- Page 1 and 2:
Procedure Pricing Action Maximum Co
- Page 3 and 4:
00402 ANESTH, SURGERY OF BREAST A $
- Page 5 and 6:
00794 ANESTH, PANCREAS REMOVAL A $0
- Page 7 and 8:
0111T RBC MEMBRANES FATTY ACIDS 9 $
- Page 9 and 10:
01634 ANESTH, SHOULDER JOINT AMPUT
- Page 11 and 12:
0195T ARTHROD PRESAC INTERBODY 9 $0
- Page 13 and 14:
10141 INCISION AND DRAINAGE OF HEMA
- Page 15 and 16:
11422 EXC H-F-NK-SP B9+MARG 1.1-2 3
- Page 17 and 18:
12021 CLOSURE OF SPLIT WOUND 3 $148
- Page 19 and 20:
15343 CULTURE SKN GRAFT ADDL 25 CM
- Page 21 and 22:
15876 SUCTION ASSISTED LIPECTOMY 5
- Page 23 and 24:
17313 MOHS, 1 STAGE, T/A/L 3 $587.8
- Page 25 and 26:
20251 OPEN BONE BIOPSY 3 $389.97 20
- Page 27 and 28:
21015 RESECT FACE TUM < 2 CM 3 $602
- Page 29 and 30:
21260 REVISE EYE SOCKETS 3 $1,215.7
- Page 31 and 32:
21742 REPAIR STERN/NUSS W/O SCOPE 5
- Page 33 and 34:
22842 INSERT SPINE FIXATION DEVICE
- Page 35 and 36:
23515 TREAT CLAVICLE FRACTURE 3 $67
- Page 37 and 38:
24358 REPAIR ELBOW W/DEB, OPEN 3 $4
- Page 39 and 40:
25107 REMOVE WRIST JOINT CARTILAGE
- Page 41 and 42:
25570 TREATMENT OF OPEN RADIAL AND
- Page 43 and 44:
26262 RESECT DISTAL FINGER TUMOR 3
- Page 45 and 46:
26610 TREATMENT OF OPEN METACARPAL
- Page 47 and 48:
27093 INJECTION FOR HIP X-RAY 3 $18
- Page 49 and 50:
27307 INCISION OF THIGH TENDONS 3 $
- Page 51 and 52:
27506 TREATMENT OF THIGH FRACTURE 3
- Page 53 and 54:
27704 REMOVAL OF ANKLE IMPLANT 3 $5
- Page 55 and 56:
28050 BIOPSY OF FOOT JOINT LINING 3
- Page 57 and 58:
28406 TREATMENT OF HEEL FRACTURE 3
- Page 59 and 60:
29280 STRAPPING OF HAND OR FINGER 3
- Page 61 and 62:
29901 MCP JOINT ARTHROSCOPY, SURG 3
- Page 63 and 64:
30901 CONTROL OF NOSEBLEED 3 $98.42
- Page 65 and 66:
31368 PARTIAL REMOVAL OF LARYNX 3 $
- Page 67 and 68:
31725 CLEARANCE OF AIRWAYS 3 $93.80
- Page 69 and 70:
32655 THORACOSCOPY, SURGICAL 3 $943
- Page 71 and 72:
33214 UPGRADE OF PACEMAKER SYSTEM 3
- Page 73 and 74:
33471 VALVOTOMY, PULMONARY VALVE 3
- Page 75 and 76:
3374F AJCC BRST CNCR STAGE 1+DOCD 9
- Page 77 and 78:
34101 REMOVAL OF ARTERY CLOT 3 $626
- Page 79 and 80:
35226 REPAIR BLOOD VESSEL LESION 3
- Page 81 and 82:
35570 ARTERY BYPASS GRAFT 3 $1,528.
- Page 83 and 84:
36261 REVISION OF INFUSION PUMP 3 $
- Page 85 and 86:
36821 AV FUSION DIRECT ANY SITE 3 $
- Page 87 and 88:
38240 BONE MARROW/STEM TRANSPLANT 3
- Page 89 and 90:
40527 RECONSTRUCT LIP WITH FLAP 3 $
- Page 91 and 92:
4149F HEP B VAC INJXN ADMIN/RECVD 9
- Page 93 and 94:
42326 CREATE SALIVARY CYST DRAIN O
- Page 95 and 96:
43100 EXCISION OF ESOPHAGUS LESION
- Page 97 and 98:
43360 GASTROINTESTINAL REPAIR 3 $2,
- Page 99 and 100:
44110 EXCISE INTESTINE LESION(S) 3
- Page 101 and 102:
44615 INTESTINAL STRICTUROPLASTY 3
- Page 103 and 104:
45505 REPAIR OF RECTUM 3 $533.70 45
- Page 105 and 106:
46947 HEMORRHOIDOPEXY BY STAPLING 3
- Page 107 and 108:
48140 PARTIAL REMOVAL OF PANCREAS 3
- Page 109 and 110:
49507 PRP I/HERN INIT BLOCK >5 YR 3
- Page 111 and 112:
50392 INSERT KIDNEY DRAIN 3 $187.72
- Page 113 and 114:
5100F RSK FX REF W/N 24 HRS X-RAY 9
- Page 115 and 116:
52305 CYSTOSCOPY AND TREATMENT 3 $2
- Page 117 and 118:
53661 DILATION OF URETHRA 3 $74.40
- Page 119 and 120:
54670 REPAIR TESTIS INJURY 3 $421.1
- Page 121 and 122:
56342 LAPAROSCOPIC CHOLECYSTECTOMY
- Page 123 and 124:
57295 REVISE VAG GRAFT VIA VAGINA 3
- Page 125 and 126:
58548 LAP RADICAL HYST 3 $1,730.60
- Page 127 and 128:
59160 D & C AFTER DELIVERY 3 $202.4
- Page 129 and 130:
61150 PIERCE SKULL FOR DRAINAGE 3 $
- Page 131 and 132:
61606 RESECT/EXCISE CRANIAL LESION
- Page 133 and 134:
62225 REPLACE/IRRIGATE CATHETER 3 $
- Page 135 and 136:
63198 INCISE SPINAL COLUMN & CORD 3
- Page 137 and 138:
64475 INJ PARAVERTEBRAL L/S O $0.00
- Page 139 and 140:
64823 REMOVE SYMPATHETIC NERVES 3 $
- Page 141 and 142:
65782 OCULAR RECONST, TRANSPLANT 3
- Page 143 and 144:
67120 REMOVE EYE IMPLANT MATERIAL 3
- Page 145 and 146:
68020 INCISE/DRAIN EYELID LINING 3
- Page 147 and 148:
69620 REPAIR OF EARDRUM 3 $661.13 6
- Page 149 and 150:
70482 CT ORBIT/EAR/FOSSA W/O&W/DYE
- Page 151 and 152:
72195 MRI PELVIS W/O DYE 3 $432.90
- Page 153 and 154:
74181 MRI ABDOMEN W/O DYE 3 $432.28
- Page 155 and 156:
75564 HT MRI W/FLO/VEL/STRS & DYE O
- Page 157 and 158:
75804 LYMPHANGIOGRAPHY, EXTREMITY O
- Page 159 and 160:
76013 PERCUT VERTEBROPLASTY, CT O $
- Page 161 and 162:
76831 ECHO EXAM, UTERUS 3 $121.16 7
- Page 163 and 164:
77371 SRS, MULTISOURCE 3 $1,188.49
- Page 165 and 166:
78191 PLATELET SURVIVAL 3 $181.37 7
- Page 167 and 168:
78591 VENT IMAGE, 1 BREATH, 1 PROJ
- Page 169 and 170:
80049 METABOLIC PANEL, BASIC 9 $0.0
- Page 171 and 172:
80439 TRH STIMULATION PANEL 3 $94.3
