2010 HCPCS Schedule - DE Medical Assistance Program

Procedure
Pricing Action Maximum
Code Description
Code Allowable
00001 AMBULATORY SURGICAL CENTER GROUP LE 7 $0.00
00002 AMBULATORY SURGICAL CENTER GROUP LE 7 $0.00
00003 AMBULATORY SURGICAL CENTER GROUP LE 7 $0.00
00004 AMBULATORY SURGICAL CENTER GROUP LE 7 $0.00
00005 AMBULATORY SURGICAL CENTER GROUP LE 7 $0.00
00006 AMBULATORY SURGICAL CENTER GROUP LE 7 $0.00
00007 AMBULATORY SURGICAL CENTER GROUP LE 7 $0.00
00008 AMBULATORY SURGICAL CENTER GROUP LE 7 $0.00
00009 AMBULATORY SURGICAL CENTER GROUP LE 7 $0.00
0001F HEART FAILURE COMPOSITE 9 $0.00
0001T ENDOVAS REPR ABDO AO ANEURYS O $0.00
0002F TOBACCO USE, SMOKING, ASSESS O $0.00
0002T ENDOVAS REPR ABDO AO ANEURYS 9 $0.00
0003F TOBACCO USE, NON-SMOKING O $0.00
0003T CERVICOGRAPHY O $0.00
0004F TOBACCO USE TXMNT COUNSELING O $0.00
0005F OSTEOARTHRITIS COMPOSITE 9 $0.00
0005T PERC CATH STENT/BRAIN CV ART O $0.00
0006F STATIN THERAPY, PRESCRIBED O $0.00
0006T PERC CATH STENT/BRAIN CV ART O $0.00
0007F BETA-BLOCKER THX PRESCRIBED O $0.00
0007T PERC CATH STENT/BRAIN CV ART O $0.00
0008F ACE INHIBITOR THX PRESCRIBED O $0.00
0008T UPPER GI ENDOSCOPY W/SUTURE O $0.00
0009F ASSESS ANGINAL SYMPTOM/LEVEL O $0.00
0009T ENDOMETRIAL CRYOABLATION O $0.00
00100 ANESTH, SALIVARY GLAND A $0.00
00102 ANESTH, REPAIR OF CLEFT LIP A $0.00
00103 ANESTH, BLEPHAROPLASTY A $0.00
00104 ANESTH, ELECTROSHOCK A $0.00
0010F ASSESS ANGINAL SYMPTOM/LEVEL O $0.00
0010T TB TEST, GAMMA INTERFERON O $0.00
0011F ORAL ANTIPLAT THX PRESCRIBED O $0.00
00120 ANESTH, EAR SURGERY A $0.00
00124 ANESTH, EAR EXAM A $0.00
00126 ANESTH, TYMPANOTOMY A $0.00
0012F CAP BACTERIAL ASSESS 9 $0.00
0012T OSTEOCHONDRAL KNEE AUTOGRAFT O $0.00
0013T OSTEOCHONDRAL KNEE ALLOGRAFT O $0.00
00140 ANESTH, PROCEDURES ON EYE A $0.00
00142 ANESTH, LENS SURGERY A $0.00
00144 ANESTH, CORNEAL TRANSPLANT A $0.00
00145 ANESTH, VITREORETINAL SURG A $0.00
00147 ANESTH, IRIDECTOMY A $0.00
00148 ANESTH, EYE EXAM A $0.00
0014F COMP PREOP ASSESS CAT SURG 9 $0.00
0014T MENISCAL TRANSPLANTATION, MEDIAL OR O $0.00

0015F MELAN FOLLOW-UP COMPLETE 9 $0.00
00160 ANESTH, NOSE/SINUS SURGERY A $0.00
00162 ANESTH, NOSE/SINUS SURGERY A $0.00
00164 ANESTH, BIOPSY OF NOSE A $0.00
0016T THERMOTX CHOROID VASC LESION 9 $0.00
00170 ANESTH, PROCEDURE ON MOUTH A $0.00
00172 ANESTH, CLEFT PALATE REPAIR A $0.00
00174 ANESTH, PHARYNGEAL SURGERY A $0.00
00176 ANESTH, PHARYNGEAL SURGERY A $0.00
0017T PHOTOCOAGULAT MACULAR DRUSEN 9 $0.00
0018T TRANSCRANIAL MAGNETIC STIMUL O $0.00
00190 ANESTH, FACE/SKULL BONE SURG A $0.00
00192 ANESTH, FACIAL BONE SURGERY A $0.00
0019T EXTRACORP SHOCK WV TX,MS NOS 9 $0.00
0020T EXTRACORP SHOCK WAVE TX, FT O $0.00
00210 ANESTH, CRANIAL SURG NOS A $0.00
00211 ANESTH, CRAN SURG, HEMOTOMA A $0.00
00212 ANESTH, SKULL DRAINAGE A $0.00
00214 ANESTH, SKULL DRAINAGE A $0.00
00215 ANESTH, SKULL REPAIR/FRACT A $0.00
00216 ANESTH, HEAD VESSEL SURGERY A $0.00
00218 ANESTH, SPECIAL HEAD SURGERY A $0.00
0021T FETAL OXIMETRY, TRNSVAG/CERV O $0.00
00220 ANESTH, INTRCRN NERVE A $0.00
00222 ANESTH, HEAD NERVE SURGERY A $0.00
0023T PHENOTYPE DRUG TEST, HIV 1 O $0.00
0024T TRANSCATH CARDIAC REDUCTION O $0.00
0025T ULTRASONIC PACHYMETRY O $0.00
0026T MEASURE REMNANT LIPOPROTEINS O $0.00
0027T ENDOSCOPIC EPIDURAL LYSIS O $0.00
0028T DEXA BODY COMPOSITION STUDY O $0.00
0029T MAGNETIC TX FOR INCONTINENCE O $0.00
00300 ANESTH, HEAD/NECK/PTRUNK A $0.00
0030T ANTIPROTHROMBIN ANTIBODY 9 $0.00
0031T SPECULOSCOPY O $0.00
00320 ANESTH, NECK ORGAN, 1 & OVER A $0.00
00322 ANESTH, BIOPSY OF THYROID A $0.00
00326 ANESTH, LARYNX/TRACH, < 1 YR A $0.00
0032T SPECULOSCOPY W/DIRECT SAMPLE O $0.00
0033T ENDOVASC TAA REPR INCL SUBCL O $0.00
0034T ENDOVASC TAA REPR W/O SUBCL O $0.00
00350 ANESTH, NECK VESSEL SURGERY A $0.00
00352 ANESTH, NECK VESSEL SURGERY A $0.00
0035T INSERT ENDOVASC PROSTH, TAA O $0.00
0036T ENDOVASC PROSTH, TAA, ADD-ON O $0.00
0037T ARTERY TRANSPOSE/ENDOVAS TAA O $0.00
0038T RAD ENDOVASC TAA RPR W/COVER O $0.00
0039T RAD S/I, ENDOVASC TAA REPAIR O $0.00
00400 ANESTH, SKIN, EXT/PER/ATRUNK A $0.00

00402 ANESTH, SURGERY OF BREAST A $0.00
00404 ANESTH, SURGERY OF BREAST A $0.00
00406 ANESTH, SURGERY OF BREAST A $0.00
0040T RAD S/I, ENDOVASC TAA PROSTH O $0.00
00410 ANESTH, CORRECT HEART RHYTHM A $0.00
0041T DETECT UR INFECT AGNT W/CPAS O $0.00
00420 ANESTH, SKIN SURGERY, BACK 9 $0.00
0042T CT PERFUSION W/CONTRAST, CBF 9 $0.00
0043T CO EXPIRED GAS ANALYSIS O $0.00
0044T WHOLE BODY PHOTOGRAPHY O $0.00
00450 ANESTH, SURGERY OF SHOULDER A $0.00
00452 ANESTH, SURGERY OF SHOULDER A $0.00
00454 ANESTH, COLLAR BONE BIOPSY A $0.00
0045T WHOLE BODY PHOTOGRAPHY O $0.00
0046T CATH LAVAGE, MAMMARY DUCT(S) O $0.00
00470 ANESTH, REMOVAL OF RIB A $0.00
00472 ANESTH, CHEST WALL REPAIR A $0.00
00474 ANESTH, SURGERY OF RIB(S) A $0.00
0047T CATH LAVAGE, MAMMARY DUCT(S) O $0.00
0048T IMPLANT VENTRICULAR DEVICE 9 $0.00
0049T EXTERNAL CIRCULATION ASSIST O $0.00
00500 ANESTH, ESOPHAGEAL SURGERY A $0.00
0050T REMOVAL CIRCULATION ASSIST 9 $0.00
0051T IMPLANT TOTAL HEART SYSTEM 9 $0.00
00520 ANESTH, CHEST PROCEDURE A $0.00
00522 ANESTH, CHEST LINING BIOPSY A $0.00
00524 ANESTH, CHEST DRAINAGE A $0.00
00528 ANESTH, CHEST PARTITION VIEW A $0.00
00529 ANESTH, CHEST PARTITION VIEW 9 $0.00
0052T REPLACE COMPONENT HEART SYST 9 $0.00
00530 ANESTH, PACEMAKER INSERTION A $0.00
00532 ANESTH, VASCULAR ACCESS A $0.00
00534 ANESTH, CARDIOVERTER/DEFIB A $0.00
00537 ANESTH, CARDIAC ELECTROPHYS A $0.00
00539 ANESTH, TRACH-BRONCH RECONST A $0.00
0053T REPLACE COMPONENT HEART SYST 9 $0.00
00540 ANESTH, CHEST SURGERY A $0.00
00541 ANESTH, ONE LUNG VENTILATION A $0.00
00542 ANESTH, RELEASE OF LUNG A $0.00
00544 ANESTH, CHEST LINING REMOVAL O $0.00
00546 ANESTH, LUNG,CHEST WALL SURG A $0.00
00548 ANESTH, TRACHEA,BRONCHI SURG A $0.00
0054T BONE SURGERY USING COMPUTER O $0.00
00550 ANESTH, STERNAL DEBRIDEMENT A $0.00
0055T BONE SURGERY USING COMPUTER O $0.00
00560 ANESTH, HEART SURG W/O PUMP A $0.00
00561 ANESTH, HEART SURG < AGE 1 A $0.00
00562 ANESTH HRT SURG W/PMP AGE 1+ A $0.00
00563 ANESTH, HEART SURG W/ARREST A $0.00

00566 ANESTH, CABG W/O PUMP A $0.00
00567 ANESTH, CABG W/PUMP A $0.00
0056T BONE SURGERY USING COMPUTER O $0.00
0057T UPPR GI SCOPE W/ THRML TXMNT O $0.00
00580 ANESTH, HEART/LUNG TRANSPLNT A $0.00
0058T CRYOPRESERVATION, OVARY TISS O $0.00
0059T CRYOPRESERVATION, OOCYTE O $0.00
00600 ANESTH, SPINE, CORD SURGERY A $0.00
00604 ANESTH, SITTING PROCEDURE A $0.00
0060T ELECTRICAL IMPEDANCE SCAN O $0.00
0061T DESTRUCTION OF TUMOR, BREAST O $0.00
00620 ANESTH, SPINE, CORD SURGERY A $0.00
00622 ANESTH, REMOVAL OF NERVES A $0.00
00625 ANES SPINE TRANTHOR W/O VENT A $0.00
00626 ANES, SPINE TRANSTHOR W/VENT A $0.00
0062T REP INTRADISC ANNULUS;1 LEV O $0.00
00630 ANESTH, SPINE, CORD SURGERY A $0.00
00632 ANESTH, REMOVAL OF NERVES A $0.00
00634 ANESTH FOR CHEMONUCLEOLYSIS 5 $0.00
00635 ANESTH, LUMBAR PUNCTURE A $0.00
0063T REP INTRADISC ANNULUS;>1LEV O $0.00
00640 ANESTH, SPINE MANIPULATION A $0.00
0064T SPECTROSCOP EVAL EXPIRED GAS O $0.00
0065T OCULAR PHOTOSCREEN BILAT O $0.00
0066T CT COLONOGRAPHY;SCREEN O $0.00
00670 ANESTH, SPINE, CORD SURGERY A $0.00
0067T CT COLONOGRAPHY;DX O $0.00
0068T INTERP/REPT HEART SOUND O $0.00
0069T ANALYSIS ONLY HEART SOUND O $0.00
00700 ANESTH, ABDOMINAL WALL SURG A $0.00
00702 ANESTH, FOR LIVER BIOPSY A $0.00
0070T INTERP ONLY HEART SOUND O $0.00
0071T U/S LEIOMYOMATA ABLATE 200 9 $0.00
00730 ANESTH, ABDOMINAL WALL SURG A $0.00
0073T DELIVERY, COMP IMRT 9 $0.00
00740 ANESTH, UPPER GI VISUALIZE A $0.00
0074T ONLINE PHYSICIAN E/M O $0.00
00750 ANESTH, REPAIR OF HERNIA A $0.00
00752 ANESTH, REPAIR OF HERNIA A $0.00
00754 ANESTH, REPAIR OF HERNIA A $0.00
00756 ANESTH, REPAIR OF HERNIA A $0.00
0075T PERQ STENT/CHEST VERT ART 9 $0.00
0076T S&I STENT/CHEST VERT ART 9 $0.00
00770 ANESTH, BLOOD VESSEL REPAIR A $0.00
0077T CEREB THERM PERFUSION PROBE O $0.00
0078T ENDOVASC AORT REPR W/DEVICE 9 $0.00
00790 ANESTH, SURG UPPER ABDOMEN A $0.00
00792 ANESTH, HEMORR/EXCISE LIVER A $0.00

00794 ANESTH, PANCREAS REMOVAL A $0.00
00796 ANESTH, FOR LIVER TRANSPLANT A $0.00
00797 ANESTH, SURGERY FOR OBESITY A $0.00
0079T ENDOVASC VISC EXTNSN REPR 9 $0.00
00800 ANESTH, ABDOMINAL WALL SURG A $0.00
00802 ANESTH, FAT LAYER REMOVAL A $0.00
00806 ANESTHESIA FOR LAPAROSCOPIC PROCEDU O $0.00
0080T ENDOVASC AORT REPR RAD S&I 9 $0.00
00810 ANESTH, LOW INTESTINE SCOPE A $0.00
0081T ENDOVASC VISC EXTNSN S&I 9 $0.00
00820 ANESTH, ABDOMINAL WALL SURG A $0.00
0082T STEREOTACTIC RAD DELIVERY O $0.00
00830 ANESTH, REPAIR OF HERNIA A $0.00
00832 ANESTH, REPAIR OF HERNIA A $0.00
00834 ANESTH, HERNIA REPAIR< 1 YR A $0.00
00836 ANESTH HERNIA REPAIR PREEMIE A $0.00
0083T STEREOTACTIC RAD TX MNGMT O $0.00
00840 ANESTH, SURG LOWER ABDOMEN A $0.00
00842 ANESTH, AMNIOCENTESIS A $0.00
00844 ANESTH, PELVIS SURGERY A $0.00
00846 ANESTH, HYSTERECTOMY A $0.00
00848 ANESTH, PELVIC ORGAN SURG A $0.00
0084T TEMP PROSTATE URETHRAL STENT O $0.00
00850 ANESTH, CESAREAN SECTION 9 $0.00
00851 ANESTH, TUBAL LIGATION A $0.00
00855 ANESTH, HYSTERECTOMY 9 $0.00
00857 ANALGESIA, LABOR & C-SECTION 9 $0.00
0085T BREATH TEST HEART REJECT 9 $0.00
00860 ANESTH, SURGERY OF ABDOMEN A $0.00
00862 ANESTH, KIDNEY/URETER SURG A $0.00
00864 ANESTH, REMOVAL OF BLADDER A $0.00
00865 ANESTH, REMOVAL OF PROSTATE A $0.00
00866 ANESTH, REMOVAL OF ADRENAL A $0.00
00868 ANESTH, KIDNEY TRANSPLANT A $0.00
00869 ANESTH, VASECTOMY O $0.00
0086T L VENTRICLE FILL PRESSURE O $0.00
00870 ANESTH, BLADDER STONE SURG A $0.00
00872 ANESTH KIDNEY STONE DESTRUCT A $0.00
00873 ANESTH KIDNEY STONE DESTRUCT A $0.00
0087T SPERM EVAL HYALURONAN O $0.00
00880 ANESTH, ABDOMEN VESSEL SURG A $0.00
00882 ANESTH, MAJOR VEIN LIGATION A $0.00
00884 ANESTH, MAJOR VEIN REVISION 9 $0.00
0088T RF TONGUE BASE VOL REDUXN O $0.00
0089T ACTIGRAPHY TESTING, 3-DAY O $0.00
00900 ANESTH, PERINEAL PROCEDURE 9 $0.00
00902 ANESTH, ANORECTAL SURGERY A $0.00
00904 ANESTH, PERINEAL SURGERY A $0.00
00906 ANESTH, REMOVAL OF VULVA A $0.00

00908 ANESTH, REMOVAL OF PROSTATE A $0.00
0090T CERVICAL ARTIFIC DISC O $0.00
00910 ANESTH, BLADDER SURGERY A $0.00
00912 ANESTH, BLADDER TUMOR SURG A $0.00
00914 ANESTH, REMOVAL OF PROSTATE A $0.00
00916 ANESTH, BLEEDING CONTROL A $0.00
00918 ANESTH, STONE REMOVAL A $0.00
0091T LUMBAR ARTIFIC DISC O $0.00
00920 ANESTH, GENITALIA SURGERY A $0.00
00921 ANESTH, VASECTOMY A $0.00
00922 ANESTH, SPERM DUCT SURGERY A $0.00
00924 ANESTH, TESTIS EXPLORATION A $0.00
00926 ANESTH, REMOVAL OF TESTIS A $0.00
00928 ANESTH, REMOVAL OF TESTIS A $0.00
0092T ARTIFIC DISC ADDL 9 $0.00
00930 ANESTH, TESTIS SUSPENSION A $0.00
00932 ANESTH, AMPUTATION OF PENIS A $0.00
00934 ANESTH, PENIS, NODES REMOVAL A $0.00
00936 ANESTH, PENIS, NODES REMOVAL A $0.00
00938 ANESTH, INSERT PENIS DEVICE 9 $0.00
0093T CERVICAL ARTIFIC DISKECTOMY O $0.00
00940 ANESTH, VAGINAL PROCEDURES A $0.00
00942 ANESTH, SURG ON VAG/URETHRAL A $0.00
00944 ANESTH, VAGINAL HYSTERECTOMY A $0.00
00946 ANESTH, VAGINAL DELIVERY 9 $0.00
00948 ANESTH, REPAIR OF CERVIX A $0.00
0094T LUMBAR ARTIFIC DISKECTOMY O $0.00
00950 ANESTH, VAGINAL ENDOSCOPY A $0.00
00952 ANESTH, HYSTEROSCOPE/GRAPH A $0.00
00955 ANALGESIA, VAGINAL DELIVERY 9 $0.00
0095T ARTIFIC DISKECTOMY ADDL 9 $0.00
0096T REV CERVICAL ARTIFIC DISC O $0.00
0097T REV LUMBAR ARTIFIC DISC O $0.00
0098T REV ARTIFIC DISC ADDL 9 $0.00
0099T IMPLANT CORNEAL RING 9 $0.00
01000 ANESTH, SKIN SURGERY, PELVIS 9 $0.00
0100T PROSTH RETINA RECEIVE&GEN 9 $0.00
0101T EXTRACORP SHOCKWV TX,HI ENRG 9 $0.00
0102T EXTRACORP SHOCKWV TX,ANESTH 9 $0.00
0103T HOLOTRANSCOBALAMIN 9 $0.00
0104T AT REST CARDIO GAS REBREATHE 9 $0.00
0105T EXERC CARDIO GAS REBREATHE 9 $0.00
0106T TOUCH QUANT SENSORY TEST 9 $0.00
0107T VIBRATE QUANT SENSORY TEST 9 $0.00
0108T COOL QUANT SENSORY TEST 9 $0.00
0109T HEAT QUANT SENSORY TEST 9 $0.00
0110T NOS QUANT SENSORY TEST 9 $0.00
01110 ANESTH, SKIN SURGERY, PELVIS 9 $0.00
01112 ANESTH, BONE ASPIRATE/BX A $0.00

0111T RBC MEMBRANES FATTY ACIDS 9 $0.00
01120 ANESTH, PELVIS SURGERY A $0.00
01130 ANESTH, BODY CAST PROCEDURE A $0.00
01140 ANESTH, AMPUTATION AT PELVIS A $0.00
01150 ANESTH, PELVIC TUMOR SURGERY A $0.00
0115T MED TX MNGMT 15 MIN O $0.00
01160 ANESTH, PELVIS PROCEDURE A $0.00
0116T MED TX MNGMT SUBSQT O $0.00
01170 ANESTH, PELVIS SURGERY A $0.00
01173 ANESTH, FX REPAIR, PELVIS A $0.00
0117T MED TX MNGMT ADDL 15 MIN O $0.00
01180 ANESTH, PELVIS NERVE REMOVAL A $0.00
01190 ANESTH, PELVIS NERVE REMOVAL A $0.00
01200 ANESTH, HIP JOINT PROCEDURE A $0.00
01202 ANESTH, ARTHROSCOPY OF HIP A $0.00
0120T FIBROADENOMA CRYOABLATE, EA O $0.00
01210 ANESTH, HIP JOINT SURGERY A $0.00
01212 ANESTH, HIP DISARTICULATION A $0.00
01214 ANESTH, HIP ARTHROPLASTY A $0.00
01215 ANESTH, REVISE HIP REPAIR A $0.00
01220 ANESTH, PROCEDURE ON FEMUR A $0.00
01230 ANESTH, SURGERY OF FEMUR A $0.00
01232 ANESTH, AMPUTATION OF FEMUR A $0.00
01234 ANESTH, RADICAL FEMUR SURG A $0.00
0123T SCLERAL FISTULIZATION 9 $0.00
01240 ANESTH, UPPER LEG SKIN SURG 9 $0.00
0124T CONJUNCTIVAL DRUG PLACEMENT 9 $0.00
01250 ANESTH, UPPER LEG SURGERY A $0.00
01260 ANESTH, UPPER LEG VEINS SURG A $0.00
0126T CHD RISK IMT STUDY 9 $0.00
01270 ANESTH, THIGH ARTERIES SURG A $0.00
01272 ANESTH, FEMORAL ARTERY SURG A $0.00
01274 ANESTH, FEMORAL EMBOLECTOMY A $0.00
01300 ANESTH, SKIN SURGERY, KNEE 9 $0.00
0130T CHRON CARE DRUG INVESTIGATN 9 $0.00
01320 ANESTH, KNEE AREA SURGERY A $0.00
0133T ESOPHAGEAL IMPLANT INJEXN O $0.00
01340 ANESTH, KNEE AREA PROCEDURE A $0.00
0135T PERQ CRYOABLATE RENAL TUMOR O $0.00
01360 ANESTH, KNEE AREA SURGERY A $0.00
0137T PROSTATE SATURATION SAMPLING O $0.00
01380 ANESTH, KNEE JOINT PROCEDURE A $0.00
01382 ANESTH, DX KNEE ARTHROSCOPY A $0.00
01390 ANESTH, KNEE AREA PROCEDURE A $0.00
01392 ANESTH, KNEE AREA SURGERY A $0.00
01400 ANESTH, KNEE JOINT SURGERY A $0.00
01402 ANESTH, KNEE ARTHROPLASTY A $0.00
01404 ANESTH, AMPUTATION AT KNEE A $0.00
0140T EXHALED BREATH CONDENSATE PH 9 $0.00

0141T PERQ ISLET TRANSPLANT 9 $0.00
01420 ANESTH, KNEE JOINT CASTING A $0.00
0142T OPEN ISLET TRANSPLANT 9 $0.00
01430 ANESTH, KNEE VEINS SURGERY A $0.00
01432 ANESTH, KNEE VESSEL SURG A $0.00
0143T LAPAROSCOPIC ISLET TRANSPLNT 9 $0.00
01440 ANESTH, KNEE ARTERIES SURG A $0.00
01442 ANESTH, KNEE ARTERY SURG A $0.00
01444 ANESTH, KNEE ARTERY REPAIR A $0.00
0144T CT HEART WO DYE; QUAL CALC O $0.00
0145T CT HEART W/WO DYE FUNCT O $0.00
01460 ANESTH, LOWER LEG SKIN SURG 9 $0.00
01462 ANESTH, LOWER LEG PROCEDURE A $0.00
01464 ANESTH, ANKLE/FT ARTHROSCOPY A $0.00
0146T CCTA W/WO DYE O $0.00
01470 ANESTH, LOWER LEG SURGERY A $0.00
01472 ANESTH, ACHILLES TENDON SURG A $0.00
01474 ANESTH, LOWER LEG SURGERY A $0.00
0147T CCTA W/WO, QUAN CALCIUM O $0.00
01480 ANESTH, LOWER LEG BONE SURG A $0.00
01482 ANESTH, RADICAL LEG SURGERY A $0.00
01484 ANESTH, LOWER LEG REVISION A $0.00
01486 ANESTH, ANKLE REPLACEMENT A $0.00
0148T CCTA W/WO, STRXR O $0.00
01490 ANESTH, LOWER LEG CASTING A $0.00
0149T CCTA W/WO, STRXR QUAN CALC O $0.00
01500 ANESTH, LEG ARTERIES SURG A $0.00
01502 ANESTH, LWR LEG EMBOLECTOMY A $0.00
0150T CCTA W/WO, DISEASE STRXR O $0.00
0151T CT HEART FUNCT ADD-ON O $0.00
01520 ANESTH, LOWER LEG VEIN SURG A $0.00
01522 ANESTH, LOWER LEG VEIN SURG A $0.00
0152T COMPUTER CHEST ADD-ON 9 $0.00
0153T TCATH SENSOR ANEURYSM SAC O $0.00
0154T STUDY SENSOR ANEURYSM SAC O $0.00
0155T LAP IMPL GAST CURVE ELECTRD 9 $0.00
0156T LAP REMV GAST CURVE ELECTRD 9 $0.00
0157T OPEN IMPL GAST CURVE ELECTRD 9 $0.00
0158T OPEN REMV GAST CURVE ELECTRD 9 $0.00
0159T CAD BREAST MRI 9 $0.00
01600 ANESTH, SHOULDER SKIN SURG 9 $0.00
0160T TCRANIAL MAGN STIM TX PLAN 9 $0.00
01610 ANESTH, SURGERY OF SHOULDER A $0.00
0161T TCRANIAL MAGN STIM TX DELIV 9 $0.00
01620 ANESTH, SHOULDER PROCEDURE A $0.00
01622 ANES DX SHOULDER ARTHROSCOPY A $0.00
0162T ANAL PROGRAM GAST NEUROSTIM O $0.00
01630 ANESTH, SURGERY OF SHOULDER A $0.00
01632 ANESTH, SURGERY OF SHOULDER O $0.00

01634 ANESTH, SHOULDER JOINT AMPUT A $0.00
01636 ANESTH, FOREQUARTER AMPUT A $0.00
01638 ANESTH, SHOULDER REPLACEMENT A $0.00
0163T LUMB ARTIF DISKECTOMY ADDL 9 $0.00
0164T REMOVE LUMB ARTIF DISC ADDL 9 $0.00
01650 ANESTH, SHOULDER ARTERY SURG A $0.00
01652 ANESTH, SHOULDER VESSEL SURG A $0.00
01654 ANESTH, SHOULDER VESSEL SURG A $0.00
01656 ANESTH, ARM-LEG VESSEL SURG A $0.00
0165T REVISE LUMB ARTIF DISC ADDL 9 $0.00
0166T TCATH VSD CLOSE W/O BYPASS 9 $0.00
01670 ANESTH, SHOULDER VEIN SURG A $0.00
0167T TCATH VSD CLOSE W BYPASS 9 $0.00
01680 ANESTH, SHOULDER CASTING A $0.00
01682 ANESTH, AIRPLANE CAST A $0.00
0168T RHINOPHOTOTX LIGHT APP BILAT 9 $0.00
0169T PLACE STEREO CATH BRAIN 9 $0.00
01700 ANESTH, ELBOW AREA SKIN SURG 9 $0.00
0170T ANORECTAL FISTULA PLUG RPR O $0.00
01710 ANESTH, ELBOW AREA SURGERY A $0.00
01712 ANESTH, UPPR ARM TENDON SURG A $0.00
01714 ANESTH, UPPR ARM TENDON SURG A $0.00
01716 ANESTH, BICEPS TENDON REPAIR A $0.00
0171T LUMBAR SPINE PROCES DISTRACT 9 $0.00
0172T LUMBAR SPINE PROCESS ADDL 9 $0.00
01730 ANESTH, UPPR ARM PROCEDURE A $0.00
01732 ANESTH, DX ELBOW ARTHROSCOPY A $0.00
0173T IOP MONIT IO PRESSURE 9 $0.00
01740 ANESTH, UPPER ARM SURGERY A $0.00
01742 ANESTH, HUMERUS SURGERY A $0.00
01744 ANESTH, HUMERUS REPAIR A $0.00
0174T CAD CXR WITH INTERP 9 $0.00
01756 ANESTH, RADICAL HUMERUS SURG A $0.00
01758 ANESTH, HUMERAL LESION SURG A $0.00
0175T CAD CXR REMOTE 9 $0.00
01760 ANESTH, ELBOW REPLACEMENT A $0.00
0176T AQU CANAL DILAT W/O RETENT 9 $0.00
01770 ANESTH, UPPR ARM ARTERY SURG A $0.00
01772 ANESTH, UPPR ARM EMBOLECTOMY A $0.00
0177T AQU CANAL DILAT W RETENT 9 $0.00
01780 ANESTH, UPPER ARM VEIN SURG A $0.00
01782 ANESTH, UPPR ARM VEIN REPAIR A $0.00
0178T 64 LEAD ECG W I&R 9 $0.00
0179T 64 LEAD ECG W TRACING 9 $0.00
01800 ANESTH, LOWER ARM SKIN SURG 9 $0.00
0180T 64 LEAD ECG W I&R ONLY 9 $0.00
01810 ANESTH, LOWER ARM SURGERY A $0.00
0181T CORNEAL HYSTERESIS 9 $0.00
01820 ANESTH, LOWER ARM PROCEDURE A $0.00

01829 ANESTH, DX WRIST ARTHROSCOPY A $0.00
0182T HDR ELECT BRACHYTHERAPY 9 $0.00
01830 ANESTH, LOWER ARM SURGERY A $0.00
01832 ANESTH, WRIST REPLACEMENT A $0.00
0183T WOUND ULTRASOUND 9 $0.00
01840 ANESTH, LWR ARM ARTERY SURG A $0.00
01842 ANESTH, LWR ARM EMBOLECTOMY A $0.00
01844 ANESTH, VASCULAR SHUNT SURG A $0.00
0184T EXC RECTAL TUMOR ENDOSCOPIC 9 $0.00
01850 ANESTH, LOWER ARM VEIN SURG A $0.00
01852 ANESTH, LWR ARM VEIN REPAIR A $0.00
0185T COMPTR PROBABILITY ANALYSIS 9 $0.00
01860 ANESTH, LOWER ARM CASTING A $0.00
0186T SUPRACHOROIDAL DRUG DELIVERY 9 $0.00
0187T OPHTHALMIC DX IMAGE ANTERIOR 9 $0.00
0188T VIDEOCONF CRIT CARE 74 MIN 9 $0.00
0189T VIDEOCONF CRIT CARE ADDL 30 9 $0.00
01900 ANESTH, UTERUS/TUBE INJECT 9 $0.00
01902 ANESTH, BURR HOLES, SKULL 9 $0.00
01904 ANESTH, SKULL X-RAY INJECT 9 $0.00
01905 ANES, SPINE INJECT, X-RAY/RE O $0.00
01906 ANESTH, LUMBAR MYELOGRAPHY 9 $0.00
01908 ANESTH, CERVICAL MYELOGRAPHY 9 $0.00
0190T PLACE INTRAOC RADIATION SRC 9 $0.00
01910 ANESTH, SKULL MYELOGRAPHY 9 $0.00
01912 ANESTH, LUMBAR DISKOGRAPHY 9 $0.00
01914 ANESTH, CERVICAL DISKOGRAPHY 9 $0.00
01916 ANESTH, DX ARTERIOGRAPHY A $0.00
01918 ANESTH, LIMB ARTERIOGRAM 9 $0.00
0191T INSERT ANT SEGMENT DRAIN INT 9 $0.00
01920 ANESTH, CATHETERIZE HEART A $0.00
01921 ANESTH, VESSEL SURGERY 9 $0.00
01922 ANESTH, CAT OR MRI SCAN A $0.00
01924 ANES, THER INTERVEN RAD, ART A $0.00
01925 ANES, THER INTERVEN RAD, CAR A $0.00
01926 ANES, TX INTERV RAD HRT/CRAN A $0.00
0192T INSERT ANT SEGMENT DRAIN EXT 9 $0.00
01930 ANES, THER INTERVEN RAD, VEI A $0.00
01931 ANES, THER INTERVEN RAD, TIP A $0.00
01932 ANES, TX INTERV RAD, TH VEIN A $0.00
01933 ANES, TX INTERV RAD, CRAN V A $0.00
01935 ANESTH, PERC IMG DX SP PROC A $0.00
01936 ANESTH, PERC IMG TX SP PROC A $0.00
0193T RF BLADDER NECK MICROREMODEL 9 $0.00
0194T PROCALCITONIN (PCT) O $0.00
01951 ANESTH, BURN, LESS 4 PERCENT A $0.00
01952 ANESTH, BURN, 4-9 PERCENT A $0.00
01953 ANESTH, BURN, EACH 9 PERCENT 5 $0.00
01958 ANESTH, ANTEPARTUM MANIPUL A $0.00

0195T ARTHROD PRESAC INTERBODY 9 $0.00
01960 ANESTH, VAGINAL DELIVERY A $0.00
01961 ANESTH, CS DELIVERY A $0.00
01962 ANESTH, EMER HYSTERECTOMY A $0.00
01963 ANESTH, CS HYSTERECTOMY A $0.00
01964 ANESTH, ABORTION PROCEDURES O $0.00
01965 ANESTH, INC/MISSED AB PROC A $0.00
01966 ANESTH, INDUCED AB PROCEDURE A $0.00
01967 ANESTH/ANALG, VAG DELIVERY A $0.00
01968 ANES/ANALG CS DELIVER ADD-ON A $0.00
01969 ANESTH/ANALG CS HYST ADD-ON A $0.00
0196T ARTHROD PRESAC INTERBODY EAC 9 $0.00
0197T INTRAFRACTION TRACK MOTION 9 $0.00
0198T OCULAR BLOOD FLOW MEASURE 9 $0.00
01990 SUPPORT FOR ORGAN DONOR A $0.00
01991 ANESTH, NERVE BLOCK/INJ A $0.00
01992 ANESTH, N BLOCK/INJ, PRONE A $0.00
01995 REGIONAL ANESTHESIA LIMB O $0.00
01996 HOSP MANAGE CONT DRUG ADMIN 3 $48.15
01999 UNLISTED ANESTH PROCEDURE 5 $0.00
0199T PHYSIOLOGIC TREMOR RECORD 9 $0.00
0200T PERQ SACRAL AUGMT UNILAT INJ 9 $0.00
0201T PERQ SACRAL AUGMT BILAT INJ 9 $0.00
0202T POST VERT ARTHRPLST 1 LUMBAR 9 $0.00
0203T UNATTEND SLEEP STUDY W/TIME 9 $0.00
0204T UNATTENDED SLEEP STUDY 9 $0.00
0205T INIRS EACH VESSEL ADD-ON 9 $0.00
0206T REMOTE ALGORITHM ANALYS ECG 9 $0.00
0207T CLEAR EYELID GLAND W/HEAT 9 $0.00
0208T AUTOMATED AUDIOMETRY AIR 9 $0.00
0209T AUTO AUDIOMETRY AIR/BONE 9 $0.00
0210T AUTO AUDIOMETRY SP THRESH 9 $0.00
0211T AUTO AUDIOMETRY SP THRESH 9 $0.00
0212T COMPREHEN AUTO AUDIOMETRY 9 $0.00
0213T US FACET JT INJ CERV/T 1 LEV 9 $0.00
0214T US FACET JT INJ CERV/T 2 LEV 9 $0.00
0215T US FACET JT INJ CERV/T 3 LEV 9 $0.00
0216T US FACET JT INJ LS 1 LEVEL 9 $0.00
0217T US FACET JT INJ LS 2 LEVEL 9 $0.00
0218T US FACET JT INJ LS 3 LEVEL 9 $0.00
0219T FUSE SPINE FACET JT CERV 9 $0.00
0220T FUSE SPINE FACET JT THOR 9 $0.00
0221T FUSE SPINE FACET JT LUMBAR 9 $0.00
0222T FUSE SPINE FACET JT ADD SEG 9 $0.00
0500F INITIAL PRENATAL CARE VISIT 9 $0.00
0501F PRENATAL FLOW SHEET 9 $0.00
0502F SUBSEQUENT PRENATAL CARE 9 $0.00
0503F POSTPARTUM CARE VISIT 9 $0.00
0505F HEMODIALYSIS PLAN DOCD 9 $0.00

0507F PERITON DIALYSIS PLAN DOCD 9 $0.00
0509F URINE INCON PLAN DOCD 9 $0.00
0513F ELEV BP PLAN OF CARE DOCD 9 $0.00
0514F CARE PLAN HGB DOCD ESA PT 9 $0.00
0516F ANEMIA PLAN OF CARE DOCD 9 $0.00
0517F GLAUCOMA PLAN OF CARE DOCD 9 $0.00
0518F FALL PLAN OF CARE DOCD 9 $0.00
0519F PLAND CHEMO DOCD B/4 TXMNT 9 $0.00
0520F RAD DOS LIMTS B/4 3D RAD 9 $0.00
0521F PLAN OF CARE 4 PAIN DOCD 9 $0.00
0525F INITIAL VISIT FOR EPISODE 9 $0.00
0526F SUBS VISIT FOR EPISODE 9 $0.00
0528F RCMND FLW-UP 10 YRS DOCD 9 $0.00
0529F INTRVL 3+YRS PTS CLNSCP DOCD 9 $0.00
0535F DYSPNEA MNGMNT PLAN DOCD 9 $0.00
0540F GLUCO MNGMNT PLAN DOCD 9 $0.00
0545F FOLLOW UP CARE PLAN MDD DOCD 9 $0.00
0575F HIV RNA PLAN CARE DOCD 9 $0.00
10000 INCISION AND DRAINAGE OF INFECTED O O $0.00
10001 INCISION AND DRAINAGE OF INFECTED O O $0.00
10002 INCISION AND DRAINAGE OF INFECTED O O $0.00
10003 INCISION AND DRAINAGE OF INFECTED O O $0.00
1000F TOBACCO USE ASSESSED 9 $0.00
1000H PART H-ONLY DME, SUPPLIES AND HEARI O $0.00
1001F TOBACCO USE, NON-SMOKING O $0.00
10020 INCISION AND DRAINAGE OF FURUNCLE O $0.00
10021 FNA W/O IMAGE 3 $134.23
10022 FNA W/IMAGE 3 $133.52
1002F ASSESS ANGINAL SYMPTOM/LEVEL 9 $0.00
1003F LEVEL OF ACTIVITY ASSESS 9 $0.00
10040 ACNE SURGERY 3 $96.53
1004F CLIN SYMP VOL OVRLD ASSESS 9 $0.00
1005F ASTHMA SYMPTOMS EVALUATE 9 $0.00
10060 DRAINAGE OF SKIN ABSCESS 3 $103.47
10061 DRAINAGE OF SKIN ABSCESS 3 $174.27
1006F OSTEOARTHRITIS ASSESS 9 $0.00
1007F ANTI-INFLM/ANLGSC OTC ASSESS 9 $0.00
10080 DRAINAGE OF PILONIDAL CYST 3 $155.97
10081 DRAINAGE OF PILONIDAL CYST 3 $243.42
1008F GI/RENAL RISK ASSESS 9 $0.00
10100 INCISION AND DRAINAGE OF ONYCHIA OR O $0.00
10101 INCISION AND DRAINAGE OF ONYCHIA OR O $0.00
1010H TRANSPORTATION IN VEHICLE OTHER THA O $0.00
1011H TRANSPORTATION IN VEHICLE OTHER THA O $0.00
10120 REMOVE FOREIGN BODY 3 $127.22
10121 REMOVE FOREIGN BODY 3 $245.03
1012H TRANSPORTATION IN VEHICLE OTHER THA O $0.00
1013H TRANSPORTATION IN VEHICLE OTHER THA O $0.00
10140 DRAINAGE OF HEMATOMA/FLUID 3 $145.30

10141 INCISION AND DRAINAGE OF HEMATOMA C O $0.00
1015F COPD SYMPTOMS ASSESS 9 $0.00
1015H SOCIAL WORK O $0.00
10160 PUNCTURE DRAINAGE OF LESION 3 $90.56
1016H PARENT TRAINING O $0.00
10180 COMPLEX DRAINAGE, WOUND 3 $219.23
1018F ASSESS DYSPNEA NOT PRESENT 9 $0.00
1019F ASSESS DYSPNEA PRESENT 9 $0.00
1020H INDIVIDUAL DEVELOPMENTAL SERVICES O $0.00
1021H GROUP DEVELOPMENTAL SERVICES O $0.00
1022F PNEUMO IMM STATUS ASSESS 9 $0.00
1022H CO-TREAT/SIMULTANEOUS DEVELOPMENTAL O $0.00
1023H DEVELOPMENTAL EVALUATION O $0.00
1026F CO-MORBID CONDITION ASSESS 9 $0.00
1030F INFLUENZA IMM STATUS ASSESS 9 $0.00
1034F CURRENT TOBACCO SMOKER 9 $0.00
1035F SMOKELESS TOBACCO USER 9 $0.00
1036F TOBACCO NON-USER 9 $0.00
1038F PERSISTENT ASTHMA 9 $0.00
1039F INTERMITTENT ASTHMA 9 $0.00
1040F DSM-IV INFO MDD DOCD 9 $0.00
1050F HISTORY OF MOLE CHANGES 9 $0.00
1055F VISUAL FUNCT STATUS ASSESS 9 $0.00
1060F DOC PERM/CONT/PAROX ATR FIB 9 $0.00
1061F DOC LACK PERM+CONT+PAROX FIB 9 $0.00
1065F ISCHM STROKE SYMP LT3 HRSB/4 9 $0.00
1066F ISCHM STROKE SYMP GE3 HRSB/4 9 $0.00
1070F ALARM SYMP ASSESSED-ABSENT 9 $0.00
1071F ALARM SYMP ASSESSED-1+ PRSNT 9 $0.00
1080F DECIS MKR/ADVNCD PLAN DOC'D 9 $0.00
1090F PRES/ABSN URINE INCON ASSESS 9 $0.00
1091F URINE INCON CHARACTERIZED 9 $0.00
11000 DEBRIDE INFECTED SKIN 3 $49.74
11001 DEBRIDE INFECTED SKIN ADD-ON 3 $20.52
11004 DEBRIDE GENITALIA & PERINEUM 3 $568.46
11005 DEBRIDE ABDOM WALL 3 $752.42
11006 DEBRIDE GENIT/PER/ABDOM WALL 3 $691.95
11008 REMOVE MESH FROM ABD WALL 3 $264.28
1100F PTFALLS ASSESS-DOCD GE2+/YR 9 $0.00
11010 DEBRIDE SKIN, FX 3 $439.31
11011 DEBRIDE SKIN/MUSCLE, FX 3 $486.88
11012 DEBRIDE SKIN/MUSCLE/BONE, FX 3 $657.01
1101F PT FALLS ASSESS-DOCD LE1/YR 9 $0.00
11040 DEBRIDE SKIN, PARTIAL 3 $43.57
11041 DEBRIDE SKIN, FULL 3 $50.12
11042 DEBRIDE SKIN/TISSUE 3 $68.36
11043 DEBRIDE TISSUE/MUSCLE 3 $261.74
11044 DEBRIDE TISSUE/MUSCLE/BONE 3 $359.74
11050 PARING OR CURETTEMENT OF BENIGN HYP O $0.00

11051 PARING OR CURETTEMENT OF BENIGN HYP O $0.00
11052 PARING OR CURETTEMENT OF BENIGN HYP O $0.00
11055 TRIM SKIN LESION 3 $45.31
11056 TRIM SKIN LESIONS, 2 TO 4 3 $54.77
11057 TRIM SKIN LESIONS, OVER 4 3 $65.37
11060 SHAVING OF EPIDERMAL OR SUPERFICIAL O $0.00
11061 SHAVING OF EPIDERMAL OR SUPERFICIAL O $0.00
11062 SHAVING OF EPIDERMAL OR SPUERFICIAL O $0.00
11100 BIOPSY, SKIN LESION 3 $97.32
11101 BIOPSY, SKIN ADD-ON 3 $31.46
1110F PT LFT INPT FAC W/IN 60 DAYS 9 $0.00
1111F DSCHRG MED/CURRENT MED MERGE 9 $0.00
1116F AURIC/PERI PAIN ASSESSED 9 $0.00
1118F GERD SYMPS ASSESSED 12 MONTH 9 $0.00
1119F INIT EVAL FOR CONDITION 9 $0.00
11200 REMOVAL OF SKIN TAGS 3 $78.78
11201 REMOVE SKIN TAGS ADD-ON 3 $17.76
1121F SUBS EVAL FOR CONDITION 9 $0.00
1123F ACP DISCUSS/DSCN MKR DOCD 9 $0.00
1124F ACP DISCUSS-NO DSCNMKR DOCD 9 $0.00
1125F AMNT PAIN NOTED PAIN PRSNT 9 $0.00
1126F AMNT PAIN NOTED NONE PRSNT 9 $0.00
1127F NEW EPISODE FOR CONDITION O $0.00
1128F SUBS EPISODE FOR CONDITION O $0.00
11300 SHAVE SKIN LESION 3 $64.08
11301 SHAVE SKIN LESION 3 $87.45
11302 SHAVE SKIN LESION 3 $104.31
11303 SHAVE SKIN LESION 3 $122.57
11305 SHAVE SKIN LESION 3 $64.77
11306 SHAVE SKIN LESION 3 $89.92
11307 SHAVE SKIN LESION 3 $106.47
11308 SHAVE SKIN LESION 3 $117.84
1130F BK PAIN + FXN ASSESSED 9 $0.00
11310 SHAVE SKIN LESION 3 $79.41
11311 SHAVE SKIN LESION 3 $100.53
11312 SHAVE SKIN LESION 3 $116.57
11313 SHAVE SKIN LESION 3 $145.24
1134F EPSD BK PAIN FOR =< 6 WKS 9 $0.00
1135F EPSD BK PAIN FOR > 6 WKS 9 $0.00
1136F EPSD BK PAIN FOR 12 WKS 9 $0.00
11400 EXC TR-EXT B9+MARG 0.5 < CM 3 $109.93
11401 EXC TR-EXT B9+MARG 0.6-1 CM 3 $134.73
11402 EXC TR-EXT B9+MARG 1.1-2 CM 3 $149.99
11403 EXC TR-EXT B9+MARG 2.1-3 CM 3 $172.64
11404 EXC TR-EXT B9+MARG 3.1-4 CM 3 $195.96
11406 EXC TR-EXT B9+MARG > 4.0 CM 3 $278.94
11420 EXC H-F-NK-SP B9+MARG 0.5 < 3 $110.51
11421 EXC H-F-NK-SP B9+MARG 0.6-1 3 $143.05

11422 EXC H-F-NK-SP B9+MARG 1.1-2 3 $159.39
11423 EXC H-F-NK-SP B9+MARG 2.1-3 3 $185.08
11424 EXC H-F-NK-SP B9+MARG 3.1-4 3 $213.24
11426 EXC H-F-NK-SP B9+MARG > 4 CM 3 $305.03
11440 EXC FACE-MM B9+MARG 0.5 < CM 3 $121.43
11441 EXC FACE-MM B9+MARG 0.6-1 CM 3 $153.29
11442 EXC FACE-MM B9+MARG 1.1-2 CM 3 $172.24
11443 EXC FACE-MM B9+MARG 2.1-3 CM 3 $206.11
11444 EXC FACE-MM B9+MARG 3.1-4 CM 3 $259.65
11446 EXC FACE-MM B9+MARG > 4 CM 3 $355.37
11450 REMOVAL, SWEAT GLAND LESION 3 $332.75
11451 REMOVAL, SWEAT GLAND LESION 3 $429.74
11462 REMOVAL, SWEAT GLAND LESION 3 $328.64
11463 REMOVAL, SWEAT GLAND LESION 3 $440.83
11470 REMOVAL, SWEAT GLAND LESION 3 $363.69
11471 REMOVAL, SWEAT GLAND LESION 3 $452.47
1150F DOC PT RSK DEATH W/IN 1YR 9 $0.00
1151F DOC NO PT RSK DEATH W/IN 1YR 9 $0.00
1152F DOC ADVNCD DIS COMFORT 1ST 9 $0.00
1153F DOC ADVNCD DIS CMFRT NOT 1ST 9 $0.00
1157F ADVNC CARE PLAN IN RCRD 9 $0.00
1158F ADVNC CARE PLAN TLK DOCD 9 $0.00
1159F MED LIST DOCD IN RCRD 9 $0.00
11600 EXC TR-EXT MLG+MARG 0.5 < CM 3 $170.79
11601 EXC TR-EXT MLG+MARG 0.6-1 CM 3 $209.01
11602 EXC TR-EXT MLG+MARG 1.1-2 CM 3 $229.28
11603 EXC TR-EXT MLG+MARG 2.1-3 CM 3 $260.30
11604 EXC TR-EXT MLG+MARG 3.1-4 CM 3 $287.65
11606 EXC TR-EXT MLG+MARG > 4 CM 3 $406.46
1160F RVW MEDS BY RX/DR IN RCRD 9 $0.00
11620 EXC H-F-NK-SP MLG+MARG 0.5 < 3 $174.19
11621 EXC H-F-NK-SP MLG+MARG 0.6-1 3 $210.90
11622 EXC H-F-NK-SP MLG+MARG 1.1-2 3 $237.91
11623 EXC H-F-NK-SP MLG+MARG 2.1-3 3 $277.78
11624 EXC H-F-NK-SP MLG+MARG 3.1-4 3 $311.98
11626 EXC H-F-NK-SP MLG+MAR > 4 CM 3 $377.15
11640 EXC FACE-MM MALIG+MARG 0.5 < 3 $181.33
11641 EXC FACE-MM MALIG+MARG 0.6-1 3 $220.47
11642 EXC FACE-MM MALIG+MARG 1.1-2 3 $253.63
11643 EXC FACE-MM MALIG+MARG 2.1-3 3 $298.41
11644 EXC FACE-MM MALIG+MARG 3.1-4 3 $367.09
11646 EXC FACE-MM MLG+MARG > 4 CM 3 $481.53
11700 DEBRIDEMENT OF NAILS, MANUAL; FIVE O $0.00
11701 DEBRIDEMENT OF NAILS, MANUAL; EACH O $0.00
1170F FXNL STATUS ASSESSED 9 $0.00
11710 DEBRIDEMENT OF NAILS, ELECTRIC GRIN O $0.00
11711 DEBRIDEMENT OF NAILS, ELECTRIC GRIN O $0.00
11719 TRIM NAIL(S) 3 $20.06
11720 DEBRIDE NAIL, 1-5 3 $28.81

11721 DEBRIDE NAIL, 6 OR MORE 3 $40.49
11730 REMOVAL OF NAIL PLATE 3 $90.41
11731 REMOVAL OF SECOND NAIL PLATE O $0.00
11732 REMOVE NAIL PLATE, ADD-ON 3 $41.59
11740 DRAIN BLOOD FROM UNDER NAIL 3 $42.36
11750 REMOVAL OF NAIL BED 3 $202.98
11752 REMOVE NAIL BED/FINGER TIP 3 $290.16
11755 BIOPSY, NAIL UNIT 3 $123.90
11760 REPAIR OF NAIL BED 3 $193.85
11762 RECONSTRUCTION OF NAIL BED 3 $251.76
11765 EXCISION OF NAIL FOLD, TOE 3 $123.65
11770 REMOVAL OF PILONIDAL LESION 3 $244.45
11771 REMOVAL OF PILONIDAL LESION 3 $505.96
11772 REMOVAL OF PILONIDAL LESION 3 $611.73
1180F THROMBOEMB RISK ASSESSED 9 $0.00
11900 INJECTION INTO SKIN LESIONS 3 $53.11
11901 ADDED SKIN LESIONS INJECTION 3 $67.47
11920 CORRECT SKIN COLOR DEFECTS 3 $166.88
11921 CORRECT SKIN COLOR DEFECTS 3 $190.89
11922 CORRECT SKIN COLOR DEFECTS 3 $56.79
11950 THERAPY FOR CONTOUR DEFECTS 3 $70.58
11951 THERAPY FOR CONTOUR DEFECTS 3 $97.02
11952 THERAPY FOR CONTOUR DEFECTS 3 $128.90
11954 THERAPY FOR CONTOUR DEFECTS 3 $151.82
11960 INSERT TISSUE EXPANDER(S) 3 $871.26
11970 REPLACE TISSUE EXPANDER 3 $571.03
11971 REMOVE TISSUE EXPANDER(S) 3 $435.45
11975 INSERT CONTRACEPTIVE CAP 5 $0.00
11976 REMOVAL OF CONTRACEPTIVE CAP 3 $139.21
11977 REMOVAL/REINSERT CONTRA CAP 5 $0.00
11980 IMPLANT HORMONE PELLET(S) 5 $0.00
11981 INSERT DRUG IMPLANT DEVICE 5 $0.00
11982 REMOVE DRUG IMPLANT DEVICE 3 $145.03
11983 REMOVE/INSERT DRUG IMPLANT 5 $0.00
12001 REPAIR SUPERFICIAL WOUND(S) 3 $140.51
12002 REPAIR SUPERFICIAL WOUND(S) 3 $149.12
12004 REPAIR SUPERFICIAL WOUND(S) 3 $175.57
12005 REPAIR SUPERFICIAL WOUND(S) 3 $217.94
12006 REPAIR SUPERFICIAL WOUND(S) 3 $269.89
12007 REPAIR SUPERFICIAL WOUND(S) 3 $302.93
1200F SEIZURE TYPE(S)+ FRQ DOCD 9 $0.00
12011 REPAIR SUPERFICIAL WOUND(S) 3 $149.24
12013 REPAIR SUPERFICIAL WOUND(S) 3 $164.19
12014 REPAIR SUPERFICIAL WOUND(S) 3 $192.65
12015 REPAIR SUPERFICIAL WOUND(S) 3 $241.56
12016 REPAIR SUPERFICIAL WOUND(S) 3 $287.69
12017 REPAIR SUPERFICIAL WOUND(S) 3 $248.19
12018 REPAIR SUPERFICIAL WOUND(S) 3 $301.12
12020 CLOSURE OF SPLIT WOUND 3 $250.65

12021 CLOSURE OF SPLIT WOUND 3 $148.01
12031 INTMD WND REPAIR S/TR/EXT 3 $225.09
12032 INTMD WND REPAIR S/TR/EXT 3 $286.78
12034 INTMD WND REPAIR S/TR/EXT 3 $284.26
12035 INTMD WND REPAIR S/TR/EXT 3 $344.66
12036 INTMD WND REPAIR S/TR/EXT 3 $376.18
12037 INTMD WND REPAIR S/TR/EXT 3 $422.59
12041 INTMD WND REPAIR N-HF/GENIT 3 $235.26
12042 INTMD WND REPAIR N-HG/GENIT 3 $272.19
12044 INTMD WND REPAIR N-HG/GENIT 3 $317.86
12045 INTMD WND REPAIR N-HG/GENIT 3 $346.04
12046 INTMD WND REPAIR N-HG/GENIT 3 $422.89
12047 INTMD WND REPAIR N-HG/GENIT 3 $450.83
12051 INTMD WND REPAIR FACE/MM 3 $250.73
12052 INTMD WND REPAIR FACE/MM 3 $286.32
12053 INTMD WND REPAIR FACE/MM 3 $314.62
12054 INTMD WND REPAIR, FACE/MM 3 $333.06
12055 INTMD WND REPAIR FACE/MM 3 $398.78
12056 INTMD WND REPAIR FACE/MM 3 $467.60
12057 INTMD WND REPAIR FACE/MM 3 $517.91
1205F EPI ETIOL SYND RVWD AND DOCD 9 $0.00
1220F PT SCREENED FOR DEPRESSION 9 $0.00
13100 REPAIR OF WOUND OR LESION 3 $295.34
13101 REPAIR OF WOUND OR LESION 3 $374.16
13102 REPAIR WOUND/LESION ADD-ON 3 $101.24
13120 REPAIR OF WOUND OR LESION 3 $306.70
13121 REPAIR OF WOUND OR LESION 3 $416.90
13122 REPAIR WOUND/LESION ADD-ON 3 $112.45
13131 REPAIR OF WOUND OR LESION 3 $339.07
13132 REPAIR OF WOUND OR LESION 3 $548.69
13133 REPAIR WOUND/LESION ADD-ON 3 $159.08
13150 REPAIR OF WOUND OR LESION 3 $336.88
13151 REPAIR OF WOUND OR LESION 3 $384.31
13152 REPAIR OF WOUND OR LESION 3 $531.08
13153 REPAIR WOUND/LESION ADD-ON 3 $174.31
13160 LATE CLOSURE OF WOUND 3 $766.55
13300 REPAIR OF WOUND OR LESION O $0.00
14000 SKIN TISSUE REARRANGEMENT 3 $583.02
14001 SKIN TISSUE REARRANGEMENT 3 $754.39
14020 SKIN TISSUE REARRANGEMENT 3 $655.24
14021 SKIN TISSUE REARRANGEMENT 3 $826.02
14040 SKIN TISSUE REARRANGEMENT 3 $725.75
14041 SKIN TISSUE REARRANGEMENT 3 $901.82
14060 SKIN TISSUE REARRANGEMENT 3 $737.64
14061 SKIN TISSUE REARRANGEMENT 3 $967.34
14300 SKIN TISSUE REARRANGEMENT O $0.00
14301 SKIN TISSUE REARRANGEMENT 3 $1,042.62
14302 SKIN TISSUE REARRANGE ADD-ON 3 $226.54
14350 SKIN TISSUE REARRANGEMENT 3 $705.28

15000 WOUND PREP, 1ST 100 SQ CM O $0.00
15001 WOUND PREP, ADDL 100 SQ CM O $0.00
15002 WOUND PREP, TRK/ARM/LEG 3 $312.17
15003 WOUND PREP, ADDL 100 CM 3 $68.07
15004 WOUND PREP, F/N/HF/G 3 $372.47
15005 WND PREP, F/N/HF/G, ADDL CM 3 $113.60
15040 HARVEST CULTURED SKIN GRAFT 3 $237.68
15050 SKIN PINCH GRAFT 3 $514.86
15100 SKIN SPLT GRFT, TRNK/ARM/LEG 3 $808.32
15101 SKIN SPLT GRFT T/A/L, ADD-ON 3 $175.55
15110 EPIDRM AUTOGRFT TRNK/ARM/LEG 3 $798.94
15111 EPIDRM AUTOGRFT T/A/L ADD-ON 3 $113.76
15115 EPIDRM A-GRFT FACE/NCK/HF/G 3 $807.89
15116 EPIDRM A-GRFT F/N/HF/G ADDL 3 $157.99
15120 SKN SPLT A-GRFT FAC/NCK/HF/G 3 $888.51
15121 SKN SPLT A-GRFT F/N/HF/G ADD 3 $249.11
15130 DERM AUTOGRAFT, TRNK/ARM/LEG 3 $629.50
15131 DERM AUTOGRAFT T/A/L ADD-ON 3 $91.42
15135 DERM AUTOGRAFT FACE/NCK/HF/G 3 $812.10
15136 DERM AUTOGRAFT, F/N/HF/G ADD 3 $81.84
15150 CULT EPIDERM GRFT T/ARM/LEG 3 $656.25
15151 CULT EPIDERM GRFT T/A/L ADDL 3 $118.83
15152 CULT EPIDERM GRAFT T/A/L +% 3 $152.31
15155 CULT EPIDERM GRAFT, F/N/HF/G 3 $649.12
15156 CULT EPIDRM GRFT F/N/HFG ADD 3 $166.56
15157 CULT EPIDERM GRFT F/N/HFG +% 3 $173.62
15170 ACELL GRAFT TRUNK/ARMS/LEGS 3 $405.12
15171 ACELL GRAFT T/ARM/LEG ADD-ON 3 $89.10
15175 ACELLULAR GRAFT, F/N/HF/G 3 $498.24
15176 ACELL GRAFT, F/N/HF/G ADD-ON 3 $140.84
15200 SKIN FULL GRAFT, TRUNK 3 $761.18
15201 SKIN FULL GRAFT TRUNK ADD-ON 3 $137.54
15220 SKIN FULL GRAFT SCLP/ARM/LEG 3 $719.68
15221 SKIN FULL GRAFT ADD-ON 3 $128.53
15240 SKIN FULL GRFT FACE/GENIT/HF 3 $870.55
15241 SKIN FULL GRAFT ADD-ON 3 $172.11
15260 SKIN FULL GRAFT EEN & LIPS 3 $947.33
15261 SKIN FULL GRAFT ADD-ON 3 $201.85
15300 APPLY SKINALLOGRFT, T/ARM/LG 3 $324.41
15301 APPLY SKNALLOGRFT T/A/L ADDL 3 $60.24
15320 APPLY SKIN ALLOGRFT F/N/HF/G 3 $357.21
15321 APLY SKNALLOGRFT F/N/HFG ADD 3 $89.30
15330 APLY ACELL ALOGRFT T/ARM/LEG 3 $298.96
15331 APLY ACELL GRFT T/A/L ADD-ON 3 $60.24
15335 APPLY ACELL GRAFT, F/N/HF/G 3 $303.87
15336 APLY ACELL GRFT F/N/HF/G ADD 3 $77.77
15340 APPLY CULT SKIN SUBSTITUTE 3 $296.66
15341 APPLY CULT SKIN SUB ADD-ON 3 $44.06
15342 CULTURED SKIN GRAFT, 25 CM O $0.00

15343 CULTURE SKN GRAFT ADDL 25 CM O $0.00
15350 SKIN HOMOGRAFT O $0.00
15351 SKIN HOMOGRAFT ADD-ON O $0.00
15360 APPLY CULT DERM SUB, T/A/L 3 $337.93
15361 APLY CULT DERM SUB T/A/L ADD 3 $66.86
15365 APPLY CULT DERM SUB F/N/HF/G 3 $326.21
15366 APPLY CULT DERM F/HF/G ADD 3 $79.72
15400 APPLY SKIN XENOGRAFT, T/A/L 3 $375.37
15401 APPLY SKN XENOGRFT T/A/L ADD 3 $86.56
15410 FREE TRANSPLANTATION OF SKIN FLAP B O $0.00
15412 FREE TRANSPLANTATION OF SKIN FLAP B O $0.00
15414 FREE TRANSPLANTATION OF SKIN FLAP B O $0.00
15416 FREE TRANSPLANTATION OF SKIN FLAP B O $0.00
15420 APPLY SKIN XGRAFT, F/N/HF/G 3 $415.43
15421 APPLY SKN XGRFT F/N/HF/G ADD 3 $108.19
15430 APPLY ACELLULAR XENOGRAFT 3 $503.91
15431 APPLY ACELLULAR XGRAFT ADD 6 $0.00
15500 FORMATION OF TUBE PEDICLE WITHOUT T O $0.00
15505 FORMATION OF TUBE PEDICLE WITHOUT T O $0.00
15510 FORMATION OF TUBE PEDICLE WITHOUT T O $0.00
15515 FORMATION OF TUBE PEDICLE WITHOUT T O $0.00
15540 PRIMARY ATTACHMENT OF OPEN OR TUBED O $0.00
15545 PRIMARY ATTACHMENT OF OPEN OR TUBED O $0.00
15550 PRIMARY ATTACHMENT OF OPEN OR TUBED O $0.00
15555 PRIMARY ATTACHMENT OF OPEN OR TUBED O $0.00
15570 FORM SKIN PEDICLE FLAP 3 $831.30
15572 FORM SKIN PEDICLE FLAP 3 $807.35
15574 FORM SKIN PEDICLE FLAP 3 $850.46
15576 FORM SKIN PEDICLE FLAP 3 $756.67
15580 ATTACH SKIN PEDICLE GRAFT O $0.00
15600 SKIN GRAFT 3 $303.67
15610 SKIN GRAFT 3 $311.43
15620 SKIN GRAFT 3 $409.96
15625 SKIN GRAFT O $0.00
15630 SKIN GRAFT 3 $433.34
15650 TRANSFER SKIN PEDICLE FLAP 3 $480.02
15700 EXCISION OF LESION AND/OR EXCISIONA O $0.00
15710 EXCISION OF LESION AND/OR EXCISIONA O $0.00
15720 EXCISION OF LESION AND/OR EXCISIONA O $0.00
15730 EXCISION OF LESION AND/OR EXCISIONA O $0.00
15731 FOREHEAD FLAP W/VASC PEDICLE 3 $1,075.95
15732 MUSCLE-SKIN GRAFT, HEAD/NECK 3 $1,417.39
15734 MUSCLE-SKIN GRAFT, TRUNK 3 $1,284.16
15736 MUSCLE-SKIN GRAFT, ARM 3 $1,266.63
15738 MUSCLE-SKIN GRAFT, LEG 3 $1,352.32
15740 ISLAND PEDICLE FLAP GRAFT 3 $967.16
15750 NEUROVASCULAR PEDICLE GRAFT 3 $871.82
15755 FREE FLAP (MICROVASCULAR TRANSFER) O $0.00
15756 FREE MYO/SKIN FLAP MICROVASC 3 $2,258.82

15757 FREE SKIN FLAP, MICROVASC 3 $2,244.30
15758 FREE FASCIAL FLAP, MICROVASC 3 $2,234.41
15760 COMPOSITE SKIN GRAFT 3 $799.49
15770 DERMA-FAT-FASCIA GRAFT 3 $629.26
15775 HAIR TRANSPLANT PUNCH GRAFTS 3 $288.92
15776 HAIR TRANSPLANT PUNCH GRAFTS 3 $400.14
15780 ABRASION TREATMENT OF SKIN 3 $780.45
15781 ABRASION TREATMENT OF SKIN 3 $506.30
15782 ABRASION TREATMENT OF SKIN 3 $538.60
15783 ABRASION TREATMENT OF SKIN 3 $457.38
15786 ABRASION, LESION, SINGLE 3 $227.77
15787 ABRASION, LESIONS, ADD-ON 3 $45.68
15788 CHEMICAL PEEL, FACE, EPIDERM 9 $0.00
15789 CHEMICAL PEEL, FACE, DERMAL 9 $0.00
15790 CHEMICAL PEEL (CHEMEXFOLIATION) TOT O $0.00
15791 CHEMICAL PEEL (CHEMEXFOLIATION) REG O $0.00
15792 CHEMICAL PEEL, NONFACIAL 9 $0.00
15793 CHEMICAL PEEL, NONFACIAL 9 $0.00
15810 SALABRASION O $0.00
15811 SALABRASION O $0.00
15819 PLASTIC SURGERY, NECK 3 $709.16
15820 REVISION OF LOWER EYELID 3 $520.10
15821 REVISION OF LOWER EYELID 3 $553.97
15822 REVISION OF UPPER EYELID 3 $403.08
15823 REVISION OF UPPER EYELID 3 $645.22
15824 REMOVAL OF FOREHEAD WRINKLES 9 $0.00
15825 REMOVAL OF NECK WRINKLES 5 $0.00
15826 REMOVAL OF BROW WRINKLES 5 $0.00
15828 REMOVAL OF FACE WRINKLES 5 $0.00
15829 REMOVAL OF SKIN WRINKLES 5 $0.00
15830 EXC SKIN ABD 3 $1,097.70
15831 EXCISE EXCESSIVE SKIN TISSUE O $0.00
15832 EXCISE EXCESSIVE SKIN TISSUE 3 $848.38
15833 EXCISE EXCESSIVE SKIN TISSUE 3 $808.50
15834 EXCISE EXCESSIVE SKIN TISSUE 3 $808.25
15835 EXCISE EXCESSIVE SKIN TISSUE 3 $856.27
15836 EXCISE EXCESSIVE SKIN TISSUE 3 $694.22
15837 EXCISE EXCESSIVE SKIN TISSUE 3 $734.02
15838 EXCISE EXCESSIVE SKIN TISSUE 3 $551.83
15839 EXCISE EXCESSIVE SKIN TISSUE 3 $809.22
15840 GRAFT FOR FACE NERVE PALSY 3 $972.89
15841 GRAFT FOR FACE NERVE PALSY 3 $1,587.93
15842 FLAP FOR FACE NERVE PALSY 3 $2,425.96
15845 SKIN AND MUSCLE REPAIR, FACE 3 $927.78
15847 EXC SKIN ABD ADD-ON 6 $0.00
15850 REMOVAL OF SUTURES 9 $0.00
15851 REMOVAL OF SUTURES 3 $88.43
15852 DRESSING CHANGE NOT FOR BURN 3 $45.59
15860 TEST FOR BLOOD FLOW IN GRAFT 3 $109.85

15876 SUCTION ASSISTED LIPECTOMY 5 $0.00
15877 SUCTION ASSISTED LIPECTOMY 9 $0.00
15878 SUCTION ASSISTED LIPECTOMY 9 $0.00
15879 SUCTION ASSISTED LIPECTOMY 9 $0.00
15920 REMOVAL OF TAIL BONE ULCER 3 $560.14
15922 REMOVAL OF TAIL BONE ULCER 3 $692.77
15931 REMOVE SACRUM PRESSURE SORE 3 $633.81
15933 REMOVE SACRUM PRESSURE SORE 3 $782.92
15934 REMOVE SACRUM PRESSURE SORE 3 $867.63
15935 REMOVE SACRUM PRESSURE SORE 3 $1,034.48
15936 REMOVE SACRUM PRESSURE SORE 3 $837.98
15937 REMOVE SACRUM PRESSURE SORE 3 $978.65
15940 REMOVE HIP PRESSURE SORE 3 $649.13
15941 REMOVE HIP PRESSURE SORE 3 $846.84
15944 REMOVE HIP PRESSURE SORE 3 $833.68
15945 REMOVE HIP PRESSURE SORE 3 $925.39
15946 REMOVE HIP PRESSURE SORE 3 $1,545.45
15950 REMOVE THIGH PRESSURE SORE 3 $538.61
15951 REMOVE THIGH PRESSURE SORE 3 $762.19
15952 REMOVE THIGH PRESSURE SORE 3 $799.77
15953 REMOVE THIGH PRESSURE SORE 3 $910.78
15954 EXCISION, TROCHANTERIC PRESSURE ULC O $0.00
15955 EXCISION, TROCHANTERIC PRESSURE ULC O $0.00
15956 REMOVE THIGH PRESSURE SORE 3 $1,080.83
15958 REMOVE THIGH PRESSURE SORE 3 $1,102.69
15960 EXCISION, HEEL PRESSURE ULCER, WITH O $0.00
15961 EXCISION, HEEL PRESSURE ULCER, WITH O $0.00
15964 EXCISION, HEEL PRESSURE ULCER, WITH O $0.00
15965 EXCISION, HEEL PRESSURE ULCER, WITH O $0.00
15966 EXCISION, HEEL PRESSURE ULCER, WITH O $0.00
15967 EXCISION, HEEL PRESSURE ULCER, WITH O $0.00
15970 EXCISION, LEG PRESSURE ULCER, WITH O $0.00
15971 EXCISION, LEG PRESSURE ULCER, WITH O $0.00
15972 EXCISION, LEG PRESSURE ULCER, WITH O $0.00
15973 EXCISION, LEG PRESSURE ULCER, WITH O $0.00
15974 EXCISION, LEG PRESSURE ULCER, WITH O $0.00
15975 EXCISION, LEG PRESSURE ULCER, WITH O $0.00
15980 EXCISION, KNEE PRESSURE ULCER, WITH O $0.00
15981 EXCISION, KNEE PRESSURE ULCER, WITH O $0.00
15982 EXCISION, KNEE PRESSURE ULCER, WITH O $0.00
15983 EXCISION, KNEE PRESSURE ULCER, WITH O $0.00
15999 REMOVAL OF PRESSURE SORE 5 $0.00
16000 INITIAL TREATMENT OF BURN(S) 3 $64.95
16010 TREATMENT OF BURN(S) O $0.00
16015 TREATMENT OF BURN(S) O $0.00
16020 DRESS/DEBRID P-THICK BURN, S 3 $76.55
16025 DRESS/DEBRID P-THICK BURN, M 3 $138.99
16030 DRESS/DEBRID P-THICK BURN, L 3 $166.14
16035 INCISION OF BURN SCAB, INITI 3 $200.07

16036 ESCHAROTOMY; ADDL INCISION 3 $80.87
16040 BURN WOUND EXCISION O $0.00
16041 BURN WOUND EXCISION O $0.00
16042 BURN WOUND EXCISION O $0.00
17000 DESTRUCT PREMALG LESION 3 $75.49
17001 DESTRUCTION BY ANY METHOD, INCLUDIN O $0.00
17002 DESTRUCTION BY ANY METHOD, INCLUDIN O $0.00
17003 DESTRUCT PREMALG LES, 2-14 3 $6.96
17004 DESTROY PREMLG LESIONS 15+ 3 $165.09
17010 DESTRUCTION BY ANY METHOD, INCLUDIN O $0.00
17100 DESTRUCTION BY ANY METHOD, INCLUDIN O $0.00
17101 DESTRUCTION BY ANY METHOD, INCLUDIN O $0.00
17102 DESTRUCTION BY ANY METHOD, INCLUDIN O $0.00
17104 DESTRUCTION BY ANY METHOD, INCLUDIN O $0.00
17105 DESTRUCTION BY ANY METHOD, INCLUDIN O $0.00
17106 DESTRUCTION OF SKIN LESIONS 3 $323.90
17107 DESTRUCTION OF SKIN LESIONS 3 $422.19
17108 DESTRUCTION OF SKIN LESIONS 3 $594.24
17110 DESTRUCT B9 LESION, 1-14 3 $103.02
17111 DESTRUCT LESION, 15 OR MORE 3 $123.07
17200 ELECTROSURGICAL DESTRUCTION OF MULT O $0.00
17201 ELECTROSURGICAL DESTRUCTION OF MULT O $0.00
17250 CHEMICAL CAUTERY, TISSUE 3 $69.77
17260 DESTRUCTION OF SKIN LESIONS 3 $89.82
17261 DESTRUCTION OF SKIN LESIONS 3 $134.69
17262 DESTRUCTION OF SKIN LESIONS 3 $163.88
17263 DESTRUCTION OF SKIN LESIONS 3 $180.73
17264 DESTRUCTION OF SKIN LESIONS 3 $193.13
17266 DESTRUCTION OF SKIN LESIONS 3 $219.69
17270 DESTRUCTION OF SKIN LESIONS 3 $140.28
17271 DESTRUCTION OF SKIN LESIONS 3 $154.55
17272 DESTRUCTION OF SKIN LESIONS 3 $176.22
17273 DESTRUCTION OF SKIN LESIONS 3 $196.64
17274 DESTRUCTION OF SKIN LESIONS 3 $232.71
17276 DESTRUCTION OF SKIN LESIONS 3 $269.42
17280 DESTRUCTION OF SKIN LESIONS 3 $131.29
17281 DESTRUCTION OF SKIN LESIONS 3 $167.22
17282 DESTRUCTION OF SKIN LESIONS 3 $193.63
17283 DESTRUCTION OF SKIN LESIONS 3 $233.64
17284 DESTRUCTION OF SKIN LESIONS 3 $271.57
17286 DESTRUCTION OF SKIN LESIONS 3 $343.49
17303 CHEMOSURGERY (MOHS' TECHNIQUE), FIR O $0.00
17304 1 STAGE MOHS, UP TO 5 SPEC O $0.00
17305 2 STAGE MOHS, UP TO 5 SPEC O $0.00
17306 3 STAGE MOHS, UP TO 5 SPEC O $0.00
17307 MOHS ADDL STAGE UP TO 5 SPEC O $0.00
17310 MOHS ANY STAGE > 5 SPEC EACH O $0.00
17311 MOHS, 1 STAGE, H/N/HF/G 3 $644.35
17312 MOHS ADDL STAGE 3 $384.91

17313 MOHS, 1 STAGE, T/A/L 3 $587.88
17314 MOHS, ADDL STAGE, T/A/L 3 $356.76
17315 MOHS SURG, ADDL BLOCK 3 $77.21
17340 CRYOTHERAPY OF SKIN 3 $46.85
17360 SKIN PEEL THERAPY 3 $125.29
17380 HAIR REMOVAL BY ELECTROLYSIS 9 $0.00
17999 SKIN TISSUE PROCEDURE 5 $0.00
19000 DRAINAGE OF BREAST LESION 3 $105.60
19001 DRAIN BREAST LESION ADD-ON 3 $26.15
19020 INCISION OF BREAST LESION 3 $413.18
19030 INJECTION FOR BREAST X-RAY 3 $159.64
19100 BX BREAST PERCUT W/O IMAGE 3 $133.07
19101 BIOPSY OF BREAST, OPEN 3 $304.25
19102 BX BREAST PERCUT W/IMAGE 3 $210.03
19103 BX BREAST PERCUT W/DEVICE 3 $191.77
19105 CRYOSURG ABLATE FA, EACH 3 $2,029.15
19110 NIPPLE EXPLORATION 3 $428.71
19112 EXCISE BREAST DUCT FISTULA 3 $402.36
19120 REMOVAL OF BREAST LESION 3 $440.27
19125 EXCISION, BREAST LESION 3 $418.05
19126 EXCISION, ADDL BREAST LESION 3 $153.09
19140 REMOVAL OF BREAST TISSUE O $0.00
19160 PARTIAL MASTECTOMY O $0.00
19162 P-MASTECTOMY W/LN REMOVAL O $0.00
19180 REMOVAL OF BREAST O $0.00
19182 REMOVAL OF BREAST O $0.00
19200 REMOVAL OF BREAST O $0.00
19220 REMOVAL OF BREAST O $0.00
19240 REMOVAL OF BREAST O $0.00
19260 REMOVAL OF CHEST WALL LESION 3 $1,140.78
19271 REVISION OF CHEST WALL 3 $1,555.46
19272 EXTENSIVE CHEST WALL SURGERY 3 $1,720.81
19290 PLACE NEEDLE WIRE, BREAST 3 $65.99
19291 PLACE NEEDLE WIRE, BREAST 3 $67.08
19295 PLACE BREAST CLIP, PERCUT 3 $87.55
19296 PLACE PO BREAST CATH FOR RAD 3 $3,752.12
19297 PLACE BREAST CATH FOR RAD 3 $89.99
19298 PLACE BREAST RAD TUBE/CATHS 3 $1,226.24
19300 REMOVAL OF BREAST TISSUE 9 $0.00
19301 PARTICAL MASTECTOMY 3 $593.62
19302 P-MASTECTOMY W/LN REMOVAL 3 $824.80
19303 MAST, SIMPLE, COMPLETE 3 $919.50
19304 MAST, SUBQ 3 $521.28
19305 MAST, RADICAL 3 $1,041.77
19306 MAST, RAD, URBAN TYPE 3 $1,094.41
19307 MAST, MOD RAD 3 $1,097.68
19316 SUSPENSION OF BREAST 3 $730.35
19318 REDUCTION OF LARGE BREAST 3 $1,059.37
19324 ENLARGE BREAST 9 $0.00

19325 ENLARGE BREAST WITH IMPLANT 9 $0.00
19328 REMOVAL OF BREAST IMPLANT 3 $463.12
19330 REMOVAL OF IMPLANT MATERIAL 3 $592.48
19340 IMMEDIATE BREAST PROSTHESIS 3 $757.51
19342 DELAYED BREAST PROSTHESIS 3 $871.52
19350 BREAST RECONSTRUCTION 3 $787.11
19355 CORRECT INVERTED NIPPLE(S) 9 $0.00
19357 BREAST RECONSTRUCTION 3 $1,474.07
19360 BREAST RECONSTRUCTION WITH MUSCLE O O $0.00
19361 BREAST RECONSTR W/LAT FLAP 3 $1,586.72
19362 BREAST RECONSTRUCTION WITH TRANSVER O $0.00
19364 BREAST RECONSTRUCTION 3 $2,647.10
19366 BREAST RECONSTRUCTION 3 $1,308.38
19367 BREAST RECONSTRUCTION 3 $1,714.94
19368 BREAST RECONSTRUCTION 3 $2,119.01
19369 BREAST RECONSTRUCTION 3 $1,951.95
19370 SURGERY OF BREAST CAPSULE 3 $645.16
19371 REMOVAL OF BREAST CAPSULE 3 $739.69
19380 REVISE BREAST RECONSTRUCTION 3 $727.51
19396 DESIGN CUSTOM BREAST IMPLANT 3 $218.52
19499 BREAST SURGERY PROCEDURE 5 $0.00
20000 INCISION OF ABSCESS 3 $191.52
20005 INCISION OF DEEP ABSCESS 3 $285.34
2000F BLOOD PRESSURE MEASURE 9 $0.00
2001F WEIGHT RECORD 9 $0.00
2002F CLIN SIGN VOL OVRLD ASSESS 9 $0.00
2003F AUSCULTATION HEART PERFORM O $0.00
2004F INITIAL EXAM INVOLVED JOINTS 9 $0.00
20100 EXPLORE WOUND, NECK 3 $566.81
20101 EXPLORE WOUND, CHEST 3 $369.00
20102 EXPLORE WOUND, ABDOMEN 3 $437.67
20103 EXPLORE WOUND, EXTREMITY 3 $528.20
2010F VITAL SIGNS RECORDED 9 $0.00
2014F MENTAL STATUS ASSESS 9 $0.00
20150 EXCISE EPIPHYSEAL BAR 3 $904.50
2018F HYDRATION STATUS ASSESS 9 $0.00
2019F DILATED MACUL EXAM DONE 9 $0.00
20200 MUSCLE BIOPSY 3 $180.55
20205 DEEP MUSCLE BIOPSY 3 $248.98
20206 NEEDLE BIOPSY, MUSCLE 3 $242.36
2020F DILATED FUNDUS EVAL DONE 9 $0.00
2021F DILAT MACUL+ EXAM DONE 9 $0.00
20220 BONE BIOPSY, TROCAR/NEEDLE 3 $163.64
20225 BONE BIOPSY, TROCAR/NEEDLE 3 $113.31
2022F DIL RETINA EXAM INTERP REV 9 $0.00
20240 BONE BIOPSY, EXCISIONAL 3 $215.32
20245 BONE BIOPSY, EXCISIONAL 3 $595.50
2024F 7 FIELD PHOTO INTERP DOC REV 9 $0.00
20250 OPEN BONE BIOPSY 3 $354.15

20251 OPEN BONE BIOPSY 3 $389.97
2026F EYE IMAGE VALID TO DX REV 9 $0.00
2027F OPTIC NERVE HEAD EVAL DONE 9 $0.00
2028F FOOT EXAM PERFORMED 9 $0.00
2029F COMPLETE PHYS SKIN EXAM DONE 9 $0.00
2030F H2O STAT DOCD, NORMAL 9 $0.00
2031F H2O STAT DOCD, DEHYDRATED 9 $0.00
2035F TYMP MEMB MOTION EXAMD 9 $0.00
2040F BK PN XM ON INIT VISIT DATE 9 $0.00
2044F DOC MNTL TST B/4 BK TRXMNT 9 $0.00
20500 INJECTION OF SINUS TRACT 3 $107.17
20501 INJECT SINUS TRACT FOR X-RAY 3 $39.57
2050F WOUND CHAR SIZE ETC DOCD 9 $0.00
20520 REMOVAL OF FOREIGN BODY 3 $180.63
20525 REMOVAL OF FOREIGN BODY 3 $436.80
20526 THER INJECTION, CARP TUNNEL 3 $70.43
20550 INJ TENDON SHEATH/LIGAMENT 3 $54.19
20551 INJ TENDON ORIGIN/INSERTION 3 $54.58
20552 INJ TRIGGER POINT, 1/2 MUSCL 3 $49.90
20553 INJECT TRIGGER POINTS, =/> 3 3 $56.60
20555 PLACE NDL MUSC/TIS FOR RT 3 $326.48
20600 DRAIN/INJECT, JOINT/BURSA 3 $51.04
20605 DRAIN/INJECT, JOINT/BURSA 3 $55.42
2060F PT TALK EVAL HLTHWKR RE MDD 9 $0.00
20610 DRAIN/INJECT, JOINT/BURSA 3 $72.65
20612 ASPIRATE/INJ GANGLION CYST 3 $55.02
20615 TREATMENT OF BONE CYST 3 $203.66
20650 INSERT AND REMOVE BONE PIN 3 $184.06
20660 APPLY, REM FIXATION DEVICE 3 $229.86
20661 APPLICATION OF HEAD BRACE 3 $447.09
20662 APPLICATION OF PELVIS BRACE 3 $435.37
20663 APPLICATION OF THIGH BRACE 3 $424.18
20664 HALO BRACE APPLICATION 3 $755.24
20665 REMOVAL OF FIXATION DEVICE 3 $110.61
20670 REMOVAL OF SUPPORT IMPLANT 3 $140.34
20680 REMOVAL OF SUPPORT IMPLANT 3 $399.00
20690 APPLY BONE FIXATION DEVICE 3 $537.01
20692 APPLY BONE FIXATION DEVICE 3 $1,008.10
20693 ADJUST BONE FIXATION DEVICE 3 $430.87
20694 REMOVE BONE FIXATION DEVICE 3 $395.73
20696 COMP MULTIPLANE EXT FIXATION 3 $988.36
20697 COMP EXT FIXATE STRUT CHANGE 3 $1,320.89
20802 REPLANTATION, ARM, COMPLETE 3 $2,291.14
20804 REPLANTATION, ARM (INCLUDES SURGICA O $0.00
20805 REPLANT FOREARM, COMPLETE 3 $2,982.50
20806 REPLANTATION, FOREARM (INCLUDES RAD O $0.00
20808 REPLANTATION HAND, COMPLETE 3 $3,963.35
20812 REPLANTATION, HAND (INCLUDES HAND T O $0.00
20816 REPLANTATION DIGIT, COMPLETE 3 $2,073.58

20820 REPLANTATION, DIGIT, EXCLUDING THUM O $0.00
20822 REPLANTATION DIGIT, COMPLETE 3 $1,793.36
20823 REPLANTATION, DIGIT, EXCLUDING THUM O $0.00
20824 REPLANTATION THUMB, COMPLETE 3 $2,107.80
20826 REPLANTATION, THUMB (INCLUDES CARPO O $0.00
20827 REPLANTATION THUMB, COMPLETE 3 $1,871.75
20828 REPLANTATION, THUMB (INCLUDES DISTA O $0.00
20832 REPLANTATION, LEG; COMPLETE AMPUTAT O $0.00
20834 REPLANTATION, LEG; INCOMPLETE AMPUT O $0.00
20838 REPLANTATION FOOT, COMPLETE 3 $2,382.53
20840 REPLANTATION, FOOT; INCOMPLETE AMPU O $0.00
20900 REMOVAL OF BONE FOR GRAFT 3 $384.60
20902 REMOVAL OF BONE FOR GRAFT 3 $320.96
20910 REMOVE CARTILAGE FOR GRAFT 3 $405.64
20912 REMOVE CARTILAGE FOR GRAFT 3 $463.56
20920 REMOVAL OF FASCIA FOR GRAFT 3 $385.01
20922 REMOVAL OF FASCIA FOR GRAFT 3 $575.56
20924 REMOVAL OF TENDON FOR GRAFT 3 $475.75
20926 REMOVAL OF TISSUE FOR GRAFT 3 $414.79
20930 SP BONE ALGRFT MORSEL ADD-ON 9 $0.00
20931 SP BONE ALGRFT STRUCT ADD-ON 3 $106.78
20936 SP BONE AGRFT LOCAL ADD-ON 9 $0.00
20937 SP BONE AGRFT MORSEL ADD-ON 3 $162.56
20938 SP BONE AGRFT STRUCT ADD-ON 3 $176.67
20950 FLUID PRESSURE, MUSCLE 3 $228.98
20955 FIBULA BONE GRAFT, MICROVASC 3 $2,441.69
20956 ILIAC BONE GRAFT, MICROVASC 3 $2,519.66
20957 MT BONE GRAFT, MICROVASC 3 $2,456.47
20960 BONE GRAFT WITH MICROVASCULAR ANAST O $0.00
20962 OTHER BONE GRAFT, MICROVASC 3 $2,481.03
20969 BONE/SKIN GRAFT, MICROVASC 3 $2,711.07
20970 BONE/SKIN GRAFT, ILIAC CREST 3 $2,716.22
20971 FREE OSTEOCUTANEOUS FLAP WITH MICRO O $0.00
20972 BONE/SKIN GRAFT, METATARSAL 3 $2,337.94
20973 BONE/SKIN GRAFT, GREAT TOE 3 $2,506.20
20974 ELECTRICAL BONE STIMULATION 3 $63.03
20975 ELECTRICAL BONE STIMULATION 3 $167.51
20976 ELECTRICAL STIMULATION TO AID BONE O $0.00
20979 US BONE STIMULATION 3 $49.44
20982 ABLATE, BONE TUMOR(S) PERQ 3 $3,490.97
20985 CPTR-ASST DIR MS PX 3 $142.48
20986 CPTR-ASST DIR MS PX IO IMG O $0.00
20987 CPTR-ASST DIR MS PX PRE IMG O $0.00
20999 MUSCULOSKELETAL SURGERY 5 $0.00
21010 INCISION OF JAW JOINT 3 $703.22
21011 EXC FACE LES SC < 2 CM 3 $312.36
21012 EXC FACE LES SC = 2 CM 3 $331.66
21013 EXC FACE TUM DEEP < 2 CM 3 $483.72
21014 EXC FACE TUM DEEP = 2 CM 3 $511.87

21015 RESECT FACE TUM < 2 CM 3 $602.39
21016 RESECT FACE TUM = 2 CM 3 $1,022.30
21025 EXCISION OF BONE, LOWER JAW 3 $833.49
21026 EXCISION OF FACIAL BONE(S) 3 $563.36
21029 CONTOUR OF FACE BONE LESION 3 $716.40
21030 EXCISE MAX/ZYGOMA B9 TUMOR 3 $470.16
21031 REMOVE EXOSTOSIS, MANDIBLE 3 $355.83
21032 REMOVE EXOSTOSIS, MAXILLA 3 $361.69
21034 EXCISE MAX/ZYGOMA MLG TUMOR 3 $1,260.12
21040 EXCISE MANDIBLE LESION 3 $474.45
21041 REMOVAL OF JAW BONE LESION O $0.00
21044 REMOVAL OF JAW BONE LESION 3 $845.19
21045 EXTENSIVE JAW SURGERY 3 $1,177.94
21046 REMOVE MANDIBLE CYST COMPLEX 3 $1,033.13
21047 EXCISE LWR JAW CYST W/REPAIR 3 $1,244.30
21048 REMOVE MAXILLA CYST COMPLEX 3 $1,052.24
21049 EXCIS UPPR JAW CYST W/REPAIR 3 $1,205.24
21050 REMOVAL OF JAW JOINT 3 $830.49
21060 REMOVE JAW JOINT CARTILAGE 3 $768.98
21070 REMOVE CORONOID PROCESS 3 $603.88
21073 MNPJ OF TMJ W/ANESTH 3 $351.09
21076 PREPARE FACE/ORAL PROSTHESIS 3 $901.92
21077 PREPARE FACE/ORAL PROSTHESIS 3 $2,227.55
21079 PREPARE FACE/ORAL PROSTHESIS 3 $1,525.18
21080 PREPARE FACE/ORAL PROSTHESIS 3 $1,726.51
21081 PREPARE FACE/ORAL PROSTHESIS 3 $1,581.91
21082 PREPARE FACE/ORAL PROSTHESIS 3 $1,474.98
21083 PREPARE FACE/ORAL PROSTHESIS 3 $1,382.26
21084 PREPARE FACE/ORAL PROSTHESIS 3 $1,621.46
21085 PREPARE FACE/ORAL PROSTHESIS 3 $687.68
21086 PREPARE FACE/ORAL PROSTHESIS 3 $1,618.52
21087 PREPARE FACE/ORAL PROSTHESIS 3 $1,617.01
21088 PREPARE FACE/ORAL PROSTHESIS 5 $0.00
21089 PREPARE FACE/ORAL PROSTHESIS 5 $0.00
21100 MAXILLOFACIAL FIXATION 3 $672.66
21110 INTERDENTAL FIXATION 3 $714.10
21116 INJECTION, JAW JOINT X-RAY 3 $142.84
21120 RECONSTRUCTION OF CHIN 3 $595.27
21121 RECONSTRUCTION OF CHIN 3 $715.06
21122 RECONSTRUCTION OF CHIN 3 $650.89
21123 RECONSTRUCTION OF CHIN 3 $807.09
21125 AUGMENTATION, LOWER JAW BONE 3 $2,989.27
21127 AUGMENTATION, LOWER JAW BONE 3 $3,468.77
21137 REDUCTION OF FOREHEAD 3 $696.62
21138 REDUCTION OF FOREHEAD 3 $848.48
21139 REDUCTION OF FOREHEAD 3 $928.80
21141 RECONSTRUCT MIDFACE, LEFORT 3 $1,300.98
21142 RECONSTRUCT MIDFACE, LEFORT 3 $1,308.06
21143 RECONSTRUCT MIDFACE, LEFORT 3 $1,345.78

21144 RECONSTRUCTION MIDFACE, LEFORT I; I O $0.00
21145 RECONSTRUCT MIDFACE, LEFORT 3 $1,459.85
21146 RECONSTRUCT MIDFACE, LEFORT 3 $1,609.09
21147 RECONSTRUCT MIDFACE, LEFORT 3 $1,616.94
21150 RECONSTRUCT MIDFACE, LEFORT 3 $1,547.67
21151 RECONSTRUCT MIDFACE, LEFORT 3 $1,922.06
21154 RECONSTRUCT MIDFACE, LEFORT 3 $1,968.70
21155 RECONSTRUCT MIDFACE, LEFORT 3 $2,126.28
21159 RECONSTRUCT MIDFACE, LEFORT 3 $2,584.53
21160 RECONSTRUCT MIDFACE, LEFORT 3 $2,665.94
21172 RECONSTRUCT ORBIT/FOREHEAD 3 $1,700.92
21175 RECONSTRUCT ORBIT/FOREHEAD 3 $2,151.71
21179 RECONSTRUCT ENTIRE FOREHEAD 3 $1,405.25
21180 RECONSTRUCT ENTIRE FOREHEAD 3 $1,558.12
21181 CONTOUR CRANIAL BONE LESION 3 $660.64
21182 RECONSTRUCT CRANIAL BONE 3 $1,935.24
21183 RECONSTRUCT CRANIAL BONE 3 $2,205.50
21184 RECONSTRUCT CRANIAL BONE 3 $2,319.92
21188 RECONSTRUCTION OF MIDFACE 3 $1,588.07
21193 RECONST LWR JAW W/O GRAFT 3 $1,176.74
21194 RECONST LWR JAW W/GRAFT 3 $1,351.09
21195 RECONST LWR JAW W/O FIXATION 3 $1,286.85
21196 RECONST LWR JAW W/FIXATION 3 $1,396.75
21198 RECONSTR LWR JAW SEGMENT 3 $1,102.61
21199 RECONSTR LWR JAW W/ADVANCE 3 $987.07
21200 OSTEOTOMY (EG, FOR PROGNATHISM, MIC O $0.00
21202 OSTEOTOMY (EG, FOR PROGNATHISM, MIC O $0.00
21203 OSTEOTOMY (EG, FOR PROGNATHISM, MIC O $0.00
21204 OSTEOTOMY (EG, FOR PROGNATHISM, MIC O $0.00
21206 RECONSTRUCT UPPER JAW BONE 3 $1,125.61
21208 AUGMENTATION OF FACIAL BONES 3 $1,684.54
21209 REDUCTION OF FACIAL BONES 3 $798.69
21210 FACE BONE GRAFT 3 $1,986.96
21215 LOWER JAW BONE GRAFT 3 $839.16
21230 RIB CARTILAGE GRAFT 3 $743.48
21235 EAR CARTILAGE GRAFT 3 $689.59
21240 RECONSTRUCTION OF JAW JOINT 3 $1,047.17
21242 RECONSTRUCTION OF JAW JOINT 3 $964.46
21243 RECONSTRUCTION OF JAW JOINT 3 $1,593.28
21244 RECONSTRUCTION OF LOWER JAW 3 $1,006.35
21245 RECONSTRUCTION OF JAW 3 $1,075.66
21246 RECONSTRUCTION OF JAW 3 $807.43
21247 RECONSTRUCT LOWER JAW BONE 3 $1,552.32
21248 RECONSTRUCTION OF JAW 3 $1,013.42
21249 RECONSTRUCTION OF JAW 3 $1,393.71
21250 OSTEOPLASTY OF MAXILLA AND/OR OTHER O $0.00
21254 OSTEOPLASTY OF MAXILLA AND/OR OTHER O $0.00
21255 RECONSTRUCT LOWER JAW BONE 3 $1,341.58
21256 RECONSTRUCTION OF ORBIT 3 $1,131.48

21260 REVISE EYE SOCKETS 3 $1,215.72
21261 REVISE EYE SOCKETS 3 $2,175.71
21263 REVISE EYE SOCKETS 3 $1,877.12
21267 REVISE EYE SOCKETS 3 $1,513.88
21268 REVISE EYE SOCKETS 3 $1,888.94
21270 AUGMENTATION, CHEEK BONE 3 $880.45
21275 REVISION, ORBITOFACIAL BONES 3 $783.62
21280 REVISION OF EYELID 3 $524.59
21282 REVISION OF EYELID 3 $346.10
21295 REVISION OF JAW MUSCLE/BONE 3 $169.77
21296 REVISION OF JAW MUSCLE/BONE 3 $409.41
21299 CRANIO/MAXILLOFACIAL SURGERY 5 $0.00
21300 TREATMENT OF SKULL FRACTURE O $0.00
21310 TREATMENT OF NOSE FRACTURE 3 $102.66
21315 TREATMENT OF NOSE FRACTURE 3 $249.65
21320 TREATMENT OF NOSE FRACTURE 3 $237.25
21325 TREATMENT OF NOSE FRACTURE 3 $448.19
21330 TREATMENT OF NOSE FRACTURE 3 $541.13
21335 TREATMENT OF NOSE FRACTURE 3 $701.96
21336 TREAT NASAL SEPTAL FRACTURE 3 $613.37
21337 TREAT NASAL SEPTAL FRACTURE 3 $373.55
21338 TREAT NASOETHMOID FRACTURE 3 $700.33
21339 TREAT NASOETHMOID FRACTURE 3 $784.17
21340 TREATMENT OF NOSE FRACTURE 3 $756.41
21343 TREATMENT OF SINUS FRACTURE 3 $1,119.15
21344 TREATMENT OF SINUS FRACTURE 3 $1,517.44
21345 TREAT NOSE/JAW FRACTURE 3 $756.12
21346 TREAT NOSE/JAW FRACTURE 3 $895.94
21347 TREAT NOSE/JAW FRACTURE 3 $1,027.49
21348 TREAT NOSE/JAW FRACTURE 3 $1,077.35
21355 TREAT CHEEK BONE FRACTURE 3 $414.15
21356 TREAT CHEEK BONE FRACTURE 3 $464.36
21360 TREAT CHEEK BONE FRACTURE 3 $504.36
21365 TREAT CHEEK BONE FRACTURE 3 $1,061.89
21366 TREAT CHEEK BONE FRACTURE 3 $1,182.22
21385 TREAT EYE SOCKET FRACTURE 3 $672.16
21386 TREAT EYE SOCKET FRACTURE 3 $635.54
21387 TREAT EYE SOCKET FRACTURE 3 $711.79
21390 TREAT EYE SOCKET FRACTURE 3 $747.84
21395 TREAT EYE SOCKET FRACTURE 3 $906.86
21400 TREAT EYE SOCKET FRACTURE 3 $169.69
21401 TREAT EYE SOCKET FRACTURE 3 $445.65
21406 TREAT EYE SOCKET FRACTURE 3 $508.21
21407 TREAT EYE SOCKET FRACTURE 3 $613.71
21408 TREAT EYE SOCKET FRACTURE 3 $846.35
21421 TREAT MOUTH ROOF FRACTURE 3 $705.78
21422 TREAT MOUTH ROOF FRACTURE 3 $632.58
21423 TREAT MOUTH ROOF FRACTURE 3 $760.28
21431 TREAT CRANIOFACIAL FRACTURE 3 $718.33

21432 TREAT CRANIOFACIAL FRACTURE 3 $639.21
21433 TREAT CRANIOFACIAL FRACTURE 3 $1,620.76
21435 TREAT CRANIOFACIAL FRACTURE 3 $1,265.85
21436 TREAT CRANIOFACIAL FRACTURE 3 $1,925.47
21440 TREAT DENTAL RIDGE FRACTURE 3 $511.12
21445 TREAT DENTAL RIDGE FRACTURE 3 $707.31
21450 TREAT LOWER JAW FRACTURE 3 $532.84
21451 TREAT LOWER JAW FRACTURE 3 $689.98
21452 TREAT LOWER JAW FRACTURE 3 $554.37
21453 TREAT LOWER JAW FRACTURE 3 $808.00
21454 TREAT LOWER JAW FRACTURE 3 $528.20
21455 CLOSED MANIPULATIVE TREATMENT BY IN O $0.00
21461 TREAT LOWER JAW FRACTURE 3 $874.87
21462 TREAT LOWER JAW FRACTURE 3 $1,974.39
21465 TREAT LOWER JAW FRACTURE 3 $883.05
21470 TREAT LOWER JAW FRACTURE 3 $1,141.63
21480 RESET DISLOCATED JAW 3 $85.23
21485 RESET DISLOCATED JAW 3 $623.36
21490 REPAIR DISLOCATED JAW 3 $879.76
21493 TREAT HYOID BONE FRACTURE O $0.00
21494 TREAT HYOID BONE FRACTURE O $0.00
21495 TREAT HYOID BONE FRACTURE 3 $659.99
21497 INTERDENTAL WIRING 3 $628.67
21499 HEAD SURGERY PROCEDURE 5 $0.00
21501 DRAIN NECK/CHEST LESION 3 $415.90
21502 DRAIN CHEST LESION 3 $500.14
21510 DRAINAGE OF BONE LESION 3 $438.69
21550 BIOPSY OF NECK/CHEST 3 $240.84
21552 EXC NECK LES SC = 3 CM 3 $439.29
21554 EXC NECK TUM DEEP = 5 CM 3 $720.77
21555 EXC NECK LES SC < 3 CM 3 $383.91
21556 EXC NECK TUM DEEP < 5 CM 3 $481.57
21557 RESECT NECK TUM < 5 CM 3 $821.54
21558 RESECT NECK TUM = 5 CM 3 $1,350.98
21600 PARTIAL REMOVAL OF RIB 3 $529.64
21610 PARTIAL REMOVAL OF RIB 3 $1,051.53
21615 REMOVAL OF RIB 3 $643.08
21616 REMOVAL OF RIB AND NERVES 3 $799.83
21620 PARTIAL REMOVAL OF STERNUM 3 $498.84
21627 STERNAL DEBRIDEMENT 3 $525.02
21630 EXTENSIVE STERNUM SURGERY 3 $1,210.41
21632 EXTENSIVE STERNUM SURGERY 3 $1,207.05
21633 RADICAL RESECTION OF STERNUM; FOR O O $0.00
21685 HYOID MYOTOMY & SUSPENSION 3 $965.46
21700 REVISION OF NECK MUSCLE 3 $406.40
21705 REVISION OF NECK MUSCLE/RIB 3 $601.85
21720 REVISION OF NECK MUSCLE 3 $407.12
21725 REVISION OF NECK MUSCLE 3 $500.96
21740 RECONSTRUCTION OF STERNUM 3 $1,022.24

21742 REPAIR STERN/NUSS W/O SCOPE 5 $0.00
21743 REPAIR STERNUM/NUSS W/SCOPE 5 $0.00
21750 REPAIR OF STERNUM SEPARATION 3 $686.34
21800 TREATMENT OF RIB FRACTURE 3 $94.14
21805 TREATMENT OF RIB FRACTURE 3 $247.63
21810 TREATMENT OF RIB FRACTURE(S) 3 $478.99
21820 TREAT STERNUM FRACTURE 3 $125.02
21825 TREAT STERNUM FRACTURE 3 $542.35
21899 NECK/CHEST SURGERY PROCEDURE 5 $0.00
21920 BIOPSY SOFT TISSUE OF BACK 3 $241.96
21925 BIOPSY SOFT TISSUE OF BACK 3 $397.85
21930 EXC BACK LES SC < 3 CM 3 $433.57
21931 EXC BACK LES SC = 3 CM 3 $459.01
21932 EXC BACK TUM DEEP < 5 CM 3 $658.55
21933 EXC BACK TUM DEEP = 5 CM 3 $725.30
21935 RESECT BACK TUM < 5 CM 3 $987.04
21936 RESECT BACK TUM = 5 CM 3 $1,404.05
22010 I&D, P-SPINE, C/T/CERV-THOR 3 $870.94
22015 I&D, P-SPINE, L/S/LS 3 $863.37
22100 REMOVE PART OF NECK VERTEBRA 3 $795.95
22101 REMOVE PART, THORAX VERTEBRA 3 $807.81
22102 REMOVE PART, LUMBAR VERTEBRA 3 $768.79
22103 REMOVE EXTRA SPINE SEGMENT 3 $137.45
22105 PARTIAL RESECTION OF VERTEBRAL COMP O $0.00
22106 PARTIAL RESECTION OF VERTEBRAL COMP O $0.00
22107 PARTIAL RESECTION OF VERTEBRAL COMP O $0.00
22110 REMOVE PART OF NECK VERTEBRA 3 $979.33
22112 REMOVE PART, THORAX VERTEBRA 3 $971.17
22114 REMOVE PART, LUMBAR VERTEBRA 3 $937.82
22116 REMOVE EXTRA SPINE SEGMENT 3 $134.85
22140 RECONSTRUCTION OF SPINE WITH BONE G O $0.00
22141 RECONSTRUCTION OF SPINE WITH BONE G O $0.00
22142 RECONSTRUCTION OF SPINE WITH BONE G O $0.00
22145 RECONSTRUCTION OF SPINE FOLLOWING V O $0.00
22148 HARVESTING OF BONE AUTOGRAFT FOR VE O $0.00
22150 RECONSTRUCTION OF SPINE WITH PREFAB O $0.00
22151 RECONSTRUCTION OF SPINE WITH PREFAB O $0.00
22152 RECONSTRUCTION OF SPINE WITH PREFAB O $0.00
22206 CUT SPINE 3 COL, THOR 3 $2,236.99
22207 CUT SPINE 3 COL, LUMB 3 $2,247.24
22208 CUT SPINE 3 COL, ADDL SEG 3 $559.34
22210 REVISION OF NECK SPINE 3 $1,651.98
22212 REVISION OF THORAX SPINE 3 $1,376.35
22214 REVISION OF LUMBAR SPINE 3 $1,386.56
22216 REVISE, EXTRA SPINE SEGMENT 3 $352.19
22220 REVISION OF NECK SPINE 3 $1,496.86
22222 REVISION OF THORAX SPINE 3 $1,380.09
22224 REVISION OF LUMBAR SPINE 3 $1,480.45
22226 REVISE, EXTRA SPINE SEGMENT 3 $351.90

22230 OSTEOTOMY OF SPINE, ANY APPROACH, E O $0.00
22305 TREAT SPINE PROCESS FRACTURE 3 $173.23
22310 TREAT SPINE FRACTURE 3 $277.03
22315 TREAT SPINE FRACTURE 3 $805.61
22318 TREAT ODONTOID FX W/O GRAFT 3 $1,503.42
22319 TREAT ODONTOID FX W/GRAFT 3 $1,661.16
22325 TREAT SPINE FRACTURE 3 $1,326.12
22326 TREAT NECK SPINE FRACTURE 3 $1,373.33
22327 TREAT THORAX SPINE FRACTURE 3 $1,367.22
22328 TREAT EACH ADD SPINE FX 3 $270.41
22505 MANIPULATION OF SPINE 3 $112.01
22520 PERCUT VERTEBROPLASTY THOR 3 $2,132.81
22521 PERCUT VERTEBROPLASTY LUMB 3 $2,086.06
22522 PERCUT VERTEBROPLASTY ADDL 3 $229.63
22523 PERCUT KYPHOPLASTY, THOR 3 $568.05
22524 PERCUT KYPHOPLASTY, LUMBAR 3 $545.55
22525 PERCUT KYPHOPLASTY, ADD-ON 3 $254.15
22526 IDET, SINGLE LEVEL 9 $0.00
22527 IDET, 1 OR MORE LEVELS 9 $0.00
22532 LAT THORAX SPINE FUSION 3 $1,661.75
22533 LAT LUMBAR SPINE FUSION 3 $1,578.45
22534 LAT THOR/LUMB, ADDL SEG 3 $349.93
22548 NECK SPINE FUSION 3 $1,775.46
22554 NECK SPINE FUSION 3 $1,189.26
22556 THORAX SPINE FUSION 3 $1,566.34
22558 LUMBAR SPINE FUSION 3 $1,454.80
22585 ADDITIONAL SPINAL FUSION 3 $322.93
22590 SPINE & SKULL SPINAL FUSION 3 $1,454.81
22595 NECK SPINAL FUSION 3 $1,384.15
22600 NECK SPINE FUSION 3 $1,185.04
22610 THORAX SPINE FUSION 3 $1,165.90
22612 LUMBAR SPINE FUSION 3 $1,501.00
22614 SPINE FUSION, EXTRA SEGMENT 3 $377.12
22625 ARTHRODESIS, LATERAL TRANSVERSE PRO O $0.00
22630 LUMBAR SPINE FUSION 3 $1,441.94
22632 SPINE FUSION, EXTRA SEGMENT 3 $306.86
22650 ARTHRODESIS, POSTERIOR, POSTEROLATE O $0.00
22800 FUSION OF SPINE 3 $1,274.20
22802 FUSION OF SPINE 3 $2,003.03
22804 FUSION OF SPINE 3 $2,311.30
22808 FUSION OF SPINE 3 $1,728.90
22810 FUSION OF SPINE 3 $1,934.29
22812 FUSION OF SPINE 3 $2,099.25
22818 KYPHECTOMY, 1-2 SEGMENTS 3 $2,077.46
22819 KYPHECTOMY, 3 OR MORE 3 $2,508.76
22820 HARVESTING OF BONE AUTOGRAFT THROUG O $0.00
22830 EXPLORATION OF SPINAL FUSION 3 $757.66
22840 INSERT SPINE FIXATION DEVICE 3 $734.80
22841 INSERT SPINE FIXATION DEVICE 9 $0.00

22842 INSERT SPINE FIXATION DEVICE 3 $736.67
22843 INSERT SPINE FIXATION DEVICE 3 $783.40
22844 INSERT SPINE FIXATION DEVICE 3 $955.79
22845 INSERT SPINE FIXATION DEVICE 3 $703.94
22846 INSERT SPINE FIXATION DEVICE 3 $730.65
22847 INSERT SPINE FIXATION DEVICE 3 $825.43
22848 INSERT PELV FIXATION DEVICE 3 $349.28
22849 REINSERT SPINAL FIXATION 3 $1,226.11
22850 REMOVE SPINE FIXATION DEVICE 3 $671.52
22851 APPLY SPINE PROSTH DEVICE 3 $392.60
22852 REMOVE SPINE FIXATION DEVICE 3 $642.32
22855 REMOVE SPINE FIXATION DEVICE 3 $1,042.51
22856 CERV ARTIFIC DISKECTOMY 3 $1,549.07
22857 LUMBAR ARTIF DISKECTOMY 3 $1,622.92
22861 REVISE CERV ARTIFIC DISC 3 $1,789.91
22862 REVISE LUMBAR ARTIF DISC 3 $1,853.89
22864 REMOVE CERV ARTIF DISC 3 $1,588.56
22865 REMOVE LUMB ARTIF DISC 3 $1,986.37
22899 SPINE SURGERY PROCEDURE 5 $0.00
22900 EXC BACK TUM DEEP < 5 CM 3 $490.55
22901 EXC BACK TUM DEEP = 5 CM 3 $647.47
22902 EXC ABD LES SC < 3 CM 3 $416.12
22903 EXC ABD LES SC > 3 CM 3 $430.25
22904 RESECT ABD TUM < 5 CM 3 $1,010.83
22905 RESECT ABD TUM > 5 CM 3 $1,310.78
22999 ABDOMEN SURGERY PROCEDURE 5 $0.00
23000 REMOVAL OF CALCIUM DEPOSITS 3 $502.27
23020 RELEASE SHOULDER JOINT 3 $647.95
23030 DRAIN SHOULDER LESION 3 $394.53
23031 DRAIN SHOULDER BURSA 3 $360.94
23035 DRAIN SHOULDER BONE LESION 3 $642.90
23040 EXPLORATORY SHOULDER SURGERY 3 $675.11
23044 EXPLORATORY SHOULDER SURGERY 3 $537.44
23065 BIOPSY SHOULDER TISSUES 3 $201.64
23066 BIOPSY SHOULDER TISSUES 3 $478.45
23071 EXC SHOULDER LES SC > 3 CM 3 $408.56
23073 EXC SHOULDER TUM DEEP > 5 CM 3 $675.57
23075 EXC SHOULDER LES SC < 3 CM 3 $342.35
23076 EXC SHOULDER TUM DEEP < 5 CM 3 $510.33
23077 RESECT SHOULDER TUM < 5 CM 3 $1,104.08
23078 RESECT SHOULDER TUM > 5 CM 3 $1,363.74
23100 BIOPSY OF SHOULDER JOINT 3 $459.09
23101 SHOULDER JOINT SURGERY 3 $419.43
23105 REMOVE SHOULDER JOINT LINING 3 $596.71
23106 INCISION OF COLLARBONE JOINT 3 $450.61
23107 EXPLORE TREAT SHOULDER JOINT 3 $619.50
23120 PARTIAL REMOVAL, COLLAR BONE 3 $541.50
23125 REMOVAL OF COLLAR BONE 3 $659.88
23130 REMOVE SHOULDER BONE, PART 3 $566.43

23140 REMOVAL OF BONE LESION 3 $484.79
23145 REMOVAL OF BONE LESION 3 $649.63
23146 REMOVAL OF BONE LESION 3 $567.26
23150 REMOVAL OF HUMERUS LESION 3 $617.18
23155 REMOVAL OF HUMERUS LESION 3 $742.51
23156 REMOVAL OF HUMERUS LESION 3 $632.00
23170 REMOVE COLLAR BONE LESION 3 $504.33
23172 REMOVE SHOULDER BLADE LESION 3 $518.17
23174 REMOVE HUMERUS LESION 3 $707.71
23180 REMOVE COLLAR BONE LESION 3 $640.34
23182 REMOVE SHOULDER BLADE LESION 3 $621.99
23184 REMOVE HUMERUS LESION 3 $697.22
23190 PARTIAL REMOVAL OF SCAPULA 3 $526.02
23195 REMOVAL OF HEAD OF HUMERUS 3 $706.40
23200 RESECT CLAVICLE TUMOR 3 $1,289.00
23210 RESECT SCAPULA TUMOR 3 $1,504.85
23220 RESECT PROX HUMERUS TUMOR 3 $1,670.21
23221 PARTIAL REMOVAL OF HUMERUS O $0.00
23222 PARTIAL REMOVAL OF HUMERUS O $0.00
23330 REMOVE SHOULDER FOREIGN BODY 3 $212.23
23331 REMOVE SHOULDER FOREIGN BODY 3 $551.38
23332 REMOVE SHOULDER FOREIGN BODY 3 $832.57
23350 INJECTION FOR SHOULDER X-RAY 3 $145.97
23395 MUSCLE TRANSFER,SHOULDER/ARM 3 $1,216.74
23397 MUSCLE TRANSFERS 3 $1,083.07
23400 FIXATION OF SHOULDER BLADE 3 $918.82
23405 INCISION OF TENDON & MUSCLE 3 $592.11
23406 INCISE TENDON(S) & MUSCLE(S) 3 $737.14
23410 REPAIR ROTATOR CUFF, ACUTE 3 $778.46
23412 REPAIR ROTATOR CUFF, CHRONIC 3 $811.24
23415 RELEASE OF SHOULDER LIGAMENT 3 $651.38
23420 REPAIR OF SHOULDER 3 $918.51
23430 REPAIR BICEPS TENDON 3 $695.08
23440 REMOVE/TRANSPLANT TENDON 3 $715.48
23450 REPAIR SHOULDER CAPSULE 3 $897.38
23455 REPAIR SHOULDER CAPSULE 3 $954.78
23460 REPAIR SHOULDER CAPSULE 3 $1,035.33
23462 REPAIR SHOULDER CAPSULE 3 $1,016.69
23465 REPAIR SHOULDER CAPSULE 3 $1,058.88
23466 REPAIR SHOULDER CAPSULE 3 $1,057.79
23470 RECONSTRUCT SHOULDER JOINT 3 $1,152.22
23472 RECONSTRUCT SHOULDER JOINT 3 $1,428.70
23480 REVISION OF COLLAR BONE 3 $772.58
23485 REVISION OF COLLAR BONE 3 $910.58
23490 REINFORCE CLAVICLE 3 $805.24
23491 REINFORCE SHOULDER BONES 3 $960.11
23500 TREAT CLAVICLE FRACTURE 3 $195.43
23505 TREAT CLAVICLE FRACTURE 3 $317.32
23510 TREATMENT OF OPEN CLAVICULAR FRACTU O $0.00

23515 TREAT CLAVICLE FRACTURE 3 $672.30
23520 TREAT CLAVICLE DISLOCATION 3 $203.01
23525 TREAT CLAVICLE DISLOCATION 3 $323.29
23530 TREAT CLAVICLE DISLOCATION 3 $513.15
23532 TREAT CLAVICLE DISLOCATION 3 $581.35
23540 TREAT CLAVICLE DISLOCATION 3 $200.03
23545 TREAT CLAVICLE DISLOCATION 3 $290.68
23550 TREAT CLAVICLE DISLOCATION 3 $535.82
23552 TREAT CLAVICLE DISLOCATION 3 $617.05
23570 TREAT SHOULDER BLADE FX 3 $207.45
23575 TREAT SHOULDER BLADE FX 3 $356.57
23580 TREATMENT OF OPEN SCAPULAR FRACTURE O $0.00
23585 TREAT SCAPULA FRACTURE 3 $915.83
23600 TREAT HUMERUS FRACTURE 3 $290.71
23605 TREAT HUMERUS FRACTURE 3 $424.37
23610 TREATMENT OF OPEN HUMERAL (SURGICAL O $0.00
23615 TREAT HUMERUS FRACTURE 3 $830.01
23616 TREAT HUMERUS FRACTURE 3 $1,195.54
23620 TREAT HUMERUS FRACTURE 3 $239.94
23625 TREAT HUMERUS FRACTURE 3 $345.18
23630 TREAT HUMERUS FRACTURE 3 $720.86
23650 TREAT SHOULDER DISLOCATION 3 $273.41
23655 TREAT SHOULDER DISLOCATION 3 $358.40
23658 TREATMENT OF OPEN SHOULDER DISLOCAT O $0.00
23660 TREAT SHOULDER DISLOCATION 3 $544.16
23665 TREAT DISLOCATION/FRACTURE 3 $385.37
23670 TREAT DISLOCATION/FRACTURE 3 $810.75
23675 TREAT DISLOCATION/FRACTURE 3 $499.71
23680 TREAT DISLOCATION/FRACTURE 3 $866.89
23700 FIXATION OF SHOULDER 3 $182.08
23800 FUSION OF SHOULDER JOINT 3 $969.53
23802 FUSION OF SHOULDER JOINT 3 $1,192.43
23900 AMPUTATION OF ARM & GIRDLE 3 $1,271.05
23920 AMPUTATION AT SHOULDER JOINT 3 $1,032.64
23921 AMPUTATION FOLLOW-UP SURGERY 3 $384.28
23929 SHOULDER SURGERY PROCEDURE 5 $0.00
23930 DRAINAGE OF ARM LESION 3 $328.14
23931 DRAINAGE OF ARM BURSA 3 $256.29
23935 DRAIN ARM/ELBOW BONE LESION 3 $464.77
24000 EXPLORATORY ELBOW SURGERY 3 $442.38
24006 RELEASE ELBOW JOINT 3 $667.61
24065 BIOPSY ARM/ELBOW SOFT TISSUE 3 $236.64
24066 BIOPSY ARM/ELBOW SOFT TISSUE 3 $548.94
24071 EXC ARM/ELBOW LES SC = 3 CM 3 $396.88
24073 EX ARM/ELBOW TUM DEEP > 5 CM 3 $679.62
24075 EXC ARM/ELBOW LES SC < 3 CM 3 $449.04
24076 EX ARM/ELBOW TUM DEEP < 5 CM 3 $490.94
24077 RESECT ARM/ELBOW TUM < 5 CM 3 $936.65
24079 RESECT ARM/ELBOW TUM > 5 CM 3 $1,257.81

24100 BIOPSY ELBOW JOINT LINING 3 $379.87
24101 EXPLORE/TREAT ELBOW JOINT 3 $464.77
24102 REMOVE ELBOW JOINT LINING 3 $575.38
24105 REMOVAL OF ELBOW BURSA 3 $316.26
24110 REMOVE HUMERUS LESION 3 $545.40
24115 REMOVE/GRAFT BONE LESION 3 $674.98
24116 REMOVE/GRAFT BONE LESION 3 $811.82
24120 REMOVE ELBOW LESION 3 $488.63
24125 REMOVE/GRAFT BONE LESION 3 $572.49
24126 REMOVE/GRAFT BONE LESION 3 $604.58
24130 REMOVAL OF HEAD OF RADIUS 3 $471.93
24134 REMOVAL OF ARM BONE LESION 3 $705.34
24136 REMOVE RADIUS BONE LESION 3 $566.33
24138 REMOVE ELBOW BONE LESION 3 $623.53
24140 PARTIAL REMOVAL OF ARM BONE 3 $670.13
24145 PARTIAL REMOVAL OF RADIUS 3 $562.85
24147 PARTIAL REMOVAL OF ELBOW 3 $586.14
24149 RADICAL RESECTION OF ELBOW 3 $1,096.01
24150 RESECT DISTAL HUMERUS TUMOR 3 $1,350.84
24151 EXTENSIVE HUMERUS SURGERY O $0.00
24152 RESECT RADIUS TUMOR 3 $1,137.12
24153 EXTENSIVE RADIUS SURGERY O $0.00
24155 REMOVAL OF ELBOW JOINT 3 $800.54
24160 REMOVE ELBOW JOINT IMPLANT 3 $565.66
24164 REMOVE RADIUS HEAD IMPLANT 3 $463.69
24200 REMOVAL OF ARM FOREIGN BODY 3 $184.78
24201 REMOVAL OF ARM FOREIGN BODY 3 $510.78
24220 INJECTION FOR ELBOW X-RAY 3 $160.44
24300 MANIPULATE ELBOW W/ANESTH 3 $369.60
24301 MUSCLE/TENDON TRANSFER 3 $707.51
24305 ARM TENDON LENGTHENING 3 $541.76
24310 REVISION OF ARM TENDON 3 $444.84
24320 REPAIR OF ARM TENDON 3 $730.41
24330 REVISION OF ARM MUSCLES 3 $672.66
24331 REVISION OF ARM MUSCLES 3 $742.51
24332 TENOLYSIS, TRICEPS 3 $568.64
24340 REPAIR OF BICEPS TENDON 3 $573.83
24341 REPAIR ARM TENDON/MUSCLE 3 $689.20
24342 REPAIR OF RUPTURED TENDON 3 $735.24
24343 REPR ELBOW LAT LIGMNT W/TISS 3 $659.98
24344 RECONSTRUCT ELBOW LAT LIGMNT 3 $1,029.36
24345 REPR ELBW MED LIGMNT W/TISSU 3 $655.44
24346 RECONSTRUCT ELBOW MED LIGMNT 3 $1,031.64
24350 REPAIR OF TENNIS ELBOW O $0.00
24351 REPAIR OF TENNIS ELBOW O $0.00
24352 REPAIR OF TENNIS ELBOW O $0.00
24354 REPAIR OF TENNIS ELBOW O $0.00
24356 REVISION OF TENNIS ELBOW O $0.00
24357 REPAIR ELBOW, PERC 3 $414.67

24358 REPAIR ELBOW W/DEB, OPEN 3 $487.34
24359 REPAIR ELBOW DEB/ATTCH OPEN 3 $613.33
24360 RECONSTRUCT ELBOW JOINT 3 $848.40
24361 RECONSTRUCT ELBOW JOINT 3 $953.73
24362 RECONSTRUCT ELBOW JOINT 3 $1,002.50
24363 REPLACE ELBOW JOINT 3 $1,421.75
24365 RECONSTRUCT HEAD OF RADIUS 3 $599.67
24366 RECONSTRUCT HEAD OF RADIUS 3 $641.41
24400 REVISION OF HUMERUS 3 $773.13
24410 REVISION OF HUMERUS 3 $989.18
24420 REVISION OF HUMERUS 3 $932.11
24430 REPAIR OF HUMERUS 3 $996.21
24435 REPAIR HUMERUS WITH GRAFT 3 $1,011.92
24470 REVISION OF ELBOW JOINT 3 $600.37
24495 DECOMPRESSION OF FOREARM 3 $618.91
24498 REINFORCE HUMERUS 3 $820.07
24500 TREAT HUMERUS FRACTURE 3 $317.52
24505 TREAT HUMERUS FRACTURE 3 $455.03
24506 TREATMENT OF CLOSED HUMERAL SHAFT F O $0.00
24510 TREATMENT OF OPEN HUMERAL SHAFT FRA O $0.00
24515 TREAT HUMERUS FRACTURE 3 $824.72
24516 TREAT HUMERUS FRACTURE 3 $814.03
24530 TREAT HUMERUS FRACTURE 3 $340.07
24531 TREATMENT OF CLOSED HUMERAL SUPRACO O $0.00
24535 TREAT HUMERUS FRACTURE 3 $566.84
24536 TREATMENT OF CLOSED HUMERAL SUPRACO O $0.00
24538 TREAT HUMERUS FRACTURE 3 $696.50
24540 TREATMENT OF OPEN HUMERAL SUPRACOND O $0.00
24542 TREATMENT OF OPEN HUMERAL SUPRACOND O $0.00
24545 TREAT HUMERUS FRACTURE 3 $869.29
24546 TREAT HUMERUS FRACTURE 3 $988.48
24560 TREAT HUMERUS FRACTURE 3 $285.22
24565 TREAT HUMERUS FRACTURE 3 $472.89
24566 TREAT HUMERUS FRACTURE 3 $663.44
24570 TREATMENT OF OPEN HUMERAL EPICONDYL O $0.00
24575 TREAT HUMERUS FRACTURE 3 $687.15
24576 TREAT HUMERUS FRACTURE 3 $301.11
24577 TREAT HUMERUS FRACTURE 3 $490.73
24578 TREATMENT OF OPEN HUMERAL CONDYLAR O $0.00
24579 TREAT HUMERUS FRACTURE 3 $783.82
24580 TREATMENT OF CLOSED COMMINUTED ELBO O $0.00
24581 TREATMENT OF CLOSED COMMINUTED ELBO O $0.00
24582 TREAT HUMERUS FRACTURE 3 $742.23
24583 TREATMENT OF OPEN COMMINUTED ELBOW O $0.00
24585 OPEN TREATMENT OF CLOSED OR OPEN CO O $0.00
24586 TREAT ELBOW FRACTURE 3 $1,031.65
24587 TREAT ELBOW FRACTURE 3 $1,029.80
24588 OPEN TREATMENT OF CLOSED OR OPEN CO O $0.00
24600 TREAT ELBOW DISLOCATION 3 $331.74

24605 TREAT ELBOW DISLOCATION 3 $428.24
24610 TREATMENT OF OPEN ELBOW DISLOCATION O $0.00
24615 TREAT ELBOW DISLOCATION 3 $670.76
24620 TREAT ELBOW FRACTURE 3 $513.92
24625 TREATMENT OF OPEN MONTEGGIA TYPE OF O $0.00
24635 TREAT ELBOW FRACTURE 3 $674.42
24640 TREAT ELBOW DISLOCATION 3 $113.33
24650 TREAT RADIUS FRACTURE 3 $231.46
24655 TREAT RADIUS FRACTURE 3 $396.64
24660 TREATMENT OF OPEN RADIAL HEAD OR NE O $0.00
24665 TREAT RADIUS FRACTURE 3 $606.98
24666 TREAT RADIUS FRACTURE 3 $687.47
24670 TREAT ULNAR FRACTURE 3 $259.29
24675 TREAT ULNAR FRACTURE 3 $415.64
24680 TREATMENT OF OPEN ULNAR FRACTURE, P O $0.00
24685 TREAT ULNAR FRACTURE 3 $608.22
24800 FUSION OF ELBOW JOINT 3 $758.89
24802 FUSION/GRAFT OF ELBOW JOINT 3 $943.40
24900 AMPUTATION OF UPPER ARM 3 $680.31
24920 AMPUTATION OF UPPER ARM 3 $674.59
24925 AMPUTATION FOLLOW-UP SURGERY 3 $524.36
24930 AMPUTATION FOLLOW-UP SURGERY 3 $715.71
24931 AMPUTATE UPPER ARM & IMPLANT 3 $761.02
24935 REVISION OF AMPUTATION 3 $1,000.97
24940 REVISION OF UPPER ARM 5 $0.00
24999 UPPER ARM/ELBOW SURGERY 5 $0.00
25000 INCISION OF TENDON SHEATH 3 $322.64
25001 INCISE FLEXOR CARPI RADIALIS 3 $311.48
25005 TENDON SHEATH INCISION; AT WRIST FO O $0.00
25020 DECOMPRESS FOREARM 1 SPACE 3 $536.08
25023 DECOMPRESS FOREARM 1 SPACE 3 $1,039.44
25024 DECOMPRESS FOREARM 2 SPACES 3 $729.50
25025 DECOMPRESS FOREARM 2 SPACES 3 $1,138.65
25028 DRAINAGE OF FOREARM LESION 3 $480.88
25031 DRAINAGE OF FOREARM BURSA 3 $349.73
25035 TREAT FOREARM BONE LESION 3 $589.28
25040 EXPLORE/TREAT WRIST JOINT 3 $533.60
25065 BIOPSY FOREARM SOFT TISSUES 3 $235.38
25066 BIOPSY FOREARM SOFT TISSUES 3 $348.48
25071 EXC FOREARM LES SC > 3 CM 3 $416.14
25073 EXC FOREARM TUM DEEP = 3 CM 3 $519.32
25075 EXC FOREARM LES SC < 3 CM 3 $345.11
25076 EXC FOREARM TUM DEEP < 3 CM 3 $485.84
25077 RESECT FOREARM/WRIST TUM

25107 REMOVE WRIST JOINT CARTILAGE 3 $579.08
25109 EXCISE TENDON FOREARM/WRIST 3 $494.68
25110 REMOVE WRIST TENDON LESION 3 $332.67
25111 REMOVE WRIST TENDON LESION 3 $295.18
25112 REREMOVE WRIST TENDON LESION 3 $358.65
25115 REMOVE WRIST/FOREARM LESION 3 $749.83
25116 REMOVE WRIST/FOREARM LESION 3 $601.45
25118 EXCISE WRIST TENDON SHEATH 3 $358.38
25119 PARTIAL REMOVAL OF ULNA 3 $473.06
25120 REMOVAL OF FOREARM LESION 3 $507.53
25125 REMOVE/GRAFT FOREARM LESION 3 $597.31
25126 REMOVE/GRAFT FOREARM LESION 3 $598.98
25130 REMOVAL OF WRIST LESION 3 $421.50
25135 REMOVE & GRAFT WRIST LESION 3 $530.08
25136 REMOVE & GRAFT WRIST LESION 3 $462.70
25145 REMOVE FOREARM BONE LESION 3 $523.52
25150 PARTIAL REMOVAL OF ULNA 3 $539.79
25151 PARTIAL REMOVAL OF RADIUS 3 $590.87
25170 RESECT RADIUS/ULNAR TUMOR 3 $1,307.70
25210 REMOVAL OF WRIST BONE 3 $461.03
25215 REMOVAL OF WRIST BONES 3 $589.84
25230 PARTIAL REMOVAL OF RADIUS 3 $406.63
25240 PARTIAL REMOVAL OF ULNA 3 $410.36
25246 INJECTION FOR WRIST X-RAY 3 $162.77
25248 REMOVE FOREARM FOREIGN BODY 3 $409.02
25250 REMOVAL OF WRIST PROSTHESIS 3 $492.21
25251 REMOVAL OF WRIST PROSTHESIS 3 $675.13
25259 MANIPULATE WRIST W/ANESTHES 3 $371.49
25260 REPAIR FOREARM TENDON/MUSCLE 3 $628.86
25263 REPAIR FOREARM TENDON/MUSCLE 3 $627.93
25265 REPAIR FOREARM TENDON/MUSCLE 3 $745.45
25270 REPAIR FOREARM TENDON/MUSCLE 3 $501.37
25272 REPAIR FOREARM TENDON/MUSCLE 3 $563.09
25274 REPAIR FOREARM TENDON/MUSCLE 3 $671.05
25275 REPAIR FOREARM TENDON SHEATH 3 $632.84
25280 REVISE WRIST/FOREARM TENDON 3 $571.96
25290 INCISE WRIST/FOREARM TENDON 3 $475.31
25295 RELEASE WRIST/FOREARM TENDON 3 $531.78
25300 FUSION OF TENDONS AT WRIST 3 $645.10
25301 FUSION OF TENDONS AT WRIST 3 $609.60
25310 TRANSPLANT FOREARM TENDON 3 $620.66
25312 TRANSPLANT FOREARM TENDON 3 $720.06
25315 REVISE PALSY HAND TENDON(S) 3 $771.49
25316 REVISE PALSY HAND TENDON(S) 3 $891.39
25317 FLEXOR ORIGIN SLIDE FOR VOLKMANN CO O $0.00
25318 FLEXOR ORIGIN SLIDE FOR VOLKMANN CO O $0.00
25320 REPAIR/REVISE WRIST JOINT 3 $920.73
25330 ARTHROPLASTY, WRIST; O $0.00
25331 ARTHROPLASTY, WRIST; WITH IMPLANT O $0.00

25332 REVISE WRIST JOINT 3 $793.91
25335 REALIGNMENT OF HAND 3 $845.00
25337 RECONSTRUCT ULNA/RADIOULNAR 3 $837.48
25350 REVISION OF RADIUS 3 $678.88
25355 REVISION OF RADIUS 3 $765.52
25360 REVISION OF ULNA 3 $660.02
25365 REVISE RADIUS & ULNA 3 $901.85
25370 REVISE RADIUS OR ULNA 3 $986.92
25375 REVISE RADIUS & ULNA 3 $887.88
25390 SHORTEN RADIUS OR ULNA 3 $770.18
25391 LENGTHEN RADIUS OR ULNA 3 $984.65
25392 SHORTEN RADIUS & ULNA 3 $1,003.26
25393 LENGTHEN RADIUS & ULNA 3 $1,117.60
25394 REPAIR CARPAL BONE, SHORTEN 3 $734.96
25400 REPAIR RADIUS OR ULNA 3 $806.52
25405 REPAIR/GRAFT RADIUS OR ULNA 3 $1,029.25
25415 REPAIR RADIUS & ULNA 3 $971.20
25420 REPAIR/GRAFT RADIUS & ULNA 3 $1,155.75
25425 REPAIR/GRAFT RADIUS OR ULNA 3 $989.57
25426 REPAIR/GRAFT RADIUS & ULNA 3 $1,059.56
25430 VASC GRAFT INTO CARPAL BONE 3 $669.85
25431 REPAIR NONUNION CARPAL BONE 3 $735.91
25440 REPAIR/GRAFT WRIST BONE 3 $728.88
25441 RECONSTRUCT WRIST JOINT 3 $877.65
25442 RECONSTRUCT WRIST JOINT 3 $751.39
25443 RECONSTRUCT WRIST JOINT 3 $735.23
25444 RECONSTRUCT WRIST JOINT 3 $726.48
25445 RECONSTRUCT WRIST JOINT 3 $677.52
25446 WRIST REPLACEMENT 3 $1,112.67
25447 REPAIR WRIST JOINT(S) 3 $771.85
25449 REMOVE WRIST JOINT IMPLANT 3 $979.59
25450 REVISION OF WRIST JOINT 3 $563.26
25455 REVISION OF WRIST JOINT 3 $622.88
25490 REINFORCE RADIUS 3 $689.08
25491 REINFORCE ULNA 3 $741.09
25492 REINFORCE RADIUS AND ULNA 3 $892.63
25500 TREAT FRACTURE OF RADIUS 3 $238.01
25505 TREAT FRACTURE OF RADIUS 3 $457.74
25510 TREATMENT OF OPEN RADIAL SHAFT FRAC O $0.00
25515 TREAT FRACTURE OF RADIUS 3 $624.52
25520 TREAT FRACTURE OF RADIUS 3 $506.93
25525 TREAT FRACTURE OF RADIUS 3 $744.09
25526 TREAT FRACTURE OF RADIUS 3 $919.54
25530 TREAT FRACTURE OF ULNA 3 $230.55
25535 TREAT FRACTURE OF ULNA 3 $443.63
25540 TREATMENT OF OPEN ULNAR SHAFT FRACT O $0.00
25545 TREAT FRACTURE OF ULNA 3 $582.23
25560 TREAT FRACTURE RADIUS & ULNA 3 $241.91
25565 TREAT FRACTURE RADIUS & ULNA 3 $477.74

25570 TREATMENT OF OPEN RADIAL AND ULNAR O $0.00
25574 TREAT FRACTURE RADIUS & ULNA 3 $625.39
25575 TREAT FRACTURE RADIUS/ULNA 3 $843.03
25600 TREAT FRACTURE RADIUS/ULNA 3 $261.31
25605 TREAT FRACTURE RADIUS/ULNA 3 $569.17
25606 TREAT FX DISTAL RADIAL 3 $622.03
25607 TREAT FX RAD EXTRA-ARTICUL 3 $677.66
25608 TREAT FX RAD INTRA-ARTICUL 3 $763.32
25609 TREAT FX RADIAL 3+ FRAG 3 $973.38
25610 TREATMENT OF CLOSED, COMPLEX, DISTA O $0.00
25611 TREAT FRACTURE RADIUS/ULNA O $0.00
25615 TREATMENT OF OPEN DISTAL RADIAL FRA O $0.00
25620 TREAT FRACTURE RADIUS/ULNA O $0.00
25622 TREAT WRIST BONE FRACTURE 3 $269.61
25624 TREAT WRIST BONE FRACTURE 3 $421.14
25626 TREATMENT OF OPEN CARPAL SCAPHOID ( O $0.00
25628 TREAT WRIST BONE FRACTURE 3 $673.79
25630 TREAT WRIST BONE FRACTURE 3 $274.19
25635 TREAT WRIST BONE FRACTURE 3 $401.93
25640 TREATMENT OF OPEN CARPAL BONE FRACT O $0.00
25645 TREAT WRIST BONE FRACTURE 3 $529.61
25650 TREAT WRIST BONE FRACTURE 3 $286.78
25651 PIN ULNAR STYLOID FRACTURE 3 $444.51
25652 TREAT FRACTURE ULNAR STYLOID 3 $579.45
25660 TREAT WRIST DISLOCATION 3 $375.38
25665 TREATMENT OF OPEN RADIOCARPAL OR IN O $0.00
25670 TREAT WRIST DISLOCATION 3 $569.32
25671 PIN RADIOULNAR DISLOCATION 3 $487.09
25675 TREAT WRIST DISLOCATION 3 $394.27
25676 TREAT WRIST DISLOCATION 3 $589.08
25680 TREAT WRIST FRACTURE 3 $430.27
25685 TREAT WRIST FRACTURE 3 $687.24
25690 TREAT WRIST DISLOCATION 3 $434.79
25695 TREAT WRIST DISLOCATION 3 $592.90
25800 FUSION OF WRIST JOINT 3 $696.81
25805 FUSION/GRAFT OF WRIST JOINT 3 $804.83
25810 FUSION/GRAFT OF WRIST JOINT 3 $818.75
25820 FUSION OF HAND BONES 3 $573.73
25825 FUSE HAND BONES WITH GRAFT 3 $708.31
25830 FUSION, RADIOULNAR JNT/ULNA 3 $891.65
25900 AMPUTATION OF FOREARM 3 $699.14
25905 AMPUTATION OF FOREARM 3 $688.68
25907 AMPUTATION FOLLOW-UP SURGERY 3 $603.54
25909 AMPUTATION FOLLOW-UP SURGERY 3 $674.82
25915 AMPUTATION OF FOREARM 3 $1,112.06
25920 AMPUTATE HAND AT WRIST 3 $646.99
25922 AMPUTATE HAND AT WRIST 3 $513.93
25924 AMPUTATION FOLLOW-UP SURGERY 3 $631.30
25927 AMPUTATION OF HAND 3 $740.51

25929 AMPUTATION FOLLOW-UP SURGERY 3 $535.62
25931 AMPUTATION FOLLOW-UP SURGERY 3 $662.64
25999 FOREARM OR WRIST SURGERY 5 $0.00
26010 DRAINAGE OF FINGER ABSCESS 3 $234.59
26011 DRAINAGE OF FINGER ABSCESS 3 $354.28
26020 DRAIN HAND TENDON SHEATH 3 $399.17
26025 DRAINAGE OF PALM BURSA 3 $388.34
26030 DRAINAGE OF PALM BURSA(S) 3 $457.80
26034 TREAT HAND BONE LESION 3 $497.10
26035 DECOMPRESS FINGERS/HAND 3 $784.77
26037 DECOMPRESS FINGERS/HAND 3 $533.09
26040 RELEASE PALM CONTRACTURE 3 $284.61
26045 RELEASE PALM CONTRACTURE 3 $432.66
26055 INCISE FINGER TENDON SHEATH 3 $517.89
26060 INCISION OF FINGER TENDON 3 $244.25
26070 EXPLORE/TREAT HAND JOINT 3 $280.22
26075 EXPLORE/TREAT FINGER JOINT 3 $295.83
26080 EXPLORE/TREAT FINGER JOINT 3 $356.05
26100 BIOPSY HAND JOINT LINING 3 $301.37
26105 BIOPSY FINGER JOINT LINING 3 $306.48
26110 BIOPSY FINGER JOINT LINING 3 $294.16
26111 EXC HAND LES SC > 1.5 CM 3 $405.26
26113 EXC HAND TUM DEEP > 1.5 CM 3 $532.87
26115 EXC HAND LES SC < 1.5 CM 3 $538.78
26116 EXC HAND TUM DEEP < 1.5 CM 3 $488.53
26117 EXC HAND TUM RA < 3 CM 3 $673.65
26118 EXC HAND TUM RA > 3 CM 3 $1,041.50
26121 RELEASE PALM CONTRACTURE 3 $557.47
26123 RELEASE PALM CONTRACTURE 3 $772.96
26125 RELEASE PALM CONTRACTURE 3 $267.04
26130 REMOVE WRIST JOINT LINING 3 $423.28
26135 REVISE FINGER JOINT, EACH 3 $513.45
26140 REVISE FINGER JOINT, EACH 3 $469.16
26145 TENDON EXCISION, PALM/FINGER 3 $476.13
26160 REMOVE TENDON SHEATH LESION 3 $522.05
26170 REMOVAL OF PALM TENDON, EACH 3 $375.86
26180 REMOVAL OF FINGER TENDON 3 $410.43
26185 REMOVE FINGER BONE 3 $500.86
26200 REMOVE HAND BONE LESION 3 $418.93
26205 REMOVE/GRAFT BONE LESION 3 $563.57
26210 REMOVAL OF FINGER LESION 3 $408.43
26215 REMOVE/GRAFT FINGER LESION 3 $521.75
26230 PARTIAL REMOVAL OF HAND BONE 3 $466.48
26235 PARTIAL REMOVAL, FINGER BONE 3 $460.50
26236 PARTIAL REMOVAL, FINGER BONE 3 $409.50
26250 EXTENSIVE HAND SURGERY 3 $892.92
26255 EXTENSIVE HAND SURGERY O $0.00
26260 RESECT PROX FINGER TUMOR 3 $694.73
26261 EXTENSIVE FINGER SURGERY O $0.00

26262 RESECT DISTAL FINGER TUMOR 3 $544.06
26320 REMOVAL OF IMPLANT FROM HAND 3 $319.76
26340 MANIPULATE FINGER W/ANESTH 3 $296.81
26350 REPAIR FINGER/HAND TENDON 3 $661.47
26352 REPAIR/GRAFT HAND TENDON 3 $753.89
26356 REPAIR FINGER/HAND TENDON 3 $1,003.85
26357 REPAIR FINGER/HAND TENDON 3 $806.34
26358 REPAIR/GRAFT HAND TENDON 3 $853.79
26370 REPAIR FINGER/HAND TENDON 3 $712.66
26372 REPAIR/GRAFT HAND TENDON 3 $826.54
26373 REPAIR FINGER/HAND TENDON 3 $788.57
26390 REVISE HAND/FINGER TENDON 3 $774.57
26392 REPAIR/GRAFT HAND TENDON 3 $903.89
26410 REPAIR HAND TENDON 3 $524.83
26412 REPAIR/GRAFT HAND TENDON 3 $636.67
26415 EXCISION, HAND/FINGER TENDON 3 $665.71
26416 GRAFT HAND OR FINGER TENDON 3 $755.37
26418 REPAIR FINGER TENDON 3 $531.03
26420 REPAIR/GRAFT FINGER TENDON 3 $663.82
26426 REPAIR FINGER/HAND TENDON 3 $519.08
26428 REPAIR/GRAFT FINGER TENDON 3 $698.98
26432 REPAIR FINGER TENDON 3 $460.40
26433 REPAIR FINGER TENDON 3 $492.55
26434 REPAIR/GRAFT FINGER TENDON 3 $594.58
26437 REALIGNMENT OF TENDONS 3 $576.12
26440 RELEASE PALM/FINGER TENDON 3 $578.12
26442 RELEASE PALM & FINGER TENDON 3 $889.51
26445 RELEASE HAND/FINGER TENDON 3 $537.50
26449 RELEASE FOREARM/HAND TENDON 3 $699.71
26450 INCISION OF PALM TENDON 3 $373.34
26455 INCISION OF FINGER TENDON 3 $370.98
26460 INCISE HAND/FINGER TENDON 3 $360.53
26471 FUSION OF FINGER TENDONS 3 $568.67
26474 FUSION OF FINGER TENDONS 3 $549.52
26476 TENDON LENGTHENING 3 $536.22
26477 TENDON SHORTENING 3 $537.41
26478 LENGTHENING OF HAND TENDON 3 $580.15
26479 SHORTENING OF HAND TENDON 3 $576.41
26480 TRANSPLANT HAND TENDON 3 $699.48
26483 TRANSPLANT/GRAFT HAND TENDON 3 $786.25
26485 TRANSPLANT PALM TENDON 3 $754.20
26489 TRANSPLANT/GRAFT PALM TENDON 3 $833.46
26490 REVISE THUMB TENDON 3 $731.99
26492 TENDON TRANSFER WITH GRAFT 3 $817.23
26494 HAND TENDON/MUSCLE TRANSFER 3 $740.61
26496 REVISE THUMB TENDON 3 $799.31
26497 FINGER TENDON TRANSFER 3 $803.85
26498 FINGER TENDON TRANSFER 3 $1,070.04
26499 REVISION OF FINGER 3 $768.62

26500 HAND TENDON RECONSTRUCTION 3 $580.92
26502 HAND TENDON RECONSTRUCTION 3 $655.38
26504 HAND TENDON RECONSTRUCTION O $0.00
26508 RELEASE THUMB CONTRACTURE 3 $580.50
26510 THUMB TENDON TRANSFER 3 $554.09
26516 FUSION OF KNUCKLE JOINT 3 $651.29
26517 FUSION OF KNUCKLE JOINTS 3 $767.36
26518 FUSION OF KNUCKLE JOINTS 3 $776.68
26520 RELEASE KNUCKLE CONTRACTURE 3 $605.90
26525 RELEASE FINGER CONTRACTURE 3 $607.39
26527 ARTHROPLASTY, CARPOMETACARPAL JOINT O $0.00
26530 REVISE KNUCKLE JOINT 3 $499.05
26531 REVISE KNUCKLE WITH IMPLANT 3 $581.30
26535 REVISE FINGER JOINT 3 $378.14
26536 REVISE/IMPLANT FINGER JOINT 3 $631.92
26540 REPAIR HAND JOINT 3 $612.06
26541 REPAIR HAND JOINT WITH GRAFT 3 $747.31
26542 REPAIR HAND JOINT WITH GRAFT 3 $630.98
26545 RECONSTRUCT FINGER JOINT 3 $645.39
26546 REPAIR NONUNION HAND 3 $913.16
26548 RECONSTRUCT FINGER JOINT 3 $709.38
26550 CONSTRUCT THUMB REPLACEMENT 3 $1,442.49
26551 GREAT TOE-HAND TRANSFER 3 $3,035.46
26552 RECONSTRUCTION THUMB WITH TOE O $0.00
26553 SINGLE TRANSFER, TOE-HAND 3 $2,646.66
26554 DOUBLE TRANSFER, TOE-HAND 3 $3,251.13
26555 POSITIONAL CHANGE OF FINGER 3 $1,291.78
26556 TOE JOINT TRANSFER 3 $2,635.69
26557 TOE TO FINGER TRANSFER; FIRST STAGE O $0.00
26558 TOE TO FINGER TRANSFER; EACH DELAY O $0.00
26559 TOE TO FINGER TRANSFER; SECOND STAG O $0.00
26560 REPAIR OF WEB FINGER 3 $530.44
26561 REPAIR OF WEB FINGER 3 $841.37
26562 REPAIR OF WEB FINGER 3 $1,160.23
26565 CORRECT METACARPAL FLAW 3 $630.73
26567 CORRECT FINGER DEFORMITY 3 $633.33
26568 LENGTHEN METACARPAL/FINGER 3 $833.00
26580 REPAIR HAND DEFORMITY 3 $1,346.46
26585 REPAIR FINGER DEFORMITY O $0.00
26587 RECONSTRUCT EXTRA FINGER 3 $910.27
26590 REPAIR FINGER DEFORMITY 3 $1,219.29
26591 REPAIR MUSCLES OF HAND 3 $403.62
26593 RELEASE MUSCLES OF HAND 3 $553.61
26596 EXCISION CONSTRICTING TISSUE 3 $689.28
26597 RELEASE OF SCAR CONTRACTURE O $0.00
26600 TREAT METACARPAL FRACTURE 3 $255.51
26605 TREAT METACARPAL FRACTURE 3 $287.81
26607 TREAT METACARPAL FRACTURE 3 $409.43
26608 TREAT METACARPAL FRACTURE 3 $440.61

26610 TREATMENT OF OPEN METACARPAL FRACTU O $0.00
26615 TREAT METACARPAL FRACTURE 3 $521.20
26641 TREAT THUMB DISLOCATION 3 $333.95
26645 TREAT THUMB FRACTURE 3 $378.66
26650 TREAT THUMB FRACTURE 3 $441.37
26655 TREATMENT OF OPEN CARPOMETACARPAL F O $0.00
26660 TREATMENT OF OPEN CARPOMETACARPAL F O $0.00
26665 TREAT THUMB FRACTURE 3 $577.34
26670 TREAT HAND DISLOCATION 3 $300.47
26675 TREAT HAND DISLOCATION 3 $403.01
26676 PIN HAND DISLOCATION 3 $462.40
26680 TREATMENT OF OPEN CARPOMETACARPAL D O $0.00
26685 TREAT HAND DISLOCATION 3 $528.58
26686 TREAT HAND DISLOCATION 3 $579.88
26700 TREAT KNUCKLE DISLOCATION 3 $287.38
26705 TREAT KNUCKLE DISLOCATION 3 $369.75
26706 PIN KNUCKLE DISLOCATION 3 $402.40
26710 TREATMENT OF OPEN METACARPOPHALANGE O $0.00
26715 TREAT KNUCKLE DISLOCATION 3 $519.99
26720 TREAT FINGER FRACTURE, EACH 3 $174.50
26725 TREAT FINGER FRACTURE, EACH 3 $306.85
26727 TREAT FINGER FRACTURE, EACH 3 $433.61
26730 TREATMENT OF OPEN PHALANGEAL SHAFT O $0.00
26735 TREAT FINGER FRACTURE, EACH 3 $542.26
26740 TREAT FINGER FRACTURE, EACH 3 $202.19
26742 TREAT FINGER FRACTURE, EACH 3 $335.64
26744 TREATMENT OF OPEN ARTICULAR FRACTUR O $0.00
26746 TREAT FINGER FRACTURE, EACH 3 $673.22
26750 TREAT FINGER FRACTURE, EACH 3 $163.11
26755 TREAT FINGER FRACTURE, EACH 3 $283.50
26756 PIN FINGER FRACTURE, EACH 3 $383.73
26760 TREATMENT OF OPEN DISTAL PHALANGEAL O $0.00
26765 TREAT FINGER FRACTURE, EACH 3 $447.24
26770 TREAT FINGER DISLOCATION 3 $245.08
26775 TREAT FINGER DISLOCATION 3 $345.10
26776 PIN FINGER DISLOCATION 3 $406.98
26780 TREATMENT OF OPEN INTERPHALANGEAL J O $0.00
26785 TREAT FINGER DISLOCATION 3 $488.20
26820 THUMB FUSION WITH GRAFT 3 $731.32
26841 FUSION OF THUMB 3 $677.15
26842 THUMB FUSION WITH GRAFT 3 $734.67
26843 FUSION OF HAND JOINT 3 $683.08
26844 FUSION/GRAFT OF HAND JOINT 3 $761.20
26850 FUSION OF KNUCKLE 3 $644.49
26852 FUSION OF KNUCKLE WITH GRAFT 3 $739.65
26860 FUSION OF FINGER JOINT 3 $519.66
26861 FUSION OF FINGER JNT, ADD-ON 3 $100.58
26862 FUSION/GRAFT OF FINGER JOINT 3 $673.52
26863 FUSE/GRAFT ADDED JOINT 3 $225.14

26910 AMPUTATE METACARPAL BONE 3 $664.57
26951 AMPUTATION OF FINGER/THUMB 3 $587.84
26952 AMPUTATION OF FINGER/THUMB 3 $600.99
26989 HAND/FINGER SURGERY 5 $0.00
26990 DRAINAGE OF PELVIS LESION 3 $579.28
26991 DRAINAGE OF PELVIS BURSA 3 $648.79
26992 DRAINAGE OF BONE LESION 3 $904.85
27000 INCISION OF HIP TENDON 3 $414.27
27001 INCISION OF HIP TENDON 3 $505.68
27003 INCISION OF HIP TENDON 3 $550.75
27005 INCISION OF HIP TENDON 3 $684.25
27006 INCISION OF HIP TENDONS 3 $692.27
27010 GLUTEAL-ILIOTIBIAL FASCIOTOMY (OBER O $0.00
27015 ILIAC CREST FASCIOTOMY (SOUTTER OR O $0.00
27025 INCISION OF HIP/THIGH FASCIA 3 $852.48
27027 BUTTOCK FASCIOTOMY 3 $797.83
27030 DRAINAGE OF HIP JOINT 3 $891.04
27033 EXPLORATION OF HIP JOINT 3 $923.41
27035 DENERVATION OF HIP JOINT 3 $1,065.98
27036 EXCISION OF HIP JOINT/MUSCLE 3 $950.14
27040 BIOPSY OF SOFT TISSUES 3 $318.23
27041 BIOPSY OF SOFT TISSUES 3 $646.40
27043 EXC HIP PELVIS LES SC > 3 CM 3 $458.26
27045 EXC HIP/PELV TUM DEEP > 5 CM 3 $728.12
27047 EXC HIP/PELVIS LES SC < 3 CM 3 $464.57
27048 EXC HIP/PELV TUM DEEP < 5 CM 3 $552.83
27049 RESECT HIP/PELV TUM < 5 CM 3 $1,225.78
27050 BIOPSY OF SACROILIAC JOINT 3 $341.78
27052 BIOPSY OF HIP JOINT 3 $529.23
27054 REMOVAL OF HIP JOINT LINING 3 $640.44
27057 BUTTOCK FASCIOTOMY W/DBRDMT 3 $902.86
27059 RESECT HIP/PELV TUM > 5 CM 3 $1,780.75
27060 REMOVAL OF ISCHIAL BURSA 3 $404.09
27062 REMOVE FEMUR LESION/BURSA 3 $422.04
27065 REMOVAL OF HIP BONE LESION 3 $472.10
27066 REMOVAL OF HIP BONE LESION 3 $762.20
27067 REMOVE/GRAFT HIP BONE LESION 3 $976.86
27070 PARTIAL REMOVAL OF HIP BONE 3 $800.77
27071 PARTIAL REMOVAL OF HIP BONE 3 $857.09
27075 RESECT HIP TUMOR 3 $2,007.49
27076 RESECT HIP TUM INCL ACETABUL 3 $2,221.12
27077 RESECT HIP TUM W/INNOM BONE 3 $2,662.20
27078 RSECT HIP TUM INCL FEMUR 3 $1,752.02
27079 EXTENSIVE HIP SURGERY O $0.00
27080 REMOVAL OF TAIL BONE 3 $470.71
27086 REMOVE HIP FOREIGN BODY 3 $227.35
27087 REMOVE HIP FOREIGN BODY 3 $595.87
27090 REMOVAL OF HIP PROSTHESIS 3 $783.46
27091 REMOVAL OF HIP PROSTHESIS 3 $1,520.72

27093 INJECTION FOR HIP X-RAY 3 $182.23
27095 INJECTION FOR HIP X-RAY 3 $221.27
27096 INJECT SACROILIAC JOINT 3 $172.41
27097 REVISION OF HIP TENDON 3 $628.90
27098 TRANSFER TENDON TO PELVIS 3 $592.79
27100 TRANSFER OF ABDOMINAL MUSCLE 3 $773.47
27105 TRANSFER OF SPINAL MUSCLE 3 $814.48
27110 TRANSFER OF ILIOPSOAS MUSCLE 3 $906.23
27111 TRANSFER OF ILIOPSOAS MUSCLE 3 $816.87
27120 RECONSTRUCTION OF HIP SOCKET 3 $1,224.43
27122 RECONSTRUCTION OF HIP SOCKET 3 $1,045.69
27125 PARTIAL HIP REPLACEMENT 3 $1,071.77
27126 PARTIAL HIP REPLACEMENT (HEMIARTHRO O $0.00
27127 PARTIAL HIP REPLACEMENT (HEMIARTHRO O $0.00
27130 TOTAL HIP ARTHROPLASTY 3 $1,374.05
27132 TOTAL HIP ARTHROPLASTY 3 $1,605.71
27134 REVISE HIP JOINT REPLACEMENT 3 $1,851.17
27137 REVISE HIP JOINT REPLACEMENT 3 $1,414.63
27138 REVISE HIP JOINT REPLACEMENT 3 $1,472.22
27140 TRANSPLANT FEMUR RIDGE 3 $848.61
27146 INCISION OF HIP BONE 3 $1,205.72
27147 REVISION OF HIP BONE 3 $1,395.46
27151 INCISION OF HIP BONES 3 $1,466.61
27156 REVISION OF HIP BONES 3 $1,627.91
27157 ACETABULAR AUGMENTATION (WILSON PRO O $0.00
27158 REVISION OF PELVIS 3 $1,317.37
27161 INCISION OF NECK OF FEMUR 3 $1,155.62
27165 INCISION/FIXATION OF FEMUR 3 $1,301.76
27170 REPAIR/GRAFT FEMUR HEAD/NECK 3 $1,121.22
27175 TREAT SLIPPED EPIPHYSIS 3 $626.22
27176 TREAT SLIPPED EPIPHYSIS 3 $861.65
27177 TREAT SLIPPED EPIPHYSIS 3 $1,051.98
27178 TREAT SLIPPED EPIPHYSIS 3 $857.11
27179 REVISE HEAD/NECK OF FEMUR 3 $920.06
27181 TREAT SLIPPED EPIPHYSIS 3 $1,054.24
27185 REVISION OF FEMUR EPIPHYSIS 3 $596.94
27187 REINFORCE HIP BONES 3 $940.37
27190 TREATMENT OF CLOSED SACRAL FRACTURE O $0.00
27192 OPEN TREATMENT OF CLOSED OR OPEN SA O $0.00
27193 TREAT PELVIC RING FRACTURE 3 $436.43
27194 TREAT PELVIC RING FRACTURE 3 $662.95
27195 TREATMENT OF SACROILIAC AND/OR SYMP O $0.00
27196 TREATMENT OF SACROILIAC AND/OR SYMP O $0.00
27200 TREAT TAIL BONE FRACTURE 3 $160.80
27201 TREATMENT OF OPEN COCCYGEAL FRACTUR O $0.00
27202 TREAT TAIL BONE FRACTURE 3 $578.27
27210 TREATMENT OF CLOSED ILIAC, PUBIC OR O $0.00
27212 TREATMENT OF OPEN ILIAC, PUBIC OR I O $0.00
27214 OPEN TREATMENT OF CLOSED OR OPEN IL O $0.00

27215 TREAT PELVIC FRACTURE(S) 3 $640.68
27216 TREAT PELVIC RING FRACTURE 3 $945.39
27217 TREAT PELVIC RING FRACTURE 3 $894.63
27218 TREAT PELVIC RING FRACTURE 3 $1,222.10
27220 TREAT HIP SOCKET FRACTURE 3 $491.63
27222 TREAT HIP SOCKET FRACTURE 3 $924.67
27224 OPEN TREATMENT OF CLOSED OR OPEN AC O $0.00
27225 OPEN TREATMENT OF CLOSED OR OPEN AC O $0.00
27226 TREAT HIP WALL FRACTURE 3 $987.80
27227 TREAT HIP FRACTURE(S) 3 $1,588.83
27228 TREAT HIP FRACTURE(S) 3 $1,817.06
27230 TREAT THIGH FRACTURE 3 $438.45
27232 TREAT THIGH FRACTURE 3 $728.64
27234 TREATMENT OF OPEN FEMORAL FRACTURE, O $0.00
27235 TREAT THIGH FRACTURE 3 $860.79
27236 TREAT THIGH FRACTURE 3 $1,132.56
27238 TREAT THIGH FRACTURE 3 $424.30
27240 TREAT THIGH FRACTURE 3 $904.17
27242 TREATMENT OF OPEN INTERTROCHANTERIC O $0.00
27244 TREAT THIGH FRACTURE 3 $1,164.93
27245 TREAT THIGH FRACTURE 3 $1,183.07
27246 TREAT THIGH FRACTURE 3 $356.40
27248 TREAT THIGH FRACTURE 3 $709.85
27250 TREAT HIP DISLOCATION 3 $209.01
27252 TREAT HIP DISLOCATION 3 $715.08
27253 TREAT HIP DISLOCATION 3 $893.39
27254 TREAT HIP DISLOCATION 3 $1,204.32
27255 OPEN TREATMENT OF CLOSED OR OPEN HI O $0.00
27256 TREAT HIP DISLOCATION 3 $275.67
27257 TREAT HIP DISLOCATION 3 $317.76
27258 TREAT HIP DISLOCATION 3 $1,049.34
27259 TREAT HIP DISLOCATION 3 $1,472.58
27265 TREAT HIP DISLOCATION 3 $368.73
27266 TREAT HIP DISLOCATION 3 $542.99
27267 CLTX THIGH FX 3 $395.54
27268 CLTX THIGH FX W/MNPJ 3 $486.82
27269 OPTX THIGH FX 3 $1,159.29
27275 MANIPULATION OF HIP JOINT 3 $166.70
27280 FUSION OF SACROILIAC JOINT 3 $971.99
27282 FUSION OF PUBIC BONES 3 $773.54
27284 FUSION OF HIP JOINT 3 $1,491.53
27286 FUSION OF HIP JOINT 3 $1,580.08
27290 AMPUTATION OF LEG AT HIP 3 $1,511.00
27295 AMPUTATION OF LEG AT HIP 3 $1,205.91
27299 PELVIS/HIP JOINT SURGERY 5 $0.00
27301 DRAIN THIGH/KNEE LESION 3 $615.26
27303 DRAINAGE OF BONE LESION 3 $599.28
27305 INCISE THIGH TENDON & FASCIA 3 $440.22
27306 INCISION OF THIGH TENDON 3 $355.76

27307 INCISION OF THIGH TENDONS 3 $437.98
27310 EXPLORATION OF KNEE JOINT 3 $684.47
27315 PARTIAL REMOVAL, THIGH NERVE O $0.00
27320 PARTIAL REMOVAL, THIGH NERVE O $0.00
27323 BIOPSY, THIGH SOFT TISSUES 3 $249.71
27324 BIOPSY, THIGH SOFT TISSUES 3 $360.98
27325 NEURECTOMY, HAMSTRING 3 $502.07
27326 NEURECTOMY, POPLITEAL 3 $461.75
27327 EXC THIGH/KNEE LES SC < 3 CM 3 $401.03
27328 EXC THIGH/KNEE TUM DEEP 3 CM 3 $409.69
27339 EXC THIGH/KNEE TUM DEEP >5CM 3 $736.06
27340 REMOVAL OF KNEECAP BURSA 3 $340.45
27345 REMOVAL OF KNEE CYST 3 $449.29
27347 REMOVE KNEE CYST 3 $486.97
27350 REMOVAL OF KNEECAP 3 $610.21
27355 REMOVE FEMUR LESION 3 $564.85
27356 REMOVE FEMUR LESION/GRAFT 3 $692.16
27357 REMOVE FEMUR LESION/GRAFT 3 $764.15
27358 REMOVE FEMUR LESION/FIXATION 3 $273.13
27360 PARTIAL REMOVAL, LEG BONE(S) 3 $799.51
27364 RESECT THIGH/KNEE TUM >5 CM 3 $1,534.83
27365 RESECT FEMUR/KNEE TUMOR 3 $1,799.14
27370 INJECTION FOR KNEE X-RAY 3 $158.60
27372 REMOVAL OF FOREIGN BODY 3 $553.29
27380 REPAIR OF KNEECAP TENDON 3 $553.77
27381 REPAIR/GRAFT KNEECAP TENDON 3 $752.22
27385 REPAIR OF THIGH MUSCLE 3 $592.17
27386 REPAIR/GRAFT OF THIGH MUSCLE 3 $781.32
27390 INCISION OF THIGH TENDON 3 $412.13
27391 INCISION OF THIGH TENDONS 3 $536.20
27392 INCISION OF THIGH TENDONS 3 $660.66
27393 LENGTHENING OF THIGH TENDON 3 $474.18
27394 LENGTHENING OF THIGH TENDONS 3 $611.79
27395 LENGTHENING OF THIGH TENDONS 3 $826.92
27396 TRANSPLANT OF THIGH TENDON 3 $575.74
27397 TRANSPLANTS OF THIGH TENDONS 3 $856.34
27400 REVISE THIGH MUSCLES/TENDONS 3 $647.58
27403 REPAIR OF KNEE CARTILAGE 3 $601.69
27405 REPAIR OF KNEE LIGAMENT 3 $635.07
27407 REPAIR OF KNEE LIGAMENT 3 $729.29
27409 REPAIR OF KNEE LIGAMENTS 3 $909.83

27412 AUTOCHONDROCYTE IMPLANT KNEE 3 $1,567.06
27415 OSTEOCHONDRAL KNEE ALLOGRAFT 3 $1,293.96
27416 OSTEOCHONDRAL KNEE AUTOGRAFT 3 $915.64
27418 REPAIR DEGENERATED KNEECAP 3 $785.35
27420 REVISION OF UNSTABLE KNEECAP 3 $702.64
27422 REVISION OF UNSTABLE KNEECAP 3 $700.19
27424 REVISION/REMOVAL OF KNEECAP 3 $701.91
27425 LAT RETINACULAR RELEASE OPEN 3 $412.95
27427 RECONSTRUCTION, KNEE 3 $675.31
27428 RECONSTRUCTION, KNEE 3 $1,046.62
27429 RECONSTRUCTION, KNEE 3 $1,174.98
27430 REVISION OF THIGH MUSCLES 3 $696.09
27435 INCISION OF KNEE JOINT 3 $754.83
27437 REVISE KNEECAP 3 $619.27
27438 REVISE KNEECAP WITH IMPLANT 3 $793.02
27440 REVISION OF KNEE JOINT 3 $730.48
27441 REVISION OF KNEE JOINT 3 $754.43
27442 REVISION OF KNEE JOINT 3 $820.20
27443 REVISION OF KNEE JOINT 3 $768.34
27445 REVISION OF KNEE JOINT 3 $1,194.74
27446 REVISION OF KNEE JOINT 3 $1,055.62
27447 TOTAL KNEE ARTHROPLASTY 3 $1,469.57
27448 INCISION OF THIGH 3 $772.99
27450 INCISION OF THIGH 3 $963.91
27454 REALIGNMENT OF THIGH BONE 3 $1,220.88
27455 REALIGNMENT OF KNEE 3 $889.53
27457 REALIGNMENT OF KNEE 3 $914.57
27465 SHORTENING OF THIGH BONE 3 $1,174.16
27466 LENGTHENING OF THIGH BONE 3 $1,123.30
27468 SHORTEN/LENGTHEN THIGHS 3 $1,269.06
27470 REPAIR OF THIGH 3 $1,119.21
27472 REPAIR/GRAFT OF THIGH 3 $1,206.75
27475 SURGERY TO STOP LEG GROWTH 3 $619.64
27477 SURGERY TO STOP LEG GROWTH 3 $688.19
27479 SURGERY TO STOP LEG GROWTH 3 $814.56
27485 SURGERY TO STOP LEG GROWTH 3 $629.95
27486 REVISE/REPLACE KNEE JOINT 3 $1,343.34
27487 REVISE/REPLACE KNEE JOINT 3 $1,688.94
27488 REMOVAL OF KNEE PROSTHESIS 3 $1,140.50
27495 REINFORCE THIGH 3 $1,073.67
27496 DECOMPRESSION OF THIGH/KNEE 3 $482.61
27497 DECOMPRESSION OF THIGH/KNEE 3 $521.30
27498 DECOMPRESSION OF THIGH/KNEE 3 $573.92
27499 DECOMPRESSION OF THIGH/KNEE 3 $628.67
27500 TREATMENT OF THIGH FRACTURE 3 $477.10
27501 TREATMENT OF THIGH FRACTURE 3 $468.58
27502 TREATMENT OF THIGH FRACTURE 3 $742.10
27503 TREATMENT OF THIGH FRACTURE 3 $756.07
27504 TREATMENT OF OPEN FEMORAL SHAFT FRA O $0.00

27506 TREATMENT OF THIGH FRACTURE 3 $1,268.62
27507 TREATMENT OF THIGH FRACTURE 3 $930.08
27508 TREATMENT OF THIGH FRACTURE 3 $483.17
27509 TREATMENT OF THIGH FRACTURE 3 $603.10
27510 TREATMENT OF THIGH FRACTURE 3 $656.41
27511 TREATMENT OF THIGH FRACTURE 3 $965.12
27512 TREATMENT OF OPEN FEMORAL FRACTURE, O $0.00
27513 TREATMENT OF THIGH FRACTURE 3 $1,208.17
27514 TREATMENT OF THIGH FRACTURE 3 $952.84
27516 TREAT THIGH FX GROWTH PLATE 3 $457.65
27517 TREAT THIGH FX GROWTH PLATE 3 $639.56
27518 TREATMENT OF OPEN DISTAL FEMORAL EP O $0.00
27519 TREAT THIGH FX GROWTH PLATE 3 $868.26
27520 TREAT KNEECAP FRACTURE 3 $289.04
27522 TREATMENT OF OPEN PATELLAR FRACTURE O $0.00
27524 TREAT KNEECAP FRACTURE 3 $709.42
27530 TREAT KNEE FRACTURE 3 $360.69
27532 TREAT KNEE FRACTURE 3 $569.38
27534 TREATMENT OF OPEN TIBIAL FRACTURE, O $0.00
27535 TREAT KNEE FRACTURE 3 $864.90
27536 TREAT KNEE FRACTURE 3 $1,129.08
27537 OPEN TREATMENT OF CLOSED OR OPEN TI O $0.00
27538 TREAT KNEE FRACTURE(S) 3 $429.87
27540 TREAT KNEE FRACTURE 3 $773.66
27550 TREAT KNEE DISLOCATION 3 $456.41
27552 TREAT KNEE DISLOCATION 3 $582.88
27554 TREATMENT OF OPEN KNEE DISLOCATION, O $0.00
27556 TREAT KNEE DISLOCATION 3 $854.23
27557 TREAT KNEE DISLOCATION 3 $1,022.63
27558 TREAT KNEE DISLOCATION 3 $1,157.32
27560 TREAT KNEECAP DISLOCATION 3 $340.54
27562 TREAT KNEECAP DISLOCATION 3 $436.33
27564 TREATMENT OF OPEN PATELLAR DISLOCAT O $0.00
27566 TREAT KNEECAP DISLOCATION 3 $843.93
27570 FIXATION OF KNEE JOINT 3 $138.43
27580 FUSION OF KNEE 3 $1,370.58
27590 AMPUTATE LEG AT THIGH 3 $797.38
27591 AMPUTATE LEG AT THIGH 3 $873.15
27592 AMPUTATE LEG AT THIGH 3 $674.59
27594 AMPUTATION FOLLOW-UP SURGERY 3 $490.05
27596 AMPUTATION FOLLOW-UP SURGERY 3 $706.55
27598 AMPUTATE LOWER LEG AT KNEE 3 $715.63
27599 LEG SURGERY PROCEDURE 5 $0.00
27600 DECOMPRESSION OF LOWER LEG 3 $403.72
27601 DECOMPRESSION OF LOWER LEG 3 $422.60
27602 DECOMPRESSION OF LOWER LEG 3 $496.59
27603 DRAIN LOWER LEG LESION 3 $491.92
27604 DRAIN LOWER LEG BURSA 3 $430.36
27605 INCISION OF ACHILLES TENDON 3 $332.79

27606 INCISION OF ACHILLES TENDON 3 $277.19
27607 TREAT LOWER LEG BONE LESION 3 $580.70
27610 EXPLORE/TREAT ANKLE JOINT 3 $618.46
27612 EXPLORATION OF ANKLE JOINT 3 $536.29
27613 BIOPSY LOWER LEG SOFT TISSUE 3 $233.77
27614 BIOPSY LOWER LEG SOFT TISSUE 3 $527.98
27615 RESECT LEG/ANKLE TUM < 5 CM 3 $958.22
27616 RESECT LEG/ANKLE TUM > 5 CM 3 $1,253.88
27618 EXC LEG/ANKLE TUM < 3 CM 3 $407.37
27619 EXC LEG/ANKLE TUM DEEP 3 CM 3 $405.20
27634 EXC LEG/ANKLE TUM DEEP >5 CM 3 $659.82
27635 REMOVE LOWER LEG BONE LESION 3 $559.57
27637 REMOVE/GRAFT LEG BONE LESION 3 $713.03
27638 REMOVE/GRAFT LEG BONE LESION 3 $737.92
27640 PARTIAL REMOVAL OF TIBIA 3 $813.05
27641 PARTIAL REMOVAL OF FIBULA 3 $651.94
27645 RESECT TIBIA TUMOR 3 $1,544.92
27646 RESECT FIBULA TUMOR 3 $1,330.14
27647 RESECT TALUS/CALCANEUS TUM 3 $1,047.67
27648 INJECTION FOR ANKLE X-RAY 3 $153.31
27650 REPAIR ACHILLES TENDON 3 $635.80
27652 REPAIR/GRAFT ACHILLES TENDON 3 $686.36
27654 REPAIR OF ACHILLES TENDON 3 $681.38
27656 REPAIR LEG FASCIA DEFECT 3 $522.61
27658 REPAIR OF LEG TENDON, EACH 3 $360.89
27659 REPAIR OF LEG TENDON, EACH 3 $468.15
27664 REPAIR OF LEG TENDON, EACH 3 $344.27
27665 REPAIR OF LEG TENDON, EACH 3 $395.18
27675 REPAIR LOWER LEG TENDONS 3 $477.77
27676 REPAIR LOWER LEG TENDONS 3 $589.20
27680 RELEASE OF LOWER LEG TENDON 3 $408.96
27681 RELEASE OF LOWER LEG TENDONS 3 $496.48
27685 REVISION OF LOWER LEG TENDON 3 $594.58
27686 REVISE LOWER LEG TENDONS 3 $529.42
27687 REVISION OF CALF TENDON 3 $437.27
27690 REVISE LOWER LEG TENDON 3 $605.59
27691 REVISE LOWER LEG TENDON 3 $713.53
27692 REVISE ADDITIONAL LEG TENDON 3 $105.44
27695 REPAIR OF ANKLE LIGAMENT 3 $465.96
27696 REPAIR OF ANKLE LIGAMENTS 3 $547.08
27698 REPAIR OF ANKLE LIGAMENT 3 $621.32
27700 REVISION OF ANKLE JOINT 3 $584.62
27702 RECONSTRUCT ANKLE JOINT 3 $940.08
27703 RECONSTRUCTION, ANKLE JOINT 3 $1,091.22

27704 REMOVAL OF ANKLE IMPLANT 3 $538.73
27705 INCISION OF TIBIA 3 $724.81
27707 INCISION OF FIBULA 3 $374.50
27709 INCISION OF TIBIA & FIBULA 3 $1,093.58
27712 REALIGNMENT OF LOWER LEG 3 $1,042.70
27715 REVISION OF LOWER LEG 3 $1,012.84
27720 REPAIR OF TIBIA 3 $831.82
27722 REPAIR/GRAFT OF TIBIA 3 $832.44
27724 REPAIR/GRAFT OF TIBIA 3 $1,216.42
27725 REPAIR OF LOWER LEG 3 $1,146.31
27726 REPAIR FIBULA NONUNION 3 $897.03
27727 REPAIR OF LOWER LEG 3 $936.76
27730 REPAIR OF TIBIA EPIPHYSIS 3 $545.73
27732 REPAIR OF FIBULA EPIPHYSIS 3 $390.42
27734 REPAIR LOWER LEG EPIPHYSES 3 $539.10
27740 REPAIR OF LEG EPIPHYSES 3 $636.11
27742 REPAIR OF LEG EPIPHYSES 3 $676.81
27745 REINFORCE TIBIA 3 $714.05
27750 TREATMENT OF TIBIA FRACTURE 3 $310.77
27752 TREATMENT OF TIBIA FRACTURE 3 $495.42
27754 TREATMENT OF OPEN TIBIAL SHAFT FRAC O $0.00
27756 TREATMENT OF TIBIA FRACTURE 3 $536.51
27758 TREATMENT OF TIBIA FRACTURE 3 $840.52
27759 TREATMENT OF TIBIA FRACTURE 3 $949.15
27760 CLTX MEDIAL ANKLE FX 3 $300.92
27762 CLTX MED ANKLE FX W/MNPJ 3 $444.00
27764 TREATMENT OF OPEN DISTAL TIBIAL FRA O $0.00
27766 OPTX MEDIAL ANKLE FX 3 $572.08
27767 CLTX POST ANKLE FX 3 $246.12
27768 CLTX POST ANKLE FX W/MNPJ 3 $387.21
27769 OPTX POST ANKLE FX 3 $667.02
27780 TREATMENT OF FIBULA FRACTURE 3 $270.56
27781 TREATMENT OF FIBULA FRACTURE 3 $386.72
27782 TREATMENT OF OPEN PROXIMAL FIBULA O O $0.00
27784 TREATMENT OF FIBULA FRACTURE 3 $664.14
27786 TREATMENT OF ANKLE FRACTURE 3 $284.93
27788 TREATMENT OF ANKLE FRACTURE 3 $388.05
27790 TREATMENT OF OPEN DISTAL FIBULAR FR O $0.00
27792 TREATMENT OF ANKLE FRACTURE 3 $666.75
27800 TREATMENT OF CLOSED TIBIA AND FIBUL O $0.00
27802 TREATMENT OF CLOSED TIBIA AND FIBUL O $0.00
27804 TREATMENT OF OPEN TIBIA AND FIBULA O $0.00
27806 OPEN TREATMENT OF CLOSED OR OPEN TI O $0.00
27808 TREATMENT OF ANKLE FRACTURE 3 $298.76
27810 TREATMENT OF ANKLE FRACTURE 3 $434.74
27812 TREATMENT OF OPEN BIMALLEOLAR ANKLE O $0.00
27814 TREATMENT OF ANKLE FRACTURE 3 $730.89
27816 TREATMENT OF ANKLE FRACTURE 3 $283.35
27818 TREATMENT OF ANKLE FRACTURE 3 $447.85

27820 TREATMENT OF OPEN TRIMALLEOLAR ANKL O $0.00
27822 TREATMENT OF ANKLE FRACTURE 3 $801.14
27823 TREATMENT OF ANKLE FRACTURE 3 $910.99
27824 TREAT LOWER LEG FRACTURE 3 $283.90
27825 TREAT LOWER LEG FRACTURE 3 $508.21
27826 TREAT LOWER LEG FRACTURE 3 $782.65
27827 TREAT LOWER LEG FRACTURE 3 $1,027.93
27828 TREAT LOWER LEG FRACTURE 3 $1,232.38
27829 TREAT LOWER LEG JOINT 3 $634.22
27830 TREAT LOWER LEG DISLOCATION 3 $333.40
27831 TREAT LOWER LEG DISLOCATION 3 $358.55
27832 TREAT LOWER LEG DISLOCATION 3 $687.01
27840 TREAT ANKLE DISLOCATION 3 $333.22
27842 TREAT ANKLE DISLOCATION 3 $456.62
27844 TREATMENT OF OPEN ANKLE DISLOCATION O $0.00
27846 TREAT ANKLE DISLOCATION 3 $697.10
27848 TREAT ANKLE DISLOCATION 3 $786.90
27860 FIXATION OF ANKLE JOINT 3 $166.99
27870 FUSION OF ANKLE JOINT, OPEN 3 $996.71
27871 FUSION OF TIBIOFIBULAR JOINT 3 $655.87
27880 AMPUTATION OF LOWER LEG 3 $900.99
27881 AMPUTATION OF LOWER LEG 3 $855.16
27882 AMPUTATION OF LOWER LEG 3 $606.90
27884 AMPUTATION FOLLOW-UP SURGERY 3 $564.50
27886 AMPUTATION FOLLOW-UP SURGERY 3 $644.54
27888 AMPUTATION OF FOOT AT ANKLE 3 $672.17
27889 AMPUTATION OF FOOT AT ANKLE 3 $661.98
27892 DECOMPRESSION OF LEG 3 $524.71
27893 DECOMPRESSION OF LEG 3 $528.52
27894 DECOMPRESSION OF LEG 3 $818.56
27899 LEG/ANKLE SURGERY PROCEDURE 5 $0.00
28001 DRAINAGE OF BURSA OF FOOT 3 $251.25
28002 TREATMENT OF FOOT INFECTION 3 $475.84
28003 TREATMENT OF FOOT INFECTION 3 $641.14
28005 TREAT FOOT BONE LESION 3 $583.61
28008 INCISION OF FOOT FASCIA 3 $396.91
28010 INCISION OF TOE TENDON 3 $219.62
28011 INCISION OF TOE TENDONS 3 $310.70
28020 EXPLORATION OF FOOT JOINT 3 $476.45
28022 EXPLORATION OF FOOT JOINT 3 $437.41
28024 EXPLORATION OF TOE JOINT 3 $414.63
28030 REMOVAL OF FOOT NERVE O $0.00
28035 DECOMPRESSION OF TIBIA NERVE 3 $479.13
28039 EXC FOOT/TOE TUM SC > 1.5 CM 3 $472.77
28041 EXC FOOT/TOE TUM DEEP >1.5CM 3 $441.16
28043 EXC FOOT/TOE TUM SC < 1.5 CM 3 $340.38
28045 EXC FOOT/TOE TUM DEEP 3 CM 3 $928.74

28050 BIOPSY OF FOOT JOINT LINING 3 $413.92
28052 BIOPSY OF FOOT JOINT LINING 3 $394.14
28054 BIOPSY OF TOE JOINT LINING 3 $357.19
28055 NEURECTOMY, FOOT 3 $375.42
28060 PARTIAL REMOVAL, FOOT FASCIA 3 $469.39
28062 REMOVAL OF FOOT FASCIA 3 $546.22
28070 REMOVAL OF FOOT JOINT LINING 3 $464.55
28072 REMOVAL OF FOOT JOINT LINING 3 $464.78
28080 REMOVAL OF FOOT LESION 3 $463.18
28086 EXCISE FOOT TENDON SHEATH 3 $494.73
28088 EXCISE FOOT TENDON SHEATH 3 $420.54
28090 REMOVAL OF FOOT LESION 3 $424.26
28092 REMOVAL OF TOE LESIONS 3 $384.45
28100 REMOVAL OF ANKLE/HEEL LESION 3 $544.59
28102 REMOVE/GRAFT FOOT LESION 3 $505.61
28103 REMOVE/GRAFT FOOT LESION 3 $414.51
28104 REMOVAL OF FOOT LESION 3 $466.92
28106 REMOVE/GRAFT FOOT LESION 3 $441.47
28107 REMOVE/GRAFT FOOT LESION 3 $504.95
28108 REMOVAL OF TOE LESIONS 3 $394.52
28110 PART REMOVAL OF METATARSAL 3 $415.14
28111 PART REMOVAL OF METATARSAL 3 $469.18
28112 PART REMOVAL OF METATARSAL 3 $446.07
28113 PART REMOVAL OF METATARSAL 3 $541.03
28114 REMOVAL OF METATARSAL HEADS 3 $983.98
28116 REVISION OF FOOT 3 $692.00
28118 REMOVAL OF HEEL BONE 3 $536.40
28119 REMOVAL OF HEEL SPUR 3 $477.26
28120 PART REMOVAL OF ANKLE/HEEL 3 $643.61
28122 PARTIAL REMOVAL OF FOOT BONE 3 $611.59
28124 PARTIAL REMOVAL OF TOE 3 $436.70
28126 PARTIAL REMOVAL OF TOE 3 $356.06
28130 REMOVAL OF ANKLE BONE 3 $623.66
28140 REMOVAL OF METATARSAL 3 $575.61
28150 REMOVAL OF TOE 3 $395.71
28153 PARTIAL REMOVAL OF TOE 3 $371.10
28160 PARTIAL REMOVAL OF TOE 3 $380.68
28171 RESECT TARSAL TUMOR 3 $833.33
28173 RESECT METATARSAL TUMOR 3 $744.67
28175 RESECT PHALANX OF TOE TUMOR 3 $467.37
28190 REMOVAL OF FOOT FOREIGN BODY 3 $227.92
28192 REMOVAL OF FOOT FOREIGN BODY 3 $432.16
28193 REMOVAL OF FOOT FOREIGN BODY 3 $493.95
28200 REPAIR OF FOOT TENDON 3 $431.47
28202 REPAIR/GRAFT OF FOOT TENDON 3 $565.00
28208 REPAIR OF FOOT TENDON 3 $420.40
28210 REPAIR/GRAFT OF FOOT TENDON 3 $531.68
28220 RELEASE OF FOOT TENDON 3 $410.80
28222 RELEASE OF FOOT TENDONS 3 $471.22

28225 RELEASE OF FOOT TENDON 3 $359.91
28226 RELEASE OF FOOT TENDONS 3 $421.53
28230 INCISION OF FOOT TENDON(S) 3 $394.31
28232 INCISION OF TOE TENDON 3 $352.45
28234 INCISION OF FOOT TENDON 3 $368.53
28236 TRANSFER OF TENDON, ANTERIOR TIBIAL O $0.00
28238 REVISION OF FOOT TENDON 3 $624.87
28240 RELEASE OF BIG TOE 3 $406.23
28250 REVISION OF FOOT FASCIA 3 $518.97
28260 RELEASE OF MIDFOOT JOINT 3 $632.68
28261 REVISION OF FOOT TENDON 3 $899.98
28262 REVISION OF FOOT AND ANKLE 3 $1,283.10
28264 RELEASE OF MIDFOOT JOINT 3 $774.19
28270 RELEASE OF FOOT CONTRACTURE 3 $442.42
28272 RELEASE OF TOE JOINT, EACH 3 $359.38
28280 FUSION OF TOES 3 $480.29
28285 REPAIR OF HAMMERTOE 3 $427.66
28286 REPAIR OF HAMMERTOE 3 $415.05
28288 PARTIAL REMOVAL OF FOOT BONE 3 $544.90
28289 REPAIR HALLUX RIGIDUS 3 $677.40
28290 CORRECTION OF BUNION 3 $527.87
28292 CORRECTION OF BUNION 3 $725.79
28293 CORRECTION OF BUNION 3 $963.07
28294 CORRECTION OF BUNION 3 $688.98
28296 CORRECTION OF BUNION 3 $669.15
28297 CORRECTION OF BUNION 3 $762.32
28298 CORRECTION OF BUNION 3 $660.05
28299 CORRECTION OF BUNION 3 $840.90
28300 INCISION OF HEEL BONE 3 $635.35
28302 INCISION OF ANKLE BONE 3 $648.15
28304 INCISION OF MIDFOOT BONES 3 $733.73
28305 INCISE/GRAFT MIDFOOT BONES 3 $653.85
28306 INCISION OF METATARSAL 3 $556.55
28307 INCISION OF METATARSAL 3 $672.11
28308 INCISION OF METATARSAL 3 $504.53
28309 INCISION OF METATARSALS 3 $859.30
28310 REVISION OF BIG TOE 3 $491.10
28312 REVISION OF TOE 3 $453.30
28313 REPAIR DEFORMITY OF TOE 3 $478.46
28315 REMOVAL OF SESAMOID BONE 3 $434.90
28320 REPAIR OF FOOT BONES 3 $598.25
28322 REPAIR OF METATARSALS 3 $718.42
28340 RESECT ENLARGED TOE TISSUE 3 $557.51
28341 RESECT ENLARGED TOE 3 $642.78
28344 REPAIR EXTRA TOE(S) 3 $425.78
28345 REPAIR WEBBED TOE(S) 3 $512.54
28360 RECONSTRUCT CLEFT FOOT 3 $942.58
28400 TREATMENT OF HEEL FRACTURE 3 $225.57
28405 TREATMENT OF HEEL FRACTURE 3 $359.17

28406 TREATMENT OF HEEL FRACTURE 3 $493.19
28410 TREATMENT OF OPEN CALCANEAL FRACTUR O $0.00
28415 TREAT HEEL FRACTURE 3 $1,077.10
28420 TREAT/GRAFT HEEL FRACTURE 3 $1,155.48
28430 TREATMENT OF ANKLE FRACTURE 3 $211.83
28435 TREATMENT OF ANKLE FRACTURE 3 $304.73
28436 TREATMENT OF ANKLE FRACTURE 3 $404.53
28440 TREATMENT OF OPEN TALUS FRACTURE, W O $0.00
28445 TREAT ANKLE FRACTURE 3 $1,019.21
28446 OSTEOCHONDRAL TALUS AUTOGRFT 3 $1,139.72
28450 TREAT MIDFOOT FRACTURE, EACH 3 $195.59
28455 TREAT MIDFOOT FRACTURE, EACH 3 $270.97
28456 TREAT MIDFOOT FRACTURE 3 $269.88
28460 TREATMENT OF OPEN TARSAL BONE FRACT O $0.00
28465 TREAT MIDFOOT FRACTURE, EACH 3 $584.29
28470 TREAT METATARSAL FRACTURE 3 $193.43
28475 TREAT METATARSAL FRACTURE 3 $240.80
28476 TREAT METATARSAL FRACTURE 3 $318.34
28480 TREATMENT OF OPEN METATARSAL FRACTU O $0.00
28485 TREAT METATARSAL FRACTURE 3 $507.05
28490 TREAT BIG TOE FRACTURE 3 $127.70
28495 TREAT BIG TOE FRACTURE 3 $159.16
28496 TREAT BIG TOE FRACTURE 3 $386.50
28500 TREATMENT OF OPEN FRACTURE GREAT TO O $0.00
28505 TREAT BIG TOE FRACTURE 3 $617.30
28510 TREATMENT OF TOE FRACTURE 3 $109.83
28515 TREATMENT OF TOE FRACTURE 3 $144.09
28520 TREATMENT OF OPEN FRACTURE, PHALANX O $0.00
28525 TREAT TOE FRACTURE 3 $521.57
28530 TREAT SESAMOID BONE FRACTURE 3 $104.50
28531 TREAT SESAMOID BONE FRACTURE 3 $364.89
28540 TREAT FOOT DISLOCATION 3 $185.60
28545 TREAT FOOT DISLOCATION 3 $239.75
28546 TREAT FOOT DISLOCATION 3 $455.61
28550 TREATMENT OF OPEN TARSAL BONE DISLO O $0.00
28555 REPAIR FOOT DISLOCATION 3 $807.43
28570 TREAT FOOT DISLOCATION 3 $156.08
28575 TREAT FOOT DISLOCATION 3 $313.62
28576 TREAT FOOT DISLOCATION 3 $344.11
28580 TREATMENT OF OPEN TALOTARSAL JOINT O $0.00
28585 REPAIR FOOT DISLOCATION 3 $862.62
28600 TREAT FOOT DISLOCATION 3 $195.74
28605 TREAT FOOT DISLOCATION 3 $264.17
28606 TREAT FOOT DISLOCATION 3 $367.83
28610 TREATMENT OF OPEN TARSOMETATARSAL J O $0.00
28615 REPAIR FOOT DISLOCATION 3 $744.04
28630 TREAT TOE DISLOCATION 3 $138.41
28635 TREAT TOE DISLOCATION 3 $161.70
28636 TREAT TOE DISLOCATION 3 $270.45

28640 TREATMENT OF OPEN METATARSOPHALANGE O $0.00
28645 REPAIR TOE DISLOCATION 3 $585.99
28660 TREAT TOE DISLOCATION 3 $102.22
28665 TREAT TOE DISLOCATION 3 $144.80
28666 TREAT TOE DISLOCATION 3 $188.89
28670 TREATMENT OF OPEN INTERPHALANGEAL J O $0.00
28675 REPAIR OF TOE DISLOCATION 3 $536.30
28705 FUSION OF FOOT BONES 3 $1,252.47
28715 FUSION OF FOOT BONES 3 $932.51
28725 FUSION OF FOOT BONES 3 $761.88
28730 FUSION OF FOOT BONES 3 $805.40
28735 FUSION OF FOOT BONES 3 $765.40
28737 REVISION OF FOOT BONES 3 $670.54
28740 FUSION OF FOOT BONES 3 $606.17
28750 FUSION OF BIG TOE JOINT 3 $770.53
28755 FUSION OF BIG TOE JOINT 3 $460.86
28760 FUSION OF BIG TOE JOINT 3 $564.82
28800 AMPUTATION OF MIDFOOT 3 $548.38
28805 AMPUTATION THRU METATARSAL 3 $737.15
28810 AMPUTATION TOE & METATARSAL 3 $428.69
28820 AMPUTATION OF TOE 3 $491.47
28825 PARTIAL AMPUTATION OF TOE 3 $540.16
28890 HIGH ENERGY ESWT, PLANTAR F 3 $319.88
28899 FOOT/TOES SURGERY PROCEDURE 5 $0.00
29000 APPLICATION OF BODY CAST 3 $233.93
29010 APPLICATION OF BODY CAST 3 $207.09
29015 APPLICATION OF BODY CAST 3 $221.26
29020 APPLICATION OF BODY CAST 3 $202.15
29025 APPLICATION OF BODY CAST 3 $243.67
29035 APPLICATION OF BODY CAST 3 $218.95
29040 APPLICATION OF BODY CAST 3 $214.56
29044 APPLICATION OF BODY CAST 3 $237.89
29046 APPLICATION OF BODY CAST 3 $257.26
29049 APPLICATION OF FIGURE EIGHT 3 $81.81
29055 APPLICATION OF SHOULDER CAST 3 $191.97
29058 APPLICATION OF SHOULDER CAST 3 $102.29
29065 APPLICATION OF LONG ARM CAST 3 $86.13
29075 APPLICATION OF FOREARM CAST 3 $80.10
29085 APPLY HAND/WRIST CAST 3 $84.88
29086 APPLY FINGER CAST 3 $66.45
29105 APPLY LONG ARM SPLINT 3 $78.83
29125 APPLY FOREARM SPLINT 3 $62.20
29126 APPLY FOREARM SPLINT 3 $71.29
29130 APPLICATION OF FINGER SPLINT 3 $37.26
29131 APPLICATION OF FINGER SPLINT 3 $46.88
29200 STRAPPING OF CHEST 3 $49.68
29220 STRAPPING OF LOW BACK O $0.00
29240 STRAPPING OF SHOULDER 3 $54.14
29260 STRAPPING OF ELBOW OR WRIST 3 $47.53

29280 STRAPPING OF HAND OR FINGER 3 $46.21
29305 APPLICATION OF HIP CAST 3 $215.45
29325 APPLICATION OF HIP CASTS 3 $239.49
29345 APPLICATION OF LONG LEG CAST 3 $123.32
29355 APPLICATION OF LONG LEG CAST 3 $127.18
29358 APPLY LONG LEG CAST BRACE 3 $140.16
29365 APPLICATION OF LONG LEG CAST 3 $110.77
29405 APPLY SHORT LEG CAST 3 $80.87
29425 APPLY SHORT LEG CAST 3 $87.10
29435 APPLY SHORT LEG CAST 3 $108.12
29440 ADDITION OF WALKER TO CAST 3 $48.37
29445 APPLY RIGID LEG CAST 3 $132.94
29450 APPLICATION OF LEG CAST 3 $139.25
29505 APPLICATION, LONG LEG SPLINT 3 $70.64
29515 APPLICATION LOWER LEG SPLINT 3 $65.42
29520 STRAPPING OF HIP 3 $46.17
29530 STRAPPING OF KNEE 3 $48.27
29540 STRAPPING OF ANKLE AND/OR FT 3 $39.02
29550 STRAPPING OF TOES 3 $38.32
29580 APPLICATION OF PASTE BOOT 3 $48.53
29581 APPLY MULTLAY COMPRS LWR LEG 3 $88.92
29590 APPLICATION OF FOOT SPLINT 3 $51.05
29700 REMOVAL/REVISION OF CAST 3 $59.20
29705 REMOVAL/REVISION OF CAST 3 $61.34
29710 REMOVAL/REVISION OF CAST 3 $110.17
29715 REMOVAL/REVISION OF CAST 3 $80.77
29720 REPAIR OF BODY CAST 3 $73.16
29730 WINDOWING OF CAST 3 $59.59
29740 WEDGING OF CAST 3 $84.93
29750 WEDGING OF CLUBFOOT CAST 3 $95.29
29799 CASTING/STRAPPING PROCEDURE 5 $0.00
29800 JAW ARTHROSCOPY/SURGERY 3 $491.23
29804 JAW ARTHROSCOPY/SURGERY 3 $611.68
29805 SHOULDER ARTHROSCOPY, DX 3 $440.80
29806 SHOULDER ARTHROSCOPY/SURGERY 3 $1,005.91
29807 SHOULDER ARTHROSCOPY/SURGERY 3 $979.97
29815 SHOULDER ARTHROSCOPY O $0.00
29819 SHOULDER ARTHROSCOPY/SURGERY 3 $551.29
29820 SHOULDER ARTHROSCOPY/SURGERY 3 $508.24
29821 SHOULDER ARTHROSCOPY/SURGERY 3 $556.19
29822 SHOULDER ARTHROSCOPY/SURGERY 3 $540.83
29823 SHOULDER ARTHROSCOPY/SURGERY 3 $591.09
29824 SHOULDER ARTHROSCOPY/SURGERY 3 $634.71
29825 SHOULDER ARTHROSCOPY/SURGERY 3 $550.92
29826 SHOULDER ARTHROSCOPY/SURGERY 3 $630.81
29827 ARTHROSCOP ROTATOR CUFF REPR 3 $1,025.95
29828 ARTHROSCOPY BICEPS TENODESIS 3 $866.37
29830 ELBOW ARTHROSCOPY 3 $425.25
29834 ELBOW ARTHROSCOPY/SURGERY 3 $462.59

29835 ELBOW ARTHROSCOPY/SURGERY 3 $474.53
29836 ELBOW ARTHROSCOPY/SURGERY 3 $547.98
29837 ELBOW ARTHROSCOPY/SURGERY 3 $497.17
29838 ELBOW ARTHROSCOPY/SURGERY 3 $556.36
29840 WRIST ARTHROSCOPY 3 $420.99
29843 WRIST ARTHROSCOPY/SURGERY 3 $451.35
29844 WRIST ARTHROSCOPY/SURGERY 3 $465.90
29845 WRIST ARTHROSCOPY/SURGERY 3 $536.63
29846 WRIST ARTHROSCOPY/SURGERY 3 $489.21
29847 WRIST ARTHROSCOPY/SURGERY 3 $510.36
29848 WRIST ENDOSCOPY/SURGERY 3 $471.85
29850 KNEE ARTHROSCOPY/SURGERY 3 $551.26
29851 KNEE ARTHROSCOPY/SURGERY 3 $881.85
29855 TIBIAL ARTHROSCOPY/SURGERY 3 $741.63
29856 TIBIAL ARTHROSCOPY/SURGERY 3 $946.09
29860 HIP ARTHROSCOPY, DX 3 $618.67
29861 HIP ARTHROSCOPY/SURGERY 3 $682.33
29862 HIP ARTHROSCOPY/SURGERY 3 $766.53
29863 HIP ARTHROSCOPY/SURGERY 3 $764.88
29866 AUTGRFT IMPLNT, KNEE W/SCOPE 3 $988.64
29867 ALLGRFT IMPLNT, KNEE W/SCOPE 3 $1,203.06
29868 MENISCAL TRNSPL, KNEE W/SCPE 3 $1,588.99
29870 KNEE ARTHROSCOPY, DX 3 $548.92
29871 KNEE ARTHROSCOPY/DRAINAGE 3 $480.35
29873 KNEE ARTHROSCOPY/SURGERY 3 $484.37
29874 KNEE ARTHROSCOPY/SURGERY 3 $505.24
29875 KNEE ARTHROSCOPY/SURGERY 3 $464.79
29876 KNEE ARTHROSCOPY/SURGERY 3 $615.08
29877 KNEE ARTHROSCOPY/SURGERY 3 $582.60
29879 KNEE ARTHROSCOPY/SURGERY 3 $622.59
29880 KNEE ARTHROSCOPY/SURGERY 3 $649.19
29881 KNEE ARTHROSCOPY/SURGERY 3 $606.23
29882 KNEE ARTHROSCOPY/SURGERY 3 $655.40
29883 KNEE ARTHROSCOPY/SURGERY 3 $794.95
29884 KNEE ARTHROSCOPY/SURGERY 3 $581.11
29885 KNEE ARTHROSCOPY/SURGERY 3 $704.22
29886 KNEE ARTHROSCOPY/SURGERY 3 $594.43
29887 KNEE ARTHROSCOPY/SURGERY 3 $700.26
29888 KNEE ARTHROSCOPY/SURGERY 3 $939.15
29889 KNEE ARTHROSCOPY/SURGERY 3 $1,153.37
29891 ANKLE ARTHROSCOPY/SURGERY 3 $658.09
29892 ANKLE ARTHROSCOPY/SURGERY 3 $689.65
29893 SCOPE, PLANTAR FASCIOTOMY 3 $558.21
29894 ANKLE ARTHROSCOPY/SURGERY 3 $488.63
29895 ANKLE ARTHROSCOPY/SURGERY 3 $470.18
29897 ANKLE ARTHROSCOPY/SURGERY 3 $493.82
29898 ANKLE ARTHROSCOPY/SURGERY 3 $550.40
29899 ANKLE ARTHROSCOPY/SURGERY 3 $999.07
29900 MCP JOINT ARTHROSCOPY, DX 3 $407.75

29901 MCP JOINT ARTHROSCOPY, SURG 3 $478.72
29902 MCP JOINT ARTHROSCOPY, SURG 3 $542.98
29904 SUBTALAR ARTHRO W/FB RMVL 3 $590.19
29905 SUBTALAR ARTHRO W/EXC 3 $637.08
29906 SUBTALAR ARTHRO W/DEB 3 $670.84
29907 SUBTALAR ARTHRO W/FUSION 3 $815.04
29909 ARTHROSCOPY OF JOINT O $0.00
29999 ARTHROSCOPY OF JOINT 5 $0.00
30000 DRAINAGE OF NOSE LESION 3 $215.98
3000F BLOOD PRESS 140/90 MMHG O $0.00
3006F CXR DOC REV 9 $0.00
3008F BODY MASS INDEX DOCD 9 $0.00
30100 INTRANASAL BIOPSY 3 $130.79
30110 REMOVAL OF NOSE POLYP(S) 3 $212.20
30115 REMOVAL OF NOSE POLYP(S) 3 $406.59
30117 REMOVAL OF INTRANASAL LESION 3 $784.13
30118 REMOVAL OF INTRANASAL LESION 3 $734.04
3011F LIPID PANEL DOC REV 9 $0.00
30120 REVISION OF NOSE 3 $489.54
30124 REMOVAL OF NOSE LESION 3 $258.82
30125 REMOVAL OF NOSE LESION 3 $583.84
30130 EXCISE INFERIOR TURBINATE 3 $356.48
30140 RESECT INFERIOR TURBINATE 3 $408.76
3014F SCREEN MAMMO DOC REV 9 $0.00
30150 PARTIAL REMOVAL OF NOSE 3 $747.05
3015F CERV CANCER SCREEN DOCD 9 $0.00
30160 REMOVAL OF NOSE 3 $750.47
3016F PT SCRND UNHLTHY OH USE 9 $0.00
3017F COLORECTAL CA SCREEN DOC REV 9 $0.00
3018F PRE-PRXD RSK ET AL DOCD 9 $0.00
30200 INJECTION TREATMENT OF NOSE 3 $105.05
3020F LVF ASSESS 9 $0.00
30210 NASAL SINUS THERAPY 3 $138.60
3021F LVEF MOD/SEVER DEPRS SYST 9 $0.00
30220 INSERT NASAL SEPTAL BUTTON 9 $0.00
3022F LVEF >=40% SYSTOLIC 9 $0.00
3023F SPIROM DOC REV 9 $0.00
3025F SPIROM FEV/FVC=70%/W/O COPD 9 $0.00
3028F O2 SATURATION DOC REV 9 $0.00
30300 REMOVE NASAL FOREIGN BODY 3 $211.60
30310 REMOVE NASAL FOREIGN BODY 3 $194.50
30320 REMOVE NASAL FOREIGN BODY 3 $428.25
3035F O2 SATURATION55 9 $0.00
3038F PULM FX W/IN 12 MON B/4 SURG 9 $0.00
30400 RECONSTRUCTION OF NOSE 3 $979.26

3040F FEV=40% PREDICTED VALUE 9 $0.00
30430 REVISION OF NOSE 3 $863.89
30435 REVISION OF NOSE 9 $0.00
3044F HG A1C LEVEL LT 7.0% 9 $0.00
30450 REVISION OF NOSE 3 $1,483.61
3045F HG A1C LEVEL 7.0-9.0% 9 $0.00
30460 REVISION OF NOSE 3 $744.01
30462 REVISION OF NOSE 3 $1,443.00
30465 REPAIR NASAL STENOSIS 3 $936.48
3046F HEMOGLOBIN A1C LEVEL > 9.0% 9 $0.00
3047F HEMOGLOBIN A1C LEVEL = 9.0% O $0.00
3048F LDL-C = 130 MG/DL 9 $0.00
30520 REPAIR OF NASAL SEPTUM 3 $582.21
30540 REPAIR NASAL DEFECT 3 $642.98
30545 REPAIR NASAL DEFECT 3 $865.58
30560 RELEASE OF NASAL ADHESIONS 3 $250.62
30580 REPAIR UPPER JAW FISTULA 3 $592.84
30600 REPAIR MOUTH/NOSE FISTULA 3 $544.04
3060F POS MICROALBUMINURIA REV 9 $0.00
3061F NEG MICROALBUMINURIA REV 9 $0.00
30620 INTRANASAL RECONSTRUCTION 3 $586.06
3062F POS MACROALBUMINURIA REV 9 $0.00
30630 REPAIR NASAL SEPTUM DEFECT 3 $594.15
3066F NEPHROPATHY DOC TX 9 $0.00
3072F LOW RISK FOR RETINOPATHY 9 $0.00
3073F PRE-SURG EYE MEASURES DOCD 9 $0.00
3074F SYST BP LT 130 MM HG 9 $0.00
3075F SYST BP GE 130 - 139MM HG 9 $0.00
3076F SYST BP < 140 MM HG O $0.00
3077F SYST BP >= 140 MM HG6 IT 9 $0.00
3078F DIAST BP < 80 MM HG 9 $0.00
3079F DIAST BP 80-89 MM HG 9 $0.00
30800 CAUTERIZATION TURBINATES, UNILATERA O $0.00
30801 ABLATE INF TURBINATE, SUPERF 3 $210.41
30802 ABLATE INF TURBINATE SUBMUC 3 $271.01
30805 CAUTERIZATION TURBINATES, UNILATERA O $0.00
3080F DIAST BP >= 90 MM HG 9 $0.00
30820 CRYOSURGERY OF TURBINATES, UNILATER O $0.00
3082F KT/V LT1.2 9 $0.00
3083F KT/V GE 1.2 AND

