treatment of gastroesophageal reflux disease $ 1,070.28 43259 Esophagogastroduodenoscopy, flexible, transoral; with endoscopic ultrasound examination, including the esophagus, stomach, and either the duodenum or a surgically altered stomach where the jejunum is examined distal to the anastomosis 43260 Endoscopic retrograde cholangiopancreatography (ERCP); diagnostic, including collection of specimen(s) by brushing or washing, when performed (separate procedure) 43261 43262 sphincterotomy/papillotomy $ 1,642.50 43263 pressure measurement of sphincter of Oddi $ 1,542.60 43264 removal of calculi/debris from biliary/pancreatic duct(s) 43265 destruction of calculi, any method (eg, mechanical, electrohydraulic, lithotripsy) 43266 Esophagogastroduodenoscopy, flexible, transoral; with placement of endoscopic stent (includes pre- and post-dilation and guide wire passage, when performed) $2,371.40 43270 Esophagogastroduodenoscopy, flexible, transoral; with ablation of tumor(s), polyp(s), or other lesion(s) (includes pre- and post-dilation and guide wire passage, when performed) $1,013.05 43273 Endoscopic cannulation of papilla with direct visualization of pancreatic/common bile duct(s) (List separately in addition to code(s) for primary procedure) $ 320.58 43274 placement of endoscopic stent into biliary or pancreatic duct, including pre- and post-dilation and guide wire passage, when performed, including sphincterotomy, when performed, each stent 43275 removal of foreign body(s) or stent(s) from biliary/pancreatic duct(s) 43276 removal and exchange of stent(s), biliary or pancreatic duct, including pre- and post-dilation and guide wire passage, when performed, including sphincterotomy, when performed, each stent exchang 43277 trans-endoscopic balloon dilation of biliary/pancreatic duct(s) or of ampulla (sphincteroplasty), including sphincterotomy, when performed, each duct

Row # CPT-4 HCPCS Price 43278 ablation of tumor(s), polyp(s), or other lesion(s), including pre- and post-dilation and guide wire passage, when performed 43279 Laparoscopy, surgical, esophagomyotomy (Heller type), with fundoplasty, when performed $ 2,872.69 43280 Laparoscopy, surgical, esophagogastric fundoplasty (eg, Nissen, Toupet procedures) 43281 Laparoscopy, surgical, repair of paraesophageal hernia, includes fundoplasty, when performed; without implantation of mesh $ 3,859.31 43282 Laparoscopy, surgical, repair of paraesophageal hernia, includes fundoplasty, when performed; with implantation of mesh $ 4,088.80 43289 Unlisted laparoscopy procedure, esophagus Cost 43300 Esophagoplasty (plastic repair or reconstruction), cervical approach; without repair of tracheoesophageal fistula $ 3,110.40 43305 Esophagoplasty (plastic repair or reconstruction), cervical approach; with repair of tracheoesophageal fistula $ 3,627.90 43310 Esophagoplasty (plastic repair or reconstruction), thoracic approach; without repair of tracheoesophageal fistula $ 4,030.20 43312 Esophagoplasty (plastic repair or reconstruction), thoracic approach; with repair of tracheoesophageal fistula $ 4,640.40 43313 Esophagoplasty for congenital defect (plastic repair or reconstruction), thoracic approach; without repair of congenital tracheoesophageal fistula $ 5,873.36 43314 Esophagoplasty for congenital defect (plastic repair or reconstruction), thoracic approach; with repair of congenital tracheoesophageal fistula $ 6,478.08 43320 Esophagogastrostomy (cardioplasty), with or without vagotomy and pyloroplasty, transabdominal or transthoracic approach $ 3,590.10 43325 Esophagogastric fundoplasty; with fundic patch (Thal-Nissen $ 3,429.90 43330 Esophagomyotomy (Heller type); abdominal approach $ 2,917.80 43331 Esophagomyotomy (Heller type); thoracic approach $ 3,198.60 43332 laparotomy, except neonatal; without implantation of mesh or other prosthesis $ 2,635.13 43333 laparotomy, except neonatal; with implantation of mesh or other $ 2,873.14 43334 thoracotomy, except neonatal; without implantation of mesh or other prosthesis $ 2,906.96 43335 thoracotomy, except neonatal; with implantation of mesh or other $ 3,144.71 43336 thoracoabdominal incision, except neonatal; without implantation of mesh or other prosthesis $ 3,422.52 43337 thoracoabdominal incision, except neonatal; with implantation of mesh or other prosthesis $ 3,761.84 43340 Esophagojejunostomy (without total gastrectomy); abdominal $ 3,551.40 43350 Esophagostomy, fistulization of esophagus, external; abdominal $ 2,381.40 43351 Esophagostomy, fistulization of esophagus, external; thoracic 43352 Esophagostomy, fistulization of esophagus, external; cervical 43360 Gastrointestinal reconstruction for previous esophagectomy, for obstructing esophageal lesion or fistula, or for previous esophageal exclusion; with stomach, with or without pyloroplasty $ 5,664.60

Row # CPT-4 HCPCS Price 43361 Gastrointestinal reconstruction for previous esophagectomy, for obstructing esophageal lesion or fistula, or for previous esophageal exclusion; with colon interposition or small intestine reconstruction, including intestine mobilization, preparation, and 43400 Ligation, direct, esophageal varices $ 3,172.50 43401 Transection of esophagus with repair, for esophageal varices 43405 Ligation or stapling at gastroesophageal junction for pre-existing esophageal perforation $ 3,349.80 43410 Suture of esophageal wound or injury; cervical approach 43415 Suture of esophageal wound or injury; transthoracic or transabdominal approach $ 3,114.00 43420 Closure of esophagostomy or fistula; cervical approach $ 1,954.80 43425 Closure of esophagostomy or fistula; transthoracic or transabdominal approach $ 3,115.80 43450 Dilation of esophagus, by unguided sound or bougie, single or multiple passes $ 285.30 43453 Dilation of esophagus, over guide wire 43460 Esophagogastric tamponade, with balloon (Sengstaken type) $ 697.50 43496 Free jejunum transfer with microvascular anastomosis $ - 43499 Unlisted procedure, esophagus Cost 43500 Gastrotomy; with exploration or foreign body removal $ 1,981.80 43501 Gastrotomy; with suture repair of bleeding ulcer $ 2,765.70 43502 Gastrotomy; with suture repair of pre-existing esophagogastric laceration (eg, Mallory-Weiss) 43510 Gastrotomy; with esophageal dilation and insertion of permanent intraluminal tube (eg, Celestin or Mousseaux-Barbin) $ 2,067.30 43520 Pyloromyotomy, cutting of pyloric muscle (Fredet-Ramstedt type $ 1,850.40 43605 Biopsy of stomach, by laparotomy $ 1,977.30 43610 Excision, local; ulcer or benign tumor of stomach $ 2,572.20 43611 Excision, local; malignant tumor of stomach 43620 Gastrectomy, total; with esophagoenterostomy $ 4,644.90 43621 Gastrectomy, total; with Roux-en-Y reconstruction $ 4,995.90 43622 Gastrectomy, total; with formation of intestinal pouch, any type 43631 Gastrectomy, partial, distal; with gastroduodenostomy $ 3,541.50 43632 Gastrectomy, partial, distal; with gastrojejunostomy $ 3,864.60 43633 Gastrectomy, partial, distal; with Roux-en-Y reconstruction $ 3,953.70 43634 Gastrectomy, partial, distal; with formation of intestinal pouch 43635 Vagotomy when performed with partial distal gastrectomy (List separately in addition to code[s] for primary procedure) 43640 Vagotomy including pyloroplasty, with or without gastrostomy; truncal or selective $ 3,064.50 43641 Vagotomy including pyloroplasty, with or without gastrostomy; parietal cell (highly selective) 43644 Laparoscopy, surgical, gastric restrictive procedure; with gastric bypass and Roux-en-Y gastroenterostomy (roux limb 150 cm or less) $ 5,644.84 43645 Laparoscopy, surgical, gastric restrictive procedure; with gastric bypass and small intestine reconstruction to limit absorption $ 6,078.45 43647 Laparoscopy, surgical; implantation or replacement of gastric neurostimulator electrodes, antrum $ - 43648 Laparoscopy, surgical; revision or removal of gastric neurostimulator electrodes, antrum $ - 43651 Laparoscopy, surgical; transection of vagus nerves, truncal $ 2,584.61 43652 Laparoscopy, surgical; transection of vagus nerves, selective or highly selective $ 2,984.62 43653 Laparoscopy, surgical; gastrostomy, without construction of gastric tube (eg, Stamm procedure) (separate procedure) $ 1,909.82 43659 Unlisted laparoscopy procedure, stomach Cost 43752 Naso- or oro-gastric tube placement, requiring physician's skill and fluoroscopic guidance (includes fluoroscopy, image documentation $ 87.45

Row # CPT-4 HCPCS Price 43753 Gastric intubation and aspiration(s) therapeutic, necessitating physician's skill (eg, for gastrointestinal hemorrhage), including lavage if performed $ 51.44 43754 Gastric intubation and aspiration, diagnostic; single specimen (eg, acid analysis) $ 92.15 43755 Gastric intubation and aspiration, diagnostic; collection of multiple fractional specimens with gastric stimulation, single or double lumen tube (gastric secretory study) (eg, histamine, insulin, pentagastrin, calcium, secretin), includes drug administrat $ 216.19 43760 Change of gastrostomy tube, percutaneous, without imaging or endoscopic guidance $ 192.60 43761 Repositioning of a naso- or oro-gastric feeding tube, through the duodenum for enteric nutrition $ 320.40 43770 Laparoscopy, surgical, gastric restrictive procedure; placement of adjustable gastric restrictive device (eg, gastric band and subcutaneous port components) $ 3,192.15 43771 Laparoscopy, surgical, gastric restrictive procedure; revision of adjustable gastric restrictive device component only $ 2,947.87 43772 Laparoscopy, surgical, gastric restrictive procedure; removal of adjustable gastric restrictive device component only $ 2,562.77 43773 Laparoscopy, surgical, gastric restrictive procedure; removal and replacement of adjustable gastric restrictive device component only $ 3,259.75 43774 Laparoscopy, surgical, gastric restrictive procedure; removal of adjustable gastric restrictive device and subcutaneous port components $ 2,594.55 43775 Laparoscopy, surgical, gastric restrictive procedure; longitudinal gastrectomy (ie, sleeve gastrectomy) $ 3,427.22 43800 Pyloroplasty $ 2,172.60 43810 Gastroduodenostomy $ 2,296.80 43820 Gastrojejunostomy; without vagotomy $ 2,688.30 43825 Gastrojejunostomy; with vagotomy, any type $ 3,096.00 43830 Gastrostomy, open; without construction of gastric tube (eg, Stamm procedure) (separate procedure) 43831 Gastrostomy, open; neonatal, for feeding $ 1,642.50 43832 Gastrostomy, open; with construction of gastric tube (eg, Janeway $ 2,553.30 43840 Gastrorrhaphy, suture of perforated duodenal or gastric ulcer, wound, or injury $ 2,344.50 43842 Gastric restrictive procedure, without gastric bypass, for morbid obesity; vertical-banded gastroplasty 43843 Gastric restrictive procedure, without gastric bypass, for morbid obesity; other than vertical-banded gastroplasty 43845 Gastric restrictive procedure with partial gastrectomy, pylorus- preserving duodenoileostomy and ileoileostomy (50 to 100 cm common channel) to limit absorption (biliopancreatic diversion with duodenal switch) $ 5,446.89 43846 Gastric restrictive procedure, with gastric bypass for morbid obesity; with short limb (150 cm or less) Roux-en-Y gastroenterostomy 43847 Gastric restrictive procedure, with gastric bypass for morbid obesity; with small intestine reconstruction to limit absorption $ 5,096.43 43848 Revision, open, of gastric restrictive procedure for morbid obesity, other than adjustable gastric restrictive device (separate procedure) $ 5,284.93 43850 Revision of gastroduodenal anastomosis (gastroduodenostomy) with reconstruction; without vagotomy $ 4,078.80 43855 Revision of gastroduodenal anastomosis (gastroduodenostomy) with reconstruction; with vagotomy $ 4,171.50 43860 Revision of gastrojejunal anastomosis (gastrojejunostomy) with reconstruction, with or without partial gastrectomy or intestine resection; without vagotomy $ 4,131.90 43865 Revision of gastrojejunal anastomosis (gastrojejunostomy) with reconstruction, with or without partial gastrectomy or intestine resection; with vagotomy $ 3,879.90 43870 Closure of gastrostomy, surgical $ 1,687.50 43880 Closure of gastrocolic fistula

Row # CPT-4 HCPCS Price 43881 Implantation or replacement of gastric neurostimulator electrodes, antrum, open $ - 43882 Revision or removal of gastric neurostimulator electrodes, antrum, open $ - 43886 Gastric restrictive procedure, open; revision of subcutaneous port component only $ 925.03 43887 Gastric restrictive procedure, open; removal of subcutaneous port component only $ 886.07 43888 Gastric restrictive procedure, open; removal and replacement of subcutaneous port component only $ 1,353.63 43999 Unlisted procedure, stomach Cost 44005 Enterolysis (freeing of intestinal adhesion) (separate procedure) $ 2,305.69 44010 Duodenotomy, for exploration, biopsy(s), or foreign body removal $ 2,306.70 44015 Tube or needle catheter jejunostomy for enteral alimentation, intraoperative, any method (List separately in addition to primary $ 1,448.10 44020 Enterotomy, small intestine, other than duodenum; for exploration, biopsy(s), or foreign body removal $ 2,232.00 44021 Enterotomy, small intestine, other than duodenum; for decompression (eg, Baker tube) $ 2,319.30 44025 Colotomy, for exploration, biopsy(s), or foreign body removal $ 2,389.50 44050 Reduction of volvulus, intussusception, internal hernia, by laparotomy $ 2,321.10 44055 Correction of malrotation by lysis of duodenal bands and/or reduction of midgut volvulus (eg, Ladd procedure) 44100 Biopsy of intestine by capsule, tube, peroral (1 or more specimens) $ 485.10 44110 Excision of 1 or more lesions of small or large intestine not requiring anastomosis, exteriorization, or fistulization; single enterotomy $ 2,351.70 44111 Excision of 1 or more lesions of small or large intestine not requiring anastomosis, exteriorization, or fistulization; multiple enterotomies $ 3,157.20 44120 Enterectomy, resection of small intestine; single resection and anastomosis $ 2,880.00 44121 Enterectomy, resection of small intestine; each additional resection and anastomosis (List separately in addition to code for primary 44125 Enterectomy, resection of small intestine; with enterostomy $ 3,114.00 44126 without tapering $ 5,370.66 44127 with tapering $ 5,598.46 44128 each additional resection and anastomosis (List separately in $ 1,016.67 44130 Enteroenterostomy, anastomosis of intestine, with or without cutaneous enterostomy (separate procedure) $ 2,694.60 44132 Donor enterectomy (including cold preservation), open; from cadaver donor $ - 44133 Donor enterectomy (including cold preservation), open; partial, from living donor $ - 44136 Intestinal allotransplantation; from living donor $ - 44137 Removal of transplanted intestinal allograft, complete $ - 44139 Mobilization (take-down) of splenic flexure performed in conjunction with partial colectomy (List separately in addition to 44140 Colectomy, partial; with anastomosis $ 3,340.80 44141 Colectomy, partial; with skin level cecostomy or colostomy $ 3,333.65 44143 Colectomy, partial; with end colostomy and closure of distal segment (Hartmann type procedure)

Row # CPT-4 HCPCS Price 44144 Colectomy, partial; with resection, with colostomy or ileostomy and creation of mucofistula 44145 Colectomy, partial; with coloproctostomy (low pelvic anastomosis) $ 3,887.10 44146 Colectomy, partial; with coloproctostomy (low pelvic anastomosis), with colostomy $ 4,293.90 44147 Colectomy, partial; abdominal and transanal approach $ 4,626.90 44150 Colectomy, total, abdominal, without proctectomy; with ileostomy or ileoproctostomy $ 4,718.70 44151 Colectomy, total, abdominal, without proctectomy; with continent $ 5,408.10 44155 Colectomy, total, abdominal, with proctectomy; with ileostomy $ 5,751.90 44156 Colectomy, total, abdominal, with proctectomy; with continent 44157 Colectomy, total, abdominal, with proctectomy; with ileoanal anastomosis, includes loop ileostomy, and rectal mucosectomy, $ 4,865.79 44158 Colectomy, total, abdominal, with proctectomy; with ileoanal anastomosis, creation of ileal reservoir (S or J), includes loop ileostomy, and rectal mucosectomy, when performed $ 5,014.80 44160 Colectomy, partial, with removal of terminal ileum with ileocolostomy $ 4,014.90 44180 Laparoscopy, surgical, enterolysis (freeing of intestinal adhesion) $ 1,859.50 44186 Laparoscopy, surgical; jejunostomy (eg, for decompression or feeding) $ 1,441.07 44187 Laparoscopy, surgical; ileostomy or jejunostomy, non-tube $ 2,229.44 44188 Laparoscopy, surgical, colostomy or skin level cecostomy $ 2,477.27 44202 Laparoscopy, surgical; enterectomy, resection of small intestine, single resection and anastomosis $ 4,013.10 44203 Laparoscopy, surgical; each additional small intestine resection and anastomosis (List separately in addition to code for primary $ 742.32 44204 Laparoscopy, surgical; colectomy, partial, with anastomosis $ 3,237.04 44205 Laparoscopy, surgical; colectomy, partial, with removal of terminal ileum with ileocolostomy $ 3,053.39 44206 Laparoscopy, surgical; colectomy, partial, with end colostomy and closure of distal segment (Hartmann type procedure) $ 3,562.31 44207 Laparoscopy, surgical; colectomy, partial, with anastomosis, with coloproctostomy (low pelvic anastomosis) $ 3,989.43 44208 Laparoscopy, surgical; colectomy, partial, with anastomosis, with coloproctostomy (low pelvic anastomosis) with colostomy $ 4,162.98 44210 Laparoscopy, surgical; colectomy, total, abdominal, without proctectomy, with ileostomy or ileoproctostomy $ 3,925.87 44211 Laparoscopy, surgical; colectomy, total, abdominal, with proctectomy, with ileoanal anastomosis, creation of ileal reservoir (S or J), with loop ileostomy, includes rectal mucosectomy, when $ 5,320.26 44212 Laparoscopy, surgical; colectomy, total, abdominal, with proctectomy, with ileostomy $ 4,588.99 44213 Laparoscopy, surgical, mobilization (take-down) of splenic flexure performed in conjunction with partial colectomy (List separately in addition to primary procedure) $ 455.45 44227 Laparoscopy, surgical, closure of enterostomy, large or small intestine, with resection and anastomosis $ 3,432.69 44238 Unlisted laparoscopy procedure, intestine (except rectum) $ - 44300 Placement, enterostomy or cecostomy, tube open (eg, for feeding or decompression) (separate procedure) 44310 Ileostomy or jejunostomy, non-tube 44312 Revision of ileostomy; simple (release of superficial scar) (separate $ 1,269.00 44314 Revision of ileostomy; complicated (reconstruction in-depth) $ 2,343.60 44316 Continent ileostomy (Kock procedure) (separate procedure) 44320 Colostomy or skin level cecostomy; $ 2,201.40

Row # CPT-4 HCPCS Price 44322 Colostomy or skin level cecostomy; with multiple biopsies (eg, for congenital megacolon) (separate procedure) $ 2,568.60 44340 Revision of colostomy; simple (release of superficial scar) (separate $ 918.00 44345 Revision of colostomy; complicated (reconstruction in-depth) $ 2,093.40 44346 Revision of colostomy; with repair of paracolostomy hernia $ 2,365.20 44360 duodenum, not including ileum; diagnostic, with or without collection of specimen(s) by brushing or washing (separate $ 864.90 44361 duodenum, not including ileum; with biopsy, single or multiple $ 863.10 44363 duodenum, not including ileum; with removal of foreign body $ 804.60 44364 duodenum, not including ileum; with removal of tumor(s), polyp(s), or other lesion(s) by snare technique 44365 duodenum, not including ileum; with removal of tumor(s), polyp(s), or other lesion(s) by hot biopsy forceps or bipolar cautery 44366 duodenum, not including ileum; with control of bleeding (eg, injection, bipolar cautery, unipolar cautery, laser, heater probe, stapler, plasma coagulator) $ 1,076.40 44369 duodenum, not including ileum; with ablation of tumor(s), polyp(s), or other lesion(s) not amenable to removal by hot biopsy forceps, bipolar cautery or snare technique 44370 duodenum, not including ileum; with transendoscopic stent placement (includes predilation) 44372 duodenum, not including ileum; with placement of percutaneous jejunostomy tube $ 1,199.70 44373 duodenum, not including ileum; with conversion of percutaneous gastrostomy tube to percutaneous jejunostomy tube $ 904.50 44376 duodenum, including ileum; diagnostic, with or without collection of 44377 duodenum, including ileum; with biopsy, single or multiple 44378 duodenum, including ileum; with control of bleeding (eg, injection, 44379 duodenum, including ileum; with transendoscopic stent placement $ 1,137.60 44380 Ileoscopy, through stoma; diagnostic, with or without collection of $ 546.30 44382 Ileoscopy, through stoma; with biopsy, single or multiple 44383 Ileoscopy, through stoma; with transendoscopic stent placement $ 917.99 44385 Endoscopic evaluation of small intestinal (abdominal or pelvic) pouch; diagnostic, with or without collection of specimen(s) by brushing or washing (separate procedure) 44386 Endoscopic evaluation of small intestinal (abdominal or pelvic) pouch; with biopsy, single or multiple $ 741.60

Row # CPT-4 HCPCS Price 44388 Colonoscopy through stoma; diagnostic, with or without collection of specimen(s) by brushing or washing (separate procedure) $ 739.80 44389 Colonoscopy through stoma; with biopsy, single or multiple 44390 Colonoscopy through stoma; with removal of foreign body 44391 Colonoscopy through stoma; with control of bleeding (eg, injection, $ 1,166.40 44392 Colonoscopy through stoma; with removal of tumor(s), polyp(s), or other lesion(s) by hot biopsy forceps or bipolar cautery $ 1,255.50 44393 Colonoscopy through stoma; with ablation of tumor(s), polyp(s), or other lesion(s) not amenable to removal by hot biopsy forceps, bipolar cautery or snare technique $ 1,321.20 44394 Colonoscopy through stoma; with removal of tumor(s), polyp(s), or other lesion(s) by snare technique $ 1,102.50 44397 Colonoscopy through stoma; with transendoscopic stent placement $ 596.70 44500 Introduction of long gastrointestinal tube (eg, Miller-Abbott) 44602 Suture of small intestine (enterorrhaphy) for perforated ulcer, diverticulum, wound, injury or rupture; single perforation $ 2,248.20 44603 Suture of small intestine (enterorrhaphy) for perforated ulcer, diverticulum, wound, injury or rupture; multiple perforations $ 2,656.80 44604 Suture of large intestine (colorrhaphy) for perforated ulcer, diverticulum, wound, injury or rupture (single or multiple perforations); without colostomy $ 2,258.45 44605 Suture of large intestine (colorrhaphy) for perforated ulcer, diverticulum, wound, injury or rupture (single or multiple perforations); with colostomy $ 2,991.60 44615 Intestinal stricturoplasty (enterotomy and enterorrhaphy) with or without dilation, for intestinal obstruction $ 2,626.20 44620 Closure of enterostomy, large or small intestine; $ 1,713.65 44625 Closure of enterostomy, large or small intestine; with resection and anastomosis other than colorectal $ 3,033.90 44626 Closure of enterostomy, large or small intestine; with resection and colorectal anastomosis (eg, closure of Hartmann type procedure) $ 3,744.90 44640 Closure of intestinal cutaneous fistula $ 2,372.40 44650 Closure of enteroenteric or enterocolic fistula 44660 Closure of enterovesical fistula; without intestinal or bladder 44661 Closure of enterovesical fistula; with intestine and/or bladder $ 3,927.60 44680 Intestinal plication (separate procedure) $ 2,871.90 44700 Exclusion of small intestine from pelvis by mesh or other prosthesis, or native tissue (eg, bladder or omentum) $ 2,709.90 44701 Intraoperative colonic lavage (List separately in addition to code for $ 305.32 44715 Backbench standard preparation of cadaver or living donor intestine allograft prior to transplantation, including mobilization and fashioning of the superior mesenteric artery and vein $ - 44720 Backbench reconstruction of cadaver or living donor intestine allograft prior to transplantation; venous anastomosis, each $ 581.85 44721 Backbench reconstruction of cadaver or living donor intestine allograft prior to transplantation; arterial anastomosis, each $ 929.76 44799 Unlisted procedure, intestine Cost 44800 Excision of Meckel's diverticulum (diverticulectomy) or omphalomesenteric duct 44820 Excision of lesion of mesentery (separate procedure) $ 2,034.00 44850 Suture of mesentery (separate procedure) 44899 Unlisted procedure, Meckel's diverticulum and the mesentery Cost 44900 Incision and drainage of appendiceal abscess, open 44950 Appendectomy; $ 1,537.19

Row # CPT-4 HCPCS Price 44955 Appendectomy; when done for indicated purpose at time of other major procedure (not as separate procedure) (List separately in 44960 Appendectomy; for ruptured appendix with abscess or generalized peritonitis $ 2,357.10 44970 Laparoscopy, surgical, appendectomy $ 2,130.30 44979 Unlisted laparoscopy procedure, appendix Cost 45000 Transrectal drainage of pelvic abscess 45005 Incision and drainage of submucosal abscess, rectum $ 522.90 45020 Incision and drainage of deep supralevator, pelvirectal, or retrorectal abscess $ 893.70 45100 Biopsy of anorectal wall, anal approach (eg, congenital megacolon) 45108 Anorectal myomectomy 45110 Proctectomy; complete, combined abdominoperineal, with colostomy $ 4,392.90 45111 Proctectomy; partial resection of rectum, transabdominal approach $ 3,498.30 45112 Proctectomy, combined abdominoperineal, pull-through procedure (eg, colo-anal anastomosis) $ 4,645.80 45113 Proctectomy, partial, with rectal mucosectomy, ileoanal anastomosis, creation of ileal reservoir (S or J), with or without loop $ 4,837.19 45114 Proctectomy, partial, with anastomosis; abdominal and transsacral $ 4,489.20 45116 Proctectomy, partial, with anastomosis; transsacral approach only (Kraske type) 45119 Proctectomy, combined abdominoperineal pull-through procedure (eg, colo-anal anastomosis), with creation of colonic reservoir (eg, J- pouch), with diverting enterostomy when performed 45120 Proctectomy, complete (for congenital megacolon), abdominal and perineal approach; with pull-through procedure and anastomosis (eg, Swenson, Duhamel, or Soave type operation) $ 4,650.30 45121 Proctectomy, complete (for congenital megacolon), abdominal and perineal approach; with subtotal or total colectomy, with multiple biopsies 45123 Proctectomy, partial, without anastomosis, perineal approach $ 3,149.10 45126 Pelvic exenteration for colorectal malignancy, with proctectomy (with or without colostomy), with removal of bladder and ureteral transplantations, and/or hysterectomy, or cervicectomy, with or without removal of tube(s), with or without removal of ovary( $ 6,470.10 45130 Excision of rectal procidentia, with anastomosis; perineal approach $ 2,864.70 45135 Excision of rectal procidentia, with anastomosis; abdominal and perineal approach $ 4,033.80 45136 Excision of ileoanal reservoir with ileostomy $ 4,548.02 45150 Division of stricture of rectum $ 1,278.00 45160 Excision of rectal tumor by proctotomy, transsacral or transcoccygeal approach $ 2,827.80 45171 Excision of rectal tumor, transanal approach; not including muscularis propria (ie, partial thickness) $ 1,349.29 45172 Excision of rectal tumor, transanal approach; including muscularis propria (ie, full thickness) $ 1,853.35 45190 Destruction of rectal tumor (eg, electrodesiccation, electrosurgery, laser ablation, laser resection, cryosurgery) transanal approach 45300 Proctosigmoidoscopy, rigid; diagnostic, with or without collection of $ 142.39 45303 Proctosigmoidoscopy, rigid; with dilation (eg, balloon, guide wire, bougie) $ 220.50 45305 Proctosigmoidoscopy, rigid; with biopsy, single or multiple 45307 Proctosigmoidoscopy, rigid; with removal of foreign body $ 386.10 45308 Proctosigmoidoscopy, rigid; with removal of single tumor, polyp, or other lesion by hot biopsy forceps or bipolar cautery $ 417.60

Row # CPT-4 HCPCS Price 45309 Proctosigmoidoscopy, rigid; with removal of single tumor, polyp, or other lesion by snare technique $ 430.20 45315 Proctosigmoidoscopy, rigid; with removal of multiple tumors, polyps, or other lesions by hot biopsy forceps, bipolar cautery or $ 582.30 45317 Proctosigmoidoscopy, rigid; with control of bleeding (eg, injection, $ 585.00 45320 Proctosigmoidoscopy, rigid; with ablation of tumor(s), polyp(s), or other lesion(s) not amenable to removal by hot biopsy forceps, bipolar cautery or snare technique (eg, laser) $ 639.00 45321 Proctosigmoidoscopy, rigid; with decompression of volvulus $ 534.60 45327 Proctosigmoidoscopy, rigid; with transendoscopic stent placement $ 219.12 45330 Sigmoidoscopy, flexible; diagnostic, with or without collection of $ 253.73 45331 Sigmoidoscopy, flexible; with biopsy, single or multiple $ 339.86 45332 Sigmoidoscopy, flexible; with removal of foreign body $ 449.10 45333 Sigmoidoscopy, flexible; with removal of tumor(s), polyp(s), or other lesion(s) by hot biopsy forceps or bipolar cautery $ 558.90 45334 Sigmoidoscopy, flexible; with control of bleeding (eg, injection, 45335 Sigmoidoscopy, flexible; with directed submucosal injection(s), any substance $ 714.94 45337 Sigmoidoscopy, flexible; with decompression of volvulus, any 45338 Sigmoidoscopy, flexible; with removal of tumor(s), polyp(s), or other lesion(s) by snare technique 45339 Sigmoidoscopy, flexible; with ablation of tumor(s), polyp(s), or other lesion(s) not amenable to removal by hot biopsy forceps, bipolar cautery or snare technique $ 604.80 45340 Sigmoidoscopy, flexible; with dilation by balloon, 1 or more strictures $ 400.18 45341 Sigmoidoscopy, flexible; with endoscopic ultrasound examination 45342 Sigmoidoscopy, flexible; with transendoscopic ultrasound guided intramural or transmural fine needle aspiration/biopsy(s) $ 700.20 45345 Sigmoidoscopy, flexible; with transendoscopic stent placement 45355 Colonoscopy, rigid or flexible, transabdominal via colotomy, single or multiple 45378 Colonoscopy, flexible, proximal to splenic flexure; diagnostic, with or without collection of specimen(s) by brushing or washing, with or without colon decompression (separate procedure) $ 858.15 45378-53 53 45378 Colonoscopy, flexible, proximal to splenic flexure; diagnostic, with or without collection of specimen(s) by brushing or washing, with or without colon decompression (separate procedure) $ 304.71 45379 $ 1,099.80 45380 Colonoscopy, flexible, proximal to splenic flexure; with biopsy, $ 961.77 45381 Colonoscopy, flexible, proximal to splenic flexure; with directed submucosal injection(s), any substance $ 975.00 45382 Colonoscopy, flexible, proximal to splenic flexure; with control of bleeding (eg, injection, bipolar cautery, unipolar cautery, laser, heater probe, stapler, plasma coagulator) $ 1,107.00 45383 Colonoscopy, flexible, proximal to splenic flexure; with ablation of tumor(s), polyp(s), or other lesion(s) not amenable to removal by hot biopsy forceps, bipolar cautery or snare technique $ 1,203.49

Row # CPT-4 HCPCS Price 45384 tumor(s), polyp(s), or other lesion(s) by hot biopsy forceps or bipolar cautery $ 1,162.09 45385 tumor(s), polyp(s), or other lesion(s) by snare technique $ 1,287.91 45386 Colonoscopy, flexible, proximal to splenic flexure; with dilation by balloon, 1 or more strictures $ 958.72 45387 Colonoscopy, flexible, proximal to splenic flexure; with transendoscopic stent placement (includes predilation) $ 950.40 45391 Colonoscopy, flexible, proximal to splenic flexure; with endoscopic ultrasound examination $ 568.04 45392 Colonoscopy, flexible, proximal to splenic flexure; with needle aspiration/biopsy(s) 45395 Laparoscopy, surgical; proctectomy, complete, combined abdominoperineal, with colostomy $ 3,966.46 45397 Laparoscopy, surgical; proctectomy, combined abdominoperineal pull-through procedure (eg, colo-anal anastomosis), with creation of colonic reservoir (eg, J-pouch), with diverting enterostomy, when $ 4,303.15 45400 Laparoscopy, surgical; proctopexy (for prolapse) $ 2,322.57 45402 Laparoscopy, surgical; proctopexy (for prolapse), with sigmoid $ 3,124.42 45499 Unlisted laparoscopy procedure, rectum Cost 45500 Proctoplasty; for stenosis $ 1,570.50 45505 Proctoplasty; for prolapse of mucous membrane 45520 Perirectal injection of sclerosing solution for prolapse 45540 Proctopexy (eg, for prolapse); abdominal approach $ 3,206.70 45541 Proctopexy (eg, for prolapse); perineal approach 45550 Proctopexy (eg, for prolapse); with sigmoid resection, abdominal $ 3,591.00 45560 Repair of rectocele (separate procedure) 45562 Exploration, repair, and presacral drainage for rectal injury; 45563 Exploration, repair, and presacral drainage for rectal injury; with colostomy $ 3,095.10 45800 Closure of rectovesical fistula; $ 3,066.30 45805 Closure of rectovesical fistula; with colostomy $ 3,103.20 45820 Closure of rectourethral fistula; 45825 Closure of rectourethral fistula; with colostomy $ 3,057.30 45900 Reduction of procidentia (separate procedure) under anesthesia $ 497.70 45905 Dilation of anal sphincter (separate procedure) under anesthesia other than local 45910 Dilation of rectal stricture (separate procedure) under anesthesia other than local $ 384.30 45915 Removal of fecal impaction or foreign body (separate procedure) under anesthesia 45990 Anorectal exam, surgical, requiring anesthesia (general, spinal, or epidural), diagnostic $ 219.72 45999 Unlisted procedure, rectum Cost 46020 Placement of seton $ 230.01 46030 Removal of anal seton, other marker 46040 Incision and drainage of ischiorectal and/or perirectal abscess 46045 Incision and drainage of intramural, intramuscular, or submucosal abscess, transanal, under anesthesia $ 775.80 46050 Incision and drainage, perianal abscess, superficial $ 282.60 46060 Incision and drainage of ischiorectal or intramural abscess, with fistulectomy or fistulotomy, submuscular, with or without placement of seton $ 1,665.00 46070 Incision, anal septum (infant) 46080 Sphincterotomy, anal, division of sphincter (separate procedure) 46083 Incision of thrombosed hemorrhoid, external $ 214.20 46200 Fissurectomy, including sphincterotomy, when performed $ 867.60 46220 Excision of single external papilla or tag, anus 46221 Hemorrhoidectomy, internal, by rubber band ligation(s) 46230 Excision of multiple external papillae or tags, anus 46250 Hemorrhoidectomy, external, 2 or more columns/groups $ 952.20

Row # CPT-4 HCPCS Price 46255 $ 1,133.02 46257 with fissurectomy $ 1,395.90 46258 with fistulectomy, including fissurectomy, when performed $ 1,494.90 46260 columns/groups; $ 1,744.20 46261 columns/groups; with fissurectomy $ 1,469.73 46262 columns/groups; with fistulectomy, including fissurectomy, when 46270 subcutaneous 46275 intersphincteric $ 1,426.50 46280 transsphincteric, suprasphincteric, extrasphincteric or multiple, including placement of seton, when performed 46285 Surgical treatment of anal fistula (fistulectomy/fistulotomy); second stage 46288 Closure of anal fistula with rectal advancement flap 46320 Excision of thrombosed hemorrhoid, external $ 252.07 46500 Injection of sclerosing solution, hemorrhoids 46505 Chemodenervation of internal anal sphincter $ 620.82 46600 Anoscopy; diagnostic, with or without collection of specimen(s) by brushing or washing (separate procedure) $ 70.85 46604 Anoscopy; with dilation (eg, balloon, guide wire, bougie) $ 197.10 46606 Anoscopy; with biopsy, single or multiple $ 156.60 46608 Anoscopy; with removal of foreign body 46610 Anoscopy; with removal of single tumor, polyp, or other lesion by hot biopsy forceps or bipolar cautery $ 277.20 46611 Anoscopy; with removal of single tumor, polyp, or other lesion by 46612 Anoscopy; with removal of multiple tumors, polyps, or other lesions by hot biopsy forceps, bipolar cautery or snare technique 46614 Anoscopy; with control of bleeding (eg, injection, bipolar cautery, unipolar cautery, laser, heater probe, stapler, plasma coagulator) 46615 Anoscopy; with ablation of tumor(s), polyp(s), or other lesion(s) not amenable to removal by hot biopsy forceps, bipolar cautery or $ 414.00 46700 Anoplasty, plastic operation for stricture; adult $ 1,498.68 46705 Anoplasty, plastic operation for stricture; infant 46706 Repair of anal fistula with fibrin glue $ 389.22 46707 Repair of anorectal fistula with plug (eg, porcine small intestine submucosa [SIS]) $ 1,162.37 46710 Repair of ileoanal pouch fistula/sinus (eg, perineal or vaginal), pouch advancement; transperineal approach $ 2,534.97 46712 Repair of ileoanal pouch fistula/sinus (eg, perineal or vaginal), pouch advancement; combined transperineal and transabdominal $ 4,490.29 46715 Repair of low imperforate anus; with anoperineal fistula (cut-back $ 1,563.30 46716 Repair of low imperforate anus; with transposition of anoperineal or anovestibular fistula $ 1,954.80 46730 Repair of high imperforate anus without fistula; perineal or sacroperineal approach $ 3,294.00 46735 Repair of high imperforate anus without fistula; combined transabdominal and sacroperineal approaches $ 3,994.20 46740 Repair of high imperforate anus with rectourethral or rectovaginal fistula; perineal or sacroperineal approach $ 4,257.00 46742 Repair of high imperforate anus with rectourethral or rectovaginal fistula; combined transabdominal and sacroperineal approaches

Row # CPT-4 HCPCS Price 46744 urethroplasty, sacroperineal approach $ 5,304.60 46746 urethroplasty, combined abdominal and sacroperineal approach; 46748 urethroplasty, combined abdominal and sacroperineal approach; with vaginal lengthening by intestinal graft or pedicle flaps $ 7,020.00 46750 Sphincteroplasty, anal, for incontinence or prolapse; adult $ 1,944.72 46751 Sphincteroplasty, anal, for incontinence or prolapse; child 46753 Graft (Thiersch operation) for rectal incontinence and/or prolapse 46754 Removal of Thiersch wire or suture, anal canal $ 287.10 46760 Sphincteroplasty, anal, for incontinence, adult; muscle transplant $ 1,932.30 46761 Sphincteroplasty, anal, for incontinence, adult; levator muscle imbrication (Park posterior anal repair) $ 2,142.41 46762 Sphincteroplasty, anal, for incontinence, adult; implantation artificial sphincter $ 2,033.00 46900 contagiosum, herpetic vesicle), simple; chemical 46910 contagiosum, herpetic vesicle), simple; electrodesiccation $ 325.80 46916 contagiosum, herpetic vesicle), simple; cryosurgery $ 330.30 46917 contagiosum, herpetic vesicle), simple; laser surgery 46922 contagiosum, herpetic vesicle), simple; surgical excision $ 441.90 46924 contagiosum, herpetic vesicle), extensive (eg, laser surgery, $ 861.30 46930 Destruction of internal hemorrhoid(s) by thermal energy (eg, infrared coagulation, cautery, radiofrequency) $ 309.16 46940 Curettage or cautery of anal fissure, including dilation of anal sphincter (separate procedure); initial $ 342.90 46942 Curettage or cautery of anal fissure, including dilation of anal sphincter (separate procedure); subsequent $ 241.20 46945 Hemorrhoidectomy, internal, by ligation other than rubber band; single hemorrhoid column/group $ 319.50 46946 Hemorrhoidectomy, internal, by ligation other than rubber band; 2 or more hemorrhoid columns/groups $ 372.60 46947 Hemorrhoidopexy (eg, for prolapsing internal hemorrhoids) by stapling $ 578.58 46999 Unlisted procedure, anus $ 472.86 47000 Biopsy of liver, needle; percutaneous 47001 Biopsy of liver, needle; when done for indicated purpose at time of other major procedure (List separately in addition to code for $ 362.70 47010 Hepatotomy, for open drainage of abscess or cyst, 1 or 2 stages $ 2,399.40 47015 Laparotomy, with aspiration and/or injection of hepatic parasitic (eg, amoebic or echinococcal) cyst(s) or abscess(es) 47120 Hepatectomy, resection of liver; partial lobectomy $ 4,094.10 47122 Hepatectomy, resection of liver; trisegmentectomy $ 5,055.30 47125 Hepatectomy, resection of liver; total left lobectomy $ 5,123.70 47130 Hepatectomy, resection of liver; total right lobectomy $ 5,660.10 47133 Donor hepatectomy (including cold preservation), from cadaver donor $ - 47135 Liver allotransplantation; orthotopic, partial or whole, from cadaver or living donor, any age $ 11,907.94 47136 Liver allotransplantation; heterotopic, partial or whole, from cadaver or living donor, any age $ 10,222.38

