Listas para Publicar en el Portal-1 (2) - Triple-S Salud

Procedure & 

Place of Service 

Tarifas 

Servicios de Salud 

Description Fee 

10021-00 fine needle aspiration w/o imaging guidance $66.30 

10022-00 fine needle aspiration with imaging guidance $68.25 

10040-00 acne surgery $14.63 

10060-00 incision & drainage abscess simple/single $19.50 

10061-00 incision&drainage abscess complicated/multiple $78.00 

10080-00 incision & drainage pilonidal cyst simple $19.50 

10081-00 incision & drainage pilonidal cyst complicated $78.00 

10120-00 incision&removal foreign body subq tiss smpl $19.50 

10121-00 incision&removal foreign body subq tiss comp $78.00 

10140-00 i&d hematoma seroma/fluid collection $19.50 

10160-00 puncture aspiration abscess hematoma bulla/cyst $9.75 

10180-00 incision&drainage complex po wound infection $87.75 

11000-00 dbrdmt x10sv eczmt/infct skn up 10% bdy surf $19.50 

11001-00 dbrdmt x10sv eczmt/infct skn ea 10% bdy surf $9.75 

11004-00 dbrdmt skn subq t/m/f necro infctj gent&pr $378.20 

11005-00 dbrdmt skn subq t/m/f necro infctj abdl wall $515.09 

11006-00 dbrdmt skn subq t/m/f necro infctj gent/abdl $476.48 

11008-00 removal prosthetic matrl abdl wall for infection $193.93 

11010-00 dbrdmt w/rmvl fm fx&/dislc skn&subq tiss $270.76 

11011-00 dbrdmt w/rmvl fm fx&/dislc skn subq t/m/f musc $273.78 

11012-00 dbrdmt fx&/dislc subq t/m/f bone $368.55 

11042-00 Deb subq tissue 20 sq cm/2.0 cm $69.23 

11310-00 shaving skin lesion 1 f/e/e/n/l/m diam 0.5 cm/< $34.13 

11311-00 shvg skin lesion 1 f/e/e/n/l/m diam 0.6-1.0 cm $50.70 

11312-00 shvg skin lesion 1 f/e/e/n/l/m diam 1.1-2.0 cm $70.20 

11400-00 exc b9 les mrgn xcp sk tg t/a/l 0.5 cm/< $39.00 

11401-00 exc b9 les mrgn xcp sk tg t/a/l 0.6-1.0 cm $48.75 




11406-00 exc b9 les mrgn xcp sk tg t/a/l > 4.0 cm $141.38 

1

Procedure & 


Tarifas 



11420-00 exc b9 les mrgn xcp sk tg s/n/h/f/g 0.5 cm/< $39.00 

11421-00 exc b9 les mrgn xcp sk tg s/n/h/f/g 0.6-1.0cm $39.00 




11426-00 exc b9 les mrgn xcp sk tg s/n/h/f/g > 4.0cm $136.50 

11440-00 exc b9 les mrgn xcp sk tg f/e/e/n/l/m 0.5cm/< $39.00 

11441-00 exc b9 les mrgn xcp sk tg f/e/e/n/l/m 0.6-1.0cm $39.00 




11446-00 exc b9 les mrgn xcp sk tg f/e/e/n/l/m > 4.0cm $165.75 

11450-00 excision hidradenitis axillary smpl/intrm rpr $149.18 

11451-00 excision hidradenitis axillary complex repair $184.28 

11462-00 excision hidradenitis inguinal smpl/intrm rpr $200.07 

11463-00 excision hidradenitis inguinal complex repair $175.50 

11470-00 excision h/p/p/u simple/intermediate repair $185.25 

11471-00 excision h/p/p/u complex repair $214.50 

11600-00 excision mal lesion trunk/arm/leg 0.5 cm/< $58.50 

11601-00 excision mal lesion trunk/arm/leg 0.6-1.0 cm $78.00 




11606-00 excision malignant lesion trunk/arm/leg >4.0 cm $224.25 

11620-00 excision malignant lesion s/n/h/f/g 0.5 cm/< $97.50 

11621-00 excision malignant lesion s/n/h/f/g 0.6-1.0 cm $146.25 




11640-00 excision malignant lesion f/e/e/n/l/m 0.5 cm/< $146.25 

11641-00 excision malignant les f/e/e/n/l/m 0.6-1.0 cm $195.00 




11720-00 debridement nail any method 1-5 $17.55 

11721-00 debridement nail any method 6/> $29.25 

11730-00 avulsion nail plate partial/complete simple 1 $19.50 

11732-00 avulsion nail plate partial/complete smpl ea $9.75 

11740-00 evacuation subungual hematoma $19.50 

11750-00 excision nail matrix permanent removal $97.50 

11752-00 exc nail matrix prm rmvl w/amp tuft dstl phalanx $141.28 

11755-00 biopsy nail unit spx $48.26 

11760-00 repair nail bed $58.50 

11762-00 reconstruction nail bed w/graft $126.75 

11765-00 wedge excision skin nail fold $28.28 

11770-00 excision pilonidal cyst/sinus simple $292.50 

11771-00 excision pilonidal cyst/sinus extensive $292.50 

11772-00 excision pilonidal cyst/sinus complicated $390.00 

11900-00 injection intralesional up to & incl 7 $19.50 

11901-00 injection intralesional >7 $29.25 

2

Procedure & 


Tarifas 



11920-00 tattooing incl micropigmentation 6.0 cm/< $80.76 

11921-00 tattooing incl micropigmentation 6.1-20.0 cm $97.40 

11922-00 tattooing incl micropigmentation ea 20.0 cm $24.50 

11960-00 insertion tissue expander incl sbsq xpnsj $526.50 

11970-00 replacement tiss expander permanent prosthesis $426.47 

11971-00 removal tiss expander w/o insertion prosthesis $87.75 

11975-00 insertion implantable contraceptive capsules $596.70 

11976-00 removal implantable contraceptive capsules $87.75 

11977-00 rmvl w/rinsj implantable contraceptive capsules $688.84 

12001-00 simple repair scalp/neck/ax/genit/trunk 2.5cm/< $19.50 

12002-00 smpl repair scalp/neck/ax/genit/trunk 2.6-7.5cm $29.25 

12004-00 simple rpr scalp/neck/ax/genit/trunk 7.6-12.5cm $48.75 

12005-00 smpl rpr scalp/neck/ax/genit/trunk 12.6-20.0cm $68.25 

12006-00 smpl rpr scalp/neck/ax/genit/trunk 20.1-30.0cm $87.75 

12007-00 simple repair scalp/neck/ax/genit/trunk >30.0cm $136.50 

12011-00 simple repair f/e/e/n/l/m 2.5cm/< $39.00 

12013-00 simple repair f/e/e/n/l/m 2.6cm-5.0cm $48.75 





12020-00 tx superficial wound dehiscence simple closure $29.25 

12021-00 tx superficial wound dehiscence w/packing $48.75 

12031-00 repair intermediate s/a/t/e 2.5 cm/< $29.25 

12032-00 repair intermediate s/a/t/e 2.6-7.5 cm $48.75 


12035-00 repair intermediate s/a/t/e 12.6-20.0cm $87.75 


12041-00 repair intermediate n/h/f/xtrnl gent 2.5cm/< $39.00 

12042-00 repair intermediate n/h/f/xtrnl gent 2.6-7.5 cm $68.25 

12044-00 repair intermediate n/h/f/xtrnl gent 7.6-12.5cm $82.88 

12045-00 repair intermediate n/h/f/xtrnl gent 12.6-20 cm $107.25 

12046-00 rpr intermediate n/h/f/xtrnl gent 20.1-30.0 cm $146.25 

12051-00 repair intermediate f/e/e/n/l/m&/muc 2.5 cm/< $48.75 

12052-00 repair intermediate f/e/e/n/l/m&/muc 2.6-5.0 cm $68.25 



12055-00 repair intermediate f/e/e/n/l/m&/muc 12.6-20.0cm $214.50 

12056-00 repair intermediate f/e/e/n/l/m&/muc 20.1-30.0cm $243.75 

13100-00 repair complex trunk 1.1 cm-2.5 cm $68.25 

13101-00 repair complex trunk 2.6 cm-7.5 cm $146.25 

13102-00 repair complex trunk ea 5 cm/< $59.48 

13120-00 repair complex scalp/arm/leg 1.1 cm-2.5 cm $97.50 

13121-00 repair complex scalp/arm/leg 2.6 cm-7.5 cm $217.62 

13122-00 repair complex scalp/arm/leg ea 5 cm/< $390.00 

13131-00 repair complex f/c/c/m/n/ax/g/h/f 1.1 cm-2.5 cm $136.50 

13132-00 repair complex f/c/c/m/n/ax/g/h/f 2.6 cm-7.5 cm $292.50 

13133-00 repair complex f/c/c/m/n/ax/g/h/f ea 5 cm/< $390.00 

13150-00 repair complex eyelid/nose/ear/lip 1.0 cm/< $97.50 

13151-00 repair complex eyelid/nose/ear/lip 1.1-2.5 cm $165.75 

3

Procedure & 


Tarifas 



13152-00 repair complex eyelid/nose/ear/lip 2.6-7.5 cm $390.00 

13153-00 repair complex eyelid/nose/ear/lip ea 5 cm/< $390.00 

14000-00 adjacent tissue transfer/reargmt trunk 10 cm/< $195.00 

14001-00 att/rearrangement trunk 10.1-30.0cm $292.50 

14020-00 att/rearrangement scalp/arm/leg 10 cm/< $292.50 

14021-00 att/rearrangement scalp/arm/leg 10.1-30.0 cm $390.00 

14040-00 att/rearrangement f/c/c/m/n/ax/g/h/f 10 cm/< $437.00 

14041-00 att/reargmt f/c/c/m/n/ax/g/h/f 10.1-30.0cm $487.50 

14060-00 att/reargmt e/n/e/l dfct 10 cm/< $487.50 

14061-00 att/reargmt eyelid/nose/ear/lip 10.1-30.0 cm $585.00 

14301-00 att/r any area defect 30.1-60sqcm $555.75 

14302-00 att/r any area defect ea addl 30sqcm or part $111.15 

14350-00 filleted finger/toe flap w/prepj recipient site $380.25 

15002-00 prep site trunk/arm/leg 1st 100 sq cm/1pct $131.63 

15003-00 prep site t/a/l addl 100 sq cm/1pct $29.84 

15004-00 prep site f/s/n/h/f/g/m/d gt 1st 100 sq cm/1pct $131.63 

15005-00 prep site f/s/n/h/f/g/m/d gt addl 100 sq cm/1pct $29.84 

15050-00 pinch graft 1/mlt c> sm ulcer tip/oth area 2cm $48.75 

15100-00 split agrft t/a/l 1st 100 cm/

Procedure & 


Tarifas 



15320-00 algrft temp closure f/s/n/h/f/g/m/d 1st 100cm $181.64 

15321-00 algrft temp closure f/s/n/h/f/g/m/d ea 100cm $49.14 

15330-00 aclr dermal allograft trunk/arm/leg 1st 100 cm $156.20 

15331-00 aclr dermal allograft trunk/arm/leg ea 100cm/ea $32.47 

15335-00 aclr drm allograft f/s/n/h/f/g/m/d gt 1st 100cm $173.75 

15336-00 aclr drm algrft f/s/n/h/f/g/m/d gt ea 100 cm/ea $47.39 

15340-00 tissue cultured allogeneic skin 1st 25cm/< $160.10 

15341-00 tiss cltr algc skn ea 25 cm $23.12 

15360-00 tissue cltr algc drm trunk/arm/leg 1st 100 cm $179.01 

15361-00 tissue cltr algc dermal t/a/l ea 100cm/ea 1 pct $37.73 

15365-00 tiss cltr algc drm f/s/n/h/f/g/m/d 1st 100 cm $186.03 

15366-00 tiss cltr algc drm f/s/n/h/f/g/m/d ea 100 cm $47.39 

15400-00 xenograft temp closure trunk/arm/leg 1st 100cm $156.00 

15401-00 xenograft temp closure trunk/arm/leg ea 100cm $35.10 

15420-00 xenogrf temp closure f/s/n/h/f/g/m/d 1st 100cm $197.44 

15421-00 xenograft temp closure f/s/n/h/f/g/m/d ea 100cm $61.43 

15430-00 acellular xenograft implant 1st 100 cm/1 pct $263.25 

15431-00 acellular xenograft implant ea 100 cm/1 pct $84.24 

15570-00 frmj direct/tubed pedicle +-transfer trunk $175.50 

15572-00 frmj direct/tubed pedicle +-tr scalp arms/legs $263.25 

15574-00 frmj dir/tubed pedcl +-tr ft/ch/ch/m/n/ax/g/h/f $364.65 

15576-00 frmj direct/tubed pedicle +-tr e/n/e/l/ntroral $438.75 

15600-00 delay flap/sectioning flap trunk $146.25 

15610-00 delay flap/sectioning flap scalp arms/legs $214.50 

15620-00 delay flap/sectioning flap f/c/c/n/ax/g/h/f $234.00 

15630-00 delay flap/sctj flap eyelids nose ears/lips $360.75 

15650-00 transfer any pedicle flap any location $399.75 

15731-00 forehead flap w/ preservation vascular pedicle $649.69 

15732-00 musc myocutaneous/fasciocutaneous flap head&nck $414.38 

15734-00 musc myocutaneous/fasciocutaneous flap trunk $302.25 

15736-00 musc myocutaneous/fasciocutaneous flap uxtr $243.75 

15738-00 musc myocutaneous/fasciocutaneous flap lxtr $302.25 

15740-00 flap island pedicle $497.25 

15750-00 flap neurovascular pedicle $419.25 

15756-00 free muscle/myocutaneous flap w/mvasc anast $1,501.40 

15757-00 free skin flap w/microvascular anastomosis $1,540.40 

15758-00 free fascial flap w/microvascular anastomosis $1,232.89 

15760-00 graft composite w/primary closure donor area $243.75 

15770-00 graft derma-fat-fascia $438.75 

15820-00 blepharoplasty lower eyelid $585.00 

15821-00 blepharoplasty lower eyelid herniated fat pad $219.38 

15822-00 blepharoplasty upper eyelid $390.00 

15823-00 blepharoplasty upper eyelid w/excessive skin $133.38 

15832-00 excision excessive skin&subq tissue thigh $609.86 

15833-00 excision excessive skin&subq tissue leg $565.99 

15834-00 excision excessive skin&subq tissue hip $570.38 

15835-00 excision excessive skin&subq tissue buttock $592.31 

15836-00 excision excessive skin&subq tissue arm $504.56 

15837-00 exc excessive skin&subq tissue forearm/hand $504.56 

15838-00 exc excsv skin&subq tissue submental fat pad $421.20 

5

Procedure & 


Tarifas 



15839-00 excision excessive skin&subq tissue other area $526.50 

15840-00 graft facial nerve paralysis free fascial graft $975.00 

15841-00 graft facial nerve paralysis free muscle graft $1,160.25 

15842-00 grf facial nrv palyss fr muscle flap microsurg $1,053.10 

15845-00 grf facial nerve paralysis regional muscle tr $1,170.00 

15850-00 removal sutures under anesthesia same surgeon $52.65 

15851-00 removal sutures under anesthesia other surgeon $27.30 

15860-00 iv injection test vascular flow flap/graft $90.38 

15920-00 exc coccygeal pr ulc w/coccygectomy w/prim sutr $253.50 

15922-00 exc coccygeal pr ulc w/coccygectomy w/flap clsr $292.50 

15931-00 excision sacral pressure ulcer w/primary suture $351.00 

15933-00 exc sacral pressure ulc w/prim sutr w/ostectomy $497.25 

15934-00 excision sacral pressure ulcer w/skin flap clsr $390.00 

15935-00 exc sacral pr ulcer w/skn flap clsr w/ostectomy $546.00 

15936-00 exc sac pr ulc prepj musc/myoq flap/skn grf clsr $672.75 

15937-00 exc sac pr ulc prepj musc/myoq flap/skn grf ostc $789.75 

15940-00 exc ischial pressure ulcer w/primary suture $365.63 

15941-00 exc ischial pr ulc w/prim sutr w/ostc ischiect $575.25 

15944-00 exc ischial pressure ulcer w/skin flap closure $546.00 

15945-00 exc ischial pr ulc w/skn flap clsr w/ostectomy $711.75 

15946-00 exc ischial pr ulcer w/ostc musc/myoq flap/skin $906.75 

15950-00 exc trochanteric pressure ulcer w/primary sutr $302.25 

15951-00 exc trchntric pr ulcer w/prim sutr w/ostectomy $546.00 

15952-00 exc trochanteric pr ulcer w/skin flap closure $487.50 

15953-00 exc trchntric pr ulc w/skn flap clsr w/ostectomy $658.13 

15956-00 exc trochanteric pr ulcer musc/myoq flap/skin $833.63 

15958-00 exc trchntric pr ulc musc/myoq flap/skin w/ostc $877.50 

16000-00 initial tx 1st degree burn local tx $14.63 

16020-00 drs&/dbrdmt prtl-thkns burns 1st/sbsq small $19.50 

16025-00 drs&/dbrdmt prtl-thkns burns 1st/sbsq medium $29.25 

16030-00 drs&/dbrdmt prtl-thkns burns 1st/sbsq large $39.00 

16035-00 escharotomy first incision $165.75 

16036-00 escharotomy each additional incision $56.16 

17000-00 destruction premalignant lesion 1st $29.25 

17003-00 destruction premalignant lesion 2-14 ea $7.02 

17004-00 destruction premalignant lesion 15/> $133.38 

17106-00 destruction cutaneous vasc proliferative 50.0cm $400.73 

17110-00 destruction benign lesions up to 14 $19.50 

17111-00 destruction benign lesions 15/> $39.49 

17250-00 chemical cauterization granulation tissue $27.76 

17260-00 destruction malignant lesion t/a/l 0.5 cm/< $48.75 

17261-00 destruction mal lesion trunk/arm/leg 0.6-1.0 cm $61.43 

17262-00 destruction mal lesion trunk/arm/leg 1.1-2.0cm $81.90 



17270-00 destruction malignant lesion s/n/h/f/g 0.5 cm/< $87.75 

17271-00 destruction malignant lesion s/n/h/f/g 0.6-1.0cm $95.55 


6

Procedure & 


Tarifas 





17276-00 dstrj mal les s/n/h/f/g les diam > 4.0 cm $219.38 

17280-00 destruction malignant lesion f/e/e/n/l/m 0.5cm/< $67.28 

17281-00 destruction mal lesion f/e/e/n/l/m 0.6-1.0cm $91.65 




17311-00 mohs micrographic h/n/h/f/g 1st stage 5 blocks $292.50 

17312-00 mohs micrographic h/n/h/f/g each addl stage $107.25 

17313-00 mohs trunk/arm/leg 1st stage 5 blocks $292.50 

17314-00 mohs trunk/arm/leg ea stage after 1st stage $107.25 

17315-00 mohs trunk/arm/leg ea addl block any stage $21.45 

17340-00 cryotherapy co2 slush liq n2 acne $14.63 

17380-00 electrolysis epilation ea 30 minutes $26.33 

19000-00 puncture aspiration cyst breast $19.50 

19001-00 puncture aspiration breast ea addl cyst $9.75 

19020-00 mastotomy w/expl/drainage abscess deep $97.50 

19030-00 injection mammary ductogram/galactogram $57.53 

19100-00 bx breast needle core w/o imaging guidance spx $58.50 

19101-00 biopsy breast open incisional $146.25 

19102-00 biopsy breast needle core w/imaging guidance $71.08 

19103-00 breast biopsy vacuum assisted/rotating device $84.24 

19110-00 nipple exploration $185.25 

19112-00 excision lactiferous duct fistula $166.73 

19120-00 exc cyst/aberrant breast tissue open 1/> les $185.25 

19125-00 exc brst les preop plmt rad marker opn 1 les $240.83 

19126-00 exc brst les preop plmt rad marker opn ea addl $124.80 

19260-00 excision chest wall tumor including ribs $682.50 

19271-00 exc chest tumor w/rcnstj w/o medstnl lmphadec $975.00 

19272-00 exc chest tumor w/rcnstj w/medstnl lmphadec $1,170.00 

19290-00 preop placement localization wire breast $46.80 

19291-00 preop plmt localization wire breast ea lesion $21.45 

19295-00 img gid plmt mtlc loclzj clip prq brst bx/aspir $25.36 

19296-00 plmt expandable cath brst following prtl mast $3,289.75 

19297-00 plmt expandable cath brst concurrent prtl mast $64.06 

19298-00 plmt radthx brachytx brst following prtl mast $1,235.52 

19300-00 mastectomy gynecomastia $243.75 

19301-00 mastectomy partial $243.75 

19302-00 mastectomy partial w/axillary lymphadenectomy $567.20 

19303-00 mastectomy simple complete $292.50 

19304-00 mastectomy subcutaneous $341.25 

19305-00 mast rad w/pectoral muscles axillary lymph nodes $682.50 

19306-00 mast rad w/pectoral musc ax int mam lymph nodes $1,062.75 

19307-00 mast modf rad w/ax lymph nod w/wo pect/alis min $672.75 

19316-00 mastopexy $553.80 

19318-00 reduction mammaplasty $1,625.33 

19324-00 mammaplasty augmentation w/o prosthetic implant $524.83 

19325-00 mammaplasty augmentation w/prosthetic implant $731.25 

19328-00 removal intact mammary implant $162.09 

7

Procedure & 


Tarifas 



19330-00 removal mammary implant material $162.09 

19340-00 immt insj brst prosth flwg mastopexy mast/rcnstj $602.55 

19342-00 dlyd insj brst prosth flwg mastopexy mast/rcnstj $679.58 

19350-00 nipple/areola reconstruction $659.10 

19355-00 correction inverted nipples $334.43 

19357-00 brst rcnstj immt/dlyd w/tiss expander sbsq xpnsj $1,790.10 

19361-00 brst rcnstj w/latsms d/si flap wo prsthc impl $1,687.73 

19364-00 breast reconstruction free flap $1,246.05 

19366-00 breast reconstruction other technique $859.95 

19367-00 breast reconstruction tram flap 1 pedicle $4,111.58 

19368-00 breast reconstruction tram 1 pedcl mvasc anast $1,597.33 

19369-00 breast reconstruction tram flap double pedicle $3,474.90 

19370-00 open periprosthetic capsulotomy breast $185.25 

19371-00 periprosthetic capsulectomy breast $382.03 

19380-00 revision reconstructed breast $473.85 

19396-00 preparation moulage custom breast implant $107.25 

20005-00 i&d soft tissue abscess subfasc $195.00 

20100-00 exploration penetrating wound spx neck $397.80 

20101-00 exploration penetrating wound spx chest $125.78 

20102-00 expl penetrating wound spx abdomen/flank/back $154.05 

20103-00 exploration penetrating wound spx extremity $230.10 

20150-00 excision epiphyseal bar $698.10 

20200-00 biopsy muscle superficial $48.75 

20205-00 biopsy muscle deep $97.50 

20206-00 biopsy muscle percutaneous needle $48.75 

20220-00 biopsy bone trocar/needle superficial $97.50 

20225-00 biopsy bone trocar/needle deep $175.50 

20240-00 biopsy bone open superficial $97.50 

20245-00 biopsy bone open deep $384.35 

20250-00 biopsy vertebral body open thoracic $390.00 

20251-00 biopsy vertebral body open lumbar/cervical $390.00 

20500-00 injection sinus tract therapeutic spx $19.50 

20501-00 injection sinus tract diagnostic $26.33 

20520-00 removal foreign body muscle/tendon sheath simple $116.31 

20525-00 rmvl foreign body muscle/tendon sheath deep/comp $272.90 

20526-00 injection therapeutic carpal tunnel $44.75 

20550-00 injection 1 tendon sheath/ligament aponeurosis $19.50 

20551-00 injection single tendon origin/insertion $36.80 

20552-00 injection single/mlt trigger point 1/2 muscles $19.50 

20553-00 injection single/mlt trigger point 3/> muscles $24.38 

20555-00 placement needles muscle subsequent radioelement $212.74 

20600-00 arthrocentesis aspir&/injection small jt/bursa $33.35 

20605-00 arthrocentesis aspir&/injection interm jt/bursa $19.50 

20610-00 Drain/inject joint/bursa, arthrocentesis aspir&/injection major jt/bursa $19.50 