30901 CONTROL OF NOSEBLEED 3 $98.42
30903 CONTROL OF NOSEBLEED 3 $183.27
30905 CONTROL OF NOSEBLEED 3 $227.79
30906 REPEAT CONTROL OF NOSEBLEED 3 $260.18
3090F MDD, SEVERE; W/O PSYCH 9 $0.00
30915 LIGATION, NASAL SINUS ARTERY 3 $552.00
3091F MDD, SEVERE; W/ PSYCH 9 $0.00
30920 LIGATION, UPPER JAW ARTERY 3 $796.05
3092F MDD, IN REMISSION 9 $0.00
30930 THER FX, NASAL INF TURBINATE 3 $116.05
3093F DOC NEW DIAG 1ST/ADDL MDD 9 $0.00
3095F CENTRAL DEXA RESULTS DOCD 9 $0.00
3096F CENTRAL DEXA ORDERED 9 $0.00
30999 NASAL SURGERY PROCEDURE 5 $0.00
31000 IRRIGATION, MAXILLARY SINUS 3 $167.25
31002 IRRIGATION, SPHENOID SINUS 3 $190.40
3100F IMAGE TEST REF CAROT DIAM 9 $0.00
31020 EXPLORATION, MAXILLARY SINUS 3 $450.37
31030 EXPLORATION, MAXILLARY SINUS 3 $649.95
31032 EXPLORE SINUS, REMOVE POLYPS 3 $542.43
31040 EXPLORATION BEHIND UPPER JAW 3 $714.91
31050 EXPLORATION, SPHENOID SINUS 3 $467.34
31051 SPHENOID SINUS SURGERY 3 $612.01
31070 EXPLORATION OF FRONTAL SINUS 3 $413.56
31071 SINUSOTOMY FRONTAL; INTRANASAL O $0.00
31075 EXPLORATION OF FRONTAL SINUS 3 $747.46
31080 REMOVAL OF FRONTAL SINUS 3 $967.68
31081 REMOVAL OF FRONTAL SINUS 3 $1,238.23
31084 REMOVAL OF FRONTAL SINUS 3 $1,122.35
31085 REMOVAL OF FRONTAL SINUS 3 $1,289.42
31086 REMOVAL OF FRONTAL SINUS 3 $1,070.85
31087 REMOVAL OF FRONTAL SINUS 3 $1,047.01
31090 EXPLORATION OF SINUSES 3 $961.43
3110F DOC PRES/ABSN HMRHG/LESION 9 $0.00
3111F CT/MRI BRAIN DONE W/IN 24HRS 9 $0.00
3112F CT/MRI BRAIN DONE GT 24 HRS 9 $0.00
31200 REMOVAL OF ETHMOID SINUS 3 $515.11
31201 REMOVAL OF ETHMOID SINUS 3 $696.49
31205 REMOVAL OF ETHMOID SINUS 3 $829.07
3120F 12-LEAD ECG PERFORMED 9 $0.00
31225 REMOVAL OF UPPER JAW 3 $1,778.32
31230 REMOVAL OF UPPER JAW 3 $1,989.48
31231 NASAL ENDOSCOPY, DX 3 $179.22
31233 NASAL/SINUS ENDOSCOPY, DX 3 $251.10
31235 NASAL/SINUS ENDOSCOPY, DX 3 $286.78
31237 NASAL/SINUS ENDOSCOPY, SURG 3 $309.63
31238 NASAL/SINUS ENDOSCOPY, SURG 3 $319.22
31239 NASAL/SINUS ENDOSCOPY, SURG 3 $645.87
31240 NASAL/SINUS ENDOSCOPY, SURG 3 $158.55

31245 NASAL/SINUS ENDOSCOPY, SURGICAL, WI O $0.00
31246 NASAL/SINUS ENDOSCOPY, SURGICAL, WI O $0.00
31247 NASAL/SINUS ENDOSCOPY, SURGICAL, WI O $0.00
31248 NASAL/SINUS ENDOSCOPY, SURGICAL, WI O $0.00
31249 NASAL/SINUS ENDOSCOPY, SURGICAL, WI O $0.00
31250 NASAL ENDOSCOPY, DIAGNOSTIC (INCLUD O $0.00
31251 NASAL/SINUS ENDOSCOPY, SURGICAL, WI O $0.00
31252 NASAL ENDOSCOPY, SURGICAL WITH NASA O $0.00
31254 REVISION OF ETHMOID SINUS 3 $270.63
31255 REMOVAL OF ETHMOID SINUS 3 $397.20
31256 EXPLORATION MAXILLARY SINUS 3 $195.58
31258 NASAL ENDOSCOPY, SURGICAL WITH REMO O $0.00
31260 MAXILLARY SINUS ENDOSCOPY, DIAGNOST O $0.00
31261 NASAL/SINUS ENDOSCOPY, SURGICAL, WI O $0.00
31262 NASAL/SINUS ENDOSCOPY, SURGICAL, WI O $0.00
31263 MAXILLARY SINUS ENDOSCOPY, SURGICAL O $0.00
31264 NASAL/SINUS ENDOSCOPY, SURGICAL, WI O $0.00
31265 MAXILLARY SINUS ENDOSCOPY, SURGICAL O $0.00
31266 NASAL/SINUS ENDOSCOPY, SURGICAL, WI O $0.00
31267 ENDOSCOPY, MAXILLARY SINUS 3 $314.79
31268 MAXILLARY SINUS ENDOSCOPY, SURGICAL O $0.00
31269 NASAL/SINUS ENDOSCOPY, SURGICAL, WI O $0.00
31270 SPHENOID ENDOSCOPY, DIAGNOSTIC O $0.00
31271 NASAL/SINUS ENDOSCOPY, SURGICAL, WI O $0.00
31275 SPHENOID ENDOSCOPY, SURGICAL; O $0.00
31276 SINUS ENDOSCOPY, SURGICAL 3 $501.52
31277 SPHENOID ENDOSCOPY, SURGICAL WITH R O $0.00
31280 NASAL/SINUS ENDOSCOPY, SURGICAL, WI O $0.00
31281 NASAL/SINUS ENDOSCOPY, SURGICAL, WI O $0.00
31282 NASAL/SINUS ENDOSCOPY, SURGICAL, WI O $0.00
31283 NASAL/SINUS ENDOSCOPY, SURGICAL, WI O $0.00
31284 NASAL/SINUS ENDOSCOPY, SURGICAL, WI O $0.00
31285 SINUS ENDOSCOPY, TWO OR MORE SINUSE O $0.00
31286 NASAL/SINUS ENDOSCOPY, SURGICAL, WI O $0.00
31287 NASAL/SINUS ENDOSCOPY, SURG 3 $230.15
31288 NASAL/SINUS ENDOSCOPY, SURG 3 $266.56
31290 NASAL/SINUS ENDOSCOPY, SURG 3 $1,133.35
31291 NASAL/SINUS ENDOSCOPY, SURG 3 $1,194.51
31292 NASAL/SINUS ENDOSCOPY, SURG 3 $977.83
31293 NASAL/SINUS ENDOSCOPY, SURG 3 $1,065.46
31294 NASAL/SINUS ENDOSCOPY, SURG 3 $1,221.43
31299 SINUS SURGERY PROCEDURE 5 $0.00
31300 REMOVAL OF LARYNX LESION 3 $1,211.54
3130F UPPER GI ENDOSCOPY PERFORMED 9 $0.00
31320 DIAGNOSTIC INCISION, LARYNX 3 $618.06
3132F DOC REF UPPER GI ENDOSCOPY 9 $0.00
31360 REMOVAL OF LARYNX 3 $1,964.19
31365 REMOVAL OF LARYNX 3 $2,446.99
31367 PARTIAL REMOVAL OF LARYNX 3 $2,103.43

31368 PARTIAL REMOVAL OF LARYNX 3 $2,340.17
31370 PARTIAL REMOVAL OF LARYNX 3 $1,975.03
31375 PARTIAL REMOVAL OF LARYNX 3 $1,871.31
31380 PARTIAL REMOVAL OF LARYNX 3 $1,842.00
31382 PARTIAL REMOVAL OF LARYNX 3 $2,022.20
31390 REMOVAL OF LARYNX & PHARYNX 3 $2,718.73
31395 RECONSTRUCT LARYNX & PHARYNX 3 $2,875.57
31400 REVISION OF LARYNX 3 $959.87
3140F UPPER GI ENDO SHOWS BARRTTS 9 $0.00
3141F UPPER GI ENDO NOT BARRTTS 9 $0.00
31420 REMOVAL OF EPIGLOTTIS 3 $805.00
3142F BARIUM SWALLOW TEST ORDERED 9 $0.00
31500 INSERT EMERGENCY AIRWAY 3 $108.90
31502 CHANGE OF WINDPIPE AIRWAY 3 $34.42
31505 DIAGNOSTIC LARYNGOSCOPY 3 $78.69
3150F FORCEPS ESOPH BIOPSY DONE 9 $0.00
31510 LARYNGOSCOPY WITH BIOPSY 3 $201.42
31511 REMOVE FOREIGN BODY, LARYNX 3 $201.34
31512 REMOVAL OF LARYNX LESION 3 $199.20
31513 INJECTION INTO VOCAL CORD 9 $0.00
31515 LARYNGOSCOPY FOR ASPIRATION 3 $199.06
31520 DX LARYNGOSCOPY, NEWBORN 3 $152.70
31525 DX LARYNGOSCOPY EXCL NB 3 $239.41
31526 DX LARYNGOSCOPY W/OPER SCOPE 3 $156.08
31527 LARYNGOSCOPY FOR TREATMENT 9 $0.00
31528 LARYNGOSCOPY AND DILATION 3 $142.86
31529 LARYNGOSCOPY AND DILATION 9 $0.00
31530 LARYNGOSCOPY W/FB REMOVAL 3 $195.95
31531 LARYNGOSCOPY W/FB & OP SCOPE 3 $211.44
31535 LARYNGOSCOPY W/BIOPSY 3 $188.18
31536 LARYNGOSCOPY W/BX & OP SCOPE 3 $209.97
31540 LARYNGOSCOPY W/EXC OF TUMOR 3 $241.33
31541 LARYNSCOP W/TUMR EXC + SCOPE 3 $263.73
31545 REMOVE VC LESION W/SCOPE 3 $361.03
31546 REMOVE VC LESION SCOPE/GRAFT 3 $545.83
3155F CYTOGEN TEST MARROW B/4 TX 9 $0.00
31560 LARYNGOSCOP W/ARYTENOIDECTOM 3 $312.52
31561 LARYNSCOP, REMVE CART + SCOP 3 $341.78
31570 LARYNGOSCOPE W/VC INJ 3 $330.49
31571 LARYNGOSCOP W/VC INJ + SCOPE 3 $248.96
31575 DIAGNOSTIC LARYNGOSCOPY 3 $110.04
31576 LARYNGOSCOPY WITH BIOPSY 3 $215.10
31577 REMOVE FOREIGN BODY, LARYNX 9 $0.00
31578 REMOVAL OF LARYNX LESION 3 $269.63
31579 DIAGNOSTIC LARYNGOSCOPY 3 $207.77
31580 REVISION OF LARYNX 3 $1,160.54
31582 REVISION OF LARYNX 3 $1,832.02
31584 TREAT LARYNX FRACTURE 3 $1,456.19
31585 TREAT LARYNX FRACTURE O $0.00

31586 TREAT LARYNX FRACTURE O $0.00
31587 REVISION OF LARYNX 3 $963.31
31588 REVISION OF LARYNX 3 $1,097.23
31590 REINNERVATE LARYNX 9 $0.00
31595 LARYNX NERVE SURGERY 9 $0.00
31599 LARYNX SURGERY PROCEDURE 5 $0.00
31600 INCISION OF WINDPIPE 3 $389.42
31601 INCISION OF WINDPIPE 3 $257.30
31603 INCISION OF WINDPIPE 3 $219.69
31605 INCISION OF WINDPIPE 3 $179.87
3160F DOC FE+ STORES B/4 EPO THX 9 $0.00
31610 INCISION OF WINDPIPE 3 $682.82
31611 SURGERY/SPEECH PROSTHESIS 3 $513.37
31612 PUNCTURE/CLEAR WINDPIPE 3 $77.17
31613 REPAIR WINDPIPE OPENING 3 $426.96
31614 REPAIR WINDPIPE OPENING 9 $0.00
31615 VISUALIZATION OF WINDPIPE 3 $175.50
31620 ENDOBRONCHIAL US ADD-ON 3 $269.55
31622 DX BRONCHOSCOPE/WASH 3 $145.11
31623 DX BRONCHOSCOPE/BRUSH 3 $331.74
31624 DX BRONCHOSCOPE/LAVAGE 3 $147.29
31625 BRONCHOSCOPY W/BIOPSY(S) 3 $332.87
31626 BRONCHOSCOPY W/MARKERS 3 $433.16
31627 NAVIGATIONAL BRONCHOSCOPY 3 $1,207.94
31628 BRONCHOSCOPY/LUNG BX, EACH 3 $189.95
31629 BRONCHOSCOPY/NEEDLE BX, EACH 3 $204.68
31630 BRONCHOSCOPY DILATE/FX REPR 3 $202.82
31631 BRONCHOSCOPY, DILATE W/STENT 3 $230.54
31632 BRONCHOSCOPY/LUNG BX, ADDL 3 $70.60
31633 BRONCHOSCOPY/NEEDLE BX ADDL 3 $86.60
31635 BRONCHOSCOPY W/FB REMOVAL 3 $341.51
31636 BRONCHOSCOPY, BRONCH STENTS 3 $224.21
31637 BRONCHOSCOPY, STENT ADD-ON 3 $77.07
31638 BRONCHOSCOPY, REVISE STENT 3 $256.18
31640 BRONCHOSCOPY W/TUMOR EXCISE 3 $258.52
31641 BRONCHOSCOPY, TREAT BLOCKAGE 3 $257.81
31643 DIAG BRONCHOSCOPE/CATHETER 3 $175.35
31645 BRONCHOSCOPY, CLEAR AIRWAYS 3 $160.65
31646 BRONCHOSCOPY, RECLEAR AIRWAY 3 $139.18
31656 BRONCHOSCOPY, INJ FOR X-RAY 3 $304.85
31659 BRONCHOSCOPY; WITH OTHER BRONCHOSCO O $0.00
31700 INSERTION OF AIRWAY CATHETER O $0.00
31708 INSTILL AIRWAY CONTRAST DYE O $0.00
3170F FLOW CYTO DONE B/4 TX 9 $0.00
31710 INSERTION OF AIRWAY CATHETER O $0.00
31715 INJECTION FOR BRONCHUS X-RAY 3 $54.50
31717 BRONCHIAL BRUSH BIOPSY 3 $281.09
31719 TRANSTRACHEAL (PERCUTANEOUS) INTROD O $0.00
31720 CLEARANCE OF AIRWAYS 3 $51.54

31725 CLEARANCE OF AIRWAYS 3 $93.80
31730 INTRO, WINDPIPE WIRE/TUBE 3 $913.13
31750 REPAIR OF WINDPIPE 3 $1,296.75
31755 REPAIR OF WINDPIPE 3 $1,641.27
31760 REPAIR OF WINDPIPE 3 $1,367.77
31766 RECONSTRUCTION OF WINDPIPE 3 $1,793.74
31770 REPAIR/GRAFT OF BRONCHUS 3 $1,324.84
31775 RECONSTRUCT BRONCHUS 3 $1,374.67
31780 RECONSTRUCT WINDPIPE 3 $1,169.17
31781 RECONSTRUCT WINDPIPE 3 $1,455.45
31785 REMOVE WINDPIPE LESION 3 $1,062.13
31786 REMOVE WINDPIPE LESION 3 $1,461.95
31800 REPAIR OF WINDPIPE INJURY 3 $673.01
31805 REPAIR OF WINDPIPE INJURY 3 $821.14
31820 CLOSURE OF WINDPIPE LESION 3 $412.08
31825 REPAIR OF WINDPIPE DEFECT 3 $575.91
31830 REVISE WINDPIPE SCAR 3 $414.35
31899 AIRWAYS SURGICAL PROCEDURE 5 $0.00
32000 DRAINAGE OF CHEST O $0.00
32001 TOTAL LUNG LAVAGE O $0.00
32002 TREATMENT OF COLLAPSED LUNG O $0.00
32005 TREAT LUNG LINING CHEMICALLY O $0.00
3200F BARIUM SWALLOW TEST NOT REQ 9 $0.00
32019 INSERT PLEURAL CATHETER O $0.00
32020 INSERTION OF CHEST TUBE O $0.00
32035 EXPLORATION OF CHEST 3 $701.80
32036 EXPLORATION OF CHEST 3 $760.45
32095 BIOPSY THROUGH CHEST WALL 3 $621.99
32100 EXPLORATION/BIOPSY OF CHEST 3 $949.77
3210F GRP A STREP TEST PERFORMED 9 $0.00
32110 EXPLORE/REPAIR CHEST 3 $1,437.81
32120 RE-EXPLORATION OF CHEST 3 $864.02
32124 EXPLORE CHEST FREE ADHESIONS 3 $916.71
32140 REMOVAL OF LUNG LESION(S) 3 $981.47
32141 REMOVE/TREAT LUNG LESIONS 3 $1,509.91
32150 REMOVAL OF LUNG LESION(S) 3 $988.05
32151 REMOVE LUNG FOREIGN BODY 3 $1,003.37
3215F PT IMMUNITY TO HEP A DOCD 9 $0.00
32160 OPEN CHEST HEART MASSAGE 3 $764.94
3216F PT IMMUNITY TO HEP B DOCD 9 $0.00
3218F RNA TSTNG HEP C DOCD-DONE 9 $0.00
32200 DRAIN, OPEN, LUNG LESION 3 $1,114.15
32201 DRAIN, PERCUT, LUNG LESION 3 $899.13
3220F HEP C QUANT RNA TSTNG DOCD 9 $0.00
32215 TREAT CHEST LINING 3 $792.44
32220 RELEASE OF LUNG 3 $1,579.92
32225 PARTIAL RELEASE OF LUNG 3 $986.00
3230F NOTE HRING TST W/IN 6 MON 9 $0.00
32310 REMOVAL OF CHEST LINING 3 $908.76

32315 PLEURECTOMY; PARTIAL O $0.00
32320 FREE/REMOVE CHEST LINING 3 $1,584.56
32400 NEEDLE BIOPSY CHEST LINING 3 $148.37
32402 OPEN BIOPSY CHEST LINING 3 $559.62
32405 BIOPSY, LUNG OR MEDIASTINUM 3 $100.53
32420 PUNCTURE/CLEAR LUNG 3 $112.02
32421 THORACENTESIS FOR ASPIRATION 3 $153.96
32422 THORACENTESIS W/TUBE INSERT 3 $195.05
32440 REMOVAL OF LUNG 3 $1,571.03
32442 SLEEVE PNEUMONECTOMY 3 $2,825.86
32445 REMOVAL OF LUNG 3 $3,453.99
32450 PNEUMONECTOMY, EXTRAPLEURAL WITH EM O $0.00
32480 PARTIAL REMOVAL OF LUNG 3 $1,483.96
32482 BILOBECTOMY 3 $1,586.41
32484 SEGMENTECTOMY 3 $1,439.10
32485 REMOVAL OF LUNG, OTHER THAN TOTAL P O $0.00
32486 SLEEVE LOBECTOMY 3 $2,340.97
32488 COMPLETION PNEUMONECTOMY 3 $2,370.20
32490 LOBECTOMY, TOTAL OR SEGMENTAL WITH O $0.00
32491 LUNG VOLUME REDUCTION 3 $1,479.61
32500 PARTIAL REMOVAL OF LUNG 3 $1,439.22
32501 REPAIR BRONCHUS ADD-ON 3 $248.03
32503 RESECT APICAL LUNG TUMOR 3 $1,806.71
32504 RESECT APICAL LUNG TUM/CHEST 3 $2,069.23
3250F NONPRIM LOC ANAT BX SITE TUM 9 $0.00
32520 REMOVE LUNG & REVISE CHEST O $0.00
32522 REMOVE LUNG & REVISE CHEST O $0.00
32525 REMOVE LUNG & REVISE CHEST O $0.00
32540 REMOVAL OF LUNG LESION 3 $1,704.60
32545 EXTRAPLEURAL ENUCLEATION OF EMPYEMA O $0.00
32550 INSERT PLEURAL CATH 3 $772.25
32551 INSERTION OF CHEST TUBE 3 $172.59
32552 REMOVE LUNG CATHETER 3 $180.69
32553 INS MARK THOR FOR RT PERQ 3 $593.58
32560 TREAT PLEURODESIS W/AGENT 3 $258.08
32561 LYSE CHEST FIBRIN INIT DAY 3 $94.12
32562 LYSE CHEST FIBRIN SUBQ DAY 3 $84.24
32601 THORACOSCOPY, DIAGNOSTIC 3 $308.45
32602 THORACOSCOPY, DIAGNOSTIC 3 $334.47
32603 THORACOSCOPY, DIAGNOSTIC 3 $435.28
32604 THORACOSCOPY, DIAGNOSTIC 3 $485.66
32605 THORACOSCOPY, DIAGNOSTIC 3 $384.40
32606 THORACOSCOPY, DIAGNOSTIC 3 $464.90
3260F PT CAT/PN CAT/HIST GRD DOCD 9 $0.00
32650 THORACOSCOPY, SURGICAL 3 $664.38
32651 THORACOSCOPY, SURGICAL 3 $1,074.45
32652 THORACOSCOPY, SURGICAL 3 $1,634.27
32653 THORACOSCOPY, SURGICAL 3 $1,037.02
32654 THORACOSCOPY, SURGICAL 3 $1,159.26

32655 THORACOSCOPY, SURGICAL 3 $943.59
32656 THORACOSCOPY, SURGICAL 3 $795.59
32657 THORACOSCOPY, SURGICAL 3 $782.89
32658 THORACOSCOPY, SURGICAL 3 $715.04
32659 THORACOSCOPY, SURGICAL 3 $731.60
3265F RNA TSTNG HEPC VIR ORD/DOCD 9 $0.00
32660 THORACOSCOPY, SURGICAL 3 $1,042.27
32661 THORACOSCOPY, SURGICAL 3 $798.46
32662 THORACOSCOPY, SURGICAL 3 $895.97
32663 THORACOSCOPY, SURGICAL 3 $1,398.17
32664 THORACOSCOPY, SURGICAL 3 $844.14
32665 THORACOSCOPY, SURGICAL 3 $1,226.55
3266F HEPC GN TSTNG DOCD B/4TXMNT 9 $0.00
3268F PSA/T/GLSC DOCD B/4 TXMNT 9 $0.00
3269F BONE SCN B/4 TXMNT/AFTR DX 9 $0.00
32700 THORACOSCOPY, EXPLORATORY (SEPARATE O $0.00
32705 THORACOSCOPY, EXPLORATORY (SEPARATE O $0.00
3270F NO BONE SCN B/4 TXMNT/AFTRDX 9 $0.00
3271F LOW RISK PROSTATE CANCER 9 $0.00
3272F MED RISK PROSTATE CANCER 9 $0.00
3273F HIGH RISK PROSTATE CANCER 9 $0.00
3274F PROST CNCR RSK NOT LW/MD/HGH 9 $0.00
3278F SERUM LVLS CA/IPTH/LPD ORD 9 $0.00
3279F HGB LVL >/= 13 G/DL 9 $0.00
32800 REPAIR LUNG HERNIA 3 $912.85
3280F HGB LVL 11-12.9 G/DL 9 $0.00
32810 CLOSE CHEST AFTER DRAINAGE 3 $893.61
32815 CLOSE BRONCHIAL FISTULA 3 $2,742.64
3281F HGB LVL < 11 G/DL 9 $0.00
32820 RECONSTRUCT INJURED CHEST 3 $1,335.84
3284F IOP DOWN>=15% OF PRE-SVC LVL 9 $0.00
32850 DONOR PNEUMONECTOMY 9 $0.00
32851 LUNG TRANSPLANT, SINGLE 3 $2,578.35
32852 LUNG TRANSPLANT WITH BYPASS 3 $2,856.12
32853 LUNG TRANSPLANT, DOUBLE 3 $3,068.20
32854 LUNG TRANSPLANT WITH BYPASS 3 $3,357.69
32855 PREPARE DONOR LUNG, SINGLE 9 $0.00
32856 PREPARE DONOR LUNG, DOUBLE 9 $0.00
3285F IOP DOWN

32960 THERAPEUTIC PNEUMOTHORAX 3 $141.34
32997 TOTAL LUNG LAVAGE 3 $357.18
32998 PERQ RF ABLATE TX, PUL TUMOR 3 $2,779.08
32999 CHEST SURGERY PROCEDURE 5 $0.00
3300F AJCC STAGE DOCD B/4 THXPY 9 $0.00
33010 DRAINAGE OF HEART SAC 3 $125.45
33011 REPEAT DRAINAGE OF HEART SAC 3 $124.29
33015 INCISION OF HEART SAC 3 $532.65
3301F CANCER STAGE DOCD METAST 9 $0.00
33020 INCISION OF HEART SAC 3 $872.83
33025 INCISION OF HEART SAC 3 $800.96
3302F AJCC STAGE 0 DOCÏD O $0.00
33030 PARTIAL REMOVAL OF HEART SAC 3 $1,286.83
33031 PARTIAL REMOVAL OF HEART SAC 3 $1,435.60
3303F AJCC STAGE IA DOCÏD O $0.00
3304F AJCC STAGE IB DOCÏD O $0.00
33050 REMOVAL OF HEART SAC LESION 3 $995.78
3305F AJCC STAGE IC DOCÏD O $0.00
3306F AJCC STAGE IIA DOCÏD O $0.00
3307F AJCC STAGE IIB DOCÏD O $0.00
3308F AJCC STAGE IIC DOCÏD O $0.00
3309F AJCC STAGE IIIA DOCÏD O $0.00
33100 PERICARDIECTOMY (SEPARATE PROCEDURE O $0.00
3310F AJCC STAGE IIIB DOCÏD O $0.00
3311F AJCC STAGE IIIC DOCÏD O $0.00
33120 REMOVAL OF HEART LESION 3 $1,563.39
3312F AJCC STAGE IVA DOCÏD O $0.00
33130 REMOVAL OF HEART LESION 3 $1,455.18
3313F AJCC STAGE IVB DOCÏD O $0.00
33140 HEART REVASCULARIZE (TMR) 3 $1,594.01
33141 HEART TMR W/OTHER PROCEDURE 3 $141.24
3314F AJCC STAGE IVC DOCÏD O $0.00
3315F ER+ OR PR+ BREAST CANCER 9 $0.00
3316F ER- OR PR- BREAST CANCER 9 $0.00
3317F PATH RPT MALIG CANCER DOCD 9 $0.00
3318F PATH RPT MALIG CANCER DOCD 9 $0.00
3319F X-RAY/CT/ULTRSND ET AL ORD 9 $0.00
33200 INSERTION OF HEART PACEMAKER O $0.00
33201 INSERTION OF HEART PACEMAKER O $0.00
33202 INSERT EPICARD ELTRD, OPEN 3 $779.84
33203 INSERT EPICARD ELTRD, ENDO 3 $824.92
33206 INSERTION OF HEART PACEMAKER 3 $477.53
33207 INSERTION OF HEART PACEMAKER 3 $508.88
33208 INSERTION OF HEART PACEMAKER 3 $550.35
3320F NO XRAY/CT/ ET AL ORDD 9 $0.00
33210 INSERTION OF HEART ELECTRODE 3 $189.24
33211 INSERTION OF HEART ELECTRODE 3 $190.62
33212 INSERTION OF PULSE GENERATOR 3 $353.87
33213 INSERTION OF PULSE GENERATOR 3 $404.60

33214 UPGRADE OF PACEMAKER SYSTEM 3 $503.76
33215 REPOSITION PACING-DEFIB LEAD 3 $320.43
33216 INSERT 1 ELECTRODE PM-DEFIB 3 $396.61
33217 INSERT 2 ELECTRODE PM-DEFIB 3 $393.24
33218 REPAIR LEAD PACE-DEFIB, ONE 3 $411.83
33219 REPAIR OF PACEMAKER WITH REPLACEMEN O $0.00
3321F AJCC CNCR 0/IA MELAN DOCD 9 $0.00
33220 REPAIR LEAD PACE-DEFIB, DUAL 3 $416.13
33222 REVISE POCKET, PACEMAKER 3 $361.87
33223 REVISE POCKET FOR DEFIB 3 $436.35
33224 INSERT PACING LEAD & CONNECT 3 $533.47
33225 L VENTRIC PACING LEAD ADD-ON 3 $481.53
33226 REPOSITION L VENTRIC LEAD 3 $513.56
3322F MELAN >AJCC STAGE 0 OR IA 9 $0.00
33232 REMOVAL OF PERMANENT PACEMAKER O $0.00
33233 REMOVAL OF PACEMAKER SYSTEM 3 $251.98
33234 REMOVAL OF PACEMAKER SYSTEM 3 $510.83
33235 REMOVAL PACEMAKER ELECTRODE 3 $665.99
33236 REMOVE ELECTRODE/THORACOTOMY 3 $788.12
33237 REMOVE ELECTRODE/THORACOTOMY 3 $856.48
33238 REMOVE ELECTRODE/THORACOTOMY 3 $937.43
3323F CLIN NODE STGNG DOCDB/4 SURG 9 $0.00
33240 INSERT PULSE GENERATOR 3 $488.54
33241 REMOVE PULSE GENERATOR 3 $237.63
33242 REPAIR PULSE GENERATOR/LEADS O $0.00
33243 REMOVE ELTRD/THORACOTOMY 3 $1,392.56
33244 REMOVE ELTRD, TRANSVEN 3 $898.82
33245 INSERT EPIC ELTRD PACE-DEFIB O $0.00
33246 INSERT EPIC ELTRD/GENERATOR O $0.00
33247 INSERT/REPLACE LEADS O $0.00
33248 REVISION OR REMOVAL OF AUTOMATIC IM O $0.00
33249 ELTRD/INSERT PACE-DEFIB 3 $956.43
3324F MRI CT SCAN ORD RVWD RQSTD 9 $0.00
33250 ABLATE HEART DYSRHYTHM FOCUS 3 $1,481.00
33251 ABLATE HEART DYSRHYTHM FOCUS 3 $1,643.84
33253 RECONSTRUCT ATRIA O $0.00
33254 ABLATE ATRIA, LMTD 3 $1,374.56
33255 ABLATE ATRIA W/O BYPASS, EXT 3 $1,676.45
33256 ABLATE ATRIA W/BYPASS, EXTEN 3 $1,993.08
33257 ABLATE ATRIA, LMTD, ADD-ON 3 $588.12
33258 ABLATE ATRIA, X10SV, ADD-ON 3 $661.95
33259 ABLATE ATRIA W/BYPASS ADD-ON 3 $854.99
3325F PREOP ASSES 4 CATARACT SURG 9 $0.00
33260 OPERATIVE ABLATION OF ARRHYTHMOGENI O $0.00
33261 ABLATE HEART DYSRHYTHM FOCUS 3 $1,636.42
33265 ABLATE ATRIA, LMTD, ENDO 3 $1,366.26
33266 ABLATE ATRIA, X10SV, ENDO 3 $1,868.07
33282 IMPLANT PAT-ACTIVE HT RECORD 3 $341.64
33284 REMOVE PAT-ACTIVE HT RECORD 3 $246.40

3328F PRFRMNC DOCD 2 WKS B/4 SURG 9 $0.00
33300 REPAIR OF HEART WOUND 3 $2,417.14
33305 REPAIR OF HEART WOUND 3 $4,068.24
3330F IMAGING STUDY ORDERED (BKP) 9 $0.00
33310 EXPLORATORY HEART SURGERY 3 $1,172.42
33315 EXPLORATORY HEART SURGERY 3 $1,496.74
3331F BK IMAGING TST NOT ORDERED 9 $0.00
33320 REPAIR MAJOR BLOOD VESSEL(S) 3 $1,069.22
33321 REPAIR MAJOR VESSEL 3 $1,193.81
33322 REPAIR MAJOR BLOOD VESSEL(S) 3 $1,404.81
33330 INSERT MAJOR VESSEL GRAFT 3 $1,446.43
33332 INSERT MAJOR VESSEL GRAFT 3 $1,411.18
33335 INSERT MAJOR VESSEL GRAFT 3 $1,905.80
33350 GREAT VESSEL REPAIR WITH OTHER MAJO O $0.00
33400 REPAIR OF AORTIC VALVE 3 $2,314.49
33401 VALVULOPLASTY, OPEN 3 $1,472.45
33403 VALVULOPLASTY, W/CP BYPASS 3 $1,517.18
33404 PREPARE HEART-AORTA CONDUIT 3 $1,786.85
33405 REPLACEMENT OF AORTIC VALVE 3 $2,330.70
33406 REPLACEMENT OF AORTIC VALVE 3 $2,915.61
33407 VALVOTOMY, AORTIC VALVE (COMMISSURO O $0.00
33408 VALVOTOMY, AORTIC VALVE (COMMISSURO O $0.00
3340F MAMMO ASSESS INC XRAY DOCD 9 $0.00
33410 REPLACEMENT OF AORTIC VALVE 3 $2,577.26
33411 REPLACEMENT OF AORTIC VALVE 3 $3,388.70
33412 REPLACEMENT OF AORTIC VALVE 3 $2,502.47
33413 REPLACEMENT OF AORTIC VALVE 3 $3,280.95
33414 REPAIR OF AORTIC VALVE 3 $2,198.28
33415 REVISION, SUBVALVULAR TISSUE 3 $2,041.48
33416 REVISE VENTRICLE MUSCLE 3 $2,047.51
33417 REPAIR OF AORTIC VALVE 3 $1,691.81
3341F MAMMO ASSESS NEGATIVE DOCD 9 $0.00
33420 REVISION OF MITRAL VALVE 3 $1,390.29
33422 REVISION OF MITRAL VALVE 3 $1,703.84
33425 REPAIR OF MITRAL VALVE 3 $2,727.06
33426 REPAIR OF MITRAL VALVE 3 $2,425.49
33427 REPAIR OF MITRAL VALVE 3 $2,501.96
3342F MAMMO ASSESS BENGN DOCD 9 $0.00
33430 REPLACEMENT OF MITRAL VALVE 3 $2,833.54
3343F MAMMO PROBABLY BENGN DOCD 9 $0.00
3344F MAMMO ASSESS SUSP, DOCD 9 $0.00
33452 VALVOTOMY, TRICUSPID VALVE, WITH CA O $0.00
3345F MAMMO ASSESS HGHLYMALIG DOC 9 $0.00
33460 REVISION OF TRICUSPID VALVE 3 $2,554.21
33463 VALVULOPLASTY, TRICUSPID 3 $3,089.81
33464 VALVULOPLASTY, TRICUSPID 3 $2,459.16
33465 REPLACE TRICUSPID VALVE 3 $2,761.35
33468 REVISION OF TRICUSPID VALVE 3 $1,896.15
33470 REVISION OF PULMONARY VALVE 3 $1,243.70

33471 VALVOTOMY, PULMONARY VALVE 3 $1,265.20
33472 REVISION OF PULMONARY VALVE 3 $1,269.85
33474 REVISION OF PULMONARY VALVE 3 $2,128.63
33475 REPLACEMENT, PULMONARY VALVE 3 $2,357.47
33476 REVISION OF HEART CHAMBER 3 $1,516.22
33478 REVISION OF HEART CHAMBER 3 $1,587.43
33480 REPLACEMENT AND/OR REPAIR, DOUBLE V O $0.00
33481 SINGLE VALVE REPLACEMENT WITH COMMI O $0.00
33482 SINGLE VALVE REPLACEMENT WITH COMMI O $0.00
33483 DOUBLE VALVE REPLACEMENT O $0.00
33485 DOUBLE VALVE REPLACEMENT WITH COMMI O $0.00
33490 REPLACEMENT AND/OR REPAIR, TRIPLE V O $0.00
33492 TRIPLE VALVE REPLACEMENT O $0.00
33496 REPAIR, PROSTH VALVE CLOT 3 $1,692.83
33500 REPAIR HEART VESSEL FISTULA 3 $1,592.43
33501 REPAIR HEART VESSEL FISTULA 3 $1,128.42
33502 CORONARY ARTERY CORRECTION 3 $1,282.78
33503 CORONARY ARTERY GRAFT 3 $1,369.16
33504 CORONARY ARTERY GRAFT 3 $1,468.26
33505 REPAIR ARTERY W/TUNNEL 3 $2,077.92
33506 REPAIR ARTERY, TRANSLOCATION 3 $2,073.19
33507 REPAIR ART, INTRAMURAL 3 $1,746.99
33508 ENDOSCOPIC VEIN HARVEST 3 $16.33
3350F MAMMO BX PROVEN MALIG DOCD 9 $0.00
33510 CABG, VEIN, SINGLE 3 $1,985.33
33511 CABG, VEIN, TWO 3 $2,174.54
33512 CABG, VEIN, THREE 3 $2,462.81
33513 CABG, VEIN, FOUR 3 $2,519.07
33514 CABG, VEIN, FIVE 3 $2,674.48
33516 CABG, VEIN, SIX OR MORE 3 $2,776.72
33517 CABG, ARTERY-VEIN, SINGLE 3 $190.03
33518 CABG, ARTERY-VEIN, TWO 3 $416.24
33519 CABG, ARTERY-VEIN, THREE 3 $552.53
3351F NEG SCRN DEP SYMP BY DEPTOOL 9 $0.00
33520 CORONARY ARTERY BYPASS, NONAUTOGENO O $0.00
33521 CABG, ARTERY-VEIN, FOUR 3 $665.65
33522 CABG, ARTERY-VEIN, FIVE 3 $750.30
33523 CABG, ART-VEIN, SIX OR MORE 3 $852.44
33525 CORONARY ARTERY BYPASS, NONAUTOGENO O $0.00
33528 CORONARY ARTERY BYPASS, NONAUTOGENO O $0.00
3352F NO SIG DEP SYMP BY DEP TOOL 9 $0.00
33530 CORONARY ARTERY, BYPASS/REOP 3 $530.10
33533 CABG, ARTERIAL, SINGLE 3 $1,923.16
33534 CABG, ARTERIAL, TWO 3 $2,254.21
33535 CABG, ARTERIAL, THREE 3 $2,509.52
33536 CABG, ARTERIAL, FOUR OR MORE 3 $2,695.50
3353F MILD-MOD DEP SYMP BY DEPTOOL 9 $0.00
33542 REMOVAL OF HEART LESION 3 $2,633.32
33545 REPAIR OF HEART DAMAGE 3 $3,097.33

33548 RESTORE/REMODEL, VENTRICLE 3 $3,020.05
3354F CLIN SIG DEP SYM BY DEP TOOL 9 $0.00
33570 CORONARY ANGIOPLASTY (ENDARTERECTOM O $0.00
33572 OPEN CORONARY ENDARTERECTOMY 3 $236.75
33575 CORONARY ANGIOPLASTY (ENDARTERECTOM O $0.00
33600 CLOSURE OF VALVE 3 $1,715.12
33602 CLOSURE OF VALVE 3 $1,660.96
33606 ANASTOMOSIS/ARTERY-AORTA 3 $1,793.76
33608 REPAIR ANOMALY W/CONDUIT 3 $1,819.03
33610 REPAIR BY ENLARGEMENT 3 $1,781.39
33611 REPAIR DOUBLE VENTRICLE 3 $1,982.45
33612 REPAIR DOUBLE VENTRICLE 3 $2,004.21
33615 REPAIR, MODIFIED FONTAN 3 $2,028.03
33617 REPAIR SINGLE VENTRICLE 3 $2,161.81
33619 REPAIR SINGLE VENTRICLE 3 $2,677.09
33641 REPAIR HEART SEPTUM DEFECT 3 $1,647.23
33645 REVISION OF HEART VEINS 3 $1,599.01
33647 REPAIR HEART SEPTUM DEFECTS 3 $1,798.60
33649 REPAIR OF TRICUSPID ATRESIA (EG, FO O $0.00
33660 REPAIR OF HEART DEFECTS 3 $1,776.75
33665 REPAIR OF HEART DEFECTS 3 $2,039.76
33670 REPAIR OF HEART CHAMBERS 3 $2,006.80
33675 CLOSE MULT VSD 3 $1,994.78
33676 CLOSE MULT VSD W/RESECTION 3 $1,961.50
33677 CL MULT VSD W/REM PUL BAND 3 $2,037.91
33681 REPAIR HEART SEPTUM DEFECT 3 $1,854.05
33684 REPAIR HEART SEPTUM DEFECT 3 $2,009.57
33688 REPAIR HEART SEPTUM DEFECT 3 $1,897.41
33690 REINFORCE PULMONARY ARTERY 3 $1,187.88
33692 REPAIR OF HEART DEFECTS 3 $1,687.95
33694 REPAIR OF HEART DEFECTS 3 $1,990.76
33696 COMPLETE REPAIR TETRALOGY OF FALLOT O $0.00
33697 REPAIR OF HEART DEFECTS 3 $2,140.29
33698 COMPLETE REPAIR TETRALOGY OF FALLOT O $0.00
33702 REPAIR OF HEART DEFECTS 3 $1,554.22
3370F AJCC BRST CNCR STAGE 0 DOCD 9 $0.00
33710 REPAIR OF HEART DEFECTS 3 $1,827.23
33720 REPAIR OF HEART DEFECT 3 $1,557.56
33722 REPAIR OF HEART DEFECT 3 $1,632.37
33724 REPAIR VENOUS ANOMALY 3 $1,570.04
33726 REPAIR PUL VENOUS STENOSIS 3 $2,074.66
3372F AJCC BRST CNCR STAGE 1+DOCD 9 $0.00
33730 REPAIR HEART-VEIN DEFECT(S) 3 $1,991.61
33732 REPAIR HEART-VEIN DEFECT 3 $1,665.34
33735 REVISION OF HEART CHAMBER 3 $1,295.26
33736 REVISION OF HEART CHAMBER 3 $1,416.55
33737 REVISION OF HEART CHAMBER 3 $1,302.00
33738 ATRIAL SEPTECTOMY OR SEPTOSTOMY TRA O $0.00
33739 ATRIAL SEPTECTOMY OR SEPTOSTOMY BLA O $0.00

3374F AJCC BRST CNCR STAGE 1+DOCD 9 $0.00
33750 MAJOR VESSEL SHUNT 3 $1,443.30
33755 MAJOR VESSEL SHUNT 3 $1,287.64
33762 MAJOR VESSEL SHUNT 3 $1,236.31
33764 MAJOR VESSEL SHUNT & GRAFT 3 $1,298.91
33766 MAJOR VESSEL SHUNT 3 $1,371.49
33767 MAJOR VESSEL SHUNT 3 $1,423.74
33768 CAVOPULMONARY SHUNTING 3 $407.39
3376F AJCC BRSTCNCR STAGE 2 DOCD 9 $0.00
33770 REPAIR GREAT VESSELS DEFECT 3 $2,166.00
33771 REPAIR GREAT VESSELS DEFECT 3 $2,102.35
33774 REPAIR GREAT VESSELS DEFECT 3 $1,821.74
33775 REPAIR GREAT VESSELS DEFECT 3 $1,794.80
33776 REPAIR GREAT VESSELS DEFECT 3 $1,894.95
33777 REPAIR GREAT VESSELS DEFECT 3 $1,841.52
33778 REPAIR GREAT VESSELS DEFECT 3 $2,275.47
33779 REPAIR GREAT VESSELS DEFECT 3 $2,257.84
33780 REPAIR GREAT VESSELS DEFECT 3 $2,422.90
33781 REPAIR GREAT VESSELS DEFECT 3 $2,234.81
33782 NIKAIDOH PROC 3 $3,230.26
33783 NIKAIDOH PROC W/OSTIA IMPLT 3 $3,491.07
33786 REPAIR ARTERIAL TRUNK 3 $2,202.04
33788 REVISION OF PULMONARY ARTERY 3 $1,482.92
3378F AJCC BRSTCNCR STAGE 3 DOCD 9 $0.00
33800 AORTIC SUSPENSION 3 $985.64
33802 REPAIR VESSEL DEFECT 3 $1,073.31
33803 REPAIR VESSEL DEFECT 3 $1,146.71
3380F AJCC BRSTCNCR STAGE 4 DOCD 9 $0.00
33813 REPAIR SEPTAL DEFECT 3 $1,285.52
33814 REPAIR SEPTAL DEFECT 3 $1,538.14
33820 REVISE MAJOR VESSEL 3 $984.30
33822 REVISE MAJOR VESSEL 3 $987.42
33824 REVISE MAJOR VESSEL 3 $1,189.06
3382F AJCC CLN CNCR STAGE 0 DOCD 9 $0.00
33830 PATENT DUCTUS ARTERIOSUS LIGATION O O $0.00
33840 REMOVE AORTA CONSTRICTION 3 $1,217.72
33845 REMOVE AORTA CONSTRICTION 3 $1,375.14
3384F AJCC CLN CNCR STAGE 1 DOCD 9 $0.00
33851 REMOVE AORTA CONSTRICTION 3 $1,269.87
33852 REPAIR SEPTAL DEFECT 3 $1,480.43
33853 REPAIR SEPTAL DEFECT 3 $1,983.56
33855 EXCISION OF COARCTATION OF AORTA, W O $0.00
33860 ASCENDING AORTIC GRAFT 3 $3,231.58
33861 ASCENDING AORTIC GRAFT 3 $2,458.90
33863 ASCENDING AORTIC GRAFT 3 $3,195.23
33864 ASCENDING AORTIC GRAFT 3 $3,280.40
33865 ASCENDING AORTA GRAFT, WITH CARDIOP O $0.00
3386F AJCC CLN CNCR STAGE 2 DOCD 9 $0.00
33870 TRANSVERSE AORTIC ARCH GRAFT 3 $2,562.53

33875 THORACIC AORTIC GRAFT 3 $1,995.08
33877 THORACOABDOMINAL GRAFT 3 $3,646.90
33880 ENDOVASC TAA REPR INCL SUBCL 3 $1,872.43
33881 ENDOVASC TAA REPR W/O SUBCL 3 $1,608.43
33883 INSERT ENDOVASC PROSTH, TAA 3 $1,164.95
33884 ENDOVASC PROSTH, TAA, ADD-ON 3 $424.11
33886 ENDOVASC PROSTH, DELAYED 3 $1,001.75
33889 ARTERY TRANSPOSE/ENDOVAS TAA 3 $820.94
3388F AJCC CLN CNCR STAGE 3 DOCD 9 $0.00
33891 CAR-CAR BP GRFT/ENDOVAS TAA 3 $1,027.83
3390F AJCC CLN CNCR STAGE 4 DOCD 9 $0.00
33910 REMOVE LUNG ARTERY EMBOLI 3 $1,690.26
33915 REMOVE LUNG ARTERY EMBOLI 3 $1,375.75
33916 SURGERY OF GREAT VESSEL 3 $1,668.49
33917 REPAIR PULMONARY ARTERY 3 $1,498.41
33918 REPAIR PULMONARY ATRESIA O $0.00
33919 REPAIR PULMONARY ATRESIA O $0.00
33920 REPAIR PULMONARY ATRESIA 3 $1,835.08
33922 TRANSECT PULMONARY ARTERY 3 $1,397.91
33924 REMOVE PULMONARY SHUNT 3 $288.61
33925 RPR PUL ART UNIFOCAL W/O CPB 3 $1,756.07
33926 REPR PUL ART, UNIFOCAL W/CPB 3 $2,414.32
33930 REMOVAL OF DONOR HEART/LUNG 9 $0.00
33933 PREPARE DONOR HEART/LUNG 9 $0.00
33935 TRANSPLANTATION, HEART/LUNG 3 $3,502.26
33940 REMOVAL OF DONOR HEART 9 $0.00
33944 PREPARE DONOR HEART 9 $0.00
33945 TRANSPLANTATION OF HEART 3 $4,830.87
33960 EXTERNAL CIRCULATION ASSIST 3 $999.17
33961 EXTERNAL CIRCULATION ASSIST 3 $560.00
33967 INSERT IA PERCUT DEVICE 3 $277.82
33968 REMOVE AORTIC ASSIST DEVICE 3 $35.28
33970 AORTIC CIRCULATION ASSIST 3 $370.79
33971 AORTIC CIRCULATION ASSIST 3 $726.25
33972 INTRA-AORTIC BALLOON COUNTERPULSATI O $0.00
33973 INSERT BALLOON DEVICE 3 $537.47
33974 REMOVE INTRA-AORTIC BALLOON 3 $923.11
33975 IMPLANT VENTRICULAR DEVICE 3 $1,117.19
33976 IMPLANT VENTRICULAR DEVICE 3 $1,241.91
33977 REMOVE VENTRICULAR DEVICE 3 $1,219.95
33978 REMOVE VENTRICULAR DEVICE 3 $1,345.19
33979 INSERT INTRACORPOREAL DEVICE 3 $2,442.12
33980 REMOVE INTRACORPOREAL DEVICE 3 $3,655.84
33981 REPLACE VAD PUMP EXT 6 $0.00
33982 REPLACE VAD INTRA W/O BP 6 $0.00
33983 REPLACE VAD INTRA W/BP 6 $0.00
33999 CARDIAC SURGERY PROCEDURE 5 $0.00
34001 REMOVAL OF ARTERY CLOT 3 $996.34
34051 REMOVAL OF ARTERY CLOT 3 $991.57

34101 REMOVAL OF ARTERY CLOT 3 $626.59
34111 REMOVAL OF ARM ARTERY CLOT 3 $626.47
34151 REMOVAL OF ARTERY CLOT 3 $1,444.56
34201 REMOVAL OF ARTERY CLOT 3 $1,053.82
34203 REMOVAL OF LEG ARTERY CLOT 3 $1,000.50
34401 REMOVAL OF VEIN CLOT 3 $1,487.31
34421 REMOVAL OF VEIN CLOT 3 $761.08
34451 REMOVAL OF VEIN CLOT 3 $1,546.44
34471 REMOVAL OF VEIN CLOT 3 $1,153.55
34490 REMOVAL OF VEIN CLOT 3 $629.66
34501 REPAIR VALVE, FEMORAL VEIN 3 $964.29
34502 RECONSTRUCT VENA CAVA 3 $1,566.24
3450F DYSPNEA SCRND, NO-MILD DYSP 9 $0.00
34510 TRANSPOSITION OF VEIN VALVE 3 $1,123.33
3451F DYSPNEA SCRND MOD-HIGH DYSP 9 $0.00
34520 CROSS-OVER VEIN GRAFT 3 $1,062.23
3452F DYSPNEA NOT SCREENED 9 $0.00
34530 LEG VEIN FUSION 3 $1,030.04
3455F TB SCRNG DONE-INTERPD 6MON 9 $0.00
3470F RA DISEASE ACTIVITY, LOW 9 $0.00
3471F RA DISEASE ACTIVITY, MOD 9 $0.00
3472F RA DISEASE ACTIVITY, HIGH 9 $0.00
3475F DISEASE PROGN RA POOR DOCD 9 $0.00
3476F DISEASE PROGN RA GOOD DOCD 9 $0.00
34800 ENDOVAS AAA REPR W/SM TUBE 3 $1,181.82
34802 ENDOVAS AAA REPR W/2-P PART 3 $1,302.81
34803 ENDOVAS AAA REPR W/3-P PART 3 $1,344.85
34804 ENDOVAS AAA REPR W/1-P PART 3 $1,304.17
34805 ENDOVAS AAA REPR W/LONG TUBE 3 $1,232.95
34806 ANEURYSM PRESS SENSOR ADD-ON 3 $107.54
34808 ENDOVAS ILIAC A DEVICE ADDON 3 $212.42
34812 XPOSE FOR ENDOPROSTH, FEMORL 3 $349.00
34813 FEMORAL ENDOVAS GRAFT ADD-ON 3 $246.62
34820 XPOSE FOR ENDOPROSTH, ILIAC 3 $503.89
34825 ENDOVASC EXTEND PROSTH, INIT 3 $730.67
34826 ENDOVASC EXTEN PROSTH, ADDL 3 $214.44
34830 OPEN AORTIC TUBE PROSTH REPR 3 $1,886.90
34831 OPEN AORTOILIAC PROSTH REPR 3 $2,006.17
34832 OPEN AORTOFEMOR PROSTH REPR 3 $2,028.47
34833 XPOSE FOR ENDOPROSTH, ILIAC 3 $632.66
34834 XPOSE, ENDOPROSTH, BRACHIAL 3 $286.55
34900 ENDOVASC ILIAC REPR W/GRAFT 3 $938.93
3490F HISTORY - AIDS-DEFINING COND 9 $0.00
3491F HIV UNSURE BABY OF HIV+MOMS 9 $0.00
3492F HISTORY CD4+ CELL COUNT

3497F CD4+ CELL PERCENTAGE =15% 9 $0.00
35001 REPAIR DEFECT OF ARTERY 3 $1,174.69
35002 REPAIR ARTERY RUPTURE, NECK 3 $1,250.28
35005 REPAIR DEFECT OF ARTERY 3 $1,087.54
3500F CD4+CELL CNT/% DOCD AS DONE 9 $0.00
35011 REPAIR DEFECT OF ARTERY 3 $1,029.52
35013 REPAIR ARTERY RUPTURE, ARM 3 $1,281.25
35021 REPAIR DEFECT OF ARTERY 3 $1,256.56
35022 REPAIR ARTERY RUPTURE, CHEST 3 $1,427.43
3502F HIV RNA VRL LD

35226 REPAIR BLOOD VESSEL LESION 3 $866.96
35231 REPAIR BLOOD VESSEL LESION 3 $1,203.30
35236 REPAIR BLOOD VESSEL LESION 3 $1,005.27
35241 REPAIR BLOOD VESSEL LESION 3 $1,461.45
35246 REPAIR BLOOD VESSEL LESION 3 $1,562.73
35251 REPAIR BLOOD VESSEL LESION 3 $1,712.38
35256 REPAIR BLOOD VESSEL LESION 3 $1,055.18
35261 REPAIR BLOOD VESSEL LESION 3 $1,076.32
35266 REPAIR BLOOD VESSEL LESION 3 $888.04
35271 REPAIR BLOOD VESSEL LESION 3 $1,404.21
35276 REPAIR BLOOD VESSEL LESION 3 $1,460.64
35281 REPAIR BLOOD VESSEL LESION 3 $1,635.83
35286 REPAIR BLOOD VESSEL LESION 3 $971.43
35301 RECHANNELING OF ARTERY 3 $1,088.40
35302 RECHANNELING OF ARTERY 3 $1,158.19
35303 RECHANNELING OF ARTERY 3 $1,274.78
35304 RECHANNELING OF ARTERY 3 $1,324.69
35305 RECHANNELING OF ARTERY 3 $1,273.27
35306 RECHANNELING OF ARTERY 3 $470.73
35311 RECHANNELING OF ARTERY 3 $1,565.66
35321 RECHANNELING OF ARTERY 3 $926.06
35331 RECHANNELING OF ARTERY 3 $1,523.57
35341 RECHANNELING OF ARTERY 3 $1,428.65
35351 RECHANNELING OF ARTERY 3 $1,335.26
35355 RECHANNELING OF ARTERY 3 $1,085.43
35361 RECHANNELING OF ARTERY 3 $1,632.12
35363 RECHANNELING OF ARTERY 3 $1,786.37
35371 RECHANNELING OF ARTERY 3 $854.47
35372 RECHANNELING OF ARTERY 3 $1,023.45
35381 RECHANNELING OF ARTERY O $0.00
35390 REOPERATION, CAROTID ADD-ON 3 $166.05
35400 ANGIOSCOPY 3 $156.24
35450 REPAIR ARTERIAL BLOCKAGE 3 $533.83
35452 REPAIR ARTERIAL BLOCKAGE 3 $370.46
35454 REPAIR ARTERIAL BLOCKAGE 3 $323.04
35456 REPAIR ARTERIAL BLOCKAGE 3 $391.78
35458 REPAIR ARTERIAL BLOCKAGE 3 $505.38
35459 REPAIR ARTERIAL BLOCKAGE 3 $461.45
35460 REPAIR VENOUS BLOCKAGE 3 $322.30
35470 REPAIR ARTERIAL BLOCKAGE 3 $476.04
35471 REPAIR ARTERIAL BLOCKAGE 3 $567.34
35472 REPAIR ARTERIAL BLOCKAGE 3 $372.61
35473 REPAIR ARTERIAL BLOCKAGE 3 $335.94
35474 REPAIR ARTERIAL BLOCKAGE 3 $407.10
35475 REPAIR ARTERIAL BLOCKAGE 3 $508.34
35476 REPAIR VENOUS BLOCKAGE 3 $323.68
35480 ATHERECTOMY, OPEN 3 $581.37
35481 ATHERECTOMY, OPEN 3 $414.07
35482 ATHERECTOMY, OPEN 3 $360.95

35483 ATHERECTOMY, OPEN 3 $438.37
35484 ATHERECTOMY, OPEN 3 $549.00
35485 ATHERECTOMY, OPEN 3 $509.15
35490 ATHERECTOMY, PERCUTANEOUS 3 $638.57
35491 ATHERECTOMY, PERCUTANEOUS 3 $430.44
35492 ATHERECTOMY, PERCUTANEOUS 3 $389.36
35493 ATHERECTOMY, PERCUTANEOUS 3 $471.32
35494 ATHERECTOMY, PERCUTANEOUS 3 $601.30
35495 ATHERECTOMY, PERCUTANEOUS 3 $546.63
35500 HARVEST VEIN FOR BYPASS 3 $333.66
35501 ARTERY BYPASS GRAFT 3 $1,620.98
35506 ARTERY BYPASS GRAFT 3 $1,392.36
35507 ARTERY BYPASS GRAFT O $0.00
35508 ARTERY BYPASS GRAFT 3 $1,455.65
35509 ARTERY BYPASS GRAFT 3 $1,552.58
3550F LOW RSK THROMBOEMBOLISM 9 $0.00
35510 ARTERY BYPASS GRAFT 3 $1,325.52
35511 ARTERY BYPASS GRAFT 3 $1,247.40
35512 ARTERY BYPASS GRAFT 3 $1,293.57
35515 ARTERY BYPASS GRAFT 3 $1,410.09
35516 ARTERY BYPASS GRAFT 3 $1,281.92
35518 ARTERY BYPASS GRAFT 3 $1,239.10
3551F INTRMED RSK THROMBOEMBOLISM 9 $0.00
35521 ARTERY BYPASS GRAFT 3 $1,313.14
35522 ARTERY BYPASS GRAFT 3 $1,273.69
35523 ARTERY BYPASS GRAFT 3 $1,344.65
35525 ARTERY BYPASS GRAFT 3 $1,187.04
35526 ARTERY BYPASS GRAFT 3 $1,747.15
3552F HGH RISK FOR THROMBOEMBOLISM 9 $0.00
35531 ARTERY BYPASS GRAFT 3 $2,102.19
35533 ARTERY BYPASS GRAFT 3 $1,658.28
35535 ARTERY BYPASS GRAFT 3 $1,970.16
35536 ARTERY BYPASS GRAFT 3 $1,801.78
35537 ARTERY BYPASS GRAFT 3 $2,230.83
35538 ARTERY BYPASS GRAFT 3 $2,504.91
35539 ARTERY BYPASS GRAFT 3 $2,327.39
35540 ARTERY BYPASS GRAFT 3 $2,621.84
35541 ARTERY BYPASS GRAFT O $0.00
35546 ARTERY BYPASS GRAFT O $0.00
35548 ARTERY BYPASS GRAFT 3 $1,242.71
35549 ARTERY BYPASS GRAFT 3 $1,334.04
35551 ARTERY BYPASS GRAFT 3 $1,553.54
35556 ARTERY BYPASS GRAFT 3 $1,453.63
35558 ARTERY BYPASS GRAFT 3 $1,278.20
3555F PT INR MEASUREMENT PERFORMED 9 $0.00
35560 ARTERY BYPASS GRAFT 3 $1,849.50
35563 ARTERY BYPASS GRAFT 3 $1,446.33
35565 ARTERY BYPASS GRAFT 3 $1,376.38
35566 ARTERY BYPASS GRAFT 3 $1,740.17

35570 ARTERY BYPASS GRAFT 3 $1,528.15
35571 ARTERY BYPASS GRAFT 3 $1,394.46
35572 HARVEST FEMOROPOPLITEAL VEIN 3 $359.47
35582 VEIN BYPASS GRAFT O $0.00
35583 VEIN BYPASS GRAFT 3 $1,501.64
35585 VEIN BYPASS GRAFT 3 $1,747.90
35587 VEIN BYPASS GRAFT 3 $1,437.10
35600 HARVEST ART FOR CABG ADD-ON 3 $265.16
35601 ARTERY BYPASS GRAFT 3 $1,509.80
35606 ARTERY BYPASS GRAFT 3 $1,228.07
35612 ARTERY BYPASS GRAFT 3 $950.72
35616 ARTERY BYPASS GRAFT 3 $1,197.31
35621 ARTERY BYPASS GRAFT 3 $1,150.44
35623 BYPASS GRAFT, NOT VEIN 3 $1,406.30
35626 ARTERY BYPASS GRAFT 3 $1,618.50
35631 ARTERY BYPASS GRAFT 3 $1,928.31
35632 ARTERY BYPASS GRAFT 3 $1,870.84
35633 ARTERY BYPASS GRAFT 3 $2,018.54
35634 ARTERY BYPASS GRAFT 3 $1,830.93
35636 ARTERY BYPASS GRAFT 3 $1,710.29
35637 ARTERY BYPASS GRAFT 3 $1,782.42
35638 ARTERY BYPASS GRAFT 3 $1,818.55
35641 ARTERY BYPASS GRAFT O $0.00
35642 ARTERY BYPASS GRAFT 3 $1,072.52
35645 ARTERY BYPASS GRAFT 3 $1,030.39
35646 ARTERY BYPASS GRAFT 3 $1,792.12
35647 ARTERY BYPASS GRAFT 3 $1,621.19
35650 ARTERY BYPASS GRAFT 3 $1,109.60
35651 ARTERY BYPASS GRAFT 3 $1,451.23
35654 ARTERY BYPASS GRAFT 3 $1,432.97
35656 ARTERY BYPASS GRAFT 3 $1,128.18
35661 ARTERY BYPASS GRAFT 3 $1,133.75
35663 ARTERY BYPASS GRAFT 3 $1,312.91
35665 ARTERY BYPASS GRAFT 3 $1,228.02
35666 ARTERY BYPASS GRAFT 3 $1,326.36
35671 ARTERY BYPASS GRAFT 3 $1,169.46
35681 COMPOSITE BYPASS GRAFT 3 $83.21
35682 COMPOSITE BYPASS GRAFT 3 $370.42
35683 COMPOSITE BYPASS GRAFT 3 $436.14
35685 BYPASS GRAFT PATENCY/PATCH 3 $208.10
35686 BYPASS GRAFT/AV FIST PATENCY 3 $173.67
35691 ARTERIAL TRANSPOSITION 3 $1,017.69
35693 ARTERIAL TRANSPOSITION 3 $902.84
35694 ARTERIAL TRANSPOSITION 3 $1,054.66
35695 ARTERIAL TRANSPOSITION 3 $1,099.06
35697 REIMPLANT ARTERY EACH 3 $155.36
35700 REOPERATION, BYPASS GRAFT 3 $159.66
35701 EXPLORATION, CAROTID ARTERY 3 $555.18
3570F RPRT BONE SCINT XREF W XRAY 9 $0.00

35721 EXPLORATION, FEMORAL ARTERY 3 $468.74
3572F PT CONSID POSS RISK FX 9 $0.00
3573F PT NOT CONSID POSS RISK FX 9 $0.00
35741 EXPLORATION POPLITEAL ARTERY 3 $517.06
35761 EXPLORATION OF ARTERY/VEIN 3 $385.06
35800 EXPLORE NECK VESSELS 3 $492.89
35820 EXPLORE CHEST VESSELS 3 $1,992.41
35840 EXPLORE ABDOMINAL VESSELS 3 $643.87
35860 EXPLORE LIMB VESSELS 3 $418.47
35870 REPAIR VESSEL GRAFT DEFECT 3 $1,330.78
35875 REMOVAL OF CLOT IN GRAFT 3 $616.54
35876 REMOVAL OF CLOT IN GRAFT 3 $983.81
35879 REVISE GRAFT W/VEIN 3 $967.23
35881 REVISE GRAFT W/VEIN 3 $1,070.87
35883 REVISE GRAFT W/NONAUTO GRAFT 3 $1,247.18
35884 REVISE GRAFT W/VEIN 3 $1,308.78
35900 EXCISION OF INFECTED GRAFT O $0.00
35901 EXCISION, GRAFT, NECK 3 $519.23
35903 EXCISION, GRAFT, EXTREMITY 3 $584.55
35905 EXCISION, GRAFT, THORAX 3 $1,800.31
35907 EXCISION, GRAFT, ABDOMEN 3 $1,993.94
35910 EXCISION OF INFECTED GRAFT WITH REV O $0.00
36000 PLACE NEEDLE IN VEIN 3 $24.83
36002 PSEUDOANEURYSM INJECTION TRT 3 $166.95
36005 INJECTION EXT VENOGRAPHY 3 $50.76
36010 PLACE CATHETER IN VEIN 3 $126.52
36011 PLACE CATHETER IN VEIN 3 $163.38
36012 PLACE CATHETER IN VEIN 3 $874.59
36013 PLACE CATHETER IN ARTERY 3 $796.38
36014 PLACE CATHETER IN ARTERY 3 $835.50
36015 PLACE CATHETER IN ARTERY 3 $911.97
36100 ESTABLISH ACCESS TO ARTERY 3 $526.77
36120 ESTABLISH ACCESS TO ARTERY 3 $442.92
36140 ESTABLISH ACCESS TO ARTERY 3 $107.37
36145 ARTERY TO VEIN SHUNT O $0.00
36147 ACCESS AV DIAL GRFT FOR EVAL 3 $791.68
36148 ACCESS AV DIAL GRFT FOR PROC 3 $248.89
36160 ESTABLISH ACCESS TO AORTA 3 $524.14
36200 PLACE CATHETER IN AORTA 3 $155.51
36215 PLACE CATHETER IN ARTERY 3 $254.10
36216 PLACE CATHETER IN ARTERY 3 $286.30
36217 PLACE CATHETER IN ARTERY 3 $340.75
36218 PLACE CATHETER IN ARTERY 3 $54.20
36230 SELECTIVE CATHETER PLACEMENT, CORON O $0.00
36245 PLACE CATHETER IN ARTERY 3 $259.99
36246 PLACE CATHETER IN ARTERY 3 $284.63
36247 PLACE CATHETER IN ARTERY 3 $338.80
36248 PLACE CATHETER IN ARTERY 3 $162.68
36260 INSERTION OF INFUSION PUMP 3 $596.43

36261 REVISION OF INFUSION PUMP 3 $361.23
36262 REMOVAL OF INFUSION PUMP 3 $277.33
36299 VESSEL INJECTION PROCEDURE 5 $0.00
36400 BL DRAW < 3 YRS FEM/JUGULAR 3 $26.58
36405 BL DRAW < 3 YRS SCALP VEIN 3 $24.02
36406 BL DRAW < 3 YRS OTHER VEIN 3 $17.27
36410 NON-ROUTINE BL DRAW > 3 YRS 3 $19.16
36415 ROUTINE VENIPUNCTURE 3 $2.94
36416 CAPILLARY BLOOD DRAW 9 $0.00
36420 VEIN ACCESS CUTDOWN < 1 YR 3 $50.07
36425 VEIN ACCESS CUTDOWN > 1 YR 3 $39.17
36430 BLOOD TRANSFUSION SERVICE 3 $34.64
36440 BL PUSH TRANSFUSE, 2 YR OR < 3 $53.75
36450 BL EXCHANGE/TRANSFUSE, NB 3 $114.80
36455 BL EXCHANGE/TRANSFUSE NON-NB 3 $127.14
36460 TRANSFUSION SERVICE, FETAL 3 $344.24
36468 INJECTION(S), SPIDER VEINS 5 $0.00
36469 INJECTION(S), SPIDER VEINS 9 $0.00
36470 INJECTION THERAPY OF VEIN 3 $138.97
36471 INJECTION THERAPY OF VEINS 3 $170.86
36475 ENDOVENOUS RF, 1ST VEIN 3 $357.16
36476 ENDOVENOUS RF, VEIN ADD-ON 3 $175.02
36478 ENDOVENOUS LASER, 1ST VEIN 3 $357.71
36479 ENDOVENOUS LASER VEIN ADDON 3 $174.93
36481 INSERTION OF CATHETER, VEIN 3 $812.94
36488 INSERTION OF CATHETER, VEIN O $0.00
36489 INSERTION OF CATHETER, VEIN O $0.00
36490 INSERTION OF CATHETER, VEIN O $0.00
36491 INSERTION OF CATHETER, VEIN O $0.00
36493 REPOSITIONING OF CVC O $0.00
36495 INSERTION OF IMPLANTABLE INTRAVENOU O $0.00
36496 REVISION OF IMPLANTABLE INTRAVENOUS O $0.00
36497 REMOVAL OF IMPLANTABLE INTRAVENOUS O $0.00
36500 INSERTION OF CATHETER, VEIN 3 $186.54
3650F EEG ORDERED RVWD REQSTD 9 $0.00
36510 INSERTION OF CATHETER, VEIN 3 $106.22
36511 APHERESIS WBC 3 $93.41
36512 APHERESIS RBC 3 $92.21
36513 APHERESIS PLATELETS 3 $96.53
36514 APHERESIS PLASMA 3 $509.57
36515 APHERESIS, ADSORP/REINFUSE 3 $1,911.74
36516 APHERESIS, SELECTIVE 3 $2,121.49
36520 PLASMA AND/OR CELL EXCHANGE O $0.00
36521 APHERESIS W/ ADSORP/REINFUSE O $0.00
36522 PHOTOPHERESIS 3 $101.37
36530 INSERTION OF INFUSION PUMP O $0.00
36531 REVISION OF INFUSION PUMP O $0.00
36532 REMOVAL OF INFUSION PUMP O $0.00
36533 INSERTION OF ACCESS DEVICE O $0.00

36534 REVISION OF ACCESS DEVICE O $0.00
36535 REMOVAL OF ACCESS DEVICE O $0.00
36536 REMOVE CVA DEVICE OBSTRUCT O $0.00
36537 REMOVE CVA LUMEN OBSTRUCT O $0.00
36540 COLLECT BLOOD VENOUS DEVICE O $0.00
36550 DECLOT VASCULAR DEVICE O $0.00
36555 INSERT NON-TUNNEL CV CATH 3 $265.11
36556 INSERT NON-TUNNEL CV CATH 3 $121.54
36557 INSERT TUNNELED CV CATH 3 $310.56
36558 INSERT TUNNELED CV CATH 3 $276.92
36560 INSERT TUNNELED CV CATH 3 $348.43
36561 INSERT TUNNELED CV CATH 3 $351.25
36563 INSERT TUNNELED CV CATH 3 $363.36
36565 INSERT TUNNELED CV CATH 3 $975.70
36566 INSERT TUNNELED CV CATH 3 $3,978.73
36568 INSERT PICC CATH 3 $97.52
36569 INSERT PICC CATH 3 $95.37
36570 INSERT PICVAD CATH 3 $1,132.57
36571 INSERT PICVAD CATH 3 $315.14
36575 REPAIR TUNNELED CV CATH 3 $156.98
36576 REPAIR TUNNELED CV CATH 3 $365.02
36578 REPLACE TUNNELED CV CATH 3 $503.25
36580 REPLACE CVAD CATH 3 $68.56
36581 REPLACE TUNNELED CV CATH 3 $204.53
36582 REPLACE TUNNELED CV CATH 3 $1,068.39
36583 REPLACE TUNNELED CV CATH 3 $1,128.92
36584 REPLACE PICC CATH 3 $217.40
36585 REPLACE PICVAD CATH 3 $1,080.47
36589 REMOVAL TUNNELED CV CATH 3 $165.88
36590 REMOVAL TUNNELED CV CATH 3 $275.02
36591 DRAW BLOOD OFF VENOUS DEVICE 3 $22.55
36592 COLLECT BLOOD FROM PICC 3 $24.81
36593 DECLOT VASCULAR DEVICE 3 $27.08
36595 MECH REMOV TUNNELED CV CATH 3 $591.83
36596 MECH REMOV TUNNELED CV CATH 3 $134.19
36597 REPOSITION VENOUS CATHETER 3 $125.92
36598 INJ W/FLUOR, EVAL CV DEVICE 3 $112.93
36600 WITHDRAWAL OF ARTERIAL BLOOD 3 $30.32
36620 INSERTION CATHETER, ARTERY 3 $50.53
36625 INSERTION CATHETER, ARTERY 3 $106.60
36640 INSERTION CATHETER, ARTERY 3 $121.74
36660 INSERTION CATHETER, ARTERY 3 $68.23
36680 INSERT NEEDLE, BONE CAVITY 3 $59.86
36800 INSERTION OF CANNULA 3 $159.50
36810 INSERTION OF CANNULA 3 $212.71
36815 INSERTION OF CANNULA 3 $150.36
36818 AV FUSE, UPPR ARM, CEPHALIC 3 $680.21
36819 AV FUSE, UPPR ARM, BASILIC 3 $809.44
36820 AV FUSION/FOREARM VEIN 3 $813.72

36821 AV FUSION DIRECT ANY SITE 3 $690.74
36822 INSERTION OF CANNULA(S) 3 $380.98
36823 INSERTION OF CANNULA(S) 3 $1,302.75
36825 ARTERY-VEIN AUTOGRAFT 3 $810.05
36830 ARTERY-VEIN NONAUTOGRAFT 3 $668.54
36831 OPEN THROMBECT AV FISTULA 3 $463.27
36832 AV FISTULA REVISION, OPEN 3 $589.73
36833 AV FISTULA REVISION 3 $666.09
36834 REPAIR A-V ANEURYSM O $0.00
36835 ARTERY TO VEIN SHUNT 3 $474.28
36838 DIST REVAS LIGATION, HEMO 3 $1,189.76
36840 INSERTION MANDRIL O $0.00
36845 ANASTOMOSIS MANDRIL O $0.00
36860 EXTERNAL CANNULA DECLOTTING 3 $194.50
36861 CANNULA DECLOTTING 3 $152.80
36870 PERCUT THROMBECT AV FISTULA 3 $311.84
37140 REVISION OF CIRCULATION 3 $1,406.68
37145 REVISION OF CIRCULATION 3 $1,482.21
37160 REVISION OF CIRCULATION 3 $1,297.90
37180 REVISION OF CIRCULATION 3 $1,450.02
37181 SPLICE SPLEEN/KIDNEY VEINS 3 $1,568.55
37182 INSERT HEPATIC SHUNT (TIPS) 3 $894.80
37183 REMOVE HEPATIC SHUNT (TIPS) 3 $5,112.61
37184 PRIM ART MECH THROMBECTOMY 3 $2,377.84
37185 PRIM ART M-THROMBECT ADD-ON 3 $786.65
37186 SEC ART M-THROMBECT ADD-ON 3 $1,581.42
37187 VENOUS MECH THROMBECTOMY 3 $433.13
37188 VENOUS M-THROMBECTOMY ADD-ON 3 $1,920.48
37190 PLASTIC REPAIR OF ARTERIOVENOUS ANE O $0.00
37195 THROMBOLYTIC THERAPY, STROKE 3 $326.02
37200 TRANSCATHETER BIOPSY 3 $237.32
37201 TRANSCATHETER THERAPY INFUSE 3 $287.49
37202 TRANSCATHETER THERAPY INFUSE 3 $349.41
37203 TRANSCATHETER RETRIEVAL 3 $275.02
37204 TRANSCATHETER OCCLUSION 3 $945.72
37205 TRANSCATH IV STENT, PERCUT 3 $454.66
37206 TRANSCATH IV STENT/PERC ADDL 3 $223.05
37207 TRANSCATH IV STENT, OPEN 3 $441.15
37208 TRANSCATH IV STENT/OPEN ADDL 3 $212.91
37209 CHANGE IV CATH AT THROMB TX 3 $118.67
37210 EMBOLIZATION UTERINE FIBROID 3 $561.73
37215 TRANSCATH STENT, CCA W/EPS 3 $1,150.86
37216 TRANSCATH STENT, CCA W/O EPS 3 $1,030.78
37250 IV US FIRST VESSEL ADD-ON 3 $113.53
37251 IV US EACH ADD VESSEL ADD-ON 3 $84.10
37500 ENDOSCOPY LIGATE PERF VEINS 3 $704.19
37501 VASCULAR ENDOSCOPY PROCEDURE 5 $0.00
37565 LIGATION OF NECK VEIN 3 $706.51
37600 LIGATION OF NECK ARTERY 3 $716.14

37605 LIGATION OF NECK ARTERY 3 $815.53
37606 LIGATION OF NECK ARTERY 3 $537.09
37607 LIGATION OF A-V FISTULA 3 $380.07
37609 TEMPORAL ARTERY PROCEDURE 3 $291.89
37615 LIGATION OF NECK ARTERY 3 $484.69
37616 LIGATION OF CHEST ARTERY 3 $1,092.23
37617 LIGATION OF ABDOMEN ARTERY 3 $1,301.21
37618 LIGATION OF EXTREMITY ARTERY 3 $381.64
37620 REVISION OF MAJOR VEIN 3 $668.00
37650 REVISION OF MAJOR VEIN 3 $512.55
37660 REVISION OF MAJOR VEIN 3 $1,233.58
37700 REVISE LEG VEIN 3 $253.40
37718 LIGATE/STRIP SHORT LEG VEIN 3 $437.20
37720 REMOVAL OF LEG VEIN O $0.00
37722 LIGATE/STRIP LONG LEG VEIN 3 $487.55
37730 REMOVAL OF LEG VEINS O $0.00
37735 REMOVAL OF LEG VEINS/LESION 3 $635.23
37760 LIGATE LEG VEINS RADICAL 3 $636.07
37761 LIGATE LEG VEINS OPEN 3 $571.80
37765 PHLEB VEINS - EXTREM - TO 20 3 $462.17
37766 PHLEB VEINS - EXTREM 20+ 3 $565.69
37780 REVISION OF LEG VEIN 3 $261.82
37785 LIGATE/DIVIDE/EXCISE VEIN 3 $352.15
37788 REVASCULARIZATION, PENIS 3 $1,391.02
37790 PENILE VENOUS OCCLUSION 3 $493.14
37799 VASCULAR SURGERY PROCEDURE 5 $0.00
38100 REMOVAL OF SPLEEN, TOTAL 3 $1,075.35
38101 REMOVAL OF SPLEEN, PARTIAL 3 $1,080.61
38102 REMOVAL OF SPLEEN, TOTAL 3 $250.33
38115 REPAIR OF RUPTURED SPLEEN 3 $1,191.37
38120 LAPAROSCOPY, SPLENECTOMY 3 $983.74
38129 LAPAROSCOPE PROC, SPLEEN 5 $0.00
38200 INJECTION FOR SPLEEN X-RAY 3 $145.89
38204 BL DONOR SEARCH MANAGEMENT 9 $0.00
38205 HARVEST ALLOGENIC STEM CELLS 9 $0.00
38206 HARVEST AUTO STEM CELLS 3 $80.19
38207 CRYOPRESERVE STEM CELLS 9 $0.00
38208 THAW PRESERVED STEM CELLS 9 $0.00
38209 WASH HARVEST STEM CELLS 9 $0.00
38210 T-CELL DEPLETION OF HARVEST 9 $0.00
38211 TUMOR CELL DEPLETE OF HARVST 9 $0.00
38212 RBC DEPLETION OF HARVEST 9 $0.00
38213 PLATELET DEPLETE OF HARVEST 9 $0.00
38214 VOLUME DEPLETE OF HARVEST 9 $0.00
38215 HARVEST STEM CELL CONCENTRTE 9 $0.00
38220 BONE MARROW ASPIRATION 3 $149.52
38221 BONE MARROW BIOPSY 3 $164.16
38230 BONE MARROW COLLECTION 3 $322.14
38231 STEM CELL COLLECTION O $0.00

38240 BONE MARROW/STEM TRANSPLANT 3 $124.09
38241 BONE MARROW/STEM TRANSPLANT 3 $124.35
38242 LYMPHOCYTE INFUSE TRANSPLANT 3 $94.42
38300 DRAINAGE, LYMPH NODE LESION 3 $257.23
38305 DRAINAGE, LYMPH NODE LESION 3 $438.14
38308 INCISION OF LYMPH CHANNELS 3 $422.79
38380 THORACIC DUCT PROCEDURE 3 $544.87
38381 THORACIC DUCT PROCEDURE 3 $795.25
38382 THORACIC DUCT PROCEDURE 3 $657.29
38500 BIOPSY/REMOVAL, LYMPH NODES 3 $302.10
38505 NEEDLE BIOPSY, LYMPH NODES 3 $123.23
38510 BIOPSY/REMOVAL, LYMPH NODES 3 $487.27
38520 BIOPSY/REMOVAL, LYMPH NODES 3 $439.92
38525 BIOPSY/REMOVAL, LYMPH NODES 3 $401.53
38530 BIOPSY/REMOVAL, LYMPH NODES 3 $512.52
38542 EXPLORE DEEP NODE(S), NECK 9 $0.00
38550 REMOVAL, NECK/ARMPIT LESION 3 $461.06
38555 REMOVAL, NECK/ARMPIT LESION 3 $945.43
38562 REMOVAL, PELVIC LYMPH NODES 3 $671.79
38564 REMOVAL, ABDOMEN LYMPH NODES 3 $669.72
38570 LAPAROSCOPY, LYMPH NODE BIOP 3 $530.00
38571 LAPAROSCOPY, LYMPHADENECTOMY 3 $823.71
38572 LAPAROSCOPY, LYMPHADENECTOMY 3 $920.14
38589 LAPAROSCOPE PROC, LYMPHATIC 5 $0.00
38700 REMOVAL OF LYMPH NODES, NECK 3 $772.74
38720 REMOVAL OF LYMPH NODES, NECK 3 $1,287.75
38724 REMOVAL OF LYMPH NODES, NECK 3 $1,393.34
38740 REMOVE ARMPIT LYMPH NODES 3 $640.97
38745 REMOVE ARMPIT LYMPH NODES 3 $814.25
38746 REMOVE THORACIC LYMPH NODES 3 $258.96
38747 REMOVE ABDOMINAL LYMPH NODES 3 $255.49
38760 REMOVE GROIN LYMPH NODES 3 $796.13
38765 REMOVE GROIN LYMPH NODES 3 $1,233.07
38770 REMOVE PELVIS LYMPH NODES 3 $804.41
38780 REMOVE ABDOMEN LYMPH NODES 3 $1,020.78
38790 INJECT FOR LYMPHATIC X-RAY 3 $81.02
38792 IDENTIFY SENTINEL NODE 3 $38.98
38794 ACCESS THORACIC LYMPH DUCT 3 $301.11
38999 BLOOD/LYMPH SYSTEM PROCEDURE 5 $0.00
39000 EXPLORATION OF CHEST 3 $484.72
39010 EXPLORATION OF CHEST 3 $793.35
39020 MEDIASTINOTOMY WITH EXPLORATION, DR O $0.00
39200 REMOVAL CHEST LESION 3 $877.30
39220 REMOVAL CHEST LESION 3 $1,133.51
39400 VISUALIZATION OF CHEST 3 $500.26
39499 CHEST PROCEDURE 5 $0.00
39501 REPAIR DIAPHRAGM LACERATION 3 $811.09
39502 REPAIR PARAESOPHAGEAL HERNIA 3 $976.51
39503 REPAIR OF DIAPHRAGM HERNIA 3 $5,748.66

39520 REPAIR OF DIAPHRAGM HERNIA 3 $968.49
39530 REPAIR OF DIAPHRAGM HERNIA 3 $929.53
39531 REPAIR OF DIAPHRAGM HERNIA 3 $976.46
39540 REPAIR OF DIAPHRAGM HERNIA 3 $829.54
39541 REPAIR OF DIAPHRAGM HERNIA 3 $897.44
39545 REVISION OF DIAPHRAGM 3 $880.54
39547 IMBRICATION OF DIAPHRAGM FOR EVENTR O $0.00
39560 RESECT DIAPHRAGM, SIMPLE 3 $761.70
39561 RESECT DIAPHRAGM, COMPLEX 3 $1,195.47
39599 DIAPHRAGM SURGERY PROCEDURE 5 $0.00
4000F TOBACCO USE TXMNT COUNSELING 9 $0.00
4001F TOBACCO USE TXMNT, PHARMACOL 9 $0.00
4002F STATIN THERAPY, RX 9 $0.00
4003F PT ED WRITE/ORAL, PTS W/ HF 9 $0.00
4004F PT TOBACCO USE DONE RCVD TLK 9 $0.00
4005F PHARM THX FOR OP RXD 9 $0.00
4006F BETA-BLOCKER THERAPY RX 9 $0.00
4007F ANTIOX VIT/MIN SUPP RXÏD O $0.00
4009F ACE/ARB INHIBITOR THERAPY RX 9 $0.00
4011F ORAL ANTIPLATELET THERAPY RX 9 $0.00
4012F WARFARIN THERAPY RX 9 $0.00
4014F WRITTEN DISCHARGE INSTR PRVD 9 $0.00
4015F PERSIST ASTHMA MEDICINE CTRL 9 $0.00
4016F ANTI-INFLM/ANLGSC AGENT RX 9 $0.00
4017F GI PROPHYLAXIS FOR NSAID RX 9 $0.00
4018F THERAPY EXERCISE JOINT RX 9 $0.00
4019F DOC RECPT COUNSL VIT D/CALC+ 9 $0.00
4025F INHALED BRONCHODILATOR RX 9 $0.00
4030F OXYGEN THERAPY RX 9 $0.00
4033F PULMONARY REHAB REC 9 $0.00
4035F INFLUENZA IMM REC 9 $0.00
4037F INFLUENZA IMM ORDER/ADMIN 9 $0.00
4040F PNEUMOC VAC/ADMIN/RCVD 9 $0.00
4041F DOC ORDER CEFAZOLIN/CEFUROX 9 $0.00
4042F DOC ANTIBIO NOT GIVEN 9 $0.00
4043F DOC ORDER GIVEN STOP ANTIBIO 9 $0.00
4044F DOC ORDER GIVEN VTE PROPHYLX 9 $0.00
4045F EMPIRIC ANTIBIOTIC RX 9 $0.00
4046F DOC ANTIBIO GIVEN B/4 SURG 9 $0.00
4047F DOC ANTIBIO GIVEN B/4 SURG 9 $0.00
4048F DOC ANTIBIO GIVEN B/4 SURG 9 $0.00
40490 BIOPSY OF LIP 3 $123.35
4049F DOC ORDER GIVEN STOP ANTIBIO 9 $0.00
40500 PARTIAL EXCISION OF LIP 3 $473.15
4050F HT CARE PLAN DOC 9 $0.00
40510 PARTIAL EXCISION OF LIP 3 $454.17
4051F REFERRED FOR AN AV FISTULA 9 $0.00
40520 PARTIAL EXCISION OF LIP 3 $465.15
40525 RECONSTRUCT LIP WITH FLAP 3 $533.87

40527 RECONSTRUCT LIP WITH FLAP 3 $620.59
4052F HEMODIALYSIS VIA AV FISTULA 9 $0.00
40530 PARTIAL REMOVAL OF LIP 3 $514.92
4053F HEMODIALYSIS VIA AV GRAFT 9 $0.00
4054F HEMODIALYSIS VIA CATHETER 9 $0.00
4055F PT RCVNG PERITON DIALYSIS 9 $0.00
4056F APPROP ORAL REHYD RECOMMD 9 $0.00
4058F PED GASTRO ED GIVEN, CAREGVR 9 $0.00
4060F PSYCH SVCS PROVIDED 9 $0.00
4062F PT REFERRAL PSYCH DOCD 9 $0.00
4063F ANTIDEPRES RXTHXPY NOT RXD 9 $0.00
4064F ANTIDEPRESSANT RX 9 $0.00
40650 REPAIR LIP 3 $390.25
40652 REPAIR LIP 3 $457.53
40654 REPAIR LIP 3 $537.77
4065F ANTIPSYCHOTIC RX 9 $0.00
4066F ECT PROVIDED 9 $0.00
4067F PT REFERRAL FOR ECT DOCD 9 $0.00
40700 REPAIR CLEFT LIP/NASAL 3 $896.35
40701 REPAIR CLEFT LIP/NASAL 3 $1,089.84
40702 REPAIR CLEFT LIP/NASAL 3 $828.85
4070F DVT PROPHYLX RECVD DAY 2 9 $0.00
40720 REPAIR CLEFT LIP/NASAL 3 $963.26
4073F ORAL ANTIPLAT THX RX DISCHRG 9 $0.00
4075F ANTICOAG THX RX AT DISCHRG 9 $0.00
40761 REPAIR CLEFT LIP/NASAL 3 $1,034.93
4077F DOC T-PA ADMIN CONSIDERED 9 $0.00
40799 LIP SURGERY PROCEDURE 5 $0.00
4079F DOC REHAB SVCS CONSIDERED 9 $0.00
40800 DRAINAGE OF MOUTH LESION 3 $190.24
40801 DRAINAGE OF MOUTH LESION 3 $289.80
40804 REMOVAL, FOREIGN BODY, MOUTH 3 $195.58
40805 REMOVAL, FOREIGN BODY, MOUTH 3 $300.31
40806 INCISION OF LIP FOLD 3 $97.86
40808 BIOPSY OF MOUTH LESION 3 $170.64
40810 EXCISION OF MOUTH LESION 3 $189.32
40812 EXCISE/REPAIR MOUTH LESION 3 $264.57
40814 EXCISE/REPAIR MOUTH LESION 3 $356.02
40816 EXCISION OF MOUTH LESION 3 $375.71
40818 EXCISE ORAL MUCOSA FOR GRAFT 3 $333.01
40819 EXCISE LIP OR CHEEK FOLD 3 $283.92
40820 TREATMENT OF MOUTH LESION 3 $246.42
40830 REPAIR MOUTH LACERATION 3 $230.12
40831 REPAIR MOUTH LACERATION 3 $303.32
40840 RECONSTRUCTION OF MOUTH 3 $755.86
40842 RECONSTRUCTION OF MOUTH 3 $763.05
40843 RECONSTRUCTION OF MOUTH 3 $985.81
40844 RECONSTRUCTION OF MOUTH 3 $1,300.60
40845 RECONSTRUCTION OF MOUTH 3 $1,403.88

4084F ASPIRIN RECVD W/IN 24 HRS 9 $0.00
40899 MOUTH SURGERY PROCEDURE 5 $0.00
4090F PT RCVNG EPO THXPY 9 $0.00
4095F PT NOT RCVNG EPO THXPY 9 $0.00
41000 DRAINAGE OF MOUTH LESION 3 $150.40
41005 DRAINAGE OF MOUTH LESION 3 $212.19
41006 DRAINAGE OF MOUTH LESION 3 $337.50
41007 DRAINAGE OF MOUTH LESION 3 $337.43
41008 DRAINAGE OF MOUTH LESION 3 $347.05
41009 DRAINAGE OF MOUTH LESION 3 $368.63
4100F BIPHOS THXPY VEIN ORD/RECVD 9 $0.00
41010 INCISION OF TONGUE FOLD 3 $190.79
41015 DRAINAGE OF MOUTH LESION 3 $397.24
41016 DRAINAGE OF MOUTH LESION 3 $404.91
41017 DRAINAGE OF MOUTH LESION 3 $409.44
41018 DRAINAGE OF MOUTH LESION 3 $466.16
41019 PLACE NEEDLES H&N FOR RT 3 $476.92
41100 BIOPSY OF TONGUE 3 $158.36
41105 BIOPSY OF TONGUE 3 $159.44
41108 BIOPSY OF FLOOR OF MOUTH 3 $137.13
4110F INT MAM ART USED FOR CABG 9 $0.00
41110 EXCISION OF TONGUE LESION 3 $197.73
41112 EXCISION OF TONGUE LESION 3 $310.33
41113 EXCISION OF TONGUE LESION 3 $339.08
41114 EXCISION OF TONGUE LESION 3 $612.41
41115 EXCISION OF TONGUE FOLD 3 $227.93
41116 EXCISION OF MOUTH LESION 3 $305.32
41120 PARTIAL REMOVAL OF TONGUE 3 $1,010.10
41130 PARTIAL REMOVAL OF TONGUE 3 $1,250.91
41135 TONGUE AND NECK SURGERY 3 $2,078.75
41140 REMOVAL OF TONGUE 3 $2,120.21
41145 TONGUE REMOVAL, NECK SURGERY 3 $2,666.30
41150 TONGUE, MOUTH, JAW SURGERY 3 $2,115.05
41153 TONGUE, MOUTH, NECK SURGERY 3 $2,296.06
41155 TONGUE, JAW, & NECK SURGERY 3 $2,868.36
4115F BETA BLCKR ADMIN W/IN 24 HRS 9 $0.00
4120F ANTIBIOT RXD/GIVEN 9 $0.00
4124F ANTIBIOT NOT RXD/GIVEN 9 $0.00
41250 REPAIR TONGUE LACERATION 3 $219.61
41251 REPAIR TONGUE LACERATION 3 $227.73
41252 REPAIR TONGUE LACERATION 3 $291.27
4130F TOPICAL PREP RX AOE 9 $0.00
4131F SYST ANTIMICROBIAL THX RX 9 $0.00
4132F NO SYST ANTIMICROBIAL THX RX 9 $0.00
4133F ANTIHIST/DECONG RX/RECOM 9 $0.00
4134F NO ANTIHIST/DECONG RX/RECOM 9 $0.00
4135F SYSTEMIC CORTICOSTEROIDS RX 9 $0.00
4136F SYST CORTICOSTEROIDS NOT RX 9 $0.00
4148F HEP A VAC INJXN ADMIN/RECVD 9 $0.00

4149F HEP B VAC INJXN ADMIN/RECVD 9 $0.00
41500 FIXATION OF TONGUE 3 $429.99
4150F PT RECVNG ANTIVIR TXMNT HEPC 9 $0.00
41510 TONGUE TO LIP SURGERY 3 $401.04
41512 TONGUE SUSPENSION 3 $596.97
4151F PT NOT RECVNG ANTIV HEP C 9 $0.00
41520 RECONSTRUCTION, TONGUE FOLD 3 $324.07
4152F DOCÏD PEGINTF/RIB THXY CONSD O $0.00
41530 TONGUE BASE VOL REDUCTION 3 $2,988.22
4153F COMBO PEGINTF/RIB RX 9 $0.00
4154F HEP A VAC SERIES RECOMMENDED O $0.00
4155F HEP A VAC SERIES PREV RECVD 9 $0.00
4156F HEP B VAC SERIES RECOMMENDED O $0.00
4157F HEP B VAC SERIES PREV RECVD 9 $0.00
4158F PT EDU RE ALCOH DRNKNG DONE 9 $0.00
41599 TONGUE AND MOUTH SURGERY 5 $0.00
4159F CONTRCP TALK B/4 ANTIV TXMNT 9 $0.00
4163F PT COUNS 4 TXMNT OPT PROST 9 $0.00
4164F ADJV HRMNL THXPY RXD 9 $0.00
4165F 3D-CRT/IMRT) RECEIVED 9 $0.00
4167F HD BED TILTED 1ST DAY VENT 9 $0.00
4168F PT CARE ICU&VENT W/IN 24HRS 9 $0.00
4169F NO PT CARE ICU/VENT IN 24HRS 9 $0.00
4171F PT RCVNG ESA THXPY 9 $0.00
4172F PT NOT RCVNG ESA THXPY 9 $0.00
4174F COUNS POTENT GLAUC IMPCT 9 $0.00
4175F VIS OF >= 20/40 W/IN 90 DAYS 9 $0.00
4176F TALK RE UV LIGHT PT/CRGVR 9 $0.00
4177F TALK PT/CRGVR RE AREDS PREV 9 $0.00
4178F ANTID GLBLN RCVD W/IN 26WKS 9 $0.00
4179F TAMOXIFEN/AI PRESCRIBED 9 $0.00
41800 DRAINAGE OF GUM LESION 3 $221.17
41805 REMOVAL FOREIGN BODY, GUM 3 $227.90
41806 REMOVAL FOREIGN BODY,JAWBONE 3 $323.02
4180F ADJV THXPYRXD/RCVD STG3A-C 9 $0.00
4181F CONFORMAL RADN THXPY RCVD 9 $0.00
41820 EXCISION, GUM, EACH QUADRANT 5 $0.00
41821 EXCISION OF GUM FLAP 5 $0.00
41822 EXCISION OF GUM LESION 3 $267.55
41823 EXCISION OF GUM LESION 3 $398.42
41825 EXCISION OF GUM LESION 3 $193.90
41826 EXCISION OF GUM LESION 3 $273.98
41827 EXCISION OF GUM LESION 3 $403.88
41828 EXCISION OF GUM LESION 3 $282.08
4182F NO CONFORMAL RADN THXPY 9 $0.00
41830 REMOVAL OF GUM TISSUE 3 $359.91
41850 TREATMENT OF GUM LESION 5 $0.00
4185F CONTINUOUS PPI OR H2RA RCVD 9 $0.00
4186F NO CONT PPI OR H2RA RCVD 9 $0.00

41870 GUM GRAFT 5 $0.00
41872 REPAIR GUM 3 $343.75
41874 REPAIR TOOTH SOCKET 3 $341.36
4187F ANTI RHEUM DRUGTHXPYRXD/GVN 9 $0.00
4188F APPROP ACE/ARB TSTNG DONE 9 $0.00
41899 DENTAL SURGERY PROCEDURE 5 $0.00
4189F APPROP DIGOXIN TSTNG DONE 9 $0.00
4190F APPROP DIURETIC TSTNG DONE 9 $0.00
4191F APPROP ANTICONVULS TSTNG 9 $0.00
4192F PT NOT RCVNG GLUCOCO THXPY 9 $0.00
4193F PT RCVNG=10MG PREDNISON QD 9 $0.00
4195F PT RCVNG ANTI-RHEUM THXPY RA 9 $0.00
4196F PTNOT RCVNG ANTI-RHM THXPYRA 9 $0.00
42000 DRAINAGE MOUTH ROOF LESION 3 $147.60
4200F EXTERNAL BEAM TO PROST ONLY 9 $0.00
4201F EXTRNL BEAM OTHER THAN PROST 9 $0.00
42100 BIOPSY ROOF OF MOUTH 3 $140.56
42104 EXCISION LESION, MOUTH ROOF 3 $197.44
42106 EXCISION LESION, MOUTH ROOF 3 $248.49
42107 EXCISION LESION, MOUTH ROOF 3 $431.12
4210F ACE/ARB THXPY FOR >= 6 MONS 9 $0.00
42120 REMOVE PALATE/LESION 3 $948.67
42140 EXCISION OF UVULA 3 $236.74
42145 REPAIR PALATE, PHARYNX/UVULA 3 $682.97
42160 TREATMENT MOUTH ROOF LESION 3 $224.32
42180 REPAIR PALATE 3 $230.19
42182 REPAIR PALATE 3 $309.71
42200 RECONSTRUCT CLEFT PALATE 3 $845.37
42205 RECONSTRUCT CLEFT PALATE 3 $891.48
4220F DIGOXIN THXPY FOR >= 6 MONS 9 $0.00
42210 RECONSTRUCT CLEFT PALATE 3 $1,027.73
42215 RECONSTRUCT CLEFT PALATE 3 $665.56
4221F DIURETIC THXPY FOR >= 6 MONS 9 $0.00
42220 RECONSTRUCT CLEFT PALATE 3 $518.60
42225 RECONSTRUCT CLEFT PALATE 3 $891.25
42226 LENGTHENING OF PALATE 3 $887.58
42227 LENGTHENING OF PALATE 3 $855.04
42235 REPAIR PALATE 3 $712.28
42260 REPAIR NOSE TO LIP FISTULA 3 $785.82
42280 PREPARATION, PALATE MOLD 9 $0.00
42281 INSERTION, PALATE PROSTHESIS 3 $193.03
42299 PALATE/UVULA SURGERY 5 $0.00
42300 DRAINAGE OF SALIVARY GLAND 3 $197.43
42305 DRAINAGE OF SALIVARY GLAND 3 $418.70
4230F ANTICONV THXPY FOR >= 6 MONS 9 $0.00
42310 DRAINAGE OF SALIVARY GLAND 3 $153.45
42320 DRAINAGE OF SALIVARY GLAND 3 $236.94
42325 CREATE SALIVARY CYST DRAIN O $0.00

42326 CREATE SALIVARY CYST DRAIN O $0.00
42330 REMOVAL OF SALIVARY STONE 3 $220.25
42335 REMOVAL OF SALIVARY STONE 3 $351.78
42340 REMOVAL OF SALIVARY STONE 3 $441.62
42400 BIOPSY OF SALIVARY GLAND 3 $103.29
42405 BIOPSY OF SALIVARY GLAND 3 $286.47
42408 EXCISION OF SALIVARY CYST 3 $430.87
42409 DRAINAGE OF SALIVARY CYST 3 $314.01
4240F INSTR XRCZ 4BK PN >12 WEEKS 9 $0.00
42410 EXCISE PAROTID GLAND/LESION 3 $604.64
42415 EXCISE PAROTID GLAND/LESION 3 $1,088.86
42420 EXCISE PAROTID GLAND/LESION 3 $1,247.16
42425 EXCISE PAROTID GLAND/LESION 3 $822.70
42426 EXCISE PAROTID GLAND/LESION 3 $1,332.22
4242F SPRVSD XRCZ BK PN >12 WEEKS 9 $0.00
42440 EXCISE SUBMAXILLARY GLAND 3 $455.28
42450 EXCISE SUBLINGUAL GLAND 3 $431.50
4245F PT INSTR NRML LIFEST 9 $0.00
4248F PT INSTR NO BD REST>= 4 DAYS 9 $0.00
42500 REPAIR SALIVARY DUCT 3 $411.89
42505 REPAIR SALIVARY DUCT 3 $532.23
42507 PAROTID DUCT DIVERSION 3 $498.67
42508 PAROTID DUCT DIVERSION 3 $698.81
42509 PAROTID DUCT DIVERSION 3 $827.09
4250F WRMNG 4 SURG - NORMOTHERMIA 9 $0.00
42510 PAROTID DUCT DIVERSION 3 $612.42
42550 INJECTION FOR SALIVARY X-RAY 3 $139.10
4255F ANESTH >= 60 MIN AS DOCD 9 $0.00
4256F ANESTH < 60 MIN AS DOCD 9 $0.00
42600 CLOSURE OF SALIVARY FISTULA 3 $461.11
4260F WOUND SRFC CULTURETECH USED 9 $0.00
4261F TECH OTHER THAN SURFC CULTR 9 $0.00
42650 DILATION OF SALIVARY DUCT 3 $78.61
4265F WET-DRY DRESSINGS RX-RECMD 9 $0.00
42660 DILATION OF SALIVARY DUCT 3 $101.19
42665 LIGATION OF SALIVARY DUCT 3 $294.60
4266F NO WET-DRY DRSSINGS RX-RECMD 9 $0.00
4267F COMPRSSION THXPY PRESCRIBED 9 $0.00
4268F PT ED RE COMP THXPY RCVD 9 $0.00
42699 SALIVARY SURGERY PROCEDURE 5 $0.00
4269F APPROPOS MTHD OFFLOADING RXD 9 $0.00
42700 DRAINAGE OF TONSIL ABSCESS 3 $178.95
4270F PT RCVNG ANTI R-VIRAL THXPY 9 $0.00
4271F PT RCVNG ANTI R-VIRAL THXPY 9 $0.00
42720 DRAINAGE OF THROAT ABSCESS 3 $439.75
42725 DRAINAGE OF THROAT ABSCESS 3 $790.09
4274F FLU IMMUNO ADMIND RCVD 9 $0.00
4275F HEP B VAC INJ ADMIN/ RCVD 9 $0.00
4276F POTENT ANTIVIR THXPY RXD 9 $0.00

4279F PCP PROPHYLAXIS RXD 9 $0.00
42800 BIOPSY OF THROAT 3 $150.40
42802 BIOPSY OF THROAT 3 $226.80
42804 BIOPSY OF UPPER NOSE/THROAT 3 $189.91
42806 BIOPSY OF UPPER NOSE/THROAT 3 $213.90
42808 EXCISE PHARYNX LESION 3 $217.49
42809 REMOVE PHARYNX FOREIGN BODY 3 $162.44
4280F PCP PROPHYLAX RXD 3MON LOW % 9 $0.00
42810 EXCISION OF NECK CYST 3 $368.44
42815 EXCISION OF NECK CYST 3 $539.19
42820 REMOVE TONSILS AND ADENOIDS 3 $284.30
42821 REMOVE TONSILS AND ADENOIDS 3 $295.57
42825 REMOVAL OF TONSILS 3 $255.52
42826 REMOVAL OF TONSILS 3 $245.76
42830 REMOVAL OF ADENOIDS 3 $201.59
42831 REMOVAL OF ADENOIDS 3 $217.13
42835 REMOVAL OF ADENOIDS 3 $182.67
42836 REMOVAL OF ADENOIDS 3 $235.68
42842 EXTENSIVE SURGERY OF THROAT 3 $950.71
42844 EXTENSIVE SURGERY OF THROAT 3 $1,323.21
42845 EXTENSIVE SURGERY OF THROAT 3 $2,158.65
42860 EXCISION OF TONSIL TAGS 3 $182.78
42870 EXCISION OF LINGUAL TONSIL 3 $555.34
42880 EXCISION NASOPHARYNGEAL LESION (EG, O $0.00
42890 PARTIAL REMOVAL OF PHARYNX 3 $1,355.39
42892 REVISION OF PHARYNGEAL WALLS 3 $1,784.28
42894 REVISION OF PHARYNGEAL WALLS 3 $2,274.73
42900 REPAIR THROAT WOUND 3 $334.02
4290F PT SCRNED FOR INJ DRUG USE 9 $0.00
4293F PT SCRND - HGH-RSK SEX BEHAV 9 $0.00
42950 RECONSTRUCTION OF THROAT 3 $765.69
42953 REPAIR THROAT, ESOPHAGUS 3 $935.72
42955 SURGICAL OPENING OF THROAT 3 $719.84
42960 CONTROL THROAT BLEEDING 3 $165.16
42961 CONTROL THROAT BLEEDING 3 $409.61
42962 CONTROL THROAT BLEEDING 3 $506.35
42970 CONTROL NOSE/THROAT BLEEDING 3 $381.27
42971 CONTROL NOSE/THROAT BLEEDING 3 $446.05
42972 CONTROL NOSE/THROAT BLEEDING 3 $500.16
42999 THROAT SURGERY PROCEDURE 5 $0.00
43000 ESOPHAGOTOMY, CERVICAL APPROACH; WI O $0.00
4300F PT RCVNG WARF THXPY 9 $0.00
4301F PT NOT RCVNG WARF THXPY 9 $0.00
43020 INCISION OF ESOPHAGUS 3 $514.06
43030 THROAT MUSCLE SURGERY 3 $508.76
43040 ESOPHAGOTOMY, THORACIC APPROACH; WI O $0.00
43045 INCISION OF ESOPHAGUS 3 $1,286.83
4305F PT ED RE FT CARE INSPCT RCVD 9 $0.00
4306F PT TLK PSYCH & RX OPD ADDIC 9 $0.00

43100 EXCISION OF ESOPHAGUS LESION 3 $607.28
43101 EXCISION OF ESOPHAGUS LESION 3 $995.39
43105 WIDE EXCISION OF MALIGNANT LESION O O $0.00
43106 WIDE EXCISION OF MALIGNANT LESION O O $0.00
43107 REMOVAL OF ESOPHAGUS 3 $2,484.10
43108 REMOVAL OF ESOPHAGUS 3 $4,363.01
43110 ESOPHAGECTOMY (AT UPPER TWO-THIRDS O $0.00
43111 ESOPHAGECTOMY (AT UPPER TWO-THIRDS O $0.00
43112 REMOVAL OF ESOPHAGUS 3 $2,646.53
43113 REMOVAL OF ESOPHAGUS 3 $4,324.27
43115 ESOPHAGECTOMY (AT UPPER TWO-THIRDS O $0.00
43116 PARTIAL REMOVAL OF ESOPHAGUS 3 $4,922.51
43117 PARTIAL REMOVAL OF ESOPHAGUS 3 $2,423.16
43118 PARTIAL REMOVAL OF ESOPHAGUS 3 $3,567.65
43119 TOTAL ESOPHAGECTOMY WITH GASTROPHAR O $0.00
43120 ESOPHAGOGASTRECTOMY (LOWER THIRD) A O $0.00
43121 PARTIAL REMOVAL OF ESOPHAGUS 3 $2,795.86
43122 PARTIAL REMOVAL OF ESOPHAGUS 3 $2,459.15
43123 PARTIAL REMOVAL OF ESOPHAGUS 3 $4,392.91
43124 REMOVAL OF ESOPHAGUS 3 $3,716.08
43130 REMOVAL OF ESOPHAGUS POUCH 3 $770.20
43135 REMOVAL OF ESOPHAGUS POUCH 3 $1,455.58
43136 DIVERTICULOPEXY OF HYPOPHARYNX, WIT O $0.00
43200 ESOPHAGUS ENDOSCOPY 3 $207.02
43201 ESOPH SCOPE W/SUBMUCOUS INJ 3 $283.21
43202 ESOPHAGUS ENDOSCOPY, BIOPSY 3 $271.12
43204 ESOPH SCOPE W/SCLEROSIS INJ 3 $221.61
43205 ESOPHAGUS ENDOSCOPY/LIGATION 3 $222.22
4320F PT TALK PSYCHSOC+RX OH DPND 9 $0.00
43215 ESOPHAGUS ENDOSCOPY 3 $152.61
43216 ESOPHAGUS ENDOSCOPY/LESION 3 $195.73
43217 ESOPHAGUS ENDOSCOPY 3 $362.34
43219 ESOPHAGUS ENDOSCOPY 3 $169.45
43220 ESOPH ENDOSCOPY, DILATION 3 $125.44
43226 ESOPH ENDOSCOPY, DILATION 3 $140.10
43227 ESOPH ENDOSCOPY, REPAIR 3 $208.23
43228 ESOPH ENDOSCOPY, ABLATION 3 $220.85
43231 ESOPH ENDOSCOPY W/US EXAM 3 $188.99
43232 ESOPH ENDOSCOPY W/US FN BX 3 $260.08
43234 UPPER GI ENDOSCOPY, EXAM 3 $268.92
43235 UPPR GI ENDOSCOPY, DIAGNOSIS 3 $287.45
43236 UPPR GI SCOPE W/SUBMUC INJ 3 $357.31
43237 ENDOSCOPIC US EXAM, ESOPH 3 $234.04
43238 UPPR GI ENDOSCOPY W/US FN BX 3 $292.50
43239 UPPER GI ENDOSCOPY, BIOPSY 3 $333.18
43240 ESOPH ENDOSCOPE W/DRAIN CYST 3 $394.36
43241 UPPER GI ENDOSCOPY WITH TUBE 3 $154.26
43242 UPPR GI ENDOSCOPY W/US FN BX 3 $421.36
43243 UPPER GI ENDOSCOPY & INJECT 3 $266.15

43244 UPPER GI ENDOSCOPY/LIGATION 3 $294.12
43245 UPPR GI SCOPE DILATE STRICTR 3 $186.09
43246 PLACE GASTROSTOMY TUBE 3 $249.69
43247 OPERATIVE UPPER GI ENDOSCOPY 3 $198.94
43248 UPPR GI ENDOSCOPY/GUIDE WIRE 3 $187.42
43249 ESOPH ENDOSCOPY, DILATION 3 $172.88
43250 UPPER GI ENDOSCOPY/TUMOR 3 $186.69
43251 OPERATIVE UPPER GI ENDOSCOPY 3 $216.29
43255 OPERATIVE UPPER GI ENDOSCOPY 3 $281.06
43256 UPPR GI ENDOSCOPY W/STENT 3 $253.20
43257 UPPR GI SCOPE W/THRML TXMNT 3 $313.66
43258 OPERATIVE UPPER GI ENDOSCOPY 3 $265.04
43259 ENDOSCOPIC ULTRASOUND EXAM 3 $302.11
43260 ENDO CHOLANGIOPANCREATOGRAPH 3 $345.31
43261 ENDO CHOLANGIOPANCREATOGRAPH 3 $363.04
43262 ENDO CHOLANGIOPANCREATOGRAPH 3 $426.42
43263 ENDO CHOLANGIOPANCREATOGRAPH 3 $421.01
43264 ENDO CHOLANGIOPANCREATOGRAPH 3 $511.58
43265 ENDO CHOLANGIOPANCREATOGRAPH 3 $574.59
43267 ENDO CHOLANGIOPANCREATOGRAPH 3 $424.91
43268 ENDO CHOLANGIOPANCREATOGRAPH 3 $431.71
43269 ENDO CHOLANGIOPANCREATOGRAPH 3 $472.57
43271 ENDO CHOLANGIOPANCREATOGRAPH 3 $426.05
43272 ENDO CHOLANGIOPANCREATOGRAPH 3 $425.66
43273 ENDOSCOPIC PANCREATOSCOPY 3 $128.15
43279 LAP MYOTOMY, HELLER 3 $1,224.01
43280 LAPAROSCOPY, FUNDOPLASTY 3 $1,018.60
43281 LAP PARAESOPHAG HERN REPAIR 3 $1,529.54
43282 LAP PARAESOPH HER RPR W/MESH 3 $1,719.15
43289 LAPAROSCOPE PROC, ESOPH 5 $0.00
43300 REPAIR OF ESOPHAGUS 3 $597.89
43305 REPAIR ESOPHAGUS AND FISTULA 3 $1,075.58
4330F CNSLNG EPI SPEC SFTY ISSUES 9 $0.00
43310 REPAIR OF ESOPHAGUS 3 $1,489.78
43312 REPAIR ESOPHAGUS AND FISTULA 3 $1,624.48
43313 ESOPHAGOPLASTY CONGENITAL 3 $2,658.49
43314 TRACHEO-ESOPHAGOPLASTY CONG 3 $2,980.55
43320 FUSE ESOPHAGUS & STOMACH 3 $1,323.38
43321 ESOPHAGOGASTROSTOMY (CARDIOPLASTY), O $0.00
43324 REVISE ESOPHAGUS & STOMACH 3 $1,286.99
43325 REVISE ESOPHAGUS & STOMACH 3 $1,270.94
43326 REVISE ESOPHAGUS & STOMACH 3 $1,283.96
43330 REPAIR OF ESOPHAGUS 3 $1,243.27
43331 REPAIR OF ESOPHAGUS 3 $1,331.67
43340 FUSE ESOPHAGUS & INTESTINE 3 $1,297.00
43341 FUSE ESOPHAGUS & INTESTINE 3 $1,423.17
43350 SURGICAL OPENING, ESOPHAGUS 3 $1,129.20
43351 SURGICAL OPENING, ESOPHAGUS 3 $1,293.01
43352 SURGICAL OPENING, ESOPHAGUS 3 $1,053.71

43360 GASTROINTESTINAL REPAIR 3 $2,240.15
43361 GASTROINTESTINAL REPAIR 3 $2,545.39
43400 LIGATE ESOPHAGUS VEINS 3 $1,532.65
43401 ESOPHAGUS SURGERY FOR VEINS 3 $1,475.38
43405 LIGATE/STAPLE ESOPHAGUS 3 $1,436.59
4340F CNSLNG CHLDBRNG+ WOMEN EPI 9 $0.00
43410 REPAIR ESOPHAGUS WOUND 3 $979.29
43415 REPAIR ESOPHAGUS WOUND 3 $1,662.96
43420 REPAIR ESOPHAGUS OPENING 3 $979.06
43425 REPAIR ESOPHAGUS OPENING 3 $1,455.19
43450 DILATE ESOPHAGUS 3 $152.23
43451 DILATION OF ESOPHAGUS, BY UNGUIDED O $0.00
43453 DILATE ESOPHAGUS 3 $286.11
43455 DILATION OF ESOPHAGUS, BY BALLOON O O $0.00
43456 DILATE ESOPHAGUS 3 $153.66
43458 DILATE ESOPHAGUS 3 $373.88
43460 PRESSURE TREATMENT ESOPHAGUS 3 $218.19
43496 FREE JEJUNUM FLAP, MICROVASC 5 $0.00
43499 ESOPHAGUS SURGERY PROCEDURE 5 $0.00
43500 SURGICAL OPENING OF STOMACH 3 $734.11
43501 SURGICAL REPAIR OF STOMACH 3 $1,258.62
43502 SURGICAL REPAIR OF STOMACH 3 $1,423.31
43510 SURGICAL OPENING OF STOMACH 3 $896.18
43520 INCISION OF PYLORIC MUSCLE 3 $660.13
43600 BIOPSY OF STOMACH 3 $105.54
43605 BIOPSY OF STOMACH 3 $778.20
43610 EXCISION OF STOMACH LESION 3 $916.96
43611 EXCISION OF STOMACH LESION 3 $1,143.62
43620 REMOVAL OF STOMACH 3 $1,855.71
43621 REMOVAL OF STOMACH 3 $2,129.26
43622 REMOVAL OF STOMACH 3 $2,156.02
43625 GASTRECTOMY, TOTAL WITH REPAIR BY I O $0.00
43630 HEMIGASTRECTOMY OR DISTAL SUBTOTAL O $0.00
43631 REMOVAL OF STOMACH, PARTIAL 3 $1,360.94
43632 REMOVAL OF STOMACH, PARTIAL 3 $1,888.63
43633 REMOVAL OF STOMACH, PARTIAL 3 $1,789.82
43634 REMOVAL OF STOMACH, PARTIAL 3 $1,978.50
43635 REMOVAL OF STOMACH, PARTIAL 3 $107.05
43638 REMOVAL OF STOMACH, PARTIAL O $0.00
43639 REMOVAL OF STOMACH, PARTIAL O $0.00
43640 VAGOTOMY & PYLORUS REPAIR 3 $1,100.65
43641 VAGOTOMY & PYLORUS REPAIR 3 $1,113.01
43644 LAP GASTRIC BYPASS/ROUX-EN-Y 3 $1,629.78
43645 LAP GASTR BYPASS INCL SMLL I 3 $1,741.47
43647 LAP IMPL ELECTRODE, ANTRUM 6 $0.00
43648 LAP REVISE/REMV ELTRD ANTRUM 6 $0.00
43651 LAPAROSCOPY, VAGUS NERVE 3 $606.34
43652 LAPAROSCOPY, VAGUS NERVE 3 $709.68
43653 LAPAROSCOPY, GASTROSTOMY 3 $525.70

43659 LAPAROSCOPE PROC, STOM 5 $0.00
43750 PLACE GASTROSTOMY TUBE O $0.00
43752 NASAL/OROGASTRIC W/STENT 3 $41.64
43760 CHANGE GASTROSTOMY TUBE 3 $49.31
43761 REPOSITION GASTROSTOMY TUBE 3 $119.80
43770 LAP PLACE GASTR ADJ DEVICE 3 $1,042.94
43771 LAP REVISE GASTR ADJ DEVICE 3 $1,188.26
43772 LAP RMVL GASTR ADJ DEVICE 3 $895.64
43773 LAP REPLACE GASTR ADJ DEVICE 3 $1,189.01
43774 LAP RMVL GASTR ADJ ALL PARTS 3 $899.73
43775 LAP SLEEVE GASTRECTOMY 3 $1,286.61
43800 RECONSTRUCTION OF PYLORUS 3 $871.57
43810 FUSION OF STOMACH AND BOWEL 3 $946.32
43820 FUSION OF STOMACH AND BOWEL 3 $1,242.21
43825 FUSION OF STOMACH AND BOWEL 3 $1,216.42
43830 PLACE GASTROSTOMY TUBE 3 $649.37
43831 PLACE GASTROSTOMY TUBE 3 $546.11
43832 PLACE GASTROSTOMY TUBE 3 $991.99
43840 REPAIR OF STOMACH LESION 3 $1,259.45
43842 V-BAND GASTROPLASTY 3 $1,142.22
43843 GASTROPLASTY W/O V-BAND 3 $1,184.29
43844 GASTRIC BYPASS, OTHER THAN WITH ROU O $0.00
43845 GASTROPLASTY DUODENAL SWITCH 3 $1,832.42
43846 GASTRIC BYPASS FOR OBESITY 3 $1,529.83
43847 GASTRIC BYPASS INCL SMALL I 3 $1,672.52
43848 REVISION GASTROPLASTY 3 $1,808.62
43850 REVISE STOMACH-BOWEL FUSION 3 $1,516.34
43855 REVISE STOMACH-BOWEL FUSION 3 $1,572.40
43860 REVISE STOMACH-BOWEL FUSION 3 $1,536.74
43865 REVISE STOMACH-BOWEL FUSION 3 $1,597.61
43870 REPAIR STOMACH OPENING 3 $662.54
43880 REPAIR STOMACH-BOWEL FISTULA 3 $1,499.30
43881 IMPL/REDO ELECTRD, ANTRUM 6 $0.00
43882 REVISE/REMOVE ELECTRD ANTRUM 6 $0.00
43885 ANTERIOR GASTROPEXY FOR HIATAL HERN O $0.00
43886 REVISE GASTRIC PORT, OPEN 3 $326.50
43887 REMOVE GASTRIC PORT, OPEN 3 $297.46
43888 CHANGE GASTRIC PORT, OPEN 3 $420.66
43999 STOMACH SURGERY PROCEDURE 5 $0.00
44005 FREEING OF BOWEL ADHESION 3 $1,025.46
44010 INCISION OF SMALL BOWEL 3 $809.07
44015 INSERT NEEDLE CATH BOWEL 3 $137.13
44020 EXPLORE SMALL INTESTINE 3 $908.57
44021 DECOMPRESS SMALL BOWEL 3 $918.26
44025 INCISION OF LARGE BOWEL 3 $924.57
44040 EXTERIORIZATION OF INTESTINE (MIKUL O $0.00
44050 REDUCE BOWEL OBSTRUCTION 3 $874.01
44055 CORRECT MALROTATION OF BOWEL 3 $1,401.62
44100 BIOPSY OF BOWEL 3 $113.46

44110 EXCISE INTESTINE LESION(S) 3 $794.54
44111 EXCISION OF BOWEL LESION(S) 3 $923.67
44120 REMOVAL OF SMALL INTESTINE 3 $1,145.06
44121 REMOVAL OF SMALL INTESTINE 3 $230.92
44125 REMOVAL OF SMALL INTESTINE 3 $1,108.14
44126 ENTERECTOMY W/O TAPER, CONG 3 $2,298.91
44127 ENTERECTOMY W/TAPER, CONG 3 $2,665.28
44128 ENTERECTOMY CONG, ADD-ON 3 $231.78
44130 BOWEL TO BOWEL FUSION 3 $1,217.15
44131 ENTEROENTEROSTOMY, ANASTOMOSIS OF I O $0.00
44132 ENTERECTOMY, CADAVER DONOR 9 $0.00
44133 ENTERECTOMY, LIVE DONOR 5 $0.00
44135 INTESTINE TRANSPLNT, CADAVER 5 $0.00
44136 INTESTINE TRANSPLANT, LIVE 5 $0.00
44137 REMOVE INTESTINAL ALLOGRAFT 6 $0.00
44139 MOBILIZATION OF COLON 3 $115.77
44140 PARTIAL REMOVAL OF COLON 3 $1,258.83
44141 PARTIAL REMOVAL OF COLON 3 $1,691.90
44143 PARTIAL REMOVAL OF COLON 3 $1,560.12
44144 PARTIAL REMOVAL OF COLON 3 $1,651.07
44145 PARTIAL REMOVAL OF COLON 3 $1,565.59
44146 PARTIAL REMOVAL OF COLON 3 $1,979.54
44147 PARTIAL REMOVAL OF COLON 3 $1,805.24
44150 REMOVAL OF COLON 3 $1,741.22
44151 REMOVAL OF COLON/ILEOSTOMY 3 $1,992.59
44152 REMOVAL OF COLON/ILEOSTOMY O $0.00
44153 REMOVAL OF COLON/ILEOSTOMY O $0.00
44155 REMOVAL OF COLON/ILEOSTOMY 3 $1,943.83
44156 REMOVAL OF COLON/ILEOSTOMY 3 $2,143.23
44157 COLECTOMY W/ILEOANAL ANAST 3 $2,032.21
44158 COLECTOMY W/NEO-RECTUM POUCH 3 $2,080.34
44160 REMOVAL OF COLON 3 $1,163.41
44180 LAP, ENTEROLYSIS 3 $864.03
44186 LAP, JEJUNOSTOMY 3 $611.91
44187 LAP, ILEO/JEJUNO-STOMY 3 $1,032.74
44188 LAP, COLOSTOMY 3 $1,143.40
44200 LAPAROSCOPY, ENTEROLYSIS O $0.00
44201 LAPAROSCOPY, JEJUNOSTOMY O $0.00
44202 LAP, ENTERECTOMY 3 $1,302.31
44203 LAP RESECT S/INTESTINE, ADDL 3 $231.03
44204 LAPARO PARTIAL COLECTOMY 3 $1,451.24
44205 LAP COLECTOMY PART W/ILEUM 3 $1,264.24
44206 LAP PART COLECTOMY W/STOMA 3 $1,651.67
44207 L COLECTOMY/COLOPROCTOSTOMY 3 $1,727.91
44208 L COLECTOMY/COLOPROCTOSTOMY 3 $1,879.27
44209 LAPAROSCOPE PROC, INTESTINE O $0.00
44210 LAPARO TOTAL PROCTOCOLECTOMY 3 $1,687.70
44211 LAP COLECTOMY W/PROCTECTOMY 3 $2,088.76
44212 LAPARO TOTAL PROCTOCOLECTOMY 3 $1,941.15

44213 LAP, MOBIL SPLENIC FL ADD-ON 3 $181.06
44227 LAP, CLOSE ENTEROSTOMY 3 $1,573.64
44238 LAPAROSCOPE PROC, INTESTINE 5 $0.00
44239 LAPAROSCOPE PROC, RECTUM O $0.00
44300 OPEN BOWEL TO SKIN 3 $788.35
44305 ENTEROSTOMY OR CECOSTOMY, TUBE (EG, O $0.00
44310 ILEOSTOMY/JEJUNOSTOMY 3 $981.15
44312 REVISION OF ILEOSTOMY 3 $559.83
44314 REVISION OF ILEOSTOMY 3 $951.50
44316 DEVISE BOWEL POUCH 3 $1,315.70
44320 COLOSTOMY 3 $1,124.18
44322 COLOSTOMY WITH BIOPSIES 3 $907.48
44340 REVISION OF COLOSTOMY 3 $572.78
44345 REVISION OF COLOSTOMY 3 $984.02
44346 REVISION OF COLOSTOMY 3 $1,106.35
44360 SMALL BOWEL ENDOSCOPY 3 $156.29
44361 SMALL BOWEL ENDOSCOPY/BIOPSY 3 $171.92
44363 SMALL BOWEL ENDOSCOPY 3 $204.09
44364 SMALL BOWEL ENDOSCOPY 3 $219.77
44365 SMALL BOWEL ENDOSCOPY 3 $195.89
44366 SMALL BOWEL ENDOSCOPY 3 $258.82
44369 SMALL BOWEL ENDOSCOPY 3 $264.22
44370 SMALL BOWEL ENDOSCOPY/STENT 3 $284.63
44372 SMALL BOWEL ENDOSCOPY 3 $252.61
44373 SMALL BOWEL ENDOSCOPY 3 $203.96
44376 SMALL BOWEL ENDOSCOPY 3 $301.75
44377 SMALL BOWEL ENDOSCOPY/BIOPSY 3 $319.93
44378 SMALL BOWEL ENDOSCOPY 3 $410.14
44379 S BOWEL ENDOSCOPE W/STENT 3 $433.50
44380 SMALL BOWEL ENDOSCOPY 3 $68.02
44382 SMALL BOWEL ENDOSCOPY 3 $81.82
44383 ILEOSCOPY W/STENT 3 $171.87
44385 ENDOSCOPY OF BOWEL POUCH 3 $241.24
44386 ENDOSCOPY, BOWEL POUCH/BIOP 3 $332.42
44388 COLONOSCOPY 3 $332.60
44389 COLONOSCOPY WITH BIOPSY 3 $383.22
44390 COLONOSCOPY FOR FOREIGN BODY 3 $444.05
44391 COLONOSCOPY FOR BLEEDING 3 $492.01
44392 COLONOSCOPY & POLYPECTOMY 3 $418.45
44393 COLONOSCOPY, LESION REMOVAL 3 $484.24
44394 COLONOSCOPY W/SNARE 3 $485.81
44397 COLONOSCOPY W/STENT 3 $272.78
44500 INTRO, GASTROINTESTINAL TUBE 9 $0.00
44600 SUTURE OF INTESTINE (ENTERORRHAPHY) O $0.00
44602 SUTURE, SMALL INTESTINE 3 $1,313.98
44603 SUTURE, SMALL INTESTINE 3 $1,507.36
44604 SUTURE, LARGE INTESTINE 3 $993.77
44605 REPAIR OF BOWEL LESION 3 $1,227.76
44610 SUTURE OF INTESTINE (ENTERORRHAPHY) O $0.00

44615 INTESTINAL STRICTUROPLASTY 3 $1,011.03
44620 REPAIR BOWEL OPENING 3 $811.34
44625 REPAIR BOWEL OPENING 3 $957.52
44626 REPAIR BOWEL OPENING 3 $1,514.27
44640 REPAIR BOWEL-SKIN FISTULA 3 $1,321.68
44650 REPAIR BOWEL FISTULA 3 $1,371.71
44660 REPAIR BOWEL-BLADDER FISTULA 3 $1,315.14
44661 REPAIR BOWEL-BLADDER FISTULA 3 $1,488.31
44680 SURGICAL REVISION, INTESTINE 3 $1,003.79
44700 SUSPEND BOWEL W/PROSTHESIS 3 $961.60
44701 INTRAOP COLON LAVAGE ADD-ON 3 $160.07
44715 PREPARE DONOR INTESTINE 9 $0.00
44720 PREP DONOR INTESTINE/VENOUS 9 $0.00
44721 PREP DONOR INTESTINE/ARTERY 9 $0.00
44799 UNLISTED PROCEDURE INTESTINE 5 $0.00
44800 EXCISION OF BOWEL POUCH 3 $711.62
44820 EXCISION OF MESENTERY LESION 3 $786.90
44850 REPAIR OF MESENTERY 3 $694.87
44899 BOWEL SURGERY PROCEDURE 5 $0.00
44900 DRAIN APP ABSCESS, OPEN 3 $718.79
44901 DRAIN APP ABSCESS, PERCUT 3 $931.93
44950 APPENDECTOMY 3 $601.30
44955 APPENDECTOMY ADD-ON 3 $80.43
44960 APPENDECTOMY 3 $815.28
44970 LAPAROSCOPY, APPENDECTOMY 3 $556.14
44979 LAPAROSCOPE PROC, APP 5 $0.00
45000 DRAINAGE OF PELVIC ABSCESS 3 $392.25
45005 DRAINAGE OF RECTAL ABSCESS 3 $236.76
45020 DRAINAGE OF RECTAL ABSCESS 3 $520.28
45100 BIOPSY OF RECTUM 3 $272.46
45108 REMOVAL OF ANORECTAL LESION 3 $333.27
45110 REMOVAL OF RECTUM 3 $1,738.13
45111 PARTIAL REMOVAL OF RECTUM 3 $1,020.89
45112 REMOVAL OF RECTUM 3 $1,785.08
45113 PARTIAL PROCTECTOMY 3 $1,853.56
45114 PARTIAL REMOVAL OF RECTUM 3 $1,689.20
45116 PARTIAL REMOVAL OF RECTUM 3 $1,485.78
45119 REMOVE RECTUM W/RESERVOIR 3 $1,836.72
45120 REMOVAL OF RECTUM 3 $1,479.78
45121 REMOVAL OF RECTUM AND COLON 3 $1,616.84
45123 PARTIAL PROCTECTOMY 3 $1,045.07
45126 PELVIC EXENTERATION 3 $2,736.61
45130 EXCISION OF RECTAL PROLAPSE 3 $1,021.37
45135 EXCISION OF RECTAL PROLAPSE 3 $1,266.99
45136 EXCISE ILEOANAL RESERVIOR 3 $1,716.72
45150 EXCISION OF RECTAL STRICTURE 3 $369.27
45160 EXCISION OF RECTAL LESION 3 $940.90
45170 EXCISION OF RECTAL LESION O $0.00
45171 EXC RECT TUM TRANSANAL PART 3 $584.63

45172 EXC RECT TUM TRANSANAL FULL 3 $799.32
45180 EXCISION AND/OR ELECTRODESICCATION O $0.00
45190 DESTRUCTION, RECTAL TUMOR 3 $636.49
45300 PROCTOSIGMOIDOSCOPY DX 3 $105.52
45302 PROCTOSIGMOIDOSCOPY; WITH COLLECTIO O $0.00
45303 PROCTOSIGMOIDOSCOPY DILATE 3 $813.90
45305 PROCTOSIGMOIDOSCOPY W/BX 3 $169.65
45307 PROCTOSIGMOIDOSCOPY FB 3 $191.58
45308 PROCTOSIGMOIDOSCOPY REMOVAL 3 $177.14
45309 PROCTOSIGMOIDOSCOPY REMOVAL 3 $192.37
45310 PROCTOSIGMOIDOSCOPY; WITH REMOVAL O O $0.00
45315 PROCTOSIGMOIDOSCOPY REMOVAL 3 $208.47
45317 PROCTOSIGMOIDOSCOPY BLEED 3 $204.06
45320 PROCTOSIGMOIDOSCOPY ABLATE 3 $201.44
45321 PROCTOSIGMOIDOSCOPY VOLVUL 3 $101.94
45327 PROCTOSIGMOIDOSCOPY W/STENT 3 $119.22
45330 DIAGNOSTIC SIGMOIDOSCOPY 3 $130.88
45331 SIGMOIDOSCOPY AND BIOPSY 3 $164.64
45332 SIGMOIDOSCOPY W/FB REMOVAL 3 $272.38
45333 SIGMOIDOSCOPY & POLYPECTOMY 3 $275.03
45334 SIGMOIDOSCOPY FOR BLEEDING 3 $162.78
45335 SIGMOIDOSCOPY W/SUBMUC INJ 3 $237.80
45336 SIGMOIDOSCOPY, FLEXIBLE FIBEROPTIC; O $0.00
45337 SIGMOIDOSCOPY & DECOMPRESS 3 $139.57
45338 SIGMOIDOSCOPY W/TUMR REMOVE 3 $304.28
45339 SIGMOIDOSCOPY W/ABLATE TUMR 3 $318.32
45340 SIG W/BALLOON DILATION 3 $425.20
45341 SIGMOIDOSCOPY W/ULTRASOUND 3 $155.52
45342 SIGMOIDOSCOPY W/US GUIDE BX 3 $237.36
45345 SIGMOIDOSCOPY W/STENT 3 $172.34
45355 SURGICAL COLONOSCOPY 3 $198.86
45378 DIAGNOSTIC COLONOSCOPY 3 $381.20
45379 COLONOSCOPY W/FB REMOVAL 3 $484.45
45380 COLONOSCOPY AND BIOPSY 3 $456.19
45381 COLONOSCOPY, SUBMUCOUS INJ 3 $444.42
45382 COLONOSCOPY/CONTROL BLEEDING 3 $599.92
45383 LESION REMOVAL COLONOSCOPY 3 $546.11
45384 LESION REMOVE COLONOSCOPY 3 $450.66
45385 LESION REMOVAL COLONOSCOPY 3 $514.62
45386 COLONOSCOPY DILATE STRICTURE 3 $635.78
45387 COLONOSCOPY W/STENT 3 $341.83
45391 COLONOSCOPY W/ENDOSCOPE US 3 $294.06
45392 COLONOSCOPY W/ENDOSCOPIC FNB 3 $376.36
45395 LAP, REMOVAL OF RECTUM 3 $1,874.30
45397 LAP, REMOVE RECTUM W/POUCH 3 $2,027.98
45400 LAPAROSCOPIC PROC 3 $1,084.71
45402 LAP PROCTOPEXY W/SIG RESECT 3 $1,445.67
45499 LAPAROSCOPE PROC, RECTUM 6 $0.00
45500 REPAIR OF RECTUM 3 $480.72

45505 REPAIR OF RECTUM 3 $533.70
45520 TREATMENT OF RECTAL PROLAPSE 3 $124.51
45540 CORRECT RECTAL PROLAPSE 3 $997.03
45541 CORRECT RECTAL PROLAPSE 3 $862.34
45550 REPAIR RECTUM/REMOVE SIGMOID 3 $1,374.80
45560 REPAIR OF RECTOCELE 3 $672.07
45562 EXPLORATION/REPAIR OF RECTUM 3 $1,046.08
45563 EXPLORATION/REPAIR OF RECTUM 3 $1,519.87
45800 REPAIR RECT/BLADDER FISTULA 3 $1,158.66
45805 REPAIR FISTULA W/COLOSTOMY 3 $1,349.08
45820 REPAIR RECTOURETHRAL FISTULA 3 $1,123.80
45825 REPAIR FISTULA W/COLOSTOMY 3 $1,388.22
45900 REDUCTION OF RECTAL PROLAPSE 3 $186.18
45905 DILATION OF ANAL SPHINCTER 3 $156.70
45910 DILATION OF RECTAL NARROWING 3 $184.50
45915 REMOVE RECTAL OBSTRUCTION 3 $292.16
45990 SURG DX EXAM, ANORECTAL 3 $102.39
45999 RECTUM SURGERY PROCEDURE 5 $0.00
46000 FISTULOTOMY, SUBCUTANEOUS O $0.00
46020 PLACEMENT OF SETON 3 $241.48
46030 REMOVAL OF RECTAL MARKER 3 $120.88
46040 INCISION OF RECTAL ABSCESS 3 $468.29
46045 INCISION OF RECTAL ABSCESS 3 $388.98
46050 INCISION OF ANAL ABSCESS 3 $170.28
46060 INCISION OF RECTAL ABSCESS 3 $426.76
46070 INCISION OF ANAL SEPTUM 3 $206.53
46080 INCISION OF ANAL SPHINCTER 3 $218.06
46083 INCISE EXTERNAL HEMORRHOID 3 $162.08
46200 REMOVAL OF ANAL FISSURE 3 $373.74
46210 REMOVAL OF ANAL CRYPT O $0.00
46211 REMOVAL OF ANAL CRYPTS O $0.00
46220 EXCISE ANAL EXT TAG/PAPILLA 3 $178.36
46221 LIGATION OF HEMORRHOID(S) 3 $233.42
46230 REMOVAL OF ANAL TAGS 3 $241.12
46250 REMOVE EXT HEM GROUPS = 2 3 $403.94
46255 REMOVE INT/EXT HEM 1 GROUP 3 $448.19
46257 REMOVE IN/EX HEM GRP & FISS 3 $379.84
46258 REMOVE IN/EX HEM GRP W/FISTU 3 $421.08
46260 REMOVE IN/EX HEM GROUPS = 2 3 $429.67
46261 REMOVE IN/EX HEM GRPS & FISS 3 $481.97
46262 REMOVE IN/EX HEM GRPS W/FIST 3 $502.80
46270 REMOVE ANAL FIST SUBQ 3 $441.56
46275 REMOVE ANAL FIST INTER 3 $466.24
46280 REMOVE ANAL FIST COMPLEX 3 $421.61
46281 CLOSURE OF ANAL FISTULA WITH RECTAL O $0.00
46285 REMOVE ANAL FIST 2 STAGE 3 $456.33
46288 REPAIR ANAL FISTULA 3 $496.43
46320 REMOVAL OF HEMORRHOID CLOT 3 $159.80
46500 INJECTION INTO HEMORRHOID(S) 3 $198.80

46505 CHEMODENERVATION ANAL MUSC 3 $257.11
46600 DIAGNOSTIC ANOSCOPY 3 $77.13
46602 ANOSCOPY FOR COLLECTION OF SPECIMEN O $0.00
46604 ANOSCOPY AND DILATION 3 $496.41
46606 ANOSCOPY AND BIOPSY 3 $198.81
46608 ANOSCOPY, REMOVE FOR BODY 3 $204.23
46610 ANOSCOPY, REMOVE LESION 3 $201.61
46611 ANOSCOPY 3 $156.73
46612 ANOSCOPY, REMOVE LESIONS 3 $238.46
46614 ANOSCOPY, CONTROL BLEEDING 3 $117.60
46615 ANOSCOPY 3 $134.02
46700 REPAIR OF ANAL STRICTURE 3 $596.43
46705 REPAIR OF ANAL STRICTURE 3 $466.72
46706 REPR OF ANAL FISTULA W/GLUE 3 $156.07
46707 REPAIR ANORECTAL FIST W/PLUG 3 $448.43
46710 REPR PER/VAG POUCH SNGL PROC 3 $1,024.57
46712 REPR PER/VAG POUCH DBL PROC 3 $1,958.37
46715 REP PERF ANOPER FISTU 3 $459.91
46716 REP PERF ANOPER/VESTIB FISTU 3 $1,122.33
46730 CONSTRUCTION OF ABSENT ANUS 3 $1,812.08
46735 CONSTRUCTION OF ABSENT ANUS 3 $2,005.77
46740 CONSTRUCTION OF ABSENT ANUS 3 $1,971.81
46742 REPAIR OF IMPERFORATED ANUS 3 $2,309.97
46744 REPAIR OF CLOACAL ANOMALY 3 $3,170.09
46746 REPAIR OF CLOACAL ANOMALY 3 $3,515.58
46748 REPAIR OF CLOACAL ANOMALY 3 $3,795.19
46750 REPAIR OF ANAL SPHINCTER 3 $714.88
46751 REPAIR OF ANAL SPHINCTER 3 $583.37
46753 RECONSTRUCTION OF ANUS 3 $539.45
46754 REMOVAL OF SUTURE FROM ANUS 3 $264.97
46760 REPAIR OF ANAL SPHINCTER 3 $1,012.07
46761 REPAIR OF ANAL SPHINCTER 3 $872.83
46762 IMPLANT ARTIFICIAL SPHINCTER 3 $861.61
46900 DESTRUCTION, ANAL LESION(S) 3 $211.62
46910 DESTRUCTION, ANAL LESION(S) 3 $222.18
46916 CRYOSURGERY, ANAL LESION(S) 3 $216.04
46917 LASER SURGERY, ANAL LESIONS 3 $415.83
46922 EXCISION OF ANAL LESION(S) 3 $231.50
46924 DESTRUCTION, ANAL LESION(S) 3 $172.73
46930 DESTROY INTERNAL HEMORRHOIDS 3 $196.90
46934 DESTRUCTION OF HEMORRHOIDS O $0.00
46935 DESTRUCTION OF HEMORRHOIDS O $0.00
46936 DESTRUCTION OF HEMORRHOIDS O $0.00
46937 CRYOTHERAPY OF RECTAL LESION O $0.00
46938 CRYOTHERAPY OF RECTAL LESION O $0.00
46940 TREATMENT OF ANAL FISSURE 3 $199.81
46942 TREATMENT OF ANAL FISSURE 3 $186.58
46945 REMOVE BY LIGAT INT HEM GRP 3 $262.60
46946 REMOVE BY LIGAT INT HEM GRPS 3 $276.28

46947 HEMORRHOIDOPEXY BY STAPLING 3 $349.33
46999 ANUS SURGERY PROCEDURE 5 $0.00
47000 NEEDLE BIOPSY OF LIVER 3 $325.19
47001 NEEDLE BIOPSY, LIVER ADD-ON 3 $98.95
47010 OPEN DRAINAGE, LIVER LESION 3 $1,125.50
47011 PERCUT DRAIN, LIVER LESION 3 $192.58
47015 INJECT/ASPIRATE LIVER CYST 3 $1,073.99
47100 WEDGE BIOPSY OF LIVER 3 $781.33
47120 PARTIAL REMOVAL OF LIVER 3 $2,182.03
47122 EXTENSIVE REMOVAL OF LIVER 3 $3,232.88
47125 PARTIAL REMOVAL OF LIVER 3 $2,894.92
47130 PARTIAL REMOVAL OF LIVER 3 $3,109.34
47133 REMOVAL OF DONOR LIVER 9 $0.00
47134 PARTIAL REMOVAL, DONOR LIVER O $0.00
47135 TRANSPLANTATION OF LIVER 3 $4,595.60
47136 TRANSPLANTATION OF LIVER 3 $3,927.60
47140 PARTIAL REMOVAL, DONOR LIVER 9 $0.00
47141 PARTIAL REMOVAL, DONOR LIVER 9 $0.00
47142 PARTIAL REMOVAL, DONOR LIVER 9 $0.00
47143 PREP DONOR LIVER, WHOLE 9 $0.00
47144 PREP DONOR LIVER, 3-SEGMENT 9 $0.00
47145 PREP DONOR LIVER, LOBE SPLIT 9 $0.00
47146 PREP DONOR LIVER/VENOUS 9 $0.00
47147 PREP DONOR LIVER/ARTERIAL 9 $0.00
47300 SURGERY FOR LIVER LESION 3 $1,051.94
47350 REPAIR LIVER WOUND 3 $1,281.11
47355 HEPATORRHAPHY, SUTURE OF LIVER WOUN O $0.00
47360 REPAIR LIVER WOUND 3 $1,745.44
47361 REPAIR LIVER WOUND 3 $2,847.85
47362 REPAIR LIVER WOUND 3 $1,337.48
47370 LAPARO ABLATE LIVER TUMOR RF 3 $1,163.16
47371 LAPARO ABLATE LIVER CRYOSURG 3 $1,185.60
47379 LAPAROSCOPE PROCEDURE, LIVER 5 $0.00
47380 OPEN ABLATE LIVER TUMOR RF 3 $1,359.50
47381 OPEN ABLATE LIVER TUMOR CRYO 3 $1,394.94
47382 PERCUT ABLATE LIVER RF 3 $4,419.96
47399 LIVER SURGERY PROCEDURE 5 $0.00
47400 INCISION OF LIVER DUCT 3 $2,015.06
47420 INCISION OF BILE DUCT 3 $1,252.84
47425 INCISION OF BILE DUCT 3 $1,268.95
47440 DUODENOCHOLEDOCHOTOMY, TRANSDUODENA O $0.00
47460 INCISE BILE DUCT SPHINCTER 3 $1,198.34
47480 INCISION OF GALLBLADDER 3 $804.18
47490 INCISION OF GALLBLADDER 3 $515.60
47500 INJECTION FOR LIVER X-RAYS 3 $102.50
47505 INJECTION FOR LIVER X-RAYS 3 $39.57
47510 INSERT CATHETER, BILE DUCT 3 $488.49
47511 INSERT BILE DUCT DRAIN 3 $608.00
47525 CHANGE BILE DUCT CATHETER 3 $503.21

47530 REVISE/REINSERT BILE TUBE 3 $1,404.54
47550 BILE DUCT ENDOSCOPY ADD-ON 3 $158.26
47552 BILIARY ENDOSCOPY THRU SKIN 3 $329.08
47553 BILIARY ENDOSCOPY THRU SKIN 3 $329.82
47554 BILIARY ENDOSCOPY THRU SKIN 3 $490.11
47555 BILIARY ENDOSCOPY THRU SKIN 3 $393.64
47556 BILIARY ENDOSCOPY THRU SKIN 3 $446.25
47560 LAPAROSCOPY W/CHOLANGIO 3 $256.11
47561 LAPARO W/CHOLANGIO/BIOPSY 3 $279.40
47562 LAPAROSCOPIC CHOLECYSTECTOMY 3 $693.45
47563 LAPARO CHOLECYSTECTOMY/GRAPH 3 $704.54
47564 LAPARO CHOLECYSTECTOMY/EXPLR 3 $808.83
47570 LAPARO CHOLECYSTOENTEROSTOMY 3 $722.32
47579 LAPAROSCOPE PROC, BILIARY 5 $0.00
47600 REMOVAL OF GALLBLADDER 3 $1,001.94
47605 REMOVAL OF GALLBLADDER 3 $915.30
47610 REMOVAL OF GALLBLADDER 3 $1,173.23
47612 REMOVAL OF GALLBLADDER 3 $1,185.56
47620 REMOVAL OF GALLBLADDER 3 $1,285.53
47630 REMOVE BILE DUCT STONE 3 $560.69
47700 EXPLORATION OF BILE DUCTS 3 $977.70
47701 BILE DUCT REVISION 3 $1,660.03
47710 EXCISION OF BILE DUCT TUMOR, WITH R O $0.00
47711 EXCISION OF BILE DUCT TUMOR 3 $1,456.94
47712 EXCISION OF BILE DUCT TUMOR 3 $1,866.85
47715 EXCISION OF BILE DUCT CYST 3 $1,231.44
47716 FUSION OF BILE DUCT CYST O $0.00
47719 FUSION OF BILE DUCT CYST O $0.00
47720 FUSE GALLBLADDER & BOWEL 3 $1,064.90
47721 FUSE UPPER GI STRUCTURES 3 $1,254.90
47740 FUSE GALLBLADDER & BOWEL 3 $1,213.74
47741 FUSE GALLBLADDER & BOWEL 3 $1,371.17
47760 FUSE BILE DUCTS AND BOWEL 3 $2,090.62
47765 FUSE LIVER DUCTS & BOWEL 3 $2,799.52
47780 FUSE BILE DUCTS AND BOWEL 3 $2,293.64
47785 FUSE BILE DUCTS AND BOWEL 3 $3,005.31
47800 RECONSTRUCTION OF BILE DUCTS 3 $1,473.29
47801 PLACEMENT, BILE DUCT SUPPORT 3 $1,018.32
47802 FUSE LIVER DUCT & INTESTINE 3 $1,418.18
47900 SUTURE BILE DUCT INJURY 3 $1,275.23
47999 BILE TRACT SURGERY PROCEDURE 5 $0.00
48000 DRAINAGE OF ABDOMEN 3 $1,751.68
48001 PLACEMENT OF DRAIN, PANCREAS 3 $2,165.06
48005 RESECT/DEBRIDE PANCREAS O $0.00
48020 REMOVAL OF PANCREATIC STONE 3 $1,095.22
48100 BIOPSY OF PANCREAS, OPEN 3 $827.47
48102 NEEDLE BIOPSY, PANCREAS 3 $528.04
48105 RESECT/DEBRIDE PANCREAS 3 $2,674.13
48120 REMOVAL OF PANCREAS LESION 3 $1,034.30

48140 PARTIAL REMOVAL OF PANCREAS 3 $1,462.65
48145 PARTIAL REMOVAL OF PANCREAS 3 $1,520.52
48146 PANCREATECTOMY 3 $1,737.59
48148 REMOVAL OF PANCREATIC DUCT 3 $1,157.19
48150 PARTIAL REMOVAL OF PANCREAS 3 $2,915.70
48151 PANCREATECTOMY, NEAR-TOTAL, WITH PR O $0.00
48152 PANCREATECTOMY 3 $2,699.80
48153 PANCREATECTOMY 3 $2,910.60
48154 PANCREATECTOMY 3 $2,707.43
48155 REMOVAL OF PANCREAS 3 $1,688.52
48160 PANCREAS REMOVAL/TRANSPLANT 5 $0.00
48180 FUSE PANCREAS AND BOWEL O $0.00
48400 INJECTION, INTRAOP ADD-ON 9 $0.00
48500 SURGERY OF PANCREATIC CYST 3 $1,061.86
48510 DRAIN PANCREATIC PSEUDOCYST 3 $1,007.91
48511 DRAIN PANCREATIC PSEUDOCYST 3 $915.01
48520 FUSE PANCREAS CYST AND BOWEL 3 $1,022.07
48540 FUSE PANCREAS CYST AND BOWEL 3 $1,219.70
48545 PANCREATORRHAPHY 3 $1,245.75
48547 DUODENAL EXCLUSION 3 $1,670.37
48548 FUSE PANCREAS AND BOWEL 3 $1,558.23
48550 DONOR PANCREATECTOMY 9 $0.00
48551 PREP DONOR PANCREAS 9 $0.00
48552 PREP DONOR PANCREAS/VENOUS 9 $0.00
48554 TRANSPL ALLOGRAFT PANCREAS 3 $2,356.48
48556 REMOVAL, ALLOGRAFT PANCREAS 3 $1,171.93
48999 PANCREAS SURGERY PROCEDURE 5 $0.00
49000 EXPLORATION OF ABDOMEN 3 $724.41
49002 REOPENING OF ABDOMEN 3 $971.54
49010 EXPLORATION BEHIND ABDOMEN 3 $899.81
49020 DRAIN ABDOMINAL ABSCESS 3 $1,493.28
49021 DRAIN ABDOMINAL ABSCESS 3 $873.74
49040 DRAIN, OPEN, ABDOM ABSCESS 3 $938.18
49041 DRAIN, PERCUT, ABDOM ABSCESS 3 $894.22
49060 DRAIN, OPEN, RETROP ABSCESS 3 $1,046.11
49061 DRAIN, PERCUT, RETROPER ABSC 3 $191.96
49062 DRAIN TO PERITONEAL CAVITY 3 $705.09
49080 PUNCTURE, PERITONEAL CAVITY 3 $70.42
49081 REMOVAL OF ABDOMINAL FLUID 3 $157.45
49085 REMOVE ABDOMEN FOREIGN BODY O $0.00
49180 BIOPSY, ABDOMINAL MASS 3 $164.04
49200 REMOVAL OF ABDOMINAL LESION O $0.00
49201 REMOVE ABDOM LESION, COMPLEX O $0.00
49203 EXC ABD TUM 5 CM OR LESS 3 $1,131.66
49204 EXC ABD TUM OVER 5 CM 3 $1,442.49
49205 EXC ABD TUM OVER 10 CM 3 $1,653.77
49215 EXCISE SACRAL SPINE TUMOR 3 $2,070.78
49220 MULTIPLE SURGERY, ABDOMEN 3 $907.73
49250 EXCISION OF UMBILICUS 3 $542.16

49255 REMOVAL OF OMENTUM 3 $738.64
49300 PERITONEOSCOPY WITHOUT BIOPSY O $0.00
49301 PERITONEOSCOPY WITH BIOPSY O $0.00
49302 PERITONEOSCOPY WITH GUIDED TRANSHEP O $0.00
49303 PERITONEOSCOPY WITH GUIDED TRANSHEP O $0.00
49310 LAPAROSCOPY, SURGICAL; CHOLECYSTECT O $0.00
49311 LAPAROSCOPY, SURGICAL; CHOLECYSTECT O $0.00
49315 LAPAROSCOPY, SURGICAL;APPENDECTOMY O $0.00
49320 DIAG LAPARO SEPARATE PROC 3 $308.83
49321 LAPAROSCOPY, BIOPSY 3 $325.66
49322 LAPAROSCOPY, ASPIRATION 3 $352.27
49323 LAPARO DRAIN LYMPHOCELE 3 $602.70
49324 LAP INSERTION PERM IP CATH 3 $370.94
49325 LAP REVISION PERM IP CATH 3 $396.57
49326 LAP W/OMENTOPEXY ADD-ON 3 $180.41
49329 LAPARO PROC, ABDM/PER/OMENT 5 $0.00
49400 AIR INJECTION INTO ABDOMEN 3 $172.50
49401 PNEUMOPERITONEUM (SEPARATE PROCEDUR O $0.00
49402 REMOVE FOREIGN BODY, ADBOMEN 3 $800.52
49411 INS MARK ABD/PEL FOR RT PERQ 3 $518.99
49419 INSRT ABDOM CATH FOR CHEMOTX 3 $422.07
49420 INSERT ABDOM DRAIN, TEMP 3 $132.58
49421 INSERT ABDOM DRAIN, PERM 3 $363.99
49422 REMOVE PERM CANNULA/CATHETER 3 $364.19
49423 EXCHANGE DRAINAGE CATHETER 3 $77.09
49424 ASSESS CYST, CONTRAST INJECT 3 $40.71
49425 INSERT ABDOMEN-VENOUS DRAIN 3 $716.32
49426 REVISE ABDOMEN-VENOUS SHUNT 3 $606.53
49427 INJECTION, ABDOMINAL SHUNT 3 $46.71
49428 LIGATION OF SHUNT 3 $412.37
49429 REMOVAL OF SHUNT 3 $428.23
49435 INSERT SUBQ EXTEN TO IP CATH 3 $114.86
49436 EMBEDDED IP CATH EXIT-SITE 3 $174.92
49440 PLACE GASTROSTOMY TUBE PERC 3 $1,067.29
49441 PLACE DUOD/JEJ TUBE PERC 3 $1,163.40
49442 PLACE CECOSTOMY TUBE PERC 3 $1,017.18
49446 CHANGE G-TUBE TO G-J PERC 3 $979.66
49450 REPLACE G/C TUBE PERC 3 $69.66
49451 REPLACE DUOD/JEJ TUBE PERC 3 $96.98
49452 REPLACE G-J TUBE PERC 3 $149.45
49460 FIX G/COLON TUBE W/DEVICE 3 $785.56
49465 FLUORO EXAM OF G/COLON TUBE 3 $168.39
49491 RPR HERN PREEMIE REDUC 3 $731.43
49492 RPR ING HERN PREMIE, BLOCKED 3 $872.08
49495 RPR ING HERNIA BABY, REDUC 3 $372.35
49496 RPR ING HERNIA BABY, BLOCKED 3 $568.28
49500 RPR ING HERNIA, INIT, REDUCE 3 $372.10
49501 RPR ING HERNIA, INIT BLOCKED 3 $558.01
49505 PRP I/HERN INIT REDUC >5 YR 3 $481.34

49507 PRP I/HERN INIT BLOCK >5 YR 3 $592.10
49510 REPAIR INGUINAL HERNIA, AGE 5 OR OV O $0.00
49515 REPAIR INGUINAL HERNIA, AGE 5 OR OV O $0.00
49520 REREPAIR ING HERNIA, REDUCE 3 $586.77
49521 REREPAIR ING HERNIA, BLOCKED 3 $713.93
49525 REPAIR ING HERNIA, SLIDING 3 $531.41
49530 REPAIR INGUINAL HERNIA, ANY AGE INC O $0.00
49535 REPAIR INGUINAL HERNIA, ANY AGE STR O $0.00
49540 REPAIR LUMBAR HERNIA 3 $627.69
49550 RPR REM HERNIA, INIT, REDUCE 3 $534.46
49552 REPAIR FEMORAL HERNIA, HENRY APPROA O $0.00
49553 RPR FEM HERNIA, INIT BLOCKED 3 $585.34
49555 REREPAIR FEM HERNIA, REDUCE 3 $556.22
49557 REREPAIR FEM HERNIA, BLOCKED 3 $674.23
49560 RPR VENTRAL HERN INIT, REDUC 3 $687.57
49561 RPR VENTRAL HERN INIT, BLOCK 3 $868.52
49565 REREPAIR VENTRL HERN, REDUCE 3 $715.29
49566 REREPAIR VENTRL HERN, BLOCK 3 $877.62
49568 HERNIA REPAIR W/MESH 3 $255.11
49570 RPR EPIGASTRIC HERN, REDUCE 3 $381.64
49572 RPR EPIGASTRIC HERN, BLOCKED 3 $474.02
49575 REPAIR EPIGASTRIC HERNIA, PROPERITO O $0.00
49580 RPR UMBIL HERN, REDUC < 5 YR 3 $310.47
49581 REPAIR UMBILICAL HERNIA AGE 5 OR OV O $0.00
49582 RPR UMBIL HERN, BLOCK < 5 YR 3 $441.75
49585 RPR UMBIL HERN, REDUC > 5 YR 3 $409.13
49587 RPR UMBIL HERN, BLOCK > 5 YR 3 $484.37
49590 REPAIR SPIGELIAN HERNIA 3 $530.18
49600 REPAIR UMBILICAL LESION 3 $684.15
49605 REPAIR UMBILICAL LESION 3 $4,703.30
49606 REPAIR UMBILICAL LESION 3 $1,061.20
49610 REPAIR UMBILICAL LESION 3 $641.68
49611 REPAIR UMBILICAL LESION 3 $548.02
49650 LAP ING HERNIA REPAIR INIT 3 $394.32
49651 LAP ING HERNIA REPAIR RECUR 3 $512.86
49652 LAP VENT/ABD HERNIA REPAIR 3 $709.72
49653 LAP VENT/ABD HERN PROC COMP 3 $888.95
49654 LAP INC HERNIA REPAIR 3 $815.77
49655 LAP INC HERN REPAIR COMP 3 $982.11
49656 LAP INC HERNIA REPAIR RECUR 3 $818.22
49657 LAP INC HERN RECUR COMP 3 $1,178.74
49659 LAPARO PROC, HERNIA REPAIR 5 $0.00
49900 REPAIR OF ABDOMINAL WALL 3 $759.62
49904 OMENTAL FLAP, EXTRA-ABDOM 3 $1,401.70
49905 OMENTAL FLAP, INTRA-ABDOM 3 $339.83
49906 FREE OMENTAL FLAP, MICROVASC 5 $0.00
49999 ABDOMEN SURGERY PROCEDURE 5 $0.00
50010 EXPLORATION OF KIDNEY 3 $731.56
50020 RENAL ABSCESS, OPEN DRAIN 3 $1,042.93

50021 RENAL ABSCESS, PERCUT DRAIN 3 $175.24
50040 DRAINAGE OF KIDNEY 3 $964.81
50045 EXPLORATION OF KIDNEY 3 $967.56
5005F PT COUNSLD ON EXAM FOR MOLES 9 $0.00
50060 REMOVAL OF KIDNEY STONE 3 $1,192.07
50065 INCISION OF KIDNEY 3 $1,252.75
50070 INCISION OF KIDNEY 3 $1,244.31
50075 REMOVAL OF KIDNEY STONE 3 $1,528.71
50080 REMOVAL OF KIDNEY STONE 3 $911.01
50081 REMOVAL OF KIDNEY STONE 3 $1,338.25
50100 REVISE KIDNEY BLOOD VESSELS 3 $1,016.08
5010F MACUL+ FNDNGS TO DR MNG DM 9 $0.00
50120 EXPLORATION OF KIDNEY 3 $987.09
50125 EXPLORE AND DRAIN KIDNEY 3 $1,032.65
50130 REMOVAL OF KIDNEY STONE 3 $1,080.59
50135 EXPLORATION OF KIDNEY 3 $1,170.49
5015F DOC FX & TEST/TXMNT FOR OP 9 $0.00
50200 RENAL BIOPSY PERQ 3 $556.80
50205 RENAL BIOPSY OPEN 3 $713.61
5020F TXMNTS 2 MAIN DR BY 1 MON 9 $0.00
50220 REMOVE KIDNEY, OPEN 3 $1,072.86
50225 REMOVAL KIDNEY OPEN, COMPLEX 3 $1,238.71
50230 REMOVAL KIDNEY OPEN, RADICAL 3 $1,337.28
50234 REMOVAL OF KIDNEY & URETER 3 $1,357.53
50236 REMOVAL OF KIDNEY & URETER 3 $1,534.82
50240 PARTIAL REMOVAL OF KIDNEY 3 $1,382.40
50250 CRYOABLATE RENAL MASS OPEN 3 $1,280.72
50280 REMOVAL OF KIDNEY LESION 3 $988.26
50290 REMOVAL OF KIDNEY LESION 3 $907.72
50300 REMOVE CADAVER DONOR KIDNEY 9 $0.00
50320 REMOVE KIDNEY, LIVING DONOR 3 $1,376.10
50323 PREP CADAVER RENAL ALLOGRAFT 9 $0.00
50325 PREP DONOR RENAL GRAFT 9 $0.00
50327 PREP RENAL GRAFT/VENOUS 9 $0.00
50328 PREP RENAL GRAFT/ARTERIAL 9 $0.00
50329 PREP RENAL GRAFT/URETERAL 9 $0.00
50340 REMOVAL OF KIDNEY 3 $870.96
50360 TRANSPLANTATION OF KIDNEY 3 $2,393.17
50365 TRANSPLANTATION OF KIDNEY 3 $2,688.66
50370 REMOVE TRANSPLANTED KIDNEY 3 $1,117.95
50380 REIMPLANTATION OF KIDNEY 3 $1,897.27
50382 CHANGE URETER STENT, PERCUT 3 $1,271.98
50384 REMOVE URETER STENT, PERCUT 3 $1,080.62
50385 CHANGE STENT VIA TRANSURETH 3 $1,246.28
50386 REMOVE STENT VIA TRANSURETH 3 $809.95
50387 CHANGE EXT/INT URETER STENT 3 $588.90
50389 REMOVE RENAL TUBE W/FLUORO 3 $334.84
50390 DRAINAGE OF KIDNEY LESION 3 $102.01
50391 INSTLL RX AGNT INTO RNAL TUB 3 $131.59

50392 INSERT KIDNEY DRAIN 3 $187.72
50393 INSERT URETERAL TUBE 3 $228.40
50394 INJECTION FOR KIDNEY X-RAY 3 $104.97
50395 CREATE PASSAGE TO KIDNEY 3 $189.09
50396 MEASURE KIDNEY PRESSURE 3 $121.98
50398 CHANGE KIDNEY TUBE 3 $75.51
50400 REVISION OF KIDNEY/URETER 3 $1,205.99
50405 REVISION OF KIDNEY/URETER 3 $1,458.13
50500 REPAIR OF KIDNEY WOUND 3 $1,218.67
5050F PLAN 2 MAIN DR BY 1 MONTH 9 $0.00
50520 CLOSE KIDNEY-SKIN FISTULA 3 $1,075.84
50525 REPAIR RENAL-ABDOMEN FISTULA 3 $1,420.43
50526 REPAIR RENAL-ABDOMEN FISTULA 3 $1,419.59
50540 REVISION OF HORSESHOE KIDNEY 3 $1,183.44
50541 LAPARO ABLATE RENAL CYST 3 $961.80
50542 LAPARO ABLATE RENAL MASS 3 $1,221.37
50543 LAPARO PARTIAL NEPHRECTOMY 3 $1,558.37
50544 LAPAROSCOPY, PYELOPLASTY 3 $1,307.80
50545 LAPARO RADICAL NEPHRECTOMY 3 $1,405.83
50546 LAPAROSCOPIC NEPHRECTOMY 3 $1,250.86
50547 LAPARO REMOVAL DONOR KIDNEY 3 $1,543.26
50548 LAPARO REMOVE W/URETER 3 $1,414.54
50549 LAPAROSCOPE PROC, RENAL 5 $0.00
50551 KIDNEY ENDOSCOPY 3 $380.71
50553 KIDNEY ENDOSCOPY 3 $401.07
50555 KIDNEY ENDOSCOPY & BIOPSY 3 $433.91
50557 KIDNEY ENDOSCOPY & TREATMENT 3 $442.36
50559 RENAL ENDOSCOPY/RADIOTRACER O $0.00
50561 KIDNEY ENDOSCOPY & TREATMENT 3 $502.06
50562 RENAL SCOPE W/TUMOR RESECT 3 $613.49
50570 KIDNEY ENDOSCOPY 3 $518.79
50572 KIDNEY ENDOSCOPY 3 $561.82
50574 KIDNEY ENDOSCOPY & BIOPSY 3 $596.98
50575 KIDNEY ENDOSCOPY 3 $754.48
50576 KIDNEY ENDOSCOPY & TREATMENT 3 $595.63
50578 RENAL ENDOSCOPY/RADIOTRACER O $0.00
50580 KIDNEY ENDOSCOPY & TREATMENT 3 $638.96
50590 FRAGMENTING OF KIDNEY STONE 3 $958.80
50592 PERC RF ABLATE RENAL TUMOR 3 $3,518.86
50593 PERC CRYO ABLATE RENAL TUM 3 $4,685.51
50600 EXPLORATION OF URETER 3 $976.93
50605 INSERT URETERAL SUPPORT 3 $962.04
5060F FNDNGS MAMMO 2PT W/IN 3 DAYS 9 $0.00
50610 REMOVAL OF URETER STONE 3 $988.16
50620 REMOVAL OF URETER STONE 3 $944.89
5062F DOC F2FMAMMO FNDNG IN 5 DAYS 9 $0.00
50630 REMOVAL OF URETER STONE 3 $923.13
50650 REMOVAL OF URETER 3 $1,079.55
50660 REMOVAL OF URETER 3 $1,191.47

50684 INJECTION FOR URETER X-RAY 3 $51.67
50686 MEASURE URETER PRESSURE 3 $108.98
50688 CHANGE OF URETER TUBE/STENT 3 $82.84
50690 INJECTION FOR URETER X-RAY 3 $101.55
50700 REVISION OF URETER 3 $964.70
50715 RELEASE OF URETER 3 $1,158.57
50722 RELEASE OF URETER 3 $1,018.32
50725 RELEASE/REVISE URETER 3 $1,133.59
50727 REVISE URETER 3 $522.93
50728 REVISE URETER 3 $718.40
50740 FUSION OF URETER & KIDNEY 3 $1,167.58
50750 FUSION OF URETER & KIDNEY 3 $1,209.99
50760 FUSION OF URETERS 3 $1,145.60
50770 SPLICING OF URETERS 3 $1,178.23
50780 REIMPLANT URETER IN BLADDER 3 $1,140.14
50782 REIMPLANT URETER IN BLADDER 3 $1,150.13
50783 REIMPLANT URETER IN BLADDER 3 $1,164.17
50785 REIMPLANT URETER IN BLADDER 3 $1,260.77
50800 IMPLANT URETER IN BOWEL 3 $959.33
50810 FUSION OF URETER & BOWEL 3 $1,319.31
50815 URINE SHUNT TO INTESTINE 3 $1,274.75
50820 CONSTRUCT BOWEL BLADDER 3 $1,360.28
50825 CONSTRUCT BOWEL BLADDER 3 $1,724.09
50830 REVISE URINE FLOW 3 $1,867.91
50840 REPLACE URETER BY BOWEL 3 $1,283.91
50845 APPENDICO-VESICOSTOMY 3 $1,302.34
50860 TRANSPLANT URETER TO SKIN 3 $983.22
50900 REPAIR OF URETER 3 $871.11
50920 CLOSURE URETER/SKIN FISTULA 3 $919.37
50930 CLOSURE URETER/BOWEL FISTULA 3 $1,161.24
50940 RELEASE OF URETER 3 $920.22
50945 LAPAROSCOPY URETEROLITHOTOMY 3 $1,017.83
50947 LAPARO NEW URETER/BLADDER 3 $1,439.34
50948 LAPARO NEW URETER/BLADDER 3 $1,339.49
50949 LAPAROSCOPE PROC, URETER 5 $0.00
50951 ENDOSCOPY OF URETER 3 $397.65
50953 ENDOSCOPY OF URETER 3 $420.43
50955 URETER ENDOSCOPY & BIOPSY 3 $461.34
50957 URETER ENDOSCOPY & TREATMENT 3 $452.22
50959 URETER ENDOSCOPY & TRACER O $0.00
50961 URETER ENDOSCOPY & TREATMENT 3 $408.09
50970 URETER ENDOSCOPY 3 $391.04
50972 URETER ENDOSCOPY & CATHETER 3 $377.12
50974 URETER ENDOSCOPY & BIOPSY 3 $499.11
50976 URETER ENDOSCOPY & TREATMENT 3 $491.10
50978 URETER ENDOSCOPY & TRACER O $0.00
50980 URETER ENDOSCOPY & TREATMENT 3 $375.79
51000 DRAINAGE OF BLADDER O $0.00
51005 DRAINAGE OF BLADDER O $0.00

5100F RSK FX REF W/N 24 HRS X-RAY 9 $0.00
51010 DRAINAGE OF BLADDER O $0.00
51020 INCISE & TREAT BLADDER 3 $487.67
51030 INCISE & TREAT BLADDER 3 $478.71
51040 INCISE & DRAIN BLADDER 3 $302.27
51045 INCISE BLADDER/DRAIN URETER 3 $493.42
51050 REMOVAL OF BLADDER STONE 3 $492.61
51060 REMOVAL OF URETER STONE 3 $606.80
51065 REMOVE URETER CALCULUS 3 $602.64
51080 DRAINAGE OF BLADDER ABSCESS 3 $422.83
51100 DRAIN BLADDER BY NEEDLE 3 $63.23
51101 DRAIN BLADDER BY TROCAR/CATH 3 $129.05
51102 DRAIN BL W/CATH INSERTION 3 $239.47
51500 REMOVAL OF BLADDER CYST 3 $644.92
51520 REMOVAL OF BLADDER LESION 3 $611.63
51525 REMOVAL OF BLADDER LESION 3 $896.92
51530 REMOVAL OF BLADDER LESION 3 $804.17
51535 REPAIR OF URETER LESION 3 $804.72
51550 PARTIAL REMOVAL OF BLADDER 3 $991.86
51555 PARTIAL REMOVAL OF BLADDER 3 $1,312.43
51565 REVISE BLADDER & URETER(S) 3 $1,340.36
51570 REMOVAL OF BLADDER 3 $1,532.56
51575 REMOVAL OF BLADDER & NODES 3 $1,907.31
51580 REMOVE BLADDER/REVISE TRACT 3 $1,987.26
51585 REMOVAL OF BLADDER & NODES 3 $2,212.98
51590 REMOVE BLADDER/REVISE TRACT 3 $2,019.70
51595 REMOVE BLADDER/REVISE TRACT 3 $2,292.61
51596 REMOVE BLADDER/CREATE POUCH 3 $2,464.66
51597 REMOVAL OF PELVIC STRUCTURES 3 $2,385.19
51600 INJECTION FOR BLADDER X-RAY 3 $46.09
51605 PREPARATION FOR BLADDER XRAY 3 $39.86
51610 INJECTION FOR BLADDER X-RAY 3 $113.02
51700 IRRIGATION OF BLADDER 3 $88.81
51701 INSERT BLADDER CATHETER 3 $61.20
51702 INSERT TEMP BLADDER CATH 3 $78.59
51703 INSERT BLADDER CATH, COMPLEX 3 $142.34
51705 CHANGE OF BLADDER TUBE 3 $115.29
51710 CHANGE OF BLADDER TUBE 3 $161.17
51715 ENDOSCOPIC INJECTION/IMPLANT 3 $301.74
51720 TREATMENT OF BLADDER LESION 3 $117.73
51725 SIMPLE CYSTOMETROGRAM 3 $220.52
51726 COMPLEX CYSTOMETROGRAM 3 $323.57
51727 CYSTOMETROGRAM W/UP 3 $299.72
51728 CYSTOMETROGRAM W/VP 3 $298.61
51729 CYSTOMETROGRAM W/VP&UP 3 $326.16
51736 URINE FLOW MEASUREMENT 3 $55.02
51739 SOUND RECORDING OF EXTERNAL STREAM O $0.00
51741 ELECTRO-UROFLOWMETRY, FIRST 3 $85.83
51772 URETHRA PRESSURE PROFILE O $0.00

51784 ANAL/URINARY MUSCLE STUDY 3 $205.38
51785 ANAL/URINARY MUSCLE STUDY 3 $223.90
51792 URINARY REFLEX STUDY 3 $230.38
51795 URINE VOIDING PRESSURE STUDY O $0.00
51797 INTRAABDOMINAL PRESSURE TEST 3 $142.71
51798 US URINE CAPACITY MEASURE 3 $19.52
51800 REVISION OF BLADDER/URETHRA 3 $1,088.00
51820 REVISION OF URINARY TRACT 3 $1,103.90
51840 ATTACH BLADDER/URETHRA 3 $668.00
51841 ATTACH BLADDER/URETHRA 3 $792.89
51845 REPAIR BLADDER NECK 3 $606.68
51860 REPAIR OF BLADDER WOUND 3 $748.77
51865 REPAIR OF BLADDER WOUND 3 $919.44
51880 REPAIR OF BLADDER OPENING 3 $480.41
51900 REPAIR BLADDER/VAGINA LESION 3 $848.36
51920 CLOSE BLADDER-UTERUS FISTULA 3 $781.17
51925 HYSTERECTOMY/BLADDER REPAIR 3 $1,037.04
51940 CORRECTION OF BLADDER DEFECT 3 $1,677.22
51960 REVISION OF BLADDER & BOWEL 3 $1,449.69
51980 CONSTRUCT BLADDER OPENING 3 $741.32
51990 LAPARO URETHRAL SUSPENSION 3 $766.00
51992 LAPARO SLING OPERATION 3 $845.36
51999 LAPAROSCOPE PROC, BLA 6 $0.00
52000 CYSTOSCOPY 3 $130.99
52001 CYSTOSCOPY, REMOVAL OF CLOTS 3 $395.39
52005 CYSTOSCOPY & URETER CATHETER 3 $295.85
52007 CYSTOSCOPY AND BIOPSY 3 $542.46
5200F EVAL APPROS SURG THXPY EPI 9 $0.00
52010 CYSTOSCOPY & DUCT CATHETER 3 $410.92
52204 CYSTOSCOPY W/BIOPSY(S) 3 $148.04
52214 CYSTOSCOPY AND TREATMENT 3 $616.66
52224 CYSTOSCOPY AND TREATMENT 3 $809.77
52234 CYSTOSCOPY AND TREATMENT 3 $258.64
52235 CYSTOSCOPY AND TREATMENT 3 $303.55
52240 CYSTOSCOPY AND TREATMENT 3 $530.63
52250 CYSTOSCOPY AND RADIOTRACER 3 $254.90
52260 CYSTOSCOPY AND TREATMENT 3 $219.87
52265 CYSTOSCOPY AND TREATMENT 3 $426.74
52270 CYSTOSCOPY & REVISE URETHRA 3 $410.60
52275 CYSTOSCOPY & REVISE URETHRA 3 $560.42
52276 CYSTOSCOPY AND TREATMENT 3 $279.56
52277 CYSTOSCOPY AND TREATMENT 3 $344.30
52281 CYSTOSCOPY AND TREATMENT 3 $311.54
52282 CYSTOSCOPY, IMPLANT STENT 3 $353.31
52283 CYSTOSCOPY AND TREATMENT 3 $291.80
52285 CYSTOSCOPY AND TREATMENT 3 $293.86
52290 CYSTOSCOPY AND TREATMENT 3 $256.80
52300 CYSTOSCOPY AND TREATMENT 3 $296.66
52301 CYSTOSCOPY AND TREATMENT 3 $308.39

52305 CYSTOSCOPY AND TREATMENT 3 $293.27
52310 CYSTOSCOPY AND TREATMENT 3 $258.61
52315 CYSTOSCOPY AND TREATMENT 3 $455.31
52317 REMOVE BLADDER STONE 3 $345.49
52318 REMOVE BLADDER STONE 3 $499.47
52320 CYSTOSCOPY AND TREATMENT 3 $259.55
52325 CYSTOSCOPY, STONE REMOVAL 3 $337.51
52327 CYSTOSCOPY, INJECT MATERIAL 3 $276.04
52330 CYSTOSCOPY AND TREATMENT 3 $277.62
52332 CYSTOSCOPY AND TREATMENT 3 $149.06
52334 CREATE PASSAGE TO KIDNEY 3 $269.71
52335 ENDOSCOPY OF URINARY TRACT O $0.00
52336 CYSTOSCOPY, STONE REMOVAL O $0.00
52337 CYSTOSCOPY, STONE REMOVAL O $0.00
52338 CYSTOSCOPY AND TREATMENT O $0.00
52339 CYSTOSCOPY AND TREATMENT O $0.00
52340 CYSTOSCOPY AND TREATMENT O $0.00
52341 CYSTO W/URETER STRICTURE TX 3 $305.30
52342 CYSTO W/UP STRICTURE TX 3 $331.87
52343 CYSTO W/RENAL STRICTURE TX 3 $369.49
52344 CYSTO/URETERO, STRICTURE TX 3 $400.58
52345 CYSTO/URETERO W/UP STRICTURE 3 $427.53
52346 CYSTOURETERO W/RENAL STRICT 3 $482.61
52347 CYSTOSCOPY, RESECT DUCTS O $0.00
52351 CYSTOURETERO & OR PYELOSCOPE 3 $329.98
52352 CYSTOURETERO W/STONE REMOVE 3 $387.72
52353 CYSTOURETERO W/LITHOTRIPSY 3 $445.51
52354 CYSTOURETERO W/BIOPSY 3 $412.06
52355 CYSTOURETERO W/EXCISE TUMOR 3 $491.13
52400 CYSTOURETERO W/CONGEN REPR 3 $494.44
52402 CYSTOURETHRO CUT EJACUL DUCT 3 $281.72
52450 INCISION OF PROSTATE 3 $488.96
52500 REVISION OF BLADDER NECK 3 $509.40
52510 DILATION PROSTATIC URETHRA O $0.00
52601 PROSTATECTOMY (TURP) 3 $869.44
52606 CONTROL POSTOP BLEEDING O $0.00
52612 PROSTATECTOMY, FIRST STAGE O $0.00
52614 PROSTATECTOMY, SECOND STAGE O $0.00
52620 REMOVE RESIDUAL PROSTATE O $0.00
52630 REMOVE PROSTATE REGROWTH 3 $462.94
52640 RELIEVE BLADDER CONTRACTURE 3 $311.21
52647 LASER SURGERY OF PROSTATE 3 $674.95
52648 LASER SURGERY OF PROSTATE 3 $2,214.71
52649 PROSTATE LASER ENUCLEATION 3 $1,018.22
52650 TRANSURETHRAL CRYOSURGICAL REMOVAL O $0.00
52700 DRAINAGE OF PROSTATE ABSCESS 3 $454.06
53000 INCISION OF URETHRA 3 $155.30
53010 INCISION OF URETHRA 3 $306.24
53020 INCISION OF URETHRA 3 $101.87

53025 INCISION OF URETHRA 3 $67.84
53040 DRAINAGE OF URETHRA ABSCESS 3 $408.04
53060 DRAINAGE OF URETHRA ABSCESS 3 $183.61
53080 DRAINAGE OF URINARY LEAKAGE 3 $448.89
53085 DRAINAGE OF URINARY LEAKAGE 3 $649.72
53200 BIOPSY OF URETHRA 3 $160.75
53210 REMOVAL OF URETHRA 3 $803.56
53215 REMOVAL OF URETHRA 3 $972.69
53220 TREATMENT OF URETHRA LESION 3 $470.76
53230 REMOVAL OF URETHRA LESION 3 $629.26
53235 REMOVAL OF URETHRA LESION 3 $664.40
53240 SURGERY FOR URETHRA POUCH 3 $445.53
53250 REMOVAL OF URETHRA GLAND 3 $425.08
53260 TREATMENT OF URETHRA LESION 3 $207.03
53265 TREATMENT OF URETHRA LESION 3 $228.53
53270 REMOVAL OF URETHRA GLAND 3 $214.23
53275 REPAIR OF URETHRA DEFECT 3 $275.59
53400 REVISE URETHRA, STAGE 1 3 $835.38
53405 REVISE URETHRA, STAGE 2 3 $916.29
53410 RECONSTRUCTION OF URETHRA 3 $1,024.51
53415 RECONSTRUCTION OF URETHRA 3 $1,181.92
53420 RECONSTRUCT URETHRA, STAGE 1 3 $848.90
53425 RECONSTRUCT URETHRA, STAGE 2 3 $984.37
53430 RECONSTRUCTION OF URETHRA 3 $994.33
53431 RECONSTRUCT URETHRA/BLADDER 3 $1,205.88
53440 MALE SLING PROCEDURE 3 $919.85
53442 REMOVE/REVISE MALE SLING 3 $811.55
53443 RECONSTRUCTION OF URETHRA O $0.00
53444 INSERT TANDEM CUFF 3 $831.17
53445 INSERT URO/VES NCK SPHINCTER 3 $920.17
53446 REMOVE URO SPHINCTER 3 $672.79
53447 REMOVE/REPLACE UR SPHINCTER 3 $848.55
53448 REMOV/REPLC UR SPHINCTR COMP 3 $1,340.75
53449 REPAIR URO SPHINCTER 3 $640.14
53450 REVISION OF URETHRA 3 $426.54
53460 REVISION OF URETHRA 3 $478.17
53500 URETHRLYS, TRANSVAG W/ SCOPE 3 $773.64
53502 REPAIR OF URETHRA INJURY 3 $504.45
53505 REPAIR OF URETHRA INJURY 3 $507.86
53510 REPAIR OF URETHRA INJURY 3 $659.90
53515 REPAIR OF URETHRA INJURY 3 $829.24
53520 REPAIR OF URETHRA DEFECT 3 $580.46
53600 DILATE URETHRA STRICTURE 3 $88.49
53601 DILATE URETHRA STRICTURE 3 $86.03
53605 DILATE URETHRA STRICTURE 3 $67.87
53620 DILATE URETHRA STRICTURE 3 $126.75
53621 DILATE URETHRA STRICTURE 3 $119.18
53640 PASSAGE OF FILIFORM AND FOLLOWER FO O $0.00
53660 DILATION OF URETHRA 3 $75.17

53661 DILATION OF URETHRA 3 $74.40
53665 DILATION OF URETHRA 3 $39.82
53670 INSERT URINARY CATHETER O $0.00
53675 INSERT URINARY CATHETER O $0.00
53800 TWO OR THREE GLASS TEST INCLUDING E O $0.00
53850 PROSTATIC MICROWAVE THERMOTX 3 $2,468.41
53852 PROSTATIC RF THERMOTX 3 $2,379.49
53853 PROSTATIC WATER THERMOTHER O $0.00
53855 INSERT PROST URETHRAL STENT 3 $675.94
53899 UROLOGY SURGERY PROCEDURE 5 $0.00
54000 SLITTING OF PREPUCE 3 $160.33
54001 SLITTING OF PREPUCE 3 $198.25
54015 DRAIN PENIS LESION 3 $323.04
54050 DESTRUCTION, PENIS LESION(S) 3 $127.17
54055 DESTRUCTION, PENIS LESION(S) 3 $118.80
54056 CRYOSURGERY, PENIS LESION(S) 3 $134.22
54057 LASER SURG, PENIS LESION(S) 3 $141.56
54060 EXCISION OF PENIS LESION(S) 3 $190.02
54065 DESTRUCTION, PENIS LESION(S) 3 $214.93
54100 BIOPSY OF PENIS 3 $195.16
54105 BIOPSY OF PENIS 3 $284.24
54110 TREATMENT OF PENIS LESION 3 $651.26
54111 TREAT PENIS LESION, GRAFT 3 $838.92
54112 TREAT PENIS LESION, GRAFT 3 $984.23
54115 TREATMENT OF PENIS LESION 3 $470.77
54120 PARTIAL REMOVAL OF PENIS 3 $659.95
54125 REMOVAL OF PENIS 3 $849.29
54130 REMOVE PENIS & NODES 3 $1,250.36
54135 REMOVE PENIS & NODES 3 $1,586.76
54150 CIRCUMCISION W/REGIONL BLOCK 3 $101.55
54152 CIRCUMCISION O $0.00
54160 CIRCUMCISION, NEONATE 3 $150.89
54161 CIRCUM 28 DAYS OR OLDER 3 $205.28
54162 LYSIS PENIL CIRCUMIC LESION 3 $278.36
54163 REPAIR OF CIRCUMCISION 3 $227.33
54164 FRENULOTOMY OF PENIS 9 $0.00
54200 TREATMENT OF PENIS LESION 3 $114.08
54205 TREATMENT OF PENIS LESION 3 $559.72
54220 TREATMENT OF PENIS LESION 3 $217.80
54230 PREPARE PENIS STUDY 3 $101.05
54231 DYNAMIC CAVERNOSOMETRY O $0.00
54235 PENILE INJECTION O $0.00
54240 PENIS STUDY O $0.00
54250 PENIS STUDY O $0.00
54300 REVISION OF PENIS 3 $676.35
54304 REVISION OF PENIS 3 $791.29
54308 RECONSTRUCTION OF URETHRA 3 $753.73
54312 RECONSTRUCTION OF URETHRA 3 $864.13
54316 RECONSTRUCTION OF URETHRA 3 $1,052.13

54318 RECONSTRUCTION OF URETHRA 3 $747.22
54322 RECONSTRUCTION OF URETHRA 3 $824.00
54324 RECONSTRUCTION OF URETHRA 3 $1,023.43
54326 RECONSTRUCTION OF URETHRA 3 $969.69
54328 REVISE PENIS/URETHRA 3 $981.33
54332 REVISE PENIS/URETHRA 3 $1,067.20
54336 REVISE PENIS/URETHRA 3 $1,204.04
54340 SECONDARY URETHRAL SURGERY 3 $590.62
54344 SECONDARY URETHRAL SURGERY 3 $1,000.26
54348 SECONDARY URETHRAL SURGERY 3 $1,070.53
54352 RECONSTRUCT URETHRA/PENIS 3 $1,497.08
54360 PENIS PLASTIC SURGERY 3 $760.20
54380 REPAIR PENIS 3 $842.52
54385 REPAIR PENIS 3 $1,052.65
54390 REPAIR PENIS AND BLADDER 3 $1,248.38
54400 INSERT SEMI-RIGID PROSTHESIS O $0.00
54401 INSERT SELF-CONTD PROSTHESIS O $0.00
54402 REMOVE PENIS PROSTHESIS O $0.00
54405 INSERT MULTI-COMP PENIS PROS O $0.00
54406 REMOVE MUTI-COMP PENIS PROS 9 $0.00
54407 REMOVE MULTI-COMP PROSTHESIS O $0.00
54408 REPAIR MULTI-COMP PENIS PROS 9 $0.00
54409 REVISE PENIS PROSTHESIS O $0.00
54410 REMOVE/REPLACE PENIS PROSTH 9 $0.00
54411 REMOV/REPLC PENIS PROS, COMP 9 $0.00
54415 REMOVE SELF-CONTD PENIS PROS 9 $0.00
54416 REMV/REPL PENIS CONTAIN PROS 9 $0.00
54417 REMV/REPLC PENIS PROS, COMPL 9 $0.00
54420 REVISION OF PENIS 3 $740.55
54430 REVISION OF PENIS 3 $671.74
54435 REVISION OF PENIS 3 $435.93
54440 REPAIR OF PENIS 5 $0.00
54450 PREPUTIAL STRETCHING 3 $75.14
54500 BIOPSY OF TESTIS 3 $78.41
54505 BIOPSY OF TESTIS 3 $220.92
54510 REMOVAL OF TESTIS LESION O $0.00
54512 EXCISE LESION TESTIS 3 $558.97
54520 REMOVAL OF TESTIS 3 $337.70
54522 ORCHIECTOMY, PARTIAL 3 $604.64
54530 REMOVAL OF TESTIS 3 $528.10
54535 EXTENSIVE TESTIS SURGERY 3 $767.59
54550 EXPLORATION FOR TESTIS 3 $510.18
54560 EXPLORATION FOR TESTIS 3 $697.71
54600 REDUCE TESTIS TORSION 3 $472.26
54620 SUSPENSION OF TESTIS 3 $315.06
54640 SUSPENSION OF TESTIS 3 $489.33
54645 ORCHIOPEXY, ANY TYPE, WITH OR WITHO O $0.00
54650 ORCHIOPEXY (FOWLER-STEPHENS) 3 $736.01
54660 REVISION OF TESTIS 9 $0.00

54670 REPAIR TESTIS INJURY 3 $421.15
54680 RELOCATION OF TESTIS(ES) 3 $814.11
54690 LAPAROSCOPY, ORCHIECTOMY 3 $696.16
54692 LAPAROSCOPY, ORCHIOPEXY 3 $796.36
54699 LAPAROSCOPE PROC, TESTIS 5 $0.00
54700 DRAINAGE OF SCROTUM 3 $220.43
54800 BIOPSY OF EPIDIDYMIS 3 $143.54
54820 EXPLORATION OF EPIDIDYMIS O $0.00
54830 REMOVE EPIDIDYMIS LESION 3 $386.56
54840 REMOVE EPIDIDYMIS LESION 3 $336.02
54860 REMOVAL OF EPIDIDYMIS 3 $436.25
54861 REMOVAL OF EPIDIDYMIS 3 $589.12
54865 EXPLORE EPIDIDYMIS 3 $372.03
54900 FUSION OF SPERMATIC DUCTS 3 $798.33
54901 FUSION OF SPERMATIC DUCTS 3 $1,106.30
55000 DRAINAGE OF HYDROCELE 3 $124.62
55040 REMOVAL OF HYDROCELE 3 $350.73
55041 REMOVAL OF HYDROCELES 3 $529.25
55060 REPAIR OF HYDROCELE 3 $393.92
55100 DRAINAGE OF SCROTUM ABSCESS 3 $224.54
55110 EXPLORE SCROTUM 3 $401.12
55120 REMOVAL OF SCROTUM LESION 3 $368.92
55150 REMOVAL OF SCROTUM 3 $508.23
55175 REVISION OF SCROTUM 3 $377.55
55180 REVISION OF SCROTUM 3 $714.81
55200 INCISION OF SPERM DUCT 9 $0.00
55250 REMOVAL OF SPERM DUCT(S) 3 $235.58
55300 PREPARE, SPERM DUCT X-RAY 9 $0.00
55400 REPAIR OF SPERM DUCT 9 $0.00
55450 LIGATION OF SPERM DUCT 3 $390.93
55500 REMOVAL OF HYDROCELE 3 $396.24
55520 REMOVAL OF SPERM CORD LESION 3 $419.38
55530 REVISE SPERMATIC CORD VEINS 3 $367.24
55535 REVISE SPERMATIC CORD VEINS 3 $445.64
55540 REVISE HERNIA & SPERM VEINS 3 $504.46
55550 LAPARO LIGATE SPERMATIC VEIN 3 $439.95
55559 LAPARO PROC, SPERMATIC CORD 5 $0.00
55600 INCISE SPERM DUCT POUCH 3 $439.95
55605 INCISE SPERM DUCT POUCH 3 $527.23
55650 REMOVE SPERM DUCT POUCH 3 $744.24
55680 REMOVE SPERM POUCH LESION 3 $353.02
55700 BIOPSY OF PROSTATE 3 $237.25
55705 BIOPSY OF PROSTATE 3 $280.06
55706 PROSTATE SATURATION SAMPLING 3 $396.39
55720 DRAINAGE OF PROSTATE ABSCESS 3 $470.64
55725 DRAINAGE OF PROSTATE ABSCESS 3 $614.22
55740 PROSTATOLITHOTOMY, REMOVAL OF PROST O $0.00
55801 REMOVAL OF PROSTATE 3 $1,137.01
55810 EXTENSIVE PROSTATE SURGERY 3 $1,374.96

55812 EXTENSIVE PROSTATE SURGERY 3 $1,684.15
55815 EXTENSIVE PROSTATE SURGERY 3 $1,847.96
55821 REMOVAL OF PROSTATE 3 $914.76
55831 REMOVAL OF PROSTATE 3 $990.13
55840 EXTENSIVE PROSTATE SURGERY 3 $1,401.28
55842 EXTENSIVE PROSTATE SURGERY 3 $1,501.01
55845 EXTENSIVE PROSTATE SURGERY 3 $1,714.85
55859 PERCUT/NEEDLE INSERT, PROS O $0.00
55860 SURGICAL EXPOSURE, PROSTATE 3 $916.06
55862 EXTENSIVE PROSTATE SURGERY 3 $1,151.69
55865 EXTENSIVE PROSTATE SURGERY 3 $1,400.11
55866 LAPARO RADICAL PROSTATECTOMY 3 $1,823.38
55870 VAG HYST W/ENTEROCELE REPAIR O $0.00
55873 CRYOABLATE PROSTATE 3 $6,049.26
55875 TRANSPERI NEEDLE PLACE, PROS 3 $797.36
55876 PLACE RT DEVICE/MARKER, PROS 3 $142.49
55899 GENITAL SURGERY PROCEDURE 5 $0.00
55920 PLACE NEEDLES PELVIC FOR RT 3 $452.22
55970 SEX TRANSFORMATION, M TO F 9 $0.00
55980 SEX TRANSFORMATION, F TO M 9 $0.00
56000 INCISION AND DRAINAGE OF PERINEAL A O $0.00
56100 BIOPSY OF PERINEUM (SEPARATE PROCED O $0.00
56200 PERINEOPLASTY, REPAIR OF PERINEUM, O $0.00
56300 LAPAROSCOPY; DIAGNOSTIC O $0.00
56301 LAPAROSCOPY; TUBAL CAUTERY O $0.00
56302 LAPAROSCOPY; TUBAL BLOCK O $0.00
56303 LAPAROSCOPY; EXCISE LESIONS O $0.00
56304 LAPAROSCOPY; LYSIS O $0.00
56305 LAPAROSCOPY; BIOPSY O $0.00
56306 LAPAROSCOPY; ASPIRATION O $0.00
56307 LAPAROSCOPY; REMOVE ADNEXA O $0.00
56308 LAPAROSCOPY; HYSTERECTOMY O $0.00
56309 LAPAROSCOPY; REMOVE MYOMA O $0.00
56310 LAPAROSCOPIC ENTEROLYSIS O $0.00
56311 LAPAROSCOPIC LYMPH NODE BIOP O $0.00
56312 LAPAROSCOPIC LYMPHADENECTOMY O $0.00
56313 LAPAROSCOPIC LYMPHADENECTOMY O $0.00
56314 LAPAR; DRAIN LYMPHOCELE O $0.00
56315 LAPAROSCOPIC APPENDECTOMY O $0.00
56316 LAPAROSCOPIC HERNIA REPAIR O $0.00
56317 LAPAROSCOPIC HERNIA REPAIR O $0.00
56318 LAPAROSCOPIC ORCHIECTOMY O $0.00
56320 LAPAROSCOPY, SPERMATIC VEINS O $0.00
56321 LAPAROSCOPY; ADRENALECTOMY O $0.00
56322 LAPAROSCOPY, VAGUS NERVES O $0.00
56323 LAPAROSCOPY, VAGUS NERVES O $0.00
56324 LAPAROSCOPY, CHOLECYSTOENTER O $0.00
56340 LAPAROSCOPIC CHOLECYSTECTOMY O $0.00
56341 LAPAROSCOPIC CHOLECYSTECTOMY O $0.00

56342 LAPAROSCOPIC CHOLECYSTECTOMY O $0.00
56343 LAPAROSCOPIC SALPINGOSTOMY O $0.00
56344 LAPAROSCOPIC FIMBRIOPLASTY O $0.00
56345 LAPAROSCOPIC SPLENECTOMY O $0.00
56346 LAPAROSCOPIC GASTROSTOMY O $0.00
56347 LAPAROSCOPIC JEJUNOSTOMY O $0.00
56348 LAPARO; RESECT INTESTINE O $0.00
56349 LAPAROSCOPY; FUNDOPLASTY O $0.00
56350 HYSTEROSCOPY; DIAGNOSTIC O $0.00
56351 HYSTEROSCOPY; BIOPSY O $0.00
56352 HYSTEROSCOPY; LYSIS O $0.00
56353 HYSTEROSCOPY; RESECT SEPTUM O $0.00
56354 HYSTEROSCOPY; REMOVE MYOMA O $0.00
56355 HYSTEROSCOPY; REMOVE IMPACT O $0.00
56356 HYSTEROSCOPY; ABLATION O $0.00
56360 PERITONEOSCOPY; WITHOUT BIOPSY O $0.00
56361 PERITONEOSCOPY; WITH BIOPSY O $0.00
56362 LAPAROSCOPY W/CHOLANGIO O $0.00
56363 LAPAROSCOPY W/BIOPSY O $0.00
56399 LAPAROSCOPY PROCEDURE O $0.00
56400 INCISION AND DRAINAGE, ABSCESS OF V O $0.00
56405 I & D OF VULVA/PERINEUM 3 $106.34
56420 DRAINAGE OF GLAND ABSCESS 3 $121.65
56440 SURGERY FOR VULVA LESION 3 $178.28
56441 LYSIS OF LABIAL LESION(S) 3 $144.71
56442 HYMENOTOMY 3 $47.22
56501 DESTROY, VULVA LESIONS, SIM 3 $126.88
56515 DESTROY VULVA LESION/S COMPL 3 $216.83
56600 BIOPSY OF VULVA (SEPARATE PROCEDURE O $0.00
56605 BIOPSY OF VULVA/PERINEUM 3 $80.41
56606 BIOPSY OF VULVA/PERINEUM 3 $36.68
56620 PARTIAL REMOVAL OF VULVA 3 $484.60
56625 COMPLETE REMOVAL OF VULVA 3 $582.37
56630 EXTENSIVE VULVA SURGERY 3 $853.22
56631 EXTENSIVE VULVA SURGERY 3 $1,083.82
56632 EXTENSIVE VULVA SURGERY 3 $1,255.32
56633 EXTENSIVE VULVA SURGERY 3 $1,111.45
56634 EXTENSIVE VULVA SURGERY 3 $1,173.03
56635 VULVECTOMY, RADICAL WITH INGUINOFEM O $0.00
56637 EXTENSIVE VULVA SURGERY 3 $1,381.57
56640 EXTENSIVE VULVA SURGERY 3 $1,371.71
56680 CLITORIDECTOMY SIMPLE O $0.00
56685 CLITORIDECTOMY EXTENSIVE O $0.00
56700 PARTIAL REMOVAL OF HYMEN 3 $182.25
56710 PLASTIC REVISION OF HYMEN O $0.00
56720 INCISION OF HYMEN O $0.00
56740 REMOVE VAGINA GLAND LESION 3 $289.23
56800 REPAIR OF VAGINA 3 $236.73
56805 REPAIR CLITORIS 3 $1,120.41

56810 REPAIR OF PERINEUM 3 $253.89
56820 EXAM OF VULVA W/SCOPE 3 $107.46
56821 EXAM/BIOPSY OF VULVA W/SCOPE 3 $143.00
57000 EXPLORATION OF VAGINA 3 $186.30
57010 DRAINAGE OF PELVIC ABSCESS 3 $421.90
57020 DRAINAGE OF PELVIC FLUID 3 $91.58
57022 I & D VAGINAL HEMATOMA, PP 3 $163.39
57023 I & D VAG HEMATOMA, NON-OB 3 $303.95
57061 DESTROY VAG LESIONS, SIMPLE 3 $110.76
57065 DESTROY VAG LESIONS, COMPLEX 3 $186.28
57100 BIOPSY OF VAGINA 3 $85.69
57105 BIOPSY OF VAGINA 3 $131.83
57106 REMOVE VAGINA WALL, PARTIAL 3 $467.03
57107 REMOVE VAGINA TISSUE, PART 3 $1,365.07
57108 PARTIAL REMOVAL OF VAGINA O $0.00
57109 VAGINECTOMY PARTIAL W/NODES 3 $1,564.36
57110 REMOVE VAGINA WALL, COMPLETE 3 $876.66
57111 REMOVE VAGINA TISSUE, COMPL 3 $1,577.97
57112 VAGINECTOMY W/NODES, COMPL 3 $1,635.23
57120 CLOSURE OF VAGINA 3 $499.35
57126 COMPLEX CYSTOMETROGRAM (EG, CALIBRA 9 $0.00
57130 REMOVE VAGINA LESION 3 $174.70
57135 REMOVE VAGINA LESION 3 $187.37
57150 TREAT VAGINA INFECTION 3 $48.02
57155 INSERT UTERI TANDEMS/OVOIDS 3 $411.44
57160 INSERT PESSARY/OTHER DEVICE 3 $74.66
57170 FITTING OF DIAPHRAGM/CAP 3 $65.18
57180 TREAT VAGINAL BLEEDING 3 $138.15
57200 REPAIR OF VAGINA 3 $290.26
57210 REPAIR VAGINA/PERINEUM 3 $357.69
57220 REVISION OF URETHRA 3 $312.59
57230 REPAIR OF URETHRAL LESION 3 $392.15
57240 REPAIR BLADDER & VAGINA 3 $655.90
57250 REPAIR RECTUM & VAGINA 3 $649.87
57260 REPAIR OF VAGINA 3 $804.40
57265 EXTENSIVE REPAIR OF VAGINA 3 $889.07
57267 INSERT MESH/PELVIC FLR ADDON 3 $257.79
57268 REPAIR OF BOWEL BULGE 3 $470.20
57270 REPAIR OF BOWEL POUCH 3 $779.84
57280 SUSPENSION OF VAGINA 3 $942.24
57282 COLPOPEXY, EXTRAPERITONEAL 3 $493.00
57283 COLPOPEXY, INTRAPERITONEAL 3 $675.96
57284 REPAIR PARAVAG DEFECT, OPEN 3 $813.45
57285 REPAIR PARAVAG DEFECT, VAG 3 $665.52
57287 REVISE/REMOVE SLING REPAIR 3 $686.29
57288 REPAIR BLADDER DEFECT 3 $714.10
57289 REPAIR BLADDER & VAGINA 3 $739.76
57291 CONSTRUCTION OF VAGINA 3 $528.07
57292 CONSTRUCT VAGINA WITH GRAFT 3 $808.73

57295 REVISE VAG GRAFT VIA VAGINA 3 $476.20
57296 REVISE VAG GRAFT, OPEN ABD 3 $929.25
57300 REPAIR RECTUM-VAGINA FISTULA 3 $528.20
57305 REPAIR RECTUM-VAGINA FISTULA 3 $877.27
57307 FISTULA REPAIR & COLOSTOMY 3 $989.75
57308 FISTULA REPAIR, TRANSPERINE 3 $620.68
57310 REPAIR URETHROVAGINAL LESION 3 $473.38
57311 REPAIR URETHROVAGINAL LESION 3 $539.00
57320 REPAIR BLADDER-VAGINA LESION 3 $541.71
57330 REPAIR BLADDER-VAGINA LESION 3 $759.26
57335 REPAIR VAGINA 3 $1,141.27
57400 DILATION OF VAGINA 3 $131.37
57410 PELVIC EXAMINATION 3 $104.23
57415 REMOVE VAGINAL FOREIGN BODY 3 $156.55
57420 EXAM OF VAGINA W/SCOPE 3 $112.62
57421 EXAM/BIOPSY OF VAG W/SCOPE 3 $151.63
57423 REPAIR PARAVAG DEFECT, LAP 3 $904.06
57425 LAPAROSCOPY, SURG, COLPOPEXY 3 $952.15
57426 REVISE PROSTH VAG GRAFT LAP 3 $854.56
57450 CULDOSCOPY, DIAGNOSTIC O $0.00
57451 CULDOSCOPY, DIAGNOSTIC WITH BIOPSY O $0.00
57452 EXAM OF CERVIX W/SCOPE 3 $105.70
57454 BX/CURETT OF CERVIX W/SCOPE 3 $149.43
57455 BIOPSY OF CERVIX W/SCOPE 3 $139.05
57456 ENDOCERV CURETTAGE W/SCOPE 3 $131.81
57460 BX OF CERVIX W/SCOPE, LEEP 3 $285.84
57461 CONZ OF CERVIX W/SCOPE, LEEP 3 $321.43
57500 BIOPSY OF CERVIX 3 $127.65
57505 ENDOCERVICAL CURETTAGE 3 $98.93
57510 CAUTERIZATION OF CERVIX 3 $128.34
57511 CRYOCAUTERY OF CERVIX 3 $141.37
57513 LASER SURGERY OF CERVIX 3 $139.48
57520 CONIZATION OF CERVIX 3 $298.10
57522 CONIZATION OF CERVIX 3 $256.85
57530 REMOVAL OF CERVIX 3 $335.21
57531 REMOVAL OF CERVIX, RADICAL 3 $1,660.41
57540 REMOVAL OF RESIDUAL CERVIX 3 $758.91
57545 REMOVE CERVIX/REPAIR PELVIS 3 $801.30
57550 REMOVAL OF RESIDUAL CERVIX 3 $398.01
57555 REMOVE CERVIX/REPAIR VAGINA 3 $585.04
57556 REMOVE CERVIX, REPAIR BOWEL 3 $557.53
57558 D&C OF CERVICAL STUMP 3 $122.03
57700 REVISION OF CERVIX 3 $302.30
57720 REVISION OF CERVIX 3 $299.31
57800 DILATION OF CERVICAL CANAL 3 $58.31
57820 D & C OF RESIDUAL CERVIX O $0.00
58100 BIOPSY OF UTERUS LINING 3 $106.66
58101 ENDOMETRIAL WASHINGS (EG, FOR CYTOL O $0.00
58102 OFFICE ENDOMETRIAL CURETTAGE O $0.00

58110 BX DONE W/COLPOSCOPY ADD-ON 3 $47.34
58120 DILATION AND CURETTAGE 3 $245.36
58140 MYOMECTOMY ABDOM METHOD 3 $891.15
58145 MYOMECTOMY VAG METHOD 3 $529.35
58146 MYOMECTOMY ABDOM COMPLEX 3 $1,128.99
58150 TOTAL HYSTERECTOMY 3 $966.52
58152 TOTAL HYSTERECTOMY 3 $1,215.61
58180 PARTIAL HYSTERECTOMY 3 $930.95
58200 EXTENSIVE HYSTERECTOMY 3 $1,274.20
58210 EXTENSIVE HYSTERECTOMY 3 $1,701.05
58240 REMOVAL OF PELVIS CONTENTS 3 $2,702.39
58260 VAGINAL HYSTERECTOMY 3 $806.26
58262 VAG HYST INCLUDING T/O 3 $899.58
58263 VAG HYST W/T/O & VAG REPAIR 3 $968.78
58265 VAGINAL HYSTERECTOMY WITH PLASTIC R O $0.00
58267 VAG HYST W/URINARY REPAIR 3 $1,029.61
58270 VAG HYST W/ENTEROCELE REPAIR 3 $860.77
58275 HYSTERECTOMY/REVISE VAGINA 3 $960.09
58280 HYSTERECTOMY/REVISE VAGINA 3 $1,026.65
58285 EXTENSIVE HYSTERECTOMY 3 $1,281.38
58290 VAG HYST COMPLEX 3 $1,124.30
58291 VAG HYST INCL T/O, COMPLEX 3 $1,220.40
58292 VAG HYST T/O & REPAIR, COMPL 3 $1,285.95
58293 VAG HYST W/URO REPAIR, COMPL 3 $1,335.90
58294 VAG HYST W/ENTEROCELE, COMPL 3 $1,189.59
58300 INSERT INTRAUTERINE DEVICE 5 $0.00
58301 REMOVE INTRAUTERINE DEVICE 3 $93.40
58310 ARTIFICIAL INSEMINATION 9 $0.00
58311 ARTIFICIAL INSEMINATION WITH SPERM 9 $0.00
58320 INSUFFLATION OF UTERUS AND TUBES WI O $0.00
58321 ARTIFICIAL INSEMINATION 9 $0.00
58322 ARTIFICIAL INSEMINATION 9 $0.00
58323 SPERM WASHING 9 $0.00
58340 CATHETER FOR HYSTEROGRAPHY 3 $122.05
58345 REOPEN FALLOPIAN TUBE 9 $0.00
58346 INSERT HEYMAN UTERI CAPSULE 3 $442.43
58350 REOPEN FALLOPIAN TUBE 9 $0.00
58353 ENDOMETR ABLATE, THERMAL 3 $214.74
58356 ENDOMETRIAL CRYOABLATION 3 $1,982.02
58400 SUSPENSION OF UTERUS 3 $434.41
58410 SUSPENSION OF UTERUS 3 $783.18
58520 REPAIR OF RUPTURED UTERUS 3 $781.64
58540 REVISION OF UTERUS 3 $884.40
58541 LSH, UTERUS 250 G OR LESS 3 $836.51
58542 LSH W/T/O UT 250 G OR LESS 3 $934.03
58543 LSH UTERUS ABOVE 250 G 3 $949.73
58544 LSH W/T/O UTERUS ABOVE 250 G 3 $1,026.20
58545 LAPAROSCOPIC MYOMECTOMY 3 $871.24
58546 LAPARO-MYOMECTOMY, COMPLEX 3 $1,100.92

