fee schedule 2009 new - DE Medical Assistance Program

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P9024 9 FACTOR VIII DILUTION, EACH BOTTLE. 0.00 P9031 9 PLATELETS LEUKOCYTES REDUCED 0.00 P9032 9 PLATELETS, IRRADIATED 0.00 P9033 9 PLATELETS LEUKOREDUCED IRRAD 0.00 P9034 9 PLATELETS, PHERESIS 0.00 P9035 9 PLATELET PHERES LEUKOREDUCED 0.00 P9036 9 PLATELET PHERESIS IRRADIATED 0.00 P9037 9 PLATE PHERES LEUKOREDU IRRAD 0.00 P9038 9 RBC IRRADIATED 0.00 P9039 9 RBC DEGLYCEROLIZED 0.00 P9040 9 RBC LEUKOREDUCED IRRADIATED 0.00 P9041 9 ALBUMIN (HUMAN),5%, 50ML 0.00 P9042 9 ALBUMIN (HUMAN), 25% 0.00 P9043 9 PLASMA PROTEIN FRACT,5%,50ML 0.00 P9044 9 CRYOPRECIPITATEREDUCEDPLASMA 0.00 P9045 9 ALBUMIN (HUMAN), 5%, 250 ML 0.00 P9046 9 ALBUMIN (HUMAN), 25%, 20 ML 0.00 P9047 9 ALBUMIN (HUMAN), 25%, 50ML 0.00 P9048 9 PLASMAPROTEIN FRACT,5%,250ML 0.00 P9050 9 GRANULOCYTES, PHERESIS UNIT 0.00 P9051 9 BLOOD, L/R, CMV-NEG 0.00 P9052 9 PLATELETS, HLA-M, L/R, UNIT 0.00 P9053 9 PLT, PHER, L/R CMV-NEG, IRR 0.00 P9054 9 BLOOD, L/R, FROZ/DEGLY/WASH 0.00 P9055 9 PLT, APH/PHER, L/R, CMV-NEG 0.00 P9056 9 BLOOD, L/R, IRRADIATED 0.00 P9057 9 RBC, FRZ/DEG/WSH, L/R, IRRAD 0.00 P9058 9 RBC, L/R, CMV-NEG, IRRAD 0.00 P9059 9 PLASMA, FRZ BETWEEN 8-24HOUR 0.00 P9060 9 FR FRZ PLASMA DONOR RETESTED 0.00 P9603 9 ONE-WAY ALLOW PRORATED MILES 0.00 P9604 9 ONE-WAY ALLOW PRORATED TRIP 0.00 P9605 O ROUTINE VENIPUNCTURE FOR COLLECTION 0.00 P9610 9 URINE SPECIMEN COLLECT SINGL 0.00 P9612 9 CATHETERIZE FOR URINE SPEC 0.00 P9615 9 URINE SPECIMEN COLLECT MULT 0.00 PEDCL O MCO SPECIFIC CODE: SMART START PREN 0.00 Q0033 9 LINOZ V. BOWEN AMBULANCE REIMBURSE 0.00 Q0034 9 ADMIN OF INFLUENZA VACCINE 0.00 Q0035 9 CARDIOKYMOGRAPHY 0.00 Q0036 O OXYGEN CONCENTRATOR, HIGH HUMIDITY 0.00 Q0037 5 OXYGEN AND WATER VAPOR ENRICHING SY 0.00 Q0038 O OXYGEN CONTENTS, GASEOUS, PER UNIT 0.00 Q0039 9 OXYGEN CONTENTS, LIQUID, PER UNIT, 0.00 Q0040 O PORTABLE OXYGEN CONTENTS, GASEOUS P 0.00 Q0041 O PORTABLE OXYGEN CONTENTS, LIQUID, P 0.00 Q0042 O STATIONARY COMPRESSED GAS SYSTEM RE 0.00 Q0043 O STATIONARY LIQUID OXYGEN SYSTEM REN 0.00 Q0045 9 ANESTHESIA FOR IRIDECTOMY 0.00 Q0046 9 PORTABLE LIQUID OXYGEN SYSTEM RENTA 0.00