Row # CPT-4 HCPCS Price 47140 left lateral segment only (segments II and III) $ 8,705.32 47141 total left lobectomy (segments II, III and IV) $ 9,173.83 47142 total right lobectomy (segments V, VI, VII and VIII) $ 11,446.63 47143 $ - 47144 $ - 47145 $ - 47146 Backbench reconstruction of cadaver or living donor liver graft prior to allotransplantation; venous anastomosis, each $ 795.89 47147 Backbench reconstruction of cadaver or living donor liver graft prior to allotransplantation; arterial anastomosis, each $ 928.21 47300 Marsupialization of cyst or abscess of liver $ 2,345.40 47350 Management of liver hemorrhage; simple suture of liver wound or injury $ 2,863.80 47360 Management of liver hemorrhage; complex suture of liver wound or injury, with or without hepatic artery ligation 47361 Management of liver hemorrhage; exploration of hepatic wound, extensive debridement, coagulation and/or suture, with or without packing of liver $ 5,294.70 47362 Management of liver hemorrhage; re-exploration of hepatic wound for removal of packing $ 2,229.30 47370 Laparoscopy, surgical, ablation of 1 or more liver tumor(s); radiofrequency $ 3,013.06 47371 Laparoscopy, surgical, ablation of 1 or more liver tumor(s); cryosurgical $ 3,066.51 47379 Unlisted laparoscopic procedure, liver Cost 47380 Ablation, open, of 1 or more liver tumor(s); radiofrequency $ 3,485.82 47381 Ablation, open, of 1 or more liver tumor(s); cryosurgical $ 3,608.38 47382 Ablation, 1 or more liver tumor(s), percutaneous, radiofrequency $ 12,779.28 47399 Unlisted procedure, liver Cost 47400 Hepaticotomy or hepaticostomy with exploration, drainage, or removal of calculus $ 2,941.20 47420 Choledochotomy or choledochostomy with exploration, drainage, or removal of calculus, with or without cholecystotomy; without transduodenal sphincterotomy or sphincteroplasty $ 2,731.50 47425 Choledochotomy or choledochostomy with exploration, drainage, or removal of calculus, with or without cholecystotomy; with transduodenal sphincterotomy or sphincteroplasty $ 3,064.50 47460 Transduodenal sphincterotomy or sphincteroplasty, with or without transduodenal extraction of calculus (separate procedure) $ 3,170.70 47480 Cholecystotomy or cholecystostomy, open, with exploration, drainage, or removal of calculus (separate procedure) $ 1,964.70 47490 Cholecystostomy, percutaneous, complete procedure, including imaging guidance, catheter placement, cholecystogram when performed, and radiological supervision and interpretation 47500 Injection procedure for percutaneous transhepatic cholangiography $ 501.30 47505 Injection procedure for cholangiography through an existing catheter (eg, percutaneous transhepatic or T-tube)

Row # CPT-4 HCPCS Price 47510 Introduction of percutaneous transhepatic catheter for biliary drainage $ 825.30 47511 Introduction of percutaneous transhepatic stent for internal and external biliary drainage $ 932.40 47525 Change of percutaneous biliary drainage catheter 47530 Revision and/or reinsertion of transhepatic tube $ 613.80 47550 Biliary endoscopy, intraoperative (choledochoscopy) (List separately 47552 Biliary endoscopy, percutaneous via T-tube or other tract; diagnostic, with collection of specimen(s) by brushing and/or washing, when performed (separate procedure) 47553 47554 removal of calculus/calculi $ 1,421.10 47555 dilation of biliary duct stricture(s) without stent $ 1,138.50 47556 dilation of biliary duct stricture(s) with stent 47560 Laparoscopy, surgical; with guided transhepatic cholangiography, $ 1,510.58 47561 Laparoscopy, surgical; with guided transhepatic cholangiography with biopsy 47562 Laparoscopy, surgical; cholecystectomy 47563 Laparoscopy, surgical; cholecystectomy with cholangiography $ 2,978.08 47564 Laparoscopy, surgical; cholecystectomy with exploration of common duct 47570 Laparoscopy, surgical; cholecystoenterostomy $ 2,934.90 47579 Unlisted laparoscopy procedure, biliary tract Cost 47600 Cholecystectomy; $ 2,425.73 47605 Cholecystectomy; with cholangiography $ 2,408.40 47610 Cholecystectomy with exploration of common duct; 47612 Cholecystectomy with exploration of common duct; with choledochoenterostomy $ 3,743.10 47620 Cholecystectomy with exploration of common duct; with transduodenal sphincterotomy or sphincteroplasty, with or without cholangiography 47630 Biliary duct stone extraction, percutaneous via T-tube tract, basket, or snare (eg, Burhenne technique) 47700 Exploration for congenital atresia of bile ducts, without repair, with or without liver biopsy, with or without cholangiography $ 2,565.00 47701 Portoenterostomy (eg, Kasai procedure) $ 3,919.50 47711 Excision of bile duct tumor, with or without primary repair of bile duct; extrahepatic $ 3,893.40 47712 Excision of bile duct tumor, with or without primary repair of bile duct; intrahepatic $ 4,233.60 47715 Excision of choledochal cyst $ 2,894.40 47720 Cholecystoenterostomy; direct $ 2,518.20 47721 Cholecystoenterostomy; with gastroenterostomy 47740 Cholecystoenterostomy; Roux-en-Y $ 3,231.00 47741 Cholecystoenterostomy; Roux-en-Y with gastroenterostomy $ 3,558.60 47760 Anastomosis, of extrahepatic biliary ducts and gastrointestinal tract 47765 Anastomosis, of intrahepatic ducts and gastrointestinal tract 47780 Anastomosis, Roux-en-Y, of extrahepatic biliary ducts and gastrointestinal tract $ 4,051.80 47785 Anastomosis, Roux-en-Y, of intrahepatic biliary ducts and gastrointestinal tract $ 4,861.80 47800 Reconstruction, plastic, of extrahepatic biliary ducts with end-to- end anastomosis $ 3,579.30 47801 Placement of choledochal stent $ 2,097.00 47802 U-tube hepaticoenterostomy 47900 Suture of extrahepatic biliary duct for pre-existing injury (separate $ 3,095.10 47999 Unlisted procedure, biliary tract Cost 48000 Placement of drains, peripancreatic, for acute pancreatitis; $ 2,626.20

Row # CPT-4 HCPCS Price 48001 Placement of drains, peripancreatic, for acute pancreatitis; with cholecystostomy, gastrostomy, and jejunostomy 48020 Removal of pancreatic calculus 48100 Biopsy of pancreas, open (eg, fine needle aspiration, needle core biopsy, wedge biopsy) $ 2,138.40 48102 Biopsy of pancreas, percutaneous needle $ 634.50 48105 Resection or debridement of pancreas and peripancreatic tissue for acute necrotizing pancreatitis $ 5,451.85 48120 Excision of lesion of pancreas (eg, cyst, adenoma) 48140 Pancreatectomy, distal subtotal, with or without splenectomy; without pancreaticojejunostomy $ 3,533.40 48145 Pancreatectomy, distal subtotal, with or without splenectomy; with pancreaticojejunostomy $ 3,700.80 48146 Pancreatectomy, distal, near-total with preservation of duodenum (Child-type procedure) 48148 Excision of ampulla of Vater $ 3,132.00 48150 Pancreatectomy, proximal subtotal with total duodenectomy, partial gastrectomy, choledochoenterostomy and gastrojejunostomy (Whipple-type procedure); with pancreatojejunostomy $ 6,010.20 48152 Pancreatectomy, proximal subtotal with total duodenectomy, partial gastrectomy, choledochoenterostomy and gastrojejunostomy (Whipple-type procedure); without pancreatojejunostomy $ 5,525.10 48153 Pancreatectomy, proximal subtotal with near-total duodenectomy, choledochoenterostomy and duodenojejunostomy (pylorus-sparing, Whipple-type procedure); with pancreatojejunostomy 48154 Pancreatectomy, proximal subtotal with near-total duodenectomy, choledochoenterostomy and duodenojejunostomy (pylorus-sparing, Whipple-type procedure); without pancreatojejunostomy $ 5,545.84 48155 Pancreatectomy, total $ 5,987.70 48160 Pancreatectomy, total or subtotal, with autologous transplantation of pancreas or pancreatic islet cells $ - 48400 Injection procedure for intraoperative pancreatography (List $ 278.10 48500 Marsupialization of pancreatic cyst 48510 External drainage, pseudocyst of pancreas, open $ 3,393.00 48520 Internal anastomosis of pancreatic cyst to gastrointestinal tract; direct $ 3,391.20 48540 Internal anastomosis of pancreatic cyst to gastrointestinal tract; Roux-en-Y $ 3,727.80 48545 Pancreatorrhaphy for injury 48547 Duodenal exclusion with gastrojejunostomy for pancreatic injury 48548 Pancreaticojejunostomy, side-to-side anastomosis (Puestow-type $ 3,894.97 48550 Donor pancreatectomy (including cold preservation), with or without duodenal segment for transplantation $ - 48551 Backbench standard preparation of cadaver donor pancreas allograft prior to transplantation, including dissection of allograft from surrounding soft tissues, splenectomy, duodenotomy, ligation of bile duct, ligation of mesenteric vessels, and Y-graft arte $ - 48552 Backbench reconstruction of cadaver donor pancreas allograft prior to transplantation, venous anastomosis, each $ 568.43 48554 Transplantation of pancreatic allograft $ 5,886.90 48556 Removal of transplanted pancreatic allograft $ 2,919.60 48999 Unlisted procedure, pancreas Cost 49000 Exploratory laparotomy, exploratory celiotomy with or without biopsy(s) (separate procedure) $ 2,088.85 49002 Reopening of recent laparotomy $ 1,898.10 49010 Exploration, retroperitoneal area with or without biopsy(s) $ 2,083.50 49020 Drainage of peritoneal abscess or localized peritonitis, exclusive of appendiceal abscess, open $ 1,682.10 49040 Drainage of subdiaphragmatic or subphrenic abscess, open 49060 Drainage of retroperitoneal abscess, open $ 1,845.90

Row # CPT-4 HCPCS Price 49062 Drainage of extraperitoneal lymphocele to peritoneal cavity, open $ 1,874.70 49082 Abdominal paracentesis (diagnostic or therapeutic); without imaging guidance $ 439.20 49083 Abdominal paracentesis (diagnostic or therapeutic); with imaging guidance $ 793.44 49084 Peritoneal lavage, including imaging guidance, when performed $ 237.37 49180 Biopsy, abdominal or retroperitoneal mass, percutaneous needle $ 811.80 49203 retroperitoneal primary or secondary tumors; largest tumor 5 cm diameter or less $ 2,801.62 49204 retroperitoneal primary or secondary tumors; largest tumor 5.1- 10.0 cm diameter $ 3,508.35 49205 retroperitoneal primary or secondary tumors; largest tumor greater than 10.0 cm diameter $ 4,192.01 49215 Excision of presacral or sacrococcygeal tumor $ 3,955.50 49220 Staging laparotomy for Hodgkins disease or lymphoma (includes splenectomy, needle or open biopsies of both liver lobes, possibly also removal of abdominal nodes, abdominal node and/or bone marrow biopsies, ovarian repositioning) $ 3,829.50 49250 Umbilectomy, omphalectomy, excision of umbilicus (separate 49255 Omentectomy, epiploectomy, resection of omentum (separate 49320 Laparoscopy, abdomen, peritoneum, and omentum, diagnostic, with or without collection of specimen(s) by brushing or washing $ 1,557.11 49321 Laparoscopy, surgical; with biopsy (single or multiple) $ 1,716.30 49322 Laparoscopy, surgical; with aspiration of cavity or cyst (eg, ovarian cyst) (single or multiple) 49323 Laparoscopy, surgical; with drainage of lymphocele to peritoneal cavity $ 1,908.90 49324 Laparoscopy, surgical; with insertion of tunneled intraperitoneal $ 943.82 49325 Laparoscopy, surgical; with revision of previously placed intraperitoneal cannula or catheter, with removal of intraluminal obstructive material if performed $ 950.46 49326 Laparoscopy, surgical; with omentopexy (omental tacking $ 706.80 49329 Unlisted laparoscopy procedure, abdomen, peritoneum and omentum Cost 49400 Injection of air or contrast into peritoneal cavity (separate $ 233.10 49402 Removal of peritoneal foreign body from peritoneal cavity $ 1,902.20 49405 hematoma, seroma, lymphocele, cyst); visceral (eg, kidney, liver, spleen, lung/mediastinum), percutaneous $ 1,223.25 49406 hematoma, seroma, lymphocele, cyst); peritoneal or retroperitoneal, percutaneous $ 1,223.25 49407 hematoma, seroma, lymphocele, cyst); peritoneal or retroperitoneal, transvaginal or transrectal $ 757.76 49411 (eg, fiducial markers, dosimeter), percutaneous, intra-abdominal, intra-pelvic (except prostate), and/or retroperitoneum, single or multiple $ 880.63

Row # CPT-4 HCPCS Price 49418 Insertion of tunneled intraperitoneal catheter (eg, dialysis, intraperitoneal chemotherapy instillation, management of ascites), complete procedure, including imaging guidance, catheter placement, contrast injection when performed, and radiological superv $ 1,335.02 49419 Insertion of tunneled intraperitoneal catheter, with subcutaneous port (ie, totally implantable) $ 985.96 49421 Insertion of tunneled intraperitoneal catheter for dialysis, open $ 1,449.00 49422 Removal of tunneled intraperitoneal catheter $ 1,191.60 49423 Exchange of previously placed abscess or cyst drainage catheter under radiological guidance (separate procedure) $ 277.20 49424 Contrast injection for assessment of abscess or cyst via previously placed drainage catheter or tube (separate procedure) 49425 Insertion of peritoneal-venous shunt 49426 Revision of peritoneal-venous shunt 49427 Injection procedure (eg, contrast media) for evaluation of previously placed peritoneal-venous shunt $ 216.00 49428 Ligation of peritoneal-venous shunt $ 953.79 49429 Removal of peritoneal-venous shunt $ 1,148.24 49435 Insertion of subcutaneous extension to intraperitoneal cannula or catheter with remote chest exit site (List separately in addition to $ 343.46 49436 Delayed creation of exit site from embedded subcutaneous segment of intraperitoneal cannula or catheter $ 485.16 49440 Insertion of gastrostomy tube, percutaneous, under fluoroscopic guidance including contrast injection(s), image documentation and $ 2,849.89 49441 Insertion of duodenostomy or jejunostomy tube, percutaneous, under fluoroscopic guidance including contrast injection(s), image $ 3,205.41 49442 Insertion of cecostomy or other colonic tube, percutaneous, under fluoroscopic guidance including contrast injection(s), image $ 2,719.49 49446 Conversion of gastrostomy tube to gastro-jejunostomy tube, percutaneous, under fluoroscopic guidance including contrast injection(s), image documentation and report $ 2,770.54 49450 Replacement of gastrostomy or cecostomy (or other colonic) tube, percutaneous, under fluoroscopic guidance including contrast injection(s), image documentation and report $ 2,007.64 49451 Replacement of duodenostomy or jejunostomy tube, percutaneous, under fluoroscopic guidance including contrast injection(s), image $ 2,121.12 49452 Replacement of gastro-jejunostomy tube, percutaneous, under fluoroscopic guidance including contrast injection(s), image $ 2,487.98 49460 Mechanical removal of obstructive material from gastrostomy, duodenostomy, jejunostomy, gastro-jejunostomy, or cecostomy (or other colonic) tube, any method, under fluoroscopic guidance including contrast injection(s), if performed, image documentation an $ 2,124.43 49465 Contrast injection(s) for radiological evaluation of existing gastrostomy, duodenostomy, jejunostomy, gastro-jejunostomy, or cecostomy (or other colonic) tube, from a percutaneous approach including image documentation and report $ 492.81 49491 Repair, initial inguinal hernia, preterm infant (younger than 37 weeks gestation at birth), performed from birth up to 50 weeks postconception age, with or without hydrocelectomy; reducible $ 1,510.04 49492 Repair, initial inguinal hernia, preterm infant (younger than 37 weeks gestation at birth), performed from birth up to 50 weeks postconception age, with or without hydrocelectomy; incarcerated or strangulated $ 1,735.71 49495 Repair, initial inguinal hernia, full term infant younger than age 6 months, or preterm infant older than 50 weeks postconception age and younger than age 6 months at the time of surgery, with or without hydrocelectomy; reducible $ 1,575.90

Row # CPT-4 HCPCS Price 49496 Repair, initial inguinal hernia, full term infant younger than age 6 months, or preterm infant older than 50 weeks postconception age and younger than age 6 months at the time of surgery, with or without hydrocelectomy; incarcerated or strangulated $ 1,755.00 49500 Repair initial inguinal hernia, age 6 months to younger than 5 years, with or without hydrocelectomy; reducible 49501 Repair initial inguinal hernia, age 6 months to younger than 5 years, with or without hydrocelectomy; incarcerated or strangulated 49505 Repair initial inguinal hernia, age 5 years or older; reducible $ 1,547.55 49507 Repair initial inguinal hernia, age 5 years or older; incarcerated or $ 1,889.72 49520 Repair recurrent inguinal hernia, any age; reducible $ 2,031.30 49521 Repair recurrent inguinal hernia, any age; incarcerated or 49525 Repair inguinal hernia, sliding, any age 49540 Repair lumbar hernia $ 1,574.10 49550 Repair initial femoral hernia, any age; reducible $ 1,616.40 49553 Repair initial femoral hernia, any age; incarcerated or strangulated 49555 Repair recurrent femoral hernia; reducible $ 1,916.10 49557 Repair recurrent femoral hernia; incarcerated or strangulated 49560 Repair initial incisional or ventral hernia; reducible $ 1,978.57 49561 Repair initial incisional or ventral hernia; incarcerated or $ 2,116.80 49565 Repair recurrent incisional or ventral hernia; reducible 49566 Repair recurrent incisional or ventral hernia; incarcerated or $ 2,693.70 49568 Implantation of mesh or other prosthesis for open incisional or ventral hernia repair or mesh for closure of debridement for necrotizing soft tissue infection (List separately in addition to code for the incisional or ventral hernia repair) $ 736.24 49570 Repair epigastric hernia (eg, preperitoneal fat); reducible (separate $ 1,421.10 49572 Repair epigastric hernia (eg, preperitoneal fat); incarcerated or $ 1,670.40 49580 Repair umbilical hernia, younger than age 5 years; reducible $ 1,189.80 49582 Repair umbilical hernia, younger than age 5 years; incarcerated or 49585 Repair umbilical hernia, age 5 years or older; reducible 49587 Repair umbilical hernia, age 5 years or older; incarcerated or $ 1,646.00 49590 Repair spigelian hernia 49600 Repair of small omphalocele, with primary closure 49605 Repair of large omphalocele or gastroschisis; with or without $ 3,263.40 49606 Repair of large omphalocele or gastroschisis; with removal of prosthesis, final reduction and closure, in operating room 49610 Repair of omphalocele (Gross type operation); first stage 49611 Repair of omphalocele (Gross type operation); second stage 49650 Laparoscopy, surgical; repair initial inguinal hernia $ 1,924.20 49651 Laparoscopy, surgical; repair recurrent inguinal hernia $ 2,074.50 49652 Laparoscopy, surgical, repair, ventral, umbilical, spigelian or epigastric hernia (includes mesh insertion, when performed); reducible $ 2,109.14 49653 Laparoscopy, surgical, repair, ventral, umbilical, spigelian or epigastric hernia (includes mesh insertion, when performed); incarcerated or strangulated $ 2,603.68 49654 Laparoscopy, surgical, repair, incisional hernia (includes mesh insertion, when performed); reducible $ 2,373.28 49655 Laparoscopy, surgical, repair, incisional hernia (includes mesh insertion, when performed); incarcerated or strangulated $ 2,891.21 49656 Laparoscopy, surgical, repair, recurrent incisional hernia (includes mesh insertion, when performed); reducible $ 2,400.68

Row # CPT-4 HCPCS Price 49657 Laparoscopy, surgical, repair, recurrent incisional hernia (includes mesh insertion, when performed); incarcerated or strangulated $ 3,469.04 49659 Unlisted laparoscopy procedure, hernioplasty, herniorrhaphy, herniotomy Cost 49900 Suture, secondary, of abdominal wall for evisceration or dehiscence 49904 Omental flap, extra-abdominal (eg, for reconstruction of sternal and chest wall defects) $ 3,010.88 49905 Omental flap, intra-abdominal (List separately in addition to code 49906 Free omental flap with microvascular anastomosis $ - 49999 Unlisted procedure, abdomen, peritoneum and omentum Cost 50010 Renal exploration, not necessitating other specific procedures $ 2,369.70 50020 Drainage of perirenal or renal abscess, open 50040 Nephrostomy, nephrotomy with drainage $ 2,388.60 50045 Nephrotomy, with exploration $ 2,695.50 50060 Nephrolithotomy; removal of calculus $ 3,464.10 50065 Nephrolithotomy; secondary surgical operation for calculus 50070 Nephrolithotomy; complicated by congenital kidney abnormality $ 3,739.50 50075 Nephrolithotomy; removal of large staghorn calculus filling renal pelvis and calyces (including anatrophic pyelolithotomy) $ 3,556.80 50080 Percutaneous nephrostolithotomy or pyelostolithotomy, with or without dilation, endoscopy, lithotripsy, stenting, or basket extraction; up to 2 cm $ 3,374.10 50081 Percutaneous nephrostolithotomy or pyelostolithotomy, with or without dilation, endoscopy, lithotripsy, stenting, or basket extraction; over 2 cm $ 3,953.70 50100 Transection or repositioning of aberrant renal vessels (separate 50120 Pyelotomy; with exploration 50125 Pyelotomy; with drainage, pyelostomy $ 2,860.20 50130 Pyelotomy; with removal of calculus (pyelolithotomy, pelviolithotomy, including coagulum pyelolithotomy) $ 3,258.00 50135 Pyelotomy; complicated (eg, secondary operation, congenital kidney abnormality) $ 3,535.20 50200 Renal biopsy; percutaneous, by trocar or needle $ 563.40 50205 Renal biopsy; by surgical exposure of kidney $ 1,523.70 50220 including rib resection; $ 3,236.40 50225 including rib resection; complicated because of previous surgery on same kidney 50230 including rib resection; radical, with regional lymphadenectomy and/or vena caval thrombectomy $ 4,735.80 50234 Nephrectomy with total ureterectomy and bladder cuff; through same incision 50236 Nephrectomy with total ureterectomy and bladder cuff; through separate incision $ 4,327.20 50240 Nephrectomy, partial $ 3,764.70 50250 Ablation, open, 1 or more renal mass lesion(s), cryosurgical, including intraoperative ultrasound guidance and monitoring, if $ 3,098.95 50280 Excision or unroofing of cyst(s) of kidney $ 2,828.70 50290 Excision of perinephric cyst $ 2,653.20 50300 Donor nephrectomy (including cold preservation); from cadaver donor, unilateral or bilateral $ 2,830.50 50320 Donor nephrectomy (including cold preservation); open, from living donor 50323 Backbench standard preparation of cadaver donor renal allograft prior to transplantation, including dissection and removal of perinephric fat, diaphragmatic and retroperitoneal attachments, excision of adrenal gland, and preparation of ureter(s), renal ve $ -

Row # CPT-4 HCPCS Price 50325 Backbench standard preparation of living donor renal allograft (open or laparoscopic) prior to transplantation, including dissection and removal of perinephric fat and preparation of ureter(s), renal vein(s), and renal artery(s), ligating branches, as nec $ - 50327 prior to transplantation; venous anastomosis, each $ 518.41 50328 prior to transplantation; arterial anastomosis, each $ 452.32 50329 prior to transplantation; ureteral anastomosis, each $ 410.96 50340 Recipient nephrectomy (separate procedure) $ 2,797.20 50360 Renal allotransplantation, implantation of graft; without recipient nephrectomy $ 6,304.50 50365 Renal allotransplantation, implantation of graft; with recipient nephrectomy $ 7,696.80 50370 Removal of transplanted renal allograft $ 2,430.90 50380 Renal autotransplantation, reimplantation of kidney $ 4,360.50 50382 Removal (via snare/capture) and replacement of internally dwelling ureteral stent via percutaneous approach, including radiological supervision and interpretation $ 1,292.64 50384 Removal (via snare/capture) of internally dwelling ureteral stent via percutaneous approach, including radiological supervision and $ 1,139.86 50385 Removal (via snare/capture) and replacement of internally dwelling ureteral stent via transurethral approach, without use of cystoscopy, including radiological supervision and interpretation $ 1,174.03 50386 Removal (via snare/capture) of internally dwelling ureteral stent via transurethral approach, without use of cystoscopy, including radiological supervision and interpretation $ 916.76 50387 Removal and replacement of externally accessible transnephric ureteral stent (eg, external/internal stent) requiring fluoroscopic guidance, including radiological supervision and interpretation $ 540.10 50389 Removal of nephrostomy tube, requiring fluoroscopic guidance (eg, with concurrent indwelling ureteral stent) $ 344.26 50390 Aspiration and/or injection of renal cyst or pelvis by needle, percutaneous $ 465.30 50391 Instillation(s) of therapeutic agent into renal pelvis and/or ureter through established nephrostomy, pyelostomy or ureterostomy tube (eg, anticarcinogenic or antifungal agent) $ 374.44 50392 Introduction of intracatheter or catheter into renal pelvis for drainage and/or injection, percutaneous $ 666.00 50393 Introduction of ureteral catheter or stent into ureter through renal pelvis for drainage and/or injection, percutaneous 50394 Injection procedure for pyelography (as nephrostogram, pyelostogram, antegrade pyeloureterograms) through nephrostomy or pyelostomy tube, or indwelling ureteral catheter $ 221.40 50395 Introduction of guide into renal pelvis and/or ureter with dilation to establish nephrostomy tract, percutaneous 50396 Manometric studies through nephrostomy or pyelostomy tube, or indwelling ureteral catheter 50398 Change of nephrostomy or pyelostomy tube 50400 Pyeloplasty (Foley Y-pyeloplasty), plastic operation on renal pelvis, with or without plastic operation on ureter, nephropexy, nephrostomy, pyelostomy, or ureteral splinting; simple $ 3,541.50 50405 Pyeloplasty (Foley Y-pyeloplasty), plastic operation on renal pelvis, with or without plastic operation on ureter, nephropexy, nephrostomy, pyelostomy, or ureteral splinting; complicated (congenital kidney abnormality, secondary pyeloplasty, solitary kidn $ 3,802.50 50500 Nephrorrhaphy, suture of kidney wound or injury $ 3,298.50 50520 Closure of nephrocutaneous or pyelocutaneous fistula $ 2,853.00

Row # CPT-4 HCPCS Price 50525 Closure of nephrovisceral fistula (eg, renocolic), including visceral repair; abdominal approach $ 3,438.00 50526 Closure of nephrovisceral fistula (eg, renocolic), including visceral repair; thoracic approach 50540 Symphysiotomy for horseshoe kidney with or without pyeloplasty and/or other plastic procedure, unilateral or bilateral (1 operation) $ 4,071.60 50541 Laparoscopy, surgical; ablation of renal cysts $ 2,673.90 50542 Laparoscopy, surgical; ablation of renal mass lesion(s), including intraoperative ultrasound guidance and monitoring, when $ 2,662.34 50543 Laparoscopy, surgical; partial nephrectomy $ 3,268.75 50544 Laparoscopy, surgical; pyeloplasty $ 3,692.70 50545 Laparoscopy, surgical; radical nephrectomy (includes removal of Gerota's fascia and surrounding fatty tissue, removal of regional lymph nodes, and adrenalectomy) $ 3,990.60 50546 Laparoscopy, surgical; nephrectomy, including partial ureterectomy $ 3,727.80 50547 Laparoscopy, surgical; donor nephrectomy (including cold preservation), from living donor $ 4,762.80 50548 Laparoscopy, surgical; nephrectomy with total ureterectomy $ 5,098.50 50549 Unlisted laparoscopy procedure, renal Cost 50551 exclusive of radiologic service; $ 777.60 50553 exclusive of radiologic service; with ureteral catheterization, with or without dilation of ureter $ 774.00 50555 exclusive of radiologic service; with biopsy $ 995.40 50557 exclusive of radiologic service; with fulguration and/or incision, with or without biopsy 50561 exclusive of radiologic service; with removal of foreign body or calculus 50562 exclusive of radiologic service; with resection of tumor $ 1,158.89 50570 $ 1,117.80 50572 radiologic service; with ureteral catheterization, with or without dilation of ureter $ 2,024.10 50574 radiologic service; with biopsy $ 2,061.00 50575 radiologic service; with endopyelotomy (includes cystoscopy, ureteroscopy, dilation of ureter and ureteral pelvic junction, inci $ 2,292.30 50576 radiologic service; with fulguration and/or incision, with or without 50580 radiologic service; with removal of foreign body or calculus 50590 Lithotripsy, extracorporeal shock wave $ 3,424.50

Row # CPT-4 HCPCS Price 50592 Ablation, 1 or more renal tumor(s), percutaneous, unilateral, radiofrequency $ 2,900.54 50593 Ablation, renal tumor(s), unilateral, percutaneous, cryotherapy $ 3,501.52 50600 Ureterotomy with exploration or drainage (separate procedure) $ 2,530.80 50605 Ureterotomy for insertion of indwelling stent, all types $ 2,730.60 50610 Ureterolithotomy; upper one-third of ureter $ 3,156.30 50620 Ureterolithotomy; middle one-third of ureter $ 3,373.20 50630 Ureterolithotomy; lower one-third of ureter 50650 Ureterectomy, with bladder cuff (separate procedure) $ 3,143.70 50660 Ureterectomy, total, ectopic ureter, combination abdominal, vaginal and/or perineal approach 50684 Injection procedure for ureterography or ureteropyelography through ureterostomy or indwelling ureteral catheter 50686 Manometric studies through ureterostomy or indwelling ureteral 50688 Change of ureterostomy tube or externally accessible ureteral stent via ileal conduit 50690 Injection procedure for visualization of ileal conduit and/or ureteropyelography, exclusive of radiologic service $ 143.10 50700 Ureteroplasty, plastic operation on ureter (eg, stricture) $ 2,943.00 50715 Ureterolysis, with or without repositioning of ureter for retroperitoneal fibrosis 50722 Ureterolysis for ovarian vein syndrome 50725 Ureterolysis for retrocaval ureter, with reanastomosis of upper urinary tract or vena cava $ 3,769.20 50727 Revision of urinary-cutaneous anastomosis (any type urostomy); $ 1,869.30 50728 Revision of urinary-cutaneous anastomosis (any type urostomy); with repair of fascial defect and hernia 50740 Ureteropyelostomy, anastomosis of ureter and renal pelvis $ 3,374.10 50750 Ureterocalycostomy, anastomosis of ureter to renal calyx 50760 Ureteroureterostomy $ 3,244.50 50770 Transureteroureterostomy, anastomosis of ureter to contralateral ureter 50780 Ureteroneocystostomy; anastomosis of single ureter to bladder $ 3,356.10 50782 Ureteroneocystostomy; anastomosis of duplicated ureter to bladder $ 3,492.90 50783 Ureteroneocystostomy; with extensive ureteral tailoring 50785 Ureteroneocystostomy; with vesico-psoas hitch or bladder flap $ 3,877.20 50800 Ureteroenterostomy, direct anastomosis of ureter to intestine 50810 Ureterosigmoidostomy, with creation of sigmoid bladder and establishment of abdominal or perineal colostomy, including intestine anastomosis $ 4,635.00 50815 Ureterocolon conduit, including intestine anastomosis $ 4,789.80 50820 Ureteroileal conduit (ileal bladder), including intestine anastomosis (Bricker operation) $ 5,985.00 50825 Continent diversion, including intestine anastomosis using any segment of small and/or large intestine (Kock pouch or Camey enterocystoplasty) 50830 Urinary undiversion (eg, taking down of ureteroileal conduit, ureterosigmoidostomy or ureteroenterostomy with ureteroureterostomy or ureteroneocystostomy) $ 5,469.30 50840 Replacement of all or part of ureter by intestine segment, including intestine anastomosis $ 3,718.80 50845 Cutaneous appendico-vesicostomy $ 4,222.80 50860 Ureterostomy, transplantation of ureter to skin 50900 Ureterorrhaphy, suture of ureter (separate procedure) 50920 Closure of ureterocutaneous fistula $ 2,907.90 50930 Closure of ureterovisceral fistula (including visceral repair) 50940 Deligation of ureter 50945 Laparoscopy, surgical; ureterolithotomy $ 2,889.90 50947 Laparoscopy, surgical; ureteroneocystostomy with cystoscopy and ureteral stent placement $ 4,301.10

Row # CPT-4 HCPCS Price 50948 Laparoscopy, surgical; ureteroneocystostomy without cystoscopy and ureteral stent placement $ 3,933.00 50949 Unlisted laparoscopy procedure, ureter Cost 50951 50953 radiologic service; with ureteral catheterization, with or without dilation of ureter 50955 radiologic service; with biopsy $ 731.70 50957 radiologic service; with fulguration and/or incision, with or without 50961 radiologic service; with removal of foreign body or calculus 50970 50972 service; with ureteral catheterization, with or without dilation of ureter $ 791.10 50974 service; with biopsy 50976 service; with fulguration and/or incision, with or without biopsy $ 1,040.40 50980 service; with removal of foreign body or calculus $ 936.90 51020 Cystotomy or cystostomy; with fulguration and/or insertion of radioactive material $ 1,968.30 51030 Cystotomy or cystostomy; with cryosurgical destruction of intravesical lesion $ 1,923.30 51040 Cystostomy, cystotomy with drainage $ 1,717.20 51045 Cystotomy, with insertion of ureteral catheter or stent (separate $ 1,909.80 51050 Cystolithotomy, cystotomy with removal of calculus, without vesical neck resection 51060 Transvesical ureterolithotomy $ 2,581.20 51065 Cystotomy, with calculus basket extraction and/or ultrasonic or electrohydraulic fragmentation of ureteral calculus 51080 Drainage of perivesical or prevesical space abscess 51100 Aspiration of bladder; by needle $ 178.51 51101 Aspiration of bladder; by trocar or intracatheter $ 271.08 51102 Aspiration of bladder; with insertion of suprapubic catheter $ 591.70 51500 Excision of urachal cyst or sinus, with or without umbilical hernia $ 2,151.00 51520 Cystotomy; for simple excision of vesical neck (separate procedure) 51525 Cystotomy; for excision of bladder diverticulum, single or multiple 51530 Cystotomy; for excision of bladder tumor $ 2,457.00 51535 Cystotomy for excision, incision, or repair of ureterocele $ 2,631.60 51550 Cystectomy, partial; simple $ 2,953.80 51555 Cystectomy, partial; complicated (eg, postradiation, previous surgery, difficult location) $ 3,749.40 51565 Cystectomy, partial, with reimplantation of ureter(s) into bladder (ureteroneocystostomy) $ 4,053.60 51570 Cystectomy, complete; (separate procedure) $ 5,027.40

Row # CPT-4 HCPCS Price 51575 Cystectomy, complete; with bilateral pelvic lymphadenectomy, including external iliac, hypogastric, and obturator nodes $ 6,365.70 51580 Cystectomy, complete, with ureterosigmoidostomy or ureterocutaneous transplantations; $ 5,994.00 51585 Cystectomy, complete, with ureterosigmoidostomy or ureterocutaneous transplantations; with bilateral pelvic $ 6,684.30 51590 Cystectomy, complete, with ureteroileal conduit or sigmoid bladder, including intestine anastomosis; $ 7,559.10 51595 Cystectomy, complete, with ureteroileal conduit or sigmoid bladder, including intestine anastomosis; with bilateral pelvic $ 8,475.30 51596 Cystectomy, complete, with continent diversion, any open technique, using any segment of small and/or large intestine to construct neobladder $ 8,883.90 51597 Pelvic exenteration, complete, for vesical, prostatic or urethral malignancy, with removal of bladder and ureteral transplantations, with or without hysterectomy and/or abdominoperineal resection of rectum and colon and colostomy, or any combination there $ 10,661.40 51600 Injection procedure for cystography or voiding urethrocystography $ 147.60 51605 Injection procedure and placement of chain for contrast and/or chain urethrocystography 51610 Injection procedure for retrograde urethrocystography 51700 Bladder irrigation, simple, lavage and/or instillation $ 116.10 51701 Insertion of non-indwelling bladder catheter (eg, straight catheterization for residual urine) $ 119.17 51702 Insertion of temporary indwelling bladder catheter; simple (eg, Foley) $ 222.55 51705 Change of cystostomy tube; simple 51710 Change of cystostomy tube; complicated $ 319.50 51715 Endoscopic injection of implant material into the submucosal tissues of the urethra and/or bladder neck 51720 Bladder instillation of anticarcinogenic agent (including retention time) 51725 $ 301.50 51725-26 26 51725 $ 253.80 51725-TC TC 51725 $ 187.19 51726 51726-26 26 51726 51726-TC TC 51726 51727 with urethral pressure profile studies (ie, urethral closure pressure profile), any technique $ 686.90 51728 with voiding pressure studies (ie, bladder voiding pressure), any technique $ 686.02 51729 with voiding pressure studies (ie, bladder voiding pressure) and urethral pressure profile studies (ie, urethral closure pressure profile), any technique $ 704.40 51736 51736-26 26 51736 $ 131.40 51736-TC TC 51736 $ 77.28 51741 51741-26 26 51741 51741-TC TC 51741 $ 79.98

Row # CPT-4 HCPCS Price 51784 51784-26 26 51784 $ 201.60 51784-TC TC 51784 $ 148.69 51785 51785-26 26 51785 51785-TC TC 51785 $ 175.98 51792 51792-26 26 51792 51792-TC TC 51792 $ 181.58 51797 51797-26 26 51797 51797-TC TC 51797 $ 166.46 51798 Measurement of post-voiding residual urine and/or bladder capacity by ultrasound, non-imaging $ 51.15 51800 Cystoplasty or cystourethroplasty, plastic operation on bladder and/or vesical neck (anterior Y-plasty, vesical fundus resection), any procedure, with or without wedge resection of posterior vesical neck $ 2,849.40 51820 Cystourethroplasty with unilateral or bilateral ureteroneocystostomy $ 3,780.00 51840 Anterior vesicourethropexy, or urethropexy (eg, Marshall-Marchetti- Krantz, Burch); simple $ 2,495.70 51841 Anterior vesicourethropexy, or urethropexy (eg, Marshall-Marchetti- Krantz, Burch); complicated (eg, secondary repair) 51845 Abdomino-vaginal vesical neck suspension, with or without endoscopic control (eg, Stamey, Raz, modified Pereyra) 51860 Cystorrhaphy, suture of bladder wound, injury or rupture; simple $ 2,200.50 51865 Cystorrhaphy, suture of bladder wound, injury or rupture; $ 2,982.60 51880 Closure of cystostomy (separate procedure) 51900 Closure of vesicovaginal fistula, abdominal approach $ 3,454.20 51920 Closure of vesicouterine fistula; $ 2,559.60 51925 Closure of vesicouterine fistula; with hysterectomy 51940 Closure, exstrophy of bladder 51960 Enterocystoplasty, including intestinal anastomosis $ 4,652.10 51980 Cutaneous vesicostomy $ 2,439.00 51990 Laparoscopy, surgical; urethral suspension for stress incontinence $ 2,447.10 51992 Laparoscopy, surgical; sling operation for stress incontinence (eg, fascia or synthetic) $ 2,637.00 51999 Unlisted laparoscopy procedure, bladder Cost 52000 Cystourethroscopy (separate procedure) $ 405.34 52001 Cystourethroscopy with irrigation and evacuation of multiple obstructing clots $ 676.66 52005 Cystourethroscopy, with ureteral catheterization, with or without 52007 Cystourethroscopy, with ureteral catheterization, with or without service; with brush biopsy of ureter and/or renal pelvis $ 640.80

Row # CPT-4 HCPCS Price 52010 Cystourethroscopy, with ejaculatory duct catheterization, with or without irrigation, instillation, or duct radiography, exclusive of $ 576.00 52204 Cystourethroscopy, with biopsy(s) $ 595.75 52214 surgery) of trigone, bladder neck, prostatic fossa, urethra, or periurethral glands 52224 surgery) or treatment of MINOR (less than 0.5 cm) lesion(s) with or 52234 surgery) and/or resection of; SMALL bladder tumor(s) (0.5 up to 2.0 cm) 52235 surgery) and/or resection of; MEDIUM bladder tumor(s) (2.0 to 5.0 cm) $ 1,761.30 52240 surgery) and/or resection of; LARGE bladder tumor(s) $ 2,543.40 52250 Cystourethroscopy with insertion of radioactive substance, with or without biopsy or fulguration 52260 Cystourethroscopy, with dilation of bladder for interstitial cystitis; general or conduction (spinal) anesthesia $ 592.18 52265 Cystourethroscopy, with dilation of bladder for interstitial cystitis; local anesthesia 52270 Cystourethroscopy, with internal urethrotomy; female $ 819.00 52275 Cystourethroscopy, with internal urethrotomy; male $ 882.00 52276 Cystourethroscopy with direct vision internal urethrotomy $ 1,261.80 52277 Cystourethroscopy, with resection of external sphincter (sphincterotomy) $ 1,206.90 52281 Cystourethroscopy, with calibration and/or dilation of urethral stricture or stenosis, with or without meatotomy, with or without injection procedure for cystography, male or female $ 580.93 52282 Cystourethroscopy, with insertion of permanent urethral stent 52283 Cystourethroscopy, with steroid injection into stricture $ 563.40 52285 Cystourethroscopy for treatment of the female urethral syndrome with any or all of the following: urethral meatotomy, urethral dilation, internal urethrotomy, lysis of urethrovaginal septal fibrosis, lateral incisions of the bladder neck, and fulguration $ 686.56 52290 Cystourethroscopy; with ureteral meatotomy, unilateral or bilateral $ 737.10 52300 Cystourethroscopy; with resection or fulguration of orthotopic ureterocele(s), unilateral or bilateral $ 975.60 52301 Cystourethroscopy; with resection or fulguration of ectopic ureterocele(s), unilateral or bilateral 52305 Cystourethroscopy; with incision or resection of orifice of bladder diverticulum, single or multiple $ 1,019.70 52310 Cystourethroscopy, with removal of foreign body, calculus, or ureteral stent from urethra or bladder (separate procedure); simple $ 751.50 52315 Cystourethroscopy, with removal of foreign body, calculus, or ureteral stent from urethra or bladder (separate procedure); $ 1,328.40 52317 Litholapaxy: crushing or fragmentation of calculus by any means in bladder and removal of fragments; simple or small (less than 2.5 cm) $ 1,377.90 52318 Litholapaxy: crushing or fragmentation of calculus by any means in bladder and removal of fragments; complicated or large (over 2.5 cm) $ 1,948.50 52320 removal of ureteral calculus $ 1,344.60 52325 fragmentation of ureteral calculus (eg, ultrasonic or electro- hydraulic technique) $ 1,559.70 52327 subureteric injection of implant material