20612-00 aspiration&/injection ganglion cyst any location $34.98 

20615-00 aspiration&injection treatment bone cyst $156.00 

20650-00 insertion wire/pin w/appl skeletal traction spx $134.78 

20660-00 application cranial tong/strtctc frame w/removal $68.25 

20661-00 application halo cranial including removal $126.75 

20662-00 application halo pelvic including removal $126.75 

8

Procedure & 


Tarifas 



20663-00 application halo femoral including removal $156.00 

20664-00 appl halo 6/> pins thin skull osteology $473.40 

20665-00 removal tong/halo applied by another physician $19.50 

20670-00 Removal of support implant, removal implant superficial spx $19.50 

20680-00 Removal of support implant, removal implant deep $146.25 

20690-00 application uniplane external fixation system $156.00 

20692-00 application multiplane external fixation system $351.98 

20693-00 adjustment/revj xtrnl fixation system req anes $183.30 

20694-00 removal external fixation system under anes $185.25 

20696-00 xtrnl fixj w/stereotactic adjustment 1st&subq $343.10 

20697-00 xtrnl fixj w/strtctc adjustment exchange strut $403.65 

20802-00 replantation arm complete amputation $2,121.60 

20805-00 replantation forearm complete amputation $2,597.40 

20808-00 replantation hand complete amputation $3,229.20 

20816-00 rplj dgt except thmb mtcarphlngl jt compl amp $1,592.18 

20822-00 rplj dgt excluding thmb sublimis tdn compl amp $1,461.53 

20824-00 rplj thmb carp/mtcrpl jt mp jt compl amputation $1,303.58 

20827-00 rplj thumb distal tip mp joint compl amputation $1,312.35 

20838-00 replantation foot complete amputation $2,125.50 

20900-00 bone graft any donor area minor/small $361.92 

20902-00 bone graft any donor area major/large $204.75 

20910-00 cartilage graft costochondral $204.75 

20912-00 cartilage graft nasal septum $682.50 

20920-00 fascia lata graft by stripper $312.56 

20922-00 fascia lata graft incision & area exposure $175.50 

20924-00 tendon graft from a distance $282.75 

20930-00 allograft for spine surgery only morselized $117.00 

20931-00 allograft for spine surgery only structural $97.50 

20936-00 autograft spine surgery local from same incision $131.63 

20937-00 autograft spine surgery morselized sep incision $166.73 

20938-00 autograft spine surgery bicort/tricort sep inc $185.00 

20950-00 mntr interstitial fluid pressure cmprt syndrome $93.02 

20955-00 bone graft microvascular anastomosis fibula $1,864.69 

20956-00 bone graft microvascular anast iliac crest $1,876.97 

20957-00 bone graft microvascular anast metatarsal $1,755.00 

20969-00 free ostq flap w/mvasc anast metar/great toe $2,044.58 

20970-00 free ostq flap w/mvasc anastomosis iliac crest $1,977.01 

20972-00 free ostq flap w/mvasc anastomosis metatarsal $1,714.05 

20973-00 fr ostq flap w/mvasc anast grt toe w/web space $2,053.35 

20974-00 electrical stimulation bone healing noninvasive $28.08 

20975-00 electrical stimulation bone healing invasive $111.44 

20979-00 low intensity us stimj bone healing noninvasive $34.24 

20982-00 ablation bone tumor rf percutaneous ct guidance $348.88 

21010-00 arthrotomy temporomandibular joint $390.00 

21011-00 excision tumor soft tiss face/scalp subq < 2cm $149.18 

21012-00 excision tumor soft tiss face/scalp subq 2+cm $160.88 

21013-00 exc tumor soft tiss face&scalp subfascial < 2cm $232.05 

21014-00 exc tumor soft tiss face&scalp subfascial 2+cm $247.65 

21015-00 rad resection tumor soft tiss face/scalp < 2cm $342.23 

21016-00 rad resection tumor soft tiss face/scalp 2+cm $376.35 

9

Procedure & 


Tarifas 



21025-00 excision bone mandible $259.35 

21026-00 excision facial bone $270.27 

21029-00 removal contouring benign tumor facial bone $391.37 

21030-00 exc benign tumor/cyst maxl/zygoma encl & curtg $243.75 

21031-00 excision torus mandibularis $175.50 

21032-00 excision maxillary torus palatinus $175.50 

21034-00 excision malignant tumor maxilla/zygoma $487.50 

21040-00 excision benign tumor/cyst mandible encl&/curtg $214.50 

21044-00 excision malignant tumor mandible $570.38 

21045-00 excision malignant tumor mandible radical $877.50 

21046-00 exc benign tumor/cyst mndbl intra-oral osteot $621.27 

21047-00 exc b9 tum/cst mndbl xtr-oral osteot&prtl mndblc $766.06 

21048-00 exc benign tumor/cyst maxl intra-oral osteot $638.82 

21049-00 exc b9 tum/cst maxl xtr-oral osteot&prtl maxlct $725.69 

21050-00 condylectomy temporomandibular joint spx $731.25 

21060-00 meniscectomy prtl/compl temporomandibular jt spx $731.25 

21070-00 coronoidectomy spx $390.00 

21116-00 injection temporomandibular joint arthrography $33.49 

21122-00 genioplasty 2/> sliding osteotomies $749.78 

21141-00 rcnstj midface lefort i 1 piece w/o bone graft $1,842.75 

21142-00 rcnstj midface lefort i 2 pieces w/o bone graft $1,956.30 

21143-00 rcnstj midface lefort i 3/>piece w/o bone graft $1,956.30 

21145-00 rcnstj midface lefort i 1 piece w/bone grafts $2,101.13 

21146-00 rcnstj midface lefort i 2 pieces w/bone grafts $2,101.13 

21147-00 rcnstj midface lefort i 3/>piece w/bone grafts $2,101.13 

21193-00 rcnstj mndblr rami hrzntl/ver/c/l osteot w/o grf $770.25 

21194-00 rcnstj mndblr rami hrzntl/ver/c/l osteot w/grf $954.53 

21195-00 rcnstj mndblr rami&/body sgtl splt w/o int rgd $1,667.25 

21196-00 rcnstj mndblr rami&/bdy sgtl splt w/int rgd fixj $1,772.55 

21198-00 osteotomy mandible segmental $789.75 

21199-00 osteotomy mandible sgmtl w/genioglossus advmnt $789.75 

21206-00 osteotomy maxilla segmental $711.75 

21208-00 osteoplasty facial bones augmentation $509.93 

21209-00 osteoplasty facial bones reduction $312.00 

21210-00 graft bone nasal/maxillary/malar areas $438.75 

21215-00 graft bone mandible $1,365.00 

21230-00 graft rib crtlg autogenous face/chin/nose/ear $682.50 

21235-00 graft ear crtlg autogenous nose/ear $321.75 

21240-00 arthrp temporomandibular joint +-autograft $994.50 

21242-00 arthroplasty temporomandibular jt w/allograft $1,160.25 

21243-00 arthrp tmprmand joint w/prosthetic replacement $903.83 

21247-00 rcnstj mndblr condyle w/bone cartlg autografts $1,462.50 

21255-00 rcnstj zygmtc arch/glenoid fossa w/bone cartlg $1,019.85 

21256-00 reconstruction orbit w/osteotomies&bone grafts $1,010.10 

21310-00 closed treatment nasal fracture w/o manipulation $126.75 

21315-00 closed tx nasal fracture w/o stabilization $48.75 

21320-00 closed treatment nasal fracture w/stabilization $126.75 

21325-00 open treatment nasal fracture uncomplicated $48.75 

21330-00 open tx nasal fx comp w/int&/xtrnl skeletal fixj $390.00 

21335-00 open tx nasal fx w/concomitant optx fxd septum $780.00 

10

Procedure & 


Tarifas 



21336-00 open tx nasal septal fracture +-stabilization $249.60 

21337-00 closed tx nasal septal fracture +-stabilization $48.75 

21338-00 open tx nasoethmoid fx w/o external fixation $643.50 

21339-00 open tx nasoethmoid fx w/external fixation $804.38 

21340-00 percutaneous tx nasoethmoid complex fracture $468.00 

21343-00 open tx depressed frontal sinus fracture $154.05 

21344-00 open tx complicated frontal sinus fracture $787.80 

21345-00 closed tx nasomaxillary complex fracture $263.25 

21346-00 optx nasomax cplx fx left ii type w/wirg&fixj $643.50 

21347-00 optx nasomax cplx fx left ii type req mlt opn $653.25 

21348-00 optx nasomax cplx fx left ii type w/b1 grfg $389.03 

21355-00 percutaneous tx malar area fracture $48.75 

21356-00 open tx depressed zygomatic arch fracture $260.33 

21360-00 open tx depressed malar fracture $302.25 

21365-00 open tx comp fx malar w/internal fx&mult surg $633.75 

21366-00 open tx comp fracture malar area w/bone graft $611.33 

21385-00 open tx orbital floor blowout fx transantral $341.25 

21386-00 open tx orbital floor blowout fx periorbital $594.75 

21387-00 open tx orbital floor blowout fx combined appr $585.00 

21390-00 optx orb floor blwt fx pri/bital appr w/allplstc $594.75 

21395-00 optx orb floor blwt fx pri/bital appr w/b1 grf $770.25 

21400-00 clsd tx fx orbit except blowout w/o manipulation $19.50 

21401-00 closed tx fx orbit except blowout w/manipulation $146.25 

21406-00 open tx fx orbit except blowout w/o implant $195.00 

21407-00 open tx fx orbit except blowout w/implant $292.50 

21408-00 open tx fx orbit except blowout w/bone graft $468.00 

21421-00 closed tx palatal/maxillary fx w/fixation/splint $292.50 

21422-00 open treatment palatal/maxillary fracture $487.50 

21423-00 open tx palatal/maxillary fx comp multiple appr $565.50 

21431-00 closed tx craniofacial separation $341.25 

21432-00 open tx craniofacial sep w/wiring&/int fixj $390.00 

21433-00 open tx craniofacial sep complicated mlt appr $487.50 

21435-00 open tx craniofacial sep comp w/int&/xtrnl fixj $663.00 

21436-00 optx cranfcl sep left iii typ comp int fixj w/b1 $1,159.28 

21440-00 cltx mandibular/maxillary alveolar ridge fx spx $160.88 

21445-00 optx mandibular/maxillary alveolar ridge fx spx $253.50 

21450-00 closed tx mandibular fracture w/o manipulation $126.75 

21451-00 closed tx mandibular fracture w/manipulation $195.00 

21452-00 percutaneous tx mandibular fx w/external fixj $126.75 

21453-00 closed tx mandibular fx w/interdental fixation $195.00 

21454-00 open tx mandibular fx w/external fixation $390.00 

21461-00 open tx mandibular fx w/o interdental fixation $487.50 

21462-00 open tx mandibular fx w/interdental fixation $711.75 

21465-00 open tx mandibular condylar fx $468.00 

21470-00 optx comp mandibular fx mlt appr w/int fixation $487.50 

21480-00 closed tx temporomandibular dislocation 1st/sbsq $58.50 

21485-00 closed tx temporomandibular dislc comp 1st/sbsq $175.50 

21490-00 open treatment temporomandibular dislocation $243.75 

21495-00 open treatment hyoid fracture $195.00 

21497-00 interdental wiring other than fracture $217.43 

11

Procedure & 


Tarifas 



21501-00 i&d deep absc/hmtma soft tissue neck/thorax $165.75 

21502-00 i&d dp absc/hmtma soft tiss nck/thorax prtl rib $253.50 

21510-00 incision deep opening bone cortex thorax $390.00 

21550-00 biopsy soft tissue neck/thorax $48.75 

21552-00 exc tumor soft tissue neck/ant thorax subq 3+cm $160.88 

21554-00 exc tumor soft tissue neck/thorax subfasc 5+cm $300.30 

21555-00 exc tumor soft tissue neck/ant thorax subq

Procedure & 


Tarifas 



22206-00 osteotomy spine posterior 3 column thoracic $1,462.50 

22207-00 osteotomy spine posterior 3 column lumbar $1,365.00 

22208-00 osteotomy spine posterior 3 column ea addl sgm $370.50 

22210-00 osteotomy spine pst/pstlat appr 1 vrt sgm crv $877.50 

22212-00 osteotomy spine pst/pstlat appr 1 vrt sgm thrc $877.50 

22214-00 osteotomy spine pst/pstlat appr 1 vrt sgm lmbr $810.23 

22216-00 osteot spi pst/pstlat appr 1 vrt sgm ea vrt sgm $305.18 

22220-00 osteotomy spine w/dskc ant appr 1 vrt sgm crv $965.25 

22222-00 osteotomy spine w/dskc ant appr 1 vrt sgm thrc $877.50 

22224-00 osteotomy spine w/dskc ant appr 1 vrt sgm lmbr $877.50 

22226-00 osteot spi w/dskc ant appr 1 vrt sgm ea vrt sgm $339.30 

22305-00 closed tx vertebral process fracture $19.50 

22310-00 cltx vrt bdy fx w/o mnpj req&w/csting/bracing $203.58 

22315-00 cltx vrt fx&/dislc csting/bracing mnpj/trcj $302.25 

22318-00 optx&/rdctj odntd fx&/dislc ant fixj w/o grfg $1,167.08 

22319-00 optx&/rdctj odntd fx&/dislc ant w/int fixj grf $1,167.08 

22325-00 optx&/rdctj vrt fx&/dislc pst 1 vrt sgm lmbr $926.25 

22326-00 optx&/rdctj vrt fx&/dislc pst 1 vrt sgm crv $926.25 

22327-00 optx&/rdctj vrt fx&/dislc pst 1 vrt sgm thrc $926.25 

22328-00 optx&/rdctj vrt fx&/dislc pst 1 vrt sgm ea sgm $262.28 

22505-00 manipulation spine requiring anesthesia $60.06 

22522-00 percutaneous vertebroplasty ea addl thrc/lmbr $161.46 

22532-00 arthrodesis lateral extracavitary thoracic $1,228.50 

22533-00 arthrodesis lateral extracavitary lumbar $1,103.90 

22534-00 arthrodesis lat extracavitary ea addl thrc/lmbr $308.36 

22548-00 arthrd ant transoral/xtroral c1-c2 +-exc odntd $1,096.88 

22551-00 arthrd ant interbody decompress cervical belw c2 $1,003.17 

22552-00 arthrd ant interdy cervcl belw c2 ea addl ntrspc $234.00 

22554-00 arthrd ant min discect interbody cerv belw c2 $1,170.00 

22556-00 arthrd ant min discectomy interbody thoracic $1,316.25 

22558-00 arthrodesis anterior interbody lumbar $1,053.00 

22585-00 arthrodesis anterior interbody ea addl ntrspc $87.75 

22590-00 arthrodesis posterior craniocervical $1,308.45 

22595-00 arthrodesis posterior atlas-axis c1-c2 $1,308.45 

22600-00 arthrodesis pst/pstlat cervical belw c2 sgm $877.50 

22610-00 arthrodesis posterior/posterolateral thoracic $831.68 

22612-00 arthrodesis posterior/posterolateral lumbar $1,194.38 

22614-00 arthrodesis posterior/posterolateral ea addl $253.50 

22630-00 arthrodesis posterior interbody lumbar $1,755.00 

22632-00 arthrodesis posterior interbody ea addl $364.65 

22800-00 arthrodesis posterior spinal dfrm up 6 vrt seg $1,901.25 

22802-00 arthrodesis posterior spinal dfrm 7-12 vrt seg $3,000.00 

22804-00 arthrodesis posterior spinal dfrm 13/> vrt seg $2,437.50 

22808-00 arthrodesis anterior spinal dfrm 2-3 vrt seg $2,437.50 

22810-00 arthrodesis anterior spinal dfrm 4-7 vrt seg $2,437.50 

22812-00 arthrodesis posterior spinal dfrm 8/> vrt seg $2,437.50 

22830-00 exploration spinal fusion $654.23 

22840-00 posterior non-segmental instrumentation $1,316.25 

22841-00 internal spinal fixation wiring spinous process $2,193.75 

22842-00 posterior segmental instrumentation 3-6 vrt seg $2,437.50 

13

Procedure & 


Tarifas 



22843-00 posterior segmental instrumentation 7-12 vrt seg $2,437.50 

22844-00 posterior segmental instrumentation 13/> vrt seg $2,437.50 

22845-00 anterior instrumentation 2-3 vertebral segments $1,316.25 

22846-00 anterior instrumentation 4-7 vertebral segments $2,500.00 

22847-00 anterior instrumentation 8/> vertebral segments $2,437.50 

22848-00 pelvic fixation other than sacrum $333.45 

22849-00 reinsertion spinal fixation device $688.84 

22850-00 removal posterior nonsegmental instrumentation $487.50 

22851-00 application intervertebral biomechanical device $673.73 

22852-00 removal posterior segmental instrumentation $1,140.75 

22855-00 removal anterior instrumentation $487.50 

22900-00 exc tumor soft tissue abdl wall subfascial

Procedure & 


Tarifas 



23182-00 partial excision bone scapula $243.75 

23184-00 partial excision bone proximal humerus $603.01 

23190-00 ostectomy scapula partial $292.50 

23195-00 resection humeral head $448.50 

23200-00 radical resection tumor clavicle $195.00 

23210-00 radical resection tumor scapula $292.50 

23220-00 radical resection bone tumor proximal humerus $780.00 

23330-00 removal foreign body shoulder subcutaneous $78.00 

23331-00 removal foreign body shoulder deep $468.00 

23332-00 removal foreign body shoulder complicated $970.13 

23350-00 injection shoulder arthrography/ ct/mri arthg $37.05 

23395-00 muscle transfer shoulder/upper arm single $731.25 

23397-00 muscle transfer shoulder/upper arm multiple $812.18 

23400-00 scapulopexy $633.75 

23405-00 tenotomy shoulder area 1 tendon $351.00 

23406-00 tenotomy shoulder multiple thru same incision $482.63 

23410-00 open repair of rotator cuff acute $686.21 

23412-00 open repair of rotator cuff chronic $737.10 

23415-00 coracoacromial ligament release +-acromioplasty $554.58 

23420-00 reconstruction rotator cuff avulsion chronic $773.96 

23430-00 tenodesis long tendon biceps $581.78 

23440-00 resection/transplantation long tendon biceps $516.75 

23450-00 capsulorrhaphy anterior putti-platt/magnuson $682.50 

23455-00 capsulorrhaphy anterior w/labral repair $816.86 

23460-00 capsulorrhaphy anterior with bone block $867.75 

23462-00 capsulorrhaphy anterior w/coracoid process tr $965.25 

23465-00 capsulorrhaphy glenohumeral jt pst +-bone blk $741.00 

23466-00 capsulorrhaphy glenohumrl jt multi-dirional ins $785.36 

23470-00 arthroplasty glenohumrl jt hemiarthroplasty $927.52 

23472-00 arthroplasty glenohumeral joint total shoulder $1,657.50 

23480-00 osteotomy clavicle +-internal fixation $390.00 

23485-00 osteotomy clav +-int fixj w/b1 grf non/mal $472.88 

23490-00 proph tx +-methylmethacrylate clavicle $555.75 

23491-00 proph tx +-methylmethacrylate proximal humerus $741.00 

23500-00 clsd tx clavicular fracture w/o manipulation $146.25 

23505-00 clsd tx clavicular fracture w/manipulation $237.28 

23515-00 open tx clavicular fracture internal fixation $429.10 

23520-00 clsd tx sternoclavicular dislc w/o manipulation $19.50 

23525-00 closed tx sternoclavicular dislc w/manipulation $117.00 

23530-00 open tx sternoclavicular dislc acute/chronic $429.00 

23532-00 optx strnclav dislc acute/chronic w/fascial grf $468.00 

23540-00 clsd tx acromioclavicular dislc w/o manipulation $117.00 

23545-00 clsd tx acromioclavicular dislc w/manipulation $146.25 

23550-00 open tx acromioclavicular dislc acute/chronic $516.75 

23552-00 optx acromclav dislc acute/chronic w/fascial grf $555.75 

23570-00 closed tx scapular fracture w/o manipulation $34.13 

23575-00 cltx scapular fx w/manipulation +-skel traction $121.88 

23585-00 open tx scapular fx w/internal fixation if pfrmd $516.75 

23600-00 cltx proximal humeral fracture w/o manipulation $199.19 

23605-00 cltx prox humrl fx w/manipulation +-skel tracj $292.50 

15

Procedure & 


Tarifas 



23615-00 open treatment proximal humeral fracture $554.58 

23616-00 open prox humeral fracture prosthetic rplcmt $1,029.31 

23620-00 cltx greater humeral tuberosity fx w/o mnpj $174.90 

23625-00 cltx grter humeral tuberosity fx w/manipulation $267.14 

23630-00 open treatment grter humeral tuberosity fracture $292.50 

23650-00 clsd tx shoulder dislc w/manipulation w/o anes $175.50 

23655-00 clsd tx shoulder dislc w/manipulation req anes $240.44 

23660-00 open tx acute shoulder dislocation $516.75 

23665-00 cltx shoulder dislc w/fx humeral tubrst w/mnpj $263.25 

23670-00 open tx shoulder dislc w/humeral tuberosity fx $516.75 

23675-00 cltx shoulder dislc w/surg/antmcl nck fx w/mnpj $175.50 

23680-00 open tx shoulder dislocation w/neck fracture $741.00 

23700-00 mnpj w/anes shoulder joint w/fixation apparatus $155.45 

23800-00 arthrodesis glenohumeral joint $877.50 

23802-00 arthrodesis glenohumeral jt w/autogenous graft $936.00 

23900-00 interthoracoscapular amputation $975.00 

23920-00 disarticulation shoulder $731.25 

23921-00 disrtcj shoulder secondary clsr/scar revision $334.33 

23930-00 i&d upper arm/elbow deep abscess/hematoma $195.00 

23931-00 incision&drainage upper arm/elbow bursa $58.50 

23935-00 inc deep w/opening bone cortex humerus/elbow $390.00 

24000-00 arthrt elbow w/exploration drainage/removal fb $487.50 

24006-00 arthrt elbow capsular excision capsular rls spx $463.13 

24065-00 biopsy soft tissue upper arm/elbow superficial $53.63 

24066-00 biopsy soft tissue upper arm/elbow area deep $107.25 

24071-00 exc tumor soft tissue upper arm/elbow subq 3+cm $267.15 

24073-00 exc tumor soft tiss upper arm/elbw subfasc 5+cm $370.50 

24075-00 exc tumor soft tiss upper arm/elbow subq

Procedure & 


Tarifas 



24152-00 radical resection tumor radial head/neck $975.00 

24155-00 resection elbow joint arthrectomy $682.50 

24160-00 implant removal elbow joint $253.50 

24164-00 implant removal radial head $185.25 

24200-00 rmvl foreign body upper arm/elbow subcutaneous $19.50 

24201-00 removal foreign body upper arm/elbow deep $284.77 

24220-00 injection elbow arthrography $29.25 

24300-00 manipulation elbow under anesthesia $248.33 

24301-00 muscle/tendon transfer upper arm/elbow single $526.50 

24305-00 tendon lengthening upper arm/elbow ea tendon $292.50 

24310-00 tenotomy open elbow to shoulder each tendon $195.00 

24320-00 tenoplasty elbow to shoulder single $487.50 

24330-00 flexor-plasty elbow $292.50 

24331-00 flexor-plasty elbow w/extensor advancement $453.38 

24332-00 tenolysis triceps $341.35 

24340-00 tenodesis biceps tendon elbow spx $438.75 

24342-00 rinsj rptd biceps/triceps tdn dstl +-tdn grf $594.75 

24343-00 repair lateral collateral ligament elbow $449.28 

24344-00 rcnstj lat coltrl ligm elbow w/tendon graft $686.21 

24345-00 repair medial collateral ligament elbow $449.28 

24346-00 rcnstj medial coltrl ligm elbw w/tdn grf $703.80 

24357-00 tenotomy elbow lateral/medial percutaneous $253.50 

24358-00 tnot elbow lateral/medial debride open $320.00 

24359-00 tnot elbow lateral/medial debride open tdn rpr $372.94 

24360-00 arthroplasty elbow w/membrane $780.00 

24361-00 arthroplasty elbow w/distal humrl prostc rplcmt $1,316.25 

24362-00 arthrp elbow w/implt&fsca lata ligament rcnstj $1,316.25 

24363-00 arthrp elbow w/distal hum&prox ur prostc rplcmt $1,413.75 

24365-00 arthroplasty radial head $429.00 

24366-00 arthroplasty radial head w/implant $539.61 

24400-00 osteotomy humerus +-internal fixation $487.50 

24410-00 mlt osteot w/relignmt imed rod humeral shaft $487.50 

24420-00 osteoplasty humerus $975.00 

24430-00 repair non/malunion humerus w/o graft $741.00 

24435-00 repair non/malunion humerus w/iliac/oth agrft $867.75 

24470-00 hemiepiphyseal arrest $429.00 

24495-00 decompression fasct f/arm w/brach art expl $390.00 

24498-00 prophylactic tx +-methylmethacrylate humrl shft $476.78 

24500-00 clsd tx humeral shaft fracture w/o manipulation $78.00 

24505-00 cltx humeral shft fx w/manipulation +-skel tracj $333.19 

24515-00 optx humeral shft fx w/plate/screws +-cerclage $631.80 

24516-00 tx humeral shaft fx w/insj imed implt +-cerclage $645.84 

24530-00 cltx sprcndylr/transcndylr humeral fx+-mnpj $58.50 

24535-00 cltx sprcndylr/transcndylr humeral fx w/mnpj $426.93 

24538-00 prq skel fixj sprcndylr/transcndylr humeral fx $547.56 

24545-00 open tx humeral supracondylar fracture w/o xtn $566.87 

24546-00 open tx humeral supracondylar fracture w/xtn $805.55 

24560-00 cltx humeral epicondylar fx medial/lat w/o mnpj $68.25 

24565-00 cltx humeral epicondylar fx medial/lat w/mnpj $350.69 

24566-00 prq skel fixj humrl epcndylr fx medial/lat mnpj $402.68 

17

Procedure & 


Tarifas 



24575-00 open tx humeral epicondylar fracture $522.11 

24576-00 cltx humeral condylar fx medial/lat w/o mnpj $58.50 

24577-00 cltx humeral condylar fx medial/lateral w/mnpj $367.46 

24579-00 open treatment humeral condylar fracture $623.90 

24582-00 prq skel fixj humrl cndylr fx medial/lat w/mnpj $417.30 

24586-00 optx periarticular fracture &/dislocation elbow $820.46 

24587-00 optx priarticular fx&/dislc elbw w/implt arthrp $833.63 

24600-00 treatment closed elbow dislocation w/o anes $250.61 

24605-00 treatment closed elbow dislocation req anes $285.19 

24615-00 open tx acute/chronic elbow dislocation $243.75 

24620-00 closed tx monteggia fx dislocation elbow w/mnpj $331.70 

24635-00 open tx monteggia fracture dislocation elbow $805.55 

24640-00 cltx rdl head sublxtj chld nursemaid elbw w/mnpj $19.50 

24650-00 closed tx radial head/neck fx w/o manipulation $58.50 

24655-00 closed tx radial head/neck fx w/manipulation $288.21 

24665-00 open tx radial head/neck fracture $482.63 

24666-00 open tx radial head/neck fracture prosthetic $541.42 

24670-00 closed tx ulnar fracture proximal end w/o mnpj $39.00 

24675-00 closed tx ulnar fracture proximal end w mnpj $126.75 

24685-00 open treatment ulnar fracture proximal end $511.58 

24800-00 arthrodesis elbow joint local $682.50 

24802-00 arthrodesis elbow joint w/autogenous graft $682.50 

24900-00 amputation arm thru humerus w/primary closure $390.00 

24920-00 amputation arm thru humerus open circular $341.25 

24925-00 amp arm thru humerus secondary clsr/scar revj $48.75 

24930-00 amputation arm thru humerus re-amputation $390.00 

24931-00 amputation arm thru humerus w/implant $516.75 

24935-00 stump elongation upper extremity $509.93 

25000-00 incision extensor tendon sheath wrist $290.45 

25001-00 incision flexor tendon sheath wrist $207.97 

25020-00 dcmprn fasct f/arm&wrst flxr/xtnsr w/o dbrdmt $331.50 

25023-00 dcmprn fasct f/arm&/wrst flxr/xtnsr w/dbrdmt $414.38 

25024-00 dcmprn fasct f/arm&/wrst flxr&xtnsr w/o dbrdmt $478.24 

25025-00 dcmprn fasct f/arm&/wrst flxr&xtnsr dbrdmt nv $774.83 

25028-00 i&d forearm&/wrist deep abscess/hematoma $224.25 

25031-00 incision & drainage forearm&/wrist bursa $156.00 

25035-00 incision deep bone cortex forearm&/wrist $331.50 

25040-00 arthrt rdcrpl/midcarpl jt w/expl drg/rmvl fb $447.53 

25065-00 biopsy soft tissue forearm&/wrist superficial $78.00 

25066-00 biopsy soft tissue forearm&/wrist deep $156.00 

25071-00 exc tumor soft tiss forearm and/wrist subq 3+cm $310.05 

25073-00 exc tumor sft tiss forearm&//wrist subfasc 3+cm $312.00 

25075-00 exc tumor soft tissue forearm &/wrist subq

Procedure & 


Tarifas 



25107-00 arthrotomy dstl radioulnar joint rpr cartilage $292.50 

25109-00 exc tendon forearm&/wrist flexor/extensor ea $333.66 

25110-00 excision lesion tendon sheath forearm&/wrist $97.50 

25111-00 excision ganglion wrist dorsal/volar primary $146.25 

25112-00 excision ganglion wrist dorsal/volar recurrent $234.00 

25115-00 rad exc bursa synva wrst/f/arm tdn shths flxrs $487.50 

25116-00 rad exc bursa synva wrst/f/arm tdn shths xtnsrs $438.75 

25118-00 synovectomy extensor tendon shth wrist 1 cmprt $390.00 

25119-00 synvct xtnsr tdn shth wrst 1 rescj dstl ulna $370.50 

25120-00 excision/curettage cyst/tumor radius/ulna $351.00 

25125-00 exc/curtg cyst/tumor radius/ulna w/autograft $429.00 

25126-00 exc/curtg cyst/tumor radius/ulna w/allograft $370.50 

25130-00 excision/curettage cyst/tumor carpal bones $195.00 

25135-00 exc/curtg cyst/tumor carpal bones w/autograft $312.00 

25136-00 exc/curtg cyst/tumor carpal bones w/allograft $273.00 

25145-00 sequestrectomy forearm &/wrist $564.41 

25150-00 partial excision bone ulna $487.50 

25151-00 partial excision bone radius $487.50 

25170-00 radical resection tumor radius or ulna $633.75 

25210-00 carpectomy 1 bone $394.88 

25215-00 carpectomy all bones proximal row $419.25 

25230-00 radical styloidectomy spx $273.00 

25240-00 excision distal ulna partial/complete $379.71 

25246-00 injection wrist arthrography $29.25 

25248-00 expl w/removal deep foreign body forearm/wrist $224.25 

25250-00 removal wrist prosthesis spx $273.00 

25251-00 removal wrist prosth complicated w/total wrist $312.00 

25259-00 manipulation wrist under anesthesia $195.00 

25260-00 rpr tdn/musc flxr f/arm&/wrst prim 1 ea tdn/musc $526.50 

25263-00 rpr tdn/musc flxr f/arm&/wrst sec 1 ea tdn/musc $409.50 

25265-00 rpr tdn/musc flxr f/arm&/wrst sec fr grf ea $585.00 

25270-00 rpr tdn/musc xtnsr f/arm&/wrst prim 1 ea tdn $117.00 

25272-00 rpr tdn/musc xtnsr f/arm&/wrst sec 1 ea tdn/musc $611.09 

25274-00 rpr tdn/musc xtnsr f/arm&/wrst sec fr grf ea tdn $351.00 

25275-00 rpr tendon sheath extensor f/arm&/wrst w/graft $433.49 

25280-00 lngth/shrt flxr/xtnsr tdn f/arm&/wrst 1 ea tdn $292.50 

25290-00 tnot flxr/xtnsr tendon forearm&/wrist 1 ea $292.50 

25295-00 tnols flxr/xtnsr tendon forearm&/wrist 1 ea $243.75 

25300-00 tenodesis wrist flexors fingers $463.13 

25301-00 tenodesis wrist extensors fingers $404.63 

25310-00 tdn trnsplj/tr flxr/xtnsr f/arm&/wrst 1 ea tdn $331.50 

25312-00 tdn trnsplj/tr flxr/xtnsr f/arm&/wrst 1/tdn grf $390.00 

25315-00 flexor origin slide forearm &/wrist $390.00 

25316-00 flexor origin slide f/arm&/wrst tendon transfer $487.50 

25320-00 capsl-rhphy/rcnstj wrst opn carpl ins $448.50 

25332-00 arthrp wrst +-interpos +-xtrnl/int fixj $468.00 

25335-00 centralization wrst ulna $585.00 

25337-00 rcnstj stablj dstl u/dstl jt 2 soft tiss stablj $644.09 

25350-00 osteotomy radius distal third $684.45 

25355-00 osteotomy radius middle/proximal third $472.88 

19

Procedure & 


Tarifas 



25360-00 osteotomy ulna $673.04 

25365-00 osteotomy radius & ulna $555.75 

25370-00 mlt osteotomies w/relignmt imed rod radius/ulna $487.50 

25375-00 mlt osteotomies w/relignmt imed rod radius&ulna $872.24 

25390-00 osteoplasty radius/ulna shortening $633.75 

25391-00 osteoplasty radius/ulna lengthening w/autograft $975.00 

25392-00 osteoplasty radius & ulna shortening $594.75 

25393-00 osteoplasty radius&ulna lengthening w/autograft $1,062.50 

25394-00 osteoplasty carpal bone shortening $510.71 

25400-00 rpir nonunion/malunion radius/ulna w/o autograft $482.63 

25405-00 rpr nonunion/malunion radius/ulna w/autograft $565.50 

25415-00 rpr nonunion/malunion radius&ulna w/o autograft $643.50 

25420-00 rpr nonunion/malunion radius&ulna w/autograft $741.00 

25425-00 repair defect w/autograft radius/ulna $536.25 

25426-00 repair defect w/autograft radius&ulna $672.75 

25430-00 insertion vascular pedicle carpal bone $456.30 

25431-00 repair nonunion carpal bone each bone $441.38 

25440-00 rpr nonunion scaphoid carpal bone +-rdl stylodc $639.81 

25441-00 arthroplasty w/prosthetic rplcmt distal radius $677.63 

25442-00 arthroplasty w/prosthetic rplcmt distal ulna $321.75 

25443-00 arthroplasty w/prosthetic rplcmt scaphoid carpal $370.50 

25444-00 arthroplasty w/prosthetic replacement lunate $370.50 

25445-00 arthroplasty w/prosthetic replacement trapezium $370.50 

25446-00 arthrp w/prostc rplcmt dstl rds&prtl/carpus $994.50 

25447-00 arthrp interpos intercarpal/metacarpal joints $526.50 

25449-00 revj arthrp w/rmvl implt wrst jt $526.50 

25450-00 epiphysl arrst epiphysiod/stapling dstl rds/u $731.25 

25455-00 epiphysl arrst epiphysiod/stapling dstl rds&u $975.00 

25490-00 proph tx n/p/pltwr +-mma rds $526.50 

25491-00 proph tx n/p/pltwr +-mma u $526.50 

25492-00 proph tx n/p/pltwr +-mma rds&u $526.50 

25500-00 closed tx radial shaft fracture w/o manipulation $58.50 

25505-00 closed tx radial shaft fracture w/manipulation $243.75 

25515-00 open treatment radial shaft fracture $457.18 

25520-00 cltx rdl shft fx&cltx dislc dstl rad/uln jt $324.68 

25525-00 open rdl shaft fx closed rad/uln jt dislocate $644.09 

25526-00 open rdl shaft fx open rad/uln jt dislocate $684.45 

25530-00 closed tx ulnar shaft fracture w/o manipulation $107.25 

25535-00 closed tx ulnar shaft fracture w/manipulation $175.50 

25545-00 open treatment of ulnar shaft fracture $515.09 

25560-00 closed tx radial&ulnar shaft fractures w/o mnpj $97.50 

25565-00 closed tx radial&ulnar shaft fractures w/mnpj $346.61 

25574-00 open tx radial & ulnar shaft fx fixj radius/ulna $450.95 

25575-00 open tx rdl& ulnar shaft fx fixj radius &ulna $581.78 

25600-00 cltx dstl radial fx/epiphysl sep w/o mnpj $146.25 

25605-00 cltx dstl rdl fx/epiphysl sep +-w/mnpj $376.48 

25606-00 perq skel fixj distal radial fx/epiphysl sep $501.30 

25607-00 optx dstl radl x-artic fx/epiphysl sep $428.69 

25608-00 optx dstl radl i-artic fx/epiphysl sep 2 frag $499.30 

25609-00 optx dstl radl i-artic fx/epiphysl sep 3 frag $512.10 

20

Procedure & 


Tarifas 



25622-00 closed tx carpal scaphoid fracture w/o mnpj $78.00 

25624-00 closed tx carpal scaphoid fracture w/mnpj $298.77 

25628-00 open tx carpal scaphoid navicular fracture $495.79 

25630-00 cltx carpl b1 fx w/o mnpj ea b1 $78.00 

25635-00 cltx carpl b1 fx w/mnpj ea b1 $146.25 

25645-00 open tx carpal bone fracture oth/thn scaphoid ea $448.40 

25650-00 closed treatment ulnar styloid fracture $198.88 

25651-00 prq skeletal fixation ulnar styloid fracture $284.07 

25652-00 open treatment ulnar styloid fracture $393.12 

25660-00 cltx rdcrpl/intercarpl dislc 1+ b1s w/mnpj $48.75 

25670-00 open tx radiocarpal/intercarpal dislc 1+ bones $321.75 

25671-00 prq skeletal fixj distal radioulnar dislocation $326.43 

25675-00 closed tx distal radioulnar dislocation w/mnpj $126.75 

25676-00 open tx distal radioulnar dislc acute/chronic $273.00 

25680-00 cltx trans-scaphoprilunar typ fx dislc w/mnpj $253.50 

25685-00 open tx trans-scaphoperilunar fracture dislc $370.50 

25690-00 closed tx lunate dislocation w/manipulation $214.50 

25695-00 open treatment lunate dislocation $321.75 

25800-00 arthrd wrst compl w/o b1 grf $482.63 

25805-00 arthrd wrst w/sliding grf $516.75 

25810-00 arthrd wrst w/iliac/oth agrft $594.75 

25820-00 arthrodesis wrist limited w/o bone graft $526.50 

25825-00 arthrodesis wrist limited w/autograft $527.48 

25830-00 arthrd dstl rad/uln jt sgmtl rescj u +-b1 grf $552.83 

25900-00 amputation forearm through radius & ulna $390.00 

25905-00 amp forearm thru radius&ulna open circular $341.25 

25907-00 amp f/arm thru radius&ulna sec closure/scar revj $48.75 

25909-00 amp forearm thru radius&ulna re-amputation $390.00 

25915-00 krukenberg procedure $1,160.25 

25920-00 disarticulation through wrist $390.00 

25922-00 disarticulation thru wrist sec closure/scar revj $126.75 

25924-00 disarticulation thru wrist re-amputation $341.25 

25927-00 transmetacarpal amputation $390.00 

25929-00 transmetacarpal amputation sec closure/scar revj $126.75 

25931-00 transmetacarpal amputation re-amputation $390.00 

26010-00 drainage finger abscess simple $29.25 

26011-00 drainage finger abscess complicated $107.25 

26020-00 drainage tendon sheath digit&/palm each $292.50 

26025-00 drainage of palmar bursa single bursa $292.50 

26030-00 drainage of palmar bursa multiple bursa $390.00 

26034-00 incision bone cortex hand/finger $185.25 

26035-00 decompression fingers&/hand injection injury $472.97 

26037-00 decompressive fasciotomy hand $371.18 

26040-00 fasciotomy palmar percutaneous $107.25 

26045-00 fasciotomy palmar open partial $292.50 

26055-00 tendon sheath incision $195.00 

26060-00 tenotomy percutaneous single each digit $48.75 

26070-00 arthrt expl drg/rmvl loose/fb carp/mtcrpl jt $214.50 

26075-00 arthrt expl drg/rmvl loose/fb mtcarphlngl jt ea $185.25 

26080-00 arthrt expl drg/rmvl loose/fb iphal jt ea $165.75 

21

Procedure & 


Tarifas 



26100-00 arthrotomy biopsy carp/mtcrpl joint each $214.50 

26105-00 arthrotomy biopsy mtcarphlngl joint each $165.75 

26110-00 arthrotomy biopsy interphalangeal joint each $131.63 

26111-00 ex tum/vasc malf sft tiss hand/fngr subq 1.5+cm $173.55 

26113-00 ex tum/vasc mal sft tis hand/fngr subfsc 1.5+cm $214.50 

26115-00 exc tum/vasc mal sft tiss hand/fngr subq

Procedure & 


Tarifas 



26432-00 cltx dstl xtnsr tdn insj +-prq pinning $107.25 

26433-00 repair extensor tendon distal insertion w/o grf $117.00 

26434-00 repair extensor tendon distal insertion w/graft $273.00 

26437-00 realignment extensor tendon hand each tendon $273.00 

26440-00 tenolysis flexor tendon palm/finger each tendon $214.50 

26442-00 tenolysis flexor tendon palm&finger each tendon $253.50 

26445-00 tenolysis extensor tendon hand/finger each $523.94 

26449-00 tenolysis cplx xtnsr tendon finger w/forearm ea $507.00 

26450-00 tenotomy flexor palm open each tendon $160.88 

26455-00 tenotomy flexor finger open each tendon $107.25 

26460-00 tenotomy extensor hand/finger open each tendon $107.25 

26471-00 tenodesis proximal interphalangeal joint each $273.00 

26474-00 tenodesis distal joint each $273.00 

26476-00 lengthening tendon extensor hand/finger each $312.00 

26477-00 shortening tendon extensor hand/finger each $312.00 

26478-00 lengthening tendon flexor hand/finger each $351.00 

26479-00 shortening tendon flexor hand/finger each $351.00 

26480-00 tr/trnspl tdn carp/mtcrpl hand w/o fr grf ea tdn $341.25 

26483-00 tendon transfer transplant carp/mtcrpl graft $448.50 

26485-00 transfer/transplant tendon palmar w/o graft each $429.00 

26489-00 transfer/transplant tendon palmar w/graft each $536.25 

26490-00 opponensplasty supfcis tdn tr typ ea tdn $429.00 

26492-00 opponensplasty tdn tr w/grf ea tdn $536.25 

26494-00 opponensplasty hypothenar musc tr $482.63 

26497-00 tr tdn restore intrnsc funcj ring&sm fngr $390.00 

26498-00 tr tdn restore intrnsc funcj all 4 fngrs $585.00 

26499-00 correction claw finger other methods $390.00 

26500-00 rcnstj tendon pulley each w/local tissues spx $273.00 

26502-00 rcnstj tdn pulley ea tdn w/tdn/fscal grf spx $321.75 

26508-00 release thenar muscle $321.75 

26510-00 cross intrinsic transfer each tendon $268.13 

26516-00 capsulodesis mtcarphlngl joint single digit $273.00 

26517-00 capsulodesis mtcarphlngl joint 2 digits $390.00 

26518-00 capsulodesis mtcarphlngl joint 3/4 digits $482.63 

26520-00 capsulectomy/capsulotomy mtcarphlngl joint each $273.00 

26525-00 capsulectomy/capsulotomy iphal joint each $273.00 

26530-00 arthroplasty metacarpophalangeal joint each $321.75 

26531-00 arthrp mtcarphlngl jt w/prostc implt ea jt $480.68 

26535-00 arthroplasty interphalangeal joint each $273.00 

26536-00 arthroplasty interphalangeal jt w/prosthetic ea $444.89 

26540-00 rpr coltrl ligm mtcarphlngl/iphal jt $370.50 

26541-00 rcnstj coltrl ligm mtcarphlngl 1 w/tdn/fscal grf $458.25 

26542-00 rcnstj coltrl ligm mtcarphlngl 1 w/local tiss $303.23 

26545-00 rcnstj coltrl ligm iphal jt 1 w/grf ea jt $321.75 

26546-00 rpr non-union mtcrpl/phalanx $456.30 

26548-00 rpr&rcnstj finger volar plate interphalangeal jt $334.43 

26550-00 pollicization digit $1,113.45 

26551-00 tr toe-to-hand w/mvasc anast grt toe wrp/arnd $2,249.69 

26553-00 tr toe-to-hand w/mvasc anast oth/thn grt toe 1 $1,162.79 

26554-00 tr toe-to-hand w/mvasc anast oth/thn grt toe 2 $1,032.29 

23

Procedure & 


Tarifas 



26555-00 tr fngr axh pos w/o mvasc anast $866.78 

26556-00 transfer free toe joint w/mvasc anastomosis $2,242.89 

26560-00 repair syndactyly each space w/skin flaps $370.50 

26561-00 repair syndactyly each space w/skin flaps&grafts $458.25 

26562-00 repair syndactyly each space complex $604.50 

26565-00 osteotomy metacarpal each $321.75 

26567-00 osteotomy phalanx finger each $321.75 

26568-00 osteoplasty lengthening metacarpal/phalanx $417.30 

26580-00 repair cleft hand $902.95 

26587-00 rcnstj polydactylous dgt soft tiss&b1 $548.44 

26590-00 repair macrodactylia each digit $933.66 

26591-00 repair intrinsic muscles hand each muscle $126.75 

26593-00 release intrinsic muscles hand each muscle $224.25 

26600-00 cltx mtcrpl fx 1 w/o mnpj ea b1 $58.50 

26605-00 cltx mtcrpl fx 1 w/mnpj ea b1 $201.04 

26607-00 cltx mtcrpl fx w/mnpj w/xtrnl fixj ea b1 $330.82 

26608-00 prq skel fixj mtcrpl fx ea b1 $367.94 

26615-00 open tx metacarpal fracture single ea bone $345.20 

26641-00 cltx carp/mtcrpl dislc thmb w/mnpj $97.50 

26645-00 cltx carp/mtcrpl fx dislc thmb w/mnpj $265.01 

26650-00 prq skel fixation carp/mtcrpl fx dislocate thumb $214.50 

26665-00 open tx carpometacarpal fracture dislocate thumb $459.81 

26670-00 cltx carp/mtcrpl dislc thmb mnpj ea w/o anes $29.25 

26675-00 cltx carp/mtcrpl dislc thmb mnpj ea jt req anes $107.25 

26676-00 prq skel fixj carp/mtcrpl dislc thmb mnpj ea jt $110.18 

26685-00 open tx carpometacarpal dislocate not thumb $253.50 

26686-00 optx carp/mtcrpl dislc thmb cplx mlt/dlyd rdctj $331.50 

26700-00 cltx mtcarphlngl dislc 1 w/mnpj w/o anes $131.63 

26705-00 cltx mtcarphlngl dislc 1 w/mnpj req anes $107.25 

26706-00 prq skel fixj mtcarphlngl dislc 1 w/mnpj $110.18 

26715-00 open treatment metacarpophalangeal dislocation 1 $253.50 

26720-00 cltx phlngl fx prox/middle px/f/t w/o mnpj ea $29.25 

26725-00 cltx phlngl fx prox/middle px/f/t w/mnpj ea $231.02 

26727-00 prq skel fixj phlngl shft fx prox/middle px/f/t $364.02 

26735-00 open tx phalangeal shaft fracture prox/middle ea $378.29 

26740-00 cltx articular fx invg mtcarphlngl/iphal jt w/o $83.36 

26742-00 cltx articular fx invg mtcarphlngl/iphal jt w/ $245.34 

26746-00 open tx articular fracture mcp/ip joint ea $373.02 

26750-00 cltx dstl phlngl fx fngr/thmb w/o mnpj ea $29.25 

26755-00 cltx dstl phlngl fx fngr/thmb w/mnpj ea $196.30 

26756-00 prq skel fixj dstl phlngl fx fngr/thmb ea $322.64 

26765-00 open tx distal phalangeal fracture each $281.39 

26770-00 cltx iphal jt dislc 1 w/mnpj w/o anes $143.03 

26775-00 cltx iphal jt dislc 1 w/mnpj req anes $187.79 

26776-00 prq skel fixj iphal jt dislc 1 w/mnpj $78.98 

26785-00 open tx interphalangeal joint dislocation 1 $126.75 

26820-00 fusion opposition thumb w/autogenous graft $429.00 

26841-00 arthrd carp/mtcrpl jt thmb +-int fixj $341.25 

26842-00 arthrd carp/mtcrpl jt thmb +-int fixj w/agrft $429.00 

26843-00 arthrd carp/mtcrpl jt dgt other than thumb each $341.25 

24

Procedure & 


Tarifas 



26844-00 arthrd carp/mtcrpl jt dgt oth/thn thmb w/agrft $429.00 

26850-00 arthrd mtcarphlngl jt +-int fixj $321.75 

26852-00 arthrd mtcarphlngl jt +-int fixj w/agrft $404.63 

26860-00 arthrd iphal jt +-int fixj $476.77 

26861-00 arthrd iphal jt +-int fixj ea iphal jt $97.50 

26862-00 arthrd iphal jt +-int fixj w/agrft $601.97 

26863-00 arthrd iphal jt +-int fixj w/agrft ea jt $117.00 

26910-00 amp mtcrpl w/fngr/thmb 1 +-inteross tr $292.50 

26951-00 amp f/th 1/2 jt/phalanx 1 w/neurect w/dir clsr $448.63 

26952-00 amp f/th 1/2 jt/phalanx 1 w/neurect local flap $185.25 

26990-00 i&d pelvis/hip jt area dp absc/hmtma $480.54 

26991-00 i&d pelvis/hip jt area infct bursa $186.23 

26992-00 incision bone cortex pelvis&/hip joint $497.25 

27000-00 tenotomy adductor hip percutaneous spx $107.25 

27001-00 tenotomy adductor hip open $416.81 

27003-00 tx adduxor subq opn w/obturator neurectomy $447.54 

27005-00 tenotomy hip flexor open spx $555.46 

27006-00 tenotomy abductors&/extensor hip open spx $253.50 

27025-00 fasciotomy hip/thigh any type $429.00 

27027-00 decompression fasciotomy pelvic compartment uni $579.15 

27030-00 arthrotomy hip w/drainage $682.50 

27033-00 arthrotomy hip exploration/removal foreign body $713.41 

27035-00 dnrvtj hip jt intrapel/xtrpel intra-artclr brnch $312.00 

27036-00 capslctomy/capsul hip w/rls hip flxr musc $741.00 

27040-00 biopsy soft tissue pelvis&hip area superficial $78.00 

27041-00 biopsy soft tissue pelvis&hip deep/subfscal/im $495.79 

27043-00 excision tumor soft tissue pelvis&hip subq 3+cm $214.50 

27045-00 exc tumor soft tissue pelvis & hip subfasc 5+cm $268.13 

27047-00 exc tumor soft tissue pelvis & hip subq

Procedure & 


Tarifas 



27090-00 removal hip prosthesis spx $594.75 

27091-00 rmvl hip prosth comp w/tot hip prosth mma $975.00 

27093-00 injection hip arthrography w/o anesthesia $39.00 

27095-00 injection hip arthrography w/anesthesia $165.75 

27096-00 injection si joint arthrography&/anes/steroid $56.16 

27097-00 release/recession hamstring proximal $410.00 

27098-00 transfer adductor ischium $410.00 

27100-00 tr xtrnl oblq musc trchntr w/fscal/tdn xtn grf $660.00 

27105-00 tr paraspi musc hip fasc/tdn xtn grf $690.00 

27110-00 transfer iliopsoas greater trochanter femur $867.75 

27111-00 transfer iliopsoas femoral neck $660.00 

27120-00 acetabuloplasty $1,033.50 

27122-00 acetabuloplasty resection femoral head $867.75 

27125-00 hemiarthroplasty hip partial $975.00 

27130-00 arthrp acetblr/prox fem prostc agrft/algrft $1,218.75 

27132-00 conv previous hip tot hip arthrp +-agrft/algrft $1,579.50 

27134-00 revj tot hip arthrp bth +-agrft/algrft $2,018.25 

27137-00 revj tot hip arthrp actblr only +-agrft/algrft $1,579.50 

27138-00 revj tot hip arthrp fem only +-algrft $1,579.50 

27140-00 osteotomy&transfer greater trochanter spx $530.00 

27146-00 osteotomy iliac acetabular/innominate bone $920.50 

27147-00 osteotomy iliac acetabular/innominate hip rdctj $936.00 

27151-00 osteotomy iliac acetabular/innominate fem osteot $1,062.75 

27156-00 osteot iliac actblr/innominate b1 osteot rdctj $1,092.00 

27158-00 osteotomy pelvis bilateral $974.90 

27161-00 osteotomy femoral neck spx $975.00 

27165-00 osteot intertrchntric/subtrchntric w/int/xtrnl $1,013.53 

27170-00 b1 grf fem h/n intertrchntric/subtrchntric area $1,033.50 

27175-00 tx slp fem epiphysis trcj w/o rdctj $117.00 

27176-00 tx slp fem epiphysis 1/mlt pinning situ $867.75 

27177-00 optx slp fem epiphysis 1/mlt pinning/b1 grf $994.50 

27178-00 optx slp fem epiphysis clsd mnpj 1/mlt pinning $780.00 

27179-00 optx slp fem epiphysis ostpl fem nck heyman px $672.75 

27181-00 optx slp fem epiphysis osteot&int fixj $1,033.50 

27185-00 epiphysl arrst epiphysiod/stapling trchntr femur $341.25 

27187-00 proph tx n/p/pltwr +-mma fem nck&prox femur $877.50 

27193-00 cltx pel ring fx dislc diast/sublxtj w/o mnpj $225.00 

27194-00 cltx pel ring fx dislc diast/sublxtj w/mnpj anes $342.23 

27200-00 closed treatment coccygeal fracture $125.86 

27202-00 open treatment coccygeal fracture $312.00 

27215-00 optx iliac tubrst avls/wing fx fixj if prfrmd $740.00 

27216-00 perq skeletal fixation pst pelvic bone fx&/dislc $473.85 

27217-00 optx ant pelvic bone fx&/dislc int fixj if pfrmd $756.00 

27218-00 optx post pel bone fx&/dislc int fixj if pfrmd $855.00 

27220-00 cltx acetabulum hip/sockt fx w/o mnpj $19.50 

27222-00 cltx acetabulum hip/sockt fx mnpj +-skel tracj $633.56 

27226-00 optx pst/ant actblr wall fx w/int fixj $855.00 

27227-00 optx actblr fx invg ant/pst 1 column/fx w/int $1,013.00 

27228-00 optx actblr fx invg ant&pst 2 columns fx w/int $1,076.00 

27230-00 cltx fem fx prox end nck w/o mnpj $19.50 

26

Procedure & 


Tarifas 



27232-00 cltx fem fx prox end nck w/mnpj +-skel tracj $549.32 

27235-00 prq skel fixj fem fx prox end nck $780.00 

27236-00 optx fem fx prox end nck int fixj/prostc rplcmt $876.14 

27238-00 cltx inter/peri/subtrochanteric fem fx w/o mnpj $19.50 

27240-00 cltx intr/peri/sbtrchntc fem fx w/mnpj $438.75 

27244-00 tx inter/pr/subtrchntric fem fx screw implt $877.50 

27245-00 tx inter/pr/subtrchntric fem fx imed impltscrew $986.31 

27246-00 cltx grter trchntric fx w/o mnpj $19.50 

27248-00 open treatment greater trochanteric fracture $609.05 

27250-00 cltx hip dislc traumtc w/o anes $195.00 

27252-00 cltx hip dislc traumtc req anes $204.75 

27253-00 optx hip dislc traumtc w/o int fixj $657.25 

27254-00 optx hip dislc traumtc w/actblr wall&fem head fx $936.00 

27256-00 tx spon hip dislc abdct splnt/trcj w/o anes $195.00 

27257-00 tx spon hip dislc abdct splnt/trcj w/mnpj anes $195.00 

27258-00 optx spon hip dislc rplcmt fem head actblm $807.30 

27259-00 optx spon hip dislc rplcmt fem head actblm shrt $910.00 

27265-00 cltx post hip arthrp dislc w/o anes $219.38 

27266-00 cltx post hip arthrp dislc req anes $307.13 

27267-00 closed tx femoral fracture prox head w/o mnpj $270.00 

27268-00 closed tx femoral fracture prox head w mnpj $316.88 

27269-00 open tx femoral fracture proximal end head $780.00 

27275-00 manipulation hip joint general anesthesia $108.81 

27280-00 arthrodesis sacroiliac joint w/obtaining graft $594.75 

27282-00 arthrodesis symphysis pubis w/obtaining graft $497.25 

27284-00 arthrodesis hip joint w/obtaining graft $975.00 

27286-00 arthrd hip jt w/obtg grf w/subtrchntric osteot $1,390.00 

27290-00 interpelviabdominal amputation $2,125.50 

27295-00 disarticulation hip $780.00 

27301-00 i&d dp absc bursa/hmtma thi/kne region $397.67 

27303-00 inc dp w/opng b1 cortex femur/kne $526.50 

27305-00 fasciotomy iliotibial open $214.50 

27306-00 tenotomy prq adductor/hamstring 1 tendon spx $107.25 

27307-00 tenotomy prq adductor/hamstring multiple tendon $160.88 

27310-00 arthrt kne w/expl drg/rmvl fb $532.64 

27323-00 biopsy soft tissue thigh/knee area superficial $78.00 

27324-00 biopsy soft tissue thigh/knee area deep $297.70 

27325-00 neurectomy hamstring muscle $400.00 

27326-00 neurectomy popliteal $500.00 

27327-00 excision tumor soft tissue thigh/knee subq

Procedure & 


Tarifas 



27340-00 excision prepatellar bursa $276.05 

27345-00 excision synovial cyst popliteal space $292.50 

27347-00 excision lesion meniscus/capsule knee $355.39 

27350-00 patellectomy/hemipatellectomy $487.89 

27355-00 excision/curettage cyst/tumor femur $443.63 

27356-00 excision/curettage cyst/tumor femur w/allograft $443.63 

27357-00 excision/curettage cyst/tumor femur w/autograft $643.50 

27358-00 excision/curettage cyst/tumor femur int fixation $156.00 

27360-00 prtl exc b1 femur prox tibia&/fibula $656.10 

27364-00 rad resection tumor soft tissue thigh/knee 5+cm $724.43 

27365-00 radical resection tumor femor or knee $702.00 

27370-00 injection knee arthrography $29.25 

27372-00 removal foreign body deep thigh/knee $313.08 

27380-00 suture infrapatellar tendon primary $585.00 

27381-00 sutr infrapatellar tdn 2 rcnstj w/fscal/tdn grf $585.00 

27385-00 suture quadriceps/hamstring rupture primary $516.75 

27386-00 sutr quadriceps/hamstring musc rpt 2 rcnstj $672.75 

27390-00 tenotomy open hamstring knee hip single tendon $214.50 

27391-00 tenotomy opn hamstring knee hip multiple 1 leg $302.25 

27392-00 tenotomy open hamstring knee hip multiple bi $546.00 

27393-00 lengthening hamstring tendon single $253.50 

27394-00 lengthening hamstring tendon multiple 1 leg $511.52 

27395-00 lengthening hamstring tendon multiple bilateral $555.75 

27396-00 transplant/transfer thigh xtnsr to flxr 1 tendon $643.50 

27397-00 transplant/transfer thigh xtnsr to flxr mult tdn $741.00 

27400-00 transfer tendon/muscle hamstrings femur $672.75 

27403-00 arthrotomy w/meniscus repair knee $474.73 

27405-00 rpr primary torn ligm&/capsule knee collateral $536.25 

27407-00 repair primary torn ligm&/capsule knee cruciate $536.25 

27409-00 rpr 1 torn ligm&/capsl kne coltrl&cruciate ligms $731.25 

27412-00 autologous chondrocyte implantation knee $1,077.57 

27415-00 osteochondral allograft knee open $899.44 

27418-00 anterior tibial tubercleplasty $624.00 

27420-00 rcnstj dislocating patella $643.50 

27422-00 rcnstj dislc patella w/xtnsr relignmt&/musc rls $643.50 

27424-00 rcnstj dislc patella w/patellectomy $643.50 

27425-00 lateral retinacular release open $337.40 

27427-00 ligamentous reconstruction knee extra-articular $592.80 

27428-00 ligamentous reconstruction knee intra-articular $570.38 

27429-00 ligmous rcnstj agmntj kne intra-articular xtr $658.13 

27430-00 quadricepsplasty $643.50 

27435-00 capsulotomy posterior capsular release knee $594.75 

27437-00 arthroplasty patella w/o prosthesis $585.00 

27438-00 arthroplasty patella w/prosthesis $795.00 

27440-00 arthroplasty knee tibial plateau $1,174.88 

27441-00 arthrp knee tibial plateau dbrdmt&prtl synvct $1,267.50 

27442-00 arthroplasty fem condyles/tibial plateau knee $1,413.75 

27443-00 arthrp fem condyles/tibl platu kne dbrdmt&prtl $1,462.50 

27445-00 arthroplasty knee hinge prosthesis $1,550.25 

27446-00 arthrp knee condyle&plateau medial/lat cmprt $1,121.25 

28

Procedure & 


Tarifas 



27447-00 arthrp kne condyle&platu medial&lat cmprts $324.00 

27448-00 osteotomy femur shaft/supracondylar w/o fixation $682.50 

27450-00 osteotomy femur shaft/supracondylar w/fixation $804.38 

27454-00 osteot mlt w/relignmt imed rod fem shft $975.00 

27455-00 osteot prox tibia fib exc/osteot before epiphysl $710.78 

27457-00 osteot prox tibia fib exc/osteot after epiphysl $732.71 

27465-00 osteoplasty femur shortening excluding 64876 $975.00 

27466-00 osteoplasty femur lengthening $975.00 

27468-00 ostpl femur cmbn lngth&shrt w/fem sgm tr $1,316.25 

27470-00 rpr non/mal femur dstl h/n w/o grf $867.75 

27472-00 rpr non/mal femur dstl h/n w/iliac/autog b1 grf $1,020.00 

27475-00 arrest epiphyseal distal femur $594.75 

27477-00 arrest epiphyseal tibia&fibula proximal $672.75 

27479-00 arrst epiphysl cmbn dstl femur prox tibfib $867.75 

27485-00 arrst hemiepiphysl dstl femur/prox tibia/fibula $505.44 

27486-00 revj tot kne arthrp +-algrft 1 comp $1,316.25 

27487-00 revj tot kne arthrp fem&entire tibl comp $1,950.00 

27488-00 rmvl prosth tot kne prosth mma +-insj spacer $1,170.00 

27495-00 proph tx n/p/pltwr +-mma femur $877.50 

27496-00 dcmprn fasct thi&/kne 1 cmprt $263.25 

27497-00 dcmprn fasct thi&/kne 1 dbrdmt nv musc&/nrv $315.90 

27498-00 dcmprn fasct thi&/kne mlt cmprts $360.00 

27499-00 dcmprn fasct thi&/kne mlt dbrdmt nv musc&/nrv $417.30 

27500-00 closed tx femoral shaft fx w/o manipulation $117.00 

27501-00 cltx sprcndylr/trnscndylr fem fx w/o mnpj $360.00 

27502-00 cltx fem shft fx w/mnpj +-skn/skel tracj $601.97 

27503-00 cltx sprcndylr/trnscndylr fem fx w/mnpj $438.75 

27506-00 optx fem shft fx w/insj imed implt +-screw $901.19 

27507-00 optx fem shft fx w/plate/screws +-cerclage $816.08 

27508-00 cltx fem fx dstl end medial/lat condyle w/o mnpj $29.25 

27509-00 prq skel fixj fem fx dstl end $315.00 

27510-00 cltx fem fx dstl end medial/lat condyle w/mnpj $341.25 

27511-00 open tx femoral supracondylar fracture w/o xtn $808.30 

27513-00 open tx femoral supracondylar fracture w xtn $900.00 

27514-00 open tx femoral fracture distal med/lat condyle $917.10 

27516-00 cltx dstl fem epiphysl sep w/o mnpj $19.50 

27517-00 cltx dstl fem epiphysl sep w/mnpj +-skn/skel $302.25 

27519-00 open tx distal femoral epiphyseal separation $643.50 

27520-00 closed tx patellar fracture w/o manipulation $78.00 

27524-00 optx patllr fx w/int fixj/patllc&soft tiss rpr $558.97 

27530-00 cltx tibl fx prox w/o mnpj $151.13 

27532-00 cltx tibl fx prox +-mnpj w/skel tracj $409.79 

27535-00 open tx tibial fracture proximal unicondylar $660.60 

27536-00 optx tibl fx prox bicondylar +-int fixj $760.79 

27538-00 cltx intercondylar spi&/tubrst fx kne +-mnpj $19.50 

27540-00 open tx intercondylar spine/tubrst fracture knee $654.62 

27550-00 closed tx knee dislocation w/o anesthesia $58.50 

27552-00 closed tx knee dislocation w/anesthesia $126.75 

27556-00 open tx knee dislocation w/o ligamentous repair $585.00 

27557-00 open tx knee dislocation w ligamentous repair $780.00 

29

Procedure & 


Tarifas 



27558-00 open tx knee dislocation w repair/reconstruction $877.50 

27560-00 closed tx patellar dislocation w/o anesthesia $29.25 

27562-00 closed tx patellar dislocation w/anesthesia $78.00 

27566-00 optx patellar dislc +-prtl/tot patellectomy $619.52 

27570-00 manipulation knee joint under general anesthesia $113.09 

27580-00 arthrodesis knee any technique $780.00 

27590-00 amputation thigh through femur any level $637.14 

27591-00 amp thi thru femur lvl immt fitg tq w/1st cst $585.00 

27592-00 amputation thigh thru femur open circular $487.50 

27594-00 amp thigh thru femur sec closure/scar revision $48.75 

27596-00 amputation thigh through femur re-amputation $585.00 

27598-00 disarticulation knee $390.00 

27600-00 dcmprn fasct leg ant&/lat cmprts only $263.25 

27601-00 dcmprn fasct leg pst cmprt only $219.38 

27602-00 dcmprn fasct leg ant&/lat&pst cmprt $273.00 

27603-00 incision&drainage leg/ankle abscess/hematoma $195.00 

27604-00 incision&drainage leg/ankle infected bursa $195.00 

27605-00 tenotomy prq achilles tendon spx local anes $58.50 

27606-00 tenotomy prq achilles tendon spx general anes $107.25 

27607-00 incision leg/ankle $331.50 

27610-00 arthrotomy ankle w/expl drainage/removal fb $499.79 

27612-00 arthrt pst capsular rls ankle +-achll tdn lngth $437.00 

27613-00 biopsy soft tissue leg/ankle area superficial $78.00 

27614-00 biopsy soft tissue leg/ankle area deep $333.01 

27615-00 rad resection tumor soft tissue leg/ankle

Procedure & 


Tarifas 



27665-00 rpr extensor tendon leg secondary +/-graft each $341.25 

27675-00 rpr dislocating peroneal tendon w/o fib osteot $422.99 

27676-00 repair dislocating peroneal tendon w/fib osteot $253.50 

27680-00 tenolysis flxr/xtnsr tendon leg&/ankle 1 each $352.48 

27681-00 tnols flxr/xtnsr tdn leg&/ankle mlt tdn $292.50 

27685-00 lngth/shrt tdn leg/ankle 1 tdn spx $389.81 

27686-00 lngth/shrt tdn leg/ankle mlt tdn same inc ea $341.25 

27687-00 gastrocnemius recession $377.63 

27690-00 tr/trnspl 1 tdn w/musc redirion/rerouting supfc $341.25 

27691-00 tr/trnspl 1 tdn w/musc redirion/rerouting dp $429.00 

27692-00 tr/trnspl 1 tdn w/musc redirion/rerouting ea tdn $107.25 

27695-00 rpr primary disrupted ligament ankle collateral $429.00 

27696-00 rpr prim disrupted ligm ankle bth coltrl ligms $594.75 

27698-00 repair secondary disrupted ligament ankle coltrl $438.75 

27700-00 arthroplasty ankle $731.25 

27702-00 arthroplasty ankle w/implant $1,238.25 

27703-00 arthroplasty ankle revision total ankle $745.88 

27704-00 removal ankle implant $624.00 

27705-00 osteotomy tibia $603.72 

27707-00 osteotomy fibula $292.50 

27709-00 osteotomy tibia&fibula $487.50 

27712-00 osteot mlt w/relignmt imed rod $487.50 

27715-00 osteoplasty tibia&fibula lengthening/shortening $975.00 

27720-00 repair nonunion/malunion tibia w/o graft $692.93 

27722-00 repair nonunion/malunion tibia w/sliding graft $680.00 

27724-00 rpr non/mal tibia w/iliac/oth agrft $825.00 

27725-00 rpr non/mal tibia synostosis w/fibula any meth $612.00 

27726-00 repair fibula nonunion/malunion w int fixation $565.50 

27727-00 repair congenital pseudarthrosis tibia $630.00 

27730-00 arrest epiphyseal open distal tibia $429.00 

27732-00 arrest epiphyseal open distal fibula $253.50 

27734-00 arrest epiphyseal open distal tibia&fibula $536.25 

27740-00 arrst epiphysl any meth tibfib $770.25 

27742-00 arrst epiphysl any meth tibfib&dstl femur $936.00 

27745-00 proph tx n/p/pltwr +-mma tibia $461.18 

27750-00 cltx tibl shft fx w/o mnpj $107.25 

27752-00 cltx tibl shft fx w/mnpj +-skel tracj $364.19 

27756-00 prq skel fixj tibl shft fx $485.10 

27758-00 optx tibl shft fx w/plate/screws +-cerclage $699.30 

27759-00 tx tibl shft fx imed implt +-screws&/cerclage $748.51 

27760-00 cltx medial malls fx w/o mnpj $87.75 

27762-00 cltx medial malls fx w/mnpj +-skn/skel tracj $332.89 

27766-00 open treatment medial malleolus fracture $462.44 

27767-00 closed treatment pst malleolus fracture w/o mnpj $156.00 

27768-00 closed treatment pst malleolus fracture w mnpj $260.00 

27769-00 open treatment posterior malleolus fracture $440.00 

27780-00 cltx prox fibula/shft fx w/o mnpj $87.75 

27781-00 cltx prox fibula/shft fx w/mnpj $165.00 

27784-00 open treatment proximal fibula/shaft fracture $292.50 

27786-00 cltx dstl fibular fx lat malls w/o mnpj $78.00 

31

Procedure & 


Tarifas 



27788-00 cltx dstl fibular fx lat malls w/mnpj $285.49 

27792-00 open tx distal fibular fracture lat malleolus $435.24 

27808-00 closed tx bimalleolar ankle fracture w/o mnpj $136.50 

27810-00 closed tx bimalleolar ankle fracture w mnpj $324.12 

27814-00 open treatment bimalleolar ankle fracture $594.07 

27816-00 cltx trimal ankle fx w/o mnpj $136.50 

27818-00 cltx trimal ankle fx w/mnpj $292.50 

27822-00 open tx trimalleolar ankle fx w/o fixj pst lip $655.49 

27823-00 open tx trimalleolar ankle fx w fixj pst lip $742.37 

27824-00 cltx fx w8 brg artclr prtn dstl tibia w/o mnpj $184.28 

27825-00 cltx fx w8 brg artclr prtn dstl tib w/skel tracj $386.92 

27826-00 open treatment fracture distal tibia fibula $554.48 

27827-00 open treatment fracture distal tibia only $794.14 

27828-00 open treatment fracture distal tibia & fibula $875.75 

27829-00 open tx distal tibiofibular joint disruption $384.04 

27830-00 cltx prox tibfib jt dislc w/o anes $19.50 

27831-00 cltx prox tibfib jt dislc req anes $231.66 

27832-00 open tx prox tibfib joint dislocate exc prox fib $438.75 

27840-00 closed tx ankle dislocation w/o anesthesia $97.50 

27842-00 cltx ankle dislc req anes +-prq skel fixj $260.62 

27846-00 optx ankle dislc w/o rpr/int fixj $487.50 

27848-00 optx ankle dislc w/rpr/int/xtrnl fixj $702.00 

27860-00 mnpj ankle under general anes $140.90 

27870-00 arthrodesis ankle open $760.79 

27871-00 arthrodesis tibiofibular joint proximal/distal $390.00 

27880-00 amputation leg through tibia&fibula $487.50 

27881-00 amp leg thru tibfib w/immt fitg tq w/1st cst $516.75 

27882-00 amputation leg thru tibia&fibula open circular $468.00 

27884-00 amp leg thru tibia&fibula sec closure/scar revj $214.50 

27886-00 amp leg thru tibia&fibula re-amputation $468.00 

27888-00 amp ankle-malli tibfib w/plstc clsr&rescj nrv $468.00 

27889-00 ankle disarticulation $468.00 

27892-00 dcmprn fasct leg ant&/lat w/dbrdmt musc&/nrv $241.80 

27893-00 dcmprn fasct leg pst w/dbrdmt musc&/nrv $241.80 

27894-00 dcmprn fasct leg ant&/lat&pst w/dbrdmt musc&/nrv $324.68 

28001-00 incision&drainage bursa foot $29.25 

28002-00 i&d belw fsca foot 1 bursal space $219.38 

28003-00 i&d belw fsca foot mlt areas $474.44 

28005-00 incision bone cortex foot $493.84 

28008-00 fasciotomy foot&/toe $97.50 

28010-00 tenotomy percutaneous toe single tendon $29.25 

28011-00 tenotomy percutaneous toe multiple tendon $58.50 

28020-00 arthrt w/expl drg/rmvl loose/fb ntrtrsl/tars jt $298.40 

28022-00 arthrt w/expl drg/rmvl loose/fb mttarphlngl jt $156.00 

28024-00 arthrt w/expl drg/rmvl loose/fb iphal jt $107.25 

28035-00 release tarsal tunnel $341.25 

28039-00 excision tumor soft tissue foot/toe subq 1.5+cm $177.45 

28041-00 exc tumor soft tissue foot/toe subfasc 1.5+cm $282.75 

28043-00 excision tumor soft tissue foot/toe subq

Procedure & 


Tarifas 



28046-00 rad resection tumor soft tissue foot/toe

Procedure & 


Tarifas 



28222-00 tenolysis flexor foot multiple tendons $292.50 

28225-00 tenolysis extensor foot single tendon $121.88 

28226-00 tenolysis extensor foot multiple tendon $156.00 

28230-00 tx opn tdn flxr foot 1/mlt tdn spx $126.75 

28232-00 tx opn tdn flxr toe 1 tdn spx $58.50 

28234-00 tenotomy open extensor foot/toe each tendon $39.00 

28238-00 rcnstj pst tibl tdn w/exc accessory tarsl navclr $302.25 

28240-00 tenotomy lengthening/rls abductor hallucis musc $259.66 

28250-00 division plantar fascia&muscle spx $334.86 

28260-00 capsulotomy midfoot medial release only spx $341.25 

28261-00 capsulotomy midfoot w/tendon lengthening $390.00 

28262-00 capsul midfoot w/pst talotibl capsul&tdn lngth $898.22 

28264-00 capsulotomy midtarsal $516.75 

28270-00 capsul mttarphlngl jt +-tenorrhaphy ea jt spx $126.75 

28272-00 capsul iphal jt ea jt spx $58.50 

28280-00 syndactylization toes $341.25 

28285-00 correction hammertoe $195.00 

28286-00 correction cock-up 5th toe w/plastic closure $156.00 

28288-00 ostc prtl exostc/condylc metar head $107.25 

28289-00 hallux rgdus corrj w/cheilc $477.75 

28290-00 corrj hallux valgus +-sesmdc smpl exostectomy $195.00 

28292-00 keller/mcbride/mayo procedure $416.47 

28293-00 corrj hallux valgus +-sesmdc rescj jt w/implt $341.25 

28294-00 corrj hallux valgus +-sesmdc w/tdn trnspls $341.25 

28296-00 corrj hallux valgus +-sesmdc w/metar osteot $499.18 

28297-00 corrj hallux valgus +-sesmdc lapidus-typ px $263.25 

28298-00 corrj hallux valgus +-sesmdc phalanx osteot $292.50 

28299-00 corrj hallux valgus +-sesmdc 2 osteot $341.25 

28300-00 osteotomy calcaneus +-internal fixation $545.60 

28302-00 osteotomy talus $390.00 

28304-00 osteotomy tarsal bones oth/thn calcaneus/talus $495.23 

28305-00 osteot tarsal oth/thn calcaneus/talus w/agrft $390.00 

28306-00 osteot +-lngth shrt/corrj 1st metar $332.68 

28307-00 osteot +-lngth shrt/corrj 1st metar xcp 1st toe $287.63 

28308-00 osteot +-lngth shrt/corrj metar xcp 1st ea $298.35 

28309-00 osteot +-lngth shrt/angular corrj metar mlt $390.00 

28310-00 osteot shrt corrj prox phalanx 1st toe $308.93 

28312-00 osteot shrt corrj oth phalanges any toe $82.88 

28313-00 rcnstj angular dfrm toe soft tiss px only $331.29 

28315-00 sesamoidectomy first toe spx $146.25 

28320-00 repair nonunion/malunion tarsal bones $146.25 

28322-00 rpr non/mal metar +-b1 grf $204.75 

28340-00 rcnstj toe macrodactyly soft tissue resection $441.38 

28341-00 rcnstj toe macrodactyly requiring bone resection $447.95 

28344-00 reconstruction toe polydactyly $224.25 

28345-00 rcnstj toe syndactyly +-skn grf ea web $321.75 

28360-00 reconstruction cleft foot $740.12 

28400-00 closed tx calcaneal fracture w/o manipulation $159.29 

28405-00 closed tx calcaneal fracture w/manipulation $290.83 

28406-00 prq skel fixj calcaneal fx w/mnpj $273.00 

34

Procedure & 


Tarifas 



28415-00 open treatment calcaneal fracture $861.71 

28420-00 open treatment calcaneal fracture w bone graft $526.50 

28430-00 closed tx talus fracture w/o manipulation $146.95 

28435-00 closed tx talus fracture w/ manipulation $175.50 

28436-00 prq skeletal fixation talus fracture w/mnpj $254.48 

28445-00 open treatment talus fracture $788.00 

28450-00 tx tarsal b1 fx xcp talus&calcn w/o mnpj $102.67 

28455-00 tx tarsal b1 fx xcp talus&calcn w/mnpj $205.95 

28456-00 prq skel fixj tarsl fx xcp talus&calcns w/mnpj $263.25 

28465-00 open tx tarsal fracture xcp talus &calcaneus ea $292.50 

28470-00 closed tx metatarsal fracture w/o manipulation $73.13 

28475-00 cltx metar fx w/mnpj $159.71 

28476-00 prq skel fixj metar fx w/mnpj $257.39 

28485-00 open treatment metatarsal fracture each $360.72 

28490-00 cltx fx grt toe phlx/phlg w/o mnpj $19.50 

28495-00 cltx fx grt toe phlx/phlg w/mnpj $113.16 

28496-00 prq skel fixj fx grt toe phlx/phlg w/mnpj $182.72 

28505-00 open tx fracture great toe/phalanx/phalanges $266.01 

28510-00 cltx fx phlx/phlg oth/thn grt toe w/o mnpj $29.25 

28515-00 cltx fx phlx/phlg oth/thn grt toe w/mnpj $78.10 

28525-00 open tx fracture phalanx/phalanges not great toe $236.19 

28530-00 closed treatment sesamoid fracture $55.58 

28531-00 open tx sesamoid fracture +-internal fixation $116.03 

28540-00 cltx tarsal dislc oth/thn talotarsal w/o anes $29.25 

28545-00 cltx tarsal dislc oth/thn talotarsal w/anes $97.50 

28546-00 prq skel fixj tarsl dislc xcp talotarsal w/mnpj $126.75 

28555-00 open treatment tarsal bone dislocation $408.84 

28570-00 closed tx talotarsal joint dislc w/o anes $39.00 

28575-00 closed tx talotarsal joint dislocation w/anes $107.25 

28576-00 prq skel fixj talotarsal jt dislc w/mnpj $195.00 

28585-00 open treatment talotarsal joint dislocation $341.25 

28600-00 closed tx tarsometatarsal dislocation w/o anes $29.25 

28605-00 closed tx tarsometatarsal dislocation w/anes $82.88 

28606-00 prq skel fixj tars jt dislc w/mnpj $126.75 

28615-00 open treatment tarsometatarsal joint dislocation $472.10 

28630-00 cltx metatarsophlngl jt dislc w/o anes $29.25 

28635-00 cltx metatarsophlngl jt dislc req anes $58.50 

28636-00 prq skel fixj metatarsophlngl jt dislc w/mnpj $148.20 

28645-00 open tx metatarsophalangeal joint dislocation $175.50 

28660-00 cltx iphal jt dislc w/o anes $76.11 

28665-00 cltx iphal jt dislc req anes $48.75 

28666-00 prq skel fixj iphal jt dislc w/mnpj $148.20 

28675-00 open treatment interphalangeal joint dislocation $102.38 

28705-00 arthrodesis pantalar $741.00 

28715-00 arthrodesis triple $706.39 

28725-00 arthrodesis subtalar $663.00 

28730-00 arthrd midtarsl/tars mlt/transvrs $468.00 

28735-00 arthrd midtarsl/tars mlt/transvrs w/osteot $553.70 

28737-00 arthrd w/tdn lngth&advmnt tarsl nvclr-cuneiform $493.16 

28740-00 arthrodesis midtarsometatarsal single joint $471.53 

35

Procedure & 


Tarifas 



28750-00 arthrodesis great toe metatarsophalangeal joint $302.25 

28755-00 arthrodesis great toe interphalangeal joint $175.50 

28760-00 arthrd w/xtnsr hallucis longus tr 1st metar nck $146.25 

28800-00 amputation foot midtarsal $341.25 

28805-00 amputation foot transmetarsal $467.71 

28810-00 amputation metatarsal w/toe single $357.28 

28820-00 amputation toe metatarsophalangeal joint $272.49 

28825-00 amputation toe interphalangeal joint $233.64 

29000-00 application halo type body cast $195.00 

29010-00 application risser jacket localizer body only $121.88 

29015-00 application risser jacket localizer body w/head $146.25 

29020-00 application turnbuckle jacket body only $121.88 

29025-00 application turnbuckle jacket body w/head $146.25 

29035-00 application body cast shoulder hips $107.18 

29040-00 application body cast shoulder hips head minerva $97.50 

29044-00 application body cast shoulder hips w/one thigh $117.59 

29046-00 application body cast shoulder hips both thighs $129.87 

29049-00 application cast figure-of-8 $47.77 

29055-00 application cast shoulder spica $78.00 

29058-00 application cast plaster velpeau $68.27 

29065-00 application cast shoulder hand long arm $29.25 

29075-00 application cast elbow finger short arm $46.66 

29085-00 application cast hand&lower forearm gauntlet $49.27 

29105-00 application long arm splint shoulder hand $46.42 

29125-00 application short arm splint forearm-hand static $32.53 

29126-00 application short arm splint dynamic $40.64 

29305-00 application hip spica cast 1 leg $121.64 

29325-00 appl hip spica cast one&one-half spica/both legs $137.06 

29345-00 application long leg cast thigh-toe $79.85 

29355-00 application long leg cast walker/ambulatory type $82.49 

29358-00 application long leg cast brace $156.00 

29365-00 application cylinder cast thigh ankle $69.11 

29405-00 application short leg cast below knee-toe $50.82 

29425-00 application short leg cast walking/ambulatory $34.13 

29435-00 application patellar tendon bearing cast $68.59 

29440-00 adding walker previously applied cast $9.75 

29445-00 application rigid total contact leg cast $91.21 

29450-00 appl clubfoot cast molding/mnpj long/short leg $91.26 

29505-00 application long leg splint thigh ankle/toes $37.72 

29515-00 Application lower leg splint, application short leg splint calf foot $39.54 

