2023-03-01T04:42:00 CPT®2023 American Medical Association.  All Rights Reserved. This is the hospital’s machine-readable pricing file and does NOT contain patient’s out-of-pocket cost information; patients are encouraged to use the online patient estimation tool for an estimate of out-of-pocket costs specific to a medical service. This file identifies an individual item/service charge and the contracted rate negotiated between payer and provider for the single item/service. If NA is listed for an item/service for a payer or the discounted cash charge, the contracted rates negotiated between payer and provider were either not found within the payer contract, are bundled with other services, or reimburse using a different code set. Contracts are often complex and the rates contained in this file may not reflect actual negotiated rates or final charges once services are rendered. The information is not an estimate of out-of-pocket costs, nor is it a guarantee of payment or benefits for healthcare services. Infectious disease (viral respiratory tract infection), pathogen-specific RNA, 3 targets (severe acute respiratory syndrome coronavirus 2 [SARS-CoV-2], influenza A, influenza B), upper respiratory specimen, each pathogen reported as detected or not detected 1.0000 each 204.00 163.2000 126.28 204.00 Infectious disease (viral respiratory tract infection), pathogen-specific RNA, 4 targets (severe acute respiratory syndrome coronavirus 2 [SARS-CoV-2], influenza A, influenza B, respiratory syncytial virus [RSV]), upper respiratory specimen, each pathogen reported as detected or not detected 1.0000 each 257.00 205.6000 135.50 257.00 Fine needle aspiration biopsy, including ultrasound guidance; first lesion Each 311.00 248.8000 192.51 654.36 Fine needle aspiration biopsy, including ultrasound guidance; each additional lesion (List separately in addition to code for primary procedure) 1.0000 each 263.00 210.4000 162.80 263.00 Incision and drainage of abscess (eg, carbuncle, suppurative hidradenitis, cutaneous or subcutaneous abscess, cyst, furuncle, or paronychia); simple or single Each 315.00 252.0000 167.94 315.00 Incision and drainage of abscess (eg, carbuncle, suppurative hidradenitis, cutaneous or subcutaneous abscess, cyst, furuncle, or paronychia); complicated or multiple Each 315.00 252.0000 194.98 376.17 Incision and drainage of pilonidal cyst; simple Each 315.00 252.0000 194.98 654.36 Incision and drainage of pilonidal cyst; complicated Each 2284.00 1827.2000 603.54 2284.00 Incision and removal of foreign body, subcutaneous tissues; simple Each 315.00 252.0000 194.98 376.17 Incision and removal of foreign body, subcutaneous tissues; complicated Each 2410.00 1928.0000 1394.57 2410.00 Incision and drainage of hematoma, seroma or fluid collection Each 1910.00 1528.0000 1182.29 1910.00 Puncture aspiration of abscess, hematoma, bulla, or cyst Each 297.00 237.6000 183.84 376.17 Debridement, subcutaneous tissue (includes epidermis and dermis, if performed); first 20 sq cm or less Each 5814.77 4651.8100 346.95 5814.76 Debridement, muscle and/or fascia (includes epidermis, dermis, and subcutaneous tissue, if performed); first 20 sq cm or less Each 3252.32 2601.8500 540.28 3252.32 Debridement, bone (includes epidermis, dermis, subcutaneous tissue, muscle and/or fascia, if performed); first 20 sq cm or less Each 5434.04 4347.2300 1394.57 5434.04 Debridement, subcutaneous tissue (includes epidermis and dermis, if performed); each additional 20 sq cm, or part thereof (List separately in addition to code for primary procedure) 1.0000 each 1972.94 1578.3600 1221.25 1972.94 Debridement, muscle and/or fascia (includes epidermis, dermis, and subcutaneous tissue, if performed); each additional 20 sq cm, or part thereof (List separately in addition to code for primary procedure) 1.0000 each 3792.76 3034.2000 2347.72 3792.76 Debridement, bone (includes epidermis, dermis, subcutaneous tissue, muscle and/or fascia, if performed); each additional 20 sq cm, or part thereof (List separately in addition to code for primary procedure) 1.0000 each 4676.99 3741.5900 2895.05 4676.98 Removal of skin tags, multiple fibrocutaneous tags, any area; up to and including 15 lesions Each 210.00 168.0000 129.99 210.00 Excision, benign lesion including margins, except skin tag (unless listed elsewhere), trunk, arms or legs; excised diameter 1.1 to 2.0 cm Each 5424.36 4339.4900 603.54 5424.36 Excision, benign lesion including margins, except skin tag (unless listed elsewhere), trunk, arms or legs; excised diameter 2.1 to 3.0 cm Each 5618.74 4494.9900 603.54 5618.74 Excision, benign lesion including margins, except skin tag (unless listed elsewhere), trunk, arms or legs; excised diameter 3.1 to 4.0 cm Each 7631.32 6105.0600 1394.57 7631.32 Excision, benign lesion including margins, except skin tag (unless listed elsewhere), trunk, arms or legs; excised diameter over 4.0 cm Each 5552.48 4441.9800 1394.57 5552.48 Excision, benign lesion including margins, except skin tag (unless listed elsewhere), scalp, neck, hands, feet, genitalia; excised diameter 1.1 to 2.0 cm Each 8359.81 6687.8500 1394.57 8359.81 Excision, benign lesion including margins, except skin tag (unless listed elsewhere), scalp, neck, hands, feet, genitalia; excised diameter 3.1 to 4.0 cm Each 12195.07 9756.0600 1394.57 12195.07 Excision, benign lesion including margins, except skin tag (unless listed elsewhere), scalp, neck, hands, feet, genitalia; excised diameter over 4.0 cm Each 9781.54 7825.2300 2402.40 9781.54 Excision, other benign lesion including margins, except skin tag (unless listed elsewhere), face, ears, eyelids, nose, lips, mucous membrane; excised diameter 0.6 to 1.0 cm Each 956.40 765.1200 592.01 956.40 Excision, other benign lesion including margins, except skin tag (unless listed elsewhere), face, ears, eyelids, nose, lips, mucous membrane; excised diameter 1.1 to 2.0 cm Each 5437.01 4349.6000 603.54 5437.00 Excision, other benign lesion including margins, except skin tag (unless listed elsewhere), face, ears, eyelids, nose, lips, mucous membrane; excised diameter 2.1 to 3.0 cm Each 13159.98 10527.9900 1394.57 13159.98 Excision, other benign lesion including margins, except skin tag (unless listed elsewhere), face, ears, eyelids, nose, lips, mucous membrane; excised diameter over 4.0 cm Each 15842.52 12674.0200 2402.40 15842.52 Excision of skin and subcutaneous tissue for hidradenitis, axillary; with complex repair Each 18111.68 14489.3400 2402.40 18111.68 Excision of skin and subcutaneous tissue for hidradenitis, perianal, perineal, or umbilical; with simple or intermediate repair Each 4580.62 3664.5000 2402.40 4580.62 Excision, malignant lesion including margins, trunk, arms, or legs; excised diameter over 4.0 cm Each 8793.37 7034.7000 1394.57 8793.37 Excision, malignant lesion including margins, scalp, neck, hands, feet, genitalia; excised diameter 1.1 to 2.0 cm Each 6879.03 5503.2200 603.54 6879.03 Excision, malignant lesion including margins, scalp, neck, hands, feet, genitalia; excised diameter 3.1 to 4.0 cm Each 6129.12 4903.2900 1394.57 6129.12 Debridement of nail(s) by any method(s); 1 to 5 1.0000 each 72.80 58.2400 45.06 72.80 Avulsion of nail plate, partial or complete, simple; single Each 126.00 100.8000 77.99 182.08 Evacuation of subungual hematoma Each 77.00 61.6000 47.66 117.07 Excision of nail and nail matrix, partial or complete (eg, ingrown or deformed nail), for permanent removal Each 968.85 775.0800 346.95 968.85 Repair of nail bed Each 523.00 418.4000 323.74 585.78 Reconstruction of nail bed with graft Each 2306.30 1845.0400 1427.60 2306.30 Wedge excision of skin of nail fold (eg, for ingrown toenail) Each 438.00 350.4000 271.12 438.00 Excision of pilonidal cyst or sinus; complicated Each 17849.44 14279.5500 2402.40 17849.44 Injection, intralesional; up to and including 7 lesions Each 5437.01 4349.6000 167.94 5437.00 Removal, non-biodegradable drug delivery implant Each 10768.14 8614.5100 351.14 10768.14 Simple repair of superficial wounds of scalp, neck, axillae, external genitalia, trunk and/or extremities (including hands and feet); 2.5 cm or less Each 251.00 200.8000 155.37 251.00 Simple repair of superficial wounds of scalp, neck, axillae, external genitalia, trunk and/or extremities (including hands and feet); 2.6 cm to 7.5 cm Each 251.00 200.8000 155.37 251.00 Simple repair of superficial wounds of scalp, neck, axillae, external genitalia, trunk and/or extremities (including hands and feet); 7.6 cm to 12.5 cm Each 251.00 200.8000 155.37 251.00 Simple repair of superficial wounds of scalp, neck, axillae, external genitalia, trunk and/or extremities (including hands and feet); 12.6 cm to 20.0 cm Each 251.00 200.8000 155.37 376.17 Simple repair of superficial wounds of scalp, neck, axillae, external genitalia, trunk and/or extremities (including hands and feet); 20.1 cm to 30.0 cm Each 238.60 190.8800 147.69 376.17 Simple repair of superficial wounds of scalp, neck, axillae, external genitalia, trunk and/or extremities (including hands and feet); over 30.0 cm Each 238.60 190.8800 147.69 238.60 Simple repair of superficial wounds of face, ears, eyelids, nose, lips and/or mucous membranes; 2.5 cm or less Each 251.00 200.8000 155.37 251.00 Simple repair of superficial wounds of face, ears, eyelids, nose, lips and/or mucous membranes; 2.6 cm to 5.0 cm Each 251.00 200.8000 155.37 251.00 Simple repair of superficial wounds of face, ears, eyelids, nose, lips and/or mucous membranes; 5.1 cm to 7.5 cm Each 251.00 200.8000 155.37 251.00 Simple repair of superficial wounds of face, ears, eyelids, nose, lips and/or mucous membranes; 7.6 cm to 12.5 cm Each 251.00 200.8000 155.37 251.00 Simple repair of superficial wounds of face, ears, eyelids, nose, lips and/or mucous membranes; 12.6 cm to 20.0 cm Each 238.60 190.8800 147.69 376.17 Simple repair of superficial wounds of face, ears, eyelids, nose, lips and/or mucous membranes; 20.1 cm to 30.0 cm Each 238.60 190.8800 147.69 376.17 Simple repair of superficial wounds of face, ears, eyelids, nose, lips and/or mucous membranes; over 30.0 cm Each 238.60 190.8800 147.69 238.60 Treatment of superficial wound dehiscence; simple closure Each 1228.25 982.6000 540.28 1228.25 Repair, intermediate, wounds of scalp, axillae, trunk and/or extremities (excluding hands and feet); 2.5 cm or less Each 308.25 246.6000 190.81 376.17 Repair, intermediate, wounds of scalp, axillae, trunk and/or extremities (excluding hands and feet); 2.6 cm to 7.5 cm Each 523.00 418.4000 323.74 523.00 Repair, intermediate, wounds of scalp, axillae, trunk and/or extremities (excluding hands and feet); 7.6 cm to 12.5 cm Each 251.00 200.8000 155.37 376.17 Repair, intermediate, wounds of scalp, axillae, trunk and/or extremities (excluding hands and feet); 12.6 cm to 20.0 cm Each 238.60 190.8800 147.69 376.17 Repair, intermediate, wounds of scalp, axillae, trunk and/or extremities (excluding hands and feet); 20.1 cm to 30.0 cm Each 497.25 397.8000 307.80 585.78 Repair, intermediate, wounds of scalp, axillae, trunk and/or extremities (excluding hands and feet); over 30.0 cm Each 497.25 397.8000 307.80 1740.20 Repair, intermediate, wounds of neck, hands, feet and/or external genitalia; 2.5 cm or less Each 238.60 190.8800 147.69 376.17 Repair, intermediate, wounds of neck, hands, feet and/or external genitalia; 2.6 cm to 7.5 cm Each 238.60 190.8800 147.69 376.17 Repair, intermediate, wounds of neck, hands, feet and/or external genitalia; 7.6 cm to 12.5 cm Each 238.60 190.8800 147.69 585.78 Repair, intermediate, wounds of neck, hands, feet and/or external genitalia; 12.6 cm to 20.0 cm Each 497.25 397.8000 307.80 585.78 Repair, intermediate, wounds of neck, hands, feet and/or external genitalia; 20.1 cm to 30.0 cm Each 497.25 397.8000 307.80 585.78 Repair, intermediate, wounds of neck, hands, feet and/or external genitalia; over 30.0 cm Each 497.25 397.8000 307.80 1740.20 Repair, intermediate, wounds of face, ears, eyelids, nose, lips and/or mucous membranes; 2.5 cm or less Each 497.25 397.8000 307.80 497.25 Repair, intermediate, wounds of face, ears, eyelids, nose, lips and/or mucous membranes; 2.6 cm to 5.0 cm Each 497.25 397.8000 307.80 497.25 Repair, intermediate, wounds of face, ears, eyelids, nose, lips and/or mucous membranes; 5.1 cm to 7.5 cm Each 497.25 397.8000 307.80 497.25 Repair, intermediate, wounds of face, ears, eyelids, nose, lips and/or mucous membranes; 7.6 cm to 12.5 cm Each 497.25 397.8000 307.80 497.25 Repair, intermediate, wounds of face, ears, eyelids, nose, lips and/or mucous membranes; 12.6 cm to 20.0 cm Each 497.25 397.8000 307.80 497.25 Repair, intermediate, wounds of face, ears, eyelids, nose, lips and/or mucous membranes; 20.1 cm to 30.0 cm Each 497.25 397.8000 307.80 497.25 Repair, intermediate, wounds of face, ears, eyelids, nose, lips and/or mucous membranes; over 30.0 cm Each 497.25 397.8000 307.80 497.25 Repair, complex, trunk; 1.1 cm to 2.5 cm Each 640.40 512.3200 396.41 640.40 Repair, complex, trunk; 2.6 cm to 7.5 cm Each 3036.41 2429.1300 540.28 3036.41 Repair, complex, trunk; each additional 5 cm or less (List separately in addition to code for primary procedure) 1.0000 Each 640.40 512.3200 396.41 640.40 Repair, complex, scalp, arms, and/or legs; 1.1 cm to 2.5 cm Each 497.25 397.8000 307.80 585.78 Repair, complex, scalp, arms, and/or legs; 2.6 cm to 7.5 cm Each 7631.32 6105.0600 540.28 7631.32 Repair, complex, scalp, arms, and/or legs; each additional 5 cm or less (List separately in addition to code for primary procedure) 1.0000 Each 497.25 397.8000 307.80 497.25 Repair, complex, forehead, cheeks, chin, mouth, neck, axillae, genitalia, hands and/or feet; 1.1 cm to 2.5 cm Each 497.25 397.8000 307.80 497.25 Repair, complex, forehead, cheeks, chin, mouth, neck, axillae, genitalia, hands and/or feet; 2.6 cm to 7.5 cm Each 864.43 691.5500 535.08 864.43 Repair, complex, forehead, cheeks, chin, mouth, neck, axillae, genitalia, hands and/or feet; each additional 5 cm or less (List separately in addition to code for primary procedure) 1.0000 each 497.25 397.8000 307.80 497.25 Repair, complex, eyelids, nose, ears and/or lips; 1.1 cm to 2.5 cm Each 639.30 511.4400 395.73 639.30 Repair, complex, eyelids, nose, ears and/or lips; 2.6 cm to 7.5 cm Each 639.30 511.4400 395.73 639.30 Repair, complex, eyelids, nose, ears and/or lips; each additional 5 cm or less (List separately in addition to code for primary procedure) 1.0000 each 497.25 397.8000 307.80 497.25 Adjacent tissue transfer or rearrangement, trunk; defect 10 sq cm or less Each 6051.20 4840.9600 1605.04 6051.20 Adjacent tissue transfer or rearrangement, trunk; defect 10.1 sq cm to 30.0 sq cm Each 6209.09 4967.2700 1605.04 6209.09 Adjacent tissue transfer or rearrangement, forehead, cheeks, chin, mouth, neck, axillae, genitalia, hands and/or feet; defect 10 sq cm or less Each 6129.12 4903.2900 1605.04 6129.12 Adjacent tissue transfer or rearrangement, any area; defect 30.1 sq cm to 60.0 sq cm Each 12116.11 9692.8900 3025.30 12116.11 Split-thickness autograft, trunk, arms, legs; first 100 sq cm or less, or 1% of body area of infants and children (except 15050) Each 17768.91 14215.1300 1605.04 17768.91 Muscle, myocutaneous, or fasciocutaneous flap; trunk Each 10684.82 8547.8500 3025.30 10684.82 Excision, excessive skin and subcutaneous tissue (includes lipectomy); abdomen, infraumbilical panniculectomy Each 46715.48 37372.3800 5527.09 46715.48 Initial treatment, first degree burn, when no more than local treatment is required Each 173.95 139.1600 107.68 182.08 Dressings and/or debridement of partial-thickness burns, initial or subsequent; small (less than 5% total body surface area) Each 219.15 175.3200 135.65 219.15 Dressings and/or debridement of partial-thickness burns, initial or subsequent; medium (eg, whole face or whole extremity, or 5% to 10% total body surface area) Each 262.55 210.0400 162.52 262.55 Dressings and/or debridement of partial-thickness burns, initial or subsequent; large (eg, more than 1 extremity, or greater than 10% total body surface area) Each 262.55 210.0400 162.52 376.17 Destruction (eg, laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical curettement), of benign lesions other than skin tags or cutaneous vascular proliferative lesions; up to 14 lesions Each 6822.80 5458.2400 167.94 6822.80 Unlisted procedure, skin, mucous membrane and subcutaneous tissue Each 87.55 70.0400 54.19 182.08 Puncture aspiration of cyst of breast Each 1069.00 855.2000 603.54 1069.00 Puncture aspiration of cyst of breast; each additional cyst (List separately in addition to code for primary procedure) 1.0000 each 1018.00 814.4000 630.14 1018.00 Mastotomy with exploration or drainage of abscess, deep Each 12235.21 9788.1700 1394.57 12235.21 Biopsy, breast, with placement of breast localization device(s) (eg, clip, metallic pellet), when performed, and imaging of the biopsy specimen, when performed, percutaneous; first lesion, including stereotactic guidance Each 1798.00 1438.4000 1112.96 1798.00 Biopsy, breast, with placement of breast localization device(s) (eg, clip, metallic pellet), when performed, and imaging of the biopsy specimen, when performed, percutaneous; each additional lesion, including stereotactic guidance (List separately in addition to code for primary procedure) 1.0000 each 1797.00 1437.6000 1112.34 1797.00 Biopsy, breast, with placement of breast localization device(s) (eg, clip, metallic pellet), when performed, and imaging of the biopsy specimen, when performed, percutaneous; first lesion, including ultrasound guidance Each 1917.00 1533.6000 1186.62 1917.00 Biopsy, breast, with placement of breast localization device(s) (eg, clip, metallic pellet), when performed, and imaging of the biopsy specimen, when performed, percutaneous; each additional lesion, including ultrasound guidance (List separately in addition to code for primary procedure) 1.0000 each 849.60 679.6800 525.90 849.60 Biopsy of breast; percutaneous, needle core, not using imaging guidance (separate procedure) Each 757.00 605.6000 468.58 1512.01 Excision of cyst, fibroadenoma, or other benign or malignant tumor, aberrant breast tissue, duct lesion, nipple or areolar lesion (except 19300), open, male or female, 1 or more lesions Each 5795.68 4636.5500 3197.13 5795.68 Excision of breast lesion identified by preoperative placement of radiological marker, open; single lesion Each 6051.20 4840.9600 3197.13 6051.20 Placement of breast localization device(s) (eg, clip, metallic pellet, wire/needle, radioactive seeds), percutaneous; first lesion, including mammographic guidance Each 1943.00 1554.4000 1202.72 1943.00 Placement of breast localization device(s) (eg, clip, metallic pellet, wire/needle, radioactive seeds), percutaneous; each additional lesion, including mammographic guidance (List separately in addition to code for primary procedure) 1.0000 each 785.00 628.0000 485.92 785.00 Mastectomy, partial (eg, lumpectomy, tylectomy, quadrantectomy, segmentectomy) Each 6279.80 5023.8400 3197.13 6279.80 Mastectomy, simple, complete Each 5707.82 4566.2500 3533.14 5992.53 Breast reduction Each 16882.24 13505.7900 5527.09 16882.24 Unlisted procedure, breast Each 3837.30 3069.8400 2375.29 3837.30 Exploration of penetrating wound (separate procedure); extremity Each 2306.30 1845.0400 1394.57 2306.30 Biopsy, muscle, percutaneous needle Each 659.00 527.2000 407.92 1512.01 Biopsy, bone, trocar, or needle; superficial (eg, ilium, sternum, spinous process, ribs) Each 802.00 641.6000 496.44 1512.01 Biopsy, bone, trocar, or needle; deep (eg, vertebral body, femur) Each 802.00 641.6000 496.44 1512.01 Biopsy, bone, open; superficial (eg, sternum, spinous process, rib, patella, olecranon process, calcaneus, tarsal, metatarsal, carpal, metacarpal, phalanx) Each 2520.18 2016.1500 1559.99 2604.71 Injection of sinus tract; diagnostic (sinogram) Each 369.00 295.2000 228.41 369.00 Removal of foreign body in muscle or tendon sheath; simple Each 645.90 516.7200 399.81 1512.01 Removal of foreign body in muscle or tendon sheath; deep or complicated Each 3153.65 2522.9200 1952.11 3153.65 Injection(s); single tendon sheath, or ligament, aponeurosis (eg, plantar "fascia") Each 564.30 451.4400 252.86 564.30 Injection(s); single or multiple trigger point(s), 1 or 2 muscle(s) Each 115.00 92.0000 71.18 274.15 Injection(s); single or multiple trigger point(s), 3 or more muscles Each 4977.48 3981.9800 252.86 4977.48 Arthrocentesis, aspiration and/or injection, small joint or bursa (eg, fingers, toes); without ultrasound guidance Each 378.00 302.4000 233.98 378.00 Arthrocentesis, aspiration and/or injection, intermediate joint or bursa (eg, temporomandibular, acromioclavicular, wrist, elbow or ankle, olecranon bursa); without ultrasound guidance Each 378.00 302.4000 233.98 378.00 Arthrocentesis, aspiration and/or injection, major joint or bursa (eg, shoulder, hip, knee, subacromial bursa); without ultrasound guidance Each 345.00 276.0000 213.56 345.00 Arthrocentesis, aspiration and/or injection, major joint or bursa (eg, shoulder, hip, knee, subacromial bursa); with ultrasound guidance, with permanent recording and reporting Each 448.00 358.4000 252.86 448.00 Aspiration and/or injection of ganglion cyst(s) any location Each 3819.88 3055.9100 252.86 3819.88 Aspiration and injection for treatment of bone cyst Each 170.00 136.0000 105.23 654.36 Removal of implant; deep (eg, buried wire, pin, screw, metal band, nail, rod or plate) Each 11034.46 8827.5700 2402.40 11034.46 Adjustment or revision of external fixation system requiring anesthesia (eg, new pin[s] or wire[s] and/or new ring[s] or bar[s]) Each 5524.84 4419.8700 3419.87 6669.59 Removal, under anesthesia, of external fixation system Each 8282.47 6625.9800 1334.09 8282.47 Manual preparation and insertion of drug-delivery device(s), deep (eg, subfascial) (List separately in addition to code for primary procedure) 1.0000 each 5028.21 4022.5700 3112.46 5028.21 Manual preparation and insertion of drug-delivery device(s), intra-articular (List separately in addition to code for primary procedure) 1.0000 each 6927.21 5541.7600 4287.94 6927.20 Allograft, morselized, or placement of osteopromotive material, for spine surgery only (List separately in addition to code for primary procedure) 1.0000 each 8814.58 7051.6700 5456.23 8814.58 Autograft for spine surgery only (includes harvesting the graft); local (eg, ribs, spinous process, or laminar fragments) obtained from same incision (List separately in addition to code for primary procedure) 1.0000 each 8814.58 7051.6700 5456.23 8814.58 Excision, tumor, soft tissue of face or scalp, subcutaneous; 2 cm or greater Each 15442.27 12353.8200 1394.57 15442.27 Excision, tumor, soft tissue of face and scalp, subfascial (eg, subgaleal, intramuscular); less than 2 cm Each 3950.12 3160.0900 1394.57 3950.12 Excision, tumor, soft tissue of face and scalp, subfascial (eg, subgaleal, intramuscular); 2 cm or greater Each 11055.59 8844.4700 2402.40 11055.59 Impression and custom preparation; oral surgical splint Each 1557.00 1245.6000 193.28 1557.00 Closed treatment of nasal bone fracture with manipulation; without stabilization Each 2489.25 1991.4000 1290.96 2489.25 Closed treatment of nasal bone fracture with manipulation; with stabilization Each 2489.25 1991.4000 1540.85 2868.67 Percutaneous treatment of fracture of malar area, including zygomatic arch and malar tripod, with manipulation Each 6752.70 5402.1600 2645.86 6752.70 Closed treatment of fracture of orbit, except blowout; without manipulation Each 1087.30 869.8400 424.84 1087.30 Closed treatment of mandibular or maxillary alveolar ridge fracture (separate procedure) Each 3574.40 2859.5200 2212.55 3574.40 Closed treatment of mandibular fracture; without manipulation Each 477.60 382.0800 295.63 477.60 Closed treatment of temporomandibular dislocation; initial or subsequent Each 197.05 157.6400 121.97 208.73 Incision and drainage, deep abscess or hematoma, soft tissues of neck or thorax Each 930.63 744.5000 576.06 2604.71 Biopsy, soft tissue of neck or thorax Each 1235.00 988.0000 764.46 1512.01 Excision, tumor, soft tissue of neck or anterior thorax, subcutaneous; less than 3 cm Each 7906.87 6325.4900 1394.57 7906.86 Excision, tumor, soft tissue of neck or anterior thorax, subfascial (eg, intramuscular); less than 5 cm Each 8386.00 6708.8000 2402.40 8386.00 Closed treatment of sternum fracture Each 230.65 184.5200 142.77 230.65 Excision, tumor, soft tissue of back or flank, subcutaneous; 3 cm or greater Each 7588.29 6070.6300 1394.57 7588.29 Excision, tumor, soft tissue of back or flank, subfascial (eg, intramuscular); less than 5 cm Each 13703.49 10962.7900 2402.40 13703.49 Excision, tumor, soft tissue of back or flank, subfascial (eg, intramuscular); 5 cm or greater Each 23367.29 18693.8300 2402.40 23367.29 Arthrodesis, anterior interbody, including disc space preparation, discectomy, osteophytectomy and decompression of spinal cord and/or nerve roots; cervical below C2 Each 7555.48 6044.3800 4676.84 13156.49 Arthrodesis, combined posterior or posterolateral technique with posterior interbody technique including laminectomy and/or discectomy sufficient to prepare interspace (other than for decompression), single interspace, lumbar; Each 10467.24 8373.7900 6479.22 22079.56 Insertion of interbody biomechanical device(s) (eg, synthetic cage, mesh) with integral anterior instrumentation for device anchoring (eg, screws, flanges), when performed, to intervertebral disc space in conjunction with interbody arthrodesis, each interspace (List separately in addition to code for primary procedure) 1.0000 each 8814.58 7051.6700 5456.23 8814.58 Total disc arthroplasty (artificial disc), anterior approach, including discectomy with end plate preparation (includes osteophytectomy for nerve root or spinal cord decompression and microdissection); single interspace, cervical Each 6296.38 5037.1000 3897.46 22079.56 Excision, tumor, soft tissue of abdominal wall, subcutaneous; less than 3 cm Each 2712.18 2169.7400 1394.57 2712.18 Capsular contracture release (eg, Sever type procedure) Each 3365.97 2692.7800 2083.54 3365.97 Claviculectomy; partial Each 7045.46 5636.3600 2768.27 7045.46 Acromioplasty or acromionectomy, partial, with or without coracoacromial ligament release Each 3365.97 2692.7800 2083.54 3365.97 Injection procedure for shoulder arthrography or enhanced CT/MRI shoulder arthrography Each 452.00 361.6000 279.79 452.00 Tenotomy, shoulder area; single tendon Each 7076.39 5661.1100 4380.28 7076.39 Repair of ruptured musculotendinous cuff (eg, rotator cuff) open; acute Each 6690.41 5352.3300 4141.36 6690.41 Repair of ruptured musculotendinous cuff (eg, rotator cuff) open; chronic Each 6366.65 5093.3200 3940.96 6669.59 Reconstruction of complete shoulder (rotator) cuff avulsion, chronic (includes acromioplasty) Each 8160.35 6528.2800 5051.26 8160.35 Arthroplasty, glenohumeral joint; hemiarthroplasty Each 18952.43 15161.9400 11731.55 18952.42 Arthroplasty, glenohumeral joint; total shoulder (glenoid and proximal humeral replacement (eg, total shoulder)) Each 28962.88 23170.3000 12134.62 28962.88 Revision of total shoulder arthroplasty, including allograft when performed; humeral and glenoid component Each 11659.37 9327.4900 7217.15 11659.36 Closed treatment of clavicular fracture; without manipulation Each 176.10 140.8800 109.01 208.73 Closed treatment of clavicular fracture; with manipulation Each 2869.05 2295.2400 1334.09 2869.05 Open treatment of clavicular fracture, includes internal fixation, when performed Each 9014.86 7211.8900 5580.20 9014.86 Closed treatment of sternoclavicular dislocation; with manipulation Each 887.35 709.8800 192.52 887.35 Closed treatment of acromioclavicular dislocation; without manipulation Each 230.65 184.5200 142.77 230.65 Closed treatment of acromioclavicular dislocation; with manipulation Each 887.35 709.8800 192.52 887.35 Closed treatment of scapular fracture; without manipulation Each 230.65 184.5200 142.77 230.65 Closed treatment of scapular fracture; with manipulation, with or without skeletal traction (with or without shoulder joint involvement) Each 887.35 709.8800 549.27 1446.44 Closed treatment of proximal humeral (surgical or anatomical neck) fracture; without manipulation Each 230.65 184.5200 142.77 230.65 Closed treatment of proximal humeral (surgical or anatomical neck) fracture; with manipulation, with or without skeletal traction Each 5768.11 4614.4900 1334.09 5768.11 Closed treatment of greater humeral tuberosity fracture; without manipulation Each 230.65 184.5200 142.77 230.65 Closed treatment of greater humeral tuberosity fracture; with manipulation Each 2869.05 2295.2400 1334.09 2869.05 Closed treatment of shoulder dislocation, with manipulation; without anesthesia Each 243.00 194.4000 150.42 243.00 Closed treatment of shoulder dislocation, with manipulation; requiring anesthesia Each 8925.02 7140.0100 1334.09 8925.02 Closed treatment of shoulder dislocation, with fracture of greater humeral tuberosity, with manipulation Each 887.35 709.8800 549.27 1446.44 Closed treatment of shoulder dislocation, with surgical or anatomical neck fracture, with manipulation Each 230.65 184.5200 142.77 1446.44 Incision and drainage, upper arm or elbow area; deep abscess or hematoma Each 7246.54 5797.2300 2402.40 7246.54 Excision, tumor, soft tissue of upper arm or elbow area, subcutaneous; 3 cm or greater Each 13862.61 11090.0900 2402.40 13862.61 Excision, tumor, soft tissue of upper arm or elbow area, subfascial (eg, intramuscular); 5 cm or greater Each 7671.28 6137.0200 2402.40 7671.28 Excision, olecranon bursa Each 4165.60 3332.4800 2578.50 4165.60 Partial excision (craterization, saucerization, or diaphysectomy) bone (eg, osteomyelitis), olecranon process Each 2681.16 2144.9300 1659.64 3001.39 Removal of foreign body, upper arm or elbow area; deep (subfascial or intramuscular) Each 10459.60 8367.6800 2402.40 10459.60 Injection procedure for elbow arthrography Each 279.00 223.2000 172.70 279.00 Manipulation, elbow, under anesthesia Each 7847.59 6278.0700 1334.09 7847.59 Reinsertion of ruptured biceps or triceps tendon, distal, with or without tendon graft Each 13435.13 10748.1000 6151.56 13435.13 Tenotomy, elbow, lateral or medial (eg, epicondylitis, tennis elbow, golfer's elbow); debridement, soft tissue and/or bone, open with tendon repair or reattachment Each 5766.74 4613.3900 2768.27 5766.74 Closed treatment of humeral shaft fracture; without manipulation Each 230.65 184.5200 142.77 230.65 Closed treatment of supracondylar or transcondylar humeral fracture, with or without intercondylar extension; without manipulation Each 230.65 184.5200 142.77 230.65 Treatment of closed elbow dislocation; without anesthesia Each 243.00 194.4000 150.42 243.00 Closed treatment of Monteggia type of fracture dislocation at elbow (fracture proximal end of ulna with dislocation of radial head), with manipulation Each 2581.20 2064.9600 1334.09 2581.20 Closed treatment of radial head subluxation in child, nursemaid elbow, with manipulation Each 243.00 194.4000 150.42 243.00 Closed treatment of radial head or neck fracture; without manipulation Each 230.65 184.5200 142.77 230.65 Closed treatment of radial head or neck fracture; with manipulation Each 1295.00 1036.0000 801.60 1446.44 Open treatment of radial head or neck fracture, includes internal fixation or radial head excision, when performed Each 6471.19 5176.9500 4005.67 6669.59 Closed treatment of ulnar fracture, proximal end (eg, olecranon or coronoid process[es]); without manipulation Each 230.65 184.5200 142.77 230.65 Open treatment of ulnar fracture, proximal end (eg, olecranon or coronoid process[es]), includes internal fixation, when performed Each 4327.91 3462.3300 2678.98 6669.59 Incision, extensor tendon sheath, wrist (eg, de Quervains disease) Each 10748.25 8598.6000 1334.09 10748.25 Excision of ganglion, wrist (dorsal or volar); primary Each 12842.93 10274.3400 1334.09 12842.93 Carpectomy; 1 bone Each 13630.45 10904.3600 2768.27 13630.45 Tendon transplantation or transfer, flexor or extensor, forearm and/or wrist, single; each tendon Each 4449.09 3559.2700 2753.98 4449.08 Capsulorrhaphy or reconstruction, wrist, open (eg, capsulodesis, ligament repair, tendon transfer or graft) (includes synovectomy, capsulotomy and open reduction) for carpal instability Each 4783.54 3826.8300 2961.01 6669.59 Closed treatment of radial shaft fracture; without manipulation Each 230.65 184.5200 142.77 230.65 Closed treatment of radial shaft fracture; with manipulation Each 6925.50 5540.4000 1334.09 6925.50 Closed treatment of ulnar shaft fracture; without manipulation Each 230.65 184.5200 142.77 230.65 Closed treatment of ulnar shaft fracture; with manipulation Each 6925.50 5540.4000 192.52 6925.50 Closed treatment of radial and ulnar shaft fractures; without manipulation Each 230.65 184.5200 142.77 230.65 Closed treatment of radial and ulnar shaft fractures; with manipulation Each 536.00 428.8000 331.78 1446.44 Closed treatment of distal radial fracture (eg, Colles or Smith type) or epiphyseal separation, includes closed treatment of fracture of ulnar styloid, when performed; without manipulation Each 252.95 202.3600 156.58 252.95 Closed treatment of distal radial fracture (eg, Colles or Smith type) or epiphyseal separation, includes closed treatment of fracture of ulnar styloid, when performed; with manipulation Each 932.00 745.6000 576.91 1446.44 Percutaneous skeletal fixation of distal radial fracture or epiphyseal separation Each 6262.99 5010.3900 2768.27 6262.99 Open treatment of distal radial extra-articular fracture or epiphyseal separation, with internal fixation Each 5732.27 4585.8200 3548.28 6669.59 Open treatment of distal radial intra-articular fracture or epiphyseal separation; with internal fixation of 3 or more fragments Each 1283.66 1026.9300 794.58 6669.59 Closed treatment of carpal scaphoid (navicular) fracture; without manipulation Each 230.65 184.5200 142.77 230.65 Closed treatment of carpal bone fracture (excluding carpal scaphoid [navicular]); without manipulation, each bone Each 230.65 184.5200 142.77 230.65 Closed treatment of ulnar styloid fracture Each 230.65 184.5200 142.77 230.65 Open treatment of ulnar styloid fracture Each 1283.66 1026.9300 794.58 6669.59 Closed treatment of radiocarpal or intercarpal dislocation, 1 or more bones, with manipulation Each 230.65 184.5200 142.77 230.65 Closed treatment of distal radioulnar dislocation with manipulation Each 230.65 184.5200 142.77 230.65 Closed treatment of trans-scaphoperilunar type of fracture dislocation, with manipulation Each 230.65 184.5200 142.77 230.65 Closed treatment of lunate dislocation, with manipulation Each 2869.05 2295.2400 1334.09 2869.05 Arthrodesis, wrist; with autograft (includes obtaining graft) Each 13630.45 10904.3600 6151.56 13630.45 Drainage of finger abscess; simple Each 204.40 163.5200 126.52 204.40 Drainage of finger abscess; complicated (eg, felon) Each 11855.19 9484.1500 1394.57 11855.19 Tendon sheath incision (eg, for trigger finger) Each 9218.95 7375.1600 1334.09 9218.95 Excision, tumor or vascular malformation, soft tissue of hand or finger, subcutaneous; less than 1.5 cm Each 5278.13 4222.5000 1394.57 5278.12 Fasciectomy, partial palmar with release of single digit including proximal interphalangeal joint, with or without Z-plasty, other local tissue rearrangement, or skin grafting (includes obtaining graft) Each 5611.69 4489.3500 2768.27 5611.69 Partial excision (craterization, saucerization, or diaphysectomy) bone (eg, osteomyelitis); distal phalanx of finger Each 2398.60 1918.8800 1334.09 2398.60 Repair, extensor tendon, hand, primary or secondary; without free graft, each tendon Each 2441.10 1952.8800 1334.09 2441.10 Repair, extensor tendon, finger, primary or secondary; without free graft, each tendon Each 4840.19 3872.1500 1334.09 4840.18 Closed treatment of distal extensor tendon insertion, with or without percutaneous pinning (eg, mallet finger) Each 4449.09 3559.2700 1334.09 4449.08 Tenotomy, flexor, finger, open, each tendon Each 15847.90 12678.3200 1334.09 15847.90 Closed treatment of metacarpal fracture, single; without manipulation, each bone Each 230.65 184.5200 142.77 230.65 Closed treatment of metacarpal fracture, single; with manipulation, each bone Each 230.65 184.5200 142.77 230.65 Closed treatment of metacarpal fracture, with manipulation, with external fixation, each bone Each 2869.05 2295.2400 1775.94 3001.39 Closed treatment of carpometacarpal dislocation, thumb, with manipulation Each 252.95 202.3600 156.58 252.95 Closed treatment of carpometacarpal fracture dislocation, thumb (Bennett fracture), with manipulation Each 887.35 709.8800 549.27 1446.44 Closed treatment of carpometacarpal dislocation, other than thumb, with manipulation, each joint; without anesthesia Each 413.00 330.4000 192.52 413.00 Closed treatment of carpometacarpal dislocation, other than thumb, with manipulation, each joint; requiring anesthesia Each 887.35 709.8800 549.27 1446.44 Closed treatment of metacarpophalangeal dislocation, single, with manipulation; without anesthesia Each 243.00 194.4000 150.42 243.00 Closed treatment of metacarpophalangeal dislocation, single, with manipulation; requiring anesthesia Each 1081.55 865.2400 669.48 1446.44 Closed treatment of phalangeal shaft fracture, proximal or middle phalanx, finger or thumb; without manipulation, each Each 230.65 184.5200 142.77 230.65 Closed treatment of phalangeal shaft fracture, proximal or middle phalanx, finger or thumb; with manipulation, with or without skin or skeletal traction, each Each 405.25 324.2000 192.52 405.25 Closed treatment of articular fracture, involving metacarpophalangeal or interphalangeal joint; without manipulation, each Each 230.65 184.5200 142.77 230.65 Closed treatment of articular fracture, involving metacarpophalangeal or interphalangeal joint; with manipulation, each Each 230.65 184.5200 142.77 1446.44 Closed treatment of distal phalangeal fracture, finger or thumb; without manipulation, each Each 230.65 184.5200 142.77 230.65 Closed treatment of distal phalangeal fracture, finger or thumb; with manipulation, each Each 413.00 330.4000 192.52 413.00 Open treatment of distal phalangeal fracture, finger or thumb, includes internal fixation, when performed, each Each 3920.11 3136.0900 2426.55 3920.11 Closed treatment of interphalangeal joint dislocation, single, with manipulation; without anesthesia Each 426.00 340.8000 192.52 426.00 Closed treatment of interphalangeal joint dislocation, single, with manipulation; requiring anesthesia Each 2247.85 1798.2800 223.11 2247.85 Open treatment of interphalangeal joint dislocation, includes internal fixation, when performed, single Each 3920.11 3136.0900 2426.55 3920.11 Amputation, finger or thumb, primary or secondary, any joint or phalanx, single, including neurectomies; with local advancement flaps (V-Y, hood) Each 2494.00 1995.2000 1543.79 3001.39 Unlisted procedure, hands or fingers Each 875.50 700.4000 192.52 875.50 Arthrotomy, hip, with drainage (eg, infection) Each 6159.98 4927.9800 3813.03 6159.98 Removal of hip prosthesis; (separate procedure) Each 8940.63 7152.5100 5534.25 8940.63 Injection procedure for hip arthrography; without anesthesia Each 671.00 536.8000 415.35 671.00 Injection