Row # CPT-4 HCPCS Price 52330 manipulation, without removal of ureteral calculus 52332 Cystourethroscopy, with insertion of indwelling ureteral stent (eg, Gibbons or double-J type) $ 924.30 52334 Cystourethroscopy with insertion of ureteral guide wire through kidney to establish a percutaneous nephrostomy, retrograde 52341 Cystourethroscopy; with treatment of ureteral stricture (eg, balloon dilation, laser, electrocautery, and incision) $ 1,350.00 52342 Cystourethroscopy; with treatment of ureteropelvic junction $ 1,461.60 52343 Cystourethroscopy; with treatment of intra-renal stricture (eg, balloon dilation, laser, electrocautery, and incision) $ 1,619.10 52344 Cystourethroscopy with ureteroscopy; with treatment of ureteral $ 1,776.60 52345 Cystourethroscopy with ureteroscopy; with treatment of ureteropelvic junction stricture (eg, balloon dilation, laser, electrocautery, and incision) $ 1,845.00 52346 Cystourethroscopy with ureteroscopy; with treatment of intra-renal $ 2,074.50 52351 Cystourethroscopy, with ureteroscopy and/or pyeloscopy; diagnostic $ 1,377.90 52352 removal or manipulation of calculus (ureteral catheterization is included) $ 1,629.42 52353 lithotripsy (ureteral catheterization is included) $ 2,027.72 52354 biopsy and/or fulguration of ureteral or renal pelvic lesion $ 1,728.00 52355 resection of ureteral or renal pelvic tumor $ 2,030.40 52400 Cystourethroscopy with incision, fulguration, or resection of congenital posterior urethral valves, or congenital obstructive hypertrophic mucosal folds $ 2,414.70 52402 Cystourethroscopy with transurethral resection or incision of ejaculatory ducts $ 641.48 52450 Transurethral incision of prostate $ 1,562.40 52500 Transurethral resection of bladder neck (separate procedure) $ 1,719.90 52601 Transurethral electrosurgical resection of prostate, including control of postoperative bleeding, complete (vasectomy, meatotomy, cystourethroscopy, urethral calibration and/or dilation, and internal urethrotomy are included) $ 2,701.80 52630 Transurethral resection; residual or regrowth of obstructive prostate tissue including control of postoperative bleeding, complete (vasectomy, meatotomy, cystourethroscopy, urethral calibration and/or dilation, and internal urethrotomy are included) 52640 Transurethral resection; of postoperative bladder neck contracture $ 2,140.20 52647 Laser coagulation of prostate, including control of postoperative bleeding, complete (vasectomy, meatotomy, cystourethroscopy, urethral calibration and/or dilation, and internal urethrotomy are included if performed) $ 2,169.90 52648 Laser vaporization of prostate, including control of postoperative bleeding, complete (vasectomy, meatotomy, cystourethroscopy, urethral calibration and/or dilation, internal urethrotomy and transurethral resection of prostate are included if performed) 52649 Laser enucleation of the prostate with morcellation, including control of postoperative bleeding, complete (vasectomy, meatotomy, cystourethroscopy, urethral calibration and/or dilation, internal urethrotomy and transurethral resection of prostate are inc $ 2,156.95 52700 Transurethral drainage of prostatic abscess $ 1,305.00

Row # CPT-4 HCPCS Price 53000 Urethrotomy or urethrostomy, external (separate procedure); pendulous urethra 53010 Urethrotomy or urethrostomy, external (separate procedure); perineal urethra, external 53020 Meatotomy, cutting of meatus (separate procedure); except infant $ 583.86 53025 Meatotomy, cutting of meatus (separate procedure); infant 53040 Drainage of deep periurethral abscess $ 692.10 53060 Drainage of Skene's gland abscess or cyst 53080 Drainage of perineal urinary extravasation; uncomplicated (separate $ 761.40 53085 Drainage of perineal urinary extravasation; complicated 53200 Biopsy of urethra 53210 Urethrectomy, total, including cystostomy; female $ 2,104.20 53215 Urethrectomy, total, including cystostomy; male 53220 Excision or fulguration of carcinoma of urethra $ 1,617.30 53230 Excision of urethral diverticulum (separate procedure); female 53235 Excision of urethral diverticulum (separate procedure); male 53240 Marsupialization of urethral diverticulum, male or female $ 852.30 53250 Excision of bulbourethral gland (Cowper's gland) 53260 Excision or fulguration; urethral polyp(s), distal urethra $ 520.20 53265 Excision or fulguration; urethral caruncle 53270 Excision or fulguration; Skene's glands 53275 Excision or fulguration; urethral prolapse $ 622.80 53400 Urethroplasty; first stage, for fistula, diverticulum, or stricture (eg, Johannsen type) 53405 Urethroplasty; second stage (formation of urethra), including urinary diversion $ 2,250.90 53410 Urethroplasty, 1-stage reconstruction of male anterior urethra $ 2,686.50 53415 Urethroplasty, transpubic or perineal, 1-stage, for reconstruction or repair of prostatic or membranous urethra $ 3,239.10 53420 Urethroplasty, 2-stage reconstruction or repair of prostatic or membranous urethra; first stage $ 2,888.10 53425 Urethroplasty, 2-stage reconstruction or repair of prostatic or membranous urethra; second stage $ 2,995.20 53430 Urethroplasty, reconstruction of female urethra $ 2,496.60 53431 Urethroplasty with tubularization of posterior urethra and/or lower bladder for incontinence (eg, Tenago, Leadbetter procedure) $ 2,797.78 53440 Sling operation for correction of male urinary incontinence (eg, fascia or synthetic) $ 2,991.60 53442 Removal or revision of sling for male urinary incontinence (eg, fascia or synthetic) 53444 Insertion of tandem cuff (dual cuff) $ 2,081.89 53445 Insertion of inflatable urethral/bladder neck sphincter, including placement of pump, reservoir, and cuff $ 5,150.70 53446 Removal of inflatable urethral/bladder neck sphincter, including pump, reservoir, and cuff $ 1,825.77 53447 Removal and replacement of inflatable urethral/bladder neck sphincter including pump, reservoir, and cuff at the same operative $ 2,507.40 53448 Removal and replacement of inflatable urethral/bladder neck sphincter including pump, reservoir, and cuff through an infected field at the same operative session including irrigation and debridement of infected tissue $ 3,364.59 53449 Repair of inflatable urethral/bladder neck sphincter, including pump, reservoir, and cuff 53450 Urethromeatoplasty, with mucosal advancement 53460 Urethromeatoplasty, with partial excision of distal urethral segment (Richardson type procedure) 53500 Urethrolysis, transvaginal, secondary, open, including cystourethroscopy (eg, postsurgical obstruction, scarring) $ 1,914.08 53502 Urethrorrhaphy, suture of urethral wound or injury, female $ 1,486.80 53505 Urethrorrhaphy, suture of urethral wound or injury; penile 53510 Urethrorrhaphy, suture of urethral wound or injury; perineal $ 1,917.90

Row # CPT-4 HCPCS Price 53515 Urethrorrhaphy, suture of urethral wound or injury; prostatomembranous 53520 Closure of urethrostomy or urethrocutaneous fistula, male $ 1,213.20 53600 Dilation of urethral stricture by passage of sound or urethral dilator, male; initial $ 154.80 53601 Dilation of urethral stricture by passage of sound or urethral dilator, male; subsequent $ 149.40 53605 Dilation of urethral stricture or vesical neck by passage of sound or urethral dilator, male, general or conduction (spinal) anesthesia $ 230.40 53620 Dilation of urethral stricture by passage of filiform and follower, male; initial $ 218.70 53621 Dilation of urethral stricture by passage of filiform and follower, male; subsequent $ 137.70 53660 Dilation of female urethra including suppository and/or instillation; 53661 Dilation of female urethra including suppository and/or instillation; 53665 Dilation of female urethra, general or conduction (spinal) anesthesia $ 215.10 53850 Transurethral destruction of prostate tissue; by microwave thermotherapy $ 1,637.10 53852 Transurethral destruction of prostate tissue; by radiofrequency thermotherapy $ 1,448.10 53855 Insertion of a temporary prostatic urethral stent, including urethral measurement $ 1,749.79 53899 Unlisted procedure, urinary system Cost 54000 Slitting of prepuce, dorsal or lateral (separate procedure); newborn 54001 Slitting of prepuce, dorsal or lateral (separate procedure); except newborn $ 314.10 54015 Incision and drainage of penis, deep 54050 molluscum contagiosum, herpetic vesicle), simple; chemical $ 134.50 54055 molluscum contagiosum, herpetic vesicle), simple; electrodesiccation $ 271.58 54056 molluscum contagiosum, herpetic vesicle), simple; cryosurgery $ 239.88 54057 molluscum contagiosum, herpetic vesicle), simple; laser surgery $ 601.20 54060 molluscum contagiosum, herpetic vesicle), simple; surgical excision $ 481.62 54065 molluscum contagiosum, herpetic vesicle), extensive (eg, laser surgery, electrosurgery, cryosurgery, chemosurgery) $ 906.65 54100 Biopsy of penis; (separate procedure) $ 266.40 54105 Biopsy of penis; deep structures $ 447.30 54110 Excision of penile plaque (Peyronie disease); $ 1,395.90 54111 Excision of penile plaque (Peyronie disease); with graft to 5 cm in $ 2,362.50 54112 Excision of penile plaque (Peyronie disease); with graft greater than 5 cm in length $ 2,682.90 54115 Removal foreign body from deep penile tissue (eg, plastic implant) $ 1,062.00 54120 Amputation of penis; partial $ 2,043.00 54125 Amputation of penis; complete $ 2,709.00 54130 Amputation of penis, radical; with bilateral inguinofemoral $ 3,754.80 54135 Amputation of penis, radical; in continuity with bilateral pelvic $ 4,963.50 54150 Circumcision, using clamp or other device with regional dorsal penile or ring block $ 272.00

Row # CPT-4 HCPCS Price 54160 Circumcision, surgical excision other than clamp, device, or dorsal slit; neonate (28 days of age or less) $ 403.94 54161 Circumcision, surgical excision other than clamp, device, or dorsal slit; older than 28 days of age $ 860.79 54162 Lysis or excision of penile post-circumcision adhesions $ 426.82 54163 Repair incomplete circumcision $ 415.19 54164 Frenulotomy of penis $ 409.15 54200 Injection procedure for Peyronie disease; 54205 Injection procedure for Peyronie disease; with surgical exposure of plaque 54220 Irrigation of corpora cavernosa for priapism $ 500.40 54230 Injection procedure for corpora cavernosography 54231 Dynamic cavernosometry, including intracavernosal injection of vasoactive drugs (eg, papaverine, phentolamine) 54235 Injection of corpora cavernosa with pharmacologic agent(s) (eg, papaverine, phentolamine) 54240 54240-26 26 54240 54240-TC TC 54240 $ 114.40 54250 $ 354.60 54250-26 26 54250 $ 300.60 54250-TC TC 54250 $ 36.49 54300 Plastic operation of penis for straightening of chordee (eg, hypospadias), with or without mobilization of urethra 54304 Plastic operation on penis for correction of chordee or for first stage hypospadias repair with or without transplantation of prepuce and/or skin flaps $ 2,242.80 54308 urinary diversion); less than 3 cm $ 2,268.00 54312 urinary diversion); greater than 3 cm 54316 urinary diversion) with free skin graft obtained from site other than genitalia $ 3,016.80 54318 Urethroplasty for third stage hypospadias repair to release penis from scrotum (eg, third stage Cecil repair) $ 1,798.20 54322 circumcision); with simple meatal advancement (eg, Magpi, V-flap) $ 2,155.50 54324 circumcision); with urethroplasty by local skin flaps (eg, flip-flap, prepucial flap) $ 2,382.30 54326 circumcision); with urethroplasty by local skin flaps and mobilization of urethra $ 2,894.40 54328 circumcision); with extensive dissection to correct chordee and urethroplasty with local skin flaps, skin graft patch, and/or island flap $ 3,250.80 54332 1-stage proximal penile or penoscrotal hypospadias repair requiring extensive dissection to correct chordee and urethroplasty by use of skin graft tube and/or island flap $ 3,355.20 54336 1-stage perineal hypospadias repair requiring extensive dissection to correct chordee and urethroplasty by use of skin graft tube and/or island flap $ 3,821.40 54340 diverticula); by closure, incision, or excision, simple 54344 diverticula); requiring mobilization of skin flaps and urethroplasty with flap or patch graft $ 2,642.40 54348 diverticula); requiring extensive dissection and urethroplasty with flap, patch or tubed graft (includes urinary diversion) $ 2,793.60 54352 Repair of hypospadias cripple requiring extensive dissection and excision of previously constructed structures including re-release of chordee and reconstruction of urethra and penis by use of local skin as grafts and island flaps and skin brought in as f $ 4,481.10

Row # CPT-4 HCPCS Price 54360 Plastic operation on penis to correct angulation $ 2,171.70 54380 Plastic operation on penis for epispadias distal to external sphincter; $ 1,931.40 54385 Plastic operation on penis for epispadias distal to external sphincter; with incontinence $ 2,791.80 54390 Plastic operation on penis for epispadias distal to external sphincter; with exstrophy of bladder $ 3,728.70 54400 Insertion of penile prosthesis; non-inflatable (semi-rigid) $ 2,731.50 54401 Insertion of penile prosthesis; inflatable (self-contained) 54405 Insertion of multi-component, inflatable penile prosthesis, including placement of pump, cylinders, and reservoir $ 4,616.10 54406 Removal of all components of a multi-component, inflatable penile prosthesis without replacement of prosthesis $ 1,880.16 54408 Repair of component(s) of a multi-component, inflatable penile $ 1,921.58 54410 Removal and replacement of all component(s) of a multi- component, inflatable penile prosthesis at the same operative $ 2,100.99 54411 Removal and replacement of all components of a multi-component inflatable penile prosthesis through an infected field at the same operative session, including irrigation and debridement of infected tissue $ 2,627.25 54415 Removal of non-inflatable (semi-rigid) or inflatable (self-contained) penile prosthesis, without replacement of prosthesis $ 1,371.75 54416 Removal and replacement of non-inflatable (semi-rigid) or inflatable (self-contained) penile prosthesis at the same operative session $ 1,604.70 54417 Removal and replacement of non-inflatable (semi-rigid) or inflatable (self-contained) penile prosthesis through an infected field at the same operative session, including irrigation and debridement of infected tissue $ 2,244.96 54420 Corpora cavernosa-saphenous vein shunt (priapism operation), unilateral or bilateral 54430 Corpora cavernosa-corpus spongiosum shunt (priapism operation), unilateral or bilateral $ 2,107.80 54435 Corpora cavernosa-glans penis fistulization (eg, biopsy needle, Winter procedure, rongeur, or punch) for priapism $ 1,043.10 54440 Plastic operation of penis for injury $ 2,582.10 54450 Foreskin manipulation including lysis of preputial adhesions and stretching $ 306.90 54500 Biopsy of testis, needle (separate procedure) $ 216.90 54505 Biopsy of testis, incisional (separate procedure) $ 644.40 54512 Excision of extraparenchymal lesion of testis 54520 Orchiectomy, simple (including subcapsular), with or without testicular prosthesis, scrotal or inguinal approach $ 1,175.40 54522 Orchiectomy, partial $ 1,944.00 54530 Orchiectomy, radical, for tumor; inguinal approach 54535 Orchiectomy, radical, for tumor; with abdominal exploration 54550 Exploration for undescended testis (inguinal or scrotal area) $ 1,594.80 54560 Exploration for undescended testis with abdominal exploration $ 1,918.80 54600 Reduction of torsion of testis, surgical, with or without fixation of contralateral testis $ 1,393.65 54620 Fixation of contralateral testis (separate procedure) $ 835.20 54640 Orchiopexy, inguinal approach, with or without hernia repair $ 1,790.10 54650 Orchiopexy, abdominal approach, for intra-abdominal testis (eg, Fowler-Stephens) $ 2,026.80 54660 Insertion of testicular prosthesis (separate procedure) $ 810.90 54670 Suture or repair of testicular injury 54680 Transplantation of testis(es) to thigh (because of scrotal destruction) 54690 Laparoscopy, surgical; orchiectomy $ 1,737.90 54692 Laparoscopy, surgical; orchiopexy for intra-abdominal testis $ 1,801.80 54699 Unlisted laparoscopy procedure, testis Cost 54700 Incision and drainage of epididymis, testis and/or scrotal space (eg, abscess or hematoma) $ 458.10

Row # CPT-4 HCPCS Price 54800 Biopsy of epididymis, needle 54830 Excision of local lesion of epididymis $ 927.90 54840 Excision of spermatocele, with or without epididymectomy $ 1,296.00 54860 Epididymectomy; unilateral $ 1,228.50 54861 Epididymectomy; bilateral $ 1,728.00 54865 Exploration of epididymis, with or without biopsy $ 355.87 54900 Epididymovasostomy, anastomosis of epididymis to vas deferens; $ 2,325.60 54901 Epididymovasostomy, anastomosis of epididymis to vas deferens; bilateral 55000 Puncture aspiration of hydrocele, tunica vaginalis, with or without injection of medication 55040 Excision of hydrocele; unilateral $ 1,405.80 55041 Excision of hydrocele; bilateral $ 2,132.10 55060 Repair of tunica vaginalis hydrocele (Bottle type) 55100 Drainage of scrotal wall abscess 55110 Scrotal exploration $ 1,147.50 55120 Removal of foreign body in scrotum $ 633.60 55150 Resection of scrotum 55175 Scrotoplasty; simple $ 1,220.40 55180 Scrotoplasty; complicated 55200 Vasotomy, cannulization with or without incision of vas, unilateral or bilateral (separate procedure) $ 648.90 55250 Vasectomy, unilateral or bilateral (separate procedure), including postoperative semen examination(s) 55300 Vasotomy for vasograms, seminal vesiculograms, or epididymograms, unilateral or bilateral 55400 Vasovasostomy, vasovasorrhaphy 55450 Ligation (percutaneous) of vas deferens, unilateral or bilateral 55500 Excision of hydrocele of spermatic cord, unilateral (separate $ 1,228.50 55520 Excision of lesion of spermatic cord (separate procedure) $ 1,085.40 55530 $ 1,527.30 55535 $ 1,635.30 55540 with hernia repair $ 1,801.80 55550 Laparoscopy, surgical, with ligation of spermatic veins for varicocele $ 1,717.20 55559 Unlisted laparoscopy procedure, spermatic cord Cost 55600 Vesiculotomy; $ 1,231.20 55605 Vesiculotomy; complicated 55650 Vesiculectomy, any approach $ 2,868.30 55680 Excision of Mullerian duct cyst $ 2,533.50 55700 Biopsy, prostate; needle or punch, single or multiple, any approach $ 395.58 55705 Biopsy, prostate; incisional, any approach 55706 Biopsies, prostate, needle, transperineal, stereotactic template guided saturation sampling, including imaging guidance $ 1,380.90 55720 Prostatotomy, external drainage of prostatic abscess, any approach; $ 1,424.70 55725 Prostatotomy, external drainage of prostatic abscess, any approach; $ 1,768.50 55801 Prostatectomy, perineal, subtotal (including control of postoperative bleeding, vasectomy, meatotomy, urethral calibration and/or dilation, and internal urethrotomy) 55810 Prostatectomy, perineal radical; $ 3,842.10 55812 Prostatectomy, perineal radical; with lymph node biopsy(s) (limited pelvic lymphadenectomy) $ 4,482.00 55815 Prostatectomy, perineal radical; with bilateral pelvic $ 6,071.40 55821 Prostatectomy (including control of postoperative bleeding, vasectomy, meatotomy, urethral calibration and/or dilation, and internal urethrotomy); suprapubic, subtotal, 1 or 2 stages $ 3,183.30

Row # CPT-4 HCPCS Price 55831 Prostatectomy (including control of postoperative bleeding, vasectomy, meatotomy, urethral calibration and/or dilation, and internal urethrotomy); retropubic, subtotal $ 3,345.30 55840 $ 3,969.90 55842 with lymph node biopsy(s) (limited pelvic lymphadenectomy) $ 4,228.20 55845 with bilateral pelvic lymphadenectomy, including external iliac, hypogastric, and obturator nodes $ 5,271.39 55860 substance; $ 2,182.50 55862 substance; with lymph node biopsy(s) (limited pelvic $ 3,091.50 55865 substance; with bilateral pelvic lymphadenectomy, including external iliac, hypogastric and obturator nodes $ 3,793.50 55866 Laparoscopy, surgical prostatectomy, retropubic radical, including nerve sparing, includes robotic assistance, when performed $ 4,611.87 55870 Electroejaculation 55873 Cryosurgical ablation of the prostate (includes ultrasonic guidance and monitoring) $ 2,685.60 55875 Transperineal placement of needles or catheters into prostate for interstitial radioelement application, with or without cystoscopy $ 1,796.65 55876 (eg, fiducial markers, dosimeter), prostate (via needle, any approach), single or multiple $ 323.66 55899 Unlisted procedure, male genital system Cost 55920 Placement of needles or catheters into pelvic organs and/or genitalia (except prostate) for subsequent interstitial radioelement application $ 1,072.06 55970 Intersex surgery; male to female $ - 55980 Intersex surgery; female to male $ - 56405 Incision and drainage of vulva or perineal abscess $ 259.20 56420 Incision and drainage of Bartholin's gland abscess $ 243.90 56440 Marsupialization of Bartholin's gland cyst 56441 Lysis of labial adhesions 56442 Hymenotomy, simple incision $ 126.23 56501 Destruction of lesion(s), vulva; simple (eg, laser surgery, $ 259.47 56515 Destruction of lesion(s), vulva; extensive (eg, laser surgery, $ 850.10 56605 Biopsy of vulva or perineum (separate procedure); 1 lesion $ 199.48 56606 Biopsy of vulva or perineum (separate procedure); each separate additional lesion (List separately in addition to code for primary 56620 Vulvectomy simple; partial $ 2,186.10 56625 Vulvectomy simple; complete 56630 Vulvectomy, radical, partial; $ 3,249.90 56631 Vulvectomy, radical, partial; with unilateral inguinofemoral $ 4,042.80 56632 Vulvectomy, radical, partial; with bilateral inguinofemoral $ 4,846.50 56633 Vulvectomy, radical, complete; $ 4,097.70 56634 Vulvectomy, radical, complete; with unilateral inguinofemoral $ 4,748.40 56637 Vulvectomy, radical, complete; with bilateral inguinofemoral $ 5,682.60 56640 Vulvectomy, radical, complete, with inguinofemoral, iliac, and pelvic $ 5,745.60 56700 Partial hymenectomy or revision of hymenal ring $ 637.20 56740 Excision of Bartholin's gland or cyst $ 920.70 56800 Plastic repair of introitus $ 898.20 56805 Clitoroplasty for intersex state $ 2,296.80

Row # CPT-4 HCPCS Price 56810 Perineoplasty, repair of perineum, nonobstetrical (separate $ 1,035.90 56820 Colposcopy of the vulva; $ 198.44 56821 Colposcopy of the vulva; with biopsy(s) $ 293.12 57000 Colpotomy; with exploration 57010 Colpotomy; with drainage of pelvic abscess 57020 Colpocentesis (separate procedure) $ 249.30 57022 Incision and drainage of vaginal hematoma; obstetrical/postpartum 57023 Incision and drainage of vaginal hematoma; non-obstetrical (eg, post-trauma, spontaneous bleeding) 57061 Destruction of vaginal lesion(s); simple (eg, laser surgery, $ 442.80 57065 Destruction of vaginal lesion(s); extensive (eg, laser surgery, $ 1,008.47 57100 Biopsy of vaginal mucosa; simple (separate procedure) 57105 Biopsy of vaginal mucosa; extensive, requiring suture (including cysts) 57106 Vaginectomy, partial removal of vaginal wall; $ 1,195.20 57107 Vaginectomy, partial removal of vaginal wall; with removal of paravaginal tissue (radical vaginectomy) $ 3,107.70 57109 Vaginectomy, partial removal of vaginal wall; with removal of paravaginal tissue (radical vaginectomy) with bilateral total pelvic $ 3,578.40 57110 Vaginectomy, complete removal of vaginal wall; $ 2,316.60 57111 Vaginectomy, complete removal of vaginal wall; with removal of paravaginal tissue (radical vaginectomy) $ 3,666.60 57112 Vaginectomy, complete removal of vaginal wall; with removal of paravaginal tissue (radical vaginectomy) with bilateral total pelvic $ 3,849.30 57120 Colpocleisis (Le Fort type) $ 2,274.30 57130 Excision of vaginal septum $ 940.50 57135 Excision of vaginal cyst or tumor $ 710.87 57150 Irrigation of vagina and/or application of medicament for treatment of bacterial, parasitic, or fungoid disease 57155 Insertion of uterine tandem and/or vaginal ovoids for clinical brachytherapy $ 1,064.04 57160 Fitting and insertion of pessary or other intravaginal support device 57170 Diaphragm or cervical cap fitting with instructions $ 99.00 57180 Introduction of any hemostatic agent or pack for spontaneous or traumatic nonobstetrical vaginal hemorrhage (separate procedure) 57200 Colporrhaphy, suture of injury of vagina (nonobstetrical) 57210 Colpoperineorrhaphy, suture of injury of vagina and/or perineum (nonobstetrical) 57220 Plastic operation on urethral sphincter, vaginal approach (eg, Kelly urethral plication) 57230 Plastic repair of urethrocele 57240 Anterior colporrhaphy, repair of cystocele with or without repair of urethrocele 57250 Posterior colporrhaphy, repair of rectocele with or without perineorrhaphy $ 1,559.70 57260 Combined anteroposterior colporrhaphy; $ 2,090.70 57265 Combined anteroposterior colporrhaphy; with enterocele repair $ 2,418.62 57267 Insertion of mesh or other prosthesis for repair of pelvic floor defect, each site (anterior, posterior compartment), vaginal approach (List separately in addition to code for primary procedure) $ 693.09 57268 Repair of enterocele, vaginal approach (separate procedure) $ 1,725.30 57270 Repair of enterocele, abdominal approach (separate procedure) $ 2,124.90 57280 Colpopexy, abdominal approach 57282 Colpopexy, vaginal; extra-peritoneal approach (sacrospinous, iliococcygeus)

Row # CPT-4 HCPCS Price 57283 Colpopexy, vaginal; intra-peritoneal approach (uterosacral, levator myorrhaphy) $ 1,612.15 57284 Paravaginal defect repair (including repair of cystocele, if performed); open abdominal approach 57287 Removal or revision of sling for stress incontinence (eg, fascia or synthetic) $ 2,081.70 57288 Sling operation for stress incontinence (eg, fascia or synthetic) 57289 Pereyra procedure, including anterior colporrhaphy $ 2,429.10 57291 Construction of artificial vagina; without graft 57292 Construction of artificial vagina; with graft $ 3,924.90 57295 Revision (including removal) of prosthetic vaginal graft; vaginal $ 1,167.58 57296 Revision (including removal) of prosthetic vaginal graft; open $ 2,490.17 57300 Closure of rectovaginal fistula; vaginal or transanal approach $ 1,933.20 57305 Closure of rectovaginal fistula; abdominal approach 57307 Closure of rectovaginal fistula; abdominal approach, with concomitant colostomy $ 2,581.20 57308 Closure of rectovaginal fistula; transperineal approach, with perineal body reconstruction, with or without levator plication 57310 Closure of urethrovaginal fistula; 57311 Closure of urethrovaginal fistula; with bulbocavernosus transplant 57320 Closure of vesicovaginal fistula; vaginal approach 57330 Closure of vesicovaginal fistula; transvesical and vaginal approach 57335 Vaginoplasty for intersex state $ 3,069.90 57400 Dilation of vagina under anesthesia (other than local) $ 370.80 57410 Pelvic examination under anesthesia (other than local) 57415 Removal of impacted vaginal foreign body (separate procedure) under anesthesia (other than local) $ 415.80 57420 Colposcopy of the entire vagina, with cervix if present; $ 238.08 57421 Colposcopy of the entire vagina, with cervix if present; with biopsy(s) of vagina/cervix $ 339.81 57423 Paravaginal defect repair (including repair of cystocele, if performed), laparoscopic approach $ 2,061.99 57425 Laparoscopy, surgical, colpopexy (suspension of vaginal apex) $ 2,099.02 57426 Revision (including removal) of prosthetic vaginal graft, laparoscopic $ 1,885.00 57452 Colposcopy of the cervix including upper/adjacent vagina; $ 242.93 57454 biopsy(s) of the cervix and endocervical curettage $ 343.46 57455 biopsy(s) of the cervix $ 169.72 57456 endocervical curettage $ 187.31 57460 Colposcopy of the cervix including upper/adjacent vagina; with loop electrode biopsy(s) of the cervix $ 953.23 57461 Colposcopy of the cervix including upper/adjacent vagina; with loop electrode conization of the cervix $ 893.18 57500 Biopsy of cervix, single or multiple, or local excision of lesion, with or without fulguration (separate procedure) $ 251.05 57505 Endocervical curettage (not done as part of a dilation and curettage) $ 221.40 57510 Cautery of cervix; electro or thermal $ 308.03 57511 Cautery of cervix; cryocautery, initial or repeat $ 287.10 57513 Cautery of cervix; laser ablation 57520 Conization of cervix, with or without fulguration, with or without dilation and curettage, with or without repair; cold knife or laser $ 1,079.10 57522 Conization of cervix, with or without fulguration, with or without dilation and curettage, with or without repair; loop electrode excision $ 1,080.48 57530 Trachelectomy (cervicectomy), amputation of cervix (separate $ 979.20

Row # CPT-4 HCPCS Price 57531 Radical trachelectomy, with bilateral total pelvic lymphadenectomy and para-aortic lymph node sampling biopsy, with or without $ 4,499.10 57540 Excision of cervical stump, abdominal approach; $ 2,022.30 57545 Excision of cervical stump, abdominal approach; with pelvic floor 57550 Excision of cervical stump, vaginal approach; 57555 Excision of cervical stump, vaginal approach; with anterior and/or posterior repair $ 2,096.10 57556 Excision of cervical stump, vaginal approach; with repair of $ 2,295.90 57558 Dilation and curettage of cervical stump $ 286.85 57700 Cerclage of uterine cervix, nonobstetrical 57720 Trachelorrhaphy, plastic repair of uterine cervix, vaginal approach $ 1,098.90 57800 Dilation of cervical canal, instrumental (separate procedure) 58100 Endometrial sampling (biopsy) with or without endocervical sampling (biopsy), without cervical dilation, any method (separate $ 266.06 58110 Endometrial sampling (biopsy) performed in conjunction with colposcopy (List separately in addition to code for primary $ 146.06 58120 Dilation and curettage, diagnostic and/or therapeutic (nonobstetrical) $ 903.20 58140 Myomectomy, excision of fibroid tumor(s) of uterus, 1 to 4 intramural myoma(s) with total weight of 250 g or less and/or removal of surface myomas; abdominal approach $ 2,851.59 58145 Myomectomy, excision of fibroid tumor(s) of uterus, 1 to 4 intramural myoma(s) with total weight of 250 g or less and/or removal of surface myomas; vaginal approach $ 2,299.50 58146 Myomectomy, excision of fibroid tumor(s) of uterus, 5 or more intramural myomas and/or intramural myomas with total weight greater than 250 g, abdominal approach $ 2,845.00 58150 Total abdominal hysterectomy (corpus and cervix), with or without $ 3,175.21 58152 Total abdominal hysterectomy (corpus and cervix), with or without removal of tube(s), with or without removal of ovary(s); with colpo- urethrocystopexy (eg, Marshall-Marchetti-Krantz, Burch) 58180 Supracervical abdominal hysterectomy (subtotal hysterectomy), with or without removal of tube(s), with or without removal of ovary(s) $ 3,280.50 58200 Total abdominal hysterectomy, including partial vaginectomy, with para-aortic and pelvic lymph node sampling, with or without $ 3,940.20 58210 Radical abdominal hysterectomy, with bilateral total pelvic with or without removal of tube(s), with or without removal of ovary(s) $ 6,048.90 58240 Pelvic exenteration for gynecologic malignancy, with total abdominal hysterectomy or cervicectomy, with or without removal of tube(s), with or without removal of ovary(s), with removal of bladder and ureteral transplantations, and/or abdominoperineal rese $ 8,435.70 58260 Vaginal hysterectomy, for uterus 250 g or less; $ 3,085.20 58262 Vaginal hysterectomy, for uterus 250 g or less; with removal of tube(s), and/or ovary(s) 58263 Vaginal hysterectomy, for uterus 250 g or less; with removal of tube(s), and/or ovary(s), with repair of enterocele $ 3,879.90 58267 Vaginal hysterectomy, for uterus 250 g or less; with colpo- urethrocystopexy (Marshall-Marchetti-Krantz type, Pereyra type) with or without endoscopic control $ 3,544.20 58270 Vaginal hysterectomy, for uterus 250 g or less; with repair of $ 3,762.90 58275 Vaginal hysterectomy, with total or partial vaginectomy;

Row # CPT-4 HCPCS Price 58280 Vaginal hysterectomy, with total or partial vaginectomy; with repair of enterocele $ 3,493.80 58285 Vaginal hysterectomy, radical (Schauta type operation) $ 3,948.30 58290 Vaginal hysterectomy, for uterus greater than 250 g; $ 3,249.20 58291 Vaginal hysterectomy, for uterus greater than 250 g; with removal of tube(s) and/or ovary(s) $ 3,588.32 58292 Vaginal hysterectomy, for uterus greater than 250 g; with removal of tube(s) and/or ovary(s), with repair of enterocele $ 3,867.52 58293 Vaginal hysterectomy, for uterus greater than 250 g; with colpo- urethrocystopexy (Marshall-Marchetti-Krantz type, Pereyra type) with or without endoscopic control $ 4,011.49 58294 Vaginal hysterectomy, for uterus greater than 250 g; with repair of $ 3,502.18 58300 Insertion of intrauterine device (IUD) $ 308.70 58301 Removal of intrauterine device (IUD) 58321 Artificial insemination; intra-cervical $ 183.60 58322 Artificial insemination; intra-uterine 58323 Sperm washing for artificial insemination $ 200.70 58340 Catheterization and introduction of saline or contrast material for saline infusion sonohysterography (SIS) or hysterosalpingography $ 279.39 58345 Transcervical introduction of fallopian tube catheter for diagnosis and/or re-establishing patency (any method), with or without hysterosalpingography $ 1,163.70 58346 Insertion of Heyman capsules for clinical brachytherapy $ 1,416.42 58350 Chromotubation of oviduct, including materials 58353 Endometrial ablation, thermal, without hysteroscopic guidance 58356 Endometrial cryoablation with ultrasonic guidance, including endometrial curettage, when performed $ 2,930.73 58400 Uterine suspension, with or without shortening of round ligaments, with or without shortening of sacrouterine ligaments; (separate $ 1,903.50 58410 Uterine suspension, with or without shortening of round ligaments, with or without shortening of sacrouterine ligaments; with presacral sympathectomy $ 2,566.80 58520 Hysterorrhaphy, repair of ruptured uterus (nonobstetrical) 58540 Hysteroplasty, repair of uterine anomaly (Strassman type) 58541 Laparoscopy, surgical, supracervical hysterectomy, for uterus 250 g $ 2,275.20 58542 Laparoscopy, surgical, supracervical hysterectomy, for uterus 250 g or less; with removal of tube(s) and/or ovary(s) $ 2,512.31 58543 Laparoscopy, surgical, supracervical hysterectomy, for uterus greater than 250 g; $ 2,546.70 58544 Laparoscopy, surgical, supracervical hysterectomy, for uterus greater than 250 g; with removal of tube(s) and/or ovary(s) $ 2,839.57 58545 Laparoscopy, surgical, myomectomy, excision; 1 to 4 intramural myomas with total weight of 250 g or less and/or removal of surface myomas $ 2,496.86 58546 Laparoscopy, surgical, myomectomy, excision; 5 or more intramural myomas and/or intramural myomas with total weight greater than 250 g $ 3,009.13 58548 Laparoscopy, surgical, with radical hysterectomy, with bilateral total pelvic lymphadenectomy and para-aortic lymph node sampling (biopsy), with removal of tube(s) and ovary(s), if performed $ 4,382.63 58550 Laparoscopy, surgical, with vaginal hysterectomy, for uterus 250 g $ 3,277.49 58552 Laparoscopy, surgical, with vaginal hysterectomy, for uterus 250 g or less; with removal of tube(s) and/or ovary(s) $ 2,608.28 58553 Laparoscopy, surgical, with vaginal hysterectomy, for uterus greater than 250 g; $ 3,010.69 58554 Laparoscopy, surgical, with vaginal hysterectomy, for uterus greater than 250 g; with removal of tube(s) and/or ovary(s) $ 3,357.56 58555 Hysteroscopy, diagnostic (separate procedure) $ 857.70 58558 Hysteroscopy, surgical; with sampling (biopsy) of endometrium and/or polypectomy, with or without D & C $ 1,402.27

Row # CPT-4 HCPCS Price 58559 Hysteroscopy, surgical; with lysis of intrauterine adhesions (any 58560 Hysteroscopy, surgical; with division or resection of intrauterine septum (any method) 58561 Hysteroscopy, surgical; with removal of leiomyomata $ 2,065.50 58562 Hysteroscopy, surgical; with removal of impacted foreign body 58563 Hysteroscopy, surgical; with endometrial ablation (eg, endometrial resection, electrosurgical ablation, thermoablation) $ 2,528.26 58565 Hysteroscopy, surgical; with bilateral fallopian tube cannulation to induce occlusion by placement of permanent implants $ 4,424.15 58570 Laparoscopy, surgical, with total hysterectomy, for uterus 250 g or less; $ 2,503.83 58571 Laparoscopy, surgical, with total hysterectomy, for uterus 250 g or less; with removal of tube(s) and/or ovary(s) $ 2,801.61 58572 Laparoscopy, surgical, with total hysterectomy, for uterus greater than 250 g; $ 3,013.79 58573 Laparoscopy, surgical, with total hysterectomy, for uterus greater than 250 g; with removal of tube(s) and/or ovary(s) $ 3,509.08 58578 Unlisted laparoscopy procedure, uterus Cost 58579 Unlisted hysteroscopy procedure, uterus Cost 58600 Ligation or transection of fallopian tube(s), abdominal or vaginal approach, unilateral or bilateral $ 1,508.40 58605 Ligation or transection of fallopian tube(s), abdominal or vaginal approach, postpartum, unilateral or bilateral, during same hospitalization (separate procedure) $ 1,312.20 58611 Ligation or transection of fallopian tube(s) when done at the time of cesarean delivery or intra-abdominal surgery (not a separate $ 861.75 58615 Occlusion of fallopian tube(s) by device (eg, band, clip, Falope ring) vaginal or suprapubic approach 58660 Laparoscopy, surgical; with lysis of adhesions (salpingolysis, ovariolysis) (separate procedure) $ 2,250.71 58661 Laparoscopy, surgical; with removal of adnexal structures (partial or total oophorectomy and/or salpingectomy) 58662 Laparoscopy, surgical; with fulguration or excision of lesions of the ovary, pelvic viscera, or peritoneal surface by any method $ 2,523.37 58670 Laparoscopy, surgical; with fulguration of oviducts (with or without transection) 58671 Laparoscopy, surgical; with occlusion of oviducts by device (eg, band, clip, or Falope ring) 58672 Laparoscopy, surgical; with fimbrioplasty 58673 Laparoscopy, surgical; with salpingostomy (salpingoneostomy) 58679 Unlisted laparoscopy procedure, oviduct, ovary Cost 58700 Salpingectomy, complete or partial, unilateral or bilateral (separate 58720 Salpingo-oophorectomy, complete or partial, unilateral or bilateral $ 2,178.51 58740 Lysis of adhesions (salpingolysis, ovariolysis) $ 2,415.84 58750 Tubotubal anastomosis $ 3,936.60 58752 Tubouterine implantation 58760 Fimbrioplasty 58770 Salpingostomy (salpingoneostomy) 58800 Drainage of ovarian cyst(s), unilateral or bilateral (separate procedure); vaginal approach 58805 Drainage of ovarian cyst(s), unilateral or bilateral (separate procedure); abdominal approach $ 1,800.90 58820 Drainage of ovarian abscess; vaginal approach, open 58822 Drainage of ovarian abscess; abdominal approach $ 1,772.10 58825 Transposition, ovary(s) 58900 Biopsy of ovary, unilateral or bilateral (separate procedure) 58920 Wedge resection or bisection of ovary, unilateral or bilateral $ 2,329.20 58925 Ovarian cystectomy, unilateral or bilateral $ 2,331.00 58940 Oophorectomy, partial or total, unilateral or bilateral; $ 2,069.10

Row # CPT-4 HCPCS Price 58943 Oophorectomy, partial or total, unilateral or bilateral; for ovarian, tubal or primary peritoneal malignancy, with para-aortic and pelvic lymph node biopsies, peritoneal washings, peritoneal biopsies, diaphragmatic assessments, with or without salpingecto $ 3,457.80 58950 with bilateral salpingo-oophorectomy and omentectomy; $ 3,549.60 58951 with bilateral salpingo-oophorectomy and omentectomy; with total abdominal hysterectomy, pelvic and limited para-aortic 58952 with bilateral salpingo-oophorectomy and omentectomy; with radical dissection for debulking (ie, radical excision or destruction, intra-abdominal or retroperitoneal tumors) $ 5,935.50 58953 Bilateral salpingo-oophorectomy with omentectomy, total abdominal hysterectomy and radical dissection for debulking; $ 7,745.77 58954 Bilateral salpingo-oophorectomy with omentectomy, total abdominal hysterectomy and radical dissection for debulking; with pelvic lymphadenectomy and limited para-aortic lymphadenectomy $ 8,407.75 58956 Bilateral salpingo-oophorectomy with total omentectomy, total abdominal hysterectomy for malignancy $ 5,467.49 58957 Resection (tumor debulking) of recurrent ovarian, tubal, primary peritoneal, uterine malignancy (intra-abdominal, retroperitoneal tumors), with omentectomy, if performed; $ 5,807.52 58958 Resection (tumor debulking) of recurrent ovarian, tubal, primary peritoneal, uterine malignancy (intra-abdominal, retroperitoneal tumors), with omentectomy, if performed; with pelvic lymphadenectomy and limited para-aortic lymphadenectomy $ 6,432.44 58960 Laparotomy, for staging or restaging of ovarian, tubal, or primary peritoneal malignancy (second look), with or without omentectomy, peritoneal washing, biopsy of abdominal and pelvic peritoneum, diaphragmatic assessment with pelvic and limited para-aorti $ 3,839.96 58970 Follicle puncture for oocyte retrieval, any method $ 1,406.70 58974 Embryo transfer, intrauterine 58976 Gamete, zygote, or embryo intrafallopian transfer, any method 58999 Unlisted procedure, female genital system (nonobstetrical) Cost 59000 Amniocentesis; diagnostic $ 332.21 59001 Amniocentesis; therapeutic amniotic fluid reduction (includes ultrasound guidance) $ 440.43 59012 Cordocentesis (intrauterine), any method 59015 Chorionic villus sampling, any method 59020 $ 178.81 59020-26 26 59020 $ 90.59 59020-TC TC 59020 $ 88.22 59025 $ 115.69 59025-26 26 59025 $ 69.45 59025-TC TC 59025 $ 46.24 59030 Fetal scalp blood sampling $ 194.40 59050 Fetal monitoring during labor by consulting physician (ie, non- attending physician) with written report; supervision and $ 285.30 59051 Fetal monitoring during labor by consulting physician (ie, non- attending physician) with written report; interpretation only $ 109.29 59070 Transabdominal amnioinfusion, including ultrasound guidance $ 959.77 59072 Fetal umbilical cord occlusion, including ultrasound guidance $ 1,227.78 59074 Fetal fluid drainage (eg, vesicocentesis, thoracocentesis, paracentesis), including ultrasound guidance $ 935.82 59076 Fetal shunt placement, including ultrasound guidance $ 1,204.41