29580-00 strapping unna boot $30.66 

29590-00 denis-browne splint strapping $33.35 

29700-00 removal/bivalving gauntlet boot/body cast $35.10 

29705-00 removal/bivalving full arm/full leg cast $14.63 

29710-00 rmvl/bivalv sho/hip spica minerva/risser jacket $68.97 

29715-00 removal/bivalving turnbuckle jacket $19.50 

29720-00 repair spica body cast/jacket $35.77 

29730-00 windowing cast $37.80 

29740-00 wedging cast except clubfoot casts $55.23 

29750-00 wedging clubfoot cast $61.43 

36

Procedure & 


Tarifas 



29800-00 arthrs tmprmand jt dx +-synval bx spx $394.88 

29804-00 arthroscopy temporomandibular joint surgical $658.13 

29805-00 arthroscopy shoulder dx +-synovial biopsy spx $386.10 

29806-00 arthroscopy shoulder surgical capsulorrhaphy $725.69 

29807-00 arthroscopy shoulder surgical repair slap lesion $680.94 

29819-00 arthroscopy shoulder surgical removal loose/fb $390.00 

29820-00 arthroscopy shoulder surg synovectomy partial $292.50 

29821-00 arthroscopy shoulder surg synovectomy complete $390.00 

29822-00 arthroscopy shoulder surg debridement limited $512.00 

29823-00 arthroscopy shoulder surg debridement extensive $494.38 

29824-00 arthroscopy shoulder distal claviculectomy $503.52 

29825-00 arthroscopy shoulder lysis&rescj adhesion +-mnpj $509.52 

29826-00 shoulder scope bone shaving $789.75 

29827-00 arthroscopy shoulder rotator cuff repair $873.70 

29828-00 arthroscopy shoulder biceps tenodesis $576.00 

29830-00 arthroscopy elbow diagnostic +-synovial bx spx $253.50 

29834-00 arthroscopy elbow surgical w/removal loose/fb $390.00 

29835-00 arthroscopy elbow surgical synovectomy partial $390.00 

29836-00 arthroscopy elbow surgical synovectomy complete $438.75 

29837-00 arthroscopy elbow surgical debridement limited $390.00 

29838-00 arthroscopy elbow surgical debridement extensive $487.50 

29840-00 arthroscopy wrist diagnostic +-synovial bx spx $254.48 

29843-00 arthroscopy wrist infection lavage&drainage $333.45 

29844-00 arthroscopy wrist surgical synovectomy partial $346.13 

29845-00 arthroscopy wrist surgical synovectomy complete $409.50 

29846-00 arthrs wrst exc&/rpr triang fibrocart&/jt dbrdmt $503.10 

29847-00 arthrs wrst surg int fixj f/fx/ins $402.68 

29848-00 ndsc wrst surg w/rls transvrs carpl ligm $232.05 

29850-00 arthrs aid tx spi&/fx kne w/o fixj $569.40 

29851-00 arthrs aid tx spi&/fx kne w/fixj $695.18 

29855-00 arthrs aid tibial fracture proximal unicondylar $629.85 

29856-00 arthrs aid tibial fx prox unicondylar bicondylar $741.00 

29860-00 arthroscopy hip diagnostic +-synovial biopsy spx $347.49 

29861-00 arthroscopy hip surgical w/removal loose/fb $515.09 

29862-00 arthrs hip debridement/shaving articular crtlg $566.87 

29863-00 arthroscopy hip surgical w/synovectomy $517.73 

29866-00 arthroscopy knee osteochondral agrft mosaicplast $853.00 

29867-00 arthroscopy knee osteochondral allograft $980.10 

29868-00 arthroscopy knee meniscal trnsplj med/lat $1,137.24 

29870-00 arthroscopy knee diagnostic +-synovial bx spx $321.75 

29871-00 arthroscopy knee infection lavage & drainage $366.80 

29873-00 arthroscopy knee lateral release $346.50 

29874-00 arthroscopy knee removal loose/foreign body $487.50 

29875-00 arthroscopy knee synovectomy limited spx $458.25 

29876-00 arthroscopy knee synovectomy 2/>compartments $585.00 

29877-00 arthrs knee debridement/shaving artclr crtlg $480.87 

29879-00 arthrs knee abrasion arthrp/mlt drlg/microfx $542.10 

29880-00 arthrs knee w/meniscectomy med&lat w/shaving $706.88 

29881-00 arthrs kne surg w/meniscectomy med/lat w/shvg $633.75 

29882-00 arthroscopy knee w/meniscus rpr medial/lateral $789.75 

37

Procedure & 


Tarifas 



29883-00 arthroscopy knee w/meniscus rpr medial&lateral $902.85 

29884-00 arthroscopy knee w/lysis adhesions+-mnpj spx $536.25 

29885-00 arthrs kne drlg osteo diss grfg $648.38 

29886-00 arthrs kne drlg osteo diss les $658.13 

29887-00 arthrs kne drlg osteo diss les int fixj $643.50 

29888-00 arthrs aided ant cruciate ligm rpr/agmntj/rcnstj $853.13 

29889-00 arthrs aided pst cruciate ligm rpr/agmntj/rcnstj $853.13 

29891-00 arthrs ankle exc ostchndrl dfct w/drlg dfct $518.95 

29892-00 arthrs aid rpr les/talar dome fx/tibl plafond fx $547.40 

29893-00 endoscopic plantar fasciotomy $276.41 

29894-00 arthroscopy ankle w/removal loose/foreign body $390.00 

29895-00 arthroscopy ankle surgical synovectomy partial $390.00 

29897-00 arthroscopy ankle surgical debridement limited $390.00 

29898-00 arthroscopy ankle surgical debridement extensive $487.50 

29900-00 arthroscopy metacarpophalangeal synovial biopsy $307.13 

29901-00 arthrs metacarpophalangeal joint debridement $337.84 

29902-00 arthrs mtcarphlngl jt w/rdctj ur coltrl ligm $361.53 

29914-00 arthroscopy hip w/femoroplasty $618.15 

29915-00 arthroscopy hip w/acetabuloplasty $629.96 

29916-00 arthroscopy hip w/labral repair $629.96 

30000-00 drainage abscess/hematoma nasal int approach $19.50 

30020-00 drainage abscess/hematoma nasal septum $24.38 

30100-00 biopsy intranasal $29.25 

30110-00 excision nasal polyp simple $68.25 

30115-00 excision nasal polyp extensive $195.00 

30117-00 excision/destruction intranasal lesion int appr $165.75 

30118-00 excision/destruction intranasal lesion xtrnl $663.00 

30120-00 excision/surgical planing skin nose rhinophyma $341.25 

30124-00 excision dermoid cyst nose simple subcutaneous $102.38 

30125-00 exc dermoid cyst nose complex under bone/crtlg $331.50 

30130-00 excision inferior turbinate partial/complete $82.88 

30140-00 submucous rescj inferior turbinate prtl/compl $146.25 

30150-00 rhinectomy partial $546.00 

30160-00 rhinectomy total $592.80 

30200-00 injection turbinate therapeutic $19.50 

30210-00 displacement therapy proetz type $9.75 

30220-00 insertion nasal septal prosthesis button $39.00 

30300-00 removal foreign body intranasal office procedure $19.50 

30310-00 removal foreign body intranasal general anes $156.00 

30320-00 rmvl foreign body intranasal lateral rhinotomy $214.50 

30400-00 rhinp prim lat&alar crtlgs&/elvtn nsl tip $390.00 

30410-00 rhinp prim complete xtrnl parts $780.00 

30420-00 rhinoplasty primary w/major septal repair $877.50 

30430-00 rhinoplasty secondary minor revision $146.25 

30435-00 rhinoplasty secondary intermediate revision $175.50 

30450-00 rhinoplasty secondary major revision $307.13 

30460-00 rhinp dfrm w/colum lngth tip only $487.50 

30462-00 rhinp dfrm colum lngth tip septum osteot $975.98 

30465-00 repair nasal vestibular stenosis $540.54 

30520-00 septop/sbmcsl rescj $390.00 

38

Procedure & 


Tarifas 



30540-00 repair choanal atresia intranasal $97.50 

30545-00 repair choanal atresia transpalatine $585.00 

30560-00 lysis intranasal synechia $19.50 

30580-00 repair fistula oromaxillary $429.00 

30600-00 repair fistula oronasal $195.00 

30620-00 septal/other intranasal dermatoplasty $390.00 

30630-00 repair nasal septal perforations $548.44 

30801-00 abltj sof tiss inf turbs uni/bi supfc $19.50 

30802-00 abltj sof tiss inf turbs uni/bi supfc intramural $78.98 

30901-00 control nasal hemorrhage anterior simple $19.50 

30903-00 control nasal hemorrhage anterior complex $39.00 

30905-00 ctrl nsl hemrrg pst pst nsl packs&/caut 1st $97.50 

30906-00 ctrl nsl hemrrg pst pst nsl packs&/caut sbsq $19.50 

30915-00 ligation arteries ethmoidal $292.50 

30920-00 ligation arteries int maxillary transantral $663.00 

30930-00 fracture nasal inferior turbinate therapeutic $68.25 

31000-00 lavage cannulation maxillary sinus $19.50 

31002-00 lavage cannulation sphenoid sinus $39.00 

31020-00 sinusotomy maxillary antrotomy intranasal $146.25 

31030-00 sinusotomy maxillary rad w/o rmvl antroch polyps $487.50 

31032-00 sinusot max antrt rad w/rmvl antroch polyps $585.00 

31040-00 pterygomaxillary fossa surgery any approach $848.25 

31050-00 sinusotomy sphenoid +-biopsy $292.50 

31051-00 sinusot sphenoid w/mucosal stripping/rmvl polyp $406.58 

31070-00 sinusotomy frontal external simple $195.00 

31075-00 sinusotomy frontal transorbital unilateral $390.00 

31080-00 sinusotomy frnt obliterative w/o flap brow inc $663.00 

31081-00 sinusot frnt oblit w/o ostpl flap coronal inc $614.25 

31084-00 sinusot frnt oblit w/ostpl flap brow inc $1,140.75 

31085-00 sinusot frnt oblit w/ostpl flap coronal inc $926.25 

31086-00 sinusot frnt nonoblit w/ostpl flap brow inc $789.75 

31087-00 sinusot frnt nonoblit w/ostpl flap coronal inc $789.75 

31090-00 sinusot uni 3/> paransl sinuses $1,092.00 

31200-00 ethmoidectomy intranasal anterior $292.50 

31201-00 ethmoidectomy intranasal total $394.88 

31205-00 ethmoidectomy extranasal total $555.75 

31225-00 maxillectomy w/o orbital exenteration $975.00 

31230-00 maxillectomy w/orbital exenteration $1,218.75 

31231-00 nasal endoscopy diagnostic uni/bi spx $34.13 

31233-00 nsl/sinus ndsc dx max sinusc $165.75 

31235-00 nsl/sinus ndsc dx sphenoid sinusoscopy $165.75 

31237-00 nsl/sinus ndsc surg w/bx polypc/dbrdmt spx $117.00 

31238-00 nsl/sinus ndsc surg w/ctrl nsl hemrrg $201.83 

31239-00 nsl/sinus ndsc surg w/dacryocstorhinostomy $526.50 

31240-00 nsl/sinus ndsc surg w/concha bullosa rescj $166.73 

31254-00 nasal/sinus endoscopy w/ethmoidectomy partial $263.25 

31255-00 nasal/sinus endoscopy w/ethmoidectomy total $307.13 

31256-00 nasal/sinus endoscopy w/maxillary antrostomy $110.18 

31267-00 nsl/sinus ndsc max antrost w/rmvl tiss max sinus $219.38 

31276-00 nsl/sinus ndsc w/frnt sinus expl $215.48 

39

Procedure & 


Tarifas 



31287-00 nasal/sinus endoscopy w/sphenoidectomy $241.80 

31288-00 nsl/sinus ndsc sphendt rmvl tiss sphenoid sinus $316.88 

31290-00 nsl/sinus ndsc rpr cerebsp flu leak ethmoid $745.88 

31291-00 nsl/sinus ndsc rpr cerebsp flu leak sphenoid $789.75 

31292-00 nsl/sinus ndsc surg w/medial/inf orb wall dcmprn $614.25 

31293-00 nsl/sinus ndsc medial orb&inf orb wall dcmprn $658.13 

31294-00 nsl/sinus ndsc surg w/optic nrv dcmprn $789.75 

31300-00 lryngot w/rmvl tum/laryngocele cordectomy $585.00 

31320-00 laryngotomy thyrotomy laryngofissure dx $341.25 

31360-00 largtom tot w/o rad nck dsj $975.00 

31365-00 largtom tot w/rad nck dsj $1,365.00 

31367-00 largtom stot supraglottic w/o rad nck dsj $1,023.75 

31368-00 largtom stot supraglottic w/rad nck dsj $1,365.00 

31370-00 prtl largtom hemilargtom hrzntl $585.00 

31375-00 prtl largtom hemilargtom later> $994.50 

31380-00 prtl largtom hemilargtom anter> $994.50 

31382-00 prtl largtom hemilargtom antero-latero-ver $994.50 

31390-00 pharyngolargtom w/rad nck dsj w/o rcnstj $1,394.25 

31395-00 pharyngolargtom w/rad nck dsj w/rcnstj $1,750.13 

31400-00 arytenoidectomy/arytenoidopexy xtrnl appr $682.50 

31420-00 epiglottidectomy $585.00 

31500-00 intubation endotracheal emergency procedure $48.75 

31502-00 tracheotomy tube change prior to fistula tract $30.23 

31510-00 laryngoscopy indirect w/biopsy $53.63 

31511-00 laryngoscopy indirect w/removal foreign body $68.25 

31512-00 laryngoscopy indirect w/removal lesion $243.75 

31513-00 laryngoscopy indirect w/vocal cord injection $234.00 

31515-00 laryngoscopy +-tracheoscopy aspiration $39.00 

31520-00 laryngoscopy +-tracheoscopy diagnostic newborn $97.50 

31525-00 laryngoscopy +-tracheoscopy dx except newborn $126.75 

31526-00 laryngoscopy +-tracheoscopy microscope/telescope $133.38 

31527-00 laryngoscopy +-tracheoscopy insertion obturator $273.00 

31528-00 laryngoscopy +-tracheoscopy w/dilation initial $234.00 

31529-00 laryngoscopy +-tracheoscopy dilation subsequent $195.00 

31530-00 laryngoscopy w/foreign body removal $175.50 

31531-00 laryngoscopy f body rmvl microscope/telescope $193.13 

31535-00 laryngoscopy direct operative w/biopsy $146.25 

31536-00 laryngoscopy w/biopsy microscope/telescope $191.52 

31540-00 largsc exc tum&/stripping cords/epigl $243.75 

31541-00 largsc exc tum&/strpg cords/epigl mcrscp/tlscp $302.25 

31545-00 largsc mcrscp/tlscp rmvl les vocal c/d flap $326.63 

31546-00 largsc mcrscp/tlscp rmvl les vocal c/d grf $482.63 

31560-00 laryngoscopy direct operative w/arytenoidectomy $487.50 

31561-00 largsc arytenoidectomy microscope/telescope $310.64 

31570-00 laryngoscope injection vocal cord therapeutic $234.00 

31571-00 largsc w/njx vocal cord ther w/mcrscp/tlscp $116.61 

31575-00 laryngoscopy flexible fiberoptic diagnostic $97.50 

31576-00 laryngoscopy flexible fiberoptic w/biopsy $126.75 

31577-00 laryngoscopy flx fiberoptic rmvl foreign body $146.25 

31578-00 laryngoscopy flexible fiberoptic removal lesion $204.75 

40

Procedure & 


Tarifas 



31579-00 laryngoscopy flx/rgd fibopt w/stroboscopy $124.80 

31580-00 laryngoplasty laryn web 2 stg w/keel insj&rmvl $1,009.13 

31582-00 laryngp laryn stenosis grf/core mold w/tracht $1,082.25 

31584-00 laryngoplasty w/opn rdctj fx $836.55 

31587-00 laryngoplasty cricoid split $410.48 

31590-00 laryngeal reinnervation neuromuscular pedicle $508.07 

31595-00 section recurrent laryngeal nerve ther uni spx $1,009.13 

31600-00 tracheostomy planned spx $195.00 

31601-00 tracheostomy planned under 2 years spx $234.00 

31603-00 tracheostomy emergency procedure transtracheal $209.63 

31605-00 tracheostomy emergency cricothyroid membrane $209.63 

31610-00 tracheostomy fenestration w/skin flaps $487.50 

31611-00 constj tracheoesophgl fstl&insj sp prosth $438.75 

31612-00 tracheal pnxr prq w/transtracheal aspir&/njx $9.75 

31613-00 tracheostoma revj smpl w/o flap rotation $156.00 

31614-00 tracheostoma revj cplx w/flap rotation $234.00 

31615-00 tracheobrnchsc thru est trachs inc $117.00 

31620-00 endobrncl us bronchoscopic dx/ther ivntj $184.28 

31622-00 brnchsc incl fluor gid dx w/cell washg spx $146.25 

31623-00 brnchsc brushing/protected brushings $135.31 

31624-00 brnchsc w/brncl alveolar lavage $223.76 

31625-00 brnchsc brncl/endobrncl bx 1+ sits $365.63 

31628-00 brnchsc w/transbrncl lung bx 1 lobe $365.63 

31629-00 brnchsc ndl bx trachea main stem&/bronchusi $219.38 

31630-00 brnchsc w/tracheal/brncl dilat/clsd rdctj fx $365.63 

31631-00 brnchsc w/placement tracheal stent $231.08 

31632-00 brnchsc w/transbrncl lung bx ea lobe $47.45 

31633-00 brnchsc w/transbrncl ndl aspir bx ea lobe $60.06 

31634-00 bronchoscopy balloon occlusion $0.00 

31635-00 brnchsc w/removal foreign body $365.63 

31636-00 brnchsc w/placement brncl stent 1st bronchus $207.68 

31637-00 brnchsc ea major bronchus stented $57.92 

31638-00 brnchsc revj tracheal/brncl stent ins prev sess $179.89 

31640-00 brnchsc w/excision tumor $365.63 

31641-00 brnchsc w/dstrj tum relief stenosis oth/thn exc $364.65 

31643-00 brnchsc w/plmt cath intrcv radioelmnt appl $162.92 

31645-00 brnchsc w/ther aspir tracheobrncl tree 1st $273.00 

31646-00 brnchsc w/ther aspir tracheobrncl tree sbsq $146.25 

31656-00 brnchsc w/njx contrast sgmtl bronchog $273.00 

31715-00 transtracheal injection bronchography $39.00 

31717-00 catheterization w/bronchial brush biopsy $90.34 

31720-00 catheter aspiration nasotracheal spx $39.00 

31725-00 cath aspir tracheobrncl fiberscope bedside spx $67.57 

31730-00 ttrach intro ndl wire dil/stent/tube o2 ther $137.77 

31750-00 tracheoplasty cervical $877.50 

31755-00 tracheoplasty tracheopharyngeal fstlj ea stg $975.00 

31760-00 tracheoplasty intrathoracic $1,033.50 

31766-00 carinal reconstruction $1,140.75 

31770-00 bronchoplasty graft repair $1,033.50 

31775-00 bronchoplasty excision stenosis & anastomosis $1,033.50 

41

Procedure & 


Tarifas 



31780-00 excision tracheal stenosis&anastomosis cervical $1,033.50 

31781-00 exc tracheal stenosis&anast cervicothoracic $1,033.50 

31785-00 excision tracheal tumor/carcinoma cervical $1,160.25 

31786-00 excision tracheal tumor/carcinoma thoracic $1,160.25 

31800-00 suture tracheal wound/injury cervical $448.50 

31805-00 suture tracheal wound/injury intrathoracic $770.25 

31820-00 surg clsr trachs/fstl w/o plstc rpr $243.75 

31825-00 surg clsr trachs/fstl w/plstc rpr $292.50 

31830-00 revision tracheostomy scar $292.50 

32035-00 thoracostomy w/rib resection empyema $351.00 

32036-00 thoracostomy open flap drainage empyema $390.00 

32095-00 thoracotomy limited biopsy lung/pleura $351.00 

32100-00 thoracotomy with exploration $458.25 

32110-00 thorcom major ctrl traumtc hemrrg&/rpr lng tear $731.25 

32120-00 thoracotomy major postoperative complications $731.25 

32124-00 thoracotomy major opn intrapleural pneumonolysis $653.25 

32140-00 thorcom w/ removal of cyst $731.25 

32141-00 thoracotomy w/excision bullae $770.25 

32150-00 thorcom major w/rmvl intrapleural fb/fibrin dep $682.50 

32151-00 thorcom major w/rmvl ipul fb $682.50 

32160-00 thoracotomy major w/cardiac massage $682.50 

32200-00 pneumonostomy w/open drainage abscess/cyst $585.00 

32201-00 pneumonostomy percutaneous drainage abscess/cyst $246.58 

32215-00 pleural scarification repeat pneumothorax $404.63 

32220-00 decortication pulmonary total spx $975.00 

32225-00 decortication pulmonary partial spx $546.00 

32310-00 pleurectomy parietal spx $770.25 

32320-00 decortication & parietal pleurectomy $1,033.50 

32400-00 biopsy pleura percutaneous needle $39.00 

32402-00 biopsy pleura open $292.50 

32405-00 biopsy lung/mediastinum percutaneous needle $88.78 

32420-00 pneumocentesis puncture lung aspiration $48.75 

32421-00 thoracentesis puncture pleural cavity aspiration $70.28 

32422-00 thoracentesis with insertion tube water seal $92.63 

32440-00 removal of lung $975.00 

32442-00 removal lung pneumonectomy extrapleural $1,184.63 

32445-00 removal lung total pneumonectomy extrapleural $1,238.25 

32480-00 rmvl lng oth/thn pnumec 1 lobe lobec $975.00 

32482-00 rmvl lng oth/thn pnumec 2 lobes bilobec $1,009.13 

32484-00 rmvl lng oth/thn pnumec 1 sgm sgmectomy $1,023.75 

32486-00 rmvl lng xcp pnumec sleeve lobectomy $1,218.75 

32488-00 rmvl lng oth/thn pnumec completion pnumec $1,140.75 

32491-00 rmvl lng oth/thn pnumec exc-plctj emphy lng $1,010.00 

32500-00 rmvl lng oth/thn tot pnumec wedge rescj 1/mlt $780.00 

32501-00 rescj&bronchoplasty pfrmd tm lobec/sgmectomy $246.58 

32503-00 rescj apical lng tum w/o ch wall rcnstj $1,006.20 

32504-00 rescj apical lng tum w/ch wall rcnstj $1,150.21 

32540-00 extrapleural enucleation empyema empyemectomy $804.38 

32550-00 insertion indwelling tunneled pleural catheter $627.41 

32551-00 tube thoracostomy includes water seal $185.91 

42

Procedure & 


Tarifas 



32552-00 rmvl ndwellg tun pleural cath w/cuff $106.28 

32553-00 plmt ntrstl dev radj thx gid prq intrathrc 1/mlt $323.70 

32560-00 instlj via chest tube/cath agent for pleurodesis $97.50 

32561-00 instlj via ch tube/cath agent fbrnlysis 1st day $55.58 

32562-00 instlj ch tube/cath agent fbrnlysis sbsq day $50.70 

32601-00 thorsc dx lungs/pleural space/med/pericar w/o bx $238.88 

32602-00 thoracoscopy dx lungs&pleural space w/bx spx $268.13 

32603-00 thoracoscopy dx pericardial sac w/o biopsy spx $302.25 

32604-00 thoracoscopy dx pericardial sac w/biopsy spx $341.25 

32605-00 thoracoscopy dx mediastinal space w/o biopsy spx $280.80 

32606-00 thoracoscopy dx mediastinal space w/biopsy spx $329.55 

32650-00 thoracoscopy w/pleurodesis $482.63 

32651-00 thoracoscopy w/partial pulmonary decortication $666.90 

32652-00 thrsc tot pulm dcrtctj intrapleural pneumonolss $877.50 

32653-00 thoracoscopy rmvl intrapleural fb/fibrin deposit $636.68 

32654-00 thoracoscopy control traumatic hemorrhage $643.50 

32655-00 thoracoscopy w/excision bullae $728.33 

32656-00 thoracoscopy w/parietal pleurectomy $715.65 

32657-00 thrsc w/wedge rescj lng 1/mlt $745.88 

32658-00 thrsc w/rmvl clot/fb from prcrd sac $684.45 

32659-00 thrsc crtj prcrd window/prtl rescj prcrd sac $702.00 

32660-00 thoracoscopy w/total pericardiectomy $965.25 

32661-00 thrsc w/exc prcrd cst tum/mass $596.70 

32662-00 thrsc w/exc medstnl cst tum/mass $842.40 

32663-00 thoracoscopy w/lobectomy total/sgmtl $719.55 

32664-00 thoracoscopy w/thoracic sympathectomy $671.78 

32665-00 thoracoscopy w/esophagomyotomy heller type $807.30 

32800-00 repair lung hernia through chest wall $321.75 

32810-00 clsr ch wall flwg opn flap drg empyema $224.25 

32815-00 open closure major bronchial fistula $585.00 

32820-00 major reconstruction chest wall posttraumatic $560.63 

32900-00 resection ribs extrapleural all stages $560.63 

32905-00 thoracoplasty schede type/extrapleural $560.63 

32906-00 thoracop schede typ/xtrpleural clsr brncplr fstl $1,014.00 

32940-00 pneumonolss xtrpriosteal w/filling/packing px $682.50 

32960-00 pneumothorax ther intrapleural njx air $48.75 

32997-00 total lung lavage unilateral $394.88 

33010-00 pericardiocentesis initial $195.00 

33011-00 pericardiocentesis subsequent $58.50 

33015-00 tube pericardiostomy $58.50 

33020-00 pericardiotomy removal clot/foreign body primary $975.00 

33025-00 crtj pericardial window/prtl resecj w/drg/bx $643.50 

33030-00 pricardiectomy stot/compl w/o card byp $1,126.13 

33031-00 pricardiectomy stot/compl w/card byp $899.93 

33050-00 resecj pericardial cyst/tumor $643.50 

33120-00 exc intracardiac tumor rescj cardiopulmonary byp $1,950.00 

33130-00 resection external cardiac tumor $804.38 

33140-00 transmyocrd laser revsc thorcom spx $727.06 

33141-00 transmyocrd laser revsc pfrmd tm oth opn car px $176.38 

33202-00 insertion epicardial electrode open $544.00 

43

Procedure & 


Tarifas 



33203-00 insertion epicardial electrode endoscopic $564.77 

33206-00 insj/rplcmt prm pm w/transvns eltrd atr $1,170.00 

33207-00 insj/rplcmt prm pm w/transvns eltrd ventr $1,023.75 

33208-00 insj/rplcmt prm pm w/transvns eltrd atr&ventr $819.00 

33210-00 insj/rplcmt temp transvns 1chmbr eltrd/pm cath $292.50 

33211-00 insj/rplcmt temp transvns 2chmbr pacg eltrds spx $307.13 

33212-00 insj/rplcmt pm pls gen only 1chmbr atr/ventr $160.88 

33213-00 insj/rplcmt pm pls gen only 2chmbr $438.75 

33214-00 upg pm sys conv 1chmbr sys 2chmbr sys $482.63 

33215-00 rpsg prev implted pm/cvdfb r atr/r ventr eltrd $209.72 

33216-00 insj 1 transvns eltrd perm pacemaker or cvdfb $312.00 

33217-00 insj 2 transvns eltrd perm pacemaker or cvdfb $307.13 

33218-00 rpr 1 eltrd 1chmbr prm pm/1chmbr cvdfb $394.88 

33220-00 rpr 2 eltrds 2 chmbr prm pm/2chmbr cvdfb $394.88 

33222-00 revision/relocation skin pocket pacemaker $197.93 

33223-00 revj skn pocket for cardioverter-defibrillator $329.55 

33224-00 insj eltrd car ven sys attch pm/cvdfb pls gen $338.72 

33225-00 insj eltrd car ven sys tm insj cvdfb/pm pls gen $300.11 

33226-00 rpsg prev implted car ven sys l ventr eltrd $326.43 

33233-00 removal permanent pacemaker pulse generator $140.40 

33234-00 rmvl transvns pm eltrd 1 lead sys atr/ventr $236.93 

33235-00 rmvl transvns pm eltrd dual lead sys $291.53 

33236-00 rmvl prm epicar pm&eltrds thorcom 1 lead sys $417.30 

33237-00 rmvl prm epicar pm&eltrds thorcom dual lead sys $610.35 

33238-00 rmvl prm transvns eltrd thorcom $684.45 

33240-00 insj 1/2chmbr pacg cvdfb pls gen $347.10 

33241-00 subq rmvl 1/2chmbr pacg cvdfb pls gen $136.50 

33243-00 rmvl 1/2chmbr pacg cvdfb eltrd thorcom $816.08 

33244-00 rmvl 1/2chmbr pacg cvdfb eltrd transvns xtrj $482.63 

33249-00 insj/rpsg lead 1/2chmbr cvdfb&insj pls gen $877.50 

33250-00 abltj arrhytgnic foc/pthwy trc&/foc $833.63 

33251-00 abltj arrhytgnic foc/pthwy trc&/foc card byp $1,053.00 

33254-00 ablation & rcnstj atria lmtd $1,181.70 

33255-00 ablation & rcnstj atria x10sv w/o bypass $1,423.50 

33256-00 ablation & rcnstj atria x10sv w/bypass $1,583.40 

33257-00 atria ablate & rcnstj w other procedure limited $359.78 

33258-00 atria abltj &rcnstj w other px extensive w/o byp $416.81 

33259-00 atria ablate &rcnstj w other px extensive w byp $526.50 

33261-00 oprative abltj ventr arrhytgnic foc w/card byp $1,009.13 

33265-00 ndsc ablation & rcnstj atria lmtd w/o bypass $1,181.70 

33266-00 ndsc ablation & rcnstj atria x10sv w/o bypass $1,583.40 

33300-00 repair cardiac wound w/o bypass $975.00 

33305-00 repair cardiac wound w/cardiopulmonary bypass $1,082.25 

33310-00 cardiot expl w/rmvl fb atr/ventr thrmb w/o byp $975.00 

33315-00 cardiot expl rmvl fb atr/ventr thrmb card byp $1,287.00 

33320-00 sutr rpr aorta/grt vsl w/o shunt/card byp $643.50 

33321-00 sutr rpr aorta/grt vsl w/shunt byp $1,053.00 

33322-00 sutr rpr aorta/grt vsl w/card byp $1,087.13 

33330-00 insj grf aorta/grt vsl w/o shunt/card byp $975.00 

33332-00 insj grf aorta/grt vsl w/shunt byp $1,053.00 

44

Procedure & 


Tarifas 



33335-00 insj grf aorta/grt vsl w/card byp $1,608.75 

33400-00 vlvp aortic valve opn w/card byp $2,413.13 

33401-00 vlvp aortic valve opn w/infl occlusion $1,755.00 

33403-00 vlvp aortic valve w/transventr dilat w/card byp $2,062.13 

33404-00 construction apical-aortic conduit $2,614.95 

33405-00 rplcmt a-valve prostc xcp homogrf/stent< valve $2,778.75 

33406-00 rplcmt a-valve algrft valve frhand $2,778.75 

33410-00 rplcmt a-valve stent< tiss valve $1,336.43 

33411-00 rplcmt aortic valve annulus enlgment nonc sinus $2,154.75 

33412-00 rplcmt a-valve konno procedure $2,457.00 

33413-00 rplcmt a-valve ross px $1,667.25 

33414-00 rpr ventr o/f trc obstrcj patch enlgment o/f trc $1,404.00 

33415-00 rescj/inc subvalvular tissue $1,267.50 

33416-00 ventriculomyotomy-myectomy $1,579.50 

33417-00 aortoplasty supravalvular stenosis $1,287.00 

33420-00 valvotomy mitral valve closed heart $2,413.13 

33422-00 valvotomy mitral valve opn hrt w/card byp $1,413.75 

33425-00 vlvp mitral valve w/card byp $1,540.50 

33426-00 vlvp mitral valve w/card byp w/prostc ring $2,544.75 

33427-00 vlvp mitral valve w/card byp rad rcnstj +-ring $2,588.63 

33430-00 replacement mitral valve w/cardiopulmonary byp $1,950.00 

33460-00 valvectomy tricuspid valve w/cardiopulmonary byp $1,681.88 

33463-00 valvuloplasty tricuspid valve w/o ring insertion $1,667.25 

33464-00 valvuloplasty tricuspid valve w/ring insertion $1,755.00 

33465-00 replacement tricuspid valve w/card bypass $1,828.13 

33468-00 tricuspid valve rpsg&plctj ebstein anomaly $1,735.50 

33470-00 valvotomy pulmonary valve clsd heart transventr $1,828.13 

33471-00 valvotomy pulm valve clsd hrt via p-art $1,645.80 

33472-00 valvotomy pulm valve opn hrt w/infl occlusion $1,033.50 

33474-00 valvotomy pulm valve opn hrt w/card byp $1,287.00 

33475-00 replacement pulmonary valve $1,930.50 

33476-00 r ventr rescj infund sten +-commissurotomy $1,413.75 

33478-00 o/f trc agmntj +-commissurotomy/infund rescj $1,018.88 

33496-00 rpr non-structural prostc valve dysf card byp $1,375.96 

33500-00 rpr c arven/arteriocar chamber fstl w/card byp $983.78 

33501-00 rpr c arven/arteriocar chamber fstl w/o card byp $899.93 

33502-00 rpr anom c art from p-art origin lig $804.38 

33503-00 rpr anom c art from p-art origin grf $1,126.13 

33504-00 rpr anom c art from p-art origin grf w/card byp $1,608.75 

33505-00 rpr anom c art w/constj intrap-art tunnel $1,579.50 

33506-00 rpr anom c art from p-art to aorta $1,579.50 

33507-00 rpr anom aortic origin c art unroofing/tlcj $970.52 

33508-00 ndsc surg w/vid-asstd harvest vein cab $11.45 

33510-00 coronary artery bypass 1 coronary venous graft $2,486.25 

33511-00 coronary artery bypass 2 coronary venous grafts $2,851.88 




33516-00 coronary artery bypass 6/+ coronary venous graft $3,948.75 

33517-00 coronary artery byp w vein &artery graft 1 vein $329.55 

45

Procedure & 


Tarifas 





33521-00 coronary artery byp w vein &artery graft 4 vein $1,316.25 



33530-00 roprtj cab/valve px > 1 mo after original operj $464.10 

33533-00 cab w/artl grf 1 artl grf $2,237.63 

33534-00 cab w/artl grf 2 c artl grfs $2,567.18 

33535-00 cab w/artl grf 3 c artl grfs $2,895.75 

33536-00 cab w/artl grf 4/> c artl grfs $3,225.30 

33542-00 myocardial resection $2,486.25 

33545-00 rpr postinfrcj ventr septal dfct $1,930.50 

33548-00 surg ventr rstrj px w/prostc patch pfrmd $1,866.42 

33572-00 c endartercomy opn any meth $833.63 

33600-00 clsr atrioventricular valve suture/patch $1,360.13 

33602-00 clsr semilunar valve aortic/pulm sutr/patch $1,316.25 

33606-00 anast p-art aorta damus-kaye-stansel px $1,404.00 

33608-00 rpr car anomal xcp pulm atresia ventr septl dfct $1,447.88 

33610-00 rpr car anomal surg enlgment ventr septl dfct $1,404.00 

33611-00 rpr 2 outlet r vntrc w/intraventr tunnel rpr $1,491.75 

33612-00 rpr 2 outlet r vntrc rpr r ventr o/f trc obstrcj $1,535.63 

33615-00 rpr car anomal clsr septl dfct smpl fontan px $1,465.43 

33617-00 rpr cplx car anomal modf fontan px $1,544.40 

33619-00 rpr 1 vntrc w/o/f obstrcj&aortic arch hypoplasia $1,755.00 

33620-00 application right & left pulmonary artery bands $1,006.24 

33621-00 tthrc catheter insert for stent placement $544.43 

33622-00 reconstruction complex cardiac anomaly $2,132.69 

33641-00 rpr atr septal dfct secundum w/card byp +-patch $1,150.50 

33645-00 dir/patch clsr sinus venosus +-anom pulm ven drg $1,287.00 

33647-00 rpr atr&ventr septal dfct dir/patch clsr $3,071.25 

33660-00 rpr incompl/prtl av canal +-av valve rpr $1,550.25 

33665-00 rpr intrm/transj av canal +-av valve rpr $1,608.75 

33670-00 rpr compl av canal +-prostc valve $1,930.50 

33675-00 closure multiple ventricular septal defects $1,507.12 

33676-00 closure multiple vsd w/resection $1,548.73 

33677-00 closure multiple vsd w/removal artery band $1,609.74 

33681-00 clsr 1 ventr septal dfct +- patch $2,413.13 

33684-00 clsr v-septl dfct w/pulm vlvt/infund rescj $1,608.75 

33688-00 clsr v-septl dfct w/rmvl p-art band +-gusset $1,876.88 

33690-00 banding pulmonary artery $643.50 

33692-00 compl rpr tetralogy fallot w/o pulm atresia $2,559.38 

33694-00 compl rpr t-fallot w/o pulm atresia tanulr patch $2,691.00 

33697-00 compl rpr t-fallot w/pulm atresia $1,631.37 

33702-00 rpr sinus valsalva fistula $1,950.00 

33710-00 rpr sinus valsalva fstl w/rpr v-septl dfct $2,593.50 

33720-00 rpr sinus valsalva aneurysm $1,608.75 

33722-00 closure aortico-left ventricular tunnel $2,193.75 

33724-00 repair isolated partial pulm venous return $1,082.74 

33726-00 repair pulmonary venous stenosis $1,434.28 

33730-00 compl rpr anom ven return $1,608.75 

46

Procedure & 


Tarifas 



33732-00 rpr c triatm/supvalvr ring rescj l atr memb $1,316.25 

33735-00 atr septect/septost clsd hrt $1,462.50 

33736-00 atr septect/septost opn hrt w/card byp $1,316.25 

33737-00 atr septect/septost opn hrt w/infl occlusion $1,033.50 

33750-00 shunt subcla p-art $1,170.00 

33755-00 shunt ascending aorta p-art $1,170.00 

33762-00 shunt descending aorta p-art $1,462.50 

33764-00 shunt ctr w/prostc grf $1,316.25 

33766-00 shunt suprior v/c p-art flo 1 lng $1,462.50 

33767-00 shunt suprior v/c p-art flo bth lngs $1,372.80 

33768-00 anast cavopulm 2nd suprior v/c $301.86 

33770-00 rpr tga w/o surg enlgmnt v-septl dfct $1,671.77 

33771-00 rpr tga enlgmnt v-septl dfct $3,071.25 

33774-00 rpr tga atr baffle w/card byp $2,457.00 

33775-00 rpr tga atr baffle w/rmvl pulm band $3,071.25 

33776-00 rpr tga atr baffle w/clsr v-septl dfct $3,071.25 

33777-00 rpr tga atr baffle rpr sbpulmc obstrcj $3,071.25 

33778-00 rpr tga aortic p-art rcnstj $3,071.25 

33779-00 rpr tga aortic p-art rcnstj w/rmvl pulm band $3,159.00 

33780-00 rpr tga aortic p-art rcnstj w/clsr v-septl dfct $3,217.50 

33786-00 total repair truncus arteriosus $1,930.50 

33788-00 reimplantation anomalous pulmonary artery $1,126.13 

33800-00 aortic ssp tracheal dcmprn spx $702.00 

33802-00 division aberrant vessel vascular ring $770.25 

33803-00 division aberrant vessel w/reanastomosis $965.25 

33813-00 obltrj aortopulm septal dfct w/o card byp $1,335.75 

33814-00 obltrj aortopulm septal dfct w/card byp $1,852.50 

33820-00 repair patent ductus arteriosus ligation $975.00 

33822-00 rpr patent duxus arteriosus div under 18 yr $1,101.75 

33824-00 rpr patent duxus arteriosus div 18 yr&older $1,296.75 

33840-00 exc coarcj aorta +-pda w/dir anast $965.25 

33845-00 exc coarctation aorta +-pda w/grf $1,287.00 

33851-00 exc coarcj aorta w/l subcla art/prostc as gusset $1,579.50 

33852-00 rpr hypoplstc a-arch w/agrft/prostc $1,579.50 

33853-00 rpr hypoplstc a-arch agrft/prostc card byp $1,755.00 

33860-00 ascending aorta grf w/card byp & valve ssp $1,803.75 

33863-00 as-aort grf w/card byp & aortic root rplcmt $1,984.51 

33864-00 ascending aorta grf valve spare root remodel $1,974.38 

33870-00 transverse arch graft w/cardiopulmonary bypass $2,574.00 

33875-00 descending thoracic aorta graft +-bypass $1,608.75 

33877-00 rpr thoracoaaa w/grf +-card byp $1,316.25 

33880-00 evasc rpr dta coverage art origin 1st endoprosth $1,253.36 

33881-00 evasc rpr dta exp coverage w/o art origin $1,075.82 

33883-00 plmt prox xtn prosth evasc rpr dta 1st xtn $795.89 

33884-00 plmt prox xtn prosth evasc rpr dta ea prox xtn $298.35 

33886-00 plmt dstl xtn prosth dlyd after evasc rpr dta $687.96 

33889-00 opn subcla crtd art trpos nck inc ulat $591.44 

33891-00 byp grf w/dta rpr nck inc $755.53 

33910-00 pulmonary artery embolectomy w/card bypass $2,559.38 

33915-00 pulmonary artery embolectomy w/o card bypass $1,560.00 

47

Procedure & 


Tarifas 



33916-00 pulm endartercomy +-embolectomy w/card byp $2,303.93 

33917-00 rpr p-art stenosis rcnstj w/patch/grf $1,462.50 

33920-00 rpr pulm atresia w/constj/rplcmt conduit $3,008.07 

33922-00 transection pulmonary artery w/card bypass $1,474.25 

33924-00 lig&tkdn sysic-to-p-art shunt w/cgen hrt px $290.55 

33925-00 rpr p-art arborizj anomal unifclizj w/o card byp $1,444.80 

33926-00 rpr p-art arborizj anomal unifclizj w/card byp $1,975.05 

33960-00 prolng xtrcorp crcj 1st 24 hr $673.04 

33961-00 prolng xtrcorp crcj ea 24 hr $407.55 

33967-00 insertion intra-aortic balloon assist dev prq $789.75 

33968-00 removal intra-aortic balloon assist device prq $23.69 

33970-00 insj i-aort balo assist dev thru fem art opn $1,316.25 

33971-00 rmvl i-aort balo assist dev w/rpr fem art +-grf $292.50 

33973-00 insj i-aort balo assist dev thru as-aort $482.63 

33974-00 rmvl i-aort balo dev from as-aort rpr as-aort $526.50 

33975-00 insj ventr assist dev xtrcorp 1 vntrc $737.10 

33976-00 insj ventr assist dev xtrcorp biventr $847.28 

33977-00 removal ventr assist device xtrcorp 1 ventricle $819.59 

33978-00 removal ventr assist device xtrcorp biventr $909.09 

33979-00 insj ventr assist dev impltable icorp 1 vntrc $1,725.17 

33980-00 rmvl ventr assist dev impltable icorp 1 vntrc $2,220.08 

34001-00 emblc/thrmbc cath crtd subcla/innominate art $780.00 

34051-00 emblc/thrmbc innominate subcla art $1,170.00 

34101-00 emblc/thrmbc ax brach innominate subcla art $1,170.00 

34111-00 emblc/thrmbc +-cath rdl/ur art arm inc $438.75 

34151-00 emblc/thrmbc rnl celiac mesentery a-iliac art $1,491.75 

34201-00 emblc/thrmbc fempop a-iliac art $1,170.00 

34203-00 emblc/thrmbc pop-tibio-proneal art leg inc $498.23 

34401-00 thrmbc dir/w/cath v/c iliac vein abdl inc $1,462.50 

34421-00 thrmbc dir/w/cath v/c iliac fempop vein leg inc $429.00 

34451-00 thrmbc dir/w/cath v/c iliac fempop vein abdl&leg $604.50 

34471-00 thrmbc dir/w/cath subcla vein nck inc $390.00 

34490-00 thrmbc dir/w/cath ax&subcla vein arm inc $448.50 

34501-00 valvuloplasty femoral vein $1,228.50 

34502-00 reconstruction vena cava any method $1,184.63 

34510-00 venous valve transposition any vein donor $842.40 

34520-00 cross-over vein graft venous system $842.40 

34530-00 saphenopopliteal vein anastomosis $754.65 

34800-00 evasc rpr aaa w/aorto-aortic tube prosth $792.38 

34802-00 evasc rpr aaa w/mdlr bfrc prosth 1 limb $873.11 

34803-00 evasc rpr aaa w/mdlr bfrc prosth 2 limbs $1,061.78 

34804-00 evasc rpr aaa w/unibdy bfrc prosth $873.11 

34805-00 evasc rpr aaa aorto-uniiliac/aorto-unifem prosth $811.69 

34808-00 evasc plmt iliac art occlusion dev $147.42 

34812-00 opn fem art expos dlvr evasc prosth uni $242.19 

34813-00 plmt fem-fem prostc grf evasc aortic arysm rpr $171.11 

34820-00 iliac art expos prosth/iliac occls evasc uni $349.25 

34825-00 plmt xtn prosth evasc rpr arysm/dsj 1st vsl $478.24 

34826-00 plmt xtn prosth evasc rpr arysm/dsj ea vsl $148.30 

34830-00 opn rpr arysm rpr artl trauma tube prosth $1,226.75 

48

Procedure & 


Tarifas 



34831-00 opn rpr arysm rpr artl trma aortobiiliac prosth $1,260.09 

34832-00 opn rpr arysm rpr artl trma aorto-bifem prosth $1,328.54 

34833-00 iliac art expos w/crtj conduit uni $449.28 

34834-00 brach art expos dplmnt aortic/iliac prosth uni $211.48 

34900-00 evasc rpr iliac art ilio-iliac prosthesis $663.39 

35001-00 dir rpr arysm/&grf insj crtd subcla art $1,033.50 

35002-00 dir rpr arysm&grf insj rptd arysm crtd subcla $799.50 

35005-00 dir rpr arysm&grf insj vrt art $789.75 

35011-00 dir rpr arysm&grf insj ax-brach art $643.50 

35013-00 dir rpr arysm&grf insj ax-brach art $780.00 

35021-00 dir rpr arysm&grf insj innominate subcla art $1,287.00 

35022-00 dir rpr arysm&grf rptd arysm innom subcla art $1,540.50 

35045-00 dir rpr arysm&grf insj rdl/ur art $640.58 

35081-00 dir rpr arysm&grf insj abdl aorta $2,193.75 

35082-00 dir rpr arysm&grf insj rptd arysm abdl aorta $2,193.75 

35091-00 dir rpr arysm&grf insj abdl aorta visc vsl $1,384.50 

35092-00 dir rpr arysm&grf rptd arysm abdl aorta visc vsl $1,569.75 

35102-00 dir rpr arysm&grf insj abdl aorta iliac vsl $1,287.00 

35103-00 dir rpr arysm&grf rptd arysm abdl aorta iliac $1,482.00 

35111-00 dir rpr arysm&grf insj splenic art $1,033.50 

35112-00 dir rpr arysm&grf insj rptd arysm splenic art $702.00 

35121-00 dir rpr arysm&grf insj hepatc celiac rnl/msn art $1,287.00 

35122-00 dir rpr arysm&grf rptd arysm hepatc cel rnl/msn $1,257.75 

35131-00 dir rpr arysm&grf insj iliac art $1,062.75 

35132-00 dir rpr arysm&grf insj rptd arysm iliac art $994.50 

35141-00 dir rpr arysm&grf insj common fem art $804.38 

35142-00 dir rpr arysm&grf insj rptd arysm common fem art $789.75 

35151-00 dir rpr arysm&grf insj pop art $867.75 

35152-00 dir rpr arysm&grf insj rptd arysm pop art $624.00 

35180-00 repair congenital arteriovenous fistula head&nck $1,096.88 

35182-00 rpr congenital arteriovenous fistula thorax&abd $1,096.88 

35184-00 rpr congenital arteriovenous fistula extremities $1,053.00 

35188-00 rpr/traumtc arven fstl head&nck $1,096.88 

35189-00 rpr/traumtc arven fstl thorax&abd $1,096.88 

35190-00 rpr/traumtc arven fstl xtr $1,053.00 

35201-00 repair blood vessel direct neck $487.50 

35206-00 repair blood vessel direct upper extremity $477.75 

35207-00 repair blood vessel direct hand finger $507.00 

35211-00 rpr blood vessel direct intrathoracic w/bypass $838.50 

35216-00 rpr blood vessel direct intrathoracic w/o bypass $692.25 

35221-00 rpr blood vessel direct intra-abdominal $663.00 

35226-00 rpr blood vessel direct lower extremity $477.75 

35231-00 repair blood vessel w/vein graft neck $692.25 

35236-00 repair blood vessel w/vein graft upper extremity $575.25 

35241-00 rpr blood vessel vein graft intrathoracic w/byp $867.75 

35246-00 rpr blood vessel vein grf intrathoracic w/o byp $867.75 

35251-00 repair blood vessel vein graft intra-abdominal $643.50 

35256-00 repair blood vessel vein graft lower extremity $585.00 

35261-00 repair blood vessel w/graft other/than vein neck $614.25 

35266-00 rpr blood vsl grf oth/thn vein upper extremity $536.25 

49

Procedure & 


Tarifas 



35271-00 rpr blood vsl grf oth/thn vein intrathrc w/byp $819.00 

35276-00 rpr blood vsl grf oth/thn vein intrathrc w/o byp $702.00 

35281-00 rpr blvsl w/grf oth/thn vein intra-abdl $828.75 

35286-00 rpr blvsl w/grf oth/thn vein lxtr $536.25 

35301-00 teaec w/patch grf crtd vrt subcla nck inc $1,535.63 

35302-00 teaec w/graft superficial femoral art $965.25 

35303-00 teaec w/graft popliteal art $965.25 

35304-00 teaec w/graft tibioperoneal trunk art $965.25 

35305-00 teaec w/graft tibial/peroneal art 1st vessel $965.25 

35306-00 teaec w/graft ea addl tibial/peroneal art $270.08 

35311-00 teaec +-patch grf subcla innominate thrc inc $1,150.50 

35321-00 teaec +-patch grf ax-brach $624.00 

35331-00 teaec +-patch grf abdl aorta $1,062.75 

35341-00 teaec +-patch grf mesenteric celiac/rnl $1,287.00 

35351-00 teaec +-patch grf iliac $1,033.50 

35355-00 teaec +-patch grf iliofem $1,053.00 

35361-00 teaec +-patch grf cmbn aortoiliac $1,189.50 

35363-00 teaec +-patch grf cmbn aortoiliofem $1,316.25 

35371-00 teaec +-patch grf common fem $741.00 

35372-00 teaec +-patch grf dp profunda fem $1,053.00 

35390-00 roprtj crtd teaec > 1 mo after original opration $140.40 

35400-00 angioscopy non-c vsl/grfs ther ivntj $143.81 

35450-00 trluml balo angiop opn rnl/oth visc art $745.88 

35452-00 trluml balo angiop opn aortic $768.30 

35458-00 trluml balo angiop opn brch/cphlc trnk/brnch ea $596.70 

35460-00 trluml balo angiop opn ven $253.50 

35471-00 trluml balo angiop prq rnl/visc art $614.25 

35472-00 trluml balo angiop prq aortic $702.00 

35475-00 trluml balo angiop prq brch/cphlc trnk/brnch ea $548.93 

35476-00 Repair venous blockage, trluml balo angiop prq ven $263.25 

35500-00 harvest uxtr vein 1 sgm lxtr/cab px $232.54 

35501-00 byp w/vein common-ipsilateral crtd $965.25 

35506-00 byp w/vein carotid-subcla/ subcla carotid $1,033.50 

35508-00 byp w/vein crtd-vrt $1,009.13 

35509-00 byp w/vein carotid-contralateral carotid $1,033.50 

35510-00 byp w/vein crtd-brach $1,053.00 

35511-00 byp w/vein subcla-subcla $724.43 

35512-00 byp w/vein subcla-brach $1,035.45 

35515-00 byp w/vein subcla-vrt $708.83 

35516-00 byp w/vein subcla-ax $921.38 

35518-00 byp w/vein ax-ax $1,342.58 

35521-00 byp w/vein ax-fem $930.15 

35522-00 byp w/vein ax-brach $965.25 

35523-00 bypass graft with vein brachial-ulnar/-radial $789.75 

35525-00 byp w/vein brach-brach $967.69 

35526-00 bypass w/vein aortosubclav/carotid/innominate $975.00 

35531-00 byp w/vein aortoceliac/aortomesenteric $1,287.00 

35533-00 byp w/vein ax-fem-fem $1,163.18 

35535-00 bypass graft with vein hepatorenal $1,195.16 

35536-00 byp w/vein splenornl $1,228.50 

50

Procedure & 


Tarifas 



35537-00 byp w/vein aortoiliac $1,189.50 

35538-00 byp w/vein aortobi-iliac $1,189.50 

35539-00 byp w/vein aortofemoral $1,316.25 

35540-00 byp w/vein aortobifemoral $1,462.50 

35548-00 byp w/vein aortoiliofem uni $1,316.25 

35549-00 byp w/vein aortoiliofem bi $1,550.25 

35551-00 byp w/vein aortofempop $1,287.00 

35556-00 byp w/vein fempop $1,608.75 

35558-00 byp w/vein fem-fem $867.75 

35560-00 byp w/vein aortornl $1,755.00 

35563-00 byp w/vein ilioiliac $1,238.25 

35565-00 byp w/vein iliofem $1,160.25 

35566-00 byp fem-ant tibl pst tibl proneal art/oth dstl $1,608.75 

35570-00 byp tibl-tibl/proneal-tibl/tibl/proneal trk-tibl $1,404.39 

35571-00 byp w/vein pop-tibl-proneal art/oth dstl vsl $1,033.50 

35572-00 harvest fempop vein 1 sgm vasc rcnstj px $254.57 

35583-00 in-situ vein byp fempop $1,053.00 

35585-00 in-situ fem-ant tibl pst tibl/proneal art $1,100.78 

35587-00 in-situ vein byp pop-tibl proneal $1,140.75 

35600-00 harvest upper extremity art 1 segment for cabg $184.28 

35601-00 byp oth/thn vein common-ipsilateral crtd $897.00 

35606-00 byp oth/thn vein crtd-subcla $1,053.00 

35612-00 byp oth/thn vein subcla-subcla $741.00 

35616-00 byp oth/thn vein subcla-ax $1,023.75 

35621-00 byp oth/thn vein ax-fem $867.75 

35623-00 byp oth/thn vein ax-pop/-tibl $731.25 

35626-00 bypass not vein aortosubcla/carotid/innominate $975.00 

35631-00 byp oth/thn vein aortoceliac aortomsn aortornl $1,272.38 

35632-00 bypass graft w/other than vein ilio-celiac $1,371.53 

35633-00 bypass graft w/other than vein ilio-mesenteric $1,481.22 

35634-00 bypass graft w/other than vein iliorenal $1,342.58 

35636-00 byp oth/thn vein splenornl $1,228.50 

35637-00 byp oth/thn vein aortoiliac $1,228.50 

35638-00 byp oth/thn vein aortobi-iliac $1,404.00 

35642-00 byp oth/thn vein crtd-vrt $1,009.13 

35645-00 byp oth/thn vein subcla-vrt $789.75 

35646-00 byp oth/thn vein aortobifem $1,062.75 

35647-00 byp oth/thn vein aortofem $1,184.63 

35650-00 byp oth/thn vein ax-ax $1,053.00 

35651-00 byp oth/thn vein aortofempop $1,462.50 

35654-00 byp oth/thn vein ax-fem-fem $1,162.69 

35656-00 byp oth/thn vein fempop $1,608.75 

35661-00 byp oth/thn vein fem-fem $741.00 

35663-00 byp oth/thn vein ilioiliac $936.00 

35665-00 byp oth/thn vein iliofem $828.75 

35666-00 byp oth/thn vein fem-ant tibl pst tibl/proneal $804.38 

35671-00 byp oth/thn vein pop-tibl/-proneal art $804.38 

35681-00 byp composit prostc&vein $65.57 

35682-00 byp autog composit 2 seg veins from 2 locations $295.01 

35683-00 byp autog composit 3/> seg from 2/> locations $348.95 

51

Procedure & 


Tarifas 



35685-00 plmt vein patch/cuff dstl anast byp conduit $147.42 

35686-00 crtj dstl arven fstl lxtr byp surg non-hemo $121.97 

35691-00 trpos&/rimpltj vrt crtd art $1,053.00 

35693-00 trpos&/rimpltj vrt subcla art $658.13 

35694-00 trpos&/rimpltj subcla crtd art $745.88 

35695-00 trpos&/rimpltj crtd subcla art $745.88 

35697-00 rimpltj visc art infrarnl aortic prosth ea art $105.30 

35700-00 roprtj > 1 mo after original opration $131.63 

35701-00 expl n/flwd surg rpr +-lss art crtd art $321.75 

35721-00 expl n/flwd surg rpr +-lss art fem art $273.00 

35741-00 expl n/flwd surg rpr +-lss art pop art $273.00 

35761-00 expl n/flwd surg rpr +-lss art oth vsl $298.35 

35800-00 expl po hemrrg thrombosis/infctj nck $320.78 

35820-00 expl po hemrrg thrombosis/infctj ch $548.93 

35840-00 expl po hemrrg thrombosis/infctj abd $452.40 

35860-00 expl po hemrrg thrombosis/infctj xtr $303.23 

35870-00 rpr grf-enteric fstl $896.81 

35875-00 thrmbc artl/ven grf oth/thn hemo grf/fstl $394.88 

35876-00 thrmbc artl/ven grf xcp hemo grf/fstl w/revj grf $596.70 

35879-00 revj lxtr artl byp opn vein patch angiop $633.75 

35881-00 revj lxtr artl byp opn w/sgmtl vein interpos $709.02 

35883-00 revision femoral anast open nonautog graft $895.93 

35884-00 revision femoral anast open w/autog graft $951.21 

35901-00 exc infct grf nck $408.53 

35903-00 exc infct grf xtr $438.75 

35905-00 exc infct grf thorax $658.13 

35907-00 exc infct grf abd $680.55 

36002-00 njx px prq tx xtr pseudoarysm $114.08 

36005-00 njx px xtr vngrph w/intro ndl/intracath $43.88 

36010-00 intro cath suprior/ivc $78.00 

36011-00 Place catheter in vein, slctv cath plmt ven sys 1st order branch $131.63 

36012-00 slctv cath plmt ven sys 2nd order/> slctv branch $166.73 

36013-00 intro cath r hrt/main p-art $127.73 

36014-00 slctv cath plmt l/r p-art $118.95 

36015-00 slctv cath plmt sgmtl/subsgmtl p-art $136.50 

36100-00 intro ndl/intracath crtd/vrt art $141.38 

36120-00 intro ndl/intracath rtrgr brach art $141.38 

36140-00 intro ndl/intracath xtr art $78.00 

36147-00 intro ndl/cath av shunt ist access w/ rad eval $426.08 

36148-00 intro ndl/cath av shunt addl access ther ivntj $133.58 

36160-00 intro ndl/intracath aortic translmbr $107.25 

36200-00 intro cath aorta $187.20 

36215-00 Place catheter in artery, slctv cathj ea 1st ord thrc/brch/cphlc brnch $232.05 

36216-00 slctv cathj 1st 2nd ord thrc/brch/cphlc brnch $212.55 

36217-00 slctv cathj 3rd+ ord slctv thrc/brch/cphlc brnch $253.50 

36218-00 slctv cathj ea 2nd+ ord thrc/brch/cphlc brnch $117.98 

36245-00 Place catheter in artery, slctv cathj ea 1st ord abdl pel/lxtr art brnch $131.63 

36246-00 Place catheter in artery, slctv cathj 2nd order abdl pel/lxtr art brnch $191.10 

36247-00 slctv cathj 3rd+ ord slctv abdl pel/lxtr brnch $241.80 

36248-00 slctv cathj ea 2nd+ ord abdl pel/lxtr art brnch $87.75 

52

Procedure & 


Tarifas 



36260-00 insj impltable ia nfs pmp $819.00 

36261-00 revj implted ia nfs pmp $390.00 

36262-00 rmvl implted ia nfs pmp $234.00 

36400-00 vnpnxr $125.00 

36557-00 insj tun ctr cvc w/o subq port/pmp under 5 yr $280.00 

36558-00 Insert tunneled cv cath, insj tun ctr cvc w/o subq port/pmp age 5 yr/> $255.00 

36560-00 insj tun ctr ctr vad w/subq port under 5 yr $310.00 

36561-00 insj tun ctr ctr vad w/subq port age 5 yr/> $300.00 

36563-00 insj tun ctr ctr vad w/subq pmp $325.00 

36565-00 Insert tunneled cv cath, insj tun vad req 2 cath 2 sits w/o subq port/pmp $290.00 

36566-00 insj tun vad req 2 cath 2 sits w/subq port $330.00 

36568-00 insj prph cvc w/o subq port/pmp under 5 yr $80.00 

36569-00 insj prph cvc w/o subq port/pmp age 5 yr/> $75.00 

36570-00 insj prph ctr vad w/subq port under 5 yr $270.00 

36571-00 Insert picvad cath, insj prph ctr vad w/subq port age 5 yr/> $275.00 

36575-00 rpr tun/non-tun ctr vad cath w/o subq port/pmp $35.00 

36576-00 rpr ctr vad w/subq port/pmp ctr/prph insj sit $180.00 

36580-00 rplcmt compl non-tun cvc w/o subq port/pmp $65.00 

36581-00 rplcmt compl tun cvc w/o subq port/pmp $185.00 

36582-00 rplcmt compl tun ctr vad w/subq port $275.00 

53

Procedure & 


Tarifas 



36584-00 rplcmt compl prph cvc w/o subq port/pmp $62.00 

36589-00 rmvl tun cvc w/o subq port/pmp $125.00 

36590-00 rmvl tun ctr vad w/subq port/pmp ctr/prph insj $190.00 

36593-00 declot by thrombolytic agent implant device/cath $24.20 

36595-00 mchnl rmvl pricath obstr cv dev via ven access $170.00 

36596-00 mchnl rmvl intral obstr cv dev thru dev lumen $44.00 

36597-00 rpsg previously placed cvc under fluor gdn $60.00 

36598-00 cntrst njx rad eval ctr vad fluor img&reprt $47.00 

36600-00 artl pnxr w/drawal bld dx $24.38 

36620-00 artl cathj/cannulj mntr/transfusion spx prq $39.00 

36625-00 artl cathj/cannulj mntr/transfusion spx cutdown $68.25 

36640-00 artl cathj prolng nfs ther chemotx cutdown $78.00 

36660-00 catheterization umbilical newborn art dx/therapy $39.00 

36680-00 plmt ndl intraoss nfs $71.18 

36800-00 insj cannula hemo oth purpose spx vein vein $117.00 

36810-00 insj cannula hemo oth purpose spx arven xtrnl $273.00 

36815-00 insj cannula hemo oth spx arven xtrnl revj/clsr $136.50 

36818-00 arven anast opn upr arm cephalic vein trpos $494.03 

36819-00 arven anast opn upr arm basilic vein trpos $558.09 

36820-00 arven anast opn f/arm vein trpos $446.65 

36821-00 arteriovenous anastomosis open direct $399.75 

36822-00 insj cannula prolng xc-circj ecmo spx $298.35 

36823-00 insj cnula isltd xc-circj reg chemotx xtr rmvl $852.93 

36825-00 Artery-vein autograft, crtj arven fstl xcp dir arven anast autog grf $643.50 

36830-00 crtj arven fstl xcp dir arven anast nonautog grf $536.25 

36831-00 thrmbc opn arven fstl w/o revj dial grf $236.05 

36832-00 revj opn arven fstl w/o thrmbc dial grf $429.00 

36833-00 revj opn arven fstl w/thrmbc dial grf $336.96 

36835-00 insj thomas shunt spx $585.00 

36838-00 dstl revsc&interval lig uxtr hemo access $836.26 

36860-00 xtrnl cannula decltng spx w/o balo cath $53.63 

36861-00 xtrnl cannula decltng spx w/balo cath $112.13 

36870-00 thrmbc prq arven fstl autog/nonautog grf $1,208.81 

37140-00 ven anast opn portocaval $975.00 

37145-00 ven anast opn renoportal $117.00 

37160-00 ven anast opn caval-mesenteric $1,062.75 

37180-00 ven anast opn splenornl prox $975.00 

37181-00 ven anast opn splenornl dstl $1,316.25 

37182-00 insj transvns intrahepatc portosysic shunt $631.80 

37183-00 revj transvns intrahepatic portosystemic shunt $293.09 

37184-00 prim prq trluml mchnl thrmbc 1st vsl $393.25 

37185-00 prim prq trluml mchnl thrmbc sbsq vsl $144.96 

37186-00 sec prq trluml thrmbc $217.36 

37187-00 prq trluml mchnl thrmbc vein $365.48 

37188-00 prq trluml mchnl thrmbc vein repeat tx $263.16 

37195-00 thrombolss cere iv nfs $213.23 

37200-00 tcat bx $157.95 

37201-00 Transcatheter therapy infuse, tcat ther nfs thrombolss oth/thn c $390.00 

37202-00 Transcatheter therapy infuse, tcat ther nfs oth/thn thrombolss any typ $272.03 