58548 LAP RADICAL HYST 3 $1,730.60
58550 LAPARO-ASST VAG HYSTERECTOMY 3 $860.78
58551 LAPAROSCOPY, REMOVE MYOMA O $0.00
58552 LAPARO-VAG HYST INCL T/O 3 $954.84
58553 LAPARO-VAG HYST, COMPLEX 3 $1,107.07
58554 LAPARO-VAG HYST W/T/O, COMPL 3 $1,279.45
58555 HYSTEROSCOPY, DX, SEP PROC 3 $247.36
58558 HYSTEROSCOPY, BIOPSY 3 $331.25
58559 HYSTEROSCOPY, LYSIS 3 $336.13
58560 HYSTEROSCOPY, RESECT SEPTUM 3 $379.49
58561 HYSTEROSCOPY, REMOVE MYOMA 3 $536.84
58562 HYSTEROSCOPY, REMOVE FB 3 $348.15
58563 HYSTEROSCOPY, ABLATION 3 $336.13
58565 HYSTEROSCOPY, STERILIZATION 3 $423.04
58570 TLH, UTERUS 250 G OR LESS 3 $898.91
58571 TLH W/T/O 250 G OR LESS 3 $993.72
58572 TLH, UTERUS OVER 250 G 3 $1,115.34
58573 TLH W/T/O UTERUS OVER 250 G 3 $1,273.42
58578 LAPARO PROC, UTERUS 5 $0.00
58579 HYSTEROSCOPE PROCEDURE 5 $0.00
58600 DIVISION OF FALLOPIAN TUBE 3 $354.24
58605 DIVISION OF FALLOPIAN TUBE 3 $320.70
58611 LIGATE OVIDUCT(S) ADD-ON 3 $75.90
58615 OCCLUDE FALLOPIAN TUBE(S) 3 $241.36
58660 LAPAROSCOPY, LYSIS 3 $653.69
58661 LAPAROSCOPY, REMOVE ADNEXA 3 $627.09
58662 LAPAROSCOPY, EXCISE LESIONS 3 $686.74
58670 LAPAROSCOPY, TUBAL CAUTERY 3 $356.12
58671 LAPAROSCOPY, TUBAL BLOCK 3 $355.75
58672 LAPAROSCOPY, FIMBRIOPLASTY 3 $718.72
58673 LAPAROSCOPY, SALPINGOSTOMY 3 $782.47
58679 LAPARO PROC, OVIDUCT-OVARY 5 $0.00
58700 REMOVAL OF FALLOPIAN TUBE 3 $747.79
58720 REMOVAL OF OVARY/TUBE(S) 3 $699.15
58740 ADHESIOLYSIS TUBE, OVARY 3 $851.91
58750 REPAIR OVIDUCT 9 $0.00
58752 REVISE OVARIAN TUBE(S) 9 $0.00
58760 FIMBRIOPLASTY 9 $0.00
58770 CREATE NEW TUBAL OPENING 3 $821.17
58800 DRAINAGE OF OVARIAN CYST(S) 3 $313.29
58805 DRAINAGE OF OVARIAN CYST(S) 3 $395.13
58820 DRAIN OVARY ABSCESS, OPEN 3 $305.11
58822 DRAIN OVARY ABSCESS, PERCUT 3 $704.70
58823 DRAIN PELVIC ABSCESS, PERCUT 3 $887.82
58825 TRANSPOSITION, OVARY(S) 3 $677.17
58900 BIOPSY OF OVARY(S) 3 $415.28
58920 PARTIAL REMOVAL OF OVARY(S) 3 $680.47
58925 REMOVAL OF OVARIAN CYST(S) 3 $715.40
58940 REMOVAL OF OVARY(S) 3 $493.92

58943 REMOVAL OF OVARY(S) 3 $1,091.44
58950 RESECT OVARIAN MALIGNANCY 3 $1,042.63
58951 RESECT OVARIAN MALIGNANCY 3 $1,341.37
58952 RESECT OVARIAN MALIGNANCY 3 $1,513.14
58953 TAH, RAD DISSECT FOR DEBULK 3 $1,874.32
58954 TAH RAD DEBULK/LYMPH REMOVE 3 $2,032.93
58956 BSO, OMENTECTOMY W/TAH 3 $1,280.07
58957 RESECT RECURRENT GYN MAL 3 $1,452.97
58958 RESECT RECUR GYN MAL W/LYM 3 $1,606.22
58960 EXPLORATION OF ABDOMEN 3 $898.73
58970 RETRIEVAL OF OOCYTE 9 $0.00
58972 CULTURE AND FERTILIZATION OF OOCYTE O $0.00
58974 TRANSFER OF EMBRYO 9 $0.00
58976 TRANSFER OF EMBRYO 9 $0.00
58980 LAPAROSCOPY, SURGICAL O $0.00
58982 LAPAROSCOPY, SURGICAL WITH FULGURAT O $0.00
58983 LAPAROSCOPY, SURGICAL WITH OCCLUSIO O $0.00
58984 LAPAROSCOPY, SURGICAL WITH FULGURAT O $0.00
58985 LAPAROSCOPY, SURGICAL WITH LYSIS OF O $0.00
58986 LAPAROSCOPY, SURGICAL WITH BIOPSY ( O $0.00
58987 LAPAROSCOPY, SURGICAL WITH ASPIRATI O $0.00
58988 LAPAROSCOPY, SURGICAL WITH REMOVAL O $0.00
58990 HYSTEROSCOPY DIAGNOSTIC O $0.00
58992 HYSTEROSCOPY WITH LYSIS OF INTRAUTE O $0.00
58994 HYSTEROSCOPY WITH REMOVAL OF SUBMUC O $0.00
58996 HYSTEROSCOPY; WITH ENDOMETRIAL ABLA O $0.00
58999 GENITAL SURGERY PROCEDURE 5 $0.00
59000 AMNIOCENTESIS, DIAGNOSTIC 3 $122.90
59001 AMNIOCENTESIS, THERAPEUTIC 3 $176.06
59012 FETAL CORD PUNCTURE,PRENATAL 3 $194.96
59015 CHORION BIOPSY 3 $149.10
59020 FETAL CONTRACT STRESS TEST 3 $65.47
59025 FETAL NON-STRESS TEST 3 $44.49
59030 FETAL SCALP BLOOD SAMPLE 3 $99.85
59050 FETAL MONITOR W/REPORT 3 $48.51
59051 FETAL MONITOR/INTERPRET ONLY 3 $40.41
59070 TRANSABDOM AMNIOINFUS W/US 3 $401.19
59072 UMBILICAL CORD OCCLUD W/US 3 $506.51
59074 FETAL FLUID DRAINAGE W/US 3 $387.96
59076 FETAL SHUNT PLACEMENT, W/US 3 $498.20
59100 REMOVE UTERUS LESION 3 $792.26
59120 TREAT ECTOPIC PREGNANCY 3 $758.21
59121 TREAT ECTOPIC PREGNANCY 3 $759.87
59130 TREAT ECTOPIC PREGNANCY 3 $824.65
59135 TREAT ECTOPIC PREGNANCY 3 $832.55
59136 TREAT ECTOPIC PREGNANCY 3 $838.14
59140 TREAT ECTOPIC PREGNANCY 3 $356.65
59150 TREAT ECTOPIC PREGNANCY 3 $733.43
59151 TREAT ECTOPIC PREGNANCY 3 $716.05

59160 D & C AFTER DELIVERY 3 $202.49
59200 INSERT CERVICAL DILATOR 3 $70.82
59300 EPISIOTOMY OR VAGINAL REPAIR 3 $183.83
59320 REVISION OF CERVIX 3 $146.19
59325 REVISION OF CERVIX 3 $216.59
59350 REPAIR OF UTERUS 3 $266.05
59400 OBSTETRICAL CARE 7 $0.00
59409 OBSTETRICAL CARE 3 $733.09
59410 OBSTETRICAL CARE 3 $859.31
59412 ANTEPARTUM MANIPULATION 9 $0.00
59414 DELIVER PLACENTA 3 $87.69
59420 ANTEPARTUM CARE ONLY (SEPARATE PROC O $0.00
59425 ANTEPARTUM CARE ONLY 9 $0.00
59426 ANTEPARTUM CARE ONLY 9 $0.00
59430 CARE AFTER DELIVERY 3 $133.33
59510 CESAREAN DELIVERY 7 $0.00
59514 CESAREAN DELIVERY ONLY 3 $733.09
59515 CESAREAN DELIVERY 3 $859.31
59525 REMOVE UTERUS AFTER CESAREAN 3 $465.47
59610 VBAC DELIVERY 9 $0.00
59612 VBAC DELIVERY ONLY 3 $733.09
59614 VBAC CARE AFTER DELIVERY 3 $859.31
59618 ATTEMPTED VBAC DELIVERY 9 $0.00
59620 ATTEMPTED VBAC DELIVERY ONLY 3 $733.09
59622 ATTEMPTED VBAC AFTER CARE 3 $859.31
59812 TREATMENT OF MISCARRIAGE 3 $303.06
59820 CARE OF MISCARRIAGE 3 $363.21
59821 TREATMENT OF MISCARRIAGE 3 $366.25
59830 TREAT UTERUS INFECTION 3 $417.69
59840 ABORTION 3 $205.68
59841 ABORTION 3 $363.70
59850 ABORTION 3 $346.87
59851 ABORTION 3 $381.59
59852 ABORTION 3 $500.95
59855 ABORTION 3 $396.74
59856 ABORTION 3 $466.89
59857 ABORTION 3 $520.43
59866 ABORTION (MPR) 9 $0.00
59870 EVACUATE MOLE OF UTERUS 3 $453.24
59871 REMOVE CERCLAGE SUTURE 3 $128.53
59897 FETAL INVAS PX W/US 6 $0.00
59898 LAPARO PROC, OB CARE/DELIVER 5 $0.00
59899 MATERNITY CARE PROCEDURE 5 $0.00
60000 DRAIN THYROID/TONGUE CYST 3 $154.45
60001 ASPIRATE/INJECT THYRIOD CYST O $0.00
6005F CARE LEVEL RATIONALE DOC 9 $0.00
60100 BIOPSY OF THYROID 3 $110.96
6010F DYSPHAG TEST DONE B/4 EATING 9 $0.00
6015F DYSPHAG TEST DONE B/4 EATING 9 $0.00

60200 REMOVE THYROID LESION 3 $628.39
6020F NPO (NOTHING-MOUTH) ORDERED 9 $0.00
60210 PARTIAL THYROID EXCISION 3 $670.51
60212 PARTIAL THYROID EXCISION 3 $959.25
60220 PARTIAL REMOVAL OF THYROID 3 $734.04
60225 PARTIAL REMOVAL OF THYROID 3 $882.68
60240 REMOVAL OF THYROID 3 $928.08
60245 THYROIDECTOMY, SUBTOTAL OR PARTIAL; O $0.00
60246 THYROIDECTOMY, SUBTOTAL OR PARTIAL; O $0.00
60252 REMOVAL OF THYROID 3 $1,260.58
60254 EXTENSIVE THYROID SURGERY 3 $1,621.43
60260 REPEAT THYROID SURGERY 3 $1,049.26
60270 REMOVAL OF THYROID 3 $1,327.86
60271 REMOVAL OF THYROID 3 $1,016.11
60280 REMOVE THYROID DUCT LESION 3 $424.68
60281 REMOVE THYROID DUCT LESION 3 $565.80
60300 ASPIR/INJ THYROID CYST 3 $106.57
6030F MAX STERILE BARRIERS FOLLWD 9 $0.00
6040F APPRO RAD DS DVCS TECHS DOCD 9 $0.00
6045F RADXPS IN END RPRT4FLURO PXD 9 $0.00
60500 EXPLORE PARATHYROID GLANDS 3 $966.91
60502 RE-EXPLORE PARATHYROIDS 3 $1,214.79
60505 EXPLORE PARATHYROID GLANDS 3 $1,332.35
60512 AUTOTRANSPLANT PARATHYROID 3 $233.85
60520 REMOVAL OF THYMUS GLAND 3 $989.50
60521 REMOVAL OF THYMUS GLAND 3 $1,125.86
60522 REMOVAL OF THYMUS GLAND 3 $1,362.74
60540 EXPLORE ADRENAL GLAND 3 $1,037.26
60545 EXPLORE ADRENAL GLAND 3 $1,185.19
60600 REMOVE CAROTID BODY LESION 3 $1,398.45
60605 REMOVE CAROTID BODY LESION 3 $1,772.26
60650 LAPAROSCOPY ADRENALECTOMY 3 $1,157.32
60659 LAPARO PROC, ENDOCRINE 5 $0.00
60699 ENDOCRINE SURGERY PROCEDURE 5 $0.00
6070F PT ASKED/CNSLD AED EFFECTS 9 $0.00
61000 REMOVE CRANIAL CAVITY FLUID 3 $105.15
61001 REMOVE CRANIAL CAVITY FLUID 3 $115.77
61020 REMOVE BRAIN CAVITY FLUID 3 $124.33
61026 INJECTION INTO BRAIN CANAL 3 $121.14
61050 REMOVE BRAIN CANAL FLUID 3 $103.11
61055 INJECTION INTO BRAIN CANAL 3 $133.64
61070 BRAIN CANAL SHUNT PROCEDURE 3 $78.53
61105 TWIST DRILL HOLE 3 $410.92
61106 DRILL SKULL FOR EXAM/SURGERY O $0.00
61107 DRILL SKULL FOR IMPLANTATION 3 $296.79
61108 DRILL SKULL FOR DRAINAGE 3 $820.62
61120 BURR HOLE FOR PUNCTURE 3 $675.26
61130 PIERCE SKULL, EXAM/SURGERY O $0.00
61140 PIERCE SKULL FOR BIOPSY 3 $1,153.72

61150 PIERCE SKULL FOR DRAINAGE 3 $1,240.35
61151 PIERCE SKULL FOR DRAINAGE 3 $902.84
61154 PIERCE SKULL & REMOVE CLOT 3 $1,157.09
61156 PIERCE SKULL FOR DRAINAGE 3 $1,147.45
61210 PIERCE SKULL, IMPLANT DEVICE 3 $346.48
61215 INSERT BRAIN-FLUID DEVICE 3 $452.80
61250 PIERCE SKULL & EXPLORE 3 $782.78
61253 PIERCE SKULL & EXPLORE 3 $815.12
61304 OPEN SKULL FOR EXPLORATION 3 $1,512.64
61305 OPEN SKULL FOR EXPLORATION 3 $1,849.64
61312 OPEN SKULL FOR DRAINAGE 3 $1,917.50
61313 OPEN SKULL FOR DRAINAGE 3 $1,822.88
61314 OPEN SKULL FOR DRAINAGE 3 $1,679.63
61315 OPEN SKULL FOR DRAINAGE 3 $1,909.28
61316 IMPLT CRAN BONE FLAP TO ABDO 3 $81.90
61320 OPEN SKULL FOR DRAINAGE 3 $1,760.52
61321 OPEN SKULL FOR DRAINAGE 3 $1,946.31
61322 DECOMPRESSIVE CRANIOTOMY 3 $2,170.38
61323 DECOMPRESSIVE LOBECTOMY 3 $2,194.07
61330 DECOMPRESS EYE SOCKET 3 $1,595.94
61332 EXPLORE/BIOPSY EYE SOCKET 3 $1,797.67
61333 EXPLORE ORBIT/REMOVE LESION 3 $1,860.20
61334 EXPLORE ORBIT/REMOVE OBJECT 3 $1,235.56
61340 SUBTEMPORAL DECOMPRESSION 3 $1,320.24
61343 INCISE SKULL (PRESS RELIEF) 3 $2,030.48
61345 RELIEVE CRANIAL PRESSURE 3 $1,880.79
61440 INCISE SKULL FOR SURGERY 3 $1,842.44
61450 INCISE SKULL FOR SURGERY 3 $1,766.86
61458 INCISE SKULL FOR BRAIN WOUND 3 $1,854.20
61460 INCISE SKULL FOR SURGERY 3 $1,921.79
61470 INCISE SKULL FOR SURGERY 3 $1,767.60
61480 INCISE SKULL FOR SURGERY 3 $1,528.97
61490 INCISE SKULL FOR SURGERY 3 $1,748.89
61500 REMOVAL OF SKULL LESION 3 $1,242.90
61501 REMOVE INFECTED SKULL BONE 3 $1,071.04
61510 REMOVAL OF BRAIN LESION 3 $2,010.54
61512 REMOVE BRAIN LINING LESION 3 $2,360.22
61514 REMOVAL OF BRAIN ABSCESS 3 $1,757.10
61516 REMOVAL OF BRAIN LESION 3 $1,708.66
61517 IMPLT BRAIN CHEMOTX ADD-ON 3 $81.92
61518 REMOVAL OF BRAIN LESION 3 $2,547.47
61519 REMOVE BRAIN LINING LESION 3 $2,731.00
61520 REMOVAL OF BRAIN LESION 3 $3,513.89
61521 REMOVAL OF BRAIN LESION 3 $2,941.36
61522 REMOVAL OF BRAIN ABSCESS 3 $2,020.19
61524 REMOVAL OF BRAIN LESION 3 $1,912.72
61526 REMOVAL OF BRAIN LESION 3 $3,328.22
61530 REMOVAL OF BRAIN LESION 3 $2,827.01
61531 IMPLANT BRAIN ELECTRODES 3 $1,116.83

61533 IMPLANT BRAIN ELECTRODES 3 $1,399.80
61534 REMOVAL OF BRAIN LESION 3 $1,510.94
61535 REMOVE BRAIN ELECTRODES 3 $910.52
61536 REMOVAL OF BRAIN LESION 3 $2,390.60
61537 REMOVAL OF BRAIN TISSUE 3 $2,255.27
61538 REMOVAL OF BRAIN TISSUE 3 $2,431.30
61539 REMOVAL OF BRAIN TISSUE 3 $2,171.19
61540 REMOVAL OF BRAIN TISSUE 3 $2,016.95
61541 INCISION OF BRAIN TISSUE 3 $1,978.47
61542 REMOVAL OF BRAIN TISSUE 3 $2,116.88
61543 REMOVAL OF BRAIN TISSUE 3 $1,986.64
61544 REMOVE & TREAT BRAIN LESION 3 $1,675.36
61545 EXCISION OF BRAIN TUMOR 3 $2,934.62
61546 REMOVAL OF PITUITARY GLAND 3 $2,125.80
61548 REMOVAL OF PITUITARY GLAND 3 $1,461.42
61550 RELEASE OF SKULL SEAMS 3 $915.21
61552 RELEASE OF SKULL SEAMS 3 $1,196.34
61553 CRANIECTOMY FOR CRANIOSTENOSIS EACH O $0.00
61555 RECONSTRUCTION OF SKULL BY MULTIPLE O $0.00
61556 INCISE SKULL/SUTURES 3 $1,546.17
61557 INCISE SKULL/SUTURES 3 $1,551.08
61558 EXCISION OF SKULL/SUTURES 3 $1,729.40
61559 EXCISION OF SKULL/SUTURES 3 $1,977.53
61561 RECONSTRUCTION OF SKULL BY ORBITAL O $0.00
61563 EXCISION OF SKULL TUMOR 3 $1,827.50
61564 EXCISION OF SKULL TUMOR 3 $2,224.71
61566 REMOVAL OF BRAIN TISSUE 3 $2,083.26
61567 INCISION OF BRAIN TISSUE 3 $2,378.41
61570 REMOVE FOREIGN BODY, BRAIN 3 $1,707.46
61571 INCISE SKULL FOR BRAIN WOUND 3 $1,835.98
61575 SKULL BASE/BRAINSTEM SURGERY 3 $2,281.67
61576 SKULL BASE/BRAINSTEM SURGERY 3 $3,450.28
61580 CRANIOFACIAL APPROACH, SKULL 3 $2,323.12
61581 CRANIOFACIAL APPROACH, SKULL 3 $2,587.59
61582 CRANIOFACIAL APPROACH, SKULL 3 $2,716.63
61583 CRANIOFACIAL APPROACH, SKULL 3 $2,663.83
61584 ORBITOCRANIAL APPROACH/SKULL 3 $2,614.32
61585 ORBITOCRANIAL APPROACH/SKULL 3 $2,878.09
61586 RESECT NASOPHARYNX, SKULL 3 $2,104.19
61590 INFRATEMPORAL APPROACH/SKULL 3 $2,939.20
61591 INFRATEMPORAL APPROACH/SKULL 3 $2,966.60
61592 ORBITOCRANIAL APPROACH/SKULL 3 $2,923.20
61595 TRANSTEMPORAL APPROACH/SKULL 3 $2,241.55
61596 TRANSCOCHLEAR APPROACH/SKULL 3 $2,428.57
61597 TRANSCONDYLAR APPROACH/SKULL 3 $2,696.68
61598 TRANSPETROSAL APPROACH/SKULL 3 $2,481.03
61600 RESECT/EXCISE CRANIAL LESION 3 $2,018.70
61601 RESECT/EXCISE CRANIAL LESION 3 $2,188.10
61605 RESECT/EXCISE CRANIAL LESION 3 $2,108.34

61606 RESECT/EXCISE CRANIAL LESION 3 $2,793.90
61607 RESECT/EXCISE CRANIAL LESION 3 $2,672.84
61608 RESECT/EXCISE CRANIAL LESION 3 $2,994.73
61609 TRANSECT ARTERY, SINUS 3 $577.21
61610 TRANSECT ARTERY, SINUS 3 $1,755.22
61611 TRANSECT ARTERY, SINUS 3 $396.81
61612 TRANSECT ARTERY, SINUS 3 $1,464.73
61613 REMOVE ANEURYSM, SINUS 3 $2,995.22
61615 RESECT/EXCISE LESION, SKULL 3 $2,262.34
61616 RESECT/EXCISE LESION, SKULL 3 $3,077.12
61618 REPAIR DURA 3 $1,207.88
61619 REPAIR DURA 3 $1,392.64
61623 ENDOVASC TEMPORY VESSEL OCCL 3 $547.63
61624 TRANSCATH OCCLUSION, CNS 3 $1,093.57
61626 TRANSCATH OCCLUSION, NON-CNS 3 $876.99
61630 INTRACRANIAL ANGIOPLASTY 3 $1,250.78
61635 INTRACRAN ANGIOPLSTY W/STENT 3 $1,359.04
61640 DILATE IC VASOSPASM, INIT 3 $627.92
61641 DILATE IC VASOSPASM ADD-ON 3 $220.90
61642 DILATE IC VASOSPASM ADD-ON 3 $441.17
61680 INTRACRANIAL VESSEL SURGERY 3 $2,090.67
61682 INTRACRANIAL VESSEL SURGERY 3 $3,897.54
61684 INTRACRANIAL VESSEL SURGERY 3 $2,614.23
61686 INTRACRANIAL VESSEL SURGERY 3 $4,186.31
61690 INTRACRANIAL VESSEL SURGERY 3 $2,010.90
61692 INTRACRANIAL VESSEL SURGERY 3 $3,388.83
61697 BRAIN ANEURYSM REPR, COMPLX 3 $3,898.68
61698 BRAIN ANEURYSM REPR, COMPLX 3 $4,251.51
61700 BRAIN ANEURYSM REPR, SIMPLE 3 $3,183.23
61702 INNER SKULL VESSEL SURGERY 3 $3,698.95
61703 CLAMP NECK ARTERY 3 $1,249.44
61705 REVISE CIRCULATION TO HEAD 3 $2,381.23
61708 REVISE CIRCULATION TO HEAD 3 $2,022.56
61710 REVISE CIRCULATION TO HEAD 3 $1,817.61
61711 FUSION OF SKULL ARTERIES 3 $2,402.59
61712 SKULL OR SPINE MICROSURGERY O $0.00
61720 INCISE SKULL/BRAIN SURGERY 3 $1,129.19
61735 INCISE SKULL/BRAIN SURGERY 3 $1,409.85
61750 INCISE SKULL/BRAIN BIOPSY 3 $1,293.45
61751 BRAIN BIOPSY W/CT/MR GUIDE 3 $1,261.32
61760 IMPLANT BRAIN ELECTRODES 3 $1,430.84
61770 INCISE SKULL FOR TREATMENT 3 $1,457.71
61780 STEREOTACTIC LOCALIZATION, ANY METH O $0.00
61790 TREAT TRIGEMINAL NERVE 3 $787.70
61791 TREAT TRIGEMINAL TRACT 3 $1,013.75
61793 FOCUS RADIATION BEAM O $0.00
61795 BRAIN SURGERY USING COMPUTER 3 $232.10
61796 SRS, CRANIAL LESION SIMPLE 3 $875.31
61797 SRS, CRAN LES SIMPLE, ADDL 3 $201.25

61798 SRS, CRANIAL LESION COMPLEX 3 $1,152.43
61799 SRS, CRAN LES COMPLEX, ADDL 3 $278.09
61800 APPLY SRS HEADFRAME ADD-ON 3 $139.28
61850 IMPLANT NEUROELECTRODES 3 $901.54
61855 IMPLANT NEUROELECTRODES O $0.00
61860 IMPLANT NEUROELECTRODES 3 $1,442.74
61862 IMPLANT NEUROSTIMUL, SUBCORT O $0.00
61863 IMPLANT NEUROELECTRODE 3 $1,382.01
61864 IMPLANT NEUROELECTRDE, ADDL 3 $267.79
61865 IMPLANT NEUROELECTRODES O $0.00
61867 IMPLANT NEUROELECTRODE 3 $2,110.91
61868 IMPLANT NEUROELECTRDE, ADDL 3 $471.71
61870 IMPLANT NEUROELECTRODES 3 $1,091.86
61875 IMPLANT NEUROELECTRODES 3 $972.03
61880 REVISE/REMOVE NEUROELECTRODE 3 $509.16
61885 INSRT/REDO NEUROSTIM 1 ARRAY 3 $599.41
61886 IMPLANT NEUROSTIM ARRAYS 3 $756.58
61888 REVISE/REMOVE NEURORECEIVER 3 $361.79
62000 TREAT SKULL FRACTURE 3 $888.60
62005 TREAT SKULL FRACTURE 3 $1,156.01
62010 TREATMENT OF HEAD INJURY 3 $1,395.69
62100 REPAIR BRAIN FLUID LEAKAGE 3 $1,490.77
62115 REDUCTION OF SKULL DEFECT 3 $1,208.95
62116 REDUCTION OF SKULL DEFECT 3 $1,632.89
62117 REDUCTION OF SKULL DEFECT 3 $1,690.13
62120 REPAIR SKULL CAVITY LESION 3 $1,656.57
62121 INCISE SKULL REPAIR 3 $1,598.48
62140 REPAIR OF SKULL DEFECT 3 $960.26
62141 REPAIR OF SKULL DEFECT 3 $1,056.83
62142 REMOVE SKULL PLATE/FLAP 3 $812.22
62143 REPLACE SKULL PLATE/FLAP 3 $950.31
62145 REPAIR OF SKULL & BRAIN 3 $1,303.38
62146 REPAIR OF SKULL WITH GRAFT 3 $1,132.70
62147 REPAIR OF SKULL WITH GRAFT 3 $1,340.10
62148 RETR BONE FLAP TO FIX SKULL 3 $117.93
62160 NEUROENDOSCOPY ADD-ON 3 $178.85
62161 DISSECT BRAIN W/SCOPE 3 $1,395.84
62162 REMOVE COLLOID CYST W/SCOPE 3 $1,746.23
62163 NEUROENDOSCOPY W/FB REMOVAL 3 $1,125.11
62164 REMOVE BRAIN TUMOR W/SCOPE 3 $1,900.53
62165 REMOVE PITUIT TUMOR W/SCOPE 3 $1,465.65
62180 ESTABLISH BRAIN CAVITY SHUNT 3 $1,474.02
62190 ESTABLISH BRAIN CAVITY SHUNT 3 $840.37
62192 ESTABLISH BRAIN CAVITY SHUNT 3 $893.81
62194 REPLACE/IRRIGATE CATHETER 3 $361.37
62200 ESTABLISH BRAIN CAVITY SHUNT 3 $1,264.86
62201 BRAIN CAVITY SHUNT W/SCOPE 3 $1,096.22
62220 ESTABLISH BRAIN CAVITY SHUNT 3 $932.06
62223 ESTABLISH BRAIN CAVITY SHUNT 3 $965.63

62225 REPLACE/IRRIGATE CATHETER 3 $465.40
62230 REPLACE/REVISE BRAIN SHUNT 3 $771.84
62252 CSF SHUNT REPROGRAM 3 $95.94
62256 REMOVE BRAIN CAVITY SHUNT 3 $540.66
62258 REPLACE BRAIN CAVITY SHUNT 3 $1,035.01
62263 EPIDURAL LYSIS MULT SESSIONS 3 $647.38
62264 EPIDURAL LYSIS ON SINGLE DAY 3 $388.21
62267 INTERDISCAL PERQ ASPIR, DX 3 $252.19
62268 DRAIN SPINAL CORD CYST 3 $433.75
62269 NEEDLE BIOPSY, SPINAL CORD 3 $465.97
62270 SPINAL FLUID TAP, DIAGNOSTIC 3 $150.22
62272 DRAIN CEREBRO SPINAL FLUID 3 $179.93
62273 INJECT EPIDURAL PATCH 3 $159.71
62274 INJECT SPINAL ANESTHETIC O $0.00
62275 INJECT SPINAL ANESTHETIC O $0.00
62276 INJECT SPINAL ANESTHETIC O $0.00
62277 INJECT SPINAL ANESTHETIC O $0.00
62278 INJECT SPINAL ANESTHETIC O $0.00
62279 INJECT SPINAL ANESTHETIC O $0.00
62280 TREAT SPINAL CORD LESION 3 $297.16
62281 TREAT SPINAL CORD LESION 3 $277.46
62282 TREAT SPINAL CANAL LESION 3 $281.52
62284 INJECTION FOR MYELOGRAM 3 $210.26
62287 PERCUTANEOUS DISKECTOMY 3 $530.55
62288 INJECTION INTO SPINAL CANAL O $0.00
62289 INJECTION INTO SPINAL CANAL O $0.00
62290 INJECT FOR SPINE DISK X-RAY 3 $315.70
62291 INJECT FOR SPINE DISK X-RAY 3 $296.04
62292 INJECTION INTO DISK LESION 3 $474.26
62294 INJECTION INTO SPINAL ARTERY 3 $709.67
62298 INJECTION INTO SPINAL CANAL O $0.00
62310 INJECT SPINE C/T 3 $213.33
62311 INJECT SPINE L/S (CD) 3 $185.85
62318 INJECT SPINE W/CATH, C/T 3 $222.23
62319 INJECT SPINE W/CATH L/S (CD) 3 $203.17
62350 IMPLANT SPINAL CANAL CATH 3 $367.65
62351 IMPLANT SPINAL CANAL CATH 3 $794.27
62355 REMOVE SPINAL CANAL CATHETER 3 $277.98
62360 INSERT SPINE INFUSION DEVICE 3 $280.07
62361 IMPLANT SPINE INFUSION PUMP 3 $370.26
62362 IMPLANT SPINE INFUSION PUMP 3 $384.38
62365 REMOVE SPINE INFUSION DEVICE 3 $305.24
62367 ANALYZE SPINE INFUSION PUMP 3 $38.17
62368 ANALYZE SPINE INFUSION PUMP 3 $54.33
63001 REMOVAL OF SPINAL LAMINA 3 $1,141.49
63003 REMOVAL OF SPINAL LAMINA 3 $1,147.91
63005 REMOVAL OF SPINAL LAMINA 3 $1,094.54
63010 LAMINECTOMY FOR EXPLORATION/DECOMPR O $0.00
63011 REMOVAL OF SPINAL LAMINA 3 $1,016.37

63012 REMOVAL OF SPINAL LAMINA 3 $1,106.98
63015 REMOVAL OF SPINAL LAMINA 3 $1,369.43
63016 REMOVAL OF SPINAL LAMINA 3 $1,406.49
63017 REMOVAL OF SPINAL LAMINA 3 $1,154.01
63020 NECK SPINE DISK SURGERY 3 $1,082.50
63030 LOW BACK DISK SURGERY 3 $897.69
63035 SPINAL DISK SURGERY ADD-ON 3 $184.68
63040 LAMINOTOMY, SINGLE CERVICAL 3 $1,308.12
63042 LAMINOTOMY, SINGLE LUMBAR 3 $1,217.78
63043 LAMINOTOMY, ADDL CERVICAL 5 $0.00
63044 LAMINOTOMY, ADDL LUMBAR 5 $0.00
63045 REMOVAL OF SPINAL LAMINA 3 $1,178.09
63046 REMOVAL OF SPINAL LAMINA 3 $1,126.86
63047 REMOVAL OF SPINAL LAMINA 3 $1,025.67
63048 REMOVE SPINAL LAMINA ADD-ON 3 $203.11
63050 CERVICAL LAMINOPLASTY 3 $1,434.02
63051 C-LAMINOPLASTY W/GRAFT/PLATE 3 $1,604.31
63055 DECOMPRESS SPINAL CORD 3 $1,512.71
63056 DECOMPRESS SPINAL CORD 3 $1,385.58
63057 DECOMPRESS SPINE CORD ADD-ON 3 $307.44
63064 DECOMPRESS SPINAL CORD 3 $1,649.42
63066 DECOMPRESS SPINE CORD ADD-ON 3 $194.97
63075 NECK SPINE DISK SURGERY 3 $1,282.27
63076 NECK SPINE DISK SURGERY 3 $238.54
63077 SPINE DISK SURGERY, THORAX 3 $1,415.45
63078 SPINE DISK SURGERY, THORAX 3 $188.11
63081 REMOVAL OF VERTEBRAL BODY 3 $1,655.40
63082 REMOVE VERTEBRAL BODY ADD-ON 3 $256.89
63085 REMOVAL OF VERTEBRAL BODY 3 $1,794.36
63086 REMOVE VERTEBRAL BODY ADD-ON 3 $184.76
63087 REMOVAL OF VERTEBRAL BODY 3 $2,268.19
63088 REMOVE VERTEBRAL BODY ADD-ON 3 $250.26
63090 REMOVAL OF VERTEBRAL BODY 3 $1,869.24
63091 REMOVE VERTEBRAL BODY ADD-ON 3 $173.22
63101 REMOVAL OF VERTEBRAL BODY 3 $2,162.83
63102 REMOVAL OF VERTEBRAL BODY 3 $2,117.63
63103 REMOVE VERTEBRAL BODY ADD-ON 3 $281.76
63170 INCISE SPINAL CORD TRACT(S) 3 $1,445.58
63172 DRAINAGE OF SPINAL CYST 3 $1,290.39
63173 DRAINAGE OF SPINAL CYST 3 $1,588.05
63180 REVISE SPINAL CORD LIGAMENTS 3 $1,295.32
63182 REVISE SPINAL CORD LIGAMENTS 3 $1,413.95
63185 INCISE SPINAL COLUMN/NERVES 3 $1,093.02
63190 INCISE SPINAL COLUMN/NERVES 3 $1,199.30
63191 INCISE SPINAL COLUMN/NERVES 3 $1,099.51
63194 INCISE SPINAL COLUMN & CORD 3 $1,329.92
63195 INCISE SPINAL COLUMN & CORD 3 $1,401.43
63196 INCISE SPINAL COLUMN & CORD 3 $1,465.41
63197 INCISE SPINAL COLUMN & CORD 3 $1,570.37

63198 INCISE SPINAL COLUMN & CORD 3 $1,581.86
63199 INCISE SPINAL COLUMN & CORD 3 $1,778.38
63200 RELEASE OF SPINAL CORD 3 $1,400.14
63250 REVISE SPINAL CORD VESSELS 3 $2,735.49
63251 REVISE SPINAL CORD VESSELS 3 $2,805.03
63252 REVISE SPINAL CORD VESSELS 3 $2,802.41
63265 EXCISE INTRASPINAL LESION 3 $1,542.65
63266 EXCISE INTRASPINAL LESION 3 $1,589.52
63267 EXCISE INTRASPINAL LESION 3 $1,275.71
63268 EXCISE INTRASPINAL LESION 3 $1,318.85
63270 EXCISE INTRASPINAL LESION 3 $1,907.42
63271 EXCISE INTRASPINAL LESION 3 $1,912.76
63272 EXCISE INTRASPINAL LESION 3 $1,762.93
63273 EXCISE INTRASPINAL LESION 3 $1,686.48
63275 BIOPSY/EXCISE SPINAL TUMOR 3 $1,659.88
63276 BIOPSY/EXCISE SPINAL TUMOR 3 $1,650.20
63277 BIOPSY/EXCISE SPINAL TUMOR 3 $1,441.32
63278 BIOPSY/EXCISE SPINAL TUMOR 3 $1,444.82
63280 BIOPSY/EXCISE SPINAL TUMOR 3 $1,956.26
63281 BIOPSY/EXCISE SPINAL TUMOR 3 $1,933.67
63282 BIOPSY/EXCISE SPINAL TUMOR 3 $1,824.36
63283 BIOPSY/EXCISE SPINAL TUMOR 3 $1,739.61
63285 BIOPSY/EXCISE SPINAL TUMOR 3 $2,402.22
63286 BIOPSY/EXCISE SPINAL TUMOR 3 $2,381.58
63287 BIOPSY/EXCISE SPINAL TUMOR 3 $2,530.43
63290 BIOPSY/EXCISE SPINAL TUMOR 3 $2,573.83
63295 REPAIR OF LAMINECTOMY DEFECT 3 $308.39
63300 REMOVAL OF VERTEBRAL BODY 3 $1,702.73
63301 REMOVAL OF VERTEBRAL BODY 3 $1,984.87
63302 REMOVAL OF VERTEBRAL BODY 3 $1,965.08
63303 REMOVAL OF VERTEBRAL BODY 3 $2,070.46
63304 REMOVAL OF VERTEBRAL BODY 3 $2,157.08
63305 REMOVAL OF VERTEBRAL BODY 3 $2,247.60
63306 REMOVAL OF VERTEBRAL BODY 3 $2,266.74
63307 REMOVAL OF VERTEBRAL BODY 3 $2,154.20
63308 REMOVE VERTEBRAL BODY ADD-ON 3 $306.54
63600 REMOVE SPINAL CORD LESION 3 $782.26
63610 STIMULATION OF SPINAL CORD 3 $1,172.20
63615 REMOVE LESION OF SPINAL CORD 3 $1,082.38
63620 SRS, SPINAL LESION 3 $953.54
63621 SRS, SPINAL LESION, ADDL 3 $231.13
63650 IMPLANT NEUROELECTRODES 3 $397.02
63652 PERCUTANEOUS IMPLANTATION OF NEUROS O $0.00
63655 IMPLANT NEUROELECTRODES 3 $792.52
63656 LAMINECTOMY FOR IMPLANTATION OF NEU O $0.00
63657 LAMINECTOMY FOR IMPLANTATION OF NEU O $0.00
63658 LAMINECTOMY FOR IMPLANTATION OF NEU O $0.00
63660 REVISE/REMOVE NEUROELECTRODE O $0.00
63661 REMOVE SPINE ELTRD PERQ ARAY 3 $563.83

63662 REMOVE SPINE ELTRD PLATE 3 $691.35
63663 REVISE SPINE ELTRD PERQ ARAY 3 $806.95
63664 REVISE SPINE ELTRD PLATE 3 $719.27
63685 INSRT/REDO SPINE N GENERATOR 3 $373.16
63688 REVISE/REMOVE NEURORECEIVER 3 $337.25
63690 ANALYSIS OF NEURORECEIVER O $0.00
63691 ANALYSIS OF NEURORECEIVER O $0.00
63700 REPAIR OF SPINAL HERNIATION 3 $1,167.84
63702 REPAIR OF SPINAL HERNIATION 3 $1,300.22
63704 REPAIR OF SPINAL HERNIATION 3 $1,467.70
63706 REPAIR OF SPINAL HERNIATION 3 $1,669.32
63707 REPAIR SPINAL FLUID LEAKAGE 3 $842.99
63709 REPAIR SPINAL FLUID LEAKAGE 3 $1,024.38
63710 GRAFT REPAIR OF SPINE DEFECT 3 $1,022.38
63740 INSTALL SPINAL SHUNT 3 $869.58
63741 INSTALL SPINAL SHUNT 3 $561.61
63744 REVISION OF SPINAL SHUNT 3 $603.60
63746 REMOVAL OF SPINAL SHUNT 3 $531.28
63750 INSERTION, SUBARACHNOID CATHETER WI O $0.00
63780 INSERTION OR REPLACEMENT, SUBARACHN O $0.00
64400 N BLOCK INJ, TRIGEMINAL 3 $105.35
64402 N BLOCK INJ, FACIAL 3 $107.44
64405 N BLOCK INJ, OCCIPITAL 3 $103.53
64408 N BLOCK INJ, VAGUS 3 $115.31
64410 N BLOCK INJ, PHRENIC 3 $138.63
64412 N BLOCK INJ, SPINAL ACCESSOR 3 $138.63
64413 N BLOCK INJ, CERVICAL PLEXUS 3 $111.51
64415 N BLOCK INJ, BRACHIAL PLEXUS 3 $122.93
64416 N BLOCK CONT INFUSE, B PLEX 3 $81.80
64417 N BLOCK INJ, AXILLARY 3 $123.36
64418 N BLOCK INJ, SUPRASCAPULAR 3 $129.80
64420 N BLOCK INJ, INTERCOST, SNG 3 $154.55
64421 N BLOCK INJ, INTERCOST, MLT 3 $228.71
64425 N BLOCK INJ, ILIO-ING/HYPOGI 3 $124.30
64430 N BLOCK INJ, PUDENDAL 3 $144.24
64435 N BLOCK INJ, PARACERVICAL 3 $136.38
64440 INJECTION FOR NERVE BLOCK O $0.00
64441 INJECTION FOR NERVE BLOCK O $0.00
64442 INJECTION FOR NERVE BLOCK O $0.00
64443 INJECT, NERVE BLOCK ADD-ON O $0.00
64445 N BLOCK INJ, SCIATIC, SNG 3 $129.20
64446 N BLK INJ, SCIATIC, CONT INF 3 $84.07
64447 N BLOCK INJ FEM, SINGLE 3 $66.21
64448 N BLOCK INJ FEM, CONT INF 3 $74.23
64449 N BLOCK INJ, LUMBAR PLEXUS 3 $84.83
64450 N BLOCK, OTHER PERIPHERAL 3 $97.87
64455 N BLOCK INJ, PLANTAR DIGIT 3 $49.66
64470 INJ PARAVERTEBRAL C/T O $0.00
64472 INJ PARAVERTEBRAL C/T ADD-ON O $0.00

64475 INJ PARAVERTEBRAL L/S O $0.00
64476 INJ PARAVERTEBRAL L/S ADD-ON O $0.00
64479 INJ FORAMEN EPIDURAL C/T 3 $268.34
64480 INJ FORAMEN EPIDURAL ADD-ON 3 $135.64
64483 INJ FORAMEN EPIDURAL L/S 3 $259.07
64484 INJ FORAMEN EPIDURAL ADD-ON 3 $131.44
64490 INJ PARAVERT F JNT C/T 1 LEV 3 $108.72
64491 INJ PARAVERT F JNT C/T 2 LEV 3 $61.72
64492 INJ PARAVERT F JNT C/T 3 LEV 3 $62.86
64493 INJ PARAVERT F JNT L/S 1 LEV 3 $92.00
64494 INJ PARAVERT F JNT L/S 2 LEV 3 $52.74
64495 INJ PARAVERT F JNT L/S 3 LEV 3 $53.88
64505 N BLOCK, SPENOPALATINE GANGL 3 $95.25
64508 N BLOCK, CAROTID SINUS S/P 3 $144.74
64510 N BLOCK, STELLATE GANGLION 3 $131.71
64517 N BLOCK INJ, HYPOGAS PLXS 3 $165.58
64520 N BLOCK, LUMBAR/THORACIC 3 $179.04
64530 N BLOCK INJ, CELIAC PELUS 3 $184.15
64550 APPLY NEUROSTIMULATOR 3 $15.14
64553 IMPLANT NEUROELECTRODES 3 $198.91
64555 IMPLANT NEUROELECTRODES 3 $200.16
64560 IMPLANT NEUROELECTRODES 3 $197.95
64561 IMPLANT NEUROELECTRODES 3 $411.25
64565 IMPLANT NEUROELECTRODES 3 $167.30
64573 IMPLANT NEUROELECTRODES 3 $558.43
64575 IMPLANT NEUROELECTRODES 3 $268.34
64577 IMPLANT NEUROELECTRODES 3 $351.91
64580 IMPLANT NEUROELECTRODES 3 $288.06
64581 IMPLANT NEUROELECTRODES 3 $793.59
64585 REVISE/REMOVE NEUROELECTRODE 3 $301.59
64590 INSRT/REDO PN/GASTR STIMUL 3 $289.69
64595 REVISE/RMV PN/GASTR STIMUL 3 $292.71
64600 INJECTION TREATMENT OF NERVE 3 $386.52
64605 INJECTION TREATMENT OF NERVE 3 $576.36
64610 INJECTION TREATMENT OF NERVE 3 $666.87
64612 DESTROY NERVE, FACE MUSCLE 3 $158.14
64613 DESTROY NERVE, NECK MUSCLE 3 $153.13
64614 DESTROY NERVE, EXTREM MUSC 3 $166.59
64620 INJECTION TREATMENT OF NERVE 3 $265.32
64622 DESTR PARAVERTEBRL NERVE L/S 3 $315.65
64623 DESTR PARAVERTEBRAL N ADD-ON 3 $117.01
64626 DESTR PARAVERTEBRL NERVE C/T 3 $373.10
64627 DESTR PARAVERTEBRAL N ADD-ON 3 $159.75
64630 INJECTION TREATMENT OF NERVE 3 $220.36
64632 N BLOCK INJ, COMMON DIGIT 3 $84.45
64640 INJECTION TREATMENT OF NERVE 3 $214.41
64650 CHEMODENERV ECCRINE GLANDS 3 $65.71
64653 CHEMODENERV ECCRINE GLANDS 3 $78.52
64680 INJECTION TREATMENT OF NERVE 3 $296.08

64681 INJECTION TREATMENT OF NERVE 3 $362.34
64702 REVISE FINGER/TOE NERVE 3 $449.27
64704 REVISE HAND/FOOT NERVE 3 $313.43
64708 REVISE ARM/LEG NERVE 3 $454.26
64712 REVISION OF SCIATIC NERVE 3 $518.03
64713 REVISION OF ARM NERVE(S) 3 $721.31
64714 REVISE LOW BACK NERVE(S) 3 $629.85
64716 REVISION OF CRANIAL NERVE 3 $503.24
64718 REVISE ULNAR NERVE AT ELBOW 3 $542.16
64719 REVISE ULNAR NERVE AT WRIST 3 $369.45
64721 CARPAL TUNNEL SURGERY 3 $394.24
64722 RELIEVE PRESSURE ON NERVE(S) 3 $322.44
64726 RELEASE FOOT/TOE NERVE 3 $270.07
64727 INTERNAL NERVE REVISION 3 $177.33
64732 INCISION OF BROW NERVE 3 $377.56
64734 INCISION OF CHEEK NERVE 3 $394.28
64736 INCISION OF CHIN NERVE 3 $402.15
64738 INCISION OF JAW NERVE 3 $463.01
64740 INCISION OF TONGUE NERVE 3 $436.73
64742 INCISION OF FACIAL NERVE 3 $451.14
64744 INCISE NERVE, BACK OF HEAD 3 $410.89
64746 INCISE DIAPHRAGM NERVE 3 $434.03
64752 INCISION OF VAGUS NERVE 3 $479.84
64755 INCISION OF STOMACH NERVES 9 $0.00
64760 INCISION OF VAGUS NERVE 3 $464.19
64761 INCISION OF PELVIS NERVE 3 $431.43
64763 INCISE HIP/THIGH NERVE 3 $510.72
64766 INCISE HIP/THIGH NERVE 3 $580.10
64771 SEVER CRANIAL NERVE 3 $544.15
64772 INCISION OF SPINAL NERVE 3 $536.34
64774 REMOVE SKIN NERVE LESION 3 $390.27
64776 REMOVE DIGIT NERVE LESION 3 $369.45
64778 DIGIT NERVE SURGERY ADD-ON 3 $177.18
64782 REMOVE LIMB NERVE LESION 3 $434.47
64783 LIMB NERVE SURGERY ADD-ON 3 $209.77
64784 REMOVE NERVE LESION 3 $686.69
64786 REMOVE SCIATIC NERVE LESION 3 $1,015.09
64787 IMPLANT NERVE END 3 $239.66
64788 REMOVE SKIN NERVE LESION 3 $368.40
64790 REMOVAL OF NERVE LESION 3 $777.29
64792 REMOVAL OF NERVE LESION 3 $1,058.66
64795 BIOPSY OF NERVE 3 $185.14
64802 REMOVE SYMPATHETIC NERVES 3 $577.62
64804 REMOVE SYMPATHETIC NERVES 3 $808.51
64809 REMOVE SYMPATHETIC NERVES 3 $765.61
64818 REMOVE SYMPATHETIC NERVES 3 $635.97
64820 REMOVE SYMPATHETIC NERVES 3 $712.79
64821 REMOVE SYMPATHETIC NERVES 3 $648.72
64822 REMOVE SYMPATHETIC NERVES 3 $641.54

64823 REMOVE SYMPATHETIC NERVES 3 $727.15
64830 MICROREPAIR OF NERVE O $0.00
64831 REPAIR OF DIGIT NERVE 3 $638.45
64832 REPAIR NERVE ADD-ON 3 $327.35
64834 REPAIR OF HAND OR FOOT NERVE 3 $701.14
64835 REPAIR OF HAND OR FOOT NERVE 3 $764.38
64836 REPAIR OF HAND OR FOOT NERVE 3 $765.14
64837 REPAIR NERVE ADD-ON 3 $358.46
64840 REPAIR OF LEG NERVE 3 $818.06
64856 REPAIR/TRANSPOSE NERVE 3 $961.21
64857 REPAIR ARM/LEG NERVE 3 $1,003.82
64858 REPAIR SCIATIC NERVE 3 $1,131.14
64859 NERVE SURGERY 3 $245.43
64861 REPAIR OF ARM NERVES 3 $1,281.15
64862 REPAIR OF LOW BACK NERVES 3 $1,325.87
64864 REPAIR OF FACIAL NERVE 3 $832.74
64865 REPAIR OF FACIAL NERVE 3 $1,100.44
64866 FUSION OF FACIAL/OTHER NERVE 3 $1,134.21
64868 FUSION OF FACIAL/OTHER NERVE 3 $1,000.84
64870 FUSION OF FACIAL/OTHER NERVE 3 $1,024.47
64872 SUBSEQUENT REPAIR OF NERVE 3 $114.78
64874 REPAIR & REVISE NERVE ADD-ON 3 $166.13
64876 REPAIR NERVE/SHORTEN BONE 3 $191.20
64885 NERVE GRAFT, HEAD OR NECK 3 $1,080.28
64886 NERVE GRAFT, HEAD OR NECK 3 $1,280.73
64890 NERVE GRAFT, HAND OR FOOT 3 $1,031.12
64891 NERVE GRAFT, HAND OR FOOT 3 $1,087.93
64892 NERVE GRAFT, ARM OR LEG 3 $998.90
64893 NERVE GRAFT, ARM OR LEG 3 $1,055.31
64895 NERVE GRAFT, HAND OR FOOT 3 $1,250.73
64896 NERVE GRAFT, HAND OR FOOT 3 $1,444.05
64897 NERVE GRAFT, ARM OR LEG 3 $1,205.10
64898 NERVE GRAFT, ARM OR LEG 3 $1,312.29
64901 NERVE GRAFT ADD-ON 3 $593.11
64902 NERVE GRAFT ADD-ON 3 $683.26
64905 NERVE PEDICLE TRANSFER 3 $974.57
64907 NERVE PEDICLE TRANSFER 3 $1,170.74
64910 NERVE REPAIR W/ALLOGRAFT 3 $775.18
64911 NEURORRAPHY W/VEIN AUTOGRAFT 3 $952.25
64999 NERVOUS SYSTEM SURGERY 5 $0.00
65091 REVISE EYE 3 $584.88
65093 REVISE EYE WITH IMPLANT 3 $580.41
65101 REMOVAL OF EYE 3 $676.58
65103 REMOVE EYE/INSERT IMPLANT 3 $706.59
65105 REMOVE EYE/ATTACH IMPLANT 3 $780.32
65110 REMOVAL OF EYE 3 $1,110.78
65112 REMOVE EYE/REVISE SOCKET 3 $1,299.94
65114 REMOVE EYE/REVISE SOCKET 3 $1,361.15
65125 REVISE OCULAR IMPLANT 3 $413.32

65130 INSERT OCULAR IMPLANT 3 $670.25
65135 INSERT OCULAR IMPLANT 3 $681.85
65140 ATTACH OCULAR IMPLANT 3 $732.02
65150 REVISE OCULAR IMPLANT 3 $518.91
65155 REINSERT OCULAR IMPLANT 3 $781.35
65175 REMOVAL OF OCULAR IMPLANT 3 $593.65
65205 REMOVE FOREIGN BODY FROM EYE 3 $51.47
65210 REMOVE FOREIGN BODY FROM EYE 3 $63.13
65220 REMOVE FOREIGN BODY FROM EYE 3 $52.47
65222 REMOVE FOREIGN BODY FROM EYE 3 $69.69
65230 REMOVAL OF FOREIGN BODY, INTRAOCULA O $0.00
65235 REMOVE FOREIGN BODY FROM EYE 3 $640.23
65240 REMOVAL OF FOREIGN BODY, INTRAOCULA O $0.00
65245 REMOVAL OF FOREIGN BODY, INTRAOCULA O $0.00
65260 REMOVE FOREIGN BODY FROM EYE 3 $856.56
65265 REMOVE FOREIGN BODY FROM EYE 3 $1,002.21
65270 REPAIR OF EYE WOUND 3 $239.81
65272 REPAIR OF EYE WOUND 3 $312.62
65273 REPAIR OF EYE WOUND 3 $341.78
65275 REPAIR OF EYE WOUND 3 $509.43
65280 REPAIR OF EYE WOUND 3 $621.06
65285 REPAIR OF EYE WOUND 3 $959.15
65286 REPAIR OF EYE WOUND 3 $634.47
65290 REPAIR OF EYE SOCKET WOUND 3 $454.74
65300 DELIMITING KERATOTOMY O $0.00
65400 REMOVAL OF EYE LESION 3 $610.12
65410 BIOPSY OF CORNEA 3 $131.54
65420 REMOVAL OF EYE LESION 3 $463.02
65426 REMOVAL OF EYE LESION 3 $585.97
65430 CORNEAL SMEAR 3 $105.25
65435 CURETTE/TREAT CORNEA 3 $73.22
65436 CURETTE/TREAT CORNEA 3 $353.81
65450 TREATMENT OF CORNEAL LESION 3 $291.07
65600 REVISION OF CORNEA 3 $353.20
65710 CORNEAL TRANSPLANT 3 $1,007.55
65730 CORNEAL TRANSPLANT 3 $1,119.03
65750 CORNEAL TRANSPLANT 3 $1,127.70
65755 CORNEAL TRANSPLANT 3 $1,123.99
65756 CORNEAL TRNSPL, ENDOTHELIAL 3 $1,062.38
65757 PREP CORNEAL ENDO ALLOGRAFT 6 $0.00
65760 REVISION OF CORNEA 5 $0.00
65765 REVISION OF CORNEA 5 $0.00
65767 CORNEAL TISSUE TRANSPLANT 5 $0.00
65770 REVISE CORNEA WITH IMPLANT 3 $1,369.79
65771 RADIAL KERATOTOMY 5 $0.00
65772 CORRECTION OF ASTIGMATISM 3 $405.97
65775 CORRECTION OF ASTIGMATISM 3 $492.59
65780 OCULAR RECONST, TRANSPLANT 3 $804.41
65781 OCULAR RECONST, TRANSPLANT 3 $1,203.94

65782 OCULAR RECONST, TRANSPLANT 3 $1,073.16
65800 DRAINAGE OF EYE 3 $137.04
65805 DRAINAGE OF EYE 3 $150.74
65810 DRAINAGE OF EYE 3 $426.62
65815 DRAINAGE OF EYE 3 $578.48
65820 RELIEVE INNER EYE PRESSURE 3 $669.02
65825 GONIOTOMY WITH GONIOPUNCTURE O $0.00
65830 GONIOPUNCTURE, WITHOUT GONIOTOMY O $0.00
65850 INCISION OF EYE 3 $777.32
65855 LASER SURGERY OF EYE 3 $310.12
65860 INCISE INNER EYE ADHESIONS 3 $297.41
65865 INCISE INNER EYE ADHESIONS 3 $423.90
65870 INCISE INNER EYE ADHESIONS 3 $541.21
65875 INCISE INNER EYE ADHESIONS 3 $570.77
65880 INCISE INNER EYE ADHESIONS 3 $590.99
65900 REMOVE EYE LESION 3 $863.78
65920 REMOVE IMPLANT OF EYE 3 $712.92
65930 REMOVE BLOOD CLOT FROM EYE 3 $589.48
66020 INJECTION TREATMENT OF EYE 3 $165.82
66030 INJECTION TREATMENT OF EYE 3 $148.58
66130 REMOVE EYE LESION 3 $645.92
66150 GLAUCOMA SURGERY 3 $775.90
66155 GLAUCOMA SURGERY 3 $775.15
66160 GLAUCOMA SURGERY 3 $878.42
66165 GLAUCOMA SURGERY 3 $759.76
66170 GLAUCOMA SURGERY 3 $1,081.07
66172 INCISION OF EYE 3 $1,361.33
66180 IMPLANT EYE SHUNT 3 $1,065.36
66185 REVISE EYE SHUNT 3 $684.39
66220 REPAIR EYE LESION 3 $664.66
66225 REPAIR/GRAFT EYE LESION 3 $862.81
66250 FOLLOW-UP SURGERY OF EYE 3 $682.25
66500 INCISION OF IRIS 3 $314.16
66505 INCISION OF IRIS 3 $344.01
66600 REMOVE IRIS AND LESION 3 $734.57
66605 REMOVAL OF IRIS 3 $943.82
66625 REMOVAL OF IRIS 3 $389.17
66630 REMOVAL OF IRIS 3 $519.71
66635 REMOVAL OF IRIS 3 $511.77
66680 REPAIR IRIS & CILIARY BODY 3 $474.53
66682 REPAIR IRIS & CILIARY BODY 9 $0.00
66700 DESTRUCTION, CILIARY BODY 3 $401.47
66701 CYCLODIATHERMY SUBSEQUENT O $0.00
66702 CILIARY BODY DESTRUCTION, ANY METHO O $0.00
66710 CILIARY TRANSSLERAL THERAPY 3 $403.84
66711 CILIARY ENDOSCOPIC ABLATION 3 $569.25
66720 DESTRUCTION, CILIARY BODY 3 $419.81
66721 CYCLOCRYOTHERAPY SUBSEQUENT O $0.00
66740 DESTRUCTION, CILIARY BODY 3 $389.19

66741 CYCLODIALYSIS SUBSEQUENT O $0.00
66761 REVISION OF IRIS 3 $410.81
66762 REVISION OF IRIS 3 $426.89
66770 REMOVAL OF INNER EYE LESION 3 $468.16
66800 DISCISSION OF LENS CAPSULE INCISION O $0.00
66801 DISCISSION OF LENS CAPSULE INCISION O $0.00
66802 DISCISSION OF LENS CAPSULE LASER SU O $0.00
66820 INCISION, SECONDARY CATARACT 3 $358.45
66821 AFTER CATARACT LASER SURGERY 3 $295.14
66825 REPOSITION INTRAOCULAR LENS 3 $687.76
66830 REMOVAL OF LENS LESION 3 $637.68
66840 REMOVAL OF LENS MATERIAL 3 $641.99
66850 REMOVAL OF LENS MATERIAL 3 $721.57
66852 REMOVAL OF LENS MATERIAL 3 $778.30
66915 EXPRESSION OF LENS, LINEAR, ONE OR O $0.00
66920 EXTRACTION OF LENS 3 $675.38
66930 EXTRACTION OF LENS 3 $767.68
66940 EXTRACTION OF LENS 3 $717.12
66982 CATARACT SURGERY, COMPLEX 3 $976.16
66983 CATARACT SURG W/IOL, 1 STAGE 3 $670.02
66984 CATARACT SURG W/IOL, 1 STAGE 3 $702.37
66985 INSERT LENS PROSTHESIS 3 $696.30
66986 EXCHANGE LENS PROSTHESIS 3 $832.12
66990 OPHTHALMIC ENDOSCOPE ADD-ON 3 $83.34
66999 EYE SURGERY PROCEDURE 5 $0.00
67005 PARTIAL REMOVAL OF EYE FLUID 3 $434.64
67010 PARTIAL REMOVAL OF EYE FLUID 3 $492.90
67015 RELEASE OF EYE FLUID 3 $526.31
67025 REPLACE EYE FLUID 3 $661.29
67027 IMPLANT EYE DRUG SYSTEM 3 $785.32
67028 INJECTION EYE DRUG 3 $193.55
67030 INCISE INNER EYE STRANDS 3 $468.56
67031 LASER SURGERY, EYE STRANDS 3 $349.60
67036 REMOVAL OF INNER EYE FLUID 3 $879.29
67038 STRIP RETINAL MEMBRANE O $0.00
67039 LASER TREATMENT OF RETINA 3 $1,140.85
67040 LASER TREATMENT OF RETINA 3 $1,300.89
67041 VIT FOR MACULAR PUCKER 3 $1,213.44
67042 VIT FOR MACULAR HOLE 3 $1,388.78
67043 VIT FOR MEMBRANE DISSECT 3 $1,475.00
67101 REPAIR DETACHED RETINA 3 $709.63
67105 REPAIR DETACHED RETINA 3 $650.57
67107 REPAIR DETACHED RETINA 3 $1,121.74
67108 REPAIR DETACHED RETINA 3 $1,473.03
67109 REPAIR OF RETINAL DETACHMENT, ONE O O $0.00
67110 REPAIR DETACHED RETINA 3 $784.27
67112 REREPAIR DETACHED RETINA 3 $1,214.35
67113 REPAIR RETINAL DETACH, CPLX 3 $1,598.13
67115 RELEASE ENCIRCLING MATERIAL 3 $448.10

67120 REMOVE EYE IMPLANT MATERIAL 3 $599.85
67121 REMOVE EYE IMPLANT MATERIAL 3 $835.73
67141 TREATMENT OF RETINA 3 $475.60
67145 TREATMENT OF RETINA 3 $475.00
67208 TREATMENT OF RETINAL LESION 3 $534.34
67210 TREATMENT OF RETINAL LESION 3 $632.41
67218 TREATMENT OF RETINAL LESION 3 $1,252.70
67220 TREATMENT OF CHOROID LESION 3 $980.49
67221 OCULAR PHOTODYNAMIC THER 3 $268.04
67225 EYE PHOTODYNAMIC THER ADD-ON 3 $27.11
67227 TREATMENT OF RETINAL LESION 3 $543.94
67228 TREATMENT OF RETINAL LESION 3 $1,095.59
67229 TR RETINAL LES PRETERM INF 3 $1,034.22
67250 REINFORCE EYE WALL 3 $717.02
67255 REINFORCE/GRAFT EYE WALL 3 $775.08
67299 EYE SURGERY PROCEDURE 5 $0.00
67311 REVISE EYE MUSCLE 3 $547.77
67312 REVISE TWO EYE MUSCLES 3 $659.73
67313 STRABISMUS SURGERY ON PATIENT NOT P O $0.00
67314 REVISE EYE MUSCLE 3 $615.44
67316 REVISE TWO EYE MUSCLES 3 $740.40
67318 REVISE EYE MUSCLE(S) 3 $627.80
67320 REVISE EYE MUSCLE(S) ADD-ON 3 $294.47
67331 EYE SURGERY FOLLOW-UP ADD-ON 3 $287.89
67332 REREVISE EYE MUSCLES ADD-ON 3 $312.77
67334 REVISE EYE MUSCLE W/SUTURE 3 $275.53
67335 EYE SUTURE DURING SURGERY 3 $141.40
67340 REVISE EYE MUSCLE ADD-ON 3 $327.71
67343 RELEASE EYE TISSUE 3 $601.26
67345 DESTROY NERVE OF EYE MUSCLE 3 $219.67
67346 BIOPSY, EYE MUSCLE 3 $189.20
67350 BIOPSY EYE MUSCLE O $0.00
67399 EYE MUSCLE SURGERY PROCEDURE 5 $0.00
67400 EXPLORE/BIOPSY EYE SOCKET 3 $857.26
67405 EXPLORE/DRAIN EYE SOCKET 3 $720.27
67412 EXPLORE/TREAT EYE SOCKET 3 $788.59
67413 EXPLORE/TREAT EYE SOCKET 3 $793.01
67414 EXPLR/DECOMPRESS EYE SOCKET 3 $1,203.43
67415 ASPIRATION, ORBITAL CONTENTS 3 $98.57
67420 EXPLORE/TREAT EYE SOCKET 3 $1,513.15
67430 EXPLORE/TREAT EYE SOCKET 3 $1,119.07
67440 EXPLORE/DRAIN EYE SOCKET 3 $1,097.30
67445 EXPLR/DECOMPRESS EYE SOCKET 3 $1,305.74
67450 EXPLORE/BIOPSY EYE SOCKET 3 $1,140.14
67500 INJECT/TREAT EYE SOCKET 3 $80.64
67505 INJECT/TREAT EYE SOCKET 3 $82.80
67515 INJECT/TREAT EYE SOCKET 3 $88.31
67550 INSERT EYE SOCKET IMPLANT 3 $892.84
67560 REVISE EYE SOCKET IMPLANT 3 $898.37

67570 DECOMPRESS OPTIC NERVE 3 $1,108.03
67599 ORBIT SURGERY PROCEDURE 5 $0.00
67700 DRAINAGE OF EYELID ABSCESS 3 $239.38
67710 INCISION OF EYELID 3 $202.13
67715 INCISION OF EYELID FOLD 3 $213.58
67800 REMOVE EYELID LESION 3 $115.64
67801 REMOVE EYELID LESIONS 3 $148.96
67805 REMOVE EYELID LESIONS 3 $184.89
67808 REMOVE EYELID LESION(S) 3 $338.06
67810 BIOPSY OF EYELID 3 $202.38
67820 REVISE EYELASHES 3 $47.55
67825 REVISE EYELASHES 3 $117.99
67830 REVISE EYELASHES 3 $241.29
67835 REVISE EYELASHES 3 $406.97
67840 REMOVE EYELID LESION 3 $251.06
67850 TREAT EYELID LESION 3 $200.65
67875 CLOSURE OF EYELID BY SUTURE 3 $156.54
67880 REVISION OF EYELID 3 $415.59
67882 REVISION OF EYELID 3 $515.27
67900 REPAIR BROW DEFECT 3 $587.57
67901 REPAIR EYELID DEFECT 3 $647.82
67902 REPAIR EYELID DEFECT 3 $661.90
67903 REPAIR EYELID DEFECT 3 $556.19
67904 REPAIR EYELID DEFECT 3 $668.99
67906 REPAIR EYELID DEFECT 3 $458.91
67907 REPAIR OF BLEPHAROPTOSIS SUPERIOR R O $0.00
67908 REPAIR EYELID DEFECT 3 $451.75
67909 REVISE EYELID DEFECT 3 $492.83
67911 REVISE EYELID DEFECT 3 $514.68
67912 CORRECTION EYELID W/IMPLANT 3 $814.84
67914 REPAIR EYELID DEFECT 3 $355.62
67915 REPAIR EYELID DEFECT 3 $315.80
67916 REPAIR EYELID DEFECT 3 $492.14
67917 REPAIR EYELID DEFECT 3 $538.01
67921 REPAIR EYELID DEFECT 3 $339.73
67922 REPAIR EYELID DEFECT 3 $305.62
67923 REPAIR EYELID DEFECT 3 $521.07
67924 REPAIR EYELID DEFECT 3 $537.09
67930 REPAIR EYELID WOUND 3 $335.83
67935 REPAIR EYELID WOUND 3 $547.07
67938 REMOVE EYELID FOREIGN BODY 3 $218.76
67950 REVISION OF EYELID 3 $527.46
67961 REVISION OF EYELID 3 $528.37
67966 REVISION OF EYELID 3 $703.80
67971 RECONSTRUCTION OF EYELID 3 $677.28
67973 RECONSTRUCTION OF EYELID 3 $875.47
67974 RECONSTRUCTION OF EYELID 3 $872.49
67975 RECONSTRUCTION OF EYELID 3 $640.00
67999 REVISION OF EYELID 5 $0.00

68020 INCISE/DRAIN EYELID LINING 3 $108.85
68040 TREATMENT OF EYELID LESIONS 3 $60.46
68100 BIOPSY OF EYELID LINING 3 $154.67
68110 REMOVE EYELID LINING LESION 3 $204.77
68115 REMOVE EYELID LINING LESION 3 $280.40
68130 REMOVE EYELID LINING LESION 3 $481.08
68135 REMOVE EYELID LINING LESION 3 $142.12
68200 TREAT EYELID BY INJECTION 3 $38.65
68320 REVISE/GRAFT EYELID LINING 3 $657.06
68325 REVISE/GRAFT EYELID LINING 3 $608.35
68326 REVISE/GRAFT EYELID LINING 3 $595.04
68328 REVISE/GRAFT EYELID LINING 3 $659.26
68330 REVISE EYELID LINING 3 $551.13
68335 REVISE/GRAFT EYELID LINING 3 $597.50
68340 SEPARATE EYELID ADHESIONS 3 $495.79
68360 REVISE EYELID LINING 3 $483.93
68362 REVISE EYELID LINING 3 $604.97
68371 HARVEST EYE TISSUE, ALOGRAFT 3 $369.97
68399 EYELID LINING SURGERY 5 $0.00
68400 INCISE/DRAIN TEAR GLAND 3 $254.90
68420 INCISE/DRAIN TEAR SAC 3 $287.79
68440 INCISE TEAR DUCT OPENING 3 $97.29
68500 REMOVAL OF TEAR GLAND 3 $909.36
68505 PARTIAL REMOVAL, TEAR GLAND 3 $902.80
68510 BIOPSY OF TEAR GLAND 3 $414.41
68520 REMOVAL OF TEAR SAC 3 $625.96
68525 BIOPSY OF TEAR SAC 3 $253.64
68530 CLEARANCE OF TEAR DUCT 3 $394.60
68540 REMOVE TEAR GLAND LESION 3 $845.07
68550 REMOVE TEAR GLAND LESION 3 $1,020.28
68700 REPAIR TEAR DUCTS 3 $557.48
68705 REVISE TEAR DUCT OPENING 3 $216.73
68720 CREATE TEAR SAC DRAIN 3 $696.52
68745 CREATE TEAR DUCT DRAIN 3 $704.38
68750 CREATE TEAR DUCT DRAIN 3 $727.30
68760 CLOSE TEAR DUCT OPENING 3 $183.79
68761 CLOSE TEAR DUCT OPENING 3 $133.67
68770 CLOSE TEAR SYSTEM FISTULA 3 $559.18
68800 DILATION OF LACRIMAL PUNCTUM, WITH O $0.00
68801 DILATE TEAR DUCT OPENING 3 $112.04
68810 PROBE NASOLACRIMAL DUCT 3 $217.19
68811 PROBE NASOLACRIMAL DUCT 3 $189.93
68815 PROBE NASOLACRIMAL DUCT 3 $402.86
68816 PROBE NL DUCT W/BALLOON 3 $625.66
68820 PROBING OF NASOLACRIMAL DUCT, WITH O $0.00
68825 PROBING OF NASOLACRIMAL DUCT, WITH O $0.00
68830 PROBING OF NASOLACRIMAL DUCT, WITH O $0.00
68840 EXPLORE/IRRIGATE TEAR DUCTS 3 $114.65
68850 INJECTION FOR TEAR SAC X-RAY 3 $60.31

68899 TEAR DUCT SYSTEM SURGERY 5 $0.00
69000 DRAIN EXTERNAL EAR LESION 3 $172.11
69005 DRAIN EXTERNAL EAR LESION 3 $202.36
69020 DRAIN OUTER EAR CANAL LESION 3 $218.70
69090 PIERCE EARLOBES 9 $0.00
69100 BIOPSY OF EXTERNAL EAR 3 $99.59
69105 BIOPSY OF EXTERNAL EAR CANAL 3 $132.17
69110 REMOVE EXTERNAL EAR, PARTIAL 3 $432.20
69120 REMOVAL OF EXTERNAL EAR 3 $382.77
69140 REMOVE EAR CANAL LESION(S) 3 $835.96
69145 REMOVE EAR CANAL LESION(S) 3 $367.71
69150 EXTENSIVE EAR CANAL SURGERY 3 $1,012.65
69155 EXTENSIVE EAR/NECK SURGERY 3 $1,626.86
69200 CLEAR OUTER EAR CANAL 3 $115.27
69205 CLEAR OUTER EAR CANAL 3 $97.41
69210 REMOVE IMPACTED EAR WAX O $0.00
69220 CLEAN OUT MASTOID CAVITY 3 $129.56
69222 CLEAN OUT MASTOID CAVITY 3 $208.49
69300 REVISE EXTERNAL EAR 3 $624.58
69310 REBUILD OUTER EAR CANAL 3 $1,041.33
69320 REBUILD OUTER EAR CANAL 3 $1,478.84
69399 OUTER EAR SURGERY PROCEDURE 5 $0.00
69400 INFLATE MIDDLE EAR CANAL 3 $135.60
69401 INFLATE MIDDLE EAR CANAL 3 $79.05
69405 CATHETERIZE MIDDLE EAR CANAL 3 $247.67
69410 INSET MIDDLE EAR (BAFFLE) O $0.00
69420 INCISION OF EARDRUM 3 $180.98
69421 INCISION OF EARDRUM 3 $145.55
69424 REMOVE VENTILATING TUBE 3 $121.59
69433 CREATE EARDRUM OPENING 3 $188.65
69436 CREATE EARDRUM OPENING 3 $157.08
69440 EXPLORATION OF MIDDLE EAR 3 $658.26
69450 EARDRUM REVISION 9 $0.00
69501 MASTOIDECTOMY 3 $704.77
69502 MASTOIDECTOMY 3 $936.76
69505 REMOVE MASTOID STRUCTURES 3 $1,157.35
69511 EXTENSIVE MASTOID SURGERY 3 $1,189.28
69530 EXTENSIVE MASTOID SURGERY 3 $1,600.08
69535 REMOVE PART OF TEMPORAL BONE 3 $2,595.82
69540 REMOVE EAR LESION 3 $197.53
69550 REMOVE EAR LESION 3 $1,001.03
69552 REMOVE EAR LESION 3 $1,520.57
69554 REMOVE EAR LESION 3 $2,398.40
69601 MASTOID SURGERY REVISION 3 $1,010.20
69602 MASTOID SURGERY REVISION 3 $1,050.10
69603 MASTOID SURGERY REVISION 3 $1,220.99
69604 MASTOID SURGERY REVISION 3 $1,080.76
69605 MASTOID SURGERY REVISION 3 $1,508.71
69610 REPAIR OF EARDRUM 3 $374.16

69620 REPAIR OF EARDRUM 3 $661.13
69631 REPAIR EARDRUM STRUCTURES 3 $846.27
69632 REBUILD EARDRUM STRUCTURES 3 $1,037.06
69633 REBUILD EARDRUM STRUCTURES 3 $1,000.75
69635 REPAIR EARDRUM STRUCTURES 3 $1,172.39
69636 REBUILD EARDRUM STRUCTURES 3 $1,329.48
69637 REBUILD EARDRUM STRUCTURES 3 $1,324.44
69641 REVISE MIDDLE EAR & MASTOID 3 $1,003.76
69642 REVISE MIDDLE EAR & MASTOID 3 $1,292.79
69643 REVISE MIDDLE EAR & MASTOID 3 $1,180.84
69644 REVISE MIDDLE EAR & MASTOID 3 $1,429.13
69645 REVISE MIDDLE EAR & MASTOID 3 $1,400.70
69646 REVISE MIDDLE EAR & MASTOID 3 $1,488.35
69650 RELEASE MIDDLE EAR BONE 3 $766.85
69660 REVISE MIDDLE EAR BONE 3 $896.80
69661 REVISE MIDDLE EAR BONE 9 $0.00
69662 REVISE MIDDLE EAR BONE 3 $1,122.25
69666 REPAIR MIDDLE EAR STRUCTURES 3 $775.92
69667 REPAIR MIDDLE EAR STRUCTURES 3 $778.18
69670 REMOVE MASTOID AIR CELLS 3 $908.54
69676 REMOVE MIDDLE EAR NERVE 3 $800.01
69700 CLOSE MASTOID FISTULA 3 $665.69
69710 IMPLANT/REPLACE HEARING AID 5 $0.00
69711 REMOVE/REPAIR HEARING AID 3 $834.68
69714 IMPLANT TEMPLE BONE W/STIMUL 3 $1,043.00
69715 TEMPLE BNE IMPLNT W/STIMULAT 3 $1,294.92
69717 TEMPLE BONE IMPLANT REVISION 3 $1,106.10
69718 REVISE TEMPLE BONE IMPLANT 3 $1,309.84
69720 RELEASE FACIAL NERVE 3 $1,133.13
69725 RELEASE FACIAL NERVE 3 $1,832.32
69740 REPAIR FACIAL NERVE 3 $1,136.09
69745 REPAIR FACIAL NERVE 3 $1,210.95
69799 MIDDLE EAR SURGERY PROCEDURE 5 $0.00
69801 INCISE INNER EAR 3 $720.31
69802 INCISE INNER EAR 3 $1,006.36
69805 EXPLORE INNER EAR 3 $1,022.39
69806 EXPLORE INNER EAR 3 $916.04
69820 ESTABLISH INNER EAR WINDOW 3 $830.65
69840 REVISE INNER EAR WINDOW 3 $874.66
69905 REMOVE INNER EAR 3 $886.99
69910 REMOVE INNER EAR & MASTOID 3 $991.06
69915 INCISE INNER EAR NERVE 3 $1,462.05
69930 IMPLANT COCHLEAR DEVICE 3 $1,200.80
69949 INNER EAR SURGERY PROCEDURE 5 $0.00
69950 INCISE INNER EAR NERVE 3 $1,762.02
69955 RELEASE FACIAL NERVE 3 $1,933.26
69960 RELEASE INNER EAR CANAL 3 $1,881.47
69970 REMOVE INNER EAR LESION 3 $2,098.48
69979 TEMPORAL BONE SURGERY 5 $0.00

69990 MICROSURGERY ADD-ON 3 $204.68
70010 CONTRAST X-RAY OF BRAIN 3 $164.94
70011 MYELOGRAPHY, POSTERIOR FOSSA COMPLE O $0.00
70015 CONTRAST X-RAY OF BRAIN 3 $144.35
70016 CISTERNOGRAPHY, POSITIVE CONTRAST C O $0.00
70030 X-RAY EYE FOR FOREIGN BODY 3 $28.24
70100 X-RAY EXAM OF JAW 3 $30.88
7010F PT INFO INTO RECALL SYSTEM 9 $0.00
70110 X-RAY EXAM OF JAW 3 $39.10
70120 X-RAY EXAM OF MASTOIDS 3 $33.53
70130 X-RAY EXAM OF MASTOIDS 3 $54.49
70134 X-RAY EXAM OF MIDDLE EAR 3 $45.80
70140 X-RAY EXAM OF FACIAL BONES 3 $28.98
70150 X-RAY EXAM OF FACIAL BONES 3 $41.74
70160 X-RAY EXAM OF NASAL BONES 3 $32.03
70170 X-RAY EXAM OF TEAR DUCT 3 $0.00
70171 DACRYOCYSTOGRAPHY, NASOLACRIMAL DUC O $0.00
70190 X-RAY EXAM OF EYE SOCKETS 3 $35.00
70200 X-RAY EXAM OF EYE SOCKETS 3 $43.23
7020F MAMMO ASSESS CAT IN DBASE 9 $0.00
70210 X-RAY EXAM OF SINUSES 3 $29.75
70220 X-RAY EXAM OF SINUSES 3 $38.35
70240 X-RAY EXAM, PITUITARY SADDLE 3 $29.35
70250 X-RAY EXAM OF SKULL 3 $35.72
7025F PT INFOSYS ALARM 4 NXT MAMMO 9 $0.00
70260 X-RAY EXAM OF SKULL 3 $46.55
70300 X-RAY EXAM OF TEETH 3 $13.97
70310 X-RAY EXAM OF TEETH 3 $35.44
70320 FULL MOUTH X-RAY OF TEETH 3 $42.54
70328 X-RAY EXAM OF JAW JOINT 3 $29.74
70330 X-RAY EXAM OF JAW JOINTS 3 $46.68
70332 X-RAY EXAM OF JAW JOINT 3 $83.21
70333 TEMPOROMANDIBULAR JOINT ARTHROGRAPH O $0.00
70336 MAGNETIC IMAGE, JAW JOINT 3 $433.00
70350 X-RAY HEAD FOR ORTHODONTIA 3 $20.69
70355 PANORAMIC X-RAY OF JAWS 3 $21.79
70360 X-RAY EXAM OF NECK 3 $27.11
70370 THROAT X-RAY & FLUOROSCOPY 3 $75.69
70371 SPEECH EVALUATION, COMPLEX 3 $94.17
70373 CONTRAST X-RAY OF LARYNX 3 $79.31
70374 LARYNGOGRAPHY, CONTRAST COMPLETE PR O $0.00
70380 X-RAY EXAM OF SALIVARY GLAND 3 $37.32
70390 X-RAY EXAM OF SALIVARY DUCT 3 $98.15
70391 SIALOGRAPHY COMPLETE PROCEDURE O $0.00
70450 CT HEAD/BRAIN W/O DYE 3 $199.85
70460 CT HEAD/BRAIN W/DYE 3 $259.85
70470 CT HEAD/BRAIN W/O & W/DYE 3 $313.96
70480 CT ORBIT/EAR/FOSSA W/O DYE 3 $265.19
70481 CT ORBIT/EAR/FOSSA W/DYE 3 $362.45

70482 CT ORBIT/EAR/FOSSA W/O&W/DYE 3 $413.38
70486 CT MAXILLOFACIAL W/O DYE 3 $257.95
70487 CT MAXILLOFACIAL W/DYE 3 $316.20
70488 CT MAXILLOFACIAL W/O & W/DYE 3 $384.70
70490 CT SOFT TISSUE NECK W/O DYE 3 $259.14
70491 CT SOFT TISSUE NECK W/DYE 3 $310.80
70492 CT SFT TSUE NCK W/O & W/DYE 3 $376.35
70496 CT ANGIOGRAPHY, HEAD 3 $438.58
70498 CT ANGIOGRAPHY, NECK 3 $438.58
70540 MRI ORBIT/FACE/NECK W/O DYE 3 $427.12
70541 MAGNETIC IMAGE, HEAD (MRA) O $0.00
70542 MRI ORBIT/FACE/NECK W/DYE 3 $516.61
70543 MRI ORBT/FAC/NCK W/O & W/DYE 3 $657.79
70544 MR ANGIOGRAPHY HEAD W/O DYE 3 $419.51
70545 MR ANGIOGRAPHY HEAD W/DYE 3 $495.48
70546 MR ANGIOGRAPH HEAD W/O&W/DYE 3 $640.22
70547 MR ANGIOGRAPHY NECK W/O DYE 3 $419.51
70548 MR ANGIOGRAPHY NECK W/DYE 3 $495.48
70549 MR ANGIOGRAPH NECK W/O&W/DYE 3 $639.98
70551 MRI BRAIN W/O DYE 3 $433.76
70552 MRI BRAIN W/DYE 3 $525.34
70553 MRI BRAIN W/O & W/DYE 3 $668.73
70554 FMRI BRAIN BY TECH 3 $572.42
70555 FMRI BRAIN BY PHYS/PSYCH 3 $0.00
70557 MRI BRAIN W/O DYE 3 $0.00
70558 MRI BRAIN W/DYE 3 $0.00
70559 MRI BRAIN W/O & W/DYE 3 $0.00
71010 CHEST X-RAY 3 $23.70
71015 CHEST X-RAY 3 $29.70
71020 CHEST X-RAY 3 $31.20
71021 CHEST X-RAY 3 $37.56
71022 CHEST X-RAY 3 $45.83
71023 CHEST X-RAY AND FLUOROSCOPY 3 $67.29
71030 CHEST X-RAY 3 $45.83
71034 CHEST X-RAY AND FLUOROSCOPY 3 $89.11
71035 CHEST X-RAY 3 $34.66
71036 X-RAY GUIDANCE FOR BIOPSY O $0.00
71037 NEEDLE BIOPSY OF INTRATHORACIC LESI O $0.00
71038 X-RAY GUIDANCE FOR BIOPSY O $0.00
71040 CONTRAST X-RAY OF BRONCHI 3 $94.63
71041 BRONCHOGRAPHY, UNILATERAL COMPLETE O $0.00
71060 CONTRAST X-RAY OF BRONCHI 3 $139.14
71061 BRONCHOGRAPHY, BILATERAL COMPLETE P O $0.00
71090 X-RAY & PACEMAKER INSERTION 3 $0.00
71100 X-RAY EXAM OF RIBS 3 $32.34
71101 X-RAY EXAM OF RIBS/CHEST 3 $38.70
71110 X-RAY EXAM OF RIBS 3 $39.84
71111 X-RAY EXAM OF RIBS/CHEST 3 $51.49
71120 X-RAY EXAM OF BREASTBONE 3 $31.99

71130 X-RAY EXAM OF BREASTBONE 3 $36.88
71250 CT THORAX W/O DYE 3 $259.30
71260 CT THORAX W/DYE 3 $314.37
71270 CT THORAX W/O & W/DYE 3 $387.15
71275 CT ANGIOGRAPHY, CHEST 3 $446.92
71550 MRI CHEST W/O DYE 3 $432.65
71551 MRI CHEST W/DYE 3 $522.13
71552 MRI CHEST W/O & W/DYE 3 $664.08
71555 MRI ANGIO CHEST W OR W/O DYE 3 $604.81
72010 X-RAY EXAM OF SPINE 3 $70.47
72020 X-RAY EXAM OF SPINE 3 $23.74
72040 X-RAY EXAM OF NECK SPINE 3 $37.12
72050 X-RAY EXAM OF NECK SPINE 3 $51.74
72052 X-RAY EXAM OF NECK SPINE 3 $64.92
72069 X-RAY EXAM OF TRUNK SPINE 3 $35.61
72070 X-RAY EXAM OF THORACIC SPINE 3 $33.09
72072 X-RAY EXAM OF THORACIC SPINE 3 $37.63
72074 X-RAY EXAM OF THORACIC SPINE 3 $44.06
72080 X-RAY EXAM OF TRUNK SPINE 3 $35.23
72090 X-RAY EXAM OF TRUNK SPINE 3 $47.49
72100 X-RAY EXAM OF LOWER SPINE 3 $39.01
72110 X-RAY EXAM OF LOWER SPINE 3 $53.64
72114 X-RAY EXAM OF LOWER SPINE 3 $71.21
72120 X-RAY EXAM OF LOWER SPINE 3 $48.83
72125 CT NECK SPINE W/O DYE 3 $259.30
72126 CT NECK SPINE W/DYE 3 $314.02
72127 CT NECK SPINE W/O & W/DYE 3 $380.87
72128 CT CHEST SPINE W/O DYE 3 $259.30
72129 CT CHEST SPINE W/DYE 3 $314.02
72130 CT CHEST SPINE W/O & W/DYE 3 $382.38
72131 CT LUMBAR SPINE W/O DYE 3 $259.30
72132 CT LUMBAR SPINE W/DYE 3 $313.27
72133 CT LUMBAR SPINE W/O & W/DYE 3 $381.62
72141 MRI NECK SPINE W/O DYE 3 $439.52
72142 MRI NECK SPINE W/DYE 3 $531.96
72146 MRI CHEST SPINE W/O DYE 3 $439.52
72147 MRI CHEST SPINE W/DYE 3 $532.35
72148 MRI LUMBAR SPINE W/O DYE 3 $433.63
72149 MRI LUMBAR SPINE W/DYE 3 $525.34
72156 MRI NECK SPINE W/O & W/DYE 3 $679.91
72157 MRI CHEST SPINE W/O & W/DYE 3 $679.91
72158 MRI LUMBAR SPINE W/O & W/DYE 3 $669.22
72159 MR ANGIO SPINE W/O&W/DYE 3 $662.17
72170 X-RAY EXAM OF PELVIS 3 $26.22
72190 X-RAY EXAM OF PELVIS 3 $39.78
72191 CT ANGIOGRAPH PELV W/O&W/DYE 3 $442.02
72192 CT PELVIS W/O DYE 3 $247.80
72193 CT PELVIS W/DYE 3 $297.85
72194 CT PELVIS W/O & W/DYE 3 $380.17

72195 MRI PELVIS W/O DYE 3 $432.90
72196 MRI PELVIS W/DYE 3 $522.52
72197 MRI PELVIS W/O & W/DYE 3 $663.70
72198 MR ANGIO PELVIS W/O & W/DYE 3 $601.80
72200 X-RAY EXAM SACROILIAC JOINTS 3 $29.00
72202 X-RAY EXAM SACROILIAC JOINTS 3 $34.27
72220 X-RAY EXAM OF TAILBONE 3 $28.63
72240 CONTRAST X-RAY OF NECK SPINE 3 $148.24
72241 MYELOGRAPHY, CERVICAL COMPLETE PROC O $0.00
72255 CONTRAST X-RAY, THORAX SPINE 3 $137.42
72256 MYELOGRAPHY, THORACIC COMPLETE PROC O $0.00
72265 CONTRAST X-RAY, LOWER SPINE 3 $139.41
72266 MYELOGRAPHY, LUMBOSACRAL COMPLETE P O $0.00
72270 CONTRAST X-RAY, SPINE 3 $217.50
72271 MYELOGRAPHY, ENTIRE SPINAL CANAL CO O $0.00
72275 EPIDUROGRAPHY 3 $103.96
72285 X-RAY C/T SPINE DISK 3 $156.61
72286 DISKOGRAPHY, CERVICAL COMPLETE PROC O $0.00
72291 PERQ VERTE/SACROPLSTY, FLUOR 3 $0.00
72292 PERQ VERTE/SACROPLSTY, CT 3 $0.00
72295 X-RAY OF LOWER SPINE DISK 3 $137.90
72296 DISKOGRAPHY, LUMBAR COMPLETE PROCED O $0.00
73000 X-RAY EXAM OF COLLAR BONE 3 $27.50
73010 X-RAY EXAM OF SHOULDER BLADE 3 $28.87
73020 X-RAY EXAM OF SHOULDER 3 $23.35
73030 X-RAY EXAM OF SHOULDER 3 $29.62
73040 CONTRAST X-RAY OF SHOULDER 3 $105.38
73041 RADIOLOGIC EXAMINATION, SHOULDER, A O $0.00
73050 X-RAY EXAM OF SHOULDERS 3 $36.39
73060 X-RAY EXAM OF HUMERUS 3 $28.63
73070 X-RAY EXAM OF ELBOW 3 $27.14
73080 X-RAY EXAM OF ELBOW 3 $34.29
73085 CONTRAST X-RAY OF ELBOW 3 $94.55
73086 RADIOLOGIC EXAMINATION, ELBOW, ARTH O $0.00
73090 X-RAY EXAM OF FOREARM 3 $27.13
73092 X-RAY EXAM OF ARM, INFANT 3 $28.25
73100 X-RAY EXAM OF WRIST 3 $29.26
73110 X-RAY EXAM OF WRIST 3 $34.67
73115 CONTRAST X-RAY OF WRIST 3 $103.11
73116 RADIOLOGIC EXAMINATION, WRIST, ARTH O $0.00
73120 X-RAY EXAM OF HAND 3 $26.74
73130 X-RAY EXAM OF HAND 3 $30.89
73140 X-RAY EXAM OF FINGER(S) 3 $29.43
73200 CT UPPER EXTREMITY W/O DYE 3 $250.69
73201 CT UPPER EXTREMITY W/DYE 3 $300.50
73202 CT UPPR EXTREMITY W/O&W/DYE 3 $384.71
73206 CT ANGIO UPR EXTRM W/O&W/DYE 3 $441.66
73218 MRI UPPER EXTREMITY W/O DYE 3 $426.50
73219 MRI UPPER EXTREMITY W/DYE 3 $516.98

73220 MRI UPPR EXTREMITY W/O&W/DYE 3 $658.17
73221 MRI JOINT UPR EXTREM W/O DYE 3 $426.99
73222 MRI JOINT UPR EXTREM W/DYE 3 $516.98
73223 MRI JOINT UPR EXTR W/O&W/DYE 3 $657.79
73225 MR ANGIO UPR EXTR W/O&W/DYE 3 $649.78
73500 X-RAY EXAM OF HIP 3 $25.47
73510 X-RAY EXAM OF HIP 3 $36.76
73520 X-RAY EXAM OF HIPS 3 $39.34
73525 CONTRAST X-RAY OF HIP 3 $95.92
73526 RADIOLOGIC EXAMINATION, HIP, ARTHRO O $0.00
73530 X-RAY EXAM OF HIP 3 $0.00
73540 X-RAY EXAM OF PELVIS & HIPS 3 $38.28
73542 X-RAY EXAM, SACROILIAC JOINT 3 $78.61
73550 X-RAY EXAM OF THIGH 3 $27.73
73560 X-RAY EXAM OF KNEE, 1 OR 2 3 $28.87
73562 X-RAY EXAM OF KNEE, 3 3 $34.53
73564 X-RAY EXAM, KNEE, 4 OR MORE 3 $40.14
73565 X-RAY EXAM OF KNEES 3 $31.52
73580 CONTRAST X-RAY OF KNEE JOINT 3 $123.01
73581 RADIOLOGIC EXAMINATION, KNEE, ARTHR O $0.00
73590 X-RAY EXAM OF LOWER LEG 3 $27.11
73592 X-RAY EXAM OF LEG, INFANT 3 $28.64
73600 X-RAY EXAM OF ANKLE 3 $27.13
73610 X-RAY EXAM OF ANKLE 3 $31.27
73615 CONTRAST X-RAY OF ANKLE 3 $99.32
73616 RADIOLOGIC EXAMINATION, ANKLE, ARTH O $0.00
73620 X-RAY EXAM OF FOOT 3 $26.37
73630 X-RAY EXAM OF FOOT 3 $30.89
73650 X-RAY EXAM OF HEEL 3 $26.74
73660 X-RAY EXAM OF TOE(S) 3 $27.54
73700 CT LOWER EXTREMITY W/O DYE 3 $251.07
73701 CT LOWER EXTREMITY W/DYE 3 $302.76
73702 CT LWR EXTREMITY W/O&W/DYE 3 $385.46
73706 CT ANGIO LWR EXTR W/O&W/DYE 3 $446.95
73718 MRI LOWER EXTREMITY W/O DYE 3 $427.12
73719 MRI LOWER EXTREMITY W/DYE 3 $516.61
73720 MRI LWR EXTREMITY W/O&W/DYE 3 $658.17
73721 MRI JNT OF LWR EXTRE W/O DYE 3 $427.37
73722 MRI JOINT OF LWR EXTR W/DYE 3 $517.61
73723 MRI JOINT LWR EXTR W/O&W/DYE 3 $658.17
73725 MR ANG LWR EXT W OR W/O DYE 3 $602.91
74000 X-RAY EXAM OF ABDOMEN 3 $25.21
74010 X-RAY EXAM OF ABDOMEN 3 $37.24
74020 X-RAY EXAM OF ABDOMEN 3 $39.84
74022 X-RAY EXAM SERIES, ABDOMEN 3 $47.71
74150 CT ABDOMEN W/O DYE 3 $250.94
74160 CT ABDOMEN W/DYE 3 $335.89
74170 CT ABDOMEN W/O & W/DYE 3 $413.45
74175 CT ANGIO ABDOM W/O & W/DYE 3 $446.44

74181 MRI ABDOMEN W/O DYE 3 $432.28
74182 MRI ABDOMEN W/DYE 3 $522.52
74183 MRI ABDOMEN W/O & W/DYE 3 $663.32
74185 MRI ANGIO, ABDOM W ORW/O DYE 3 $600.29
74190 X-RAY EXAM OF PERITONEUM 3 $0.00
74210 CONTRST X-RAY EXAM OF THROAT 3 $76.01
74220 CONTRAST X-RAY, ESOPHAGUS 3 $87.85
74230 CINE/VID X-RAY, THROAT/ESOPH 3 $88.89
74235 REMOVE ESOPHAGUS OBSTRUCTION 3 $0.00
74240 X-RAY EXAM, UPPER GI TRACT 3 $107.46
74241 X-RAY EXAM, UPPER GI TRACT 3 $114.77
74245 X-RAY EXAM, UPPER GI TRACT 3 $172.05
74246 CONTRST X-RAY UPPR GI TRACT 3 $122.95
74247 CONTRST X-RAY UPPR GI TRACT 3 $124.84
74249 CONTRST X-RAY UPPR GI TRACT 3 $184.91
74250 X-RAY EXAM OF SMALL BOWEL 3 $102.58
74251 X-RAY EXAM OF SMALL BOWEL 3 $180.15
74260 X-RAY EXAM OF SMALL BOWEL 3 $115.14
74261 CT COLONOGRAPHY, W/O DYE 3 $311.40
74262 CT COLONOGRAPHY, W/DYE 3 $426.64
74263 CT COLONOGRAPHY, SCREEN 3 $729.82
74270 CONTRAST X-RAY EXAM OF COLON 3 $124.84
74280 CONTRAST X-RAY EXAM OF COLON 3 $195.76
74283 CONTRAST X-RAY EXAM OF COLON 3 $191.44
74290 CONTRAST X-RAY, GALLBLADDER 3 $65.86
74291 CONTRAST X-RAYS, GALLBLADDER 3 $58.82
74300 X-RAY BILE DUCTS/PANCREAS O $0.00
74301 X-RAYS AT SURGERY ADD-ON 3 $0.00
74305 X-RAY BILE DUCTS/PANCREAS 3 $0.00
74320 CONTRAST X-RAY OF BILE DUCTS 3 $108.91
74321 CHOLANGIOGRAPHY, PERCUTANEOUS, TRAN O $0.00
74327 X-RAY BILE STONE REMOVAL 3 $131.97
74328 X-RAY BILE DUCT ENDOSCOPY 3 $0.00
74329 X-RAY FOR PANCREAS ENDOSCOPY 3 $0.00
74330 X-RAY BILE/PANC ENDOSCOPY 3 $0.00
74340 X-RAY GUIDE FOR GI TUBE 3 $0.00
74350 X-RAY GUIDE, STOMACH TUBE O $0.00
74351 PERCUTANEOUS PLACEMENT OF GASTROSTO O $0.00
74355 X-RAY GUIDE, INTESTINAL TUBE 3 $0.00
74356 PERCUTANEOUS PLACEMENT OF ENTEROCLY O $0.00
74360 X-RAY GUIDE, GI DILATION 3 $0.00
74361 INTRALUMINAL DILATION OF STRICTURES O $0.00
74363 X-RAY, BILE DUCT DILATION 3 $0.00
74400 CONTRST X-RAY, URINARY TRACT 3 $108.59
74405 CONTRAST X-RAY URINARY TRACT O $0.00
74410 CONTRST X-RAY, URINARY TRACT 3 $113.13
74415 CONTRST X-RAY, URINARY TRACT 3 $131.65
74420 CONTRST X-RAY, URINARY TRACT 3 $126.86
74425 CONTRST X-RAY, URINARY TRACT 3 $72.93

74426 UROGRAPHY, ANTEGRADE, (PYELOSTOGRAM O $0.00
74430 CONTRAST X-RAY, BLADDER 3 $78.70
74431 CYSTOGRAPHY, MINIMUM OF THREE VIEWS O $0.00
74440 X-RAY, MALE GENITAL TRACT 3 $84.54
74441 VASOGRAPHY, VESICULOGRAPHY, OR EPID O $0.00
74445 X-RAY EXAM OF PENIS 3 $107.47
74446 CORPORA CAVERNOSOGRAPHY COMPLETE PR O $0.00
74450 X-RAY, URETHRA/BLADDER 3 $77.62
74451 URETHROCYSTOGRAPHY, RETROGRADE COMP O $0.00
74455 X-RAY, URETHRA/BLADDER 3 $88.90
74456 URETHROCYSTOGRAPHY, VOIDING COMPLET O $0.00
74470 X-RAY EXAM OF KIDNEY LESION 3 $79.83
74471 RADIOLOGIC EXAMINATION, RENAL CYST O $0.00
74475 X-RAY CONTROL, CATH INSERT 3 $114.95
74476 INTRODUCTION OF INTRACATHETER OR CA O $0.00
74480 X-RAY CONTROL, CATH INSERT 3 $115.34
74481 INTRODUCTION OF URETERAL CATHETER O O $0.00
74485 X-RAY GUIDE, GU DILATION 3 $111.94
74486 DILATION OF NEPHROSTOMY OR URETERS O $0.00
74710 X-RAY MEASUREMENT OF PELVIS 3 $41.26
74740 X-RAY, FEMALE GENITAL TRACT 3 $77.50
74741 HYSTEROSALPINGOGRAPHY COMPLETE PROC O $0.00
74742 X-RAY, FALLOPIAN TUBE 9 $0.00
74775 X-RAY EXAM OF PERINEUM 3 $0.00
75120 RADIOLOGIC EXAMINATION, HAND; TWO V O $0.00
75500 ANGIOCARDIOGRAPHY BY CINERADIOGRAPH O $0.00
75501 ANGIOCARDIOGRAPHY BY CINERADIOGRAPH O $0.00
75505 ANGIOCARDIOGRAPHY BY SERIALOGRAPHY, O $0.00
75506 ANGIOCARDIOGRAPHY BY SERIALOGRAPHY, O $0.00
75507 ANGIOCARDIOGRAPHY BY SERIALOGRAPHY, O $0.00
75509 ANGIOCARDIOGRAPHY BY SERIALOGRAPHY, O $0.00
75519 CARDIAC RADIOGRAPHY, SELECTIVE CARD O $0.00
75520 CARDIAC RADIOGRAPHY, SELECTIVE CARD O $0.00
75523 CARDIAC RADIOGRAPHY, SELECTIVE CARD O $0.00
75524 CARDIAC RADIOGRAPHY, SELECTIVE CARD O $0.00
75527 CARDIAC RADIOGRAPHY, SELECTIVE CARD O $0.00
75528 CARDIAC RADIOGRAPHY, SELECTIVE CARD O $0.00
75552 HEART MRI FOR MORPH W/O DYE O $0.00
75553 HEART MRI FOR MORPH W/DYE O $0.00
75554 CARDIAC MRI/FUNCTION O $0.00
75555 CARDIAC MRI/LIMITED STUDY O $0.00
75556 CARDIAC MRI/FLOW MAPPING O $0.00
75557 CARDIAC MRI FOR MORPH 3 $460.87
75558 CARDIAC MRI FLOW/VELOCITY O $0.00
75559 CARDIAC MRI W/STRESS IMG 3 $515.79
75560 CARDIAC MRI FLOW/VEL/STRESS O $0.00
75561 CARDIAC MRI FOR MORPH W/DYE 3 $624.85
75562 CARD MRI FLOW/VEL W/DYE O $0.00
75563 CARD MRI W/STRESS IMG & DYE 3 $710.52

75564 HT MRI W/FLO/VEL/STRS & DYE O $0.00
75565 CARD MRI VEL FLW MAP ADD-ON 3 $95.05
75571 CT HRT W/O DYE W/CA TEST 9 $0.00
75572 CT HRT W/3D IMAGE 3 $315.76
75573 CT HRT W/3D IMAGE, CONGEN 3 $399.53
75574 CT ANGIO HRT W/3D IMAGE 3 $393.42
75600 CONTRAST X-RAY EXAM OF AORTA 3 $288.13
75601 AORTOGRAPHY, THORACIC, WITHOUT SERI O $0.00
75605 CONTRAST X-RAY EXAM OF AORTA 3 $237.40
75606 AORTOGRAPHY, THORACIC, BY SERIALOGR O $0.00
75625 CONTRAST X-RAY EXAM OF AORTA 3 $235.62
75626 AORTOGRAPHY, ABDOMINAL, TRANSLUMBAR O $0.00
75627 AORTOGRAPHY, ABDOMINAL, CATHETER, B O $0.00
75628 AORTOGRAPHY, ABDOMINAL, CATHETER, B O $0.00
75630 X-RAY AORTA, LEG ARTERIES 3 $274.49
75631 AORTOGRAPHY, ABDOMINAL PLUS BILATER O $0.00
75635 CT ANGIO ABDOMINAL ARTERIES 3 $472.64
75650 ARTERY X-RAYS, HEAD & NECK 3 $254.46
75651 ANGIOGRAPHY, CERVICOCEREBRAL, CATHE O $0.00
75652 ANGIOGRAPHY, CERVICOCEREBRAL, SELEC O $0.00
75653 ANGIOGRAPHY, CERVICOCEREBRAL, SELEC O $0.00
75654 ANGIOGRAPHY, CERVICOCEREBRAL, SELEC O $0.00
75655 ANGIOGRAPHY, CERVICOCEREBRAL, SELEC O $0.00
75656 ANGIOGRAPHY, CERVICOCEREBRAL, SELEC O $0.00
75657 ANGIOGRAPHY, CERVICOCEREBRAL, SELEC O $0.00
75658 ARTERY X-RAYS, ARM 3 $255.57
75659 ANGIOGRAPHY, BRACHIAL, RETROGRADE C O $0.00
75660 ARTERY X-RAYS, HEAD & NECK 3 $258.99
75661 ANGIOGRAPHY, EXTERNAL CAROTID, CERE O $0.00
75662 ARTERY X-RAYS, HEAD & NECK 3 $302.00
75663 ANGIOGRAPHY, EXTERNAL CAROTID, CERE O $0.00
75665 ARTERY X-RAYS, HEAD & NECK 3 $267.40
75667 ANGIOGRAPHY, CAROTID, CEREBRAL, UNI O $0.00
75669 ANGIOGRAPHY, CAROTID, CEREBRAL, UNI O $0.00
75671 ARTERY X-RAYS, HEAD & NECK 3 $308.53
75672 ANGIOGRAPHY, CAROTID, CEREBRAL, BIL O $0.00
75673 ANGIOGRAPHY, CAROTID, CEREBRAL, BIL O $0.00
75676 ARTERY X-RAYS, NECK 3 $259.46
75677 ANGIOGRAPHY, CAROTID, CERVICAL, UNI O $0.00
75678 ANGIOGRAPHY, CAROTID, CERVICAL, UNI O $0.00
75680 ARTERY X-RAYS, NECK 3 $292.79
75681 ANGIOGRAPHY, CAROTID, CERVICAL, BIL O $0.00
75682 ANGIOGRAPHY, CAROTID, CERVICAL, BIL O $0.00
75685 ARTERY X-RAYS, SPINE 3 $259.73
75686 ANGIOGRAPHY, VERTEBRAL DIRECT PUNCT O $0.00
75687 ANGIOGRAPHY, VERTEBRAL CATHETER, CO O $0.00
75690 ANGIOGRAPHY, VERTEBRAL, CERVICAL, U O $0.00
75692 ANGIOGRAPHY, VERTEBRAL, CERVICAL, U O $0.00
75695 ANGIOGRAPHY, VERTEBRAL, CERVICAL, B O $0.00

75697 ANGIOGRAPHY, VERTEBRAL, CERVICAL, B O $0.00
75705 ARTERY X-RAYS, SPINE 3 $302.99
75706 ANGIOGRAPHY, SPINAL, SELECTIVE COMP O $0.00
75710 ARTERY X-RAYS, ARM/LEG 3 $251.89
75711 ANGIOGRAPHY, EXTREMITY, UNILATERAL O $0.00
75712 ANGIOGRAPHY, EXTREMITY, UNILATERAL O $0.00
75716 ARTERY X-RAYS, ARMS/LEGS 3 $286.68
75717 ANGIOGRAPHY, EXTREMITY, BILATERAL W O $0.00
75718 ANGIOGRAPHY, EXTREMITY, BILATERAL B O $0.00
75722 ARTERY X-RAYS, KIDNEY 3 $246.84
75723 ANGIOGRAPHY, RENAL, UNILATERAL, SEL O $0.00
75724 ARTERY X-RAYS, KIDNEYS 3 $291.38
75725 ANGIOGRAPHY, RENAL, BILATERAL, SELE O $0.00
75726 ARTERY X-RAYS, ABDOMEN 3 $249.36
75727 ANGIOGRAPHY, VISCERAL SELECTIVE (WI O $0.00
75728 ANGIOGRAPHY, VISCERAL SUPRASELECTIV O $0.00
75731 ARTERY X-RAYS, ADRENAL GLAND 3 $253.92
75732 ANGIOGRAPHY, ADRENAL, UNILATERAL, S O $0.00
75733 ARTERY X-RAYS, ADRENALS 3 $293.64
75734 ANGIOGRAPHY, ADRENAL, BILATERAL, SE O $0.00
75736 ARTERY X-RAYS, PELVIS 3 $250.01
75737 ANGIOGRAPHY, PELVIC SELECTIVE, COMP O $0.00
75738 ANGIOGRAPHY, PELVIC SUPRASELECTIVE, O $0.00
75741 ARTERY X-RAYS, LUNG 3 $238.56
75742 ANGIOGRAPHY, PULMONARY, UNILATERAL, O $0.00
75743 ARTERY X-RAYS, LUNGS 3 $265.20
75744 ANGIOGRAPHY, PULMONARY, BILATERAL, O $0.00
75746 ARTERY X-RAYS, LUNG 3 $242.31
75747 ANGIOGRAPHY, PULMONARY CATHETER, NO O $0.00
75748 ANGIOGRAPHY, PULMONARY VENOUS INJEC O $0.00
75750 ANGIOGRAPHY, CORONARY, ROOT INJECTI O $0.00
75751 ANGIOGRAPHY, CORONARY, ROOT INJECTI O $0.00
75752 ANGIOGRAPHY, CORONARY, UNILATERAL S O $0.00
75753 ANGIOGRAPHY, CORONARY, UNILATERAL S O $0.00
75754 ANGIOGRAPHY, CORONARY, BILATERAL SE O $0.00
75755 ANGIOGRAPHY, CORONARY, BILATERAL SE O $0.00
75756 ARTERY X-RAYS, CHEST 3 $260.12
75757 ANGIOGRAPHY, INTERNAL MAMMARY COMPL O $0.00
75762 ANGIOGRAPHY, CORONARY BYPASS, UNILA O $0.00
75764 ANGIOGRAPHY, CORONARY BYPASS, UNILA O $0.00
75766 ANGIOGRAPHY, CORONARY BYPASS, MULTI O $0.00
75767 ANGIOGRAPHY, CORONARY BYPASS, MULTI O $0.00
75774 ARTERY X-RAY, EACH VESSEL 3 $178.68
75775 ANGIOGRAPHY, SELECTIVE, EACH ADDITI O $0.00
75790 VISUALIZE A-V SHUNT O $0.00
75791 AV DIALYSIS SHUNT IMAGING 3 $249.64
75801 LYMPH VESSEL X-RAY, ARM/LEG 3 $0.00
75802 LYMPHANGIOGRAPHY, EXTREMITY ONLY, U O $0.00
75803 LYMPH VESSEL X-RAY,ARMS/LEGS 3 $0.00

75804 LYMPHANGIOGRAPHY, EXTREMITY ONLY, B O $0.00
75805 LYMPH VESSEL X-RAY, TRUNK 3 $0.00
75806 LYMPHANGIOGRAPHY, PELVIC/ABDOMINAL, O $0.00
75807 LYMPH VESSEL X-RAY, TRUNK 3 $0.00
75808 LYMPHANGIOGRAPHY, PELVIC/ABDOMINAL, O $0.00
75809 NONVASCULAR SHUNT, X-RAY 3 $90.47
75810 VEIN X-RAY, SPLEEN/LIVER 3 $0.00
75811 SPLENOPORTOGRAPHY COMPLETE PROCEDUR O $0.00
75820 VEIN X-RAY, ARM/LEG 3 $121.80
75821 VENOGRAPHY, EXTREMITY, UNILATERAL C O $0.00
75822 VEIN X-RAY, ARMS/LEGS 3 $148.68
75823 VENOGRAPHY, EXTREMITY, BILATERAL CO O $0.00
75825 VEIN X-RAY, TRUNK 3 $225.93
75826 VENOGRAPHY, CAVAL, INFERIOR, WITH S O $0.00
75827 VEIN X-RAY, CHEST 3 $226.81
75828 VENOGRAPHY, CAVAL, SUPERIOR, WITH S O $0.00
75831 VEIN X-RAY, KIDNEY 3 $232.27
75832 VENOGRAPHY, RENAL, UNILATERAL, SELE O $0.00
75833 VEIN X-RAY, KIDNEYS 3 $260.63
75834 VENOGRAPHY, RENAL, BILATERAL, SELEC O $0.00
75840 VEIN X-RAY, ADRENAL GLAND 3 $228.87
75841 VENOGRAPHY, ADRENAL, UNILATERAL, SE O $0.00
75842 VEIN X-RAY, ADRENAL GLANDS 3 $261.39
75843 VENOGRAPHY, ADRENAL, BILATERAL, SEL O $0.00
75860 VEIN X-RAY, NECK 3 $233.49
75861 VENOGRAPHY, SINUS OR JUGULAR, CATHE O $0.00
75870 VEIN X-RAY, SKULL 3 $233.24
75871 VENOGRAPHY, SUPERIOR SAGITTAL SINUS O $0.00
75872 VEIN X-RAY, SKULL 3 $278.59
75873 VENOGRAPHY, EPIDURAL COMPLETE PROCE O $0.00
75880 VEIN X-RAY, EYE SOCKET 3 $123.70
75881 VENOGRAPHY, ORBITAL COMPLETE PROCED O $0.00
75885 VEIN X-RAY, LIVER 3 $245.20
75886 PERCUTANEOUS TRANSHEPATIC PORTOGRAP O $0.00
75887 VEIN X-RAY, LIVER 3 $247.73
75888 PERCUTANEOUS TRANSHEPATIC PORTOGRAP O $0.00
75889 VEIN X-RAY, LIVER 3 $229.46
75890 HEPATIC VENOGRAPHY WEDGED OR FREE, O $0.00
75891 VEIN X-RAY, LIVER 3 $229.46
75892 HEPATIC VENOGRAPHY, WEDGED OR FREE, O $0.00
75893 VENOUS SAMPLING BY CATHETER 3 $197.11
75894 X-RAYS, TRANSCATH THERAPY 3 $0.00
75895 TRANSCATHETER THERAPY, EMBOLIZATION O $0.00
75896 X-RAYS, TRANSCATH THERAPY 3 $0.00
75897 TRANSCATHETER THERAPY, INFUSION (EG O $0.00
75898 FOLLOW-UP ANGIOGRAPHY 3 $0.00
75900 INTRAVASCULAR CATH EXCHANGE 3 $0.00
75901 REMOVE CVA DEVICE OBSTRUCT 3 $154.71
75902 REMOVE CVA LUMEN OBSTRUCT 3 $75.32

75940 X-RAY PLACEMENT, VEIN FILTER 3 $0.00
75941 PERCUTANEOUS PLACEMENT OF IVC FILTE O $0.00
75945 INTRAVASCULAR US 3 $0.00
75946 INTRAVASCULAR US ADD-ON 3 $0.00
75950 TRANSCATHETER INTRAVASCULAR OCCLUSI O $0.00
75951 TRANSCATHETER INTRAVASCULAR OCCLUSI O $0.00
75952 ENDOVASC REPAIR ABDOM AORTA 3 $0.00
75953 ABDOM ANEURYSM ENDOVAS RPR 3 $0.00
75954 ILIAC ANEURYSM ENDOVAS RPR 3 $0.00
75955 TRANSCATHETER INTRAVASCULAR OCCLUSI O $0.00
75956 XRAY, ENDOVASC THOR AO REPR 3 $0.00
75957 XRAY, ENDOVASC THOR AO REPR 3 $0.00
75958 XRAY, PLACE PROX EXT THOR AO 3 $0.00
75959 XRAY, PLACE DIST EXT THOR AO 3 $0.00
75960 TRANSCATH IV STENT RS&I 3 $219.41
75961 RETRIEVAL, BROKEN CATHETER 3 $387.59
75962 REPAIR ARTERIAL BLOCKAGE 3 $237.04
75963 PERCUTANEOUS TRANSLUMINAL ANGIOPLAS O $0.00
75964 REPAIR ARTERY BLOCKAGE, EACH 3 $144.53
75965 PERCUTANEOUS TRANSLUMINAL ANGIOPLAS O $0.00
75966 REPAIR ARTERIAL BLOCKAGE 3 $283.30
75967 PERCUTANEOUS TRANSLUMINAL ANGIOPLAS O $0.00
75968 REPAIR ARTERY BLOCKAGE, EACH 3 $142.91
75969 PERCUTANEOUS TRANSLUMINAL ANGIOPLAS O $0.00
75970 VASCULAR BIOPSY 3 $0.00
75971 TRANSCATHETER BIOPSY COMPLETE PROCE O $0.00
75978 REPAIR VENOUS BLOCKAGE 3 $234.78
75979 PERCUTANEOUS TRANSLUMINAL ANGIOPLAS O $0.00
75980 CONTRAST XRAY EXAM BILE DUCT 3 $0.00
75981 PERCUTANEOUS TRANSHEPATIC BILIARY D O $0.00
75982 CONTRAST XRAY EXAM BILE DUCT 9 $0.00
75983 PERCUTANEOUS PLACEMENT OF DRAINAGE O $0.00
75984 XRAY CONTROL CATHETER CHANGE 3 $113.46
75985 CHANGE OF PERCUTANEOUS DRAINAGE CAT O $0.00
75989 ABSCESS DRAINAGE UNDER X-RAY 3 $138.06
75990 RADIOLOGICAL GUIDANCE FOR PERCUTANE O $0.00
75992 ATHERECTOMY, X-RAY EXAM 3 $0.00
75993 ATHERECTOMY, X-RAY EXAM 3 $0.00
75994 ATHERECTOMY, X-RAY EXAM 3 $0.00
75995 ATHERECTOMY, X-RAY EXAM 3 $0.00
75996 ATHERECTOMY, X-RAY EXAM 3 $0.00
75998 FLUOROGUIDE FOR VEIN DEVICE O $0.00
76000 FLUOROSCOPE EXAMINATION 3 $96.29
76001 FLUOROSCOPE EXAM, EXTENSIVE 3 $0.00
76003 NEEDLE LOCALIZATION BY X-RAY O $0.00
76005 FLUOROGUIDE FOR SPINE INJECT O $0.00
76006 X-RAY STRESS VIEW O $0.00
76010 X-RAY, NOSE TO RECTUM 3 $27.85
76012 PERCUT VERTEBROPLASTY FLUOR O $0.00

76013 PERCUT VERTEBROPLASTY, CT O $0.00
76020 X-RAYS FOR BONE AGE O $0.00
76040 X-RAYS, BONE EVALUATION O $0.00
76061 X-RAYS, BONE SURVEY O $0.00
76062 X-RAYS, BONE SURVEY O $0.00
76065 X-RAYS, BONE EVALUATION O $0.00
76066 JOINT SURVEY, SINGLE VIEW O $0.00
76070 CT BONE DENSITY, AXIAL O $0.00
76071 CT BONE DENSITY, PERIPHERAL O $0.00
76075 DXA BONE DENSITY, AXIAL O $0.00
76076 DXA BONE DENSITY/PERIPHERAL O $0.00
76077 DXA BONE DENSITY/V-FRACTURE O $0.00
76078 RADIOGRAPHIC ABSORPTIOMETRY O $0.00
76080 X-RAY EXAM OF FISTULA 3 $62.42
76081 RADIOLOGIC EXAMINATION, FISTULA OR O $0.00
76082 COMPUTER MAMMOGRAM ADD-ON O $0.00
76083 COMPUTER MAMMOGRAM ADD-ON O $0.00
76085 COMPUTER MAMMOGRAM ADD-ON O $0.00
76086 X-RAY OF MAMMARY DUCT O $0.00
76087 MAMMARY DUCTOGRAM OR GALACTOGRAM, S O $0.00
76088 X-RAY OF MAMMARY DUCTS O $0.00
76089 MAMMARY DUCTOGRAM OR GALACTOGRAM, M O $0.00
76090 MAMMOGRAM, ONE BREAST O $0.00
76091 MAMMOGRAM, BOTH BREASTS O $0.00
76092 MAMM0GRAM, SCREENING O $0.00
76093 MAGNETIC IMAGE, BREAST O $0.00
76094 MAGNETIC IMAGE, BOTH BREASTS O $0.00
76095 STEREOTACTIC BREAST BIOPSY O $0.00
76096 X-RAY OF NEEDLE WIRE, BREAST O $0.00
76097 LOCALIZATION OF BREAST NODULE OR CA O $0.00
76098 X-RAY EXAM, BREAST SPECIMEN 3 $19.56
76100 X-RAY EXAM OF BODY SECTION 3 $107.46
76101 COMPLEX BODY SECTION X-RAY 3 $179.39
76102 COMPLEX BODY SECTION X-RAYS 3 $240.86
76120 CINE/VIDEO X-RAYS 3 $75.47
76125 CINE/VIDEO X-RAYS ADD-ON 3 $0.00
76140 X-RAY CONSULTATION 3 $38.59
76150 X-RAY EXAM, DRY PROCESS 3 $19.52
76350 SPECIAL X-RAY CONTRAST STUDY 5 $0.00
76355 CT SCAN FOR LOCALIZATION O $0.00
76360 CT SCAN FOR NEEDLE BIOPSY O $0.00
76361 COMPUTERIZED TOMOGRAPHY GUIDANCE FO O $0.00
76362 CT GUIDE FOR TISSUE ABLATION O $0.00
76365 CAT SCAN FOR CYST ASPIRATION O $0.00
76366 COMPUTERIZED TOMOGRAPHY GUIDANCE FO O $0.00
76370 CT SCAN FOR THERAPY GUIDE O $0.00
76375 3D/HOLOGRAPH RECONSTR ADD-ON O $0.00
76376 3D RENDER W/O POSTPROCESS 3 $74.70
76377 3D RENDERING W/POSTPROCESS 3 $98.25

76380 CAT SCAN FOLLOW-UP STUDY 3 $162.27
76390 MR SPECTROSCOPY 3 $458.32
76393 MR GUIDANCE FOR NEEDLE PLACE O $0.00
76394 MRI FOR TISSUE ABLATION O $0.00
76400 MAGNETIC IMAGE, BONE MARROW O $0.00
76490 US FOR TISSUE ABLATION O $0.00
76496 FLUOROSCOPIC PROCEDURE 5 $0.00
76497 CT PROCEDURE 5 $0.00
76498 MRI PROCEDURE 5 $0.00
76499 RADIOGRAPHIC PROCEDURE 5 $0.00
76506 ECHO EXAM OF HEAD 3 $96.57
76510 OPHTH US, B & QUANT A 3 $157.91
76511 OPHTH US, QUANT A ONLY 3 $97.20
76512 OPHTH US, B W/NON-QUANT A 3 $90.89
76513 ECHO EXAM OF EYE, WATER BATH 3 $84.70
76514 ECHO EXAM OF EYE, THICKNESS 3 $13.50
76516 ECHO EXAM OF EYE 3 $68.97
76519 ECHO EXAM OF EYE 3 $74.14
76529 ECHO EXAM OF EYE 3 $69.56
76536 US EXAM OF HEAD AND NECK 3 $112.66
76604 US EXAM, CHEST 3 $85.84
76645 US EXAM, BREAST(S) 3 $91.39
76700 US EXAM, ABDOM, COMPLETE 3 $137.16
76705 ECHO EXAM OF ABDOMEN 3 $103.93
76770 US EXAM ABDO BACK WALL, COMP 3 $130.45
76775 US EXAM ABDO BACK WALL, LIM 3 $110.37
76776 US EXAM K TRANSPL W/DOPPLER 3 $146.68
76778 US EXAM KIDNEY TRANSPLANT O $0.00
76800 US EXAM, SPINAL CANAL 3 $126.18
76801 OB US < 14 WKS, SINGLE FETUS 3 $129.12
76802 OB US < 14 WKS, ADDL FETUS 3 $70.75
76805 OB US >/= 14 WKS, SNGL FETUS 3 $146.14
76810 OB US >/= 14 WKS, ADDL FETUS 3 $96.64
76811 OB US, DETAILED, SNGL FETUS 3 $194.24
76812 OB US, DETAILED, ADDL FETUS 3 $153.18
76813 OB US NUCHAL MEAS, 1 GEST 3 $126.11
76814 OB US NUCHAL MEAS, ADD-ON 3 $80.75
76815 OB US, LIMITED, FETUS(S) 3 $90.00
76816 OB US, FOLLOW-UP, PER FETUS 3 $106.25
76817 TRANSVAGINAL US, OBSTETRIC 3 $101.46
76818 FETAL BIOPHYS PROFILE W/NST 3 $120.36
76819 FETAL BIOPHYS PROFIL W/O NST 3 $91.61
76820 UMBILICAL ARTERY ECHO 3 $48.99
76821 MIDDLE CEREBRAL ARTERY ECHO 3 $95.85
76825 ECHO EXAM OF FETAL HEART 3 $211.29
76826 ECHO EXAM OF FETAL HEART 3 $119.50
76827 ECHO EXAM OF FETAL HEART 3 $68.17
76828 ECHO EXAM OF FETAL HEART 3 $50.05
76830 TRANSVAGINAL US, NON-OB 3 $120.81

76831 ECHO EXAM, UTERUS 3 $121.16
76855 ECHOGRAPHY, PELVIC AREA (DOPPLER) O $0.00
76856 US EXAM, PELVIC, COMPLETE 3 $121.20
76857 US EXAM, PELVIC, LIMITED 3 $83.79
76870 US EXAM, SCROTUM 3 $119.99
76872 US, TRANSRECTAL 3 $135.80
76873 ECHOGRAP TRANS R, PROS STUDY 3 $178.16
76880 US EXAM, EXTREMITY 3 $128.88
76885 US EXAM INFANT HIPS, DYNAMIC 3 $101.72
76886 US EXAM INFANT HIPS, STATIC 3 $94.95
76925 ECHOGRAPHY, PERIPHERAL VASCULAR SYS O $0.00
76926 ECHOGRAPHY, HEAD AND TRUNK, VASCULA O $0.00
76930 ECHO GUIDE, CARDIOCENTESIS 3 $93.76
76931 ULTRASONIC GUIDANCE FOR PERICARDIOC O $0.00
76932 ECHO GUIDE FOR HEART BIOPSY 3 $0.00
76933 ULTRASONIC GUIDANCE FOR ENDOMYOCARD O $0.00
76934 ECHO GUIDE FOR CHEST TAP O $0.00
76935 ULTRASONIC GUIDANCE FOR THORACENTES O $0.00
76936 ECHO GUIDE FOR ARTERY REPAIR 3 $214.70
76937 US GUIDE, VASCULAR ACCESS 3 $34.37
76938 ECHO EXAM FOR DRAINAGE O $0.00
76939 ULTRASONIC GUIDANCE FOR CYST (ANY L O $0.00
76940 US GUIDE, TISSUE ABLATION 3 $0.00
76941 ECHO GUIDE FOR TRANSFUSION 3 $0.00
76942 ECHO GUIDE FOR BIOPSY 3 $188.74
76943 ULTRASONIC GUIDANCE FOR NEEDLE BIOP O $0.00
76945 ECHO GUIDE, VILLUS SAMPLING 3 $0.00
76946 ECHO GUIDE FOR AMNIOCENTESIS 3 $40.45
76947 ULTRASONIC GUIDANCE FOR AMNIOCENTES O $0.00
76948 ECHO GUIDE, OVA ASPIRATION 9 $0.00
76949 ULTRASONIC GUIDANCE FOR ASPIRATION O $0.00
76950 ECHO GUIDANCE RADIOTHERAPY 3 $69.92
76960 ECHO GUIDANCE RADIOTHERAPY O $0.00
76965 ECHO GUIDANCE RADIOTHERAPY 3 $130.42
76970 ULTRASOUND EXAM FOLLOW-UP 3 $84.01
76975 GI ENDOSCOPIC ULTRASOUND 3 $0.00
76977 US BONE DENSITY MEASURE 3 $11.77
76986 ULTRASOUND GUIDE INTRAOPER O $0.00
76998 US GUIDE, INTRAOP 3 $0.00
76999 ECHO EXAMINATION PROCEDURE 5 $0.00
77001 FLUOROGUIDE FOR VEIN DEVICE 3 $107.98
77002 NEEDLE LOCALIZATION BY XRAY 3 $71.86
77003 FLUOROGUIDE FOR SPINE INJECT 3 $59.32
77011 CT SCAN FOR LOCALIZATION 3 $711.18
77012 CT SCAN FOR NEEDLE BIOPSY 3 $176.03
77013 CT GUIDE FOR TISSUE ABLATION 3 $0.00
77014 CT SCAN FOR THERAPY GUIDE 3 $188.51
77021 MR GUIDANCE FOR NEEDLE PLACE 3 $432.95
77022 MRI FOR TISSUE ABLATION 3 $0.00

77031 STEREOTACT GUIDE FOR BRST BX 3 $173.18
77032 GUIDANCE FOR NEEDLE, BREAST 3 $57.10
77051 COMPUTER DX MAMMOGRAM ADD-ON 3 $11.75
77052 COMP SCREEN MAMMOGRAM ADD-ON 3 $11.75
77053 X-RAY OF MAMMARY DUCT 3 $70.33
77054 X-RAY OF MAMMARY DUCTS 3 $94.66
77055 MAMMOGRAM, ONE BREAST 3 $84.76
77056 MAMMOGRAM, BOTH BREASTS 3 $108.22
77057 MAMMOGRAM, SCREENING 3 $80.61
77058 MRI, ONE BREAST 3 $764.55
77059 MRI, BOTH BREASTS 3 $806.12
77071 X-RAY STRESS VIEW 3 $42.29
77072 X-RAYS FOR BONE AGE 3 $23.30
77073 X-RAYS, BONE LENGTH STUDIES 3 $37.68
77074 X-RAYS, BONE SURVEY, LIMITED 3 $68.20
77075 X-RAYS, BONE SURVEY COMPLETE 3 $99.84
77076 X-RAYS, BONE SURVEY, INFANT 3 $95.34
77077 JOINT SURVEY, SINGLE VIEW 3 $41.79
77078 CT BONE DENSITY, AXIAL 3 $87.11
77079 CT BONE DENSITY, PERIPHERAL 3 $53.88
77080 DXA BONE DENSITY, AXIAL 3 $98.16
77081 DXA BONE DENSITY/PERIPHERAL 3 $28.94
77082 DXA BONE DENSITY, VERT FX 3 $27.53
77083 RADIOGRAPHIC ABSORPTIOMETRY 3 $25.19
77084 MAGNETIC IMAGE, BONE MARROW 3 $440.27
77261 RADIATION THERAPY PLANNING 3 $72.90
77262 RADIATION THERAPY PLANNING 3 $110.13
77263 RADIATION THERAPY PLANNING 3 $163.59
77280 SET RADIATION THERAPY FIELD 3 $186.19
77285 SET RADIATION THERAPY FIELD 3 $323.82
77290 SET RADIATION THERAPY FIELD 3 $511.66
77295 SET RADIATION THERAPY FIELD 3 $613.22
77299 RADIATION THERAPY PLANNING 5 $0.00
77300 RADIATION THERAPY DOSE PLAN 3 $70.63
77301 RADIOTHERAPY DOSE PLAN, IMRT 3 $2,247.48
77305 TELETX ISODOSE PLAN SIMPLE 3 $69.39
77310 TELETX ISODOSE PLAN INTERMED 3 $98.17
77315 TELETX ISODOSE PLAN COMPLEX 3 $146.15
77321 SPECIAL TELETX PORT PLAN 3 $113.55
77326 BRACHYTX ISODOSE CALC SIMP 3 $144.43
77327 BRACHYTX ISODOSE CALC INTERM 3 $204.82
77328 BRACHYTX ISODOSE PLAN COMPL 3 $278.75
77331 SPECIAL RADIATION DOSIMETRY 3 $63.76
77332 RADIATION TREATMENT AID(S) 3 $78.29
77333 RADIATION TREATMENT AID(S) 3 $64.17
77334 RADIATION TREATMENT AID(S) 3 $155.76
77336 RADIATION PHYSICS CONSULT 3 $55.81
77338 DESIGN MLC DEVICE FOR IMRT 3 $493.12
77370 RADIATION PHYSICS CONSULT 3 $116.02

77371 SRS, MULTISOURCE 3 $1,188.49
77372 SRS, LINEAR BASED 3 $841.22
77373 SBRT DELIVERY 3 $1,561.89
77380 PROTON BEAM DELIVERY O $0.00
77381 PROTON BEAM TREATMENT O $0.00
77399 EXTERNAL RADIATION DOSIMETRY 5 $0.00
77400 DAILY MEGAVOLTAGE TREATMENT MANAGEM O $0.00
77401 RADIATION TREATMENT DELIVERY 3 $27.08
77402 RADIATION TREATMENT DELIVERY 3 $141.98
77403 RADIATION TREATMENT DELIVERY 3 $124.98
77404 RADIATION TREATMENT DELIVERY 3 $138.21
77405 DAILY MEGAVOLTAGE TREATMENT MANAGEM O $0.00
77406 RADIATION TREATMENT DELIVERY 3 $139.72
77407 RADIATION TREATMENT DELIVERY 3 $230.81
77408 RADIATION TREATMENT DELIVERY 3 $169.20
77409 RADIATION TREATMENT DELIVERY 3 $187.35
77410 DAILY MEGAVOLTAGE TREATMENT MANAGEM O $0.00
77411 RADIATION TREATMENT DELIVERY 3 $186.21
77412 RADIATION TREATMENT DELIVERY 3 $219.47
77413 RADIATION TREATMENT DELIVERY 3 $220.98
77414 RADIATION TREATMENT DELIVERY 3 $246.69
77415 THERAPEUTIC RADIOLOGY TREATMENT POR O $0.00
77416 RADIATION TREATMENT DELIVERY 3 $247.82
77417 RADIOLOGY PORT FILM(S) 3 $15.37
77418 RADIATION TX DELIVERY, IMRT 3 $523.37
77419 WEEKLY RADIATION THERAPY O $0.00
77420 WEEKLY RADIATION THERAPY O $0.00
77421 STEREOSCOPIC X-RAY GUIDANCE 3 $111.50
77422 NEUTRON BEAM TX, SIMPLE 3 $209.64
77423 NEUTRON BEAM TX, COMPLEX 3 $238.75
77425 WEEKLY RADIATION THERAPY O $0.00
77427 RADIATION TX MANAGEMENT, X5 3 $196.13
77430 WEEKLY RADIATION THERAPY O $0.00
77431 RADIATION THERAPY MANAGEMENT 3 $99.57
77432 STEREOTACTIC RADIATION TRMT 3 $413.74
77435 SBRT MANAGEMENT 3 $687.05
77465 DAILY KILOVOLTAGE TREATMENT MANAGEM O $0.00
77470 SPECIAL RADIATION TREATMENT 3 $224.59
77499 RADIATION THERAPY MANAGEMENT 5 $0.00
77520 PROTON TRMT, SIMPLE W/O COMP 5 $0.00
77522 PROTON TRMT, SIMPLE W/COMP 5 $0.00
77523 PROTON TRMT, INTERMEDIATE 5 $0.00
77525 PROTON TREATMENT, COMPLEX 5 $0.00
77600 HYPERTHERMIA TREATMENT 9 $0.00
77605 HYPERTHERMIA TREATMENT 9 $0.00
77610 HYPERTHERMIA TREATMENT 9 $0.00
77615 HYPERTHERMIA TREATMENT 9 $0.00
77620 HYPERTHERMIA TREATMENT 3 $429.63
77750 INFUSE RADIOACTIVE MATERIALS 3 $352.60

77761 APPLY INTRCAV RADIAT SIMPLE 3 $365.04
77762 APPLY INTRCAV RADIAT INTERM 3 $493.86
77763 APPLY INTRCAV RADIAT COMPL 3 $699.64
77776 APPLY INTERSTIT RADIAT SIMPL 3 $421.36
77777 APPLY INTERSTIT RADIAT INTER 3 $585.39
77778 APPLY INTERSTIT RADIAT COMPL 3 $844.98
77781 REMOTE AFTERLOADING HIGH INTENSITY O $0.00
77782 REMOTE AFTERLOADING HIGH INTENSITY O $0.00
77783 REMOTE AFTERLOADING HIGH INTENSITY O $0.00
77784 REMOTE AFTERLOADING HIGH INTENSITY O $0.00
77785 HDR BRACHYTX, 1 CHANNEL 3 $204.03
77786 HDR BRACHYTX, 2-12 CHANNEL 3 $569.05
77787 HDR BRACHYTX OVER 12 CHAN 3 $876.47
77789 APPLY SURFACE RADIATION 3 $109.77
77790 RADIATION HANDLING 3 $90.75
77799 RADIUM/RADIOISOTOPE THERAPY 5 $0.00
78000 THYROID, SINGLE UPTAKE 3 $69.04
78001 THYROID, MULTIPLE UPTAKES 3 $88.47
78003 THYROID SUPPRESS/STIMUL 3 $77.18
78006 THYROID IMAGING WITH UPTAKE 3 $221.48
78007 THYROID IMAGE, MULT UPTAKES 3 $158.34
78010 THYROID IMAGING 3 $152.95
78011 THYROID IMAGING WITH FLOW 3 $171.64
78015 THYROID MET IMAGING 3 $204.86
78016 THYROID MET IMAGING/STUDIES 3 $301.57
78017 THYROID MET IMAGING, MULT O $0.00
78018 THYROID MET IMAGING, BODY 3 $308.19
78020 THYROID MET UPTAKE 3 $86.53
78070 PARATHYROID NUCLEAR IMAGING 3 $166.50
78075 ADRENAL NUCLEAR IMAGING 3 $407.61
78099 ENDOCRINE NUCLEAR PROCEDURE 5 $0.00
78102 BONE MARROW IMAGING, LTD 3 $160.17
78103 BONE MARROW IMAGING, MULT 3 $213.84
78104 BONE MARROW IMAGING, BODY 3 $243.63
78110 PLASMA VOLUME, SINGLE 3 $78.36
78111 PLASMA VOLUME, MULTIPLE 3 $90.41
78120 RED CELL MASS, SINGLE 3 $83.98
78121 RED CELL MASS, MULTIPLE 3 $95.96
78122 BLOOD VOLUME 9 $0.00
78130 RED CELL SURVIVAL STUDY 3 $150.75
78135 RED CELL SURVIVAL KINETICS 3 $323.20
78140 RED CELL SEQUESTRATION 3 $139.92
78160 PLASMA IRON TURNOVER O $0.00
78162 RADIOIRON ABSORPTION EXAM O $0.00
78170 RED CELL IRON UTILIZATION O $0.00
78172 TOTAL BODY IRON ESTIMATION O $0.00
78185 SPLEEN IMAGING 3 $188.46
78186 SPLEEN IMAGING ONLY WITH VASCULAR F O $0.00
78190 PLATELET SURVIVAL, KINETICS 3 $239.99

78191 PLATELET SURVIVAL 3 $181.37
78192 WHITE BLOOD CELL LOCALIZATION LIMIT O $0.00
78193 WHITE BLOOD CELL LOCALIZATION WHOLE O $0.00
78195 LYMPH SYSTEM IMAGING 3 $326.02
78199 BLOOD/LYMPH NUCLEAR EXAM 5 $0.00
78201 LIVER IMAGING 3 $175.67
78202 LIVER IMAGING WITH FLOW 3 $197.02
78205 LIVER IMAGING (3D) 3 $226.73
78206 LIVER IMAGE (3D) WITH FLOW 3 $336.79
78215 LIVER AND SPLEEN IMAGING 3 $183.68
78216 LIVER & SPLEEN IMAGE/FLOW 3 $131.79
78220 LIVER FUNCTION STUDY 3 $136.95
78223 HEPATOBILIARY IMAGING 3 $312.38
78225 LIVER-LUNG IMAGING (EG, SUBPHRENIC O $0.00
78230 SALIVARY GLAND IMAGING 3 $157.65
78231 SERIAL SALIVARY IMAGING 3 $127.46
78232 SALIVARY GLAND FUNCTION EXAM 3 $123.61
78258 ESOPHAGEAL MOTILITY STUDY 3 $221.54
78261 GASTRIC MUCOSA IMAGING 3 $239.24
78262 GASTROESOPHAGEAL REFLUX EXAM 3 $235.36
78264 GASTRIC EMPTYING STUDY 3 $273.52
78267 BREATH TST ATTAIN/ANAL C-14 5 $0.00
78268 BREATH TEST ANALYSIS, C-14 5 $0.00
78270 VIT B-12 ABSORPTION EXAM 3 $77.72
78271 VIT B-12 ABSRP EXAM, INT FAC 3 $81.12
78272 VIT B-12 ABSORP, COMBINED 3 $88.08
78276 GASTROINTESTINAL ASPIRATE BLOOD LOS O $0.00
78278 ACUTE GI BLOOD LOSS IMAGING 3 $303.73
78280 GASTROINTESTINAL BLOOD LOSS STUDY ( O $0.00
78282 GI PROTEIN LOSS EXAM 3 $0.00
78290 MECKELS DIVERT EXAM 3 $288.38
78291 LEVEEN/SHUNT PATENCY EXAM 3 $241.13
78299 GI NUCLEAR PROCEDURE 5 $0.00
78300 BONE IMAGING, LIMITED AREA 3 $168.39
78305 BONE IMAGING, MULTIPLE AREAS 3 $222.80
78306 BONE IMAGING, WHOLE BODY 3 $245.07
78310 BONE IMAGING VASCULAR FLOW ONLY O $0.00
78315 BONE IMAGING, 3 PHASE 3 $305.21
78320 BONE IMAGING (3D) 3 $243.20
78350 BONE MINERAL, SINGLE PHOTON 3 $32.72
78351 BONE MINERAL, DUAL PHOTON 3 $15.37
78380 JOINT IMAGING LIMITED AREA O $0.00
78381 JOINT IMAGING MULTIPLE AREAS O $0.00
78399 MUSCULOSKELETAL NUCLEAR EXAM 5 $0.00
78414 NON-IMAGING HEART FUNCTION 3 $0.00
78415 CARDIAC BLOOD POOL IMAGING, FUNCTIO O $0.00
78425 CARDIAC REGURGITANT INDEX O $0.00
78428 CARDIAC SHUNT IMAGING 3 $193.14
78435 CARDIAC FLOW IMAGING (IE, ANGIOCARD O $0.00

78445 VASCULAR FLOW IMAGING 3 $164.53
78451 HT MUSCLE IMAGE SPECT, SING 3 $325.54
78452 HT MUSCLE IMAGE SPECT, MULT 3 $457.78
78453 HT MUSCLE IMAGE,PLANAR,SING 3 $280.66
78454 HT MUSC IMAGE, PLANAR, MULT 3 $398.41
78455 VENOUS THROMBOSIS STUDY O $0.00
78456 ACUTE VENOUS THROMBUS IMAGE 3 $258.00
78457 VENOUS THROMBOSIS IMAGING 3 $188.48
78458 VEN THROMBOSIS IMAGES, BILAT 3 $199.15
78459 HEART MUSCLE IMAGING (PET) 3 $250.04
78460 HEART MUSCLE BLOOD, SINGLE O $0.00
78461 HEART MUSCLE BLOOD, MULTIPLE O $0.00
78464 HEART IMAGE (3D), SINGLE O $0.00
78465 HEART IMAGE (3D), MULTIPLE O $0.00
78466 HEART INFARCT IMAGE 3 $176.24
78467 MYOCARDIAL IMAGING, INFARCT AVID, A O $0.00
78468 HEART INFARCT IMAGE (EF) 3 $219.20
78469 HEART INFARCT IMAGE (3D) 3 $250.04
78470 CARDIAC OUTPUT O $0.00
78471 CARDIAC BLOOD POOL IMAGING, GATED E O $0.00
78472 GATED HEART, PLANAR, SINGLE 3 $251.34
78473 GATED HEART, MULTIPLE 3 $338.66
78474 CARDIAC BLOOD POOL IMAGING, GATED E O $0.00
78475 CARDIAC BLOOD POOL IMAGING, GATED E O $0.00
78476 CARDIAC BLOOD POOL IMAGING, GATED E O $0.00
78477 CARDIAC BLOOD POOL IMAGING, GATED E O $0.00
78478 HEART WALL MOTION ADD-ON O $0.00
78479 CARDIAC BLOOD POOL IMAGING, GATED E O $0.00
78480 HEART FUNCTION ADD-ON O $0.00
78481 HEART FIRST PASS, SINGLE 3 $215.70
78483 HEART FIRST PASS, MULTIPLE 3 $302.37
78484 CARDIAC BLOOD POOL IMAGING, FIRST P O $0.00
78485 CARDIAC BLOOD POOL IMAGING, FIRST P O $0.00
78486 CARDIAC BLOOD POOL IMAGING, FIRST P O $0.00
78487 CARDIAC BLOOD POOL IMAGING, FIRST P O $0.00
78489 CARDIAC BLOOD POOL IMAGING, FIRST P O $0.00
78491 HEART IMAGE (PET), SINGLE 3 $323.62
78492 HEART IMAGE (PET), MULTIPLE 3 $323.62
78494 HEART IMAGE, SPECT 3 $271.49
78496 HEART FIRST PASS ADD-ON 3 $95.48
78499 CARDIOVASCULAR NUCLEAR EXAM 5 $0.00
78580 LUNG PERFUSION IMAGING 3 $205.28
78581 PULMONARY PERFUSION IMAGING GASEOUS O $0.00
78582 PULMONARY PERFUSION IMAGING GASEOUS O $0.00
78584 LUNG V/Q IMAGE SINGLE BREATH 3 $152.16
78585 LUNG V/Q IMAGING 3 $340.27
78586 AEROSOL LUNG IMAGE, SINGLE 3 $158.22
78587 AEROSOL LUNG IMAGE, MULTIPLE 3 $199.93
78588 PERFUSION LUNG IMAGE 3 $323.64

78591 VENT IMAGE, 1 BREATH, 1 PROJ 3 $159.74
78593 VENT IMAGE, 1 PROJ, GAS 3 $187.45
78594 VENT IMAGE, MULT PROJ, GAS 3 $213.87
78596 LUNG DIFFERENTIAL FUNCTION 3 $361.35
78599 RESPIRATORY NUCLEAR EXAM 5 $0.00
78600 BRAIN IMAGE < 4 VIEWS 3 $172.16
78601 BRAIN IMAGE W/FLOW < 4 VIEWS 3 $204.07
78605 BRAIN IMAGE 4+ VIEWS 3 $190.05
78606 BRAIN IMAGE W/FLOW 4 + VIEWS 3 $307.22
78607 BRAIN IMAGING (3D) 3 $352.95
78608 BRAIN IMAGING (PET) 3 $323.62
78609 BRAIN IMAGING (PET) 3 $323.62
78610 BRAIN FLOW IMAGING ONLY 3 $172.33
78615 CEREBRAL VASCULAR FLOW IMAGE O $0.00
78630 CEREBROSPINAL FLUID SCAN 3 $320.26
78635 CSF VENTRICULOGRAPHY 3 $299.70
78645 CSF SHUNT EVALUATION 3 $230.58
78647 CEREBROSPINAL FLUID SCAN 3 $319.34
78650 CSF LEAKAGE IMAGING 3 $311.90
78652 CSF LEAKAGE DETECTION AND LOCALIZAT O $0.00
78655 RADIOPHARMACEUTICAL IDENTIFICATION O $0.00
78660 NUCLEAR EXAM OF TEAR FLOW 3 $164.36
78699 NERVOUS SYSTEM NUCLEAR EXAM 5 $0.00
78700 KIDNEY IMAGING, MORPHOL 3 $168.61
78701 KIDNEY IMAGING WITH FLOW 3 $204.09
78704 IMAGING RENOGRAM O $0.00
78707 K FLOW/FUNCT IMAGE W/O DRUG 3 $232.85
78708 K FLOW/FUNCT IMAGE W/DRUG 3 $183.26
78709 K FLOW/FUNCT IMAGE, MULTIPLE 3 $352.20
78710 KIDNEY IMAGING (3D) 3 $221.77
78715 RENAL VASCULAR FLOW EXAM O $0.00
78725 KIDNEY FUNCTION STUDY 3 $98.90
78726 KIDNEY FUNCTION STUDY INCLUDING PHA O $0.00
78727 KIDNEY TRANSPLANT EVALUATION O $0.00
78730 URINARY BLADDER RETENTION 3 $73.25
78740 URETERAL REFLUX STUDY 3 $207.77
78760 TESTICULAR IMAGING O $0.00
78761 TESTICULAR IMAGING W/FLOW 3 $203.30
78799 GENITOURINARY NUCLEAR EXAM 5 $0.00
78800 TUMOR IMAGING, LIMITED AREA 3 $181.44
78801 TUMOR IMAGING, MULT AREAS 3 $241.76
78802 TUMOR IMAGING, WHOLE BODY 3 $315.37
78803 TUMOR IMAGING (3D) 3 $344.05
78804 TUMOR IMAGING, WHOLE BODY 3 $563.04
78805 ABSCESS IMAGING, LTD AREA 3 $179.47
78806 ABSCESS IMAGING, WHOLE BODY 3 $328.22
78807 NUCLEAR LOCALIZATION/ABSCESS 3 $343.43
78808 IV INJ RA DRUG DX STUDY 3 $44.48
78810 TUMOR IMAGING (PET) O $0.00

78811 PET IMAGE, LTD AREA 3 $1,446.92
78812 PET IMAGE, SKULL-THIGH 3 $1,886.58
78813 PET IMAGE, FULL BODY 3 $1,975.81
78814 PET IMAGE W/CT, LMTD 3 $2,206.07
78815 PET IMAGE W/CT, SKULL-THIGH 3 $2,478.88
78816 PET IMAGE W/CT, FULL BODY 3 $2,547.03
78890 NUCLEAR MEDICINE DATA PROC O $0.00
78891 NUCLEAR MED DATA PROC O $0.00
78990 PROVIDE DIAG RADIONUCLIDE(S) O $0.00
78999 NUCLEAR DIAGNOSTIC EXAM 5 $0.00
79000 INIT HYPERTHYROID THERAPY O $0.00
79001 REPEAT HYPERTHYROID THERAPY O $0.00
79005 NUCLEAR RX, ORAL ADMIN 3 $146.98
79020 THYROID ABLATION O $0.00
79030 THYROID ABLATION, CARCINOMA O $0.00
79035 THYROID METASTATIC THERAPY O $0.00
79100 HEMATOPOETIC NUCLEAR THERAPY O $0.00
79101 NUCLEAR RX, IV ADMIN 3 $166.06
79200 NUCLEAR RX, INTRACAV ADMIN 3 $170.53
79300 NUCLR RX, INTERSTIT COLLOID 3 $0.00
79400 NONHEMATO NUCLEAR THERAPY O $0.00
79403 HEMATOPOIETIC NUCLEAR TX 3 $211.27
79420 INTRAVASCULAR NUCLEAR THER O $0.00
79440 NUCLEAR RX, INTRA-ARTICULAR 3 $155.19
79445 NUCLEAR RX, INTRA-ARTERIAL 3 $0.00
79900 PROVIDE THER RADIOPHARM(S) O $0.00
79999 NUCLEAR MEDICINE THERAPY 5 $0.00
80002 AUTOMATED MULTICHANNEL TEST 1 OR 2 O $0.00
80003 AUTOMATED MULTICHANNEL TEST 3 CLINI O $0.00
80004 AUTOMATED MULTICHANNEL TEST 4 CLINI O $0.00
80005 AUTOMATED MULTICHANNEL TEST 5 CLINI O $0.00
80006 AUTOMATED MULTICHANNEL TEST 6 CLINI O $0.00
80007 AUTOMATED MULTICHANNEL TEST 7 CLINI O $0.00
80008 AUTOMATED MULTICHANNEL TEST 8 CLINI O $0.00
80009 AUTOMATED MULTICHANNEL TEST 9 CLINI O $0.00
80010 AUTOMATED MULTICHANNEL TEST 10 CLIN O $0.00
80011 AUTOMATED MULTICHANNEL TEST 11 CLIN O $0.00
80012 AUTOMATED MULTICHANNEL TEST 12 CLIN O $0.00
80016 AUTOMATED MULTICHANNEL TEST 13-16 C O $0.00
80018 AUTOMATED MULTICHANNEL TEST 17-18 C O $0.00
80019 AUTOMATED MULTICHANNEL TEST; 19 CLI O $0.00
80031 THERAPEUTIC QUANTITATIVE DRUG MONIT O $0.00
80032 THERAPEUTIC QUANTITATIVE DRUG MONIT O $0.00
80033 THERAPEUTIC QUANTITATIVE DRUG MONIT O $0.00
80034 THERAPEUTIC QUANTITATIVE DRUG MONIT O $0.00
80040 SERUM RADIOIMMUNOASSAY FOR CIRCULAT O $0.00
80042 SERUM ANTIMICROBIAL LEVEL, BIOASSAY O $0.00
80047 METABOLIC PANEL IONIZED CA 3 $11.88
80048 METABOLIC PANEL TOTAL CA 3 $11.88

80049 METABOLIC PANEL, BASIC 9 $0.00
80050 GENERAL HEALTH PANEL 3 $16.32
80051 ELECTROLYTE PANEL 3 $9.85
80052 PRE-MARITAL PROFILE 9 $0.00
80053 COMPREHEN METABOLIC PANEL 3 $14.84
80054 COMPREHEN METABOLIC PANEL 9 $0.00
80055 OBSTETRIC PANEL 3 $23.08
80056 AMENORRHEA PROFILE 9 $0.00
80057 MALE INFERTILITY AND/OR GYNECOMASTI 9 $0.00
80058 HEPATIC FUNCTION PANEL O $0.00
80059 HEPATITIS PANEL O $0.00
80060 HYPERTENSION PANEL O $0.00
80061 LIPID PANEL 3 $18.81
80062 CARDIAC EVALUATION (INCLUDING CORON O $0.00
80063 CARDIAC INJURY PANEL O $0.00
80064 CARDIAC INJURY PANEL WITH CREATINE O $0.00
80065 METABOLIC PANEL O $0.00
80066 MALABSORPTION PANEL O $0.00
80067 PULMONARY (LUNG FUNCTION) PANEL O $0.00
80068 LUNG MATURITY PROFILE O $0.00
80069 RENAL FUNCTION PANEL 3 $12.18
80070 THYROID PANEL O $0.00
80071 THYROID PANEL WITH THYROTROPIN RELE O $0.00
80072 ARTHRITIS PANEL O $0.00
80073 RENAL PANEL O $0.00
80074 ACUTE HEPATITIS PANEL 3 $66.59
80075 PARATHYROID PANEL O $0.00
80076 HEPATIC FUNCTION PANEL 3 $11.47
80080 PROSTATIC PANEL O $0.00
80082 PANCREATIC PANEL O $0.00
80084 PITUITARY PANEL O $0.00
80085 MICROCYTIC ANEMIA PANEL O $0.00
80086 MACROCYTIC ANEMIA PANEL O $0.00
80088 TRANSITION PANEL (FOR MANAGEMENT OF O $0.00
80089 MUSCLE PANEL O $0.00
80090 TORCH ANTIBODY PANEL O $0.00
80091 THYROID PANEL O $0.00
80092 THYROID PANEL W/TSH O $0.00
80099 UNLISTED PANEL O $0.00
80100 DRUG SCREEN, QUALITATE/MULTI 3 $20.41
80101 DRUG SCREEN, SINGLE 3 $19.33
80102 DRUG CONFIRMATION 3 $18.59
80103 DRUG ANALYSIS, TISSUE PREP 5 $0.00
80150 ASSAY OF AMIKACIN 3 $21.16
80152 ASSAY OF AMITRIPTYLINE 3 $25.13
80154 ASSAY OF BENZODIAZEPINES 3 $22.53
80156 ASSAY, CARBAMAZEPINE, TOTAL 3 $20.43
80157 ASSAY, CARBAMAZEPINE, FREE 3 $18.61
80158 ASSAY OF CYCLOSPORINE 3 $25.34

80160 ASSAY OF DESIPRAMINE 3 $24.16
80162 ASSAY OF DIGOXIN 3 $18.64
80164 ASSAY, DIPROPYLACETIC ACID 3 $19.01
80166 ASSAY OF DOXEPIN 3 $21.77
80168 ASSAY OF ETHOSUXIMIDE 3 $21.15
80170 ASSAY OF GENTAMICIN 3 $23.01
80172 ASSAY OF GOLD 3 $22.86
80173 ASSAY OF HALOPERIDOL 3 $20.43
80174 ASSAY OF IMIPRAMINE 3 $24.16
80176 ASSAY OF LIDOCAINE 3 $20.62
80178 ASSAY OF LITHIUM 3 $9.27
80182 ASSAY OF NORTRIPTYLINE 3 $19.01
80184 ASSAY OF PHENOBARBITAL 3 $16.08
80185 ASSAY OF PHENYTOIN, TOTAL 3 $18.61
80186 ASSAY OF PHENYTOIN, FREE 3 $19.32
80188 ASSAY OF PRIMIDONE 3 $23.29
80190 ASSAY OF PROCAINAMIDE 3 $23.51
80192 ASSAY OF PROCAINAMIDE 3 $23.51
80194 ASSAY OF QUINIDINE 3 $20.49
80195 ASSAY OF SIROLIMUS 3 $19.27
80196 ASSAY OF SALICYLATE 3 $9.96
80197 ASSAY OF TACROLIMUS 3 $19.27
80198 ASSAY OF THEOPHYLLINE 3 $19.86
80200 ASSAY OF TOBRAMYCIN 3 $22.63
80201 ASSAY OF TOPIRAMATE 3 $16.73
80202 ASSAY OF VANCOMYCIN 3 $19.01
80299 QUANTITATIVE ASSAY, DRUG 3 $19.22
80400 ACTH STIMULATION PANEL 3 $45.77
80402 ACTH STIMULATION PANEL 3 $122.03
80406 ACTH STIMULATION PANEL 3 $109.84
80408 ALDOSTERONE SUPPRESSION EVAL 3 $176.16
80410 CALCITONIN STIMUL PANEL 3 $63.06
80412 CRH STIMULATION PANEL 3 $462.58
80414 TESTOSTERONE RESPONSE 3 $72.48
80415 ESTRADIOL RESPONSE PANEL 3 $78.44
80416 RENIN STIMULATION PANEL 3 $185.28
80417 RENIN STIMULATION PANEL 3 $61.76
80418 PITUITARY EVALUATION PANEL 3 $813.48
80420 DEXAMETHASONE PANEL 3 $100.76
80422 GLUCAGON TOLERANCE PANEL 3 $64.68
80424 GLUCAGON TOLERANCE PANEL 3 $70.89
80426 GONADOTROPIN HORMONE PANEL 3 $208.35
80428 GROWTH HORMONE PANEL 3 $93.61
80430 GROWTH HORMONE PANEL 3 $110.13
80432 INSULIN SUPPRESSION PANEL 3 $189.61
80434 INSULIN TOLERANCE PANEL 3 $141.95
80435 INSULIN TOLERANCE PANEL 3 $144.55
80436 METYRAPONE PANEL 3 $127.95
80438 TRH STIMULATION PANEL 3 $70.74

80439 TRH STIMULATION PANEL 3 $94.32
80440 TRH STIMULATION PANEL 3 $81.61
80500 LAB PATHOLOGY CONSULTATION 3 $22.88
80502 LAB PATHOLOGY CONSULTATION 3 $76.36
81000 URINALYSIS, NONAUTO W/SCOPE 3 $4.43
81001 URINALYSIS, AUTO W/SCOPE 3 $4.43
81002 URINALYSIS NONAUTO W/O SCOPE 3 $3.66
81003 URINALYSIS, AUTO, W/O SCOPE 3 $3.16
81004 URINALYSIS COMPONENTS, SINGLE, NOT O $0.00
81005 URINALYSIS 3 $3.04
81007 URINE SCREEN FOR BACTERIA 3 $3.61
81010 URINALYSIS CONCENTRATION AND DILUTI O $0.00
81011 URINALYSIS WATER DEPRIVATION TEST O $0.00
81012 URINALYSIS WATER DEPRIVATION TEST W O $0.00
81015 MICROSCOPIC EXAM OF URINE 3 $4.26
81020 URINALYSIS, GLASS TEST 3 $4.40
81025 URINE PREGNANCY TEST 3 $8.88
81030 QUANTITATIVE SEDIMENT ANALYSIS AND O $0.00
81050 URINALYSIS, VOLUME MEASURE 3 $4.04
81099 URINALYSIS TEST PROCEDURE 5 $0.00
82000 ASSAY OF BLOOD ACETALDEHYDE 3 $17.39
82003 ASSAY OF ACETAMINOPHEN 3 $28.41
82005 ACETOACETIC ACID O $0.00
82009 TEST FOR ACETONE/KETONES 3 $6.34
82010 ACETONE ASSAY 3 $11.48
82011 ACETYLSALICYLIC ACID QUANTITATIVE O $0.00
82012 ACETYLSALICYLIC ACID QUALITATIVE O $0.00
82013 ACETYLCHOLINESTERASE ASSAY 3 $12.13
82015 ACIDITY, TITRATABLE, URINE O $0.00
82016 ACYLCARNITINES, QUAL 3 $19.45
82017 ACYLCARNITINES, QUANT 3 $23.68
82024 ASSAY OF ACTH 3 $54.21
82030 ASSAY OF ADP & AMP 3 $36.21
82035 ADENOSINE 5'-TRIPHOSPHATE, BLOOD O $0.00
82040 ASSAY OF SERUM ALBUMIN 3 $6.95
82042 ASSAY OF URINE ALBUMIN 3 $2.47
82043 MICROALBUMIN, QUANTITATIVE 3 $8.12
82044 MICROALBUMIN, SEMIQUANT 3 $3.57
82045 ALBUMIN, ISCHEMIA MODIFIED 3 $47.65
82055 ASSAY OF ETHANOL 3 $15.16
82060 ALCOHOL (ETHANOL), BLOOD BY GAS-LIQ O $0.00
82065 ALCOHOL (ETHANOL), URINE CHEMICAL O $0.00
82070 ALCOHOL (ETHANOL), URINE BY GAS-LIQ O $0.00
82072 ALCOHOL (ETHANOL) GELATION O $0.00
82075 ASSAY OF BREATH ETHANOL 3 $16.91
82076 ALCOHOL ISOPROPYL O $0.00
82078 ALCOHOL METHYL O $0.00
82085 ASSAY OF ALDOLASE 3 $13.62
82086 ALDOLASE, BLOOD COLORIMETRIC O $0.00

82087 ALDOSTERONE DOUBLE ISOTOPE TECHNIQU O $0.00
82088 ASSAY OF ALDOSTERONE 3 $57.20
82089 ALDOSTERONE RIA, URINE O $0.00
82091 ALDOSTERONE SALINE INFUSION TEST O $0.00
82095 ALKALOIDS, TISSUE SCREENING O $0.00
82096 ALKALOIDS, TISSUE QUANTITATIVE O $0.00
82100 ALKALOIDS, URINE SCREENING O $0.00
82101 ASSAY OF URINE ALKALOIDS 3 $42.13
82103 ALPHA-1-ANTITRYPSIN, TOTAL 3 $18.86
82104 ALPHA-1-ANTITRYPSIN, PHENO 3 $20.30
82105 ALPHA-FETOPROTEIN, SERUM 3 $23.55
82106 ALPHA-FETOPROTEIN, AMNIOTIC 3 $23.55
82107 ALPHA-FETOPROTEIN L3 3 $88.93
82108 ASSAY OF ALUMINUM 3 $35.76
82112 AMIKACIN O $0.00
82120 AMINES, VAGINAL FLUID QUAL 3 $5.28
82126 AMINO ACID NITROGEN, ALPHA O $0.00
82127 AMINO ACID, SINGLE QUAL 3 $19.45
82128 AMINO ACIDS, MULT QUAL 3 $19.45
82130 AMINO ACIDS ANALYSIS O $0.00
82131 AMINO ACIDS, SINGLE QUANT 3 $23.68
82134 AMINOHIPPURATE, PARA (PAH) O $0.00
82135 ASSAY, AMINOLEVULINIC ACID 3 $23.11
82136 AMINO ACIDS, QUANT, 2-5 3 $23.68
82137 AMINOPHYLLINE O $0.00
82138 AMITRIPTYLINE O $0.00
82139 AMINO ACIDS, QUAN, 6 OR MORE 3 $23.68
82140 ASSAY OF AMMONIA 3 $20.45
82141 AMMONIA URINE O $0.00
82142 AMMONIUM CHLORIDE LOADING TEST O $0.00
82143 AMNIOTIC FLUID SCAN 3 $9.64
82145 ASSAY OF AMPHETAMINES 3 $21.82
82150 ASSAY OF AMYLASE 3 $9.10
82154 ANDROSTANEDIOL GLUCURONIDE 3 $40.47
82156 AMYLASE, URINE (DIASTASE) O $0.00
82157 ASSAY OF ANDROSTENEDIONE 3 $41.09
82159 ANDROSTERONE O $0.00
82160 ASSAY OF ANDROSTERONE 3 $35.10
82163 ASSAY OF ANGIOTENSIN II 3 $28.81
82164 ANGIOTENSIN I ENZYME TEST 3 $20.49
82165 ANILINE O $0.00
82168 ANTIHISTAMINES O $0.00
82170 ANTIMONY, URINE O $0.00
82172 ASSAY OF APOLIPOPROTEIN 3 $21.75
82173 ARGININE TOLERANCE TEST O $0.00
82175 ASSAY OF ARSENIC 3 $26.63
82180 ASSAY OF ASCORBIC ACID 3 $13.88
82190 ATOMIC ABSORPTION 3 $20.93
82205 ASSAY OF BARBITURATES 3 $16.08

82210 BARBITURATES QUANTITATIVE AND IDENT O $0.00
82225 BARIUM O $0.00
82230 BERYLLIUM, URINE O $0.00
82231 BETA-2 MICROGLOBULIN, RIA URINE O $0.00
82232 ASSAY OF BETA-2 PROTEIN 3 $22.71
82235 BICARBONATE EXCRETION, URINE O $0.00
82236 BICARBONATE LOADING TEST O $0.00
82239 BILE ACIDS, TOTAL 3 $24.05
82240 BILE ACIDS, CHOLYLGLYCINE 3 $37.31
82245 BILE PIGMENTS, URINE O $0.00
82247 BILIRUBIN, TOTAL 3 $7.05
82248 BILIRUBIN, DIRECT 3 $7.05
82250 ASSAY BILIRUBIN O $0.00
82251 ASSAY OF BILIRUBIN O $0.00
82252 FECAL BILIRUBIN TEST 3 $6.38
82260 BILIRUBIN URINE, QUANTITATIVE O $0.00
82261 ASSAY OF BIOTINIDASE 3 $23.68
82265 BILIRUBIN AMNIOTIC FLUID, QUANTITAT O $0.00
82268 BISMUTH O $0.00
82270 OCCULT BLOOD, FECES 3 $4.57
82271 OCCULT BLOOD, OTHER SOURCES 3 $4.57
82272 OCCULT BLD FECES, 1-3 TESTS 3 $4.57
82273 TEST FOR BLOOD, OTHER SOURCE O $0.00
82274 ASSAY TEST FOR BLOOD, FECAL 3 $22.32
82280 BORIC ACID BLOOD O $0.00
82285 BORIC ACID URINE O $0.00
82286 ASSAY OF BRADYKININ 3 $9.66
82290 BROMIDES BLOOD O $0.00
82291 BROMIDES URINE O $0.00
82300 ASSAY OF CADMIUM 3 $32.48
82305 CAFFEINE O $0.00
82306 VITAMIN D, 25 HYDROXY 3 $41.55
82307 ASSAY OF VITAMIN D O $0.00
82308 ASSAY OF CALCITONIN 3 $21.02
82310 ASSAY OF CALCIUM 3 $7.24
82315 CALCIUM, BLOOD FLUOROMETRIC O $0.00
82320 CALCIUM, BLOOD EMISSION FLAME PHOTO O $0.00
82325 CALCIUM, BLOOD ATOMIC ABSORPTION FL O $0.00
82330 ASSAY OF CALCIUM 3 $8.89
82331 CALCIUM INFUSION TEST 3 $7.26
82335 CALCIUM, URINE QUALITATIVE (SULKOWI O $0.00
82340 ASSAY OF CALCIUM IN URINE 3 $8.47
82355 CALCULUS ANALYSIS, QUAL 3 $16.25
82360 CALCULUS ASSAY, QUANT 3 $18.07
82365 CALCULUS SPECTROSCOPY 3 $18.10
82370 X-RAY ASSAY, CALCULUS 3 $17.59
82372 CARBAMAZEPINE, SERUM O $0.00
82373 ASSAY, C-D TRANSFER MEASURE 3 $25.34
82374 ASSAY, BLOOD CARBON DIOXIDE 3 $6.86

82375 ASSAY, CARBOXYHB, QUANT 3 $17.31
82376 ASSAY, CARBOXYHB, QUAL 3 $7.71
82378 CARCINOEMBRYONIC ANTIGEN 3 $26.63
82379 ASSAY OF CARNITINE 3 $23.68
82380 ASSAY OF CAROTENE 3 $12.95
82382 ASSAY, URINE CATECHOLAMINES 3 $24.14
82383 ASSAY, BLOOD CATECHOLAMINES 3 $35.17
82384 ASSAY, THREE CATECHOLAMINES 3 $35.45
82387 ASSAY OF CATHEPSIN-D 3 $29.20
82390 ASSAY OF CERULOPLASMIN 3 $15.07
82397 CHEMILUMINESCENT ASSAY 3 $19.84
82400 CHLORAL HYDRATE BLOOD O $0.00
82405 CHLORAL HYDRATE URINE O $0.00
82415 ASSAY OF CHLORAMPHENICOL 3 $17.79
82418 CHLORAZEPATE DIPOTASSIUM O $0.00
82420 CHLORDIAZEPOXIDE BLOOD O $0.00
82425 CHLORDIAZEPOXIDE URINE O $0.00
82435 ASSAY OF BLOOD CHLORIDE 3 $6.45
82436 ASSAY OF URINE CHLORIDE 3 $7.06
82437 CHLORIDES SWEAT (WITHOUT IONTOPHORE O $0.00
82438 ASSAY, OTHER FLUID CHLORIDES 3 $6.87
82441 TEST FOR CHLOROHYDROCARBONS 3 $8.43
82443 CHLOROTHIAZIDE-HYDROCHLOROTHIAZIDE O $0.00
82465 ASSAY, BLD/SERUM CHOLESTEROL 3 $6.12
82470 CHOLESTEROL, SERUM TOTAL AND ESTERS O $0.00
82480 ASSAY, SERUM CHOLINESTERASE 3 $11.06
82482 ASSAY, RBC CHOLINESTERASE 3 $10.78
82484 CHOLINESTERASE SERUM AND RBC O $0.00
82485 ASSAY, CHONDROITIN SULFATE 3 $28.99
82486 GAS/LIQUID CHROMATOGRAPHY 3 $25.34
82487 PAPER CHROMATOGRAPHY 3 $22.41
82488 PAPER CHROMATOGRAPHY 3 $30.00
82489 THIN LAYER CHROMATOGRAPHY 3 $25.96
82491 CHROMOTOGRAPHY, QUANT, SING 3 $25.34
82492 CHROMOTOGRAPHY, QUANT, MULT 3 $25.34
82495 ASSAY OF CHROMIUM 3 $28.47
82507 ASSAY OF CITRATE 3 $39.03
82512 CLONAZEPAM O $0.00
82520 ASSAY OF COCAINE 3 $19.58
82523 COLLAGEN CROSSLINKS 3 $15.24
82525 ASSAY OF COPPER 3 $17.41
82526 COPPER URINE O $0.00
82528 ASSAY OF CORTICOSTERONE 3 $31.60
82529 CORTISOL FLUOROMETRIC, PLASMA O $0.00
82530 CORTISOL, FREE 3 $23.46
82531 CORTISOL CPB, PLASMA O $0.00
82532 CORTISOL CPB, URINE O $0.00
82533 TOTAL CORTISOL 3 $22.88
82534 CORTISOL RIA, URINE O $0.00

82536 CORTISOL AFTER ADRENOCORTICOTROPIC O $0.00
82537 CORTISOL 48 HOURS AFTER CONTINUOUS O $0.00
82538 CORTISOL AFTER METYRAPONE TARTRATE O $0.00
82539 CORTISOL DEXAMETHASONE SUPPRESSION O $0.00
82540 ASSAY OF CREATINE 3 $6.51
82541 COLUMN CHROMOTOGRAPHY, QUAL 3 $25.34
82542 COLUMN CHROMOTOGRAPHY, QUANT 3 $25.34
82543 COLUMN CHROMOTOGRAPH/ISOTOPE 3 $25.34
82544 COLUMN CHROMOTOGRAPH/ISOTOPE 3 $25.34
82545 CREATINE URINE O $0.00
82546 CREATINE AND CREATININE O $0.00
82550 ASSAY OF CK (CPK) 3 $9.14
82552 ASSAY OF CPK IN BLOOD 3 $18.81
82553 CREATINE, MB FRACTION 3 $10.65
82554 CREATINE, ISOFORMS 3 $16.66
82555 CREATINE PHOSPHOKINASE (CPK), BLOOD O $0.00
82565 ASSAY OF CREATININE 3 $6.44
82570 ASSAY OF URINE CREATININE 3 $7.26
82575 CREATININE CLEARANCE TEST 3 $13.26
82585 ASSAY OF CRYOFIBRINOGEN 3 $12.03
82595 ASSAY OF CRYOGLOBULIN 3 $9.08
82600 ASSAY OF CYANIDE 3 $27.23
82601 CYANIDE TISSUE O $0.00
82606 CYANOCOBALAMIN (VITAMIN B-12) BIOAS O $0.00
82607 VITAMIN B-12 3 $21.16
82608 B-12 BINDING CAPACITY 3 $20.10
82610 CYSTATIN C 3 $19.08
82614 CYSTINE, BLOOD, QUALITATIVE O $0.00
82615 TEST FOR URINE CYSTINES 3 $11.46
82620 CYSTINE AND HOMOCYSTINE, URINE QUAN O $0.00
82624 CYSTINE AMINOPEPTIDASE O $0.00
82626 DEHYDROEPIANDROSTERONE 3 $35.48
82627 DEHYDROEPIANDROSTERONE 3 $31.21
82628 DESIPRAMINE O $0.00
82633 DESOXYCORTICOSTERONE 3 $43.48
82634 DEOXYCORTISOL 3 $41.09
82635 DIACETIC ACID O $0.00
82636 DIAZEPAM O $0.00
82638 ASSAY OF DIBUCAINE NUMBER 3 $16.34
82639 DICUMAROL O $0.00
82640 DIGITOXIN (DIGITALIS) BLOOD, RIA O $0.00
82641 DIGITOXIN (DIGITALIS) URINE O $0.00
82643 DIGOXIN, RIA O $0.00
82646 ASSAY OF DIHYDROCODEINONE 3 $28.99
82649 ASSAY OF DIHYDROMORPHINONE 3 $36.08
82651 ASSAY OF DIHYDROTESTOSTERONE 3 $36.23
82652 VIT D 1, 25-DIHYDROXY 3 $54.04
82654 ASSAY OF DIMETHADIONE 3 $19.43
82656 PANCREATIC ELASTASE, FECAL 3 $15.45

82657 ENZYME CELL ACTIVITY 3 $25.34
82658 ENZYME CELL ACTIVITY, RA 3 $25.34
82660 DRUG SCREEN (AMPHETAMINES, BARBITUR O $0.00
82664 ELECTROPHORETIC TEST 3 $48.23
82666 ASSAY OF EPIANDROSTERONE 3 $30.15
82668 ASSAY OF ERYTHROPOIETIN 3 $24.42
82670 ASSAY OF ESTRADIOL 3 $39.22
82671 ASSAY OF ESTROGENS 3 $45.33
82672 ASSAY OF ESTROGEN 3 $13.98
82673 ESTRIOL FLUOROMETRIC O $0.00
82674 ESTRIOL GLC O $0.00
82676 ESTRIOL CHEMICAL O $0.00
82677 ASSAY OF ESTRIOL 3 $33.95
82678 ESTRONE CHEMICAL O $0.00
82679 ASSAY OF ESTRONE 3 $32.95
82690 ASSAY OF ETHCHLORVYNOL 3 $24.26
82691 ETHCHLORVYNOL URINE O $0.00
82692 ETHOSUXIMIDE O $0.00
82693 ASSAY OF ETHYLENE GLYCOL 3 $18.09
82694 ETIOCHOLANOLONE O $0.00
82696 ASSAY OF ETIOCHOLANOLONE 3 $33.10
82705 FATS/LIPIDS, FECES, QUAL 3 $7.14
82710 FATS/LIPIDS, FECES, QUANT 3 $4.04
82715 ASSAY OF FECAL FAT 3 $12.28
82720 FATTY ACIDS, BLOOD ESTERIFIED O $0.00
82725 ASSAY OF BLOOD FATTY ACIDS 3 $18.69
82726 LONG CHAIN FATTY ACIDS 3 $25.34
82727 FERRIC CHLORIDE, URINE O $0.00
82728 ASSAY OF FERRITIN 3 $19.12
82730 FIBRINOGEN, QUANTITATIVE O $0.00
82731 ASSAY OF FETAL FIBRONECTIN 3 $88.93
82735 ASSAY OF FLUORIDE 3 $26.03
82740 FLUORIDE URINE O $0.00
82741 FLUCYTOSINE (5-FLUOROCYTOSINE) O $0.00
82742 ASSAY OF FLURAZEPAM 3 $22.07
82745 FOLIC ACID (FOLATE), BLOOD BIOASSAY O $0.00
82746 BLOOD FOLIC ACID SERUM 3 $20.64
82747 ASSAY OF FOLIC ACID, RBC 3 $24.18
82750 FORMIMINOGLUTAMIC ACID (FIGLU), URI O $0.00
82755 FREE RADICAL ASSAY TECHNIQUE FOR DR O $0.00
82756 FREE THYROXINE INDEX (T-7) O $0.00
82757 ASSAY OF SEMEN FRUCTOSE 3 $24.34
82759 ASSAY OF RBC GALACTOKINASE 3 $30.15
82760 ASSAY OF GALACTOSE 3 $15.72
82763 GALACTOSE TOLERANCE TEST O $0.00
82765 GALACTOSE URINE O $0.00
82775 ASSAY GALACTOSE TRANSFERASE 3 $29.57
82776 GALACTOSE TRANSFERASE TEST 3 $11.77
82780 GALLIUM O $0.00

82784 ASSAY, IGA/IGD/IGG/IGM EACH 3 $13.05
82785 ASSAY OF IGE 3 $23.12
82786 GAMMAGLOBULIN, SALT PRECIPITATION M O $0.00
82787 IGG 1, 2, 3 OR 4, EACH 3 $11.26
82790 GASES, BLOOD, OXYGEN SATURATION BY O $0.00
82791 GASES, BLOOD, OXYGEN SATURATION BY O $0.00
82792 GASES, BLOOD, OXYGEN SATURATION QUA O $0.00
82793 GASES, BLOOD, OXYGEN SATURATION BY O $0.00
82795 GASES, BLOOD, OXYGEN SATURATION BY O $0.00
82800 BLOOD PH 3 $11.89
82801 GASES, BLOOD PCO2 O $0.00
82802 GASES, BLOOD PH, PCO2 BY ELECTRODE O $0.00
82803 BLOOD GASES: PH, PO2 & PCO2 3 $27.16
82804 GASES, BLOOD PO2 BY ELECTRODE O $0.00
82805 BLOOD GASES W/02 SATURATION 3 $39.84
82810 BLOOD GASES, O2 SAT ONLY 3 $12.25
82812 GASES, BLOOD PO2 BY MANOMETRY O $0.00
82817 GASES, BLOOD PH, PCO2 BY TONOMETRY O $0.00
82820 HEMOGLOBIN-OXYGEN AFFINITY 3 $14.03
82926 ASSAY OF GASTRIC ACID 3 $7.65
82927 GASTRIC ACID, FREE AND TOTAL EACH A O $0.00
82928 ASSAY OF GASTRIC ACID 3 $9.19
82929 GASTRIC ACID, FREE OR TOTAL EACH AD O $0.00
82931 GASTRIC ACID, PH TITRATION SINGLE S O $0.00
82932 GASTRIC ACID, PH TITRATION EACH ADD O $0.00
82938 GASTRIN TEST 3 $24.84
82941 ASSAY OF GASTRIN 3 $24.75
82942 GLOBULIN, SERUM O $0.00
82943 ASSAY OF GLUCAGON 3 $20.05
82944 GLUCOSAMINE O $0.00
82945 GLUCOSE OTHER FLUID 3 $5.51
82946 GLUCAGON TOLERANCE TEST 3 $21.16
82947 ASSAY, GLUCOSE, BLOOD QUANT 3 $5.51
82948 REAGENT STRIP/BLOOD GLUCOSE 3 $4.45
82949 GLUCOSE FERMENTATION O $0.00
82950 GLUCOSE TEST 3 $6.66
82951 GLUCOSE TOLERANCE TEST (GTT) 3 $18.07
82952 GTT-ADDED SAMPLES 3 $4.04
82953 GLUCOSE-TOLBUTAMIDE TEST 3 $21.27
82954 GLUCOSE, URINE O $0.00
82955 ASSAY OF G6PD ENZYME 3 $13.61
82960 TEST FOR G6PD ENZYME 3 $8.50
82961 GLUCOSE TOLERANCE TEST, INTRAVENOUS O $0.00
82962 GLUCOSE BLOOD TEST 3 $3.35
82963 ASSAY OF GLUCOSIDASE 3 $30.15
82965 ASSAY OF GDH ENZYME 3 $10.85
82975 ASSAY OF GLUTAMINE 3 $22.24
82977 ASSAY OF GGT 3 $9.40
82978 ASSAY OF GLUTATHIONE 3 $8.36

82979 ASSAY, RBC GLUTATHIONE 3 $9.66
82980 ASSAY OF GLUTETHIMIDE 3 $25.72
82985 GLYCATED PROTEIN 3 $21.16
82995 GOLD, BLOOD O $0.00
83000 GONADOTROPIN, PITUITARY, FOLLICLE S O $0.00
83001 GONADOTROPIN (FSH) 3 $26.09
83002 GONADOTROPIN (LH) 3 $26.00
83003 ASSAY, GROWTH HORMONE (HGH) 3 $23.40
83004 GROWTH HORMONE, HUMAN (HGH) (SOMATO O $0.00
83008 ASSAY OF GUANOSINE 3 $23.56
83009 H PYLORI (C-13), BLOOD 3 $94.54
83010 ASSAY OF HAPTOGLOBIN, QUANT 3 $17.66
83011 HAPTOGLOBIN QUANTITATIVE, ELECTROPH O $0.00
83012 ASSAY OF HAPTOGLOBINS 3 $24.14
83013 H PYLORI (C-13), BREATH 3 $94.54
83014 H PYLORI DRUG ADMIN 3 $11.03
83015 HEAVY METAL SCREEN 3 $26.43
83018 QUANTITATIVE SCREEN, METALS 3 $30.83
83019 BREATH ISOTOPE TEST O $0.00
83020 HEMOGLOBIN ELECTROPHORESIS 3 $18.07
83021 HEMOGLOBIN CHROMOTOGRAPHY 3 $25.34
83026 HEMOGLOBIN, COPPER SULFATE 3 $3.38
83030 FETAL HEMOGLOBIN, CHEMICAL 3 $11.61
83033 FETAL HEMOGLOBIN ASSAY, QUAL 3 $8.09
83036 GLYCOSYLATED HEMOGLOBIN TEST 3 $13.62
83037 GLYCOSYLATED HB, HOME DEVICE 3 $13.62
83040 HEMOGLOBIN METHEMOGLOBIN, ELECTROPH O $0.00
83045 BLOOD METHEMOGLOBIN TEST 3 $6.96
83050 BLOOD METHEMOGLOBIN ASSAY 3 $10.28
83051 ASSAY OF PLASMA HEMOGLOBIN 3 $4.04
83052 HEMOGLOBIN SICKLE, TURBIDIMETRIC O $0.00
83053 HEMOGLOBIN SOLUBILITY, S-D, ETC O $0.00
83055 BLOOD SULFHEMOGLOBIN TEST 3 $4.04
83060 BLOOD SULFHEMOGLOBIN ASSAY 3 $11.61
83065 ASSAY OF HEMOGLOBIN HEAT 3 $9.66
83068 HEMOGLOBIN STABILITY SCREEN 3 $3.36
83069 ASSAY OF URINE HEMOGLOBIN 3 $5.54
83070 ASSAY OF HEMOSIDERIN, QUAL 3 $6.66
83071 ASSAY OF HEMOSIDERIN, QUANT 3 $9.01
83080 ASSAY OF B HEXOSAMINIDASE 3 $23.68
83086 HISTIDINE BLOOD, QUALITATIVE O $0.00
83087 HISTIDINE URINE, QUALITATIVE O $0.00
83088 ASSAY OF HISTAMINE 3 $41.45
83090 ASSAY OF HOMOCYSTINE 3 $23.68
83093 HOMOGENTISIC ACID BLOOD, QUALITATIV O $0.00
83094 HOMOGENTISIC ACID URINE, QUALITATIV O $0.00
83095 HOMOGENTISIC ACID URINE, QUANTITATI O $0.00
83150 ASSAY OF FOR HVA 3 $27.16
83485 HYDROXYBUTYRIC DEHYDROGENASE, ALPHA O $0.00

83486 HYDROXYBUTYRIC DEHYDROGENASE, ALPHA O $0.00
83491 ASSAY OF CORTICOSTEROIDS 3 $24.59
83492 HYDROXYCORTICOSTEROIDS, 17- (17-OHC O $0.00
83493 HYDROXYCORTICOSTEROIDS, 17- (17-OHC O $0.00
83494 HYDROXYCORTICOSTEROIDS, 17- (17-OHC O $0.00
83495 HYDROXYCORTICOSTEROIDS, 17- (17-OHC O $0.00
83496 HYDROXYCORTICOSTEROIDS, 17- (17-OHC O $0.00
83497 ASSAY OF 5-HIAA 3 $18.10
83498 ASSAY OF PROGESTERONE 3 $38.13
83499 ASSAY OF PROGESTERONE 3 $20.37
83500 ASSAY, FREE HYDROXYPROLINE 3 $31.79
83505 ASSAY, TOTAL HYDROXYPROLINE 3 $34.12
83510 HYDROXYPROLINE, URINE FREE AND TOTA O $0.00
83516 IMMUNOASSAY, NONANTIBODY 3 $15.45
83518 IMMUNOASSAY, DIPSTICK 3 $11.90
83519 RIA NONANTIBODY 3 $18.96
83520 IMMUNOASSAY QUANT NOS NONAB 3 $18.17
83523 IMIPRAMINE O $0.00
83524 INDICAN, URINE O $0.00
83525 ASSAY OF INSULIN 3 $16.05
83526 INSULIN TOLERANCE TEST O $0.00
83527 ASSAY OF INSULIN 3 $18.18
83528 ASSAY OF INTRINSIC FACTOR 3 $22.32
83530 INULIN CLEARANCE O $0.00
83540 ASSAY OF IRON 3 $9.09
83545 IRON, SERUM AUTOMATED O $0.00
83546 IRON, SERUM RADIOACTIVE UPTAKE METH O $0.00
83550 IRON BINDING TEST 3 $12.27
83555 IRON BINDING CAPACITY, SERUM AUTOMA O $0.00
83565 IRON BINDING CAPACITY, SERUM RADIOA O $0.00
83570 ASSAY OF IDH ENZYME 3 $10.55
83571 ISOCITRIC DEHYDROGENASE (IDH), BLOO O $0.00
83576 ISONICOTINIC ACID HYDRAZIDE (INH) O $0.00
83578 KANAMYCIN O $0.00
83582 ASSAY OF KETOGENIC STEROIDS 3 $19.89
83583 KETOGENIC STEROIDS, URINE 11-DESOXY O $0.00
83584 KETOGLUTARATE, ALPHA O $0.00
83586 ASSAY 17- KETOSTEROIDS 3 $17.97
83587 KETOSTEROIDS, 17- (17-KS), BLOOD FR O $0.00
83588 KETOSTEROIDS, 17- (17-KS), BLOOD RI O $0.00
83589 KETOSTEROIDS, 17- (17-KS), URINE TO O $0.00
83590 KETOSTEROIDS, 17- (17-KS), URINE FR O $0.00
83593 FRACTIONATION, KETOSTEROIDS 3 $36.92
83597 KETOSTEROIDS, 17- (17-KS), URINE 11 O $0.00
83599 KETOSTEROIDS, 17-OH, RIA O $0.00
83600 KYNURENIC ACID O $0.00
83605 ASSAY OF LACTIC ACID 3 $14.99
83610 LACTIC DEHYDROGENASE (LDH), RIA O $0.00
83615 LACTATE (LD) (LDH) ENZYME 3 $7.86

83620 LACTIC DEHYDROGENASE (LDH), BLOOD C O $0.00
83624 LACTIC DEHYDROGENASE (LDH), BLOOD H O $0.00
83625 ASSAY OF LDH ENZYMES 3 $17.96
83626 LACTIC DEHYDROGENASE (LDH), BLOOD I O $0.00
83628 LACTIC DEHYDROGENASE, LIVER (LLDH) O $0.00
83629 LACTIC DEHYDROGENASE (LDH), URINE O $0.00
83630 LACTOFERRIN, FECAL (QUAL) 3 $27.55
83631 LACTOFERRIN, FECAL (QUANT) 3 $27.55
83632 PLACENTAL LACTOGEN 3 $28.37
83633 TEST URINE FOR LACTOSE 3 $7.72
83634 ASSAY OF URINE FOR LACTOSE 3 $16.18
83645 LEAD, SCREENING BLOOD O $0.00
83650 LEAD, SCREENING URINE O $0.00
83655 ASSAY OF LEAD 3 $16.99
83660 LEAD, QUANTITATIVE URINE O $0.00
83661 L/S RATIO, FETAL LUNG 3 $30.86
83662 FOAM STABILITY, FETAL LUNG 3 $26.56
83663 FLUORO POLARIZE, FETAL LUNG 3 $26.56
83664 LAMELLAR BDY, FETAL LUNG 3 $26.56
83670 ASSAY OF LAP ENZYME 3 $12.87
83675 LEUCINE AMINOPEPTIDASE (LAP), BLOOD O $0.00
83680 LEUCINE AMINOPEPTIDASE (LAP), URINE O $0.00
83681 LEUCINE TOLERANCE TEST O $0.00
83685 LIDOCAINE O $0.00
83690 ASSAY OF LIPASE 3 $9.66
83695 ASSAY OF LIPOPROTEIN(A) 3 $18.17
83698 ASSAY LIPOPROTEIN PLA2 3 $47.65
83700 LIPOPRO BLD, ELECTROPHORETIC 3 $15.80
83701 LIPOPROTEIN BLD, HR FRACTION 3 $34.84
83704 LIPOPROTEIN, BLD, BY NMR 3 $44.29
83705 LIPIDS, BLOOD FRACTIONATED (CHOLEST O $0.00
83715 ASSAY OF BLOOD LIPOPROTEINS O $0.00
83716 ASSAY OF BLOOD LIPOPROTEINS O $0.00
83717 ASSAY BLOOD LIPOPROTEINS O $0.00
83718 ASSAY OF LIPOPROTEIN 3 $11.50
83719 ASSAY OF BLOOD LIPOPROTEIN 3 $16.33
83720 LIPOPROTEIN CHOLESTEROL FRACTIONATI O $0.00
83721 ASSAY OF BLOOD LIPOPROTEIN 3 $13.39
83725 LITHIUM, BLOOD, QUANTITATIVE O $0.00
83727 ASSAY OF LRH HORMONE 3 $24.14
83728 LYSERGIC ACID DIETHYLAMIDE (LSD), R O $0.00
83730 MACROGLOBULINS (SIA TEST) O $0.00
83735 ASSAY OF MAGNESIUM 3 $9.41
83740 MAGNESIUM, BLOOD FLUOROMETRIC O $0.00
83750 MAGNESIUM, BLOOD ATOMIC ABSORPTION O $0.00
83755 MAGNESIUM, URINE CHEMICAL O $0.00
83760 MAGNESIUM, URINE FLUOROMETRIC O $0.00
83765 MAGNESIUM, URINE ATOMIC ABSORPTION O $0.00
83775 ASSAY OF MD ENZYME 3 $10.35

83785 ASSAY OF MANGANESE 3 $15.28
83788 MASS SPECTROMETRY QUAL 3 $25.34
83789 MASS SPECTROMETRY QUANT 3 $25.34
83790 MANNITOL CLEARANCE O $0.00
83795 MELANIN, URINE, QUALITATIVE O $0.00
83799 MEPERIDINE, QUANTITATIVE O $0.00
83805 ASSAY OF MEPROBAMATE 3 $24.75
83825 ASSAY OF MERCURY 3 $22.82
83830 MERCURY, QUANTITATIVE URINE O $0.00
83835 ASSAY OF METANEPHRINES 3 $23.77
83840 ASSAY OF METHADONE 3 $22.86
83842 METHAPYRILENE O $0.00
83845 METHAQUALONE O $0.00
83857 ASSAY OF METHEMALBUMIN 3 $15.07
83858 ASSAY OF METHSUXIMIDE 3 $20.80
83859 METHYPRYLON O $0.00
83860 MORPHINE SCREENING O $0.00
83861 MORPHINE QUANTITATIVE O $0.00
83862 MORPHINE RIA O $0.00
83864 MUCOPOLYSACCHARIDES 3 $27.94
83865 MUCOPOLYSACCHARIDES, ACID, URINE QU O $0.00
83866 MUCOPOLYSACCHARIDES SCREEN 3 $13.83
83872 ASSAY SYNOVIAL FLUID MUCIN 3 $8.23
83873 ASSAY OF CSF PROTEIN 3 $24.15
83874 ASSAY OF MYOGLOBIN 3 $18.13
83875 MYOGLOBIN, URINE O $0.00
83876 ASSAY, MYELOPEROXIDASE 3 $47.65
83880 NATRIURETIC PEPTIDE 3 $47.65
83883 ASSAY, NEPHELOMETRY NOT SPEC 3 $19.08
83885 ASSAY OF NICKEL 3 $34.39
83887 ASSAY OF NICOTINE 3 $33.24
83890 MOLECULE ISOLATE 3 $5.63
83891 MOLECULE ISOLATE NUCLEIC 3 $5.63
83892 MOLECULAR DIAGNOSTICS 3 $5.63
83893 MOLECULE DOT/SLOT/BLOT 3 $5.63
83894 MOLECULE GEL ELECTROPHOR 3 $5.63
83895 NITROGEN, TOTAL URINE, 24-HOUR SPEC O $0.00
83896 MOLECULAR DIAGNOSTICS 3 $5.63
83897 MOLECULE NUCLEIC TRANSFER 3 $5.63
83898 MOLECULE NUCLEIC AMPLI, EACH 3 $23.53
83900 MOLECULE NUCLEIC AMPLI 2 SEQ 3 $47.06
83901 MOLECULE NUCLEIC AMPLI ADDON 3 $23.53
83902 MOLECULAR DIAGNOSTICS 3 $19.92
83903 MOLECULE MUTATION SCAN 3 $23.53
83904 MOLECULE MUTATION IDENTIFY 3 $23.53
83905 MOLECULE MUTATION IDENTIFY 3 $23.53
83906 MOLECULE MUTATION IDENTIFY 3 $23.53
83907 LYSE CELLS FOR NUCLEIC EXT 3 $18.75
83908 NUCLEIC ACID, SIGNAL AMPLI 3 $23.53

83909 NUCLEIC ACID, HIGH RESOLUTE 3 $23.53
83910 NONPROTEIN NITROGEN (NPN), BLOOD O $0.00
83912 GENETIC EXAMINATION 3 $5.63
83913 MOLECULAR, RNA STABILIZATION 3 $18.75
83914 MUTATION IDENT OLA/SBCE/ASPE 3 $23.53
83915 ASSAY OF NUCLEOTIDASE 3 $15.66
83916 OLIGOCLONAL BANDS 3 $28.22
83917 ORGANIC ACIDS SCREEN, QUALITATIVE O $0.00
83918 ORGANIC ACIDS, TOTAL, QUANT 3 $23.11
83919 ORGANIC ACIDS, QUAL, EACH 3 $23.11
83920 ORNITHINE CARBAMYL TRANSFERASE (OCT O $0.00
83921 ORGANIC ACID, SINGLE, QUANT 3 $23.11
83925 ASSAY OF OPIATES 3 $27.31
83930 ASSAY OF BLOOD OSMOLALITY 3 $9.27
83935 ASSAY OF URINE OSMOLALITY 3 $9.56
83937 ASSAY OF OSTEOCALCIN 3 $41.90
83938 OUABAIN O $0.00
83945 ASSAY OF OXALATE 3 $18.07
83946 OXAZEPAM O $0.00
83947 OXYBUTYRIC ACID, BETA O $0.00
83948 OXYCODINONE O $0.00
83949 OXYTOCINASE, RIA O $0.00
83950 ONCOPROTEIN, HER-2/NEU 3 $88.93
83951 ONCOPROTEIN, DCP 3 $88.93
83965 PARALDEHYDE, BLOOD, QUANTITATIVE O $0.00
83970 ASSAY OF PARATHORMONE 3 $57.94
83971 PENICILLIN, URINE O $0.00
83972 PENTAZOCINE O $0.00
83973 PENTOSE, URINE, QUALITATIVE O $0.00
83975 PEPSINOGEN, BLOOD O $0.00
83985 PESTICIDE OTHER THAN CHLORINATED HY O $0.00
83986 ASSAY PH BODY FLUID NOS 3 $3.36
83987 EXHALED BREATH CONDENSATE 3 $22.29
83992 ASSAY FOR PHENCYCLIDINE 3 $20.63
83993 ASSAY FOR CALPROTECTIN FECAL 3 $27.55
83995 PHENOL, BLOOD OR URINE O $0.00
84005 PHENOLSULFONPHTHALEIN (PSP) TEST, U O $0.00
84021 PHENOTHIAZINE, URINE QUALITATIVE, C O $0.00
84022 ASSAY OF PHENOTHIAZINE 3 $21.86
84030 ASSAY OF BLOOD PKU 3 $7.72
84031 PHENYLALANINE (PKU), BLOOD FLUOROME O $0.00
84033 PHENYLBUTAZONE O $0.00
84035 ASSAY OF PHENYLKETONES 3 $5.14
84037 PHENYLKETONES URINE, QUALITATIVE O $0.00
84038 PHENYLPROPANOLAMINE O $0.00
84039 PHENYLPYRUVIC ACID BLOOD O $0.00
84040 PHENYLPYRUVIC ACID URINE O $0.00
84045 PHENYTOIN O $0.00
84060 ASSAY ACID PHOSPHATASE 3 $8.09

84061 PHOSPHATASE, FORENSIC EXAM 3 $8.09
84065 PHOSPHATASE, ACID PROSTATIC FRACTIO O $0.00
84066 ASSAY PROSTATE PHOSPHATASE 3 $13.16
84075 ASSAY ALKALINE PHOSPHATASE 3 $6.40
84078 ASSAY ALKALINE PHOSPHATASE 3 $10.25
84080 ASSAY ALKALINE PHOSPHATASES 3 $20.77
84081 AMNIOTIC FLUID ENZYME TEST 3 $23.20
84082 PHOSPHATES, TUBULAR REABSORPTION OF O $0.00
84083 PHOSPHOGLUCOMUTASE, ISOENZYMES O $0.00
84085 ASSAY OF RBC PG6D ENZYME 3 $9.47
84087 ASSAY PHOSPHOHEXOSE ENZYMES 3 $14.49
84090 PHOSPHOLIPIDS, BLOOD O $0.00
84100 ASSAY OF PHOSPHORUS 3 $6.79
84105 ASSAY OF URINE PHOSPHORUS 3 $7.26
84106 TEST FOR PORPHOBILINOGEN 3 $6.01
84110 ASSAY OF PORPHOBILINOGEN 3 $10.85
84118 PORPHYRINS, COPRO-, URINE QUANTITAT O $0.00
84119 TEST URINE FOR PORPHYRINS 3 $12.09
84120 ASSAY OF URINE PORPHYRINS 3 $20.49
84121 PORPHYRINS URO-, COPRO- AND PORPHOB O $0.00
84126 ASSAY OF FECES PORPHYRINS 3 $35.75
84127 ASSAY OF FECES PORPHYRINS 3 $16.36
84128 PORPHYRINS, PLASMA O $0.00
84132 ASSAY OF SERUM POTASSIUM 3 $6.45
84133 ASSAY OF URINE POTASSIUM 3 $6.04
84134 ASSAY OF PREALBUMIN 3 $20.47
84135 ASSAY OF PREGNANEDIOL 3 $26.85
84136 PREGNANEDIOL OTHER METHOD (SPECIFY) O $0.00
84138 ASSAY OF PREGNANETRIOL 3 $26.58
84139 PREGNANETRIOL OTHER METHOD (SPECIFY O $0.00
84140 ASSAY OF PREGNENOLONE 3 $29.02
84141 PRIMIDONE O $0.00
84142 PROCAINAMIDE O $0.00
84143 ASSAY OF 17-HYDROXYPREGNENO 3 $32.04
84144 ASSAY OF PROGESTERONE 3 $29.28
84145 PROCALCITONIN (PCT) 3 $27.20
84146 ASSAY OF PROLACTIN 3 $27.20
84147 PROPOXYPHENE O $0.00
84149 PROPRANOLOL O $0.00
84150 ASSAY OF PROSTAGLANDIN 3 $35.03
84152 ASSAY OF PSA, COMPLEXED 3 $25.81
84153 ASSAY OF PSA, TOTAL 3 $25.81
84154 ASSAY OF PSA, FREE 3 $25.81
84155 ASSAY OF PROTEIN, SERUM 3 $4.69
84156 ASSAY OF PROTEIN, URINE 3 $4.69
84157 ASSAY OF PROTEIN, OTHER 3 $4.69
84160 ASSAY OF PROTEIN, ANY SOURCE 3 $7.26
84163 PAPPA, SERUM 3 $20.36
84165 PROTEIN E-PHORESIS, SERUM 3 $15.07

84166 PROTEIN E-PHORESIS/URINE/CSF 3 $25.03
84170 PROTEIN, TOTAL, AND ALBUMIN/GLOBULI O $0.00
84175 PROTEIN;ELECTROPHORESIS,OTHER SOURC O $0.00
84176 PROTEIN, SPECIAL STUDIES (EG, MONOC O $0.00
84180 PROTEIN, URINE QUANTITATIVE, 24-HOU O $0.00
84181 WESTERN BLOT TEST 3 $23.91
84182 PROTEIN, WESTERN BLOT TEST 3 $25.26
84185 PROTEIN, URINE BENCE-JONES O $0.00
84190 PROTEIN, URINE ELECTROPHORETIC FRAC O $0.00
84195 PROTEIN, SPINAL FLUID SEMI-QUANTITA O $0.00
84200 PROTEIN, SPINAL FLUID ELECTROPHORET O $0.00
84201 PROTIRELIN, THYROTROPIN RELEASING H O $0.00
84202 ASSAY RBC PROTOPORPHYRIN 3 $20.14
84203 TEST RBC PROTOPORPHYRIN 3 $12.08
84205 PROTRIPTYLENE O $0.00
84206 ASSAY OF PROINSULIN 3 $10.96
84207 ASSAY OF VITAMIN B-6 3 $39.44
84208 PYROPHOSPHATE VS URATE, CRYSTALS (P O $0.00
84210 ASSAY OF PYRUVATE 3 $15.24
84220 ASSAY OF PYRUVATE KINASE 3 $13.24
84228 ASSAY OF QUININE 3 $16.33
84230 QUINIDINE, BLOOD O $0.00
84231 RADIOIMMUNOASSAY (RIA) NOT ELSEWHER O $0.00
84232 RELEASING FACTOR O $0.00
84233 ASSAY OF ESTROGEN 3 $88.93
84234 ASSAY OF PROGESTERONE 3 $91.06
84235 ASSAY OF ENDOCRINE HORMONE 3 $73.46
84236 RECEPTOR ASSAY PROGESTERONE AND EST O $0.00
84238 ASSAY, NONENDOCRINE RECEPTOR 3 $51.33
84244 ASSAY OF RENIN 3 $30.88
84246 RENIN (ANGIOTENSIN I) FUROSEMIDE TE O $0.00
84252 ASSAY OF VITAMIN B-2 3 $27.68
84255 ASSAY OF SELENIUM 3 $35.83
84260 ASSAY OF SEROTONIN 3 $43.48
84270 ASSAY OF SEX HORMONE GLOBUL 3 $27.68
84275 ASSAY OF SIALIC ACID 3 $18.86
84285 ASSAY OF SILICA 3 $33.06
84295 ASSAY OF SERUM SODIUM 3 $6.53
84300 ASSAY OF URINE SODIUM 3 $6.82
84302 ASSAY OF SWEAT SODIUM 3 $6.82
84305 ASSAY OF SOMATOMEDIN 3 $27.57
84307 ASSAY OF SOMATOSTATIN 3 $25.67
84310 SORBITOL DEHYDROGENASE, SERUM O $0.00
84311 SPECTROPHOTOMETRY 3 $9.81
84315 BODY FLUID SPECIFIC GRAVITY 3 $3.52
84318 STERCOBILIN, QUALITATIVE, FECES O $0.00
84324 STRYCHNINE O $0.00
84375 CHROMATOGRAM ASSAY, SUGARS 3 $27.52
84376 SUGARS, SINGLE, QUAL 3 $7.72

84377 SUGARS, MULTIPLE, QUAL 3 $7.72
84378 SUGARS, SINGLE, QUANT 3 $16.18
84379 SUGARS MULTIPLE QUANT 3 $16.18
84392 ASSAY OF URINE SULFATE 3 $6.66
84395 SULFONAMIDE, BLOOD, CHEMICAL O $0.00
84402 ASSAY OF TESTOSTERONE 3 $35.74
84403 ASSAY OF TOTAL TESTOSTERONE 3 $36.24
84405 TESTOSTERONE, URINE, RIA O $0.00
84406 TESTOSTERONE, BINDING PROTEIN O $0.00
84407 TETRACAINE O $0.00
84408 TETRAHYDROCANNABINOL THC (MARIJUANA O $0.00
84409 TETRAHYDROCORTISONE OR TETRAHYDROCO O $0.00
84410 THALLIUM, BLOOD OR URINE O $0.00
84420 THEOPHYLLINE, BLOOD OR SALIVA O $0.00
84425 ASSAY OF VITAMIN B-1 3 $29.80
84430 ASSAY OF THIOCYANATE 3 $6.40
84431 THROMBOXANE, URINE 3 $18.17
84432 ASSAY OF THYROGLOBULIN 3 $22.55
84434 THIORIDAZINE O $0.00
84435 THYROXINE, (T-4), CPB OR RESIN UPTA O $0.00
84436 ASSAY OF TOTAL THYROXINE 3 $9.64
84437 ASSAY OF NEONATAL THYROXINE 3 $9.08
84439 ASSAY OF FREE THYROXINE 3 $12.66
84442 ASSAY OF THYROID ACTIVITY 3 $20.77
84443 ASSAY THYROID STIM HORMONE 3 $23.58
84444 THYROTROPIN RELEASING FACTOR (TRF) O $0.00
84445 ASSAY OF TSI 3 $71.37
84446 ASSAY OF VITAMIN E 3 $19.90
84447 TOXICOLOGY, SCREEN GENERAL O $0.00
84448 TOXICOLOGY, SCREEN SEDATIVE (ACID A O $0.00
84449 ASSAY OF TRANSCORTIN 3 $25.26
84450 TRANSFERASE (AST) (SGOT) 3 $7.26
84455 TRANSAMINASE, GLUTAMIC OXALOACETIC O $0.00
84460 ALANINE AMINO (ALT) (SGPT) 3 $7.43
84465 TRANSAMINASE, GLUTAMIC PYRUVIC (SGP O $0.00
84466 ASSAY OF TRANSFERRIN 3 $17.92
84472 TRICHLOROETHANOL O $0.00
84474 TRICHLOROACETIC ACID O $0.00
84476 TRIFLUOPERAZINE O $0.00
84478 ASSAY OF TRIGLYCERIDES 3 $8.08
84479 ASSAY OF THYROID (T3 OR T4) 3 $9.08
84480 ASSAY, TRIIODOTHYRONINE (T3) 3 $19.90
84481 FREE ASSAY (FT-3) 3 $23.77
84482 T3 REVERSE 3 $22.13
84483 TRIMETHADIONE O $0.00
84484 ASSAY OF TROPONIN, QUANT 3 $12.23
84485 ASSAY DUODENAL FLUID TRYPSIN 3 $10.53
84488 TEST FECES FOR TRYPSIN 3 $10.25
84490 ASSAY OF FECES FOR TRYPSIN 3 $10.68