Row # CPT-4 HCPCS Price 59100 Hysterotomy, abdominal (eg, for hydatidiform mole, abortion) $ 1,908.00 59120 Surgical treatment of ectopic pregnancy; tubal or ovarian, requiring salpingectomy and/or oophorectomy, abdominal or vaginal $ 2,453.40 59121 Surgical treatment of ectopic pregnancy; tubal or ovarian, without salpingectomy and/or oophorectomy $ 2,041.20 59130 Surgical treatment of ectopic pregnancy; abdominal pregnancy $ 2,061.90 59135 Surgical treatment of ectopic pregnancy; interstitial, uterine pregnancy requiring total hysterectomy $ 2,800.80 59136 Surgical treatment of ectopic pregnancy; interstitial, uterine pregnancy with partial resection of uterus $ 2,285.10 59140 Surgical treatment of ectopic pregnancy; cervical, with evacuation $ 1,562.40 59150 Laparoscopic treatment of ectopic pregnancy; without salpingectomy and/or oophorectomy 59151 Laparoscopic treatment of ectopic pregnancy; with salpingectomy and/or oophorectomy $ 2,414.78 59160 Curettage, postpartum 59200 Insertion of cervical dilator (eg, laminaria, prostaglandin) (separate $ 276.79 59300 Episiotomy or vaginal repair, by other than attending 59320 Cerclage of cervix, during pregnancy; vaginal $ 1,122.47 59325 Cerclage of cervix, during pregnancy; abdominal 59350 Hysterorrhaphy of ruptured uterus $ 2,176.20 59400 Routine obstetric care including antepartum care, vaginal delivery (with or without episiotomy, and/or forceps) and postpartum care 59409 Vaginal delivery only (with or without episiotomy and/or forceps); $ 1,588.98 59410 Vaginal delivery only (with or without episiotomy and/or forceps); including postpartum care $ 1,924.97 59412 External cephalic version, with or without tocolysis 59414 Delivery of placenta (separate procedure) $ 484.20 59425 Antepartum care only; 4-6 visits 59426 Antepartum care only; 7 or more visits $ 1,168.00 59430 Postpartum care only (separate procedure) $ 240.30 59514 Cesarean delivery only; $ 2,233.35 59515 Cesarean delivery only; including postpartum care $ 2,676.17 59525 Subtotal or total hysterectomy after cesarean delivery (List 59610 Routine obstetric care including antepartum care, vaginal delivery (with or without episiotomy, and/or forceps) and postpartum care, after previous cesarean delivery 59612 Vaginal delivery only, after previous cesarean delivery (with or without episiotomy and/or forceps); 59614 Vaginal delivery only, after previous cesarean delivery (with or without episiotomy and/or forceps); including postpartum care $ 2,339.10 59618 Routine obstetric care including antepartum care, cesarean delivery, and postpartum care, following attempted vaginal delivery after previous cesarean delivery 59620 Cesarean delivery only, following attempted vaginal delivery after previous cesarean delivery; 59622 Cesarean delivery only, following attempted vaginal delivery after previous cesarean delivery; including postpartum care $ 2,632.19 59812 Treatment of incomplete abortion, any trimester, completed surgically $ 800.34 59820 Treatment of missed abortion, completed surgically; first trimester $ 815.24 59821 Treatment of missed abortion, completed surgically; second trimester 59830 Treatment of septic abortion, completed surgically 59840 Induced abortion, by dilation and curettage 59841 Induced abortion, by dilation and evacuation $ 1,118.90 59850 delivery of fetus and secundines; $ 1,398.60

Row # CPT-4 HCPCS Price 59851 delivery of fetus and secundines; with dilation and curettage and/or evacuation 59852 delivery of fetus and secundines; with hysterotomy (failed intra- amniotic injection) $ 1,869.30 59855 secundines; 59856 secundines; with dilation and curettage and/or evacuation 59857 secundines; with hysterotomy (failed medical evacuation) $ 1,810.80 59866 Multifetal pregnancy reduction(s) (MPR) 59870 Uterine evacuation and curettage for hydatidiform mole 59871 Removal of cerclage suture under anesthesia (other than local) $ 444.60 59897 Unlisted fetal invasive procedure, including ultrasound guidance, Cost 59898 Unlisted laparoscopy procedure, maternity care and delivery Cost 59899 Unlisted procedure, maternity care and delivery Cost 60000 Incision and drainage of thyroglossal duct cyst, infected $ 305.10 60100 Biopsy thyroid, percutaneous core needle $ 279.00 60200 Excision of cyst or adenoma of thyroid, or transection of isthmus $ 1,590.30 60210 Partial thyroid lobectomy, unilateral; with or without isthmusectomy $ 2,587.50 60212 Partial thyroid lobectomy, unilateral; with contralateral subtotal lobectomy, including isthmusectomy $ 3,165.30 60220 Total thyroid lobectomy, unilateral; with or without isthmusectomy $ 2,613.60 60225 Total thyroid lobectomy, unilateral; with contralateral subtotal lobectomy, including isthmusectomy $ 3,329.10 60240 Thyroidectomy, total or complete $ 3,250.80 60252 Thyroidectomy, total or subtotal for malignancy; with limited neck $ 3,743.10 60254 Thyroidectomy, total or subtotal for malignancy; with radical neck $ 5,427.00 60260 Thyroidectomy, removal of all remaining thyroid tissue following previous removal of a portion of thyroid 60270 Thyroidectomy, including substernal thyroid; sternal split or transthoracic approach $ 4,066.20 60271 Thyroidectomy, including substernal thyroid; cervical approach $ 3,284.10 60280 Excision of thyroglossal duct cyst or sinus; $ 2,004.30 60281 Excision of thyroglossal duct cyst or sinus; recurrent $ 2,155.50 60300 60001 Aspiration and/or injection, thyroid cyst $ 304.43 60500 Parathyroidectomy or exploration of parathyroid(s); $ 3,088.80 60502 Parathyroidectomy or exploration of parathyroid(s); re-exploration 60505 Parathyroidectomy or exploration of parathyroid(s); with mediastinal exploration, sternal split or transthoracic approach $ 3,624.30 60512 Parathyroid autotransplantation (List separately in addition to code $ 802.80 60520 Thymectomy, partial or total; transcervical approach (separate $ 3,260.70 60521 Thymectomy, partial or total; sternal split or transthoracic approach, without radical mediastinal dissection (separate

Row # CPT-4 HCPCS Price 60522 Thymectomy, partial or total; sternal split or transthoracic approach, with radical mediastinal dissection (separate procedure) $ 4,230.00 60540 Adrenalectomy, partial or complete, or exploration of adrenal gland with or without biopsy, transabdominal, lumbar or dorsal (separate $ 3,249.90 60545 Adrenalectomy, partial or complete, or exploration of adrenal gland with or without biopsy, transabdominal, lumbar or dorsal (separate procedure); with excision of adjacent retroperitoneal tumor $ 3,646.80 60600 Excision of carotid body tumor; without excision of carotid artery $ 3,170.70 60605 Excision of carotid body tumor; with excision of carotid artery 60650 Laparoscopy, surgical, with adrenalectomy, partial or complete, or exploration of adrenal gland with or without biopsy, transabdominal, lumbar or dorsal $ 2,901.27 60659 Unlisted laparoscopy procedure, endocrine system Cost 60699 Unlisted procedure, endocrine system Cost 61000 Subdural tap through fontanelle, or suture, infant, unilateral or bilateral; initial $ 347.40 61001 Subdural tap through fontanelle, or suture, infant, unilateral or bilateral; subsequent taps 61020 Ventricular puncture through previous burr hole, fontanelle, suture, or implanted ventricular catheter/reservoir; without injection $ 477.00 61026 Ventricular puncture through previous burr hole, fontanelle, suture, or implanted ventricular catheter/reservoir; with injection of medication or other substance for diagnosis or treatment $ 539.10 61050 Cisternal or lateral cervical (C1-C2) puncture; without injection $ 422.10 61055 Cisternal or lateral cervical (C1-C2) puncture; with injection of medication or other substance for diagnosis or treatment (eg, C1- C2) 61070 Puncture of shunt tubing or reservoir for aspiration or injection $ 314.10 61105 Twist drill hole for subdural or ventricular puncture 61107 Twist drill hole(s) for subdural, intracerebral, or ventricular puncture; for implanting ventricular catheter, pressure recording device, or other intracerebral monitoring device 61108 Twist drill hole(s) for subdural, intracerebral, or ventricular puncture; for evacuation and/or drainage of subdural hematoma 61120 Burr hole(s) for ventricular puncture (including injection of gas, contrast media, dye, or radioactive material) $ 1,748.70 61140 Burr hole(s) or trephine; with biopsy of brain or intracranial lesion $ 3,785.40 61150 Burr hole(s) or trephine; with drainage of brain abscess or cyst 61151 Burr hole(s) or trephine; with subsequent tapping (aspiration) of intracranial abscess or cyst $ 1,149.30 61154 Burr hole(s) with evacuation and/or drainage of hematoma, extradural or subdural $ 4,333.50 61156 Burr hole(s); with aspiration of hematoma or cyst, intracerebral $ 3,850.20 61210 Burr hole(s); for implanting ventricular catheter, reservoir, EEG electrode(s), pressure recording device, or other cerebral monitoring device (separate procedure) 61215 Insertion of subcutaneous reservoir, pump or continuous infusion system for connection to ventricular catheter 61250 Burr hole(s) or trephine, supratentorial, exploratory, not followed by other surgery $ 2,483.10 61253 Burr hole(s) or trephine, infratentorial, unilateral or bilateral $ 3,609.90 61304 Craniectomy or craniotomy, exploratory; supratentorial 61305 Craniectomy or craniotomy, exploratory; infratentorial (posterior fossa) $ 5,964.30 61312 supratentorial; extradural or subdural $ 6,644.70

Row # CPT-4 HCPCS Price 61313 supratentorial; intracerebral $ 6,731.10 61314 infratentorial; extradural or subdural $ 6,798.60 61315 infratentorial; intracerebellar $ 7,305.30 61316 Incision and subcutaneous placement of cranial bone graft (List $ 1,146.13 61320 Craniectomy or craniotomy, drainage of intracranial abscess; supratentorial $ 6,000.30 61321 Craniectomy or craniotomy, drainage of intracranial abscess; infratentorial $ 5,699.70 61322 Craniectomy or craniotomy, decompressive, with or without duraplasty, for treatment of intracranial hypertension, without evacuation of associated intraparenchymal hematoma; without $ 5,756.79 61323 Craniectomy or craniotomy, decompressive, with or without duraplasty, for treatment of intracranial hypertension, without evacuation of associated intraparenchymal hematoma; with $ 6,798.55 61330 Decompression of orbit only, transcranial approach $ 4,500.90 61332 Exploration of orbit (transcranial approach); with biopsy $ 5,355.00 61333 Exploration of orbit (transcranial approach); with removal of lesion $ 5,422.50 61334 Exploration of orbit (transcranial approach); with removal of foreign body $ 5,355.00 61340 Subtemporal cranial decompression (pseudotumor cerebri, slit ventricle syndrome) $ 4,254.30 61343 Craniectomy, suboccipital with cervical laminectomy for decompression of medulla and spinal cord, with or without dural graft (eg, Arnold-Chiari malformation) $ 7,812.00 61345 Other cranial decompression, posterior fossa $ 3,861.00 61440 Craniotomy for section of tentorium cerebelli (separate procedure) 61450 Craniectomy, subtemporal, for section, compression, or decompression of sensory root of gasserian ganglion $ 5,769.00 61458 Craniectomy, suboccipital; for exploration or decompression of cranial nerves $ 6,541.20 61460 Craniectomy, suboccipital; for section of 1 or more cranial nerves $ 6,573.60 61470 Craniectomy, suboccipital; for medullary tractotomy $ 5,194.80 61480 Craniectomy, suboccipital; for mesencephalic tractotomy or pedunculotomy $ 4,833.00 61490 Craniotomy for lobotomy, including cingulotomy $ 3,848.40 61500 Craniectomy; with excision of tumor or other bone lesion of skull $ 5,799.60 61501 Craniectomy; for osteomyelitis $ 5,518.80 61510 brain tumor, supratentorial, except meningioma $ 7,210.80 61512 meningioma, supratentorial $ 7,498.80 61514 brain abscess, supratentorial $ 6,441.30 61516 Craniectomy, trephination, bone flap craniotomy; for excision or fenestration of cyst, supratentorial $ 6,448.50 61517 Implantation of brain intracavitary chemotherapy agent (List $ 317.57 61518 fossa; except meningioma, cerebellopontine angle tumor, or midline tumor at base of skull $ 7,177.50 61519 fossa; meningioma $ 7,713.00 61520 fossa; cerebellopontine angle tumor $ 8,054.10 61521 fossa; midline tumor at base of skull $ 8,868.60 61522 Craniectomy, infratentorial or posterior fossa; for excision of brain $ 6,534.00 61524 Craniectomy, infratentorial or posterior fossa; for excision or fenestration of cyst $ 6,491.70

Row # CPT-4 HCPCS Price 61526 Craniectomy, bone flap craniotomy, transtemporal (mastoid) for excision of cerebellopontine angle tumor; $ 7,533.00 61530 Craniectomy, bone flap craniotomy, transtemporal (mastoid) for excision of cerebellopontine angle tumor; combined with middle/posterior fossa craniotomy/craniectomy $ 7,915.50 61531 Subdural implantation of strip electrodes through 1 or more burr or trephine hole(s) for long-term seizure monitoring $ 4,017.60 61533 Craniotomy with elevation of bone flap; for subdural implantation of an electrode array, for long-term seizure monitoring $ 5,459.40 61534 Craniotomy with elevation of bone flap; for excision of epileptogenic focus without electrocorticography during surgery $ 5,832.00 61535 Craniotomy with elevation of bone flap; for removal of epidural or subdural electrode array, without excision of cerebral tissue $ 3,613.50 61536 Craniotomy with elevation of bone flap; for excision of cerebral epileptogenic focus, with electrocorticography during surgery (includes removal of electrode array) $ 6,593.40 61537 Craniotomy with elevation of bone flap; for lobectomy, temporal lobe, without electrocorticography during surgery $ 5,691.54 61538 Craniotomy with elevation of bone flap; for lobectomy, temporal lobe, with electrocorticography during surgery $ 7,169.40 61539 Craniotomy with elevation of bone flap; for lobectomy, other than temporal lobe, partial or total, with electrocorticography during $ 6,920.10 61540 Craniotomy with elevation of bone flap; for lobectomy, other than temporal lobe, partial or total, without electrocorticography during $ 6,750.11 61541 Craniotomy with elevation of bone flap; for transection of corpus callosum $ 7,540.20 61542 Craniotomy with elevation of bone flap; for total hemispherectomy 61543 Craniotomy with elevation of bone flap; for partial or subtotal (functional) hemispherectomy $ 6,798.60 61544 Craniotomy with elevation of bone flap; for excision or coagulation of choroid plexus $ 5,931.00 61545 Craniotomy with elevation of bone flap; for excision of craniopharyngioma $ 9,750.60 61546 Craniotomy for hypophysectomy or excision of pituitary tumor, intracranial approach $ 7,222.50 61548 Hypophysectomy or excision of pituitary tumor, transnasal or transseptal approach, nonstereotactic $ 6,168.60 61550 Craniectomy for craniosynostosis; single cranial suture $ 3,863.70 61552 Craniectomy for craniosynostosis; multiple cranial sutures $ 4,626.90 61556 Craniotomy for craniosynostosis; frontal or parietal bone flap $ 4,708.80 61557 Craniotomy for craniosynostosis; bifrontal bone flap $ 5,355.90 61558 Extensive craniectomy for multiple cranial suture craniosynostosis (eg, cloverleaf skull); not requiring bone grafts $ 6,180.30 61559 Extensive craniectomy for multiple cranial suture craniosynostosis (eg, cloverleaf skull); recontouring with multiple osteotomies and bone autografts (eg, barrel-stave procedure) (includes obtaining 61563 Excision, intra and extracranial, benign tumor of cranial bone (eg, fibrous dysplasia); without optic nerve decompression $ 5,598.00 61564 Excision, intra and extracranial, benign tumor of cranial bone (eg, fibrous dysplasia); with optic nerve decompression 61566 Craniotomy with elevation of bone flap; for selective amygdalohippocampectomy $ 6,648.74 61567 Craniotomy with elevation of bone flap; for multiple subpial transections, with electrocorticography during surgery $ 7,585.18 61570 Craniectomy or craniotomy; with excision of foreign body from brain $ 6,655.50

Row # CPT-4 HCPCS Price 61571 Craniectomy or craniotomy; with treatment of penetrating wound of brain $ 7,112.70 61575 Transoral approach to skull base, brain stem or upper spinal cord for biopsy, decompression or excision of lesion; $ 5,925.60 61576 Transoral approach to skull base, brain stem or upper spinal cord for biopsy, decompression or excision of lesion; requiring splitting of tongue and/or mandible (including tracheostomy) $ 6,066.00 61580 lateral rhinotomy, ethmoidectomy, sphenoidectomy, without maxillectomy or orbital exenteration $ 5,279.40 61581 lateral rhinotomy, orbital exenteration, ethmoidectomy, sphenoidectomy and/or maxillectomy $ 6,869.70 61582 unilateral or bifrontal craniotomy, elevation of frontal lobe(s), osteotomy of base of anterior cranial fossa $ 6,235.20 61583 Craniofacial approach to anterior cranial fossa; intradural, including unilateral or bifrontal craniotomy, elevation or resection of frontal lobe, osteotomy of base of anterior cranial fossa $ 6,881.40 61584 Orbitocranial approach to anterior cranial fossa, extradural, including supraorbital ridge osteotomy and elevation of frontal and/or temporal lobe(s); without orbital exenteration 61585 Orbitocranial approach to anterior cranial fossa, extradural, including supraorbital ridge osteotomy and elevation of frontal and/or temporal lobe(s); with orbital exenteration $ 7,112.70 61586 Bicoronal, transzygomatic and/or LeFort I osteotomy approach to anterior cranial fossa with or without internal fixation, without bone graft $ 4,247.10 61590 Infratemporal pre-auricular approach to middle cranial fossa (parapharyngeal space, infratemporal and midline skull base, nasopharynx), with or without disarticulation of the mandible, including parotidectomy, craniotomy, decompression and/or mobilization $ 8,847.90 61591 Infratemporal post-auricular approach to middle cranial fossa (internal auditory meatus, petrous apex, tentorium, cavernous sinus, parasellar area, infratemporal fossa) including mastoidectomy, resection of sigmoid sinus, with or without decompression and $ 9,154.80 61592 Orbitocranial zygomatic approach to middle cranial fossa (cavernous sinus and carotid artery, clivus, basilar artery or petrous apex) including osteotomy of zygoma, craniotomy, extra- or intradural elevation of temporal lobe $ 7,725.60 61595 Transtemporal approach to posterior cranial fossa, jugular foramen or midline skull base, including mastoidectomy, decompression of sigmoid sinus and/or facial nerve, with or without mobilization $ 6,030.00 61596 Transcochlear approach to posterior cranial fossa, jugular foramen or midline skull base, including labyrinthectomy, decompression, with or without mobilization of facial nerve and/or petrous carotid 61597 Transcondylar (far lateral) approach to posterior cranial fossa, jugular foramen or midline skull base, including occipital condylectomy, mastoidectomy, resection of C1-C3 vertebral body(s), decompression of vertebral artery, with or without mobilization $ 7,729.20 61598 Transpetrosal approach to posterior cranial fossa, clivus or foramen magnum, including ligation of superior petrosal sinus and/or sigmoid sinus $ 6,545.70 61600 base of anterior cranial fossa; extradural $ 5,345.10 61601 base of anterior cranial fossa; intradural, including dural repair, with or without graft $ 6,008.40 61605 infratemporal fossa, parapharyngeal space, petrous apex; $ 5,562.90

Row # CPT-4 HCPCS Price 61606 infratemporal fossa, parapharyngeal space, petrous apex; intradural, including dural repair, with or without graft $ 7,875.00 61607 parasellar area, cavernous sinus, clivus or midline skull base; $ 7,877.70 61608 parasellar area, cavernous sinus, clivus or midline skull base; intradural, including dural repair, with or without graft $ 8,641.80 61609 Transection or ligation, carotid artery in cavernous sinus; without repair (List separately in addition to code for primary procedure) $ 2,159.10 61610 Transection or ligation, carotid artery in cavernous sinus; with repair by anastomosis or graft (List separately in addition to code $ 5,758.20 61611 Transection or ligation, carotid artery in petrous canal; without repair (List separately in addition to code for primary procedure) $ 1,481.40 61612 Transection or ligation, carotid artery in petrous canal; with repair by anastomosis or graft (List separately in addition to code for 61613 Obliteration of carotid aneurysm, arteriovenous malformation, or carotid-cavernous fistula by dissection within cavernous sinus $ 8,973.90 61615 base of posterior cranial fossa, jugular foramen, foramen magnum, or C1-C3 vertebral bodies; extradural $ 6,874.20 61616 base of posterior cranial fossa, jugular foramen, foramen magnum, or C1-C3 vertebral bodies; intradural, including dural repair, with or without graft $ 8,987.40 61618 Secondary repair of dura for cerebrospinal fluid leak, anterior, middle or posterior cranial fossa following surgery of the skull base; by free tissue graft (eg, pericranium, fascia, tensor fascia lata, adipose tissue, homologous or synthetic grafts) $ 3,795.30 61619 Secondary repair of dura for cerebrospinal fluid leak, anterior, middle or posterior cranial fossa following surgery of the skull base; by local or regionalized vascularized pedicle flap or myocutaneous flap (including galea, temporalis, frontalis or occi $ 6,327.00 61623 Endovascular temporary balloon arterial occlusion, head or neck (extracranial/intracranial) including selective catheterization of vessel to be occluded, positioning and inflation of occlusion balloon, concomitant neurological monitoring, and radiologic s $ 2,587.65 61624 Transcatheter permanent occlusion or embolization (eg, for tumor destruction, to achieve hemostasis, to occlude a vascular malformation), percutaneous, any method; central nervous system (intracranial, spinal cord) $ 4,705.20 61626 Transcatheter permanent occlusion or embolization (eg, for tumor destruction, to achieve hemostasis, to occlude a vascular malformation), percutaneous, any method; non-central nervous system, head or neck (extracranial, brachiocephalic branch) 61630 Balloon angioplasty, intracranial (eg, atherosclerotic stenosis), percutaneous $ 4,445.59 61635 Transcatheter placement of intravascular stent(s), intracranial (eg, atherosclerotic stenosis), including balloon angioplasty, if $ 5,059.80 61640 Balloon dilatation of intracranial vasospasm, percutaneous; initial vessel $ 3,692.54 61641 Balloon dilatation of intracranial vasospasm, percutaneous; each additional vessel in same vascular family (List separately in addition $ 1,825.26 61642 Balloon dilatation of intracranial vasospasm, percutaneous; each additional vessel in different vascular family (List separately in $ 1,874.98

Row # CPT-4 HCPCS Price 61680 Surgery of intracranial arteriovenous malformation; supratentorial, $ 7,841.70 61682 Surgery of intracranial arteriovenous malformation; supratentorial, $ 9,553.50 61684 Surgery of intracranial arteriovenous malformation; infratentorial, $ 8,433.00 61686 Surgery of intracranial arteriovenous malformation; infratentorial, $ 10,935.90 61690 Surgery of intracranial arteriovenous malformation; dural, simple $ 7,769.70 61692 Surgery of intracranial arteriovenous malformation; dural, complex $ 8,279.10 61697 Surgery of complex intracranial aneurysm, intracranial approach; carotid circulation $ 8,145.00 61698 Surgery of complex intracranial aneurysm, intracranial approach; vertebrobasilar circulation $ 7,839.00 61700 Surgery of simple intracranial aneurysm, intracranial approach; carotid circulation $ 8,034.30 61702 Surgery of simple intracranial aneurysm, intracranial approach; vertebrobasilar circulation $ 7,725.60 61703 Surgery of intracranial aneurysm, cervical approach by application of occluding clamp to cervical carotid artery (Selverstone- Crutchfield type) 61705 fistula; by intracranial and cervical occlusion of carotid artery $ 8,181.00 61708 fistula; by intracranial electrothrombosis $ 6,218.10 61710 fistula; by intra-arterial embolization, injection procedure, or balloon catheter $ 5,119.20 61711 Anastomosis, arterial, extracranial-intracranial (eg, middle cerebral/cortical) arteries $ 6,508.80 61720 Creation of lesion by stereotactic method, including burr hole(s) and localizing and recording techniques, single or multiple stages; globus pallidus or thalamus $ 4,897.80 61735 Creation of lesion by stereotactic method, including burr hole(s) and localizing and recording techniques, single or multiple stages; subcortical structure(s) other than globus pallidus or thalamus $ 5,054.40 61750 Stereotactic biopsy, aspiration, or excision, including burr hole(s), for intracranial lesion; 61751 Stereotactic biopsy, aspiration, or excision, including burr hole(s), for intracranial lesion; with computed tomography and/or magnetic resonance guidance $ 5,544.00 61760 Stereotactic implantation of depth electrodes into the cerebrum for long-term seizure monitoring $ 5,960.70 61770 Stereotactic localization, including burr hole(s), with insertion of catheter(s) or probe(s) for placement of radiation source $ 5,312.70 61790 Creation of lesion by stereotactic method, percutaneous, by neurolytic agent (eg, alcohol, thermal, electrical, radiofrequency); gasserian ganglion $ 4,118.40 61791 Creation of lesion by stereotactic method, percutaneous, by neurolytic agent (eg, alcohol, thermal, electrical, radiofrequency); trigeminal medullary tract $ 3,960.90 61796 accelerator); 1 simple cranial lesion $ 4,260.08 61797 accelerator); each additional cranial lesion, simple (List separately in $ 1,148.15 61798 accelerator); 1 complex cranial lesion $ 4,339.38 61799 accelerator); each additional cranial lesion, complex (List separately $ 1,612.19 61800 Application of stereotactic headframe for stereotactic radiosurgery $ 806.16

Row # CPT-4 HCPCS Price 61850 Twist drill or burr hole(s) for implantation of neurostimulator electrodes, cortical $ 3,304.80 61860 Craniectomy or craniotomy for implantation of neurostimulator electrodes, cerebral, cortical $ 4,075.20 61863 periaqueductal gray), without use of intraoperat $ 3,473.61 61864 periaqueductal gray), without use of intraoperat $ 1,609.63 61867 periaqueductal gray), with use of intraoperative $ 5,176.91 61868 periaqueductal gray), with use of intraoperative $ 2,433.01 61870 Craniectomy for implantation of neurostimulator electrodes, cerebellar; cortical $ 3,723.30 61875 Craniectomy for implantation of neurostimulator electrodes, cerebellar; subcortical 61880 Revision or removal of intracranial neurostimulator electrodes $ 2,471.40 61885 Insertion or replacement of cranial neurostimulator pulse generator or receiver, direct or inductive coupling; with connection to a single electrode array $ 943.20 61886 Insertion or replacement of cranial neurostimulator pulse generator or receiver, direct or inductive coupling; with connection to 2 or more electrode arrays 61888 Revision or removal of cranial neurostimulator pulse generator or receiver 62000 Elevation of depressed skull fracture; simple, extradural $ 3,420.00 62005 Elevation of depressed skull fracture; compound or comminuted, $ 4,185.00 62010 Elevation of depressed skull fracture; with repair of dura and/or debridement of brain $ 5,310.00 62100 Craniotomy for repair of dural/cerebrospinal fluid leak, including surgery for rhinorrhea/otorrhea $ 5,804.10 62115 Reduction of craniomegalic skull (eg, treated hydrocephalus); not requiring bone grafts or cranioplasty $ 2,946.76 62116 Reduction of craniomegalic skull (eg, treated hydrocephalus); with simple cranioplasty $ 4,497.88 62117 Reduction of craniomegalic skull (eg, treated hydrocephalus); requiring craniotomy and reconstruction with or without bone graft (includes obtaining grafts) 62120 Repair of encephalocele, skull vault, including cranioplasty $ 4,874.40 62121 Craniotomy for repair of encephalocele, skull base $ 4,878.00 62140 Cranioplasty for skull defect; up to 5 cm diameter $ 4,598.10 62141 Cranioplasty for skull defect; larger than 5 cm diameter $ 4,816.80 62142 Removal of bone flap or prosthetic plate of skull $ 3,197.70 62143 Replacement of bone flap or prosthetic plate of skull 62145 Cranioplasty for skull defect with reparative brain surgery $ 4,948.20 62146 Cranioplasty with autograft (includes obtaining bone grafts); up to 5 cm diameter 62147 Cranioplasty with autograft (includes obtaining bone grafts); larger than 5 cm diameter $ 4,841.10 62148 Incision and retrieval of subcutaneous cranial bone graft for cranioplasty (List separately in addition to code for primary $ 445.59 62160 Neuroendoscopy, intracranial, for placement or replacement of ventricular catheter and attachment to shunt system or external drainage (List separately in addition to code for primary procedure) $ 479.08

Row # CPT-4 HCPCS Price 62161 Neuroendoscopy, intracranial; with dissection of adhesions, fenestration of septum pellucidum or intraventricular cysts (including placement, replacement, or removal of ventricular $ 5,992.94 62162 Neuroendoscopy, intracranial; with fenestration or excision of colloid cyst, including placement of external ventricular catheter for drainage $ 6,085.95 62163 Neuroendoscopy, intracranial; with retrieval of foreign body $ 6,926.90 62164 Neuroendoscopy, intracranial; with excision of brain tumor, including placement of external ventricular catheter for drainage $ 7,165.41 62165 Neuroendoscopy, intracranial; with excision of pituitary tumor, transnasal or trans-sphenoidal approach $ 6,442.36 62180 Ventriculocisternostomy (Torkildsen type operation) 62190 Creation of shunt; subarachnoid/subdural-atrial, -jugular, -auricular $ 3,469.50 62192 Creation of shunt; subarachnoid/subdural-peritoneal, -pleural, other terminus $ 3,523.50 62194 Replacement or irrigation, subarachnoid/subdural catheter $ 1,296.90 62200 Ventriculocisternostomy, third ventricle; $ 4,726.80 62201 Ventriculocisternostomy, third ventricle; stereotactic, neuroendoscopic method $ 4,996.62 62220 Creation of shunt; ventriculo-atrial, -jugular, -auricular $ 4,307.40 62223 Creation of shunt; ventriculo-peritoneal, -pleural, other terminus $ 4,331.70 62225 Replacement or irrigation, ventricular catheter $ 1,852.20 62230 Replacement or revision of cerebrospinal fluid shunt, obstructed valve, or distal catheter in shunt system $ 3,162.60 62252 62252-26 26 62252 $ 122.96 62252-TC TC 62252 $ 113.74 62256 Removal of complete cerebrospinal fluid shunt system; without $ 1,863.00 62258 Removal of complete cerebrospinal fluid shunt system; with replacement by similar or other shunt at same operation $ 4,531.50 62263 Percutaneous lysis of epidural adhesions using solution injection (eg, hypertonic saline, enzyme) or mechanical means (eg, catheter) including radiologic localization (includes contrast when administered), multiple adhesiolysis sessions; 2 or more days $ 1,090.80 62264 Percutaneous lysis of epidural adhesions using solution injection (eg, hypertonic saline, enzyme) or mechanical means (eg, catheter) including radiologic localization (includes contrast when administered), multiple adhesiolysis sessions; 1 day $ 1,042.86 62267 Percutaneous aspiration within the nucleus pulposus, intervertebral disc, or paravertebral tissue for diagnostic purposes $ 816.24 62268 Percutaneous aspiration, spinal cord cyst or syrinx $ 1,906.20 62269 Biopsy of spinal cord, percutaneous needle 62270 Spinal puncture, lumbar, diagnostic 62272 Spinal puncture, therapeutic, for drainage of cerebrospinal fluid (by needle or catheter) 62273 Injection, epidural, of blood or clot patch $ 512.10 62280 subarachnoid 62281 epidural, cervical or thoracic 62282 epidural, lumbar, sacral (caudal) $ 636.30 62284 Injection procedure for myelography and/or computed tomography, spinal (other than C1-C2 and posterior fossa) $ 522.90

Row # CPT-4 HCPCS Price 62287 Decompression procedure, percutaneous, of nucleus pulposus of intervertebral disc, any method utilizing needle based technique to remove disc material under fluoroscopic imaging or other form of indirect visualization, with the use of an endoscope, with d $ 3,543.30 62290 Injection procedure for discography, each level; lumbar $ 551.70 62291 Injection procedure for discography, each level; cervical or thoracic $ 524.70 62292 Injection procedure for chemonucleolysis, including discography, intervertebral disc, single or multiple levels, lumbar $ 2,452.50 62294 Injection procedure, arterial, for occlusion of arteriovenous malformation, spinal $ 1,232.10 62310 Injection(s), of diagnostic or therapeutic substance(s) (including anesthetic, antispasmodic, opioid, steroid, other solution), not including neurolytic substances, including needle or catheter placement, includes contrast for localization when performed, 62311 Injection(s), of diagnostic or therapeutic substance(s) (including anesthetic, antispasmodic, opioid, steroid, other solution), not including neurolytic substances, including needle or catheter placement, includes contrast for localization when performed, $ 933.30 62318 Injection(s), including indwelling catheter placement, continuous infusion or intermittent bolus, of diagnostic or therapeutic substance(s) (including anesthetic, antispasmodic, opioid, steroid, other solution), not including neurolytic substances, includ $ 968.40 62319 Injection(s), including indwelling catheter placement, continuous infusion or intermittent bolus, of diagnostic or therapeutic substance(s) (including anesthetic, antispasmodic, opioid, steroid, other solution), not including neurolytic substances, includ $ 942.30 62350 Implantation, revision or repositioning of tunneled intrathecal or epidural catheter, for long-term medication administration via an external pump or implantable reservoir/infusion pump; without 62351 Implantation, revision or repositioning of tunneled intrathecal or epidural catheter, for long-term medication administration via an external pump or implantable reservoir/infusion pump; with $ 2,763.90 62355 Removal of previously implanted intrathecal or epidural catheter $ 1,368.00 62360 drug infusion; subcutaneous reservoir 62361 drug infusion; nonprogrammable pump $ 1,849.28 62362 drug infusion; programmable pump, including preparation of pump, with or without programming 62365 Removal of subcutaneous reservoir or pump, previously implanted for intrathecal or epidural infusion 62367 Electronic analysis of programmable, implanted pump for intrathecal or epidural drug infusion (includes evaluation of reservoir status, alarm status, drug prescription status); without reprogramming or refill $ 103.05 62368 Electronic analysis of programmable, implanted pump for intrathecal or epidural drug infusion (includes evaluation of reservoir status, alarm status, drug prescription status); with reprogramming $ 136.97 63001 discectomy (eg, spinal stenosis), 1 or 2 vertebral segments; cervical $ 4,944.60 63003 discectomy (eg, spinal stenosis), 1 or 2 vertebral segments; thoracic $ 5,364.90

Row # CPT-4 HCPCS Price 63005 discectomy (eg, spinal stenosis), 1 or 2 vertebral segments; lumbar, except for spondylolisthesis $ 4,862.70 63011 discectomy (eg, spinal stenosis), 1 or 2 vertebral segments; sacral 63012 Laminectomy with removal of abnormal facets and/or pars inter- articularis with decompression of cauda equina and nerve roots for spondylolisthesis, lumbar (Gill type procedure) 63015 cervical $ 6,095.70 63016 63017 $ 5,402.70 63020 excision of herniated intervertebral disc; 1 interspace, cervical $ 4,932.00 63030 excision of herniated intervertebral disc; 1 interspace, lumbar $ 5,275.80 63035 excision of herniated intervertebral disc; each additional interspace, cervical or lumbar (List separately in addition to code for primar $ 1,433.70 63040 interspace; cervical $ 5,602.50 63042 interspace; lumbar $ 6,077.70 63043 interspace; each additional cervical interspace (List separately in addi $ 304.43 63044 interspace; each additional lumbar interspace (List separately in additi $ - 63045 $ 5,896.80 63046 $ 5,850.90 63047 $ 6,197.40

Row # CPT-4 HCPCS Price 63048 segment; each additional segment, cervical, thoracic, or lu 63050 Laminoplasty, cervical, with decompression of the spinal cord, 2 or more vertebral segments; $ 5,247.21 63051 Laminoplasty, cervical, with decompression of the spinal cord, 2 or more vertebral segments; with reconstruction of the posterior bony elements (including the application of bridging bone graft and non- segmental fixation devices [eg, wire, suture, mini-pl $ 5,950.77 63055 $ 6,694.20 63056 segment; lumbar (including transfacet, or lateral extraforaminal approach) (eg, far lateral herniated intervertebral disc) $ 5,550.30 63057 segment; each additional segment, thoracic or lumbar (List 63064 Costovertebral approach with decompression of spinal cord or nerve root(s) (eg, herniated intervertebral disc), thoracic; single segment $ 5,833.80 63066 Costovertebral approach with decompression of spinal cord or nerve root(s) (eg, herniated intervertebral disc), thoracic; each additional segment (List separately in addition to code for primary 63075 nerve root(s), including osteophytectomy; cervical, single interspace $ 5,081.40 63076 nerve root(s), including osteophytectomy; cervical, each additional interspace (List separately in addition to code for primary $ 1,952.10 63077 nerve root(s), including osteophytectomy; thoracic, single interspace $ 4,871.70 63078 nerve root(s), including osteophytectomy; thoracic, each additional interspace (List separately in addition to code for primary $ 1,342.80 63081 complete, anterior approach with decompression of spinal cord and/or nerve root(s); cervical, single segment $ 6,626.70 63082 complete, anterior approach with decompression of spinal cord and/or nerve root(s); cervical, each additional segment (List 63085 complete, transthoracic approach with decompression of spinal cord and/or nerve root(s); thoracic, single segment $ 7,022.70 63086 complete, transthoracic approach with decompression of spinal cord and/or nerve root(s); thoracic, each additional segment (List $ 1,986.30 63087 complete, combined thoracolumbar approach with decompression of spinal cord, cauda equina or nerve root(s), lower thoracic or lumbar; single segment 63088 complete, combined thoracolumbar approach with decompression of spinal cord, cauda equina or nerve root(s), lower thoracic or lumbar; each additional segment (List separately in addition to code

Row # CPT-4 HCPCS Price 63090 complete, transperitoneal or retroperitoneal approach with decompression of spinal cord, cauda equina or nerve root(s), lower thoracic, lumbar, or sacral; single segment $ 6,551.10 63091 complete, transperitoneal or retroperitoneal approach with decompression of spinal cord, cauda equina or nerve root(s), lower thoracic, lumbar, or sacral; each additional segment (List separately 63101 fragments); thoracic, single segment $ 6,101.26 63102 fragments); lumbar, single segment $ 6,074.85 63103 fragments); thoracic or lumbar, each additional segment (List se $ 1,901.26 63170 Laminectomy with myelotomy (eg, Bischof or DREZ type), cervical, thoracic, or thoracolumbar 63172 Laminectomy with drainage of intramedullary cyst/syrinx; to subarachnoid space $ 5,694.30 63173 Laminectomy with drainage of intramedullary cyst/syrinx; to peritoneal or pleural space $ 5,922.90 63180 Laminectomy and section of dentate ligaments, with or without dural graft, cervical; 1 or 2 segments $ 5,348.70 63182 Laminectomy and section of dentate ligaments, with or without dural graft, cervical; more than 2 segments $ 5,603.40 63185 Laminectomy with rhizotomy; 1 or 2 segments $ 4,599.00 63190 Laminectomy with rhizotomy; more than 2 segments $ 5,452.20 63191 Laminectomy with section of spinal accessory nerve $ 3,994.20 63194 Laminectomy with cordotomy, with section of 1 spinothalamic tract, 1 stage; cervical $ 4,356.90 63195 Laminectomy with cordotomy, with section of 1 spinothalamic tract, 1 stage; thoracic $ 4,849.20 63196 tracts, 1 stage; cervical $ 4,980.60 63197 tracts, 1 stage; thoracic $ 5,346.00 63198 tracts, 2 stages within 14 days; cervical $ 5,892.30 63199 tracts, 2 stages within 14 days; thoracic $ 5,892.30 63200 Laminectomy, with release of tethered spinal cord, lumbar $ 4,874.40 63250 malformation of spinal cord; cervical 63251 malformation of spinal cord; thoracic $ 6,669.90 63252 malformation of spinal cord; thoracolumbar $ 7,471.80 63265 than neoplasm, extradural; cervical $ 5,824.80 63266 than neoplasm, extradural; thoracic $ 6,412.50 63267 than neoplasm, extradural; lumbar $ 5,632.20 63268 than neoplasm, extradural; sacral $ 4,805.10 63270 intradural; cervical $ 5,739.30 63271 intradural; thoracic $ 5,804.10 63272 intradural; lumbar $ 5,796.00

Row # CPT-4 HCPCS Price 63273 intradural; sacral $ 5,023.80 63275 extradural, cervical $ 6,346.80 63276 extradural, thoracic $ 6,246.90 63277 extradural, lumbar $ 5,616.90 63278 extradural, sacral $ 5,306.40 63280 intradural, extramedullary, cervical $ 6,412.50 63281 intradural, extramedullary, thoracic $ 6,556.50 63282 intradural, extramedullary, lumbar $ 6,702.30 63283 intradural, sacral $ 5,282.10 63285 intradural, intramedullary, cervical $ 6,808.50 63286 intradural, intramedullary, thoracic $ 7,128.00 63287 intradural, intramedullary, thoracolumbar $ 7,533.00 63290 Laminectomy for biopsy/excision of intraspinal neoplasm; combined extradural-intradural lesion, any level $ 7,120.80 63295 Osteoplastic reconstruction of dorsal spinal elements, following primary intraspinal procedure (List separately in addition to code $ 876.68 63300 extradural, cervical $ 6,033.60 63301 extradural, thoracic by transthoracic approach $ 6,150.60 63302 extradural, thoracic by thoracolumbar approach $ 6,551.10 63303 extradural, lumbar or sacral by transperitoneal or retroperitoneal 63304 intradural, cervical $ 6,502.50 63305 intradural, thoracic by transthoracic approach $ 6,653.70 63306 intradural, thoracic by thoracolumbar approach $ 6,643.80 63307 intradural, lumbar or sacral by transperitoneal or retroperitoneal $ 7,065.90 63308 complete, for excision of intraspinal lesion, single segment; each additional segment (List separately in addition to codes for single segment) 63600 Creation of lesion of spinal cord by stereotactic method, percutaneous, any modality (including stimulation and/or recording) $ 3,244.50 63610 Stereotactic stimulation of spinal cord, percutaneous, separate procedure not followed by other surgery $ 2,502.90 63615 Stereotactic biopsy, aspiration, or excision of lesion, spinal cord $ 3,785.40 63620 accelerator); 1 spinal lesion $ 1,894.72