37203-00 tcat retrieval prq iv fb $241.80 

54

Procedure & 


Tarifas 



37204-00 tcat occls/embolj prq non-cns non-head/nck $975.00 

37205-00 tcat plmt iv stent percutaneous 1st vessel $390.00 

37206-00 tcat plmt iv stent percutaneous each addl vessel $175.50 

37207-00 tcat plmt iv stent open 1st vessel $195.00 

37208-00 tcat plmt iv stent open each addl vessel $351.00 

37209-00 exchng prev placed iv cath thrombolytic ther $351.00 

37210-00 uterine fibroid embolization perq w/rad gid $364.16 

37215-00 tcat iv stent crv crtd art embolic protecj $844.16 

37216-00 tcat iv stent crv crtd art w/o embolic protecj $813.44 

37220-00 revascularization iliac artery angiop 1st vsl $596.70 

37221-00 revsc opn/prq iliac art w/stnt plmt & angiop uni $791.70 

37222-00 revascularization iliac art angiop ea ipsi vsl $179.40 

37223-00 revsc opn/prq iliac art w/stnt & angiop ipsi vsl $479.70 

37224-00 revsc opn/prg fem/pop w/angioplasty uni $715.65 

37225-00 revsc opn/prq fem/pop w/athrc/angiop sm vsl $978.90 

37226-00 revsc opn/prq fem/pop w/stnt/angiop sm vsl $910.65 

37227-00 #N/A $1,173.90 

37228-00 revsc opn/prq tib/pero w/angioplasty uni $847.28 

37229-00 revsc opn/prq tib/pero w/athrc/angiop sm vsl $1,110.53 

37230-00 revsc opn/prq tib/pero w/stnt/angiop sm vsl $1,042.28 

37231-00 revsc opn/prq tib/pero w/stnt/athr/angiop sm vsl $1,305.53 

37232-00 revsc opn/prq tib/pero w/angioplasty uni ea vsl $254.48 

37233-00 revsc opn/prq tib/pero w/athrc/angiop uni ea vsl $653.25 

37234-00 revsc opn/prq tib/pero w/stnt/angiop uni ea vsl $516.75 

37235-00 revsc opn/prq tib/pero w/stnt/athr/angiop ea vsl $848.25 

37250-00 iv us non-c vsl dx eval&/ther ivntj 1st vsl $77.22 

37251-00 iv us non-c vsl dx eval&/ther ivntj ea vsl $67.00 

37500-00 vasc ndsc seps $582.00 

37565-00 lig int jug vein $273.00 

37600-00 lig xtrnl crtd art $390.00 

37605-00 lig int/common crtd art $507.00 

37606-00 lig int/common crtd art w/gradual occls $565.50 

37607-00 lig/banding angioaccess arven fstl $250.58 

37609-00 lig/bx temporal art $136.50 

37615-00 lig major art nck $365.63 

37616-00 lig major art ch $458.25 

37617-00 lig major art abd $994.50 

37618-00 lig major art xtr $331.50 

37620-00 interrupj ivc sutr lig plctj clip xtrvasc iv $585.00 

37650-00 lig fem vein $243.75 

37660-00 lig common iliac vein $463.13 

37700-00 lig&div long saph vein saphfem junct/interrupj $160.88 

37718-00 lig div&stripping short saphenous vein $280.80 

37722-00 lig div&strip long saph saphfem junct kne/belw $332.67 

37735-00 lig&div&compl strip long/short saph rad exc $468.00 

37760-00 lig prfratr vein subfscal rad incl skn grf 1 leg $458.25 

37761-00 lig prfratr vein subfscal open incl us gid 1 leg $504.08 

37765-00 stab phlebt varicose veins 1 xtr 10-20 stab incs $314.15 

37766-00 stab phlebt varicose veins 1 xtr > 20 incs $381.71 

37780-00 lig&div short saph vein saphenopop junct spx $121.88 

55

Procedure & 


Tarifas 



37785-00 lig div&/exc varicose vein cluster 1 leg $48.75 

37788-00 pen revsc art +-vein grf $964.37 

37790-00 pen ven occlusive px $362.41 

38100-00 splenc tot spx $643.50 

38101-00 splenc prtl spx $624.00 

38102-00 splenc tot en bloc x10sv ds conjunct w/oth px $89.51 

38115-00 rpr rptd spleen splenorrhaphy +-prtl splenc $624.00 

38120-00 laps surg splenc $671.78 

38200-00 njx px splenoportograpy $97.50 

38220-00 marrow aspiration only $29.25 

38221-00 marrow bx ndl/trocar $97.50 

38230-00 marrow hrvg trnsplj $1,316.25 

38300-00 drg lymph node absc/lymphadenitis smpl $29.25 

38305-00 drg lymph node absc/lymphadenitis x10sv $136.50 

38308-00 lymphangiotomy/oth oprations lymphatic channels $195.00 

38380-00 sutr&/lig thrc dux crv appr $390.00 

38381-00 sutr&/lig thrc dux thrc appr $775.13 

38382-00 sutr&/lig thrc dux abdl appr $394.88 

38500-00 bx/exc lymph node opn supfc $48.75 

38505-00 bx/exc lymph node ndl supfc $56.55 

38510-00 bx/exc lymph node opn dp crv node $141.38 

38520-00 bx/exc lymph node opn dp crv node w/exc fat pad $146.25 

38525-00 bx/exc lymph node opn dp ax node $141.38 

38530-00 bx/exc lymph node opn int mam node $282.75 

38542-00 dsj dp jug node $234.00 

38550-00 exc cstic hygroma ax/crv w/o dp neurovasc dsj $253.50 

38555-00 exc cstic hygroma ax/crv w/dp neurovasc dsj $360.75 

38562-00 lmtd lmphadec staging spx pel&para-aortic $316.88 

38564-00 lmtd lmphadec staging spx rpr aortic&/splenic $486.53 

38570-00 laps surg rpr lymph node bx 1/mlt $394.88 

38571-00 laps surg bi tot pel lmphadec $552.83 

38572-00 laps bi tot pel lmphadec&pri-aortic lymph bx 1/+ $680.55 

38700-00 suprahyoid lmphadec $487.50 

38720-00 crv lmphadec compl $780.00 

38724-00 crv lmphadec modf rad nck dsj $692.25 

38740-00 ax lmphadec supfc $487.50 

38745-00 ax lmphadec compl $614.25 

38746-00 thorcom thrc w/medstnl & regional lmphadec $197.93 

38747-00 abdl lmphadec reg celiac gstr portal pripncrtc $210.60 

38760-00 inguinofem lmphadec supfc w/cloquets node spx $487.50 

38765-00 inguinofem lmphadec supfc w/pel lmphadec $780.00 

38770-00 pel lmphadec w/xtrnl iliac hypogstr&obturator $643.50 

38780-00 rpr tabdl lmphadec x10sv w/pel aortic&rnl $975.00 

38790-00 njx px lymphangrph $97.50 

38792-00 injection for identification of sentinel node $21.42 

38794-00 cannulation thrc dux $156.00 

38900-00 intraop sentinel lymph id w/dye njx $27.30 

39000-00 mediast w/expl drg rmvl fb/bx crv appr $682.50 

39010-00 mediast w/expl drg rmvl fb/bx tthrc appr $780.00 

39200-00 resecj mediastinal cyst $780.00 

56

Procedure & 


Tarifas 



39220-00 resecj mediastinal tumor $975.00 

39400-00 mediastinoscopy w/bx when performed $273.00 

39501-00 rpr lac dphrm any appr $578.18 

39503-00 rpr neonatal diphrg hrna +-ch tube insj $897.00 

39540-00 rpr diphrg hrna oth/thn neonatal traumtc aqt $780.00 

39541-00 rpr diphrg hrna oth/thn neonatal traumtc chrnc $658.13 

39545-00 imbrcj of diaphragm $897.00 

39560-00 rescj dphrm smpl rpr $577.72 

39561-00 rescj dphrm cplx rpr $810.55 

40490-00 bx lip $19.50 

40500-00 vermilionectomy lip shv w/mucosal advmnt $390.00 

40510-00 exc lip transvrs wedge exc w/prim clsr $243.75 

40520-00 exc lip v-exc w/prim dir linr clsr $243.75 

40525-00 exc lip full thkns rcnstj w/local flap $487.50 

40527-00 exc lip full thkns rcnstj w/cross lip flap $487.50 

40530-00 rescj lip > one-4th w/o rcnstj $380.25 

40650-00 rpr lip full thkns vermilion only $487.50 

40652-00 rpr lip full thkns up half ver h8 $497.25 

40654-00 rpr lip full thkns > one-half ver h8/cplx $628.88 

40700-00 plstc rpr cl lip/nsl dfrm prim prtl/compl uni $682.50 

40701-00 plstc rpr cl lip/nsl dfrm prim bi 1 stg px $877.50 

40702-00 plstc rpr cl lip/nsl dfrm prim bi 1 2 stgs $585.00 

40720-00 plstc rpr cl lip/nsl dfrm sec recrtj dfct&reclsr $682.50 

40761-00 plstc rpr cl lip/nsl dfrm w/cross lip pedcl flap $360.75 

40800-00 drg absc cst hmtma vestibule mouth smpl $19.50 

40801-00 drg absc cst hmtma vestibule mouth comp $78.00 

40804-00 rmvl embedded fb vestibule mouth smpl $19.50 

40805-00 rmvl embedded fb vestibule mouth comp $126.75 

40806-00 inc labial frenum frexomy $19.50 

40808-00 bx vestibule mouth $29.25 

40810-00 exc les mucosa&sbmcsl vestibule mouth w/o rpr $29.25 

40812-00 exc les mucosa&sbmcsl vestibule smpl rpr $39.00 

40814-00 exc les mucosa&sbmcsl vestibule cplx rpr $165.75 

40816-00 exc les mucosa&sbmcsl vestibule cplx exc musc $58.50 

40818-00 exc mucosa vestibule mouth as don grf $53.63 

40819-00 exc frenum labial/buccal $78.00 

40820-00 dstrj les/scar vestibule mouth physical meths $19.50 

40830-00 clsr lac vestibule mouth 2.5 cm/< $19.50 

40831-00 clsr lac vestibule mouth > 2.5 cm/cplx $107.25 

40840-00 vestibuloplasty ant $400.14 

40842-00 vestibuloplasty pst uni $400.14 

40843-00 vestibuloplasty pst bi $558.09 

40844-00 vestibuloplasty entire arch $737.10 

40845-00 vestibuloplasty cplx w/ridge xtn musc rpsg $745.88 

41000-00 intraoral i&d tongue/floor lngl $19.50 

41005-00 intraoral i&d tongue/floor sublngl supfc $19.50 

41006-00 intraoral i&d tongue/floor sublngl dp sprmlhyd $121.88 

41007-00 intraoral i&d tongue/floor submental space $58.50 

41008-00 intraoral i&d tongue/floor submndblr space $58.50 

41009-00 intraoral i&d tongue/floor masticator space $58.50 

57

Procedure & 


Tarifas 



41010-00 inc lngl frenum frexomy $19.50 

41015-00 xtroral i&d absc cst/hmtma floor mouth sublngl $39.00 

41016-00 xtroral i&d absc cst/hmtma floor mouth submental $58.50 

41017-00 xtroral i&d absc cst/hmtma floor mouth submndblr $58.50 

41018-00 xtroral i&d floor masticator space $58.50 

41019-00 placement needle head/neck radioelement applicat $307.13 

41100-00 bx tongue ant 2-3rd $29.25 

41105-00 bx tongue pst one-3rd $48.75 

41108-00 bx floor mouth $19.50 

41110-00 exc les tongue w/o clsr $78.00 

41112-00 exc les tongue w/clsr ant 2-3rd $136.50 

41113-00 exc les tongue w/clsr pst one-3rd $195.00 

41114-00 exc les tongue w/clsr w/local tongue flap $117.00 

41115-00 exc lngl frenum frenectomy $68.25 

41116-00 exc les floor mouth $68.25 

41120-00 glssc < one-half tongue $331.50 

41130-00 glssc hemiglssc $390.00 

41135-00 glssc prtl w/uni rad nck dsj $897.00 

41140-00 glssc compl/tot +-trachs w/o rad nck dsj $682.50 

41145-00 glssc compl/tot +-trachs w/uni rad nck dsj $1,062.75 

41150-00 glssc composit w/rescj floor&mndblr rescj $1,101.75 

41153-00 glssc composit rescj floor suprahyoid nck dsj $1,101.75 

41155-00 glssc composit rescj flr mndblr rescj&rad nck $1,530.75 

41250-00 rpr lac 2.5 cm/< floor mouth&/ant 2-3rd tongue $39.00 

41251-00 rpr lac 2.5 cm/< pst one-3rd tongue $48.75 

41252-00 rpr lac tongue floor mouth > 2.6 cm/cplx $165.75 

41500-00 fixj tongue mchnl oth/thn sutr $230.36 

41510-00 sutr tongue lip micrognathia $214.99 

41512-00 tongue base suspension permanent suture tq $398.39 

41520-00 frenoplasty surg revj frenum eg w/z-plasty $165.75 

41800-00 drg absc cst hmtma from dentoalveolar struxs $19.50 

41805-00 rmvl embedded fb from dentalvlr struxs soft tiss $53.63 

41806-00 rmvl embedded fb from dentoalveolar struxs b1 $68.25 

42000-00 drg absc palate uvula $19.50 

42100-00 bx palate uvula $29.25 

42104-00 exc les palate uvula w/o clsr $195.00 

42106-00 exc les palate uvula w/smpl prim clsr $165.75 

42107-00 exc les palate uvula w/local flap clsr $224.25 

42120-00 rescj palate/x10sv rescj les $390.00 

42140-00 uvulectomy exc uvula $29.25 

42145-00 palatopharyngoplasty $514.80 

42160-00 dstrj les palate/uvula thermal cryo/chem $19.50 

42180-00 rpr lac palate up 2 cm $102.38 

42182-00 rpr lac palate > 2 cm/cplx $224.25 

42200-00 palatop cl palate soft&/hard palate only $585.00 

42205-00 palatop w/clsr alveolar ridge soft tiss $804.38 

42210-00 palatop clsr alveolar ridge grf alveolar ridge $901.88 

42215-00 palatop cl palate major revj $585.00 

42220-00 palatop cl palate sec lngth px $682.50 

42225-00 palatop cl palate attachment pharyngeal flap $585.00 

58

Procedure & 


Tarifas 



42226-00 lngth palate&pharyngeal flap $515.09 

42227-00 lngth palate w/island flap $465.08 

42235-00 rpr ant palate w/vomer flap $643.50 

42260-00 rpr nasolabial fstl $204.75 

42300-00 drg absc prtd smpl $48.75 

42305-00 drg absc prtd comp $224.25 

42310-00 drg absc submax/sublngl intraoral $29.25 

42320-00 drg absc submax xtrnl $39.00 

42330-00 sialot submndblr sublngl/prtd uncomp intraoral $19.50 

42335-00 sialolithotomy submndblr submax comp intraoral $97.50 

42340-00 sialolithotomy prtd xtroral/comp intraoral $243.75 

42400-00 bx salivary glnd ndl $48.75 

42405-00 bx salivary glnd incal $78.00 

42408-00 exc sublngl salivary cst ranula $136.50 

42409-00 marsupialization sublngl salivary cst ranula $136.50 

42410-00 exc prtd tum/prtd glnd lat lobe w/o nrv dsj $195.00 

42415-00 exc prtd tum/prtd glnd lat dsj&prsrv facial nrv $585.00 

42420-00 exc prtd tum/prtd glnd tot dsj&prsrv facial nrv $682.50 

42425-00 exc prtd tum/prtd glnd tot en bloc rmvl $585.00 

42426-00 exc prtd tum/prtd glnd tot w/uni rad nck dsj $1,126.13 

42440-00 exc submndblr submax glnd $390.00 

42450-00 exc sublngl glnd $214.50 

42500-00 plstc rpr salivary dux sialodochoplasty prim $341.25 

42505-00 plstc rpr salivary dux sialodochoplasty sec/comp $331.50 

42507-00 prtd dux dvrj bi $326.63 

42508-00 prtd dux dvrj bi w/exc 1 submndblr glnd $399.75 

42509-00 prtd dux dvrj bi w/exc bth submndblr glnds $775.13 

42510-00 parotid duct dvrj bilateral with lig both ducts $468.00 

42550-00 njx sialograpy $9.75 

42600-00 clsr salivary fstl $390.00 

42650-00 dilat salivary dux $9.75 

42660-00 dilat&cathj salivary dux +-njx $19.50 

42665-00 lig salivary dux intraoral $107.25 

42700-00 i&d absc pritonsillar $29.25 

42720-00 i&d absc rtrphrngl/parapharyngeal intraoral $97.50 

42725-00 i&d absc rtrphrngl/parapharyngeal xtrnl appr $204.75 

42800-00 bx oropharynx $29.25 

42802-00 bx hypopharynx $48.75 

42804-00 bx nasopharynx visible les smpl $48.75 

42806-00 bx nasopharynx surv unknown prim les $87.75 

42808-00 exc/dstrj les pharynx any meth $117.00 

42809-00 rmvl fb from pharynx $234.00 

42810-00 exc branchial cl cst confined skn&subq tiss $146.25 

42815-00 exc branchial cl cst extg belw subq tiss&/phrnx $487.50 

42820-00 tonsillectomy&adenoidectomy under age 12 $146.25 

42821-00 tonsillectomy&adenoidectomy age 12/> $195.00 

42825-00 tonsillectomy 1/2 under age 12 $146.25 

42826-00 tonsillectomy 1/2 age 12/> $195.00 

42830-00 adenoidectomy prim under age 12 $97.50 

42831-00 adenoidectomy prim age 12/> $97.50 

59

Procedure & 


Tarifas 



42835-00 adenoidectomy sec under age 12 $97.50 

42836-00 adenoidectomy sec age 12/> $107.25 

42842-00 rad rescj tonsil w/o clsr $468.00 

42844-00 rad rescj tonsil clsr w/local flap $721.50 

42845-00 rad rescj tonsil clsr w/oth flap $1,170.00 

42860-00 exc tonsil tags $97.50 

42870-00 exc/dstrj lngl tonsil any meth spx $97.50 

42890-00 lmtd pharyngectomy $565.50 

42892-00 rescj lat phrngl wall/pyriform sinus dir clsr $755.63 

42894-00 rescj phrngl wall clsr w/flp or flp w/mvasc anas $1,121.25 

42900-00 sutr pharynx wnd/inj $146.25 

42950-00 pharyngoplasty plstc/rcnstv opration pharynx $546.00 

42953-00 pharyngoesophgl rpr $360.75 

42955-00 pharyngostomy fstlj pharynx xtrnl feeding $234.00 

42960-00 ctrl oropharyngeal hemrrg 1/2 smpl $116.71 

42961-00 ctrl oropharyngeal hemrrg 1/2 comp req hospitj $286.07 

42962-00 ctrl oropharyngeal hemrrg 1/2 w/sec surg ivntj $351.00 

42970-00 ctrl nasphryngl hemrrg 1/2 smpl w/pst nsl packs $82.88 

42971-00 ctrl nasphryngl hemrrg 1/2 comp req hospization $316.78 

42972-00 ctrl nasphryngl hemrrg 1/2 w/sec surg ivntj $337.84 

43020-00 esophagotomy crv appr w/rmvl fb $585.00 

43030-00 cricopharyngeal myotomy $546.00 

43045-00 esophagotomy thrc appr w/rmvl fb $780.00 

43100-00 exc les esoph w/prim rpr crv appr $643.50 

43101-00 exc les esoph w/prim rpr thrc/abdl appr $838.50 

43107-00 tot esphg w/o thorcom phrngstrsty/egst $1,306.50 

43108-00 tot esphg w/o thorcom colon ntrpstj/int rcnstj $1,633.03 

43112-00 tot esphg w/thorcom w/phrngstrsty/egst $994.50 

43113-00 tot esphg w/thorcom w/colon ntrpstj/int rcnstj $1,550.34 

43116-00 prtl esphg crv w/fr intstinal grf $1,557.56 

43117-00 prtl esphg dstl thorcom abdl inc egst $1,625.57 

43118-00 prtl esphg dstl thorcom abdl inc ntrpstj/rcnstj $1,608.46 

43121-00 prtl esphg dstl thorcom only thrc egst $1,391.72 

43122-00 prtl esphg thoracoabdl/abdl appr egst $1,170.00 

43123-00 prtl esphg thoracoabdl/abdl appr ntrpstj/rcnstj $1,608.46 

43124-00 tot/prtl esphg w/o rcnstj w/crv esophagostomy $1,379.43 

43130-00 diverticulectomy hypopharynx/esoph crv appr $546.00 

43135-00 diverticulectomy hypopharynx/esoph thrc appr $804.38 

43200-00 esphgsc rgd/flx dx +-collj spec br/wa spx $146.25 

43201-00 esphgsc rgd/flx dired sbmcsl njx any sbst $110.37 

43202-00 esphgsc rgd/flx w/bx 1/mlt $195.00 

43204-00 esphgsc rgd/flx w/njx sclerosis esophgl varc $375.38 

43205-00 esphgsc rgd/flx w/band lig esophgl varc $263.25 

43215-00 esphgsc rgd/flx w/rmvl fb $243.75 

43216-00 esphgsc rgd/flx rmvl tum hot bx forceps/caut $243.75 

43217-00 esphgsc rgd/flx w/rmvl tum snare tq $175.50 

43219-00 esphgsc rgd/flx w/insj plstc tube/stent $204.75 

43220-00 esphgsc rgd/flx w/balo dilat < 30 mm diam $195.00 

43226-00 esphgsc rgd/flx w/insj gd wire dilat $195.00 

43227-00 esphgsc rgd/flx w/ctrl bld $312.00 

60

Procedure & 


Tarifas 



43228-00 esphgsc rgd/flx abltj tum xcp hot bx/caut/snare $312.00 

43231-00 esphgsc rgd/flx w/ndsc us xm $140.40 

43234-00 upper stomach-intestine scope simple $123.83 

43235-00 upper stomach-intestine scope for diagnosis $253.50 

43236-00 stomach-intestine scope inject intestine wall $140.61 

43237-00 upr gi ndsc ndsc us xm lmtd esoph $149.18 

43238-00 upr gi ndsc tndsc us fine ndl aspir/bx esoph $184.28 

43239-00 upper stomach-intestine scope for biopsy $290.00 

43240-00 upr gi ndsc transmural drg pseudocst $254.48 

43241-00 upr gi ndsc tndsc intral tube/cath plmt $241.80 

43242-00 stomach-intestine scope ultrasound guided biopsy $263.25 

43243-00 upr gi ndsc njx sclerosis esophgl&/gstr varc $273.00 

43244-00 upr gi ndsc band lig esophgl&/gstr varc $263.25 

43245-00 upr gi ndsc dilat gstr outlet for obstrcj $282.75 

43246-00 upr gi ndsc dired plmt prq gastrostomy tube $321.75 

43247-00 stomach-intestine scope for foreign body removal $263.25 

43248-00 upr gi ndsc insj gd wire dilat esoph > gd wire $175.50 

43249-00 upr gi ndsc balo dilat esoph < 30 mm diam $219.38 

43250-00 upr gi ndsc rmvl les hot bx/bipolar caut $245.70 

43251-00 upr gi ndsc rmvl tum polyp/oth les snare tq $263.25 

43255-00 upr gi ndsc ctrl bld any meth $273.00 

43256-00 upr gi ndsc tndsc stent plmt w/predilat $206.60 

43258-00 upr gi ndsc abltj les x rmvl forceps/caut/snare $273.00 

43259-00 stomach-intestine scope with ultrasound exam $236.93 

43260-00 ercp dx collj spec br/wa spx $341.25 

43261-00 ercp w/bx 1/mlt $548.93 

43262-00 ercp w/sphnctrotomy/papillotomy $409.50 

43263-00 ercp w/press meas sphnctr oddi $346.11 

43264-00 ercp w/rmvl st1/calculi biliary&/pncrtc duxs $443.63 

43265-00 ercp w/dstrj lithotrp st1/calculi any meth $377.33 

43267-00 ercp w/insj nasobiliary/nasopncrtc drg tube $350.42 

43268-00 ercp w/insj tube/stent bile/pncrtc dux $443.63 

43269-00 ercp w/rtrgr rmvl fb&/chng tube/stent $570.38 

43271-00 ercp w/balo dilat ampulla biliary&/pncrtc dux $409.50 

43272-00 ercp w/abltj les x rmvl forceps/caut/snare $388.05 

43273-00 endoscopic papilla cannulation bile pancreatic $106.53 

43279-00 laps esophagomyotomy w/fundoplasty if performed $833.63 

43280-00 laps surg esopg/gstr fundoplasty $765.38 

43281-00 laps rpr paraesphgl hrna incl fundplsty w/o mesh $926.25 

43282-00 laps rpr paraesphgl hrna incl fundplsty w/mesh $1,041.30 

43283-00 laps esophageal lengthening addl $97.50 

43300-00 esphgp crv appr w/o rpr tracheoesophgl fstl $526.50 

43305-00 esphgp crv appr w/rpr tracheoesophgl fstl $804.38 

43310-00 esphgp thrc appr w/o rpr tracheoesophgl fstl $994.50 

43312-00 esphgp thrc appr w/rpr tracheoesophgl fstl $1,062.75 

43313-00 esphgp cgen dfct thrc appr w/o rpr fstl $1,840.12 

43314-00 esphgp cgen dfct thrc appr w/rpr fstl $2,020.88 

43320-00 egst+-vagotomy&pyloroplasty tabdl/tthrc appr $780.00 

43325-00 esopg/gstr fundoplasty w/fundic patch $975.00 

43327-00 esopg/gstr fundoplasty w/lapt $490.47 

61

Procedure & 


Tarifas 



43328-00 esopg/gstr fundoplasty w/thorcom $708.83 

43330-00 esophagomyotomy heller typ abdl appr $780.00 

43331-00 esophagomyotomy heller typ thrc appr $780.00 

43332-00 rpr paraesoph hiatal hernia w/lapt w/o mesh $619.52 

43333-00 lapt rpr paraesoph hiatal hernia w/ mesh $761.64 

43334-00 rpr paraesoph hiatal hernia w/thorcom w/o mesh $769.28 

43335-00 rpr paraesoph hiatal hernia w/thorcom w/mesh $828.75 

43336-00 rpr paraesoph hiatal hernia thorcoabdom w/o mesh $902.99 

43337-00 rpr paraesoph hiatal hernia thorcoabdom w/mesh $986.70 

43338-00 esophagus lengthening $80.31 

43340-00 esophagojejunostomy w/o tot gstrct abdl appr $975.00 

43341-00 esophagojejunostomy w/o tot gstrct thrc appr $975.00 

43350-00 esophagostomy fstlj esoph xtrnl abdl appr $585.00 

43351-00 esophagostomy fstlj esoph xtrnl thrc appr $585.00 

43352-00 esophagostomy fstlj esoph xtrnl crv appr $516.75 

43360-00 gi rcnstj prev esphg/exclusion w/stomach $1,404.00 

43361-00 gi rcnstj prev esphg/exclusion w/colon sm int $447.53 

43400-00 lig dir esophgl varc $780.00 

43401-00 trnsxj esoph w/rpr esophgl varc $1,316.25 

43405-00 lig/stapling g-esop junct pre-esophgl prf8j $791.51 

43410-00 sutr esophgl wnd/inj crv appr $468.00 

43415-00 sutr esophgl wnd/inj tthrc/tabdl appr $682.50 

43420-00 clsr esophagostomy/fstl crv appr $438.75 

43425-00 clsr esophagostomy/fstl tthrc/tabdl appr $682.50 

43450-00 opening of esophagus $48.75 

43453-00 dilat esoph > gd wire $102.38 

43456-00 dilat esoph balo/dilator rtrgr $195.00 

43458-00 dilat esoph balo 30 mm diam/lgr achalasia $175.50 

43460-00 esopg/gstr tamponade w/balo sengstaken typ $87.75 

43500-00 gstrt w/expl/fb rmvl $487.50 

43501-00 gstrt w/sutr rpr bld ulcer $529.43 

43502-00 gstrt w/sutr rpr pre-esopg/gstr lac $592.80 

43510-00 gstrt w/esophgl dilat&insj prm intral tube $536.25 

43520-00 pyloromyotomy cutting pyloric musc $487.50 

43605-00 bx stomach lapt $487.50 

43610-00 exc local ulcer/b9 tum stomach $585.00 

43611-00 exc local mal tum stomach $570.38 

43620-00 gstrct tot w/esophagontrstm $975.00 

43621-00 gstrct tot w/roux-en-y rcnstj $978.90 

43622-00 gstrct tot w/frmj intstinal pouch any typ $1,061.78 

43631-00 gstrct prtl dstl w/gastroduodenostomy $833.63 

43632-00 gstrct prtl dstl w/gastrojejunostomy $833.63 

43633-00 gstrct prtl dstl w/roux-en-y rcnstj $856.05 

43634-00 gstrct prtl dstl w/frmj intstinal pouch $1,140.75 

43635-00 vagotomy pfrmd w/prtl dstl gstrct $848.25 

43640-00 vgtmy w/pyps +-gastrostomy truncal/slctv $682.50 

43641-00 vgtmy w/pyps +-gastrostomy parietal cell $789.75 

43644-00 laps gstr rstcv px w/byp roux-en-y

Procedure & 


Tarifas 



43652-00 laps surg trnsxj vagus nrv slctv/hily slctv $789.75 

43653-00 laps surg gastrostomy w/o constj gstr tube spx $357.83 

43752-00 naso/oro-gastric tube plmt req phys&fluor gdn $43.88 

43753-00 gastric tube plmt w/aspir & lavage $13.07 

43754-00 gastric tube dx plmt w/aspir 1 specimen $28.28 

43755-00 gastric tube dx plmt w/aspir mult specimens $28.28 

43756-00 duodenal tube dx plmt w/img gid 1 specimen $135.86 

43757-00 duodenal tube dx plmt w/img gid mult specimen $175.50 

43760-00 change gastrostomy tube percutaneous w/o guide $39.00 

43761-00 repos naso/oro gastric feeding tube thru duo $43.88 

43774-00 laps gastric restrictive px remove device &port $724.11 

43800-00 pyloroplasty $487.50 

43810-00 gastroduodenostomy $585.00 

43820-00 gastrojejunostomy w/o vagotomy $585.00 

43825-00 gastrojejunostomy w/vagotomy any typ $731.25 

43830-00 gastrostomy opn w/o constj gstr tube spx $390.00 

43831-00 gastrostomy opn neonatal feeding $331.50 

43832-00 gastrostomy opn w/constj gstr tube $575.25 

43840-00 gastrorrhaphy sutr prf8 duol/gstr ulcer wnd/inj $487.50 

43846-00 gstr rstcv w/byp w/short limb 150 cm/< $997.72 

43847-00 gstr rstcv w/byp w/sm int rcnstj limit absrpj $2,983.50 

43848-00 revision open gastric restrictive px not device $1,358.53 

43850-00 revj gastroduol anast w/rcnstj w/o vagotomy $877.50 

43855-00 revj gastroduol anast w/rcnstj w/vgtmy $975.00 

43860-00 revj gstr/jj anast w/rcnstj w/o vgtmy $877.50 

43865-00 revj gstr/jj anast w/rcnstj w/vgtmy $975.00 

43870-00 clsr gastrostomy surg $390.00 

43880-00 clsr gastrocolic fstl $653.25 

44005-00 enterolss fring intstinal adhesion spx $585.00 

44010-00 duodexomy expl bx/fb rmvl $585.00 

44015-00 tube/ndl cath jejunostomy any meth $82.88 

44020-00 enterotomy sm int oth/thn duo expl bx/fb rmvl $585.00 

44021-00 enterotomy sm int oth/thn duo dcmprn $482.63 

44025-00 colotomy expl bx/fb rmvl $633.75 

44050-00 rdctj volvulus intussusception int hrna lapt $585.00 

44055-00 corrj malrotation bands&/rdctj volvulus $702.00 

44100-00 bx int capsl tube proral 1+ specs $97.50 

44110-00 exc 1+ < sm/lg int 1 enterotomy $585.00 

44111-00 exc 1+ < sm/lg int mlt enterotomies $682.50 

44120-00 entrc rescj sm int 1 rescj&anast $682.50 

44121-00 entrc rescj sm int ea rescj&anast $186.03 

44125-00 entrc rescj sm int w/ntrstm $683.57 

44126-00 entrc rescj atresia rescj&anast w/o tapring $1,364.51 

44127-00 entrc rescj atresia rescj&anast sgm w/tapring $1,568.97 

44128-00 entrc rescj atresia ea rescj&anast $168.48 

44130-00 enterontrstm anast int +-cutan ntrstm spx $585.00 

44139-00 moblj splenic flxr pfrmd conjunct w/prtl colct $175.50 

44140-00 colct prtl w/anast $975.00 

44141-00 colct prtl w/skn lvl cecostomy/clst $1,072.50 

44143-00 colct prtl w/end clst&clsr dstl sgm $1,004.25 

63

Procedure & 


Tarifas 



44144-00 colct prtl w/rescj w/clst/ileost&mucofstl $975.00 

44145-00 colct prtl w/colopxtstmy lw pel anast $1,170.00 

44146-00 colct prtl w/colopxtstmy lw pel anast w/clst $1,267.50 

44147-00 colct prtl abdl&transanal appr $1,140.75 

44150-00 colct tot abdl w/o prctect w/ileost/ileopxts $1,072.50 

44151-00 colct tot abdl w/o prctect w/continent ileost $1,053.00 

44155-00 colct tot abdl w/prctect w/ileost $1,170.00 

44156-00 colct tot abdl w/prctect w/continent ileost $780.00 

44157-00 colct ttl abd w/prctect ileoanal anast $1,400.49 

44158-00 colct ttl abd w/prctect ileoanal anast & rsvr $1,437.35 

44160-00 colct prtl w/rmvl terminal ile w/ileoclst $965.25 

44180-00 laps enterolss fring intstinal adhesion spx $263.25 

44186-00 laps jejunostomy $474.48 

44187-00 laps ileost/jejunostomy non-tube $665.15 

44188-00 laps clst/skn lvl cecostomy $860.06 

44202-00 laps entrc rescj sm int 1 rescj&anast $953.55 

44203-00 laps ea sm int rescj&anast $164.09 

44204-00 laps colct prtl w/anast $1,060.46 

44205-00 laps colct prtl w/rmvl terminal ile $851.18 

44206-00 laps colct prtl w/end clst&clsr dstl sgm $1,023.17 

44207-00 laps colct prtl w/colopxtstmy lw anast $1,119.69 

44208-00 laps colct prtl w/colopxtstmy lw anast w/clst $1,210.95 

44210-00 laps colct tot w/o prctect w/ileost/ileopxts $1,071.72 

44211-00 laps colct ttl abd w/prctect ileoanal anast&rsvr $1,331.17 

44212-00 laps colct abdl w/prctect w/ileost $1,243.42 

44213-00 laps moblj splenic flxr pfrmd w/prtl colct $131.63 

44227-00 laps clsr ntrstm lg/sm int w/rescj&anast $824.85 

44300-00 placement enterostomy/cecostomy tube open $487.50 

44310-00 ileost/jejunostomy non-tube $604.50 

44312-00 revj ileost smpl rls supfc scar spx $204.75 

44314-00 revj ileost comp rcnstj in-depth spx $604.50 

44316-00 continent ileost kock px spx $682.50 

44320-00 clst/skn lvl cecostomy $487.50 

44322-00 clst/skn lvl cecostomy w/mlt bxs spx $473.85 

44340-00 revj clst smpl rls supfc scar spx $48.75 

44345-00 revj clst comp rcnstj in-depth spx $243.75 

44346-00 revj clst w/rpr paraclst hrna spx $491.40 

44360-00 scope of upper small intestine $87.75 

44361-00 scope of upper small intestine with biopsy $263.25 

44363-00 enteroscopy > 2nd prtn x ile rmvl fb $165.75 

44364-00 enteroscopy > 2nd prtn x ile rmvl les snare $224.25 

44365-00 enteroscopy > 2nd prtn x ile rmvl les caut $245.70 

44366-00 enteroscopy > 2nd prtn x ile ctrl bld $263.25 

44369-00 enteroscopy > 2nd prtn x ile abltj les $263.25 

44370-00 enteroscopy > 2nd prtn x ile tndsc stent plmt $228.39 

44372-00 enteroscopy > 2nd prtn x ile w/plmt prq tube $263.25 

44373-00 enteroscopy > 2nd prtn x ile conv gstrst tube $222.89 

44376-00 enteroscopy > 2nd prtn w/ile +-collj spec spx $254.48 

44377-00 enteroscopy > 2nd prtn w/ile w/bx 1/mlt $267.64 

44378-00 enteroscopy > 2nd prtn ile ctrl bld $338.72 

64

Procedure & 


Tarifas 



44379-00 enteroscopy > 2nd prtn w/ile w/stent plmt $201.83 

44380-00 ilesc thru stoma dx +-collj spec br/wa spx $86.00 

44382-00 ilesc thru stoma w/bx 1/mlt $104.33 

44383-00 ilesc thru stoma w/tndsc stent plmt $114.08 

44385-00 ndsc eval intstinal pouch dx +-collj spec spx $114.08 

44386-00 ndsc eval intstinal pouch w/bx 1/mlt $96.53 

44388-00 scope of colon thru ostomy for diagnosis $156.00 

44389-00 scope of colon with biopsy thru ostomy $185.25 

44390-00 colsc thru stoma w/rmvl fb $195.00 

44391-00 colsc thru stoma ctrl bld $253.50 

44392-00 colsc thru stoma rmvl les caut $273.00 

44393-00 colsc thru stoma abltj les $282.75 

44394-00 colsc thru stoma w/rmvl tum polyp/oth les snare $254.48 

44397-00 colsc thru stoma w/tndsc stent plmt $201.83 

44500-00 intro long gi tube spx $17.55 

44602-00 enterorrhaphy 1 prf8j $602.84 

44603-00 enterorrhaphy mlt prf8j $701.12 

44604-00 sutr lg int 1/mlt prf8j w/o clst $613.37 

44605-00 sutr lg int 1/mlt prf8j w/clst $682.50 

44615-00 intstinal stricturoplasty+-dilat obstrcj $615.13 

44620-00 clsr ntrstm lg/sm int $476.48 

44625-00 clsr ntrstm lg/sm rescj&anast oth/thn clrct $682.50 

44626-00 clsr ntrstm lg/sm rescj&clrct anast $965.25 

44640-00 clsr intstinal cutan fstl $811.69 

44650-00 clsr enteroenteric/enterocolic fstl $585.00 

44660-00 clsr enteroves fstl w/o intstinal/bldr rescj $789.75 

44661-00 clsr enteroves fstl w/int&/bldr rescj $926.25 

44680-00 intstinal plctj spx $838.50 

44700-00 exclusion sm int from pelvis mesh/prosth/tiss $715.16 

44701-00 intraop colonic lvg $114.08 

44800-00 exc meckel's diverticulum/omphalomesenteric duct $487.50 

44820-00 exc les mesentery spx $487.50 

44850-00 sutr mesentery spx $390.00 

44900-00 i&d appendiceal absc opn $292.50 

44901-00 i&d appendiceal absc prq $204.46 

44950-00 appendec $390.00 

44955-00 appendec indicated purpose oth major px x spx $355.88 

44960-00 appendec rptd appendix absc/pritonitis $453.38 

44970-00 laps surg appendec $438.75 

45000-00 transrct drg pel absc $146.25 

45005-00 i&d sbmcsl absc rectum $117.00 

45020-00 i&d dp supralevator pelvirct/retrorct absc $195.00 

45100-00 bx anrct wall anal appr $175.50 

45108-00 anrct myomectomy $219.38 

45110-00 prctect compl cmbn abdominoprnl w/clst $975.00 

45111-00 prctect prtl rescj rectum tabdl appr $838.50 

45112-00 prctect cmbn abdominoprnl pull-thru px $877.50 

45113-00 prctect prtl w/mucosec ileoanal anast rsvr $1,202.18 

45114-00 prctect prtl w/anast abdl&transsac appr $926.25 

45116-00 prctect prtl w/anast transsac appr only $804.38 

65

Procedure & 


Tarifas 



45119-00 prctect cmbn pull-thru w/rsvr w/ntrstm $1,206.56 

45120-00 prctect compl w/pull-thru px&anast $975.00 

45121-00 prctect compl w/stot/tot colct w/mlt bxs $1,316.25 

45123-00 prctect prtl w/o anast prnl appr $745.88 

45126-00 pel exntj clrct mal $1,724.29 

45130-00 exc rct procidentia w/anast prnl appr $585.00 

45135-00 exc rct procidentia w/anast abdl&prnl appr $975.00 

45136-00 exc ileoanal rsvr w/ileost $1,096.88 

45150-00 div strix rectum $195.00 

45160-00 exc rct tum proctotomy transsac/transcoccygeal $804.38 

45171-00 exc rct tum not incl muscularis propria $375.38 

45172-00 exc rct tum incl muscularis propria $516.75 

45190-00 dstrj rct tum transanal appr $396.63 

45300-00 proctosgmdsc rgd dx +-collj spec br/wa spx $29.25 

45303-00 proctosgmdsc rgd w/dilat $53.63 

45305-00 proctosgmdsc rgd w/bx 1/mlt $48.75 

45307-00 proctosgmdsc rgd w/rmvl fb $48.75 

45308-00 proctosgmdsc rgd rmvl 1 les caut $83.85 

45309-00 proctosgmdsc rgd rmvl 1 les snare tq $83.85 

45315-00 proctosgmdsc rgd rmvl mlt tum < caut/snare $87.75 

45317-00 proctosgmdsc rgd ctrl bld $58.50 

45320-00 proctosgmdsc rgd abltj les $126.75 

45321-00 proctosgmdsc rgd dcmprn volvulus $146.25 

45327-00 proctosgmdsc rgd tndsc stent plmt $79.38 

45330-00 scope of sigmoid colon only for diagnosis $78.00 

45331-00 scope of sigmoid colon only with biopsy $107.25 

45332-00 sgmdsc flx rmvl fb $117.00 

45333-00 sgmdsc flx rmvl les caut $136.50 

45334-00 sgmdsc flx ctrl bld $117.00 

45335-00 sgmdsc flx dired sbmcsl njx any sbst $99.16 

45337-00 sgmdsc flx dcmprn volvulus any meth $143.33 

45338-00 sgmdsc flx rmvl tum polyp/oth les snare tq $122.85 

45339-00 sgmdsc flx abltj les $157.95 

45340-00 sgmdsc flx dilat balo 1/more strixs $226.40 

45341-00 sgmdsc flx ndsc us xm $114.08 

45342-00 sgmdsc flx tndsc us gid ndl aspir/bx $191.64 

45345-00 sgmdsc flx tndsc stent plmt $131.63 

45355-00 colsc rgd/flx tabdl via colotomy 1/mlt $29.25 

45378-00 scope of colon for diagnosis $273.00 

45379-00 colsc flx prox splenic flxr rmvl fb $243.75 

45380-00 scope of colon with biopsy $292.50 

45381-00 colsc flx prox splenic flxr sbmcsl njx $268.52 

45382-00 colsc flx prox splenic flxr ctrl bld $282.75 

45383-00 colsc flx prox splenic flxr abltj les $282.75 

45384-00 colsc flx prox splenic flxr rmvl les caut $333.45 

45385-00 colsc flx prox splenic flxr rmvl les snare tq $575.25 

45386-00 colsc flx prox splenic flxr dilat balo 1+ strixs $510.71 

45387-00 colsc flx prox splenic flxr tndsc stent plmt $263.25 

45391-00 colsc flx prox splenic flxr ndsc us xm $219.38 

45392-00 colsc flx prox splenic flxr us gid ndl aspir/bx $279.05 

66

Procedure & 


Tarifas 



45395-00 laps prctect compl cmbn abdominoprnl w/clst $1,216.22 

45397-00 laps prctect cmbn pull-thru crtj rsvr $213.69 

45400-00 laps proctopexy for prolapse $710.78 

45402-00 laps proctopexy for prolapse sigmoid rescj $956.48 

45500-00 proctoplasty stenosis $390.00 

45505-00 proctoplasty prolapse muc memb $390.00 

45520-00 prirct njx sclrsg sln prolapse $19.50 

45540-00 proctopexy abdl appr $585.00 

45541-00 proctopexy prnl appr $585.00 

45550-00 proctopexy w/sigmoid rescj abdl appr $877.50 

45560-00 rpr rectocele spx $234.00 

45562-00 expl rpr&presac drg rct inj $605.48 

45563-00 expl rpr&presac drg rct inj w/clst $920.50 

45800-00 clsr rectovesical fstl $585.00 

45805-00 clsr rectovesical fstl w/clst $828.75 

45820-00 clsr rectourtl fstl $682.50 

45825-00 clsr rectourtl fstl w/clst $936.00 

45900-00 rdctj procidentia spx under anes $19.50 

45905-00 dilat anal sphnctr spx under anes oth/thn local $29.25 

45910-00 dilat rct strix spx under anes oth/thn local $29.25 

45915-00 rmvl fecal impaction/fb spx under anes $29.25 

45990-00 anrct xm surg req anes general spi/edrl dx $70.20 

46020-00 plmt seton $154.58 

46030-00 rmvl anal seton oth marker $19.50 

46040-00 i&d ischiorct&/prirct absc spx $97.50 

46045-00 i&d intramural im/absc transanal anes $87.75 

46050-00 i&d prianal absc supfc $19.50 

46060-00 i&d ischiorct/intramural absc +-seton $390.00 

46070-00 inc anal septum inft $48.75 

46080-00 sphnctrotomy anal div sphnctr spx $48.75 

46083-00 inc thrombosed hemorrhoid xtrnl $29.25 

46200-00 fissurectomy incl sphincterotomy when performed $195.00 

46220-00 excision single external papilla or tag anus $29.25 

46221-00 hemorrhoidectomy internal rubber band ligations $53.63 

46230-00 excision multiple external papillae/tags anus $48.75 

46250-00 hemorrhoidectomy xtrnl 2+ column/group $244.82 

46255-00 hemorrhoidectomy ntrnl & xtrnl 1 column/group $292.50 

46257-00 hrhc smpl w/fissurectomy $292.50 

46258-00 hrhc 1 col/grp w/fstulectmy incl fssrectomy $390.00 

46260-00 hemorrhoidectomy int & xtrnl 2+ column/group $390.00 

46261-00 hrhc cplx/x10sv w/fissurectomy $419.25 

46262-00 hrhc 2+ col/grp w/fstulectmy incl fssrectmy $433.88 

46270-00 surg tx anal fstl subq $230.78 

46275-00 surg tx anal fistula intersphincteric $390.00 

46280-00 tx anal fstl trans/supra/xtrasphnctrc incl seton $438.75 

46285-00 surg tx anal fstl 2nd stg $97.50 

46288-00 clsr anal fstl w/rct advmnt flap $351.00 