Q0047 9 ANESTHESIA FOR BLEPHAROPLASTY 0.00 Q0066 9 ASSESSMENT OF CARDIAC OUTPUT BY ELE 0.00 Q0068 9 EXTRACORPEAL PLASMAPHERESIS 0.00 Q0081 9 INFUSION THER OTHER THAN CHE 0.00 Q0082 9 ACTIVITY THERAPY W/PARTIAL H 0.00 Q0083 9 CHEMO BY OTHER THAN INFUSION 0.00 Q0084 9 CHEMOTHERAPY BY INFUSION 0.00 Q0085 9 CHEMO BY BOTH INFUSION AND O 0.00 Q0086 O PHYSICAL THERAPY EVALUATION/ 0.00 Q0091 9 OBTAINING SCREEN PAP SMEAR 0.00 Q0092 O SET UP PORT XRAY EQUIPMENT 0.00 Q0093 O FILGRASTIM (G-CSF), PER 100 MCG 0.00 Q0094 O SARGRAMOSTIM (GM-CSF), PER 250 MCG 0.00 Q0095 O URINE PREGNANCY TESTS, VISUAL COLOR 0.00 Q0096 O OVULATION TEST KITS, VISUAL COLOR C 0.00 Q0097 O HEMOGLOBIN; BY COPPER SULFATE METHO 0.00 Q0098 O GLUCOSE, BLOOD; BY GLUCOSE MONITORI 0.00 Q0100 O URINALYSIS BY DIP STICK OR TABLET F 0.00 Q0101 O MICROHEMATOCRIT, SPUN 0.00 Q0102 O SEDIMENTATION RATE, ERYTHROCYTE; NO 0.00 Q0103 9 PHYSICAL THERAPY EVALUATION, INITIA 0.00 Q0104 9 PHYSICAL THERAPY RE-EVALUATION, PER 0.00 Q0109 9 OCCUPATIONAL THERAPY EVALUATION, IN 0.00 Q0110 9 OCCUPATIONAL THERAPY RE-EVALUATION, 0.00 Q0111 O WET MOUNTS/ W PREPARATIONS 0.00 Q0112 O POTASSIUM HYDROXIDE PREPS 0.00 Q0113 O PINWORM EXAMINATIONS 0.00 Q0114 9 FERN TEST 0.00 Q0115 9 POST-COITAL MUCOUS EXAM 0.00 Q0116 O HEMOGLOBIN BY SINGLE ANALYTE INSTRU 0.00 Q0117 9 FOR DIABETICS ONLY, FITTING (INCLUD 0.00 Q0118 9 FOR DIABETICS ONLY, FITTING (INCLUD 0.00 Q0119 9 FOR DIABETICS ONLY, MULTIPLE DENSIT 0.00 Q0120 9 FOR DIABETICS ONLY, MODIFICATION (I 0.00 Q0121 9 FOR DIABETICS ONLY, MODIFICATION (I 0.00 Q0122 9 FOR DIABETICS ONLY, MODIFICATION (I 0.00 Q0123 9 FOR DIABETICS ONLY, MODIFICATION (I 0.00 Q0132 9 DISPENSING FEE DME NEB DRUG 0.00 Q0136 O NON ESRD EPOETIN ALPHA INJ 0.00 Q0137 O INJECTION, DARBEPOETIN ALFA 0.00 Q0138 O INJECTION, DEXAMETHASONE ACETATE, 1 0.00 Q0144 9 AZITHROMYCIN DIHYDRATE, ORAL 0.00 Q0156 9 HUMAN ALBUMIN 5% 0.00 Q0157 O HUMAN ALBUMIN 25% 0.00 Q0160 9 FACTOR IX NON-RECOMBINANT 0.00 Q0161 9 FACTOR IX RECOMBINANT 0.00 Q0163 9 DIPHENHYDRAMINE HCL 50MG 0.00 Q0164 9 PROCHLORPERAZINE MALEATE 5MG 0.00 Q0165 9 PROCHLORPERAZINE MALEATE10MG 0.00 Q0166 9 GRANISETRON HCL 1 MG ORAL 0.00
Page 1 and 2:
Fee Schedule 2009 Procedure Code Pr
Page 3 and 4:
00404 A ANESTH, SURGERY OF BREAST 0
Page 5 and 6:
0079T 9 ENDOVASC VISC EXTNSN REPR 0
Page 7 and 8:
0115T O MED TX MNGMT 15 MIN 0.00 01
Page 9 and 10:
01654 A ANESTH, SHOULDER VESSEL SUR