procedure for sacroiliac joint, anesthetic/steroid, with image guidance (fluoroscopy or CT) including arthrography when performed Each 423.00 338.4000 261.84 423.00 Hemiarthroplasty, hip, partial (eg, femoral stem prosthesis, bipolar arthroplasty) Each 6396.55 5117.2400 3959.46 6396.55 Arthroplasty, acetabular and proximal femoral prosthetic replacement (total hip arthroplasty), with or without autograft or allograft Each 24491.04 19592.8300 12134.62 24491.04 Revision of total hip arthroplasty; both components, with or without autograft or allograft Each 16454.63 13163.7000 10185.42 16454.63 Revision of total hip arthroplasty; femoral component only, with or without allograft Each 7340.64 5872.5100 4543.86 7340.64 Closed treatment of coccygeal fracture Each 230.65 184.5200 142.77 230.65 Percutaneous skeletal fixation of femoral fracture, proximal end, neck Each 11427.90 9142.3200 6151.56 11427.90 Closed treatment of intertrochanteric, peritrochanteric, or subtrochanteric femoral fracture; with manipulation, with or without skin or skeletal traction Each 206.40 165.1200 127.76 206.40 Treatment of intertrochanteric, peritrochanteric, or subtrochanteric femoral fracture; with intramedullary implant, with or without interlocking screws and/or cerclage Each 24181.97 19345.5800 14968.64 24181.97 Closed treatment of hip dislocation, traumatic; without anesthesia Each 230.65 184.5200 142.77 230.65 Treatment of spontaneous hip dislocation (developmental, including congenital or pathological), by abduction, splint or traction; with manipulation, requiring anesthesia Each 923.46 738.7700 571.62 1446.44 Closed treatment of post hip arthroplasty dislocation; without anesthesia Each 563.00 450.4000 192.52 563.00 Closed treatment of post hip arthroplasty dislocation; requiring regional or general anesthesia Each 1801.65 1441.3200 1115.22 1801.65 Unlisted procedure, pelvis or hip joint Each 8149.40 6519.5200 192.52 8149.40 Arthrotomy, knee, with exploration, drainage, or removal of foreign body (eg, infection) Each 6752.63 5402.1000 2768.27 6752.63 Excision, tumor, soft tissue of thigh or knee area, subcutaneous; 3 cm or greater Each 4634.86 3707.8900 2402.40 4634.86 Excision, prepatellar bursa Each 9253.75 7403.0000 2768.27 9253.74 Patellectomy or hemipatellectomy Each 7512.13 6009.7000 4650.01 7512.13 Suture of quadriceps or hamstring muscle rupture; primary Each 27826.97 22261.5700 6151.56 27826.96 Suture of quadriceps or hamstring muscle rupture; secondary reconstruction, including fascial or tendon graft Each 7512.13 6009.7000 4650.01 7512.13 Anterior tibial tubercleplasty (eg, Maquet type procedure) Each 7138.37 5710.6900 4418.65 7138.37 Reconstruction of dislocating patella; (eg, Hauser type procedure) Each 9333.17 7466.5400 5777.23 9333.17 Arthroplasty, patella; with prosthesis Each 6867.31 5493.8500 4250.86 13156.49 Arthroplasty, knee, condyle and plateau; medial OR lateral compartment Each 12683.12 10146.4900 7850.85 13156.49 Arthroplasty, knee, condyle and plateau; medial AND lateral compartments with or without patella resurfacing (total knee arthroplasty) Each 28500.59 22800.4700 12134.62 28500.59 Revision of total knee arthroplasty, with or without allograft; 1 component Each 27960.96 22368.7700 17307.83 27960.96 Revision of total knee arthroplasty, with or without allograft; femoral and entire tibial component Each 9853.42 7882.7300 6099.26 9853.42 Percutaneous skeletal fixation of femoral fracture, distal end, medial or lateral condyle, or supracondylar or transcondylar, with or without intercondylar extension, or distal femoral epiphyseal separation Each 4175.76 3340.6100 2584.80 6669.59 Closed treatment of patellar fracture, without manipulation Each 230.65 184.5200 142.77 230.65 Closed treatment of tibial fracture, proximal (plateau); without manipulation Each 230.65 184.5200 142.77 230.65 Closed treatment of tibial fracture, proximal (plateau); with or without manipulation, with skeletal traction Each 226.20 180.9600 140.02 3001.39 Open treatment of tibial fracture, proximal (plateau); unicondylar, includes internal fixation, when performed Each 19237.95 15390.3600 11908.29 19237.95 Closed treatment of intercondylar spine(s) and/or tuberosity fracture(s) of knee, with or without manipulation Each 230.65 184.5200 142.77 230.65 Closed treatment of knee dislocation; without anesthesia Each 230.65 184.5200 142.77 230.65 Closed treatment of knee dislocation; requiring anesthesia Each 2247.85 1798.2800 1334.09 2247.85 Closed treatment of patellar dislocation; without anesthesia Each 230.65 184.5200 142.77 230.65 Closed treatment of patellar dislocation; requiring anesthesia Each 2247.85 1798.2800 192.52 2247.85 Manipulation of knee joint under general anesthesia (includes application of traction or other fixation devices) Each 1722.50 1378.0000 1066.23 1722.50 Incision and drainage, leg or ankle; deep abscess or hematoma Each 1293.77 1035.0200 800.84 2604.71 Excision or curettage of bone cyst or benign tumor, tibia or fibula Each 14650.37 11720.3000 2768.27 14650.37 Injection procedure for ankle arthrography Each 288.00 230.4000 178.27 288.00 Repair, secondary, disrupted ligament, ankle, collateral (eg, Watson-Jones procedure) Each 2663.48 2130.7800 1648.69 6669.59 Closed treatment of tibial shaft fracture (with or without fibular fracture); without manipulation Each 230.65 184.5200 142.77 230.65 Closed treatment of tibial shaft fracture (with or without fibular fracture); with manipulation, with or without skeletal traction Each 2645.69 2116.5500 1334.09 2645.69 Treatment of tibial shaft fracture (with or without fibular fracture) by intramedullary implant, with or without interlocking screws and/or cerclage Each 63.11 50.4900 39.07 13156.49 Closed treatment of medial malleolus fracture; without manipulation Each 230.65 184.5200 142.77 230.65 Closed treatment of medial malleolus fracture; with manipulation, with or without skin or skeletal traction Each 224.00 179.2000 138.66 1446.44 Closed treatment of proximal fibula or shaft fracture; without manipulation Each 230.65 184.5200 142.77 230.65 Closed treatment of proximal fibula or shaft fracture; with manipulation Each 213.10 170.4800 131.91 1446.44 Closed treatment of distal fibular fracture (lateral malleolus); without manipulation Each 350.00 280.0000 192.52 350.00 Closed treatment of distal fibular fracture (lateral malleolus); with manipulation Each 1635.45 1308.3600 192.52 1635.45 Open treatment of distal fibular fracture (lateral malleolus), includes internal fixation, when performed Each 3902.61 3122.0800 2415.71 6669.59 Closed treatment of bimalleolar ankle fracture (eg, lateral and medial malleoli, or lateral and posterior malleoli or medial and posterior malleoli); without manipulation Each 230.65 184.5200 142.77 230.65 Closed treatment of bimalleolar ankle fracture (eg, lateral and medial malleoli, or lateral and posterior malleoli or medial and posterior malleoli); with manipulation Each 887.35 709.8800 549.27 1446.44 Open treatment of bimalleolar ankle fracture (eg, lateral and medial malleoli, or lateral and posterior malleoli, or medial and posterior malleoli), includes internal fixation, when performed Each 3111.91 2489.5200 1926.27 6669.59 Closed treatment of trimalleolar ankle fracture; without manipulation Each 230.65 184.5200 142.77 230.65 Closed treatment of trimalleolar ankle fracture; with manipulation Each 887.35 709.8800 549.27 1446.44 Open treatment of trimalleolar ankle fracture, includes internal fixation, when performed, medial and/or lateral malleolus; without fixation of posterior lip Each 3266.59 2613.2700 2022.02 6669.59 Closed treatment of fracture of weight bearing articular portion of distal tibia (eg, pilon or tibial plafond), with or without anesthesia; without manipulation Each 230.65 184.5200 142.77 230.65 Closed treatment of fracture of weight bearing articular portion of distal tibia (eg, pilon or tibial plafond), with or without anesthesia; with skeletal traction and/or requiring manipulation Each 213.10 170.4800 131.91 1446.44 Open treatment of distal tibiofibular joint (syndesmosis) disruption, includes internal fixation, when performed Each 3112.04 2489.6300 1926.35 6669.59 Closed treatment of proximal tibiofibular joint dislocation; without anesthesia Each 230.65 184.5200 142.77 230.65 Closed treatment of proximal tibiofibular joint dislocation; requiring anesthesia Each 1081.55 865.2400 669.48 3001.39 Closed treatment of ankle dislocation; without anesthesia Each 932.00 745.6000 192.52 932.00 Closed treatment of ankle dislocation; requiring anesthesia, with or without percutaneous skeletal fixation Each 2055.50 1644.4000 1272.35 2055.50 Fasciotomy, foot and/or toe Each 6357.22 5085.7700 2768.27 6357.22 Arthrotomy, including exploration, drainage, or removal of loose or foreign body; interphalangeal joint Each 5262.39 4209.9100 1334.09 5262.39 Ostectomy, calcaneus; for spur, with or without plantar fascial release Each 6456.89 5165.5100 2768.27 6456.88 Removal of foreign body, foot; subcutaneous Each 1241.25 993.0000 603.54 1241.25 Removal of foreign body, foot; deep Each 2310.85 1848.6800 1394.57 2310.85 Correction, hammertoe (eg, interphalangeal fusion, partial or total phalangectomy) Each 6804.60 5443.6800 2768.27 6804.60 Closed treatment of calcaneal fracture; without manipulation Each 230.65 184.5200 142.77 230.65 Closed treatment of calcaneal fracture; with manipulation Each 213.10 170.4800 131.91 213.10 Closed treatment of talus fracture; without manipulation Each 230.65 184.5200 142.77 230.65 Closed treatment of talus fracture; with manipulation Each 230.65 184.5200 142.77 1446.44 Treatment of tarsal bone fracture (except talus and calcaneus); without manipulation, each Each 230.65 184.5200 142.77 230.65 Treatment of tarsal bone fracture (except talus and calcaneus); with manipulation, each Each 230.65 184.5200 142.77 1446.44 Closed treatment of metatarsal fracture; without manipulation, each Each 230.65 184.5200 142.77 230.65 Closed treatment of metatarsal fracture; with manipulation, each Each 230.65 184.5200 142.77 230.65 Closed treatment of fracture great toe, phalanx or phalanges; without manipulation Each 230.65 184.5200 142.77 230.65 Closed treatment of fracture great toe, phalanx or phalanges; with manipulation Each 230.65 184.5200 142.77 230.65 Closed treatment of fracture, phalanx or phalanges, other than great toe; without manipulation, each Each 230.65 184.5200 142.77 230.65 Closed treatment of fracture, phalanx or phalanges, other than great toe; with manipulation, each Each 243.00 194.4000 150.42 243.00 Closed treatment of sesamoid fracture Each 230.65 184.5200 142.77 230.65 Closed treatment of tarsal bone dislocation, other than talotarsal; without anesthesia Each 230.65 184.5200 142.77 230.65 Closed treatment of tarsal bone dislocation, other than talotarsal; requiring anesthesia Each 3673.80 2939.0400 2274.08 3673.80 Closed treatment of talotarsal joint dislocation; without anesthesia Each 887.35 709.8800 192.52 887.35 Closed treatment of talotarsal joint dislocation; requiring anesthesia Each 2869.05 2295.2400 1775.94 3001.39 Closed treatment of tarsometatarsal joint dislocation; without anesthesia Each 230.65 184.5200 142.77 230.65 Closed treatment of tarsometatarsal joint dislocation; requiring anesthesia Each 1081.55 865.2400 192.52 1081.55 Closed treatment of metatarsophalangeal joint dislocation; without anesthesia Each 230.65 184.5200 142.77 230.65 Closed treatment of interphalangeal joint dislocation; without anesthesia Each 235.00 188.0000 145.46 235.00 Amputation, toe; metatarsophalangeal joint Each 14701.56 11761.2400 2768.27 14701.56 Application, cast; shoulder to hand (long arm) Each 350.85 280.6800 217.18 350.85 Application, cast; elbow to finger (short arm) Each 350.85 280.6800 217.18 350.85 Application, cast; hand and lower forearm (gauntlet) Each 170.85 136.6800 105.76 170.85 Application of long arm splint (shoulder to hand) Each 180.00 144.0000 111.42 180.00 Application of short arm splint (forearm to hand); static Each 180.00 144.0000 107.98 180.00 Application of short arm splint (forearm to hand); dynamic Each 170.85 136.6800 105.76 170.85 Application of finger splint; static Each 180.00 144.0000 107.98 180.00 Application of finger splint; dynamic Each 170.85 136.6800 53.46 170.85 Strapping; thorax Each 170.85 136.6800 105.76 170.85 Strapping; shoulder (eg, Velpeau) Each 170.85 136.6800 105.76 170.85 Strapping; elbow or wrist Each 79.00 63.2000 48.90 79.00 Strapping; hand or finger Each 170.85 136.6800 53.46 170.85 Application of long leg cast (thigh to toes) Each 350.85 280.6800 217.18 350.85 Application of long leg cast (thigh to toes); walker or ambulatory type Each 350.85 280.6800 217.18 350.85 Application of short leg cast (below knee to toes) Each 350.85 280.6800 217.18 350.85 Application of short leg cast (below knee to toes); walking or ambulatory type Each 350.85 280.6800 217.18 350.85 Application of long leg splint (thigh to ankle or toes) Each 165.00 132.0000 102.14 165.00 Application of short leg splint (calf to foot) Each 165.00 132.0000 102.14 165.00 Strapping; hip Each 156.90 125.5200 97.12 156.90 Strapping; knee Each 156.90 125.5200 97.12 156.90 Strapping; ankle and/or foot Each 160.00 128.0000 99.04 160.00 Strapping; toes Each 156.90 125.5200 53.46 156.90 Strapping; Unna boot Each 156.90 125.5200 97.12 156.90 Unlisted procedure, casting or strapping Each 170.85 136.6800 105.76 170.85 Arthroscopy, shoulder, diagnostic, with or without synovial biopsy (separate procedure) Each 4061.24 3248.9900 2513.91 4061.24 Arthroscopy, shoulder, surgical; repair of SLAP lesion Each 7871.46 6297.1700 4872.44 7871.46 Arthroscopy, shoulder, surgical; debridement, limited, 1 or 2 discrete structures (eg, humeral bone, humeral articular cartilage, glenoid bone, glenoid articular cartilage, biceps tendon, biceps anchor complex, labrum, articular capsule, articular side of the rotator cuff, bursal side of the rotator cuff, subacromial bursa, foreign body[ies]) Each 11044.57 8835.6500 2768.27 11044.56 Arthroscopy, shoulder, surgical; debridement, extensive, 3 or more discrete structures (eg, humeral bone, humeral articular cartilage, glenoid bone, glenoid articular cartilage, biceps tendon, biceps anchor complex, labrum, articular capsule, articular side of the rotator cuff, bursal side of the rotator cuff, subacromial bursa, foreign body[ies]) Each 6433.23 5146.5800 2768.27 6433.23 Arthroscopy, shoulder, surgical; distal claviculectomy including distal articular surface (Mumford procedure) Each 6776.66 5421.3200 2768.27 6776.66 Arthroscopy, shoulder, surgical; with lysis and resection of adhesions, with or without manipulation Each 18489.15 14791.3200 2768.27 18489.15 Arthroscopy, shoulder, surgical; decompression of subacromial space with partial acromioplasty, with coracoacromial ligament (ie, arch) release, when performed (List separately in addition to code for primary procedure) 1.0000 each 6862.90 5490.3200 4248.14 6862.90 Arthroscopy, shoulder, surgical; with rotator cuff repair Each 7120.22 5696.1800 4407.42 7120.22 Arthroscopy, shoulder, surgical; biceps tenodesis Each 6261.25 5009.0000 3875.71 6669.59 Arthroscopy, knee, surgical; for infection, lavage and drainage Each 15076.19 12060.9500 2768.27 15076.19 Arthroscopy, knee, surgical; with lateral release Each 4986.52 3989.2200 2768.27 4986.52 Arthroscopy, knee, surgical; synovectomy, limited (eg, plica or shelf resection) (separate procedure) Each 13332.32 10665.8600 2768.27 13332.32 Arthroscopy, knee, surgical; debridement/shaving of articular cartilage (chondroplasty) Each 4175.76 3340.6100 2584.80 4175.76 Arthroscopy, knee, surgical; with meniscectomy (medial AND lateral, including any meniscal shaving) including debridement/shaving of articular cartilage (chondroplasty), same or separate compartment(s), when performed Each 15404.22 12323.3800 2768.27 15404.22 Arthroscopy, knee, surgical; with meniscectomy (medial OR lateral, including any meniscal shaving) including debridement/shaving of articular cartilage (chondroplasty), same or separate compartment(s), when performed Each 15082.73 12066.1800 2768.27 15082.73 Arthroscopy, knee, surgical; with lysis of adhesions, with or without manipulation (separate procedure) Each 16590.27 13272.2200 2768.27 16590.27 Arthroscopically aided anterior cruciate ligament repair/augmentation or reconstruction Each 9052.25 7241.8000 5603.34 9052.25 Arthroscopically aided posterior cruciate ligament repair/augmentation or reconstruction Each 11634.16 9307.3300 7201.54 13156.49 Arthroscopically aided repair of large osteochondritis dissecans lesion, talar dome fracture, or tibial plafond fracture, with or without internal fixation (includes arthroscopy) Each 20764.16 16611.3300 6151.56 20764.16 Biopsy, intranasal Each 10584.64 8467.7100 1290.96 10584.64 Excision or destruction (eg, laser), intranasal lesion; internal approach Each 2790.47 2232.3800 1727.30 2868.67 Excision inferior turbinate, partial or complete, any method Each 9243.29 7394.6300 2645.86 9243.29 Submucous resection inferior turbinate, partial or complete, any method Each 6928.70 5542.9600 2645.86 6928.70 Removal foreign body, intranasal; office type procedure Each 165.10 132.0800 102.20 165.10 Repair of nasal vestibular stenosis (eg, spreader grafting, lateral nasal wall reconstruction) Each 5580.95 4464.7600 3454.61 5580.95 Septoplasty or submucous resection, with or without cartilage scoring, contouring or replacement with graft Each 6928.70 5542.9600 2645.86 6928.70 Control nasal hemorrhage, anterior, simple (limited cautery and/or packing) any method Each 228.00 182.4000 107.98 228.00 Control nasal hemorrhage, anterior, complex (extensive cautery and/or packing) any method Each 217.05 173.6400 107.98 217.05 Control nasal hemorrhage, posterior, with posterior nasal packs and/or cautery, any method; initial Each 217.05 173.6400 107.98 217.05 Nasal endoscopy, diagnostic, unilateral or bilateral (separate procedure) Each 10131.90 8105.5200 166.24 10131.90 Nasal/sinus endoscopy, surgical; with biopsy, polypectomy or debridement (separate procedure) Each 13764.82 11011.8600 1486.65 13764.82 Nasal/sinus endoscopy, surgical; with control of nasal hemorrhage Each 13682.60 10946.0800 1486.65 13682.60 Nasal/sinus endoscopy, surgical; with concha bullosa resection Each 5024.84 4019.8700 1486.65 5024.84 Nasal/sinus endoscopy, surgical with ethmoidectomy; total (anterior and posterior), including frontal sinus exploration, with removal of tissue from frontal sinus, when performed Each 6692.24 5353.7900 4142.50 6692.24 Nasal/sinus endoscopy, surgical with ethmoidectomy; total (anterior and posterior) Each 4432.06 3545.6500 2743.45 6238.48 Nasal/sinus endoscopy, surgical with ethmoidectomy; total (anterior and posterior), including sphenoidotomy Each 7795.27 6236.2200 4825.27 7795.27 Nasal/sinus endoscopy, surgical with ethmoidectomy; total (anterior and posterior), including sphenoidotomy, with removal of tissue from the sphenoid sinus Each 6069.28 4855.4300 3756.89 6238.48 Nasal/sinus endoscopy, surgical, with maxillary antrostomy; with removal of tissue from maxillary sinus Each 6380.76 5104.6100 3949.69 6380.76 Nasal/sinus endoscopy, surgical, with frontal sinus exploration, including removal of tissue from frontal sinus, when performed Each 8042.93 6434.3400 4978.57 8042.93 Intubation, endotracheal, emergency procedure Each 557.00 445.6000 193.28 557.00 Laryngoscopy, indirect; diagnostic (separate procedure) Each 325.00 260.0000 166.24 325.00 Laryngoscopy, indirect; with removal of foreign body Each 261.25 209.0000 161.71 261.25 Laryngoscopy direct, with or without tracheoscopy; diagnostic, with operating microscope or telescope Each 11501.59 9201.2700 1486.65 11501.59 Laryngoscopy, direct, operative, with biopsy; with operating microscope or telescope Each 13831.92 11065.5300 3100.27 13831.92 Laryngoscopy, flexible; diagnostic Each 6819.15 5455.3200 166.24 6819.15 Tracheostomy, emergency procedure; cricothyroid membrane Each 1180.65 944.5200 193.28 1180.65 Catheter aspiration (separate procedure); nasotracheal Each 57.95 46.3600 35.87 193.09 Biopsy, pleura, percutaneous needle Each 659.00 527.2000 407.92 1512.01 Insertion of indwelling tunneled pleural catheter with cuff 1.0000 each 8565.00 6852.0000 3293.97 8565.00 Tube thoracostomy, includes connection to drainage system (eg, water seal), when performed, open (separate procedure) Each 467.00 373.6000 289.07 1500.21 Thoracentesis, needle or catheter, aspiration of the pleural space; without imaging guidance Each 464.00 371.2000 287.22 583.31 Thoracentesis, needle or catheter, aspiration of the pleural space; with imaging guidance Each 1292.00 1033.6000 538.00 1292.00 Repair blood vessel, direct; lower extremity Each 4191.75 3353.4000 603.54 4191.75 Introduction of needle or intracatheter, vein 1.0000 each 32.00 25.6000 19.81 32.00 Injection procedures (eg, thrombin) for percutaneous treatment of extremity pseudoaneurysm Each 795.00 636.0000 492.10 795.00 Injection procedure for extremity venography (including introduction of needle or intracatheter) Each 369.00 295.2000 228.41 369.00 Venipuncture, age 3 years or older, necessitating the skill of a physician or other qualified health care professional (separate procedure), for diagnostic or therapeutic purposes (not to be used for routine venipuncture) Each 1128.89 903.1100 698.78 1128.89 Collection of venous blood by venipuncture 1.0000 Each 50.00 40.0000 8.14 50.00 Collection of capillary blood specimen (eg, finger, heel, ear stick) 1.0000 Each 14.00 11.2000 8.67 14.00 Venipuncture, cutdown; younger than age 1 year Each 512.15 409.7200 107.98 512.15 Venipuncture, cutdown; age 1 or over Each 512.15 409.7200 317.02 512.15 Transfusion, blood or blood components 1.0000 Each 683.00 546.4000 379.20 683.00 Endovenous ablation therapy of incompetent vein, extremity, inclusive of all imaging guidance and monitoring, percutaneous, radiofrequency; first vein treated Each 8700.00 6960.0000 2770.42 8700.00 Endovenous ablation therapy of incompetent vein, extremity, inclusive of all imaging guidance and monitoring, percutaneous, radiofrequency; subsequent vein(s) treated in a single extremity, each through separate access sites (List separately in addition to code for primary procedure) 1.0000 each 2900.00 2320.0000 1795.10 2900.00 Insertion of non-tunneled centrally inserted central venous catheter; age 5 years or older 1.0000 each 788.00 630.4000 487.77 3003.72 Insertion of tunneled centrally inserted central venous catheter, without subcutaneous port or pump; age 5 years or older Each 3933.60 3146.8800 2434.90 3933.60 Insertion of peripherally inserted central venous catheter (PICC), without subcutaneous port or pump, without imaging guidance; age 5 years or older 1.0000 each 1599.00 1279.2000 989.78 1599.00 Insertion of peripherally inserted central venous catheter (PICC), without subcutaneous port or pump, including all imaging guidance, image documentation, and all associated radiological supervision and interpretation required to perform the insertion; age 5 years or older 1.0000 each 1730.00 1384.0000 1070.87 1730.00 Replacement, complete, of a peripherally inserted central venous catheter (PICC), without subcutaneous port or pump, through same venous access, including all imaging guidance, image documentation, and all associated radiological supervision and interpretation required to perform the replacement 1.0000 each 1667.00 1333.6000 1031.87 1667.00 Removal of tunneled central venous catheter, without subcutaneous port or pump Each 1462.00 1169.6000 538.00 1462.00 Removal of tunneled central venous access device, with subcutaneous port or pump, central or peripheral insertion Each 15149.37 12119.5000 1383.69 15149.37 Collection of blood specimen from a completely implantable venous access device 1.0000 Each 76.00 60.8000 47.04 117.07 Collection of blood specimen using established central or peripheral catheter, venous, not otherwise specified 1.0000 Each 70.00 56.0000 43.33 117.07 Declotting by thrombolytic agent of implanted vascular access device or catheter Each 324.00 259.2000 200.56 335.38 Contrast injection(s) for radiologic evaluation of existing central venous access device, including fluoroscopy, image documentation and report Each 670.00 536.0000 192.11 670.00 Arterial puncture, withdrawal of blood for diagnosis Each 178.00 142.4000 107.98 178.00 Arterial catheterization or cannulation for sampling, monitoring or transfusion (separate procedure); percutaneous 1.0000 each 3338.99 2671.1900 2066.83 3338.99 Placement of needle for intraosseous infusion Each 175.00 140.0000 108.32 380.71 Insertion of intravascular vena cava filter, endovascular approach including vascular access, vessel selection, and radiological supervision and interpretation, intraprocedural roadmapping, and imaging guidance (ultrasound and fluoroscopy), when performed Each 10560.00 8448.0000 4779.94 10560.00 Retrieval (removal) of intravascular vena cava filter, endovascular approach including vascular access, vessel selection, and radiological supervision and interpretation, intraprocedural roadmapping, and imaging guidance (ultrasound and fluoroscopy), when performed Each 8704.00 6963.2000 2770.42 8704.00 Thrombolysis, cerebral, by intravenous infusion Each 498.90 399.1200 308.82 498.90 Ligation of inferior vena cava Each 8104.00 6483.2000 4779.94 8104.00 Diagnostic bone marrow; aspiration(s) Each 225.00 180.0000 139.28 1512.01 Diagnostic bone marrow; biopsy(ies) Each 225.00 180.0000 139.28 1512.01 Drainage of lymph node abscess or lymphadenitis; simple Each 1439.00 1151.2000 890.74 2604.71 Biopsy or excision of lymph node(s); by needle, superficial (eg, cervical, inguinal, axillary) Each 1953.00 1562.4000 1208.91 1953.00 Biopsy or excision of lymph node(s); open, deep cervical node(s) Each 8264.51 6611.6000 3197.13 8264.50 Biopsy or excision of lymph node(s); open, deep axillary node(s) Each 5760.97 4608.7800 3197.13 5760.97 Repair lip, full thickness; vermilion only Each 1294.00 1035.2000 424.84 1294.00 Drainage of abscess, cyst, hematoma, vestibule of mouth; simple Each 408.00 326.4000 252.55 654.36 Removal of embedded foreign body, vestibule of mouth; simple Each 435.00 348.0000 269.26 832.37 Incision of labial frenum (frenotomy) Each 241.35 193.0800 149.40 460.62 Excision of lesion of mucosa and submucosa, vestibule of mouth; with simple repair Each 12402.69 9922.1500 1290.96 12402.69 Intraoral incision and drainage of abscess, cyst, or hematoma of tongue or floor of mouth; lingual Each 375.00 300.0000 232.12 460.62 Incision of lingual frenum (frenotomy) Each 9661.37 7729.1000 1290.96 9661.37 Excision of lesion of tongue with closure; anterior two-thirds Each 10444.41 8355.5300 2645.86 10444.41 Excision of lingual frenum (frenectomy) Each 10161.42 8129.1400 1290.96 10161.42 Repair of laceration 2.5 cm or less; floor of mouth and/or anterior two-thirds of tongue Each 222.00 177.6000 137.42 380.71 Repair of laceration of tongue, floor of mouth, over 2.6 cm or complex Each 642.00 513.6000 193.28 642.00 Drainage of abscess, cyst, hematoma from dentoalveolar structures Each 256.00 204.8000 107.98 256.00 Unlisted procedure, dentoalveolar structures Each 241.30 193.0400 149.36 241.30 Drainage of abscess of palate, uvula Each 415.00 332.0000 193.28 415.00 Uvulectomy, excision of uvula Each 12818.60 10254.8800 2645.86 12818.60 Sialolithotomy; submandibular (submaxillary), sublingual or parotid, uncomplicated, intraoral Each 543.00 434.4000 336.12 2868.67 Biopsy of salivary gland; needle Each 659.00 527.2000 407.92 659.00 Excision of parotid tumor or parotid gland; lateral lobe, with dissection and preservation of facial nerve Each 12445.68 9956.5400 4965.86 12445.68 Incision and drainage abscess; peritonsillar Each 746.00 596.8000 193.28 746.00 Removal of foreign body from pharynx Each 165.10 132.0800 102.20 380.71 Tonsillectomy and adenoidectomy; younger than age 12 Each 13574.85 10859.8800 4965.86 13574.85 Tonsillectomy and adenoidectomy; age 12 or over Each 12335.10 9868.0800 2645.86 12335.10 Tonsillectomy, primary or secondary; age 12 or over Each 13292.04 10633.6300 2645.86 13292.04 Adenoidectomy, secondary; younger than age 12 Each 8835.33 7068.2600 2645.86 8835.32 Adenoidectomy, secondary; age 12 or over Each 14642.06 11713.6500 2645.86 14642.06 Esophagoscopy, flexible, transoral; diagnostic, including collection of specimen(s) by brushing or washing, when performed (separate procedure) Each 7798.35 6238.6800 767.72 7798.34 Esophagogastroduodenoscopy, flexible, transoral; with dilation of esophagus with balloon (30 mm diameter or larger) (includes fluoroscopic guidance, when performed) Each 8406.06 6724.8500 1619.67 8406.06 Esophagogastroduodenoscopy, flexible, transoral; diagnostic, including collection of specimen(s) by brushing or washing, when performed (separate procedure) Each 656.31 525.0500 406.26 832.37 Esophagogastroduodenoscopy, flexible, transoral; with directed submucosal injection(s), any substance Each 3634.49 2907.5900 767.72 3634.48 Esophagogastroduodenoscopy, flexible, transoral; with biopsy, single or multiple Each 7310.91 5848.7300 767.72 7310.91 Esophagogastroduodenoscopy, flexible, transoral; with directed placement of percutaneous gastrostomy tube Each 8476.55 6781.2400 1619.67 8476.55 Esophagogastroduodenoscopy, flexible, transoral; with removal of foreign body(s) Each 9020.35 7216.2800 767.72 9020.35 Esophagogastroduodenoscopy, flexible, transoral; with transendoscopic balloon dilation of esophagus (less than 30 mm diameter) Each 8006.09 6404.8700 1619.67 8006.09 Esophagogastroduodenoscopy, flexible, transoral; with removal of tumor(s), polyp(s), or other lesion(s) by snare technique Each 9903.58 7922.8600 1619.67 9903.58 Esophagogastroduodenoscopy, flexible, transoral; with control of bleeding, any method Each 7768.63 6214.9000 1619.67 7768.63 Esophagogastroduodenoscopy, flexible, transoral; with ablation of tumor(s), polyp(s), or other lesion(s) (includes pre- and post-dilation and guide wire passage, when performed) Each 6033.02 4826.4200 1619.67 6033.02 Gastric intubation and aspiration(s) therapeutic, necessitating physician's skill (eg, for gastrointestinal hemorrhage), including lavage if performed 1.0000 each 233.80 187.0400 144.72 282.39 Gastric intubation and aspiration, diagnostic; single specimen (eg, acid analysis) 1.0000 each 218.60 174.8800 135.31 282.39 Repositioning of a naso- or oro-gastric feeding tube, through the duodenum for enteric nutrition Each 1249.05 999.2400 199.83 1249.05 Replacement of gastrostomy tube, percutaneous, includes removal, when performed, without imaging or endoscopic guidance; not requiring revision of gastrostomy tract Each 698.00 558.4000 199.83 698.00 Ileoscopy, through stoma; diagnostic, including collection of specimen(s) by brushing or washing, when performed (separate procedure) Each 13508.05 10806.4400 767.72 13508.04 Endoscopic evaluation of small intestinal pouch (eg, Kock pouch, ileal reservoir [S or J]); with biopsy, single or multiple Each 7480.47 5984.3800 772.86 7480.47 Laparoscopy, surgical, appendectomy Each 19688.47 15750.7800 4847.26 19688.47 Transrectal drainage of pelvic abscess Each 1456.00 1164.8000 901.26 1456.00 Incision and drainage of submucosal abscess, rectum Each 527.16 421.7300 326.31 1091.91 Excision of rectal tumor, transanal approach; not including muscularis propria (ie, partial thickness) Each 16674.52 13339.6200 2389.59 16674.52 Sigmoidoscopy, flexible; diagnostic, including collection of specimen(s) by brushing or washing, when performed (separate procedure) Each 8519.65 6815.7200 772.86 8519.64 Sigmoidoscopy, flexible; with biopsy, single or multiple Each 7388.50 5910.8000 772.86 7388.50 Sigmoidoscopy, flexible; with control of bleeding, any method Each 4933.41 3946.7200 1007.10 4933.40 Sigmoidoscopy, flexible; with directed submucosal injection(s), any substance Each 3357.38 2685.9000 772.86 3357.38 Colonoscopy, flexible; diagnostic, including collection of specimen(s) by brushing or washing, when performed (separate procedure) Each 7111.62 5689.3000 772.86 7111.62 Colonoscopy, flexible; with removal of foreign body(s) Each 3682.67 2946.1400 1007.10 3682.67 Colonoscopy, flexible; with biopsy, single or multiple Each 7267.21 5813.7700 1007.10 7267.21 Colonoscopy, flexible; with directed submucosal injection(s), any substance Each 3679.00 2943.2000 1007.10 3679.00 Colonoscopy, flexible; with control of bleeding, any method Each 6205.60 4964.4800 1007.10 6205.60 Colonoscopy, flexible; with removal of tumor(s), polyp(s), or other lesion(s) by hot biopsy forceps Each 8023.77 6419.0200 1007.10 8023.77 Colonoscopy, flexible; with removal of tumor(s), polyp(s), or other lesion(s) by snare technique Each 7991.79 6393.4300 1007.10 7991.79 Colonoscopy, flexible; with endoscopic mucosal resection Each 3629.77 2903.8200 2246.83 3629.77 Anorectal exam, surgical, requiring anesthesia (general, spinal, or epidural), diagnostic Each 9523.86 7619.0900 2389.59 9523.86 Incision and drainage of ischiorectal and/or perirectal abscess (separate procedure) Each 1125.00 900.0000 696.38 1125.00 Incision and drainage, perianal abscess, superficial Each 931.00 744.8000 576.29 931.00 Incision of thrombosed hemorrhoid, external Each 444.00 355.2000 199.83 444.00 Excision of multiple external papillae or tags, anus Each 6936.13 5548.9000 2389.59 6936.13 Hemorrhoidectomy, internal and external, single column/group Each 13871.39 11097.1100 2389.59 13871.39 Hemorrhoidectomy, internal and external, 2 or more columns/groups Each 16586.86 13269.4900 2389.59 16586.86 Excision of thrombosed hemorrhoid, external Each 3348.20 2678.5600 1007.10 3348.20 Anoscopy; diagnostic, including collection of specimen(s) by brushing or washing, when performed (separate procedure) Each 154.50 123.6000 95.64 154.50 Anoscopy; with removal of foreign body Each 859.05 687.2400 531.75 859.05 Anoscopy; with ablation of tumor(s), polyp(s), or other lesion(s) not amenable to removal by hot biopsy forceps, bipolar cautery or snare technique Each 5351.40 4281.1200 2389.59 5351.40 Hemorrhoidectomy, internal, by ligation other than rubber band; 2 or more hemorrhoid columns/groups, without imaging guidance Each 9024.40 7219.5200 2389.59 9024.40 Biopsy of liver, needle; percutaneous Each 863.48 690.7800 534.49 1512.01 Cholecystostomy, percutaneous, complete procedure, including imaging guidance, catheter placement, cholecystogram when performed, and radiological supervision and interpretation Each 889.00 711.2000 550.29 3571.36 Injection procedure for cholangiography, percutaneous, complete diagnostic procedure including imaging guidance (eg, ultrasound and/or fluoroscopy) and all associated radiological supervision and interpretation; existing access Each 339.00 271.2000 209.84 3571.36 Injection procedure for cholangiography, percutaneous, complete diagnostic procedure including imaging guidance (eg, ultrasound and/or fluoroscopy) and all associated radiological supervision and interpretation; new access (eg, percutaneous transhepatic cholangiogram) Each 4643.00 3714.4000 2874.02 4643.00 Laparoscopy, surgical; cholecystectomy Each 20872.28 16697.8200 4847.26 20872.28 Laparoscopy, surgical; cholecystectomy with cholangiography Each 24547.64 19638.1100 4847.26 24547.64 Biopsy of pancreas, percutaneous needle Each 659.00 527.2000 407.92 1512.01 Exploratory laparotomy, exploratory celiotomy with or without biopsy(s) (separate procedure) Each 11652.56 9322.0400 7212.93 11652.56 Drainage of subdiaphragmatic or subphrenic abscess, open Each 649.00 519.2000 401.73 649.00 Abdominal paracentesis (diagnostic or therapeutic); without imaging guidance Each 1020.00 816.0000 631.38 1020.00 Abdominal paracentesis (diagnostic or therapeutic); with imaging guidance Each 1947.00 1557.6000 767.72 1947.00 Biopsy, abdominal or retroperitoneal mass, percutaneous needle Each 659.00 527.2000 407.92 1512.01 Laparoscopy, abdomen, peritoneum, and omentum, diagnostic, with or without collection of specimen(s) by brushing or washing (separate procedure) Each 19358.04 15486.4300 4847.26 19358.04 Laparoscopy, surgical; with biopsy (single or multiple) Each 13159.98 10527.9900 4847.26 13159.98 Laparoscopy, surgical; with aspiration of cavity or cyst (eg, ovarian cyst) (single or multiple) Each 9131.00 7304.8000 4847.26 9131.00 Removal of peritoneal foreign body from peritoneal cavity Each 26067.46 20853.9700 3293.97 26067.46 Image-guided fluid collection drainage by catheter (eg, abscess, hematoma, seroma, lymphocele, cyst); visceral (eg, kidney, liver, spleen, lung/mediastinum), percutaneous Each 649.00 519.2000 401.73 1512.01 Image-guided fluid collection drainage by catheter (eg, abscess, hematoma, seroma, lymphocele, cyst); peritoneal or retroperitoneal, percutaneous Each 808.00 646.4000 500.15 1512.01 Contrast injection for assessment of abscess or cyst via previously placed drainage catheter or tube (separate procedure) Each 369.00 295.2000 228.41 369.00 Replacement of gastrostomy or cecostomy (or other colonic) tube, percutaneous, under fluoroscopic guidance including contrast injection(s), image documentation and report Each 925.10 740.0800 572.64 925.10 Contrast injection(s) for radiological evaluation of existing gastrostomy, duodenostomy, jejunostomy, gastro-jejunostomy, or cecostomy (or other colonic) tube, from a percutaneous approach including image documentation and report Each 1069.00 855.2000 217.17 1069.00 Repair initial inguinal hernia, age 5 years or older; reducible Each 8337.68 6670.1400 3293.97 8337.68 Repair initial inguinal hernia, age 5 years or older; incarcerated or strangulated Each 22407.78 17926.2200 3293.97 22407.78 Repair recurrent inguinal hernia, any age; incarcerated or strangulated Each 13861.96 11089.5600 3293.97 13861.96 Repair inguinal hernia, sliding, any age Each 10492.59 8394.0700 3293.97 10492.59 Repair initial incisional or ventral hernia; incarcerated or strangulated 1.0000 each 8192.89 6554.3100 3021.87 8192.89 Repair recurrent incisional or ventral hernia; incarcerated or strangulated 1.0000 each 14023.64 11218.9100 4805.92 14023.64 Implantation of mesh or other prosthesis for open incisional or ventral hernia repair or mesh for closure of debridement for necrotizing soft tissue infection (List separately in addition to code for the incisional or ventral hernia repair) 1.0000 each 8288.27 6630.6200 5130.44 8288.27 Repair umbilical hernia, age 5 years or older; incarcerated or strangulated 1.0000 each 22467.79 17974.2300 3021.87 22467.79 Laparoscopy, surgical; repair initial inguinal hernia Each 27300.62 21840.5000 4847.26 27300.62 Laparoscopy, surgical; repair recurrent inguinal hernia Each 15513.42 12410.7300 4847.26 15513.42 Laparoscopy, surgical, repair, ventral, umbilical, spigelian or epigastric hernia (includes mesh insertion, when performed); reducible 1.0000 each 24933.42 19946.7400 4805.92 24933.42 Laparoscopy, surgical, repair, ventral, umbilical, spigelian or epigastric hernia (includes mesh insertion, when performed); incarcerated or strangulated 1.0000 each 21805.63 17444.5000 4805.92 21805.63 Laparoscopy, surgical, repair, incisional hernia (includes mesh insertion, when performed); incarcerated or strangulated 1.0000 each 15084.96 12067.9600 8459.64 15084.96 Drainage