46320-00 exc thrombosed hemorrhoid xtrnl $142.16 

46500-00 njx sclrsg sln hemorrhoids $19.50 

46505-00 chemodnrvtj int anal sphnctr $122.85 

67

Procedure & 


Tarifas 



46600-00 anosc dx +-collj spec br/wa spx $21.06 

46604-00 anosc dilat $19.50 

46606-00 anosc bx 1/mlt $35.10 

46608-00 anosc rmvl fb $48.75 

46610-00 anosc rmvl 1 les caut $107.25 

46611-00 anosc rmvl 1 tum polyp/oth les snare tq $66.30 

46612-00 anosc rmvl mlt tums caut/snare $183.30 

46614-00 anosc ctrl bld $105.30 

46615-00 anosc abltj les $175.50 

46700-00 anoplasty plstc opration strix adlt $390.00 

46705-00 anoplasty plstc opration strix inft $404.63 

46706-00 rpr anal fstl w/fibrin glue $96.53 

46707-00 repair anorectal fistula plug $265.20 

46710-00 rpr ileoanal pouch fstl/pouch advmnt tprnl appr $638.82 

46712-00 rpr ileoanal pouch fstl/pouch advmnt cmbn appr $1,316.25 

46715-00 rpr lw imprf8 anus w/anoprnl fstl cut-bk $282.75 

46716-00 rpr lw imprf8 anus w/trpos fstl $468.00 

46730-00 rpr hi imprf8 anus w/o fstl prnl/sacroprnl appr $1,042.47 

46735-00 rpr hi imprf8 anus w/o fstl cmbn appr $780.00 

46740-00 rpr hi imprf8 anus w/fstl prnl/sacroprnl appr $1,131.98 

46742-00 rpr hi imprf8 anus w/fstl tabdl&sacroprnl $114.08 

46744-00 rpr cloacal anomal sacroprnl $140.40 

46746-00 rpr cloacal anomal cmbn abdl&sacroprnl $149.18 

46748-00 rpr cloacal anomal cmbn abdl&sacroprnl w/grf $1,667.25 

46750-00 sphnctrop anal incont/prolapse adlt $390.00 

46751-00 sphnctrop anal incont/prolapse chld $497.25 

46753-00 grf thiersch rct incont&/prolapse $243.75 

46754-00 rmvl thiersch wire/sutr anal canal $105.43 

46760-00 sphnctrop anal musc trnspl $438.75 

46761-00 sphnctrop anal levator musc imbrcj $452.40 

46762-00 sphnctrop anal impltj artif sphnctr $333.45 

46900-00 dstrj les anus smpl chem $139.52 

46910-00 dstrj les anus smpl eltrdsiccation $29.25 

46916-00 dstrj les anus smpl cryosurg $35.10 

46917-00 dstrj les anus smpl laser surg $175.50 

46922-00 dstrj les anus smpl surg exc $175.50 

46924-00 dstrj les anus x10sv $175.50 

46930-00 destruction internal hemorrhoid thermal energy $53.63 

46940-00 curtg/caut anal fissure w/dilat sphnctr spx 1st $68.25 

46942-00 curtg/caut anal fissure w/dilat sphnctr spx sbsq $58.50 

46945-00 hrhc ntrnl lig oth than rbbr band 1 col/grp $78.00 

46946-00 hrhc ntrnl lig oth than rbbr band 2+ col/grp $117.00 

46947-00 hemorrhoidopexy stapling $220.25 

47000-00 bx lvr ndl prq $48.75 

47001-00 bx lvr ndl done purpose tm oth major px $79.95 

47010-00 hepatotomy opn drg absc/cst 1/2 stgs $546.00 

47011-00 hepatotomy prq drg absc/cst 1/2 stgs $208.85 

47015-00 lapt w/aspir&/njx hepatc parasitic cst/absces $605.48 

47100-00 bx lvr wedge $419.25 

47120-00 hptc rescj lvr prtl lobec $780.00 

68

Procedure & 


Tarifas 



47122-00 hptc rescj lvr trisgmectomy $1,404.00 

47125-00 hptc rescj lvr tot l lobec $1,160.25 

47130-00 hptc rescj lvr tot r lobec $1,267.50 

47300-00 marsupialization cst/absc lvr $682.50 

47350-00 mgmt lvr hemrrg smpl sutr lvr wnd/inj $585.00 

47360-00 mgmt lvr hemrrg cplx sutr wnd/inj $887.25 

47361-00 mgmt lvr hemrrg expl wnd dbrdmt coagj/sutr $1,171.46 

47362-00 mgmt lvr hemrrg re-expl wnd rmvl packing $418.57 

47380-00 abltj opn 1+ lvr tum rf $1,077.38 

47400-00 hepatcotomy/hepatcostomy w/expl drg/rmvl st1 $682.50 

47420-00 choledochot/ost w/o sphnctrotomy/sphnctrop $682.50 

47425-00 choledochot/ost w/sphnctrotomy/sphnctrop $809.25 

47460-00 transduol sphnctrotomy/sphnctrop +-xtrj st1 spx $780.00 

47480-00 cholecstot/cholecstost w/expl drg/rmvl st1 spx $487.50 

47490-00 cholecstost prq w/img gid $263.25 

47500-00 njx prq transhepatc cholangrph $97.50 

47505-00 njx cholangrph thru an cath $63.38 

47510-00 intro prq transhepatc cath biliary drg $160.88 

47511-00 intro prq transhepatc stent biliary drg $333.45 

47525-00 chng prq biliary drg cath $175.50 

47530-00 revj&/rinsj transhepatc tube $184.28 

47550-00 biliary ndsc intraop $136.50 

47552-00 biliary ndsc prq t-tube dx +-collj spec spx $175.50 

47553-00 biliary ndsc prq t-tube w/bx 1/mlt $253.50 

47554-00 biliary ndsc prq t-tube rmvl st1 $321.75 

47555-00 biliary ndsc prq t-tube dilat strix w/o stent $243.75 

47556-00 biliary ndsc prq t-tube dilat strix w/stent $298.35 

47560-00 laps surg w/gid transhepatc cholangrph w/o bx $329.55 

47561-00 laps surg w/gid transhepatc cholangrph w/bx $351.00 

47562-00 laps surg cholecstc $702.00 

47563-00 laps surg cholecstc w/cholangrph $702.00 

47564-00 laps surg cholecstc w/expl common dux $777.08 

47570-00 laps surg cholecstontrstm $675.68 

47600-00 cholecstc $585.00 

47605-00 cholecstc cholangrph $594.75 

47610-00 cholecstc expl dux $645.45 

47612-00 cholecstc expl dux choledochontrstm $780.98 

47620-00 cholecstc expl dux sphnctrotomy/sphnctrop $838.50 

47630-00 biliary dux stone xtrj prq via basket/snare $195.00 

47700-00 expl cgen atresia bile duxs $487.50 

47701-00 portontrstm $1,053.00 

47711-00 exc bile dux tum +-prim rpr xtrhepatc $916.11 

47712-00 exc bile dux tum +-prim rpr intrahepatc $1,182.87 

47715-00 exc choledochal cst $636.68 

47720-00 cholecstontrstm dir $604.50 

47721-00 cholecstontrstm w/gastrontrstm $633.75 

47740-00 cholecstontrstm roux-en-y $633.75 

47741-00 cholecstontrstm roux-en-y w/gastrontrstm $965.25 

47760-00 anast xtrhepatc biliary duxs&gi $731.25 

47765-00 anast intrahepatc duxs&gi $848.25 

69

Procedure & 


Tarifas 



47780-00 anast roux-en-y xtrhepatc biliary duxs&gi $828.75 

47785-00 anast roux-en-y intrahepatc biliary duxs&gi $965.25 

47800-00 rcnstj plstc biliary duxs w/end-to-end anast $780.00 

47801-00 plmt choledochal stent $438.75 

47802-00 u-tube hepatcontrstm $702.00 

48000-00 place drain peripancreatic acute pancreatitis $487.50 

48001-00 place drain peripancreatic w/cholecystostomy $614.25 

48020-00 rmvl pncrtc st1 $682.50 

48100-00 bx pncrs opn $594.75 

48102-00 bx pncrs prq ndl $156.00 

48105-00 resecj/dbrdmt pancreas necrotizing pancreatitis $737.10 

48120-00 exc les pncrs $711.75 

48140-00 pncrtect dstl stot w/o pncrtcojejunostomy $780.00 

48145-00 pncrtect dstl stot w/pncrtcojejunostomy $936.00 

48146-00 pncrtect dstl nr-tot w/prsrv duo chld-typ px $1,053.00 

48148-00 exc ampulla vater $544.05 

48150-00 pncrtect prox stot w/pancreatojejunostomy $1,365.00 

48152-00 pncrtect whipple w/o pancreatojejunostomy $1,491.75 

48153-00 pncrtect w/pancreatojejunostomy $1,579.50 

48154-00 pncrtect prox stot w/o pancreatojejunostomy $1,491.75 

48155-00 pncrtect tot $1,365.00 

48400-00 injection intraoperative pancreatography $82.49 

48500-00 marsupialization pncrtc cst $585.00 

48510-00 xtrnl drg pseudocst pncrs opn $272.03 

48511-00 xtrnl drg pseudocst pncrs prq $200.07 

48520-00 int anast pncrtc cst gi trc dir $682.50 

48540-00 int anast pncrtc cst gi trc roux-en-y $780.00 

48545-00 pancreatorrhaphy inj $614.25 

48547-00 duol exclusion w/gastrojejunostomy pncrtc inj $877.50 

48548-00 pancreaticojejunostomy side-to-side anast $780.00 

49000-00 expl lapt expl celiotomy +-bx spx $390.00 

49002-00 reopng recent lapt $321.75 

49010-00 expl rpr area +-bx spx $463.13 

49020-00 drg prtl absc/loclzd pritonitis opn $390.00 

49021-00 drg prtl absc/loclzd pritonitis prq $375.57 

49040-00 drg subdiphrg/subphrenic absc opn $487.50 

49041-00 drg subdiphrg/subphrenic absc prq $248.33 

49060-00 drg rpr absc opn $390.00 

49061-00 drg rpr absc prq $241.31 

49062-00 drg xtrprtl lymphocele prtl cavity opn $514.22 

49080-00 pritoneocnts abdl pcnts/prtl lvg 1st $39.00 

49081-00 pritoneocnts abdl pcnts/prtl lvg sbsq $29.25 

49180-00 bx abdl/rpr mass prq ndl $97.50 

49203-00 excision/destruction open abdominal tumors 5 cm $682.50 

49204-00 exc/destruction open abdmnl tumors 5.1-10.0 cm $750.75 

49205-00 exc/destruction open abdominal tumors >10.0 cm $819.00 

49215-00 exc presac/sacrococcygeal tum $812.18 

49220-00 staging laparotomy hodgkins disease/lymphoma $741.00 

49250-00 umbilectomy omphalectomy exc umbilicus spx $390.00 

49255-00 omntc epiploectomy rescj omentum spx $429.00 

70

Procedure & 


Tarifas 



49320-00 laps abd prtm&omentum dx +-spec br/wa spx $243.75 

49321-00 laps surg w/bx 1/mlt $233.03 

49322-00 laps surg w/aspir cavity/cst 1/mlt $329.55 

49323-00 laps surg w/drg lymphocele prtl cavity $408.53 

49324-00 laps insertion tunneled intraperitoneal catheter $250.09 

49325-00 laps w/revision intraperitoneal catheter $268.52 

49326-00 laps w/omentopexy $123.73 

49327-00 laps w/insertion ntrstl dev w/img gid 1+ $78.98 

49400-00 njx air/cntrst in prtl cavity spx $39.00 

49402-00 removal peritoneal foreign body from cavity $546.00 

49412-00 plmt intrstl dev opn w/img gid 1+ $48.96 

49418-00 insj intraperitoneal catheter w/img gid $279.92 

49419-00 insertion tunnel intraperitoneal cath subq port $279.92 

49421-00 insertion tunnel intraperitoneal cath dial open $165.75 

49422-00 removal tunneled intraperitoneal catheter $341.25 

49423-00 exchng absc/cst drg cath rad gid spx $68.36 

49424-00 cntrst njx assmt absc/cst via drg cath/tube spx $35.98 

49425-00 insj prtl-ven shunt $463.13 

49426-00 revj prtl-ven shunt $117.00 

49427-00 inject evaluate previous peritoneal-venous shunt $36.08 

49428-00 lig prtl-ven shunt $87.75 

49429-00 rmvl prtl-ven shunt $265.01 

49435-00 insj subq extension intraperitoneal catheter $79.85 

49436-00 delayed creation exit site embedded catheter $116.71 

49440-00 insert gastrostomy tube percutaneous $156.59 

49441-00 insert duodenostomy/jejunostomy tube perq $175.16 

49442-00 insert cecostomy/other colonic tube percutaneous $144.79 

49446-00 convert gastrostomy-gastro-jejunostomy tube perq $114.08 

49450-00 replace gastrostomy/cecostomy tube percutaneous $46.92 

49451-00 replace duodenostomy/jejunostomy tube perq $64.42 

49452-00 replacement gastro-jejunostomy tube percutaneous $100.91 

49460-00 obstructive material removal from gi tube $33.14 

49465-00 contrast injection perq radiologic eval gi tube $21.87 

49491-00 rpr 1st ingun hrna preterm inft rdc $451.04 

49492-00 rpr 1st ingun hrna preterm inft ncrc8 $553.70 

49495-00 rpr 1st ingun hrna full term inft ncrc8 $341.25 

49520-00 rpr recrt ingun hrna any age rdc $390.00 

49521-00 rpr recrt ingun hrna any age ncrc8 $394.88 

49525-00 rpr ingun hrna sliding any age $390.00 

49540-00 rpr lmbr hrna $390.00 

49550-00 rpr 1st fem hrna any age rdc $341.25 

49553-00 rpr 1st fem hrna any age ncrc8 $385.13 

49555-00 rpr recrt fem hrna rdc $438.75 

49557-00 rpr recrt fem hrna ncrc8 $412.43 

49560-00 repair first abdominal wall hernia $438.75 

71

Procedure & 


Tarifas 



49561-00 rpr 1st incal/vnt hrna ncrc8 $465.08 

49565-00 rpr recrt incal/vnt hrna rdc $487.50 

49566-00 rpr recrt incal/vnt hrna ncrc8 $491.40 

49568-00 implant mesh opn hernia rpr/debridement closure $206.70 

49570-00 rpr epigstr hrna rdc spx $341.25 

49572-00 rpr epigstr hrna ncrc8 $329.55 

49580-00 rpr umbilical hrna < 5 yrs rdc $292.50 

49582-00 rpr umbilical hrna rdc $307.13 

49587-00 rpr umbilical hrna age 5 yrs/> ncrc8 $342.23 

49590-00 rpr spigelian hrna $370.50 

49600-00 rpr sm omphalocele w/prim clsr $390.00 

49605-00 rpr lg omphalocele/gastroschisis +-prosth $624.00 

49606-00 rpr lg omphalocele/gastroschisis rmvl prosth $633.75 

49610-00 rpr omphalocele gross typ opration 1st stg $487.50 

49611-00 rpr omphalocele gross typ opration 2nd stg $487.50 

49650-00 laps surg rpr 1st ingun hrna $456.30 

49651-00 laps surg rpr recrt ingun hrna $491.40 

49652-00 laps repair hernia except incal/ingun reducible $504.56 

49653-00 lap rpr hrna xcpt incal/ingun ncrc8/strangulated $630.92 

49654-00 laparoscopy repair incisional hernia reducible $580.03 

49655-00 laps rpr incisional hernia ncrc8/strangulated $698.49 

49656-00 laps rpr recurrent incisional hernia reducible $581.78 

49657-00 laps rpr recurrent incal hrna ncrc8/strangulated $840.65 

49900-00 sec abdominal wall suture evisceration/dehsn $195.00 

49904-00 omental flap xtr-abdl $963.50 

50010-00 rnl expl x necessitating oth spec px $585.00 

50020-00 drg prirnl/rnl absc opn $487.50 

50021-00 drg prirnl/rnl absc prq $343.10 

50040-00 nfros nfrot w/drg $780.00 

50045-00 nfrot w/expl $780.00 

50060-00 nephrolithotomy rmvl st1 $780.00 

50065-00 nephrolithotomy secondary for calculus $897.00 

50070-00 nephrolithotomy comp cgen kdn abnormality $897.00 

50075-00 nephrolithotomy rmvl lg staghorn st1 $936.00 

50080-00 prq nephrostolithotomy/pyelostolithotomy up 2 cm $1,218.75 

50081-00 prq nephrostolithotomy/pyelostolithotomy > 2 cm $1,345.50 

50100-00 trnsxj/rpsg aberrant rnl vsl spx $682.50 

50120-00 plot w/expl $682.50 

50125-00 plot w/drg pyelostomy $682.50 

50130-00 plot w/rmvl st1 $682.50 

50135-00 plot comp $958.23 

50200-00 rnl bx prq trocar/ndl $159.90 

50205-00 rnl bx surg expos kdn $302.25 

50220-00 nfrct w/prtl urtrec any opn rib rescj $780.00 

50225-00 nfrct w/prtl urtrec any opn rib rescj comp $897.00 

50230-00 nfrct w/prtl urtrec any opn rib rescj rad $965.25 

50234-00 nfrct w/tot urtrec&bldr cuff thru sm inc $975.00 

50236-00 nfrct tot urtrec&bldr cuff thru sep inc $975.00 

50240-00 nfrct prtl $780.00 

72

Procedure & 


Tarifas 



50280-00 exc/unroofing cst kdn $682.50 

50290-00 exc prinephric cst $618.45 

50382-00 rmvl&rplcmt intly dwelling urtrl stent $243.17 

50384-00 rmvl intly dwelling urtrl stent $221.32 

50385-00 remove & replace int dwell ureteral stent trurl $249.60 

50386-00 remove int dwell ureteral stent transurethral $160.88 

50387-00 rmvl&rplcmt xtrnlly accessible urtrl stent $88.15 

50389-00 rmvl nfros tube req fluor gid $48.56 

50390-00 aspir&/njx rnl cst/pelvis ndl prq $48.75 

50391-00 instlj agt rnl pelvis&/urtr thru tube $93.89 

50392-00 intro intracath/cath in rnl pelvis drg&/njx prq $87.75 

50393-00 intro urtrl cath/stent thru pelvis drg&/njx prq $156.00 

50394-00 njx px plog thru tube/cath $9.75 

50395-00 intro gd pelvis&/urtr w/dilat nfros trc $195.00 

50396-00 manometric stds thru tube/ndwellg urtrl cath $9.75 

50398-00 chng nfros/pyelostomy tube $9.75 

50400-00 plop rnl pelvis smpl $780.00 

50405-00 plop rnl pelvis comp $965.25 

50500-00 nephrorrhaphy sutr kdn wnd/inj $780.00 

50520-00 clsr nephrocutan/pyelocutan fstl $780.00 

50525-00 clsr nephrovisc fstl w/visc rpr abdl appr $897.00 

50526-00 clsr nephrovisc fstl w/visc rpr thrc appr $897.00 

50540-00 symphysiotomy horseshoe kdn +-plop uni/bi $975.00 

50541-00 laps abltj rnl csts $1,095.56 

50542-00 laps abltj rnl mass les w/intraop us $1,382.06 

50543-00 laps prtl nfrct $1,765.09 

50544-00 laps plop $1,498.77 

50545-00 laps radical nfrct $2,632.50 

50546-00 laps nfrct w/prtl urtrec $1,421.99 

50547-00 laps don nfrct from liv don $877.50 

50548-00 laps nfrct w/tot urtrec $2,632.50 

50551-00 rnl ndsc nfros/pyelostomy $82.88 

50553-00 rnl ndsc nfros/pyelostomy urtrl cathj $97.50 

50555-00 rnl ndsc nfros/pyelostomy bx $97.50 

50557-00 rnl ndsc nfros/pyelostomy fulg&/inc +-bx $102.38 

50561-00 rnl ndsc nfros/pyelostomy rmvl fb/st1 $102.38 

50562-00 rnl ndsc nfros/pyelostomy rescj tum $412.74 

50570-00 rnl ndsc nfrot/plot $48.75 

50572-00 rnl ndsc nfrot/plot w/urtrl cathj +-dilat urtr $58.50 

50574-00 rnl ndsc nfrot/plot bx $58.50 

50575-00 rnl ndsc nfrot/plot w/endoplot $585.00 

50576-00 rnl ndsc nfrot fulguration&/inc +-bx $68.25 

50580-00 rnl ndsc nfrot/plot w/rmvl fb/st1 $68.25 

50590-00 lithotrp xtrcorp shock wave $1,218.75 

50600-00 urtrotomy w/expl/drg spx $682.50 

50605-00 ureterotomy insertion indwelling stent all types $711.75 

50610-00 urtrolithotomy upper one-third ureter $682.50 

50620-00 urtrolithotomy middle one-third ureter $672.75 

50630-00 urtrolithotomy lower one-third ureter $780.00 

50650-00 urtrec w/bldr cuff spx $741.00 

73

Procedure & 


Tarifas 



50660-00 urtrec tot ectopic urtr cmbn appr $780.00 

50684-00 njx urtrg/urtroplog thru urtrost/urtrl cath $9.75 

50686-00 manometric stds thru urtrost/ndwellg urtrl cath $9.75 

50688-00 chng urtrost tube/xtrnlly accessible stent ileal $9.75 

50690-00 njx visualization ileal conduit&/urtroplog $9.75 

50700-00 urtroplasty plstc opration urtr $780.00 

50715-00 urtrolss +-rpsg urtr rpr fibrosis $682.50 

50722-00 ureterolysis for ovarian vein syndrome $594.75 

50725-00 urtrolss retrocaval urtr w/reanast $877.50 

50727-00 revj ur-cutan anast $351.00 

50728-00 revj ur-cutan anast rpr fscal dfct&hrna $505.05 

50740-00 urtropyelostomy anast urtr&rnl pelvis $780.00 

50750-00 urtrocalycostomy anast urtr rnl calyx $897.00 

50760-00 urtrourtrost $780.00 

50770-00 transurtrourtrost anast urtr clat urtr $897.00 

50780-00 urtroneocstost anast 1 urtr bldr $780.00 

50782-00 urtroneocstost anast duplicated urtr bldr $873.60 

50783-00 urtroneocstost w/x10sv urtrl tailoring $898.95 

50785-00 urtroneocstost w/vesico-psoas hitch/bldr flap $897.00 

50800-00 urtrontrstm dir anast urtr int $780.00 

50810-00 urtrosigmoidostomy crtj clst int anast $1,126.13 

50815-00 urtrocolon conduit int anast $1,160.25 

50820-00 urtroileal conduit w/int anast $789.75 

50825-00 continent dvrj w/int anast w/any sgm sm&/lg int $1,140.75 

50830-00 ur undvrj $1,218.75 

50840-00 rplcmt all/part urtr int sgm w/int anast $1,126.13 

50845-00 cutan appendico-vesicostomy $877.50 

50860-00 urtrost trnsplj urtr skn $682.50 

50900-00 urtrorrhaphy sutr urtr spx $780.00 

50920-00 clsr urtrocutan fstl $741.00 

50930-00 clsr urtrovisc fstl w/visc rpr $897.00 

50940-00 delig urtr $741.00 

50945-00 laps urtrolithotomy $680.06 

50947-00 laps urtroneocstost w/cstsc&urtrl stent plmt $924.89 

50948-00 laps urtroneocstost w/o cstsc&urtrl stent plmt $843.28 

50951-00 ndsc thru urtrost $82.88 

50953-00 ndsc urtrost w/urtrl cathj $97.50 

50955-00 ndsc thru urtrost bx $97.50 

50957-00 ndsc thru urtrost fulg&/inc +-bx $102.38 

50961-00 ndsc thru urtrost rmvl fb/st1 $102.38 

50970-00 ndsc thru urtrotomy $39.00 

50972-00 ndsc thru urtrotomy urtrl cathj +-dilat $58.50 

50974-00 ndsc thru urtrotomy bx $58.50 

50976-00 ndsc thru urtrotomy fulg&/inc +-bx $68.25 

50980-00 ndsc thru urtrotomy rmvl fb/st1 $68.25 

51020-00 cstotomy/cstost fulg&/insj radact matrl $585.00 

51030-00 cstotomy/cstost cryosurg dstrj intravesical les $585.00 

51040-00 cstost cstotomy w/drg $487.50 

51045-00 cstotomy w/insj urtrl cath/stent spx $404.63 

51050-00 cstolithotomy cstotomy w/rmvl st1 $487.50 

74

Procedure & 


Tarifas 



51060-00 transvesical urtrolithotomy $672.75 

51065-00 cstotomy w/st1 basket xtrj&/fragmentation $458.25 

51080-00 drg privesical/prevesical space absc $487.50 

51100-00 aspiration bladder needle $48.75 

51101-00 aspiration bladder trocar/intracatheter $48.75 

51102-00 aspiration bladder insert suprapubic catheter $97.50 

51500-00 exc urachal cst/sinus +-umbilical hrna rpr $536.25 

51520-00 cystotomy simple excision vesical neck $585.00 

51525-00 cystotomy excise bladder diverticulum 1/multiple $682.50 

51530-00 cystotomy excision bladder tumor $585.00 

51535-00 cystotomy excise/incise/repair ureterocele $594.75 

51550-00 cstc prtl smpl $682.50 

51555-00 cstc prtl comp $741.00 

51565-00 cstc prtl w/rimpltj urtr in bldr urtroneocstost $780.00 

51570-00 cstc compl spx $975.00 

51575-00 cstc compl w/bi pel lmphadec $1,287.00 

51580-00 cstc compl w/trnspljs $1,170.00 

51585-00 cstc compl w/trnspljs w/lmphadec $1,560.00 

51590-00 cstc compl w/urtroileal conduit/bldr w/int anast $1,365.00 

51595-00 cstc compl w/conduit/sigmoid bldr pel lmphadec $1,930.50 

51596-00 cstc compl w/continent dvrj opn neobldr $1,228.50 

51597-00 pel exntj compl mal $1,170.00 

51600-00 njx cstograpy/voiding urethrocstograpy $9.75 

51605-00 njx&plmt chain c+&/urethrocstograpy $9.75 

51610-00 njx rtrgr urethrocstograpy $9.75 

51700-00 bldr irrigation smpl lvg&/instlj $9.75 

51701-00 insj non-ndwellg bldr cath $19.31 

51705-00 chng cstost tube smpl $9.75 

51710-00 chng cstost tube comp $48.75 

51715-00 ndsc njx implt matrl urt&/bldr nck $175.50 

51720-00 bldr instlj anticarcinogenic agt $29.25 

51725-00 smpl cstometrogram $34.13 

51725-26 smpl cstometrogram $40.40 

51725-TC smpl cstometrogram $90.91 

51726-00 bladder pressure measurement during filling $48.75 

51726-26 bladder pressure measurement during filling $50.70 

51726-TC bladder pressure measurement during filling $114.08 

51727-00 complex cystometrogram urethral press profile $165.75 

51727-26 complex cystometrogram urethral press profile $66.30 

51727-TC complex cystometrogram urethral press profile $99.45 

51728-00 complex cystometrogram voiding pressure studies $165.75 

51728-26 complex cystometrogram voiding pressure studies $66.30 

51728-TC complex cystometrogram voiding pressure studies $99.45 

51729-00 complx cystometro w/void press&urethral profile $180.38 

51729-26 complx cystometro w/void press&urethral profile $72.15 

51729-TC complx cystometro w/void press&urethral profile $108.23 

51736-00 smpl uroflometry $19.50 

51736-26 smpl uroflometry $5.46 

51736-TC smpl uroflometry $12.29 

51741-00 cplx uroflometry $29.25 

75

Procedure & 


Tarifas 



51741-26 cplx uroflometry $10.45 

51741-TC cplx uroflometry $23.52 

51784-00 emg stds anal/urtl sphnctr oth/thn ndl $68.25 

51784-26 emg stds anal/urtl sphnctr oth/thn ndl $23.40 

51784-TC emg stds anal/urtl sphnctr oth/thn ndl $52.65 

51785-00 ndl emg stds emg anal/urtl sphnctr any tq $39.00 

51785-26 ndl emg stds emg anal/urtl sphnctr any tq $24.96 

51785-TC ndl emg stds emg anal/urtl sphnctr any tq $56.16 

51792-00 stimulus evoked rspse $48.75 

51792-26 stimulus evoked rspse $21.06 

51792-TC stimulus evoked rspse $47.39 

51797-00 void pressure studies intraabdominal $186.15 

51797-26 void pressure studies intraabdominal $27.30 

51797-TC void pressure studies intraabdominal $61.43 

51798-00 meas post-voiding residual urine&/bldr cap $12.95 

51800-00 cstoplasty/cstourtp plstc any $780.00 

51820-00 cstourtp w/uni/bi urtroneocstost $1,121.25 

51840-00 ant vesicourethropexy/urethropexy smpl $390.00 

51841-00 ant vesicourethropexy/urethropexy comp $672.75 

51845-00 abdomino-vag vesical nck ssp +-ndsc ctrl $565.50 

51860-00 cstorr sutr bldr wnd inj/rpt smpl $585.00 

51865-00 cstorr sutr bldr wnd inj/rpt comp $741.00 

51880-00 clsr cstost spx $292.50 

51900-00 clsr vesicovag fstl abdl appr $585.00 

51920-00 clsr vesicouterine fstl $741.00 

51925-00 clsr vesicouterine fstl w/hyst $741.00 

51940-00 clsr exstrophy bldr $1,072.50 

51960-00 enterocstoplasty w/intstinal anast $1,126.13 

51980-00 cutan vesicostomy $741.00 

51990-00 laparoscopy urethral suspension stress incont $527.38 

51992-00 laparoscopy sling operation stress incont $543.17 

52000-00 cystourethroscopy $48.75 

52001-00 csto w/irrg&evac mlt obstructing clots $101.43 

52005-00 scope bladder insert tube for injection $78.00 

52007-00 csto w/urtrl cathj brush bx urtr&/rnl pelvis $146.25 

52010-00 csto w/ejaculatory dux cathj $58.50 

52204-00 cystourethroscopy with biopsy $263.25 

52214-00 scope bladder destruction of lesions $102.38 

52224-00 scope bladder removal of lesions small $97.50 

52234-00 scope bladder removal of tumors small $243.75 

52235-00 scope bladder removal of tumors medium $458.25 

52240-00 scope bladder w/ removal of tumors large $672.75 

52250-00 csto insj radact sbst +-bx/fulg $292.50 

52260-00 scope bladder opening of bladder $146.25 

52265-00 cysto bladder dilat intrstl cystitis local $58.50 

52270-00 csto int urethrotomy female $195.00 

52275-00 csto int urethrotomy male $195.00 

52276-00 csto dir vis int urethrotomy $390.00 

52277-00 csto rescj xtrnl sphnctr $224.25 

52281-00 csto calibration dilat urtl strix/stenosis $117.00 

76

Procedure & 


Tarifas 



52282-00 cystourethroscopy insertion perm urethral stent $290.45 

52283-00 csto strd njx in strix $102.38 

52285-00 scope bladder open narrowed female urethra $117.00 

52290-00 csto urtrl meatotomy uni/bi $195.00 

52300-00 csto orthotopic urtrocele uni/bi $195.00 

52301-00 csto ectopic urtrocele uni/bi $245.70 

52305-00 csto inc/rescj orifice bldr diverticulum 1/mlt $224.25 

52310-00 scope bladder w/simple removal stone & stent $195.00 

52315-00 scope bladder w/complex removal stone & stent $292.50 

52317-00 litholapaxy smpl/sm < 2.5 cm $487.50 

52318-00 litholapaxy comp/lg > 2.5 cm $516.75 

52320-00 csto rmvl urtrl st1 $292.50 

52325-00 csto fragmentation urtrl st1 $575.25 

52330-00 csto mnpj w/o rmvl urtrl st1 $195.00 

52332-00 scope bladder & ureter insert stent into ureter $195.00 

52334-00 csto insj urtrl gd wire prq nfros rtrgr $224.25 

52341-00 csto w/tx urtrl strix $228.36 

52342-00 csto w/tx urtropel junct strix $245.66 

52343-00 csto w/tx intra-rnl strix $271.05 

52344-00 csto w/urtroscopy w/tx urtrl strix $291.17 

52345-00 csto w/urtroscopy w/tx urtropel junct strix $309.23 

52346-00 csto w/urtroscopy w/tx intra-rnl strix $346.11 

52351-00 csto w/urtroscopy&/pyeloscopy dx $235.95 

52352-00 scope bladder & ureter remove or move stones $438.75 

52353-00 scope bladder & ureter break up kidney stone $544.05 

52354-00 csto/pyeloscopy bx&/fulg pel les $295.43 

52355-00 csto/pyeloscopy rescj pel tum $399.75 

52400-00 csto inc fulg/rescj urtl valves/folds $379.41 

52402-00 csto w/trurl rescj/inc ejaculatory duxs $187.79 

52450-00 trurl inc prst8 $291.53 

52500-00 surgery on bladder neck through urethra $487.50 

52601-00 trurl electrosurg rescj prst8 ctrl bld compl $780.00 

52630-00 trurl rescj residual/regrowth obstr prst8 tissue $741.00 

52640-00 opening of postoperative bladder neck narrowing $370.50 

52647-00 laser coagulation of prostate for urine flow $416.81 

52648-00 laser vaporization of prostate for urine flow $702.00 

52649-00 laser enucleation prostate w morcellation $631.80 

52700-00 trurl drg prostatic absc $292.50 

53000-00 urtt/urts xtrnl spx pendulous urt $97.50 

53010-00 urtt/urts xtrnl spx prnl urt xtrnl $243.75 

53020-00 meatotomy cutting meatus spx xcp inft $29.25 

53025-00 meatotomy cutting meatus spx inft $58.50 

53040-00 drg dp priurtl absc $97.50 

53060-00 drg of skene's gland absc or cyst $48.75 

53080-00 drg prnl ur xtrvasation uncomp spx $146.25 

53085-00 drg prnl ur xtrvasation comp $487.50 

53200-00 bx urt $78.00 

53210-00 urethrectomy tot w/cstost female $536.25 

53215-00 urethrectomy tot w/cstost male $672.75 

53220-00 exc/fulguration carc urt $331.50 

77

Procedure & 


Tarifas 



53230-00 exc urtl diverticulum spx female $487.50 

53235-00 exc urtl diverticulum spx male $487.50 

53240-00 marsupialization urtl diverticulum male/female $146.25 

53250-00 exc of bulbourtl gland $121.88 

53260-00 exc/fulguration urtl polyp dstl urt $48.75 

53265-00 exc/fulguration urtl caruncle $68.25 

53270-00 exc or fulguration skene's glands $68.25 

53275-00 exc/fulguration urtl prolapse $117.00 

53400-00 urethroplasty 1st stg fistula/diverticulum/strix $370.50 

53405-00 urtp 2nd stg w/ur dvrj $516.75 

53410-00 urtp one-stg rcnstj male ant urt $594.75 

53415-00 urtp transpubic/prnl 1 stg rcnstj/rpr urt $731.25 

53420-00 urtp 2-stg rcnstj/rpr urt 1st stg $741.00 

53425-00 urtp 2-stg rcnstj/rpr urt 2nd stg $741.00 

53430-00 urtp rcnstj female urt $516.75 

53431-00 urtp w/tubularization post urt&/lwr bldr $770.25 

53440-00 sling opration corrj male ur incont $741.00 

53442-00 rmvl/revj sling male ur incont $253.50 

53444-00 insj tandem cuff $519.48 

53445-00 insj nfltbl urtl/bldr nck sphnctr $741.00 

53446-00 rmvl nfltbl urtl/bldr nck sphnctr $424.71 

53447-00 rmvl&rplcmt nfltbl nck sphnctr sm sess $526.50 

53448-00 rmvl&rplcmt nfltbl nck sphnctr thru infct fld $823.10 

53449-00 rpr nfltbl urtl/bldr nck sphnctr $526.50 

53450-00 urethromeatoplasty w/mucosal advmnt $146.25 

53460-00 urethromeatoplasty w/prtl exc dstl urtl sgm $117.00 

53500-00 urethrolss trvg sec opn w/csto $508.95 

53502-00 urtorr sutr urtl wnd/inj female $253.50 

53505-00 urtorr sutr urtl wnd/inj pen $370.50 

53510-00 urtorr sutr urtl wnd/inj prnl $516.75 

53515-00 urtorr sutr urtl wnd/inj prostatomembranous $741.00 

53520-00 clsr urethrostomy/urethroq fstl male spx $292.50 

53600-00 dilat urtl strix dilator male 1st $29.25 

53601-00 dilat urtl strix dilator male sbsq $14.63 

53605-00 dilat urtl strix/vesical nck dilator male anes $51.68 

53620-00 dilat urtl strix filiform&follwr male 1st $48.75 

53621-00 dilat urtl strix filiform&follwr male sbsq $24.38 

53660-00 dilat female urt w/suppository&/instlj 1st $19.50 

53661-00 dilat female urt w/suppository&/instlj sbsq $9.75 

53665-00 dilat female urt general/cndj spi anes $30.71 

53850-00 trurl dstrj prst8 tiss microwave thermoth $2,281.50 

53852-00 trurl dstrj prst8 tiss rf thermoth $2,018.25 

53855-00 insert temp prostatic ureth stent w/measurement $290.55 

54000-00 slitting prepuce dorsal/lat spx nb $29.25 

54001-00 slitting prepuce dorsal/lat spx xcp nb $58.50 

54015-00 i&d pns dp $48.75 

54050-00 dstrj les pns smpl chem $19.50 

54055-00 dstrj les pns smpl eltrdsiccation $29.25 

54056-00 dstrj les pns smpl cryosurg $35.10 

54057-00 dstrj les pns smpl laser surg $35.10 

78

Procedure & 


Tarifas 



54060-00 dstrj les pns smpl surg exc $39.00 

54065-00 dstrj les pns x10sv $112.13 

54100-00 bx pns spx $29.25 

54105-00 bx pns dp struxs $58.50 

54110-00 exc pen plaque $302.25 

54111-00 exc pen plaque grf 5 cm length $536.25 

54112-00 exc pen plaque grf > 5 cm length $633.75 

54115-00 rmvl fb from dp pen tiss $185.25 

54120-00 amp pns prtl $390.00 

54125-00 amp pns compl $585.00 

54130-00 amp pns rad w/bi inguinofem lmphadec $975.00 

54135-00 amp pns rad bi pel lmphadec $1,199.25 

54150-00 circumcision w/clamp/oth dev w/block $29.25 

54160-00 circumcision neonate $97.50 

54161-00 circumcision >28 days $107.25 

54162-00 lss/exc pen post-circumcision ads $139.52 

54163-00 rpr incompl circumcision $133.38 

54164-00 frenulotomy pns $115.83 

54200-00 njx peyronie $19.50 

54205-00 njx peyronie expos plaque $302.25 

54220-00 irrigation corpora cavernosa priapism $165.75 

54230-00 injection corpora cavernosograpy $35.10 

54231-00 dynamic cavernosometry njx vasoactive drugs $131.63 

54235-00 njx c/p/a cavernosa w/pharmacologic agt $39.00 

54240-00 pen plethysmograpy $56.55 

54240-26 pen plethysmograpy $13.57 

54240-TC pen plethysmograpy $22.62 

54250-00 nocturnal pen tumescence&/rgdity tst $72.15 

54250-26 nocturnal pen tumescence&/rgdity tst $17.32 

54250-TC nocturnal pen tumescence&/rgdity tst $28.86 

54300-00 pns straightening chordee $292.50 

54304-00 pns corrj chordee 1st stg hypspad rpr $516.75 

54308-00 urtp 2nd stg hypspad rpr < 3 cm $516.75 

54312-00 urtp 2nd stg hypspad rpr > 3 cm $575.25 

54316-00 urtp 2nd stg hypspad rpr skn grf $643.50 

54318-00 urtp 3rd stg hypspad rpr rls pns $331.50 

54322-00 1 stg dstl hypspad rpr w/smpl meatal advmnt $617.18 

54324-00 1 stg dstl hypspad rpr w/urtp skn flaps $516.75 

54326-00 1 stg dstl hypspad rpr urtp skn flaps&moblj $764.40 

54328-00 1 stg dstl hypspad rpr w/x10sv dsj $575.25 

54332-00 1 stg prox pen/penoscrotal hypspad rpr $741.00 

54336-00 1 stg prnl hypspad rpr req x10sv dsj skn grf $1,021.41 

54340-00 rpr hypspad complctjs clsr inc/exc smpl $253.50 

54344-00 rpr hypspad complctjs moblj flaps&urtp $448.50 

54348-00 rpr hypspad complctjs x10sv dsj&urtp flap/grf $482.63 

54352-00 rpr hypspad cripple req x10sv dsj&exc $877.50 

54360-00 plstc pns correct angulation $419.25 

54380-00 plstc pns epspad dstl sphnctr $487.50 

54385-00 plstc pns epspad dstl sphnctr w/incont $604.50 

54390-00 plstc pns epspad dstl sphnctr w/exstrophy bldr $838.50 

79

Procedure & 


Tarifas 



54401-00 insj pen prosth nfltbl self-contained $680.55 

54405-00 insj multi-component nfltbl pen prosth $1,053.00 

54406-00 rmvl nfltbl pen prosth w/o rplcmt prosth $580.13 

54408-00 rpr component multi-component nfltbl pen prosth $580.13 

54410-00 rmvl&rplcmt nfltbl pen prosth sm sess $580.13 

54411-00 rmvl&rplcmt nfltbl pen prosth thru infct fld $730.94 

54415-00 rmvl non-nfltbl/nfltbl pen prosth w/o rplcmt $354.90 

54416-00 rmvl&rplcmt non-nfltbl/nfltbl prosth sm sess $354.90 

54417-00 rmvl&rplcmt non-nfltbl/nfltbl pen infct sm sess $644.84 

54420-00 c/p/a cavernosa-saphenous vein shunt uni/bi $351.00 

54430-00 c/p/a cavernosa-corpus spongiosum shunt uni/bi $400.73 

54435-00 corpora cavernosa-glans penis fstlj priapism $351.00 

54440-00 plastic operation penis injury $487.50 

54450-00 foreskn mnpj w/lss preputial ads&stretching $78.00 

54500-00 bx tstis ndl spx $19.50 

54505-00 bx tstis incal spx $97.50 

54512-00 exc xtrparenchymal les tstis $351.98 

54520-00 orchiectomy smpl scrotal/ingun appr $731.25 

54522-00 orchiectomy prtl $260.06 

54530-00 orchiectomy rad tum ingun appr $487.50 

54535-00 orchiectomy rad tum w/abdl expl $526.50 

54550-00 expl undescended tstis ingun/scrotal area $302.25 

54560-00 expl undescended tstis w/abdl expl $458.25 

54600-00 rdctj torsion tstis +-fixj clat tstis $292.50 

54620-00 fixj clat tstis spx $195.00 

54640-00 orchiopexy ingun appr +-hrna rpr $487.50 

54650-00 orchiopexy abdl appr intra-abdl tstis $513.34 

54660-00 insj tsticular prosth spx $146.25 

54670-00 sutr/rpr tsticular inj $302.25 

54680-00 trnsplj tstis thi $370.50 

54690-00 laparoscopy surgical orchiectomy $528.45 

54692-00 laparoscopy orchiopexy intra-abdominal testis $548.44 

54700-00 i&d epididymis tstis&/scrotal space $29.25 

54800-00 bx epididymis ndl $19.50 

54830-00 exc local les epididymis $97.50 

54840-00 exc sprmatocele +-epididymectomy $292.50 

54860-00 epididymectomy uni $292.50 

54861-00 epididymectomy bi $438.75 

54865-00 exploration epididymis w/wo biopsy $97.50 

54900-00 epididymovasostomy anast epididymis uni $390.00 

54901-00 epididymovasostomy anast epididymis bi $487.50 

55000-00 pnxr aspir hydrocele tunica vagis +-njx med $19.50 

55040-00 exc hydrocele uni $292.50 

55041-00 exc hydrocele bi $438.75 

55060-00 rpr tunica vagis hydrocele bottle typ $195.00 

55100-00 drg scrotal wall absc $19.50 

55110-00 scrotal expl $214.50 

55120-00 rmvl fb scrotum $204.75 

55150-00 rescj scrotum $321.75 

55175-00 scrotoplasty smpl $292.50 

80

Procedure & 


Tarifas 



55180-00 scrotoplasty comp $585.00 

55200-00 vasotomy cannulization +-inc vas uni/bi spx $146.25 

55250-00 vasect uni/bi spx w/po semen xm $146.25 

55300-00 vasotomy vasograms uni/bi $146.25 

55400-00 vasovasostomy vasovasorrhaphy $403.65 

55450-00 lig prq vas deferens uni/bi spx $179.89 

55500-00 exc hydrocele sprmatic cord uni spx $292.50 

55520-00 exc les sprmatic cord spx $224.25 

55530-00 exc varicocele/lig sprmatic veins spx $292.50 

55535-00 exc varicocele/lig sprmatic veins abdl $351.00 

55540-00 exc varicocele/lig veins w/hrna rpr $390.00 

55550-00 laps lig sprmatic veins varicocele $268.13 

55600-00 vesiculotomy $302.25 

55605-00 vesiculotomy comp $390.00 

55650-00 vesiculectomy any appr $741.00 

55680-00 exc mullerian dux cst $277.88 

55700-00 prostate needle biopsy any approach $48.75 

55705-00 bx prst8 incal any appr $292.50 

55706-00 bx prostate strtctc saturation sampling img gid $307.13 

55720-00 prostatotomy xtrnl drg absc smpl $292.50 

55725-00 prostatotomy xtrnl drg absc comp $390.00 

55801-00 prst8ect prnl stot $780.00 

55810-00 prst8ect prnl rad $975.00 

55812-00 prst8ect prnl rad lymph node bx $1,199.25 

55815-00 prst8ect prnl rad bi pel lmphadec $1,560.00 

55821-00 prst8ect suprapubic stot 1/2 stgs $780.00 

55831-00 prst8ect retropubic stot $780.00 

55840-00 prst8ect retropubic rad +-nrv sparing $975.00 

55842-00 prst8ect retropubic rad lymph node bx $1,033.50 