Page 11 and 12:
01968 A ANES/ANALG CS DELIVER ADD-O
Page 13 and 14:
11008 3 REMOVE MESH FROM ABD WALL 2
Page 15 and 16:
11643 3 EXC FACE-MM MALIG+MARG 2.1-
Page 17 and 18:
14060 3 SKIN TISSUE REARRANGEMENT 6
Page 19 and 20:
15755 O FREE FLAP (MICROVASCULAR TR
Page 21 and 22:
16036 3 ESCHAROTOMY; ADDÏL INCISIO
Page 23 and 24:
19330 3 REMOVAL OF IMPLANT MATERIAL
Page 25 and 26:
20827 3 REPLANTATION THUMB, COMPLET
Page 27 and 28:
21179 3 RECONSTRUCT ENTIRE FOREHEAD
Page 29 and 30:
21465 3 TREAT LOWER JAW FRACTURE 83
Page 31 and 32:
22554 3 NECK SPINE FUSION 1,179.36
Page 33 and 34:
23440 3 REMOVE/TRANSPLANT TENDON 70
Page 35 and 36:
24342 3 REPAIR OF RUPTURED TENDON 7
Page 37 and 38:
25076 3 REMOVAL FOREARM LESION DEEP
Page 39 and 40:
25540 O TREATMENT OF OPEN ULNAR SHA
Page 41 and 42:
26320 3 REMOVAL OF IMPLANT FROM HAN
Page 43 and 44:
26645 3 TREAT THUMB FRACTURE 363.93
Page 45 and 46:
27111 3 TRANSFER OF ILIOPSOAS MUSCL
Page 47 and 48:
27329 3 REMOVE TUMOR, THIGH/KNEE 93
Page 49 and 50:
27524 3 TREAT KNEECAP FRACTURE 698.
Page 51 and 52:
27754 O TREATMENT OF OPEN TIBIAL SH
Page 53 and 54:
28116 3 REVISION OF FOOT 653.00 281
Page 55 and 56:
28520 O TREATMENT OF OPEN FRACTURE,
Page 57 and 58:
29799 5 CASTING/STRAPPING PROCEDURE
Page 59 and 60:
30210 3 NASAL SINUS THERAPY 130.90
Page 61 and 62:
31201 3 REMOVAL OF ETHMOID SINUS 66
Page 63 and 64:
31571 3 LARYNGOSCOP W/VC INJ + SCOP
Page 65 and 66:
3220F 9 HEP C QUANT RNA TSTNG DOCÏ
Page 67 and 68:
32998 3 PERQ RF ABLATE TX, PUL TUMO
Page 69 and 70:
33320 3 REPAIR MAJOR BLOOD VESSEL(S
Page 71 and 72:
33610 3 REPAIR BY ENLARGEMENT 1,728
Page 73 and 74:
33916 3 SURGERY OF GREAT VESSEL 1,5
Page 75 and 76:
35103 3 REPAIR ARTERY RUPTURE, GROI
Page 77 and 78:
35516 3 ARTERY BYPASS GRAFT 1,167.2
Page 79 and 80:
36000 3 PLACE NEEDLE IN VEIN 26.52
Page 81 and 82:
36585 3 REPLACE PICVAD CATH 1,160.3
Page 83 and 84:
38120 3 LAPAROSCOPY, SPLENECTOMY 92
Page 85 and 86:
4041F 9 DOC ORDER CEFAZOLIN/CEFUROX
Page 87 and 88:
4120F 9 ANTIBIOT RXÏD/GIVEN 0.00 4
Page 89 and 90:
42235 3 REPAIR PALATE 726.80 42260
Page 91 and 92:
43020 3 INCISION OF ESOPHAGUS 498.5
Page 93 and 94:
43352 3 SURGICAL OPENING, ESOPHAGUS
Page 95 and 96:
44121 3 REMOVAL OF SMALL INTESTINE
Page 97 and 98:
44650 3 REPAIR BOWEL FISTULA 1,274.