- Page 173 and 174:
82210 BARBITURATES QUANTITATIVE AND
- Page 175 and 176:
82536 CORTISOL AFTER ADRENOCORTICOT
- Page 177 and 178:
82784 ASSAY, IGA/IGD/IGG/IGM EACH 3
- Page 179 and 180:
83486 HYDROXYBUTYRIC DEHYDROGENASE,
- Page 181 and 182:
83785 ASSAY OF MANGANESE 3 $15.28 8
- Page 183 and 184:
84061 PHOSPHATASE, FORENSIC EXAM 3
- Page 185 and 186:
84377 SUGARS, MULTIPLE, QUAL 3 $7.7
- Page 187 and 188:
85012 BLOOD COUNT EOSINOPHIL COUNT,
- Page 189 and 190:
85420 FIBRINOLYTIC PLASMINOGEN 3 $9
- Page 191 and 192:
86085 BLOOD TYPING ANTIGEN SCREENIN
- Page 193 and 194:
86360 T CELL, ABSOLUTE COUNT/RATIO
- Page 195 and 196:
86704 HEP B CORE ANTIBODY, TOTAL 3
- Page 197 and 198:
87040 BLOOD CULTURE FOR BACTERIA 3
- Page 199 and 200:
87301 ADENOVIRUS AG, EIA 3 $15.45 8
- Page 201 and 202:
87652 STREP A, DNA, QUANT 3 $39.83
- Page 203 and 204:
88261 CHROMOSOME ANALYSIS, 5 3 $248
- Page 205 and 206:
89259 CRYOPRESERVATION, SPERM 9 $0.
- Page 207 and 208:
90460 REST HOME (EG, BOARDING HOME)
- Page 209 and 210:
90723 DTAP-HEP B-IPV VACCINE, IM 5
- Page 211 and 212:
90857 INTAC GROUP PSYTX 3 $35.98 90
- Page 213 and 214:
92014 EYE EXAM & TREATMENT 3 $111.0
- Page 215 and 216:
92562 LOUDNESS BALANCE TEST 3 $25.9
- Page 217 and 218:
93024 CARDIAC DRUG STRESS TEST 3 $1
- Page 219 and 220:
93547 COMBINED LEFT HEART CATHETERI
- Page 221 and 222:
93971 EXTREMITY STUDY 3 $122.87 939
- Page 223 and 224:
95031 INTRACUTANEOUS (INTRADERMAL)
- Page 225 and 226:
95904 SENSE NERVE CONDUCTION TEST 3
- Page 227 and 228:
96413 CHEMO, IV INFUSION, 1 HR 3 $1
- Page 229 and 230:
97605 NEG PRESS WOUND TX, < 50 CM 3
- Page 231 and 232:
99183 HYPERBARIC OXYGEN THERAPY 3 $
- Page 233 and 234:
99336 DOMICIL/R-HOME VISIT EST PAT
- Page 235 and 236:
99499 UNLISTED E&M SERVICE 5 $0.00
- Page 237 and 238:
A0396 ALS ESOPHAGEAL INTUB SUPPLS 9
- Page 239 and 240:
A4321 CATH THERAPEUTIC IRRIG AGENT
- Page 241 and 242:
A4427 OST PCH DRAIN/BARR LK FLNG/F
- Page 243 and 244:
A4635 UNDERARM CRUTCH PAD 3 $4.16 A
- Page 245 and 246:
A5062 DRNBLE OSTOMY POUCH W/O BARR
- Page 247 and 248:
A6246 HYDROGEL DRG >16 48 SQ IN W/B
- Page 249 and 250:
A7008 DISPOSABLE NEBULIZER PREFILL
- Page 251 and 252:
A9518 I-131 SODIUM IODIDE SOLUTION
- Page 253 and 254:
B4150 EF COMPLET W/INTACT NUTRIENT
- Page 255 and 256:
C1068 PULSAR DDD PMKR 9 $0.00 C1069
- Page 257 and 258:
C1178 BUSULFAN IV, 6 MG O $0.00 C11
- Page 259 and 260: C1721 AICD, DUAL CHAMBER 9 $0.00 C1
- Page 261 and 262: C1869 GORE THYROPLASTY DEVICE 9 $0.