55845-00 prst8ect retropubic rad w/bi pel lmphadec $1,287.00 

55860-00 expos prst8 any appr insj radact sbst $390.00 

55862-00 expos prst8 insj radact node bx $419.25 

55865-00 expos prst8 insj radact bi pel lmphadec $575.25 

55866-00 laps prstect retropubic rad w/nrv sparing robot $1,116.18 

55875-00 tprnl plmt ndl/caths into prst8 radj insj $375.57 

55876-00 place interstitial dev radiation tx prostate 1+ $77.22 

55920-00 placement needle pelvic organ radioelement appl $276.41 

56405-00 i&d vulva/prnl absc $61.43 

56420-00 i&d of bartholin's gland absc $48.75 

56440-00 marsupialization bartholin's gland cyst $146.25 

56441-00 lss labial ads $89.70 

56442-00 hymenotomy simple incision $58.50 

56501-00 dstrj les vulva smpl $48.75 

56515-00 dstrj les vulva x10sv $165.75 

56605-00 bx vulva/pr spx 1 les $29.25 

56606-00 bx vulva/pr spx ea sep addl les $8.78 

56620-00 vulvectomy smpl prtl $390.00 

56625-00 vulvectomy smpl compl $536.25 

56630-00 vulvectomy rad prtl $711.75 

56631-00 vulvectomy rad prtl uni inguinofem lmphadec $1,053.00 

81

Procedure & 


Tarifas 



56632-00 vulvectomy rad prtl bi inguinofem lmphadec $1,140.75 

56633-00 vulvectomy rad compl $965.25 

56634-00 vulvectomy rad compl uni inguinofem lmphadec $1,184.63 

56637-00 vulvectomy rad compl bi inguinofem lmphadec $1,228.50 

56640-00 vulvectomy rad compl iliac&pel lmphadec $975.00 

56700-00 prtl hymenectomy/revj hymenal ring $97.50 

56740-00 exc bartholin's gland or cyst $195.00 

56800-00 plstc rpr introitus $185.25 

56810-00 prineoplasty rpr pr nonobal spx $195.00 

56820-00 colposcopy vulva $82.49 

56821-00 colposcopy vulva w/bx $106.18 

57000-00 colpotomy w/expl $146.25 

57010-00 colpotomy w/drg pel absc $156.00 

57020-00 colpocnts spx $39.00 

57022-00 i&d vag hmtma obal/postpartum $122.85 

57023-00 i&d vag hmtma non-obal $200.07 

57061-00 dstrj vag les smpl $39.00 

57065-00 dstrj vag les x10sv $156.00 

57100-00 bx vag mucosa smpl spx $29.25 

57105-00 bx vag mucosa x10sv req sutr $165.75 

57106-00 vagnc prtl rmvl vag wall $183.40 

57107-00 vagnc prtl rmvl vag wall paravag tiss $606.35 

57109-00 vagnc prtl rmvl vag wall w/bi tot pel lmphadec $763.43 

57110-00 vagnc compl rmvl vag wall $487.50 

57111-00 vagnc compl rmvl vag wall paravag tiss $763.43 

57112-00 vagnc compl rmvl vag wall tot pel lmphadec bx $814.32 

57120-00 colpocleisis le fort typ $341.25 

57130-00 exc vag septum $224.25 

57135-00 exc vag cst/tum $165.75 

57150-00 irrg vag&/appl medicament disease $9.75 

57155-00 insj uterine tandem&/vag ovoids $272.03 

57156-00 insj vaginal radiation device $93.87 

57160-00 fitg&insj pessary/oth intravag support dev $9.75 

57170-00 dphrm/crv cap fitg w/instructions $9.75 

57180-00 intro any hemostatic agt/pack vag hemrrg spx $29.25 

57200-00 colporrhaphy sutr inj vag $195.00 

57210-00 colpoprineorrhaphy sutr inj vag&/pr $214.50 

57220-00 plstc urtl sphnctr vag appr $292.50 

57230-00 plstc rpr urethrocele $292.50 

57240-00 ant colporrhaphy rpr cstocele +-rpr urethrocele $341.25 

57250-00 post colporrhaphy rpr rectocele +-prineorrhaphy $292.50 

57260-00 cmbn anteropost colporrhaphy $487.50 

57265-00 cmbn anteropost colporrhaphy w/ntrcl rpr $516.75 

57267-00 insj mesh/prosth pel floor dfct ea sit $190.42 

57268-00 rpr ntrcl vag appr spx $438.75 

57270-00 rpr ntrcl abdl appr spx $438.75 

57280-00 colpopexy abdl appr $438.75 

57282-00 colpopexy vag xtr-prtl appr $434.85 

57283-00 colpopexy vag intra-prtl appr $451.91 

57284-00 paravaginal defect repair open abdominal appr $614.25 

82

Procedure & 


Tarifas 



57285-00 paravaginal defect repair vaginal approach $416.81 

57287-00 rmvl/revj sling stress incontinence $433.49 

57288-00 sling operation stress incontinence $594.75 

57289-00 preyra px w/ant colporrhaphy $458.25 

57291-00 constj artif vag w/o grf $468.00 

57292-00 constj artif vag w/grf $575.25 

57295-00 revj rmvl prostc vag grf vag appr $346.61 

57296-00 revj w/rmvl prosthetic vag grf abd appro $632.68 

57300-00 clsr rectovag fstl vag/transanal appr $565.50 

57305-00 clsr rectovag fstl abdl appr $697.13 

57307-00 clsr rectovag fstl abdl appr w/concomitant clst $770.25 

57308-00 clsr rectovag fstl tprnl prnl bdy rcnstj $472.10 

57310-00 clsr urethrovag fstl $487.50 

57311-00 clsr urethrovag fstl w/bulbocavernosus trnspl $570.38 

57320-00 clsr vesicovag fstl vag appr $565.50 

57330-00 clsr vesicovag fstl transvesical&vag appr $487.50 

57400-00 dilation vagina w/anesthesia other than local $19.50 

57410-00 pelvic examination w/anesthesia other than local $19.50 

57415-00 removal impacted vag fb spx w/anes oth/thn local $131.63 

57420-00 colposcopy entire vag w/cervix if present $197.44 

57421-00 colposcopy entire vag w/cervix bx $250.09 

57423-00 paravaginal defect repair laparoscopic approach $526.50 

57425-00 laps surg colpopexy ssp vag apex $614.25 

57426-00 revision prosthetic vaginal graft laparoscopic $515.78 

57452-00 colposcopy cervix upr/adj vag $195.00 

57454-00 colposcopy cervix bx cervix&endocrv curtg $253.50 

57455-00 colposcopy cervix vag bx cervix $250.09 

57456-00 colposcopy cervix vag endocrv curtg $232.54 

57460-00 colposcopy cervix vag loop eltrd bx cervix $394.88 

57461-00 colposcopy cervix vag eltrd conization cervix $416.81 

57500-00 biopsy cervix 1/mlt or excision of lesion $29.25 

57505-00 endocrv curtg x done as part dilat&curtg $19.50 

57510-00 caut cervix electro/thermal $29.25 

57511-00 caut cervix cryocaut 1st/repeat $82.88 

57513-00 caut cervix laser abltj $117.00 

57520-00 conization cervix +-d&c rpr knife/laser $195.00 

57522-00 conization cervix +-d&c rpr eltrd exc $184.28 

57530-00 trachelectomy cervicectomy amp cervix spx $195.00 

57531-00 rad trachelectomy w/bi pel lmphadec $1,118.81 

57540-00 exc crv stump abdl appr $487.50 

57545-00 exc crv stump abdl appr w/pel floor rpr $394.88 

57550-00 exc crv stump vag appr $585.00 

57555-00 exc crv stump vag appr w/ant&/post rpr $589.88 

57556-00 exc crv stump vag appr w/rpr ntrcl $546.00 

57558-00 dilation & curettage cervical stump $146.25 

57700-00 cerclage uterine cervix nonobal $224.25 

57720-00 trachelorrhaphy plstc rpr uterine cervix vag $224.25 

57800-00 dilat crv canal instrumental spx $29.25 

58100-00 endometrial bx +-endocrv bx w/o dilat spx $29.25 

58110-00 endometrial bx conjunct w/colposcopy $35.62 

83

Procedure & 


Tarifas 



58120-00 d&c dx&/ther $146.25 

58140-00 myomectomy 1-4 250 gm abdl $555.75 

58145-00 myomectomy 1-4 250 gm/< vag $546.00 

58146-00 myomectomy 5+ > 250 gm abdl $752.90 

58150-00 tah +-rmvl tube +-rmvl ovary $585.00 

58152-00 tah +-rmvl tube ovary colpo-urtcstopexy $754.65 

58180-00 supracrv abdl hyst +-rmvl tube ovary $536.25 

58200-00 tah w/prtl vagnc pel lymph node sampling $672.75 

58210-00 rad abdl hyst w/bi pel lmphadec $975.00 

58240-00 pel exntj gynecologic mal $1,984.13 

58260-00 vag hyst 250 gm/< $585.00 

58262-00 vag hyst 250 gm/< w/rmvl tube&/ovary $636.68 

58263-00 vag hyst 250 gm/< w/rmvl tube ovary w/rpr ntrcl $833.63 

58267-00 vag hyst 250 gm/< w/colpo-urtcstopexy $804.38 

58270-00 vag hyst 250 gm/< w/rpr ntrcl $672.75 

58275-00 vag hyst w/tot/prtl vagnc $697.13 

58280-00 vag hyst w/tot/prtl vagnc w/rpr ntrcl $697.13 

58285-00 vag hyst rad schauta $926.25 

58290-00 vaginal hysterectomy uterus > 250 gm $753.19 

58291-00 vag hyst > 250 gm rmvl tube&/ovary $827.48 

58292-00 vag hyst > 250 gm rmvl tube&/ovary w/rpr ntrcl $876.62 

58293-00 vag hyst > 250 gm colpo-urtcstopexy +-ndsc ctrl $910.85 

58294-00 vag hyst > 250 gm rpr ntrcl $807.30 

58321-00 artif insemination intra-crv $87.75 

58322-00 artif insemination intra-uterine $131.63 

58323-00 sprm washg artif insemination $22.43 

58340-00 cathj&intro saline nfs shg/hsg $29.25 

58346-00 insj heyman capsls clinical brachytx $286.07 

58350-00 chromotubation ovidux matrls $29.25 

58353-00 endometrial abltj thermal w/o hysteroscopic gid $157.95 

58356-00 endometrial cryoabltj us curtg $356.27 

58400-00 uterine ssp spx $390.00 

58410-00 uterine ssp presac sympth $438.75 

58520-00 hysterorrhaphy rpr rptd $390.00 

58540-00 hysteroplasty rpr uterine anomal $546.00 

58541-00 laps supracrv hyst 250 g/< $569.50 

58542-00 laps supracrv hyst 250 g/< rmvl tube/ovary $630.05 

58543-00 laps supracrv hyst >250 g $640.58 

58544-00 laps supracrv hyst >250 g rmvl tube/ovary $694.10 

58545-00 laps myomectomy exc 1-4 250 gm/< $605.48 

58546-00 laps myomectomy exc 5+ > 250 grams $762.55 

58548-00 laps w/rad hyst w/bilat lmphadec rmvl tube/ovary $1,432.96 

58550-00 laps w/vag hyst 250 gm/< $322.73 

58552-00 laps w/vag hyst 250 gm/< rmvl tube&/ovary $589.68 

58553-00 laps w/vag hyst > 250 grams $759.04 

58554-00 laps vag hyst > 250 gm rmvl tube&/ovary $750.26 

58555-00 hystsc dx spx $78.00 

58558-00 hystsc bx endometrium&/polypc +-d&c $197.44 

58559-00 hystsc lss intrauterine ads $219.38 

58560-00 hystsc div/rescj intrauterine septum $300.30 

84

Procedure & 


Tarifas 



58561-00 hystsc rmvl leiomyomata $394.88 

58562-00 hystsc rmvl impacted fb $219.38 

58563-00 hystsc endometrial abltj $221.53 

58570-00 laparoscopy w total hysterectomy uterus 250 g/< $570.38 

58571-00 laps total hysterectomy 250 g/250 g $723.59 

58573-00 laparoscopy tot hysterectomy >250 g w tube/ovary $811.69 

58600-00 lig/trnsxj flp tube abdl/vag appr uni/bi $390.00 

58605-00 lig/trnsxj flp tube abdl/vag postpartum spx $292.50 

58611-00 lig/trnsxj flp tube done tm c dlvr/surg $78.00 

58615-00 occlusion flp tube dev vag/suprapubic appr $390.00 

58661-00 laps rmvl adnexal struxs $494.78 

58662-00 laps fulg/exc ovary viscera/prtl surf $329.55 

58670-00 laps fulg oviduxs $365.63 

58671-00 laps occlusion oviduxs dev $273.55 

58672-00 laps fimbrioplasty $342.23 

58673-00 laps salpingostomy $339.30 

58700-00 salpingectomy compl/prtl uni/bi spx $438.75 

58720-00 salpingo-oophorectomy compl/prtl uni/bi spx $468.00 

58740-00 lss ads $565.50 

58770-00 salpingostomy $468.00 

58800-00 drg ovarian cst uni/bi spx vag $243.75 

58805-00 drg ovarian cst uni/bi spx abdl $390.00 

58820-00 drg ovarian absc vag opn $195.00 

58822-00 drg ovarian absc abdl $390.00 

58823-00 drg pel absc trvg/transrct prq $158.83 

58825-00 trpos ovary $440.51 

58900-00 bx ovary uni/bi spx $438.75 

58920-00 wedge rescj/bisctj ovary uni/bi $482.63 

58925-00 ovarian cstc uni/bi $482.63 

58940-00 oophorectomy prtl/tot uni/bi $438.75 

58943-00 oophorectomy prtl/tot uni/bi ovarian mal $749.78 

58950-00 rescj prim prtl mal w/bso&omntc $804.38 

58951-00 rescj prim prtl mal w/bso&omntc tah&lmphadec $1,110.53 

58952-00 rescj prim prtl mal w/bso&omntc rad debulking $1,128.08 

58953-00 bso w/omntc tah&rad dsj debulking $1,281.15 

58954-00 bso w/omntc tah debulking w/lmphadec $1,390.84 

58956-00 bso tot omntc tah mal $891.54 

58957-00 resection recrt mal w/omentectomy $982.80 

58958-00 resection recrt mal w/omentectomy pel lmphadec $1,088.10 

58960-00 lapt stg/restg ovarian tubal/prim mal 2nd look $636.68 

58999-00 unlis px female gen sys $73.13 

59000-00 amniocnts dx $48.75 

59001-00 amniocnts ther amniotic flu rdctj us gid $115.83 

59012-00 cordocnts intrauterine $162.83 

59015-00 chornc villus sampling $811.69 

59020-00 ftl contrcj strs tst $55.58 

59020-26 ftl contrcj strs tst $33.15 

59020-TC ftl contrcj strs tst $22.43 

59025-00 ftl non-strs tst $29.25 

85

Procedure & 


Tarifas 



59025-26 ftl non-strs tst $23.40 

59025-TC ftl non-strs tst $15.60 

59030-00 ftl scalp bld sampling $97.50 

59050-00 ftl mntr labor phys wrttn reprt s&i $58.50 

59051-00 ftl mntr labor phys wrttn reprt interpj only $43.88 

59070-00 tabdl amnionfs us gid $255.96 

59072-00 ftl umbilical cord occlusion w/us gid $325.55 

59074-00 ftl flu drg us gid $255.96 

59076-00 ftl shunt plmt us gid $325.55 

59100-00 hystot abdl $438.75 

59120-00 tx ectopic pregnancy req so $487.50 

59121-00 tx ectopic pregnancy w/o so $487.50 

59130-00 tx ectopic pregnancy abdl pregnancy $487.50 

59135-00 tx ectopic pregnancy ntrstl req tot hyst $643.50 

59136-00 tx ectopic pregnancy ntrstl prtl rescj uter $526.50 

59140-00 tx ectopic pregnancy crv w/evac $234.00 

59150-00 laps tx ectopic pregnancy w/o so $276.90 

59151-00 laps tx ectopic pregnancy w/so $658.13 

59160-00 curtg postpartum $146.25 

59200-00 insj crv dilator spx $33.15 

59320-00 cerclage cervix pregnancy vag $175.50 

59325-00 cerclage cervix pregnancy abdl $658.13 

59350-00 hysterorrhaphy rptd uter $390.00 

59410-00 vag dlvr only postpartum care $525.00 

59425-00 antepartum care only 4-6 vsts $24.38 

59515-00 c dlvr only w/postpartum care $460.00 

59525-00 stot/tot hyst after c dlvr $336.08 

59612-00 vag dlvr after c dlvr $706.88 

59614-00 vag dlvr after c dlvr postpartum care $828.75 

59620-00 c dlvr only fa v ap c dlver $706.88 

59622-00 c dlvr only fa v ap c dlver w/postpartum care $952.66 

59812-00 tx incompl ab any tri compld surgly $146.25 

59820-00 tx missed ab compld surgly 1st tri $185.25 

59821-00 tx missed ab compld surgly 2nd tri $180.38 

59830-00 tx septic ab compld surgly $273.00 

59840-00 induced ab dilat&curtg $179.89 

59870-00 uterine evac&curtg hydatidiform mole $234.00 

59871-00 rmvl cerclage sutr under anes $114.08 

60000-00 i&d thyroglossal dux cst infct $29.25 

60100-00 bx thyr prq core ndl $48.75 

60200-00 exc cst/adenoma thyr/trnsxj isthmus $390.00 

60210-00 prtl thyr lobec uni +-isthmusectomy $438.75 

60212-00 prtl thyr lobec uni w/clat stot lobec $438.75 

60220-00 tot thyr lobec uni +-isthmusectomy $487.50 

60225-00 tot thyr lobec uni w/clat stot lobec $575.25 

60240-00 trdec tot/compl $682.50 

60252-00 thyroidectomy total/subtotal lmtd neck dissect $780.00 

60254-00 thyroidectomy total/subtotal rad neck dissect $975.00 

60260-00 trdec rmvl remaining tiss flwg rmvl prtn $585.00 

60270-00 trdec w/substernal thyr sternal splt/tthrc $838.50 

86

Procedure & 


Tarifas 



60271-00 trdec w/substernal thyr crv appr $789.75 

60280-00 exc thyroglossal dux cst/sinus $438.75 

60281-00 exc thyroglossal dux cst/sinus recrt $394.88 

60300-00 aspiration and/or injection thyroid cyst $52.65 

60500-00 paratrdec/expl parathyr $682.50 

60502-00 paratrdec/expl parathyr re-expl $614.25 

60505-00 paratrdec/expl parathyr medstnl sternal/tthrc $877.50 

60512-00 parathyr autotrnsplj $175.50 

60520-00 thymectomy prtl/tot transcrv appr spx $838.50 

60521-00 thymectomy prtl/tot w/o rad medstnl dsj spx $859.95 

60522-00 thymectomy prtl/tot rad medstnl dsj spx $1,053.00 

60540-00 adrnlectomy expl adrnl tabdl lmbr/dorsal spx $780.00 

60545-00 adrnlectomy expl adrnl spx exc adj tum $936.00 

60600-00 exc crtd bdy tum w/o exc crtd art $682.50 

60605-00 exc crtd bdy tum w/exc crtd art $975.00 

60650-00 laps adrnlectomy prtl/compl tabdl $947.70 

61000-00 sdrl tap thru fontanelle/sutr inft uni/bi 1st $85.00 

61001-00 sdrl tap thru fontanelle/sutr inft uni/bi sbsq $39.00 

61020-00 ventr pnxr previous burr hole w/o njx $100.00 

61026-00 ventr pnxr previous burr hole w/njx $125.00 

61050-00 cisternal/lat crv c1-c2 pnxr w/o njx spx $30.00 

61055-00 cisternal/lat crv c1-c2 pnxr w/njx $146.25 

61070-00 pnxr shunt tubing/rsvr aspir/njx $68.25 

61105-00 tdh sdrl/ventr pnxr $292.50 

61107-00 tdh sdrl/ventr pnxr implting ventr cath/dev $375.00 

61108-00 tdh sdrl/ventr pnxr evac&/drg sdrl hmtma $750.00 

61140-00 burr hole/trephine w/bx brn/icra les $938.00 

61150-00 burr hole/trephine w/drg brn absc/cst $1,000.00 

61151-00 burr hole/trephine w/sbsq tapping icra absc/cst $68.25 

61154-00 burr hole w/evac&/drg hmtma xdrl/sdrl $877.50 

61156-00 burr hole w/aspir hmtma/cst icere $1,025.00 

61210-00 burr hole implant ventricular cath/other device $435.00 

61215-00 insj subq rsvr pmp/nfs sys ventr cath $600.00 

61250-00 burr hole/trephine sttl expl n/flwd oth surg $610.00 

61253-00 burr hole/trephine ittl uni/bi $458.25 

61304-00 crnec/crx expl sttl $1,290.00 

61305-00 crnec/crx expl ittl $1,752.00 

61312-00 craniectomy hmtma supratentorial extra/subdural $975.00 

61313-00 craniectomy hmtma supratentorial intracerebral $1,890.00 

61314-00 craniectomy hmtma infratentorial extra/subdural $1,890.00 

61315-00 craniectomy hmtma supratentorial intracerebral $1,620.00 

61316-00 inc&subq plmt crnl b1 grf $69.00 

61320-00 crnec/crx drg icra absc sttl $1,092.00 

61321-00 crnec/crx drg icra absc ittl $1,480.00 

61322-00 crnec/crx dcmprive w/o lobec $1,402.00 

61323-00 crnec/crx dcmprive w/lobec $1,451.00 

61330-00 dcmprn orbit only transcrnl $936.00 

61332-00 expl orbit transcrnl bx $1,470.00 

61333-00 expl orbit transcrnl rmvl les $1,507.00 

61334-00 expl orbit transcrnl w/rmvl fb $995.00 

87

Procedure & 


Tarifas 



61340-00 stpl crnl dcmprn $1,000.00 

61343-00 crnec sopl crv lam dcmprn medulla&spi cord $2,193.75 

61345-00 oth crnl dcmprn post fossa $741.00 

61440-00 crx sctj tentorium cerebelli spx $1,440.00 

61450-00 crnec stpl sctj compression/dcmprn ganglion $975.00 

61458-00 crnec sopl expl/dcmprn crnl nrv $1,218.75 

61460-00 crnec sopl sctj 1+ crnl nrv $1,658.00 

61470-00 crnec sopl medullary trcotomy $1,520.00 

61480-00 crnec sopl mesencephal trcotomy/pedunculotomy $1,391.00 

61490-00 crx lobotomy w/cingulotomy $390.00 

61500-00 crnec exc tum/oth b1 les skl $994.50 

61501-00 crnec osteomyelitis $838.50 

61510-00 crnec treph b1 flap crx exc tum sttl $2,500.00 

61512-00 crnec treph b1 flap crx exc meningioma sttl $2,500.00 

61514-00 crnec treph b1 flap crx exc brn absc sttl $1,600.00 

61516-00 crnec treph b1 flap crx exc cst sttl $1,600.00 

61517-00 impltj brn intrcv chemotx agt $58.00 

61518-00 crnec exc tum ittl/pfos meningioma $1,608.75 

61519-00 crnec exc tum ittl/pfos meningioma $2,253.00 

61520-00 crnec exc tum ittl/pfos crblopnt angl tum $1,482.00 

61521-00 crnec exc tum ittl/pfos midline tum base skl $2,500.00 

61522-00 crnec ittl/pfos exc absc $1,287.00 

61524-00 crnec ittl/pfos exc/fenestration cst $1,287.00 

61526-00 crnec exc crblopnt angl tum $1,755.00 

61530-00 crnec exc crblopnt angl tum middle/pfos $2,437.50 

61531-00 sdrl impltj strip eltrds seizure mntr $860.00 

61533-00 crx b1 flap impltj eltrd ra seizure mntr $1,100.00 

61534-00 crx b1 flap exc epileptogenic foc w/o ecog $1,108.00 

61535-00 crx b1 flap rmvl eltrd ra w/o exc cere tiss spx $638.00 

61536-00 crx b1 flap exc cere foc w/ecog $1,832.00 

61537-00 crx b1 flap temporal lobe w/o ecog $1,331.00 

61538-00 crx b1 flap lobec temporal lobe w/ecog $1,846.00 

61539-00 crx b1 flap lobec oth/thn temporal lobe w/ecog $1,700.00 

61540-00 crx b1 flap lobec oth/thn temporal lobe w/o ecog $1,607.00 

61541-00 crx b1 flap trnsxj corpus callosum $1,500.00 

61542-00 crx b1 flap tot hemisphercomy $1,639.00 

61543-00 crx b1 flap prtl/stot hemisphercomy $1,126.13 

61544-00 crx b1 flap exc/coagj choroid plexus $1,600.00 

61545-00 crx b1 flap exc craniopharyngioma $2,251.00 

61546-00 crx hypphsec/exc pituitary tum icra $1,686.75 

61548-00 hypphsec/exc pituitary tum transnsl/septal $2,450.00 

61550-00 crnec craniosynostosis 1 crnl sutr $2,100.00 

61552-00 crnec craniosynostosis mlt crnl sutrs $2,300.00 

61556-00 crx craniosynostosis frnt/parietal b1 flap $2,100.00 

61557-00 crx craniosynostosis bifrnt b1 flap $2,300.00 

61558-00 x10sv crnec mlt sutr craniosynostosis x w/b1 grf $2,300.00 

61559-00 x10sv crnec mlt sutr craniosynostosis b1 agrft $2,690.00 

61563-00 exc b9 tum crnl b1 w/o optic nrv dcmprn $1,500.00 

61564-00 exc b9 tum crnl b1 w/optic nrv dcmprn $1,728.00 

61566-00 crx b1 flap slctv amygdalohippocampectomy $1,591.00 

88

Procedure & 


Tarifas 



61567-00 crx b1 flap mlt subpial trnsxjs w/ecog $1,818.00 

61570-00 crnec/crx exc fb from brn $975.00 

61571-00 crnec/crx tx pentrg wnd brn $1,371.00 

61575-00 transoral sb bx dcmprn/exc les $2,091.00 

61576-00 transoral sb bx dcmprn/exc les spltting tongue $2,547.00 

61580-00 cranfcl acf xdrl w/o orb exntj $1,580.00 

61581-00 cranfcl acf xdrl orb exntj $1,800.00 

61582-00 cranfcl acf xdrl elvtn lobe $1,630.00 

61583-00 cranfcl acf idrl elvtn/rescj lobe $1,900.00 

61584-00 oc acf xdrl w/o orb exntj $1,800.00 

61585-00 oc acf xdrl w/orb exntj $2,000.00 

61586-00 bicoronal transzygmtc&/left w/o b1 grf $1,600.00 

61590-00 itprl pre-aur mcf&msb $2,200.00 

61591-00 itprl post-aur mcf $2,300.00 

61592-00 oc zygmtc mcf $2,100.00 

61595-00 transtemporal pcf jug foramen/msb $1,505.00 

61596-00 transcochlear pcf jug foramen/msb $1,850.00 

61597-00 transcondylar pcf jug foramen/msb $2,000.00 

61598-00 transpetrosal pcf clivus/foramen magnum $1,750.00 

61600-00 rescj/exc les base acf xdrl $1,370.00 

61601-00 rescj/exc les base acf idrl w/rpr $1,463.00 

61605-00 rescj/exc les itprl fossa space apex xdrl $1,513.00 

61606-00 rescj/exc les itprl fossa space apex idrl w/rpr $2,026.00 

61607-00 rescj/exc les parasellar sinus clivus/msb xdrl $1,900.00 

61608-00 rescj/exc les parasellar sinus clivus/msb idrl $2,200.00 

61609-00 trnsxj/lig crtd art sinus w/o rpr $489.00 

61610-00 trnsxj/lig crtd art sinus w/rpr anast/grf $1,352.00 

61611-00 trnsxj/lig crtd art petrous canal w/o rpr $358.00 

61612-00 trnsxj/lig crtd art petrous canal rpr anast/grf $1,307.00 

61613-00 obltrj crtd arysm arven crtd-fstl dsj $2,160.00 

61615-00 rescj/exc les base pcf vrt bodies xdrl $1,660.00 

61616-00 rescj/exc les base pcf foramen vrt bodies idrl $2,295.00 

61618-00 sec rpr dura csf leak fr tiss grf $909.00 

61619-00 sec rpr dura csf leak local/regionalized flap $1,087.00 

61623-00 evasc temp balo artl occlusion $425.00 

61624-00 tcat prm occlusion/embolization prq cns $1,078.00 

61626-00 tcat prm occlusion/embolization prq non-cns $889.00 

61680-00 surg icra arven malfrmj sttl smpl $1,535.63 

61682-00 surg icra arven malfrmj sttl cplx $2,325.38 

61684-00 surg icra arven malfrmj ittl smpl $1,842.75 

61686-00 surg icra arven malfrmj ittl cplx $3,100.00 

61690-00 surg icra arven malfrmj dural smpl $1,943.00 

61692-00 surg icra arven malfrmj dural cplx $2,633.00 

61697-00 surg cplx icra arysm icra appr crtd crcj $2,595.00 

61698-00 cplx icra icra vertebrobasilar crcj $2,485.00 

61700-00 smpl icra icra appr crtd crcj $3,000.00 

61702-00 smpl icra icra vertebrobasilar crcj $3,000.00 

61703-00 icra crv appl occluding clamp crv crtd art $711.75 

61705-00 arysm vasc malfrmj/crtd-occlusion crtd art $2,500.00 

61708-00 arysm vasc malfrmj/icra electrothrombosis $1,771.00 

89

Procedure & 


Tarifas 



61710-00 arysm vasc malfrmj ia embolization $1,401.00 

61711-00 anast artl xtrc-icra arts $2,195.00 

61720-00 crtj les strtctc burr globus pallidus/thalamus $1,332.00 

61735-00 crtj les strtctc burr subcortical strux oth/thn $1,082.00 

61750-00 strtctc bx aspir/exc burr icra les $1,139.00 

61751-00 strtctc bx aspir/exc burr icra les w/ct&/mrg $1,337.00 

61760-00 strtctc impltj eltrd cerebrum seizure mntr $1,200.00 

61770-00 strtctc loclzj insj cath/prb plmt radj src $1,200.00 

61781-00 strtctc cptr asstd px idrl crnl $137.48 

61782-00 strtctc cptr asstd px xdrl crnl $115.22 

61783-00 strtctc cptr asstd px spinal $130.65 

61790-00 crtj les strtctc prq nulyt gasserian $909.00 

61791-00 crtj les strtctc prq nulyt trigeminal trc $825.00 

61850-00 tdh/burr impltj nstim eltrd cortical $658.00 

61860-00 crnec/crx impltj nstim eltrd cere cortical $1,095.00 

61863-00 strtctc impltj nstim eltrd w/o mer 1st ra $810.00 

61864-00 strtctc impltj nstim eltrd w/o mer ea ra $229.00 

61867-00 strtctc impltj nstim eltrd w/mer 1st ra $1,205.00 

61868-00 strtctc impltj nstim eltrdw/mer ea ra $381.00 

61870-00 crnec impltj nstim eltrd cerebellar cortical $796.00 

61875-00 crnec impltj nstim eltrd cerebellar subcortical $775.00 

61880-00 revj/rmvl icra nstim eltrds $375.00 

61885-00 insj/rplcmt crnl npgr 1 eltrd ra $335.00 

61886-00 insj/rplcmt crnl npgr 2+ eltrd ra $457.00 

61888-00 revj/rmvl crnl npgr $290.00 

62000-00 elvtn deprs skl fx smpl xdrl $731.25 

62005-00 elvtn deprs skl fx compound/commind xdrl $1,000.00 

62010-00 elvtn deprs skl fx w/rpr dura&/dbrdmt brn $1,220.00 

62100-00 crx rpr dural/csf leak rhinorrhea/otorrhea $975.00 

62115-00 rdctj craniomegalic skl x w/b1 grfs/crnop $1,400.00 

62116-00 rdctj craniomegalic skl w/smpl crnop $1,500.00 

62117-00 rdctj craniomegalic req crx&rcnstj +-b1 grf $1,600.00 

62120-00 rpr encephalocele skl vault w/crnop $1,033.50 

62121-00 craniotomy for encephalocele repair skull base $1,225.00 

62140-00 cranioplasty skull defect up to 5 cm diameter $850.00 

62141-00 cranioplasty skull defect larger than 5 cm diam $1,039.00 

62142-00 rmvl b1 flap/prostc plate skl $802.00 

62143-00 rplcmt b1 flap/prostc plate skl $705.00 

62145-00 cranioplasty skull defect reparative brain surg $994.00 

62146-00 crnop w/agrft up 5 cm diam $745.88 

62147-00 crnop w/agrft > 5 cm diam $1,018.00 

62148-00 incise&retrieval subq cranioplasty bone graft $94.00 

62160-00 nundsc icra plmt/rplcmt ventr cath shunt sys $135.00 

62161-00 nundsc icra dsj ads fenestration septum csts $968.00 

62162-00 nundsc icra fenestration/exc cst plmt cath drg $1,243.00 

62163-00 nundsc icra w/retrieval fb $787.30 

62164-00 nundsc icra exc tum plmt cath drg $1,344.00 

62165-00 nundsc icra exc pituitary tum $1,052.00 

62180-00 ventriculocisternostomy $1,238.25 

62190-00 crtj shunt sarach/sdrl-atr-jug-aur $1,043.25 

90

Procedure & 


Tarifas 



62192-00 crtj shunt sarach/sdrl-prtl-pleural oth $975.00 

62194-00 rplcmt/irrg sarach/sdrl cath $300.00 

62200-00 ventriculocisternostomy 3rd vntrc $1,089.00 

62201-00 ventriculocisternostomy 3rd vntrc neurondsc $670.00 

62220-00 crtj shunt ventriculo-atr-jug-aur $936.00 

62223-00 crtj shunt ventriculo-prtl-pleural oth $1,316.25 

62225-00 rplcmt/irrigation ventr cath $328.00 

62230-00 rplcmt/revj csf shunt valve/cath shunt sys $585.00 

62252-00 reprgrmg prgrbl cerebsp shunt $70.00 

62252-26 reprgrmg prgrbl cerebsp shunt $16.80 

62252-TC reprgrmg prgrbl cerebsp shunt $28.00 

62256-00 rmvl compl cerebsp flu shunt sys w/o rplcmt $292.50 

62258-00 rmvl compl csf shunt sys w/rplcmt $1,000.00 

62263-00 prq lss edrl ads sln njx/mchnl loclzj 2+ d $395.18 

62264-00 prq lss edrl ads sln njx/mchnl loclzj 1 d $420.30 

62268-00 prq aspir spi cord cst/syrinx $224.00 

62269-00 bx spi cord prq ndl $225.00 

62270-00 spi pnxr lmbr dx $19.50 

62272-00 spinal puncture ther drain cerebrospinal fluid $19.50 

62273-00 njx edrl bld/clot patch $100.43 

62280-00 njx/nfs nulyt sbst sbst sarach $182.84 

62281-00 njx/nfs nulyt sbst edrl crv/thrc $173.68 

62282-00 njx/nfs nulyt sbst edrl lmbr sac $66.69 

62284-00 injection procedure myelography/ct spinal $97.50 

62287-00 dcmprn perq nucleus pulposus 1/> levels lumbar $660.00 

62290-00 njx diskograpy ea lvl lmbr $97.50 

62291-00 njx diskograpy ea lvl crv/thrc $117.00 

62292-00 njx chemonucleolss diskograpy 1+ lmbr $507.00 

62294-00 njx artl occlusion arven malfrmj spi $460.00 

62310-00 njx c+-dx/ther sbst edrl/sarach crv/thrc $128.93 

62311-00 njx c+-dx/ther sbst edrl/sarach lmbr sac $109.35 

62318-00 njx nfs/bolus dx/sbst edrl/sarach crv/thrc $59.67 

62319-00 njx nfs/bolus dx/sbst edrl/sarach lmbr sac $121.81 

62350-00 impltj revj/rpsg ithcl/edrl cath pmp w/o lam $323.00 

62351-00 impltj revj/rpsg ithcl/edrl cath w/lam $449.48 

62355-00 rmvl previously implted ithcl/edrl cath $253.50 

62360-00 impltj/rplcmt ithcl/edrl drug nfs subq rsvr $126.00 

62361-00 impltj/rplcmt ithcl/edrl nfs non-prgrbl pmp $239.00 

62362-00 impltj/rplcmt ithcl/edrl drug nfs prgrbl pmp $314.00 

62365-00 rmvl subq rsvr/pmp $259.00 

62367-00 elec alys prgrbl pmp w/o reprgrmg $21.41 

62368-00 elec alys prgrbl pmp reprgrmg $52.68 

63001-00 lam w/o facetec foramot/dskc 1/2 vrt seg crv $975.00 

63003-00 lam w/o ffd 1/2 vrt seg thrc $975.00 

63005-00 lam w/o ffd 1/2 vrt seg lmbr $877.50 

63011-00 lam w/o ffd 1/2 vrt seg sac $1,840.00 

63012-00 lam w/rmvl abnormal facets lmbr $1,840.00 

63015-00 lam w/o ffd > 2 vrt seg crv $1,379.63 

63016-00 lam w/o ffd > 2 vrt seg thrc $1,209.00 

63017-00 lam w/o ffd > 2 vrt seg lmbr $1,267.50 

91

Procedure & 


Tarifas 



63020-00 laminotomy incl opn & ndsc 1 interspace cervical $1,126.13 

63030-00 laminotomy incl open & ndsc 1 interspace lumbar $1,830.00 

63035-00 lamot incl open&ndsc ea addl interspace crv/lmbr $204.75 

63040-00 lamot prtl ffd hrna8 reexpl 1 ntrspc crv $1,491.75 

63042-00 lamot prtl ffd hrna8 reexpl 1 ntrspc lmbr $1,326.00 

63045-00 lam facetec&foramot 1 sgm crv $1,020.83 

63046-00 Removal of spinal lamina, lam facetec&foramot 1 sgm thrc $1,560.00 

63047-00 lam facetec&foramot 1 sgm lmbr $1,608.75 

63048-00 lam facetec&foramot 1 sgm ea crv thrc/lmbr $300.00 

63050-00 lamop crv w/dcmprn spi cord 2/more vrt seg $1,079.00 

63051-00 lamop crv dcmprn spi cord 2+ seg rcnstj b1 $1,228.00 

63055-00 transpedicular dcmprn spi cord 1 sgm thrc $1,500.00 

63056-00 transpedicular dcmprn spi cord 1 sgm lmbr $1,400.00 

63057-00 transpedicular dcmprn 1 sgm ea thrc/lmbr $272.00 

63064-00 costovrt dcmprn thrc 1 sgm $1,500.00 

63066-00 costovrt dcmprn thrc ea sgm $200.00 

63075-00 dskc ant dcmprn crv 1 ntrspc $1,228.01 

63076-00 dskc ant dcmprn crv ea ntrspc $310.00 

63077-00 dskc ant dcmprn thrc 1 ntrspc $1,270.91 

63078-00 dskc ant dcmprn thrc ea ntrspc $200.00 

63081-00 vcrpec ant dcmprn crv 1 sgm $1,581.94 

63082-00 vcrpec ant dcmprn crv ea sgm $326.63 

63085-00 vcrpec tthrc dcmprn thrc 1 sgm $1,700.00 

63086-00 vcrpec tthrc dcmprn thrc ea sgm $253.50 

63087-00 vcrpec thoracolmbr dcmprn lwr thrc/lmbr 1 sgm $1,833.98 

63088-00 vcrpec thoracolmbr dcmprn lwr thrc/lmbr ea sgm $375.00 

63090-00 vcrpec transprtl/rpr dcmprn thrc lmbr/sac 1 sgm $1,817.89 

63091-00 vcrpec transprtl/rpr dcmprn thrc lmbr/sac ea sgm $187.69 

63101-00 vcrpec lat xtrcavitary dcmprn thrc 1 sgm $1,653.00 

63102-00 vcrpec lat xtrcavitary dcmprn lmbr 1 sgm $1,653.00 

63103-00 vcrpec lat xtrcavitary dcmprn thrc/lmbr ea sgm $169.36 

63170-00 lam w/myelotomy crv thrc/thoracolmbr $1,200.00 

63172-00 lam w/drg imed cst/syrinx sarach space $1,535.63 

63173-00 lam w/drg imed cst/syrinx prtl/pleural space $1,535.63 

63180-00 lam&sctj dentate ligms crv 1/2 seg $1,800.00 

63182-00 lam&sctj dentate ligms crv > 2 seg $1,900.00 

63185-00 lam w/rhizotomy 1/2 seg $1,033.50 

63190-00 lam w/rhizotomy > 2 seg $1,400.00 

63191-00 lam w/sctj spi accessory nrv $1,300.00 

63194-00 lam cordotomy sctj 1 trc 1 stg crv $1,600.00 

63195-00 lam cordotomy sctj 1 trc 1 stg thrc $1,600.00 

63196-00 lam cordotomy sctj bth trcs 1 stg crv $1,600.00 

63197-00 lam cordotomy sctj bth trcs 1 stg thrc $1,600.00 

63198-00 lam cordotomy sctj bth trcs 2 stgs crv $1,202.00 

63199-00 lam cordotomy sctj bth trcs 2 stgs thrc $1,414.00 

63200-00 lam rls tethered spi cord lmbr $1,500.00 

63250-00 lam exc/occlusion avm spi cord crv $2,130.00 

63251-00 lam exc/occlusion avm spi cord thrc $2,099.00 

63252-00 lam exc/occlusion avm spi cord thoracolmbr $2,150.00 

63265-00 lam exc/evac ispi les oth/thn neo xdrl crv $1,419.00 

92

Procedure & 


Tarifas 



63266-00 lam exc/evac ispi les oth/thn neo xdrl thrc $1,529.00 

63267-00 lam exc/evac ispi les oth/thn neo xdrl lmbr $1,310.00 

63268-00 lam exc/evac ispi les oth/thn neo xdrl sac $958.00 

63270-00 lam exc ispi les oth/thn neo idrl crv $1,365.00 

63271-00 lam exc ispi les oth/thn neo idrl thrc $1,694.55 

63272-00 lam exc ispi les oth/thn neo idrl lmbr $1,584.00 

63273-00 lam exc ispi les oth/thn neo idrl sac $1,324.54 

63275-00 lam bx/exc ispi neo xdrl crv $1,683.00 

63276-00 lam bx/exc ispi neo xdrl thrc $1,550.00 

63277-00 lam bx/exc ispi neo xdrl lmbr $1,406.00 

63278-00 lam bx/exc ispi neo xdrl sac $1,390.00 

63280-00 lam bx/exc ispi neo idrl xmed crv $1,775.00 

63281-00 lam bx/exc ispi neo idrl xmed thrc $1,775.00 

63282-00 lam bx/exc ispi neo idrl xmed lmbr $1,580.00 

63283-00 lam bx/exc ispi neo idrl sac $1,316.25 

63285-00 lam bx/exc ispi neo idrl imed crv $2,091.38 

63286-00 lam bx/exc ispi neo idrl imed thrc $2,000.00 

63287-00 lam bx/exc ispi neo idrl imed thoracolmbr $1,920.00 

63290-00 lam bx/exc ispi neo xdrl-idrl les any lvl $1,980.00 

63295-00 ostpl rcnstj dorsal spi elmnts flwg ispi px $244.00 

63300-00 vcrpec les 1 sgm xdrl crv $1,276.00 

63301-00 vcrpec les 1 sgm xdrl thrc tthrc $1,455.00 

63302-00 vcrpec les 1 sgm xdrl thrc thoracolmbr $1,390.35 

63303-00 vcrpec les 1 sgm xdrl lmbr/sac transprtl/rpr $1,499.55 

63304-00 vcrpec les 1 sgm idrl crv $1,540.00 

63305-00 vcrpec les 1 sgm idrl thrc tthrc $1,650.00 

63306-00 vcrpec les 1 sgm idrl thrc thoracolmbr $1,640.00 

63307-00 vcrpec les 1 sgm idrl lmbr/sac transprtl/rpr $1,680.00 

63308-00 vcrpec les 1 sgm ea sgm $300.00 

63600-00 crtj les spi cord strtctc prq $616.00 

63610-00 strtctc stimj spi cord prq spx n/flwd oth surg $375.00 

63615-00 strtctc bx aspir/exc les spi cord $844.00 

63650-00 prq impltj nstim eltrd ra edrl $293.29 

63655-00 lam impltj nstim eltrds plate/paddle edrl $561.00 

63685-00 insj/rplcmt spi npgr dir/induxive coupling $332.57 

63688-00 revj/rmvl implted spi npgr $248.33 

63700-00 rpr meningocele < 5 cm diam $731.25 

63702-00 rpr meningocele > 5 cm diam $888.00 

63704-00 rpr myelomeningocele < 5 cm diam $1,650.00 

63706-00 rpr myelomeningocele > 5 cm diam $1,750.00 

63707-00 rpr dural/cerebsp flu leak x req lam $820.00 

63709-00 rpr dural/csf leak/pseudomeningocele w/lam $1,820.00 

63710-00 dural grf spi $756.00 

63740-00 crtj shunt lmbr sarach-prtl-pleural/oth w/lam $936.00 

63741-00 crtj shunt lmbr sarach-prtl-pleural prq x lam $879.00 

63744-00 rplcmt irrigation/revj lumbosarach shunt $850.00 

63746-00 rmvl entire lumbosarach shunt sys w/o rplcmt $400.00 

64400-00 njx anes trigeminal nrv any div/branch $19.50 

64402-00 njx anes facial nrv $19.50 

64405-00 njx anes grter occipital nrv $29.25 

93

Procedure & 


Tarifas 



64408-00 njx anes vagus nrv $29.25 

64410-00 njx anes phrenic nrv $29.25 

64412-00 njx anes spi accessory nrv $29.25 

64413-00 njx anes crv plexus $48.75 

64415-00 single nerve block injection arm nerve $48.75 

64416-00 injection anes brachial plexus cont nfs cath $92.14 

64417-00 njx anes ax nrv $29.25 

64418-00 njx anes suprascapular nrv $29.25 

64420-00 njx anes intercostal nrv 1 $29.25 

64421-00 multiple nerve block injections rib nerves $136.01 

64425-00 njx anes ilioingun iliohypogstr nrv $48.75 

64430-00 njx anes pudendal nrv $48.75 

64435-00 njx anes paracrv nrv $48.75 

64445-00 njx anes sciatic nrv 1 $29.25 

64446-00 injection anes sciatic nerve cont infusion cath $109.69 

64447-00 njx anes fem nrv 1 $52.65 

64448-00 injection anes femoral nerve cont infusion cath $104.42 

64449-00 injection anes lumbar plexus post cont nfs cath $103.55 

64450-00 njx anes oth prph nrv/branch $29.25 

64455-00 njx anes&/steroid plantar common digital nerve $30.71 

64479-00 njx anes&/strd w/img tfrml edrl crv/thrc 1 lvl $43.88 

64480-00 njx anes&/strd w/img tfrml edrl crv/thrc ea lvl $97.00 

64483-00 njx anes&/strd w/img tfrml edrl lmbr/sac 1 lvl $48.75 

64484-00 njx anes&/strd w/img tfrml edrl lmbr/sac ea lvl $87.97 

64490-00 njx dx/ther agt pvrt facet jt crv/thrc 1 level $43.88 

64491-00 njx dx/ther agt pvrt facet jt crv/thrc 2nd level $21.45 

64492-00 njx dx/ther agt pvrt facet jt crv/thrc 3+ level $34.13 

64493-00 njx dx/ther agt pvrt facet jt lmbr/sac 1 level $34.13 

64494-00 njx dx/ther agt pvrt facet jt lmbr/sac 2nd level $16.58 

64495-00 njx dx/ther agt pvrt facet jt lmbr/sac 3+ level $29.25 

64505-00 njx anes sphenopalatine ganglion $70.00 

64508-00 njx anes crtd sinus spx $39.00 

