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Fee Schedule 2009 Procedure Code Pr
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00404 A ANESTH, SURGERY OF BREAST 0
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0079T 9 ENDOVASC VISC EXTNSN REPR 0
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0115T O MED TX MNGMT 15 MIN 0.00 01
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01654 A ANESTH, SHOULDER VESSEL SUR
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01968 A ANES/ANALG CS DELIVER ADD-O
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11008 3 REMOVE MESH FROM ABD WALL 2
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11643 3 EXC FACE-MM MALIG+MARG 2.1-
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14060 3 SKIN TISSUE REARRANGEMENT 6
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15755 O FREE FLAP (MICROVASCULAR TR
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16036 3 ESCHAROTOMY; ADDÏL INCISIO
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19330 3 REMOVAL OF IMPLANT MATERIAL
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20827 3 REPLANTATION THUMB, COMPLET
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21179 3 RECONSTRUCT ENTIRE FOREHEAD
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21465 3 TREAT LOWER JAW FRACTURE 83
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22554 3 NECK SPINE FUSION 1,179.36
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23440 3 REMOVE/TRANSPLANT TENDON 70
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24342 3 REPAIR OF RUPTURED TENDON 7
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25076 3 REMOVAL FOREARM LESION DEEP
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25540 O TREATMENT OF OPEN ULNAR SHA
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26320 3 REMOVAL OF IMPLANT FROM HAN
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26645 3 TREAT THUMB FRACTURE 363.93
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27111 3 TRANSFER OF ILIOPSOAS MUSCL
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27329 3 REMOVE TUMOR, THIGH/KNEE 93
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27524 3 TREAT KNEECAP FRACTURE 698.
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27754 O TREATMENT OF OPEN TIBIAL SH
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28116 3 REVISION OF FOOT 653.00 281
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28520 O TREATMENT OF OPEN FRACTURE,
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29799 5 CASTING/STRAPPING PROCEDURE
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30210 3 NASAL SINUS THERAPY 130.90
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31201 3 REMOVAL OF ETHMOID SINUS 66
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31571 3 LARYNGOSCOP W/VC INJ + SCOP
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3220F 9 HEP C QUANT RNA TSTNG DOCÏ
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32998 3 PERQ RF ABLATE TX, PUL TUMO
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33320 3 REPAIR MAJOR BLOOD VESSEL(S
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33610 3 REPAIR BY ENLARGEMENT 1,728
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33916 3 SURGERY OF GREAT VESSEL 1,5
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35103 3 REPAIR ARTERY RUPTURE, GROI
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35516 3 ARTERY BYPASS GRAFT 1,167.2
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36000 3 PLACE NEEDLE IN VEIN 26.52
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36585 3 REPLACE PICVAD CATH 1,160.3
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38120 3 LAPAROSCOPY, SPLENECTOMY 92
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4041F 9 DOC ORDER CEFAZOLIN/CEFUROX
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4120F 9 ANTIBIOT RXÏD/GIVEN 0.00 4
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42235 3 REPAIR PALATE 726.80 42260
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43020 3 INCISION OF ESOPHAGUS 498.5
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43352 3 SURGICAL OPENING, ESOPHAGUS
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44121 3 REMOVAL OF SMALL INTESTINE
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44650 3 REPAIR BOWEL FISTULA 1,274.
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45805 3 REPAIR FISTULA W/COLOSTOMY
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47133 9 REMOVAL OF DONOR LIVER 0.00
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48510 3 DRAIN PANCREATIC PSEUDOCYST
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49566 3 REREPAIR VENTRL HERN, BLOCK
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50546 3 LAPAROSCOPIC NEPHRECTOMY 1,
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51570 3 REMOVAL OF BLADDER 1,434.15
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52354 3 CYSTOURETERO W/BIOPSY 388.0
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54152 O CIRCUMCISION 0.00 54160 3 C
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55530 3 REVISE SPERMATIC CORD VEINS
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56631 3 EXTENSIVE VULVA SURGERY 1,0
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57545 3 REMOVE CERVIX/REPAIR PELVIS
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58800 3 DRAINAGE OF OVARIAN CYST(S)
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59898 5 LAPARO PROC, OB CARE/DELIVE
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61522 3 REMOVAL OF BRAIN ABSCESS 1,
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61795 3 BRAIN SURGERY USING COMPUTE
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63011 3 REMOVAL OF SPINAL LAMINA 97
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63690 O ANALYSIS OF NEURORECEIVER 0
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64727 3 INTERNAL NERVE REVISION 172
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65265 3 REMOVE FOREIGN BODY FROM EY
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66940 3 EXTRACTION OF LENS 643.79 6
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67900 3 REPAIR BROW DEFECT 561.45 6
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69399 5 OUTER EAR SURGERY PROCEDURE
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70250 3 X-RAY EXAM OF SKULL 36.71 7
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72126 3 CT NECK SPINE W/DYE 341.82
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73630 3 X-RAY EXAM OF FOOT 31.45 73
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75520 O CARDIAC RADIOGRAPHY, SELECT
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75764 O ANGIOGRAPHY, CORONARY BYPAS
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76000 3 FLUOROSCOPE EXAMINATION 89.