of perirenal or renal abscess, open Each 4129.00 3303.2000 1725.03 4129.00 Renal biopsy; percutaneous, by trocar or needle Each 659.00 527.2000 407.92 1512.01 Removal of nephrostomy tube, requiring fluoroscopic guidance (eg, with concurrent indwelling ureteral stent) Each 4663.10 3730.4800 581.56 4663.10 Aspiration and/or injection of renal cyst or pelvis by needle, percutaneous Each 692.00 553.6000 428.35 692.00 Injection procedure for antegrade nephrostogram and/or ureterogram, complete diagnostic procedure including imaging guidance (eg, ultrasound and fluoroscopy) and all associated radiological supervision and interpretation; new access Each 554.00 443.2000 342.93 630.54 Placement of nephrostomy catheter, percutaneous, including diagnostic nephrostogram and/or ureterogram when performed, imaging guidance (eg, ultrasound and/or fluoroscopy) and all associated radiological supervision and interpretation Each 2347.00 1877.6000 1452.79 2347.00 Placement of ureteral stent, percutaneous, including diagnostic nephrostogram and/or ureterogram when performed, imaging guidance (eg, ultrasound and/or fluoroscopy), and all associated radiological supervision and interpretation; pre-existing nephrostomy tract Each 1388.00 1110.4000 859.17 3231.75 Cystostomy, cystotomy with drainage Each 10835.71 8668.5700 1725.03 10835.71 Drainage of perivesical or prevesical space abscess Each 889.00 711.2000 550.29 2604.71 Aspiration of bladder; with insertion of suprapubic catheter Each 373.00 298.4000 230.89 1870.29 Injection procedure for cystography or voiding urethrocystography Each 446.00 356.8000 276.07 446.00 Injection procedure and placement of chain for contrast and/or chain urethrocystography Each 369.00 295.2000 228.41 369.00 Injection procedure for retrograde urethrocystography Each 446.00 356.8000 276.07 446.00 Bladder irrigation, simple, lavage and/or instillation Each 270.00 216.0000 167.13 270.00 Insertion of non-indwelling bladder catheter (eg, straight catheterization for residual urine) Each 93.50 74.8000 57.88 117.07 Insertion of temporary indwelling bladder catheter; simple (eg, Foley) Each 99.00 79.2000 61.28 117.07 Insertion of temporary indwelling bladder catheter; complicated (eg, altered anatomy, fractured catheter/balloon) Each 161.80 129.4400 100.15 161.80 Change of cystostomy tube; simple Each 421.30 337.0400 199.83 421.30 Electromyography studies (EMG) of anal or urethral sphincter, other than needle, any technique Each 222.45 177.9600 135.25 222.45 Stimulus evoked response (eg, measurement of bulbocavernosus reflex latency time) Each 331.30 265.0400 53.46 331.30 Cystourethroscopy (separate procedure) Each 10159.95 8127.9600 581.56 10159.95 Cystourethroscopy, with ureteral catheterization, with or without irrigation, instillation, or ureteropyelography, exclusive of radiologic service Each 3836.42 3069.1300 1725.03 3836.42 Cystourethroscopy, with fulguration (including cryosurgery or laser surgery) of trigone, bladder neck, prostatic fossa, urethra, or periurethral glands Each 6900.16 5520.1300 2980.74 6900.16 Cystourethroscopy, with fulguration (including cryosurgery or laser surgery) or treatment of MINOR (less than 0.5 cm) lesion(s) with or without biopsy Each 13593.78 10875.0200 2980.74 13593.78 Cystourethroscopy, with fulguration (including cryosurgery or laser surgery) and/or resection of; SMALL bladder tumor(s) (0.5 up to 2.0 cm) Each 13426.02 10740.8200 2980.74 13426.02 Cystourethroscopy, with fulguration (including cryosurgery or laser surgery) and/or resection of; MEDIUM bladder tumor(s) (2.0 to 5.0 cm) Each 13967.59 11174.0700 2980.74 13967.59 Cystourethroscopy, with fulguration (including cryosurgery or laser surgery) and/or resection of; LARGE bladder tumor(s) Each 14588.88 11671.1000 4372.99 14588.88 Cystourethroscopy, with dilation of bladder for interstitial cystitis; general or conduction (spinal) anesthesia Each 10248.39 8198.7100 1725.03 10248.39 Cystourethroscopy with direct vision internal urethrotomy Each 13332.27 10665.8200 1725.03 13332.27 Cystourethroscopy, with resection of external sphincter (sphincterotomy) Each 13969.84 11175.8700 2980.74 13969.84 Cystourethroscopy, with calibration and/or dilation of urethral stricture or stenosis, with or without meatotomy, with or without injection procedure for cystography, male or female Each 10548.85 8439.0800 1725.03 10548.84 Cystourethroscopy, with injection(s) for chemodenervation of the bladder Each 10805.33 8644.2600 1725.03 10805.33 Cystourethroscopy, with removal of foreign body, calculus, or ureteral stent from urethra or bladder (separate procedure); simple Each 10476.13 8380.9000 1725.03 10476.13 Litholapaxy: crushing or fragmentation of calculus by any means in bladder and removal of fragments; simple or small (less than 2.5 cm) Each 13700.89 10960.7100 2980.74 13700.89 Litholapaxy: crushing or fragmentation of calculus by any means in bladder and removal of fragments; complicated or large (over 2.5 cm) Each 14112.24 11289.7900 2980.74 14112.24 Cystourethroscopy, with insertion of indwelling ureteral stent (eg, Gibbons or double-J type) Each 11795.60 9436.4800 2980.74 11795.60 Cystourethroscopy; with treatment of ureteral stricture (eg, balloon dilation, laser, electrocautery, and incision) Each 11354.17 9083.3300 2980.74 11354.16 Cystourethroscopy; with treatment of ureteropelvic junction stricture (eg, balloon dilation, laser, electrocautery, and incision) Each 5724.78 4579.8200 2980.74 5724.78 Cystourethroscopy with ureteroscopy; with treatment of ureteral stricture (eg, balloon dilation, laser, electrocautery, and incision) Each 7544.96 6035.9600 2980.74 7544.96 Cystourethroscopy, with ureteroscopy and/or pyeloscopy; diagnostic Each 12220.20 9776.1600 2980.74 12220.20 Cystourethroscopy, with ureteroscopy and/or pyeloscopy; with removal or manipulation of calculus (ureteral catheterization is included) Each 13752.59 11002.0700 2980.74 13752.59 Cystourethroscopy, with ureteroscopy and/or pyeloscopy; with lithotripsy (ureteral catheterization is included) Each 10373.61 8298.8900 4372.99 10373.61 Cystourethroscopy, with ureteroscopy and/or pyeloscopy; with biopsy and/or fulguration of ureteral or renal pelvic lesion Each 9257.09 7405.6700 4372.99 9257.09 Cystourethroscopy, with ureteroscopy and/or pyeloscopy; with lithotripsy including insertion of indwelling ureteral stent (eg, Gibbons or double-J type) Each 17894.48 14315.5800 4372.99 17894.48 Cystourethroscopy, with insertion of permanent adjustable transprostatic implant; single implant Each 5873.41 4698.7300 3635.64 5873.41 Cystourethroscopy, with insertion of permanent adjustable transprostatic implant; each additional permanent adjustable transprostatic implant (List separately in addition to code for primary procedure) 1.0000 each 1174.68 939.7500 727.13 1174.68 Transurethral resection of bladder neck (separate procedure) Each 14142.39 11313.9100 2980.74 14142.39 Transurethral electrosurgical resection of prostate, including control of postoperative bleeding, complete (vasectomy, meatotomy, cystourethroscopy, urethral calibration and/or dilation, and internal urethrotomy are included) Each 15741.60 12593.2800 4372.99 15741.60 Transurethral resection; residual or regrowth of obstructive prostate tissue including control of postoperative bleeding, complete (vasectomy, meatotomy, cystourethroscopy, urethral calibration and/or dilation, and internal urethrotomy are included) Each 15101.59 12081.2700 4372.99 15101.59 Transurethral drainage of prostatic abscess Each 2286.00 1828.8000 1415.03 3231.75 Drainage of deep periurethral abscess Each 2599.00 2079.2000 1608.78 3231.75 Urethromeatoplasty, with mucosal advancement Each 10196.35 8157.0800 2980.74 10196.35 Destruction of lesion(s), penis (eg, condyloma, papilloma, molluscum contagiosum, herpetic vesicle), simple; surgical excision Each 5134.60 4107.6800 1605.04 5134.60 Destruction of lesion(s), penis (eg, condyloma, papilloma, molluscum contagiosum, herpetic vesicle), extensive (eg, laser surgery, electrosurgery, cryosurgery, chemosurgery) Each 5134.60 4107.6800 1605.04 5134.60 Biopsy of penis; (separate procedure) Each 3403.20 2722.5600 1394.57 3403.20 Circumcision, surgical excision other than clamp, device, or dorsal slit; older than 28 days of age Each 14308.12 11446.5000 1725.03 14308.12 Irrigation of corpora cavernosa for priapism Each 725.00 580.0000 199.83 725.00 Injection of corpora cavernosa with pharmacologic agent(s) (eg, papaverine, phentolamine) Each 741.00 592.8000 199.83 741.00 Plastic operation of penis for straightening of chordee (eg, hypospadias), with or without mobilization of urethra Each 7327.41 5861.9200 2980.74 7327.40 Foreskin manipulation including lysis of preputial adhesions and stretching Each 717.95 574.3600 199.83 717.95 Orchiectomy, simple (including subcapsular), with or without testicular prosthesis, scrotal or inguinal approach Each 21968.06 17574.4400 2980.74 21968.06 Reduction of torsion of testis, surgical, with or without fixation of contralateral testis Each 14343.24 11474.5900 2980.74 14343.24 Incision and drainage of epididymis, testis and/or scrotal space (eg, abscess or hematoma) Each 510.00 408.0000 315.69 1870.29 Biopsy of epididymis, needle Each 659.00 527.2000 407.92 1512.01 Excision of hydrocele; unilateral Each 14469.50 11575.6000 3293.97 14469.50 Excision of hydrocele; bilateral Each 7418.06 5934.4500 3293.97 7418.06 Drainage of scrotal wall abscess Each 1910.00 1528.0000 1182.29 1910.00 Vasectomy, unilateral or bilateral (separate procedure), including postoperative semen examination(s) Each 12038.82 9631.0600 1725.03 12038.82 Excision of lesion of spermatic cord (separate procedure) Each 7771.69 6217.3500 2980.74 7771.69 Biopsy, prostate; needle or punch, single or multiple, any approach Each 659.00 527.2000 407.92 1870.29 Incision and drainage of vulva or perineal abscess Each 456.00 364.8000 271.52 456.00 Incision and drainage of Bartholin's gland abscess Each 246.00 196.8000 152.27 246.00 Destruction of lesion(s), vulva; simple (eg, laser surgery, electrosurgery, cryosurgery, chemosurgery) Each 7034.53 5627.6200 1605.04 7034.53 Partial hymenectomy or revision of hymenal ring Each 3028.71 2422.9700 1874.77 3028.71 Excision of Bartholin's gland or cyst Each 7544.67 6035.7300 2629.50 7544.66 Anterior colporrhaphy, repair of cystocele with or without repair of urethrocele, including cystourethroscopy, when performed Each 9491.36 7593.0900 4310.62 9491.36 Colpopexy, vaginal; extra-peritoneal approach (sacrospinous, iliococcygeus) Each 9491.36 7593.0900 5875.15 9491.36 Sling operation for stress incontinence (eg, fascia or synthetic) Each 17918.53 14334.8200 4310.62 17918.53 Pelvic examination under anesthesia (other than local) Each 397.61 318.0900 246.12 2850.93 Biopsy of cervix, single or multiple, or local excision of lesion, with or without fulguration (separate procedure) Each 7543.59 6034.8700 654.22 7543.58 Dilation and curettage, diagnostic and/or therapeutic (nonobstetrical) Each 6892.07 5513.6600 2629.50 6892.07 Vaginal hysterectomy, for uterus 250 g or less; with removal of tube(s), and/or ovary(s) Each 10529.97 8423.9700 4310.62 10529.96 Insertion of intrauterine device (IUD) 1.0000 each 10809.53 8647.6200 6691.10 10809.53 Removal of intrauterine device (IUD) Each 342.40 273.9200 211.95 342.40 Catheterization and introduction of saline or contrast material for saline infusion sonohysterography (SIS) or hysterosalpingography Each 388.00 310.4000 240.17 388.00 Hysteroscopy, surgical; with sampling (biopsy) of endometrium and/or polypectomy, with or without D & C Each 11216.51 8973.2100 2629.50 11216.51 Hysteroscopy, surgical; with removal of impacted foreign body Each 9236.73 7389.3800 2629.50 9236.73 Hysteroscopy, surgical; with endometrial ablation (eg, endometrial resection, electrosurgical ablation, thermoablation) Each 8889.42 7111.5300 4310.62 8889.42 Occlusion of fallopian tube(s) by device (eg, band, clip, Falope ring) vaginal or suprapubic approach Each 8068.52 6454.8200 2629.50 8068.52 Laparoscopy, surgical; with lysis of adhesions (salpingolysis, ovariolysis) (separate procedure) Each 9131.00 7304.8000 4847.26 9131.00 Laparoscopy, surgical; with removal of adnexal structures (partial or total oophorectomy and/or salpingectomy) Each 26028.87 20823.1000 4847.26 26028.87 Laparoscopy, surgical; with fulguration or excision of lesions of the ovary, pelvic viscera, or peritoneal surface by any method Each 22477.93 17982.3400 4847.26 22477.93 Laparoscopy, surgical; with fulguration of oviducts (with or without transection) Each 8120.41 6496.3200 4847.26 8120.40 Laparoscopy, surgical; with occlusion of oviducts by device (eg, band, clip, or Falope ring) Each 18839.19 15071.3500 4847.26 18839.19 Laparoscopy, surgical; with fimbrioplasty Each 18441.34 14753.0700 4847.26 18441.34 Salpingo-oophorectomy, complete or partial, unilateral or bilateral (separate procedure) Each 17.50 14.0000 10.83 17.50 Tubotubal anastomosis Each 13624.87 10899.8900 8433.79 13624.86 Drainage of ovarian cyst(s), unilateral or bilateral (separate procedure); vaginal approach Each 2307.00 1845.6000 1428.03 2850.93 Drainage of ovarian abscess; vaginal approach, open Each 2307.00 1845.6000 1428.03 2850.93 Unlisted procedure, female genital system (nonobstetrical) Each 392.80 314.2400 165.66 392.80 Amniocentesis; diagnostic Each 194.00 155.2000 120.09 709.31 Fetal contraction stress test Each 400.00 320.0000 165.66 400.00 Fetal non-stress test Each 400.00 320.0000 165.66 400.00 Laparoscopic treatment of ectopic pregnancy; with salpingectomy and/or oophorectomy Each 18572.91 14858.3300 4847.26 18572.91 Cerclage of cervix, during pregnancy; vaginal Each 5428.86 4343.0900 2629.50 5428.86 External cephalic version, with or without tocolysis 1.0000 each 1385.00 1108.0000 857.32 2850.93 Delivery of placenta (separate procedure) Each 477.00 381.6000 295.26 2850.93 Treatment of incomplete abortion, any trimester, completed surgically Each 11384.05 9107.2400 2629.50 11384.04 Treatment of missed abortion, completed surgically; first trimester Each 5657.51 4526.0100 2629.50 5657.51 Treatment of missed abortion, completed surgically; second trimester Each 5582.28 4465.8200 2629.50 5582.28 Treatment of septic abortion, completed surgically Each 5819.26 4655.4100 3602.12 5819.26 Removal of cerclage suture under anesthesia (other than local) Each 10649.67 8519.7400 2629.50 10649.67 Biopsy thyroid, percutaneous core needle Each 659.00 527.2000 407.92 659.00 Partial thyroid lobectomy, unilateral; with or without isthmusectomy Each 9702.77 7762.2200 4847.26 9702.77 Total thyroid lobectomy, unilateral; with or without isthmusectomy Each 26766.36 21413.0900 4847.26 26766.36 Thyroidectomy, total or complete Each 38224.31 30579.4500 4847.26 38224.31 Excision of thyroglossal duct cyst or sinus Each 11598.58 9278.8600 4847.26 11598.58 Aspiration and/or injection, thyroid cyst Each 624.00 499.2000 386.26 654.36 Puncture of shunt tubing or reservoir for aspiration or injection procedure Each 1731.00 1384.8000 599.23 1731.00 Stereotactic computer-assisted (navigational) procedure; cranial, extradural (List separately in addition to code for primary procedure) 1.0000 each 7024.65 5619.7200 4348.26 7024.65 Percutaneous aspiration, spinal cord cyst or syrinx Each 458.00 366.4000 283.50 859.26 Biopsy of spinal cord, percutaneous needle Each 659.00 527.2000 407.92 1512.01 Spinal puncture, lumbar, diagnostic Each 397.00 317.6000 245.74 649.69 Injection, epidural, of blood or clot patch Each 1122.27 897.8200 599.23 1122.27 Myelography via lumbar injection, including radiological supervision and interpretation; thoracic Each 1583.00 1266.4000 688.89 1583.00 Myelography via lumbar injection, including radiological supervision and interpretation; lumbosacral Each 1646.00 1316.8000 688.89 1646.00 Injection(s), of diagnostic or therapeutic substance(s) (eg, anesthetic, antispasmodic, opioid, steroid, other solution), not including neurolytic substances, including needle or catheter placement, interlaminar epidural or subarachnoid, cervical or thoracic; without imaging guidance Each 1412.00 1129.6000 599.23 1412.00 Injection(s), of diagnostic or therapeutic substance(s) (eg, anesthetic, antispasmodic, opioid, steroid, other solution), not including neurolytic substances, including needle or catheter placement, interlaminar epidural or subarachnoid, cervical or thoracic; with imaging guidance (ie, fluoroscopy or CT) Each 4738.75 3791.0000 599.23 4738.75 Injection(s), of diagnostic or therapeutic substance(s) (eg, anesthetic, antispasmodic, opioid, steroid, other solution), not including neurolytic substances, including needle or catheter placement, interlaminar epidural or subarachnoid, lumbar or sacral (caudal); with imaging guidance (ie, fluoroscopy or CT) Each 1637.66 1310.1300 599.23 1637.66 Laminotomy (hemilaminectomy), with decompression of nerve root(s), including partial facetectomy, foraminotomy and/or excision of herniated intervertebral disc; 1 interspace, lumbar Each 29747.62 23798.1000 6151.56 29747.62 Transpedicular approach with decompression of spinal cord, equina and/or nerve root(s) (eg, herniated intervertebral disc), single segment; lumbar (including transfacet, or lateral extraforaminal approach) (eg, far lateral herniated intervertebral disc) Each 9728.05 7782.4400 6021.66 9728.05 Injection(s), anesthetic agent(s) and/or steroid; trigeminal nerve, each branch (ie, ophthalmic, maxillary, mandibular) Each 400.00 320.0000 247.60 400.00 Injection(s), anesthetic agent(s) and/or steroid; brachial plexus, including imaging guidance, when performed Each 6862.90 5490.3200 792.52 6862.90 Injection(s), anesthetic agent(s) and/or steroid; axillary nerve, including imaging guidance, when performed Each 3107.95 2486.3600 792.52 3107.95 Injection(s), anesthetic agent(s) and/or steroid; suprascapular nerve Each 7253.36 5802.6800 599.23 7253.36 Injection(s), anesthetic agent(s) and/or steroid; ilioinguinal, iliohypogastric nerves Each 7674.48 6139.5800 599.23 7674.48 Injection(s), anesthetic agent(s) and/or steroid; pudendal nerve Each 9300.87 7440.7000 792.52 9300.87 Injection(s), anesthetic agent(s) and/or steroid; sciatic nerve, including imaging guidance, when performed Each 2663.48 2130.7800 599.23 2663.48 Injection(s), anesthetic agent(s) and/or steroid; femoral nerve, including imaging guidance, when performed Each 7760.59 6208.4700 599.23 7760.58 Injection(s), anesthetic agent(s) and/or steroid; other peripheral nerve or branch Each 783.00 626.4000 484.68 783.00 Injection(s), anesthetic agent(s) and/or steroid; nerves innervating the sacroiliac joint, with image guidance (ie, fluoroscopy or computed tomography) Each 1581.64 1265.3100 599.23 1581.64 Injection(s), anesthetic agent(s) and/or steroid; plantar common digital nerve(s) (eg, Morton's neuroma) Each 5611.69 4489.3500 252.86 5611.69 Paravertebral block (PVB) (paraspinous block), thoracic; single injection site (includes imaging guidance, when performed) Each 13984.19 11187.3500 599.23 13984.19 Paravertebral block (PVB) (paraspinous block), thoracic; second and any additional injection site(s) (includes imaging guidance, when performed) (List separately in addition to code for primary procedure) 1.0000 each 13984.19 11187.3500 8656.21 13984.19 Injection(s), anesthetic agent(s) and/or steroid; transforaminal epidural, with imaging guidance (fluoroscopy or CT), cervical or thoracic, single level Each 1556.66 1245.3300 792.52 1556.66 Injection(s), anesthetic agent(s) and/or steroid; transforaminal epidural, with imaging guidance (fluoroscopy or CT), lumbar or sacral, single level Each 1637.74 1310.1900 792.52 1637.74 Injection(s), anesthetic agent(s) and/or steroid; transforaminal epidural, with imaging guidance (fluoroscopy or CT), lumbar or sacral, each additional level (List separately in addition to code for primary procedure) 1.0000 each 2425.09 1940.0700 1501.13 2425.08 Transversus abdominis plane (TAP) block (abdominal plane block, rectus sheath block) unilateral; by injection(s) (includes imaging guidance, when performed) Each 9679.36 7743.4900 5991.52 9679.36 Transversus abdominis plane (TAP) block (abdominal plane block, rectus sheath block) bilateral; by injections (includes imaging guidance, when performed) Each 10854.24 8683.3900 6718.77 10854.24 Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with image guidance (fluoroscopy or CT), cervical or thoracic; single level Each 1788.53 1430.8200 792.52 1788.53 Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with image guidance (fluoroscopy or CT), cervical or thoracic; second level (List separately in addition to code for primary procedure) 1.0000 each 1295.10 1036.0800 801.67 1295.10 Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with image guidance (fluoroscopy or CT), cervical or thoracic; third and any additional level(s) (List separately in addition to code for primary procedure) 1.0000 each 1788.53 1430.8200 1107.10 1788.53 Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with image guidance (fluoroscopy or CT), lumbar or sacral; single level Each 2972.68 2378.1400 792.52 2972.68 Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with image guidance (fluoroscopy or CT), lumbar or sacral; second level (List separately in addition to code for primary procedure) 1.0000 each 1295.10 1036.0800 801.67 1295.10 Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with image guidance (fluoroscopy or CT), lumbar or sacral; third and any additional level(s) (List separately in addition to code for primary procedure) 1.0000 each 521.82 417.4600 323.01 521.82 Injection, anesthetic agent; stellate ganglion (cervical sympathetic) Each 3848.38 3078.7000 792.52 3848.38 Injection, anesthetic agent; lumbar or thoracic (paravertebral sympathetic) Each 848.26 678.6100 525.07 859.26 Destruction by neurolytic agent, paravertebral facet joint nerve(s), with imaging guidance (fluoroscopy or CT); cervical or thoracic, single facet joint Each 6138.47 4910.7800 1671.68 6138.47 Destruction by neurolytic agent, paravertebral facet joint nerve(s), with imaging guidance (fluoroscopy or CT); lumbar or sacral, single facet joint Each 2783.88 2227.1000 1671.68 2783.88 Destruction by neurolytic agent, paravertebral facet joint nerve(s), with imaging guidance (fluoroscopy or CT); lumbar or sacral, each additional facet joint (List separately in addition to code for primary procedure) 1.0000 each 2956.82 2365.4600 1830.27 2956.82 Neuroplasty, major peripheral nerve, arm or leg, open; other than specified Each 12878.40 10302.7200 1671.68 12878.40 Neuroplasty and/or transposition; ulnar nerve at elbow Each 12740.73 10192.5800 1671.68 12740.73 Neuroplasty and/or transposition; median nerve at carpal tunnel Each 3708.21 2966.5700 1671.68 3708.21 Suture of digital nerve, hand or foot; 1 nerve Each 5505.18 4404.1400 1671.68 5505.18 Suture of digital nerve, hand or foot; each additional digital nerve (List separately in addition to code for primary procedure) 1.0000 each 5505.18 4404.1400 3407.71 5505.18 Unlisted procedure, nervous system Each 395.00 316.0000 244.50 395.00 Removal of foreign body, external eye; conjunctival superficial Each 388.95 311.1600 107.98 388.95 Removal of foreign body, external eye; conjunctival embedded (includes concretions), subconjunctival, or scleral nonperforating Each 259.30 207.4400 160.51 380.71 Removal of foreign body, external eye; corneal, without slit lamp Each 259.30 207.4400 160.51 380.71 Removal of foreign body, intraocular; from anterior chamber of eye or lens Each 2326.75 1861.4000 1440.26 2326.75 Insertion of anterior segment aqueous drainage device, without extraocular reservoir, external approach Each 21442.34 17153.8700 3715.86 21442.34 Extracapsular cataract removal with insertion of intraocular lens prosthesis (1-stage procedure), manual or mechanical technique (eg, irrigation and aspiration or phacoemulsification), complex, requiring devices or techniques not generally used in routine cataract surgery (eg, iris expansion device, suture support for intraocular lens, or primary posterior capsulorrhexis) or performed on patients in the amblyogenic developmental stage; without endoscopic cyclophotocoagulation Each 3958.96 3167.1600 2008.26 3958.96 Extracapsular cataract removal with insertion of intraocular lens prosthesis (1 stage procedure), manual or mechanical technique (eg, irrigation and aspiration or phacoemulsification); without endoscopic cyclophotocoagulation Each 8141.46 6513.1600 2008.26 8141.46 Exchange of intraocular lens Each 12767.68 10214.1400 2008.26 12767.68 Vitrectomy, mechanical, pars plana approach; with removal of preretinal cellular membrane (eg, macular pucker) Each 13506.97 10805.5800 3715.86 13506.97 Vitrectomy, mechanical, pars plana approach; with removal of internal limiting membrane of retina (eg, for repair of macular hole, diabetic macular edema), includes, if performed, intraocular tamponade (ie, air, gas or silicone oil) Each 19186.42 15349.1400 3715.86 19186.42 Repair of retinal detachment; with vitrectomy, any method, including, when performed, air or gas tamponade, focal endolaser photocoagulation, cryotherapy, drainage of subretinal fluid, scleral buckling, and/or removal of lens by same technique Each 20706.16 16564.9300 3715.86 20706.16 Repair of complex retinal detachment (eg, proliferative vitreoretinopathy, stage C-1 or greater, diabetic traction retinal detachment, retinopathy of prematurity, retinal tear of greater than 90 degrees), with vitrectomy and membrane peeling, including, when performed, air, gas, or silicone oil tamponade, cryotherapy, endolaser photocoagulation, drainage of subretinal fluid, scleral buckling, and/or removal of lens Each 18156.40 14525.1200 3715.86 18156.40 Blepharotomy, drainage of abscess, eyelid Each 216.00 172.8000 133.70 266.91 Excision of chalazion; single Each 9074.15 7259.3200 246.18 9074.14 Excision of chalazion; under general anesthesia and/or requiring hospitalization, single or multiple Each 11333.91 9067.1300 1966.21 11333.91 Removal of embedded foreign body, eyelid Each 247.20 197.7600 153.02 266.91 Drainage external ear, abscess or hematoma; simple Each 408.00 326.4000 252.55 654.36 Drainage external ear, abscess or hematoma; complicated Each 5769.00 4615.2000 1394.57 5769.00 Drainage external auditory canal, abscess Each 408.00 326.4000 252.55 654.36 Removal foreign body from external auditory canal; without general anesthesia Each 224.00 179.2000 107.98 224.00 Removal foreign body from external auditory canal; with general anesthesia Each 8255.23 6604.1800 1394.57 8255.23 Removal impacted cerumen using irrigation/lavage, unilateral Each 108.00 86.4000 53.46 108.00 Removal impacted cerumen requiring instrumentation, unilateral Each 108.00 86.4000 53.46 108.00 Debridement, mastoidectomy cavity, complex (eg, with anesthesia or more than routine cleaning) Each 9635.95 7708.7600 424.84 9635.95 Tympanostomy (requiring insertion of ventilating tube), general anesthesia Each 10167.69 8134.1500 1290.96 10167.69 Radiologic examination, eye, for detection of foreign body 1.0000 each 152.00 121.6000 80.80 152.00 Radiologic examination, mandible; partial, less than 4 views 1.0000 each 157.00 125.6000 80.80 157.00 Radiologic examination, mandible; complete, minimum of 4 views 1.0000 each 219.00 175.2000 99.40 219.00 Radiologic examination, mastoids; complete, minimum of 3 views per side 1.0000 each 229.00 183.2000 99.40 229.00 Radiologic examination, facial bones; less than 3 views 1.0000 each 154.00 123.2000 80.80 154.00 Radiologic examination, facial bones; complete, minimum of 3 views 1.0000 each 256.00 204.8000 99.40 256.00 Radiologic examination, nasal bones, complete, minimum of 3 views 1.0000 each 201.00 160.8000 80.80 201.00 Radiologic examination; optic foramina 1.0000 each 172.00 137.6000 80.80 172.00 Radiologic examination; orbits, complete, minimum of 4 views 1.0000 each 271.00 216.8000 99.40 271.00 Radiologic examination, sinuses, paranasal, less than 3 views 1.0000 each 144.00 115.2000 80.80 144.00 Radiologic examination, sinuses, paranasal, complete, minimum of 3 views 1.0000 each 295.00 236.0000 80.80 295.00 Radiologic examination, skull; less than 4 views 1.0000 each 171.00 136.8000 99.40 171.00 Radiologic examination, skull; complete, minimum of 4 views 1.0000 each 333.00 266.4000 99.40 333.00 Radiologic examination, temporomandibular joint, open and closed mouth; bilateral 1.0000 each 221.00 176.8000 80.80 221.00 Magnetic resonance (eg, proton) imaging, temporomandibular joint(s) Each 1606.00 1284.8000 217.17 1606.00 Radiologic examination; neck, soft tissue 1.0000 each 157.00 125.6000 80.80 157.00 Computed tomography, head or brain; without contrast material Each 4595.00 3676.0000 99.40 4595.00 Computed tomography, head or brain; with contrast material(s) Each 2735.00 2188.0000 167.71 2735.00 Computed tomography, head or brain; without contrast material, followed by contrast material(s) and further sections Each 2945.00 2356.0000 167.71 2945.00 Computed tomography, orbit, sella, or posterior fossa or outer, middle, or inner ear; without contrast material Each 2296.00 1836.8000 99.40 2296.00 Computed tomography, orbit, sella, or posterior fossa or outer, middle, or inner ear; with contrast material(s) Each 2348.00 1878.4000 167.71 2348.00 Computed tomography, orbit, sella, or posterior fossa or outer, middle, or inner ear; without contrast material, followed by contrast material(s) and further sections Each 2376.00 1900.8000 167.71 2376.00 Computed tomography, maxillofacial area; without contrast material Each 2744.00 2195.2000 99.40 2744.00 Computed tomography, maxillofacial area; with contrast material(s) Each 2469.00 1975.2000 167.71 2469.00 Computed tomography, maxillofacial area; without contrast material, followed by contrast material(s) and further sections Each 2281.00 1824.8000 167.71 2281.00 Computed tomography, soft tissue neck; without contrast material Each 2298.00 1838.4000 99.40 2298.00 Computed tomography, soft tissue neck; with contrast material(s) Each 2558.00 2046.4000 167.71 2558.00 Computed tomography, soft tissue neck; without contrast material followed by contrast material(s) and further sections Each 2854.00 2283.2000 167.71 2854.00 Computed tomographic angiography, head, with contrast material(s), including noncontrast images, if performed, and image postprocessing Each 2634.00 2107.2000 167.71 2634.00 Computed tomographic angiography, neck, with contrast material(s), including noncontrast images, if performed, and image postprocessing Each 2634.00 2107.2000 167.71 2634.00 Magnetic resonance (eg, proton) imaging, orbit, face, and/or neck; without contrast material(s) Each 1999.00 1599.2000 217.17 1999.00 Magnetic resonance (eg, proton) imaging, orbit, face, and/or neck; with contrast material(s) Each 2226.00 1780.8000 342.64 2226.00 Magnetic resonance (eg, proton) imaging, orbit, face, and/or neck; without contrast material(s), followed by contrast material(s) and further sequences Each 4725.00 3780.0000 342.64 4725.00 Magnetic resonance angiography, head; without contrast material(s) Each 3938.00 3150.4000 217.17 3938.00 Magnetic resonance angiography, head; with contrast material(s) Each 2392.00 1913.6000 342.64 2392.00 Magnetic resonance angiography, head; without contrast material(s), followed by contrast material(s) and further sequences Each 2375.00 1900.0000 342.64 2375.00 Magnetic resonance angiography, neck; without contrast material(s) Each 3938.00 3150.4000 217.17 3938.00 Magnetic resonance angiography, neck; with contrast material(s) Each 3174.00 2539.2000 342.64 3174.00 Magnetic resonance angiography, neck; without contrast material(s), followed by contrast material(s) and further sequences Each 4725.00 3780.0000 342.64 4725.00 Magnetic resonance (eg, proton) imaging, brain (including brain stem); without contrast material Each 3938.00 3150.4000 217.17 3938.00 Magnetic resonance (eg, proton) imaging, brain (including brain stem); with contrast material(s) Each 2634.00 2107.2000 342.64 2634.00 Magnetic resonance (eg, proton) imaging, brain (including brain stem); without contrast material, followed by contrast material(s) and further sequences Each 5513.00 4410.4000 342.64 5513.00 Radiologic examination, chest; single view 1.0000 each 441.00 352.8000 80.80 441.00 Radiologic examination, chest; 2 views 1.0000 each 450.00 360.0000 80.80 450.00 Radiologic examination, chest; 3 views 1.0000 each 258.00 206.4000 80.80 258.00 Radiologic examination, chest; 4 or more views 1.0000 each 245.00 196.0000 99.40 245.00 Radiologic examination, ribs, unilateral; 2 views 1.0000 each 328.00 262.4000 80.80 328.00 Radiologic examination, ribs, unilateral; including posteroanterior chest, minimum of 3 views 1.0000 each 259.00 207.2000 99.40 259.00 Radiologic examination, ribs, bilateral; 3 views 1.0000 each 341.00 272.8000 99.40 341.00 Radiologic examination, ribs, bilateral; including posteroanterior chest, minimum of 4 views 1.0000 each 301.00 240.8000 99.40 301.00 Radiologic examination; sternum, minimum of 2 views 1.0000 each 180.00 144.0000 80.80 180.00 Radiologic examination; sternoclavicular joint or joints, minimum of 3 views 1.0000 each 243.00 194.4000 80.80 243.00 Computed tomography, thorax, diagnostic; without contrast material Each 2468.00 1974.4000 99.40 2468.00 Computed tomography, thorax, diagnostic; with contrast material(s) Each 2789.00 2231.2000 167.71 2789.00 Computed tomography, thorax, diagnostic; without contrast material, followed by contrast material(s) and further sections Each 2997.00 2397.6000 167.71 2997.00 Computed tomography, thorax, low dose for lung cancer screening, without contrast material(s) Each 2789.00 2231.2000 99.40 2789.00 Computed tomographic angiography, chest (noncoronary), with contrast material(s), including noncontrast images, if performed, and image postprocessing Each 2400.00 1920.0000 167.71 2400.00 Magnetic resonance (eg, proton) imaging, chest (eg, for evaluation of hilar and mediastinal lymphadenopathy); without contrast material(s) Each 1723.00 1378.4000 217.17 1723.00 Radiologic examination, spine, single view, specify level 1.0000 each 157.00 125.6000 80.80 157.00 Radiologic examination, spine, cervical; 2 or 3 views 1.0000 each 162.00 129.6000 80.80 162.00 Radiologic examination, spine, cervical; 4 or 5 views 1.0000 each 424.00 339.2000 99.40 424.00 Radiologic examination, spine, cervical; 6 or more views 1.0000 each 344.00 275.2000 99.40 344.00 Radiologic examination, spine; thoracic, 2 views 1.0000 each 238.00 190.4000 99.40 238.00 Radiologic examination, spine; thoracolumbar junction, minimum of 2 views 1.0000 each 207.00 165.6000 80.80 207.00 Radiologic examination, spine, entire thoracic and lumbar, including skull, cervical and sacral spine if performed (eg, scoliosis evaluation); one view 1.0000 each 241.00 192.8000 80.80 241.00 Radiologic examination, spine, entire thoracic and lumbar, including skull, cervical and sacral spine if performed (eg, scoliosis evaluation); 2 or 3 views 1.0000 each 281.00 224.8000 99.40 281.00 Radiologic examination, spine, entire thoracic and lumbar, including skull, cervical and sacral spine if performed (eg, scoliosis evaluation); 4 or 5 views 1.0000 each 229.00 183.2000 99.40 229.00 Radiologic examination, spine, entire thoracic and lumbar, including skull, cervical and sacral spine if performed (eg, scoliosis evaluation); minimum of 6 views 1.0000 each 229.00 183.2000 99.40 229.00 Radiologic examination, spine, lumbosacral; 2 or 3 views 1.0000 each 220.00 176.0000 99.40 220.00 Radiologic examination, spine, lumbosacral; minimum of 4 views 1.0000 each 185.40 148.3200 99.40 185.40 Radiologic examination, spine, lumbosacral; complete, including bending views, minimum of 6 views 1.0000 each 383.00 306.4000 99.40 383.00 Computed tomography, cervical spine; without contrast material Each 5752.00 4601.6000 99.40 5752.00 Computed tomography, cervical spine; with contrast material Each 2561.00 2048.8000 342.64 2561.00 Computed tomography, cervical spine; without contrast material, followed by contrast material(s) and further sections Each 2231.00 1784.8000 167.71 2231.00 Computed tomography, thoracic spine; without contrast material Each 2298.00 1838.4000 99.40 2298.00 Computed tomography, thoracic spine; with contrast material Each 1855.00 1484.0000 167.71 1855.00 Computed tomography, thoracic spine; without contrast material, followed by contrast material(s) and further sections Each 1722.00 1377.6000 167.71 1722.00 Computed tomography, lumbar spine; without contrast material Each 2382.00 1905.6000 99.40 2382.00 Computed tomography, lumbar spine; with contrast material Each 2561.00 2048.8000 342.64 2561.00 Computed tomography, lumbar spine; without contrast material, followed by contrast material(s) and further sections Each 2678.00 2142.4000 167.71 2678.00 Magnetic resonance (eg, proton) imaging, spinal canal and contents, cervical; without contrast material Each 3938.00 3150.4000 217.17 3938.00 Magnetic resonance (eg, proton) imaging, spinal canal and contents, cervical; with contrast material(s) Each 1961.00 1568.8000 342.64 1961.00 Magnetic resonance (eg, proton) imaging, spinal canal and contents, thoracic; without contrast material Each 3938.00 3150.4000 217.17 3938.00 Magnetic resonance (eg, proton) imaging, spinal canal and contents, thoracic; with contrast material(s) Each 2083.00 1666.4000 342.64 2083.00 Magnetic resonance (eg, proton) imaging, spinal canal and contents, lumbar; without contrast material Each 4300.00 3440.0000 217.17 4300.00 Magnetic resonance (eg, proton) imaging, spinal canal and contents, lumbar; with contrast material(s) Each 2565.00 2052.0000 342.64 2565.00 Magnetic resonance (eg, proton) imaging, spinal canal and contents, without contrast material, followed by contrast material(s) and further sequences; cervical Each 4725.00 3780.0000 342.64 4725.00 Magnetic resonance (eg, proton) imaging, spinal canal and contents, without contrast material, followed by contrast material(s) and further sequences; thoracic Each 5513.00 4410.4000 342.64 5513.00 Magnetic resonance (eg, proton) imaging, spinal canal and contents, without contrast material, followed by contrast material(s) and further sequences; lumbar Each 4725.00 3780.0000 342.64 4725.00 Radiologic examination, pelvis; 1 or 2 views 1.0000 each 180.00 144.0000 99.40 180.00 Radiologic examination, pelvis; complete, minimum of 3 views 1.0000 each 187.00 149.6000 99.40 187.00 Computed tomographic angiography, pelvis, with contrast material(s), including noncontrast images, if performed, and image postprocessing Each 2090.00 1672.0000 167.71 2090.00 Computed tomography, pelvis; without contrast material Each 2357.00 1885.6000 99.40 2357.00 Computed tomography, pelvis; with contrast material(s) Each 2681.00 2144.8000 167.71 2681.00 Computed tomography, pelvis; without contrast material, followed by contrast material(s) and further sections Each 3063.00 2450.4000 167.71 3063.00 Magnetic resonance (eg, proton) imaging, pelvis; without contrast material(s) Each 3938.00 3150.4000 217.17 3938.00 Magnetic resonance (eg, proton) imaging, pelvis; with contrast material(s) Each 2135.00 1708.0000 342.64 2135.00 Magnetic resonance (eg, proton) imaging, pelvis; without contrast material(s), followed by