84510 ASSAY OF TYROSINE 3 $14.60
84512 ASSAY OF TROPONIN, QUAL 3 $10.36
84520 ASSAY OF UREA NITROGEN 3 $5.54
84525 UREA NITROGEN SEMI-QUANT 3 $5.28
84540 ASSAY OF URINE/UREA-N 3 $6.66
84545 UREA-N CLEARANCE TEST 3 $9.27
84550 ASSAY OF BLOOD/URIC ACID 3 $6.34
84555 URIC ACID URICASE, ULTRAVIOLET METH O $0.00
84560 ASSAY OF URINE/URIC ACID 3 $4.85
84565 UROBILIN, URINE QUALITATIVE O $0.00
84570 UROBILIN, URINE QUANTITATIVE, TIMED O $0.00
84575 UROBILIN, FECES, QUANTITATIVE O $0.00
84577 ASSAY OF FECES/UROBILINOGEN 3 $17.51
84578 TEST URINE UROBILINOGEN 3 $4.04
84580 ASSAY OF URINE UROBILINOGEN 3 $9.96
84583 ASSAY OF URINE UROBILINOGEN 3 $7.06
84584 UROPEPSIN, URINE O $0.00
84585 ASSAY OF URINE VMA 3 $21.77
84586 ASSAY OF VIP 3 $49.60
84588 ASSAY OF VASOPRESSIN 3 $47.65
84589 VISCOSITY O $0.00
84590 ASSAY OF VITAMIN A 3 $16.28
84591 ASSAY OF NOS VITAMIN 3 $16.28
84595 VITAMIN A, BLOOD INCLUDING CAROTENE O $0.00
84597 ASSAY OF VITAMIN K 3 $19.24
84600 ASSAY OF VOLATILES 3 $22.56
84605 VOLUME, BLOOD, DYE METHOD (EVANS BL O $0.00
84610 VOLUME, BLOOD, DYE METHOD (EVANS BL O $0.00
84613 WARFARIN O $0.00
84615 XANTHURENIC ACID O $0.00
84620 XYLOSE TOLERANCE TEST 3 $6.53
84630 ASSAY OF ZINC 3 $15.98
84635 ZINC, QUANTITATIVE URINE O $0.00
84681 ASSAY OF C-PEPTIDE 3 $29.20
84695 GENTAMICIN O $0.00
84702 CHORIONIC GONADOTROPIN TEST 3 $20.36
84703 CHORIONIC GONADOTROPIN ASSAY 3 $10.54
84704 HCG, FREE BETACHAIN TEST 3 $20.36
84800 THYROID STIMULATING HORMONE (TSH), O $0.00
84810 TOBRAMYCIN O $0.00
84830 OVULATION TESTS 9 $0.00
84999 CLINICAL CHEMISTRY TEST 5 $0.00
85000 BLEEDING TIME DUKE O $0.00
85002 BLEEDING TIME TEST 3 $6.32
85004 AUTOMATED DIFF WBC COUNT 3 $9.08
85005 BLOOD COUNT BASOPHIL COUNT, DIRECT O $0.00
85007 BL SMEAR W/DIFF WBC COUNT 3 $4.83
85008 BL SMEAR W/O DIFF WBC COUNT 3 $4.83
85009 MANUAL DIFF WBC COUNT B-COAT 3 $5.22

85012 BLOOD COUNT EOSINOPHIL COUNT, DIREC O $0.00
85013 SPUN MICROHEMATOCRIT 3 $3.39
85014 HEMATOCRIT 3 $3.39
85018 HEMOGLOBIN 3 $3.39
85021 AUTOMATED HEMOGRAM O $0.00
85022 AUTOMATED HEMOGRAM O $0.00
85023 AUTOMATED HEMOGRAM O $0.00
85024 AUTOMATED HEMOGRAM O $0.00
85025 COMPLETE CBC W/AUTO DIFF WBC 3 $10.92
85027 COMPLETE CBC, AUTOMATED 3 $9.08
85029 AUTOMATED HEMOGRAM O $0.00
85030 AUTOMATED HEMOGRAM O $0.00
85031 MANUAL HEMOGRAM, CBC O $0.00
85032 MANUAL CELL COUNT, EACH 3 $6.04
85041 AUTOMATED RBC COUNT 3 $4.04
85044 MANUAL RETICULOCYTE COUNT 3 $6.04
85045 AUTOMATED RETICULOCYTE COUNT 3 $5.63
85046 RETICYTE/HGB CONCENTRATE 3 $7.83
85048 AUTOMATED LEUKOCYTE COUNT 3 $3.57
85049 AUTOMATED PLATELET COUNT 3 $6.27
85055 RETICULATED PLATELET ASSAY 3 $37.58
85060 BLOOD SMEAR INTERPRETATION 3 $25.45
85095 BONE MARROW ASPIRATION O $0.00
85097 BONE MARROW INTERPRETATION 3 $104.59
85100 BONE MARROW SMEAR AND/OR CELL BLOCK O $0.00
85101 BONE MARROW SMEAR AND/OR CELL BLOCK O $0.00
85102 BONE MARROW BIOPSY O $0.00
85103 BONE MARROW BIOPSY, NEEDLE OR TROCA O $0.00
85105 BONE MARROW BIOPSY, NEEDLE OR TROCA O $0.00
85109 BONE MARROW BIOPSY, NEEDLE OR TROCA O $0.00
85130 CHROMOGENIC SUBSTRATE ASSAY 3 $16.69
85170 BLOOD CLOT RETRACTION 3 $5.08
85171 CLOT RETRACTION QUANTITATIVE O $0.00
85172 CLOT RETRACTION INHIBITION BY DRUGS O $0.00
85175 BLOOD CLOT LYSIS TIME 3 $6.38
85210 BLOOD CLOT FACTOR II TEST 3 $8.09
85220 BLOOD CLOT FACTOR V TEST 3 $24.77
85230 BLOOD CLOT FACTOR VII TEST 3 $25.14
85240 BLOOD CLOT FACTOR VIII TEST 3 $25.14
85242 CLOTTING FACTOR VIII (AHG), TWO STA O $0.00
85244 BLOOD CLOT FACTOR VIII TEST 3 $28.66
85245 BLOOD CLOT FACTOR VIII TEST 3 $32.21
85246 BLOOD CLOT FACTOR VIII TEST 3 $32.21
85247 BLOOD CLOT FACTOR VIII TEST 3 $32.21
85250 BLOOD CLOT FACTOR IX TEST 3 $26.72
85260 BLOOD CLOT FACTOR X TEST 3 $25.14
85270 BLOOD CLOT FACTOR XI TEST 3 $25.14
85280 BLOOD CLOT FACTOR XII TEST 3 $27.16
85290 BLOOD CLOT FACTOR XIII TEST 3 $11.37

85291 BLOOD CLOT FACTOR XIII TEST 3 $11.37
85292 BLOOD CLOT FACTOR ASSAY 3 $26.59
85293 BLOOD CLOT FACTOR ASSAY 3 $26.59
85300 ANTITHROMBIN III TEST 3 $13.58
85301 ANTITHROMBIN III TEST 3 $15.18
85302 BLOOD CLOT INHIBITOR ANTIGEN 3 $16.88
85303 BLOOD CLOT INHIBITOR TEST 3 $19.41
85305 BLOOD CLOT INHIBITOR ASSAY 3 $16.28
85306 BLOOD CLOT INHIBITOR TEST 3 $21.51
85307 ASSAY ACTIVATED PROTEIN C 3 $21.51
85310 CLOTTING INHIBITORS OR ANTICOAGULAN O $0.00
85311 CLOTTING INHIBITORS OR ANTICOAGULAN O $0.00
85320 CLOTTING INHIBITORS OR ANTICOAGULAN O $0.00
85330 CLOTTING INHIBITORS OR ANTICOAGULAN O $0.00
85335 FACTOR INHIBITOR TEST 3 $18.07
85337 THROMBOMODULIN 3 $14.63
85340 CLOTTING INHIBITORS OR ANTICOAGULAN O $0.00
85341 CLOTTING INHIBITORS OR ANTICOAGULAN O $0.00
85345 COAGULATION TIME 3 $4.69
85347 COAGULATION TIME 3 $5.98
85348 COAGULATION TIME 3 $5.23
85360 EUGLOBULIN LYSIS 3 $11.77
85362 FIBRIN DEGRADATION PRODUCTS 3 $9.66
85363 FIBRIN DEGRADATION (SPLIT) PRODUCTS O $0.00
85364 FIBRIN DEGRADATION (SPLIT) PRODUCTS O $0.00
85365 FIBRIN DEGRADATION (SPLIT) PRODUCTS O $0.00
85366 FIBRINOGEN TEST 3 $12.09
85367 FIBRIN DEGRADATION (SPLIT) PRODUCTS O $0.00
85368 FIBRIN DEGRADATION (SPLIT) PRODUCTS O $0.00
85369 FIBRIN DEGRADATION (SPLIT) PRODUCTS O $0.00
85370 FIBRINOGEN TEST 3 $11.37
85371 FIBRINOGEN, SEMIQUANTITATIVE LATEX O $0.00
85372 FIBRINOGEN, SEMIQUANTITATIVE TURBID O $0.00
85376 FIBRINOGEN THROMBIN WITH PLASMA DIL O $0.00
85377 FIBRINOGEN THROMBIN TIME DILUTION O $0.00
85378 FIBRIN DEGRADE, SEMIQUANT 3 $10.01
85379 FIBRIN DEGRADATION, QUANT 3 $11.37
85380 FIBRIN DEGRADATION, VTE 3 $11.37
85384 FIBRINOGEN 3 $11.93
85385 FIBRINOGEN 3 $11.93
85390 FIBRINOLYSINS SCREEN 3 $7.25
85392 FIBRINOLYSINS WITH EACA CONTROL O $0.00
85395 FIBRINOLYSINS SEMIQUANTITATIVE O $0.00
85396 CLOTTING ASSAY, WHOLE BLOOD 3 $21.84
85397 CLOTTING FUNCT ACTIVITY 3 $32.21
85398 FIBRINOLYSIS, QUANTITATIVE O $0.00
85400 FIBRINOLYTIC PLASMIN 3 $12.42
85410 FIBRINOLYTIC ANTIPLASMIN 3 $10.83
85415 FIBRINOLYTIC PLASMINOGEN 3 $20.39

85420 FIBRINOLYTIC PLASMINOGEN 3 $9.17
85421 FIBRINOLYTIC PLASMINOGEN 3 $14.30
85426 FIBRINOLYTIC MECHANISMS VON WILLEBR O $0.00
85441 HEINZ BODIES, DIRECT 3 $5.90
85445 HEINZ BODIES, INDUCED 3 $8.09
85460 HEMOGLOBIN, FETAL 3 $10.87
85461 HEMOGLOBIN, FETAL 3 $9.31
85475 HEMOLYSIN 3 $10.96
85520 HEPARIN ASSAY 3 $18.37
85525 HEPARIN NEUTRALIZATION 3 $16.63
85530 HEPARIN-PROTAMINE TOLERANCE 3 $19.90
85535 IRON STAIN, BLOOD CELLS O $0.00
85536 IRON STAIN PERIPHERAL BLOOD 3 $9.08
85538 LEDER STAIN (ESTERASE) BLOOD OR BON O $0.00
85540 WBC ALKALINE PHOSPHATASE 3 $12.07
85544 LUPUS ERYTHEMATOSUS (LE) CELL PREP O $0.00
85547 RBC MECHANICAL FRAGILITY 3 $12.07
85548 MORPHOLOGY OF RED BLOOD CELLS, ONLY O $0.00
85549 MURAMIDASE 3 $20.37
85555 RBC OSMOTIC FRAGILITY 3 $9.39
85556 OSMOTIC FRAGILITY, RBC INCUBATED, Q O $0.00
85557 RBC OSMOTIC FRAGILITY 3 $18.75
85560 PEROXIDASE STAIN, WBC O $0.00
85575 PLATELET; IN VITRO AGGREGATION,EACH O $0.00
85576 BLOOD PLATELET AGGREGATION 3 $30.15
85577 PLATELET RETENTION (IN VITRO), GLAS O $0.00
85580 PLATELET COUNT (REES-ECKER) O $0.00
85585 BLOOD PLATELET ESTIMATION O $0.00
85590 PLATELET COUNT, MANUAL O $0.00
85595 PLATELET COUNT, AUTOMATED O $0.00
85597 PLATELET NEUTRALIZATION 3 $25.23
85610 PROTHROMBIN TIME 3 $5.62
85611 PROTHROMBIN TEST 3 $5.53
85612 VIPER VENOM PROTHROMBIN TIME 3 $13.43
85613 RUSSELL VIPER VENOM, DILUTED 3 $13.43
85615 PROTHROMBIN UTILIZATION (CONSUMPTIO O $0.00
85618 PROTHROMBIN-PROCONVERTIN, P&P (OWRE O $0.00
85630 RED BLOOD CELL SIZE (PRICE-JONES) O $0.00
85632 RED BLOOD CELL PEROXIDE HEMOLYSIS O $0.00
85635 REPTILASE TEST 3 $9.82
85650 SEDIMENTATION RATE (ESR) WINTROBE T O $0.00
85651 RBC SED RATE, NONAUTOMATED 3 $4.98
85652 RBC SED RATE, AUTOMATED 3 $3.79
85660 RBC SICKLE CELL TEST 3 $6.33
85665 STREPTOKINASE TITER (PLASMINOGEN AC O $0.00
85667 T-CELL DEPLETION (ANY METHOD) OF BO O $0.00
85670 THROMBIN TIME, PLASMA 3 $8.27
85675 THROMBIN TIME, TITER 3 $9.61
85700 THROMBOPLASTIN GENERATION TEST SCRE O $0.00

85705 THROMBOPLASTIN INHIBITION 3 $11.95
85710 THROMBOPLASTIN GENERATION TEST DEFI O $0.00
85711 THROMBOPLASTIN GENERATION TEST WITH O $0.00
85720 THROMBOPLASTIN GENERATION TEST ALL O $0.00
85730 THROMBOPLASTIN TIME, PARTIAL 3 $8.43
85732 THROMBOPLASTIN TIME, PARTIAL 3 $9.08
85810 BLOOD VISCOSITY EXAMINATION 3 $16.39
85820 VISCOSITY SERUM OR PLASMA O $0.00
85999 HEMATOLOGY PROCEDURE 5 $0.00
86000 AGGLUTININS, FEBRILE 3 $9.80
86001 ALLERGEN SPECIFIC IGG 3 $7.32
86002 AGGLUTININS FEBRILE PANEL (TYPHOID O $0.00
86003 ALLERGEN SPECIFIC IGE 3 $7.32
86004 AGGLUTININS WARM O $0.00
86005 ALLERGEN SPECIFIC IGE 3 $4.07
86006 ANTIBODY, NON-RBC QUALITATIVE FIRST O $0.00
86007 ANTIBODY, NON-RBC QUALITATIVE EACH O $0.00
86008 ANTIBODY, NON-RBC, QUANTITATIVE FIR O $0.00
86009 ANTIBODY, NON-RBC, QUANTITATIVE EAC O $0.00
86011 ANTIBODY, DETECTION, LEUKOCYTE ANTI O $0.00
86012 ANTIBODY ABSORPTION, COLD AUTO ABSO O $0.00
86013 ANTIBODY ABSORPTION, COLD AUTO ABSO O $0.00
86014 ANTIBODY, PLATELET ANTIBODIES (AGGL O $0.00
86016 ANTIBODY SCREEN, RBC, EACH SERUM O $0.00
86019 ANTIBODY (RBC) ELUTION, ANY METHOD, O $0.00
86021 WBC ANTIBODY IDENTIFICATION 3 $18.67
86022 PLATELET ANTIBODIES 3 $18.67
86023 IMMUNOGLOBULIN ASSAY 3 $17.48
86024 ANTIBODY IDENTIFICATION RBC ANTIBOD O $0.00
86031 ANTIHUMAN GLOBULIN TEST DIRECT (COO O $0.00
86032 ANTIHUMAN GLOBULIN TEST INDIRECT, Q O $0.00
86033 ANTIHUMAN GLOBULIN TEST INDIRECT, T O $0.00
86034 ANTIHUMAN GLOBULIN TEST ENZYME TECH O $0.00
86038 ANTINUCLEAR ANTIBODIES 3 $16.97
86039 ANTINUCLEAR ANTIBODIES (ANA) 3 $15.67
86060 ANTISTREPTOLYSIN O, TITER 3 $10.25
86063 ANTISTREPTOLYSIN O, SCREEN 3 $8.27
86064 B CELLS, TOTAL COUNT O $0.00
86066 ANTITRYPSIN, ALPHA-1 PI (PROTEASE I O $0.00
86067 ANTITRYPSIN, ALPHA-1 OTHER METHOD ( O $0.00
86068 BLOOD COMPATIBILITY TEST CROSSMATCH O $0.00
86070 BLOOD COMPATIBILITY TEST CROSSMATCH O $0.00
86077 PHYSICIAN BLOOD BANK SERVICE 9 $0.00
86078 PHYSICIAN BLOOD BANK SERVICE 9 $0.00
86079 PHYSICIAN BLOOD BANK SERVICE 9 $0.00
86080 BLOOD TYPING ABO ONLY O $0.00
86082 BLOOD TYPING ABO AND RHO(D) O $0.00
86083 BLOOD TYPING ABO, RH(D) AND RBC ANT O $0.00
86084 BLOOD TYPING ANTIGEN SCREENING FOR O $0.00

86085 BLOOD TYPING ANTIGEN SCREENING FOR O $0.00
86095 BLOOD TYPING RBC ANTIGENS, OTHER TH O $0.00
86100 BLOOD TYPING RHO(D) ONLY O $0.00
86105 BLOOD TYPING RH GENOTYPING, COMPLET O $0.00
86115 BLOOD TYPING ANTI-RH IMMUNOGLOBULIN O $0.00
86128 COLLECTION, PROCESSING AND STORAGE O $0.00
86130 COLLECTION AND PROCESSING FOR TRANS O $0.00
86140 C-REACTIVE PROTEIN 3 $7.26
86141 C-REACTIVE PROTEIN, HS 3 $18.17
86146 GLYCOPROTEIN ANTIBODY 3 $35.71
86147 CARDIOLIPIN ANTIBODY 3 $35.71
86148 PHOSPHOLIPID ANTIBODY 3 $13.93
86149 CARCINOEMBRYONIC ANTIGEN (CEA) GEL O $0.00
86151 CARCINOEMBRYONIC ANTIGEN (CEA) RIA O $0.00
86155 CHEMOTAXIS ASSAY 3 $22.43
86156 COLD AGGLUTININ, SCREEN 3 $8.96
86157 COLD AGGLUTININ, TITER 3 $11.32
86158 COMPLEMENT C'1 ESTERASE O $0.00
86159 COMPLEMENT C'2 ESTERASE O $0.00
86160 COMPLEMENT, ANTIGEN 3 $16.86
86161 COMPLEMENT/FUNCTION ACTIVITY 3 $16.86
86162 COMPLEMENT, TOTAL (CH50) 3 $28.52
86163 COMPLEMENT C'3 ESTERASE O $0.00
86164 COMPLEMENT C'4 ESTERASE O $0.00
86171 COMPLEMENT FIXATION, EACH 3 $9.92
86185 COUNTERIMMUNOELECTROPHORESIS 3 $12.55
86200 CCP ANTIBODY 3 $18.17
86215 DEOXYRIBONUCLEASE, ANTIBODY 3 $18.60
86225 DNA ANTIBODY 3 $19.29
86226 DNA ANTIBODY, SINGLE STRAND 3 $17.00
86235 NUCLEAR ANTIGEN ANTIBODY 3 $25.18
86243 FC RECEPTOR 3 $28.80
86244 FETO-PROTEIN, ALPHA-1, RIA OR EIA O $0.00
86255 FLUORESCENT ANTIBODY, SCREEN 3 $16.91
86256 FLUORESCENT ANTIBODY, TITER 3 $12.28
86265 FROZEN BLOOD, PREPARATION FOR FREEZ O $0.00
86266 FROZEN BLOOD, PREPARATION FOR FREEZ O $0.00
86267 FROZEN BLOOD, PREPARATION FOR FREEZ O $0.00
86277 GROWTH HORMONE ANTIBODY 3 $22.09
86280 HEMAGGLUTINATION INHIBITION 3 $11.50
86281 HEMOLYSINS, ACID (FOR PAROXYSMAL HE O $0.00
86282 HEMOLYSINS AND AGGLUTININS, AUTO, S O $0.00
86283 HEMOLYSINS AND AGGLUTININS, AUTO, S O $0.00
86287 HEPATITIS B SURFACE ANTIGEN (HBSAG) O $0.00
86288 HEPATITIS B CORE ANTIGEN (HBCAG), R O $0.00
86289 HEPATITIS B CORE ANTIBODY (HBCAB); O $0.00
86290 HEPATITIS B CORE ANTIBODY (HBCAB); O $0.00
86291 HEPATITIS B SURFACE ANTIBODY (HBSAB O $0.00
86293 HEPATITIS BE ANTIGEN (HBEAG) O $0.00

86294 IMMUNOASSAY, TUMOR, QUAL 3 $24.56
86295 HEPATITIS BE ANTIBODY (HBEAB) O $0.00
86296 HEPATITIS A ANTIBODY (HAAB); IGG AN O $0.00
86298 HEPATITIS A ANTIBODY (HAAB) (EG, RI O $0.00
86299 HEPATITIS A ANTIBODY (HAAB); IGM AN O $0.00
86300 IMMUNOASSAY, TUMOR, CA 15-3 3 $29.21
86301 IMMUNOASSAY, TUMOR, CA 19-9 3 $29.21
86302 HEPATITIS C ANTIBODY; O $0.00
86303 HEPATITIS C ANTIBODY; CONFIRMATORY O $0.00
86304 IMMUNOASSAY, TUMOR, CA 125 3 $29.21
86305 HUMAN EPIDIDYMIS PROTEIN 4 (HE4) 3 $29.21
86306 HEPATITIS, DELTA AGENT O $0.00
86308 HETEROPHILE ANTIBODIES 3 $7.26
86309 HETEROPHILE ANTIBODIES 3 $8.62
86310 HETEROPHILE ANTIBODIES 3 $10.35
86311 HIV, ANTIGEN O $0.00
86312 HIV (HTLV-III) ANTIBODY DETECTION I O $0.00
86313 IMMUNOASSAY FOR INFECTIOUS AGENT AN O $0.00
86314 HIV (HTLV-III) ANTIBODY DETECTION C O $0.00
86315 IMMUNOASSAY FOR INFECTIOUS AGENT AN O $0.00
86316 IMMUNOASSAY, TUMOR OTHER 3 $29.21
86317 IMMUNOASSAY,INFECTIOUS AGENT 3 $21.04
86318 IMMUNOASSAY,INFECTIOUS AGENT 3 $18.17
86319 IMMUNOASSAY TECHNIQUE FOR DRUGS O $0.00
86320 SERUM IMMUNOELECTROPHORESIS 3 $31.46
86325 OTHER IMMUNOELECTROPHORESIS 3 $29.92
86327 IMMUNOELECTROPHORESIS ASSAY 3 $31.85
86329 IMMUNODIFFUSION 3 $19.71
86331 IMMUNODIFFUSION OUCHTERLONY 3 $16.83
86332 IMMUNE COMPLEX ASSAY 3 $34.21
86333 IMMUNE COMPLEX ASSAY RAJI CELL O $0.00
86334 IMMUNOFIX E-PHORESIS, SERUM 3 $31.36
86335 IMMUNFIX E-PHORSIS/URINE/CSF 3 $41.20
86336 INHIBIN A 3 $21.87
86337 INSULIN ANTIBODIES 3 $20.51
86338 INSULIN FACTOR ANTIBODIES, RIA O $0.00
86340 INTRINSIC FACTOR ANTIBODY 3 $21.16
86341 ISLET CELL ANTIBODY 3 $27.77
86342 IRRADIATION OF BLOOD PRODUCTS, EACH O $0.00
86343 LEUKOCYTE HISTAMINE RELEASE 3 $17.49
86344 LEUKOCYTE PHAGOCYTOSIS 3 $11.21
86349 LEUKOCYTE TRANSFUSION (LEUKAPHERESI O $0.00
86352 CELL FUNCTION ASSAY W/STIM 3 $95.35
86353 LYMPHOCYTE TRANSFORMATION 3 $68.82
86355 B CELLS, TOTAL COUNT 3 $52.95
86356 MONONUCLEAR CELL ANTIGEN 3 $37.58
86357 NK CELLS, TOTAL COUNT 3 $52.95
86358 LYMPHOCYTES B-CELL EVALUATION O $0.00
86359 T CELLS, TOTAL COUNT 3 $52.95

86360 T CELL, ABSOLUTE COUNT/RATIO 3 $65.95
86361 T CELL, ABSOLUTE COUNT 3 $37.58
86367 STEM CELLS, TOTAL COUNT 3 $52.95
86376 MICROSOMAL ANTIBODY 3 $20.42
86377 MICROSOMAL ANTIBODY (THYROID) OTHER O $0.00
86378 MIGRATION INHIBITORY FACTOR 3 $27.64
86379 NK CELLS, TOTAL COUNT O $0.00
86382 NEUTRALIZATION TEST, VIRAL 3 $23.74
86384 NITROBLUE TETRAZOLIUM DYE 3 $15.98
86385 PATERNITY TESTING, ABO+RH FACTORS+M O $0.00
86386 PATERNITY TESTING, ABO+RH FACTORS+M O $0.00
86403 PARTICLE AGGLUTINATION TEST 3 $14.31
86404 POOLING OF PLATELETS OR OTHER BLOOD O $0.00
86405 PRECIPITIN TEST FOR BLOOD (SPECIES O $0.00
86406 PARTICLE AGGLUTINATION TEST 3 $14.94
86410 PRETREATMENT OF RBC'S FOR USE IN RB O $0.00
86411 PRETREATMENT OF RBC'S FOR USE IN RB O $0.00
86412 PRETREATMENT OF RBC'S FOR USE IN RB O $0.00
86417 PRETREATMENT OF SERUM FOR USE IN RB O $0.00
86418 PRETREATMENT OF SERUM FOR USE IN RB O $0.00
86419 PRETREATMENT OF SERUM FOR USE IN RB O $0.00
86420 PRETREATMENT OF SERUM FOR USE IN RB O $0.00
86421 RADIOALLERGOSORBENT TEST, IN VITRO O $0.00
86422 RADIOALLERGOSORBENT TEST, IN VITRO 9 $0.00
86423 RADIOIMMUNOSORBENT TEST (RIST) IGE, O $0.00
86430 RHEUMATOID FACTOR TEST 3 $7.97
86431 RHEUMATOID FACTOR, QUANT 3 $7.97
86455 SKIN TEST ANERGY TESTING, ONE OR MO O $0.00
86480 TB TEST, CELL IMMUN MEASURE 3 $86.99
86485 SKIN TEST, CANDIDA 3 $15.56
86486 SKIN TEST, NOS ANTIGEN 6 $0.00
86490 COCCIDIOIDOMYCOSIS SKIN TEST 3 $11.81
86510 HISTOPLASMOSIS SKIN TEST 3 $12.97
86540 SKIN TEST MUMPS O $0.00
86580 TB INTRADERMAL TEST 3 $5.00
86585 TB TINE TEST O $0.00
86586 SKIN TEST, UNLISTED O $0.00
86587 STEM CELLS (IE, CD34), TOTAL COUNT O $0.00
86588 STREPTOCOLLUS, DIRECT SCREEN O $0.00
86590 STREPTOKINASE, ANTIBODY 3 $15.49
86592 SYPHILIS TEST NON-TREP QUAL 3 $5.76
86593 SYPHILIS TEST NON-TREP QUANT 3 $6.13
86594 THYROID AUTOANTIBODIES O $0.00
86595 TISSUE CULTURE O $0.00
86600 TOXOPLASMOSIS, DYE TEST O $0.00
86602 ANTINOMYCES ANTIBODY 3 $14.28
86603 ADENOVIRUS ANTIBODY 3 $18.06
86606 ASPERGILLUS ANTIBODY 3 $21.13
86609 BACTERIUM ANTIBODY 3 $18.09

86611 BARTONELLA ANTIBODY 3 $14.28
86612 BLASTOMYCES ANTIBODY 3 $18.12
86615 BORDETELLA ANTIBODY 3 $18.51
86617 LYME DISEASE ANTIBODY 3 $21.75
86618 LYME DISEASE ANTIBODY 3 $23.91
86619 BORRELIA ANTIBODY 3 $18.79
86622 BRUCELLA ANTIBODY 3 $11.48
86625 CAMPYLOBACTER ANTIBODY 3 $18.42
86628 CANDIDA ANTIBODY 3 $16.86
86630 TRANSFER FACTOR TEST (TFT) O $0.00
86631 CHLAMYDIA ANTIBODY 3 $9.92
86632 CHLAMYDIA IGM ANTIBODY 3 $17.82
86635 COCCIDIOIDES ANTIBODY 3 $16.10
86638 Q FEVER ANTIBODY 3 $17.02
86641 CRYPTOCOCCUS ANTIBODY 3 $20.24
86644 CMV ANTIBODY 3 $20.21
86645 CMV ANTIBODY, IGM 3 $23.64
86648 DIPHTHERIA ANTIBODY 3 $21.35
86650 TREPONEMA ANTIBODIES, FLUORESCENT, O $0.00
86651 ENCEPHALITIS ANTIBODY 3 $18.51
86652 ENCEPHALITIS ANTIBODY 3 $18.51
86653 ENCEPHALITIS ANTIBODY 3 $18.51
86654 ENCEPHALITIS ANTIBODY 3 $18.51
86658 ENTEROVIRUS ANTIBODY 3 $18.29
86662 TREPONEMA PALLIDUM TEST, OTHER, SPE O $0.00
86663 EPSTEIN-BARR ANTIBODY 3 $18.42
86664 EPSTEIN-BARR ANTIBODY 3 $21.47
86665 EPSTEIN-BARR ANTIBODY 3 $25.46
86666 EHRLICHIA ANTIBODY 3 $14.28
86668 FRANCISELLA TULARENSIS 3 $14.60
86671 FUNGUS ANTIBODY 3 $17.21
86674 GIARDIA LAMBLIA ANTIBODY 3 $20.66
86677 HELICOBACTER PYLORI 3 $20.37
86681 ADRENAL CORTEX ANTIBODIES, RIA O $0.00
86682 HELMINTH ANTIBODY 3 $18.26
86683 HEMOGLOBIN, FECAL ANTIBODY O $0.00
86684 HEMOPHILUS INFLUENZA 3 $22.25
86685 ANTI-ACHR (ACETYLCHOLINE RECEPTOR) O $0.00
86687 HTLV-I ANTIBODY 3 $11.78
86688 HTLV-II ANTIBODY 3 $14.83
86689 HTLV/HIV CONFIRMATORY TEST 3 $27.17
86692 HEPATITIS, DELTA AGENT 3 $24.09
86694 HERPES SIMPLEX TEST 3 $20.21
86695 HERPES SIMPLEX TEST 3 $18.51
86696 HERPES SIMPLEX TYPE 2 3 $27.17
86698 HISTOPLASMA 3 $17.55
86701 HIV-1 3 $12.47
86702 HIV-2 3 $14.83
86703 HIV-1/HIV-2, SINGLE ASSAY 3 $19.26

86704 HEP B CORE ANTIBODY, TOTAL 3 $16.91
86705 HEP B CORE ANTIBODY, IGM 3 $16.52
86706 HEP B SURFACE ANTIBODY 3 $15.07
86707 HEP BE ANTIBODY 3 $16.24
86708 HEP A ANTIBODY, TOTAL 3 $17.39
86709 HEP A ANTIBODY, IGM 3 $15.80
86710 INFLUENZA VIRUS ANTIBODY 3 $19.03
86713 LEGIONELLA ANTIBODY 3 $21.48
86717 LEISHMANIA ANTIBODY 3 $17.20
86720 LEPTOSPIRA ANTIBODY 3 $18.51
86723 LISTERIA MONOCYTOGENES AB 3 $18.51
86727 LYMPH CHORIOMENINGITIS AB 3 $18.06
86729 LYMPHO VENEREUM ANTIBODY 3 $9.92
86732 MUCORMYCOSIS ANTIBODY 3 $18.51
86735 MUMPS ANTIBODY 3 $18.32
86738 MYCOPLASMA ANTIBODY 3 $18.59
86741 NEISSERIA MENINGITIDIS 3 $18.51
86744 NOCARDIA ANTIBODY 3 $18.51
86747 PARVOVIRUS ANTIBODY 3 $21.10
86750 MALARIA ANTIBODY 3 $18.51
86753 PROTOZOA ANTIBODY NOS 3 $17.39
86756 RESPIRATORY VIRUS ANTIBODY 3 $18.09
86757 RICKETTSIA ANTIBODY 3 $27.17
86759 ROTAVIRUS ANTIBODY 3 $18.51
86762 RUBELLA ANTIBODY 3 $20.21
86765 RUBEOLA ANTIBODY 3 $13.75
86768 SALMONELLA ANTIBODY 3 $18.51
86771 SHIGELLA ANTIBODY 3 $18.51
86774 TETANUS ANTIBODY 3 $20.77
86777 TOXOPLASMA ANTIBODY 3 $20.21
86778 TOXOPLASMA ANTIBODY, IGM 3 $20.22
86780 TREPONEMA PALLIDUM 3 $18.59
86781 TREPONEMA PALLIDUM, CONFIRM O $0.00
86784 TRICHINELLA ANTIBODY 3 $17.64
86787 VARICELLA-ZOSTER ANTIBODY 3 $18.09
86788 WEST NILE VIRUS AB, IGM 3 $23.64
86789 WEST NILE VIRUS ANTIBODY 3 $20.21
86790 VIRUS ANTIBODY NOS 3 $18.09
86793 YERSINIA ANTIBODY 3 $12.18
86800 THYROGLOBULIN ANTIBODY 3 $22.32
86803 HEPATITIS C AB TEST 3 $20.03
86804 HEP C AB TEST, CONFIRM 3 $21.75
86805 LYMPHOCYTOTOXICITY ASSAY 3 $47.26
86806 LYMPHOCYTOTOXICITY ASSAY 3 $47.26
86807 CYTOTOXIC ANTIBODY SCREENING 3 $55.55
86808 CYTOTOXIC ANTIBODY SCREENING 3 $41.66
86812 HLA TYPING, A, B, OR C 3 $36.22
86813 HLA TYPING, A, B, OR C 3 $81.40
86816 HLA TYPING, DR/DQ 3 $39.10

86817 HLA TYPING, DR/DQ 3 $90.38
86821 LYMPHOCYTE CULTURE, MIXED 3 $79.25
86822 LYMPHOCYTE CULTURE, PRIMED 3 $51.31
86825 HLA X-MATCH, NON-CYTOTOXIC 3 $112.74
86826 HLA X-MATCH, NON-CYT ADD-ON 3 $37.58
86849 IMMUNOLOGY PROCEDURE 5 $0.00
86850 RBC ANTIBODY SCREEN 3 $15.00
86860 RBC ANTIBODY ELUTION 5 $0.00
86870 RBC ANTIBODY IDENTIFICATION 3 $15.00
86880 COOMBS TEST, DIRECT 3 $7.55
86885 COOMBS TEST, INDIRECT, QUAL 3 $8.04
86886 COOMBS TEST, INDIRECT, TITER 3 $7.26
86890 AUTOLOGOUS BLOOD PROCESS 5 $0.00
86891 AUTOLOGOUS BLOOD, OP SALVAGE 5 $0.00
86900 BLOOD TYPING, ABO 3 $4.18
86901 BLOOD TYPING, RH (D) 3 $4.18
86903 BLOOD TYPING, ANTIGEN SCREEN 3 $13.25
86904 BLOOD TYPING, PATIENT SERUM 3 $13.35
86905 BLOOD TYPING, RBC ANTIGENS 3 $5.37
86906 BLOOD TYPING, RH PHENOTYPE 3 $10.88
86910 BLOOD TYPING, PATERNITY TEST 9 $0.00
86911 BLOOD TYPING, ANTIGEN SYSTEM 9 $0.00
86915 BONE MARROW/STEM CELL PREP O $0.00
86920 COMPATIBILITY TEST, SPIN 3 $36.00
86921 COMPATIBILITY TEST, INCUBATE 3 $36.00
86922 COMPATIBILITY TEST, ANTIGLOB 3 $36.00
86923 COMPATIBILITY TEST, ELECTRIC 6 $0.00
86927 PLASMA, FRESH FROZEN 5 $0.00
86930 FROZEN BLOOD PREP 5 $0.00
86931 FROZEN BLOOD THAW 5 $0.00
86932 FROZEN BLOOD FREEZE/THAW 5 $0.00
86940 HEMOLYSINS/AGGLUTININS, AUTO 3 $8.57
86941 HEMOLYSINS/AGGLUTININS 3 $16.70
86945 BLOOD PRODUCT/IRRADIATION 3 $42.00
86950 LEUKACYTE TRANSFUSION 5 $0.00
86960 VOL REDUCTION OF BLOOD/PROD 6 $0.00
86965 POOLING BLOOD PLATELETS 5 $0.00
86970 RBC PRETREATMENT 5 $0.00
86971 RBC PRETREATMENT 5 $0.00
86972 RBC PRETREATMENT 5 $0.00
86975 RBC PRETREATMENT, SERUM 5 $0.00
86976 RBC PRETREATMENT, SERUM 5 $0.00
86977 RBC PRETREATMENT, SERUM 5 $0.00
86978 RBC PRETREATMENT, SERUM 5 $0.00
86985 SPLIT BLOOD OR PRODUCTS 5 $0.00
86999 TRANSFUSION PROCEDURE 5 $0.00
87001 SMALL ANIMAL INOCULATION 3 $18.55
87003 SMALL ANIMAL INOCULATION 3 $23.63
87015 SPECIMEN CONCENTRATION 3 $9.38

87040 BLOOD CULTURE FOR BACTERIA 3 $14.49
87045 FECES CULTURE, BACTERIA 3 $13.24
87046 STOOL CULTR, BACTERIA, EACH 3 $13.24
87060 NOSE/THROAT CULTURE, BACT O $0.00
87070 CULTURE, BACTERIA, OTHER 3 $12.09
87071 CULTURE BACTERI AEROBIC OTHR 3 $13.24
87072 CULTURE OF SPECIMEN BY KIT O $0.00
87073 CULTURE BACTERIA ANAEROBIC 3 $13.24
87075 CULTR BACTERIA, EXCEPT BLOOD 3 $13.28
87076 CULTURE ANAEROBE IDENT, EACH 3 $11.34
87077 CULTURE AEROBIC IDENTIFY 3 $11.34
87081 CULTURE SCREEN ONLY 3 $9.31
87082 CULTURE OF SPECIMEN BY KIT O $0.00
87083 CULTURE OF SPECIMEN BY KIT O $0.00
87084 CULTURE OF SPECIMEN BY KIT 3 $12.09
87085 CULTURE OF SPECIMEN BY KIT O $0.00
87086 URINE CULTURE/COLONY COUNT 3 $11.34
87087 URINE BACTERIA CULTURE O $0.00
87088 URINE BACTERIA CULTURE 3 $11.37
87101 SKIN FUNGI CULTURE 3 $10.83
87102 FUNGUS ISOLATION CULTURE 3 $11.79
87103 BLOOD FUNGUS CULTURE 3 $12.66
87106 FUNGI IDENTIFICATION, YEAST 3 $14.49
87107 FUNGI IDENTIFICATION, MOLD 3 $14.49
87109 MYCOPLASMA 3 $21.60
87110 CHLAMYDIA CULTURE 3 $27.50
87116 MYCOBACTERIA CULTURE 3 $15.17
87117 MYCOBACTERIA CULTURE O $0.00
87118 MYCOBACTERIC IDENTIFICATION 3 $15.36
87140 CULTURE TYPE IMMUNOFLUORESC 3 $6.79
87143 CULTURE TYPING, GLC/HPLC 3 $17.59
87145 CULTURE TYPING, PHAGE METHOD O $0.00
87147 CULTURE TYPE, IMMUNOLOGIC 3 $7.26
87149 DNA/RNA DIRECT PROBE 3 $28.15
87150 DNA/RNA, AMPLIFIED PROBE 3 $49.26
87151 CULTURE TYPING, SEROLOGIC O $0.00
87152 CULTURE TYPE PULSE FIELD GEL 3 $7.34
87153 DNA/RNA SEQUENCING 3 $161.92
87155 CULTURE TYPING, PRECIPITIN O $0.00
87158 CULTURE TYPING, ADDED METHOD 3 $7.34
87163 SPECIAL MICROBIOLOGY CULTURE O $0.00
87164 DARK FIELD EXAMINATION 3 $15.07
87166 DARK FIELD EXAMINATION 3 $15.86
87168 MACROSCOPIC EXAM ARTHROPOD 3 $5.99
87169 MACROSCOPIC EXAM PARASITE 3 $5.99
87172 PINWORM EXAM 3 $5.99
87174 ENDOTOXIN, BACTERIAL O $0.00
87175 ASSAY, ENDOTOXIN, BACTERIAL O $0.00
87176 TISSUE HOMOGENIZATION, CULTR 3 $8.26

87177 OVA AND PARASITES SMEARS 3 $12.49
87178 MICROBIAL IDENTIFICATION, NUCLEIC A O $0.00
87179 MICROBIAL IDENTIFICATION, NUCLEIC A O $0.00
87181 MICROBE SUSCEPTIBLE, DIFFUSE 3 $6.66
87184 MICROBE SUSCEPTIBLE, DISK 3 $9.68
87185 MICROBE SUSCEPTIBLE, ENZYME 3 $6.66
87186 MICROBE SUSCEPTIBLE, MIC 3 $12.13
87187 MICROBE SUSCEPTIBLE, MLC 3 $14.54
87188 MICROBE SUSCEPT, MACROBROTH 3 $9.01
87190 MICROBE SUSCEPT, MYCOBACTERI 3 $7.94
87192 ANTIBIOTIC SENSITIVITY, EACH O $0.00
87197 BACTERICIDAL LEVEL, SERUM 3 $16.32
87198 CYTOMEGALOVIRUS ANTIBODY DFA O $0.00
87199 ENTEROVIRUS ANTIBODY, DFA O $0.00
87205 SMEAR, GRAM STAIN 3 $5.99
87206 SMEAR, FLUORESCENT/ACID STAI 3 $6.79
87207 SMEAR, SPECIAL STAIN 3 $8.09
87208 SMEAR, STAIN & INTERPRET O $0.00
87209 SMEAR, COMPLEX STAIN 3 $24.29
87210 SMEAR, WET MOUNT, SALINE/INK 3 $5.99
87211 SMEAR, STAIN & INTERPRET O $0.00
87220 TISSUE EXAM FOR FUNGI 3 $4.85
87230 ASSAY, TOXIN OR ANTITOXIN 3 $24.49
87250 VIRUS INOCULATE, EGGS/ANIMAL 3 $27.45
87252 VIRUS INOCULATION, TISSUE 3 $36.58
87253 VIRUS INOCULATE TISSUE, ADDL 3 $28.35
87254 VIRUS INOCULATION, SHELL VIA 3 $27.45
87255 GENET VIRUS ISOLATE, HSV 3 $47.53
87260 ADENOVIRUS AG, IF 3 $15.45
87265 PERTUSSIS AG, IF 3 $15.45
87267 ENTEROVIRUS ANTIBODY, DFA 3 $15.45
87269 GIARDIA AG, IF 3 $15.45
87270 CHLAMYDIA TRACHOMATIS AG, IF 3 $15.45
87271 CYTOMEGALOVIRUS DFA 3 $15.45
87272 CRYPTOSPORIDIUM AG, IF 3 $15.45
87273 HERPES SIMPLEX 2, AG, IF 3 $15.45
87274 HERPES SIMPLEX 1, AG, IF 3 $15.45
87275 INFLUENZA B, AG, IF 3 $15.45
87276 INFLUENZA A, AG, IF 3 $15.45
87277 LEGIONELLA MICDADEI, AG, IF 3 $15.45
87278 LEGION PNEUMOPHILIA AG, IF 3 $15.45
87279 PARAINFLUENZA, AG, IF 3 $15.45
87280 RESPIRATORY SYNCYTIAL AG, IF 3 $15.45
87281 PNEUMOCYSTIS CARINII, AG, IF 3 $15.45
87283 RUBEOLA, AG, IF 3 $15.45
87285 TREPONEMA PALLIDUM, AG, IF 3 $15.45
87290 VARICELLA ZOSTER, AG, IF 3 $15.45
87299 ANTIBODY DETECTION, NOS, IF 3 $15.45
87300 AG DETECTION, POLYVAL, IF 3 $15.45

87301 ADENOVIRUS AG, EIA 3 $15.45
87305 ASPERGILLUS AG, EIA 3 $15.45
87320 CHYLMD TRACH AG, EIA 3 $15.45
87324 CLOSTRIDIUM AG, EIA 3 $15.45
87327 CRYPTOCOCCUS NEOFORM AG, EIA 3 $15.45
87328 CRYPTOSPORIDIUM AG, EIA 3 $15.45
87329 GIARDIA AG, EIA 3 $15.45
87332 CYTOMEGALOVIRUS AG, EIA 3 $15.45
87335 E COLI 0157 AG, EIA 3 $15.45
87336 ENTAMOEB HIST DISPR, AG, EIA 3 $15.45
87337 ENTAMOEB HIST GROUP, AG, EIA 3 $15.45
87338 HPYLORI, STOOL, EIA 3 $15.45
87339 H PYLORI AG, EIA 3 $15.45
87340 HEPATITIS B SURFACE AG, EIA 3 $14.24
87341 HEPATITIS B SURFACE, AG, EIA 3 $14.24
87350 HEPATITIS BE AG, EIA 3 $16.18
87380 HEPATITIS DELTA AG, EIA 3 $23.05
87385 HISTOPLASMA CAPSUL AG, EIA 3 $15.45
87390 HIV-1 AG, EIA 3 $24.76
87391 HIV-2 AG, EIA 3 $24.76
87400 INFLUENZA A/B, AG, EIA 3 $15.45
87420 RESP SYNCYTIAL AG, EIA 3 $15.45
87425 ROTAVIRUS AG, EIA 3 $15.45
87427 SHIGA-LIKE TOXIN AG, EIA 3 $15.45
87430 STREP A AG, EIA 3 $15.45
87449 AG DETECT NOS, EIA, MULT 3 $15.45
87450 AG DETECT NOS, EIA, SINGLE 3 $13.46
87451 AG DETECT POLYVAL, EIA, MULT 3 $13.46
87470 BARTONELLA, DNA, DIR PROBE 3 $28.15
87471 BARTONELLA, DNA, AMP PROBE 3 $49.26
87472 BARTONELLA, DNA, QUANT 3 $39.83
87475 LYME DIS, DNA, DIR PROBE 3 $28.15
87476 LYME DIS, DNA, AMP PROBE 3 $49.26
87477 LYME DIS, DNA, QUANT 3 $39.83
87480 CANDIDA, DNA, DIR PROBE 3 $28.15
87481 CANDIDA, DNA, AMP PROBE 3 $49.26
87482 CANDIDA, DNA, QUANT 3 $39.83
87485 CHYLMD PNEUM, DNA, DIR PROBE 3 $28.15
87486 CHYLMD PNEUM, DNA, AMP PROBE 3 $49.26
87487 CHYLMD PNEUM, DNA, QUANT 3 $39.83
87490 CHYLMD TRACH, DNA, DIR PROBE 3 $28.15
87491 CHYLMD TRACH, DNA, AMP PROBE 3 $49.26
87492 CHYLMD TRACH, DNA, QUANT 3 $39.83
87493 C DIFF AMPLIFIED PROBE 3 $49.26
87495 CYTOMEG, DNA, DIR PROBE 3 $28.15
87496 CYTOMEG, DNA, AMP PROBE 3 $49.26
87497 CYTOMEG, DNA, QUANT 3 $39.83
87498 ENTEROVIRUS, DNA, AMP PROBE 3 $49.26
87500 VANOMYCIN, DNA, AMP PROBE 3 $49.26

87510 GARDNER VAG, DNA, DIR PROBE 3 $28.15
87511 GARDNER VAG, DNA, AMP PROBE 3 $49.26
87512 GARDNER VAG, DNA, QUANT 3 $39.83
87515 HEPATITIS B, DNA, DIR PROBE 3 $28.15
87516 HEPATITIS B, DNA, AMP PROBE 3 $49.26
87517 HEPATITIS B, DNA, QUANT 3 $39.83
87520 HEPATITIS C, RNA, DIR PROBE 3 $28.15
87521 HEPATITIS C, RNA, AMP PROBE 3 $49.26
87522 HEPATITIS C, RNA, QUANT 3 $39.83
87525 HEPATITIS G, DNA, DIR PROBE 3 $28.15
87526 HEPATITIS G, DNA, AMP PROBE 3 $49.26
87527 HEPATITIS G, DNA, QUANT 3 $39.83
87528 HSV, DNA, DIR PROBE 3 $28.15
87529 HSV, DNA, AMP PROBE 3 $49.26
87530 HSV, DNA, QUANT 3 $39.83
87531 HHV-6, DNA, DIR PROBE 3 $28.15
87532 HHV-6, DNA, AMP PROBE 3 $49.26
87533 HHV-6, DNA, QUANT 3 $39.83
87534 HIV-1, DNA, DIR PROBE 3 $28.15
87535 HIV-1, DNA, AMP PROBE 3 $49.26
87536 HIV-1, DNA, QUANT 3 $119.44
87537 HIV-2, DNA, DIR PROBE 3 $28.15
87538 HIV-2, DNA, AMP PROBE 3 $49.26
87539 HIV-2, DNA, QUANT 3 $39.83
87540 LEGION PNEUMO, DNA, DIR PROB 3 $28.15
87541 LEGION PNEUMO, DNA, AMP PROB 3 $49.26
87542 LEGION PNEUMO, DNA, QUANT 3 $39.83
87550 MYCOBACTERIA, DNA, DIR PROBE 3 $28.15
87551 MYCOBACTERIA, DNA, AMP PROBE 3 $49.26
87552 MYCOBACTERIA, DNA, QUANT 3 $39.83
87555 M.TUBERCULO, DNA, DIR PROBE 3 $28.15
87556 M.TUBERCULO, DNA, AMP PROBE 3 $49.26
87557 M.TUBERCULO, DNA, QUANT 3 $39.83
87560 M.AVIUM-INTRA, DNA, DIR PROB 3 $28.15
87561 M.AVIUM-INTRA, DNA, AMP PROB 3 $49.26
87562 M.AVIUM-INTRA, DNA, QUANT 3 $39.83
87580 M.PNEUMON, DNA, DIR PROBE 3 $28.15
87581 M.PNEUMON, DNA, AMP PROBE 3 $49.26
87582 M.PNEUMON, DNA, QUANT 3 $39.83
87590 N.GONORRHOEAE, DNA, DIR PROB 3 $28.15
87591 N.GONORRHOEAE, DNA, AMP PROB 3 $49.26
87592 N.GONORRHOEAE, DNA, QUANT 3 $39.83
87620 HPV, DNA, DIR PROBE 3 $28.15
87621 HPV, DNA, AMP PROBE 3 $49.26
87622 HPV, DNA, QUANT 3 $39.83
87640 STAPH A, DNA, AMP PROBE 3 $49.26
87641 MR-STAPH, DNA, AMP PROBE 3 $49.26
87650 STREP A, DNA, DIR PROBE 3 $28.15
87651 STREP A, DNA, AMP PROBE 3 $49.26

87652 STREP A, DNA, QUANT 3 $39.83
87653 STREP B, DNA, AMP PROBE 3 $49.26
87660 TRICHOMONAS VAGIN, DIR PROBE 3 $28.15
87797 DETECT AGENT NOS, DNA, DIR 3 $28.15
87798 DETECT AGENT NOS, DNA, AMP 3 $49.26
87799 DETECT AGENT NOS, DNA, QUANT 3 $60.12
87800 DETECT AGNT MULT, DNA, DIREC 3 $56.30
87801 DETECT AGNT MULT, DNA, AMPLI 3 $98.53
87802 STREP B ASSAY W/OPTIC 3 $15.45
87803 CLOSTRIDIUM TOXIN A W/OPTIC 3 $15.45
87804 INFLUENZA ASSAY W/OPTIC 3 $15.45
87807 RSV ASSAY W/OPTIC 3 $15.45
87808 TRICHOMONAS ASSAY W/OPTIC 3 $15.45
87809 ADENOVIRUS ASSAY W/OPTIC 3 $15.45
87810 CHYLMD TRACH ASSAY W/OPTIC 3 $15.45
87850 N. GONORRHOEAE ASSAY W/OPTIC 3 $15.45
87880 STREP A ASSAY W/OPTIC 3 $15.45
87899 AGENT NOS ASSAY W/OPTIC 3 $15.45
87900 PHENOTYPE, INFECT AGENT DRUG 3 $182.96
87901 GENOTYPE, DNA, HIV REVERSE T 3 $361.36
87902 GENOTYPE, DNA, HEPATITIS C 3 $361.36
87903 PHENOTYPE, DNA HIV W/CULTURE 3 $685.88
87904 PHENOTYPE, DNA HIV W/CLT ADD 3 $36.58
87905 SIALIDASE ENZYME ASSAY 3 $8.82
87999 MICROBIOLOGY PROCEDURE 5 $0.00
88000 AUTOPSY (NECROPSY), GROSS 9 $0.00
88005 AUTOPSY (NECROPSY), GROSS 9 $0.00
88007 AUTOPSY (NECROPSY), GROSS 9 $0.00
88012 AUTOPSY (NECROPSY), GROSS 9 $0.00
88014 AUTOPSY (NECROPSY), GROSS 9 $0.00
88016 AUTOPSY (NECROPSY), GROSS 9 $0.00
88020 AUTOPSY (NECROPSY), COMPLETE 9 $0.00
88025 AUTOPSY (NECROPSY), COMPLETE 9 $0.00
88027 AUTOPSY (NECROPSY), COMPLETE 9 $0.00
88028 AUTOPSY (NECROPSY), COMPLETE 9 $0.00
88029 AUTOPSY (NECROPSY), COMPLETE 9 $0.00
88036 LIMITED AUTOPSY 9 $0.00
88037 LIMITED AUTOPSY 9 $0.00
88040 FORENSIC AUTOPSY (NECROPSY) 9 $0.00
88045 CORONERS AUTOPSY (NECROPSY) 9 $0.00
88099 NECROPSY (AUTOPSY) PROCEDURE 9 $0.00
88104 CYTOPATH FL NONGYN, SMEARS 3 $51.49
88106 CYTOPATH FL NONGYN, FILTER 3 $46.46
88107 CYTOPATH FL NONGYN, SM/FLTR 3 $68.58
88108 CYTOPATH, CONCENTRATE TECH 3 $53.81
88112 CYTOPATH, CELL ENHANCE TECH 3 $123.81
88125 FORENSIC CYTOPATHOLOGY 3 $20.54
88130 SEX CHROMATIN IDENTIFICATION 3 $21.13
88140 SEX CHROMATIN IDENTIFICATION 3 $11.22

88141 CYTOPATH, C/V, INTERPRET 3 $23.24
88142 CYTOPATH, C/V, THIN LAYER 3 $28.44
88143 CYTOPATH C/V THIN LAYER REDO 3 $28.44
88144 CYTOPATH, C/V, THIN LYR REDO O $0.00
88145 CYTOPATH, C/V, THIN LYR SEL O $0.00
88147 CYTOPATH, C/V, AUTOMATED 3 $15.97
88148 CYTOPATH, C/V, AUTO RESCREEN 3 $21.33
88150 CYTOPATH, C/V, MANUAL 3 $14.83
88151 CYTOPATHOLOGY, SMEARS, CERVICAL OR O $0.00
88152 CYTOPATH, C/V, AUTO REDO 3 $14.83
88153 CYTOPATH, C/V, REDO 3 $14.83
88154 CYTOPATH, C/V, SELECT 3 $14.83
88155 CYTOPATH, C/V, INDEX ADD-ON 3 $8.41
88156 CYTOPATH CERV/VAG TBS O $0.00
88157 CYTOPATHOLOGY, SMEARS, CERVICAL OR O $0.00
88158 CYTOPATH CERV/VAG TBS AUTO O $0.00
88160 CYTOPATH SMEAR, OTHER SOURCE 3 $55.77
88161 CYTOPATH SMEAR, OTHER SOURCE 3 $54.23
88162 CYTOPATH SMEAR, OTHER SOURCE 3 $56.99
88164 CYTOPATH TBS, C/V, MANUAL 3 $14.83
88165 CYTOPATH TBS, C/V, REDO 3 $14.83
88166 CYTOPATH TBS, C/V, AUTO REDO 3 $14.83
88167 CYTOPATH TBS, C/V, SELECT 3 $14.83
88170 FINE NEEDLE ASPIRATION O $0.00
88171 FINE NEEDLE ASPIRATION O $0.00
88172 CYTOPATHOLOGY EVAL OF FNA 3 $49.53
88173 CYTOPATH EVAL, FNA, REPORT 3 $122.91
88174 CYTOPATH, C/V AUTO, IN FLUID 3 $29.99
88175 CYTOPATH C/V AUTO FLUID REDO 3 $37.18
88180 CELL MARKER STUDY O $0.00
88182 CELL MARKER STUDY 3 $93.14
88184 FLOWCYTOMETRY/ TC, 1 MARKER 3 $49.26
88185 FLOWCYTOMETRY/TC, ADD-ON 3 $24.22
88187 FLOWCYTOMETRY/READ, 2-8 3 $63.03
88188 FLOWCYTOMETRY/READ, 9-15 3 $83.19
88189 FLOWCYTOMETRY/READ, 16 & > 3 $109.59
88199 CYTOPATHOLOGY PROCEDURE 5 $0.00
88230 TISSUE CULTURE, LYMPHOCYTE 3 $163.52
88233 TISSUE CULTURE, SKIN/BIOPSY 3 $197.54
88235 TISSUE CULTURE, PLACENTA 3 $206.69
88237 TISSUE CULTURE, BONE MARROW 3 $177.29
88239 TISSUE CULTURE, TUMOR 3 $207.07
88240 CELL CRYOPRESERVE/STORAGE 3 $14.18
88241 FROZEN CELL PREPARATION 3 $14.18
88245 CHROMOSOME ANALYSIS, 20-25 3 $208.96
88248 CHROMOSOME ANALYSIS, 50-100 3 $243.08
88249 CHROMOSOME ANALYSIS, 100 3 $243.08
88250 CHROMOSOME ANALYSIS O $0.00
88260 CHROMOSOME ANALYSIS: 5 CELLS O $0.00

88261 CHROMOSOME ANALYSIS, 5 3 $248.08
88262 CHROMOSOME ANALYSIS, 15-20 3 $174.96
88263 CHROMOSOME ANALYSIS, 45 3 $210.94
88264 CHROMOSOME ANALYSIS, 20-25 3 $174.96
88267 CHROMOSOME ANALYS, PLACENTA 3 $252.33
88269 CHROMOSOME ANALYS, AMNIOTIC 3 $233.46
88271 CYTOGENETICS, DNA PROBE 3 $30.07
88272 CYTOGENETICS, 3-5 3 $37.58
88273 CYTOGENETICS, 10-30 3 $45.10
88274 CYTOGENETICS, 25-99 3 $48.86
88275 CYTOGENETICS, 100-300 3 $56.37
88280 CHROMOSOME KARYOTYPE STUDY 3 $35.23
88283 CHROMOSOME BANDING STUDY 3 $96.28
88285 CHROMOSOME COUNT, ADDITIONAL 3 $26.67
88289 CHROMOSOME STUDY, ADDITIONAL 3 $48.33
88291 CYTO/MOLECULAR REPORT 3 $31.20
88299 CYTOGENETIC STUDY 5 $0.00
88300 SURGICAL PATH, GROSS 3 $14.46
88302 TISSUE EXAM BY PATHOLOGIST 3 $32.51
88304 TISSUE EXAM BY PATHOLOGIST 3 $42.89
88305 TISSUE EXAM BY PATHOLOGIST 3 $97.57
88307 TISSUE EXAM BY PATHOLOGIST 3 $166.79
88309 TISSUE EXAM BY PATHOLOGIST 3 $217.13
88311 DECALCIFY TISSUE 3 $17.46
88312 SPECIAL STAINS GROUP 1 3 $73.61
88313 SPECIAL STAINS GROUP 2 3 $51.85
88314 HISTOCHEMICAL STAIN ADD-ON 3 $52.71
88317 INTERPRETATION AND REPORT BY TREATI O $0.00
88318 CHEMICAL HISTOCHEMISTRY 3 $47.79
88319 ENZYME HISTOCHEMISTRY 3 $94.40
88321 MICROSLIDE CONSULTATION 3 $82.65
88323 MICROSLIDE CONSULTATION 9 $0.00
88325 COMPREHENSIVE REVIEW OF DATA 3 $199.53
88329 PATH CONSULT INTROP 3 $50.44
88331 PATH CONSULT INTRAOP, 1 BLOC 3 $85.84
88332 PATH CONSULT INTRAOP, ADDL 3 $42.97
88333 INTRAOP CYTO PATH CONSULT, 1 3 $90.40
88334 INTRAOP CYTO PATH CONSULT, 2 3 $52.97
88342 IMMUNOHISTOCHEMISTRY 3 $86.31
88346 IMMUNOFLUORESCENT STUDY 3 $90.16
88347 IMMUNOFLUORESCENT STUDY 3 $102.53
88348 ELECTRON MICROSCOPY 3 $388.66
88349 SCANNING ELECTRON MICROSCOPY 3 $417.97
88355 ANALYSIS, SKELETAL MUSCLE 3 $175.05
88356 ANALYSIS, NERVE 3 $231.50
88358 ANALYSIS, TUMOR 3 $63.47
88360 TUMOR IMMUNOHISTOCHEM/MANUAL 3 $106.57
88361 TUMOR IMMUNOHISTOCHEM/COMPUT 3 $141.54
88362 NERVE TEASING PREPARATIONS 3 $256.79

88365 INSITU HYBRIDIZATION (FISH) 3 $122.58
88367 INSITU HYBRIDIZATION, AUTO 3 $200.25
88368 INSITU HYBRIDIZATION, MANUAL 3 $143.52
88371 PROTEIN, WESTERN BLOT TISSUE 3 $31.19
88372 PROTEIN ANALYSIS W/PROBE 3 $31.93
88380 MICRODISSECTION, LASER 5 $0.00
88381 MICRODISSECTION, MANUAL 6 $0.00
88384 EVAL MOLECULAR PROBES, 11-50 3 $326.65
88385 EVAL MOLECUL PROBES, 51-250 3 $335.50
88386 EVAL MOLECUL PROBES, 251-500 3 $349.50
88387 TISS EXAM MOLECULAR STUDY 6 $0.00
88388 TISS EX MOLECUL STUDY ADD-ON 6 $0.00
88399 SURGICAL PATHOLOGY PROCEDURE 5 $0.00
88400 BILIRUBIN TOTAL TRANSCUT O $0.00
88720 BILIRUBIN TOTAL TRANSCUT 3 $7.05
88738 HGB QUANT TRANSCUTANEOUS 3 $7.05
88740 TRANSCUTANEOUS CARBOXYHB 3 $7.05
88741 TRANSCUTANEOUS METHB 3 $7.05
89049 CHCT FOR MAL HYPERTHERMIA 6 $0.00
89050 BODY FLUID CELL COUNT 3 $6.63
89051 BODY FLUID CELL COUNT 3 $7.73
89055 LEUKOCYTE ASSESSMENT, FECAL 3 $5.99
89060 EXAM,SYNOVIAL FLUID CRYSTALS 3 $10.04
89100 SAMPLE INTESTINAL CONTENTS 3 $85.26
89105 SAMPLE INTESTINAL CONTENTS 3 $106.19
89125 SPECIMEN FAT STAIN 3 $6.07
89130 SAMPLE STOMACH CONTENTS 3 $84.96
89132 SAMPLE STOMACH CONTENTS 3 $64.72
89135 SAMPLE STOMACH CONTENTS 3 $92.70
89136 SAMPLE STOMACH CONTENTS 3 $70.12
89140 SAMPLE STOMACH CONTENTS 3 $116.57
89141 SAMPLE STOMACH CONTENTS 3 $138.65
89160 EXAM FECES FOR MEAT FIBERS 3 $5.17
89190 NASAL SMEAR FOR EOSINOPHILS 3 $6.66
89205 OCCULT BLOOD, ANY SOURCE EXCEPT FEC O $0.00
89220 SPUTUM SPECIMEN COLLECTION 3 $16.06
89225 STARCH GRANULES, FECES 3 $4.78
89230 COLLECT SWEAT FOR TEST 3 $17.60
89235 WATER LOAD TEST 3 $7.72
89240 PATHOLOGY LAB PROCEDURE 6 $0.00
89250 CULTR OOCYTE/EMBRYO

89259 CRYOPRESERVATION, SPERM 9 $0.00
89260 SPERM ISOLATION, SIMPLE 9 $0.00
89261 SPERM ISOLATION, COMPLEX 9 $0.00
89264 IDENTIFY SPERM TISSUE 9 $0.00
89268 INSEMINATION OF OOCYTES 9 $0.00
89272 EXTENDED CULTURE OF OOCYTES 9 $0.00
89280 ASSIST OOCYTE FERTILIZATION 9 $0.00
89281 ASSIST OOCYTE FERTILIZATION 9 $0.00
89290 BIOPSY, OOCYTE POLAR BODY 9 $0.00
89291 BIOPSY, OOCYTE POLAR BODY 9 $0.00
89300 SEMEN ANALYSIS W/HUHNER 9 $0.00
89310 SEMEN ANALYSIS W/COUNT 3 $12.08
89320 SEMEN ANAL VOL/COUNT/MOT 3 $16.91
89321 SEMEN ANAL, SPERM DETECTION 3 $16.91
89322 SEMEN ANAL, STRICT CRITERIA 3 $21.76
89325 SPERM ANTIBODY TEST 3 $14.98
89329 SPERM EVALUATION TEST 9 $0.00
89330 EVALUATION, CERVICAL MUCUS 9 $0.00
89331 RETROGRADE EJACULATION ANAL 3 $27.50
89335 CRYOPRESERVE TESTICULAR TISS 9 $0.00
89342 STORAGE/YEAR; EMBRYO(S) 9 $0.00
89343 STORAGE/YEAR; SPERM/SEMEN 9 $0.00
89344 STORAGE/YEAR; REPROD TISSUE 9 $0.00
89346 STORAGE/YEAR; OOCYTE(S) 9 $0.00
89350 SPUTUM SPECIMEN COLLECTION O $0.00
89352 THAWING CRYOPRESRVED; EMBRYO 9 $0.00
89353 THAWING CRYOPRESRVED; SPERM 9 $0.00
89354 THAW CRYOPRSVRD; REPROD TISS 9 $0.00
89355 EXAM FECES FOR STARCH O $0.00
89356 THAWING CRYOPRESRVED; OOCYTE 9 $0.00
89360 COLLECT SWEAT FOR TEST O $0.00
89365 WATER LOAD TEST O $0.00
89398 UNLISTED REPROD MED LAB PROC 9 $0.00
89399 PATHOLOGY LAB PROCEDURE O $0.00
90000 OFFICE AND OTHER OUTPATIENT MEDICAL O $0.00
90010 OFFICE AND OTHER OUTPATIENT MEDICAL O $0.00
90015 OFFICE AND OTHER OUTPATIENT MEDICAL O $0.00
90017 OFFICE AND OTHER OUTPATIENT MEDICAL O $0.00
90020 OFFICE AND OTHER OUTPATIENT MEDICAL O $0.00
90030 OFFICE AND OTHER OUTPATIENT MEDICAL O $0.00
90040 OFFICE AND OTHER OUTPATIENT MEDICAL O $0.00
90050 OFFICE AND OTHER OUTPATIENT MEDICAL O $0.00
90060 OFFICE AND OTHER OUTPATIENT MEDICAL O $0.00
90070 OFFICE AND OTHER OUTPATIENT MEDICAL O $0.00
90080 OFFICE AND OTHER OUTPATIENT MEDICAL O $0.00
90100 HOME MEDICAL SERVICE, NEW PATIENT B O $0.00
90110 HOME MEDICAL SERVICE, NEW PATIENT L O $0.00
90115 HOME MEDICAL SERVICE, NEW PATIENT I O $0.00
90117 HOME MEDICAL SERVICE, NEW PATIENT E O $0.00

90130 HOME MEDICAL SERVICE, ESTABLISHED P O $0.00
90140 HOME MEDICAL SERVICE, ESTABLISHED P O $0.00
90150 HOME MEDICAL SERVICE, ESTABLISHED P O $0.00
90160 HOME MEDICAL SERVICE, ESTABLISHED P O $0.00
90170 HOME MEDICAL SERVICE, ESTABLISHED P O $0.00
90200 INITIAL HOSPITAL CARE BRIEF HISTORY O $0.00
90215 INITIAL HOSPITAL CARE INTERMEDIATE O $0.00
90220 INITIAL HOSPITAL CARE COMPREHENSIVE O $0.00
90225 HISTORY AND EXAMINATION OF THE NORM O $0.00
90240 SUBSEQUENT HOSPITAL CARE, EACH DAY O $0.00
90250 SUBSEQUENT HOSPITAL CARE, EACH DAY O $0.00
90260 SUBSEQUENT HOSPITAL CARE, EACH DAY O $0.00
90270 SUBSEQUENT HOSPITAL CARE, EACH DAY O $0.00
90280 SUBSEQUENT HOSPITAL CARE, EACH DAY O $0.00
90281 HUMAN IG, IM 5 $0.00
90282 SUBSEQUENT HOSPITAL CARE, EACH DAY O $0.00
90283 HUMAN IG, IV 5 $0.00
90284 HUMAN IG, SC 6 $0.00
90287 BOTULINUM ANTITOXIN 5 $0.00
90288 BOTULISM IG, IV 5 $0.00
90291 CMV IG, IV 5 $0.00
90292 HOSPITAL DISCHARGE DAY MANAGEMENT O $0.00
90296 DIPHTHERIA ANTITOXIN 5 $0.00
90300 INITIAL CARE, SKILLED NURSING FACIL O $0.00
90315 INITIAL CARE, SKILLED NURSING FACIL O $0.00
90320 INITIAL CARE, SKILLED NURSING FACIL O $0.00
90340 SUBSEQUENT CARE, SKILLED NURSING FA O $0.00
90350 SUBSEQUENT CARE, SKILLED NURSING FA O $0.00
90360 SUBSEQUENT CARE, SKILLED NURSING FA O $0.00
90370 SUBSEQUENT CARE, SKILLED NURSING FA O $0.00
90371 HEP B IG, IM 5 $0.00
90375 RABIES IG, IM/SC 5 $0.00
90376 RABIES IG, HEAT TREATED 5 $0.00
90378 RSV, MAB, IM, 50MG 5 $0.00
90379 RSV IG, IV O $0.00
90384 RH IG, FULL-DOSE, IM 5 $0.00
90385 RH IG, MINIDOSE, IM 3 $25.42
90386 RH IG, IV 5 $0.00
90389 TETANUS IG, IM 5 $0.00
90393 VACCINA IG, IM 5 $0.00
90396 VARICELLA-ZOSTER IG, IM 5 $0.00
90399 IMMUNE GLOBULIN 5 $0.00
90400 REST HOME (EG, BOARDING HOME), DOMI O $0.00
90410 REST HOME (EG, BOARDING HOME), DOMI O $0.00
90415 REST HOME (EG, BOARDING HOME), DOMI O $0.00
90420 REST HOME (EG, BOARDING HOME), DOMI O $0.00
90430 REST HOME (EG, BOARDING HOME), DOMI O $0.00
90440 REST HOME (EG, BOARDING HOME), DOMI O $0.00
90450 REST HOME (EG, BOARDING HOME), DOMI O $0.00

90460 REST HOME (EG, BOARDING HOME), DOMI O $0.00
90465 IMMUNE ADMIN 1 INJ, < 8 YRS 9 $0.00
90466 IMMUNE ADMIN ADDL INJ, < 8 Y 9 $0.00
90467 IMMUNE ADMIN O OR N, < 8 YRS 9 $0.00
90468 IMMUNE ADMIN O/N, ADDL < 8 Y 9 $0.00
90470 IMMUNE ADMIN H1N1 IM/NASAL 3 $8.00
90471 IMMUNIZATION ADMIN 9 $0.00
90472 IMMUNIZATION ADMIN, EACH ADD 9 $0.00
90473 IMMUNE ADMIN ORAL/NASAL 9 $0.00
90474 IMMUNE ADMIN ORAL/NASAL ADDL 9 $0.00
90476 ADENOVIRUS VACCINE, TYPE 4 5 $0.00
90477 ADENOVIRUS VACCINE, TYPE 7 5 $0.00
90500 EMERGENCY DEPARTMENT SERVICE, NEW P O $0.00
90505 EMERGENCY DEPARTMENT SERVICE, NEW P O $0.00
90510 EMERGENCY DEPARTMENT SERVICE, NEW P O $0.00
90515 EMERGENCY DEPARTMENT SERVICE, NEW P O $0.00
90517 EMERGENCY DEPARTMENT SERVICE, NEW P O $0.00
90520 EMERGENCY DEPARTMENT SERVICE, NEW P O $0.00
90530 EMERGENCY DEPARTMENT SERVICE, ESTAB O $0.00
90540 EMERGENCY DEPARTMENT SERVICE, ESTAB O $0.00
90550 EMERGENCY DEPARTMENT SERVICE, ESTAB O $0.00
90560 EMERGENCY DEPARTMENT SERVICE, ESTAB O $0.00
90570 EMERGENCY DEPARTMENT SERVICE, ESTAB O $0.00
90580 EMERGENCY DEPARTMENT SERVICE, ESTAB O $0.00
90581 ANTHRAX VACCINE, SC 5 $0.00
90585 BCG VACCINE, PERCUT 5 $0.00
90586 BCG VACCINE, INTRAVESICAL 5 $0.00
90590 PHYSICIAN DIRECTION OF EMERGENCY ME 9 $0.00
90592 CHOLERA VACCINE, ORAL 9 $0.00
90600 INITIAL CONSULTATION LIMITED O $0.00
90605 INITIAL CONSULTATION INTERMEDIATE O $0.00
90610 INITIAL CONSULTATION EXTENDED O $0.00
90620 INITIAL CONSULTATION COMPREHENSIVE O $0.00
90630 INITIAL CONSULTATION COMPLEX O $0.00
90632 HEP A VACCINE, ADULT IM 3 $44.06
90633 HEP A VACC, PED/ADOL, 2 DOSE 5 $0.00
90634 HEP A VACC, PED/ADOL, 3 DOSE 5 $0.00
90636 HEP A/HEP B VACC, ADULT IM 3 $91.92
90640 FOLLOW-UP CONSULTATION BRIEF 9 $0.00
90641 FOLLOW-UP CONSULTATION LIMITED 9 $0.00
90642 FOLLOW-UP CONSULTATION INTERMEDIATE 9 $0.00
90643 FOLLOW-UP CONSULTATION COMPLEX 9 $0.00
90644 HIB/MEN/TT VACCINE, IM 9 $0.00
90645 HIB VACCINE, HBOC, IM 5 $0.00
90646 HIB VACCINE, PRP-D, IM 5 $0.00
90647 HIB VACCINE, PRP-OMP, IM 5 $0.00
90648 HIB VACCINE, PRP-T, IM 5 $0.00
90649 HPV VACCINE 4 VALENT, IM 3 $133.53
90650 HPV VACCINE 2 VALENT, IM 3 $131.97

90651 CONFIRMATORY CONSULTATION INTERMEDI 9 $0.00
90652 CONFIRMATORY CONSULTATION EXTENDED 9 $0.00
90653 CONFIRMATORY CONSULTATION COMPREHEN 9 $0.00
90654 CONFIRMATORY CONSULTATION COMPLEX 9 $0.00
90655 FLU VACCINE NO PRESERV 6-35M 5 $0.00
90656 FLU VACCINE NO PRESERV 3 & > 5 $0.00
90657 FLU VACCINE, 3 YRS, IM 5 $0.00
90658 FLU VACCINE, 3 YRS & >, IM 3 $11.37
90659 FLU VACCINE, WHOLE, IM O $0.00
90660 FLU VACCINE, NASAL 5 $0.00
90661 FLU VACC CELL CULT PRSV FREE 9 $0.00
90662 FLU VACC PRSV FREE INC ANTIG 3 $26.29
90663 FLU VACC PANDEMIC H1N1 9 $0.00
90665 LYME DISEASE VACCINE, IM 3 $53.35
90669 PNEUMOCOCCAL VACC, 7 VAL IM 5 $0.00
90670 PNEUMOCOCCAL VACC, 13 VAL IM 3 $111.45
90675 RABIES VACCINE, IM 5 $0.00
90676 RABIES VACCINE, ID 5 $0.00
90680 ROTOVIRUS VACC 3 DOSE, ORAL 5 $0.00
90681 ROTAVIRUS VACC 2 DOSE ORAL 6 $0.00
90690 TYPHOID VACCINE, ORAL 9 $0.00
90691 TYPHOID VACCINE, IM 9 $0.00
90692 TYPHOID VACCINE, H-P, SC/ID 9 $0.00
90693 TYPHOID VACCINE, AKD, SC 9 $0.00
90696 DTAP-IPV VACC 4-6 YR IM 6 $0.00
90698 DTAP-HIB-IP VACCINE, IM 6 $0.00
90699 UNLISTED MEDICAL SERVICE, GENERAL O $0.00
90700 DTAP VACCINE, < 7 YRS, IM 5 $0.00
90701 DTP VACCINE, IM 5 $0.00
90702 DT VACCINE < 7, IM 5 $0.00
90703 TETANUS VACCINE, IM 3 $22.22
90704 MUMPS VACCINE, SC 5 $0.00
90705 MEASLES VACCINE, SC 5 $0.00
90706 RUBELLA VACCINE, SC 5 $0.00
90707 MMR VACCINE, SC 3 $47.15
90708 MEASLES-RUBELLA VACCINE, SC 5 $0.00
90709 RUBELLA & MUMPS VACCINE, SC O $0.00
90710 MMRV VACCINE, SC 5 $0.00
90711 COMBINED VACCINE O $0.00
90712 ORAL POLIOVIRUS VACCINE 5 $0.00
90713 POLIOVIRUS, IPV, SC/IM 3 $25.22
90714 TD VACCINE NO PRSRV >/= 7 IM 3 $19.75
90715 TDAP VACCINE >7 IM 3 $33.17
90716 CHICKEN POX VACCINE, SC 3 $81.76
90717 YELLOW FEVER VACCINE, SC 9 $0.00
90718 TD VACCINE > 7, IM 3 $19.75
90719 DIPHTHERIA VACCINE, IM 5 $0.00
90720 DTP/HIB VACCINE, IM 5 $0.00
90721 DTAP/HIB VACCINE, IM 3 $44.88

90723 DTAP-HEP B-IPV VACCINE, IM 5 $0.00
90724 INFLUENZA IMMUNIZATION O $0.00
90725 CHOLERA VACCINE, INJECTABLE 9 $0.00
90726 RABIES IMMUNIZATION O $0.00
90727 PLAGUE VACCINE, IM 9 $0.00
90728 BCG IMMUNIZATION O $0.00
90730 HEPATITIS A VACCINE O $0.00
90731 IMMUNIZATION, ACTIVE; HEPATITIS B V O $0.00
90732 PNEUMOCOCCAL VACCINE 3 $37.61
90733 MENINGOCOCCAL VACCINE, SC 3 $100.43
90734 MENINGOCOCCAL VACCINE, IM 3 $108.02
90735 ENCEPHALITIS VACCINE, SC 9 $0.00
90736 ZOSTER VACC, SC 3 $165.69
90737 INFLUENZA B IMMUNIZATION O $0.00
90738 INACTIVATED JE VACC IM 9 $0.00
90740 HEPB VACC, ILL PAT 3 DOSE IM 3 $119.42
90741 PASSIVE IMMUNIZATION, ISG O $0.00
90742 SPECIAL PASSIVE IMMUNIZATION O $0.00
90743 HEP B VACC, ADOL, 2 DOSE, IM 5 $0.00
90744 HEPB VACC PED/ADOL 3 DOSE IM 5 $0.00
90745 HEPB VACCINE, ADOL/RISK, IM O $0.00
90746 HEP B VACCINE, ADULT, IM 3 $53.74
90747 HEPB VACC, ILL PAT 4 DOSE IM 5 $0.00
90749 VACCINE TOXOID 5 $0.00
90750 INITIAL HISTORY AND EXAMINATION REL 9 $0.00
90751 INITIAL HISTORY AND EXAMINATION REL 9 $0.00
90752 INITIAL HISTORY AND EXAMINATION REL O $0.00
90753 INITIAL HISTORY AND EXAMINATION REL O $0.00
90754 INITIAL HISTORY AND EXAMINATION REL O $0.00
90755 INFANT CARE TO ONE YEAR OF AGE, WIT 9 $0.00
90757 NEWBORN CARE, IN OTHER THAN HOSPITA O $0.00
90760 HYDRATION IV INFUSION, INIT O $0.00
90761 HYDRATE IV INFUSION, ADD-ON O $0.00
90762 INTERVAL HISTORY AND EXAMINATION RE O $0.00
90763 INTERVAL HISTORY AND EXAMINATION RE O $0.00
90764 INTERVAL HISTORY AND EXAMINATION RE O $0.00
90765 THER/PROPH/DIAG IV INF, INIT O $0.00
90766 THER/PROPH/DG IV INF, ADD-ON O $0.00
90767 TX/PROPH/DG ADDL SEQ IV INF O $0.00
90768 THER/DIAG CONCURRENT INF O $0.00
90769 SC THER INFUSION, UP TO 1 HR O $0.00
90770 SC THER INFUSION, ADDL HR O $0.00
90771 SC THER INFUSION, RESET PUMP O $0.00
90772 THER/PROPH/DIAG INJ, SC/IM O $0.00
90773 THER/PROPH/DIAG INJ, IA O $0.00
90774 THERAPEUTIC, PROPHYLACTIC OR DIAG O $0.00
90775 TX/PRO/DX INJ NEW DRUG ADDON O $0.00
90776 TX/PRO/DX INJ SAME DRUG ADON O $0.00
90778 CIRCADIAN RESPIRATORY PATTERN RECOR O $0.00

90779 THER/PROP/DIAG INJ/INF PROC O $0.00
90780 IV INFUSION THERAPY, 1 HOUR O $0.00
90781 IV INFUSION, ADDITIONAL HOUR O $0.00
90782 INJECTION, SC/IM O $0.00
90783 INJECTION, IA O $0.00
90784 INJECTION, IV O $0.00
90788 INJECTION OF ANTIBIOTIC O $0.00
90798 INTRAVENOUS THERAPY FOR SEVERE OR I O $0.00
90799 THER/PROPHYLACTIC/DX INJECT O $0.00
90801 PSY DX INTERVIEW 3 $156.42
90802 INTAC PSY DX INTERVIEW 3 $167.73
90804 PSYTX, OFFICE, 20-30 MIN 3 $67.83
90805 PSYTX, OFF, 20-30 MIN W/E&M 3 $76.60
90806 PSYTX, OFF, 45-50 MIN 3 $93.67
90807 PSYTX, OFF, 45-50 MIN W/E&M 3 $107.21
90808 PSYTX, OFFICE, 75-80 MIN 3 $137.40
90809 PSYTX, OFF, 75-80, W/E&M 3 $151.19
90810 INTAC PSYTX, OFF, 20-30 MIN 3 $71.90
90811 INTAC PSYTX, 20-30, W/E&M 3 $85.45
90812 INTAC PSYTX, OFF, 45-50 MIN 3 $102.25
90813 INTAC PSYTX, 45-50 MIN W/E&M 3 $115.80
90814 INTAC PSYTX, OFF, 75-80 MIN 3 $148.23
90815 INTAC PSYTX, 75-80 W/E&M 3 $160.44
90816 PSYTX, HOSP, 20-30 MIN 3 $61.82
90817 PSYTX, HOSP, 20-30 MIN W/E&M 3 $69.80
90818 PSYTX, HOSP, 45-50 MIN 3 $92.04
90819 PSYTX, HOSP, 45-50 MIN W/E&M 3 $100.42
90820 INTERACTIVE MEDICAL PSYCHIATRIC DIA 9 $0.00
90821 PSYTX, HOSP, 75-80 MIN 3 $135.76
90822 PSYTX, HOSP, 75-80 MIN W/E&M 3 $144.80
90823 INTAC PSYTX, HOSP, 20-30 MIN 3 $66.43
90824 INTAC PSYTX, HSP 20-30 W/E&M 3 $75.47
90825 PSYCHIATRIC EVALUATION OF HOSPITAL 9 $0.00
90826 INTAC PSYTX, HOSP, 45-50 MIN 3 $97.44
90827 INTAC PSYTX, HSP 45-50 W/E&M 3 $105.44
90828 INTAC PSYTX, HOSP, 75-80 MIN 3 $140.77
90829 INTAC PSYTX, HSP 75-80 W/E&M 3 $149.80
90830 PSYCHOLOGICAL TESTING (INCLUDES PSY O $0.00
90835 NARCOSYNTHESIS FOR PSYCHIATRIC DIAG 9 $0.00
90841 INDIVIDUAL MEDICAL PSYCHOTHERAPY BY 9 $0.00
90842 INDIVIDUAL MEDICAL PSYCHOTHERAPY BY 9 $0.00
90843 INDIVIDUAL MEDICAL PSYCHOTHERAPY BY 9 $0.00
90844 INDIVIDUAL MEDICAL PSYCHOTHERAPY BY 9 $0.00
90845 PSYCHOANALYSIS 3 $82.87
90846 FAMILY PSYTX W/O PATIENT 3 $87.74
90847 FAMILY PSYTX W/PATIENT 3 $109.43
90849 MULTIPLE FAMILY GROUP PSYTX 3 $33.39
90853 GROUP PSYCHOTHERAPY 3 $32.25
90855 INTERACTIVE INDIVIDUAL MEDICAL PSYC 9 $0.00

90857 INTAC GROUP PSYTX 3 $35.98
90862 MEDICATION MANAGEMENT 3 $57.36
90865 NARCOSYNTHESIS 9 $0.00
90870 ELECTROCONVULSIVE THERAPY 3 $141.59
90871 ELECTROCONVULSIVE THERAPY O $0.00
90875 PSYCHOPHYSIOLOGICAL THERAPY 9 $0.00
90876 PSYCHOPHYSIOLOGICAL THERAPY 9 $0.00
90880 HYPNOTHERAPY 9 $0.00
90882 ENVIRONMENTAL MANIPULATION 9 $0.00
90885 PSY EVALUATION OF RECORDS 3 $49.89
90887 CONSULTATION WITH FAMILY 9 $0.00
90889 PREPARATION OF REPORT 9 $0.00
90899 PSYCHIATRIC SERVICE/THERAPY O $0.00
90900 BIOFEEDBACK TRAINING; BY ELECTROMYO O $0.00
90901 BIOFEEDBACK TRAIN, ANY METH 9 $0.00
90902 BIOFEEDBACK TRAINING; IN CONDUCTION O $0.00
90904 BIOFEEDBACK TRAINING; REGULATION OF O $0.00
90906 BIOFEEDBACK TRAINING REGULATION OF 9 $0.00
90908 BIOFEEDBACK TRAINING; BY ELECTROENC O $0.00
90910 BIOFEEDBACK TRAINING; BY ELECTRO-OC O $0.00
90911 BIOFEEDBACK PERI/URO/RECTAL 3 $86.65
90915 BIOFEEDBACK TRAINING; OTHER O $0.00
90918 ESRD RELATED SERVICES, MONTH O $0.00
90919 ESRD RELATED SERVICES, MONTH O $0.00
90920 ESRD RELATED SERVICES, MONTH O $0.00
90921 ESRD RELATED SERVICES, MONTH O $0.00
90922 ESRD RELATED SERVICES, DAY O $0.00
90923 ESRD RELATED SERVICES, DAY O $0.00
90924 ESRD RELATED SERVICES, DAY O $0.00
90925 ESRD RELATED SERVICES, DAY O $0.00
90935 HEMODIALYSIS, ONE EVALUATION 3 $68.47
90937 HEMODIALYSIS, REPEATED EVAL 3 $112.31
90939 HEMODIALYSIS STUDY, TRANSCUT O $0.00
90940 HEMODIALYSIS ACCESS STUDY 5 $0.00
90945 DIALYSIS, ONE EVALUATION 3 $71.04
90947 DIALYSIS, REPEATED EVAL 3 $114.76
90951 ESRD SERV, 4 VISITS P MO,

90964 ESRD HOME PT SERV P MO, 2-11 3 $466.44
90965 ESRD HOME PT SERV P MO 12-19 3 $444.60
90966 ESRD HOME PT, SERV P MO, 20+ 3 $233.23
90967 ESRD HOME PT SERV P DAY, 1H 3 $138.55
91040 ESOPH BALLOON DISTENSION TST 3 $357.07
91052 GASTRIC ANALYSIS TEST 3 $124.60
91055 GASTRIC INTUBATION FOR SMEAR 3 $136.75
91060 GASTRIC SALINE LOAD TEST O $0.00
91065 BREATH HYDROGEN TEST 3 $66.39
91100 PASS INTESTINE BLEEDING TUBE O $0.00
91105 GASTRIC INTUBATION TREATMENT 3 $82.80
91110 GI TRACT CAPSULE ENDOSCOPY 3 $895.52
91111 ESOPHAGEAL CAPSULE ENDOSCOPY 3 $705.78
91120 RECTAL SENSATION TEST 3 $390.19
91122 ANAL PRESSURE RECORD 3 $226.13
91123 IRRIGATE FECAL IMPACTION 3 $92.29
91132 ELECTROGASTROGRAPHY 3 $0.00
91133 ELECTROGASTROGRAPHY W/TEST 3 $0.00
91299 GASTROENTEROLOGY PROCEDURE 5 $0.00
92002 EYE EXAM, NEW PATIENT 3 $72.30
92004 EYE EXAM, NEW PATIENT 3 $135.22
92012 EYE EXAM ESTABLISHED PAT 3 $76.04

92014 EYE EXAM & TREATMENT 3 $111.04
92015 REFRACTION 3 $29.49
92018 NEW EYE EXAM & TREATMENT 3 $135.85
92019 EYE EXAM & TREATMENT 3 $66.85
92020 SPECIAL EYE EVALUATION 3 $25.34
92025 CORNEAL TOPOGRAPHY 3 $33.31
92060 SPECIAL EYE EVALUATION 3 $57.31
92065 ORTHOPTIC/PLEOPTIC TRAINING 3 $45.76
92070 FITTING OF CONTACT LENS 9 $0.00
92081 VISUAL FIELD EXAMINATION(S) 3 $51.69
92082 VISUAL FIELD EXAMINATION(S) 3 $69.22
92083 VISUAL FIELD EXAMINATION(S) 3 $78.72
92100 SERIAL TONOMETRY EXAM(S) 3 $86.38
92120 TONOGRAPHY & EYE EVALUATION 3 $71.01
92130 WATER PROVOCATION TONOGRAPHY 3 $78.70
92135 OPHTH DX IMAGING POST SEG 3 $45.40
92136 OPHTHALMIC BIOMETRY 3 $78.80
92140 GLAUCOMA PROVOCATIVE TESTS 3 $55.80
92225 SPECIAL EYE EXAM, INITIAL 3 $24.58
92226 SPECIAL EYE EXAM, SUBSEQUENT 3 $22.13
92230 EYE EXAM WITH PHOTOS 3 $57.05
92235 EYE EXAM WITH PHOTOS 3 $122.93
92240 ICG ANGIOGRAPHY 3 $195.14
92250 EYE EXAM WITH PHOTOS 3 $69.85
92260 OPHTHALMOSCOPY/DYNAMOMETRY 3 $17.00
92265 EYE MUSCLE EVALUATION 3 $74.69
92270 ELECTRO-OCULOGRAPHY 3 $84.76
92275 ELECTRORETINOGRAPHY 3 $132.00
92280 VISUALLY EVOKED POTENTIAL (RESPONSE O $0.00
92283 COLOR VISION EXAMINATION 3 $45.26
92284 DARK ADAPTATION EYE EXAM 3 $58.02
92285 EYE PHOTOGRAPHY 3 $40.92
92286 INTERNAL EYE PHOTOGRAPHY 3 $114.18
92287 INTERNAL EYE PHOTOGRAPHY 3 $110.46
92310 CONTACT LENS FITTING 9 $0.00
92311 CONTACT LENS FITTING O $0.00
92312 CONTACT LENS FITTING O $0.00
92313 CONTACT LENS FITTING 9 $0.00
92314 PRESCRIPTION OF CONTACT LENS 9 $0.00
92315 PRESCRIPTION OF CONTACT LENS O $0.00
92316 PRESCRIPTION OF CONTACT LENS O $0.00
92317 PRESCRIPTION OF CONTACT LENS 9 $0.00
92325 MODIFICATION OF CONTACT LENS 9 $0.00
92326 REPLACEMENT OF CONTACT LENS 9 $0.00
92330 FITTING OF ARTIFICIAL EYE O $0.00
92335 FITTING OF ARTIFICIAL EYE O $0.00
92340 FITTING OF SPECTACLES 9 $0.00
92341 FITTING OF SPECTACLES 9 $0.00
92342 FITTING OF SPECTACLES 9 $0.00

92352 SPECIAL SPECTACLES FITTING 9 $0.00
92353 SPECIAL SPECTACLES FITTING 9 $0.00
92354 SPECIAL SPECTACLES FITTING 9 $0.00
92355 SPECIAL SPECTACLES FITTING 9 $0.00
92358 EYE PROSTHESIS SERVICE 9 $0.00
92370 REPAIR & ADJUST SPECTACLES 9 $0.00
92371 REPAIR & ADJUST SPECTACLES 9 $0.00
92390 SUPPLY OF SPECTACLES O $0.00
92391 SUPPLY OF CONTACT LENSES O $0.00
92392 SUPPLY OF LOW VISION AIDS O $0.00
92393 SUPPLY OF ARTIFICIAL EYE O $0.00
92395 SUPPLY OF SPECTACLES O $0.00
92396 SUPPLY OF CONTACT LENSES O $0.00
92499 EYE SERVICE OR PROCEDURE 5 $0.00
92502 EAR AND THROAT EXAMINATION 3 $95.32
92504 EAR MICROSCOPY EXAMINATION 3 $29.13
92506 SPEECH/HEARING EVALUATION 3 $159.40
92507 SPEECH/HEARING THERAPY 3 $65.97
92508 SPEECH/HEARING THERAPY 3 $32.42
92510 REHAB FOR EAR IMPLANT O $0.00
92511 NASOPHARYNGOSCOPY 3 $152.75
92512 NASAL FUNCTION STUDIES 3 $59.89
92516 FACIAL NERVE FUNCTION TEST 3 $63.07
92520 LARYNGEAL FUNCTION STUDIES 3 $62.53
92525 ORAL FUNCTION EVALUATION O $0.00
92526 ORAL FUNCTION THERAPY 3 $102.34
92531 SPONTANEOUS NYSTAGMUS STUDY 5 $0.00
92532 POSITIONAL NYSTAGMUS TEST 5 $0.00
92533 CALORIC VESTIBULAR TEST 5 $0.00
92534 OPTOKINETIC NYSTAGMUS TEST 5 $0.00
92540 BASIC VESTIBULAR EVALUATION 3 $96.98
92541 SPONTANEOUS NYSTAGMUS TEST 3 $51.39
92542 POSITIONAL NYSTAGMUS TEST 3 $52.62
92543 CALORIC VESTIBULAR TEST 3 $24.93
92544 OPTOKINETIC NYSTAGMUS TEST 3 $42.88
92545 OSCILLATING TRACKING TEST 3 $39.89
92546 SINUSOIDAL ROTATIONAL TEST 3 $86.68
92547 SUPPLEMENTAL ELECTRICAL TEST 3 $4.40
92548 POSTUROGRAPHY 3 $94.35
92550 TYMPANOMETRY & REFLEX THRESH 3 $20.97
92551 PURE TONE HEARING TEST, AIR 3 $10.59
92552 PURE TONE AUDIOMETRY, AIR 3 $22.55
92553 AUDIOMETRY, AIR & BONE 3 $28.97
92555 SPEECH THRESHOLD AUDIOMETRY 3 $16.12
92556 SPEECH AUDIOMETRY, COMPLETE 3 $24.81
92557 COMPREHENSIVE HEARING TEST 3 $41.31
92559 GROUP AUDIOMETRIC TESTING 9 $0.00
92560 BEKESY AUDIOMETRY, SCREEN 5 $0.00
92561 BEKESY AUDIOMETRY, DIAGNOSIS 3 $28.97

92562 LOUDNESS BALANCE TEST 3 $25.95
92563 TONE DECAY HEARING TEST 3 $21.79
92564 SISI HEARING TEST 3 $20.28
92565 STENGER TEST, PURE TONE 3 $12.34
92566 IMPEDANCE TESTING O $0.00
92567 TYMPANOMETRY 3 $15.87
92568 ACOUSTIC REFL THRESHOLD TST 3 $16.89
92569 ACOUSTIC REFLEX DECAY TEST O $0.00
92570 ACOUSTIC IMMITTANCE TESTING 3 $31.92
92571 FILTERED SPEECH HEARING TEST 3 $16.88
92572 STAGGERED SPONDAIC WORD TEST 3 $23.68
92573 LOMBARD TEST O $0.00
92574 SWINGING STORY TEST O $0.00
92575 SENSORINEURAL ACUITY TEST 3 $39.94
92576 SYNTHETIC SENTENCE TEST 3 $22.55
92577 STENGER TEST, SPEECH 3 $15.37
92578 DELAYED AUDITORY FEEDBACK TEST O $0.00
92579 VISUAL AUDIOMETRY (VRA) 3 $43.83
92580 ELECTRODERMAL AUDIOMETRY O $0.00
92581 EVOKED RESPONSE (EEG) AUDIOMETRY O $0.00
92582 CONDITIONING PLAY AUDIOMETRY 3 $43.71
92583 SELECT PICTURE AUDIOMETRY 3 $33.51
92584 ELECTROCOCHLEOGRAPHY 3 $62.23
92585 AUDITOR EVOKE POTENT, COMPRE 3 $102.29
92586 AUDITOR EVOKE POTENT, LIMIT 3 $62.23
92587 EVOKED AUDITORY TEST 3 $35.86
92588 EVOKED AUDITORY TEST 3 $61.64
92589 AUDITORY FUNCTION TEST(S) O $0.00
92590 HEARING AID EXAM, ONE EAR 9 $0.00
92591 HEARING AID EXAM, BOTH EARS 9 $0.00
92592 HEARING AID CHECK, ONE EAR 9 $0.00
92593 HEARING AID CHECK, BOTH EARS 9 $0.00
92594 ELECTRO HEARNG AID TEST, ONE 9 $0.00
92595 ELECTRO HEARNG AID TST, BOTH 9 $0.00
92596 EAR PROTECTOR EVALUATION 9 $0.00
92597 ORAL SPEECH DEVICE EVAL 9 $0.00
92598 MODIFY ORAL SPEECH DEVICE 9 $0.00
92599 ENT PROCEDURE/SERVICE O $0.00
92601 COCHLEAR IMPLT F/UP EXAM < 7 3 $153.26
92602 REPROGRAM COCHLEAR IMPLT < 7 3 $96.72
92603 COCHLEAR IMPLT F/UP EXAM 7 > 3 $141.24
92604 REPROGRAM COCHLEAR IMPLT 7 > 3 $83.31
92605 EVAL FOR NONSPEECH DEVICE RX 5 $0.00
92606 NON-SPEECH DEVICE SERVICE 5 $0.00
92607 EX FOR SPEECH DEVICE RX, 1HR 3 $164.51
92608 EX FOR SPEECH DEVICE RX ADDL 3 $33.51
92609 USE OF SPEECH DEVICE SERVICE 3 $89.18
92610 EVALUATE SWALLOWING FUNCTION 3 $116.38
92611 MOTION FLUOROSCOPY/SWALLOW 3 $124.88

92612 ENDOSCOPY SWALLOW TST (FEES) 3 $160.64
92613 ENDOSCOPY SWALLOW TST (FEES) 3 $38.39
92614 LARYNGOSCOPIC SENSORY TEST 3 $143.25
92615 EVAL LARYNGOSCOPY SENSE TST 3 $34.08
92616 FEES W/LARYNGEAL SENSE TEST 3 $194.76
92617 INTERPRT FEES/LARYNGEAL TEST 3 $42.07
92620 AUDITORY FUNCTION, 60 MIN 9 $0.00
92621 AUDITORY FUNCTION, + 15 MIN 9 $0.00
92625 TINNITUS ASSESSMENT 9 $0.00
92626 EVAL AUD REHAB STATUS 9 $0.00
92627 EVAL AUD STATUS REHAB ADD-ON 9 $0.00
92630 AUD REHAB PRE-LING HEAR LOSS 9 $0.00
92633 AUD REHAB POSTLING HEAR LOSS 9 $0.00
92640 AUD BRAINSTEM IMPLT PROGRAMG 3 $87.54
92700 ENT PROCEDURE/SERVICE 5 $0.00
92950 HEART/LUNG RESUSCITATION CPR 3 $275.39
92953 TEMPORARY EXTERNAL PACING 9 $0.00
92960 CARDIOVERSION ELECTRIC, EXT 3 $250.96
92961 CARDIOVERSION, ELECTRIC, INT 9 $0.00
92970 CARDIOASSIST, INTERNAL 3 $182.53
92971 CARDIOASSIST, EXTERNAL 3 $103.28
92973 PERCUT CORONARY THROMBECTOMY 3 $190.39
92974 CATH PLACE, CARDIO BRACHYTX 3 $174.66
92975 DISSOLVE CLOT, HEART VESSEL 3 $419.54
92977 DISSOLVE CLOT, HEART VESSEL 3 $105.95
92978 INTRAVASC US, HEART ADD-ON 3 $0.00
92979 INTRAVASC US, HEART ADD-ON 3 $0.00
92980 INSERT INTRACORONARY STENT 3 $868.09
92981 INSERT INTRACORONARY STENT 3 $241.47
92982 CORONARY ARTERY DILATION 3 $643.61
92984 CORONARY ARTERY DILATION 3 $172.18
92986 REVISION OF AORTIC VALVE 3 $1,432.07
92987 REVISION OF MITRAL VALVE 3 $1,480.52
92990 REVISION OF PULMONARY VALVE 3 $1,145.94
92992 REVISION OF HEART CHAMBER 5 $0.00
92993 REVISION OF HEART CHAMBER 5 $0.00
92995 CORONARY ATHERECTOMY 3 $708.97
92996 CORONARY ATHERECTOMY ADD-ON 3 $189.29
92997 PUL ART BALLOON REPR, PERCUT 3 $674.45
92998 PUL ART BALLOON REPR, PERCUT 3 $341.38
93000 ELECTROCARDIOGRAM, COMPLETE 3 $20.31
93005 ELECTROCARDIOGRAM, TRACING 3 $11.21
93010 ELECTROCARDIOGRAM REPORT 3 $9.10
93012 TRANSMISSION OF ECG 9 $0.00
93014 REPORT ON TRANSMITTED ECG 9 $0.00
93015 CARDIOVASCULAR STRESS TEST 3 $95.41
93016 CARDIOVASCULAR STRESS TEST 9 $0.00
93017 CARDIOVASCULAR STRESS TEST 3 $55.06
93018 CARDIOVASCULAR STRESS TEST 3 $16.12

93024 CARDIAC DRUG STRESS TEST 3 $119.70
93025 MICROVOLT T-WAVE ASSESS 3 $202.38
93040 RHYTHM ECG WITH REPORT 3 $13.51
93041 RHYTHM ECG, TRACING 3 $5.54
93042 RHYTHM ECG, REPORT 3 $7.98
93201 PHONOCARDIOGRAM WITH OR WITHOUT ECG O $0.00
93202 PHONOCARDIOGRAM WITH OR WITHOUT ECG O $0.00
93204 PHONOCARDIOGRAM WITH OR WITHOUT ECG O $0.00
93205 PHONOCARDIOGRAM WITH ECG LEAD, WITH O $0.00
93208 PHONOCARDIOGRAM WITH ECG LEAD, WITH O $0.00
93209 PHONOCARDIOGRAM WITH ECG LEAD, WITH O $0.00
93210 PHONOCARDIOGRAM, INTRACARDIAC O $0.00
93220 VECTORCARDIOGRAM (VCG), WITH OR WIT O $0.00
93221 VECTORCARDIOGRAM (VCG), WITH OR WIT O $0.00
93222 VECTORCARDIOGRAM (VCG), WITH OR WIT O $0.00
93224 ECG MONITOR/REPORT, 24 HRS 3 $109.31
93225 ECG MONITOR/RECORD, 24 HRS 3 $32.37
93226 ECG MONITOR/REPORT, 24 HRS 3 $48.63
93227 ECG MONITOR/REVIEW, 24 HRS 3 $28.31
93228 REMOTE 30 DAY ECG REV/REPORT 3 $26.29
93229 REMOTE 30 DAY ECG TECH SUPP 6 $0.00
93230 ECG MONITOR/REPORT, 24 HRS 3 $111.20
93231 ECG MONITOR/RECORD, 24 HRS 3 $30.86
93232 ECG MONITOR/REPORT, 24 HRS 3 $53.17
93233 ECG MONITOR/REVIEW, 24 HRS 3 $27.18
93235 ECG MONITOR/REPORT, 24 HRS 3 $124.39
93236 ECG MONITOR/REPORT, 24 HRS 3 $101.38
93237 ECG MONITOR/REVIEW, 24 HRS 3 $24.49
93255 APEXCARDIOGRAPHY O $0.00
93268 ECG RECORD/REVIEW 3 $254.83
93270 ECG RECORDING 3 $17.26
93271 ECG/MONITORING AND ANALYSIS 3 $210.40
93272 ECG/REVIEW, INTERPRET ONLY 3 $27.18
93278 ECG/SIGNAL-AVERAGED 3 $36.46
93279 PM DEVICE PROGR EVAL, SNGL 3 $54.72
93280 PM DEVICE PROGR EVAL, DUAL 3 $64.78
93281 PM DEVICE PROGR EVAL, MULTI 3 $75.20
93282 ICD DEVICE PROG EVAL, 1 SNGL 3 $69.21
93283 ICD DEVICE PROGR EVAL, DUAL 3 $88.35
93284 ICD DEVICE PROGR EVAL, MULT 3 $98.80
93285 ILR DEVICE EVAL PROGR 3 $46.32
93286 PRE-OP PM DEVICE EVAL 3 $27.32
93287 PRE-OP ICD DEVICE EVAL 3 $36.21
93288 PM DEVICE EVAL IN PERSON 3 $41.52
93289 ICD DEVICE INTERROGATE 3 $70.26
93290 ICM DEVICE EVAL 3 $31.69
93291 ILR DEVICE INTERROGATE 3 $40.01
93292 WCD DEVICE INTERROGATE 3 $35.86
93293 PM PHONE R-STRIP DEVICE EVAL 3 $56.40

93294 PM DEVICE INTERROGATE REMOTE 3 $36.20
93295 ICD DEVICE INTERROGAT REMOTE 3 $70.89
93296 PM/ICD REMOTE TECH SERV 3 $35.77
93297 ICM DEVICE INTERROGAT REMOTE 3 $26.29
93298 ILR DEVICE INTERROGAT REMOTE 3 $29.31
93299 ICM/ILR REMOTE TECH SERV 6 $0.00
93303 ECHO TRANSTHORACIC 3 $211.00
93304 ECHO TRANSTHORACIC 3 $133.21
93306 TTE W/DOPPLER, COMPLETE 3 $246.53
93307 TTE W/O DOPPLER, COMPLETE 3 $159.46
93308 TTE, F-UP OR LMTD 3 $107.16
93312 ECHO TRANSESOPHAGEAL 3 $320.97
93313 ECHO TRANSESOPHAGEAL 3 $41.60
93314 ECHO TRANSESOPHAGEAL 3 $278.59
93315 ECHO TRANSESOPHAGEAL 3 $0.00
93316 ECHO TRANSESOPHAGEAL 3 $45.38
93317 ECHO TRANSESOPHAGEAL 3 $0.00
93318 ECHO TRANSESOPHAGEAL INTRAOP 3 $0.00
93320 DOPPLER ECHO EXAM, HEART 3 $69.56
93321 DOPPLER ECHO EXAM, HEART 3 $31.29
93325 DOPPLER COLOR FLOW ADD-ON 3 $41.60
93350 STRESS TTE ONLY 3 $210.29
93351 STRESS TTE COMPLETE 3 $250.23
93352 ADMIN ECG CONTRAST AGENT 3 $37.04
93501 RIGHT HEART CATHETERIZATION 3 $766.59
93503 INSERT/PLACE HEART CATHETER 3 $140.32
93505 BIOPSY OF HEART LINING 3 $773.80
93508 CATH PLACEMENT, ANGIOGRAPHY 3 $1,060.70
93510 LEFT HEART CATHETERIZATION 3 $1,228.08
93511 LEFT HEART CATHETERIZATION 3 $0.00
93514 LEFT HEART CATHETERIZATION 3 $0.00
93524 LEFT HEART CATHETERIZATION 3 $0.00
93526 RT & LT HEART CATHETERS 3 $1,570.90
93527 RT & LT HEART CATHETERS 3 $0.00
93528 RT & LT HEART CATHETERS 3 $0.00
93529 RT, LT HEART CATHETERIZATION 3 $0.00
93530 RT HEART CATH, CONGENITAL 3 $0.00
93531 R & L HEART CATH, CONGENITAL 3 $0.00
93532 R & L HEART CATH, CONGENITAL 3 $0.00
93533 R & L HEART CATH, CONGENITAL 3 $0.00
93536 INSERT CIRCULATION ASSI O $0.00
93539 INJECTION, CARDIAC CATH 3 $83.90
93540 INJECTION, CARDIAC CATH 3 $252.81
93541 INJECTION FOR LUNG ANGIOGRAM 3 $15.75
93542 INJECTION FOR HEART X-RAYS 3 $153.71
93543 INJECTION FOR HEART X-RAYS 3 $83.41
93544 INJECTION FOR AORTOGRAPHY 3 $60.41
93545 INJECT FOR CORONARY X-RAYS 3 $22.29
93546 COMBINED LEFT HEART CATHETERIZATION O $0.00

93547 COMBINED LEFT HEART CATHETERIZATION O $0.00
93548 COMBINED LEFT HEART CATHETERIZATION O $0.00
93549 COMBINED RIGHT AND LEFT HEART CATHE O $0.00
93550 COMBINED RIGHT AND LEFT HEART CATHE O $0.00
93551 SELECTIVE OPACIFICATION OF AORTOCOR O $0.00
93552 COMBINED LEFT HEART CATHETERIZATION O $0.00
93553 COMBINED LEFT HEART CATHETERIZATION O $0.00
93555 IMAGING, CARDIAC CATH 3 $93.83
93556 IMAGING, CARDIAC CATH 3 $128.58
93561 CARDIAC OUTPUT MEASUREMENT 3 $0.00
93562 CARDIAC OUTPUT MEASUREMENT 3 $0.00
93571 HEART FLOW RESERVE MEASURE 3 $0.00
93572 HEART FLOW RESERVE MEASURE 3 $0.00
93580 TRANSCATH CLOSURE OF ASD 3 $1,046.44
93581 TRANSCATH CLOSURE OF VSD 3 $1,379.17
93600 BUNDLE OF HIS RECORDING 3 $0.00
93602 INTRA-ATRIAL RECORDING 3 $0.00
93603 RIGHT VENTRICULAR RECORDING 3 $0.00
93607 LEFT VENTRICULAR RECORDING O $0.00
93609 MAP TACHYCARDIA, ADD-ON 3 $0.00
93610 INTRA-ATRIAL PACING 3 $0.00
93612 INTRAVENTRICULAR PACING 3 $0.00
93613 ELECTROPHYS MAP 3D, ADD-ON 3 $404.89
93615 ESOPHAGEAL RECORDING 3 $0.00
93616 ESOPHAGEAL RECORDING 3 $0.00
93618 HEART RHYTHM PACING 3 $0.00
93619 ELECTROPHYSIOLOGY EVALUATION 3 $0.00
93620 ELECTROPHYSIOLOGY EVALUATION 3 $0.00
93621 ELECTROPHYSIOLOGY EVALUATION 3 $0.00
93622 ELECTROPHYSIOLOGY EVALUATION 3 $0.00
93623 STIMULATION, PACING HEART 3 $0.00
93624 ELECTROPHYSIOLOGIC STUDY 3 $0.00
93631 HEART PACING, MAPPING 3 $0.00
93640 EVALUATION HEART DEVICE 3 $0.00
93641 ELECTROPHYSIOLOGY EVALUATION 3 $0.00
93642 ELECTROPHYSIOLOGY EVALUATION 3 $448.81
93650 ABLATE HEART DYSRHYTHM FOCUS 3 $616.54
93651 ABLATE HEART DYSRHYTHM FOCUS 3 $938.60
93652 ABLATE HEART DYSRHYTHM FOCUS 3 $1,021.43
93660 TILT TABLE EVALUATION 3 $169.92
93662 INTRACARDIAC ECG (ICE) 3 $0.00
93668 PERIPHERAL VASCULAR REHAB 9 $0.00
93701 BIOIMPEDANCE, CV ANALYSIS 3 $27.08
93720 TOTAL BODY PLETHYSMOGRAPHY 3 $46.01
93721 PLETHYSMOGRAPHY TRACING 3 $37.66
93722 PLETHYSMOGRAPHY REPORT 3 $8.35
93724 ANALYZE PACEMAKER SYSTEM 3 $318.91
93727 ANALYZE ILR SYSTEM O $0.00
93731 ANALYZE PACEMAKER SYSTEM O $0.00

93732 ANALYZE PACEMAKER SYSTEM O $0.00
93733 TELEPHONE ANALY, PACEMAKER O $0.00
93734 ANALYZE PACEMAKER SYSTEM O $0.00
93735 ANALYZE PACEMAKER SYSTEM O $0.00
93736 TELEPHONIC ANALY, PACEMAKER O $0.00
93737 ANALYZE CARDIO/DEFIBRILLATOR O $0.00
93738 ANALYZE CARDIO/DEFIBRILLATOR O $0.00
93740 TEMPERATURE GRADIENT STUDIES O $0.00
93741 ANALYZE HT PACE DEVICE SNGL O $0.00
93742 ANALYZE HT PACE DEVICE SNGL O $0.00
93743 ANALYZE HT PACE DEVICE DUAL O $0.00
93744 ANALYZE HT PACE DEVICE DUAL O $0.00
93745 SET-UP CARDIOVERT-DEFIBRILL 3 $215.95
93750 INTERROGATION VAD, IN PERSON 3 $52.35
93760 CEPHALIC THERMOGRAM O $0.00
93762 PERIPHERAL THERMOGRAM O $0.00
93770 MEASURE VENOUS PRESSURE 3 $8.22
93784 AMBULATORY BP MONITORING 3 $66.40
93786 AMBULATORY BP RECORDING 3 $30.11
93788 AMBULATORY BP ANALYSIS 3 $16.88
93790 REVIEW/REPORT BP RECORDING 3 $19.42
93797 CARDIAC REHAB 3 $18.16
93798 CARDIAC REHAB/MONITOR 3 $25.97
93799 CARDIOVASCULAR PROCEDURE 5 $0.00
93850 NON-INVASIVE STUDIES OF CEREBRAL AR O $0.00
93860 NON-INVASIVE STUDIES OF CAROTID ART O $0.00
93870 NON-INVASIVE STUDIES OF CAROTID ART O $0.00
93875 EXTRACRANIAL STUDY 3 $102.26
93880 EXTRACRANIAL STUDY 3 $189.96
93882 EXTRACRANIAL STUDY 3 $165.14
93886 INTRACRANIAL STUDY 3 $206.16
93888 INTRACRANIAL STUDY 3 $95.58
93890 TCD, VASOREACTIVITY STUDY 3 $149.53
93892 TCD, EMBOLI DETECT W/O INJ 3 $157.14
93893 TCD, EMBOLI DETECT W/INJ 3 $157.52
93910 NON-INVASIVE STUDIES OF LOWER EXTRE O $0.00
93920 NON-INVASIVE PHYSIOLOGIC STUDIES OF O $0.00
93921 NON-INVASIVE PHYSIOLOGIC STUDIES OF O $0.00
93922 EXTREMITY STUDY 3 $121.13
93923 EXTREMITY STUDY 3 $185.99
93924 EXTREMITY STUDY 3 $229.03
93925 LOWER EXTREMITY STUDY 3 $188.10
93926 LOWER EXTREMITY STUDY 3 $119.80
93930 UPPER EXTREMITY STUDY 3 $182.58
93931 UPPER EXTREMITY STUDY 3 $115.25
93950 NON-INVASIVE STUDIES OF EXTREMITY V O $0.00
93960 QUANTITATIVE VENOUS FLOW STUDIES (E O $0.00
93965 EXTREMITY STUDY 3 $123.14
93970 EXTREMITY STUDY 3 $193.76

93971 EXTREMITY STUDY 3 $122.87
93975 VASCULAR STUDY 3 $251.02
93976 VASCULAR STUDY 3 $213.37
93978 VASCULAR STUDY 3 $191.90
93979 VASCULAR STUDY 3 $122.13
93980 PENILE VASCULAR STUDY 3 $175.27
93981 PENILE VASCULAR STUDY 3 $120.76
93982 ANEURYSM PRESSURE SENS STUDY 3 $41.80
93990 DOPPLER FLOW TESTING 3 $112.17
94002 VENT MGMT INPAT, INIT DAY 9 $0.00
94003 VENT MGMT INPAT, SUBQ DAY 9 $0.00
94004 VENT MGMT NF PER DAY 9 $0.00
94005 HOME VENT MGMT SUPERVISION 9 $0.00
94010 BREATHING CAPACITY TEST 3 $33.54
94011 UP TO 2 YRS OLD, SPIROMETRY 3 $99.33
94012 = 2 YRS, SPIROMTRY W/DILATOR 3 $152.95
94013 = 2 YRS, LUNG VOLUMES 3 $31.65
94014 PATIENT RECORDED SPIROMETRY 3 $49.34
94015 PATIENT RECORDED SPIROMETRY 3 $24.06
94016 REVIEW PATIENT SPIROMETRY 3 $25.29
94060 EVALUATION OF WHEEZING 3 $58.68
94070 EVALUATION OF WHEEZING 3 $58.56
94150 VITAL CAPACITY TEST 3 $23.08
94160 VITAL CAPACITY SCREENING TESTS: TOT O $0.00
94200 LUNG FUNCTION TEST (MBC/MVV) 3 $22.65
94240 RESIDUAL LUNG CAPACITY 3 $38.71
94250 EXPIRED GAS COLLECTION 3 $24.54
94260 THORACIC GAS VOLUME 3 $31.32
94350 LUNG NITROGEN WASHOUT CURVE 3 $34.18
94360 MEASURE AIRFLOW RESISTANCE 3 $42.88
94370 BREATH AIRWAY CLOSING VOLUME 3 $33.43
94375 RESPIRATORY FLOW VOLUME LOOP 3 $37.51
94400 CO2 BREATHING RESPONSE CURVE 3 $51.76
94450 HYPOXIA RESPONSE CURVE 3 $55.16
94452 HAST W/REPORT 3 $55.66
94453 HAST W/OXYGEN TITRATE 3 $75.21
94610 SURFACTANT ADMIN THRU TUBE 3 $58.72
94620 PULMONARY STRESS TEST/SIMPLE 3 $66.45
94621 PULM STRESS TEST/COMPLEX 3 $161.20
94640 AIRWAY INHALATION TREATMENT 3 $14.23
94642 AEROSOL INHALATION TREATMENT 3 $34.88
94644 CBT, 1ST HOUR 3 $36.15
94645 CBT, EACH ADDL HOUR 3 $13.48
94650 PRESSURE BREATHING (IPPB) O $0.00
94651 PRESSURE BREATHING (IPPB) O $0.00
94652 PRESSURE BREATHING (IPPB) O $0.00
94656 INITIAL VENTILATOR MGMT O $0.00
94657 CONTINUED VENTILATOR MGMT O $0.00
94660 POS AIRWAY PRESSURE, CPAP 9 $0.00

94662 NEG PRESS VENTILATION, CNP 9 $0.00
94664 EVALUATE PT USE OF INHALER 3 $14.61
94665 AEROSOL OR VAPOR INHALATIONS O $0.00
94667 CHEST WALL MANIPULATION 9 $0.00
94668 CHEST WALL MANIPULATION 9 $0.00
94680 EXHALED AIR ANALYSIS, O2 3 $56.86
94681 EXHALED AIR ANALYSIS, O2/CO2 3 $58.45
94690 EXHALED AIR ANALYSIS 3 $49.92
94700 ANALYSIS OF ARTERIAL BLOOD GAS (OXY O $0.00
94705 ANALYSIS OF ARTERIAL BLOOD GAS (OXY O $0.00
94710 ANALYSIS OF ARTERIAL BLOOD GAS (OXY O $0.00
94715 HEMOGLOBIN-OXYGEN AFFINITY (PO2 FOR O $0.00
94720 MONOXIDE DIFFUSING CAPACITY 3 $50.81
94725 MEMBRANE DIFFUSION CAPACITY 3 $60.63
94750 PULMONARY COMPLIANCE STUDY 3 $73.15
94760 MEASURE BLOOD OXYGEN LEVEL 3 $2.51
94761 MEASURE BLOOD OXYGEN LEVEL 3 $4.03
94762 MEASURE BLOOD OXYGEN LEVEL 3 $23.30
94770 EXHALED CARBON DIOXIDE TEST 3 $35.46
94772 BREATH RECORDING, INFANT 3 $167.00
94774 PED HOME APNEA REC, COMPL 9 $0.00
94775 PED HOME APNEA REC, HK-UP 9 $0.00
94776 PED HOME APNEA REC, DOWNLD 9 $0.00
94777 PED HOME APNEA REC, REPORT 9 $0.00
94799 PULMONARY SERVICE/PROCEDURE O $0.00
95000 PERCUTANEOUS TESTS (SCRATCH, PUNCTU O $0.00
95001 PERCUTANEOUS TESTS (SCRATCH, PUNCTU O $0.00
95002 PERCUTANEOUS TESTS (SCRATCH, PUNCTU O $0.00
95003 PERCUTANEOUS TESTS (SCRATCH, PUNCTU O $0.00
95004 PERCUT ALLERGY SKIN TESTS 3 $5.90
95005 PERCUTANEOUS TESTS (SCRATCH, PUNCTU O $0.00
95006 PERCUTANEOUS TESTS (SCRATCH, PUNCTU O $0.00
95007 PERCUTANEOUS TESTS (SCRATCH, PUNCTU O $0.00
95010 PERCUT ALLERGY TITRATE TEST 3 $17.44
95011 PERCUTANEOUS TESTS (SCRATCH, PUNCTU O $0.00
95012 EXHALED NITRIC OXIDE MEAS 3 $19.90
95014 INTRACUTANEOUS (INTRADERMAL) TESTS, O $0.00
95015 ID ALLERGY TITRATE-DRUG/BUG 3 $13.29
95016 INTRACUTANEOUS (INTRADERMAL) TESTS, O $0.00
95017 INTRACUTANEOUS (INTRADERMAL) TESTS, O $0.00
95018 INTRACUTANEOUS (INTRADERMAL) TESTS, O $0.00
95020 INTRACUTANEOUS (INTRADERMAL) TESTS O $0.00
95021 INTRACUTANEOUS (INTRADERMAL) TESTS O $0.00
95022 INTRACUTANEOUS (INTRADERMAL) TESTS O $0.00
95023 INTRACUTANEOUS (INTRADERMAL) TESTS O $0.00
95024 ID ALLERGY TEST, DRUG/BUG 3 $7.04
95027 ID ALLERGY TITRATE-AIRBORNE 3 $4.77
95028 ID ALLERGY TEST-DELAYED TYPE 3 $11.58
95030 INTRACUTANEOUS (INTRADERMAL) TESTS O $0.00

95031 INTRACUTANEOUS (INTRADERMAL) TESTS O $0.00
95032 INTRACUTANEOUS (INTRADERMAL) TESTS O $0.00
95033 INTRACUTANEOUS (INTRADERMAL) TESTS O $0.00
95034 INTRACUTANEOUS (INTRADERMAL) TESTS O $0.00
95040 PATCH OR APPLICATION TESTS UP TO 10 O $0.00
95041 PATCH OR APPLICATION TESTS 11-20 TE O $0.00
95042 PATCH OR APPLICATION TESTS 21-30 TE O $0.00
95043 PATCH OR APPLICATION TESTS MORE THA O $0.00
95044 ALLERGY PATCH TESTS 3 $5.92
95050 PHOTO PATCH TESTS UP TO 10 TESTS 9 $0.00
95051 PHOTO PATCH TESTS MORE THAN 10 TEST 9 $0.00
95052 PHOTO PATCH TEST 3 $6.67
95056 PHOTOSENSITIVITY TESTS 3 $37.29
95060 EYE ALLERGY TESTS 3 $25.57
95065 NOSE ALLERGY TEST 3 $22.55
95070 BRONCHIAL ALLERGY TESTS 3 $39.94
95071 BRONCHIAL ALLERGY TESTS 3 $49.76
95075 INGESTION CHALLENGE TEST 3 $63.79
95078 PROVOCATIVE TESTING O $0.00
95080 PASSIVE TRANSFER TESTS UP TO 10 TES 9 $0.00
95081 PASSIVE TRANSFER TESTS 11-20 TESTS 9 $0.00
95082 PASSIVE TRANSFER TESTS MORE THAN 20 9 $0.00
95105 MEDICAL CONFERENCE SERVICES (EG, US O $0.00
95115 IMMUNOTHERAPY, ONE INJECTION 3 $10.07
95117 IMMUNOTHERAPY INJECTIONS 3 $12.34
95120 IMMUNOTHERAPY, ONE INJECTION 9 $0.00
95125 IMMUNOTHERAPY, MANY ANTIGENS 9 $0.00
95130 IMMUNOTHERAPY, INSECT VENOM 9 $0.00
95131 IMMUNOTHERAPY, INSECT VENOMS 9 $0.00
95132 IMMUNOTHERAPY, INSECT VENOMS 9 $0.00
95133 IMMUNOTHERAPY, INSECT VENOMS 9 $0.00
95134 IMMUNOTHERAPY, INSECT VENOMS 9 $0.00
95135 PROFESSIONAL SERVICES FOR THE SUPER 9 $0.00
95140 PROFESSIONAL SERVICES FOR THE SUPER 9 $0.00
95144 ANTIGEN THERAPY SERVICES 3 $11.89
95145 ANTIGEN THERAPY SERVICES 3 $15.67
95146 ANTIGEN THERAPY SERVICES 3 $25.87
95147 ANTIGEN THERAPY SERVICES 3 $25.12
95148 ANTIGEN THERAPY SERVICES 3 $35.70
95149 ANTIGEN THERAPY SERVICES 3 $46.66
95150 PROFESSIONAL SERVICE FOR THE SUPERV 9 $0.00
95155 PROFESSIONAL SERVICE FOR THE SUPERV O $0.00
95165 ANTIGEN THERAPY SERVICES 3 $11.89
95170 ANTIGEN THERAPY SERVICES 3 $9.24
95180 RAPID DESENSITIZATION 3 $141.93
95199 ALLERGY IMMUNOLOGY SERVICES 5 $0.00
95250 GLUCOSE MONITORING, CONT 3 $136.32
95251 GLUC MONITOR, CONT, PHYS I&R 3 $41.61
95803 ACTIGRAPHY TESTING 9 $0.00

95805 MULTIPLE SLEEP LATENCY TEST 3 $401.00
95806 SLEEP STUDY UNATT&RESP EFFT 9 $0.00
95807 SLEEP STUDY, ATTENDED 3 $486.16
95808 POLYSOMNOGRAPHY, 1-3 3 $678.03
95810 POLYSOMNOGRAPHY, 4 OR MORE 3 $778.59
95811 POLYSOMNOGRAPHY W/CPAP 3 $859.49
95812 EEG, 41-60 MINUTES 3 $271.24
95813 EEG, OVER 1 HOUR 3 $324.46
95816 EEG, AWAKE AND DROWSY 3 $248.81
95817 ELECTROENCEPHALOGRAM (EEG) INCLUDIN O $0.00
95819 EEG, AWAKE AND ASLEEP 3 $272.38
95821 ELECTROENCEPHALOGRAM (EEG) INCLUDIN O $0.00
95822 EEG, COMA OR SLEEP ONLY 3 $262.55
95823 ELECTROENCEPHALOGRAM (EEG); PHYSICA O $0.00
95824 EEG, CEREBRAL DEATH ONLY 3 $0.00
95826 ELECTROENCEPHALOGRAM (EEG); INTRACE O $0.00
95827 EEG, ALL NIGHT RECORDING 3 $464.48
95828 POLYSOMNOGRAPHY (RECORDING, ANALYSI O $0.00
95829 SURGERY ELECTROCORTICOGRAM 3 $1,332.99
95830 INSERT ELECTRODES FOR EEG 9 $0.00
95831 LIMB MUSCLE TESTING, MANUAL 3 $27.35
95832 HAND MUSCLE TESTING, MANUAL 3 $25.82
95833 BODY MUSCLE TESTING, MANUAL 3 $35.94
95834 BODY MUSCLE TESTING, MANUAL 3 $43.58
95842 MUSCLE TESTING, ELECTRICAL: REACTIO O $0.00
95851 RANGE OF MOTION MEASUREMENTS 9 $0.00
95852 RANGE OF MOTION MEASUREMENTS 3 $13.71
95857 TENSILON TEST 3 $44.29
95858 TENSILON TEST & MYOGRAM O $0.00
95860 MUSCLE TEST, ONE LIMB 3 $84.95
95861 MUSCLE TEST, 2 LIMBS 3 $123.25
95863 MUSCLE TEST, 3 LIMBS 3 $147.65
95864 MUSCLE TEST, 4 LIMBS 3 $165.64
95865 MUSCLE TEST, LARYNX 3 $115.41
95866 MUSCLE TEST, HEMIDIAPHRAGM 3 $97.54
95867 MUSCLE TEST CRAN NERV UNILAT 3 $74.58
95868 MUSCLE TEST CRAN NERVE BILAT 3 $101.92
95869 MUSCLE TEST, THOR PARASPINAL 3 $51.43
95870 MUSCLE TEST, NONPARASPINAL 3 $49.91
95872 MUSCLE TEST, ONE FIBER 9 $0.00
95873 GUIDE NERV DESTR, ELEC STIM 3 $51.43
95874 GUIDE NERV DESTR, NEEDLE EMG 3 $48.78
95875 LIMB EXERCISE TEST 3 $97.73
95880 ASSESSMENT OF APHASIA (INCLUDES ASS O $0.00
95881 DEVELOPMENTAL TESTING (INCLUDES ASS O $0.00
95882 NEUROBEHAVIORAL STATUS EXAM (CLINIC O $0.00
95883 NEUROPSYCHOLOGICAL TESTING BATTERY O $0.00
95900 MOTOR NERVE CONDUCTION TEST 3 $55.90
95903 MOTOR NERVE CONDUCTION TEST 3 $64.98

95904 SENSE NERVE CONDUCTION TEST 3 $49.20
95905 MOTOR/SENS NRVE CONDUCT TEST 3 $79.05
95920 INTRAOP NERVE TEST ADD-ON 3 $152.51
95921 AUTONOMIC NERV FUNCTION TEST 3 $75.95
95922 AUTONOMIC NERV FUNCTION TEST 3 $92.50
95923 AUTONOMIC NERV FUNCTION TEST 3 $127.60
95925 SOMATOSENSORY TESTING 3 $133.23
95926 SOMATOSENSORY TESTING 3 $130.46
95927 SOMATOSENSORY TESTING 3 $127.18
95928 C MOTOR EVOKED, UPPR LIMBS 3 $208.47
95929 C MOTOR EVOKED, LWR LIMBS 3 $220.93
95930 VISUAL EVOKED POTENTIAL TEST 3 $116.46
95933 BLINK REFLEX TEST 3 $67.65
95934 H-REFLEX TEST 3 $51.63
95935 ''H'' OR ''F'' REFLEX STUDY, BY ELE O $0.00
95936 H-REFLEX TEST 3 $44.02
95937 NEUROMUSCULAR JUNCTION TEST 3 $59.12
95950 AMBULATORY EEG MONITORING 3 $253.43
95951 EEG MONITORING/VIDEORECORD 3 $0.00
95952 MONITORING FOR LOCALIZATION OF CERE 9 $0.00
95953 EEG MONITORING/COMPUTER 3 $428.64
95954 EEG MONITORING/GIVING DRUGS 9 $0.00
95955 EEG DURING SURGERY 9 $0.00
95956 EEG MONITORING, CABLE/RADIO 3 $744.98
95957 EEG DIGITAL ANALYSIS 3 $292.77
95958 EEG MONITORING/FUNCTION TEST 9 $0.00
95961 ELECTRODE STIMULATION, BRAIN 3 $234.42
95962 ELECTRODE STIM, BRAIN ADD-ON 3 $215.22
95965 MEG, SPONTANEOUS 3 $0.00
95966 MEG, EVOKED, SINGLE 3 $0.00
95967 MEG, EVOKED, EACH ADDL 3 $0.00
95970 ANALYZE NEUROSTIM, NO PROG 3 $53.84
95971 ANALYZE NEUROSTIM, SIMPLE 3 $56.94
95972 ANALYZE NEUROSTIM, COMPLEX 3 $102.99
95973 ANALYZE NEUROSTIM, COMPLEX 3 $57.38
95974 CRANIAL NEUROSTIM, COMPLEX 3 $177.38
95975 CRANIAL NEUROSTIM, COMPLEX 3 $96.44
95978 ANALYZE NEUROSTIM BRAIN/1H 3 $213.72
95979 ANALYZ NEUROSTIM BRAIN ADDON 3 $94.49
95980 IO ANAL GAST N-STIM INIT 3 $42.75
95981 IO ANAL GAST N-STIM SUBSQ 3 $28.84
95982 IO GA N-STIM SUBSQ W/REPROG 3 $45.51
95990 SPIN/BRAIN PUMP REFIL & MAIN 3 $65.50
95991 SPIN/BRAIN PUMP REFIL & MAIN 3 $95.26
95992 CANALITH REPOSITIONING PROC 3 $42.37
95999 NEUROLOGICAL PROCEDURE 5 $0.00
96000 MOTION ANALYSIS, VIDEO/3D 9 $0.00
96001 MOTION TEST W/FT PRESS MEAS 9 $0.00
96002 DYNAMIC SURFACE EMG 9 $0.00

96003 DYNAMIC FINE WIRE EMG 9 $0.00
96004 PHYS REVIEW OF MOTION TESTS 9 $0.00
96020 FUNCTIONAL BRAIN MAPPING 3 $0.00
96040 GENETIC COUNSELING, 30 MIN 9 $0.00
96100 PSYCHOLOGICAL TESTING O $0.00
96101 PSYCHO TESTING BY PSYCH/PHYS 3 $83.92
96102 PSYCHO TESTING BY TECHNICIAN 9 $0.00
96103 PSYCHO TESTING ADMIN BY COMP 9 $0.00
96105 ASSESSMENT OF APHASIA 9 $0.00
96110 DEVELOPMENTAL TEST, LIM 3 $7.43
96111 DEVELOPMENTAL TEST, EXTEND 7 $0.00
96115 NEUROBEHAVIOR STATUS EXAM O $0.00
96116 NEUROBEHAVIORAL STATUS EXAM 9 $0.00
96117 NEUROPSYCH TEST BATTERY O $0.00
96118 NEUROPSYCH TST BY PSYCH/PHYS 3 $102.44
96119 NEUROPSYCH TESTING BY TEC 9 $0.00
96120 NEUROPSYCH TST ADMIN W/COMP 9 $0.00
96125 COGNITIVE TEST BY HC PRO 9 $0.00
96150 ASSESS HLTH/BEHAVE, INIT 9 $0.00
96151 ASSESS HLTH/BEHAVE, SUBSEQ 9 $0.00
96152 INTERVENE HLTH/BEHAVE, INDIV 9 $0.00
96153 INTERVENE HLTH/BEHAVE, GROUP 9 $0.00
96154 INTERV HLTH/BEHAV, FAM W/PT 7 $0.00
96155 INTERV HLTH/BEHAV FAM NO PT 7 $0.00
96360 HYDRATION IV INFUSION, INIT 3 $55.84
96361 HYDRATE IV INFUSION, ADD-ON 3 $15.63
96365 THER/PROPH/DIAG IV INF, INIT 3 $68.64
96366 THER/PROPH/DIAG IV INF ADDON 3 $21.19
96367 TX/PROPH/DG ADDL SEQ IV INF 3 $33.27
96368 THER/DIAG CONCURRENT INF 3 $19.69
96369 SC THER INFUSION, UP TO 1 HR 3 $151.79
96370 SC THER INFUSION, ADDL HR 3 $15.14
96371 SC THER INFUSION, RESET PUMP 3 $78.49
96372 THER/PROPH/DIAG INJ, SC/IM 9 $0.00
96373 THER/PROPH/DIAG INJ, IA 9 $0.00
96374 THER/PROPH/DIAG INJ, IV PUSH 9 $0.00
96375 TX/PRO/DX INJ NEW DRUG ADDON 9 $0.00
96376 TX/PRO/DX INJ NEW DRUG ADON 6 $0.00
96379 THER/PROP/DIAG INJ/INF PROC 9 $0.00
96400 CHEMOTHERAPY, SC/IM O $0.00
96401 CHEMO, ANTI-NEOPL, SQ/IM 3 $70.02
96402 CHEMO HORMON ANTINEOPL SQ/IM 3 $36.29
96405 CHEMO INTRALESIONAL, UP TO 7 3 $84.88
96406 CHEMO INTRALESIONAL OVER 7 3 $118.03
96408 CHEMOTHERAPY, PUSH TECHNIQUE O $0.00
96409 CHEMO, IV PUSH, SNGL DRUG 3 $111.43
96410 CHEMOTHERAPY,INFUSION METHOD O $0.00
96411 CHEMO, IV PUSH, ADDL DRUG 3 $62.60
96412 CHEMO, INFUSE METHOD ADD-ON O $0.00

96413 CHEMO, IV INFUSION, 1 HR 3 $145.77
96414 CHEMO, INFUSE METHOD ADD-ON O $0.00
96415 CHEMO, IV INFUSION, ADDL HR 3 $31.38
96416 CHEMO PROLONG INFUSE W/PUMP 3 $159.71
96417 CHEMO IV INFUS EACH ADDL SEQ 3 $72.04
96420 CHEMO, IA, PUSH TECNIQUE 3 $107.47
96422 CHEMO IA INFUSION UP TO 1 HR 3 $173.23
96423 CHEMO IA INFUSE EACH ADDL HR 3 $78.38
96425 CHEMOTHERAPY,INFUSION METHOD 3 $173.86
96440 CHEMOTHERAPY, INTRACAVITARY 3 $675.06
96445 CHEMOTHERAPY, INTRACAVITARY 3 $285.89
96450 CHEMOTHERAPY, INTO CNS 3 $204.51
96520 PORT PUMP REFILL & MAIN O $0.00
96521 REFILL/MAINT, PORTABLE PUMP 3 $128.47
96522 REFILL/MAINT PUMP/RESVR SYST 3 $108.82
96523 IRRIG DRUG DELIVERY DEVICE 3 $25.14
96530 SYST PUMP REFILL & MAIN O $0.00
96542 CHEMOTHERAPY INJECTION 3 $130.57
96545 PROVIDE CHEMOTHERAPY AGENT O $0.00
96549 CHEMOTHERAPY, UNSPECIFIED 5 $0.00
96567 PHOTODYNAMIC TX, SKIN 3 $122.71
96570 PHOTODYNMC TX, 30 MIN ADD-ON 3 $58.49
96571 PHOTODYNAMIC TX, ADDL 15 MIN 3 $27.64
96900 ULTRAVIOLET LIGHT THERAPY 3 $19.90
96902 TRICHOGRAM 3 $21.52
96904 WHOLE BODY PHOTOGRAPHY 9 $0.00
96910 PHOTOCHEMOTHERAPY WITH UV-B 3 $64.88
96912 PHOTOCHEMOTHERAPY WITH UV-A 3 $83.40
96913 PHOTOCHEMOTHERAPY, UV-A OR B 3 $115.15
96920 LASER TX, SKIN < 250 SQ CM 3 $167.10
96921 LASER TX, SKIN 250-500 SQ CM 3 $165.56
96922 LASER TX, SKIN > 500 SQ CM 3 $242.23
96999 DERMATOLOGICAL PROCEDURE 5 $0.00
97001 PT EVALUATION 3 $72.03
97002 PT RE-EVALUATION 3 $39.04
97003 OT EVALUATION 3 $77.32
97004 OT RE-EVALUATION 3 $45.84
97005 ATHLETIC TRAIN EVAL 9 $0.00
97006 ATHLETIC TRAIN REEVAL 9 $0.00
97010 HOT OR COLD PACKS THERAPY 3 $5.09
97012 MECHANICAL TRACTION THERAPY 3 $15.04
97014 ELECTRIC STIMULATION THERAPY 3 $14.00
97016 VASOPNEUMATIC DEVICE THERAPY 3 $16.27
97018 PARAFFIN BATH THERAPY 3 $8.49
97020 MICROWAVE THERAPY O $0.00
97022 WHIRLPOOL THERAPY 3 $18.93
97024 DIATHERMY EG, MICROWAVE 3 $5.84
97026 INFRARED THERAPY 3 $5.09
97028 ULTRAVIOLET THERAPY 3 $6.57

97032 ELECTRICAL STIMULATION 3 $16.93
97033 ELECTRIC CURRENT THERAPY 3 $26.37
97034 CONTRAST BATH THERAPY 3 $15.86
97035 ULTRASOUND THERAPY 3 $12.07
97036 HYDROTHERAPY 3 $27.48
97039 PHYSICAL THERAPY TREATMENT 3 $11.27
97110 THERAPEUTIC EXERCISES 3 $29.16
97112 NEUROMUSCULAR REEDUCATION 3 $30.29
97113 AQUATIC THERAPY/EXERCISES 3 $36.73
97114 PHYSICAL MEDICINE TREATMENT TO ONE O $0.00
97116 GAIT TRAINING THERAPY 3 $25.82
97118 PHYSICAL MEDICINE TREATMENT TO ONE O $0.00
97120 PHYSICAL MEDICINE TREATMENT TO ONE O $0.00
97122 MANUAL TRACTION THERAPY O $0.00
97124 MASSAGE THERAPY 3 $23.62
97126 PHYSICAL MEDICINE TREATMENT TO ONE O $0.00
97128 PHYSICAL MEDICINE TREATMENT TO ONE O $0.00
97139 PHYSICAL MEDICINE PROCEDURE 3 $15.30
97140 MANUAL THERAPY 3 $27.29
97145 PHYSICAL MEDICINE TREATMENT TO ONE O $0.00
97150 GROUP THERAPEUTIC PROCEDURES 3 $18.81
97220 HUBBARD TANK; INITIAL 30 MINUTES, E O $0.00
97221 HUBBARD TANK; EACH ADDITIONAL 15 MI O $0.00
97240 POOL THERAPY OR HUBBARD TANK WITH T O $0.00
97241 POOL THERAPY OR HUBBARD TANK WITH T O $0.00
97250 MYOFASCIAL RELEASE O $0.00
97260 REGIONAL MANIPULATION O $0.00
97261 SUPPLEMENTAL MANIPULATIONS O $0.00
97265 JOINT MOBILIZATION O $0.00
97500 ORTHOTICS TRAINING (DYNAMIC BRACING O $0.00
97501 ORTHOTICS TRAINING (DYNAMIC BRACING O $0.00
97504 ORTHOTIC TRAINING O $0.00
97520 PROSTHETIC TRAINING O $0.00
97521 PROSTHETIC TRAINING; EACH ADDITIONA O $0.00
97530 THERAPEUTIC ACTIVITIES 3 $31.44
97531 KINETIC ACTIVITIES TO INCREASE COOR O $0.00
97532 COGNITIVE SKILLS DEVELOPMENT 3 $25.01
97533 SENSORY INTEGRATION 3 $27.28
97535 SELF CARE MNGMENT TRAINING 3 $31.43
97537 COMMUNITY/WORK REINTEGRATION 3 $28.03
97540 TRAINING IN ACTIVITIES OF DAILY LIV O $0.00
97541 TRAINING IN ACTIVITIES OF DAILY LIV O $0.00
97542 WHEELCHAIR MNGMENT TRAINING 3 $28.40
97545 WORK HARDENING O $0.00
97546 WORK HARDENING ADD-ON O $0.00
97597 ACTIVE WOUND CARE/20 CM OR < 3 $63.37
97598 ACTIVE WOUND CARE > 20 CM 3 $78.08
97601 WOUND(S) CARE, SELECTIVE O $0.00
97602 WOUND(S) CARE NON-SELECTIVE 9 $0.00

97605 NEG PRESS WOUND TX, < 50 CM 3 $37.44
97606 NEG PRESS WOUND TX, > 50 CM 3 $39.89
97700 OFFICE VISIT, INCLUDING ONE OF THE O $0.00
97701 OFFICE VISIT, INCLUDING ONE OF THE O $0.00
97703 PROSTHETIC CHECKOUT O $0.00
97720 EXTREMITY TESTING FOR STRENGTH, DEX O $0.00
97721 EXTREMITY TESTING FOR STRENGTH, DEX O $0.00
97750 PHYSICAL PERFORMANCE TEST 3 $30.15
97752 MUSCLE TESTING WITH TORQUE CURVES D O $0.00
97755 ASSISTIVE TECHNOLOGY ASSESS 3 $34.10
97760 ORTHOTIC MGMT AND TRAINING 3 $33.57
97761 PROSTHETIC TRAINING 3 $29.78
97762 C/O FOR ORTHOTIC/PROSTH USE 3 $36.59
97770 COGNITIVE SKILLS DEVELOPMENT O $0.00
97780 ACUPUNCTURE W/O STIMUL O $0.00
97781 ACUPUNCTURE W/STIMUL O $0.00
97799 PHYSICAL MEDICINE PROCEDURE 5 $0.00
97802 MEDICAL NUTRITION, INDIV, IN 7 $0.00
97803 MED NUTRITION, INDIV, SUBSEQ 7 $0.00
97804 MEDICAL NUTRITION, GROUP 9 $0.00
97810 ACUPUNCT W/O STIMUL 15 MIN 9 $0.00
97811 ACUPUNCT W/O STIMUL ADDL 15M 9 $0.00
97813 ACUPUNCT W/STIMUL 15 MIN 9 $0.00
97814 ACUPUNCT W/STIMUL ADDL 15M 9 $0.00
98900 MEDICAL CONFERENCE BY PHYSICIAN REG O $0.00
98902 MEDICAL CONFERENCE BY PHYSICIAN REG O $0.00
98910 MEDICAL CONFERENCE BY PHYSICIAN WIT O $0.00
98912 MEDICAL CONFERENCE BY PHYSICIAN WIT O $0.00
98920 TELEPHONE CALL BY A PHYSICIAN TO PA 9 $0.00
98921 TELEPHONE CALL BY A PHYSICIAN TO PA 9 $0.00
98922 TELEPHONE CALL BY A PHYSICIAN TO PA 9 $0.00
98925 OSTEOPATHIC MANIPULATION 3 $29.03
98926 OSTEOPATHIC MANIPULATION 3 $39.73
98927 OSTEOPATHIC MANIPULATION 3 $51.79
98928 OSTEOPATHIC MANIPULATION 3 $60.53
98929 OSTEOPATHIC MANIPULATION 3 $69.65
98940 CHIROPRACTIC MANIPULATION 9 $0.00
98941 CHIROPRACTIC MANIPULATION 9 $0.00
98942 CHIROPRACTIC MANIPULATION 9 $0.00
98943 CHIROPRACTIC MANIPULATION 9 $0.00
98960 SELF-MGMT EDUC & TRAIN, 1 PT 9 $0.00
98961 SELF-MGMT EDUC/TRAIN, 2-4 PT 9 $0.00
98962 SELF-MGMT EDUC/TRAIN, 5-8 PT 9 $0.00
98966 HC PRO PHONE CALL 5-10 MIN 9 $0.00
98967 HC PRO PHONE CALL 11-20 MIN 9 $0.00
98968 HC PRO PHONE CALL 21-30 MIN 9 $0.00
98969 ONLINE SERVICE BY HC PRO 9 $0.00
99000 SPECIMEN HANDLING 9 $0.00
99001 SPECIMEN HANDLING 3 $3.10

99002 DEVICE HANDLING 9 $0.00
99024 POSTOP FOLLOW-UP VISIT 9 $0.00
99025 INITIAL SURGICAL EVALUATION O $0.00
99026 IN-HOSPITAL ON CALL SERVICE 9 $0.00
99027 OUT-OF-HOSP ON CALL SERVICE 9 $0.00
99050 MEDICAL SERVICES AFTER HRS 3 $20.00
99051 MED SERV, EVE/WKEND/HOLIDAY 9 $0.00
99052 MEDICAL SERVICES AT NIGHT O $0.00
99053 MED SERV 10PM-8AM, 24 HR FAC 9 $0.00
99054 MEDICAL SERVCS, UNUSUAL HRS O $0.00
99056 MED SERVICE OUT OF OFFICE O $0.00
99058 OFFICE EMERGENCY CARE 9 $0.00
99060 OUT OF OFFICE EMERG MED SERV 9 $0.00
99062 EMERGENCY CARE FACILITY SERVICES: W O $0.00
99064 EMERGENCY CARE FACILITY SERVICES: W O $0.00
99065 EMERGENCY CARE FACILITY SERVICES: W O $0.00
99070 SPECIAL SUPPLIES O $0.00
99071 PATIENT EDUCATION MATERIALS 9 $0.00
99075 MEDICAL TESTIMONY 9 $0.00
99078 GROUP HEALTH EDUCATION 9 $0.00
99080 SPECIAL REPORTS OR FORMS 9 $0.00
99082 UNUSUAL PHYSICIAN TRAVEL 9 $0.00
99090 COMPUTER DATA ANALYSIS 9 $0.00
99091 COLLECT/REVIEW DATA FROM PT 9 $0.00
99100 SPECIAL ANESTHESIA SERVICE 9 $0.00
99116 ANESTHESIA WITH HYPOTHERMIA 9 $0.00
99135 SPECIAL ANESTHESIA PROCEDURE 9 $0.00
99140 EMERGENCY ANESTHESIA 9 $0.00
99141 SEDATION, IV/IM OR INHALANT O $0.00
99142 SEDATION, ORAL/RECTAL/NASAL O $0.00
99143 MOD CS BY SAME PHYS, < 5 YRS 9 $0.00
99144 MOD CS BY SAME PHYS, 5 YRS + 9 $0.00
99145 MOD CS BY SAME PHYS ADD-ON 9 $0.00
99148 MOD CS DIFF PHYS < 5 YRS 3 $112.36
99149 MOD CS DIFF PHYS 5 YRS + 3 $112.36
99150 MOD CS DIFF PHYS ADD-ON 3 $56.18
99151 PROLONGED PHYSICIAN ATTENDANCE REQU O $0.00
99152 NEWBORN RESUSCITATION: CARE OF THE O $0.00
99160 CRITICAL CARE, INITIAL, INCLUDING T O $0.00
99162 CRITICAL CARE, INITIAL, INCLUDING T O $0.00
99170 ANOGENITAL EXAM, CHILD 3 $144.00
99171 CRITICAL CARE, SUBSEQUENT FOLLOW-UP O $0.00
99172 OCULAR FUNCTION SCREEN O $0.00
99173 VISUAL ACUITY SCREEN 3 $2.46
99174 OCULAR PHOTOSCREENING 3 $26.32
99175 INDUCTION OF VOMITING 3 $23.30
99178 ADMINISTRATION AND MEDICAL INTERPRE O $0.00
99180 HYPERBARIC OXYGEN PRESSURIZATION IN O $0.00
99182 HYPERBARIC OXYGEN PRESSURIZATION SU O $0.00

99183 HYPERBARIC OXYGEN THERAPY 3 $198.62
99185 REGIONAL HYPOTHERMIA O $0.00
99186 TOTAL BODY HYPOTHERMIA O $0.00
99190 SPECIAL PUMP SERVICES 9 $0.00
99191 SPECIAL PUMP SERVICES 9 $0.00
99192 SPECIAL PUMP SERVICES 9 $0.00
99195 PHLEBOTOMY 3 $76.20
99199 SPECIAL SERVICE/PROC/REPORT 5 $0.00
99201 OFFICE/OUTPATIENT VISIT, NEW 3 $39.82
99202 OFFICE/OUTPATIENT VISIT, NEW 3 $68.46
99203 OFFICE/OUTPATIENT VISIT, NEW 3 $99.30
99204 OFFICE/OUTPATIENT VISIT, NEW 3 $153.79
99205 OFFICE/OUTPATIENT VISIT, NEW 3 $192.90
99211 OFFICE/OUTPATIENT VISIT, EST 3 $19.67
99212 OFFICE/OUTPATIENT VISIT, EST 3 $39.82
99213 OFFICE/OUTPATIENT VISIT, EST 3 $66.52
99214 OFFICE/OUTPATIENT VISIT, EST 3 $99.61
99215 OFFICE/OUTPATIENT VISIT, EST 3 $134.34
99217 OBSERVATION CARE DISCHARGE 3 $68.64
99218 OBSERVATION CARE 3 $64.11
99219 OBSERVATION CARE 3 $106.71
99220 OBSERVATION CARE 3 $149.57
99221 INITIAL HOSPITAL CARE 3 $95.63
99222 INITIAL HOSPITAL CARE 3 $129.89
99223 INITIAL HOSPITAL CARE 3 $191.52
99231 SUBSEQUENT HOSPITAL CARE 3 $38.19
99232 SUBSEQUENT HOSPITAL CARE 3 $69.26
99233 SUBSEQUENT HOSPITAL CARE 3 $99.46
99234 OBSERV/HOSP SAME DATE 3 $130.70
99235 OBSERV/HOSP SAME DATE 3 $171.45
99236 OBSERV/HOSP SAME DATE 3 $212.93
99238 HOSPITAL DISCHARGE DAY 3 $68.39
99239 HOSPITAL DISCHARGE DAY 3 $100.10
99241 OFFICE CONSULTATION 9 $0.00
99242 OFFICE CONSULTATION 9 $0.00
99243 OFFICE CONSULTATION 9 $0.00
99244 OFFICE CONSULTATION 9 $0.00
99245 OFFICE CONSULTATION 9 $0.00
99251 INPATIENT CONSULTATION 9 $0.00
99252 INPATIENT CONSULTATION 9 $0.00
99253 INPATIENT CONSULTATION 9 $0.00
99254 INPATIENT CONSULTATION 9 $0.00
99255 INPATIENT CONSULTATION 9 $0.00
99261 FOLLOW-UP INPATIENT CONSULT O $0.00
99262 FOLLOW-UP INPATIENT CONSULT O $0.00
99263 FOLLOW-UP INPATIENT CONSULT O $0.00
99271 CONFIRMATORY CONSULTATION O $0.00
99272 CONFIRMATORY CONSULTATION O $0.00
99273 CONFIRMATORY CONSULTATION O $0.00

99274 CONFIRMATORY CONSULTATION O $0.00
99275 CONFIRMATORY CONSULTATION O $0.00
99281 EMERGENCY DEPT VISIT 3 $20.71
99282 EMERGENCY DEPT VISIT 3 $40.55
99283 EMERGENCY DEPT VISIT 3 $61.63
99284 EMERGENCY DEPT VISIT 3 $116.35
99285 EMERGENCY DEPT VISIT 3 $171.43
99288 DIRECT ADVANCED LIFE SUPPORT 9 $0.00
99289 PED CRIT CARE TRANSPORT O $0.00
99290 PED CRIT CARE TRANSPORT ADDL O $0.00
99291 CRITICAL CARE, FIRST HOUR 3 $261.61
99292 CRITICAL CARE, ADDL 30 MIN 3 $117.89
99293 PED CRITICAL CARE, INITIAL O $0.00
99294 PED CRITICAL CARE, SUBSEQ O $0.00
99295 NEONATE CRIT CARE, INITIAL O $0.00
99296 NEONATE CRITICAL CARE SUBSEQ O $0.00
99297 NEONATAL CRITICAL CARE O $0.00
99298 IC FOR LBW INFANT < 1500 GM O $0.00
99299 IC, LBW INFANT 1500-2500 GM O $0.00
99300 IC, INFANT PBW 2501-5000 GM O $0.00
99301 NURSING FACILITY CARE O $0.00
99302 NURSING FACILITY CARE O $0.00
99303 NURSING FACILITY CARE O $0.00
99304 NURSING FACILITY CARE, INIT 3 $85.80
99305 NURSING FACILITY CARE, INIT 3 $120.52
99306 NURSING FACILITY CARE, INIT 3 $154.13
99307 NURSING FAC CARE, SUBSEQ 3 $41.36
99308 NURSING FAC CARE, SUBSEQ 3 $63.63
99309 NURSING FAC CARE, SUBSEQ 3 $83.80
99310 NURSING FAC CARE, SUBSEQ 3 $124.22
99311 NURSING FAC CARE, SUBSEQ O $0.00
99312 NURSING FAC CARE, SUBSEQ O $0.00
99313 NURSING FAC CARE, SUBSEQ O $0.00
99315 NURSING FAC DISCHARGE DAY 9 $0.00
99316 NURSING FAC DISCHARGE DAY 9 $0.00
99318 ANNUAL NURSING FAC ASSESSMNT 3 $87.99
99321 REST HOME VISIT, NEW PATIENT O $0.00
99322 REST HOME VISIT, NEW PATIENT O $0.00
99323 REST HOME VISIT, NEW PATIENT O $0.00
99324 DOMICIL/R-HOME VISIT NEW PAT 9 $0.00
99325 DOMICIL/R-HOME VISIT NEW PAT 9 $0.00
99326 DOMICIL/R-HOME VISIT NEW PAT 9 $0.00
99327 DOMICIL/R-HOME VISIT NEW PAT 9 $0.00
99328 DOMICIL/R-HOME VISIT NEW PAT 9 $0.00
99331 REST HOME VISIT, EST PAT O $0.00
99332 REST HOME VISIT, EST PAT O $0.00
99333 REST HOME VISIT, EST PAT O $0.00
99334 DOMICIL/R-HOME VISIT EST PAT 9 $0.00
99335 DOMICIL/R-HOME VISIT EST PAT 9 $0.00

99336 DOMICIL/R-HOME VISIT EST PAT 9 $0.00
99337 DOMICIL/R-HOME VISIT EST PAT 9 $0.00
99339 DOMICIL/R-HOME CARE SUPERVIS 9 $0.00
99340 DOMICIL/R-HOME CARE SUPERVIS 9 $0.00
99341 HOME VISIT, NEW PATIENT 3 $54.75
99342 HOME VISIT, NEW PATIENT 3 $79.79
99343 HOME VISIT, NEW PATIENT 3 $130.01
99344 HOME VISIT, NEW PATIENT 3 $172.38
99345 HOME VISIT, NEW PATIENT 3 $207.00
99347 HOME VISIT, EST PATIENT 3 $54.39
99348 HOME VISIT, EST PATIENT 3 $81.76
99349 HOME VISIT, EST PATIENT 3 $120.08
99350 HOME VISIT, EST PATIENT 3 $167.59
99351 HOME VISIT FOR THE EVALUATION AND M O $0.00
99352 HOME VISIT FOR THE EVALUATION AND M O $0.00
99353 HOME VISIT FOR THE EVALUATION AND M O $0.00
99354 PROLONGED SERVICE, OFFICE 3 $94.59
99355 PROLONGED SERVICE, OFFICE 3 $93.84
99356 PROLONGED SERVICE, INPATIENT 3 $86.73
99357 PROLONGED SERVICE, INPATIENT 3 $86.73
99358 PROLONG SERVICE W/O CONTACT 9 $0.00
99359 PROLONG SERV W/O CONTACT ADD 9 $0.00
99360 PHYSICIAN STANDBY SERVICES 3 $61.18
99361 PHYSICIAN/TEAM CONFERENCE O $0.00
99362 PHYSICIAN/TEAM CONFERENCE O $0.00
99363 ANTICOAG MGMT, INIT 9 $0.00
99364 ANTICOAG MGMT, SUBSEQ 9 $0.00
99366 TEAM CONF W/PAT BY HC PRO 9 $0.00
99367 TEAM CONF W/O PAT BY PHYS 9 $0.00
99368 TEAM CONF W/O PAT BY HC PRO 9 $0.00
99371 PHYSICIAN PHONE CONSULTATION O $0.00
99372 PHYSICIAN PHONE CONSULTATION O $0.00
99373 PHYSICIAN PHONE CONSULTATION O $0.00
99374 HOME HEALTH CARE SUPERVISION 9 $0.00
99375 HOME HEALTH CARE SUPERVISION 9 $0.00
99376 PHYSICIAN SUPERVISION OF PATIENTS U 9 $0.00
99377 HOSPICE CARE SUPERVISION 9 $0.00
99378 HOSPICE CARE SUPERVISION 9 $0.00
99379 NURSING FAC CARE SUPERVISION 9 $0.00
99380 NURSING FAC CARE SUPERVISION 9 $0.00
99381 INIT PM E/M, NEW PAT, INF 3 $92.94
99382 INIT PM E/M, NEW PAT 1-4 YRS 3 $101.05
99383 PREV VISIT, NEW, AGE 5-11 3 $100.67
99384 PREV VISIT, NEW, AGE 12-17 3 $109.40
99385 PREV VISIT, NEW, AGE 18-39 3 $109.40
99386 PREV VISIT, NEW, AGE 40-64 3 $127.96
99387 INIT PM E/M, NEW PAT 65+ YRS 3 $140.45
99391 PER PM REEVAL, EST PAT, INF 3 $78.17
99392 PREV VISIT, EST, AGE 1-4 3 $86.90

99393 PREV VISIT, EST, AGE 5-11 3 $86.52
99394 PREV VISIT, EST, AGE 12-17 3 $95.00
99395 PREV VISIT, EST, AGE 18-39 3 $95.37
99396 PREV VISIT, EST, AGE 40-64 3 $104.11
99397 PER PM REEVAL EST PAT 65+ YR 3 $116.97
99401 PREVENTIVE COUNSELING, INDIV 7 $0.00
99402 PREVENTIVE COUNSELING, INDIV 7 $0.00
99403 PREVENTIVE COUNSELING, INDIV 7 $0.00
99404 PREVENTIVE COUNSELING, INDIV 7 $0.00
99406 BEHAV CHNG SMOKING 3-10 MIN 9 $0.00
99407 BEHAV CHNG SMOKING > 10 MIN 9 $0.00
99408 AUDIT/DAST, 15-30 MIN 9 $0.00
99409 AUDIT/DAST, OVER 30 MIN 9 $0.00
99411 PREVENTIVE COUNSELING, GROUP 9 $0.00
99412 PREVENTIVE COUNSELING, GROUP 9 $0.00
99420 HEALTH RISK ASSESSMENT TEST 9 $0.00
99429 UNLISTED PREVENTIVE SERVICE 9 $0.00
99431 INITIAL CARE, NORMAL NEWBORN O $0.00
99432 NEWBORN CARE, NOT IN HOSP O $0.00
99433 NORMAL NEWBORN CARE/HOSPITAL O $0.00
99435 NEWBORN DISCHARGE DAY HOSP O $0.00
99436 ATTENDANCE, BIRTH O $0.00
99438 INFANT CARE TO ONE YEAR OF AGE, WIT 9 $0.00
99440 NEWBORN RESUSCITATION O $0.00
99441 PHONE E/M BY PHYS 5-10 MIN 9 $0.00
99442 PHONE E/M BY PHYS 11-20 MIN 9 $0.00
99443 PHONE E/M BY PHYS 21-30 MIN 9 $0.00
99444 ONLINE E/M BY PHYS 9 $0.00
99450 BASIC LIFE DISABILITY EXAM 9 $0.00
99455 WORK RELATED DISABILITY EXAM 9 $0.00
99456 DISABILITY EXAMINATION 9 $0.00
99460 INIT NB EM PER DAY, HOSP 3 $57.71
99461 INIT NB EM PER DAY, NON-FAC 3 $88.33
99462 SBSQ NB EM PER DAY, HOSP 3 $30.95
99463 SAME DAY NB DISCHARGE 3 $78.19
99464 ATTENDANCE AT DELIVERY 3 $72.28
99465 NB RESUSCITATION 3 $149.14
99466 PED CRIT CARE TRANSPORT 3 $250.82
99467 PED CRIT CARE TRANSPORT ADDL 3 $119.24
99468 NEONATE CRIT CARE, INITIAL 3 $899.14
99469 NEONATE CRIT CARE, SUBSQ 3 $388.70
99471 PED CRITICAL CARE, INITIAL 3 $779.01
99472 PED CRITICAL CARE, SUBSQ 3 $390.43
99475 PED CRIT CARE AGE 2-5, INIT 3 $540.96
99476 PED CRIT CARE AGE 2-5, SUBSQ 3 $324.70
99477 INIT DAY HOSP NEONATE CARE 3 $343.85
99478 IC, LBW INF < 1500 GM SUBSQ 3 $140.32
99479 IC LBW INF 1500-2500 G SUBSQ 3 $124.14
99480 IC INF PBW 2501-5000 G SUBSQ 3 $119.34

99499 UNLISTED E&M SERVICE 5 $0.00
99500 HOME VISIT, PRENATAL 9 $0.00
99501 HOME VISIT, POSTNATAL 9 $0.00
99502 HOME VISIT, NB CARE 9 $0.00
99503 HOME VISIT, RESP THERAPY 9 $0.00
99504 HOME VISIT MECH VENTILATOR 9 $0.00
99505 HOME VISIT, STOMA CARE 9 $0.00
99506 HOME VISIT, IM INJECTION 9 $0.00
99507 HOME VISIT, CATH MAINTAIN 9 $0.00
99508 HOME VISIT, SLEEP STUDIES 9 $0.00
99509 HOME VISIT DAY LIFE ACTIVITY 9 $0.00
99510 HOME VISIT, SING/M/FAM COUNS 7 $0.00
99511 HOME VISIT, FECAL/ENEMA MGMT 9 $0.00
99512 HOME VISIT FOR HEMODIALYSIS 9 $0.00
99539 HOME VISIT, NOS 9 $0.00
99551 HOME INFUS, PAIN MGMT, IV/SC O $0.00
99552 HM INFUS PAIN MGMT, EPID/ITH O $0.00
99553 HOME INFUSE, TOCOLYTIC TX O $0.00
99554 HOME INFUS, HORMONE/PLATELET O $0.00
99555 HOME INFUSE, CHEMOTHERAPHY O $0.00
99556 HOME INFUS, ANTIBIO/FUNG/VIR O $0.00
99557 HOME INFUSE, ANTICOAGULANT O $0.00
99558 HOME INFUSE, IMMUNOTHERAPY O $0.00
99559 HOME INFUS, PERITON DIALYSIS O $0.00
99560 HOME INFUS, ENTERO NUTRITION O $0.00
99561 HOME INFUSE, HYDRATION TX O $0.00
99562 HOME INFUS, PARENT NUTRITION O $0.00
99563 HOME ADMIN, PENTAMIDINE O $0.00
99564 HME INFUS, ANTIHEMOPHIL AGNT O $0.00
99565 HOME INFUS, PROTEINASE INHIB O $0.00
99566 HOME INFUSE, IV THERAPY O $0.00
99567 HOME INFUSE, SYMPATH AGENT O $0.00
99568 HOME INFUS, MISC DRUG, DAILY O $0.00
99569 HOME INFUSE, EACH ADDL TX O $0.00
99600 HOME VISIT NOS 9 $0.00
99601 HOME INFUSION/VISIT, 2 HRS 9 $0.00
99602 HOME INFUSION, EACH ADDTL HR 9 $0.00
99605 MTMS BY PHARM, NP, 15 MIN 9 $0.00
99606 MTMS BY PHARM, EST, 15 MIN 9 $0.00
99607 MTMS BY PHARM, ADDL 15 MIN 9 $0.00
A0010 AMBULANCE SERVICE, BASIC LIFE SUPPO 9 $0.00
A0020 AMBULANCE SERVICE, (BLS) PER MILE, 9 $0.00
A0021 OUTSIDE STATE AMBULANCE SERV 9 $0.00
A0030 AIR AMBULANCE SERVICE 9 $0.00
A0040 HELICOPTER AMBULANCE SERVICE O $0.00
A0050 WATER AMB SERVICE EMERGENCY 9 $0.00
A0060 AMBULANCE SERVICE, WAITING TIME, ON 9 $0.00
A0070 AMBULANCE SERVICE, OXYGEN, ADMINIST O $0.00
A0080 NONINTEREST ESCORT IN NON ER 9 $0.00

A0090 INTEREST ESCORT IN NON ER 3 $0.20
A0100 NONEMERGENCY TRANSPORT TAXI 7 $0.00
A0110 NONEMERGENCY TRANSPORT BUS 7 $0.00
A0120 NONER TRANSPORT MINI-BUS 7 $0.00
A0130 NONER TRANSPORT WHEELCH VAN 3 $11.01
A0140 NONEMERGENCY TRANSPORT AIR 5 $0.00
A0150 NON-EMERGENCY TRANSPORTATION, AMBUL O $0.00
A0160 NONER TRANSPORT CASE WORKER 9 $0.00
A0170 TRANSPORT PARKING FEES/TOLLS 5 $0.00
A0180 NONER TRANSPORT LODGNG RECIP 5 $0.00
A0190 NONER TRANSPORT MEALS RECIP 5 $0.00
A0200 NONER TRANSPORT LODGNG ESCRT 5 $0.00
A0210 NONER TRANSPORT MEALS ESCORT 5 $0.00
A0215 AMBULANCE SERVICE, MISCELLANEOUS DI 9 $0.00
A0220 AMBULANCE SERVICE, ADVANCED LIFE SU 9 $0.00
A0221 AMBULANCE SERVICE, (ALS) PER MILE, 9 $0.00
A0222 AMBULANCE SERVICE, RETURN TRIP, TRA 9 $0.00
A0223 AMBULANCE SERVICE, ADVANCED LIFE SU 9 $0.00
A0225 NEONATAL EMERGENCY TRANSPORT 3 $95.00
A0300 AMBULANCE BASIC NON-EMER ALL 9 $0.00
A0302 AMBULANCE BASIC EMERGENY ALL 9 $0.00
A0304 AMB ADV NON-ER NO SERV ALL 9 $0.00
A0306 AMB ADV NON-ER SPEC SERV ALL 9 $0.00
A0308 AMB ADV ER NO SPEC SERV ALL 9 $0.00
A0310 AMB ADV ER SPEC SERV ALL 9 $0.00
A0320 AMB BASIC NON-ER + SUPPLIES 9 $0.00
A0322 AMB BASIC EMERG + SUPPLIES 9 $0.00
A0324 ADV NON-ER SERV SEP MILEAGE 9 $0.00
A0326 ADV NON-ER NO SERV SEP MILE 9 $0.00
A0328 ADV ER NO SERV SEP MILEAGE 9 $0.00
A0330 ADV ER SPEC SERV SEP MILE 9 $0.00
A0340 AMB BASIC NON-ER + MILEAGE 9 $0.00
A0342 AMBUL BASIC EMER + MILEAGE 9 $0.00
A0344 AMB ADV NON-ER NO SERV +MILE 9 $0.00
A0346 AMB ADV NON-ER SERV + MILE 9 $0.00
A0348 ADV EMER NO SPEC SERV + MILE 9 $0.00
A0350 ADV EMER SPEC SERV + MILEAGE 9 $0.00
A0360 BASIC NON-ER SEP MILE & SUPP 9 $0.00
A0362 BASIC EMER SEP MILE & SUPPLY 9 $0.00
A0364 ADV NON-ER NO SERV SEP MI&SU 9 $0.00
A0366 ADV NON-ER SERV SEP MIL&SUPP 9 $0.00
A0368 ADV ER NO SERV SEP MILE&SUPP 9 $0.00
A0370 ADV ER SPEC SERV SEP MI&SUPP 9 $0.00
A0380 BASIC LIFE SUPPORT MILEAGE 3 $1.50
A0382 BASIC SUPPORT ROUTINE SUPPLS 9 $0.00
A0384 BLS DEFIBRILLATION SUPPLIES 9 $0.00
A0390 ADVANCED LIFE SUPPORT MILEAG 3 $1.50
A0392 ALS DEFIBRILLATION SUPPLIES 9 $0.00
A0394 ALS IV DRUG THERAPY SUPPLIES 9 $0.00

A0396 ALS ESOPHAGEAL INTUB SUPPLS 9 $0.00
A0398 ALS ROUTINE DISPOSBLE SUPPLS 9 $0.00
A0420 AMBULANCE WAITING 1/2 HR 9 $0.00
A0422 AMBULANCE 02 LIFE SUSTAINING 3 $12.00
A0424 EXTRA AMBULANCE ATTENDANT 5 $0.00
A0425 GROUND MILEAGE 9 $0.00
A0426 ALS 1 3 $35.00
A0427 ALS1-EMERGENCY 3 $55.00
A0428 BLS 3 $35.00
A0429 BLS-EMERGENCY 3 $55.00
A0430 FIXED WING AIR TRANSPORT 9 $0.00
A0431 ROTARY WING AIR TRANSPORT 3 $2,124.00
A0432 PI VOLUNTEER AMBULANCE CO 9 $0.00
A0433 ALS 2 9 $0.00
A0434 SPECIALTY CARE TRANSPORT 9 $0.00
A0435 FIXED WING AIR MILEAGE 9 $0.00
A0436 ROTARY WING AIR MILEAGE 3 $12.80
A0800 AMB TRANS 7PM-7AM O $0.00
A0888 NONCOVERED AMBULANCE MILEAGE 9 $0.00
A0998 AMBULANCE RESPONSE/TREATMENT 9 $0.00
A0999 UNLISTED AMBULANCE SERVICE 9 $0.00
A2000 MANIPULATION OF SPINE BY CHIROPRACT 9 $0.00
A4190 TRANSPARENT FILM, EACH O $0.00
A4200 GAUZE PADS, MEDICATED OR NON-MEDICA O $0.00
A4202 GAUZE, ELASTIC, ALL TYPES, PER ROLL O $0.00
A4203 GAUZE, NON-ELASTIC, PER ROLL O $0.00
A4204 ABSORPTIVE DRESSING (E.G. HYDROCOLL O $0.00
A4205 NON-ABSORPTIVE DRESSING (E.G. HYDRO O $0.00
A4206 1 CC STERILE SYRINGE&NEEDLE 3 $0.22
A4207 2 CC STERILE SYRINGE&NEEDLE 3 $0.20
A4208 3 CC STERILE SYRINGE&NEEDLE 3 $0.18
A4209 5+ CC STERILE SYRINGE&NEEDLE 3 $0.36
A4210 NONNEEDLE INJECTION DEVICE 3 $1.50
A4211 SUPP FOR SELF-ADM INJECTIONS O $0.00
A4212 NON CORING NEEDLE OR STYLET 5 $0.00
A4213 20+ CC SYRINGE ONLY 3 $0.68
A4214 30 CC STERILE WATER/SALINE O $0.00
A4215 STERILE NEEDLE 5 $0.00
A4216 STERILE WATER/SALINE, 10 ML 3 $0.54
A4217 STERILE WATER/SALINE, 500 ML 3 $3.13
A4218 STERILE SALINE OR WATER 6 $0.00
A4220 INFUSION PUMP REFILL KIT 9 $0.00
A4221 MAINT DRUG INFUS CATH PER WK 3 $22.52
A4222 INFUSION SUPPLIES WITH PUMP 3 $46.50
A4223 INFUSION SUPPLIES W/O PUMP 6 $0.00
A4230 INFUS INSULIN PUMP NON NEEDL 3 $10.07
A4231 INFUSION INSULIN PUMP NEEDLE 5 $0.00
A4232 SYRINGE W/NEEDLE INSULIN 3CC 3 $2.54
A4233 ALKALIN BATT FOR GLUCOSE MON 6 $0.00

A4234 J-CELL BATT FOR GLUCOSE MON 6 $0.00
A4235 LITHIUM BATT FOR GLUCOSE MON 3 $2.34
A4236 SILVR OXIDE BATT GLUCOSE MON 6 $0.00
A4244 ALCOHOL OR PEROXIDE PER PINT 3 $1.00
A4245 ALCOHOL WIPES PER BOX 3 $10.00
A4246 BETADINE/PHISOHEX SOLUTION 3 $10.00
A4247 BETADINE/IODINE SWABS/WIPES 3 $8.00
A4248 CHLORHEXIDINE ANTISEPT 6 $0.00
A4250 URINE REAGENT STRIPS/TABLETS 3 $17.25
A4252 BLOOD KETONE TEST OR STRIP 6 $0.00
A4253 BLOOD GLUCOSE/REAGENT STRIPS 9 $0.00
A4254 BATTERY FOR GLUCOSE MONITOR O $0.00
A4255 GLUCOSE MONITOR PLATFORMS 9 $0.00
A4256 CALIBRATOR SOLUTION/CHIPS 9 $0.00
A4257 REPLACE LENSSHIELD CARTRIDGE 9 $0.00
A4258 LANCET DEVICE EACH 9 $0.00
A4259 LANCETS PER BOX 9 $0.00
A4260 LEVONORGESTREL (CONTRACEPTIVE) IMP O $0.00
A4261 CERVICAL CAP CONTRACEPTIVE 9 $0.00
A4262 TEMPORARY TEAR DUCT PLUG 9 $0.00
A4263 PERMANENT TEAR DUCT PLUG 9 $0.00
A4264 INTRATUBAL OCCLUSION DEVICE 9 $0.00
A4265 PARAFFIN 9 $0.00
A4266 DIAPHRAGM 9 $0.00
A4267 MALE CONDOM 9 $0.00
A4268 FEMALE CONDOM 9 $0.00
A4269 SPERMICIDE 9 $0.00
A4270 DISPOSABLE ENDOSCOPE SHEATH 9 $0.00
A4280 BRST PRSTHS ADHSV ATTCHMNT 3 $4.62
A4281 REPLACEMENT BREASTPUMP TUBE 5 $0.00
A4282 REPLACEMENT BREASTPUMP ADPT 5 $0.00
A4283 REPLACEMENT BREASTPUMP CAP 5 $0.00
A4284 REPLCMNT BREAST PUMP SHIELD 5 $0.00
A4285 REPLCMNT BREAST PUMP BOTTLE 5 $0.00
A4286 REPLCMNT BREASTPUMP LOK RING 5 $0.00
A4290 SACRAL NERVE STIM TEST LEAD 5 $0.00
A4300 CATH IMPL VASC ACCESS PORTAL 9 $0.00
A4301 IMPLANTABLE ACCESS SYST PERC 9 $0.00
A4305 DRUG DELIVERY SYSTEM >=50 ML 3 $17.04
A4306 DRUG DELIVERY SYSTEM

A4321 CATH THERAPEUTIC IRRIG AGENT 9 $0.00
A4322 IRRIGATION SYRINGE 3 $2.81
A4323 SALINE IRRIGATION SOLUTION O $0.00
A4324 MALE EXT CATH W/ADH COATING O $0.00
A4325 MALE EXT CATH W/ADH STRIP O $0.00
A4326 MALE EXTERNAL CATHETER 3 $10.29
A4327 FEM URINARY COLLECT DEV CUP 3 $40.32
A4328 FEM URINARY COLLECT POUCH 3 $9.97
A4329 EXTERNAL CATHETER START SET O $0.00
A4330 STOOL COLLECTION POUCH 3 $6.82
A4331 EXTENSION DRAINAGE TUBING 3 $3.04
A4332 LUBE STERILE PACKET 3 $0.12
A4333 URINARY CATH ANCHOR DEVICE 3 $2.10
A4334 URINARY CATH LEG STRAP 3 $4.71
A4335 INCONTINENCE SUPPLY 5 $0.00
A4336 URETHRAL INSERT 9 $0.00
A4338 INDWELLING CATHETER LATEX 3 $10.08
A4340 INDWELLING CATHETER SPECIAL 3 $30.28
A4344 CATH INDW FOLEY 2 WAY SILICN 3 $12.99
A4346 CATH INDW FOLEY 3 WAY 3 $16.26
A4347 MALE EXTERNAL CATHETER O $0.00
A4348 MALE EXT CATH EXTENDED WEAR O $0.00
A4349 DISPOSABLE MALE EXTERNAL CAT 3 $2.02
A4350 CATHETER CARE KIT 9 $0.00
A4351 STRAIGHT TIP URINE CATHETER 3 $1.66
A4352 COUDE TIP URINARY CATHETER 3 $6.12
A4353 INTERMITTENT URINARY CATH 3 $6.66
A4354 CATH INSERTION TRAY W/BAG 3 $11.16
A4355 BLADDER IRRIGATION TUBING 3 $8.50
A4356 EXT URETH CLMP OR COMPR DVC 3 $43.52
A4357 BEDSIDE DRAINAGE BAG 3 $8.77
A4358 URINARY LEG OR ABDOMEN BAG 3 $6.33
A4359 URINARY SUSPENSORY W/O LEG B O $0.00
A4360 DISPOSABLE EXT URETHRAL DEV 6 $0.00
A4361 OSTOMY FACE PLATE 3 $17.42
A4362 SOLID SKIN BARRIER 3 $3.30
A4363 OSTOMY CLAMP, REPLACEMENT 6 $0.00
A4364 ADHESIVE, LIQUID OR EQUAL 3 $2.80
A4365 ADHESIVE REMOVER WIPES O $0.00
A4366 OSTOMY VENT 6 $0.00
A4367 OSTOMY BELT 3 $7.01
A4368 OSTOMY FILTER 9 $0.00
A4369 SKIN BARRIER LIQUID PER OZ 3 $2.30
A4370 SKIN BARRIER PASTE PER OZ O $0.00
A4371 SKIN BARRIER POWDER PER OZ 3 $3.48
A4372 SKIN BARRIER SOLID 4X4 EQUIV 3 $3.98
A4373 SKIN BARRIER WITH FLANGE 3 $5.99
A4374 SKIN BARRIER EXTENDED WEAR O $0.00
A4375 DRAINABLE PLASTIC PCH W FCPL 3 $16.38

A4376 DRAINABLE RUBBER PCH W FCPLT 3 $45.38
A4377 DRAINABLE PLSTIC PCH W/O FP 3 $4.09
A4378 DRAINABLE RUBBER PCH W/O FP 3 $29.33
A4379 URINARY PLASTIC POUCH W FCPL 3 $14.33
A4380 URINARY RUBBER POUCH W FCPLT 3 $35.60
A4381 URINARY PLASTIC POUCH W/O FP 3 $4.40
A4382 URINARY HVY PLSTC PCH W/O FP 3 $23.48
A4383 URINARY RUBBER POUCH W/O FP 3 $26.89
A4384 OSTOMY FACEPLT/SILICONE RING 3 $9.18
A4385 OST SKN BARRIER SLD EXT WEAR 3 $4.86
A4386 OST SKN BARRIER W FLNG EX WR O $0.00
A4387 OST CLSD POUCH W ATT ST BARR 3 $3.83
A4388 DRAINABLE PCH W EX WEAR BARR 3 $4.16
A4389 DRAINABLE PCH W ST WEAR BARR 3 $5.93
A4390 DRAINABLE PCH EX WEAR CONVEX 3 $9.17
A4391 URINARY POUCH W EX WEAR BARR 3 $6.74
A4392 URINARY POUCH W ST WEAR BARR 3 $6.34
A4393 URINE PCH W EX WEAR BAR CONV 3 $8.75
A4394 OSTOMY POUCH LIQ DEODORANT 3 $2.46
A4395 OSTOMY POUCH SOLID DEODORANT 3 $0.05
A4396 PERISTOMAL HERNIA SUPPRT BLT 3 $38.61
A4397 IRRIGATION SUPPLY SLEEVE 3 $4.57
A4398 OSTOMY IRRIGATION BAG 3 $13.17
A4399 OSTOMY IRRIG CONE/CATH W BRS 3 $11.70
A4400 OSTOMY IRRIGATION SET 3 $46.62
A4402 LUBRICANT PER OUNCE 3 $1.32
A4404 OSTOMY RING EACH 3 $1.52
A4405 NONPECTIN BASED OSTOMY PASTE 3 $3.40
A4406 PECTIN BASED OSTOMY PASTE 3 $5.74
A4407 EXT WEAR OST SKN BARR

A4427 OST PCH DRAIN/BARR LK FLNG/F 3 $2.78
A4428 URINE OST POUCH W FAUCET/TAP 3 $6.51
A4429 URINE OST POUCH W BLTINCONV 3 $8.25
A4430 OST URINE PCH W B/BLTIN CONV 3 $8.52
A4431 OST PCH URINE W BARRIER/TAPV 3 $6.22
A4432 OS PCH URINE W BAR/FANGE/TAP 3 $3.59
A4433 URINE OST PCH BAR W LOCK FLN 3 $3.34
A4434 OST PCH URINE W LOCK FLNG/FT 3 $3.76
A4450 NON-WATERPROOF TAPE 3 $0.09
A4452 WATERPROOF TAPE 3 $0.36
A4454 TAPE ALL TYPES ALL SIZES O $0.00
A4455 ADHESIVE REMOVER PER OUNCE 3 $1.33
A4456 ADHESIVE REMOVER, WIPES 6 $0.00
A4458 REUSABLE ENEMA BAG 5 $0.00
A4460 ELASTIC COMPRESSION BANDAGE O $0.00
A4461 SURGICL DRESS HOLD NON-REUSE 6 $0.00
A4462 ABDMNL DRSSNG HOLDER/BINDER O $0.00
A4463 SURGICAL DRESS HOLDER REUSE 6 $0.00
A4464 JOINT SUPPORT DEVICE/GARMENT O $0.00
A4465 NON-ELASTIC EXTREMITY BINDER 9 $0.00
A4466 ELASTIC GARMENT/COVERING 6 $0.00
A4470 GRAVLEE JET WASHER 5 $0.00
A4480 VABRA ASPIRATOR 3 $20.00
A4481 TRACHEOSTOMA FILTER 9 $0.00
A4483 MOISTURE EXCHANGER 3 $2.86
A4490 ABOVE KNEE SURGICAL STOCKING 3 $60.00
A4495 THIGH LENGTH SURG STOCKING 3 $60.00
A4500 BELOW KNEE SURGICAL STOCKING 3 $30.00
A4510 FULL LENGTH SURG STOCKING 3 $60.00
A4520 INCONTINENCE GARMENT ANYTYPE 9 $0.00
A4521 ADULT SIZE DIAPER SM EACH O $0.00
A4522 ADULT SIZE DIAPER MED EACH O $0.00
A4523 ADULT SIZE DIAPER LG EACH O $0.00
A4524 ADULT SIZE DIAPER XL EACH O $0.00
A4525 ADULT SIZE BRIEF SM EACH O $0.00
A4526 ADULT SIZE BRIEF MED EACH O $0.00
A4527 ADULT SIZE BRIEF LG EACH O $0.00
A4528 ADULT SIZE BRIEF XL EACH O $0.00
A4529 CHILD SIZE DIAPER SM/MED EA O $0.00
A4530 CHILD SIZE DIAPER LG EACH O $0.00
A4531 CHILD SIZE BRIEF SM/MED EACH O $0.00
A4532 CHILD SIZE BRIEF LG EACH O $0.00
A4533 YOUTH SIZE DIAPER EACH O $0.00
A4534 YOUTH SIZE BRIEF EACH 9 $0.00
A4535 DISP INCONT LINER/SHIELD EA O $0.00
A4536 PROT UNDERWR WSHBL ANY SZ EA O $0.00
A4537 UNDER PAD REUSABLE ANY SZ EA O $0.00
A4538 REUSABLE DIAPER FROM DPR SVC O $0.00
A4550 SURGICAL TRAYS 9 $0.00

A4554 DISPOSABLE UNDERPADS 3 $0.20
A4555 PRIMARY SURGICAL DRESSING KIT, (E.G 9 $0.00
A4556 ELECTRODES, PAIR 5 $0.00
A4557 LEAD WIRES, PAIR 3 $17.16
A4558 CONDUCTIVE GEL OR PASTE 3 $4.44
A4559 COUPLING GEL OR PASTE 9 $0.00
A4560 PESSARY O $0.00
A4561 PESSARY RUBBER, ANY TYPE 3 $17.78
A4562 PESSARY, NON RUBBER,ANY TYPE 3 $44.25
A4565 SLINGS 3 $60.00
A4570 SPLINT 3 $50.00
A4572 RIB BELT O $0.00
A4575 HYPERBARIC O2 CHAMBER DISPS 9 $0.00
A4580 CAST SUPPLIES (PLASTER) O $0.00
A4581 SUPPLIES RISSER JACKET 9 $0.00
A4590 SPECIAL CASTING MATERIAL O $0.00
A4595 TENS SUPPL 2 LEAD PER MONTH 3 $27.56
A4600 SLEEVE, INTER LIMB COMP DEV 6 $0.00
A4601 LITH ION BATT, NON-PROS USE 6 $0.00
A4604 TUBING WITH HEATING ELEMENT 3 $66.81
A4605 TRACH SUCTION CATH CLOSE SYS 6 $0.00
A4606 OXYGEN PROBE USED W OXIMETER 5 $0.00
A4608 TRANSTRACHEAL OXYGEN CATH 3 $58.32
A4609 TRACH SUCTION CATH CLSED SYS O $0.00
A4610 TRACH SUCTION CATH CLSED SYS O $0.00
A4611 HEAVY DUTY BATTERY 3 $187.94
A4612 BATTERY CABLES 3 $65.00
A4613 BATTERY CHARGER 3 $137.96
A4614 HAND-HELD PEFR METER 3 $22.75
A4615 CANNULA NASAL 3 $20.00
A4616 TUBING (OXYGEN) PER FOOT 3 $1.00
A4617 MOUTH PIECE 3 $5.00
A4618 BREATHING CIRCUITS 3 $8.51
A4619 FACE TENT 3 $1.21
A4620 VARIABLE CONCENTRATION MASK 3 $20.00
A4621 TRACHEOTOMY MASK OR COLLAR O $0.00
A4622 TRACHEOSTOMY OR LARNGECTOMY O $0.00
A4623 TRACHEOSTOMY INNER CANNULA 3 $6.25
A4624 TRACHEAL SUCTION TUBE 3 $2.25
A4625 TRACH CARE KIT FOR NEW TRACH 3 $6.61
A4626 TRACHEOSTOMY CLEANING BRUSH 3 $3.05
A4627 SPACER BAG/RESERVOIR 9 $0.00
A4628 OROPHARYNGEAL SUCTION CATH 3 $3.51
A4629 TRACHEOSTOMY CARE KIT 3 $4.42
A4630 REPL BAT T.E.N.S. OWN BY PT 3 $5.45
A4631 WHEELCHAIR BATTERY O $0.00
A4632 INFUS PUMP RPLCEMNT BATTERY O $0.00
A4633 UVL REPLACEMENT BULB 3 $41.04
A4634 REPLACEMENT BULB TH LIGHTBOX 5 $0.00

A4635 UNDERARM CRUTCH PAD 3 $4.16
A4636 HANDGRIP FOR CANE ETC 3 $3.42
A4637 REPL TIP CANE/CRUTCH/WALKER 3 $1.90
A4638 REPL BATT PULSE GEN SYS 6 $0.00
A4639 INFRARED HT SYS REPLCMNT PAD 3 $287.21
A4640 ALTERNATING PRESSURE PAD 3 $51.49
A4641 RADIOPHARM DX AGENT NOC 9 $0.00
A4642 IN111 SATUMOMAB 9 $0.00
A4643 HIGH DOSE CONTRAST MRI O $0.00
A4644 CONTRAST 100-199 MGS IODINE O $0.00
A4645 CONTRAST 200-299 MGS IODINE O $0.00
A4646 CONTRAST 300-399 MGS IODINE O $0.00
A4647 SUPP- PARAMAGNETIC CONTR MAT O $0.00
A4648 IMPLANTABLE TISSUE MARKER 9 $0.00
A4649 SURGICAL SUPPLIES 9 $0.00
A4650 IMPLANT RADIATION DOSIMETER 9 $0.00
A4651 CALIBRATED MICROCAP TUBE 9 $0.00
A4652 MICROCAPILLARY TUBE SEALANT 9 $0.00
A4653 PD CATHETER ANCHOR BELT 5 $0.00
A4655 ESRD SYRINGE/NEEDLE 9 $0.00
A4656 NEEDLE ANY SIZE O $0.00
A4657 SYRINGE W/WO NEEDLE 9 $0.00
A4660 SPHYG/BP APP W CUFF AND STET 3 $20.00
A4663 DIALYSIS BLOOD PRESSURE CUFF 3 $6.27
A4670 AUTOMATIC BP MONITOR, DIAL 5 $0.00
A4671 DISPOSABLE CYCLER SET 6 $0.00
A4672 DRAINAGE EXT LINE, DIALYSIS 6 $0.00
A4673 EXT LINE W EASY LOCK CONNECT 6 $0.00
A4674 CHEM/ANTISEPT SOLUTION, 8OZ 6 $0.00
A4680 ACTIVATED CARBON FILTER, EA 9 $0.00
A4690 DIALYZER, EACH 9 $0.00
A4700 STANDARD DIALYSATE SOLUTION 9 $0.00
A4705 BICARB DIALYSATE SOLUTION 9 $0.00
A4706 BICARBONATE CONC SOL PER GAL 9 $0.00
A4707 BICARBONATE CONC POW PER PAC 9 $0.00
A4708 ACETATE CONC SOL PER GALLON 9 $0.00
A4709 ACID CONC SOL PER GALLON 9 $0.00
A4712 STERILE WATER INJ PER 10 ML O $0.00
A4714 TREATED WATER PER GALLON 9 $0.00
A4719 Y SET TUBING 9 $0.00
A4720 DIALYSAT SOL FLD VOL > 249CC 9 $0.00
A4721 DIALYSAT SOL FLD VOL > 999CC 9 $0.00
A4722 DIALYS SOL FLD VOL > 1999CC 9 $0.00
A4723 DIALYS SOL FLD VOL > 2999CC 9 $0.00
A4724 DIALYS SOL FLD VOL > 3999CC 9 $0.00
A4725 DIALYS SOL FLD VOL > 4999CC 9 $0.00
A4726 DIALYS SOL FLD VOL > 5999CC 9 $0.00
A4728 DIALYSATE SOLUTION, NON-DEX 6 $0.00
A4730 FISTULA CANNULATION SET, EA 9 $0.00

A4735 LOCAL/TOPICAL ANESTHETICS 9 $0.00
A4736 TOPICAL ANESTHETIC, PER GRAM 9 $0.00
A4737 INJ ANESTHETIC PER 10 ML 9 $0.00
A4740 SHUNT ACCESSORY 9 $0.00
A4750 ART OR VENOUS BLOOD TUBING 9 $0.00
A4755 COMB ART/VENOUS BLOOD TUBING 9 $0.00
A4760 DIALYSATE SOL TEST KIT, EACH 9 $0.00
A4765 DIALYSATE CONC POW PER PACK 9 $0.00
A4766 DIALYSATE CONC SOL ADD 10 ML 9 $0.00
A4770 BLOOD COLLECTION TUBE/VACUUM 9 $0.00
A4771 SERUM CLOTTING TIME TUBE 9 $0.00
A4772 BLOOD GLUCOSE TEST STRIPS 9 $0.00
A4773 OCCULT BLOOD TEST STRIPS 9 $0.00
A4774 AMMONIA TEST STRIPS 9 $0.00
A4780 ESRD STERILIZING AGENT 9 $0.00
A4790 ESRD CLEANSING AGENTS 9 $0.00
A4800 HEPARIN/ANTIDOTE DIALYSIS 9 $0.00
A4801 HEPARIN PER 1000 UNITS 9 $0.00
A4802 PROTAMINE SULFATE PER 50 MG 9 $0.00
A4820 SUPPLIES HEMODIALYSIS KIT 9 $0.00
A4850 RUBBER TIPPED HEMOSTATS 9 $0.00
A4860 DISPOSABLE CATHETER TIPS 9 $0.00
A4870 PLUMB/ELEC WK HM HEMO EQUIP 9 $0.00
A4880 WATER STORAGE TANKS 9 $0.00
A4890 REPAIR/MAINT CONT HEMO EQUIP 9 $0.00
A4900 CAPD SUPPLY KIT 9 $0.00
A4901 CCPD SUPPLY KIT 9 $0.00
A4905 IPD SUPPLY KIT 9 $0.00
A4910 ESRD NONMEDICAL SUPPLIES 9 $0.00
A4911 DRAIN BAG/BOTTLE 9 $0.00
A4912 GOMCO DRAIN BOTTLE 9 $0.00
A4913 MISC DIALYSIS SUPPLIES NOC 9 $0.00
A4914 PREPARATION KIT 9 $0.00
A4918 VENOUS PRESSURE CLAMP 9 $0.00
A4919 SUPP DIALYSIS DIALYZER HOLDE 9 $0.00
A4920 HARVARD PRESSURE CLAMP 9 $0.00
A4921 MEASURING CYLINDER 9 $0.00
A4927 NON-STERILE GLOVES 3 $6.19
A4928 SURGICAL MASK 9 $0.00
A4929 TOURNIQUET FOR DIALYSIS, EA 9 $0.00
A4930 STERILE, GLOVES PER PAIR 3 $0.44
A4931 REUSABLE ORAL THERMOMETER 9 $0.00
A4932 REUSABLE RECTAL THERMOMETER 9 $0.00
A5051 POUCH CLSD W BARR ATTACHED 3 $2.21
A5052 CLSD OSTOMY POUCH W/O BARR 3 $1.59
A5053 CLSD OSTOMY POUCH FACEPLATE 3 $1.66
A5054 CLSD OSTOMY POUCH W/FLANGE 3 $1.37
A5055 STOMA CAP 3 $1.35
A5061 POUCH DRAINABLE W BARRIER AT 3 $2.58

A5062 DRNBLE OSTOMY POUCH W/O BARR 3 $2.12
A5063 DRAIN OSTOMY POUCH W/FLANGE 3 $2.09
A5064 DRAIN OSTOMY POUCH W/FCEPLTE O $0.00
A5065 DRAIN OSTOMY POUCH ON FCPLTE O $0.00
A5071 URINARY POUCH W/BARRIER 3 $4.15
A5072 URINARY POUCH W/O BARRIER 3 $3.36
A5073 URINARY POUCH ON BARR W/FLNG 3 $3.04
A5074 URINARY POUCH W/FACEPLATE O $0.00
A5075 URINARY POUCH ON FACEPLATE O $0.00
A5081 CONTINENT STOMA PLUG 3 $3.14
A5082 CONTINENT STOMA CATHETER 3 $11.34
A5083 STOMA ABSORPTIVE COVER 6 $0.00
A5093 OSTOMY ACCESSORY CONVEX INSE 3 $1.85
A5102 BEDSIDE DRAIN BTL W/WO TUBE 3 $21.39
A5105 URINARY SUSPENSORY 3 $38.88
A5112 URINARY LEG BAG 3 $28.07
A5113 LATEX LEG STRAP 3 $4.48
A5114 FOAM/FABRIC LEG STRAP 3 $8.52
A5119 SKIN BARRIER WIPES BOX PR 50 O $0.00
A5120 SKIN BARRIER, WIPE OR SWAB 3 $0.23
A5121 SOLID SKIN BARRIER 6X6 3 $6.24
A5122 SOLID SKIN BARRIER 8X8 3 $10.42
A5123 SKIN BARRIER WITH FLANGE O $0.00
A5126 DISK/FOAM PAD +OR- ADHESIVE 3 $1.26
A5131 APPLIANCE CLEANER 3 $15.13
A5149 INCONTINENCE/OSTOMY SUPPLY O $0.00
A5200 PERCUTANEOUS CATHETER ANCHOR 3 $10.78
A5500 DIAB SHOE FOR DENSITY INSERT 5 $0.00
A5501 DIABETIC CUSTOM MOLDED SHOE 5 $0.00
A5502 DIABETIC SHOE DENSITY INSERT 9 $0.00
A5503 DIABETIC SHOE W/ROLLER/ROCKR 5 $0.00
A5504 DIABETIC SHOE WITH WEDGE 5 $0.00
A5505 DIAB SHOE W/METATARSAL BAR 5 $0.00
A5506 DIABETIC SHOE W/OFF SET HEEL 5 $0.00
A5507 MODIFICATION DIABETIC SHOE 5 $0.00
A5508 DIABETIC DELUXE SHOE 5 $0.00
A5509 DIRECT HEAT FORM SHOE INSERT O $0.00
A5510 COMPRESSION FORM SHOE INSERT 5 $0.00
A5511 CUSTOM FAB MOLDED SHOE INSER O $0.00
A5512 MULTI DEN INSERT DIRECT FORM 6 $0.00
A5513 MULTI DEN INSERT CUSTOM MOLD 6 $0.00
A6000 WOUND WARMING WOUND COVER 5 $0.00
A6010 COLLAGEN BASED WOUND FILLER 3 $30.62
A6011 COLLAGEN GEL/PASTE WOUND FIL 3 $2.28
A6020 COLLAGEN WOUND DRESSING O $0.00
A6021 COLLAGEN DRESSING 1648 SQ IN 3 $181.51
A6024 COLLAGEN DSG WOUND FILLER 3 $5.90

A6025 SILICONE GEL SHEET, EACH 9 $0.00
A6154 WOUND POUCH EACH 9 $0.00
A6196 ALGINATE DRESSING 16 48 SQ IN 3 $15.68
A6199 ALGINATE DRSG WOUND FILLER 3 $5.04
A6200 COMPOS DRSG 1648 NO BORDER O $0.00
A6203 COMPOSITE DRSG 16 48 SQ IN 3 $5.94
A6206 CONTACT LAYER 16 48 SQ IN 3 $7.00
A6209 FOAM DRSG 16 48 SQ IN W/O BRDR 3 $28.01
A6212 FOAM DRG 16 48 SQ IN W/BORDER 3 $9.82
A6215 FOAM DRESSING WOUND FILLER 5 $0.00
A6216 NON-STERILE GAUZE16 48 SQ IN 3 $0.41
A6219 GAUZE 16 48 SQ IN W/BORDER 3 $2.46
A6222 GAUZE 16 48 IN NO W/SAL W/O B 3 $3.44
A6228 GAUZE 16 48 SQ IN WATER/SALNE 3 $3.44
A6231 HYDROGEL DSG1648 SQ IN 3 $18.30
A6234 HYDROCOLLD DRG 16 48 IN W/O B 3 $25.99
A6237 HYDROCOLLD DRG 16 48 IN W/BDR 3 $21.74
A6240 HYDROCOLLD DRG FILLER PASTE 3 $11.68
A6241 HYDROCOLLOID DRG FILLER DRY 3 $2.45
A6242 HYDROGEL DRG 1648 IN W/O BDR 3 $37.46
A6245 HYDROGEL DRG

A6246 HYDROGEL DRG >16 48 SQ IN W/B 3 $22.68
A6248 HYDROGEL DRSG GEL FILLER 3 $15.49
A6250 SKIN SEAL PROTECT MOISTURIZR 9 $0.00
A6251 ABSORPT DRG 16 48 SQ IN W/O B 3 $6.05
A6254 ABSORPT DRG 16 48 SQ IN W/BDR 3 $2.89
A6257 TRANSPARENT FILM 16 48 SQ IN 3 $10.43
A6260 WOUND CLEANSER ANY TYPE/SIZE 9 $0.00
A6261 WOUND FILLER GEL/PASTE /OZ 5 $0.00
A6262 WOUND FILLER DRY FORM / GRAM 5 $0.00
A6263 NON-STERILE ELASTIC GAUZE/YD O $0.00
A6264 NON-STERILE NO ELASTIC GAUZE O $0.00
A6265 TAPE PER 18 SQ INCHES O $0.00
A6266 IMPREG GAUZE NO H20/SAL/YARD 3 $1.83
A6402 STERILE GAUZE 16 48 SQ IN 3 $0.41
A6405 STERILE ELASTIC GAUZE /YD O $0.00
A6406 STERILE NON-ELASTIC GAUZE/YD O $0.00
A6407 PACKING STRIPS, NON-IMPREG 3 $1.88
A6410 STERILE EYE PAD 5 $0.00
A6411 NON-STERILE EYE PAD 5 $0.00
A6412 OCCLUSIVE EYE PATCH 5 $0.00
A6413 ADHESIVE BANDAGE, FIRST-AID 9 $0.00
A6421 PAD BANDAGE >=3 =3=5ÊW /ROLL O $0.00
A6426 CONF BANDAGE S >=3=5Ê W /ROLL O $0.00
A6430 LT COMPRES BDG >=3=5ÊW /ROLL O $0.00
A6434 MO COMPRES BDG >=3=3=3=3=3" =3"

A6449 LT COMPRES BAND >=3" =3"=5"/YD 3 $1.39
A6456 ZINC PASTE BAND W >=3"

A7008 DISPOSABLE NEBULIZER PREFILL 3 $10.52
A7009 NEBULIZER RESERVOIR BOTTLE 3 $36.26
A7010 DISPOSABLE CORRUGATED TUBING 3 $22.31
A7011 NONDISPOS CORRUGATED TUBING 5 $0.00
A7012 NEBULIZER WATER COLLEC DEVIC 3 $3.42
A7013 DISPOSABLE COMPRESSOR FILTER 3 $0.71
A7014 COMPRESSOR NONDISPOS FILTER 3 $3.87
A7015 AEROSOL MASK USED W NEBULIZE 3 $1.57
A7016 NEBULIZER DOME & MOUTHPIECE 3 $6.24
A7017 NEBULIZER NOT USED W OXYGEN 3 $128.23
A7018 WATER DISTILLED W/NEBULIZER 3 $0.37
A7019 SALINE SOLUTION DISPENSER O $0.00
A7020 STERILE H2O OR NSS W LGV NEB O $0.00
A7025 REPLACE CHEST COMPRESS VEST 3 $434.94
A7026 REPLACE CHST CMPRSS SYS HOSE 3 $28.75
A7027 COMBINATION ORAL/NASAL MASK 6 $0.00
A7028 REPL ORAL CUSHION COMBO MASK 6 $0.00
A7029 REPL NASAL PILLOW COMB MASK 6 $0.00
A7030 CPAP FULL FACE MASK 3 $188.64
A7031 REPLACEMENT FACEMASK INTERFA 3 $69.77
A7032 REPLACEMENT NASAL CUSHION 3 $40.53
A7033 REPLACEMENT NASAL PILLOWS 3 $28.41
A7034 NASAL APPLICATION DEVICE 3 $117.64
A7035 POS AIRWAY PRESS HEADGEAR 3 $35.42
A7036 POS AIRWAY PRESS CHINSTRAP 3 $18.20
A7037 POS AIRWAY PRESSURE TUBING 3 $39.21
A7038 POS AIRWAY PRESSURE FILTER 3 $4.58
A7039 FILTER, NON DISPOSABLE W PAP 3 $15.33
A7040 ONE WAY CHEST DRAIN VALVE 6 $0.00
A7041 WATER SEAL DRAIN CONTAINER 6 $0.00
A7042 IMPLANTED PLEURAL CATHETER 9 $0.00
A7043 VACUUM DRAINAGEBOTTLE/TUBING 5 $0.00
A7044 PAP ORAL INTERFACE 3 $120.91
A7045 REPL EXHALATION PORT FOR PAP 3 $19.47
A7046 REPL WATER CHAMBER, PAP DEV 6 $0.00
A7501 TRACHEOSTOMA VALVE W DIAPHRA 3 $100.18
A7502 REPLACEMENT DIAPHRAGM/FPLATE 3 $47.61
A7503 HMES FILTER HOLDER OR CAP 3 $10.81
A7504 TRACHEOSTOMA HMES FILTER 3 $0.64
A7505 HMES OR TRACH VALVE HOUSING 3 $4.46
A7506 HMES/TRACHVALVE ADHESIVEDISK 3 $0.32
A7507 INTEGRATED FILTER & HOLDER 3 $2.37
A7508 HOUSING & INTEGRATED ADHESIV 3 $2.74
A7509 HEAT & MOISTURE EXCHANGE SYS 3 $1.34
A7520 TRACH/LARYN TUBE NON-CUFFED 6 $0.00
A7521 TRACH/LARYN TUBE CUFFED 6 $0.00
A7522 TRACH/LARYN TUBE STAINLESS 6 $0.00
A7523 TRACHEOSTOMY SHOWER PROTECT 6 $0.00
A7524 TRACHEOSTOMA STENT/STUD/BTTN 6 $0.00

A7525 TRACHEOSTOMY MASK 3 $2.07
A7526 TRACHEOSTOMY TUBE COLLAR 3 $3.37
A7527 TRACH/LARYN TUBE PLUG/STOP 6 $0.00
A8000 SOFT PROTECT HELMET PREFAB 6 $0.00
A8001 HARD PROTECT HELMET PREFAB 6 $0.00
A8002 SOFT PROTECT HELMET CUSTOM 6 $0.00
A8003 HARD PROTECT HELMET CUSTOM 6 $0.00
A8004 REPL SOFT INTERFACE, HELMET 6 $0.00
A9150 MISC/EXPER NON-PRESCRIPT DRU 9 $0.00
A9152 SINGLE VITAMIN NOS 9 $0.00
A9153 MULTI-VITAMIN NOS 9 $0.00
A9155 ARTIFICIAL SALIVA 6 $0.00
A9160 PODIATRIST NON-COVERED SERVI 9 $0.00
A9170 CHIROPRACTOR NON-COVERED SER 9 $0.00
A9180 LICE TREATMENT, TOPICAL 9 $0.00
A9190 MISC/EXPE PERSONAL COMFORT I 9 $0.00
A9250 NURSING HOME RENTALS 9 $0.00
A9260 NON-CERTIFIED PHYSICAL THERAPISTS 9 $0.00
A9270 NON-COVERED ITEM OR SERVICE 9 $0.00
A9274 EXT AMB INSULIN DELIVERY SYS 6 $0.00
A9275 DISP HOME GLUCOSE MONITOR 9 $0.00
A9276 DISPOSABLE SENSOR, CGM SYS 9 $0.00
A9277 EXTERNAL TRANSMITTER, CGM 9 $0.00
A9278 EXTERNAL RECEIVER, CGM SYS 9 $0.00
A9279 MONITORING FEATURE/DEVICENOC 9 $0.00
A9280 ALERT DEVICE, NOC 6 $0.00
A9281 REACHING/GRABBING DEVICE 9 $0.00
A9282 WIG ANY TYPE 9 $0.00
A9283 FOOT PRESS OFF LOAD SUPP DEV 6 $0.00
A9284 NON-ELECTRONIC SPIROMETER 9 $0.00
A9290 DESCRIPTION OF SERVICE DOES NOT IND 9 $0.00
A9300 EXERCISE EQUIPMENT O $0.00
A9500 TC99M SESTAMIBI 9 $0.00
A9501 TECHNETIUM TC-99M TEBOROXIME 9 $0.00
A9502 TC99M TETROFOSMIN 9 $0.00
A9503 TC99M MEDRONATE 9 $0.00
A9504 TC99M APCITIDE 9 $0.00
A9505 TL201 THALLIUM 9 $0.00
A9507 IN111 CAPROMAB 9 $0.00
A9508 I131 IODOBENGUATE, DX 9 $0.00
A9509 IODINE I-123 SOD IODIDE MIL 9 $0.00
A9510 TC99M DISOFENIN 9 $0.00
A9511 TECHNETIUM TC 99M DEPREOTIDE O $0.00
A9512 TC99M PERTECHNETATE 9 $0.00
A9513 TECHNETIUM TC-99M MEBROFENIN O $0.00
A9514 TECHNETIUMTC99MPYROPHOSPHATE O $0.00
A9515 TECHNETIUM TC-99M PENTETATE O $0.00
A9516 IODINE I-123 SOD IODIDE MIC 9 $0.00
A9517 I131 IODIDE CAP, RX 9 $0.00

