2010 HCPCS Schedule - DE Medical Assistance Program

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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
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 and 310:
G0415 OPEN TX POST PELVIC FXCTURE 9
Page 311 and 312:
G8153 PT NOT DOC FOR AB 1 HR PRIOR
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: T2004 N-ET; COMMERC CARRIER PASS 9
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
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