- Page 263 and 264: C2607 SPINECATH INTRADISCAL CATH 9
- Page 265 and 266: C4602 TENDRIL SDX, 1488K PMKR LEAD
- Page 267 and 268: C6036 BARD EPTFE: 50/75SQCM-1,2MM 9
- Page 269 and 270: C8830 GIANTURCO-ROUBIN COR SNT 9 $0
- Page 271 and 272: C9224 INJECTION, GALSULFASE O $0.00
- Page 273 and 274: C9700 WATER INDUCED THERMO 9 $0.00
- Page 275 and 276: D1320 TOBACCO COUNSELING 1 $0.00 D1
- Page 277 and 278: D2975 COPING 9 $0.00 D2980 CROWN RE
- Page 279 and 280: D5640 REPLACE PART DENTURE TEETH 1
- Page 281 and 282: D6067 IMPLANT SUPPORTED MTL CROWN 9
- Page 283 and 284: D7140 EXTRACTION ERUPTED TOOTH/EXR
- Page 285 and 286: D7877 TMJ ARTHROSCOPY DEBRIDEMENT 9
- Page 287 and 288: D9941 FABRICATION ATHLETIC GUARD 9
- Page 289 and 290: E0232 WARMING CARD FOR NWT 5 $0.00
- Page 291 and 292: E0480 PERCUSSOR ELECT/PNEUM HOME M
- Page 293 and 294: E0754 PULSEGENERATOR PT PROGRAMMER
- Page 295 and 296: E1001 WHEELCHAIR WHEEL O $0.00 E100
- Page 297 and 298: E1298 WHEELCHAIR SPEC SEAT DEPTH/W
- Page 299 and 300: E2206 COMPLETE WHEEL LOCK ASSEMBLY
- Page 301 and 302: E2599 SGD ACCESSORY NOC 6 $0.00 E26
- Page 303 and 304: G0073 INDIVIDUAL PSYCHOTHERAPY, INS
- Page 305 and 306: G0194 SENSORYTESTINGENDOSCOPICSTUD
- Page 307 and 308: G0304 PRE-OP SERVICE LVRS 1-9 DOS 9
- Page 309: G0415 OPEN TX POST PELVIC FXCTURE 9
- Page 313 and 314: G8268 PT NOT DOC REC CARE URIN INC
- Page 315 and 316: G8366 PT DOC TO HAVE EMPIRIC AB 9 $
- Page 317 and 318: G8473 ACE/ARB THXPY RX'D 9 $0.00 G8
- Page 319 and 320: G8573 STK/CVA CABG 9 $0.00 G8574 NO
- Page 321 and 322: G9052 ONC SURVEILLANCE FOR DISEASE
- Page 323 and 324: H0007 ALCOHOL AND/OR DRUG SERVICES
- Page 325 and 326: H5200 NURSING CARE, OTHER 9 $0.00 H
- Page 327 and 328: J0390 CHLOROQUINE INJECTION 5 $0.00
- Page 329 and 330: J1070 TESTOSTERONE CYPIONAT 100 MG
- Page 331 and 332: J1675 HISTRELIN ACETATE 6 $0.00 J16
- Page 333 and 334: J2469 PALONOSETRON HCL 3 $17.51 J24
- Page 335 and 336: J3265 INJECTION TORSEMIDE 10 MG/ML
- Page 337 and 338: J7321 HYALGAN/SUPARTZ INJ PER DOSE
- Page 339 and 340: J7672 METAPROTERENOL SULFATE .6% O
- Page 341 and 342: J9240 MEDROXYPROGESTERONE ACETATE,
- Page 343 and 344: K0064 ZERO PRESSURE TUBE FLAT FREE
- Page 345 and 346: K0169 DISPOSABLE NEBULIZER SMALL 9
- Page 347 and 348: K0276 OSTOMY FACEPLATE; CONVEX; CUS
- Page 349 and 350: K0531 HEATED HUMIDIFIER USED W PAP