64510-00 njx anes stellate ganglion crv sympathetic $48.75 

64517-00 njx anes suprior hypogstr plexus $103.91 

64520-00 njx anes lmbr/thrc pvrt sympathetic $19.50 

64530-00 njx anes celiac plexus +-rad mntr $100.00 

64553-00 prq impltj nstim eltrds crnl nrv $112.50 

64555-00 prq impltj nstim eltrds prph nrv $126.00 

64560-00 prq impltj nstim eltrds autonomic nrv $124.78 

64561-00 prq impltj nstim eltrds sac nrv $336.59 

64565-00 prq impltj nstim eltrds neuromuscular $100.21 

64568-00 inc impltj crnl nrv nstim eltrds & pulse gener $403.25 

64569-00 revision/replmt nstim crnl eltrds $372.00 

64570-00 removal crnl nrv nstim eltrds & pulse generator $319.00 

64575-00 inc impltj periph nrv nstim eltrds $196.56 

64577-00 inc impltj nstim eltrds autonomic nrv $222.89 

64580-00 inc impltj nstim eltrds neuromuscular $212.36 

64581-00 inc impltj nstim eltrds sac nrv $519.48 

64585-00 revj/rmvl prph nstim eltrds $150.00 

64590-00 insertion/rplcmt peripheral/gastric npgr $142.35 

94

Procedure & 


Tarifas 



64595-00 revision/rmvl peripheral/gastric npgr $112.00 

64600-00 dstrj trigeminal nrv supraorb infraorb branch $87.75 

64605-00 dstrj nulyt trigeminal nrv 2/3 div $485.00 

64610-00 dstrj nulyt trigeminal nrv 2/3 div rad mntr $146.25 

64611-00 chemodenerv parotid&submandibl salivary glnds bi $59.52 

64612-00 chemodnrvtj musc musc innervated facial nrv $91.65 

64613-00 chemodnrvtj musc nck musc $105.30 

64614-00 chemodnrvtj musc xtr&/trnk musc $96.96 

64620-00 dstrj nulyt intercostal nrv $265.00 

64622-00 dstrj nulyt pvrt facet jt nrv lmbr/sac 1 lvl $339.00 

64623-00 dstrj nulyt pvrt facet jt nrv lmbr/sac ea lvl $102.00 

64626-00 dstrj nulyt pvrt facet jt nrv crv/thrc 1 lvl $223.78 

64627-00 dstrj nulyt pvrt facet jt nrv crv/thrc ea lvl $44.33 

64630-00 dstrj nulyt pudendal nrv $221.00 

64632-00 dstrj neurolytic plantar common digital nerve $28.96 

64640-00 dstrj nulyt oth prph nrv/branch $39.00 

64650-00 chemodnrvtj eccrine glnds bth ax $32.63 

64653-00 chemodnrvtj eccrine glnds oth area pr d $38.61 

64680-00 dstrj nulyt +-rad mntr celiac plexus $291.00 

64681-00 dstrj nulyt +-rad mntr suprior hypogstr plexus $185.06 

64702-00 neurp dgtal 1/bth sm dgt $146.25 

64704-00 neurp nrv hand/foot $195.00 

64708-00 neurp major prph nrv arm/leg opn oth/thn spec $390.00 

64712-00 neurp major prph nrv opn arm/leg sciatic nrv $414.38 

64713-00 neurp major prph nrv opn arm/leg brach plexus $497.25 

64714-00 neurp major prph nrv opn arm/leg lmbr plexus $409.50 

64716-00 neurp&/trpos crnl nrv $731.25 

64718-00 neurp&/trpos ur nrv elbw $243.75 

64719-00 neurp&/trpos ur nrv wrst $243.75 

64721-00 neurp&/trpos median nrv carpl tunnel $292.50 

64722-00 dcmprn unspecified nrv $438.75 

64726-00 dcmprn plntar dgtal nrv $175.50 

64727-00 int neurolss req mcrscp $175.50 

64732-00 trnsxj/avlsn supraorb nrv $270.00 

64734-00 trnsxj/avlsn infraorb nrv $195.00 

64736-00 trnsxj/avlsn mental nrv $275.00 

64738-00 trnsxj/avlsn inf alveolar nrv osteom $330.00 

64740-00 trnsxj/avlsn lngl nrv $330.00 

64742-00 trnsxj/avlsn facial nrv diffial/compl $337.00 

64744-00 trnsxj/avlsn grter occipital nrv $390.00 

64746-00 trnsxj/avlsn phrenic nrv $323.00 

64752-00 trnsxj/avlsn vagus nrv tthrc $364.00 

64755-00 trnsxj/avlsn vagus nrv prox stomach $760.00 

64760-00 trnsxj/avlsn vagus nrv abdl $436.00 

64761-00 trnsxj/avlsn pudendal nrv $334.00 

64763-00 trnsxj/avlsn obturator nrv xtrpel $214.50 

64766-00 trnsxj/avlsn obturator nrv intrapel $370.50 

64771-00 trnsxj/avlsn oth crnl nrv xdrl $420.00 

64772-00 trnsxj/avlsn oth spi nrv xdrl $390.00 

64774-00 exc neuroma cutan nrv surgly identifiable $78.00 

95

Procedure & 


Tarifas 



64776-00 exc neuroma dgtal nrv 1/bth sm dgt $97.50 

64778-00 exc neuroma dgtal nrv ea dgt $58.50 

64782-00 exc neuroma hand/foot xcp dgtal nrv $146.25 

64783-00 exc neuroma hand/foot ea nrv xcp sm dgt $58.50 

64784-00 exc neuroma major prph nrv xcp sciatic $243.75 

64786-00 exc neuroma sciatic nrv $633.75 

64787-00 impltj nrv end in b1/musc $240.83 

64788-00 exc neurofibroma/neurolemmoma cutan nrv $214.50 

64790-00 exc neurofibroma/neurolemmoma major prph nrv $546.00 

64792-00 exc neurofibroma/neurolemmoma x10sv $585.00 

64795-00 bx nrv $117.00 

64802-00 sympth crv $585.00 

64804-00 sympth cervicothrc $682.50 

64809-00 sympth thoracolmbr $741.00 

64818-00 sympth lmbr $536.25 

64820-00 sympth dgtal arts ea dgt $482.63 

64821-00 sympth rdl art $459.85 

64822-00 sympth ur art $459.85 

64823-00 sympth supfc plmr arch $532.08 

64831-00 sutr dgtal nrv hand/foot 1 nrv $146.25 

64832-00 sutr dgtal nrv hand/foot ea dgtal nrv $48.75 

64834-00 suture 1 nerve hand/foot common sensory nerve $195.00 

64835-00 suture 1 nerve median motor thenar $292.50 

64836-00 suture 1 nerve ulnar motor $292.50 

64837-00 sutr ea nrv hand/foot $48.75 

64840-00 sutr post tibl nrv $390.00 

64856-00 sutr prph nrv arm/leg xcp sciatic w/trpos $800.00 

64857-00 sutr prph nrv arm/leg xcp sciatic w/o trpos $390.00 

64858-00 sutr sciatic nrv $458.25 

64859-00 sutr ea major prph nrv $250.00 

64861-00 sutr brach plexus $760.50 

64862-00 sutr lmbr plexus $965.25 

64864-00 sutr facial nrv xtrc $507.00 

64865-00 sutr facial nrv itprl +-grfg $849.00 

64866-00 anast facial-spi accessory $731.25 

64868-00 anast facial-hypoglossal $731.25 

64870-00 anast facial-phrenic $936.00 

64872-00 sutr nrv req sec/dlyd sutr $107.00 

64874-00 sutr nrv req x10sv moblj/trpos nrv $140.40 

64876-00 sutr nrv req shrt b1 xtr $157.95 

64885-00 nrv grf head/nck 4 cm $1,030.00 

64890-00 nrv grf 1 strand hand/foot 4 cm $875.00 

64892-00 nrv grf 1 strand arm/leg 4 cm $925.00 

64895-00 nrv grf mlt strands hand/foot 4 cm $1,155.00 

64897-00 nrv grf mlt strands arm/leg 4 cm $1,050.00 

96

Procedure & 


Tarifas 



64901-00 nrv grf ea nrv 1 strand $633.00 

64902-00 nrv grf ea nrv mlt strands $725.00 

64905-00 nrv pedcl tr 1st stg $709.00 

64907-00 nrv pedcl tr 2nd stg $1,000.00 

64910-00 nerve repair w/conduit ea nerve $461.57 

64911-00 nerve repair w/autogenous vein graft ea nerve $561.60 

65091-00 evsc oc cnts w/o implt $390.00 

65093-00 evsc oc cnts w/implt $487.50 

65101-00 encl eye w/o implt $390.00 

65103-00 encl eye implt musc x attached implt $487.50 

65105-00 encl eye implt musc attached implt $585.00 

65110-00 exntj orbit rmvl orb cnts only $585.00 

65112-00 exntj orbit rmvl orb cnts w/ther rmvl b1 $663.00 

65114-00 exntj orbit rmvl orb cnts w/musc/myoq flap $867.75 

65125-00 modificaj oc implt w/plmt/rplcmt pegs spx $43.88 

65130-00 insj oc implt sec after evsc scll shell $585.00 

65135-00 insj oc implt after encl musc x attached $429.00 

65140-00 insj oc implt after encl musc attached $682.50 

65150-00 rinsj oc implt +-cjncl grf $526.50 

65155-00 rinsj oc implt rnfcmt&/attachment musc $526.50 

65175-00 rmvl oc implt $351.00 

65205-00 rmvl fb xtrnl eye cjncl supfc $9.75 

65210-00 rmvl fb xtrnl eye embedded scjncl/scll nonprf8 $19.50 

65220-00 rmvl fb xtrnl eye crnl w/o slit lamp $19.50 

65222-00 rmvl fb xtrnl eye crnl w/slit lamp $29.25 

65235-00 rmvl fb io from ant chamber eye/lens $487.50 

65260-00 rmvl fb io from post sgm mag xtrj ant/post route $487.50 

65265-00 rmvl fb io from post sgm nonmag xtrj $575.25 

65270-00 rpr lac cjnc +-nonprf8 lac scl dir clsr $48.75 

65272-00 rpr lac cjnc moblj&reargmt w/o hospization $146.25 

65273-00 rpr lac cjnc moblj&reargmt w/hospization $209.63 

65275-00 rpr lac crn nonprf8 +-rmvl fb $165.75 

65280-00 rpr lac crn&/scl prf8 x invg uveal tiss $546.00 

65285-00 rpr lac crn&/scl prf8 w/repos/rescj uveal tiss $663.00 

65286-00 rpr lac appl tiss glue wnd crn&/scl $277.29 

65290-00 rpr wnd eo muscle tendon&/tenon's capsule $141.38 

65400-00 exc les crn xcp pterygium $292.50 

65410-00 bx crn $48.75 

65420-00 exc/trpos pterygium w/o grf $292.50 

65426-00 exc/trpos pterygium w/grf $331.50 

65430-00 cornea scraping diagnostic smear &/culture $9.75 

65435-00 rmvl crnl epithe +-chemocaut $39.00 

65436-00 rmvl crnl epithe w/appl chelating agt $107.25 

65450-00 dstrj les crn crtx pc/thermocaut $48.75 

65730-00 keratoplasty pentrg except aphakia/pseudophakia $1,072.50 

65755-00 keratoplasty pentrg pseudophakia $941.85 

65771-00 rdl keratotomy $702.00 

65772-00 crnl relaxing inc corrj induced astigmatism $373.43 

65775-00 crnl wedge rescj corrj induced astigmatism $373.43 

65800-00 pcnts eye spx dx aspir aqueous $97.50 

97

Procedure & 


Tarifas 



65805-00 pcnts eye spx ther rls aqueous $97.50 

65810-00 pcnts eye spx rmvl vts&/dscj memb $292.50 

65815-00 pcnts eye spx rmvl bld $175.50 

65820-00 goniotomy $487.50 

65850-00 trabeculotomy ab externo $565.50 

65855-00 trabeculoplasty laser surg 1+ sess $292.50 

65860-00 severing ads ant sgm laser tq spx $307.13 

65865-00 severing ads ant sgm incal tq spx goniosynechiae $429.00 

65870-00 severing ads ant sgm incal spx ant synechiae $360.75 

65875-00 severing ads ant sgm incal spx post synechiae $360.75 

65880-00 severing ads ant sgm incal spx corneovitreal $360.75 

65900-00 rmvl epithelial downgrowth ant chamber eye $448.50 

65920-00 rmvl implted matrl ant sgm eye $731.25 

65930-00 rmvl bld clot ant sgm eye $438.75 

66020-00 njx ant chamber eye spx air/liq $146.25 

66030-00 njx ant chamber eye spx med $146.25 

66130-00 exc les scl $302.25 

66150-00 fstlj scl glc treph irdec $585.00 

66155-00 fstlj scl glc thermocaut irdec $585.00 

66160-00 fstlj scl glc sclercomy punch/scissors irdec $585.00 

66165-00 fstlj scl glc iridencleisis/iridotasis $544.05 

66170-00 fstlj scl glc trbec ab externo $780.00 

66172-00 fstlj scl glc trbec ab externo scarring $886.28 

66180-00 aqueous shunt eo rsvr $877.50 

66185-00 revj aqueous shunt eo rsvr $494.33 

66220-00 rpr scll staphyloma w/o grf $392.93 

66225-00 rpr scll staphyloma w/grf $729.30 

66250-00 revj/rpr oprative wnd ant sgm $399.75 

66500-00 iridotomy stab inc spx xcp transfixion $195.00 

66505-00 iridotomy stab inc spx transfixion $195.00 

66600-00 irdec crnlsclrl/crnl sctj rmvl les $585.00 

66605-00 irdec crnlsclrl/crnl sctj cyclectomy $780.00 

66625-00 irdec crnlsclrl/crnl sctj prph glc spx $487.50 

66630-00 irdec crnlsclrl/crnl sctj sector glc spx $487.50 

66635-00 irdec crnlsclrl/crnl sctj optical spx $487.50 

66680-00 rpr iris ciliary bdy $390.00 

66682-00 sutr iris ciliary bdy spx retrieval sutr $312.00 

66700-00 ciliary bdy dstrj dthrm $292.50 

66710-00 ciliary bdy dstrj cyclopc transscll $327.60 

66711-00 ciliary bdy dstrj cyclopc ndsc $339.59 

66720-00 ciliary bdy dstrj crtx $214.50 

66740-00 ciliary bdy dstrj cyclodial $487.50 

66761-00 iridotomy/irdec laser surg per session $214.50 

66762-00 iridoplasty pc 1+ sess $214.50 

66770-00 dstrj cst/les iris/ciliary bdy $292.50 

66820-00 dscj sec membranous ctrc stab inc $175.50 

66821-00 post-cataract laser surgery $233.03 

66825-00 rpsg io lens prosth req inc spx $401.70 

66830-00 rmvl sec membranous ctrc corneo-scll sctj $459.23 

66840-00 rmvl lens matrl aspir tq 1+ stgs $585.00 

98

Procedure & 


Tarifas 



66850-00 rmvl lens matrl phacofragmentation aspir $775.13 

66852-00 rmvl lens matrl pars plna appr +-vtrc $570.38 

66920-00 rmvl lens matrl icapsl $780.00 

66930-00 removal lens matrl intracapsular dislocated lens $780.00 

66940-00 rmvl lens matrl xcapsl $780.00 

66982-00 xcapsl ctrc rmvl insj lens prosth 1 stg $588.80 

66983-00 icapsl ctrc xtrj insj io lens prosth 1 stg $1,150.50 

66984-00 cataract removal insertion of lens $680.00 

66985-00 insj io lens prosth x w/cncrnt rmvl $975.00 

66986-00 exchng io lens $640.58 

67005-00 rmvl vts ant appr prtl rmvl $585.00 

67010-00 rmvl vts ant appr stot rmvl vtrc $1,160.25 

67015-00 aspir/rls flu pars plna $292.50 

67025-00 njx vts sub pars plna/limbal spx $429.00 

67027-00 impltj intravitreal drug dlvr sys rmvl vts $534.30 

67028-00 intravitreal njx pharmacologic agt spx $143.33 

67030-00 dscj vts strands pars plna $341.25 

67031-00 severing vts strands laser 1+ stgs $561.60 

67036-00 vtrc mchnl pars plna $1,238.25 

67039-00 vtrc mchnl pars plna focal endolaser pc $1,667.25 

67040-00 vtrc mchnl pars plna endolaser panrta pc $1,198.28 

67041-00 vitrectomy pars plana remove preretinal membrane $851.76 

67042-00 vitrectomy pars plana remove int memb retina $1,310.40 

67043-00 vitrectomy pars plana remove subretinal membrane $1,310.40 

67101-00 rpr rta dtchmnt 1+ sess crtx/dthrm +-drg $438.75 

67105-00 rpr rta dtchmnt 1+ sess pc +-drg subrta $975.00 

67107-00 rpr rta dtchmnt scll buckling +-implt $975.00 

67108-00 rpr rta dtchmnt w/vtrc any meth $1,355.25 

67110-00 rpr rta dtchmnt njx air/oth gas $556.73 

67112-00 rpr rta dtchmnt scll buckling/vtrc pt $1,101.75 

67113-00 rpr complex retina detach vitrectomy & memb peel $975.00 

67115-00 rls encircling matrl $390.00 

67120-00 rmvl implted matrl post sgm eo $390.00 

67121-00 rmvl implted matrl post sgm io $360.75 

67141-00 proph rta dtchmnt w/o drg 1+ sess crtx dthrm $390.00 

67145-00 proph rta dtchmnt w/o drg 1+ sess $390.00 

67208-00 dstrj loclzd les retina 1+ sess crtx dthrm $403.65 

67210-00 dstrj loclzd les retina 1+ sess pc $448.50 

67218-00 dstrj les retina 1+ sess radj impltj $624.00 

67220-00 dstrj les choroid pc 1+ sess $438.75 

67221-00 dstrj les choroid pdt $228.15 

67225-00 dstrj les choroid pdt 2nd eye 1 sess $22.82 

67227-00 destruction retinopathy 1+ sess diathermy $516.75 

67228-00 extensive retinopathy 1+ sess photocoagulation $516.75 

67229-00 extensive retinopathy 1+ sess preterm infant $637.94 

67250-00 scll rnfcmt spx w/o grf $711.75 

67255-00 scll rnfcmt spx w/grf $755.63 

67311-00 strabismus recession/rescj 1 hrzntl musc $585.00 

67312-00 strabismus recession/rescj 2 hrzntl musc $585.00 

67314-00 strabismus recession/rescj 1 ver musc $526.50 

99

Procedure & 


Tarifas 



67316-00 strabismus recession/rescj 2/more ver musc $526.50 

67318-00 strabismus any suprior oblq musc $526.50 

67320-00 trpos any eo musc $643.50 

67331-00 strabismus previous eye x involve eo musc $585.00 

67332-00 strabismus scarring eo musc/rstcv myopathy $585.00 

67334-00 strabismus post fixj sutr tq +-musc recession $526.50 

67335-00 plmt adjustable sutr strabismus $526.50 

67340-00 strabismus expl&/rpr detached eo musc $526.50 

67343-00 rls x10sv scar tiss w/o detaching eo musc spx $342.23 

67345-00 chemodnrvtj eo musc $140.40 

67346-00 biopsy extraocular muscle $141.38 

67400-00 orbt w/o b1 flap expl +-bx $585.00 

67405-00 orbt w/o b1 flap drg only $585.00 

67412-00 orbt w/o b1 flap rmvl les $594.75 

67413-00 orbt w/o b1 flap rmvl fb $585.00 

67414-00 orbt w/o b1 flap rmvl b1 dcmprn $526.50 

67415-00 fine ndl aspir orb cnts $68.25 

67420-00 orbt b1 flap/window lat rmvl les $877.50 

67430-00 orbt b1 flap/window lat rmvl fb $877.50 

67440-00 orbt b1 flap/window lat drg $877.50 

67445-00 orbt b1 flap/window lat rmvl b1 dcmprn $789.75 

67450-00 orbt b1 flap/window lat expl +-bx $877.50 

67500-00 retrobulbar njx med spx $19.50 

67505-00 retrobulbar njx alcohol $97.50 

67515-00 njx med/other sbst tenon's capsule $19.50 

67550-00 orb implt insj $497.25 

67560-00 orb implt rmvl/revj $390.00 

67570-00 optic nrv dcmprn $476.78 

67700-00 blepharotomy drg absc eyelid $19.50 

67710-00 severing tarsorrhaphy $19.50 

67715-00 canthotomy spx $19.50 

67800-00 exc chalazion 1 $48.75 

67801-00 exc chalazion mlt sm lid $58.50 

67805-00 exc chalazion mlt diff lids $68.25 

67808-00 exc chalazion anes req hospization 1/mlt $141.38 

67810-00 bx eyelid $48.75 

67820-00 corrj trichiasis epilation forceps only $14.63 

67825-00 corrj trichiasis epilation oth/thn forceps $39.00 

67830-00 corrj trichiasis inc lid mrgn $29.25 

67835-00 corrj trichiasis inc lid mrgn w/fr muc memb grf $58.50 

67840-00 exc les eyelid w/o clsr/w/smpl dir clsr $58.50 

67850-00 dstrj les lid mrgn

Procedure & 


Tarifas 



67906-00 rpr blpos suprior rectus fscal sling $585.00 

67908-00 rpr blpos conjunctivo-tarso-musc-levator rescj $451.43 

67909-00 rdctj >corrj ptosis $312.00 

67911-00 corrj lid retrcj $376.35 

67912-00 corrj lagophthalmos impltj upr eyelid lid load $345.74 

67914-00 rpr ectropion sutr $48.75 

67915-00 rpr ectropion thermocaut $48.75 

67916-00 rpr ectropion exc tarsal wedge $292.50 

67917-00 rpr ectropion x10sv $390.00 

67921-00 rpr entropion sutr $48.75 

67922-00 rpr entropion thermocaut $48.75 

67923-00 rpr entropion exc tarsal wedge $292.50 

67924-00 rpr entropion x10sv $390.00 

67930-00 sutr recent wnd eyelid prtl thkns $58.50 

67935-00 sutr recent wnd eyelid full thkns $107.25 

67938-00 rmvl embedded fb eyelid $52.65 

67950-00 canthoplasty $401.70 

67961-00 exc&rpr eyelid < one-4th lid mrgn $390.00 

67966-00 exc&rpr eyelid > one-4th lid mrgn $487.50 

67971-00 rcnstj eyelid full thkns < 2-3rd 1 stg $487.50 

67973-00 rcnstj eyelid full thkns tot lwr 1 stg $731.25 

67974-00 rcnstj eyelid full thkns tot upr 1 stg $828.75 

67975-00 rcnstj eyelid full thkns 2nd stg $78.00 

68020-00 inc cjnc drg cst $48.75 

68040-00 expression cjncl follicles $19.50 

68100-00 bx cjnc $48.75 

68110-00 exc les cjnc up 1 cm $48.75 

68115-00 exc les cjnc > 1 cm $125.78 

68130-00 exc les cjnc w/adj scl $214.50 

68135-00 dstrj les cjnc $19.50 

68200-00 scjncl njx $19.50 

68320-00 cjp cjncl grf/x10sv reargmt $487.50 

68325-00 cjp buccal muc memb grf $585.00 

68326-00 cjp rcnstj cul-de-sac cjncl grf/reargmt $370.50 

68328-00 cjp rcnstj cul-de-sac buccal muc memb grf $477.75 

68330-00 rpr symblepharon cjp w/o grf $263.25 

68335-00 rpr symblepharon fr grf cjnc/buccal muc memb $438.75 

68340-00 rpr symblepharon div $165.75 

68360-00 cjncl flap bridge/prtl spx $273.00 

68362-00 cjncl flap tot $360.75 

68400-00 inc drg lacrimal glnd $97.50 

68420-00 inc drg lacrimal sac $73.13 

68440-00 snip inc lacrimal punctum $19.50 

68500-00 exc lacrimal glnd xcp tum tot $487.50 

68505-00 exc lacrimal glnd xcp tum prtl $429.00 

68510-00 bx lacrimal glnd $195.00 

68520-00 exc lacrimal sac $487.50 

68525-00 bx lacrimal sac $195.00 

68530-00 rmvl fb/dacryolith lacrimal psages $492.38 

68540-00 exc lacrimal glnd tum frnt appr $585.00 

101

Procedure & 


Tarifas 



68550-00 exc lacrimal glnd tum invg osteom $575.25 

68700-00 plstc rpr canaliculi $414.38 

68705-00 corrj everted punctum caut $39.00 

68720-00 dacryocstorhinostomy $682.50 

68745-00 conjunctivorhinostomy w/o tube $770.25 

68750-00 conjunctivorhinostomy insj tube/stent $770.25 

68760-00 clsr lacrimal punctum thermocaut lig/laser $39.00 

68761-00 clsr lacrimal punctum plug ea $58.50 

68770-00 clsr lacrimal fstl spx $175.50 

68801-00 dilat lacrimal punctum +-irrg $19.50 

68810-00 probe nasolacrimal dux +-irrg $47.39 

68811-00 probe nasolacrimal dux +-irrg anes $97.50 

68815-00 probe nasolacrimal dux +-irrg insj tube/stent $128.12 

68816-00 probe nasolacrimal duct with catheter dilation $138.73 

68840-00 probe lacrimal canaliculi +-irrg $19.50 

68850-00 njx cntrst medium dacryocstograpy $29.25 

69000-00 drg xtrnl ear absc/hmtma smpl $19.50 

69005-00 drg xtrnl ear absc/hmtma comp $126.75 

69020-00 drg xtrnl aud canal absc $19.50 

69100-00 bx xtrnl ear $29.25 

69105-00 bx xtrnl aud canal $29.25 

69110-00 exc xtrnl ear prtl smpl rpr $97.50 

69120-00 exc xtrnl ear compl amp $195.00 

69140-00 exc exostosis xtrnl aud canal $487.50 

69145-00 exc soft tiss les xtrnl aud canal $48.75 

69150-00 rad exc xtrnl aud canal les w/o nck dsj $468.00 

69155-00 rad exc xtrnl aud canal les nck dsj $1,043.25 

69200-00 rmvl fb xtrnl aud canal w/o anes $19.50 

69205-00 rmvl fb xtrnl aud canal anes $82.88 

69210-00 rmvl impacted cerumen spx 1/bth ears $17.55 

69220-00 dbrdmt mstdc cavity smpl $39.00 

69222-00 dbrdmt mstdc cavity cplx $117.00 

69300-00 otoplasty protruding ear +-size rdctj $487.50 

69310-00 rcnstj xtrnl aud canal spx $561.60 

69320-00 rcnstj xtrnl aud canal cgen atresia 1 stg $975.00 

69400-00 eustachian tube nfltj transnsl cathj $14.63 

69401-00 eustachian tube nfltj transnsl w/o cathj $9.75 

69405-00 eustachian tube cathj transtympanic $80.93 

69420-00 mrgt aspir&/eustachian tube nfltj $29.25 

69421-00 mrgt aspir&/eustachian tube nfltj anes $76.34 

69424-00 ventilating tube rmvl anes $29.25 

69433-00 tmpst local/topical anes $48.75 

69436-00 tmpst anes $243.75 

69440-00 middle ear expl thru postaur/ear canal inc $487.50 

69450-00 tympanolss transcanal $780.00 

69501-00 transmastoid antrt $409.50 

69502-00 mstdc compl $487.50 

69505-00 mstdc modf rad $780.00 

69511-00 mstdc rad $780.00 

69530-00 petrous apicectomy rad mstdc $1,160.25 

102

Procedure & 


Tarifas 



69535-00 rescj temporal b1 xtrnl $1,452.75 

69540-00 exc aural polyp $39.00 

69550-00 exc aural glomus tum transcanal $897.00 

69552-00 exc aural glomus tum transmastoid $1,082.25 

69554-00 exc aural glomus tum extnd $1,189.50 

69601-00 revj mstdc rsltg compl mstdc $877.50 

69602-00 revj mstdc rsltg modf rad mstdc $926.25 

69603-00 revj mstdc rsltg rad mstdc $950.63 

69604-00 revj mstdc rsltg tmpp $1,126.13 

69605-00 revj mstdc w/apicectomy $1,008.15 

69610-00 tympanic memb rpr +-sit prepj prf8j patch $19.50 

69620-00 myringoplasty $780.00 

69631-00 tmpp w/o mstdc 1st/revj w/o ocr $975.00 

69632-00 tmpp w/o mstdc 1st/revj ocr $1,072.50 

69633-00 tmpp w/o mstdc 1st/revj prosth torp $1,072.50 

69635-00 tmpp antrt/mastoidotomy w/o ocr $1,170.00 

69636-00 tmpp antrt/mastoidotomy ocr $1,296.75 

69637-00 tmpp antrt/mastoidotomy prosth torp $1,092.00 

69641-00 tmpp mstdc w/o ocr $994.50 

69642-00 tmpp mstdc ocr $1,126.13 

69643-00 tmpp mstdc ntc/rcnsted wall w/o ocr $1,126.13 

69644-00 tmpp mstdc ntc/rcnsted canal wall ocr $1,189.50 

69645-00 tmpp mstdc rad/compl w/o ocr $994.50 

69646-00 tmpp mstdc rad/compl ocr $1,126.13 

69650-00 stapes moblj $682.50 

69660-00 stapedectomy/stapedotomy $975.00 

69661-00 stapedectomy/stapedotomy w/footplate drill out $830.70 

69662-00 revj stapedectomy/stapedotomy $1,140.75 

69666-00 rpr oval window fstl $975.00 

69667-00 rpr round window fstl $975.00 

69670-00 mastoid obltrj spx $780.00 

69676-00 tympanic neurectomy $538.20 

69700-00 clsr postaur fstl mastoid spx $243.75 

69710-00 impltj/rplcmt emgnt b1 cndj dev temporal b1 $702.00 

69711-00 rmvl/rpr emgnt b1 cndj dev temporal b1 $482.63 

69714-00 impltj oi implt b1 w/o mstdc $665.15 

69715-00 impltj oi implt b1 mstdc $846.79 

69717-00 rplcmt oi implt b1 w/o mstdc $676.55 

69718-00 rplcmt oi implt b1 mstdc $850.30 

69720-00 dcmprn nrv itprl lat geniculate $975.00 

69725-00 dcmprn nrv itprl medial geniculate $1,160.25 

69740-00 sutr nrv itprl +-grf/dcmprn lat geniculate $1,170.00 

69745-00 sutr nrv itprl +-grf/dcmprn medial geniculate $1,355.25 

69801-00 labyrinthotomy transcanal $975.00 

69802-00 labyrinthotomy mastoidectomy $1,033.50 

69805-00 endolymphatic sac w/o shunt $1,033.50 

69806-00 endolymphatic sac shunt $1,140.75 

69820-00 fenestration semicircular canal $975.00 

69840-00 revj fenestration opration $585.00 

69905-00 labyrinthectomy transcanal $975.00 

103

Procedure & 


Tarifas 



69910-00 labyrinthectomy mstdc $1,296.75 

69915-00 vstblr nrv sctj translabyrinthine appr $1,092.00 

69930-00 cochlear dev impltj +-mstdc $1,435.20 

69950-00 vstblr nrv sctj transcrnl $965.25 

69955-00 tot facial nrv dcmprn&/rpr $838.50 

69960-00 dcmprn int aud canal $916.50 

69970-00 rmvl tum temporal b1 $1,033.50 

90470-00 immune admin h1n1 im/nasal incl cnsl $3.90 

90471-00 imadm prq id subq/im njxs 1 vacc $3.90 

90472-00 imadm prq id subq/im njxs ea vacc $3.90 

90473-00 imadm intransl/oral 1 vacc $3.90 

90474-00 imadm intransl/oral ea vacc $3.90 

90633-00 hepatitis a vaccine pediatric 2 dose schedule im $3.90 

90636-00 hepatitis a & b vaccine hepa-hepb adult im $3.90 

90645-00 hemophilus influenza b vacc hboc conj 4 dose im $3.90 

90646-00 hemophilus influenza b vaccine prp-d booster im $3.90 

90647-00 hemophilus influenza b vaccine prp-omp 3 dose im $3.90 

90648-00 hemophilus influenza b vaccine prp-t 4 dose im $3.90 

90649-00 human papilloma virus vaccine quadriv 3 dose im $3.90 

90650-00 human papilloma virus bivalent vaccine 3 dose im $3.90 

90655-00 influenza virus vacc split prsrv free 6-35 mo im $3.90 

90656-00 influenza virus vacc split prsrv fr 3 years + im $3.90 

90657-00 influenza virus vaccine split virus 6-35 mo im $3.90 

90658-00 influenza virus vaccine split virus 3 years + im $3.90 

90660-00 influenza virus vaccine live intranasal $3.90 

90669-00 pneumococcal conj vaccine 7 valent im $3.90 

90670-00 pneumococcal conj vaccine 13 valent im $3.90 

90680-00 rotavirus vaccine pentavalent 3 dose live oral $3.90 

90681-00 rotavirus vacc human attenuated 2 dose live oral $3.90 

90696-00 dtap-ipv inactivated if admin pts age 4-6 yrs im $3.90 

90698-00 dtap-hib-ipv vaccine im $3.90 

90700-00 dtap vaccine < 7 yr im $3.90 

90701-00 diphtheria tetanus toxoid pertussis vaccine im $3.90 

90702-00 diphtheria tetanus toxoid adsorbed < 7 yr im $3.90 

90703-00 tetanus toxoid adsorbed intramuscular $3.90 

90704-00 mumps virus vaccine live subcutaneous $3.90 

90705-00 measles virus vaccine live subcutaneous $3.90 

90706-00 rubella virus vaccine live subcutaneous $3.90 

90707-00 measles mumps rubella virus vaccine live subq $3.90 

90708-00 measles & rubella virus vaccine live subq $3.90 

90710-00 measles mumps rubella varicella vacc live subq $3.90 

90712-00 poliovirus vaccine any live oral $3.90 

90713-00 poliovirus vaccine inactivated subq/im $3.90 

90714-00 td toxoids adsorbed prsrv fr 7 yr + im $3.90 

90715-00 tdap vaccine 7 yr + im $3.90 

90716-00 varicella virus vaccine live subq $3.90 

90718-00 tetanus & diphtheria toxoids adsorbed 7 yr + im $3.90 

90720-00 dtp-hib vaccine intramuscular $3.90 

90721-00 dtap-hib vaccine intramuscular $3.90 

90723-00 dtap-hepb-ipv vaccine intramuscular $3.90 

104

Procedure & 


Tarifas 



90732-00 pneumococcal polysac vaccine 23-v 2 yr + subq/im $3.90 

90733-00 meningococcal polysac vaccine subcutaneous $3.90 

90734-00 meningococcal conj vaccine tetravalent im $3.90 

90744-00 hepatitis b vaccine pediatric3 dose im $3.90 

90746-00 hepatitis b vaccine adult dosage intramuscular $3.90 

90747-00 hepatitis b vaccine dialysis dosage 4 dose im $3.90 

90748-00 hepb-hib vaccine intramuscular $3.90 

90801-00 psyc dx interview xm $39.98 

90805-00 ipi-ob-m/s office 20-30 min medical e/m $39.98 

90806-00 ipi-ob-m/s office 45-50 min $39.98 

90935-00 hemo px w/1 phys eval $68.25 

90937-00 hemo repeated eval +-revj dial rx $96.53 

90945-00 dial oth/thn hemo 1 phys eval $68.25 

90947-00 dial oth/thn hemo repeated phys evals $105.50 

90951-00 esrd related svc monthly visits $159.90 

90952-00 esrd related svc monthly visits $159.90 

90958-00 esrd related svc monthly 12-19 yr old 2/3 visits $159.90 

90959-00 esrd related svc monthly 12-19 yr old 1 visit $159.90 

90960-00 esrd related svc monthly 20&> yr old 4/> visits $159.90 

90961-00 esrd related svc monthly 20&> yr old 2/3 visits $159.90 

90962-00 esrd related svc monthly 20&> yr old 1 visit $159.90 

90963-00 esrd svc home dialysis full month

Procedure & 


Tarifas 



91065-00 brth hydrogen tst $22.43 

91065-26 brth hydrogen tst $5.38 

91065-TC brth hydrogen tst $8.97 

91110-00 gi trc img intral esoph thru ile phys i&r $681.07 

91117-00 colon motility stdy min 6 hr cont record w/i&r $86.25 

91122-00 anrct mano $58.50 

92002-00 oph medical xm&eval intrm new pt $24.38 

92012-00 oph medical xm&eval intrm est pt $19.50 

92015-00 deter refractive state $14.63 

92018-00 oph xm&eval anes +-mnpj globe compl $34.22 

92019-00 oph xm&eval anes +-mnpj globe lmtd $28.96 

92020-00 gonioscopy spx $7.02 

92060-00 sensimotr xm w/mlt meas oc devij w/i&r spx $20.18 

92060-26 sensimotr xm w/mlt meas oc devij w/i&r spx $4.85 

92060-TC sensimotr xm w/mlt meas oc devij w/i&r spx $8.07 

92065-00 orthoptic&/pleoptic trainj $3.51 

92065-26 orthoptic&/pleoptic trainj $0.84 

92065-TC orthoptic&/pleoptic trainj $1.40 

92081-00 vis fld xm uni/bi i&r lmtd xm $15.80 

92081-26 vis fld xm uni/bi i&r lmtd xm $3.79 

92081-TC vis fld xm uni/bi i&r lmtd xm $6.32 

92082-00 vis fld xm uni/bi i&r intrm xm $20.18 

92082-26 vis fld xm uni/bi i&r intrm xm $4.85 

92082-TC vis fld xm uni/bi i&r intrm xm $8.07 

92083-00 vis fld xm uni/bi i&r extnd xm $24.57 

92083-26 vis fld xm uni/bi i&r extnd xm $5.90 

92083-TC vis fld xm uni/bi i&r extnd xm $9.83 

92100-00 srl tnmtry spx mlt meas io press $10.53 

92120-00 tngrphy i&r rec indentaj tnmtr sucj $6.14 

92130-00 tngrphy water provocation $13.16 

92133-00 computerized ophthalmic imaging optic nerve $13.85 

92133-26 computerized ophthalmic imaging optic nerve $5.55 

92133-TC computerized ophthalmic imaging optic nerve $8.31 

92134-00 computerized ophthalmic imaging retina $27.72 

92134-26 computerized ophthalmic imaging retina $11.09 

92134-TC computerized ophthalmic imaging retina $16.63 

92136-00 oph bmtry prtl coher intrfrmtry io lens pwr cal $17.55 

92136-26 oph bmtry prtl coher intrfrmtry io lens pwr cal $8.42 

92136-TC oph bmtry prtl coher intrfrmtry io lens pwr cal $14.04 

92140-00 provocative tsts glc i&r w/o tngrphy $39.00 

92225-00 opscpy extnd rta drawing i&r 1st $18.87 

92226-00 opscpy extnd rta drawing i&r sbsq $14.92 

92230-00 fluorescein angioscopy i&r $40.80 

92235-00 fluorescein angrph i&r $40.80 

92235-26 fluorescein angrph i&r $19.59 

92235-TC fluorescein angrph i&r $32.64 

92240-00 indocya9-green angrph i&r $41.24 

92240-26 indocya9-green angrph i&r $19.79 

92240-TC indocya9-green angrph i&r $32.99 

92250-00 fundus phtgrphy i&r $11.41 

106

Procedure & 


Tarifas 



92250-26 fundus phtgrphy i&r $2.74 

92250-TC fundus phtgrphy i&r $4.56 

92260-00 ophthalmodynamometry $11.41 

92265-00 ndl oculoemg 1+ eo musc 1/ou i&r $107.25 

92265-26 ndl oculoemg 1+ eo musc 1/ou i&r $25.74 

92265-TC ndl oculoemg 1+ eo musc 1/ou i&r $42.90 

92270-00 electro-oculograpy i&r $39.00 

92270-26 electro-oculograpy i&r $9.36 

92270-TC electro-oculograpy i&r $15.60 

92275-00 electroretinograpy i&r $97.50 

92275-26 electroretinograpy i&r $25.74 

92275-TC electroretinograpy i&r $42.90 

92285-00 xtrnl oc phtgrphy i&r progress $11.41 

92285-26 xtrnl oc phtgrphy i&r progress $2.74 

92285-TC xtrnl oc phtgrphy i&r progress $4.56 

92286-00 spec ant sgm phtgrphy i&r speclr endothelial $42.12 

92286-26 spec ant sgm phtgrphy i&r speclr endothelial $10.11 

92286-TC spec ant sgm phtgrphy i&r speclr endothelial $16.85 

92287-00 spec ant sgm phtgrphy i&r fluorescein angrph $64.06 

92502-00 otolaryngologic xm anes $78.00 

92504-00 binoc mic $107.25 

92506-00 eval sp lang voice comunicaj&/aud $34.13 

92507-00 tx sp lang comunicaj pcx disorder indiv $21.94 

92511-00 nasopharyngoscopy w/endoscope spx $97.50 

92512-00 nsl funcj std $24.88 

92516-00 facial nrv funcj std $29.25 

92520-00 laryn funcj std $35.10 

92526-00 tx swlng dysf&/oral funcj feeding $25.40 

92533-00 caloric vstblr tst ea irrigation $30.71 

92541-00 spon nystagmus tst $21.94 

92541-26 spon nystagmus tst $5.27 

92541-TC spon nystagmus tst $8.78 

92542-00 posal nystagmus tst $21.94 

92542-26 posal nystagmus tst $5.27 

92542-TC posal nystagmus tst $8.78 

92543-00 caloric vstblr tst ea irrigation rec $30.23 

92543-26 caloric vstblr tst ea irrigation rec $7.25 

92543-TC caloric vstblr tst ea irrigation rec $12.09 

92544-00 okn tst bidirec foveal/prph stimj rec $17.55 

92544-26 okn tst bidirec foveal/prph stimj rec $4.21 

92544-TC okn tst bidirec foveal/prph stimj rec $7.02 

92545-00 oscillating tracking tst w/rec $21.94 

92545-26 oscillating tracking tst w/rec $5.27 

92545-TC oscillating tracking tst w/rec $8.78 

92546-00 sinusoidal ver axis rotational tstg $21.94 

92546-26 sinusoidal ver axis rotational tstg $5.27 

92546-TC sinusoidal ver axis rotational tstg $8.78 

92547-00 use ver eltrds $8.78 

92552-00 pure tone audiomtry air only $10.73 

92553-00 pure tone audiomtry air&b1 $13.16 

107

Procedure & 


Tarifas 



92555-00 sp audiomtry threshold $21.50 

92556-00 sp audiomtry threshold sp recognij $26.33 

92557-00 compre audiomtry threshold eval sp recognij $34.13 

92560-00 bekesy audiomtry scr $10.53 

92561-00 bekesy audiomtry dx $13.16 

92562-00 loudness balance binaural/monaural $10.75 

92563-00 tone decay $11.70 

92564-00 short increment sensitivity index $13.65 

92565-00 stenger tst pure tone $11.70 

92567-00 tympanometry $15.60 

92568-00 acous rflx threshold $13.16 

92571-00 filtered sp $10.24 

92572-00 staggered spondaic word $2.43 

92575-00 sensorineural acuity lvl $7.98 

92576-00 synth sentence id $11.90 

92577-00 stenger sp $19.34 

92579-00 vis rnfcmt audiomtry $19.51 

92582-00 conditioning play audiomtry $19.51 

92583-00 select picture audiomtry $23.85 

92584-00 electrocochleograpy $65.81 

92585-00 aep era&/tstg cns compre $68.25 

92585-26 aep era&/tstg cns compre $16.38 

92585-TC aep era&/tstg cns compre $27.30 

92586-00 aep era&/tstg cns lmtd $49.58 

92587-00 evoked otoacous emijs lmtd $41.18 

92587-26 evoked otoacous emijs lmtd $16.48 

92587-TC evoked otoacous emijs lmtd $24.71 

92588-00 evoked otoacous emijs compre/dx eval $53.63 

92601-00 alys cochlear implt pt sbsq reprgrmg $38.79 

92607-00 rx sp-genratj augmnt&comunicaj dev 1st hr $80.73 

92608-00 rx sp-genratj augmnt&comunicaj dev ea 30 min $15.80 

92609-00 ther sp-genratj dev prgrmg&modificaj $15.80 

92610-00 eval oral&pharyngeal swlng funcj $30.71 

92611-00 motion fluor eval swlng funcj c/v rec $33.35 

92612-00 flx fibopt ndsc eval swlng c/v rec $64.38 

92613-00 flx fibopt ndsc eval swlng c/v rec phys i&r $36.45 

92614-00 flx fibopt ndsc eval laryn sens c/v rec $62.83 

92615-00 flx fibopt ndsc eval laryn sens phys i&r $32.75 

92616-00 flx fibopt ndsc eval swlng&laryn sens c/v rec $94.36 

92617-00 flx fibopt ndsc eval swlng&laryn sens phys i&r $40.65 

92620-00 eval ctr aud funcj w/reprt 1st 60 min $30.23 

92621-00 eval ctr aud funcj w/reprt ea 15 min $7.09 

92630-00 aud rhab prelng hearing loss $39.00 

92640-00 analysis w/prgrmg aud brainstem implant pr hr $34.43 

92950-00 cardiopulm resuscitation $97.50 

92953-00 temp tc pacg $13.16 

92960-00 cardioversion elective arrhyt xtrnl $170.63 

108

Procedure & 


Tarifas 



92961-00 cardioversion elective arrhyt int spx $177.26 

92970-00 cardioassist-meth crc assist int $127.24 

92973-00 prq trluml c thrmbc $131.63 

92974-00 tcat plmt radj dlvr dev sbsq c iv brachytx $118.46 

92975-00 thrombolss c intrac nfs slctv c angrph $339.04 

92977-00 thrombolss c iv nfs $191.10 

92978-00 iv us c vsl dx&/ther 1st vsl $193.05 

92978-26 iv us c vsl dx&/ther 1st vsl $77.22 

92978-TC iv us c vsl dx&/ther 1st vsl $115.83 

92979-00 iv us c vsl dx&/ther ea vsl $119.34 

92979-26 iv us c vsl dx&/ther ea vsl $47.74 

92979-TC iv us c vsl dx&/ther ea vsl $71.60 

92980-00 tcat plmt an intrac stent prq 1 vsl $1,140.75 

92981-00 tcat plmt intrac stent prq ea vsl $298.35 

92982-00 prq trluml c balo angiop 1 vsl $975.00 

92984-00 prq trluml c balo angiop ea vsl $185.25 

92986-00 prq balo vlvp aortic valve $921.38 

92987-00 prq balo vlvp mitral valve $986.31 

92990-00 prq balo vlvp pulm valve $731.25 

92995-00 prq trluml c athrc 1 vsl $578.96 

92996-00 prq trluml c athrc ea vsl $154.51 

92997-00 prq trluml p-art balo angiop 1 vsl $572.66 

92998-00 prq trluml p-art balo angiop ea vsl $280.80 

93000-00 ecg routine ecg w/least 12 lds w/i&r $17.00 

93005-00 ecg routine ecg w/least 12 lds trcg only w/o i&r $6.80 

93010-00 Electrocardiogram report, ecg routine ecg w/least 12 lds i&r only $10.20 