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76825 3 ECHO EXAM OF FETAL HEART 17
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77336 3 RADIATION PHYSICS CONSULT 8
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78191 3 PLATELET SURVIVAL 250.20 78
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78601 3 BRAIN IMAGE W/FLOW < 4 VIEW
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80057 9 MALE INFERTILITY AND/OR GYN
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81007 3 URINE SCREEN FOR BACTERIA 3
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82250 O ASSAY BILIRUBIN 0.00 82251
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82554 3 CREATINE, ISOFORMS 16.58 82
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82812 O GASES, BLOOD PO2 BY MANOMET
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83524 O INDICAN, URINE 0.00 83525 3
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83865 O MUCOPOLYSACCHARIDES, ACID,
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84132 3 ASSAY OF SERUM POTASSIUM 6.
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84446 3 ASSAY OF VITAMIN E 19.81 84
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85109 O BONE MARROW BIOPSY, NEEDLE
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85610 3 PROTHROMBIN TIME 5.49 85611
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86255 3 FLUORESCENT ANTIBODY, SCREE
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86586 O SKIN TEST, UNLISTED 0.00 86
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86800 3 THYROGLOBULIN ANTIBODY 22.2
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87172 3 PINWORM EXAM 5.96 87174 O E
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87500 3 VANOMYCIN, DNA, AMP PROBE 4
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88142 3 CYTOPATH, C/V, THIN LAYER 2
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88371 3 PROTEIN, WESTERN BLOT TISSU
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90240 O SUBSEQUENT HOSPITAL CARE, E
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90665 3 LYME DISEASE VACCINE, IM 53
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90808 3 PSYTX, OFFICE, 75-80 MIN 13
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90999 5 DIALYSIS PROCEDURE 0.00 910
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92510 O REHAB FOR EAR IMPLANT 0.00
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92977 3 DISSOLVE CLOT, HEART VESSEL
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93505 3 BIOPSY OF HEART LINING 645.
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93882 3 EXTRACRANIAL STUDY 171.47 9
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95011 O PERCUTANEOUS TESTS (SCRATCH
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95868 3 MUSCLE TEST CRAN NERVE BILA
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96400 O CHEMOTHERAPY, SC/IM 0.00 96
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97541 O TRAINING IN ACTIVITIES OF D
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99173 3 VISUAL ACUITY SCREEN 2.66 9
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99332 O REST HOME VISIT, EST PAT 0.
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99479 6 IC LBW INF 1500-2500 G SUBS
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A0396 9 ALS ESOPHAGEAL INTUB SUPPLS
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A4324 O MALE EXT CATH W/ADH COATING
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A4433 3 URINE OST PCH BAR W LOCK FL
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A4645 O CONTRAST 200-299 MGS IODINE
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A5093 3 OSTOMY ACCESSORY CONVEX INS
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A6261 5 WOUND FILLER GEL/PASTE /OZ
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A7028 6 REPL ORAL CUSHION COMBO MAS
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A9536 9 TC99M DEPREOTIDE 0.00 A9537
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B4197 9 PARENTERAL SOL 74-100 GM PR
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C1096 9 TC 99M EXAMETAZIME, PER DOS
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C1319 9 WALLSTENT: ENTERAL--60MM 0.
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C1769 9 GUIDE WIRE 0.00 C1770 9 IMA
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C1931 9 TALON DIL CATH 0.00 C1932 9
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C2676 9 RSPONSE CV CATHETER 0.00 C2
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C5030 9 STENT, CORONARY, S660 9/12M
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C8102 9 SURGIVISION ESOPH COIL 0.00
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C9001 9 LINEZOLID INJ, 200MG 0.00 C
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C9419 O INJ CLADRIBINE, BRAND 0.00
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D0474 1 MICRO W EXAM OF SURG MARGIN
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D2799 1 PROVISIONAL CROWN 0.00 D281
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D5130 1 DENTURES IMMEDIAT MAXILLARY
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D6010 9 ODONTICS ENDOSTEAL IMPLANT
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D6930 1 DENTAL RECEMENT BRIDGE 0.00
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D7840 9 REMOVAL OF TMJ CONDYLE 0.00
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D9410 9 DENTAL HOUSE CALL 0.00 D942
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E0203 5 THERAPEUTIC LIGHTBOX TABLET
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E0460 O NEG PRESS VENT PORTABL/STAT
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E0748 3 ELEC OSTEOGEN STIM SPINAL 3
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E0997 O WHEELCHAIR CASTER W/ A FORK
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E1297 3 WHEELCHAIR SPECIAL SEAT DEP
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E2207 6 CRUTCH AND CANE HOLDER 0.00
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E2603 6 SKIN PROTECT WC CUS WD =22I
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G0078 9 INDIVIDUAL PSYCHOTHERAPY, I
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G0201 9 MODIFORTRAININGINUSEVOICEPR
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G0313 O ESRD RELATED SVS 1 MON 2-11
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G8012 9 PNEUM PT RECV ANTIBIOTIC 4