A9518 I-131 SODIUM IODIDE SOLUTION O $0.00
A9519 TECHNETIUMTC-99MMACROAG ALBU O $0.00
A9520 TECHNETIUMTC-99M SULFUR CLLD O $0.00
A9521 TC99M EXAMETAZIME 9 $0.00
A9522 INDIUM111IBRITUMOMABTIUXETAN O $0.00
A9523 YTTRIUM90IBRITUMOMABTIUXETAN O $0.00
A9524 I131 SERUM ALBUMIN, DX 9 $0.00
A9525 LOW/ISO-OSMOLAR CONTRAST MAT O $0.00
A9526 NITROGEN N-13 AMMONIA 9 $0.00
A9527 IODINE I-125 SODIUM IODIDE 9 $0.00
A9528 IODINE I-131 IODIDE CAP, DX 9 $0.00
A9529 I131 IODIDE SOL, DX 9 $0.00
A9530 I131 IODIDE SOL, RX 9 $0.00
A9531 I131 MAX 100UCI 9 $0.00
A9532 I125 SERUM ALBUMIN, DX 9 $0.00
A9533 I-131 TOSITUMOMAB DIAGNOSTIC O $0.00
A9534 I-131 TOSITUMOMAB THERAPEUT O $0.00
A9535 INJECTION, METHYLENE BLUE O $0.00
A9536 TC99M DEPREOTIDE 9 $0.00
A9537 TC99M MEBROFENIN 9 $0.00
A9538 TC99M PYROPHOSPHATE 9 $0.00
A9539 TC99M PENTETATE 9 $0.00
A9540 TC99M MAA 9 $0.00
A9541 TC99M SULFUR COLLOID 9 $0.00
A9542 IN111 IBRITUMOMAB, DX 9 $0.00
A9543 Y90 IBRITUMOMAB, RX 9 $0.00
A9544 I131 TOSITUMOMAB, DX 9 $0.00
A9545 I131 TOSITUMOMAB, RX 9 $0.00
A9546 CO57/58 9 $0.00
A9547 IN111 OXYQUINOLINE 9 $0.00
A9548 IN111 PENTETATE 9 $0.00
A9549 TC99M ARCITUMOMAB O $0.00
A9550 TC99M GLUCEPTATE 9 $0.00
A9551 TC99M SUCCIMER 9 $0.00
A9552 F18 FDG 9 $0.00
A9553 CR51 CHROMATE 9 $0.00
A9554 I125 IOTHALAMATE, DX 9 $0.00
A9555 RB82 RUBIDIUM 9 $0.00
A9556 GA67 GALLIUM 9 $0.00
A9557 TC99M BICISATE 9 $0.00
A9558 XE133 XENON 10MCI 9 $0.00
A9559 CO57 CYANO 9 $0.00
A9560 TC99M LABELED RBC 9 $0.00
A9561 TC99M OXIDRONATE 9 $0.00
A9562 TC99M MERTIATIDE 9 $0.00
A9563 P32 NA PHOSPHATE 9 $0.00
A9564 P32 CHROMIC PHOSPHATE 9 $0.00
A9565 IN111 PENTETREOTIDE O $0.00
A9566 TC99M FANOLESOMAB 9 $0.00

A9567 TECHNETIUM TC-99M AEROSOL 9 $0.00
A9568 TECHNETIUM TC99M ARCITUMOMAB 9 $0.00
A9569 TECHNETIUM TC-99M AUTO WBC 9 $0.00
A9570 INDIUM IN-111 AUTO WBC 9 $0.00
A9571 INDIUM IN-111 AUTO PLATELET 9 $0.00
A9572 INDIUM IN-111 PENTETREOTIDE 9 $0.00
A9576 INJ PROHANCE MULTIPACK 9 $0.00
A9577 INJ MULTIHANCE 9 $0.00
A9578 INJ MULTIHANCE MULTIPACK 9 $0.00
A9579 GAD-BASE MR CONTRAST NOS,1ML 9 $0.00
A9580 SODIUM FLUORIDE F-18 9 $0.00
A9581 GADOXETATE DISODIUM INJ 9 $0.00
A9582 IODINE I-123 IOBENGUANE 9 $0.00
A9583 GADOFOSVESET TRISODIUM INJ 9 $0.00
A9600 SR89 STRONTIUM 9 $0.00
A9603 I-131SODIUMIODIDECAP PER MCI 9 $0.00
A9604 SM 153 LEXIDRONAM 9 $0.00
A9605 SM 153 LEXIDRONM O $0.00
A9698 NON-RAD CONTRAST MATERIALNOC 9 $0.00
A9699 RADIOPHARM RX AGENT NOC 9 $0.00
A9700 ECHOCARDIOGRAPHY CONTRAST 9 $0.00
A9900 SUPPLY/ACCESSORY/SERVICE 5 $0.00
A9901 DELIVERY/SET UP/DISPENSING 9 $0.00
A9999 DME SUPPLY OR ACCESSORY, NOS 5 $0.00
ASC0001 AMBULATORY SURGICAL CENTER O $0.00
ASC0002 AMBULATORY SURGICAL CENTER O $0.00
ASC0003 AMBULATORY SURGICAL CENTER O $0.00
ASC0004 AMBULATORY SURGICAL CENTER O $0.00
ASC0005 AMBULATORY SURGICAL CENTER O $0.00
ASC0006 AMBULATORY SURGICAL CENTER O $0.00
ASC0007 AMBULATORY SURGICAL CENTER O $0.00
ASC0008 AMBULATORY SURGICAL CENTER O $0.00
ASC0009 AMBULATORY SURGICAL CENTER O $0.00
B4034 ENTER FEED SUPKIT SYR BY DAY 3 $5.60
B4035 ENTERAL FEED SUPP PUMP PER D 3 $10.67
B4036 ENTERAL FEED SUP KIT GRAV BY 3 $7.31
B4081 ENTERAL NG TUBING W/ STYLET 3 $19.78
B4082 ENTERAL NG TUBING W/O STYLET 3 $14.73
B4083 ENTERAL STOMACH TUBE LEVINE 3 $2.25
B4084 GASTROSTOMY/JEJUNOSTOMY TUBI O $0.00
B4085 GASTROSTOMY TUBE W/RING EACH 9 $0.00
B4086 GASTROSTOMY/JEJUNOSTOMY TUBE O $0.00
B4087 GASTRO/JEJUNO TUBE, STD 6 $0.00
B4088 GASTRO/JEJUNO TUBE, LOW-PRO 6 $0.00
B4100 FOOD THICKENER ORAL 5 $0.00
B4102 EF ADULT FLUIDS AND ELECTRO 6 $0.00
B4103 EF PED FLUID AND ELECTROLYTE 6 $0.00
B4104 ADDITIVE FOR ENTERAL FORMULA 6 $0.00
B4149 EF BLENDERIZED FOODS 6 $0.00

B4150 EF COMPLET W/INTACT NUTRIENT 3 $0.61
B4151 ENTERAL FORMULAE CAT1NATURAL O $0.00
B4152 EF CALORIE DENSE>/=1.5KCAL 3 $0.51
B4153 EF HYDROLYZED/AMINO ACIDS 3 $1.74
B4154 EF SPEC METABOLIC NONINHERIT 3 $1.12
B4155 EF INCOMPLETE/MODULAR 3 $0.89
B4156 ENTERAL FORMULAE CATEGORY VI O $0.00
B4157 EF SPECIAL METABOLIC INHERIT 6 $0.00
B4158 EF PED COMPLETE INTACT NUT 3 $0.65
B4159 EF PED COMPLETE SOY BASED 6 $0.00
B4160 EF PED CALORIC DENSE>/=0.7KC 6 $0.00
B4161 EF PED HYDROLYZED/AMINO ACID 3 $1.80
B4162 EF PED SPECMETABOLIC INHERIT 6 $0.00
B4164 PARENTERAL 50% DEXTROSE SOLU 9 $0.00
B4168 PARENTERAL SOL AMINO ACID 3. 9 $0.00
B4172 PARENTERAL SOL AMINO ACID 5. 9 $0.00
B4176 PARENTERAL SOL AMINO ACID 7- 9 $0.00
B4178 PARENTERAL SOL AMINO ACID > 9 $0.00
B4180 PARENTERAL SOL CARB > 50% 9 $0.00
B4184 PARENTERAL SOL LIPIDS 10% O $0.00
B4185 PARENTERAL SOL 10 GM LIPIDS 6 $0.00
B4186 PARENTERAL SOL LIPIDS 20% O $0.00
B4189 PARENTERAL SOL AMINO ACID & 9 $0.00
B4193 PARENTERAL SOL 52-73 GM PROT 9 $0.00
B4197 PARENTERAL SOL 74-100 GM PRO 9 $0.00
B4199 PARENTERAL SOL > 100GM PROTE 9 $0.00
B4216 PARENTERAL NUTRITION ADDITIV 9 $0.00
B4220 PARENTERAL SUPPLY KIT PREMIX 3 $8.09
B4222 PARENTERAL SUPPLY KIT HOMEMI O $0.00
B4224 PARENTERAL ADMINISTRATION KI 3 $25.29
B5000 PARENTERAL SOL RENAL-AMIROSY 9 $0.00
B5100 PARENTERAL SOL HEPATIC-FREAM 9 $0.00
B5200 PARENTERAL SOL STRES-BRNCH C 9 $0.00
B9000 ENTER INFUSION PUMP W/O ALRM 3 $988.00
B9002 ENTERAL INFUSION PUMP W/ ALA 3 $988.00
B9004 PARENTERAL INFUS PUMP PORTAB 3 $2,551.22
B9006 PARENTERAL INFUS PUMP STATIO 3 $1,970.80
B9998 ENTERAL SUPP NOT OTHERWISE C 5 $0.00
B9999 PARENTERAL SUPP NOT OTHRWS C 5 $0.00
BONUS MCO SPECIFIC CODE: SMART START OUT O $0.00
C1000 PERCLOSCLOSR PROSTARARTVAS 9 $0.00
C1001 ACUNAV-DIAGNSTIC ULTRSND CA 9 $0.00
C1003 CATH, ABLATION, LIVEWIRE TC 9 $0.00
C1004 FAST-CATH,SWARTZ,SAFL,CSTA 9 $0.00
C1006 ARRAY POST CHAMB IOL 9 $0.00
C1007 AMS 700/AMBICOR PROSTHESIS 9 $0.00
C1008 UROLUME-IMPLT URETHRAL STNT 9 $0.00
C1009 PLASMA,CRYOPRECIPITATE-REDUC 9 $0.00
C1010 BLOOD, L/R, CMV-NEG O $0.00

C1011 PLATELETS, HLA-M, L/R, UNIT O $0.00
C1012 PLATELET CONC, L/R, IRRAD 9 $0.00
C1013 PLATELET CONC, L/R, UNIT 9 $0.00
C1014 PLATELET,APH/PHER, L/R, UNIT 9 $0.00
C1015 PLT, PHER,L/R,CMV, IRRAD O $0.00
C1016 BLOOD,L/R,FROZ/DEGLY/WASHED O $0.00
C1017 PLT, APH/PHER,L/R,CMV-NEG O $0.00
C1018 BLOOD, L/R, IRRADIATED O $0.00
C1019 PLT, APH/PHER, L/R, IRRAD 9 $0.00
C1020 RBC, FRZ/DEG/WSH, L/R, IRRAD O $0.00
C1021 RBC, L/R, CMV NEG, IRRAD O $0.00
C1022 PLASMA, FRZ WITHIN 24 HOUR O $0.00
C1024 QUINOPRISTIN 10ML/DALFOPRIS 9 $0.00
C1025 MARINR CS CATH 9 $0.00
C1026 RF PERFRMR CATH 5F RF MARINR 9 $0.00
C1027 MAGIC X/SHORT RADIUS 14MM 9 $0.00
C1028 PRCIS TWST TRSNSVG ANCH SYS 9 $0.00
C1029 CRE GUIDED BALLOON DIL CATH 9 $0.00
C1030 CTHTR:MRSHAL,BLU MAX UTR DMD 9 $0.00
C1031 MR COMP/MOD LEVEEN NED ELECT 9 $0.00
C1033 SONICATH MDL 37-410 9 $0.00
C1034 SURPASS, LONG30 SURPASS-CATH 9 $0.00
C1035 CATH, ULTRA ICE 9 $0.00
C1036 R PORT/RESERVOIR IMPL DEV 9 $0.00
C1037 VAXCELCHRONIC DIALYSIS CATH 9 $0.00
C1038 ULTRACROSS IMAGING CATH 9 $0.00
C1039 WALLSTENT, RP/TRACH 9 $0.00
C1040 WALLSTENT, TIPS 9 $0.00
C1042 WALLSTENT, BILIARY 9 $0.00
C1043 ATHERECTOMY SYS, CORONARY 9 $0.00
C1045 I-131 MIBG(IOBEN-SULFATE)0.5 9 $0.00
C1047 NOGA/NAVI-STAR CATH 9 $0.00
C1048 NEUROCYBERNETICPROS:GEN 9 $0.00
C1050 PROSORBA COLUMN 9 $0.00
C1051 OASIS THROMBECTOMY CATH 9 $0.00
C1053 ENSITE 3000 CATHETER 9 $0.00
C1054 HYDROLYSER THROMB CATH 6/7F 9 $0.00
C1055 TRANSESOPH 210, 210-S CATH 9 $0.00
C1056 THERMACHOICE II CATH 9 $0.00
C1057 MICROMARK TISSUE MARKER 9 $0.00
C1058 TC 99M OXIDRONATE, PER VIAL 9 $0.00
C1059 CARTICEL,AUTO CULT-CHNDR CYT 9 $0.00
C1060 ACS MULTI-LINK TRISTAR STENT 9 $0.00
C1061 ACS VIKING GUIDING CATH 9 $0.00
C1063 ENDOTAK ENDURANCE EZ,RX LEAD 9 $0.00
C1064 I-131 CAP, EACH ADD MCI 9 $0.00
C1065 I-131 SOL, EACH ADD MCI 9 $0.00
C1066 IN 111 SATUMOMAB PENDETIDE 9 $0.00
C1067 MEGALINK BILIARY STENT 9 $0.00

C1068 PULSAR DDD PMKR 9 $0.00
C1069 DISCOVERY DR, PMKR 9 $0.00
C1071 PULSAR MAX, PULSAR SR PMKR 9 $0.00
C1072 GUIDANT:BLLN DIL CATH 9 $0.00
C1073 MORCELLATOR 9 $0.00
C1074 RX/OTW VIATRAC-PERI DIL CATH 9 $0.00
C1075 GUIDANT:LEAD,PMKR 9 $0.00
C1076 VENTAK MINI SC DEFIB 9 $0.00
C1077 VENTAK VR,PRIZM VR, SC DEFIB 9 $0.00
C1078 VENTAK:PRIZM,AV III DR DEFIB 9 $0.00
C1079 CO 57/58 PER 0.5 UCI O $0.00
C1080 I-131 TOSITUMOMAB, DX O $0.00
C1081 I-131 TOSITUMOMAB, TX O $0.00
C1082 IN-111 IBRITUMOMAB TIUXETAN O $0.00
C1083 YTTRIUM 90 IBRITUMOMAB TIUXE O $0.00
C1084 DENILEUKIN DIFTITOX, 300 MCG 9 $0.00
C1086 TEMOZOLOMIDE, 5 MG 9 $0.00
C1087 I-123 PER 100 UCI 9 $0.00
C1088 LASER OPTIC TR SYS 9 $0.00
C1089 CO 57, 0.5 MCI 9 $0.00
C1090 IN 111 CHLORIDE, PER MCI 9 $0.00
C1091 IN111 OXYQUINOLINE,PER0.5MCI O $0.00
C1092 IN 111 PENTETATE PER 0.5 MCI O $0.00
C1093 TC99M FANOLESOMAB O $0.00
C1094 TC99MALBUMIN AGGR,PER 1.0MCI 9 $0.00
C1095 TC 99M DEPREOTIDE, PER VIAL 9 $0.00
C1096 TC 99M EXAMETAZIME, PER DOSE 9 $0.00
C1097 TC 99M MEBROFENIN, PER VIAL 9 $0.00
C1098 TC 99M PENTETATE, PER VIAL 9 $0.00
C1099 TC 99M PYROPHOSPHATE,PER VIA 9 $0.00
C1100 MEDTRONIC AVE GT1 GUIDEWIRE 9 $0.00
C1101 MEDTRONIC AVE ZUMA GUIDECATH 9 $0.00
C1102 SYNERGY NEUROSTIM GENRTR 9 $0.00
C1103 MICRO JEWEL DEFIBRILLATOR 9 $0.00
C1104 RF CONDUCTR ABLATION CATH 9 $0.00
C1105 SIGMA 300VDD PMKR 9 $0.00
C1106 SYNERGYEX PT PROGRMR 9 $0.00
C1107 TORQR,SOLOIST CATH 9 $0.00
C1109 IMPLANTABLE ANCHOR:ETHICON 9 $0.00
C1110 STABLE MAPPER,CATH ELECTR 9 $0.00
C1111 ANEURXAORT-UNI-ILIAC STNT 9 $0.00
C1112 ANEURX STENT GRAFT/DEL CATH 9 $0.00
C1113 TLNT ENDO SPRNG STNT GRFT SY 9 $0.00
C1114 TALNTSPRGSTNT+GRAF ENDO PROS 9 $0.00
C1115 5038S, 5038 5038L PACE LEAD 9 $0.00
C1116 CAPSURESP PACING LEAD 9 $0.00
C1117 ANCURE ENDOGRAFT DEL SYS 9 $0.00
C1118 SIGMA300DR LEGIIDR, PMKR 9 $0.00
C1119 SPRINT6932,6943 DEFIB LEAD 9 $0.00

C1120 SPRINT6942,6945 DEFIB LEAD 9 $0.00
C1121 GEM DEFIBRILLATOR 9 $0.00
C1122 TC 99M ARCITUMOMAB PER VIAL O $0.00
C1123 GEM II VR DEFIBRILLATOR 9 $0.00
C1124 INTERSTIM TEST STIM KIT 9 $0.00
C1125 KAPPA 400SR,TOPAZ II SR PMKR 9 $0.00
C1126 KAPPA 700 DR, PMKR 9 $0.00
C1127 KAPPA 700SR, SC PMKR 9 $0.00
C1128 KAPPA 700D, RUBY IID PMKR 9 $0.00
C1129 KAPPA 700VDD, PMKR 9 $0.00
C1130 SIGMA200D, LGCY IID DC PMKR 9 $0.00
C1131 SIGMA 200DR, PMKR 9 $0.00
C1132 SIGMA 200 SR LEG II:SC PA 9 $0.00
C1133 SIGMA SR, VITA SR, PMKR 9 $0.00
C1134 SIGMA 300D PMKR 9 $0.00
C1135 ENTITY DR 5326L/R, DC, PMKR 9 $0.00
C1136 AFFINITY DR 5330L/R, DC, PMK 9 $0.00
C1137 CARDIOSEAL IMPLANT SYS 9 $0.00
C1143 ADDVENT MOD 2060BL, VDD 9 $0.00
C1144 AFNTY SP 5130,INTEGRITY SR 9 $0.00
C1145 ANGIO-SEAL 6FR,8FR 9 $0.00
C1146 VETT TUBE 9 $0.00
C1147 AV PLUS DX 1368:LEAD 9 $0.00
C1148 CONTOUR MD SC DEFIB 9 $0.00
C1149 ENTITY DC 5226R,PMKR 9 $0.00
C1151 PASSIVEPLUS DX LEAD, 10MDLS 9 $0.00
C1152 LIFESITE ACCESS SYSTEM 9 $0.00
C1153 REGENCY SC+2402L PMKR 9 $0.00
C1154 SPL:SPO1,02,04-DEFIB LEAD 9 $0.00
C1155 REPLIFORM 8 SQ CM 9 $0.00
C1156 TR1102TRSR+2260L,2264L,5131 9 $0.00
C1157 TRILOGY DCT 23/8L PMKR 9 $0.00
C1158 TVL LEAD SV01,SV02,SV04 9 $0.00
C1159 TVL RV02, RV06,RV07:LEAD 9 $0.00
C1160 TVL-ADX 1559:LEAD 9 $0.00
C1161 TENDRIL DX, 1388 PACING LEAD 9 $0.00
C1162 TEMPODR TRILOGYDR+DC PMKR 9 $0.00
C1163 TENDRIL SDX, 1488T LEAD 9 $0.00
C1164 IODINE-125 BRACHYTX SEED 9 $0.00
C1166 CYTARABINE LIPOSOMAL, 10 MG O $0.00
C1167 EPIRUBICIN HCL, 2 MG O $0.00
C1170 ABBI DISP BIOPSY DEVICE 9 $0.00
C1171 AUTOSUTURE SITE MARKER STPLE 9 $0.00
C1172 SPACEMAKER DISSECT BALLOON 9 $0.00
C1173 COR STNTS540,S670,O-WIRE STN 9 $0.00
C1174 BARD BRACHYTX NEEDLE 9 $0.00
C1175 MIBB DISP BIOPSY DEVICE 9 $0.00
C1176 MAMMOTOME HH PROBE W/VAC SYS 9 $0.00
C1177 11-G MAMMOTOME PROBE 9 $0.00

C1178 BUSULFAN IV, 6 MG O $0.00
C1179 14-G MAMMOTOME PROBE 9 $0.00
C1180 VIGOR SR, SC, PMKR 9 $0.00
C1181 MERIDIAN SSI, SC, PMKR 9 $0.00
C1182 PULSAR SSI, SC, PMKR 9 $0.00
C1183 JADE IIS, SIGMA 300S, SC, PM 9 $0.00
C1184 SIGMA 200S, SC, PMKR 9 $0.00
C1188 I-131 CAP, PER 1-5 MCI 9 $0.00
C1200 TC 99M SODIUM GLUCOHEPTONAT O $0.00
C1201 TC 99M SUCCIMER, PER VIAL O $0.00
C1202 TC 99M SULFUR COLLOID, VIAL 9 $0.00
C1203 VERTEPORFIN FOR INJ 9 $0.00
C1205 TC 99M DISOFENIN, PER VIAL 9 $0.00
C1207 OCTREOTIDE ACETATE DEPOT 1MG O $0.00
C1300 HYPERBARIC OXYGEN 9 $0.00
C1302 SQ01: LEAD 9 $0.00
C1303 CAPSURE FIX 6940/4068-110 9 $0.00
C1304 SONCATH MDL 37-416,-418 9 $0.00
C1305 APLIGRAF O $0.00
C1306 NEUROCYBERNETICPROS:LEAD 9 $0.00
C1311 TRILOGY DR+/DAO PMKR 9 $0.00
C1312 MAGIC WALLSTENT--MINI 9 $0.00
C1313 MAGIC MEDIUM,RADIUS 31MM 9 $0.00
C1314 MAGIC WALLSTENT--LONG 9 $0.00
C1315 VIGOR DR, MERIDIAN DR PMKR 9 $0.00
C1316 MERIDIAN DDD PMKR 9 $0.00
C1317 DISCOVERY SR, PMKR 9 $0.00
C1318 MERIDIAN SR PMKR 9 $0.00
C1319 WALLSTENT: ENTERAL--60MM 9 $0.00
C1320 WALLSTENT: ILIAC 9 $0.00
C1321 PALATE/BASE OF TONGUE ELECTR 9 $0.00
C1322 TURBINATE SOMNOPLASTY ELECTR 9 $0.00
C1323 VAPR/T DISP ELECTRODE 9 $0.00
C1324 LIGASURE DISPOSABLE ELECTROD 9 $0.00
C1325 PALLADIUM-103 SEED 9 $0.00
C1326 ANGIO-JET RHEOLYTIC THROMB 9 $0.00
C1328 ANS RENEW NS TRNSMTR 9 $0.00
C1329 VERSAPOINT DISP ELECTRODE 9 $0.00
C1333 PALMAZ CORINTHIAN BIL STENT 9 $0.00
C1334 CROWN,MINI-CROWN,CROSSLC 9 $0.00
C1335 MESH, PROLENE 9 $0.00
C1336 CONSTANT FLOW IMP PUMP 9 $0.00
C1337 ISOMED 8472-20/35/60 9 $0.00
C1348 I-131 SOL, PER 1-6 MCI 9 $0.00
C1350 PROSTASEED I-125, PER SOURCE 9 $0.00
C1351 CAPSURE FIX LEAD 9 $0.00
C1352 GEM II DR 9 $0.00
C1353 ITREL INTERSTM NEUROSTIM+EXT 9 $0.00
C1354 KAPPA 400DR,DIAMOND II 820DR 9 $0.00

C1355 KAPPA 600DR, VITA DR 9 $0.00
C1356 PROFILE MD V-186HV3 SC DEFIB 9 $0.00
C1357 ANGSTROM MD V-190HV3 SC DEF 9 $0.00
C1358 AFFINITY DC 5230R, PMKR 9 $0.00
C1359 PULSAR,PULSAR MAX DR, PMKR 9 $0.00
C1360 OCULAR PHOTODYNAMIC TX 9 $0.00
C1361 REVEAL CARDIAC RECORDER 9 $0.00
C1362 HERCULINK,OTW,SDS BIL STNT 9 $0.00
C1363 GEM DR, DC, DEFIB 9 $0.00
C1364 PHOTON DR V-230HV3 DC DEFIB 9 $0.00
C1365 GUIDEWIRE, HI-TORQUE14/18/35 9 $0.00
C1366 GUIDEWIRE,PTCA,HI-TORQUE 9 $0.00
C1367 GUIDE WIRE, HI-TORQUECROSSIT 9 $0.00
C1368 ON-Q PAIN MGT SYS 9 $0.00
C1369 ANS RENEW STIM SYS RECVR 9 $0.00
C1370 TENSION-FREE VAGINAL TAPE 9 $0.00
C1371 SYMP NITINOL TRANSHEP BIL SY 9 $0.00
C1372 CORDIS NITINOL BIL STENT 9 $0.00
C1375 STENT, CORONARY, NIR 9 $0.00
C1376 ANS RENEW STIM SYS LEAD 9 $0.00
C1377 SPECIFY 3988 NEURO LEAD 9 $0.00
C1378 INTERSTIM TX 3080/3886 LEAD 9 $0.00
C1379 PISCES-QUAD 3887 LEAD 9 $0.00
C1420 STAPLETAC2 BONEW/DERMIS 9 $0.00
C1421 STAPLETAC2 BONE WO DERMIS 9 $0.00
C1450 ORTHOSPHERE ARTHROPLASTY 9 $0.00
C1451 ORTHOSPHERE ARTHROPLASTY KIT 9 $0.00
C1500 ATHERECTOMY SYS, PERIPHERAL 9 $0.00
C1700 AUTHEN MICK TP BRACHY NEEDLE 9 $0.00
C1701 MEDTEC MT-BT-5201-25 NEEDLE 9 $0.00
C1702 WWMT BRACHY NEEDLE 9 $0.00
C1703 MENTOR PROSTATE BRACHY 9 $0.00
C1704 MT-BT-5001-25/5051-25 9 $0.00
C1705 BEST FLEXI BRACHY NEEDLE 9 $0.00
C1706 INDIGO PROSTATE SEEDING NDL 9 $0.00
C1707 VARISOURCE IMPLT NDL 9 $0.00
C1708 UROMED PROSTATE SEED NDL 9 $0.00
C1709 REMINGTON BRACHYTX NEEDLE 9 $0.00
C1710 US BIOPSY PROSTATE NEEDLE 9 $0.00
C1711 MD TECH BRACHYTX NEEDLE 9 $0.00
C1712 IMAGYN BRACHYTX NEEDLE 9 $0.00
C1713 ANCHOR/SCREW BN/BN,TIS/BN 9 $0.00
C1714 CATH, TRANS ATHERECTOMY, DIR 9 $0.00
C1715 BRACHYTHERAPY NEEDLE 9 $0.00
C1716 BRACHYTX, NON-STR, GOLD-198 9 $0.00
C1717 BRACHYTX, NON-STR,HDR IR-192 O $0.00
C1718 BRACHYTX SOURCE, IODINE 125 O $0.00
C1719 BRACHYTX, NS, NON-HDRIR-192 9 $0.00
C1720 BRACHYTX SOUR, PALLADIUM 103 O $0.00

C1721 AICD, DUAL CHAMBER 9 $0.00
C1722 AICD, SINGLE CHAMBER 9 $0.00
C1724 CATH, TRANS ATHEREC,ROTATION 9 $0.00
C1725 CATH, TRANSLUMIN NON-LASER 9 $0.00
C1726 CATH, BAL DIL, NON-VASCULAR 9 $0.00
C1727 CATH, BAL TIS DIS, NON-VAS 9 $0.00
C1728 CATH, BRACHYTX SEED ADM 9 $0.00
C1729 CATH, DRAINAGE 9 $0.00
C1730 CATH, EP, 19 OR FEW ELECT 9 $0.00
C1731 CATH, EP, 20 OR MORE ELEC 9 $0.00
C1732 CATH, EP, DIAG/ABL, 3D/VECT 9 $0.00
C1733 CATH, EP, OTHR THAN COOL-TIP 9 $0.00
C1750 CATH, HEMODIALYSIS,LONG-TERM 9 $0.00
C1751 CATH, INF, PER/CENT/MIDLINE 9 $0.00
C1752 CATH,HEMODIALYSIS,SHORT-TERM 9 $0.00
C1753 CATH, INTRAVAS ULTRASOUND 9 $0.00
C1754 CATHETER, INTRADISCAL 9 $0.00
C1755 CATHETER, INTRASPINAL 9 $0.00
C1756 CATH, PACING, TRANSESOPH 9 $0.00
C1757 CATH, THROMBECTOMY/EMBOLECT 9 $0.00
C1758 CATHETER, URETERAL 9 $0.00
C1759 CATH, INTRA ECHOCARDIOGRAPHY 9 $0.00
C1760 CLOSURE DEV, VASC 9 $0.00
C1762 CONN TISS, HUMAN(INC FASCIA) 9 $0.00
C1763 CONN TISS, NON-HUMAN 9 $0.00
C1764 EVENT RECORDER, CARDIAC 9 $0.00
C1765 ADHESION BARRIER 9 $0.00
C1766 INTRO/SHEATH,STRBLE,NON-PEEL 9 $0.00
C1767 GENERATOR, NEURO NON-RECHARG 9 $0.00
C1768 GRAFT, VASCULAR 9 $0.00
C1769 GUIDE WIRE 9 $0.00
C1770 IMAGING COIL, MR, INSERTABLE 9 $0.00
C1771 REP DEV, URINARY, W/SLING 9 $0.00
C1772 INFUSION PUMP, PROGRAMMABLE 9 $0.00
C1773 RET DEV, INSERTABLE 9 $0.00
C1775 FDG, PER DOSE (4-40 MCI/ML) O $0.00
C1776 JOINT DEVICE (IMPLANTABLE) 9 $0.00
C1777 LEAD, AICD, ENDO SINGLE COIL 9 $0.00
C1778 LEAD, NEUROSTIMULATOR 9 $0.00
C1779 LEAD, PMKR, TRANSVENOUS VDD 9 $0.00
C1780 LENS, INTRAOCULAR (NEW TECH) 9 $0.00
C1781 MESH (IMPLANTABLE) 9 $0.00
C1782 MORCELLATOR 9 $0.00
C1783 OCULAR IMP, AQUEOUS DRAIN DE 9 $0.00
C1784 OCULAR DEV, INTRAOP, DET RET 9 $0.00
C1785 PMKR, DUAL, RATE-RESP 9 $0.00
C1786 PMKR, SINGLE, RATE-RESP 9 $0.00
C1787 PATIENT PROGR, NEUROSTIM 9 $0.00
C1788 PORT, INDWELLING, IMP 9 $0.00

C1789 PROSTHESIS, BREAST, IMP 9 $0.00
C1790 IRIDIUM 192 HDR 9 $0.00
C1791 ONCOSEED, RAPID STRAND I-125 9 $0.00
C1792 UROMED I-125 BRACHY SEED 9 $0.00
C1793 BARD INTERSOURCE P-103 SEED 9 $0.00
C1794 BARD ISOSEED P-103 SEED 9 $0.00
C1795 BARD BRACHYSOURCE I-125 9 $0.00
C1796 SOURCETECH MED I-125 9 $0.00
C1797 DRAXIMAGE I-125 SEED 9 $0.00
C1798 SYNCOR I-125 PHARMASEED 9 $0.00
C1799 I-PLANT I-125 BRACHYTX SEED 9 $0.00
C1800 PD-103 BRACHYTX SEED 9 $0.00
C1801 IOGOLD I-125 BRACHYTX SEED 9 $0.00
C1802 IRIDIUM 192 BRACHYTX SEEDS 9 $0.00
C1803 BEST IODINE 125 BRACHYTX SDS 9 $0.00
C1804 BEST PALLADIUM 103 SEEDS 9 $0.00
C1805 ISOSTAR IODINE-125 SEEDS 9 $0.00
C1806 BEST GOLD 198 BRACHYTX SEED 9 $0.00
C1810 D114S DILATATION CATH 9 $0.00
C1811 SUGICAL DYNAMICS ANCHORS 9 $0.00
C1812 OBL ANCHORS 9 $0.00
C1813 PROSTHESIS, PENILE, INFLATAB 9 $0.00
C1814 RETINAL TAMP, SILICONE OIL 9 $0.00
C1815 PROS, URINARY SPH, IMP 9 $0.00
C1816 RECEIVER/TRANSMITTER, NEURO 9 $0.00
C1817 SEPTAL DEFECT IMP SYS 9 $0.00
C1818 INTEGRATED KERATOPROSTHESIS 9 $0.00
C1819 TISSUE LOCALIZATION-EXCISION 9 $0.00
C1820 GENERATOR NEURO RECHG BAT SY 9 $0.00
C1821 INTERSPINOUS IMPLANT 9 $0.00
C1850 REPLIFORM 14/21 SQ CM 9 $0.00
C1851 REPLIFORM 24/28 SQ CM 9 $0.00
C1852 TRANSCYTE, PER 247 SQ CM 9 $0.00
C1853 SUSPEND, PER 8/14 SQ CM 9 $0.00
C1854 SUSPEND, PER 24/28 SQ CM 9 $0.00
C1855 SUSPEND, PER 36 SQ CM 9 $0.00
C1856 SUSPEND, PER 48 SQ CM 9 $0.00
C1857 SUSPEND, PER 84 SQ CM 9 $0.00
C1858 DURADERM, PER 8/14 SQ CM 9 $0.00
C1859 DURADERM, PER 21/24/28 SQ CM 9 $0.00
C1860 DURADERM, PER 48 SQ CM 9 $0.00
C1861 DURADERM, PER 36 SQ CM 9 $0.00
C1862 DURADERM, PER 72 SQ CM 9 $0.00
C1863 DURADERM, PER 84 SQ CM 9 $0.00
C1864 SPERMATEX, PER 13.44 SQ CM 9 $0.00
C1865 FASLATA, PER 8/14 SQ CM 9 $0.00
C1866 FASLATA, PER 24/28 SQ CM 9 $0.00
C1867 FASLATA, PER 36/48 SQ CM 9 $0.00
C1868 FASLATA, PER 96 SQ CM 9 $0.00

C1869 GORE THYROPLASTY DEVICE 9 $0.00
C1870 DERMMATRIX, PER 16 SQ CM 9 $0.00
C1871 DERMMATRIX, 32 OR 64 SQ CM 9 $0.00
C1872 DERMAGRAFT, PER 37.5 SQ CM 9 $0.00
C1873 BARD 3DMAX MESH 9 $0.00
C1874 STENT, COATED/COV W/DEL SYS 9 $0.00
C1875 STENT, COATED/COV W/O DEL SY 9 $0.00
C1876 STENT, NON-COA/NON-COV W/DEL 9 $0.00
C1877 STENT, NON-COAT/COV W/O DEL 9 $0.00
C1878 MATRL FOR VOCAL CORD 9 $0.00
C1879 TISSUE MARKER, IMPLANTABLE O $0.00
C1880 VENA CAVA FILTER 9 $0.00
C1881 DIALYSIS ACCESS SYSTEM 9 $0.00
C1882 AICD, OTHER THAN SING/DUAL 9 $0.00
C1883 ADAPT/EXT, PACING/NEURO LEAD 9 $0.00
C1884 EMBOLIZATION PROTECT SYST 9 $0.00
C1885 CATH, TRANSLUMIN ANGIO LASER 9 $0.00
C1887 CATHETER, GUIDING 9 $0.00
C1888 ENDOVAS NON-CARDIAC ABL CATH 9 $0.00
C1891 INFUSION PUMP,NON-PROG, PERM 9 $0.00
C1892 INTRO/SHEATH,FIXED,PEEL-AWAY 9 $0.00
C1893 INTRO/SHEATH, FIXED,NON-PEEL 9 $0.00
C1894 INTRO/SHEATH, NON-LASER 9 $0.00
C1895 LEAD, AICD, ENDO DUAL COIL 9 $0.00
C1896 LEAD, AICD, NON SING/DUAL 9 $0.00
C1897 LEAD, NEUROSTIM TEST KIT 9 $0.00
C1898 LEAD, PMKR, OTHER THAN TRANS 9 $0.00
C1899 LEAD, PMKR/AICD COMBINATION 9 $0.00
C1900 LEAD, CORONARY VENOUS 9 $0.00
C1925 INJECTION, RISPERIDONE 9 $0.00
C1929 MAVERICK PTCA CATH 9 $0.00
C1930 COYOTE DIL CATH, 20/30/40MM 9 $0.00
C1931 TALON DIL CATH 9 $0.00
C1932 SCIMED REMEDY DIL CATH 9 $0.00
C1933 OPTI-PLAST XL/CENTURION CATH 9 $0.00
C1934 ULTRAVERSE 3.5F BAL DIL CATH 9 $0.00
C1935 WORKHORSE PTA BAL CATH 9 $0.00
C1936 UROMAX ULTRA BAL DIL CATH 9 $0.00
C1937 SYNERGY/EXPLORER CATH 9 $0.00
C1938 UROFORCE BAL DIL CATH 9 $0.00
C1939 RAPTUR, NINJA PTCA DIL CATH 9 $0.00
C1940 POWERFLEX,OPTA 5/LP BAL CATH 9 $0.00
C1941 JUPITER PTA DIL CATH 9 $0.00
C1942 CORDIS MAXI LD PTA BAL CATH 9 $0.00
C1943 RXCROSSSAIL OTW OPENSAIL 9 $0.00
C1944 RAPID EXCHANGE BIL DIL CATH 9 $0.00
C1945 SAVVY PTA DIL CATH 9 $0.00
C1946 R1S RAPID DIL CATH 9 $0.00
C1947 GAZELLE BAL DIL CATH 9 $0.00

C1948 ORACLE MEGASONICS CATH 9 $0.00
C1949 ORACLE MEGASONICS CATH 9 $0.00
C1979 VISIONS PV/AVANAR US CATH 9 $0.00
C1980 ATLANTIS SR CORONARY CATH 9 $0.00
C1981 PTCA CATHETERS 9 $0.00
C2000 ORBITER ST STEERABLE CATH 9 $0.00
C2001 CONSTELLATION DIAG CATH 9 $0.00
C2002 IRVINE 5F INQUIRY EP CATH 9 $0.00
C2003 IRVINE 6F INQUIRY EP CATH 9 $0.00
C2004 EP CATH--OCTAPOLAR 9 $0.00
C2005 EP TIP CATH--HEXAPOLAR 9 $0.00
C2006 EP CATH--DECAPOLAR 9 $0.00
C2007 IRVINE 6F LUMA-CATH EP CATH 9 $0.00
C2008 LUMA-CATH EP CATH 81910-15 9 $0.00
C2009 IRVINE 7F LUMA-CATH EP CATH 9 $0.00
C2010 FIXED CURVE EP CATH 9 $0.00
C2011 DEFLECTABLE TIP CATH--QUAD 9 $0.00
C2012 CELSIUS ABLN CATH 9 $0.00
C2013 CELSIUS LARGE ABLN CATH 9 $0.00
C2014 CELSIUS II ASYM ABLN CATH 9 $0.00
C2015 CELSIUS II SYM ABLN CATH 9 $0.00
C2016 NAVI-STAR DS, NAVI-STAR THER 9 $0.00
C2017 NAVI-STAR ABLN CATH 9 $0.00
C2018 POLARIS T ABLATION CATH 9 $0.00
C2019 EP DEFLECTABLE CATH 9 $0.00
C2020 BLAZER II XP ABLN CATH 9 $0.00
C2021 SILVERFLEX EP CATH 9 $0.00
C2022 CP CHILLI COOLED ABLN CATH 9 $0.00
C2023 CHILLI CLD ABLNCATH-STD,LG 9 $0.00
C2100 CP CS REFERENCE CATH 9 $0.00
C2101 CP RV REFERENCE CATH 9 $0.00
C2102 CP RADII 7F EP CATH 9 $0.00
C2103 CP RADII 7F EP CATH W/TRACK 9 $0.00
C2104 LASSO DEFLECTABLE CATH 9 $0.00
C2151 VERIPATH GUIDING CATH 9 $0.00
C2152 CORDIS VISTA BRITE TIP CATH 9 $0.00
C2153 BARD VIKING CATH 9 $0.00
C2200 ARROW-TREROTOLA PTD CATH 9 $0.00
C2300 VARISOURCE STND CATH 9 $0.00
C2597 CLINICATH 16/18 SGL/DBL 9 $0.00
C2598 CLINICATH 18/20/24G--SINGLE 9 $0.00
C2599 CLINICATH 16/18 DOUBLE 9 $0.00
C2600 GOLD PROBE CATHETER 9 $0.00
C2601 BARD DL URETERAL CATH 9 $0.00
C2602 VITESSE LASER CATH 1.4/1.7MM 9 $0.00
C2603 VITESSE LASER CATH 2.0MM 9 $0.00
C2604 VITESSE E LASER CATH 2.0MM 9 $0.00
C2605 EXTREME LASER CATH 9 $0.00
C2606 SPINECATH XL CATHETER 9 $0.00

C2607 SPINECATH INTRADISCAL CATH 9 $0.00
C2608 SCIMED 6F WISEGUIDE CATHETER 9 $0.00
C2609 FLEXIMA BIL DRAINAGE CATH 9 $0.00
C2610 FLEXTIPPLUS INTRASPINAL CATH 9 $0.00
C2611 ALGOLINE INTRASPINAL CATH 9 $0.00
C2612 INDURA CATHETER 9 $0.00
C2614 PROBE, PERC LUMB DISC 9 $0.00
C2615 SEALANT, PULMONARY, LIQUID 9 $0.00
C2616 BRACHYTX, NON-STR,YTTRIUM-90 9 $0.00
C2617 STENT, NON-COR, TEM W/O DEL 9 $0.00
C2618 PROBE, CRYOABLATION 9 $0.00
C2619 PMKR, DUAL, NON RATE-RESP 9 $0.00
C2620 PMKR, SINGLE, NON RATE-RESP 9 $0.00
C2621 PMKR, OTHER THAN SING/DUAL 9 $0.00
C2622 PROSTHESIS, PENILE, NON-INF 9 $0.00
C2625 STENT, NON-COR, TEM W/DEL SY 9 $0.00
C2626 INFUSION PUMP, NON-PROG,TEMP 9 $0.00
C2627 CATH, SUPRAPUBIC/CYSTOSCOPIC 9 $0.00
C2628 CATHETER, OCCLUSION 9 $0.00
C2629 INTRO/SHEATH, LASER 9 $0.00
C2630 CATH, EP, COOL-TIP 9 $0.00
C2631 REP DEV, URINARY, W/O SLING 9 $0.00
C2632 BRACHYTX SOL, I-125, PER MCI O $0.00
C2633 BRACHYTX SOURCE, CESIUM-131 O $0.00
C2634 BRACHYTX, NON-STR, HA, I-125 9 $0.00
C2635 BRACHYTX, NON-STR, HA, P-103 9 $0.00
C2636 BRACHY LINEAR, NON-STR,P-103 9 $0.00
C2637 BRACHY,NON-STR,YTTERBIUM-169 9 $0.00
C2638 BRACHYTX, STRANDED, I-125 9 $0.00
C2639 BRACHYTX, NON-STRANDED,I-125 9 $0.00
C2640 BRACHYTX, STRANDED, P-103 9 $0.00
C2641 BRACHYTX, NON-STRANDED,P-103 9 $0.00
C2642 BRACHYTX, STRANDED, C-131 9 $0.00
C2643 BRACHYTX, NON-STRANDED,C-131 9 $0.00
C2676 RSPONSE CV CATHETER 9 $0.00
C2698 BRACHYTX, STRANDED, NOS 9 $0.00
C2699 BRACHYTX, NON-STRANDED, NOS 9 $0.00
C2700 MYCROPHYLAX PLUS SC DEFIB 9 $0.00
C2701 PHYLAX XM SC DEFIB 9 $0.00
C2702 VENTAK PRIZM 2 VR DEFIB 9 $0.00
C2703 VENTAK PRIZM VR HE DEFIB 9 $0.00
C2704 VENTAK MINI IV+ DEFIB 9 $0.00
C2801 DEFENDER IV DR 612 DC DEFIB 9 $0.00
C2802 PHYLAX AV 9 $0.00
C2803 VENTAK PRIZM DR HE DEFIB 9 $0.00
C2804 VENTAK PRIZM 2 DR DEFIB 9 $0.00
C2805 JEWEL AF 7250 DEFIB 9 $0.00
C2806 GEM VR 7227 DEFIB 9 $0.00
C2807 CONTAK CD 1823 9 $0.00

C2808 CONTAK TR 1241 9 $0.00
C3001 KAINOX SL/RV DEFIB LEAD 9 $0.00
C3002 EASYTRAK DEFIB LEAD 9 $0.00
C3003 ENDOTAK SQ ARAY XP LEAD 9 $0.00
C3004 INTERVENE DEFIB LEAD 9 $0.00
C3400 SILTEX SPECTRUM,CONTOUR PROF 9 $0.00
C3401 SALINE-FILLED SPECTRUM 9 $0.00
C3500 ALPHA I INF PRO 9 $0.00
C3510 AMS 800 URINARY PROS 9 $0.00
C3551 CHOICE/PT GRAPHIX/LUGE/TROOP 9 $0.00
C3552 HI-TORQUE WHISPER 9 $0.00
C3553 CORDIS GUIDEWIRES 9 $0.00
C3554 JINDO GUIDEWIRE 9 $0.00
C3555 WHOLEY HI-TORQUE PLUS GW 9 $0.00
C3556 WAVE/FLOWWIRE GUIDEWIRE 9 $0.00
C3557 HYTEK GUIDEWIRE 9 $0.00
C3800 SYNCHROMED EL INFUSION PUMP 9 $0.00
C3801 ARROW/MICROJECT PCA SYS 9 $0.00
C3851 ELASTIC UV IOLAA-4203T/TF/TL 9 $0.00
C4000 OPUS G 4621, 4624 SC PMKR 9 $0.00
C4001 OPUS S 4121/4124 SC PMKR 9 $0.00
C4002 TALENT 113 SC PMKR 9 $0.00
C4003 KAIROS SR SC PMKR 9 $0.00
C4004 ACTROS SR, ACTROSSR-B SC PMK 9 $0.00
C4005 PHILOS SR/SR-B SC PMKR 9 $0.00
C4006 PULSAR MAX II SR PMKR 9 $0.00
C4007 MARATHON SR PMKR 9 $0.00
C4008 DISCOVERY II SSI PMKR 9 $0.00
C4009 DISCOVERY II SR PMKR 9 $0.00
C4300 INTEGRITY AFX DR 5342 PMKR 9 $0.00
C4301 INTEGRITY AFX DR 5346 PMKR 9 $0.00
C4302 AFFINITY VDR 5430 PMKR 9 $0.00
C4303 BRIO 112 DC PMKR 9 $0.00
C4304 BRIO212,TALENT213/223DCPMKR 9 $0.00
C4305 BRIO 222 DC PMKR 9 $0.00
C4306 BRIO 220 DC PMKR 9 $0.00
C4307 KAIROS DR DC PMKR 9 $0.00
C4308 INOS2, INOS2+ DC PMKR 9 $0.00
C4309 ACTROS DR,D,DR-A,SLR DC PMKR 9 $0.00
C4310 ACTROS DR-B DC PMKR 9 $0.00
C4311 PHILOS DR/DR-B/SLR DC PMKR 9 $0.00
C4312 PULSAR MAX II DR PMKR 9 $0.00
C4313 MARATHON DR PMKR 9 $0.00
C4314 MOMENTUM DR PMKR 9 $0.00
C4315 SELECTION AFM PMKR 9 $0.00
C4316 DISCOVERY II DR 9 $0.00
C4317 DISCOVERY II DDD 9 $0.00
C4600 SYNOX,POLYROX,ELOX,RETROX 9 $0.00
C4601 AESCULA LV PMKR LEAD 9 $0.00

C4602 TENDRIL SDX, 1488K PMKR LEAD 9 $0.00
C4603 OSCOR PR/FLEXION PMKR LEAD 9 $0.00
C4604 CRYSTALLINEACTFIX,CAPSUREFIX 9 $0.00
C4605 CAPSURE EPI PMKR LEAD 9 $0.00
C4606 FLEXTEND PMKR LEAD 9 $0.00
C4607 FINELINEII/EZ, THINLINEII/EZ 9 $0.00
C5000 BX VELOCITY W/HEPACOAT 9 $0.00
C5001 MEMOTHERM BIL STENT, SM, MED 9 $0.00
C5002 MEMOTHERM BIL STENT, LARGE 9 $0.00
C5003 MEMOTHERM BIL STENT, X-LARGE 9 $0.00
C5004 PALMAZCORINTHIAN IQ BIL STNT 9 $0.00
C5005 PALMAZCORINTHIAN IQ TRANS/BI 9 $0.00
C5006 PALMAZTRANS BIL STENTSYS-MED 9 $0.00
C5007 PALMAZTRANS XL BIL ST-40MM 9 $0.00
C5008 PALMAZTRANS XL BIL ST-50MM 9 $0.00
C5009 VISTAFLEX BILIARY STENT 9 $0.00
C5010 RAPID EXCHANGE BIL STENT SYS 9 $0.00
C5011 INTRASTENT, INTRASTENT LP 9 $0.00
C5012 INTRASTENT DOUBLESTRUT LD 9 $0.00
C5013 INTRASTENT DOUBLESTRUT, XS 9 $0.00
C5014 AVE BRIDGE STENTSYS10/17/28 9 $0.00
C5015 AVE/X3 BRIDGE SYS, 40-100 9 $0.00
C5016 BILIARY STENT SINGLE USE COV 9 $0.00
C5017 WALLSTENTRP-BIL-20/40/60/68 9 $0.00
C5018 WALLSTENTRP BIL--80/94MM 9 $0.00
C5019 FLEXIMA BIL STENT SYS 9 $0.00
C5020 SMART NITINOL STENT--20MM 9 $0.00
C5021 SMART NITINOL STENT--40/60MM 9 $0.00
C5022 SMART NITINOL STENT--80MM 9 $0.00
C5023 BX VELOCITY STENT--8/13MM 9 $0.00
C5024 BX VELOCITY STENT 9 $0.00
C5025 BX VELOCITY STENT--23MM 9 $0.00
C5026 BX VELOCITY STENT--28/33MM 9 $0.00
C5027 BX VELOCITY W/HEP--8/13MM 9 $0.00
C5028 BX VELOCITY W/HEP--18MM 9 $0.00
C5029 BX VELOCITY W/HEP--23MM 9 $0.00
C5030 STENT, CORONARY, S660 9/12MM 9 $0.00
C5031 STENT, CORONARY, S660 15/18 9 $0.00
C5032 STENT,CORONARY, S660 24/30 9 $0.00
C5033 NIROYAL STNT SYS, 9MM 9 $0.00
C5034 NIROYAL STENT SYS, 12/15MM 9 $0.00
C5035 NIROYAL STENT SYS, 18MM 9 $0.00
C5036 NIROYAL STENT SYS, 25MM 9 $0.00
C5037 NIROYAL STENT SYS, 31MM 9 $0.00
C5038 BX VELOCITY STNT W/RAPTOR 9 $0.00
C5039 INTRACOIL PERIP STENT--40MM 9 $0.00
C5040 INTRACOIL PERIPH STENT--60MM 9 $0.00
C5041 BESTENT OVER-THE-WIRE24/30MM 9 $0.00
C5042 BESTENT OVER-THE-WIRE 18MM 9 $0.00

C5043 BESTENT OVER-THE-WIRE 15MM 9 $0.00
C5044 BESTENT OVER-THE-WIRE 9/12MM 9 $0.00
C5045 MULTILINK TETRA COR STENT SY 9 $0.00
C5046 RADIUS 20MM COR STENT 9 $0.00
C5047 NIROYAL ELITE COR STENT SYS 9 $0.00
C5048 GR II CORONARY STENT 9 $0.00
C5130 WILSON-COOK Z-STENT 9 $0.00
C5131 BARD COLORECTAL STENT--60MM 9 $0.00
C5132 BARD COLORECTAL STENT--80MM 9 $0.00
C5133 BARD COLORECTAL STENT-100MM 9 $0.00
C5134 ENTERAL WALLSTENT--90MM 9 $0.00
C5279 CONTOUR/PERCUFLEX STENT 9 $0.00
C5280 INLAY DBL URETERAL STENT 9 $0.00
C5281 WALLGRAFT TRACH SYS 70MM 9 $0.00
C5282 WALLGRAFT TRACH SYS 20/30/50 9 $0.00
C5283 WALLSTENT/RP TIPS--80MM 9 $0.00
C5284 WALLSTENT TRACHULTRAFLEX 9 $0.00
C5600 CLOSURE DEV, VASOSEAL ES 9 $0.00
C5601 VASOSEAL 1000 9 $0.00
C6001 COMPOSIX MESH 8/18 IN 9 $0.00
C6002 COMPOSIX MESH 32 IN 9 $0.00
C6003 COMPOSIX MESH 48 IN 9 $0.00
C6004 COMPOSIX MESH 80 IN 9 $0.00
C6005 COMPOSIX MESH 140 IN 9 $0.00
C6006 COMPOSIX MESH 144 IN 9 $0.00
C6012 PELVICOL COLLAGEN 8/14 SQ CM 9 $0.00
C6013 PELVICOL COLLAGEN 21/24/28 9 $0.00
C6014 PELVICOL COLLAGEN 40 SQ CM 9 $0.00
C6015 PELVICOL COLLAGEN 48 SQ CM 9 $0.00
C6016 PELVICOL COLLAGEN 96 SQ CM 9 $0.00
C6017 GORE-TEX DUALMESH 75/96 SQCM 9 $0.00
C6018 GORE-TEX DUALMESH 150SQCM 9 $0.00
C6019 GORE-TEX DUALMESH 285 SQCM 9 $0.00
C6020 GORE-TEX DUALMESH 432SQCM 9 $0.00
C6021 GORE-TEX DUALMESH 600 SQCM 9 $0.00
C6022 GORE-TEX DUALMESH 884 SQCM 9 $0.00
C6023 GORE-TEXPLUS 1MM,75/96 SQCM 9 $0.00
C6024 GORE-TEXPLUS 1MM, 150 SQ CM 9 $0.00
C6025 GORE-TEXPLUS 1MM, 285 SQ CM 9 $0.00
C6026 GORE-TEXPLUS 1MM, 432 SQCM 9 $0.00
C6027 GORE-TEXPLUS 1MM, 600 SQCM 9 $0.00
C6028 GORE-TEXPLUS 1MM,884 SQ CM 9 $0.00
C6029 GORE-TEXPLUS 2MM, 150 SQ CM 9 $0.00
C6030 GORE-TEXPLUS 2MM, 285 SQ CM 9 $0.00
C6031 GORE-TEXPLUS 2MM, 432 SQ CM 9 $0.00
C6032 GORE-TEXPLUS 2MM, 600 SQ CM 9 $0.00
C6033 GORE-TEXPLUS 2MM,884 SQ CM 9 $0.00
C6034 BARD EPTFE: 150 SQ CM-2MM 9 $0.00
C6035 BARD EPTFE150SQCM-1MM,75-2MM 9 $0.00

C6036 BARD EPTFE: 50/75SQCM-1,2MM 9 $0.00
C6037 BARD EPFTE: 300SQ CM-1MM 9 $0.00
C6038 BARD EPTFE: 600SQ CM-1MM 9 $0.00
C6039 BARD EPTFE: 884 CM--1MM 9 $0.00
C6040 BARD EPTFE: 600SQ CM-2MM 9 $0.00
C6041 BARD EPTFE: 884SQ CM-2MM 9 $0.00
C6050 FEMALE SLING SYS W/WO MATRL 9 $0.00
C6051 STRATASIS SLING, 20/40CM 9 $0.00
C6052 STRATASIS SLING, 60CM 9 $0.00
C6053 SURGISIS SOFT GRAFT 9 $0.00
C6054 SURGISIS ENCHANCED GRAFT 9 $0.00
C6055 SURGISIS ENHANCED TISSUE 9 $0.00
C6056 SURGISIS SOFT TISSUE GRAFT 9 $0.00
C6057 SURGISIS HERNIA GRAFT 9 $0.00
C6058 SURGIPRO HERNIA PLUG,MED/LG 9 $0.00
C6080 MALE SLING SYS W/WO MATRL 9 $0.00
C6200 EXXCEL SFT EPTFE VAS GRAFT 9 $0.00
C6201 IMPRA VENAFLO-10/20CM 9 $0.00
C6202 IMPRA VENAFLO-30/40CM 9 $0.00
C6203 IMPRA VENAFLO-50CM/VT45 9 $0.00
C6204 IMPRA VENAFLO-STEPPED 9 $0.00
C6205 IMPRA CARBOFLO-10CM 9 $0.00
C6206 IMPRA CARBOFLO-20CM 9 $0.00
C6207 IMPRA CARBOFLO-30/34/40CM 9 $0.00
C6208 IMPRA CARBOFLO-40/50CM 9 $0.00
C6209 IMPRA CARBOFLO-CTRFLEX 9 $0.00
C6210 EXXCEL EPTFE VAS GRAFT 9 $0.00
C6300 VANGUARD III ENDOVAS GRAFT 9 $0.00
C6500 PREFACE GUIDING SHEATH 9 $0.00
C6501 SOFT TIP SHEATHS 9 $0.00
C6525 SPECTRANETICS LASER SHEATH 9 $0.00
C6600 MICRO LITHO FLEX PROBES 9 $0.00
C6650 FAST-CATH GUIDING INTRODUCER 9 $0.00
C6651 SEAL-AWAYGUIDING INTRODUCER 9 $0.00
C6652 BARD EXCALIBUR INTRODUCER 9 $0.00
C6700 FOCAL SEAL-L 9 $0.00
C8099 SPECTRANETICS LEAD LOCK DEV 9 $0.00
C8100 ADHESION BARRIER, ADCON-L 9 $0.00
C8102 SURGIVISION ESOPH COIL 9 $0.00
C8103 CAPIO CAPTURING DEV 9 $0.00
C8500 ATHEROCATH-GTO 9 $0.00
C8501 VIGOR SSI, SC, PMKR 9 $0.00
C8502 LIVEWIRE STEERABLE EP CATH 9 $0.00
C8503 SYNCHROMED VAS CATH 9 $0.00
C8504 VASOSEAL HEMOSTASIS DEV 9 $0.00
C8505 SYNCHROMED INFUSION PUMP 9 $0.00
C8506 PMKR LEADS 4057M,4058M 9 $0.00
C8507 6721L/M/S,6939 LEAD 9 $0.00
C8508 CAPSURE 4965 DEFIB LEAD 9 $0.00

C8509 TRANSVENE 6933/6937 LEAD 9 $0.00
C8510 DP-3238 DEFIB LEAD 9 $0.00
C8511 ENDOTAK DSP DEFIB LEAD 9 $0.00
C8512 ON-POINT,PISCES-QUAD LEAD 9 $0.00
C8513 PISCES,RESUME II LEAD 9 $0.00
C8514 DURA II PENILE PROSTHESIS 9 $0.00
C8516 MENTOR ACU-FORM/MAL PROS 9 $0.00
C8518 VIGOR DDD DC PMKR 9 $0.00
C8519 VISTA DDD C PMKR 9 $0.00
C8520 LEGACY II S, SC, PMKR 9 $0.00
C8521 MEDTRONIC MATTRIX RCVR/TRMR 9 $0.00
C8522 PALMAZ BAL STENT 9 $0.00
C8523 WALLSTENT TRANS BIL 9 $0.00
C8524 WALLSTENT ESOP 9 $0.00
C8525 WALLSTENT ESOPH--DOUBLE 9 $0.00
C8526 OPTIPLAST XT PTA CATH 9 $0.00
C8528 MS CLASSIQUE BL DIL CATH 9 $0.00
C8529 CRISTA CATH II DEF 20-POLE 9 $0.00
C8530 GEL-FILLED/SMOOTH MAMMARY PR 9 $0.00
C8531 WILSON-COOK ESOPH Z-STENT 9 $0.00
C8532 ULTRAFLEX ESOPHAGEAL PROS 9 $0.00
C8533 SYNCHROMED VAS CATH 8700A/V 9 $0.00
C8534 AMS 650 PENILE PROSTHESIS 9 $0.00
C8535 ZA/SPIRAL Z BIL STENT 9 $0.00
C8536 ESOPH Z METAL STENT 9 $0.00
C8539 QUANTUM DIL BALLOON 9 $0.00
C8540 FLEX-EZ BAL DILATOR 9 $0.00
C8541 CARSON/PASSPRT DIL CATH 9 $0.00
C8542 URETHRAMAX DIL CATH 9 $0.00
C8543 AMPLATZ RENAL DIL 9 $0.00
C8550 LIVEWIRE 5F, 7F EP CATH 9 $0.00
C8551 LIVEWIRE 7F DUO-DECAPOLAR 9 $0.00
C8552 SANTURO FIXED CURVE CATH 9 $0.00
C8597 WISDOM ST GUIDEWIRE 9 $0.00
C8598 SV GUIDEWIRE-5/8/14CM 9 $0.00
C8599 STABILIZER XS GUIDEWIRE 9 $0.00
C8600 SHINOBI PLUS GUIDEWIRE 9 $0.00
C8650 XL CHECK-FLO INTRODUCER 9 $0.00
C8724 OCTAD NEURO LEAD 9 $0.00
C8725 SYMMIX NEURO LEAD 9 $0.00
C8748 ENDOTAK SQ PATCH DEFIB LEAD 9 $0.00
C8749 ENDOTAK SQ ARRAY DEFIB LEAD 9 $0.00
C8750 UNITY VDDR DC PMKR 9 $0.00
C8775 2188 COR PMKR LEAD 9 $0.00
C8776 INNOMEDICA PMKR LEAD 9 $0.00
C8777 UNIPASS PMKR LEAD 9 $0.00
C8800 LG PALMAZ BIL STENT 9 $0.00
C8801 GIANTURCO BIL Z STENT 9 $0.00
C8802 OASIS STENT INTRO SYS 9 $0.00

C8830 GIANTURCO-ROUBIN COR SNT 9 $0.00
C8890 PERFLUORON, 2ML 9 $0.00
C8891 PERFLUORON, 5/7ML 9 $0.00
C8900 MRA W/CONT, ABD 9 $0.00
C8901 MRA W/O CONT, ABD 9 $0.00
C8902 MRA W/O FOL W/CONT, ABD 9 $0.00
C8903 MRI W/CONT, BREAST, UNI 9 $0.00
C8904 MRI W/O CONT, BREAST, UNI 9 $0.00
C8905 MRI W/O FOL W/CONT, BRST, UN 9 $0.00
C8906 MRI W/CONT, BREAST, BI 9 $0.00
C8907 MRI W/O CONT, BREAST, BI 9 $0.00
C8908 MRI W/O FOL W/CONT, BREAST, 9 $0.00
C8909 MRA W/CONT, CHEST 9 $0.00
C8910 MRA W/O CONT, CHEST 9 $0.00
C8911 MRA W/O FOL W/CONT, CHEST 9 $0.00
C8912 MRA W/CONT, LWR EXT 9 $0.00
C8913 MRA W/O CONT, LWR EXT 9 $0.00
C8914 MRA W/O FOL W/CONT, LWR EXT 9 $0.00
C8918 MRA W/CONT, PELVIS 9 $0.00
C8919 MRA W/O CONT, PELVIS 9 $0.00
C8920 MRA W/O FOL W/CONT, PELVIS 9 $0.00
C8921 TTE W OR W/O FOL W/CONT, COM 9 $0.00
C8922 TTE W OR W/O FOL W/CONT, F/U 9 $0.00
C8923 2D TTE W OR W/O FOL W/CON,CO 9 $0.00
C8924 2D TTE W OR W/O FOL W/CON,FU 9 $0.00
C8925 2D TEE W OR W/O FOL W/CON,IN 9 $0.00
C8926 TEE W OR W/O FOL W/CONT,CONG 9 $0.00
C8927 TEE W OR W/O FOL W/CONT, MON 9 $0.00
C8928 TTE W OR W/O FOL W/CON,STRES 9 $0.00
C8929 TTE W OR WO FOL WCON,DOPPLER 9 $0.00
C8930 TTE W OR W/O CONTR, CONT ECG 9 $0.00
C8950 INTRAVENOUS INFUSION FOR THERAPY/ O $0.00
C8951 INTRAVENOUS INFUSION FOR THERAPY/ O $0.00
C8952 THERAPEUTIC, PROPHYLACTIC OR DIAGN O $0.00
C8953 CHEMOTHERAPY ADMINISTRATION, INTRA O $0.00
C8954 CHEMOTHERAPY ADMINISTRATION, INTRA O $0.00
C8955 CHEMOTHERAPY ADMINISTRATION, INTRA O $0.00
C8956 REFILLING AND MAINTENANCE OF PORTA 9 $0.00
C8957 PROLONGED IV INF, REQ PUMP 9 $0.00
C9000 NA CHROMATECR51, PER 0.25MCI O $0.00
C9001 LINEZOLID INJ, 200MG 9 $0.00
C9002 TENECTEPLASE, 50MG/VIAL 9 $0.00
C9003 PALIVIZUMAB, PER 50 MG O $0.00
C9004 GEMTUZUMAB OZOGAMICIN INJ,5M 9 $0.00
C9005 RETEPLASE INJ, HALF-KIT,18.8 9 $0.00
C9006 TACROLIMUS INJ, PER 5 MG 9 $0.00
C9007 BACLOFEN INTRATHECAL KIT-1AM O $0.00
C9008 BACLOFEN REFILL KIT-500MCG O $0.00
C9009 BACLOFEN REFILL KIT-2000MCG O $0.00

C9010 BACLOFEN REFILL KIT--4000MCG O $0.00
C9011 CAFFEINE CITRATE, INJ, 1ML 9 $0.00
C9013 CO 57 COBALTOUS CHLORIDE O $0.00
C9019 CASPOFUNGIN ACETATE, 5 MG 9 $0.00
C9020 SIROLIMUS TABLET, 1 MG 9 $0.00
C9100 IODINATED I-131 ALBUMIN 9 $0.00
C9102 51 NA CHROMATE, 50MCI O $0.00
C9103 NA IOTHALAMATE I-125, 10 UCI O $0.00
C9104 ANTI-THYMOCYTE GLOBULIN,25MG 9 $0.00
C9105 HEP B IMM GLOB, PER 1 ML O $0.00
C9106 SIROLIMUS 1MG/ML 9 $0.00
C9107 TINZAPARIN SODIUM, 2ML VIAL 9 $0.00
C9108 THYROTROPIN ALFA, 1.1 MG 9 $0.00
C9109 TIROFIBAN HCL, 6.25 MG O $0.00
C9110 ALEMTUZUMAB, PER 10MG/ML 9 $0.00
C9111 INJ, BIVALIRUDIN, 250MG VIAL O $0.00
C9112 PERFLUTREN LIPID MICRO, 2ML O $0.00
C9113 INJ PANTOPRAZOLE SODIUM, VIA 9 $0.00
C9114 NESIRITIDE, PER 1.5 MG VIAL 9 $0.00
C9115 INJ, ZOLEDRONIC ACID, 2 MG 9 $0.00
C9116 ERTAPENEM SODIUM, PER 1 GM O $0.00
C9119 INJECTION, PEGFILGRASTIM O $0.00
C9120 INJECTION, FULVESTRANT O $0.00
C9121 INJECTION, ARGATROBAN 9 $0.00
C9123 TRANSCYTE, PER 247 SQ CM O $0.00
C9124 INJECTION, DAPTOMYCIN O $0.00
C9125 INJECTION, RISPERIDONE O $0.00
C9126 INJECTION, NATALIZUMAB O $0.00
C9200 ORCEL, PER 36 CM2 O $0.00
C9201 DERMAGRAFT, PER 37.5 SQ CM O $0.00
C9202 OCTAFLUOROPROPANE O $0.00
C9203 PERFLEXANE LIPID MICRO O $0.00
C9205 OXALIPLATIN O $0.00
C9206 INTEGRA, PER CM2 O $0.00
C9207 INJECTION, BORTEZOMIB O $0.00
C9208 INJECTION, AGALSIDASE BETA O $0.00
C9209 INJECTION, LARONIDASE O $0.00
C9210 INJECTION, PALONOSETRON HCL O $0.00
C9211 INJ, ALEFACEPT, IV O $0.00
C9212 INJ, ALEFACEPT, IM O $0.00
C9213 INJECTION, PEMETREXED O $0.00
C9214 INJECTION, BEVACIZUMAB O $0.00
C9215 INJECTION, CETUXIMAB O $0.00
C9216 ABARELIX, INJECT SUSPENSION O $0.00
C9217 INJECTION, OMALIZUMAB O $0.00
C9218 INJECTION, AZACITIDINE O $0.00
C9220 SODIUM HYALURONATE O $0.00
C9221 GRAFTJACKET REG MATRIX O $0.00
C9222 GRAFTJACKET SFTTIS O $0.00

C9224 INJECTION, GALSULFASE O $0.00
C9225 FLUOCINOLONE ACETONIDE O $0.00
C9227 INJECTION, MICAFUNGIN SODIUM, PER O $0.00
C9228 INJECTION, TIGECYCLINE, PER 1 MG O $0.00
C9229 INJECTION, IBANDRONATE SODIUM, PER O $0.00
C9230 INJECTION, ABATACEPT, PER 10 MG O $0.00
C9231 INJECTION, DECITABINE, PER 1 MG O $0.00
C9232 INJECTION, IDURSULFASE O $0.00
C9233 INJECTION, RANIBIZUMAB O $0.00
C9234 INJ, ALGLUCOSIDASE ALFA O $0.00
C9235 INJECTION, PANITUMUMAB O $0.00
C9236 INJECTION, ECULIZUMAB 9 $0.00
C9237 INJ, LANREOTIDE ACETATE 9 $0.00
C9238 INJ, LEVETIRACETAM O $0.00
C9239 INJ, TEMSIROLIMUS O $0.00
C9240 INJECTION, IXABEPILONE 9 $0.00
C9241 INJ DORIPENEM 10 MG O $0.00
C9242 INJECTION, FOSAPREPITANT 9 $0.00
C9243 INJECTION, BENDAMUSTINE HCL 9 $0.00
C9244 INJECTION, REGADENOSON 9 $0.00
C9245 INJECTION, ROMIPLOSTIM O $0.00
C9246 INJ, GADOXETATE DISODIUM O $0.00
C9247 INJ, IOBENGUANE, I-123, DX O $0.00
C9248 INJ, CLEVIDIPINE BUTYRATE 9 $0.00
C9249 INJ, CERTOLIZUMAB PEGOL O $0.00
C9250 ARTISS FIBRIN SEALANT 9 $0.00
C9251 INJ, C1 ESTERASE INHIBITOR O $0.00
C9252 INJECTION, PLERIXAFOR O $0.00
C9253 INJECTION, TEMOZOLOMIDE O $0.00
C9254 INJECTION, LACOSAMIDE 9 $0.00
C9255 PALIPERIDONE PALMITATE INJ 9 $0.00
C9256 DEXAMETHASONE INTRAVITREAL 9 $0.00
C9257 BEVACIZUMAB INJECTION 9 $0.00
C9258 INJECTION, TELAVANCIN, 10 MG 9 $0.00
C9259 INJECTION, PRALATREXATE, 1 MG 9 $0.00
C9260 INJECTION, OFATUMUMAB, 10 MG 9 $0.00
C9261 INJECTION, USTEKINUMAB, 1 MG 9 $0.00
C9262 FLUDARABINE PHOSPHATE, ORAL, 1 MG 9 $0.00
C9263 INJECTION, ECALLANTIDE, 1 MG 9 $0.00
C9350 POROUS COLLAGEN TUBE PER CM O $0.00
C9351 ACELLULAR DERM TISSUE PERCM2 O $0.00
C9352 NEURAGEN NERVE GUIDE, PER CM 9 $0.00
C9353 NEURAWRAP NERVE PROTECTOR,CM 9 $0.00
C9354 VERITAS COLLAGEN MATRIX, CM2 9 $0.00
C9355 NEUROMATRIX NERVE CUFF, CM 9 $0.00
C9356 TENOGLIDE TENDON PROT, CM2 9 $0.00
C9357 FLOWABLE WOUND MATRIX, 1 CC 9 $0.00
C9358 SURGIMEND, FETAL 9 $0.00
C9359 IMPLNT,BON VOID FILLER-PUTTY 9 $0.00

C9360 SURGIMEND, NEONATAL 9 $0.00
C9361 NEUROMEND NERVE WRAP 9 $0.00
C9362 IMPLNT,BON VOID FILLER-STRIP 9 $0.00
C9363 INTEGRA MESHED BIL WOUND MAT 9 $0.00
C9364 PORCINE IMPLANT, PERMACOL 9 $0.00
C9399 UNCLASSIFIED DRUGS OR BIOLOG 9 $0.00
C9400 THALLOUS CHLORIDE, BRAND O $0.00
C9401 STRONTIUM-89 CHLORIDE,BRAND O $0.00
C9402 TH I131 SO IODIDE CAP, BRAND O $0.00
C9403 DX I131 SO IODIDE CAP, BRAND O $0.00
C9404 DX I131 SO IODIDE SOL, BRAND O $0.00
C9405 TH I131 SO IODIDE SOL, BRAND O $0.00
C9408 FDG, BRAND, PER DOSE 9 $0.00
C9410 DEXRAZOXANE HCL INJ, BRAND O $0.00
C9411 PAMIDRONATE DISODIUM, BRAND O $0.00
C9412 GANCICLOVIR IMPLANT, BRAND O $0.00
C9413 SODIUM HYALURONATE INJ, BRAND O $0.00
C9414 ETOPOSIDE ORAL, BRAND O $0.00
C9415 DOXORUBIC HCL CHEMO, BRAND O $0.00
C9416 BCG LIVE INTRAVESICAL, BRAND 9 $0.00
C9417 BLEOMYCIN SULFATE INJ, BRAND O $0.00
C9418 CISPLATIN INJ, BRAND O $0.00
C9419 INJ CLADRIBINE, BRAND O $0.00
C9420 CYCLOPHOSPHAMIDE INJ, BRAND O $0.00
C9421 CYCLOPHOSPHAMIDE LYO, BRAND O $0.00
C9422 CYTARABINE HCL INJ, BRAND O $0.00
C9423 DACARBAZINE INJ, BRAND O $0.00
C9424 DAUNORUBICIN, BRAND O $0.00
C9425 ETOPOSIDE INJ, BRAND O $0.00
C9426 FLOXURIDINE INJ, BRAND O $0.00
C9427 IFOSFOMIDE INJ, BRAND O $0.00
C9428 MESNA INJECTION, BRAND O $0.00
C9429 IDARUBICIN HCL INJ, BRAND O $0.00
C9430 LEUPROLIDE ACETATE INJ, BRAN O $0.00
C9431 PACLITAXEL INJ, BRAND O $0.00
C9432 MITOMYCIN INJ, BRAND O $0.00
C9433 THIOTEPA INJ, BRAND O $0.00
C9434 GALLIUM GA 67, BRAND 9 $0.00
C9435 GONADORELIN HYDROCH, BRAND O $0.00
C9436 AZATHIOPRINE PARENTERAL,BRND O $0.00
C9437 CARMUS BISCHL NITRO INJ O $0.00
C9438 CYCLOSPORINE ORAL, BRAND O $0.00
C9439 DIETHYLSTILBESTROL INJECTION O $0.00
C9500 PLATELETS, IRRAD, EA UNIT 9 $0.00
C9501 PLATELETS, PHERESIS, EA UNIT 9 $0.00
C9502 PLATELETS, PHER/IRRAD, EA UN 9 $0.00
C9503 FRESH FROZEN PLASMA, EA UNIT O $0.00
C9504 RBC, DEGLYCEROLIZED, EA UNIT 9 $0.00
C9505 RBC, IRRADIATED, EACH UNIT 9 $0.00

C9700 WATER INDUCED THERMO 9 $0.00
C9701 STRETTA SYSTEM O $0.00
C9702 CHKMATE/NOVOST/GALILEO BRACH 9 $0.00
C9703 BARD ENDOSCOPIC SUTURING SYS O $0.00
C9704 INJ INERT SUBS UPPER GI O $0.00
C9708 PREVIEW TX PLANNING SOFTWARE 9 $0.00
C9711 H.E.L.P. APHERESIS SYSTEM O $0.00
C9712 INSERT PH CAPSULE, GERD O $0.00
C9713 NON-CONTACT LASER VAP PROSTA O $0.00
C9714 BREAST INTERS RAD TX, IMMED O $0.00
C9715 BREAST INTERS RAD TX, DELAY O $0.00
C9716 RADIOFREQUENCY ENERGY TO ANU 9 $0.00
C9718 KYPHOPLASTY, FIRST VERTEBRA O $0.00
C9719 KYPHOPLASTY, EACH ADDL O $0.00
C9720 HE ESW TX, TENNIS ELBOW O $0.00
C9721 HE ESW TX, PLANTAR FASCIITIS O $0.00
C9722 KV IMAGING W/IR TRACKING O $0.00
C9723 DYN IR PERF IMG O $0.00
C9724 EPS GAST CARDIA PLIC 9 $0.00
C9725 PLACE ENDORECTAL APP 9 $0.00
C9726 RXT BREAST APPL PLACE/REMOV 9 $0.00
C9727 INSERT PALATE IMPLANTS 9 $0.00
C9728 PLACE DEVICE/MARKER, NON PRO 9 $0.00
C9898 INPNT STAY RADIOLABELED ITEM 9 $0.00
C9899 INPT IMPLANT PROS DEV,NO COV 9 $0.00
CEDCL MCO SPECIFIC CODE: SMART START COM O $0.00
CEDRV MCO SPECIFIC CODE: SMART START CHI O $0.00
D0110 INITIAL ORAL EXAMINATION O $0.00
D0120 PERIODIC ORAL EVALUATION 1 $0.00
D0130 EMERGENCY ORAL EXAMINATION O $0.00
D0140 LIMIT ORAL EVAL PROBLM FOCUS 1 $0.00
D0145 ORAL EVALUATION, PT < 3YRS 1 $0.00
D0150 COMPREHENSVE ORAL EVALUATION 1 $0.00
D0160 EXTENSV ORAL EVAL PROB FOCUS 1 $0.00
D0170 RE-EVAL,EST PT,PROBLEM FOCUS 1 $0.00
D0180 COMP PERIODONTAL EVALUATION 9 $0.00
D0210 INTRAOR COMPLETE FILM SERIES 1 $0.00
D0220 INTRAORAL PERIAPICAL FIRST F 1 $0.00
D0230 INTRAORAL PERIAPICAL EA ADD 1 $0.00
D0240 INTRAORAL OCCLUSAL FILM 1 $0.00
D0250 EXTRAORAL FIRST FILM 1 $0.00
D0260 EXTRAORAL EA ADDITIONAL FILM 1 $0.00
D0270 DENTAL BITEWING SINGLE FILM 1 $0.00
D0272 DENTAL BITEWINGS TWO FILMS 1 $0.00
D0273 BITEWINGS - THREE FILMS 1 $0.00
D0274 DENTAL BITEWINGS FOUR FILMS 1 $0.00
D0275 BITEWINGS-EACH ADDITIONAL FILM 9 $0.00
D0277 VERT BITEWINGS-SEV TO EIGHT 1 $0.00
D0290 DENTAL FILM SKULL/FACIAL BON 1 $0.00

D0310 DENTAL SALIOGRAPHY 1 $0.00
D0320 DENTAL TMJ ARTHROGRAM INCL I 1 $0.00
D0321 DENTAL OTHER TMJ FILMS 1 $0.00
D0322 DENTAL TOMOGRAPHIC SURVEY 1 $0.00
D0330 DENTAL PANORAMIC FILM 1 $0.00
D0340 DENTAL CEPHALOMETRIC FILM 1 $0.00
D0350 ORAL/FACIAL PHOTO IMAGES 9 $0.00
D0360 CONE BEAM CT 1 $0.00
D0362 CONE BEAM, TWO DIMENSIONAL 1 $0.00
D0363 CONE BEAM, THREE DIMENSIONAL 1 $0.00
D0410 BACTERIOLOGIC STUDIES FOR DETERMINA 9 $0.00
D0415 COLLECTION OF MICROORGANISMS 9 $0.00
D0416 VIRAL CULTURE 9 $0.00
D0417 COLLECT & PREP SALIVA SAMPLE 9 $0.00
D0418 ANALYSIS OF SALIVA SAMPLE 9 $0.00
D0420 CARIES SUSCEPTIBILITY TESTS 9 $0.00
D0421 GEN TST SUSCEPT ORAL DISEASE 9 $0.00
D0425 CARIES SUSCEPTIBILITY TEST 9 $0.00
D0431 DIAG TST DETECT MUCOS ABNORM 9 $0.00
D0460 PULP VITALITY TEST 1 $0.00
D0470 DIAGNOSTIC CASTS 1 $0.00
D0471 DIAGNOSTIC PHOTOGRAPHS 9 $0.00
D0472 GROSS EXAM, PREP & REPORT 1 $0.00
D0473 MICRO EXAM, PREP & REPORT 1 $0.00
D0474 MICRO W EXAM OF SURG MARGINS 1 $0.00
D0475 DECALCIFICATION PROCEDURE 9 $0.00
D0476 SPEC STAINS FOR MICROORGANIS 9 $0.00
D0477 SPEC STAINS NOT FOR MICROORG 9 $0.00
D0478 IMMUNOHISTOCHEMICAL STAINS 9 $0.00
D0479 TISSUE IN-SITU HYBRIDIZATION 9 $0.00
D0480 CYTOPATH SMEAR PREP & REPORT 1 $0.00
D0481 ELECTRON MICROSCOPY DIAGNOST 9 $0.00
D0482 DIRECT IMMUNOFLUORESCENCE 9 $0.00
D0483 INDIRECT IMMUNOFLUORESCENCE 9 $0.00
D0484 CONSULT SLIDES PREP ELSEWHER 9 $0.00
D0485 CONSULT INC PREP OF SLIDES 9 $0.00
D0486 ACCESSION OF BRUSH BIOPSY 9 $0.00
D0501 HISTOPATHOLOGIC EXAMINATIONS O $0.00
D0502 OTHER ORAL PATHOLOGY PROCEDU 1 $0.00
D0999 UNSPECIFIED DIAGNOSTIC PROCE 1 $0.00
D1110 DENTAL PROPHYLAXIS ADULT 1 $0.00
D1120 DENTAL PROPHYLAXIS CHILD 1 $0.00
D1201 TOPICAL FLUOR W PROPHY CHILD O $0.00
D1202 TOPICAL APPLICATION OF FLUORIDE (IN 9 $0.00
D1203 TOPICAL APP FLUORIDE CHILD 1 $0.00
D1204 TOPICAL APP FLUORIDE ADULT 1 $0.00
D1205 TOPICAL FLUORIDE W/ PROPHY A O $0.00
D1206 TOPICAL FLUORIDE VARNISH 1 $0.00
D1310 NUTRI COUNSEL-CONTROL CARIES 9 $0.00

D1320 TOBACCO COUNSELING 1 $0.00
D1330 ORAL HYGIENE INSTRUCTION 9 $0.00
D1351 DENTAL SEALANT PER TOOTH 1 $0.00
D1510 SPACE MAINTAINER FXD UNILAT 1 $0.00
D1515 FIXED BILAT SPACE MAINTAINER 1 $0.00
D1520 REMOVE UNILAT SPACE MAINTAIN 1 $0.00
D1525 REMOVE BILAT SPACE MAINTAIN 1 $0.00
D1550 RECEMENT SPACE MAINTAINER 1 $0.00
D1555 REMOVE FIX SPACE MAINTAINER 1 $0.00
D2110 AMALGAM ONE SURFACE PRIMARY O $0.00
D2120 AMALGAM TWO SURFACES PRIMARY O $0.00
D2130 AMALGAM THREE SURFACES PRIMA O $0.00
D2131 AMALGAM FOUR/MORE SURF PRIMA O $0.00
D2140 AMALGAM ONE SURFACE PERMANEN 1 $0.00
D2150 AMALGAM TWO SURFACES PERMANE 1 $0.00
D2160 AMALGAM THREE SURFACES PERMA 1 $0.00
D2161 AMALGAM 4 OR > SURFACES PERM 1 $0.00
D2210 SILCATE CEMENT PER RESTORAT 9 $0.00
D2330 RESIN ONE SURFACE-ANTERIOR 1 $0.00
D2331 RESIN TWO SURFACES-ANTERIOR 1 $0.00
D2332 RESIN THREE SURFACES-ANTERIO 1 $0.00
D2335 RESIN 4/> SURF OR W INCIS AN 1 $0.00
D2336 COMPOSITE RESIN CROWN O $0.00
D2337 COMPO RESIN CROWN ANT-PERM O $0.00
D2380 RESIN ONE SURF POSTER PRIMAR O $0.00
D2381 RESIN TWO SURF POSTER PRIMAR O $0.00
D2382 RESIN THREE/MORE SURF POST P O $0.00
D2385 RESIN ONE SURF POSTER PERMAN O $0.00
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D2387 RESIN THREE/MORE SURF POST P O $0.00
D2388 RESIN FOUR/MORE, POST PERM O $0.00
D2390 ANT RESIN-BASED CMPST CROWN 1 $0.00
D2391 POST 1 SRFC RESINBASED CMPST 1 $0.00
D2392 POST 2 SRFC RESINBASED CMPST 1 $0.00
D2393 POST 3 SRFC RESINBASED CMPST 1 $0.00
D2394 POST >=4SRFC RESINBASE CMPST 1 $0.00
D2410 DENTAL GOLD FOIL ONE SURFACE 9 $0.00
D2420 DENTAL GOLD FOIL TWO SURFACE 9 $0.00
D2430 DENTAL GOLD FOIL THREE SURFA 9 $0.00
D2510 DENTAL INLAY METALIC 1 SURF 9 $0.00
D2520 DENTAL INLAY METALLIC 2 SURF 9 $0.00
D2530 DENTAL INLAY METL 3/MORE SUR 9 $0.00
D2540 ONLAY-METALLIC-PER TOOTH (IN ADDITI O $0.00
D2542 DENTAL ONLAY METALLIC 2 SURF 9 $0.00
D2543 DENTAL ONLAY METALLIC 3 SURF 9 $0.00
D2544 DENTAL ONLAY METL 4/MORE SUR 9 $0.00
D2610 INLAY PORCELAIN/CERAMIC 1 SU 9 $0.00
D2620 INLAY PORCELAIN/CERAMIC 2 SU 9 $0.00
D2630 DENTAL ONLAY PORC 3/MORE SUR 9 $0.00

D2642 DENTAL ONLAY PORCELIN 2 SURF 9 $0.00
D2643 DENTAL ONLAY PORCELIN 3 SURF 9 $0.00
D2644 DENTAL ONLAY PORC 4/MORE SUR 9 $0.00
D2650 INLAY COMPOSITE/RESIN ONE SU 9 $0.00
D2651 INLAY COMPOSITE/RESIN TWO SU 9 $0.00
D2652 DENTAL INLAY RESIN 3/MRE SUR 9 $0.00
D2662 DENTAL ONLAY RESIN 2 SURFACE 9 $0.00
D2663 DENTAL ONLAY RESIN 3 SURFACE 9 $0.00
D2664 DENTAL ONLAY RESIN 4/MRE SUR 9 $0.00
D2710 CROWN RESIN-BASED INDIRECT 1 $0.00
D2712 CROWN 3/4 RESIN-BASED COMPOS 1 $0.00
D2720 CROWN RESIN W/ HIGH NOBLE ME 9 $0.00
D2721 CROWN RESIN W/ BASE METAL 1 $0.00
D2722 CROWN RESIN W/ NOBLE METAL 1 $0.00
D2740 CROWN PORCELAIN/CERAMIC SUBS 9 $0.00
D2750 CROWN PORCELAIN W/ H NOBLE M 9 $0.00
D2751 CROWN PORCELAIN FUSED BASE M 1 $0.00
D2752 CROWN PORCELAIN W/ NOBLE MET 1 $0.00
D2780 CROWN 3/4 CAST HI NOBLE MET 9 $0.00
D2781 CROWN 3/4 CAST BASE METAL 1 $0.00
D2782 CROWN 3/4 CAST NOBLE METAL 1 $0.00
D2783 CROWN 3/4 PORCELAIN/CERAMIC 9 $0.00
D2790 CROWN FULL CAST HIGH NOBLE M 9 $0.00
D2791 CROWN FULL CAST BASE METAL 1 $0.00
D2792 CROWN FULL CAST NOBLE METAL 1 $0.00
D2794 CROWN-TITANIUM 9 $0.00
D2799 PROVISIONAL CROWN 1 $0.00
D2810 CROWN 3/4 CAST METALLIC 9 $0.00
D2910 RECEMENT INLAY ONLAY OR PART 1 $0.00
D2915 RECEMENT CAST OR PREFAB POST 1 $0.00
D2920 DENTAL RECEMENT CROWN 1 $0.00
D2930 PREFAB STNLSS STEEL CRWN PRI 1 $0.00
D2931 PREFAB STNLSS STEEL CROWN PE 1 $0.00
D2932 PREFABRICATED RESIN CROWN 1 $0.00
D2933 PREFAB STAINLESS STEEL CROWN 1 $0.00
D2934 PREFAB STEEL CROWN PRIMARY 1 $0.00
D2940 DENTAL SEDATIVE FILLING 1 $0.00
D2950 CORE BUILD-UP INCL ANY PINS 1 $0.00
D2951 TOOTH PIN RETENTION 1 $0.00
D2952 POST AND CORE CAST + CROWN 1 $0.00
D2953 EACH ADDTNL CAST POST 1 $0.00
D2954 PREFAB POST/CORE + CROWN 1 $0.00
D2955 POST REMOVAL 1 $0.00
D2957 EACH ADDTNL PREFAB POST 1 $0.00
D2960 LAMINATE LABIAL VENEER 9 $0.00
D2961 LAB LABIAL VENEER RESIN 9 $0.00
D2962 LAB LABIAL VENEER PORCELAIN 9 $0.00
D2970 TEMP CROWN (FRACTURED TOOTH) 1 $0.00
D2971 ADD PROC CONSTRUCT NEW CROWN 9 $0.00

D2975 COPING 9 $0.00
D2980 CROWN REPAIR 1 $0.00
D2999 DENTAL UNSPEC RESTORATIVE PR 1 $0.00
D3110 PULP CAP DIRECT 1 $0.00
D3120 PULP CAP INDIRECT 1 $0.00
D3220 THERAPEUTIC PULPOTOMY 1 $0.00
D3221 GROSS PULPAL DEBRIDEMENT 1 $0.00
D3222 PART PULP FOR APEXOGENESIS 1 $0.00
D3230 PULPAL THERAPY ANTERIOR PRIM 1 $0.00
D3240 PULPAL THERAPY POSTERIOR PRI 1 $0.00
D3310 END THXPY, ANTERIOR TOOTH 1 $0.00
D3320 END THXPY, BICUSPID TOOTH 1 $0.00
D3330 END THXPY, MOLAR 1 $0.00
D3331 NON-SURG TX ROOT CANAL OBS 9 $0.00
D3332 INCOMPLETE ENDODONTIC TX 1 $0.00
D3333 INTERNAL ROOT REPAIR 1 $0.00
D3340 FOUR OR MORE CANALS (EXCLUDING FINA 9 $0.00
D3346 RETREAT ROOT CANAL ANTERIOR 1 $0.00
D3347 RETREAT ROOT CANAL BICUSPID 1 $0.00
D3348 RETREAT ROOT CANAL MOLAR 1 $0.00
D3350 APEXIFICATION (PER TREATMENT VISIT) 9 $0.00
D3351 APEXIFICATION/RECALC INITIAL 1 $0.00
D3352 APEXIFICATION/RECALC INTERIM 1 $0.00
D3353 APEXIFICATION/RECALC FINAL 1 $0.00
D3410 APICOECT/PERIRAD SURG ANTER 1 $0.00
D3411 APICOECTOMY (PER TOOTH) - EACH ADDI 9 $0.00
D3421 ROOT SURGERY BICUSPID 1 $0.00
D3425 ROOT SURGERY MOLAR 1 $0.00
D3426 ROOT SURGERY EA ADD ROOT 1 $0.00
D3430 RETROGRADE FILLING 1 $0.00
D3440 APICAL CURETTAGE 9 $0.00
D3450 ROOT AMPUTATION 1 $0.00
D3460 ENDODONTIC ENDOSSEOUS IMPLAN 9 $0.00
D3470 INTENTIONAL REPLANTATION 1 $0.00
D3910 ISOLATION- TOOTH W RUBB DAM 1 $0.00
D3920 TOOTH SPLITTING 9 $0.00
D3940 RECALCIFICATION OR REPAIR (PERFORAT 9 $0.00
D3950 CANAL PREP/FITTING OF DOWEL 9 $0.00
D3960 BLEACHING OF DISCOLORED TOOT 9 $0.00
D3999 ENDODONTIC PROCEDURE 1 $0.00
D4210 GINGIVECTOMY/PLASTY PER QUAD 1 $0.00
D4211 GINGIVECTOMY/PLASTY PER TOOT 1 $0.00
D4220 GINGIVAL CURETTAGE PER QUADR O $0.00
D4230 ANA CROWN EXP 4 OR> PER QUAD 1 $0.00
D4231 ANA CROWN EXP 1-3 PER QUAD 1 $0.00
D4240 GINGIVAL FLAP PROC W/ PLANIN 1 $0.00
D4241 GNGVL FLAP W ROOTPLAN 1-3 TH 1 $0.00
D4245 APICALLY POSITIONED FLAP 1 $0.00
D4249 CROWN LENGTHEN HARD TISSUE 1 $0.00

D4260 OSSEOUS SURGERY PER QUADRANT 1 $0.00
D4261 OSSEOUS SURGL-3TEETHPERQUAD 1 $0.00
D4262 BONE REPLACEMENT GRAFT-MULTIPLE SIT O $0.00
D4263 BONE REPLCE GRAFT FIRST SITE 1 $0.00
D4264 BONE REPLCE GRAFT EACH ADD 1 $0.00
D4265 BIO MTRLS TO AID SOFT/OS REG 1 $0.00
D4266 GUIDED TISS REGEN RESORBLE 1 $0.00
D4267 GUIDED TISS REGEN NONRESORB 1 $0.00
D4268 SURGICAL REVISION PROCEDURE 1 $0.00
D4270 PEDICLE SOFT TISSUE GRAFT PR 1 $0.00
D4271 FREE SOFT TISSUE GRAFT PROC 1 $0.00
D4272 APICALLY REPOSITIONING FLAP PROCEDU 9 $0.00
D4273 SUBEPITHELIAL TISSUE GRAFT 1 $0.00
D4274 DISTAL/PROXIMAL WEDGE PROC 1 $0.00
D4275 SOFT TISSUE ALLOGRAFT 1 $0.00
D4276 CON TISSUE W DBLE PED GRAFT 1 $0.00
D4320 PROVISION SPLNT INTRACORONAL 1 $0.00
D4321 PROVISIONAL SPLINT EXTRACORO 1 $0.00
D4340 PERIODONTAL SCALING AND ROOT PLANIN 9 $0.00
D4341 PERIODONTAL SCALING & ROOT 1 $0.00
D4342 PERIODONTAL SCALING 1-3TEETH 1 $0.00
D4355 FULL MOUTH DEBRIDEMENT 1 $0.00
D4381 LOCALIZED DELIVERY ANTIMICRO 1 $0.00
D4910 PERIODONTAL MAINT PROCEDURES 1 $0.00
D4920 UNSCHEDULED DRESSING CHANGE 1 $0.00
D4999 UNSPECIFIED PERIODONTAL PROC 1 $0.00
D5110 DENTURES COMPLETE MAXILLARY 1 $0.00
D5120 DENTURES COMPLETE MANDIBLE 1 $0.00
D5130 DENTURES IMMEDIAT MAXILLARY 1 $0.00
D5140 DENTURES IMMEDIAT MANDIBLE 1 $0.00
D5211 DENTURES MAXILL PART RESIN 1 $0.00
D5212 DENTURES MAND PART RESIN 1 $0.00
D5213 DENTURES MAXILL PART METAL 1 $0.00
D5214 DENTURES MANDIBL PART METAL 1 $0.00
D5215 UPPER PARTIAL - HIGH NOBLE CAST BAS 9 $0.00
D5216 LOWER PARTIAL - HIGH NOBLE CAST BAS 9 $0.00
D5225 MAXILLARY PART DENTURE FLEX 1 $0.00
D5226 MANDIBULAR PART DENTURE FLEX 1 $0.00
D5280 REMOVABLE UNILATERAL PARTIAL DENTUR 9 $0.00
D5281 REMOVABLE PARTIAL DENTURE 9 $0.00
D5410 DENTURES ADJUST CMPLT MAXIL 1 $0.00
D5411 DENTURES ADJUST CMPLT MAND 1 $0.00
D5421 DENTURES ADJUST PART MAXILL 1 $0.00
D5422 DENTURES ADJUST PART MANDBL 1 $0.00
D5510 DENTUR REPR BROKEN COMPL BAS 1 $0.00
D5520 REPLACE DENTURE TEETH COMPLT 1 $0.00
D5610 DENTURES REPAIR RESIN BASE 1 $0.00
D5620 REP PART DENTURE CAST FRAME 1 $0.00
D5630 REP PARTIAL DENTURE CLASP 1 $0.00

D5640 REPLACE PART DENTURE TEETH 1 $0.00
D5650 ADD TOOTH TO PARTIAL DENTURE 1 $0.00
D5660 ADD CLASP TO PARTIAL DENTURE 1 $0.00
D5670 REPLC TTH&ACRLC ON MTL FRMWK 1 $0.00
D5671 REPLC TTH&ACRLC MANDIBULAR 1 $0.00
D5710 DENTURES REBASE CMPLT MAXIL 9 $0.00
D5711 DENTURES REBASE CMPLT MAND 9 $0.00
D5720 DENTURES REBASE PART MAXILL 9 $0.00
D5721 DENTURES REBASE PART MANDBL 9 $0.00
D5730 DENTURE RELN CMPLT MAXIL CH 1 $0.00
D5731 DENTURE RELN CMPLT MAND CHR 1 $0.00
D5740 DENTURE RELN PART MAXIL CHR 1 $0.00
D5741 DENTURE RELN PART MAND CHR 1 $0.00
D5750 DENTURE RELN CMPLT MAX LAB 1 $0.00
D5751 DENTURE RELN CMPLT MAND LAB 1 $0.00
D5760 DENTURE RELN PART MAXIL LAB 1 $0.00
D5761 DENTURE RELN PART MAND LAB 1 $0.00
D5810 DENTURE INTERM CMPLT MAXILL 1 $0.00
D5811 DENTURE INTERM CMPLT MANDBL 1 $0.00
D5820 DENTURE INTERM PART MAXILL 1 $0.00
D5821 DENTURE INTERM PART MANDBL 1 $0.00
D5850 DENTURE TISS CONDITN MAXILL 1 $0.00
D5851 DENTURE TISS CONDTIN MANDBL 1 $0.00
D5860 OVERDENTURE COMPLETE 9 $0.00
D5861 OVERDENTURE PARTIAL 9 $0.00
D5862 PRECISION ATTACHMENT 9 $0.00
D5867 REPLACEMENT OF PRECISION ATT 9 $0.00
D5875 PROSTHESIS MODIFICATION 9 $0.00
D5899 REMOVABLE PROSTHODONTIC PROC 1 $0.00
D5911 FACIAL MOULAGE SECTIONAL 1 $0.00
D5912 FACIAL MOULAGE COMPLETE 1 $0.00
D5913 NASAL PROSTHESIS 1 $0.00
D5914 AURICULAR PROSTHESIS 1 $0.00
D5915 ORBITAL PROSTHESIS 1 $0.00
D5916 OCULAR PROSTHESIS 1 $0.00
D5917 COMPOSITE FACIAL PROSTHESIS 9 $0.00
D5918 REPLACEMENT PROSTHESIS 9 $0.00
D5919 FACIAL PROSTHESIS 1 $0.00
D5920 OCULAR IMPLANT 9 $0.00
D5921 ORBITAL IMPLANT 9 $0.00
D5922 NASAL SEPTAL PROSTHESIS 1 $0.00
D5923 OCULAR PROSTHESIS INTERIM 1 $0.00
D5924 CRANIAL PROSTHESIS 1 $0.00
D5925 FACIAL AUGMENTATION IMPLANT 1 $0.00
D5926 REPLACEMENT NASAL PROSTHESIS 1 $0.00
D5927 AURICULAR REPLACEMENT 1 $0.00
D5928 ORBITAL REPLACEMENT 1 $0.00
D5929 FACIAL REPLACEMENT 1 $0.00
D5931 SURGICAL OBTURATOR 1 $0.00

D5932 POSTSURGICAL OBTURATOR 1 $0.00
D5933 REFITTING OF OBTURATOR 1 $0.00
D5934 MANDIBULAR FLANGE PROSTHESIS 1 $0.00
D5935 MANDIBULAR DENTURE PROSTH 1 $0.00
D5936 TEMP OBTURATOR PROSTHESIS 1 $0.00
D5937 TRISMUS APPLIANCE 1 $0.00
D5951 FEEDING AID 1 $0.00
D5952 PEDIATRIC SPEECH AID 1 $0.00
D5953 ADULT SPEECH AID 1 $0.00
D5954 SUPERIMPOSED PROSTHESIS 1 $0.00
D5955 PALATAL LIFT PROSTHESIS 1 $0.00
D5956 OBTURATOR 9 $0.00
D5957 SPEECH BULB 9 $0.00
D5958 INTRAORAL CON DEF INTER PLT 1 $0.00
D5959 INTRAORAL CON DEF MOD PALAT 1 $0.00
D5960 MODIFY SPEECH AID PROSTHESIS 1 $0.00
D5971 SIMPLE IMPLANT 9 $0.00
D5972 COMPLEX IMPLANT 9 $0.00
D5973 SUBPERIOSTEAL IMPLANT 9 $0.00
D5974 ENDOSSEOUS IMPLANT (IN THE BONE) 9 $0.00
D5976 MANDIBULAR STAPLE IMPLANT 9 $0.00
D5982 SURGICAL STENT 9 $0.00
D5983 RADIATION APPLICATOR 9 $0.00
D5984 RADIATION SHIELD 9 $0.00
D5985 RADIATION CONE LOCATOR 9 $0.00
D5986 FLUORIDE APPLICATOR 1 $0.00
D5987 COMMISSURE SPLINT 1 $0.00
D5988 SURGICAL SPLINT 1 $0.00
D5991 TOPICAL MEDICAMENT CARRIER 1 $0.00
D5999 MAXILLOFACIAL PROSTHESIS 1 $0.00
D6010 ODONTICS ENDOSTEAL IMPLANT 9 $0.00
D6012 ENDOSTEAL IMPLANT 9 $0.00
D6020 ODONTICS ABUTMENT PLACEMENT O $0.00
D6040 ODONTICS EPOSTEAL IMPLANT 9 $0.00
D6050 ODONTICS TRANSOSTEAL IMPLNT 9 $0.00
D6053 IMPLNT/ABTMNT SPPRT REMV DNT 9 $0.00
D6054 IMPLNT/ABTMNT SPPRT REMVPRTL 9 $0.00
D6055 IMPLANT CONNECTING BAR 9 $0.00
D6056 PREFABRICATED ABUTMENT 9 $0.00
D6057 CUSTOM ABUTMENT 9 $0.00
D6058 ABUTMENT SUPPORTED CROWN 9 $0.00
D6059 ABUTMENT SUPPORTED MTL CROWN 9 $0.00
D6060 ABUTMENT SUPPORTED MTL CROWN 9 $0.00
D6061 ABUTMENT SUPPORTED MTL CROWN 9 $0.00
D6062 ABUTMENT SUPPORTED MTL CROWN 9 $0.00
D6063 ABUTMENT SUPPORTED MTL CROWN 9 $0.00
D6064 ABUTMENT SUPPORTED MTL CROWN 9 $0.00
D6065 IMPLANT SUPPORTED CROWN 9 $0.00
D6066 IMPLANT SUPPORTED MTL CROWN 9 $0.00

D6067 IMPLANT SUPPORTED MTL CROWN 9 $0.00
D6068 ABUTMENT SUPPORTED RETAINER 9 $0.00
D6069 ABUTMENT SUPPORTED RETAINER 9 $0.00
D6070 ABUTMENT SUPPORTED RETAINER 9 $0.00
D6071 ABUTMENT SUPPORTED RETAINER 9 $0.00
D6072 ABUTMENT SUPPORTED RETAINER 9 $0.00
D6073 ABUTMENT SUPPORTED RETAINER 9 $0.00
D6074 ABUTMENT SUPPORTED RETAINER 9 $0.00
D6075 IMPLANT SUPPORTED RETAINER 9 $0.00
D6076 IMPLANT SUPPORTED RETAINER 9 $0.00
D6077 IMPLANT SUPPORTED RETAINER 9 $0.00
D6078 IMPLNT/ABUT SUPRTD FIXD DENT 9 $0.00
D6079 IMPLNT/ABUT SUPRTD FIXD DENT 9 $0.00
D6080 IMPLANT MAINTENANCE 9 $0.00
D6090 REPAIR IMPLANT 9 $0.00
D6091 REPL SEMI/PRECISION ATTACH 9 $0.00
D6092 RECEMENT SUPP CROWN 9 $0.00
D6093 RECEMENT SUPP PART DENTURE 9 $0.00
D6094 ABUT SUPPORT CROWN TITANIUM 9 $0.00
D6095 ODONTICS REPR ABUTMENT 9 $0.00
D6100 REMOVAL OF IMPLANT 9 $0.00
D6190 RADIO/SURGICAL IMPLANT INDEX 9 $0.00
D6194 ABUT SUPPORT RETAINER TITANI 9 $0.00
D6199 IMPLANT PROCEDURE 9 $0.00
D6205 PONTIC-INDIRECT RESIN BASED 9 $0.00
D6210 PROSTHODONT HIGH NOBLE METAL 9 $0.00
D6211 BRIDGE BASE METAL CAST 1 $0.00
D6212 BRIDGE NOBLE METAL CAST 1 $0.00
D6214 PONTIC TITANIUM 9 $0.00
D6240 BRIDGE PORCELAIN HIGH NOBLE 9 $0.00
D6241 BRIDGE PORCELAIN BASE METAL 1 $0.00
D6242 BRIDGE PORCELAIN NOBEL METAL 1 $0.00
D6245 BRIDGE PORCELAIN/CERAMIC 9 $0.00
D6250 BRIDGE RESIN W/HIGH NOBLE 9 $0.00
D6251 BRIDGE RESIN BASE METAL 1 $0.00
D6252 BRIDGE RESIN W/NOBLE METAL 1 $0.00
D6253 PROVISIONAL PONTIC 9 $0.00
D6519 INLAY/ONLAY PORCE/CERAMIC 9 $0.00
D6520 DENTAL RETAINER TWO SURFACES 9 $0.00
D6530 RETAINER METALLIC 3+ SURFACE 9 $0.00
D6540 ONLAY-METALLIC-PER TOOTH (IN ADDITI O $0.00
D6543 DENTAL RETAINR ONLAY 3 SURF 9 $0.00
D6544 DENTAL RETAINR ONLAY 4/MORE 9 $0.00
D6545 DENTAL RETAINR CAST METL 1 $0.00
D6548 PORCELAIN/CERAMIC RETAINER 9 $0.00
D6600 PORCELAIN/CERAMIC INLAY 2SRF 9 $0.00
D6601 PORC/CERAM INLAY >= 3 SURFAC 9 $0.00
D6602 CST HGH NBLE MTL INLAY 2 SRF 9 $0.00
D6603 CST HGH NBLE MTL INLAY >=3SR 9 $0.00

D6604 CST BSE MTL INLAY 2 SURFACES 9 $0.00
D6605 CST BSE MTL INLAY >= 3 SURFA 9 $0.00
D6606 CAST NOBLE METAL INLAY 2 SUR 9 $0.00
D6607 CST NOBLE MTL INLAY >=3 SURF 9 $0.00
D6608 ONLAY PORC/CRMC 2 SURFACES 9 $0.00
D6609 ONLAY PORC/CRMC >=3 SURFACES 9 $0.00
D6610 ONLAY CST HGH NBL MTL 2 SRFC 9 $0.00
D6611 ONLAY CST HGH NBL MTL >=3SRF 9 $0.00
D6612 ONLAY CST BASE MTL 2 SURFACE 9 $0.00
D6613 ONLAY CST BASE MTL >=3 SURFA 9 $0.00
D6614 ONLAY CST NBL MTL 2 SURFACES 9 $0.00
D6615 ONLAY CST NBL MTL >=3 SURFAC 9 $0.00
D6624 INLAY TITANIUM 9 $0.00
D6634 ONLAY TITANIUM 9 $0.00
D6710 CROWN-INDIRECT RESIN BASED 9 $0.00
D6720 RETAIN CROWN RESIN W HI NBLE 9 $0.00
D6721 CROWN RESIN W/BASE METAL 1 $0.00
D6722 CROWN RESIN W/NOBLE METAL 1 $0.00
D6740 CROWN PORCELAIN/CERAMIC 9 $0.00
D6750 CROWN PORCELAIN HIGH NOBLE 9 $0.00
D6751 CROWN PORCELAIN BASE METAL 1 $0.00
D6752 CROWN PORCELAIN NOBLE METAL 1 $0.00
D6780 CROWN 3/4 HIGH NOBLE METAL 9 $0.00
D6781 CROWN 3/4 CAST BASED METAL 9 $0.00
D6782 CROWN 3/4 CAST NOBLE METAL 9 $0.00
D6783 CROWN 3/4 PORCELAIN/CERAMIC 9 $0.00
D6790 CROWN FULL HIGH NOBLE METAL 9 $0.00
D6791 CROWN FULL BASE METAL CAST 1 $0.00
D6792 CROWN FULL NOBLE METAL CAST 1 $0.00
D6793 PROVISIONAL RETAINER CROWN 9 $0.00
D6794 CROWN TITANIUM 9 $0.00
D6920 DENTAL CONNECTOR BAR 9 $0.00
D6930 DENTAL RECEMENT BRIDGE 1 $0.00
D6940 STRESS BREAKER 9 $0.00
D6950 PRECISION ATTACHMENT 9 $0.00
D6970 POST & CORE PLUS RETAINER 9 $0.00
D6971 CAST POST BRIDGE RETAINER O $0.00
D6972 PREFAB POST & CORE PLUS RETA 1 $0.00
D6973 CORE BUILD UP FOR RETAINER 9 $0.00
D6975 COPING METAL 9 $0.00
D6976 EACH ADDTNL CAST POST 9 $0.00
D6977 EACH ADDTL PREFAB POST 9 $0.00
D6980 BRIDGE REPAIR 1 $0.00
D6985 PEDIATRIC PARTIAL DENTURE FX 1 $0.00
D6999 FIXED PROSTHODONTIC PROC 1 $0.00
D7110 ORAL SURGERY SINGLE TOOTH O $0.00
D7111 EXTRACTION CORONAL REMNANTS 1 $0.00
D7120 EACH ADD TOOTH EXTRACTION O $0.00
D7130 TOOTH ROOT REMOVAL O $0.00

D7140 EXTRACTION ERUPTED TOOTH/EXR 1 $0.00
D7210 REM IMP TOOTH W MUCOPER FLP 1 $0.00
D7220 IMPACT TOOTH REMOV SOFT TISS 1 $0.00
D7230 IMPACT TOOTH REMOV PART BONY 1 $0.00
D7240 IMPACT TOOTH REMOV COMP BONY 1 $0.00
D7241 IMPACT TOOTH REM BONY W/COMP 1 $0.00
D7250 TOOTH ROOT REMOVAL 1 $0.00
D7260 ORAL ANTRAL FISTULA CLOSURE 1 $0.00
D7261 PRIMARY CLOSURE SINUS PERF 1 $0.00
D7270 TOOTH REIMPLANTATION 1 $0.00
D7271 TOOTH IMPLANTATION O $0.00
D7272 TOOTH TRANSPLANTATION 1 $0.00
D7280 EXPOSURE IMPACT TOOTH ORTHOD 1 $0.00
D7281 EXPOSURE TOOTH AID ERUPTION O $0.00
D7282 MOBILIZE ERUPTED/MALPOS TOOT 1 $0.00
D7283 PLACE DEVICE IMPACTED TOOTH 1 $0.00
D7285 BIOPSY OF ORAL TISSUE HARD 9 $0.00
D7286 BIOPSY OF ORAL TISSUE SOFT 9 $0.00
D7287 EXFOLIATIVE CYTOLOG COLLECT 9 $0.00
D7288 BRUSH BIOPSY 9 $0.00
D7290 REPOSITIONING OF TEETH 1 $0.00
D7291 TRANSSEPTAL FIBEROTOMY 1 $0.00
D7292 SCREW RETAINED PLATE 9 $0.00
D7293 TEMP ANCHORAGE DEV W FLAP 9 $0.00
D7294 TEMP ANCHORAGE DEV W/O FLAP 9 $0.00
D7310 ALVEOPLASTY W/ EXTRACTION 1 $0.00
D7311 ALVEOLOPLASTY W/EXTRACT 1-3 1 $0.00
D7320 ALVEOPLASTY W/O EXTRACTION 1 $0.00
D7321 ALVEOLOPLASTY NOT W/EXTRACTS 1 $0.00
D7340 VESTIBULOPLASTY RIDGE EXTENS 1 $0.00
D7350 VESTIBULOPLASTY EXTEN GRAFT 1 $0.00
D7410 RAD EXC LESION UP TO 1.25 CM 9 $0.00
D7411 EXCISION BENIGN LESION>1.25C 9 $0.00
D7412 EXCISION BENIGN LESION COMPL 9 $0.00
D7413 EXCISION MALIG LESION1.25CM 9 $0.00
D7415 EXCISION MALIG LES COMPLICAT 9 $0.00
D7420 LESION > 1.25 CM 9 $0.00
D7430 EXC BENIGN TUMOR TO 1.25 CM 9 $0.00
D7431 BENIGN TUMOR EXC > 1.25 CM 9 $0.00
D7440 MALIG TUMOR EXC TO 1.25 CM 9 $0.00
D7441 MALIG TUMOR > 1.25 CM 9 $0.00
D7450 REM ODONTOGEN CYST TO 1.25CM 9 $0.00
D7451 REM ODONTOGEN CYST > 1.25 CM 9 $0.00
D7460 REM NONODONTO CYST TO 1.25CM 9 $0.00
D7461 REM NONODONTO CYST > 1.25 CM 9 $0.00
D7465 LESION DESTRUCTION 9 $0.00
D7470 REM EXOSTOSIS MAXILLA/MANDIB 9 $0.00
D7471 REM EXOSTOSIS ANY SITE 9 $0.00

D7472 REMOVAL OF TORUS PALATINUS 9 $0.00
D7473 REMOVE TORUS MANDIBULARIS 9 $0.00
D7480 PARTIAL OSTECTOMY 9 $0.00
D7485 SURG REDUCT OSSEOUSTUBEROSIT 9 $0.00
D7490 MAXILLA OR MANDIBLE RESECTIO 9 $0.00
D7510 I&D ABSC INTRAORAL SOFT TISS 1 $0.00
D7511 INCISION/DRAIN ABSCESS INTRA 1 $0.00
D7520 I&D ABSCESS EXTRAORAL 1 $0.00
D7521 INCISION/DRAIN ABSCESS EXTRA 1 $0.00
D7530 REMOVAL FB SKIN/AREOLAR TISS 1 $0.00
D7540 REMOVAL OF FB REACTION 1 $0.00
D7550 REMOVAL OF SLOUGHED OFF BONE 1 $0.00
D7560 MAXILLARY SINUSOTOMY 1 $0.00
D7610 MAXILLA OPEN REDUCT SIMPLE 9 $0.00
D7620 CLSD REDUCT SIMPL MAXILLA FX 9 $0.00
D7630 OPEN RED SIMPL MANDIBLE FX 9 $0.00
D7640 CLSD RED SIMPL MANDIBLE FX 9 $0.00
D7650 OPEN RED SIMP MALAR/ZYGOM FX 9 $0.00
D7660 CLSD RED SIMP MALAR/ZYGOM FX 9 $0.00
D7670 CLOSD RDUCTN SPLINT ALVEOLUS 9 $0.00
D7671 ALVEOLUS OPEN REDUCTION 9 $0.00
D7680 REDUCT SIMPLE FACIAL BONE FX 9 $0.00
D7710 MAXILLA OPEN REDUCT COMPOUND 9 $0.00
D7720 CLSD REDUCT COMPD MAXILLA FX 9 $0.00
D7730 OPEN REDUCT COMPD MANDBLE FX 9 $0.00
D7740 CLSD REDUCT COMPD MANDBLE FX 9 $0.00
D7750 OPEN RED COMP MALAR/ZYGMA FX 9 $0.00
D7760 CLSD RED COMP MALAR/ZYGMA FX 9 $0.00
D7770 OPEN REDUC COMPD ALVEOLUS FX 9 $0.00
D7771 ALVEOLUS CLSD REDUC STBLZ TE 9 $0.00
D7780 REDUCT COMPND FACIAL BONE FX 9 $0.00
D7810 TMJ OPEN REDUCT-DISLOCATION 9 $0.00
D7820 CLOSED TMP MANIPULATION 9 $0.00
D7830 TMJ MANIPULATION UNDER ANEST 9 $0.00
D7840 REMOVAL OF TMJ CONDYLE 9 $0.00
D7850 TMJ MENISCECTOMY 9 $0.00
D7852 TMJ REPAIR OF JOINT DISC 9 $0.00
D7854 TMJ EXCISN OF JOINT MEMBRANE 9 $0.00
D7856 TMJ CUTTING OF A MUSCLE 9 $0.00
D7858 TMJ RECONSTRUCTION 9 $0.00
D7860 TMJ CUTTING INTO JOINT 9 $0.00
D7865 TMJ RESHAPING COMPONENTS 9 $0.00
D7870 TMJ ASPIRATION JOINT FLUID 9 $0.00
D7871 LYSIS + LAVAGE W CATHETERS 9 $0.00
D7872 TMJ DIAGNOSTIC ARTHROSCOPY 9 $0.00
D7873 TMJ ARTHROSCOPY LYSIS ADHESN 9 $0.00
D7874 TMJ ARTHROSCOPY DISC REPOSIT 9 $0.00
D7875 TMJ ARTHROSCOPY SYNOVECTOMY 9 $0.00
D7876 TMJ ARTHROSCOPY DISCECTOMY 9 $0.00

D7877 TMJ ARTHROSCOPY DEBRIDEMENT 9 $0.00
D7880 OCCLUSAL ORTHOTIC APPLIANCE 1 $0.00
D7899 TMJ UNSPECIFIED THERAPY 1 $0.00
D7910 DENT SUTUR RECENT WND TO 5CM 1 $0.00
D7911 DENTAL SUTURE WOUND TO 5 CM 1 $0.00
D7912 SUTURE COMPLICATE WND > 5 CM 1 $0.00
D7920 DENTAL SKIN GRAFT 9 $0.00
D7940 RESHAPING BONE ORTHOGNATHIC 9 $0.00
D7941 BONE CUTTING RAMUS CLOSED 9 $0.00
D7942 BONE CUTTING RAMUS OPEN 9 $0.00
D7943 CUTTING RAMUS OPEN W/GRAFT 9 $0.00
D7944 BONE CUTTING SEGMENTED 9 $0.00
D7945 BONE CUTTING BODY MANDIBLE 9 $0.00
D7946 RECONSTRUCTION MAXILLA TOTAL 9 $0.00
D7947 RECONSTRUCT MAXILLA SEGMENT 9 $0.00
D7948 RECONSTRUCT MIDFACE NO GRAFT 9 $0.00
D7949 RECONSTRUCT MIDFACE W/GRAFT 9 $0.00
D7950 MANDIBLE GRAFT 9 $0.00
D7951 SINUS AUG W BONE/BONE SUP 9 $0.00
D7953 BONE REPLACEMENT GRAFT 9 $0.00
D7955 REPAIR MAXILLOFACIAL DEFECTS 9 $0.00
D7960 FRENULECTOMY/FRENULOTOMY 1 $0.00
D7963 FRENULOPLASTY 1 $0.00
D7970 EXCISION HYPERPLASTIC TISSUE 1 $0.00
D7971 EXCISION PERICORONAL GINGIVA 1 $0.00
D7972 SURG REDCT FIBROUS TUBEROSIT 9 $0.00
D7980 SIALOLITHOTOMY 9 $0.00
D7981 EXCISION OF SALIVARY GLAND 9 $0.00
D7982 SIALODOCHOPLASTY 9 $0.00
D7983 CLOSURE OF SALIVARY FISTULA 9 $0.00
D7990 EMERGENCY TRACHEOTOMY 9 $0.00
D7991 DENTAL CORONOIDECTOMY 9 $0.00
D7992 EMINENECTOMY 9 $0.00
D7993 IMPLANT-FACIAL BONES (HOMOLOGOUS, H O $0.00
D7994 IMPLANT-OTHER THAN FACIAL BONES O $0.00
D7995 SYNTHETIC GRAFT FACIAL BONES 9 $0.00
D7996 IMPLANT MANDIBLE FOR AUGMENT 9 $0.00
D7997 APPLIANCE REMOVAL 1 $0.00
D7998 INTRAORAL PLACE OF FIX DEV 9 $0.00
D7999 ORAL SURGERY PROCEDURE 1 $0.00
D8010 LIMITED DENTAL TX PRIMARY 1 $0.00
D8020 LIMITED DENTAL TX TRANSITION 1 $0.00
D8030 LIMITED DENTAL TX ADOLESCENT 1 $0.00
D8040 LIMITED DENTAL TX ADULT 1 $0.00
D8050 INTERCEP DENTAL TX PRIMARY 1 $0.00
D8060 INTERCEP DENTAL TX TRANSITN 1 $0.00
D8070 COMPRE DENTAL TX TRANSITION 1 $0.00
D8080 COMPRE DENTAL TX ADOLESCENT 3 $1,585.00
D8090 COMPRE DENTAL TX ADULT 1 $0.00

D8110 REMOVABLE APPLIANCE THERAPY O $0.00
D8120 FIXED APPLIANCE THERAPY O $0.00
D8210 ORTHODONTIC REM APPLIANCE TX 1 $0.00
D8220 FIXED APPLIANCE THERAPY HABT 1 $0.00
D8360 REMOVABLE APPLIANCE THERAPY O $0.00
D8370 FIXED APPLIANCE THERAPY O $0.00
D8460 CLASS I MALOCCLUSION O $0.00
D8470 CLASS II MALOCCLUSION O $0.00
D8480 CLASS III MALOCCLUSION O $0.00
D8560 CLASS I MALOCCLUSION O $0.00
D8570 CLASS II MALOCCLUSION O $0.00
D8580 CLASS III MALOCCLUSION O $0.00
D8650 TREATMENT OF THE ATYPICAL OR EXTEND O $0.00
D8660 PREORTHODONTIC TX VISIT 3 $225.00
D8670 PERIODIC ORTHODONTC TX VISIT 3 $465.00
D8680 ORTHODONTIC RETENTION 1 $0.00
D8690 ORTHODONTIC TREATMENT 1 $0.00
D8691 REPAIR ORTHO APPLIANCE 1 $0.00
D8692 REPLACEMENT RETAINER 1 $0.00
D8693 REBOND/CEMENT/REPAIR RETAIN 9 $0.00
D8750 POST-TREATMENT STABILIZATION O $0.00
D8999 ORTHODONTIC PROCEDURE 1 $0.00
D9110 TX DENTAL PAIN MINOR PROC 1 $0.00
D9120 FIX PARTIAL DENTURE SECTION 1 $0.00
D9210 DENT ANESTHESIA W/O SURGERY 1 $0.00
D9211 REGIONAL BLOCK ANESTHESIA 9 $0.00
D9212 TRIGEMINAL BLOCK ANESTHESIA 9 $0.00
D9215 LOCAL ANESTHESIA 9 $0.00
D9220 GENERAL ANESTHESIA 1 $0.00
D9221 GENERAL ANESTHESIA EA AD 15M 1 $0.00
D9230 ANALGESIA 1 $0.00
D9240 INTRAVENOUS SEDATION 9 $0.00
D9241 INTRAVENOUS SEDATION 1 $0.00
D9242 IV SEDATION EA AD 30 M 1 $0.00
D9248 SEDATION (NON-IV) 1 $0.00
D9310 DENTAL CONSULTATION 1 $0.00
D9410 DENTAL HOUSE CALL 9 $0.00
D9420 HOSPITAL CALL 9 $0.00
D9430 OFFICE VISIT DURING HOURS 9 $0.00
D9440 OFFICE VISIT AFTER HOURS 1 $0.00
D9450 CASE PRESENTATION TX PLAN 9 $0.00
D9610 DENT THERAPEUTIC DRUG INJECT 1 $0.00
D9612 THERA PAR DRUGS 2 OR > ADMIN 1 $0.00
D9630 OTHER DRUGS/MEDICAMENTS 9 $0.00
D9910 DENT APPL DESENSITIZING MED 1 $0.00
D9911 APPL DESENSITIZING RESIN 1 $0.00
D9920 BEHAVIOR MANAGEMENT 1 $0.00
D9930 TREATMENT OF COMPLICATIONS 1 $0.00
D9940 DENTAL OCCLUSAL GUARD 1 $0.00

D9941 FABRICATION ATHLETIC GUARD 9 $0.00
D9942 REPAIR/RELINE OCCLUSAL GUARD 9 $0.00
D9950 OCCLUSION ANALYSIS 9 $0.00
D9951 LIMITED OCCLUSAL ADJUSTMENT 9 $0.00
D9952 COMPLETE OCCLUSAL ADJUSTMENT 9 $0.00
D9960 COMPLETION OF CLAIM FORM 9 $0.00
D9970 ENAMEL MICROABRASION 9 $0.00
D9971 ODONTOPLASTY 1-2 TEETH 9 $0.00
D9972 EXTRNL BLEACHING PER ARCH 9 $0.00
D9973 EXTRNL BLEACHING PER TOOTH 9 $0.00
D9974 INTRNL BLEACHING PER TOOTH 9 $0.00
D9999 ADJUNCTIVE PROCEDURE 1 $0.00
DCD03 MCO SPECIFIC CODE: DEVELOPMENTAL CE O $0.00
DCP01 MCO SPECIFIC CODE: PARENT INFANT PR O $0.00
DCT02 MCO SPECIFIC CODE: TODDLER PROGRAM O $0.00
E0100 CANE ADJUST/FIXED WITH TIP 3 $20.16
E0105 CANE ADJUST/FIXED QUAD/3 PRO 3 $46.99
E0110 CRUTCH FOREARM PAIR 3 $69.54
E0111 CRUTCH FOREARM EACH 3 $50.95
E0112 CRUTCH UNDERARM PAIR WOOD 3 $35.40
E0113 CRUTCH UNDERARM EACH WOOD 3 $20.21
E0114 CRUTCH UNDERARM PAIR NO WOOD 3 $45.15
E0116 CRUTCH UNDERARM EACH NO WOOD 3 $22.76
E0117 UNDERARM SPRINGASSIST CRUTCH 5 $0.00
E0118 CRUTCH SUBSTITUTE 6 $0.00
E0130 WALKER RIGID ADJUST/FIXED HT 3 $57.13
E0135 WALKER FOLDING ADJUST/FIXED 3 $77.57
E0140 WALKER W TRUNK SUPPORT 6 $0.00
E0141 RIGID WHEELED WALKER ADJ/FIX 3 $110.30
E0142 WALKER RIGID WHEELED WITH SE O $0.00
E0143 WALKER FOLDING WHEELED W/O S 3 $115.02
E0144 ENCLOSED WALKER W REAR SEAT 3 $304.66
E0145 WALKER WHLED SEAT/CRUTCH ATT O $0.00
E0146 FOLDING WALKER WHEELS W SEAT O $0.00
E0147 WALKER VARIABLE WHEEL RESIST 3 $549.91
E0148 HEAVYDUTY WALKER NO WHEELS 3 $121.55
E0149 HEAVY DUTY WHEELED WALKER 3 $213.53
E0150 UNDERARM PAD, CRUTCH, REPLACEMENT, 9 $0.00
E0151 HANDGRIP, CANE, CRUTCH, OR WALKER R 9 $0.00
E0152 TIP, CANE OR CRUTCH WALKER REPLACEM 9 $0.00
E0153 FOREARM CRUTCH PLATFORM ATTA 3 $66.38
E0154 WALKER PLATFORM ATTACHMENT 3 $66.38
E0155 WALKER WHEEL ATTACHMENT,PAIR 3 $30.20
E0156 WALKER SEAT ATTACHMENT 3 $25.29
E0157 WALKER CRUTCH ATTACHMENT 3 $66.61
E0158 WALKER LEG EXTENDERS SET OF4 3 $30.78
E0159 BRAKE FOR WHEELED WALKER 9 $0.00
E0160 SITZ TYPE BATH OR EQUIPMENT 3 $31.62
E0161 SITZ BATH/EQUIPMENT W/FAUCET 3 $25.09

E0162 SITZ BATH CHAIR 3 $139.39
E0163 COMMODE CHAIR WITH FIXED ARM 3 $98.08
E0164 COMMODE CHAIR MOBILE FIXED A O $0.00
E0165 COMMODE CHAIR WITH DETACHARM 3 $144.20
E0166 COMMODE CHAIR MOBILE DETACH O $0.00
E0167 COMMODE CHAIR PAIL OR PAN 3 $10.11
E0168 HEAVYDUTY/WIDE COMMODE CHAIR 3 $144.38
E0169 SEATLIFT INCORP COMMODECHAIR O $0.00
E0170 COMMODE CHAIR ELECTRIC 6 $0.00
E0171 COMMODE CHAIR NON-ELECTRIC 6 $0.00
E0172 SEAT LIFT MECHANISM TOILET 6 $0.00
E0175 COMMODE CHAIR FOOT REST 3 $53.86
E0176 AIR PRESSRE PAD/CUSHION NONP O $0.00
E0177 WATER PRESS PAD/CUSHION NONP O $0.00
E0178 GEL PRESSRE PAD/CUSHION NONP O $0.00
E0179 DRY PRESSRE PAD/CUSHION NONP O $0.00
E0180 PRESS PAD ALTERNATING W PUMP O $0.00
E0181 PRESS PAD ALTERNATING W/ PUM 3 $304.20
E0182 REPLACE PUMP, ALT PRESS PAD 3 $235.90
E0183 FLOTATION PAD FOR WHEELCHAIR 9 $0.00
E0184 DRY PRESSURE MATTRESS 3 $186.27
E0185 GEL PRESSURE MATTRESS PAD 3 $306.01
E0186 AIR PRESSURE MATTRESS 3 $182.80
E0187 WATER PRESSURE MATTRESS 3 $209.20
E0188 SYNTHETIC SHEEPSKIN PAD 3 $23.85
E0189 LAMBSWOOL SHEEPSKIN PAD 3 $36.30
E0190 POSITIONING CUSHION 6 $0.00
E0191 PROTECTOR HEEL OR ELBOW 3 $9.56
E0192 PAD WHEELCHR LOW PRESS/POSIT O $0.00
E0193 POWERED AIR FLOTATION BED 3 $6,956.30
E0194 AIR FLUIDIZED BED 3 $0.00
E0195 REPLACEMENT PAD FOR USE WITH MEDICA 9 $0.00
E0196 GEL PRESSURE MATTRESS 3 $287.60
E0197 AIR PRESSURE PAD FOR MATTRES 3 $211.98
E0198 WATER PRESSURE PAD FOR MATTR 3 $211.98
E0199 DRY PRESSURE PAD FOR MATTRES 3 $30.66
E0200 HEAT LAMP WITHOUT STAND 3 $75.85
E0202 PHOTOTHERAPY LIGHT W/ PHOTOM 3 $564.10
E0203 THERAPEUTIC LIGHTBOX TABLETP 5 $0.00
E0205 HEAT LAMP WITH STAND 3 $157.81
E0210 ELECTRIC HEAT PAD STANDARD 3 $31.22
E0215 ELECTRIC HEAT PAD MOIST 3 $67.77
E0217 WATER CIRC HEAT PAD W PUMP 3 $403.72
E0218 WATER CIRC COLD PAD W PUMP 9 $0.00
E0220 HOT WATER BOTTLE 3 $6.89
E0221 INFRARED HEATING PAD SYSTEM 5 $0.00
E0225 HYDROCOLLATOR UNIT 3 $316.04
E0230 ICE CAP OR COLLAR 3 $6.89
E0231 WOUND WARMING DEVICE 5 $0.00

E0232 WARMING CARD FOR NWT 5 $0.00
E0235 PARAFFIN BATH UNIT PORTABLE 3 $155.40
E0236 PUMP FOR WATER CIRCULATING P 3 $358.90
E0237 WATER CIRCULATING HEAT/COLD PAD WIT O $0.00
E0238 HEAT PAD NON-ELECTRIC MOIST 3 $25.87
E0239 HYDROCOLLATOR UNIT PORTABLE 3 $430.35
E0240 BATH/SHOWER CHAIR 6 $0.00
E0241 BATH TUB WALL RAIL 5 $0.00
E0242 BATH TUB RAIL FLOOR 5 $0.00
E0243 TOILET RAIL 5 $0.00
E0244 TOILET SEAT RAISED 5 $0.00
E0245 TUB STOOL OR BENCH 5 $0.00
E0246 TRANSFER TUB RAIL ATTACHMENT 5 $0.00
E0247 TRANS BENCH W/WO COMM OPEN 6 $0.00
E0248 HDTRANS BENCH W/WO COMM OPEN 6 $0.00
E0249 PAD WATER CIRCULATING HEAT U 3 $95.29
E0250 HOSP BED FIXED HT W/ MATTRES 3 $880.70
E0251 HOSP BED FIXD HT W/O MATTRES 3 $667.40
E0252 HOSPITAL BED, FIXED HEIGHT, WITH MA 9 $0.00
E0255 HOSPITAL BED VAR HT W/ MATTR 3 $1,058.30
E0256 HOSPITAL BED VAR HT W/O MATT 3 $706.90
E0260 HOSP BED SEMI-ELECTR W/ MATT 3 $1,512.70
E0261 HOSP BED SEMI-ELECTR W/O MAT 3 $1,233.60
E0265 HOSP BED TOTAL ELECTR W/ MAT 3 $1,800.70
E0266 HOSP BED TOTAL ELEC W/O MATT 3 $1,359.80
E0270 HOSPITAL BED INSTITUTIONAL T 9 $0.00
E0271 MATTRESS INNERSPRING 3 $212.42
E0272 MATTRESS FOAM RUBBER 3 $186.47
E0273 BED BOARD 5 $0.00
E0274 OVER-BED TABLE 5 $0.00
E0275 BED PAN STANDARD 3 $14.64
E0276 BED PAN FRACTURE 3 $12.73
E0277 POWERED PRES-REDU AIR MATTRS 3 $1.00
E0280 BED CRADLE 3 $35.40
E0290 HOSP BED FX HT W/O RAILS W/M 3 $673.30
E0291 HOSP BED FX HT W/O RAIL W/O 3 $489.00
E0292 HOSP BED VAR HT W/O RAIL W/O 3 $701.60
E0293 HOSP BED VAR HT W/O RAIL W/ 3 $644.30
E0294 HOSP BED SEMI-ELECT W/ MATTR 3 $1,177.20
E0295 HOSP BED SEMI-ELECT W/O MATT 3 $1,147.10
E0296 HOSP BED TOTAL ELECT W/ MATT 3 $1,479.10
E0297 HOSP BED TOTAL ELECT W/O MAT 3 $1,077.10
E0298 HEAVYDUTY/XTRA WIDE HOSP BED O $0.00
E0300 ENCLOSED PED CRIB HOSP GRADE 6 $0.00
E0301 HD HOSP BED, 350-600 LBS 6 $0.00
E0302 EX HD HOSP BED > 600 LBS 6 $0.00
E0303 HOSP BED HVY DTY XTRA WIDE 6 $0.00
E0304 HOSP BED XTRA HVY DTY X WIDE 6 $0.00
E0305 RAILS BED SIDE HALF LENGTH 3 $160.00

E0310 RAILS BED SIDE FULL LENGTH 3 $185.74
E0315 BED ACCESSORY BRD/TBL/SUPPRT 9 $0.00
E0316 BED SAFETY ENCLOSURE 5 $0.00
E0325 URINAL MALE JUG-TYPE 3 $9.67
E0326 URINAL FEMALE JUG-TYPE 3 $9.48
E0328 PED HOSPITAL BED, MANUAL 6 $0.00
E0329 PED HOSPITAL BED SEMI/ELECT 6 $0.00
E0350 CONTROL UNIT BOWEL SYSTEM 9 $0.00
E0352 DISPOSABLE PACK W/BOWEL SYST 9 $0.00
E0370 AIR ELEVATOR FOR HEEL 9 $0.00
E0371 NONPOWER MATTRESS OVERLAY 5 $0.00
E0372 POWERED AIR MATTRESS OVERLAY 3 $0.00
E0373 NONPOWERED PRESSURE MATTRESS 5 $0.00
E0400 OXYGEN CONTENTS, GASEOUS, PER CUBIC O $0.00
E0405 OXYGEN CONTENTS, GASEOUS, PER 100 C O $0.00
E0410 OXYGEN CONTENTS, LIQUID, PER POUND O $0.00
E0415 OXYGEN CONTENTS, LIQUID, PER 100 PO O $0.00
E0416 OXYGEN REFILL FOR PORTABLE GASEOUS O $0.00
E0424 STATIONARY COMPRESSED GAS 02 3 $1.00
E0425 GAS SYSTEM STATIONARY COMPRE 5 $0.00
E0430 OXYGEN SYSTEM GAS PORTABLE 5 $0.00
E0431 PORTABLE GASEOUS 02 3 $0.00
E0433 PORTABLE LIQUID OXYGEN SYS 6 $0.00
E0434 PORTABLE LIQUID 02 3 $1.00
E0435 OXYGEN SYSTEM LIQUID PORTABL 5 $0.00
E0439 STATIONARY LIQUID 02 3 $1.00
E0440 OXYGEN SYSTEM LIQUID STATION 5 $0.00
E0441 STATIONARY O2 CONTENTS, GAS 3 $148.00
E0442 STATIONARY O2 CONTENTS, LIQ 3 $148.00
E0443 PORTABLE 02 CONTENTS, GAS 3 $77.45
E0444 PORTABLE 02 CONTENTS, LIQUID 3 $77.45
E0445 OXIMETER NON-INVASIVE 3 $1.00
E0450 VOL CONTROL VENT INVASIV INT 3 $1.00
E0451 VOLUME VENTILATOR; PORTABLE (INCLUD O $0.00
E0452 INTERMIT ASSIS DEVICE W CPAP O $0.00
E0453 VENTILATOR 12 HRS/LESS PER D 9 $0.00
E0454 PRESSURE VENTILATOR O $0.00
E0455 OXYGEN TENT EXCL CROUP/PED T O $0.00
E0457 CHEST SHELL 3 $0.00
E0458 NEGATIVE PRESSURE PUMP 9 $0.00
E0459 CHEST WRAP 3 $458.40
E0460 NEG PRESS VENT PORTABL/STATN O $0.00
E0461 VOL CONTROL VENT NONINV INT 5 $0.00
E0462 ROCKING BED W/ OR W/O SIDE R 3 $2,625.00
E0463 PRESS SUPP VENT INVASIVE INT 6 $0.00
E0464 PRESS SUPP VENT NONINV INT 6 $0.00
E0470 RAD W/O BACKUP NON-INV INTFC 3 $0.00
E0471 RAD W/BACKUP NON INV INTRFC 3 $0.00
E0472 RAD W BACKUP INVASIVE INTRFC 6 $0.00

E0480 PERCUSSOR ELECT/PNEUM HOME M 3 $395.80
E0481 INTRPULMNRY PERCUSS VENT SYS 5 $0.00
E0482 COUGH STIMULATING DEVICE 5 $0.00
E0483 CHEST COMPRESSION GEN SYSTEM 5 $0.00
E0484 NON-ELEC OSCILLATORY PEP DVC 3 $36.92
E0485 ORAL DEVICE/APPLIANCE PREFAB 6 $0.00
E0486 ORAL DEVICE/APPLIANCE CUSFAB 6 $0.00
E0487 ELECTRONIC SPIROMETER 6 $0.00
E0500 IPPB ALL TYPES 3 $0.00
E0505 IPPB MACHINES WITH MANUAL VALVES EL 9 $0.00
E0510 IPPB MACHINES WITH AUTOMATIC VALVES 9 $0.00
E0515 IPPB MACHINES WITH AUTOMATIC VALVES 9 $0.00
E0550 HUMIDIF EXTENS SUPPLE W IPPB 3 $451.60
E0555 HUMIDIFIER FOR USE W/ REGULA 9 $0.00
E0560 HUMIDIFIER SUPPLEMENTAL W/ I 3 $164.09
E0561 HUMIDIFIER NONHEATED W PAP 3 $107.00
E0562 HUMIDIFIER HEATED USED W PAP 3 $301.22
E0565 COMPRESSOR AIR POWER SOURCE 3 $467.20
E0570 NEBULIZER WITH COMPRESSION 3 $177.80
E0571 AEROSOL COMPRESSOR FOR SVNEB 5 $0.00
E0572 AEROSOL COMPRESSOR ADJUST PR 5 $0.00
E0574 ULTRASONIC GENERATOR W SVNEB 5 $0.00
E0575 NEBULIZER ULTRASONIC 3 $530.00
E0580 NEBULIZER FOR USE W/ REGULAT 9 $0.00
E0585 NEBULIZER W/ COMPRESSOR & HE 3 $315.90
E0590 DISPENSING FEE DME NEB DRUG O $0.00
E0600 SUCTION PUMP PORTAB HOM MODL 3 $1.00
E0601 CONT AIRWAY PRESSURE DEVICE 3 $0.00
E0602 MANUAL BREAST PUMP 9 $0.00
E0603 ELECTRIC BREAST PUMP 3 $742.80
E0604 HOSP GRADE ELEC BREAST PUMP 5 $0.00
E0605 VAPORIZER ROOM TYPE 3 $25.29
E0606 DRAINAGE BOARD POSTURAL 3 $175.60
E0607 BLOOD GLUCOSE MONITOR HOME 9 $0.00
E0608 APNEA MONITOR O $0.00
E0609 BLOOD GLUC MON W/SPECIAL FEA O $0.00
E0610 PACEMAKER MONITR AUDIBLE/VIS 3 $227.56
E0615 PACEMAKER MONITR DIGITAL/VIS 3 $403.28
E0616 CARDIAC EVENT RECORDER 9 $0.00
E0617 AUTOMATIC EXT DEFIBRILLATOR 5 $0.00
E0618 APNEA MONITOR 3 $3,000.00
E0619 APNEA MONITOR W RECORDER 3 $1.00
E0620 CAP BLD SKIN PIERCING LASER 9 $0.00
E0621 PATIENT LIFT SLING OR SEAT 3 $91.83
E0625 PATIENT LIFT BATHROOM OR TOI 5 $0.00
E0627 SEAT LIFT INCORP LIFT-CHAIR 3 $316.39
E0628 SEAT LIFT FOR PT FURN-ELECTR 3 $316.39
E0629 SEAT LIFT FOR PT FURN-NON-EL 3 $316.39
E0630 PATIENT LIFT HYDRAULIC 3 $917.70

E0635 PATIENT LIFT ELECTRIC 3 $936.90
E0636 PT SUPPORT & POSITIONING SYS 5 $0.00
E0637 COMBINATION SIT TO STAND SYS 6 $0.00
E0638 STANDING FRAME SYS 6 $0.00
E0639 MOVEABLE PATIENT LIFT SYSTEM 6 $0.00
E0640 FIXED PATIENT LIFT SYSTEM 6 $0.00
E0641 MULTI-POSITION STND FRAM SYS 6 $0.00
E0642 DYNAMIC STANDING FRAME 6 $0.00
E0650 PNEUMA COMPRESOR NON-SEGMENT 3 $689.02
E0651 PNEUM COMPRESSOR SEGMENTAL 3 $878.65
E0652 PNEUM COMPRES W/CAL PRESSURE 3 $5,012.71
E0655 PNEUMATIC APPLIANCE HALF ARM 3 $87.76
E0656 SEGMENTAL PNEUMATIC TRUNK 6 $0.00
E0657 SEGMENTAL PNEUMATIC CHEST 6 $0.00
E0660 PNEUMATIC APPLIANCE FULL LEG 3 $139.07
E0665 PNEUMATIC APPLIANCE FULL ARM 3 $111.40
E0666 PNEUMATIC APPLIANCE HALF LEG 3 $112.29
E0667 SEG PNEUMATIC APPL FULL LEG 3 $309.75
E0668 SEG PNEUMATIC APPL FULL ARM 3 $359.33
E0669 SEG PNEUMATIC APPLI HALF LEG 3 $166.53
E0670 SEGMENTAL PNEUMATIC APPLIANCE FOR U O $0.00
E0671 PRESSURE PNEUM APPL FULL LEG 9 $0.00
E0672 PRESSURE PNEUM APPL FULL ARM 9 $0.00
E0673 PRESSURE PNEUM APPL HALF LEG 9 $0.00
E0675 PNEUMATIC COMPRESSION DEVICE 6 $0.00
E0676 INTER LIMB COMPRESS DEV NOS 6 $0.00
E0690 ULTRAVIOLET CABINET O $0.00
E0691 UVL PNL 2 SQ FT OR LESS 5 $0.00
E0692 UVL SYS PANEL 4 FT 5 $0.00
E0693 UVL SYS PANEL 6 FT 5 $0.00
E0694 UVL MD CABINET SYS 6 FT 5 $0.00
E0700 SAFETY EQUIPMENT 5 $0.00
E0701 HELMET W FACE GUARD PREFAB O $0.00
E0705 TRANSFER DEVICE 6 $0.00
E0710 RESTRAINTS ANY TYPE 5 $0.00
E0720 TENS TWO LEAD 3 $314.34
E0730 TENS FOUR LEAD 3 $354.51
E0731 CONDUCTIVE GARMENT FOR TENS/ 3 $341.24
E0740 INCONTINENCE TREATMENT SYSTM 9 $0.00
E0744 NEUROMUSCULAR STIM FOR SCOLI 3 $824.90
E0745 NEUROMUSCULAR STIM FOR SHOCK 3 $806.30
E0746 ELECTROMYOGRAPH BIOFEEDBACK O $0.00
E0747 ELEC OSTEOGEN STIM NOT SPINE 3 $3,774.74
E0748 ELEC OSTEOGEN STIM SPINAL 3 $3,890.70
E0749 ELEC OSTEOGEN STIM IMPLANTED O $0.00
E0750 IMPLANTABLE ELECTRICAL NERVE STIMUL O $0.00
E0751 PULSE GENERATOR OR RECEIVER 9 $0.00
E0752 NEUROSTIMULATOR ELECTRODE O $0.00
E0753 NEUROSTIMULATOR ELECTRODES 9 $0.00

E0754 PULSEGENERATOR PT PROGRAMMER O $0.00
E0755 ELECTRONIC SALIVARY REFLEX S 5 $0.00
E0756 IMPLANTABLE PULSE GENERATOR O $0.00
E0757 IMPLANTABLE RF RECEIVER O $0.00
E0758 EXTERNAL RF TRANSMITTER O $0.00
E0759 REPLACE RDFRQUNCY TRANSMITTR O $0.00
E0760 OSTEOGEN ULTRASOUND STIMLTOR 9 $0.00
E0761 NONTHERM ELECTROMGNTC DEVICE 5 $0.00
E0762 TRANS ELEC JT STIM DEV SYS 6 $0.00
E0764 FUNCTIONAL NEUROMUSCULARSTIM 6 $0.00
E0765 NERVE STIMULATOR FOR TX N&V 5 $0.00
E0769 ELECTRIC WOUND TREATMENT DEV 6 $0.00
E0770 FUNCTIONAL ELECTRIC STIM NOS 6 $0.00
E0776 IV POLE 3 $136.96
E0779 AMB INFUSION PUMP MECHANICAL 3 $15.67
E0780 MECH AMB INFUSION PUMP

E0948 FRACTURE FRAME ATTACHMNTS CE 3 $561.19
E0950 TRAY 3 $99.45
E0951 LOOP HEEL 3 $18.02
E0952 TOE LOOP/HOLDER, EACH 3 $18.02
E0953 PNEUMATIC TIRE O $0.00
E0954 WHEELCHAIR SEMI-PNEUMATIC CA O $0.00
E0955 CUSHIONED HEADREST 6 $0.00
E0956 W/C LATERAL TRUNK/HIP SUPPOR 6 $0.00
E0957 W/C MEDIAL THIGH SUPPORT 6 $0.00
E0958 WHLCHR ATT- CONV 1 ARM DRIVE 3 $393.10
E0959 AMPUTEE ADAPTER 3 $84.59
E0960 W/C SHOULDER HARNESS/STRAPS 6 $0.00
E0961 WHEELCHAIR BRAKE EXTENSION 3 $27.82
E0962 WHEELCHAIR 1 INCH CUSHION O $0.00
E0963 WHEELCHAIR 2 INCH CUSHION O $0.00
E0964 WHEELCHAIR 3 INCH CUSHION O $0.00
E0965 WHEELCHAIR 4 INCH CUSHION O $0.00
E0966 WHEELCHAIR HEAD REST EXTENSI 3 $61.94
E0967 MANUAL WC HAND RIM W PROJECT 3 $126.41
E0968 WHEELCHAIR COMMODE SEAT 3 $161.60
E0969 WHEELCHAIR NARROWING DEVICE 3 $139.86
E0970 WHEELCHAIR NO. 2 FOOTPLATES 3 $46.08
E0971 WHEELCHAIR ANTI-TIPPING DEVI 3 $62.90
E0972 TRANSFER BOARD OR DEVICE O $0.00
E0973 W/CH ACCESS DET ADJ ARMREST 3 $109.99
E0974 W/CH ACCESS ANTI-ROLLBACK 3 $75.59
E0975 WHEELCHAIR REINFORCED SEAT U O $0.00
E0976 WHEELCHAIR REINFORCED BACK U O $0.00
E0977 WHEELCHAIR WEDGE CUSHION O $0.00
E0978 W/C ACC,SAF BELT PELV STRAP 3 $42.81
E0979 WHEELCHAIR BELT WITH VELCRO O $0.00
E0980 WHEELCHAIR SAFETY VEST 3 $31.62
E0981 SEAT UPHOLSTERY, REPLACEMENT 6 $0.00
E0982 BACK UPHOLSTERY, REPLACEMENT 6 $0.00
E0983 ADD PWR JOYSTICK 6 $0.00
E0984 ADD PWR TILLER 6 $0.00
E0985 W/C SEAT LIFT MECHANISM 6 $0.00
E0986 MAN W/C PUSH-RIM POW ASSIST 6 $0.00
E0990 WHEELCHAIR ELEVATING LEG RES 3 $112.35
E0991 WHEELCHAIR UPHOLSTRY SEAT O $0.00
E0992 WHEELCHAIR SOLID SEAT INSERT 3 $88.48
E0993 WHEELCHAIR BACK UPHOLSTERY O $0.00
E0994 WHEELCHAIR ARM REST 3 $15.18
E0995 WHEELCHAIR CALF REST 3 $25.29
E0996 WHEELCHAIR TIRE SOLID O $0.00
E0997 WHEELCHAIR CASTER W/ A FORK O $0.00
E0998 WHEELCHAIR CASTER W/O A FORK O $0.00
E0999 WHEELCHR PNEUMATIC TIRE W/WH O $0.00
E1000 WHEELCHAIR TIRE PNEUMATIC CA O $0.00

E1001 WHEELCHAIR WHEEL O $0.00
E1002 PWR SEAT TILT 6 $0.00
E1003 PWR SEAT RECLINE 6 $0.00
E1004 PWR SEAT RECLINE MECH 6 $0.00
E1005 PWR SEAT RECLINE PWR 6 $0.00
E1006 PWR SEAT COMBO W/O SHEAR 6 $0.00
E1007 PWR SEAT COMBO W/SHEAR 3 $8,741.27
E1008 PWR SEAT COMBO PWR SHEAR 3 $8,742.05
E1009 ADD MECH LEG ELEVATION 6 $0.00
E1010 ADD PWR LEG ELEVATION 6 $0.00
E1011 PED WC MODIFY WIDTH ADJUSTM 5 $0.00
E1012 INT SEAT SYS PLANAR PED W/C O $0.00
E1013 INT SEAT SYS CONTOUR PED W/C O $0.00
E1014 RECLINING BACK ADD PED W/C 5 $0.00
E1015 SHOCK ABSORBER FOR MAN W/C 5 $0.00
E1016 SHOCK ABSORBER FOR POWER W/C 5 $0.00
E1017 HD SHCK ABSRBR FOR HD MAN WC 5 $0.00
E1018 HD SHCK ABSRBER FOR HD POWWC 5 $0.00
E1019 HD FEATURE POWER SEAT O $0.00
E1020 RESIDUAL LIMB SUPPORT SYSTEM 5 $0.00
E1021 EX HD FEATURE POWER SEAT O $0.00
E1025 PEDWC LAT/THOR SUP NOCONTOUR O $0.00
E1026 PEDWC CONTOURED LAT/THOR SUP O $0.00
E1027 PED WC LAT/ANT SUPPORT O $0.00
E1028 W/C MANUAL SWINGAWAY 3 $186.92
E1029 W/C VENT TRAY FIXED 6 $0.00
E1030 W/C VENT TRAY GIMBALED 6 $0.00
E1031 ROLLABOUT CHAIR WITH CASTERS 3 $455.00
E1035 PATIENT TRANSFER SYSTEM 300 6 $0.00
E1037 TRANSPORT CHAIR, PED SIZE 5 $0.00
E1038 TRANSPORT CHAIR PT WT300LB 6 $0.00
E1050 WHELCHR FXD FULL LENGTH ARMS 3 $917.40
E1060 WHEELCHAIR DETACHABLE ARMS 3 $1,135.60
E1065 WHEELCHAIR POWER ATTACHMENT O $0.00
E1066 WHEELCHAIR BATTERY CHARGER O $0.00
E1069 WHEELCHAIR DEEP CYCLE BATTER O $0.00
E1070 WHEELCHAIR DETACHABLE FOOT R 3 $838.60
E1083 HEMI-WHEELCHAIR FIXED ARMS 3 $709.40
E1084 HEMI-WHEELCHAIR DETACHABLE A 3 $883.70
E1085 HEMI-WHEELCHAIR FIXED ARMS 3 $623.40
E1086 HEMI-WHEELCHAIR DETACHABLE A 3 $757.10
E1087 WHEELCHAIR LIGHTWT FIXED ARM 3 $1,139.60
E1088 WHEELCHAIR LIGHTWEIGHT DET A 3 $1,358.29
E1089 WHEELCHAIR LIGHTWT FIXED ARM 3 $1,082.80
E1090 WHEELCHAIR LIGHTWEIGHT DET A 3 $1,042.60
E1091 WHEELCHAIR YOUTH O $0.00
E1092 WHEELCHAIR WIDE W/ LEG RESTS 3 $1,157.70

E1093 WHEELCHAIR WIDE W/ FOOT REST 3 $995.60
E1100 WHCHR S-RECL FXD ARM LEG RES 3 $935.10
E1110 WHEELCHAIR SEMI-RECL DETACH 3 $778.30
E1130 WHLCHR STAND FXD ARM FT REST 3 $420.70
E1140 WHEELCHAIR STANDARD DETACH A 3 $647.00
E1150 WHEELCHAIR STANDARD W/ LEG R 3 $735.00
E1160 WHEELCHAIR FIXED ARMS 3 $563.00
E1161 MANUAL ADULT WC W TILTINSPAC 5 $0.00
E1170 WHLCHR AMPU FXD ARM LEG REST 3 $804.60
E1171 WHEELCHAIR AMPUTEE W/O LEG R 3 $643.40
E1172 WHEELCHAIR AMPUTEE DETACH AR 3 $827.40
E1180 WHEELCHAIR AMPUTEE W/ FOOT R 3 $776.00
E1190 WHEELCHAIR AMPUTEE W/ LEG RE 3 $1,054.70
E1195 WHEELCHAIR AMPUTEE HEAVY DUT 3 $961.90
E1200 WHEELCHAIR AMPUTEE FIXED ARM 3 $689.20
E1210 WHLCHR MOTO FUL ARM LEG REST O $0.00
E1211 WHEELCHAIR MOTORIZED W/ DET O $0.00
E1212 WHEELCHAIR MOTORIZED W FULL O $0.00
E1213 WHEELCHAIR MOTORIZED W/ DET O $0.00
E1220 WHLCHR SPECIAL SIZE/CONSTRC 5 $0.00
E1221 WHEELCHAIR SPEC SIZE W FOOT 3 $428.10
E1222 WHEELCHAIR SPEC SIZE W/ LEG 3 $610.70
E1223 WHEELCHAIR SPEC SIZE W FOOT 3 $666.80
E1224 WHEELCHAIR SPEC SIZE W/ LEG 3 $731.10
E1225 MANUAL SEMI-RECLINING BACK 3 $407.20
E1226 MANUAL FULLY RECLINING BACK 3 $522.01
E1227 WHEELCHAIR SPEC SZ SPEC HT A 3 $265.23
E1228 WHEELCHAIR SPEC SZ SPEC HT B 3 $214.50
E1229 PEDIATRIC WHEELCHAIR NOS 6 $0.00
E1230 POWER OPERATED VEHICLE 3 $1,946.92
E1231 RIGID PED W/C TILT-IN-SPACE 5 $0.00
E1232 FOLDING PED WC TILT-IN-SPACE 5 $0.00
E1233 RIG PED WC TLTNSPC W/O SEAT 5 $0.00
E1234 FLD PED WC TLTNSPC W/O SEAT 5 $0.00
E1235 RIGID PED WC ADJUSTABLE 5 $0.00
E1236 FOLDING PED WC ADJUSTABLE 5 $0.00
E1237 RGD PED WC ADJSTABL W/O SEAT 5 $0.00
E1238 FLD PED WC ADJSTABL W/O SEAT 5 $0.00
E1239 PED POWER WHEELCHAIR NOS 6 $0.00
E1240 WHCHR LITWT DET ARM LEG REST 3 $928.10
E1250 WHEELCHAIR LIGHTWT FIXED ARM 3 $684.70
E1260 WHEELCHAIR LIGHTWT FOOT REST 3 $713.70
E1270 WHEELCHAIR LIGHTWEIGHT LEG R 3 $604.40
E1280 WHCHR H-DUTY DET ARM LEG RES 3 $1,005.00
E1285 WHEELCHAIR HEAVY DUTY FIXED 3 $923.50
E1290 WHEELCHAIR HVY DUTY DETACH A 3 $958.20
E1295 WHEELCHAIR HEAVY DUTY FIXED 3 $1,046.20
E1296 WHEELCHAIR SPECIAL SEAT HEIG 3 $399.82
E1297 WHEELCHAIR SPECIAL SEAT DEPT 3 $85.07

E1298 WHEELCHAIR SPEC SEAT DEPTH/W 3 $365.36
E1300 WHIRLPOOL PORTABLE 5 $0.00
E1310 WHIRLPOOL NON-PORTABLE 3 $2,054.39
E1340 REPAIR FOR DME, PER 15 MIN O $0.00
E1350 REPAIR OR NON-ROUTINE SERVICE (E.G. O $0.00
E1353 OXYGEN SUPPLIES REGULATOR 5 $0.00
E1354 WHEELED CART, PORT CYL/CONC 6 $0.00
E1355 OXYGEN SUPPLIES STAND/RACK 3 $46.67
E1356 BREATHING CIRCUITS O $0.00
E1357 BATTERY CHARGER, PORT CONC 6 $0.00
E1358 DC POWER ADAPTER, PORT CONC 6 $0.00
E1372 OXY SUPPL HEATER FOR NEBULIZ 3 $155.98
E1375 OXYGEN SUPPL NEBULIZER PORTA O $0.00
E1377 OXYGEN CONCENTRATOR TO 244 C O $0.00
E1378 OXYGEN CONCENTRATOR TO 488 C O $0.00
E1379 OXYGEN CONCENTRATOR TO 732 C O $0.00
E1380 OXYGEN CONCENTRATOR TO 976 C O $0.00
E1381 OXYGEN CONCENTRAT TO 1220 CU O $0.00
E1382 OXYGEN CONCENTRAT TO 1464 CU O $0.00
E1383 OXYGEN CONCENTRAT TO 1708 CU O $0.00
E1384 OXYGEN CONCENTRAT TO 1952 CU O $0.00
E1385 OXYGEN CONCENTRATOR > 1952 C O $0.00
E1388 OXYGEN CONCENTRATOR, EQUIVALENT TO O $0.00
E1389 OXYGEN CONCENTRATOR, EQUIVALENT TO O $0.00
E1390 OXYGEN CONCENTRATOR 3 $0.00
E1391 OXYGEN CONCENTRATOR, DUAL 6 $0.00
E1392 PORTABLE OXYGEN CONCENTRATOR 6 $0.00
E1393 OXYGEN CONCENTRATOR, EQUIVALENT TO O $0.00
E1394 OXYGEN CONCENTRATOR, EQUIVALENT TO O $0.00
E1395 OXYGEN CONCENTRATOR, EQUIVALENT TO O $0.00
E1396 OXYGEN CONCENTRATOR, EQUIVALENT TO O $0.00
E1399 DURABLE MEDICAL EQUIPMENT MI 3 $325.00
E1400 OXYGEN CONCENTRATOR < 2 LITE 9 $0.00
E1401 OXYGEN CONCENTRATOR 2-3 LITE O $0.00
E1402 OXYGEN CONCENTRATOR 3-4 LITE O $0.00
E1403 OXYGEN CONCENTRATOR 4-5 LITE O $0.00
E1404 OXYGEN CONCENTRATOR > 5 LITE 9 $0.00
E1405 O2/WATER VAPOR ENRICH W/HEAT 5 $0.00
E1406 O2/WATER VAPOR ENRICH W/O HE 5 $0.00
E1500 CENTRIFUGE 9 $0.00
E1510 KIDNEY DIALYSATE DELIVRY SYS 5 $0.00
E1520 HEPARIN INFUSION PUMP 5 $0.00
E1530 REPLACEMENT AIR BUBBLE DETEC 5 $0.00
E1540 REPLACEMENT PRESSURE ALARM 5 $0.00
E1550 BATH CONDUCTIVITY METER 5 $0.00
E1560 REPLACE BLOOD LEAK DETECTOR 5 $0.00
E1570 ADJUSTABLE CHAIR FOR ESRD PT 5 $0.00
E1575 TRANSDUCER PROTECT/FLD BAR 5 $0.00
E1580 UNIPUNCTURE CONTROL SYSTEM 5 $0.00

E1590 HEMODIALYSIS MACHINE 5 $0.00
E1592 AUTO INTERM PERITONEAL DIALY 5 $0.00
E1594 CYCLER DIALYSIS MACHINE 5 $0.00
E1600 DELI/INSTALL CHRG HEMO EQUIP 5 $0.00
E1610 REVERSE OSMOSIS H2O PURI SYS 5 $0.00
E1615 DEIONIZER H2O PURI SYSTEM 5 $0.00
E1620 REPLACEMENT BLOOD PUMP 5 $0.00
E1625 WATER SOFTENING SYSTEM 5 $0.00
E1630 RECIPROCATING PERITONEAL DIA 5 $0.00
E1632 WEARABLE ARTIFICIAL KIDNEY 5 $0.00
E1634 PERITONEAL DIALYSIS CLAMP 6 $0.00
E1635 COMPACT TRAVEL HEMODIALYZER 5 $0.00
E1636 SORBENT CARTRIDGES PER 10 5 $0.00
E1637 HEMOSTATS FOR DIALYSIS, EACH 9 $0.00
E1638 PERI DIALYSIS HEATING PAD 9 $0.00
E1639 DIALYSIS SCALE 9 $0.00
E1640 REPLACEMENT COMPONENTS FOR D O $0.00
E1699 DIALYSIS EQUIPMENT NOC 5 $0.00
E1700 JAW MOTION REHAB SYSTEM O $0.00
E1701 REPL CUSHIONS FOR JAW MOTION O $0.00
E1702 REPL MEASR SCALES JAW MOTION O $0.00
E1800 ADJUST ELBOW EXT/FLEX DEVICE 9 $0.00
E1801 SPS ELBOW DEVICE 9 $0.00
E1802 ADJST FOREARM PRO/SUP DEVICE 5 $0.00
E1805 ADJUST WRIST EXT/FLEX DEVICE 9 $0.00
E1806 SPS WRIST DEVICE 9 $0.00
E1810 ADJUST KNEE EXT/FLEX DEVICE 9 $0.00
E1811 SPS KNEE DEVICE 9 $0.00
E1812 KNEE EXT/FLEX W ACT RES CTRL 6 $0.00
E1815 ADJUST ANKLE EXT/FLEX DEVICE 9 $0.00
E1816 SPS ANKLE DEVICE 9 $0.00
E1818 SPS FOREARM DEVICE 9 $0.00
E1820 SOFT INTERFACE MATERIAL 9 $0.00
E1821 REPLACEMENT INTERFACE SPSD 9 $0.00
E1825 ADJUST FINGER EXT/FLEX DEVC 9 $0.00
E1830 ADJUST TOE EXT/FLEX DEVICE 9 $0.00
E1840 ADJ SHOULDER EXT/FLEX DEVICE 9 $0.00
E1841 STATIC STR SHLDR DEV ROM ADJ 6 $0.00
E1900 SPEECH COMMUNICATION DEVICE O $0.00
E1902 AAC NON-ELECTRONIC BOARD 5 $0.00
E2000 GASTRIC SUCTION PUMP HME MDL 3 $1.00
E2100 BLD GLUCOSE MONITOR W VOICE 5 $0.00
E2101 BLD GLUCOSE MONITOR W LANCE 5 $0.00
E2120 PULSE GEN SYS TX ENDOLYMP FL 6 $0.00
E2201 MAN W/CH ACC SEAT W>=20"

E2206 COMPLETE WHEEL LOCK ASSEMBLY 3 $40.68
E2207 CRUTCH AND CANE HOLDER 6 $0.00
E2208 CYLINDER TANK CARRIER 6 $0.00
E2209 ARM TROUGH EACH 6 $0.00
E2210 WHEELCHAIR BEARINGS 6 $0.00
E2211 PNEUMATIC PROPULSION TIRE 6 $0.00
E2212 PNEUMATIC PROP TIRE TUBE 6 $0.00
E2213 PNEUMATIC PROP TIRE INSERT 6 $0.00
E2214 PNEUMATIC CASTER TIRE EACH 6 $0.00
E2215 PNEUMATIC CASTER TIRE TUBE 6 $0.00
E2216 FOAM FILLED PROPULSION TIRE 6 $0.00
E2217 FOAM FILLED CASTER TIRE EACH 6 $0.00
E2218 FOAM PROPULSION TIRE EACH 6 $0.00
E2219 FOAM CASTER TIRE ANY SIZE EA 6 $0.00
E2220 SOLID PROPULSION TIRE EACH 6 $0.00
E2221 SOLID CASTER TIRE EACH 6 $0.00
E2222 SOLID CASTER INTEGRATED WHL 6 $0.00
E2223 VALVE REPLACEMENT ONLY EACH O $0.00
E2224 PROPULSION WHL EXCLUDES TIRE 6 $0.00
E2225 CASTER WHEEL EXCLUDES TIRE 6 $0.00
E2226 CASTER FORK REPLACEMENT ONLY 6 $0.00
E2227 GEAR REDUCTION DRIVE WHEEL 6 $0.00
E2228 MWC ACC, WHEELCHAIR BRAKE 6 $0.00
E2230 MANUAL STANDING SYSTEM 6 $0.00
E2231 SOLID SEAT SUPPORT BASE 6 $0.00
E2291 PLANAR BACK FOR PED SIZE WC 6 $0.00
E2292 PLANAR SEAT FOR PED SIZE WC 6 $0.00
E2293 CONTOUR BACK FOR PED SIZE WC 6 $0.00
E2294 CONTOUR SEAT FOR PED SIZE WC 6 $0.00
E2295 PED DYNAMIC SEATING FRAME 6 $0.00
E2300 PWR SEAT ELEVATION SYS 6 $0.00
E2301 PWR STANDING 6 $0.00
E2310 ELECTRO CONNECT BTW CONTROL 6 $0.00
E2311 ELECTRO CONNECT BTW 2 SYS 3 $2,144.13
E2312 MINI-PROP REMOTE JOYSTICK 6 $0.00
E2313 PWC HARNESS, EXPAND CONTROL 6 $0.00
E2320 HAND CHIN CONTROL O $0.00
E2321 HAND INTERFACE JOYSTICK 6 $0.00
E2322 MULT MECH SWITCHES 6 $0.00
E2323 SPECIAL JOYSTICK HANDLE 6 $0.00
E2324 CHIN CUP INTERFACE 6 $0.00
E2325 SIP AND PUFF INTERFACE 6 $0.00
E2326 BREATH TUBE KIT 6 $0.00
E2327 HEAD CONTROL INTERFACE MECH 6 $0.00
E2328 HEAD/EXTREMITY CONTROL INTER 6 $0.00
E2329 HEAD CONTROL NONPROPORTIONAL 6 $0.00
E2330 HEAD CONTROL PROXIMITY SWITC 6 $0.00
E2331 ATTENDANT CONTROL 6 $0.00
E2340 W/C WDTH 20-23 IN SEAT FRAME 6 $0.00

E2341 W/C WDTH 24-27 IN SEAT FRAME 6 $0.00
E2342 W/C DPTH 20-21 IN SEAT FRAME 6 $0.00
E2343 W/C DPTH 22-25 IN SEAT FRAME 6 $0.00
E2351 ELECTRONIC SGD INTERFACE 6 $0.00
E2360 22NF NONSEALED LEADACID 3 $112.34
E2361 22NF SEALED LEADACID BATTERY 3 $139.47
E2362 GR24 NONSEALED LEADACID 3 $91.98
E2363 GR24 SEALED LEADACID BATTERY 3 $186.00
E2364 U1NONSEALED LEADACID BATTERY 3 $112.34
E2365 U1 SEALED LEADACID BATTERY 3 $112.17
E2366 BATTERY CHARGER, SINGLE MODE 3 $263.62
E2367 BATTERY CHARGER, DUAL MODE 3 $419.07
E2368 POWER WC MOTOR REPLACEMENT 6 $0.00
E2369 PWR WC GEAR BOX REPLACEMENT 6 $0.00
E2370 PWR WC MOTOR/GEAR BOX COMBO 6 $0.00
E2371 GR27 SEALED LEADACID BATTERY 6 $0.00
E2372 GR27 NON-SEALED LEADACID 6 $0.00
E2373 HAND/CHIN CTRL SPEC JOYSTICK 6 $0.00
E2374 HAND/CHIN CTRL STD JOYSTICK 6 $0.00
E2375 NON-EXPANDABLE CONTROLLER 6 $0.00
E2376 EXPANDABLE CONTROLLER, REPL 6 $0.00
E2377 EXPANDABLE CONTROLLER, INITL 6 $0.00
E2381 PNEUM DRIVE WHEEL TIRE 6 $0.00
E2382 TUBE, PNEUM WHEEL DRIVE TIRE 6 $0.00
E2383 INSERT, PNEUM WHEEL DRIVE 6 $0.00
E2384 PNEUMATIC CASTER TIRE 6 $0.00
E2385 TUBE, PNEUMATIC CASTER TIRE 6 $0.00
E2386 FOAM FILLED DRIVE WHEEL TIRE 6 $0.00
E2387 FOAM FILLED CASTER TIRE 6 $0.00
E2388 FOAM DRIVE WHEEL TIRE 6 $0.00
E2389 FOAM CASTER TIRE 6 $0.00
E2390 SOLID DRIVE WHEEL TIRE 6 $0.00
E2391 SOLID CASTER TIRE 6 $0.00
E2392 SOLID CASTER TIRE, INTEGRATE 6 $0.00
E2393 VALVE, PNEUMATIC TIRE TUBE O $0.00
E2394 DRIVE WHEEL EXCLUDES TIRE 6 $0.00
E2395 CASTER WHEEL EXCLUDES TIRE 6 $0.00
E2396 CASTER FORK 6 $0.00
E2397 PWC ACC, LITH-BASED BATTERY 6 $0.00
E2399 NOC INTERFACE O $0.00
E2402 NEG PRESS WOUND THERAPY PUMP 6 $0.00
E2500 SGD DIGITIZED PRE-REC 8MIN 20MIN 40 MIN 6 $0.00
E2508 SGD SPELLING PHYS CONTACT 6 $0.00
E2510 SGD W MULTI METHODS MSG/ACCS 6 $0.00
E2511 SGD SFTWRE PRGRM FOR PC/PDA 6 $0.00
E2512 SGD ACCESSORY, MOUNTING SYS 6 $0.00

E2599 SGD ACCESSORY NOC 6 $0.00
E2601 GEN W/C CUSHION WDTH < 22 IN 6 $0.00
E2602 GEN W/C CUSHION WDTH >=22 IN 6 $0.00
E2603 SKIN PROTECT WC CUS WD =22IN 6 $0.00
E2605 POSITION WC CUSH WDTH =22 IN 6 $0.00
E2607 SKIN PRO/POS WC CUS WD =22IN 6 $0.00
E2609 CUSTOM FABRICATE W/C CUSHION 6 $0.00
E2610 POWERED W/C CUSHION 6 $0.00
E2611 GEN USE BACK CUSH WDTH =22IN 6 $0.00
E2613 POSITION BACK CUSH WD =22IN 6 $0.00
E2615 POS BACK POST/LAT WDTH =22IN 6 $0.00
E2617 CUSTOM FAB W/C BACK CUSHION 6 $0.00
E2618 WC ACC SOLID SEAT SUPP BASE O $0.00
E2619 REPLACE COVER W/C SEAT CUSH 6 $0.00
E2620 WC PLANAR BACK CUSH WD =22IN 6 $0.00
E4610 LANCET DEVICE 9 $0.00
E8000 POSTERIOR GAIT TRAINER 6 $0.00
E8001 UPRIGHT GAIT TRAINER 6 $0.00
E8002 ANTERIOR GAIT TRAINER 6 $0.00
EDUCW MCO SPECIFIC CODE: SMART START INDI O $0.00
EDURN MCO SPECIFIC CODE: SMART START INDI O $0.00
EDUSW MCO SPECIFIC CODE: SMART START INDI O $0.00
EXRCL MCO SPECIFIC CODE: SMART START PRE O $0.00
FS001 MCO SPECIFIC CODE: FULL BABY FIRST O $0.00
FS002 MCO SPECIFIC CODE: LATE REFERRAL BA O $0.00
FS003 MCO SPECIFIC CODE: PARTIAL BABY FIR O $0.00
FS100 MCO SPECIFIC CODE: PREGNANT MOTHER O $0.00
FS104 MCO SPECIFIC CODE: SMART START, PRE O $0.00
FS105 MCO SPECIFIC CODE: SMART START, PRE O $0.00
FS106 MCO SPECIFIC CODE: SMART START, PRE O $0.00
FS107 MCO SPECIFIC CODE: SMART START, PRE O $0.00
FS108 MCO SPECIFIC CODE: SMART START, PRE O $0.00
FS109 MCO SPECIFIC CODE: SMART START, PRE O $0.00
FS110 MCO SPECIFIC CODE: RESOURCE MOTHER' O $0.00
FS111 MCO SPECIFIC CODE: RESOURCE MOTHER' O $0.00
FS112 MCO SPECIFIC CODE: RSEOURCE MOTHER' O $0.00
FS912 MCO SPECIFIC CODE: NEOCATE 1+, 100 O $0.00
FS913 MCO SPECIFIC CODE: NEOCATE 1+, 8 OU O $0.00
G0001 DRAWING BLOOD FOR SPECIMEN O $0.00
G0002 TEMPORARY URINARY CATHETER 9 $0.00
G0004 ECG TRANSM PHYS REVIEW & INT 9 $0.00
G0005 ECG 24 HOUR RECORDING 9 $0.00

G0006 ECG TRANSMISSION & ANALYSIS 9 $0.00
G0007 ECG PHY REVIEW & INTERPRET 9 $0.00
G0008 ADMIN INFLUENZA VIRUS VAC 9 $0.00
G0009 ADMIN PNEUMOCOCCAL VACCINE 9 $0.00
G0010 ADMIN HEPATITIS B VACCINE 9 $0.00
G0015 POST SYMPTOM ECG TRACING 9 $0.00
G0016 POST SYMPTOM ECG MD REVIEW 9 $0.00
G0020 IMPRESSION AND CUSTOM PREPARATION; O $0.00
G0021 IMPRESSION AND CUSTOM PREPARATION; O $0.00
G0025 COLLAGEN SKIN TEST KIT O $0.00
G0026 FECAL LEUKOCYTE EXAMINATION O $0.00
G0027 SEMEN ANALYSIS 9 $0.00
G0030 PET IMAGING PREV PET SINGLE O $0.00
G0031 PET IMAGING PREV PET MULTPLE O $0.00
G0032 PET FOLLOW SPECT 78464 SINGL O $0.00
G0033 PET FOLLOW SPECT 78464 MULT O $0.00
G0034 PET FOLLOW SPECT 76865 SINGL O $0.00
G0035 PET FOLLOW SPECT 78465 MULT O $0.00
G0036 PET FOLLOW CORNRY ANGIO SING O $0.00
G0037 PET FOLLOW CORNRY ANGIO MULT O $0.00
G0038 PET FOLLOW MYOCARD PERF SING O $0.00
G0039 PET FOLLOW MYOCARD PERF MULT O $0.00
G0040 PET FOLLOW STRESS ECHO SINGL O $0.00
G0041 PET FOLLOW STRESS ECHO MULT O $0.00
G0042 PET FOLLOW VENTRICULOGM SING O $0.00
G0043 PET FOLLOW VENTRICULOGM MULT O $0.00
G0044 PET FOLLOWING REST ECG SINGL O $0.00
G0045 PET FOLLOWING REST ECG MULT O $0.00
G0046 PET FOLLOW STRESS ECG SINGL O $0.00
G0047 PET FOLLOW STRESS ECG MULT O $0.00
G0050 RESIDUAL URINE BY ULTRASOUND 9 $0.00
G0051 DESTRUCTION BY ANY METHOD, INCLUDIN 9 $0.00
G0052 DESTRUCTION BY ANY METHOD, INCLUDIN 9 $0.00
G0053 DESTRUCTION BY ANY METHOD, INCLUDIN 9 $0.00
G0054 BLOOD CHOLESTEROL TEST, BY CHOLESTE O $0.00
G0055 GLUCOSE POST DOSE (INCLUDES GLUCOSE O $0.00
G0056 GLUCOSE TOLERANCE TEST (GTT), BY DI O $0.00
G0057 GLUCOSE TOLERANCE TEST (GTT), BY DI O $0.00
G0058 AUTOMATED MULTICHANNEL TEST; 20 CLI O $0.00
G0059 AUTOMATED MULTICHANNEL TEST; 21 CLI O $0.00
G0060 AUTOMATED MULTICHANNEL TEST, 22 CLI O $0.00
G0061 LUNG VOLUME REDUCTION SURGERY (REDU O $0.00
G0062 PERIPHERAL SKELETAL BONE MINERAL DE 9 $0.00
G0063 CENTRAL SKELETAL BONE MINERAL DENSI 9 $0.00
G0064 PHYSICIAN SUPERVISION OF A PATIENT 9 $0.00
G0065 PHYSICIAN SUPERVISION OF A HOSPICE 9 $0.00
G0066 PHYSICIAN SUPERVISION OF A NURSING 9 $0.00
G0071 INDIVIDUAL PSYCHOTHERAPY, INSIGHT O 9 $0.00
G0072 INDIVIDUAL PSYCHOTHERAPY, INSIGHT O 9 $0.00

G0073 INDIVIDUAL PSYCHOTHERAPY, INSIGHT O 9 $0.00
G0074 INDIVIDUAL PSYCHOTHERAPY, INSIGHT O 9 $0.00
G0075 INDIVIDUAL PSYCHOTHERAPY, INSIGHT O 9 $0.00
G0076 INDIVIDUAL PSYCHOTHERAPY, INSIGHT O 9 $0.00
G0077 INDIVIDUAL PSYCHOTHERAPY, INTERACTI 9 $0.00
G0078 INDIVIDUAL PSYCHOTHERAPY, INTERACTI 9 $0.00
G0079 INDIVIDUAL PSYCHOTHERAPY, INTERACTI 9 $0.00
G0080 INDIVIDUAL PSYCHOTHERAPY, INTERACTI 9 $0.00
G0081 INDIVIDUAL PSYCHOTHERAPY, INTERACTI 9 $0.00
G0082 INDIVIDUAL PSYCHOTHERAPY, INTERACTI 9 $0.00
G0083 INDIVIDUAL PSYCHOTHERAPY, INSIGHT O 9 $0.00
G0084 INDIVIDUAL PSYCHOTHERAPY, INSIGHT O 9 $0.00
G0085 INDIVIDUAL PSYCHOTHERAPY, INSIGHT O 9 $0.00
G0086 INDIVIDUAL PSYCHOTHERAPY, INSIGHT O 9 $0.00
G0087 INDIVIDUAL PSYCHOTHERAPY, INSIGHT O 9 $0.00
G0088 INDIVIDUAL PSYCHOTHERAPY, INSIGHT O 9 $0.00
G0089 INDIVIDUAL PSYCHOTHERAPY, INTERACTI 9 $0.00
G0090 INDIVIDUAL PSYCHOTHERAPY, INTERACTI 9 $0.00
G0091 INDIVIDUAL PSYCHOTHERAPY, INTERACTI 9 $0.00
G0092 INDIVIDUAL PSYCHOTHERAPY, INTERACTI 9 $0.00
G0093 INDIVIDUAL PSYCHOTHERAPY, INTERACTI 9 $0.00
G0094 INDIVIDUAL PSYCHOTHERAPY, INTERACTI 9 $0.00
G0101 CA SCREEN;PELVIC/BREAST EXAM 9 $0.00
G0102 PROSTATE CA SCREENING; DRE 9 $0.00
G0103 PSA SCREENING 9 $0.00
G0104 CA SCREEN;FLEXI SIGMOIDSCOPE 9 $0.00
G0105 COLORECTAL SCRN; HI RISK IND 9 $0.00
G0106 COLON CA SCREEN;BARIUM ENEMA 9 $0.00
G0107 CA SCREEN; FECAL BLOOD TEST O $0.00
G0108 DIAB MANAGE TRN PER INDIV 9 $0.00
G0109 DIAB MANAGE TRN IND/GROUP 9 $0.00
G0110 NETT PULM-REHAB EDUC; IND O $0.00
G0111 NETT PULM-REHAB EDUC; GROUP O $0.00
G0112 NETT;NUTRITION GUID, INITIAL O $0.00
G0113 NETT;NUTRITION GUID,SUBSEQNT O $0.00
G0114 NETT; PSYCHOSOCIAL CONSULT O $0.00
G0115 NETT; PSYCHOLOGICAL TESTING O $0.00
G0116 NETT; PSYCHOSOCIAL COUNSEL O $0.00
G0117 GLAUCOMA SCRN HGH RISK DIREC 9 $0.00
G0118 GLAUCOMA SCRN HGH RISK DIREC 9 $0.00
G0120 COLON CA SCRN; BARIUM ENEMA 9 $0.00
G0121 COLON CA SCRN NOT HI RSK IND 9 $0.00
G0122 COLON CA SCRN; BARIUM ENEMA 9 $0.00
G0123 SCREEN CERV/VAG THIN LAYER 3 $28.00
G0124 SCREEN C/V THIN LAYER BY MD 9 $0.00
G0125 PET IMAGE PULMONARY NODULE O $0.00
G0126 LUNG IMAGE (PET) STAGING 9 $0.00
G0127 TRIM NAIL(S) 9 $0.00
G0128 CORF SKILLED NURSING SERVICE 9 $0.00

G0129 PARTIAL HOSP PROG SERVICE 9 $0.00
G0130 SINGLE ENERGY X-RAY STUDY 9 $0.00
G0131 CT SCAN, BONE DENSITY STUDY 9 $0.00
G0132 CT SCAN, BONE DENSITY STUDY 9 $0.00
G0141 SCR C/V CYTO,AUTOSYS AND MD 9 $0.00
G0143 SCR C/V CYTO,THINLAYER,RESCR 9 $0.00
G0144 SCR C/V CYTO,THINLAYER,RESCR 9 $0.00
G0145 SCR C/V CYTO,THINLAYER,RESCR 9 $0.00
G0147 SCR C/V CYTO, AUTOMATED SYS 9 $0.00
G0148 SCR C/V CYTO, AUTOSYS, RESCR 9 $0.00
G0151 HHCP-SERV OF PT,EA 15 MIN 7 $0.00
G0152 HHCP-SERV OF OT,EA 15 MIN 7 $0.00
G0153 HHCP-SVS OF S/L PATH,EA 15MN 7 $0.00
G0154 HHCP-SVS OF RN,EA 15 MIN 7 $0.00
G0155 HHCP-SVS OF CSW,EA 15 MIN 9 $0.00
G0156 HHCP-SVS OF AIDE,EA 15 MIN 7 $0.00
G0159 PERC DECLOT DIALYSIS GRAFT 9 $0.00
G0160 CRYO. ABLATION, PROSTATE 9 $0.00
G0161 ECHO GUIDE FOR CRYO PROBES 9 $0.00
G0163 PET FOR REC OF COLORECTAL CA 9 $0.00
G0164 PET FOR LYMPHOMA STAGING 9 $0.00
G0165 PET,REC OF MELANOMA/MET CA 9 $0.00
G0166 EXTRNL COUNTERPULSE, PER TX 9 $0.00
G0167 HYPERBARIC OZ TX;NO MD REQRD O $0.00
G0168 WOUND CLOSURE BY ADHESIVE 9 $0.00
G0169 REMOVAL TISSUE; NO ANESTHSIA 9 $0.00
G0170 SKIN BIOGRAFT 9 $0.00
G0171 SKIN BIOGRAFT ADD-ON 9 $0.00
G0172 PHP;TRAIN & ED, PER DAY 9 $0.00
G0173 LINEAR ACC STEREO RADSUR COM 9 $0.00
G0174 INTENSITYMODULATEDRADIATION 9 $0.00
G0175 OPPS SERVICE,SCHED TEAM CONF 7 $0.00
G0176 OPPS/PHP;ACTIVITY THERAPY 3 $10,128.26
G0177 OPPS/PHP; TRAIN & EDUC SERV O $0.00
G0178 INTENSITYMODULATEDRADIATION 9 $0.00
G0179 MD RECERTIFICATION HHA PT 9 $0.00
G0180 MD CERTIFICATION HHA PATIENT 9 $0.00
G0181 HOME HEALTH CARE SUPERVISION 9 $0.00
G0182 HOSPICE CARE SUPERVISION 9 $0.00
G0183 DESTRUCTION OF LOCALIZED LESION OF 9 $0.00
G0184 OCULAR PHOTDYNAMICTX 2ND EYE 9 $0.00
G0185 TRANSPUPPILLARY THERMOTX 9 $0.00
G0186 DSTRY EYE LESN,FDR VSSL TECH 9 $0.00
G0187 DSTRY MCLR DRUSEN,PHOTOCOAG 9 $0.00
G0188 XRAY LWR EXTRMTY-FULL LNGTH 9 $0.00
G0190 IMMUNIZATION ADMINISTRATION 9 $0.00
G0191 IMMUNIZATION ADMIN,EACH ADD 9 $0.00
G0192 IMMUNIZATION ORAL/INTRANASAL 9 $0.00
G0193 ENDOSCOPICSTUDYSWALLOWFUNCTN 9 $0.00

G0194 SENSORYTESTINGENDOSCOPICSTUD 9 $0.00
G0195 CLINICALEVALSWALLOWINGFUNCT 9 $0.00
G0196 EVALOFSWALLOWINGWITHRADIOOPA 9 $0.00
G0197 EVALOFPTFORPRESCIPSPEECHDEVI 9 $0.00
G0198 PATIENTADAPATION&TRAINFORSPE 9 $0.00
G0199 REEVALUATIONOFPATIENTUSESPEC 9 $0.00
G0200 EVALOFPATIENTPRESCIPOFVOICEP 9 $0.00
G0201 MODIFORTRAININGINUSEVOICEPRO 9 $0.00
G0202 SCREENINGMAMMOGRAPHYDIGITAL 3 $130.93
G0204 DIAGNOSTICMAMMOGRAPHYDIGITAL 3 $153.88
G0206 DIAGNOSTICMAMMOGRAPHYDIGITAL 3 $122.19
G0210 PET IMG WHOLEBODY DXLUNG O $0.00
G0211 PET IMG WHOLBODY INIT LUNG O $0.00
G0212 PET IMG WHOLEBOD RESTAG LUNG O $0.00
G0213 PET IMG WHOLBODY DX O $0.00
G0214 PET IMG WHOLEBOD INIT O $0.00
G0215 PETIMG WHOLEBOD RESTAG O $0.00
G0216 PET IMG WHOLEBOD DX MELANOMA O $0.00
G0217 PET IMG WHOLEBOD INIT MELAN O $0.00
G0218 PET IMG WHOLEBOD RESTAG MELA O $0.00
G0219 PET IMG WHOLBOD MELANO NONCO 9 $0.00
G0220 PET IMG WHOLEBOD DX LYMPHOMA O $0.00
G0221 PET IMAG WHOLBOD INIT LYMPHO O $0.00
G0222 PET IMAG WHOLBOD RESTA LYMPH O $0.00
G0223 PET IMAG WHOLBOD REG DX HEAD O $0.00
G0224 PET IMAG WHOLBOD REG INI HEA O $0.00
G0225 PET WHOL RESTAG HEADNECKONLY O $0.00
G0226 PET IMG WHOLBODY DX ESOPHAGL O $0.00
G0227 PET IMG WHOLBOD INI ESOPHAGE O $0.00
G0228 PET IMG WHOLBOD RESTG ESOPHA O $0.00
G0229 PET IMG METABOLOC BRAIN PRES O $0.00
G0230 PET MYOCARD VIABILITY POST O $0.00
G0231 PET WHBD COLOREC; GAMMA CAM O $0.00
G0232 PET WHBD LYMPHOMA; GAMMA CAM O $0.00
G0233 PET WHBD MELANOMA; GAMMA CAM O $0.00
G0234 PET WHBD PULM NOD; GAMMA CAM O $0.00
G0235 PET NOT OTHERWISE SPECIFIED 6 $0.00
G0236 DIGITAL FILM CONVERT DIAG MA O $0.00
G0237 THERAPEUTIC PROCD STRG ENDUR 9 $0.00
G0238 OTH RESP PROC, INDIV 9 $0.00
G0239 OTH RESP PROC, GROUP 9 $0.00
G0240 CRITIC CARE BY MD TRANSPORT 9 $0.00
G0241 EACH ADDITIONAL 30 MINUTES 9 $0.00
G0242 MULTISOURCE PHOTON STER PLAN O $0.00
G0243 MULTISOUR PHOTON STERO TREAT O $0.00
G0244 OBSERV CARE BY FACILITY TOPT O $0.00
G0245 INITIAL FOOT EXAM PT LOPS 9 $0.00
G0246 FOLLOWUP EVAL OF FOOT PT LOP 9 $0.00
G0247 ROUTINE FOOTCARE PT W LOPS 9 $0.00

G0248 DEMONSTRATE USE HOME INR MON 9 $0.00
G0249 PROVIDE INR TEST MATER/EQUIP 9 $0.00
G0250 MD INR TEST REVIE INTER MGMT 9 $0.00
G0251 LINEAR ACC BASED STERO RADIO 9 $0.00
G0252 PET IMAGING INITIAL DX 3 $521.95
G0253 PET IMAGE BRST DECTION RECUR O $0.00
G0254 PET IMAGE BRST EVAL TO TX O $0.00
G0255 CURRENT PERCEP THRESHOLD TST 5 $0.00
G0256 PROSTATE BRACHY W PALLADIUM O $0.00
G0257 UNSCHED DIALYSIS ESRD PT HOS 5 $0.00
G0258 IV INFUSION DURING OBS STAY O $0.00
G0259 INJECT FOR SACROILIAC JOINT 5 $0.00
G0260 INJ FOR SACROILIAC JT ANESTH 5 $0.00
G0261 PROSTATE BRACHY W IODINE SEE O $0.00
G0262 SM INTESTINAL IMAGE CAPSULE O $0.00
G0263 ADM WITH CHF, CP, ASTHMA O $0.00
G0264 ASSMT OTR CHF, CP, ASTHMA O $0.00
G0265 CRYOPRESEVATION FREEZE+STORA O $0.00
G0266 THAWING + EXPANSION FROZ CEL O $0.00
G0267 BONE MARROW OR PSC HARVEST O $0.00
G0268 REMOVAL OF IMPACTED WAX MD 9 $0.00
G0269 OCCLUSIVE DEVICE IN VEIN ART 9 $0.00
G0270 MNT SUBS TX FOR CHANGE DX 5 $0.00
G0271 GROUP MNT 2 OR MORE 30 MINS 5 $0.00
G0272 NASO/ORO GASTRIC TUBE PL MD O $0.00
G0273 PRETX PLANNING, NON-HODGKINS O $0.00
G0274 RADIOPHARM TX, NON-HODGKINS O $0.00
G0275 RENAL ANGIO, CARDIAC CATH 3 $13.49
G0278 ILIAC ART ANGIO,CARDIAC CATH 3 $13.85
G0279 EXCORP SHOCK TX, ELBOW EPI O $0.00
G0280 EXCORP SHOCK TX OTHER THAN O $0.00
G0281 ELEC STIM UNATTEND FOR PRESS 5 $0.00
G0282 ELECT STIM WOUND CARE NOT PD 5 $0.00
G0283 ELEC STIM OTHER THAN WOUND 9 $0.00
G0288 RECON, CTA FOR SURG PLAN 3 $234.70
G0289 ARTHRO, LOOSE BODY + CHONDRO 3 $84.90
G0290 DRUG-ELUTING STENTS, SINGLE 5 $0.00
G0291 DRUG-ELUTING STENTS,EACH ADD 5 $0.00
G0292 ADM EXP DRUGS,CLINICAL TRIAL O $0.00
G0293 NON-COV SURG PROC,CLIN TRIAL 9 $0.00
G0294 NON-COV PROC, CLINICAL TRIAL 9 $0.00
G0295 ELECTROMAGNETIC THERAPY ONC 9 $0.00
G0296 PET IMGE RESTAG THYROD CANCE O $0.00
G0297 INSERT SINGLE CHAMBER/CD O $0.00
G0298 INSERT DUAL CHAMBER/CD O $0.00
G0299 INSER/REPOS SINGLE ICD+LEADS O $0.00
G0300 INSERT REPOSIT LEAD DUAL+GEN O $0.00
G0302 PRE-OP SERVICE LVRS COMPLETE 9 $0.00
G0303 PRE-OP SERVICE LVRS 10-15DOS 9 $0.00

G0304 PRE-OP SERVICE LVRS 1-9 DOS 9 $0.00
G0305 POST OP SERVICE LVRS MIN 6 9 $0.00
G0306 CBC/DIFFWBC W/O PLATELET 9 $0.00
G0307 CBC WITHOUT PLATELET 9 $0.00
G0308 ESRD RELATED SVC 4+MO < 2YRS O $0.00
G0309 ESRD RELATED SVC 2-3MO

G0358 IV PUSH EACH ADDITIONAL DRUG O $0.00
G0359 CHEMOTHERAPY IV ONE HR INITI O $0.00
G0360 EACH ADDITIONAL HR 1-8 HRS O $0.00
G0361 PROLONG CHEMO INFUSE>8HRS PU O $0.00
G0362 EACH ADD SEQUENTIAL INFUSION O $0.00
G0363 IRRIGATE IMPLANTED VENOUS DE O $0.00
G0364 BONE MARROW ASPIRATE &BIOPSY 3 $12.24
G0365 VESSEL MAPPING HEMO ACCESS 9 $0.00
G0366 EKG FOR INITIAL PREVENT EXAM O $0.00
G0367 EKG TRACING FOR INITIAL PREV O $0.00
G0368 EKG INTERPRET & REPORT PREVE O $0.00
G0369 SUPPLYING FEE FOR THE INITIAL SUPP O $0.00
G0370 SUPPLYING FEE FOR EACH SUPPLIED PR O $0.00
G0371 DISPENSING FEE FOR A 30 DAY PERIOD O $0.00
G0372 MD SERVICE REQUIRED FOR PMD 9 $0.00
G0374 DISPENSING FEE FOR EACH DISPENSED O $0.00
G0375 SMOKE/TOBACCO COUNSELNG 3-10 O $0.00
G0376 SMOKE/TOBACCO COUNSELING >10 O $0.00
G0377 ADMINISTRA PART D VACCINE 9 $0.00
G0378 HOSPITAL OBSERVATION PER HR 9 $0.00
G0379 DIRECT REFER HOSPITAL OBSERV 9 $0.00
G0380 LEV 1 HOSP TYPE B ED VISIT 9 $0.00
G0381 LEV 2 HOSP TYPE B ED VISIT 9 $0.00
G0382 LEV 3 HOSP TYPE B ED VISIT 9 $0.00
G0383 LEV 4 HOSP TYPE B ED VISIT 9 $0.00
G0384 LEV 5 HOSP TYPE B ED VISIT 9 $0.00
G0389 ULTRASOUND EXAM AAA SCREEN 6 $0.00
G0390 TRAUMA RESPONS W/HOSP CRITI 9 $0.00
G0392 AV FISTULA OR GRAFT ARTERIAL O $0.00
G0393 AV FISTULA OR GRAFT VENOUS O $0.00
G0394 BLOOD OCCULT TEST,COLORECTAL O $0.00
G0396 ALCOHOL/SUBS INTERV 15-30MN 9 $0.00
G0397 ALCOHOL/SUBS INTERV >30 MIN 9 $0.00
G0398 HOME SLEEP TEST/TYPE 2 PORTA 9 $0.00
G0399 HOME SLEEP TEST/TYPE 3 PORTA 9 $0.00
G0400 HOME SLEEP TEST/TYPE 4 PORTA 9 $0.00
G0402 INITIAL PREVENTIVE EXAM 9 $0.00
G0403 EKG FOR INITIAL PREVENT EXAM 9 $0.00
G0404 EKG TRACING FOR INITIAL PREV 9 $0.00
G0405 EKG INTERPRET & REPORT PREVE 9 $0.00
G0406 TELHEALTH INPT CONSULT 15MIN 9 $0.00
G0407 TELHEATH INPT CONSULT 25MIN 9 $0.00
G0408 TELHEALTH INPT CONSULT 35MIN 9 $0.00
G0409 CORF RELATED SERV 15 MINS EA 9 $0.00
G0410 GRP PSYCH PARTIAL HOSP 45-50 9 $0.00
G0411 INTER ACTIVE GRP PSYCH PARTI 9 $0.00
G0412 OPEN TX ILIAC SPINE UNI/BIL 9 $0.00
G0413 PELVIC RING FRACTURE UNI/BIL 9 $0.00
G0414 PELVIC RING FX TREAT INT FIX 9 $0.00

G0415 OPEN TX POST PELVIC FXCTURE 9 $0.00
G0416 SAT BIOPSY PROSTATE 1-20 SPC 6 $0.00
G0417 SAT BIOPSY PROSTATE 21-40 6 $0.00
G0418 SAT BIOPSY PROSTATE 41-60 6 $0.00
G0419 SAT BIOPSY PROSTATE: >60 6 $0.00
G0420 ED SVC CKD IND PER SESSION 9 $0.00
G0421 ED SVC CKD GRP PER SESSION 9 $0.00
G0422 INTENS CARDIAC REHAB W/EXERC 9 $0.00
G0423 INTENS CARDIAC REHAB NO EXER 9 $0.00
G0424 PULMONARY REHAB W EXER 9 $0.00
G0425 INPT TELEHEALTH CONSULT 30M 9 $0.00
G0426 INPT TELEHEALTH CONSULT 50M 9 $0.00
G0427 INPT TELEHEALTH CON 70/>M 9 $0.00
G0430 DRUG SCREEN MULTI CLASS 9 $0.00
G0431 DRUG SCREEN SINGLE CLASS 9 $0.00
G3001 ADMIN + SUPPLY, TOSITUMOMAB 6 $0.00
G8006 AMI PT RECD ASPIRIN AT ARRIV 9 $0.00
G8007 AMI PT DID NOT RECEIV ASPIRI 9 $0.00
G8008 AMI PT INELIGIBLE FOR ASPIRI 9 $0.00
G8009 AMI PT RECD BBLOCK AT ARR 9 $0.00
G8010 AMI PT DID NOT REC BBLOCK 9 $0.00
G8011 AMI PT INELIG BBLOC AT ARRIV 9 $0.00
G8012 PNEUM PT RECV ANTIBIOTIC 4 H 9 $0.00
G8013 PNEUM PT W/O ANTIBIOTIC 4 HR 9 $0.00
G8014 PNEUM PT NOT ELIG ANTIBIOTIC 9 $0.00
G8015 DIABETIC PT W/ HBA1C>9% 9 $0.00
G8016 DIABETIC PT W/ HBA1C= 100MG/DL 9 $0.00
G8020 DIAB PT W/LDL< 100MG/DL 9 $0.00
G8021 DIAB PT INELIG FOR LDL MEAS 9 $0.00
G8022 CARE NOT PROVIDED FOR LDL 9 $0.00
G8023 DM PT W BP>=140/80 9 $0.00
G8024 DIABETIC PT WBP

G8039 CAD PT W/LDL>100MG/DL 9 $0.00
G8040 CAD PT W/LDL=65% 9 $0.00
G8076 ESRD PT W/ DIALY OF URROR=33 9 $0.00
G8079 ESRD PT W/HCT

G8153 PT NOT DOC FOR AB 1 HR PRIOR 9 $0.00
G8154 PT INELIGI FOR AB THERAPY 9 $0.00
G8155 PT RECD THROMBOEMB PROPHYLAX 9 $0.00
G8156 PT DID NOT REC THROMBOEMBO 9 $0.00
G8157 PT INELIGI FOR THROMBOLISM 9 $0.00
G8158 PT RECD CABG W/ IMA O $0.00
G8159 PT W/CABG W/O IMA 9 $0.00
G8160 PT INELIG FOR CABG W/IMA O $0.00
G8161 ISO CABG PT REC PREOP BBLOCK O $0.00
G8162 ISO CABG PT W/O PREOP BBLOCK 9 $0.00
G8163 ISO CABG PT INELIG FOR PREO O $0.00
G8164 ISO CABG PT W/PROLNG INTUB 9 $0.00
G8165 ISO CABG PT W/O PROLNG INTUB 9 $0.00
G8166 ISO CABG REQ SURG REXPO 9 $0.00
G8167 ISO CABG W/O SURG EXPLO 9 $0.00
G8170 CEA/EXT BYPASS PT ON ASPIRIN 9 $0.00
G8171 PT W/CAROT ENDARCT/EXT BYPAS 9 $0.00
G8172 CEA/EXT BYPASS PT NOT ON ASP 9 $0.00
G8182 CAD PT CARE NOT PROV LDL 9 $0.00
G8183 HF/ATRIAL FIB PT ON WARFARIN 9 $0.00
G8184 HF/ATRIAL FIB PT INELIG WARF 9 $0.00
G8185 OSTEOARTH PT W/ ASSESS PAIN 9 $0.00
G8186 OSTEOARTH PT INELIG ASSESS 9 $0.00
G8191 ANTIBIOTIC GIVEN PRIOR SURG O $0.00
G8192 ANTIB GIVEN PRIOR SURG INCIS O $0.00
G8193 ANTIBIO NOT DOC PRIOR SURG 9 $0.00
G8194 PT NOT ELIG FOR ANTIBIOTIC O $0.00
G8195 ANTIBIOTIC GIVEN PRIOR SURG O $0.00
G8196 ANTIBIO NOT DOCUM PRIOR SURG 9 $0.00
G8197 ANTIB ORDER PRIOR TO SURG O $0.00
G8198 CEFAZOLIN DOCUMENTED ORDERED O $0.00
G8199 CEFAZOLIN GIVEN PROPHYLAXIS O $0.00
G8200 CEFAZOLIN NOT DOCUM PROPHY 9 $0.00
G8201 PT NOT ELIGI FOR CEFAZOLIN O $0.00
G8202 ORDER GIVEN TO D/C ANTIBIO O $0.00
G8203 ANTIB WAS D/C 24HRS SURG TIM O $0.00
G8204 MD NOT DOC ORDER TO D/C ANTI 9 $0.00
G8205 PT NOT ELIGI FOR PROPH ANTIB O $0.00
G8206 MD DOC PROPHYLACTIC AB GIVEN O $0.00
G8207 CLINI DOC ORDER TO D/C ANTIB O $0.00
G8208 CLINI DOC AB WAS D/C 48 H O $0.00
G8209 CLINICIAN DID NOT DOC 9 $0.00
G8210 CLINI DOC PT INELIGIB ANTI O $0.00
G8211 CLINI DOC PROPH AB GIV O $0.00
G8212 CLINI ORDER GIVEN FOR VTE O $0.00
G8213 CLINI GIVEN VTE PROP O $0.00
G8214 CLINI NOT DOC ORDER VTE 9 $0.00
G8215 CLINI DOC PT INELIG VTE O $0.00
G8216 PT RECEIVED DVT PROPHYLAXIS O $0.00

G8217 PT NOT RECEIVED DVT PROPH 9 $0.00
G8218 PT INELIG DVT PROPHYLAXIS O $0.00
G8219 RECEIVED DVT PROPH DAY 2 9 $0.00
G8220 PT NOT REC DVT PROPH DAY 2 9 $0.00
G8221 PT INELIG FOR DVT PROPH 9 $0.00
G8222 PT PRESCRIBE PLATELET AT D/C O $0.00
G8223 PT NOT DOC FOR PRESC ANTIPLA 9 $0.00
G8224 PT INELIG FOR ANTIPLAT PROPH O $0.00
G8225 PT PRESCRIB ANTICOAG AT D/C O $0.00
G8226 PT NO PRESCR ANTICOA AT D/C 9 $0.00
G8227 PT NOT DOC TO HAVE PERM/AF O $0.00
G8228 CLIN PT INELIG ANTICOAG D/C O $0.00
G8229 PT DOC TO HAVE ADMIN T-PA O $0.00
G8230 PT INELIG T-PA ISCH STROK>3H O $0.00
G8231 PT NOT DOC FOR ADMIN T-PA 9 $0.00
G8232 PT RECEIVED DYSPHAGIA SCREEN O $0.00
G8234 PT NOT DOC DYSPHAGIA SCREEN 9 $0.00
G8235 PT RECEIVED NPO O $0.00
G8236 PT INELIG DYSPHAGIA SCREEN O $0.00
G8237 PT DOC REC REHAB SERV O $0.00
G8238 PT NOT DOC TO REC REHAB SERV 9 $0.00
G8239 INTER CAROTID STENOSIS