Page 99 and 100:
45805 3 REPAIR FISTULA W/COLOSTOMY
Page 101 and 102:
47133 9 REMOVAL OF DONOR LIVER 0.00
Page 103 and 104:
48510 3 DRAIN PANCREATIC PSEUDOCYST
Page 105 and 106:
49566 3 REREPAIR VENTRL HERN, BLOCK
Page 107 and 108:
50546 3 LAPAROSCOPIC NEPHRECTOMY 1,
Page 109 and 110:
51570 3 REMOVAL OF BLADDER 1,434.15
Page 111 and 112:
52354 3 CYSTOURETERO W/BIOPSY 388.0
Page 113 and 114:
54152 O CIRCUMCISION 0.00 54160 3 C
Page 115 and 116:
55530 3 REVISE SPERMATIC CORD VEINS
Page 117 and 118:
56631 3 EXTENSIVE VULVA SURGERY 1,0
Page 119 and 120:
57545 3 REMOVE CERVIX/REPAIR PELVIS
Page 121 and 122:
58800 3 DRAINAGE OF OVARIAN CYST(S)
Page 123 and 124:
59898 5 LAPARO PROC, OB CARE/DELIVE
Page 125 and 126:
61522 3 REMOVAL OF BRAIN ABSCESS 1,
Page 127 and 128:
61795 3 BRAIN SURGERY USING COMPUTE
Page 129 and 130:
63011 3 REMOVAL OF SPINAL LAMINA 97
Page 131 and 132:
63690 O ANALYSIS OF NEURORECEIVER 0
Page 133 and 134:
64727 3 INTERNAL NERVE REVISION 172
Page 135 and 136:
65265 3 REMOVE FOREIGN BODY FROM EY
Page 137 and 138:
66940 3 EXTRACTION OF LENS 643.79 6
Page 139 and 140:
67900 3 REPAIR BROW DEFECT 561.45 6
Page 141 and 142:
69399 5 OUTER EAR SURGERY PROCEDURE
Page 143 and 144:
70250 3 X-RAY EXAM OF SKULL 36.71 7
Page 145 and 146:
72126 3 CT NECK SPINE W/DYE 341.82
Page 147 and 148:
73630 3 X-RAY EXAM OF FOOT 31.45 73
Page 149 and 150:
75520 O CARDIAC RADIOGRAPHY, SELECT
Page 151 and 152:
75764 O ANGIOGRAPHY, CORONARY BYPAS
Page 153 and 154:
76000 3 FLUOROSCOPE EXAMINATION 89.
Page 155 and 156:
76825 3 ECHO EXAM OF FETAL HEART 17
Page 157 and 158:
77336 3 RADIATION PHYSICS CONSULT 8
Page 159 and 160:
78191 3 PLATELET SURVIVAL 250.20 78
Page 161 and 162:
78601 3 BRAIN IMAGE W/FLOW < 4 VIEW
Page 163 and 164:
80057 9 MALE INFERTILITY AND/OR GYN
Page 165 and 166:
81007 3 URINE SCREEN FOR BACTERIA 3
Page 167 and 168:
82250 O ASSAY BILIRUBIN 0.00 82251
Page 169 and 170:
82554 3 CREATINE, ISOFORMS 16.58 82
Page 171 and 172:
82812 O GASES, BLOOD PO2 BY MANOMET
Page 173 and 174:
83524 O INDICAN, URINE 0.00 83525 3
Page 175 and 176:
83865 O MUCOPOLYSACCHARIDES, ACID,
Page 177 and 178:
84132 3 ASSAY OF SERUM POTASSIUM 6.