Row # CPT-4 HCPCS Price 63621 accelerator); each additional spinal lesion (List separately in $ 590.80 63650 epidural $ 3,397.50 63655 Laminectomy for implantation of neurostimulator electrodes, plate/paddle, epidural $ 4,462.20 63661 Removal of spinal neurostimulator electrode percutaneous array(s), including fluoroscopy, when performed $ 1,863.09 63662 Removal of spinal neurostimulator electrode plate/paddle(s) placed via laminotomy or laminectomy, including fluoroscopy, when $ 3,176.79 63663 Revision including replacement, when performed, of spinal neurostimulator electrode percutaneous array(s), including fluoroscopy, when performed $ 2,705.03 63664 Revision including replacement, when performed, of spinal neurostimulator electrode plate/paddle(s) placed via laminotomy or laminectomy, including fluoroscopy, when performed $ 3,472.26 63685 Insertion or replacement of spinal neurostimulator pulse generator or receiver, direct or inductive coupling $ 2,304.90 63688 Revision or removal of implanted spinal neurostimulator pulse generator or receiver $ 1,452.60 63700 Repair of meningocele; less than 5 cm diameter $ 3,715.20 63702 Repair of meningocele; larger than 5 cm diameter $ 3,716.10 63704 Repair of myelomeningocele; less than 5 cm diameter $ 4,053.60 63706 Repair of myelomeningocele; larger than 5 cm diameter $ 4,401.00 63707 Repair of dural/cerebrospinal fluid leak, not requiring laminectomy $ 4,411.80 63709 Repair of dural/cerebrospinal fluid leak or pseudomeningocele, with $ 5,055.30 63710 Dural graft, spinal $ 4,424.40 63740 Creation of shunt, lumbar, subarachnoid-peritoneal, -pleural, or other; including laminectomy $ 4,424.40 63741 Creation of shunt, lumbar, subarachnoid-peritoneal, -pleural, or other; percutaneous, not requiring laminectomy $ 2,841.30 63744 Replacement, irrigation or revision of lumbosubarachnoid shunt 63746 Removal of entire lumbosubarachnoid shunt system without 64400 Injection, anesthetic agent; trigeminal nerve, any division or branch 64402 Injection, anesthetic agent; facial nerve $ 243.90 64405 Injection, anesthetic agent; greater occipital nerve $ 242.10 64408 Injection, anesthetic agent; vagus nerve $ 284.40 64410 Injection, anesthetic agent; phrenic nerve 64412 Injection, anesthetic agent; spinal accessory nerve $ 242.10 64413 Injection, anesthetic agent; cervical plexus $ 299.70 64415 Injection, anesthetic agent; brachial plexus, single 64416 Injection, anesthetic agent; brachial plexus, continuous infusion by $ 305.64 64417 Injection, anesthetic agent; axillary nerve 64418 Injection, anesthetic agent; suprascapular nerve $ 274.07 64420 Injection, anesthetic agent; intercostal nerve, single $ 261.90 64421 Injection, anesthetic agent; intercostal nerves, multiple, regional block $ 486.90 64425 Injection, anesthetic agent; ilioinguinal, iliohypogastric nerves 64430 Injection, anesthetic agent; pudendal nerve 64435 Injection, anesthetic agent; paracervical (uterine) nerve 64445 Injection, anesthetic agent; sciatic nerve, single $ 326.70 64446 Injection, anesthetic agent; sciatic nerve, continuous infusion by $ 305.97 64447 Injection, anesthetic agent; femoral nerve, single $ 228.81 64448 Injection, anesthetic agent; femoral nerve, continuous infusion by $ 275.13 64449 Injection, anesthetic agent; lumbar plexus, posterior approach, continuous infusion by catheter (including catheter placement) $ 306.30

Row # CPT-4 HCPCS Price 64450 Injection, anesthetic agent; other peripheral nerve or branch 64455 Injection(s), anesthetic agent and/or steroid, plantar common digital nerve(s) (eg, Morton's neuroma) $ 157.67 64479 epidural, with imaging guidance (fluoroscopy or CT); cervical or thoracic, single level $ 485.10 64480 epidural, with imaging guidance (fluoroscopy or CT); cervical or thoracic, each additional level (List separately in addition to code for $ 436.50 64483 epidural, with imaging guidance (fluoroscopy or CT); lumbar or sacral, single level $ 398.11 64484 epidural, with imaging guidance (fluoroscopy or CT); lumbar or sacral, each additional level (List separately in addition to code for $ 447.30 64490 guidance (fluoroscopy or CT), cervical or thoracic; single level $ 404.72 64491 guidance (fluoroscopy or CT), cervical or thoracic; second level (List separately in addition to code for primary proced $ 287.25 64492 guidance (fluoroscopy or CT), cervical or thoracic; third and any additional level(s) (List separately in addition to co $ 287.36 64493 guidance (fluoroscopy or CT), lumbar or sacral; single level $ 398.98 64494 guidance (fluoroscopy or CT), lumbar or sacral; second level (List $ 227.39 64495 guidance (fluoroscopy or CT), lumbar or sacral; third and any additional level(s) (List separately in addition to code f $ 227.49 64505 Injection, anesthetic agent; sphenopalatine ganglion $ 244.80 64508 Injection, anesthetic agent; carotid sinus (separate procedure) 64510 Injection, anesthetic agent; stellate ganglion (cervical sympathetic) $ 295.20 64517 Injection, anesthetic agent; superior hypogastric plexus $ 385.18 64520 Injection, anesthetic agent; lumbar or thoracic (paravertebral sympathetic) $ 490.41 64530 Injection, anesthetic agent; celiac plexus, with or without radiologic monitoring 64550 Application of surface (transcutaneous) neurostimulator $ 123.54 64553 cranial nerve 64555 peripheral nerve (excludes sacral nerve) 64561 sacral nerve (transforaminal placement) including image guidance, if performed $ 1,611.28 64565 neuromuscular 64566 Posterior tibial neurostimulation, percutaneous needle electrode, single treatment, includes programming $ 266.83

Row # CPT-4 HCPCS Price 64568 Incision for implantation of cranial nerve (eg, vagus nerve) neurostimulator electrode array and pulse generator $ 1,127.59 64569 Revision or replacement of cranial nerve (eg, vagus nerve) neurostimulator electrode array, including connection to existing pulse generator $ 1,130.12 64570 Removal of cranial nerve (eg, vagus nerve) neurostimulator electrode array and pulse generator $ 999.18 64575 Incision for implantation of neurostimulator electrode array; peripheral nerve (excludes sacral nerve) $ 963.90 64580 Incision for implantation of neurostimulator electrode array; neuromuscular $ 793.80 64581 Incision for implantation of neurostimulator electrode array; sacral nerve (transforaminal placement) $ 1,141.09 64585 Revision or removal of peripheral neurostimulator electrode array $ 678.60 64590 Insertion or replacement of peripheral or gastric neurostimulator pulse generator or receiver, direct or inductive coupling $ 738.90 64595 Revision or removal of peripheral or gastric neurostimulator pulse generator or receiver 64600 Destruction by neurolytic agent, trigeminal nerve; supraorbital, infraorbital, mental, or inferior alveolar branch 64605 Destruction by neurolytic agent, trigeminal nerve; second and third division branches at foramen ovale 64610 Destruction by neurolytic agent, trigeminal nerve; second and third division branches at foramen ovale under radiologic monitoring 64612 Chemodenervation of muscle(s); muscle(s) innervated by facial nerve, unilateral (eg, for blepharospasm, hemifacial spasm) $ 377.10 64616 Chemodenervation of muscle(s); neck muscle(s), excluding muscles of the larynx, unilateral (eg, for cervical dystonia, spasmodic torticollis) $ 202.21 64617 Chemodenervation of muscle(s); larynx, unilateral, percutaneous (eg, for spasmodic dysphonia), includes guidance by needle electromyography, when performed 64620 Destruction by neurolytic agent, intercostal nerve $ 417.60 64630 Destruction by neurolytic agent; pudendal nerve 64632 Destruction by neurolytic agent; plantar common digital nerve $ 278.02 64633 with imaging guidance (fluoroscopy or CT); cervical or thoracic, single facet joint $ 1,004.45 64634 with imaging guidance (fluoroscopy or CT); cervical or thoracic, each additional facet joint (List separately in addition to code for primary $ 457.76 64635 with imaging guidance (fluoroscopy or CT); lumbar or sacral, single facet joint $ 986.15 64636 with imaging guidance (fluoroscopy or CT); lumbar or sacral, each additional facet joint (List separately in addition to code for primary $ 412.31 64640 Destruction by neurolytic agent; other peripheral nerve or branch $ 394.20 64642 Chemodenervation of one extremity; 1-4 muscle(s) 64643 Chemodenervation of one extremity; each additional extremity, 1-4 muscle(s) (List separately in addition to code for primary procedure) $ 73.55 64644 Chemodenervation of one extremity; 5 or more muscle(s) 64645 Chemodenervation of one extremity; each additional extremity, 5 or more muscle(s) (List separately in addition to code for primary $ 84.31 64646 Chemodenervation of trunk muscle(s); 1-5 muscle(s) 64647 Chemodenervation of trunk muscle(s); 6 or more muscle(s) 64650 Chemodenervation of eccrine glands; both axillae $ 106.28 64653 Chemodenervation of eccrine glands; other area(s) (eg, scalp, face, neck), per day $ 139.04

Row # CPT-4 HCPCS Price 64680 Destruction by neurolytic agent, with or without radiologic monitoring; celiac plexus $ 685.80 64681 Destruction by neurolytic agent, with or without radiologic monitoring; superior hypogastric plexus $ 734.56 64702 Neuroplasty; digital, 1 or both, same digit 64704 Neuroplasty; nerve of hand or foot 64708 Neuroplasty, major peripheral nerve, arm or leg, open; other than $ 1,944.90 64712 Neuroplasty, major peripheral nerve, arm or leg, open; sciatic nerve 64713 Neuroplasty, major peripheral nerve, arm or leg, open; brachial plexus $ 2,725.20 64714 Neuroplasty, major peripheral nerve, arm or leg, open; lumbar plexus $ 2,422.80 64716 Neuroplasty and/or transposition; cranial nerve (specify) $ 2,464.20 64718 Neuroplasty and/or transposition; ulnar nerve at elbow 64719 Neuroplasty and/or transposition; ulnar nerve at wrist $ 1,989.90 64721 Neuroplasty and/or transposition; median nerve at carpal tunnel 64722 Decompression; unspecified nerve(s) (specify) $ 2,050.20 64726 Decompression; plantar digital nerve 64727 Internal neurolysis, requiring use of operating microscope (List separately in addition to code for neuroplasty) (Neuroplasty includes external neurolysis) $ 2,111.40 64732 Transection or avulsion of; supraorbital nerve 64734 Transection or avulsion of; infraorbital nerve 64736 Transection or avulsion of; mental nerve $ 1,255.50 64738 Transection or avulsion of; inferior alveolar nerve by osteotomy 64740 Transection or avulsion of; lingual nerve 64742 Transection or avulsion of; facial nerve, differential or complete 64744 Transection or avulsion of; greater occipital nerve $ 1,597.50 64746 Transection or avulsion of; phrenic nerve $ 803.70 64752 Transection or avulsion of; vagus nerve (vagotomy), transthoracic $ 2,326.50 64755 Transection or avulsion of; vagus nerves limited to proximal stomach (selective proximal vagotomy, proximal gastric vagotomy, parietal cell vagotomy, supra- or highly selective vagotomy) $ 3,316.50 64760 Transection or avulsion of; vagus nerve (vagotomy), abdominal $ 1,964.70 64761 Transection or avulsion of; pudendal nerve $ 855.00 64763 Transection or avulsion of obturator nerve, extrapelvic, with or without adductor tenotomy $ 1,021.50 64766 Transection or avulsion of obturator nerve, intrapelvic, with or without adductor tenotomy 64771 Transection or avulsion of other cranial nerve, extradural 64772 Transection or avulsion of other spinal nerve, extradural $ 2,052.90 64774 Excision of neuroma; cutaneous nerve, surgically identifiable 64776 Excision of neuroma; digital nerve, 1 or both, same digit 64778 Excision of neuroma; digital nerve, each additional digit (List $ 461.70 64782 Excision of neuroma; hand or foot, except digital nerve $ 1,261.80 64783 Excision of neuroma; hand or foot, each additional nerve, except same digit (List separately in addition to code for primary 64784 Excision of neuroma; major peripheral nerve, except sciatic 64786 Excision of neuroma; sciatic nerve $ 2,403.00 64787 Implantation of nerve end into bone or muscle (List separately in addition to neuroma excision) 64788 Excision of neurofibroma or neurolemmoma; cutaneous nerve 64790 Excision of neurofibroma or neurolemmoma; major peripheral nerve $ 2,151.90 64792 Excision of neurofibroma or neurolemmoma; extensive (including malignant type) 64795 Biopsy of nerve 64802 Sympathectomy, cervical

Row # CPT-4 HCPCS Price 64804 Sympathectomy, cervicothoracic $ 3,587.40 64809 Sympathectomy, thoracolumbar $ 2,945.70 64818 Sympathectomy, lumbar 64820 Sympathectomy; digital arteries, each digit $ 1,219.55 64821 Sympathectomy; radial artery $ 1,203.16 64822 Sympathectomy; ulnar artery $ 1,201.92 64823 Sympathectomy; superficial palmar arch $ 1,223.47 64831 Suture of digital nerve, hand or foot; 1 nerve $ 1,704.60 64832 Suture of digital nerve, hand or foot; each additional digital nerve $ 927.90 64834 Suture of 1 nerve; hand or foot, common sensory nerve $ 1,899.00 64835 Suture of 1 nerve; median motor thenar $ 1,967.40 64836 Suture of 1 nerve; ulnar motor $ 2,360.70 64837 Suture of each additional nerve, hand or foot (List separately in $ 1,134.90 64840 Suture of posterior tibial nerve $ 2,778.30 64856 Suture of major peripheral nerve, arm or leg, except sciatic; including transposition $ 2,831.40 64857 Suture of major peripheral nerve, arm or leg, except sciatic; without $ 2,518.20 64858 Suture of sciatic nerve $ 2,503.80 64859 Suture of each additional major peripheral nerve (List separately in $ 1,147.50 64861 Suture of; brachial plexus $ 2,703.60 64862 Suture of; lumbar plexus $ 3,292.20 64864 Suture of facial nerve; extracranial $ 2,355.30 64865 Suture of facial nerve; infratemporal, with or without grafting $ 3,441.60 64866 Anastomosis; facial-spinal accessory $ 3,690.90 64868 Anastomosis; facial-hypoglossal $ 4,108.50 64870 Anastomosis; facial-phrenic $ 3,644.10 64872 Suture of nerve; requiring secondary or delayed suture (List separately in addition to code for primary neurorrhaphy) $ 1,768.50 64874 Suture of nerve; requiring extensive mobilization, or transposition of nerve (List separately in addition to code for nerve suture) $ 2,524.50 64876 Suture of nerve; requiring shortening of bone of extremity (List separately in addition to code for nerve suture) $ 441.19 64885 Nerve graft (includes obtaining graft), head or neck; up to 4 cm in 64886 Nerve graft (includes obtaining graft), head or neck; more than 4 cm $ 3,234.60 64890 Nerve graft (includes obtaining graft), single strand, hand or foot; up to 4 cm length $ 3,495.60 64891 Nerve graft (includes obtaining graft), single strand, hand or foot; more than 4 cm length $ 2,845.80 64892 Nerve graft (includes obtaining graft), single strand, arm or leg; up to 4 cm length $ 2,796.30 64893 Nerve graft (includes obtaining graft), single strand, arm or leg; more than 4 cm length $ 3,074.40 64895 Nerve graft (includes obtaining graft), multiple strands (cable), hand or foot; up to 4 cm length $ 3,388.50 64896 Nerve graft (includes obtaining graft), multiple strands (cable), hand or foot; more than 4 cm length $ 3,841.20 64897 Nerve graft (includes obtaining graft), multiple strands (cable), arm or leg; up to 4 cm length $ 3,540.60 64898 Nerve graft (includes obtaining graft), multiple strands (cable), arm or leg; more than 4 cm length $ 3,940.20 64901 Nerve graft, each additional nerve; single strand (List separately in $ 2,362.50 64902 Nerve graft, each additional nerve; multiple strands (cable) (List $ 2,455.20 64905 Nerve pedicle transfer; first stage $ 2,021.40 64907 Nerve pedicle transfer; second stage $ 2,226.60 64910 Nerve repair; with synthetic conduit or vein allograft (eg, nerve tube), each nerve $ 1,599.15 64911 Nerve repair; with autogenous vein graft (includes harvest of vein graft), each nerve $ 1,901.18 64999 Unlisted procedure, nervous system $ 468.58

Row # CPT-4 HCPCS Price 65091 Evisceration of ocular contents; without implant $ 1,363.50 65093 Evisceration of ocular contents; with implant $ 1,705.50 65101 Enucleation of eye; without implant $ 2,083.44 65103 Enucleation of eye; with implant, muscles not attached to implant $ 1,895.40 65105 Enucleation of eye; with implant, muscles attached to implant $ 2,379.60 65110 orbital contents; only $ 3,046.50 65112 orbital contents; with therapeutic removal of bone $ 3,127.50 65114 orbital contents; with muscle or myocutaneous flap $ 3,379.50 65125 Modification of ocular implant with placement or replacement of pegs (eg, drilling receptacle for prosthesis appendage) (separate 65130 Insertion of ocular implant secondary; after evisceration, in scleral shell 65135 Insertion of ocular implant secondary; after enucleation, muscles not attached to implant $ 1,566.00 65140 Insertion of ocular implant secondary; after enucleation, muscles attached to implant $ 2,068.20 65150 Reinsertion of ocular implant; with or without conjunctival graft 65155 Reinsertion of ocular implant; with use of foreign material for reinforcement and/or attachment of muscles to implant 65175 Removal of ocular implant $ 1,166.40 65205 Removal of foreign body, external eye; conjunctival superficial $ 116.74 65210 Removal of foreign body, external eye; conjunctival embedded (includes concretions), subconjunctival, or scleral nonperforating $ 131.60 65220 Removal of foreign body, external eye; corneal, without slit lamp $ 112.50 65222 Removal of foreign body, external eye; corneal, with slit lamp $ 163.91 65235 Removal of foreign body, intraocular; from anterior chamber of eye or lens $ 1,715.40 65260 Removal of foreign body, intraocular; from posterior segment, magnetic extraction, anterior or posterior route 65265 Removal of foreign body, intraocular; from posterior segment, nonmagnetic extraction 65270 Repair of laceration; conjunctiva, with or without nonperforating laceration sclera, direct closure $ 275.02 65272 Repair of laceration; conjunctiva, by mobilization and rearrangement, without hospitalization $ 494.10 65273 Repair of laceration; conjunctiva, by mobilization and rearrangement, with hospitalization 65275 Repair of laceration; cornea, nonperforating, with or without removal foreign body $ 821.70 65280 Repair of laceration; cornea and/or sclera, perforating, not involving uveal tissue $ 2,082.60 65285 Repair of laceration; cornea and/or sclera, perforating, with reposition or resection of uveal tissue $ 3,026.69 65286 Repair of laceration; application of tissue glue, wounds of cornea and/or sclera 65290 Repair of wound, extraocular muscle, tendon and/or Tenon's capsule 65400 Excision of lesion, cornea (keratectomy, lamellar, partial), except pterygium 65410 Biopsy of cornea $ 466.20 65420 Excision or transposition of pterygium; without graft $ 944.78 65426 Excision or transposition of pterygium; with graft $ 1,369.33 65430 Scraping of cornea, diagnostic, for smear and/or culture 65435 Removal of corneal epithelium; with or without chemocauterization (abrasion, curettage) 65436 Removal of corneal epithelium; with application of chelating agent (eg, EDTA) 65450 Destruction of lesion of cornea by cryotherapy, photocoagulation or thermocauterization

Row # CPT-4 HCPCS Price 65600 Multiple punctures of anterior cornea (eg, for corneal erosion, tattoo) $ 817.20 65710 Keratoplasty (corneal transplant); anterior lamellar $ 3,068.10 65730 Keratoplasty (corneal transplant); penetrating (except in aphakia or pseudophakia) 65750 Keratoplasty (corneal transplant); penetrating (in aphakia) 65755 Keratoplasty (corneal transplant); penetrating (in pseudophakia) $ 3,698.10 65756 Keratoplasty (corneal transplant); endothelial $ 2,478.45 65757 Backbench preparation of corneal endothelial allograft prior to transplantation (List separately in addition to code for primary $ - 65760 Keratomileusis $ 3,709.80 65765 Keratophakia $ 3,844.80 65767 Epikeratoplasty $ 3,079.80 65770 Keratoprosthesis 65771 Radial keratotomy $ 1,617.30 65772 Corneal relaxing incision for correction of surgically induced astigmatism $ 1,199.70 65775 Corneal wedge resection for correction of surgically induced astigmatism 65780 Ocular surface reconstruction; amniotic membrane transplantation, multiple layers $ 1,555.66 65781 Ocular surface reconstruction; limbal stem cell allograft (eg, cadaveric or living donor) $ 2,458.31 65782 Ocular surface reconstruction; limbal conjunctival autograft $ 1,989.88 65800 removal of aqueous 65810 removal of vitreous and/or discission of anterior hyaloid membrane, with or without air injection $ 1,247.40 65815 removal of blood, with or without irrigation and/or air injection $ 1,110.60 65820 Goniotomy 65850 Trabeculotomy ab externo $ 2,154.60 65855 Trabeculoplasty by laser surgery, 1 or more sessions (defined treatment series) 65860 Severing adhesions of anterior segment, laser technique (separate $ 1,277.10 65865 goniosynechiae 65870 anterior synechiae, except goniosynechiae 65875 posterior synechiae $ 1,417.50 65880 corneovitreal adhesions $ 1,403.10 65900 Removal of epithelial downgrowth, anterior chamber of eye 65920 Removal of implanted material, anterior segment of eye $ 1,873.17 65930 Removal of blood clot, anterior segment of eye $ 1,298.70 66020 Injection, anterior chamber of eye (separate procedure); air or liquid 66030 Injection, anterior chamber of eye (separate procedure); medication $ 232.20 66130 Excision of lesion, sclera 66150 Fistulization of sclera for glaucoma; trephination with iridectomy 66155 Fistulization of sclera for glaucoma; thermocauterization with iridectomy 66160 Fistulization of sclera for glaucoma; sclerectomy with punch or scissors, with iridectomy $ 1,874.70

Row # CPT-4 HCPCS Price 66165 Fistulization of sclera for glaucoma; iridencleisis or iridotasis $ 1,788.30 66170 Fistulization of sclera for glaucoma; trabeculectomy ab externo in absence of previous surgery $ 2,064.60 66172 Fistulization of sclera for glaucoma; trabeculectomy ab externo with scarring from previous ocular surgery or trauma (includes injection of antifibrotic agents) $ 2,304.00 66180 Aqueous shunt to extraocular reservoir (eg, Molteno, Schocket, Denver-Krupin) $ 2,621.70 66185 Revision of aqueous shunt to extraocular reservoir $ 1,754.10 66220 Repair of scleral staphyloma; without graft 66225 Repair of scleral staphyloma; with graft $ 3,115.80 66250 Revision or repair of operative wound of anterior segment, any type, early or late, major or minor procedure 66500 Iridotomy by stab incision (separate procedure); except transfixion $ 891.00 66505 Iridotomy by stab incision (separate procedure); with transfixion as for iris bombe 66600 Iridectomy, with corneoscleral or corneal section; for removal of lesion $ 1,434.60 66605 Iridectomy, with corneoscleral or corneal section; with cyclectomy 66625 Iridectomy, with corneoscleral or corneal section; peripheral for glaucoma (separate procedure) $ 1,401.30 66630 Iridectomy, with corneoscleral or corneal section; sector for glaucoma (separate procedure) $ 1,356.30 66635 Iridectomy, with corneoscleral or corneal section; optical (separate $ 1,356.30 66680 Repair of iris, ciliary body (as for iridodialysis) $ 1,522.80 66682 Suture of iris, ciliary body (separate procedure) with retrieval of suture through small incision (eg, McCannel suture) $ 1,645.20 66700 Ciliary body destruction; diathermy $ 1,231.20 66710 Ciliary body destruction; cyclophotocoagulation, transscleral 66711 Ciliary body destruction; cyclophotocoagulation, endoscopic $ 1,283.69 66720 Ciliary body destruction; cryotherapy 66740 Ciliary body destruction; cyclodialysis $ 1,275.30 66761 Iridotomy/iridectomy by laser surgery (eg, for glaucoma) (per 66762 Iridoplasty by photocoagulation (1 or more sessions) (eg, for improvement of vision, for widening of anterior chamber angle) $ 1,241.10 66770 Destruction of cyst or lesion iris or ciliary body (nonexcisional $ 1,347.30 66820 Discission of secondary membranous cataract (opacified posterior lens capsule and/or anterior hyaloid); stab incision technique (Ziegler or Wheeler knife) 66821 Discission of secondary membranous cataract (opacified posterior lens capsule and/or anterior hyaloid); laser surgery (eg, YAG laser) (1 or more stages) $ 1,117.54 66825 Repositioning of intraocular lens prosthesis, requiring an incision 66830 Removal of secondary membranous cataract (opacified posterior lens capsule and/or anterior hyaloid) with corneo-scleral section, with or without iridectomy (iridocapsulotomy, iridocapsulectomy) 66840 Removal of lens material; aspiration technique, 1 or more stages 66850 Removal of lens material; phacofragmentation technique (mechanical or ultrasonic) (eg, phacoemulsification), with aspiration 66852 Removal of lens material; pars plana approach, with or without vitrectomy $ 2,191.50 66920 Removal of lens material; intracapsular $ 2,442.60 66930 Removal of lens material; intracapsular, for dislocated lens $ 2,337.30 66940 Removal of lens material; extracapsular (other than 66840, 66850, 66852)

Row # CPT-4 HCPCS Price 66982 Extracapsular cataract removal with insertion of intraocular lens prosthesis (1-stage procedure), manual or mechanical technique (eg, irrigation and aspiration or phacoemulsification), complex, requiring devices or techniques not generally used in routine $ 2,692.80 66983 Intracapsular cataract extraction with insertion of intraocular lens prosthesis (1 stage procedure) $ 2,913.30 66984 Extracapsular cataract removal with insertion of intraocular lens prosthesis (1 stage procedure), manual or mechanical technique (eg, irrigation and aspiration or phacoemulsification) $ 2,961.00 66985 Insertion of intraocular lens prosthesis (secondary implant), not associated with concurrent cataract removal 66986 Exchange of intraocular lens $ 2,513.70 66990 Use of ophthalmic endoscope (List separately in addition to code for $ 208.58 66999 Unlisted procedure, anterior segment of eye Cost 67005 Removal of vitreous, anterior approach (open sky technique or limbal incision); partial removal 67010 Removal of vitreous, anterior approach (open sky technique or limbal incision); subtotal removal with mechanical vitrectomy $ 3,078.00 67015 Aspiration or release of vitreous, subretinal or choroidal fluid, pars plana approach (posterior sclerotomy) $ 1,328.40 67025 Injection of vitreous substitute, pars plana or limbal approach (fluid- gas exchange), with or without aspiration (separate procedure) 67027 Implantation of intravitreal drug delivery system (eg, ganciclovir implant), includes concomitant removal of vitreous 67028 Intravitreal injection of a pharmacologic agent (separate procedure) $ 677.70 67030 Discission of vitreous strands (without removal), pars plana 67031 Severing of vitreous strands, vitreous face adhesions, sheets, membranes or opacities, laser surgery (1 or more stages) $ 1,725.30 67036 Vitrectomy, mechanical, pars plana approach; $ 3,816.00 67039 Vitrectomy, mechanical, pars plana approach; with focal endolaser photocoagulation $ 4,336.20 67040 Vitrectomy, mechanical, pars plana approach; with endolaser panretinal photocoagulation 67041 preretinal cellular membrane (eg, macular pucker) $ 3,643.85 67042 internal limiting membrane of retina (eg, for repair of macular hole, diabetic macular edema), includes, if performed, intraocular tamponade (ie, air, gas or silicone oil) $ 4,430.03 67043 subretinal membrane (eg, choroidal neovascularization), includes, if performed, intraocular tamponade (ie, air, gas or silicone oil) and laser photocoagulation $ 4,581.88 67101 Repair of retinal detachment, 1 or more sessions; cryotherapy or diathermy, with or without drainage of subretinal fluid $ 2,293.20 67105 Repair of retinal detachment, 1 or more sessions; photocoagulation, with or without drainage of subretinal fluid 67107 Repair of retinal detachment; scleral buckling (such as lamellar scleral dissection, imbrication or encircling procedure), with or without implant, with or without cryotherapy, photocoagulation, and drainage of subretinal fluid $ 3,351.60 67108 Repair of retinal detachment; with vitrectomy, any method, with or without air or gas tamponade, focal endolaser photocoagulation, cryotherapy, drainage of subretinal fluid, scleral buckling, and/or removal of lens by same technique $ 4,954.50 67110 Repair of retinal detachment; by injection of air or other gas (eg, pneumatic retinopexy) $ 2,899.80

Row # CPT-4 HCPCS Price 67112 Repair of retinal detachment; by scleral buckling or vitrectomy, on patient having previous ipsilateral retinal detachment repair(s) using scleral buckling or vitrectomy techniques $ 3,100.50 67113 Repair of complex retinal detachment (eg, proliferative vitreoretinopathy, stage C-1 or greater, diabetic traction retinal detachment, retinopathy of prematurity, retinal tear of greater than 90 degrees), with vitrectomy and membrane peeling, may include $ 4,729.72 67115 Release of encircling material (posterior segment) 67120 Removal of implanted material, posterior segment; extraocular $ 1,269.90 67121 Removal of implanted material, posterior segment; intraocular $ 1,663.20 67141 Prophylaxis of retinal detachment (eg, retinal break, lattice degeneration) without drainage, 1 or more sessions; cryotherapy, diathermy 67145 Prophylaxis of retinal detachment (eg, retinal break, lattice degeneration) without drainage, 1 or more sessions; photocoagulation (laser or xenon arc) $ 1,518.03 67208 tumors), 1 or more sessions; cryotherapy, diathermy 67210 tumors), 1 or more sessions; photocoagulation $ 1,524.43 67218 tumors), 1 or more sessions; radiation by implantation of source (includes removal of source) 67220 neovascularization); photocoagulation (eg, laser), 1 or more sessions $ 1,760.40 67221 neovascularization); photodynamic therapy (includes intravenous infusion) 67225 neovascularization); photodynamic therapy, second eye, at single session (List separately in addition to code for primary eye treatment) $ 424.48 67227 Destruction of extensive or progressive retinopathy (eg, diabetic retinopathy), 1 or more sessions, cryotherapy, diathermy $ 1,713.60 67228 Treatment of extensive or progressive retinopathy, 1 or more sessions; (eg, diabetic retinopathy), photocoagulation $ 1,702.39 67229 Treatment of extensive or progressive retinopathy, 1 or more sessions; preterm infant (less than 37 weeks gestation at birth), performed from birth up to 1 year of age (eg, retinopathy of prematurity), photocoagulation or cryotherapy $ 1,631.69 67250 Scleral reinforcement (separate procedure); without graft $ 1,955.70 67255 Scleral reinforcement (separate procedure); with graft $ 2,400.30 67299 Unlisted procedure, posterior segment Cost 67311 Strabismus surgery, recession or resection procedure; 1 horizontal muscle 67312 Strabismus surgery, recession or resection procedure; 2 horizontal muscles 67314 Strabismus surgery, recession or resection procedure; 1 vertical muscle (excluding superior oblique) 67316 Strabismus surgery, recession or resection procedure; 2 or more vertical muscles (excluding superior oblique) 67318 Strabismus surgery, any procedure, superior oblique muscle $ 2,106.90 67320 Transposition procedure (eg, for paretic extraocular muscle), any extraocular muscle (specify) (List separately in addition to code for 67331 Strabismus surgery on patient with previous eye surgery or injury that did not involve the extraocular muscles (List separately in

Row # CPT-4 HCPCS Price 67332 Strabismus surgery on patient with scarring of extraocular muscles (eg, prior ocular injury, strabismus or retinal detachment surgery) or restrictive myopathy (eg, dysthyroid ophthalmopathy) (List $ 2,152.80 67334 Strabismus surgery by posterior fixation suture technique, with or without muscle recession (List separately in addition to code for 67335 Placement of adjustable suture(s) during strabismus surgery, including postoperative adjustment(s) of suture(s) (List separately in addition to code for specific strabismus surgery) 67340 Strabismus surgery involving exploration and/or repair of detached extraocular muscle(s) (List separately in addition to code for 67343 Release of extensive scar tissue without detaching extraocular muscle (separate procedure) 67345 Chemodenervation of extraocular muscle $ 539.10 67346 Biopsy of extraocular muscle $ 544.18 67399 Unlisted procedure, ocular muscle Cost 67400 approach); for exploration, with or without biopsy 67405 approach); with drainage only $ 1,980.90 67412 approach); with removal of lesion $ 2,352.60 67413 approach); with removal of foreign body $ 2,716.20 67414 approach); with removal of bone for decompression $ 2,228.40 67415 Fine needle aspiration of orbital contents 67420 Kroenlein); with removal of lesion 67430 Kroenlein); with removal of foreign body $ 2,887.20 67440 Kroenlein); with drainage $ 3,031.20 67445 Kroenlein); with removal of bone for decompression $ 2,722.50 67450 Kroenlein); for exploration, with or without biopsy $ 2,966.40 67500 Retrobulbar injection; medication (separate procedure, does not include supply of medication) 67505 Retrobulbar injection; alcohol 67515 Injection of medication or other substance into Tenon's capsule $ 139.50 67550 Orbital implant (implant outside muscle cone); insertion 67560 Orbital implant (implant outside muscle cone); removal or revision 67570 Optic nerve decompression (eg, incision or fenestration of optic nerve sheath) $ 2,440.80 67599 Unlisted procedure, orbit Cost 67700 Blepharotomy, drainage of abscess, eyelid $ 184.47 67710 Severing of tarsorrhaphy 67715 Canthotomy (separate procedure) $ 366.30 67800 Excision of chalazion; single $ 218.88 67801 Excision of chalazion; multiple, same lid $ 304.59 67805 Excision of chalazion; multiple, different lids $ 356.44 67808 Excision of chalazion; under general anesthesia and/or requiring hospitalization, single or multiple $ 565.20 67810 Incisional biopsy of eyelid skin including lid margin 67820 Correction of trichiasis; epilation, by forceps only $ 94.99 67825 Correction of trichiasis; epilation by other than forceps (eg, by electrosurgery, cryotherapy, laser surgery) 67830 Correction of trichiasis; incision of lid margin 67835 Correction of trichiasis; incision of lid margin, with free mucous membrane graft $ 1,691.10 67840 Excision of lesion of eyelid (except chalazion) without closure or with simple direct closure $ 353.47 67850 Destruction of lesion of lid margin (up to 1 cm) $ 252.00

Row # CPT-4 HCPCS Price 67875 Temporary closure of eyelids by suture (eg, Frost suture) $ 442.80 67880 Construction of intermarginal adhesions, median tarsorrhaphy, or canthorrhaphy; $ 864.00 67882 Construction of intermarginal adhesions, median tarsorrhaphy, or canthorrhaphy; with transposition of tarsal plate 67900 Repair of brow ptosis (supraciliary, mid-forehead or coronal $ 1,399.50 67901 Repair of blepharoptosis; frontalis muscle technique with suture or other material (eg, banked fascia) $ 2,169.00 67902 Repair of blepharoptosis; frontalis muscle technique with autologous fascial sling (includes obtaining fascia) $ 2,372.40 67903 Repair of blepharoptosis; (tarso) levator resection or advancement, internal approach 67904 Repair of blepharoptosis; (tarso) levator resection or advancement, external approach $ 2,879.10 67906 Repair of blepharoptosis; superior rectus technique with fascial sling (includes obtaining fascia) $ 2,122.20 67908 Repair of blepharoptosis; conjunctivo-tarso-Muller's muscle-levator resection (eg, Fasanella-Servat type) $ 1,909.80 67909 Reduction of overcorrection of ptosis $ 1,689.30 67911 Correction of lid retraction 67912 Correction of lagophthalmos, with implantation of upper eyelid lid load (eg, gold weight) $ 2,145.90 67914 Repair of ectropion; suture $ 977.40 67915 Repair of ectropion; thermocauterization 67916 Repair of ectropion; excision tarsal wedge $ 1,341.90 67917 Repair of ectropion; extensive (eg, tarsal strip operations) 67921 Repair of entropion; suture 67922 Repair of entropion; thermocauterization 67923 Repair of entropion; excision tarsal wedge 67924 Repair of entropion; extensive (eg, tarsal strip or capsulopalpebral fascia repairs operation) $ 1,857.60 67930 Suture of recent wound, eyelid, involving lid margin, tarsus, and/or palpebral conjunctiva direct closure; partial thickness $ 949.50 67935 Suture of recent wound, eyelid, involving lid margin, tarsus, and/or palpebral conjunctiva direct closure; full thickness 67938 Removal of embedded foreign body, eyelid $ 222.30 67950 Canthoplasty (reconstruction of canthus) $ 1,822.50 67961 Excision and repair of eyelid, involving lid margin, tarsus, conjunctiva, canthus, or full thickness, may include preparation for skin graft or pedicle flap with adjacent tissue transfer or rearrangement; up to one-fourth of lid margin $ 2,062.80 67966 Excision and repair of eyelid, involving lid margin, tarsus, conjunctiva, canthus, or full thickness, may include preparation for skin graft or pedicle flap with adjacent tissue transfer or rearrangement; over one-fourth of lid margin 67971 tarsoconjunctival flap from opposing eyelid; up to two-thirds of eyelid, 1 stage or first stage $ 2,272.50 67973 tarsoconjunctival flap from opposing eyelid; total eyelid, lower, 1 stage or first stage $ 3,181.50 67974 tarsoconjunctival flap from opposing eyelid; total eyelid, upper, 1 stage or first stage $ 3,420.90 67975 tarsoconjunctival flap from opposing eyelid; second stage $ 1,535.40 67999 Unlisted procedure, eyelids Cost 68020 Incision of conjunctiva, drainage of cyst $ 166.30 68040 Expression of conjunctival follicles (eg, for trachoma) 68100 Biopsy of conjunctiva 68110 Excision of lesion, conjunctiva; up to 1 cm $ 365.72 68115 Excision of lesion, conjunctiva; over 1 cm $ 454.50 68130 Excision of lesion, conjunctiva; with adjacent sclera 68135 Destruction of lesion, conjunctiva 68200 Subconjunctival injection

Row # CPT-4 HCPCS Price 68320 Conjunctivoplasty; with conjunctival graft or extensive rearrangement 68325 Conjunctivoplasty; with buccal mucous membrane graft (includes $ 2,090.70 68326 Conjunctivoplasty, reconstruction cul-de-sac; with conjunctival graft or extensive rearrangement $ 2,130.30 68328 Conjunctivoplasty, reconstruction cul-de-sac; with buccal mucous membrane graft (includes obtaining graft) $ 2,104.20 68330 Repair of symblepharon; conjunctivoplasty, without graft $ 1,292.40 68335 Repair of symblepharon; with free graft conjunctiva or buccal mucous membrane (includes obtaining graft) $ 1,466.10 68340 Repair of symblepharon; division of symblepharon, with or without insertion of conformer or contact lens $ 1,123.20 68360 Conjunctival flap; bridge or partial (separate procedure) 68362 Conjunctival flap; total (such as Gunderson thin flap or purse string flap) $ 1,544.40 68371 Harvesting conjunctival allograft, living donor $ 817.41 68399 Unlisted procedure, conjunctiva Cost 68400 Incision, drainage of lacrimal gland $ 301.50 68420 Incision, drainage of lacrimal sac (dacryocystotomy or dacryocystostomy) $ 362.70 68440 Snip incision of lacrimal punctum $ 276.30 68500 Excision of lacrimal gland (dacryoadenectomy), except for tumor; total 68505 Excision of lacrimal gland (dacryoadenectomy), except for tumor; partial $ 1,574.10 68510 Biopsy of lacrimal gland $ 674.10 68520 Excision of lacrimal sac (dacryocystectomy) $ 1,632.60 68525 Biopsy of lacrimal sac $ 518.40 68530 Removal of foreign body or dacryolith, lacrimal passages 68540 Excision of lacrimal gland tumor; frontal approach $ 2,062.80 68550 Excision of lacrimal gland tumor; involving osteotomy 68700 Plastic repair of canaliculi $ 1,694.70 68705 Correction of everted punctum, cautery 68720 Dacryocystorhinostomy (fistulization of lacrimal sac to nasal cavity) $ 2,123.10 68745 Conjunctivorhinostomy (fistulization of conjunctiva to nasal cavity); without tube 68750 Conjunctivorhinostomy (fistulization of conjunctiva to nasal cavity); with insertion of tube or stent $ 2,332.80 68760 Closure of the lacrimal punctum; by thermocauterization, ligation, or laser surgery 68761 Closure of the lacrimal punctum; by plug, each 68770 Closure of lacrimal fistula (separate procedure) 68801 Dilation of lacrimal punctum, with or without irrigation 68810 Probing of nasolacrimal duct, with or without irrigation; 68811 Probing of nasolacrimal duct, with or without irrigation; requiring general anesthesia $ 422.10 68815 Probing of nasolacrimal duct, with or without irrigation; with insertion of tube or stent $ 532.80 68816 Probing of nasolacrimal duct, with or without irrigation; with transluminal balloon catheter dilation $ 1,322.33 68840 Probing of lacrimal canaliculi, with or without irrigation 68850 Injection of contrast medium for dacryocystography $ 170.10 68899 Unlisted procedure, lacrimal system Cost 69000 Drainage external ear, abscess or hematoma; simple 69005 Drainage external ear, abscess or hematoma; complicated 69020 Drainage external auditory canal, abscess $ 200.70 69090 Ear piercing 69100 Biopsy external ear 69105 Biopsy external auditory canal 69110 Excision external ear; partial, simple repair $ 848.70 69120 Excision external ear; complete amputation $ 1,729.80 69140 Excision exostosis(es), external auditory canal 69145 Excision soft tissue lesion, external auditory canal 69150 Radical excision external auditory canal lesion; without neck $ 2,611.80 69155 Radical excision external auditory canal lesion; with neck dissection $ 4,492.80