G8268 PT NOT DOC REC CARE URIN INC 9 $0.00
G8269 CLIN NOT PROV CARE URIN INCO O $0.00
G8270 PT RECEIV SCREEN FOR FALL O $0.00
G8271 PT NO DOC SCREEN FALL 9 $0.00
G8272 CLIN DOC PT INELIG FALL RISK O $0.00
G8273 CLIN NOT PROV CARE SCRE FALL O $0.00
G8274 CLINI NOT DOC PRES/ABS ALARM 9 $0.00
G8275 PT HX W/ NEW MOLES O $0.00
G8276 PT NOT DOC MOLE CHANGE 9 $0.00
G8277 PT INELIG FOR ASSESS MOLE O $0.00
G8278 PT DOC REC PE SKIN O $0.00
G8279 PT NOT DOC REC PE 9 $0.00
G8280 PT INELIG PE SKIN O $0.00
G8281 PT REC COUNSEL FOR SELF-EXAM O $0.00
G8282 PT NOT DOC TO REC COUNS 9 $0.00
G8283 PT INELIG FOR COUNSEL O $0.00
G8284 PT DOC TO REC PRES OSTEO O $0.00
G8285 PT DID NOT REC PRES OSTEO 9 $0.00
G8286 PT INELIG TO REC PRES OSTEO O $0.00
G8287 CLIN NOT PROV CARE FOR PHARM O $0.00
G8288 PT DOC REC CA/VIT D O $0.00
G8289 PT NOT DOC REC CA/VIT D 9 $0.00
G8290 CLIN DOC PT INELIG CA/VIT D O $0.00
G8291 CLIN NO PRO CARE PT CA/VIT D O $0.00
G8292 COPD PT W/SPIR RESULTS O $0.00
G8293 COPD PT W/O SPIR RESULTS 9 $0.00
G8294 COPD PT INELIG SPIR RESULTS O $0.00
G8295 COPD PT DOC BRONCH THER O $0.00
G8296 COPD PT NOT DOC BRONCH THER 9 $0.00
G8297 COPD PT INELIG BRONCH THERAP O $0.00
G8298 PT DOC OPTIC NERVE EVAL 9 $0.00
G8299 PT NOT DOC OPTIC NERV EVAL 9 $0.00
G8300 PT INELIG FOR OPTIC NERV EVA O $0.00
G8301 CLIN NOT PROV CARE POAG O $0.00
G8302 PT DOC W/ TARGET IOP 9 $0.00
G8303 PT NOT DOC W/ IOP 9 $0.00
G8304 CLIN DOC PT INELIG IOP 9 $0.00
G8305 CLIN NOT PROV CARE POAG 9 $0.00
G8306 POAG W/ IOP REC CARE PLAN 9 $0.00
G8307 POAG W/ IOP NO CARE PLAN 9 $0.00
G8308 POAG W/ IOP NOT DOC PLAN 9 $0.00
G8309 PT DOC REC ANTIOXIDANT O $0.00
G8310 PT NOT DOC REC ANTIOX 9 $0.00
G8311 PT INELIG FOR ANTIOXIDANT O $0.00
G8312 CLIN NO PROV CARE FOR ANTIOX O $0.00
G8313 PT DOC REC MACULAR EXAM O $0.00
G8314 PT NOT DOC TO REC MAC EXAM 9 $0.00
G8315 CLIN DOC PT INELIG MAC EXAM O $0.00
G8316 CLIN NO PRO CARE FOR MAC DEG O $0.00

G8317 PT DOC TO HAVE VISUAL FUNC O $0.00
G8318 PT DOC NOT HAVE VISUAL FUNC 9 $0.00
G8319 PT INELIG FOR VIS FUNC STAT O $0.00
G8320 CLIN NOT PROV CARE CATARAC O $0.00
G8321 PT DOC TO PRE AXIAL LENG O $0.00
G8322 PT NOT DOC PRE AXIAL LENG 9 $0.00
G8323 PT INELIG FOR PRE SURG AXIAL O $0.00
G8324 CLIN NOT PROV CARE FOR IOL O $0.00
G8325 PT REC FUND EXAM PRIOR SURG O $0.00
G8326 PT NOT DOC REC FUNDUS EXAM 9 $0.00
G8327 PT INELIG FOR PRE SURG FUNDU O $0.00
G8328 CLIN NOT PROV CARE FUND EVAL O $0.00
G8329 PT DOC REC DILATED MACULAR O $0.00
G8330 PT NOT DOC REC DILATED MAC 9 $0.00
G8331 PT INELIG DILATE FUNDUS O $0.00
G8332 CLIN PROV NO CARE DIABETIC R O $0.00
G8333 PT DOC TO HAVE MACULAR EXAM O $0.00
G8334 DOC OF MACULAR NOT GIV MD 9 $0.00
G8335 CLIN DOC PT INELIG MACULAR O $0.00
G8336 CLIN DID NOT PRO CARE DIABET O $0.00
G8337 CLIN DOC PT WAS TEST OSTEO O $0.00
G8338 CLIN NOT DOC PT TEST OSTEO 9 $0.00
G8339 PT INELIG FOR TEST OSTEO O $0.00
G8340 PT DOC HAVE DEXA O $0.00
G8341 PT NOT DOC FOR DEXA 9 $0.00
G8342 CLIN DOC PT INELIG DEXA O $0.00
G8343 CLIN NOT PROV CARE DEXA O $0.00
G8344 PT DOC HAVE DEXA PERFORM O $0.00
G8345 PT NOT DOC HAVE DEXA 9 $0.00
G8346 CLIN DOC PT INELIG DEXA O $0.00
G8347 CLIN NOT PROV CARE DEXA O $0.00
G8348 INT CAROTID STENOSIS MEAS 9 $0.00
G8349 PT INELIG FOR DOC OF ALARM 9 $0.00
G8350 PT DOC 12 LEAD ECG 9 $0.00
G8351 PT NOT DOC ECG 9 $0.00
G8352 PT INELIG FOR ECG 9 $0.00
G8353 PT DOC REC ASPIRIN 24HRS ER 9 $0.00
G8354 PT NOT REC ASPIRIN PRIOR ER 9 $0.00
G8355 CLIN DOC PT INELIG ASPIRIN 9 $0.00
G8356 PT DOC TO HAVE ECG 9 $0.00
G8357 PT NOT DOC TO HAVE ECG 9 $0.00
G8358 CLIN DOC PT INELIG ECG 9 $0.00
G8359 PT DOC VITAL SIGNS RECORDED 9 $0.00
G8360 PT NOT DOC VITAL SIGNS RECOR 9 $0.00
G8361 PT DOC TO HAVE 02 SAT ASSESS 9 $0.00
G8362 PT NOT DOC 02 SAT ASSESS 9 $0.00
G8363 CLIN DOC PT INELIG 02 SAT 9 $0.00
G8364 PT DOC MENTAL STATUS ASSESS 9 $0.00
G8365 PT NOT DOC MENTAL STATUS 9 $0.00

G8366 PT DOC TO HAVE EMPIRIC AB 9 $0.00
G8367 PT NOT DOC HAVE EMPIRIC AB 9 $0.00
G8368 CLIN DOC PT INELIG EMPIRI AB 9 $0.00
G8370 ASTHMA PT W SURVEY NOT DOCUM 9 $0.00
G8371 CHEMOTHER NOT REC STG3 COLON 9 $0.00
G8372 CHEMOTHER REC STG3 COLON CA 9 $0.00
G8373 CHEMO PLAN DOCUMEN PRIOR CHE 9 $0.00
G8374 CHEMO PLAN NOT DOC PRIOR CHE 9 $0.00
G8375 CLL PT W/O DOC FLOW CYTOMETR 9 $0.00
G8376 BRST CA PT INELIG TAMOXIFEN 9 $0.00
G8377 MD DOC COLON CA PT INELIG CH 9 $0.00
G8378 MD DOC PT INELIG RADIATION 9 $0.00
G8379 DOC RADIAT TX RECOM 12MO OV 9 $0.00
G8380 PT W STGIC-3BRST CA NOT REC 9 $0.00
G8381 PT W STGIC-3BRST CA REC TAM 9 $0.00
G8382 MM PT W/O DOC IV BISPHOPHON 9 $0.00
G8383 NO DOC RADIATION REC 12MO OV 9 $0.00
G8384 BASE CYTOGEN TEST MDS NOTPER 9 $0.00
G8385 DIABET PT NO DO HGB A1C 12M 9 $0.00
G8386 DIABET PT NODOC LDLIPROTEI 9 $0.00
G8387 ESRD PT W HCT/HGB NOT DOCUME 9 $0.00
G8388 ESRD PT W URR/KTV NOTDOC ELI 9 $0.00
G8389 MDS PT NO DOC FE ST PRIO EPO 9 $0.00
G8390 DIABETIC W/O DOCUMENT BP 12M 9 $0.00
G8391 PT W ASTHMA NO DOC MED OR TX 9 $0.00
G8395 LVEF>=40% DOC NORMAL OR MILD 9 $0.00
G8396 LVEF NOT PERFORMED 9 $0.00
G8397 DIL MACULA/FUNDUS EXAM/W DOC 9 $0.00
G8398 DIL MACULAR/FUNDUS NOT PERFO 9 $0.00
G8399 PT W/DXA DOCUMENT OR ORDER 9 $0.00
G8400 PT W/DXA NO DOCUMENT OR ORDE 9 $0.00
G8401 PT INELIG OSTEO SCREEN MEASU 9 $0.00
G8402 SMOKE PREVEN INTERVEN COUNSE 9 $0.00
G8403 SMOKE PREVEN NOCOUNSEL 9 $0.00
G8404 LOW EXTEMITY NEUR EXAM DOCUM 9 $0.00
G8405 LOW EXTEMITY NEUR NOT PERFOR 9 $0.00
G8406 PT INELIG LOWER EXTREM NEURO 9 $0.00
G8407 ABI DOCUMENTED 9 $0.00
G8408 ABI NOT DOCUMENTED 9 $0.00
G8409 PT INELIG FOR ABI MEASURE 9 $0.00
G8410 EVAL ON FOOT DOCUMENTED 9 $0.00
G8415 EVAL ON FOOT NOT PERFORMED 9 $0.00
G8416 PT INELIG FOOTWEAR EVALUATIO 9 $0.00
G8417 CALC BMI ABV UP PARAM F/U 9 $0.00
G8418 CALC BMI BLW LOW PARAM F/U 9 $0.00
G8419 CALC BMI OUT NRM PARAM NOF/U 9 $0.00
G8420 CALC BMI NORM PARAMETERS 9 $0.00
G8421 BMI NOT CALCULATED 9 $0.00
G8422 PT INELIG BMI CALCULATION 9 $0.00

G8423 PT SCREEN FLU VAC & COUNSEL 9 $0.00
G8424 FLU VACCINE NOT SCREEN 9 $0.00
G8425 FLU VACCINE SCREEN NOT CURRE 9 $0.00
G8426 PT NOT APPROP SCREEN & COUNC 9 $0.00
G8427 DOC MEDS VERIFIED W/PT OR RE 9 $0.00
G8428 MEDS DOCUMENT W/O VERIFICA 9 $0.00
G8429 INCOMPLETE DOC PT ON MEDS 9 $0.00
G8430 PT INELIG MED CHECK 9 $0.00
G8431 POS CLIN DEPRES SCRN F/U DOC 9 $0.00
G8432 CLIN DEPRESSION SCREEN NOT D 9 $0.00
G8433 PT INELIG; SCRN CLIN DEP 9 $0.00
G8434 COGNITIVE IMPAIRMENT SCREEN 9 $0.00
G8435 COGNITIVE SCREEN NOT DOCUMEN 9 $0.00
G8436 PT INELIG FOR COGNITIVE IMPA 9 $0.00
G8437 CARE PLAN DEVELOP & DOCUMENT 9 $0.00
G8438 PT INELIG FOR DEVLP CARE PLN 9 $0.00
G8439 CARE PLAN DEVELP & NOT DOCUM 9 $0.00
G8440 PAIN ASSESS F/U PLN DOCUMENT 9 $0.00
G8441 NO DOCUMENT OF PAIN ASSESS 9 $0.00
G8442 PT INELIG PAIN ASSESSMENT 9 $0.00
G8443 PRESCRIPTION BY E-PRESCRIB S 9 $0.00
G8445 PRESCRIP NOT GEN AT ENCOUNTE 9 $0.00
G8446 SOME PRESCRIB PRINT OR CALL 9 $0.00
G8447 PT VIS DOC USE CCHIT CER EHR 9 $0.00
G8448 PT VIS DOC W/NON-CCHIT EHR 9 $0.00
G8449 PT NOT DOC W/EMR DUE TO SYST 9 $0.00
G8450 BETA-BLOC RX PT W/ABN LVEF 9 $0.00
G8451 PT W/ABN LVEF INELIG B-BLOC 9 $0.00
G8452 PT W/ABN LVEF B-BLOC NO RX 9 $0.00
G8453 TOB USE CESS INT COUNSEL 9 $0.00
G8454 TOB USE CESS INT NO COUNSEL 9 $0.00
G8455 CURRENT TOBACCO SMOKER 9 $0.00
G8456 CURRENT SMKLESS TOBACCO USER 9 $0.00
G8457 CUR TOBACCO NON-USER 9 $0.00
G8458 PT INELIG GENO NO ANTVIR TX 9 $0.00
G8459 DOC PT REC ANTIVIR TREAT 9 $0.00
G8460 PT INELIG RNA NO ANTVIR TX 9 $0.00
G8461 PT REC ANTIVIR TREAT HEP C 9 $0.00
G8462 PT INELIG COUNS NO ANTVIR TX 9 $0.00
G8463 PT REC ANTIVIRAL TREAT DOC 9 $0.00
G8464 PT INELIG; LO TO NO DTER RSK 9 $0.00
G8465 HIGH RISK RECURRENCE PRO CA 9 $0.00
G8466 PT INELIG SUIC; MDD REMIS 9 $0.00
G8467 NEW DX INIT/REC EPISODE MDD 9 $0.00
G8468 ACE/ARB RX PT W/ABN LVEF 9 $0.00
G8469 PT W/ABN LVEF INELIG ACE/ARB 9 $0.00
G8470 PT W/ NORMAL LVEF 9 $0.00
G8471 LVEF NOT PERFORMED/DOC 9 $0.00
G8472 ACE/ARB NO RX PT W/ABN LVEF 9 $0.00

G8473 ACE/ARB THXPY RX'D 9 $0.00
G8474 ACE/ARB NOT RX'D; DOC REAS 9 $0.00
G8475 ACE/ARB THXPY NOT RX'D 9 $0.00
G8476 BP SYS =80 9 $0.00
G8478 BP NOT PERFORMED/DOC 9 $0.00
G8479 MD RX'D ACE/ARB THXPY 9 $0.00
G8480 PT INELIG ACE/ARB THXPY 9 $0.00
G8481 MD NOT RX'D ACE/ARB THXPY 9 $0.00
G8482 FLU IMMUNIZE ORDER/ADMIN 9 $0.00
G8483 FLU IMM NO ORD/ADMIN DOC REA 9 $0.00
G8484 FLU IMMUNIZE NO ORDER/ADMIN 9 $0.00
G8485 REPORT, DIABETES MEASURES 9 $0.00
G8486 REPORT, PREV CARE MEASURES 9 $0.00
G8487 REPORT CKD MEASURES 9 $0.00
G8488 REPORT ESRD MEASURES 9 $0.00
G8489 CAD MEASURES GRP 9 $0.00
G8490 RA MEASURES GRP 9 $0.00
G8491 HIV/AIDS MEASURES GRP 9 $0.00
G8492 PERIOP CARE MEASURES GRP 9 $0.00
G8493 BACK PAIN MEASURES GRP 9 $0.00
G8494 DM MEAS QUAL ACT PERFORM 9 $0.00
G8495 CKD MEAS QUAL ACT PERFORM 9 $0.00
G8496 PREV CARE MG QUAL ACT PERFRM 9 $0.00
G8497 CABG MEAS QUAL ACT PERFORM 9 $0.00
G8498 CAD MEAS QUAL ACT PERFORM 9 $0.00
G8499 RA MEAS QUAL ACT PERFORM 9 $0.00
G8500 HIV MEAS QUAL ACT PERFORM 9 $0.00
G8501 PERIO MEAS QUAL ACT PERFORM 9 $0.00
G8502 BACK PAIN MG QUAL ACT PERFRM 9 $0.00
G8503 DOC PROPH ANTIBX W/IN 1 HR O $0.00
G8504 DOC ORD PRO ANTBX W/IN 1 HR O $0.00
G8505 NO DOC PROPH ANTIBX W/IN 1HR O $0.00
G8506 PT REC ACE/ARB 9 $0.00
G8507 PT INELIG PT VERIF MEDS 9 $0.00
G8508 PT INELIG; PAIN ASSES NO F/U 9 $0.00
G8509 PAIN ASSESS NO F/U PLN DOC 9 $0.00
G8510 PT INELIG NEG SCRN DEPRES 9 $0.00
G8511 CLIN DEPRES SCRN NO F/U DOC 9 $0.00
G8512 PAIN SEV QUANT PRESENT O $0.00
G8513 ABI MEAS & DOC O $0.00
G8514 PT INELIG; ABI MEASURE O $0.00
G8515 NO ABI MEASUREMENT O $0.00
G8516 SCRN FAL RSK >2 FAL OR W/INJ O $0.00
G8517 SCRN FALL RSK;

G8522 PT INELIG; ANTIPLT THERAPY O $0.00
G8523 ANTPLT NOT RECD REAS NO SPEC O $0.00
G8524 PATCH CLOSURE CONV CEA 9 $0.00
G8525 NO PATCH CLOSURE CEA 9 $0.00
G8526 NO PATCH CLOSURE CONV CEA 9 $0.00
G8527 DOC ORD ANTIMIC PROPHY O $0.00
G8528 PT INELIG; PROPH ANTIBIOT O $0.00
G8529 NO DOC ORD ANTIMIC PROPHY O $0.00
G8530 AUTO AV FISTULA RECD 9 $0.00
G8531 PT INELIG; AUTO AV FISTULA 9 $0.00
G8532 NO AUTO AV FISTULA; NO REAS 9 $0.00
G8533 PARTIC IN CLIN DATA BASE REG O $0.00
G8534 DOC ELDER MAL SCRN F/U PLAN 9 $0.00
G8535 PT INELIG NO ELD MAL SCRN 9 $0.00
G8536 NO DOC ELDER MAL SCRN 9 $0.00
G8537 PT INELIG ELDMAL SCRN NO F/U 9 $0.00
G8538 ELD MAL SCRN NO F/U PLN 9 $0.00
G8539 CUR FUNCT ASSESS & CARE PLN 9 $0.00
G8540 PT INELIG FUNCT ASSESS 9 $0.00
G8541 NO DOC CUR FUNCT ASSESS 9 $0.00
G8542 PT INELIG FUNC ASSES NO PLN 9 $0.00
G8543 CUR FUNCT ASSES; NO CARE PLN 9 $0.00
G8544 CABG MEASURES GRP 9 $0.00
G8545 HEPC MEASURES GRP 9 $0.00
G8546 CAP MEASURES GRP 9 $0.00
G8547 IVD MEASURES GRP 9 $0.00
G8548 HF MEASURES GRP 9 $0.00
G8549 HEPC MG QUAL ACT PERFORM 9 $0.00
G8550 CAP MG QUAL ACT PERFORM 9 $0.00
G8551 HF MG QUAL ACT PERFORM 9 $0.00
G8552 IVD MG QUAL ACT PERFORM 9 $0.00
G8553 1 RX VIA QUALIFIED ERX SYS 9 $0.00
G8556 REF TO DOC OTOLOG EVAL 9 $0.00
G8557 PT INELIG REF OTOLOG EVAL 9 $0.00
G8558 NO REF TO DOC OTOLOG EVAL 9 $0.00
G8559 PT REF DOC OTO EVAL 9 $0.00
G8560 PT HX ACT DRAIN PREV 90 DAYS 9 $0.00
G8561 PT INELIG FOR REF OTO EVAL 9 $0.00
G8562 PT NO HX ACT DRAIN 90 D 9 $0.00
G8563 PT NO REF OTO REAS NO SPEC 9 $0.00
G8564 PT REF OTO EVAL 9 $0.00
G8565 VER DOC HEAR LOSS 9 $0.00
G8566 PT INELIG REF OTO EVAL 9 $0.00
G8567 PT NO DOC HEAR LOSS 9 $0.00
G8568 PT NO REF OTOLO NO SPEC 9 $0.00
G8569 PROL INTUBATION REQ 9 $0.00
G8570 NO PROL INTUB REQ 9 $0.00
G8571 STER WD IFX 30 D POSTOP 9 $0.00
G8572 NO STER WD IFX 9 $0.00

G8573 STK/CVA CABG 9 $0.00
G8574 NO STRK/CVA CABG 9 $0.00
G8575 POSTOP REN INSUF 9 $0.00
G8576 NO POSTOP REN INSUF 9 $0.00
G8577 REOP REQ BLD GRFT OTH 9 $0.00
G8578 NO REOP REQ BLD GRFT OTH 9 $0.00
G8579 ANTPLT MED DISCH 9 $0.00
G8580 ANTPLT MED CONTRAIND 9 $0.00
G8581 NO ANTPLT MED DISCH 9 $0.00
G8582 BBLOCK DISCH 9 $0.00
G8583 BBLOCK CONTRAIND 9 $0.00
G8584 NO BBLOCK DISCH 9 $0.00
G8585 ANTILIPID TREAT DISCH 9 $0.00
G8586 ANTLIP DISCH CONTRA 9 $0.00
G8587 NO ANTLIPID TREAT DISCH 9 $0.00
G8588 SYS BP = 140 9 $0.00
G8590 DIA BP < 90 9 $0.00
G8591 DIA BP >= 90 9 $0.00
G8592 NO BP MEASURE 9 $0.00
G8593 LIPID PN RESULTS 9 $0.00
G8594 NO LIPID PROF PERF 9 $0.00
G8595 LDL < 100 9 $0.00
G8596 NO LDL PERF 9 $0.00
G8597 LDL >= 100 9 $0.00
G8598 ASP THERP USED 9 $0.00
G8599 NO ASP THERP USED 9 $0.00
G8600 TPA INITI W/IN 3 HRS 9 $0.00
G8601 NO ELIG TPA INIT W/IN 3 HRS 9 $0.00
G8602 NO TPA INIT W/IN 3 HRS 9 $0.00
G8603 SPOK LANG COMP SCORE 9 $0.00
G8604 NO HIGH SCORE SPOK LANG 9 $0.00
G8605 NO SPOK LANG COMP SCORE 9 $0.00
G8606 ATTENTION SCORE 9 $0.00
G8607 NO HIGH SCORE ATTENTION 9 $0.00
G8608 NO ATTENTION SCORE 9 $0.00
G8609 MEMORY SCORE 9 $0.00
G8610 NO HIGH SCORE MEMORY 9 $0.00
G8611 NO MEMORY SCORE 9 $0.00
G8612 MOTO SPEECH SCORE 9 $0.00
G8613 NO HIGH SCORE MOTO SPEECH 9 $0.00
G8614 NO MOTO SPEECH SCORE 9 $0.00
G8615 READING SCORE 9 $0.00
G8616 NO HIGH SCORE READING 9 $0.00
G8617 NO READING SCORE 9 $0.00
G8618 SPOK LANG EXP SCORE 9 $0.00
G8619 NO HIGH SCORE SPOK LANG EXP 9 $0.00
G8620 NO SPOK LANG EXP SCORE 9 $0.00
G8621 WRITING SCORE 9 $0.00

G8622 NO HIGH SCORE WRITING 9 $0.00
G8623 NO WRITING SCORE 9 $0.00
G8624 SWALLOWING SCORE 9 $0.00
G8625 NO HIGH SCORE SWALLOWING 9 $0.00
G8626 NO SWALLOWING SCORE 9 $0.00
G8627 SURG PROC W/IN 30 DAYS 9 $0.00
G8628 NO SURG PROC W/IN 30 DAYS 9 $0.00
G9001 MCCD, INITIAL RATE 7 $0.00
G9002 MCCD,MAINTENANCE RATE 7 $0.00
G9003 MCCD, RISK ADJ HI, INITIAL 9 $0.00
G9004 MCCD, RISK ADJ LO, INITIAL 9 $0.00
G9005 MCCD, RISK ADJ, MAINTENANCE 7 $0.00
G9006 MCCD, HOME MONITORING 7 $0.00
G9007 MCCD, SCH TEAM CONF 7 $0.00
G9008 MCCD,PHYS COOR-CARE OVRSGHT 7 $0.00
G9009 MCCD, RISK ADJ, LEVEL 3 7 $0.00
G9010 MCCD, RISK ADJ, LEVEL 4 9 $0.00
G9011 MCCD, RISK ADJ, LEVEL 5 7 $0.00
G9012 OTHER SPECIFIED CASE MGMT 7 $0.00
G9013 ESRD DEMO BUNDLE LEVEL I 9 $0.00
G9014 ESRD DEMO BUNDLE-LEVEL II 9 $0.00
G9016 DEMO-SMOKING CESSATION COUN 9 $0.00
G9017 AMANTADINE HCL 100MG ORAL 9 $0.00
G9018 ZANAMIVIR,INHALATION PWD 10M 9 $0.00
G9019 OSELTAMIVIR PHOSPHATE 75MG 9 $0.00
G9020 RIMANTADINE HCL 100MG ORAL 9 $0.00
G9021 CHEMOTHERAPY ASSESSMENT FOR NAUSEA O $0.00
G9022 CHEMOTHERAPY ASSESSMENT FOR NAUSEA O $0.00
G9023 CHEMOTHERAPY ASSESSMENT FOR NAUSEA O $0.00
G9024 CHEMOTHERAPY ASSESSMENT FOR NAUSEA O $0.00
G9025 CHEMOTHERAPY ASSESSMENT FOR PAIN O $0.00
G9026 CHEMOTHERAPY ASSESSMENT FOR PAIN O $0.00
G9027 CHEMOTHERAPY ASSESSMENT FOR PAIN O $0.00
G9028 CHEMOTHERAPY ASSESSMENT FOR PAIN O $0.00
G9029 CHEMOTHERAPY ASSESSMENT FOR LACK O O $0.00
G9030 CHEMOTHERAPY ASSESSMENT FOR LACK O O $0.00
G9031 CHEMOTHERAPY ASSESSMENT FOR LACK O O $0.00
G9032 CHEMOTHERAPY ASSESSMENT FOR LACK O O $0.00
G9033 AMANTADINE HCL ORAL BRAND 9 $0.00
G9034 ZANAMIVIR, INH PWDR, BRAND 9 $0.00
G9035 OSELTAMIVIR PHOSP, BRAND 9 $0.00
G9036 RIMANTADINE HCL, BRAND 9 $0.00
G9037 SERVICES PROVIDED BY REHABILITATIO 9 $0.00
G9041 LOW VISION REHAB OCCUPATIONA 9 $0.00
G9042 LOW VISION REHAB ORIENT/MOBI 9 $0.00
G9043 LOW VISION LOWVISION THERAPI 9 $0.00
G9044 LOW VISION REHABILATE TEACHE 9 $0.00
G9050 ONCOLOGY WORK-UP EVALUATION 9 $0.00
G9051 ONCOLOGY TX DECISION-MGMT 9 $0.00

G9052 ONC SURVEILLANCE FOR DISEASE 9 $0.00
G9053 ONC EXPECTANT MANAGEMENT PT 9 $0.00
G9054 ONC SUPERVISION PALLIATIVE 9 $0.00
G9055 ONC VISIT UNSPECIFIED NOS 9 $0.00
G9056 ONC PRAC MGMT ADHERES GUIDE 9 $0.00
G9057 ONC PRACT MGMT DIFFERS TRIAL 9 $0.00
G9058 ONC PRAC MGMT DISAGREE W/GUI 9 $0.00
G9059 ONC PRAC MGMT PT OPT ALTERNA 9 $0.00
G9060 ONC PRAC MGMT DIF PT COMORB 9 $0.00
G9061 ONC PRAC COND NOADD BY GUIDE 9 $0.00
G9062 ONC PRAC GUIDE DIFFERS NOS 9 $0.00
G9063 ONC DX NSCLC STGI NO PROGRES 9 $0.00
G9064 ONC DX NSCLC STG2 NO PROGRES 9 $0.00
G9065 ONC DX NSCLC STG3A NO PROGRE 9 $0.00
G9066 ONC DX NSCLC STG3B-4 METASTA 9 $0.00
G9067 ONC DX NSCLC DX UNKNOWN NOS 9 $0.00
G9068 ONC DX SCLC/NSCLC LIMITED 9 $0.00
G9069 ONC DX SCLC/NSCLC EXT AT DX 9 $0.00
G9070 ONC DX SCLC/NSCLC EXT UNKNWN 9 $0.00
G9071 ONC DX BRST STG1-2B HR,NOPRO 9 $0.00
G9072 ONC DX BRST STG1-2 NOPROGRES 9 $0.00
G9073 ONC DX BRST STG3-HR, NO PRO 9 $0.00
G9074 ONC DX BRST STG3-NOPROGRESS 9 $0.00
G9075 ONC DX BRST METASTIC/ RECUR 9 $0.00
G9076 ONC DX BRST UNKNOWN NOS O $0.00
G9077 ONC DX PROSTATE T1NO PROGRES 9 $0.00
G9078 ONC DX PROSTATE T2NO PROGRES 9 $0.00
G9079 ONC DX PROSTATE T3B-T4NOPROG 9 $0.00
G9080 ONC DX PROSTATE W/RISE PSA 9 $0.00
G9081 ONC DX PROSTATE METS NO CAST O $0.00
G9082 ONC DX PROSTATE CASTRATE MET O $0.00
G9083 ONC DX PROSTATE UNKNWN NOS 9 $0.00
G9084 ONC DX COLON T1-3,N1-2,NO PR 9 $0.00
G9085 ONC DX COLON T4, N0 W/O PROG 9 $0.00
G9086 ONC DX COLON T1-4 NO DX PROG 9 $0.00
G9087 ONC DX COLON METAS EVID DX 9 $0.00
G9088 ONC DX COLON METAS NOEVID DX 9 $0.00
G9089 ONC DX COLON EXTENT UNKNOWN 9 $0.00
G9090 ONC DX RECTAL T1-2 NO PROGR 9 $0.00
G9091 ONC DX RECTAL T3 N0 NO PROG 9 $0.00
G9092 ONC DX RECTAL T1-3,N1-2NOPRG 9 $0.00
G9093 ONC DX RECTAL T4,N,M0 NO PRG 9 $0.00
G9094 ONC DX RECTAL M1 W/METS PROG 9 $0.00
G9095 ONC DX RECTAL EXTENT UNKNWN 9 $0.00
G9096 ONC DX ESOPHAG T1-T3 NOPROG 9 $0.00
G9097 ONC DX ESOPHAGEAL T4 NO PROG 9 $0.00
G9098 ONC DX ESOPHAGEAL METS RECUR 9 $0.00
G9099 ONC DX ESOPHAGEAL UNKNOWN 9 $0.00
G9100 ONC DX GASTRIC NO RECURRENCE 9 $0.00

G9101 ONC DX GASTRIC P R1-R2NOPROG 9 $0.00
G9102 ONC DX GASTRIC UNRESECTABLE 9 $0.00
G9103 ONC DX GASTRIC RECURRENT 9 $0.00
G9104 ONC DX GASTRIC UNKNOWN NOS 9 $0.00
G9105 ONC DX PANCREATC P R0 RES NO 9 $0.00
G9106 ONC DX PANCREATC P R1/R2 NO 9 $0.00
G9107 ONC DX PANCREATIC UNRESECTAB 9 $0.00
G9108 ONC DX PANCREATIC UNKNWN NOS 9 $0.00
G9109 ONC DX HEAD/NECK T1-T2NO PRG 9 $0.00
G9110 ONC DX HEAD/NECK T3-4 NOPROG 9 $0.00
G9111 ONC DX HEAD/NECK M1 METS REC 9 $0.00
G9112 ONC DX HEAD/NECK EXT UNKNOWN 9 $0.00
G9113 ONC DX OVARIAN STG1A-B NO PR 9 $0.00
G9114 ONC DX OVARIAN STG1A-B OR 2 9 $0.00
G9115 ONC DX OVARIAN STG3/4 NOPROG 9 $0.00
G9116 ONC DX OVARIAN RECURRENCE 9 $0.00
G9117 ONC DX OVARIAN UNKNOWN NOS 9 $0.00
G9118 ONC DX NHL STG 1-2 NOT RELAP O $0.00
G9119 ONC DX NHL STG 3-4 NOT RELAP O $0.00
G9120 ONC DX NHL TRANS TO LG BCELL O $0.00
G9121 ONC NHLSTG 1-2 NO RELAP NO O $0.00
G9122 ONC DX NHL STG 3/4NO RELAP O $0.00
G9123 ONC DX CML CHRONIC PHASE 9 $0.00
G9124 ONC DX CML ACCELER PHASE 9 $0.00
G9125 ONC DX CML BLAST PHASE 9 $0.00
G9126 ONC DX CML REMISSION 9 $0.00
G9127 ONC DX MULTI MYELOMA STAGE I O $0.00
G9128 ONC DX MULTI MYELOMA STAGE I 9 $0.00
G9129 ONC DX MULT MYELOMA STG2 HIG 9 $0.00
G9130 ONC DX MULTI MYELOMA UNKNOWN 9 $0.00
G9131 ONC DX BRST UNKNOWN NOS 9 $0.00
G9132 ONC DX PROSTATE METS NO CAST 9 $0.00
G9133 ONC DX PROSTATE CLINICAL MET 9 $0.00
G9134 ONC NHLSTG 1-2 NO RELAP NO 9 $0.00
G9135 ONC DX NHL STG 3-4 NOT RELAP 9 $0.00
G9136 ONC DX NHL TRANS TO LG BCELL 9 $0.00
G9137 ONC DX NHL RELAPSE/REFRACTOR 9 $0.00
G9138 ONC DX NHL STG UNKNOWN 9 $0.00
G9139 ONC DX CML DX STATUS UNKNOWN 9 $0.00
G9140 FRONTIER EXTENDED STAY DEMO 9 $0.00
G9141 INFLUENZA A H1N1,ADMIN W COU 9 $0.00
G9142 INFLUENZA A H1N1, VACCINE 9 $0.00
G9143 WARFARIN RESPON GENETIC TEST 9 $0.00
H0001 ALCOHOL AND/OR DRUG ASSESS 7 $0.00
H0002 ALCOHOL AND/OR DRUG SCREENIN 7 $0.00
H0003 ALCOHOL AND/OR DRUG SCREENIN 9 $0.00
H0004 ALCOHOL AND/OR DRUG SERVICES 9 $0.00
H0005 ALCOHOL AND/OR DRUG SERVICES 7 $0.00
H0006 ALCOHOL AND/OR DRUG SERVICES 9 $0.00

H0007 ALCOHOL AND/OR DRUG SERVICES 7 $0.00
H0008 ALCOHOL AND/OR DRUG SERVICES 9 $0.00
H0009 ALCOHOL AND/OR DRUG SERVICES 9 $0.00
H0010 ALCOHOL AND/OR DRUG SERVICES 9 $0.00
H0011 ALCOHOL AND/OR DRUG SERVICES 9 $0.00
H0012 ALCOHOL AND/OR DRUG SERVICES 9 $0.00
H0013 ALCOHOL AND/OR DRUG SERVICES 9 $0.00
H0014 ALCOHOL AND/OR DRUG SERVICES 9 $0.00
H0015 ALCOHOL AND/OR DRUG SERVICES 7 $0.00
H0016 ALCOHOL AND/OR DRUG SERVICES 9 $0.00
H0017 ALCOHOL AND/OR DRUG SERVICES 7 $0.00
H0018 ALCOHOL AND/OR DRUG SERVICES 7 $0.00
H0019 ALCOHOL AND/OR DRUG SERVICES 7 $0.00
H0020 ALCOHOL AND/OR DRUG SERVICES 3 $4.00
H0021 ALCOHOL AND/OR DRUG TRAINING 9 $0.00
H0022 ALCOHOL AND/OR DRUG INTERVEN 9 $0.00
H0023 ALCOHOL AND/OR DRUG OUTREACH 9 $0.00
H0024 ALCOHOL AND/OR DRUG PREVENTI 9 $0.00
H0025 ALCOHOL AND/OR DRUG PREVENTI 9 $0.00
H0026 ALCOHOL AND/OR DRUG PREVENTI 9 $0.00
H0027 ALCOHOL AND/OR DRUG PREVENTI 9 $0.00
H0028 ALCOHOL AND/OR DRUG PREVENTI 9 $0.00
H0029 ALCOHOL AND/OR DRUG PREVENTI 9 $0.00
H0030 ALCOHOL AND/OR DRUG HOTLINE 9 $0.00
H0031 MH HEALTH ASSESS BY NON-MD 7 $0.00
H0032 MH SVC PLAN DEV BY NON-MD 7 $0.00
H0033 ORAL MED ADM DIRECT OBSERVE 9 $0.00
H0034 MED TRNG & SUPPORT PER 15MIN 9 $0.00
H0035 MH PARTIAL HOSP TX UNDER 24H 9 $0.00
H0036 COMM PSY FACE-FACE PER 15MIN 9 $0.00
H0037 COMM PSY SUP TX PGM PER DIEM 7 $0.00
H0038 SELF-HELP/PEER SVC PER 15MIN 9 $0.00
H0039 ASSER COM TX FACE-FACE/15MIN 7 $0.00
H0040 ASSERT COMM TX PGM PER DIEM 9 $0.00
H0041 FOS C CHLD NON-THER PER DIEM 9 $0.00
H0042 FOS C CHLD NON-THER PER MON 9 $0.00
H0043 SUPPORTED HOUSING, PER DIEM 7 $0.00
H0044 SUPPORTED HOUSING, PER MONTH 9 $0.00
H0045 RESPITE NOT-IN-HOME PER DIEM 9 $0.00
H0046 MENTAL HEALTH SERVICE, NOS 7 $0.00
H0047 ALCOHOL/DRUG ABUSE SVC NOS 9 $0.00
H0048 SPEC COLL NON-BLOOD:A/D TEST 9 $0.00
H0049 ALCOHOL/DRUG SCREENING 9 $0.00
H0050 ALCOHOL/DRUG SERVICE 15 MIN 9 $0.00
H1000 PRENATAL CARE ATRISK ASSESSM 9 $0.00
H1001 ANTEPARTUM MANAGEMENT 9 $0.00
H1002 CARECOORDINATION PRENATAL 9 $0.00
H1003 PRENATAL AT RISK EDUCATION 9 $0.00
H1004 FOLLOW UP HOME VISIT/PRENTAL 9 $0.00

H1005 PRENATALCARE ENHANCED SRV PK 9 $0.00
H1010 NONMED FAMILY PLANNING ED 9 $0.00
H1011 FAMILY ASSESSMENT 9 $0.00
H2000 COMP MULTIDISIPLN EVALUATION 9 $0.00
H2001 REHABILITATION PROGRAM 1/2 D 9 $0.00
H2010 COMPREHENSIVE MED SVC 15 MIN 9 $0.00
H2011 CRISIS INTERVEN SVC, 15 MIN 7 $0.00
H2012 BEHAV HLTH DAY TREAT, PER HR 7 $0.00
H2013 PSYCH HLTH FAC SVC, PER DIEM 9 $0.00
H2014 SKILLS TRAIN AND DEV, 15 MIN 9 $0.00
H2015 COMP COMM SUPP SVC, 15 MIN 9 $0.00
H2016 COMP COMM SUPP SVC, PER DIEM 7 $0.00
H2017 PSYSOC REHAB SVC, PER 15 MIN 9 $0.00
H2018 PSYSOC REHAB SVC, PER DIEM 7 $0.00
H2019 THER BEHAV SVC, PER 15 MIN 9 $0.00
H2020 THER BEHAV SVC, PER DIEM 7 $0.00
H2021 COM WRAP-AROUND SV, 15 MIN 9 $0.00
H2022 COM WRAP-AROUND SV, PER DIEM 9 $0.00
H2023 SUPPORTED EMPLOY, PER 15 MIN 9 $0.00
H2024 SUPPORTED EMPLOY, PER DIEM 7 $0.00
H2025 SUPP MAINT EMPLOY, 15 MIN 9 $0.00
H2026 SUPP MAINT EMPLOY, PER DIEM 9 $0.00
H2027 PSYCHOED SVC, PER 15 MIN 7 $0.00
H2028 SEX OFFEND TX SVC, 15 MIN 9 $0.00
H2029 SEX OFFEND TX SVC, PER DIEM 9 $0.00
H2030 MH CLUBHOUSE SVC, PER 15 MIN 9 $0.00
H2031 MH CLUBHOUSE SVC, PER DIEM 9 $0.00
H2032 ACTIVITY THERAPY, PER 15 MIN 9 $0.00
H2033 MULTISYS THER/JUVENILE 15MIN 9 $0.00
H2034 A/D HALFWAY HOUSE, PER DIEM 9 $0.00
H2035 A/D TX PROGRAM, PER HOUR 7 $0.00
H2036 A/D TX PROGRAM, PER DIEM 7 $0.00
H2037 DEV DELAY PREV DP CH, 15 MIN 9 $0.00
H5010 THERAPY, INDIVIDUAL, BY SOCIAL WORK 9 $0.00
H5020 PSYCHOTHERAPY, GROUP (MAXIMUM 8 PER 9 $0.00
H5025 PSYCHOTHERAPY, GROUP (MAXIMUM 8 PER 9 $0.00
H5030 OTHER SERVICES BY SOCIAL WORKER, PS 9 $0.00
H5040 RESIDENTIAL CARE IN PUBLIC INSTITUT 9 $0.00
H5050 RESIDENTIAL CARE IN PRIVATE INSTITU 9 $0.00
H5060 PUBLIC SPECIAL SCHOOLS OR DAY CARE 9 $0.00
H5090 SPECIAL CLASS PRIVATE 9 $0.00
H5100 SPECIAL CLASS PRIVATE PROPRIETARY 9 $0.00
H5110 SUMMER TREATMENT CAMP 9 $0.00
H5120 SPECIALIZED CARE NURSING HOME, CONV 9 $0.00
H5130 VISITING TEACHER SERVICES 9 $0.00
H5160 READING THERAPY 9 $0.00
H5170 OTHER SPECIAL EDUCATION OR VOCATION 9 $0.00
H5180 TRANSPORTATION FOR HANDICAPPED 9 $0.00
H5190 NURSING CARE, HOME 9 $0.00

H5200 NURSING CARE, OTHER 9 $0.00
H5220 REHABILITATIVE EVALUATION, 0-20 MIN 9 $0.00
H5230 REHABILITATIVE EVALUATION, 21-40 MI 9 $0.00
H5240 REHABILITATIVE EVALUATION, 41-60 MI 9 $0.00
H5299 REHABILITATIVE EVALUATION, NOT OTHE 9 $0.00
H5300 OCCUPATIONAL THERAPY, EXCLUDING INI 9 $0.00
HI010 MCO SPECIFIC CODE: HOME INFUSION PA O $0.00
HI011 MCO SPECIFIC CODE: HOME INFUSION PA O $0.00
HI012 MCO SPECIFIC CODE: HOME INFUSION PA O $0.00
HI013 MCO SPECIFIC CODE: HOME INFUSION PA O $0.00
HI014 MCO SPECIFIC CODE: HOME INFUSION PA O $0.00
HI020 MCO SPECIFIC CODE: HOME INFUSION PA O $0.00
HI021 MCO SPECIFIC: HOME INFUSION PACKAGE O $0.00
HI022 MCO SPECIFIC CODE: HOME INFUSION PA O $0.00
HI023 MCO SPECIFIC CODE: HOME INFUSION PA O $0.00
HI024 MCO SPECIFIC CODE: HOME INFUSION PA O $0.00
HI030 MCO SPECIFIC CODE: HOME INFUSION PA O $0.00
HI031 MCO SCPECIFIC CODE: HOME INFUSION P O $0.00
HI032 MCO SPECIFIC CODE: HOME INFUSION PA O $0.00
HI033 MCO SPECIFIC CODE: HOME INFUSION PA O $0.00
HI034 MCO SPECIFIC CODE: HOME INFUSION PA O $0.00
HI040 MCO SPECIFIC CODE: HOME INFUSION PA O $0.00
HI041 MCO SPECIFIC CODE: HOME INFUSION PA O $0.00
HI042 MCO SPECIFIC CODE: HOME INFUSION PA O $0.00
HI043 MCO SPECIFIC CODE: HOME INFUSION PA O $0.00
HI044 MCO SPECIFIC CODE: HOME INFUSION PA O $0.00
HI050 MCO SPECIFIC CODE: HOME INFUSION PA O $0.00
HI060 MCO SPECIFIC CODE: HOME INFUSION PA O $0.00
HI070 MCO SPECIFIC CODE: HOME INFUSION PA O $0.00
HI080 MCO SPECIFIC CODE: HOME INFUSION, S O $0.00
HI081 MCO SPECIFIC CODE: HOME INFUSION, S O $0.00
HI082 MCO SPECIFIC CODE: HOME INFUSION, S O $0.00
HI090 MCO SPECIFIC CODE: HOME INFUSION PA O $0.00
HI091 MCO SPECIFIC CODE: HOME INFUSION PA O $0.00
HI092 MCO SPECIFIC CODE: HOME INFUSION PA O $0.00
HI093 MCO SPECIFIC CODE: HOME INFUSION PA O $0.00
HI094 MCO SPECIFIC CODE: HOME INFUSION PA O $0.00
HI100 MCO SPECIFIC CODE: HOME INFUSION PA O $0.00
HI110 MCO SPECIFIC CODE: HOME INFUSION PA O $0.00
HI120 MCO SPECIFIC CODE: HOME INFUSION, E O $0.00
HI130 MCO SPECIFIC CODE: HOME INFUSION PA O $0.00
HI140 MCO SPECIFIC CODE: HOME INFUSION PA O $0.00
HI160 MCO SPECIFIC CODE: HOME INFUSION PA O $0.00
HI170 MCO SPECIFIC CODE: HOME INFUSION PA O $0.00
HI171 MCO SPECIFIC CODE: HOME INFUSION PA O $0.00
HI172 MCO SPECIFIC CODE: HOME INFUSION PA O $0.00
HI180 MCO SPECIFIC CODE: HOME INFUSION PA O $0.00
HI190 MCO SPECIFIC CODE: HOME INFUSION PA O $0.00
HM1CW MCO SPECIFIC CODE: SMART START INIT O $0.00

HM1RN MCO SPECIFIC CODE: SMART START INIT O $0.00
HM1SW MCO SPECIFIC CODE: SMART START INIT O $0.00
HM2CW MCO SPECIFIC CODE: SMART START POST O $0.00
HM2RN MCO SPECIFIC CODE: SMART START POST O $0.00
HM2SW MCO SPECIFIC CODE: SMART START POST O $0.00
J0110 ADMINISTRATION OF INJECTION, INCLUD O $0.00
J0120 TETRACYCLIN INJECTION 5 $0.00
J0128 ABARELIX INJECTION 3 $66.41
J0129 ABATACEPT INJECTION 3 $19.52
J0130 ABCIXIMAB INJECTION 3 $463.45
J0132 ACETYLCYSTEINE INJECTION 3 $0.19
J0133 ACYCLOVIR INJECTION 3 $0.03
J0135 ADALIMUMAB INJECTION 3 $366.81
J0150 INJECTION ADENOSINE 6 MG 3 $9.62
J0151 ADENOSINE INJECTION O $0.00
J0152 ADENOSINE INJECTION 3 $8.09
J0170 ADRENALIN EPINEPHRIN INJECT 3 $0.86
J0180 AGALSIDASE BETA INJECTION 3 $131.94
J0190 INJ BIPERIDEN LACTATE/5 MG 5 $0.00
J0200 ALATROFLOXACIN MESYLATE 9 $0.00
J0205 ALGLUCERASE INJECTION 5 $0.00
J0207 AMIFOSTINE 3 $188.30
J0210 METHYLDOPATE HCL INJECTION 5 $0.00
J0215 ALEFACEPT 6 $0.00
J0220 ALGLUCOSIDASE ALFA INJECTION 3 $123.12
J0230 INJECTION, ALLERGY DESENSITIZATION, O $0.00
J0240 INJECTION, ALLERGY DESENSITIZATION, O $0.00
J0256 ALPHA 1 PROTEINASE INHIBITOR 5 $0.00
J0270 ALPROSTADIL FOR INJECTION 9 $0.00
J0275 ALPROSTADIL URETHRAL SUPPOS 9 $0.00
J0278 AMIKACIN SULFATE INJECTION 3 $0.55
J0280 AMINOPHYLLIN 250 MG INJ 3 $0.39
J0282 AMIODARONE HCL 5 $0.00
J0285 AMPHOTERICIN B 5 $0.00
J0286 AMPHOTERICIN B LIPID COMPLEX O $0.00
J0287 AMPHOTERICIN B LIPID COMPLEX 3 $9.65
J0288 AMPHO B CHOLESTERYL SULFATE 5 $0.00
J0289 AMPHOTERICIN B LIPOSOME INJ 3 $15.59
J0290 AMPICILLIN 500 MG INJ 3 $1.34
J0295 AMPICILLIN SODIUM PER 1.5 GM 3 $2.09
J0300 AMOBARBITAL 125 MG INJ 5 $0.00
J0330 SUCCINYCHOLINE CHLORIDE INJ 3 $0.15
J0340 NANDROLON PHENPROPIONATE INJ O $0.00
J0348 ANIDULAFUNGIN INJECTION 3 $1.24
J0350 INJECTION ANISTREPLASE 30 U 5 $0.00
J0360 HYDRALAZINE HCL INJECTION 5 $0.00
J0364 APOMORPHINE HYDROCHLORIDE 3 $4.21
J0365 APROTONIN, 10,000 KIU 3 $1.68
J0380 INJ METARAMINOL BITARTRATE 5 $0.00

J0390 CHLOROQUINE INJECTION 5 $0.00
J0395 ARBUTAMINE HCL INJECTION 5 $0.00
J0400 ARIPIPRAZOLE INJECTION 3 $0.33
J0456 AZITHROMYCIN 3 $6.98
J0460 ATROPINE SULFATE INJECTION O $0.00
J0461 ATROPINE SULFATE INJECTION 3 $0.25
J0470 DIMECAPROL INJECTION 5 $0.00
J0475 BACLOFEN 10 MG INJECTION 3 $203.25
J0476 BACLOFEN INTRATHECAL TRIAL 3 $71.82
J0480 BASILIXIMAB 3 $1,728.91
J0500 DICYCLOMINE INJECTION 5 $0.00
J0510 BENZQUINAMIDE INJECTION O $0.00
J0515 INJ BENZTROPINE MESYLATE 5 $0.00
J0520 BETHANECHOL CHLORIDE INJECT 5 $0.00
J0530 PENICILLIN G BENZATHINE INJ O $0.00
J0540 PENICILLIN G BENZATHINE INJ O $0.00
J0550 PENICILLIN G BENZATHINE INJ O $0.00
J0559 PENG BENZATHINE/PROCAINE INJ 3 $0.07
J0560 PENICILLIN G BENZATHINE INJ 3 $25.54
J0570 PENICILLIN G BENZATHINE INJ 3 $13.60
J0580 PENICILLIN G BENZATHINE INJ 3 $46.07
J0583 BIVALIRUDIN 6 $0.00
J0585 INJECTION,ONABOTULINUMTOXINA 3 $5.38
J0586 ABOBOTULINUMTOXINA 3 $7.28
J0587 INJ, RIMABOTULINUMTOXINB 3 $10.24
J0590 ETHYLNOREPINEPHRINE HCL INJ O $0.00
J0592 BUPRENORPHINE HYDROCHLORIDE 5 $0.00
J0594 BUSULFAN INJECTION 3 $14.29
J0595 BUTORPHANOL TARTRATE 1 MG 6 $0.00
J0598 C1 ESTERASE INHIBITOR INJ 3 $43.09
J0600 EDETATE CALCIUM DISODIUM INJ 5 $0.00
J0610 CALCIUM GLUCONATE INJECTION 3 $0.31
J0620 CALCIUM GLYCER & LACT/10 ML 5 $0.00
J0630 CALCITONIN SALMON INJECTION 5 $0.00
J0635 CALCITRIOL INJECTION O $0.00
J0636 INJ CALCITRIOL PER 0.1 MCG 5 $0.00
J0637 CASPOFUNGIN ACETATE 5 $0.00
J0640 LEUCOVORIN CALCIUM INJECTION 3 $1.95
J0641 LEVOLEUCOVORIN INJECTION 3 $1.36
J0670 INJ MEPIVACAINE HCL/10 ML 3 $1.82
J0680 INJECTION, DESLANOSIDE, UP TO 0.4 M O $0.00
J0690 CEFAZOLIN SODIUM INJECTION 3 $0.60
J0692 CEFEPIME HCL FOR INJECTION 3 $3.64
J0694 CEFOXITIN SODIUM INJECTION 3 $6.11
J0695 CEFONOCID SODIUM INJECTION O $0.00
J0696 CEFTRIAXONE SODIUM INJECTION 3 $13.78
J0697 STERILE CEFUROXIME INJECTION 5 $0.00
J0698 CEFOTAXIME SODIUM INJECTION 5 $0.00
J0700 INJECTION, BETAMETHASONE, UP TO 6 M O $0.00

J0702 BETAMETHASONE ACET&SOD PHOSP 3 $6.56
J0704 BETAMETHASONE SOD PHOSP/4 MG 5 $0.00
J0706 CAFFEINE CITRATE INJECTION 5 $0.00
J0710 CEPHAPIRIN SODIUM INJECTION 5 $0.00
J0713 INJ CEFTAZIDIME PER 500 MG 3 $2.13
J0715 CEFTIZOXIME SODIUM / 500 MG 5 $0.00
J0718 CERTOLIZUMAB PEGOL INJ 3 $3.72
J0720 CHLORAMPHENICOL SODIUM INJEC 5 $0.00
J0725 CHORIONIC GONADOTROPIN/1000U 5 $0.00
J0730 CHLORPHENIRAMIN MALEATE INJ O $0.00
J0735 CLONIDINE HYDROCHLORIDE 3 $84.84
J0740 CIDOFOVIR INJECTION 3 $759.24
J0743 CILASTATIN SODIUM INJECTION 3 $11.52
J0744 CIPROFLOXACIN IV 3 $1.23
J0745 INJ CODEINE PHOSPHATE /30 MG 5 $0.00
J0760 COLCHICINE INJECTION 3 $6.57
J0770 COLISTIMETHATE SODIUM INJ 5 $0.00
J0780 PROCHLORPERAZINE INJECTION 5 $0.00
J0790 INJECTION, NIKETHAMIDE, UP TO 1.5 M O $0.00
J0795 CORTICORELIN OVINE TRIFLUTAL 3 $4.31
J0800 CORTICOTROPIN INJECTION 3 $2,440.35
J0810 CORTISONE INJECTION O $0.00
J0820 INJECTION, CORTIGEL 40, UP TO 40 UN O $0.00
J0830 INJECTION, CORTROPHIN ZINC HYDROXID O $0.00
J0833 COSYNTROPIN INJECTION NOS 3 $65.42
J0834 COSYNTROPIN CORTROSYN INJ 3 $91.20
J0835 INJ COSYNTROPIN PER 0.25 MG O $0.00
J0840 INJECTION, WARFARIN SODIUM, UP TO 5 O $0.00
J0850 CYTOMEGALOVIRUS IMM IV /VIAL 3 $878.83
J0878 DAPTOMYCIN INJECTION 3 $0.43
J0880 DARBEPOETIN ALFA INJECTION O $0.00
J0881 DARBEPOETIN ALFA, NON-ESRD 3 $2.83
J0882 DARBEPOETIN ALFA, ESRD USE 3 $2.83
J0885 EPOETIN ALFA, NON-ESRD 3 $9.54
J0886 EPOETIN ALFA 1000 UNITS ESRD 3 $9.54
J0894 DECITABINE INJECTION 3 $28.34
J0895 DEFEROXAMINE MESYLATE INJ 5 $0.00
J0900 TESTOSTERONE ENANTHATE INJ 5 $0.00
J0945 BROMPHENIRAMINE MALEATE INJ 5 $0.00
J0970 ESTRADIOL VALERATE INJECTION 5 $0.00
J1000 DEPO-ESTRADIOL CYPIONATE INJ 3 $6.74
J1020 METHYLPREDNISOLONE 20 MG INJ 3 $1.65
J1030 METHYLPREDNISOLONE 40 MG INJ 3 $3.30
J1040 METHYLPREDNISOLONE 80 MG INJ 3 $10.57
J1050 MEDROXYPROGESTERONE INJ O $0.00
J1051 MEDROXYPROGESTERONE INJ 3 $7.67
J1055 MEDRXYPROGESTER ACETATE INJ 3 $37.96
J1056 MA/EC CONTRACEPTIVEINJECTION 3 $22.50
J1060 TESTOSTERONE CYPIONATE 1 ML 5 $0.00

J1070 TESTOSTERONE CYPIONAT 100 MG 5 $0.00
J1080 TESTOSTERONE CYPIONAT 200 MG 5 $0.00
J1090 TESTOSTERONE CYPIONATE 50 MG O $0.00
J1094 INJ DEXAMETHASONE ACETATE 3 $0.23
J1095 INJ DEXAMETHASONE ACETATE O $0.00
J1100 DEXAMETHASONE SODIUM PHOS 3 $0.09
J1110 INJ DIHYDROERGOTAMINE MESYLT 3 $22.46
J1120 ACETAZOLAMID SODIUM INJECTIO 5 $0.00
J1155 INJECTION, DIGITOXIN O $0.00
J1160 DIGOXIN INJECTION 5 $0.00
J1162 DIGOXIN IMMUNE FAB (OVINE) 3 $476.58
J1165 PHENYTOIN SODIUM INJECTION 5 $0.00
J1170 HYDROMORPHONE INJECTION 3 $1.41
J1180 DYPHYLLINE INJECTION 5 $0.00
J1190 DEXRAZOXANE HCL INJECTION 3 $221.09
J1200 DIPHENHYDRAMINE HCL INJECTIO 3 $0.79
J1205 CHLOROTHIAZIDE SODIUM INJ 5 $0.00
J1212 DIMETHYL SULFOXIDE 50% 50 ML 5 $0.00
J1230 METHADONE INJECTION 5 $0.00
J1240 DIMENHYDRINATE INJECTION 5 $0.00
J1245 DIPYRIDAMOLE INJECTION 3 $7.52
J1250 INJ DOBUTAMINE HCL/250 MG 3 $2.97
J1260 DOLASETRON MESYLATE 3 $4.01
J1265 DOPAMINE INJECTION 3 $0.08
J1267 DORIPENEM INJECTION 3 $0.55
J1270 INJECTION, DOXERCALCIFEROL 5 $0.00
J1300 ECULIZUMAB INJECTION 3 $175.17
J1320 AMITRIPTYLINE INJECTION 5 $0.00
J1324 ENFUVIRTIDE INJECTION 3 $28.21
J1325 EPOPROSTENOL INJECTION 3 $11.86
J1327 EPTIFIBATIDE INJECTION 5 $0.00
J1330 ERGONOVINE MALEATE INJECTION 5 $0.00
J1335 ERTAPENEM INJECTION 3 $26.51
J1340 INJECTION, AQUEOUS OR SALINE PLACEB O $0.00
J1350 INJECTION, ERYTHROMYCIN-IM, UP TO 1 O $0.00
J1360 INJECTION, ERTHROMYCIN-IV, UP TO 50 O $0.00
J1362 ERYTHROMYCIN GLUCEP / 250 MG O $0.00
J1364 ERYTHRO LACTOBIONATE /500 MG 5 $0.00
J1380 ESTRADIOL VALERATE 10 MG INJ 5 $0.00
J1390 ESTRADIOL VALERATE 20 MG INJ 5 $0.00
J1410 INJ ESTROGEN CONJUGATE 25 MG 3 $87.57
J1430 ETHANOLAMINE OLEATE 100 MG 3 $79.00
J1435 INJECTION ESTRONE PER 1 MG 5 $0.00
J1436 ETIDRONATE DISODIUM INJ 5 $0.00
J1438 ETANERCEPT INJECTION 5 $0.00
J1440 FILGRASTIM 300 MCG INJECTION 3 $219.71
J1441 FILGRASTIM 480 MCG INJECTION 3 $274.45
J1450 FLUCONAZOLE 5 $0.00
J1451 FOMEPIZOLE, 15 MG 3 $7.17

J1452 INTRAOCULAR FOMIVIRSEN NA 5 $0.00
J1453 FOSAPREPITANT INJECTION 3 $1.57
J1455 FOSCARNET SODIUM INJECTION 3 $10.10
J1457 GALLIUM NITRATE INJECTION 3 $1.60
J1458 GALSULFASE INJECTION 3 $334.47
J1459 INJ IVIG PRIVIGEN 500 MG 3 $35.14
J1460 GAMMA GLOBULIN 1 CC INJ 5 $0.00
J1470 GAMMA GLOBULIN 2 CC INJ 5 $0.00
J1480 GAMMA GLOBULIN 3 CC INJ 5 $0.00
J1490 GAMMA GLOBULIN 4 CC INJ 5 $0.00
J1500 GAMMA GLOBULIN 5 CC INJ 5 $0.00
J1510 GAMMA GLOBULIN 6 CC INJ 5 $0.00
J1520 GAMMA GLOBULIN 7 CC INJ 5 $0.00
J1530 GAMMA GLOBULIN 8 CC INJ 5 $0.00
J1540 GAMMA GLOBULIN 9 CC INJ 5 $0.00
J1550 GAMMA GLOBULIN 10 CC INJ 5 $0.00
J1560 GAMMA GLOBULIN > 10 CC INJ 5 $0.00
J1561 GAMUNEX INJECTION 3 $37.62
J1562 VIVAGLOBIN, INJ 3 $7.18
J1563 IV IMMUNE GLOBULIN O $0.00
J1564 IMMUNE GLOBULIN 10 MG O $0.00
J1565 RSV-IVIG O $0.00
J1566 IMMUNE GLOBULIN, POWDER 3 $30.48
J1567 IMMUNE GLOBULIN, LIQUID O $0.00
J1568 OCTAGAM INJECTION 3 $37.71
J1569 GAMMAGARD LIQUID INJECTION 3 $38.53
J1570 GANCICLOVIR SODIUM INJECTION 3 $46.56
J1571 HEPAGAM B IM INJECTION 3 $50.22
J1572 FLEBOGAMMA INJECTION 3 $37.12
J1573 HEPAGAM B INTRAVENOUS, INJ 3 $50.22
J1580 GARAMYCIN GENTAMICIN INJ 3 $0.87
J1590 GATIFLOXACIN INJECTION 5 $0.00
J1595 INJECTION GLATIRAMER ACETATE 3 $85.65
J1600 GOLD SODIUM THIOMALEATE INJ 5 $0.00
J1610 GLUCAGON HYDROCHLORIDE/1 MG 5 $0.00
J1620 GONADORELIN HYDROCH/ 100 MCG 5 $0.00
J1625 INJECTION, GRANISETRON HYDROCHLORID O $0.00
J1626 GRANISETRON HCL INJECTION 3 $0.35
J1630 HALOPERIDOL INJECTION 5 $0.00
J1631 HALOPERIDOL DECANOATE INJ 3 $2.68
J1640 HEMIN, 1 MG 3 $8.07
J1642 INJ HEPARIN SODIUM PER 10 U 3 $0.12
J1644 INJ HEPARIN SODIUM PER 1000U 3 $0.06
J1645 DALTEPARIN SODIUM 5 $0.00
J1650 INJ ENOXAPARIN SODIUM 3 $6.47
J1652 FONDAPARINUX SODIUM 5 $0.00
J1655 TINZAPARIN SODIUM INJECTION 3 $2.65
J1660 INJECTION, HISTAMINE, UP TO 2.75 MG O $0.00
J1670 TETANUS IMMUNE GLOBULIN INJ 5 $0.00

J1675 HISTRELIN ACETATE 6 $0.00
J1680 HUMAN FIBRINOGEN CONC INJ 6 $0.00
J1690 PREDNISOLONE TEBUTATE INJ O $0.00
J1700 HYDROCORTISONE ACETATE INJ 6 $0.00
J1710 HYDROCORTISONE SODIUM PH INJ 5 $0.00
J1720 HYDROCORTISONE SODIUM SUCC I 3 $2.10
J1730 DIAZOXIDE INJECTION 5 $0.00
J1739 HYDROXYPROGESTERONE CAP 125 O $0.00
J1740 IBANDRONATE SODIUM INJECTION 3 $141.12
J1741 HYDROXYPROGESTERONE CAP 250 O $0.00
J1742 IBUTILIDE FUMARATE INJECTION 5 $0.00
J1743 IDURSULFASE INJECTION 3 $449.42
J1745 INFLIXIMAB INJECTION 3 $58.66
J1750 INJ IRON DEXTRAN 3 $12.93
J1751 IRON DEXTRAN 165 INJECTION O $0.00
J1752 IRON DEXTRAN 267 INJECTION O $0.00
J1755 IRON SUCROSE INJECTION O $0.00
J1756 IRON SUCROSE INJECTION 3 $0.37
J1760 IRON DEXTRAN 2 CC INJ O $0.00
J1770 IRON DEXTRAN 5 CC INJ O $0.00
J1780 IRON DEXTRAN 10 CC INJ O $0.00
J1785 INJECTION IMIGLUCERASE /UNIT 5 $0.00
J1790 DROPERIDOL INJECTION 3 $1.83
J1800 PROPRANOLOL INJECTION 5 $0.00
J1810 DROPERIDOL/FENTANYL INJ 5 $0.00
J1815 INSULIN INJECTION 3 $0.30
J1817 INSULIN FOR INSULIN PUMP USE 5 $0.00
J1820 INSULIN INJECTION O $0.00
J1825 INTERFERON BETA-1A 3 $590.46
J1830 INTERFERON BETA-1B / .25 MG 5 $0.00
J1835 ITRACONAZOLE INJECTION 5 $0.00
J1840 KANAMYCIN SULFATE 500 MG INJ 5 $0.00
J1850 KANAMYCIN SULFATE 75 MG INJ 5 $0.00
J1885 KETOROLAC TROMETHAMINE INJ 3 $0.26
J1890 CEPHALOTHIN SODIUM INJECTION 5 $0.00
J1910 KUTAPRESSIN INJECTION O $0.00
J1930 LANREOTIDE INJECTION 3 $27.14
J1931 LARONIDASE INJECTION 3 $25.56
J1940 FUROSEMIDE INJECTION 3 $0.23
J1945 LEPIRUDIN 3 $231.26
J1950 LEUPROLIDE ACETATE /3.75 MG 5 $0.00
J1953 LEVETIRACETAM INJECTION 3 $0.46
J1955 INJ LEVOCARNITINE PER 1 GM 5 $0.00
J1956 LEVOFLOXACIN INJECTION 3 $5.62
J1960 LEVORPHANOL TARTRATE INJ 5 $0.00
J1970 METHOTRIMEPRAZINE INJECTION O $0.00
J1980 HYOSCYAMINE SULFATE INJ 5 $0.00
J1990 CHLORDIAZEPOXIDE INJECTION 5 $0.00
J2000 LIDOCAINE INJECTION O $0.00

J2001 LIDOCAINE INJECTION 3 $0.02
J2010 LINCOMYCIN INJECTION 5 $0.00
J2020 LINEZOLID INJECTION 5 $0.00
J2050 INJECTION, LIVER, UP TO 20 MCG O $0.00
J2060 LORAZEPAM INJECTION 3 $0.75
J2100 INJECTION, LUMINAL SODIUM, UP TO 12 O $0.00
J2150 MANNITOL INJECTION 3 $0.91
J2160 INJECTION, CYCLIZINE LACTATE, UP TO O $0.00
J2170 MECASERMIN INJECTION 3 $18.78
J2175 MEPERIDINE HYDROCHL /100 MG 3 $0.54
J2180 MEPERIDINE/PROMETHAZINE INJ 6 $0.00
J2185 MEROPENEM 6 $0.00
J2190 INJECTION, MERSALYL WITH THEOPHYLLI O $0.00
J2210 METHYLERGONOVIN MALEATE INJ 5 $0.00
J2220 INJECTION, METHYLANDROSTENEDIOL, AL O $0.00
J2240 METOCURINE IODIDE INJECTION O $0.00
J2248 MICAFUNGIN SODIUM INJECTION 3 $1.12
J2250 INJ MIDAZOLAM HYDROCHLORIDE 3 $0.11
J2260 INJ MILRINONE LACTATE / 5 MG 5 $0.00
J2270 MORPHINE SULFATE INJECTION 3 $0.26
J2271 MORPHINE SO4 INJECTION 100MG 5 $0.00
J2275 MORPHINE SULFATE INJECTION 5 $0.00
J2278 ZICONOTIDE INJECTION 3 $6.50
J2280 INJ, MOXIFLOXACIN 100 MG 6 $0.00
J2300 INJ NALBUPHINE HYDROCHLORIDE 3 $1.55
J2310 INJ NALOXONE HYDROCHLORIDE 3 $4.99
J2315 NALTREXONE, DEPOT FORM 3 $2.14
J2320 NANDROLONE DECANOATE 50 MG 5 $0.00
J2321 NANDROLONE DECANOATE 100 MG 5 $0.00
J2322 NANDROLONE DECANOATE 200 MG 5 $0.00
J2323 NATALIZUMAB INJECTION 3 $8.24
J2324 NESIRITIDE O $0.00
J2325 NESIRITIDE INJECTION 3 $37.97
J2330 THIOTHIXENE INJECTION O $0.00
J2350 NIACINAMIDE/NIACIN INJECTION O $0.00
J2352 OCTREOTIDE ACETATE INJECTION O $0.00
J2353 OCTREOTIDE INJECTION, DEPOT 6 $0.00
J2354 OCTREOTIDE INJ, NON-DEPOT 6 $0.00
J2355 OPRELVEKIN INJECTION 5 $0.00
J2357 OMALIZUMAB INJECTION 3 $19.22
J2360 ORPHENADRINE INJECTION 5 $0.00
J2370 PHENYLEPHRINE HCL INJECTION 5 $0.00
J2400 CHLOROPROCAINE HCL INJECTION 5 $0.00
J2405 ONDANSETRON HCL INJECTION 3 $0.24
J2410 OXYMORPHONE HCL INJECTION 5 $0.00
J2425 PALIFERMIN INJECTION 3 $11.29
J2430 PAMIDRONATE DISODIUM /30 MG 3 $20.36
J2440 PAPAVERIN HCL INJECTION 5 $0.00
J2460 OXYTETRACYCLINE INJECTION 5 $0.00

J2469 PALONOSETRON HCL 3 $17.51
J2480 HYDROCHLORIDES OF OPIUM INJ O $0.00
J2490 INJECTION, PARALDEHYDE, UP TO 5 ML O $0.00
J2495 INJECTION, TRIDIHEXETHYL CHLORIDE P O $0.00
J2500 PARICALCITOL O $0.00
J2501 PARICALCITOL 5 $0.00
J2503 PEGAPTANIB SODIUM INJECTION 6 $0.00
J2504 PEGADEMASE BOVINE, 25 IU 3 $247.33
J2505 INJECTION, PEGFILGRASTIM 6MG 3 $2,364.70
J2510 PENICILLIN G PROCAINE INJ 5 $0.00
J2512 INJ PENTAGASTRIN PER 2 ML O $0.00
J2513 PENTASTARCH 10% SOLUTION 3 $13.05
J2515 PENTOBARBITAL SODIUM INJ 3 $12.24
J2520 INJECTION, THIOPENTAL SODIUM O $0.00
J2540 PENICILLIN G POTASSIUM INJ 3 $0.82
J2543 PIPERACILLIN/TAZOBACTAM 3 $6.10
J2545 PENTAMIDINE NON-COMP UNIT 9 $0.00
J2550 PROMETHAZINE HCL INJECTION 3 $1.35
J2560 PHENOBARBITAL SODIUM INJ 5 $0.00
J2562 PLERIXAFOR INJECTION 3 $222.83
J2590 OXYTOCIN INJECTION 5 $0.00
J2595 INJECTION, VASOPRESSIN TANNATE O $0.00
J2597 INJ DESMOPRESSIN ACETATE 5 $0.00
J2600 INJECTION, POSTERIOR PITUITARY, UP O $0.00
J2640 PREDNISOLONE SODIUM PH INJ O $0.00
J2650 PREDNISOLONE ACETATE INJ 5 $0.00
J2670 TOTAZOLINE HCL INJECTION 5 $0.00
J2672 INJECTION, PROPANTHELINE BROMIDE O $0.00
J2675 INJ PROGESTERONE PER 50 MG O $0.00
J2680 FLUPHENAZINE DECANOATE 25 MG 5 $0.00
J2690 PROCAINAMIDE HCL INJECTION 5 $0.00
J2700 OXACILLIN SODIUM INJECITON 3 $2.00
J2710 NEOSTIGMINE METHYLSLFTE INJ 6 $0.00
J2720 INJ PROTAMINE SULFATE/10 MG 5 $0.00
J2724 PROTEIN C CONCENTRATE 3 $11.79
J2725 INJ PROTIRELIN PER 250 MCG 5 $0.00
J2730 PRALIDOXIME CHLORIDE INJ 5 $0.00
J2760 PHENTOLAINE MESYLATE INJ 9 $0.00
J2765 METOCLOPRAMIDE HCL INJECTION 3 $1.30
J2770 QUINUPRISTIN/DALFOPRISTIN 5 $0.00
J2778 RANIBIZUMAB INJECTION 3 $404.64
J2780 RANITIDINE HYDROCHLORIDE INJ 3 $1.15
J2783 RASBURICASE 6 $0.00
J2785 REGADENOSON INJECTION 3 $50.85
J2788 RHO D IMMUNE GLOBULIN 50 MCG 3 $25.96
J2790 RHO D IMMUNE GLOBULIN INJ 3 $86.13
J2791 RHOPHYLAC INJECTION 3 $5.22
J2792 RHO(D) IMMUNE GLOBULIN H, SD 3 $18.57
J2793 RILONACEPT INJECTION 3 $23.29

J2794 RISPERIDONE, LONG ACTING 3 $5.04
J2795 ROPIVACAINE HCL INJECTION 5 $0.00
J2796 ROMIPLOSTIM INJECTION 3 $43.60
J2800 METHOCARBAMOL INJECTION 5 $0.00
J2805 SINCALIDE INJECTION 3 $59.85
J2810 INJ THEOPHYLLINE PER 40 MG 5 $0.00
J2820 SARGRAMOSTIM INJECTION 3 $24.27
J2825 INJECTION, SARRACENIA PURPUREA PLAN O $0.00
J2850 INJ SECRETIN SYNTHETIC HUMAN 3 $208.41
J2860 SECOBARBITAL SODIUM INJ O $0.00
J2910 AUROTHIOGLUCOSE INJECITON 5 $0.00
J2912 SODIUM CHLORIDE INJECTION O $0.00
J2914 INJECTION, SODIUM SALICYLATE O $0.00
J2915 NA FERRIC GLUCONATE COMPLEX O $0.00
J2916 NA FERRIC GLUCONATE COMPLEX 3 $4.70
J2920 METHYLPREDNISOLONE INJECTION 3 $1.63
J2930 METHYLPREDNISOLONE INJECTION 3 $2.81
J2940 SOMATREM INJECTION 5 $0.00
J2941 SOMATROPIN INJECTION 5 $0.00
J2950 PROMAZINE HCL INJECTION 5 $0.00
J2970 METHICILLIN SODIUM INJECTION O $0.00
J2993 RETEPLASE INJECTION 5 $0.00
J2994 RETEPLASE DOUBLE BOLUS 9 $0.00
J2995 INJ STREPTOKINASE /250000 IU 5 $0.00
J2996 ALTEPLASE RECOMBINANT INJ O $0.00
J2997 ALTEPLASE RECOMBINANT 3 $36.93
J3000 STREPTOMYCIN INJECTION 3 $7.64
J3005 INJECTION, STRONTIUM-89 CHLORIDE, P O $0.00
J3010 FENTANYL CITRATE INJECITON 3 $0.17
J3030 SUMATRIPTAN SUCCINATE / 6 MG 3 $43.55
J3050 INJECTION, DECAMETHONIUM BROMIDE, U O $0.00
J3070 PENTAZOCINE INJECTION 5 $0.00
J3080 CHLORPROTHIXENE INJECTION O $0.00
J3100 TENECTEPLASE INJECTION O $0.00
J3101 TENECTEPLASE INJECTION 9 $0.00
J3105 TERBUTALINE SULFATE INJ 5 $0.00
J3110 TERIPARATIDE INJECTION 3 $13.63
J3120 TESTOSTERONE ENANTHATE INJ 5 $0.00
J3130 TESTOSTERONE ENANTHATE INJ 5 $0.00
J3140 TESTOSTERONE SUSPENSION INJ 5 $0.00
J3150 TESTOSTERON PROPIONATE INJ 5 $0.00
J3180 INJECTION, TETANUS TOXOID, UP TO 1 O $0.00
J3230 CHLORPROMAZINE HCL INJECTION 5 $0.00
J3240 THYROTROPIN INJECTION 5 $0.00
J3243 TIGECYCLINE INJECTION 3 $1.17
J3245 TIROFIBAN HYDROCHLORIDE O $0.00
J3246 TIROFIBAN HCL 3 $7.89
J3250 TRIMETHOBENZAMIDE HCL INJ 3 $2.30
J3260 TOBRAMYCIN SULFATE INJECTION 5 $0.00

J3265 INJECTION TORSEMIDE 10 MG/ML 5 $0.00
J3270 IMIPRAMINE HCL INJECTION O $0.00
J3280 THIETHYLPERAZINE MALEATE INJ 5 $0.00
J3285 TREPROSTINIL INJECTION 6 $0.00
J3300 TRIAMCINOLONE A INJ PRS-FREE 3 $0.32
J3301 TRIAMCINOLONE ACET INJ NOS 3 $1.40
J3302 TRIAMCINOLONE DIACETATE INJ 5 $0.00
J3303 TRIAMCINOLONE HEXACETONL INJ 3 $1.48
J3305 INJ TRIMETREXATE GLUCORONATE 5 $0.00
J3310 PERPHENAZINE INJECITON 5 $0.00
J3315 TRIPTORELIN PAMOATE 5 $0.00
J3320 SPECTINOMYCN DI-HCL INJ 5 $0.00
J3340 INJECTION, CRYPTENAMINE ACETATE, UP O $0.00
J3350 UREA INJECTION 5 $0.00
J3355 UROFOLLITROPIN, 75 IU 9 $0.00
J3360 DIAZEPAM INJECTION 3 $0.52
J3364 UROKINASE 5000 IU INJECTION 5 $0.00
J3365 UROKINASE 250,000 IU INJ 5 $0.00
J3370 VANCOMYCIN HCL INJECTION 3 $3.23
J3380 INJECTION, ISOXSUPRINE HCL, UP TO 1 O $0.00
J3390 METHOXAMINE INJECTION O $0.00
J3395 VERTEPORFIN INJECTION O $0.00
J3396 VERTEPORFIN INJECTION 3 $9.49
J3400 TRIFLUPROMAZINE HCL INJ 5 $0.00
J3410 HYDROXYZINE HCL INJECTION 3 $1.43
J3411 THIAMINE HCL 100 MG 3 $2.50
J3415 PYRIDOXINE HCL 100 MG 6 $0.00
J3420 VITAMIN B12 INJECTION 3 $0.27
J3430 VITAMIN K PHYTONADIONE INJ 5 $0.00
J3450 MEPHENTERMINE SULFATE INJ O $0.00
J3465 INJECTION, VORICONAZOLE 6 $0.00
J3470 HYALURONIDASE INJECTION 5 $0.00
J3471 OVINE, UP TO 999 USP UNITS 3 $0.15
J3472 OVINE, 1000 USP UNITS 3 $132.92
J3473 HYALURONIDASE RECOMBINANT 3 $0.48
J3475 INJ MAGNESIUM SULFATE 3 $0.05
J3480 INJ POTASSIUM CHLORIDE 3 $0.02
J3485 ZIDOVUDINE 5 $0.00
J3486 ZIPRASIDONE MESYLATE 3 $5.91
J3487 ZOLEDRONIC ACID 3 $219.39
J3488 RECLAST INJECTION 3 $220.20
J3490 DRUGS UNCLASSIFIED INJECTION 5 $0.00
J3500 VITAMIN THERAPY O $0.00
J3520 EDETATE DISODIUM PER 150 MG 5 $0.00
J3530 NASAL VACCINE INHALATION 9 $0.00
J3535 METERED DOSE INHALER DRUG 9 $0.00
J3540 AUTOGENOUS BLOOD EXTRACT, INTRAVENO O $0.00
J3550 INTRA-ARTERIAL OXYGEN INJECTION O $0.00
J3560 ADRENAL CORTEX EXTRACT O $0.00

J3570 LAETRILE AMYGDALIN VIT B17 9 $0.00
J3590 UNCLASSIFIED BIOLOGICS 5 $0.00
J6015 TYPHUS O $0.00
J7010 VIAL OF ALLERGY VACCINE, SINGLE DOS O $0.00
J7020 VIAL OF ALLERGY VACCINE, MULTIPLE D O $0.00
J7030 NORMAL SALINE SOLUTION INFUS 3 $0.46
J7040 NORMAL SALINE SOLUTION INFUS 3 $0.56
J7042 5% DEXTROSE/NORMAL SALINE 3 $0.34
J7050 NORMAL SALINE SOLUTION INFUS 3 $0.28
J7051 STERILE SALINE/WATER O $0.00
J7060 5% DEXTROSE/WATER 3 $1.13
J7070 D5W INFUSION 5 $0.00
J7080 INFUSION, ALBUMISOL 5%, 500 ML VIAL O $0.00
J7090 INFUSION, ALBUMISOL 25%, 50 ML VIAL O $0.00
J7100 DEXTRAN 40 INFUSION 5 $0.00
J7110 DEXTRAN 75 INFUSION 5 $0.00
J7120 RINGERS LACTATE INFUSION 3 $6.14
J7130 HYPERTONIC SALINE SOLUTION 5 $0.00
J7140 PRESCRIPTION DRUG, ORAL, DISPENSED 9 $0.00
J7150 PRESCRIPTION DRUG, ORAL CHEMOTHERAP 9 $0.00
J7185 XYNTHA INJ 3 $1.02
J7186 ANTIHEMOPHILIC VIII/VWF COMP 3 $0.67
J7187 HUMATE-P, INJ 3 $0.67
J7188 INJ VONWILLEBRAND FACTOR IU O $0.00
J7189 FACTOR VIIA 3 $1.30
J7190 FACTOR VIII 5 $0.00
J7191 FACTOR VIII (PORCINE) 5 $0.00
J7192 FACTOR VIII RECOMBINANT NOS 5 $0.00
J7193 FACTOR IX NON-RECOMBINANT 3 $0.77
J7194 FACTOR IX COMPLEX 5 $0.00
J7195 FACTOR IX RECOMBINANT 5 $0.00
J7196 OTHR HEMOPHILIA CLOT FACTORS O $0.00
J7197 ANTITHROMBIN III INJECTION 3 $2.32
J7198 ANTI-INHIBITOR 3 $1.03
J7199 HEMOPHILIA CLOT FACTOR NOC 5 $0.00
J7300 INTRAUT COPPER CONTRACEPTIVE 9 $0.00
J7302 LEVONORGESTREL IU CONTRACEPT 3 $703.05
J7303 CONTRACEPTIVE VAGINAL RING 9 $0.00
J7304 CONTRACEPTIVE HORMONE PATCH 9 $0.00
J7306 LEVONORGESTREL IMPLANT SYS 9 $0.00
J7307 ETONOGESTREL IMPLANT SYSTEM 3 $610.76
J7308 AMINOLEVULINIC ACID HCL TOP 9 $0.00
J7310 GANCICLOVIR LONG ACT IMPLANT 9 $0.00
J7311 FLUOCINOLONE ACETONIDE IMPLT 9 $0.00
J7315 SODIUM HYALURONATE INJECTION O $0.00
J7316 SODIUM HYALURONATE INJECTION O $0.00
J7317 SODIUM HYALURONATE INJECTION O $0.00
J7319 SODIUM HYALURONATE INJECTION O $0.00
J7320 HYLAN G-F 20 INJECTION O $0.00

J7321 HYALGAN/SUPARTZ INJ PER DOSE 3 $92.28
J7322 SYNVISC INJ PER DOSE O $0.00
J7323 EUFLEXXA INJ PER DOSE 3 $107.08
J7324 ORTHOVISC INJ PER DOSE 3 $176.05
J7325 SYNVISC OR SYNVISC-ONE 3 $11.74
J7330 CULTURED CHONDROCYTES IMPLNT 9 $0.00
J7340 METABOLIC ACTIVE D/E TISSUE O $0.00
J7341 NON-HUMAN, METABOLIC TISSUE O $0.00
J7342 METABOLICALLY ACTIVE TISSUE O $0.00
J7343 NONMETABOLIC ACT D/E TISSUE O $0.00
J7344 NONMETABOLIC ACTIVE TISSUE O $0.00
J7345 NON-HUMAN, NON-METAB TISSUE O $0.00
J7346 INJECTABLE HUMAN TISSUE O $0.00
J7347 INTEGRA MATRIX TISSUE O $0.00
J7348 TISSUEMEND TISSUE O $0.00
J7349 PRIMATRIX TISSUE O $0.00
J7350 INJECTABLE HUMAN TISSUE O $0.00
J7500 AZATHIOPRINE ORAL 50MG 9 $0.00
J7501 AZATHIOPRINE PARENTERAL 5 $0.00
J7502 CYCLOSPORINE ORAL 100 MG 9 $0.00
J7503 CYCLOSPORINE PARENTERAL O $0.00
J7504 LYMPHOCYTE IMMUNE GLOBULIN 5 $0.00
J7505 MONOCLONAL ANTIBODIES 5 $0.00
J7506 PREDNISONE ORAL 9 $0.00
J7507 TACROLIMUS ORAL PER 1 MG 9 $0.00
J7508 TACROLIMUS ORAL PER 5 MG O $0.00
J7509 METHYLPREDNISOLONE ORAL 9 $0.00
J7510 PREDNISOLONE ORAL PER 5 MG 9 $0.00
J7511 ANTITHYMOCYTE GLOBULN RABBIT 5 $0.00
J7513 DACLIZUMAB, PARENTERAL 5 $0.00
J7515 CYCLOSPORINE ORAL 25 MG 9 $0.00
J7516 CYCLOSPORIN PARENTERAL 250MG 5 $0.00
J7517 MYCOPHENOLATE MOFETIL ORAL 9 $0.00
J7518 MYCOPHENOLIC ACID 9 $0.00
J7520 SIROLIMUS, ORAL 9 $0.00
J7525 TACROLIMUS INJECTION 5 $0.00
J7599 IMMUNOSUPPRESSIVE DRUG NOC 5 $0.00
J7602 ALBUTEROL INH NON-COMP CON O $0.00
J7603 ALBUTEROL INH NON-COMP U D O $0.00
J7604 ACETYLCYSTEINE COMP UNIT 9 $0.00
J7605 ARFORMOTEROL NON-COMP UNIT 9 $0.00
J7606 FORMOTEROL FUMARATE, INH 9 $0.00
J7607 LEVALBUTEROL COMP CON 9 $0.00
J7608 ACETYLCYSTEINE NON-COMP UNIT 9 $0.00
J7609 ALBUTEROL COMP UNIT 9 $0.00
J7610 ALBUTEROL COMP CON 9 $0.00
J7611 ALBUTEROL NON-COMP CON O $0.00
J7612 LEVALBUTEROL NON-COMP CON O $0.00
J7613 ALBUTEROL NON-COMP UNIT O $0.00

J7614 LEVALBUTEROL NON-COMP UNIT O $0.00
J7615 LEVALBUTEROL COMP UNIT 9 $0.00
J7616 ALBUTEROL COMPOUND SOLUTION O $0.00
J7617 LEVALBUTEROL COMPOUNDED SOL O $0.00
J7618 ALBUTEROL INH SOL CON O $0.00
J7619 ALBUTEROL INH SOL U D O $0.00
J7620 ALBUTEROL IPRATROP NON-COMP 9 $0.00
J7621 (LEVO)ALBUTEROL/IPRA-BROMIDE O $0.00
J7622 BECLOMETHASONE COMP UNIT 9 $0.00
J7624 BETAMETHASONE COMP UNIT 9 $0.00
J7625 ALBUTEROL SULFATE .5% INJ O $0.00
J7626 BUDESONIDE NON-COMP UNIT 9 $0.00
J7627 BUDESONIDE COMP UNIT 9 $0.00
J7628 BITOLTEROL MESYLATE COMP CON 9 $0.00
J7629 BITOLTEROL MESYLATE COMP UNT 9 $0.00
J7630 CROMOLYN SODIUM INJECITON O $0.00
J7631 CROMOLYN SODIUM NONCOMP UNIT 9 $0.00
J7632 CROMOLYN SODIUM COMP UNIT 9 $0.00
J7633 BUDESONIDE NON-COMP CON 9 $0.00
J7634 BUDESONIDE COMP CON 9 $0.00
J7635 ATROPINE COMP CON 9 $0.00
J7636 ATROPINE COMP UNIT 9 $0.00
J7637 DEXAMETHASONE COMP CON 9 $0.00
J7638 DEXAMETHASONE COMP UNIT 9 $0.00
J7639 DORNASE ALFA NON-COMP UNIT 9 $0.00
J7640 FORMOTEROL COMP UNIT 9 $0.00
J7641 FLUNISOLIDE COMP UNIT 9 $0.00
J7642 GLYCOPYRROLATE COMP CON 9 $0.00
J7643 GLYCOPYRROLATE COMP UNIT 9 $0.00
J7644 IPRATROPIUM BROMIDE NON-COMP 9 $0.00
J7645 IPRATROPIUM BROMIDE COMP 9 $0.00
J7647 ISOETHARINE COMP CON 9 $0.00
J7648 ISOETHARINE NON-COMP CON 9 $0.00
J7649 ISOETHARINE NON-COMP UNIT 9 $0.00
J7650 ISOETHARINE COMP UNIT 9 $0.00
J7651 ISOETHARINE HCL .125% INJ O $0.00
J7652 ISOETHARINE HCL .167% INJ O $0.00
J7653 ISOETHARINE HCL .2%/ INJ O $0.00
J7654 ISOETHARINE HCL .25% INJ O $0.00
J7655 ISOETHARINE HCL 1% INJ O $0.00
J7657 ISOPROTERENOL COMP CON 9 $0.00
J7658 ISOPROTERENOL NON-COMP CON 9 $0.00
J7659 ISOPROTERENOL NON-COMP UNIT 9 $0.00
J7660 ISOPROTERENOL COMP UNIT 9 $0.00
J7665 ISOPROTERENOL HCL 1% INJ O $0.00
J7667 METAPROTERENOL COMP CON 9 $0.00
J7668 METAPROTERENOL NON-COMP CON 9 $0.00
J7669 METAPROTERENOL NON-COMP UNIT 9 $0.00
J7670 METAPROTERENOL COMP UNIT 9 $0.00

J7672 METAPROTERENOL SULFATE .6% O $0.00
J7674 METHACHOLINE CHLORIDE, NEB 9 $0.00
J7675 METAPROTERENOL SULFATE 5% O $0.00
J7676 PENTAMIDINE COMP UNIT DOSE 9 $0.00
J7680 TERBUTALINE SULF COMP CON 9 $0.00
J7681 TERBUTALINE SULF COMP UNIT 9 $0.00
J7682 TOBRAMYCIN NON-COMP UNIT 9 $0.00
J7683 TRIAMCINOLONE COMP CON 9 $0.00
J7684 TRIAMCINOLONE COMP UNIT 9 $0.00
J7685 TOBRAMYCIN COMP UNIT 9 $0.00
J7699 INHALATION SOLUTION FOR DME O $0.00
J7799 NON-INHALATION DRUG FOR DME O $0.00
J8498 ANTIEMETIC RECTAL/SUPP NOS 9 $0.00
J8499 ORAL PRESCRIP DRUG NON CHEMO 9 $0.00
J8501 ORAL APREPITANT 9 $0.00
J8510 ORAL BUSULFAN 9 $0.00
J8515 CABERGOLINE, ORAL 0.25MG 9 $0.00
J8520 CAPECITABINE, ORAL, 150 MG 9 $0.00
J8521 CAPECITABINE, ORAL, 500 MG 9 $0.00
J8530 CYCLOPHOSPHAMIDE ORAL 25 MG 9 $0.00
J8540 ORAL DEXAMETHASONE 9 $0.00
J8560 ETOPOSIDE ORAL 50 MG 9 $0.00
J8565 GEFITINIB ORAL 9 $0.00
J8597 ANTIEMETIC DRUG ORAL NOS 9 $0.00
J8600 MELPHALAN ORAL 2 MG 9 $0.00
J8610 METHOTREXATE ORAL 2.5 MG 9 $0.00
J8650 NABILONE ORAL 9 $0.00
J8700 TEMOZOLOMIDE 9 $0.00
J8705 TOPOTECAN ORAL 9 $0.00
J8999 ORAL PRESCRIPTION DRUG CHEMO 9 $0.00
J9000 DOXORUBICIN HCL INJECTION 3 $3.48
J9001 DOXORUBICIN HCL LIPOSOME INJ 3 $464.27
J9010 ALEMTUZUMAB INJECTION O $0.00
J9015 ALDESLEUKIN INJECTION 5 $0.00
J9017 ARSENIC TRIOXIDE INJECTION 3 $37.26
J9020 ASPARAGINASE INJECTION 3 $60.21
J9025 AZACITIDINE INJECTION 3 $4.79
J9027 CLOFARABINE INJECTION 3 $115.43
J9031 BCG LIVE INTRAVESICAL VAC 3 $110.63
J9033 BENDAMUSTINE INJECTION 3 $18.46
J9035 BEVACIZUMAB INJECTION 3 $57.46
J9040 BLEOMYCIN SULFATE INJECTION 3 $24.24
J9041 BORTEZOMIB INJECTION 3 $35.90
J9045 CARBOPLATIN INJECTION 3 $4.84
J9050 CARMUSTINE INJECTION 5 $0.00
J9055 CETUXIMAB INJECTION 3 $49.24
J9060 CISPLATIN 10 MG INJECTION 3 $2.08
J9062 CISPLATIN 50 MG INJECTION 3 $10.41
J9065 INJ CLADRIBINE PER 1 MG 5 $0.00

J9070 CYCLOPHOSPHAMIDE 100 MG INJ 5 $0.00
J9080 CYCLOPHOSPHAMIDE 200 MG INJ 5 $0.00
J9090 CYCLOPHOSPHAMIDE 500 MG INJ 3 $21.69
J9091 CYCLOPHOSPHAMIDE 1.0 GRM INJ 3 $43.39
J9092 CYCLOPHOSPHAMIDE 2.0 GRM INJ 5 $0.00
J9093 CYCLOPHOSPHAMIDE LYOPHILIZED 3 $5.16
J9094 CYCLOPHOSPHAMIDE LYOPHILIZED 3 $4.45
J9095 CYCLOPHOSPHAMIDE LYOPHILIZED 3 $11.13
J9096 CYCLOPHOSPHAMIDE LYOPHILIZED 3 $22.26
J9097 CYCLOPHOSPHAMIDE LYOPHILIZED 5 $0.00
J9098 CYTARABINE LIPOSOME INJ 6 $0.00
J9100 CYTARABINE HCL 100 MG INJ 3 $1.80
J9110 CYTARABINE HCL 500 MG INJ 3 $3.86
J9120 DACTINOMYCIN INJECTION 5 $0.00
J9130 DACARBAZINE 100 MG INJ 3 $4.14
J9140 DACARBAZINE 200 MG INJ 3 $8.11
J9150 DAUNORUBICIN INJECTION 3 $16.26
J9151 DAUNORUBICIN CITRATE INJ 5 $0.00
J9155 DEGARELIX INJECTION 3 $2.28
J9160 DENILEUKIN DIFTITOX INJ 5 $0.00
J9165 DIETHYLSTILBESTROL INJECTION 5 $0.00
J9170 DOCETAXEL INJECTION O $0.00
J9171 DOCETAXEL INJECTION 3 $17.62
J9175 ELLIOTTS B SOLUTION PER ML 3 $4.02
J9178 INJ, EPIRUBICIN HCL, 2 MG 3 $2.09
J9180 EPIRUBICIN HCL INJECTION O $0.00
J9181 ETOPOSIDE INJECTION 3 $0.45
J9182 ETOPOSIDE 100 MG INJ O $0.00
J9185 FLUDARABINE PHOSPHATE INJ 3 $151.12
J9190 FLUOROURACIL INJECTION 3 $1.60
J9200 FLOXURIDINE INJECTION 5 $0.00
J9201 GEMCITABINE HCL INJECTION 3 $144.88
J9202 GOSERELIN ACETATE IMPLANT 3 $203.86
J9206 IRINOTECAN INJECTION 3 $6.94
J9207 IXABEPILONE INJECTION 3 $63.37
J9208 IFOSFOMIDE INJECTION 5 $0.00
J9209 MESNA INJECTION 5 $0.00
J9211 IDARUBICIN HCL INJECTION 5 $0.00
J9212 INTERFERON ALFACON-1 INJ 5 $0.00
J9213 INTERFERON ALFA-2A INJ 5 $0.00
J9214 INTERFERON ALFA-2B INJ 3 $14.71
J9215 INTERFERON ALFA-N3 INJ 5 $0.00
J9216 INTERFERON GAMMA 1-B INJ 5 $0.00
J9217 LEUPROLIDE ACETATE SUSPNSION 3 $515.00
J9218 LEUPROLIDE ACETATE INJECITON 5 $0.00
J9219 LEUPROLIDE ACETATE IMPLANT 5 $0.00
J9225 VANTAS IMPLANT 3 $1,462.69
J9226 SUPPRELIN LA IMPLANT 6 $0.00
J9230 MECHLORETHAMINE HCL INJ 3 $152.79

J9240 MEDROXYPROGESTERONE ACETATE, 100 MG O $0.00
J9245 INJ MELPHALAN HYDROCHL 50 MG 5 $0.00
J9250 METHOTREXATE SODIUM INJ 5 $0.00
J9260 METHOTREXATE SODIUM INJ 3 $1.72
J9261 NELARABINE INJECTION 3 $103.30
J9263 OXALIPLATIN 3 $5.08
J9264 PACLITAXEL PROTEIN BOUND 3 $9.38
J9265 PACLITAXEL INJECTION 3 $9.44
J9266 PEGASPARGASE INJECTION 5 $0.00
J9268 PENTOSTATIN INJECTION 5 $0.00
J9270 PLICAMYCIN (MITHRAMYCIN) INJ 5 $0.00
J9280 MITOMYCIN 5 MG INJ 3 $15.64
J9290 MITOMYCIN 20 MG INJ 5 $0.00
J9291 MITOMYCIN 40 MG INJ 5 $0.00
J9293 MITOXANTRONE HYDROCHL / 5 MG 5 $0.00
J9295 POLYESTRADIOL PHOSPHATE 40 MG O $0.00
J9300 GEMTUZUMAB OZOGAMICIN INJ 5 $0.00
J9303 PANITUMUMAB INJECTION 3 $87.08
J9305 PEMETREXED INJECTION 3 $50.66
J9310 RITUXIMAB INJECTION 3 $567.99
J9320 STREPTOZOCIN INJECTION 5 $0.00
J9328 TEMOZOLOMIDE INJECTION 3 $4.84
J9330 TEMSIROLIMUS INJECTION 3 $49.22
J9340 THIOTEPA INJECTION 5 $0.00
J9350 TOPOTECAN INJECTION 3 $1,081.56
J9355 TRASTUZUMAB INJECTION 3 $64.18
J9357 VALRUBICIN INJECTION 5 $0.00
J9360 VINBLASTINE SULFATE INJ 3 $3.69
J9370 VINCRISTINE SULFATE 1 MG INJ 3 $5.68
J9375 VINCRISTINE SULFATE 2 MG INJ 3 $11.36
J9380 VINCRISTINE SULFATE 5 MG INJ 5 $0.00
J9390 VINORELBINE TARTRATE INJ 3 $19.64
J9395 INJECTION, FULVESTRANT 3 $82.36
J9600 PORFIMER SODIUM INJECTION 5 $0.00
J9999 CHEMOTHERAPY DRUG 5 $0.00
K0001 STANDARD WHEELCHAIR 3 $532.70
K0002 STND HEMI (LOW SEAT) WHLCHR 5 $0.00
K0003 LIGHTWEIGHT WHEELCHAIR 3 $0.00
K0004 HIGH STRENGTH LTWT WHLCHR 3 $1.00
K0005 ULTRALIGHTWEIGHT WHEELCHAIR 3 $1,839.61
K0006 HEAVY DUTY WHEELCHAIR 3 $0.00
K0007 EXTRA HEAVY DUTY WHEELCHAIR 5 $0.00
K0008 CSTM MANUAL WHEELCHAIR/BASE 9 $0.00
K0009 OTHER MANUAL WHEELCHAIR/BASE 5 $0.00
K0010 STND WT FRAME POWER WHLCHR 5 $0.00
K0011 STND WT PWR WHLCHR W CONTROL 5 $0.00
K0012 LTWT PORTBL POWER WHLCHR 5 $0.00
K0013 CUSTOM POWER WHLCHR BASE 9 $0.00
K0014 OTHER POWER WHLCHR BASE 5 $0.00

K0015 DETACH NON-ADJUS HGHT ARMRST 3 $180.80
K0016 DETACH ADJUST ARMRST CMPLETE O $0.00
K0017 DETACH ADJUST ARMREST BASE 3 $50.85
K0018 DETACH ADJUST ARMRST UPPER 3 $28.41
K0019 ARM PAD EACH 3 $14.58
K0020 FIXED ADJUST ARMREST PAIR 3 $46.23
K0021 ANTI-TIPPING DEVICE EACH O $0.00
K0022 REINFORCED BACK UPHOLSTERY O $0.00
K0023 PLANR BACK INSRT FOAM W/STRP O $0.00
K0024 PLNR BACK INSRT FOAM W/HRDWR O $0.00
K0025 HOOK-ON HEADREST EXTENSION O $0.00
K0026 BACK UPHOLST LGTWT WHLCHR O $0.00
K0027 BACK UPHOLST OTHER WHLCHR O $0.00
K0028 MANUAL FULLY RECLINING BACK O $0.00
K0029 REINFORCED SEAT UPHOLSTERY O $0.00
K0030 SOLID PLNR SEAT SNGL DNSFOAM O $0.00
K0031 SAFETY BELT/PELVIC STRAP O $0.00
K0032 SEAT UPHOLS LGTWT WHLCHR O $0.00
K0033 SEAT UPHOLSTERY OTHER WHLCHR O $0.00
K0034 HEEL LOOP EACH O $0.00
K0035 HEEL LOOP WITH ANKLE STRAP O $0.00
K0036 TOE LOOP EACH O $0.00
K0037 HIGH MOUNT FLIP-UP FOOTREST 3 $47.93
K0038 LEG STRAP EACH 3 $24.14
K0039 LEG STRAP H STYLE EACH 3 $53.61
K0040 ADJUSTABLE ANGLE FOOTPLATE 3 $67.58
K0041 LARGE SIZE FOOTPLATE EACH 3 $52.65
K0042 STANDARD SIZE FOOTPLATE EACH 3 $36.25
K0043 FTRST LOWER EXTENSION TUBE 3 $19.44
K0044 FTRST UPPER HANGER BRACKET 3 $16.56
K0045 FOOTREST COMPLETE ASSEMBLY 3 $56.34
K0046 ELEVAT LEGRST LOW EXTENSION 3 $19.44
K0047 ELEVAT LEGRST UP HANGR BRACK 3 $76.10
K0048 ELEVATE LEGREST COMPLETE O $0.00
K0049 CALF PAD EACH O $0.00
K0050 RATCHET ASSEMBLY 3 $32.34
K0051 CAM RELESE ASSEM FTRST/LGRST 3 $52.35
K0052 SWINGAWAY DETACH FOOTREST 3 $91.98
K0053 ELEVATE FOOTREST ARTICULATE 3 $101.51
K0054 SEAT WDTH 10-12/15/17/20 WC O $0.00
K0055 SEAT DPTH 15/17/18 LTWT WC O $0.00
K0056 SEAT HT =21 LTWT WC 3 $94.63
K0057 SEAT WDTH 19/20 HVY DTY WC O $0.00
K0058 SEAT DPTH 17/18 POWER WC O $0.00
K0059 PLASTIC COATED HANDRIM EACH O $0.00
K0060 STEEL HANDRIM EACH O $0.00
K0061 ALUMINUM HANDRIM EACH O $0.00
K0062 HANDRIM 8-10 VERT/OBLIQ PROJ O $0.00
K0063 HNDRM 12-16 VERT/OBLIQ PROJ O $0.00

K0064 ZERO PRESSURE TUBE FLAT FREE O $0.00
K0065 SPOKE PROTECTORS 3 $44.24
K0066 SOLID TIRE ANY SIZE EACH O $0.00
K0067 PNEUMATIC TIRE ANY SIZE EACH O $0.00
K0068 PNEUMATIC TIRE TUBE EACH O $0.00
K0069 REAR WHL COMPLETE SOLID TIRE 3 $99.42
K0070 REAR WHL COMPL PNEUM TIRE 3 $182.26
K0071 FRONT CASTR COMPL PNEUM TIRE 3 $108.71
K0072 FRNT CSTR CMPL SEM-PNEUM TIR 3 $65.43
K0073 CASTER PIN LOCK EACH 3 $34.63
K0074 PNEUMATIC CASTER TIRE EACH O $0.00
K0075 SEMI-PNEUMATIC CASTER TIRE O $0.00
K0076 SOLID CASTER TIRE EACH O $0.00
K0077 FRONT CASTER ASSEM COMPLETE 3 $58.56
K0078 PNEUMATIC CASTER TIRE TUBE O $0.00
K0079 WHEEL LOCK EXTENSION PAIR O $0.00
K0080 ANTI-ROLLBACK DEVICE PAIR O $0.00
K0081 WHEEL LOCK ASSEMBLY COMPLETE O $0.00
K0082 22 NF NONSEALED LEADACID O $0.00
K0083 22NF SEALED LEADACID BATTERY O $0.00
K0084 GR24 NONSEALED LEADACID O $0.00
K0085 GR 24 SEALED LEAD ACID BATTERY O $0.00
K0086 U1NONSEALED LEADACID BATTERY O $0.00
K0087 U1 SEALED LEADACID BATTERY O $0.00
K0088 BATTERY CHARGER, SINGLE MODE O $0.00
K0089 BATTERY CHARGER, DUAL MODE O $0.00
K0090 REAR TIRE POWER WHEELCHAIR O $0.00
K0091 REAR TIRE TUBE POWER WHLCHR O $0.00
K0092 REAR ASSEM CMPLT POWR WHLCHR O $0.00
K0093 REAR ZERO PRESSURE TIRE TUBE O $0.00
K0094 WHEEL TIRE FOR POWER BASE O $0.00
K0095 WHEEL TIRE TUBE EACH BASE O $0.00
K0096 WHEEL ASSEM POWR BASE COMPLT O $0.00
K0097 WHEEL ZERO PRESURE TIRE TUBE O $0.00
K0098 DRIVE BELT POWER WHEELCHAIR 3 $27.07
K0099 PWR WHEELCHAIR FRONT CASTER O $0.00
K0100 AMPUTEE ADAPTER PAIR O $0.00
K0101 ONE-ARM DRIVE ATTACHMENT O $0.00
K0102 CRUTCH AND CANE HOLDER O $0.00
K0103 TRANSFER BOARD < 25" O $0.00
K0104 CYLINDER TANK CARRIER O $0.00
K0105 IV HANGER 3 $98.94
K0106 ARM TROUGH EACH O $0.00
K0107 WHEELCHAIR TRAY O $0.00
K0108 W/C COMPONENT-ACCESSORY NOS 5 $0.00
K0109 CUSTOMIZE WHLCHR BASE FRAME 9 $0.00
K0110 SUPPLIES FOR MAINTENANCE OF DRUG IN 9 $0.00
K0111 SUPPLIES FOR EXTERNAL DRUG INFUSION 9 $0.00
K0112 TRUNK VEST SUPPRT INNR FRAME O $0.00

K0113 TRUNK VEST SUPRT W/O INR FRM O $0.00
K0114 WHLCHR BACK SUPRT INR FRAME O $0.00
K0115 BACK MODULE ORTHOTIC SYSTEM O $0.00
K0116 BACK & SEAT MODUL ORTHOT SYS O $0.00
K0117 UNLISTED ITEM, ORTHOTIC SEATING, BA O $0.00
K0118 TENS SUPPLIES - ONE MONTH SUPPLY FO O $0.00
K0119 AZATHIOPRINE ORAL TAB 50 MG 9 $0.00
K0120 AZATHIOPRINE PRENTRL 100 MG 9 $0.00
K0121 CYCLOSPORINE ORAL 25 MG 9 $0.00
K0122 CYCLOSPORINE PRENTRL 250 MG 9 $0.00
K0123 IMUN/ANTITYMOCYT GLOB 250 MG 9 $0.00
K0124 MONOCLONAL ANTIBODIES - PARENTERAL, 9 $0.00
K0125 PREDNISONE - ORAL, 5 MG 9 $0.00
K0126 REPLACE SOFT INTERFACE MATERIAL, MU 9 $0.00
K0127 REPLACE SOFT INTERFACE MATERIAL, AN 9 $0.00
K0128 REPLACE SOFT INTERFACE MATERIAL, FO 9 $0.00
K0129 ANKLE CONTRACTURE SPLINT 9 $0.00
K0130 FOOT DROP SPLINT, RECUMBENT POSITIO 9 $0.00
K0131 SPRING-POWERED DEVICE FOR LANCET O $0.00
K0132 MALE EXTERNAL CATHETER WITH OR WITH O $0.00
K0133 INTERMITTENT URINARY CATHETER, DISP O $0.00
K0134 INTERMITTENT URINARY CATHETER, DISP O $0.00
K0135 INTERMITTENT URINARY CATHETER, REUS O $0.00
K0136 INTERMITTENT URINARY CATHETER, REUS O $0.00
K0137 SKIN BARRIER LIQUID PER OZ 9 $0.00
K0138 SKIN BARRIER PASTE PER OZ 9 $0.00
K0139 SKIN BARRIER POWDER PER OZ 9 $0.00
K0140 ACETYLCYSTEINE, COMPOUNDED, PER MG, 9 $0.00
K0141 ALBUTEROL SULFATE, COMPOUNDED, PER 9 $0.00
K0142 CROMOLYN SODIUM, COMPOUNDED, PER MG 9 $0.00
K0143 ISOETHARINE HYDROCHLORIDE, COMPOUND 9 $0.00
K0144 ISOPROTHERENOL HYDROCHLORIDE, COMPO 9 $0.00
K0145 METAPROTERENOL, COMPOUNDED, PER MG, 9 $0.00
K0146 TERBUTALINE, COMPOUNDED, PER MG, IN 9 $0.00
K0147 GASTROSTOMY TUBE, SILICONE WITH SLI O $0.00
K0148 HYDROGEL DRESSING, EACH O $0.00
K0149 HYDROCOLLOID DRESSING, EACH O $0.00
K0150 ALGINATE DRESSING, EACH O $0.00
K0151 FOAM DRESSING, EACH O $0.00
K0152 PASTES, POWDERS, GRANULES, BEADS, C 9 $0.00
K0153 COMPOSITE DRESSING, EACH O $0.00
K0154 WOUND POUCH, EACH 9 $0.00
K0162 PROGRESSIVE LENS, EACH LENS O $0.00
K0163 VACUUM ERECTION SYSTEM 9 $0.00
K0164 OROPHARYNGEAL SUCTION CATHETER, EAC O $0.00
K0165 TRACHEOSTOMY CARE KIT FOR ESTABLISH O $0.00
K0166 METHYLPREDNISOLONE - ORAL, 4 MG O $0.00
K0167 PREDNISOLONE - ORAL, 5 MG O $0.00
K0168 DISPOSABLE NEBULIZER SET 9 $0.00

K0169 DISPOSABLE NEBULIZER SMALL 9 $0.00
K0170 NON DISPOSABLE NEBULIZER SET 9 $0.00
K0171 FILTERED NEBULIZER SET 9 $0.00
K0172 DISPOSABLE NEBULIZER UNFILL 9 $0.00
K0173 DISPOSABLE NEBULIZER PREFILL 9 $0.00
K0174 RESERVOIR BOTTLE W NEBULIZER 9 $0.00
K0175 DISPOSABLE CORRUGATED TUBING 9 $0.00
K0176 NON DISPOS CORRUGATED TUBING 9 $0.00
K0177 WATER COLLEC DEV W NEBULIZER 9 $0.00
K0178 DISPOSBL FILTER W COMPRESSOR 9 $0.00
K0179 NON-DISPOS FILTER W/COMPRESS 9 $0.00
K0180 AEROSOL MASK WITH NEBULIZER 9 $0.00
K0181 DOME & MOUTHPIECE W/ NEBULIZ 9 $0.00
K0182 WATER DISTILLED W/ NEBULIZER 9 $0.00
K0183 NASAL APPLICATION DEVICE O $0.00
K0184 NASAL PILLOW OR FACE SEAL O $0.00
K0185 POS AIRWAY PRESSURE HEADGEAR O $0.00
K0186 POS AIRWAY PRSSURE CHINSTRAP O $0.00
K0187 POS AIRWAY PRESSURE TUBING O $0.00
K0188 POS AIRWAY PRESSURE FILTER O $0.00
K0189 FILTER NONDISPOSABLE W PAP O $0.00
K0190 DISPOSABLE CANISTER W/PUMP 9 $0.00
K0191 NON-DISPOSBL CANISTER W/PUMP 9 $0.00
K0192 TUBING USED W/ SUCTION PUMP 9 $0.00
K0193 AIRWAY PRESSURE DEV/W HMDFER 9 $0.00
K0194 ASSIST DEVICE W/HUMIDIFIER 9 $0.00
K0195 ELEVATING WHLCHAIR LEG RESTS 3 $0.00
K0196 ALGINATE DRESSING, WOUND COVER, PAD 9 $0.00
K0197 ALGINATE DRESSING, WOUND COVER, PAD 9 $0.00
K0198 ALGINATE DRESSING, WOUND COVER, PAD 9 $0.00
K0199 ALGINATE DRESSING, WOUND FILLER, PE 9 $0.00
K0203 COMPOSITE DRESSING, PAD SIZE 16 SQ. 9 $0.00
K0204 COMPOSITE DRESSING, PAD SIZE MORE T 9 $0.00
K0205 COMPOSITE DRESSING, PAD SIZE MORE T 9 $0.00
K0206 CONTACT LAYER, 16 SQ. IN. OR LESS, 9 $0.00
K0207 CONTACT LAYER, MORE THAN 16 BUT LES 9 $0.00
K0208 CONTACT LAYER, MORE THAN 48 SQ. IN. 9 $0.00
K0209 FOAM DRESSING, WOUND COVER, PAD SIZ 9 $0.00
K0210 FOAM DRESSING, WOUND COVER, PAD SIZ 9 $0.00
K0211 FOAM DRESSING, WOUND COVER, PAD SIZ 9 $0.00
K0212 FOAM DRESSING, WOUND COVER, PAD SIZ 9 $0.00
K0213 FOAM DRESSING, WOUND COVER, PAD SIZ 9 $0.00
K0214 FOAM DRESSING, WOUND COVER, PAD SIZ 9 $0.00
K0215 FOAM DRESSING, WOUND FILLER, PER GR 9 $0.00
K0216 GAUZE, NON-IMPREGNATED, NON-STERILE 9 $0.00
K0217 GAUZE, NON-IMPREGNATED, NON-STERILE 9 $0.00
K0218 GAUZE, NON-IMPREGNATED, NON-STERILE 9 $0.00
K0219 GAUZE, NON-IMPREGNATED, PAD SIZE 16 9 $0.00
K0220 GAUZE, NON-IMPREGNATED, PAD SIZE MO 9 $0.00

K0221 GAUZE, NON-IMPREGNATED, PAD SIZE MO 9 $0.00
K0222 GAUZE, IMPREGNATED, OTHER THAN WATE 9 $0.00
K0223 GAUZE, IMPREGNATED, OTHER THAN WATE 9 $0.00
K0224 GAUZE, IMPREGNATED, OTHER THAN WATE 9 $0.00
K0228 GAUZE, IMPREGNATED, WATER OR NORMAL 9 $0.00
K0229 GAUZE, IMPREGNATED, WATER OR NORMAL 9 $0.00
K0230 GAUZE, IMPREGNATED, WATER OR NORMAL 9 $0.00
K0234 HYDROCOLLOID DRESSING, WOUND COVER, 9 $0.00
K0235 HYDROCOLLOID DRESSING, WOUND COVER, 9 $0.00
K0236 HYDROCOLLOID DRESSING, WOUND COVER, 9 $0.00
K0237 HYDROCOLLOID DRESSING, WOUND COVER, 9 $0.00
K0238 HYDROCOLLOID DRESSING, WOUND COVER, 9 $0.00
K0239 HYDROCOLLOID DRESSING, WOUND COVER, 9 $0.00
K0240 HYDROCOLLOID DRESSING, WOUND FILLER 9 $0.00
K0241 HYDROCOLLOID DRESSING, WOUND FILLER 9 $0.00
K0242 HYDROGEL DRESSING, WOUND COVER, PAD 9 $0.00
K0243 HYDROGEL DRESSING, WOUND COVER, PAD 9 $0.00
K0244 HYDROGEL DRESSING, WOUND COVER, PAD 9 $0.00
K0245 HYDROGEL DRESSING, WOUND COVER, PAD 9 $0.00
K0246 HYDROGEL DRESSING, WOUND COVER, PAD 9 $0.00
K0247 HYDROGEL DRESSING, WOUND COVER, PAD 9 $0.00
K0248 HYDROGEL DRESSING, WOUND FILLER, GE 9 $0.00
K0249 HYDROGEL DRESSING, WOUND FILLER, DR 9 $0.00
K0250 SKIN SEALANTS, PROTECTANTS, MOISTUR 9 $0.00
K0251 SPECIALTY ABSORPTIVE DRESSING, WOUN 9 $0.00
K0252 SPECIALTY ABSORPTIVE DRESSING, WOUN 9 $0.00
K0253 SPECIALTY ABSORPTIVE DRESSING, WOUN 9 $0.00
K0254 SPECIALTY ABSORPTIVE DRESSING, WOUN 9 $0.00
K0255 SPECIALTY ABSORPTIVE DRESSING, WOUN 9 $0.00
K0256 SPECIALTY ABSORPTIVE DRESSING, WOUN 9 $0.00
K0257 TRANSPARENT FILM, 16 SQ. IN. OR LES 9 $0.00
K0258 TRANSPARENT FILM, MORE THAN 16 BUT 9 $0.00
K0259 TRANSPARENT FILM, MORE THAN 48 SQ. 9 $0.00
K0260 WOUND CLEANSERS, ANY TYPE, ANY SIZE 9 $0.00
K0261 WOUND FILLER, NOT ELSEWHERE CLASSIF 9 $0.00
K0262 WOUND FILLER, NOT ELSEWHERE CLASSIF 9 $0.00
K0263 GAUZE, ELASTIC, NON-STERILE, ALL T 9 $0.00
K0264 GAUZE, NON-ELASTIC, NON-STERILE, PE 9 $0.00
K0265 TAPE, ALL TYPES, PER 18 SQUARE INCH 9 $0.00
K0266 GAUZE, IMPREGNATED, OTHER THAN WATE 9 $0.00
K0267 REPLACEMENT BATTERY, ANY TYPE, FOR O $0.00
K0268 HUMIDIFIER NONHEATED W PAP O $0.00
K0269 AEROSOL COMPRESSOR CPAP DEV 9 $0.00
K0270 ULTRASONIC GENERATOR W NEBUL 9 $0.00
K0271 POUCH, DRAINABLE; WITH FACEPLATE AT 9 $0.00
K0272 POUCH, DRAINABLE; WITHOUT FACEPLATE 9 $0.00
K0273 POUCH, URINARY; WITH FACEPLATE ATTA 9 $0.00
K0274 POUCH, URINARY; WITHOUT FACEPLATE A 9 $0.00
K0275 OSTOMY FACEPLATE; CONVEX; REUSABLE; 9 $0.00

K0276 OSTOMY FACEPLATE; CONVEX; CUSTOM FI 9 $0.00
K0277 SKIN BARRIER SOLID 4X4 EQUIV 9 $0.00
K0278 SKIN BARRIER WITH FLANGE 9 $0.00
K0279 SKIN BARRIER EXTENDED WEAR 9 $0.00
K0280 EXTENSION DRAINAGE TUBING 9 $0.00
K0281 LUBRICANT CATHETER INSERTION 9 $0.00
K0283 SALINE SOLUTION DISPENSER 9 $0.00
K0284 EXTERNAL INFUSION PUMP REUSE 9 $0.00
K0285 REPAIR OF PROSTHETIC DEVICE, LABOR 9 $0.00
K0400 SKIN SUPPORT ATTACHMENT EACH 9 $0.00
K0401 DIABETIC DELUXE SHOE 9 $0.00
K0402 GAUZE, NON-IMPREGNATED, STERILE, PA 9 $0.00
K0403 GAUZE, NON-IMPREGNATED, STERILE, PA 9 $0.00
K0404 GAUZE, NON-IMPREGNATED, STERILE, PA 9 $0.00
K0405 GAUZE, ELASTIC, STERILE, ALL TYPES, 9 $0.00
K0406 GAUZE, NON-ELASTIC, STERILE, PER LI 9 $0.00
K0407 URINARY CATH SKIN ATTACHMENT 9 $0.00
K0408 URINARY CATH LEG STRAP 9 $0.00
K0409 STERILE H2O IRRIGATION SOLUT 9 $0.00
K0410 MALE EXT CATH W/ADH COATING 9 $0.00
K0411 MALE EXT CATH W/ADH STRIP 9 $0.00
K0412 MYCOPHENOLATE MOFETIL 25O MG 9 $0.00
K0413 NON-POWERED, ADVANCED PRESSURE-REDU O $0.00
K0414 POWERED AIR OVERLAY FOR MATTRESS, S O $0.00
K0415 RX ANTIEMETIC DRG, ORAL NOS O $0.00
K0416 RX ANTIEMETIC DRG,RECTAL NOS O $0.00
K0417 MECH INFUS PUMP SHT TRM DRUG 9 $0.00
K0418 ORAL CYCLOSPORIN 9 $0.00
K0419 DRAINABLE PLSTIC PCH W FCPLT 9 $0.00
K0420 DRAINABLE RUBBER PCH W FCPLT 9 $0.00
K0421 DRAINABLE PLSTIC PCH W/O FP 9 $0.00
K0422 DRAINABLE RUBBER PCH W/O FP 9 $0.00
K0423 URINARY PLSTIC POUCH W FCPLT 9 $0.00
K0424 URINARY RUBBER POUCH W FCPLT 9 $0.00
K0425 URINARY PLSTIC POUCH W/O FP 9 $0.00
K0426 URINARY HVY PLSTC PCH W/O FP 9 $0.00
K0427 URINARY RUBBER POUCH W/O FP 9 $0.00
K0428 OSTOMY FACEPLT/SILICONE RING 9 $0.00
K0429 SKIN BARRIER SOLID EXT WEAR 9 $0.00
K0430 SKIN BARRIER W FLANG EX WEAR 9 $0.00
K0431 CLOSED POUCH W ST WEAR BAR 9 $0.00
K0432 DRAINABLE PCH W EX WEAR BAR 9 $0.00
K0433 DRAINABLE PCH W ST WEAR BAR 9 $0.00
K0434 DRAINABLE PCH EX WEAR CONVEX 9 $0.00
K0435 URINARY POUCH W EX WEAR BAR 9 $0.00
K0436 URINARY POUCH W ST WEAR BAR 9 $0.00
K0437 URINE PCH W EX WEAR BAR CONV 9 $0.00
K0438 OSTOMY POUCH LIQ DEODORANT 9 $0.00
K0439 OSTOMY POUCH SOLID DEODORANT 9 $0.00

K0440 NASAL PROSTHESIS 9 $0.00
K0441 MIDFACIAL PROSTHESIS 9 $0.00
K0442 ORBITAL PROSTHESIS 9 $0.00
K0443 UPPER FACIAL PROSTHESIS 9 $0.00
K0444 HEMI-FACIAL PROSTHESIS 9 $0.00
K0445 AURICULAR PROSTHESIS 9 $0.00
K0446 PARTIAL FACIAL PROSTHESIS 9 $0.00
K0447 NASAL SEPTAL PROSTHESIS 9 $0.00
K0448 UNSPEC MAXILLOFACIAL PROSTH 9 $0.00
K0449 REPAIR MAXILLOFACIAL PROSTH 9 $0.00
K0450 LIQ ADHES FOR FACIAL PROSTH 9 $0.00
K0451 ADHESIVE REMOVER WIPES 9 $0.00
K0452 WHEELCHAIR BEARINGS O $0.00
K0453 AMPHOTERICIN B 9 $0.00
K0455 PUMP UNINTERRUPTED INFUSION 9 $0.00
K0456 HEAVYDUTY/XTRA WIDE HOSP BED O $0.00
K0457 HEAVYDUTY/WIDE COMMODE CHAIR O $0.00
K0458 HEAVYDUTY WALKER NO WHEELS O $0.00
K0459 HEAVY DUTY WHEELED WALKER O $0.00
K0460 WC POWER ADD-ON JOYSTICK O $0.00
K0461 WC POWER ADD-ON TILLER CNTRL O $0.00
K0462 TEMPORARY REPLACEMENT EQPMNT 9 $0.00
K0501 AEROSOL COMPRESSOR FOR SVNEB 9 $0.00
K0503 ACETYLCYSTEINE INH SOL U D 9 $0.00
K0504 ALBUTEROL INH SOL CON 9 $0.00
K0505 ALBUTEROL INH SOL U D 9 $0.00
K0506 ATROPINE INH SOL CON 9 $0.00
K0507 ATROPINE INH SOL U D 9 $0.00
K0508 BITOLTEROL MES INH SOL CON 9 $0.00
K0509 BITOLTEROL MES INH SOL U D 9 $0.00
K0511 CROMOLYN SODIUM INH SOL U D 9 $0.00
K0512 DEXAMETHASONE INH SOL CON 9 $0.00
K0513 DEXAMETHASONE INH SOL U D 9 $0.00
K0514 DORNASE ALPHA INH SOL U D 9 $0.00
K0515 GLYCOPYRROLATE INH SOL CON 9 $0.00
K0516 GLYCOPYRROLATE INH SOL U D 9 $0.00
K0518 IPRATROPIUM BROM INH SOL U D 9 $0.00
K0519 ISOETHARINE HCL INH SOL CON 9 $0.00
K0520 ISOETHARINE HCL INH SOL U D 9 $0.00
K0521 ISOPROTERENOLHCL INH SOL CON 9 $0.00
K0522 ISOPROTERENOLHCL INH SOL U D 9 $0.00
K0523 METAPROTERENOL INH SOL CON 9 $0.00
K0524 METAPROTERENOL INH SOL U D 9 $0.00
K0525 TERBUTALINE SO4 INH SOL CON 9 $0.00
K0526 TERBUTALINE SO4 INH SOL U D 9 $0.00
K0527 TRIAMCINOLONE INH SOL CON 9 $0.00
K0528 TRIAMCINOLONE INH SOL U D 9 $0.00
K0529 STERILE H20 OR NSS W LV NEB 9 $0.00
K0530 NEBULIZER NOT USED W OXYGEN 9 $0.00

K0531 HEATED HUMIDIFIER USED W PAP O $0.00
K0532 NONINVASIVE ASSIST WO BACKUP O $0.00
K0533 NONINVASIVE ASSIST W BACKUP O $0.00
K0534 INVASIVE ASSIST W BACKUP O $0.00
K0538 NEG PRESSURE WND THRPY PUMP O $0.00
K0539 NEG PRES WND THRPY DSG SET O $0.00
K0540 NEG PRES WND THRP CANISTER O $0.00
K0541 SGD PRERECORDED MSG 8 MIN O $0.00
K0543 SGD MSG FORMED BY SPELLING O $0.00
K0544 SGD W MULTI METHODS MSG/ACCS O $0.00
K0545 SGD SFTWRE PRGRM FOR PC/PDA O $0.00
K0546 SGD ACCESSORY,MOUNTING SYSTM O $0.00
K0547 SGD ACCESSORY NOC O $0.00
K0549 HOSPITAL BED, HEAVY DUTY, EXTRA WI O $0.00
K0550 HOSPITAL BED, EXTRA HEAVY DUTY, EX O $0.00
K0551 RESIDUAL LIMB SUPPORT SYSTEM 9 $0.00
K0552 SUPPLY/EXT INF PUMP SYR TYPE 6 $0.00
K0553 COMBINATION ORAL/NASAL MASK 9 $0.00
K0554 REPL ORAL CUSHION COMBO MASK 9 $0.00
K0555 REPL NASAL PILLOW COMB MASK 9 $0.00
K0556 SOCKET INSERT W LOCK MECH O $0.00
K0557 SOCKET INSERT W/O LOCK MECH O $0.00
K0558 INTL CUSTM CONG/ATYP INSERT O $0.00
K0559 INITIAL CUSTOM SOCKET INSERT O $0.00
K0561 NONPECTIN BASED OSTOMY PASTE 9 $0.00
K0562 PECTIN BASED OSTOMY PASTE 9 $0.00
K0563 OSTOMY SKIN BARRIER WITH FLANGE (S O $0.00
K0565 OSTOMY SKIN BARRIER WITH FLANGE (S O $0.00
K0570 BUILT IN CONVEXITY, 4X INCHES OR S O $0.00
K0572 TAPE, NON WATERPROOF, PER 18 SQUAR O $0.00
K0573 TAPE, WATERPROOF, PER 18 SQUARE IN O $0.00
K0581 OST PCH CLSD W BARRIER/FILTR O $0.00
K0582 OST PCH W BAR/BLTINCONV/FLTR O $0.00
K0583 OST PCH CLSD W/O BAR W FILTR O $0.00
K0584 OST PCH FOR BAR W FLANGE/FLT O $0.00
K0585 OST PCH CLSD FOR BAR W LK FL O $0.00
K0586 OST PCH FOR BAR W LK FL/FLTR O $0.00
K0587 OST PCH DRAIN W BAR & FILTER O $0.00
K0588 OST PCH DRAIN FOR BARRIER FL O $0.00
K0589 OST PCH DRAIN 2 PIECE SYSTEM O $0.00
K0590 OST PCH DRAIN/BARR LK FLNG/F O $0.00
K0591 URINE OST POUCH W FAUCET/TAP O $0.00
K0592 URINE OST POUCH W BLTINCONV O $0.00
K0593 OST URINE PCH W B/BLTIN CONV O $0.00
K0594 OST PCH URINE W BARRIER/TAPV O $0.00
K0595 OS PCH URINE W BAR/FANGE/TAP O $0.00
K0596 URINE OST PCH BAR W LOCK FLN O $0.00
K0597 OST PCH URINE W LOCK FLNG/FT O $0.00

K0600 FUNCTIONAL NEUROMUSCULARSTIM O $0.00
K0601 REPL BATT SILVER OXIDE 1.5 V 6 $0.00
K0602 REPL BATT SILVER OXIDE 3 V 6 $0.00
K0603 REPL BATT ALKALINE 1.5 V 6 $0.00
K0604 REPL BATT LITHIUM 3.6 V 6 $0.00
K0605 REPL BATT LITHIUM 4.5 V 6 $0.00
K0606 AED GARMENT W ELEC ANALYSIS 6 $0.00
K0607 REPL BATT FOR AED 6 $0.00
K0608 REPL GARMENT FOR AED 6 $0.00
K0609 REPL ELECTRODE FOR AED 6 $0.00
K0618 TLSO 2 PIECE RIGID SHELL O $0.00
K0619 TLSO 3 PIECE RIGID SHELL O $0.00
K0620 TUBULAR ELASTIC DRESSING O $0.00
K0627 CERVICAL PNEUM TRAC EQUIP O $0.00
K0628 MULT DENS INSERT DIRECT FORM O $0.00
K0629 MULT DENS INSERT CUSTOM MOLD O $0.00
K0630 SIO FLEX PELVISACRAL PREFAB O $0.00
K0631 SIO FLEX PELVISACRAL CUSTOM O $0.00
K0632 SIO PANEL PREFAB O $0.00
K0633 SIO PANEL CUSTOM O $0.00
K0634 LO FLEXIBLE L1 BELOW L5 PRE O $0.00
K0635 LO SAG STAYS/PANELS PRE-FAB O $0.00
K0636 LO SAGITT RIGID PANEL PREFAB O $0.00
K0637 LO FLEX W/O RIGID STAYS PRE O $0.00
K0638 LSO FLEX W/RIGID STAYS CUST O $0.00
K0639 LSO POST RIGID PANEL PRE O $0.00
K0640 LSO SAG-CORO RIGID FRAME PRE O $0.00
K0641 LSO SAG-COR RIGID FRAME CUST O $0.00
K0642 LSO FLEXION CONTROL PREFAB O $0.00
K0643 LSO FLEXION CONTROL CUSTOM O $0.00
K0644 LSO SAGIT RIGID PANEL PREFAB O $0.00
K0645 LSO SAGITTAL RIGID PANEL CUS O $0.00
K0646 LSO SAG-CORONAL PANEL PREFAB O $0.00
K0647 LSO SAG-CORONAL PANEL CUSTOM O $0.00
K0648 LSO S/C SHELL/PANEL PREFAB O $0.00
K0649 LSO S/C SHELL/PANEL CUSTOM O $0.00
K0650 GEN W/C CUSHION WIDTH LESS THAN 22 O $0.00
K0651 GEN W/C CUSHION WIDTH GREATER THAN O $0.00
K0652 SKIN PROTECT W/C CUS WD LESS THAN2 O $0.00
K0653 SKIN PROTECT W/C CUS WD GREATER TH O $0.00
K0654 POSITION W/C CUSH WIDTH LESS THAN2 O $0.00
K0655 POSITION W/C CUSH WIDTH GREATER TH O $0.00
K0656 SKIN PRO/POS W/C CUS WD LESS THAN2 O $0.00
K0657 SKIN PRO/POS W/C CUS WD GREATER TH O $0.00
K0658 CUSTOM FABRICATE W/C CUSHION O $0.00
K0659 POWERED W/C CUSHION O $0.00
K0660 GEN USE BACK CUSH WIDTH LESS THAN2 O $0.00
K0661 GEN USE BACK CUSH WIDTH GREATER TH O $0.00
K0662 POSITION BACK CUSH WDTH LESS THAN2 O $0.00

K0663 POSITION BACK CUSH WDTH GREATER TH O $0.00
K0664 POS BACK POST/LAT WIDTH LESS THAN2 O $0.00
K0665 POS BACK POST/LAT WIDTH GREATER TH O $0.00
K0666 CUSTOM FAB W/C BACK CUSHION O $0.00
K0667 MT HARDWRE MAN/LIGHT PWR W/C O $0.00
K0668 REP ACE COVER W/C SEAT CUSH O $0.00
K0669 SEAT/BACK CUS NO SADMERC VER 6 $0.00
K0670 STANCE PHASE ONLY O $0.00
K0672 REMOVABLE SOFT INTERFACE LE 6 $0.00
K0730 CTRL DOSE INH DRUG DELIV SYS 6 $0.00
K0733 12-24HR SEALED LEAD ACID 6 $0.00
K0734 ADJ SKIN PRO W/C CUS WD=22IN 6 $0.00
K0736 ADJ SKIN PRO/POS WC CUS=22I 6 $0.00
K0738 PORTABLE GAS OXYGEN SYSTEM 6 $0.00
K0739 REPAIR/SVC DME NON-OXYGEN EQ. 3 $24.71
K0740 REPAIR/SVC OXYGEN EQUIPMENT 9 $0.00
K0800 POV GROUP 1 STD UP TO 300LBS 6 $0.00
K0801 POV GROUP 1 HD 301-450 LBS 6 $0.00
K0802 POV GROUP 1 VHD 451-600 LBS 6 $0.00
K0806 POV GROUP 2 STD UP TO 300LBS 6 $0.00
K0807 POV GROUP 2 HD 301-450 LBS 6 $0.00
K0808 POV GROUP 2 VHD 451-600 LBS 6 $0.00
K0812 POWER OPERATED VEHICLE NOC 6 $0.00
K0813 PWC GP 1 STD PORT SEAT/BACK 6 $0.00
K0814 PWC GP 1 STD PORT CAP CHAIR 6 $0.00
K0815 PWC GP 1 STD SEAT/BACK 6 $0.00
K0816 PWC GP 1 STD CAP CHAIR 6 $0.00
K0820 PWC GP 2 STD PORT SEAT/BACK 6 $0.00
K0821 PWC GP 2 STD PORT CAP CHAIR 6 $0.00
K0822 PWC GP 2 STD SEAT/BACK 6 $0.00
K0823 PWC GP 2 STD CAP CHAIR 6 $0.00
K0824 PWC GP 2 HD SEAT/BACK 6 $0.00
K0825 PWC GP 2 HD CAP CHAIR 6 $0.00
K0826 PWC GP 2 VHD SEAT/BACK 6 $0.00
K0827 PWC GP VHD CAP CHAIR 6 $0.00
K0828 PWC GP 2 XTRA HD SEAT/BACK 6 $0.00
K0829 PWC GP 2 XTRA HD CAP CHAIR 6 $0.00
K0830 PWC GP2 STD SEAT ELEVATE S/B 6 $0.00
K0831 PWC GP2 STD SEAT ELEVATE CAP 6 $0.00
K0835 PWC GP2 STD SING POW OPT S/B 6 $0.00
K0836 PWC GP2 STD SING POW OPT CAP 6 $0.00
K0837 PWC GP 2 HD SING POW OPT S/B 6 $0.00
K0838 PWC GP 2 HD SING POW OPT CAP 6 $0.00
K0839 PWC GP2 VHD SING POW OPT S/B 6 $0.00
K0840 PWC GP2 XHD SING POW OPT S/B 6 $0.00
K0841 PWC GP2 STD MULT POW OPT S/B 6 $0.00
K0842 PWC GP2 STD MULT POW OPT CAP 6 $0.00

K0843 PWC GP2 HD MULT POW OPT S/B 6 $0.00
K0848 PWC GP 3 STD SEAT/BACK 6 $0.00
K0849 PWC GP 3 STD CAP CHAIR 6 $0.00
K0850 PWC GP 3 HD SEAT/BACK 6 $0.00
K0851 PWC GP 3 HD CAP CHAIR 6 $0.00
K0852 PWC GP 3 VHD SEAT/BACK 6 $0.00
K0853 PWC GP 3 VHD CAP CHAIR 6 $0.00
K0854 PWC GP 3 XHD SEAT/BACK 6 $0.00
K0855 PWC GP 3 XHD CAP CHAIR 6 $0.00
K0856 PWC GP3 STD SING POW OPT S/B 6 $0.00
K0857 PWC GP3 STD SING POW OPT CAP 6 $0.00
K0858 PWC GP3 HD SING POW OPT S/B 6 $0.00
K0859 PWC GP3 HD SING POW OPT CAP 6 $0.00
K0860 PWC GP3 VHD SING POW OPT S/B 6 $0.00
K0861 PWC GP3 STD MULT POW OPT S/B 6 $0.00
K0862 PWC GP3 HD MULT POW OPT S/B 6 $0.00
K0863 PWC GP3 VHD MULT POW OPT S/B 6 $0.00
K0864 PWC GP3 XHD MULT POW OPT S/B 6 $0.00
K0868 PWC GP 4 STD SEAT/BACK 6 $0.00
K0869 PWC GP 4 STD CAP CHAIR 6 $0.00
K0870 PWC GP 4 HD SEAT/BACK 6 $0.00
K0871 PWC GP 4 VHD SEAT/BACK 6 $0.00
K0877 PWC GP4 STD SING POW OPT S/B 6 $0.00
K0878 PWC GP4 STD SING POW OPT CAP 6 $0.00
K0879 PWC GP4 HD SING POW OPT S/B 6 $0.00
K0880 PWC GP4 VHD SING POW OPT S/B 6 $0.00
K0884 PWC GP4 STD MULT POW OPT S/B 6 $0.00
K0885 PWC GP4 STD MULT POW OPT CAP 6 $0.00
K0886 PWC GP4 HD MULT POW S/B 6 $0.00
K0890 PWC GP5 PED SING POW OPT S/B 6 $0.00
K0891 PWC GP5 PED MULT POW OPT S/B 6 $0.00
K0898 POWER WHEELCHAIR NOC 6 $0.00
K0899 POW MOBIL DEV NO SADMERC 9 $0.00
KKEVL MCO SPECIFIC CODE: DPH KIDS KARE IN O $0.00
KKTX1 MCO SPECIFIC CODE: DPH KIDS KARE TE O $0.00
KKTX2 MCO SPECIFIC CODE: DPH KIDS KARE TE O $0.00
L0100 CRANIAL ORTHOSIS/HELMET MOLD O $0.00
L0101 ONE-ARM DRIVE ATTACHMENT, EACH O $0.00
L0110 CRANIAL ORTHOSIS/HELMET NONM O $0.00
L0112 CRANIAL CERVICAL ORTHOSIS 6 $0.00
L0113 CRANIAL CERVICAL TORTICOLLIS 6 $0.00
L0120 CERV FLEXIBLE NON-ADJUSTABLE 3 $20.07
L0130 FLEX THERMOPLASTIC COLLAR MO 3 $141.92
L0140 CERVICAL SEMI-RIGID ADJUSTAB 3 $46.91
L0150 CERV SEMI-RIG ADJ MOLDED CHN 3 $86.11
L0160 CERV SEMI-RIG WIRE OCC/MAND 3 $112.45
L0170 CERVICAL COLLAR MOLDED TO PT 3 $463.04
L0172 CERV COL THERMPLAS FOAM 2 PI 3 $100.39
L0174 CERV COL FOAM 2 PIECE W THOR 3 $197.24

L0180 CER POST COL OCC/MAN SUP ADJ 3 $273.50
L0190 CERV COLLAR SUPP ADJ CERV BA 3 $355.67
L0200 CERV COL SUPP ADJ BAR & THOR 3 $370.78
L0210 THORACIC RIB BELT O $0.00
L0220 THOR RIB BELT CUSTOM FABRICA 3 $101.25
L0300 TLSO FLEX SURGICAL SUPPORT O $0.00
L0310 TLSO FLEXIBLE CUSTOM FABRICA O $0.00
L0315 TLSO FLEX ELAS RIGID POST PA O $0.00
L0317 TLSO FLEX HYPEXT ELAS POST P O $0.00
L0320 TLSO A-P CONTRL W APRON FRNT O $0.00
L0321 TLSO ANTI-POST-CNTRL PREFAB O $0.00
L0330 TLSO ANT-POS-LATERAL CONTROL O $0.00
L0331 TLSO ANT-POST-LAT CNTRL PRFB O $0.00
L0340 TLSO A-P-L-ROTARY WITH APRON O $0.00
L0350 TLSO FLEX COMPRESS JACKET CU O $0.00
L0360 TLSO FLEX COMPRESS JACKET MO O $0.00
L0370 TLSO A-P-L-ROTARY HYPEREXTEN O $0.00
L0380 TLSO A-P-L-ROT W/ POS EXTENS O $0.00
L0390 TLSO A-P-L CONTROL MOLDED O $0.00
L0391 TLSO ANT-POST-LAT-ROT CNTRL O $0.00
L0400 TLSO A-P-L W INTERFACE MATER O $0.00
L0410 TLSO A-P-L TWO PIECE CONSTR O $0.00
L0420 TLSO A-P-L 2 PIECE W INTERFA O $0.00
L0430 DEWALL POSTURE PROTECTOR 6 $0.00
L0440 TLSO A-P-L OVERLAP FRNT CUST O $0.00
L0450 TLSO FLEX PREFAB THORACIC 5 $0.00
L0452 TLSO FLEX CUSTOM FAB THORACI 5 $0.00
L0454 TLSO FLEX PREFAB SACROCOC-T9 5 $0.00
L0456 TLSO FLEX PREFAB 5 $0.00
L0458 TLSO 2MOD SYMPHIS-XIPHO PRE 5 $0.00
L0460 TLSO2MOD SYMPHYSIS-STERN PRE 5 $0.00
L0462 TLSO 3MOD SACRO-SCAP PRE 3 $1,050.90
L0464 TLSO 4MOD SACRO-SCAP PRE 5 $0.00
L0466 TLSO RIGID FRAME PRE SOFT AP 5 $0.00
L0468 TLSO RIGID FRAME PREFAB PELV 5 $0.00
L0470 TLSO RIGID FRAME PRE SUBCLAV 5 $0.00
L0472 TLSO RIGID FRAME HYPEREX PRE 5 $0.00
L0474 TLSO RIGID FRAME PRE PELVIC O $0.00
L0476 TLSO FLEXION COMPRES JAC PRE O $0.00
L0478 TLSO FLEXION COMPRES JAC CUS O $0.00
L0480 TLSO RIGID PLASTIC CUSTOM FA 5 $0.00
L0482 TLSO RIGID LINED CUSTOM FAB 5 $0.00
L0484 TLSO RIGID PLASTIC CUST FAB 5 $0.00
L0486 TLSO RIGIDLINED CUST FAB TWO 5 $0.00
L0488 TLSO RIGID LINED PRE ONE PIE 5 $0.00
L0490 TLSO RIGID PLASTIC PRE ONE 5 $0.00
L0491 TLSO 2 PIECE RIGID SHELL 6 $0.00
L0492 TLSO 3 PIECE RIGID SHELL 6 $0.00
L0500 LSO FLEX SURGICAL SUPPORT O $0.00

L0510 LSO FLEXIBLE CUSTOM FABRICAT O $0.00
L0515 LSO FLEX ELAS W/ RIG POST PA O $0.00
L0520 LSO A-P-L CONTROL WITH APRON O $0.00
L0530 LSO ANT-POS CONTROL W APRON O $0.00
L0540 LSO LUMBAR FLEXION A-P-L O $0.00
L0550 LSO A-P-L CONTROL MOLDED O $0.00
L0560 LSO A-P-L W INTERFACE O $0.00
L0561 PREFAB LSO O $0.00
L0565 LSO A-P-L CONTROL CUSTOM O $0.00
L0600 SACROILIAC FLEX SURG SUPPORT O $0.00
L0610 SACROILIAC FLEXIBLE CUSTM FA O $0.00
L0620 SACROILIAC SEMI-RIG W APRON O $0.00
L0621 SIO FLEX PELVISACRAL PREFAB 6 $0.00
L0622 SIO FLEX PELVISACRAL CUSTOM 6 $0.00
L0623 SIO PANEL PREFAB 6 $0.00
L0624 SIO PANEL CUSTOM 6 $0.00
L0625 LO FLEXIBL L1-BELOW L5 PRE 6 $0.00
L0626 LO SAG STAYS/PANELS PRE-FAB 6 $0.00
L0627 LO SAGITT RIGID PANEL PREFAB 6 $0.00
L0628 LO FLEX W/O RIGID STAYS PRE 6 $0.00
L0629 LSO FLEX W/RIGID STAYS CUST 6 $0.00
L0630 LSO POST RIGID PANEL PRE 3 $127.26
L0631 LSO SAG-CORO RIGID FRAME PRE 6 $0.00
L0632 LSO SAG RIGID FRAME CUST 6 $0.00
L0633 LSO FLEXION CONTROL PREFAB 6 $0.00
L0634 LSO FLEXION CONTROL CUSTOM 6 $0.00
L0635 LSO SAGIT RIGID PANEL PREFAB 6 $0.00
L0636 LSO SAGITTAL RIGID PANEL CUS 6 $0.00
L0637 LSO SAG-CORONAL PANEL PREFAB 6 $0.00
L0638 LSO SAG-CORONAL PANEL CUSTOM 6 $0.00
L0639 LSO S/C SHELL/PANEL PREFAB 6 $0.00
L0640 LSO S/C SHELL/PANEL CUSTOM 6 $0.00
L0700 CTLSO A-P-L CONTROL MOLDED 3 $1,467.79
L0710 CTLSO A-P-L CONTROL W/ INTER 3 $1,499.54
L0810 HALO CERVICAL INTO JCKT VEST 3 $1,875.37
L0820 HALO CERVICAL INTO BODY JACK 3 $1,683.27
L0830 HALO CERV INTO MILWAUKEE TYP 3 $2,372.22
L0859 MRI COMPATIBLE SYSTEM 6 $0.00
L0860 MAGNETIC RESONANC IMAGE COMP O $0.00
L0861 HALO REPL LINER/INTERFACE 6 $0.00
L0900 TORSO/PTOSIS SUPPORT O $0.00
L0910 TORSO & PTOSIS SUPP CUSTM FA O $0.00
L0920 TORSO/PENDULOUS ABD SUPPORT O $0.00
L0930 PENDULOUS ABDOMEN SUPP CUSTM O $0.00
L0940 TORSO/POSTSURGICAL SUPPORT O $0.00
L0950 POST SURG SUPPORT CUSTOM FAB O $0.00
L0960 POST SURGICAL SUPPORT PADS O $0.00
L0970 TLSO CORSET FRONT 3 $96.55
L0972 LSO CORSET FRONT 3 $86.71

L0974 TLSO FULL CORSET 3 $128.76
L0976 LSO FULL CORSET 3 $114.81
L0978 AXILLARY CRUTCH EXTENSION 3 $151.56
L0980 PERONEAL STRAPS PAIR 3 $16.53
L0982 STOCKING SUPP GRIPS SET OF F 3 $11.69
L0984 PROTECTIVE BODY SOCK EACH 3 $48.54
L0986 SPINAL ORTH ABDM PNL PREFAB O $0.00
L0999 ADD TO SPINAL ORTHOSIS NOS 5 $0.00
L1000 CTLSO MILWAUKE INITIAL MODEL 3 $1,472.64
L1001 CTLSO INFANT IMMOBILIZER 6 $0.00
L1005 TENSION BASED SCOLIOSIS ORTH 5 $0.00
L1010 CTLSO AXILLA SLING 3 $48.19
L1020 KYPHOSIS PAD 3 $62.06
L1025 KYPHOSIS PAD FLOATING 3 $118.46
L1030 LUMBAR BOLSTER PAD 3 $45.67
L1040 LUMBAR OR LUMBAR RIB PAD 3 $59.77
L1050 STERNAL PAD 3 $72.03
L1060 THORACIC PAD 3 $86.42
L1070 TRAPEZIUS SLING 3 $84.40
L1080 OUTRIGGER 3 $47.48
L1085 OUTRIGGER BIL W/ VERT EXTENS 3 $128.42
L1090 LUMBAR SLING 3 $84.96
L1100 RING FLANGE PLASTIC/LEATHER 3 $135.65
L1110 RING FLANGE PLAS/LEATHER MOL 3 $183.38
L1120 COVERS FOR UPRIGHT EACH 3 $31.00
L1200 FURNSH INITIAL ORTHOSIS ONLY 3 $1,124.98
L1210 LATERAL THORACIC EXTENSION 3 $187.88
L1220 ANTERIOR THORACIC EXTENSION 3 $179.47
L1230 MILWAUKEE TYPE SUPERSTRUCTUR 3 $460.04
L1240 LUMBAR DEROTATION PAD 3 $62.18
L1250 ANTERIOR ASIS PAD 3 $62.18
L1260 ANTERIOR THORACIC DEROTATION 3 $63.50
L1270 ABDOMINAL PAD 3 $64.52
L1280 RIB GUSSET (ELASTIC) EACH 3 $74.19
L1290 LATERAL TROCHANTERIC PAD 3 $58.74
L1300 BODY JACKET MOLD TO PATIENT 3 $1,322.50
L1310 POST-OPERATIVE BODY JACKET 3 $1,358.90
L1499 SPINAL ORTHOSIS NOS 5 $0.00
L1500 THKAO MOBILITY FRAME 3 $1,363.82
L1510 THKAO STANDING FRAME 3 $862.81
L1520 THKAO SWIVEL WALKER 3 $1,638.02
L1600 ABDUCT HIP FLEX FREJKA W CVR 3 $92.52
L1610 ABDUCT HIP FLEX FREJKA COVR 3 $40.82
L1620 ABDUCT HIP FLEX PAVLIK HARNE 3 $115.65
L1630 ABDUCT CONTROL HIP SEMI-FLEX 3 $121.67
L1640 PELV BAND/SPREAD BAR THIGH C 3 $370.37
L1650 HO ABDUCTION HIP ADJUSTABLE 3 $187.41
L1652 HO BI THIGHCUFFS W SPRDR BAR 5 $0.00
L1660 HO ABDUCTION STATIC PLASTIC 3 $122.87

L1680 PELVIC & HIP CONTROL THIGH C 3 $874.83
L1685 POST-OP HIP ABDUCT CUSTOM FA 3 $892.79
L1686 HO POST-OP HIP ABDUCTION 3 $824.39
L1690 COMBINATION BILATERAL HO 3 $1,449.30
L1700 LEG PERTHES ORTH TORONTO TYP 3 $1,096.46
L1710 LEGG PERTHES ORTH NEWINGTON 3 $1,283.53
L1720 LEGG PERTHES ORTHOSIS TRILAT 3 $946.12
L1730 LEGG PERTHES ORTH SCOTTISH R 3 $812.63
L1750 LEGG PERTHES SLING O $0.00
L1755 LEGG PERTHES PATTEN BOTTOM T 3 $1,289.59
L1800 KNEE ORTHOSES ELAS W STAYS O $0.00
L1810 KO ELASTIC WITH JOINTS 3 $70.71
L1815 ELASTIC WITH CONDYLAR PADS O $0.00
L1820 KO ELAS W/ CONDYLE PADS & JO 3 $109.56
L1825 KO ELASTIC KNEE CAP O $0.00
L1830 KO IMMOBILIZER CANVAS LONGIT 3 $66.62
L1831 KNEE ORTH POS LOCKING JOINT 6 $0.00
L1832 KO ADJ JNT POS RIGID SUPPORT 3 $507.82
L1834 KO W/0 JOINT RIGID MOLDED TO 3 $557.35
L1836 RIGID KO WO JOINTS 5 $0.00
L1840 KO DEROT ANT CRUCIATE CUSTOM 3 $742.41
L1843 KO SINGLE UPRIGHT CUSTOM FIT 3 $672.48
L1844 KO W/ADJ JT ROT CNTRL MOLDED 3 $1,165.61
L1845 KO W/ ADJ FLEX/EXT ROTAT CUS 3 $697.85
L1846 KO W ADJ FLEX/EXT ROTAT MOLD 3 $791.83
L1847 KO ADJUSTABLE W AIR CHAMBERS 3 $431.07
L1850 KO SWEDISH TYPE 3 $218.25
L1855 KO PLAS DOUB UPRIGHT JNT MOL O $0.00
L1858 KO POLYCENTRIC PNEUMATIC PAD O $0.00
L1860 KO SUPRACONDYLAR SOCKET MOLD 3 $770.45
L1870 KO DOUB UPRIGHT LACERS MOLDE O $0.00
L1880 KO DOUB UPRIGHT CUFFS/LACERS O $0.00
L1885 KNEE UPRIGHT W/RESISTANCE O $0.00
L1900 AFO SPRNG WIR DRSFLX CALF BD 3 $193.70
L1901 PREFAB ANKLE ORTHOSIS O $0.00
L1902 AFO ANKLE GAUNTLET 3 $66.93
L1904 AFO MOLDED ANKLE GAUNTLET 3 $402.52
L1906 AFO MULTILIGAMENTUS ANKLE SU 3 $86.35
L1907 AFO SUPRAMALLEOLAR CUSTOM 6 $0.00
L1910 AFO SING BAR CLASP ATTACH SH 3 $196.12
L1920 AFO SING UPRIGHT W/ ADJUST S 3 $251.01
L1930 AFO PLASTIC 3 $169.85
L1932 AFO RIG ANT TIB PREFAB TCF/= 6 $0.00
L1940 AFO MOLDED TO PATIENT PLASTI 3 $355.08
L1945 AFO MOLDED PLAS RIG ANT TIB 3 $848.95
L1950 AFO SPIRAL MOLDED TO PT PLAS 3 $562.89
L1951 AFO SPIRAL PREFABRICATED 6 $0.00
L1960 AFO POS SOLID ANK PLASTIC MO 3 $424.55
L1970 AFO PLASTIC MOLDED W/ANKLE J 3 $510.90

L1971 AFO W/ANKLE JOINT, PREFAB 6 $0.00
L1980 AFO SING SOLID STIRRUP CALF 3 $263.51
L1990 AFO DOUB SOLID STIRRUP CALF 3 $320.05
L2000 KAFO SING FRE STIRR THI/CALF 3 $758.23
L2005 KAFO SNG/DBL MECHANICAL ACT 6 $0.00
L2010 KAFO SNG SOLID STIRRUP W/O J 3 $707.32
L2020 KAFO DBL SOLID STIRRUP BAND/ 3 $890.63
L2030 KAFO DBL SOLID STIRRUP W/O J 3 $808.48
L2034 KAFO PLA SIN UP W/WO K/A CUS 6 $0.00
L2035 KAFO PLASTIC PEDIATRIC SIZE 3 $131.14
L2036 KAFO PLAS DOUB FREE KNEE MOL 3 $1,380.47
L2037 KAFO PLAS SING FREE KNEE MOL 3 $1,287.91
L2038 KAFO W/O JOINT MULTI-AXIS AN 3 $1,308.30
L2039 KAFO,PLSTIC,MEDLAT ROTAT CON O $0.00
L2040 HKAFO TORSION BIL ROT STRAPS 3 $158.68
L2050 HKAFO TORSION CABLE HIP PELV 3 $342.03
L2060 HKAFO TORSION BALL BEARING J 3 $416.86
L2070 HKAFO TORSION UNILAT ROT STR 3 $107.04
L2080 HKAFO UNILAT TORSION CABLE 3 $258.25
L2090 HKAFO UNILAT TORSION BALL BR 3 $314.84
L2102 AFO TIBIAL FX CAST PLSTR MOL O $0.00
L2104 AFO TIB FX CAST SYNTHETIC MO O $0.00
L2106 AFO TIB FX CAST PLASTER MOLD 3 $488.18
L2108 AFO TIB FX CAST MOLDED TO PT 3 $850.00
L2112 AFO TIBIAL FRACTURE SOFT 3 $390.97
L2114 AFO TIB FX SEMI-RIGID 3 $490.39
L2116 AFO TIBIAL FRACTURE RIGID 3 $564.23
L2122 KAFO FEM FX CAST PLASTER MOL O $0.00
L2124 KAFO FEM FX CAST SYNTHET MOL O $0.00
L2126 KAFO FEM FX CAST THERMOPLAS 3 $943.82
L2128 KAFO FEM FX CAST MOLDED TO P 3 $1,336.53
L2132 KAFO FEMORAL FX CAST SOFT 3 $724.60
L2134 KAFO FEM FX CAST SEMI-RIGID 3 $773.23
L2136 KAFO FEMORAL FX CAST RIGID 3 $922.89
L2180 PLAS SHOE INSERT W ANK JOINT 3 $86.13
L2182 DROP LOCK KNEE 3 $71.37
L2184 LIMITED MOTION KNEE JOINT 3 $97.56
L2186 ADJ MOTION KNEE JNT LERMAN T 3 $135.31
L2188 QUADRILATERAL BRIM 3 $259.14
L2190 WAIST BELT 3 $66.96
L2192 PELVIC BAND & BELT THIGH FLA 3 $294.02
L2200 LIMITED ANKLE MOTION EA JNT 3 $34.14
L2210 DORSIFLEXION ASSIST EACH JOI 3 $49.41
L2220 DORSI & PLANTAR FLEX ASS/RES 3 $58.80
L2230 SPLIT FLAT CALIPER STIRR & P 3 $55.09
L2232 ROCKER BOTTOM, CONTACT AFO 6 $0.00
L2240 ROUND CALIPER AND PLATE ATTA 3 $68.19
L2250 FOOT PLATE MOLDED STIRRUP AT 3 $276.47
L2260 REINFORCED SOLID STIRRUP 3 $143.93

L2265 LONG TONGUE STIRRUP 3 $84.55
L2270 VARUS/VALGUS STRAP PADDED/LI 3 $39.65
L2275 PLASTIC MOD LOW EXT PAD/LINE 3 $93.48
L2280 MOLDED INNER BOOT 3 $326.87
L2300 ABDUCTION BAR JOINTED ADJUST 3 $204.94
L2310 ABDUCTION BAR-STRAIGHT 3 $102.64
L2320 NON-MOLDED LACER 3 $147.73
L2330 LACER MOLDED TO PATIENT MODE 3 $309.23
L2335 ANTERIOR SWING BAND 3 $190.92
L2340 PRE-TIBIAL SHELL MOLDED TO P 3 $413.33
L2350 PROSTHETIC TYPE SOCKET MOLDE 3 $713.86
L2360 EXTENDED STEEL SHANK 3 $37.15
L2370 PATTEN BOTTOM 3 $240.71
L2375 TORSION ANK & HALF SOLID STI 3 $101.69
L2380 TORSION STRAIGHT KNEE JOINT 3 $88.39
L2385 STRAIGHT KNEE JOINT HEAVY DU 3 $96.17
L2387 ADD LE POLY KNEE CUSTOM KAFO 6 $0.00
L2390 OFFSET KNEE JOINT EACH 3 $80.51
L2395 OFFSET KNEE JOINT HEAVY DUTY 3 $112.34
L2397 SUSPENSION SLEEVE LOWER EXT 3 $87.53
L2405 KNEE JOINT DROP LOCK EA JNT 3 $65.34
L2415 KNEE JOINT CAM LOCK EACH JOI 3 $91.03
L2425 KNEE DISC/DIAL LOCK/ADJ FLEX 3 $107.43
L2430 KNEE JNT RATCHET LOCK EA JNT 3 $107.43
L2435 KNEE JOINT POLYCENTRIC JOINT O $0.00
L2492 KNEE LIFT LOOP DROP LOCK RIN 3 $97.54
L2500 THI/GLUT/ISCHIA WGT BEARING 3 $233.34
L2510 TH/WGHT BEAR QUAD-LAT BRIM M 3 $523.55
L2520 TH/WGHT BEAR QUAD-LAT BRIM C 3 $345.37
L2525 TH/WGHT BEAR NAR M-L BRIM MO 3 $931.80
L2526 TH/WGHT BEAR NAR M-L BRIM CU 3 $531.72
L2530 THIGH/WGHT BEAR LACER NON-MO 3 $168.70
L2540 THIGH/WGHT BEAR LACER MOLDED 3 $303.55
L2550 THIGH/WGHT BEAR HIGH ROLL CU 3 $206.21
L2570 HIP CLEVIS TYPE 2 POSIT JNT 3 $341.99
L2580 PELVIC CONTROL PELVIC SLING 3 $333.23
L2600 HIP CLEVIS/THRUST BEARING FR 3 $182.48
L2610 HIP CLEVIS/THRUST BEARING LO 3 $193.28
L2620 PELVIC CONTROL HIP HEAVY DUT 3 $217.32
L2622 HIP JOINT ADJUSTABLE FLEXION 3 $246.37
L2624 HIP ADJ FLEX EXT ABDUCT CONT 3 $237.76
L2627 PLASTIC MOLD RECIPRO HIP & C 3 $1,297.39
L2628 METAL FRAME RECIPRO HIP & CA 3 $1,276.17
L2630 PELVIC CONTROL BAND & BELT U 3 $177.79
L2640 PELVIC CONTROL BAND & BELT B 3 $241.29
L2650 PELV & THOR CONTROL GLUTEAL 3 $102.75
L2660 THORACIC CONTROL THORACIC BA 3 $133.82
L2670 THORAC CONT PARASPINAL UPRIG 3 $129.79
L2680 THORAC CONT LAT SUPPORT UPRI 3 $120.23

L2750 PLATING CHROME/NICKEL PR BAR 3 $60.02
L2755 CARBON GRAPHITE LAMINATION 3 $97.91
L2760 EXTENSION PER EXTENSION PER 3 $43.62
L2768 ORTHO SIDEBAR DISCONNECT 5 $0.00
L2770 LOW EXT ORTHOSIS PER BAR/JNT O $0.00
L2780 NON-CORROSIVE FINISH 3 $48.59
L2785 DROP LOCK RETAINER EACH 3 $22.86
L2795 KNEE CONTROL FULL KNEECAP 3 $61.97
L2800 KNEE CAP MEDIAL OR LATERAL P 3 $95.24
L2810 KNEE CONTROL CONDYLAR PAD 3 $74.77
L2820 SOFT INTERFACE BELOW KNEE SE 3 $62.35
L2830 SOFT INTERFACE ABOVE KNEE SE 3 $67.46
L2840 TIBIAL LENGTH SOCK FX OR EQU 3 $39.88
L2850 FEMORAL LGTH SOCK FX OR EQUA 3 $44.46
L2860 TORSION MECHANISM KNEE/ANKLE O $0.00
L2861 TORSION MECHANISM KNEE/ANKLE 6 $0.00
L2999 LOWER EXTREMITY ORTHOSIS NOS 5 $0.00
L3000 FT INSERT UCB BERKELEY SHELL 3 $80.00
L3001 FOOT INSERT REMOV MOLDED SPE 5 $0.00
L3002 FOOT INSERT PLASTAZOTE OR EQ 5 $0.00
L3003 FOOT INSERT SILICONE GEL EAC 5 $0.00
L3010 FOOT LONGITUDINAL ARCH SUPPO 5 $0.00
L3020 FOOT LONGITUD/METATARSAL SUP 3 $155.91
L3030 FOOT ARCH SUPPORT REMOV PREM 5 $0.00
L3031 FOOT LAMIN/PREPREG COMPOSITE 6 $0.00
L3040 FT ARCH SUPRT PREMOLD LONGIT 5 $0.00
L3050 FOOT ARCH SUPP PREMOLD METAT 5 $0.00
L3060 FOOT ARCH SUPP LONGITUD/META 5 $0.00
L3070 ARCH SUPRT ATT TO SHO LONGIT 5 $0.00
L3080 ARCH SUPP ATT TO SHOE METATA 5 $0.00
L3090 ARCH SUPP ATT TO SHOE LONG/M 5 $0.00
L3100 HALLUS-VALGUS NGHT DYNAMIC S 5 $0.00
L3140 ABDUCTION ROTATION BAR SHOE 5 $0.00
L3150 ABDUCT ROTATION BAR W/O SHOE 5 $0.00
L3160 SHOE STYLED POSITIONING DEV 5 $0.00
L3170 FOOT PLASTIC HEEL STABILIZER 5 $0.00
L3201 OXFORD W SUPINAT/PRONAT INF 5 $0.00
L3202 OXFORD W/ SUPINAT/PRONATOR C 5 $0.00
L3203 OXFORD W/ SUPINATOR/PRONATOR 5 $0.00
L3204 HIGHTOP W/ SUPP/PRONATOR INF 5 $0.00
L3206 HIGHTOP W/ SUPP/PRONATOR CHI 5 $0.00
L3207 HIGHTOP W/ SUPP/PRONATOR JUN 5 $0.00
L3208 SURGICAL BOOT EACH INFANT 5 $0.00
L3209 SURGICAL BOOT EACH CHILD 5 $0.00
L3211 SURGICAL BOOT EACH JUNIOR 5 $0.00
L3212 BENESCH BOOT PAIR INFANT 5 $0.00
L3213 BENESCH BOOT PAIR CHILD 5 $0.00
L3214 BENESCH BOOT PAIR JUNIOR 5 $0.00
L3215 ORTHOPEDIC FTWEAR LADIES OXF 3 $86.72

L3216 ORTHOPED LADIES SHOES DPTH I 5 $0.00
L3217 LADIES SHOES HIGHTOP DEPTH I 5 $0.00
L3218 LADIES SURGICAL BOOT EACH O $0.00
L3219 ORTHOPEDIC MENS SHOES OXFORD 3 $89.02
L3221 ORTHOPEDIC MENS SHOES DPTH I 5 $0.00
L3222 MENS SHOES HIGHTOP DEPTH INL 5 $0.00
L3223 MENS SURGICAL BOOT EACH O $0.00
L3224 WOMAN'S SHOE OXFORD BRACE 3 $47.77
L3225 MAN'S SHOE OXFORD BRACE 3 $49.05
L3230 CUSTOM SHOES DEPTH INLAY 5 $0.00
L3250 CUSTOM MOLD SHOE REMOV PROST 5 $0.00
L3251 SHOE MOLDED TO PT SILICONE S 5 $0.00
L3252 SHOE MOLDED PLASTAZOTE CUST 5 $0.00
L3253 SHOE MOLDED PLASTAZOTE CUST 5 $0.00
L3254 ORTH FOOT NON-STNDARD SIZE/W 5 $0.00
L3255 ORTH FOOT NON-STANDARD SIZE/ 5 $0.00
L3257 ORTH FOOT ADD CHARGE SPLIT S 5 $0.00
L3260 AMBULATORY SURGICAL BOOT EAC 5 $0.00
L3265 PLASTAZOTE SANDAL EACH 5 $0.00
L3300 SHO LIFT TAPER TO METATARSAL 5 $0.00
L3310 SHOE LIFT ELEV HEEL/SOLE NEO 5 $0.00
L3320 SHOE LIFT ELEV HEEL/SOLE COR 5 $0.00
L3330 LIFTS ELEVATION METAL EXTENS 5 $0.00
L3332 SHOE LIFTS TAPERED TO ONE-HA 5 $0.00
L3334 SHOE LIFTS ELEVATION HEEL /I 5 $0.00
L3340 SHOE WEDGE SACH 5 $0.00
L3350 SHOE HEEL WEDGE 5 $0.00
L3360 SHOE SOLE WEDGE OUTSIDE SOLE 5 $0.00
L3370 SHOE SOLE WEDGE BETWEEN SOLE 5 $0.00
L3380 SHOE CLUBFOOT WEDGE 5 $0.00
L3390 SHOE OUTFLARE WEDGE 5 $0.00
L3400 SHOE METATARSAL BAR WEDGE RO 5 $0.00
L3410 SHOE METATARSAL BAR BETWEEN 5 $0.00
L3420 FULL SOLE/HEEL WEDGE BTWEEN 5 $0.00
L3430 SHO HEEL COUNT PLAST REINFOR 5 $0.00
L3440 HEEL LEATHER REINFORCED 5 $0.00
L3450 SHOE HEEL SACH CUSHION TYPE 5 $0.00
L3455 SHOE HEEL NEW LEATHER STANDA 5 $0.00
L3460 SHOE HEEL NEW RUBBER STANDAR 5 $0.00
L3465 SHOE HEEL THOMAS WITH WEDGE 5 $0.00
L3470 SHOE HEEL THOMAS EXTEND TO B 5 $0.00
L3480 SHOE HEEL PAD & DEPRESS FOR 5 $0.00
L3485 SHOE HEEL PAD REMOVABLE FOR 5 $0.00
L3500 ORTHO SHOE ADD LEATHER INSOL 5 $0.00
L3510 ORTHOPEDIC SHOE ADD RUB INSL 5 $0.00
L3520 O SHOE ADD FELT W LEATH INSL 5 $0.00
L3530 ORTHO SHOE ADD HALF SOLE 5 $0.00
L3540 ORTHO SHOE ADD FULL SOLE 5 $0.00
L3550 O SHOE ADD STANDARD TOE TAP 5 $0.00

L3560 O SHOE ADD HORSESHOE TOE TAP 5 $0.00
L3570 O SHOE ADD INSTEP EXTENSION 5 $0.00
L3580 O SHOE ADD INSTEP VELCRO CLO 5 $0.00
L3590 O SHOE CONVERT TO SOF COUNTE 5 $0.00
L3595 ORTHO SHOE ADD MARCH BAR 5 $0.00
L3600 TRANS SHOE CALIP PLATE EXIST 5 $0.00
L3610 TRANS SHOE CALIPER PLATE NEW 3 $30.00
L3620 TRANS SHOE SOLID STIRRUP EXI 5 $0.00
L3630 TRANS SHOE SOLID STIRRUP NEW 5 $0.00
L3640 SHOE DENNIS BROWNE SPLINT BO 5 $0.00
L3649 ORTHOPEDIC SHOE MODIFICA NOS 5 $0.00
L3650 SHLDER FIG 8 ABDUCT RESTRAIN 3 $47.75
L3651 PREFAB SHOULDER ORTHOSIS O $0.00
L3652 PREFAB DBL SHOULDER ORTHOSIS O $0.00
L3660 ABDUCT RESTRAINER CANVAS&WEB 3 $72.21
L3670 ACROMIO/CLAVICULAR CANVAS&WE 3 $95.42
L3671 SO CAP DESIGN W/O JNTS CF 6 $0.00
L3672 SO AIRPLANE W/O JNTS CF 6 $0.00
L3673 SO AIRPLANE W/JOINT CF 6 $0.00
L3675 CANVAS VEST SO 3 $119.70
L3677 SO HARD PLASTIC STABILIZER 5 $0.00
L3700 ELBOW ORTHOSES ELAS W STAYS O $0.00
L3701 PREFAB ELBOW ORTHOSIS O $0.00
L3702 EO W/O JOINTS CF 6 $0.00
L3710 ELBOW ELASTIC WITH METAL JOI 3 $109.80
L3720 FOREARM/ARM CUFFS FREE MOTIO 3 $489.89
L3730 FOREARM/ARM CUFFS EXT/FLEX A 3 $633.36
L3740 CUFFS ADJ LOCK W/ ACTIVE CON 3 $750.90
L3760 EO WITHJOINT, PREFABRICATED 3 $341.11
L3762 RIGID EO WO JOINTS 5 $0.00
L3763 EWHO RIGID W/O JNTS CF 6 $0.00
L3764 EWHO W/JOINT(S) CF 6 $0.00
L3765 EWHFO RIGID W/O JNTS CF 6 $0.00
L3766 EWHFO W/JOINT(S) CF 6 $0.00
L3800 WHFO SHORT OPPONEN NO ATTACH O $0.00
L3805 WHFO LONG OPPONENS NO ATTACH O $0.00
L3806 WHFO W/JOINT(S) CUSTOM FAB 6 $0.00
L3807 WHFO,NO JOINT, PREFABRICATED 3 $170.55
L3808 WHFO, RIGID W/O JOINTS 6 $0.00
L3810 WHFO THUMB ABDUCTION BAR O $0.00
L3815 WHFO SECOND M.P. ABDUCTION A O $0.00
L3820 WHFO IP EXT ASST W/ MP EXT S O $0.00
L3825 WHFO M.P. EXTENSION STOP O $0.00
L3830 WHFO M.P. EXTENSION ASSIST O $0.00
L3835 WHFO M.P. SPRING EXTENSION A O $0.00
L3840 WHFO SPRING SWIVEL THUMB O $0.00
L3845 WHFO THUMB IP EXT ASS W/ MP O $0.00
L3850 ACTION WRIST W/ DORSIFLEX AS O $0.00
L3855 WHFO ADJ M.P. FLEXION CONTRO O $0.00

L3860 WHFO ADJ M.P. FLEX CTRL & I. O $0.00
L3890 TORSION MECHANISM WRIST/ELBO O $0.00
L3891 TORSION MECHANISM WRIST/ELBO 6 $0.00
L3900 HINGE EXTENSION/FLEX WRIST/F 3 $994.57
L3901 HINGE EXT/FLEX WRIST FINGER 3 $1,129.43
L3902 WHFO EXT POWER COMPRESS GAS O $0.00
L3904 WHFO ELECTRIC CUSTOM FITTED 3 $2,057.53
L3905 WHO W/NONTORSION JNT(S) CF 6 $0.00
L3906 WHO W/O JOINTS CF 3 $300.34
L3907 WHFO WRST GAUNTLT THMB SPICA O $0.00
L3908 WRIST COCK-UP NON-MOLDED 3 $47.27
L3909 PREFAB WRIST ORTHOSIS O $0.00
L3910 WHFO SWANSON DESIGN O $0.00
L3911 PREFAB HAND FINGER ORTHOSIS O $0.00
L3912 FLEX GLOVE W/ELASTIC FINGER 3 $81.88
L3913 HFO W/O JOINTS CF 6 $0.00
L3914 WHO WRIST EXTENSION COCK-UP O $0.00
L3915 WHO W NONTOR JNT(S) PREFAB 6 $0.00
L3916 WHFO WRIST EXTENS W/ OUTRIGG O $0.00
L3917 PREFAB METACARPL FX ORTHOSIS 6 $0.00
L3918 HFO KNUCKLE BENDER O $0.00
L3919 HO W/O JOINTS CF 6 $0.00
L3920 KNUCKLE BENDER WITH OUTRIGGE O $0.00
L3921 HFO W/JOINT(S) CF 6 $0.00
L3922 KNUCKLE BEND 2 SEG TO FLEX J O $0.00
L3923 HFO W/O JOINTS PF 3 $25.99
L3924 OPPENHEIMER O $0.00
L3925 FO PIP/DIP WITH JOINT/SPRING 6 $0.00
L3926 THOMAS SUSPENSION O $0.00
L3927 FO PIP/DIP W/O JOINT/SPRING 6 $0.00
L3928 FINGER EXTENSION W/ CLOCK SP O $0.00
L3929 HFO NONTORSION JOINT, PREFAB 6 $0.00
L3930 FINGER EXTENSION WITH WRIST O $0.00
L3931 WHFO NONTORSION JOINT PREFAB 6 $0.00
L3932 SAFETY PIN SPRING WIRE O $0.00
L3933 FO W/O JOINTS CF 6 $0.00
L3934 SAFETY PIN MODIFIED O $0.00
L3935 FO NONTORSION JOINT CF 6 $0.00
L3936 PALMER O $0.00
L3938 DORSAL WRIST O $0.00
L3940 DORSAL WRIST W/ OUTRIGGER AT O $0.00
L3942 REVERSE KNUCKLE BENDER O $0.00
L3944 REVERSE KNUCKLE BEND W/ OUTR O $0.00
L3946 HFO COMPOSITE ELASTIC O $0.00
L3948 FINGER KNUCKLE BENDER O $0.00
L3950 OPPENHEIMER W/ KNUCKLE BEND O $0.00
L3952 OPPENHEIMER W/ REV KNUCKLE 2 O $0.00
L3954 SPREADING HAND O $0.00
L3956 ADD JOINT UPPER EXT ORTHOSIS 5 $0.00

L3960 SEWHO AIRPLAN DESIG ABDU POS 3 $516.83
L3961 SEWHO CAP DESIGN W/O JNTS CF 6 $0.00
L3962 SEWHO ERBS PALSEY DESIGN ABD 3 $504.11
L3963 MOLDED W/ ARTICULATING ELBOW O $0.00
L3964 SEO MOBILE ARM SUP ATT TO WC 3 $594.21
L3965 ARM SUPP ATT TO WC RANCHO TY 3 $948.19
L3966 MOBILE ARM SUPPORTS RECLININ 3 $714.31
L3967 SEWHO AIRPLANE W/O JNTS CF 6 $0.00
L3968 FRICTION DAMPENING ARM SUPP 3 $903.93
L3969 MONOSUSPENSION ARM/HAND SUPP 3 $615.05
L3970 ELEVAT PROXIMAL ARM SUPPORT 3 $252.86
L3971 SEWHO CAP DESIGN W/JNT(S) CF 6 $0.00
L3972 OFFSET/LAT ROCKER ARM W/ ELA 3 $160.79
L3973 SEWHO AIRPLANE W/JNT(S) CF 6 $0.00
L3974 MOBILE ARM SUPPORT SUPINATOR 3 $136.38
L3975 SEWHFO CAP DESIGN W/O JNT CF 6 $0.00
L3976 SEWHFO AIRPLANE W/O JNTS CF 6 $0.00
L3977 SEWHFO CAP DESGN W/JNT(S) CF 6 $0.00
L3978 SEWHFO AIRPLANE W/JNT(S) CF 6 $0.00
L3980 UPP EXT FX ORTHOSIS HUMERAL 3 $224.99
L3982 UPPER EXT FX ORTHOSIS RAD/UL 3 $262.29
L3984 UPPER EXT FX ORTHOSIS WRIST 3 $241.83
L3985 FOREARM HAND FX ORTH W/ WR H O $0.00
L3986 HUMERAL RAD/ULNA WRIST FX OR O $0.00
L3995 SOCK FRACTURE OR EQUAL EACH 3 $25.05
L3999 UPPER LIMB ORTHOSIS NOS 5 $0.00
L4000 REPL GIRDLE MILWAUKEE ORTH 3 $988.41
L4002 REPLACE STRAP, ANY ORTHOSIS 6 $0.00
L4010 REPLACE TRILATERAL SOCKET BR 3 $481.87
L4020 REPLACE QUADLAT SOCKET BRIM 3 $673.89
L4030 REPLACE SOCKET BRIM CUST FIT 3 $362.50
L4040 REPLACE MOLDED THIGH LACER 3 $295.81
L4045 REPLACE NON-MOLDED THIGH LAC 3 $235.52
L4050 REPLACE MOLDED CALF LACER 3 $296.42
L4055 REPLACE NON-MOLDED CALF LACE 3 $191.94
L4060 REPLACE HIGH ROLL CUFF 3 $228.18
L4070 REPLACE PROX & DIST UPRIGHT 3 $202.07
L4080 REPL MET BAND KAFO-AFO PROX 3 $82.87
L4090 REPL MET BAND KAFO-AFO CALF/ 3 $65.40
L4100 REPL LEATH CUFF KAFO PROX TH 3 $85.87
L4110 REPL LEATH CUFF KAFO-AFO CAL 3 $64.70
L4130 REPLACE PRETIBIAL SHELL 3 $362.78
L4200 REPAIR OF ORTHOTIC DEVICE, HOURLY R O $0.00
L4205 ORTHO DVC REPAIR PER 15 MIN 3 $6.25
L4210 ORTH DEV REPAIR/REPL MINOR P 5 $0.00
L4310 MULT-PODUS/EQ ORTH PREP MGMT O $0.00
L4320 LOW EXT MGMT SYS FT POS AFO O $0.00
L4350 ANKLE CONTROL ORTHOSI PREFAB 3 $71.87
L4360 PNEUMATI WALKING BOOT PREFAB 3 $220.93

L4370 PNEUMATIC FULL LEG SPLINT 3 $146.11
L4380 PNEUMATIC KNEE SPLINT 3 $82.45
L4386 NON-PNEUM WALK BOOT PREFAB 3 $124.58
L4390 REPLACE MULTI-PODUS SPLINT O $0.00
L4392 REPLACE AFO SOFT INTERFACE 3 $17.63
L4394 REPLACE FOOT DROP SPINT 3 $12.87
L4396 STATIC AFO 3 $125.77
L4398 FOOT DROP SPLINT RECUMBENT 3 $57.91
L5000 SHO INSERT W ARCH TOE FILLER 3 $426.36
L5010 MOLD SOCKET ANK HGT W/ TOE F 3 $931.27
L5020 TIBIAL TUBERCLE HGT W/ TOE F 3 $1,515.92
L5050 ANK SYMES MOLD SCKT SACH FT 3 $1,755.51
L5060 SYMES MET FR LEATH SOCKET AR 3 $2,112.77
L5100 MOLDED SOCKET SHIN SACH FOOT 3 $1,828.78
L5105 PLAST SOCKET JTS/THGH LACER 3 $2,902.64
L5150 MOLD SCKT EXT KNEE SHIN SACH 3 $2,686.23
L5160 MOLD SOCKET BENT KNEE SHIN S 3 $2,921.76
L5200 KNE SING AXIS FRIC SHIN SACH 3 $2,545.10
L5210 NO KNEE/ANKLE JOINTS W/ FT B 3 $1,856.19
L5220 NO KNEE JOINT WITH ARTIC ALI 3 $2,109.89
L5230 FEM FOCAL DEFIC CONSTANT FRI 3 $2,909.97
L5250 HIP CANAD SING AXI CONS FRIC 3 $3,968.93
L5270 TILT TABLE LOCKING HIP SING 3 $3,934.16
L5280 HEMIPELVECT CANAD SING AXIS 3 $3,894.82
L5300 BK SACH SOFT COVER & FINISH O $0.00
L5301 BK MOLD SOCKET SACH FT ENDO 5 $0.00
L5310 KNEE DISART SACH SOFT CV/FIN O $0.00
L5311 KNEE DISART, SACH FT, ENDO 5 $0.00
L5320 AK OPEN END SACH SOFT CV/FIN O $0.00
L5321 AK OPEN END SACH 5 $0.00
L5330 HIP CANADIAN SACH SFT CV/FIN O $0.00
L5331 HIP DISART CANADIAN SACH FT 5 $0.00
L5340 HEMIPELVECTOMY CANAD CV/FIN O $0.00
L5341 HEMIPELVECTOMY CANADIAN SACH 5 $0.00
L5400 POSTOP DRESS & 1 CAST CHG BK 3 $920.64
L5410 POSTOP DSG BK EA ADD CAST CH 3 $403.36
L5420 POSTOP DSG & 1 CAST CHG AK/D 3 $1,162.72
L5430 POSTOP DSG AK EA ADD CAST CH 3 $513.24
L5450 POSTOP APP NON-WGT BEAR DSG 3 $328.33
L5460 POSTOP APP NON-WGT BEAR DSG 3 $483.92
L5500 INIT BK PTB PLASTER DIRECT 3 $982.44
L5505 INIT AK ISCHAL PLSTR DIRECT 3 $1,330.47
L5510 PREP BK PTB PLASTER MOLDED 3 $1,113.65
L5520 PERP BK PTB THERMOPLS DIRECT 3 $1,100.03
L5530 PREP BK PTB THERMOPLS MOLDED 3 $1,392.40
L5535 PREP BK PTB OPEN END SOCKET 3 $1,372.22
L5540 PREP BK PTB LAMINATED SOCKET 3 $1,448.99
L5560 PREP AK ISCHIAL PLAST MOLDED 3 $1,486.72
L5570 PREP AK ISCHIAL DIRECT FORM 3 $1,545.67

L5580 PREP AK ISCHIAL THERMO MOLD 3 $1,804.46
L5585 PREP AK ISCHIAL OPEN END 3 $1,957.15
L5590 PREP AK ISCHIAL LAMINATED 3 $1,838.87
L5595 HIP DISARTIC SACH THERMOPLS 3 $3,232.24
L5600 HIP DISART SACH LAMINAT MOLD 3 $3,525.47
L5610 ABOVE KNEE HYDRACADENCE 3 $1,583.72
L5611 AK 4 BAR LINK W/FRIC SWING 3 $1,232.45
L5613 AK 4 BAR LING W/HYDRAUL SWIG 3 $1,874.64
L5614 4-BAR LINK ABOVE KNEE W/SWNG 3 $1,267.18
L5616 AK UNIV MULTIPLEX SYS FRICT 3 $1,038.91
L5617 AK/BK SELF-ALIGNING UNIT EA 3 $420.17
L5618 TEST SOCKET SYMES 3 $242.04
L5620 TEST SOCKET BELOW KNEE 3 $212.67
L5622 TEST SOCKET KNEE DISARTICULA 3 $324.80
L5624 TEST SOCKET ABOVE KNEE 3 $309.88
L5626 TEST SOCKET HIP DISARTICULAT 3 $435.56
L5628 TEST SOCKET HEMIPELVECTOMY 3 $412.54
L5629 BELOW KNEE ACRYLIC SOCKET 3 $315.05
L5630 SYME TYP EXPANDABL WALL SCKT 3 $343.30
L5631 AK/KNEE DISARTIC ACRYLIC SOC 3 $410.52
L5632 SYMES TYPE PTB BRIM DESIGN S 3 $169.85
L5634 SYMES TYPE POSTER OPENING SO 3 $232.68
L5636 SYMES TYPE MEDIAL OPENING SO 3 $194.91
L5637 BELOW KNEE TOTAL CONTACT 3 $260.35
L5638 BELOW KNEE LEATHER SOCKET 3 $372.27
L5639 BELOW KNEE WOOD SOCKET 3 $873.31
L5640 KNEE DISARTICULAT LEATHER SO 3 $531.69
L5642 ABOVE KNEE LEATHER SOCKET 3 $476.00
L5643 HIP FLEX INNER SOCKET EXT FR 3 $1,190.58
L5644 ABOVE KNEE WOOD SOCKET 3 $451.81
L5645 BK FLEX INNER SOCKET EXT FRA 3 $610.34
L5646 BELOW KNEE CUSHION SOCKET 3 $419.12
L5647 BELOW KNEE SUCTION SOCKET 3 $608.48
L5648 ABOVE KNEE CUSHION SOCKET 3 $503.62
L5649 ISCH CONTAINMT/NARROW M-L SO 3 $1,528.91
L5650 TOT CONTACT AK/KNEE DISART S 3 $373.43
L5651 AK FLEX INNER SOCKET EXT FRA 3 $918.63
L5652 SUCTION SUSP AK/KNEE DISART 3 $333.50
L5653 KNEE DISART EXPAND WALL SOCK 3 $445.19
L5654 SOCKET INSERT SYMES 3 $253.68
L5655 SOCKET INSERT BELOW KNEE 3 $214.80
L5656 SOCKET INSERT KNEE ARTICULAT 3 $302.59
L5658 SOCKET INSERT ABOVE KNEE 3 $294.67
L5660 SOCK INSRT SYME SILICONE GEL O $0.00
L5661 MULTI-DUROMETER SYMES 3 $512.05
L5662 SOCKET INSERT BK SILICONE GE O $0.00
L5663 SOCK KNEE DISARTIC SILICONE O $0.00
L5664 SOCKET INSERT AK SILICONE GE O $0.00
L5665 MULTI-DUROMETER BELOW KNEE 3 $391.67

L5666 BELOW KNEE CUFF SUSPENSION 3 $58.20
L5667 SOCKET INSERT W LOCK LOWER O $0.00
L5668 SOCKET INSERT W/O LOCK LOWER 3 $77.71
L5669 BELOW KNEE SOCKET W/O LOCK O $0.00
L5670 BK MOLDED SUPRACONDYLAR SUSP 3 $236.56
L5671 BK/AK LOCKING MECHANISM 5 $0.00
L5672 BK REMOVABLE MEDIAL BRIM SUS 3 $289.06
L5673 SOCKET INSERT W LOCK MECH 6 $0.00
L5674 BK SUSPENSION SLEEVE O $0.00
L5675 BK HEAVY DUTY SUSP SLEEVE O $0.00
L5676 BK KNEE JOINTS SINGLE AXIS P 3 $277.19
L5677 BK KNEE JOINTS POLYCENTRIC P 3 $377.16
L5678 BK JOINT COVERS PAIR 3 $30.37
L5679 SOCKET INSERT W/O LOCK MECH 6 $0.00
L5680 BK THIGH LACER NON-MOLDED 3 $264.93
L5681 INTL CUSTM CONG/LATYP INSERT 6 $0.00
L5682 BK THIGH LACER GLUT/ISCHIA M 3 $478.39
L5683 INITIAL CUSTOM SOCKET INSERT 6 $0.00
L5684 BK FORK STRAP 3 $36.81
L5685 BELOW KNEE SUS/SEAL SLEEVE 6 $0.00
L5686 BK BACK CHECK 3 $49.66
L5688 BK WAIST BELT WEBBING 3 $46.72
L5690 BK WAIST BELT PADDED AND LIN 3 $90.49
L5692 AK PELVIC CONTROL BELT LIGHT 3 $105.02
L5694 AK PELVIC CONTROL BELT PAD/L 3 $138.77
L5695 AK SLEEVE SUSP NEOPRENE/EQUA 3 $145.59
L5696 AK/KNEE DISARTIC PELVIC JOIN 3 $159.10
L5697 AK/KNEE DISARTIC PELVIC BAND 3 $64.62
L5698 AK/KNEE DISARTIC SILESIAN BA 3 $80.36
L5699 SHOULDER HARNESS 3 $142.63
L5700 REPLACE SOCKET BELOW KNEE 3 $2,203.73
L5701 REPLACE SOCKET ABOVE KNEE 3 $2,733.93
L5702 REPLACE SOCKET HIP 3 $3,445.70
L5703 SYMES ANKLE W/O (SACH) FOOT 6 $0.00
L5704 CUSTOM SHAPE COVER BK 3 $449.33
L5705 CUSTOM SHAPE COVER AK 3 $823.79
L5706 CUSTOM SHAPE CVR KNEE DISART 3 $803.52
L5707 CUSTOM SHAPE CVR HIP DISART 3 $1,079.50
L5710 KNE-SHIN EXO SNG AXI MNL LOC 3 $275.12
L5711 KNEE-SHIN EXO MNL LOCK ULTRA 3 $417.34
L5712 KNEE-SHIN EXO FRICT SWG & ST 3 $329.61
L5714 KNEE-SHIN EXO VARIABLE FRICT 3 $339.91
L5716 KNEE-SHIN EXO MECH STANCE PH 3 $557.52
L5718 KNEE-SHIN EXO FRCT SWG & STA 3 $696.84
L5722 KNEE-SHIN PNEUM SWG FRCT EXO 3 $727.18
L5724 KNEE-SHIN EXO FLUID SWING PH 3 $1,154.61
L5726 KNEE-SHIN EXT JNTS FLD SWG E 3 $1,516.14
L5728 KNEE-SHIN FLUID SWG & STANCE 3 $1,888.89
L5780 KNEE-SHIN PNEUM/HYDRA PNEUM 3 $910.73

L5781 LOWER LIMB PROS VACUUM PUMP 5 $0.00
L5782 HD LOW LIMB PROS VACUUM PUMP 5 $0.00
L5785 EXOSKELETAL BK ULTRALT MATER 3 $397.43
L5790 EXOSKELETAL AK ULTRA-LIGHT M 3 $550.01
L5795 EXOSKEL HIP ULTRA-LIGHT MATE 3 $821.31
L5810 ENDOSKEL KNEE-SHIN MNL LOCK 3 $382.08
L5811 ENDO KNEE-SHIN MNL LCK ULTRA 3 $557.88
L5812 ENDO KNEE-SHIN FRCT SWG & ST 3 $432.41
L5814 ENDO KNEE-SHIN HYDRAL SWG PH 3 $2,788.88
L5816 ENDO KNEE-SHIN POLYC MCH STA 3 $650.54
L5818 ENDO KNEE-SHIN FRCT SWG & ST 3 $734.59
L5822 ENDO KNEE-SHIN PNEUM SWG FRC 3 $1,425.17
L5824 ENDO KNEE-SHIN FLUID SWING P 3 $1,173.08
L5826 MINIATURE KNEE JOINT 3 $2,368.56
L5828 ENDO KNEE-SHIN FLUID SWG/STA 3 $2,236.15
L5830 ENDO KNEE-SHIN PNEUM/SWG PHA 3 $1,588.87
L5840 MULTI-AXIAL KNEE/SHIN SYSTEM 3 $2,801.79
L5845 KNEE-SHIN SYS STANCE FLEXION 3 $1,345.96
L5846 KNEE-SHIN SYS MICROPROCESSOR O $0.00
L5847 MICROPROCESSOR CNTRL FEATURE O $0.00
L5848 KNEE-SHIN SYS HYDRAUL STANCE 5 $0.00
L5850 ENDO AK/HIP KNEE EXTENS ASSI 3 $101.61
L5855 MECH HIP EXTENSION ASSIST 3 $236.23
L5856 ELEC KNEE-SHIN SWING/STANCE 6 $0.00
L5857 ELEC KNEE-SHIN SWING ONLY 6 $0.00
L5858 STANCE PHASE ONLY 6 $0.00
L5910 ENDO BELOW KNEE ALIGNABLE SY 3 $279.01
L5920 ENDO AK/HIP ALIGNABLE SYSTEM 3 $405.87
L5925 ABOVE KNEE MANUAL LOCK 3 $257.02
L5930 HIGH ACTIVITY KNEE FRAME 3 $2,527.60
L5940 ENDO BK ULTRA-LIGHT MATERIAL 3 $383.70
L5950 ENDO AK ULTRA-LIGHT MATERIAL 3 $648.20
L5960 ENDO HIP ULTRA-LIGHT MATERIA 3 $776.46
L5962 BELOW KNEE FLEX COVER SYSTEM 3 $449.63
L5964 ABOVE KNEE FLEX COVER SYSTEM 3 $805.38
L5966 HIP FLEXIBLE COVER SYSTEM 3 $1,037.45
L5968 MULTIAXIAL ANKLE W DORSIFLEX 3 $2,728.85
L5970 FOOT EXTERNAL KEEL SACH FOOT 3 $167.93
L5971 SACH FOOT, REPLACEMENT 6 $0.00
L5972 FLEXIBLE KEEL FOOT 3 $269.59
L5973 ANK-FOOT SYS DORS-PLANT FLEX 6 $0.00
L5974 FOOT SINGLE AXIS ANKLE/FOOT 3 $227.45
L5975 COMBO ANKLE/FOOT PROSTHESIS 3 $348.14
L5976 ENERGY STORING FOOT 3 $428.39
L5978 FT PROSTH MULTIAXIAL ANKL/FT 3 $223.23
L5979 MULTI-AXIAL ANKLE/FT PROSTH 3 $1,791.29
L5980 FLEX FOOT SYSTEM 3 $2,836.17
L5981 FLEX-WALK SYS LOW EXT PROSTH 3 $2,451.49
L5982 EXOSKELETAL AXIAL ROTATION U 3 $442.22

L5984 ENDOSKELETAL AXIAL ROTATION 3 $438.30
L5985 LWR EXT DYNAMIC PROSTH PYLON 3 $212.05
L5986 MULTI-AXIAL ROTATION UNIT 3 $487.29
L5987 SHANK FT W VERT LOAD PYLON 3 $5,402.07
L5988 VERTICAL SHOCK REDUCING PYLO 3 $1,500.16
L5989 PYLON W ELCTRNC FORCE SENSOR O $0.00
L5990 USER ADJUSTABLE HEEL HEIGHT 5 $0.00
L5993 HEAVY DUTY FEATURE, FOOT O $0.00
L5994 HEAVY DUTY FEATURE, KNEE O $0.00
L5995 LOWER EXT PROS HEAVYDUTY FEA O $0.00
L5999 LOWR EXTREMITY PROSTHES NOS 5 $0.00
L6000 PAR HAND ROBIN-AIDS THUM REM 3 $1,016.37
L6010 HAND ROBIN-AIDS LITTLE/RING 3 $1,131.05
L6020 PART HAND ROBIN-AIDS NO FING 3 $1,054.53
L6025 PART HAND DISART MYOELECTRIC 5 $0.00
L6050 WRST MLD SCK FLX HNG TRI PAD 3 $1,453.10
L6055 WRST MOLD SOCK W/EXP INTERFA 3 $2,309.76
L6100 ELB MOLD SOCK FLEX HINGE PAD 3 $1,472.21
L6110 ELBOW MOLD SOCK SUSPENSION T 3 $1,561.53
L6120 ELBOW MOLD DOUB SPLT SOC STE 3 $1,819.73
L6130 ELBOW STUMP ACTIVATED LOCK H 3 $1,980.21
L6200 ELBOW MOLD OUTSID LOCK HINGE 3 $2,086.82
L6205 ELBOW MOLDED W/ EXPAND INTER 3 $3,477.47
L6250 ELBOW INTER LOC ELBOW FORARM 3 $2,054.13
L6300 SHLDER DISART INT LOCK ELBOW 3 $2,849.88
L6310 SHOULDER PASSIVE RESTOR COMP 3 $2,343.65
L6320 SHOULDER PASSIVE RESTOR CAP 3 $1,307.24
L6350 THORACIC INTERN LOCK ELBOW 3 $2,996.21
L6360 THORACIC PASSIVE RESTOR COMP 3 $2,459.71
L6370 THORACIC PASSIVE RESTOR CAP 3 $1,851.78
L6380 POSTOP DSG CAST CHG WRST/ELB 3 $1,000.12
L6382 POSTOP DSG CAST CHG ELB DIS/ 3 $1,196.80
L6384 POSTOP DSG CAST CHG SHLDER/T 3 $1,460.42
L6386 POSTOP EA CAST CHG & REALIGN 3 $350.22
L6388 POSTOP APPLICAT RIGID DSG ON 3 $336.28
L6400 BELOW ELBOW PROSTH TISS SHAP 3 $1,778.70
L6450 ELB DISART PROSTH TISS SHAP 3 $2,358.38
L6500 ABOVE ELBOW PROSTH TISS SHAP 3 $2,360.31
L6550 SHLDR DISAR PROSTH TISS SHAP 3 $2,916.91
L6570 SCAP THORAC PROSTH TISS SHAP 3 $3,539.21
L6580 WRIST/ELBOW BOWDEN CABLE MOL 3 $1,235.42
L6582 WRIST/ELBOW BOWDEN CBL DIR F 3 $1,052.79
L6584 ELBOW FAIR LEAD CABLE MOLDED 3 $1,705.33
L6586 ELBOW FAIR LEAD CABLE DIR FO 3 $1,491.81
L6588 SHDR FAIR LEAD CABLE MOLDED 3 $2,462.65
L6590 SHDR FAIR LEAD CABLE DIRECT 3 $2,252.61
L6600 POLYCENTRIC HINGE PAIR 3 $151.99
L6605 SINGLE PIVOT HINGE PAIR 3 $141.87
L6610 FLEXIBLE METAL HINGE PAIR 3 $127.35

L6611 ADDITIONAL SWITCH, EXT POWER 6 $0.00
L6615 DISCONNECT LOCKING WRIST UNI 3 $157.03
L6616 DISCONNECT INSERT LOCKING WR 3 $66.15
L6620 FLEXION/EXTENSION WRIST UNIT 3 $246.46
L6621 FLEX/EXT WRIST W/WO FRICTION 6 $0.00
L6623 SPRING-ASS ROT WRST W/ LATCH 3 $564.15
L6624 FLEX/EXT/ROTATION WRIST UNIT 6 $0.00
L6625 ROTATION WRST W/ CABLE LOCK 3 $410.51
L6628 QUICK DISCONN HOOK ADAPTER O 3 $419.48
L6629 LAMINATION COLLAR W/ COUPLIN 3 $111.91
L6630 STAINLESS STEEL ANY WRIST 3 $164.86
L6632 LATEX SUSPENSION SLEEVE EACH 3 $54.98
L6635 LIFT ASSIST FOR ELBOW 3 $152.70
L6637 NUDGE CONTROL ELBOW LOCK 3 $316.97
L6638 ELEC LOCK ON MANUAL PW ELBOW 5 $0.00
L6639 HEAVY DUTY ELBOW FEATURE O $0.00
L6640 SHOULDER ABDUCTION JOINT PAI 3 $216.31
L6641 EXCURSION AMPLIFIER PULLEY T 3 $143.76
L6642 EXCURSION AMPLIFIER LEVER TY 3 $204.69
L6645 SHOULDER FLEXION-ABDUCTION J 3 $248.55
L6646 MULTIPO LOCKING SHOULDER JNT 5 $0.00
L6647 SHOULDER LOCK ACTUATOR 5 $0.00
L6648 EXT PWRD SHLDER LOCK/UNLOCK 5 $0.00
L6650 SHOULDER UNIVERSAL JOINT 3 $258.92
L6655 STANDARD CONTROL CABLE EXTRA 3 $57.46
L6660 HEAVY DUTY CONTROL CABLE 3 $70.21
L6665 TEFLON OR EQUAL CABLE LINING 3 $40.14
L6670 HOOK TO HAND CABLE ADAPTER 3 $38.06
L6672 HARNESS CHEST/SHLDER SADDLE 3 $128.98
L6675 HARNESS FIGURE OF 8 SING CON 3 $91.86
L6676 HARNESS FIGURE OF 8 DUAL CON 3 $92.77
L6677 UE TRIPLE CONTROL HARNESS 6 $0.00
L6680 TEST SOCK WRIST DISART/BEL E 3 $177.47
L6682 TEST SOCK ELBW DISART/ABOVE 3 $198.90
L6684 TEST SOCKET SHLDR DISART/THO 3 $266.63
L6686 SUCTION SOCKET 3 $495.85
L6687 FRAME TYP SOCKET BEL ELBOW/W 3 $441.23
L6688 FRAME TYP SOCK ABOVE ELB/DIS 3 $426.80
L6689 FRAME TYP SOCKET SHOULDER DI 3 $515.42
L6690 FRAME TYP SOCK INTERSCAP-THO 3 $558.16
L6691 REMOVABLE INSERT EACH 3 $333.79
L6692 SILICONE GEL INSERT OR EQUAL 3 $427.78
L6693 LOCKINGELBOW FOREARM CNTRBAL 3 $2,131.93
L6694 ELBOW SOCKET INS USE W/LOCK 6 $0.00
L6695 ELBOW SOCKET INS USE W/O LCK 6 $0.00
L6696 CUS ELBO SKT IN FOR CON/ATYP 6 $0.00
L6697 CUS ELBO SKT IN NOT CON/ATYP 6 $0.00
L6698 BELOW/ABOVE ELBOW LOCK MECH 6 $0.00
L6700 TERMINAL DEVICE MODEL #3 O $0.00

L6703 TERM DEV, PASSIVE HAND MITT 6 $0.00
L6704 TERM DEV, SPORT/REC/WORK ATT 6 $0.00
L6705 TERMINAL DEVICE MODEL #5 O $0.00
L6706 TERM DEV MECH HOOK VOL OPEN 6 $0.00
L6707 TERM DEV MECH HOOK VOL CLOSE 6 $0.00
L6708 TERM DEV MECH HAND VOL OPEN 6 $0.00
L6709 TERM DEV MECH HAND VOL CLOSE 6 $0.00
L6710 TERMINAL DEVICE MODEL #5X O $0.00
L6711 PED TERM DEV, HOOK, VOL OPEN 6 $0.00
L6712 PED TERM DEV, HOOK, VOL CLOS 6 $0.00
L6713 PED TERM DEV, HAND, VOL OPEN 6 $0.00
L6714 PED TERM DEV, HAND, VOL CLOS 6 $0.00
L6715 TERMINAL DEVICE MODEL #5XA O $0.00
L6720 TERMINAL DEVICE MODEL #6 O $0.00
L6721 HOOK/HAND, HVY DTY, VOL OPEN 6 $0.00
L6722 HOOK/HAND, HVY DTY, VOL CLOS 6 $0.00
L6725 TERMINAL DEVICE MODEL #7 O $0.00
L6730 TERMINAL DEVICE MODEL #7LO O $0.00
L6735 TERMINAL DEVICE MODEL #8 O $0.00
L6740 TERMINAL DEVICE MODEL #8X O $0.00
L6745 TERMINAL DEVICE MODEL #88X O $0.00
L6750 TERMINAL DEVICE MODEL #10P O $0.00
L6755 TERMINAL DEVICE MODEL #10X O $0.00
L6765 TERMINAL DEVICE MODEL #12P O $0.00
L6770 TERMINAL DEVICE MODEL #99X O $0.00
L6775 TERMINAL DEVICE MODEL#555 O $0.00
L6780 TERMINAL DEVICE MODEL #SS555 O $0.00
L6790 HOOKS-ACCU HOOK OR EQUAL O $0.00
L6795 HOOKS-2 LOAD OR EQUAL O $0.00
L6800 HOOKS-APRL VC OR EQUAL O $0.00
L6805 TERM DEV MODIFIER WRIST UNIT 3 $275.35
L6806 TRS GRIP VC OR EQUAL O $0.00
L6807 TERM DEVICE GRIP1/2 OR EQUAL O $0.00
L6808 TERM DEVICE INFANT OR CHILD O $0.00
L6809 TRS SUPER SPORT PASSIVE O $0.00
L6810 TERM DEV PRECISION PINCH DEV 3 $150.10
L6825 HANDS DORRANCE VO O $0.00
L6830 HAND APRL VC O $0.00
L6835 HAND SIERRA VO O $0.00
L6840 HAND BECKER IMPERIAL O $0.00
L6845 HAND BECKER LOCK GRIP O $0.00
L6850 TERM DVC-HAND BECKER PLYLITE O $0.00
L6855 HAND ROBIN-AIDS VO O $0.00
L6860 HAND ROBIN-AIDS VO SOFT O $0.00
L6865 HAND PASSIVE HAND O $0.00
L6867 HAND DETROIT INFANT HAND O $0.00
L6868 PASSIVE INF HAND STEEPER/HOS O $0.00
L6870 HAND CHILD MITT O $0.00
L6872 HAND NYU CHILD HAND O $0.00

L6873 HAND MECH INF STEEPER OR EQU O $0.00
L6875 HAND BOCK VC O $0.00
L6880 HAND BOCK VO O $0.00
L6881 TERM DEV AUTO GRASP FEATURE 5 $0.00
L6882 MICROPROCESSOR CONTROL UPLMB 9 $0.00
L6883 REPLC SOCKT BELOW E/W DISA 6 $0.00
L6884 REPLC SOCKT ABOVE ELBOW DISA 6 $0.00
L6885 REPLC SOCKT SHLDR DIS/INTERC 6 $0.00
L6890 PREFAB GLOVE FOR TERM DEVICE 3 $130.10
L6895 CUSTOM GLOVE FOR TERM DEVICE 3 $473.54
L6900 HAND RESTORAT THUMB/1 FINGER 3 $1,228.99
L6905 HAND RESTORATION MULTIPLE FI 3 $1,206.52
L6910 HAND RESTORATION NO FINGERS 3 $1,238.56
L6915 HAND RESTORATION REPLACMNT G 3 $478.87
L6920 WRIST DISARTICUL SWITCH CTRL 3 $5,896.34
L6925 WRIST DISART MYOELECTRONIC C 3 $6,464.09
L6930 BELOW ELBOW SWITCH CONTROL 3 $5,578.08
L6935 BELOW ELBOW MYOELECTRONIC CT 3 $6,600.69
L6940 ELBOW DISARTICULATION SWITCH 3 $7,272.04
L6945 ELBOW DISART MYOELECTRONIC C 3 $8,133.63
L6950 ABOVE ELBOW SWITCH CONTROL 3 $7,706.82
L6955 ABOVE ELBOW MYOELECTRONIC CT 3 $9,372.94
L6960 SHLDR DISARTIC SWITCH CONTRO 3 $9,950.82
L6965 SHLDR DISARTIC MYOELECTRONIC 3 $11,398.65
L6970 INTERSCAPULAR-THOR SWITCH CT 3 $12,251.26
L6975 INTERSCAP-THOR MYOELECTRONIC 3 $13,525.58
L7007 ADULT ELECTRIC HAND 6 $0.00
L7008 PEDIATRIC ELECTRIC HAND 6 $0.00
L7009 ADULT ELECTRIC HOOK 6 $0.00
L7010 HAND OTTO BACK STEEPER/EQ SW O $0.00
L7015 HAND SYS TEKNIK VILLAGE SWIT O $0.00
L7020 ELECTRONIC GREIFER SWITCH CT O $0.00
L7025 ELECTRON HAND MYOELECTRONIC O $0.00
L7030 HAND SYS TEKNIK VILL MYOELEC O $0.00
L7035 ELECTRON GREIFER MYOELECTRO O $0.00
L7040 PREHENSILE ACTUATOR 3 $2,225.23
L7045 PEDIATRIC ELECTRIC HOOK 3 $1,236.40
L7160 ELECTRONIC ELBOW, BOSTON OR EQUAL, O $0.00
L7165 ELECTRONIC ELBOW, BOSTON OR EQUAL, O $0.00
L7170 ELECTRONIC ELBOW HOSMER SWIT 3 $4,485.23
L7180 ELECTRONIC ELBOW SEQUENTIAL 3 $26,708.37
L7181 ELECTRONIC ELBO SIMULTANEOUS 6 $0.00
L7185 ELECTRON ELBOW ADOLESCENT SW 3 $4,592.13
L7186 ELECTRON ELBOW CHILD SWITCH 3 $7,012.55
L7190 ELBOW ADOLESCENT MYOELECTRON 3 $5,978.78
L7191 ELBOW CHILD MYOELECTRONIC CT 3 $7,553.10
L7260 ELECTRON WRIST ROTATOR OTTO 3 $1,945.02
L7261 ELECTRON WRIST ROTATOR UTAH 3 $3,581.46
L7266 SERVO CONTROL STEEPER OR EQU 3 $757.35