contrast material(s) and further sequences Each 4101.00 3280.8000 342.64 4101.00 Radiologic examination, sacroiliac joints; less than 3 views 1.0000 each 137.00 109.6000 84.80 137.00 Radiologic examination, sacroiliac joints; 3 or more views 1.0000 each 162.00 129.6000 99.40 162.00 Radiologic examination, sacrum and coccyx, minimum of 2 views 1.0000 each 201.00 160.8000 80.80 201.00 Myelography, cervical, radiological supervision and interpretation 1.0000 each 677.00 541.6000 419.06 746.90 Myelography, lumbosacral, radiological supervision and interpretation 1.0000 each 644.00 515.2000 398.64 746.90 Discography, cervical or thoracic, radiological supervision and interpretation 1.0000 each 574.00 459.2000 355.31 1812.45 Discography, lumbar, radiological supervision and interpretation 1.0000 Each 574.00 459.2000 355.31 1812.45 Radiologic examination; clavicle, complete 1.0000 each 162.00 129.6000 80.80 162.00 Radiologic examination; scapula, complete 1.0000 each 184.00 147.2000 99.40 184.00 Radiologic examination, shoulder; 1 view 1.0000 each 201.00 160.8000 80.80 201.00 Radiologic examination, shoulder; complete, minimum of 2 views 1.0000 each 450.00 360.0000 80.80 450.00 Radiologic examination, shoulder, arthrography, radiological supervision and interpretation 1.0000 each 390.00 312.0000 241.41 390.00 Radiologic examination; acromioclavicular joints, bilateral, with or without weighted distraction 1.0000 each 380.00 304.0000 80.80 380.00 Radiologic examination; humerus, minimum of 2 views 1.0000 each 144.00 115.2000 80.80 144.00 Radiologic examination, elbow; 2 views 1.0000 each 201.00 160.8000 80.80 201.00 Radiologic examination, elbow; complete, minimum of 3 views 1.0000 each 240.00 192.0000 80.80 240.00 Radiologic examination, elbow, arthrography, radiological supervision and interpretation 1.0000 each 367.00 293.6000 227.17 371.49 Radiologic examination; forearm, 2 views 1.0000 each 199.00 159.2000 80.80 199.00 Radiologic examination; upper extremity, infant, minimum of 2 views 1.0000 each 115.00 92.0000 71.18 115.00 Radiologic examination, wrist; 2 views 1.0000 each 128.00 102.4000 79.23 128.00 Radiologic examination, wrist; complete, minimum of 3 views 1.0000 each 226.00 180.8000 80.80 226.00 Radiologic examination, wrist, arthrography, radiological supervision and interpretation 1.0000 each 389.00 311.2000 240.79 389.00 Radiologic examination, hand; 2 views 1.0000 each 197.00 157.6000 99.40 197.00 Radiologic examination, hand; minimum of 3 views 1.0000 each 450.00 360.0000 80.80 450.00 Radiologic examination, finger(s), minimum of 2 views 1.0000 each 183.00 146.4000 80.80 183.00 Computed tomography, upper extremity; without contrast material Each 2298.00 1838.4000 99.40 2298.00 Computed tomography, upper extremity; with contrast material(s) Each 2226.00 1780.8000 342.64 2226.00 Computed tomography, upper extremity; without contrast material, followed by contrast material(s) and further sections Each 1722.00 1377.6000 167.71 1722.00 Computed tomographic angiography, upper extremity, with contrast material(s), including noncontrast images, if performed, and image postprocessing Each 1567.00 1253.6000 167.71 1567.00 Magnetic resonance (eg, proton) imaging, upper extremity, other than joint; without contrast material(s) Each 3938.00 3150.4000 217.17 3938.00 Magnetic resonance (eg, proton) imaging, upper extremity, other than joint; with contrast material(s) Each 1497.00 1197.6000 342.64 1497.00 Magnetic resonance (eg, proton) imaging, upper extremity, other than joint; without contrast material(s), followed by contrast material(s) and further sequences Each 2260.00 1808.0000 342.64 2260.00 Magnetic resonance (eg, proton) imaging, any joint of upper extremity; without contrast material(s) Each 3938.00 3150.4000 217.17 3938.00 Magnetic resonance (eg, proton) imaging, any joint of upper extremity; with contrast material(s) Each 3938.00 3150.4000 688.89 3938.00 Magnetic resonance (eg, proton) imaging, any joint of upper extremity; without contrast material(s), followed by contrast material(s) and further sequences Each 4725.00 3780.0000 342.64 4725.00 Radiologic examination, hip, unilateral, with pelvis when performed; 1 view 1.0000 each 93.00 74.4000 57.57 93.00 Radiologic examination, hip, unilateral, with pelvis when performed; 2-3 views 1.0000 each 219.00 175.2000 80.80 219.00 Radiologic examination, hips, bilateral, with pelvis when performed; 2 views 1.0000 each 222.00 177.6000 99.40 222.00 Radiologic examination, hip, arthrography, radiological supervision and interpretation 1.0000 each 1593.00 1274.4000 342.64 1593.00 Radiologic examination, femur; 1 view 1.0000 each 132.00 105.6000 80.80 132.00 Radiologic examination, femur; minimum 2 views 1.0000 each 183.00 146.4000 80.80 183.00 Radiologic examination, knee; 1 or 2 views 1.0000 each 185.00 148.0000 80.80 185.00 Radiologic examination, knee; 3 views 1.0000 each 259.00 207.2000 80.80 259.00 Radiologic examination, knee; complete, 4 or more views 1.0000 each 230.00 184.0000 99.40 230.00 Radiologic examination, knee; both knees, standing, anteroposterior 1.0000 each 171.00 136.8000 80.80 171.00 Radiologic examination, knee, arthrography, radiological supervision and interpretation 1.0000 each 515.00 412.0000 318.78 515.00 Radiologic examination; tibia and fibula, 2 views 1.0000 each 203.00 162.4000 80.80 203.00 Radiologic examination; lower extremity, infant, minimum of 2 views 1.0000 each 115.00 92.0000 71.18 115.00 Radiologic examination, ankle; 2 views 1.0000 each 192.00 153.6000 80.80 192.00 Radiologic examination, ankle; complete, minimum of 3 views 1.0000 each 450.00 360.0000 80.80 450.00 Radiologic examination, ankle, arthrography, radiological supervision and interpretation 1.0000 each 1063.00 850.4000 342.64 1063.00 Radiologic examination, foot; 2 views 1.0000 each 137.00 109.6000 80.80 137.00 Radiologic examination, foot; complete, minimum of 3 views 1.0000 each 450.00 360.0000 80.80 450.00 Radiologic examination; calcaneus, minimum of 2 views 1.0000 each 99.00 79.2000 61.28 99.00 Radiologic examination; toe(s), minimum of 2 views 1.0000 each 174.00 139.2000 80.80 174.00 Computed tomography, lower extremity; without contrast material Each 2298.00 1838.4000 99.40 2298.00 Computed tomography, lower extremity; with contrast material(s) Each 2161.00 1728.8000 167.71 2161.00 Computed tomography, lower extremity; without contrast material, followed by contrast material(s) and further sections Each 1727.00 1381.6000 167.71 1727.00 Computed tomographic angiography, lower extremity, with contrast material(s), including noncontrast images, if performed, and image postprocessing Each 2117.00 1693.6000 167.71 2117.00 Magnetic resonance (eg, proton) imaging, lower extremity other than joint; without contrast material(s) Each 3938.00 3150.4000 217.17 3938.00 Magnetic resonance (eg, proton) imaging, lower extremity other than joint; with contrast material(s) Each 3332.00 2665.6000 342.64 3332.00 Magnetic resonance (eg, proton) imaging, lower extremity other than joint; without contrast material(s), followed by contrast material(s) and further sequences Each 3150.00 2520.0000 342.64 3150.00 Magnetic resonance (eg, proton) imaging, any joint of lower extremity; without contrast material Each 3938.00 3150.4000 217.17 3938.00 Magnetic resonance (eg, proton) imaging, any joint of lower extremity; with contrast material(s) Each 1893.00 1514.4000 688.89 1893.00 Magnetic resonance (eg, proton) imaging, any joint of lower extremity; without contrast material(s), followed by contrast material(s) and further sequences Each 3140.00 2512.0000 342.64 3140.00 Radiologic examination, abdomen; 1 view 1.0000 each 378.00 302.4000 80.80 378.00 Radiologic examination, abdomen; 2 views 1.0000 each 252.00 201.6000 99.40 252.00 Radiologic examination, abdomen; 3 or more views 1.0000 each 273.00 218.4000 99.40 273.00 Radiologic examination, complete acute abdomen series, including 2 or more views of the abdomen (eg, supine, erect, decubitus), and a single view chest 1.0000 each 188.00 150.4000 99.40 188.00 Computed tomography, abdomen; without contrast material Each 2045.00 1636.0000 99.40 2045.00 Computed tomography, abdomen; with contrast material(s) Each 2690.00 2152.0000 167.71 2690.00 Computed tomography, abdomen; without contrast material, followed by contrast material(s) and further sections Each 3302.00 2641.6000 167.71 3302.00 Computed tomographic angiography, abdomen and pelvis, with contrast material(s), including noncontrast images, if performed, and image postprocessing Each 3869.00 3095.2000 342.64 3869.00 Computed tomographic angiography, abdomen, with contrast material(s), including noncontrast images, if performed, and image postprocessing Each 3292.00 2633.6000 167.71 3292.00 Computed tomography, abdomen and pelvis; without contrast material Each 4675.00 3740.0000 217.17 4675.00 Computed tomography, abdomen and pelvis; with contrast material(s) Each 6500.00 5200.0000 342.64 6500.00 Computed tomography, abdomen and pelvis; without contrast material in one or both body regions, followed by contrast material(s) and further sections in one or both body regions Each 6363.00 5090.4000 342.64 6363.00 Magnetic resonance (eg, proton) imaging, abdomen; without contrast material(s) Each 3938.00 3150.4000 217.17 3938.00 Magnetic resonance (eg, proton) imaging, abdomen; with contrast material(s) Each 2436.00 1948.8000 342.64 2436.00 Magnetic resonance (eg, proton) imaging, abdomen; without contrast material(s), followed by with contrast material(s) and further sequences Each 4725.00 3780.0000 342.64 4725.00 Radiologic examination, esophagus, including scout chest radiograph(s) and delayed image(s), when performed; single-contrast (eg, barium) study 1.0000 each 339.00 271.2000 167.71 339.00 Radiologic examination, swallowing function, with cineradiography/videoradiography, including scout neck radiograph(s) and delayed image(s), when performed, contrast (eg, barium) study 1.0000 each 416.00 332.8000 167.71 416.00 Radiologic examination, upper gastrointestinal tract, including scout abdominal radiograph(s) and delayed image(s), when performed; single-contrast (eg, barium) study 1.0000 each 532.00 425.6000 167.71 532.00 Radiologic examination, small intestine, including multiple serial images and scout abdominal radiograph(s), when performed; single-contrast (eg, barium) study 1.0000 each 420.00 336.0000 167.71 420.00 Radiologic examination, small intestine, including multiple serial images and scout abdominal radiograph(s), when performed; double-contrast (eg, high-density barium and air via enteroclysis tube) study, including glucagon, when administered 1.0000 each 212.00 169.6000 131.23 212.00 Radiologic examination, colon, including scout abdominal radiograph(s) and delayed image(s), when performed; single-contrast (eg, barium) study 1.0000 each 449.00 359.2000 167.71 449.00 Radiologic examination, colon, including scout abdominal radiograph(s) and delayed image(s), when performed; double-contrast (eg, high density barium and air) study, including glucagon, when administered 1.0000 each 612.00 489.6000 167.71 612.00 Cholecystography, oral contrast 1.0000 each 289.00 231.2000 167.71 289.00 Cholangiography and/or pancreatography; intraoperative, radiological supervision and interpretation 1.0000 each 441.00 352.8000 272.98 441.00 Urography (pyelography), intravenous, with or without KUB, with or without tomography 1.0000 each 485.00 388.0000 167.71 485.00 Urography, infusion, drip technique and/or bolus technique 1.0000 each 576.00 460.8000 167.71 576.00 Urography, infusion, drip technique and/or bolus technique; with nephrotomography 1.0000 each 682.00 545.6000 167.71 682.00 Urography, retrograde, with or without KUB 1.0000 Each 288.00 230.4000 178.27 371.49 Urography, antegrade, radiological supervision and interpretation 1.0000 Each 458.00 366.4000 283.50 458.00 Cystography, minimum of 3 views, radiological supervision and interpretation 1.0000 each 344.00 275.2000 212.94 371.49 Urethrocystography, retrograde, radiological supervision and interpretation 1.0000 each 278.00 222.4000 172.08 278.00 Urethrocystography, voiding, radiological supervision and interpretation 1.0000 each 310.00 248.0000 191.89 310.00 Hysterosalpingography, radiological supervision and interpretation 1.0000 each 268.00 214.4000 165.89 268.00 Computed tomography, heart, without contrast material, with quantitative evaluation of coronary calcium Each 123.75 99.0000 76.60 123.75 Computed tomographic angiography, heart, coronary arteries and bypass grafts (when present), with contrast material, including 3D image postprocessing (including evaluation of cardiac structure and morphology, assessment of cardiac function, and evaluation of venous structures, if performed) Each 2022.00 1617.6000 167.71 2022.00 Computed tomographic angiography, abdominal aorta and bilateral iliofemoral lower extremity runoff, with contrast material(s), including noncontrast images, if performed, and image postprocessing Each 1997.00 1597.6000 167.71 1997.00 Venography, extremity, unilateral, radiological supervision and interpretation Each 635.00 508.0000 393.06 1500.21 Venography, extremity, bilateral, radiological supervision and interpretation Each 674.00 539.2000 417.21 1500.21 Radiological guidance (ie, fluoroscopy, ultrasound, or computed tomography), for percutaneous drainage (eg, abscess, specimen collection), with placement of catheter, radiological supervision and interpretation 1.0000 each 359.00 287.2000 222.22 359.00 Fluoroscopy (separate procedure), up to 1 hour physician or other qualified health care professional time 1.0000 each 258.00 206.4000 159.70 258.00 Radiologic examination, abscess, fistula or sinus tract study, radiological supervision and interpretation 1.0000 each 228.00 182.4000 141.13 507.31 Radiological examination, surgical specimen 1.0000 Each 213.00 170.4000 131.85 507.31 Radiologic examination, single plane body section (eg, tomography), other than with urography 1.0000 each 148.00 118.4000 91.61 148.00 3D rendering with interpretation and reporting of computed tomography, magnetic resonance imaging, ultrasound, or other tomographic modality with image postprocessing under concurrent supervision; not requiring image postprocessing on an independent workstation 1.0000 each 656.00 524.8000 406.06 656.00 3D rendering with interpretation and reporting of computed tomography, magnetic resonance imaging, ultrasound, or other tomographic modality with image postprocessing under concurrent supervision; requiring image postprocessing on an independent workstation 1.0000 Each 946.00 756.8000 585.57 946.00 Computed tomography, limited or localized follow-up study 1.0000 each 1127.00 901.6000 80.80 1127.00 Echoencephalography, real time with image documentation (gray scale) (for determination of ventricular size, delineation of cerebral contents, and detection of fluid masses or other intracranial abnormalities), including A-mode encephalography as secondary component where indicated 1.0000 each 227.00 181.6000 99.40 227.00 Ultrasound, soft tissues of head and neck (eg, thyroid, parathyroid, parotid), real time with image documentation 1.0000 each 788.00 630.4000 99.40 788.00 Ultrasound, chest (includes mediastinum), real time with image documentation Each 788.00 630.4000 99.40 788.00 Ultrasound, breast, unilateral, real time with image documentation, including axilla when performed; complete 1.0000 each 788.00 630.4000 99.40 788.00 Ultrasound, abdominal, real time with image documentation; complete Each 788.00 630.4000 99.40 788.00 Ultrasound, abdominal, real time with image documentation; limited (eg, single organ, quadrant, follow-up) Each 788.00 630.4000 99.40 788.00 Ultrasound, abdominal aorta, real time with image documentation, screening study for abdominal aortic aneurysm (AAA) 1.0000 each 788.00 630.4000 99.40 788.00 Ultrasound, retroperitoneal (eg, renal, aorta, nodes), real time with image documentation; complete Each 788.00 630.4000 99.40 788.00 Ultrasound, retroperitoneal (eg, renal, aorta, nodes), real time with image documentation; limited Each 232.00 185.6000 99.40 232.00 Ultrasound, spinal canal and contents 1.0000 each 296.00 236.8000 99.40 296.00 Ultrasound, pregnant uterus, real time with image documentation, fetal and maternal evaluation, first trimester (< 14 weeks 0 days), transabdominal approach; single or first gestation 1.0000 each 788.00 630.4000 99.40 788.00 Ultrasound, pregnant uterus, real time with image documentation, fetal and maternal evaluation, first trimester (< 14 weeks 0 days), transabdominal approach; each additional gestation (List separately in addition to code for primary procedure) 1.0000 each 765.00 612.0000 473.54 765.00 Ultrasound, pregnant uterus, real time with image documentation, fetal and maternal evaluation, after first trimester (> or = 14 weeks 0 days), transabdominal approach; single or first gestation 1.0000 each 788.00 630.4000 99.40 788.00 Ultrasound, pregnant uterus, real time with image documentation, fetal and maternal evaluation, after first trimester (> or = 14 weeks 0 days), transabdominal approach; each additional gestation (List separately in addition to code for primary procedure) 1.0000 each 765.00 612.0000 473.54 765.00 Ultrasound, pregnant uterus, real time with image documentation, fetal and maternal evaluation plus detailed fetal anatomic examination, transabdominal approach; single or first gestation 1.0000 each 634.00 507.2000 217.17 634.00 Ultrasound, pregnant uterus, real time with image documentation, limited (eg, fetal heart beat, placental location, fetal position and/or qualitative amniotic fluid volume), 1 or more fetuses 1.0000 each 788.00 630.4000 99.40 788.00 Ultrasound, pregnant uterus, real time with image documentation, follow-up (eg, re-evaluation of fetal size by measuring standard growth parameters and amniotic fluid volume, re-evaluation of organ system(s) suspected or confirmed to be abnormal on a previous scan), transabdominal approach, per fetus 1.0000 each 788.00 630.4000 99.40 788.00 Ultrasound, pregnant uterus, real time with image documentation, transvaginal 1.0000 each 788.00 630.4000 99.40 788.00 Fetal biophysical profile; with non-stress testing 1.0000 each 449.00 359.2000 99.40 449.00 Fetal biophysical profile; without non-stress testing 1.0000 each 788.00 630.4000 99.40 788.00 Doppler velocimetry, fetal; umbilical artery 1.0000 each 788.00 630.4000 99.40 788.00 Ultrasound, transvaginal 1.0000 each 900.00 720.0000 99.40 900.00 Saline infusion sonohysterography (SIS), including color flow Doppler, when performed Each 395.00 316.0000 217.17 395.00 Ultrasound, pelvic (nonobstetric), real time with image documentation; complete Each 1200.00 960.0000 99.40 1200.00 Ultrasound, pelvic (nonobstetric), real time with image documentation; limited or follow-up (eg, for follicles) Each 394.00 315.2000 99.40 394.00 Ultrasound, scrotum and contents Each 788.00 630.4000 99.40 788.00 Ultrasound, transrectal 1.0000 each 788.00 630.4000 99.40 788.00 Ultrasound, complete joint (ie, joint space and peri-articular soft-tissue structures), real-time with image documentation 1.0000 each 408.00 326.4000 99.40 408.00 Ultrasound, limited, joint or focal evaluation of other nonvascular extremity structure(s) (eg, joint space, peri-articular tendon[s], muscle[s], nerve[s], other soft-tissue structure[s], or soft-tissue mass[es]), real-time with image documentation 1.0000 each 788.00 630.4000 99.40 788.00 Ultrasound, infant hips, real time with imaging documentation; dynamic (requiring physician or other qualified health care professional manipulation) 1.0000 each 788.00 630.4000 80.80 788.00 Ultrasound guidance for vascular access requiring ultrasound evaluation of potential access sites, documentation of selected vessel patency, concurrent realtime ultrasound visualization of vascular needle entry, with permanent recording and reporting (List separately in addition to code for primary procedure) 1.0000 Each 691.00 552.8000 427.73 691.00 Ultrasonic guidance for needle placement (eg, biopsy, aspiration, injection, localization device), imaging supervision and interpretation 1.0000 Each 945.00 756.0000 584.96 945.00 Ultrasonic guidance for amniocentesis, imaging supervision and interpretation 1.0000 each 544.00 435.2000 336.74 544.00 Ultrasonic guidance, intraoperative 1.0000 each 350.00 280.0000 216.65 350.00 Fluoroscopic guidance for central venous access device placement, replacement (catheter only or complete), or removal (includes fluoroscopic guidance for vascular access and catheter manipulation, any necessary contrast injections through access site or catheter with related venography radiologic supervision and interpretation, and radiographic documentation of final catheter position) (List separately in addition to code for primary procedure) 1.0000 each 214.00 171.2000 132.47 214.00 Fluoroscopic guidance for needle placement (eg, biopsy, aspiration, injection, localization device) (List separately in addition to code for primary procedure) 1.0000 each 408.00 326.4000 252.55 408.00 Fluoroscopic guidance and localization of needle or catheter tip for spine or paraspinous diagnostic or therapeutic injection procedures (epidural or subarachnoid) (List separately in addition to code for primary procedure) 1.0000 each 408.00 326.4000 252.55 408.00 Computed tomography guidance for needle placement (eg, biopsy, aspiration, injection, localization device), radiological supervision and interpretation 1.0000 each 1588.00 1270.4000 982.97 1588.00 Mammary ductogram or galactogram, single duct, radiological supervision and interpretation 1.0000 each 825.00 660.0000 217.17 825.00 Mammary ductogram or galactogram, multiple ducts, radiological supervision and interpretation 1.0000 each 825.00 660.0000 217.17 825.00 Screening digital breast tomosynthesis, bilateral (List separately in addition to code for primary procedure) 1.0000 each 158.00 126.4000 48.32 158.00 Diagnostic mammography, including computer-aided detection (CAD) when performed; unilateral 1.0000 each 263.00 210.4000 113.81 263.00 Diagnostic mammography, including computer-aided detection (CAD) when performed; bilateral 1.0000 each 375.00 300.0000 143.51 375.00 Screening mammography, bilateral (2-view study of each breast), including computer-aided detection (CAD) when performed 1.0000 each 375.00 300.0000 116.38 375.00 Manual application of stress performed by physician or other qualified health care professional for joint radiography, including contralateral joint if indicated 1.0000 each 210.00 168.0000 80.80 210.00 Bone age studies 1.0000 each 165.00 132.0000 99.40 165.00 Bone length studies (orthoroentgenogram, scanogram) 1.0000 each 202.00 161.6000 99.40 202.00 Radiologic examination, osseous survey; complete (axial and appendicular skeleton) 1.0000 each 656.00 524.8000 99.40 656.00 Computed tomography, bone mineral density study, 1 or more sites, axial skeleton (eg, hips, pelvis, spine) 1.0000 each 1174.00 939.2000 80.80 1174.00 Dual-energy X-ray absorptiometry (DXA), bone density study, 1 or more sites; axial skeleton (eg, hips, pelvis, spine) 1.0000 each 630.00 504.0000 99.40 630.00 Magnetic resonance (eg, proton) imaging, bone marrow blood supply 1.0000 each 1571.00 1256.8000 217.17 1571.00 Thyroid imaging (including vascular flow, when performed) 1.0000 Each 561.00 448.8000 347.26 561.00 Thyroid imaging (including vascular flow, when performed); with single or multiple uptake(s) quantitative measurement(s) (including stimulation, suppression, or discharge, when performed) 1.0000 each 593.00 474.4000 361.47 593.00 Thyroid carcinoma metastases imaging; limited area (eg, neck and chest only) 1.0000 each 769.00 615.2000 361.47 769.00 Thyroid carcinoma metastases imaging; whole body 1.0000 each 1073.00 858.4000 469.18 1073.00 Parathyroid planar imaging (including subtraction, when performed) 1.0000 each 577.00 461.6000 357.16 577.00 Bone marrow imaging; limited area 1.0000 each 618.00 494.4000 361.47 618.00 Bone marrow imaging; multiple areas 1.0000 each 842.00 673.6000 361.47 842.00 Bone marrow imaging; whole body 1.0000 each 921.00 736.8000 361.47 921.00 Lymphatics and lymph nodes imaging 1.0000 each 605.00 484.0000 374.50 605.00 Liver imaging; static only 1.0000 each 626.00 500.8000 387.49 626.00 Liver imaging; with vascular flow 1.0000 each 758.00 606.4000 469.18 758.00 Liver and spleen imaging; static only 1.0000 each 626.00 500.8000 361.47 626.00 Liver and spleen imaging; with vascular flow 1.0000 each 687.00 549.6000 361.47 687.00 Hepatobiliary system imaging, including gallbladder when present 1.0000 each 1131.00 904.8000 361.47 1131.00 Hepatobiliary system imaging, including gallbladder when present; with pharmacologic intervention, including quantitative measurement(s) when performed 1.0000 each 1583.00 1266.4000 469.18 1583.00 Salivary gland imaging 1.0000 each 622.00 497.6000 361.47 622.00 Salivary gland imaging; with serial images 1.0000 each 732.00 585.6000 361.47 732.00 Gastroesophageal reflux study 1.0000 each 728.00 582.4000 361.47 728.00 Gastric emptying imaging study (eg, solid, liquid, or both) 1.0000 each 752.00 601.6000 361.47 752.00 Acute gastrointestinal blood loss imaging 1.0000 each 867.00 693.6000 361.47 867.00 Intestine imaging (eg, ectopic gastric mucosa, Meckel's localization, volvulus) 1.0000 each 568.00 454.4000 351.59 568.00 Bone and/or joint imaging; limited area 1.0000 each 489.00 391.2000 302.69 489.00 Bone and/or joint imaging; multiple areas 1.0000 each 1143.00 914.4000 361.47 1143.00 Bone and/or joint imaging; whole body Each 1192.00 953.6000 361.47 1192.00 Bone and/or joint imaging; 3 phase study 1.0000 each 1206.00 964.8000 361.47 1206.00 Non-cardiac vascular flow imaging (ie, angiography, venography) Each 510.00 408.0000 315.69 510.00 Myocardial perfusion imaging, tomographic (SPECT) (including attenuation correction, qualitative or quantitative wall motion, ejection fraction by first pass or gated technique, additional quantification, when performed); single study, at rest or stress (exercise or pharmacologic) Each 2067.00 1653.6000 1234.35 2067.00 Myocardial perfusion imaging, tomographic (SPECT) (including attenuation correction, qualitative or quantitative wall motion, ejection fraction by first pass or gated technique, additional quantification, when performed); multiple studies, at rest and/or stress (exercise or pharmacologic) and/or redistribution and/or rest reinjection Each 2067.00 1653.6000 1234.35 2067.00 Myocardial perfusion imaging, planar (including qualitative or quantitative wall motion, ejection fraction by first pass or gated technique, additional quantification, when performed); multiple studies, at rest and/or stress (exercise or pharmacologic) and/or redistribution and/or rest reinjection Each 1298.00 1038.4000 803.46 1338.30 Myocardial imaging, infarct avid, planar; qualitative or quantitative Each 568.00 454.4000 351.59 568.00 Cardiac blood pool imaging, gated equilibrium; planar, single study at rest or stress (exercise and/or pharmacologic), wall motion study plus ejection fraction, with or without additional quantitative processing Each 1037.00 829.6000 361.47 1037.00 Cardiac blood pool imaging, gated equilibrium; multiple studies, wall motion study plus ejection fraction, at rest and stress (exercise and/or pharmacologic), with or without additional quantification Each 1329.00 1063.2000 361.47 1329.00 Pulmonary ventilation imaging (eg, aerosol or gas) 1.0000 each 855.00 684.0000 361.47 855.00 Pulmonary perfusion imaging (eg, particulate) 1.0000 each 907.00 725.6000 361.47 907.00 Pulmonary ventilation (eg, aerosol or gas) and perfusion imaging 1.0000 each 1293.00 1034.4000 469.18 1293.00 Brain imaging, minimum 4 static views; with vascular flow 1.0000 each 1006.00 804.8000 469.18 1006.00 Cerebrospinal fluid flow, imaging (not including introduction of material); shunt evaluation 1.0000 each 1980.00 1584.0000 469.18 1980.00 Kidney imaging morphology; with vascular flow 1.0000 each 539.00 431.2000 333.64 539.00 Kidney imaging morphology; with vascular flow and function, single study without pharmacological intervention 1.0000 each 883.00 706.4000 469.18 883.00 Kidney imaging morphology; with vascular flow and function, single study, with pharmacological intervention (eg, angiotensin converting enzyme inhibitor and/or diuretic) 1.0000 each 829.00 663.2000 469.18 829.00 Kidney imaging morphology; with vascular flow and function, multiple studies, with and without pharmacological intervention (eg, angiotensin converting enzyme inhibitor and/or diuretic) 1.0000 each 1469.00 1175.2000 469.18 1469.00 Kidney function study, non-imaging radioisotopic study 1.0000 each 482.00 385.6000 298.36 482.00 Testicular imaging with vascular flow 1.0000 each 578.00 462.4000 357.78 578.00 Radiopharmaceutical localization of tumor, inflammatory process or distribution of radiopharmaceutical agent(s) (includes vascular flow and blood pool imaging, when performed); planar, 2 or more areas (eg, abdomen and pelvis, head and chest), 1 or more days imaging or single area imaging over 2 or more days 1.0000 each 940.00 752.0000 361.47 940.00 Radiopharmaceutical localization of tumor, inflammatory process or distribution of radiopharmaceutical agent(s) (includes vascular flow and blood pool imaging, when performed); planar, whole body, single day imaging Each 1090.00 872.0000 674.71 1338.30 Radiopharmaceutical localization of tumor, inflammatory process or distribution of radiopharmaceutical agent(s) (includes vascular flow and blood pool imaging, when performed); tomographic (SPECT), single area (eg, head, neck, chest, pelvis) or acquisition, single day imaging Each 1260.00 1008.0000 779.94 1338.30 Radiopharmaceutical therapy, by oral administration 1.0000 each 885.00 708.0000 232.25 885.00 Basic metabolic panel (Calcium, ionized) This panel must include the following: Calcium, ionized (82330) Carbon dioxide (bicarbonate) (82374) Chloride (82435) Creatinine (82565) Glucose (82947) Potassium (84132) Sodium (84295) Urea Nitrogen (BUN) (84520) 1.0000 Each 263.00 210.4000 13.04 263.00 Basic metabolic panel (Calcium, total) This panel must include the following: Calcium, total (82310) Carbon dioxide (bicarbonate) (82374) Chloride (82435) Creatinine (82565) Glucose (82947) Potassium (84132) Sodium (84295) Urea nitrogen (BUN) (84520) 1.0000 Each 342.00 273.6000 8.04 342.00 General health panel This panel must include the following: Comprehensive metabolic panel (80053) Blood count, complete (CBC), automated and automated differential WBC count (85025 or 85027 and 85004) OR Blood count, complete (CBC), automated (85027) and appropriate manual differential WBC count (85007 or 85009) Thyroid stimulating hormone (TSH) (84443) 1.0000 each 134.00 107.2000 82.95 134.00 Electrolyte panel This panel must include the following: Carbon dioxide (bicarbonate) (82374) Chloride (82435) Potassium (84132) Sodium (84295) 1.0000 Each 89.00 71.2000 6.66 89.00 Comprehensive metabolic panel This panel must include the following: Albumin (82040) Bilirubin, total (82247) Calcium, total (82310) Carbon dioxide (bicarbonate) (82374) Chloride (82435) Creatinine (82565) Glucose (82947) Phosphatase, alkaline (84075) Potassium (84132) Protein, total (84155) Sodium (84295) Transferase, alanine amino (ALT) (SGPT) (84460) Transferase, aspartate amino (AST) (SGOT) (84450) Urea nitrogen (BUN) (84520) 1.0000 Each 447.00 357.6000 10.03 447.00 Obstetric panel This panel must include the following: Blood count, complete (CBC), automated and automated differential WBC count (85025 or 85027 and 85004) OR Blood count, complete (CBC), automated (85027) and appropriate manual differential WBC count (85007 or 85009) Hepatitis B surface antigen (HBsAg) (87340) Antibody, rubella (86762) Syphilis test, non-treponemal antibody; qualitative (eg, VDRL, RPR, ART) (86592) Antibody screen, RBC, each serum technique (86850) Blood typing, ABO (86900) AND Blood typing, Rh (D) (86901) 1.0000 each 161.00 128.8000 45.42 161.00 Lipid panel This panel must include the following: Cholesterol, serum, total (82465) Lipoprotein, direct measurement, high density cholesterol (HDL cholesterol) (83718) Triglycerides (84478) 1.0000 Each 263.00 210.4000 12.72 263.00 Renal function panel This panel must include the following: Albumin (82040) Calcium, total (82310) Carbon dioxide (bicarbonate) (82374) Chloride (82435) Creatinine (82565) Glucose (82947) Phosphorus inorganic (phosphate) (84100) Potassium (84132) Sodium (84295) Urea nitrogen (BUN) (84520) 1.0000 each 207.00 165.6000 8.25 207.00 Acute hepatitis panel This panel must include the following: Hepatitis A antibody (HAAb), IgM antibody (86709) Hepatitis B core antibody (HBcAb), IgM antibody (86705) Hepatitis B surface antigen (HBsAg) (87340) Hepatitis C antibody (86803) 1.0000 each 374.00 299.2000 45.25 374.00 Hepatic function panel This panel must include the following: Albumin (82040) Bilirubin, total (82247) Bilirubin, direct (82248) Phosphatase, alkaline (84075) Protein, total (84155) Transferase, alanine amino (ALT) (SGPT) (84460) Transferase, aspartate amino (AST) (SGOT) (84450) 1.0000 Each 315.00 252.0000 7.76 315.00 Amikacin 1.0000 each 165.25 132.2000 14.33 165.25 Carbamazepine; total 1.0000 each 146.00 116.8000 13.84 146.00 Carbamazepine; free 1.0000 each 119.88 95.9000 12.59 119.88 Cyclosporine 1.0000 each 87.00 69.6000 17.15 87.00 Digoxin; total 1.0000 each 118.00 94.4000 12.62 118.00 Valproic acid (dipropylacetic acid); total 1.0000 Each 109.00 87.2000 12.86 109.00 Gentamicin 1.0000 Each 146.00 116.8000 15.56 146.00 Lamotrigine 1.0000 each 180.00 144.0000 12.59 180.00 Levetiracetam 1.0000 each 94.00 75.2000 12.59 94.00 Lithium 1.0000 each 73.00 58.4000 6.28 73.00 Oxcarbazepine 1.0000 each 71.00 56.8000 12.59 71.00 Phenobarbital 1.0000 each 141.00 112.8000 14.54 141.00 Phenytoin; total 1.0000 Each 123.00 98.4000 12.59 123.00 Phenytoin; free 1.0000 each 44.70 35.7600 13.07 44.70 Primidone 1.0000 each 57.00 45.6000 15.76 57.00 Procainamide; with metabolites (eg, n-acetyl procainamide) 1.0000 each 85.50 68.4000 15.91 85.50 Quinidine 1.0000 each 88.55 70.8400 13.87 88.55 Sirolimus 1.0000 each 86.20 68.9600 13.04 86.20 Tacrolimus 1.0000 Each 246.00 196.8000 13.04 246.00 Theophylline 1.0000 each 57.00 45.6000 13.43 57.00 Tobramycin 1.0000 each 93.00 74.4000 15.32 93.00 Topiramate 1.0000 each 72.00 57.6000 11.32 72.00 Vancomycin 1.0000 Each 139.00 111.2000 12.86 139.00 Quantitation of therapeutic drug, not elsewhere specified 1.0000 Each 115.05 92.0400 17.71 115.05 Drug test(s), presumptive, any number of drug classes, any number of devices or procedures; by instrument chemistry analyzers (eg, utilizing immunoassay [eg, EIA, ELISA, EMIT, FPIA, IA, KIMS, RIA]), chromatography (eg, GC, HPLC), and mass spectrometry either with or without chromatography, (eg, DART, DESI, GC-MS, GC-MS/MS, LC-MS, LC-MS/MS, LDTD, MALDI, TOF) includes sample validation when performed, per date of service 1.0000 each 234.00 187.2000 59.03 234.00 Alcohols 1.0000 each 109.85 87.8800 68.00 109.85 Anabolic steroids; 1 or 2 1.0000 each 134.00 107.2000 82.95 134.00 Analgesics, non-opioid; 1 or 2 1.0000 each 252.00 201.6000 155.99 252.00 Antidepressants, tricyclic and other cyclicals; 1 or 2 1.0000 each 86.00 68.8000 53.23 86.00 Antiepileptics, not otherwise specified; 1-3 1.0000 each 721.00 576.8000 446.30 721.00 Gabapentin, non-blood 1.0000 each 147.05 117.6400 91.02 147.05 Heroin metabolite 1.0000 each 46.00 36.8000 28.47 46.00 Drug(s) or substance(s), definitive, qualitative or quantitative, not otherwise specified; 1-3 1.0000 each 350.25 280.2000 216.80 350.25 Urinalysis, by dip stick or tablet reagent for bilirubin, glucose, hemoglobin, ketones, leukocytes, nitrite, pH, protein, specific gravity, urobilinogen, any number of these constituents; non-automated, with microscopy 1.0000 each 39.15 31.3200 3.82 39.15 Urinalysis, by dip stick or tablet reagent for bilirubin, glucose, hemoglobin, ketones, leukocytes, nitrite, pH, protein, specific gravity, urobilinogen, any number of these constituents; automated, with microscopy 1.0000 Each 30.10 24.0800 3.01 30.10 Urinalysis, by dip stick or tablet reagent for bilirubin, glucose, hemoglobin, ketones, leukocytes, nitrite, pH, protein, specific gravity, urobilinogen, any number of these constituents; non-automated, without microscopy 1.0000 Each 18.55 14.8400 3.31 18.55 Urinalysis, by dip stick or tablet reagent for bilirubin, glucose, hemoglobin, ketones, leukocytes, nitrite, pH, protein, specific gravity, urobilinogen, any number of these constituents; automated, without microscopy 1.0000 Each 18.55 14.8400 2.14 18.55 Urinalysis; qualitative or semiquantitative, except immunoassays 1.0000 each 83.00 66.4000 2.06 83.00 Urinalysis; microscopic only 1.0000 Each 17.00 13.6000 2.90 17.00 Urine pregnancy test, by visual color comparison methods 1.0000 each 113.00 90.4000 8.18 113.00 Volume measurement for timed collection, each 1.0000 Each 13.00 10.4000 3.46 13.00 Unlisted urinalysis procedure 1.0000 each 25.00 20.0000 15.48 25.00 BCR/ABL1 (t(9;22)) (eg, chronic myelogenous leukemia) translocation analysis; major breakpoint, qualitative or quantitative 1.0000 each 575.70 460.5600 155.76 575.70 BCR/ABL1 (t(9;22)) (eg, chronic myelogenous leukemia) translocation analysis; minor breakpoint, qualitative or quantitative 1.0000 each 575.70 460.5600 137.60 575.70 BRAF (B-Raf proto-oncogene, serine/threonine kinase) (eg, colon cancer, melanoma), gene analysis, V600 variant(s) 1.0000 each 293.00 234.4000 166.63 293.00 CFTR (cystic fibrosis transmembrane conductance regulator) (eg, cystic fibrosis) gene analysis; common variants (eg, ACMG/ACOG guidelines) 1.0000 each 1458.00 1166.4000 528.77 1458.00 EGFR (epidermal growth factor receptor) (eg, non-small cell lung cancer) gene analysis, common variants (eg, exon 19 LREA deletion, L858R, T790M, G719A, G719S, L861Q) 1.0000 each 4028.10 3222.4800 308.35 4028.10 F2 (prothrombin, coagulation factor II) (eg, hereditary hypercoagulability) gene analysis, 20210G>A variant 1.0000 each 272.64 218.1100 62.41 272.64 F5 (coagulation factor V) (eg, hereditary hypercoagulability) gene analysis, Leiden variant 1.0000 each 274.00 219.2000 69.70 274.00 HFE (hemochromatosis) (eg, hereditary hemochromatosis) gene analysis, common variants (eg, C282Y, H63D) 1.0000 each 288.00 230.4000 62.09 288.00 IGH@ (Immunoglobulin heavy chain locus) (eg, leukemias and lymphomas, B-cell), gene rearrangement analysis to detect abnormal clonal population(s); amplified methodology (eg, polymerase chain reaction) 1.0000 each 809.00 647.2000 188.09 809.00 IGK@ (Immunoglobulin kappa light chain locus) (eg, leukemia and lymphoma, B-cell), gene rearrangement analysis, evaluation to detect abnormal clonal population(s) 1.0000 each 611.00 488.8000 164.09 611.00 JAK2 (Janus kinase 2) (eg, myeloproliferative disorder) gene analysis, p.Val617Phe (V617F) variant 1.0000 each 583.20 466.5600 87.08 583.20 KRAS (Kirsten rat sarcoma viral oncogene homolog) (eg, carcinoma) gene analysis; variants in exon 2 (eg, codons 12 and 13) 1.0000 each 493.00 394.4000 183.59 493.00 KRAS (Kirsten rat sarcoma viral oncogene homolog) (eg, carcinoma) gene analysis; additional variant(s) (eg, codon 61, codon 146) 1.0000 each 625.00 500.0000 183.59 625.00 MTHFR (5,10-methylenetetrahydrofolate reductase) (eg, hereditary hypercoagulability) gene analysis, common variants (eg, 677T, 1298C) 1.0000 each 399.00 319.2000 62.07 399.00 Microsatellite instability analysis (eg, hereditary non-polyposis colorectal cancer, Lynch syndrome) of markers for mismatch repair deficiency (eg, BAT25, BAT26), includes comparison of neoplastic and normal tissue, if performed 1.0000 each 678.00 542.4000 331.13 678.00 NRAS (neuroblastoma RAS viral [v-ras] oncogene homolog) (eg, colorectal carcinoma), gene analysis, variants in exon 2 (eg, codons 12 and 13) and exon 3 (eg, codon 61) 1.0000 each 937.00 749.6000 281.00 937.00 TRG@ (T cell antigen receptor, gamma) (eg, leukemia and lymphoma), gene rearrangement analysis, evaluation to detect abnormal clonal population(s) 1.0000 each 823.00 658.4000 191.42 823.00 HLA Class I typing, low resolution (eg, antigen equivalents); one antigen equivalent (eg, B*27), each 1.0000 each 397.00 317.6000 70.61 397.00 Molecular pathology procedure, Level 1 (eg, identification of single germline variant [eg, SNP] by techniques such as restriction enzyme digestion or melt curve analysis) ACADM (acyl-CoA dehydrogenase, C-4 to C-12 straight chain, MCAD) (eg, medium chain acyl dehydrogenase deficiency), K304E variant ACE (angiotensin converting enzyme) (eg, hereditary blood pressure regulation), insertion/deletion variant AGTR1 (angiotensin II receptor, type 1) (eg, essential hypertension), 1166A>C variant BCKDHA (branched chain keto acid dehydrogenase E1, alpha polypeptide) (eg, maple syrup urine disease, type 1A), Y438N variant CCR5 (chemokine C-C motif receptor 5) (eg, HIV resistance), 32-bp deletion mutation/794 825del32 deletion CLRN1 (clarin 1) (eg, Usher syndrome, type 3), N48K variant F2 (coagulation factor 2) (eg, hereditary hypercoagulability), 1199G>A variant F5 (coagulation factor V) (eg, hereditary hypercoagulability), HR2 variant F7 (coagulation factor VII [serum prothrombin conversion accelerator]) (eg, hereditary hypercoagulability), R353Q variant F13B (coagulation factor XIII, B polypeptide) (eg, hereditary hypercoagulability), V34L variant FGB (fibrinogen beta chain) (eg, hereditary ischemic heart disease), -455G>A variant FGFR1 (fibroblast growth factor receptor 1) (eg, Pfeiffer syndrome type 1, craniosynostosis), P252R variant FGFR3 (fibroblast growth factor receptor 3) (eg, Muenke syndrome), P250R variant FKTN (fukutin) (eg, Fukuyama congenital muscular dystrophy), retrotransposon insertion variant GNE (glucosamine [UDP-N-acetyl]-2-epimerase/N-acetylmannosamine kinase) (eg, inclusion body myopathy 2 [IBM2], Nonaka myopathy), M712T variant IVD (isovaleryl-CoA dehydrogenase) (eg, isovaleric acidemia), A282V variant LCT (lactase-phlorizin hydrolase) (eg, lactose intolerance), 13910 C>T variant NEB (nebulin) (eg, nemaline myopathy 2), exon 55 deletion variant PCDH15 (protocadherin-related 15) (eg, Usher syndrome type 1F), R245X variant SERPINE1 (serpine peptidase inhi 1.0000 each 454.25 363.4000 60.76 454.25 Molecular pathology procedure, Level 4 (eg, analysis of single exon by DNA sequence analysis, analysis of >10 amplicons using multiplex PCR in 2 or more independent reactions, mutation scanning or duplication/deletion variants of 2-5 exons) ANG (angiogenin, ribonuclease, RNase A family, 5) (eg, amyotrophic lateral sclerosis), full gene sequence ARX (aristaless-related homeobox) (eg, X-linked lissencephaly with ambiguous genitalia, X-linked mental retardation), duplication/deletion analysis CEL (carboxyl ester lipase [bile salt-stimulated lipase]) (eg, maturity-onset diabetes of the young [MODY]), targeted sequence analysis of exon 11 (eg, c.1785delC, c.1686delT) CTNNB1 (catenin [cadherin-associated protein], beta 1, 88kDa) (eg, desmoid tumors), targeted sequence analysis (eg, exon 3) DAZ/SRY (deleted in azoospermia and sex determining region Y) (eg, male infertility), common deletions (eg, AZFa, AZFb, AZFc, AZFd) DNMT3A (DNA [cytosine-5-]-methyltransferase 3 alpha) (eg, acute myeloid leukemia), targeted sequence analysis (eg, exon 23) EPCAM (epithelial cell adhesion molecule) (eg, Lynch syndrome), duplication/deletion analysis F8 (coagulation factor VIII) (eg, hemophilia A), inversion analysis, intron 1 and intron 22A F12 (coagulation factor XII [Hageman factor]) (eg, angioedema, hereditary, type III; factor XII deficiency), targeted sequence analysis of exon 9 FGFR3 (fibroblast growth factor receptor 3) (eg, isolated craniosynostosis), targeted sequence analysis (eg, exon 7) (For targeted sequence analysis of multiple FGFR3 exons, use 81404) GJB1 (gap junction protein, beta 1) (eg, Charcot-Marie-Tooth X-linked), full gene sequence GNAQ (guanine nucleotide-binding protein G[q] subunit alpha) (eg, uveal melanoma), common variants (eg, R183, Q209) Human erythrocyte antigen gene analyses (eg, SLC14A1 [Kidd blood group], BCAM [Lutheran blood group], ICAM4 [Landsteiner-Wiener blood group], SLC4A1 [Diego blood group], AQP1 [Colton blood group], ERMAP [Scianna blood group] 1.0000 each 1350.00 1080.0000 175.94 1350.00 Unlisted molecular pathology procedure 1.0000 each 840.00 672.0000 519.96 840.00 Ketone body(s) (eg, acetone, acetoacetic acid, beta-hydroxybutyrate); qualitative 1.0000 each 22.50 18.0000 4.29 22.50 Ketone body(s) (eg, acetone, acetoacetic acid, beta-hydroxybutyrate); quantitative 1.0000 each 48.00 38.4000 7.76 48.00 Adrenocorticotropic hormone (ACTH) 1.0000 each 142.00 113.6000 36.69 142.00 Albumin; serum, plasma or whole blood 1.0000 each 100.00 80.0000 4.70 100.00 Albumin; other source, quantitative, each specimen 1.0000 Each 24.00 19.2000 7.39 24.00 Albumin; urine (eg, microalbumin), quantitative 1.0000 each 40.00 32.0000 5.49 40.00 Alcohol (ethanol); breath 1.0000 each 49.00 39.2000 28.50 49.00 Aldolase 1.0000 each 40.00 32.0000 9.22 40.00 Aldosterone 1.0000 Each 254.00 203.2000 38.71 254.00 Alpha-1-antitrypsin; total 1.0000 each 46.00 36.8000 12.77 46.00 Alpha-fetoprotein (AFP); serum 1.0000 each 130.00 104.0000 15.93 130.00 Alpha-fetoprotein (AFP); amniotic fluid 1.0000 each 103.45 82.7600 16.15 103.45 Ammonia 1.0000 Each 128.00 102.4000 13.84 128.00 Amniotic fluid scan (spectrophotometric) 1.0000 each 59.35 47.4800 8.88 59.35 Amylase 1.0000 Each 84.00 67.2000 6.16 84.00 Androstenedione 1.0000 each 112.10 89.6800 27.82 112.10 Angiotensin I - converting enzyme (ACE) 1.0000 each 59.00 47.2000 13.87 59.00 Apolipoprotein, each 1.0000 Each 130.00 104.0000 20.04 130.00 Arsenic 1.0000 each 66.00 52.8000 18.02 66.00 Beta-2 microglobulin 1.0000 each 70.00 56.0000 15.37 70.00 Bile acids; total 1.0000 each 56.00 44.8000 16.26 56.00 Bilirubin; total 1.0000 Each 100.00 80.0000 4.77 100.00 Bilirubin; direct 1.0000 Each 100.00 80.0000 4.77 100.00 Blood, occult, by peroxidase activity (eg, guaiac), qualitative; other sources 1.0000 each 38.00 30.4000 5.05 38.00 Blood, occult, by peroxidase activity (eg, guaiac), qualitative, feces, 1-3 simultaneous determinations, performed for other than colorectal neoplasm screening 1.0000 each 32.00 25.6000 4.02 32.00 Cadmium 1.0000 each 81.00 64.8000 22.46 81.00 Vitamin D; 25 hydroxy, includes fraction(s), if performed 1.0000 Each 222.00 177.6000 28.12 222.00 Calcitonin 1.0000 each 121.85 97.4800 25.45 121.85 Calcium; total 1.0000 Each 100.00 80.0000 4.90 100.00 Calcium; ionized 1.0000 Each 55.00 44.0000 13.00 55.00 Calculus; quantitative analysis, chemical 1.0000 each 88.00 70.4000 12.23 88.00 Carbon dioxide (bicarbonate) 1.0000 Each 23.00 18.4000 4.64 23.00 Carboxyhemoglobin; quantitative 1.0000 Each 46.00 36.8000 11.70 46.00 Carcinoembryonic antigen (CEA) 1.0000 each 108.00 86.4000 18.01 108.00 Catecholamines; fractionated 1.0000 each 93.00 74.4000 23.99 93.00 Ceruloplasmin 1.0000 each 39.00 31.2000 10.20 39.00 Chloride; blood 1.0000 Each 29.00 23.2000 4.37 29.00 Chloride; urine 1.0000 each 22.50 18.0000 5.46 22.50 Chloride; other source 1.0000 each 76.00 60.8000 4.75 76.00 Cholesterol, serum or whole blood, total 1.0000 each 26.00 20.8000 4.13 26.00 Chromium 1.0000 each 73.00 58.4000 19.27 73.00 Copper 1.0000 each 78.00 62.4000 11.79 78.00 Cortisol; free 1.0000 Each 62.00 49.6000 15.87 62.00 Cortisol; total 1.0000 Each 164.00 131.2000 15.48 164.00 Creatine kinase (CK), (CPK); total 1.0000 Each 68.00 54.4000 6.18 68.00 Creatine kinase (CK), (CPK); isoenzymes 1.0000 each 85.90 68.7200 12.72 85.90 Creatine kinase (CK), (CPK); MB fraction only 1.0000 Each 108.00 86.4000 10.97 108.00 Creatinine; blood 1.0000 Each 74.00 59.2000 4.86 74.00 Creatinine; other source 1.0000 Each 44.00 35.2000 4.92 44.00 Creatinine; clearance 1.0000 each 52.95 42.3600 8.99 52.95 Cryoglobulin, qualitative or semi-quantitative (eg, cryocrit) 1.0000 each 23.00 18.4000 6.15 23.00 Cyanocobalamin (Vitamin B-12) 1.0000 Each 118.00 94.4000 14.33 118.00 Dehydroepiandrosterone (DHEA) 1.0000 each 158.00 126.4000 24.01 158.00 Dehydroepiandrosterone-sulfate (DHEA-S) 1.0000 each 152.00 121.6000 21.12 152.00 Dibucaine number 1.0000 each 60.95 48.7600 11.64 60.95 Erythropoietin 1.0000 each 76.00 60.8000 17.85 76.00 Estradiol; total 1.0000 each 162.00 129.6000 26.54 162.00 Estrogens; total 1.0000 each 135.00 108.0000 20.62 135.00 Estriol 1.0000 each 175.00 140.0000 22.97 175.00 Estrone 1.0000 each 83.00 66.4000 23.70 83.00 Fat or lipids, feces; qualitative 1.0000 each 22.00 17.6000 4.84 22.00 Ferritin 1.0000 each 93.00 74.4000 12.95 93.00 Folic acid; serum 1.0000 Each 100.00 80.0000 13.96 100.00 Folic acid; RBC 1.0000 each 56.00 44.8000 16.77 56.00 Gammaglobulin (immunoglobulin); IgA, IgD, IgG, IgM, each 1.0000 Each 38.00 30.4000 8.84 38.00 Gammaglobulin (immunoglobulin); IgE 1.0000 each 61.00 48.8000 15.64 61.00 Gases, blood, any combination of pH, pCO2, pO2, CO2, HCO3 (including calculated O2 saturation) 1.0000 Each 238.00 190.4000 24.77 238.00 Gastrin 1.0000 each 93.00 74.4000 16.75 93.00 Glucose, body fluid, other than blood 1.0000 each 22.00 17.6000 3.73 22.00 Glucose; quantitative, blood (except reagent strip) 1.0000 Each 35.00 28.0000 3.73 35.00 Glucose; tolerance test (GTT), 3 specimens (includes glucose) 1.0000 each 88.00 70.4000 12.23 88.00 Glucose; tolerance test, each additional beyond 3 specimens (List separately in addition to code for primary procedure) 1.0000 Each 21.00 16.8000 3.72 21.00 Glucose-6-phosphate dehydrogenase (G6PD); quantitative 1.0000 each 16.00 12.8000 9.22 16.00 Glutamyltransferase, gamma (GGT) 1.0000 each 50.00 40.0000 6.84 50.00 Gonadotropin; follicle stimulating hormone (FSH) 1.0000 each 127.00 101.6000 17.65 127.00 Gonadotropin; luteinizing hormone (LH) 1.0000 each 129.00 103.2000 17.59 129.00 Growth hormone, human (HGH) (somatotropin) 1.0000 each 58.40 46.7200 15.84 58.40 Haptoglobin; quantitative 1.0000 Each 61.00 48.8000 11.95 61.00 Helicobacter pylori; breath test analysis for urease activity, non-radioactive isotope (eg, C-13) 1.0000 each 379.00 303.2000 63.99 379.00 Heavy metal (eg, arsenic, barium, beryllium, bismuth, antimony, mercury); quantitative, each, not elsewhere specified 1.0000 Each 187.00 149.6000 20.86 187.00 Hemoglobin fractionation and quantitation; electrophoresis (eg, A2, S, C, and/or F) 1.0000 each 48.15 38.5200 12.23 48.15 Hemoglobin fractionation and quantitation; chromatography (eg, A2, S, C, and/or F) 1.0000 each 79.00 63.2000 17.16 79.00 Hemoglobin; glycosylated (A1C) 1.0000 Each 105.00 84.0000 9.22 105.00 Homocysteine 1.0000 each 188.00 150.4000 17.02 188.00 Hydroxycorticosteroids, 17- (17-OHCS) 1.0000 each 151.90 121.5200 17.00 151.90 Hydroxyindolacetic acid, 5-(HIAA) 1.0000 each 95.00 76.0000 12.26 95.00 Immunoassay for analyte other than infectious agent antibody or infectious agent antigen; qualitative or semiquantitative, multiple step method 1.0000 Each 49.00 39.2000 10.95 49.00 Immunoassay for analyte other than infectious agent antibody or infectious agent antigen; quantitative, not otherwise specified 1.0000 Each 48.00 38.4000 16.41 48.00 Insulin; total 1.0000 each 47.00 37.6000 10.86 47.00 Iron 1.0000 Each 105.00 84.0000 6.15 105.00 Iron binding capacity 1.0000 each 60.00 48.0000 8.30 60.00 Ketosteroids, 17- (17-KS); total 1.0000 each 124.00 99.2000 12.16 124.00 Lactate (lactic acid) 1.0000 Each 105.00 84.0000 10.99 105.00 Lactate dehydrogenase (LD), (LDH) 1.0000 Each 42.00 33.6000 5.74 42.00 Lactate dehydrogenase (LD), (LDH); isoenzymes, separation and quantitation 1.0000 each 69.00 55.2000 12.15 69.00 Lactoferrin, fecal; qualitative 1.0000 each 70.00 56.0000 18.72 70.00 Lead 1.0000 each 123.00 98.4000 11.50 123.00 Fetal lung maturity assessment; lecithin sphingomyelin (L/S) ratio 1.0000 each 129.00 103.2000 20.89 129.00 Fetal lung maturity assessment; foam stability test 1.0000 each 94.15 75.3200 17.96 94.15 Fetal lung maturity assessment; lamellar body density 1.0000 each 43.30 34.6400 18.35 43.30 Lipase 1.0000 Each 113.00 90.4000 6.55 113.00 Lipoprotein (a) 1.0000 each 57.25 45.8000 13.60 57.25 Lipoprotein, blood; quantitation of lipoprotein particle number(s) (eg, by nuclear magnetic resonance spectroscopy), includes lipoprotein particle subclass(es), when performed 1.0000 each 150.00 120.0000 32.48 150.00 Lipoprotein, direct measurement; high density cholesterol (HDL cholesterol) 1.0000 each 31.40 25.1200 7.78 31.40 Lipoprotein, direct measurement; LDL cholesterol 1.0000 each 105.00 84.0000 9.98 105.00 Magnesium 1.0000 Each 134.00 107.2000 6.36 134.00 Mercury, quantitative 1.0000 each 57.00 45.6000 15.45 57.00 Metanephrines 1.0000 each 138.00 110.4000 16.09 138.00 Myelin basic protein, cerebrospinal fluid 1.0000 each 70.00 56.0000 16.34 70.00 Myoglobin 1.0000 Each 54.00 43.2000 12.27 54.00 Natriuretic peptide 1.0000 Each 244.00 195.2000 37.30 244.00 Nephelometry, each analyte not elsewhere specified 1.0000 Each 159.00 127.2000 12.92 159.00 Organic acid, single, quantitative 1.0000 each 79.00 63.2000 20.15 79.00 Osmolality; blood 1.0000 Each 34.00 27.2000 6.28 34.00 Osmolality; urine 1.0000 Each 40.00 32.0000 6.48 40.00 Parathormone (parathyroid hormone) 1.0000 Each 281.00 224.8000 39.22 281.00 pH; body fluid, not otherwise specified 1.0000 each 17.90 14.3200 3.40 17.90 Calprotectin, fecal 1.0000 each 398.00 318.4000 18.65 398.00 Phenylalanine (PKU), blood 1.0000 each 21.15 16.9200 5.22 21.15 Phosphatase, acid; total 1.0000 each 46.40 37.1200 7.26 46.40 Phosphatase, acid; prostatic 1.0000 each 50.30 40.2400 9.18 50.30 Phosphatase, alkaline 1.0000 Each 24.00 19.2000 4.92 24.00 Phosphatidylglycerol 1.0000 each 136.40 109.1200 15.69 136.40 Phosphorus inorganic (phosphate) 1.0000 Each 66.00 52.8000 4.50 66.00 Potassium; serum, plasma or whole blood 1.0000 Each 39.00 31.2000 4.52 39.00 Potassium; urine 1.0000 Each 24.00 19.2000 4.49 24.00 Prealbumin 1.0000 each 88.00 70.4000 13.86 88.00 Pregnenolone 1.0000 each 71.00 56.8000 19.64 71.00 Progesterone 1.0000 each 142.00 113.6000 19.82 142.00 Procalcitonin (PCT) 1.0000 each 150.00 120.0000 25.86 150.00 Prolactin 1.0000 each 200.00 160.0000 18.41 200.00 Prostate specific antigen (PSA); total 1.0000 Each 210.00 168.0000 17.47 210.00 Prostate specific antigen (PSA); free 1.0000 each 109.00 87.2000 17.47 109.00 Protein, total, except by refractometry; serum, plasma or whole blood 1.0000 Each 51.00 40.8000 3.49 51.00 Protein, total, except by refractometry; urine 1.0000 Each 48.00 38.4000 3.49 48.00 Protein, total, except by refractometry; other source (eg, synovial fluid, cerebrospinal fluid) 1.0000 each 24.00 19.2000 3.80 24.00 Protein; electrophoretic fractionation and quantitation, serum 1.0000 Each 103.00 82.4000 10.20 103.00 Protein; electrophoretic fractionation and quantitation, other fluids with concentration (eg, urine, CSF) 1.0000 Each 72.00 57.6000 16.94 72.00 Protoporphyrin, RBC; quantitative 1.0000 each 71.45 57.1600 13.63 71.45 Pyridoxal phosphate (Vitamin B-6) 1.0000 each 96.00 76.8000 26.70 96.00 Receptor assay; estrogen 1.0000 each 320.35 256.2800 83.49 320.35 Renin 1.0000 each 248.00 198.4000 20.89 248.00 Sex hormone binding globulin (SHBG) 1.0000 each 72.00 57.6000 20.64 72.00 Sodium; serum, plasma or whole blood 1.0000 Each 39.00 31.2000 4.57 39.00 Sodium; urine 1.0000 Each 39.00 31.2000 4.81 39.00 Sodium; other source 1.0000 each 76.00 60.8000 4.62 76.00 Somatomedin 1.0000 each 48.55 38.8400 20.20 48.55 Specific gravity (except urine) 1.0000 each 12.55 10.0400 3.12 12.55 Sugars (mono-, di-, and oligosaccharides); multiple qualitative, each specimen 1.0000 Each 25.10 20.0800 5.22 25.10 Testosterone; free 1.0000 each 168.00 134.4000 24.20 168.00 Testosterone; total 1.0000 Each 186.00 148.8000 24.52 186.00 Thiamine (Vitamin B-1) 1.0000 each 102.00 81.6000 20.17 102.00 Thyroglobulin 1.0000 each 60.00 48.0000 15.26 60.00 Thyroxine; total 1.0000 each 39.50 31.6000 6.53 39.50 Thyroxine; free 1.0000 Each 243.00 194.4000 8.57 243.00 Thyroxine binding globulin (TBG) 1.0000 each 71.00 56.8000 14.04 71.00 Thyroid stimulating hormone (TSH) 1.0000 Each 329.00 263.2000 15.96 329.00 Thyroid stimulating immune globulins (TSI) 1.0000 each 174.00 139.2000 48.32 174.00 Tocopherol alpha (Vitamin E) 1.0000 each 62.00 49.6000 13.47 62.00 Transferase; aspartate amino (AST) (SGOT) 1.0000 each 100.00 80.0000 4.92 100.00 Transferase; alanine amino (ALT) (SGPT) 1.0000 each 38.00 30.4000 5.04 38.00 Transferrin 1.0000 each 52.00 41.6000 12.12 52.00 Triglycerides 1.0000 each 26.00 20.8000 5.45 26.00 Thyroid hormone (T3 or T4) uptake or thyroid hormone binding ratio (THBR) 1.0000 each 41.00 32.8000 6.15 41.00 Triiodothyronine T3; total (TT-3) 1.0000 each 70.55 56.4400 13.47 70.55 Triiodothyronine T3; free 1.0000 each 295.00 236.0000 16.09 295.00 Troponin, quantitative 1.0000 Each 365.00 292.0000 11.85 365.00 Urea nitrogen; quantitative 1.0000 Each 100.00 80.0000 3.75 100.00 Urea nitrogen, urine 1.0000 Each 21.00 16.8000 5.28 21.00 Uric acid; blood 1.0000 Each 46.00 36.8000 4.29 46.00 Uric acid; other source 1.0000 each 27.90 22.3200 4.83 27.90 Vanillylmandelic acid (VMA), urine 1.0000 each 50.35 40.2800 14.72 50.35 Vasopressin (antidiuretic hormone, ADH) 1.0000 each 110.25 88.2000 32.24 110.25 Vitamin A 1.0000 each 39.00 31.2000 11.03 39.00 Vitamin K 1.0000 each 425.00 340.0000 13.03 425.00 Volatiles (eg, acetic anhydride, diethylether) 1.0000 each 74.35 59.4800 16.25 74.35 Zinc 1.0000 each 71.00 56.8000 10.82 71.00 C-peptide 1.0000 each 56.00 44.8000 19.77 56.00 Gonadotropin, chorionic (hCG); quantitative 1.0000 Each 190.00 152.0000 14.30 190.00 Gonadotropin, chorionic (hCG); qualitative 1.0000 Each 79.00 63.2000 7.14 79.00 Unlisted chemistry procedure 1.0000 Each 109.00 87.2000 67.47 109.00 Bleeding time 1.0000 each 52.95 42.3600 4.58 52.95 Blood count; blood smear, microscopic examination with manual differential WBC count 1.0000 Each 30.00 24.0000 3.61 30.00 Blood count; blood smear, microscopic examination without manual differential WBC count 1.0000 each 24.05 19.2400 3.26 24.05 Blood count; hematocrit (Hct) 1.0000 Each 12.00 9.6000 2.25 12.00 Blood count; complete (CBC), automated (Hgb, Hct, RBC, WBC and platelet count) and automated differential WBC count 1.0000 Each 275.00 220.0000 7.38 275.00 Blood count; complete (CBC), automated (Hgb, Hct, RBC, WBC and platelet count) 1.0000 Each 263.00 210.4000 6.15 263.00 Blood count; manual cell count (erythrocyte, leukocyte, or platelet) each 1.0000 Each 16.00 12.8000 4.09 16.00 Blood count; red blood cell (RBC), automated 1.0000 Each 14.00 11.2000 2.87 14.00 Blood count; reticulocyte, manual 1.0000 each 60.00 48.0000 4.09 60.00 Blood smear, peripheral, interpretation by physician with written report 1.0000 each 16.00 12.8000 9.90 16.00 Bone marrow, smear interpretation 1.0000 Each 116.60 93.2800 72.18 782.96 Clot retraction 1.0000 each 36.35 29.0800 15.48 36.35 Clotting; factor II, prothrombin, specific 1.0000 each 254.00 203.2000 12.33 254.00 Clotting; factor VIII (AHG), 1-stage 1.0000 each 154.00 123.2000 17.00 154.00 Clotting; factor VIII related antigen 1.0000 each 426.90 341.5200 19.40 426.90 Clotting; factor VIII, VW factor, ristocetin cofactor 1.0000 each 127.00 101.6000 21.79 127.00 Clotting; factor IX (PTC or Christmas) 1.0000 each 189.65 151.7200 18.09 189.65 Clotting inhibitors or anticoagulants; antithrombin III, activity 1.0000 each 98.00 78.4000 11.26 98.00 Clotting inhibitors or anticoagulants; protein C, antigen 1.0000 each 91.00 72.8000 11.41 91.00 Clotting inhibitors or anticoagulants; protein C, activity 1.0000 each 62.00 49.6000 13.15 62.00 Clotting inhibitors or anticoagulants; protein S, total 1.0000 each 51.00 40.8000 11.03 51.00 Clotting inhibitors or anticoagulants; protein S, free 1.0000 Each 86.00 68.8000 14.55 86.00 Fibrin degradation products, D-dimer; quantitative 1.0000 Each 100.00 80.0000 9.67 100.00 Fibrinogen; activity 1.0000 Each 72.00 57.6000 9.23 72.00 Hemoglobin or RBCs, fetal, for fetomaternal hemorrhage; differential lysis (Kleihauer-Betke) 1.0000 each 37.60 30.0800 7.34 37.60 Hemoglobin or RBCs, fetal, for fetomaternal hemorrhage; rosette 1.0000 each 42.00 33.6000 8.89 42.00 Heparin assay 1.0000 each 131.00 104.8000 12.44 131.00 Phospholipid neutralization; hexagonal phospholipid 1.0000 each 179.43 143.5400 17.08 179.43 Prothrombin time 1.0000 Each 42.00 33.6000 4.08 42.00 Prothrombin time; substitution, plasma fractions, each 1.0000 Each 30.75 24.6000 3.74 30.75 Russell viper venom time (includes venom); diluted 1.0000 each 171.00 136.8000 9.10 171.00 Sedimentation rate, erythrocyte; automated 1.0000 each 36.00 28.8000 2.56 36.00 Sickling of RBC, reduction 1.0000 each 28.00 22.4000 5.23 28.00 Thromboplastin time, partial (PTT); plasma or whole blood 1.0000 Each 84.00 67.2000 5.71 84.00 Thromboplastin time, partial (PTT); substitution, plasma fractions, each 1.0000 Each 50.00 40.0000 6.15 50.00 Allergen specific IgE; quantitative or semiquantitative, crude allergen extract, each 1.0000 Each 27.00 21.6000 4.96 27.00 Allergen specific IgE; qualitative, multiallergen screen (eg, disk, sponge, card) 1.0000 each 28.00 22.4000 7.57 28.00 Antibody identification; platelet antibodies 1.0000 Each 210.00 168.0000 17.45 210.00 Antinuclear antibodies (ANA) 1.0000 each 128.00 102.4000 11.49 128.00 Antistreptolysin 0; titer 1.0000 each 39.00 31.2000 6.94 39.00 Blood bank physician services; investigation of transfusion reaction including suspicion of transmissible disease, interpretation and written report 1.0000 each 250.00 200.0000 146.24 250.00 C-reactive protein 1.0000 each 57.00 45.6000 4.92 57.00 C-reactive protein; high sensitivity (hsCRP) 1.0000 each 47.00 37.6000 12.30 47.00 Beta 2 Glycoprotein I antibody, each 1.0000 Each 50.00 40.0000 24.18 50.00 Cardiolipin (phospholipid) antibody, each Ig class 1.0000 Each 99.00 79.2000 24.18 99.00 Cold agglutinin; titer 1.0000 each 38.85 31.0800 7.66 38.85 Complement; antigen, each component 1.0000 Each 82.00 65.6000 11.40 82.00 Complement; total hemolytic (CH50) 1.0000 each 84.00 67.2000 19.30 84.00 Complement fixation tests, each antigen 1.0000 Each 49.90 39.9200 9.51 49.90 Cyclic citrullinated peptide (CCP), antibody 1.0000 each 89.00 71.2000 12.30 89.00 Deoxyribonuclease, antibody 1.0000 each 58.00 46.4000 12.59 58.00 Deoxyribonucleic acid (DNA) antibody; native or double stranded 1.0000 each 100.00 80.0000 13.05 100.00 Extractable nuclear antigen, antibody to, any method (eg, nRNP, SS-A, SS-B, Sm, RNP, Sc170, J01), each antibody 1.0000 Each 122.00 97.6000 17.03 122.00 Fluorescent noninfectious agent antibody; screen, each antibody 1.0000 Each 42.00 33.6000 11.45 42.00 Fluorescent noninfectious agent antibody; titer, each antibody 1.0000 Each 45.00 36.0000 11.45 45.00 Immunoassay for tumor antigen, quantitative; CA 15-3 (27.29) 1.0000 Each 79.70 63.7600 19.77 79.70 Immunoassay for tumor antigen, quantitative; CA 19-9 1.0000 each 84.00 67.2000 19.77 84.00 Immunoassay for tumor antigen, quantitative; CA 125 1.0000 each 142.00 113.6000 19.77 142.00 Heterophile antibodies; screening 1.0000 each 56.00 44.8000 4.92 56.00 Immunoassay for tumor antigen, other antigen, quantitative (eg, CA 50, 72-4, 549), each 1.0000 Each 141.85 113.4800 19.77 141.85 Immunofixation electrophoresis; serum 1.0000 Each 213.00 170.4000 21.22 213.00 Immunofixation electrophoresis; other fluids with concentration (eg, urine, CSF) 1.0000 Each 108.00 86.4000 27.88 108.00 Inhibin A 1.0000 each 147.00 117.6000 14.81 147.00 T cells; absolute CD4 and CD8 count, including ratio 1.0000 Each 198.36 158.6900 44.63 198.36 T cells; absolute CD4 count 1.0000 each 92.00 73.6000 25.44 92.00 Microsomal antibodies (eg, thyroid or liver-kidney), each 1.0000 Each 52.00 41.6000 13.82 52.00 Particle agglutination; screen, each antibody 1.0000 Each 50.80 40.6400 10.96 50.80 Rheumatoid factor; quantitative 1.0000 each 54.00 43.2000 5.39 54.00 Tuberculosis test, cell mediated immunity antigen response measurement; gamma interferon 1.0000 each 347.00 277.6000 58.88 347.00 Skin test; tuberculosis, intradermal 1.0000 each 67.00 53.6000 23.21 67.00 Syphilis test, non-treponemal antibody; qualitative (eg, VDRL, RPR, ART) 1.0000 Each 56.00 44.8000 4.06 56.00 Syphilis test, non-treponemal antibody; quantitative 1.0000 each 38.85 31.0800 4.18 38.85 Antibody; Aspergillus 1.0000 Each 63.55 50.8400 14.30 63.55 Antibody; Blastomyces 1.0000 Each 63.55 50.8400 12.26 63.55 Antibody; Borrelia burgdorferi (Lyme disease) confirmatory test (eg, Western Blot or immunoblot) 1.0000 Each 80.00 64.0000 14.72 80.00 Antibody; Borrelia burgdorferi (Lyme disease) 1.0000 each 109.00 87.2000 16.18 109.00 Antibody; Coccidioides 1.0000 Each 57.15 45.7200 10.90 57.15 Antibody; cytomegalovirus (CMV) 1.0000 Each 43.00 34.4000 13.67 43.00 Antibody; cytomegalovirus (CMV), IgM 1.0000 each 80.00 64.0000 16.01 80.00 Antibody; Epstein-Barr (EB) virus, early antigen (EA) 1.0000 each 52.00 41.6000 12.46 52.00 Antibody; Epstein-Barr (EB) virus, nuclear antigen (EBNA) 1.0000 each 57.00 45.6000 14.53 57.00 Antibody; Epstein-Barr (EB) virus, viral capsid (VCA) 1.0000 Each 64.00 51.2000 17.23 64.00 Antibody; Ehrlichia 1.0000 Each 51.00 40.8000 9.67 51.00 Antibody; fungus, not elsewhere specified 1.0000 each 279.70 223.7600 11.64 279.70 Antibody; Helicobacter pylori 1.0000 each 154.00 123.2000 16.01 154.00 Antibody; HTLV or HIV antibody, confirmatory test (eg, Western Blot) 1.0000 each 150.60 120.4800 18.38 150.60 Antibody; herpes simplex, non-specific type test 1.0000 each 90.00 72.0000 13.67 90.00 Antibody; herpes simplex, type 1 1.0000 Each 91.00 72.8000 12.53 91.00 Antibody; herpes simplex, type 2 1.0000 Each 128.00 102.4000 18.38 128.00 Antibody; histoplasma 1.0000 Each 62.25 49.8000 13.10 62.25 Antibody; HIV-1 1.0000 each 54.00 43.2000 8.45 54.00 Antibody; HIV-2 1.0000 each 53.00 42.4000 12.84 53.00 Antibody; HIV-1 and HIV-2, single result 1.0000 Each 70.00 56.0000 13.02 70.00 Hepatitis B core antibody (HBcAb); total 1.0000 Each 122.00 97.6000 11.45 122.00 Hepatitis B core antibody (HBcAb); IgM antibody 1.0000 each 122.00 97.6000 11.18 122.00 Hepatitis B surface antibody (HBsAb) 1.0000 Each 91.00 72.8000 10.20 91.00 Hepatitis Be antibody (HBeAb) 1.0000 each 73.00 58.4000 10.99 73.00 Hepatitis A antibody (HAAb) 1.0000 each 57.00 45.6000 11.77 57.00 Hepatitis A antibody (HAAb), IgM antibody 1.0000 each 66.00 52.8000 10.70 66.00 Antibody; Legionella 1.0000 each 101.00 80.8000 14.54 101.00 Antibody; mumps 1.0000 each 53.00 42.4000 12.40 53.00 Antibody; parvovirus 1.0000 Each 50.85 40.6800 14.28 50.85 Antibody; protozoa, not elsewhere specified 1.0000 each 133.50 106.8000 11.77 133.50 Antibody; Rickettsia 1.0000 Each 155.00 124.0000 18.38 155.00 Antibody; rubella 1.0000 each 98.00 78.4000 13.67 98.00 Antibody; rubeola 1.0000 Each 50.00 40.0000 12.24 50.00 Antibody; severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (Coronavirus disease [COVID-19]) 1.0000 each 62.00 49.6000 38.38 62.00 Antibody; Toxoplasma 1.0000 each 112.90 90.3200 13.67 112.90 Antibody; Toxoplasma, IgM 1.0000 each 62.05 49.6400 13.69 62.05 Antibody; Treponema pallidum 1.0000 Each 74.00 59.2000 12.58 74.00 Antibody; varicella-zoster 1.0000 Each 52.00 41.6000 12.24 52.00 Antibody; virus, not elsewhere specified 1.0000 each 54.48 43.5800 12.24 54.48 Thyroglobulin antibody 1.0000 Each 59.00 47.2000 15.11 59.00 Hepatitis C antibody 1.0000 Each 167.00 133.6000 13.56 167.00 Hepatitis C antibody; confirmatory test (eg, immunoblot) 1.0000 each 305.00 244.0000 14.72 305.00 Antibody screen, RBC, each serum technique 1.0000 Each 64.00 51.2000 39.62 64.00 Antibody elution (RBC), each elution 1.0000 Each 239.75 191.8000 146.24 239.75 Antibody identification, RBC antibodies, each panel for each serum technique 1.0000 Each 73.00 58.4000 45.19 326.80 Antihuman globulin test (Coombs test); direct, each antiserum 1.0000 Each 100.00 80.0000 53.46 100.00 Antihuman globulin test (Coombs test); indirect, qualitative, each reagent red cell 1.0000 Each 36.00 28.8000 22.28 158.56 Autologous blood or component, collection processing and storage; predeposited 1.0000 each 373.90 299.1200 146.24 373.90 Blood typing, serologic; ABO 1.0000 Each 100.00 80.0000 61.90 117.07 Blood typing, serologic; Rh (D) 1.0000 Each 100.00 80.0000 31.58 100.00 Blood typing, serologic; antigen testing of donor blood using reagent serum, each antigen test 1.0000 Each 114.00 91.2000 70.57 326.80 Blood typing, serologic; RBC antigens, other than ABO or Rh (D), each 1.0000 Each 46.00 36.8000 28.47 326.80 Blood typing, serologic; Rh phenotyping, complete 1.0000 each 173.10 138.4800 31.58 173.10 Compatibility test each unit; immediate spin technique 1.0000 Unit(s) 101.00 80.8000 62.52 158.56 Fresh frozen plasma, thawing, each unit 1.0000 Unit(s) 38.00 30.4000 23.52 158.56 Hemolysins and agglutinins; incubated 1.0000 each 128.00 102.4000 11.50 128.00 Pooling of platelets or other blood products 1.0000 each 73.85 59.0800 45.71 158.56 Pretreatment of RBCs for use in RBC antibody detection, identification, and/or compatibility testing; incubation with enzymes, each 1.0000 Each 46.25 37.0000 28.63 326.80 Pretreatment of serum for use in RBC antibody identification; incubation with drugs, each 1.0000 Each 73.85 59.0800 45.71 380.71 Concentration (any type), for infectious agents 1.0000 Each 29.00 23.2000 6.35 29.00 Culture, bacterial; blood, aerobic, with isolation and presumptive identification of isolates (includes anaerobic culture, if appropriate) 1.0000 Each 118.00 94.4000 9.80 118.00 Culture, bacterial; stool, aerobic, with isolation and preliminary examination (eg, KIA, LIA), Salmonella and Shigella species 1.0000 Each 65.00 52.0000 8.97 65.00 Culture, bacterial; stool, aerobic, additional pathogens, isolation and presumptive identification of isolates, each plate 1.0000 Each 65.00 52.0000 8.97 65.00 Culture, bacterial; any other source except urine, blood or stool, aerobic, with isolation and presumptive identification of isolates 1.0000 Each 42.90 34.3200 8.19 42.90 Culture, bacterial; quantitative, aerobic with isolation and presumptive identification of isolates, any source except urine, blood or stool 1.0000 Each 65.00 52.0000 9.40 65.00 Culture, bacterial; any source, except blood, anaerobic with isolation and presumptive identification of isolates 1.0000 Each 65.00 52.0000 9.00 65.00 Culture, bacterial; aerobic isolate, additional methods required for definitive identification, each isolate 1.0000 Each 55.00 44.0000 7.68 55.00 Culture, presumptive, pathogenic organisms, screening only 1.0000 Each 47.00 37.6000 6.30 47.00 Culture, bacterial; with isolation and presumptive identification of each isolate, urine 1.0000 Each 132.00 105.6000 7.69 132.00 Culture, fungi (mold or yeast) isolation, with presumptive identification of isolates; skin, hair, or nail 1.0000 Each 32.00 25.6000 7.32 32.00 Culture, fungi (mold or yeast) isolation, with presumptive identification of isolates; blood 1.0000 Each 54.00 43.2000 19.44 54.00 Culture, mycoplasma, any source 1.0000 each 119.70 95.7600 14.62 119.70 Culture, chlamydia, any source 1.0000 each 89.15 71.3200 18.62 89.15 Culture, tubercle or other acid-fast bacilli (eg, TB, AFB, mycobacteria) any source, with isolation and presumptive identification of isolates 1.0000 Each 41.45 33.1600 10.26 41.45 Culture, typing; immunofluorescent method, each antiserum 1.0000 Each 25.40 20.3200 5.29 25.40 Culture, typing; immunologic method, other than immunofluorescence (eg, agglutination grouping), per antiserum 1.0000 Each 49.00 39.2000 4.92 49.00 Macroscopic examination; arthropod 1.0000 each 135.45 108.3600 4.06 135.45 Homogenization, tissue, for culture 1.0000 each 39.00 31.2000 5.59 39.00 Ova and parasites, direct smears, concentration and identification 1.0000 each 61.00 48.8000 8.46 61.00 Susceptibility studies, antimicrobial agent; agar dilution method, per agent (eg, antibiotic gradient strip) 1.0000 Each 47.50 38.0000 4.51 47.50 Susceptibility studies, antimicrobial agent; disk method, per plate (12 or fewer agents) 1.0000 Each 53.10 42.4800 7.11 53.10 Susceptibility studies, antimicrobial agent; enzyme detection (eg, beta lactamase), per enzyme 1.0000 each 206.00 164.8000 4.51 206.00 Susceptibility studies, antimicrobial agent; microdilution or agar dilution (minimum inhibitory concentration [MIC] or breakpoint), each multi-antimicrobial, per plate 1.0000 Each 103.00 82.4000 8.22 103.00 Smear, primary source with interpretation; Gram or Giemsa stain for bacteria, fungi, or cell types 1.0000 Each 37.00 29.6000 4.06 37.00 Smear, primary source with interpretation; fluorescent and/or acid fast stain for bacteria, fungi, parasites, viruses or cell types 1.0000 Each 22.00 17.6000 5.12 22.00 Smear, primary source with interpretation; special stain for inclusion bodies or parasites (eg, malaria, coccidia, microsporidia, trypanosomes, herpes viruses) 1.0000 Each 104.22 83.3800 5.69 104.22 Smear, primary source with interpretation; complex special stain (eg, trichrome, iron hemotoxylin) for ova and parasites 1.0000 each 123.00 98.4000 17.08 123.00 Smear, primary source with interpretation; wet mount for infectious agents (eg, saline, India ink, KOH preps) 1.0000 each 22.00 17.6000 5.53 22.00 Tissue examination by KOH slide of samples from skin, hair, or nails for fungi or ectoparasite ova or mites (eg, scabies) 1.0000 each 18.95 15.1600 4.06 18.95 Toxin or antitoxin assay, tissue culture (eg, Clostridium difficile toxin) 1.0000 each 98.30 78.6400 18.75 98.30 Virus isolation; tissue culture inoculation, observation, and presumptive identification by cytopathic effect 1.0000 Each 307.00 245.6000 24.77 307.00 Virus isolation; tissue culture, additional studies or definitive identification (eg, hemabsorption, neutralization, immunofluorescence stain), each isolate 1.0000 Each 271.50 217.2000 19.19 271.50 Virus isolation; centrifuge enhanced (shell vial) technique, includes identification with immunofluorescence stain, each virus 1.0000 Each 63.40 50.7200 18.58 63.40 Infectious agent antigen detection by immunoassay technique (eg, enzyme immunoassay [EIA], enzyme-linked immunosorbent assay [ELISA], fluorescence immunoassay [FIA], immunochemiluminometric assay [IMCA]), qualitative or semiquantitative; Chlamydia trachomatis 1.0000 each 106.75 85.4000 14.25 106.75 Infectious agent antigen detection by immunoassay technique (eg, enzyme immunoassay [EIA], enzyme-linked immunosorbent assay [ELISA], fluorescence immunoassay [FIA], immunochemiluminometric assay [IMCA]), qualitative or semiquantitative; Clostridium difficile toxin(s) 1.0000 Each 49.15 39.3200 11.38 49.15 Infectious agent antigen detection by immunoassay technique (eg, enzyme immunoassay [EIA], enzyme-linked immunosorbent assay [ELISA], fluorescence immunoassay [FIA], immunochemiluminometric assay [IMCA]), qualitative or semiquantitative; cryptosporidium 1.0000 each 260.28 208.2200 13.13 260.28 Infectious agent antigen detection by immunoassay technique (eg, enzyme immunoassay [EIA], enzyme-linked immunosorbent assay [ELISA], fluorescence immunoassay [FIA], immunochemiluminometric assay [IMCA]), qualitative or semiquantitative; giardia 1.0000 each 40.00 32.0000 11.38 40.00 Infectious agent antigen detection by immunoassay technique (eg, enzyme immunoassay [EIA], enzyme-linked immunosorbent assay [ELISA], fluorescence immunoassay [FIA], immunochemiluminometric assay [IMCA]), qualitative or semiquantitative; Helicobacter pylori, stool 1.0000 each 81.00 64.8000 13.66 81.00 Infectious agent antigen detection by immunoassay technique (eg, enzyme immunoassay [EIA], enzyme-linked immunosorbent assay [ELISA], fluorescence immunoassay [FIA], immunochemiluminometric assay [IMCA]), qualitative or semiquantitative; hepatitis B surface antigen (HBsAg) 1.0000 Each 71.00 56.8000 9.81 71.00 Infectious agent antigen detection by immunoassay technique (eg, enzyme immunoassay [EIA], enzyme-linked immunosorbent assay [ELISA], fluorescence immunoassay [FIA], immunochemiluminometric assay [IMCA]), qualitative or semiquantitative; hepatitis Be antigen (HBeAg) 1.0000 each 83.00 66.4000 10.95 83.00 Infectious agent antigen detection by immunoassay technique (eg, enzyme immunoassay [EIA], enzyme-linked immunosorbent assay [ELISA], fluorescence immunoassay [FIA], immunochemiluminometric assay [IMCA]), qualitative or semiquantitative; HIV-1 1.0000 each 104.00 83.2000 22.86 104.00 Infectious agent antigen detection by immunoassay technique (eg, enzyme immunoassay [EIA], enzyme-linked immunosorbent assay [ELISA], fluorescence immunoassay [FIA], immunochemiluminometric assay [IMCA]), qualitative or semiquantitative; rotavirus 1.0000 each 42.65 34.1200 11.38 42.65 Infectious agent antigen detection by immunoassay technique (eg, enzyme immunoassay [EIA], enzyme-linked immunosorbent assay [ELISA], fluorescence immunoassay [FIA], immunochemiluminometric assay [IMCA]), qualitative or semiquantitative; severe acute respiratory syndrome coronavirus (eg, SARS-CoV, SARS-CoV-2 [COVID-19]) 1.0000 each 108.00 86.4000 33.56 108.00 Infectious agent antigen detection by immunoassay technique (eg, enzyme immunoassay [EIA], enzyme-linked immunosorbent assay [ELISA], fluorescence immunoassay [FIA], immunochemiluminometric assay [IMCA]), qualitative or semiquantitative; severe acute respiratory syndrome coronavirus (eg, SARS-CoV, SARS-CoV-2 [COVID-19]) and influenza virus types A and B 1.0000 each 104.00 83.2000 64.38 104.00 Infectious agent antigen detection by immunoassay technique (eg, enzyme immunoassay [EIA], enzyme-linked immunosorbent assay [ELISA], fluorescence immunoassay [FIA], immunochemiluminometric assay [IMCA]), qualitative or semiquantitative; not otherwise specified, each organism 1.0000 Each 103.00 82.4000 11.38 103.00 Infectious agent detection by nucleic acid (DNA or RNA); Candida species, direct probe technique 1.0000 each 112.00 89.6000 19.05 112.00 Infectious agent detection by nucleic acid (DNA or RNA); Chlamydia trachomatis, direct probe technique 1.0000 each 99.85 79.8800 21.61 99.85 Infectious agent detection by nucleic acid (DNA or RNA); Chlamydia trachomatis, amplified probe technique 1.0000 Each 71.00 56.8000 33.34 71.00 Infectious agent detection by nucleic acid (DNA or RNA); Clostridium difficile, toxin gene(s), amplified probe technique 1.0000 each 142.00 113.6000 35.41 142.00 Infectious agent detection by nucleic acid (DNA or RNA); cytomegalovirus, amplified probe technique 1.0000 each 371.52 297.2200 33.34 371.52 Infectious agent detection by nucleic acid (DNA or RNA); cytomegalovirus, quantification 1.0000 Each 791.00 632.8000 40.70 791.00 Infectious agent detection by nucleic acid (DNA or RNA); influenza virus, for multiple types or