Row # CPT-4 HCPCS Price 69200 Removal foreign body from external auditory canal; without general 69205 Removal foreign body from external auditory canal; with general $ 525.89 69210 Removal impacted cerumen requiring instrumentation, unilateral $ 64.34 69220 Debridement, mastoidectomy cavity, simple (eg, routine cleaning) $ 104.73 69222 Debridement, mastoidectomy cavity, complex (eg, with anesthesia or more than routine cleaning) $ 315.90 69300 Otoplasty, protruding ear, with or without size reduction $ 2,126.70 69310 Reconstruction of external auditory canal (meatoplasty) (eg, for stenosis due to injury, infection) (separate procedure) $ 3,252.60 69320 Reconstruction external auditory canal for congenital atresia, single stage $ 3,473.10 69399 Unlisted procedure, external ear Cost 69400 Eustachian tube inflation, transnasal; with catheterization $ 144.90 69401 Eustachian tube inflation, transnasal; without catheterization $ 108.90 69405 Eustachian tube catheterization, transtympanic $ 154.80 69420 Myringotomy including aspiration and/or eustachian tube inflation 69421 Myringotomy including aspiration and/or eustachian tube inflation requiring general anesthesia 69424 Ventilating tube removal requiring general anesthesia 69433 Tympanostomy (requiring insertion of ventilating tube), local or topical anesthesia $ 426.42 69436 Tympanostomy (requiring insertion of ventilating tube), general $ 621.90 69440 Middle ear exploration through postauricular or ear canal incision $ 2,028.60 69450 Tympanolysis, transcanal $ 2,083.50 69501 Transmastoid antrotomy (simple mastoidectomy) $ 2,442.60 69502 Mastoidectomy; complete $ 3,323.70 69505 Mastoidectomy; modified radical $ 3,462.30 69511 Mastoidectomy; radical 69530 Petrous apicectomy including radical mastoidectomy $ 4,139.10 69535 Resection temporal bone, external approach $ 6,341.40 69540 Excision aural polyp 69550 Excision aural glomus tumor; transcanal $ 3,636.90 69552 Excision aural glomus tumor; transmastoid $ 4,195.80 69554 Excision aural glomus tumor; extended (extratemporal) $ 5,842.80 69601 Revision mastoidectomy; resulting in complete mastoidectomy $ 3,073.50 69602 Revision mastoidectomy; resulting in modified radical mastoidectomy $ 3,607.20 69603 Revision mastoidectomy; resulting in radical mastoidectomy $ 3,481.20 69604 Revision mastoidectomy; resulting in tympanoplasty $ 3,876.30 69605 Revision mastoidectomy; with apicectomy $ 3,746.70 69610 Tympanic membrane repair, with or without site preparation of perforation for closure, with or without patch 69620 Myringoplasty (surgery confined to drumhead and donor area) $ 2,461.50 69631 atticotomy and/or middle ear surgery), initial or revision; without ossicular chain reconstruction $ 3,134.70 69632 atticotomy and/or middle ear surgery), initial or revision; with ossicular chain reconstruction (eg, postfenestration) 69633 atticotomy and/or middle ear surgery), initial or revision; with ossicular chain reconstruction and synthetic prosthesis (eg, partial ossicular replacement prosthesis [PORP], total ossicular repl

Row # CPT-4 HCPCS Price 69635 membrane repair); without ossicular chain reconstruction 69636 membrane repair); with ossicular chain reconstruction $ 4,133.70 69637 membrane repair); with ossicular chain reconstruction and synthetic prosthesis (eg, partial ossicular replacement prosthesis [PORP], total $ 4,131.90 69641 ear surgery, tympanic membrane repair); without ossicular chain $ 3,818.70 69642 ear surgery, tympanic membrane repair); with ossicular chain $ 4,161.60 69643 ear surgery, tympanic membrane repair); with intact or reconstructed wall, without ossicular chain reconstruction $ 4,333.50 69644 ear surgery, tympanic membrane repair); with intact or reconstructed canal wall, with ossicular chain reconstruction $ 4,814.10 69645 ear surgery, tympanic membrane repair); radical or complete, without ossicular chain reconstruction $ 4,619.70 69646 ear surgery, tympanic membrane repair); radical or complete, with ossicular chain reconstruction $ 5,045.40 69650 Stapes mobilization $ 2,429.10 69660 Stapedectomy or stapedotomy with reestablishment of ossicular continuity, with or without use of foreign material; $ 3,344.40 69661 Stapedectomy or stapedotomy with reestablishment of ossicular continuity, with or without use of foreign material; with footplate drill out $ 3,737.70 69662 Revision of stapedectomy or stapedotomy $ 4,239.90 69666 Repair oval window fistula $ 3,217.50 69667 Repair round window fistula $ 3,156.30 69670 Mastoid obliteration (separate procedure) 69676 Tympanic neurectomy $ 2,268.90 69700 Closure postauricular fistula, mastoid (separate procedure) $ 1,625.40 69710 Implantation or replacement of electromagnetic bone conduction hearing device in temporal bone $ 1,761.30 69711 Removal or repair of electromagnetic bone conduction hearing device in temporal bone 69714 Implantation, osseointegrated implant, temporal bone, with percutaneous attachment to external speech processor/cochlear stimulator; without mastoidectomy $ 2,985.05 69715 Implantation, osseointegrated implant, temporal bone, with percutaneous attachment to external speech processor/cochlear stimulator; with mastoidectomy $ 3,580.56 69717 Replacement (including removal of existing device), osseointegrated implant, temporal bone, with percutaneous attachment to external speech processor/cochlear stimulator; without mastoidectomy $ 3,079.84 69718 Replacement (including removal of existing device), osseointegrated implant, temporal bone, with percutaneous attachment to external speech processor/cochlear stimulator; with mastoidectomy $ 3,691.07 69720 Decompression facial nerve, intratemporal; lateral to geniculate ganglion $ 3,883.50 69725 Decompression facial nerve, intratemporal; including medial to geniculate ganglion $ 5,624.10 69740 Suture facial nerve, intratemporal, with or without graft or decompression; lateral to geniculate ganglion $ 4,449.60

Row # CPT-4 HCPCS Price 69745 Suture facial nerve, intratemporal, with or without graft or decompression; including medial to geniculate ganglion $ 5,244.30 69799 Unlisted procedure, middle ear Cost 69801 Labyrinthotomy, with perfusion of vestibuloactive drug(s); transcanal $ 3,175.20 69805 Endolymphatic sac operation; without shunt 69806 Endolymphatic sac operation; with shunt 69820 Fenestration semicircular canal $ 3,438.00 69840 Revision fenestration operation $ 2,353.50 69905 Labyrinthectomy; transcanal $ 3,857.40 69910 Labyrinthectomy; with mastoidectomy $ 4,439.70 69915 Vestibular nerve section, translabyrinthine approach $ 5,052.60 69930 Cochlear device implantation, with or without mastoidectomy $ 5,318.10 69949 Unlisted procedure, inner ear Cost 69950 Vestibular nerve section, transcranial approach $ 5,448.60 69955 Total facial nerve decompression and/or repair (may include graft) $ 5,846.40 69960 Decompression internal auditory canal $ 5,529.60 69970 Removal of tumor, temporal bone $ 6,309.00 69979 Unlisted procedure, temporal bone, middle fossa approach Cost 69990 Microsurgical techniques, requiring use of operating microscope $ 834.30 90291 Cytomegalovirus immune globulin (CMV-IgIV), human, for intravenous use $ 72.90 90296 Diphtheria antitoxin, equine, any route $ 77.40 90474 Immunization administration by intranasal or oral route; each additional vaccine (single or combination vaccine/toxoid) (List $ 17.03 90703 Tetanus toxoid adsorbed, for intramuscular use $ 19.30 90785 Interactive complexity (List separately in addition to the code for $ 8.74 90791 Psychiatric diagnostic evaluation $ 276.51 90792 Psychiatric diagnostic evaluation with medical services $ 222.74 90832 Psychotherapy, 30 minutes with patient and/or family member $ 114.22 90833 Psychotherapy, 30 minutes with patient and/or family member $ 74.62 90834 Psychotherapy, 45 minutes with patient and/or family member $ 144.87 90836 Psychotherapy, 45 minutes with patient and/or family member $ 120.89 90837 Psychotherapy, 60 minutes with patient and/or family member $ 211.77 90838 Psychotherapy, 60 minutes with patient and/or family member $ 195.68 90845 Psychoanalysis $ 166.50 90846 Family psychotherapy (without the patient present) 90847 Family psychotherapy (conjoint psychotherapy) (with patient present) $ 151.62 90849 Multiple-family group psychotherapy 90853 Group psychotherapy (other than of a multiple-family group) $ 87.30 90863 Pharmacologic management, including prescription and review of medication, when performed with psychotherapy services (List $ 93.77 90865 Narcosynthesis for psychiatric diagnostic and therapeutic purposes (eg, sodium amobarbital (Amytal) interview) $ 271.80 90870 Electroconvulsive therapy (includes necessary monitoring) $ 209.70

Row # CPT-4 HCPCS Price 90875 Individual psychophysiological therapy incorporating biofeedback training by any modality (face-to-face with the patient), with psychotherapy (eg, insight oriented, behavior modifying or supportive psychotherapy); 30 minutes $ 117.06 90876 Individual psychophysiological therapy incorporating biofeedback training by any modality (face-to-face with the patient), with psychotherapy (eg, insight oriented, behavior modifying or supportive psychotherapy); 45 minutes 90880 Hypnotherapy $ 183.60 90882 Environmental intervention for medical management purposes on a psychiatric patient's behalf with agencies, employers, or institutions $ 118.80 90885 Psychiatric evaluation of hospital records, other psychiatric reports, psychometric and/or projective tests, and other accumulated data for medical diagnostic purposes $ 120.97 90887 Interpretation or explanation of results of psychiatric, other medical examinations and procedures, or other accumulated data to family or other responsible persons, or advising them how to assist patient $ 159.30 90889 Preparation of report of patient's psychiatric status, history, treatment, or progress (other than for legal or consultative purposes) for other individuals, agencies, or insurance carriers $ 171.00 90899 Unlisted psychiatric service or procedure Cost 90901 Biofeedback training by any modality 90911 Biofeedback training, perineal muscles, anorectal or urethral sphincter, including EMG and/or manometry 90935 Hemodialysis procedure with single evaluation by a physician or other qualified health care professional $ 249.80 90937 Hemodialysis procedure requiring repeated evaluation(s) with or without substantial revision of dialysis prescription 90940 Hemodialysis access flow study to determine blood flow in grafts and arteriovenous fistulae by an indicator method $ - 90945 Dialysis procedure other than hemodialysis (eg, peritoneal dialysis, hemofiltration, or other continuous renal replacement therapies), with single evaluation by a physician or other qualified health care $ 300.60 90947 Dialysis procedure other than hemodialysis (eg, peritoneal dialysis, hemofiltration, or other continuous renal replacement therapies) requiring repeated evaluations by a physician or other qualified health care professional, with or without substantial re $ 482.40 90951 counseling of parents; with 4 or more face-to-face visits by a $ 1,568.42 90952 counseling of parents; with 2-3 face-to-face visits by a physi $ - 90953 counseling of parents; with 1 face-to-face visit by a physicia $ - 90954 of parents; with 4 or more face-to-face visits by a physician $ 1,325.75 90955 of parents; with 2-3 face-to-face visits by a physician or ot $ 742.53

Row # CPT-4 HCPCS Price 90956 of parents; with 1 face-to-face visit by a physician or other $ 521.08 90957 counseling of parents; with 4 or more face-to-face visits by a physicia $ 1,046.60 90958 counseling of parents; with 2-3 face-to-face visits by a physician or o $ 702.47 90959 counseling of parents; with 1 face-to-face visit by a physician or othe $ 462.30 90960 patients 20 years of age and older; with 4 or more face-to-face visits by a physician or other qualified health care professional per month $ 515.18 90961 patients 20 years of age and older; with 2-3 face-to-face visits by a physician or other qualified health care professional per month $ 413.70 90962 patients 20 years of age and older; with 1 face-to-face visit by a physician or other qualified health care professional per month $ 301.29 90963 End-stage renal disease (ESRD) related services for home dialysis per full month, for patients younger than 2 years of age to include monitoring for the adequacy of nutrition, assessment of growth and $ 898.85 90964 per full month, for patients 2-11 years of age to include monitoring for the adequacy of nutrition, assessment of growth and $ 750.40 90965 per full month, for patients 12-19 years of age to include monitoring for the adequacy of nutrition, assessment of growth and $ 704.13 90966 per full month, for patients 20 years of age and older $ 368.71 90967 a full month of service, per day; for patients younger than 2 years of age $ 33.03 90968 a full month of service, per day; for patients 2-11 years of age $ 26.85 90969 a full month of service, per day; for patients 12-19 years of age $ 19.63 90970 a full month of service, per day; for patients 20 years of age and older $ 13.50 90989 Dialysis training, patient, including helper where applicable, any mode, completed course $ 653.40 90993 Dialysis training, patient, including helper where applicable, any mode, course not completed, per training session $ 135.90 90997 Hemoperfusion (eg, with activated charcoal or resin) $ 597.60 90999 Unlisted dialysis procedure, inpatient or outpatient Cost

Row # CPT-4 HCPCS Price 91010 $ 101.54 91013 with stimulation or perfusion (eg, stimulant, acid or alkali perfusion) (List separately in addition to code for primary procedu $ 68.42 91013-26 26 with stimulation or perfusion (eg, stimulant, acid or alkali perfusion) (List separately in addition to code for primary procedu $ 29.29 91013-TC TC $ 39.13 91020 $ 255.60 91020-26 26 91020 $ 74.00 91020-TC TC 91020 $ 181.60 91022 Duodenal motility (manometric) study $ 213.12 91030 $ 158.40 91030-26 26 91030 $ 49.29 91030-TC TC 91030 $ 109.11 91034 Esophagus, gastroesophageal reflux test; with nasal catheter pH electrode(s) placement, recording, analysis and interpretation $ 170.59 91035 Esophagus, gastroesophageal reflux test; with mucosal attached telemetry pH electrode placement, recording, analysis and $ 236.07 91037 Esophageal function test, gastroesophageal reflux test with nasal catheter intraluminal impedance electrode(s) placement, recording, analysis and interpretation; $ 148.35 91038 Esophageal function test, gastroesophageal reflux test with nasal catheter intraluminal impedance electrode(s) placement, recording, analysis and interpretation; prolonged (greater than 1 hour, up to 24 hours) $ 163.99 91040 Esophageal balloon distension provocation study $ 142.29 91065 Breath hydrogen or methane test (eg, for detection of lactase deficiency, fructose intolerance, bacterial overgrowth, or oro-cecal gastrointestinal transit) $ 16.38 91110 Gastrointestinal tract imaging, intraluminal (eg, capsule endoscopy), esophagus through ileum, with interpretation and report $ 522.07 91111 Gastrointestinal tract imaging, intraluminal (eg, capsule endoscopy), esophagus with interpretation and report $ 122.66 91120 Rectal sensation, tone, and compliance test (ie, response to graded balloon distention) $ 129.65 91122 $ 357.30 91122-26 26 91122 $ 131.95 91122-TC TC 91122 $ 225.35 91132 Electrogastrography, diagnostic, transcutaneous; $ 74.61 91133 Electrogastrography, diagnostic, transcutaneous; with provocative $ 110.50 91299 Unlisted diagnostic gastroenterology procedure Cost 92002 with initiation of diagnostic and treatment program; intermediate, new patient $ 87.67 92004 with initiation of diagnostic and treatment program; comprehensive, new patient, 1 or more visits $ 103.19 92012 with initiation or continuation of diagnostic and treatment program; intermediate, established patient $ 62.82 92014 with initiation or continuation of diagnostic and treatment program; comprehensive, established patient, 1 or more visits $ 87.18 92015 Determination of refractive state $ 28.58 92018 Ophthalmological examination and evaluation, under general anesthesia, with or without manipulation of globe for passive range of motion or other manipulation to facilitate diagnostic examination; complete $ 246.60

Row # CPT-4 HCPCS Price 92019 Ophthalmological examination and evaluation, under general anesthesia, with or without manipulation of globe for passive range of motion or other manipulation to facilitate diagnostic examination; limited 92020 Gonioscopy (separate procedure) $ 53.27 92025 Computerized corneal topography, unilateral or bilateral, with $ 28.67 92060 $ 66.59 92060-26 26 92060 $ 37.17 92060-TC TC 92060 $ 29.42 92065 $ 56.70 92065-26 26 92065 $ 16.99 92065-TC TC 92065 $ 39.71 92071 Fitting of contact lens for treatment of ocular surface disease $ 62.75 92072 Fitting of contact lens for management of keratoconus, initial fitting $ 238.67 92081 $ 46.80 92081-26 26 92081 $ 21.54 92081-TC TC 92081 $ 25.26 92082 $ 81.78 92082-26 26 92082 $ 35.28 92082-TC TC 92082 $ 46.50 92083 $ 125.94 92083-26 26 92083 $ 51.26

Row # CPT-4 HCPCS Price 92083-TC TC 92083 $ 74.68 92100 Serial tonometry (separate procedure) with multiple measurements of intraocular pressure over an extended time period with interpretation and report, same day (eg, diurnal curve or medical treatment of acute elevation of intraocular pressure) $ 52.70 92136 $ 123.93 92136-26 26 92136 $ 44.16 92136-TC TC 92136 $ 79.77 92140 Provocative tests for glaucoma, with interpretation and report, without tonography $ 57.90 92225 Ophthalmoscopy, extended, with retinal drawing (eg, for retinal detachment, melanoma), with interpretation and report; initial $ 79.44 92226 Ophthalmoscopy, extended, with retinal drawing (eg, for retinal detachment, melanoma), with interpretation and report; $ 70.28 92230 Fluorescein angioscopy with interpretation and report $ 126.90 92235 92235-26 26 92235 $ 98.35 92235-TC TC 92235 $ 149.15 92240 $ 225.00 92240-26 26 92240 $ 50.91 92240-TC TC 92240 $ 174.09 92250 $ 79.20 92250-26 26 92250 $ 21.57 92250-TC TC 92250 $ 57.63 92260 Ophthalmodynamometry $ 66.60 92265 92265-26 26 92265 $ 64.52 92265-TC TC 92265 $ 64.18 92270 92270-26 26 92270 $ 53.38 92270-TC TC 92270 $ 75.32 92275 $ 162.90 92275-26 26 92275 $ 55.10 92275-TC TC 92275 $ 107.80 92283 $ 56.70 92283-26 26 92283 $ 8.54 92283-TC TC 92283 $ 48.16 92284 92284-26 26 92284 $ 20.35 92284-TC TC 92284 $ 93.05 92285 $ 59.40 92285-26 26 92285 $ 8.25

Row # CPT-4 HCPCS Price 92285-TC TC 92285 $ 51.15 92286 $ 235.92 92286-26 26 92286 $ 127.49 92286-TC TC 92286 $ 108.43 92287 92287-26 26 92287 $ 56.26 92287-TC TC 92287 $ 123.74 92310 both eyes, except for aphakia 92311 for aphakia, 1 eye $ 180.90 92312 for aphakia, both eyes 92313 contact lens, with medical supervision of adaptation; corneoscleral lens $ 91.51 92314 independent technician; corneal lens, both eyes except for aphakia $ 67.48 92315 independent technician; corneal lens for aphakia, 1 eye $ 63.02 92316 independent technician; corneal lens for aphakia, both eyes $ 98.58 92317 independent technician; corneoscleral lens $ 66.07 92325 Modification of contact lens (separate procedure), with medical supervision of adaptation $ 43.20 92326 Replacement of contact lens $ 118.80 92340 Fitting of spectacles, except for aphakia; monofocal $ 56.70 92341 Fitting of spectacles, except for aphakia; bifocal $ 40.23 92342 Fitting of spectacles, except for aphakia; multifocal, other than bifocal $ 52.41 92352 Fitting of spectacle prosthesis for aphakia; monofocal $ 22.45 92353 Fitting of spectacle prosthesis for aphakia; multifocal $ 51.30 92354 Fitting of spectacle mounted low vision aid; single element system $ 28.49 92355 Fitting of spectacle mounted low vision aid; telescopic or other compound lens system $ 43.94 92358 Prosthesis service for aphakia, temporary (disposable or loan, including materials) $ 23.79 92370 Repair and refitting spectacles; except for aphakia $ 48.20 92371 Repair and refitting spectacles; spectacle prosthesis for aphakia $ 70.29 92499 Unlisted ophthalmological service or procedure $ - 92502 Otolaryngologic examination under general anesthesia 92504 Binocular microscopy (separate diagnostic procedure) $ 61.25 92511 Nasopharyngoscopy with endoscope (separate procedure) $ 229.50 92512 Nasal function studies (eg, rhinomanometry) 92516 Facial nerve function studies (eg, electroneuronography) 92520 Laryngeal function studies (ie, aerodynamic testing and acoustic

Row # CPT-4 HCPCS Price 92521 Evaluation of speech fluency (eg, stuttering, cluttering) $ 114.48 92521 Speech therapy, in the home, per diem $ 114.48 92522 Evaluation of speech sound production (eg, articulation, phonological process, apraxia, dysarthria); $ 92.94 92523 Evaluation of speech sound production (eg, articulation, phonological process, apraxia, dysarthria); with evaluation of language comprehension and expression (eg, receptive and expressive language) $ 193.07 92524 Behavioral and qualitative analysis of voice and resonance $ 96.89 92526 Treatment of swallowing dysfunction and/or oral function for feeding 92531 Spontaneous nystagmus, including gaze $ 54.00 92532 Positional nystagmus test $ 62.10 92533 stimulation constitutes 4 tests) $ 76.50 92534 Optokinetic nystagmus test $ 63.00 92540 Basic vestibular evaluation, includes spontaneous nystagmus test with eccentric gaze fixation nystagmus, with recording, positional nystagmus test, minimum of 4 positions, with recording, optokinetic nystagmus test, bidirectional foveal and peripheral sti $ 124.58 92541 $ 121.50 92541-26 26 92541 $ 79.30 92541-TC TC 92541 $ 42.20 92542 92542-26 26 92542 $ 69.82 92542-TC TC 92542 $ 44.48 92543 92543-26 26 92543 $ 40.96 92543-TC TC 92543 $ 87.74 92544 $ 77.40 92544-26 26 92544 $ 43.16 92544-TC TC 92544 $ 34.24 92545 $ 77.40 92545-26 26 92545 $ 41.96 92545-TC TC 92545 $ 35.44 92546 $ 101.70 92546-26 26 92546 $ 12.98 92546-TC TC 92546 $ 88.72 92547 Use of vertical electrodes (List separately in addition to code for $ 72.00 92548 $ 216.00 92548-26 26 92548 $ 47.62 92548-TC TC 92548 $ 168.38 92550 Tympanometry and reflex threshold measurements $ 38.60 92551 Screening test, pure tone, air only $ 34.20 92552 Pure tone audiometry (threshold); air only $ 40.77 92553 Pure tone audiometry (threshold); air and bone $ 61.69 92555 Speech audiometry threshold; $ 36.90 92556 Speech audiometry threshold; with speech recognition $ 54.76 92557 Comprehensive audiometry threshold evaluation and speech recognition (92553 and 92556 combined) $ 92.70 92559 Audiometric testing of groups $ 41.40 92560 Bekesy audiometry; screening $ 66.60 92561 Bekesy audiometry; diagnostic $ 83.70 92562 Loudness balance test, alternate binaural or monaural $ 40.50 92563 Tone decay test $ 45.00 92564 Short increment sensitivity index (SISI) $ 41.40

Row # CPT-4 HCPCS Price 92565 Stenger test, pure tone $ 50.40 92567 Tympanometry (impedance testing) $ 43.18 92568 Acoustic reflex testing, threshold $ 41.40 92570 Acoustic immittance testing, includes tympanometry (impedance testing), acoustic reflex threshold testing, and acoustic reflex decay $ 58.15 92571 Filtered speech test $ 38.70 92572 Staggered spondaic word test $ 42.30 92575 Sensorineural acuity level test $ 36.00 92576 Synthetic sentence identification test $ 38.70 92577 Stenger test, speech $ 51.30 92579 Visual reinforcement audiometry (VRA) 92582 Conditioning play audiometry $ 65.70 92583 Select picture audiometry $ 72.00 92584 Electrocochleography $ 252.00 92585 $ 353.70 92585-26 26 92585 $ 65.25 92585-TC TC 92585 $ 288.45 92586 testing of the central nervous system; limited $ 151.11 92587 92587-26 26 92587 $ 105.08 92587-TC TC 92587 $ 19.12 92588 $ 141.30 92588-26 26 92588 $ 122.06 92588-TC TC 92588 $ 19.24 92590 Hearing aid examination and selection; monaural 92591 Hearing aid examination and selection; binaural $ 146.70 92592 Hearing aid check; monaural $ 40.50 92593 Hearing aid check; binaural $ 57.60 92594 Electroacoustic evaluation for hearing aid; monaural $ 36.00 92595 Electroacoustic evaluation for hearing aid; binaural $ 38.70 92596 Ear protector attenuation measurements $ 51.30 92597 Evaluation for use and/or fitting of voice prosthetic device to supplement oral speech $ 188.10 92601 Diagnostic analysis of cochlear implant, patient younger than 7 years of age; with programming $ 279.88 92602 Diagnostic analysis of cochlear implant, patient younger than 7 years of age; subsequent reprogramming $ 200.79 92603 Diagnostic analysis of cochlear implant, age 7 years or older; with programming $ 187.38 92604 Diagnostic analysis of cochlear implant, age 7 years or older; subsequent reprogramming $ 124.41

Row # CPT-4 HCPCS Price 92605 Evaluation for prescription of non-speech-generating augmentative and alternative communication device, face-to-face with the patient; first hour $ 166.79 92606 Therapeutic service(s) for the use of non-speech-generating device, including programming and modification $ 151.11 92607 Evaluation for prescription for speech-generating augmentative and alternative communication device, face-to-face with the patient; first hour $ 259.20 92608 Evaluation for prescription for speech-generating augmentative and alternative communication device, face-to-face with the patient; each additional 30 minutes (List separately in addition to code for $ 57.16 92609 Therapeutic services for the use of speech-generating device, including programming and modification $ 139.99 92610 Evaluation of oral and pharyngeal swallowing function $ 270.34 92611 Motion fluoroscopic evaluation of swallowing function by cine or video recording $ 264.89 92612 Flexible fiberoptic endoscopic evaluation of swallowing by cine or video recording; $ 336.75 92613 Flexible fiberoptic endoscopic evaluation of swallowing by cine or video recording; interpretation and report only $ 86.41 92614 Flexible fiberoptic endoscopic evaluation, laryngeal sensory testing by cine or video recording; $ 296.87 92615 Flexible fiberoptic endoscopic evaluation, laryngeal sensory testing by cine or video recording; interpretation and report only $ 78.45 92616 Flexible fiberoptic endoscopic evaluation of swallowing and laryngeal sensory testing by cine or video recording; $ 438.23 92617 Flexible fiberoptic endoscopic evaluation of swallowing and laryngeal sensory testing by cine or video recording; interpretation and report only $ 103.33 92620 Evaluation of central auditory function, with report; initial 60 $ 99.31 92621 Evaluation of central auditory function, with report; each additional 15 minutes (List separately in addition to code for primary $ 25.94 92625 Assessment of tinnitus (includes pitch, loudness matching, and masking) $ 93.11 92626 Evaluation of auditory rehabilitation status; first hour $ 174.65 92627 Evaluation of auditory rehabilitation status; each additional 15 minutes (List separately in addition to code for primary procedure) $ 43.12 92630 Auditory rehabilitation; prelingual hearing loss $ - 92633 Auditory rehabilitation; postlingual hearing loss $ - 92640 Diagnostic analysis with programming of auditory brainstem implant, per hour $ 122.67 92700 Unlisted otorhinolaryngological service or procedure $ 32.92 92920 Percutaneous transluminal coronary angioplasty; single major coronary artery or branch $ 1,048.78 92921 Percutaneous transluminal coronary angioplasty; each additional branch of a major coronary artery (List separately in addition to 92924 Percutaneous transluminal coronary atherectomy, with coronary angioplasty when performed; single major coronary artery or branch $ 1,247.20 92925 Percutaneous transluminal coronary atherectomy, with coronary angioplasty when performed; each additional branch of a major coronary artery (List separately in addition to code for primary 92928 Percutaneous transcatheter placement of intracoronary stent(s), with coronary angioplasty when performed; single major coronary artery or branch $ 1,165.44 92929 Percutaneous transcatheter placement of intracoronary stent(s), with coronary angioplasty when performed; each additional branch of a major coronary artery (List separately in addition to code for 92933 Percutaneous transluminal coronary atherectomy, with intracoronary stent, with coronary angioplasty when performed; single major coronary artery or branch $ 1,303.22

Row # CPT-4 HCPCS Price 92934 Percutaneous transluminal coronary atherectomy, with intracoronary stent, with coronary angioplasty when performed; each additional branch of a major coronary artery (List separately in 92937 Percutaneous transluminal revascularization of or through coronary artery bypass graft (internal mammary, free arterial, venous), any combination of intracoronary stent, atherectomy and angioplasty, including distal protection when performed; single vesse $ 1,164.19 92938 Percutaneous transluminal revascularization of or through coronary artery bypass graft (internal mammary, free arterial, venous), any combination of intracoronary stent, atherectomy and angioplasty, including distal protection when performed; each additio 92941 Percutaneous transluminal revascularization of acute total/subtotal occlusion during acute myocardial infarction, coronary artery or coronary artery bypass graft, any combination of intracoronary stent, atherectomy and angioplasty, including aspiration th $ 1,306.01 92943 Percutaneous transluminal revascularization of chronic total occlusion, coronary artery, coronary artery branch, or coronary artery bypass graft, any combination of intracoronary stent, atherectomy and angioplasty; single vessel $ 1,306.01 92944 Percutaneous transluminal revascularization of chronic total occlusion, coronary artery, coronary artery branch, or coronary artery bypass graft, any combination of intracoronary stent, atherectomy and angioplasty; each additional coronary artery, coronar 92950 Cardiopulmonary resuscitation (eg, in cardiac arrest) $ 482.59 92953 Temporary transcutaneous pacing $ 329.40 92960 Cardioversion, elective, electrical conversion of arrhythmia; external $ 425.70 92961 Cardioversion, elective, electrical conversion of arrhythmia; internal $ 945.23 92970 Cardioassist-method of circulatory assist; internal $ 684.90 92971 Cardioassist-method of circulatory assist; external $ 275.40 92973 Percutaneous transluminal coronary thrombectomy mechanical $ 1,041.07 92974 Transcatheter placement of radiation delivery device for subsequent coronary intravascular brachytherapy (List separately in $ 801.14 92975 Thrombolysis, coronary; by intracoronary infusion, including selective coronary angiography $ 1,488.60 92977 Thrombolysis, coronary; by intravenous infusion $ 753.30 92978 Intravascular ultrasound (coronary vessel or graft) during diagnostic evaluation and/or therapeutic intervention including imaging supervision, interpretation and report; initial vessel (List separately $ 333.84 92979 Intravascular ultrasound (coronary vessel or graft) during diagnostic evaluation and/or therapeutic intervention including imaging supervision, interpretation and report; each additional vessel (List $ 236.88 92986 Percutaneous balloon valvuloplasty; aortic valve 92987 Percutaneous balloon valvuloplasty; mitral valve $ 3,403.45 92990 Percutaneous balloon valvuloplasty; pulmonary valve 92992 Atrial septectomy or septostomy; transvenous method, balloon (eg, Rashkind type) (includes cardiac catheterization) $ - 92993 Atrial septectomy or septostomy; blade method (Park septostomy) (includes cardiac catheterization) $ 4,408.20 92997 Percutaneous transluminal pulmonary artery balloon angioplasty; single vessel $ 2,449.80 92998 Percutaneous transluminal pulmonary artery balloon angioplasty; each additional vessel (List separately in addition to code for $ 949.50

Row # CPT-4 HCPCS Price 93000 Electrocardiogram, routine ECG with at least 12 leads; with $ 71.00 93005 Electrocardiogram, routine ECG with at least 12 leads; tracing only, without interpretation and report $ 56.70 93010 Electrocardiogram, routine ECG with at least 12 leads; interpretation and report only $ 51.30 93015 and/or pharmacological stress; with supervision, interpretation and $ 338.10 93016 and/or pharmacological stress; supervision only, without 93017 and/or pharmacological stress; tracing only, without interpretation 93018 and/or pharmacological stress; interpretation and report only $ 170.10 93024 93024-26 26 93024 $ 180.32 93024-TC TC 93024 $ 200.38 93025 Microvolt T-wave alternans for assessment of ventricular arrhythmias $ 119.07 93040 Rhythm ECG, 1-3 leads; with interpretation and report $ 49.49 93041 Rhythm ECG, 1-3 leads; tracing only without interpretation and $ 44.10 93042 Rhythm ECG, 1-3 leads; interpretation and report only $ 36.00 93224 continuous rhythm recording and storage; includes recording, scanning analysis with report, review and interpretation by a physician or other qualified health care professional $ 481.75 93225 continuous rhythm recording and storage; recording (includes connection, recording, and disconnection) 93226 continuous rhythm recording and storage; scanning analysis with 93227 continuous rhythm recording and storage; review and interpretation by a physician or other qualified health care 93228 External mobile cardiovascular telemetry with electrocardiographic recording, concurrent computerized real time data analysis and greater than 24 hours of accessible ECG data storage (retrievable with query) with ECG triggered and patient selected events $ 71.24 93229 External mobile cardiovascular telemetry with electrocardiographic recording, concurrent computerized real time data analysis and greater than 24 hours of accessible ECG data storage (retrievable with query) with ECG triggered and patient selected events $ 1,453.15 93268 days, 24-hour attended monitoring; includes transmission, review and interpr $ 382.17 93270 days, 24-hour attended monitoring; recording (includes connection, recording

Row # CPT-4 HCPCS Price 93271 days, 24-hour attended monitoring; transmission and analysis 93272 days, 24-hour attended monitoring; review and interpretation by a physician $ 91.80 93278 93278-26 26 93278 $ 79.25 93278-TC TC 93278 $ 132.25 93279 care $ 82.45 93280 care $ 98.60 93281 care $ 114.49 93282 care $ 107.41 93283 care $ 135.22 93284 care $ 171.39 93285 care $ 67.31 93286 Peri-procedural device evaluation (in person) and programming of device system parameters before or after a surgery, procedure, or test with analysis, review and report by a physician or other qualified health care professional; single, dual, or multiple $ 31.89 93287 Peri-procedural device evaluation (in person) and programming of device system parameters before or after a surgery, procedure, or test with analysis, review and report by a physician or other qualified health care professional; single, dual, or multiple $ 56.46 93288 encounter; single, dual, or multiple lead pacemaker syste $ 55.14

Row # CPT-4 HCPCS Price 93289 encounter; single, dual, or multiple lead implantable car 93290 encounter; implantable cardiovascular monitor system, inc $ 52.49 93291 encounter; implantable loop recorder system, including he $ 55.68 93293 $ 38.13 93294 dual, or multiple lead pacemaker system with interim analysis, review(s) and report(s) by a physician or other qualified health care $ 94.89 93295 dual, or multiple lead implantable cardioverter-defibrillator system with interim analysis, review(s) and report(s) by a physician or other qualified health care professional $ 152.27 93296 dual, or multiple lead pacemaker system or implantable cardioverter-defibrillator system, remote data acquisition(s), receipt of transmissions and technician review, technical support and $ 93.78 93297 implantable cardiovascular monitor system, including analysis of 1 or more recorded physiologic cardiovascular data elements from all internal and external sensors, analysis, review(s) and report $ 56.66 93298 implantable loop recorder system, including analysis of recorded heart rhythm data, analysis, review(s) and report(s) by a physician or other qualified health care professional $ 75.22 93299 implantable cardiovascular monitor system or implantable loop recorder system, remote data acquisition(s), receipt of transmissions and technician review, technical support and distribution of re $ - 93303 $ 513.90 93303-26 26 93303 $ 152.41 93303-TC TC 93303 $ 361.49 93304 93304-26 26 93304 $ 72.52 93304-TC TC 93304 $ 208.28 93306 complete, with spectral Doppler echocardiography, and with color flow Doppler echocardiography $ 230.29 93307 $ 499.03

Row # CPT-4 HCPCS Price 93307-26 26 93307 $ 182.92 93307-TC TC 93307 $ 316.11 93308 $ 58.08 93312 $ 665.35 93312-26 26 93312 $ 208.89 93312-TC TC 93312 $ 456.47 93313 documentation (2D) (with or without M-mode recording); placement of transesophageal probe only 93314 $ 424.80 93314-26 26 93314 $ 81.18 93314-TC TC 93314 $ 343.62 93315 anomalies; including probe placement, image acquisition, $ 663.30 93315-26 26 93315 anomalies; including probe placement, image acquisition, $ 463.40 93316 anomalies; placement of transesophageal probe only $ 135.90 93317 anomalies; image acquisition, interpretation and report only 93317-26 26 93317 anomalies; image acquisition, interpretation and report only $ 300.16 93318 Echocardiography, transesophageal (TEE) for monitoring purposes, including probe placement, real time 2-dimensional image acquisition and interpretation leading to ongoing (continuous) assessment of (dynamically changing) cardiac pumping function and to t $ 847.00 93320 $ 307.08 93320-26 26 93320 $ 116.49 93320-TC TC 93320 $ 190.59 93321

Row # CPT-4 HCPCS Price 93321-26 26 93321 $ 52.95 93321-TC TC 93321 $ 134.25 93325 $ 247.27 93325-26 26 93325 $ 44.14 93325-TC TC 93325 $ 203.13 93350 $ 853.56 93350-26 26 93350 $ 280.69 93350-TC TC 93350 $ 572.87 93351 $ 274.13 93352 Use of echocardiographic contrast agent during stress echocardiography (List separately in addition to code for primary $ 113.06 93462 Left heart catheterization by transseptal puncture through intact septum or by transapical puncture (List separately in addition to $ 756.48 93503 Insertion and placement of flow directed catheter (eg, Swan-Ganz) for monitoring purposes $ 725.40 93505 93505-26 26 93505 $ 290.16 93505-TC TC 93505 $ 716.94 93530 Right heart catheterization, for congenital cardiac anomalies $ - 93531 Combined right heart catheterization and retrograde left heart catheterization, for congenital cardiac anomalies $ - 93532 Combined right heart catheterization and transseptal left heart catheterization through intact septum with or without retrograde left heart catheterization, for congenital cardiac anomalies $ - 93533 Combined right heart catheterization and transseptal left heart catheterization through existing septal opening, with or without retrograde left heart catheterization, for congenital cardiac anomalies $ - 93561 Indicator dilution studies such as dye or thermodilution, including arterial and/or venous catheterization; with cardiac output measurement (separate procedure) $ - 93562 Indicator dilution studies such as dye or thermodilution, including arterial and/or venous catheterization; subsequent measurement of cardiac output $ - 93563 supervision, interpretation, and report; for selective coronary angiography during congenital heart catheterization (List separately $ 206.77

Row # CPT-4 HCPCS Price 93564 supervision, interpretation, and report; for selective opacification of aortocoronary venous or arterial bypass graft(s) (eg, aortocoronary saphenous vein, free radial artery, or free ma $ 207.05 93565 supervision, interpretation, and report; for selective left ventricular or left atrial angiography (List separately in addition to code for $ 160.18 93566 supervision, interpretation, and report; for selective right ventricular or right atrial angiography (List separately in addition to $ 642.05 93567 supervision, interpretation, and report; for supravalvular aortography (List separately in addition to code for primary $ 525.96 93568 supervision, interpretation, and report; for pulmonary angiography $ 578.40 93571 initial vessel (List separately in addition to code for primary pro $ 693.90 93571-26 26 93571 initial vessel (List separately in addition to code for primary pro $ 352.53 93572 each additional vessel (List separately in addition to code for pri $ 637.20 93572-26 26 93572 each additional vessel (List separately in addition to code for pri $ 290.14 93580 Percutaneous transcatheter closure of congenital interatrial communication (ie, Fontan fenestration, atrial septal defect) with $ 10,167.89 93600 Bundle of His recording 93600-26 26 93600 Bundle of His recording $ 310.59 93602 Intra-atrial recording $ 510.30 93602-26 26 93602 Intra-atrial recording $ 254.62 93603 Right ventricular recording 93603-26 26 93603 Right ventricular recording $ 221.61 93609 Intraventricular and/or intra-atrial mapping of tachycardia site(s) with catheter manipulation to record from multiple sites to identify origin of tachycardia (List separately in addition to code for primary 93609-26 26 93609 Intraventricular and/or intra-atrial mapping of tachycardia site(s) with catheter manipulation to record from multiple sites to identify origin of tachycardia (List separately in addition to code for primary $ 825.96 93610 Intra-atrial pacing 93610-26 26 93610 Intra-atrial pacing $ 416.14 93612 Intraventricular pacing 93612-26 26 93612 Intraventricular pacing $ 327.81 93613 Intracardiac electrophysiologic 3-dimensional mapping (List $ 1,153.65 93615 ventricular electrogram(s); 93615-26 26 93615 ventricular electrogram(s); $ 103.31 93616 ventricular electrogram(s); with pacing $ 358.20

Row # CPT-4 HCPCS Price 93616-26 26 93616 ventricular electrogram(s); with pacing 93618 Induction of arrhythmia by electrical pacing 93618-26 26 93618 Induction of arrhythmia by electrical pacing $ 730.18 93619 Comprehensive electrophysiologic evaluation with right atrial pacing and recording, right ventricular pacing and recording, His bundle recording, including insertion and repositioning of multiple electrode catheters, without induction or attempted inducti $ 2,567.70 93619-26 26 93619 Comprehensive electrophysiologic evaluation with right atrial pacing and recording, right ventricular pacing and recording, His bundle recording, including insertion and repositioning of multiple electrode catheters, without induction or attempted inducti $ 1,141.78 93620 attempted induction of arrhythmia; with right atrial pacing and recording, right ventricular pacing and recording, His bund $ 3,511.80 93620-26 26 93620 attempted induction of arrhythmia; with right atrial pacing and recording, right ventricular pacing and recording, His bund $ 1,780.00 93621 attempted induction of arrhythmia; with left atrial pacing and recording from coronary sinus or left atrium (List separatel $ 3,800.70 93621-26 26 93621 attempted induction of arrhythmia; with left atrial pacing and recording from coronary sinus or left atrium (List separatel $ 425.44 93622 attempted induction of arrhythmia; with left ventricular pacing and recording (List separately in addition to code for prim $ - 93623 Programmed stimulation and pacing after intravenous drug infusion $ 625.50 93623-26 26 93623 Programmed stimulation and pacing after intravenous drug infusion $ 377.16 93624 Electrophysiologic follow-up study with pacing and recording to test effectiveness of therapy, including induction or attempted induction of arrhythmia 93624-26 26 93624 Electrophysiologic follow-up study with pacing and recording to test effectiveness of therapy, including induction or attempted induction of arrhythmia $ 841.51 93631 Intraoperative epicardial and endocardial pacing and mapping to localize the site of tachycardia or zone of slow conduction for surgical correction $ 1,283.52 93640 $ 578.16 93641 $ 1,702.80 93641-26 26 93641 $ 890.84