L7272 ANALOGUE CONTROL UNB OR EQUA 3 $1,688.10
L7274 PROPORTIONAL CTL 12 VOLT UTA 3 $5,406.56
L7360 SIX VOLT BAT OTTO BOCK/EQ EA 3 $228.56
L7362 BATTERY CHRGR SIX VOLT OTTO 3 $205.92
L7364 TWELVE VOLT BATTERY UTAH/EQU 3 $380.62
L7366 BATTERY CHRGR 12 VOLT UTAH/E 3 $512.77
L7367 REPLACEMNT LITHIUM IONBATTER 5 $0.00
L7368 LITHIUM ION BATTERY CHARGER 5 $0.00
L7400 ADD UE PROST BE/WD, ULTLITE 6 $0.00
L7401 ADD UE PROST A/E ULTLITE MAT 6 $0.00
L7402 ADD UE PROST S/D ULTLITE MAT 6 $0.00
L7403 ADD UE PROST B/E ACRYLIC 6 $0.00
L7404 ADD UE PROST A/E ACRYLIC 6 $0.00
L7405 ADD UE PROST S/D ACRYLIC 6 $0.00
L7499 UPPER EXTREMITY PROSTHES NOS 5 $0.00
L7500 PROSTHETIC DVC REPAIR HOURLY 5 $0.00
L7510 PROSTHETIC DEVICE REPAIR REP 5 $0.00
L7520 REPAIR PROSTHESIS PER 15 MIN 3 $6.25
L7600 PROSTHETIC DONNING SLEEVE 6 $0.00
L7611 PED TERM DEV, HOOK, VOL OPEN O $0.00
L7612 PED TERM DEV, HOOK, VOL CLOS O $0.00
L7613 PED TERM DEV, HAND, VOL OPEN O $0.00
L7614 PED TERM DEV, HAND, VOL CLOS O $0.00
L7621 HOOK/HAND, HVY DTY, VOL OPEN O $0.00
L7622 HOOK/HAND, HVY DTY, VOL CLOS O $0.00
L7900 MALE VACUUM ERECTION SYSTEM 9 $0.00
L8000 MASTECTOMY BRA 3 $27.93
L8001 BREAST PROSTHESIS BRA & FORM 5 $0.00
L8002 BRST PRSTH BRA & BILAT FORM 5 $0.00
L8010 MASTECTOMY SLEEVE 3 $46.39
L8015 EXT BREASTPROSTHESIS GARMENT 3 $45.02
L8020 MASTECTOMY FORM 3 $191.37
L8030 BREAST PROSTHES W/O ADHESIVE 3 $247.69
L8031 BREAST PROSTHESIS W ADHESIVE 6 $0.00
L8032 REUSABLE NIPPLE PROSTHESIS 6 $0.00
L8035 CUSTOM BREAST PROSTHESIS 3 $2,751.16
L8039 BREAST PROSTHESIS NOS 5 $0.00
L8040 NASAL PROSTHESIS 3 $1,294.46
L8041 MIDFACIAL PROSTHESIS 3 $1,560.25
L8042 ORBITAL PROSTHESIS 3 $1,753.08
L8043 UPPER FACIAL PROSTHESIS 3 $1,963.45
L8044 HEMI-FACIAL PROSTHESIS 3 $2,173.82
L8045 AURICULAR PROSTHESIS 3 $1,517.49
L8046 PARTIAL FACIAL PROSTHESIS 3 $1,402.47
L8047 NASAL SEPTAL PROSTHESIS 3 $718.77
L8048 UNSPEC MAXILLOFACIAL PROSTH 5 $0.00
L8049 REPAIR MAXILLOFACIAL PROSTH 3 $15.69
L8100 COMPRESSION STOCKING BK18-30 O $0.00
L8110 COMPRESSION STOCKING BK30-40 O $0.00

L8120 COMPRESSION STOCKING BK40-50 O $0.00
L8130 GC STOCKING THIGHLNGTH 18-30 O $0.00
L8140 GC STOCKING THIGHLNGTH 30-40 O $0.00
L8150 GC STOCKING THIGHLNGTH 40-50 O $0.00
L8160 GC STOCKING FULL LNGTH 18-30 O $0.00
L8170 GC STOCKING FULL LNGTH 30-40 O $0.00
L8180 GC STOCKING FULL LNGTH 40-50 O $0.00
L8190 GC STOCKING WAISTLNGTH 18-30 O $0.00
L8195 GC STOCKING WAISTLNGTH 30-40 O $0.00
L8200 GC STOCKING WAISTLNGTH 40-50 O $0.00
L8210 GC STOCKING CUSTOM MADE O $0.00
L8220 GC STOCKING LYMPHEDEMA O $0.00
L8230 GC STOCKING GARTER BELT O $0.00
L8239 G COMPRESSION STOCKING NOS O $0.00
L8300 TRUSS SINGLE W/ STANDARD PAD 3 $64.52
L8310 TRUSS DOUBLE W/ STANDARD PAD 3 $101.87
L8320 TRUSS ADDITION TO STD PAD WA 3 $45.67
L8330 TRUSS ADD TO STD PAD SCROTAL 3 $37.77
L8400 SHEATH BELOW KNEE 3 $13.28
L8410 SHEATH ABOVE KNEE 3 $17.75
L8415 SHEATH UPPER LIMB 3 $17.44
L8417 PROS SHEATH/SOCK W GEL CUSHN 3 $56.42
L8420 PROSTHETIC SOCK MULTI PLY BK 3 $15.68
L8430 PROSTHETIC SOCK MULTI PLY AK 3 $16.93
L8435 PROS SOCK MULTI PLY UPPER LM 3 $16.09
L8440 SHRINKER BELOW KNEE 3 $31.99
L8460 SHRINKER ABOVE KNEE 3 $50.98
L8465 SHRINKER UPPER LIMB 3 $45.15
L8470 PROS SOCK SINGLE PLY BK 3 $5.11
L8480 PROS SOCK SINGLE PLY AK 3 $7.04
L8485 PROS SOCK SINGLE PLY UPPER L 3 $8.84
L8490 AIR SEAL SUCTION RETEN SYSTM O $0.00
L8499 UNLISTED MISC PROSTHETIC SER 5 $0.00
L8500 ARTIFICIAL LARYNX 3 $673.10
L8501 TRACHEOSTOMY SPEAKING VALVE 3 $92.40
L8505 ARTIFICIAL LARYNX, ACCESSORY 5 $0.00
L8507 TRACH-ESOPH VOICE PROS PT IN 5 $0.00
L8509 TRACH-ESOPH VOICE PROS MD IN 5 $0.00
L8510 VOICE AMPLIFIER 5 $0.00
L8511 INDWELLING TRACH INSERT 6 $0.00
L8512 GEL CAP FOR TRACH VOICE PROS 6 $0.00
L8513 TRACH PROS CLEANING DEVICE 6 $0.00
L8514 REPL TRACH PUNCTURE DILATOR 6 $0.00
L8515 GEL CAP APP DEVICE FOR TRACH 6 $0.00
L8600 IMPLANT BREAST SILICONE/EQ 9 $0.00
L8603 COLLAGEN IMP URINARY 2.5 ML 9 $0.00
L8604 DEXTRANOMER/HYALURONIC ACID 9 $0.00
L8606 SYNTHETIC IMPLNT URINARY 1ML 3 $166.75
L8609 ARTIFICIAL CORNEA 6 $0.00

L8610 OCULAR IMPLANT 9 $0.00
L8612 AQUEOUS SHUNT PROSTHESIS 9 $0.00
L8613 OSSICULAR IMPLANT 9 $0.00
L8614 COCHLEAR DEVICE 9 $0.00
L8615 COCH IMPLANT HEADSET REPLACE 6 $0.00
L8616 COCH IMPLANT MICROPHONE REPL 6 $0.00
L8617 COCH IMPLANT TRANS COIL REPL 6 $0.00
L8618 COCH IMPLANT TRAN CABLE REPL 6 $0.00
L8619 COCH IMP EXT PROC/CONTR RPLC 3 $6,403.44
L8620 REPL LITHIUM ION BATTERY O $0.00
L8621 REPL ZINC AIR BATTERY 6 $0.00
L8622 REPL ALKALINE BATTERY 6 $0.00
L8623 LITH ION BATT CID,NON-EARLVL 6 $0.00
L8624 LITH ION BATT CID, EAR LEVEL 6 $0.00
L8627 CID EXT SPEECH PROCESS REPL 6 $0.00
L8628 CID EXT CONTROLLER REPL 6 $0.00
L8629 CID TRANSMIT COIL AND CABLE 6 $0.00
L8630 METACARPOPHALANGEAL IMPLANT 9 $0.00
L8631 MCP JOINT REPL 2 PC OR MORE 9 $0.00
L8641 METATARSAL JOINT IMPLANT 9 $0.00
L8642 HALLUX IMPLANT 9 $0.00
L8658 INTERPHALANGEAL JOINT SPACER 9 $0.00
L8659 INTERPHALANGEAL JOINT REPL 9 $0.00
L8670 VASCULAR GRAFT, SYNTHETIC 9 $0.00
L8680 IMPLT NEUROSTIM ELCTR EACH 9 $0.00
L8681 PT PRGRM FOR IMPLT NEUROSTIM 6 $0.00
L8682 IMPLT NEUROSTIM RADIOFQ REC 9 $0.00
L8683 RADIOFQ TRSMTR FOR IMPLT NEU 6 $0.00
L8684 RADIOF TRSMTR IMPLT SCRL NEU 6 $0.00
L8685 IMPLT NROSTM PLS GEN SNG REC 9 $0.00
L8686 IMPLT NROSTM PLS GEN SNG NON 9 $0.00
L8687 IMPLT NROSTM PLS GEN DUA REC 9 $0.00
L8688 IMPLT NROSTM PLS GEN DUA NON 9 $0.00
L8689 EXTERNAL RECHARG SYS INTERN 6 $0.00
L8690 AUD OSSEO DEV, INT/EXT COMP 9 $0.00
L8691 OSSEOINTEGRATED SND PROC RPL 6 $0.00
L8692 NON-OSSEOINTEGRATED SND PROC 6 $0.00
L8695 EXTERNAL RECHARG SYS EXTERN 6 $0.00
L8699 PROSTHETIC IMPLANT NOS 9 $0.00
L9900 O&P SUPPLY/ACCESSORY/SERVICE 5 $0.00
L9999 SALES TAX, ORTHOTIC/PROSTHETIC/OTHE O $0.00
M0005 OFFICE VISITS WITH TWO OR MORE MODA 9 $0.00
M0006 OFFICE VISITS WITH ONE OF THE ABOVE 9 $0.00
M0007 OFFICE VISITS INCLUDING COMBINATION 9 $0.00
M0008 OFFICE VISIT INCLUDING COMBINATION 9 $0.00
M0009 NOT OTHERWISE CLASSIFIED, OFFICE VI 9 $0.00
M0019 NOT OTHERWISE CLASSIFIED, HOME VISI 9 $0.00
M0021 PER DIEM INPATIENT HOSPITAL CARE WH 9 $0.00
M0022 I.C.U. CARE FOLLOW-UP WHEN ONE OR 9 $0.00

M0023 ROUTINE NEWBORN CARE, INHOSPITAL, I 9 $0.00
M0024 CHEMOTHERAPY(FOR MALIGNANCIES, FOLL 9 $0.00
M0029 NOT OTHERWISE CLASSIFIED, HOSPITAL 9 $0.00
M0039 NOT OTHERWISE CLASSIFIED, SNF, ECF, 9 $0.00
M0049 NOT OTHERWISE CLASSIFIED, NH, BOARD 9 $0.00
M0059 NOT OTHERWISE CLASSIFIED, EMERGENCY 9 $0.00
M0064 VISIT FOR DRUG MONITORING 9 $0.00
M0070 INSULIN SHOCK THERAPY, HYPOGLYCEMIA 9 $0.00
M0071 ORTHOMOLECULAR THERAPY 9 $0.00
M0072 IMMUNOTHERAPY FOR MALIGNANT DISEASE 9 $0.00
M0075 CELLULAR THERAPY 9 $0.00
M0076 PROLOTHERAPY 9 $0.00
M0080 HYPERTHERMIA THERAPY (TO INCLUDE SY 9 $0.00
M0100 INTRAGASTRIC HYPOTHERMIA 9 $0.00
M0101 FOOT CARE HYGIENIC/PM 9 $0.00
M0260 TONSILLECTOMY, WITH OR WITHOUT ADEN 9 $0.00
M0261 TONSILLECTOMY, WITH OR WITHOUT ADEN 9 $0.00
M0300 IV CHELATIONTHERAPY 9 $0.00
M0301 FABRIC WRAPPING OF ANEURYSM 9 $0.00
M0520 ELECTRONIC PACEMAKER ANALYSIS, PULS 9 $0.00
M0525 SINGLE LEAD EKG WITH ANALYSIS OF PA 9 $0.00
M0526 COMPUTER TRACING AND INTERPRETATION 9 $0.00
M0530 CARDIAC EVENTS RECORDER, ELECTROCAR 9 $0.00
M0535 CARDIAC EVENTS RECORDER, ELECTROCAR 9 $0.00
M0540 SIGNAL-AVERAGING EKG 9 $0.00
M0560 PNEUMOPLETHYSMOGRAPHY VENOUS OCCLUS 9 $0.00
M0575 ELECTROENCEPHALOGRAM (EEG), INTERPR 9 $0.00
M0580 TRANSTELEPHONIC ELECTROENCEPHALOGRA 9 $0.00
M0585 ACHILLES REFLEX RESPONSE, ELECTRICA 9 $0.00
M0590 MONITORING ECG, EEG OR PRESSURE IN 9 $0.00
M0601 PSYCHOLOGICAL TESTING, WITH WRITTEN 9 $0.00
M0702 BRIEF, OSTEOPATHIC MANIPULATIVE THE 9 $0.00
M0704 LIMITED, OSTEOPATHIC MANIPULATIVE T 9 $0.00
M0706 INTERMEDIATE OSTEOPATHIC MANIPULATI 9 $0.00
M0708 EXTENDED OSTEOPATHIC MANIPULATIVE T 9 $0.00
M0710 COMPREHENSIVE OSTEOPATHIC MANIPULAT 9 $0.00
M0722 BRIEF INPATIENT HOSPITAL OMT (UP TO 9 $0.00
M0724 LIMITED INPATIENT HOSPITAL OMT (UP 9 $0.00
M0726 INTERMEDIATE INPATIENT HOSPITAL OMT 9 $0.00
M0728 EXTENDED INPATIENT HOSPITAL OMT (UP 9 $0.00
M0730 COMPREHENSIVE INPATIENT HOSPITAL OM 9 $0.00
M0799 PHYSICAL MEDICINE, NOT OTHERWISE CL 9 $0.00
M0900 EXCISION, REVISION OR REMOVAL OF A- 9 $0.00
M0910 INSERTION CATHETERS FEMORAL VEIN, U 9 $0.00
M0945 OUTPATIENT DIALYSIS RELATED PHYSICI 9 $0.00
M0974 SELF DIALYSIS TRAINING, ANY MODE, C 9 $0.00
M0978 SELF DIALYSIS TRAINING, ANY MODE, C 9 $0.00
ORVCW MCO SPECIFIC CODE: SMART START OUR O $0.00
ORVRN MCO SPECIFIC CODE: SMART START OUTR O $0.00

ORVSW MCO SPECIFIC CODE: SMART START OUTR O $0.00
P2028 CEPHALIN FLOCULATION TEST 9 $0.00
P2029 CONGO RED BLOOD TEST 9 $0.00
P2031 HAIR ANALYSIS 9 $0.00
P2032 ICTERUS INDEX, BLOOD 9 $0.00
P2033 BLOOD THYMOL TURBIDITY 9 $0.00
P2038 BLOOD MUCOPROTEIN 9 $0.00
P3000 SCREEN PAP BY TECH W MD SUPV 9 $0.00
P3001 SCREENING PAP SMEAR BY PHYS 9 $0.00
P7001 CULTURE BACTERIAL URINE 9 $0.00
P7020 VACCINE, AUTOGENOUS (MEDICAL NECESS 9 $0.00
P9005 ADMINISTRATION FEE CHARGE BY A PROV 9 $0.00
P9006 MULTIPLE PATHOLOGY SERVICES 9 $0.00
P9007 HANDLING CHARGE FOR PURCHASED LAB S 9 $0.00
P9010 WHOLE BLOOD FOR TRANSFUSION 9 $0.00
P9011 BLOOD SPLIT UNIT 9 $0.00
P9012 CRYOPRECIPITATE EACH UNIT 9 $0.00
P9013 UNIT/S BLOOD FIBRINOGEN 9 $0.00
P9014 GAMMA GLOBULIN 1 ML 9 $0.00
P9015 RH IMMUNE GLOBULIN 1 ML 9 $0.00
P9016 RBC LEUKOCYTES REDUCED 9 $0.00
P9017 PLASMA 1 DONOR FRZ W/IN 8 HR 9 $0.00
P9018 PLASMA PROTEIN FRACT, UNIT 9 $0.00
P9019 PLATELETS, EACH UNIT 9 $0.00
P9020 PLAELET RICH PLASMA UNIT 9 $0.00
P9021 RED BLOOD CELLS UNIT 9 $0.00
P9022 WASHED RED BLOOD CELLS UNIT 9 $0.00
P9023 FROZEN PLASMA, POOLED, SD 9 $0.00
P9024 FACTOR VIII DILUTION, EACH BOTTLE. 9 $0.00
P9031 PLATELETS LEUKOCYTES REDUCED 9 $0.00
P9032 PLATELETS, IRRADIATED 9 $0.00
P9033 PLATELETS LEUKOREDUCED IRRAD 9 $0.00
P9034 PLATELETS, PHERESIS 9 $0.00
P9035 PLATELET PHERES LEUKOREDUCED 9 $0.00
P9036 PLATELET PHERESIS IRRADIATED 9 $0.00
P9037 PLATE PHERES LEUKOREDU IRRAD 9 $0.00
P9038 RBC IRRADIATED 9 $0.00
P9039 RBC DEGLYCEROLIZED 9 $0.00
P9040 RBC LEUKOREDUCED IRRADIATED 9 $0.00
P9041 ALBUMIN (HUMAN),5%, 50ML 9 $0.00
P9042 ALBUMIN (HUMAN), 25% 9 $0.00
P9043 PLASMA PROTEIN FRACT,5%,50ML 9 $0.00
P9044 CRYOPRECIPITATEREDUCEDPLASMA 9 $0.00
P9045 ALBUMIN (HUMAN), 5%, 250 ML 9 $0.00
P9046 ALBUMIN (HUMAN), 25%, 20 ML 9 $0.00
P9047 ALBUMIN (HUMAN), 25%, 50ML 9 $0.00
P9048 PLASMAPROTEIN FRACT,5%,250ML 9 $0.00
P9050 GRANULOCYTES, PHERESIS UNIT 9 $0.00
P9051 BLOOD, L/R, CMV-NEG 9 $0.00

P9052 PLATELETS, HLA-M, L/R, UNIT 9 $0.00
P9053 PLT, PHER, L/R CMV-NEG, IRR 9 $0.00
P9054 BLOOD, L/R, FROZ/DEGLY/WASH 9 $0.00
P9055 PLT, APH/PHER, L/R, CMV-NEG 9 $0.00
P9056 BLOOD, L/R, IRRADIATED 9 $0.00
P9057 RBC, FRZ/DEG/WSH, L/R, IRRAD 9 $0.00
P9058 RBC, L/R, CMV-NEG, IRRAD 9 $0.00
P9059 PLASMA, FRZ BETWEEN 8-24HOUR 9 $0.00
P9060 FR FRZ PLASMA DONOR RETESTED 9 $0.00
P9603 ONE-WAY ALLOW PRORATED MILES 9 $0.00
P9604 ONE-WAY ALLOW PRORATED TRIP 9 $0.00
P9605 ROUTINE VENIPUNCTURE FOR COLLECTION O $0.00
P9610 URINE SPECIMEN COLLECT SINGL 9 $0.00
P9612 CATHETERIZE FOR URINE SPEC 9 $0.00
P9615 URINE SPECIMEN COLLECT MULT 9 $0.00
PEDCL MCO SPECIFIC CODE: SMART START PREN O $0.00
Q0033 LINOZ V. BOWEN AMBULANCE REIMBURSE 9 $0.00
Q0034 ADMIN OF INFLUENZA VACCINE 9 $0.00
Q0035 CARDIOKYMOGRAPHY 9 $0.00
Q0036 OXYGEN CONCENTRATOR, HIGH HUMIDITY O $0.00
Q0037 OXYGEN AND WATER VAPOR ENRICHING SY O $0.00
Q0038 OXYGEN CONTENTS, GASEOUS, PER UNIT O $0.00
Q0039 OXYGEN CONTENTS, LIQUID, PER UNIT, 9 $0.00
Q0040 PORTABLE OXYGEN CONTENTS, GASEOUS P O $0.00
Q0041 PORTABLE OXYGEN CONTENTS, LIQUID, P O $0.00
Q0042 STATIONARY COMPRESSED GAS SYSTEM RE O $0.00
Q0043 STATIONARY LIQUID OXYGEN SYSTEM REN O $0.00
Q0045 ANESTHESIA FOR IRIDECTOMY 9 $0.00
Q0046 PORTABLE LIQUID OXYGEN SYSTEM RENTA 9 $0.00
Q0047 ANESTHESIA FOR BLEPHAROPLASTY 9 $0.00
Q0066 ASSESSMENT OF CARDIAC OUTPUT BY ELE 9 $0.00
Q0068 EXTRACORPEAL PLASMAPHERESIS 9 $0.00
Q0081 INFUSION THER OTHER THAN CHE 9 $0.00
Q0082 ACTIVITY THERAPY W/PARTIAL H 9 $0.00
Q0083 CHEMO BY OTHER THAN INFUSION 9 $0.00
Q0084 CHEMOTHERAPY BY INFUSION 9 $0.00
Q0085 CHEMO BY BOTH INFUSION AND O 9 $0.00
Q0086 PHYSICAL THERAPY EVALUATION/ O $0.00
Q0091 OBTAINING SCREEN PAP SMEAR 9 $0.00
Q0092 SET UP PORT XRAY EQUIPMENT O $0.00
Q0093 FILGRASTIM (G-CSF), PER 100 MCG O $0.00
Q0094 SARGRAMOSTIM (GM-CSF), PER 250 MCG O $0.00
Q0095 URINE PREGNANCY TESTS, VISUAL COLOR O $0.00
Q0096 OVULATION TEST KITS, VISUAL COLOR C O $0.00
Q0097 HEMOGLOBIN; BY COPPER SULFATE METHO O $0.00
Q0098 GLUCOSE, BLOOD; BY GLUCOSE MONITORI O $0.00
Q0100 URINALYSIS BY DIP STICK OR TABLET F O $0.00
Q0101 MICROHEMATOCRIT, SPUN O $0.00
Q0102 SEDIMENTATION RATE, ERYTHROCYTE; NO O $0.00

Q0103 PHYSICAL THERAPY EVALUATION, INITIA 9 $0.00
Q0104 PHYSICAL THERAPY RE-EVALUATION, PER 9 $0.00
Q0109 OCCUPATIONAL THERAPY EVALUATION, IN 9 $0.00
Q0110 OCCUPATIONAL THERAPY RE-EVALUATION, 9 $0.00
Q0111 WET MOUNTS/ W PREPARATIONS O $0.00
Q0112 POTASSIUM HYDROXIDE PREPS O $0.00
Q0113 PINWORM EXAMINATIONS O $0.00
Q0114 FERN TEST 9 $0.00
Q0115 POST-COITAL MUCOUS EXAM 9 $0.00
Q0116 HEMOGLOBIN BY SINGLE ANALYTE INSTRU O $0.00
Q0117 FOR DIABETICS ONLY, FITTING (INCLUD 9 $0.00
Q0118 FOR DIABETICS ONLY, FITTING (INCLUD 9 $0.00
Q0119 FOR DIABETICS ONLY, MULTIPLE DENSIT 9 $0.00
Q0120 FOR DIABETICS ONLY, MODIFICATION (I 9 $0.00
Q0121 FOR DIABETICS ONLY, MODIFICATION (I 9 $0.00
Q0122 FOR DIABETICS ONLY, MODIFICATION (I 9 $0.00
Q0123 FOR DIABETICS ONLY, MODIFICATION (I 9 $0.00
Q0132 DISPENSING FEE DME NEB DRUG 9 $0.00
Q0136 NON ESRD EPOETIN ALPHA INJ O $0.00
Q0137 INJECTION, DARBEPOETIN ALFA O $0.00
Q0138 FERUMOXYTOL, NON-ESRD USE 3 $0.80
Q0139 FERUMOXYTOL, ESRD USE 3 $0.80
Q0144 AZITHROMYCIN DIHYDRATE, ORAL 9 $0.00
Q0156 HUMAN ALBUMIN 5% 9 $0.00
Q0157 HUMAN ALBUMIN 25% O $0.00
Q0160 FACTOR IX NON-RECOMBINANT 9 $0.00
Q0161 FACTOR IX RECOMBINANT 9 $0.00
Q0163 DIPHENHYDRAMINE HCL 50MG 9 $0.00
Q0164 PROCHLORPERAZINE MALEATE 5MG 9 $0.00
Q0165 PROCHLORPERAZINE MALEATE10MG 9 $0.00
Q0166 GRANISETRON HCL 1 MG ORAL 9 $0.00
Q0167 DRONABINOL 2.5MG ORAL 9 $0.00
Q0168 DRONABINOL 5MG ORAL 9 $0.00
Q0169 PROMETHAZINE HCL 12.5MG ORAL 9 $0.00
Q0170 PROMETHAZINE HCL 25 MG ORAL 9 $0.00
Q0171 CHLORPROMAZINE HCL 10MG ORAL 9 $0.00
Q0172 CHLORPROMAZINE HCL 25MG ORAL 9 $0.00
Q0173 TRIMETHOBENZAMIDE HCL 250MG 9 $0.00
Q0174 THIETHYLPERAZINE MALEATE10MG 9 $0.00
Q0175 PERPHENAZINE 4MG ORAL 9 $0.00
Q0176 PERPHENAZINE 8MG ORAL 9 $0.00
Q0177 HYDROXYZINE PAMOATE 25MG 9 $0.00
Q0178 HYDROXYZINE PAMOATE 50MG 9 $0.00
Q0179 ONDANSETRON HCL 8 MG ORAL 9 $0.00
Q0180 DOLASETRON MESYLATE ORAL 9 $0.00
Q0181 UNSPECIFIED ORAL ANTI-EMETIC 9 $0.00
Q0182 NONMETABOLIC ACT D/E TISSUE O $0.00
Q0183 NONMETABOLIC ACTIVE TISSUE O $0.00
Q0184 METABOLICALLY ACTIVE TISSUE 9 $0.00

Q0185 METABOLIC ACTIVE D/E TISSUE 9 $0.00
Q0186 PARAMEDIC INTERCEPT, RURAL 9 $0.00
Q0187 FACTOR VIIA RECOMBINANT O $0.00
Q0480 DRIVER PNEUMATIC VAD, REP 9 $0.00
Q0481 MICROPRCSR CU ELEC VAD, REP 9 $0.00
Q0482 MICROPRCSR CU COMBO VAD, REP 9 $0.00
Q0483 MONITOR ELEC VAD, REP 9 $0.00
Q0484 MONITOR ELEC OR COMB VAD REP 9 $0.00
Q0485 MONITOR CABLE ELEC VAD, REP 9 $0.00
Q0486 MON CABLE ELEC/PNEUM VAD REP 9 $0.00
Q0487 LEADS ANY TYPE VAD, REP ONLY 9 $0.00
Q0488 PWR PACK BASE ELEC VAD, REP 9 $0.00
Q0489 PWR PCK BASE COMBO VAD, REP 9 $0.00
Q0490 EMR PWR SOURCE ELEC VAD, REP 9 $0.00
Q0491 EMR PWR SOURCE COMBO VAD REP 9 $0.00
Q0492 EMR PWR CBL ELEC VAD, REP 9 $0.00
Q0493 EMR PWR CBL COMBO VAD, REP 9 $0.00
Q0494 EMR HD PMP ELEC/COMBO, REP 9 $0.00
Q0495 CHARGER ELEC/COMBO VAD, REP 9 $0.00
Q0496 BATTERY ELEC/COMBO VAD, REP 9 $0.00
Q0497 BAT CLPS ELEC/COMB VAD, REP 9 $0.00
Q0498 HOLSTER ELEC/COMBO VAD, REP 9 $0.00
Q0499 BELT/VEST ELEC/COMBO VAD REP 9 $0.00
Q0500 FILTERS ELEC/COMBO VAD, REP 9 $0.00
Q0501 SHWR COV ELEC/COMBO VAD, REP 9 $0.00
Q0502 MOBILITY CART PNEUM VAD, REP 9 $0.00
Q0503 BATTERY PNEUM VAD REPLACEMNT 9 $0.00
Q0504 PWR ADPT PNEUM VAD, REP VEH 9 $0.00
Q0505 MISCL SUPPLY/ACCESSORY VAD 9 $0.00
Q0506 LITH-ION BATT ELEC/PNEUM VAD 9 $0.00
Q0510 DISPENS FEE IMMUNOSUPRESSIVE 9 $0.00
Q0511 SUP FEE ANTIEM,ANTICA,IMMUNO 9 $0.00
Q0512 PX SUP FEE ANTI-CAN SUB PRES 9 $0.00
Q0513 DISP FEE INHAL DRUGS/30 DAYS 9 $0.00
Q0514 DISP FEE INHAL DRUGS/90 DAYS 9 $0.00
Q0515 SERMORELIN ACETATE INJECTION 6 $0.00
Q1001 NTIOL CATEGORY 1 O $0.00
Q1002 NTIOL CATEGORY 2 O $0.00
Q1003 NTIOL CATEGORY 3 9 $0.00
Q1004 NTIOL CATEGORY 4 9 $0.00
Q1005 NTIOL CATEGORY 5 9 $0.00
Q2001 ORAL CABERGOLINE 0.5 MG O $0.00
Q2002 ELLIOTTS B SOLUTION PER ML O $0.00
Q2003 APROTININ, 10,000 KIU O $0.00
Q2004 BLADDER CALCULI IRRIG SOL 5 $0.00
Q2005 CORTICORELIN OVINE TRIFLUTAT O $0.00
Q2006 DIGOXIN IMMUNE FAB (OVINE) O $0.00
Q2007 ETHANOLAMINE OLEATE 100 MG O $0.00
Q2008 FOMEPIZOLE, 15 MG O $0.00

Q2009 FOSPHENYTOIN INJ PE 5 $0.00
Q2010 GLATIRAMER ACETATE, PER DOSE O $0.00
Q2011 HEMIN, PER 1 MG O $0.00
Q2012 PEGADEMASE BOVINE, 25 IU O $0.00
Q2013 PENTASTARCH 10% SOLUTION O $0.00
Q2014 SERMORELIN ACETATE, 0.5 MG O $0.00
Q2015 SOMATREM, 5 MG O $0.00
Q2016 SOMATROPIN, 1 MG O $0.00
Q2017 TENIPOSIDE, 50 MG 5 $0.00
Q2018 UROFOLLITROPIN, 75 IU O $0.00
Q2019 BASILIXIMAB O $0.00
Q2020 HISTRELIN ACETATE O $0.00
Q2021 LEPIRUDIN O $0.00
Q2022 VONWILLEBRANDFACTRCMPLXPERIU O $0.00
Q2023 XYNTHA, INJ O $0.00
Q2024 BEVACIZUMAB INJECTION O $0.00
Q3000 RUBIDIUM RB 82 O $0.00
Q3001 BRACHYTHERAPY RADIOELEMENTS 5 $0.00
Q3002 GALLIUM GA 67 O $0.00
Q3003 TECHNETIUM TC99M BICISATE O $0.00
Q3004 XENON XE 133 O $0.00
Q3005 TECHNETIUM TC99M MERTIATIDE O $0.00
Q3006 TECHNETIUM TC99M GLUCEPATATE O $0.00
Q3007 SODIUM PHOSPHATE P32 O $0.00
Q3008 INDIUM 111-IN PENTETREOTIDE O $0.00
Q3009 TECHNETIUM TC99M OXIDRONATE O $0.00
Q3010 TECHNETIUM TC99MLABELEDRBCS O $0.00
Q3011 CHROMIC PHOSPHATE P32 O $0.00
Q3012 CYANOCOBALAMIN COBALT CO57 O $0.00
Q3014 TELEHEALTH FACILITY FEE 9 $0.00
Q3017 ALS ASSESSMENT 9 $0.00
Q3019 ALS EMER TRANS NO ALS SERV O $0.00
Q3020 ALS NONEMER TRANS NO ALS SER O $0.00
Q3021 PED HEPATITIS B VACCINE INJ O $0.00
Q3022 HEPATITIS B VACCINE ADULT DS O $0.00
Q3023 INJECTION HEPATITIS BVACCINE O $0.00
Q3025 IM INJ INTERFERON BETA 1-A 5 $0.00
Q3026 SUBC INJ INTERFERON BETA-1A 5 $0.00
Q3031 COLLAGEN SKIN TEST 9 $0.00
Q4001 CAST SUP BODY CAST PLASTER 9 $0.00
Q4002 CAST SUP BODY CAST FIBERGLAS 9 $0.00
Q4003 CAST SUP SHOULDER CAST PLSTR 9 $0.00
Q4004 CAST SUP SHOULDER CAST FBRGL 9 $0.00
Q4005 CAST SUP LONG ARM ADULT PLST 9 $0.00
Q4006 CAST SUP LONG ARM ADULT FBRG 9 $0.00
Q4007 CAST SUP LONG ARM PED PLSTER 9 $0.00
Q4008 CAST SUP LONG ARM PED FBRGLS 9 $0.00
Q4009 CAST SUP SHT ARM ADULT PLSTR 9 $0.00
Q4010 CAST SUP SHT ARM ADULT FBRGL 9 $0.00

Q4011 CAST SUP SHT ARM PED PLASTER 9 $0.00
Q4012 CAST SUP SHT ARM PED FBRGLAS 9 $0.00
Q4013 CAST SUP GAUNTLET PLASTER 9 $0.00
Q4014 CAST SUP GAUNTLET FIBERGLASS 9 $0.00
Q4015 CAST SUP GAUNTLET PED PLSTER 9 $0.00
Q4016 CAST SUP GAUNTLET PED FBRGLS 9 $0.00
Q4017 CAST SUP LNG ARM SPLINT PLST 9 $0.00
Q4018 CAST SUP LNG ARM SPLINT FBRG 9 $0.00
Q4019 CAST SUP LNG ARM SPLNT PED P 9 $0.00
Q4020 CAST SUP LNG ARM SPLNT PED F 9 $0.00
Q4021 CAST SUP SHT ARM SPLINT PLST 9 $0.00
Q4022 CAST SUP SHT ARM SPLINT FBRG 9 $0.00
Q4023 CAST SUP SHT ARM SPLNT PED P 9 $0.00
Q4024 CAST SUP SHT ARM SPLNT PED F 9 $0.00
Q4025 CAST SUP HIP SPICA PLASTER 9 $0.00
Q4026 CAST SUP HIP SPICA FIBERGLAS 9 $0.00
Q4027 CAST SUP HIP SPICA PED PLSTR 9 $0.00
Q4028 CAST SUP HIP SPICA PED FBRGL 9 $0.00
Q4029 CAST SUP LONG LEG PLASTER 9 $0.00
Q4030 CAST SUP LONG LEG FIBERGLASS 9 $0.00
Q4031 CAST SUP LNG LEG PED PLASTER 9 $0.00
Q4032 CAST SUP LNG LEG PED FBRGLS 9 $0.00
Q4033 CAST SUP LNG LEG CYLINDER PL 9 $0.00
Q4034 CAST SUP LNG LEG CYLINDER FB 9 $0.00
Q4035 CAST SUP LNGLEG CYLNDR PED P 9 $0.00
Q4036 CAST SUP LNGLEG CYLNDR PED F 9 $0.00
Q4037 CAST SUP SHRT LEG PLASTER 9 $0.00
Q4038 CAST SUP SHRT LEG FIBERGLASS 9 $0.00
Q4039 CAST SUP SHRT LEG PED PLSTER 9 $0.00
Q4040 CAST SUP SHRT LEG PED FBRGLS 9 $0.00
Q4041 CAST SUP LNG LEG SPLNT PLSTR 9 $0.00
Q4042 CAST SUP LNG LEG SPLNT FBRGL 9 $0.00
Q4043 CAST SUP LNG LEG SPLNT PED P 9 $0.00
Q4044 CAST SUP LNG LEG SPLNT PED F 9 $0.00
Q4045 CAST SUP SHT LEG SPLNT PLSTR 9 $0.00
Q4046 CAST SUP SHT LEG SPLNT FBRGL 9 $0.00
Q4047 CAST SUP SHT LEG SPLNT PED P 9 $0.00
Q4048 CAST SUP SHT LEG SPLNT PED F 9 $0.00
Q4049 FINGER SPLINT, STATIC 9 $0.00
Q4050 CAST SUPPLIES UNLISTED 9 $0.00
Q4051 SPLINT SUPPLIES MISC 9 $0.00
Q4054 DARBEPOETIN ALFA, ESRD USE O $0.00
Q4055 EPOETIN ALFA, ESRD USE O $0.00
Q4074 ILOPROST NON-COMP UNIT DOSE 9 $0.00
Q4075 ACYCLOVIR, 5 MG O $0.00
Q4076 DOPAMINE HCL, 40 MG O $0.00
Q4077 TREPROSTINIL, 1 MG O $0.00
Q4079 NATALIZUMAB INJECTION 3 $0.50
Q4080 ILOPROST NON-COMP UNIT DOSE O $0.00

Q4081 EPOETIN ALFA, 100 UNITS ESRD 3 $1.28
Q4082 DRUG/BIO NOC PART B DRUG CAP 9 $0.00
Q4083 HYALURONAN OR DERIVATIVE, HYALGAN O $0.00
Q4084 HYALURONAN OR DERIVATIVE, SYNVISC, O $0.00
Q4085 EUFLEXXA INJ PER DOSE O $0.00
Q4086 HYALURONAN OR DERIVATIVE, ORTHVISC O $0.00
Q4087 OCTAGAM INJECTION 9 $0.00
Q4088 GAMMAGARD LIQUID INJECTION 9 $0.00
Q4089 RHOPHYLAC INJECTION 9 $0.00
Q4090 HEPAGAM B IM INJECTION 9 $0.00
Q4091 FLEBOGAMMA INJECTION 9 $0.00
Q4092 GAMUNEX INJECTION 9 $0.00
Q4093 ALBUTEROL INH NON-COMP CON 9 $0.00
Q4094 ALBUTEROL INH NON-COMP U D 9 $0.00
Q4095 RECLAST INJECTION 9 $0.00
Q4096 INJECTION, VON WILLEBRAND FACTOR C O $0.00
Q4097 INJECTION, IMMUNE GLOBULIN (PRIVIG O $0.00
Q4098 INJECTION, IRON DEXTRAN, 50 MG O $0.00
Q4099 FORMOTEROL FUMARATE INHALATION UD O $0.00
Q4100 SKIN SUBSTITUTE, NOS 9 $0.00
Q4101 APLIGRAF SKIN SUB 9 $0.00
Q4102 OASIS WOUND MATRIX SKIN SUB 9 $0.00
Q4103 OASIS BURN MATRIX SKIN SUB 9 $0.00
Q4104 INTEGRA BMWD SKIN SUB 9 $0.00
Q4105 INTEGRA DRT SKIN SUB 9 $0.00
Q4106 DERMAGRAFT SKIN SUB 9 $0.00
Q4107 GRAFTJACKET SKIN SUB 9 $0.00
Q4108 INTEGRA MATRIX SKIN SUB 9 $0.00
Q4109 TISSUEMEND SKIN SUB 9 $0.00
Q4110 PRIMATRIX SKIN SUB 9 $0.00
Q4111 GAMMAGRAFT SKIN SUB 9 $0.00
Q4112 CYMETRA ALLOGRAFT 9 $0.00
Q4113 GRAFTJACKET EXPRESS ALLOGRAF 9 $0.00
Q4114 INTEGRA FLOWABLE WOUND MATRI 9 $0.00
Q4115 ALLOSKIN SKIN SUB 9 $0.00
Q4116 ALLODERM SKIN SUB 9 $0.00
Q5001 HOSPICE IN PATIENT HOME 9 $0.00
Q5002 HOSPICE IN ASSISTED LIVING 9 $0.00
Q5003 HOSPICE IN LT/NON-SKILLED NF 9 $0.00
Q5004 HOSPICE IN SNF 9 $0.00
Q5005 HOSPICE, INPATIENT HOSPITAL 9 $0.00
Q5006 HOSPICE IN HOSPICE FACILITY 9 $0.00
Q5007 HOSPICE IN LTCH 9 $0.00
Q5008 HOSPICE IN INPATIENT PSYCH 9 $0.00
Q5009 HOSPICE CARE, NOS 9 $0.00
Q9920 EPOETIN WITH HCT

Q9924 EPOETIN WITH HCT = 24 O $0.00
Q9925 EPOETIN WITH HCT = 25 O $0.00
Q9926 EPOETIN WITH HCT = 26 O $0.00
Q9927 EPOETIN WITH HCT = 27 O $0.00
Q9928 EPOETIN WITH HCT = 28 O $0.00
Q9929 EPOETIN WITH HCT = 29 O $0.00
Q9930 EPOETIN WITH HCT = 30 O $0.00
Q9931 EPOETIN WITH HCT = 31 O $0.00
Q9932 EPOETIN WITH HCT = 32 O $0.00
Q9933 EPOETIN WITH HCT = 33 O $0.00
Q9934 EPOETIN WITH HCT = 34 O $0.00
Q9935 EPOETIN WITH HCT = 35 O $0.00
Q9936 EPOETIN WITH HCT = 36 O $0.00
Q9937 EPOETIN WITH HCT = 37 O $0.00
Q9938 EPOETIN WITH HCT = 38 O $0.00
Q9939 EPOETIN WITH HCT = 39 O $0.00
Q9940 EPOETIN WITH HCT >= 40 O $0.00
Q9945 LOCM = 400 MG/ML IODINE,1ML 9 $0.00
Q9952 INJ GAD-BASE MR CONTRAST,1ML O $0.00
Q9953 INJ FE-BASED MR CONTRAST,1ML 9 $0.00
Q9954 ORAL MR CONTRAST, 100 ML 9 $0.00
Q9955 INJ PERFLEXANE LIP MICROS,ML 6 $0.00
Q9956 INJ OCTAFLUOROPROPANE MIC,ML 3 $48.01
Q9957 INJ PERFLUTREN LIP MICROS,ML 6 $0.00
Q9958 HOCM = 400MG/ML IODINE, 1ML 9 $0.00
Q9965 LOCM 100-199MG/ML IODINE,1ML 9 $0.00
Q9966 LOCM 200-299MG/ML IODINE,1ML 9 $0.00
Q9967 LOCM 300-399MG/ML IODINE,1ML 9 $0.00
Q9968 VISUALIZATION ADJUNCT 9 $0.00
R0059 NOT OTHERWISE CLASSIFIED, CHEST 9 $0.00
R0065 CIRCULATION TIME, RADIONUCLIDE STUD 9 $0.00
R0070 TRANSPORT PORTABLE X-RAY 9 $0.00
R0075 TRANSPORT PORT X-RAY MULTIPL 9 $0.00
R0076 TRANSPORT PORTABLE EKG 9 $0.00
R0085 MULTIPLE RADIOLOGY SERVICES 9 $0.00
S0009 INJECTION, BUTORPHANOL TARTR O $0.00
S0010 INJECTION, SOMATREM, 5 MG O $0.00

S0011 INJECTION, SOMATROPIN, 5 MG O $0.00
S0012 BUTORPHANOL TARTRATE, NASAL 9 $0.00
S0014 TACRINE HYDROCHLORIDE, 10 MG 9 $0.00
S0016 INJECTION, AMIKACIN SULFATE O $0.00
S0017 INJECTION, AMINOCAPROIC ACID 5 $0.00
S0020 INJECTION, BUPIVICAINE HYDRO 3 $2.44
S0021 INJECTION, CEFOPERAZONE SOD 5 $0.00
S0023 INJECTION, CIMETIDINE HYDROC 3 $2.85
S0024 INJECTION, CIPROFLOXACIN O $0.00
S0028 INJECTION, FAMOTIDINE, 20 MG 5 $0.00
S0029 INJECTION, FLUCONAZOLE O $0.00
S0030 INJECTION, METRONIDAZOLE 5 $0.00
S0032 INJECTION, NAFCILLIN SODIUM 5 $0.00
S0034 INJECTION, OFLOXACIN, 400 MG 5 $0.00
S0039 INJECTION, SULFAMETHOXAZOLE 5 $0.00
S0040 INJECTION, TICARCILLIN DISOD 5 $0.00
S0071 INJECTION, ACYCLOVIR SODIUM O $0.00
S0072 INJECTION, AMIKACIN SULFATE O $0.00
S0073 INJECTION, AZTREONAM, 500 MG 3 $17.43
S0074 INJECTION, CEFOTETAN DISODIU 5 $0.00
S0077 INJECTION, CLINDAMYCIN PHOSP 5 $0.00
S0078 INJECTION, FOSPHENYTOIN SODI 5 $0.00
S0079 OCTREOTIDE 100 MCG O $0.00
S0080 INJECTION, PENTAMIDINE ISETH 5 $0.00
S0081 INJECTION, PIPERACILLIN SODI 5 $0.00
S0085 INJECTION, GATIFLOXACIN O $0.00
S0086 INJECTION, VERTEPORFIN, 15MG O $0.00
S0087 ALEMTUZUMAB 30 MG O $0.00
S0088 IMATINIB 100 MG 9 $0.00
S0090 SILDENAFIL CITRATE, 25 MG 9 $0.00
S0091 GRANISETRON 1MG 5 $0.00
S0092 HYDROMORPHONE 250 MG 9 $0.00
S0093 MORPHINE 500 MG 9 $0.00
S0096 INJECTION, ITRACONAZOLE, 200 O $0.00
S0097 INJECTION, IBUTILIDE FUMARAT O $0.00
S0098 INJECTION, SODIUM FERRIC GLU O $0.00
S0104 ZIDOVUDINE, ORAL, 100 MG 9 $0.00
S0106 BUPROPION HCL SR 60 TABLETS 9 $0.00
S0107 INJ, OMALIZUMAB 25 MG O $0.00
S0108 MERCAPTOPURINE 50 MG 9 $0.00
S0109 METHADONE ORAL 5MG 9 $0.00
S0114 TREPROSTINIL SODIUM INJECT O $0.00
S0115 BORTEZOMIB 3.5 MG O $0.00
S0116 BEVACIZUMAB, 100MG O $0.00
S0117 TRETINOIN TOPICAL 5 G 9 $0.00
S0118 ZICONOTIDE INJ O $0.00
S0122 INJ MENOTROPINS 75 IU 9 $0.00
S0124 INJ UROFOLLITROPIN 75 IU O $0.00
S0126 INJ FOLLITROPIN ALFA 75 IU 9 $0.00

S0128 INJ FOLLITROPIN BETA 75 IU 9 $0.00
S0130 INJ C GONADOTROPIN 5000 IU O $0.00
S0132 INJ GANIRELIX ACETAT 250 MCG 9 $0.00
S0133 HISTRELIN IMPLANT O $0.00
S0135 PEGFILGRASTIM INJECTION 6MG O $0.00
S0136 CLOZAPINE, 25 MG 9 $0.00
S0137 DIDANOSINE, 25 MG 9 $0.00
S0138 FINASTERIDE, 5 MG 9 $0.00
S0139 MINOXIDIL, 10 MG 9 $0.00
S0140 SAQUINAVIR, 200 MG 9 $0.00
S0141 ZALCITABINE, 0.375 MG O $0.00
S0142 COLISTIMETHATE INH SOL MG 9 $0.00
S0143 AZTREONAM, INH SOL GRAM O $0.00
S0145 PEG INTERFERON ALFA-2A/180 3 $503.69
S0146 PEG INTERFERON ALFA-2B/10 3 $454.96
S0147 ALGLUCOSIDASE ALFA 20 MG O $0.00
S0155 EPOPROSTENOL DILUTANT 5 $0.00
S0156 EXEMESTANE, 25 MG 5 $0.00
S0157 BECAPLERMIN GEL 1%, 0.5 GM 9 $0.00
S0158 INJECTION LARONIDASE O $0.00
S0159 INJECTION AGALSIDASE O $0.00
S0160 DEXTROAMPHETAMINE 9 $0.00
S0161 CALCITROL 9 $0.00
S0162 INJECTION EFALIZUMAB O $0.00
S0163 INJECTION RISPERIDONELA O $0.00
S0164 INJECTION PANTROPRAZOLE 3 $12.31
S0165 INJECTION ABARELIX O $0.00
S0166 INJ OLANZAPINE 2.5MG 9 $0.00
S0167 INJ APOMORPHINE HCL 1MG O $0.00
S0168 INJ AZACITIDINE 100 MG O $0.00
S0170 ANASTROZOLE 1 MG 9 $0.00
S0171 BUMETANIDE 0.5 MG 5 $0.00
S0172 CHLORAMBUCIL 2 MG 9 $0.00
S0173 DEXAMETHASONE 4 MG O $0.00
S0174 DOLASETRON 50 MG 9 $0.00
S0175 FLUTAMIDE 125 MG 9 $0.00
S0176 HYDROXYUREA 500 MG 9 $0.00
S0177 LEVAMISOLE 50 MG 9 $0.00
S0178 LOMUSTINE 10 MG 9 $0.00
S0179 MEGESTROL 20 MG 9 $0.00
S0180 ETONOGESTREL IMPLANT SYSTEM O $0.00
S0181 ONDANSETRON 4 MG 9 $0.00
S0182 PROCARBAZINE 5 MG 9 $0.00
S0183 PROCHLORPERAZINE 5 MG 9 $0.00
S0187 TAMOXIFEN 10 MG 9 $0.00
S0189 TESTOSTERONE PELLET 75 MG 9 $0.00
S0190 MIFEPRISTONE, ORAL, 200 MG 5 $0.00
S0191 MISOPROSTOL, ORAL, 200 MCG 5 $0.00
S0194 VITAMIN SUPPL 100 CAPS 9 $0.00

S0195 PNEUMO VACCINE 5-9 YRS 5 $0.00
S0196 POLY-L-LACTIC ACID 1ML FACE 9 $0.00
S0197 PRENATAL VITAMINS 30 DAY 9 $0.00
S0198 INJ PEGAPTANIB 0.3 MG O $0.00
S0199 MED ABORTION INC ALL EX DRUG 9 $0.00
S0201 PARTIAL HOSPITALIZATION SERV 9 $0.00
S0206 SURGERY IN OFFICE 9 $0.00
S0207 PARAMEDICINTERCEP NONHOSPALS 9 $0.00
S0208 PARAMED INTRCEPT NONVOL 9 $0.00
S0209 WC VAN MILEAGE PER MI 3 $0.42
S0215 NONEMERG TRANSP MILEAGE 3 $0.42
S0220 MEDICAL CONFERENCE BY PHYSIC 6 $0.00
S0221 MEDICAL CONFERENCE, 60 MIN 6 $0.00
S0250 COMP GERIATR ASSMT TEAM 9 $0.00
S0255 HOSPICE REFER VISIT NONMD 9 $0.00
S0257 END OF LIFE COUNSELING 9 $0.00
S0260 H&P FOR SURGERY 9 $0.00
S0265 GENETIC COUNSEL 15 MINS 9 $0.00
S0270 HOME STD CASE RATE 30 DAYS 9 $0.00
S0271 HOME HOSPICE CASE 30 DAYS 9 $0.00
S0272 HOME EPISODIC CASE 30 DAYS 9 $0.00
S0273 MD HOME VISIT OUTSIDE CAP 9 $0.00
S0274 NURSE PRACTR VISIT OUTS CAP 9 $0.00
S0280 MEDICAL HOME, INITIAL PLAN 9 $0.00
S0281 MEDICAL HOME, MAINTENANCE 9 $0.00
S0302 COMPLETED EPSDT 9 $0.00
S0310 HOSPITALIST VISIT 9 $0.00
S0315 DISEASE MANAGEMENT PROGRAM 9 $0.00
S0316 FOLLOW-UP/REASSESSMENT 9 $0.00
S0317 DISEASE MGMT PER DIEM 9 $0.00
S0320 RN TELEPHONE CALLS TO DMP 9 $0.00
S0340 LIFESTYLE MOD 1ST STAGE 9 $0.00
S0341 LIFESTYLE MOD 2 OR 3 STAGE 9 $0.00
S0342 LIFESTYLE MOD 4TH STAGE 9 $0.00
S0345 HOME ECG MONITRNG GLOBAL 24H O $0.00
S0346 HOME ECG MONITRNG TECH 24HR O $0.00
S0347 HOME ECG MONITRNG PROF 24HR O $0.00
S0390 ROUT FOOT CARE PER VISIT 5 $0.00
S0395 IMPRESSION CASTING FT 9 $0.00
S0400 GLOBAL ESWL KIDNEY 9 $0.00
S0500 DISPOS CONT LENS 6 $0.00
S0504 SINGL PRSCRP LENS 9 $0.00
S0506 BIFOC PRSCP LENS 9 $0.00
S0508 TRIFOC PRSCRP LENS 9 $0.00
S0510 NON-PRSCRP LENS 9 $0.00
S0512 DAILY CONT LENS 6 $0.00
S0514 COLOR CONT LENS 9 $0.00
S0515 SCLERAL LENS LIQUID BANDAGE 9 $0.00
S0516 SAFETY FRAMES 6 $0.00

S0518 SUNGLASS FRAMES 9 $0.00
S0580 POLYCARB LENS 3 $18.96
S0581 NONSTND LENS 6 $0.00
S0590 MISC INTEGRAL LENS SERV 9 $0.00
S0592 COMP CONT LENS EVAL 6 $0.00
S0595 NEW LENSES IN PTS OLD FRAME 9 $0.00
S0601 SCREENING PROCTOSCOPY 9 $0.00
S0605 DIGITAL RECTAL EXAMINATION, O $0.00
S0610 ANNUAL GYNECOLOGICAL EXAMINA 3 $68.46
S0612 ANNUAL GYNECOLOGICAL EXAMINA 3 $66.52
S0613 ANN BREAST EXAM 9 $0.00
S0618 AUDIOMETRY FOR HEARING AID 9 $0.00
S0620 ROUTINE OPHTHALMOLOGICAL EXA 6 $0.00
S0621 ROUTINE OPHTHALMOLOGICAL EXA 6 $0.00
S0622 PHYS EXAM FOR COLLEGE 9 $0.00
S0625 DIGITAL SCREENING RETINA 9 $0.00
S0630 REMOVAL OF SUTURES 9 $0.00
S0800 LASER IN SITU KERATOMILEUSIS 9 $0.00
S0810 PHOTOREFRACTIVE KERATECTOMY 9 $0.00
S0812 PHOTOTHERAP KERATECT 9 $0.00
S0820 COMPUTERIZED CORNEAL TOPOGRA O $0.00
S0830 ULTRASOUND PACHYMETRY O $0.00
S1001 DELUXE ITEM 9 $0.00
S1002 CUSTOM ITEM 9 $0.00
S1015 IV TUBING EXTENSION SET 9 $0.00
S1016 NON-PVC INTRAVENOUS ADMINIST 9 $0.00
S1025 INHAL NITRIC OXIDE NEONATE O $0.00
S1030 GLUC MONITOR PURCHASE 9 $0.00
S1031 GLUC MONITOR RENTAL 9 $0.00
S1040 CRANIAL REMOLDING ORTHOSIS 6 $0.00
S2050 DONOR ENTERECTOMY, WITH PREP 9 $0.00
S2052 TRANSPLANTATION OF SMALL INT 9 $0.00
S2053 TRANSPLANTATION OF SMALL INT 9 $0.00
S2054 TRANSPLANTATION OF MULTIVISC 9 $0.00
S2055 HARVESTING OF DONOR MULTIVIS 9 $0.00
S2060 LOBAR LUNG TRANSPLANTATION 9 $0.00
S2061 DONOR LOBECTOMY (LUNG) 9 $0.00
S2065 SIMULT PANC KIDN TRANS 9 $0.00
S2066 BREAST GAP FLAP RECONST 9 $0.00
S2067 BREAST STACKED DIEP/GAP 9 $0.00
S2068 BREAST DIEP OR SIEA FLAP 9 $0.00
S2070 CYSTO LASER TX URETERAL CALC 9 $0.00
S2075 LAP INC/VENT HERNIA REPAIR O $0.00
S2076 LAP UMBILICAL HERNIA REPAIR O $0.00
S2077 LAP MESH IMPLANT HERN REP O $0.00
S2078 LAP SUPRACERV HYSTERECTOMY O $0.00
S2079 LAP ESOPHAGOMYOTOMY 9 $0.00
S2080 LAUP 9 $0.00
S2082 LAP ADJUSTABLE GASTRIC BAND O $0.00

S2083 ADJUSTMENT GASTRIC BAND 9 $0.00
S2085 LAPAROSCOP GASTRIC BYPASS O $0.00
S2090 OPEN CRYOSURG RENAL O $0.00
S2091 PERC CRYOSURG RENAL O $0.00
S2095 TRANSCATH EMBOLIZ MICROSPHER 9 $0.00
S2102 ISLET CELL TISSUE TRANSPLANT 9 $0.00
S2103 ADRENAL TISSUE TRANSPLANT 9 $0.00
S2107 ADOPTIVE IMMUNOTHERAPY 5 $0.00
S2109 AUTOLOGOUS CHONDROCYTE TRANS 9 $0.00
S2112 KNEE ARTHROSCP HARV 9 $0.00
S2113 ARTHRO CHONDROCYTE IMPLANT O $0.00
S2114 ARTHROSC SH TENODESIS BICEPS O $0.00
S2115 PERIACETABULAR OSTEOTOMY 9 $0.00
S2117 ARTHROEREISIS, SUBTALAR 9 $0.00
S2118 TOTAL HIP RESURFACING 9 $0.00
S2120 LOW DENSITY LIPOPROTEIN(LDL) 9 $0.00
S2130 ERA OF REFLUX SAPHENOUS VEIN O $0.00
S2131 LASER ABLAT SAPHENOUS VEIN O $0.00
S2135 NEUROLYSIS INTERSPACE FOOT O $0.00
S2140 CORD BLOOD HARVESTING 9 $0.00
S2142 CORD BLOOD-DERIVED STEM-CELL 9 $0.00
S2150 BMT HARV/TRANSPL 28D PKG 9 $0.00
S2152 SOLID ORGAN TRANSPL PKG 9 $0.00
S2180 DONOR LEUKOCYTE INFUSION 9 $0.00
S2190 SUBCUTANEOUS IMPLANTATION OF 9 $0.00
S2202 ECHOSCLEROTHERAPY 9 $0.00
S2204 TRANSMYOCARDIAL LASER REVASC 9 $0.00
S2205 MINIMALLY INVASIVE DIRECT CO 9 $0.00
S2206 MINIMALLY INVASIVE DIRECT CO 9 $0.00
S2207 MINIMALLY INVASIVE DIRECT CO 9 $0.00
S2208 MINIMALLY INVASIVE DIRECT CO 9 $0.00
S2209 MINIMALLY INVASIVE DIRECT CO 9 $0.00
S2210 CRYOSURGICAL ABLATION (IN SI 9 $0.00
S2211 TRANSV CAROTID STENT PLACEMT O $0.00
S2213 IMPLANT GASTRIC STIM O $0.00
S2215 UGI ENDOSCOPY INJ IMPLANT O $0.00
S2220 THROMBECTOMY, CORONARY 9 $0.00
S2225 MYRINGOTOMY LASER-ASSIST 9 $0.00
S2230 IMPLANT SEMI-IMP HEAR 9 $0.00
S2235 IMPLANT AUDITORY BRAIN IMP 9 $0.00
S2250 UTERINE ARTERY EMBOLIZ O $0.00
S2260 INDUCED ABORTION 17-24 WEEKS 9 $0.00
S2262 ABORTION MATERNAL INDIC 25W O $0.00
S2265 INDUCED ABORTION 25-28 WKS 9 $0.00
S2266 INDUCED ABORTION 29-31 WKS 9 $0.00
S2267 INDUCED ABORTION 32 OR MORE 9 $0.00
S2270 INSERTION VAGINAL CYLINDER 9 $0.00
S2300 ARTHROSCOPY, SHOULDER, SURGI 9 $0.00
S2325 HIP CORE DECOMPRESSION 6 $0.00

S2340 CHEMODENERVATION OF ABDUCTOR 9 $0.00
S2341 CHEMODENERV ADDUCT VOCAL 9 $0.00
S2342 NASAL ENDOSCOP PO DEBRID 9 $0.00
S2344 ENDOSC BALLOON SINUPLASTY 9 $0.00
S2348 DECOMPRESS DISC RF LUMBAR 9 $0.00
S2350 DISKECTOMY, ANTERIOR, WITH D 9 $0.00
S2351 DISKECTOMY, ANTERIOR, WITH D 9 $0.00
S2360 VERTEBROPLAST CERV 1ST 9 $0.00
S2361 VERTEBROPLAST CERV ADDL 9 $0.00
S2362 KYPHOPLASTY, FIRST VERTEBRA O $0.00
S2363 KYPHOPLASTY, EACH ADDL O $0.00
S2370 INTRADISCAL ELECTROTHERMAL O $0.00
S2371 EACH ADDITIONAL INTERSPACE O $0.00
S2400 FETAL SURG CONGEN HERNIA 5 $0.00
S2401 FETAL SURG URIN TRAC OBSTR 9 $0.00
S2402 FETAL SURG CONG CYST MALF 9 $0.00
S2403 FETAL SURG PULMON SEQUEST 9 $0.00
S2404 FETAL SURG MYELOMENINGO 9 $0.00
S2405 FETAL SURG SACROCOC TERATOMA 5 $0.00
S2409 FETAL SURG NOC 9 $0.00
S2411 FETOSCOP LASER THER TTTS 9 $0.00
S2900 ROBOTIC SURGICAL SYSTEM 9 $0.00
S3000 BILAT DIL RETINAL EXAM 9 $0.00
S3005 EVAL SELF-ASSESS DEPRESSION 9 $0.00
S3600 STAT LAB 9 $0.00
S3601 STAT LAB HOME/NF 9 $0.00
S3618 FREE BETA HCG 9 $0.00
S3620 NEWBORN METABOLIC SCREENING 9 $0.00
S3625 MATERNAL TRIPLE SCREEN TEST 9 $0.00
S3626 MATERNAL SERUM QUAD SCREEN 9 $0.00
S3628 PAMG-1 RAPID ASSAY FOR ROM 6 $0.00
S3630 EOSINOPHIL BLOOD COUNT 9 $0.00
S3645 HIV-1 ANTIBODY TESTING OF OR 9 $0.00
S3650 SALIVA TEST, HORMONE LEVEL; 9 $0.00
S3652 SALIVA TEST, HORMONE LEVEL; 9 $0.00
S3655 ANTISPERM ANTIBODIES TEST 9 $0.00
S3700 BLADDER TUMOR-ASSOCIATED 9 $0.00
S3701 NMP-22 ASSAY O $0.00
S3708 GASTROINTESTINAL FAT ABSORPT 9 $0.00
S3711 CIRCULATING TUMOR CELL TEST 9 $0.00
S3713 KRAS MUTATION ANALYSIS 9 $0.00
S3800 GENETIC TESTING ALS 9 $0.00
S3818 BRCA1 GENE ANAL 9 $0.00
S3819 BRCA2 GENE ANAL 9 $0.00
S3820 COMP BRCA1/BRCA2 3 $3,120.00
S3822 SING MUTATION BRST/OVAR 9 $0.00
S3823 3 MUTATION BRST/OVAR 9 $0.00
S3828 COMP MLH1 GENE 9 $0.00
S3829 COMP MLH2 GENE 9 $0.00

S3830 GENE TEST HNPCC COMP 9 $0.00
S3831 GENE TEST HNPCC SINGLE 9 $0.00
S3833 COMP APC SEQUENCE 9 $0.00
S3834 SING MUTATION APC 9 $0.00
S3835 GENE TEST CYSTIC FIBROSIS 9 $0.00
S3837 GENE TEST HEMOCHROMATO 9 $0.00
S3840 DNA ANALYSIS RET-ONCOGENE 9 $0.00
S3841 GENE TEST RETINOBLASTOMA 9 $0.00
S3842 GENE TEST HIPPEL-LINDAU 9 $0.00
S3843 DNA ANALYSIS FACTOR V 9 $0.00
S3844 DNA ANALYSIS DEAFNESS 9 $0.00
S3845 GENE TEST ALPHA-THALASSEMIA 9 $0.00
S3846 GENE TEST BETA-THALASSEMIA 9 $0.00
S3847 GENE TEST TAY-SACHS 9 $0.00
S3848 GENE TEST GAUCHER 9 $0.00
S3849 GENE TEST NIEMANN-PICK 9 $0.00
S3850 GENE TEST SICKLE CELL 9 $0.00
S3851 GENE TEST CANAVAN 9 $0.00
S3852 DNA ANALYSIS APOE ALZHEIMER 9 $0.00
S3853 GENE TEST MYO MUSCLR DYST 9 $0.00
S3854 GENE PROFILE PANEL BREAST 9 $0.00
S3855 GENE TEST PRESENILIN-1 GENE 9 $0.00
S3860 GENET TEST CARDIAC ION-COMP 9 $0.00
S3861 GENETIC TEST BRUGADA 9 $0.00
S3862 GENET TEST CARDIAC ION-SPEC 9 $0.00
S3865 COMP GENET TEST HYP CARDIOMY 9 $0.00
S3866 SPEC GENE TEST HYP CARDIOMY 9 $0.00
S3870 CGH TEST DEVELOPMENTAL DELAY 9 $0.00
S3890 FECAL DNA ANALYSIS 9 $0.00
S3900 SURFACE EMG 9 $0.00
S3902 BALLISTOCARDIOGRAM 9 $0.00
S3904 MASTERS TWO STEP 9 $0.00
S3905 AUTO HANDHELD DIAG NERV TEST 9 $0.00
S3906 TRANSFUSION, DIRECT, BLOOD 9 $0.00
S4005 INTERIM LABOR FACILITY GLOBA 9 $0.00
S4011 IVF PACKAGE 9 $0.00
S4013 COMPL GIFT CASE RATE 9 $0.00
S4014 COMPL ZIFT CASE RATE 9 $0.00
S4015 COMPLETE IVF NOS CASE RATE 9 $0.00
S4016 FROZEN IVF CASE RATE 9 $0.00
S4017 IVF CANC A STIM CASE RATE 9 $0.00
S4018 F EMB TRNS CANC CASE RATE 9 $0.00
S4020 IVF CANC A ASPIR CASE RATE 9 $0.00
S4021 IVF CANC P ASPIR CASE RATE 9 $0.00
S4022 ASST OOCYTE FERT CASE RATE 9 $0.00
S4023 INCOMPL DONOR EGG CASE RATE 9 $0.00
S4025 DONOR SERV IVF CASE RATE 9 $0.00
S4026 PROCURE DONOR SPERM 9 $0.00
S4027 STORE PREV FROZ EMBRYOS 9 $0.00

S4028 MICROSURG EPI SPERM ASP 9 $0.00
S4030 SPERM PROCURE INIT VISIT 9 $0.00
S4031 SPERM PROCURE SUBS VISIT 9 $0.00
S4035 STIMULATED IUI CASE RATE 9 $0.00
S4036 INTRAVAG CULT CASE RATE O $0.00
S4037 CRYO EMBRYO TRANSF CASE RATE 9 $0.00
S4040 MONIT STORE CRYO EMBRYO 30 D 9 $0.00
S4042 OVULATION MGMT PER CYCLE 9 $0.00
S4386 EARLY INTERVENTION O $0.00
S4516 MULTI-DISCIPLINARY ASSESSMENT/EVALU O $0.00
S4518 ENVIROMENTAL LEAD TESTING O $0.00
S4981 INSERT LEVONORGESTREL IUS 9 $0.00
S4989 CONTRACEPT IUD 9 $0.00
S4990 NICOTINE PATCH LEGEND 9 $0.00
S4991 NICOTINE PATCH NONLEGEND 9 $0.00
S4993 CONTRACEPTIVE PILLS FOR BC 9 $0.00
S4995 SMOKING CESSATION GUM 9 $0.00
S5000 PRESCRIPTION DRUG, GENERIC 9 $0.00
S5001 PRESCRIPTION DRUG,BRAND NAME 9 $0.00
S5002 FAT EMULSION 10% IN 250 ML 9 $0.00
S5003 FAT EMULSION 20% IN 250 ML 9 $0.00
S5010 5% DEXTROSE AND 0.45% SALINE 9 $0.00
S5011 5% DEXTROSE IN LACTATED RING 9 $0.00
S5012 5% DEXTROSE WITH POTASSIUM 9 $0.00
S5013 5%DEXTROSE/0.45%SALINE1000ML 9 $0.00
S5014 D5W/0.45NS W KCL AND MGS04 9 $0.00
S5016 ANTIBIOTIC ADMIN SUPPLIES W/ 9 $0.00
S5017 ANTIBIOTIC ADMINSUPPLIES W/O 9 $0.00
S5018 PAIN THERAPY ADMIN SUPPLIES 9 $0.00
S5019 CHEMOTHERAPY ADMIN SUPPLIES 9 $0.00
S5020 CHEMOTHERAPY ADMIN SUPPLIES 9 $0.00
S5021 HYDRATION THERAPY ADMIN SUPP 9 $0.00
S5022 GROWTH HORMONE THERAPY 9 $0.00
S5025 INFUSION PUMP RENTAL,PERDIEM 9 $0.00
S5035 HIT ROUTINE DEVICE MAINT 9 $0.00
S5036 HIT DEVICE REPAIR 9 $0.00
S5100 ADULT DAYCARE SERVICES 15MIN 9 $0.00
S5101 ADULT DAY CARE PER HALF DAY 7 $0.00
S5102 ADULT DAY CARE PER DIEM 7 $0.00
S5105 CENTERBASED DAY CARE PERDIEM 7 $0.00
S5108 HOMECARE TRAIN PT 15 MIN 9 $0.00
S5109 HOMECARE TRAIN PT SESSION 9 $0.00
S5110 FAMILY HOMECARE TRAINING 15M 9 $0.00
S5111 FAMILY HOMECARE TRAIN/SESSIO 9 $0.00
S5115 NONFAMILY HOMECARE TRAIN/15M 9 $0.00
S5116 NONFAMILY HC TRAIN/SESSION 9 $0.00
S5120 CHORE SERVICES PER 15 MIN 9 $0.00
S5121 CHORE SERVICES PER DIEM 9 $0.00
S5125 ATTENDANT CARE SERVICE /15M 9 $0.00

S5126 ATTENDANT CARE SERVICE /DIEM 9 $0.00
S5130 HOMAKER SERVICE NOS PER 15M 7 $0.00
S5131 HOMEMAKER SERVICE NOS /DIEM 9 $0.00
S5135 ADULT COMPANIONCARE PER 15M 9 $0.00
S5136 ADULT COMPANIONCARE PER DIEM 9 $0.00
S5140 ADULT FOSTER CARE PER DIEM 7 $0.00
S5141 ADULT FOSTER CARE PER MONTH 9 $0.00
S5145 CHILD FOSTERCARE TH PER DIEM 7 $0.00
S5146 THER FOSTERCARE CHILD /MONTH 9 $0.00
S5150 UNSKILLED RESPITE CARE /15M 9 $0.00
S5151 UNSKILLED RESPITECARE /DIEM 9 $0.00
S5160 EMER RESPONSE SYS INSTAL&TST 7 $0.00
S5161 EMER RSPNS SYS SERV PERMONTH 7 $0.00
S5162 EMER RSPNS SYSTEM PURCHASE 7 $0.00
S5165 HOME MODIFICATIONS PER SERV 5 $0.00
S5170 HOMEDELIVERED PREPARED MEAL 9 $0.00
S5175 LAUNDRY SERV,EXT,PROF,/ORDER 9 $0.00
S5180 HH RESPIRATORY THRPY IN EVAL 9 $0.00
S5181 HH RESPIRATORY THRPY NOS/DAY 9 $0.00
S5185 MED REMINDER SERV PER MONTH 9 $0.00
S5190 WELLNESS ASSESSMENT BY NONPH 6 $0.00
S5199 PERSONAL CARE ITEM NOS EACH 9 $0.00
S5497 HIT CATH CARE NOC 9 $0.00
S5498 HIT SIMPLE CATH CARE 9 $0.00
S5501 HIT COMPLEX CATH CARE 9 $0.00
S5502 HIT INTERIM CATH CARE 9 $0.00
S5503 MAINTENANCE OF IMPLANTED VAS 9 $0.00
S5517 HIT DECLOTTING KIT 9 $0.00
S5518 HIT CATH REPAIR KIT 9 $0.00
S5520 HIT PICC INSERT KIT 9 $0.00
S5521 HIT MIDLINE CATH INSERT KIT 9 $0.00
S5522 HIT PICC INSERT NO SUPP 9 $0.00
S5523 HIP MIDLINE CATH INSERT KIT 9 $0.00
S5550 INSULIN RAPID 5 U 6 $0.00
S5551 INSULIN MOST RAPID 5 U 6 $0.00
S5552 INSULIN INTERMED 5 U 6 $0.00
S5553 INSULIN LONG ACTING 5 U 6 $0.00
S5560 INSULIN REUSE PEN 1.5 ML 6 $0.00
S5561 INSULIN REUSE PEN 3 ML 6 $0.00
S5565 INSULIN CARTRIDGE 150 U 9 $0.00
S5566 INSULIN CARTRIDGE 300 U 9 $0.00
S5570 INSULIN DISPOS PEN 1.5 ML 9 $0.00
S5571 INSULIN DISPOS PEN 3 ML 9 $0.00
S8001 RADIOFREQUENCY STIMULATION 9 $0.00
S8004 WHOLEBODY RADIOPHARM TRGCELL O $0.00
S8030 TANTALUM RING APPLICATION 9 $0.00
S8035 MAGNETIC SOURCE IMAGING 9 $0.00
S8037 MRCP 9 $0.00
S8040 TOPOGRAPHIC BRAIN MAPPING 9 $0.00

S8042 MRI LOW FIELD 5 $0.00
S8048 ISOLATED LIMB PERFUSION 9 $0.00
S8049 INTRAOPERATIVE RADIATION THE 9 $0.00
S8055 US GUIDANCE FETAL REDUCT 9 $0.00
S8060 SUPPLY OF CONTRAST MATERIAL 9 $0.00
S8075 CAD OF DIGITAL MAMMOGR O $0.00
S8080 SCINTIMAMMOGRAPHY 9 $0.00
S8085 FLUORINE-18 FLUORODEOXYGLUCO 9 $0.00
S8092 ELECTRON BEAM COMPUTED TOMOG 9 $0.00
S8093 CT ANGIOGRAPHY CORONARY O $0.00
S8095 WIG (FOR MEDICALLY-INDUCED H O $0.00
S8096 PORTABLE PEAK FLOW METER 9 $0.00
S8097 ASTHMA KIT 9 $0.00
S8100 SPACER WITHOUT MASK 9 $0.00
S8101 SPACER WITH MASK 9 $0.00
S8105 OXIMETER FOR MEASURING BLOOD O $0.00
S8110 PEAK EXPIRATORY FLOW RATE (P 9 $0.00
S8120 O2 CONTENTS GAS CUBIC FT 9 $0.00
S8121 O2 CONTENTS LIQUID LB 9 $0.00
S8180 TRACH SHOWER PROTECTOR O $0.00
S8181 TRACH TUBE HOLDER O $0.00
S8182 HUMIDIFIER NON-SERVO O $0.00
S8183 HUMIDIFIER DUAL SERVO O $0.00
S8185 FLUTTER DEVICE 9 $0.00
S8186 SWIVEL ADAPTOR 9 $0.00
S8189 TRACH SUPPLY NOC 9 $0.00
S8190 ELECTRONIC SPIROMETER O $0.00
S8200 CHEST COMPRESSION VEST 9 $0.00
S8205 CHEST COMPRESSION SYSTEM GEN 9 $0.00
S8210 MUCUS TRAP 9 $0.00
S8260 ORAL ORTHOTIC FOR TREATMENT O $0.00
S8262 MANDIB ORTHO REPOS DEVICE 5 $0.00
S8265 HABERMAN FEEDER 5 $0.00
S8270 ENURESIS ALARM 9 $0.00
S8300 SACRAL NERVE STIMULATION TES 9 $0.00
S8301 INFECT CONTROL SUPPLIES NOS 9 $0.00
S8400 INCONTINENCE PANTS, EACH 9 $0.00
S8401 CHILD-SIZE DIAPER O $0.00
S8402 DIAPERS, EACH 9 $0.00
S8403 ADULT-SIZE PULL-UP BRIEF O $0.00
S8404 CHILD-SIZE PULL-UP BRIEF 9 $0.00
S8405 INCONTINENCE LINERS, EACH O $0.00
S8415 SUPPLIES FOR HOME DELIVERY 9 $0.00
S8420 CUSTOM GRADIENT SLEEV/GLOV 9 $0.00
S8421 READY GRADIENT SLEEV/GLOV 9 $0.00
S8422 CUSTOM GRAD SLEEVE MED 9 $0.00
S8423 CUSTOM GRAD SLEEVE HEAVY 9 $0.00
S8424 READY GRADIENT SLEEVE 9 $0.00
S8425 CUSTOM GRAD GLOVE MED 9 $0.00

S8426 CUSTOM GRAD GLOVE HEAVY 9 $0.00
S8427 READY GRADIENT GLOVE 9 $0.00
S8428 READY GRADIENT GAUNTLET 9 $0.00
S8429 GRADIENT PRESSURE WRAP 9 $0.00
S8430 PADDING FOR COMPRSSN BDG 9 $0.00
S8431 COMPRESSION BANDAGE 9 $0.00
S8433 SKIN SUPPORT/BREAST PROSTH O $0.00
S8450 SPLINT DIGIT 9 $0.00
S8451 SPLINT WRIST OR ANKLE 9 $0.00
S8452 SPLINT ELBOW 9 $0.00
S8460 CAMISOLE POST-MAST 9 $0.00
S8490 100 INSULIN SYRINGES 9 $0.00
S8940 HIPPOTHERAPY PER SESSION 9 $0.00
S8945 PT PHONOPHORESIS 30 MINS O $0.00
S8948 LOW-LEVEL LASER TRMT 15 MIN 6 $0.00
S8950 COMPLEX LYMPHEDEMA THERAPY, 9 $0.00
S8990 PT OR MANIP FOR MAINT 9 $0.00
S8999 RESUSCITATION BAG 9 $0.00
S9001 HOME UTERINE MONITOR WITH OR 9 $0.00
S9007 ULTRAFILTRATION MONITOR 9 $0.00
S9015 AUTOMATED EEG MONITORING 9 $0.00
S9022 DIGITAL SUBTRACTION ANGIOGRA O $0.00
S9023 XENON REGIONAL CEREBRAL BLOO 9 $0.00
S9024 PARANASAL SINUS ULTRASOUND 9 $0.00
S9025 OMNICARDIOGRAM/CARDIOINTEGRA 9 $0.00
S9033 GAIT ANALYSIS 9 $0.00
S9034 ESWL FOR GALLSTONES 5 $0.00
S9035 MEDICAL EQUIPMENT OR SUPPLIE 9 $0.00
S9055 PROCUREN OR OTHER GROWTH FAC 9 $0.00
S9056 COMA STIMULATION PER DIEM 9 $0.00
S9061 MEDICAL SUPPLIES AND EQUIPME 9 $0.00
S9075 SMOKING CESSATION TREATMENT 9 $0.00
S9083 URGENT CARE CENTER GLOBAL 7 $0.00
S9085 MENISCAL ALLOGRAFT TRANSPLAN 9 $0.00
S9088 SERVICES PROVIDED IN URGENT 9 $0.00
S9090 VERTEBRAL AXIAL DECOMPRESSIO 9 $0.00
S9092 CANOLITH REPOSITIONING O $0.00
S9097 HOME VISIT WOUND CARE 9 $0.00
S9098 HOME PHOTOTHERAPY VISIT 9 $0.00
S9105 EVALUATION BY OCULARIST O $0.00
S9109 CHF TELEMONITORING MONTH 9 $0.00
S9117 BACK SCHOOL VISIT 9 $0.00
S9122 HOME HEALTH AIDE OR CERTIFIE 7 $0.00
S9123 NURSING CARE IN HOME RN 3 $51.50
S9124 NURSING CARE, IN THE HOME; B 3 $46.14
S9125 RESPITE CARE, IN THE HOME, P 7 $0.00
S9126 HOSPICE CARE, IN THE HOME, P 9 $0.00
S9127 SOCIAL WORK VISIT, IN THE HO 7 $0.00
S9128 SPEECH THERAPY, IN THE HOME, 3 $43.50

S9129 OCCUPATIONAL THERAPY, IN THE 3 $43.50
S9131 PT IN THE HOME PER DIEM 3 $43.50
S9140 DIABETIC MANAGEMENT PROGRAM, 9 $0.00
S9141 DIABETIC MANAGEMENT PROGRAM, 9 $0.00
S9145 INSULIN PUMP INITIATION 5 $0.00
S9150 EVALUATION BY OCULARIST 9 $0.00
S9152 SPEECH THERAPY, RE-EVAL 9 $0.00
S9200 NURSING SERVICES AND ALL NEC 9 $0.00
S9208 HOME MGMT PRETERM LABOR 9 $0.00
S9209 HOME MGMT PPROM 9 $0.00
S9210 NURSING SERVICES AND ALL NEC 9 $0.00
S9211 HOME MGMT GEST HYPERTENSION 5 $0.00
S9212 HM POSTPAR HYPER PER DIEM 9 $0.00
S9213 HM PREECLAMP PER DIEM 9 $0.00
S9214 HM GEST DM PER DIEM 9 $0.00
S9216 GEST HYPER W NURS DIEM 9 $0.00
S9217 POSTPAR HYPER W NURS DIEM 9 $0.00
S9218 PREECLAMP W NURS DIEM 9 $0.00
S9220 NURSING SERVICES AND ALL NEC 9 $0.00
S9225 NURSING SERVICES AND ALL NEC 9 $0.00
S9230 NURSING SERVICES AND ALL NEC 9 $0.00
S9300 NURSING SERVICES AND ALL NEC 9 $0.00
S9308 NURSING SERVICES AND ALL NEC 9 $0.00
S9310 NURSING SERVICES AND ALL NEC 9 $0.00
S9325 HIT PAIN MGMT PER DIEM 9 $0.00
S9326 HIT CONT PAIN PER DIEM 9 $0.00
S9327 HIT INT PAIN PER DIEM 9 $0.00
S9328 HIT PAIN IMP PUMP DIEM 9 $0.00
S9329 HIT CHEMO PER DIEM 9 $0.00
S9330 HIT CONT CHEM DIEM 9 $0.00
S9331 HIT INTERMIT CHEMO DIEM 9 $0.00
S9335 HT HEMODIALYSIS DIEM 9 $0.00
S9336 HIT CONT ANTICOAG DIEM 9 $0.00
S9338 HIT IMMUNOTHERAPY DIEM 9 $0.00
S9339 HIT PERITON DIALYSIS DIEM 9 $0.00
S9340 HIT ENTERAL PER DIEM 9 $0.00
S9341 HIT ENTERAL GRAV DIEM 9 $0.00
S9342 HIT ENTERAL PUMP DIEM 9 $0.00
S9343 HIT ENTERAL BOLUS NURS 9 $0.00
S9345 HIT ANTI-HEMOPHIL DIEM 9 $0.00
S9346 HIT ALPHA-1-PROTEINAS DIEM 9 $0.00
S9347 HIT LONGTERM INFUSION DIEM 9 $0.00
S9348 HIT SYMPATHOMIM DIEM 9 $0.00
S9349 HIT TOCOLYSIS DIEM 9 $0.00
S9351 HIT CONT ANTIEMETIC DIEM 9 $0.00
S9353 HIT CONT INSULIN DIEM 9 $0.00
S9355 HIT CHELATION DIEM 9 $0.00
S9357 HIT ENZYME REPLACE DIEM 9 $0.00
S9359 HIT ANTI-TNF PER DIEM 9 $0.00

S9361 HIT DIURETIC INFUS DIEM 9 $0.00
S9363 HIT ANTI-SPASMOTIC DIEM 9 $0.00
S9364 HIT TPN TOTAL DIEM 9 $0.00
S9365 HIT TPN 1 LITER DIEM 9 $0.00
S9366 HIT TPN 2 LITER DIEM 9 $0.00
S9367 HIT TPN 3 LITER DIEM 9 $0.00
S9368 HIT TPN OVER 3L DIEM 9 $0.00
S9370 HT INJ ANTIEMETIC DIEM 9 $0.00
S9372 HT INJ ANTICOAG DIEM 9 $0.00
S9373 HIT HYDRA TOTAL DIEM 9 $0.00
S9374 HIT HYDRA 1 LITER DIEM 9 $0.00
S9375 HIT HYDRA 2 LITER DIEM 9 $0.00
S9376 HIT HYDRA 3 LITER DIEM 9 $0.00
S9377 HIT HYDRA OVER 3L DIEM 9 $0.00
S9379 HIT NOC PER DIEM 9 $0.00
S9381 HIT HIGH RISK/ESCORT 9 $0.00
S9395 NURSING SERVICES AND ALL NEC 9 $0.00
S9401 ANTICOAG CLINIC PER SESSION 9 $0.00
S9420 NURSING SERVICES AND ALL NEC 9 $0.00
S9423 NURSING SERVICES, PATIENT AS 9 $0.00
S9425 NURSING SERVICES AND ALL NEC 9 $0.00
S9430 PHARMACY COMP/DISP SERV 9 $0.00
S9433 MEDICAL FOOD ORAL 100% NUTR 9 $0.00
S9434 MOD SOLID FOOD SUPPL 6 $0.00
S9435 MEDICAL FOODS FOR INBORN ERR 9 $0.00
S9436 LAMAZE CLASS 9 $0.00
S9437 CHILDBIRTH REFRESHER CLASS 9 $0.00
S9438 CESAREAN BIRTH CLASS 9 $0.00
S9439 VBAC CLASS 9 $0.00
S9441 ASTHMA EDUCATION 9 $0.00
S9442 BIRTHING CLASS 9 $0.00
S9443 LACTATION CLASS 9 $0.00
S9444 PARENTING CLASS 9 $0.00
S9445 PT EDUCATION NOC INDIVID 7 $0.00
S9446 PT EDUCATION NOC GROUP 9 $0.00
S9447 INFANT SAFETY CLASS 9 $0.00
S9449 WEIGHT MGMT CLASS 9 $0.00
S9451 EXERCISE CLASS 9 $0.00
S9452 NUTRITION CLASS 9 $0.00
S9453 SMOKING CESSATION CLASS 9 $0.00
S9454 STRESS MGMT CLASS 9 $0.00
S9455 DIABETIC MANAGEMENT PROGRAM, 9 $0.00
S9460 DIABETIC MANAGEMENT PROGRAM, 9 $0.00
S9465 DIABETIC MANAGEMENT PROGRAM, 9 $0.00
S9470 NUTRITIONAL COUNSELING, DIET 3 $44.00
S9472 CARDIAC REHABILITATION PROGR 9 $0.00
S9473 PULMONARY REHABILITATION PRO 9 $0.00
S9474 ENTEROSTOMAL THERAPY BY A RE 9 $0.00
S9475 AMBULATORY SETTING SUBSTANCE 9 $0.00

S9476 VESTIBULAR REHAB PER DIEM 9 $0.00
S9480 INTENSIVE OUTPATIENT PSYCHIA 9 $0.00
S9482 FAMILY STABILIZATION 15 MIN 9 $0.00
S9484 CRISIS INTERVENTION PER HOUR 7 $0.00
S9485 CRISIS INTERVENTION MENTAL H 9 $0.00
S9490 HIT CORTICOSTEROID/DIEM 9 $0.00
S9494 HIT ANTIBIOTIC TOTAL DIEM 9 $0.00
S9497 HIT ANTIBIOTIC Q3H DIEM 9 $0.00
S9500 HIT ANTIBIOTIC Q24H DIEM 9 $0.00
S9501 HIT ANTIBIOTIC Q12H DIEM 9 $0.00
S9502 HIT ANTIBIOTIC Q8H DIEM 9 $0.00
S9503 HIT ANTIBIOTIC Q6H DIEM 9 $0.00
S9504 HIT ANTIBIOTIC Q4H DIEM 9 $0.00
S9524 NURSING SERVICES RELATED TO O $0.00
S9526 SKILLED NURSING VISITS FOR 9 $0.00
S9527 INSERTION OF A PERIPHERALLY 9 $0.00
S9528 INSERTION OF MIDLINE CENTRAL 9 $0.00
S9529 VENIPUNCTURE HOME/SNF 9 $0.00
S9533 PAIN MANAGEMENT, INTRAVENOUS 9 $0.00
S9535 ADMINISTRATION OF HEMATOPOIE 9 $0.00
S9537 HT HEM HORM INJ DIEM 9 $0.00
S9538 HIT BLOOD PRODUCTS DIEM 9 $0.00
S9539 ADMINISTRATION OF ANTIBIOTIC 9 $0.00
S9542 HT INJ NOC PER DIEM 9 $0.00
S9543 ADMINISTRATION OF MEDICATION O $0.00
S9545 ADMINISTRATION OF IMMUNE GLO 9 $0.00
S9546 HOME INF BLOOD PROD NURS SER O $0.00
S9550 HOME IV THERAPY, HYDRATION 9 $0.00
S9555 ADDITIONAL HOME INFUSION 9 $0.00
S9558 HT INJ GROWTH HORM DIEM 9 $0.00
S9559 HIT INJ INTERFERON DIEM 9 $0.00
S9560 HT INJ HORMONE DIEM 9 $0.00
S9562 HT INJ PALIVIZUMAB DIEM 9 $0.00
S9590 HT IRRIGATION DIEM 9 $0.00
S9800 HT RN PER HOUR 9 $0.00
S9802 SPECIALTY DRUG ADMIN/NSG SRV O $0.00
S9803 EACH ADDITIONAL HOUR O $0.00
S9806 RN INFUSION SUITE VISIT O $0.00
S9810 HT PHARM PER HOUR 9 $0.00
S9900 CHRISTIAN SCI PRACT VISIT 9 $0.00
S9970 HEALTH CLUB MEMBERSHIP YR 9 $0.00
S9975 TRANSPLANT RELATED PER DIEM 9 $0.00
S9976 LODGING PER DIEM 9 $0.00
S9977 MEALS PER DIEM 9 $0.00
S9981 MED RECORD COPY ADMIN 9 $0.00
S9982 MED RECORD COPY PER PAGE 9 $0.00
S9986 NOT MEDICALLY NECESSARY SVC 9 $0.00
S9988 SERV PART OF PHASE I TRIAL 9 $0.00
S9989 SERVICES OUTSIDE US 9 $0.00

S9990 SERVICES PROVIDED AS PART OF 9 $0.00
S9991 SERVICES PROVIDED AS PART OF 9 $0.00
S9992 TRANSPORTATION COSTS TO AND 9 $0.00
S9994 LODGING COSTS (E.G. HOTEL CH 9 $0.00
S9996 MEALS FOR CLINICAL TRIAL PAR 9 $0.00
S9999 SALES TAX 9 $0.00
SARCW MCO SPECIFIC CODE: SMART START SUBS O $0.00
SARRN MCO SPECIFIC CODE: SMART START SUBS O $0.00
SARSW MCO SPECIFIC CODE: SMART START SUBS O $0.00
T1000 PRIVATE DUTY/INDEPENDENT NSG 7 $0.00
T1001 NURSING ASSESSMENT/EVALUATN 7 $0.00
T1002 RN SERVICES UP TO 15 MINUTES 3 $19.00
T1003 LPN/LVN SERVICES UP TO 15MIN 9 $0.00
T1004 NSG AIDE SERVICE UP TO 15MIN 9 $0.00
T1005 RESPITE CARE SERVICE 15 MIN 7 $0.00
T1006 FAMILY/COUPLE COUNSELING 9 $0.00
T1007 TREATMENT PLAN DEVELOPMENT 9 $0.00
T1008 DAY TREATMENT FOR INDIVIDUAL O $0.00
T1009 CHILD SITTING SERVICES 9 $0.00
T1010 MEALS WHEN RECEIVE SERVICES 9 $0.00
T1011 ALCOHOL/SUBSTANCE ABUSE NOC O $0.00
T1012 ALCOHOL/SUBSTANCE ABUSE SKIL 9 $0.00
T1013 SIGN LANG/ORAL INTERPRETER 9 $0.00
T1014 TELEHEALTH TRANSMIT, PER MIN 9 $0.00
T1015 CLINIC SERVICE 9 $0.00
T1016 CASE MANAGEMENT 9 $0.00
T1017 TARGETED CASE MANAGEMENT 9 $0.00
T1018 SCHOOL-BASED IEP SER BUNDLED 9 $0.00
T1019 PERSONAL CARE SER PER 15 MIN 9 $0.00
T1020 PERSONAL CARE SER PER DIEM 9 $0.00
T1021 HH AIDE OR CN AIDE PER VISIT 9 $0.00
T1022 CONTRACTED SERVICES PER DAY 9 $0.00
T1023 PROGRAM INTAKE ASSESSMENT 7 $0.00
T1024 TEAM EVALUATION & MANAGEMENT 3 $1,429.81
T1025 PED COMPR CARE PKG, PER DIEM 9 $0.00
T1026 PED COMPR CARE PKG, PER HOUR 9 $0.00
T1027 FAMILY TRAINING & COUNSELING 9 $0.00
T1028 HOME ENVIRONMENT ASSESSMENT 9 $0.00
T1029 DWELLING LEAD INVESTIGATION 5 $0.00
T1030 RN HOME CARE PER DIEM 9 $0.00
T1031 LPN HOME CARE PER DIEM 9 $0.00
T1035 UTILITY SERVICES WAIVER 9 $0.00
T1500 REUSABLE DIAPER/PANT O $0.00
T1502 MEDICATION ADMIN VISIT 9 $0.00
T1503 MED ADMIN, NOT ORAL/INJECT 9 $0.00
T1999 NOC RETAIL ITEMS ANDSUPPLIES 9 $0.00
T2001 N-ET; PATIENT ATTEND/ESCORT 3 $10.10
T2002 N-ET; PER DIEM 7 $0.00
T2003 N-ET; ENCOUNTER/TRIP 3 $10.10

T2004 N-ET; COMMERC CARRIER PASS 9 $0.00
T2005 N-ET; STRETCHER VAN 9 $0.00
T2006 AMB RESPONSE & TRT, NO TRANS O $0.00
T2007 NON-EMER TRANSPORT WAIT TIME 9 $0.00
T2010 PASRR LEVEL I 9 $0.00
T2011 PASRR LEVEL II 9 $0.00
T2012 HABIL ED WAIVER, PER DIEM 9 $0.00
T2013 HABIL ED WAIVER PER HOUR 9 $0.00
T2014 HABIL PREVOC WAIVER, PER D 7 $0.00
T2015 HABIL PREVOC WAIVER PER HR 7 $0.00
T2016 HABIL RES WAIVER PER DIEM 7 $0.00
T2017 HABIL RES WAIVER 15 MIN 9 $0.00
T2018 HABIL SUP EMPL WAIVER/DIEM 7 $0.00
T2019 HABIL SUP EMPL WAIVER 15MIN 9 $0.00
T2020 DAY HABIL WAIVER PER DIEM 7 $0.00
T2021 DAY HABIL WAIVER PER 15 MIN 7 $0.00
T2022 CASE MANAGEMENT, PER MONTH 7 $0.00
T2023 TARGETED CASE MGMT PER MONTH 9 $0.00
T2024 SERV ASMNT/CARE PLAN WAIVER 9 $0.00
T2025 WAIVER SERVICE, NOS 7 $0.00
T2026 SPECIAL CHILDCARE WAIVER/D 9 $0.00
T2027 SPEC CHILDCARE WAIVER 15 MIN 9 $0.00
T2028 SPECIAL SUPPLY, NOS WAIVER 9 $0.00
T2029 SPECIAL MED EQUIP, NOSWAIVER 9 $0.00
T2030 ASSIST LIVING WAIVER/MONTH 9 $0.00
T2031 ASSIST LIVING WAIVER/DIEM 9 $0.00
T2032 RES CARE, NOS WAIVER/MONTH 9 $0.00
T2033 RES, NOS WAIVER PER DIEM 7 $0.00
T2034 CRISIS INTERVEN WAIVER/DIEM 9 $0.00
T2035 UTILITY SERVICES WAIVER 9 $0.00
T2036 CAMP OVERNITE WAIVER/SESSION 9 $0.00
T2037 CAMP DAY WAIVER/SESSION 9 $0.00
T2038 COMM TRANS WAIVER/SERVICE 9 $0.00
T2039 VEHICLE MOD WAIVER/SERVICE 9 $0.00
T2040 FINANCIAL MGT WAIVER/15MIN 9 $0.00
T2041 SUPPORT BROKER WAIVER/15 MIN 9 $0.00
T2042 HOSPICE ROUTINE HOME CARE 9 $0.00
T2043 HOSPICE CONTINUOUS HOME CARE 9 $0.00
T2044 HOSPICE RESPITE CARE 9 $0.00
T2045 HOSPICE GENERAL CARE 9 $0.00
T2046 HOSPICE LONG TERM CARE, R&B 9 $0.00
T2048 BH LTC RES R&B, PER DIEM 9 $0.00
T2049 N-ET; STRETCHER VAN, MILEAGE 9 $0.00
T2101 BREAST MILK PROC/STORE/DIST 9 $0.00
T4521 ADULT SIZE BRIEF/DIAPER SM 3 $0.50
T4522 ADULT SIZE BRIEF/DIAPER MED 3 $0.50
T4523 ADULT SIZE BRIEF/DIAPER LG 3 $0.74
T4524 ADULT SIZE BRIEF/DIAPER XL 3 $0.88
T4525 ADULT SIZE PULL-ON SM 3 $0.50

T4526 ADULT SIZE PULL-ON MED 3 $0.50
T4527 ADULT SIZE PULL-ON LG 3 $0.74
T4528 ADULT SIZE PULL-ON XL 3 $0.88
T4529 PED SIZE BRIEF/DIAPER SM/MED 3 $0.25
T4530 PED SIZE BRIEF/DIAPER LG 3 $0.37
T4531 PED SIZE PULL-ON SM/MED 3 $0.25
T4532 PED SIZE PULL-ON LG 3 $0.37
T4533 YOUTH SIZE BRIEF/DIAPER 3 $0.47
T4534 YOUTH SIZE PULL-ON 3 $0.47
T4535 DISPOSABLE LINER/SHIELD/PAD 3 $0.33
T4536 REUSABLE PULL-ON ANY SIZE 9 $0.00
T4537 REUSABLE UNDERPAD BED SIZE 9 $0.00
T4538 DIAPER SERV REUSABLE DIAPER 9 $0.00
T4539 REUSE DIAPER/BRIEF ANY SIZE 9 $0.00
T4540 REUSABLE UNDERPAD CHAIR SIZE 9 $0.00
T4541 LARGE DISPOSABLE UNDERPAD 3 $0.54
T4542 SMALL DISPOSABLE UNDERPAD 3 $0.20
T4543 DISP BARIATRIC BRIEF/DIAPER 6 $0.00
T5001 POSITION SEAT SPEC ORTH NEED 6 $0.00
T5999 SUPPLY, NOS 9 $0.00
TBEVL MCO SPECIFIC CODE: DPH INITIAL EVAL O $0.00
TBTXA MCO SPECIFIC CODE: DPH TB TREATMENT O $0.00
TBTXS MCO SPECIFIC CODE: DPH TB TREATMENT O $0.00
TI10H PART C SPECIFIC CODE: INTERPERIODIC O $0.00
TI11H PART C SPECIFIC CODE: INTERPERIODIC O $0.00
TI12H PART C SPECIFIC CODE: INTERPERIODIC O $0.00
TI13H PART C SPECIFIC CODE: INTERPERIODIC O $0.00
TI420 MCO SPECIFIC CODE: INTERPERIODIC CO O $0.00
TI42H INTERPERIODIC CONSULTATION BY A PHY O $0.00
TI430 MCO SPECIFIC CODE: INTERPERIODIC CO O $0.00
TI43H INTERPERIODIC CONSULTATION BY A OCC O $0.00
TI440 MCO SPECIFIC CODE: INTERPERIODIC CO O $0.00
TI44H INTERPERIODIC CONSULTATION BY A SPE O $0.00
TV10H PART C SPECIFIC CODE: TREATMENT VIS O $0.00
TV11H PART C SPECIFIC CODE: TREATMENT VIS O $0.00
TV12H PART C SPECIFIC CODE: TREATMENT VIS O $0.00
TV420 MCO SPECIFIC CODE: TRANSDISCIPLINAR O $0.00
TV42H TRANSDISCIPLINARY VISIT BY A PHYSIC O $0.00
TV430 MCO SPECIFIC CODE: TRANSDISCIPLINAR O $0.00
TV43H TRANSDISCIPLINARY VISIT BY A OCCUPA O $0.00
TV440 MCO SPECIFIC CODE: TRANSDISCIPLINAR O $0.00
TV44H TRANSDISCIPLINARY VISIT BY A SPEECH O $0.00
V2020 VISION SVCS FRAMES PURCHASES 3 $49.74
V2025 EYEGLASSES DELUX FRAMES 6 $0.00
V2100 LENS SPHER SINGLE PLANO 4.00 3 $38.15
V2101 SINGLE VISN SPHERE 4.12-7.00 3 $40.00
V2102 SINGL VISN SPHERE 7.12-20.00 3 $58.93
V2103 SPHEROCYLINDR 4.00D/12-2.00D 3 $35.97
V2104 SPHEROCYLINDR 4.00D/2.12-4D 3 $38.98

V2105 SPHEROCYLINDER 4.00D/4.25-6D 3 $43.37
V2106 SPHEROCYLINDER 4.00D/>6.00D 3 $48.13
V2107 SPHEROCYLINDER 4.25D/12-2D 3 $44.62
V2108 SPHEROCYLINDER 4.25D/2.12-4D 3 $47.40
V2109 SPHEROCYLINDER 4.25D/4.25-6D 3 $52.44
V2110 SPHEROCYLINDER 4.25D/OVER 6D 3 $51.74
V2111 SPHEROCYLINDR 7.25D/.25-2.25 3 $53.06
V2112 SPHEROCYLINDR 7.25D/2.25-4D 3 $58.86
V2113 SPHEROCYLINDR 7.25D/4.25-6D 3 $1.79
V2114 SPHEROCYLINDER OVER 12.00D 3 $71.89
V2115 LENS LENTICULAR BIFOCAL 3 $63.63
V2116 NONASPHERIC LENS BIFOCAL O $0.00
V2117 ASPHERIC LENS BIFOCAL O $0.00
V2118 LENS ANISEIKONIC SINGLE 3 $77.56
V2121 LENTICULAR LENS, SINGLE 6 $0.00
V2199 LENS SINGLE VISION NOT OTH C 6 $0.00
V2200 LENS SPHER BIFOC PLANO 4.00D 3 $52.57
V2201 LENS SPHERE BIFOCAL 4.12-7.0 3 $57.57
V2202 LENS SPHERE BIFOCAL 7.12-20. 3 $69.55
V2203 LENS SPHCYL BIFOCAL 4.00D/.1 3 $54.25
V2204 LENS SPHCY BIFOCAL 4.00D/2.1 3 $57.19
V2205 LENS SPHCY BIFOCAL 4.00D/4.2 3 $61.83
V2206 LENS SPHCY BIFOCAL 4.00D/OVE 3 $66.43
V2207 LENS SPHCY BIFOCAL 4.25-7D/. 3 $58.71
V2208 LENS SPHCY BIFOCAL 4.25-7/2. 3 $62.97
V2209 LENS SPHCY BIFOCAL 4.25-7/4. 3 $67.36
V2210 LENS SPHCY BIFOCAL 4.25-7/OV 3 $75.32
V2211 LENS SPHCY BIFO 7.25-12/.25- 3 $72.60
V2212 LENS SPHCYL BIFO 7.25-12/2.2 3 $72.60
V2213 LENS SPHCYL BIFO 7.25-12/4.2 3 $68.64
V2214 LENS SPHCYL BIFOCAL OVER 12. 3 $88.57
V2215 LENS LENTICULAR BIFOCAL 3 $75.38
V2216 LENS LENTICULAR NONASPHERIC O $0.00
V2217 LENS LENTICULAR ASPHERIC BIF O $0.00
V2218 LENS ANISEIKONIC BIFOCAL 3 $106.98
V2219 LENS BIFOCAL SEG WIDTH OVER 3 $47.09
V2220 LENS BIFOCAL ADD OVER 3.25D 3 $38.19
V2221 LENTICULAR LENS, BIFOCAL 6 $0.00
V2299 LENS BIFOCAL SPECIALITY 6 $0.00
V2300 LENS SPHERE TRIFOCAL 4.00D 3 $62.84
V2301 LENS SPHERE TRIFOCAL 4.12-7. 3 $73.64
V2302 LENS SPHERE TRIFOCAL 7.12-20 3 $86.73
V2303 LENS SPHCY TRIFOCAL 4.0/.12- 3 $57.57
V2304 LENS SPHCY TRIFOCAL 4.0/2.25 3 $67.29
V2305 LENS SPHCY TRIFOCAL 4.0/4.25 3 $77.94
V2306 LENS SPHCYL TRIFOCAL 4.00/>6 3 $82.73
V2307 LENS SPHCY TRIFOCAL 4.25-7/. 3 $76.36
V2308 LENS SPHC TRIFOCAL 4.25-7/2. 3 $79.36
V2309 LENS SPHC TRIFOCAL 4.25-7/4. 3 $82.96

V2310 LENS SPHC TRIFOCAL 4.25-7/>6 3 $88.00
V2311 LENS SPHC TRIFO 7.25-12/.25- 3 $79.49
V2312 LENS SPHC TRIFO 7.25-12/2.25 3 $79.95
V2313 LENS SPHC TRIFO 7.25-12/4.25 3 $82.94
V2314 LENS SPHCYL TRIFOCAL OVER 12 3 $106.56
V2315 LENS LENTICULAR TRIFOCAL 3 $94.65
V2316 LENS LENTICULAR NONASPHERIC O $0.00
V2317 LENS LENTICULAR ASPHERIC TRI O $0.00
V2318 LENS ANISEIKONIC TRIFOCAL 3 $148.07
V2319 LENS TRIFOCAL SEG WIDTH > 28 3 $52.52
V2320 LENS TRIFOCAL ADD OVER 3.25D 3 $55.41
V2321 LENTICULAR LENS, TRIFOCAL 6 $0.00
V2399 LENS TRIFOCAL SPECIALITY 6 $0.00
V2410 LENS VARIAB ASPHERICITY SING 3 $82.58
V2430 LENS VARIABLE ASPHERICITY BI 3 $92.26
V2499 VARIABLE ASPHERICITY LENS 6 $0.00
V2500 CONTACT LENS PMMA SPHERICAL 3 $85.97
V2501 CNTCT LENS PMMA-TORIC/PRISM 3 $116.84
V2502 CONTACT LENS PMMA BIFOCAL 3 $153.78
V2503 CNTCT LENS PMMA COLOR VISION 3 $148.27
V2510 CNTCT GAS PERMEABLE SPHERICL 3 $116.23
V2511 CNTCT TORIC PRISM BALLAST 3 $150.69
V2512 CNTCT LENS GAS PERMBL BIFOCL 3 $185.42
V2513 CONTACT LENS EXTENDED WEAR 3 $151.11
V2520 CONTACT LENS HYDROPHILIC 3 $107.68
V2521 CNTCT LENS HYDROPHILIC TORIC 3 $169.90
V2522 CNTCT LENS HYDROPHIL BIFOCL 3 $151.60
V2523 CNTCT LENS HYDROPHIL EXTEND 3 $149.83
V2530 CONTACT LENS GAS IMPERMEABLE 3 $202.40
V2531 CONTACT LENS GAS PERMEABLE 3 $421.66
V2599 CONTACT LENS/ES OTHER TYPE 6 $0.00
V2600 HAND HELD LOW VISION AIDS 6 $0.00
V2610 SINGLE LENS SPECTACLE MOUNT 6 $0.00
V2615 TELESCOP/OTHR COMPOUND LENS 6 $0.00
V2620 PROSTHETIC, EYE, GLASS, STOCK 9 $0.00
V2621 PROSTHETIC, EYE PLASTIC, STOCK 9 $0.00
V2622 PROSTHETIC, EYE, GLASS, CUSTOM 9 $0.00
V2623 PLASTIC EYE PROSTH CUSTOM 3 $712.05
V2624 POLISHING ARTIFICAL EYE 3 $64.39
V2625 ENLARGEMNT OF EYE PROSTHESIS 3 $293.59
V2626 REDUCTION OF EYE PROSTHESIS 3 $158.26
V2627 SCLERAL COVER SHELL 3 $1,022.12
V2628 FABRICATION & FITTING 3 $241.34
V2629 PROSTHETIC EYE OTHER TYPE 6 $0.00
V2630 ANTER CHAMBER INTRAOCUL LENS 6 $0.00
V2631 IRIS SUPPORT INTRAOCLR LENS 6 $0.00
V2632 POST CHMBR INTRAOCULAR LENS 6 $0.00
V2700 BALANCE LENS 3 $42.70
V2702 DELUXE LENS FEATURE 9 $0.00

V2710 GLASS/PLASTIC SLAB OFF PRISM 3 $59.65
V2715 PRISM LENS/ES 3 $9.76
V2718 FRESNELL PRISM PRESS-ON LENS 3 $23.48
V2730 SPECIAL BASE CURVE 3 $16.73
V2740 ROSE TINT PLASTIC O $0.00
V2741 NON-ROSE TINT PLASTIC O $0.00
V2742 ROSE TINT GLASS O $0.00
V2743 NON-ROSE TINT GLASS O $0.00
V2744 TINT PHOTOCHROMATIC LENS/ES 5 $0.00
V2745 TINT, ANY COLOR/SOLID/GRAD 9 $0.00
V2750 ANTI-REFLECTIVE COATING 5 $0.00
V2755 UV LENS/ES 9 $0.00
V2756 EYE GLASS CASE 9 $0.00
V2760 SCRATCH RESISTANT COATING 3 $16.31
V2761 MIRROR COATING 9 $0.00
V2762 POLARIZATION, ANY LENS 9 $0.00
V2770 OCCLUDER LENS/ES 9 $0.00
V2780 OVERSIZE LENS/ES 9 $0.00
V2781 PROGRESSIVE LENS PER LENS 9 $0.00
V2782 LENS, 1.54-1.65 P/1.60-1.79G 6 $0.00
V2783 LENS, >= 1.66 P/>=1.80 G 6 $0.00
V2784 LENS POLYCARB OR EQUAL 3 $37.16
V2785 CORNEAL TISSUE PROCESSING 6 $0.00
V2786 OCCUPATIONAL MULTIFOCAL LENS 9 $0.00
V2787 ASTIGMATISM-CORRECT FUNCTION 9 $0.00
V2788 PRESBYOPIA-CORRECT FUNCTION 9 $0.00
V2790 AMNIOTIC MEMBRANE 6 $0.00
V2797 VIS ITEM/SVC IN OTHER CODE 9 $0.00
V2799 MISCELLANEOUS VISION SERVICE 6 $0.00
V5000 BASIC AUDIOLOGIC ASSESSMENT - HEARI 9 $0.00
V5001 COMPREHENSIVE AUDIOLOGIC ASSESSMENT 9 $0.00
V5002 ASSESSMENT OF VESTIBULAR AND/OR AUD 9 $0.00
V5003 ASSESSMENT OF VESTIBULAR AND/OR AUD 9 $0.00
V5008 HEARING SCREENING 3 $16.00
V5010 ASSESSMENT FOR HEARING AID 9 $0.00
V5011 HEARING AID FITTING/CHECKING 9 $0.00
V5012 COMPLETE COCHLEAR IMPLANT REHABILIT 9 $0.00
V5014 HEARING AID REPAIR/MODIFYING 5 $0.00
V5016 UNLISTED AUDIOLOGIC PROCEDURE (SPEC 9 $0.00
V5020 CONFORMITY EVALUATION 9 $0.00
V5030 BODY-WORN HEARING AID AIR 5 $0.00
V5040 BODY-WORN HEARING AID BONE 5 $0.00
V5050 HEARING AID MONAURAL IN EAR 5 $0.00
V5060 BEHIND EAR HEARING AID 5 $0.00
V5070 GLASSES AIR CONDUCTION 5 $0.00
V5080 GLASSES BONE CONDUCTION 5 $0.00
V5090 HEARING AID DISPENSING FEE 3 $400.00
V5095 IMPLANT MID EAR HEARING PROS 5 $0.00
V5100 BODY-WORN BILAT HEARING AID 5 $0.00

V5110 HEARING AID DISPENSING FEE 9 $0.00
V5120 BODY-WORN BINAUR HEARING AID 5 $0.00
V5130 IN EAR BINAURAL HEARING AID 5 $0.00
V5140 BEHIND EAR BINAUR HEARING AI 5 $0.00
V5150 GLASSES BINAURAL HEARING AID 5 $0.00
V5160 DISPENSING FEE BINAURAL 9 $0.00
V5170 WITHIN EAR CROS HEARING AID 5 $0.00
V5180 BEHIND EAR CROS HEARING AID 5 $0.00
V5190 GLASSES CROS HEARING AID 5 $0.00
V5200 CROS HEARING AID DISPENS FEE 9 $0.00
V5210 IN EAR BICROS HEARING AID 5 $0.00
V5220 BEHIND EAR BICROS HEARING AI 5 $0.00
V5230 GLASSES BICROS HEARING AID 5 $0.00
V5240 DISPENSING FEE BICROS 9 $0.00
V5241 DISPENSING FEE, MONAURAL 9 $0.00
V5242 HEARING AID, MONAURAL, CIC 5 $0.00
V5243 HEARING AID, MONAURAL, ITC 5 $0.00
V5244 HEARING AID, PROG, MON, CIC 5 $0.00
V5245 HEARING AID, PROG, MON, ITC 5 $0.00
V5246 HEARING AID, PROG, MON, ITE 5 $0.00
V5247 HEARING AID, PROG, MON, BTE 5 $0.00
V5248 HEARING AID, BINAURAL, CIC 5 $0.00
V5249 HEARING AID, BINAURAL, ITC 5 $0.00
V5250 HEARING AID, PROG, BIN, CIC 5 $0.00
V5251 HEARING AID, PROG, BIN, ITC 5 $0.00
V5252 HEARING AID, PROG, BIN, ITE 5 $0.00
V5253 HEARING AID, PROG, BIN, BTE 5 $0.00
V5254 HEARING ID, DIGIT, MON, CIC 5 $0.00
V5255 HEARING AID, DIGIT, MON, ITC 5 $0.00
V5256 HEARING AID, DIGIT, MON, ITE 5 $0.00
V5257 HEARING AID, DIGIT, MON, BTE 5 $0.00
V5258 HEARING AID, DIGIT, BIN, CIC 5 $0.00
V5259 HEARING AID, DIGIT, BIN, ITC 5 $0.00
V5260 HEARING AID, DIGIT, BIN, ITE 5 $0.00
V5261 HEARING AID, DIGIT, BIN, BTE 5 $0.00
V5262 HEARING AID, DISP, MONAURAL 5 $0.00
V5263 HEARING AID, DISP, BINAURAL 5 $0.00
V5264 EAR MOLD/INSERT 9 $0.00
V5265 EAR MOLD/INSERT, DISP 9 $0.00
V5266 BATTERY FOR HEARING DEVICE 5 $0.00
V5267 HEARING AID SUPPLY/ACCESSORY 5 $0.00
V5268 ALD TELEPHONE AMPLIFIER 9 $0.00
V5269 ALERTING DEVICE, ANY TYPE 9 $0.00
V5270 ALD, TV AMPLIFIER, ANY TYPE 9 $0.00
V5271 ALD, TV CAPTION DECODER 9 $0.00
V5272 TDD 9 $0.00
V5273 ALD FOR COCHLEAR IMPLANT 9 $0.00
V5274 ALD UNSPECIFIED 9 $0.00
V5275 EAR IMPRESSION 9 $0.00

V5298 HEARING AID NOC 5 $0.00
V5299 HEARING SERVICE 9 $0.00
V5301 BASIC ASSESSMENT OF SPECIFIC SINGLE 9 $0.00
V5310 COMPREHENSIVE ASSESSMENT OF SPEECH, 9 $0.00
V5321 ASSESSMENT FOR ORAL OR LARYNGEAL PR 9 $0.00
V5322 ASSESSMENT FOR AUGMENTATIVE COMMUNI 9 $0.00
V5330 TREATMENT FOR SPEECH, LANGUAGE, ORA 9 $0.00
V5335 REPAIR/MODIFICATION OF ORAL OR LARY 9 $0.00
V5336 REPAIR COMMUNICATION DEVICE 5 $0.00
V5360 UNLISTED SPEECH-LANGUAGE SERVICE (S 9 $0.00
V5362 SPEECH SCREENING 3 $16.00
V5363 LANGUAGE SCREENING 3 $16.00
V5364 DYSPHAGIA SCREENING 3 $16.00
W5950 MCO SPECIFIC CODE: INTAKE/RISK ASSE O $0.00
W9026 HOSPITAL VISIT,INITIAL,OUTPATIENT;E O $0.00
W9045 ER SUPPORT SERVICES,SPECIAL NON-EME O $0.00
W9047 ER SUPPORT SERVICES, SPECIAL EMERGE O $0.00
W9049 HOSPITAL OUTPATIENT CLINIC VISIT O $0.00
W9057 RURAL HEALTH CLINIC VISIT O $0.00
WW101 OFFICE VISIT COPAY O $0.00
WW102 EMERGENCY ROOM COPAY O $0.00
WW103 VISION CARE COPAY O $0.00
WW104 TRANSPORTATION COPAY O $0.00
WW105 INPATIENT HOSPITAL VISIT OR PROCEDU O $0.00
WW106 OUTPATIENT HOSPITAL CO-PAY, EXCLUDI O $0.00
WW201 INJECTION, AMPICILLIN SODIUM AND SU O $0.00
WW202 INJECTION, AMPICILLIN SODIUM AND SU O $0.00
WW203 INJECTION, LEUCOVORIN CALCIUM, UP T O $0.00
WW204 INJECTION, CYTOVENE, UP TO 500 MG O $0.00
WW205 INJECTION, HEPARIN SODIUM, UP TO 50 O $0.00
WW206 INJECTION, HEPARIN SODIUM, UP TO 10 O $0.00
WW207 INJECTION, HEPARIN SODIUM, UP TO 20 O $0.00
WW208 INJECTION, PROMETHAZINE HCL, UP TO O $0.00
WW209 INJECTION, NALBUPHINE, UP TO 20 MG. O $0.00
WW210 INJECTION, LORAZEPAN, UP TO 2 MG. O $0.00
WW211 INJECTION, CEFTAZADIME, UP TO 500 M O $0.00
WW212 INJECTION, CEFTAZADIME, UP TO 1,000 O $0.00
WW213 INFECTION, STINGING INSECT VENOM, S O $0.00
WW214 INJECTION, STINGING INSECT VENOM, M O $0.00
WW215 INJECTION, POISON IVY/ OAK, PROPHYL O $0.00
WW216 INJECTION, LONG ACTING ADRENALIN, U O $0.00
WW217 INJECTION, LEUPROLIDE ACETATE DEPOT O $0.00
WW218 INJECTION, LEUPROLIDE ACETATE DEPOT O $0.00
WW219 INJECTION, HEPARIN SODIUM FLUSH, UP O $0.00
WW220 INJECTION, KETOROLAC TROMETHAMINE, O $0.00
WW221 INJECTION, KETOROLAC TROMETHAMINE, O $0.00
WW222 INJECTION, MARCAINE HCL, UP TO 10CC O $0.00
WW223 INJECTION, ONDANSETRON HCL, UP TO 1 O $0.00
WW224 IMMUNIZATION, ACTIVE; DIPHTHEIA AND O $0.00

WW225 INJECTION, DEPO-PROVERA, 150 MG/ML O $0.00
WW226 IMMUNIZATION, ACTIVE; DPT AND HIB O $0.00
WW227 INJECTION, MIDAZOLAM, UP TO 10 MG. O $0.00
WW228 INJECTION, FLUMAZENIL, UP TO 0.5 MG O $0.00
WW229 INJECTION, NALOXONE HCL, UP TO O.4 O $0.00
WW230 INJECTION, KYTRIL, 1MG/ML O $0.00
WW231 INJECTION, HEPARIN SODIUM, PER 100 O $0.00
WW232 INJECTION, DEXAMETHASONE ACETATE, 1 O $0.00
WW301 ROUTINE GYNECOLOGICAL EVALUATION IN O $0.00
WW302 ROUTINE GYNECOLOGICAL EVALUATION IN O $0.00
WW303 INITIAL ANTEPARTUM CARE O $0.00
WW304 USE OF A BIRTHING CENTER FACILITY F O $0.00
WW305 USE OF A BIRTHING CENTER FACILITY W O $0.00
WW310 INSERTION OF HORMONAL CONTRACEPTIVE O $0.00
WW311 REMOVAL OF HORMONAL CONTRACEPTIVE I O $0.00
WW312 PROVISION AND INSERTION OF VAGINAL O $0.00
WW313 INSERTION OF VAGINAL RING CONTAININ O $0.00
WW351 HOSPITAL BASED EMERGENCY ROOM PHYSI O $0.00
WW401 METHADONE CLINIC SERVICES O $0.00
WW402 OPIOID MEDICATION DISPENSING FOR IN O $0.00
WW403 OPIOID THERAPY PHYSICAL EVALUATION O $0.00
WW404 OPIOID DOSAGE MONITORING FOR INDIVI O $0.00
WW430 CHRONIC RENAL DISEASE PROGRAM-NEPRO O $0.00
WW451 INSERTION OF AN EPIDURAL OR SUBARAC O $0.00
WW452 RE-INJECTION OF A NARCOTIC INTO AN O $0.00
WW453 MAINTENANCE OF INTRAVENOUS ACCESS C O $0.00
WW501 VISION PROGRAM UNDER EPSDT - ROUTIN O $0.00
WW502 VISION PROGRAM UNDER EPSDT - PROVIS O $0.00
WW503 VISION PROGRAM UNDER EPSDT - PROVIS O $0.00
WW504 EPSDT/VISION-CONTACT LENS TO CORREC O $0.00
WW505 VISION PROGRAM UNDER EPSDT-PROVISIO O $0.00
WW506 VISION PROGRAM UNDER EPSDT-STOCK SI O $0.00
WW507 VISION PROGRAM UNDER EPSDT-PROVISIO O $0.00
WW508 VISION PROGRAM UNDER EPSDT-STOCK SI O $0.00
WW509 VISION PROGRAM UNDER EPSDT-PROVISIO O $0.00
WW510 VISION PROGRAM UNDER EPSDT-NON-STOC O $0.00
WW511 VISION PROGRAM UNDER EPSDT-PROVISIO O $0.00
WW512 VISION PROGRAM UNDER EPSDT-NON-STOC O $0.00
WW513 VISION PROGRAM UNDER EPSDT-PROVISIO O $0.00
WW514 VISION PROGRAM UNDER EPSDT-BIFOCAL O $0.00
WW515 VISION PROGARM UNDER EPSDT-PROVISIO O $0.00
WW516 VISION PROGRAM UNDER EPSDT-BIFOCAL O $0.00
WW517 VISION PROGRAM UNDER EPSDT-PROVISIO O $0.00
WW518 VISION PROGRAM UNDER EPSDT-BIFOCAL O $0.00
WW519 VISION PROGRAM UNDER EPSDT-REPLACEM O $0.00
WW520 VISION PROGRAM UNDER EPSDT-POLYCARB O $0.00
WW521 VISION PROGRAM UNDER EPSDT-PHOTO GR O $0.00
WW522 VISION PROGRAM UNDER EPSDT-REPLACEM O $0.00
WW523 VISION PROGRAM UNDER EPSDT-REPLACEM O $0.00

WW524 VISION PROGRAM UNDER EPSDT-UNLISTED O $0.00
WW531 EPSDT SCREENING WITHOUT TREATMENT R O $0.00
WW532 EPSDT SCREENING WITHOUT TREATMENT R O $0.00
WW533 EPSDT SCREENING WITHOUT TREATMENT R O $0.00
WW534 EPSDT SCREENING WITHOUT TREATMENT R O $0.00
WW535 EPSDT SCREENING WITHOUT TREATMENT R O $0.00
WW536 EPSDT SCREENING WITH TREATMENT REFE O $0.00
WW537 EPSDT SCREENING WITH TREATMENT REFE O $0.00
WW538 EPSDT SCREENING WITH TREATMENT REFE O $0.00
WW539 EPSDT SCREENING WITH TREATMENT REFE O $0.00
WW540 EPSDT SCREENING WITH TREATMENT REFE O $0.00
WW571 DPH SPECIAL DENTAL CLINIC REFERRALS O $0.00
WW572 EPSDT - TOTAL YEARLY DENTAL CARE FO O $0.00
WW573 DENTAL CARE FOR INDIVIDUALS, EPSDT, O $0.00
WW574 DENTAL SERVICES FOR SPECIAL NEEDS P O $0.00
WW575 ENVIRONMENTAL INSPECTION FOR SOURCE O $0.00
WW601 POTENTIAL ACUITY METER (PAM) O $0.00
WW651 COMMUNITY SUPPORT SERVICES - MENTAL O $0.00
WW652 PSYCHOSOCIAL REHABILITATION CENTER O $0.00
WW653 RESIDENTIAL REHABILITATION MENTAL H O $0.00
WW654 PERSONAL CARE-DADAMH APPROVED C.S.S O $0.00
WW655 COMMUNITY SUPPORT SERVICES-ALCOHOL O $0.00
WW660 PHYS SERVICE DADAMH COMM MENTAL HEA O $0.00
WW661 PHYS SUPERVISED DADAMH COMM MENTAL O $0.00
WW663 PHYS SUPERVISED DADAMH CMHC SERVICE O $0.00
WW664 PHYSICIAN SERVICE - DADAMH COMMUNIT O $0.00
WW665 PHYS. SUPERVISED DADAMH COMMUNITY M O $0.00
WW668 EPSDT BEHAVIORAL HEALTH SERVICES, A O $0.00
WW701 PRIVATE DUTY NURSE, EMPLOYED BY AGE O $0.00
WW702 EPSDT EXTENDED PRIVATE DUTY NURSE,E O $0.00
WW703 PRIVATE DUTY NURSE,SELF-EMPLOYED,PE O $0.00
WW704 PRIVATE DUTY NURSE,SELF-EMPLOYED, P O $0.00
WW705 PRIVATE DUTY NURSE, SELF-EMPLOYED, O $0.00
WW706 PRIVATE DUTY NURSE, SELF-EMPLOYED, O $0.00
WW707 PRIVATE DUTY NURSE,SELF-EMPLOYED,PE O $0.00
WW708 PRIVATE DUTY NURSE,SELF-EMPLOYED,PE O $0.00
WW709 PRIVATE DUTY NURSE,SELF-EMPLOYED, P O $0.00
WW710 PRIVATE DUTY NURSE,SELF-EMPLOYED,PE O $0.00
WW711 PRIVATE DUTY NURSE,SELF-EMPLOYED,PE O $0.00
WW712 PRIVATE DUTY NURSE,SELF-EMPLOYED, P O $0.00
WW713 EPSDT EXTENDED PRIVATE DUTY NURSE,S O $0.00
WW714 EPSDT EXTENDED PRIVATE DUTY NURSE,S O $0.00
WW715 EPSDT EXTENDED PRIVATE DUTY NURSE,S O $0.00
WW716 EPSDT EXTENDED PRIVATE DUTY NURSE,S O $0.00
WW717 EPSDT EXTENDED PRIVATE DUTY NURSE,S O $0.00
WW718 EPSDT EXTENDED PRIVATE DUTY NURSE,S O $0.00
WW719 EPSDT EXTENDED PRIVATE DUTY NURSE,S O $0.00
WW720 EPSDT EXTENDED PRIVATE DUTY NURSE,S O $0.00
WW721 EPSDT EXTENDED PRIVATE DUTY NURSE,S O $0.00

WW722 EPSDT EXTENDED PRIVATE DUTY NURSE,S O $0.00
WW751 'PULMONARY EVALUATION AND DIAGNOSTI O $0.00
WW752 MULTICHANNEL RECORDING OF 3 TO 5 PH O $0.00
WW753 MULTICHANNEL RECORDING OF 6 TO 12 P O $0.00
WW754 4 HR OVERNIGHT GROWTH HORMONE TEST; O $0.00
WW755 12 HR OVERNIGHT GROWTH HORMONE TEST O $0.00
WW797 ENTERAL FORMULAE NOC O $0.00
WW798 DISPOSABLE INCONTINENCE PRODUCTS ME O $0.00
WW799 DIAPERS THAT ARE MEDICALLY NECESSAR O $0.00
WW800 EPSDT NON-STATE PLAN SUPPLIES FOR U O $0.00
WW801 MISCELLANEOUS SUPPLIES O $0.00
WW802 EPSDT O $0.00
WW803 NEEDLE WASTE UNIT (ALL SIZES) - IV O $0.00
WW804 INJECTION CAPS O $0.00
WW805 HUBER NEEDLE (ALL SIZES) O $0.00
WW806 SYRINGES (ALL TYPES) O $0.00
WW808 ADMINISTRATION SET-INCLUDES TUBING O $0.00
WW809 IV TUBING - ALL SIZES & TYPES O $0.00
WW810 CLAMP SCISSORS O $0.00
WW811 INTRAVENOUS CATHETER -ANGIO CATH, B O $0.00
WW812 IV START KIT O $0.00
WW813 IV CATHETER DRESSING KIT O $0.00
WW814 PEAK EXPIRATORY FLOW METER, EPSDT, O $0.00
WW815 MOUTHPIECE FOR PEAK FLOW METER, BOX O $0.00
WW816 LANCET DEVICE O $0.00
WW821 FEDERALLY QUALIFIED HEALTH CENTER E O $0.00
WW822 LINE MAINTENANCE-WEEKLY-SINGLE LUME O $0.00
WW823 LINE MAINTENANCE-WEEKLY-DOUBLE LUME O $0.00
WW824 LINE MAINTENANCE-WEEKLY-TRIPLE LUME O $0.00
WW825 PROTECTED NEEDLE HOUSING O $0.00
WW826 THERMOMETER-MERCURY O $0.00
WW827 HIBICLENS- 4 OZ O $0.00
WW828 TUBEX HOLDER O $0.00
WW829 CHEMO SPILL KIT-INCLUDES SAFETY GLA O $0.00
WW830 VIAL ADAPTER O $0.00
WW831 PICC INSERTION TRAY O $0.00
WW838 ENURESIS ALARM FOR AGES 4-20 O $0.00
WW839 PHOTOTHERAPY BLANKET O $0.00
WW840 CARBON ELECTRODES FOR APNEA MONITOR 9 $0.00
WW841 STICKY ELECTRODES FOR APNEA MONITOR O $0.00
WW842 FOAM/VELCRO BELT FOR USE WITH CARBO O $0.00
WW843 LEAD WIRES FOR APNEA MONITOR-1 SET 9 $0.00
WW844 PULSE OXIMETER O $0.00
WW845 OXIBANDS - FOR USE WITH PULSE OXIME O $0.00
WW846 OXISENSOR / PROBE - FOR USE WITH PU O $0.00
WW847 MEMORY MONITOR - RENTAL - INCLUDES O $0.00
WW848 SKIN LEVEL GASTROSTOMY KIT O $0.00
WW849 ADAPTER FOR SKIN LEVEL GASTROSTOMY O $0.00
WW850 OXYGEN CONTENT, LIQUID, PER POUND O $0.00

WW851 OXYGEN CONTENT, GASEOUS, PER EACH D O $0.00
WW852 OXYGEN CONTENT, GASEOUS, PER EACH E O $0.00
WW853 OXYGEN CONTENT, GASEOUS, PER EACH H O $0.00
WW854 OXYGEN CONTENT, GASEOUS, PER EACH M O $0.00
WW855 OXYGEN CONTENT, GASEOUS, PER EACH C O $0.00
WW856 STATIONARY COMPRESSED GAS SYSTEM; I O $0.00
WW858 STATIONARY LIQUID OXYGEN SYSTEM, IN O $0.00
WW860 OXYGEN CONCENTRATOR O $0.00
WW870 REPAIR OF PATIENT OWNED DURABLE MED O $0.00
WW871 EPSDT NON-STATE PLAN ORTHOTIC/PROST O $0.00
WW880 ARGININGE POWDER O $0.00
WW881 SPECIAL NEEDS EQUIPMENT - MISCELLAN O $0.00
WW900 HEARING ASSESSMENT-EPSDT SCHOOL BAS O $0.00
WW901 VISION ASSESSMENT-EPSDT SCHOOL BASE O $0.00
WW902 IMMUNIZATION ASSESSMENT-EPSDT SCHOO O $0.00
WW903 DEVELOPMENTAL/ORTHOPEDIC ASSESSMENT O $0.00
WW904 DENTAL ASSESSMENT-EPSDT SCHOOL BASE O $0.00
WW905 HEALTH EDUCATION ASSESSMENT-EPSDT S O $0.00
WW906 DENTAL HEALTH EDUCATION-EPSDT SCHOO O $0.00
WW910 INDIVIDUAL NURSING TREATMENT-EPSDT O $0.00
WW920 OCCUPATIONAL THERAPY EVALUATION-EPS O $0.00
WW921 INDIVIDUAL OCCUPATIONAL THERAPY TRE O $0.00
WW922 GROUP OCCUPATIONAL THERAPY TREATMEN O $0.00
WW930 PHYSICAL THERAPY ASSESSMENT-EPSDT S O $0.00
WW931 INDIVIDUAL PHYSICAL THERAPY TREATME O $0.00
WW932 GROUP PHYSICAL THERAPY TREATMENT-EP O $0.00
WW936 ICT PLACEMENT FOR 0-0-S RTC-BASED B O $0.00
WW937 ICT PLACEMENT FOR 0-0-S RTC-BASED B O $0.00
WW938 ICT PLACEMENT FOR O-O-S RTC-BASED B O $0.00
WW939 ICT PLACEMENT FOR 0-0-S RTC-BASED B O $0.00
WW940 MENTAL HEALTH TREATMENT ASSESSMENT- O $0.00
WW941 INDIVIDUAL MENTAL HEALTH TREATMENT O $0.00
WW942 GROUP MENTAL HEALTH TREATMENT THERA O $0.00
WW943 FAMILY MENTAL HEALTH TREATMENT THER O $0.00
WW944 INDIVIDUAL MENTAL HEALTH CO-TREATME O $0.00
WW945 GROUP MENTAL HEALTH CO-TREATMENT TH O $0.00
WW946 FAMILY MENTAL HEALTH CO-TREATMENT T O $0.00
WW947 MENTAL HEALTH CASE CONSULTATION-EPS O $0.00
WW948 AU CLAIR BEHAVIORAL THERAPY, EPSDT O $0.00
WW950 SPEECH, LANGUAGE AND HEARING ASSESS O $0.00
WW951 INDIVIDUAL SPEECH/LANGUAGE THERAPY- O $0.00
WW952 INDIVIDUAL HEARING THERAPY-EPSDT SC O $0.00
WW953 GROUP SPEECH/LANGUAGE THERAPY-EPSDT O $0.00
WW954 INDIVUDUAL SPEECH/LANGUAGE CO-TREAT O $0.00
WW955 INDIVIDUAL HEARING CO-TREATMENT THE O $0.00
WW956 GROUP SPEECH/LANGAUAGE CO-TREATMENT O $0.00
WW960 TRANSPORTATION,ROUND TRIP-EPSDT SCH O $0.00
WW967 ASSESSMENT OF HIGHER CEREBRAL FUNCT O $0.00
WW968 PDDN EARLY INTERVENTION THERAPIES, O $0.00

WW969 EARLY INTERVENTION MULTI-DISCIPLINA O $0.00
WW970 CHILD DEVELOPMENT ORIENTED FAMILY T O $0.00
WW975 MENTAL HEALTH TREATMENT EVALUATION, O $0.00
WW976 INDIVIDUAL MENTAL HEALTH TREATMENT O $0.00
WW980 SPEECH/LANGUAGE/HEARING SCREEN, EPS O $0.00
WW981 SPEECH/LANGUAGE/HEARING COMPREHENSI O $0.00
WW982 SPEECH/LANGUAGE/HEARING INDIVIDUAL O $0.00
WW983 GROUP SPEECH/LANGUAGE/HEARING THERA O $0.00
WW985 OCCUPATIONAL THERAPY SCREEN, EPSDT, O $0.00
WW986 OCCUPATIONAL THERAPY EVALUATION, CO O $0.00
WW987 OCCUPATIONAL THERAPY TREATMENT, IND O $0.00
WW990 PHYSICAL THERAPY SCREEN, EPSDT, AGE O $0.00
WW991 PHYSICAL THERAPY EVALUATION, COMPRE O $0.00
WW992 INDIVIDUAL PHYSICAL THERAPY TREATME O $0.00
WW995 INITIAL NUTRITION CONSULTATION O $0.00
WW996 NUTRITION COUNSELING O $0.00
WW997 ASTHMA REHABILITATION CASE MANAGEME O $0.00
WW998 NURSING SERVICES, INTERMITTENT, EPS O $0.00
WW999 EPSDT CASE MANAGEMENT SERVICE FOR C O $0.00
X0019 MCO SPECIFIC CODE: PRIVATE DUTY NUR O $0.00
YY001 NURSING HOME ANCILLARIES - OXYGEN H O $0.00
YY002 NURSING HOME ANCILLARIES - OXYGEN P O $0.00
YY003 NURSING HOME ANCILLARIES - OXYGEN C O $0.00
YY004 NURSING HOME ANCILLARIES - PHYSICAL O $0.00
YY005 NURSING HOME ANCILLARIES - PHYSICAL O $0.00
YY006 NURSING HOME ANCILLARIES - SPEECH T O $0.00
YY007 NURSING HOME ANCILLARIES - SPEECH T O $0.00
YY008 NURSING HOME ANCILLARIES - OCCUPATI O $0.00
YY009 NURSING HOME ANCILLARIES - OCCUPATI O $0.00
YY101 EXTENDED PREGNANCY-PER FIFTEEN MINU O $0.00
YY102 EXTENDED PREGNANCY-NUTRITION PER FI O $0.00
YY103 EXTENDED PREGNANCY-SOCIAL WORK PER O $0.00
YY201 HOSPICE - ROUTINE HOME CARE PER DAY O $0.00
YY202 HOSPICE - CONTINUOUS HOME CARE PER O $0.00
YY203 HOSPICE - INPATIENT RESPIT CARE PER O $0.00
YY204 HOSPICE - GENERAL INPATIENT CARE PE O $0.00
YY205 HOSPICE - NURSING HOME ROOM AND BOA O $0.00
YY301 FAMILY AND CHILDREN'S SERVICES CLIN O $0.00
YY302 FAMILY AND CHILDREN'S SERVICES NURS O $0.00
YY303 FAMILY AND CHILDREN'S SERVICES NURS O $0.00
YY304 FAMILY AND CHILDREN'S SERVICES EPSD O $0.00
YY401 DPH SPECIALTY AUDIOLOGY CLINIC VISI O $0.00
YY402 DPH SPECIALTY CARDIAC CLINIC VISIT O $0.00
YY403 DPH SPECIALTY ORTHOPEDIC CLINIC VIS O $0.00
YY404 DPH SPECIALTY NEUROLOGY CLINIC VISI O $0.00
YY405 DPH SPECIALTY SPEECH CLINIC VISIT O $0.00
YY406 DPH GENERAL MEDICAL CLINIC VISIT O $0.00
YY407 DPH URINALYSIS O $0.00
YY408 DPH PRENATAL CLINIC VISIT O $0.00

YY409 DPH TUBERCULOSIS CLINIC VISIT O $0.00
YY410 DPH STD CLINIC VISIT O $0.00
YY411 DPH ENHANCED CARE FOR AT-RISK CHILD O $0.00
YY431 DPH - SPECIALTY FAMILY PLANNING CLI O $0.00
YY432 DPH - SPECIALTY FAMILY PLANNING CLI O $0.00
YY433 DPH - SPECIALTY FAMILY PLANNING CLI O $0.00
YY434 DPH FAMILY PLANNING CLINIC VISIT - O $0.00
YY441 DPH - SUPPLIED DIAPHRAGM O $0.00
YY442 DPH - SUPPLIED FOAM O $0.00
YY443 DPH - SUPPLIED BIRTH CONTROL PILLS O $0.00
YY444 DPH - SUPPLIED IUD O $0.00
YY445 DPH - SUPPLIED PREGNANCY TEST O $0.00
YY471 DPH - HEALTH SCREENING - AGE 35 TO O $0.00
YY472 DPH - HEALTH SCREENING - AGE 50 TO O $0.00
YY473 DPH - HEALTH SCREENING - AGE 60 AND O $0.00
YY501 TRANSPORTATION IN VEHICLE OTHER THA O $0.00
YY502 TRANSPORTATION IN VEHICLE OTHER THA O $0.00
YY503 TRANSPORTATION IN VEHICLE OTHER THA O $0.00
YY504 TRANSPORTATION IN VEHICLE OTHER THA O $0.00
YY505 TRANSPORTATION IN VEHICLE OTHER THA O $0.00
YY506 AMBULANCE - EMERGENCY TRANSPORT (ON O $0.00
YY507 AMBULANCE - EMERGENCY TRANSPORT (ON O $0.00
YY508 AMBULANCE - NON-EMERGENCY TRANSPORT O $0.00
YY509 AMBULANCE, NON-EMERGENCY TRANSPORT, O $0.00
YY510 AMBULANCE, NON-EMERGENCY TRANSPORT, O $0.00
YY511 ADDITIONAL AMBULANCE CREW(S) NECESS O $0.00
YY512 CHRONIC RENAL DISEASE PROGRAM MILEA O $0.00
YY513 AMBULANCE, NEONATAL EMERGENCY TRANS O $0.00
YY514 AMBULANCE, NEONATAL EMERGENCY TRANS O $0.00
YY515 TRANSPORTATION IN VEHICLE OTHER THA O $0.00
YY516 TRANSPORTATION IN VEHICLE OTHER THA O $0.00
YY517 TRANSPORTATION IN VEHICLE OTHER THA O $0.00
YY518 TRANSPORTATION-TAXI SERVICE-METERED O $0.00
YY519 TRANSPORTATION IN VEHICLE OTHER THA O $0.00
YY520 TRANSPORTATION IN VEHICLE OTHER THA O $0.00
YY521 TRANSPORTATION IN VEHICLE OTHER THA O $0.00
YY522 TRANSPORTATION IN VEHICLE OTHER THA O $0.00
YY523 TRANSPORTATION IN VEHICLE OTHER THA O $0.00
YY524 TRANSPORTATION IN VEHICLE OTHER THA O $0.00
YY525 TRANSPORTATION IN VEHICLE OTHER THA O $0.00
YY526 TRANSPORTATION IN VEHICLE OTHER THA O $0.00
YY560 HCBS WAIVER FOR THE MENTALLY RETARD O $0.00
YY561 HCBS WAIVER FOR THE MENTALLY RETARD O $0.00
YY562 HCBS WAIVER FOR THE MENTALLY RETARD O $0.00
YY563 HCBS WAIVER FOR THE MENTALLY RETARD O $0.00
YY564 HCBS WAIVER FOR THE MENTALLY RETARD O $0.00
YY565 HCBS WAIVER FOR THE MENTALLY RETARD O $0.00
YY566 HCBS WAIVER FOR THE MENTALLY RETARD O $0.00
YY577 HCBS WAIVER FOR THE MENTALLY RETARD O $0.00

YY578 HCBS WAIVER FOR THE MENTALLY RETARD O $0.00
YY579 HCBS WAIVER FOR THE MENTALLY RETARD O $0.00
YY580 HCBS WAIVER FOR THE MENTALLY RETARD O $0.00
YY581 HCBS WAIVER FOR THE MENTALLY RETARD O $0.00
YY582 HCBS WAIVER FOR THE MENTALLY RETARD O $0.00
YY583 HCBS WAIVER FOR THE MENTALLY RETARD O $0.00
YY584 HCBS WAIVER FOR THE MENTALLY RETARD O $0.00
YY585 HCBS WAIVER FOR THE MENTALLY RETARD O $0.00
YY586 HCBS WAIVER FOR THE MENTALLY RETARD O $0.00
YY587 HCBS WAIVER FOR THE MENTALLY RETARD O $0.00
YY599 HOME AND COMMUNITY-BASED SERVICES W O $0.00
YY600 HOME AND COMMUNITY-BASED SERVICES W O $0.00
YY601 HCBS WAIVER FOR THE MENTALLY RETARD O $0.00
YY602 HCBS WAIVER FOR THE MENTALLY RETARD O $0.00
YY603 HCBS WAIVER FOR THE MENTALLY RETARD O $0.00
YY604 HCBS WAIVER FOR THE MENTALLY RETARD O $0.00
YY605 HCBS WAIVER FOR THE MENTALLY RETARD O $0.00
YY606 HOME AND COMMUNITY - BASED SERVICES O $0.00
YY607 HCBS WAIVER FOR MENTALLY RETARDED R O $0.00
YY608 HCBS WAIVER FOR THE MENTALLY-RETARD O $0.00
YY609 HCBS WAIVER FOR THE MENTALLY RETARD O $0.00
YY610 HCBS WAIVER FOR THE MENTALLY RETARD O $0.00
YY611 HCBS WAIVER FOR THE MENTALLY RETARD O $0.00
YY612 HCBS WAIVER FOR THE MENTALLY RETARD O $0.00
YY613 HCBS WAIVER FOR THE MENTALLY RETARD O $0.00
YY614 HOME AND COMMUNITY-BASED SERVICES F O $0.00
YY615 HCBS WAIVER FOR THE MENTALLY RETARD O $0.00
YY616 HCBS WAIVER FOR THE MENTALLY RETARD O $0.00
YY617 HOME AND COMMUNITY-BASED WAIVER FOR O $0.00
YY618 HCBS WAIVER FOR THE MENTALLY RETARD O $0.00
YY619 HCBS WAIVER FOR THE MENTALLY RETARD O $0.00
YY620 HCBS WAIVER FOR THE MENTALLY RETARD O $0.00
YY621 HCBS WAIVER FOR THE MENTALLY RETARD O $0.00
YY629 HOME AND COMMUNITY-BASED SERVICES W O $0.00
YY630 HOME AND COMMUNITY-BASED SERVICES W O $0.00
YY631 HOME AND COMMUNITY-BASED SERVICES W O $0.00
YY632 HOME AND COMMUNITY-BASED SERVICES W O $0.00
YY633 HOME AND COMMUNITY-BASED SERVICES W O $0.00
YY634 HOME AND COMMUNITY-BASED SERVICES W O $0.00
YY635 HOME AND COMMUNITY-BASED SERVICES W O $0.00
YY636 HOME AND COMMUNITY-BASED SERVICES W O $0.00
YY637 HOME AND COMMUNITY-BASED SERVICES W O $0.00
YY638 HOME AND COMMUNITY-BASED SERVICES W O $0.00
YY639 HOME AND COMMUNITY-BASED SERVICES W O $0.00
YY640 HOME AND COMMUNITY-BASED SERVICES W O $0.00
YY641 HOME AND COMMUNITY-BASED SERVICES W O $0.00
YY642 HOME AND COMMUNITY-BASED SERVICES W O $0.00
YY643 HOME AND COMMUNITY-BASED SERVICES W O $0.00
YY644 HOME & COMMUNITY-BASED SERVICES WAI O $0.00

YY645 HOME & COMMUNITY-BASED WAIVER FOR A O $0.00
YY646 HOME & COMMUNITY BASED WAIVER FOR A O $0.00
YY647 HOME & COMMUNITY-BASED WAIVER FOR A O $0.00
YY648 HOME&COMMUNITY-BASED WAIVER FOR AID O $0.00
YY649 HOME & COMMUNITY-BASED WAIVER FOR A O $0.00
YY650 HOME AND COMMUNITY-BASED SERVICES W O $0.00
YY651 HOME AND COMMUNITY - BASED SERVICES O $0.00
YY652 AGED AND DISABLED WAIVER - EMERGENC O $0.00
YY653 HOME AND COMMUNITY - BASED SERVICES O $0.00
YY654 HOME AND COMMUNITY - BASED SERVICES O $0.00
YY655 HOME AND COMMUNITY - BASED SERVICES O $0.00
YY656 HOME AND COMMUNITY-BASED SERVICES W O $0.00
YY657 HOME AND COMMUNITY - BASED SERVICES O $0.00
YY658 HOME AND COMMUNITY - BASED SERVICES O $0.00
YY659 HOME AND COMMUNITY - BASED SERVICES O $0.00
YY660 HOME AND COMMUNITY-BASED SERVICES W O $0.00
YY661 HCBS-A/D-WAIVER-DURABLE MEDICAL EQU O $0.00
YY662 HOME AND COMMUNITY-BASED WAIVER FOR O $0.00
YY663 HOME AND COMMUNITY-BASED WAIVER FOR O $0.00
YY664 HOME & COMMUNITY BASED SERVICES FOR O $0.00
YY701 HOME HEALTH-SKILLED NURSE VISIT-PLA O $0.00
YY702 HOME HEALTH - NURSE AIDE - PER 15 M O $0.00
YY703 HOME HEALTH - PHYSICAL THERAPY EVAL O $0.00
YY704 HOME HEALTH - PHYSICAL THERAPY TREA O $0.00
YY705 HOME HEALTH - OCCUPATIONAL THERAPY O $0.00
YY706 HOME HEALTH - OCCUPATIONAL THERAPY O $0.00
YY707 HOME HEALTH - SPEECH THERAPY EVALUA O $0.00
YY708 HOME HEALTH - SPEECH THERAPY TREATM O $0.00
YY709 HOME HEALTH- MEDICALLY NECESSARY SU O $0.00
YY710 HOME HEALTH-SKILLED NURSE VISIT-ADU O $0.00
YY711 HOME HEALTH-NURSE AIDE-ADULT FOSTER O $0.00
YY712 HOME HEALTH-PHYSICAL THERAPY EVALUA O $0.00
YY713 HOME HEALTH-PHYSICAL THERAPY TREATM O $0.00
YY714 HOME HEALTH-OCCUPATIONAL THERAPY EV O $0.00
YY715 HOME HEALTH-OCCUPATIONAL THERAPY TR O $0.00
YY716 HOME HEALTH-SPEECH THERAPY EVALUATI O $0.00
YY717 HOME HEALTH-SPEECH THERAPY TREATMEN O $0.00
YY718 HOME HEALTH-NURSE AIDE-HCBS/WAIVER O $0.00
YY719 HOME HEALTH-SKILLED NURSE VISIT-HCB O $0.00
YY720 HOME HEALTH-PHYSICAL THERAPY EVALUA O $0.00
YY721 HOME HEALTH-PHYSICAL THERAPY TREATM O $0.00
YY722 HOME HEALTH-OCCUPATIONAL THERAPY EV O $0.00
YY723 HOME HEALTH-OCCUPATIONAL THERAPY TR O $0.00
YY724 HOME HEALTH-SPEECH THERAPY EVALUATI O $0.00
YY725 HOME HEALTH-SPEECH THERAPY TREATMEN O $0.00
YY726 HOME HEALTH-SKILLED NURSE VISIT-IN O $0.00
YY727 HOME HEALTH-SKILLED NURSE VISIT-ASS O $0.00
YY728 HOME HEALTH-NURSE AIDE-ASSISTED LIV O $0.00
YY740 MH/SA ASSESSMENT, EPSDT-DSCYF, AGE O $0.00

YY741 CLINICAL COORDINATION, EPSDT-DSCYF, O $0.00
YY742 CLINICAL BEHAVIORAL GUIDANCE,PERIOD O $0.00
YY750 MENTAL HEALTH CRISIS SERVICES, EPSD O $0.00
YY751 CENTER-BASED INDIVIDUAL OUTPATIENT O $0.00
YY752 MEDICATION MONITORING OR PSYCHIATRI O $0.00
YY753 CENTER-BASED OUTPATIENT GROUP MENTA O $0.00
YY754 RTC-BASED INDIVIDUAL OUT-PT MENTAL O $0.00
YY755 MENTAL HEALTH DAY TREATMENT, EPSDT- O $0.00
YY756 RTC-BASED INDIVIDUAL MENTAL HEALTH O $0.00
YY757 RTC-BASED INDIVIDUAL MENTAL HEALTH O $0.00
YY758 RTC-BASED INDIVIDUAL MENTAL HEALTH O $0.00
YY760 DRUG/ALCOHOL INTENSIVE INDIVIDUAL D O $0.00
YY761 DRUG/ALCOHOL INDIVIDUAL OUTPATIENT O $0.00
YY762 DRUG/ALCOHOL GROUP OUTPATIENT SERVI O $0.00
YY763 DRUG/ALCOHOL TREATMENT PROGRAM IN A O $0.00
YY764 DRUG\ALCOHOL PARTIAL DAY TREATMENT O $0.00
YY765 MENTAL HEALTH/SUBSTANCE ABUSE SERVI O $0.00
YY801 PRESCRIBED PEDIATRIC EXTENDED CARE O $0.00
YY802 PRESCRIBED PEDIATRIC EXTENDED CARE O $0.00
YY803 PRESCRIBED PEDIATRIC EXTENDED CARE( O $0.00
YY804 PRESCRIBED PEDIATRIC EXTENDED CARE O $0.00
YY805 PRESCRIBED PEDIATRIC EXTENDED CARE O $0.00
YY806 PRESCRIBED PEDIATRIC EXTENDED CARE O $0.00
YY807 PRESCRIBED PEDIATRIC EXTENDED CARE O $0.00
YY808 PRESCRIBED PEDIATRIC EXTENDED CARE O $0.00
YY822 VFC IMMUNIZATION CODE CREATED FOR L O $0.00
YY850 DAY HEALTH & REHAB FOR MR & DD CLIE O $0.00
YY851 DAY HEALTH & REHAB FOR MR & DD CLIE O $0.00
YY852 DAY HEALTH AND REHABILITATION FOR N O $0.00
YY853 DAY HEALTH AND REHABILITATION FOR N O $0.00
YY921 MONTHLY CAPITATED RATE, PEDIATRIC M O $0.00
Z0402 PORTABLE OXYGEN REFILL (13 TO 28 CU O $0.00
Z0406 H TANK REFILL (151-282 CU. FT.) O $0.00
Z0445 OXYGEN CONCENTRATOR O $0.00
Z0526 WARM-N-FORM ORTHOSIS O $0.00
Z3255 ORTHOPEDIC SHOES ATTACHED TO BRACE O $0.00
Z4442 TRACHEOSTOMY SUCTION KIT O $0.00
Z4443 TRACHEOSTOMY SUCTION CATHETER O $0.00
ZE001 MCO SPECIFIC CODE: HOME INFUSION SE O $0.00
ZE002 MCO SPECIFIC CODE: HOME INFUSION SE O $0.00
ZH003 MCO SPECIFIC CODE: HOME INFUSION SE O $0.00
ZH004 MCO SPECIFIC CODE: HOME INFUSION SE O $0.00
ZH005 MCO SPECIFIC CODE: HOME INFUSION SE O $0.00
ZH010 MCO SPECIFIC CODE: HOME INFUSION SE O $0.00
ZH011 MCO SPECIFIC CODE: HOME INFUSION SE O $0.00
ZH020 MCO SPECIFIC CODE: HOME INFUSION SE O $0.00
ZH021 MCO SPECIFIC CODE: HOME INFUSION SE O $0.00
ZM001 MCO SPECIFIC CODE: HOME INFUSION SE O $0.00
ZR001 MCO SPECIFIC CODE: HOME INFUSION SE O $0.00

ZR002 MCO SPECIFIC CODE: HOME INFUSION SE O $0.00

Pricing Action
Code Description
1 PAY PERCENTAGE OF BILLED AMOUNT.
3 LOWER OF BILLED OR ALLOWED AMOUNT.
5 MANUAL PRICE - INDIVIDUAL CONSIDERATION. SET EDIT TO SUSPEND.
6 MANUAL PRICE - NO REASONABLE CHARGE ESTABLISHED. SET EDIT TO SUSPEND.
7 ONLY LEVEL I PRICING SHOULD BE USED. SET EDIT TO SUSPEND.
9 NON-COVERED. SET EDIT TO AUTODENY.
A LOWER OF BILLED AMOUNT OR ((RVU + BILLED UNITS) X CONVERSION FACTOR DOLLAR AMOUNT) .
O OBSOLETE. SET EDIT TO AUTODENY.

Procedure Code Description Pricing Percent
D0120 PERIODIC ORAL EVALUATION 80
D0140 LIMIT ORAL EVAL PROBLM FOCUS 80
D0145 ORAL EVALUATION, PT < 3YRS 80
D0150 COMPREHENSVE ORAL EVALUATION 80
D0160 EXTENSV ORAL EVAL PROB FOCUS 80
D0170 RE-EVAL,EST PT,PROBLEM FOCUS 80
D0210 INTRAOR COMPLETE FILM SERIES 80
D0220 INTRAORAL PERIAPICAL FIRST F 80
D0230 INTRAORAL PERIAPICAL EA ADD 80
D0240 INTRAORAL OCCLUSAL FILM 80
D0250 EXTRAORAL FIRST FILM 80
D0260 EXTRAORAL EA ADDITIONAL FILM 80
D0270 DENTAL BITEWING SINGLE FILM 80
D0272 DENTAL BITEWINGS TWO FILMS 80
D0273 BITEWINGS - THREE FILMS 80
D0274 DENTAL BITEWINGS FOUR FILMS 80
D0277 VERT BITEWINGS-SEV TO EIGHT 80
D0290 DENTAL FILM SKULL/FACIAL BON 80
D0310 DENTAL SALIOGRAPHY 80
D0320 DENTAL TMJ ARTHROGRAM INCL I 80
D0321 DENTAL OTHER TMJ FILMS 80
D0322 DENTAL TOMOGRAPHIC SURVEY 80
D0330 DENTAL PANORAMIC FILM 80
D0340 DENTAL CEPHALOMETRIC FILM 80
D0360 CONE BEAM CT 80
D0362 CONE BEAM, TWO DIMENSIONAL 80
D0363 CONE BEAM, THREE DIMENSIONAL 80
D0460 PULP VITALITY TEST 80
D0470 DIAGNOSTIC CASTS 80
D0472 GROSS EXAM, PREP & REPORT 80
D0473 MICRO EXAM, PREP & REPORT 80
D0474 MICRO W EXAM OF SURG MARGINS 80
D0480 CYTOPATH SMEAR PREP & REPORT 80
D0502 OTHER ORAL PATHOLOGY PROCEDU 80
D0999 UNSPECIFIED DIAGNOSTIC PROCE 80
D1110 DENTAL PROPHYLAXIS ADULT 80
D1120 DENTAL PROPHYLAXIS CHILD 80
D1203 TOPICAL APP FLUORIDE CHILD 80
D1204 TOPICAL APP FLUORIDE ADULT 80
D1206 TOPICAL FLUORIDE VARNISH 80
D1320 TOBACCO COUNSELING 80
D1351 DENTAL SEALANT PER TOOTH 80
D1510 SPACE MAINTAINER FXD UNILAT 80
D1515 FIXED BILAT SPACE MAINTAINER 80
D1520 REMOVE UNILAT SPACE MAINTAIN 80
D1525 REMOVE BILAT SPACE MAINTAIN 80
D1550 RECEMENT SPACE MAINTAINER 80
D1555 REMOVE FIX SPACE MAINTAINER 80
D2140 AMALGAM ONE SURFACE PERMANEN 80
D2150 AMALGAM TWO SURFACES PERMANE 80
D2160 AMALGAM THREE SURFACES PERMA 80
D2161 AMALGAM 4 OR > SURFACES PERM 80

D2330 RESIN ONE SURFACE-ANTERIOR 80
D2331 RESIN TWO SURFACES-ANTERIOR 80
D2332 RESIN THREE SURFACES-ANTERIO 80
D2335 RESIN 4/> SURF OR W INCIS AN 80
D2390 ANT RESIN-BASED CMPST CROWN 80
D2391 POST 1 SRFC RESINBASED CMPST 80
D2392 POST 2 SRFC RESINBASED CMPST 80
D2393 POST 3 SRFC RESINBASED CMPST 80
D2394 POST >=4SRFC RESINBASE CMPST 80
D2710 CROWN RESIN-BASED INDIRECT 80
D2712 CROWN 3/4 RESIN-BASED COMPOS 80
D2721 CROWN RESIN W/ BASE METAL 80
D2722 CROWN RESIN W/ NOBLE METAL 80
D2751 CROWN PORCELAIN FUSED BASE M 80
D2752 CROWN PORCELAIN W/ NOBLE MET 80
D2781 CROWN 3/4 CAST BASE METAL 80
D2782 CROWN 3/4 CAST NOBLE METAL 80
D2791 CROWN FULL CAST BASE METAL 80
D2792 CROWN FULL CAST NOBLE METAL 80
D2799 PROVISIONAL CROWN 80
D2910 RECEMENT INLAY ONLAY OR PART 80
D2915 RECEMENT CAST OR PREFAB POST 80
D2920 DENTAL RECEMENT CROWN 80
D2930 PREFAB STNLSS STEEL CRWN PRI 80
D2931 PREFAB STNLSS STEEL CROWN PE 80
D2932 PREFABRICATED RESIN CROWN 80
D2933 PREFAB STAINLESS STEEL CROWN 80
D2934 PREFAB STEEL CROWN PRIMARY 80
D2940 DENTAL SEDATIVE FILLING 80
D2950 CORE BUILD-UP INCL ANY PINS 80
D2951 TOOTH PIN RETENTION 80
D2952 POST AND CORE CAST + CROWN 80
D2953 EACH ADDTNL CAST POST 80
D2954 PREFAB POST/CORE + CROWN 80
D2955 POST REMOVAL 80
D2957 EACH ADDTNL PREFAB POST 80
D2970 TEMP CROWN (FRACTURED TOOTH) 80
D2980 CROWN REPAIR 80
D2999 DENTAL UNSPEC RESTORATIVE PR 80
D3110 PULP CAP DIRECT 80
D3120 PULP CAP INDIRECT 80
D3220 THERAPEUTIC PULPOTOMY 80
D3221 GROSS PULPAL DEBRIDEMENT 80
D3222 PART PULP FOR APEXOGENESIS 80
D3230 PULPAL THERAPY ANTERIOR PRIM 80
D3240 PULPAL THERAPY POSTERIOR PRI 80
D3310 END THXPY, ANTERIOR TOOTH 80
D3320 END THXPY, BICUSPID TOOTH 80
D3330 END THXPY, MOLAR 80
D3332 INCOMPLETE ENDODONTIC TX 80
D3333 INTERNAL ROOT REPAIR 80
D3346 RETREAT ROOT CANAL ANTERIOR 80
D3347 RETREAT ROOT CANAL BICUSPID 80

D3348 RETREAT ROOT CANAL MOLAR 80
D3351 APEXIFICATION/RECALC INITIAL 80
D3352 APEXIFICATION/RECALC INTERIM 80
D3353 APEXIFICATION/RECALC FINAL 80
D3410 APICOECT/PERIRAD SURG ANTER 80
D3421 ROOT SURGERY BICUSPID 80
D3425 ROOT SURGERY MOLAR 80
D3426 ROOT SURGERY EA ADD ROOT 80
D3430 RETROGRADE FILLING 80
D3450 ROOT AMPUTATION 80
D3470 INTENTIONAL REPLANTATION 80
D3910 ISOLATION- TOOTH W RUBB DAM 80
D3999 ENDODONTIC PROCEDURE 80
D4210 GINGIVECTOMY/PLASTY PER QUAD 80
D4211 GINGIVECTOMY/PLASTY PER TOOT 80
D4230 ANA CROWN EXP 4 OR> PER QUAD 80
D4231 ANA CROWN EXP 1-3 PER QUAD 80
D4240 GINGIVAL FLAP PROC W/ PLANIN 80
D4241 GNGVL FLAP W ROOTPLAN 1-3 TH 80
D4245 APICALLY POSITIONED FLAP 80
D4249 CROWN LENGTHEN HARD TISSUE 80
D4260 OSSEOUS SURGERY PER QUADRANT 80
D4261 OSSEOUS SURGL-3TEETHPERQUAD 80
D4263 BONE REPLCE GRAFT FIRST SITE 80
D4264 BONE REPLCE GRAFT EACH ADD 80
D4265 BIO MTRLS TO AID SOFT/OS REG 80
D4266 GUIDED TISS REGEN RESORBLE 80
D4267 GUIDED TISS REGEN NONRESORB 80
D4268 SURGICAL REVISION PROCEDURE 80
D4270 PEDICLE SOFT TISSUE GRAFT PR 80
D4271 FREE SOFT TISSUE GRAFT PROC 80
D4273 SUBEPITHELIAL TISSUE GRAFT 80
D4274 DISTAL/PROXIMAL WEDGE PROC 80
D4275 SOFT TISSUE ALLOGRAFT 80
D4276 CON TISSUE W DBLE PED GRAFT 80
D4320 PROVISION SPLNT INTRACORONAL 80
D4321 PROVISIONAL SPLINT EXTRACORO 80
D4341 PERIODONTAL SCALING & ROOT 80
D4342 PERIODONTAL SCALING 1-3TEETH 80
D4355 FULL MOUTH DEBRIDEMENT 80
D4381 LOCALIZED DELIVERY ANTIMICRO 80
D4910 PERIODONTAL MAINT PROCEDURES 80
D4920 UNSCHEDULED DRESSING CHANGE 80
D4999 UNSPECIFIED PERIODONTAL PROC 80
D5110 DENTURES COMPLETE MAXILLARY 80
D5120 DENTURES COMPLETE MANDIBLE 80
D5130 DENTURES IMMEDIAT MAXILLARY 80
D5140 DENTURES IMMEDIAT MANDIBLE 80
D5211 DENTURES MAXILL PART RESIN 80
D5212 DENTURES MAND PART RESIN 80
D5213 DENTURES MAXILL PART METAL 80
D5214 DENTURES MANDIBL PART METAL 80
D5225 MAXILLARY PART DENTURE FLEX 80

D5226 MANDIBULAR PART DENTURE FLEX 80
D5410 DENTURES ADJUST CMPLT MAXIL 80
D5411 DENTURES ADJUST CMPLT MAND 80
D5421 DENTURES ADJUST PART MAXILL 80
D5422 DENTURES ADJUST PART MANDBL 80
D5510 DENTUR REPR BROKEN COMPL BAS 80
D5520 REPLACE DENTURE TEETH COMPLT 80
D5610 DENTURES REPAIR RESIN BASE 80
D5620 REP PART DENTURE CAST FRAME 80
D5630 REP PARTIAL DENTURE CLASP 80
D5640 REPLACE PART DENTURE TEETH 80
D5650 ADD TOOTH TO PARTIAL DENTURE 80
D5660 ADD CLASP TO PARTIAL DENTURE 80
D5670 REPLC TTH&ACRLC ON MTL FRMWK 80
D5671 REPLC TTH&ACRLC MANDIBULAR 80
D5730 DENTURE RELN CMPLT MAXIL CH 80
D5731 DENTURE RELN CMPLT MAND CHR 80
D5740 DENTURE RELN PART MAXIL CHR 80
D5741 DENTURE RELN PART MAND CHR 80
D5750 DENTURE RELN CMPLT MAX LAB 80
D5751 DENTURE RELN CMPLT MAND LAB 80
D5760 DENTURE RELN PART MAXIL LAB 80
D5761 DENTURE RELN PART MAND LAB 80
D5810 DENTURE INTERM CMPLT MAXILL 80
D5811 DENTURE INTERM CMPLT MANDBL 80
D5820 DENTURE INTERM PART MAXILL 80
D5821 DENTURE INTERM PART MANDBL 80
D5850 DENTURE TISS CONDITN MAXILL 80
D5851 DENTURE TISS CONDTIN MANDBL 80
D5899 REMOVABLE PROSTHODONTIC PROC 80
D5911 FACIAL MOULAGE SECTIONAL 80
D5912 FACIAL MOULAGE COMPLETE 80
D5913 NASAL PROSTHESIS 80
D5914 AURICULAR PROSTHESIS 80
D5915 ORBITAL PROSTHESIS 80
D5916 OCULAR PROSTHESIS 80
D5919 FACIAL PROSTHESIS 80
D5922 NASAL SEPTAL PROSTHESIS 80
D5923 OCULAR PROSTHESIS INTERIM 80
D5924 CRANIAL PROSTHESIS 80
D5925 FACIAL AUGMENTATION IMPLANT 80
D5926 REPLACEMENT NASAL PROSTHESIS 80
D5927 AURICULAR REPLACEMENT 80
D5928 ORBITAL REPLACEMENT 80
D5929 FACIAL REPLACEMENT 80
D5931 SURGICAL OBTURATOR 80
D5932 POSTSURGICAL OBTURATOR 80
D5933 REFITTING OF OBTURATOR 80
D5934 MANDIBULAR FLANGE PROSTHESIS 80
D5935 MANDIBULAR DENTURE PROSTH 80
D5936 TEMP OBTURATOR PROSTHESIS 80
D5937 TRISMUS APPLIANCE 80
D5951 FEEDING AID 80

D5952 PEDIATRIC SPEECH AID 80
D5953 ADULT SPEECH AID 80
D5954 SUPERIMPOSED PROSTHESIS 80
D5955 PALATAL LIFT PROSTHESIS 80
D5958 INTRAORAL CON DEF INTER PLT 80
D5959 INTRAORAL CON DEF MOD PALAT 80
D5960 MODIFY SPEECH AID PROSTHESIS 80
D5986 FLUORIDE APPLICATOR 80
D5987 COMMISSURE SPLINT 80
D5988 SURGICAL SPLINT 80
D5991 TOPICAL MEDICAMENT CARRIER 80
D5999 MAXILLOFACIAL PROSTHESIS 80
D6211 BRIDGE BASE METAL CAST 80
D6212 BRIDGE NOBLE METAL CAST 80
D6241 BRIDGE PORCELAIN BASE METAL 80
D6242 BRIDGE PORCELAIN NOBEL METAL 80
D6251 BRIDGE RESIN BASE METAL 80
D6252 BRIDGE RESIN W/NOBLE METAL 80
D6545 DENTAL RETAINR CAST METL 80
D6721 CROWN RESIN W/BASE METAL 80
D6722 CROWN RESIN W/NOBLE METAL 80
D6751 CROWN PORCELAIN BASE METAL 80
D6752 CROWN PORCELAIN NOBLE METAL 80
D6791 CROWN FULL BASE METAL CAST 80
D6792 CROWN FULL NOBLE METAL CAST 80
D6930 DENTAL RECEMENT BRIDGE 80
D6972 PREFAB POST & CORE PLUS RETA 80
D6980 BRIDGE REPAIR 80
D6985 PEDIATRIC PARTIAL DENTURE FX 80
D6999 FIXED PROSTHODONTIC PROC 80
D7111 EXTRACTION CORONAL REMNANTS 80
D7140 EXTRACTION ERUPTED TOOTH/EXR 80
D7210 REM IMP TOOTH W MUCOPER FLP 80
D7220 IMPACT TOOTH REMOV SOFT TISS 80
D7230 IMPACT TOOTH REMOV PART BONY 80
D7240 IMPACT TOOTH REMOV COMP BONY 80
D7241 IMPACT TOOTH REM BONY W/COMP 80
D7250 TOOTH ROOT REMOVAL 80
D7260 ORAL ANTRAL FISTULA CLOSURE 80
D7261 PRIMARY CLOSURE SINUS PERF 80
D7270 TOOTH REIMPLANTATION 80
D7272 TOOTH TRANSPLANTATION 80
D7280 EXPOSURE IMPACT TOOTH ORTHOD 80
D7282 MOBILIZE ERUPTED/MALPOS TOOT 80
D7283 PLACE DEVICE IMPACTED TOOTH 80
D7290 REPOSITIONING OF TEETH 80
D7291 TRANSSEPTAL FIBEROTOMY 80
D7310 ALVEOPLASTY W/ EXTRACTION 80
D7311 ALVEOLOPLASTY W/EXTRACT 1-3 80
D7320 ALVEOPLASTY W/O EXTRACTION 80
D7321 ALVEOLOPLASTY NOT W/EXTRACTS 80
D7340 VESTIBULOPLASTY RIDGE EXTENS 80
D7350 VESTIBULOPLASTY EXTEN GRAFT 80

D7510 I&D ABSC INTRAORAL SOFT TISS 80
D7511 INCISION/DRAIN ABSCESS INTRA 80
D7520 I&D ABSCESS EXTRAORAL 80
D7521 INCISION/DRAIN ABSCESS EXTRA 80
D7530 REMOVAL FB SKIN/AREOLAR TISS 80
D7540 REMOVAL OF FB REACTION 80
D7550 REMOVAL OF SLOUGHED OFF BONE 80
D7560 MAXILLARY SINUSOTOMY 80
D7880 OCCLUSAL ORTHOTIC APPLIANCE 80
D7899 TMJ UNSPECIFIED THERAPY 80
D7910 DENT SUTUR RECENT WND TO 5CM 80
D7911 DENTAL SUTURE WOUND TO 5 CM 80
D7912 SUTURE COMPLICATE WND > 5 CM 80
D7960 FRENULECTOMY/FRENULOTOMY 80
D7963 FRENULOPLASTY 80
D7970 EXCISION HYPERPLASTIC TISSUE 80
D7971 EXCISION PERICORONAL GINGIVA 80
D7997 APPLIANCE REMOVAL 80
D7999 ORAL SURGERY PROCEDURE 80
D8010 LIMITED DENTAL TX PRIMARY 80
D8020 LIMITED DENTAL TX TRANSITION 80
D8030 LIMITED DENTAL TX ADOLESCENT 80
D8040 LIMITED DENTAL TX ADULT 80
D8050 INTERCEP DENTAL TX PRIMARY 80
D8060 INTERCEP DENTAL TX TRANSITN 80
D8070 COMPRE DENTAL TX TRANSITION 80
D8090 COMPRE DENTAL TX ADULT 80
D8210 ORTHODONTIC REM APPLIANCE TX 80
D8220 FIXED APPLIANCE THERAPY HABT 80
D8680 ORTHODONTIC RETENTION 80
D8690 ORTHODONTIC TREATMENT 80
D8691 REPAIR ORTHO APPLIANCE 80
D8692 REPLACEMENT RETAINER 80
D8999 ORTHODONTIC PROCEDURE 80
D9110 TX DENTAL PAIN MINOR PROC 80
D9120 FIX PARTIAL DENTURE SECTION 80
D9210 DENT ANESTHESIA W/O SURGERY 80
D9220 GENERAL ANESTHESIA 80
D9221 GENERAL ANESTHESIA EA AD 15M 80
D9230 ANALGESIA 80
D9241 INTRAVENOUS SEDATION 80
D9242 IV SEDATION EA AD 30 M 80
D9248 SEDATION (NON-IV) 80
D9310 DENTAL CONSULTATION 80
D9440 OFFICE VISIT AFTER HOURS 80
D9610 DENT THERAPEUTIC DRUG INJECT 80
D9612 THERA PAR DRUGS 2 OR > ADMIN 80
D9910 DENT APPL DESENSITIZING MED 80
D9911 APPL DESENSITIZING RESIN 80
D9920 BEHAVIOR MANAGEMENT 80
D9930 TREATMENT OF COMPLICATIONS 80
D9940 DENTAL OCCLUSAL GUARD 80
D9999 ADJUNCTIVE PROCEDURE 80

Procedure Description RVU RVU Coeff Value
00100 ANESTH, SALIVARY GLAND 5 20.93
00102 ANESTH, REPAIR OF CLEFT LIP 6 20.93
00103 ANESTH, BLEPHAROPLASTY 5 20.93
00104 ANESTH, ELECTROSHOCK 4 20.93
00120 ANESTH, EAR SURGERY 4 20.93
00124 ANESTH, EAR EXAM 4 20.93
00126 ANESTH, TYMPANOTOMY 4 20.93
00140 ANESTH, PROCEDURES ON EYE 5 20.93
00142 ANESTH, LENS SURGERY 6 20.93
00144 ANESTH, CORNEAL TRANSPLANT 6 20.93
00145 ANESTH, VITREORETINAL SURG 6 20.93
00147 ANESTH, IRIDECTOMY 4 20.93
00148 ANESTH, EYE EXAM 4 20.93
00160 ANESTH, NOSE/SINUS SURGERY 5 20.93
00162 ANESTH, NOSE/SINUS SURGERY 7 20.93
00164 ANESTH, BIOPSY OF NOSE 4 20.93
00170 ANESTH, PROCEDURE ON MOUTH 5 20.93
00172 ANESTH, CLEFT PALATE REPAIR 6 20.93
00174 ANESTH, PHARYNGEAL SURGERY 6 20.93
00176 ANESTH, PHARYNGEAL SURGERY 7 20.93
00190 ANESTH, FACE/SKULL BONE SURG 5 20.93
00192 ANESTH, FACIAL BONE SURGERY 7 20.93
00210 ANESTH, CRANIAL SURG NOS 11 20.93
00211 ANESTH, CRAN SURG, HEMOTOMA 10 20.93
00212 ANESTH, SKULL DRAINAGE 5 20.93
00214 ANESTH, SKULL DRAINAGE 9 20.93
00215 ANESTH, SKULL REPAIR/FRACT 9 20.93
00216 ANESTH, HEAD VESSEL SURGERY 15 20.93
00218 ANESTH, SPECIAL HEAD SURGERY 13 20.93
00220 ANESTH, INTRCRN NERVE 10 20.93
00222 ANESTH, HEAD NERVE SURGERY 6 20.93
00300 ANESTH, HEAD/NECK/PTRUNK 5 20.93
00320 ANESTH, NECK ORGAN, 1 & OVER 6 20.93
00322 ANESTH, BIOPSY OF THYROID 3 20.93
00326 ANESTH, LARYNX/TRACH, < 1 YR 7 20.93
00350 ANESTH, NECK VESSEL SURGERY 10 20.93
00352 ANESTH, NECK VESSEL SURGERY 5 20.93
00400 ANESTH, SKIN, EXT/PER/ATRUNK 3 20.93
00402 ANESTH, SURGERY OF BREAST 5 20.93
00404 ANESTH, SURGERY OF BREAST 5 20.93
00406 ANESTH, SURGERY OF BREAST 13 20.93
00410 ANESTH, CORRECT HEART RHYTHM 4 20.93
00450 ANESTH, SURGERY OF SHOULDER 5 20.93
00452 ANESTH, SURGERY OF SHOULDER 6 20.93
00454 ANESTH, COLLAR BONE BIOPSY 3 20.93
00470 ANESTH, REMOVAL OF RIB 6 20.93
00472 ANESTH, CHEST WALL REPAIR 10 20.93
00474 ANESTH, SURGERY OF RIB(S) 13 20.93
00500 ANESTH, ESOPHAGEAL SURGERY 15 20.93
00520 ANESTH, CHEST PROCEDURE 6 20.93
00522 ANESTH, CHEST LINING BIOPSY 4 20.93
00524 ANESTH, CHEST DRAINAGE 4 20.93

00528 ANESTH, CHEST PARTITION VIEW 8 20.93
00530 ANESTH, PACEMAKER INSERTION 4 20.93
00532 ANESTH, VASCULAR ACCESS 4 20.93
00534 ANESTH, CARDIOVERTER/DEFIB 7 20.93
00537 ANESTH, CARDIAC ELECTROPHYS 10 20.93
00539 ANESTH, TRACH-BRONCH RECONST 18 20.93
00540 ANESTH, CHEST SURGERY 13 20.93
00541 ANESTH, ONE LUNG VENTILATION 15 20.93
00542 ANESTH, RELEASE OF LUNG 15 20.93
00546 ANESTH, LUNG,CHEST WALL SURG 15 20.93
00548 ANESTH, TRACHEA,BRONCHI SURG 17 20.93
00550 ANESTH, STERNAL DEBRIDEMENT 10 20.93
00560 ANESTH, HEART SURG W/O PUMP 15 20.93
00561 ANESTH, HEART SURG < AGE 1 25 20.93
00562 ANESTH HRT SURG W/PMP AGE 1+ 20 20.93
00563 ANESTH, HEART SURG W/ARREST 25 20.93
00566 ANESTH, CABG W/O PUMP 25 20.93
00567 ANESTH, CABG W/PUMP 18 20.93
00580 ANESTH, HEART/LUNG TRANSPLNT 20 20.93
00600 ANESTH, SPINE, CORD SURGERY 10 20.93
00604 ANESTH, SITTING PROCEDURE 13 20.93
00620 ANESTH, SPINE, CORD SURGERY 10 20.93
00622 ANESTH, REMOVAL OF NERVES 13 20.93
00625 ANES SPINE TRANTHOR W/O VENT 13 20.93
00626 ANES, SPINE TRANSTHOR W/VENT 15 20.93
00630 ANESTH, SPINE, CORD SURGERY 8 20.93
00632 ANESTH, REMOVAL OF NERVES 7 20.93
00635 ANESTH, LUMBAR PUNCTURE 4 20.93
00640 ANESTH, SPINE MANIPULATION 3 20.93
00670 ANESTH, SPINE, CORD SURGERY 13 20.93
00700 ANESTH, ABDOMINAL WALL SURG 4 20.93
00702 ANESTH, FOR LIVER BIOPSY 4 20.93
00730 ANESTH, ABDOMINAL WALL SURG 5 20.93
00740 ANESTH, UPPER GI VISUALIZE 5 20.93
00750 ANESTH, REPAIR OF HERNIA 4 20.93
00752 ANESTH, REPAIR OF HERNIA 6 20.93
00754 ANESTH, REPAIR OF HERNIA 7 20.93
00756 ANESTH, REPAIR OF HERNIA 7 20.93
00770 ANESTH, BLOOD VESSEL REPAIR 15 20.93
00790 ANESTH, SURG UPPER ABDOMEN 7 20.93
00792 ANESTH, HEMORR/EXCISE LIVER 7 20.93
00794 ANESTH, PANCREAS REMOVAL 13 20.93
00796 ANESTH, FOR LIVER TRANSPLANT 30 20.93
00797 ANESTH, SURGERY FOR OBESITY 10 20.93
00800 ANESTH, ABDOMINAL WALL SURG 4 20.93
00802 ANESTH, FAT LAYER REMOVAL 5 20.93
00810 ANESTH, LOW INTESTINE SCOPE 5 20.93
00820 ANESTH, ABDOMINAL WALL SURG 5 20.93
00830 ANESTH, REPAIR OF HERNIA 4 20.93
00832 ANESTH, REPAIR OF HERNIA 6 20.93
00834 ANESTH, HERNIA REPAIR< 1 YR 5 20.93
00836 ANESTH HERNIA REPAIR PREEMIE 6 20.93
00840 ANESTH, SURG LOWER ABDOMEN 6 20.93

00842 ANESTH, AMNIOCENTESIS 4 20.93
00844 ANESTH, PELVIS SURGERY 7 20.93
00846 ANESTH, HYSTERECTOMY 8 20.93
00848 ANESTH, PELVIC ORGAN SURG 8 20.93
00851 ANESTH, TUBAL LIGATION 6 20.93
00860 ANESTH, SURGERY OF ABDOMEN 6 20.93
00862 ANESTH, KIDNEY/URETER SURG 7 20.93
00864 ANESTH, REMOVAL OF BLADDER 8 20.93
00865 ANESTH, REMOVAL OF PROSTATE 7 20.93
00866 ANESTH, REMOVAL OF ADRENAL 10 20.93
00868 ANESTH, KIDNEY TRANSPLANT 10 20.93
00870 ANESTH, BLADDER STONE SURG 5 20.93
00872 ANESTH KIDNEY STONE DESTRUCT 7 20.93
00873 ANESTH KIDNEY STONE DESTRUCT 5 20.93
00880 ANESTH, ABDOMEN VESSEL SURG 15 20.93
00882 ANESTH, MAJOR VEIN LIGATION 10 20.93
00902 ANESTH, ANORECTAL SURGERY 5 20.93
00904 ANESTH, PERINEAL SURGERY 7 20.93
00906 ANESTH, REMOVAL OF VULVA 4 20.93
00908 ANESTH, REMOVAL OF PROSTATE 6 20.93
00910 ANESTH, BLADDER SURGERY 3 20.93
00912 ANESTH, BLADDER TUMOR SURG 5 20.93
00914 ANESTH, REMOVAL OF PROSTATE 5 20.93
00916 ANESTH, BLEEDING CONTROL 5 20.93
00918 ANESTH, STONE REMOVAL 5 20.93
00920 ANESTH, GENITALIA SURGERY 3 20.93
00921 ANESTH, VASECTOMY 3 20.93
00922 ANESTH, SPERM DUCT SURGERY 6 20.93
00924 ANESTH, TESTIS EXPLORATION 4 20.93
00926 ANESTH, REMOVAL OF TESTIS 4 20.93
00928 ANESTH, REMOVAL OF TESTIS 6 20.93
00930 ANESTH, TESTIS SUSPENSION 4 20.93
00932 ANESTH, AMPUTATION OF PENIS 4 20.93
00934 ANESTH, PENIS, NODES REMOVAL 6 20.93
00936 ANESTH, PENIS, NODES REMOVAL 8 20.93
00940 ANESTH, VAGINAL PROCEDURES 3 20.93
00942 ANESTH, SURG ON VAG/URETHRAL 4 20.93
00944 ANESTH, VAGINAL HYSTERECTOMY 6 20.93
00948 ANESTH, REPAIR OF CERVIX 4 20.93
00950 ANESTH, VAGINAL ENDOSCOPY 5 20.93
00952 ANESTH, HYSTEROSCOPE/GRAPH 4 20.93
01112 ANESTH, BONE ASPIRATE/BX 5 20.93
01120 ANESTH, PELVIS SURGERY 6 20.93
01130 ANESTH, BODY CAST PROCEDURE 3 20.93
01140 ANESTH, AMPUTATION AT PELVIS 15 20.93
01150 ANESTH, PELVIC TUMOR SURGERY 10 20.93
01160 ANESTH, PELVIS PROCEDURE 4 20.93
01170 ANESTH, PELVIS SURGERY 8 20.93
01173 ANESTH, FX REPAIR, PELVIS 12 20.93
01180 ANESTH, PELVIS NERVE REMOVAL 3 20.93
01190 ANESTH, PELVIS NERVE REMOVAL 4 20.93
01200 ANESTH, HIP JOINT PROCEDURE 4 20.93
01202 ANESTH, ARTHROSCOPY OF HIP 4 20.93

01210 ANESTH, HIP JOINT SURGERY 6 20.93
01212 ANESTH, HIP DISARTICULATION 10 20.93
01214 ANESTH, HIP ARTHROPLASTY 8 20.93
01215 ANESTH, REVISE HIP REPAIR 10 20.93
01220 ANESTH, PROCEDURE ON FEMUR 4 20.93
01230 ANESTH, SURGERY OF FEMUR 6 20.93
01232 ANESTH, AMPUTATION OF FEMUR 5 20.93
01234 ANESTH, RADICAL FEMUR SURG 8 20.93
01250 ANESTH, UPPER LEG SURGERY 4 20.93
01260 ANESTH, UPPER LEG VEINS SURG 3 20.93
01270 ANESTH, THIGH ARTERIES SURG 8 20.93
01272 ANESTH, FEMORAL ARTERY SURG 4 20.93
01274 ANESTH, FEMORAL EMBOLECTOMY 6 20.93
01320 ANESTH, KNEE AREA SURGERY 4 20.93
01340 ANESTH, KNEE AREA PROCEDURE 4 20.93
01360 ANESTH, KNEE AREA SURGERY 5 20.93
01380 ANESTH, KNEE JOINT PROCEDURE 3 20.93
01382 ANESTH, DX KNEE ARTHROSCOPY 3 20.93
01390 ANESTH, KNEE AREA PROCEDURE 3 20.93
01392 ANESTH, KNEE AREA SURGERY 4 20.93
01400 ANESTH, KNEE JOINT SURGERY 4 20.93
01402 ANESTH, KNEE ARTHROPLASTY 7 20.93
01404 ANESTH, AMPUTATION AT KNEE 5 20.93
01420 ANESTH, KNEE JOINT CASTING 3 20.93
01430 ANESTH, KNEE VEINS SURGERY 3 20.93
01432 ANESTH, KNEE VESSEL SURG 6 20.93
01440 ANESTH, KNEE ARTERIES SURG 8 20.93
01442 ANESTH, KNEE ARTERY SURG 8 20.93
01444 ANESTH, KNEE ARTERY REPAIR 8 20.93
01462 ANESTH, LOWER LEG PROCEDURE 3 20.93
01464 ANESTH, ANKLE/FT ARTHROSCOPY 3 20.93
01470 ANESTH, LOWER LEG SURGERY 3 20.93
01472 ANESTH, ACHILLES TENDON SURG 5 20.93
01474 ANESTH, LOWER LEG SURGERY 5 20.93
01480 ANESTH, LOWER LEG BONE SURG 3 20.93
01482 ANESTH, RADICAL LEG SURGERY 4 20.93
01484 ANESTH, LOWER LEG REVISION 4 20.93
01486 ANESTH, ANKLE REPLACEMENT 7 20.93
01490 ANESTH, LOWER LEG CASTING 3 20.93
01500 ANESTH, LEG ARTERIES SURG 8 20.93
01502 ANESTH, LWR LEG EMBOLECTOMY 6 20.93
01520 ANESTH, LOWER LEG VEIN SURG 3 20.93
01522 ANESTH, LOWER LEG VEIN SURG 5 20.93
01610 ANESTH, SURGERY OF SHOULDER 5 20.93
01620 ANESTH, SHOULDER PROCEDURE 4 20.93
01622 ANES DX SHOULDER ARTHROSCOPY 4 20.93
01630 ANESTH, SURGERY OF SHOULDER 5 20.93
01634 ANESTH, SHOULDER JOINT AMPUT 9 20.93
01636 ANESTH, FOREQUARTER AMPUT 15 20.93
01638 ANESTH, SHOULDER REPLACEMENT 10 20.93
01650 ANESTH, SHOULDER ARTERY SURG 6 20.93
01652 ANESTH, SHOULDER VESSEL SURG 10 20.93
01654 ANESTH, SHOULDER VESSEL SURG 8 20.93

01656 ANESTH, ARM-LEG VESSEL SURG 10 20.93
01670 ANESTH, SHOULDER VEIN SURG 4 20.93
01680 ANESTH, SHOULDER CASTING 3 20.93
01682 ANESTH, AIRPLANE CAST 4 20.93
01710 ANESTH, ELBOW AREA SURGERY 3 20.93
01712 ANESTH, UPPR ARM TENDON SURG 5 20.93
01714 ANESTH, UPPR ARM TENDON SURG 5 20.93
01716 ANESTH, BICEPS TENDON REPAIR 5 20.93
01730 ANESTH, UPPR ARM PROCEDURE 3 20.93
01732 ANESTH, DX ELBOW ARTHROSCOPY 3 20.93
01740 ANESTH, UPPER ARM SURGERY 4 20.93
01742 ANESTH, HUMERUS SURGERY 5 20.93
01744 ANESTH, HUMERUS REPAIR 5 20.93
01756 ANESTH, RADICAL HUMERUS SURG 6 20.93
01758 ANESTH, HUMERAL LESION SURG 5 20.93
01760 ANESTH, ELBOW REPLACEMENT 7 20.93
01770 ANESTH, UPPR ARM ARTERY SURG 6 20.93
01772 ANESTH, UPPR ARM EMBOLECTOMY 6 20.93
01780 ANESTH, UPPER ARM VEIN SURG 3 20.93
01782 ANESTH, UPPR ARM VEIN REPAIR 4 20.93
01810 ANESTH, LOWER ARM SURGERY 3 20.93
01820 ANESTH, LOWER ARM PROCEDURE 3 20.93
01829 ANESTH, DX WRIST ARTHROSCOPY 3 20.93
01830 ANESTH, LOWER ARM SURGERY 3 20.93
01832 ANESTH, WRIST REPLACEMENT 6 20.93
01840 ANESTH, LWR ARM ARTERY SURG 6 20.93
01842 ANESTH, LWR ARM EMBOLECTOMY 6 20.93
01844 ANESTH, VASCULAR SHUNT SURG 6 20.93
01850 ANESTH, LOWER ARM VEIN SURG 3 20.93
01852 ANESTH, LWR ARM VEIN REPAIR 4 20.93
01860 ANESTH, LOWER ARM CASTING 3 20.93
01916 ANESTH, DX ARTERIOGRAPHY 6 20.93
01920 ANESTH, CATHETERIZE HEART 7 20.93
01922 ANESTH, CAT OR MRI SCAN 7 20.93
01924 ANES, THER INTERVEN RAD, ART 6 20.93
01925 ANES, THER INTERVEN RAD, CAR 8 20.93
01926 ANES, TX INTERV RAD HRT/CRAN 10 20.93
01930 ANES, THER INTERVEN RAD, VEI 5 20.93
01931 ANES, THER INTERVEN RAD, TIP 6 20.93
01932 ANES, TX INTERV RAD, TH VEIN 8 20.93
01933 ANES, TX INTERV RAD, CRAN V 10 20.93
01935 ANESTH, PERC IMG DX SP PROC 5 20.93
01936 ANESTH, PERC IMG TX SP PROC 5 20.93
01951 ANESTH, BURN, LESS 4 PERCENT 3 20.93
01952 ANESTH, BURN, 4-9 PERCENT 5 20.93
01958 ANESTH, ANTEPARTUM MANIPUL 5 20.93
01960 ANESTH, VAGINAL DELIVERY 5 20.93
01961 ANESTH, CS DELIVERY 7 20.93
01962 ANESTH, EMER HYSTERECTOMY 5 20.93
01963 ANESTH, CS HYSTERECTOMY 8 20.93
01965 ANESTH, INC/MISSED AB PROC 4 20.93
01966 ANESTH, INDUCED AB PROCEDURE 4 20.93
01967 ANESTH/ANALG, VAG DELIVERY 5 20.93

01968 ANES/ANALG CS DELIVER ADD-ON 3 20.93
01969 ANESTH/ANALG CS HYST ADD-ON 5 20.93
01990 SUPPORT FOR ORGAN DONOR 7 20.93
01991 ANESTH, NERVE BLOCK/INJ 3 20.93
01992 ANESTH, N BLOCK/INJ, PRONE 5 20.93
10021 FNA W/O IMAGE 1.89 1.00
10022 FNA W/IMAGE 1.8 1.00
15850 REMOVAL OF SUTURES 5 1.00
33010 DRAINAGE OF HEART SAC 3.51 1.00
33011 REPEAT DRAINAGE OF HEART SAC 3.49 1.00
33015 INCISION OF HEART SAC 14.81 1.00
33020 INCISION OF HEART SAC 24.5 1.00
33025 INCISION OF HEART SAC 22.49 1.00
33030 PARTIAL REMOVAL OF HEART SAC 36.17 1.00
33031 PARTIAL REMOVAL OF HEART SAC 40.41 1.00
33050 REMOVAL OF HEART SAC LESION 27.94 1.00
33120 REMOVAL OF HEART LESION 43.98 1.00
33130 REMOVAL OF HEART LESION 40.87 1.00
33140 HEART REVASCULARIZE (TMR) 44.95 1.00
33141 HEART TMR W/OTHER PROCEDURE 3.98 1.00
33202 INSERT EPICARD ELTRD, OPEN 21.89 1.00
33203 INSERT EPICARD ELTRD, ENDO 23.14 1.00
33206 INSERTION OF HEART PACEMAKER 13.3 1.00
33207 INSERTION OF HEART PACEMAKER 14.19 1.00
33208 INSERTION OF HEART PACEMAKER 15.35 1.00
33210 INSERTION OF HEART ELECTRODE 5.3 1.00
33211 INSERTION OF HEART ELECTRODE 5.35 1.00
33212 INSERTION OF PULSE GENERATOR 9.86 1.00
33213 INSERTION OF PULSE GENERATOR 11.28 1.00
33214 UPGRADE OF PACEMAKER SYSTEM 14.03 1.00
33215 REPOSITION PACING-DEFIB LEAD 8.92 1.00
33216 INSERT 1 ELECTRODE PM-DEFIB 11.02 1.00
33217 INSERT 2 ELECTRODE PM-DEFIB 10.93 1.00
33218 REPAIR LEAD PACE-DEFIB, ONE 11.44 1.00
33220 REPAIR LEAD PACE-DEFIB, DUAL 11.56 1.00
33222 REVISE POCKET, PACEMAKER 10.04 1.00
33223 REVISE POCKET FOR DEFIB 12.14 1.00
33224 INSERT PACING LEAD & CONNECT 14.93 1.00
33225 L VENTRIC PACING LEAD ADD-ON 13.49 1.00
33226 REPOSITION L VENTRIC LEAD 14.37 1.00
33233 REMOVAL OF PACEMAKER SYSTEM 6.97 1.00
33234 REMOVAL OF PACEMAKER SYSTEM 14.23 1.00
33235 REMOVAL PACEMAKER ELECTRODE 18.54 1.00
33236 REMOVE ELECTRODE/THORACOTOMY 22.1 1.00
33237 REMOVE ELECTRODE/THORACOTOMY 23.96 1.00
33238 REMOVE ELECTRODE/THORACOTOMY 26.27 1.00
33240 INSERT PULSE GENERATOR 13.61 1.00
33241 REMOVE PULSE GENERATOR 6.58 1.00
33243 REMOVE ELTRD/THORACOTOMY 39.07 1.00
33244 REMOVE ELTRD, TRANSVEN 25.05 1.00
33249 ELTRD/INSERT PACE-DEFIB 26.67 1.00
33250 ABLATE HEART DYSRHYTHM FOCUS 41.72 1.00
33251 ABLATE HEART DYSRHYTHM FOCUS 46.27 1.00

33254 ABLATE ATRIA, LMTD 38.69 1.00
33255 ABLATE ATRIA W/O BYPASS, EXT 47.2 1.00
33256 ABLATE ATRIA W/BYPASS, EXTEN 56.16 1.00
33257 ABLATE ATRIA, LMTD, ADD-ON 16.48 1.00
33258 ABLATE ATRIA, X10SV, ADD-ON 18.56 1.00
33259 ABLATE ATRIA W/BYPASS ADD-ON 23.98 1.00
33261 ABLATE HEART DYSRHYTHM FOCUS 46.13 1.00
33265 ABLATE ATRIA, LMTD, ENDO 38.4 1.00
33266 ABLATE ATRIA, X10SV, ENDO 52.59 1.00
33282 IMPLANT PAT-ACTIVE HT RECORD 9.47 1.00
33284 REMOVE PAT-ACTIVE HT RECORD 6.8 1.00
33300 REPAIR OF HEART WOUND 68.23 1.00
33305 REPAIR OF HEART WOUND 114.97 1.00
33310 EXPLORATORY HEART SURGERY 32.86 1.00
33315 EXPLORATORY HEART SURGERY 42.1 1.00
33320 REPAIR MAJOR BLOOD VESSEL(S) 30.02 1.00
33321 REPAIR MAJOR VESSEL 33.54 1.00
33322 REPAIR MAJOR BLOOD VESSEL(S) 39.5 1.00
33330 INSERT MAJOR VESSEL GRAFT 40.75 1.00
33332 INSERT MAJOR VESSEL GRAFT 39.74 1.00
33335 INSERT MAJOR VESSEL GRAFT 53.67 1.00
33400 REPAIR OF AORTIC VALVE 65.18 1.00
33401 VALVULOPLASTY, OPEN 41.17 1.00
33403 VALVULOPLASTY, W/CP BYPASS 42.65 1.00
33404 PREPARE HEART-AORTA CONDUIT 50.22 1.00
33405 REPLACEMENT OF AORTIC VALVE 65.61 1.00
33406 REPLACEMENT OF AORTIC VALVE 82.2 1.00
33410 REPLACEMENT OF AORTIC VALVE 72.62 1.00
33411 REPLACEMENT OF AORTIC VALVE 95.59 1.00
33412 REPLACEMENT OF AORTIC VALVE 70.52 1.00
33413 REPLACEMENT OF AORTIC VALVE 92.43 1.00
33414 REPAIR OF AORTIC VALVE 62.02 1.00
33415 REVISION, SUBVALVULAR TISSUE 57.46 1.00
33416 REVISE VENTRICLE MUSCLE 57.67 1.00
33417 REPAIR OF AORTIC VALVE 47.56 1.00
33420 REVISION OF MITRAL VALVE 38.56 1.00
33422 REVISION OF MITRAL VALVE 47.99 1.00
33425 REPAIR OF MITRAL VALVE 76.92 1.00
33426 REPAIR OF MITRAL VALVE 68.31 1.00
33427 REPAIR OF MITRAL VALVE 70.48 1.00
33430 REPLACEMENT OF MITRAL VALVE 79.84 1.00
33460 REVISION OF TRICUSPID VALVE 71.96 1.00
33463 VALVULOPLASTY, TRICUSPID 87.22 1.00
33464 VALVULOPLASTY, TRICUSPID 69.33 1.00
33465 REPLACE TRICUSPID VALVE 77.93 1.00
33468 REVISION OF TRICUSPID VALVE 53.4 1.00
33470 REVISION OF PULMONARY VALVE 34.93 1.00
33471 VALVOTOMY, PULMONARY VALVE 34.66 1.00
33472 REVISION OF PULMONARY VALVE 34.79 1.00
33474 REVISION OF PULMONARY VALVE 60.02 1.00
33475 REPLACEMENT, PULMONARY VALVE 66.53 1.00
33476 REVISION OF HEART CHAMBER 42.72 1.00
33478 REVISION OF HEART CHAMBER 44.7 1.00

33496 REPAIR, PROSTH VALVE CLOT 47.59 1.00
33500 REPAIR HEART VESSEL FISTULA 44.87 1.00
33501 REPAIR HEART VESSEL FISTULA 31.77 1.00
33502 CORONARY ARTERY CORRECTION 36.08 1.00
33503 CORONARY ARTERY GRAFT 38.25 1.00
33504 CORONARY ARTERY GRAFT 41.34 1.00
33505 REPAIR ARTERY W/TUNNEL 58.74 1.00
33506 REPAIR ARTERY, TRANSLOCATION 58.41 1.00
33507 REPAIR ART, INTRAMURAL 49.17 1.00
33508 ENDOSCOPIC VEIN HARVEST 0.46 1.00
33510 CABG, VEIN, SINGLE 55.87 1.00
33511 CABG, VEIN, TWO 61.21 1.00
33512 CABG, VEIN, THREE 69.37 1.00
33513 CABG, VEIN, FOUR 71 1.00
33514 CABG, VEIN, FIVE 75.35 1.00
33516 CABG, VEIN, SIX OR MORE 78.34 1.00
33517 CABG, ARTERY-VEIN, SINGLE 5.37 1.00
33518 CABG, ARTERY-VEIN, TWO 11.77 1.00
33519 CABG, ARTERY-VEIN, THREE 15.62 1.00
33521 CABG, ARTERY-VEIN, FOUR 18.82 1.00
33522 CABG, ARTERY-VEIN, FIVE 21.21 1.00
33523 CABG, ART-VEIN, SIX OR MORE 24.09 1.00
33530 CORONARY ARTERY, BYPASS/REOP 14.99 1.00
33533 CABG, ARTERIAL, SINGLE 54.11 1.00
33534 CABG, ARTERIAL, TWO 63.45 1.00
33535 CABG, ARTERIAL, THREE 70.67 1.00
33536 CABG, ARTERIAL, FOUR OR MORE 75.96 1.00
33542 REMOVAL OF HEART LESION 74.29 1.00
33545 REPAIR OF HEART DAMAGE 87.39 1.00
33548 RESTORE/REMODEL, VENTRICLE 85.1 1.00
33572 OPEN CORONARY ENDARTERECTOMY 6.69 1.00
33600 CLOSURE OF VALVE 48.22 1.00
33602 CLOSURE OF VALVE 46.54 1.00
33606 ANASTOMOSIS/ARTERY-AORTA 50.25 1.00
33608 REPAIR ANOMALY W/CONDUIT 51.12 1.00
33610 REPAIR BY ENLARGEMENT 50.08 1.00
33611 REPAIR DOUBLE VENTRICLE 55.94 1.00
33612 REPAIR DOUBLE VENTRICLE 56.31 1.00
33615 REPAIR, MODIFIED FONTAN 57.03 1.00
33617 REPAIR SINGLE VENTRICLE 60.87 1.00
33619 REPAIR SINGLE VENTRICLE 75.41 1.00
33641 REPAIR HEART SEPTUM DEFECT 46.41 1.00
33645 REVISION OF HEART VEINS 45.06 1.00
33647 REPAIR HEART SEPTUM DEFECTS 50.48 1.00
33660 REPAIR OF HEART DEFECTS 50.13 1.00
33665 REPAIR OF HEART DEFECTS 57.39 1.00
33670 REPAIR OF HEART CHAMBERS 56.69 1.00
33675 CLOSE MULT VSD 56.3 1.00
33676 CLOSE MULT VSD W/RESECTION 53.81 1.00
33677 CL MULT VSD W/REM PUL BAND 55.91 1.00
33681 REPAIR HEART SEPTUM DEFECT 52.15 1.00
33684 REPAIR HEART SEPTUM DEFECT 56.54 1.00
33688 REPAIR HEART SEPTUM DEFECT 53.61 1.00

33690 REINFORCE PULMONARY ARTERY 33.34 1.00
33692 REPAIR OF HEART DEFECTS 46.29 1.00
33694 REPAIR OF HEART DEFECTS 56.16 1.00
33697 REPAIR OF HEART DEFECTS 60 1.00
33702 REPAIR OF HEART DEFECTS 43.79 1.00
33710 REPAIR OF HEART DEFECTS 51.2 1.00
33720 REPAIR OF HEART DEFECT 43.77 1.00
33722 REPAIR OF HEART DEFECT 46.05 1.00
33724 REPAIR VENOUS ANOMALY 44.13 1.00
33726 REPAIR PUL VENOUS STENOSIS 58.53 1.00
33730 REPAIR HEART-VEIN DEFECT(S) 56.24 1.00
33732 REPAIR HEART-VEIN DEFECT 46.9 1.00
33735 REVISION OF HEART CHAMBER 36.45 1.00
33736 REVISION OF HEART CHAMBER 39.86 1.00
33737 REVISION OF HEART CHAMBER 36.56 1.00
33750 MAJOR VESSEL SHUNT 40.99 1.00
33755 MAJOR VESSEL SHUNT 36.1 1.00
33762 MAJOR VESSEL SHUNT 33.88 1.00
33764 MAJOR VESSEL SHUNT & GRAFT 36.37 1.00
33766 MAJOR VESSEL SHUNT 38.4 1.00
33767 MAJOR VESSEL SHUNT 40.15 1.00
33768 CAVOPULMONARY SHUNTING 11.19 1.00
33770 REPAIR GREAT VESSELS DEFECT 60.98 1.00
33771 REPAIR GREAT VESSELS DEFECT 57.73 1.00
33774 REPAIR GREAT VESSELS DEFECT 51.31 1.00
33775 REPAIR GREAT VESSELS DEFECT 49.19 1.00
33776 REPAIR GREAT VESSELS DEFECT 51.93 1.00
33777 REPAIR GREAT VESSELS DEFECT 50.49 1.00
33778 REPAIR GREAT VESSELS DEFECT 62.42 1.00
33779 REPAIR GREAT VESSELS DEFECT 61.98 1.00
33780 REPAIR GREAT VESSELS DEFECT 66.38 1.00
33781 REPAIR GREAT VESSELS DEFECT 61.37 1.00
33782 NIKAIDOH PROC 91.11 1.00
33783 NIKAIDOH PROC W/OSTIA IMPLT 98.48 1.00
33786 REPAIR ARTERIAL TRUNK 60.43 1.00
33788 REVISION OF PULMONARY ARTERY 40.65 1.00
33800 AORTIC SUSPENSION 27.77 1.00
33802 REPAIR VESSEL DEFECT 30.2 1.00
33803 REPAIR VESSEL DEFECT 32.33 1.00
33813 REPAIR SEPTAL DEFECT 36.02 1.00
33814 REPAIR SEPTAL DEFECT 43.3 1.00
33820 REVISE MAJOR VESSEL 27.68 1.00
33822 REVISE MAJOR VESSEL 27.04 1.00
33824 REVISE MAJOR VESSEL 33.36 1.00
33840 REMOVE AORTA CONSTRICTION 34.31 1.00
33845 REMOVE AORTA CONSTRICTION 38.63 1.00
33851 REMOVE AORTA CONSTRICTION 35.75 1.00
33852 REPAIR SEPTAL DEFECT 41.56 1.00
33853 REPAIR SEPTAL DEFECT 55.67 1.00
33860 ASCENDING AORTIC GRAFT 91.17 1.00
33861 ASCENDING AORTIC GRAFT 69.28 1.00
33863 ASCENDING AORTIC GRAFT 90.14 1.00
33864 ASCENDING AORTIC GRAFT 92.5 1.00