- Page 351 and 352: K0663 POSITION BACK CUSH WDTH GREAT
- Page 353 and 354: L0180 CER POST COL OCC/MAN SUP ADJ
- Page 355 and 356: L0974 TLSO FULL CORSET 3 $128.76 L0
- Page 357 and 358: L1971 AFO W/ANKLE JOINT, PREFAB 6 $
- Page 359 and 360: L2750 PLATING CHROME/NICKEL PR BAR
- Page 361 and 362:
L3560 O SHOE ADD HORSESHOE TOE TAP
- Page 363 and 364:
L3960 SEWHO AIRPLAN DESIG ABDU POS
- Page 365 and 366:
L5580 PREP AK ISCHIAL THERMO MOLD 3
- Page 367 and 368:
L5781 LOWER LIMB PROS VACUUM PUMP 5
- Page 369 and 370:
L6611 ADDITIONAL SWITCH, EXT POWER
- Page 371 and 372:
L6873 HAND MECH INF STEEPER OR EQU
- Page 373 and 374:
L8120 COMPRESSION STOCKING BK40-50
- Page 375 and 376:
M0023 ROUTINE NEWBORN CARE, INHOSPI
- Page 377 and 378:
P9052 PLATELETS, HLA-M, L/R, UNIT 9
- Page 379 and 380:
Q0185 METABOLIC ACTIVE D/E TISSUE 9
- Page 381 and 382:
Q4011 CAST SUP SHT ARM PED PLASTER
- Page 383 and 384:
Q9924 EPOETIN WITH HCT = 24 O $0.00
- Page 385 and 386:
S0128 INJ FOLLITROPIN BETA 75 IU 9
- Page 387 and 388:
S0518 SUNGLASS FRAMES 9 $0.00 S0580
- Page 389 and 390:
S2340 CHEMODENERVATION OF ABDUCTOR
- Page 391 and 392:
S4028 MICROSURG EPI SPERM ASP 9 $0.
- Page 393 and 394:
S8042 MRI LOW FIELD 5 $0.00 S8048 I
- Page 395 and 396:
S9129 OCCUPATIONAL THERAPY, IN THE
- Page 397 and 398:
S9476 VESTIBULAR REHAB PER DIEM 9 $
- Page 399 and 400:
T2004 N-ET; COMMERC CARRIER PASS 9
- Page 401 and 402:
V2105 SPHEROCYLINDER 4.00D/4.25-6D
- Page 403 and 404:
V2710 GLASS/PLASTIC SLAB OFF PRISM
- Page 405 and 406:
V5298 HEARING AID NOC 5 $0.00 V5299
- Page 407 and 408:
WW524 VISION PROGRAM UNDER EPSDT-UN
- Page 409 and 410:
WW851 OXYGEN CONTENT, GASEOUS, PER
- Page 411 and 412:
YY409 DPH TUBERCULOSIS CLINIC VISIT
- Page 413 and 414:
YY645 HOME & COMMUNITY-BASED WAIVER
- Page 415 and 416:
ZR002 MCO SPECIFIC CODE: HOME INFUS
- Page 417 and 418:
Procedure Code Description Pricing
- Page 419 and 420:
D3348 RETREAT ROOT CANAL MOLAR 80 D
- Page 421 and 422:
D5952 PEDIATRIC SPEECH AID 80 D5953
- Page 423 and 424:
Procedure Description RVU RVU Coeff
- Page 425 and 426:
00842 ANESTH, AMNIOCENTESIS 4 20.93
- Page 427 and 428:
01656 ANESTH, ARM-LEG VESSEL SURG 1
- Page 429 and 430:
33254 ABLATE ATRIA, LMTD 38.69 1.00
- Page 431 and 432:
33690 REINFORCE PULMONARY ARTERY 33
- Page 433 and 434:
34802 ENDOVAS AAA REPR W/2-P PART 3
- Page 435 and 436:
35492 ATHERECTOMY, PERCUTANEOUS 10.
- Page 437 and 438:
36012 PLACE CATHETER IN VEIN 5.16 1
- Page 439 and 440:
37145 REVISION OF CIRCULATION 41.57
- Page 441 and 442:
52317 REMOVE BLADDER STONE 9.47 1.0
- Page 443 and 444:
57530 REMOVAL OF CERVIX 9.27 1.00 5
- Page 445 and 446:
61001 REMOVE CRANIAL CAVITY FLUID 3
- Page 447 and 448:
61606 RESECT/EXCISE CRANIAL LESION
- Page 449 and 450:
62281 TREAT SPINAL CORD LESION 3.99
- Page 451 and 452:
63307 REMOVAL OF VERTEBRAL BODY 61.
- Page 453 and 454:
64721 CARPAL TUNNEL SURGERY 10.81 1
- Page 455 and 456:
65400 REMOVAL OF EYE LESION 14.91 1
- Page 457 and 458:
67121 REMOVE EYE IMPLANT MATERIAL 2
- Page 459 and 460:
68362 REVISE EYELID LINING 16.73 1.
- Page 461 and 462:
71260 CT THORAX W/DYE 8.38 1.00 712
- Page 463 and 464:
73615 CONTRAST X-RAY OF ANKLE 2.66
- Page 465 and 466:
75840 VEIN X-RAY, ADRENAL GLAND 6.1
- Page 467 and 468:
77750 INFUSE RADIOACTIVE MATERIALS
- Page 469 and 470:
78645 CSF SHUNT EVALUATION 7.94 1.0
- Page 471 and 472:
93306 TTE W/DOPPLER, COMPLETE 6.58
- Page 473 and 474:
88300 26 3 4.89 E0113 RR 3 4.92 K00
- Page 475 and 476:
73030 26 3 9.71 73562 26 3 9.71 782
- Page 477 and 478:
94375 26 3 14.59 94452 26 3 14.59 K
- Page 479 and 480:
73000 TC 3 19.14 73090 TC 3 19.14 7
- Page 481 and 482:
93971 26 3 23.23 E0158 UE 3 23.24 7
- Page 483 and 484:
95926 26 3 27.4 78605 26 3 27.41 72
- Page 485 and 486:
74022 TC 3 31.24 95873 TC 3 31.24 7
- Page 487 and 488:
78761 26 3 36.51 76932 26 3 36.55 E
- Page 489 and 490:
95861 TC 3 43.71 E0600 RR 3 43.8 78
- Page 491 and 492:
95863 TC 3 52.41 88365 26 3 52.43 7
- Page 493 and 494:
92240 26 3 59.96 74445 26 3 59.99 7
- Page 495 and 496:
75685 26 3 68.23 88368 TC 3 68.23 7
- Page 497 and 498:
76826 TC 3 78.11 E0900 UE 3 78.17 7
- Page 499 and 500:
74283 TC 3 89.44 51726 26 3 89.49 7
- Page 501 and 502:
76940 26 3 104.29 E0660 UE 3 104.3
- Page 503 and 504:
K0070 UE 3 136.7 78300 TC 3 136.94
- Page 505 and 506:
75605 TC 3 177.14 75650 TC 3 177.14
- Page 507 and 508:
E0667 UE 3 232.3 75952 26 3 233.14
- Page 509 and 510:
73202 TC 3 322.28 E0239 UE 3 322.78
- Page 511 and 512:
E1086 UE 3 540.83 E1110 UE 3 541.05