Row # CPT-4 HCPCS Price 93642 cardioverter-defibrillator (includes defibrillation threshold pacing for arrhythmia termination, and programming or reprogramming $ 841.38 93650 Intracardiac catheter ablation of atrioventricular node function, atrioventricular conduction for creation of complete heart block, with or without temporary pacemaker placement 93653 attempted induction of an arrhythmia with right atrial pacing and recording, right ventricular pacing and recording (when n $ 1,587.14 93654 attempted induction of an arrhythmia with right atrial pacing and recording, right ventricular pacing and recording (when n $ 2,118.20 93655 Intracardiac catheter ablation of a discrete mechanism of arrhythmia which is distinct from the primary ablated mechanism, including repeat diagnostic maneuvers, to treat a spontaneous or induced arrhythmia (List separately in addition to code for primary $ 793.43 93656 Comprehensive electrophysiologic evaluation including transseptal catheterizations, insertion and repositioning of multiple electrode catheters with induction or attempted induction of an arrhythmia including left or right atrial pacing/recording when nec $ 2,118.70 93657 Additional linear or focal intracardiac catheter ablation of the left or right atrium for treatment of atrial fibrillation remaining after completion of pulmonary vein isolation (List separately in addition $ 794.38 93660 $ 639.00 93660-26 26 93660 $ 361.25 93660-TC TC 93660 $ 277.75 93662 Intracardiac echocardiography during therapeutic/diagnostic intervention, including imaging supervision and interpretation (List $ - 93668 Peripheral arterial disease (PAD) rehabilitation, per session $ 142.65 93701 Bioimpedance-derived physiologic cardiovascular analysis $ 86.57 93721-26 26 93721 $ 23.56 93721-TC TC 93721 $ 95.27 93722-26 26 93722 $ 23.56 93722-TC TC 93722 $ 95.27 93724 Electronic analysis of antitachycardia pacemaker system (includes electrocardiographic recording, programming of device, induction and termination of tachycardia via implanted pacemaker, and interpretation of recordings) $ 575.15 93733-26 26 93733 $ 38.13

Row # CPT-4 HCPCS Price 93733-TC TC 93733 $ 98.63 93736-26 26 93736 $ 38.13 93736-TC TC 93736 $ 98.63 93740 Temperature gradient studies 93745 Initial set-up and programming by a physician or other qualified health care professional of wearable cardioverter-defibrillator includes initial programming of system, establishing baseline electronic ECG, transmission of data to data repository, patient $ - 93750 Interrogation of ventricular assist device (VAD), in person, with physician or other qualified health care professional analysis of device parameters (eg, drivelines, alarms, power surges), review of device function (eg, flow and volume status, septum sta $ 107.14 93770 Determination of venous pressure $ 30.60 93784 including recording, scanning analysis, interpretation and report $ 369.90 93786 recording only $ 65.66 93788 scanning analysis with report $ 137.83 93790 magnetic tape and/or computer disk, for 24 hours or longer; review with interpretation and report $ 65.76 93797 Physician or other qualified health care professional services for outpatient cardiac rehabilitation; without continuous ECG monitoring (per session) $ 46.80 93798 Physician or other qualified health care professional services for outpatient cardiac rehabilitation; with continuous ECG monitoring (per session) $ 68.76 93799 Unlisted cardiovascular service or procedure Cost 93875-26 26 93875 $ 47.85 93875-TC TC 93875 $ 383.73 93880 $ 431.58 93880-26 26 93880 $ 47.85 93880-TC TC 93880 $ 383.73 93882 Duplex scan of extracranial arteries; unilateral or limited study $ 43.57 93886 Transcranial Doppler study of the intracranial arteries; complete study $ 53.54 93888 Transcranial Doppler study of the intracranial arteries; limited study $ 44.63 93890 Transcranial Doppler study of the intracranial arteries; vasoreactivity study $ 121.20 93892 Transcranial Doppler study of the intracranial arteries; emboli detection without intravenous microbubble injection $ 138.59

Row # CPT-4 HCPCS Price 93922 Limited bilateral noninvasive physiologic studies of upper or lower extremity arteries, (eg, for lower extremity: ankle/brachial indices at distal posterior tibial and anterior tibial/dorsalis pedis arteries plus bidirectional, Doppler waveform recording $ 26.81 93923 $ 364.50 93923-26 26 93923 $ 51.22 93923-TC TC 93923 $ 313.28 93924 93924-26 26 93924 $ 45.73 93924-TC TC 93924 $ 323.27 93925 $ 398.17 93925-26 26 93925 $ 56.52 93925-TC TC 93925 $ 341.65 93926 $ 245.96 93926-26 26 93926 $ 38.91 93926-TC TC 93926 $ 207.05 93930 93930-26 26 93930 $ 37.29 93930-TC TC 93930 $ 395.61 93931 93931-26 26 93931 $ 23.26 93931-TC TC 93931 $ 247.64 93965 $ 243.31 93965-26 26 93965 $ 30.99

Row # CPT-4 HCPCS Price 93965-TC TC 93965 $ 212.32 93970 $ 382.93 93970-26 26 93970 $ 64.54 93970-TC TC 93970 $ 318.39 93971 $ 237.86 93971-26 26 93971 $ 41.87 93971-TC TC 93971 $ 195.99 93975 study 93975-26 26 93975 study $ 86.92 93975-TC TC 93975 study $ 300.98 93976 pelvic, scrotal contents and/or retroperitoneal organs; limited study $ 109.12 93978 Duplex scan of aorta, inferior vena cava, iliac vasculature, or bypass grafts; complete study $ 46.67 93979 Duplex scan of aorta, inferior vena cava, iliac vasculature, or bypass grafts; unilateral or limited study $ 32.53 93980 Duplex scan of arterial inflow and venous outflow of penile vessels; complete study $ 179.39 93981 Duplex scan of arterial inflow and venous outflow of penile vessels; $ 63.58 93982 Noninvasive physiologic study of implanted wireless pressure sensor in aneurysmal sac following endovascular repair, complete study including recording, analysis of pressure and waveform tracings, $ 101.76 93990 Duplex scan of hemodialysis access (including arterial inflow, body of access and venous outflow) $ 16.62 94002 preset ventilators for assisted or controlled breathing; hospital inpatient/observation, initial day $ 218.34 94003 preset ventilators for assisted or controlled breathing; hospital inpatient/observation, each subsequent day $ 157.25 94004 preset ventilators for assisted or controlled breathing; nursing facility, per day $ 114.51 94005 Home ventilator management care plan oversight of a patient (patient not present) in home, domiciliary or rest home (eg, assisted living) requiring review of status, review of laboratories and other studies and revision of orders and respiratory care plan $ 203.72 94010 $ 92.70 94010-26 26 94010 $ 18.97

Row # CPT-4 HCPCS Price 94010-TC TC 94010 $ 73.73 94011 Measurement of spirometric forced expiratory flows in an infant or child through 2 years of age $ 216.23 94012 Measurement of spirometric forced expiratory flows, before and after bronchodilator, in an infant or child through 2 years of age $ 352.90 94013 Measurement of lung volumes (ie, functional residual capacity [FRC], forced vital capacity [FVC], and expiratory reserve volume [ERV]) in an infant or child through 2 years of age $ 76.21 94014 includes reinforced education, transmission of spirometric tracing, data capture, analysis of transmitted data, periodic recalibration and review and interpretation by a physician or other $ 91.80 94015 recording (includes hook-up, reinforced education, data transmission, data capture, trend analysis, and periodic recalibration) $ 54.46 94016 review and interpretation only by a physician or other qualified health care professional $ 58.50 94060 94060-26 26 94060 $ 24.14 94060-TC TC 94060 $ 104.56 94150 Vital capacity, total (separate procedure) $ 5.54 94200 Maximum breathing capacity, maximal voluntary ventilation $ 11.13 94250 $ 33.30 94250-26 26 94250 $ 6.45 94250-TC TC 94250 $ 26.85 94375 $ 99.00 94375-26 26 94375 $ 33.70 94375-TC TC 94375 $ 65.30 94450 Breathing response to hypoxia (hypoxia response curve) $ 24.61 94452 High altitude simulation test (HAST), with interpretation and report by a physician or other qualified health care professional; $ 37.46 94453 High altitude simulation test (HAST), with interpretation and report by a physician or other qualified health care professional; with supplemental oxygen titration $ 48.67 94610 Intrapulmonary surfactant administration by a physician or other qualified health care professional through endotracheal tube $ 157.18 94620 $ 254.70 94620-26 26 94620 $ 129.42 94620-TC TC 94620 $ 125.28 94621 Pulmonary stress testing; complex (including measurements of CO2 production, O2 uptake, and electrocardiographic recordings) $ 81.55 94640 Pressurized or nonpressurized inhalation treatment for acute airway obstruction or for sputum induction for diagnostic purposes (eg, with an aerosol generator, nebulizer, metered dose inhaler or intermittent positive pressure breathing [IPPB] device) $ 41.40

Row # CPT-4 HCPCS Price 94645 Continuous inhalation treatment with aerosol medication for acute airway obstruction; each additional hour (List separately in addition $ 32.68 94660 Continuous positive airway pressure ventilation (CPAP), initiation and management $ 180.90 94664 Demonstration and/or evaluation of patient utilization of an aerosol generator, nebulizer, metered dose inhaler or IPPB device $ 49.61 94667 Manipulation chest wall, such as cupping, percussing, and vibration to facilitate lung function; initial demonstration and/or evaluation $ 63.00 94668 Manipulation chest wall, such as cupping, percussing, and vibration to facilitate lung function; subsequent $ 54.90 94680 Oxygen uptake, expired gas analysis; rest and exercise, direct, $ 26.96 94681 $ 169.20 94681-26 26 94681 $ 28.35 94681-TC TC 94681 $ 140.85 94750 $ 98.10 94750-26 26 94750 $ 11.39 94750-TC TC 94750 $ 86.71 94760 Noninvasive ear or pulse oximetry for oxygen saturation; single determination $ 34.98 94761 Noninvasive ear or pulse oximetry for oxygen saturation; multiple determinations (eg, during exercise) $ 72.00 94774 includes monitor attachment, download of data, review, interpretation, and preparation of a report by a physician or other qualif $ - 94775 monitor attachment only (includes hook-up, initiation of recording and disconnection) $ - 94776 monitoring, download of information, receipt of transmission(s) and analyses by computer only $ - 94777 review, interpretation and preparation of report only by a physician or other qualified health care professional $ - 94799 Unlisted pulmonary service or procedure $ 27.50 95004 Percutaneous tests (scratch, puncture, prick) with allergenic extracts, immediate type reaction, including test interpretation and report, specify number of tests $ 7.55 95012 Nitric oxide expired gas determination $ 56.16 95017 Allergy testing, any combination of percutaneous (scratch, puncture, prick) and intracutaneous (intradermal), sequential and incremental, with venoms, immediate type reaction, including test interpretation and report, specify number of tests $ 17.14 95018 Allergy testing, any combination of percutaneous (scratch, puncture, prick) and intracutaneous (intradermal), sequential and incremental, with drugs or biologicals, immediate type reaction, including test interpretation and report, specify number of tests $ 42.06 95024 Intracutaneous (intradermal) tests with allergenic extracts, immediate type reaction, including test interpretation and report, specify number of tests $ 14.40 95027 Intracutaneous (intradermal) tests, sequential and incremental, with allergenic extracts for airborne allergens, immediate type reaction, including test interpretation and report, specify number of tests $ 12.83

Row # CPT-4 HCPCS Price 95028 Intracutaneous (intradermal) tests with allergenic extracts, delayed type reaction, including reading, specify number of tests $ 20.70 95044 Patch or application test(s) (specify number of tests) $ 19.08 95052 Photo patch test(s) (specify number of tests) $ 13.50 95056 Photo tests $ 12.60 95060 Ophthalmic mucous membrane tests $ 23.40 95065 Direct nasal mucous membrane test $ 20.70 95070 Inhalation bronchial challenge testing (not including necessary pulmonary function tests); with histamine, methacholine, or similar compounds 95071 Inhalation bronchial challenge testing (not including necessary pulmonary function tests); with antigens or gases, specify $ 204.30 95076 Ingestion challenge test (sequential and incremental ingestion of test items, eg, food, drug or other substance); initial 120 minutes of $ 219.54 95079 Ingestion challenge test (sequential and incremental ingestion of test items, eg, food, drug or other substance); each additional 60 minutes of testing (List separately in addition to code for primary $ 152.06 95115 Professional services for allergen immunotherapy not including provision of allergenic extracts; single injection $ 17.96 95117 Professional services for allergen immunotherapy not including provision of allergenic extracts; 2 or more injections $ 23.11 95120 professional, including provision of allergenic extract; single injection $ 26.10 95125 professional, including provision of allergenic extract; 2 or more injections $ 28.80 95130 professional, including provision of allergenic extract; single stinging insect venom $ 34.20 95131 professional, including provision of allergenic extract; 2 stinging $ 47.70 95132 professional, including provision of allergenic extract; 3 stinging $ 62.10 95133 professional, including provision of allergenic extract; 4 stinging $ 63.90 95134 professional, including provision of allergenic extract; 5 stinging $ 65.70 95144 provision of antigens for allergen immunotherapy, single dose vial(s) (specify number of vials) $ 33.49 95145 of doses); single stinging insect venom $ 36.00 95146 of doses); 2 single stinging insect venoms $ 46.80 95147 of doses); 3 single stinging insect venoms $ 64.80 95148 of doses); 4 single stinging insect venoms $ 65.70

Row # CPT-4 HCPCS Price 95149 of doses); 5 single stinging insect venoms $ 81.00 95165 provision of antigens for allergen immunotherapy; single or multiple antigens (specify number of doses) $ 15.30 95170 Professional services for the supervision of preparation and provision of antigens for allergen immunotherapy; whole body extract of biting insect or other arthropod (specify number of doses) $ 33.30 95180 Rapid desensitization procedure, each hour (eg, insulin, penicillin, equine serum) 95199 Unlisted allergy/clinical immunologic service or procedure Cost 95250 Ambulatory continuous glucose monitoring of interstitial tissue fluid via a subcutaneous sensor for a minimum of 72 hours; sensor placement, hook-up, calibration of monitor, patient training, removal of sensor, and printout of recording $ 265.16 95251 Ambulatory continuous glucose monitoring of interstitial tissue fluid via a subcutaneous sensor for a minimum of 72 hours; $ 62.92 95803 Actigraphy testing, recording, analysis, interpretation, and report (minimum of 72 hours to 14 consecutive days of recording) $ 80.02 95805 95805-26 26 95805 $ 70.32 95805-TC TC 95805 $ 495.78 95806 Sleep study, unattended, simultaneous recording of, heart rate, oxygen saturation, respiratory airflow, and respiratory effort (eg, thoracoabdominal movement) $ 66.94 95807 $ 713.70 95807-26 26 95807 $ 80.56 95807-TC TC 95807 $ 633.14 95808 $ 756.90 95808-26 26 95808 $ 91.44 95808-TC TC 95808 $ 665.46 95810 95810-26 26 95810 $ 129.14 95810-TC TC 95810 $ 617.86 95811 more additional parameters of sleep, with initiation of continuous positive airway pressure therapy or bilevel ventilation, attended by a technologist $ 455.02 95812 Electroencephalogram (EEG) extended monitoring; 41-60 minutes $ 174.48

Row # CPT-4 HCPCS Price 95813 Electroencephalogram (EEG) extended monitoring; greater than 1 hour $ 221.97 95816 Electroencephalogram (EEG); including recording awake and drowsy $ 266.90 95816-26 26 95816 Electroencephalogram (EEG); including recording awake and drowsy $ 33.98 95816-TC TC 95816 Electroencephalogram (EEG); including recording awake and drowsy $ 232.92 95819 95819-26 26 95819 $ 23.60 95819-TC TC 95819 $ 191.50 95822 95822-26 26 95822 $ 33.28 95822-TC TC 95822 $ 237.62 95824 Electroencephalogram (EEG); cerebral death evaluation only 95827 95827-26 26 95827 $ 22.14 95827-TC TC 95827 $ 321.66 95829 $ 533.70 95829-26 26 95829 $ 80.52 95829-TC TC 95829 $ 453.18 95830 Insertion by physician or other qualified health care professional of sphenoidal electrodes for electroencephalographic (EEG) recording $ 241.20 95831 Muscle testing, manual (separate procedure) with report; extremity (excluding hand) or trunk 95832 Muscle testing, manual (separate procedure) with report; hand, with or without comparison with normal side $ 72.90 95833 Muscle testing, manual (separate procedure) with report; total evaluation of body, excluding hands 95834 Muscle testing, manual (separate procedure) with report; total evaluation of body, including hands $ 139.50 95851 Range of motion measurements and report (separate procedure); each extremity (excluding hand) or each trunk section (spine) $ 87.30 95852 Range of motion measurements and report (separate procedure); hand, with or without comparison with normal side $ 72.00 95857 Cholinesterase inhibitor challenge test for myasthenia gravis 95860 $ 216.72 95860-26 26 95860 $ 82.27 95860-TC TC 95860 $ 134.45 95861 $ 282.23 95861-26 26 95861 $ 125.43 95861-TC TC 95861 $ 156.80 95863 95863-26 26 95863 $ 207.62 95863-TC TC 95863 $ 265.78 95864 95864-26 26 95864 $ 251.46

Row # CPT-4 HCPCS Price 95864-TC TC 95864 $ 366.84 95865 Needle electromyography; larynx $ 201.02 95866 Needle electromyography; hemidiaphragm $ 154.18 95867 95867-26 26 95867 $ 71.74 95867-TC TC 95867 $ 139.76 95868 95868-26 26 95868 $ 104.05 95868-TC TC 95868 $ 153.35 95869 $ 162.34 95869-26 26 95869 $ 33.27 95869-TC TC 95869 $ 129.07 95870 $ 99.09 95870-26 26 95870 $ 64.59 95870-TC TC 95870 $ 34.50 95872 95872-26 26 95872 $ 186.60 95872-TC TC 95872 $ 70.80 95873 Electrical stimulation for guidance in conjunction with chemodenervation (List separately in addition to code for primary $ 55.40 95874 Needle electromyography for guidance in conjunction with chemodenervation (List separately in addition to code for primary $ 56.80 95875 95875-26 26 95875 $ 61.86 95875-TC TC 95875 $ 82.14 95905 Motor and/or sensory nerve conduction, using preconfigured electrode array(s), amplitude and latency/velocity study, each limb, includes F-wave study when performed, with interpretation and $ 7.78 95921 95921-26 26 95921 $ 49.70

Row # CPT-4 HCPCS Price 95921-TC TC 95921 $ 54.70 95922 $ 108.90 95922-26 26 95922 $ 46.18 95922-TC TC 95922 $ 62.72 95923 95923-26 26 95923 $ 16.78 95923-TC TC 95923 $ 84.02 95925 95925-26 26 95925 $ 47.98 95925-TC TC 95925 $ 321.02 95926 95926-26 26 95926 $ 41.65 95926-TC TC 95926 $ 257.15 95927 95927-26 26 95927 $ 43.75 95927-TC TC 95927 $ 255.05 95929 Central motor evoked potential study (transcranial motor stimulation); lower limbs $ 280.97 95930 $ 339.30 95930-26 26 95930 $ 34.63

Row # CPT-4 HCPCS Price 95930-TC TC 95930 $ 304.67 95933 95933-26 26 95933 $ 56.06 95933-TC TC 95933 $ 119.44 95937 95937-26 26 95937 $ 73.30 95937-TC TC 95937 $ 106.70 95940 Continuous intraoperative neurophysiology monitoring in the operating room, one on one monitoring requiring personal attendance, each 15 minutes (List separately in addition to code for $ 58.81 95941 Continuous intraoperative neurophysiology monitoring, from outside the operating room (remote or nearby) or for monitoring of more than one case while in the operating room, per hour (List 95950 $ 655.20 95950-26 26 95950 $ 138.80 95950-TC TC 95950 $ 516.40 95951 radio, 16 or more channel telemetry, combined electroencephalographic (EEG) and video recording and interpretation (eg, for presurgical localization), each 24 hours $ 906.30 95951-26 26 95951 radio, 16 or more channel telemetry, combined electroencephalographic (EEG) and video recording and interpretation (eg, for presurgical localization), each 24 hours $ 514.81 95953 $ 763.20 95953-26 26 95953 $ 262.86 95953-TC TC 95953 $ 500.34 95954 $ 355.50 95954-26 26 95954 $ 84.88 95954-TC TC 95954 $ 270.62 95955 $ 340.20 95955-26 26 95955 $ 70.64 95955-TC TC 95955 $ 269.56

Row # CPT-4 HCPCS Price 95956 95956-26 26 95956 $ 78.24 95956-TC TC 95956 $ 701.16 95957 Digital analysis of electroencephalogram (EEG) (eg, for epileptic spike analysis) $ 166.54 95958 95958-26 26 95958 $ 232.62 95958-TC TC 95958 $ 421.68 95961 95961-26 26 95961 $ 222.66 95961-TC TC 95961 $ 206.64 95962 95962-26 26 95962 $ 291.69 95962-TC TC 95962 $ 156.51 95965 spontaneous brain magnetic activity (eg, epileptic cerebral cortex localization) $ - 95966 evoked magnetic fields, single modality (eg, sensory, motor, language, or visual cortex localization) $ - 95967 evoked magnetic fields, each additional modality (eg, sensory, motor, language, or visual cortex localization) (List separately in $ - 95970 modulation, cycling, impedance and patient compliance measureme $ 47.70

Row # CPT-4 HCPCS Price 95971 modulation, cycling, impedance and patient compliance measureme $ 78.30 95972 modulation, cycling, impedance and patient compliance measureme $ 143.10 95973 modulation, cycling, impedance and patient compliance measureme $ 90.90 95974 modulation, cycling, impedance and patient compliance measureme $ 292.50 95975 modulation, cycling, impedance and patient compliance measureme $ 173.70 95978 system (eg, rate, pulse amplitude and duration, battery status, electrode selectability and polarity, impedance and patient compliance measurements), complex deep brain neurostimulator pulse $ 527.16 95979 system (eg, rate, pulse amplitude and duration, battery status, electrode selectability and polarity, impedance and patient compliance measurements), complex deep brain neurostimulator pulse $ 253.83 95980 n $ 114.21 95981 n $ 82.55 95982 n $ 118.30 95990 Refilling and maintenance of implantable pump or reservoir for drug delivery, spinal (intrathecal, epidural) or brain (intraventricular), includes electronic analysis of pump, when $ 122.42 95992 Canalith repositioning procedure(s) (eg, Epley maneuver, Semont maneuver), per day $ 115.18 95999 Unlisted neurological or neuromuscular diagnostic procedure Cost 96000 Comprehensive computer-based motion analysis by video-taping and 3D kinematics; $ 180.36 96001 Comprehensive computer-based motion analysis by video-taping and 3D kinematics; with dynamic plantar pressure measurements during walking $ 174.93 96002 Dynamic surface electromyography, during walking or other functional activities, 1-12 muscles $ 39.63 96003 Dynamic fine wire electromyography, during walking or other functional activities, 1 muscle $ 30.57

Row # CPT-4 HCPCS Price 96004 Review and interpretation by physician or other qualified health care professional of comprehensive computer-based motion analysis, dynamic plantar pressure measurements, dynamic surface electromyography during walking or other functional activities, and $ 206.48 96020 Neurofunctional testing selection and administration during noninvasive imaging functional brain mapping, with test administered entirely by a physician or other qualified health care professional (ie, psychologist), with review of test results and report $ - 96040 Medical genetics and genetic counseling services, each 30 minutes face-to-face with patient/family $ 98.24 96101 eg, MMPI, Rorschach, WAIS), per hour of the psychologist's or physician's time, both face-to-face time administering test $ 191.25 96102 eg, MMPI and WAIS), with qualified health care professional interpretation and report, administered by technician, per ho $ 93.33 96103 eg, MMPI), administered by a computer, with qualified health care professional interpretation and report $ 87.96 96105 Assessment of aphasia (includes assessment of expressive and receptive speech and language function, language comprehension, speech production ability, reading, spelling, writing, eg, by Boston Diagnostic Aphasia Examination) with interpretation and repor $ 170.98 96110 Developmental screening, with interpretation and report, per standardized instrument form $ 41.77 96111 Developmental testing, (includes assessment of motor, language, social, adaptive, and/or cognitive functioning by standardized developmental instruments) with interpretation and report $ 175.28 96116 Neurobehavioral status exam (clinical assessment of thinking, reasoning and judgment, eg, acquired knowledge, attention, language, memory, planning and problem solving, and visual spatial abilities), per hour of the psychologist's or physician's time, bot $ 226.49 96118 Neuropsychological testing (eg, Halstead-Reitan Neuropsychological Battery, Wechsler Memory Scales and Wisconsin Card Sorting Test), per hour of the psychologist's or physician's time, both face-to-face time administering tests to the patient and time int $ 234.56 96119 Neuropsychological testing (eg, Halstead-Reitan Neuropsychological Battery, Wechsler Memory Scales and Wisconsin Card Sorting Test), with qualified health care professional interpretation and report, administered by technician, per hour of technician time $ 156.24 96120 Neuropsychological testing (eg, Wisconsin Card Sorting Test), administered by a computer, with qualified health care professional $ 115.84 96125 Standardized cognitive performance testing (eg, Ross Information Processing Assessment) per hour of a qualified health care professional's time, both face-to-face time administering tests to the patient and time interpreting these test results and prepari $ 208.77 96150 Health and behavior assessment (eg, health-focused clinical interview, behavioral observations, psychophysiological monitoring, health-oriented questionnaires), each 15 minutes face-to-face with the patient; initial assessment $ 51.14

Row # CPT-4 HCPCS Price 96151 Health and behavior assessment (eg, health-focused clinical interview, behavioral observations, psychophysiological monitoring, health-oriented questionnaires), each 15 minutes face-to-face with the patient; re-assessment $ 27.87 96152 individual $ 27.63 96153 group (2 or more patients) $ 34.17 96154 family (with the patient present) $ 37.46 96155 family (without the patient present) $ 38.51 96360 Intravenous infusion, hydration; initial, 31 minutes to 1 hour $ 115.16 96361 Intravenous infusion, hydration; each additional hour (List $ 46.20 96365 substance or drug); initial, up to 1 hour $ 132.82 96366 substance or drug); each additional hour (List separately in addition $ 58.35 96367 substance or drug); additional sequential infusion of a new drug/substance, up to 1 hour (List separately in addition to code for $ 84.16 96368 substance or drug); concurrent infusion (List separately in addition $ 48.93 96369 or drug); initial, up to 1 hour, including pump set-up and establishment of subcutaneous infusion site(s) $ 299.67 96370 or drug); each additional hour (List separately in addition to code $ 33.76 96371 or drug); additional pump set-up with establishment of new subcutaneous infusion site(s) (List separately in addition to code for $ 126.53 96372 90772 or drug); subcutaneous or intramuscular $ 34.73 96373 or drug); intra-arterial $ 31.87 96374 90774 or drug); intravenous push, single or initial substance/drug $ 97.45 96375 or drug); each additional sequential intravenous push of a new substance/drug (List separately in addition to code for primary $ 56.42 96376 or drug); each additional sequential intravenous push of the same substance/drug provided in a facility (List separately in addition to $ - 96379 Unlisted therapeutic, prophylactic, or diagnostic intravenous or intra-arterial injection or infusion Cost 96401 Chemotherapy administration, subcutaneous or intramuscular; non- hormonal anti-neoplastic $ 153.81 96402 Chemotherapy administration, subcutaneous or intramuscular; hormonal anti-neoplastic $ 82.57 96405 Chemotherapy administration; intralesional, up to and including 7 lesions $ 93.60 96406 Chemotherapy administration; intralesional, more than 7 lesions $ 126.00 96409 Chemotherapy administration; intravenous, push technique, single or initial substance/drug $ 278.82 96411 Chemotherapy administration; intravenous, push technique, each additional substance/drug (List separately in addition to code for $ 159.52

Row # CPT-4 HCPCS Price 96413 Chemotherapy administration, intravenous infusion technique; up to 1 hour, single or initial substance/drug $ 398.03 96415 Chemotherapy administration, intravenous infusion technique; each additional hour (List separately in addition to code for primary $ 89.79 96416 Chemotherapy administration, intravenous infusion technique; initiation of prolonged chemotherapy infusion (more than 8 hours), requiring use of a portable or implantable pump $ 426.61 96417 Chemotherapy administration, intravenous infusion technique; each additional sequential infusion (different substance/drug), up to 1 hour (List separately in addition to code for primary procedure) $ 190.54 96420 Chemotherapy administration, intra-arterial; push technique $ 146.70 96422 Chemotherapy administration, intra-arterial; infusion technique, up to 1 hour 96423 Chemotherapy administration, intra-arterial; infusion technique, each additional hour (List separately in addition to code for primary $ 63.90 96425 Chemotherapy administration, intra-arterial; infusion technique, initiation of prolonged infusion (more than 8 hours), requiring the use of a portable or implantable pump 96440 Chemotherapy administration into pleural cavity, requiring and including thoracentesis 96450 Chemotherapy administration, into CNS (eg, intrathecal), requiring and including spinal puncture $ 228.60 96521 Refilling and maintenance of portable pump $ 338.81 96522 Refilling and maintenance of implantable pump or reservoir for drug delivery, systemic (eg, intravenous, intra-arterial) $ 255.97 96523 Irrigation of implanted venous access device for drug delivery systems $ 79.65 96542 Chemotherapy injection, subarachnoid or intraventricular via subcutaneous reservoir, single or multiple agents 96549 Unlisted chemotherapy procedure Cost 96567 Photodynamic therapy by external application of light to destroy premalignant and/or malignant lesions of the skin and adjacent mucosa (eg, lip) by activation of photosensitive drug(s), each phototherapy exposure session $ 663.01 96570 Photodynamic therapy by endoscopic application of light to ablate abnormal tissue via activation of photosensitive drug(s); first 30 minutes (List separately in addition to code for endoscopy or bronchoscopy procedures of lung and gastrointestinal tract) $ 329.38 96571 Photodynamic therapy by endoscopic application of light to ablate abnormal tissue via activation of photosensitive drug(s); each additional 15 minutes (List separately in addition to code for endoscopy or bronchoscopy procedures of lung and gastrointestin $ 163.85 96900 Actinotherapy (ultraviolet light) $ 34.20 96902 Microscopic examination of hairs plucked or clipped by the examiner (excluding hair collected by the patient) to determine telogen and anagen counts, or structural hair shaft abnormality $ 55.80 96904 Whole body integumentary photography, for monitoring of high risk patients with dysplastic nevus syndrome or a history of dysplastic nevi, or patients with a personal or familial history of melanoma $ 200.24 96910 Photochemotherapy; tar and ultraviolet B (Goeckerman treatment) or petrolatum and ultraviolet B $ 45.00 96912 Photochemotherapy; psoralens and ultraviolet A (PUVA) $ 51.30 96913 Photochemotherapy (Goeckerman and/or PUVA) for severe photoresponsive dermatoses requiring at least 4-8 hours of care under direct supervision of the physician (includes application of medication and dressings) 96920 Laser treatment for inflammatory skin disease (psoriasis); total area less than 250 sq cm $ 398.75

Row # CPT-4 HCPCS Price 96921 Laser treatment for inflammatory skin disease (psoriasis); 250 sq cm to 500 sq cm $ 408.97 96922 Laser treatment for inflammatory skin disease (psoriasis); over 500 sq cm $ 620.53 96999 Unlisted special dermatological service or procedure Cost 97001 Physical therapy evaluation $ 88.97 97002 Physical therapy re-evaluation $ 43.47 97003 Occupational therapy evaluation $ 73.80 97004 Occupational therapy re-evaluation $ 36.00 97005 Athletic training evaluation $ 63.80 97006 Athletic training re-evaluation $ 36.00 97010 Application of a modality to 1 or more areas; hot or cold packs $ 32.94 97012 Application of a modality to 1 or more areas; traction, mechanical $ 39.16 97014 Application of a modality to 1 or more areas; electrical stimulation (unattended) $ 35.31 97016 Application of a modality to 1 or more areas; vasopneumatic devices $ 58.50 97018 Application of a modality to 1 or more areas; paraffin bath $ 43.20 97022 Application of a modality to 1 or more areas; whirlpool $ 41.40 97024 Application of a modality to 1 or more areas; diathermy (eg, microwave) $ 37.81 97032 Application of a modality to 1 or more areas; electrical stimulation (manual), each 15 minutes $ 44.42 97033 Application of a modality to 1 or more areas; iontophoresis, each 15 $ 54.90 97035 Application of a modality to 1 or more areas; ultrasound, each 15 $ 37.77 97039 Unlisted modality (specify type and time if constant attendance) $ 10.00 97110 Therapeutic procedure, 1 or more areas, each 15 minutes; therapeutic exercises to develop strength and endurance, range of motion and flexibility $ 46.60 97112 Therapeutic procedure, 1 or more areas, each 15 minutes; neuromuscular reeducation of movement, balance, coordination, kinesthetic sense, posture, and/or proprioception for sitting and/or standing activities $ 43.21 97113 Therapeutic procedure, 1 or more areas, each 15 minutes; aquatic therapy with therapeutic exercises $ 52.59 97116 Therapeutic procedure, 1 or more areas, each 15 minutes; gait training (includes stair climbing) $ 43.91 97124 Therapeutic procedure, 1 or more areas, each 15 minutes; massage, including effleurage, petrissage and/or tapotement (stroking, compression, percussion) $ 41.79 97140 Manual therapy techniques (eg, mobilization/ manipulation, manual lymphatic drainage, manual traction), 1 or more regions, each 15 $ 48.65 97150 Therapeutic procedure(s), group (2 or more individuals) $ 27.21 97530 Therapeutic activities, direct (one-on-one) patient contact (use of dynamic activities to improve functional performance), each 15 $ 56.70 97532 Development of cognitive skills to improve attention, memory, problem solving (includes compensatory training), direct (one-on- one) patient contact, each 15 minutes $ 36.03 97535 Self-care/home management training (eg, activities of daily living (ADL) and compensatory training, meal preparation, safety procedures, and instructions in use of assistive technology devices/adaptive equipment) direct one-on-one contact, each 15 $ 56.70 97537 Community/work reintegration training (eg, shopping, transportation, money management, avocational activities and/or work environment/modification analysis, work task analysis, use of assistive technology device/adaptive equipment), direct one-on-one cont $ 39.24 97542 Wheelchair management (eg, assessment, fitting, training), each 15 $ 29.60 97545 Work hardening/conditioning; initial 2 hours

Row # CPT-4 HCPCS Price 97546 Work hardening/conditioning; each additional hour (List separately $ 99.90 97597 Debridement (eg, high pressure waterjet with/without suction, sharp selective debridement with scissors, scalpel and forceps), open wound, (eg, fibrin, devitalized epidermis and/or dermis, exudate, debris, biofilm), including topical application(s), wound $ 104.34 97598 Debridement (eg, high pressure waterjet with/without suction, sharp selective debridement with scissors, scalpel and forceps), open wound, (eg, fibrin, devitalized epidermis and/or dermis, exudate, debris, biofilm), including topical application(s), wound $ 114.89 97602 Removal of devitalized tissue from wound(s), non-selective debridement, without anesthesia (eg, wet-to-moist dressings, enzymatic, abrasion), including topical application(s), wound assessment, and instruction(s) for ongoing care, per session $ 126.66 97760 Orthotic(s) management and training (including assessment and fitting when not otherwise reported), upper extremity(s), lower extremity(s) and/or trunk, each 15 minutes $ 63.04 97761 Prosthetic training, upper and/or lower extremity(s), each 15 $ 57.46 97762 Checkout for orthotic/prosthetic use, established patient, each 15 $ 57.79 97802 Medical nutrition therapy; initial assessment and intervention, individual, face-to-face with the patient, each 15 minutes $ 32.69 97803 Medical nutrition therapy; re-assessment and intervention, individual, face-to-face with the patient, each 15 minutes $ 31.73 97804 Medical nutrition therapy; group (2 or more individuals), each 30 $ 12.42 97810 Acupuncture, 1 or more needles; without electrical stimulation, initial 15 minutes of personal one-on-one contact with the patient $ 60.96 97811 Acupuncture, 1 or more needles; without electrical stimulation, each additional 15 minutes of personal one-on-one contact with the patient, with re-insertion of needle(s) (List separately in addition to $ 51.38 97813 Acupuncture, 1 or more needles; with electrical stimulation, initial 15 minutes of personal one-on-one contact with the patient $ 66.59 97814 Acupuncture, 1 or more needles; with electrical stimulation, each additional 15 minutes of personal one-on-one contact with the patient, with re-insertion of needle(s) (List separately in addition to $ 57.30 98925 Osteopathic manipulative treatment (OMT); 1-2 body regions $ 53.46 98926 Osteopathic manipulative treatment (OMT); 3-4 body regions $ 83.70 98927 Osteopathic manipulative treatment (OMT); 5-6 body regions 98928 Osteopathic manipulative treatment (OMT); 7-8 body regions $ 115.20 98929 Osteopathic manipulative treatment (OMT); 9-10 body regions $ 135.00 98940 Chiropractic manipulative treatment (CMT); spinal, 1-2 regions $ 48.32 98941 Chiropractic manipulative treatment (CMT); spinal, 3-4 regions $ 63.55 98942 Chiropractic manipulative treatment (CMT); spinal, 5 regions $ 91.80 98943 Chiropractic manipulative treatment (CMT); extraspinal, 1 or more regions $ 49.50 98960 caregiver/family) each 30 minutes; individual patient $ 63.65

Row # CPT-4 HCPCS Price 98961 caregiver/family) each 30 minutes; 2-4 patients $ 49.81 98962 caregiver/family) each 30 minutes; 5-8 patients $ 36.96 98966 $ 40.02 98967 $ 78.06 98968 $ 111.03 98969 Online assessment and management service provided by a qualified nonphysician health care professional to an established patient or guardian, not originating from a related assessment and management service provided within the previous 7 days, using the I $ - 99000 Handling and/or conveyance of specimen for transfer from the office to a laboratory $ 23.40 99001 Handling and/or conveyance of specimen for transfer from the patient in other than an office to a laboratory (distance may be indicated) $ 26.10 99002 Handling, conveyance, and/or any other service in connection with the implementation of an order involving devices (eg, designing, fitting, packaging, handling, delivery or mailing) when devices such as orthotics, protectives, prosthetics are fabricated b $ 27.00 99024 Postoperative follow-up visit, normally included in the surgical package, to indicate that an evaluation and management service was performed during a postoperative period for a reason(s) related to the original procedure $ - 99050 Services provided in the office at times other than regularly scheduled office hours, or days when the office is normally closed (eg, holidays, Saturday or Sunday), in addition to basic service $ 81.00 99051 Service(s) provided in the office during regularly scheduled evening, weekend, or holiday office hours, in addition to basic service $ - 99053 Service(s) provided between 10:00 PM and 8:00 AM at 24-hour facility, in addition to basic service $ - 99056 Service(s) typically provided in the office, provided out of the office at request of patient, in addition to basic service $ 101.70 99058 Service(s) provided on an emergency basis in the office, which disrupts other scheduled office services, in addition to basic service $ 96.58 99075 Medical testimony $ 627.30 99078 Physician or other qualified health care professional qualified by education, training, licensure/regulation (when applicable) educational services rendered to patients in a group setting (eg, prenatal, obesity, or diabetic instructions) $ 72.00 99080 Special reports such as insurance forms, more than the information conveyed in the usual medical communications or standard reporting form 99082 Unusual travel (eg, transportation and escort of patient) 99090 Analysis of clinical data stored in computers (eg, ECGs, blood pressures, hematologic data)

Row # CPT-4 HCPCS Price 99091 Collection and interpretation of physiologic data (eg, ECG, blood pressure, glucose monitoring) digitally stored and/or transmitted by the patient and/or caregiver to the physician or other qualified health care professional, qualified by education, train $ 101.30 99100 Anesthesia for patient of extreme age, younger than 1 year or older than 70 (List separately in addition to code for primary anesthesia $ 88.00 99116 Anesthesia complicated by utilization of total body hypothermia (List separately in addition to code for primary anesthesia $ - 99135 Anesthesia complicated by utilization of controlled hypotension (List separately in addition to code for primary anesthesia procedure) $ - 99140 Anesthesia complicated by emergency conditions (specify) (List separately in addition to code for primary anesthesia procedure) 99143 99144 99145 $ - 99148 $ 143.00 99149 $ - 99150 $ - 99170 Anogenital examination, magnified, in childhood for suspected trauma, including image recording when performed $ 363.95 99173 Screening test of visual acuity, quantitative, bilateral $ 29.89 99174 Instrument-based ocular screening (eg, photoscreening, automated- refraction), bilateral $ 39.61 99175 Ipecac or similar administration for individual emesis and continued observation until stomach adequately emptied of poison $ 106.20 99183 Physician or other qualified health care professional attendance and supervision of hyperbaric oxygen therapy, per session $ 271.80 99190 exchanger (with or without ECG and/or pressure monitoring); each hour $ - 99191 exchanger (with or without ECG and/or pressure monitoring); 45 $ - 99192 exchanger (with or without ECG and/or pressure monitoring); 30 $ - 99195 Phlebotomy, therapeutic (separate procedure) $ 69.30 99199 Unlisted special service, procedure or report Cost