sub-types, includes multiplex reverse transcription, when performed, and multiplex amplified probe technique, first 2 types or sub-types 1.0000 Each 338.00 270.4000 91.01 338.00 Infectious agent detection by nucleic acid (DNA or RNA); influenza virus, for multiple types or sub-types, includes multiplex reverse transcription, when performed, and multiplex amplified probe technique, each additional influenza virus type or sub-type beyond 2 (List separately in addition to code for primary procedure) 1.0000 Each 59.00 47.2000 27.76 59.00 Infectious agent detection by nucleic acid (DNA or RNA); gastrointestinal pathogen (eg, Clostridium difficile, E. coli, Salmonella, Shigella, norovirus, Giardia), includes multiplex reverse transcription, when performed, and multiplex amplified probe technique, multiple types or subtypes, 12-25 targets 1.0000 each 867.00 693.6000 395.94 867.00 Infectious agent detection by nucleic acid (DNA or RNA); Gardnerella vaginalis, direct probe technique 1.0000 each 112.00 89.6000 19.05 112.00 Infectious agent detection by nucleic acid (DNA or RNA); hepatitis B virus, quantification 1.0000 each 567.00 453.6000 40.70 567.00 Infectious agent detection by nucleic acid (DNA or RNA); hepatitis C, amplified probe technique, includes reverse transcription when performed 1.0000 each 334.00 267.2000 33.34 334.00 Infectious agent detection by nucleic acid (DNA or RNA); hepatitis C, quantification, includes reverse transcription when performed 1.0000 each 363.00 290.4000 40.70 363.00 Infectious agent detection by nucleic acid (DNA or RNA); HIV-1, amplified probe technique, includes reverse transcription when performed 1.0000 each 210.00 168.0000 33.34 210.00 Infectious agent detection by nucleic acid (DNA or RNA); Neisseria gonorrhoeae, direct probe technique 1.0000 each 99.85 79.8800 25.54 99.85 Infectious agent detection by nucleic acid (DNA or RNA); Neisseria gonorrhoeae, amplified probe technique 1.0000 each 71.00 56.8000 33.34 71.00 Infectious agent detection by nucleic acid (DNA or RNA); Human Papillomavirus (HPV), high-risk types (eg, 16, 18, 31, 33, 35, 39, 45, 51, 52, 56, 58, 59, 68) 1.0000 each 138.00 110.4000 33.34 138.00 Infectious agent detection by nucleic acid (DNA or RNA); Human Papillomavirus (HPV), types 16 and 18 only, includes type 45, if performed 1.0000 each 252.00 201.6000 38.52 252.00 Infectious agent detection by nucleic acid (DNA or RNA); severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (Coronavirus disease [COVID-19]), amplified probe technique 1.0000 each 168.00 134.4000 48.74 168.00 Infectious agent detection by nucleic acid (DNA or RNA); severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (Coronavirus disease [COVID-19]) and influenza virus types A and B, multiplex amplified probe technique 1.0000 each 204.00 163.2000 126.28 204.00 Infectious agent detection by nucleic acid (DNA or RNA); Staphylococcus aureus, amplified probe technique 1.0000 each 111.00 88.8000 33.34 111.00 Infectious agent detection by nucleic acid (DNA or RNA); Staphylococcus aureus, methicillin resistant, amplified probe technique 1.0000 each 111.00 88.8000 33.34 111.00 Infectious agent detection by nucleic acid (DNA or RNA); Streptococcus, group A, amplified probe technique 1.0000 each 137.00 109.6000 33.34 137.00 Infectious agent detection by nucleic acid (DNA or RNA); Trichomonas vaginalis, direct probe technique 1.0000 each 112.00 89.6000 19.05 112.00 Infectious agent detection by nucleic acid (DNA or RNA), not otherwise specified; amplified probe technique, each organism 1.0000 Each 153.30 122.6400 33.34 153.30 Infectious agent detection by nucleic acid (DNA or RNA), not otherwise specified; quantification, each organism 1.0000 Each 1245.00 996.0000 40.70 1245.00 Infectious agent detection by nucleic acid (DNA or RNA), multiple organisms; direct probe(s) technique 1.0000 each 224.00 179.2000 41.49 224.00 Infectious agent antigen detection by immunoassay with direct optical (ie, visual) observation; Influenza 1.0000 Each 57.10 45.6800 15.72 57.10 Infectious agent antigen detection by immunoassay with direct optical (ie, visual) observation; respiratory syncytial virus 1.0000 each 166.00 132.8000 12.44 166.00 Infectious agent antigen detection by immunoassay with direct optical (ie, visual) observation; Streptococcus, group A 1.0000 each 74.25 59.4000 15.70 74.25 Infectious agent genotype analysis by nucleic acid (DNA or RNA); Hepatitis C virus 1.0000 each 436.00 348.8000 244.58 436.00 Cytopathology, fluids, washings or brushings, except cervical or vaginal; smears with interpretation 1.0000 each 71.70 57.3600 31.58 71.70 Cytopathology, concentration technique, smears and interpretation (eg, Saccomanno technique) 1.0000 each 71.70 57.3600 31.58 71.70 Cytopathology, selective cellular enhancement technique with interpretation (eg, liquid based slide preparation method), except cervical or vaginal 1.0000 Each 76.00 60.8000 46.63 76.00 Cytopathology, cervical or vaginal (any reporting system), requiring interpretation by physician 1.0000 each 42.00 33.6000 26.00 42.00 Cytopathology, cervical or vaginal (any reporting system), collected in preservative fluid, automated thin layer preparation; manual screening under physician supervision 1.0000 each 88.00 70.4000 19.25 88.00 Cytopathology, smears, any other source; screening and interpretation 1.0000 each 38.90 31.1200 23.21 38.90 Cytopathology, evaluation of fine needle aspirate; immediate cytohistologic study to determine adequacy for diagnosis, first evaluation episode, each site 1.0000 Each 59.55 47.6400 36.86 158.56 Cytopathology, evaluation of fine needle aspirate; interpretation and report 1.0000 Each 123.00 98.4000 46.63 123.00 Cytopathology, cervical or vaginal (any reporting system), collected in preservative fluid, automated thin layer preparation; with screening by automated system and manual rescreening or review, under physician supervision 1.0000 each 147.00 117.6000 25.28 147.00 Flow cytometry, cell cycle or DNA analysis 1.0000 each 46.40 37.1200 28.72 50.56 Flow cytometry, cell surface, cytoplasmic, or nuclear marker, technical component only; first marker 1.0000 Each 330.40 264.3200 204.52 330.40 Flow cytometry, cell surface, cytoplasmic, or nuclear marker, technical component only; each additional marker (List separately in addition to code for first marker) 1.0000 Each 201.10 160.8800 124.48 201.10 Flow cytometry, interpretation; 16 or more markers 1.0000 Each 71.70 57.3600 44.38 71.70 Tissue culture for non-neoplastic disorders; amniotic fluid or chorionic villus cells 1.0000 each 732.35 585.8800 142.78 732.35 Tissue culture for neoplastic disorders; bone marrow, blood cells 1.0000 Each 540.00 432.0000 136.56 540.00 Chromosome analysis; analyze 20-25 cells 1.0000 each 532.90 426.3200 137.38 532.90 Chromosome analysis, amniotic fluid or chorionic villus, count 15 cells, 1 karyotype, with banding 1.0000 each 894.00 715.2000 179.14 894.00 Chromosome analysis, in situ for amniotic fluid cells, count cells from 6-12 colonies, 1 karyotype, with banding 1.0000 each 716.20 572.9600 164.98 716.20 Chromosome analysis; additional karyotypes, each study 1.0000 Each 107.35 85.8800 31.80 107.35 Chromosome analysis; additional cells counted, each study 1.0000 Each 81.85 65.4800 25.56 81.85 Cytogenetics and molecular cytogenetics, interpretation and report 1.0000 Each 94.00 75.2000 58.19 94.00 Level I - Surgical pathology, gross examination only 1.0000 Each 41.00 32.8000 23.21 41.00 Level II - Surgical pathology, gross and microscopic examination Appendix, incidental Fallopian tube, sterilization Fingers/toes, amputation, traumatic Foreskin, newborn Hernia sac, any location Hydrocele sac Nerve Skin, plastic repair Sympathetic ganglion Testis, castration Vaginal mucosa, incidental Vas deferens, sterilization 1.0000 Each 126.00 100.8000 23.21 126.00 Level III - Surgical pathology, gross and microscopic examination Abortion, induced Abscess Aneurysm - arterial/ventricular Anus, tag Appendix, other than incidental Artery, atheromatous plaque Bartholin's gland cyst Bone fragment(s), other than pathologic fracture Bursa/synovial cyst Carpal tunnel tissue Cartilage, shavings Cholesteatoma Colon, colostomy stoma Conjunctiva - biopsy/pterygium Cornea Diverticulum - esophagus/small intestine Dupuytren's contracture tissue Femoral head, other than fracture Fissure/fistula Foreskin, other than newborn Gallbladder Ganglion cyst Hematoma Hemorrhoids Hydatid of Morgagni Intervertebral disc Joint, loose body Meniscus Mucocele, salivary Neuroma - Morton's/traumatic Pilonidal cyst/sinus Polyps, inflammatory - nasal/sinusoidal Skin - cyst/tag/debridement Soft tissue, debridement Soft tissue, lipoma Spermatocele Tendon/tendon sheath Testicular appendage Thrombus or embolus Tonsil and/or adenoids Varicocele Vas deferens, other than sterilization Vein, varicosity 1.0000 Each 158.00 126.4000 46.63 158.00 Level IV - Surgical pathology, gross and microscopic examination Abortion - spontaneous/missed Artery, biopsy Bone marrow, biopsy Bone exostosis Brain/meninges, other than for tumor resection Breast, biopsy, not requiring microscopic evaluation of surgical margins Breast, reduction mammoplasty Bronchus, biopsy Cell block, any source Cervix, biopsy Colon, biopsy Duodenum, biopsy Endocervix, curettings/biopsy Endometrium, curettings/biopsy Esophagus, biopsy Extremity, amputation, traumatic Fallopian tube, biopsy Fallopian tube, ectopic pregnancy Femoral head, fracture Fingers/toes, amputation, non-traumatic Gingiva/oral mucosa, biopsy Heart valve Joint, resection Kidney, biopsy Larynx, biopsy Leiomyoma(s), uterine myomectomy - without uterus Lip, biopsy/wedge resection Lung, transbronchial biopsy Lymph node, biopsy Muscle, biopsy Nasal mucosa, biopsy Nasopharynx/oropharynx, biopsy Nerve, biopsy Odontogenic/dental cyst Omentum, biopsy Ovary with or without tube, non-neoplastic Ovary, biopsy/wedge resection Parathyroid gland Peritoneum, biopsy Pituitary tumor Placenta, other than third trimester Pleura/pericardium - biopsy/tissue Polyp, cervical/endometrial Polyp, colorectal Polyp, stomach/small intestine Prostate, needle biopsy Prostate, TUR Salivary gland, biopsy Sinus, paranasal biopsy Skin, other than cyst/tag/debridement/plastic repair Small intestine, biopsy Soft tissue, other than tumor/mass/lipoma/debridement Spleen Stomach, biopsy Synovium Testis, other than tumor/biopsy/castration Thyroglossal duct/brachial cleft cyst Tongue, biopsy Tonsil, biopsy Trachea, biopsy Ureter, biopsy Urethra, biopsy Urinary bladder, biopsy Uterus, with or without tubes and ovaries, for prolapse Vagina, biopsy Vulva/labia, biopsy 1.0000 Each 263.00 210.4000 46.63 263.00 Level V - Surgical pathology, gross and microscopic examination Adrenal, resection Bone - biopsy/curettings Bone fragment(s), pathologic fracture Brain, biopsy Brain/meninges, tumor resection Breast, excision of lesion, requiring microscopic evaluation of surgical margins Breast, mastectomy - partial/simple Cervix, conization Colon, segmental resection, other than for tumor Extremity, amputation, non-traumatic Eye, enucleation Kidney, partial/total nephrectomy Larynx, partial/total resection Liver, biopsy - needle/wedge Liver, partial resection Lung, wedge biopsy Lymph nodes, regional resection Mediastinum, mass Myocardium, biopsy Odontogenic tumor Ovary with or without tube, neoplastic Pancreas, biopsy Placenta, third trimester Prostate, except radical resection Salivary gland Sentinel lymph node Small intestine, resection, other than for tumor Soft tissue mass (except lipoma) - biopsy/simple excision Stomach - subtotal/total resection, other than for tumor Testis, biopsy Thymus, tumor Thyroid, total/lobe Ureter, resection Urinary bladder, TUR Uterus, with or without tubes and ovaries, other than neoplastic/prolapse 1.0000 Each 289.00 231.2000 178.89 326.80 Level VI - Surgical pathology, gross and microscopic examination Bone resection Breast, mastectomy - with regional lymph nodes Colon, segmental resection for tumor Colon, total resection Esophagus, partial/total resection Extremity, disarticulation Fetus, with dissection Larynx, partial/total resection - with regional lymph nodes Lung - total/lobe/segment resection Pancreas, total/subtotal resection Prostate, radical resection Small intestine, resection for tumor Soft tissue tumor, extensive resection Stomach - subtotal/total resection for tumor Testis, tumor Tongue/tonsil -resection for tumor Urinary bladder, partial/total resection Uterus, with or without tubes and ovaries, neoplastic Vulva, total/subtotal resection 1.0000 Each 525.00 420.0000 324.98 782.96 Decalcification procedure (List separately in addition to code for surgical pathology examination) 1.0000 Each 41.00 32.8000 25.38 41.00 Special stain including interpretation and report; Group I for microorganisms (eg, acid fast, methenamine silver) 1.0000 Each 76.00 60.8000 46.63 76.00 Special stain including interpretation and report; Group II, all other (eg, iron, trichrome), except stain for microorganisms, stains for enzyme constituents, or immunocytochemistry and immunohistochemistry 1.0000 Each 21.00 16.8000 13.00 34.24 Consultation and report on referred material requiring preparation of slides 1.0000 Each 143.00 114.4000 46.63 143.00 Pathology consultation during surgery 1.0000 Each 188.00 150.4000 31.58 188.00 Pathology consultation during surgery; first tissue block, with frozen section(s), single specimen 1.0000 Each 76.00 60.8000 47.04 158.56 Pathology consultation during surgery; each additional tissue block with frozen section(s) (List separately in addition to code for primary procedure) 1.0000 Each 41.00 32.8000 25.38 41.00 Pathology consultation during surgery; cytologic examination (eg, touch prep, squash prep), initial site 1.0000 Each 660.00 528.0000 408.54 782.96 Immunohistochemistry or immunocytochemistry, per specimen; each additional single antibody stain procedure (List separately in addition to code for primary procedure) 1.0000 each 154.00 123.2000 95.33 154.00 Immunohistochemistry or immunocytochemistry, per specimen; initial single antibody stain procedure 1.0000 Each 123.00 98.4000 76.14 158.56 Immunohistochemistry or immunocytochemistry, per specimen; each multiplex antibody stain procedure 1.0000 each 131.00 104.8000 81.09 326.80 Morphometric analysis, tumor immunohistochemistry (eg, Her-2/neu, estrogen receptor/progesterone receptor), quantitative or semiquantitative, per specimen, each single antibody stain procedure; manual 1.0000 Each 230.00 184.0000 142.37 230.00 Morphometric analysis, tumor immunohistochemistry (eg, Her-2/neu, estrogen receptor/progesterone receptor), quantitative or semiquantitative, per specimen, each single antibody stain procedure; using computer-assisted technology 1.0000 Each 329.50 263.6000 203.96 329.50 In situ hybridization (eg, FISH), per specimen; initial single probe stain procedure 1.0000 Each 218.00 174.4000 134.94 218.00 Morphometric analysis, in situ hybridization (quantitative or semi-quantitative), using computer-assisted technology, per specimen; initial single probe stain procedure 1.0000 Each 738.75 591.0000 301.42 738.75 Morphometric analysis, in situ hybridization (quantitative or semi-quantitative), manual, per specimen; initial single probe stain procedure 1.0000 Each 634.75 507.8000 301.42 634.75 Morphometric analysis, in situ hybridization (quantitative or semi-quantitative), using computer-assisted technology, per specimen; each additional single probe stain procedure (List separately in addition to code for primary procedure) 1.0000 each 118.00 94.4000 73.04 118.00 Morphometric analysis, in situ hybridization (quantitative or semi-quantitative), using computer-assisted technology, per specimen; each multiplex probe stain procedure 1.0000 each 503.00 402.4000 146.24 503.00 Morphometric analysis, in situ hybridization (quantitative or semi-quantitative), manual, per specimen; each multiplex probe stain procedure 1.0000 each 964.00 771.2000 146.24 964.00 Cell count, miscellaneous body fluids (eg, cerebrospinal fluid, joint fluid), except blood; with differential count 1.0000 Each 74.00 59.2000 5.32 74.00 Crystal identification by light microscopy with or without polarizing lens analysis, tissue or any body fluid (except urine) 1.0000 each 30.00 24.0000 6.96 30.00 Semen analysis; motility and count (not including Huhner test) 1.0000 each 36.00 28.8000 8.18 36.00 Semen analysis; volume, count, motility, and differential 1.0000 each 82.00 65.6000 11.69 82.00 Rabies immune globulin (RIg), human, for intramuscular and/or subcutaneous use 150.0000 IU 12872.42 10297.9400 264.32 12872.42 Immunization administration through 18 years of age via any route of administration, with counseling by physician or other qualified health care professional; first or only component of each vaccine or toxoid administered 1.0000 Each 54.65 43.7200 33.83 54.65 Immunization administration (includes percutaneous, intradermal, subcutaneous, or intramuscular injections); 1 vaccine (single or combination vaccine/toxoid) 1.0000 each 58.00 46.4000 35.90 68.03 Immunization administration (includes percutaneous, intradermal, subcutaneous, or intramuscular injections); each additional vaccine (single or combination vaccine/toxoid) (List separately in addition to code for primary procedure) 1.0000 Each 58.00 46.4000 35.90 58.00 Influenza virus vaccine, trivalent (ccIIV3), derived from cell cultures, subunit, preservative and antibiotic free, 0.5 mL dosage, for intramuscular use 0.5000 ml 92.93 74.3400 57.52 92.93 Pneumococcal conjugate vaccine, 13 valent (PCV13), for intramuscular use 0.5000 ML 1070.91 856.7300 662.89 1070.91 Rabies vaccine, for intramuscular use 1.0000 ML 2249.26 1799.4100 337.46 2249.26 Influenza virus vaccine, quadrivalent (IIV4), split virus, preservative free, 0.5 mL dosage, for intramuscular use 0.5000 ml 121.89 97.5100 75.45 121.89 Influenza virus vaccine, quadrivalent (IIV4), split virus, 0.5 mL dosage, for intramuscular use 0.5000 ml 112.40 89.9200 69.58 112.40 Diphtheria and tetanus toxoids adsorbed (DT) when administered to individuals younger than 7 years, for intramuscular use 1.0000 each 18.85 15.0800 11.67 18.85 Tetanus and diphtheria toxoids adsorbed (Td), preservative free, when administered to individuals 7 years or older, for intramuscular use 0.5000 ML 169.45 135.5600 104.89 169.45 Tetanus, diphtheria toxoids and acellular pertussis vaccine (Tdap), when administered to individuals 7 years or older, for intramuscular use 0.5000 ML 285.74 228.5900 176.87 285.74 Pneumococcal polysaccharide vaccine, 23-valent (PPSV23), adult or immunosuppressed patient dosage, when administered to individuals 2 years or older, for subcutaneous or intramuscular use 0.5000 ML 273.05 218.4400 169.02 273.05 Meningococcal conjugate vaccine, serogroups A, C, W, Y, quadrivalent, diphtheria toxoid carrier (MenACWY-D) or CRM197 carrier (MenACWY-CRM), for intramuscular use 1.0000 each 794.26 635.4100 491.65 794.26 Hepatitis B vaccine (HepB), pediatric/adolescent dosage, 3 dose schedule, for intramuscular use 1.0000 DOSE 1083.77 867.0200 670.85 1083.77 Hepatitis B vaccine (HepB), adult dosage, 3 dose schedule, for intramuscular use 20.0000 MCG 370.82 296.6600 229.54 370.82 Psychiatric diagnostic evaluation 1.0000 Each 244.00 195.2000 135.50 244.00 Psychotherapy, 30 minutes with patient 30.0000 min 157.00 125.6000 97.18 157.00 Psychotherapy, 30 minutes with patient when performed with an evaluation and management service (List separately in addition to the code for primary procedure) 30.0000 min 157.00 125.6000 97.18 157.00 Psychotherapy, 45 minutes with patient 45.0000 min 204.00 163.2000 126.28 204.00 Psychotherapy, 45 minutes with patient when performed with an evaluation and management service (List separately in addition to the code for primary procedure) 45.0000 min 215.00 172.0000 133.08 215.00 Psychotherapy, 60 minutes with patient 60.0000 min 215.00 172.0000 133.08 215.00 Psychotherapy, 60 minutes with patient when performed with an evaluation and management service (List separately in addition to the code for primary procedure) 60.0000 min 215.00 172.0000 133.08 215.00 Psychotherapy for crisis; first 60 minutes 60.0000 min 214.00 171.2000 132.47 214.00 Psychotherapy for crisis; each additional 30 minutes (List separately in addition to code for primary service) 30.0000 min 112.00 89.6000 69.33 112.00 Family psychotherapy (without the patient present), 50 minutes 50.0000 min 317.00 253.6000 135.50 317.00 Family psychotherapy (conjoint psychotherapy) (with patient present), 50 minutes 50.0000 min 317.00 253.6000 135.50 317.00 Group psychotherapy (other than of a multiple-family group) 1.0000 Each 382.00 305.6000 70.54 382.00 Pharmacologic management, including prescription and review of medication, when performed with psychotherapy services (List separately in addition to the code for primary procedure) 1.0000 Each 168.00 134.4000 103.99 168.00 Biofeedback training by any modality 1.0000 each 117.10 93.6800 37.31 117.10 Binocular microscopy (separate diagnostic procedure) 1.0000 each 4224.69 3379.7500 2615.08 4224.68 Treatment of speech, language, voice, communication, and/or auditory processing disorder; individual Each 158.00 126.4000 70.86 158.00 Nasopharyngoscopy with endoscope (separate procedure) Each 109.00 87.2000 67.47 180.24 Evaluation of speech fluency (eg, stuttering, cluttering) Each 182.30 145.8400 112.84 182.30 Evaluation of speech sound production (eg, articulation, phonological process, apraxia, dysarthria) Each 182.30 145.8400 102.87 182.30 Evaluation of speech sound production (eg, articulation, phonological process, apraxia, dysarthria); with evaluation of language comprehension and expression (eg, receptive and expressive language) Each 192.00 153.6000 118.85 228.83 Behavioral and qualitative analysis of voice and resonance Each 182.30 145.8400 101.68 182.30 Treatment of swallowing dysfunction and/or oral function for feeding Each 263.00 210.4000 78.41 263.00 Evoked otoacoustic emissions, screening (qualitative measurement of distortion product or transient evoked otoacoustic emissions), automated analysis 1.0000 each 300.00 240.0000 185.70 300.00 Evaluation of oral and pharyngeal swallowing function 1.0000 each 289.00 231.2000 78.32 289.00 Motion fluoroscopic evaluation of swallowing function by cine or video recording 1.0000 each 273.00 218.4000 84.14 273.00 Cardiopulmonary resuscitation (eg, in cardiac arrest) 1.0000 each 276.00 220.8000 170.84 282.39 Temporary transcutaneous pacing 1.0000 each 438.65 350.9200 271.52 593.03 Cardioversion, elective, electrical conversion of arrhythmia; external 1.0000 Each 1155.00 924.0000 546.97 1155.00 Thrombolysis, coronary; by intravenous infusion Each 354.15 283.3200 219.22 354.15 Electrocardiogram, routine ECG with at least 12 leads; tracing only, without interpretation and report Each 250.00 200.0000 53.46 250.00 Cardiovascular stress test using maximal or submaximal treadmill or bicycle exercise, continuous electrocardiographic monitoring, and/or pharmacological stress; tracing only, without interpretation and report Each 1066.00 852.8000 260.45 1066.00 External electrocardiographic recording up to 48 hours by continuous rhythm recording and storage; recording (includes connection, recording, and disconnection) Each 194.00 155.2000 107.98 194.00 External electrocardiographic recording up to 48 hours by continuous rhythm recording and storage; review and interpretation by a physician or other qualified health care professional 1.0000 each 190.00 152.0000 117.61 190.00 Transthoracic echocardiography for congenital cardiac anomalies; complete Each 509.00 407.2000 315.07 509.00 Echocardiography, transthoracic, real-time with image documentation (2D), includes M-mode recording, when performed, complete, with spectral Doppler echocardiography, and with color flow Doppler echocardiography Each 2000.00 1600.0000 467.91 2000.00 Echocardiography, transthoracic, real-time with image documentation (2D), includes M-mode recording, when performed, follow-up or limited study Each 1111.00 888.8000 217.17 1111.00 Echocardiography, transesophageal, real-time with image documentation (2D) (with or without M-mode recording); including probe placement, image acquisition, interpretation and report Each 2372.00 1897.6000 467.91 2372.00 Doppler echocardiography, pulsed wave and/or continuous wave with spectral display (List separately in addition to codes for echocardiographic imaging); complete 1.0000 each 324.00 259.2000 200.56 324.00 Doppler echocardiography color flow velocity mapping (List separately in addition to codes for echocardiography) 1.0000 each 411.00 328.8000 254.41 411.00 Echocardiography, transthoracic, real-time with image documentation (2D), includes M-mode recording, when performed, during rest and cardiovascular stress test using treadmill, bicycle exercise and/or pharmacologically induced stress, with interpretation and report Each 1321.00 1056.8000 467.91 1321.00 Duplex scan of extracranial arteries; complete bilateral study Each 999.00 799.2000 217.17 999.00 Duplex scan of extracranial arteries; unilateral or limited study Each 677.00 541.6000 99.40 677.00 Limited bilateral noninvasive physiologic studies of upper or lower extremity arteries, (eg, for lower extremity: ankle/brachial indices at distal posterior tibial and anterior tibial/dorsalis pedis arteries plus bidirectional, Doppler waveform recording and analysis at 1-2 levels, or ankle/brachial indices at distal posterior tibial and anterior tibial/dorsalis pedis arteries plus volume plethysmography at 1-2 levels, or ankle/brachial indices at distal posterior tibial and anterior tibial/dorsalis pedis arteries with, transcutaneous oxygen tension measurement at 1-2 levels) Each 840.00 672.0000 107.98 840.00 Complete bilateral noninvasive physiologic studies of upper or lower extremity arteries, 3 or more levels (eg, for lower extremity: ankle/brachial indices at distal posterior tibial and anterior tibial/dorsalis pedis arteries plus segmental blood pressure measurements with bidirectional Doppler waveform recording and analysis, at 3 or more levels, or ankle/brachial indices at distal posterior tibial and anterior tibial/dorsalis pedis arteries plus segmental volume plethysmography at 3 or more levels, or ankle/brachial indices at distal posterior tibial and anterior tibial/dorsalis pedis arteries plus segmental transcutaneous oxygen tension measurements at 3 or more levels), or single level study with provocative functional maneuvers (eg, measurements with postural provocative tests, or measurements with reactive hyperemia) Each 492.00 393.6000 135.25 492.00 Duplex scan of lower extremity arteries or arterial bypass grafts; complete bilateral study Each 999.00 799.2000 217.17 999.00 Duplex scan of lower extremity arteries or arterial bypass grafts; unilateral or limited study Each 816.00 652.8000 99.40 816.00 Duplex scan of upper extremity arteries or arterial bypass grafts; complete bilateral study Each 999.00 799.2000 217.17 999.00 Duplex scan of upper extremity arteries or arterial bypass grafts; unilateral or limited study Each 711.00 568.8000 99.40 711.00 Duplex scan of extremity veins including responses to compression and other maneuvers; complete bilateral study Each 1014.00 811.2000 217.17 1014.00 Duplex scan of extremity veins including responses to compression and other maneuvers; unilateral or limited study Each 816.00 652.8000 99.40 816.00 Duplex scan of arterial inflow and venous outflow of abdominal, pelvic, scrotal contents and/or retroperitoneal organs; complete study Each 999.00 799.2000 217.17 999.00 Duplex scan of arterial inflow and venous outflow of abdominal, pelvic, scrotal contents and/or retroperitoneal organs; limited study Each 677.00 541.6000 99.40 677.00 Duplex scan of aorta, inferior vena cava, iliac vasculature, or bypass grafts; complete study Each 951.00 760.8000 217.17 951.00 Duplex scan of aorta, inferior vena cava, iliac vasculature, or bypass grafts; unilateral or limited study Each 677.00 541.6000 99.40 677.00 Duplex scan of hemodialysis access (including arterial inflow, body of access and venous outflow) Each 395.00 316.0000 99.40 395.00 Ventilation assist and management, initiation of pressure or volume preset ventilators for assisted or controlled breathing; hospital inpatient/observation, initial day 1.0000 each 1050.00 840.0000 517.75 1050.00 Ventilation assist and management, initiation of pressure or volume preset ventilators for assisted or controlled breathing; hospital inpatient/observation, each subsequent day 1.0000 Day(s) 1050.00 840.0000 517.75 1050.00 Spirometry, including graphic record, total and timed vital capacity, expiratory flow rate measurement(s), with or without maximal voluntary ventilation 1.0000 each 88.35 70.6800 54.69 146.64 Bronchodilation responsiveness, spirometry as in 94010, pre- and post-bronchodilator administration 1.0000 each 192.30 153.8400 119.03 282.39 Vital capacity, total (separate procedure) 1.0000 each 36.80 29.4400 22.78 146.64 Maximum breathing capacity, maximal voluntary ventilation 1.0000 each 37.90 30.3200 23.46 57.96 Respiratory flow volume loop 1.0000 each 59.55 47.6400 36.86 282.39 Pressurized or nonpressurized inhalation treatment for acute airway obstruction for therapeutic purposes and/or for diagnostic purposes such as sputum induction with an aerosol generator, nebulizer, metered dose inhaler or intermittent positive pressure breathing (IPPB) device 1.0000 Each 70.00 56.0000 43.33 193.09 Continuous positive airway pressure ventilation (CPAP), initiation and management 1.0000 each 122.00 97.6000 75.52 193.09 Demonstration and/or evaluation of patient utilization of an aerosol generator, nebulizer, metered dose inhaler or IPPB device 1.0000 each 39.00 31.2000 24.14 193.09 Manipulation chest wall, such as cupping, percussing, and vibration to facilitate lung function; initial demonstration and/or evaluation 1.0000 each 38.00 30.4000 23.52 117.07 Manipulation chest wall, such as cupping, percussing, and vibration to facilitate lung function; subsequent 1.0000 Each 36.15 28.9200 22.38 117.07 Noninvasive ear or pulse oximetry for oxygen saturation; single determination 1.0000 each 15.90 12.7200 9.84 15.90 Noninvasive ear or pulse oximetry for oxygen saturation; multiple determinations (eg, during exercise) 1.0000 each 100.00 80.0000 61.90 100.00 Noninvasive ear or pulse oximetry for oxygen saturation; by continuous overnight monitoring (separate procedure) 1.0000 each 68.40 54.7200 42.34 146.64 Car seat/bed testing for airway integrity, for infants through 12 months of age, with continual clinical staff observation and continuous recording of pulse oximetry, heart rate and respiratory rate, with interpretation and report; 60 minutes 60.0000 min 150.00 120.0000 31.58 150.00 Unlisted pulmonary service or procedure 1.0000 Each 39.00 31.2000 24.14 146.64 Multiple sleep latency or maintenance of wakefulness testing, recording, analysis and interpretation of physiological measurements of sleep during multiple trials to assess sleepiness 1.0000 each 2230.00 1784.0000 449.59 2230.00 Polysomnography; age 6 years or older, sleep staging with 4 or more additional parameters of sleep, attended by a technologist 1.0000 each 1699.00 1359.2000 868.97 1699.00 Polysomnography; age 6 years or older, sleep staging with 4 or more additional parameters of sleep, with initiation of continuous positive airway pressure therapy or bilevel ventilation, attended by a technologist 1.0000 each 2342.00 1873.6000 868.97 2342.00 Range of motion measurements and report (separate procedure); each extremity (excluding hand) or each trunk section (spine) 1.0000 each 45.25 36.2000 19.12 45.25 Range of motion measurements and report (separate procedure); hand, with or without comparison with normal side 1.0000 each 42.65 34.1200 15.72 42.65 Needle electromyography; 2 extremities with or without related paraspinal areas 1.0000 each 471.00 376.8000 107.98 471.00 Continuous intraoperative neurophysiology monitoring in the operating room, one on one monitoring requiring personal attendance, each 15 minutes (List separately in addition to code for primary procedure) 15.0000 min 247.00 197.6000 152.89 247.00 Electronic analysis of implanted neurostimulator pulse generator/transmitter (eg, contact group[s], interleaving, amplitude, pulse width, frequency [Hz], on/off cycling, burst, magnet mode, dose lockout, patient selectable parameters, responsive neurostimulation, detection algorithms, closed loop parameters, and passive parameters) by physician or other qualified health care professional; with complex spinal cord or peripheral nerve (eg, sacral nerve) neurostimulator pulse generator/transmitter programming by physician or other qualified health care professional 1.0000 hr 226.00 180.8000 92.82 226.00 Assessment of aphasia (includes assessment of expressive and receptive speech and language function, language comprehension, speech production ability, reading, spelling, writing, eg, by Boston Diagnostic Aphasia Examination) with interpretation and report, per hour 1.0000 hr 250.00 200.0000 90.06 250.00 Developmental screening (eg, developmental milestone survey, speech and language delay screen), with scoring and documentation, per standardized instrument 1.0000 Hour(s) 137.95 110.3600 85.39 137.95 Developmental test administration (including assessment of fine and/or gross motor, language, cognitive level, social, memory and/or executive functions by standardized developmental instruments when performed), by physician or other qualified health care professional, with interpretation and report; first hour 1.0000 hr 207.60 166.0800 128.50 270.45 Intravenous infusion, hydration; initial, 31 minutes to 1 hour 1.0000 Hour(s) 630.00 504.0000 192.11 630.00 Intravenous infusion, hydration; each additional hour (List separately in addition to code for primary procedure) 1.0000 hr 210.00 168.0000 39.40 210.00 Intravenous infusion, for therapy, prophylaxis, or diagnosis (specify substance or drug); initial, up to 1 hour 1.0000 Hour(s) 630.00 504.0000 192.11 630.00 Intravenous infusion, for therapy, prophylaxis, or diagnosis (specify substance or drug); each additional hour (List separately in addition to code for primary procedure) 1.0000 hr 210.00 168.0000 39.40 210.00 Intravenous infusion, for therapy, prophylaxis, or diagnosis (specify substance or drug); additional sequential infusion of a new drug/substance, up to 1 hour (List separately in addition to code for primary procedure) 1.0000 Hour(s) 210.00 168.0000 62.75 210.00 Intravenous infusion, for therapy, prophylaxis, or diagnosis (specify substance or drug); concurrent infusion (List separately in addition to code for primary procedure) 1.0000 Hour(s) 207.00 165.6000 128.13 207.00 Therapeutic, prophylactic, or diagnostic injection (specify substance or drug); subcutaneous or intramuscular 1.0000 Each 289.00 231.2000 62.75 289.00 Therapeutic, prophylactic, or diagnostic injection (specify substance or drug); intra-arterial 1.0000 Each 168.00 134.4000 103.99 208.29 Therapeutic, prophylactic, or diagnostic injection (specify substance or drug); intravenous push, single or initial substance/drug 1.0000 Each 289.00 231.2000 178.89 289.00 Therapeutic, prophylactic, or diagnostic injection (specify substance or drug); each additional sequential intravenous push of a new substance/drug (List separately in addition to code for primary procedure) 1.0000 Each 289.00 231.2000 39.40 289.00 Therapeutic, prophylactic, or diagnostic injection (specify substance or drug); each additional sequential intravenous push of the same substance/drug provided in a facility (List separately in addition to code for primary procedure) 1.0000 Each 289.00 231.2000 178.89 289.00 Chemotherapy administration, subcutaneous or intramuscular; non-hormonal anti-neoplastic 1.0000 Each 99.00 79.2000 61.28 99.00 Chemotherapy administration, subcutaneous or intramuscular; hormonal anti-neoplastic 1.0000 Each 99.00 79.2000 61.28 99.00 Chemotherapy administration; intravenous, push technique, single or initial substance/drug 1.0000 Each 257.00 205.6000 159.08 257.00 Chemotherapy administration; intravenous, push technique, each additional substance/drug (List separately in addition to code for primary procedure) 1.0000 Each 174.00 139.2000 62.75 174.00 Chemotherapy administration, intravenous infusion technique; up to 1 hour, single or initial substance/drug 1.0000 Hour(s) 375.00 300.0000 232.12 375.00 Chemotherapy administration, intravenous infusion technique; each additional hour (List separately in addition to code for primary procedure) 1.0000 hr 185.00 148.0000 62.75 185.00 Chemotherapy administration, intravenous infusion technique; initiation of prolonged chemotherapy infusion (more than 8 hours), requiring use of a portable or implantable pump 1.0000 Hour(s) 375.00 300.0000 232.12 375.00 Chemotherapy administration, intravenous infusion technique; each additional sequential infusion (different substance/drug), up to 1 hour (List separately in addition to code for primary procedure) 1.0000 Hour(s) 174.00 139.2000 62.75 174.00 Refilling and maintenance of portable pump 1.0000 each 375.00 300.0000 192.11 375.00 Refilling and maintenance of implantable pump or reservoir for drug delivery, systemic (eg, intravenous, intra-arterial) 1.0000 each 257.00 205.6000 159.08 257.00 Irrigation of implanted venous access device for drug delivery systems 1.0000 each 99.00 79.2000 53.46 99.00 Application of a modality to 1 or more areas; traction, mechanical Each 95.00 76.0000 13.36 95.00 Application of a modality to 1 or more areas; paraffin bath Each 65.90 52.7200 5.15 65.90 Application of a modality to 1 or more areas; whirlpool Each 70.65 56.5200 15.56 70.65 Application of a modality to 1 or more areas; infrared Each 45.00 36.0000 6.05 45.00 Application of a modality to 1 or more areas; electrical stimulation (manual), each 15 minutes Each 95.00 76.0000 13.36 95.00 Application of a modality to 1 or more areas; iontophoresis, each 15 minutes Each 54.85 43.8800 18.16 54.85 Application of a modality to 1 or more areas; ultrasound, each 15 minutes Each 95.00 76.0000 13.27 95.00 Therapeutic procedure, 1 or more areas, each 15 minutes; therapeutic exercises to develop strength and endurance, range of motion and flexibility Each 210.00 168.0000 27.26 210.00 Therapeutic procedure, 1 or more areas, each 15 minutes; neuromuscular reeducation of movement, balance, coordination, kinesthetic sense, posture, and/or proprioception for sitting and/or standing activities Each 74.00 59.2000 31.26 74.00 Therapeutic procedure, 1 or more areas, each 15 minutes; gait training (includes stair climbing) Each 210.00 168.0000 27.26 210.00 Therapeutic procedure, 1 or more areas, each 15 minutes; massage, including effleurage, petrissage and/or tapotement (stroking, compression, percussion) Each 58.20 46.5600 27.62 58.20 Therapeutic interventions that focus on cognitive function (eg, attention, memory, reasoning, executive function, problem solving, and/or pragmatic functioning) and compensatory strategies to manage the performance of an activity (eg, managing time or schedules, initiating, organizing, and sequencing tasks), direct (one-on-one) patient contact; initial 15 minutes 15.0000 min 90.00 