Page 179 and 180:
84446 3 ASSAY OF VITAMIN E 19.81 84
Page 181 and 182:
85109 O BONE MARROW BIOPSY, NEEDLE
Page 183 and 184:
85610 3 PROTHROMBIN TIME 5.49 85611
Page 185 and 186:
86255 3 FLUORESCENT ANTIBODY, SCREE
Page 187 and 188:
86586 O SKIN TEST, UNLISTED 0.00 86
Page 189 and 190:
86800 3 THYROGLOBULIN ANTIBODY 22.2
Page 191 and 192:
87172 3 PINWORM EXAM 5.96 87174 O E
Page 193 and 194:
87500 3 VANOMYCIN, DNA, AMP PROBE 4
Page 195 and 196:
88142 3 CYTOPATH, C/V, THIN LAYER 2
Page 197 and 198:
88371 3 PROTEIN, WESTERN BLOT TISSU
Page 199 and 200:
90240 O SUBSEQUENT HOSPITAL CARE, E
Page 201 and 202:
90665 3 LYME DISEASE VACCINE, IM 53
Page 203 and 204:
90808 3 PSYTX, OFFICE, 75-80 MIN 13
Page 205 and 206:
90999 5 DIALYSIS PROCEDURE 0.00 910
Page 207 and 208:
92510 O REHAB FOR EAR IMPLANT 0.00
Page 209 and 210:
92977 3 DISSOLVE CLOT, HEART VESSEL
Page 211 and 212:
93505 3 BIOPSY OF HEART LINING 645.
Page 213 and 214:
93882 3 EXTRACRANIAL STUDY 171.47 9
Page 215 and 216:
95011 O PERCUTANEOUS TESTS (SCRATCH
Page 217 and 218:
95868 3 MUSCLE TEST CRAN NERVE BILA
Page 219 and 220:
96400 O CHEMOTHERAPY, SC/IM 0.00 96
Page 221 and 222:
97541 O TRAINING IN ACTIVITIES OF D
Page 223 and 224:
99173 3 VISUAL ACUITY SCREEN 2.66 9
Page 225 and 226:
99332 O REST HOME VISIT, EST PAT 0.
Page 227 and 228:
99479 6 IC LBW INF 1500-2500 G SUBS
Page 229 and 230:
A0396 9 ALS ESOPHAGEAL INTUB SUPPLS
Page 231 and 232:
A4324 O MALE EXT CATH W/ADH COATING
Page 233 and 234:
A4433 3 URINE OST PCH BAR W LOCK FL
Page 235 and 236:
A4645 O CONTRAST 200-299 MGS IODINE
Page 237 and 238:
A5093 3 OSTOMY ACCESSORY CONVEX INS
Page 239 and 240:
A6261 5 WOUND FILLER GEL/PASTE /OZ
Page 241 and 242:
A7028 6 REPL ORAL CUSHION COMBO MAS
Page 243 and 244:
A9536 9 TC99M DEPREOTIDE 0.00 A9537
Page 245 and 246:
B4197 9 PARENTERAL SOL 74-100 GM PR
Page 247 and 248:
C1096 9 TC 99M EXAMETAZIME, PER DOS
Page 249 and 250:
C1319 9 WALLSTENT: ENTERAL--60MM 0.