Row # CPT-4 HCPCS Price 99201 problem focused history; A problem focused examination; coordination o $ 75.03 99202 of a new patient, which requires these 3 key components: An expanded problem focused history; An expanded problem focused examination; Straightforward medical decision making. Counseling a $ 86.93 99203 detailed history; A detailed examination; Medical decision making of low complexity. Counseling and/or coordination of care with $ 119.33 99204 comprehensive history; A comprehensive examination; Medical decision making of moderate complexity. Counseling and/or coordinatio $ 157.94 99205 comprehensive history; A comprehensive examination; Medical decision making of high complexity. Counseling and/or coordination of $ 207.38 99211 of an established patient, that may not require the presence of a physician or other qualified health care professional. Usually, the presenting problem(s) are minimal. Typically, 5 minute $ 36.97 99212 components: A problem focused history; A problem focused examination; Straightforward medical decision making. Counselin $ 56.87 99213 components: An expanded problem focused history; An expanded problem focused examination; Medical decision making of low $ 74.01 99214 components: A detailed history; A detailed examination; Medical decision making of moderate complexity. Counseling and/o $ 101.53 99215 components: A comprehensive history; A comprehensive examination; Medical decision making of high complexity. Counseling $ 156.37 99218 Initial observation care, per day, for the evaluation and management of a patient which requires these 3 key components: A detailed or comprehensive history; A detailed or comprehensive examination; and Medical decision making that is straightforward or o 99219 Initial observation care, per day, for the evaluation and Medical decision making of moderate complexity. Counseling and/or coordinat 99221 a patient, which requires these 3 key components: A detailed or comprehensive history; A detailed or comprehensive examination; and Medical decision making that is straightforward or of $ 146.86 99222 a patient, which requires these 3 key components: A comprehensive history; A comprehensive examination; and Medical decision making of moderate complexity. Counseling and/or coordination $ 215.43

Row # CPT-4 HCPCS Price 99223 a patient, which requires these 3 key components: A comprehensive history; A comprehensive examination; and Medical decision making of high complexity. Counseling and/or coordination of $ 242.77 99231 components: A problem focused interval history; A problem focused examination; Medical decision making that is straightforward or o $ 76.73 99232 components: An expanded problem focused interval history; An expanded problem focused examination; Medical decision making of moder $ 99.73 99233 components: A detailed interval history; A detailed examination; Medical decision making of high complexity. Counseling and/or coor $ 152.75 99234 same date, which requires these 3 key components: A detailed or comprehensive history; A detailed or comprehensive examination; $ 174.35 99235 same date, which requires these 3 key components: A comprehensive history; A comprehensive examination; and Medical decision ma $ 238.54 99236 same date, which requires these 3 key components: A comprehensive history; A comprehensive examination; and Medical decision ma $ 384.38 99238 Hospital discharge day management; 30 minutes or less $ 133.05 99239 Hospital discharge day management; more than 30 minutes $ 172.27 99241 these 3 key components: A problem focused history; A problem focused examination; and Straightforward medical decision making. Counseling and/or coordination of care with other physician $ 105.67 99242 these 3 key components: An expanded problem focused history; An expanded problem focused examination; and Straightforward medical decision making. Counseling and/or coordination of care $ 143.19 99243 these 3 key components: A detailed history; A detailed examination; and Medical decision making of low complexity. Counseling and/or coordination of care with other physicians, other qua $ 182.41 99244 these 3 key components: A comprehensive history; A other physic $ 234.86 99245 these 3 key components: A comprehensive history; A physicians $ 298.54 99251 requires these 3 key components: A problem focused history; A problem focused examination; and Straightforward medical decision making. Counseling and/or coordination of care with other physic $ 122.67

Row # CPT-4 HCPCS Price 99252 requires these 3 key components: An expanded problem focused history; An expanded problem focused examination; and coordination of ca $ 160.52 99253 requires these 3 key components: A detailed history; A detailed examination; and Medical decision making of low complexity. Counseling and/or coordination of care with other physicians, other $ 198.36 99254 requires these 3 key components: A comprehensive history; A other phy $ 242.77 99255 requires these 3 key components: A comprehensive history; A physici $ 314.79 99281 a patient, which requires these 3 key components: A problem focused history; A problem focused examination; and coordination of care $ 91.71 99282 a patient, which requires these 3 key components: An expanded problem focused history; An expanded problem focused examination; and Medical decision making of low complexity. Counseling and/o $ 120.82 99283 a patient, which requires these 3 key components: An expanded problem focused history; An expanded problem focused examination; and Medical decision making of moderate complexity. Counseling $ 183.70 99284 a patient, which requires these 3 key components: A detailed history; A detailed examination; and Medical decision making of o $ 260.67 99285 a patient, which requires these 3 key components within the constraints imposed by the urgency of the patient's clinical condition and/or mental status: A comprehensive history; A comprehensi $ 355.91 99288 Physician or other qualified health care professional direction of emergency medical systems (EMS) emergency care, advanced life support 99291 Critical care, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes $ 370.17 99292 Critical care, evaluation and management of the critically ill or critically injured patient; each additional 30 minutes (List separately in addition to code for primary service) $ 187.78 99304 A detailed or comprehensive history; A detailed or comprehensive examination; and Medical decision making that is straightforwar $ 91.71 99305 Medical decision making of moderate complexity. Counseling and/or coor $ 128.46 99306 Medical decision making of high complexity. Counseling and/or coordina $ 157.46

Row # CPT-4 HCPCS Price 99341 which requires these 3 key components: A problem focused history; A problem focused examination; and Straightforward medical decision making. Counseling and/or coordination of care with other $ 88.12 99342 which requires these 3 key components: An expanded problem focused history; An expanded problem focused examination; and Medical decision making of low complexity. Counseling and/or coordinati $ 99.69 99343 which requires these 3 key components: A detailed history; A detailed examination; and Medical decision making of moderate physici $ 135.42 99344 which requires these 3 key components: A comprehensive history; A oth $ 189.85 99345 which requires these 3 key components: A comprehensive history; A complexity. Counseling and/or coordination of care with other p $ 250.72 99347 Home visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: A problem focused interval history; A problem focused examination; Straightforward medical decision making. Counseling and/or coor $ 63.21 99354 Prolonged service in the office or other outpatient setting requiring direct patient contact beyond the usual service; first hour (List separately in addition to code for office or other outpatient Evaluation and Management service) $ 186.25 99356 Prolonged service in the inpatient or observation setting, requiring unit/floor time beyond the usual service; first hour (List separately in addition to code for inpatient Evaluation and Management $ 224.06 99358 Prolonged evaluation and management service before and/or after direct patient care; first hour $ 202.71 99360 Standby service, requiring prolonged attendance, each 30 minutes (eg, operative standby, standby for frozen section, for cesarean/high risk delivery, for monitoring EEG) $ 186.05 99367 Medical team conference with interdisciplinary team of health care professionals, patient and/or family not present, 30 minutes or more; participation by physician $ 64.15 99368 Medical team conference with interdisciplinary team of health care professionals, patient and/or family not present, 30 minutes or more; participation by nonphysician qualified health care $ 41.06 99385 Initial comprehensive preventive medicine evaluation and laboratory/diagnos $ 142.18 99391 $ 82.75 99392 $ 86.88 99393 $ 89.13

Row # CPT-4 HCPCS Price 99394 $ 105.22 99395 $ 115.76 99396 $ 135.29 99401 Preventive medicine counseling and/or risk factor reduction intervention(s) provided to an individual (separate procedure); approximately 15 minutes $ 48.03 99460 Initial hospital or birthing center care, per day, for evaluation and management of normal newborn infant $ 144.33 99461 Initial care, per day, for evaluation and management of normal newborn infant seen in other than hospital or birthing center $ 98.43 99462 Subsequent hospital care, per day, for evaluation and management of normal newborn $ 68.89 99463 Initial hospital or birthing center care, per day, for evaluation and management of normal newborn infant admitted and discharged on the same date $ 157.01 99464 Attendance at delivery (when requested by the delivering physician or other qualified health care professional) and initial stabilization of newborn $ 155.16 99465 Delivery/birthing room resuscitation, provision of positive pressure ventilation and/or chest compressions in the presence of acute inadequate ventilation and/or cardiac output $ 278.60 99466 Critical care face-to-face services, during an interfacility transport of critically ill or critically injured pediatric patient, 24 months of age or younger; first 30-74 minutes of hands-on care during transport $ 410.44 99467 Critical care face-to-face services, during an interfacility transport of critically ill or critically injured pediatric patient, 24 months of age or younger; each additional 30 minutes (List separately in addition to code for primary service) $ 231.30 99468 Initial inpatient neonatal critical care, per day, for the evaluation and management of a critically ill neonate, 28 days of age or younger $ 1,541.18 99469 Subsequent inpatient neonatal critical care, per day, for the evaluation and management of a critically ill neonate, 28 days of age or younger $ 961.49 99471 Initial inpatient pediatric critical care, per day, for the evaluation and management of a critically ill infant or young child, 29 days through 24 months of age $ 1,358.69 99472 Subsequent inpatient pediatric critical care, per day, for the evaluation and management of a critically ill infant or young child, 29 days through 24 months of age $ 920.42 99475 Initial inpatient pediatric critical care, per day, for the evaluation and management of a critically ill infant or young child, 2 through 5 years of age $ 1,108.22 99476 Subsequent inpatient pediatric critical care, per day, for the evaluation and management of a critically ill infant or young child, 2 through 5 years of age $ 815.58 99478 management of the recovering very low birth weight infant (present body weight less than 1500 grams) $ 398.22 99479 management of the recovering low birth weight infant (present body weight of 1500-2500 grams) $ 373.08

Row # CPT-4 HCPCS Price 99480 management of the recovering infant (present body weight of 2501- 5000 grams) $ 350.97 99499 Unlisted evaluation and management service $ 38.50 99500 Home visit for prenatal monitoring and assessment to include fetal heart rate, non-stress test, uterine monitoring, and gestational diabetes monitoring $ - 99502 Home visit for newborn care and assessment $ 38.50 99503 Home visit for respiratory therapy care (eg, bronchodilator, oxygen therapy, respiratory assessment, apnea evaluation) $ - 99504 Home visit for mechanical ventilation care $ - 99505 Home visit for stoma care and maintenance including colostomy and cystostomy $ - 99506 Home visit for intramuscular injections $ - 99507 Home visit for care and maintenance of catheter(s) (eg, urinary, drainage, and enteral) $ 27.50 99509 Home visit for assistance with activities of daily living and personal care $ 33.00 99510 Home visit for individual, family, or marriage counseling $ - 99511 Home visit for fecal impaction management and enema administration $ - 99512 Home visit for hemodialysis $ - 99600 Unlisted home visit service or procedure Cost 99601 Home infusion/specialty drug administration, per visit (up to 2 hours); $ - 99602 Home infusion/specialty drug administration, per visit (up to 2 hours); each additional hour (List separately in addition to code for $ - 99605 and intervention if provided; initial 15 minutes, new patient $ - 99606 and intervention if provided; initial 15 minutes, established patient $ - 99607 and intervention if provided; each additional 15 minutes (List separately in addition to code for primary service) $ - A0380 BLS mileage (per mile) $ 8.25 A0427 Ambulance service, advanced life support, emergency transport, level 1 (ALS1- emergency) $ 187.00 A0428 Ambulance service, basic life support, non-emergency transport, (BLS) A0430 Ambulance service, conventional air services, transport, one way (fixed wing) A0998 Ambulance response and treatment, no transport D0120 Periodic oral evaluation - established patient $ 30.00 D0140 Limited oral evaluation - problem focused $ 30.00 D0150 Comprehensive oral evaluation - new or established patient $ 60.00 D0160 Detailed and extensive oral evaluation - problem focused, by report $ 71.50 D0170 Re-evaluation - limited, problem focused (established patient; not post-operative visit) $ 39.00 D0210 Intraoral - complete series of radiographic images $ 85.00 D0220 Intraoral - periapical first radiographic image $ 18.00 D0230 Intraoral - periapical each additional radiographic image $ 8.00 D0240 Intraoral - occlusal radiographic image $ 27.50 D0250 Extraoral - first radiographic image $ 38.00 D0260 Extraoral - each additional radiographic image $ 32.00 D0270 Bitewing - single radiographic image $ 18.00 D0272 Bitewings - two radiographic images $ 35.50 D0274 Bitewings - four radiographic images $ 41.00 D0277 Vertical bitewings - 7 to 8 radiographic images $ 57.00 D0290 Posterior-anterior or lateral skull and facial bone survey radiographic image $ 81.00 D0310 Sialography $ 155.00

Row # CPT-4 HCPCS Price D0320 Temporomandibular joint arthrogram, including injection D0321 Other temporomandibular joint radiographic images, by report $ 148.00 D0322 Tomographic survey $ 265.00 D0330 Panoramic radiographic image $ 60.00 D0340 Cephalometric radiographic image $ 55.00 D0350 Oral/facial photographic images $ 43.00 D0415 Collection of microorganisms for culture and sensitivity $ 95.00 D0425 Caries susceptibility tests $ 61.00 D0460 Pulp vitality tests $ 36.00 D0470 Diagnostic casts $ 69.00 D0472 Accession of tissue, gross examination, preparation and transmission of written report $ 55.00 D0501 HISTOPATHOLOGIC EXAMINATIONS Refers to gross and microscopic evaluations of presumptively abnormal tissue(s) that have been previously excised. Includes preparation and transmission of written $ 127.00 D0502 Other oral pathology procedures, by report $ 114.00 D0999 Unspecified diagnostic procedure, by report D1110 Prophylaxis - adult $ 88.00 D1120 Prophylaxis - child $ 44.00 D1206 Topical application of fluoride varnish $ 60.00 D1208 Topical application of fluoride $ 60.00 D1310 Nutritional counseling for control of dental disease $ 47.00 D1320 Tobacco counseling for the control and prevention of oral disease $ 51.00 D1330 Oral hygiene instructions $ 70.00 D1351 Sealant - per tooth $ 55.00 D1510 Space maintainer - fixed - unilateral $ 221.00 D1515 Space maintainer - fixed - bilateral $ 311.00 D1520 Space maintainer - removable - unilateral $ 266.00 D1525 Space maintainer - removable - bilateral $ 346.00 D1550 Re-cementation of space maintainer $ 53.00 D2140 Amalgam - one surface, primary or permanent $ 75.00 D2150 Amalgam - two surfaces, primary or permanent D2160 Amalgam - three surfaces, primary or permanent $ 119.00 D2161 Amalgam - four or more surfaces, primary or permanent $ 130.00 D2330 Resin-based composite - one surface, anterior $ 132.00 D2331 Resin-based composite - two surfaces, anterior $ 198.00 D2332 Resin-based composite - three surfaces, anterior D2335 Resin-based composite - four or more surfaces or involving incisal angle (anterior) $ 242.00 D2390 Resin-based composite crown, anterior D2391 Resin-based composite - one surface, posterior $ 66.00 D2392 Resin-based composite - two surfaces, posterior $ 99.00 D2393 Resin-based composite - three surfaces, posterior D2394 Resin-based composite - four or more surfaces, posterior $ 121.00 D2410 Gold foil - one surface D2420 Gold foil - two surfaces $ 443.00 D2430 Gold foil - three surfaces $ 525.00 D2510 Inlay - metallic - one surface $ 522.00 D2520 Inlay - metallic - two surfaces $ 580.00 D2530 Inlay - metallic - three or more surfaces $ 625.00 D2542 Onlay - metallic-two surfaces D2543 Onlay - metallic-three surfaces $ 691.00 D2544 Onlay - metallic-four or more surfaces $ 720.00 D2610 Inlay - porcelain/ceramic - one surface $ 583.00 D2620 Inlay - porcelain/ceramic - two surfaces $ 630.00 D2630 Inlay - porcelain/ceramic - three or more surfaces $ 671.00 D2642 Onlay - porcelain/ceramic - two surfaces $ 688.00 D2643 Onlay - porcelain/ceramic - three surfaces $ 717.00 D2644 Onlay - porcelain/ceramic - four or more surfaces $ 744.00 D2650 Inlay - resin-based composite - one surface $ 526.00 D2651 Inlay - resin-based composite - two surfaces $ 569.00 D2652 Inlay - resin-based composite - three or more surfaces $ 613.00 D2662 Onlay - resin-based composite - two surfaces D2663 Onlay - resin-based composite - three surfaces $ 669.00 D2664 Onlay - resin-based composite - four or more surfaces $ 695.00 D2710 Crown - resin-based composite (indirect) D2720 Crown - resin with high noble metal $ 733.00

Row # CPT-4 HCPCS Price D2721 Crown - resin with predominantly base metal $ 661.00 D2722 Crown - resin with noble metal $ 703.00 D2740 Crown - porcelain/ceramic substrate $ 751.00 D2750 Crown - porcelain fused to high noble metal $ 744.00 D2751 Crown - porcelain fused to predominantly base metal $ 540.00 D2752 Crown - porcelain fused to noble metal $ 795.00 D2780 Crown - 3/4 cast high noble metal $ 738.00 D2781 Crown - 3/4 cast predominantly base metal $ 697.00 D2782 Crown - 3/4 cast noble metal $ 715.00 D2783 Crown - 3/4 porcelain/ceramic D2790 Crown - full cast high noble metal $ 728.00 D2791 Crown - full cast predominantly base metal D2792 Crown - full cast noble metal D2799 Provisional crown - further treatment or completion of diagnosis necessary prior to final impression $ 215.00 D2910 Recement inlay, onlay, or partial coverage restoration $ 77.00 D2915 Recement cast or prefabricated post and core $ 218.00 D2920 Recement crown $ 99.00 D2930 Prefabricated stainless steel crown - primary tooth D2931 Prefabricated stainless steel crown - permanent tooth D2932 Prefabricated resin crown $ 200.00 D2933 Prefabricated stainless steel crown with resin window $ 239.00 D2940 Protective restoration $ 71.50 D2950 Core buildup, including any pins D2951 Pin retention - per tooth, in addition to restoration $ 77.00 D2952 Post and core in addition to crown, indirectly fabricated $ 303.50 D2953 Each additional indirectly fabricated post - same tooth $ 188.00 D2954 Prefabricated post and core in addition to crown D2955 Post removal $ 187.00 D2957 Each additional prefabricated post - same tooth $ 66.00 D2960 Labial veneer (resin laminate) - chairside $ 375.00 D2961 Labial veneer (resin laminate) - laboratory $ 450.00 D2962 Labial veneer (porcelain laminate) - laboratory $ 495.00 D2970 Temporary crown (fractured tooth) D2980 Crown repair necessitated by restorative material failure D2999 Unspecified restorative procedure, by report D3110 Pulp cap - direct (excluding final restoration) $ 55.00 D3120 Pulp cap - indirect (excluding final restoration) $ 33.00 D3220 Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction and application of medicament $ 77.00 D3221 Pulpal debridement, primary and permanent teeth $ 88.00 D3230 Pulpal therapy (resorbable filling) - anterior, primary tooth (excluding final restoration) $ 175.00 D3240 Pulpal therapy (resorbable filling) - posterior, primary tooth (excluding final restoration) $ 196.00 D3310 Endodontic therapy, anterior tooth (excluding final restoration) D3320 Endodontic therapy, bicuspid tooth (excluding final restoration) D3330 Endodontic therapy, molar (excluding final restoration) $ 852.50 D3331 Treatment of root canal obstruction; non-surgical access D3332 Incomplete endodontic therapy; inoperable, unrestorable or fractured tooth $ 233.00 D3333 Internal root repair of perforation defects $ 133.00 D3346 Retreatment of previous root canal therapy - anterior D3347 Retreatment of previous root canal therapy - bicuspid D3348 Retreatment of previous root canal therapy - molar D3351 Apexification/recalcification/pulpal regeneration - initial visit (apical closure/calcific repair of perforations, root resorption, pulp space disinfection, etc.) D3352 Apexification/recalcification/pulpal regeneration - interim medication replacement (apical closure/calcific repair of perforations, root resorption, pulp space disinfection, etc.) D3353 Apexification/recalcification - final visit (includes completed root canal therapy - apical closure/calcific repair of perforations, root resorption, etc.) D3410 Apicoectomy/periradicular surgery - anterior D3421 Apicoectomy/periradicular surgery - bicuspid (first root) D3425 Apicoectomy/periradicular surgery - molar (first root)

Row # CPT-4 HCPCS Price D3426 Apicoectomy/periradicular surgery (each additional root) D3430 Retrograde filling - per root $ 170.00 D3450 Root amputation - per root D3460 Endodontic endosseous implant $ 759.00 D3470 Intentional reimplantation (including necessary splinting) $ 539.00 D3910 Surgical procedure for isolation of tooth with rubber dam D3920 Hemisection (including any root removal), not including root canal therapy $ 299.00 D3950 Canal preparation and fitting of preformed dowel or post D3999 Unspecified endodontic procedure, by report D4210 Gingivectomy or gingivoplasty - four or more contiguous teeth or tooth bounded spaces per quadrant $ 420.00 D4211 Gingivectomy or gingivoplasty - one to three contiguous teeth or tooth bounded spaces per quadrant $ 148.00 D4240 Gingival flap procedure, including root planing - four or more $ 493.00 D4241 Gingival flap procedure, including root planing - one to three D4245 Apically positioned flap $ 554.00 D4249 Clinical crown lengthening - hard tissue $ 478.00 D4260 Osseous surgery (including flap entry and closure) - four or more $ 724.00 D4263 Bone replacement graft - first site in quadrant $ 456.00 D4264 Bone replacement graft - each additional site in quadrant $ 335.00 D4266 Guided tissue regeneration - resorbable barrier, per site $ 603.00 D4267 Guided tissue regeneration - nonresorbable barrier, per site (includes membrane removal) $ 688.00 D4268 Surgical revision procedure, per tooth $ 534.00 D4270 Pedicle soft tissue graft procedure $ 536.00 D4273 Subepithelial connective tissue graft procedures, per tooth $ 735.00 D4277 Free soft tissue graft procedure (including donor site surgery), first tooth or edentulous tooth position in graft $ 595.00 D4278 Free soft tissue graft procedure (including donor site surgery), each additional contiguous tooth or edentulous tooth position in same graft site $ 595.00 D4320 Provisional splinting - intracoronal $ 332.00 D4321 Provisional splinting - extracoronal D4341 Periodontal scaling and root planing - four or more teeth per quadrant $ 132.00 D4355 Full mouth debridement to enable comprehensive evaluation and diagnosis $ 264.00 D4360 Trismus appliance (not for TMD treatment) D4910 Periodontal maintenance $ 88.00 D4920 Unscheduled dressing change (by someone other than treating dentist) $ 71.00 D4921 Gingival irrigation per quad D4999 Unspecified periodontal procedure, by report D5110 Complete denture - maxillary D5120 Complete denture - mandibular D5130 Immediate denture - maxillary D5140 Immediate denture - mandibular D5211 Maxillary partial denture - resin base (including any conventional clasps, rests and teeth) D5212 Mandibular partial denture - resin base (including any conventional clasps, rests and teeth) D5213 Maxillary partial denture - cast metal framework with resin denture bases (including any conventional clasps, rests and teeth) D5214 Mandibular partial denture - cast metal framework with resin denture bases (including any conventional clasps, rests and teeth) D5226 Mandibular partial denture - flexible base (including any clasps, rests and teeth) D5231 Mandibular partial denture - cast metal framework with resin denture bases (including any conventional clasps, rests and teeth) D5251 Complete denture - maxillary

Row # CPT-4 HCPCS Price D5281 Removable unilateral partial denture - one piece cast metal (including clasps and teeth $ 625.00 D5310 Repair or replace broken clasp $ 27.50 D5320 Add tooth to existing partial denture $ 27.50 D5410 Adjust complete denture - maxillary $ 30.00 D5411 Adjust complete denture - mandibular $ 30.00 D5421 Adjust partial denture - maxillary $ 25.00 D5422 Adjust partial denture - mandibular $ 25.00 D5510 Repair broken complete denture base $ 55.00 D5520 Replace missing or broken teeth - complete denture (each tooth) $ 55.00 D5610 Repair resin denture base $ 50.00 D5620 Repair cast framework $ 55.00 D5630 Repair or replace broken clasp $ 55.00 D5640 Replace broken teeth - per tooth $ 55.00 D5650 Add tooth to existing partial denture $ 55.00 D5660 Add clasp to existing partial denture $ 50.00 D5710 Rebase complete maxillary denture $ 379.00 D5711 Rebase complete mandibular denture $ 380.00 D5720 Rebase maxillary partial denture $ 367.00 D5721 Rebase mandibular partial denture $ 366.00 D5730 Reline complete maxillary denture (chairside) $ 248.00 D5731 Reline complete mandibular denture (chairside) $ 249.00 D5740 Reline maxillary partial denture (chairside) $ 245.00 D5741 Reline mandibular partial denture (chairside) $ 244.00 D5750 Reline complete maxillary denture (laboratory) D5751 Reline complete mandibular denture (laboratory) D5760 Reline maxillary partial denture (laboratory) D5761 Reline mandibular partial denture (laboratory) D5810 Interim complete denture (maxillary) $ 517.00 D5811 Interim complete denture (mandibular) $ 524.00 D5820 Interim partial denture (maxillary) $ 442.00 D5821 Interim partial denture (mandibular) $ 442.00 D5850 Tissue conditioning, maxillary D5851 Tissue conditioning, mandibular D5860 Overdenture - complete, by report D5861 Overdenture - partial, by report D5862 Precision attachment, by report $ 435.00 D5875 Modification of removable prosthesis following implant surgery $ 236.00 D5899 Unspecified removable prosthodontic procedure, by report D5911 Facial moulage (sectional) D5912 Facial moulage (complete) D5913 Nasal prosthesis D5914 Auricular prosthesis D5915 Orbital prosthesis D5916 Ocular prosthesis D5919 Facial prosthesis D5922 Nasal septal prosthesis D5923 Ocular prosthesis, interim D5924 Cranial prosthesis D5925 Facial augmentation implant prosthesis D5926 Nasal prosthesis, replacement D5927 Auricular prosthesis, replacement D5928 Orbital prosthesis, replacement D5929 Facial prosthesis, replacement D5931 Obturator prosthesis, surgical D5932 Obturator prosthesis, definitive D5933 Obturator prosthesis, modification D5934 Mandibular resection prosthesis with guide flange D5935 Mandibular resection prosthesis without guide flange D5936 Obturator prosthesis, interim D5937 Trismus appliance (not for TMD treatment) D5951 Feeding aid D5952 Speech aid prosthesis, pediatric D5953 Speech aid prosthesis, adult D5954 Palatal augmentation prosthesis D5955 Palatal lift prosthesis, definitive D5958 Palatal lift prosthesis, interim D5959 Palatal lift prosthesis, modification

Row # CPT-4 HCPCS Price D5960 Speech aid prosthesis, modification D5982 Surgical stent D5983 Radiation carrier D5984 Radiation shield D5985 Radiation cone locator D5986 Fluoride gel carrier $ 115.00 D5987 Commissure splint D5988 Surgical splint $ 549.00 D5992 Adjust maxillofacial prosthetic appliance, by report D5999 Unspecified maxillofacial prosthesis, by report D6010 Surgical placement of implant body: endosteal implant $ 1,425.00 D6012 Surgical placement of interim implant body for transitional prosthesis: endosteal implant D6040 Surgical placement: eposteal implant $ 6,023.00 D6050 Surgical placement: transosteal implant $ 4,153.00 D6055 Connecting bar - implant supported or abutment supported $ 1,667.00 D6056 Prefabricated abutment - includes modification and placement $ 429.00 D6057 Custom fabricated abutment - includes placement D6058 Abutment supported porcelain/ceramic crown $ 850.00 D6059 Abutment supported porcelain fused to metal crown (high noble metal) $ 861.00 D6060 Abutment supported porcelain fused to metal crown (predominantly base metal) $ 730.00 D6061 Abutment supported porcelain fused to metal crown (noble metal) $ 800.00 D6062 Abutment supported cast metal crown (high noble metal) $ 844.00 D6063 Abutment supported cast metal crown (predominantly base metal) $ 755.00 D6064 Abutment supported cast metal crown (noble metal) $ 800.00 D6065 Implant supported porcelain/ceramic crown $ 960.00 D6066 Implant supported porcelain fused to metal crown (titanium, titanium alloy, high noble metal) D6067 Implant supported metal crown (titanium, titanium alloy, high noble metal) $ 950.00 D6068 ABUTMENT SUPPORTED RETAINER FOR PORCELAIN/CERAMIC FPD $ 844.00 D6069 Abutment supported retainer for porcelain fused to metal FPD (high noble metal) $ 836.00 D6070 Abutment supported retainer for porcelain fused to metal FPD (predominantly base metal) $ 703.00 D6071 Abutment supported retainer for porcelain fused to metal FPD (noble metal) $ 792.00 D6072 Abutment supported retainer for cast metal FPD (high noble metal) $ 810.00 D6073 Abutment supported retainer for cast metal FPD (predominantly base metal) $ 760.00 D6074 Abutment supported retainer for cast metal FPD (noble metal) $ 775.00 D6075 Implant supported retainer for ceramic FPD $ 906.00 D6077 Implant supported retainer for cast metal FPD (titanium, titanium alloy, or high noble metal) $ 935.00 D6078 Implant/abutment supported fixed denture for completely edentulous arch $ 2,500.00 D6079 Implant/abutment supported fixed denture for partially edentulous arch $ 1,650.00 D6090 Repair implant supported prosthesis, by report $ 493.00 D6095 REPAIR IMPLANT ABUTMENT, BY REPORT $ 500.00 D6100 Implant removal, by report $ 526.00 D6199 Unspecified implant procedure, by report D6210 Pontic - cast high noble metal $ 725.00 D6211 Pontic - cast predominantly base metal D6212 Pontic - cast noble metal $ 778.00 D6240 Pontic - porcelain fused to high noble metal $ 735.00 D6241 Pontic - porcelain fused to predominantly base metal $ 680.00 D6242 Pontic - porcelain fused to noble metal D6245 Pontic - porcelain/ceramic $ 749.00 D6250 Pontic - resin with high noble metal D6251 Pontic - resin with predominantly base metal $ 680.00 D6252 Pontic - resin with noble metal $ 722.00

Row # CPT-4 HCPCS Price D6545 Retainer - cast metal for resin bonded fixed prosthesis $ 452.00 D6548 Retainer - porcelain/ceramic for resin bonded fixed prosthesis $ 603.00 D6600 Inlay - porcelain/ceramic, two surfaces D6601 Inlay - porcelain/ceramic, three or more surfaces D6608 Onlay -porcelain/ceramic, two surfaces D6609 Onlay - porcelain/ceramic, three or more surfaces D6710 Crown - indirect resin based composite D6720 Crown - resin with high noble metal D6721 Crown - resin with predominantly base metal D6722 Crown - resin with noble metal D6740 Crown - porcelain/ceramic $ 768.00 D6750 Crown - porcelain fused to high noble metal D6751 Crown - porcelain fused to predominantly base metal $ 685.00 D6752 Crown - porcelain fused to noble metal D6780 Crown - 3/4 cast high noble metal D6781 Crown - 3/4 cast predominantly base metal $ 718.00 D6782 Crown - 3/4 cast noble metal $ 748.00 D6783 Crown - 3/4 porcelain/ceramic $ 773.00 D6790 Crown - full cast high noble metal $ 778.00 D6791 Crown - full cast predominantly base metal D6792 Crown - full cast noble metal $ 709.00 D6920 Connector bar $ 647.00 D6930 Recement fixed partial denture $ 95.00 D6940 Stress breaker $ 272.00 D6950 Precision attachment $ 427.00 D6975 Coping $ 471.00 D6980 Fixed partial denture repair necessitated by restorative material failure D6999 Unspecified fixed prosthodontic procedure, by report D7111 Extraction, coronal remnants - deciduous tooth $ 77.00 D7140 Extraction, erupted tooth or exposed root (elevation and/or forceps removal) $ 77.00 D7210 Surgical removal of erupted tooth requiring removal of bone and/or sectioning of tooth, and including elevation of mucoperiosteal flap if indicated D7220 Removal of impacted tooth - soft tissue D7230 Removal of impacted tooth - partially bony $ 270.00 D7240 Removal of impacted tooth - completely bony D7241 Removal of impacted tooth - completely bony, with unusual surgical complications $ 395.00 D7250 Surgical removal of residual tooth roots (cutting procedure) $ 193.00 D7260 Oroantral fistula closure $ 445.00 D7270 Tooth reimplantation and/or stabilization of accidentally evulsed or displaced tooth $ 334.00 D7272 Tooth transplantation (includes reimplantation from one site to another and splinting and/or stabilization) $ 444.00 D7280 Surgical access of an unerupted tooth $ 310.00 D7282 Mobilization of erupted or malpositioned tooth to aid eruption D7283 Placement of device to facilitate eruption of impacted tooth D7285 Biopsy of oral tissue - hard (bone, tooth) D7286 Biopsy of oral tissue - soft D7290 Surgical repositioning of teeth $ 280.00 D7291 Transseptal fiberotomy/supra crestal fiberotomy, by report $ 190.00 D7310 Alveoloplasty in conjunction with extractions - four or more teeth or tooth spaces, per quadrant D7320 Alveoloplasty not in conjunction with extractions -four or more teeth or tooth spaces, per quadrant $ 277.00 D7340 Vestibuloplasty - ridge extension (secondary epithelialization) $ 602.00 D7410 Excision of benign lesion up to 1.25 cm $ 262.00 D7440 Excision of malignant tumor - lesion diameter up to 1.25 cm $ 364.00 D7441 Excision of malignant tumor - lesion diameter greater than 1.25 cm $ 707.00 D7450 Removal of benign odontogenic cyst or tumor - lesion diameter up to 1.25 cm $ 323.00 D7451 Removal of benign odontogenic cyst or tumor - lesion diameter greater than 1.25 cm $ 448.00

Row # CPT-4 HCPCS Price D7460 Removal of benign nonodontogenic cyst or tumor - lesion diameter up to 1.25 cm $ 315.00 D7461 Removal of benign nonodontogenic cyst or tumor - lesion diameter greater than 1.25 cm $ 453.00 D7465 Destruction of lesion(s) by physical or chemical method, by report $ 229.00 D7471 Removal of lateral exostosis (maxilla or mandible) $ 373.00 D7490 Radical resection of maxilla or mandible $ 6,125.00 D7510 Incision and drainage of abscess - intraoral soft tissue $ 145.00 D7520 Incision and drainage of abscess - extraoral soft tissue $ 232.00 D7530 Removal of foreign body from mucosa, skin, or subcutaneous alveolar tissue $ 223.00 D7540 Removal of reaction producing foreign bodies, musculoskeletal system $ 359.00 D7550 Partial ostectomy/sequestrectomy for removal of non-vital bone $ 313.00 D7560 Maxillary sinusotomy for removal of tooth fragment or foreign body $ 679.00 D7610 Maxilla - open reduction (teeth immobilized, if present) $ 2,989.00 D7620 Maxilla - closed reduction (teeth immobilized, if present) $ 2,295.00 D7630 Mandible - open reduction (teeth immobilized, if present) $ 2,959.00 D7640 Mandible - closed reduction (teeth immobilized, if present) $ 2,174.00 D7650 Malar and/or zygomatic arch - open reduction $ 2,720.00 D7660 Malar and/or zygomatic arch - closed reduction $ 2,227.00 D7670 Alveolus closed reduction may include stabilization of teeth $ 862.00 D7680 Facial bones - complicated reduction with fixation and multiple $ 4,768.00 D7710 Maxilla open reduction $ 3,259.00 D7720 Maxilla - closed reduction $ 2,161.00 D7730 Mandible - open reduction $ 3,294.00 D7740 Mandible - closed reduction $ 2,435.00 D7750 Malar and/or zygomatic arch - open reduction $ 2,875.00 D7760 Malar and/or zygomatic arch - closed reduction $ 2,669.00 D7770 Alveolus - open reduction stabilization of teeth $ 1,675.00 D7780 Facial bones - complicated reduction with fixation and multiple $ 5,886.00 D7810 Open reduction of dislocation $ 2,980.00 D7820 Closed reduction of dislocation $ 305.00 D7830 Manipulation under anesthesia $ 397.00 D7840 Condylectomy $ 3,974.00 D7850 Surgical discectomy, with/without implant $ 3,935.00 D7852 Disc repair $ 4,188.00 D7854 Synovectomy $ 4,157.00 D7856 Myotomy D7858 Joint reconstruction D7860 Arthrotomy D7865 D7870 Arthrocentesis D7871 Non-arthroscopic lysis and lavage D7872 Arthroscopy - diagnosis, with or without biopsy D7873 Arthroscopy - surgical: lavage and lysis of adhesions D7874 Arthroscopy - surgical: disc repositioning and stabilization D7875 Arthroscopy - surgical: synovectomy D7876 Arthroscopy - surgical: discectomy D7877 Arthroscopy - surgical: debridement D7880 Occlusal orthotic device, by report $ 598.00 D7899 Unspecified TMD therapy, by report D7910 Suture of recent small wounds up to 5 cm $ 190.00 D7911 Complicated suture - up to 5 cm $ 294.00 D7912 Complicated suture - greater than 5 cm $ 415.00 D7920 Skin graft (identify defect covered, location and type of graft) $ 1,611.00 D7940 Osteoplasty - for orthognathic deformities $ 2,476.00 D7941 Osteotomy - mandibular rami $ 6,322.00 D7943 Osteotomy - mandibular rami with bone graft; includes obtaining the graft $ 5,948.00 D7944 Osteotomy - segmented or subapical $ 4,735.00 D7945 Osteotomy - body of mandible $ 4,895.00 D7946 LeFort I (maxilla - total) $ 5,962.00

Row # CPT-4 HCPCS Price D7947 LeFort I (maxilla - segmented) $ 6,104.00 D7949 LeFort II or LeFort III - with bone graft $ 8,333.00 D7955 Repair of maxillofacial soft and/or hard tissue defect $ 1,898.00 D7960 Frenulectomy - also known as frenectomy or frenotomy - separate procedure not incidental to another procedure $ 275.00 D7970 Excision of hyperplastic tissue - per arch $ 320.00 D7971 Excision of pericoronal gingiva D7980 Sialolithotomy $ 399.00 D7981 Excision of salivary gland, by report $ 2,389.00 D7982 Sialodochoplasty $ 1,150.00 D7983 Closure of salivary fistula $ 610.00 D7990 Emergency tracheotomy $ 870.00 D7991 Coronoidectomy $ 2,775.00 D7995 Synthetic graft - mandible or facial bones, by report D7996 Implant-mandible for augmentation purposes (excluding alveolar ridge), by report D7997 Appliance removal (not by dentist who placed appliance), includes removal of archbar D7999 Unspecified oral surgery procedure, by report D8010 Limited orthodontic treatment of the primary dentition $ 1,200.00 D8020 Limited orthodontic treatment of the transitional dentition D8030 Limited orthodontic treatment of the adolescent dentition $ 1,616.00 D8040 Limited orthodontic treatment of the adult dentition $ 1,562.00 D8050 Interceptive orthodontic treatment of the primary dentition $ 1,545.00 D8060 Interceptive orthodontic treatment of the transitional dentition $ 1,775.00 D8070 Comprehensive orthodontic treatment of the transitional dentition $ 3,968.00 D8080 Comprehensive orthodontic treatment of the adolescent dentition $ 3,998.00 D8090 Comprehensive orthodontic treatment of the adult dentition $ 4,125.00 D8210 Removable appliance therapy $ 231.00 D8220 Fixed appliance therapy $ 231.00 D8660 Pre-orthodontic treatment visit $ 170.00 D8670 Periodic orthodontic treatment visit (as part of contract) $ 129.00 D8680 Orthodontic retention (removal of appliances, construction and placement of retainer(s)) $ 275.00 D8690 Orthodontic treatment (alternative billing to a contract fee) D8691 Repair of orthodontic appliance $ 134.00 D8692 Replacement of lost or broken retainer $ 232.00 D8999 Unspecified orthodontic procedure, by report D9110 Palliative (emergency) treatment of dental pain - minor procedure $ 79.00 D9210 Local anesthesia not in conjunction with operative or surgical $ 45.00 D9211 Regional block anesthesia $ 64.00 D9212 Trigeminal division block anesthesia $ 168.00 D9215 Local anesthesia in conjunction with operative or surgical $ 39.00 D9220 Deep sedation/general anesthesia - first 30 minutes D9221 Deep sedation/general anesthesia - each additional 15 minutes $ 105.00 D9230 Inhalation of nitrous oxide / anxiolysis, analgesia $ 45.00 D9241 Intravenous conscious sedation/analgesia - first 30 minutes D9242 Intravenous conscious sedation/analgesia - each additional 15 $ 95.00 D9248 Non-intravenous conscious sedation $ 194.00 D9410 House/extended care facility call $ 129.00 D9420 Hospital or ambulatory surgical center call D9430 Office visit for observation (during regularly scheduled hours) - no other services performed $ 47.00 D9440 Office visit - after regularly scheduled hours $ 95.00 D9610 Therapeutic parenteral drug, single administration $ 60.00 D9630 Other drugs and/or medicaments, by report $ 30.00 D9910 Application of desensitizing medicament $ 40.00 D9911 Application of desensitizing resin for cervical and/or root surface, per tooth $ 46.00 D9920 Behavior management, by report $ 85.00

Row # CPT-4 HCPCS Price D9930 Treatment of complications (post-surgical) - unusual circumstances, by report $ 91.00 D9940 Occlusal guard, by report D9941 Fabrication of athletic mouthguard $ 80.00 D9950 Occlusion analysis - mounted case D9951 Occlusal adjustment - limited D9952 Occlusal adjustment - complete D9970 Enamel microabrasion $ 142.00 D9971 Odontoplasty 1 - 2 teeth; includes removal of enamel projections $ 85.00 D9972 External bleaching - per arch - performed in office $ 211.00 D9973 External bleaching - per tooth D9974 Internal bleaching - per tooth $ 189.00 D9999 Unspecified adjunctive procedure, by report HS0002 ROOM/BED: Critical Care $ 1,507.00 HS0003 ROOM/BED: High Dependancy $ 440.00 HS0009 ROOM/BED: Neonatal $ - HS0040 ROOM/BED: Isolation HS0042 ROOM/BED: Semi Private HS0043 ROOM/BED: Maternal Care $ 495.00 HS0045 ROOM/BED: Neonatal - High Dependency $ 440.00 HS0046 ROOM/BED: Neonatal - Special Care HS0048 ROOM/BED: Neonatal - Intensive $ 1,507.00 HS0050 ROOM/BED: Psychiatry HS0060 ROOM/BED: Private $ 467.50 HS0070 Day Treatment HS0070 ROOM/BED: Day Treatment HS0080 ROOM/BED: Sub Acute HS0106 Operating Room Facility Fee 1st Hour HS0108 Operating Room Facility Fee Add. Hours HS1013 Labour & Delivery Room $ 825.00 HS1015 OR Facility Fee Dental <1 Hr HS1017 OR Facility Fee Dental >1 Hr $ 517.00 S9460 Diabetic management program, nurse visit $ 36.97 S9981 Medical records copying fee, administrative $ 5.50 S9982 Medical records copying fee, per page $ 0.55 V5014 Repair/modification of a hearing aid ( In- House) $ 25.00 V5030 Hearing aid, monaural, body worn, air conduction Cost