72.0000 21.11 90.00 Unlisted therapeutic procedure (specify) 15.0000 Minutes 35.20 28.1600 21.79 35.20 Manual therapy techniques (eg, mobilization/ manipulation, manual lymphatic drainage, manual traction), 1 or more regions, each 15 minutes Each 210.00 168.0000 25.12 210.00 Therapeutic procedure(s), group (2 or more individuals) Each 42.70 34.1600 16.44 42.70 Physical therapy evaluation: low complexity, requiring these components: A history with no personal factors and/or comorbidities that impact the plan of care; An examination of body system(s) using standardized tests and measures addressing 1-2 elements from any of the following: body structures and functions, activity limitations, and/or participation restrictions; A clinical presentation with stable and/or uncomplicated characteristics; and Clinical decision making of low complexity using standardized patient assessment instrument and/or measurable assessment of functional outcome. Typically, 20 minutes are spent face-to-face with the patient and/or family. Each 368.00 294.4000 92.91 368.00 Physical therapy evaluation: moderate complexity, requiring these components: A history of present problem with 1-2 personal factors and/or comorbidities that impact the plan of care; An examination of body systems using standardized tests and measures in addressing a total of 3 or more elements from any of the following: body structures and functions, activity limitations, and/or participation restrictions; An evolving clinical presentation with changing characteristics; and Clinical decision making of moderate complexity using standardized patient assessment instrument and/or measurable assessment of functional outcome. Typically, 30 minutes are spent face-to-face with the patient and/or family. Each 420.00 336.0000 92.91 420.00 Physical therapy evaluation: high complexity, requiring these components: A history of present problem with 3 or more personal factors and/or comorbidities that impact the plan of care; An examination of body systems using standardized tests and measures addressing a total of 4 or more elements from any of the following: body structures and functions, activity limitations, and/or participation restrictions; A clinical presentation with unstable and unpredictable characteristics; and Clinical decision making of high complexity using standardized patient assessment instrument and/or measurable assessment of functional outcome. Typically, 45 minutes are spent face-to-face with the patient and/or family. Each 473.00 378.4000 92.91 473.00 Re-evaluation of physical therapy established plan of care, requiring these components: An examination including a review of history and use of standardized tests and measures is required; and Revised plan of care using a standardized patient assessment instrument and/or measurable assessment of functional outcome Typically, 20 minutes are spent face-to-face with the patient and/or family. Each 263.00 210.4000 64.09 263.00 Occupational therapy evaluation, low complexity, requiring these components: An occupational profile and medical and therapy history, which includes a brief history including review of medical and/or therapy records relating to the presenting problem; An assessment(s) that identifies 1-3 performance deficits (ie, relating to physical, cognitive, or psychosocial skills) that result in activity limitations and/or participation restrictions; and Clinical decision making of low complexity, which includes an analysis of the occupational profile, analysis of data from problem-focused assessment(s), and consideration of a limited number of treatment options. Patient presents with no comorbidities that affect occupational performance. Modification of tasks or assistance (eg, physical or verbal) with assessment(s) is not necessary to enable completion of evaluation component. Typically, 30 minutes are spent face-to-face with the patient and/or family. Each 368.00 294.4000 92.91 368.00 Occupational therapy evaluation, moderate complexity, requiring these components: An occupational profile and medical and therapy history, which includes an expanded review of medical and/or therapy records and additional review of physical, cognitive, or psychosocial history related to current functional performance; An assessment(s) that identifies 3-5 performance deficits (ie, relating to physical, cognitive, or psychosocial skills) that result in activity limitations and/or participation restrictions; and Clinical decision making of moderate analytic complexity, which includes an analysis of the occupational profile, analysis of data from detailed assessment(s), and consideration of several treatment options. Patient may present with comorbidities that affect occupational performance. Minimal to moderate modification of tasks or assistance (eg, physical or verbal) with assessment(s) is necessary to enable patient to complete evaluation component. Typically, 45 minutes are spent face-to-face with the patient and/or family. Each 420.00 336.0000 92.91 420.00 Occupational therapy evaluation, high complexity, requiring these components: An occupational profile and medical and therapy history, which includes review of medical and/or therapy records and extensive additional review of physical, cognitive, or psychosocial history related to current functional performance; An assessment(s) that identifies 5 or more performance deficits (ie, relating to physical, cognitive, or psychosocial skills) that result in activity limitations and/or participation restrictions; and Clinical decision making of high analytic complexity, which includes an analysis of the patient profile, analysis of data from comprehensive assessment(s), and consideration of multiple treatment options. Patient presents with comorbidities that affect occupational performance. Significant modification of tasks or assistance (eg, physical or verbal) with assessment(s) is necessary to enable patient to complete evaluation component. Typically, 60 minutes are spent face-to-face with the patient and/or family. Each 268.00 214.4000 92.91 268.00 Re-evaluation of occupational therapy established plan of care, requiring these components: An assessment of changes in patient functional or medical status with revised plan of care; An update to the initial occupational profile to reflect changes in condition or environment that affect future interventions and/or goals; and A revised plan of care. A formal reevaluation is performed when there is a documented change in functional status or a significant change to the plan of care is required. Typically, 30 minutes are spent face-to-face with the patient and/or family. Each 135.85 108.6800 63.79 135.85 Therapeutic activities, direct (one-on-one) patient contact (use of dynamic activities to improve functional performance), each 15 minutes Each 210.00 168.0000 34.10 210.00 Sensory integrative techniques to enhance sensory processing and promote adaptive responses to environmental demands, direct (one-on-one) patient contact, each 15 minutes Each 95.00 76.0000 57.77 95.00 Self-care/home management training (eg, activities of daily living (ADL) and compensatory training, meal preparation, safety procedures, and instructions in use of assistive technology devices/adaptive equipment) direct one-on-one contact, each 15 minutes Each 48.00 38.4000 29.71 48.00 Community/work reintegration training (eg, shopping, transportation, money management, avocational activities and/or work environment/modification analysis, work task analysis, use of assistive technology device/adaptive equipment), direct one-on-one contact, each 15 minutes Each 45.50 36.4000 28.16 45.50 Wheelchair management (eg, assessment, fitting, training), each 15 minutes Each 42.70 34.1600 26.43 42.70 Work hardening/conditioning; initial 2 hours 2.0000 hr 122.00 97.6000 75.52 122.00 Work hardening/conditioning; each additional hour (List separately in addition to code for primary procedure) 1.0000 hr 65.00 52.0000 40.24 65.00 Debridement (eg, high pressure waterjet with/without suction, sharp selective debridement with scissors, scalpel and forceps), open wound, (eg, fibrin, devitalized epidermis and/or dermis, exudate, debris, biofilm), including topical application(s), wound assessment, use of a whirlpool, when performed and instruction(s) for ongoing care, per session, total wound(s) surface area; first 20 sq cm or less Each 132.00 105.6000 81.71 182.08 Debridement (eg, high pressure waterjet with/without suction, sharp selective debridement with scissors, scalpel and forceps), open wound, (eg, fibrin, devitalized epidermis and/or dermis, exudate, debris, biofilm), including topical application(s), wound assessment, use of a whirlpool, when performed and instruction(s) for ongoing care, per session, total wound(s) surface area; each additional 20 sq cm, or part thereof (List separately in addition to code for primary procedure) 1.0000 Session 125.00 100.0000 77.38 125.00 Removal of devitalized tissue from wound(s), non-selective debridement, without anesthesia (eg, wet-to-moist dressings, enzymatic, abrasion, larval therapy), including topical application(s), wound assessment, and instruction(s) for ongoing care, per session 1.0000 Session(s) 136.45 109.1600 84.46 182.08 Negative pressure wound therapy (eg, vacuum assisted drainage collection), utilizing durable medical equipment (DME), including topical application(s), wound assessment, and instruction(s) for ongoing care, per session; total wound(s) surface area less than or equal to 50 square centimeters 1.0000 Session(s) 5434.04 4347.2300 167.94 5434.04 Physical performance test or measurement (eg, musculoskeletal, functional capacity), with written report, each 15 minutes Each 54.85 43.8800 31.14 54.85 Orthotic(s) management and training (including assessment and fitting when not otherwise reported), upper extremity(ies), lower extremity(ies) and/or trunk, initial orthotic(s) encounter, each 15 minutes Each 45.00 36.0000 27.86 48.13 Prosthetic(s) training, upper and/or lower extremity(ies), initial prosthetic(s) encounter, each 15 minutes Each 54.85 43.8800 33.95 54.85 Orthotic(s)/prosthetic(s) management and/or training, upper extremity(ies), lower extremity(ies), and/or trunk, subsequent orthotic(s)/prosthetic(s) encounter, each 15 minutes Each 42.70 34.1600 26.43 52.60 Medical nutrition therapy; initial assessment and intervention, individual, face-to-face with the patient, each 15 minutes 15.0000 min 53.25 42.6000 32.96 53.25 Medical nutrition therapy; re-assessment and intervention, individual, face-to-face with the patient, each 15 minutes 15.0000 min 53.25 42.6000 29.35 53.25 Medical nutrition therapy; group (2 or more individual(s)), each 30 minutes 30.0000 min 22.00 17.6000 13.62 22.00 Handling and/or conveyance of specimen for transfer from the patient in other than an office to a laboratory (distance may be indicated) 1.0000 each 24.00 19.2000 14.86 24.00 Supplies and materials (except spectacles), provided by the physician or other qualified health care professional over and above those usually included with the office visit or other services rendered (list drugs, trays, supplies, or materials provided) 1.0000 Each 13.71 10.9700 8.49 13.71 Anesthesia complicated by utilization of controlled hypotension (List separately in addition to code for primary anesthesia procedure) 1.0000 each 893.00 714.4000 552.77 893.00 Moderate sedation services provided by a physician or other qualified health care professional other than the physician or other qualified health care professional performing the diagnostic or therapeutic service that the sedation supports; initial 15 minutes of intraservice time, patient age 5 years or older 15.0000 min 177.00 141.6000 109.56 177.00 Phlebotomy, therapeutic (separate procedure) 1.0000 each 80.00 64.0000 49.52 117.07 Emergency department visit for the evaluation and management of a patient that may not require the presence of a physician or other qualified health care professional 1.0000 each 420.00 336.0000 69.83 550.00 Emergency department visit for the evaluation and management of a patient, which requires a medically appropriate history and/or examination and straightforward medical decision making 1.0000 each 735.00 588.0000 129.91 735.00 Emergency department visit for the evaluation and management of a patient, which requires a medically appropriate history and/or examination and low level of medical decision making 1.0000 each 1300.00 1040.0000 227.88 1300.00 Emergency department visit for the evaluation and management of a patient, which requires a medically appropriate history and/or examination and moderate level of medical decision making 1.0000 each 1800.00 1440.0000 354.89 1800.00 Emergency department visit for the evaluation and management of a patient, which requires a medically appropriate history and/or examination and high level of medical decision making 1.0000 each 2300.00 1840.0000 509.74 2300.00 Critical care, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes 1.0000 each 2310.00 1848.0000 550.00 2310.00 Critical care, evaluation and management of the critically ill or critically injured patient; each additional 30 minutes (List separately in addition to code for primary service) 30.0000 min 3000.00 2400.0000 550.00 3000.00 Delivery/birthing room resuscitation, provision of positive pressure ventilation and/or chest compressions in the presence of acute inadequate ventilation and/or cardiac output 1.0000 each 594.00 475.2000 367.69 594.00 Ground mileage, per statute mile 1.0000 Mile 21.00 16.8000 13.00 21.00 Ambulance service, advanced life support, non-emergency transport, level 1 (als 1) 1.0000 each 600.00 480.0000 371.40 600.00 Ambulance service, advanced life support, emergency transport, level 1 (als 1 - emergency) 1.0000 each 775.00 620.0000 479.72 775.00 Ambulance service, basic life support, non-emergency transport, (bls) 1.0000 each 450.00 360.0000 278.55 450.00 Ambulance service, basic life support, emergency transport (bls-emergency) 1.0000 each 675.00 540.0000 417.82 675.00 Advanced life support, level 2 (als 2) 1.0000 each 1100.00 880.0000 680.90 1100.00 Sterile water, saline and/or dextrose, diluent/flush, 10 ml 10.0000 ml 15.00 12.0000 9.28 15.00 Sterile water/saline, 500 ml 500.0000 ml 24.50 19.6000 15.17 24.50 Betadine or phisohex solution, per pint 1.0000 Pint 298.11 0.0000 N/A N/A Permanent implantable contraceptive intratubal occlusion device(s) and delivery system 1.0000 Each 3776.00 3020.8000 1246.08 3776.00 Disposable drug delivery system, flow rate of 50 ml or greater per hour 1.0000 Each 29.63 23.7000 18.34 29.63 Insertion tray without drainage bag with indwelling catheter, foley type, two-way, all silicone 1.0000 Each 47.79 38.2300 29.58 47.79 Irrigation tray with bulb or piston syringe, any purpose 1.0000 Each 11.63 9.3000 7.20 11.63 Irrigation syringe, bulb or piston, each 1.0000 Each 8.96 7.1700 5.55 8.96 Male external catheter with integral collection chamber, any type, each 1.0000 Each 9.66 7.7300 5.98 9.66 Incontinence supply; miscellaneous 1.0000 Each 37.45 29.9600 23.18 37.45 Indwelling catheter; foley type, two-way latex with coating (teflon, silicone, silicone elastomer, or hydrophilic, etc.), each 1.0000 Each 15.54 12.4300 9.62 15.54 Indwelling catheter; specialty type, (e.g., coude, mushroom, wing, etc.), each 1.0000 Each 371.70 297.3600 230.08 371.70 Indwelling catheter, foley type, two-way, all silicone, each 1.0000 Each 22.64 18.1100 14.01 22.64 Indwelling catheter; foley type, three way for continuous irrigation, each 1.0000 Each 39.11 31.2900 24.21 39.11 Intermittent urinary catheter; straight tip, with or without coating (teflon, silicone, silicone elastomer, or hydrophilic, etc.), each 1.0000 Each 7.12 5.7000 4.41 7.12 Intermittent urinary catheter; coude (curved) tip, with or without coating (teflon, silicone, silicone elastomeric, or hydrophilic, etc.), each 1.0000 Each 55.30 44.2400 34.23 55.30 Intermittent urinary catheter, with insertion supplies 1.0000 Each 13.02 10.4200 8.06 13.02 Bedside drainage bag, day or night, with or without anti-reflux device, with or without tube, each 1.0000 Each 18.76 15.0100 11.61 18.76 Urinary drainage bag, leg or abdomen, vinyl, with or without tube, with straps, each 1.0000 Each 23.66 18.9300 14.65 23.66 Adhesive, liquid or equal, any type, per oz 1.0000 Oz 79.45 63.5600 49.18 79.45 Ostomy irrigation supply; bag, each 1.0000 Each 6.90 5.5200 4.27 6.90 Surgical trays 1.0000 Each 48.89 39.1100 30.26 48.89 Electrodes, (e.g., apnea monitor), per pair 1.0000 Pair 30.48 24.3800 18.87 30.48 Slings 1.0000 Each 13.70 10.9600 8.48 13.70 Splint 1.0000 Each 52.36 41.8900 32.41 52.36 Cast supplies (e.g., plaster) 1.0000 Each 42.12 33.7000 26.07 42.12 Special casting material (e.g., fiberglass) 1.0000 Each 1693.04 0.0000 N/A N/A Electrical stimulator supplies, 2 lead, per month, (e.g., tens, nmes) 1.0000 Month 70.30 56.2400 43.52 70.30 Tubing (oxygen), per foot 1.0000 Each 6.69 5.3500 4.14 6.69 Mouth piece 1.0000 Each 3.10 2.4800 1.92 3.10 Breathing circuits 1.0000 Each 19.75 15.8000 12.23 19.75 Face tent 1.0000 Each 25.20 20.1600 15.60 25.20 Tracheal suction catheter, any type other than closed system, each 1.0000 Each 37.22 29.7800 23.04 37.22 Tracheostomy care kit for new tracheostomy 1.0000 Each 79.65 63.7200 49.30 79.65 Leg strap; foam or fabric, replacement only, per set 1.0000 Each 26.74 21.3900 16.55 26.74 Gauze, non-impregnated, non-sterile, pad size 16 sq. in. or less, without adhesive border, each dressing 1.0000 Each 5.68 4.5400 3.52 5.68 Gauze, non-impregnated, non-sterile, pad size more than 16 sq. in. but less than or equal to 48 sq. in., without adhesive border, each dressing 1.0000 Each 13.38 10.7000 8.28 13.38 Gauze, non-impregnated, non-sterile, pad size more than 48 sq. in., without adhesive border, each dressing 1.0000 Each 6.52 5.2200 4.04 6.52 Gauze, non-impregnated, sterile, pad size more than 16 sq. in. but less than or equal to 48 sq. in., with any size adhesive border, each dressing 1.0000 Each 20115.13 0.0000 N/A N/A Gauze, impregnated with other than water, normal saline, or hydrogel, sterile, pad size 16 sq. in. or less, without adhesive border, each dressing 1.0000 Each 15.40 12.3200 9.53 15.40 Gauze, impregnated with other than water, normal saline, or hydrogel, sterile, pad size more than 16 sq. in., but less than or equal to 48 sq. in., without adhesive border, each dressing 1.0000 Each 9.37 7.5000 5.80 9.37 Gauze, impregnated, water or normal saline, sterile, pad size 16 sq. in. or less, without adhesive border, each dressing 1.0000 Each 6.48 5.1800 4.01 6.48 Hydrogel dressing, wound cover, sterile, pad size 16 sq. in. or less, without adhesive border, each dressing 1.0000 Each 16.39 13.1100 10.15 16.39 Hydrogel dressing, wound cover, sterile, pad size more than 48 sq. in., without adhesive border, each dressing 1.0000 Each 52.18 41.7400 32.30 52.18 Hydrogel dressing, wound cover, sterile, pad size 16 sq. in. or less, with any size adhesive border, each dressing 1.0000 Each 24.33 19.4600 15.06 24.33 Hydrogel dressing, wound cover, sterile, pad size more than 16 sq. in. but less than or equal to 48 sq. in., with any size adhesive border, each dressing 1.0000 Each 57.09 45.6700 35.34 57.09 Hydrogel dressing, wound filler, gel, per fluid ounce 1.0000 fl oz 19.54 15.6300 12.10 19.54 Skin sealants, protectants, moisturizers, ointments, any type, any size 1.0000 Each 22.88 18.3000 14.16 22.88 Specialty absorptive dressing, wound cover, sterile, pad size 16 sq. in. or less, without adhesive border, each dressing 1.0000 Each 36.20 28.9600 22.41 36.20 Specialty absorptive dressing, wound cover, sterile, pad size more than 16 sq. in. but less than or equal to 48 sq. in., without adhesive border, each dressing 1.0000 Each 49.05 39.2400 30.36 49.05 Specialty absorptive dressing, wound cover, sterile, pad size 16 sq. in. or less, with any size adhesive border, each dressing 1.0000 Each 310.58 248.4600 192.25 310.58 Transparent film, sterile, 16 sq. in. or less, each dressing 1.0000 Each 7.63 6.1000 4.72 7.63 Transparent film, sterile, more than 16 sq. in. but less than or equal to 48 sq. in., each dressing 1.0000 Each 7.92 6.3400 4.90 7.92 Wound filler, dry form, per gram, not otherwise specified 1.0000 g 32.15 25.7200 19.90 32.15 Non-covered item or service 1.0000 Each 0.99 0.7900 0.61 0.99 Technetium tc-99m sestamibi, diagnostic, per study dose 1.0000 Each 552.00 441.6000 341.69 552.00 Technetium tc-99m medronate, diagnostic, per study dose, up to 30 millicuries 30.0000 Dose(s) 268.00 214.4000 165.89 268.00 Thallium tl-201 thallous chloride, diagnostic, per millicurie 1.0000 mCi 97.00 77.6000 60.04 97.00 Technetium tc-99m disofenin, diagnostic, per study dose, up to 15 millicuries 1.0000 Dose(s) 279.00 223.2000 172.70 279.00 Technetium tc-99m pertechnetate, diagnostic, per millicurie 1.0000 mCi 32.00 25.6000 19.81 32.00 Iodine i-123 sodium iodide, diagnostic, per 100 microcuries, up to 999 microcuries 100.0000 Microcuries 170.00 136.0000 105.23 170.00 Technetium tc-99m mebrofenin, diagnostic, per study dose, up to 15 millicuries 1.0000 Dose(s) 265.00 212.0000 164.04 265.00 Technetium tc-99m pyrophosphate, diagnostic, per study dose, up to 25 millicuries 1.0000 Dose(s) 170.00 136.0000 105.23 170.00 Technetium tc-99m pentetate, diagnostic, per study dose, up to 25 millicuries 1.0000 Dose(s) 268.00 214.4000 165.89 268.00 Technetium tc-99m macroaggregated albumin, diagnostic, per study dose, up to 10 millicuries 1.0000 Dose(s) 268.00 214.4000 165.89 268.00 Technetium tc-99m sulfur colloid, diagnostic, per study dose, up to 20 millicuries 1.0000 Dose(s) 268.00 214.4000 165.89 268.00 Indium in-111 oxyquinoline, diagnostic, per 0.5 millicurie 0.5000 mCi 2461.00 1968.8000 1523.36 2461.00 Indium in-111 pentetate, diagnostic, per 0.5 millicurie 0.5000 mCi 2307.00 1845.6000 1428.03 2307.00 Gallium ga-67 citrate, diagnostic, per millicurie 1.0000 mCi 37.00 29.6000 22.90 37.00 Technetium tc-99m labeled red blood cells, diagnostic, per study dose, up to 30 millicuries 1.0000 Dose(s) 179.00 143.2000 110.80 179.00 Technetium tc-99m mertiatide, diagnostic, per study dose, up to 15 millicuries 1.0000 Dose(s) 215.00 172.0000 133.08 215.00 Injection, gadobenate dimeglumine (multihance), per ml 1.0000 ML 411.76 329.4100 254.88 411.76 Injection, gadolinium-based magnetic resonance contrast agent, not otherwise specified (nos), per ml 1.0000 ML 22.00 17.6000 13.62 22.00 Injection, gadobutrol, 0.1 ml 0.1000 ML 587.64 470.1100 363.75 587.64 Strontium sr-89 chloride, therapeutic, per millicurie 1.0000 mCi 8166.00 6532.8000 3948.74 8166.00 Stomach tube - levine type 1.0000 Each 10.35 8.2800 6.41 10.35 Anchor/screw for opposing bone-to-bone or soft tissue-to-bone (implantable) 1.0000 Each 5800.00 4640.0000 1914.00 5800.00 Catheter, balloon dilatation, non-vascular 1.0000 Each 8700.00 6960.0000 2871.00 8700.00 Catheter, drainage 1.0000 Each 2812.00 2249.6000 927.96 2812.00 Catheter, infusion, inserted peripherally, centrally or midline (other than hemodialysis) 1.0000 Each 298.00 238.4000 98.34 298.00 Catheter, intradiscal 1.0000 Each 2954.35 2363.4800 974.94 2954.35 Catheter, intraspinal 1.0000 Each 1216.25 973.0000 401.36 1216.25 Catheter, ureteral 1.0000 Each 194.61 155.6900 64.22 194.61 Connective tissue, human (includes fascia lata) 1.0000 Each 9880.00 7904.0000 3260.40 9880.00 Connective tissue, non-human (includes synthetic) 1.0000 Each 17955.00 14364.0000 5925.15 17955.00 Event recorder, cardiac (implantable) 1.0000 Each 12750.00 10200.0000 4207.50 12750.00 Generator, neurostimulator (implantable), non-rechargeable 1.0000 Each 27977.80 22382.2400 9232.67 27977.80 Guide wire 1.0000 Each 217.71 174.1700 71.84 217.71 Repair device, urinary, incontinence, with sling graft 1.0000 Each 3796.00 3036.8000 1252.68 3796.00 Infusion pump, programmable (implantable) 1.0000 Each 22068.85 17655.0800 7282.72 22068.85 Joint device (implantable) 1.0000 Each 1458.00 1166.4000 481.14 1458.00 Lead, neurostimulator (implantable) 1.0000 Each 15468.09 12374.4700 5104.47 15468.09 Lead, pacemaker, transvenous vdd single pass 1.0000 Each 2175.00 1740.0000 1346.32 2175.00 Mesh (implantable) 1.0000 Each 632.40 505.9200 208.69 632.40 Morcellator 1.0000 Each 2322.83 1858.2600 766.53 2322.83 Ocular implant, aqueous drainage assist device 1.0000 Each 3980.00 3184.0000 1313.40 3980.00 Pacemaker, dual chamber, rate-responsive (implantable) 1.0000 Each 22420.00 17936.0000 13877.98 22420.00 Pacemaker, single chamber, rate-responsive (implantable) 1.0000 Each 12690.00 10152.0000 7855.11 12690.00 Patient programmer, neurostimulator 1.0000 Each 3654.00 2923.2000 1205.82 3654.00 Port, indwelling (implantable) 1.0000 Each 1342.66 1074.1300 443.08 1342.66 Prosthesis, breast (implantable) 1.0000 Each 6380.00 5104.0000 2105.40 6380.00 Generator, neurostimulator (implantable), with rechargeable battery and charging system 1.0000 Each 73234.00 58587.2000 24167.22 73234.00 Interspinous process distraction device (implantable) 1.0000 Each 14.02 11.2200 4.63 14.02 Vena cava filter 1.0000 Each 5060.00 4048.0000 1669.80 5060.00 Adapter/extension, pacing lead or neurostimulator lead (implantable) 1.0000 Each 3752.40 3001.9200 2322.74 3752.40 Catheter, extravascular tissue ablation, any modality (insertable) 1.0000 each 3104.82 2483.8600 1024.59 3104.82 Catheter, guiding (may include infusion/perfusion capability) 1.0000 Each 1182.81 946.2500 390.33 1182.81 Catheter, ablation, non-cardiac, endovascular (implantable) 1.0000 Each 2800.00 2240.0000 924.00 2800.00 Introducer/sheath, other than guiding, other than intracardiac electrophysiological, non-laser 1.0000 Each 1.00 0.8000 0.33 1.00 Stent, non-coronary, temporary, without delivery system 1.0000 Each 300.00 240.0000 99.00 300.00 Pacemaker, dual chamber, non rate-responsive (implantable) 1.0000 Each 18000.00 14400.0000 11142.00 18000.00 Repair device, urinary, incontinence, without sling graft 1.0000 Each 1174.80 939.8400 387.68 1174.80 Magnetic resonance angiography without contrast followed by with contrast, abdomen 1.0000 each 1571.00 1256.8000 342.64 1571.00 Magnetic resonance angiography without contrast followed by with contrast, chest (excluding myocardium) 1.0000 each 1773.00 1418.4000 342.64 1773.00 Magnetic resonance angiography without contrast followed by with contrast, lower extremity 1.0000 each 2640.00 2112.0000 342.64 2640.00 Magnetic resonance angiography without contrast followed by with contrast, pelvis 1.0000 each 1739.00 1391.2000 342.64 1739.00 Magnetic resonance angiography without contrast followed by with contrast, spinal canal and contents 1.0000 each 1845.00 1476.0000 342.64 1845.00 Injection, pantoprazole sodium, per vial 1.0000 Vial 50.15 40.1200 31.04 50.15 Human plasma fibrin sealant, vapor-heated, solvent-detergent (artiss), 2 ml 2.0000 ML 864.99 691.9900 171.51 864.99 Injection, bupivacaine liposome, 1 mg 1.0000 mg 2041.20 1632.9600 1263.50 2041.20 Porous purified collagen matrix bone void filler (integra mozaik osteoconductive scaffold putty, integra os osteoconductive scaffold putty), per 0.5 cc 0.5000 CC 3710.00 2968.0000 2296.49 3710.00 Porous purified collagen matrix bone void filler (integra mozaik osteoconductive scaffold strip), per 0.5 cc 0.5000 CC 4320.00 3456.0000 2674.08 4320.00 Cystourethroscopy, with insertion of transprostatic implant; 4 or more implants 1.0000 each 11785.41 9428.3300 7295.17 11785.41 Crutches, forearm, includes crutches of various materials, adjustable or fixed, pair, complete with tips and handgrips 1.0000 Pair 67.07 53.6600 41.52 102.50 Lambswool sheepskin pad, any size 1.0000 Each 91.57 73.2600 56.68 91.57 Positioning cushion/pillow/wedge, any shape or size, includes all components and accessories 1.0000 Each 98.64 78.9100 61.06 98.64 Heel or elbow protector, each 1.0000 Each 18.69 14.9500 10.73 18.69 Bed accessory: board, table, or support device, any type 1.0000 Each 25.59 20.4700 15.84 25.59 Restraints, any type (body, chest, wrist or ankle) 1.0000 Each 47.58 38.0600 29.45 47.58 Osteogenesis stimulator, electrical, surgically implanted 1.0000 Each 19405.65 15524.5200 12012.10 19405.65 Traction frame, attached to footboard, extremity traction, (e.g., buck's) 1.0000 Each 70.50 56.4000 43.64 135.43 Administration of pneumococcal vaccine 1.0000 each 79.00 63.2000 39.40 79.00 Prostate cancer screening; prostate specific antigen test (psa) 1.0000 each 120.00 96.0000 18.34 120.00 Colorectal cancer screening; flexible sigmoidoscopy Each 7212.56 5770.0400 772.86 7212.56 Colorectal cancer screening; colonoscopy on individual at high risk Each 8177.06 6541.6500 772.86 8177.06 Colorectal cancer screening; colonoscopy on individual not meeting criteria for high risk Each 7462.50 5970.0000 772.86 7462.50 Wound closure utilizing tissue adhesive(s) only Each 45.14 36.1100 27.94 45.14 Training and educational services related to the care and treatment of patient's disabling mental health problems per session (45 minutes or more) 1.0000 Session 52.50 42.0000 32.50 52.50 Diagnostic digital breast tomosynthesis, unilateral or bilateral (list separately in addition to 77065 or 77066) 1.0000 each 158.00 126.4000 48.32 158.00 Electrical stimulation (unattended), to one or more areas for indication(s) other than wound care, as part of a therapy plan of care Each 95.00 76.0000 11.11 95.00 Hospital observation service, per hour 1.0000 hr 52.50 42.0000 32.50 52.50 Direct admission of patient for hospital observation care 1.0000 each 1050.00 840.0000 509.74 1050.00 Surgical pathology, gross and microscopic examinations, for prostate needle biopsy, any method 1.0000 each 565.23 452.1800 301.42 565.23 Hospital outpatient clinic visit for assessment and management of a patient 1.0000 each 177.00 141.6000 109.56 177.00 Collection of venous blood by venipuncture or urine sample by catheterization from an individual in a skilled nursing facility (snf) or by a laboratory on behalf of a home health agency (hha) 1.0000 each 32.00 25.6000 10.04 32.00 Injection, acetaminophen, not otherwise specified,10 mg 10.0000 MG 250.63 200.5000 155.14 250.63 Injection, acyclovir, 5 mg 5.0000 MG 177.00 141.6000 109.56 177.00 Injection, adenosine, 1 mg (not to be used to report any adenosine phosphate compounds) 1.0000 mg 43.90 35.1200 27.17 43.90 Injection, adrenalin, epinephrine, 0.1 mg 0.1000 MG 44.25 35.4000 27.39 44.25 Injection, alatrofloxacin mesylate, 100 mg 100.0000 MG 15.00 12.0000 9.28 15.00 Injection, methyldopate hcl, up to 250 mg 250.0000 MG 147.50 118.0000 91.30 147.50 Injection, aminophyllin, up to 250 mg 250.0000 MG 86.02 68.8200 53.25 86.02 Injection, amiodarone hydrochloride, 30 mg 30.0000 MG 308.22 246.5800 190.79 308.22 Injection, amphotericin b, 50 mg 50.0000 MG 144.55 115.6400 89.48 144.55 Injection, ampicillin sodium, 500 mg 500.0000 MG 56.23 44.9800 34.81 56.23 Injection, ampicillin sodium/sulbactam sodium, per 1.5 gm 1.5000 GM 90.68 72.5400 56.13 90.68 Injection, succinylcholine chloride, up to 20 mg 20.0000 MG 68.44 54.7500 42.36 68.44 Injection, hydralazine hcl, up to 20 mg 20.0000 MG 88.50 70.8000 54.78 88.50 Injection, azithromycin, 500 mg 500.0000 MG 61.07 48.8600 37.80 61.07 Injection, atropine sulfate, 0.01 mg 0.0100 MG 73.75 59.0000 45.65 73.75 Injection, benztropine mesylate, per 1 mg 1.0000 MG 424.80 339.8400 262.95 424.80 Injection, penicillin g benzathine, 100,000 units 100000.0000 Unit(s) 1115.59 892.4700 17.21 1115.59 Injection, onabotulinumtoxina, 1 unit 1.0000 Unit(s) 3173.28 2538.6200 6.00 3173.28 Injection, buprenorphine hydrochloride, 0.1 mg 0.1000 MG 36.88 29.5000 22.83 36.88 injection, busulfan, 1 mg 1.0000 MG 15.00 12.0000 1.09 15.00 Injection, butorphanol tartrate, 1 mg 1.0000 MG 28.26 22.6100 17.49 28.26 Injection, calcium gluconate (fresenius kabi), per 10 ml 10.0000 ML 64.78 51.8200 40.10 64.78 Injection, calcitonin salmon, up to 400 units 400.0000 UNITS 10379.78 8303.8200 1840.99 10379.78 Injection, leucovorin calcium, per 50 mg 50.0000 MG 91.55 73.2400 56.67 91.55 Injection, levoleucovorin, not otherwise specified, 0.5 mg 0.5000 MG 11.47 9.1800 0.25 11.47 Injection, cefazolin sodium, 500 mg 500.0000 MG 55.85 44.6800 34.57 55.85 Injection, cefepime hydrochloride, 500 mg 500.0000 MG 171.99 137.5900 106.46 171.99 Injection, cefoxitin sodium, 1 gm 1.0000 GM 72.57 58.0600 44.92 72.57 Injection, ceftriaxone sodium, per 250 mg 250.0000 MG 15.00 12.0000 9.28 15.00 Injection, cefotaxime sodium, per gm 1.0000 GM 110.40 88.3200 68.34 110.40 Injection, betamethasone acetate 3 mg and betamethasone sodium phosphate 3 mg 3.0000 MG 72.92 58.3400 45.14 72.92 Injection, ceftazidime, per 500 mg 500.0000 MG 113.04 90.4300 69.97 113.04 Injection, ceftizoxime sodium, per 500 mg 500.0000 MG 103.59 82.8700 64.12 103.59 Injection, cidofovir, 375 mg 375.0000 MG 3907.20 3125.7600 598.29 3907.20 Injection, cilastatin sodium; imipenem, per 250 mg 250.0000 MG 173.93 139.1400 107.66 173.93 Injection, ciprofloxacin for intravenous infusion, 200 mg 200.0000 MG 55.85 44.6800 34.57 55.85 Injection, codeine phosphate, per 30 mg 30.0000 MG 16.55 13.2400 10.24 32.60 Injection, prochlorperazine, up to 10 mg 10.0000 MG 128.38 102.7000 79.47 128.38 Injection, cosyntropin, 0.25 mg 0.2500 MG 754.61 603.6900 467.10 754.61 Injection, crotalidae polyvalent immune fab (ovine), up to 1 gram 1.0000 GM 17372.16 13897.7300 2006.48 17372.16 Injection, daptomycin, 1 mg 1.0000 MG 2595.24 2076.1900 1606.45 2595.24 Injection, darbepoetin alfa, 1 microgram (non-esrd use) 1.0000 MCG 13616.64 10893.3100 2.97 13616.64 Injection, epoetin alfa, (for non-esrd use), 1000 units 1000.0000 Unit(s) 119.43 95.5400 7.83 119.43 Injection, decitabine, 1 mg 1.0000 MG 193.99 155.1900 120.08 193.99 Injection, denosumab, 1 mg 1.0000 MG 7034.30 5627.4400 21.91 7034.30 Injection, methylprednisolone acetate, 40 mg 40.0000 MG 68.26 54.6100 42.25 68.26 Injection, methylprednisolone acetate, 80 mg 80.0000 MG 101.72 81.3800 62.96 101.72 Injection, medroxyprogesterone acetate, 1 mg 1.0000 MG 318.60 254.8800 197.21 318.60 Injection, testosterone cypionate, 1 mg 1.0000 mg 1123.20 898.5600 695.26 1123.20 Injection, dexamethasone sodium phosphate, 1 mg 1.0000 MG 15.00 12.0000 9.28 15.00 Injection, dihydroergotamine mesylate, per 1 mg 1.0000 MG 929.96 743.9700 575.65 929.96 Injection, acetazolamide sodium, up to 500 mg 500.0000 MG 283.20 226.5600 175.30 283.20 Injection, digoxin, up to 0.5 mg 0.5000 MG 38.94 31.1500 24.10 38.94 Injection, digoxin immune fab (ovine), per vial 1.0000 VIAL 13632.00 10905.6000 4367.17 13632.00 Injection, phenytoin sodium, per 50 mg 50.0000 MG 15.00 12.0000 9.28 15.00 Injection, hydromorphone, up to 4 mg 4.0000 MG 15.00 12.0000 9.28 15.00 Injection, diphenhydramine hcl, up to 50 mg 50.0000 MG 35.40 28.3200 21.91 35.40 Injection, chlorothiazide sodium, per 500 mg 500.0000 MG 424.80 339.8400 262.95 424.80 Injection, methadone hcl, up to 10 mg 10.0000 MG 91.21 72.9700 56.46 91.21 Injection, dimenhydrinate, up to 50 mg 50.0000 MG 35.05 28.0400 21.70 35.05 Injection, dobutamine hydrochloride, per 250 mg 250.0000 MG 159.83 127.8600 98.93 159.83 Injection, dopamine hcl, 40 mg 40.0000 MG 91.69 73.3500 56.76 91.69 Injection, doripenem, 10 mg 10.0000 MG 265.97 212.7800 164.64 265.97 Injection, eptifibatide, 5 mg 5.0000 MG 2531.30 2025.0400 1566.87 2531.30 Injection, ertapenem sodium, 500 mg 500.0000 MG 864.00 691.2000 534.82 864.00 Injection, erythromycin lactobionate, per 500 mg 500.0000 MG 368.04 294.4300 77.72 368.04 Injection, estrogen conjugated, per 25 mg 25.0000 MG 1115.57 892.4600 337.75 1115.57 Injection, etidronate disodium, per 300 mg 300.0000 MG 332.45 265.9600 205.79 332.45 Injection, etanercept, 25 mg (code may be used for medicare when drug administered under the direct supervision of a physician, not for use when drug is self administered) 25.0000 MG 2046.44 1637.1500 751.24 2046.44 Injection, filgrastim (g-csf), excludes biosimilars, 1 microgram 1.0000 mcg 2534.40 2027.5200 0.93 2534.40 Injection fluconazole, 200 mg 200.0000 MG 85.61 68.4900 52.99 85.61 Injection, fosaprepitant, 1 mg 1.0000 MG 2250.00 1800.0000 1392.75 2250.00 Injection, garamycin, gentamicin, up to 80 mg 80.0000 MG 15.00 12.0000 9.28 15.00 Injection, glatiramer acetate, 20 mg 20.0000 MG 1319.87 1055.9000 134.48 1319.87 Injection, glucagon hydrochloride, per 1 mg 1.0000 MG 1759.05 1407.2400 165.09 1759.05 Injection, granisetron hydrochloride, 100 mcg 100.0000 MCG 141.60 113.2800 87.65 141.60 Injection, haloperidol, up to 5 mg 5.0000 MG 15.00 12.0000 9.28 15.00 Injection, heparin sodium, (heparin lock flush), per 10 units 10.0000 Unit(s) 15.00 12.0000 9.28 15.00 Injection, heparin sodium, per 1000 units 1000.0000 Unit(s) 29.32 23.4600 18.15 29.32 Injection, dalteparin sodium, per 2500 iu 2500.0000 IU 80.65 64.5200 49.92 80.65 Injection, enoxaparin sodium, 10 mg 10.0000 MG 42.95 34.3600 26.59 42.95 Injection, hydrocortisone sodium succinate, up to 100 mg 100.0000 MG 104.02 83.2200 64.39 104.02 Injection, hydroxyprogesterone caproate, (makena), 10 mg 10.0000 mg 195.30 156.2400 14.40 195.30 Injection, ibandronate sodium, 1 mg 1.0000 MG 740.20 592.1600 32.33 740.20 Injection, ibutilide fumarate, 1 mg 1.0000 MG 2013.55 1610.8400 226.23 2013.55 Injection, infliximab, excludes biosimilar, 10 mg 10.0000 MG 3564.45 2851.5600 33.12 3564.45 Injection, iron dextran, 50 mg 50.0000 MG 101.10 80.8800 15.75 101.10 Injection, iron sucrose, 1 mg 1.0000 MG 3.54 2.8300 2.19 3.54 Injection, droperidol, up to 5 mg 5.0000 MG 25.08 20.0600 15.52 25.08 Injection, propranolol hcl, up to 1 mg 1.0000 MG 92.10 73.6800 57.01 92.10 Injection, insulin, per 5 units 5.0000 Unit(s) 1.95 1.5600 1.21 1.95 Injection, kanamycin sulfate, up to 500 mg 500.0000 MG 53.70 42.9600 33.24 53.70 Injection, ketorolac tromethamine, per 15 mg 15.0000 MG 15.00 12.0000 9.28 15.00 Injection, furosemide, up to 20 mg 20.0000 MG 20.53 16.4200 12.71 20.53 Injection, leuprolide acetate (for depot suspension), per 3.75 mg 3.7500 MG 2306.77 1845.4200 1400.47 2306.77 Injection, levetiracetam, 10 mg 10.0000 MG 55.87 44.7000 34.58 55.87 Injection, levofloxacin, 250 mg 250.0000 MG 55.85 44.6800 34.57 55.85 Injection, hyoscyamine sulfate, up to 0.25 mg 0.2500 MG 420.08 336.0600 260.03 420.08 Injection, chlordiazepoxide hcl, up to 100 mg 100.0000 MG 130.60 104.4800 80.84 130.60 Injection, lidocaine hcl for intravenous infusion, 10 mg 10.0000 MG 21.24 16.9900 13.15 21.24 Injection, linezolid, 200 mg 200.0000 MG 460.97 368.7800 285.34 460.97 Injection, lorazepam, 2 mg 2.0000 MG 15.00 12.0000 9.28 15.00 Injection, mannitol, 25% in 50 ml 50.0000 ML 143.25 114.6000 88.67 143.25 Injection, meperidine hydrochloride, per 100 mg 100.0000 MG 70.65 56.5200 43.73 70.65 Injection, meperidine and promethazine hcl, up to 50 mg 50.0000 MG 41.15 32.9200 25.47 41.15 Injection, meropenem, 100 mg 100.0000 MG 77.88 62.3000 48.21 77.88 Injection, methylergonovine maleate, up to 0.2 mg 0.2000 MG 139.89 111.9100 86.59 139.89 Injection, micafungin sodium, 1 mg 1.0000 MG 1211.76 969.4100 750.08 1211.76 Injection, midazolam hydrochloride, per 1 mg 1.0000 MG 15.00 12.0000 9.28 15.00 Injection, milrinone lactate, 5 mg 5.0000 MG 107.62 86.1000 66.62 107.62 Injection, morphine sulfate, up to 10 mg 10.0000 MG 15.00 12.0000 9.28 15.00 Injection, morphine sulfate, preservative-free for epidural or intrathecal use, 10 mg 10.0000 mg 69.15 55.3200 42.80 69.15 Injection, moxifloxacin, 100 mg 