Page 251 and 252:
C1769 9 GUIDE WIRE 0.00 C1770 9 IMA
Page 253 and 254:
C1931 9 TALON DIL CATH 0.00 C1932 9
Page 255 and 256:
C2676 9 RSPONSE CV CATHETER 0.00 C2
Page 257 and 258:
C5030 9 STENT, CORONARY, S660 9/12M
Page 259 and 260:
C8102 9 SURGIVISION ESOPH COIL 0.00
Page 261 and 262:
C9001 9 LINEZOLID INJ, 200MG 0.00 C
Page 263 and 264:
C9419 O INJ CLADRIBINE, BRAND 0.00
Page 265 and 266:
D0474 1 MICRO W EXAM OF SURG MARGIN
Page 267 and 268:
D2799 1 PROVISIONAL CROWN 0.00 D281
Page 269 and 270:
D5130 1 DENTURES IMMEDIAT MAXILLARY
Page 271 and 272:
D6010 9 ODONTICS ENDOSTEAL IMPLANT
Page 273 and 274:
D6930 1 DENTAL RECEMENT BRIDGE 0.00
Page 275 and 276:
D7840 9 REMOVAL OF TMJ CONDYLE 0.00
Page 277 and 278:
D9410 9 DENTAL HOUSE CALL 0.00 D942
Page 279 and 280:
E0203 5 THERAPEUTIC LIGHTBOX TABLET
Page 281 and 282:
E0460 O NEG PRESS VENT PORTABL/STAT
Page 283 and 284:
E0748 3 ELEC OSTEOGEN STIM SPINAL 3
Page 285 and 286:
E0997 O WHEELCHAIR CASTER W/ A FORK
Page 287 and 288:
E1297 3 WHEELCHAIR SPECIAL SEAT DEP
Page 289 and 290:
E2207 6 CRUTCH AND CANE HOLDER 0.00
Page 291 and 292:
E2603 6 SKIN PROTECT WC CUS WD =22I
Page 293 and 294:
G0078 9 INDIVIDUAL PSYCHOTHERAPY, I
Page 295 and 296:
G0201 9 MODIFORTRAININGINUSEVOICEPR
Page 297 and 298:
G0313 O ESRD RELATED SVS 1 MON 2-11
Page 299 and 300:
G8012 9 PNEUM PT RECV ANTIBIOTIC 4
Page 301 and 302:
G8192 O ANTIB GIVEN PRIOR SURG INCI
Page 303 and 304:
G8294 O COPD PT INELIG SPIR RESULTS
Page 305 and 306:
G8416 9 PT INELIG FOOTWEAR EVALUATI
Page 307 and 308:
G8517 9 SCRN FALL RSK;
Page 309 and 310:
G9082 O ONC DX PROSTATE CASTRATE ME
Page 311 and 312: H0042 9 FOS C CHLD NON-THER PER MON
Page 313 and 314: HI100 O MCO SPECIFIC CODE: HOME INF
Page 315 and 316: J0695 O CEFONOCID SODIUM INJECTION
Page 317 and 318: J1452 5 INTRAOCULAR FOMIVIRSEN NA 0
Page 319 and 320: J2050 O INJECTION, LIVER, UP TO 20
Page 321 and 322: J2850 5 INJ SECRETIN SYNTHETIC HUMA
Page 323 and 324: J7070 5 D5W INFUSION 0.00 J7080 O I
Page 325 and 326: J7632 9 CROMOLYN SODIUM COMP UNIT 0
Page 327 and 328: J9170 6 DOCETAXEL INJECTION 0.00 J9
Page 329 and 330: K0041 3 LARGE SIZE FOOTPLATE EACH 5
Page 331 and 332: K0141 9 ALBUTEROL SULFATE, COMPOUND
Page 333 and 334: K0257 9 TRANSPARENT FILM, 16 SQ. IN
Page 335 and 336: K0513 9 DEXAMETHASONE INH SOL U D 0
Page 337 and 338: K0651 O GEN W/C CUSHION WIDTH GREAT
Page 339 and 340: L0120 3 CERV FLEXIBLE NON-ADJUSTABL
Page 341 and 342: L0930 O PENDULOUS ABDOMEN SUPP CUST
Page 343 and 344: L1950 3 AFO SPIRAL MOLDED TO PT PLA
Page 345 and 346: L2670 3 THORAC CONT PARASPINAL UPRI
Page 347 and 348: L3570 5 O SHOE ADD INSTEP EXTENSION
Page 349 and 350: L3964 3 SEO MOBILE ARM SUP ATT TO W
Page 351 and 352: L5611 3 AK 4 BAR LINK W/FRIC SWING
Page 353 and 354: L5814 3 ENDO KNEE-SHIN HYDRAL SWG P
Page 355 and 356: L6632 3 LATEX SUSPENSION SLEEVE EAC
Page 357 and 358: L6915 3 HAND RESTORATION REPLACMNT
Page 359 and 360: L8330 3 TRUSS ADD TO STD PAD SCROTA
Page 361: M0580 9 TRANSTELEPHONIC ELECTROENCE
Page 365 and 366: Q0513 9 DISP FEE INHAL DRUGS/30 DAY
Page 367 and 368: Q4048 9 CAST SUP SHT LEG SPLNT PED
Page 369 and 370: S0016 O INJECTION, AMIKACIN SULFATE
Page 371 and 372: S0201 9 PARTIAL HOSPITALIZATION SER
Page 373 and 374: S2112 9 KNEE ARTHROSCP HARV 0.00 S2
Page 375 and 376: S3847 9 GENE TEST TAY-SACHS 0.00 S3
Page 377 and 378: S5181 9 HH RESIRATORY THRPY NOS DAY
Page 379 and 380: S9015 9 AUTOMATED EEG MONITORING 0.