93015-00 cv strs tst xers&/or rx cont ecg phys si&r $146.25 

93016-00 cv strs tst xers&/or rx cont ecg phys supvj $30.27 

93017-00 cv strs tst xers&/or rx cont ecg trcg only $58.50 

93018-00 cv strs tst xers&/or rx cont ecg i&r only $30.27 

93024-00 ergonovine provocation tst $84.55 

93024-26 ergonovine provocation tst $54.75 

93024-TC ergonovine provocation tst $29.81 

93025-00 microvolt t-wave assess ventricular arrhythmias $240.59 

93025-26 microvolt t-wave assess ventricular arrhythmias $35.01 

93025-TC microvolt t-wave assess ventricular arrhythmias $205.58 

93040-00 rhythm ecg 1-3 lds w/i&r $29.25 

93041-00 rhythm ecg 1-3 lds trcg only w/o i&r $11.70 

93042-00 rhythm ecg 1-3 lds i&r only $17.55 

93224-00 xtrnl ecg up to 48 hr record scan stor w/phy r&i $146.25 

93225-00 xtrnl ecg up to 48 hr recording $58.50 

93226-00 external ecg scanning analysis report $66.30 

93227-00 xtrnl ecg continuous rhythm phys review&interpj $87.75 

93268-00 xtrnl pt activ ecg transmis phys r&i 30 days $215.28 

93270-00 xtrnl pt activated ecg record monitor 30 days $131.63 

93271-00 Ecg/monitoring and analysis, xtrnl pt activated ecg rec dwnld 30 days $438.75 

93272-00 xtrnl pt activtd ecg dwnld 30 days phys r&i $96.53 

93278-00 saecg +-ecg $39.49 

93278-26 saecg +-ecg $23.69 

93278-TC saecg +-ecg $15.80 

109

Procedure & 


Tarifas 



93279-00 program eval implantable in prsn 1 ld pacemaker $40.95 

93279-26 program eval implantable in prsn 1 ld pacemaker $24.57 

93279-TC program eval implantable in prsn 1 ld pacemaker $16.38 

93280-00 program eval implantable in persn dual ld pacer $46.80 

93280-26 program eval implantable in persn dual ld pacer $28.08 

93280-TC program eval implantable in persn dual ld pacer $18.72 

93281-00 program eval implantable in prsn multi ld pacer $55.28 

93281-26 program eval implantable in prsn multi ld pacer $33.17 

93281-TC program eval implantable in prsn multi ld pacer $22.11 

93282-00 program eval implantable in persn 1 ld card/dfb $51.68 

93282-26 program eval implantable in persn 1 ld card/dfb $31.01 

93282-TC program eval implantable in persn 1 ld card/dfb $20.67 

93283-00 progrm eval implantable in prsn dual l card/dfb $62.40 

93283-26 progrm eval implantable in prsn dual l card/dfb $37.44 

93283-TC progrm eval implantable in prsn dual l card/dfb $24.96 

93284-00 progrm eval implantable in prsn mlt ld card/dfb $72.83 

93284-26 progrm eval implantable in prsn mlt ld card/dfb $43.70 

93284-TC progrm eval implantable in prsn mlt ld card/dfb $29.13 

93285-00 program eval implantable dev in prsn ilr system $34.13 

93285-26 program eval implantable dev in prsn ilr system $20.48 

93285-TC program eval implantable dev in prsn ilr system $13.65 

93286-00 peri-px eval&program in prsn pacemaker system $19.31 

93286-26 peri-px eval&program in prsn pacemaker system $11.58 

93286-TC peri-px eval&program in prsn pacemaker system $7.72 

93287-00 peri-px eval&program cardioverter/defibrillator $25.45 

93287-26 peri-px eval&program cardioverter/defibrillator $15.27 

93287-TC peri-px eval&program cardioverter/defibrillator $10.18 

93288-00 interrogation eval in person 1/dual/mlt lead pm $30.23 

93288-26 interrogation eval in person 1/dual/mlt lead pm $18.14 

93288-TC interrogation eval in person 1/dual/mlt lead pm $12.09 

93289-00 interrogation eval f2f 1/dual/mlt leads cvdfb $46.80 

93289-26 interrogation eval f2f 1/dual/mlt leads cvdfb $28.08 

93289-TC interrogation eval f2f 1/dual/mlt leads cvdfb $18.72 

93290-00 interrogation eval f2f implantable cv mntr sys $22.82 

93290-26 interrogation eval f2f implantable cv mntr sys $13.69 

93290-TC interrogation eval f2f implantable cv mntr sys $9.13 

93291-00 interrogation evaluation in person ilr system $29.25 

93291-26 interrogation evaluation in person ilr system $17.55 

93291-TC interrogation evaluation in person ilr system $11.70 

93292-00 interrogation eval in person wr defibrillator $27.30 

93292-26 interrogation eval in person wr defibrillator $16.38 

93292-TC interrogation eval in person wr defibrillator $10.92 

93303-00 complete tthrc echo congenital cardiac anomaly $175.50 

93303-26 complete tthrc echo congenital cardiac anomaly $70.20 

93303-TC complete tthrc echo congenital cardiac anomaly $105.30 

93304-00 f-up/limited tthrc echo congenital car anomaly $93.02 

93304-26 f-up/limited tthrc echo congenital car anomaly $37.21 

93304-TC f-up/limited tthrc echo congenital car anomaly $55.81 

93306-00 echo tthrc r-t 2d -+m-mode compl spec&color dop $268.00 

93306-26 echo tthrc r-t 2d -+m-mode compl spec&color dop $121.20 

110

Procedure & 


Tarifas 



93306-TC echo tthrc r-t 2d -+m-mode compl spec&color dop $181.80 

93307-00 tthrc r-t img 2d +-m-mode rec compl $92.63 

93307-26 tthrc r-t img 2d +-m-mode rec compl $55.58 

93307-TC tthrc r-t img 2d +-m-mode rec compl $37.05 

93308-00 tthrc r-t img 2d +-m-mode rec f-up/lmtd $76.05 

93308-26 tthrc r-t img 2d +-m-mode rec f-up/lmtd $45.63 

93308-TC tthrc r-t img 2d +-m-mode rec f-up/lmtd $30.42 

93312-00 tee r-t img 2d w/prb img acquisj i&r $161.85 

93312-26 tee r-t img 2d w/prb img acquisj i&r $97.11 

93312-TC tee r-t img 2d w/prb img acquisj i&r $64.74 

93313-00 tee r-t img 2d w/probe plmt only $46.80 

93314-00 tee r-t img 2d img acquisj i&r only $97.11 

93314-26 tee r-t img 2d img acquisj i&r only $38.84 

93314-TC tee r-t img 2d img acquisj i&r only $58.27 

93315-00 tee cgen car anoml prb acquisj i&r $207.97 

93315-26 tee cgen car anoml prb acquisj i&r $83.17 

93315-TC tee cgen car anoml prb acquisj i&r $124.80 

93316-00 tee cgen car anoml plmt prb only $46.41 

93316-26 tee cgen car anoml plmt prb only $18.56 

93316-TC tee cgen car anoml plmt prb only $25.90 

93317-00 tee cgen car anoml img acquisj i&r $164.97 

93317-26 tee cgen car anoml img acquisj i&r $65.99 

93317-TC tee cgen car anoml img acquisj i&r $98.98 

93318-00 tee probe monitoring assmt car pump function $92.96 

93318-26 tee probe monitoring assmt car pump function $37.19 

93318-TC tee probe monitoring assmt car pump function $55.77 

93320-00 dop echo compl $97.50 

93320-26 dop echo compl $58.50 

93320-TC dop echo compl $39.00 

93321-00 dop echo p-w&/or cont w/spectral f-up/lmtd std $50.70 

93321-26 dop echo p-w&/or cont w/spectral f-up/lmtd std $30.42 

93321-TC dop echo p-w&/or cont w/spectral f-up/lmtd std $20.28 

93325-00 dop echo color flo vel mapg $71.18 

93325-26 dop echo color flo vel mapg $28.47 

93325-TC dop echo color flo vel mapg $42.71 

93350-00 echo tthrc r-t 2d -+m-mode complete rest&strs $170.63 

93350-26 echo tthrc r-t 2d -+m-mode complete rest&strs $102.38 

93350-TC echo tthrc r-t 2d -+m-mode complete rest&strs $68.25 

93451-00 right heart cath o2 saturation & cardiac output $253.50 

93451-26 right heart cath o2 saturation & cardiac output $253.50 

93452-00 l hrt cath w/njx l ventriculography img s&i $390.00 

93452-26 l hrt cath w/njx l ventriculography img s&i $390.00 

93453-00 r & l hrt cath w/njx l ventriculog img s&i $487.50 

93453-26 r & l hrt cath w/njx l ventriculog img s&i $487.50 

93454-00 cath plmt & njx coronary art angio img s&i $304.20 

93454-26 cath plmt & njx coronary art angio img s&i $304.20 

93455-00 cath plmt & njx coronary art/grft angio img s&i $175.50 

93455-26 cath plmt & njx coronary art/grft angio img s&i $175.50 

93456-00 cath plmt r hrt & arts w/njx & angio img s&i $267.38 

93456-26 cath plmt r hrt & arts w/njx & angio img s&i $267.38 

111

Procedure & 


Tarifas 



93457-00 cath plmt r hrt/arts/grfts w/njx&angio img s&i $303.23 

93457-26 cath plmt r hrt/arts/grfts w/njx&angio img s&i $303.23 

93458-00 cath plmt l hrt & arts w/njx & angio img s&i $390.00 

93458-26 cath plmt l hrt & arts w/njx & angio img s&i $390.00 

93459-00 cath plmt l hrt/arts/grfts wnjx & angio img s&i $390.00 

93459-26 cath plmt l hrt/arts/grfts wnjx & angio img s&i $390.00 

93460-00 r & l hrt cath winjx hrt art& l ventr img s&i $487.50 

93460-26 r & l hrt cath winjx hrt art& l ventr img s&i $487.50 

93461-00 r&l hrt cath w/injec hrt art/grft&l vent img s&i $487.50 

93461-26 r&l hrt cath w/injec hrt art/grft&l vent img s&i $487.50 

93462-00 left heart cath by transeptal puncture $120.26 

93462-26 left heart cath by transeptal puncture $120.26 

93463-00 medication admin & hemodynamic measurment $64.35 

93463-26 medication admin & hemodynamic measurment $64.35 

93464-00 physiologic exercise study & hemodynamic measure $154.05 

93464-26 physiologic exercise study & hemodynamic measure $154.05 

93503-00 insertion flow directed catheter for monitoring $78.00 

93503-26 insertion flow directed catheter for monitoring $78.00 

93505-00 endomyocardial biopsy $390.00 

93505-26 endomyocardial biopsy $390.00 

93530-00 r hrt catheterization congenital cardiac anomaly $623.03 

93530-26 r hrt catheterization congenital cardiac anomaly $249.21 

93530-TC r hrt catheterization congenital cardiac anomaly $498.42 

93531-00 R & l heart cath congenital, cmbn r hrt & retrograde l hrt cathj cgen anomaly $1,691.79 

93531-26 cmbn r hrt & retrograde l hrt cathj cgen anomaly $676.72 

93531-TC cmbn r hrt & retrograde l hrt cathj cgen anomaly $1,353.42 

93532-00 cmbn r hrt t-septal l hrt cathj ntc septum cgen $1,737.09 

93532-26 cmbn r hrt t-septal l hrt cathj ntc septum cgen $694.83 

93532-TC cmbn r hrt t-septal l hrt cathj ntc septum cgen $1,389.69 

93533-00 cmbn r hrt t-septal l hrt cathj septal opng cgen $1,567.03 

93533-26 cmbn r hrt t-septal l hrt cathj septal opng cgen $626.81 

93533-TC cmbn r hrt t-septal l hrt cathj septal opng cgen $1,253.62 

93561-00 indic dil std artl&/or ven cathj w/outp meas $78.00 

93562-00 indic dil std artl&/or ven cathj sbsq outp meas $19.50 

93563-00 njx sel hrt art congenital hrt cath w/s&i $35.10 

93563-26 njx sel hrt art congenital hrt cath w/s&i $35.10 

93564-00 njx sel hrt art/grft congenital hrt cath w/s&i $35.59 

93564-26 njx sel hrt art/grft congenital hrt cath w/s&i $35.59 

93565-00 njx sel l vent/atrial angio hrt cath w/s&i $27.30 

93565-26 njx sel l vent/atrial angio hrt cath w/s&i $27.30 

93566-00 njx sel r vent/atrial angio hrt cath w/s&i $105.30 

93566-26 njx sel r vent/atrial angio hrt cath w/s&i $105.30 

93567-00 njx supravalv aortog hrt cath w/s&i $50.90 

93567-26 njx supravalv aortog hrt cath w/s&i $50.90 

93568-00 njx pulmonary angio hrt cath w/s&i $69.32 

93568-26 njx pulmonary angio hrt cath w/s&i $69.32 

93571-00 iv dop vel&/or press c/flo rsrv meas 1st vsl $198.32 

93571-26 iv dop vel&/or press c/flo rsrv meas 1st vsl $79.33 

93571-TC iv dop vel&/or press c/flo rsrv meas 1st vsl $118.99 

93572-00 iv dop vel&/or press c/flo rsrv meas addl vsl $121.10 

112

Procedure & 


Tarifas 



93572-26 iv dop vel&/or press c/flo rsrv meas addl vsl $48.44 

93572-TC iv dop vel&/or press c/flo rsrv meas addl vsl $72.66 

93580-00 prq tcat clsr cgen intratrl comunicaj w/implt $714.29 

93581-00 prq tcat clsr cgen ventr septal dfct w/implt $954.72 

93600-00 bundle of his recording $321.75 

93602-00 intra-atrial recording $117.00 

93603-00 r ventricular rec $170.63 

93609-00 intra-vntr mapg tchycar sit w/cath mnpj $463.13 

93610-00 intra-atrial pacing $180.35 

93612-00 intraventrical pacing $187.22 

93613-00 icar ephys 3-dimensional mapg $276.41 

93615-00 esophgl rec atr egrm +-ventr egrm $43.88 

93615-26 esophgl rec atr egrm +-ventr egrm $17.55 

93615-TC esophgl rec atr egrm +-ventr egrm $26.33 

93616-00 esophgl rec atr egrm +-ventr egrm w/pacg $63.18 

93616-26 esophgl rec atr egrm +-ventr egrm w/pacg $25.27 

93616-TC esophgl rec atr egrm +-ventr egrm w/pacg $37.91 

93618-00 indctj arrhyt elec pacg $188.18 

93619-00 compre electrophysiologic w/o arrhyt induction $952.58 

93620-00 compre electrophysiologic arrhythmia induction $819.00 

93620-26 compre electrophysiologic arrhythmia induction $327.60 

93620-TC compre electrophysiologic arrhythmia induction $491.40 

93621-00 compre electrophysiologic w/l atr pac/rec $1,207.44 

93622-00 compre electrophysiologic w/l ventr pac/rec $1,210.95 

93623-00 programmed stimj&pacg after iv drug nfs $230.10 

93624-00 electrophysiologic follow-up w/pac/rec w/arrhyt $219.38 

93631-00 intraop epicar&endocar pacg&mapg $568.43 

93640-00 ephys eval pacg cvdfb lds initial implan/replace $455.33 

93641-00 ephys eval pacg cvdfb lds w/tstg of pulse gen $471.68 

93642-00 ephys eval pacg cvdfb prgrmg/reprgrmg parameters $430.26 

93642-26 ephys eval pacg cvdfb prgrmg/reprgrmg parameters $103.26 

93642-TC ephys eval pacg cvdfb prgrmg/reprgrmg parameters $172.11 

93650-00 icar catheter ablation atrioventr node function $2,457.00 

93651-00 Ablate heart dysrhythm focus, icar cath abltj arrhytgnic foc supventr tchycar $2,632.50 

93652-00 icar cath ablation arrhytgnic foc ventr tchycar $2,676.38 

93662-00 ice during ther/dx ivntj incl img s&i $196.95 

93668-00 prph artl disease rhab pr sess $36.86 

93701-00 biompedance-derived physiologic cv analysis $32.82 

93701-26 biompedance-derived physiologic cv analysis $8.10 

93701-TC biompedance-derived physiologic cv analysis $24.73 

93720-00 plethysmograpy tot bdy w/i&r $48.75 

93721-00 plethysmograpy tot bdy trcg only w/o i&r $19.50 

93722-00 plethysmograpy tot bdy i&r only $29.25 

93724-00 elec alys antitachycardia pm system $333.45 

93724-26 elec alys antitachycardia pm system $80.03 

93724-TC elec alys antitachycardia pm system $135.33 

93740-00 temprature gradient std $10.53 

93740-26 temprature gradient std $4.21 

93740-TC temprature gradient std $6.32 

93770-00 deter ven press $9.75 

113

Procedure & 


Tarifas 



93770-26 deter ven press $2.34 

93770-TC deter ven press $3.90 

93786-00 ambl bld press w/tape&/disk 24+ hr + rec only $23.80 

93788-00 ambl bld press w/tape/disk 24+ hr alys w/reprt $13.38 

93790-00 ambl bld press tape&/disk 24+ hr phys rev w/i&r $17.52 

93875-00 n-invas physiologic std xtrc art compl bi std $45.83 

93875-26 n-invas physiologic std xtrc art compl bi std $18.33 

93875-TC n-invas physiologic std xtrc art compl bi std $27.50 

93880-00 dup-scan xtrc art compl bi std $112.13 

93880-26 dup-scan xtrc art compl bi std $44.85 

93880-TC dup-scan xtrc art compl bi std $67.28 

93882-00 dup-scan xtrc art uni/lmtd std $75.08 

93882-26 dup-scan xtrc art uni/lmtd std $30.03 

93886-00 tcd std icra art compl std $124.80 

93886-26 tcd std icra art compl std $49.92 

93886-TC tcd std icra art compl std $74.88 

93888-00 tcd std icra art lmtd std $87.75 

93888-26 tcd std icra art lmtd std $35.10 

93888-TC tcd std icra art lmtd std $52.65 

93890-00 tcd std icra art vasoreactv std $166.73 

93890-26 tcd std icra art vasoreactv std $40.01 

93890-TC tcd std icra art vasoreactv std $66.69 

93892-00 tcd std icra art emboli detcj w/o iv mbubb njx $175.50 

93892-26 tcd std icra art emboli detcj w/o iv mbubb njx $42.12 

93892-TC tcd std icra art emboli detcj w/o iv mbubb njx $70.20 

93893-00 tcd std icra art emboli detcj w/iv mbubb njx $175.50 

93893-26 tcd std icra art emboli detcj w/iv mbubb njx $42.12 

93893-TC tcd std icra art emboli detcj w/iv mbubb njx $70.20 

93922-00 non-invas physiologic std extremity art 2 level $43.88 

93922-26 non-invas physiologic std extremity art 2 level $17.55 

93922-TC non-invas physiologic std extremity art 2 level $26.33 

93923-00 non-invasive physiologic study extremity 3 levls $97.50 

93923-26 non-invasive physiologic study extremity 3 levls $39.00 

93923-TC non-invasive physiologic study extremity 3 levls $58.50 

93924-00 n-invas physiologic std lxtr art compl bi $105.30 

93924-26 n-invas physiologic std lxtr art compl bi $42.12 

93924-TC n-invas physiologic std lxtr art compl bi $63.18 

93925-00 dup-scan lxtr art/artl bpgs compl bi std $112.13 

93925-26 dup-scan lxtr art/artl bpgs compl bi std $43.88 

93925-TC dup-scan lxtr art/artl bpgs compl bi std $68.25 

93926-00 dup-scan lxtr art/artl bpgs uni/lmtd std $65.33 

93926-26 dup-scan lxtr art/artl bpgs uni/lmtd std $26.13 

93926-TC dup-scan lxtr art/artl bpgs uni/lmtd std $39.20 

93930-00 dup-scan uxtr art/artl bpgs compl bi std $107.25 

93930-26 dup-scan uxtr art/artl bpgs compl bi std $42.90 

93930-TC dup-scan uxtr art/artl bpgs compl bi std $64.35 

93931-00 dup-scan uxtr art/artl bpgs uni/lmtd std $73.13 

93931-26 dup-scan uxtr art/artl bpgs uni/lmtd std $29.25 

93931-TC dup-scan uxtr art/artl bpgs uni/lmtd std $43.88 

93965-00 n-invas physiologic std xtr veins compl bi std $34.13 

114

Procedure & 


Tarifas 



93965-26 n-invas physiologic std xtr veins compl bi std $13.65 

93965-TC n-invas physiologic std xtr veins compl bi std $20.48 

93970-00 dup-scan xtr veins compl bi std $117.00 

93970-26 dup-scan xtr veins compl bi std $48.75 

93970-TC dup-scan xtr veins compl bi std $68.25 

93971-00 dup-scan xtr veins uni/lmtd std $63.38 

93971-26 dup-scan xtr veins uni/lmtd std $25.35 

93971-TC dup-scan xtr veins uni/lmtd std $38.03 

93975-00 dup-scan artl flo abdl/pel/scrot&/rpr orgn compl $175.50 

93975-26 dup-scan artl flo abdl/pel/scrot&/rpr orgn compl $70.20 

93975-TC dup-scan artl flo abdl/pel/scrot&/rpr orgn compl $105.30 

93976-00 dup-scan artl flo abdl/pel/scrot&/rpr orgn lmtd $105.30 

93976-26 dup-scan artl flo abdl/pel/scrot&/rpr orgn lmtd $42.12 

93976-TC dup-scan artl flo abdl/pel/scrot&/rpr orgn lmtd $63.18 

93978-00 dup-scan aorta ivc iliac vascl/bpgs compl $122.85 

93978-26 dup-scan aorta ivc iliac vascl/bpgs compl $49.14 

93978-TC dup-scan aorta ivc iliac vascl/bpgs compl $73.71 

93979-00 dup-scan aorta ivc iliac vascl/bpgs uni/lmtd $73.13 

93979-26 dup-scan aorta ivc iliac vascl/bpgs uni/lmtd $29.25 

93979-TC dup-scan aorta ivc iliac vascl/bpgs uni/lmtd $43.88 

93980-00 dup-scan artl infl&ven o/f pen vsl compl $175.50 

93980-26 dup-scan artl infl&ven o/f pen vsl compl $70.20 

93980-TC dup-scan artl infl&ven o/f pen vsl compl $105.30 

93981-00 dup-scan artl infl&ven o/f pen vsl f-up/lmtd std $105.30 

93981-26 dup-scan artl infl&ven o/f pen vsl f-up/lmtd std $42.12 

93981-TC dup-scan artl infl&ven o/f pen vsl f-up/lmtd std $63.18 

93990-00 dup-scan of hemodialysis access $100.18 

93990-26 dup-scan of hemodialysis access $11.63 

93990-TC dup-scan of hemodialysis access $88.56 

94002-00 ventilation assist & mgmt inpatient 1st day $35.10 

94003-00 ventilation assist & mgmt inpatient ea sbsq day $24.38 

94004-00 ventilation assist & mgmt nursing fac pr day $35.10 

94010-00 Breathing capacity test, spmtry w/vc expiratory flo +-mxml vol vntj $29.25 

94010-26 spmtry w/vc expiratory flo +-mxml vol vntj $11.70 

94010-TC spmtry w/vc expiratory flo +-mxml vol vntj $17.55 

94014-00 pt-initiate spirometric recording&phys r&i $28.08 

94015-00 patient-initiated spirometric recording $8.34 

94016-00 patient-initiated spirometric phys r&i only $19.74 

94060-00 brncdilat rspse spmtry pre&post-brncdilat admn $48.75 

94060-26 brncdilat rspse spmtry pre&post-brncdilat admn $19.50 

94060-TC brncdilat rspse spmtry pre&post-brncdilat admn $29.25 

94070-00 brncspsm provocation eval mlt spmtry w/admn agt $58.50 

94070-26 brncspsm provocation eval mlt spmtry w/admn agt $14.04 

94070-TC brncspsm provocation eval mlt spmtry w/admn agt $23.40 

94150-00 vc tot spx $5.85 

94150-26 vc tot spx $1.40 

94150-TC vc tot spx $2.34 

94200-00 max brthing cap mxml vol vntj $19.50 

94200-26 max brthing cap mxml vol vntj $4.68 

94200-TC max brthing cap mxml vol vntj $7.80 

115

Procedure & 


Tarifas 



94240-00 functional residual capacity or residual volume $29.25 

94240-26 functional residual capacity or residual volume $7.02 

94240-TC functional residual capacity or residual volume $11.70 

94250-00 exp gas collj quan 1 px spx $9.75 

94250-26 exp gas collj quan 1 px spx $2.34 

94250-TC exp gas collj quan 1 px spx $3.90 

94260-00 thrc gas vol $39.00 

94260-26 thrc gas vol $9.36 

94260-TC thrc gas vol $15.60 

94350-00 deter maldistribj of inspired gas n wshot curve $58.50 

94350-26 deter maldistribj of inspired gas n wshot curve $14.04 

94350-TC deter maldistribj of inspired gas n wshot curve $23.40 

94360-00 deter resist to airflo oscillatory/plethysmograp $39.00 

94360-26 deter resist to airflo oscillatory/plethysmograp $9.36 

94360-TC deter resist to airflo oscillatory/plethysmograp $15.60 

94370-00 deter airwy closing vol 1 brth tsts $28.42 

94370-26 deter airwy closing vol 1 brth tsts $11.63 

94370-TC deter airwy closing vol 1 brth tsts $16.78 

94375-00 respir flo vol loop $68.25 

94375-26 respir flo vol loop $21.45 

94375-TC respir flo vol loop $39.00 

94400-00 brthing rspse co2 co2 rspse curve $36.86 

94400-26 brthing rspse co2 co2 rspse curve $14.74 

94400-TC brthing rspse co2 co2 rspse curve $22.11 

94450-00 brthing rspse hypoxia hypoxia rspse curve $30.71 

94450-26 brthing rspse hypoxia hypoxia rspse curve $12.29 

94450-TC brthing rspse hypoxia hypoxia rspse curve $18.43 

94610-00 intrapulmonary surfactant administration $47.39 

94620-00 pulm strs tstg smpl $85.80 

94620-26 pulm strs tstg smpl $20.59 

94620-TC pulm strs tstg smpl $34.32 

94621-00 pulm strs tstg cplx $86.00 

94621-26 pulm strs tstg cplx $20.64 

94621-TC pulm strs tstg cplx $34.40 

94640-00 pressurized/nonpressurized inhalation treatment $9.75 

94642-00 pentamidine aersl inhalation pneumocystis/proph $9.75 

94644-00 continuous inhalation treatment 1st hr $22.75 

94645-00 continuous inhalation treatment ea addl hr $9.50 

94660-00 cpap vntj cpap initiation&mgmt $36.08 

94662-00 cnp vntj cnp initiation&mgmt $4.88 

94664-00 demo&/eval of pt utiliz aersl gen/neb/inhlr/ippb $4.88 

94667-00 mnpj ch wall facilitate lng funcj 1 demo&/eval $4.88 

94668-00 mnpj ch facilitate lng funcj sbsq $4.88 

94680-00 o2 uptk exp gas alys rest&xers dir smpl $59.13 

94680-26 o2 uptk exp gas alys rest&xers dir smpl $11.63 

94680-TC o2 uptk exp gas alys rest&xers dir smpl $47.50 

94681-00 o2 uptk exp gas alys w/co2 output % o2 xtrc $76.46 

94681-26 o2 uptk exp gas alys w/co2 output % o2 xtrc $9.19 

94681-TC o2 uptk exp gas alys w/co2 output % o2 xtrc $67.27 

94690-00 o2 uptk exp gas alys rest indir spx $54.09 

116

Procedure & 


Tarifas 



94690-26 o2 uptk exp gas alys rest indir spx $3.17 

94690-TC o2 uptk exp gas alys rest indir spx $50.93 

94720-00 carbon monoxide diffw/cap $78.00 

94720-26 carbon monoxide diffw/cap $31.20 

94720-TC carbon monoxide diffw/cap $46.80 

94725-00 memb diffusion cap $78.98 

94725-26 memb diffusion cap $31.59 

94725-TC memb diffusion cap $47.39 

94750-00 pulm compliance std $43.86 

94750-26 pulm compliance std $10.29 

94750-TC pulm compliance std $33.57 

94760-00 noninvasive ear/pulse oximetry single deter $5.85 

94761-00 noninvasive ear/pulse oximetry multiple deter $2.40 

94762-00 noninvasive ear/pulse oximetry overnight monitor $32.18 

94770-00 carbon dioxide exp gas deter infrared analyzer $49.53 

94770-26 carbon dioxide exp gas deter infrared analyzer $6.59 

94770-TC carbon dioxide exp gas deter infrared analyzer $42.93 

95004-00 Percut allergy skin tests, percutaneous tests w/allergenic extracts $2.98 

95010-00 perq tsts seql&incrl rx/biologic/vnm immt rxn $1.46 

95015-00 iq tsts seql&incrl rx/biologic/vnm immt rxn $1.46 

95024-00 intracutaneous tests w/allergenic extracts $3.51 

95027-00 intracutaneous tests w/allergenic xtrcs airborne $3.99 

95028-00 iq tsts w/allgic xtrcs dlyd typ rxn w/reading $0.98 

95044-00 patch/appl tst spec number tsts $2.93 

95165-00 prepj& allergen immunotherapy 1/mlt antigen $10.73 

95812-00 eeg extnd mntr 41-60 min $88.20 

95813-00 eeg extnd mntr > 1 hr $43.00 

95816-00 eeg w/rec awake&drowsy $70.20 

95816-26 eeg w/rec awake&drowsy $28.08 

95816-TC eeg w/rec awake&drowsy $42.12 

95819-00 eeg w/rec awake&asleep $53.63 

95819-26 eeg w/rec awake&asleep $36.86 

95819-TC eeg w/rec awake&asleep $24.57 

95822-00 eeg rec coma/sleep only $96.53 

95822-26 eeg rec coma/sleep only $38.61 

95822-TC eeg rec coma/sleep only $57.92 

95824-00 eeg cere death eval only $35.10 

95824-26 eeg cere death eval only $14.04 

95824-TC eeg cere death eval only $21.06 

95827-00 eeg all night rec $63.18 

95827-26 eeg all night rec $42.12 

95827-TC eeg all night rec $6.32 

95829-00 electrocorticogram surg spx $745.88 

95829-26 electrocorticogram surg spx $298.35 

95829-TC electrocorticogram surg spx $447.53 

95830-00 insertion sphenoidal electrodes eeg recording $132.00 

95831-00 musc tstg mnl w/reprt xtr ex hand/trnk $15.80 

95832-00 musc tstg mnl w/reprt hand +-cmprsn nml side $14.04 

95833-00 musc tstg mnl w/reprt tot eval bdy ex hands $24.57 

95834-00 musc tstg mnl w/reprt tot eval bdy w/hands $39.00 

117

Procedure & 


Tarifas 



95851-00 rom meas&reprt ea xtr ex hand/ea trnk sctj spine $3.61 

95852-00 rom meas&reprt hand +-cmprsn nml side $2.63 

95857-00 cholinesterase inhibitor challenge test $25.77 

95860-00 ndl emg 1 xtr +-related paraspi areas $29.25 


95860-TC ndl emg 1 xtr +-related paraspi areas $11.70 










95867-00 ndl emg crnl nrv supplied musc uni $107.25 

95867-26 ndl emg crnl nrv supplied musc uni $25.74 

95867-TC ndl emg crnl nrv supplied musc uni $42.90 

95868-00 ndl emg crnl nrv supplied musc bi $160.88 

95868-26 ndl emg crnl nrv supplied musc bi $38.61 

95868-TC ndl emg crnl nrv supplied musc bi $64.35 

95869-00 ndl emg thrc paraspi musc excluding t1/t12 $39.00 

95869-26 ndl emg thrc paraspi musc excluding t1/t12 $9.36 

95869-TC ndl emg thrc paraspi musc excluding t1/t12 $15.60 

95870-00 ndl emg lmtd std musc 1 xtr/non-limb uni/bi $23.69 

95870-26 ndl emg lmtd std musc 1 xtr/non-limb uni/bi $5.68 

95870-TC ndl emg lmtd std musc 1 xtr/non-limb uni/bi $9.48 

95872-00 ndl emg w/1 fiber eltrd quan meas jitter $65.81 

95872-26 ndl emg w/1 fiber eltrd quan meas jitter $26.33 

95872-TC ndl emg w/1 fiber eltrd quan meas jitter $39.49 

95874-00 ndl emg gdn conjunct chemodnrvtj $38.56 

95875-00 ischemic limb xers tst spec acquisj metab $70.20 

95875-26 ischemic limb xers tst spec acquisj metab $28.08 

95875-TC ischemic limb xers tst spec acquisj metab $42.12 

95900-00 nrv cndj amplt&std ea nrv motor w/o f-wave std $14.63 

95900-26 nrv cndj amplt&std ea nrv motor w/o f-wave std $3.51 

95900-TC nrv cndj amplt&std ea nrv motor w/o f-wave std $5.85 

95903-00 nrv cndj amplt&std ea nrv motor w/f-wave std $40.95 

95903-26 nrv cndj amplt&std ea nrv motor w/f-wave std $9.83 

95903-TC nrv cndj amplt&std ea nrv motor w/f-wave std $16.38 

95904-00 nrv cndj amplt&std ea nrv sens $9.75 

95904-26 nrv cndj amplt&std ea nrv sens $2.34 

95904-TC nrv cndj amplt&std ea nrv sens $3.90 

95920-00 intraop neurophysiology tstg pr hr $114.08 

95920-26 intraop neurophysiology tstg pr hr $45.63 

95920-TC intraop neurophysiology tstg pr hr $68.45 

95925-00 short-latency somatosens ep std upr limbs $185.25 

95925-26 short-latency somatosens ep std upr limbs $44.46 

95925-TC short-latency somatosens ep std upr limbs $74.10 

95926-00 short-latency somatosens ep std lwr limbs $96.00 

118

Procedure & 


Tarifas 



95927-00 short-latency somatosens ep std trnk/head $51.04 

95928-00 ctr motor ep std transcrnl motor stimj upr limbs $127.80 

95928-26 ctr motor ep std transcrnl motor stimj upr limbs $29.90 

95928-TC ctr motor ep std transcrnl motor stimj upr limbs $49.84 

95929-00 ctr motor ep std transcrnl motor stimj lwr limbs $133.20 

95929-26 ctr motor ep std transcrnl motor stimj lwr limbs $31.17 

95929-TC ctr motor ep std transcrnl motor stimj lwr limbs $51.95 

95930-00 visual ep tstg cns checkerboard/flash $35.10 

95934-00 h-reflex amplt&latency gastrcn/soleus musc $34.13 

95934-26 h-reflex amplt&latency gastrcn/soleus musc $8.19 

95934-TC h-reflex amplt&latency gastrcn/soleus musc $13.65 

95936-00 h-reflex amplt&latency oth/thn gastrcn/soleus $34.13 

95936-26 h-reflex amplt&latency oth/thn gastrcn/soleus $8.19 

95936-TC h-reflex amplt&latency oth/thn gastrcn/soleus $13.65 

95937-00 neuromuscular junct tstg ea nrv any 1 meth $54.00 

95937-26 neuromuscular junct tstg ea nrv any 1 meth $12.96 

95937-TC neuromuscular junct tstg ea nrv any 1 meth $21.06 

95950-00 monitor id& lateralization seizure focus eeg $370.50 

95950-26 monitor id& lateralization seizure focus eeg $88.92 

95950-TC monitor id& lateralization seizure focus eeg $148.20 

95951-00 localize cerebral seizure cable/radio eeg/video $438.75 

95951-26 localize cerebral seizure cable/radio eeg/video $175.50 

95951-TC localize cerebral seizure cable/radio eeg/video $263.25 

95953-00 localize cerebral seizure cptr portable eeg $285.94 

95953-26 localize cerebral seizure cptr portable eeg $134.79 

95953-TC localize cerebral seizure cptr portable eeg $154.52 

95954-00 rx/physical activaj phys attn during eeg activaj $175.50 

95954-26 rx/physical activaj phys attn during eeg activaj $70.20 

95954-TC rx/physical activaj phys attn during eeg activaj $105.30 

95955-00 eeg nonicra surg $96.53 

95955-26 eeg nonicra surg $38.61 

95955-TC eeg nonicra surg $57.92 

95956-00 mntr seizure cmptr 16>chan eeg atnd ea 24 hr $421.20 

95956-26 mntr seizure cmptr 16>chan eeg atnd ea 24 hr $168.48 

95956-TC mntr seizure cmptr 16>chan eeg atnd ea 24 hr $252.72 

95957-00 EEG digital analysis, dgtal alys eeg $130.50 

95957-26 dgtal alys eeg $78.30 

95957-TC dgtal alys eeg $52.20 

95958-00 wada activation test hemispheric function w/eeg $219.38 

95958-26 wada activation test hemispheric function w/eeg $180.00 

95958-TC wada activation test hemispheric function w/eeg $43.88 

95961-00 funcjal cort&subcort mapg eltrds 1 hr phys attn $157.95 

95961-26 funcjal cort&subcort mapg eltrds 1 hr phys attn $63.18 

95961-TC funcjal cort&subcort mapg eltrds 1 hr phys attn $94.77 

95962-00 funcjal cort&subcort mapg eltrds ea hr phys attn $166.73 

95962-26 funcjal cort&subcort mapg eltrds ea hr phys attn $66.69 

95962-TC funcjal cort&subcort mapg eltrds ea hr phys attn $100.04 

95970-00 elec alys nstim pls gen brn/sc/perph w/o reprgrm $18.00 

95971-00 elec alys nstim pls gen smpl sc/perph w/prgrmg $29.84 

95972-00 elec alys nstim pls gen cplx sc/perph 1st hr $57.92 

119

Procedure & 


Tarifas 



95973-00 elec alys nstim pls gen cplx sc/perph ea 30 min $36.86 

95974-00 elec alys nstim pls gen cplx crnl nrv 1st hr $117.00 

95975-00 elec alys nstim pls gen cplx crnl nrv ea 30 min $68.45 

95978-00 elec alys nstim pls gen cplx dp brn 1st hr $168.68 

95979-00 elec alys nstim pls gen cplx dp brn ea 30 min $70.20 

95990-00 refill&maintenance pump drug dlvr spinal/brain $39.47 

95991-00 rfl&main implt pmp/rsvr rx dlvr spi/brn by phys $33.54 

96105-00 assmt aphasia w/i&r pr hr $30.71 

96110-00 developmental tstg lmtd w/i&r $6.68 

96111-00 developmental tstg extnd w/i&r $30.71 

96155-00 hlth&behavior ivntj ea 15 min f2f fam w/o pt $17.55 

96401-00 chemotx admn subq/im non-hormonal anti-neo $30.71 

96402-00 chemotx admn subq/im hormonal anti-neo $25.01 

96405-00 chemotx admn ilesn up&w/7 < $25.35 

96406-00 chemotx admn ilesn > 7 $37.10 

96409-00 chemotx admn iv push tq 1/1st sbst/drug $30.71 

96411-00 chemotx admn iv push tq ea sbst/drug $30.71 

96413-00 chemotx admn iv nfs tq up 1 hr 1/1st sbst/drug $55.00 

96415-00 chemotherapy admn iv infusion tq ea hr $36.08 

96416-00 chemotx admn tq init prolng chemotx nfus pmp $43.88 

96417-00 chemotx admn iv nfs tq ea seql nfs to 1 hr $32.47 

96420-00 chemotx admn ia push tq $56.16 

96422-00 chemotx admn ia nfs tq up 1 hr $63.18 

96423-00 chemotherapy admn intraarterial infusion ea hr $35.10 

96425-00 chemotx admn ia nfs > 8 hr prtble impltbl pmp $49.14 

96440-00 chemotx admn pleural cavity req&w/thoracnts $84.24 

96446-00 chemotx admn prtl cavity port/cath $87.75 

96450-00 chemotx admn cns req&w/spi pnxr $65.33 

96521-00 rfl/main portable pmp $27.20 

96522-00 refill&maintenance pump drug dlvr systemic $43.88 

96523-00 irrigation implanted vad for drug dlvr $15.80 

96567-00 pdt xtrnl appl light dstr les skn by activj rx $25.79 

96570-00 pdt ndsc abl abnor tiss via activj rx 30 min $42.12 

96571-00 pdt ndsc abl abnor tiss via activj rx a 15 min $21.06 

96900-00 actixh ultraviolet light $4.88 

96910-00 photochemotx tar&uvb/petrolatum/uvb $13.16 

96912-00 photochemotx psoralens&ultraviolet puva $58.50 

96913-00 photochemotherapy dermatoses 4-8 hrs supervision $47.11 

97001-00 physical ther eval $24.38 

97002-00 Pt re-evaluation, physical ther re-eval $19.50 

97003-00 occupational ther eval $29.25 

97004-00 occupational ther re-eval $14.63 

97010-00 appl modality 1+ areas hot/cold packs $11.70 

97012-00 appl modality 1+ areas trcj mchnl $11.70 

97014-00 appl modality 1+ areas elec stimj unattn $11.70 

97016-00 appl modality 1+ areas vasopneumatic dev $11.70 

97018-00 appl modality 1+ areas paraffin bath $11.70 

97022-00 appl modality 1+ areas wp $11.70 

97024-00 appl modality 1+ areas dthrm $11.70 

97026-00 appl modality 1+ areas infrared $11.70 

120

Procedure & 


Tarifas 



97028-00 appl modality 1+ areas ultraviolet $11.70 

97032-00 appl modality 1+ areas elec stimj ea 15 min $11.70 

97033-00 appl modality 1+ areas iontophoresis ea 15 min $11.70 

97034-00 appl modality 1+ areas cntrst baths ea 15 min $11.70 

97035-00 appl modality 1+ areas us ea 15 min $11.70 

97036-00 appl modality 1+ areas hubbard tank ea 15 min $11.70 

97039-00 unlis modality spec typ&tm if constant attn $11.70 

97110-00 ther px 1+ areas ea 15 min ther xerss $10.73 

97112-00 ther px 1+ areas ea 15 min neuromusc reeducaj $10.73 

97140-00 mnl ther tqs 1+ regions ea 15 min $6.83 

97530-00 ther actv dir pt contact by provider ea 15 min $10.73 

97532-00 development of cognitive skills ea 15 min $26.33 

97533-00 sensory integrative tqs ea 15 min $26.33 

97597-00 debridement open wound 20 sq cm< $35.10 

97598-00 debridement open wound addl 20 sq cm $43.88 

97760-00 orthotic mgmt&trainj uxtr lxtr&/trnk ea 15 min $19.50 

97802-00 med nutr ther 1st assmt&ivntj indiv ea 15 min $14.63 

97803-00 med nutr ther re-assmt&ivntj indiv ea 15 min $14.63 

98940-00 cmt spi 1-2 regions $11.80 

98941-00 cmt spi 3-4 regions $14.63 

98942-00 cmt spi 5 regions $17.55 

99143-00 m-sedatj by sm phys perfrmg svc < 5 yr $39.00 

99144-00 m-sedaj by sm phys perfrmg svc 5+ yr $39.00 

99145-00 m-sedaj by sm phys perfrmg svc ea 15 min $24.38 

99148-00 m-sedation by phys oth/thn hc prof perfrmg < 5 $97.50 

99149-00 m-sedation by phys oth/thn hc prof perfrmg 5+ $97.50 

99150-00 m-sedaj phys oth/thn hc prof perfrmg ea 15 min $39.00 

99170-00 collj/int physio data dig strd/trans minim 30min $77.96 

99183-00 phys attn&supvj hyprbaric oxygen ther pr sess $33.35 

99195-00 phlebotomy ther spx $19.50 

G0104-00 CA screen;flexi sigmoidscope $78.00 

G0105-00 Colorectal scrn; hi risk ind $273.00 

G0121-00 Colon ca scrn not hi rsk ind $273.00 

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