100.0000 MG 299.25 239.4000 185.24 299.25 Injection, nalbuphine hydrochloride, per 10 mg 10.0000 MG 23.42 18.7400 14.50 23.42 Injection, naloxone hydrochloride, per 1 mg 1.0000 MG 233.64 186.9100 144.62 233.64 Injection, natalizumab, 1 mg 1.0000 MG 11.50 9.2000 7.12 24.54 Injection, nesiritide, 0.1 mg 0.1000 MG 335.20 268.1600 207.49 335.20 Injection, octreotide, depot form for intramuscular injection, 1 mg 1.0000 MG 247.80 198.2400 153.39 247.80 Injection, octreotide, non-depot form for subcutaneous or intravenous injection, 25 mcg 25.0000 MCG 31.86 25.4900 19.72 31.86 Injection, phenylephrine hcl, up to 1 ml 1.0000 ML 32.45 25.9600 20.09 32.45 Injection, chloroprocaine hydrochloride, per 30 ml 30.0000 ML 95.29 76.2300 58.98 95.29 Injection, ondansetron hydrochloride, per 1 mg 1.0000 MG 15.00 12.0000 9.28 15.00 Injection, pamidronate disodium, per 30 mg 30.0000 MG 399.08 319.2600 247.03 399.08 Injection, papaverine hcl, up to 60 mg 60.0000 MG 17.15 13.7200 10.62 17.15 Injection, palonosetron hcl, 25 mcg 25.0000 MCG 268.33 214.6600 166.10 268.33 Injection, penicillin g procaine, aqueous, up to 600,000 units 600000.0000 UNITS 272.82 218.2600 36.22 272.82 Injection, penicillin g potassium, up to 600,000 units 600000.0000 UNITS 194.70 155.7600 120.52 194.70 Injection, piperacillin sodium/tazobactam sodium, 1 gram/0.125 grams (1.125 grams) 1.1250 g 128.38 102.7000 79.47 128.38 Injection, promethazine hcl, up to 50 mg 50.0000 MG 15.00 12.0000 9.28 15.00 Injection, phenobarbital sodium, up to 120 mg 120.0000 MG 203.90 163.1200 43.56 203.90 Injection, oxytocin, up to 10 units 10.0000 UNITS 94.11 75.2900 58.25 94.11 Injection, desmopressin acetate, per 1 mcg 1.0000 MCG 327.39 261.9100 6.97 327.39 Injection, procainamide hcl, up to 1 gm 1.0000 GM 107.50 86.0000 66.54 107.50 Injection, neostigmine methylsulfate, up to 0.5 mg 0.5000 MG 54.58 43.6600 33.79 54.58 Injection, protamine sulfate, per 10 mg 10.0000 MG 53.10 42.4800 32.87 53.10 Injection, phentolamine mesylate, up to 5 mg 5.0000 MG 2754.00 2203.2000 427.84 2754.00 Injection, metoclopramide hcl, up to 10 mg 10.0000 MG 15.00 12.0000 9.28 15.00 Injection, quinupristin/dalfopristin, 500 mg (150/350) 500.0000 MG 1077.40 861.9200 469.27 1077.40 Injection, ranitidine hydrochloride, 25 mg 25.0000 MG 273.82 219.0600 169.49 273.82 Injection, regadenoson, 0.1 mg 0.1000 MG 1419.34 1135.4700 878.57 1419.34 Injection, rho d immune globulin, human, full dose, 300 micrograms (1500 i.u.) 300.0000 MCG 170.40 136.3200 105.48 170.40 Injection, rho(d) immune globulin (human), (rhophylac), intramuscular or intravenous, 100 iu 100.0000 IU 1032.26 825.8100 638.97 1032.26 Injection, ropivacaine hydrochloride, 1 mg 1.0000 MG 44.25 35.4000 27.39 44.25 Injection, methocarbamol, up to 10 ml 10.0000 ML 59.00 47.2000 36.52 59.00 Injection, sincalide, 5 micrograms 5.0000 MCG 510.17 408.1400 315.80 510.17 Injection, sodium ferric gluconate complex in sucrose injection, 12.5 mg 12.5000 MG 225.14 180.1100 139.36 225.14 Injection, methylprednisolone sodium succinate, up to 125 mg 125.0000 MG 39.77 31.8200 24.62 39.77 Injection, reteplase, 18.1 mg 18.1000 MG 11943.87 9555.1000 2413.75 11943.87 Injection, streptokinase, per 250,000 iu 250000.0000 IU 2048.30 1638.6400 1267.90 2048.30 Injection, alteplase recombinant, 1 mg 1.0000 MG 33793.38 27034.7000 83.63 33793.38 Injection, fentanyl citrate, 0.1 mg 0.1000 MG 15.00 12.0000 9.28 15.00 Injection, sumatriptan succinate, 6 mg (code may be used for medicare when drug administered under the direct supervision of a physician, not for use when drug is self administered) 6.0000 MG 501.50 401.2000 310.43 501.50 Injection, pentazocine, 30 mg 30.0000 MG 16.55 13.2400 10.24 16.55 Injection, tenecteplase, 1 mg 1.0000 MG 382.20 305.7600 136.47 382.20 Injection, terbutaline sulfate, up to 1 mg 1.0000 MG 28.32 22.6600 17.53 28.32 Injection, chlorpromazine hcl, up to 50 mg 50.0000 MG 155.76 124.6100 96.42 155.76 Injection, tigecycline, 1 mg 1.0000 MG 997.22 797.7800 617.28 997.22 Injection, tobramycin sulfate, up to 80 mg 80.0000 MG 24.01 19.2100 14.86 24.01 Injection, torsemide, 10 mg/ml 10.0000 MG 53.87 43.1000 33.35 53.87 Injection, triamcinolone acetonide, not otherwise specified, 10 mg 10.0000 MG 60.53 48.4200 37.47 60.53 Injection, triptorelin pamoate, 3.75 mg 3.7500 MG 9368.51 7494.8100 355.82 9368.51 Injection, diazepam, up to 5 mg 5.0000 MG 111.51 89.2100 69.02 111.51 Injection, urokinase, 5000 iu vial 5000.0000 IU 295.70 236.5600 183.04 295.70 Injection, vancomycin hcl, 500 mg 500.0000 MG 113.58 90.8600 70.31 113.58 Injection, hydroxyzine hcl, up to 25 mg 25.0000 MG 157.53 126.0200 97.51 157.53 Injection, vitamin b-12 cyanocobalamin, up to 1000 mcg 1000.0000 MCG 51.57 41.2600 31.92 51.57 Injection, phytonadione (vitamin k), per 1 mg 1.0000 MG 222.37 177.9000 137.65 222.37 Injection, hyaluronidase, up to 150 units 150.0000 UNITS 82.70 66.1600 51.19 82.70 Injection, magnesium sulfate, per 500 mg 500.0000 MG 55.85 44.6800 34.57 55.85 Injection, potassium chloride, per 2 meq 2.0000 MEQ 55.85 44.6800 34.57 55.85 Injection, ziprasidone mesylate, 10 mg 10.0000 MG 185.38 148.3000 114.75 185.38 Injection, zoledronic acid, 1 mg 1.0000 mg 4161.92 3329.5400 2576.23 4161.92 Unclassified drugs 1.0000 Unit(s) 41.36 33.0900 25.60 41.36 Drug administered through a metered dose inhaler 1.0000 Each 147.50 118.0000 91.30 147.50 Unclassified biologics 1.0000 Each 5020.00 4016.0000 3107.38 5020.00 Infusion, normal saline solution , 1000 cc 1000.0000 cc 55.85 44.6800 34.57 55.85 Infusion, normal saline solution, sterile (500 ml = 1 unit) 500.0000 ML 55.85 44.6800 34.57 55.85 5% dextrose/normal saline (500 ml = 1 unit) 500.0000 ML 55.85 44.6800 34.57 55.85 Infusion, normal saline solution, 250 cc 250.0000 cc 55.85 44.6800 34.57 55.85 5% dextrose/water (500 ml = 1 unit) 500.0000 ML 55.85 44.6800 34.57 55.85 Infusion, dextran 75, 500 ml 500.0000 ML 312.50 250.0000 193.44 312.50 Ringers lactate infusion, up to 1000 cc 1000.0000 CC 55.85 44.6800 34.57 55.85 Levonorgestrel-releasing intrauterine contraceptive system (liletta), 52 mg 52.0000 mg 944.25 755.4000 584.49 944.25 Mitomycin, ophthalmic, 0.2 mg 0.2000 mg 274.10 219.2800 169.67 274.10 Autologous cultured chondrocytes, implant 1.0000 EA 78325.20 62660.1600 48483.30 78325.20 Mometasone furoate sinus implant, (sinuva), 10 micrograms 10.0000 mcg 5120.50 4096.4000 10.78 5120.50 Prednisolone oral, per 5 mg 5.0000 MG 24.13 19.3000 14.94 24.13 Acetylcysteine, inhalation solution, fda-approved final product, non-compounded, administered through dme, unit dose form, per gram 1.0000 g 90.57 72.4600 56.06 90.57 Albuterol, inhalation solution, compounded product, administered through dme, unit dose, 1 mg 1.0000 MG 4.72 3.7800 2.92 4.72 Levalbuterol, inhalation solution, fda-approved final product, non-compounded, administered through dme, concentrated form, 0.5 mg 0.5000 MG 39.53 31.6200 24.47 39.53 Albuterol, inhalation solution, fda-approved final product, non-compounded, administered through dme, unit dose, 1 mg 1.0000 MG 4.00 3.2000 2.48 4.00 Albuterol, up to 2.5 mg and ipratropium bromide, up to 0.5 mg, fda-approved final product, non-compounded, administered through dme 2.5000 MG 13.57 10.8600 8.40 13.57 Cromolyn sodium, inhalation solution, fda-approved final product, non-compounded, administered through dme, unit dose form, per 10 milligrams 10.0000 MG 3.55 2.8400 2.20 3.55 Ipratropium bromide, inhalation solution, fda-approved final product, non-compounded, administered through dme, unit dose form, per milligram 1.0000 MG 7.79 6.2300 4.82 7.79 Isoetharine hcl, inhalation solution, fda-approved final product, non-compounded, administered through dme, unit dose form, per milligram 1.0000 MG 90.60 72.4800 56.08 90.60 Metaproterenol sulfate, inhalation solution, fda-approved final product, non-compounded, administered through dme, unit dose form, per 10 milligrams 10.0000 MG 6.15 4.9200 3.81 6.15 Noc drugs, other than inhalation drugs, administered through dme 1.0000 Unit(s) 39.94 31.9500 24.72 39.94 Methotrexate; oral, 2.5 mg 2.5000 MG 21.00 16.8000 13.00 21.00 Prescription drug, oral, chemotherapeutic, nos 1.0000 Unit(s) 5.19 4.1500 3.21 5.19 Injection, doxorubicin hydrochloride, 10 mg 10.0000 MG 81.13 64.9000 50.22 81.13 Injection, azacitidine, 1 mg 1.0000 MG 33.57 26.8600 20.78 33.57 Injection, bendamustine hcl (treanda), 1 mg 1.0000 MG 132.75 106.2000 14.08 132.75 Injection, bevacizumab, 10 mg 10.0000 MG 238.42 190.7400 67.21 238.42 Injection, bleomycin sulfate, 15 units 15.0000 Unit(s) 1289.65 1031.7200 798.29 1289.65 Injection, bortezomib, 0.1 mg 0.1000 MG 113.25 90.6000 8.56 113.25 Injection, cabazitaxel, 1 mg 1.0000 MG 320.00 256.0000 189.25 320.00 Injection, carboplatin, 50 mg 50.0000 MG 73.75 59.0000 45.65 73.75 Injection, carfilzomib, 1 mg 1.0000 mg 72.95 58.3600 42.81 72.95 Injection, carmustine, 100 mg 100.0000 MG 1157.00 925.6000 233.66 1157.00 Injection, cetuximab, 10 mg 10.0000 MG 354.00 283.2000 66.84 354.00 Injection, cisplatin, powder or solution, 10 mg 10.0000 MG 211.00 168.8000 130.61 211.00 Cyclophosphamide, 100 mg 100.0000 MG 186.44 149.1500 21.02 186.44 Dacarbazine, 100 mg 100.0000 MG 69.70 55.7600 43.14 69.70 Injection, daunorubicin, 10 mg 10.0000 MG 165.40 132.3200 39.56 165.40 Injection, docetaxel, 1 mg 1.0000 MG 122.19 97.7500 75.64 122.19 Injection, epirubicin hcl, 2 mg 2.0000 MG 27.60 22.0800 17.08 27.60 Injection, etoposide, 10 mg 10.0000 MG 130.05 104.0400 80.50 130.05 Injection, fludarabine phosphate, 50 mg 50.0000 MG 6116.96 4893.5700 100.32 6116.96 Injection, fluorouracil, 500 mg 500.0000 MG 21.24 16.9900 13.15 21.24 Injection, gemcitabine hydrochloride, not otherwise specified, 200 mg 200.0000 MG 992.44 793.9500 614.32 992.44 Goserelin acetate implant, per 3.6 mg 3.6000 MG 2402.14 1921.7100 539.53 2402.14 Injection, irinotecan, 20 mg 20.0000 MG 918.10 734.4800 568.30 918.10 Injection, ixabepilone, 1 mg 1.0000 MG 453.30 362.6400 112.72 453.30 Injection, interferon, alfa-2b, recombinant, 1 million units 1.0000 MIL 100.06 80.0500 30.95 100.06 Leuprolide acetate (for depot suspension), 7.5 mg 7.5000 MG 4613.54 3690.8300 178.91 4613.54 Injection, mechlorethamine hydrochloride, (nitrogen mustard), 10 mg 10.0000 MG 155.00 124.0000 95.94 155.00 Methotrexate sodium, 5 mg 5.0000 MG 23.78 19.0200 14.72 23.78 Injection, oxaliplatin, 0.5 mg 0.5000 MG 71.09 56.8700 44.00 71.09 Injection, paclitaxel protein-bound particles, 1 mg 1.0000 MG 65.31 52.2500 11.38 65.31 Injection, pentostatin, 10 mg 10.0000 MG 8501.31 6801.0500 2204.11 8501.31 Injection, mitomycin, 5 mg 5.0000 MG 501.50 401.2000 42.25 501.50 Injection, mitoxantrone hydrochloride, per 5 mg 5.0000 MG 1235.70 988.5600 52.14 1235.70 Injection, panitumumab, 10 mg 10.0000 MG 1080.00 864.0000 136.33 1080.00 Injection, pemetrexed, not otherwise specified, 10 mg 10.0000 MG 338.84 271.0700 26.30 338.84 Injection, temsirolimus, 1 mg 1.0000 MG 390.11 312.0900 33.44 390.11 Injection, topotecan, 0.1 mg 0.1000 MG 192.64 154.1100 119.24 192.64 Injection, trastuzumab, excludes biosimilar, 10 mg 10.0000 MG 446.63 357.3000 78.61 446.63 Injection, vinblastine sulfate, 1 mg 1.0000 MG 104.90 83.9200 64.93 104.90 Vincristine sulfate, 1 mg 1.0000 MG 178.95 143.1600 110.77 178.95 Injection, vinorelbine tartrate, 10 mg 10.0000 MG 497.85 398.2800 308.17 497.85 Injection, fulvestrant, 25 mg 25.0000 MG 6945.15 5556.1200 12.03 6945.15 Not otherwise classified, antineoplastic drugs 1.0000 Unit(s) 8951.25 7161.0000 5540.82 8951.25 Cervical, flexible, non-adjustable, prefabricated, off-the-shelf (foam collar) 1.0000 Each 29.31 23.4500 9.67 32.91 Cervical, collar, semi-rigid thermoplastic foam, two-piece, prefabricated, off-the-shelf 1.0000 Each 70.27 56.2200 23.19 167.25 Lumbar orthosis, flexible, provides lumbar support, posterior extends from l-1 to below l-5 vertebra, produces intracavitary pressure to reduce load on the intervertebral discs, includes straps, closures, may include pendulous abdomen design, shoulder str 1.0000 Each 57.72 46.1800 19.05 57.72 Knee orthosis, immobilizer, canvas longitudinal, prefabricated, off-the-shelf 1.0000 Each 81.48 65.1800 26.89 85.51 Ankle orthosis, ankle gauntlet or similar, with or without joints, prefabricated, off-the-shelf 1.0000 Each 67.73 54.1800 22.35 89.84 Surgical boot/shoe, each 1.0000 Each 34.65 27.7200 11.43 34.65 Plastazote sandal, each 1.0000 Each 42.80 34.2400 14.12 42.80 Shoulder orthosis, figure of eight design abduction restrainer, prefabricated, off-the-shelf 1.0000 Each 48.11 38.4900 15.88 64.07 Elbow orthosis, rigid, without joints, includes soft interface material, prefabricated, off-the-shelf 1.0000 Each 250.00 200.0000 82.50 250.00 Wrist hand orthosis, wrist extension control cock-up, non molded, prefabricated, off-the-shelf 1.0000 Each 44.60 35.6800 14.72 64.13 Ankle control orthosis, stirrup style, rigid, includes any type interface (e.g., pneumatic, gel), prefabricated, off-the-shelf 1.0000 Each 82.60 66.0800 27.26 115.00 Implantable breast prosthesis, silicone or equal 1.0000 Each 4050.00 3240.0000 1336.50 4050.00 Injectable bulking agent, synthetic implant, urinary tract, 1 ml syringe, includes shipping and necessary supplies 1.0000 ML 1980.00 1584.0000 653.40 1980.00 Ocular implant 1.0000 Each 1980.00 1584.0000 653.40 1980.00 Aqueous shunt 1.0000 Each 2380.00 1904.0000 785.40 2380.00 Prosthetic implant, not otherwise specified 1.0000 Each 4300.00 3440.0000 1419.00 4300.00 Intravenous infusion or subcutaneous injection, casirivimab and imdevimab includes infusion or injection, and post administration monitoring 1.0000 each 326.00 260.8000 201.79 454.24 Intravenous infusion, bamlanivimab and etesevimab, includes infusion and post administration monitoring 1.0000 each 326.00 260.8000 201.79 454.24 Intravenous infusion, sotrovimab, includes infusion and post administration monitoring 1.0000 each 450.00 360.0000 278.55 454.24 Cryoprecipitate, each unit 1.0000 Unit(s) 967.00 773.6000 70.67 967.00 Red blood cells, leukocytes reduced, each unit 1.0000 Unit(s) 756.00 604.8000 179.75 756.00 Platelets, each unit 1.0000 Unit(s) 217.20 173.7600 73.37 217.20 Red blood cells, washed, each unit 1.0000 Unit(s) 669.75 535.8000 375.99 669.75 Platelets, pheresis, leukocytes reduced, each unit 1.0000 Unit(s) 1768.00 1414.4000 461.38 1768.00 Platelets, pheresis, leukocytes reduced, irradiated, each unit 1.0000 Unit(s) 1873.83 1499.0600 606.28 1873.83 Red blood cells, irradiated, each unit 1.0000 Unit(s) 756.00 604.8000 186.39 756.00 Infusion, albumin (human), 5%, 50 ml 50.0000 ML 812.78 650.2200 10.03 812.78 Infusion, albumin (human), 5%, 250 ml 250.0000 ML 218.45 174.7600 50.13 218.45 Infusion, albumin (human), 25%, 50 ml 50.0000 ML 663.75 531.0000 50.13 663.75 Infusion, plasma protein fraction (human), 5%, 250 ml 250.0000 ML 434.15 347.3200 150.44 434.15 Fresh frozen plasma between 8-24 hours of collection, each unit 1.0000 Unit(s) 314.00 251.2000 72.39 314.00 Travel allowance one way in connection with medically necessary laboratory specimen collection drawn from home bound or nursing home bound patient; prorated trip charge 1.0000 each 2.28 0.0000 N/A N/A Catheterization for collection of specimen, single patient, all places of service 1.0000 each 40.00 32.0000 8.14 40.00 Infusion therapy, using other than chemotherapeutic drugs, per visit 1.0000 Visit 144.50 115.6000 89.45 144.50 Injection, ferumoxytol, for treatment of iron deficiency anemia, 1 mg (non-esrd use) 1.0000 MG 228.57 182.8600 0.53 228.57 Injection, ferumoxytol, for treatment of iron deficiency anemia, 1 mg (for esrd on dialysis) 1.0000 MG 193.34 154.6700 0.53 193.34 Azithromycin dihydrate, oral, capsules/powder, 1 gram 1.0000 g 171.87 137.5000 106.39 171.87 Granisetron hydrochloride, 1 mg, oral, fda approved prescription anti-emetic, for use as a complete therapeutic substitute for an iv anti-emetic at the time of chemotherapy treatment, not to exceed a 24 hour dosage regimen 1.0000 MG 281.65 225.3200 174.34 281.65 Promethazine hydrochloride, 12.5 mg, oral, fda approved prescription anti-emetic, for use as a complete therapeutic substitute for an iv anti-emetic at the time of chemotherapy treatment, not to exceed a 48 hour dosage regimen 12.5000 MG 4.00 3.2000 2.48 4.00 Injection, casirivimab and imdevimab, 2400 mg 2400.0000 mg 0.01 0.0100 0.01 0.01 Injection, casirivimab and imdevimab, 1200 mg 1200.0000 mg 0.01 0.0100 0.01 0.01 Injection, bamlanivimab and etesevimab, 2100 mg 2100.0000 mg 0.01 0.0100 0.01 0.01 Injection, sotrovimab, 500 mg 500.0000 mg 0.01 0.0100 0.01 0.01 Injection, fosphenytoin, 50 mg phenytoin equivalent 50.0000 MG 73.45 58.7600 45.47 73.45 Influenza virus vaccine, split virus, when administered to individuals 3 years of age and older, for intramuscular use (flulaval) 0.5000 ML 64.90 51.9200 40.17 64.90 Influenza virus vaccine, split virus, when administered to individuals 3 years of age and older, for intramuscular use (fluvirin) 0.5000 ML 58.47 46.7800 36.19 58.47 Influenza virus vaccine, split virus, when administered to individuals 3 years of age and older, for intramuscular use (fluzone) 0.5000 ML 112.40 89.9200 69.58 112.40 Skin substitute, not otherwise specified 1.0000 Sq Cm 7935.00 6348.0000 4911.76 7935.00 Apligraf, per square centimeter 1.0000 SQ CM 116.18 92.9400 71.92 116.18 Dermagraft, per square centimeter 1.0000 SQ CM 119.19 95.3500 73.78 119.19 Graftjacket, per square centimeter 1.0000 SQ CM 7324.00 5859.2000 4533.56 7324.00 Alloderm, per square centimeter 1.0000 SQ CM 145.20 116.1600 89.88 145.20 Theraskin, per square centimeter 1.0000 SQ CM 66.26 53.0100 41.01 66.26 Dermacell, dermacell awm or dermacell awm porous, per square centimeter 1.0000 Sq Cm 243.00 194.4000 150.42 243.00 Injection, perflutren lipid microspheres, per ml 1.0000 ML 767.00 613.6000 474.77 767.00 High osmolar contrast material, up to 149 mg/ml iodine concentration, per ml 1.0000 ML 32.00 25.6000 19.81 32.00 High osmolar contrast material, 350-399 mg/ml iodine concentration, per ml 1.0000 ML 146.03 116.8200 90.39 146.03 Low osmolar contrast material, 300-399 mg/ml iodine concentration, per ml 1.0000 ML 6.37 5.1000 3.94 6.37 Injection, non-radioactive, non-contrast, visualization adjunct (e.g., methylene blue, isosulfan blue), 1 mg 1.0000 mg 1159.38 927.5000 7.36 1159.38 Injection, famotidine, 20 mg 20.0000 MG 15.00 12.0000 9.28 15.00 Injection, aztreonam, 500 mg 500.0000 MG 198.42 158.7400 122.82 198.42 Injection, cefotetan disodium, 500 mg 500.0000 MG 138.65 110.9200 85.82 138.65 Injection, bumetanide, 0.5 mg 0.5000 MG 15.00 12.0000 9.28 15.00 Magnetic resonance cholangiopancreatography (mrcp) 1.0000 each 3656.00 2924.8000 2263.06 3656.00 Birthing classes, non-physician provider, per session 1.0000 Session 10.00 8.0000 6.19 10.00 Diabetic management program, dietitian visit 1.0000 each 111.00 88.8000 68.71 111.00 Nutritional counseling, dietitian visit 1.0000 each 105.60 84.4800 65.37 105.60 Infectious agent detection by nucleic acid (dna or rna); severe acute respiratory syndrome coronavirus 2 (sars-cov-2) (coronavirus disease [covid-19]), amplified probe technique, making use of high throughput technologies as described by cms-2020-01-r 1.0000 each 168.00 134.4000 71.25 168.00 Infectious agent detection by nucleic acid (dna or rna); severe acute respiratory syndrome coronavirus 2 (sars-cov-2) (coronavirus disease [covid-19]), amplified probe technique, cdc or non-cdc, making use of high throughput technologies, completed within 1.0000 each 25.00 20.0000 15.48 25.75 Prosthetic eye, other type 1.0000 Each 1840.00 1472.0000 1138.96 1840.00 Anterior chamber intraocular lens 1.0000 Each 552.50 442.0000 182.32 552.50 Posterior chamber intraocular lens 1.0000 Each 664.25 531.4000 219.20 664.25 Astigmatism correcting function of intraocular lens 1.0000 lens 385.00 308.0000 127.05 385.00 Presbyopia correcting function of intraocular lens 1.0000 each 875.00 700.0000 288.75 875.00 Amniotic membrane for surgical reconstruction, per procedure 1.0000 Each 3156.00 2524.8000 1953.56 3156.00 seizures with mcc Each 25849.81 NA N/A N/A seizures without mcc Each 30354.09 24283.2700 3844.00 30354.09 pulmonary embolism with mcc or acute cor pulmonale Each 23535.58 NA N/A N/A pulmonary embolism without mcc Each 13269.12 10615.3000 3844.00 13269.12 respiratory infections and inflammations with mcc Each 33128.78 NA N/A N/A respiratory infections and inflammations with cc Each 30095.87 NA N/A N/A respiratory infections and inflammations without cc/mcc Each 42894.49 34315.5900 3844.00 42894.48 major chest trauma with mcc Each 21333.26 NA N/A N/A pulmonary edema and respiratory failure Each 22247.95 17798.3600 3844.00 22247.95 chronic obstructive pulmonary disease with mcc Each 15587.88 NA N/A N/A chronic obstructive pulmonary disease with cc Each 22022.92 NA N/A N/A simple pneumonia and pleurisy with mcc Each 32115.39 NA N/A N/A interstitial lung disease with mcc Each 33242.51 NA N/A N/A pneumothorax with mcc Each 47772.39 NA N/A N/A pneumothorax with cc Each 38057.16 NA N/A N/A bronchitis and asthma with cc/mcc Each 25229.17 NA N/A N/A bronchitis and asthma without cc/mcc Each 15719.70 12575.7600 3844.00 15719.70 respiratory signs and symptoms Each 18046.67 14437.3400 1922.00 18046.67 other respiratory system diagnoses with mcc Each 53361.91 NA N/A N/A other respiratory system diagnoses without mcc Each 25922.46 20737.9700 3844.00 25922.46 respiratory system diagnosis with ventilator support >96 hours Each 92279.22 73823.3800 24986.00 92279.22 respiratory system diagnosis with ventilator support < = 96 hours Each 48808.08 39046.4600 9610.00 48808.08 other circulatory system o.r. procedures Each 79986.67 63989.3400 21176.72 79986.67 acute myocardial infarction, discharged alive with mcc Each 26139.30 NA N/A N/A acute myocardial infarction, discharged alive with cc Each 14694.89 NA N/A N/A acute myocardial infarction, expired with mcc Each 10660.11 NA N/A N/A acute myocardial infarction, expired with cc Each 23508.74 NA N/A N/A acute and subacute endocarditis with mcc Each 48859.09 NA N/A N/A acute and subacute endocarditis with cc Each 36738.75 NA N/A N/A heart failure and shock with mcc Each 23120.19 NA N/A N/A heart failure and shock with cc Each 25506.63 NA N/A N/A peripheral vascular disorders with cc Each 22041.75 NA N/A N/A cardiac arrhythmia and conduction disorders with mcc Each 17673.79 NA N/A N/A cardiac arrhythmia and conduction disorders with cc Each 17152.75 NA N/A N/A syncope and collapse Each 26073.03 20858.4200 3844.00 26073.02 other circulatory system diagnoses with mcc Each 9781.48 NA N/A N/A other circulatory system diagnoses with cc Each 27631.55 NA N/A N/A stomach, esophageal and duodenal procedures without cc/mcc Each 20269.60 16215.6800 10496.00 20269.60 major small and large bowel procedures with mcc Each 83419.67 NA N/A N/A major small and large bowel procedures with cc Each 82809.17 NA N/A N/A major small and large bowel procedures without cc/mcc Each 70096.09 56076.8700 10933.55 70096.09 rectal resection with mcc Each 94001.18 NA N/A N/A peritoneal adhesiolysis with mcc Each 152680.07 NA N/A N/A peritoneal adhesiolysis with cc Each 76744.86 NA N/A N/A peritoneal adhesiolysis without cc/mcc Each 67258.49 53806.7900 10080.65 67258.49 appendectomy without complicated principal diagnosis with cc Each 66456.34 NA N/A N/A appendectomy without complicated principal diagnosis without cc/mcc Each 43419.93 34735.9400 5300.00 43419.92 minor small and large bowel procedures with mcc Each 49465.37 NA N/A N/A minor small and large bowel procedures with cc Each 57538.81 NA N/A N/A inguinal and femoral hernia procedures with cc Each 49352.58 NA N/A N/A inguinal and femoral hernia procedures without cc/mcc Each 45873.25 36698.6000 7051.65 45873.25 hernia procedures except inguinal and femoral with mcc Each 49962.22 NA N/A N/A hernia procedures except inguinal and femoral with cc Each 52094.03 NA N/A N/A major esophageal disorders with mcc Each 50041.63 NA N/A N/A major gastrointestinal disorders and peritoneal infections with mcc Each 56684.02 NA N/A N/A major gastrointestinal disorders and peritoneal infections with cc Each 27237.79 NA N/A N/A digestive malignancy with cc Each 17836.05 NA N/A N/A gastrointestinal hemorrhage with mcc Each 40071.97 NA N/A N/A gastrointestinal hemorrhage with cc Each 32218.18 NA N/A N/A gastrointestinal hemorrhage without cc/mcc Each 21990.27 17592.2200 3844.00 21990.27 inflammatory bowel disease with mcc Each 26505.77 NA N/A N/A inflammatory bowel disease with cc Each 21291.30 NA N/A N/A inflammatory bowel disease without cc/mcc Each 19642.13 15713.7000 4425.12 19642.13 gastrointestinal obstruction with mcc Each 22079.47 NA N/A N/A gastrointestinal obstruction with cc Each 23247.89 NA N/A N/A gastrointestinal obstruction without cc/mcc Each 16781.32 13425.0600 3618.28 16781.32 esophagitis, gastroenteritis and miscellaneous digestive disorders with mcc Each 26457.74 NA N/A N/A esophagitis, gastroenteritis and miscellaneous digestive disorders without mcc Each 19587.67 15670.1300 5039.36 19587.66 other digestive system diagnoses with mcc Each 39050.97 NA N/A N/A other digestive system diagnoses with cc Each 22194.40 NA N/A N/A other digestive system diagnoses without cc/mcc Each 26963.17 21570.5400 4126.32 26963.17 biliary tract procedures except only cholecystectomy with or without c.d.e. with mcc Each 134933.77 NA N/A N/A laparoscopic cholecystectomy without c.d.e. with cc Each 77831.93 NA N/A N/A laparoscopic cholecystectomy without c.d.e. without cc/mcc Each 42573.30 34058.6400 2702.00 42573.30 other hepatobiliary or pancreas o.r. procedures without cc/mcc Each 18619.55 14895.6400 8314.00 18619.55 cirrhosis and alcoholic hepatitis with mcc Each 42782.95 NA N/A N/A cirrhosis and alcoholic hepatitis with cc Each 23321.16 NA N/A N/A malignancy of hepatobiliary system or pancreas with cc Each 8635.64 NA N/A N/A disorders of pancreas except malignancy with mcc Each 27055.68 NA N/A N/A disorders of pancreas except malignancy with cc Each 20112.03 NA N/A N/A disorders of pancreas except malignancy without cc/mcc Each 21319.11 17055.2900 3879.98 21319.11 disorders of liver except malignancy, cirrhosis, or alcoholic hepatitis with mcc Each 34502.84 NA N/A N/A disorders of liver except malignancy, cirrhosis, or alcoholic hepatitis with cc Each 17318.97 NA N/A N/A disorders of liver except malignancy, cirrhosis, or alcoholic hepatitis without cc/mcc Each 32047.10 25637.6800 4171.10 32047.10 disorders of the biliary tract with mcc Each 14979.67 NA N/A N/A wound debridement and skin graft except hand for musculoskeletal and connective tissue disorders with cc Each 49746.61 NA N/A N/A revision of hip or knee replacement with mcc Each 52383.02 NA N/A N/A revision of hip or knee replacement with cc Each 64722.18 NA N/A N/A revision of hip or knee replacement without cc/mcc Each 50000.57 40000.4600 17847.00 50000.57 major hip and knee joint replacement or reattachment of lower extremity without mcc Each 50922.65 40738.1200 8314.00 50922.65 amputation for musculoskeletal system and connective tissue disorders with cc Each 76752.99 NA N/A N/A biopsies of musculoskeletal system and connective tissue with mcc Each 61669.46 NA N/A N/A hip and femur procedures except major joint with mcc Each 50458.01 NA N/A N/A hip and femur procedures except major joint with cc Each 53223.19 NA N/A N/A hip and femur procedures except major joint without cc/mcc Each 38653.64 30922.9100 10532.37 38653.64 knee procedures with principal diagnosis of infection with cc Each 129132.60 NA N/A N/A knee procedures without principal diagnosis of infection with cc/mcc Each 37359.80 NA N/A N/A lower extremity and humerus procedures except hip, foot, femur with mcc Each 65599.76 NA N/A N/A lower extremity and humerus procedures except hip, foot, femur with cc Each 46801.75 NA N/A N/A lower extremity and humerus procedures except hip, foot, femur without cc/mcc Each 29680.73 23744.5800 8314.00 29680.72 local excision and removal of internal fixation devices except hip and femur with mcc Each 64353.18 NA N/A N/A soft tissue procedures with mcc Each 30122.64 NA N/A N/A soft tissue procedures with cc Each 21260.48 NA N/A N/A hip replacement with principal diagnosis of hip fracture with mcc Each 50241.24 NA N/A N/A hip replacement with principal diagnosis of hip fracture without mcc Each 54503.25 43602.6000 13903.04 54503.25 fractures of hip and pelvis with mcc Each 25345.83 NA N/A N/A fractures of hip and pelvis without mcc Each 21470.11 17176.0900 1922.00 21470.11 sprains, strains, and dislocations of hip, pelvis and thigh without cc/mcc Each 15875.02 12700.0200 4454.55 15875.02 osteomyelitis with mcc Each 34624.10 NA N/A N/A pathological fractures and musculoskeletal and connective tissue malignancy with cc Each 29832.28 NA N/A N/A connective tissue disorders with cc Each 21194.04 NA N/A N/A septic arthritis with cc Each 7259.15 NA N/A N/A medical back problems without mcc Each 19393.04 15514.4300 3844.00 19393.04 bone diseases and arthropathies with mcc Each 4821.54 NA N/A N/A bone diseases and arthropathies without mcc Each 14807.87 11846.3000 5247.95 14807.87 tendonitis, myositis and bursitis without mcc Each 30285.38 24228.3000 5560.19 30285.38 degenerative nervous system disorders with mcc Each 47392.98 NA N/A N/A aftercare, musculoskeletal system and connective tissue with cc Each 28194.22 NA N/A N/A fracture, sprain, strain and dislocation except femur, hip, pelvis and thigh with mcc Each 30069.90 NA N/A N/A fracture, sprain, strain and dislocation except femur, hip, pelvis and thigh without mcc Each 26301.82 21041.4600 5510.28 26301.82 other musculoskeletal system and connective tissue diagnoses with mcc Each 31548.99 NA N/A N/A other musculoskeletal system and connective tissue diagnoses with cc Each 38807.51 NA N/A N/A degenerative nervous system disorders without mcc Each 23780.90 19024.7200 5766.00 23780.90 skin debridement with mcc Each 29822.67 NA N/A N/A skin debridement with cc Each 44760.31 NA N/A N/A other skin, subcutaneous tissue and breast procedures with cc Each 28688.64 NA N/A N/A other skin, subcutaneous tissue and breast procedures without cc/mcc Each 20857.85 16686.2800 5300.00 20857.85 breast biopsy, local excision and other breast procedures with cc/mcc Each 36072.26 NA N/A N/A breast biopsy, local excision and other breast procedures without cc/mcc Each 22193.41 17754.7300 5300.00 22193.41 skin ulcers with mcc Each 9465.85 NA N/A N/A skin ulcers with cc Each 15048.46 NA N/A N/A major skin disorders without mcc Each 8734.97 6987.9800 3844.00 8734.97 nonmalignant breast disorders with cc/mcc Each 17426.43 NA N/A N/A cellulitis with mcc Each 22401.73 NA N/A N/A cellulitis without mcc Each 16373.04 13098.4300 5642.09 16373.04 trauma to the skin, subcutaneous tissue and breast with mcc Each 24748.69 NA N/A N/A trauma to the skin, subcutaneous tissue & breast without mcc Each 75951.64 60761.3100 5825.09 75951.64 minor skin disorders with mcc Each 30914.45 NA N/A N/A amputation of lower limb for endocrine, nutritional, and metabolic disorders with cc Each 38834.55 NA N/A N/A amputation of lower limb for endocrine, nutritional, and metabolic disorders without cc/mcc Each 48468.92 38775.1400 7504.66 48468.92 skin grafts and wound debridement for endocrine, nutritional and metabolic disorders with cc Each 29504.50 NA N/A N/A skin grafts and wound debridement for endocrine, nutritional and metabolic disorders without cc/mcc Each 55693.85 44555.0800 6328.00 55693.84 other endocrine, nutritional and metabolic o.r. procedures with cc Each 35350.47 NA N/A N/A diabetes with mcc Each 30894.87 NA N/A N/A diabetes with cc Each 16533.59 NA N/A N/A diabetes without cc/mcc Each 16950.16 13560.1300 3844.00 16950.16 intracranial hemorrhage or cerebral infarction with mcc Each 37751.12 NA N/A N/A miscellaneous disorders of nutrition, metabolism, and fluids and electrolytes with mcc Each 23496.70 NA N/A N/A miscellaneous disorders of nutrition, metabolism, and fluids and electrolytes without mcc Each 21108.66 16886.9200 3844.00 21108.66 endocrine disorders with mcc Each 22623.35 NA N/A N/A endocrine disorders with cc Each 31719.55 NA N/A N/A intracranial hemorrhage or cerebral infarction with cc or tpa in 24 hours Each 27500.19 NA N/A N/A kidney and ureter procedures for neoplasm with cc Each 49309.27 NA N/A N/A kidney and ureter procedures for non-neoplasm with mcc Each 26612.69 NA N/A N/A intracranial hemorrhage or cerebral infarction without cc/mcc Each 29531.10 23624.8800 1922.00 29531.10 kidney and ureter procedures for non-neoplasm with cc Each 27643.14 NA N/A N/A kidney and ureter procedures for non-neoplasm without cc/mcc Each 32908.89 26327.1100 5300.00 32908.88 prostatectomy with cc Each 65206.88 NA N/A N/A other kidney and urinary tract procedures with mcc Each 67320.65 NA N/A N/A renal failure with mcc Each 27491.74 NA N/A N/A renal failure with cc Each 19327.62 NA N/A N/A kidney and urinary tract infections with mcc Each 24530.68 NA N/A N/A kidney and urinary tract infections without mcc Each 20115.60 16092.4800 5090.55 20115.60 other kidney and urinary tract diagnoses with mcc Each 22389.45 NA N/A N/A other kidney and urinary tract diagnoses with cc Each 28127.21 NA N/A N/A other kidney and urinary tract diagnoses without cc/mcc Each 16802.19 13441.7500 1922.00 16802.19 nonspecific cerebrovascular disorders with cc Each 30837.68 NA N/A N/A other male reproductive system o.r. procedures except malignancy without cc/mcc Each 38920.94 31136.7500 2702.00 38920.94 malignancy, male reproductive system with mcc Each 13879.05 NA N/A N/A inflammation of the male reproductive system without mcc Each 41966.50 33573.2000 5257.55 41966.50 cranial and peripheral nerve disorders without mcc Each 16134.92 12907.9400 3844.00 16134.92 uterine and adnexa procedures for nonmalignancy with cc/mcc Each 41676.48 NA N/A N/A uterine and adnexa procedures for nonmalignancy without cc/mcc Each 36002.67 28802.1400 2702.00 36002.67 d&c, conization, laparoscopy and tubal interruption with cc/mcc Each 34478.17 NA N/A N/A menstrual and other female reproductive system disorders with cc/mcc Each 19791.13 NA N/A N/A cesarean section with cc/mcc Each 19685.29 NA N/A N/A cesarean section without cc/mcc Each 19433.83 15547.0600 3741.00 19433.83 vaginal delivery with sterilization and/or d&c Each 26603.37 21282.6900 2650.00 26603.36 vaginal delivery with o.r. procedures except sterilization and/or d&c Each 8740.18 6992.1400 3741.00 8740.18 vaginal delivery with complicating diagnoses Each 9063.52 7250.8200 3741.00 9063.52 vaginal delivery without complicating diagnoses Each 9236.29 7389.0300 3741.00 9236.29 postpartum and postabortion diagnoses without o.r. procedures Each 9045.52 7236.4200 3844.00 9045.52 cesarean section with sterilization with cc Each 19685.29 NA N/A N/A cesarean section with sterilization without cc/mcc Each 19433.83 15547.0600 3741.00 19433.83 cesarean section without sterilization with mcc Each 20195.21 NA N/A N/A cesarean section without sterilization with cc Each 18353.73 NA N/A N/A cesarean section without sterilization without cc/mcc Each 20153.59 16122.8700 3741.00 20153.59 neonates, died or transferred to another acute care facility Each 2932.24 2345.7920 416.00 2932.24 prematurity with major problems Each 1181.42 945.1360 416.00 1181.42 prematurity without major problems Each 1405.26 1124.2080 416.00 1405.26 full term neonate with major problems Each 1712.40 1369.9200 416.00 1712.40 neonate with other significant problems Each 1357.22 1085.7720 416.00 1357.22 normal newborn Each 1179.29 943.4320 416.00 1179.29 vaginal delivery with sterilization and/or d&c with cc Each 25854.54 NA N/A N/A vaginal delivery with sterilization and/or d&c without cc/mcc Each 26603.37 21282.6900 2650.00 26603.36 vaginal delivery without sterilization or d&c with mcc Each 8155.97 NA N/A N/A vaginal delivery without sterilization or d&c with cc Each 9063.52 NA N/A N/A vaginal delivery without sterilization or d&c without cc/mcc Each 9236.29 7389.0300 3741.00 9236.29 red blood cell disorders with mcc Each 24313.67 NA N/A N/A red blood cell disorders without mcc Each 14979.00 11983.2000 3844.00 14979.00 reticuloendothelial and immunity disorders with mcc Each 15578.49 NA N/A N/A other antepartum diagnoses with o.r. procedures with cc Each 15585.42 NA N/A N/A other antepartum diagnoses without o.r. procedures with mcc Each 3547.82 NA N/A N/A other antepartum diagnoses without o.r. procedures with cc Each 7129.38 NA N/A N/A other antepartum diagnoses without o.r. procedures without cc/mcc Each 8803.72 7042.9700 1922.00 8803.72 infectious and parasitic diseases with o.r. procedures with mcc Each 62885.30 NA N/A N/A infectious and parasitic diseases with o.r. procedures with cc Each 50288.47 NA N/A N/A infectious and parasitic diseases with o.r. procedures without cc/mcc Each 35332.75 28266.2000 9774.81 35332.75 postoperative or posttraumatic infections with o.r. procedures with mcc Each 57998.38 NA N/A N/A fever and inflammatory conditions Each 25359.79 20287.8300 3844.00 25359.79 viral illness with mcc Each 31332.31 NA N/A N/A septicemia or severe sepsis with mechanical ventilation >96 hours Each 115307.05 92245.6400 23064.00 115307.04 septicemia or severe sepsis without mechanical ventilation >96 hours with mcc Each 29454.09 NA N/A N/A septicemia or severe sepsis without mechanical ventilation >96 hours without mcc Each 22870.19 18296.1500 5766.00 22870.19 concussion with mcc Each 30654.73 NA N/A N/A organic disturbances and intellectual disability Each 38897.17 31117.7400 7688.00 38897.17 psychoses Each 17860.16 14288.1300 5766.00 17860.16 alcohol, drug abuse or dependence, left against medical advice Each 10067.84 8054.2700 3658.59 10067.84 alcohol, drug abuse or dependence without rehabilitation therapy with mcc Each 39336.39 NA N/A N/A alcohol, drug abuse or dependence without rehabilitation therapy without mcc Each 15701.04 12560.8300 1922.00 15701.04 other o.r. procedures for injuries with cc Each 31333.33 NA N/A N/A other o.r. procedures for injuries without cc/mcc Each 102811.16 82248.9300 8731.87 102811.16 other disorders of nervous system with mcc Each 58760.21 NA N/A N/A allergic reactions without mcc Each 14743.08 11794.4600 3844.00 14743.08 poisoning and toxic effects of drugs with mcc Each 31362.23 NA N/A N/A poisoning and toxic effects of drugs without mcc Each 22635.89 18108.7100 1922.00 22635.89 complications of treatment with mcc Each 14458.64 NA N/A N/A other disorders of nervous system with cc Each 29486.59 NA N/A N/A signs and symptoms without mcc Each 24903.84 19923.0700 1922.00 24903.84 hiv with extensive o.r. procedures with mcc Each 26574.03 NA N/A N/A nonbacterial infection of nervous system except viral meningitis with mcc Each 51640.77 NA N/A N/A hiv with major related condition with mcc Each 50740.71 NA N/A N/A hiv with major related condition with cc Each 14734.76 NA N/A N/A extensive o.r. procedures unrelated to principal diagnosis with mcc Each 54220.86 NA N/A N/A extensive o.r. procedures unrelated to principal diagnosis with cc Each 22456.65 NA N/A N/A extensive o.r. procedures unrelated to principal diagnosis without cc/mcc Each 15849.78 12679.8200 8314.00 15849.78 nonextensive o.r. procedures unrelated to principal diagnosis with mcc Each 41884.32 NA N/A N/A nonextensive o.r. procedures unrelated to principal diagnosis without cc/mcc Each 29540.35 23632.2800 2702.00 29540.35