33870 TRANSVERSE AORTIC ARCH GRAFT 72.18 1.00
33875 THORACIC AORTIC GRAFT 56.19 1.00
33877 THORACOABDOMINAL GRAFT 103.02 1.00
33880 ENDOVASC TAA REPR INCL SUBCL 52.69 1.00
33881 ENDOVASC TAA REPR W/O SUBCL 45.25 1.00
33883 INSERT ENDOVASC PROSTH, TAA 32.74 1.00
33884 ENDOVASC PROSTH, TAA, ADD-ON 11.97 1.00
33886 ENDOVASC PROSTH, DELAYED 28.22 1.00
33889 ARTERY TRANSPOSE/ENDOVAS TAA 23.23 1.00
33891 CAR-CAR BP GRFT/ENDOVAS TAA 29.09 1.00
33910 REMOVE LUNG ARTERY EMBOLI 47.63 1.00
33915 REMOVE LUNG ARTERY EMBOLI 38.64 1.00
33916 SURGERY OF GREAT VESSEL 46.93 1.00
33917 REPAIR PULMONARY ARTERY 42.02 1.00
33920 REPAIR PULMONARY ATRESIA 51.76 1.00
33922 TRANSECT PULMONARY ARTERY 39.36 1.00
33924 REMOVE PULMONARY SHUNT 8.15 1.00
33925 RPR PUL ART UNIFOCAL W/O CPB 49.4 1.00
33926 REPR PUL ART, UNIFOCAL W/CPB 68.26 1.00
33935 TRANSPLANTATION, HEART/LUNG 98.74 1.00
33945 TRANSPLANTATION OF HEART 136.32 1.00
33960 EXTERNAL CIRCULATION ASSIST 28.07 1.00
33961 EXTERNAL CIRCULATION ASSIST 15.61 1.00
33967 INSERT IA PERCUT DEVICE 7.79 1.00
33968 REMOVE AORTIC ASSIST DEVICE 0.99 1.00
33970 AORTIC CIRCULATION ASSIST 10.44 1.00
33971 AORTIC CIRCULATION ASSIST 20.34 1.00
33973 INSERT BALLOON DEVICE 15.13 1.00
33974 REMOVE INTRA-AORTIC BALLOON 25.9 1.00
33975 IMPLANT VENTRICULAR DEVICE 31.55 1.00
33976 IMPLANT VENTRICULAR DEVICE 35.11 1.00
33977 REMOVE VENTRICULAR DEVICE 34.2 1.00
33978 REMOVE VENTRICULAR DEVICE 37.82 1.00
33979 INSERT INTRACORPOREAL DEVICE 68.99 1.00
33980 REMOVE INTRACORPOREAL DEVICE 102.97 1.00
34001 REMOVAL OF ARTERY CLOT 28.01 1.00
34051 REMOVAL OF ARTERY CLOT 27.9 1.00
34101 REMOVAL OF ARTERY CLOT 17.58 1.00
34111 REMOVAL OF ARM ARTERY CLOT 17.57 1.00
34151 REMOVAL OF ARTERY CLOT 40.65 1.00
34201 REMOVAL OF ARTERY CLOT 29.69 1.00
34203 REMOVAL OF LEG ARTERY CLOT 28.13 1.00
34401 REMOVAL OF VEIN CLOT 41.7 1.00
34421 REMOVAL OF VEIN CLOT 21.35 1.00
34451 REMOVAL OF VEIN CLOT 43.62 1.00
34471 REMOVAL OF VEIN CLOT 32.39 1.00
34490 REMOVAL OF VEIN CLOT 17.65 1.00
34501 REPAIR VALVE, FEMORAL VEIN 27.11 1.00
34502 RECONSTRUCT VENA CAVA 43.9 1.00
34510 TRANSPOSITION OF VEIN VALVE 31.48 1.00
34520 CROSS-OVER VEIN GRAFT 29.92 1.00
34530 LEG VEIN FUSION 28.84 1.00
34800 ENDOVAS AAA REPR W/SM TUBE 33.17 1.00

34802 ENDOVAS AAA REPR W/2-P PART 36.58 1.00
34803 ENDOVAS AAA REPR W/3-P PART 37.79 1.00
34804 ENDOVAS AAA REPR W/1-P PART 36.63 1.00
34805 ENDOVAS AAA REPR W/LONG TUBE 34.68 1.00
34806 ANEURYSM PRESS SENSOR ADD-ON 3.03 1.00
34808 ENDOVAS ILIAC A DEVICE ADDON 5.99 1.00
34812 XPOSE FOR ENDOPROSTH, FEMORL 9.86 1.00
34813 FEMORAL ENDOVAS GRAFT ADD-ON 6.97 1.00
34820 XPOSE FOR ENDOPROSTH, ILIAC 14.22 1.00
34825 ENDOVASC EXTEND PROSTH, INIT 20.47 1.00
34826 ENDOVASC EXTEN PROSTH, ADDL 6.04 1.00
34830 OPEN AORTIC TUBE PROSTH REPR 53.26 1.00
34831 OPEN AORTOILIAC PROSTH REPR 56.68 1.00
34832 OPEN AORTOFEMOR PROSTH REPR 57.27 1.00
34833 XPOSE FOR ENDOPROSTH, ILIAC 17.86 1.00
34834 XPOSE, ENDOPROSTH, BRACHIAL 8.08 1.00
34900 ENDOVASC ILIAC REPR W/GRAFT 26.33 1.00
35001 REPAIR DEFECT OF ARTERY 33.02 1.00
35002 REPAIR ARTERY RUPTURE, NECK 35.05 1.00
35005 REPAIR DEFECT OF ARTERY 30.6 1.00
35011 REPAIR DEFECT OF ARTERY 28.95 1.00
35013 REPAIR ARTERY RUPTURE, ARM 36.04 1.00
35021 REPAIR DEFECT OF ARTERY 35.33 1.00
35022 REPAIR ARTERY RUPTURE, CHEST 40.18 1.00
35045 REPAIR DEFECT OF ARM ARTERY 28.2 1.00
35081 REPAIR DEFECT OF ARTERY 51.12 1.00
35082 REPAIR ARTERY RUPTURE, AORTA 63.78 1.00
35091 REPAIR DEFECT OF ARTERY 53.1 1.00
35092 REPAIR ARTERY RUPTURE, AORTA 76.36 1.00
35102 REPAIR DEFECT OF ARTERY 55.37 1.00
35103 REPAIR ARTERY RUPTURE, GROIN 65.71 1.00
35111 REPAIR DEFECT OF ARTERY 40.7 1.00
35112 REPAIR ARTERY RUPTURE,SPLEEN 50.01 1.00
35121 REPAIR DEFECT OF ARTERY 48.01 1.00
35122 REPAIR ARTERY RUPTURE, BELLY 57.93 1.00
35131 REPAIR DEFECT OF ARTERY 40.79 1.00
35132 REPAIR ARTERY RUPTURE, GROIN 49.55 1.00
35141 REPAIR DEFECT OF ARTERY 32.41 1.00
35142 REPAIR ARTERY RUPTURE, THIGH 38.86 1.00
35151 REPAIR DEFECT OF ARTERY 36.6 1.00
35152 REPAIR ARTERY RUPTURE, KNEE 42.39 1.00
35180 REPAIR BLOOD VESSEL LESION 24.9 1.00
35182 REPAIR BLOOD VESSEL LESION 50.02 1.00
35184 REPAIR BLOOD VESSEL LESION 29.64 1.00
35188 REPAIR BLOOD VESSEL LESION 24.74 1.00
35189 REPAIR BLOOD VESSEL LESION 46.65 1.00
35190 REPAIR BLOOD VESSEL LESION 21.61 1.00
35201 REPAIR BLOOD VESSEL LESION 26.99 1.00
35206 REPAIR BLOOD VESSEL LESION 22.08 1.00
35207 REPAIR BLOOD VESSEL LESION 19.73 1.00
35211 REPAIR BLOOD VESSEL LESION 39.46 1.00
35216 REPAIR BLOOD VESSEL LESION 56.77 1.00
35221 REPAIR BLOOD VESSEL LESION 40.58 1.00

35226 REPAIR BLOOD VESSEL LESION 24.36 1.00
35231 REPAIR BLOOD VESSEL LESION 33.62 1.00
35236 REPAIR BLOOD VESSEL LESION 28.23 1.00
35241 REPAIR BLOOD VESSEL LESION 41.15 1.00
35246 REPAIR BLOOD VESSEL LESION 44.02 1.00
35251 REPAIR BLOOD VESSEL LESION 48.18 1.00
35256 REPAIR BLOOD VESSEL LESION 29.68 1.00
35261 REPAIR BLOOD VESSEL LESION 30.31 1.00
35266 REPAIR BLOOD VESSEL LESION 24.96 1.00
35271 REPAIR BLOOD VESSEL LESION 39.56 1.00
35276 REPAIR BLOOD VESSEL LESION 41.07 1.00
35281 REPAIR BLOOD VESSEL LESION 46.04 1.00
35286 REPAIR BLOOD VESSEL LESION 27.3 1.00
35301 RECHANNELING OF ARTERY 30.63 1.00
35302 RECHANNELING OF ARTERY 32.63 1.00
35303 RECHANNELING OF ARTERY 35.92 1.00
35304 RECHANNELING OF ARTERY 37.33 1.00
35305 RECHANNELING OF ARTERY 35.88 1.00
35306 RECHANNELING OF ARTERY 13.33 1.00
35311 RECHANNELING OF ARTERY 44.11 1.00
35321 RECHANNELING OF ARTERY 26.03 1.00
35331 RECHANNELING OF ARTERY 42.9 1.00
35341 RECHANNELING OF ARTERY 40.24 1.00
35351 RECHANNELING OF ARTERY 37.61 1.00
35355 RECHANNELING OF ARTERY 30.56 1.00
35361 RECHANNELING OF ARTERY 46.05 1.00
35363 RECHANNELING OF ARTERY 50.3 1.00
35371 RECHANNELING OF ARTERY 24.03 1.00
35372 RECHANNELING OF ARTERY 28.8 1.00
35390 REOPERATION, CAROTID ADD-ON 4.69 1.00
35400 ANGIOSCOPY 4.41 1.00
35450 REPAIR ARTERIAL BLOCKAGE 15.04 1.00
35452 REPAIR ARTERIAL BLOCKAGE 10.44 1.00
35454 REPAIR ARTERIAL BLOCKAGE 9.1 1.00
35456 REPAIR ARTERIAL BLOCKAGE 11.04 1.00
35458 REPAIR ARTERIAL BLOCKAGE 14.24 1.00
35459 REPAIR ARTERIAL BLOCKAGE 13 1.00
35460 REPAIR VENOUS BLOCKAGE 9.07 1.00
35470 REPAIR ARTERIAL BLOCKAGE 13.34 1.00
35471 REPAIR ARTERIAL BLOCKAGE 15.86 1.00
35472 REPAIR ARTERIAL BLOCKAGE 10.24 1.00
35473 REPAIR ARTERIAL BLOCKAGE 9.41 1.00
35474 REPAIR ARTERIAL BLOCKAGE 11.4 1.00
35475 REPAIR ARTERIAL BLOCKAGE 14.16 1.00
35476 REPAIR VENOUS BLOCKAGE 8.98 1.00
35480 ATHERECTOMY, OPEN 16.43 1.00
35481 ATHERECTOMY, OPEN 11.67 1.00
35482 ATHERECTOMY, OPEN 10.18 1.00
35483 ATHERECTOMY, OPEN 12.34 1.00
35484 ATHERECTOMY, OPEN 15.51 1.00
35485 ATHERECTOMY, OPEN 14.34 1.00
35490 ATHERECTOMY, PERCUTANEOUS 17.88 1.00
35491 ATHERECTOMY, PERCUTANEOUS 12.11 1.00

35492 ATHERECTOMY, PERCUTANEOUS 10.9 1.00
35493 ATHERECTOMY, PERCUTANEOUS 13.18 1.00
35494 ATHERECTOMY, PERCUTANEOUS 16.82 1.00
35495 ATHERECTOMY, PERCUTANEOUS 15.3 1.00
35500 HARVEST VEIN FOR BYPASS 9.43 1.00
35501 ARTERY BYPASS GRAFT 45.59 1.00
35506 ARTERY BYPASS GRAFT 39.24 1.00
35508 ARTERY BYPASS GRAFT 41.07 1.00
35509 ARTERY BYPASS GRAFT 43.74 1.00
35510 ARTERY BYPASS GRAFT 37.38 1.00
35511 ARTERY BYPASS GRAFT 35.11 1.00
35512 ARTERY BYPASS GRAFT 36.49 1.00
35515 ARTERY BYPASS GRAFT 39.78 1.00
35516 ARTERY BYPASS GRAFT 36.21 1.00
35518 ARTERY BYPASS GRAFT 34.93 1.00
35521 ARTERY BYPASS GRAFT 37.03 1.00
35522 ARTERY BYPASS GRAFT 35.89 1.00
35523 ARTERY BYPASS GRAFT 37.8 1.00
35525 ARTERY BYPASS GRAFT 33.38 1.00
35526 ARTERY BYPASS GRAFT 49.32 1.00
35531 ARTERY BYPASS GRAFT 59.23 1.00
35533 ARTERY BYPASS GRAFT 46.71 1.00
35535 ARTERY BYPASS GRAFT 54.1 1.00
35536 ARTERY BYPASS GRAFT 50.87 1.00
35537 ARTERY BYPASS GRAFT 62.99 1.00
35538 ARTERY BYPASS GRAFT 70.73 1.00
35539 ARTERY BYPASS GRAFT 65.76 1.00
35540 ARTERY BYPASS GRAFT 73.95 1.00
35548 ARTERY BYPASS GRAFT 35.03 1.00
35549 ARTERY BYPASS GRAFT 37.46 1.00
35551 ARTERY BYPASS GRAFT 43.57 1.00
35556 ARTERY BYPASS GRAFT 40.94 1.00
35558 ARTERY BYPASS GRAFT 35.97 1.00
35560 ARTERY BYPASS GRAFT 52.16 1.00
35563 ARTERY BYPASS GRAFT 40.74 1.00
35565 ARTERY BYPASS GRAFT 38.74 1.00
35566 ARTERY BYPASS GRAFT 49.06 1.00
35570 ARTERY BYPASS GRAFT 41.94 1.00
35571 ARTERY BYPASS GRAFT 39.27 1.00
35572 HARVEST FEMOROPOPLITEAL VEIN 10.15 1.00
35583 VEIN BYPASS GRAFT 42.3 1.00
35585 VEIN BYPASS GRAFT 49.24 1.00
35587 VEIN BYPASS GRAFT 40.46 1.00
35600 HARVEST ART FOR CABG ADD-ON 7.49 1.00
35601 ARTERY BYPASS GRAFT 42.49 1.00
35606 ARTERY BYPASS GRAFT 34.6 1.00
35612 ARTERY BYPASS GRAFT 26.75 1.00
35616 ARTERY BYPASS GRAFT 33.61 1.00
35621 ARTERY BYPASS GRAFT 32.4 1.00
35623 BYPASS GRAFT, NOT VEIN 39.66 1.00
35626 ARTERY BYPASS GRAFT 45.6 1.00
35631 ARTERY BYPASS GRAFT 54.4 1.00
35632 ARTERY BYPASS GRAFT 51.37 1.00

35633 ARTERY BYPASS GRAFT 55.43 1.00
35634 ARTERY BYPASS GRAFT 50.27 1.00
35636 ARTERY BYPASS GRAFT 48.26 1.00
35637 ARTERY BYPASS GRAFT 50.24 1.00
35638 ARTERY BYPASS GRAFT 51.26 1.00
35642 ARTERY BYPASS GRAFT 30.17 1.00
35645 ARTERY BYPASS GRAFT 29.07 1.00
35646 ARTERY BYPASS GRAFT 50.48 1.00
35647 ARTERY BYPASS GRAFT 45.67 1.00
35650 ARTERY BYPASS GRAFT 31.22 1.00
35651 ARTERY BYPASS GRAFT 40.71 1.00
35654 ARTERY BYPASS GRAFT 40.36 1.00
35656 ARTERY BYPASS GRAFT 31.75 1.00
35661 ARTERY BYPASS GRAFT 31.89 1.00
35663 ARTERY BYPASS GRAFT 36.95 1.00
35665 ARTERY BYPASS GRAFT 34.56 1.00
35666 ARTERY BYPASS GRAFT 37.29 1.00
35671 ARTERY BYPASS GRAFT 32.87 1.00
35681 COMPOSITE BYPASS GRAFT 2.35 1.00
35682 COMPOSITE BYPASS GRAFT 10.47 1.00
35683 COMPOSITE BYPASS GRAFT 12.34 1.00
35685 BYPASS GRAFT PATENCY/PATCH 5.88 1.00
35686 BYPASS GRAFT/AV FIST PATENCY 4.9 1.00
35691 ARTERIAL TRANSPOSITION 28.67 1.00
35693 ARTERIAL TRANSPOSITION 25.38 1.00
35694 ARTERIAL TRANSPOSITION 29.73 1.00
35695 ARTERIAL TRANSPOSITION 30.98 1.00
35697 REIMPLANT ARTERY EACH 4.39 1.00
35700 REOPERATION, BYPASS GRAFT 4.51 1.00
35701 EXPLORATION, CAROTID ARTERY 15.46 1.00
35721 EXPLORATION, FEMORAL ARTERY 13.11 1.00
35741 EXPLORATION POPLITEAL ARTERY 14.47 1.00
35761 EXPLORATION OF ARTERY/VEIN 10.72 1.00
35800 EXPLORE NECK VESSELS 13.75 1.00
35820 EXPLORE CHEST VESSELS 56.23 1.00
35840 EXPLORE ABDOMINAL VESSELS 18.01 1.00
35860 EXPLORE LIMB VESSELS 11.7 1.00
35870 REPAIR VESSEL GRAFT DEFECT 37.53 1.00
35875 REMOVAL OF CLOT IN GRAFT 17.3 1.00
35876 REMOVAL OF CLOT IN GRAFT 27.68 1.00
35879 REVISE GRAFT W/VEIN 27.21 1.00
35881 REVISE GRAFT W/VEIN 30.14 1.00
35883 REVISE GRAFT W/NONAUTO GRAFT 35.15 1.00
35884 REVISE GRAFT W/VEIN 36.96 1.00
35901 EXCISION, GRAFT, NECK 14.51 1.00
35903 EXCISION, GRAFT, EXTREMITY 16.34 1.00
35905 EXCISION, GRAFT, THORAX 50.81 1.00
35907 EXCISION, GRAFT, ABDOMEN 56.22 1.00
36000 PLACE NEEDLE IN VEIN 0.27 1.00
36002 PSEUDOANEURYSM INJECTION TRT 3.09 1.00
36005 INJECTION EXT VENOGRAPHY 1.41 1.00
36010 PLACE CATHETER IN VEIN 3.52 1.00
36011 PLACE CATHETER IN VEIN 4.54 1.00

36012 PLACE CATHETER IN VEIN 5.16 1.00
36013 PLACE CATHETER IN ARTERY 3.72 1.00
36014 PLACE CATHETER IN ARTERY 4.39 1.00
36015 PLACE CATHETER IN ARTERY 5.07 1.00
36100 ESTABLISH ACCESS TO ARTERY 4.65 1.00
36120 ESTABLISH ACCESS TO ARTERY 2.89 1.00
36140 ESTABLISH ACCESS TO ARTERY 3.01 1.00
36147 ACCESS AV DIAL GRFT FOR EVAL 5.3 1.00
36148 ACCESS AV DIAL GRFT FOR PROC 1.4 1.00
36160 ESTABLISH ACCESS TO AORTA 3.75 1.00
36200 PLACE CATHETER IN AORTA 4.28 1.00
36215 PLACE CATHETER IN ARTERY 7.09 1.00
36216 PLACE CATHETER IN ARTERY 7.99 1.00
36217 PLACE CATHETER IN ARTERY 9.5 1.00
36218 PLACE CATHETER IN ARTERY 1.51 1.00
36245 PLACE CATHETER IN ARTERY 7.26 1.00
36246 PLACE CATHETER IN ARTERY 7.96 1.00
36247 PLACE CATHETER IN ARTERY 9.48 1.00
36248 PLACE CATHETER IN ARTERY 1.5 1.00
36260 INSERTION OF INFUSION PUMP 16.66 1.00
36261 REVISION OF INFUSION PUMP 10.09 1.00
36262 REMOVAL OF INFUSION PUMP 7.7 1.00
36400 BL DRAW < 3 YRS FEM/JUGULAR 0.52 1.00
36405 BL DRAW < 3 YRS SCALP VEIN 0.45 1.00
36406 BL DRAW < 3 YRS OTHER VEIN 0.26 1.00
36410 NON-ROUTINE BL DRAW > 3 YRS 0.25 1.00
36420 VEIN ACCESS CUTDOWN < 1 YR 1.39 1.00
36425 VEIN ACCESS CUTDOWN > 1 YR 1.09 1.00
36430 BLOOD TRANSFUSION SERVICE 0.92 1.00
36440 BL PUSH TRANSFUSE, 2 YR OR < 1.52 1.00
36450 BL EXCHANGE/TRANSFUSE, NB 3.14 1.00
36455 BL EXCHANGE/TRANSFUSE NON-NB 3.48 1.00
36460 TRANSFUSION SERVICE, FETAL 9.69 1.00
36470 INJECTION THERAPY OF VEIN 1.97 1.00
36471 INJECTION THERAPY OF VEINS 2.78 1.00
36475 ENDOVENOUS RF, 1ST VEIN 10.04 1.00
36476 ENDOVENOUS RF, VEIN ADD-ON 4.93 1.00
36478 ENDOVENOUS LASER, 1ST VEIN 10.03 1.00
36479 ENDOVENOUS LASER VEIN ADDON 4.91 1.00
36481 INSERTION OF CATHETER, VEIN 10.05 1.00
36500 INSERTION OF CATHETER, VEIN 5.19 1.00
36510 INSERTION OF CATHETER, VEIN 1.67 1.00
36511 APHERESIS WBC 2.6 1.00
36512 APHERESIS RBC 2.54 1.00
36513 APHERESIS PLATELETS 2.7 1.00
36514 APHERESIS PLASMA 2.56 1.00
36515 APHERESIS, ADSORP/REINFUSE 2.51 1.00
36516 APHERESIS, SELECTIVE 1.91 1.00
36522 PHOTOPHERESIS 2.78 1.00
36555 INSERT NON-TUNNEL CV CATH 3.46 1.00
36556 INSERT NON-TUNNEL CV CATH 3.38 1.00
36557 INSERT TUNNELED CV CATH 8.67 1.00
36558 INSERT TUNNELED CV CATH 7.91 1.00

36560 INSERT TUNNELED CV CATH 9.58 1.00
36561 INSERT TUNNELED CV CATH 9.78 1.00
36563 INSERT TUNNELED CV CATH 10.16 1.00
36565 INSERT TUNNELED CV CATH 9.77 1.00
36566 INSERT TUNNELED CV CATH 10.43 1.00
36568 INSERT PICC CATH 2.69 1.00
36569 INSERT PICC CATH 2.63 1.00
36570 INSERT PICVAD CATH 8.49 1.00
36571 INSERT PICVAD CATH 8.78 1.00
36575 REPAIR TUNNELED CV CATH 0.99 1.00
36576 REPAIR TUNNELED CV CATH 5.38 1.00
36578 REPLACE TUNNELED CV CATH 6.05 1.00
36580 REPLACE CVAD CATH 1.9 1.00
36581 REPLACE TUNNELED CV CATH 5.64 1.00
36582 REPLACE TUNNELED CV CATH 8.57 1.00
36583 REPLACE TUNNELED CV CATH 8.9 1.00
36584 REPLACE PICC CATH 1.9 1.00
36585 REPLACE PICVAD CATH 7.89 1.00
36589 REMOVAL TUNNELED CV CATH 3.89 1.00
36590 REMOVAL TUNNELED CV CATH 5.57 1.00
36591 DRAW BLOOD OFF VENOUS DEVICE 0.6 1.00
36592 COLLECT BLOOD FROM PICC 0.66 1.00
36593 DECLOT VASCULAR DEVICE 0.72 1.00
36595 MECH REMOV TUNNELED CV CATH 5.35 1.00
36596 MECH REMOV TUNNELED CV CATH 1.27 1.00
36597 REPOSITION VENOUS CATHETER 1.76 1.00
36598 INJ W/FLUOR, EVAL CV DEVICE 1.52 1.00
36600 WITHDRAWAL OF ARTERIAL BLOOD 0.42 1.00
36620 INSERTION CATHETER, ARTERY 1.4 1.00
36625 INSERTION CATHETER, ARTERY 3 1.00
36640 INSERTION CATHETER, ARTERY 3.4 1.00
36660 INSERTION CATHETER, ARTERY 1.94 1.00
36680 INSERT NEEDLE, BONE CAVITY 1.68 1.00
36800 INSERTION OF CANNULA 4.41 1.00
36810 INSERTION OF CANNULA 5.95 1.00
36815 INSERTION OF CANNULA 4.21 1.00
36818 AV FUSE, UPPR ARM, CEPHALIC 19.08 1.00
36819 AV FUSE, UPPR ARM, BASILIC 22.74 1.00
36820 AV FUSION/FOREARM VEIN 22.85 1.00
36821 AV FUSION DIRECT ANY SITE 19.38 1.00
36822 INSERTION OF CANNULA(S) 10.6 1.00
36823 INSERTION OF CANNULA(S) 36.53 1.00
36825 ARTERY-VEIN AUTOGRAFT 22.81 1.00
36830 ARTERY-VEIN NONAUTOGRAFT 18.79 1.00
36831 OPEN THROMBECT AV FISTULA 12.99 1.00
36832 AV FISTULA REVISION, OPEN 16.56 1.00
36833 AV FISTULA REVISION 18.72 1.00
36835 ARTERY TO VEIN SHUNT 13.26 1.00
36838 DIST REVAS LIGATION, HEMO 33.48 1.00
36860 EXTERNAL CANNULA DECLOTTING 2.92 1.00
36861 CANNULA DECLOTTING 4.25 1.00
36870 PERCUT THROMBECT AV FISTULA 8.6 1.00
37140 REVISION OF CIRCULATION 39.45 1.00

37145 REVISION OF CIRCULATION 41.57 1.00
37160 REVISION OF CIRCULATION 36.4 1.00
37180 REVISION OF CIRCULATION 40.69 1.00
37181 SPLICE SPLEEN/KIDNEY VEINS 44.01 1.00
37182 INSERT HEPATIC SHUNT (TIPS) 24.66 1.00
37183 REMOVE HEPATIC SHUNT (TIPS) 11.68 1.00
37184 PRIM ART MECH THROMBECTOMY 13.17 1.00
37185 PRIM ART M-THROMBECT ADD-ON 4.89 1.00
37186 SEC ART M-THROMBECT ADD-ON 7.48 1.00
37187 VENOUS MECH THROMBECTOMY 12.02 1.00
37188 VENOUS M-THROMBECTOMY ADD-ON 8.59 1.00
37195 THROMBOLYTIC THERAPY, STROKE 8.54 1.00
37200 TRANSCATHETER BIOPSY 6.54 1.00
37201 TRANSCATHETER THERAPY INFUSE 7.97 1.00
37202 TRANSCATHETER THERAPY INFUSE 9.74 1.00
37203 TRANSCATHETER RETRIEVAL 7.62 1.00
37204 TRANSCATHETER OCCLUSION 26.2 1.00
37205 TRANSCATH IV STENT, PERCUT 12.71 1.00
37206 TRANSCATH IV STENT/PERC ADDL 6.25 1.00
37207 TRANSCATH IV STENT, OPEN 12.43 1.00
37208 TRANSCATH IV STENT/OPEN ADDL 6.01 1.00
37209 CHANGE IV CATH AT THROMB TX 3.3 1.00
37210 EMBOLIZATION UTERINE FIBROID 15.48 1.00
37215 TRANSCATH STENT, CCA W/EPS 32.19 1.00
37216 TRANSCATH STENT, CCA W/O EPS 28.25 1.00
37250 IV US FIRST VESSEL ADD-ON 3.19 1.00
37251 IV US EACH ADD VESSEL ADD-ON 2.37 1.00
37500 ENDOSCOPY LIGATE PERF VEINS 19.7 1.00
37565 LIGATION OF NECK VEIN 19.76 1.00
37600 LIGATION OF NECK ARTERY 20.02 1.00
37605 LIGATION OF NECK ARTERY 22.93 1.00
37606 LIGATION OF NECK ARTERY 14.99 1.00
37607 LIGATION OF A-V FISTULA 10.62 1.00
37609 TEMPORAL ARTERY PROCEDURE 5.54 1.00
37615 LIGATION OF NECK ARTERY 13.51 1.00
37616 LIGATION OF CHEST ARTERY 30.58 1.00
37617 LIGATION OF ABDOMEN ARTERY 36.52 1.00
37618 LIGATION OF EXTREMITY ARTERY 10.64 1.00
37620 REVISION OF MAJOR VEIN 18.5 1.00
37650 REVISION OF MAJOR VEIN 14.33 1.00
37660 REVISION OF MAJOR VEIN 34.61 1.00
37700 REVISE LEG VEIN 7.05 1.00
37718 LIGATE/STRIP SHORT LEG VEIN 12.21 1.00
37722 LIGATE/STRIP LONG LEG VEIN 13.64 1.00
37735 REMOVAL OF LEG VEINS/LESION 17.79 1.00
37760 LIGATE LEG VEINS RADICAL 17.78 1.00
37761 LIGATE LEG VEINS OPEN 15.94 1.00
37765 PHLEB VEINS - EXTREM - TO 20 12.89 1.00
37766 PHLEB VEINS - EXTREM 20+ 15.81 1.00
37780 REVISION OF LEG VEIN 7.28 1.00
37785 LIGATE/DIVIDE/EXCISE VEIN 7.29 1.00
37788 REVASCULARIZATION, PENIS 38.87 1.00
37790 PENILE VENOUS OCCLUSION 13.54 1.00

38100 REMOVAL OF SPLEEN, TOTAL 30.16 1.00
38101 REMOVAL OF SPLEEN, PARTIAL 30.32 1.00
38102 REMOVAL OF SPLEEN, TOTAL 7.04 1.00
38115 REPAIR OF RUPTURED SPLEEN 33.36 1.00
38120 LAPAROSCOPY, SPLENECTOMY 27.53 1.00
38200 INJECTION FOR SPLEEN X-RAY 4.11 1.00
38206 HARVEST AUTO STEM CELLS 2.2 1.00
38220 BONE MARROW ASPIRATION 1.67 1.00
38221 BONE MARROW BIOPSY 2.07 1.00
38230 BONE MARROW COLLECTION 8.97 1.00
38240 BONE MARROW/STEM TRANSPLANT 3.4 1.00
38241 BONE MARROW/STEM TRANSPLANT 3.4 1.00
38242 LYMPHOCYTE INFUSE TRANSPLANT 2.58 1.00
38300 DRAINAGE, LYMPH NODE LESION 4.79 1.00
38305 DRAINAGE, LYMPH NODE LESION 12.16 1.00
38308 INCISION OF LYMPH CHANNELS 11.79 1.00
38380 THORACIC DUCT PROCEDURE 14.98 1.00
38381 THORACIC DUCT PROCEDURE 22.3 1.00
38382 THORACIC DUCT PROCEDURE 18.33 1.00
38500 BIOPSY/REMOVAL, LYMPH NODES 6.59 1.00
38505 NEEDLE BIOPSY, LYMPH NODES 2 1.00
38510 BIOPSY/REMOVAL, LYMPH NODES 11.15 1.00
38520 BIOPSY/REMOVAL, LYMPH NODES 12.24 1.00
38525 BIOPSY/REMOVAL, LYMPH NODES 11.19 1.00
38530 BIOPSY/REMOVAL, LYMPH NODES 14.31 1.00
38550 REMOVAL, NECK/ARMPIT LESION 12.83 1.00
38555 REMOVAL, NECK/ARMPIT LESION 26.4 1.00
38562 REMOVAL, PELVIC LYMPH NODES 18.65 1.00
38564 REMOVAL, ABDOMEN LYMPH NODES 18.68 1.00
38570 LAPAROSCOPY, LYMPH NODE BIOP 14.69 1.00
38571 LAPAROSCOPY, LYMPHADENECTOMY 22.67 1.00
38572 LAPAROSCOPY, LYMPHADENECTOMY 25.53 1.00
38700 REMOVAL OF LYMPH NODES, NECK 21.33 1.00
38720 REMOVAL OF LYMPH NODES, NECK 35.68 1.00
38724 REMOVAL OF LYMPH NODES, NECK 38.53 1.00
38740 REMOVE ARMPIT LYMPH NODES 17.9 1.00
38745 REMOVE ARMPIT LYMPH NODES 22.77 1.00
38746 REMOVE THORACIC LYMPH NODES 7.31 1.00
38747 REMOVE ABDOMINAL LYMPH NODES 7.19 1.00
38760 REMOVE GROIN LYMPH NODES 22.24 1.00
38765 REMOVE GROIN LYMPH NODES 34.45 1.00
38770 REMOVE PELVIS LYMPH NODES 22.21 1.00
38780 REMOVE ABDOMEN LYMPH NODES 28.26 1.00
38790 INJECT FOR LYMPHATIC X-RAY 2.25 1.00
38792 IDENTIFY SENTINEL NODE 1.07 1.00
38794 ACCESS THORACIC LYMPH DUCT 8.23 1.00
40799 LIP SURGERY PROCEDURE 999.99 1.00
41820 EXCISION, GUM, EACH QUADRANT 4 1.00
43496 FREE JEJUNUM FLAP, MICROVASC 5 1.00
44133 ENTERECTOMY, LIVE DONOR 6 1.00
44136 INTESTINE TRANSPLANT, LIVE 6 1.00
49906 FREE OMENTAL FLAP, MICROVASC 4 1.00
50398 CHANGE KIDNEY TUBE 2.07 1.00

52317 REMOVE BLADDER STONE 9.47 1.00
52332 CYSTOSCOPY AND TREATMENT 4.09 1.00
54440 REPAIR OF PENIS 3 1.00
54660 REVISION OF TESTIS 999.99 1.00
55920 PLACE NEEDLES PELVIC FOR RT 12.45 1.00
56405 I & D OF VULVA/PERINEUM 2.88 1.00
56420 DRAINAGE OF GLAND ABSCESS 2.5 1.00
56440 SURGERY FOR VULVA LESION 4.94 1.00
56441 LYSIS OF LABIAL LESION(S) 3.78 1.00
56442 HYMENOTOMY 1.3 1.00
56501 DESTROY, VULVA LESIONS, SIM 3.06 1.00
56515 DESTROY VULVA LESION/S COMPL 5.33 1.00
56605 BIOPSY OF VULVA/PERINEUM 1.64 1.00
56606 BIOPSY OF VULVA/PERINEUM 0.8 1.00
56620 PARTIAL REMOVAL OF VULVA 13.4 1.00
56625 COMPLETE REMOVAL OF VULVA 16.15 1.00
56630 EXTENSIVE VULVA SURGERY 23.73 1.00
56631 EXTENSIVE VULVA SURGERY 30.14 1.00
56632 EXTENSIVE VULVA SURGERY 34.9 1.00
56633 EXTENSIVE VULVA SURGERY 30.92 1.00
56634 EXTENSIVE VULVA SURGERY 32.63 1.00
56637 EXTENSIVE VULVA SURGERY 38.46 1.00
56640 EXTENSIVE VULVA SURGERY 38.2 1.00
56700 PARTIAL REMOVAL OF HYMEN 5.04 1.00
56740 REMOVE VAGINA GLAND LESION 8.03 1.00
56800 REPAIR OF VAGINA 6.56 1.00
56805 REPAIR CLITORIS 31.18 1.00
56810 REPAIR OF PERINEUM 7.04 1.00
56820 EXAM OF VULVA W/SCOPE 2.31 1.00
56821 EXAM/BIOPSY OF VULVA W/SCOPE 3.11 1.00
57000 EXPLORATION OF VAGINA 5.16 1.00
57010 DRAINAGE OF PELVIC ABSCESS 11.69 1.00
57020 DRAINAGE OF PELVIC FLUID 2.22 1.00
57022 I & D VAGINAL HEMATOMA, PP 4.53 1.00
57023 I & D VAG HEMATOMA, NON-OB 8.44 1.00
57061 DESTROY VAG LESIONS, SIMPLE 2.61 1.00
57065 DESTROY VAG LESIONS, COMPLEX 4.6 1.00
57100 BIOPSY OF VAGINA 1.79 1.00
57105 BIOPSY OF VAGINA 3.35 1.00
57106 REMOVE VAGINA WALL, PARTIAL 12.92 1.00
57107 REMOVE VAGINA TISSUE, PART 38.01 1.00
57109 VAGINECTOMY PARTIAL W/NODES 43.58 1.00
57110 REMOVE VAGINA WALL, COMPLETE 24.38 1.00
57111 REMOVE VAGINA TISSUE, COMPL 43.94 1.00
57112 VAGINECTOMY W/NODES, COMPL 44.91 1.00
57120 CLOSURE OF VAGINA 13.84 1.00
57130 REMOVE VAGINA LESION 4.32 1.00
57135 REMOVE VAGINA LESION 4.66 1.00
57150 TREAT VAGINA INFECTION 0.8 1.00
57155 INSERT UTERI TANDEMS/OVOIDS 11.27 1.00
57160 INSERT PESSARY/OTHER DEVICE 1.3 1.00
57170 FITTING OF DIAPHRAGM/CAP 1.31 1.00
57180 TREAT VAGINAL BLEEDING 2.88 1.00

57200 REPAIR OF VAGINA 8.01 1.00
57210 REPAIR VAGINA/PERINEUM 9.89 1.00
57220 REVISION OF URETHRA 8.64 1.00
57230 REPAIR OF URETHRAL LESION 10.86 1.00
57240 REPAIR BLADDER & VAGINA 18.16 1.00
57250 REPAIR RECTUM & VAGINA 18.06 1.00
57260 REPAIR OF VAGINA 22.37 1.00
57265 EXTENSIVE REPAIR OF VAGINA 24.72 1.00
57267 INSERT MESH/PELVIC FLR ADDON 7.17 1.00
57268 REPAIR OF BOWEL BULGE 13.01 1.00
57270 REPAIR OF BOWEL POUCH 21.67 1.00
57280 SUSPENSION OF VAGINA 26.16 1.00
57282 COLPOPEXY, EXTRAPERITONEAL 13.63 1.00
57283 COLPOPEXY, INTRAPERITONEAL 18.77 1.00
57284 REPAIR PARAVAG DEFECT, OPEN 22.56 1.00
57285 REPAIR PARAVAG DEFECT, VAG 18.46 1.00
57287 REVISE/REMOVE SLING REPAIR 18.91 1.00
57288 REPAIR BLADDER DEFECT 19.71 1.00
57289 REPAIR BLADDER & VAGINA 20.32 1.00
57291 CONSTRUCTION OF VAGINA 14.64 1.00
57292 CONSTRUCT VAGINA WITH GRAFT 22.47 1.00
57295 REVISE VAG GRAFT VIA VAGINA 13.17 1.00
57296 REVISE VAG GRAFT, OPEN ABD 25.86 1.00
57300 REPAIR RECTUM-VAGINA FISTULA 14.66 1.00
57305 REPAIR RECTUM-VAGINA FISTULA 24.49 1.00
57307 FISTULA REPAIR & COLOSTOMY 27.71 1.00
57308 FISTULA REPAIR, TRANSPERINE 17.24 1.00
57310 REPAIR URETHROVAGINAL LESION 12.97 1.00
57311 REPAIR URETHROVAGINAL LESION 14.78 1.00
57320 REPAIR BLADDER-VAGINA LESION 14.9 1.00
57330 REPAIR BLADDER-VAGINA LESION 20.86 1.00
57335 REPAIR VAGINA 31.74 1.00
57400 DILATION OF VAGINA 3.65 1.00
57410 PELVIC EXAMINATION 2.89 1.00
57415 REMOVE VAGINAL FOREIGN BODY 4.32 1.00
57420 EXAM OF VAGINA W/SCOPE 2.44 1.00
57421 EXAM/BIOPSY OF VAG W/SCOPE 3.33 1.00
57423 REPAIR PARAVAG DEFECT, LAP 25.16 1.00
57425 LAPAROSCOPY, SURG, COLPOPEXY 26.45 1.00
57426 REVISE PROSTH VAG GRAFT LAP 23.71 1.00
57452 EXAM OF CERVIX W/SCOPE 2.47 1.00
57454 BX/CURETT OF CERVIX W/SCOPE 3.69 1.00
57455 BIOPSY OF CERVIX W/SCOPE 3.01 1.00
57456 ENDOCERV CURETTAGE W/SCOPE 2.82 1.00
57460 BX OF CERVIX W/SCOPE, LEEP 4.44 1.00
57461 CONZ OF CERVIX W/SCOPE, LEEP 5.14 1.00
57500 BIOPSY OF CERVIX 2.03 1.00
57505 ENDOCERVICAL CURETTAGE 2.44 1.00
57510 CAUTERIZATION OF CERVIX 3.12 1.00
57511 CRYOCAUTERY OF CERVIX 3.54 1.00
57513 LASER SURGERY OF CERVIX 3.56 1.00
57520 CONIZATION OF CERVIX 7.33 1.00
57522 CONIZATION OF CERVIX 6.54 1.00

57530 REMOVAL OF CERVIX 9.27 1.00
57531 REMOVAL OF CERVIX, RADICAL 46.24 1.00
57540 REMOVAL OF RESIDUAL CERVIX 21.1 1.00
57545 REMOVE CERVIX/REPAIR PELVIS 22.28 1.00
57550 REMOVAL OF RESIDUAL CERVIX 11.02 1.00
57555 REMOVE CERVIX/REPAIR VAGINA 16.24 1.00
57556 REMOVE CERVIX, REPAIR BOWEL 15.44 1.00
57558 D&C OF CERVICAL STUMP 3.06 1.00
57700 REVISION OF CERVIX 8.33 1.00
57720 REVISION OF CERVIX 8.27 1.00
57800 DILATION OF CERVICAL CANAL 1.31 1.00
58100 BIOPSY OF UTERUS LINING 2.38 1.00
58110 BX DONE W/COLPOSCOPY ADD-ON 1.13 1.00
58120 DILATION AND CURETTAGE 5.87 1.00
58140 MYOMECTOMY ABDOM METHOD 24.83 1.00
58145 MYOMECTOMY VAG METHOD 14.69 1.00
58146 MYOMECTOMY ABDOM COMPLEX 31.44 1.00
58150 TOTAL HYSTERECTOMY 26.91 1.00
58152 TOTAL HYSTERECTOMY 33.86 1.00
58180 PARTIAL HYSTERECTOMY 25.91 1.00
58200 EXTENSIVE HYSTERECTOMY 35.49 1.00
58210 EXTENSIVE HYSTERECTOMY 47.4 1.00
58240 REMOVAL OF PELVIS CONTENTS 75.3 1.00
58260 VAGINAL HYSTERECTOMY 22.42 1.00
58262 VAG HYST INCLUDING T/O 25.03 1.00
58263 VAG HYST W/T/O & VAG REPAIR 26.96 1.00
58267 VAG HYST W/URINARY REPAIR 28.66 1.00
58270 VAG HYST W/ENTEROCELE REPAIR 23.95 1.00
58275 HYSTERECTOMY/REVISE VAGINA 26.72 1.00
58280 HYSTERECTOMY/REVISE VAGINA 28.57 1.00
58285 EXTENSIVE HYSTERECTOMY 35.7 1.00
58290 VAG HYST COMPLEX 31.31 1.00
58291 VAG HYST INCL T/O, COMPLEX 33.99 1.00
58292 VAG HYST T/O & REPAIR, COMPL 35.82 1.00
58293 VAG HYST W/URO REPAIR, COMPL 37.22 1.00
58294 VAG HYST W/ENTEROCELE, COMPL 33.14 1.00
58300 INSERT INTRAUTERINE DEVICE 1.42 1.00
58301 REMOVE INTRAUTERINE DEVICE 1.86 1.00
58340 CATHETER FOR HYSTEROGRAPHY 1.58 1.00
58346 INSERT HEYMAN UTERI CAPSULE 12.12 1.00
58353 ENDOMETR ABLATE, THERMAL 5.96 1.00
58356 ENDOMETRIAL CRYOABLATION 9.49 1.00
58400 SUSPENSION OF UTERUS 12.01 1.00
58410 SUSPENSION OF UTERUS 21.78 1.00
58520 REPAIR OF RUPTURED UTERUS 21.88 1.00
58540 REVISION OF UTERUS 24.61 1.00
58541 LSH, UTERUS 250 G OR LESS 23.26 1.00
58542 LSH W/T/O UT 250 G OR LESS 25.99 1.00
58543 LSH UTERUS ABOVE 250 G 26.43 1.00
58544 LSH W/T/O UTERUS ABOVE 250 G 28.57 1.00
58545 LAPAROSCOPIC MYOMECTOMY 24.26 1.00
58546 LAPARO-MYOMECTOMY, COMPLEX 30.67 1.00
58548 LAP RADICAL HYST 48.22 1.00

58550 LAPARO-ASST VAG HYSTERECTOMY 23.94 1.00
58552 LAPARO-VAG HYST INCL T/O 26.57 1.00
58553 LAPARO-VAG HYST, COMPLEX 30.84 1.00
58554 LAPARO-VAG HYST W/T/O, COMPL 35.64 1.00
58555 HYSTEROSCOPY, DX, SEP PROC 5.16 1.00
58558 HYSTEROSCOPY, BIOPSY 7.28 1.00
58559 HYSTEROSCOPY, LYSIS 9.37 1.00
58560 HYSTEROSCOPY, RESECT SEPTUM 10.58 1.00
58561 HYSTEROSCOPY, REMOVE MYOMA 14.97 1.00
58562 HYSTEROSCOPY, REMOVE FB 7.93 1.00
58563 HYSTEROSCOPY, ABLATION 9.37 1.00
58565 HYSTEROSCOPY, STERILIZATION 11.74 1.00
58570 TLH, UTERUS 250 G OR LESS 25.01 1.00
58571 TLH W/T/O 250 G OR LESS 27.66 1.00
58572 TLH, UTERUS OVER 250 G 31.06 1.00
58573 TLH W/T/O UTERUS OVER 250 G 35.47 1.00
58600 DIVISION OF FALLOPIAN TUBE 9.83 1.00
58605 DIVISION OF FALLOPIAN TUBE 8.89 1.00
58611 LIGATE OVIDUCT(S) ADD-ON 2.12 1.00
58615 OCCLUDE FALLOPIAN TUBE(S) 6.69 1.00
58660 LAPAROSCOPY, LYSIS 18.21 1.00
58661 LAPAROSCOPY, REMOVE ADNEXA 17.47 1.00
58662 LAPAROSCOPY, EXCISE LESIONS 19.11 1.00
58670 LAPAROSCOPY, TUBAL CAUTERY 9.88 1.00
58671 LAPAROSCOPY, TUBAL BLOCK 9.87 1.00
58672 LAPAROSCOPY, FIMBRIOPLASTY 20.01 1.00
58673 LAPAROSCOPY, SALPINGOSTOMY 21.78 1.00
58700 REMOVAL OF FALLOPIAN TUBE 20.84 1.00
58720 REMOVAL OF OVARY/TUBE(S) 19.46 1.00
58740 ADHESIOLYSIS TUBE, OVARY 23.72 1.00
58770 CREATE NEW TUBAL OPENING 22.86 1.00
58800 DRAINAGE OF OVARIAN CYST(S) 8.09 1.00
58805 DRAINAGE OF OVARIAN CYST(S) 10.95 1.00
58820 DRAIN OVARY ABSCESS, OPEN 8.43 1.00
58822 DRAIN OVARY ABSCESS, PERCUT 19.69 1.00
58823 DRAIN PELVIC ABSCESS, PERCUT 4.87 1.00
58825 TRANSPOSITION, OVARY(S) 18.82 1.00
58900 BIOPSY OF OVARY(S) 11.57 1.00
58920 PARTIAL REMOVAL OF OVARY(S) 18.92 1.00
58925 REMOVAL OF OVARIAN CYST(S) 19.92 1.00
58940 REMOVAL OF OVARY(S) 13.74 1.00
58943 REMOVAL OF OVARY(S) 30.44 1.00
58950 RESECT OVARIAN MALIGNANCY 29.04 1.00
58951 RESECT OVARIAN MALIGNANCY 37.38 1.00
58952 RESECT OVARIAN MALIGNANCY 42.17 1.00
58953 TAH, RAD DISSECT FOR DEBULK 52.25 1.00
58954 TAH RAD DEBULK/LYMPH REMOVE 56.67 1.00
58956 BSO, OMENTECTOMY W/TAH 35.66 1.00
58957 RESECT RECURRENT GYN MAL 40.56 1.00
58958 RESECT RECUR GYN MAL W/LYM 44.75 1.00
58960 EXPLORATION OF ABDOMEN 25.02 1.00
58999 GENITAL SURGERY PROCEDURE 999.99 1.00
61000 REMOVE CRANIAL CAVITY FLUID 2.87 1.00

61001 REMOVE CRANIAL CAVITY FLUID 3.25 1.00
61020 REMOVE BRAIN CAVITY FLUID 3.47 1.00
61026 INJECTION INTO BRAIN CANAL 3.36 1.00
61050 REMOVE BRAIN CANAL FLUID 2.81 1.00
61055 INJECTION INTO BRAIN CANAL 3.68 1.00
61070 BRAIN CANAL SHUNT PROCEDURE 2.16 1.00
61105 TWIST DRILL HOLE 11.55 1.00
61107 DRILL SKULL FOR IMPLANTATION 8.48 1.00
61108 DRILL SKULL FOR DRAINAGE 23.17 1.00
61120 BURR HOLE FOR PUNCTURE 19.08 1.00
61140 PIERCE SKULL FOR BIOPSY 32.68 1.00
61150 PIERCE SKULL FOR DRAINAGE 35.2 1.00
61151 PIERCE SKULL FOR DRAINAGE 25.59 1.00
61154 PIERCE SKULL & REMOVE CLOT 32.76 1.00
61156 PIERCE SKULL FOR DRAINAGE 32.56 1.00
61210 PIERCE SKULL, IMPLANT DEVICE 9.9 1.00
61215 INSERT BRAIN-FLUID DEVICE 12.71 1.00
61250 PIERCE SKULL & EXPLORE 22.16 1.00
61253 PIERCE SKULL & EXPLORE 22.46 1.00
61304 OPEN SKULL FOR EXPLORATION 42.91 1.00
61305 OPEN SKULL FOR EXPLORATION 52.55 1.00
61312 OPEN SKULL FOR DRAINAGE 54.53 1.00
61313 OPEN SKULL FOR DRAINAGE 51.76 1.00
61314 OPEN SKULL FOR DRAINAGE 47.7 1.00
61315 OPEN SKULL FOR DRAINAGE 54.26 1.00
61316 IMPLT CRAN BONE FLAP TO ABDO 2.34 1.00
61320 OPEN SKULL FOR DRAINAGE 50 1.00
61321 OPEN SKULL FOR DRAINAGE 55.35 1.00
61322 DECOMPRESSIVE CRANIOTOMY 61.73 1.00
61323 DECOMPRESSIVE LOBECTOMY 62.44 1.00
61330 DECOMPRESS EYE SOCKET 45.42 1.00
61332 EXPLORE/BIOPSY EYE SOCKET 51.17 1.00
61333 EXPLORE ORBIT/REMOVE LESION 52.91 1.00
61334 EXPLORE ORBIT/REMOVE OBJECT 35.16 1.00
61340 SUBTEMPORAL DECOMPRESSION 37.47 1.00
61343 INCISE SKULL (PRESS RELIEF) 57.72 1.00
61345 RELIEVE CRANIAL PRESSURE 53.45 1.00
61440 INCISE SKULL FOR SURGERY 52.36 1.00
61450 INCISE SKULL FOR SURGERY 50.24 1.00
61458 INCISE SKULL FOR BRAIN WOUND 52.67 1.00
61460 INCISE SKULL FOR SURGERY 54.66 1.00
61470 INCISE SKULL FOR SURGERY 50.25 1.00
61480 INCISE SKULL FOR SURGERY 41.9 1.00
61490 INCISE SKULL FOR SURGERY 49.71 1.00
61500 REMOVAL OF SKULL LESION 35.02 1.00
61501 REMOVE INFECTED SKULL BONE 30.09 1.00
61510 REMOVAL OF BRAIN LESION 57.07 1.00
61512 REMOVE BRAIN LINING LESION 67.12 1.00
61514 REMOVAL OF BRAIN ABSCESS 49.91 1.00
61516 REMOVAL OF BRAIN LESION 48.48 1.00
61517 IMPLT BRAIN CHEMOTX ADD-ON 2.34 1.00
61518 REMOVAL OF BRAIN LESION 72.43 1.00
61519 REMOVE BRAIN LINING LESION 77.71 1.00

61520 REMOVAL OF BRAIN LESION 99.52 1.00
61521 REMOVAL OF BRAIN LESION 83.75 1.00
61522 REMOVAL OF BRAIN ABSCESS 57.43 1.00
61524 REMOVAL OF BRAIN LESION 54.38 1.00
61526 REMOVAL OF BRAIN LESION 94.88 1.00
61530 REMOVAL OF BRAIN LESION 80.55 1.00
61531 IMPLANT BRAIN ELECTRODES 31.62 1.00
61533 IMPLANT BRAIN ELECTRODES 39.74 1.00
61534 REMOVAL OF BRAIN LESION 42.88 1.00
61535 REMOVE BRAIN ELECTRODES 25.75 1.00
61536 REMOVAL OF BRAIN LESION 68.01 1.00
61537 REMOVAL OF BRAIN TISSUE 64.25 1.00
61538 REMOVAL OF BRAIN TISSUE 69.31 1.00
61539 REMOVAL OF BRAIN TISSUE 61.77 1.00
61540 REMOVAL OF BRAIN TISSUE 57.33 1.00
61541 INCISION OF BRAIN TISSUE 56.25 1.00
61542 REMOVAL OF BRAIN TISSUE 60.19 1.00
61543 REMOVAL OF BRAIN TISSUE 56.51 1.00
61544 REMOVE & TREAT BRAIN LESION 47.78 1.00
61545 EXCISION OF BRAIN TUMOR 83.5 1.00
61546 REMOVAL OF PITUITARY GLAND 60.46 1.00
61548 REMOVAL OF PITUITARY GLAND 41.17 1.00
61550 RELEASE OF SKULL SEAMS 25.02 1.00
61552 RELEASE OF SKULL SEAMS 32.71 1.00
61556 INCISE SKULL/SUTURES 43.95 1.00
61557 INCISE SKULL/SUTURES 43.98 1.00
61558 EXCISION OF SKULL/SUTURES 49.1 1.00
61559 EXCISION OF SKULL/SUTURES 54.08 1.00
61563 EXCISION OF SKULL TUMOR 51.94 1.00
61564 EXCISION OF SKULL TUMOR 63.24 1.00
61566 REMOVAL OF BRAIN TISSUE 59.21 1.00
61567 INCISION OF BRAIN TISSUE 67.6 1.00
61570 REMOVE FOREIGN BODY, BRAIN 48.52 1.00
61571 INCISE SKULL FOR BRAIN WOUND 52.16 1.00
61575 SKULL BASE/BRAINSTEM SURGERY 64.98 1.00
61576 SKULL BASE/BRAINSTEM SURGERY 94.97 1.00
61580 CRANIOFACIAL APPROACH, SKULL 64.14 1.00
61581 CRANIOFACIAL APPROACH, SKULL 71.07 1.00
61582 CRANIOFACIAL APPROACH, SKULL 76.31 1.00
61583 CRANIOFACIAL APPROACH, SKULL 75.11 1.00
61584 ORBITOCRANIAL APPROACH/SKULL 73.71 1.00
61585 ORBITOCRANIAL APPROACH/SKULL 81.52 1.00
61586 RESECT NASOPHARYNX, SKULL 59.14 1.00
61590 INFRATEMPORAL APPROACH/SKULL 81.52 1.00
61591 INFRATEMPORAL APPROACH/SKULL 82.54 1.00
61592 ORBITOCRANIAL APPROACH/SKULL 82.53 1.00
61595 TRANSTEMPORAL APPROACH/SKULL 62.28 1.00
61596 TRANSCOCHLEAR APPROACH/SKULL 66.88 1.00
61597 TRANSCONDYLAR APPROACH/SKULL 76.5 1.00
61598 TRANSPETROSAL APPROACH/SKULL 70.25 1.00
61600 RESECT/EXCISE CRANIAL LESION 56.02 1.00
61601 RESECT/EXCISE CRANIAL LESION 61.56 1.00
61605 RESECT/EXCISE CRANIAL LESION 58.15 1.00

61606 RESECT/EXCISE CRANIAL LESION 78.86 1.00
61607 RESECT/EXCISE CRANIAL LESION 75.88 1.00
61608 RESECT/EXCISE CRANIAL LESION 84.73 1.00
61609 TRANSECT ARTERY, SINUS 16.52 1.00
61610 TRANSECT ARTERY, SINUS 50.18 1.00
61611 TRANSECT ARTERY, SINUS 10.88 1.00
61612 TRANSECT ARTERY, SINUS 40.19 1.00
61613 REMOVE ANEURYSM, SINUS 84.93 1.00
61615 RESECT/EXCISE LESION, SKULL 62.24 1.00
61616 RESECT/EXCISE LESION, SKULL 86.7 1.00
61618 REPAIR DURA 34.07 1.00
61619 REPAIR DURA 39.22 1.00
61623 ENDOVASC TEMPORY VESSEL OCCL 15.3 1.00
61624 TRANSCATH OCCLUSION, CNS 30.58 1.00
61626 TRANSCATH OCCLUSION, NON-CNS 24.31 1.00
61630 INTRACRANIAL ANGIOPLASTY 34.91 1.00
61635 INTRACRAN ANGIOPLSTY W/STENT 37.82 1.00
61640 DILATE IC VASOSPASM, INIT 17.25 1.00
61641 DILATE IC VASOSPASM ADD-ON 6.07 1.00
61642 DILATE IC VASOSPASM ADD-ON 12.12 1.00
61680 INTRACRANIAL VESSEL SURGERY 59.42 1.00
61682 INTRACRANIAL VESSEL SURGERY 111.12 1.00
61684 INTRACRANIAL VESSEL SURGERY 74.42 1.00
61686 INTRACRANIAL VESSEL SURGERY 119.28 1.00
61690 INTRACRANIAL VESSEL SURGERY 57.16 1.00
61692 INTRACRANIAL VESSEL SURGERY 96.55 1.00
61697 BRAIN ANEURYSM REPR, COMPLX 111.09 1.00
61698 BRAIN ANEURYSM REPR, COMPLX 121.27 1.00
61700 BRAIN ANEURYSM REPR, SIMPLE 90.58 1.00
61702 INNER SKULL VESSEL SURGERY 105.44 1.00
61703 CLAMP NECK ARTERY 35.43 1.00
61705 REVISE CIRCULATION TO HEAD 67.81 1.00
61708 REVISE CIRCULATION TO HEAD 55.55 1.00
61710 REVISE CIRCULATION TO HEAD 50.82 1.00
61711 FUSION OF SKULL ARTERIES 68.39 1.00
61720 INCISE SKULL/BRAIN SURGERY 32.1 1.00
61735 INCISE SKULL/BRAIN SURGERY 40.12 1.00
61750 INCISE SKULL/BRAIN BIOPSY 36.71 1.00
61751 BRAIN BIOPSY W/CT/MR GUIDE 35.73 1.00
61760 IMPLANT BRAIN ELECTRODES 40.68 1.00
61770 INCISE SKULL FOR TREATMENT 41.46 1.00
61790 TREAT TRIGEMINAL NERVE 22.28 1.00
61791 TREAT TRIGEMINAL TRACT 28.68 1.00
61795 BRAIN SURGERY USING COMPUTER 6.55 1.00
61796 SRS, CRANIAL LESION SIMPLE 24.82 1.00
61797 SRS, CRAN LES SIMPLE, ADDL 5.74 1.00
61798 SRS, CRANIAL LESION COMPLEX 32.86 1.00
61799 SRS, CRAN LES COMPLEX, ADDL 7.93 1.00
61800 APPLY SRS HEADFRAME ADD-ON 3.95 1.00
61850 IMPLANT NEUROELECTRODES 25.54 1.00
61860 IMPLANT NEUROELECTRODES 40.98 1.00
61863 IMPLANT NEUROELECTRODE 39.17 1.00
61864 IMPLANT NEUROELECTRDE, ADDL 7.65 1.00

61867 IMPLANT NEUROELECTRODE 60.01 1.00
61868 IMPLANT NEUROELECTRDE, ADDL 13.48 1.00
61870 IMPLANT NEUROELECTRODES 30.95 1.00
61875 IMPLANT NEUROELECTRODES 26.57 1.00
61880 REVISE/REMOVE NEUROELECTRODE 14.34 1.00
61885 INSRT/REDO NEUROSTIM 1 ARRAY 16.78 1.00
61886 IMPLANT NEUROSTIM ARRAYS 21.26 1.00
61888 REVISE/REMOVE NEURORECEIVER 10.19 1.00
62000 TREAT SKULL FRACTURE 25.27 1.00
62005 TREAT SKULL FRACTURE 32.81 1.00
62010 TREATMENT OF HEAD INJURY 39.63 1.00
62100 REPAIR BRAIN FLUID LEAKAGE 42.17 1.00
62115 REDUCTION OF SKULL DEFECT 33.17 1.00
62116 REDUCTION OF SKULL DEFECT 46.36 1.00
62117 REDUCTION OF SKULL DEFECT 46.61 1.00
62120 REPAIR SKULL CAVITY LESION 45.47 1.00
62121 INCISE SKULL REPAIR 45.2 1.00
62140 REPAIR OF SKULL DEFECT 27.12 1.00
62141 REPAIR OF SKULL DEFECT 29.87 1.00
62142 REMOVE SKULL PLATE/FLAP 22.94 1.00
62143 REPLACE SKULL PLATE/FLAP 26.91 1.00
62145 REPAIR OF SKULL & BRAIN 37.02 1.00
62146 REPAIR OF SKULL WITH GRAFT 32.15 1.00
62147 REPAIR OF SKULL WITH GRAFT 38.06 1.00
62148 RETR BONE FLAP TO FIX SKULL 3.37 1.00
62160 NEUROENDOSCOPY ADD-ON 5.11 1.00
62161 DISSECT BRAIN W/SCOPE 39.61 1.00
62162 REMOVE COLLOID CYST W/SCOPE 49.58 1.00
62163 NEUROENDOSCOPY W/FB REMOVAL 31.85 1.00
62164 REMOVE BRAIN TUMOR W/SCOPE 54 1.00
62165 REMOVE PITUIT TUMOR W/SCOPE 41.2 1.00
62180 ESTABLISH BRAIN CAVITY SHUNT 41.85 1.00
62190 ESTABLISH BRAIN CAVITY SHUNT 23.77 1.00
62192 ESTABLISH BRAIN CAVITY SHUNT 25.29 1.00
62194 REPLACE/IRRIGATE CATHETER 9.87 1.00
62200 ESTABLISH BRAIN CAVITY SHUNT 35.9 1.00
62201 BRAIN CAVITY SHUNT W/SCOPE 31.02 1.00
62220 ESTABLISH BRAIN CAVITY SHUNT 26.38 1.00
62223 ESTABLISH BRAIN CAVITY SHUNT 27.27 1.00
62225 REPLACE/IRRIGATE CATHETER 13.09 1.00
62230 REPLACE/REVISE BRAIN SHUNT 21.83 1.00
62252 CSF SHUNT REPROGRAM 2.63 1.00
62256 REMOVE BRAIN CAVITY SHUNT 15.23 1.00
62258 REPLACE BRAIN CAVITY SHUNT 29.31 1.00
62263 EPIDURAL LYSIS MULT SESSIONS 10.28 1.00
62264 EPIDURAL LYSIS ON SINGLE DAY 6.19 1.00
62267 INTERDISCAL PERQ ASPIR, DX 4.47 1.00
62268 DRAIN SPINAL CORD CYST 7.02 1.00
62269 NEEDLE BIOPSY, SPINAL CORD 7.23 1.00
62270 SPINAL FLUID TAP, DIAGNOSTIC 2.14 1.00
62272 DRAIN CEREBRO SPINAL FLUID 2.27 1.00
62273 INJECT EPIDURAL PATCH 2.99 1.00
62280 TREAT SPINAL CORD LESION 4.2 1.00

62281 TREAT SPINAL CORD LESION 3.99 1.00
62282 TREAT SPINAL CANAL LESION 3.7 1.00
62284 INJECTION FOR MYELOGRAM 2.4 1.00
62287 PERCUTANEOUS DISKECTOMY 14.55 1.00
62290 INJECT FOR SPINE DISK X-RAY 4.56 1.00
62291 INJECT FOR SPINE DISK X-RAY 4.39 1.00
62292 INJECTION INTO DISK LESION 13.05 1.00
62294 INJECTION INTO SPINAL ARTERY 19.47 1.00
62310 INJECT SPINE C/T 2.73 1.00
62311 INJECT SPINE L/S (CD) 2.26 1.00
62318 INJECT SPINE W/CATH, C/T 2.69 1.00
62319 INJECT SPINE W/CATH L/S (CD) 2.54 1.00
62350 IMPLANT SPINAL CANAL CATH 10.2 1.00
62351 IMPLANT SPINAL CANAL CATH 22.28 1.00
62355 REMOVE SPINAL CANAL CATHETER 7.69 1.00
62360 INSERT SPINE INFUSION DEVICE 7.78 1.00
62361 IMPLANT SPINE INFUSION PUMP 10.27 1.00
62362 IMPLANT SPINE INFUSION PUMP 10.69 1.00
62365 REMOVE SPINE INFUSION DEVICE 8.46 1.00
62367 ANALYZE SPINE INFUSION PUMP 0.66 1.00
62368 ANALYZE SPINE INFUSION PUMP 1.02 1.00
63001 REMOVAL OF SPINAL LAMINA 32.26 1.00
63003 REMOVAL OF SPINAL LAMINA 32.42 1.00
63005 REMOVAL OF SPINAL LAMINA 30.82 1.00
63011 REMOVAL OF SPINAL LAMINA 28.46 1.00
63012 REMOVAL OF SPINAL LAMINA 31.17 1.00
63015 REMOVAL OF SPINAL LAMINA 38.74 1.00
63016 REMOVAL OF SPINAL LAMINA 39.7 1.00
63017 REMOVAL OF SPINAL LAMINA 32.55 1.00
63020 NECK SPINE DISK SURGERY 30.49 1.00
63030 LOW BACK DISK SURGERY 25.19 1.00
63035 SPINAL DISK SURGERY ADD-ON 5.22 1.00
63040 LAMINOTOMY, SINGLE CERVICAL 36.91 1.00
63042 LAMINOTOMY, SINGLE LUMBAR 34.19 1.00
63045 REMOVAL OF SPINAL LAMINA 33.25 1.00
63046 REMOVAL OF SPINAL LAMINA 31.72 1.00
63047 REMOVAL OF SPINAL LAMINA 28.79 1.00
63048 REMOVE SPINAL LAMINA ADD-ON 5.75 1.00
63050 CERVICAL LAMINOPLASTY 40.72 1.00
63051 C-LAMINOPLASTY W/GRAFT/PLATE 45.17 1.00
63055 DECOMPRESS SPINAL CORD 42.79 1.00
63056 DECOMPRESS SPINAL CORD 38.99 1.00
63057 DECOMPRESS SPINE CORD ADD-ON 8.7 1.00
63064 DECOMPRESS SPINAL CORD 46.57 1.00
63066 DECOMPRESS SPINE CORD ADD-ON 5.57 1.00
63075 NECK SPINE DISK SURGERY 36.16 1.00
63076 NECK SPINE DISK SURGERY 6.77 1.00
63077 SPINE DISK SURGERY, THORAX 39.73 1.00
63078 SPINE DISK SURGERY, THORAX 5.28 1.00
63081 REMOVAL OF VERTEBRAL BODY 46.71 1.00
63082 REMOVE VERTEBRAL BODY ADD-ON 7.28 1.00
63085 REMOVAL OF VERTEBRAL BODY 50.51 1.00
63086 REMOVE VERTEBRAL BODY ADD-ON 5.22 1.00

63087 REMOVAL OF VERTEBRAL BODY 63.78 1.00
63088 REMOVE VERTEBRAL BODY ADD-ON 7.04 1.00
63090 REMOVAL OF VERTEBRAL BODY 52.35 1.00
63091 REMOVE VERTEBRAL BODY ADD-ON 4.86 1.00
63101 REMOVAL OF VERTEBRAL BODY 61.11 1.00
63102 REMOVAL OF VERTEBRAL BODY 59.39 1.00
63103 REMOVE VERTEBRAL BODY ADD-ON 7.95 1.00
63170 INCISE SPINAL CORD TRACT(S) 41.05 1.00
63172 DRAINAGE OF SPINAL CYST 36.63 1.00
63173 DRAINAGE OF SPINAL CYST 45.09 1.00
63180 REVISE SPINAL CORD LIGAMENTS 36.86 1.00
63182 REVISE SPINAL CORD LIGAMENTS 40.29 1.00
63185 INCISE SPINAL COLUMN/NERVES 31 1.00
63190 INCISE SPINAL COLUMN/NERVES 33.47 1.00
63191 INCISE SPINAL COLUMN/NERVES 30.69 1.00
63194 INCISE SPINAL COLUMN & CORD 36.66 1.00
63195 INCISE SPINAL COLUMN & CORD 39.81 1.00
63196 INCISE SPINAL COLUMN & CORD 40.08 1.00
63197 INCISE SPINAL COLUMN & CORD 44.59 1.00
63198 INCISE SPINAL COLUMN & CORD 43.4 1.00
63199 INCISE SPINAL COLUMN & CORD 48.68 1.00
63200 RELEASE OF SPINAL CORD 39.72 1.00
63250 REVISE SPINAL CORD VESSELS 77.91 1.00
63251 REVISE SPINAL CORD VESSELS 79.85 1.00
63252 REVISE SPINAL CORD VESSELS 79.78 1.00
63265 EXCISE INTRASPINAL LESION 43.7 1.00
63266 EXCISE INTRASPINAL LESION 45.05 1.00
63267 EXCISE INTRASPINAL LESION 36.02 1.00
63268 EXCISE INTRASPINAL LESION 37.42 1.00
63270 EXCISE INTRASPINAL LESION 54.23 1.00
63271 EXCISE INTRASPINAL LESION 54.34 1.00
63272 EXCISE INTRASPINAL LESION 50.01 1.00
63273 EXCISE INTRASPINAL LESION 47.96 1.00
63275 BIOPSY/EXCISE SPINAL TUMOR 47.06 1.00
63276 BIOPSY/EXCISE SPINAL TUMOR 46.77 1.00
63277 BIOPSY/EXCISE SPINAL TUMOR 40.69 1.00
63278 BIOPSY/EXCISE SPINAL TUMOR 41.02 1.00
63280 BIOPSY/EXCISE SPINAL TUMOR 55.57 1.00
63281 BIOPSY/EXCISE SPINAL TUMOR 54.92 1.00
63282 BIOPSY/EXCISE SPINAL TUMOR 51.78 1.00
63283 BIOPSY/EXCISE SPINAL TUMOR 49.4 1.00
63285 BIOPSY/EXCISE SPINAL TUMOR 68.36 1.00
63286 BIOPSY/EXCISE SPINAL TUMOR 67.68 1.00
63287 BIOPSY/EXCISE SPINAL TUMOR 72.01 1.00
63290 BIOPSY/EXCISE SPINAL TUMOR 73.25 1.00
63295 REPAIR OF LAMINECTOMY DEFECT 8.82 1.00
63300 REMOVAL OF VERTEBRAL BODY 48.19 1.00
63301 REMOVAL OF VERTEBRAL BODY 56.5 1.00
63302 REMOVAL OF VERTEBRAL BODY 55.92 1.00
63303 REMOVAL OF VERTEBRAL BODY 59.01 1.00
63304 REMOVAL OF VERTEBRAL BODY 61.34 1.00
63305 REMOVAL OF VERTEBRAL BODY 64.04 1.00
63306 REMOVAL OF VERTEBRAL BODY 64.46 1.00

63307 REMOVAL OF VERTEBRAL BODY 61.41 1.00
63308 REMOVE VERTEBRAL BODY ADD-ON 8.69 1.00
63600 REMOVE SPINAL CORD LESION 21.61 1.00
63610 STIMULATION OF SPINAL CORD 11.04 1.00
63615 REMOVE LESION OF SPINAL CORD 30.82 1.00
63620 SRS, SPINAL LESION 27.09 1.00
63621 SRS, SPINAL LESION, ADDL 6.59 1.00
63650 IMPLANT NEUROELECTRODES 10.91 1.00
63655 IMPLANT NEUROELECTRODES 22.29 1.00
63661 REMOVE SPINE ELTRD PERQ ARAY 8.78 1.00
63662 REMOVE SPINE ELTRD PLATE 19.06 1.00
63663 REVISE SPINE ELTRD PERQ ARAY 12.81 1.00
63664 REVISE SPINE ELTRD PLATE 19.83 1.00
63685 INSRT/REDO SPINE N GENERATOR 10.36 1.00
63688 REVISE/REMOVE NEURORECEIVER 9.36 1.00
63700 REPAIR OF SPINAL HERNIATION 33.1 1.00
63702 REPAIR OF SPINAL HERNIATION 36.85 1.00
63704 REPAIR OF SPINAL HERNIATION 41.66 1.00
63706 REPAIR OF SPINAL HERNIATION 47.37 1.00
63707 REPAIR SPINAL FLUID LEAKAGE 23.63 1.00
63709 REPAIR SPINAL FLUID LEAKAGE 28.79 1.00
63710 GRAFT REPAIR OF SPINE DEFECT 28.82 1.00
63740 INSTALL SPINAL SHUNT 24.53 1.00
63741 INSTALL SPINAL SHUNT 15.73 1.00
63744 REVISION OF SPINAL SHUNT 17.06 1.00
63746 REMOVAL OF SPINAL SHUNT 14.98 1.00
64400 N BLOCK INJ, TRIGEMINAL 1.75 1.00
64402 N BLOCK INJ, FACIAL 1.96 1.00
64405 N BLOCK INJ, OCCIPITAL 2.07 1.00
64408 N BLOCK INJ, VAGUS 2.38 1.00
64410 N BLOCK INJ, PHRENIC 2.23 1.00
64412 N BLOCK INJ, SPINAL ACCESSOR 1.95 1.00
64413 N BLOCK INJ, CERVICAL PLEXUS 2.09 1.00
64415 N BLOCK INJ, BRACHIAL PLEXUS 1.93 1.00
64416 N BLOCK CONT INFUSE, B PLEX 2.26 1.00
64417 N BLOCK INJ, AXILLARY 1.9 1.00
64418 N BLOCK INJ, SUPRASCAPULAR 1.96 1.00
64420 N BLOCK INJ, INTERCOST, SNG 1.77 1.00
64421 N BLOCK INJ, INTERCOST, MLT 2.45 1.00
64425 N BLOCK INJ, ILIO-ING/HYPOGI 2.52 1.00
64430 N BLOCK INJ, PUDENDAL 2.29 1.00
64435 N BLOCK INJ, PARACERVICAL 2.27 1.00
64445 N BLOCK INJ, SCIATIC, SNG 2.15 1.00
64446 N BLK INJ, SCIATIC, CONT INF 2.32 1.00
64447 N BLOCK INJ FEM, SINGLE 1.83 1.00
64448 N BLOCK INJ FEM, CONT INF 2.05 1.00
64449 N BLOCK INJ, LUMBAR PLEXUS 2.34 1.00
64450 N BLOCK, OTHER PERIPHERAL 1.86 1.00
64455 N BLOCK INJ, PLANTAR DIGIT 1.06 1.00
64479 INJ FORAMEN EPIDURAL C/T 3.35 1.00
64480 INJ FORAMEN EPIDURAL ADD-ON 2.21 1.00
64483 INJ FORAMEN EPIDURAL L/S 2.9 1.00
64484 INJ FORAMEN EPIDURAL ADD-ON 1.83 1.00

64490 INJ PARAVERT F JNT C/T 1 LEV 2.99 1.00
64491 INJ PARAVERT F JNT C/T 2 LEV 1.7 1.00
64492 INJ PARAVERT F JNT C/T 3 LEV 1.73 1.00
64493 INJ PARAVERT F JNT L/S 1 LEV 2.52 1.00
64494 INJ PARAVERT F JNT L/S 2 LEV 1.45 1.00
64495 INJ PARAVERT F JNT L/S 3 LEV 1.48 1.00
64505 N BLOCK, SPENOPALATINE GANGL 2.18 1.00
64508 N BLOCK, CAROTID SINUS S/P 1.98 1.00
64510 N BLOCK, STELLATE GANGLION 1.82 1.00
64517 N BLOCK INJ, HYPOGAS PLXS 3.2 1.00
64520 N BLOCK, LUMBAR/THORACIC 2.05 1.00
64530 N BLOCK INJ, CELIAC PELUS 2.41 1.00
64550 APPLY NEUROSTIMULATOR 0.24 1.00
64553 IMPLANT NEUROELECTRODES 4.28 1.00
64555 IMPLANT NEUROELECTRODES 4.04 1.00
64560 IMPLANT NEUROELECTRODES 4.08 1.00
64561 IMPLANT NEUROELECTRODES 11.32 1.00
64565 IMPLANT NEUROELECTRODES 3.25 1.00
64573 IMPLANT NEUROELECTRODES 15.68 1.00
64575 IMPLANT NEUROELECTRODES 7.36 1.00
64577 IMPLANT NEUROELECTRODES 9.9 1.00
64580 IMPLANT NEUROELECTRODES 7.99 1.00
64581 IMPLANT NEUROELECTRODES 21.88 1.00
64585 REVISE/REMOVE NEUROELECTRODE 4.14 1.00
64590 INSRT/REDO PN/GASTR STIMUL 4.62 1.00
64595 REVISE/RMV PN/GASTR STIMUL 3.63 1.00
64600 INJECTION TREATMENT OF NERVE 5.76 1.00
64605 INJECTION TREATMENT OF NERVE 8.86 1.00
64610 INJECTION TREATMENT OF NERVE 12.82 1.00
64612 DESTROY NERVE, FACE MUSCLE 3.99 1.00
64613 DESTROY NERVE, NECK MUSCLE 3.73 1.00
64614 DESTROY NERVE, EXTREM MUSC 3.95 1.00
64620 INJECTION TREATMENT OF NERVE 4.48 1.00
64622 DESTR PARAVERTEBRL NERVE L/S 4.77 1.00
64623 DESTR PARAVERTEBRAL N ADD-ON 1.33 1.00
64626 DESTR PARAVERTEBRL NERVE C/T 6.41 1.00
64627 DESTR PARAVERTEBRAL N ADD-ON 1.56 1.00
64630 INJECTION TREATMENT OF NERVE 5.06 1.00
64632 N BLOCK INJ, COMMON DIGIT 1.96 1.00
64640 INJECTION TREATMENT OF NERVE 4.55 1.00
64650 CHEMODENERV ECCRINE GLANDS 1.07 1.00
64653 CHEMODENERV ECCRINE GLANDS 1.41 1.00
64680 INJECTION TREATMENT OF NERVE 4.32 1.00
64681 INJECTION TREATMENT OF NERVE 5.46 1.00
64702 REVISE FINGER/TOE NERVE 12.37 1.00
64704 REVISE HAND/FOOT NERVE 8.59 1.00
64708 REVISE ARM/LEG NERVE 12.53 1.00
64712 REVISION OF SCIATIC NERVE 14.32 1.00
64713 REVISION OF ARM NERVE(S) 20.07 1.00
64714 REVISE LOW BACK NERVE(S) 17.46 1.00
64716 REVISION OF CRANIAL NERVE 13.84 1.00
64718 REVISE ULNAR NERVE AT ELBOW 14.97 1.00
64719 REVISE ULNAR NERVE AT WRIST 10.18 1.00

64721 CARPAL TUNNEL SURGERY 10.81 1.00
64722 RELIEVE PRESSURE ON NERVE(S) 8.91 1.00
64726 RELEASE FOOT/TOE NERVE 7.39 1.00
64727 INTERNAL NERVE REVISION 4.95 1.00
64732 INCISION OF BROW NERVE 10.61 1.00
64734 INCISION OF CHEEK NERVE 10.8 1.00
64736 INCISION OF CHIN NERVE 11.3 1.00
64738 INCISION OF JAW NERVE 13.05 1.00
64740 INCISION OF TONGUE NERVE 11.97 1.00
64742 INCISION OF FACIAL NERVE 12.39 1.00
64744 INCISE NERVE, BACK OF HEAD 11.59 1.00
64746 INCISE DIAPHRAGM NERVE 12.1 1.00
64752 INCISION OF VAGUS NERVE 13.42 1.00
64760 INCISION OF VAGUS NERVE 12.95 1.00
64761 INCISION OF PELVIS NERVE 11.91 1.00
64763 INCISE HIP/THIGH NERVE 14.18 1.00
64766 INCISE HIP/THIGH NERVE 15.9 1.00
64771 SEVER CRANIAL NERVE 14.94 1.00
64772 INCISION OF SPINAL NERVE 14.92 1.00
64774 REMOVE SKIN NERVE LESION 10.79 1.00
64776 REMOVE DIGIT NERVE LESION 10.18 1.00
64778 DIGIT NERVE SURGERY ADD-ON 4.95 1.00
64782 REMOVE LIMB NERVE LESION 11.96 1.00
64783 LIMB NERVE SURGERY ADD-ON 5.79 1.00
64784 REMOVE NERVE LESION 19.04 1.00
64786 REMOVE SCIATIC NERVE LESION 28.23 1.00
64787 IMPLANT NERVE END 6.66 1.00
64788 REMOVE SKIN NERVE LESION 10.2 1.00
64790 REMOVAL OF NERVE LESION 21.68 1.00
64792 REMOVAL OF NERVE LESION 30.01 1.00
64795 BIOPSY OF NERVE 5.21 1.00
64802 REMOVE SYMPATHETIC NERVES 15.84 1.00
64804 REMOVE SYMPATHETIC NERVES 22.25 1.00
64809 REMOVE SYMPATHETIC NERVES 21.05 1.00
64818 REMOVE SYMPATHETIC NERVES 17.74 1.00
64820 REMOVE SYMPATHETIC NERVES 19.71 1.00
64821 REMOVE SYMPATHETIC NERVES 17.95 1.00
64822 REMOVE SYMPATHETIC NERVES 17.76 1.00
64823 REMOVE SYMPATHETIC NERVES 20.16 1.00
64831 REPAIR OF DIGIT NERVE 17.62 1.00
64832 REPAIR NERVE ADD-ON 9.11 1.00
64834 REPAIR OF HAND OR FOOT NERVE 19.39 1.00
64835 REPAIR OF HAND OR FOOT NERVE 21.21 1.00
64836 REPAIR OF HAND OR FOOT NERVE 21.23 1.00
64837 REPAIR NERVE ADD-ON 9.89 1.00
64840 REPAIR OF LEG NERVE 22.39 1.00
64856 REPAIR/TRANSPOSE NERVE 26.67 1.00
64857 REPAIR ARM/LEG NERVE 27.84 1.00
64858 REPAIR SCIATIC NERVE 31.43 1.00
64859 NERVE SURGERY 6.85 1.00
64861 REPAIR OF ARM NERVES 35.66 1.00
64862 REPAIR OF LOW BACK NERVES 37.74 1.00
64864 REPAIR OF FACIAL NERVE 22.92 1.00

64865 REPAIR OF FACIAL NERVE 30.18 1.00
64866 FUSION OF FACIAL/OTHER NERVE 31.13 1.00
64868 FUSION OF FACIAL/OTHER NERVE 27.47 1.00
64870 FUSION OF FACIAL/OTHER NERVE 28.71 1.00
64872 SUBSEQUENT REPAIR OF NERVE 3.17 1.00
64874 REPAIR & REVISE NERVE ADD-ON 4.59 1.00
64876 REPAIR NERVE/SHORTEN BONE 5.34 1.00
64885 NERVE GRAFT, HEAD OR NECK 29.75 1.00
64886 NERVE GRAFT, HEAD OR NECK 35.27 1.00
64890 NERVE GRAFT, HAND OR FOOT 28.65 1.00
64891 NERVE GRAFT, HAND OR FOOT 30.25 1.00
64892 NERVE GRAFT, ARM OR LEG 27.76 1.00
64893 NERVE GRAFT, ARM OR LEG 29.35 1.00
64895 NERVE GRAFT, HAND OR FOOT 34.81 1.00
64896 NERVE GRAFT, HAND OR FOOT 40.98 1.00
64897 NERVE GRAFT, ARM OR LEG 33.52 1.00
64898 NERVE GRAFT, ARM OR LEG 36.49 1.00
64901 NERVE GRAFT ADD-ON 16.55 1.00
64902 NERVE GRAFT ADD-ON 19.07 1.00
64905 NERVE PEDICLE TRANSFER 27.06 1.00
64907 NERVE PEDICLE TRANSFER 32.01 1.00
64910 NERVE REPAIR W/ALLOGRAFT 21.4 1.00
64911 NEURORRAPHY W/VEIN AUTOGRAFT 26.41 1.00
65091 REVISE EYE 16.09 1.00
65093 REVISE EYE WITH IMPLANT 15.95 1.00
65101 REMOVAL OF EYE 18.6 1.00
65103 REMOVE EYE/INSERT IMPLANT 19.44 1.00
65105 REMOVE EYE/ATTACH IMPLANT 21.48 1.00
65110 REMOVAL OF EYE 30.43 1.00
65112 REMOVE EYE/REVISE SOCKET 35.62 1.00
65114 REMOVE EYE/REVISE SOCKET 37.32 1.00
65125 REVISE OCULAR IMPLANT 7.32 1.00
65130 INSERT OCULAR IMPLANT 18.44 1.00
65135 INSERT OCULAR IMPLANT 18.76 1.00
65140 ATTACH OCULAR IMPLANT 20 1.00
65150 REVISE OCULAR IMPLANT 14.06 1.00
65155 REINSERT OCULAR IMPLANT 21.52 1.00
65175 REMOVAL OF OCULAR IMPLANT 16.2 1.00
65205 REMOVE FOREIGN BODY FROM EYE 1.13 1.00
65210 REMOVE FOREIGN BODY FROM EYE 1.38 1.00
65220 REMOVE FOREIGN BODY FROM EYE 1.11 1.00
65222 REMOVE FOREIGN BODY FROM EYE 1.51 1.00
65235 REMOVE FOREIGN BODY FROM EYE 17.56 1.00
65260 REMOVE FOREIGN BODY FROM EYE 23.31 1.00
65265 REMOVE FOREIGN BODY FROM EYE 27.79 1.00
65270 REPAIR OF EYE WOUND 3.56 1.00
65272 REPAIR OF EYE WOUND 8.51 1.00
65273 REPAIR OF EYE WOUND 9.31 1.00
65275 REPAIR OF EYE WOUND 11.44 1.00
65280 REPAIR OF EYE WOUND 17.2 1.00
65285 REPAIR OF EYE WOUND 26.54 1.00
65286 REPAIR OF EYE WOUND 12.36 1.00
65290 REPAIR OF EYE SOCKET WOUND 12.58 1.00

65400 REMOVAL OF EYE LESION 14.91 1.00
65410 BIOPSY OF CORNEA 2.71 1.00
65420 REMOVAL OF EYE LESION 9.27 1.00
65426 REMOVAL OF EYE LESION 11.89 1.00
65430 CORNEAL SMEAR 2.64 1.00
65435 CURETTE/TREAT CORNEA 1.78 1.00
65436 CURETTE/TREAT CORNEA 9.38 1.00
65450 TREATMENT OF CORNEAL LESION 7.86 1.00
65600 REVISION OF CORNEA 8.45 1.00
65710 CORNEAL TRANSPLANT 27.65 1.00
65730 CORNEAL TRANSPLANT 30.73 1.00
65750 CORNEAL TRANSPLANT 30.96 1.00
65755 CORNEAL TRANSPLANT 30.89 1.00
65756 CORNEAL TRNSPL, ENDOTHELIAL 28.98 1.00
65767 CORNEAL TISSUE TRANSPLANT 5 1.00
65770 REVISE CORNEA WITH IMPLANT 38.73 1.00
65771 RADIAL KERATOTOMY 999.99 1.00
65772 CORRECTION OF ASTIGMATISM 10.03 1.00
65775 CORRECTION OF ASTIGMATISM 13.39 1.00
65780 OCULAR RECONST, TRANSPLANT 22 1.00
65781 OCULAR RECONST, TRANSPLANT 32.79 1.00
65782 OCULAR RECONST, TRANSPLANT 29.7 1.00
65800 DRAINAGE OF EYE 3.33 1.00
65805 DRAINAGE OF EYE 3.39 1.00
65810 DRAINAGE OF EYE 11.7 1.00
65815 DRAINAGE OF EYE 12 1.00
65820 RELIEVE INNER EYE PRESSURE 18.16 1.00
65850 INCISION OF EYE 21.46 1.00
65855 LASER SURGERY OF EYE 7.55 1.00
65860 INCISE INNER EYE ADHESIONS 7.05 1.00
65865 INCISE INNER EYE ADHESIONS 11.51 1.00
65870 INCISE INNER EYE ADHESIONS 14.9 1.00
65875 INCISE INNER EYE ADHESIONS 15.64 1.00
65880 INCISE INNER EYE ADHESIONS 16.07 1.00
65900 REMOVE EYE LESION 23.5 1.00
65920 REMOVE IMPLANT OF EYE 19.53 1.00
65930 REMOVE BLOOD CLOT FROM EYE 16.26 1.00
66020 INJECTION TREATMENT OF EYE 3.19 1.00
66030 INJECTION TREATMENT OF EYE 2.74 1.00
66130 REMOVE EYE LESION 14.8 1.00
66150 GLAUCOMA SURGERY 21.07 1.00
66155 GLAUCOMA SURGERY 21.05 1.00
66160 GLAUCOMA SURGERY 23.88 1.00
66165 GLAUCOMA SURGERY 20.63 1.00
66170 GLAUCOMA SURGERY 29.6 1.00
66172 INCISION OF EYE 37.27 1.00
66180 IMPLANT EYE SHUNT 29.28 1.00
66185 REVISE EYE SHUNT 18.86 1.00
66220 REPAIR EYE LESION 18.22 1.00
66225 REPAIR/GRAFT EYE LESION 23.89 1.00
66250 FOLLOW-UP SURGERY OF EYE 14.12 1.00
66500 INCISION OF IRIS 8.51 1.00
66505 INCISION OF IRIS 9.32 1.00

66600 REMOVE IRIS AND LESION 19.97 1.00
66605 REMOVAL OF IRIS 25.71 1.00
66625 REMOVAL OF IRIS 10.66 1.00
66630 REMOVAL OF IRIS 14.31 1.00
66635 REMOVAL OF IRIS 13.92 1.00
66680 REPAIR IRIS & CILIARY BODY 13.12 1.00
66700 DESTRUCTION, CILIARY BODY 9.66 1.00
66710 CILIARY TRANSSLERAL THERAPY 10.03 1.00
66711 CILIARY ENDOSCOPIC ABLATION 15.47 1.00
66720 DESTRUCTION, CILIARY BODY 10.37 1.00
66740 DESTRUCTION, CILIARY BODY 9.58 1.00
66761 REVISION OF IRIS 10.29 1.00
66762 REVISION OF IRIS 10.52 1.00
66770 REMOVAL OF INNER EYE LESION 11.68 1.00
66820 INCISION, SECONDARY CATARACT 9.79 1.00
66821 AFTER CATARACT LASER SURGERY 7.63 1.00
66825 REPOSITION INTRAOCULAR LENS 18.8 1.00
66830 REMOVAL OF LENS LESION 17.36 1.00
66840 REMOVAL OF LENS MATERIAL 17.76 1.00
66850 REMOVAL OF LENS MATERIAL 19.82 1.00
66852 REMOVAL OF LENS MATERIAL 21.49 1.00
66920 EXTRACTION OF LENS 18.39 1.00
66930 EXTRACTION OF LENS 20.91 1.00
66940 EXTRACTION OF LENS 19.77 1.00
66982 CATARACT SURGERY, COMPLEX 26.93 1.00
66983 CATARACT SURG W/IOL, 1 STAGE 18.29 1.00
66984 CATARACT SURG W/IOL, 1 STAGE 19.36 1.00
66985 INSERT LENS PROSTHESIS 19.09 1.00
66986 EXCHANGE LENS PROSTHESIS 22.83 1.00
66990 OPHTHALMIC ENDOSCOPE ADD-ON 2.28 1.00
67005 PARTIAL REMOVAL OF EYE FLUID 12.02 1.00
67010 PARTIAL REMOVAL OF EYE FLUID 13.53 1.00
67015 RELEASE OF EYE FLUID 14.42 1.00
67025 REPLACE EYE FLUID 15.93 1.00
67027 IMPLANT EYE DRUG SYSTEM 21.69 1.00
67028 INJECTION EYE DRUG 4.3 1.00
67030 INCISE INNER EYE STRANDS 12.71 1.00
67031 LASER SURGERY, EYE STRANDS 8.81 1.00
67036 REMOVAL OF INNER EYE FLUID 24.18 1.00
67039 LASER TREATMENT OF RETINA 31.51 1.00
67040 LASER TREATMENT OF RETINA 35.77 1.00
67041 VIT FOR MACULAR PUCKER 33.43 1.00
67042 VIT FOR MACULAR HOLE 38.29 1.00
67043 VIT FOR MEMBRANE DISSECT 40.86 1.00
67101 REPAIR DETACHED RETINA 17.03 1.00
67105 REPAIR DETACHED RETINA 16.07 1.00
67107 REPAIR DETACHED RETINA 31 1.00
67108 REPAIR DETACHED RETINA 40.55 1.00
67110 REPAIR DETACHED RETINA 19.24 1.00
67112 REREPAIR DETACHED RETINA 33.42 1.00
67113 REPAIR RETINAL DETACH, CPLX 44.03 1.00
67115 RELEASE ENCIRCLING MATERIAL 12.26 1.00
67120 REMOVE EYE IMPLANT MATERIAL 14.16 1.00

67121 REMOVE EYE IMPLANT MATERIAL 23.08 1.00
67141 TREATMENT OF RETINA 12.25 1.00
67145 TREATMENT OF RETINA 12.33 1.00
67208 TREATMENT OF RETINAL LESION 14.04 1.00
67210 TREATMENT OF RETINAL LESION 16.88 1.00
67218 TREATMENT OF RETINAL LESION 34.2 1.00
67220 TREATMENT OF CHOROID LESION 25.92 1.00
67221 OCULAR PHOTODYNAMIC THER 5.56 1.00
67225 EYE PHOTODYNAMIC THER ADD-ON 0.71 1.00
67227 TREATMENT OF RETINAL LESION 13.87 1.00
67228 TREATMENT OF RETINAL LESION 26.58 1.00
67229 TR RETINAL LES PRETERM INF 28.21 1.00
67250 REINFORCE EYE WALL 19.71 1.00
67255 REINFORCE/GRAFT EYE WALL 21.36 1.00
67311 REVISE EYE MUSCLE 15.09 1.00
67312 REVISE TWO EYE MUSCLES 18.27 1.00
67314 REVISE EYE MUSCLE 16.96 1.00
67316 REVISE TWO EYE MUSCLES 20.51 1.00
67318 REVISE EYE MUSCLE(S) 17.08 1.00
67320 REVISE EYE MUSCLE(S) ADD-ON 8.07 1.00
67331 EYE SURGERY FOLLOW-UP ADD-ON 8.01 1.00
67332 REREVISE EYE MUSCLES ADD-ON 8.7 1.00
67334 REVISE EYE MUSCLE W/SUTURE 7.55 1.00
67335 EYE SUTURE DURING SURGERY 3.93 1.00
67340 REVISE EYE MUSCLE ADD-ON 8.98 1.00
67343 RELEASE EYE TISSUE 16.62 1.00
67345 DESTROY NERVE OF EYE MUSCLE 5.61 1.00
67346 BIOPSY, EYE MUSCLE 5.26 1.00
67400 EXPLORE/BIOPSY EYE SOCKET 23.59 1.00
67405 EXPLORE/DRAIN EYE SOCKET 19.67 1.00
67412 EXPLORE/TREAT EYE SOCKET 21.69 1.00
67413 EXPLORE/TREAT EYE SOCKET 21.84 1.00
67414 EXPLR/DECOMPRESS EYE SOCKET 33.03 1.00
67415 ASPIRATION, ORBITAL CONTENTS 2.73 1.00
67420 EXPLORE/TREAT EYE SOCKET 41.88 1.00
67430 EXPLORE/TREAT EYE SOCKET 30.4 1.00
67440 EXPLORE/DRAIN EYE SOCKET 30.02 1.00
67445 EXPLR/DECOMPRESS EYE SOCKET 36.16 1.00
67450 EXPLORE/BIOPSY EYE SOCKET 31.19 1.00
67500 INJECT/TREAT EYE SOCKET 2.02 1.00
67505 INJECT/TREAT EYE SOCKET 2.09 1.00
67515 INJECT/TREAT EYE SOCKET 2.28 1.00
67550 INSERT EYE SOCKET IMPLANT 24.61 1.00
67560 REVISE EYE SOCKET IMPLANT 24.58 1.00
67570 DECOMPRESS OPTIC NERVE 31.13 1.00
67700 DRAINAGE OF EYELID ABSCESS 2.89 1.00
67710 INCISION OF EYELID 2.44 1.00
67715 INCISION OF EYELID FOLD 2.76 1.00
67800 REMOVE EYELID LESION 2.65 1.00
67801 REMOVE EYELID LESIONS 3.47 1.00
67805 REMOVE EYELID LESIONS 4.26 1.00
67808 REMOVE EYELID LESION(S) 9.33 1.00
67810 BIOPSY OF EYELID 2.41 1.00

67820 REVISE EYELASHES 1.36 1.00
67825 REVISE EYELASHES 3.06 1.00
67830 REVISE EYELASHES 3.52 1.00
67835 REVISE EYELASHES 11.25 1.00
67840 REMOVE EYELID LESION 4.02 1.00
67850 TREAT EYELID LESION 3.53 1.00
67875 CLOSURE OF EYELID BY SUTURE 2.5 1.00
67880 REVISION OF EYELID 9.27 1.00
67882 REVISION OF EYELID 12.01 1.00
67900 REPAIR BROW DEFECT 13.06 1.00
67901 REPAIR EYELID DEFECT 14.69 1.00
67902 REPAIR EYELID DEFECT 18.34 1.00
67903 REPAIR EYELID DEFECT 12.58 1.00
67904 REPAIR EYELID DEFECT 15.18 1.00
67906 REPAIR EYELID DEFECT 12.5 1.00
67908 REPAIR EYELID DEFECT 10.95 1.00
67909 REVISE EYELID DEFECT 11.24 1.00
67911 REVISE EYELID DEFECT 14.23 1.00
67912 CORRECTION EYELID W/IMPLANT 12.48 1.00
67914 REPAIR EYELID DEFECT 7.36 1.00
67915 REPAIR EYELID DEFECT 6.39 1.00
67916 REPAIR EYELID DEFECT 10.97 1.00
67917 REPAIR EYELID DEFECT 12.16 1.00
67921 REPAIR EYELID DEFECT 6.93 1.00
67922 REPAIR EYELID DEFECT 6.15 1.00
67923 REPAIR EYELID DEFECT 11.91 1.00
67924 REPAIR EYELID DEFECT 11.51 1.00
67930 REPAIR EYELID WOUND 6.35 1.00
67935 REPAIR EYELID WOUND 11.58 1.00
67938 REMOVE EYELID FOREIGN BODY 2.9 1.00
67950 REVISION OF EYELID 11.89 1.00
67961 REVISION OF EYELID 11.66 1.00
67966 REVISION OF EYELID 16.75 1.00
67971 RECONSTRUCTION OF EYELID 18.76 1.00
67973 RECONSTRUCTION OF EYELID 24.27 1.00
67974 RECONSTRUCTION OF EYELID 24.19 1.00
67975 RECONSTRUCTION OF EYELID 17.72 1.00
68020 INCISE/DRAIN EYELID LINING 2.78 1.00
68040 TREATMENT OF EYELID LESIONS 1.4 1.00
68100 BIOPSY OF EYELID LINING 2.49 1.00
68110 REMOVE EYELID LINING LESION 3.77 1.00
68115 REMOVE EYELID LINING LESION 4.59 1.00
68130 REMOVE EYELID LINING LESION 10.01 1.00
68135 REMOVE EYELID LINING LESION 3.77 1.00
68200 TREAT EYELID BY INJECTION 0.89 1.00
68320 REVISE/GRAFT EYELID LINING 13.6 1.00
68325 REVISE/GRAFT EYELID LINING 16.82 1.00
68326 REVISE/GRAFT EYELID LINING 16.45 1.00
68328 REVISE/GRAFT EYELID LINING 18.24 1.00
68330 REVISE EYELID LINING 11.69 1.00
68335 REVISE/GRAFT EYELID LINING 16.52 1.00
68340 SEPARATE EYELID ADHESIONS 10.11 1.00
68360 REVISE EYELID LINING 10.43 1.00

68362 REVISE EYELID LINING 16.73 1.00
68371 HARVEST EYE TISSUE, ALOGRAFT 10.05 1.00
68400 INCISE/DRAIN TEAR GLAND 3.47 1.00
68420 INCISE/DRAIN TEAR SAC 4.34 1.00
68440 INCISE TEAR DUCT OPENING 2.45 1.00
68500 REMOVAL OF TEAR GLAND 25.26 1.00
68505 PARTIAL REMOVAL, TEAR GLAND 24.95 1.00
68510 BIOPSY OF TEAR GLAND 7.69 1.00
68520 REMOVAL OF TEAR SAC 17.15 1.00
68525 BIOPSY OF TEAR SAC 7.08 1.00
68530 CLEARANCE OF TEAR DUCT 6.75 1.00
68540 REMOVE TEAR GLAND LESION 23.17 1.00
68550 REMOVE TEAR GLAND LESION 28 1.00
68700 REPAIR TEAR DUCTS 15.41 1.00
68705 REVISE TEAR DUCT OPENING 4.24 1.00
68720 CREATE TEAR SAC DRAIN 19.19 1.00
68745 CREATE TEAR DUCT DRAIN 19.47 1.00
68750 CREATE TEAR DUCT DRAIN 20.09 1.00
68760 CLOSE TEAR DUCT OPENING 3.7 1.00
68761 CLOSE TEAR DUCT OPENING 2.97 1.00
68770 CLOSE TEAR SYSTEM FISTULA 15.49 1.00
68801 DILATE TEAR DUCT OPENING 2.65 1.00
68810 PROBE NASOLACRIMAL DUCT 4.78 1.00
68811 PROBE NASOLACRIMAL DUCT 5.23 1.00
68815 PROBE NASOLACRIMAL DUCT 6.55 1.00
68816 PROBE NL DUCT W/BALLOON 6.33 1.00
68840 EXPLORE/IRRIGATE TEAR DUCTS 2.86 1.00
68850 INJECTION FOR TEAR SAC X-RAY 1.5 1.00
70010 CONTRAST X-RAY OF BRAIN 4.46 1.00
70015 CONTRAST X-RAY OF BRAIN 3.88 1.00
70030 X-RAY EYE FOR FOREIGN BODY 0.76 1.00
70100 X-RAY EXAM OF JAW 0.83 1.00
70110 X-RAY EXAM OF JAW 1.05 1.00
70120 X-RAY EXAM OF MASTOIDS 0.9 1.00
70130 X-RAY EXAM OF MASTOIDS 1.46 1.00
70134 X-RAY EXAM OF MIDDLE EAR 1.23 1.00
70140 X-RAY EXAM OF FACIAL BONES 0.78 1.00
70150 X-RAY EXAM OF FACIAL BONES 1.12 1.00
70160 X-RAY EXAM OF NASAL BONES 0.86 1.00
70190 X-RAY EXAM OF EYE SOCKETS 0.94 1.00
70200 X-RAY EXAM OF EYE SOCKETS 1.16 1.00
70210 X-RAY EXAM OF SINUSES 0.8 1.00
70220 X-RAY EXAM OF SINUSES 1.03 1.00
70240 X-RAY EXAM, PITUITARY SADDLE 0.79 1.00
70250 X-RAY EXAM OF SKULL 0.96 1.00
70260 X-RAY EXAM OF SKULL 1.25 1.00
70300 X-RAY EXAM OF TEETH 0.38 1.00
70310 X-RAY EXAM OF TEETH 0.95 1.00
70320 FULL MOUTH X-RAY OF TEETH 1.29 1.00
70328 X-RAY EXAM OF JAW JOINT 0.8 1.00
70330 X-RAY EXAM OF JAW JOINTS 1.25 1.00
70332 X-RAY EXAM OF JAW JOINT 2.23 1.00
70336 MAGNETIC IMAGE, JAW JOINT 12.27 1.00

70350 X-RAY HEAD FOR ORTHODONTIA 0.56 1.00
70355 PANORAMIC X-RAY OF JAWS 0.59 1.00
70360 X-RAY EXAM OF NECK 0.73 1.00
70370 THROAT X-RAY & FLUOROSCOPY 2.02 1.00
70371 SPEECH EVALUATION, COMPLEX 2.53 1.00
70373 CONTRAST X-RAY OF LARYNX 2.12 1.00
70380 X-RAY EXAM OF SALIVARY GLAND 1 1.00
70390 X-RAY EXAM OF SALIVARY DUCT 2.62 1.00
70450 CT HEAD/BRAIN W/O DYE 5.33 1.00
70460 CT HEAD/BRAIN W/DYE 6.93 1.00
70470 CT HEAD/BRAIN W/O & W/DYE 8.37 1.00
70480 CT ORBIT/EAR/FOSSA W/O DYE 8.33 1.00
70481 CT ORBIT/EAR/FOSSA W/DYE 9.66 1.00
70482 CT ORBIT/EAR/FOSSA W/O&W/DYE 11.01 1.00
70486 CT MAXILLOFACIAL W/O DYE 6.99 1.00
70487 CT MAXILLOFACIAL W/DYE 8.43 1.00
70488 CT MAXILLOFACIAL W/O & W/DYE 10.25 1.00
70490 CT SOFT TISSUE NECK W/O DYE 6.92 1.00
70491 CT SOFT TISSUE NECK W/DYE 8.29 1.00
70492 CT SFT TSUE NCK W/O & W/DYE 10.03 1.00
70496 CT ANGIOGRAPHY, HEAD 17.41 1.00
70498 CT ANGIOGRAPHY, NECK 17.43 1.00
70540 MRI ORBIT/FACE/NECK W/O DYE 13.49 1.00
70542 MRI ORBIT/FACE/NECK W/DYE 14.99 1.00
70543 MRI ORBT/FAC/NCK W/O & W/DYE 20.21 1.00
70544 MR ANGIOGRAPHY HEAD W/O DYE 15.94 1.00
70545 MR ANGIOGRAPHY HEAD W/DYE 15.85 1.00
70546 MR ANGIOGRAPH HEAD W/O&W/DYE 25.18 1.00
70547 MR ANGIOGRAPHY NECK W/O DYE 15.9 1.00
70548 MR ANGIOGRAPHY NECK W/DYE 16.6 1.00
70549 MR ANGIOGRAPH NECK W/O&W/DYE 25.17 1.00
70551 MRI BRAIN W/O DYE 13.87 1.00
70552 MRI BRAIN W/DYE 15.5 1.00
70553 MRI BRAIN W/O & W/DYE 20.04 1.00
70554 FMRI BRAIN BY TECH 15.25 1.00
71010 CHEST X-RAY 0.64 1.00
71015 CHEST X-RAY 0.8 1.00
71020 CHEST X-RAY 0.84 1.00
71021 CHEST X-RAY 1.01 1.00
71022 CHEST X-RAY 1.23 1.00
71023 CHEST X-RAY AND FLUOROSCOPY 1.8 1.00
71030 CHEST X-RAY 1.23 1.00
71034 CHEST X-RAY AND FLUOROSCOPY 2.38 1.00
71035 CHEST X-RAY 0.93 1.00
71040 CONTRAST X-RAY OF BRONCHI 2.53 1.00
71060 CONTRAST X-RAY OF BRONCHI 3.72 1.00
71100 X-RAY EXAM OF RIBS 0.87 1.00
71101 X-RAY EXAM OF RIBS/CHEST 1.04 1.00
71110 X-RAY EXAM OF RIBS 1.07 1.00
71111 X-RAY EXAM OF RIBS/CHEST 1.38 1.00
71120 X-RAY EXAM OF BREASTBONE 0.86 1.00
71130 X-RAY EXAM OF BREASTBONE 0.99 1.00
71250 CT THORAX W/O DYE 6.99 1.00

71260 CT THORAX W/DYE 8.38 1.00
71270 CT THORAX W/O & W/DYE 10.31 1.00
71275 CT ANGIOGRAPHY, CHEST 13.72 1.00
71550 MRI CHEST W/O DYE 15.11 1.00
71551 MRI CHEST W/DYE 16.97 1.00
71552 MRI CHEST W/O & W/DYE 22.94 1.00
71555 MRI ANGIO CHEST W OR W/O DYE 16.09 1.00
72010 X-RAY EXAM OF SPINE 1.89 1.00
72020 X-RAY EXAM OF SPINE 0.64 1.00
72040 X-RAY EXAM OF NECK SPINE 1 1.00
72050 X-RAY EXAM OF NECK SPINE 1.39 1.00
72052 X-RAY EXAM OF NECK SPINE 1.74 1.00
72069 X-RAY EXAM OF TRUNK SPINE 0.96 1.00
72070 X-RAY EXAM OF THORACIC SPINE 0.89 1.00
72072 X-RAY EXAM OF THORACIC SPINE 1.01 1.00
72074 X-RAY EXAM OF THORACIC SPINE 1.18 1.00
72080 X-RAY EXAM OF TRUNK SPINE 0.95 1.00
72090 X-RAY EXAM OF TRUNK SPINE 1.28 1.00
72100 X-RAY EXAM OF LOWER SPINE 1.05 1.00
72110 X-RAY EXAM OF LOWER SPINE 1.44 1.00
72114 X-RAY EXAM OF LOWER SPINE 1.91 1.00
72120 X-RAY EXAM OF LOWER SPINE 1.31 1.00
72125 CT NECK SPINE W/O DYE 7.01 1.00
72126 CT NECK SPINE W/DYE 8.37 1.00
72127 CT NECK SPINE W/O & W/DYE 10.14 1.00
72128 CT CHEST SPINE W/O DYE 6.99 1.00
72129 CT CHEST SPINE W/DYE 8.37 1.00
72130 CT CHEST SPINE W/O & W/DYE 10.18 1.00
72131 CT LUMBAR SPINE W/O DYE 6.98 1.00
72132 CT LUMBAR SPINE W/DYE 8.35 1.00
72133 CT LUMBAR SPINE W/O & W/DYE 10.16 1.00
72141 MRI NECK SPINE W/O DYE 12.63 1.00
72142 MRI NECK SPINE W/DYE 15.68 1.00
72146 MRI CHEST SPINE W/O DYE 12.88 1.00
72147 MRI CHEST SPINE W/DYE 14.25 1.00
72148 MRI LUMBAR SPINE W/O DYE 12.71 1.00
72149 MRI LUMBAR SPINE W/DYE 15.46 1.00
72156 MRI NECK SPINE W/O & W/DYE 20.09 1.00
72157 MRI CHEST SPINE W/O & W/DYE 19 1.00
72158 MRI LUMBAR SPINE W/O & W/DYE 19.78 1.00
72159 MR ANGIO SPINE W/O&W/DYE 17.6 1.00
72170 X-RAY EXAM OF PELVIS 0.71 1.00
72190 X-RAY EXAM OF PELVIS 1.07 1.00
72191 CT ANGIOGRAPH PELV W/O&W/DYE 13.23 1.00
72192 CT PELVIS W/O DYE 6.61 1.00
72193 CT PELVIS W/DYE 7.94 1.00
72194 CT PELVIS W/O & W/DYE 10.12 1.00
72195 MRI PELVIS W/O DYE 13.82 1.00
72196 MRI PELVIS W/DYE 15.31 1.00
72197 MRI PELVIS W/O & W/DYE 20.49 1.00
72198 MR ANGIO PELVIS W/O & W/DYE 16.01 1.00
72200 X-RAY EXAM SACROILIAC JOINTS 0.78 1.00
72202 X-RAY EXAM SACROILIAC JOINTS 0.92 1.00

72220 X-RAY EXAM OF TAILBONE 0.77 1.00
72240 CONTRAST X-RAY OF NECK SPINE 3.97 1.00
72255 CONTRAST X-RAY, THORAX SPINE 3.68 1.00
72265 CONTRAST X-RAY, LOWER SPINE 3.73 1.00
72270 CONTRAST X-RAY, SPINE 5.82 1.00
72275 EPIDUROGRAPHY 2.79 1.00
72285 X-RAY C/T SPINE DISK 4.2 1.00
72295 X-RAY OF LOWER SPINE DISK 3.69 1.00
73000 X-RAY EXAM OF COLLAR BONE 0.74 1.00
73010 X-RAY EXAM OF SHOULDER BLADE 0.78 1.00
73020 X-RAY EXAM OF SHOULDER 0.63 1.00
73030 X-RAY EXAM OF SHOULDER 0.8 1.00
73040 CONTRAST X-RAY OF SHOULDER 2.82 1.00
73050 X-RAY EXAM OF SHOULDERS 0.98 1.00
73060 X-RAY EXAM OF HUMERUS 0.77 1.00
73070 X-RAY EXAM OF ELBOW 0.73 1.00
73080 X-RAY EXAM OF ELBOW 0.92 1.00
73085 CONTRAST X-RAY OF ELBOW 2.53 1.00
73090 X-RAY EXAM OF FOREARM 0.73 1.00
73092 X-RAY EXAM OF ARM, INFANT 0.76 1.00
73100 X-RAY EXAM OF WRIST 0.79 1.00
73110 X-RAY EXAM OF WRIST 0.93 1.00
73115 CONTRAST X-RAY OF WRIST 2.76 1.00
73120 X-RAY EXAM OF HAND 0.72 1.00
73130 X-RAY EXAM OF HAND 0.83 1.00
73140 X-RAY EXAM OF FINGER(S) 0.79 1.00
73200 CT UPPER EXTREMITY W/O DYE 6.69 1.00
73201 CT UPPER EXTREMITY W/DYE 8.01 1.00
73202 CT UPPR EXTREMITY W/O&W/DYE 10.24 1.00
73206 CT ANGIO UPR EXTRM W/O&W/DYE 12.62 1.00
73218 MRI UPPER EXTREMITY W/O DYE 13.81 1.00
73219 MRI UPPER EXTREMITY W/DYE 15.19 1.00
73220 MRI UPPR EXTREMITY W/O&W/DYE 20.43 1.00
73221 MRI JOINT UPR EXTREM W/O DYE 13.09 1.00
73222 MRI JOINT UPR EXTREM W/DYE 14.4 1.00
73223 MRI JOINT UPR EXTR W/O&W/DYE 19.48 1.00
73225 MR ANGIO UPR EXTR W/O&W/DYE 17.27 1.00
73500 X-RAY EXAM OF HIP 0.69 1.00
73510 X-RAY EXAM OF HIP 0.99 1.00
73520 X-RAY EXAM OF HIPS 1.06 1.00
73525 CONTRAST X-RAY OF HIP 2.57 1.00
73540 X-RAY EXAM OF PELVIS & HIPS 1.03 1.00
73542 X-RAY EXAM, SACROILIAC JOINT 2.11 1.00
73550 X-RAY EXAM OF THIGH 0.75 1.00
73560 X-RAY EXAM OF KNEE, 1 OR 2 0.78 1.00
73562 X-RAY EXAM OF KNEE, 3 0.93 1.00
73564 X-RAY EXAM, KNEE, 4 OR MORE 1.08 1.00
73565 X-RAY EXAM OF KNEES 0.85 1.00
73580 CONTRAST X-RAY OF KNEE JOINT 3.29 1.00
73590 X-RAY EXAM OF LOWER LEG 0.73 1.00
73592 X-RAY EXAM OF LEG, INFANT 0.77 1.00
73600 X-RAY EXAM OF ANKLE 0.73 1.00
73610 X-RAY EXAM OF ANKLE 0.84 1.00

73615 CONTRAST X-RAY OF ANKLE 2.66 1.00
73620 X-RAY EXAM OF FOOT 0.71 1.00
73630 X-RAY EXAM OF FOOT 0.83 1.00
73650 X-RAY EXAM OF HEEL 0.72 1.00
73660 X-RAY EXAM OF TOE(S) 0.74 1.00
73700 CT LOWER EXTREMITY W/O DYE 6.7 1.00
73701 CT LOWER EXTREMITY W/DYE 8.07 1.00
73702 CT LWR EXTREMITY W/O&W/DYE 10.26 1.00
73706 CT ANGIO LWR EXTR W/O&W/DYE 13.82 1.00
73718 MRI LOWER EXTREMITY W/O DYE 13.59 1.00
73719 MRI LOWER EXTREMITY W/DYE 15.03 1.00
73720 MRI LWR EXTREMITY W/O&W/DYE 20.43 1.00
73721 MRI JNT OF LWR EXTRE W/O DYE 13.33 1.00
73722 MRI JOINT OF LWR EXTR W/DYE 14.55 1.00
73723 MRI JOINT LWR EXTR W/O&W/DYE 19.44 1.00
73725 MR ANG LWR EXT W OR W/O DYE 16.04 1.00
74000 X-RAY EXAM OF ABDOMEN 0.68 1.00
74010 X-RAY EXAM OF ABDOMEN 1 1.00
74020 X-RAY EXAM OF ABDOMEN 1.07 1.00
74022 X-RAY EXAM SERIES, ABDOMEN 1.28 1.00
74150 CT ABDOMEN W/O DYE 6.7 1.00
74160 CT ABDOMEN W/DYE 8.95 1.00
74170 CT ABDOMEN W/O & W/DYE 11.77 1.00
74175 CT ANGIO ABDOM W/O & W/DYE 14.05 1.00
74181 MRI ABDOMEN W/O DYE 12.45 1.00
74182 MRI ABDOMEN W/DYE 16.65 1.00
74183 MRI ABDOMEN W/O & W/DYE 20.51 1.00
74185 MRI ANGIO, ABDOM W ORW/O DYE 15.97 1.00
74210 CONTRST X-RAY EXAM OF THROAT 2.03 1.00
74220 CONTRAST X-RAY, ESOPHAGUS 2.35 1.00
74230 CINE/VID X-RAY, THROAT/ESOPH 2.38 1.00
74240 X-RAY EXAM, UPPER GI TRACT 2.88 1.00
74241 X-RAY EXAM, UPPER GI TRACT 3.07 1.00
74245 X-RAY EXAM, UPPER GI TRACT 4.6 1.00
74246 CONTRST X-RAY UPPR GI TRACT 3.29 1.00
74247 CONTRST X-RAY UPPR GI TRACT 3.63 1.00
74249 CONTRST X-RAY UPPR GI TRACT 4.94 1.00
74250 X-RAY EXAM OF SMALL BOWEL 2.74 1.00
74251 X-RAY EXAM OF SMALL BOWEL 8.91 1.00
74260 X-RAY EXAM OF SMALL BOWEL 7.4 1.00
74261 CT COLONOGRAPHY, W/O DYE 11.28 1.00
74262 CT COLONOGRAPHY, W/DYE 12.67 1.00
74263 CT COLONOGRAPHY, SCREEN 19.42 1.00
74270 CONTRAST X-RAY EXAM OF COLON 3.92 1.00
74280 CONTRAST X-RAY EXAM OF COLON 5.44 1.00
74283 CONTRAST X-RAY EXAM OF COLON 5.49 1.00
74290 CONTRAST X-RAY, GALLBLADDER 1.76 1.00
74291 CONTRAST X-RAYS, GALLBLADDER 1.57 1.00
74301 X-RAYS AT SURGERY ADD-ON 0.31 1.00
74320 CONTRAST X-RAY OF BILE DUCTS 2.91 1.00
74327 X-RAY BILE STONE REMOVAL 3.55 1.00
74400 CONTRST X-RAY, URINARY TRACT 2.9 1.00
74410 CONTRST X-RAY, URINARY TRACT 3.02 1.00

74415 CONTRST X-RAY, URINARY TRACT 3.51 1.00
74430 CONTRAST X-RAY, BLADDER 2.1 1.00
74440 X-RAY, MALE GENITAL TRACT 2.26 1.00
74455 X-RAY, URETHRA/BLADDER 2.37 1.00
74475 X-RAY CONTROL, CATH INSERT 3.07 1.00
74480 X-RAY CONTROL, CATH INSERT 3.08 1.00
74485 X-RAY GUIDE, GU DILATION 2.99 1.00
74710 X-RAY MEASUREMENT OF PELVIS 1.11 1.00
74740 X-RAY, FEMALE GENITAL TRACT 2.07 1.00
75557 CARDIAC MRI FOR MORPH 12.3 1.00
75559 CARDIAC MRI W/STRESS IMG 18.04 1.00
75561 CARDIAC MRI FOR MORPH W/DYE 16.65 1.00
75563 CARD MRI W/STRESS IMG & DYE 20.49 1.00
75565 CARD MRI VEL FLW MAP ADD-ON 2.53 1.00
75572 CT HRT W/3D IMAGE 8.43 1.00
75573 CT HRT W/3D IMAGE, CONGEN 12.2 1.00
75574 CT ANGIO HRT W/3D IMAGE 18.83 1.00
75600 CONTRAST X-RAY EXAM OF AORTA 7.65 1.00
75605 CONTRAST X-RAY EXAM OF AORTA 6.34 1.00
75625 CONTRAST X-RAY EXAM OF AORTA 6.3 1.00
75630 X-RAY AORTA, LEG ARTERIES 7.35 1.00
75635 CT ANGIO ABDOMINAL ARTERIES 15.75 1.00
75650 ARTERY X-RAYS, HEAD & NECK 6.81 1.00
75658 ARTERY X-RAYS, ARM 6.83 1.00
75660 ARTERY X-RAYS, HEAD & NECK 6.91 1.00
75662 ARTERY X-RAYS, HEAD & NECK 8.07 1.00
75665 ARTERY X-RAYS, HEAD & NECK 7.15 1.00
75671 ARTERY X-RAYS, HEAD & NECK 8.25 1.00
75676 ARTERY X-RAYS, NECK 6.94 1.00
75680 ARTERY X-RAYS, NECK 7.83 1.00
75685 ARTERY X-RAYS, SPINE 6.94 1.00
75705 ARTERY X-RAYS, SPINE 8.11 1.00
75710 ARTERY X-RAYS, ARM/LEG 6.72 1.00
75716 ARTERY X-RAYS, ARMS/LEGS 7.66 1.00
75722 ARTERY X-RAYS, KIDNEY 6.59 1.00
75724 ARTERY X-RAYS, KIDNEYS 7.78 1.00
75726 ARTERY X-RAYS, ABDOMEN 6.66 1.00
75731 ARTERY X-RAYS, ADRENAL GLAND 6.77 1.00
75733 ARTERY X-RAYS, ADRENALS 7.83 1.00
75736 ARTERY X-RAYS, PELVIS 6.67 1.00
75741 ARTERY X-RAYS, LUNG 6.38 1.00
75743 ARTERY X-RAYS, LUNGS 7.1 1.00
75746 ARTERY X-RAYS, LUNG 6.47 1.00
75756 ARTERY X-RAYS, CHEST 6.98 1.00
75774 ARTERY X-RAY, EACH VESSEL 4.75 1.00
75791 AV DIALYSIS SHUNT IMAGING 8.44 1.00
75809 NONVASCULAR SHUNT, X-RAY 2.42 1.00
75820 VEIN X-RAY, ARM/LEG 3.26 1.00
75822 VEIN X-RAY, ARMS/LEGS 3.99 1.00
75825 VEIN X-RAY, TRUNK 6.04 1.00
75827 VEIN X-RAY, CHEST 6.06 1.00
75831 VEIN X-RAY, KIDNEY 6.25 1.00
75833 VEIN X-RAY, KIDNEYS 6.97 1.00

75840 VEIN X-RAY, ADRENAL GLAND 6.16 1.00
75842 VEIN X-RAY, ADRENAL GLANDS 6.99 1.00
75860 VEIN X-RAY, NECK 6.24 1.00
75870 VEIN X-RAY, SKULL 6.23 1.00
75872 VEIN X-RAY, SKULL 7.43 1.00
75880 VEIN X-RAY, EYE SOCKET 3.31 1.00
75885 VEIN X-RAY, LIVER 6.56 1.00
75887 VEIN X-RAY, LIVER 6.62 1.00
75889 VEIN X-RAY, LIVER 6.13 1.00
75891 VEIN X-RAY, LIVER 6.13 1.00
75893 VENOUS SAMPLING BY CATHETER 5.24 1.00
75901 REMOVE CVA DEVICE OBSTRUCT 4.12 1.00
75902 REMOVE CVA LUMEN OBSTRUCT 2.02 1.00
75952 ENDOVASC REPAIR ABDOM AORTA 6.54 1.00
75953 ABDOM ANEURYSM ENDOVAS RPR 1.99 1.00
75954 ILIAC ANEURYSM ENDOVAS RPR 3.26 1.00
75960 TRANSCATH IV STENT RS&I 5.85 1.00
75961 RETRIEVAL, BROKEN CATHETER 10.47 1.00
75962 REPAIR ARTERIAL BLOCKAGE 6.3 1.00
75964 REPAIR ARTERY BLOCKAGE, EACH 3.85 1.00
75966 REPAIR ARTERIAL BLOCKAGE 7.56 1.00
75968 REPAIR ARTERY BLOCKAGE, EACH 3.8 1.00
75978 REPAIR VENOUS BLOCKAGE 6.24 1.00
75984 XRAY CONTROL CATHETER CHANGE 3.04 1.00
75989 ABSCESS DRAINAGE UNDER X-RAY 3.71 1.00
76000 FLUOROSCOPE EXAMINATION 2.68 1.00
76010 X-RAY, NOSE TO RECTUM 0.75 1.00
76080 X-RAY EXAM OF FISTULA 1.68 1.00
76098 X-RAY EXAM, BREAST SPECIMEN 0.53 1.00
76100 X-RAY EXAM OF BODY SECTION 3.42 1.00
76101 COMPLEX BODY SECTION X-RAY 4.79 1.00
76102 COMPLEX BODY SECTION X-RAYS 6.42 1.00
76120 CINE/VIDEO X-RAYS 2.02 1.00
76150 X-RAY EXAM, DRY PROCESS 0.52 1.00
76376 3D RENDER W/O POSTPROCESS 1.99 1.00
76377 3D RENDERING W/POSTPROCESS 2.64 1.00
76380 CAT SCAN FOLLOW-UP STUDY 5.49 1.00
76390 MR SPECTROSCOPY 12.19 1.00
77001 FLUOROGUIDE FOR VEIN DEVICE 2.88 1.00
77002 NEEDLE LOCALIZATION BY XRAY 1.93 1.00
77003 FLUOROGUIDE FOR SPINE INJECT 1.6 1.00
77011 CT SCAN FOR LOCALIZATION 18.87 1.00
77012 CT SCAN FOR NEEDLE BIOPSY 4.71 1.00
77014 CT SCAN FOR THERAPY GUIDE 5.03 1.00
77021 MR GUIDANCE FOR NEEDLE PLACE 11.54 1.00
77031 STEREOTACT GUIDE FOR BRST BX 4.67 1.00
77032 GUIDANCE FOR NEEDLE, BREAST 1.54 1.00
77051 COMPUTER DX MAMMOGRAM ADD-ON 0.32 1.00
77052 COMP SCREEN MAMMOGRAM ADD-ON 0.32 1.00
77053 X-RAY OF MAMMARY DUCT 1.88 1.00
77054 X-RAY OF MAMMARY DUCTS 2.53 1.00
77055 MAMMOGRAM, ONE BREAST 2.28 1.00
77056 MAMMOGRAM, BOTH BREASTS 2.91 1.00

77057 MAMMOGRAM, SCREENING 2.17 1.00
77058 MRI, ONE BREAST 20.31 1.00
77059 MRI, BOTH BREASTS 21.41 1.00
77261 RADIATION THERAPY PLANNING 2 1.00
77262 RADIATION THERAPY PLANNING 3.03 1.00
77263 RADIATION THERAPY PLANNING 4.5 1.00
77280 SET RADIATION THERAPY FIELD 4.96 1.00
77285 SET RADIATION THERAPY FIELD 8.62 1.00
77290 SET RADIATION THERAPY FIELD 13.61 1.00
77295 SET RADIATION THERAPY FIELD 16.45 1.00
77300 RADIATION THERAPY DOSE PLAN 1.9 1.00
77301 RADIOTHERAPY DOSE PLAN, IMRT 59.89 1.00
77305 TELETX ISODOSE PLAN SIMPLE 1.87 1.00
77310 TELETX ISODOSE PLAN INTERMED 2.65 1.00
77315 TELETX ISODOSE PLAN COMPLEX 3.94 1.00
77321 SPECIAL TELETX PORT PLAN 3.05 1.00
77326 BRACHYTX ISODOSE CALC SIMP 3.87 1.00
77327 BRACHYTX ISODOSE CALC INTERM 5.49 1.00
77328 BRACHYTX ISODOSE PLAN COMPL 7.48 1.00
77331 SPECIAL RADIATION DOSIMETRY 1.73 1.00
77332 RADIATION TREATMENT AID(S) 2.1 1.00
77333 RADIATION TREATMENT AID(S) 1.74 1.00
77334 RADIATION TREATMENT AID(S) 4.18 1.00
77336 RADIATION PHYSICS CONSULT 1.48 1.00
77338 DESIGN MLC DEVICE FOR IMRT 13.26 1.00
77370 RADIATION PHYSICS CONSULT 3.08 1.00
77371 SRS, MULTISOURCE 30.24 1.00
77372 SRS, LINEAR BASED 22.27 1.00
77373 SBRT DELIVERY 41.34 1.00
77401 RADIATION TREATMENT DELIVERY 0.72 1.00
77402 RADIATION TREATMENT DELIVERY 3.76 1.00
77403 RADIATION TREATMENT DELIVERY 3.31 1.00
77404 RADIATION TREATMENT DELIVERY 3.66 1.00
77406 RADIATION TREATMENT DELIVERY 3.7 1.00
77407 RADIATION TREATMENT DELIVERY 6.11 1.00
77408 RADIATION TREATMENT DELIVERY 4.48 1.00
77409 RADIATION TREATMENT DELIVERY 4.96 1.00
77411 RADIATION TREATMENT DELIVERY 4.93 1.00
77412 RADIATION TREATMENT DELIVERY 5.81 1.00
77413 RADIATION TREATMENT DELIVERY 5.85 1.00
77414 RADIATION TREATMENT DELIVERY 6.53 1.00
77416 RADIATION TREATMENT DELIVERY 6.56 1.00
77417 RADIOLOGY PORT FILM(S) 0.41 1.00
77418 RADIATION TX DELIVERY, IMRT 13.85 1.00
77421 STEREOSCOPIC X-RAY GUIDANCE 2.97 1.00
77422 NEUTRON BEAM TX, SIMPLE 5.55 1.00
77423 NEUTRON BEAM TX, COMPLEX 6.32 1.00
77427 RADIATION TX MANAGEMENT, X5 5.39 1.00
77431 RADIATION THERAPY MANAGEMENT 2.73 1.00
77432 STEREOTACTIC RADIATION TRMT 11.38 1.00
77435 SBRT MANAGEMENT 18.89 1.00
77470 SPECIAL RADIATION TREATMENT 6.04 1.00
77620 HYPERTHERMIA TREATMENT 11.44 1.00

77750 INFUSE RADIOACTIVE MATERIALS 9.57 1.00
77761 APPLY INTRCAV RADIAT SIMPLE 9.85 1.00
77762 APPLY INTRCAV RADIAT INTERM 13.35 1.00
77763 APPLY INTRCAV RADIAT COMPL 18.93 1.00
77776 APPLY INTERSTIT RADIAT SIMPL 11.4 1.00
77777 APPLY INTERSTIT RADIAT INTER 15.88 1.00
77778 APPLY INTERSTIT RADIAT COMPL 22.91 1.00
77785 HDR BRACHYTX, 1 CHANNEL 5.47 1.00
77786 HDR BRACHYTX, 2-12 CHANNEL 15.22 1.00
77787 HDR BRACHYTX OVER 12 CHAN 23.44 1.00
77789 APPLY SURFACE RADIATION 2.96 1.00
77790 RADIATION HANDLING 2.45 1.00
78000 THYROID, SINGLE UPTAKE 1.84 1.00
78001 THYROID, MULTIPLE UPTAKES 2.36 1.00
78003 THYROID SUPPRESS/STIMUL 2.06 1.00
78006 THYROID IMAGING WITH UPTAKE 5.89 1.00
78007 THYROID IMAGE, MULT UPTAKES 4.22 1.00
78010 THYROID IMAGING 4.07 1.00
78011 THYROID IMAGING WITH FLOW 4.57 1.00
78015 THYROID MET IMAGING 5.46 1.00
78016 THYROID MET IMAGING/STUDIES 8.02 1.00
78018 THYROID MET IMAGING, BODY 8.2 1.00
78020 THYROID MET UPTAKE 2.32 1.00
78070 PARATHYROID NUCLEAR IMAGING 4.45 1.00
78075 ADRENAL NUCLEAR IMAGING 10.83 1.00
78102 BONE MARROW IMAGING, LTD 4.27 1.00
78103 BONE MARROW IMAGING, MULT 5.7 1.00
78104 BONE MARROW IMAGING, BODY 6.49 1.00
78110 PLASMA VOLUME, SINGLE 2.09 1.00
78111 PLASMA VOLUME, MULTIPLE 2.41 1.00
78120 RED CELL MASS, SINGLE 2.24 1.00
78121 RED CELL MASS, MULTIPLE 2.56 1.00
78130 RED CELL SURVIVAL STUDY 4.03 1.00
78135 RED CELL SURVIVAL KINETICS 8.59 1.00
78140 RED CELL SEQUESTRATION 3.74 1.00
78185 SPLEEN IMAGING 5.01 1.00
78190 PLATELET SURVIVAL, KINETICS 9.92 1.00
78191 PLATELET SURVIVAL 4.84 1.00
78195 LYMPH SYSTEM IMAGING 8.95 1.00
78201 LIVER IMAGING 4.68 1.00
78202 LIVER IMAGING WITH FLOW 5.24 1.00
78205 LIVER IMAGING (3D) 6.04 1.00
78206 LIVER IMAGE (3D) WITH FLOW 8.96 1.00
78215 LIVER AND SPLEEN IMAGING 4.89 1.00
78216 LIVER & SPLEEN IMAGE/FLOW 3.52 1.00
78220 LIVER FUNCTION STUDY 3.65 1.00
78223 HEPATOBILIARY IMAGING 8.31 1.00
78230 SALIVARY GLAND IMAGING 4.2 1.00
78231 SERIAL SALIVARY IMAGING 3.4 1.00
78232 SALIVARY GLAND FUNCTION EXAM 3.3 1.00
78258 ESOPHAGEAL MOTILITY STUDY 5.9 1.00
78261 GASTRIC MUCOSA IMAGING 6.37 1.00
78262 GASTROESOPHAGEAL REFLUX EXAM 6.26 1.00

78264 GASTRIC EMPTYING STUDY 7.28 1.00
78270 VIT B-12 ABSORPTION EXAM 2.07 1.00
78271 VIT B-12 ABSRP EXAM, INT FAC 2.16 1.00
78272 VIT B-12 ABSORP, COMBINED 2.35 1.00
78278 ACUTE GI BLOOD LOSS IMAGING 8.78 1.00
78282 GI PROTEIN LOSS EXAM 0.54 1.00
78290 MECKELS DIVERT EXAM 8.02 1.00
78291 LEVEEN/SHUNT PATENCY EXAM 6.43 1.00
78300 BONE IMAGING, LIMITED AREA 4.49 1.00
78305 BONE IMAGING, MULTIPLE AREAS 5.94 1.00
78306 BONE IMAGING, WHOLE BODY 6.53 1.00
78315 BONE IMAGING, 3 PHASE 8.79 1.00
78320 BONE IMAGING (3D) 6.49 1.00
78350 BONE MINERAL, SINGLE PHOTON 0.88 1.00
78351 BONE MINERAL, DUAL PHOTON 0.42 1.00
78414 NON-IMAGING HEART FUNCTION 0.61 1.00
78428 CARDIAC SHUNT IMAGING 5.15 1.00
78445 VASCULAR FLOW IMAGING 4.38 1.00
78451 HT MUSCLE IMAGE SPECT, SING 8.68 1.00
78452 HT MUSCLE IMAGE SPECT, MULT 12.19 1.00
78453 HT MUSCLE IMAGE,PLANAR,SING 7.48 1.00
78454 HT MUSC IMAGE, PLANAR, MULT 10.61 1.00
78456 ACUTE VENOUS THROMBUS IMAGE 9.02 1.00
78457 VENOUS THROMBOSIS IMAGING 5.03 1.00
78458 VEN THROMBOSIS IMAGES, BILAT 5.32 1.00
78459 HEART MUSCLE IMAGING (PET) 6166 1.00
78466 HEART INFARCT IMAGE 4.7 1.00
78468 HEART INFARCT IMAGE (EF) 5.84 1.00
78469 HEART INFARCT IMAGE (3D) 6.66 1.00
78472 GATED HEART, PLANAR, SINGLE 6.7 1.00
78473 GATED HEART, MULTIPLE 9.03 1.00
78481 HEART FIRST PASS, SINGLE 5.75 1.00
78483 HEART FIRST PASS, MULTIPLE 8.07 1.00
78494 HEART IMAGE, SPECT 7.24 1.00
78496 HEART FIRST PASS ADD-ON 2.55 1.00
78580 LUNG PERFUSION IMAGING 5.47 1.00
78584 LUNG V/Q IMAGE SINGLE BREATH 4.08 1.00
78585 LUNG V/Q IMAGING 9.06 1.00
78586 AEROSOL LUNG IMAGE, SINGLE 4.21 1.00
78587 AEROSOL LUNG IMAGE, MULTIPLE 5.32 1.00
78588 PERFUSION LUNG IMAGE 8.62 1.00
78591 VENT IMAGE, 1 BREATH, 1 PROJ 4.25 1.00
78593 VENT IMAGE, 1 PROJ, GAS 4.99 1.00
78594 VENT IMAGE, MULT PROJ, GAS 5.69 1.00
78596 LUNG DIFFERENTIAL FUNCTION 9.62 1.00
78600 BRAIN IMAGE < 4 VIEWS 4.58 1.00
78601 BRAIN IMAGE W/FLOW < 4 VIEWS 5.43 1.00
78605 BRAIN IMAGE 4+ VIEWS 5.06 1.00
78606 BRAIN IMAGE W/FLOW 4 + VIEWS 8.16 1.00
78607 BRAIN IMAGING (3D) 9.4 1.00
78610 BRAIN FLOW IMAGING ONLY 4.58 1.00
78630 CEREBROSPINAL FLUID SCAN 8.51 1.00
78635 CSF VENTRICULOGRAPHY 7.96 1.00

78645 CSF SHUNT EVALUATION 7.94 1.00
78647 CEREBROSPINAL FLUID SCAN 8.5 1.00
78650 CSF LEAKAGE IMAGING 8.29 1.00
78660 NUCLEAR EXAM OF TEAR FLOW 4.38 1.00
78700 KIDNEY IMAGING, MORPHOL 4.49 1.00
78701 KIDNEY IMAGING WITH FLOW 5.43 1.00
78707 K FLOW/FUNCT IMAGE W/O DRUG 6.21 1.00
78708 K FLOW/FUNCT IMAGE W/DRUG 4.91 1.00
78709 K FLOW/FUNCT IMAGE, MULTIPLE 9.39 1.00
78710 KIDNEY IMAGING (3D) 5.9 1.00
78725 KIDNEY FUNCTION STUDY 2.64 1.00
78730 URINARY BLADDER RETENTION 1.95 1.00
78740 URETERAL REFLUX STUDY 5.53 1.00
78761 TESTICULAR IMAGING W/FLOW 5.42 1.00
78800 TUMOR IMAGING, LIMITED AREA 4.84 1.00
78801 TUMOR IMAGING, MULT AREAS 6.44 1.00
78802 TUMOR IMAGING, WHOLE BODY 8.39 1.00
78803 TUMOR IMAGING (3D) 9.16 1.00
78804 TUMOR IMAGING, WHOLE BODY 14.96 1.00
78805 ABSCESS IMAGING, LTD AREA 4.79 1.00
78806 ABSCESS IMAGING, WHOLE BODY 8.73 1.00
78807 NUCLEAR LOCALIZATION/ABSCESS 9.14 1.00
78808 IV INJ RA DRUG DX STUDY 1.19 1.00
79005 NUCLEAR RX, ORAL ADMIN 3.97 1.00
79101 NUCLEAR RX, IV ADMIN 4.48 1.00
79200 NUCLEAR RX, INTRACAV ADMIN 4.61 1.00
79300 NUCLR RX, INTERSTIT COLLOID 2.26 1.00
79403 HEMATOPOIETIC NUCLEAR TX 5.7 1.00
79440 NUCLEAR RX, INTRA-ARTICULAR 4.19 1.00
80048 METABOLIC PANEL TOTAL CA 1 1.00
80051 ELECTROLYTE PANEL 1 1.00
80053 COMPREHEN METABOLIC PANEL 1 1.00
80061 LIPID PANEL 1 1.00
80069 RENAL FUNCTION PANEL 1 1.00
80076 HEPATIC FUNCTION PANEL 1 1.00
90911 BIOFEEDBACK PERI/URO/RECTAL 1.26 1.00
92551 PURE TONE HEARING TEST, AIR 0.29 1.00
92950 HEART/LUNG RESUSCITATION CPR 4.87 1.00
92960 CARDIOVERSION ELECTRIC, EXT 3.64 1.00
92970 CARDIOASSIST, INTERNAL 5.01 1.00
92971 CARDIOASSIST, EXTERNAL 2.82 1.00
92973 PERCUT CORONARY THROMBECTOMY 5.33 1.00
92974 CATH PLACE, CARDIO BRACHYTX 4.89 1.00
92975 DISSOLVE CLOT, HEART VESSEL 11.75 1.00
92977 DISSOLVE CLOT, HEART VESSEL 2.81 1.00
92980 INSERT INTRACORONARY STENT 24.3 1.00
92981 INSERT INTRACORONARY STENT 6.76 1.00
92982 CORONARY ARTERY DILATION 18.01 1.00
92984 CORONARY ARTERY DILATION 4.82 1.00
92986 REVISION OF AORTIC VALVE 39.94 1.00
92987 REVISION OF MITRAL VALVE 41.29 1.00
92990 REVISION OF PULMONARY VALVE 31.96 1.00
92995 CORONARY ATHERECTOMY 19.84 1.00

92996 CORONARY ATHERECTOMY ADD-ON 5.3 1.00
92997 PUL ART BALLOON REPR, PERCUT 18.92 1.00
92998 PUL ART BALLOON REPR, PERCUT 9.57 1.00
93000 ELECTROCARDIOGRAM, COMPLETE 0.55 1.00
93005 ELECTROCARDIOGRAM, TRACING 0.3 1.00
93010 ELECTROCARDIOGRAM REPORT 0.25 1.00
93015 CARDIOVASCULAR STRESS TEST 2.56 1.00
93017 CARDIOVASCULAR STRESS TEST 1.46 1.00
93018 CARDIOVASCULAR STRESS TEST 0.44 1.00
93024 CARDIAC DRUG STRESS TEST 3.22 1.00
93025 MICROVOLT T-WAVE ASSESS 5.39 1.00
93040 RHYTHM ECG WITH REPORT 0.37 1.00
93041 RHYTHM ECG, TRACING 0.15 1.00
93042 RHYTHM ECG, REPORT 0.22 1.00
93224 ECG MONITOR/REPORT, 24 HRS 2.92 1.00
93225 ECG MONITOR/RECORD, 24 HRS 0.86 1.00
93226 ECG MONITOR/REPORT, 24 HRS 1.29 1.00
93227 ECG MONITOR/REVIEW, 24 HRS 0.77 1.00
93228 REMOTE 30 DAY ECG REV/REPORT 0.72 1.00
93230 ECG MONITOR/REPORT, 24 HRS 2.97 1.00
93231 ECG MONITOR/RECORD, 24 HRS 0.82 1.00
93232 ECG MONITOR/REPORT, 24 HRS 1.41 1.00
93233 ECG MONITOR/REVIEW, 24 HRS 0.74 1.00
93235 ECG MONITOR/REPORT, 24 HRS 3.4 1.00
93236 ECG MONITOR/REPORT, 24 HRS 2.77 1.00
93237 ECG MONITOR/REVIEW, 24 HRS 0.67 1.00
93268 ECG RECORD/REVIEW 6.77 1.00
93270 ECG RECORDING 0.46 1.00
93271 ECG/MONITORING AND ANALYSIS 5.57 1.00
93272 ECG/REVIEW, INTERPRET ONLY 0.74 1.00
93278 ECG/SIGNAL-AVERAGED 0.98 1.00
93279 PM DEVICE PROGR EVAL, SNGL 1.48 1.00
93280 PM DEVICE PROGR EVAL, DUAL 1.75 1.00
93281 PM DEVICE PROGR EVAL, MULTI 2.03 1.00
93282 ICD DEVICE PROG EVAL, 1 SNGL 1.87 1.00
93283 ICD DEVICE PROGR EVAL, DUAL 2.39 1.00
93284 ICD DEVICE PROGR EVAL, MULT 2.67 1.00
93285 ILR DEVICE EVAL PROGR 1.25 1.00
93286 PRE-OP PM DEVICE EVAL 0.74 1.00
93287 PRE-OP ICD DEVICE EVAL 0.98 1.00
93288 PM DEVICE EVAL IN PERSON 1.12 1.00
93289 ICD DEVICE INTERROGATE 1.9 1.00
93290 ICM DEVICE EVAL 0.86 1.00
93291 ILR DEVICE INTERROGATE 1.08 1.00
93292 WCD DEVICE INTERROGATE 0.97 1.00
93293 PM PHONE R-STRIP DEVICE EVAL 1.51 1.00
93294 PM DEVICE INTERROGATE REMOTE 0.99 1.00
93295 ICD DEVICE INTERROGAT REMOTE 1.94 1.00
93296 PM/ICD REMOTE TECH SERV 0.95 1.00
93297 ICM DEVICE INTERROGAT REMOTE 0.72 1.00
93298 ILR DEVICE INTERROGAT REMOTE 0.8 1.00
93303 ECHO TRANSTHORACIC 5.64 1.00
93304 ECHO TRANSTHORACIC 3.56 1.00

93306 TTE W/DOPPLER, COMPLETE 6.58 1.00
93307 TTE W/O DOPPLER, COMPLETE 4.26 1.00
93308 TTE, F-UP OR LMTD 2.86 1.00
93312 ECHO TRANSESOPHAGEAL 8.59 1.00
93313 ECHO TRANSESOPHAGEAL 1.15 1.00
93314 ECHO TRANSESOPHAGEAL 7.43 1.00
93315 ECHO TRANSESOPHAGEAL 4.12 1.00
93316 ECHO TRANSESOPHAGEAL 1.25 1.00
93317 ECHO TRANSESOPHAGEAL 2.63 1.00
93318 ECHO TRANSESOPHAGEAL INTRAOP 3.2 1.00
93320 DOPPLER ECHO EXAM, HEART 1.86 1.00
93321 DOPPLER ECHO EXAM, HEART 0.84 1.00
93325 DOPPLER COLOR FLOW ADD-ON 1.11 1.00
93350 STRESS TTE ONLY 5.63 1.00
93351 STRESS TTE COMPLETE 6.7 1.00
93352 ADMIN ECG CONTRAST AGENT 0.99 1.00
93501 RIGHT HEART CATHETERIZATION 20.53 1.00
93503 INSERT/PLACE HEART CATHETER 3.88 1.00
93505 BIOPSY OF HEART LINING 20.84 1.00
93508 CATH PLACEMENT, ANGIOGRAPHY 28.4 1.00
93510 LEFT HEART CATHETERIZATION 32.85 1.00
93526 RT & LT HEART CATHETERS 42.06 1.00
93539 INJECTION, CARDIAC CATH 0.61 1.00
93540 INJECTION, CARDIAC CATH 0.65 1.00
93541 INJECTION FOR LUNG ANGIOGRAM 0.43 1.00
93542 INJECTION FOR HEART X-RAYS 0.43 1.00
93543 INJECTION FOR HEART X-RAYS 0.43 1.00
93544 INJECTION FOR AORTOGRAPHY 0.38 1.00
93545 INJECT FOR CORONARY X-RAYS 0.61 1.00
93555 IMAGING, CARDIAC CATH 2.52 1.00
93556 IMAGING, CARDIAC CATH 3.44 1.00
93580 TRANSCATH CLOSURE OF ASD 29.3 1.00
93581 TRANSCATH CLOSURE OF VSD 38.68 1.00
93613 ELECTROPHYS MAP 3D, ADD-ON 11.34 1.00
93620 ELECTROPHYSIOLOGY EVALUATION 18.81 1.00
93621 ELECTROPHYSIOLOGY EVALUATION 3.4 1.00
93622 ELECTROPHYSIOLOGY EVALUATION 4.98 1.00
93623 STIMULATION, PACING HEART 4.62 1.00
93642 ELECTROPHYSIOLOGY EVALUATION 12.09 1.00
93650 ABLATE HEART DYSRHYTHM FOCUS 17.25 1.00
93651 ABLATE HEART DYSRHYTHM FOCUS 26.29 1.00
93652 ABLATE HEART DYSRHYTHM FOCUS 28.61 1.00
93660 TILT TABLE EVALUATION 4.58 1.00
93662 INTRACARDIAC ECG (ICE) 4.23 1.00
97039 PHYSICAL THERAPY TREATMENT 0.31 1.00
97139 PHYSICAL MEDICINE PROCEDURE 0.42 1.00
99288 DIRECT ADVANCED LIFE SUPPORT 999.99 1.00

Procedure Code Procedure Code Modifier 1 Pricing Action Code Modifier Price
93770 TC 3 0.63
E0191 RR 3 0.97
E0326 RR 3 1.14
E0167 RR 3 1.21
E0276 RR 3 1.49
E0275 RR 3 1.52
E0994 RR 3 1.52
K0019 RR 3 1.63
K0044 RR 3 1.66
E0951 RR 3 1.81
E0952 RR 3 1.81
K0043 RR 3 1.94
K0046 RR 3 1.94
E0942 RR 3 2.24
K0038 RR 3 2.41
E0995 RR 3 2.54
E0238 RR 3 2.6
K0098 RR 3 2.71
E0961 RR 3 2.78
76977 26 3 2.83
K0018 RR 3 2.83
E0210 RR 3 2.94
E0605 RR 3 2.94
E0199 RR 3 3.06
E0980 RR 3 3.15
77051 26 3 3.19
77052 26 3 3.19
K0050 RR 3 3.22
E0156 RR 3 3.23
E0158 RR 3 3.39
E0161 RR 3 3.41
K0073 RR 3 3.46
94690 26 3 3.56
K0042 RR 3 3.61
E0189 RR 3 3.63
E0155 RR 3 3.68
E0484 RR 3 3.69
88311 TC 3 3.78
E0280 RR 3 3.93
93325 26 3 3.94
94150 26 3 3.94
76514 TC 3 4.03
E0970 RR 3 4.11
E0160 RR 3 4.14
E0945 RR 3 4.24
E0978 RR 3 4.26
K0037 RR 3 4.28
E0944 RR 3 4.4
K0065 RR 3 4.43
K0020 RR 3 4.63
E1355 RR 3 4.67
E0100 RR 3 4.84

88300 26 3 4.89
E0113 RR 3 4.92
K0017 RR 3 5.08
E0116 RR 3 5.17
K0051 RR 3 5.26
K0041 RR 3 5.28
K0039 RR 3 5.37
E0175 RR 3 5.39
94200 26 3 5.4
94250 26 3 5.4
70300 26 3 5.41
92543 26 3 5.41
83912 26 3 5.6
K0045 RR 3 5.64
88125 TC 3 5.71
K0077 RR 3 5.85
94260 26 3 6.13
E0966 RR 3 6.19
E0860 RR 3 6.23
E0325 UE 3 6.4
73660 26 3 6.51
K0072 RR 3 6.54
K0040 RR 3 6.74
73140 26 3 6.88
92587 26 3 6.88
E0326 UE 3 7.07
E0215 RR 3 7.09
E0971 RR 3 7.14
E0191 UE 3 7.14
94770 26 3 7.23
85390 26 3 7.25
E0105 RR 3 7.46
E0153 RR 3 7.49
88358 TC 3 7.51
88302 26 3 7.56
E0167 UE 3 7.58
93562 26 3 7.6
73020 26 3 7.61
73070 26 3 7.61
K0047 RR 3 7.64
E0974 RR 3 7.95
73090 26 3 7.98
73092 26 3 7.98
73120 26 3 7.98
73592 26 3 7.98
73600 26 3 7.98
73620 26 3 7.98
73650 26 3 7.98
93770 26 3 7.98
72020 26 3 8
E0111 RR 3 8.06
87207 26 3 8.09
E0154 RR 3 8.19

E0114 RR 3 8.2
94010 26 3 8.35
73000 26 3 8.36
76098 26 3 8.36
78730 26 3 8.37
93321 26 3 8.37
E0959 RR 3 8.5
70300 TC 3 8.57
77051 TC 3 8.57
77052 TC 3 8.57
73100 26 3 8.6
E0157 RR 3 8.6
70030 26 3 8.72
70160 26 3 8.72
70210 26 3 8.72
70360 26 3 8.72
72200 26 3 8.72
72220 26 3 8.72
73060 26 3 8.72
73080 26 3 8.72
73110 26 3 8.72
73130 26 3 8.72
73590 26 3 8.72
73610 26 3 8.72
73630 26 3 8.72
76000 26 3 8.72
70310 26 3 8.73
E0621 RR 3 8.85
E0992 RR 3 8.85
76977 TC 3 8.94
72170 26 3 8.97
73010 26 3 8.97
73500 26 3 8.97
73550 26 3 8.97
73560 26 3 8.97
70100 26 3 9.08
70120 26 3 9.08
70328 26 3 9.08
71010 26 3 9.08
74000 26 3 9.08
70350 26 3 9.1
70380 26 3 9.1
92283 26 3 9.1
K0052 RR 3 9.19
73565 26 3 9.35
E1297 RR 3 9.44
70140 26 3 9.46
71035 26 3 9.47
76010 26 3 9.47
K0056 RR 3 9.47
76514 26 3 9.48
E0112 RR 3 9.5
88300 TC 3 9.57

73030 26 3 9.71
73562 26 3 9.71
78271 26 3 9.82
94681 26 3 9.82
70240 26 3 9.83
72202 26 3 9.83
78000 26 3 9.83
78110 26 3 9.83
88332 TC 3 9.87
K0105 RR 3 9.88
K0069 RR 3 9.94
E0950 RR 3 9.96
89060 26 3 10.04
E0276 UE 3 10.07
K0053 RR 3 10.14
71120 26 3 10.2
74291 26 3 10.2
78270 26 3 10.2
E0200 RR 3 10.29
E0249 RR 3 10.47
E0973 RR 3 10.47
70190 26 3 10.56
71015 26 3 10.56
70355 26 3 10.57
76376 26 3 10.57
91065 26 3 10.57
73050 26 3 10.82
73540 26 3 10.82
K0071 RR 3 10.87
94750 26 3 10.92
78350 26 3 10.93
E0275 UE 3 10.98
72190 26 3 11.18
73510 26 3 11.18
74301 26 3 11.18
92285 26 3 11.2
70355 TC 3 11.21
76098 TC 3 11.21
71020 26 3 11.31
71100 26 3 11.31
71130 26 3 11.31
72070 26 3 11.31
72072 26 3 11.31
72074 26 3 11.31
78111 26 3 11.31
93875 26 3 11.31
E0994 UE 3 11.37
72040 26 3 11.55
72069 26 3 11.55
72080 26 3 11.55
72100 26 3 11.55
72120 26 3 11.55
73564 26 3 11.55

70350 TC 3 11.58
74010 26 3 11.67
78120 26 3 11.67
70320 26 3 11.68
70250 26 3 12.03
92284 26 3 12.03
92545 26 3 12.05
E0655 RR 3 12.13
E0148 RR 3 12.17
K0019 UE 3 12.19
86256 26 3 12.28
94240 26 3 12.39
94350 26 3 12.39
94360 26 3 12.39
94370 26 3 12.39
94720 26 3 12.39
94725 26 3 12.39
70220 26 3 12.41
93922 26 3 12.41
K0044 UE 3 12.41
70330 26 3 12.42
93990 26 3 12.51
88304 26 3 12.53
E0850 RR 3 12.65
E0870 RR 3 12.65
E0967 RR 3 12.65
E0990 RR 3 12.65
94680 26 3 12.77
70110 26 3 12.78
A7017 RR 3 12.82
78272 26 3 13.13
70150 26 3 13.14
93278 26 3 13.16
73520 26 3 13.39
E0665 RR 3 13.46
71021 26 3 13.51
71101 26 3 13.51
71110 26 3 13.51
78001 26 3 13.52
92544 26 3 13.52
E0951 UE 3 13.52
E0952 UE 3 13.52
E0666 RR 3 13.62
88311 26 3 13.68
88313 26 3 13.68
88162 TC 3 13.74
74020 26 3 13.89
E0969 RR 3 13.99
E0188 UE 3 14.04
E0942 UE 3 14.22
70200 26 3 14.25
E0168 RR 3 14.5
76125 26 3 14.51

94375 26 3 14.59
94452 26 3 14.59
K0043 UE 3 14.59
K0046 UE 3 14.59
71010 TC 3 14.61
E0162 RR 3 14.62
88125 26 3 14.83
88106 TC 3 14.9
94060 26 3 14.97
92546 26 3 14.99
84165 26 3 15.07
87164 26 3 15.07
72090 26 3 15.12
E0113 UE 3 15.18
73530 26 3 15.24
E0110 RR 3 15.31
E0165 RR 3 15.32
K0070 RR 3 15.5
93931 26 3 15.59
70170 26 3 15.61
76937 26 3 15.61
E0840 RR 3 15.61
88172 TC 3 15.67
78121 26 3 15.72
71022 26 3 15.73
71030 26 3 15.73
78610 26 3 15.74
72020 TC 3 15.74
73020 TC 3 15.74
E0660 RR 3 15.91
72050 26 3 15.97
72110 26 3 15.97
E0100 UE 3 16.08
70370 26 3 16.09
71111 26 3 16.09
E0130 RR 3 16.1
59025 TC 3 16.12
74000 TC 3 16.12
95936 TC 3 16.12
74022 26 3 16.47
74290 26 3 16.47
74430 26 3 16.47
73500 TC 3 16.49
E0135 RR 3 16.51
E0235 RR 3 16.51
E0669 RR 3 16.66
70260 26 3 16.83
78003 26 3 16.84
86255 26 3 16.91
E0305 RR 3 17.02
E0116 UE 3 17.07
E0968 RR 3 17.15
70130 26 3 17.2

70134 26 3 17.2
74455 26 3 17.22
92542 26 3 17.22
72170 TC 3 17.26
94200 TC 3 17.26
74450 26 3 17.46
74710 26 3 17.58
95904 26 3 17.58
93965 26 3 17.82
E0776 RR 3 17.84
95930 26 3 17.94
83020 26 3 18.07
K0015 RR 3 18.09
K0038 UE 3 18.11
92065 26 3 18.3
88334 TC 3 18.3
74210 26 3 18.31
70360 TC 3 18.38
73590 TC 3 18.38
73620 TC 3 18.38
76010 TC 3 18.38
72052 26 3 18.55
75774 26 3 18.55
74425 26 3 18.56
E0606 RR 3 18.66
74300 26 O 18.66
75968 26 3 18.69
92588 26 3 18.69
73120 TC 3 18.77
73550 TC 3 18.77
73650 TC 3 18.77
76937 TC 3 18.77
72114 26 3 18.8
75964 26 3 18.8
E0161 UE 3 18.8
E0880 RR 3 18.86
E0570 RR 3 18.88
74420 26 3 18.93
92081 26 3 18.93
88331 TC 3 18.97
E0156 UE 3 18.99
E0995 UE 3 18.99
94400 26 3 19.01
94450 26 3 19.01
94453 26 3 19.01
E0238 UE 3 19.02
76946 26 3 19.04
78725 26 3 19.04
95869 26 3 19.05
95870 26 3 19.05
92135 26 3 19.08
E0910 RR 3 19.13
71015 TC 3 19.14

73000 TC 3 19.14
73090 TC 3 19.14
73600 TC 3 19.14
77331 TC 3 19.14
94150 TC 3 19.14
94250 TC 3 19.14
75996 26 3 19.16
75993 26 3 19.18
E0560 RR 3 19.23
76120 26 3 19.29
78010 26 3 19.4
74740 26 3 19.42
E0186 RR 3 19.42
95874 26 3 19.43
70030 TC 3 19.52
70140 TC 3 19.52
70240 TC 3 19.52
73070 TC 3 19.52
92543 TC 3 19.52
70390 26 3 19.67
74440 26 3 19.67
77001 26 3 19.67
78282 26 3 19.67
77421 26 3 19.79
71023 26 3 19.8
71020 TC 3 19.9
72220 TC 3 19.9
73010 TC 3 19.9
73030 TC 3 19.9
73060 TC 3 19.9
73560 TC 3 19.9
88104 TC 3 19.92
76857 26 3 20.04
93926 26 3 20.14
78185 26 3 20.15
78586 26 3 20.15
78591 26 3 20.15
95873 26 3 20.19
E0272 RR 3 20.21
76970 26 3 20.27
75902 26 3 20.28
72200 TC 3 20.28
73092 TC 3 20.28
K0098 UE 3 20.29
E0205 RR 3 20.42
93882 26 3 20.51
92541 26 3 20.53
93320 26 3 20.55
E0143 RR 3 20.66
70328 TC 3 20.66
73100 TC 3 20.66
73592 TC 3 20.66
92060 TC 3 20.66

75946 26 3 20.76
E0605 UE 3 20.82
E0961 UE 3 20.86
70210 TC 3 21.03
71100 TC 3 21.03
73660 TC 3 21.03
77333 TC 3 21.03
94370 TC 3 21.03
K0195 RR 3 21.07
70373 26 3 21.24
75945 26 3 21.27
K0018 UE 3 21.33
E0149 RR 3 21.35
E0141 RR 3 21.39
76946 TC 3 21.41
95900 26 3 21.64
74305 26 3 21.75
E0935 RR 5 21.75
E0310 RR 3 21.78
70100 TC 3 21.79
71120 TC 3 21.79
72070 TC 3 21.79
78350 TC 3 21.79
94350 TC 3 21.79
E0198 RR 3 21.96
E0271 RR 3 22.07
73130 TC 3 22.17
73565 TC 3 22.17
73630 TC 3 22.17
76828 TC 3 22.17
E0187 RR 3 22.21
78414 26 3 22.22
88108 TC 3 22.24
78600 26 3 22.36
E0181 RR 3 22.47
78201 26 3 22.48
93979 26 3 22.48
73140 TC 3 22.55
73610 TC 3 22.55
72010 26 3 22.6
93981 26 3 22.61
E1372 RR 3 22.66
E1228 RR 3 22.79
93923 26 3 22.84
51736 TC 3 22.92
93321 TC 3 22.92
94375 TC 3 22.92
78011 26 3 22.98
78230 26 3 22.98
78700 26 3 22.98
E0199 UE 3 23
E0155 UE 3 23.01
92250 26 3 23.12

93971 26 3 23.23
E0158 UE 3 23.24
70160 TC 3 23.3
93278 TC 3 23.3
E0189 UE 3 23.31
78232 26 3 23.33
E0163 RR 3 23.37
E0210 UE 3 23.42
78122 26 9 23.48
E0184 RR 3 23.5
93930 26 3 23.59
E0980 UE 3 23.59
92082 26 3 23.61
88318 26 3 23.62
70250 TC 3 23.68
72080 TC 3 23.68
74710 TC 3 23.68
E0160 UE 3 23.7
74220 26 3 23.72
88318 TC 3 23.87
84181 26 3 23.91
E0610 RR 3 24
71021 TC 3 24.06
72069 TC 3 24.06
76820 TC 3 24.06
74250 26 3 24.09
75809 26 3 24.09
K0050 UE 3 24.26
70120 TC 3 24.43
70190 TC 3 24.43
72202 TC 3 24.43
78220 26 3 24.57
78445 26 3 24.57
71034 26 3 24.61
93561 26 3 24.67
74190 26 3 24.7
74400 26 3 24.81
74415 26 3 24.81
75901 26 3 24.81
78006 26 3 24.81
78215 26 3 24.81
78593 26 3 24.81
78701 26 3 24.81
73562 TC 3 24.81
76820 26 3 24.94
88302 TC 3 24.94
84166 26 3 25.03
E0182 RR 3 25.05
74410 26 3 25.2
78587 26 3 25.2
71035 TC 3 25.2
71101 TC 3 25.2
94010 TC 3 25.2

94260 TC 3 25.2
84182 26 3 25.26
75900 26 3 25.3
78202 26 3 25.3
88107 TC 3 25.33
88314 26 3 25.45
74260 26 3 25.56
78007 26 3 25.56
71130 TC 3 25.57
72040 TC 3 25.57
73050 TC 3 25.57
73080 TC 3 25.57
73510 TC 3 25.57
74010 TC 3 25.57
95934 TC 3 25.57
92548 26 3 25.7
92585 26 3 25.7
93924 26 3 25.8
E0144 RR 3 25.91
78601 26 3 25.92
70220 TC 3 25.95
73110 TC 3 25.95
73520 TC 3 25.95
74020 TC 3 25.95
95937 TC 3 25.95
K0073 UE 3 25.97
78231 26 3 26.05
95934 26 3 26.06
88161 TC 3 26.1
51741 TC 3 26.32
70110 TC 3 26.32
71110 TC 3 26.32
72072 TC 3 26.32
92135 TC 3 26.32
94240 TC 3 26.32
E0900 RR 3 26.43
78496 26 3 26.45
E0280 UE 3 26.55
92083 26 3 26.7
75600 26 3 26.71
70310 TC 3 26.71
E0112 UE 3 27
74230 26 3 27.04
78594 26 3 27.04
78660 26 3 27.04
75893 26 3 27.16
95925 26 3 27.16
K0042 UE 3 27.18
88314 TC 3 27.26
73085 26 3 27.4
75962 26 3 27.4
75978 26 3 27.4
77002 26 3 27.4

95926 26 3 27.4
78605 26 3 27.41
72100 TC 3 27.46
73540 TC 3 27.46
92065 TC 3 27.46
95927 26 3 27.53
76645 26 3 27.65
88160 TC 3 27.65
E0484 UE 3 27.7
76604 26 3 27.76
78102 26 3 27.76
70332 26 3 27.77
74320 26 3 27.77
74475 26 3 27.77
74480 26 3 27.77
74485 26 3 27.77
76080 26 3 27.77
77332 26 3 27.77
92545 TC 3 27.84
76828 26 3 27.88
95936 26 3 27.9
73040 26 3 28.02
73115 26 3 28.02
73615 26 3 28.02
74340 26 3 28.02
74470 26 3 28.02
88160 26 3 28.12
88161 26 3 28.12
E0571 RR 5 28.12
76536 26 3 28.13
75940 26 3 28.14
91132 26 3 28.18
70380 TC 3 28.21
94770 TC 3 28.21
E0860 UE 3 28.23
59025 26 3 28.37
73525 26 3 28.4
77032 26 3 28.51
70134 TC 3 28.6
70150 TC 3 28.6
72190 TC 3 28.6
73564 TC 3 28.6
77032 TC 3 28.6
93308 26 3 28.67
E0431 RR 3 28.77
77003 26 3 28.83
94070 26 3 28.83
73542 26 3 28.85
78216 26 3 28.87
75992 26 3 28.89
70200 TC 3 28.97
76802 TC 3 28.97
92587 TC 3 28.97

71040 26 3 29
76827 26 3 29
73580 26 3 29.03
76516 26 3 29.05
74360 26 3 29.16
76880 26 3 29.22
78645 26 3 29.25
78740 26 3 29.25
E0197 RR 3 29.25
92544 TC 3 29.35
95874 TC 3 29.35
92136 26 3 29.42
93925 26 3 29.49
71090 26 3 29.54
E0720 RR 3 29.59
76950 26 3 29.62
88319 26 3 29.65
76519 26 3 29.66
70260 TC 3 29.72
92285 TC 3 29.72
94070 TC 3 29.72
86325 26 3 29.92
76705 26 3 29.98
95933 26 3 29.98
76775 26 3 30
59020 TC 3 30.11
71022 TC 3 30.11
71030 TC 3 30.11
85576 26 3 30.15
E0890 RR 3 30.34
78020 26 3 30.35
95903 26 3 30.35
88304 TC 3 30.35
88312 26 3 30.42
76100 26 3 30.49
77003 TC 3 30.49
94360 TC 3 30.49
E0196 RR 3 30.54
88333 TC 3 30.69
76529 26 3 30.76
70320 TC 3 30.86
92541 TC 3 30.86
95870 TC 3 30.86
95921 TC 3 30.86
78191 26 3 30.96
78650 26 3 30.96
93880 26 3 30.97
E0667 RR 3 30.98
94620 26 3 31.06
E0225 RR 3 31.15
88371 26 3 31.19
76886 26 3 31.21
78635 26 3 31.22

74022 TC 3 31.24
95873 TC 3 31.24
78130 26 3 31.34
78140 26 3 31.34
86334 26 3 31.36
78300 26 3 31.46
86320 26 3 31.46
88104 26 3 31.57
88106 26 3 31.57
88108 26 3 31.57
76102 26 3 31.6
76814 TC 3 31.61
95904 TC 3 31.61
E0627 RR 3 31.64
E0628 RR 3 31.64
E0629 RR 3 31.64
93888 26 3 31.7
76101 26 3 31.73
77300 26 3 31.83
86327 26 3 31.85
88372 26 3 31.93
74775 26 3 31.95
51736 26 3 32.1
E0978 UE 3 32.12
76815 26 3 32.31
78606 26 3 32.32
72090 TC 3 32.37
95869 TC 3 32.37
76506 26 3 32.45
72074 TC 3 32.75
92081 TC 3 32.75
94400 TC 3 32.75
95866 TC 3 32.75
76870 26 3 32.81
78135 26 3 32.81
E0945 UE 3 32.83
E0105 UE 3 32.84
E0944 UE 3 32.92
78710 26 3 33.05
88332 26 3 33.09
92265 TC 3 33.13
95937 26 3 33.17
K0065 UE 3 33.18
E0940 RR 3 33.26
93978 26 3 33.29
E0730 RR 3 33.38
77305 TC 3 33.51
95865 TC 3 33.51
78800 26 3 33.54
E0585 RR 3 33.55
78262 26 3 33.78
88172 26 3 33.86
95867 TC 3 33.89

76945 26 3 33.91
78015 26 3 33.91
E0114 UE 3 34.12
76513 26 3 34.18
70330 TC 3 34.26
95900 TC 3 34.26
76942 26 3 34.28
E0970 UE 3 34.56
G0202 26 3 34.61
G0206 26 3 34.61
76080 TC 3 34.64
95903 TC 3 34.64
K0020 UE 3 34.66
88334 26 3 34.67
93970 26 3 34.76
74241 26 3 34.77
76830 26 3 34.77
78630 26 3 34.78
92286 26 3 34.94
E1355 UE 3 35
78290 26 3 35.03
76821 26 3 35.13
76856 26 3 35.14
59020 26 3 35.37
75880 26 3 35.38
74240 26 3 35.39
74246 26 3 35.39
74247 26 3 35.39
74251 26 3 35.39
74270 26 3 35.39
78261 26 3 35.39
76001 26 3 35.4
71111 TC 3 35.4
92542 TC 3 35.4
94620 TC 3 35.4
95860 TC 3 35.4
E0668 RR 3 35.46
E0572 RR 5 35.76
72050 TC 3 35.77
76831 26 3 35.87
77280 26 3 35.89
77305 26 3 35.89
78466 26 3 35.91
K0037 UE 3 35.95
76930 26 3 36.06
78205 26 3 36.12
76872 26 3 36.15
92283 TC 3 36.15
94450 TC 3 36.15
E0434 RR 3 36.19
74328 26 3 36.38
74329 26 3 36.38
75820 26 3 36.51

78761 26 3 36.51
76932 26 3 36.55
E1298 RR 3 36.55
91133 26 3 36.56
91000 26 3 36.61
92060 26 3 36.66
77790 TC 3 36.91
78805 26 3 37.23
75984 26 3 37.24
70130 TC 3 37.29
72120 TC 3 37.29
72275 26 3 37.57
76770 26 3 37.59
76885 26 3 37.59
78075 26 3 37.59
74327 26 3 37.6
72110 TC 3 37.66
93325 TC 3 37.66
95933 TC 3 37.66
76817 26 3 37.72
78580 26 3 37.73
E0574 RR 5 37.81
95824 26 3 37.84
78103 26 3 37.97
71060 26 3 37.98
78258 26 3 38.11
E0236 RR 3 38.12
K0017 UE 3 38.14
88313 TC 3 38.17
94720 TC 3 38.42
88342 TC 3 38.47
E0941 RR 3 38.56
76776 26 3 38.71
76529 TC 3 38.8
77300 TC 3 38.8
76819 26 3 38.83
78457 26 3 39.07
76827 TC 3 39.18
93304 26 3 39.23
K0051 UE 3 39.24
E0111 UE 3 39.32
E0930 RR 3 39.52
76512 TC 3 39.55
74355 26 3 39.57
E0175 UE 3 39.64
78264 26 3 39.82
76516 TC 3 39.94
76377 26 3 40.18
78801 26 3 40.18
K0039 UE 3 40.21
78016 26 3 40.28
76950 TC 3 40.31
E1296 RR 3 40.61

95867 26 3 40.69
78428 26 3 40.7
93025 26 3 40.74
78104 26 3 40.92
92270 26 3 41.04
94452 TC 3 41.06
86335 26 3 41.2
91052 26 3 41.2
76700 26 3 41.29
76826 26 3 41.4
95868 TC 3 41.44
92265 26 3 41.55
72295 26 3 41.64
78070 26 3 41.65
E0958 RR 3 41.74
70371 26 3 41.76
76802 26 3 41.78
95875 TC 3 41.83
88346 TC 3 41.95
78305 26 3 42.02
E0480 RR 3 42.04
75805 26 3 42.16
K0045 UE 3 42.26
88305 26 3 42.27
72265 26 3 42.39
76816 26 3 42.5
75960 26 3 42.65
78223 26 3 42.76
G0204 26 3 42.77
78468 26 3 42.94
92588 TC 3 42.95
75801 26 3 42.98
93280 26 3 42.98
E0185 RR 3 42.99
E0239 RR 3 43.04
77333 26 3 43.14
76975 26 3 43.16
88312 TC 3 43.19
E1225 RR 3 43.24
88107 26 3 43.25
88162 26 3 43.25
88349 26 3 43.25
75970 26 3 43.27
51797 26 3 43.43
78018 26 3 43.49
78802 26 3 43.49
78806 26 3 43.49
70450 26 3 43.5
77014 26 3 43.5
62252 26 3 43.54
88182 26 3 43.63
92270 TC 3 43.71
94060 TC 3 43.71

95861 TC 3 43.71
E0600 RR 3 43.8
78306 26 3 43.87
K0077 UE 3 43.91
92235 26 3 44.07
93555 26 3 44.07
77310 TC 3 44.09
94680 TC 3 44.09
E0920 RR 3 44.14
78647 26 3 44.44
76519 TC 3 44.47
77002 TC 3 44.47
95922 TC 3 44.47
77331 26 3 44.61
E1130 RR 3 44.67
E0840 UE 3 44.67
78291 26 3 44.84
E0217 RR 3 44.96
88173 TC 3 45.04
95921 26 3 45.09
93556 26 3 45.18
E1221 RR 3 45.45
78458 26 3 45.58
92082 TC 3 45.6
95920 TC 3 45.6
72255 26 3 45.7
95923 26 3 45.71
74363 26 3 45.72
92284 TC 3 45.98
72240 26 3 46.32
72052 TC 3 46.35
94690 TC 3 46.35
E0966 UE 3 46.45
74330 26 3 46.58
74245 26 3 46.7
74249 26 3 46.7
92250 TC 3 46.74
88360 TC 3 47.05
76511 TC 3 47.12
93886 26 3 47.17
E0971 UE 3 47.17
74445 TC 3 47.47
71023 TC 3 47.49
76810 TC 3 47.49
77326 26 3 47.56
91055 26 3 47.69
88347 26 3 47.83
88342 26 3 47.84
72010 TC 3 47.87
E0550 RR 3 47.95
95922 26 3 48.04
E0855 RR 3 48.08
88346 26 3 48.22

94725 TC 3 48.25
E1031 RR 3 48.32
78459 26 3 48.46
78469 26 3 48.46
74291 TC 3 48.63
94681 TC 3 48.63
78206 26 3 48.66
78707 26 3 48.66
77321 26 3 48.67
E0459 RR 3 48.69
93320 TC 3 49
K0072 UE 3 49.07
76814 26 3 49.13
76810 26 3 49.15
74290 TC 3 49.38
92136 TC 3 49.38
88182 TC 3 49.5
95860 26 3 49.55
93307 26 3 49.6
E0565 RR 3 49.61
91120 26 3 49.75
76380 26 3 49.76
73542 TC 3 49.76
93555 TC 3 49.76
E0153 UE 3 49.77
E0154 UE 3 49.77
91030 26 3 49.85
76801 26 3 49.88
76805 26 3 49.88
E0157 UE 3 49.97
76511 26 3 50.09
93890 26 3 50.12
78278 26 3 50.37
76513 TC 3 50.52
77332 TC 3 50.52
E2000 RR 3 50.57
K0040 UE 3 50.67
74280 26 3 50.75
78584 26 3 50.75
E0215 UE 3 50.83
77789 TC 3 50.89
E0130 UE 3 51.2
78472 26 3 51.27
76512 26 3 51.33
74470 TC 3 51.81
78315 26 3 51.85
E0291 RR 3 51.95
92083 TC 3 52.03
91034 26 3 52.05
E0110 UE 3 52.16
62252 TC 3 52.41
70371 TC 3 52.41
72114 TC 3 52.41

95863 TC 3 52.41
88365 26 3 52.43
76818 26 3 52.46
91040 26 3 52.56
76819 TC 3 52.78
91037 26 3 52.91
78481 26 3 52.92
78320 26 3 52.96
93724 TC 3 53.17
95962 TC 3 53.17
78456 26 3 53.27
K0001 RR 3 53.27
93615 26 3 53.78
77790 26 3 53.83
79440 TC 3 53.92
77285 26 3 54.08
77310 26 3 54.08
95812 26 3 54.17
95819 26 3 54.17
95822 26 3 54.17
75822 26 3 54.31
74425 TC 3 54.37
95816 26 3 54.42
95827 26 3 54.42
92275 26 3 54.64
88347 TC 3 54.7
78804 26 3 54.81
78190 26 3 54.92
78807 26 3 54.92
E0147 RR 3 54.98
75902 TC 3 55.06
78803 26 3 55.16
78491 26 3 55.17
78492 26 3 55.17
78608 26 3 55.17
78609 26 3 55.17
88361 26 3 55.2
76800 26 3 55.24
88305 TC 3 55.3
70332 TC 3 55.43
78585 26 3 55.55
78588 26 3 55.55
73200 26 3 55.79
73700 26 3 55.79
91065 TC 3 55.81
95875 26 3 55.91
72192 26 3 55.92
88358 26 3 55.97
E0615 RR 3 55.97
E0948 RR 3 56.1
76120 TC 3 56.18
78020 TC 3 56.18
94453 TC 3 56.18

79005 TC 3 56.57
E0946 RR 3 56.6
E0974 UE 3 56.69
E0200 UE 3 56.9
E0135 UE 3 56.91
93024 TC 3 56.94
K0047 UE 3 57.06
75827 26 3 57.23
88112 TC 3 57.41
74210 TC 3 57.69
76815 TC 3 57.69
76930 TC 3 57.69
72285 26 3 57.72
93892 26 3 57.73
70460 26 3 57.76
51792 26 3 57.78
70373 TC 3 58.07
74740 TC 3 58.07
76377 TC 3 58.07
76604 TC 3 58.07
93893 26 3 58.11
70486 26 3 58.12
75825 26 3 58.24
91000 TC 3 58.46
75710 26 3 58.51
76813 26 3 58.58
75746 26 3 58.75
75870 26 3 58.75
75889 26 3 58.75
75891 26 3 58.75
E0457 RR 3 58.79
75736 26 3 58.88
77789 26 3 58.88
77012 26 3 58.99
75726 26 3 59
78000 TC 3 59.21
75625 26 3 59.24
71250 26 3 59.48
72125 26 3 59.48
72128 26 3 59.48
72131 26 3 59.48
72193 26 3 59.48
73201 26 3 59.48
73701 26 3 59.48
51741 26 3 59.51
88360 26 3 59.52
70370 TC 3 59.58
75810 26 3 59.61
91038 26 3 59.69
88333 26 3 59.71
E1160 RR 3 59.79
75722 26 3 59.88
E0202 RR 3 59.9

92240 26 3 59.96
74445 26 3 59.99
75860 26 3 60.12
74450 TC 3 60.16
E0947 RR 3 60.17
75605 26 3 60.26
78003 TC 3 60.34
75840 26 3 60.42
95868 26 3 60.48
75803 26 3 60.71
75807 26 3 60.71
75989 26 3 60.71
76821 TC 3 60.72
76965 TC 3 60.72
75731 26 3 60.91
74150 26 3 60.96
75872 26 3 61.01
75831 26 3 61.18
70544 26 3 61.32
70545 26 3 61.32
70547 26 3 61.32
70548 26 3 61.32
78195 26 3 61.32
70015 26 3 61.33
78708 26 3 61.44
79101 TC 3 61.48
77011 26 3 61.57
74230 TC 3 61.86
93976 26 3 61.93
78607 26 3 62.17
74430 TC 3 62.23
94750 TC 3 62.23
72126 26 3 62.43
72129 26 3 62.43
72132 26 3 62.43
72194 26 3 62.43
73202 26 3 62.43
73702 26 3 62.43
74235 26 3 62.57
78494 26 3 62.73
93024 26 3 62.76
78596 26 3 63
70010 26 3 63.02
75994 26 3 63.04
77334 26 3 63.29
71260 26 3 63.53
76998 26 3 63.61
76645 TC 3 63.75
76816 TC 3 63.75
76817 TC 3 63.75
76857 TC 3 63.75
76886 TC 3 63.75
76970 TC 3 63.75

95864 TC 3 63.75
E1297 UE 3 63.79
93888 TC 3 63.88
88356 TC 3 63.93
E0959 UE 3 64.02
E0850 UE 3 64.08
74220 TC 3 64.12
76376 TC 3 64.12
76506 TC 3 64.12
76812 TC 3 64.12
76885 TC 3 64.12
E1270 RR 3 64.19
71034 TC 3 64.5
72127 26 3 64.63
88319 TC 3 64.75
95866 26 3 64.79
75756 26 3 64.85
E1222 RR 3 64.85
74440 TC 3 64.88
77321 TC 3 64.88
78730 TC 3 64.88
70470 26 3 65.01
72130 26 3 65.01
72133 26 3 65.01
74160 26 3 65.01
93980 26 3 65.03
93314 26 3 65.3
70480 26 3 65.38
71040 TC 3 65.63
70490 26 3 65.75
E0655 UE 3 65.91
E1085 RR 3 66.21
75658 26 3 66.34
E0992 UE 3 66.38
88112 26 3 66.4
72275 TC 3 66.4
75809 TC 3 66.4
77315 TC 3 66.4
70487 26 3 66.48
93660 TC 3 66.77
88331 26 3 66.87
75995 26 3 67.09
73085 TC 3 67.15
75660 26 3 67.49
73525 TC 3 67.52
76813 TC 3 67.52
78270 TC 3 67.52
91010 26 3 67.68
88384 26 3 67.7
75716 26 3 67.72
75741 26 3 67.85
76818 TC 3 67.9
72270 26 3 67.95

75685 26 3 68.23
88368 TC 3 68.23
79200 TC 3 68.28
73218 26 3 68.31
E1171 RR 3 68.33
75665 26 3 68.34
75676 26 3 68.34
E0293 RR 3 68.41
78110 TC 3 68.52
75894 26 3 68.56
93303 26 3 68.64
92548 TC 3 68.66
76941 26 3 68.68
E1140 RR 3 68.73
75966 26 3 68.74
93616 26 3 68.86
70540 26 3 68.93
73718 26 3 68.93
K0052 UE 3 68.98
78496 TC 3 69.04
73221 26 3 69.18
73721 26 3 69.18
E0621 UE 3 69.23
88367 26 3 69.42
75896 26 3 69.7
76965 26 3 69.7
76510 TC 3 69.8
88365 TC 3 70.16
70481 26 3 70.4
70491 26 3 70.54
71270 26 3 70.54
94621 26 3 70.62
76390 26 3 70.65
E1223 RR 3 70.81
75953 26 3 70.83
E0251 RR 3 70.87
75733 26 3 70.89
76800 TC 3 70.92
K0056 UE 3 70.98
72291 26 3 71.06
77327 26 3 71.29
73615 TC 3 71.3
78271 TC 3 71.3
88355 TC 3 71.36
E0249 UE 3 71.46
E0290 RR 3 71.5
78709 26 3 71.64
74455 TC 3 71.69
92546 TC 3 71.69
74170 26 3 71.89
74240 TC 3 72.06
78120 TC 3 72.3
70488 26 3 72.63

E1250 RR 3 72.71
58300 26 5 72.89
E1200 RR 3 73.2
76705 TC 3 73.95
75887 26 3 74
70482 26 3 74.1
70492 26 3 74.1
75885 26 3 74.11
72292 26 3 74.13
K0105 UE 3 74.2
E0603 RR 3 74.28
71550 26 3 74.46
74181 26 3 74.46
G0252 26 3 74.46
E0292 RR 3 74.5
K0069 UE 3 74.56
E0950 UE 3 74.59
72195 26 3 74.71
75980 26 3 74.84
78001 TC 3 74.95
78272 TC 3 74.95
E0256 RR 3 75.06
73115 TC 3 75.09
75833 26 3 75.19
70336 26 3 75.2
88368 26 3 75.29
E1083 RR 3 75.33
E0870 UE 3 75.39
70551 26 3 75.57
95928 26 3 75.68
E1260 RR 3 75.79
72148 26 3 75.81
95950 26 3 76.05
95929 26 3 76.06
K0053 UE 3 76.13
K0003 RR 3 76.15
75984 TC 3 76.21
75842 26 3 76.31
92585 TC 3 76.6
77620 26 3 76.63
76100 TC 3 76.98
91020 26 3 77.26
E0880 UE 3 77.27
75650 26 3 77.31
73040 TC 3 77.35
75989 TC 3 77.35
92275 TC 3 77.35
77021 26 3 77.42
88307 TC 3 77.54
E1224 RR 3 77.64
78473 26 3 77.74
88173 26 3 77.87
E1150 RR 3 78.04

76826 TC 3 78.11
E0900 UE 3 78.17
70390 TC 3 78.49
74250 TC 3 78.49
93308 TC 3 78.49
93572 26 3 78.76
91038 TC 3 78.86
92235 TC 3 78.86
E0890 UE 3 78.87
51725 26 3 78.91
91022 26 3 78.91
78111 TC 3 79.11
76801 TC 3 79.24
92286 TC 3 79.24
95861 26 3 79.54
51784 26 3 79.64
91012 26 3 79.64
92979 26 3 79.64
93350 26 3 79.64
77290 26 3 79.76
77315 26 3 79.76
78725 TC 3 79.87
74241 TC 3 80
76873 26 3 80.02
51785 26 3 80.03
78811 26 3 80.23
78121 TC 3 80.24
75724 26 3 80.36
76775 TC 3 80.38
78483 26 3 80.39
E1086 RR 3 80.4
95807 26 3 80.77
74320 TC 3 81.13
E0163 UE 3 81.36
K0002 RR 5 81.43
77031 26 3 81.46
K0071 UE 3 81.52
72141 26 3 81.71
72146 26 3 81.71
95923 TC 3 81.89
95865 26 3 81.91
79300 26 3 82.07
91011 26 3 82.24
E1180 RR 3 82.41
70542 26 3 82.45
73719 26 3 82.45
E0973 UE 3 82.5
95961 TC 3 82.64
E1110 RR 3 82.66
E0141 UE 3 82.73
73219 26 3 82.82
73222 26 3 82.82
70015 TC 3 83.03

76825 26 3 83.29
91052 TC 3 83.4
93556 TC 3 83.4
73722 26 3 83.45
E0665 UE 3 83.66
74400 TC 3 83.78
74485 TC 3 84.15
E0666 UE 3 84.24
88348 26 3 84.37
76536 TC 3 84.53
88385 26 3 84.63
E0650 RR 3 85.01
75820 TC 3 85.29
76831 TC 3 85.29
E1170 RR 3 85.45
E0745 RR 3 85.64
91035 26 3 85.77
76830 TC 3 86.04
76856 TC 3 86.04
E0143 UE 3 86.08
75671 26 3 86.17
75743 26 3 86.17
88361 TC 3 86.34
75680 26 3 86.55
95813 26 3 86.73
75662 26 3 86.82
74475 TC 3 87.18
76870 TC 3 87.18
91030 TC 3 87.18
74246 TC 3 87.55
74480 TC 3 87.55
76000 TC 3 87.55
G0206 TC 3 87.58
E0744 RR 3 87.6
75898 26 3 87.77
E0990 UE 3 87.77
73225 26 3 87.86
E0651 RR 3 87.87
E1172 RR 3 87.87
74410 TC 3 87.94
71551 26 3 87.97
76510 26 3 88.12
75880 TC 3 88.32
77001 TC 3 88.32
72196 26 3 88.35
74182 26 3 88.35
88309 TC 3 88.75
76812 26 3 89.06
E1070 RR 3 89.06
91055 TC 3 89.07
88307 26 3 89.26
74247 TC 3 89.44
74270 TC 3 89.44

74283 TC 3 89.44
51726 26 3 89.49
74260 TC 3 89.58
70496 26 3 89.84
70498 26 3 89.84
79005 26 3 90.41
91122 26 3 90.57
94621 TC 3 90.58
93875 TC 3 90.96
E0148 UE 3 91.15
70552 26 3 91.18
72149 26 3 91.18
72159 26 3 91.55
70549 26 3 91.67
72255 TC 3 91.72
77031 TC 3 91.72
77421 TC 3 91.72
95805 26 3 91.83
70546 26 3 91.91
72198 26 3 92.04
74185 26 3 92.04
93975 26 3 92.4
77334 TC 3 92.47
75630 26 3 92.82
76770 TC 3 92.85
73206 26 3 92.92
73725 26 3 93.15
71555 26 3 93.17
72191 26 3 93.28
E0250 RR 3 93.53
E1084 RR 3 93.85
73580 TC 3 93.98
93304 TC 3 93.98
74327 TC 3 94.36
75822 TC 3 94.36
93317 26 3 94.83
E0575 RR 3 94.83
E0967 UE 3 94.83
76811 26 3 94.96
95863 26 3 95.25
79403 TC 3 95.74
76700 TC 3 95.87
A7017 UE 3 96.17
72295 TC 3 96.26
76805 TC 3 96.26
G0202 TC 3 96.32
E0165 UE 3 96.45
77750 TC 3 96.5
77326 TC 3 96.87
72265 TC 3 97.01
E1050 RR 3 97.43
E0630 RR 3 97.47
74175 26 3 97.7

72142 26 3 97.8
E1285 RR 3 98.07
76873 TC 3 98.14
93981 TC 3 98.14
71275 26 3 98.19
72147 26 3 98.19
73706 26 3 98.21
95930 TC 3 98.52
E1240 RR 3 98.55
E0500 RR 3 98.86
72285 TC 3 98.9
93571 26 3 99.09
51797 TC 3 99.27
76811 TC 3 99.27
E1100 RR 3 99.32
92978 26 3 99.33
93890 TC 3 99.41
93892 TC 3 99.41
93893 TC 3 99.41
E0635 RR 3 99.5
78812 26 3 99.53
E0601 RR 3 99.59
76872 TC 3 99.66
76880 TC 3 99.66
93926 TC 3 99.66
93931 TC 3 99.66
93971 TC 3 99.66
93979 TC 3 99.66
93990 TC 3 99.66
95927 TC 3 99.66
11980 26 5 99.81
95957 26 3 100.13
78232 TC 3 100.27
E0776 UE 3 100.76
71060 TC 3 101.17
79440 26 3 101.27
78231 TC 3 101.41
78584 TC 3 101.41
E1290 RR 3 101.77
95864 26 3 101.9
70010 TC 3 101.92
72240 TC 3 101.92
74283 26 3 101.99
E1195 RR 3 102.16
79200 26 3 102.25
78216 TC 3 102.92
95926 TC 3 103.06
93660 26 3 103.15
78813 26 3 103.47
76936 26 3 103.7
88355 26 3 103.7
E0305 UE 3 104.02
91022 TC 3 104.18

76940 26 3 104.29
E0660 UE 3 104.3
79101 26 3 104.58
E0969 UE 3 104.89
91037 TC 3 105.32
93965 TC 3 105.32
E1093 RR 3 105.74
95925 TC 3 106.08
88386 26 3 106.44
E1280 RR 3 106.74
74415 TC 3 106.83
95920 26 3 106.9
77328 26 3 107.17
77470 26 3 107.17
K0193 RR 9 107.84
74420 TC 3 107.93
76776 TC 3 107.97
E0162 UE 3 108.1
E0168 UE 3 108.28
78140 TC 3 108.59
93922 TC 3 108.72
70554 26 3 108.77
70543 26 3 109.48
73223 26 3 109.48
73220 26 3 109.86
73720 26 3 109.86
73723 26 3 109.86
93307 TC 3 109.86
93980 TC 3 110.24
E1090 RR 3 110.73
76936 TC 3 110.99
E1295 RR 3 111.11
G0204 TC 3 111.11
E0968 UE 3 111.15
75705 26 3 111.86
K0006 RR 3 111.93
E1190 RR 3 112.01
78220 TC 3 112.37
E0255 RR 3 112.39
76380 TC 3 112.5
K0004 RR 3 113.03
78814 26 3 113.53
E0297 RR 3 114.39
93312 26 3 114.86
E1089 RR 3 114.99
74183 26 3 115
93318 26 3 115.11
72197 26 3 115.39
E1372 UE 3 115.46
79403 26 3 115.53
71552 26 3 115.77
75954 26 3 116.38
77012 TC 3 117.04

77470 TC 3 117.41
91010 TC 3 118.18
E0205 UE 3 118.35
78130 TC 3 119.42
70553 26 3 120.42
E1060 RR 3 120.61
88362 26 3 120.9
72158 26 3 120.91
E1087 RR 3 121.03
93602 26 3 121.07
93603 26 3 121.07
93621 26 3 121.47
93600 26 3 121.82
78708 TC 3 121.82
E0295 RR 3 121.83
11975 26 5 122.3
E1092 RR 3 122.94
E0560 UE 3 123.07
79445 26 3 123.48
75968 TC 3 124.22
75635 26 3 124.28
78070 TC 3 124.84
E0669 UE 3 124.9
E0294 RR 3 124.99
B9000 RR 3 125
B9002 RR 3 125
74245 TC 3 125.35
51784 TC 3 125.73
75964 TC 3 125.73
78815 26 3 125.94
76825 TC 3 128
88309 26 3 128.39
11981 26 5 128.78
78816 26 3 128.89
95808 26 3 129.76
75901 TC 3 129.89
93350 TC 3 130.64
88367 TC 3 130.83
E0261 RR 3 131.01
72156 26 3 131.6
72157 26 3 131.6
E0910 UE 3 131.93
78102 TC 3 132.41
70555 26 3 132.73
78007 TC 3 132.78
95928 TC 3 132.78
77327 TC 3 133.53
78010 TC 3 133.53
78230 TC 3 134.67
92240 TC 3 135.18
91122 TC 3 135.56
K0015 UE 3 135.6
88362 TC 3 135.89

K0070 UE 3 136.7
78300 TC 3 136.94
78660 TC 3 137.32
78586 TC 3 138.07
74249 TC 3 138.21
78591 TC 3 139.58
E0272 UE 3 139.85
78445 TC 3 139.96
78466 TC 3 140.35
E0310 UE 3 140.55
51725 TC 3 141.61
78805 TC 3 142.23
93303 TC 3 142.36
91034 TC 3 142.75
E0184 UE 3 142.86
51785 TC 3 143.87
E1088 RR 3 144.24
E0266 RR 3 144.42
93882 TC 3 144.63
74251 TC 3 144.77
95929 TC 3 144.87
74280 TC 3 145.01
77014 TC 3 145.01
78700 TC 3 145.64
76101 TC 3 147.66
78800 TC 3 147.9
E0235 UE 3 148.28
78011 TC 3 148.66
78457 TC 3 149.41
72270 TC 3 149.55
78600 TC 3 149.79
93315 26 3 149.95
77280 TC 3 150.3
78191 TC 3 150.41
93976 TC 3 151.44
95961 26 3 151.77
91020 TC 3 151.81
78428 TC 3 152.44
78201 TC 3 153.19
78458 TC 3 153.57
93662 26 3 154.35
76942 TC 3 154.46
95956 26 3 155.04
70450 TC 3 156.35
78610 TC 3 156.59
E0296 RR 3 157.09
93925 TC 3 158.61
93975 TC 3 158.61
93978 TC 3 158.61
78215 TC 3 158.86
93880 TC 3 159
93886 TC 3 159
93930 TC 3 159

93970 TC 3 159
75774 TC 3 160.13
E0149 UE 3 160.14
E0260 RR 3 160.65
E0198 UE 3 160.86
93025 TC 3 161.64
95962 26 3 162.05
78593 TC 3 162.64
78605 TC 3 162.64
78481 TC 3 162.78
93923 TC 3 163.15
93623 26 3 164.9
70558 26 3 165.77
E0271 UE 3 165.95
95953 26 3 166.21
78761 TC 3 166.8
91011 TC 3 167.32
78580 TC 3 167.56
88356 26 3 167.57
75825 TC 3 167.69
78185 TC 3 168.32
75840 TC 3 168.44
70559 26 3 168.79
77761 TC 3 169.31
75827 TC 3 169.58
75893 TC 3 169.96
75961 TC 3 169.96
70557 26 3 170.17
95810 26 3 170.35
E0610 UE 3 170.69
75741 TC 3 170.72
75889 TC 3 170.72
75891 TC 3 170.72
78015 TC 3 170.96
75831 TC 3 171.09
75885 TC 3 171.09
77328 TC 3 171.58
93612 26 3 171.61
78202 TC 3 171.72
93501 26 3 172.54
51792 TC 3 172.6
93610 26 3 172.73
E1390 RR 3 173.17
75860 TC 3 173.36
75887 TC 3 173.73
91012 TC 3 173.73
75870 TC 3 174.49
78587 TC 3 174.73
E1310 RR 3 175.72
78103 TC 3 175.87
78468 TC 3 176.25
75625 TC 3 176.38
75960 TC 3 176.76

75605 TC 3 177.14
75650 TC 3 177.14
95950 TC 3 177.38
93622 26 3 177.79
78601 TC 3 178.13
78740 TC 3 178.52
75743 TC 3 179.03
95967 26 3 179.13
78701 TC 3 179.27
93642 TC 3 179.65
78305 TC 3 180.78
75630 TC 3 181.67
77776 TC 3 182.04
78258 TC 3 183.43
75746 TC 3 183.56
75959 26 3 183.63
95811 26 3 183.73
K0005 RR 3 183.95
78707 TC 3 184.19
75842 TC 3 185.07
78190 TC 3 185.07
75833 TC 3 185.46
E0197 UE 3 186.21
78594 TC 3 186.84
75722 TC 3 186.96
78710 TC 3 188.72
75658 TC 3 189.24
74150 TC 3 189.99
78320 TC 3 190.24
75726 TC 3 190.37
78205 TC 3 190.61
75676 TC 3 191.12
75705 TC 3 191.12
75736 TC 3 191.12
E0265 RR 3 191.23
75660 TC 3 191.5
75685 TC 3 191.5
72192 TC 3 191.88
95957 TC 3 192.64
75731 TC 3 193.01
70490 TC 3 193.39
75710 TC 3 193.39
E0144 UE 3 194.21
95816 TC 3 194.39
E1230 RR 3 194.69
73200 TC 3 194.9
E0445 RR 3 195
73700 TC 3 195.28
75756 TC 3 195.28
77761 26 3 195.74
78291 TC 3 196.28
78006 TC 3 196.66
77777 TC 3 196.77

91110 26 3 198.28
77762 TC 3 198.67
75665 TC 3 199.06
70480 TC 3 199.81
70486 TC 3 199.81
71250 TC 3 199.81
72125 TC 3 199.81
72128 TC 3 199.81
72131 TC 3 199.81
78472 TC 3 200.06
78306 TC 3 201.19
78645 TC 3 201.33
78262 TC 3 201.58
78459 TC 3 201.58
78469 TC 3 201.58
78801 TC 3 201.58
E0181 UE 3 201.6
70460 TC 3 202.09
93640 26 3 202.43
78104 TC 3 202.7
93924 TC 3 203.22
78261 TC 3 203.84
78456 TC 3 204.73
93312 TC 3 206.11
75680 TC 3 206.24
75958 26 3 207.32
75978 TC 3 207.38
77013 26 3 207.56
95966 26 3 208.09
95822 TC 3 208.38
78494 TC 3 208.76
76102 TC 3 209.27
75962 TC 3 209.64
75724 TC 3 211.02
93314 TC 3 213.29
75966 TC 3 214.56
75662 TC 3 215.18
E0781 RR 3 215.39
E0182 UE 3 216.38
77022 26 3 216.94
95812 TC 3 217.07
E0940 UE 3 217.2
75872 TC 3 217.58
75961 26 3 217.63
95819 TC 3 218.21
11977 26 5 218.32
75716 TC 3 218.96
78483 TC 3 221.98
75671 TC 3 222.36
11983 26 5 222.56
75733 TC 3 222.74
E0424 RR 3 230.17
E0439 RR 3 230.17

E0667 UE 3 232.3
75952 26 3 233.14
E0183 UE 9 233.34
78264 TC 3 233.7
51726 TC 3 234.08
77295 26 3 234.12
E0185 UE 3 234.85
E0225 UE 3 237.02
E0627 UE 3 237.27
E0628 UE 3 237.27
E0629 UE 3 237.27
95813 TC 3 237.73
93508 26 3 238.11
72193 TC 3 238.38
77776 26 3 239.33
70491 TC 3 240.26
73201 TC 3 241.01
93530 26 3 241.27
88386 TC 3 243.06
73701 TC 3 243.29
93618 26 3 246.9
E1406 RR 5 248.37
70470 TC 3 248.95
70487 TC 3 249.71
93505 26 3 249.81
71260 TC 3 250.84
72132 TC 3 250.84
88385 TC 3 250.87
93510 26 3 251.27
72126 TC 3 251.6
72129 TC 3 251.6
78278 TC 3 253.36
78290 TC 3 253.36
78315 TC 3 253.36
E0930 UE 3 254.4
77750 26 3 256.11
77763 TC 3 256.74
E0791 RR 3 257.13
88384 TC 3 258.95
78473 TC 3 260.92
78016 TC 3 261.3
75600 TC 3 261.42
95953 TC 3 262.42
E1405 RR 5 263.04
77778 TC 3 264.54
78018 TC 3 264.7
78195 TC 3 264.7
93724 26 3 265.76
E0730 UE 3 265.88
78588 TC 3 268.1
78491 TC 3 268.45
78492 TC 3 268.45
78608 TC 3 268.45

78609 TC 3 268.45
78635 TC 3 268.47
93642 26 3 269.16
E0668 UE 3 269.5
78223 TC 3 269.61
77285 TC 3 269.75
74160 TC 3 270.87
78802 TC 3 271.88
E1298 UE 3 274.02
78606 TC 3 274.9
78647 TC 3 274.9
E0958 UE 3 278.25
E0941 UE 3 278.4
E0462 RR 3 278.78
93624 26 3 280.4
78709 TC 3 280.57
78650 TC 3 280.95
93529 26 3 281.54
78585 TC 3 284.73
78806 TC 3 284.73
78630 TC 3 285.48
78206 TC 3 288.13
93609 26 3 288.45
78807 TC 3 288.51
78803 TC 3 288.88
E0480 UE 3 289.2
78135 TC 3 290.39
78607 TC 3 290.78
70481 TC 3 292.04
E0920 UE 3 292.05
93511 26 3 294.72
77762 26 3 295.2
78596 TC 3 298.33
E1296 UE 3 299.87
E0618 RR 3 300
70492 TC 3 302.25
E0615 UE 3 302.46
E0217 UE 3 302.77
88348 TC 3 304.29
91040 TC 3 304.52
95951 26 3 306.41
E1353 RR 5 308.71
95805 TC 3 309.16
95829 26 3 311.09
70488 TC 3 312.07
75957 26 3 313.2
E1130 UE 3 316.05
72127 TC 3 316.24
71270 TC 3 316.61
72133 TC 3 316.61
72130 TC 3 317.36
72194 TC 3 317.75
E0565 UE 3 318.83

73202 TC 3 322.28
E0239 UE 3 322.78
73702 TC 3 323.04
E0619 RR 3 330
70482 TC 3 339.29
91120 TC 3 340.42
74170 TC 3 341.56
93641 26 3 342.36
93526 26 3 346.9
75635 TC 3 348.36
70496 TC 3 348.74
70498 TC 3 348.74
71275 TC 3 348.74
72191 TC 3 348.74
73206 TC 3 348.74
73706 TC 3 348.74
74175 TC 3 348.74
E1031 UE 3 352.5
77620 TC 3 353.01
77021 TC 3 355.54
70336 TC 3 357.81
72141 TC 3 357.81
72146 TC 3 357.81
72148 TC 3 357.81
73221 TC 3 357.81
74181 TC 3 357.81
70540 TC 3 358.19
70544 TC 3 358.19
70547 TC 3 358.19
70551 TC 3 358.19
71550 TC 3 358.19
72195 TC 3 358.19
73218 TC 3 358.19
73718 TC 3 358.19
73721 TC 3 358.19
E0855 UE 3 360.64
75956 26 3 365.99
78075 TC 3 370.02
E0550 UE 3 373.5
88349 TC 3 374.71
93533 26 3 377.83
77295 TC 3 379.09
91035 TC 3 382.38
76390 TC 3 387.67
77777 26 3 388.63
E0948 UE 3 395.78
K0001 UE 3 399.52
B9006 RR 3 400
B9004 RR 3 403.88
95807 TC 3 405.4
93524 26 3 406.6
93514 26 3 406.96
E1270 UE 3 407.63

E0946 UE 3 408.08
77301 26 3 409.99
95827 TC 3 410.06
93631 26 3 411.92
E0147 UE 3 412.45
E0371 RR 5 415.05
95965 26 3 416.05
E1160 UE 3 420
93527 26 3 424.42
93619 26 3 426.5
77290 TC 3 431.9
70542 TC 3 434.16
70545 TC 3 434.16
70548 TC 3 434.16
70552 TC 3 434.16
71551 TC 3 434.16
72142 TC 3 434.16
72147 TC 3 434.16
72149 TC 3 434.16
72196 TC 3 434.16
73219 TC 3 434.16
73222 TC 3 434.16
73719 TC 3 434.16
73722 TC 3 434.16
74182 TC 3 434.16
E0947 UE 3 435.14
E1250 UE 3 441.68
77763 26 3 442.9
E1085 UE 3 443.55
G0252 TC 3 447.5
E1200 UE 3 447.97
E1083 UE 3 462.83
70554 TC 3 463.65
E1260 UE 3 467.33
93531 26 3 473.59
E1223 UE 3 477.15
E1171 UE 3 480.08
E1180 UE 3 497.33
E1140 UE 3 498.08
E0652 RR 3 501.26
E0372 RR 3 503.67
78804 TC 3 508.23
74185 TC 3 508.25
93528 26 3 509.75
72198 TC 3 509.76
73725 TC 3 509.76
71555 TC 3 511.65
E0650 UE 3 516.77
E0453 RR 9 520.64
E0746 UE O 521.09
E1170 UE 3 522.98
93505 TC 3 523.99
E1172 UE 3 537.75

E1086 UE 3 540.83
E1110 UE 3 541.05
E1070 UE 3 544.05
95808 TC 3 548.27
70543 TC 3 548.31
70546 TC 3 548.31
70549 TC 3 548.31
70553 TC 3 548.31
71552 TC 3 548.31
72156 TC 3 548.31
72157 TC 3 548.31
72158 TC 3 548.31
72197 TC 3 548.31
73220 TC 3 548.31
73223 TC 3 548.31
73720 TC 3 548.31
73723 TC 3 548.31
74183 TC 3 548.31
73225 TC 3 561.92
93532 26 3 562.54
E1195 UE 3 562.95
E1290 UE 3 566.33
72159 TC 3 570.61
E0373 RR 5 576.95
77778 26 3 580.43
E1150 UE 3 581.48
E0277 RR 3 584.14
95956 TC 3 589.94
E1084 UE 3 590.7
E1285 UE 3 592.05
93501 TC 3 594.05
E0251 UE 3 601.88
E0745 UE 3 603.75
95810 TC 3 608.24
E1100 UE 3 627.53
E0744 UE 3 632.4
E1090 UE 3 633.38
E0635 UE 3 637.65
E1240 UE 3 641.18
77011 TC 3 649.61
E1050 UE 3 651.53
E0651 UE 3 658.99
E0630 UE 3 662.78
93620 26 3 671.74
E0202 UE 3 673.58
95811 TC 3 675.76
E1295 UE 3 679.95
E1280 UE 3 681.23
E0255 UE 3 688.88
E1190 UE 3 693.08
91110 TC 3 697.23
E0250 UE 3 712.05
B9000 UE 3 741

B9002 UE 3 741
E1093 UE 3 763.13
E1060 UE 3 769.57
E1089 UE 3 798.38
E0193 RR 3 806.39
93508 TC 3 822.59
E0450 RR 3 850
E1087 UE 3 855.9
E1088 UE 3 890.63
E1092 UE 3 896.93
E0266 UE 3 938.4
93510 TC 3 976.81
95829 TC 3 1021.9
E0260 UE 3 1083.6
93526 TC 3 1224
E0781 UE 3 1335.9
78811 TC 3 1366.69
K0005 UE 3 1379.69
E0791 UE 3 1391.93
E0265 UE 3 1412.85
E1230 UE 3 1454.64
B9006 UE 3 1478.1
E1310 UE 3 1540.8
78812 TC 3 1787.05
E0462 UE 3 1831.27
77301 TC 3 1837.48
78813 TC 3 1872.34
B9004 UE 3 1913.41
78814 TC 3 2092.54
78815 TC 3 2352.94
78816 TC 3 2418.14
E0782 UE O 2774.69
E0194 RR 3 3113.39
E0652 UE 3 3759.53
E0451 UE O 4296.56
E0193 UE 3 5217.23