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G8192 O ANTIB GIVEN PRIOR SURG INCI
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G8294 O COPD PT INELIG SPIR RESULTS
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G8416 9 PT INELIG FOOTWEAR EVALUATI
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G8517 9 SCRN FALL RSK;
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G9082 O ONC DX PROSTATE CASTRATE ME
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H0042 9 FOS C CHLD NON-THER PER MON
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HI100 O MCO SPECIFIC CODE: HOME INF
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J0695 O CEFONOCID SODIUM INJECTION
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J1452 5 INTRAOCULAR FOMIVIRSEN NA 0
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J2050 O INJECTION, LIVER, UP TO 20
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J2850 5 INJ SECRETIN SYNTHETIC HUMA
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J7070 5 D5W INFUSION 0.00 J7080 O I
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J7632 9 CROMOLYN SODIUM COMP UNIT 0
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J9170 6 DOCETAXEL INJECTION 0.00 J9
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K0041 3 LARGE SIZE FOOTPLATE EACH 5
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K0141 9 ALBUTEROL SULFATE, COMPOUND
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K0257 9 TRANSPARENT FILM, 16 SQ. IN
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K0513 9 DEXAMETHASONE INH SOL U D 0
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K0651 O GEN W/C CUSHION WIDTH GREAT
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L0120 3 CERV FLEXIBLE NON-ADJUSTABL
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L0930 O PENDULOUS ABDOMEN SUPP CUST
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L1950 3 AFO SPIRAL MOLDED TO PT PLA
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L2670 3 THORAC CONT PARASPINAL UPRI
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L3570 5 O SHOE ADD INSTEP EXTENSION
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L3964 3 SEO MOBILE ARM SUP ATT TO W
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L5611 3 AK 4 BAR LINK W/FRIC SWING
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L5814 3 ENDO KNEE-SHIN HYDRAL SWG P
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L6632 3 LATEX SUSPENSION SLEEVE EAC
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L6915 3 HAND RESTORATION REPLACMNT
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L8330 3 TRUSS ADD TO STD PAD SCROTA
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M0580 9 TRANSTELEPHONIC ELECTROENCE
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Q0047 9 ANESTHESIA FOR BLEPHAROPLAS
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Q0513 9 DISP FEE INHAL DRUGS/30 DAY
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Q4048 9 CAST SUP SHT LEG SPLNT PED
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S0016 O INJECTION, AMIKACIN SULFATE
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S0201 9 PARTIAL HOSPITALIZATION SER
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S2112 9 KNEE ARTHROSCP HARV 0.00 S2
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S3847 9 GENE TEST TAY-SACHS 0.00 S3
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S5181 9 HH RESIRATORY THRPY NOS DAY
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S9015 9 AUTOMATED EEG MONITORING 0.
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S9434 6 MOD SOLID FOOD SUPPL 0.00 S
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T1016 9 CASE MANAGEMENT 0.00 T1017
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TI420 O MCO SPECIFIC CODE: INTERPER
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V2531 3 CONTACT LENS GAS PERMEABLE
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V5258 5 HEARING AID, DIGIT, BIN, CI
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WW508 O VISION PROGRAM UNDER EPSDT-
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WW831 O PICC INSERTION TRAY 0.00 WW
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YY301 O FAMILY AND CHILDREN'S SERVI
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YY635 O HOME AND COMMUNITY-BASED SE
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ZH004 O MCO SPECIFIC CODE: HOME INF
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Procedure Code Description Pricing
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D3320 END THXPY, BICUSPID TOOTH 85.
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D5926 REPLACEMENT NASAL PROSTHESIS
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D9120 FIX PARTIAL DENTURE SECTION 8
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00474 ANESTH, SURGERY OF RIB(S) 13.
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01120 ANESTH, PELVIS SURGERY 6.00 1
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01925 ANES, THER INTERVEN RAD, CAR
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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: 61458 INCISE SKULL FOR BRAIN WOUND
- 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
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77052 TC 3 12.10 77280 26 3 34.11 7
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78130 26 3 29.94 78130 TC 3 124.93
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78478 26 3 26.98 78478 TC 3 44.66 7
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78811 26 3 76.48 78811 TC 3 1,383.9
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88346 TC 3 41.95 88347 26 3 47.83 8
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92284 26 3 11.14 92284 TC 3 56.56 9
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93624 26 3 267.07 93631 26 3 394.51
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94621 TC 3 91.48 94680 26 3 11.91 9
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95950 26 3 74.43 95950 TC 3 166.17
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E0189 UE 3 23.31 E0191 RR 3 0.97 E0
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E0565 RR 3 49.61 E0565 UE 3 318.83
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E0946 RR 3 56.60 E0946 UE 3 408.08
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E1200 RR 3 73.20 E1200 UE 3 447.97
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K0056 UE 3 70.98 K0065 RR 3 4.43 K0