Page 381 and 382: S9434 6 MOD SOLID FOOD SUPPL 0.00 S
Page 383 and 384: T1016 9 CASE MANAGEMENT 0.00 T1017
Page 385 and 386: TI420 O MCO SPECIFIC CODE: INTERPER
Page 387 and 388: V2531 3 CONTACT LENS GAS PERMEABLE
Page 389 and 390: V5258 5 HEARING AID, DIGIT, BIN, CI
Page 391 and 392: WW508 O VISION PROGRAM UNDER EPSDT-
Page 393 and 394: WW831 O PICC INSERTION TRAY 0.00 WW
Page 395 and 396: YY301 O FAMILY AND CHILDREN'S SERVI
Page 397 and 398: YY635 O HOME AND COMMUNITY-BASED SE
Page 399 and 400: ZH004 O MCO SPECIFIC CODE: HOME INF
Page 401 and 402: Procedure Code Description Pricing
Page 403 and 404: D3320 END THXPY, BICUSPID TOOTH 85.
Page 405 and 406: D5926 REPLACEMENT NASAL PROSTHESIS
Page 407 and 408: D9120 FIX PARTIAL DENTURE SECTION 8
Page 409 and 410: 00474 ANESTH, SURGERY OF RIB(S) 13.
Page 411 and 412: 01120 ANESTH, PELVIS SURGERY 6.00 1
Page 413 and 414:
01925 ANES, THER INTERVEN RAD, CAR
Page 415 and 416:
11624 EXC H-F-NK-SP MLG+MARG 3.1-4
Page 417 and 418:
15002 WOUND PREP, TRK/ARM/LEG 5.83
Page 419 and 420:
15842 FLAP FOR FACE NERVE PALSY 67.
Page 421 and 422:
19342 DELAYED BREAST PROSTHESIS 23.
Page 423 and 424:
23630 TREAT HUMERUS FRACTURE 18.66
Page 425 and 426:
24582 TREAT HUMERUS FRACTURE 20.02
Page 427 and 428:
25393 LENGTHEN RADIUS & ULNA 32.77
Page 429 and 430:
26123 RELEASE PALM CONTRACTURE 20.6
Page 431 and 432:
26568 LENGTHEN METACARPAL/FINGER 23
Page 433 and 434:
33255 ABLATE ATRIA W/O BYPASS, EXT
Page 435 and 436:
33676 CLOSE MULT VSD W/RESECTION 58
Page 437 and 438:
34451 REMOVAL OF VEIN CLOT 42.67 1.
Page 439 and 440:
35470 REPAIR ARTERIAL BLOCKAGE 12.7
Page 441 and 442:
35870 REPAIR VESSEL GRAFT DEFECT 36
Page 443 and 444:
36800 INSERTION OF CANNULA 4.35 1.0
Page 445 and 446:
40819 EXCISE LIP OR CHEEK FOLD 5.84
Page 447 and 448:
42508 PAROTID DUCT DIVERSION 18.47
Page 449 and 450:
43259 ENDOSCOPIC ULTRASOUND EXAM 7.
Page 451 and 452:
44005 FREEING OF BOWEL ADHESION 27.
Page 453 and 454:
44680 SURGICAL REVISION, INTESTINE
Page 455 and 456:
46070 INCISION OF ANAL SEPTUM 5.19
Page 457 and 458:
47530 REVISE/REINSERT BILE TUBE 9.9
Page 459 and 460:
49428 LIGATION OF SHUNT 11.05 1.00
Page 461 and 462:
50405 REVISION OF KIDNEY/URETER 38.
Page 463 and 464:
51575 REMOVAL OF BLADDER & NODES 50
Page 465 and 466:
52648 LASER SURGERY OF PROSTATE 18.
Page 467 and 468:
61458 INCISE SKULL FOR BRAIN WOUND
Page 469 and 470:
61710 REVISE CIRCULATION TO HEAD 49
Page 471 and 472:
63042 LAMINOTOMY, SINGLE LUMBAR 33.
Page 473 and 474:
64413 N BLOCK INJ, CERVICAL PLEXUS
Page 475 and 476:
64795 BIOPSY OF NERVE 5.02 1.00 648
Page 477 and 478:
65815 DRAINAGE OF EYE 10.79 1.00 65
Page 479 and 480:
67320 REVISE EYE MUSCLE(S) ADD-ON 7
Page 481 and 482:
68700 REPAIR TEAR DUCTS 13.76 1.00
Page 483 and 484:
71555 MRI ANGIO CHEST W OR W/O DYE
Page 485 and 486:
73610 X-RAY EXAM OF ANKLE 0.83 1.00
Page 487 and 488:
75736 ARTERY X-RAYS, PELVIS 10.29 1
Page 489 and 490:
77417 RADIOLOGY PORT FILM(S) 0.52 1
Page 491 and 492:
78585 LUNG V/Q IMAGING 8.76 1.00 78
Page 493 and 494:
91037 ESOPH IMPED FUNCTION TEST 4.2
Page 495 and 496:
93270 ECG RECORDING 0.84 1.00 93271
Page 497 and 498:
94450 HYPOXIA RESPONSE CURVE 1.36 1
Page 499 and 500:
97018 PARAFFIN BATH THERAPY 0.20 1.
Page 501 and 502:
Fee Schedule Modifiers Procedure Co
Page 503 and 504:
70380 TC 3 29.51 70390 26 3 18.41 7
Page 505 and 506:
71250 26 3 56.10 71250 TC 3 195.86
Page 507 and 508:
72197 26 3 109.49 72197 TC 3 537.09
Page 509 and 510:
73560 26 3 8.43 73560 TC 3 21.05 73
Page 511 and 512:
74260 26 3 24.22 74260 TC 3 90.89 7
Page 513 and 514:
75716 26 3 64.45 75716 TC 3 354.45
Page 515 and 516:
75962 TC 3 399.51 75964 26 3 17.93
Page 517 and 518:
76813 TC 3 75.36 76814 26 3 46.39 7
Page 519 and 520:
77052 TC 3 12.10 77280 26 3 34.11 7
Page 521 and 522:
78130 26 3 29.94 78130 TC 3 124.93
Page 523 and 524:
78478 26 3 26.98 78478 TC 3 44.66 7
Page 525 and 526:
78811 26 3 76.48 78811 TC 3 1,383.9
Page 527 and 528:
88346 TC 3 41.95 88347 26 3 47.83 8
Page 529 and 530:
92284 26 3 11.14 92284 TC 3 56.56 9
Page 531 and 532:
93624 26 3 267.07 93631 26 3 394.51
Page 533 and 534:
94621 TC 3 91.48 94680 26 3 11.91 9
Page 535 and 536:
95950 26 3 74.43 95950 TC 3 166.17
Page 537 and 538:
E0189 UE 3 23.31 E0191 RR 3 0.97 E0
Page 539 and 540:
E0565 RR 3 49.61 E0565 UE 3 318.83
Page 541 and 542:
E0946 RR 3 56.60 E0946 UE 3 408.08
Page 543 and 544:
E1200 RR 3 73.20 E1200 UE 3 447.97
Page 545:
K0056 UE 3 70.98 K0065 RR 3 4.43 K0
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fee schedule 2009 new - DE Medical Assistance Program

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